Your Guide to Prescription Drug Coverage · Trial and failure of ProAir HFA. QL. or ProAir...

Your Guide to Prescription Drug Coverage 2018 PREFERRED FORMULARY DRUG LIST

This document contains information about the drugs covered in your prescription drug benefit plan.

Important Contacts For more information about your prescription drug coverage, call the phone number listed on your BlueCross BlueShield of Tennessee Member ID card. For information about your home delivery prescription, call 1-877-673-9165.

Visit bcbst.com • Locate a participating retail pharmacy • Look up possible lower-cost

prescription alternatives • Compare prescription drug pricing

and options

Drug Benefit Reconsiderations You or your doctor may ask for reconsideration of the following:

• A denial of a drug benefit • Limits on a drug quantity • Criteria for prior authorization • Use of a non-covered drug

You’ll need supportive documentation. That means written reasons from your doctor about why BlueCross shouldn’t have denied a benefit, quantity, prior authorization or non-covered drug.

All reconsiderations are considered on a case-by-case basis. See your Evidence of Coverage or member handbook for details on your rights to file reconsiderations.

Fax all information to 1-888-343-4232. Or send a written request to:

Pharmacy Management Reconsiderations BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN 37402-2555

Please provide the following information with your request:

• Patient name and cardholder ID number • Physician name and phone number • Drug and diagnosis information

2018 Preferred FormularyCheck often for updates, as this list is subject to change.

2018 Preferred Formulary

i

http://bcbst.com



Understanding the Formulary Drug List This Formulary Drug List will help you understand the drugs your plan covers. The drugs in this formulary are listed by common categories or class then alphabetically. They are placed into cost levels known as tiers. The tiers include generic, preferred brand and non-preferred brand drugs reviewed by a panel of physicians and pharmacists regularly and revised to reflect availability of new drugs and other changes in the market.

Some drugs are noted with letters next to them. The letters refer to certain pharmacy benefit programs. To make sure that prescriptions are used safely, some drugs have additional requirements that must be met before the prescription can be filled. Those drugs will have an abbreviation next to the drug name to let you and your doctor know there are additional requirements.

For more information on how to fill your prescriptions, please refer to your Evidence of Coverage or member handbook on bcbst.com or call the phone number listed on your BlueCross Member ID card.

Abbreviation Description

ACA Affordable Care Act means drugs with the ACA indicator may be available to you at no out-of-pocket cost depending on your plan. Check your Evidence of Coverage or member handbook for plan details.

Age Requirement means a person must be within a specific age group for a drug to be covered. AGE-A Prior authorization is required for members 17 years of age and younger. Your doctor must call

Express Scripts at 1-877-916-2271 to request approval for coverage.

Limited Distribution means drugs may only be available at certain pharmacies. For more LD information, please call BlueCross Member Service at the phone number listed on your

Member ID card.

Prior Authorization may be required for certain drugs. Your doctor must call Express Scripts at PA 1-877-916-2271 to get approval before you may fill your prescription.

QL Quantity Limit means you may have coverage for a limited amount of a specific drug.

Specialty Drugs includes drugs for chronic, serious diseases such as hepatitis C, multiple SPRx sclerosis, arthritis, hemophilia and other conditions. Some plans may cover specialty drugs at

different benefit levels or may require the use of a Network Specialty Pharmacy.

Step Therapy is a prior authorization program that requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. Your doctor must ST call Express Scripts at 1-877-916-2271 to request approval for coverage. Please refer to the Step Therapy list included on pages iv-v for drugs that require step therapy.

Some plans do not cover these drugs. Check your Evidence of Coverage guide or Member # Handbook for plan details.

ii

http://bcbst.com

What’s a Drug Tier? Tiers are the different cost levels you pay for a prescription drug. Each tier is assigned a cost (copay, deductible or coinsurance), which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. If you have a high deductible plan, the tier cost levels may apply once you hit your deductible. Check your Evidence of Coverage or member handbook for plan details.

Generic Drugs

Generic Drugs have the same strength and active ingredients as the brand name – but typically are the most affordable and offer you the lowest available copayment or coinsurance. The active ingredient in a generic drug is chemically identical to the active ingredient of the corresponding brand drug. To help lower your out-of-pocket costs, we encourage you to choose a generic medication whenever possible. Look for these drugs under “Tier 1” in this formulary.

Preferred Brand Drugs

Preferred Brand Drugs will usually have a slightly higher copay or coinsurance than generic drugs, but less than a non-preferred brand drug under your plan. These drugs are designated preferred brand because they have been proven to be safe, effective, and more affordable compared to other brand or over-the-counter drugs that treat the same condition. Look for these drugs under “Tier 2” in this formulary.

Non-Preferred Brand Drugs

Non-Preferred Brand Drugs are those that generally have generic alternatives and/ or one or more preferred options within the same drug class. You will usually pay the highest copay or coinsurance for a non-preferred drug under your plan. These drugs are listed as non-preferred because they have not been found to be any more effective than available generics, preferred brands, or over-the-counter drugs. Look for these drugs under “Tier 3” in this formulary.

Tier

1 Tier

2 Tier

3



iii



Step Therapy Requirements Step Therapy is a prior authorization program that requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This chart lists the drugs that require step therapy before your plan will cover the medication.

Step Therapy Drugs Step Therapy Requirements

Edarbi Edarbyclor

Non-preferred diabetic test strips (e.g., Accu-Chek, Freestyle)QL

Xalatan Zioptan

Admelog Admelog SoloStar Apidra Apidra SoloStar Humalog Humalog KwikPen Humalog Junior KwikPen

Humulin

Proventil HFAQL

Ventolin HFAQL

Xopenex HFAQL

Osphena Premarin cream

Trial and failure of a generic Angiotensin II Receptor Blocker (ARB), including candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, valsartan and valsartan-hydrochlorothiazide

Trial and failure of preferred products made by Lifescan (OneTouch)QL or Ascensia (Contour or Breeze2)QL

Trial and failure of latanoprost, Lumigan, or Travatan Z

Trial and failure of Fiasp, Fiasp FlexTouch or Novolog

Trial and failure of Novolin

Trial and failure of ProAir HFAQL or ProAir RespiClickQL

Trial and failure of Estrace 0.01% cream or estradiol 0.01% cream

For certain medical conditions, it is best practice to try a Tier 2 Preferred Drug before your plan will cover a Tier 3 Non-Preferred Drug.

iv

- -



A trial of one or two Preferred Drugs will be required before a Non-Preferred Drug will be covered. Below is a table of Preferred and Non-Preferred Drugs aligned with various medical conditions. Find your condition in the first column of the chart. If there are drugs listed in the second column, this means your doctor must prescribe one of those in order to determine effectiveness prior to prescribing a drug listed in the third or fourth columns.

Tier

2 Tier

3 Tier

3

Medical Condition

Preferred Drug

Non Preferred Drug (directed to ONE Preferred Drug)

Non Preferred Drug (directed to TWO Preferred Drugs)

Rheumatoid ActemraSC

arthritis Enbrel

Humira

Xeljanz/XR

Ankylosing Cosentyx spondylitis Enbrel

Humira

Juvenile Enbrel idiopathic

Humira arthritis

Psoriatic Cosentyx arthritis

Enbrel

Humira

StelaraSC

Psoriasis Cosentyx

Humira

Otezla

StelaraSC

Crohn’s Humira disease StelaraSC

Ulcerative Humira colitis

SC – subcutaneous

OrenciaSC

Otezla

Enbrel*

Tremfya*

Cimzia

SimponiSC

Cimzia

Kevzara

Kineret

OrenciaSC

SimponiSC

Cimzia

SimponiSC

Cimzia

OrenciaSC

SimponiSC

Taltz

Xeljanz/CR

Siliq

Taltz

*For the treatment of Psoriasis, you must try Humira first before Enbrel or Tremfya is approved. Cosentyx, Otezla or StelaraSC don’t meet the requirement for coverage of Enbrel or Tremfya for Psoriasis.

v

Where to Get Your Prescriptions Filled You’ll need to show this card when you have a prescription filled. The card shown is an example. You may have to pay part of the cost for prescription medicines and supplies. Check your Evidence of Coverage or member handbook for specific plan details.

Network Pharmacies The BlueCross pharmacy networks include many retail drug store chains and independent pharmacies across the country. If your medication is not considered a maintenance medication, the prescription is typically written for less than a 30-day supply. (See Retail 90 and Home Delivery Network for information on 90-day supplies).

Always use a network pharmacy. If you use a non-network pharmacy, you must pay all of the costs for your prescription. If you’re out of the state, you can find a pharmacy in the nationwide network. Check your Evidence of Coverage or member handbook for your Pharmacy Network details.

How to find a network pharmacy:

• Call Member Service at the number on the back of your card • Online, go to bcbst.com

Sign up for BlueAccessSM , our secure member portal

Click on Find a Doctor

Click on Pharmacy and select your Pharmacy Network

Or

On bcbst.com, click on Find A Doctor

Click on Pharmacy

Select your Pharmacy Network

RX04



–

–

–

–

–

–

vi

http://bcbst.com

http://bcbst.com

Retail 90 Networks Through Retail 90 Networks you can get up to a 90-day (three-month) supply of your prescriptions.*

• With a three-month supply, you're less likely to miss a dose, which can keep you healthier. Also, you don't have to refill as often, which can save you time and money.

• If you use a pharmacy that’s not part of your Retail 90 Network, you’re limited to a 30-day (one-month) supply.

• These networks are made up of some local pharmacies and drug store chains. Ask your pharmacy if they are part of your Retail 90 Network.

Home Delivery You can sign up for home delivery and have your prescription delivered right to your door. Home Delivery is for prescriptions with a 30-day (one-month) or a 90-day (three-month) supply.* Call 1-877-673-9165 to get started.

With home delivery you get:

• FREE standard shipping**

• Access to a pharmacist 24/7 • Automatic refill reminders so you’re

less likely to miss a dose • Extended Payment Plan available

Specialty Pharmacies Some serious medical conditions need specialty drugs. They may be given at the doctor’s office or at home. Our Specialty Pharmacies are a special network of vendors, experienced in managing these specialty drugs and providing support to you and your doctor. You and your doctor can find a list of Specialty Pharmacies at bcbst.com.

Specialty drugs:

• Usually require a Prior Authorization • Usually are limited to a 30-day supply • Are usually only available from Specialty

Pharmacies who are part of the BlueCross network. Check your Evidence of Coverage or member handbook for your Pharmacy Network details.

*Your doctor will need to write your prescription for a 90-day supply.

**Standard shipping costs are included as part of your pharmacy plan benefit



vii

http://bcbst.com

Talk with your doctor. Doctors are your partners in achieving and maintaining your good health, so discuss every aspect of the prescribed treatment, including the selection of drugs. The more you know, the better your choices.

Ask your doctor to check the drug list before

prescribing a medicine.

Give your doctor a list of all the medicines you take.

Include medicines that don’t need a prescription. This helps them choose medicines that

work well together.

Advertising, social media or the internet may not be your best source of information. Discuss all your concerns

with your doctor.

Ask for generic drugs. The U.S. Food and Drug Administration (FDA) requires generic drugs to have the same quality, strength and purity as brand-name drugs.

• Generic drugs work the same as brand name drugs, but cost less.

• Talk to your doctor about the different kinds of generic drugs.

• The Formulary Drug List has different tiers (levels) of drugs that you can use (see “What’s a Drug Tier?” on page iii).

• You will pay less for generic drugs almost every time.

• Under most BlueCross plans, if you request a brand name drug that has a generic equivalent, you will pay the cost difference between the generic and brand name drug. Check your Evidence of Coverage or member handbook to see if this applies to your plan.

Tips to Remember When Using Your Prescription Drug Benefits



viii

Talk to your pharmacist. Your pharmacist can answer questions about the drugs you take, help you avoid harmful drug interactions, and help you select appropriate, lower-cost generics and preferred brands whenever available.

• Have all of your family’s prescriptions filled at the same pharmacy. • By knowing all your prescriptions, your pharmacist can make sure all of your drugs work

well together. This can help keep you or your family safe.

Use over-the counter (OTC) medicines to save money. • OTC medicines are sold without

a prescription. • Some prescription drugs may not be

covered under your plan because there is an OTC available that works just as well.

• Don’t switch from a prescription drugs to an OTC without talking with your doctor.

Be smart with your prescriptions. • Never share prescription drugs. That

includes not giving drugs prescribed for one family member to another.

• Keep all medicines safe from children. Keep out of sight and out of reach. The best choice is locking them away.

• Don’t stop taking or giving a prescription without talking to the doctor.

• Follow-up with the doctor about any side effects.

Some prescriptions need an approval for coverage. • Some prescriptions require prior

authorization or step therapy. • Network doctors are usually familiar with

these requirements and know how to get authorizations. However, you may want to show this formulary drug list to your doctor – especially if you use an out-of-network doctor or a doctor outside Tennessee.

• There are also limits on the amount of some prescription drugs that your plan will pay for.



ix

6

Drug Name Drug Tier Requirements/Limits

Anti - Infectives Antifungal Agents ANCOBON ORAL CAPSULE Tier 3

clotrimazole mucous membrane troche Tier 1

CRESEMBA ORAL CAPSULE Tier 3

DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

DIFLUCAN ORAL TABLET Tier 3

fluconazole oral suspension for reconstitution Tier 1

fluconazole oral tablet Tier 1

flucytosine oral capsule Tier 1

griseofulvin microsize oral suspension Tier 1

griseofulvin microsize oral tablet Tier 1

griseofulvin ultramicrosize oral tablet Tier 1

GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET

Tier 3

itraconazole oral capsule Tier 1

ketoconazole oral tablet Tier 1

NOXAFIL ORAL SUSPENSION Tier 3

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

nystatin oral powder 150 million unit, 500 million unit

Tier 1

nystatin oral suspension Tier 1

nystatin oral tablet Tier 1

ONMEL ORAL TABLET Tier 3

ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET

Tier 3

SPORANOX ORAL SOLUTION Tier 3

SPORANOX PULSEPAK ORAL CAPSULE Tier 3

terbinafine hcl oral tablet Tier 1

VFEND ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

VFEND ORAL TABLET Tier 3

voriconazole oral suspension for reconstitution Tier 1

7

voriconazole oral tablet Tier 1

Antivirals abacavir oral solution Tier 1

abacavir oral tablet Tier 1

abacavir-lamivudine oral tablet Tier 1 SPRx

abacavir-lamivudine-zidovudine oral tablet Tier 1

acyclovir oral capsule Tier 1

acyclovir oral suspension 200 mg/5 ml Tier 1

acyclovir oral tablet Tier 1

adefovir oral tablet Tier 1

amantadine hcl oral capsule Tier 1

amantadine hcl oral solution Tier 1

amantadine hcl oral tablet Tier 1

APTIVUS ORAL CAPSULE Tier 3

APTIVUS ORAL SOLUTION Tier 3

atazanavir oral capsule Tier 1 SPRx

ATRIPLA ORAL TABLET Tier 3 SPRx

BARACLUDE ORAL SOLUTION Tier 3

BARACLUDE ORAL TABLET Tier 3

BIKTARVY ORAL TABLET Tier 3 SPRx

COMBIVIR ORAL TABLET Tier 3

COMPLERA ORAL TABLET Tier 3 SPRx

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

Tier 3

DESCOVY ORAL TABLET Tier 3 SPRx

didanosine oral capsule,delayed release(dr/ec) Tier 1

EDURANT ORAL TABLET Tier 3

efavirenz oral capsule Tier 1

efavirenz oral tablet Tier 1

EMTRIVA ORAL CAPSULE Tier 3

EMTRIVA ORAL SOLUTION Tier 3

entecavir oral tablet Tier 1

EPCLUSA ORAL TABLET Tier 2 PA; SPRx


8

EPIVIR HBV ORAL SOLUTION Tier 3

EPIVIR HBV ORAL TABLET Tier 3

EPIVIR ORAL SOLUTION Tier 3

EPIVIR ORAL TABLET Tier 3

EPZICOM ORAL TABLET Tier 3 SPRx

EVOTAZ ORAL TABLET Tier 3 SPRx

famciclovir oral tablet Tier 1

FLUMADINE ORAL TABLET Tier 3

FUZEON SUBCUTANEOUS RECON SOLN Tier 3 SPRx

GENVOYA ORAL TABLET Tier 3 SPRx

HARVONI ORAL TABLET Tier 2 PA; SPRx

HEPSERA ORAL TABLET Tier 3

INTELENCE ORAL TABLET Tier 3

INVIRASE ORAL CAPSULE Tier 3

INVIRASE ORAL TABLET Tier 3

ISENTRESS HD ORAL TABLET Tier 3 SPRx

ISENTRESS ORAL POWDER IN PACKET Tier 3 SPRx

ISENTRESS ORAL TABLET Tier 3 SPRx

ISENTRESS ORAL TABLET,CHEWABLE Tier 3 SPRx

JULUCA ORAL TABLET Tier 3 SPRx

KALETRA ORAL SOLUTION Tier 3

KALETRA ORAL TABLET Tier 3

lamivudine oral solution Tier 1

lamivudine oral tablet Tier 1

lamivudine-zidovudine oral tablet Tier 1

LEXIVA ORAL SUSPENSION Tier 3

LEXIVA ORAL TABLET Tier 3

lopinavir-ritonavir oral solution Tier 1

MAVYRET ORAL TABLET Tier 2 PA; SPRx

nevirapine oral suspension Tier 1

nevirapine oral tablet Tier 1

nevirapine oral tablet extended release 24 hr Tier 1

NORVIR ORAL CAPSULE Tier 3


9

NORVIR ORAL SOLUTION Tier 3

NORVIR ORAL TABLET Tier 3

ODEFSEY ORAL TABLET Tier 3 SPRx

oseltamivir oral capsule 30 mg Tier 1 QL (20 EA per 180 days)

oseltamivir oral capsule 45 mg, 75 mg Tier 1 QL (10 EA per 180 days)

oseltamivir oral suspension for reconstitution Tier 1 QL (180 ML per 180 days)

PREZCOBIX ORAL TABLET Tier 3 SPRx

PREZISTA ORAL SUSPENSION Tier 3 SPRx

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

Tier 3 SPRx

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

Tier 3 QL (20 EA per 180 days)

RESCRIPTOR ORAL TABLET Tier 3

RESCRIPTOR ORAL TABLET, DISPERSIBLE

Tier 3

RETROVIR ORAL CAPSULE Tier 3

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

Tier 3 SPRx

REYATAZ ORAL POWDER IN PACKET Tier 3 SPRx

rimantadine oral tablet Tier 1

SELZENTRY ORAL SOLUTION Tier 3

SELZENTRY ORAL TABLET Tier 3

SOVALDI ORAL TABLET Tier 2 PA; SPRx

stavudine oral capsule Tier 1

stavudine oral recon soln Tier 1

STRIBILD ORAL TABLET Tier 3 SPRx

SUSTIVA ORAL CAPSULE Tier 3

SUSTIVA ORAL TABLET Tier 3

TAMIFLU ORAL CAPSULE 30 MG Tier 3 QL (20 EA per 180 days)

TAMIFLU ORAL CAPSULE 45 MG, 75 MG Tier 3 QL (10 EA per 180 days)

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION

Tier 3 QL (180 ML per 180 days)

tenofovir disoproxil fumarate oral tablet Tier 1

TIVICAY ORAL TABLET Tier 3 SPRx

TRIUMEQ ORAL TABLET Tier 3 SPRx


10

TRIZIVIR ORAL TABLET Tier 3

TRUVADA ORAL TABLET Tier 3 SPRx

TYBOST ORAL TABLET Tier 3

valacyclovir oral tablet Tier 1

VALCYTE ORAL RECON SOLN Tier 3

VALCYTE ORAL TABLET Tier 3

valganciclovir oral recon soln Tier 1

valganciclovir oral tablet Tier 1

VALTREX ORAL TABLET Tier 3

VEMLIDY ORAL TABLET Tier 3 SPRx

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN

Tier 3

VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 3

VIRACEPT ORAL TABLET Tier 3

VIRAMUNE ORAL SUSPENSION Tier 3

VIRAMUNE ORAL TABLET Tier 3

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

VIRAZOLE INHALATION RECON SOLN Tier 3

VIREAD ORAL POWDER Tier 3

VIREAD ORAL TABLET Tier 3

VOSEVI ORAL TABLET Tier 2 PA

ZERIT ORAL CAPSULE Tier 3

ZERIT ORAL RECON SOLN Tier 3

ZIAGEN ORAL SOLUTION Tier 3

ZIAGEN ORAL TABLET Tier 3

zidovudine oral capsule Tier 1

zidovudine oral syrup Tier 1

zidovudine oral tablet Tier 1

ZOVIRAX ORAL CAPSULE Tier 3

ZOVIRAX ORAL SUSPENSION Tier 3

ZOVIRAX ORAL TABLET Tier 3

Cephalosporins


11

cefaclor oral capsule Tier 1

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

Tier 1

cefaclor oral tablet extended release 12 hr Tier 1

cefadroxil oral capsule Tier 1

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

Tier 1

cefadroxil oral tablet Tier 1

cefdinir oral capsule Tier 1

cefdinir oral suspension for reconstitution Tier 1

cefditoren pivoxil oral tablet Tier 1

cefixime oral suspension for reconstitution Tier 1

cefpodoxime oral suspension for reconstitution Tier 1

cefpodoxime oral tablet Tier 1

cefprozil oral suspension for reconstitution Tier 1

cefprozil oral tablet Tier 1

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

cefuroxime axetil oral tablet Tier 1

cephalexin oral capsule Tier 1

cephalexin oral suspension for reconstitution Tier 1

cephalexin oral tablet Tier 1

SUPRAX ORAL CAPSULE Tier 3

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

SUPRAX ORAL TABLET,CHEWABLE Tier 3

Erythromycins & Other Macrolides azithromycin oral packet Tier 1

azithromycin oral suspension for reconstitution Tier 1

azithromycin oral tablet Tier 1

clarithromycin oral suspension for reconstitution Tier 1

clarithromycin oral tablet Tier 1

clarithromycin oral tablet extended release 24 hr Tier 1

DIFICID ORAL TABLET Tier 3


12

e.e.s. 400 oral tablet Tier 1

E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

Tier 1

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

Tier 3

erythrocin (as stearate) oral tablet 250 mg Tier 1

erythromycin ethylsuccinate oral tablet Tier 1

erythromycin oral capsule,delayed release(dr/ec) Tier 1

erythromycin oral tablet Tier 1

PCE ORAL TABLET, PARTICLES/CRYSTALS

Tier 3

ZITHROMAX ORAL PACKET Tier 3

ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ZITHROMAX ORAL TABLET Tier 3

ZMAX ORAL SUSPENSION,EXTENDED REL RECON

Tier 3

Miscellaneous Antiinfectives ALBENZA ORAL TABLET Tier 3

ALINIA ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ALINIA ORAL TABLET Tier 3

atovaquone oral suspension Tier 1

atovaquone-proguanil oral tablet Tier 1

BILTRICIDE ORAL TABLET Tier 3

CAYSTON INHALATION SOLUTION FOR NEBULIZATION

Tier 3 PA; LD; SPRx

chloroquine phosphate oral tablet Tier 1

CLEOCIN HCL ORAL CAPSULE Tier 3


13

CLEOCIN PEDIATRIC ORAL RECON SOLN

Tier 3

clindamycin hcl oral capsule Tier 1

clindamycin palmitate hcl oral recon soln Tier 1

clindamycin pediatric oral recon soln Tier 1

COARTEM ORAL TABLET Tier 3

CYCLOSERINE ORAL CAPSULE Tier 3

DARAPRIM ORAL TABLET Tier 3 PA; LD; SPRx

ethambutol oral tablet Tier 1

FLAGYL ORAL CAPSULE Tier 3

FLAGYL ORAL TABLET Tier 3

hydroxychloroquine oral tablet Tier 1

isoniazid oral solution Tier 1

isoniazid oral tablet Tier 1

ivermectin oral tablet Tier 1

KITABIS PAK INHALATION SOLUTION FOR NEBULIZATION

Tier 2 LD; SPRx; QL (56 ML per 30 days)

linezolid oral suspension for reconstitution Tier 1 QL (14 day supply per 30 days)

linezolid oral tablet Tier 1 QL (14 day supply per 30 days)

MALARONE ORAL TABLET Tier 3

MALARONE PEDIATRIC ORAL TABLET Tier 3

mefloquine oral tablet Tier 1

MEPRON ORAL SUSPENSION Tier 3

metronidazole oral capsule Tier 1

metronidazole oral tablet Tier 1

MYAMBUTOL ORAL TABLET 400 MG Tier 3

MYCOBUTIN ORAL CAPSULE Tier 3

NEBUPENT INHALATION RECON SOLN Tier 3

neomycin oral tablet Tier 1

paromomycin oral capsule Tier 1

PASER ORAL GRANULES DR FOR SUSP IN PACKET

Tier 3

PLAQUENIL ORAL TABLET Tier 3

PRIFTIN ORAL TABLET Tier 3


14

PRIMAQUINE ORAL TABLET Tier 3

pyrazinamide oral tablet Tier 1

QUALAQUIN ORAL CAPSULE Tier 3

quinine sulfate oral capsule Tier 1

rifabutin oral capsule Tier 1

RIFADIN ORAL CAPSULE Tier 3

RIFAMATE ORAL CAPSULE Tier 3

rifampin oral capsule Tier 1

RIFATER ORAL TABLET Tier 3

SIRTURO ORAL TABLET Tier 3 LD; SPRx

STROMECTOL ORAL TABLET Tier 3

TINDAMAX ORAL TABLET 500 MG Tier 3

tinidazole oral tablet Tier 1

TOBI INHALATION SOLUTION FOR NEBULIZATION

Tier 3 SPRx; QL (56 ML per 30 days)

tobramycin in 0.225 % nacl inhalation solution for nebulization

Tier 1 SPRx; QL (56 ML per 30 days)

TRECATOR ORAL TABLET Tier 3

XIFAXAN ORAL TABLET 200 MG Tier 3

XIFAXAN ORAL TABLET 550 MG Tier 2

ZYVOX ORAL SUSPENSION FOR RECONSTITUTION

Tier 3 QL (14 day supply per 30 days)

ZYVOX ORAL TABLET Tier 3 QL (14 day supply per 30 days)

Penicillins amoxicillin oral capsule Tier 1

amoxicillin oral suspension for reconstitution Tier 1

amoxicillin oral tablet Tier 1

amoxicillin oral tablet,chewable 125 mg, 250 mg Tier 1

amoxicillin-pot clavulanate oral suspension for reconstitution

Tier 1

amoxicillin-pot clavulanate oral tablet Tier 1

amoxicillin-pot clavulanate oral tablet extended release 12 hr

Tier 1

amoxicillin-pot clavulanate oral tablet,chewable Tier 1

ampicillin oral capsule Tier 1


15

AUGMENTIN ES-600 ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML, 250-62.5 MG/5 ML

Tier 3

AUGMENTIN ORAL TABLET 500-125 MG, 875-125 MG

Tier 3

AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

dicloxacillin oral capsule Tier 1

penicillin v potassium oral recon soln Tier 1

penicillin v potassium oral tablet Tier 1

Quinolones AVELOX ORAL TABLET Tier 3

CIPRO ORAL SUSPENSION,MICROCAPSULE RECON

Tier 3

CIPRO ORAL TABLET 250 MG, 500 MG Tier 3

CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR

Tier 3

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr

Tier 1

ciprofloxacin hcl oral tablet Tier 1

ciprofloxacin oral suspension,microcapsule recon Tier 1

FACTIVE ORAL TABLET Tier 3

LEVAQUIN ORAL TABLET Tier 3

levofloxacin oral solution Tier 1

levofloxacin oral tablet Tier 1

moxifloxacin oral tablet Tier 1

ofloxacin oral tablet 300 mg, 400 mg Tier 1

Sulfa's & Related Agents BACTRIM DS ORAL TABLET Tier 3

BACTRIM ORAL TABLET Tier 3

sulfadiazine oral tablet Tier 1

sulfamethoxazole-trimethoprim oral suspension Tier 1

sulfamethoxazole-trimethoprim oral tablet Tier 1


16

sulfatrim oral suspension Tier 1

Tetracyclines avidoxy oral tablet Tier 1

demeclocycline oral tablet Tier 1

doxycycline hyclate oral capsule Tier 1

doxycycline hyclate oral tablet 100 mg, 20 mg Tier 1

doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg

Tier 1

doxycycline monohydrate oral capsule Tier 1

doxycycline monohydrate oral suspension for reconstitution

Tier 1

doxycycline monohydrate oral tablet Tier 1

minocycline oral capsule Tier 1

minocycline oral tablet Tier 1

tetracycline oral capsule Tier 1

VIBRAMYCIN ORAL CAPSULE 100 MG Tier 3

VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

VIBRAMYCIN ORAL SYRUP Tier 3

Urinary Tract Agents FURADANTIN ORAL SUSPENSION Tier 3

HIPREX ORAL TABLET Tier 3

MACROBID ORAL CAPSULE Tier 3

MACRODANTIN ORAL CAPSULE Tier 3

methenamine hippurate oral tablet Tier 1

methenamine mandelate oral tablet Tier 1

MONUROL ORAL PACKET Tier 3

nitrofurantoin macrocrystal oral capsule Tier 1

nitrofurantoin monohyd/m-cryst oral capsule Tier 1

nitrofurantoin oral suspension Tier 1

PRIMSOL ORAL SOLUTION Tier 3

trimethoprim oral tablet Tier 1

Vancomycin VANCOCIN ORAL CAPSULE Tier 3


17

vancomycin oral capsule Tier 1


Antineoplastic & Immunosuppressant Drugs Adjunctive Agents leucovorin calcium oral tablet Tier 1

MESNEX ORAL TABLET Tier 3

Antineoplastic & Immunosuppressant Drugs AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION

Tier 3 PA; SPRx

AFINITOR ORAL TABLET Tier 3 PA; SPRx

ALECENSA ORAL CAPSULE Tier 3 PA; LD; SPRx

ALKERAN ORAL TABLET Tier 3

ALUNBRIG ORAL TABLET Tier 3 PA; SPRx

ALUNBRIG ORAL TABLETS,DOSE PACK Tier 3 PA; SPRx

anastrozole oral tablet Tier 1

ARIMIDEX ORAL TABLET Tier 3

AROMASIN ORAL TABLET Tier 3

ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3 SPRx

AZASAN ORAL TABLET Tier 3

azathioprine oral tablet Tier 1

bexarotene oral capsule Tier 1 SPRx

bicalutamide oral tablet Tier 1

BOSULIF ORAL TABLET Tier 3 PA; LD; SPRx

CABOMETYX ORAL TABLET Tier 3 PA; LD; SPRx

CALQUENCE ORAL CAPSULE Tier 3 PA; SPRx

capecitabine oral tablet Tier 1 SPRx

CAPRELSA ORAL TABLET Tier 3 PA; LD; SPRx

CASODEX ORAL TABLET Tier 3

CELLCEPT ORAL CAPSULE Tier 3

CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

COMETRIQ ORAL CAPSULE Tier 3 LD; SPRx

COTELLIC ORAL TABLET Tier 3 PA; LD; SPRx

CYCLOPHOSPHAMIDE ORAL CAPSULE Tier 3

18

cyclosporine modified oral capsule Tier 1

cyclosporine modified oral solution Tier 1

cyclosporine oral capsule Tier 1

DROXIA ORAL CAPSULE Tier 3

EMCYT ORAL CAPSULE Tier 3

ERIVEDGE ORAL CAPSULE Tier 3 PA; LD; SPRx

etoposide oral capsule Tier 1

exemestane oral tablet Tier 1

FARESTON ORAL TABLET Tier 3

FARYDAK ORAL CAPSULE Tier 3 PA; LD; SPRx

FEMARA ORAL TABLET Tier 3

flutamide oral capsule Tier 1

gengraf oral capsule Tier 1

gengraf oral solution Tier 1

GILOTRIF ORAL TABLET Tier 3 PA; LD; SPRx

GLEEVEC ORAL TABLET Tier 3 SPRx

GLEOSTINE ORAL CAPSULE Tier 3

HEXALEN ORAL CAPSULE Tier 3

HYCAMTIN ORAL CAPSULE Tier 3 SPRx

HYDREA ORAL CAPSULE Tier 3

hydroxyurea oral capsule Tier 1

IBRANCE ORAL CAPSULE Tier 3 PA; LD; SPRx

ICLUSIG ORAL TABLET Tier 3 PA; LD; SPRx

IDHIFA ORAL TABLET Tier 3 PA; SPRx

imatinib oral tablet Tier 1 SPRx

IMBRUVICA ORAL CAPSULE Tier 3 PA; LD; SPRx

IMBRUVICA ORAL TABLET Tier 3 PA; LD; SPRx

IMURAN ORAL TABLET Tier 3

INLYTA ORAL TABLET Tier 3 PA; LD; SPRx

IRESSA ORAL TABLET Tier 3 PA; LD; SPRx

JAKAFI ORAL TABLET Tier 3 PA; LD; SPRx

KISQALI FEMARA CO-PACK ORAL TABLET

Tier 3 PA; SPRx


19

KISQALI ORAL TABLET Tier 3 PA; SPRx

LENVIMA ORAL CAPSULE Tier 3 PA; LD; SPRx

letrozole oral tablet Tier 1

LEUKERAN ORAL TABLET Tier 2

leuprolide subcutaneous kit Tier 1 PA; SPRx

LONSURF ORAL TABLET Tier 3 PA; LD; SPRx

LYNPARZA ORAL CAPSULE Tier 3 PA; LD; SPRx

LYNPARZA ORAL TABLET Tier 3 PA; SPRx

LYSODREN ORAL TABLET Tier 3

MATULANE ORAL CAPSULE Tier 3 SPRx

MEGACE ES ORAL SUSPENSION Tier 3

megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml

Tier 1

megestrol oral tablet Tier 1

MEKINIST ORAL TABLET Tier 3 PA; SPRx

melphalan oral tablet Tier 1

mercaptopurine oral tablet Tier 1

methotrexate sodium (pf) injection recon soln Tier 1

methotrexate sodium (pf) injection solution Tier 1

methotrexate sodium injection solution Tier 1

methotrexate sodium oral tablet Tier 1

mycophenolate mofetil oral capsule Tier 1

mycophenolate mofetil oral suspension for reconstitution

Tier 1

mycophenolate mofetil oral tablet Tier 1

mycophenolate sodium oral tablet,delayed release (dr/ec)

Tier 1

MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

MYLERAN ORAL TABLET Tier 3

NEORAL ORAL CAPSULE Tier 3

NEORAL ORAL SOLUTION Tier 3

NERLYNX ORAL TABLET Tier 3 PA; SPRx

NEXAVAR ORAL TABLET Tier 3 PA; LD; SPRx


20

NILANDRON ORAL TABLET Tier 3 SPRx

nilutamide oral tablet Tier 1 SPRx

NINLARO ORAL CAPSULE Tier 3 PA; LD; SPRx

octreotide acetate injection solution Tier 1 SPRx

octreotide acetate injection syringe Tier 1 SPRx

ODOMZO ORAL CAPSULE Tier 3 PA; SPRx

PROGRAF ORAL CAPSULE Tier 3

PURIXAN ORAL SUSPENSION Tier 3 SPRx

RAPAMUNE ORAL SOLUTION Tier 3

RAPAMUNE ORAL TABLET Tier 3

RUBRACA ORAL TABLET Tier 3 PA; LD; SPRx

RYDAPT ORAL CAPSULE Tier 3 PA; SPRx

SANDIMMUNE ORAL CAPSULE Tier 3

SANDIMMUNE ORAL SOLUTION Tier 3

SANDOSTATIN INJECTION SOLUTION Tier 3 SPRx

SIGNIFOR SUBCUTANEOUS SOLUTION Tier 3 PA; LD; SPRx

sirolimus oral tablet Tier 1

SOLTAMOX ORAL SOLUTION Tier 3 ACA

SPRYCEL ORAL TABLET Tier 3 SPRx

STIVARGA ORAL TABLET Tier 3 PA; LD; SPRx

SUTENT ORAL CAPSULE Tier 3 PA; LD; SPRx

TABLOID ORAL TABLET Tier 3

tacrolimus oral capsule Tier 1

TAFINLAR ORAL CAPSULE Tier 3 PA; LD; SPRx

TAGRISSO ORAL TABLET Tier 3 PA; LD; SPRx

tamoxifen oral tablet Tier 1 ACA

TARCEVA ORAL TABLET Tier 3 PA; LD; SPRx

TARGRETIN ORAL CAPSULE Tier 3 SPRx

TARGRETIN TOPICAL GEL Tier 3 SPRx

TASIGNA ORAL CAPSULE Tier 3 SPRx

TEMODAR ORAL CAPSULE Tier 3 PA; SPRx

temozolomide oral capsule Tier 1 PA; SPRx

THALOMID ORAL CAPSULE Tier 3 PA; LD; SPRx


21

tretinoin (chemotherapy) oral capsule Tier 1

TREXALL ORAL TABLET Tier 3

TYKERB ORAL TABLET Tier 3 PA; LD; SPRx

VENCLEXTA ORAL TABLET Tier 3 PA; LD; SPRx

VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK

Tier 3 PA; LD; SPRx

VERZENIO ORAL TABLET Tier 3 PA; SPRx

VOTRIENT ORAL TABLET Tier 3 PA; LD; SPRx

XALKORI ORAL CAPSULE Tier 3 PA; LD; SPRx

XELODA ORAL TABLET Tier 3 SPRx

XERMELO ORAL TABLET Tier 3 PA; SPRx

XTANDI ORAL CAPSULE Tier 3 LD; SPRx

ZEJULA ORAL CAPSULE Tier 3 PA; LD; SPRx

ZELBORAF ORAL TABLET Tier 3 PA; LD; SPRx

ZOLINZA ORAL CAPSULE Tier 3 SPRx

ZORTRESS ORAL TABLET Tier 3 SPRx

ZYDELIG ORAL TABLET Tier 3 PA; SPRx

ZYKADIA ORAL CAPSULE Tier 3 PA; SPRx

ZYTIGA ORAL TABLET Tier 3 SPRx


Autonomic & CNS Drugs, Neurology & Psych Agents for Narcotic Withdrawal BUNAVAIL BUCCAL FILM Tier 2 QL (90 EA per 30 days)

buprenorphine-naloxone sublingual tablet Tier 1 QL (90 EA per 30 days)

SUBOXONE SUBLINGUAL FILM Tier 2 QL (90 EA per 30 days)

ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 5.7-1.4 MG


Anticonvulsants APTIOM ORAL TABLET Tier 3

BANZEL ORAL SUSPENSION Tier 3

BANZEL ORAL TABLET Tier 3

carbamazepine oral capsule, er multiphase 12 hr Tier 1

carbamazepine oral suspension 100 mg/5 ml Tier 1

carbamazepine oral tablet Tier 1

22

carbamazepine oral tablet extended release 12 hr Tier 1

carbamazepine oral tablet,chewable Tier 1

CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR

Tier 3

CELONTIN ORAL CAPSULE 300 MG Tier 3

clonazepam oral tablet Tier 1

clonazepam oral tablet,disintegrating Tier 1

DEPAKENE ORAL CAPSULE Tier 3

DEPAKENE ORAL SOLUTION Tier 3

DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE

Tier 3

DIASTAT ACUDIAL RECTAL KIT Tier 3

DIASTAT RECTAL KIT Tier 3

diazepam rectal kit Tier 1

DILANTIN EXTENDED ORAL CAPSULE Tier 2

DILANTIN INFATABS ORAL TABLET,CHEWABLE

Tier 2

DILANTIN ORAL CAPSULE Tier 2

DILANTIN-125 ORAL SUSPENSION Tier 2

divalproex oral capsule, delayed rel sprinkle Tier 1

divalproex oral tablet extended release 24 hr Tier 1

divalproex oral tablet,delayed release (dr/ec) Tier 1

epitol oral tablet Tier 1

EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR

Tier 3

ethosuximide oral capsule Tier 1

ethosuximide oral solution Tier 1

felbamate oral suspension Tier 1

felbamate oral tablet Tier 1

FELBATOL ORAL SUSPENSION Tier 3

FELBATOL ORAL TABLET Tier 3


23

FYCOMPA ORAL TABLET Tier 3

gabapentin oral capsule Tier 1

gabapentin oral solution 250 mg/5 ml Tier 1

gabapentin oral tablet 600 mg, 800 mg Tier 1

GABITRIL ORAL TABLET Tier 3

KEPPRA ORAL SOLUTION Tier 3

KEPPRA ORAL TABLET Tier 3

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

KLONOPIN ORAL TABLET Tier 3

LAMICTAL ODT ORAL TABLET,DISINTEGRATING

Tier 3

LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK

Tier 3

LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK

Tier 3

LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK

Tier 3

LAMICTAL ORAL TABLET Tier 3

LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG

Tier 3

LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK

Tier 3

LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK

Tier 3

LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK

Tier 3

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR

Tier 3

LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK

Tier 3

LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK

Tier 3

LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK

Tier 3


24

lamotrigine oral tablet Tier 1

lamotrigine oral tablet disintegrating, dose pk Tier 1

lamotrigine oral tablet extended release 24hr Tier 1

lamotrigine oral tablet, chewable dispersible Tier 1

lamotrigine oral tablet,disintegrating Tier 1

levetiracetam oral solution Tier 1

levetiracetam oral tablet Tier 1

levetiracetam oral tablet extended release 24 hr Tier 1

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 2

LYRICA ORAL CAPSULE Tier 2

LYRICA ORAL SOLUTION Tier 2

MYSOLINE ORAL TABLET Tier 3

NEURONTIN ORAL CAPSULE Tier 3

NEURONTIN ORAL SOLUTION Tier 3

NEURONTIN ORAL TABLET Tier 3

ONFI ORAL SUSPENSION Tier 3

ONFI ORAL TABLET 10 MG, 20 MG Tier 3

oxcarbazepine oral suspension Tier 1

oxcarbazepine oral tablet Tier 1

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 2

PEGANONE ORAL TABLET Tier 3

phenobarbital oral elixir Tier 1

phenobarbital oral tablet Tier 1

PHENYTEK ORAL CAPSULE Tier 3

phenytoin oral suspension 125 mg/5 ml Tier 1

phenytoin oral tablet,chewable Tier 1

phenytoin sodium extended oral capsule Tier 1

primidone oral tablet Tier 1

QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR

Tier 2

roweepra oral tablet Tier 1

roweepra xr oral tablet extended release 24 hr Tier 1


25

SABRIL ORAL POWDER IN PACKET Tier 3 LD

SABRIL ORAL TABLET Tier 3 LD

SPRITAM ORAL TABLET FOR SUSPENSION

Tier 3

TEGRETOL ORAL SUSPENSION Tier 3

TEGRETOL ORAL TABLET Tier 3

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

tiagabine oral tablet Tier 1

TOPAMAX ORAL CAPSULE, SPRINKLE Tier 3

TOPAMAX ORAL TABLET Tier 3

topiramate oral capsule, sprinkle Tier 1

TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR

Tier 3

topiramate oral tablet Tier 1

TRILEPTAL ORAL SUSPENSION Tier 3

TRILEPTAL ORAL TABLET Tier 3

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 2

valproic acid (as sodium salt) oral solution 250 mg/5 ml

Tier 1

valproic acid oral capsule Tier 1

vigabatrin oral powder in packet Tier 1

VIMPAT ORAL SOLUTION Tier 2

VIMPAT ORAL TABLET Tier 2

ZARONTIN ORAL CAPSULE Tier 3

ZARONTIN ORAL SOLUTION Tier 3

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG

Tier 3

zonisamide oral capsule Tier 1

Antiparkinsonism Agents APOKYN SUBCUTANEOUS CARTRIDGE Tier 3 SPRx

AZILECT ORAL TABLET Tier 3

benztropine oral tablet Tier 1

bromocriptine oral capsule Tier 1


26

bromocriptine oral tablet Tier 1

carbidopa oral tablet Tier 1

carbidopa-levodopa oral tablet Tier 1

carbidopa-levodopa oral tablet extended release Tier 1

carbidopa-levodopa oral tablet,disintegrating Tier 1

carbidopa-levodopa-entacapone oral tablet Tier 1

COMTAN ORAL TABLET Tier 3

DUOPA J-TUBE INTESTINAL PUMP SUSPENSION

Tier 3 LD; SPRx

ELDEPRYL ORAL CAPSULE Tier 3

entacapone oral tablet Tier 1

LODOSYN ORAL TABLET Tier 3

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

MIRAPEX ORAL TABLET Tier 3

NEUPRO TRANSDERMAL PATCH 24 HOUR

Tier 3

PARLODEL ORAL CAPSULE Tier 3

PARLODEL ORAL TABLET Tier 3

pramipexole oral tablet Tier 1

pramipexole oral tablet extended release 24 hr Tier 1

rasagiline oral tablet Tier 1

REQUIP ORAL TABLET Tier 3

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

ropinirole oral tablet Tier 1

ropinirole oral tablet extended release 24 hr Tier 1

selegiline hcl oral capsule Tier 1

selegiline hcl oral tablet Tier 1

SINEMET CR ORAL TABLET EXTENDED RELEASE

Tier 3

SINEMET ORAL TABLET Tier 3

STALEVO 100 ORAL TABLET Tier 3




27




TASMAR ORAL TABLET 100 MG Tier 3

tolcapone oral tablet Tier 1

trihexyphenidyl oral elixir Tier 1

trihexyphenidyl oral tablet Tier 1

ZELAPAR ORAL TABLET,DISINTEGRATING

Tier 3

Migraine & Cluster Headache Therapy almotriptan malate oral tablet Tier 1 QL (18 EA per 30 days)

ALSUMA SUBCUTANEOUS PEN INJECTOR Tier 3 QL (8 ML per 30 days)

AMERGE ORAL TABLET Tier 3 QL (18 EA per 30 days)

CAFERGOT ORAL TABLET Tier 3

D.H.E.45 INJECTION SOLUTION Tier 3

dihydroergotamine injection solution Tier 1

dihydroergotamine nasal spray,non-aerosol Tier 1 QL (8 ML per 30 days)

eletriptan hbr oral tablet Tier 1 QL (18 EA per 30 days)

ERGOMAR SUBLINGUAL TABLET Tier 3

frovatriptan oral tablet Tier 1 QL (18 EA per 30 days)

IMITREX NASAL SPRAY,NON-AEROSOL Tier 3 QL (12 EA per 30 days)

IMITREX ORAL TABLET Tier 3 QL (18 EA per 30 days)

IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 4 MG/0.5 ML


IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML


IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML


IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 6 MG/0.5 ML


IMITREX SUBCUTANEOUS SOLUTION Tier 3 QL (8 ML per 30 days)

isometh-dichloral-acetaminophn oral capsule Tier 1


28

isomethepten-caf-acetaminophen oral tablet 65-20-325 mg

Tier 1

migergot rectal suppository Tier 1

MIGRANAL NASAL SPRAY,NON-AEROSOL


naratriptan oral tablet Tier 1 QL (18 EA per 30 days)

RELPAX ORAL TABLET Tier 3 QL (18 EA per 30 days)

rizatriptan oral tablet Tier 1 QL (18 EA per 30 days)

rizatriptan oral tablet,disintegrating Tier 1 QL (18 EA per 30 days)

sumatriptan nasal spray,non-aerosol Tier 1 QL (12 EA per 30 days)

sumatriptan succinate oral tablet Tier 1 QL (18 EA per 30 days)

sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml


sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml


sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml


sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml


sumatriptan succinate subcutaneous solution Tier 1 QL (8 ML per 30 days)

SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML


SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML


zolmitriptan oral tablet Tier 1 QL (18 EA per 30 days)

zolmitriptan oral tablet,disintegrating Tier 1 QL (18 EA per 30 days)

Miscellaneous Neurological Therapy AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR

Tier 2 PA; SPRx

ARICEPT ORAL TABLET Tier 3

AUSTEDO ORAL TABLET Tier 3 PA; LD; SPRx

donepezil oral tablet Tier 1

donepezil oral tablet,disintegrating Tier 1

galantamine oral capsule,ext rel. pellets 24 hr Tier 1

galantamine oral solution Tier 1

galantamine oral tablet Tier 1


29

HORIZANT ORAL TABLET EXTENDED RELEASE

Tier 3

KEVEYIS ORAL TABLET Tier 3 PA; LD; SPRx

memantine oral capsule,sprinkle,er 24hr Tier 1

memantine oral solution Tier 1

memantine oral tablet Tier 1

MEMANTINE ORAL TABLETS,DOSE PACK

Tier 3

NAMENDA ORAL TABLET Tier 3

NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK

Tier 3

NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK

Tier 2

NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR

Tier 2

NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR

Tier 2

NUEDEXTA ORAL CAPSULE Tier 3

RAZADYNE ER ORAL CAPSULE,EXT REL. PELLETS 24 HR

Tier 3

RAZADYNE ORAL TABLET Tier 3

rivastigmine tartrate oral capsule Tier 1

rivastigmine transdermal patch 24 hour Tier 1

tetrabenazine oral tablet Tier 1 PA; SPRx

XENAZINE ORAL TABLET Tier 3 PA; SPRx

Muscle Relaxants & Antispasmodic Therapy baclofen oral tablet Tier 1

carisoprodol oral tablet Tier 1

carisoprodol-asa-codeine oral tablet Tier 1

carisoprodol-aspirin oral tablet Tier 1

chlorzoxazone oral tablet 500 mg Tier 1

cyclobenzaprine oral tablet Tier 1

DANTRIUM ORAL CAPSULE 25 MG, 50 MG Tier 3

dantrolene oral capsule Tier 1

FEXMID ORAL TABLET Tier 3


30

meprobamate oral tablet Tier 1

MESTINON ORAL SYRUP Tier 3

MESTINON ORAL TABLET Tier 3

MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE

Tier 3

metaxalone oral tablet 800 mg Tier 1

methocarbamol oral tablet Tier 1

orphenadrine citrate oral tablet extended release Tier 1

pyridostigmine bromide oral tablet Tier 1

pyridostigmine bromide oral tablet extended release

Tier 1

ROBAXIN ORAL TABLET Tier 3

ROBAXIN-750 ORAL TABLET Tier 3

SKELAXIN ORAL TABLET Tier 3

SOMA ORAL TABLET Tier 3

tizanidine oral capsule Tier 1

tizanidine oral tablet Tier 1

ZANAFLEX ORAL CAPSULE Tier 3

ZANAFLEX ORAL TABLET Tier 3

Narcotic Analgesics ABSTRAL SUBLINGUAL TABLET Tier 3 QL (9 EA per 30 days)

acetaminophen-caff-dihydrocod oral capsule Tier 1 QL (120 EA per 30 days)

acetaminophen-codeine oral solution 120-12 mg/5 ml


acetaminophen-codeine oral tablet Tier 1 QL (180 EA per 30 days)

ACTIQ BUCCAL LOZENGE ON A HANDLE 1,200 MCG


ACTIQ BUCCAL LOZENGE ON A HANDLE 1,600 MCG


ACTIQ BUCCAL LOZENGE ON A HANDLE 200 MCG







31



ascomp with codeine oral capsule Tier 1 QL (120 EA per 30 days)

BUPAP ORAL TABLET 50-300 MG Tier 3 QL (120 EA per 30 days)

butalbital compound w/codeine oral capsule Tier 1 QL (120 EA per 30 days)

butalbital-acetaminop-caf-cod oral capsule Tier 1 QL (120 EA per 30 days)

butalbital-acetaminophen oral tablet Tier 1 QL (120 EA per 30 days)

butalbital-acetaminophen-caff oral capsule Tier 1 QL (120 EA per 30 days)

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


butalbital-aspirin-caffeine oral capsule Tier 1 QL (120 EA per 30 days)

butalbital-aspirin-caffeine oral tablet Tier 1 QL (120 EA per 30 days)

butorphanol tartrate nasal spray,non-aerosol Tier 1 QL (5 ML per 28 days)

BUTRANS TRANSDERMAL PATCH WEEKLY

Tier 2 PA; QL (4 EA per 28 days)

capacet oral capsule Tier 1 QL (120 EA per 30 days)

CAPITAL WITH CODEINE ORAL SUSPENSION

Tier 3

codeine sulfate oral tablet Tier 1 QL (180 EA per 30 days)

codeine-butalbital-asa-caff oral capsule Tier 1 QL (120 EA per 30 days)

DEMEROL ORAL TABLET 100 MG Tier 3 QL (120 EA per 30 days)

DILAUDID ORAL LIQUID Tier 3 QL (30 ML per 30 days)

DILAUDID ORAL TABLET Tier 3 QL (120 EA per 30 days)

diskets oral tablet,soluble Tier 1 PA; QL (50 EA per 30 days)

DOLOPHINE ORAL TABLET Tier 3 PA; QL (120 EA per 30 days)

DURAGESIC TRANSDERMAL PATCH 72 HOUR


endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg


ESGIC ORAL CAPSULE Tier 3 QL (120 EA per 30 days)

ESGIC ORAL TABLET Tier 3 QL (120 EA per 30 days)

fentanyl citrate buccal lozenge on a handle 1,200 mcg


fentanyl citrate buccal lozenge on a handle 1,600 mcg



32

fentanyl citrate buccal lozenge on a handle 200 mcg








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


FENTORA BUCCAL TABLET, EFFERVESCENT


FIORICET ORAL CAPSULE Tier 3 QL (120 EA per 30 days)

FIORINAL ORAL CAPSULE Tier 3 QL (120 EA per 30 days)

FIORINAL-CODEINE #3 ORAL CAPSULE Tier 3 QL (120 EA per 30 days)

HYCET ORAL SOLUTION Tier 3 QL (5550 ML per 30 days)

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml


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


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


hydromorphone oral liquid Tier 1 QL (30 ML per 30 days)

hydromorphone oral tablet Tier 1 QL (120 EA per 30 days)

hydromorphone rectal suppository Tier 1 QL (60 EA per 30 days)

IBUDONE ORAL TABLET Tier 3 QL (120 EA per 30 days)

ibuprofen-oxycodone oral tablet Tier 1 QL (28 EA per 30 days)

KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG


levorphanol tartrate oral tablet Tier 1 QL (120 EA per 30 days)

lorcet (hydrocodone) oral tablet Tier 1 QL (120 EA per 30 days)

lorcet hd oral tablet Tier 1 QL (120 EA per 30 days)

lorcet plus oral tablet 7.5-325 mg Tier 1 QL (120 EA per 30 days)


33

LORTAB ELIXIR ORAL SOLUTION 10-300 MG/15 ML


marten-tab oral tablet Tier 1 QL (120 EA per 30 days)

meperidine oral solution Tier 1 QL (480 ML per 30 days)

meperidine oral tablet Tier 1 QL (120 EA per 30 days)

methadone oral concentrate Tier 1 PA; QL (120 ML per 30 days)

methadone oral solution 10 mg/5 ml Tier 1 PA; QL (480 ML per 30 days)

methadone oral solution 5 mg/5 ml Tier 1 PA; QL (960 ML per 30 days)

methadone oral tablet Tier 1 PA; QL (120 EA per 30 days)

methadone oral tablet,soluble Tier 1 PA; QL (50 EA per 30 days)

methadose oral concentrate Tier 1 PA; QL (120 ML per 30 days)

methadose oral tablet,soluble Tier 1 PA; QL (50 EA per 30 days)

morphine concentrate oral solution Tier 1 QL (300 ML per 30 days)

morphine oral capsule, er multiphase 24 hr 120 mg


morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg


morphine oral capsule,extend.release pellets Tier 1 PA; QL (60 EA per 30 days)

morphine oral solution Tier 1 QL (900 ML per 30 days)

morphine oral tablet Tier 1 QL (120 EA per 30 days)

morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg


morphine oral tablet extended release 200 mg Tier 1 PA; QL (30 EA per 30 days)

morphine rectal suppository Tier 1 QL (120 EA per 30 days)

MS CONTIN ORAL TABLET EXTENDED RELEASE


NORCO ORAL TABLET Tier 3 QL (120 EA per 30 days)

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR


NUCYNTA ORAL TABLET Tier 3 QL (120 EA per 30 days)

OPANA ORAL TABLET Tier 3 QL (120 EA per 30 days)

oxycodone oral capsule Tier 1 QL (120 EA per 30 days)

oxycodone oral concentrate Tier 1 QL (120 ML per 30 days)

oxycodone oral solution Tier 1 QL (480 ML per 30 days)

oxycodone oral tablet Tier 1 QL (120 EA per 30 days)


34

oxycodone-acetaminophen oral solution Tier 1 QL (480 ML per 30 days)

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


oxycodone-aspirin oral tablet Tier 1 QL (120 EA per 30 days)

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


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


oxymorphone oral tablet Tier 1 QL (120 EA per 30 days)

oxymorphone oral tablet extended release 12 hr Tier 1 PA; QL (60 EA per 30 days)

pentazocine-naloxone oral tablet Tier 1 QL (120 EA per 30 days)

PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG


PRIMLEV ORAL TABLET Tier 3 QL (120 EA per 30 days)

reprexain oral tablet 2.5-200 mg Tier 1 QL (120 EA per 30 days)

ROXICODONE ORAL TABLET Tier 3 QL (120 EA per 30 days)

tencon oral tablet 50-325 mg Tier 1 QL (120 EA per 30 days)

tramadol oral tablet Tier 1 QL (240 EA per 30 days)

tramadol oral tablet extended release 24 hr Tier 1 PA; QL (30 EA per 30 days)

tramadol oral tablet, er multiphase 24 hr Tier 1 PA; QL (30 EA per 30 days)

tramadol-acetaminophen oral tablet Tier 1 QL (240 EA per 30 days)

TREZIX ORAL CAPSULE 320.5-30-16 MG Tier 3 QL (120 EA per 30 days)

TYLENOL-CODEINE #3 ORAL TABLET Tier 3 QL (180 EA per 30 days)

TYLENOL-CODEINE #4 ORAL TABLET Tier 3 QL (180 EA per 30 days)

ULTRACET ORAL TABLET Tier 3 QL (240 EA per 30 days)

ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR 300 MG


ULTRAM ORAL TABLET Tier 3 QL (240 EA per 30 days)

verdrocet oral tablet Tier 1 QL (120 EA per 30 days)

vicodin es oral tablet Tier 1 QL (120 EA per 30 days)

vicodin hp oral tablet Tier 1 QL (120 EA per 30 days)

vicodin oral tablet Tier 1 QL (120 EA per 30 days)

xylon 10 oral tablet Tier 1 QL (150 EA per 30 days)

zebutal oral capsule 50-325-40 mg Tier 1 QL (120 EA per 30 days)


35

Non-Narcotic Analgesics ANAPROX DS ORAL TABLET Tier 3

ARTHROTEC 50 ORAL TABLET,IR,DELAYED REL,BIPHASIC

Tier 3

ARTHROTEC 75 ORAL TABLET,IR,DELAYED REL,BIPHASIC

Tier 3

CELEBREX ORAL CAPSULE Tier 3

celecoxib oral capsule Tier 1

choline,magnesium salicylate oral liquid Tier 1

DAYPRO ORAL TABLET Tier 3

diclofenac potassium oral tablet Tier 1

diclofenac sodium oral tablet extended release 24 hr

Tier 1

diclofenac sodium oral tablet,delayed release (dr/ec)

Tier 1

diclofenac sodium topical gel 1 % Tier 1 QL (500 GM per 30 days)

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic

Tier 1

diflunisal oral tablet Tier 1

DISALCID ORAL TABLET Tier 3

EC-NAPROSYN ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

etodolac oral capsule Tier 1

etodolac oral tablet Tier 1

etodolac oral tablet extended release 24 hr Tier 1

FELDENE ORAL CAPSULE Tier 3

fenoprofen oral tablet Tier 1

flurbiprofen oral tablet Tier 1

ibuprofen oral suspension Tier 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1

INDOCIN ORAL SUSPENSION Tier 3

INDOCIN RECTAL SUPPOSITORY Tier 3

indomethacin oral capsule Tier 1

indomethacin oral capsule, extended release Tier 1

ketoprofen oral capsule Tier 1


36

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

Tier 1

ketorolac oral tablet Tier 1

LODINE ORAL TABLET Tier 3

meclofenamate oral capsule Tier 1

mefenamic acid oral capsule Tier 1

meloxicam oral suspension Tier 1

meloxicam oral tablet Tier 1

MOBIC ORAL TABLET Tier 3

nabumetone oral tablet Tier 1

NALFON ORAL CAPSULE 400 MG Tier 3

NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR

Tier 3

NAPROSYN ORAL SUSPENSION Tier 3

NAPROSYN ORAL TABLET 500 MG Tier 3

naproxen oral suspension Tier 1

naproxen oral tablet Tier 1

naproxen oral tablet,delayed release (dr/ec) Tier 1

naproxen sodium oral tablet 275 mg, 550 mg Tier 1

oxaprozin oral tablet Tier 1

piroxicam oral capsule Tier 1

REVIA ORAL TABLET Tier 3

salsalate oral tablet Tier 1

SPRIX NASAL SPRAY,NON-AEROSOL Tier 3 LD; SPRx

sulindac oral tablet Tier 1

tolmetin oral capsule Tier 1

tolmetin oral tablet Tier 1

VOLTAREN-XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 11.4-2.9 MG, 2.9-0.71 MG, 8.6-2.1 MG


Opiate/Narcotic Reversal Agents - Opiate Antagonists naloxone injection solution Tier 1 QL (2 units per 1 claim)

naloxone injection syringe Tier 1 QL (2 units per 1 claim)


37

naltrexone oral tablet Tier 1

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION


Psychotherapeutic Drugs ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

Tier 3 SPRx; AGE-A

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

Tier 3 SPRx; AGE-A

ABILIFY ORAL TABLET Tier 3 AGE-A

ADDERALL ORAL TABLET Tier 3

alprazolam intensol oral concentrate Tier 1

alprazolam oral tablet Tier 1

alprazolam oral tablet extended release 24 hr Tier 1

alprazolam oral tablet,disintegrating Tier 1

AMBIEN CR ORAL TABLET,EXT RELEASE MULTIPHASE

Tier 3

AMBIEN ORAL TABLET Tier 3

amitriptyline oral tablet Tier 1

amitriptyline-chlordiazepoxide oral tablet Tier 1

amoxapine oral tablet Tier 1

ANAFRANIL ORAL CAPSULE Tier 3

aripiprazole oral solution Tier 1 AGE-A

aripiprazole oral tablet Tier 1 AGE-A

aripiprazole oral tablet,disintegrating Tier 1 AGE-A

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

Tier 3 SPRx; AGE-A

armodafinil oral tablet Tier 1 PA

ATIVAN ORAL TABLET Tier 3

atomoxetine oral capsule Tier 1

bupropion hcl oral tablet Tier 1

bupropion hcl oral tablet extended release 12 hr Tier 1

bupropion hcl oral tablet extended release 24 hr Tier 1

buspirone oral tablet Tier 1

BUTISOL ORAL TABLET 30 MG Tier 3

CELEXA ORAL TABLET Tier 3


38

chlordiazepoxide hcl oral capsule Tier 1

chlorpromazine oral tablet Tier 1

citalopram oral solution Tier 1

citalopram oral tablet Tier 1

clomipramine oral capsule Tier 1

clonidine hcl oral tablet extended release 12 hr Tier 1

clorazepate dipotassium oral tablet Tier 1

clozapine oral tablet Tier 1 AGE-A

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

Tier 1 AGE-A

CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 200 MG

Tier 3 AGE-A

CLOZARIL ORAL TABLET Tier 3 AGE-A

CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 3

DAYTRANA TRANSDERMAL PATCH 24 HOUR

Tier 2

desipramine oral tablet Tier 1

desvenlafaxine succinate oral tablet extended release 24 hr

Tier 1

DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE 15 MG

Tier 3

dexmethylphenidate oral capsule,er biphasic 50-50

Tier 1

dexmethylphenidate oral tablet Tier 1

dextroamphetamine oral capsule, extended release Tier 1

dextroamphetamine oral solution Tier 1

dextroamphetamine oral tablet Tier 1

dextroamphetamine-amphetamine oral capsule,extended release 24hr

Tier 1

dextroamphetamine-amphetamine oral tablet Tier 1

diazepam intensol oral concentrate Tier 1

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

diazepam oral tablet Tier 1

DORAL ORAL TABLET Tier 3


39

doxepin oral capsule Tier 1

doxepin oral concentrate Tier 1

duloxetine oral capsule,delayed release(dr/ec) Tier 1

EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3

EMSAM TRANSDERMAL PATCH 24 HOUR Tier 3

ergoloid oral tablet Tier 1

escitalopram oxalate oral solution Tier 1

escitalopram oxalate oral tablet Tier 1

estazolam oral tablet Tier 1

eszopiclone oral tablet Tier 1

FANAPT ORAL TABLET Tier 3 AGE-A

FANAPT ORAL TABLETS,DOSE PACK Tier 3 AGE-A

FAZACLO ORAL TABLET,DISINTEGRATING

Tier 3 AGE-A

fluoxetine oral capsule Tier 1

fluoxetine oral capsule,delayed release(dr/ec) Tier 1

fluoxetine oral solution Tier 1

fluoxetine oral tablet Tier 1

fluphenazine hcl oral concentrate Tier 1

fluphenazine hcl oral elixir Tier 1

fluphenazine hcl oral tablet Tier 1

flurazepam oral capsule Tier 1

fluvoxamine oral capsule,extended release 24hr Tier 1

fluvoxamine oral tablet Tier 1

GEODON ORAL CAPSULE Tier 3 AGE-A

guanfacine oral tablet extended release 24 hr Tier 1

guanidine oral tablet Tier 1

HALCION ORAL TABLET 0.25 MG Tier 3

haloperidol lactate oral concentrate Tier 1

haloperidol oral tablet Tier 1

imipramine hcl oral tablet Tier 1

imipramine pamoate oral capsule Tier 1


40

INTUNIV ER ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

INVEGA ORAL TABLET EXTENDED RELEASE 24HR

Tier 3 AGE-A

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

Tier 3 SPRx; AGE-A

INVEGA TRINZA INTRAMUSCULAR SYRINGE

Tier 3 SPRx; AGE-A

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

LATUDA ORAL TABLET Tier 2 AGE-A

LEXAPRO ORAL TABLET Tier 3

lithium carbonate oral capsule Tier 1

lithium carbonate oral tablet Tier 1

lithium carbonate oral tablet extended release Tier 1

lithium citrate oral solution 8 meq/5 ml Tier 1

LITHOBID ORAL TABLET EXTENDED RELEASE

Tier 3

lorazepam intensol oral concentrate Tier 1

lorazepam oral concentrate Tier 1

lorazepam oral tablet Tier 1

loxapine succinate oral capsule Tier 1

LUNESTA ORAL TABLET Tier 3

maprotiline oral tablet Tier 1

MARPLAN ORAL TABLET Tier 3

metadate er oral tablet extended release Tier 1

methamphetamine oral tablet Tier 1

METHYLIN ORAL SOLUTION Tier 3

methylphenidate hcl oral capsule, er biphasic 30-70

Tier 1

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

Tier 1

methylphenidate hcl oral solution Tier 1

methylphenidate hcl oral tablet Tier 1

methylphenidate hcl oral tablet extended release Tier 1


41

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

Tier 1

methylphenidate hcl oral tablet,chewable Tier 1

midazolam oral syrup 2 mg/ml Tier 1

mirtazapine oral tablet Tier 1

mirtazapine oral tablet,disintegrating Tier 1

modafinil oral tablet Tier 1 PA

NARDIL ORAL TABLET Tier 3

nefazodone oral tablet Tier 1

NORPRAMIN ORAL TABLET 10 MG, 25 MG Tier 3

nortriptyline oral capsule Tier 1

nortriptyline oral solution Tier 1

NUPLAZID ORAL TABLET Tier 3 PA; SPRx

NUVIGIL ORAL TABLET Tier 3 PA

olanzapine oral tablet Tier 1 AGE-A

olanzapine oral tablet,disintegrating Tier 1 AGE-A

olanzapine-fluoxetine oral capsule Tier 1 AGE-A

ORAP ORAL TABLET Tier 3

oxazepam oral capsule Tier 1

paliperidone oral tablet extended release 24hr Tier 1 AGE-A

PAMELOR ORAL CAPSULE Tier 3

PARNATE ORAL TABLET Tier 3

paroxetine hcl oral tablet Tier 1

paroxetine hcl oral tablet extended release 24 hr Tier 1

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

PAXIL ORAL SUSPENSION Tier 3

PAXIL ORAL TABLET Tier 3

perphenazine oral tablet Tier 1

perphenazine-amitriptyline oral tablet Tier 1

PEXEVA ORAL TABLET Tier 3

phenelzine oral tablet Tier 1

pimozide oral tablet Tier 1


42

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

procentra oral solution Tier 1

protriptyline oral tablet Tier 1

PROZAC ORAL CAPSULE Tier 3

quazepam oral tablet Tier 1

quetiapine oral tablet Tier 1 AGE-A

quetiapine oral tablet extended release 24 hr Tier 1 AGE-A

QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON

Tier 2

REMERON ORAL TABLET Tier 3

REMERON SOLTAB ORAL TABLET,DISINTEGRATING

Tier 3

RESTORIL ORAL CAPSULE Tier 3

RISPERDAL CONSTA INTRAMUSCULAR SYRINGE

Tier 3 SPRx; AGE-A

RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING 0.5 MG, 1 MG, 3 MG, 4 MG

Tier 3 AGE-A

RISPERDAL ORAL SOLUTION Tier 3 AGE-A

RISPERDAL ORAL TABLET Tier 3 AGE-A

risperidone oral solution Tier 1 AGE-A

risperidone oral tablet Tier 1 AGE-A

risperidone oral tablet,disintegrating Tier 1 AGE-A

RITALIN ORAL TABLET Tier 3

ROZEREM ORAL TABLET Tier 3

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET

Tier 3 AGE-A

SARAFEM ORAL TABLET 10 MG, 20 MG Tier 3

seconal sodium oral capsule Tier 1

SEROQUEL ORAL TABLET Tier 3 AGE-A

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3 AGE-A

sertraline oral concentrate Tier 1

sertraline oral tablet Tier 1

SONATA ORAL CAPSULE Tier 3


43

STRATTERA ORAL CAPSULE Tier 3

SURMONTIL ORAL CAPSULE Tier 3

SYMBYAX ORAL CAPSULE Tier 3 AGE-A

temazepam oral capsule Tier 1

thioridazine oral tablet Tier 1

thiothixene oral capsule Tier 1

TOFRANIL ORAL TABLET Tier 3

TRANXENE T-TAB ORAL TABLET 7.5 MG Tier 3

tranylcypromine oral tablet Tier 1

trazodone oral tablet Tier 1

triazolam oral tablet Tier 1

trifluoperazine oral tablet Tier 1

trimipramine oral capsule Tier 1

TRINTELLIX ORAL TABLET Tier 3

VALIUM ORAL TABLET Tier 3

venlafaxine oral capsule,extended release 24hr Tier 1

venlafaxine oral tablet Tier 1

venlafaxine oral tablet extended release 24hr Tier 1

VIIBRYD ORAL TABLET Tier 2

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)

Tier 2

VRAYLAR ORAL CAPSULE Tier 3 AGE-A

VRAYLAR ORAL CAPSULE,DOSE PACK Tier 3 AGE-A

VYVANSE ORAL CAPSULE Tier 2

VYVANSE ORAL TABLET,CHEWABLE Tier 2

WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

XANAX ORAL TABLET Tier 3

XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

XYREM ORAL SOLUTION Tier 3 PA; LD; SPRx

zaleplon oral capsule Tier 1


44

zenzedi oral tablet 10 mg, 5 mg Tier 1

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

Tier 3

ziprasidone hcl oral capsule Tier 1 AGE-A

ZOLOFT ORAL CONCENTRATE Tier 3

ZOLOFT ORAL TABLET Tier 3

zolpidem oral tablet Tier 1

zolpidem oral tablet,ext release multiphase Tier 1

ZYPREXA ORAL TABLET Tier 3 AGE-A

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 3 SPRx; AGE-A

ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING

Tier 3 AGE-A


Cardiovascular, Hypertension & Lipids Antiarrhythmic Agents amiodarone oral tablet Tier 1

BETAPACE AF ORAL TABLET Tier 3

BETAPACE ORAL TABLET Tier 3

disopyramide phosphate oral capsule Tier 1

dofetilide oral capsule Tier 1

flecainide oral tablet Tier 1

mexiletine oral capsule Tier 1

MULTAQ ORAL TABLET Tier 3

NORPACE CR ORAL CAPSULE, EXTENDED RELEASE

Tier 3

NORPACE ORAL CAPSULE Tier 3

pacerone oral tablet 100 mg, 200 mg, 400 mg Tier 1

propafenone oral capsule,extended release 12 hr Tier 1

propafenone oral tablet Tier 1

quinidine gluconate oral tablet extended release Tier 1

quinidine sulfate oral tablet Tier 1

RYTHMOL SR ORAL CAPSULE,EXTENDED RELEASE 12 HR

Tier 3

sorine oral tablet Tier 1

45

sotalol af oral tablet Tier 1

sotalol oral tablet Tier 1

SOTYLIZE ORAL SOLUTION Tier 3

TIKOSYN ORAL CAPSULE Tier 3

Antihypertensive Therapy ACCUPRIL ORAL TABLET Tier 3

ACCURETIC ORAL TABLET Tier 3

acebutolol oral capsule Tier 1

ADALAT CC ORAL TABLET EXTENDED RELEASE

Tier 3

afeditab cr oral tablet extended release Tier 1

ALDACTAZIDE ORAL TABLET Tier 3

ALDACTONE ORAL TABLET Tier 3

ALTACE ORAL CAPSULE Tier 3

amiloride oral tablet Tier 1

amiloride-hydrochlorothiazide oral tablet Tier 1

amlodipine oral tablet Tier 1

amlodipine-benazepril oral capsule Tier 1

amlodipine-olmesartan oral tablet Tier 1

amlodipine-valsartan oral tablet Tier 1

amlodipine-valsartan-hcthiazid oral tablet Tier 1

ATACAND HCT ORAL TABLET Tier 3

ATACAND ORAL TABLET Tier 3

atenolol oral tablet Tier 1

atenolol-chlorthalidone oral tablet Tier 1

AVALIDE ORAL TABLET Tier 3

AVAPRO ORAL TABLET Tier 3

AZOR ORAL TABLET Tier 3

benazepril oral tablet Tier 1

benazepril-hydrochlorothiazide oral tablet Tier 1

BENICAR HCT ORAL TABLET Tier 3

BENICAR ORAL TABLET Tier 3

betaxolol oral tablet Tier 1


46

BIDIL ORAL TABLET Tier 3

bisoprolol fumarate oral tablet Tier 1

bisoprolol-hydrochlorothiazide oral tablet Tier 1

bumetanide oral tablet Tier 1

BYSTOLIC ORAL TABLET Tier 2

CALAN ORAL TABLET Tier 3

CALAN SR ORAL TABLET EXTENDED RELEASE

Tier 3

candesartan oral tablet Tier 1

candesartan-hydrochlorothiazid oral tablet Tier 1

captopril oral tablet Tier 1

captopril-hydrochlorothiazide oral tablet Tier 1

CARDIZEM CD ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG

Tier 3

CARDURA ORAL TABLET Tier 3

CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR

Tier 3

carvedilol oral tablet Tier 1

carvedilol phosphate oral capsule, er multiphase 24 hr

Tier 1

CATAPRES ORAL TABLET Tier 3

CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY

Tier 3


Tier 3


Tier 3

chlorothiazide oral tablet Tier 1

chlorthalidone oral tablet 25 mg, 50 mg Tier 1

clonidine hcl oral tablet Tier 1

clonidine transdermal patch weekly Tier 1

clorpres oral tablet 0.1-15 mg, 0.2-15 mg Tier 1


47

CLORPRES ORAL TABLET 0.3-15 MG Tier 3

COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR

Tier 2

COREG ORAL TABLET Tier 3

CORGARD ORAL TABLET Tier 3

CORZIDE ORAL TABLET Tier 3

COZAAR ORAL TABLET Tier 3

DEMADEX ORAL TABLET 10 MG, 20 MG Tier 3

DIBENZYLINE ORAL CAPSULE Tier 3

diltiazem hcl oral capsule,extended release 24 hr 240 mg

Tier 1

diltiazem hcl oral capsule,extended release 24hr 120 mg

Tier 1

DIOVAN HCT ORAL TABLET Tier 3

DIOVAN ORAL TABLET Tier 3

DIURIL ORAL SUSPENSION Tier 3

doxazosin oral tablet Tier 1

DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

DYAZIDE ORAL CAPSULE Tier 3

DYRENIUM ORAL CAPSULE Tier 3

EDARBI ORAL TABLET Tier 3 ST

EDARBYCLOR ORAL TABLET Tier 3 ST

EDECRIN ORAL TABLET Tier 3

enalapril maleate oral tablet Tier 1

enalapril-hydrochlorothiazide oral tablet Tier 1

EPANED ORAL SOLUTION Tier 3

eplerenone oral tablet Tier 1

epoprostenol (glycine) intravenous recon soln Tier 1 PA; SPRx

eprosartan oral tablet Tier 1

ethacrynic acid oral tablet Tier 1

EXFORGE HCT ORAL TABLET Tier 3

EXFORGE ORAL TABLET Tier 3

felodipine oral tablet extended release 24 hr Tier 1


48

FLOLAN INTRAVENOUS RECON SOLN Tier 3 PA; LD; SPRx

fosinopril oral tablet Tier 1

fosinopril-hydrochlorothiazide oral tablet Tier 1

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

Tier 1

furosemide oral tablet Tier 1

guanfacine oral tablet Tier 1

hydralazine oral tablet Tier 1

hydrochlorothiazide oral capsule Tier 1

hydrochlorothiazide oral tablet Tier 1

HYZAAR ORAL TABLET Tier 3

indapamide oral tablet Tier 1

INDERAL LA ORAL CAPSULE,EXTENDED RELEASE 24 HR

Tier 3

INDERAL XL ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3

INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3

INSPRA ORAL TABLET Tier 3

irbesartan oral tablet Tier 1

irbesartan-hydrochlorothiazide oral tablet Tier 1

isradipine oral capsule Tier 1

labetalol oral tablet Tier 1

LASIX ORAL TABLET Tier 3

LEVATOL ORAL TABLET Tier 3

lisinopril oral tablet Tier 1

lisinopril-hydrochlorothiazide oral tablet Tier 1

LOPRESSOR HCT ORAL TABLET Tier 3

LOPRESSOR ORAL TABLET Tier 3

losartan oral tablet Tier 1

losartan-hydrochlorothiazide oral tablet Tier 1

LOTENSIN HCT ORAL TABLET Tier 3

LOTENSIN ORAL TABLET 20 MG, 40 MG Tier 3

LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5-20 MG

Tier 3


49

matzim la oral tablet extended release 24 hr Tier 1

MAXZIDE ORAL TABLET Tier 3

MAXZIDE-25MG ORAL TABLET Tier 3

methyclothiazide oral tablet Tier 1

methyldopa oral tablet Tier 1

methyldopa-hydrochlorothiazide oral tablet Tier 1

metolazone oral tablet Tier 1

metoprolol succinate oral tablet extended release 24 hr

Tier 1

metoprolol ta-hydrochlorothiaz oral tablet Tier 1

metoprolol tartrate oral tablet Tier 1

MICARDIS HCT ORAL TABLET Tier 3

MICARDIS ORAL TABLET Tier 3

MICROZIDE ORAL CAPSULE Tier 3

MINIPRESS ORAL CAPSULE Tier 3

minoxidil oral tablet Tier 1

moexipril oral tablet Tier 1

moexipril-hydrochlorothiazide oral tablet Tier 1

nadolol oral tablet Tier 1

nadolol-bendroflumethiazide oral tablet Tier 1

nicardipine oral capsule Tier 1

nifedipine oral capsule Tier 1

nifedipine oral tablet extended release Tier 1

nifedipine oral tablet extended release 24hr Tier 1

nimodipine oral capsule Tier 1

nisoldipine oral tablet extended release 24 hr Tier 1

NORVASC ORAL TABLET Tier 3

olmesartan oral tablet Tier 1

olmesartan-amlodipin-hcthiazid oral tablet Tier 1

olmesartan-hydrochlorothiazide oral tablet Tier 1

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG

Tier 3 PA; LD; SPRx

ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG

Tier 3 PA; SPRx


50

perindopril erbumine oral tablet Tier 1

phenoxybenzamine oral capsule Tier 1

pindolol oral tablet Tier 1

prazosin oral capsule Tier 1

PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG

Tier 3

PROCARDIA ORAL CAPSULE Tier 3

PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR

Tier 3

propranolol oral capsule,extended release 24 hr Tier 1

propranolol oral solution Tier 1

propranolol oral tablet Tier 1

propranolol-hydrochlorothiazid oral tablet Tier 1

quinapril oral tablet Tier 1

quinapril-hydrochlorothiazide oral tablet Tier 1

ramipril oral capsule Tier 1

REMODULIN INJECTION SOLUTION Tier 3 PA; LD; SPRx

spironolactone oral tablet Tier 1

spironolacton-hydrochlorothiaz oral tablet Tier 1

SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG, 34 MG, 8.5 MG

Tier 3

TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR

Tier 3

TEKTURNA HCT ORAL TABLET Tier 3

TEKTURNA ORAL TABLET Tier 3

telmisartan oral tablet Tier 1

telmisartan-amlodipine oral tablet Tier 1

telmisartan-hydrochlorothiazid oral tablet Tier 1

TENORETIC 100 ORAL TABLET Tier 3

TENORETIC 50 ORAL TABLET Tier 3

TENORMIN ORAL TABLET Tier 3

terazosin oral capsule Tier 1

TIAZAC ORAL CAPSULE,EXTENDED RELEASE 24 HR

Tier 3

timolol maleate oral tablet Tier 1


51

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

torsemide oral tablet Tier 1

trandolapril oral tablet Tier 1

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr

Tier 1

triamterene-hydrochlorothiazid oral capsule Tier 1

triamterene-hydrochlorothiazid oral tablet Tier 1

TRIBENZOR ORAL TABLET Tier 3

TWYNSTA ORAL TABLET Tier 3

valsartan oral tablet Tier 1

valsartan-hydrochlorothiazide oral tablet Tier 1

VASERETIC ORAL TABLET Tier 3

VASOTEC ORAL TABLET Tier 3

veletri intravenous recon soln Tier 1 PA; LD; SPRx

verapamil oral capsule, 24 hr er pellet ct Tier 1

verapamil oral capsule,ext rel. pellets 24 hr Tier 1

verapamil oral tablet Tier 1

verapamil oral tablet extended release Tier 1

VERELAN ORAL CAPSULE,EXT REL. PELLETS 24 HR

Tier 3

VERELAN PM ORAL CAPSULE, 24 HR ER PELLET CT

Tier 3

ZESTORETIC ORAL TABLET Tier 3

ZESTRIL ORAL TABLET Tier 3

ZIAC ORAL TABLET Tier 3

Cardiac Glycosides digitek oral tablet Tier 1

digox oral tablet Tier 1

digoxin oral solution 50 mcg/ml Tier 1

digoxin oral tablet Tier 1

LANOXIN ORAL TABLET Tier 2

Coagulation Therapy ADVATE INTRAVENOUS RECON SOLN Tier 3 SPRx


52

AGGRENOX ORAL CAPSULE, ER MULTIPHASE 12 HR

Tier 3

ALPHANATE INTRAVENOUS RECON SOLN

Tier 3 SPRx

ALPHANINE SD INTRAVENOUS RECON SOLN

Tier 3 SPRx

ALPROLIX INTRAVENOUS RECON SOLN Tier 3 SPRx

AMICAR ORAL SOLUTION Tier 3

AMICAR ORAL TABLET Tier 3

ARIXTRA SUBCUTANEOUS SYRINGE Tier 3 QL (42 Day Supply per 365 days)

aspirin-dipyridamole oral capsule, er multiphase 12 hr

Tier 1

BEBULIN INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

BENEFIX INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

BRILINTA ORAL TABLET Tier 2

cilostazol oral tablet Tier 1

clopidogrel oral tablet Tier 1

COAGADEX INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

CORIFACT INTRAVENOUS RECON SOLN Tier 3 SPRx

COUMADIN ORAL TABLET Tier 3

dipyridamole oral tablet Tier 1

EFFIENT ORAL TABLET Tier 3

ELIQUIS ORAL TABLET Tier 2

ELIQUIS ORAL TABLETS,DOSE PACK Tier 2

enoxaparin subcutaneous solution Tier 1 QL (42 Day Supply per 365 days)

enoxaparin subcutaneous syringe Tier 1 QL (42 Day Supply per 365 days)

FEIBA NF INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

fondaparinux subcutaneous syringe Tier 1 QL (42 Day Supply per 365 days)

FRAGMIN SUBCUTANEOUS SOLUTION Tier 3 QL (42 Day Supply per 365 days)

FRAGMIN SUBCUTANEOUS SYRINGE Tier 3 QL (42 Day Supply per 365 days)

HELIXATE FS INTRAVENOUS RECON SOLN

Tier 3 LD; SPRx

HEMOFIL M HIGH INTRAVENOUS RECON SOLN

Tier 3 LD; SPRx


53

HEMOFIL M LOW INTRAVENOUS RECON SOLN

Tier 3 LD; SPRx

HEMOFIL M MID INTRAVENOUS RECON SOLN

Tier 3 LD; SPRx

HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN

Tier 3 LD; SPRx

hep flush-10 (pf) intravenous solution Tier 1

heparin (porcine) injection solution Tier 1

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

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

Tier 1

heparin lock flush (porcine) intravenous syringe Tier 1

heparin lock flush intravenous solution Tier 1

heparin lockflush(porcine)(pf) intravenous syringe Tier 1

heparin, porcine (pf) injection solution Tier 1

heparin, porcine (pf) injection syringe Tier 1

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

Tier 1

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

Tier 1

HUMATE-P INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

jantoven oral tablet Tier 1

KOATE INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

KOGENATE FS INTRAVENOUS RECON SOLN

Tier 3 LD; SPRx

LOVENOX SUBCUTANEOUS SOLUTION Tier 3 QL (42 Day Supply per 365 days)

LOVENOX SUBCUTANEOUS SYRINGE Tier 3 QL (42 Day Supply per 365 days)

MEPHYTON ORAL TABLET Tier 3

MONOCLATE-P INTRAVENOUS RECON SOLN

Tier 3 LD; SPRx

NOVOEIGHT INTRAVENOUS RECON SOLN

Tier 3 SPRx

NOVOSEVEN RT INTRAVENOUS RECON SOLN

Tier 3 LD; SPRx

pentoxifylline oral tablet extended release Tier 1

PLAVIX ORAL TABLET Tier 3


54

PRADAXA ORAL CAPSULE Tier 3

prasugrel oral tablet Tier 1

PROFILNINE INTRAVENOUS RECON SOLN

Tier 3 SPRx

PROMACTA ORAL TABLET Tier 3 LD; SPRx

RECOMBINATE INTRAVENOUS RECON SOLN

Tier 3 LD; SPRx

RIXUBIS INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

ticlopidine oral tablet Tier 1

warfarin oral tablet Tier 1

WILATE INTRAVENOUS RECON SOLN Tier 3 SPRx

XARELTO ORAL TABLET Tier 2

XARELTO ORAL TABLETS,DOSE PACK Tier 2

XYNTHA INTRAVENOUS SOLUTION Tier 3 LD; SPRx

XYNTHA SOLOFUSE INTRAVENOUS SYRINGE

Tier 3 LD; SPRx

ZONTIVITY ORAL TABLET Tier 3

Lipid/Cholesterol Lowering Agents amlodipine-atorvastatin oral tablet Tier 1

ANTARA ORAL CAPSULE 30 MG, 90 MG Tier 3

atorvastatin oral tablet 10 mg, 20 mg Tier 1 ACA

atorvastatin oral tablet 40 mg, 80 mg Tier 1

CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG

Tier 3

cholestyramine (with sugar) oral powder Tier 1

cholestyramine (with sugar) oral powder in packet Tier 1

cholestyramine light oral powder Tier 1

cholestyramine light oral powder in packet Tier 1

COLESTID FLAVORED ORAL PACKET Tier 3

COLESTID ORAL GRANULES Tier 3

COLESTID ORAL TABLET Tier 3

colestipol oral granules Tier 1

colestipol oral packet Tier 1

colestipol oral tablet Tier 1


55

CRESTOR ORAL TABLET Tier 3

ezetimibe oral tablet Tier 1

ezetimibe-simvastatin oral tablet Tier 1

fenofibrate micronized oral capsule Tier 1

fenofibrate nanocrystallized oral tablet Tier 1

fenofibrate oral tablet 160 mg, 54 mg Tier 1

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

Tier 1

fenofibric acid oral tablet Tier 1

FENOGLIDE ORAL TABLET Tier 3

FIBRICOR ORAL TABLET Tier 3

fluvastatin oral capsule Tier 1 ACA

fluvastatin oral tablet extended release 24 hr Tier 1 ACA

gemfibrozil oral tablet Tier 1

JUXTAPID ORAL CAPSULE Tier 3 PA; LD; SPRx

KYNAMRO SUBCUTANEOUS SYRINGE Tier 3 PA; LD; SPRx

LESCOL ORAL CAPSULE Tier 3

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

LIPITOR ORAL TABLET Tier 3

LIPOFEN ORAL CAPSULE Tier 3

LIVALO ORAL TABLET Tier 3

LOPID ORAL TABLET Tier 3

lovastatin oral tablet Tier 1 ACA

niacin oral tablet extended release 24 hr Tier 1

NIACOR ORAL TABLET Tier 3

NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR

Tier 2 PA; LD; SPRx

PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG

Tier 3

pravastatin oral tablet Tier 1 ACA

prevalite oral powder Tier 1

prevalite oral powder in packet Tier 1


56

QUESTRAN LIGHT ORAL POWDER Tier 3

QUESTRAN ORAL POWDER Tier 3

QUESTRAN ORAL POWDER IN PACKET Tier 3

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR

Tier 2 PA; SPRx

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR

Tier 2 PA; SPRx

REPATHA SYRINGE SUBCUTANEOUS SYRINGE

Tier 2 PA; SPRx

rosuvastatin oral tablet 10 mg, 5 mg Tier 1 ACA

rosuvastatin oral tablet 20 mg, 40 mg Tier 1

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1 ACA

simvastatin oral tablet 80 mg Tier 1

TRICOR ORAL TABLET Tier 3

TRIGLIDE ORAL TABLET 160 MG Tier 3

TRILIPIX ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 3

VYTORIN 10-10 ORAL TABLET Tier 3




WELCHOL ORAL POWDER IN PACKET Tier 3

WELCHOL ORAL TABLET Tier 3

ZETIA ORAL TABLET Tier 3

ZOCOR ORAL TABLET Tier 3

Miscellaneous Cardiovascular Agents CORLANOR ORAL TABLET Tier 3

ENTRESTO ORAL TABLET Tier 3

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

Nitrates DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE

Tier 3

ISOCHRON ORAL TABLET EXTENDED RELEASE

Tier 3


57

ISORDIL ORAL TABLET Tier 3

ISORDIL TITRADOSE ORAL TABLET 5 MG

Tier 3

isosorbide dinitrate oral tablet Tier 1

isosorbide dinitrate oral tablet extended release Tier 1

isosorbide mononitrate oral tablet Tier 1

isosorbide mononitrate oral tablet extended release 24 hr

Tier 1

MINITRAN TRANSDERMAL PATCH 24 HOUR

Tier 3

nitro-bid transdermal ointment Tier 1

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.2 MG/HR, 0.3 MG/HR, 0.4 MG/HR, 0.6 MG/HR, 0.8 MG/HR

Tier 3

nitroglycerin oral capsule, extended release Tier 1

nitroglycerin sublingual tablet Tier 1

nitroglycerin transdermal patch 24 hour Tier 1

nitroglycerin translingual spray,non-aerosol Tier 1

NITROLINGUAL TRANSLINGUAL SPRAY,NON-AEROSOL

Tier 3

NITROMIST TRANSLINGUAL AEROSOL,SPRAY

Tier 3

NITROSTAT SUBLINGUAL TABLET Tier 3

nitro-time oral capsule, extended release Tier 1


Dermatologicals/Topical Therapy Antipsoriatic / Antiseborrheic acitretin oral capsule Tier 1

calcipotriene scalp solution Tier 1

calcipotriene topical cream Tier 1

calcipotriene topical ointment Tier 1

calcipotriene-betamethasone topical ointment Tier 1

calcitrene topical ointment Tier 1

calcitriol topical ointment Tier 1

COAL TAR TOPICAL SOLUTION Tier 3

58

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE

Tier 2 PA; LD; SPRx

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR

Tier 2 PA; LD; SPRx

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR

Tier 2 PA; LD; SPRx

COSENTYX SUBCUTANEOUS SYRINGE Tier 2 PA; LD; SPRx

drithocreme hp topical cream Tier 1

ENSTILAR TOPICAL FOAM Tier 3

hydrocortisone-pramoxine topical cream Tier 1

OVACE PLUS SHAMPOO TOPICAL SHAMPOO

Tier 3

OVACE PLUS TOPICAL CREAM Tier 3

OVACE PLUS TOPICAL LOTION Tier 3

OVACE TOPICAL CLEANSER Tier 3

seb-prev topical cleanser Tier 1

selenium sulfide topical lotion Tier 1

selenium sulfide topical shampoo 2.25 % Tier 1

SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG

Tier 3

STELARA SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx

sulfacetamide sodium topical cleanser Tier 1

sulfacetamide sodium topical shampoo Tier 1

TACLONEX TOPICAL SUSPENSION Tier 3

Burn Therapy SILVADENE TOPICAL CREAM Tier 3

silver sulfadiazine topical cream Tier 1

ssd topical cream Tier 1

Keratolytics PODOCON TOPICAL LIQUID Tier 3

SALEX TOPICAL COMBO PACK Tier 3

SALEX TOPICAL KIT,CLEANSER AND CREAM ER

Tier 3

SALEX TOPICAL SHAMPOO Tier 3

salicylic acid er-ceramides topical combo pack Tier 1


59

salicylic acid er-ceramides topical kit,cleanser and cream er

Tier 1

salicylic acid topical cream Tier 1

salicylic acid topical cream,extended release Tier 1

salicylic acid topical film forming liquid w/appl Tier 1

salicylic acid topical foam Tier 1

salicylic acid topical liquid 26 % Tier 1

salicylic acid topical lotion Tier 1

salicylic acid topical lotion,extended release Tier 1

salicylic acid topical shampoo Tier 1

Miscellaneous Dermatologicals BIAFINE EMULSION TOPICAL EMULSION Tier 3

CONDYLOX TOPICAL GEL Tier 3

diclofenac sodium topical gel 3 % Tier 1 QL (100 GM per 30 days)

doxepin topical cream Tier 1

DUPIXENT SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx; QL (2 ML per 30 days)

EFUDEX TOPICAL CREAM Tier 3

eletone topical cream Tier 1

ELIDEL TOPICAL CREAM Tier 2

emulsion sb topical emulsion Tier 1

EPICERAM TOPICAL EMULSION, EXTENDED RELEASE

Tier 3

EUCRISA TOPICAL OINTMENT Tier 3

fluorouracil topical cream 5 % Tier 1

fluorouracil topical solution Tier 1

HYDRO 40 TOPICAL FOAM Tier 3

KERALAC TOPICAL CREAM Tier 3

LEVULAN TOPICAL SOLUTION Tier 3

LOUTREX TOPICAL CREAM Tier 3

methoxsalen oral capsule,liqd-filled,rapid rel Tier 1

NEOSALUS TOPICAL CREAM Tier 3

NEOSALUS TOPICAL FOAM Tier 3

NEOSALUS TOPICAL LOTION Tier 3


60

OXSORALEN ULTRA ORAL CAPSULE,LIQD-FILLED,RAPID REL

Tier 3

PANRETIN TOPICAL GEL Tier 3

PICATO TOPICAL GEL Tier 3

podofilox topical solution Tier 1

PROMISEB TOPICAL CREAM Tier 3

pruclair topical cream Tier 1

prudoxin topical cream Tier 1

prutect topical emulsion Tier 1

REGRANEX TOPICAL GEL Tier 3

silver nitrate applicators topical stick Tier 1

silver nitrate topical solution 10 % Tier 1

tacrolimus topical ointment Tier 1

URAMAXIN TOPICAL GEL Tier 3

VALCHLOR TOPICAL GEL Tier 3 PA; LD; SPRx

VEREGEN TOPICAL OINTMENT Tier 3

ZONALON TOPICAL CREAM Tier 3

Therapy For Acne ACANYA TOPICAL GEL WITH PUMP Tier 2

adapalene topical cream Tier 1

adapalene topical gel Tier 1

adapalene topical gel with pump Tier 1

adapalene-benzoyl peroxide topical gel with pump Tier 1

amnesteem oral capsule Tier 1

avita topical cream Tier 1 PA

AZELEX TOPICAL CREAM Tier 3

BENZAMYCIN TOPICAL GEL Tier 3

BENZEFOAM TOPICAL FOAM Tier 3

BENZEFOAM ULTRA TOPICAL FOAM Tier 3

BENZEPRO (MICROSPHERES) TOPICAL CLEANSER

Tier 3

benzepro topical towelette Tier 1

benzoyl peroxide topical cleanser 7 % Tier 1

benzoyl peroxide topical foam 9.8 % Tier 1


61

bpo topical gel Tier 1

claravis oral capsule Tier 1

CLEOCIN T TOPICAL GEL Tier 3

CLEOCIN T TOPICAL LOTION Tier 3

CLEOCIN T TOPICAL SOLUTION Tier 3

CLEOCIN T TOPICAL SWAB Tier 3

clindacin p topical swab Tier 1

CLINDAGEL TOPICAL GEL Tier 3

clindamycin phosphate topical foam Tier 1

clindamycin phosphate topical gel Tier 1

clindamycin phosphate topical lotion Tier 1

clindamycin phosphate topical solution Tier 1

clindamycin phosphate topical swab Tier 1

clindamycin-benzoyl peroxide topical gel Tier 1

clindamycin-benzoyl peroxide topical gel with pump

Tier 1

EPIDUO FORTE TOPICAL GEL WITH PUMP

Tier 2

EPIDUO TOPICAL GEL WITH PUMP Tier 2

ery pads topical swab Tier 1

erygel topical gel Tier 1

erythromycin with ethanol topical gel Tier 1

erythromycin with ethanol topical solution Tier 1

erythromycin with ethanol topical swab Tier 1

erythromycin-benzoyl peroxide topical gel Tier 1

EVOCLIN TOPICAL FOAM Tier 3

FABIOR TOPICAL FOAM Tier 3 PA

FINACEA TOPICAL FOAM Tier 2

FINACEA TOPICAL GEL Tier 2

isotretinoin oral capsule Tier 1

METROCREAM TOPICAL CREAM Tier 3

METROLOTION TOPICAL LOTION Tier 3

metronidazole topical cream Tier 1

metronidazole topical gel Tier 1


62

metronidazole topical gel with pump Tier 1

metronidazole topical lotion Tier 1

myorisan oral capsule Tier 1

neuac topical gel Tier 1

NUOX TOPICAL GEL Tier 3

PACNEX TOPICAL CLEANSER Tier 3

PLEXION CLEANSING CLOTHS TOPICAL PADS, MEDICATED

Tier 3

PLEXION TOPICAL CLEANSER Tier 3

PLEXION TOPICAL CREAM Tier 3

PLEXION TOPICAL LOTION Tier 3

RETIN-A TOPICAL CREAM Tier 3 PA

RETIN-A TOPICAL GEL Tier 3 PA

rosadan topical cream Tier 1

rosadan topical gel Tier 1

ROSANIL TOPICAL CLEANSER Tier 3

rosula cleansing cloths topical pads, medicated Tier 1

ROSULA TOPICAL CLEANSER Tier 3

sss 10-5 topical cream Tier 1

sss 10-5 topical foam Tier 1

sulfacetamide sodium-sulfur topical cleanser Tier 1

sulfacetamide sodium-sulfur topical cream Tier 1

sulfacetamide sodium-sulfur topical lotion Tier 1

sulfacetamide sodium-sulfur topical pads, medicated 10-4 %

Tier 1

sulfacetamide sodium-sulfur topical suspension Tier 1

sulfacetamide sod-sulfur-urea topical cleanser Tier 1

SUMAXIN TOPICAL PADS, MEDICATED Tier 3

tazarotene topical cream Tier 1 PA

TAZORAC TOPICAL CREAM Tier 3 PA

TAZORAC TOPICAL GEL Tier 3 PA

tretinoin (emollient) topical cream Tier 1 PA

tretinoin microspheres topical gel Tier 1 PA

tretinoin microspheres topical gel with pump Tier 1 PA


63

tretinoin topical cream Tier 1 PA

tretinoin topical gel Tier 1 PA

TRETIN-X CREAM KIT TOPICAL COMBO PACK

Tier 3 PA

TRETIN-X TOPICAL CREAM 0.075 % Tier 3 PA

VANOXIDE-HC TOPICAL SUSPENSION Tier 3

zenatane oral capsule Tier 1

Topical Anesthetics ethyl chloride topical aerosol,spray Tier 1

glydo mucous membrane jelly in applicator Tier 1

lidocaine hcl mucous membrane jelly Tier 1

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

Tier 1

lidocaine hcl-hydrocortison ac topical cream Tier 1

lidocaine topical ointment Tier 1 QL (100 GM per 30 days)

lidocaine viscous mucous membrane solution Tier 1

lidocaine-prilocaine topical cream Tier 1 QL (60 GM per 30 days)

LIDODERM TOPICAL ADHESIVE PATCH,MEDICATED


SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING

Tier 3

Topical Antibacterials ALTABAX TOPICAL OINTMENT Tier 3

CENTANY AT TOPICAL OINTMENT KIT Tier 3

CENTANY TOPICAL OINTMENT Tier 3

CORTISPORIN TOPICAL CREAM Tier 3

CORTISPORIN TOPICAL OINTMENT Tier 3

gentamicin topical cream Tier 1

gentamicin topical ointment Tier 1

KLARON TOPICAL SUSPENSION Tier 3

mafenide acetate topical packet Tier 1

mupirocin calcium topical cream Tier 1

mupirocin topical ointment Tier 1

NEO-SYNALAR KIT TOPICAL CREAM Tier 3


64

NEO-SYNALAR TOPICAL CREAM Tier 3

SULFAMYLON TOPICAL CREAM Tier 3

SULFAMYLON TOPICAL PACKET Tier 3

Topical Antifungals ciclodan topical cream Tier 1

ciclodan topical solution Tier 1

ciclopirox topical cream Tier 1

ciclopirox topical gel Tier 1

ciclopirox topical shampoo Tier 1

ciclopirox topical solution Tier 1

ciclopirox topical suspension Tier 1

ciclopirox-ure-camph-menth-euc topical solution Tier 1

clotrimazole-betamethasone topical cream Tier 1

clotrimazole-betamethasone topical lotion Tier 1

econazole topical cream Tier 1

ERTACZO TOPICAL CREAM Tier 3

EXELDERM TOPICAL CREAM Tier 3

EXELDERM TOPICAL SOLUTION Tier 3

EXODERM TOPICAL LOTION Tier 3

EXTINA TOPICAL FOAM Tier 3

ketoconazole topical cream Tier 1

ketoconazole topical foam Tier 1

ketoconazole topical shampoo Tier 1

LOPROX TOPICAL SHAMPOO Tier 3

LOTRISONE TOPICAL CREAM Tier 3

naftifine topical cream Tier 1

NAFTIN TOPICAL GEL Tier 3

NIZORAL TOPICAL SHAMPOO Tier 3

nyamyc topical powder Tier 1

nystatin topical cream Tier 1

nystatin topical ointment Tier 1

nystatin topical powder Tier 1

nystatin-triamcinolone topical cream Tier 1


65

nystatin-triamcinolone topical ointment Tier 1

nystop topical powder Tier 1

oxiconazole topical cream Tier 1

OXISTAT TOPICAL LOTION Tier 3

PENLAC TOPICAL SOLUTION Tier 3

VUSION TOPICAL OINTMENT Tier 3

XOLEGEL TOPICAL GEL Tier 3

Topical Antivirals acyclovir topical ointment Tier 1

DENAVIR TOPICAL CREAM Tier 3

ZOVIRAX TOPICAL CREAM Tier 2

ZOVIRAX TOPICAL OINTMENT Tier 3

Topical Corticosteroids ALA-SCALP TOPICAL LOTION Tier 3

alclometasone topical cream Tier 1

alclometasone topical ointment Tier 1

amcinonide topical cream Tier 1

amcinonide topical lotion Tier 1

amcinonide topical ointment Tier 1

AQUA GLYCOLIC HC TOPICAL COMBO PACK

Tier 3

betamethasone dipropionate topical cream Tier 1

betamethasone dipropionate topical lotion Tier 1

betamethasone dipropionate topical ointment Tier 1

betamethasone valerate topical cream Tier 1

betamethasone valerate topical foam Tier 1

betamethasone valerate topical lotion Tier 1

betamethasone valerate topical ointment Tier 1

betamethasone, augmented topical cream Tier 1

betamethasone, augmented topical gel Tier 1

betamethasone, augmented topical lotion Tier 1

betamethasone, augmented topical ointment Tier 1

CAPEX TOPICAL SHAMPOO Tier 3


66

clobetasol scalp solution Tier 1

clobetasol topical cream Tier 1

clobetasol topical foam Tier 1

clobetasol topical gel Tier 1

clobetasol topical lotion Tier 1

clobetasol topical ointment Tier 1

clobetasol topical shampoo Tier 1

clobetasol topical spray,non-aerosol Tier 1

clobetasol-emollient topical cream Tier 1

clobetasol-emollient topical foam Tier 1

CLOBEX TOPICAL LOTION Tier 3

CLOBEX TOPICAL SHAMPOO Tier 3

CLOBEX TOPICAL SPRAY,NON-AEROSOL Tier 3

CLOCORTOLONE PIVALATE TOPICAL CREAM

Tier 3

clodan topical shampoo Tier 1

CLODERM TOPICAL CREAM Tier 3

CORDRAN TOPICAL CREAM Tier 3

CORDRAN TOPICAL LOTION Tier 3

CORDRAN TOPICAL OINTMENT Tier 3

cormax scalp solution Tier 1

CUTIVATE TOPICAL CREAM Tier 3

CUTIVATE TOPICAL LOTION Tier 3

DERMA-SMOOTHE/FS BODY OIL TOPICAL OIL

Tier 3

DERMA-SMOOTHE/FS SCALP OIL SCALP OIL

Tier 3

DERMASORB HC COMPLETE KIT TOPICAL COMBO PACK,CLEANSER AND LOTION

Tier 3

DERMASORB TA COMPLETE KIT TOPICAL CREAM

Tier 3

DERMATOP TOPICAL CREAM Tier 3

DERMATOP TOPICAL OINTMENT Tier 3

DESONATE TOPICAL GEL Tier 3


67

desonide topical cream Tier 1

desonide topical lotion Tier 1

desonide topical ointment Tier 1

DESOWEN TOPICAL CREAM Tier 3

DESOWEN TOPICAL LOTION Tier 3

desoximetasone topical cream Tier 1

desoximetasone topical gel Tier 1

desoximetasone topical ointment Tier 1

diflorasone topical cream Tier 1

diflorasone topical ointment Tier 1

DIPROLENE TOPICAL OINTMENT Tier 3

ELOCON TOPICAL CREAM Tier 3

ELOCON TOPICAL OINTMENT Tier 3

fluocinolone and shower cap scalp oil Tier 1

fluocinolone topical cream Tier 1

fluocinolone topical oil Tier 1

fluocinolone topical ointment Tier 1

fluocinolone topical solution Tier 1

fluocinonide topical cream Tier 1

fluocinonide topical gel Tier 1

fluocinonide topical ointment Tier 1

fluocinonide topical solution Tier 1

fluocinonide-e topical cream Tier 1

fluocinonide-emollient topical cream Tier 1

flurandrenolide topical cream Tier 1

flurandrenolide topical lotion Tier 1

flurandrenolide topical ointment Tier 1

fluticasone topical cream Tier 1

fluticasone topical lotion Tier 1

fluticasone topical ointment Tier 1

halobetasol propionate topical cream Tier 1

halobetasol propionate topical ointment Tier 1

HALOG TOPICAL CREAM Tier 3


68

HALOG TOPICAL OINTMENT Tier 3

hydrocortisone butyrate topical cream Tier 1

hydrocortisone butyrate topical lotion Tier 1

hydrocortisone butyrate topical ointment Tier 1

hydrocortisone butyrate topical solution Tier 1

hydrocortisone butyr-emollient topical cream Tier 1

hydrocortisone topical cream 2.5 % Tier 1

hydrocortisone topical lotion 2.5 % Tier 1

hydrocortisone topical ointment 2.5 % Tier 1

hydrocortisone valerate topical cream Tier 1

hydrocortisone valerate topical ointment Tier 1

hydrocortisone-min oil-wht pet topical ointment Tier 1

KENALOG TOPICAL AEROSOL Tier 3

LOCOID LIPOCREAM TOPICAL CREAM Tier 3

LOCOID TOPICAL LOTION Tier 3

LUXIQ TOPICAL FOAM Tier 3

mometasone topical cream Tier 1

mometasone topical ointment Tier 1

mometasone topical solution Tier 1

OLUX TOPICAL FOAM Tier 3

OLUX-E TOPICAL FOAM Tier 3

PANDEL TOPICAL CREAM Tier 3

prednicarbate topical cream Tier 1

prednicarbate topical ointment Tier 1

PSORCON TOPICAL CREAM Tier 3

SYNALAR CREAM KIT TOPICAL CREAM Tier 3

SYNALAR OINTMENT KIT TOPICAL COMBO PACK,OINTMENT AND CREAM

Tier 3

SYNALAR TOPICAL CREAM Tier 3

SYNALAR TOPICAL SOLUTION Tier 3

SYNALAR TS TOPICAL KIT Tier 3

TEMOVATE TOPICAL CREAM Tier 3

TEMOVATE TOPICAL OINTMENT Tier 3


69

TEXACORT TOPICAL SOLUTION Tier 3

TOPICORT TOPICAL CREAM 0.05 % Tier 3

TOPICORT TOPICAL GEL Tier 3

TOPICORT TOPICAL OINTMENT 0.05 % Tier 3

TOPICORT TOPICAL SPRAY,NON-AEROSOL

Tier 3

triamcinolone acetonide topical aerosol Tier 1

triamcinolone acetonide topical cream Tier 1

triamcinolone acetonide topical lotion Tier 1

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

Tier 1

trianex topical ointment Tier 1

triderm topical cream 0.1 % Tier 1

ULTRAVATE X TOPICAL COMBO PACK Tier 3

ULTRAVATE X TOPICAL COMBO PACK,OINTMENT AND CREAM

Tier 3

VANOS TOPICAL CREAM Tier 3

VERDESO TOPICAL FOAM Tier 3

Topical Scabicides / Pediculicides ELIMITE TOPICAL CREAM Tier 3

EURAX TOPICAL CREAM Tier 3

EURAX TOPICAL LOTION Tier 3

lindane topical shampoo Tier 1

malathion topical lotion Tier 1

NATROBA TOPICAL SUSPENSION Tier 3

OVIDE TOPICAL LOTION Tier 3

permethrin topical cream Tier 1

spinosad topical suspension Tier 1

ULESFIA TOPICAL LOTION Tier 3


Diagnostics & Miscellaneous Agents Anorexiants ADIPEX-P ORAL CAPSULE Tier 3 #

ADIPEX-P ORAL TABLET Tier 3 #

BELVIQ ORAL TABLET Tier 3 #

70

benzphetamine oral tablet Tier 1 #

CONTRAVE ORAL TABLET EXTENDED RELEASE

Tier 3 #

diethylpropion oral tablet Tier 1 #

diethylpropion oral tablet extended release Tier 1 #

LOMAIRA ORAL TABLET Tier 3 #

phendimetrazine tartrate oral capsule, extended release

Tier 1 #

phendimetrazine tartrate oral tablet Tier 1 #

phentermine oral capsule Tier 1 #

phentermine oral tablet Tier 1 #

QSYMIA ORAL CAPSULE, ER MULTIPHASE 24 HR

Tier 3 #

REGIMEX ORAL TABLET Tier 3 #

SAXENDA SUBCUTANEOUS PEN INJECTOR

Tier 3 #

XENICAL ORAL CAPSULE Tier 3 #

Irrigating Solutions lactated ringers irrigation solution Tier 1

neomycin-polymyxin b gu irrigation solution Tier 1

PHYSIOLYTE IRRIGATION SOLUTION Tier 3

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION

Tier 3

ringer's irrigation solution Tier 1

SORBITOL IRRIGATION SOLUTION Tier 3

SORBITOL-MANNITOL URETHRAL SOLUTION

Tier 3

Miscellaneous Agents acamprosate oral tablet,delayed release (dr/ec) Tier 1

acetic acid irrigation solution Tier 1

ACTONEL ORAL TABLET 30 MG Tier 3

AGRYLIN ORAL CAPSULE Tier 3

alendronate oral tablet 40 mg Tier 1

anagrelide oral capsule Tier 1

ANTABUSE ORAL TABLET Tier 3


71

bd pre-filled normal saline injection syringe Tier 1

BUPHENYL ORAL POWDER Tier 3

BUPHENYL ORAL TABLET Tier 3

caffeine citrate oral solution Tier 1

CARBAGLU ORAL TABLET, DISPERSIBLE Tier 3 LD

CARNITOR (SUGAR-FREE) ORAL SOLUTION

Tier 3

CARNITOR ORAL SOLUTION Tier 3

CARNITOR ORAL TABLET Tier 3

cevimeline oral capsule Tier 1

CHEMET ORAL CAPSULE Tier 3

disulfiram oral tablet Tier 1

etidronate disodium oral tablet Tier 1

EVOXAC ORAL CAPSULE Tier 3

EXJADE ORAL TABLET, DISPERSIBLE Tier 3 LD; SPRx

FERRIPROX ORAL TABLET Tier 3 LD; SPRx

JADENU ORAL TABLET Tier 3 LD; SPRx

levocarnitine (with sugar) oral solution Tier 1

levocarnitine oral tablet Tier 1

LITHOSTAT ORAL TABLET Tier 3

METOPIRONE ORAL CAPSULE Tier 3

midodrine oral tablet Tier 1

monoject 0.9% sodium chloride injection syringe Tier 1

monoject prefill advanced ns injection syringe Tier 1

monoject prefill saline flush injection syringe Tier 1

normal saline flush injection syringe Tier 1

NORTHERA ORAL CAPSULE Tier 3 PA; LD; SPRx

ORFADIN ORAL CAPSULE Tier 3 LD; SPRx

pilocarpine hcl oral tablet 5 mg Tier 1

RADIOGARDASE ORAL CAPSULE Tier 3

RAVICTI ORAL LIQUID Tier 3 LD; SPRx

RILUTEK ORAL TABLET Tier 3

riluzole oral tablet Tier 1


72

risedronate oral tablet 30 mg Tier 1

SALAGEN (PILOCARPINE) ORAL TABLET 5 MG

Tier 3

sodium chlor 0.9% bacteriostat injection solution Tier 1

sodium chloride 0.9 % injection syringe Tier 1

sodium chloride irrigation solution Tier 1

sodium phenylbutyrate oral powder Tier 1

SYPRINE ORAL CAPSULE Tier 3 PA; SPRx

syrex sodium chloride 0.9 % injection syringe Tier 1

THIOLA ORAL TABLET Tier 3 SPRx

trientine oral capsule Tier 1 PA; SPRx

water for irrigation, sterile irrigation solution Tier 1

Phenylketonuria (Pku) Nutritional Products CAMINO PRO 15 PE PKU ORAL LIQUID IN PACKET

Tier 3

EAA SUPPLEMENT ORAL POWDER IN PACKET

Tier 3

GLYTACTIN 10 PE COMPLETE ORAL BAR Tier 3

GLYTACTIN 15 PE BETTERMILK ORAL POWDER IN PACKET

Tier 3

GLYTACTIN 15 PE COMPLETE ORAL BAR Tier 3

GLYTACTIN 20PE BETTERMILK LITE ORAL POWDER IN PACKET

Tier 3

GLYTACTIN BUILD 10 PE ORAL POWDER IN PACKET

Tier 3

GLYTACTIN RESTORE 10 PE LITE ORAL LIQUID

Tier 3

GLYTACTIN RESTORE 10 PE LITE ORAL POWDER IN PACKET

Tier 3

GLYTACTIN RESTORE 10 PE ORAL LIQUID

Tier 3

GLYTACTIN RESTORE 5 PE ORAL POWDER IN PACKET

Tier 3

GLYTACTIN RTD 10 PE ORAL LIQUID Tier 3

GLYTACTIN RTD 15 PE ORAL LIQUID Tier 3


73

GLYTACTIN SWIRL 15 PE ORAL POWDER IN PACKET

Tier 3

LANAFLEX ORAL POWDER IN PACKET Tier 3

LOPHLEX ORAL POWDER IN PACKET Tier 3

PERIFLEX ADVANCE ORAL POWDER Tier 3

PERIFLEX INFANT ORAL POWDER Tier 3

PERIFLEX JUNIOR ORAL POWDER Tier 3

PERIFLEX LQ PKU ORAL LIQUID Tier 3

PHENACTIN AA PLUS 20 PE ORAL LIQUID Tier 3

PHENEX-1 ORAL POWDER Tier 3

PHENEX-2 ORAL POWDER Tier 3

PHENYLADE 40 ORAL POWDER IN PACKET

Tier 3

PHENYLADE 60 ORAL POWDER Tier 3

PHENYLADE 60 ORAL POWDER IN PACKET

Tier 3

PHENYLADE AMINO ACID ORAL BAR Tier 3

PHENYLADE AMINO ACIDS ORAL POWDER

Tier 3

PHENYLADE AMINO ACIDS ORAL POWDER IN PACKET

Tier 3

PHENYLADE DRINK MIX ORAL POWDER Tier 3

PHENYLADE ESSENTIAL ORAL POWDER Tier 3

PHENYLADE ESSENTIAL ORAL POWDER IN PACKET

Tier 3

PHENYLADE GMP MIX-IN ORAL POWDER IN PACKET

Tier 3

PHENYLADE GMP ORAL POWDER Tier 3

PHENYLADE GMP ORAL POWDER IN PACKET

Tier 3

PHENYLADE MTE AMINO ACIDS ORAL POWDER

Tier 3

PHENYLADE MTE AMINO ACIDS ORAL POWDER IN PACKET

Tier 3

PHENYLADE PHEBLOC ORAL POWDER IN PACKET

Tier 3

phenylade phebloc oral tablet Tier 1


74

PHENYLADE RTD PKU 10 ORAL LIQUID Tier 3

PHENYL-FREE 1 ORAL POWDER Tier 3

PHENYL-FREE 2 PKU ORAL POWDER Tier 3

PHENYL-FREE 2HP PKU ORAL POWDER Tier 3

PHLEXY-10 DRINK MIX POWDER ORAL POWDER IN PACKET

Tier 3

PHLEXY-10 ORAL TABLET 8.33 GRAM-35 KCAL/10

Tier 3

PKU 2 ORAL POWDER Tier 3

PKU 3 ORAL POWDER Tier 3

PKU AIR15 ORAL LIQUID IN PACKET Tier 3

PKU AIR20 ORAL LIQUID IN PACKET Tier 3

PKU COOLER 10 ORAL SUSPENSION Tier 3



PKU EASY MICROTABS ORAL GRANULES DELAYED RELEASE

Tier 3

PKU EXPRESS15 ORAL POWDER IN PACKET

Tier 3

PKU EXPRESS20 ORAL POWDER IN PACKET

Tier 3

PKU GEL POWDER ORAL POWDER IN PACKET

Tier 3

PKU LOPHLEX ORAL LIQUID IN PACKET Tier 3

PKU PERIFLEX EARLY YEARS ORAL POWDER

Tier 3

PKU PERIFLEX JUNIOR PLUS ORAL POWDER

Tier 3

PKU SPHERE20 ORAL POWDER IN PACKET

Tier 3

PKU TRIO ORAL POWDER Tier 3

XPHE MAXAMAID ORAL POWDER Tier 3

xphe maxamum oral powder Tier 1

XPHE MAXAMUM ORAL POWDER IN PACKET

Tier 3

Smoking Deterrents


75

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

Tier 1 ACA

CHANTIX CONTINUING MONTH BOX ORAL TABLET

Tier 3 ACA

CHANTIX ORAL TABLET Tier 3 ACA

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

Tier 3 ACA

NICODERM CQ TRANSDERMAL PATCH 24 HOUR 14 MG/24 HR, 7 MG/24 HR

Tier 3 ACA

NICORETTE BUCCAL GUM 2 MG Tier 3 ACA

NICORETTE BUCCAL MINI LOZENGE 2 MG

Tier 3 ACA

nicotine (polacrilex) buccal lozenge Tier 1 ACA

nicotine (polacrilex) buccal mini lozenge Tier 1 ACA

NICOTROL INHALATION CARTRIDGE Tier 3 ACA

NICOTROL NS NASAL SPRAY,NON-AEROSOL

Tier 3 ACA

ZYBAN ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3 ACA


Ear, Nose & Throat Medications Miscellaneous Agents ARESTIN DENTAL CARTRIDGE Tier 3

ASTEPRO NASAL SPRAY,NON-AEROSOL Tier 3

azelastine nasal aerosol,spray Tier 1

azelastine nasal spray,non-aerosol Tier 1

BACTROBAN NASAL NASAL OINTMENT Tier 3

chlorhexidine gluconate mucous membrane mouthwash

Tier 1

CLINPRO 5000 DENTAL PASTE Tier 3

denta 5000 plus dental cream Tier 1

dentagel dental gel Tier 1

FLUORIDEX DAILY DEFENSE DENTAL PASTE

Tier 3

ipratropium bromide nasal spray,non-aerosol Tier 1

olopatadine nasal spray,non-aerosol Tier 1

oralone dental paste Tier 1

76

ORAMAGICRX MUCOUS MEMBRANE MOUTHWASH

Tier 3

PATANASE NASAL SPRAY,NON-AEROSOL Tier 3

PERIDEX MUCOUS MEMBRANE MOUTHWASH

Tier 3

periogard mucous membrane mouthwash Tier 1

pilocarpine hcl oral tablet 7.5 mg Tier 1

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE

Tier 3

PREVIDENT 5000 DRY MOUTH DENTAL GEL

Tier 3

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE

Tier 3

PREVIDENT 5000 SENSITIVE DENTAL PASTE

Tier 3

PREVIDENT DENTAL SOLUTION Tier 3

SALAGEN (PILOCARPINE) ORAL TABLET 7.5 MG

Tier 3

sf 5000 plus dental cream Tier 1

sf dental gel Tier 1

triamcinolone acetonide dental paste Tier 1

Miscellaneous Otic Preparations acetic acid otic (ear) solution Tier 1

ciprofloxacin hcl otic (ear) dropperette Tier 1

DERMOTIC OIL OTIC (EAR) DROPS Tier 3

floxin otic (ear) drops Tier 1

fluocinolone acetonide oil otic (ear) drops Tier 1

hydrocortisone-acetic acid otic (ear) drops Tier 1

ofloxacin otic (ear) drops Tier 1

Otic Steroid / Antibiotic CIPRO HC OTIC (EAR) DROPS,SUSPENSION

Tier 3

CIPRODEX OTIC (EAR) DROPS,SUSPENSION

Tier 2

COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION

Tier 3


77

neomycin-polymyxin-hc otic (ear) drops,suspension

Tier 1

neomycin-polymyxin-hc otic (ear) solution Tier 1

OTOVEL OTIC (EAR) SOLUTION Tier 2


Endocrine/Diabetes Adrenal Hormones ACTHAR H.P. INJECTION GEL Tier 3 PA; SPRx

CORTEF ORAL TABLET Tier 3

cortisone oral tablet Tier 1

decadron oral tablet Tier 1

deltasone oral tablet 20 mg Tier 1

dexamethasone intensol oral drops Tier 1

dexamethasone oral elixir Tier 1

dexamethasone oral solution Tier 1

dexamethasone oral tablet Tier 1

EMFLAZA ORAL SUSPENSION Tier 3 PA; LD; SPRx

EMFLAZA ORAL TABLET Tier 3 PA; LD; SPRx

fludrocortisone oral tablet Tier 1

hydrocortisone oral tablet Tier 1

MEDROL (PAK) ORAL TABLETS,DOSE PACK

Tier 3

MEDROL ORAL TABLET Tier 3

methylprednisolone oral tablet Tier 1

methylprednisolone oral tablets,dose pack Tier 1

millipred dp oral tablets,dose pack Tier 1

MILLIPRED ORAL SOLUTION Tier 3

millipred oral tablet Tier 1

ORAPRED ODT ORAL TABLET,DISINTEGRATING

Tier 3

PEDIAPRED ORAL SOLUTION Tier 3

prednisolone oral solution 15 mg/5 ml Tier 1

prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

Tier 1

78

prednisolone sodium phosphate oral tablet,disintegrating

Tier 1

prednisone intensol oral concentrate Tier 1

prednisone oral solution Tier 1

prednisone oral tablet Tier 1

prednisone oral tablets,dose pack Tier 1

veripred 20 oral solution Tier 1

Antithyroid Agents methimazole oral tablet 10 mg, 5 mg Tier 1

propylthiouracil oral tablet Tier 1

SSKI ORAL SOLUTION Tier 3

TAPAZOLE ORAL TABLET Tier 3

Blood Glucose Monitoring Devices & Supplies ACCU-CHEK AVIVA PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ACCU-CHEK SMARTVIEW TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ACCUTREND GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

ADVANCED GLUC METER TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ADVOCATE REDI-CODE STRIP Tier 3 ST; QL (102 EA per 30 days)

ADVOCATE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

AGAMATRIX AMP TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ASSURE 4 STRIP Tier 3 ST; QL (102 EA per 30 days)

ASSURE PLATINUM STRIP Tier 3 ST; QL (102 EA per 30 days)

ASSURE PRISM MULTI STRIP Tier 3 ST; QL (102 EA per 30 days)

BIONIME RIGHTEST TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

BLOOD GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

BREEZE 2 TEST STRIPS STRIP Tier 2 QL (102 EA per 30 days)

CARESENS N TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE MICRO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE PRO STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE VOICE+ TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

CONTOUR NEXT STRIP Tier 2 QL (102 EA per 30 days)

CONTOUR TEST STRIP Tier 2 QL (102 EA per 30 days)


79

COOL GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

DIATRUE PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY PLUS II TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY STEP STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY TALK GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY TOUCH TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY TRAK GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASYGLUCO PLUS STRIP Tier 3 ST; QL (102 EA per 30 days)

EASYGLUCO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASYMAX STRIP Tier 3 ST; QL (102 EA per 30 days)

ELEMENT COMPACT TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ELEMENT TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EMBRACE BLOOD GLUCOSE SYSTEM STRIP

Tier 3 ST; QL (102 EA per 30 days)

EMBRACE EVO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EMBRACE PRO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EVENCARE G2 STRIP Tier 3 ST; QL (102 EA per 30 days)

EVENCARE G3 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EVENCARE MINI GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EVOLUTION TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EZ SMART PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EZ SMART TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FIFTY50 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA D15G STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA D20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA D40-G31 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA G20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA G30A STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA GD50 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA TN'G VOICE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA V10 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA V12 GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)


80

FORA V20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORACARE GD20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORACARE GD40 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORTISCARE GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FREESTYLE INSULINX STRIP Tier 3 ST; QL (102 EA per 30 days)

FREESTYLE INSULINX TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FREESTYLE LITE STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

FREESTYLE PRECISION NEO STRIP Tier 3 ST; QL (102 EA per 30 days)

FREESTYLE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

GE100 BLOOD GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

GENSTRIP TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCO NAVII TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD 01 SENSOR PLUS STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD EXPRESSION STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD SHINE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD VITAL SENSOR STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD VITAL TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCOM GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

GM100 STRIP Tier 3 ST; QL (102 EA per 30 days)

HEALTHPRO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

INFINITY TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

MICRO BLOOD GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

MICRODOT BLOOD GLUCOSE SYSTEM STRIP

Tier 3 ST; QL (102 EA per 30 days)

MYGLUCOHEALTH STRIP Tier 3 ST; QL (102 EA per 30 days)

NEUTEK 2TEK TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

NOVA MAX GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ON CALL EXPRESS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ON CALL PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ON CALL VIVID TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ONETOUCH VERIO STRIP Tier 2 QL (102 EA per 30 days)

OPTIUM EZ STRIP Tier 3 ST; QL (102 EA per 30 days)

OPTIUM TEST STRIP Tier 3 ST; QL (102 EA per 30 days)


81

OPTUMRX STRIP Tier 3 ST; QL (102 EA per 30 days)

PHARMACIST CHOICE STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION PCX PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION PCX TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION POINT OF CARE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION Q-I-D TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION XTRA TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PREMIUM V10 STRIP Tier 3 ST; QL (102 EA per 30 days)

PRODIGY NO CODING STRIP Tier 3 ST; QL (102 EA per 30 days)

QUINTET AC STRIP Tier 3 ST; QL (102 EA per 30 days)

REFUAH PLUS STRIP Tier 3 ST; QL (102 EA per 30 days)

RELION CONFIRM-MICRO STRIP Tier 3 ST; QL (102 EA per 30 days)

RELION PRIME TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

REVEAL TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

RIGHTEST GS550 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

SMART SENSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

SMARTEST TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

SURE-TEST EASYPLUS MINI STRIP Tier 3 ST; QL (102 EA per 30 days)

TELCARE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

TEST N'GO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

TRUE METRIX GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

TRUETEST TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

TRUETRACK TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ULTIMA TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

ULTRATRAK STRIP Tier 3 ST; QL (102 EA per 30 days)

ULTRATRAK ULTIMATE STRIP Tier 3 ST; QL (102 EA per 30 days)

UNISTRIP1 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

WAVESENSE JAZZ STRIP Tier 3 ST; QL (102 EA per 30 days)

WAVESENSE PRESTO STRIP Tier 3 ST; QL (102 EA per 30 days)

Diabetes, Supplies, & Durable Medical Equipment GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN

Tier 2

Glucose Elevating Agents


82

GLUCAGEN HYPOKIT INJECTION RECON SOLN

Tier 2

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT

Tier 2

PROGLYCEM ORAL SUSPENSION Tier 3

TRUEPLUS GLUCOSE ORAL GEL IN PACKET

Tier 3

Insulin Syringes/Miscellaneous Durable Medical Equ 1ST TIER UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2"


1ST TIER UNILET COMFORTOUCH 28 GAUGE

Tier 2

ACCU-CHEK FASTCLIX Tier 2

ACCU-CHEK SAFE-T-PRO Tier 2

ACCU-CHEK SOFTCLIX LANCETS Tier 2

ACTI-LANCE LANCETS 23 GAUGE Tier 2

ADVANCED TRAVEL LANCETS 30 GAUGE Tier 2

ADVOCATE LANCET 30 GAUGE Tier 2

ADVOCATE PEN NEEDLE NEEDLE 29 GAUGE X 1/2"


ALCOHOL SWABS TOPICAL PADS, MEDICATED


ALTERNATE SITE LANCET Tier 2

ASSURE HAEMOLANCE PLUS 1.2 MM Tier 3

ASSURE LANCE 25 GAUGE Tier 2

ASSURE LANCE PLUS 21 GAUGE Tier 2

BD ECLIPSE NEEDLE 25 GAUGE X 1" Tier 2 QL (1000 EA per 30 days)

BD FILTER NEEDLE-5 MICRON NEEDLE Tier 2 QL (1000 EA per 30 days)

BD INSULIN PEN NEEDLE UF SHORT NEEDLE


BD INTEGRA NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days)

BD MICROTAINER LANCET 30 GAUGE Tier 2

BD NOKOR ADMIX NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days)

BD PRECISIONGLIDE NEEDLE 27 GAUGE X 1 1/2"



83

BD PRECISIONGLIDE NON-STERILE NEEDLE 18 GAUGE X 1 1/2"


BD SAFETYGLIDE NEEDLE NEEDLE 22 GAUGE X 1 1/2"


BD SPECIALTY USE NEEDLES NEEDLE 30 GAUGE X 1/2"


BD ULTRA FINE LANCETS Tier 2

BD ULTRA-FINE NANO PEN NEEDLES NEEDLE


BLUNT NEEDLE, DISPOSABLE NEEDLE 18 X 1 1/2 "


BULLSEYE MINI SAFETY LANCETS 21 GAUGE

Tier 2

CAREFINE PEN NEEDLE NEEDLE 31 GAUGE X 1/4"


CAREONE THIN LANCET Tier 2

CLEVER CHEK LANCETS Tier 2

CLICKFINE NEEDLE 31 GAUGE X 1/4" Tier 2 QL (1000 EA per 30 days)

COAGUCHEK LANCETS Tier 2

COLOR LANCETS Tier 2

COMFORT EZ PEN NEEDLES NEEDLE 31 GAUGE X 5/16"


COMFORT LANCETS Tier 2

DROPLET LANCETS Tier 2

DROPLET PEN NEEDLE NEEDLE 32 GAUGE X 5/32"


EASY COMFORT LANCETS Tier 2

EASY COMFORT PEN NEEDLES NEEDLE 31 GAUGE X 3/16"


EASY TOUCH FLIPLOCK NEEDLE NEEDLE 22 GAUGE X 3/4", 25 GAUGE X 1 1/2"


EASY TOUCH HYPODERMIC NEEDLE NEEDLE 32 GAUGE X 5/16"


EXEL HYPODERMIC NEEDLES NEEDLE 27 GAUGE X 1/2"


e-z ject lancets 26 gauge Tier 1


84

EZ SMART LANCETS Tier 2

FIFTY50 SAFETY SEAL LANCETS 30 GAUGE

Tier 2

FINE 30 UNIVERSAL LANCETS Tier 2

FINGERSTIX LANCETS Tier 2

FLOW-EZE VENTED NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days)

FORA V10-V12-D10-D20 STRP-LNCT COMBO PACK

Tier 3

FORACARE LANCETS Tier 2

FREESTYLE LANCETS Tier 2

FREESTYLE UNISTIK 2 Tier 2

GLUCOCOM LANCETS 28 GAUGE, 33 GAUGE

Tier 2

HEALTHY ACCENTS UNIFINE PENTIP NEEDLE 29 GAUGE X 1/2"


HEALTHY ACCENTS UNILET LANCET Tier 2

huber safety needles (disp.) needle Tier 1 QL (1000 EA per 30 days)

INCONTROL PEN NEEDLE NEEDLE 29 GAUGE X 1/2"


INCONTROL SUPER THIN LANCETS Tier 2

INCONTROL ULTRA THIN LANCETS Tier 2

INJECT EASE LANCETS 28 GAUGE Tier 2

INSUPEN NEEDLE 29 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)

INVACARE LANCETS Tier 2

lancets Tier 2

LANCETS 30 GAUGE Tier 2

LANCETS,THIN , 28 GAUGE Tier 2

LIFESHIELD BLUNT CANNULA NEEDLE Tier 2 QL (1000 EA per 30 days)

LITE TOUCH LANCETS 33 GAUGE Tier 2

MEDISENSE THIN LANCETS Tier 2

MEDLANCE PLUS LANCETS 25 GAUGE Tier 2

MEDLANCE PLUS SPECIAL BLADE Tier 3

MICRO THIN LANCETS Tier 2

MICROLET LANCET Tier 2

MINI ULTRA-THIN II NEEDLE Tier 2 QL (1000 EA per 30 days)


85

MONOJECT BLOOD COLLECTION NEEDLE 20 GAUGE X 1"


MONOJECT HYPODERMIC NEEDLES NEEDLE 18 GAUGE X 1"


MONOJECT MEDICATION TRANSF NDL NEEDLE


MONOLET THIN LANCETS Tier 2

MULTI-DRAW NEEDLE NEEDLE 20 GAUGE X 1"


MYGLUCOHEALTH LANCETS Tier 2

NEEDLES, HUBER DISPOSABLE NEEDLE Tier 2 QL (1000 EA per 30 days)

NOKOR NEEDLE NEEDLE 16 GAUGE X 1" Tier 2 QL (1000 EA per 30 days)

NOVA SAFETY LANCETS 28 GAUGE Tier 2

NOVA SUREFLEX LANCETS Tier 2

NOVOFINE 32 NEEDLE Tier 2 QL (1000 EA per 30 days)

NOVOFINE AUTOCOVER NEEDLE Tier 2 QL (1000 EA per 30 days)

NOVOFINE PLUS NEEDLE Tier 3 QL (1000 EA per 30 days)

NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN

Tier 3

ON CALL LANCET Tier 2

ON CALL PLUS LANCET Tier 2

ONETOUCH ULTRASOFT LANCETS Tier 2

ON-THE-GO LANCETS Tier 2

PEN NEEDLE NEEDLE 29 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)

PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2"


PENTIPS NEEDLE 31 GAUGE X 1/4" Tier 3 QL (1000 EA per 30 days)

PENTIPS NEEDLE 31 GAUGE X 5/16" Tier 2 QL (1000 EA per 30 days)

PHASEAL PROTECTOR DEVICE 20 MM Tier 2 QL (1000 EA per 30 days)

POLY HUB NEEDLE NEEDLE 18 GAUGE X 1"


PRESSURE ACTIVATED LANCETS 21 GAUGE

Tier 2

PRO COMFORT LANCET 30 GAUGE Tier 3

PRODIGY LANCETS 28 GAUGE Tier 2

PRODIGY TWIST TOP LANCET Tier 2


86

RELIAMED LANCET 28 GAUGE Tier 2

RELIAMED SAFETY SEAL LANCETS 28 GAUGE

Tier 2

RELION NEEDLES NEEDLE Tier 2 QL (1000 EA per 30 days)

RELION PEN NEEDLES NEEDLE Tier 3 QL (1000 EA per 30 days)

RELION THIN LANCETS Tier 2

RELION ULTRA THIN PLUS LANCETS Tier 2

RIGHTEST GL300 LANCETS Tier 2

SAFETY LANCETS 21 GAUGE Tier 2

SAFETY SEAL LANCETS 28 GAUGE Tier 2

SAFETY-LET LANCETS Tier 2

SINGLE-LET Tier 2

SMART SENSE LANCETS 26 GAUGE, 33 GAUGE

Tier 2

SMARTEST LANCET Tier 2

SOFT TOUCH LANCETS Tier 2

SOLUS V2 LANCETS 30 GAUGE Tier 2

STERILANCE TL 30 GAUGE Tier 2

SUPER THIN LANCETS 30 GAUGE Tier 2

SURE COMFORT LANCETS 28 GAUGE Tier 2

SURE COMFORT PEN NEEDLE NEEDLE 29 GAUGE X 1/2"


SURE-FINE PEN NEEDLES NEEDLE 29 GAUGE X 1/2"


SURE-LANCE 28 GAUGE Tier 2

SURE-TOUCH LANCET Tier 2

SURGUARD2 SAFETY NEEDLE 18 GAUGE X 1"


TECHLITE LANCETS 25 GAUGE Tier 2

TECHLITE PEN NEEDLE NEEDLE 31 GAUGE X 5/16"


TOPCARE UNIVERSAL1 LANCET Tier 2

TRUEPLUS LANCETS 28 GAUGE Tier 2

ULTICARE PEN NEEDLE NEEDLE 29 GAUGE X 1/2"



87

ULTILET BASIC LANCETS Tier 2

ULTILET CLASSIC LANCETS Tier 2

ULTILET LANCETS 28 GAUGE Tier 2

ULTILET PEN NEEDLE NEEDLE 29 GAUGE


ULTILET SAFETY LANCETS Tier 2

ULTRA THIN LANCETS 28 GAUGE Tier 2

ULTRA THIN PLUS LANCETS Tier 2

ULTRA TLC LANCETS Tier 2

ULTRALANCE LANCETS 26 GAUGE Tier 2

ULTRA-THIN II INS PEN NEEDLES NEEDLE


UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2"


UNIFINE PENTIPS PLUS NEEDLE 31 GAUGE X 5/16"


UNILET COMFORTOUCH LANCET 26 GAUGE

Tier 2

UNILET EXCELITE II LANCET Tier 2

UNILET EXCELITE LANCET Tier 2

UNILET GP LANCET Tier 2

UNILET LANCET 28 GAUGE Tier 2

UNISTIK 3 EXTRA LANCET Tier 2

UNISTIK CZT LANCET 23 GAUGE Tier 2

UNISTIK SAFETY 30 GAUGE Tier 2

UNISTIK TOUCH LANCETS 28 GAUGE Tier 2

UNIVERSAL 1 LANCETS 26 GAUGE Tier 2

VGO 20 DEVICE Tier 2



Insulin Therapy ADMELOG SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

ADMELOG U-100 INSULIN LISPRO SUBCUTANEOUS SOLUTION

Tier 3 ST


88

AFREZZA INHALATION CARTRIDGE WITH INHALER

Tier 3

APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 3 ST

FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 2

HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT

Tier 3 ST

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION

Tier 3

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION

Tier 3 ST

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE

Tier 3 ST

HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 3 ST

HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 3 ST

HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 3 ST

HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION

Tier 3 ST

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION

Tier 2


89

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 2

LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN

Tier 2

LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 2

NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION

Tier 2

NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION

Tier 2

NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE

Tier 2

NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION

Tier 2

SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN

Tier 2

TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN

Tier 2

TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN

Tier 2

XULTOPHY 100/3.6 SUBCUTANEOUS INSULIN PEN

Tier 2

Miscellaneous Hormones ANADROL-50 ORAL TABLET Tier 3 PA


90

ANDRODERM TRANSDERMAL PATCH 24 HOUR

Tier 3 PA

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

Tier 2 PA

ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM)

Tier 3 PA

ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

Tier 2 PA

ANDROID ORAL CAPSULE Tier 3 PA

BRAVELLE INJECTION RECON SOLN Tier 3 #

cabergoline oral tablet Tier 1

calcitonin (salmon) nasal spray,non-aerosol Tier 1

calcitriol oral capsule Tier 1

calcitriol oral solution Tier 1

CERDELGA ORAL CAPSULE Tier 3 PA; SPRx

CETROTIDE SUBCUTANEOUS KIT 0.25 MG

Tier 3 #

danazol oral capsule Tier 1

DDAVP NASAL AEROSOL,SPRAY Tier 3

DDAVP NASAL SOLUTION Tier 3

DDAVP ORAL TABLET Tier 3

DEPO-TESTOSTERONE INTRAMUSCULAR OIL

Tier 3 PA

desmopressin nasal solution Tier 1

desmopressin nasal spray,non-aerosol Tier 1

desmopressin oral tablet Tier 1

doxercalciferol oral capsule Tier 1

FOLLISTIM AQ SUBCUTANEOUS CARTRIDGE

Tier 3 #

GANIRELIX SUBCUTANEOUS SYRINGE Tier 3 #

GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR

Tier 3 #

GONAL-F RFF SUBCUTANEOUS RECON SOLN

Tier 3 #


91

GONAL-F SUBCUTANEOUS RECON SOLN Tier 3 #

KORLYM ORAL TABLET Tier 3 PA; LD; SPRx

KUVAN ORAL POWDER IN PACKET 500 MG

Tier 3 LD; SPRx

KUVAN ORAL TABLET,SOLUBLE Tier 3 LD; SPRx

MENOPUR SUBCUTANEOUS RECON SOLN Tier 3 #

METHITEST ORAL TABLET Tier 3 PA

methyltestosterone oral capsule Tier 1 PA

MIACALCIN INJECTION SOLUTION Tier 2

MYALEPT SUBCUTANEOUS RECON SOLN Tier 3 PA; LD; SPRx

NATPARA SUBCUTANEOUS CARTRIDGE Tier 3 PA; SPRx

OVIDREL SUBCUTANEOUS SYRINGE Tier 3 #

OXANDRIN ORAL TABLET Tier 3 PA

oxandrolone oral tablet Tier 1 PA

paricalcitol oral capsule Tier 1

PREGNYL INTRAMUSCULAR RECON SOLN

Tier 3 #

ROCALTROL ORAL CAPSULE Tier 3

ROCALTROL ORAL SOLUTION Tier 3

SAMSCA ORAL TABLET Tier 3 LD; SPRx

SENSIPAR ORAL TABLET Tier 3 SPRx

SOMAVERT SUBCUTANEOUS RECON SOLN 15 MG, 20 MG, 25 MG, 30 MG

Tier 3 LD; SPRx

STIMATE NASAL SPRAY,NON-AEROSOL Tier 3 SPRx

STRENSIQ SUBCUTANEOUS SOLUTION Tier 2 PA; LD; SPRx

STRIANT BUCCAL MUCOADHESIVE SYSTEM ER 12 HR

Tier 3 PA

SYNAREL NASAL SPRAY,NON-AEROSOL Tier 3

testosterone cypionate intramuscular oil Tier 1 PA

testosterone enanthate intramuscular oil Tier 1 PA

testosterone transdermal gel Tier 1 PA

testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)

Tier 1 PA

testosterone transdermal gel in packet Tier 1 PA

TESTRED ORAL CAPSULE Tier 3 PA


92

ZAVESCA ORAL CAPSULE Tier 3 LD; SPRx

ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG Tier 3

Non-Insulin Hypoglycemic Agents acarbose oral tablet Tier 1

ACTOPLUS MET ORAL TABLET Tier 3

ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR

Tier 3

ACTOS ORAL TABLET Tier 3

AMARYL ORAL TABLET Tier 3

AVANDIA ORAL TABLET 2 MG, 4 MG Tier 3

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR

Tier 2

BYDUREON SUBCUTANEOUS PEN INJECTOR

Tier 2

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON

Tier 2

BYETTA SUBCUTANEOUS PEN INJECTOR Tier 2

chlorpropamide oral tablet Tier 1

CYCLOSET ORAL TABLET Tier 3

DUETACT ORAL TABLET Tier 3

FARXIGA ORAL TABLET Tier 2

glimepiride oral tablet Tier 1

glipizide oral tablet Tier 1

glipizide oral tablet extended release 24hr Tier 1

glipizide-metformin oral tablet Tier 1

GLUCOPHAGE ORAL TABLET Tier 3

GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

GLUCOTROL ORAL TABLET Tier 3

GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR

Tier 3

GLUCOVANCE ORAL TABLET Tier 3

glyburide micronized oral tablet Tier 1

glyburide oral tablet Tier 1

glyburide-metformin oral tablet Tier 1


93

GLYNASE ORAL TABLET Tier 3

GLYSET ORAL TABLET Tier 3

GLYXAMBI ORAL TABLET Tier 2

INVOKAMET ORAL TABLET Tier 2

INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR

Tier 2

INVOKANA ORAL TABLET Tier 2

JANUMET ORAL TABLET Tier 2

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR

Tier 2

JANUVIA ORAL TABLET Tier 2

JENTADUETO ORAL TABLET Tier 2

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR

Tier 2

metformin oral tablet Tier 1

metformin oral tablet extended release 24 hr Tier 1 Generic for Glucophage XR

miglitol oral tablet Tier 1

nateglinide oral tablet Tier 1

pioglitazone oral tablet Tier 1

pioglitazone-glimepiride oral tablet Tier 1

pioglitazone-metformin oral tablet Tier 1

PRANDIN ORAL TABLET 1 MG, 2 MG Tier 3

PRECOSE ORAL TABLET Tier 3

repaglinide oral tablet Tier 1

repaglinide-metformin oral tablet Tier 1

RIOMET ORAL SOLUTION Tier 3

STARLIX ORAL TABLET Tier 3

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR

Tier 3

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR

Tier 3

tolazamide oral tablet Tier 1

tolbutamide oral tablet Tier 1

TRADJENTA ORAL TABLET Tier 2


94

TRULICITY SUBCUTANEOUS PEN INJECTOR

Tier 2

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR

Tier 2

Thyroid Hormones ARMOUR THYROID ORAL TABLET Tier 3

CYTOMEL ORAL TABLET Tier 3

LEVO-T ORAL TABLET Tier 3

levothyroxine oral tablet Tier 1

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

Tier 1

liothyronine oral tablet Tier 1

nature-throid oral tablet Tier 1

np thyroid oral tablet Tier 1

SYNTHROID ORAL TABLET Tier 3

thyroid (pork) oral tablet Tier 1

THYROLAR-1 ORAL TABLET Tier 3

THYROLAR-1/2 ORAL TABLET Tier 3

THYROLAR-1/4 ORAL TABLET Tier 3



unithroid oral tablet Tier 1

westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg

Tier 1

WP THYROID ORAL TABLET Tier 3


Gastroenterology Antidiarrheals & Antispasmodics chlordiazepoxide-clidinium oral capsule Tier 1

CUVPOSA ORAL SOLUTION Tier 3

dicyclomine oral capsule Tier 1

dicyclomine oral solution Tier 1

dicyclomine oral tablet Tier 1

diphenoxylate-atropine oral liquid Tier 1

95

diphenoxylate-atropine oral tablet Tier 1

DONNATAL ORAL ELIXIR 16.2-0.1037 -0.0194 MG/5 ML

Tier 3

DONNATAL ORAL TABLET Tier 3

glycopyrrolate oral tablet 1 mg, 2 mg Tier 1

hyoscyamine sulfate oral drops Tier 1

hyoscyamine sulfate oral elixir Tier 1

hyoscyamine sulfate oral tablet Tier 1

hyoscyamine sulfate oral tablet extended release 12 hr

Tier 1

hyoscyamine sulfate oral tablet,disintegrating Tier 1

hyoscyamine sulfate sublingual tablet Tier 1

LEVBID ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

LEVSIN ORAL TABLET Tier 3

LEVSIN/SL SUBLINGUAL TABLET Tier 3

LIBRAX (WITH CLIDINIUM) ORAL CAPSULE

Tier 3

LOMOTIL ORAL TABLET Tier 3

methscopolamine oral tablet Tier 1

MOTOFEN ORAL TABLET Tier 3

MYTESI ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

NULEV ORAL TABLET,DISINTEGRATING Tier 3

paregoric oral liquid Tier 1

propantheline oral tablet Tier 1

ROBINUL FORTE ORAL TABLET Tier 3

ROBINUL ORAL TABLET Tier 3

Miscellaneous Gastrointestinal Agents ACTIGALL ORAL CAPSULE Tier 3

alosetron oral tablet Tier 1

AMITIZA ORAL CAPSULE Tier 2

anucort-hc rectal suppository Tier 1

ANUSOL-HC RECTAL SUPPOSITORY Tier 3

ANZEMET ORAL TABLET Tier 3


96

aprepitant oral capsule Tier 1

aprepitant oral capsule,dose pack Tier 1

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 2

AURYXIA ORAL TABLET Tier 3

AZULFIDINE EN-TABS ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

AZULFIDINE ORAL TABLET Tier 3

balsalazide oral capsule Tier 1

bisacodyl oral tablet,delayed release (dr/ec) Tier 1 ACA

budesonide oral capsule,delayed,extend.release Tier 1

calcium acetate oral capsule Tier 1

calcium acetate oral tablet 667 mg Tier 1

CANASA RECTAL SUPPOSITORY Tier 2

CESAMET ORAL CAPSULE Tier 3

CHENODAL ORAL TABLET Tier 3 LD

CHOLBAM ORAL CAPSULE Tier 3 PA; LD; SPRx

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT

Tier 3 PA; SPRx

CIMZIA SUBCUTANEOUS SYRINGE KIT Tier 3 PA; SPRx

citrate of magnesia oral solution Tier 1 ACA

clearlax oral powder in packet Tier 1 ACA

COLAZAL ORAL CAPSULE Tier 3

colocort rectal enema Tier 1

COLYTE WITH FLAVOR PACKS ORAL RECON SOLN 240-22.72-6.72 -5.84 GRAM

Tier 3

COMPAZINE ORAL TABLET Tier 3

COMPAZINE RECTAL SUPPOSITORY Tier 3

compro rectal suppository Tier 1

constulose oral solution Tier 1

CORTENEMA RECTAL ENEMA Tier 3

CORTIFOAM RECTAL FOAM Tier 3

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 2

cromolyn oral concentrate Tier 1


97

CYSTADANE ORAL POWDER Tier 3 LD; SPRx

DIPENTUM ORAL CAPSULE Tier 3

dronabinol oral capsule Tier 1

eliphos oral tablet Tier 1

EMEND ORAL CAPSULE Tier 3

EMEND ORAL CAPSULE,DOSE PACK Tier 3

ENTOCORT EC ORAL CAPSULE,DELAYED,EXTEND.RELEASE

Tier 3

enulose oral solution Tier 1

FOSRENOL ORAL POWDER IN PACKET Tier 3

FOSRENOL ORAL TABLET,CHEWABLE Tier 3

GASTROCROM ORAL CONCENTRATE Tier 3

GATTEX 30-VIAL SUBCUTANEOUS KIT Tier 3 PA; LD; SPRx

GATTEX ONE-VIAL SUBCUTANEOUS KIT Tier 3 PA; SPRx

gavilyte-c oral recon soln Tier 1 ACA

gavilyte-g oral recon soln Tier 1 ACA

gavilyte-n oral recon soln Tier 1 ACA

generlac oral solution Tier 1

GIAZO ORAL TABLET Tier 3

GOLYTELY ORAL POWDER IN PACKET Tier 3 ACA

GOLYTELY ORAL RECON SOLN Tier 3

granisetron hcl oral tablet Tier 1

hemmorex-hc rectal suppository Tier 1

hydrocortisone acetate rectal suppository Tier 1

hydrocortisone rectal enema Tier 1

hydrocortisone topical cream with perineal applicator

Tier 1

hydrocortisone-pramoxine rectal cream 1-1 %, 2.5-1 % (4g)

Tier 1

kionex (with sorbitol) oral suspension Tier 1

kionex oral powder Tier 1

KRISTALOSE ORAL PACKET Tier 2

lactulose oral solution 10 gram/15 ml Tier 1

laxaclear oral powder Tier 1 ACA


98

laxative peg 3350 oral powder Tier 1 ACA

LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %

Tier 1

lidocaine hcl-hydrocortison ac rectal kit Tier 1

lidocaine-hydrocortisone-aloe rectal gel Tier 1

lidocaine-hydrocortisone-aloe rectal kit Tier 1

LINZESS ORAL CAPSULE Tier 2

LOTRONEX ORAL TABLET Tier 3

MAGNEBIND 400 ORAL TABLET Tier 3

MARINOL ORAL CAPSULE Tier 3

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

Tier 1

mesalamine rectal enema Tier 1

mesalamine with cleansing wipe rectal enema kit Tier 1

metoclopramide hcl oral solution Tier 1

metoclopramide hcl oral tablet Tier 1

NULYTELY WITH FLAVOR PACKS ORAL RECON SOLN

Tier 3

OCALIVA ORAL TABLET Tier 3 PA; SPRx

ondansetron hcl oral solution Tier 1

ondansetron hcl oral tablet Tier 1

ondansetron oral tablet,disintegrating Tier 1

OSMOPREP ORAL TABLET Tier 3 ACA

peg 3350-electrolytes oral recon soln Tier 1 ACA

peg-electrolyte soln oral recon soln Tier 1 ACA

peg-prep oral kit Tier 1 ACA

PENTASA ORAL CAPSULE, EXTENDED RELEASE

Tier 2

PHOSLYRA ORAL SOLUTION Tier 2

phosphate laxative oral liquid Tier 1 ACA

polyethylene glycol 3350 oral powder Tier 1 ACA

polyethylene glycol 3350 oral powder in packet Tier 1 ACA

pramcort rectal cream Tier 1


99

prochlorperazine maleate oral tablet Tier 1

prochlorperazine rectal suppository Tier 1

PROCTOCORT RECTAL SUPPOSITORY Tier 3

procto-med hc topical cream with perineal applicator

Tier 1

procto-pak topical cream with perineal applicator Tier 1

proctosol hc topical cream with perineal applicator

Tier 1

proctozone-hc topical cream with perineal applicator

Tier 1

REGLAN ORAL TABLET Tier 3

RELISTOR SUBCUTANEOUS SOLUTION Tier 3

RELISTOR SUBCUTANEOUS SYRINGE Tier 3

RENAGEL ORAL TABLET 800 MG Tier 3

RENVELA ORAL POWDER IN PACKET Tier 3

RENVELA ORAL TABLET Tier 3

ROWASA RECTAL ENEMA KIT Tier 3

scopolamine base transdermal patch 3 day Tier 1

sevelamer carbonate oral powder in packet Tier 1

sevelamer carbonate oral tablet Tier 1

sodium polystyrene sulfonate oral powder Tier 1

sodium polystyrene sulfonate oral suspension Tier 1

sodium polystyrene sulfonate rectal enema 30 gram/120 ml

Tier 1

SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML

Tier 3

SOLESTA IMPLANT GEL FOR IMPLANT IN SYRINGE

Tier 3

sps (with sorbitol) oral suspension Tier 1

sps (with sorbitol) rectal enema Tier 1

SUCRAID ORAL SOLUTION Tier 3

sulfasalazine oral tablet Tier 1

sulfasalazine oral tablet,delayed release (dr/ec) Tier 1

SUPREP BOWEL PREP KIT ORAL RECON SOLN

Tier 2 ACA


100

SYNDROS ORAL SOLUTION Tier 3

TIGAN ORAL CAPSULE 300 MG Tier 3

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY

Tier 3

trilyte with flavor packets oral recon soln Tier 1 ACA

trimethobenzamide oral capsule Tier 1

URSO 250 ORAL TABLET Tier 3

URSO FORTE ORAL TABLET Tier 3

ursodiol oral capsule Tier 1

ursodiol oral tablet Tier 1

VELPHORO ORAL TABLET,CHEWABLE Tier 2

VIBERZI ORAL TABLET Tier 3

VIOKACE ORAL TABLET Tier 3

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000 -55,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000- 16,000 UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000 -27,000 UNIT, 5,000-17,000- 24,000 UNIT

Tier 2

ZOFRAN (AS HYDROCHLORIDE) ORAL SOLUTION

Tier 3

ZOFRAN (AS HYDROCHLORIDE) ORAL TABLET

Tier 3

ZOFRAN ODT ORAL TABLET,DISINTEGRATING

Tier 3

Ulcer Therapy amoxicil-clarithromy-lansopraz oral combo pack Tier 1

CARAFATE ORAL SUSPENSION Tier 3

CARAFATE ORAL TABLET Tier 3

cimetidine hcl oral solution Tier 1

cimetidine oral tablet 300 mg, 400 mg, 800 mg Tier 1

CYTOTEC ORAL TABLET Tier 3

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS

Tier 3


101

esomeprazole magnesium oral capsule,delayed release(dr/ec)

Tier 1

famotidine oral suspension Tier 1

famotidine oral tablet 40 mg Tier 1

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

Tier 1

misoprostol oral tablet Tier 1

NEXIUM ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 3

NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET

Tier 3

nizatidine oral capsule Tier 1

nizatidine oral solution Tier 1

OMECLAMOX-PAK ORAL COMBO PACK Tier 2

omeprazole oral capsule,delayed release(dr/ec) Tier 1

pantoprazole oral tablet,delayed release (dr/ec) Tier 1

PEPCID ORAL SUSPENSION Tier 3

PEPCID ORAL TABLET 40 MG Tier 3

PREVACID SOLUTAB ORAL TABLET,DISINTEGRAT, DELAY REL

Tier 3

PREVPAC ORAL COMBO PACK Tier 3

PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON

Tier 3

PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET

Tier 3

PROTONIX ORAL TABLET,DELAYED RELEASE (DR/EC) 20 MG

Tier 3

PYLERA ORAL CAPSULE Tier 2

rabeprazole oral tablet,delayed release (dr/ec) Tier 1

ranitidine hcl oral capsule Tier 1

ranitidine hcl oral syrup Tier 1

ranitidine hcl oral tablet 300 mg Tier 1

sucralfate oral suspension Tier 1

sucralfate oral tablet Tier 1

ZANTAC ORAL TABLET 300 MG Tier 3


102


Immunology, Vaccines & Biotechnology Biotechnology Drugs ARANESP (IN POLYSORBATE) INJECTION SOLUTION

Tier 3 PA; SPRx

ARANESP (IN POLYSORBATE) INJECTION SYRINGE

Tier 3 PA; SPRx

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

Tier 3 PA; SPRx

MIRCERA INJECTION SYRINGE Tier 3 PA; LD; SPRx

MOZOBIL SUBCUTANEOUS SOLUTION Tier 3 LD; SPRx

NEULASTA SUBCUTANEOUS SYRINGE Tier 3 SPRx

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR

Tier 3 SPRx

NEUPOGEN INJECTION SOLUTION Tier 3 SPRx

NEUPOGEN INJECTION SYRINGE Tier 3 SPRx

PROCRIT INJECTION SOLUTION Tier 3 PA; SPRx

ZARXIO INJECTION SYRINGE Tier 3 SPRx

Growth Hormones NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR

Tier 3 PA; SPRx

Interferons AUBAGIO ORAL TABLET Tier 3 PA; LD; SPRx

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT

Tier 2 SPRx

AVONEX INTRAMUSCULAR PEN INJECTOR KIT

Tier 2 SPRx

AVONEX INTRAMUSCULAR SYRINGE KIT Tier 2 SPRx

BETASERON SUBCUTANEOUS KIT Tier 3 SPRx

BETASERON SUBCUTANEOUS RECON SOLN

Tier 3 SPRx

COPAXONE SUBCUTANEOUS SYRINGE Tier 2 SPRx

EXTAVIA SUBCUTANEOUS KIT Tier 3 SPRx

EXTAVIA SUBCUTANEOUS RECON SOLN Tier 3 SPRx

GILENYA ORAL CAPSULE Tier 2 SPRx

103

glatiramer subcutaneous syringe Tier 1 SPRx

glatopa subcutaneous syringe Tier 1 SPRx

moderiba dose pack oral tablets,dose pack Tier 1 PA; SPRx

moderiba oral tablet Tier 1 PA; SPRx

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR

Tier 2 SPRx

PEGASYS SUBCUTANEOUS SOLUTION Tier 2 SPRx

PEGASYS SUBCUTANEOUS SYRINGE Tier 2 SPRx

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML

Tier 3 SPRx

PLEGRIDY SUBCUTANEOUS PEN INJECTOR

Tier 2 SPRx

PLEGRIDY SUBCUTANEOUS SYRINGE Tier 2 SPRx

POMALYST ORAL CAPSULE Tier 3 PA; LD; SPRx

REBETOL ORAL SOLUTION Tier 3 PA; SPRx

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

Tier 2 SPRx

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR

Tier 2 SPRx

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

Tier 2 SPRx

REVLIMID ORAL CAPSULE Tier 3 PA; LD; SPRx

ribasphere oral capsule Tier 1 PA; SPRx

ribasphere oral tablet Tier 1 PA; SPRx

ribavirin oral capsule Tier 1 PA; SPRx

ribavirin oral tablet 200 mg Tier 1 PA; SPRx

SYLATRON SUBCUTANEOUS KIT Tier 3 LD; SPRx

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 2 LD; SPRx

Interleukins ACTIMMUNE SUBCUTANEOUS SOLUTION

Tier 3 SPRx

ALDARA TOPICAL CREAM IN PACKET Tier 3

ARCALYST SUBCUTANEOUS RECON SOLN

Tier 3 PA; SPRx

ILARIS (PF) SUBCUTANEOUS SOLUTION Tier 3 PA; SPRx


104

imiquimod topical cream in packet Tier 1

INTRON A INJECTION RECON SOLN Tier 3 LD; SPRx

INTRON A INJECTION SOLUTION Tier 3 LD; SPRx

KINERET SUBCUTANEOUS SYRINGE Tier 3 PA; LD; SPRx

Vaccines & Miscellaneous Immunologicals ACTHIB (PF) INTRAMUSCULAR RECON SOLN

Tier 3 ACA

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE

Tier 3 ACA

AFLURIA 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

AFLURIA 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 2 ACA

AFLURIA QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

AFLURIA QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 2 ACA

BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

BEXSERO INTRAMUSCULAR SYRINGE Tier 3 ACA

BIOTHRAX INTRAMUSCULAR SUSPENSION

Tier 3 ACA

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION

Tier 3 ACA

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

Tier 3 ACA

CUVITRU SUBCUTANEOUS SOLUTION Tier 3 PA; SPRx

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

Tier 3 ACA

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

Tier 3 ACA


105

FLUAD 2017-2018 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLUARIX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLUBLOK 2017-2018 (PF) INTRAMUSCULAR SOLUTION

Tier 2 ACA

FLUBLOK QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLUCELVAX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLUCELVAX QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 2 ACA

FLULAVAL QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLULAVAL QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 2 ACA

FLUMIST QUAD 2017-2018 NASAL NASAL SPRAY SYRINGE

Tier 3 ACA

FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLUVIRIN 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 2 ACA

FLUZONE HIGH-DOSE 2017-18 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLUZONE INTRADERM QUAD 2017-18 INTRADERMAL SYRINGE

Tier 2 ACA

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SUSPENSION

Tier 2 ACA

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLUZONE QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 2 ACA

FLUZONE QUAD PEDI 2017-18 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

GAMMAGARD LIQUID INJECTION SOLUTION

Tier 3 PA; LD; SPRx

GAMUNEX-C INJECTION SOLUTION Tier 3 PA; LD; SPRx

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA


106

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

Tier 3 ACA

GRASTEK SUBLINGUAL TABLET Tier 2 PA

HAVRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

HAVRIX (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

HIBERIX (PF) INTRAMUSCULAR RECON SOLN

Tier 3 ACA

HIZENTRA SUBCUTANEOUS SOLUTION Tier 3 PA; LD; SPRx

HYQVIA SUBCUTANEOUS SOLUTION Tier 3 PA; LD; SPRx

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN

Tier 3 ACA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

Tier 3 ACA

IPOL INJECTION SUSPENSION Tier 3 ACA

IXIARO (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

KINRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

KINRIX (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

MENACTRA (PF) INTRAMUSCULAR SOLUTION

Tier 3 ACA

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT

Tier 3 ACA

M-M-R II (PF) SUBCUTANEOUS RECON SOLN

Tier 3 ACA

ODACTRA SUBLINGUAL TABLET Tier 3 PA

ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY

Tier 3 PA; LD; SPRx

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 ACA

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION

Tier 3 ACA

PENTACEL (PF) INTRAMUSCULAR KIT Tier 3 ACA

PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN

Tier 3 ACA


107

PNEUMOVAX 23 INJECTION SOLUTION Tier 3 ACA

PNEUMOVAX 23 INJECTION SYRINGE Tier 3 ACA

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE

Tier 3 ACA

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

RAGWITEK SUBLINGUAL TABLET Tier 3 PA

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

Tier 3 ACA

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

ROTATEQ VACCINE ORAL SOLUTION Tier 3 ACA

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

TENIVAC (PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

TENIVAC (PF) INTRAMUSCULAR SYRINGE

Tier 3 ACA

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION

Tier 3 ACA

TRUMENBA INTRAMUSCULAR SYRINGE Tier 3 ACA

TWINRIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 ACA

TYPHIM VI INTRAMUSCULAR SOLUTION Tier 3 ACA

TYPHIM VI INTRAMUSCULAR SYRINGE Tier 3 ACA


108

VAQTA (PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

VAQTA (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

VIVOTIF BERNA VACCINE ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 3 ACA

VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 3 ACA

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 ACA


Musculoskeletal & Rheumatology Gout Therapy allopurinol oral tablet Tier 1

COLCRYS ORAL TABLET Tier 2

probenecid oral tablet Tier 1

probenecid-colchicine oral tablet Tier 1

ULORIC ORAL TABLET Tier 2

ZYLOPRIM ORAL TABLET Tier 3

Osteoporosis Therapy ACTONEL ORAL TABLET 150 MG, 35 MG, 5 MG

Tier 3

alendronate oral solution Tier 1

alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg Tier 1

ATELVIA ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

BINOSTO ORAL TABLET, EFFERVESCENT

Tier 3

BONIVA ORAL TABLET Tier 3

EVISTA ORAL TABLET Tier 3

FORTEO SUBCUTANEOUS PEN INJECTOR Tier 3 SPRx

FOSAMAX ORAL TABLET 70 MG Tier 3

109

FOSAMAX PLUS D ORAL TABLET Tier 3

ibandronate oral tablet Tier 1

raloxifene oral tablet Tier 1 ACA

risedronate oral tablet 150 mg, 35 mg, 5 mg Tier 1

risedronate oral tablet,delayed release (dr/ec) Tier 1

TYMLOS SUBCUTANEOUS PEN INJECTOR Tier 3

Other Rheumatologicals ACTEMRA SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx

ARAVA ORAL TABLET Tier 3

BENLYSTA SUBCUTANEOUS AUTO-INJECTOR

Tier 3 PA; SPRx

DEPEN TITRATABS ORAL TABLET Tier 3

ENBREL MINI SUBCUTANEOUS CARTRIDGE

Tier 2 PA; SPRx

ENBREL SUBCUTANEOUS RECON SOLN Tier 2 PA; SPRx

ENBREL SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

Tier 2 PA; SPRx

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT

Tier 2 PA; SPRx; QL (2 EA per 30 days)

HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT


HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT


HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT


HUMIRA SUBCUTANEOUS SYRINGE KIT Tier 2 PA; SPRx; QL (2 EA per 30 days)

leflunomide oral tablet Tier 1

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR

Tier 3 PA; SPRx; QL (4 ML per 30 days)

ORENCIA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx; QL (4 ML per 30 days)

OTEZLA ORAL TABLET Tier 2 PA; LD; SPRx

OTEZLA STARTER ORAL TABLETS,DOSE PACK

Tier 2 PA; LD; SPRx

RIDAURA ORAL CAPSULE Tier 3

SAVELLA ORAL TABLET Tier 2


110

SAVELLA ORAL TABLETS,DOSE PACK Tier 2

SIMPONI SUBCUTANEOUS PEN INJECTOR

Tier 3 PA; SPRx

SIMPONI SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx

XELJANZ ORAL TABLET Tier 2 PA; SPRx

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 2 PA; SPRx

Pulmonary Agents BENLYSTA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx


Obstetrics & Gynecology Estrogens & Progestins ACTIVELLA ORAL TABLET Tier 3

ALORA TRANSDERMAL PATCH SEMIWEEKLY

Tier 3

amabelz oral tablet Tier 1

ANGELIQ ORAL TABLET Tier 3

AYGESTIN ORAL TABLET Tier 3

camila oral tablet Tier 1 ACA

CLIMARA PRO TRANSDERMAL PATCH WEEKLY

Tier 3

CLIMARA TRANSDERMAL PATCH WEEKLY

Tier 3

COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY

Tier 3

covaryx h.s. oral tablet Tier 1

covaryx oral tablet Tier 1

CRINONE VAGINAL GEL 4 % Tier 3

deblitane oral tablet Tier 1 ACA

DELESTROGEN INTRAMUSCULAR OIL Tier 3

DEPO-ESTRADIOL INTRAMUSCULAR OIL Tier 3

DEPO-PROVERA INTRAMUSCULAR SUSPENSION

Tier 3

DEPO-PROVERA INTRAMUSCULAR SYRINGE

Tier 3

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE

Tier 3 ACA

111

DIVIGEL TRANSDERMAL GEL IN PACKET

Tier 2

DUAVEE ORAL TABLET Tier 3

eemt hs oral tablet Tier 1

eemt oral tablet Tier 1

ELESTRIN TRANSDERMAL GEL IN METERED-DOSE PUMP

Tier 3

errin oral tablet Tier 1 ACA

ESTRACE ORAL TABLET Tier 3

ESTRACE VAGINAL CREAM Tier 2

estradiol oral tablet Tier 1

estradiol transdermal patch semiweekly Tier 1

estradiol transdermal patch weekly Tier 1

estradiol vaginal cream Tier 1

estradiol vaginal tablet Tier 1

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

Tier 1

estradiol-norethindrone acet oral tablet Tier 1

ESTRING VAGINAL RING Tier 3

ESTROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP

Tier 3

estrogens-methyltestosterone oral tablet Tier 1

estropipate oral tablet Tier 1

EVAMIST TRANSDERMAL SPRAY,NON-AEROSOL

Tier 2

FEMHRT LOW DOSE ORAL TABLET Tier 3

FEMRING VAGINAL RING Tier 3

fyavolv oral tablet Tier 1 ACA

heather oral tablet Tier 1 ACA

jencycla oral tablet Tier 1 ACA

jevantique lo oral tablet Tier 1 ACA

jinteli oral tablet Tier 1 ACA

jolivette oral tablet Tier 1 ACA

lopreeza oral tablet Tier 1

lyza oral tablet Tier 1 ACA


112

medroxyprogesterone intramuscular suspension Tier 1 ACA

medroxyprogesterone intramuscular syringe Tier 1 ACA

medroxyprogesterone oral tablet Tier 1

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

Tier 3

MENOSTAR TRANSDERMAL PATCH WEEKLY

Tier 3

mimvey lo oral tablet Tier 1

mimvey oral tablet Tier 1

MINIVELLE TRANSDERMAL PATCH SEMIWEEKLY

Tier 2

nora-be oral tablet Tier 1 ACA

norethindrone (contraceptive) oral tablet Tier 1 ACA

norethindrone acetate oral tablet Tier 1

norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

Tier 1 ACA

norlyda oral tablet Tier 1 ACA

norlyroc oral tablet Tier 1 ACA

ORTHO MICRONOR ORAL TABLET Tier 3

PREFEST ORAL TABLET Tier 3

PREMARIN ORAL TABLET Tier 2

PREMARIN VAGINAL CREAM Tier 3 ST

PREMPHASE ORAL TABLET Tier 2

PREMPRO ORAL TABLET Tier 2

progesterone micronized oral capsule Tier 1

PROMETRIUM ORAL CAPSULE Tier 3

PROVERA ORAL TABLET Tier 3

sharobel oral tablet Tier 1 ACA

VAGIFEM VAGINAL TABLET Tier 3

VIVELLE-DOT TRANSDERMAL PATCH SEMIWEEKLY

Tier 3

yuvafem vaginal tablet Tier 1

Miscellaneous Ob/Gyn AVC VAGINAL VAGINAL CREAM Tier 3

CLEOCIN VAGINAL CREAM Tier 3


113

CLEOCIN VAGINAL SUPPOSITORY Tier 2

clindamycin phosphate vaginal cream Tier 1

CLINDESSE VAGINAL CREAM,EXTENDED RELEASE

Tier 3

fem ph vaginal gel Tier 1

GYNAZOLE-1 VAGINAL CREAM Tier 3

LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET

Tier 3 PA; SPRx

LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET

Tier 3 PA; SPRx

LYSTEDA ORAL TABLET Tier 3

METROGEL VAGINAL VAGINAL GEL Tier 3

metronidazole vaginal gel Tier 1

miconazole-3 vaginal suppository Tier 1

NUVARING VAGINAL RING Tier 2 ACA

NUVESSA VAGINAL GEL Tier 3

OSPHENA ORAL TABLET Tier 3 ST

RELAGARD VAGINAL GEL Tier 3

TERAZOL 7 VAGINAL CREAM Tier 3

terconazole vaginal cream Tier 1

terconazole vaginal suppository Tier 1

tranexamic acid oral tablet Tier 1

vandazole vaginal gel Tier 1

xulane transdermal patch weekly Tier 1 ACA

Oral Contraceptives & Related Agents altavera (28) oral tablet Tier 1 ACA

alyacen 1/35 (28) oral tablet Tier 1 ACA

alyacen 7/7/7 (28) oral tablet Tier 1 ACA

amethia lo oral tablets,dose pack,3 month Tier 1 ACA

amethia oral tablets,dose pack,3 month Tier 1 ACA

amethyst oral tablet Tier 1 ACA

apri oral tablet Tier 1 ACA

aranelle (28) oral tablet Tier 1 ACA

ashlyna oral tablets,dose pack,3 month Tier 1 ACA


114

aubra oral tablet Tier 1 ACA

aviane oral tablet Tier 1 ACA

azurette (28) oral tablet Tier 1 ACA

balziva (28) oral tablet Tier 1 ACA

bekyree (28) oral tablet Tier 1 ACA

BEYAZ ORAL TABLET Tier 3

blisovi 24 fe oral tablet Tier 1 ACA

blisovi fe 1.5/30 (28) oral tablet Tier 1 ACA

blisovi fe 1/20 (28) oral tablet Tier 1 ACA

BREVICON (28) ORAL TABLET Tier 3

briellyn oral tablet Tier 1 ACA

camrese lo oral tablets,dose pack,3 month Tier 1 ACA

camrese oral tablets,dose pack,3 month Tier 1 ACA

caziant (28) oral tablet Tier 1 ACA

chateal oral tablet Tier 1 ACA

cryselle (28) oral tablet Tier 1 ACA

cyclafem 1/35 (28) oral tablet Tier 1 ACA

cyclafem 7/7/7 (28) oral tablet Tier 1 ACA

CYCLESSA (28) ORAL TABLET Tier 3

cyred oral tablet Tier 1 ACA

dasetta 1/35 (28) oral tablet Tier 1 ACA

dasetta 7/7/7 (28) oral tablet Tier 1 ACA

daysee oral tablets,dose pack,3 month Tier 1 ACA

delyla (28) oral tablet Tier 1 ACA

desog-e.estradiol/e.estradiol oral tablet Tier 1 ACA

desogestrel-ethinyl estradiol oral tablet Tier 1 ACA

drospirenone-e.estradiol-lm.fa oral tablet Tier 1 ACA

drospirenone-ethinyl estradiol oral tablet Tier 1 ACA

elinest oral tablet Tier 1 ACA

ELLA ORAL TABLET Tier 3 ACA; QL (2 EA per 365 days)

emoquette oral tablet Tier 1 ACA

enpresse oral tablet Tier 1 ACA

enskyce oral tablet Tier 1 ACA


115

estarylla oral tablet Tier 1 ACA

ESTROSTEP FE-28 ORAL TABLET Tier 3

ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg

Tier 1 ACA

falmina (28) oral tablet Tier 1 ACA

fayosim oral tablets,dose pack,3 month Tier 1 ACA

femynor oral tablet Tier 1 ACA

GENERESS FE ORAL TABLET,CHEWABLE Tier 3

gianvi (28) oral tablet Tier 1 ACA

introvale oral tablets,dose pack,3 month Tier 1 ACA

isibloom oral tablet Tier 1 ACA

jolessa oral tablets,dose pack,3 month Tier 1 ACA

juleber oral tablet Tier 1 ACA

junel 1.5/30 (21) oral tablet Tier 1 ACA

junel 1/20 (21) oral tablet Tier 1 ACA

junel fe 1.5/30 (28) oral tablet Tier 1 ACA

junel fe 1/20 (28) oral tablet Tier 1 ACA

junel fe 24 oral tablet Tier 1 ACA

kaitlib fe oral tablet,chewable Tier 1 ACA

kariva (28) oral tablet Tier 1 ACA

kelnor 1/35 (28) oral tablet Tier 1 ACA

kimidess (28) oral tablet Tier 1 ACA

kurvelo oral tablet Tier 1 ACA

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month

Tier 1 ACA

larin 1.5/30 (21) oral tablet Tier 1 ACA

larin 1/20 (21) oral tablet Tier 1 ACA

larin 24 fe oral tablet Tier 1 ACA

larin fe 1.5/30 (28) oral tablet Tier 1 ACA

larin fe 1/20 (28) oral tablet Tier 1 ACA

larissia oral tablet Tier 1 ACA

layolis fe oral tablet,chewable Tier 1 ACA

leena 28 oral tablet Tier 1 ACA

lessina oral tablet Tier 1 ACA


116

levonest (28) oral tablet Tier 1 ACA

levonorgestrel-ethinyl estrad oral tablet Tier 1 ACA

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month

Tier 1 ACA

levonorg-eth estrad triphasic oral tablet Tier 1 ACA

levora-28 oral tablet Tier 1 ACA

lillow oral tablet Tier 1 ACA

LO LOESTRIN FE ORAL TABLET Tier 2 ACA

LOESTRIN 1.5/30 (21) ORAL TABLET Tier 3

LOESTRIN 1/20 (21) ORAL TABLET Tier 3

LOESTRIN FE 1.5/30 (28-DAY) ORAL TABLET

Tier 3

LOESTRIN FE 1/20 (28-DAY) ORAL TABLET

Tier 3

loryna (28) oral tablet Tier 1 ACA

LOSEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH

Tier 3

low-ogestrel (28) oral tablet Tier 1 ACA

lutera (28) oral tablet Tier 1 ACA

marlissa oral tablet Tier 1 ACA

mibelas 24 fe oral tablet,chewable Tier 1 ACA

microgestin 1.5/30 (21) oral tablet Tier 1 ACA

microgestin 1/20 (21) oral tablet Tier 1 ACA

MICROGESTIN 24 FE ORAL TABLET Tier 3

microgestin fe 1.5/30 (28) oral tablet Tier 1 ACA

microgestin fe 1/20 (28) oral tablet Tier 1 ACA

MINASTRIN 24 FE ORAL TABLET,CHEWABLE

Tier 3

MIRCETTE (28) ORAL TABLET Tier 3

mono-linyah oral tablet Tier 1 ACA

mononessa (28) oral tablet Tier 1 ACA

my choice oral tablet Tier 1 ACA; QL (2 EA per 365 days)

myzilra oral tablet Tier 1 ACA

NATAZIA ORAL TABLET Tier 3 ACA

necon 0.5/35 (28) oral tablet Tier 1 ACA


117

necon 7/7/7 (28) oral tablet Tier 1 ACA

nikki (28) oral tablet Tier 1 ACA

noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)

Tier 1 ACA

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg

Tier 1 ACA

norethindrone-e.estradiol-iron oral tablet Tier 1 ACA

norethindrone-e.estradiol-iron oral tablet,chewable

Tier 1 ACA

norgestimate-ethinyl estradiol oral tablet Tier 1 ACA

nortrel 0.5/35 (28) oral tablet Tier 1 ACA

nortrel 1/35 (21) oral tablet Tier 1 ACA

nortrel 7/7/7 (28) oral tablet Tier 1 ACA

ocella oral tablet Tier 1 ACA

ogestrel (28) oral tablet Tier 1 ACA

orsythia oral tablet Tier 1 ACA

ORTHO TRI-CYCLEN (28) ORAL TABLET Tier 3

ORTHO TRI-CYCLEN LO (28) ORAL TABLET

Tier 3

ORTHO-CYCLEN (28) ORAL TABLET Tier 3

ORTHO-NOVUM 1/35 (28) ORAL TABLET Tier 3

ORTHO-NOVUM 7/7/7 (28) ORAL TABLET Tier 3

philith oral tablet Tier 1 ACA

pimtrea (28) oral tablet Tier 1 ACA

pirmella oral tablet Tier 1 ACA

portia oral tablet Tier 1 ACA

previfem oral tablet Tier 1 ACA

QUARTETTE ORAL TABLETS,DOSE PACK,3 MONTH

Tier 3

quasense oral tablets,dose pack,3 month Tier 1 ACA

rajani oral tablet Tier 1 ACA

reclipsen (28) oral tablet Tier 1 ACA

rivelsa oral tablets,dose pack,3 month Tier 1 ACA

SAFYRAL ORAL TABLET Tier 3 ACA


118

SEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH

Tier 3

setlakin oral tablets,dose pack,3 month Tier 1 ACA

sprintec (28) oral tablet Tier 1 ACA

sronyx oral tablet Tier 1 ACA

syeda oral tablet Tier 1 ACA

tarina fe 1/20 (28) oral tablet Tier 1 ACA

tilia fe oral tablet Tier 1 ACA

tri femynor oral tablet Tier 1 ACA

tri-estarylla oral tablet Tier 1 ACA

tri-legest fe oral tablet Tier 1 ACA

tri-linyah oral tablet Tier 1 ACA

tri-lo-estarylla oral tablet Tier 1 ACA

tri-lo-marzia oral tablet Tier 1 ACA

tri-lo-sprintec oral tablet Tier 1 ACA

trinessa (28) oral tablet Tier 1 ACA

trinessa lo oral tablet Tier 1 ACA

TRI-NORINYL (28) ORAL TABLET Tier 3

tri-previfem (28) oral tablet Tier 1 ACA

tri-sprintec (28) oral tablet Tier 1 ACA

trivora (28) oral tablet Tier 1 ACA

tri-vylibra oral tablet Tier 1 ACA

velivet triphasic regimen (28) oral tablet Tier 1 ACA

vestura (28) oral tablet Tier 1 ACA

vienva oral tablet Tier 1 ACA

viorele (28) oral tablet Tier 1 ACA

vyfemla (28) oral tablet Tier 1 ACA

vylibra oral tablet Tier 1 ACA

wera (28) oral tablet Tier 1 ACA

wymzya fe oral tablet,chewable Tier 1 ACA

YASMIN (28) ORAL TABLET Tier 3

YAZ (28) ORAL TABLET Tier 3

zarah oral tablet Tier 1 ACA


119

zenchent (28) oral tablet Tier 1 ACA

zovia 1/35e (28) oral tablet Tier 1 ACA


Ophthalmology Antibiotics AZASITE OPHTHALMIC (EYE) DROPS Tier 3

bacitracin ophthalmic (eye) ointment Tier 1

bacitracin-polymyxin b ophthalmic (eye) ointment Tier 1

BETADINE OPHTHALMIC PREP OPHTHALMIC (EYE) SOLUTION

Tier 3

CILOXAN OPHTHALMIC (EYE) OINTMENT

Tier 3

ciprofloxacin hcl ophthalmic (eye) drops Tier 1

erythromycin ophthalmic (eye) ointment Tier 1

gatifloxacin ophthalmic (eye) drops Tier 1

gentak ophthalmic (eye) ointment Tier 1

gentamicin ophthalmic (eye) drops Tier 1

gentamicin ophthalmic (eye) ointment Tier 1

levofloxacin ophthalmic (eye) drops Tier 1

MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS

Tier 2

moxifloxacin ophthalmic (eye) drops Tier 1

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment

Tier 1

neomycin-polymyxin-gramicidin ophthalmic (eye) drops

Tier 1

neo-polycin ophthalmic (eye) ointment Tier 1

OCUFLOX OPHTHALMIC (EYE) DROPS Tier 3

ofloxacin ophthalmic (eye) drops Tier 1

polycin ophthalmic (eye) ointment Tier 1

polymyxin b sulf-trimethoprim ophthalmic (eye) drops

Tier 1

POLYTRIM OPHTHALMIC (EYE) DROPS Tier 3

tobramycin ophthalmic (eye) drops Tier 1

120

TOBREX OPHTHALMIC (EYE) OINTMENT Tier 3

VIGAMOX OPHTHALMIC (EYE) DROPS Tier 3

Antivirals trifluridine ophthalmic (eye) drops Tier 1

VIROPTIC OPHTHALMIC (EYE) DROPS Tier 3

ZIRGAN OPHTHALMIC (EYE) GEL Tier 3

Beta-Blockers BETAGAN OPHTHALMIC (EYE) DROPS 0.5 %

Tier 3

betaxolol ophthalmic (eye) drops Tier 1

carteolol ophthalmic (eye) drops Tier 1

levobunolol ophthalmic (eye) drops 0.5 % Tier 1

metipranolol ophthalmic (eye) drops Tier 1

timolol maleate ophthalmic (eye) drops 0.25 % Tier 1

timolol maleate ophthalmic (eye) drops 0.5 % Tier 1 Generic for Timoptic

timolol maleate ophthalmic (eye) gel forming solution

Tier 1

TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) DROPPERETTE

Tier 3

TIMOPTIC OPHTHALMIC (EYE) DROPS 0.25 %

Tier 3

TIMOPTIC-XE OPHTHALMIC (EYE) GEL FORMING SOLUTION

Tier 3

Cholinesterase Inhibitor Miotics PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS

Tier 3

Cycloplegic Mydriatics atropine 1% ophthalmic (eye) drops Tier 1

atropine ophthalmic (eye) ointment Tier 1

CYCLOGYL OPHTHALMIC (EYE) DROPS Tier 3

cyclopentolate ophthalmic (eye) drops Tier 1

MYDRIACYL OPHTHALMIC (EYE) DROPS Tier 3

PAREMYD OPHTHALMIC (EYE) DROPS Tier 3

tropicamide ophthalmic (eye) drops Tier 1


121

Direct Acting Miotics ISOPTO CARPINE OPHTHALMIC (EYE) DROPS

Tier 3

MIOCHOL-E INTRAOCULAR KIT Tier 3

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

Tier 1

Miscellaneous Ophthalmologics AKTEN (PF) OPHTHALMIC (EYE) GEL Tier 3

azelastine ophthalmic (eye) drops Tier 1

cromolyn ophthalmic (eye) drops Tier 1

CYSTARAN OPHTHALMIC (EYE) DROPS Tier 3 LD; SPRx

epinastine ophthalmic (eye) drops Tier 1

flucaine ophthalmic (eye) drops Tier 1

fluorescein-proparacaine ophthalmic (eye) drops Tier 1

LACRISERT OPHTHALMIC (EYE) INSERT Tier 3

olopatadine ophthalmic (eye) drops Tier 1

PATADAY OPHTHALMIC (EYE) DROPS Tier 3

PATANOL OPHTHALMIC (EYE) DROPS Tier 3

PAZEO OPHTHALMIC (EYE) DROPS Tier 2

proparacaine ophthalmic (eye) drops Tier 1

RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS

Tier 2

RESTASIS OPHTHALMIC (EYE) DROPPERETTE

Tier 2

tetracaine hcl (pf) ophthalmic (eye) drops Tier 1

tetracaine hcl ophthalmic (eye) drops Tier 1

TETRAVISC OPHTHALMIC (EYE) DROPS, VISCOUS

Tier 3

Non-Steroidal Anti-Inflammatory Agents ACULAR LS OPHTHALMIC (EYE) DROPS Tier 3

ACULAR OPHTHALMIC (EYE) DROPS Tier 3

bromfenac ophthalmic (eye) drops Tier 1

diclofenac sodium ophthalmic (eye) drops Tier 1

flurbiprofen sodium ophthalmic (eye) drops Tier 1


122

ketorolac ophthalmic (eye) drops Tier 1

PROLENSA OPHTHALMIC (EYE) DROPS Tier 2

Oral Drugs for Glaucoma acetazolamide oral capsule, extended release Tier 1

acetazolamide oral tablet Tier 1

methazolamide oral tablet Tier 1

NEPTAZANE ORAL TABLET 25 MG Tier 3

Other Glaucoma Drugs bimatoprost ophthalmic (eye) drops Tier 1

COMBIGAN OPHTHALMIC (EYE) DROPS Tier 2

COSOPT OPHTHALMIC (EYE) DROPS Tier 3

dorzolamide ophthalmic (eye) drops Tier 1

dorzolamide-timolol ophthalmic (eye) drops Tier 1

latanoprost ophthalmic (eye) drops Tier 1

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %

Tier 2

miostat intraocular solution Tier 1

MITOSOL OPHTHALMIC (EYE) KIT Tier 3

TRAVATAN Z OPHTHALMIC (EYE) DROPS

Tier 2

TRUSOPT OPHTHALMIC (EYE) DROPS Tier 3

XALATAN OPHTHALMIC (EYE) DROPS Tier 3 ST

ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE

Tier 3 ST

Steroid-Antibiotic Combinations MAXITROL OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

MAXITROL OPHTHALMIC (EYE) OINTMENT

Tier 3

neomycin-bacitracin-poly-hc ophthalmic (eye) ointment

Tier 1

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension

Tier 1

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment

Tier 1


123

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension

Tier 1

neo-polycin hc ophthalmic (eye) ointment Tier 1

PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT

Tier 3

tobramycin-dexamethasone ophthalmic (eye) drops,suspension

Tier 1

Steroids dexamethasone sodium phosphate ophthalmic (eye) drops

Tier 1

DUREZOL OPHTHALMIC (EYE) DROPS Tier 2

FLAREX OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

fluorometholone ophthalmic (eye) drops,suspension

Tier 1

FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

FML LIQUIFILM OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

FML S.O.P. OPHTHALMIC (EYE) OINTMENT

Tier 3

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL

Tier 2

LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 2

LOTEMAX OPHTHALMIC (EYE) OINTMENT

Tier 2

MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

OMNIPRED OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

PRED FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

prednisolone acetate ophthalmic (eye) drops,suspension

Tier 1


124

prednisolone sodium phosphate ophthalmic (eye) drops

Tier 1

Steroid-Sulfonamide Combinations BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT

Tier 3

sulfacetamide-prednisolone ophthalmic (eye) drops

Tier 1

Sulfonamides BLEPH-10 OPHTHALMIC (EYE) DROPS Tier 3

sulfacetamide sodium ophthalmic (eye) drops Tier 1

sulfacetamide sodium ophthalmic (eye) ointment Tier 1

Sympathomimetics ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %

Tier 2

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.15 %

Tier 3

apraclonidine ophthalmic (eye) drops Tier 1

brimonidine ophthalmic (eye) drops Tier 1

IOPIDINE OPHTHALMIC (EYE) DROPPERETTE

Tier 3

IOPIDINE OPHTHALMIC (EYE) DROPS Tier 3

Vasoconstrictor Decongestants CYCLOMYDRIL OPHTHALMIC (EYE) DROPS

Tier 3

phenylephrine hcl ophthalmic (eye) drops Tier 1


Respiratory, Allergy, Cough & Cold Antihistamine & Antiallergenic Agents adrenalin injection solution Tier 1

carbinoxamine maleate oral liquid Tier 1

carbinoxamine maleate oral tablet 4 mg Tier 1

CLARINEX ORAL SYRUP Tier 3

CLARINEX ORAL TABLET Tier 3

clemastine oral tablet 2.68 mg Tier 1

125

cyproheptadine oral syrup Tier 1

cyproheptadine oral tablet Tier 1

desloratadine oral tablet Tier 1

desloratadine oral tablet,disintegrating Tier 1

diphenhydramine hcl injection solution 50 mg/ml Tier 1

diphenhydramine hcl injection syringe Tier 1

EPINEPHRINE INJECTION AUTO-INJECTOR


epinephrine injection solution Tier 1

epinephrine injection syringe 0.1 mg/ml Tier 1

EPIPEN 2-PAK INJECTION AUTO-INJECTOR


EPIPEN INJECTION AUTO-INJECTOR Tier 2 QL (4 EA per 30 days)

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR


EPIPEN JR INJECTION AUTO-INJECTOR Tier 2 QL (4 EA per 30 days)

hydroxyzine hcl oral solution 10 mg/5 ml Tier 1

hydroxyzine hcl oral tablet Tier 1

hydroxyzine pamoate oral capsule Tier 1

phenadoz rectal suppository Tier 1

phenergan rectal suppository Tier 1

promethazine oral syrup Tier 1

promethazine oral tablet Tier 1

promethazine rectal suppository Tier 1

promethegan rectal suppository Tier 1

VISTARIL ORAL CAPSULE Tier 3

Cough & Cold Therapy benzonatate oral capsule Tier 1

BROMFED DM ORAL SYRUP Tier 3

brompheniramine-pseudoeph-dm oral syrup Tier 1

CAPCOF ORAL LIQUID Tier 3

cheratussin ac oral liquid Tier 1

CLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE 12 HR

Tier 3


126

codeine-guaifenesin oral liquid Tier 1

guaifenesin ac oral liquid Tier 1

guaifenesin dac oral syrup Tier 1

hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr

Tier 1

hydrocodone-cpm-pseudoephed oral solution Tier 1

hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

Tier 1

hydrocodone-homatropine oral tablet Tier 1

hydromet oral syrup Tier 1

lortuss ex oral syrup Tier 1

MAR-COF BP ORAL LIQUID Tier 3

MAR-COF CG ORAL LIQUID Tier 3

m-clear wc oral liquid Tier 1

M-END PE ORAL LIQUID Tier 3

promethazine vc oral syrup Tier 1

promethazine vc-codeine oral syrup Tier 1

promethazine-codeine oral syrup Tier 1

promethazine-dm oral syrup Tier 1

promethazine-phenyleph-codeine oral syrup Tier 1

PRO-RED AC (W/ DEXCHLORPHENIR) ORAL LIQUID

Tier 3

relcof c oral liquid Tier 1

RESPA-AR ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

robafen ac oral liquid Tier 1

rydex oral liquid Tier 1

SEMPREX-D ORAL CAPSULE Tier 3

TESSALON PERLES ORAL CAPSULE Tier 3

tusnel c oral syrup Tier 1

TUSSICAPS ORAL CAPSULE,EXTENDED RELEASE 12 HR

Tier 3

tussigon oral tablet Tier 1

TUSSIONEX PENNKINETIC ER ORAL SUSPENSION,EXTENDED REL 12 HR

Tier 3


127

virtussin ac oral liquid Tier 1

ZODRYL AC 25 ORAL SUSPENSION Tier 3







ZODRYL DAC 25 ORAL SUSPENSION Tier 3







ZODRYL DEC 25 ORAL SUSPENSION Tier 3







Z-TUSS AC ORAL LIQUID Tier 3

ZUTRIPRO ORAL SOLUTION Tier 3

Pulmonary Agents ACCOLATE ORAL TABLET Tier 3

acetylcysteine solution Tier 1

ADCIRCA ORAL TABLET Tier 2 PA; SPRx

ADEMPAS ORAL TABLET Tier 3 PA; SPRx

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE

Tier 2

ADVAIR HFA INHALATION HFA AEROSOL INHALER

Tier 2


128

AEROSPAN INHALATION HFA AEROSOL INHALER

Tier 3

albuterol sulfate inhalation solution for nebulization

Tier 1

albuterol sulfate oral syrup Tier 1

albuterol sulfate oral tablet Tier 1

albuterol sulfate oral tablet extended release 12 hr Tier 1

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 2

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 2

ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 2

ASMANEX HFA INHALATION HFA AEROSOL INHALER

Tier 2

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2

ATROVENT HFA INHALATION HFA AEROSOL INHALER

Tier 3

BERINERT INTRAVENOUS KIT Tier 3 PA; LD; SPRx

BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER

Tier 2

BREO ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 2

BROVANA INHALATION SOLUTION FOR NEBULIZATION

Tier 2

budesonide inhalation suspension for nebulization Tier 1

budesonide nasal spray,non-aerosol Tier 1

CINRYZE INTRAVENOUS RECON SOLN Tier 3 PA; LD; SPRx

COMBIVENT RESPIMAT INHALATION MIST

Tier 2

cromolyn inhalation solution for nebulization Tier 1

DALIRESP ORAL TABLET Tier 2

DULERA INHALATION HFA AEROSOL INHALER

Tier 2

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML

Tier 3


129

ESBRIET ORAL CAPSULE Tier 3 PA; LD; SPRx

ESBRIET ORAL TABLET Tier 3 PA; SPRx

FIRAZYR SUBCUTANEOUS SYRINGE Tier 3 PA; LD; SPRx

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE

Tier 2

FLOVENT HFA INHALATION HFA AEROSOL INHALER

Tier 2

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

Tier 1

fluticasone nasal spray,suspension Tier 1

HAEGARDA SUBCUTANEOUS RECON SOLN

Tier 3 PA; SPRx

ipratropium bromide inhalation solution Tier 1

ipratropium-albuterol inhalation solution for nebulization

Tier 1

KALYDECO ORAL GRANULES IN PACKET

Tier 3 PA; LD; SPRx

KALYDECO ORAL TABLET Tier 3 PA; LD; SPRx

levalbuterol hcl inhalation solution for nebulization

Tier 1

metaproterenol oral syrup Tier 1

metaproterenol oral tablet Tier 1

mometasone nasal spray,non-aerosol Tier 1

montelukast oral granules in packet Tier 1

montelukast oral tablet Tier 1

montelukast oral tablet,chewable Tier 1

OFEV ORAL CAPSULE Tier 3 PA; LD; SPRx

OPSUMIT ORAL TABLET Tier 3 PA; LD; SPRx

ORKAMBI ORAL TABLET Tier 3 PA; LD; SPRx

PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION

Tier 2

PROAIR HFA INHALATION HFA AEROSOL INHALER

Tier 2 QL (2 GM per 30 days)

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED


PROVENTIL HFA INHALATION HFA AEROSOL INHALER

Tier 3 ST; QL (2 GM per 30 days)


130

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 3

PULMICORT INHALATION SUSPENSION FOR NEBULIZATION

Tier 3

pulmosal inhalation solution for nebulization Tier 1

PULMOZYME INHALATION SOLUTION Tier 3 SPRx

QVAR INHALATION AEROSOL Tier 2

QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED

Tier 2

REVATIO INTRAVENOUS SOLUTION Tier 3 PA; SPRx

REVATIO ORAL SUSPENSION FOR RECONSTITUTION

Tier 3 PA; SPRx

REVATIO ORAL TABLET Tier 3 PA; SPRx

RUCONEST INTRAVENOUS RECON SOLN Tier 3 PA; SPRx

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

Tier 2

sildenafil (antihypertensive) intravenous solution Tier 1 PA; SPRx

sildenafil (antihypertensive) oral tablet Tier 1 PA; SPRx

SINGULAIR ORAL GRANULES IN PACKET Tier 3

SINGULAIR ORAL TABLET Tier 3

SINGULAIR ORAL TABLET,CHEWABLE Tier 3

sodium chloride inhalation solution for nebulization

Tier 1

SPIRIVA RESPIMAT INHALATION MIST Tier 2

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 2

STIOLTO RESPIMAT INHALATION MIST Tier 2

STRIVERDI RESPIMAT INHALATION MIST

Tier 2

SYMBICORT INHALATION HFA AEROSOL INHALER

Tier 2

terbutaline oral tablet Tier 1

terbutaline subcutaneous solution Tier 1

THEO-24 ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3

theochron oral tablet extended release 12 hr Tier 1


131

theophylline oral elixir Tier 1

theophylline oral solution Tier 1

theophylline oral tablet extended release 12 hr Tier 1

theophylline oral tablet extended release 24 hr Tier 1

TRACLEER ORAL TABLET Tier 3 PA; LD; SPRx

TRACLEER ORAL TABLET FOR SUSPENSION

Tier 3 PA; LD; SPRx

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 2

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2

TYVASO INHALATION SOLUTION FOR NEBULIZATION

Tier 3 PA; LD; SPRx

TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION

Tier 3 PA; LD; SPRx

TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION

Tier 3 PA; LD; SPRx

TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION

Tier 3 PA; LD; SPRx

UTIBRON NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 3

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION

Tier 3 PA; LD; SPRx

VENTOLIN HFA INHALATION HFA AEROSOL INHALER


XOPENEX CONCENTRATE INHALATION SOLUTION FOR NEBULIZATION

Tier 3

XOPENEX HFA INHALATION HFA AEROSOL INHALER


XOPENEX INHALATION SOLUTION FOR NEBULIZATION

Tier 3

zafirlukast oral tablet Tier 1


Urologicals Anticholinergics & Antispasmodics darifenacin oral tablet extended release 24 hr Tier 1

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR

Tier 3

132

flavoxate oral tablet Tier 1

GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 100 MG/GRAM (10 %)

Tier 2

GELNIQUE TRANSDERMAL GEL IN PACKET

Tier 2

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

Tier 2

oxybutynin chloride oral syrup Tier 1

oxybutynin chloride oral tablet Tier 1

oxybutynin chloride oral tablet extended release 24hr

Tier 1

OXYTROL TRANSDERMAL PATCH SEMIWEEKLY

Tier 3

tolterodine oral capsule,extended release 24hr Tier 1

tolterodine oral tablet Tier 1

trospium oral capsule,extended release 24hr Tier 1

trospium oral tablet Tier 1

VESICARE ORAL TABLET Tier 2

Benign Prostatic Hyperplasia (Bph) Therapy alfuzosin oral tablet extended release 24 hr Tier 1

AVODART ORAL CAPSULE Tier 3

CIALIS ORAL TABLET 2.5 MG, 5 MG Tier 3 PA; #; QL (8 EA per 30 days)

dutasteride oral capsule Tier 1

dutasteride-tamsulosin oral capsule, er multiphase 24 hr

Tier 1

finasteride oral tablet 5 mg Tier 1

FLOMAX ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3

JALYN ORAL CAPSULE, ER MULTIPHASE 24 HR

Tier 3

PROSCAR ORAL TABLET Tier 3

RAPAFLO ORAL CAPSULE Tier 3

tamsulosin oral capsule,extended release 24hr Tier 1

UROXATRAL ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3


133

Cholinergic Stimulants bethanechol chloride oral tablet Tier 1

URECHOLINE ORAL TABLET Tier 3

Miscellaneous Urologicals alprostadil injection solution Tier 1

CAVERJECT IMPULSE INTRACAVERNOSAL KIT

Tier 3 #; QL (8 EA per 30 days)

CAVERJECT INTRACAVERNOSAL RECON SOLN


CIALIS ORAL TABLET 10 MG, 20 MG Tier 3 #; QL (8 EA per 30 days)

CYSTAGON ORAL CAPSULE Tier 3 SPRx

EDEX INTRACAVERNOSAL KIT Tier 3 #; QL (8 EA per 30 days)

ELMIRON ORAL CAPSULE Tier 3

K-PHOS NO 2 ORAL TABLET Tier 3

K-PHOS ORIGINAL ORAL TABLET,SOLUBLE

Tier 3

LEVITRA ORAL TABLET Tier 3 #; QL (8 EA per 30 days)

methen-sod phos-meth blue-hyos oral tablet Tier 1

MUSE URETHRAL SUPPOSITORY Tier 3 #; QL (8 EA per 30 days)

pot,sodium citrate-citric acid oral solution Tier 1

potassium citrate oral tablet extended release Tier 1

PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE

Tier 3 PA; LD; SPRx

PROSTIN VR PEDIATRIC INJECTION SOLUTION

Tier 3

sildenafil oral tablet Tier 1 #; QL (8 EA per 30 days)

STAXYN ORAL TABLET,DISINTEGRATING


STENDRA ORAL TABLET Tier 3 #; QL (8 EA per 30 days)

uro-458 oral tablet Tier 1

UROCIT-K 10 ORAL TABLET EXTENDED RELEASE

Tier 3


Tier 3


Tier 3


134

VIAGRA ORAL TABLET Tier 3 #; QL (8 EA per 30 days)

Urinary Anesthetics phenazopyridine oral tablet 100 mg, 200 mg Tier 1

PYRIDIUM ORAL TABLET Tier 3


Vitamins, Hematinics & Electrolytes Electrolytes calcium 500 with d oral tablet Tier 1 ACA

calcium carbonate-vitamin d3 oral tablet 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -400 unit

Tier 1 ACA

calcium citrate + d oral tablet Tier 1 ACA

calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit

Tier 1 ACA

EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ

Tier 3

effer-k oral tablet, effervescent 25 meq Tier 1

GALZIN ORAL CAPSULE Tier 3

k-effervescent oral tablet, effervescent Tier 1

klor-con 10 oral tablet extended release Tier 1

klor-con 8 oral tablet extended release Tier 1

klor-con m10 oral tablet,er particles/crystals Tier 1



klor-con oral packet Tier 1

klor-con sprinkle oral capsule, extended release Tier 1

KLOR-CON/25 ORAL PACKET Tier 3

klor-con/ef oral tablet, effervescent Tier 1

k-phos-neutral oral tablet Tier 1

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ

Tier 3

k-tab oral tablet extended release 8 meq Tier 1

lugols oral solution Tier 1

phospha 250 neutral oral tablet Tier 1

POTABA ORAL CAPSULE Tier 3

135

potassium bicarb and chloride oral tablet, effervescent

Tier 1

potassium bicarb-citric acid oral tablet, effervescent

Tier 1

potassium chloride oral capsule, extended release Tier 1

potassium chloride oral liquid Tier 1

potassium chloride oral packet Tier 1

potassium chloride oral tablet extended release Tier 1

potassium chloride oral tablet,er particles/crystals Tier 1

strong iodine oral solution Tier 1

virt-phos 250 neutral oral tablet Tier 1

Miscellaneous Vitamins, Hematinics, & Electrolytes FORTAVIT ORAL CAPSULE Tier 3

Vitamins & Hematinics ACTIVE FE ORAL TABLET Tier 3

ANIMI-3 WITH VITAMIN D ORAL CAPSULE

Tier 3

b complex-vitamin b12 oral tablet Tier 1 ACA

b complex-vitamin c-folic acid oral tablet Tier 1 ACA

BACMIN ORAL TABLET Tier 3

bal-care dha oral combo pack,tablet and cap,dr Tier 1

b-complex with vitamin c oral tablet Tier 1 ACA

calcium pnv oral capsule Tier 1

calcium-folic acid-vitamin d oral wafer Tier 1

centratex oral capsule Tier 1

c-nate dha oral capsule Tier 1

complete natal dha oral combo pack Tier 1

completenate oral tablet,chewable Tier 1

corvita 150 oral tablet Tier 1

corvita oral tablet Tier 1

CORVITE 150 ORAL TABLET 150 MG IRON- 1 MG

Tier 3

CORVITE FE ORAL TABLET 150 MG IRON- 1 MG

Tier 3


136

CORVITE FREE ORAL TABLET Tier 3

CORVITE ORAL TABLET Tier 3

cyanocobalamin (vitamin b-12) injection solution Tier 1

DIALYVITE 800 WITH IRON ORAL TABLET

Tier 3

dialyvite oral tablet Tier 1

DIALYVITE SUPREME D ORAL TABLET Tier 3

dothelle dha oral capsule Tier 1

elite-ob oral tablet Tier 1

ergocalciferol (vitamin d2) oral capsule Tier 1

ESCAVITE ORAL TABLET,CHEWABLE Tier 3

fabb oral tablet Tier 1

fe c plus oral tablet Tier 1

ferocon oral capsule Tier 1

FERRALET 90 DUAL-IRON DELIVERY ORAL TABLET

Tier 3

ferraplus 90 oral tablet Tier 1

ferrocite plus oral tablet Tier 1

FLUORABON ORAL DROPS Tier 3

fluor-a-day (with xylitol) oral tablet,chewable 0.25 mg f (0.55 mg)-236.79mg

Tier 1 ACA

fluor-a-day (with xylitol) oral tablet,chewable 1 mg f (2.2 mg)-236.79 mg

Tier 1

FLUOR-A-DAY ORAL DROPS Tier 3

fluoride (sodium) oral drops Tier 1 ACA

fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

Tier 1 ACA

fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

Tier 1

fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)

Tier 1 ACA

fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

Tier 1

FLURA-DROPS ORAL DROPS Tier 3

folbee oral tablet Tier 1


137

folbee plus oral tablet 5 mg Tier 1

FOLGARD OS ORAL TABLET Tier 3

FOLGARD RX ORAL TABLET Tier 3

folic acid oral tablet 1 mg Tier 1

folic acid oral tablet 400 mcg, 800 mcg Tier 1 ACA

folic acid-vit b6-vit b12 oral tablet 2.2-25-0.5 mg Tier 1

folivane-f oral capsule Tier 1

folivane-ob oral capsule Tier 1

folivane-plus oral capsule Tier 1

folplex 2.2 oral tablet Tier 1

FOLTRATE ORAL TABLET Tier 3

hematinic plus vit/minerals oral tablet Tier 1

hematinic/folic acid oral tablet Tier 1

hematogen fa oral capsule Tier 1

hematogen forte oral capsule Tier 1

hematogen oral capsule Tier 1

hemenatal ob + dha oral combo pack Tier 1

hemenatal ob oral tablet Tier 1

HEMOCYTE-F ORAL TABLET Tier 3

HEMOCYTE-PLUS ORAL CAPSULE Tier 3

ICAR-C PLUS ORAL TABLET Tier 3

INTEGRA F ORAL CAPSULE Tier 3

INTEGRA PLUS ORAL CAPSULE Tier 3

IROSPAN 24/6 ORAL TABLET Tier 3

ludent fluoride oral tablet,chewable Tier 1 ACA

multi-vit with fluoride-iron oral drops Tier 1 ACA

multi-vitamin with fluoride oral drops Tier 1 ACA

multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

Tier 1 ACA

multi-vitamin with fluoride oral tablet,chewable 1 mg

Tier 1

multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

Tier 1 ACA


138

multivitamins with fluoride oral tablet,chewable 1 mg

Tier 1

multivit-fluor (vit e acetate) oral drops Tier 1 ACA

mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg Tier 1 ACA

mvc-fluoride oral tablet,chewable 1 mg Tier 1

mynatal advance oral tablet Tier 1

mynatal oral capsule Tier 1

mynatal oral tablet Tier 1

mynatal plus oral tablet Tier 1

mynatal-z oral tablet Tier 1

mynate 90 plus oral tablet extended release Tier 1

mynephrocaps oral capsule Tier 1

mynephron oral capsule Tier 1

nephplex rx oral tablet Tier 1

NEPHRON FA ORAL TABLET Tier 3

nephro-vite rx oral tablet Tier 1

NEURIN-SL SUBLINGUAL TABLET Tier 3

newgen oral tablet Tier 1

NUTRICAP ORAL TABLET Tier 3

obstetrix dha oral combo pack,tablet and cap,dr Tier 1

pnv 29-1 oral tablet Tier 1

pnv ob+dha oral combo pack 27-1-50-250 mg Tier 1

pnv-dha + docusate oral capsule Tier 1

pnv-dha oral capsule Tier 1

pnv-ferrous fumarate-docu-fa oral tablet Tier 1

pnv-omega oral capsule Tier 1

pnv-select oral tablet Tier 1

pnv-vp-u oral capsule Tier 1

POLY-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC

Tier 3

POLY-VI-FLOR ORAL TABLET,CHEWABLE

Tier 3

POLY-VI-FLOR WITH IRON ORAL DROPS,SUSPENSION BIPHASIC

Tier 3


139

POLY-VI-FLOR WITH IRON ORAL TABLET,CHEWABLE

Tier 3

pr natal 400 ec oral combo pack,tablet and cap,dr Tier 1

pr natal 400 oral combo pack Tier 1

pr natal 430 ec oral combo pack,tablet and cap,dr Tier 1

pr natal 430 oral combo pack Tier 1

prena1 chew oral tablet,chew,ir - dr,biphase Tier 1

prena1 pearl oral capsule,ir - delay rel,biphase Tier 1

prena1 true oral combo pack Tier 1

prenaissance oral capsule Tier 1

prenaissance plus oral capsule Tier 1

prenatabs fa oral tablet Tier 1

prenatabs rx oral tablet Tier 1

prenatal formula oral tablet 28 mg iron- 800 mcg Tier 1 ACA

prenatal multi-dha (algal oil) oral capsule Tier 1 ACA

prenatal one daily oral tablet Tier 1 ACA

prenatal oral tablet 28 mg iron- 800 mcg Tier 1 ACA

prenatal plus (calcium carb) oral tablet Tier 1

prenatal plus oral tablet Tier 1

prenatal vitamin oral tablet , 27 mg iron- 0.8 mg Tier 1 ACA

prenatal vitamin plus low iron oral tablet Tier 1

prenatal-u oral capsule Tier 1

preplus oral tablet Tier 1

pretab oral tablet Tier 1

PROFERRIN-FORTE ORAL TABLET Tier 3

PROTECT IRON ORAL TABLET Tier 3

purevit dualfe plus oral capsule Tier 1

relnate dha oral capsule Tier 1

renal caps oral capsule Tier 1

rena-vite rx oral tablet Tier 1

reno caps oral capsule Tier 1

risacal-d oral tablet Tier 1 ACA

se-natal 19 (with docusate) oral tablet Tier 1


140

se-natal 19 oral tablet,chewable Tier 1

se-tan plus oral capsule Tier 1

STROVITE FORTE ORAL TABLET Tier 3

STROVITE ONE ORAL TABLET Tier 3

TANDEM PLUS ORAL CAPSULE Tier 3

taron forte oral capsule Tier 1

taron-c dha oral capsule Tier 1

taron-prex prenatal-dha oral capsule Tier 1

thrivite-19 oral tablet Tier 1

tl gard rx oral tablet Tier 1

tl g-fol os oral tablet Tier 1

tl icon oral capsule Tier 1

tricon oral capsule Tier 1

trigels-f forte oral capsule Tier 1

trinatal gt oral tablet Tier 1

trinatal rx 1 oral tablet Tier 1

trinate oral tablet Tier 1

triphrocaps oral capsule Tier 1

tri-tabs dha oral combo pack Tier 1

triveen-duo dha oral combo pack Tier 1

TRI-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC

Tier 3

tri-vit with fluoride and iron oral drops Tier 1 ACA

tri-vitamin with fluoride oral drops Tier 1 ACA

trust natal dha oral combo pack Tier 1

UDAMIN SP ORAL TABLET Tier 3

ultimatecare one nf oral capsule Tier 1

ultimatecare one oral capsule Tier 1

v-c forte oral capsule Tier 1

vemavite-prx-2 oral capsule Tier 1

vinate care oral tablet,chewable Tier 1

vinate ii oral tablet Tier 1

vinate m oral tablet Tier 1


141

vinate one oral tablet Tier 1

vinate ultra oral tablet Tier 1

virt-advance oral tablet Tier 1

virt-c dha oral capsule Tier 1

VIRT-CAPS ORAL CAPSULE Tier 3

virt-gard oral tablet Tier 1

virt-nate dha oral capsule Tier 1

virt-nate oral tablet Tier 1

virt-pn dha oral capsule Tier 1

virt-pn oral tablet Tier 1

virt-pn plus oral capsule Tier 1

virt-select oral capsule Tier 1

virt-vite gt oral tablet Tier 1

virt-vite oral tablet Tier 1

VIRT-VITE PLUS ORAL TABLET Tier 3

vit 3 oral capsule Tier 1

vit b complex-folic acid oral tablet Tier 1 ACA

VITAFOL ORAL TABLET Tier 3

VITAL-D RX ORAL TABLET Tier 3

vitamin d3 oral tablet 400 unit Tier 1 ACA

vitamins a,c,d and fluoride oral drops Tier 1 ACA

VITA-RESPA ORAL TABLET Tier 3

vol-care rx oral tablet Tier 1

vol-nate oral tablet Tier 1

vol-plus oral tablet Tier 1

vol-tab rx oral tablet Tier 1

vp-ch plus oral capsule Tier 1

vp-ch-pnv oral capsule Tier 1

vp-ggr-b6 oral tablet Tier 1

vp-heme ob oral tablet Tier 1

vp-heme one oral capsule Tier 1

vp-vite rx oral tablet Tier 1

zatean-ch oral capsule Tier 1


142

zatean-pn dha oral capsule Tier 1

zatean-pn plus oral capsule Tier 1

zingiber oral tablet Tier 1


Index of Drugs

1 1ST TIER UNIFINE PENTIPS

..........................................82 1ST TIER UNILET

COMFORTOUCH ...........82 A abacavir ..................................7 abacavir-lamivudine ...............7 abacavir-lamivudine-

zidovudine ..........................7 ABILIFY ..............................37 ABILIFY MAINTENA........37 ABSTRAL............................30 acamprosate..........................70 ACANYA.............................60 acarbose................................92 ACCOLATE.......................127 ACCU-CHEK AVIVA PLUS

TEST STRP......................78 ACCU-CHEK FASTCLIX ..82 ACCU-CHEK SAFE-T-PRO

..........................................82 ACCU-CHEK SMARTVIEW

TEST STRIP ....................78 ACCU-CHEK SOFTCLIX

LANCETS........................82 ACCUPRIL ..........................45 ACCURETIC .......................45 ACCUTREND GLUCOSE..78 acebutolol .............................45 acetaminophen-caff-

dihydrocod........................30 acetaminophen-codeine........30 acetazolamide .....................122 acetic acid.......................70, 76 acetylcysteine .....................127 acitretin.................................57 ACTEMRA ........................109 ACTHAR H.P. .....................77 ACTHIB (PF).....................104 ACTIGALL..........................95 ACTI-LANCE LANCETS...82 ACTIMMUNE ...................103 ACTIQ............................30, 31 ACTIVE FE........................135 ACTIVELLA .....................110 ACTONEL ...................70, 108 ACTOPLUS MET................92

ACTOPLUS MET XR .........92 ACTOS.................................92 ACULAR............................121 ACULAR LS......................121 acyclovir ...........................7, 65 ADACEL(TDAP

ADOLESN/ADULT)(PF) ........................................104

ADALAT CC .......................45 adapalene ..............................60 adapalene-benzoyl peroxide . 60 ADCIRCA..........................127 ADDERALL ........................37 adefovir...................................7 ADEMPAS.........................127 ADIPEX-P............................69 ADMELOG SOLOSTAR U-

100 INSULIN...................87 ADMELOG U-100 INSULIN

LISPRO ............................87 adrenalin .............................124 ADVAIR DISKUS.............127 ADVAIR HFA ...................127 ADVANCED GLUC METER

TEST STRIP.....................78 ADVANCED TRAVEL

LANCETS........................82 ADVATE..............................51 ADVOCATE LANCET .......82 ADVOCATE PEN NEEDLE

..........................................82 ADVOCATE REDI-CODE . 78 ADVOCATE TEST STRIPS78 AEROSPAN.......................128 afeditab cr .............................45 AFINITOR ...........................17 AFINITOR DISPERZ ..........17 AFLURIA 2017-2018 ........104 AFLURIA 2017-2018 (PF) 104 AFLURIA QUAD 2017-2018

........................................104 AFLURIA QUAD 2017-2018

(PF).................................104 AFREZZA ............................88 AGAMATRIX AMP TEST

STRIPS.............................78 AGGRENOX........................52 AGRYLIN............................70

143

AKTEN (PF) ......................121 ALA-SCALP ........................65 ALBENZA ...........................12 albuterol sulfate ..................128 alclometasone .......................65 ALCOHOL SWABS ............82 ALDACTAZIDE..................45 ALDACTONE......................45 ALDARA ...........................103 ALECENSA .........................17 alendronate ...................70, 108 alfuzosin .............................132 ALINIA ................................12 ALKERAN ...........................17 allopurinol...........................108 almotriptan malate ................27 ALORA ..............................110 alosetron ...............................95 ALPHAGAN P...................124 ALPHANATE ......................52 ALPHANINE SD .................52 alprazolam ............................37 alprazolam intensol...............37 ALPROLIX ..........................52 alprostadil ...........................133 ALSUMA .............................27 ALTABAX ...........................63 ALTACE ..............................45 altavera (28)........................113 ALTERNATE SITE LANCET

..........................................82 ALUNBRIG .........................17 alyacen 1/35 (28) ................113 alyacen 7/7/7 (28) ...............113 amabelz...............................110 amantadine hcl........................7 AMARYL.............................92 AMBIEN ..............................37 AMBIEN CR ........................37 amcinonide ...........................65 AMERGE .............................27 amethia ...............................113 amethia lo ...........................113 amethyst..............................113 AMICAR ..............................52 amiloride...............................45 amiloride-hydrochlorothiazide

..........................................45

amiodarone ...........................44 AMITIZA .............................95 amitriptyline .........................37 amitriptyline-chlordiazepoxide

..........................................37 amlodipine............................45 amlodipine-atorvastatin........54 amlodipine-benazepril ..........45 amlodipine-olmesartan .........45 amlodipine-valsartan ............45 amlodipine-valsartan-hcthiazid

..........................................45 amnesteem............................60 amoxapine ............................37 amoxicil-clarithromy-lansopraz

........................................100 amoxicillin............................14 amoxicillin-pot clavulanate ..14 ampicillin..............................14 AMPYRA.............................28 ANADROL-50 .....................89 ANAFRANIL.......................37 anagrelide .............................70 ANAPROX DS ....................35 anastrozole............................17 ANCOBON ............................6 ANDRODERM ....................90 ANDROGEL........................90 ANDROID ...........................90 ANGELIQ ..........................110 ANIMI-3 WITH VITAMIN D

........................................135 ANORO ELLIPTA ............128 ANTABUSE.........................70 ANTARA .............................54 anucort-hc.............................95 ANUSOL-HC.......................95 ANZEMET...........................95 APIDRA SOLOSTAR U-100

INSULIN..........................88 APIDRA U-100 INSULIN...88 APOKYN .............................25 apraclonidine ......................124 aprepitant ..............................96 apri......................................113 APRISO................................96 APTIOM...............................21 APTIVUS...............................7 AQUA GLYCOLIC HC.......65 aranelle (28)........................113

ARANESP (IN POLYSORBATE) ..........102

ARAVA..............................109 ARCALYST.......................103 ARCAPTA NEOHALER...128 ARESTIN .............................75 ARICEPT .............................28 ARIMIDEX ..........................17 aripiprazole...........................37 ARISTADA..........................37 ARIXTRA ............................52 armodafinil ...........................37 ARMOUR THYROID .........94 ARNUITY ELLIPTA.........128 AROMASIN.........................17 ARTHROTEC 50.................35 ARTHROTEC 75.................35 ascomp with codeine ............31 ashlyna................................113 ASMANEX HFA ...............128 ASMANEX TWISTHALER

........................................128 aspirin-dipyridamole ............52 ASSURE 4 STRIPS..............78 ASSURE HAEMOLANCE

PLUS ................................82 ASSURE LANCE ................82 ASSURE LANCE PLUS......82 ASSURE PLATINUM.........78 ASSURE PRISM MULTI

STRIP ...............................78 ASTAGRAF XL...................17 ASTEPRO ............................75 ATACAND ..........................45 ATACAND HCT .................45 atazanavir................................7 ATELVIA...........................108 atenolol .................................45 atenolol-chlorthalidone.........45 ATIVAN...............................37 atomoxetine ..........................37 atorvastatin ...........................54 atovaquone............................12 atovaquone-proguanil ...........12 ATRIPLA ...............................7 atropine...............................120 ATROVENT HFA .............128 AUBAGIO..........................102 aubra ...................................114 AUGMENTIN......................15

144

AUGMENTIN ES-600.........15 AUGMENTIN XR ...............15 AURYXIA............................96 AUSTEDO ...........................28 AVALIDE ............................45 AVANDIA ...........................92 AVAPRO..............................45 AVC VAGINAL ................112 AVELOX..............................15 aviane..................................114 avidoxy .................................16 avita ......................................60 AVODART.........................132 AVONEX ...........................102 AVONEX (WITH ALBUMIN)

........................................102 AYGESTIN ........................110 AZASAN..............................17 AZASITE ...........................119 azathioprine ..........................17 azelastine ......................75, 121 AZELEX...............................60 AZILECT .............................25 azithromycin .........................11 AZOR ...................................45 AZULFIDINE ......................96 AZULFIDINE EN-TABS ....96 azurette (28)........................114 B b complex-vitamin b12.......135 b complex-vitamin c-folic acid

........................................135 bacitracin ............................119 bacitracin-polymyxin b.......119 baclofen ................................29 BACMIN ............................135 BACTRIM............................15 BACTRIM DS......................15 BACTROBAN NASAL .......75 bal-care dha ........................135 balsalazide ............................96 balziva (28) .........................114 BANZEL ..............................21 BARACLUDE........................7 BCG VACCINE, LIVE (PF)

........................................104 b-complex with vitamin c...135 BD ECLIPSE........................82 BD FILTER NEEDLE-5

MICRON ..........................82

BD INSULIN PEN NEEDLE UF SHORT.......................82

BD INTEGRA NEEDLE .....82 BD MICROTAINER

LANCET ..........................82 BD NOKOR ADMIX

NEEDLE ..........................82 BD PRECISIONGLIDE.......82 BD PRECISIONGLIDE NON-

STERILE..........................83 bd pre-filled normal saline ...71 BD SAFETYGLIDE NEEDLE

..........................................83 BD SPECIALTY USE

NEEDLES ........................83 BD ULTRA FINE LANCETS

..........................................83 BD ULTRA-FINE NANO

PEN NEEDLES................83 BEBULIN.............................52 bekyree (28)........................114 BELVIQ ...............................69 benazepril .............................45 benazepril-hydrochlorothiazide

..........................................45 BENEFIX .............................52 BENICAR ............................45 BENICAR HCT ...................45 BENLYSTA...............109, 110 BENZAMYCIN ...................60 BENZEFOAM .....................60 BENZEFOAM ULTRA .......60 benzepro ...............................60 BENZEPRO

(MICROSPHERES) .........60 benzonatate.........................125 benzoyl peroxide ..................60 benzphetamine......................70 benztropine ...........................25 BERINERT ........................128 BETADINE OPHTHALMIC

PREP ..............................119 BETAGAN.........................120 betamethasone dipropionate. 65 betamethasone valerate ........65 betamethasone, augmented...65 BETAPACE .........................44 BETAPACE AF ...................44 BETASERON ....................102 betaxolol .......................45, 120

bethanechol chloride...........133 BEVESPI AEROSPHERE. 128 bexarotene ............................17 BEXSERO..........................104 BEYAZ...............................114 BIAFINE EMULSION.........59 bicalutamide .........................17 BIDIL ...................................46 BIKTARVY ...........................7 BILTRICIDE........................12 bimatoprost.........................122 BINOSTO...........................108 BIONIME RIGHTEST TEST

STRIPS.............................78 BIOTHRAX .......................104 bisacodyl...............................96 bisoprolol fumarate...............46 bisoprolol-hydrochlorothiazide

..........................................46 BLEPH-10 ..........................124 BLEPHAMIDE ..................124 BLEPHAMIDE S.O.P........124 blisovi 24 fe ........................114 blisovi fe 1.5/30 (28) ..........114 blisovi fe 1/20 (28) .............114 BLOOD GLUCOSE TEST ..78 BLUNT NEEDLE,

DISPOSABLE..................83 BONIVA ............................108 BOOSTRIX TDAP.............104 BOSULIF .............................17 bpo........................................61 BRAVELLE .........................90 BREEZE 2 TEST STRIPS ...78 BREO ELLIPTA ................128 BREVICON (28)................114 briellyn................................114 BRILINTA ...........................52 brimonidine ........................124 BROMFED DM .................125 bromfenac...........................121 bromocriptine .................25, 26 brompheniramine-pseudoeph-

dm...................................125 BROVANA ........................128 budesonide....................96, 128 BULLSEYE MINI SAFETY

LANCETS........................83 bumetanide ...........................46 BUNAVAIL .........................21

145

BUPAP .................................31 BUPHENYL.........................71 buprenorphine-naloxone.......21 bupropion hcl........................37 bupropion hcl (smoking deter)

..........................................75 buspirone ..............................37 butalbital compound w/codeine

..........................................31 butalbital-acetaminop-caf-cod

..........................................31 butalbital-acetaminophen .....31 butalbital-acetaminophen-caff

..........................................31 butalbital-aspirin-caffeine.....31 BUTISOL .............................37 butorphanol tartrate ..............31 BUTRANS ...........................31 BYDUREON........................92 BYDUREON BCISE............92 BYETTA ..............................92 BYSTOLIC...........................46 C cabergoline ...........................90 CABOMETYX.....................17 CADUET..............................54 CAFERGOT .........................27 caffeine citrate ......................71 CALAN ................................46 CALAN SR ..........................46 calcipotriene .........................57 calcipotriene-betamethasone 57 calcitonin (salmon) ...............90 calcitrene...............................57 calcitriol ..........................57, 90 calcium 500 with d .............134 calcium acetate .....................96 calcium carbonate-vitamin d3

........................................134 calcium citrate + d ..............134 calcium citrate-vitamin d3..134 calcium pnv ........................135 calcium-folic acid-vitamin d

........................................135 CALQUENCE......................17 camila .................................110 CAMINO PRO 15 PE PKU . 72 camrese ...............................114 camrese lo ...........................114 CANASA..............................96

candesartan ...........................46 candesartan-hydrochlorothiazid

..........................................46 capacet ..................................31 CAPCOF ............................125 capecitabine..........................17 CAPEX.................................65 CAPITAL WITH CODEINE

..........................................31 CAPRELSA .........................17 captopril................................46 captopril-hydrochlorothiazide

..........................................46 CARAFATE.......................100 CARBAGLU........................71 carbamazepine................21, 22 CARBATROL......................22 carbidopa ..............................26 carbidopa-levodopa ..............26 carbidopa-levodopa-

entacapone........................26 carbinoxamine maleate.......124 CARDIZEM.........................46 CARDIZEM CD ..................46 CARDIZEM LA...................46 CARDURA ..........................46 CARDURA XL....................46 CAREFINE PEN NEEDLE . 83 CAREONE THIN LANCET83 CARESENS N TEST STRIPS

..........................................78 carisoprodol..........................29 carisoprodol-asa-codeine......29 carisoprodol-aspirin..............29 CARNITOR .........................71 CARNITOR (SUGAR-FREE)

..........................................71 carteolol ..............................120 carvedilol ..............................46 carvedilol phosphate.............46 CASODEX...........................17 CATAPRES .........................46 CATAPRES-TTS-1..............46 CATAPRES-TTS-2..............46 CATAPRES-TTS-3..............46 CAVERJECT .....................133 CAVERJECT IMPULSE ...133 CAYSTON...........................12 caziant (28).........................114 cefaclor .................................11

cefadroxil..............................11 cefdinir..................................11 cefditoren pivoxil .................11 cefixime................................11 cefpodoxime .........................11 cefprozil................................11 CEFTIN ................................11 cefuroxime axetil..................11 CELEBREX .........................35 celecoxib...............................35 CELEXA ..............................37 CELLCEPT ..........................17 CELONTIN..........................22 CENTANY...........................63 CENTANY AT.....................63 centratex .............................135 cephalexin.............................11 CERDELGA.........................90 CESAMET ...........................96 CETROTIDE........................90 cevimeline ............................71 CHANTIX............................75 CHANTIX CONTINUING

MONTH BOX..................75 CHANTIX STARTING

MONTH BOX..................75 chateal.................................114 CHEMET..............................71 CHENODAL........................96 cheratussin ac .....................125 chlordiazepoxide hcl.............38 chlordiazepoxide-clidinium..94 chlorhexidine gluconate .......75 chloroquine phosphate..........12 chlorothiazide .......................46 chlorpromazine.....................38 chlorpropamide.....................92 chlorthalidone.......................46 chlorzoxazone.......................29 CHOLBAM..........................96 cholestyramine (with sugar) . 54 cholestyramine light .............54 choline,magnesium salicylate

..........................................35 CIALIS .......................132, 133 ciclodan ................................64 ciclopirox ..............................64 ciclopirox-ure-camph-menth-

euc ....................................64 cilostazol...............................52

146

CILOXAN ..........................119 cimetidine ...........................100 cimetidine hcl .....................100 CIMZIA................................96 CIMZIA STARTER KIT .....96 CINRYZE...........................128 CIPRO ..................................15 CIPRO HC............................76 CIPRO XR............................15 CIPRODEX ..........................76 ciprofloxacin.........................15 ciprofloxacin (mixture).........15 ciprofloxacin hcl .....15, 76, 119 citalopram .............................38 citrate of magnesia................96 claravis..................................61 CLARINEX........................124 CLARINEX-D 12 HOUR ..125 clarithromycin.......................11 clearlax .................................96 clemastine ...........................124 CLEOCIN...................112, 113 CLEOCIN HCL....................12 CLEOCIN PEDIATRIC.......13 CLEOCIN T .........................61 CLEVER CHEK LANCETS83 CLEVER CHOICE MICRO

TEST STRIP.....................78 CLEVER CHOICE PRO......78 CLEVER CHOICE TEST

STRIPS .............................78 CLEVER CHOICE VOICE+

TEST.................................78 CLICKFINE .........................83 CLIMARA..........................110 CLIMARA PRO.................110 clindacin p ............................61 CLINDAGEL .......................61 clindamycin hcl ....................13 clindamycin palmitate hcl.....13 clindamycin pediatric ...........13 clindamycin phosphate . 61, 113 clindamycin-benzoyl peroxide

..........................................61 CLINDESSE.......................113 CLINPRO 5000 ....................75 clobetasol ..............................66 clobetasol-emollient .............66 CLOBEX ..............................66

CLOCORTOLONE PIVALATE ......................66

clodan ...................................66 CLODERM ..........................66 clomipramine........................38 clonazepam...........................22 clonidine ...............................46 clonidine hcl ...................38, 46 clopidogrel............................52 clorazepate dipotassium .......38 clorpres .................................46 CLORPRES..........................47 clotrimazole............................6 clotrimazole-betamethasone.64 clozapine...............................38 CLOZAPINE........................38 CLOZARIL ..........................38 c-nate dha ...........................135 COAGADEX .......................52 COAGUCHEK LANCETS..83 COAL TAR..........................57 COARTEM ..........................13 codeine sulfate......................31 codeine-butalbital-asa-caff ...31 codeine-guaifenesin............126 COLAZAL ...........................96 COLCRYS .........................108 COLESTID...........................54 COLESTID FLAVORED ....54 colestipol ..............................54 colocort.................................96 COLOR LANCETS .............83 COLY-MYCIN S .................76 COLYTE WITH FLAVOR

PACKS.............................96 COMBIGAN ......................122 COMBIPATCH..................110 COMBIVENT RESPIMAT128 COMBIVIR............................7 COMETRIQ.........................17 COMFORT EZ PEN

NEEDLES ........................83 COMFORT LANCETS .......83 COMPAZINE.......................96 COMPLERA ..........................7 complete natal dha..............135 completenate.......................135 compro ..................................96 COMTAN.............................26 CONDYLOX .......................59

constulose .............................96 CONTOUR NEXT STRIPS.78 CONTOUR TEST STRIPS..78 CONTRAVE ........................70 COOL GLUCOSE TEST

STRIP ...............................79 COPAXONE ......................102 CORDRAN ..........................66 COREG ................................47 COREG CR ..........................47 CORGARD ..........................47 CORIFACT ..........................52 CORLANOR........................56 cormax ..................................66 CORTEF...............................77 CORTENEMA .....................96 CORTIFOAM ......................96 cortisone ...............................77 CORTISPORIN....................63 corvita.................................135 corvita 150..........................135 CORVITE...........................136 CORVITE 150....................135 CORVITE FE.....................135 CORVITE FREE................136 CORZIDE.............................47 COSENTYX.........................58 COSENTYX (2 SYRINGES)

..........................................58 COSENTYX PEN ................58 COSENTYX PEN (2 PENS)58 COSOPT.............................122 COTELLIC...........................17 COUMADIN........................52 covaryx ...............................110 covaryx h.s.......................... 110 COZAAR..............................47 CREON ................................96 CRESEMBA ..........................6 CRESTOR............................55 CRINONE ..........................110 CRIXIVAN ............................7 cromolyn...............96, 121, 128 cryselle (28)........................114 CUTIVATE..........................66 CUVITRU ..........................104 CUVPOSA ...........................94 cyanocobalamin (vitamin b-12)

........................................136 cyclafem 1/35 (28)..............114

147

cyclafem 7/7/7 (28).............114 CYCLESSA (28) ................114 cyclobenzaprine ....................29 CYCLOGYL ......................120 CYCLOMYDRIL...............124 cyclopentolate.....................120 CYCLOPHOSPHAMIDE ....17 CYCLOSERINE...................13 CYCLOSET .........................92 cyclosporine..........................18 cyclosporine modified ..........18 CYMBALTA........................38 cyproheptadine ...................125 cyred ...................................114 CYSTADANE......................97 CYSTAGON ......................133 CYSTARAN.......................121 CYTOMEL...........................94 CYTOTEC..........................100 D D.H.E.45...............................27 DALIRESP .........................128 danazol..................................90 DANTRIUM.........................29 dantrolene .............................29 DAPTACEL (DTAP

PEDIATRIC) (PF)..........104 DARAPRIM .........................13 darifenacin ..........................131 dasetta 1/35 (28) .................114 dasetta 7/7/7 (28) ................114 DAYPRO..............................35 daysee .................................114 DAYTRANA........................38 DDAVP ................................90 deblitane .............................110 decadron ...............................77 DELESTROGEN ...............110 deltasone ...............................77 delyla (28)...........................114 DEMADEX ..........................47 demeclocycline .....................16 DEMEROL...........................31 DENAVIR ............................65 denta 5000 plus.....................75 dentagel.................................75 DEPAKENE .........................22 DEPAKOTE .........................22 DEPAKOTE ER...................22 DEPAKOTE SPRINKLES...22

DEPEN TITRATABS........109 DEPO-ESTRADIOL..........110 DEPO-PROVERA .............110 DEPO-SUBQ PROVERA 104

........................................110 DEPO-TESTOSTERONE....90 DERMA-SMOOTHE/FS

BODY OIL.......................66 DERMA-SMOOTHE/FS

SCALP OIL......................66 DERMASORB HC

COMPLETE KIT .............66 DERMASORB TA

COMPLETE KIT .............66 DERMATOP........................66 DERMOTIC OIL .................76 DESCOVY.............................7 desipramine ..........................38 desloratadine.......................125 desmopressin ........................90 desog-e.estradiol/e.estradiol

........................................114 desogestrel-ethinyl estradiol

........................................114 DESONATE.........................66 desonide................................67 DESOWEN ..........................67 desoximetasone ....................67 desvenlafaxine succinate ......38 dexamethasone .....................77 dexamethasone intensol........77 dexamethasone sodium

phosphate........................123 DEXEDRINE SPANSULE..38 DEXILANT........................100 dexmethylphenidate .............38 dextroamphetamine ..............38 dextroamphetamine-

amphetamine ....................38 dialyvite..............................136 DIALYVITE 800 WITH IRON

........................................136 DIALYVITE SUPREME D

........................................136 DIASTAT.............................22 DIASTAT ACUDIAL..........22 DIATRUE PLUS TEST STRIP

..........................................79 diazepam.........................22, 38 diazepam intensol.................38

DIBENZYLINE ...................47 diclofenac potassium ............35 diclofenac sodium...35, 59, 121 diclofenac-misoprostol .........35 dicloxacillin ..........................15 dicyclomine ..........................94 didanosine...............................7 diethylpropion ......................70 DIFICID ...............................11 diflorasone ............................67 DIFLUCAN............................6 diflunisal...............................35 digitek...................................51 digox.....................................51 digoxin ..................................51 dihydroergotamine................27 DILANTIN...........................22 DILANTIN EXTENDED.....22 DILANTIN INFATABS ......22 DILANTIN-125....................22 DILATRATE-SR .................56 DILAUDID ..........................31 diltiazem hcl .........................47 DIOVAN ..............................47 DIOVAN HCT .....................47 DIPENTUM .........................97 diphenhydramine hcl ..........125 diphenoxylate-atropine...94, 95 DIPROLENE........................67 dipyridamole.........................52 DISALCID ...........................35 diskets...................................31 disopyramide phosphate .......44 disulfiram..............................71 DITROPAN XL .................131 DIURIL ................................47 divalproex.............................22 DIVIGEL............................111 dofetilide...............................44 DOLOPHINE .......................31 donepezil ..............................28 DONNATAL........................95 DORAL ................................38 dorzolamide ........................122 dorzolamide-timolol ...........122 dothelle dha ........................136 doxazosin ..............................47 doxepin ...........................39, 59 doxercalciferol......................90 doxycycline hyclate..............16

148

doxycycline monohydrate ....16 drithocreme hp......................58 dronabinol.............................97 DROPLET LANCETS .........83 DROPLET PEN NEEDLE...83 drospirenone-e.estradiol-lm.fa

........................................114 drospirenone-ethinyl estradiol

........................................114 DROXIA...............................18 DUAVEE............................111 DUETACT ...........................92 DULERA............................128 duloxetine .............................39 DUOPA ................................26 DUPIXENT ..........................59 DURAGESIC .......................31 DUREZOL .........................123 dutasteride...........................132 dutasteride-tamsulosin........132 DUTOPROL.........................47 DYAZIDE ............................47 DYRENIUM.........................47 E e.e.s. 400 ...............................12 E.E.S. GRANULES..............12 EAA SUPPLEMENT ...........72 EASY COMFORT LANCETS

..........................................83 EASY COMFORT PEN

NEEDLES ........................83 EASY PLUS II TEST...........79 EASY STEP .........................79 EASY TALK GLUCOSE

TEST.................................79 EASY TOUCH FLIPLOCK

NEEDLE...........................83 EASY TOUCH

HYPODERMIC NEEDLE ..........................................83

EASY TOUCH TEST STRIP ..........................................79

EASY TRAK GLUCOSE TEST.................................79

EASYGLUCO PLUS ...........79 EASYGLUCO TEST ...........79 EASYMAX ..........................79 EC-NAPROSYN ..................35 econazole ..............................64 EDARBI ...............................47

EDARBYCLOR...................47 EDECRIN.............................47 EDEX .................................133 EDURANT.............................7 eemt ....................................111 eemt hs................................111 efavirenz .................................7 effer-k .................................134 EFFER-K............................134 EFFEXOR XR......................39 EFFIENT..............................52 EFUDEX ..............................59 ELDEPRYL .........................26 ELEMENT COMPACT TEST

STRIPS.............................79 ELEMENT TEST STRIPS...79 ELESTRIN.........................111 eletone ..................................59 eletriptan hbr ........................27 ELIDEL................................59 ELIMITE..............................69 elinest .................................114 eliphos ..................................97 ELIQUIS ..............................52 elite-ob ................................136 ELIXOPHYLLIN...............128 ELLA..................................114 ELMIRON..........................133 ELOCON..............................67 EMBRACE BLOOD

GLUCOSE SYSTEM.......79 EMBRACE EVO TEST

STRIPS.............................79 EMBRACE PRO TEST

STRIPS.............................79 EMCYT................................18 EMEND................................97 EMFLAZA ...........................77 emoquette ...........................114 EMSAM ...............................39 EMTRIVA..............................7 emulsion sb ...........................59 enalapril maleate ..................47 enalapril-hydrochlorothiazide

..........................................47 ENBREL ............................109 ENBREL MINI ..................109 ENBREL SURECLICK .....109 endocet .................................31 ENGERIX-B (PF) ..............104

ENGERIX-B PEDIATRIC (PF).................................104

enoxaparin ............................52 enpresse ..............................114 enskyce ...............................114 ENSTILAR...........................58 entacapone ............................26 entecavir .................................7 ENTOCORT EC...................97 ENTRESTO..........................56 enulose..................................97 EPANED ..............................47 EPCLUSA ..............................7 EPICERAM..........................59 EPIDUO ...............................61 EPIDUO FORTE..................61 epinastine............................121 epinephrine .........................125 EPINEPHRINE ..................125 EPIPEN ..............................125 EPIPEN 2-PAK ..................125 EPIPEN JR .........................125 EPIPEN JR 2-PAK.............125 epitol.....................................22 EPIVIR ...................................8 EPIVIR HBV..........................8 eplerenone ............................47 EPOGEN ............................102 epoprostenol (glycine)..........47 eprosartan .............................47 EPZICOM ..............................8 EQUETRO ...........................22 ergocalciferol (vitamin d2). 136 ergoloid .................................39 ERGOMAR..........................27 ERIVEDGE..........................18 errin ....................................111 ERTACZO............................64 ery pads.................................61 erygel ....................................61 ERYPED 200 .......................12 ERYPED 400 .......................12 ery-tab...................................12 ERY-TAB.............................12 erythrocin (as stearate) .........12 erythromycin ................12, 119 erythromycin ethylsuccinate. 12 erythromycin with ethanol....61 erythromycin-benzoyl peroxide

..........................................61

149

ESBRIET............................129 ESCAVITE.........................136 escitalopram oxalate .............39 ESGIC...................................31 esomeprazole magnesium...101 estarylla...............................115 estazolam ..............................39 ESTRACE ..........................111 estradiol ..............................111 estradiol valerate.................111 estradiol-norethindrone acet

........................................111 ESTRING ...........................111 ESTROGEL........................111 estrogens-methyltestosterone

........................................111 estropipate...........................111 ESTROSTEP FE-28 ...........115 eszopiclone ...........................39 ethacrynic acid......................47 ethambutol ............................13 ethosuximide.........................22 ethyl chloride ........................63 ethynodiol diac-eth estradiol

........................................115 etidronate disodium ..............71 etodolac.................................35 etoposide...............................18 EUCRISA .............................59 EURAX ................................69 EVAMIST ..........................111 EVENCARE G2...................79 EVENCARE G3 TEST ........79 EVENCARE MINI

GLUCOSE TEST STR.....79 EVISTA..............................108 EVOCLIN.............................61 EVOLUTION TEST STRIPS

..........................................79 EVOTAZ ................................8 EVOXAC .............................71 EXEL HYPODERMIC

NEEDLES ........................83 EXELDERM ........................64 exemestane ...........................18 EXFORGE............................47 EXFORGE HCT...................47 EXJADE...............................71 EXODERM ..........................64 EXTAVIA ..........................102

EXTINA...............................64 e-z ject lancets ......................83 EZ SMART LANCETS .......84 EZ SMART PLUS TEST.....79 EZ SMART TEST................79 ezetimibe ..............................55 ezetimibe-simvastatin...........55 F fabb.....................................136 FABIOR ...............................61 FACTIVE.............................15 falmina (28) ........................115 famciclovir .............................8 famotidine...........................101 FANAPT ..............................39 FARESTON .........................18 FARXIGA ............................92 FARYDAK...........................18 fayosim...............................115 FAZACLO ...........................39 fe c plus ..............................136 FEIBA NF ............................52 felbamate ..............................22 FELBATOL .........................22 FELDENE ............................35 felodipine..............................47 fem ph.................................113 FEMARA .............................18 FEMHRT LOW DOSE ......111 FEMRING..........................111 femynor ..............................115 fenofibrate ............................55 fenofibrate micronized .........55 fenofibrate nanocrystallized . 55 fenofibric acid ......................55 fenofibric acid (choline) .......55 FENOGLIDE .......................55 fenoprofen ............................35 fentanyl.................................32 fentanyl citrate................31, 32 FENTORA ...........................32 ferocon................................136 FERRALET 90 DUAL-IRON

DELIVERY....................136 ferraplus 90 .........................136 FERRIPROX........................71 ferrocite plus.......................136 FEXMID...............................29 FIASP FLEXTOUCH U-100

INSULIN..........................88

FIASP U-100 INSULIN.......88 FIBRICOR............................55 FIFTY50 SAFETY SEAL

LANCETS........................84 FIFTY50 TEST STRIP ........79 FINACEA.............................61 finasteride ...........................132 FINE 30 UNIVERSAL

LANCETS........................84 FINGERSTIX LANCETS....84 FIORICET ............................32 FIORINAL ...........................32 FIORINAL-CODEINE #3 ...32 FIRAZYR...........................129 FLAGYL ..............................13 FLAREX ............................123 flavoxate .............................132 flecainide ..............................44 FLOLAN ..............................48 FLOMAX ...........................132 FLOVENT DISKUS ..........129 FLOVENT HFA.................129 FLOW-EZE VENTED

NEEDLE ..........................84 floxin ....................................76 FLUAD 2017-2018 (65 YR

UP)(PF) ..........................105 FLUARIX QUAD 2017-2018

(PF).................................105 FLUBLOK 2017-2018 (PF)

........................................105 FLUBLOK QUAD 2017-2018

(PF).................................105 flucaine ...............................121 FLUCELVAX QUAD 2017-

2018................................105 FLUCELVAX QUAD 2017-

2018 (PF)........................105 fluconazole .............................6 flucytosine ..............................6 fludrocortisone......................77 FLULAVAL QUAD 2017-

2018................................105 FLULAVAL QUAD 2017-

2018 (PF)........................105 FLUMADINE ........................8 FLUMIST QUAD 2017-2018

........................................105 flunisolide...........................129 fluocinolone..........................67

150

fluocinolone acetonide oil ....76 fluocinolone and shower cap 67 fluocinonide..........................67 fluocinonide-e.......................67 fluocinonide-emollient .........67 FLUORABON....................136 FLUOR-A-DAY.................136 fluor-a-day (with xylitol) ....136 fluorescein-proparacaine ....121 fluoride (sodium) ................136 FLUORIDEX DAILY

DEFENSE.........................75 fluoritab ..............................136 fluorometholone .................123 fluorouracil ...........................59 fluoxetine..............................39 fluphenazine hcl....................39 FLURA-DROPS.................136 flurandrenolide .....................67 flurazepam ............................39 flurbiprofen...........................35 flurbiprofen sodium ............121 flutamide...............................18 fluticasone.....................67, 129 fluvastatin .............................55 FLUVIRIN 2017-2018 .......105 FLUVIRIN 2017-2018 (PF)

........................................105 fluvoxamine..........................39 FLUZONE HIGH-DOSE

2017-18 (PF)...................105 FLUZONE INTRADERM

QUAD 2017-18 ..............105 FLUZONE QUAD 2017-2018

........................................105 FLUZONE QUAD 2017-2018

(PF) .................................105 FLUZONE QUAD PEDI

2017-18 (PF)...................105 FML FORTE ......................123 FML LIQUIFILM ..............123 FML S.O.P. .........................123 folbee ..................................136 folbee plus ..........................137 FOLGARD OS ...................137 FOLGARD RX...................137 folic acid .............................137 folic acid-vit b6-vit b12 ......137 folivane-f ............................137 folivane-ob..........................137

folivane-plus.......................137 FOLLISTIM AQ ..................90 folplex 2.2...........................137 FOLTRATE .......................137 fondaparinux.........................52 FORA D15G ........................79 FORA D20 ...........................79 FORA D40-G31 TEST

STRIPS.............................79 FORA G20 ...........................79 FORA G30A ........................79 FORA GD50 TEST STRIPS 79 FORA TEST STRIP.............79 FORA TN'G VOICE TEST

STRIPS.............................79 FORA V10 ...........................79 FORA V10-V12-D10-D20

STRP-LNCT.....................84 FORA V12 GLUCOSE........79 FORA V20 ...........................80 FORACARE GD20..............80 FORACARE GD40..............80 FORACARE LANCETS .....84 FORTAVIT ........................135 FORTEO ............................108 FORTISCARE GLUCOSE

TEST STRIPS ..................80 FOSAMAX ........................108 FOSAMAX PLUS D..........109 fosinopril ..............................48 fosinopril-hydrochlorothiazide

..........................................48 FOSRENOL .........................97 FRAGMIN ...........................52 FREESTYLE INSULINX....80 FREESTYLE INSULINX

TEST STRIPS ..................80 FREESTYLE LANCETS.....84 FREESTYLE LITE STRIPS 80 FREESTYLE PRECISION

NEO STRIPS....................80 FREESTYLE TEST .............80 FREESTYLE UNISTIK 2....84 frovatriptan ...........................27 FURADANTIN....................16 furosemide............................48 FUZEON ................................8 fyavolv ................................111 FYCOMPA ..........................23

G gabapentin ............................23 GABITRIL ...........................23 galantamine ..........................28 GALZIN .............................134 GAMMAGARD LIQUID ..105 GAMUNEX-C....................105 GANIRELIX ........................90 GARDASIL 9 (PF).....105, 106 GASTROCROM ..................97 gatifloxacin.........................119 GATTEX 30-VIAL ..............97 GATTEX ONE-VIAL..........97 gavilyte-c ..............................97 gavilyte-g ..............................97 gavilyte-n..............................97 GE100 BLOOD GLUCOSE

TEST STRIP.....................80 GELNIQUE........................132 gemfibrozil ...........................55 GENERESS FE ..................115 generlac ................................97 gengraf..................................18 GENSTRIP TEST STRIP ....80 gentak .................................119 gentamicin ....................63, 119 GENVOYA ............................8 GEODON .............................39 gianvi (28) ..........................115 GIAZO..................................97 GILENYA ..........................102 GILOTRIF............................18 glatiramer............................103 glatopa ................................103 GLEEVEC............................18 GLEOSTINE........................18 glimepiride............................92 glipizide ................................92 glipizide-metformin..............92 GLUCAGEN DIAGNOSTIC

KIT ...................................81 GLUCAGEN HYPOKIT .....82 GLUCAGON EMERGENCY

KIT (HUMAN).................82 GLUCO NAVII TEST STRIP

..........................................80 GLUCOCARD 01 SENSOR

PLUS ................................80 GLUCOCARD EXPRESSION

..........................................80

151

GLUCOCARD SHINE TEST STRIPS .............................80

GLUCOCARD VITAL SENSOR...........................80

GLUCOCARD VITAL TEST STRIPS .............................80

GLUCOCOM GLUCOSE....80 GLUCOCOM LANCETS ....84 GLUCOPHAGE ...................92 GLUCOPHAGE XR ............92 GLUCOTROL......................92 GLUCOTROL XL................92 GLUCOVANCE...................92 glyburide...............................92 glyburide micronized ............92 glyburide-metformin.............92 glycopyrrolate.......................95 glydo .....................................63 GLYNASE ...........................93 GLYSET...............................93 GLYTACTIN 10 PE

COMPLETE .....................72 GLYTACTIN 15 PE

BETTERMILK.................72 GLYTACTIN 15 PE

COMPLETE .....................72 GLYTACTIN 20PE

BETTERMILK LITE .......72 GLYTACTIN BUILD 10 PE72 GLYTACTIN RESTORE 10

PE .....................................72 GLYTACTIN RESTORE 10

PE LITE............................72 GLYTACTIN RESTORE 5 PE

..........................................72 GLYTACTIN RTD 10 PE....72 GLYTACTIN RTD 15 PE....72 GLYTACTIN SWIRL 15 PE

..........................................73 GLYXAMBI.........................93 GM100 ..................................80 GOLYTELY.........................97 GONAL-F.............................91 GONAL-F RFF ....................90 GONAL-F RFF REDI-JECT90 granisetron hcl ......................97 GRASTEK..........................106 griseofulvin microsize ............6 griseofulvin ultramicrosize.....6

GRIS-PEG (ULTRAMICROSIZE) ......6

guaifenesin ac.....................126 guaifenesin dac...................126 guanfacine ......................39, 48 guanidine ..............................39 GYNAZOLE-1...................113 H HAEGARDA .....................129 HALCION............................39 halobetasol propionate..........67 HALOG..........................67, 68 haloperidol............................39 haloperidol lactate ................39 HARVONI .............................8 HAVRIX (PF) ....................106 HEALTHPRO TEST STRIPS

..........................................80 HEALTHY ACCENTS

UNIFINE PENTIP ...........84 HEALTHY ACCENTS

UNILET LANCET...........84 heather ................................111 HELIXATE FS.....................52 hematinic plus vit/minerals 137 hematinic/folic acid ............137 hematogen ..........................137 hematogen fa ......................137 hematogen forte..................137 hemenatal ob ......................137 hemenatal ob + dha ............137 hemmorex-hc........................97 HEMOCYTE-F ..................137 HEMOCYTE-PLUS...........137 HEMOFIL M HIGH.............52 HEMOFIL M LOW .............53 HEMOFIL M MID...............53 HEMOFIL M SUPER HIGH53 hep flush-10 (pf)...................53 heparin (porcine) ..................53 heparin lock flush .................53 heparin lock flush (porcine) . 53 heparin lockflush(porcine)(pf)

..........................................53 heparin, porcine (pf).............53 HEPSERA ..............................8 HEXALEN ...........................18 HIBERIX (PF)....................106 HIPREX ...............................16 HIZENTRA........................106

HORIZANT..........................29 huber safety needles (disp.) ..84 HUMALOG JUNIOR

KWIKPEN U-100 ............88 HUMALOG KWIKPEN

INSULIN ..........................88 HUMALOG MIX 50-50

INSULN U-100 ................88 HUMALOG MIX 50-50

KWIKPEN........................88 HUMALOG MIX 75-25

KWIKPEN........................88 HUMALOG MIX 75-25(U-

100)INSULN ....................88 HUMALOG U-100 INSULIN

..........................................88 HUMATE-P .........................53 HUMIRA............................109 HUMIRA PEDIATRIC

CROHN'S START .........109 HUMIRA PEN ...................109 HUMIRA PEN CROHN'S-

UC-HS START ..............109 HUMIRA PEN PSORIASIS-

UVEITIS ........................109 HUMULIN 70/30 U-100

INSULIN ..........................88 HUMULIN 70/30 U-100

KWIKPEN........................88 HUMULIN N NPH INSULIN

KWIKPEN........................88 HUMULIN N NPH U-100

INSULIN ..........................88 HUMULIN R REGULAR U-

100 INSULN ....................88 HUMULIN R U-500 (CONC)

INSULIN ..........................88 HUMULIN R U-500 (CONC)

KWIKPEN........................89 HYCAMTIN ........................18 HYCET.................................32 hydralazine ...........................48 HYDREA .............................18 HYDRO 40...........................59 hydrochlorothiazide..............48 hydrocodone-acetaminophen32 hydrocodone-chlorpheniramine

........................................126 hydrocodone-cpm-

pseudoephed ...................126

152

hydrocodone-homatropine..126 hydrocodone-ibuprofen ........32 hydrocortisone ..........68, 77, 97 hydrocortisone acetate ..........97 hydrocortisone butyrate ........68 hydrocortisone butyr-emollient

..........................................68 hydrocortisone valerate ........68 hydrocortisone-acetic acid....76 hydrocortisone-min oil-wht pet

..........................................68 hydrocortisone-pramoxine...58,

97 hydromet.............................126 hydromorphone.....................32 hydroxychloroquine..............13 hydroxyurea ..........................18 hydroxyzine hcl ..................125 hydroxyzine pamoate..........125 hyoscyamine sulfate .............95 HYQVIA ............................106 HYZAAR .............................48 I ibandronate .........................109 IBRANCE.............................18 IBUDONE ............................32 ibuprofen...............................35 ibuprofen-oxycodone............32 ICAR-C PLUS....................137 ICLUSIG ..............................18 IDHIFA.................................18 ILARIS (PF) .......................103 imatinib.................................18 IMBRUVICA .......................18 imipramine hcl......................39 imipramine pamoate .............39 imiquimod...........................104 IMITREX .............................27 IMITREX STATDOSE KIT

REFILL.............................27 IMITREX STATDOSE PEN27 IMOVAX RABIES VACCINE

(PF) .................................106 IMURAN..............................18 INCONTROL PEN NEEDLE

..........................................84 INCONTROL SUPER THIN

LANCETS ........................84 INCONTROL ULTRA THIN

LANCETS ........................84

indapamide ...........................48 INDERAL LA......................48 INDERAL XL......................48 INDOCIN .............................35 indomethacin ........................35 INFANRIX (DTAP) (PF)...106 INFINITY TEST STRIPS....80 INJECT EASE LANCETS ..84 INLYTA ...............................18 INNOPRAN XL...................48 INSPRA................................48 INSUPEN.............................84 INTEGRA F .......................137 INTEGRA PLUS................137 INTELENCE..........................8 INTRON A.........................104 introvale..............................115 INTUNIV ER .......................40 INVACARE LANCETS ......84 INVEGA...............................40 INVEGA SUSTENNA.........40 INVEGA TRINZA...............40 INVIRASE .............................8 INVOKAMET......................93 INVOKAMET XR ...............93 INVOKANA ........................93 IOPIDINE...........................124 IPOL...................................106 ipratropium bromide.....75, 129 ipratropium-albuterol .........129 irbesartan ..............................48 irbesartan-hydrochlorothiazide

..........................................48 IRESSA ................................18 IROSPAN 24/6...................137 ISENTRESS...........................8 ISENTRESS HD ....................8 isibloom..............................115 ISOCHRON .........................56 isometh-dichloral-

acetaminophn ...................27 isomethepten-caf-

acetaminophen..................28 isoniazid ...............................13 ISOPTO CARPINE............121 ISORDIL ..............................57 ISORDIL TITRADOSE.......57 isosorbide dinitrate ...............57 isosorbide mononitrate .........57 isotretinoin............................61

isradipine ..............................48 itraconazole ............................6 ivermectin.............................13 IXIARO (PF)......................106 J JADENU ..............................71 JAKAFI ................................18 JALYN ...............................132 jantoven ................................53 JANUMET ...........................93 JANUMET XR.....................93 JANUVIA.............................93 jencycla...............................111 JENTADUETO ....................93 JENTADUETO XR..............93 jevantique lo .......................111 jinteli...................................111 jolessa .................................115 jolivette...............................111 juleber.................................115 JULUCA.................................8 junel 1.5/30 (21) .................115 junel 1/20 (21) ....................115 junel fe 1.5/30 (28) .............115 junel fe 1/20 (28) ................115 junel fe 24...........................115 JUXTAPID...........................55 K KADIAN ..............................32 kaitlib fe..............................115 KALETRA .............................8 KALYDECO......................129 KAPVAY .............................40 kariva (28) ..........................115 k-effervescent .....................134 kelnor 1/35 (28) ..................115 KENALOG...........................68 KEPPRA...............................23 KEPPRA XR ........................23 KERALAC ...........................59 ketoconazole.....................6, 64 ketoprofen.......................35, 36 ketorolac .......................36, 122 KEVEYIS.............................29 kimidess (28) ......................115 KINERET...........................104 KINRIX (PF)......................106 kionex ...................................97 kionex (with sorbitol) ...........97 KISQALI..............................19

153

KISQALI FEMARA CO-PACK ...............................18

KITABIS PAK .....................13 KLARON .............................63 KLONOPIN..........................23 klor-con...............................134 klor-con 10..........................134 klor-con 8............................134 klor-con m10 ......................134 klor-con m15 ......................134 klor-con m20 ......................134 klor-con sprinkle.................134 KLOR-CON/25 ..................134 klor-con/ef ..........................134 KOATE.................................53 KOGENATE FS...................53 KORLYM.............................91 K-PHOS NO 2....................133 K-PHOS ORIGINAL .........133 k-phos-neutral.....................134 KRISTALOSE......................97 k-tab....................................134 K-TAB................................134 kurvelo ................................115 KUVAN................................91 KYNAMRO .........................55 L l norgest/e.estradiol-e.estrad

........................................115 labetalol ................................48 LACRISERT ......................121 lactated ringers......................70 lactulose................................97 LAMICTAL .........................23 LAMICTAL ODT ................23 LAMICTAL ODT STARTER

(BLUE) .............................23 LAMICTAL ODT STARTER

(GREEN) ..........................23 LAMICTAL ODT STARTER

(ORANGE).......................23 LAMICTAL STARTER

(BLUE) KIT .....................23 LAMICTAL STARTER

(GREEN) KIT ..................23 LAMICTAL STARTER

(ORANGE) KIT ...............23 LAMICTAL XR...................23 LAMICTAL XR STARTER

(BLUE) .............................23

LAMICTAL XR STARTER (GREEN)..........................23

LAMICTAL XR STARTER (ORANGE).......................23

lamivudine..............................8 lamivudine-zidovudine...........8 lamotrigine ...........................24 LANAFLEX.........................73 lancets...................................84 LANCETS............................84 LANCETS,THIN .................84 LANOXIN............................51 lansoprazole........................101 LANTUS SOLOSTAR U-100

INSULIN..........................89 LANTUS U-100 INSULIN..89 larin 1.5/30 (21)..................115 larin 1/20 (21).....................115 larin 24 fe ...........................115 larin fe 1.5/30 (28)..............115 larin fe 1/20 (28).................115 larissia.................................115 LASIX ..................................48 latanoprost ..........................122 LATUDA .............................40 laxaclear ...............................97 laxative peg 3350 .................98 layolis fe .............................115 leena 28 ..............................115 leflunomide.........................109 LENVIMA ...........................19 LESCOL...............................55 LESCOL XL ........................55 lessina .................................115 letrozole................................19 leucovorin calcium ...............17 LEUKERAN ........................19 leuprolide..............................19 levalbuterol hcl ...................129 LEVAQUIN .........................15 LEVATOL ...........................48 LEVBID ...............................95 LEVEMIR FLEXTOUCH U-

100 INSULN ....................89 LEVEMIR U-100 INSULIN 89 levetiracetam ........................24 LEVITRA...........................133 levobunolol.........................120 levocarnitine .........................71 levocarnitine (with sugar).....71

levofloxacin ..................15, 119 levonest (28) .......................116 levonorgestrel-ethinyl estrad

........................................116 levonorg-eth estrad triphasic

........................................116 levora-28.............................116 levorphanol tartrate...............32 LEVO-T................................94 levothyroxine........................94 levoxyl ..................................94 LEVSIN................................95 LEVSIN/SL..........................95 LEVULAN ...........................59 LEXAPRO............................40 LEXIVA .................................8 LIALDA ...............................98 LIBRAX (WITH

CLIDINIUM) ...................95 lidocaine ...............................63 lidocaine hcl .........................63 lidocaine hcl-hydrocortison ac

....................................63, 98 lidocaine viscous ..................63 lidocaine-hydrocortisone-aloe

..........................................98 lidocaine-prilocaine ..............63 LIDODERM.........................63 LIFESHIELD BLUNT

CANNULA ......................84 lillow...................................116 lindane ..................................69 linezolid ................................13 LINZESS..............................98 liothyronine ..........................94 LIPITOR...............................55 LIPOFEN..............................55 lisinopril................................48 lisinopril-hydrochlorothiazide

..........................................48 LITE TOUCH LANCETS....84 lithium carbonate..................40 lithium citrate .......................40 LITHOBID ...........................40 LITHOSTAT........................71 LIVALO ...............................55 LO LOESTRIN FE.............116 LOCOID...............................68 LOCOID LIPOCREAM.......68 LODINE ...............................36

154

LODOSYN ...........................26 LOESTRIN 1.5/30 (21) ......116 LOESTRIN 1/20 (21) .........116 LOESTRIN FE 1.5/30 (28-

DAY) ..............................116 LOESTRIN FE 1/20 (28-DAY)

........................................116 LOMAIRA ...........................70 LOMOTIL ............................95 LONSURF............................19 LOPHLEX............................73 LOPID ..................................55 lopinavir-ritonavir...................8 lopreeza...............................111 LOPRESSOR .......................48 LOPRESSOR HCT ..............48 LOPROX ..............................64 lorazepam .............................40 lorazepam intensol................40 lorcet (hydrocodone) ............32 lorcet hd ................................32 lorcet plus .............................32 LORTAB ELIXIR ................33 lortuss ex .............................126 loryna (28) ..........................116 losartan .................................48 losartan-hydrochlorothiazide48 LOSEASONIQUE..............116 LOTEMAX.........................123 LOTENSIN...........................48 LOTENSIN HCT..................48 LOTREL...............................48 LOTRISONE........................64 LOTRONEX.........................98 LOUTREX ...........................59 lovastatin...............................55 LOVENOX...........................53 low-ogestrel (28) ................116 loxapine succinate ................40 ludent fluoride ....................137 lugols ..................................134 LUMIGAN .........................122 LUNESTA............................40 LUPANETA PACK (1

MONTH) ........................113 LUPANETA PACK (3

MONTH) ........................113 lutera (28) ...........................116 LUXIQ..................................68 LYNPARZA.........................19

LYRICA ...............................24 LYRICA CR.........................24 LYSODREN.........................19 LYSTEDA..........................113 lyza .....................................111 M MACROBID ........................16 MACRODANTIN................16 mafenide acetate...................63 MAGNEBIND 400 ..............98 MALARONE .......................13 MALARONE PEDIATRIC . 13 malathion..............................69 maprotiline ...........................40 MAR-COF BP....................126 MAR-COF CG ...................126 MARINOL ...........................98 marlissa...............................116 MARPLAN ..........................40 marten-tab.............................33 MATULANE .......................19 matzim la..............................49 MAVYRET ............................8 MAXIDEX.........................123 MAXITROL.......................122 MAXZIDE ...........................49 MAXZIDE-25MG................49 m-clear wc ..........................126 meclofenamate .....................36 MEDISENSE THIN

LANCETS........................84 MEDLANCE PLUS

LANCETS........................84 MEDLANCE PLUS SPECIAL

BLADE.............................84 MEDROL.............................77 MEDROL (PAK) .................77 medroxyprogesterone .........112 mefenamic acid ....................36 mefloquine............................13 MEGACE ES .......................19 megestrol ..............................19 MEKINIST...........................19 meloxicam ............................36 melphalan .............................19 memantine ............................29 MEMANTINE .....................29 MENACTRA (PF) .............106 M-END PE .........................126 MENEST............................112

MENOPUR ..........................91 MENOSTAR......................112 MENVEO A-C-Y-W-135-DIP

(PF).................................106 meperidine ............................33 MEPHYTON........................53 meprobamate ........................30 MEPRON .............................13 mercaptopurine.....................19 mesalamine...........................98 mesalamine with cleansing

wipe ..................................98 MESNEX..............................17 MESTINON .........................30 MESTINON TIMESPAN ....30 metadate er ...........................40 metaproterenol....................129 metaxalone............................30 metformin .............................93 methadone ............................33 methadose.............................33 methamphetamine ................40 methazolamide....................122 methenamine hippurate ........16 methenamine mandelate .......16 methen-sod phos-meth blue-

hyos ................................133 methimazole .........................78 METHITEST........................91 methocarbamol .....................30 methotrexate sodium ............19 methotrexate sodium (pf) .....19 methoxsalen..........................59 methscopolamine..................95 methyclothiazide ..................49 methyldopa ...........................49 methyldopa-

hydrochlorothiazide..........49 METHYLIN .........................40 methylphenidate hcl .......40, 41 methylprednisolone ..............77 methyltestosterone................91 metipranolol........................120 metoclopramide hcl ..............98 metolazone............................49 METOPIRONE ....................71 metoprolol succinate.............49 metoprolol ta-hydrochlorothiaz

..........................................49 metoprolol tartrate ................49

155

METROCREAM..................61 METROGEL VAGINAL ...113 METROLOTION .................61 metronidazole ...13, 61, 62, 113 mexiletine .............................44 MIACALCIN .......................91 mibelas 24 fe.......................116 MICARDIS...........................49 MICARDIS HCT..................49 miconazole-3 ......................113 MICRO BLOOD GLUCOSE

..........................................80 MICRO THIN LANCETS ...84 MICRODOT BLOOD

GLUCOSE SYSTEM.......80 microgestin 1.5/30 (21) ......116 microgestin 1/20 (21) .........116 MICROGESTIN 24 FE ......116 microgestin fe 1.5/30 (28) ..116 microgestin fe 1/20 (28) .....116 MICROLET LANCET.........84 MICROZIDE........................49 midazolam ............................41 midodrine..............................71 migergot................................28 miglitol .................................93 MIGRANAL.........................28 millipred ...............................77 MILLIPRED.........................77 millipred dp ..........................77 mimvey...............................112 mimvey lo ...........................112 MINASTRIN 24 FE ...........116 MINI ULTRA-THIN II ........84 MINIPRESS .........................49 MINITRAN ..........................57 MINIVELLE ......................112 minocycline ..........................16 minoxidil...............................49 MIOCHOL-E......................121 miostat ................................122 MIRAPEX ............................26 MIRAPEX ER ......................26 MIRCERA..........................102 MIRCETTE (28) ................116 mirtazapine ...........................41 misoprostol .........................101 MITOSOL ..........................122 M-M-R II (PF)....................106 MOBIC .................................36

modafinil ..............................41 moderiba.............................103 moderiba dose pack............103 moexipril ..............................49 moexipril-hydrochlorothiazide

..........................................49 mometasone..................68, 129 MONOCLATE-P .................53 monoject 0.9% sodium

chloride.............................71 MONOJECT BLOOD

COLLECTION.................85 MONOJECT HYPODERMIC

NEEDLES ........................85 MONOJECT MEDICATION

TRANSF NDL .................85 monoject prefill advanced ns71 monoject prefill saline flush. 71 MONOLET THIN LANCETS

..........................................85 mono-linyah .......................116 mononessa (28) ..................116 montelukast ........................129 MONUROL..........................16 morphine...............................33 morphine concentrate ...........33 MOTOFEN...........................95 MOXEZA...........................119 moxifloxacin.................15, 119 MOZOBIL..........................102 MS CONTIN........................33 MULTAQ.............................44 MULTI-DRAW NEEDLE ...85 multi-vit with fluoride-iron 137 multi-vitamin with fluoride 137 multivitamins with fluoride

................................137, 138 multivit-fluor (vit e acetate)138 mupirocin .............................63 mupirocin calcium................63 MUSE.................................133 mvc-fluoride .......................138 my choice ...........................116 MYALEPT...........................91 MYAMBUTOL....................13 MYCOBUTIN......................13 mycophenolate mofetil .........19 mycophenolate sodium.........19 MYDRIACYL....................120 MYFORTIC .........................19

MYGLUCOHEALTH..........80 MYGLUCOHEALTH

LANCETS........................85 MYLERAN ..........................19 mynatal ...............................138 mynatal advance .................138 mynatal plus .......................138 mynatal-z ............................138 mynate 90 plus....................138 mynephrocaps.....................138 mynephron..........................138 myorisan ...............................62 MYRBETRIQ ....................132 MYSOLINE .........................24 MYTESI ...............................95 myzilra................................116 N nabumetone ..........................36 nadolol ..................................49 nadolol-bendroflumethiazide49 naftifine ................................64 NAFTIN ...............................64 NALFON..............................36 naloxone ...............................36 naltrexone .............................37 NAMENDA..........................29 NAMENDA TITRATION

PAK..................................29 NAMENDA XR...................29 NAMZARIC.........................29 NAPRELAN CR ..................36 NAPROSYN ........................36 naproxen ...............................36 naproxen sodium ..................36 naratriptan.............................28 NARCAN .............................37 NARDIL...............................41 NATACYN ........................119 NATAZIA ..........................116 nateglinide ............................93 NATPARA ...........................91 NATROBA...........................69 nature-throid .........................94 NEBUPENT .........................13 necon 0.5/35 (28)................116 necon 7/7/7 (28)..................117 NEEDLES, HUBER

DISPOSABLE..................85 nefazodone............................41 neomycin ..............................13

156

neomycin-bacitracin-poly-hc ........................................122

neomycin-bacitracin-polymyxin .......................119

neomycin-polymyxin b gu ....70 neomycin-polymyxin b-

dexameth.........................122 neomycin-polymyxin-

gramicidin.......................119 neomycin-polymyxin-hc......77,

123 neo-polycin .........................119 neo-polycin hc ....................123 NEORAL..............................19 NEOSALUS .........................59 NEO-SYNALAR..................64 NEO-SYNALAR KIT ..........63 nephplex rx .........................138 NEPHRON FA ...................138 nephro-vite rx .....................138 NEPTAZANE.....................122 NERLYNX ...........................19 neuac.....................................62 NEULASTA .......................102 NEUPOGEN.......................102 NEUPRO ..............................26 NEURIN-SL.......................138 NEURONTIN.......................24 NEUTEK 2TEK TEST

STRIPS .............................80 nevirapine ...............................8 newgen................................138 NEXAVAR...........................19 NEXIUM ............................101 NEXIUM PACKET............101 niacin ....................................55 NIACOR...............................55 NIASPAN EXTENDED-

RELEASE.........................55 nicardipine ............................49 NICODERM CQ ..................75 NICORETTE........................75 nicotine (polacrilex)..............75 NICOTROL..........................75 NICOTROL NS....................75 nifedipine..............................49 nikki (28) ............................117 NILANDRON ......................20 nilutamide .............................20 nimodipine............................49

NINLARO............................20 nisoldipine ............................49 nitro-bid ................................57 NITRO-DUR........................57 nitrofurantoin ........................16 nitrofurantoin macrocrystal ..16 nitrofurantoin monohyd/m-

cryst ..................................16 nitroglycerin .........................57 NITROLINGUAL................57 NITROMIST ........................57 NITROSTAT........................57 nitro-time..............................57 nizatidine ............................101 NIZORAL ............................64 NOKOR NEEDLE ...............85 nora-be................................112 NORCO................................33 NORDITROPIN FLEXPRO

........................................102 noreth-ethinyl estradiol-iron

........................................117 norethindrone (contraceptive)

........................................112 norethindrone acetate .........112 norethindrone ac-eth estradiol

................................112, 117 norethindrone-e.estradiol-iron

........................................117 norgestimate-ethinyl estradiol

........................................117 norlyda................................112 norlyroc ..............................112 normal saline flush ...............71 NORPACE ...........................44 NORPACE CR.....................44 NORPRAMIN......................41 NORTHERA ........................71 nortrel 0.5/35 (28) ..............117 nortrel 1/35 (21) .................117 nortrel 7/7/7 (28) ................117 nortriptyline..........................41 NORVASC...........................49 NORVIR.............................8, 9 NOVA MAX GLUCOSE

TEST ................................80 NOVA SAFETY LANCETS85 NOVA SUREFLEX

LANCETS........................85 NOVOEIGHT ......................53

NOVOFINE 32.....................85 NOVOFINE AUTOCOVER 85 NOVOFINE PLUS...............85 NOVOLIN 70/30 U-100

INSULIN ..........................89 NOVOLIN N NPH U-100

INSULIN ..........................89 NOVOLIN R REGULAR U-

100 INSULN ....................89 NOVOLOG FLEXPEN U-100

INSULIN ..........................89 NOVOLOG MIX 70-30 U-100

INSULN ...........................89 NOVOLOG MIX 70-

30FLEXPEN U-100 .........89 NOVOLOG PENFILL U-100

INSULIN ..........................89 NOVOLOG U-100 INSULIN

ASPART...........................89 NOVOPEN ECHO...............85 NOVOSEVEN RT ...............53 NOXAFIL ..............................6 np thyroid .............................94 NUCYNTA ..........................33 NUCYNTA ER ....................33 NUEDEXTA ........................29 NULEV ................................95 NULYTELY WITH FLAVOR

PACKS .............................98 NUOX ..................................62 NUPLAZID..........................41 NUTRICAP ........................138 NUVARING.......................113 NUVESSA..........................113 NUVIGIL .............................41 nyamyc .................................64 nystatin .............................6, 64 nystatin-triamcinolone....64, 65 nystop ...................................65 O obstetrix dha .......................138 OCALIVA............................98 ocella ..................................117 octreotide acetate..................20 OCUFLOX .........................119 ODACTRA.........................106 ODEFSEY..............................9 ODOMZO ............................20 OFEV..................................129 ofloxacin.................15, 76, 119

157

ogestrel (28)........................117 olanzapine.............................41 olanzapine-fluoxetine ...........41 olmesartan.............................49 olmesartan-amlodipin-

hcthiazid ...........................49 olmesartan-

hydrochlorothiazide..........49 olopatadine ...................75, 121 OLUX ...................................68 OLUX-E ...............................68 OMECLAMOX-PAK.........101 omeprazole .........................101 OMNIPRED .......................123 ON CALL EXPRESS TEST

STRIP ...............................80 ON CALL LANCET ............85 ON CALL PLUS LANCET . 85 ON CALL PLUS TEST STRIP

..........................................80 ON CALL VIVID TEST

STRIP ...............................80 ondansetron...........................98 ondansetron hcl.....................98 ONETOUCH ULTRASOFT

LANCETS ........................85 ONETOUCH VERIO...........80 ONFI.....................................24 ONMEL..................................6 ON-THE-GO LANCETS .....85 OPANA ................................33 OPSUMIT...........................129 OPTIUM EZ.........................80 OPTIUM TEST ....................80 OPTUMRX...........................81 ORALAIR ..........................106 oralone ..................................75 ORAMAGICRX...................76 ORAP ...................................41 ORAPRED ODT ..................77 ORAVIG.................................6 ORENCIA ..........................109 ORENCIA CLICKJECT ....109 ORENITRAM ......................49 ORFADIN ............................71 ORKAMBI .........................129 orphenadrine citrate ..............30 orsythia ...............................117 ORTHO MICRONOR........112

ORTHO TRI-CYCLEN (28) ........................................117

ORTHO TRI-CYCLEN LO (28) .................................117

ORTHO-CYCLEN (28) .....117 ORTHO-NOVUM 1/35 (28)

........................................117 ORTHO-NOVUM 7/7/7 (28)

........................................117 oseltamivir..............................9 OSMOPREP.........................98 OSPHENA .........................113 OTEZLA ............................109 OTEZLA STARTER..........109 OTOVEL..............................77 OVACE ................................58 OVACE PLUS .....................58 OVACE PLUS SHAMPOO. 58 OVIDE .................................69 OVIDREL ............................91 OXANDRIN.........................91 oxandrolone..........................91 oxaprozin..............................36 oxazepam..............................41 oxcarbazepine.......................24 oxiconazole...........................65 OXISTAT.............................65 OXSORALEN ULTRA .......60 OXTELLAR XR ..................24 oxybutynin chloride............132 oxycodone ............................33 oxycodone-acetaminophen...34 oxycodone-aspirin ................34 OXYCONTIN ......................34 oxymorphone........................34 OXYTROL.........................132 P pacerone ...............................44 PACNEX..............................62 paliperidone..........................41 PAMELOR...........................41 PANDEL ..............................68 PANRETIN ..........................60 pantoprazole .......................101 paregoric...............................95 PAREMYD ........................120 paricalcitol ............................91 PARLODEL.........................26 PARNATE ...........................41 paromomycin........................13

paroxetine hcl .......................41 PASER..................................13 PATADAY.........................121 PATANASE .........................76 PATANOL .........................121 PAXIL ..................................41 PAXIL CR............................41 PAZEO ...............................121 PCE.......................................12 PEDIAPRED........................77 PEDIARIX (PF) .................106 PEDVAX HIB (PF)............106 peg 3350-electrolytes ...........98 PEGANONE ........................24 PEGASYS ..........................103 PEGASYS PROCLICK .....103 peg-electrolyte soln ..............98 PEGINTRON .....................103 peg-prep................................98 PEN NEEDLE......................85 PEN NEEDLE, DIABETIC . 85 penicillin v potassium...........15 PENLAC ..............................65 PENTACEL (PF) ...............106 PENTACEL ACTHIB

COMPONENT (PF) .......106 PENTASA............................98 pentazocine-naloxone...........34 PENTIPS ..............................85 pentoxifylline........................53 PEPCID ..............................101 PERCOCET..........................34 PERFOROMIST ................129 PERIDEX .............................76 PERIFLEX ADVANCE.......73 PERIFLEX INFANT............73 PERIFLEX JUNIOR ............73 PERIFLEX LQ PKU............73 perindopril erbumine ............50 periogard...............................76 permethrin ............................69 perphenazine.........................41 perphenazine-amitriptyline...41 PEXEVA ..............................41 PHARMACIST CHOICE ....81 PHASEAL PROTECTOR....85 PHENACTIN AA PLUS 20

PE .....................................73 phenadoz.............................125 phenazopyridine .................134

158

phendimetrazine tartrate .......70 phenelzine.............................41 phenergan ...........................125 PHENEX-1 ...........................73 PHENEX-2 ...........................73 phenobarbital ........................24 phenoxybenzamine ...............50 phentermine ..........................70 PHENYLADE 40 .................73 PHENYLADE 60 .................73 PHENYLADE AMINO ACID

..........................................73 PHENYLADE AMINO

ACIDS ..............................73 PHENYLADE DRINK MIX73 PHENYLADE ESSENTIAL73 PHENYLADE GMP ............73 PHENYLADE GMP MIX-IN

..........................................73 PHENYLADE MTE AMINO

ACIDS ..............................73 phenylade phebloc ................73 PHENYLADE PHEBLOC...73 PHENYLADE RTD PKU 10

..........................................74 phenylephrine hcl ...............124 PHENYL-FREE 1 ................74 PHENYL-FREE 2 PKU .......74 PHENYL-FREE 2HP PKU ..74 PHENYTEK .........................24 phenytoin ..............................24 phenytoin sodium extended ..24 philith..................................117 PHLEXY-10 .........................74 PHLEXY-10 DRINK MIX

POWDER .........................74 PHOSLYRA .........................98 phospha 250 neutral............134 phosphate laxative ................98 PHOSPHOLINE IODIDE..120 PHYSIOLYTE .....................70 PHYSIOSOL IRRIGATION70 PICATO................................60 pilocarpine hcl ........71, 76, 121 pimozide ...............................41 pimtrea (28) ........................117 pindolol.................................50 pioglitazone ..........................93 pioglitazone-glimepiride.......93 pioglitazone-metformin ........93

pirmella...............................117 piroxicam..............................36 PKU 2...................................74 PKU 3...................................74 PKU AIR15 ..........................74 PKU AIR20 ..........................74 PKU COOLER 10................74 PKU COOLER 15................74 PKU COOLER 20................74 PKU EASY MICROTABS ..74 PKU EXPRESS15................74 PKU EXPRESS20................74 PKU GEL POWDER ...........74 PKU LOPHLEX...................74 PKU PERIFLEX EARLY

YEARS.............................74 PKU PERIFLEX JUNIOR

PLUS ................................74 PKU SPHERE20..................74 PKU TRIO............................74 PLAQUENIL .......................13 PLAVIX ...............................53 PLEGRIDY ........................103 PLEXION.............................62 PLEXION CLEANSING

CLOTHS ..........................62 PNEUMOVAX 23 .............107 pnv 29-1 138 ..............................pnv ob+dha.........................138 pnv-dha...............................138 pnv-dha + docusate ............138 pnv-ferrous fumarate-docu-fa

........................................138 pnv-omega..........................138 pnv-select ...........................138 pnv-vp-u .............................138 PODOCON...........................58 podofilox ..............................60 POLY HUB NEEDLE .........85 polycin................................119 polyethylene glycol 3350 .....98 polymyxin b sulf-trimethoprim

........................................119 POLYTRIM .......................119 POLY-VI-FLOR ................138 POLY-VI-FLOR WITH IRON

................................138, 139 POMALYST ......................103 portia...................................117

pot,sodium citrate-citric acid ........................................133

POTABA............................134 potassium bicarb and chloride

........................................135 potassium bicarb-citric acid135 potassium chloride..............135 potassium citrate.................133 pr natal 400.........................139 pr natal 400 ec ....................139 pr natal 430.........................139 pr natal 430 ec ....................139 PRADAXA...........................54 PRALUENT PEN.................55 pramcort................................98 pramipexole ..........................26 PRANDIN ............................93 prasugrel ...............................54 PRAVACHOL......................55 pravastatin ............................55 prazosin ................................50 PRECISION PCX PLUS TEST

..........................................81 PRECISION PCX TEST......81 PRECISION POINT OF

CARE TEST.....................81 PRECISION Q-I-D TEST....81 PRECISION XTRA TEST...81 PRECOSE ............................93 PRED FORTE ....................123 PRED MILD.......................123 PRED-G..............................123 PRED-G S.O.P. ..................123 prednicarbate ........................68 prednisolone .........................77 prednisolone acetate ...........123 prednisolone sodium phosphate

............................77, 78, 124 prednisone ............................78 prednisone intensol...............78 PREFEST ...........................112 PREGNYL............................91 PREMARIN .......................112 PREMIUM V10 ...................81 PREMPHASE ....................112 PREMPRO .........................112 prena1 chew........................139 prena1 pearl ........................139 prena1 true..........................139 prenaissance........................139

159

prenaissance plus ................139 prenatabs fa.........................139 prenatabs rx ........................139 prenatal ...............................139 prenatal formula..................139 prenatal multi-dha (algal oil)

........................................139 prenatal one daily ...............139 prenatal plus........................139 prenatal plus (calcium carb)139 prenatal vitamin ..................139 prenatal vitamin plus low iron

........................................139 prenatal-u ............................139 preplus ................................139 PRESSURE ACTIVATED

LANCETS ........................85 pretab ..................................139 PREVACID SOLUTAB.....101 prevalite ................................55 PREVIDENT........................76 PREVIDENT 5000 BOOSTER

PLUS ................................76 PREVIDENT 5000 DRY

MOUTH ...........................76 PREVIDENT 5000 ENAMEL

PROTECT ........................76 PREVIDENT 5000

SENSITIVE......................76 previfem..............................117 PREVNAR 13 (PF) ............107 PREVPAC ..........................101 PREZCOBIX..........................9 PREZISTA .............................9 PRIFTIN ...............................13 PRILOSEC .........................101 PRIMAQUINE .....................14 primidone..............................24 PRIMLEV.............................34 PRIMSOL.............................16 PRINIVIL .............................50 PRISTIQ ...............................42 PRO COMFORT LANCET . 85 PROAIR HFA ....................129 PROAIR RESPICLICK......129 probenecid ..........................108 probenecid-colchicine.........108 PROCARDIA .......................50 PROCARDIA XL.................50 procentra ...............................42

prochlorperazine...................99 prochlorperazine maleate .....99 PROCRIT...........................102 PROCTOCORT ...................99 procto-med hc.......................99 procto-pak.............................99 proctosol hc ..........................99 proctozone-hc .......................99 PROCYSBI ........................133 PRODIGY LANCETS .........85 PRODIGY NO CODING.....81 PRODIGY TWIST TOP

LANCET ..........................85 PROFERRIN-FORTE........139 PROFILNINE.......................54 progesterone micronized ....112 PROGLYCEM .....................82 PROGRAF ...........................20 PROLENSA .......................122 PROMACTA........................54 promethazine ......................125 promethazine vc .................126 promethazine vc-codeine....126 promethazine-codeine ........126 promethazine-dm................126 promethazine-phenyleph-

codeine ...........................126 promethegan .......................125 PROMETRIUM .................112 PROMISEB..........................60 propafenone..........................44 propantheline........................95 proparacaine .......................121 propranolol ...........................50 propranolol-hydrochlorothiazid

..........................................50 propylthiouracil ....................78 PROQUAD (PF) ................107 PRO-RED AC (W/

DEXCHLORPHENIR) ..126 PROSCAR..........................132 PROSTIN VR PEDIATRIC

........................................133 PROTECT IRON ...............139 PROTONIX........................101 protriptyline..........................42 PROVENTIL HFA.............129 PROVERA .........................112 PROZAC ..............................42 pruclair .................................60

prudoxin................................60 prutect ...................................60 PSORCON............................68 PULMICORT.....................130 PULMICORT FLEXHALER

........................................130 pulmosal .............................130 PULMOZYME...................130 purevit dualfe plus ..............139 PURIXAN ............................20 PYLERA ............................101 pyrazinamide ........................14 PYRIDIUM ........................134 pyridostigmine bromide .......30 Q QSYMIA ..............................70 QUADRACEL (PF) ...........107 QUALAQUIN......................14 QUARTETTE ....................117 quasense..............................117 quazepam..............................42 QUDEXY XR.......................24 QUESTRAN.........................56 QUESTRAN LIGHT............56 quetiapine .............................42 QUILLIVANT XR...............42 quinapril................................50 quinapril-hydrochlorothiazide

..........................................50 quinidine gluconate ..............44 quinidine sulfate ...................44 quinine sulfate ......................14 QUINTET AC ......................81 QVAR.................................130 QVAR REDIHALER.........130 R RABAVERT (PF) ..............107 rabeprazole .........................101 RADIOGARDASE ..............71 RAGWITEK.......................107 rajani ...................................117 raloxifene............................109 ramipril .................................50 RANEXA .............................56 ranitidine hcl.......................101 RAPAFLO..........................132 RAPAMUNE........................20 rasagiline ..............................26 RAVICTI..............................71 RAZADYNE........................29

160

RAZADYNE ER ..................29 REBETOL ..........................103 REBIF (WITH ALBUMIN)

........................................103 REBIF REBIDOSE ............103 REBIF TITRATION PACK

........................................103 reclipsen (28) ......................117 RECOMBINATE .................54 RECOMBIVAX HB (PF)...107 REFUAH PLUS ...................81 REGIMEX............................70 REGLAN..............................99 REGRANEX ........................60 RELAGARD ......................113 relcof c ................................126 RELENZA DISKHALER ......9 RELIAMED LANCET.........86 RELIAMED SAFETY SEAL

LANCETS ........................86 RELION CONFIRM-MICRO

..........................................81 RELION NEEDLES.............86 RELION PEN NEEDLES ....86 RELION PRIME TEST

STRIPS .............................81 RELION THIN LANCETS..86 RELION ULTRA THIN PLUS

LANCETS ........................86 RELISTOR ...........................99 relnate dha ..........................139 RELPAX...............................28 REMERON...........................42 REMERON SOLTAB..........42 REMODULIN ......................50 RENAGEL ...........................99 renal caps ............................139 rena-vite rx..........................139 reno caps .............................139 RENVELA ...........................99 repaglinide ............................93 repaglinide-metformin..........93 REPATHA PUSHTRONEX 56 REPATHA SURECLICK ....56 REPATHA SYRINGE .........56 reprexain ...............................34 REQUIP................................26 REQUIP XL .........................26 RESCRIPTOR........................9 RESPA-AR.........................126

RESTASIS .........................121 RESTASIS MULTIDOSE . 121 RESTORIL...........................42 RETIN-A..............................62 RETROVIR............................9 REVATIO ..........................130 REVEAL TEST STRIP........81 REVIA..................................36 REVLIMID ........................103 REYATAZ .............................9 ribasphere ...........................103 ribavirin ..............................103 RIDAURA..........................109 rifabutin ................................14 RIFADIN..............................14 RIFAMATE .........................14 rifampin ................................14 RIFATER .............................14 RIGHTEST GL300 LANCETS

..........................................86 RIGHTEST GS550 TEST

STRIPS.............................81 RILUTEK.............................71 riluzole..................................71 rimantadine.............................9 ringer's ..................................70 RIOMET...............................93 risacal-d ..............................139 risedronate ....................72, 109 RISPERDAL ........................42 RISPERDAL CONSTA .......42 RISPERDAL M-TAB ..........42 risperidone............................42 RITALIN..............................42 rivastigmine..........................29 rivastigmine tartrate..............29 rivelsa .................................117 RIXUBIS..............................54 rizatriptan .............................28 robafen ac ...........................126 ROBAXIN............................30 ROBAXIN-750 ....................30 ROBINUL ............................95 ROBINUL FORTE ..............95 ROCALTROL......................91 ropinirole ..............................26 rosadan .................................62 ROSANIL.............................62 ROSULA..............................62 rosula cleansing cloths .........62

rosuvastatin ...........................56 ROTARIX ..........................107 ROTATEQ VACCINE.......107 ROWASA.............................99 roweepra ...............................24 roweepra xr...........................24 ROXICODONE....................34 ROZEREM...........................42 RUBRACA...........................20 RUCONEST.......................130 RYDAPT..............................20 rydex...................................126 RYTHMOL SR ....................44 S SABRIL................................25 SAFETY LANCETS............86 SAFETY SEAL LANCETS. 86 SAFETY-LET LANCETS ...86 SAFYRAL..........................117 SALAGEN (PILOCARPINE)

....................................72, 76 SALEX .................................58 salicylic acid .........................59 salicylic acid er-ceramides ..58,

59 salsalate ................................36 SAMSCA..............................91 SANDIMMUNE ..................20 SANDOSTATIN..................20 SAPHRIS (BLACK

CHERRY) ........................42 SARAFEM ...........................42 SAVELLA..................109, 110 SAXENDA...........................70 scopolamine base..................99 SEASONIQUE...................118 seb-prev ................................58 seconal sodium .....................42 selegiline hcl.........................26 selenium sulfide....................58 SELZENTRY .........................9 SEMPREX-D .....................126 se-natal 19...........................140 se-natal 19 (with docusate). 139 SENSIPAR ...........................91 SEREVENT DISKUS ........130 SEROQUEL .........................42 SEROQUEL XR...................42 sertraline ...............................42 se-tan plus...........................140

161

setlakin................................118 sevelamer carbonate .............99 sf 76 sf 5000 plus...........................76 sharobel...............................112 SHINGRIX (PF).................107 SHINGRIX GE ANTIGEN

COMPONENT ...............107 SIGNIFOR............................20 sildenafil .............................133 sildenafil (antihypertensive)

........................................130 SILVADENE........................58 silver nitrate ..........................60 silver nitrate applicators .......60 silver sulfadiazine.................58 SIMPONI............................110 simvastatin............................56 SINEMET.............................26 SINEMET CR ......................26 SINGLE-LET .......................86 SINGULAIR.......................130 sirolimus ...............................20 SIRTURO .............................14 SKELAXIN ..........................30 SMART SENSE LANCETS 86 SMART SENSE TEST

STRIPS .............................81 SMARTEST LANCET ........86 SMARTEST TEST...............81 sodium chlor 0.9% bacteriostat

..........................................72 sodium chloride ............72, 130 sodium chloride 0.9 %..........72 sodium phenylbutyrate .........72 sodium polystyrene sulfonate

..........................................99 SODIUM POLYSTYRENE

SULFONATE...................99 SOFT TOUCH LANCETS...86 SOLESTA.............................99 SOLIQUA 100/33 ................89 SOLTAMOX........................20 SOLUS V2 LANCETS.........86 SOMA...................................30 SOMAVERT ........................91 SONATA..............................42 SORBITOL...........................70 SORBITOL-MANNITOL....70 SORIATANE .......................58

sorine ....................................44 sotalol ...................................45 sotalol af ...............................45 SOTYLIZE...........................45 SOVALDI ..............................9 spinosad ................................69 SPIRIVA RESPIMAT .......130 SPIRIVA WITH

HANDIHALER..............130 spironolactone ......................50 spironolacton-hydrochlorothiaz

..........................................50 SPORANOX ..........................6 SPORANOX PULSEPAK .....6 sprintec (28)........................118 SPRITAM.............................25 SPRIX...................................36 SPRYCEL ............................20 sps (with sorbitol).................99 sronyx .................................118 ssd.........................................58 SSKI .....................................78 sss 10-5.................................62 STALEVO 100.....................26 STALEVO 125.....................26 STALEVO 150.....................26 STALEVO 200.....................27 STALEVO 50.......................27 STALEVO 75.......................27 STAMARIL (PF) ...............107 STARLIX .............................93 stavudine.................................9 STAXYN............................133 STELARA............................58 STENDRA .........................133 STERILANCE TL................86 STIMATE.............................91 STIOLTO RESPIMAT ......130 STIVARGA..........................20 STRATTERA.......................43 STRENSIQ...........................91 STRIANT.............................91 STRIBILD..............................9 STRIVERDI RESPIMAT ..130 STROMECTOL ...................14 strong iodine.......................135 STROVITE FORTE...........140 STROVITE ONE ...............140 SUBOXONE ........................21 SUCRAID ............................99

sucralfate ............................101 SULAR.................................50 sulfacetamide sodium...58, 124 sulfacetamide sodium-sulfur 62 sulfacetamide sod-sulfur-urea

..........................................62 sulfacetamide-prednisolone 124 sulfadiazine...........................15 sulfamethoxazole-trimethoprim

..........................................15 SULFAMYLON...................64 sulfasalazine .........................99 sulfatrim................................16 sulindac.................................36 sumatriptan ...........................28 sumatriptan succinate ...........28 SUMAVEL DOSEPRO .......28 SUMAXIN ...........................62 SUPER THIN LANCETS....86 SUPRAX ..............................11 SUPREP BOWEL PREP KIT

..........................................99 SURE COMFORT LANCETS

..........................................86 SURE COMFORT PEN

NEEDLE ..........................86 SURE-FINE PEN NEEDLES

..........................................86 SURE-LANCE .....................86 SURE-TEST EASYPLUS

MINI.................................81 SURE-TOUCH LANCET....86 SURGUARD2 SAFETY......86 SURMONTIL.......................43 SUSTIVA ...............................9 SUTENT...............................20 syeda...................................118 SYLATRON.......................103 SYMBICORT.....................130 SYMBYAX..........................43 SYMLINPEN 120 ................93 SYMLINPEN 60 ..................93 SYNALAR ...........................68 SYNALAR CREAM KIT ....68 SYNALAR OINTMENT KIT

..........................................68 SYNALAR TS .....................68 SYNAREL............................91 SYNDROS .........................100 SYNERA..............................63

162

SYNTHROID .......................94 SYPRINE .............................72 syrex sodium chloride 0.9 % 72 T TABLOID.............................20 TACLONEX.........................58 tacrolimus .......................20, 60 TAFINLAR ..........................20 TAGRISSO...........................20 TAMIFLU ..............................9 tamoxifen..............................20 tamsulosin...........................132 TANDEM PLUS ................140 TAPAZOLE .........................78 TARCEVA ...........................20 TARGRETIN .......................20 tarina fe 1/20 (28) ...............118 TARKA ................................50 taron forte ...........................140 taron-c dha ..........................140 taron-prex prenatal-dha ......140 TASIGNA.............................20 TASMAR .............................27 tazarotene..............................62 TAZORAC ...........................62 TECFIDERA ......................103 TECHLITE LANCETS ........86 TECHLITE PEN NEEDLE..86 TEGRETOL .........................25 TEGRETOL XR...................25 TEKTURNA.........................50 TEKTURNA HCT................50 TELCARE TEST STRIPS ...81 telmisartan ............................50 telmisartan-amlodipine .........50 telmisartan-hydrochlorothiazid

..........................................50 temazepam............................43 TEMODAR ..........................20 TEMOVATE ........................68 temozolomide .......................20 tencon ...................................34 TENIVAC (PF) ..................107 tenofovir disoproxil fumarate . 9 TENORETIC 100.................50 TENORETIC 50...................50 TENORMIN .........................50 TERAZOL 7.......................113 terazosin................................50 terbinafine hcl .........................6

terbutaline...........................130 terconazole .........................113 TESSALON PERLES........126 TEST N'GO TEST ...............81 testosterone...........................91 testosterone cypionate ..........91 testosterone enanthate ..........91 TESTRED ............................91 TETANUS,DIPHTHERIA

TOX PED(PF) ................107 TETANUS-DIPHTHERIA

TOXOIDS-TD................107 tetrabenazine.........................29 tetracaine hcl ......................121 tetracaine hcl (pf) ...............121 tetracycline ...........................16 TETRAVISC......................121 TEXACORT.........................69 THALOMID.........................20 THEO-24............................130 theochron............................130 theophylline........................131 THIOLA...............................72 thioridazine...........................43 thiothixene............................43 thrivite-19 ...........................140 thyroid (pork) .......................94 THYROLAR-1.....................94 THYROLAR-1/2..................94 THYROLAR-1/4..................94 THYROLAR-2.....................94 THYROLAR-3.....................94 tiagabine ...............................25 TIAZAC ...............................50 ticlopidine.............................54 TIGAN ...............................100 TIKOSYN ............................45 tilia fe..................................118 timolol maleate.............50, 120 TIMOPTIC .........................120 TIMOPTIC OCUDOSE (PF)

........................................120 TIMOPTIC-XE ..................120 TINDAMAX ........................14 tinidazole ..............................14 TIVICAY ...............................9 tizanidine ..............................30 tl gard rx .............................140 tl g-fol os ............................140 tl icon..................................140

TOBI.....................................14 tobramycin..........................119 tobramycin in 0.225 % nacl..14 tobramycin-dexamethasone 123 TOBREX............................120 TOFRANIL ..........................43 tolazamide ............................93 tolbutamide...........................93 tolcapone ..............................27 tolmetin.................................36 tolterodine...........................132 TOPAMAX ..........................25 TOPCARE UNIVERSAL1

LANCET ..........................86 TOPICORT ..........................69 topiramate.............................25 TOPIRAMATE ....................25 TOPROL XL ........................51 torsemide ..............................51 TOUJEO SOLOSTAR U-300

INSULIN ..........................89 TRACLEER .......................131 TRADJENTA.......................93 tramadol................................34 tramadol-acetaminophen ......34 trandolapril ...........................51 trandolapril-verapamil ..........51 tranexamic acid...................113 TRANSDERM-SCOP........100 TRANXENE T-TAB............43 tranylcypromine....................43 TRAVATAN Z...................122 trazodone ..............................43 TRECATOR.........................14 TRELEGY ELLIPTA.........131 TRESIBA FLEXTOUCH U-

100....................................89 TRESIBA FLEXTOUCH U-

200....................................89 tretinoin ................................63 tretinoin (chemotherapy) ......21 tretinoin (emollient)..............62 tretinoin microspheres ..........62 TRETIN-X............................63 TRETIN-X CREAM KIT.....63 TREXALL............................21 TREZIX................................34 tri femynor..........................118 triamcinolone acetonide . 69, 76

163

triamterene-hydrochlorothiazid ..........................................51

trianex ...................................69 triazolam...............................43 TRIBENZOR........................51 tricon...................................140 TRICOR ...............................56 triderm ..................................69 trientine.................................72 tri-estarylla..........................118 trifluoperazine.......................43 trifluridine...........................120 trigels-f forte .......................140 TRIGLIDE............................56 trihexyphenidyl.....................27 tri-legest fe..........................118 TRILEPTAL.........................25 tri-linyah .............................118 TRILIPIX .............................56 tri-lo-estarylla .....................118 tri-lo-marzia........................118 tri-lo-sprintec ......................118 trilyte with flavor packets ...100 trimethobenzamide .............100 trimethoprim .........................16 trimipramine .........................43 trinatal gt.............................140 trinatal rx 1 .........................140 trinate..................................140 trinessa (28) ........................118 trinessa lo............................118 TRI-NORINYL (28)...........118 TRINTELLIX.......................43 triphrocaps ..........................140 tri-previfem (28) .................118 tri-sprintec (28) ...................118 tri-tabs dha ..........................140 TRIUMEQ..............................9 triveen-duo dha ...................140 TRI-VI-FLOR.....................140 tri-vit with fluoride and iron

........................................140 tri-vitamin with fluoride .....140 trivora (28)..........................118 tri-vylibra ............................118 TRIZIVIR .............................10 TROKENDI XR ...................25 tropicamide .........................120 trospium..............................132

TRUE METRIX GLUCOSE TEST STRIP ....................81

TRUEPLUS GLUCOSE ......82 TRUEPLUS LANCETS.......86 TRUETEST TEST STRIPS . 81 TRUETRACK TEST ...........81 TRULICITY.........................94 TRUMENBA .....................107 TRUSOPT ..........................122 trust natal dha .....................140 TRUVADA ..........................10 TUDORZA PRESSAIR .....131 tusnel c................................126 TUSSICAPS.......................126 tussigon 126 ...............................TUSSIONEX PENNKINETIC

ER...................................126 TWINRIX (PF) ..................107 TWYNSTA ..........................51 TYBOST ..............................10 TYKERB..............................21 TYLENOL-CODEINE #3....34 TYLENOL-CODEINE #4....34 TYMLOS ...........................109 TYPHIM VI .......................107 TYVASO............................131 TYVASO INSTITUTIONAL

START KIT....................131 TYVASO REFILL KIT .....131 TYVASO STARTER KIT . 131 U UDAMIN SP......................140 ULESFIA .............................69 ULORIC .............................108 ULTICARE PEN NEEDLE. 86 ULTILET BASIC LANCETS

..........................................87 ULTILET CLASSIC

LANCETS........................87 ULTILET LANCETS ..........87 ULTILET PEN NEEDLE ....87 ULTILET SAFETY

LANCETS........................87 ULTIMA TEST STRIPS......81 ultimatecare one .................140 ultimatecare one nf .............140 ULTRA THIN LANCETS...87 ULTRA THIN PLUS

LANCETS........................87 ULTRA TLC LANCETS.....87

ULTRACET .........................34 ULTRALANCE LANCETS 87 ULTRAM .............................34 ULTRAM ER.......................34 ULTRA-THIN II INS PEN

NEEDLES ........................87 ULTRATRAK......................81 ULTRATRAK ULTIMATE 81 ULTRAVATE X ..................69 UNIFINE PENTIPS .............87 UNIFINE PENTIPS PLUS ..87 UNILET COMFORTOUCH

LANCET ..........................87 UNILET EXCELITE II

LANCET ..........................87 UNILET EXCELITE

LANCET ..........................87 UNILET GP LANCET.........87 UNILET LANCET...............87 UNISTIK 3 EXTRA LANCET

..........................................87 UNISTIK CZT LANCET.....87 UNISTIK SAFETY..............87 UNISTIK TOUCH LANCETS

..........................................87 UNISTRIP1 TEST STRIP ...81 unithroid ...............................94 UNIVERSAL 1 LANCETS . 87 URAMAXIN........................60 URECHOLINE ..................133 uro-458 ...............................133 UROCIT-K 10....................133 UROCIT-K 15....................133 UROCIT-K 5......................133 UROXATRAL ...................132 URSO 250 ..........................100 URSO FORTE....................100 ursodiol...............................100 UTIBRON NEOHALER....131 V VAGIFEM..........................112 valacyclovir ..........................10 VALCHLOR ........................60 VALCYTE ...........................10 valganciclovir .......................10 VALIUM..............................43 valproic acid .........................25 valproic acid (as sodium salt)

..........................................25 valsartan................................51

164

valsartan-hydrochlorothiazide ..........................................51

VALTREX ...........................10 VANCOCIN .........................16 vancomycin...........................17 vandazole............................113 VANOS ................................69 VANOXIDE-HC ..................63 VAQTA (PF) ......................108 VARIVAX (PF)..................108 VASERETIC ........................51 VASOTEC............................51 VAXCHORA VACCINE...108 v-c forte ..............................140 veletri ....................................51 velivet triphasic regimen (28)

........................................118 VELPHORO.......................100 vemavite-prx-2 ...................140 VEMLIDY............................10 VENCLEXTA ......................21 VENCLEXTA STARTING

PACK ...............................21 venlafaxine ...........................43 VENTAVIS ........................131 VENTOLIN HFA...............131 verapamil ..............................51 VERDESO............................69 verdrocet ...............................34 VEREGEN ...........................60 VERELAN ...........................51 VERELAN PM.....................51 veripred 20............................78 VERZENIO ..........................21 VESICARE.........................132 vestura (28) .........................118 VFEND...................................6 VGO 20 ................................87 VGO 30 ................................87 VGO 40 ................................87 VIAGRA.............................134 VIBERZI ............................100 VIBRAMYCIN ....................16 vicodin ..................................34 vicodin es..............................34 vicodin hp .............................34 VIDEX 2 GRAM PEDIATRIC

..........................................10 VIDEX EC............................10 vienva .................................118

vigabatrin..............................25 VIGAMOX.........................120 VIIBRYD .............................43 VIMPAT...............................25 vinate care ..........................140 vinate ii ...............................140 vinate m..............................140 vinate one ...........................141 vinate ultra..........................141 VIOKACE..........................100 viorele (28) .........................118 VIRACEPT ..........................10 VIRAMUNE ........................10 VIRAMUNE XR..................10 VIRAZOLE..........................10 VIREAD...............................10 VIROPTIC .........................120 virt-advance........................141 virt-c dha ............................141 VIRT-CAPS .......................141 virt-gard..............................141 virt-nate ..............................141 virt-nate dha........................141 virt-phos 250 neutral ..........135 virt-pn .................................141 virt-pn dha ..........................141 virt-pn plus .........................141 virt-select ............................141 virtussin ac..........................127 virt-vite ...............................141 virt-vite gt ...........................141 VIRT-VITE PLUS .............141 VISTARIL..........................125 vit 3.....................................141 vit b complex-folic acid......141 VITAFOL...........................141 VITAL-D RX .....................141 vitamin d3...........................141 vitamins a,c,d and fluoride . 141 VITA-RESPA.....................141 VIVELLE-DOT .................112 VIVOTIF............................108 VIVOTIF BERNA VACCINE

........................................108 vol-care rx ..........................141 vol-nate...............................141 vol-plus...............................141 vol-tab rx ............................141 VOLTAREN-XR .................36 voriconazole .......................6, 7

VOSEVI ...............................10 VOTRIENT..........................21 vp-ch plus ...........................141 vp-ch-pnv............................141 vp-ggr-b6 ............................141 vp-heme ob .........................141 vp-heme one .......................141 vp-vite rx ............................141 VRAYLAR...........................43 VUSION...............................65 vyfemla (28) .......................118 vylibra.................................118 VYTORIN 10-10..................56 VYTORIN 10-20..................56 VYTORIN 10-40..................56 VYTORIN 10-80..................56 VYVANSE...........................43 W warfarin ................................54 water for irrigation, sterile....72 WAVESENSE JAZZ ...........81 WAVESENSE PRESTO......81 WELCHOL ..........................56 WELLBUTRIN SR ..............43 WELLBUTRIN XL..............43 wera (28).............................118 westhroid ..............................94 WILATE...............................54 WP THYROID.....................94 wymzya fe ..........................118 X XALATAN.........................122 XALKORI............................21 XANAX................................43 XANAX XR.........................43 XARELTO ...........................54 XELJANZ ..........................110 XELJANZ XR....................110 XELODA..............................21 XENAZINE..........................29 XENICAL ............................70 XERMELO...........................21 XIFAXAN............................14 XIGDUO XR........................94 XOLEGEL............................65 XOPENEX .........................131 XOPENEX CONCENTRATE

........................................131 XOPENEX HFA ................131 XPHE MAXAMAID............74

165

xphe maxamum ....................74 XPHE MAXAMUM ............74 XTANDI...............................21 xulane .................................113 XULTOPHY 100/3.6 ...........89 xylon 10 ................................34 XYNTHA .............................54 XYNTHA SOLOFUSE ........54 XYREM................................43 Y YASMIN (28).....................118 YAZ (28) ............................118 YF-VAX (PF).....................108 yuvafem ..............................112 Z zafirlukast ...........................131 zaleplon.................................43 ZANAFLEX .........................30 ZANTAC............................101 zarah ...................................118 ZARONTIN..........................25 ZARXIO .............................102 zatean-ch.............................141 zatean-pn dha......................142 zatean-pn plus .....................142 ZAVESCA............................92 zebutal...................................34 ZEJULA ...............................21 ZELAPAR ............................27 ZELBORAF .........................21 ZEMPLAR ...........................92 zenatane ................................63 zenchent (28) ......................119 ZENPEP .............................100 zenzedi..................................44 ZENZEDI .............................44 ZERIT...................................10 ZESTORETIC ......................51 ZESTRIL ..............................51 ZETIA...................................56 ZIAC.....................................51 ZIAGEN ...............................10 zidovudine ............................10 zingiber ...............................142 ZIOPTAN (PF)...................122 ziprasidone hcl......................44 ZIRGAN .............................120 ZITHROMAX ......................12 ZMAX ..................................12 ZOCOR.................................56

ZODRYL AC 25 ................127 ZODRYL AC 30 ................127 ZODRYL AC 35 ................127 ZODRYL AC 40 ................127 ZODRYL AC 50 ................127 ZODRYL AC 60 ................127 ZODRYL AC 80 ................127 ZODRYL DAC 25 .............127 ZODRYL DAC 30 .............127 ZODRYL DAC 35 .............127 ZODRYL DAC 40 .............127 ZODRYL DAC 50 .............127 ZODRYL DAC 60 .............127 ZODRYL DAC 80 .............127 ZODRYL DEC 25..............127 ZODRYL DEC 30..............127

ZODRYL DEC 35..............127 ZODRYL DEC 40..............127 ZODRYL DEC 50..............127 ZODRYL DEC 60..............127 ZODRYL DEC 80..............127 ZOFRAN (AS

HYDROCHLORIDE) ....100 ZOFRAN ODT...................100 ZOLINZA.............................21 zolmitriptan ..........................28 ZOLOFT...............................44 zolpidem ...............................44 ZONALON...........................60 ZONEGRAN........................25 zonisamide............................25 ZONTIVITY ........................54

166

ZORTRESS ..........................21 ZOSTAVAX (PF) ..............108 zovia 1/35e (28)..................119 ZOVIRAX ......................10, 65 Z-TUSS AC ........................127 ZUBSOLV......................21, 36 ZUTRIPRO.........................127 ZYBAN ................................75 ZYDELIG.............................21 ZYKADIA............................21 ZYLOPRIM........................108 ZYPREXA............................44 ZYPREXA RELPREVV ......44 ZYPREXA ZYDIS...............44 ZYTIGA ...............................21 ZYVOX ................................14

BlueCross BlueShield of Tennessee 1 Cameron Hill Circle | Chattanooga, TN 37402 | bcbst.com

BlueCross BlueShield of Tennessee (BlueCross) complies with applicable Federal civil rights laws anddoes not discriminate on the basis of race, color, nationalorigin, age, disability or sex. BlueCross does not excludepeople or treat them differently because of race, color, national origin, age, disability or sex. BlueCross: • Provides free aids and services to people withdisabilities to communicate effectively with us, such as: (1) qualified interpreters and (2) written informationin other formats, such as large print, audio and accessible electronic formats.

• Provides free language services to people whoseprimary language is not English, such as: (1) qualifiedinterpreters and (2) written information in otherlanguages.

If you need these services, contact a consumer advisorat the number on the back of your Member ID card orcall 1-800-565-9140 (TTY: 1-800-848-0298 or 711). If you believe that BlueCross has failed to providethese services or discriminated in another way onthe basis of race, color, national origin, age, disabilityor sex, you can file a grievance (“NondiscriminationGrievance”). For help with preparing and submittingyour Nondiscrimination Grievance, contact a consumer advisor at the number on the back of your Member ID cardor call 1-800-565-9140 (TTY: 1-800-848-0298 or 711). They can provide you with the appropriate form to usein submitting a Nondiscrimination Grievance. You can file a Nondiscrimination Grievance in person or by mail, fax or email. Address your Nondiscrimination Grievanceto: Nondiscrimination Compliance Coordinator; c/oManager, Operations, Member Benefits Administration;1 Cameron Hill Circle, Suite 0019, Chattanooga, TN37402-0019; (423) 591-9208 (fax); [email protected] (email). You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:U.S. Department of Health and Human Services,200 Independence Avenue SW., Room 509F, HHHBuilding, Washington, DC 20201, 1–800–368–1019,800–537–7697 (TDD). Complaint forms are available athttp://www.hhs.gov/ocr/office/file/index.html. BlueCross BlueShield of Tennessee, Inc., anIndependent Licensee of the BlueCross BlueShieldAssociation.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-565-9140 (TTY: 1-800-848-0298).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-565-9140 (TTY:1-800-848-0298) 。

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-565-9140 (TTY:1-800-848-0298).

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.1-800-565-9140 (TTY: 1-800-848-0298) 번으로 전화해 주십시오.

ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-565-9140 (ATS : 1-800-848-0298).

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ,ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-800-565-9140(TTY: 1-800-848-0298).

ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-565-9140 (መስማት ለተሳናቸው: 1-800-848-0298).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-565-9140(TTY: 1-800-848-0298).

સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-800-565-9140 (TTY:1-800-848-0298)

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-565-9140 (TTY:1-800-848-0298) まで、お電話にてご連絡ください。

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-565-9140(TTY:1-800-848-0298).

ध्यान दें: यिद आप िहंदी बोलते हैं तो आपके िलए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-800-565-9140 (TTY:1-800-848-0298) पर कॉल करें।

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-565-9140 (телетайп: 1-800-848-0298).

انی بصورت رایگان برای شما فراهم می باشد. با توجه: اگر به زبان فارسی گفتگو می کنید، تسهیالت زب-1-800-565-9140 (TTY:1-800-848-0298) . تماس بگیرید.

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-565-9140 (TTY: 1-800-848-0298).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-565-9140 (TTY: 1-800-848-0298).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-565-9140 (TTY: 1-800-848-0298).

ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-565-9140 (TTY: 1-800-848-0298).

D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-565-9140 (TTY: 1-800-848-0298).

(رقم 1-9140-565-800م اتصل برقلمجان. لك باللغویة تتوافر لمساعدة اللغة، فإن خدمات ات تتحدث اذكر املحوظة: إذا كن 1-0298-848-800).لبكم: م والصھاتف ا

RX-11 (5/18) 2018 Preferred Formulary Guidebook and

Prescription Drug List

http://www.hhs.gov/ocr/office/file/index.html

http://bcbst.com

mailto:[email protected]

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Your Guide to Prescription Drug Coverage · Trial and failure of ProAir HFA. QL. or ProAir...

Documents

Transcript of Your Guide to Prescription Drug Coverage · Trial and failure of ProAir HFA. QL. or ProAir...