Danh sách thuốc được bảo hiểm (Danh mục) năm 2016

Transcription

CARE1ST CAl MEdiConnECT plAn
Danh sách thuốc được bảo
hiểm (Danh mục) năm 2016
Quận: Los AngeLes và sAn Diego
vui LÒng ĐỌC KỸ: Tài LiỆu nàY CÓ THÔng Tin vỀ CÁC LoẠi
THuỐC ĐƯỢC BẢo HiỂM TRong CHƯƠng TRÌnH nàY
Danh sách thuốc na y đã được cập nhật va o nga y 08/19/2015. Để được biết thêm vê những
thông tin gâ n đây hoặc khi có những thắc mắc khác, xin liên lạc Care1st Cal MediConnect Plan
theo số 1-855-905-3825 (TTY: 711), 8:00 giơ sáng – 8:00 giơ tối, bảy nga y mỗi tuâ n, hoặc
va o trang mạng www.care1st.com/ca/calmediconnect.
Formulary ID: 00016515, Version: 6
H0148_16_008_RX_FINAL_VIET Approved
H0148_16_008_RX_FINAL_VIET Approved
Care1st Cal MediConnect Plan (Medicare-Medicaid Plan) | Danh sách thuốc được đài thọ (Danh mục
thuốc) năm 2016
Đây là danh sách thuốc mà hội viên có thể nhận được từ Care1st Cal MediConnect Plan.
 Care1st Health Plan là chương trình bảo hiểm y tế có ký hợp đồng với cả Medicare và Medi-Cal để cung cấp phúc lợi của cả hai chương trình
cho người ghi danh.
 Danh sách thuốc được đài thọ và/hoặc mạng lưới nhà cung cấp dịch vụ và nhà thuốc có thể sẽ thay đổi trong cả năm. Chúng tôi sẽ gửi thông
báo cho quý vị trước khi thực hiện bất kỳ thay đổi nào ảnh hưởng đến quý vị.
 Các quyền lợi và/hoặc tiền đồng trả có thể sẽ thay đổi vào ngày 1 tháng 1 mỗi năm.
 Quý vị luôn có thể kiểm tra Danh sách thuốc được đài thọ đã cập nhật của Care1st Cal MediConnect Plan trên mạng tại
www.care1st.com/ca/calmediconnect hoặc bằng cách gọi số 1-855-905-3825 (TTY: 711).
 Quý vị có thể yêu cầu tài liệu miễn phí này ở các dạng thức khác, như chữ in lớn, chữ nổi braille, hoặc âm thanh. Xin gọi 1-855-905-3825
(TTY: 711). Cuộc gọi này là miễn phí.
 Những giới hạn, tiền đồng trả và những điều khoản hạn chế có thể được áp dụng. Để biết thêm thông tin, xin gọi phòng Phục vụ thành viên của
Care1st Cal MediConnect Plan hoặc đọc Sổ tay thành viên của Care1st Cal MediConnect Plan.
 Tiền đồng trả cho các loại thuốc toa có thể thay đổi theo mức trợ giúp phụ trội Extra Help quý vị được cấp. Vui lòng liên lạc với chương trình để
biết thêm chi tiết.
You can get this information for free in other languages. Call 1-855-905-3825 (TTY users should call 711). The call is free. Puede recibir esta información sin cargo en otros idiomas. Llame al 1-855-905-3825. Los usuarios de TTY deben llamar al 711. La llamada es gratuita.
您可免费获得本资讯的其他语言版本。请致电免费电话 1-855-905-3825，听障及语障人士请致电711。
您可免費獲得本資訊的其他語言版本。請致電免費電話 1-855-905-3825。聽障及語障人士請致電 711。
.‫ﻤﺎ‬ѧѧ‫ﻮﻧﺎ ﯼم ﺷ‬ѧѧѧ‫ﻪ ار اﻃﻼﻋﺎت نﯼا دﯼﺗ‬ѧѧѧ‫ﻮﺗﺮ ﺑ‬ѧѧѧ ‫ﺎنﯼار ﺻ‬ѧѧѧ
‫ﺎن رد ﮔ‬ѧѧѧ
‫ﺮﯼد ﯼﻩﺎ زﺑ‬ѧѧѧ
‫ﺖﯼرد ﮔ‬ѧѧѧѧ ‫ﻦ ﻓا‬ѧ
ѧѧ‫دﯼﮐ‬
‫( ﺗﻠﻔﻦ‬1-855-905-3825) .‫ارﻳﮕﺎن اﺳﺖ‬
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Nếu quý vị có thắc mắc, vui lòng gọi cho Care1st Cal MediConnect Plan theo số 1-855-905-3825 (TTY: 711), 8:00 sáng – 8:00 tối, bảy ngày
i
trong tuần. Cuộc gọi làmiễn phí. Để biết thêm thông tin, hãy vào trang mạng www.care1st.com/ca/calmediconnect.
‫ﺎ‬ѧѧѧ
‫ﻤﺎرﻩ ﺑ‬ѧѧ‫ﻦ ﺷ‬ѧ ѧѧѧѧѧѧѧ
‫ ﺗﻠﻔ‬711 .‫ﺎس‬ѧѧѧ‫ﮓ ﺗﻤ‬ѧ
ѧ‫( دﯼرﯼﺑ‬TTY) ‫ﺮا‬ѧ
ѧѧ‫ﺧﺪﻣﺎت ﯼﺑ‬
Դուք կարող եք անվճար ստանալ այս տեղեկությունն այլ լեզուներով: Զանգահարեք 1-855-905-3825 հեռախոսահամարներով: TTY
օգտվողները պետք է զանգահարել 711: Զանգն անվճար է:
អ្នកអាចយកព័ត៌មានេនះេដាយឥតគតៃថេនៅកុ
ិ
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ងភាសាេផĀងេទៀត។
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េហៅ 1-855-905-3825 េលាកអ្នកែដលេ្រលើ TTY េលតាទរសពេលៅលលខ
711។ ការេហៅេនះគឺ
ŋ ូ ័ ្ទ
ឥតគិតៃថ។
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본 정보를 무료로 다른 언어로 받아보실 수 있습니다. 1-855-905-3825 번으로 전화해 주십시오. TTY 사용자는 711번으로 전화해 주십시오.
통화는 무료입니다.
Эту информацию вы можете получить бесплатно в переводе на другие языки. Позвоните по телефону 1-855-905-3825. Пользователи
TTY должны позвонить 711. Звонки по этому телефону бесплатные.
Maaari ninyong makuha nang libre ang impormasyon na ito sa ibang mga wika. Tawagan ang 1-855-905-3825. Ang gumagamit ng TTY ay
dapat tumawag sa 711. Libre ang tawag.
3825-905-855-1‫اﺗﺼﻞ‬. ‫ﻳﻤﻜﻨﻚ اﻟﺤﺼﻮل ﻋﻠﻰ هﺬﻩ اﻟﻤﻌﻠﻮﻣﺎت ﻣﺠﺎﻧﺎ ﻓﻲ ﻟﻐﺎت أﺧﺮى‬
. .
‫اﻟﻤﻜﺎﻟﻤﺔ ﻣﺠﺎﻧﻴﺔ‬. 711 ‫( ﻳﺠﺐ ﻋﻠﻰ اﻟﻤﺴﺘﺨﺪﻣﻴﻦ اﻻﺗﺼﺎل ب‬TTY) ‫واﻟﻨﻄﻖ اﻟﺴﻤﻊ ﺿﻌﺎف‬
Quý vị có thể nhận thông tin này miễn phí bằng các ngôn ngữ khác. Hãy gọi 1-855-905-3825. Người sử dụng TTY nên gọi 711. Cuộc gọi này là
miễn phí.
?
Nếu quý vị có thắc mắc, vui lòng gọi cho Care1st Cal MediConnect Plan theo số 1-855-905-3825 (TTY: 711), 8:00 sáng – 8:00 tối, bảy ngày
ii
trong tuần. Cuộc gọi làmiễn phí. Để biết thêm thông tin, hãy vào trang mạng www.care1st.com/ca/calmediconnect.
Các câu hỏi thường gặp (FAQ)
Hãy tìm các câu trả lời cho các câu hỏi của quý vị về Danh sách thuốc được đài thọ tại đây. Quý vị có thể đọc tất cả các Câu hỏi thường gặp
để biết thêm hoặc tìm một câu hỏi và đáp cụ thể.
1. Loại thuốc toa nào trong Danh sách thuốc được đài thọ?
(Chúng tôi gọi tắt Danh sách thuốc được đài thọ là “Danh sách thuốc”.)
Thuốc có trong Danh sách thuốc là những thuốc được Care1st Cal MediConnect Plan bao trả. Thuốc có sẵn tại các nhà thuốc trong mạng
lưới của chúng tôi. Một nhà thuốc được xem là nằm trong mạng lưới của chúng tôi nếu chúng tôi có hợp đồng làm việc với họ và họ cung cấp
dịch vụ cho quý vị. Chúng tôi gọi những nhà thuốc này là “nhà thuốc trong mạng lưới.”
Care1st Cal MediConnect Plan sẽ bao trả cho tất cả các loại thuốc cần thiết về mặt y tế có tên trong Danh sách thuốc nếu:
 bác sĩ hoặc người kê toa của quý vị nói rằng quý vị cần những loại thuốc này để phục hồi hoặc để giữ gìn sức khỏe, và
 quý vị mua thuốc theo toa tại một nhà thuốc trong mạng lưới của Care1st Cal MediConnect Plan.
Trong một số trường hợp, quý vị cần làm gì đó trước khi quý vị có thể nhận được thuốc (xem câu hỏi số 5 bên dưới).
Quý vị cũng có thể xem danh sách thuốc được chúng tôi đài thọ đã cập nhật trên trang mạng của chúng tôi tại
www.care1st.com/ca/calmediconnect hoặc gọi Dịch vụ hội viên theo số 1-855-905-3825 (TTY: 711).
2. Danh sách thuốc có bao giờ thay đổi không?
Có. Care1st Cal MediConnect Plan có thể thêm vào hoặc loại bỏ thuốc ra khỏi Danh sách thuốc trong cả năm. Nói chung, Danh sách thuốc
sẽ chỉ thay đổi nếu:
 một loại thuốc rẻ hơn xuất hiện có hiệu quả như thuốc trong Danh sách thuốc hiện tại, hoặc
 chúng tôi phát hiện rằng loại thuốc đó không an toàn.
Chúng tôi cũng có thể thay đổi quy tắc về thuốc. Ví dụ, chúng tôi có thể:
 Quyết định yêu cầu hoặc không yêu cầu sự chấp thuận trước cho một thuốc nào đó. (Chấp thuận trước là sự cho phép của Care1st Cal MediConnect Plan trước khi quý vị có thể nhận thuốc.)  Bổ sung hoặc thay đổi số lượng thuốc của một thuốc nào đó quý vị có thể nhận được (gọi là “giới hạn số lượng”).
?
Nếu quý vị có thắc mắc, vui lòng gọi cho Care1st Cal MediConnect Plan theo số 1-855-905-3825 (TTY: 711), 8:00 sáng – 8:00 tối, bảy
ngày trong tuần. Cuộc gọi làmiễn phí. Để biết thêm thông tin, hãy vào trang mạng www.care1st.com/ca/calmediconnect.
iii
 Bổ sung hoặc thay đổi quy định hạn chế về phương pháp trị liệu từng bước đối với một thuốc nào đó. (Trị liệu từng bước nghĩa là quý vị
phải thử một loại thuốc trước khi chúng tôi bao trả cho một loại thuốc khác.)
(Để biết thêm thông tin về những quy tắc về thuốc này, hãy xem trang v.)
Chúng tôi sẽ cho quý vị biết khi thuốc quý vị đang dùng bị loại ra khỏi Danh sách thuốc. Chúng tôi cũng sẽ cho quý vị biết khi nào chúng tôi
thay đổi quy tắc về việc bao trả cho một loại thuốc. Các câu hỏi 3, 4 và 7 dưới đây có thêm thông tin về điều gì sẽ xảy ra khi Danh sách thuốc
thay đổi.
→ Quý vị luôn có thể kiểm tra Danh sách thuốc cập nhật của Care1st Cal MediConnect Plan trên mạng tại
www.care1st.com/ca/calmediconnect. Quý vị cũng có thể gọi phòng Phụ vụ thành viên để kiểm tra Danh sách thuốc hiện tại theo số 1
855-905-3825 (TTY: 711).
3. Điều gì sẽ xảy ra khi một loại thuốc rẻ hơn xuất hiện có hiệu quả như thuốc trong Danh sách thuốc
hiện tại?
Nếu quý vị đang dùng một loại thuốc bị loại bỏ vì một loại thuốc rẻ hơn có hiệu quả tương tự xuất hiện, chúng tôi sẽ thông báo cho quý vị
biết. Chúng tôi sẽ thông báo cho quý vị ít nhất 60 ngày trước khi chúng tôi loại bỏ thuốc đó ra khỏi Danh sách thuốc hoặc khi quý vị yêu cầu
mua thêm thuốc. Khi đó quý vị có thể nhận được một lượng thuốc đủ dùng trong 60 ngày trước khi thuốc đó bị loại ra khỏi danh sách thuốc.
Mỗi tháng Care1st Cal MediConnect Plan gửi cho quý vị qua đường bưu điện bản báo cáo có tên là “Bản giải thích về phúc lợi” hay gọi tắt là
“EOB” (Explanation of Benefits - EOB). Bản EOB cho quý vị biết tổng số tiền quý vị đã trả cho thuốc theo toa và tổng số tiền chúng tôi đã trả
cho mỗi loại thuốc theo toa của quý vị trong tháng. Cùng với bản EOB, chúng tôi sẽ gửi cho quý vị "Phụ bản về những thay đổi trong danh
mục thuốc" nếu danh mục thuốc được sửa đổi gần đây. Ngay cả khi quý vị không mua thuốc theo toa nào cả trong thời gian gần đây, khi
nhận được tài liệu này, xin quý vị hãy đọc kỹ để xem danh mục thuốc có gì thay đổi hay không.
4. Điều gì sẽ xảy ra khi chúng tôi phát hiện một loại thuốc không an toàn?
Nếu Cơ Quan Quản Lý Thực Phẩm và Dược Phẩm Hoa Kỳ (Food and Drug Administration - FDA) nói rằng loại thuốc quý vị đang dùng
không an toàn, chúng tôi sẽ loại bỏ thuốc đó ra khỏi Danh sách thuốc ngay lập tức. Chúng tôi cũng sẽ gửi thư cho quý vị để thông báo rằng
thuốc đó đã bị loại bỏ ra khỏi Danh sách thuốc và hướng dẫn quý vị điều cần làm tiếp theo.
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5. Có bất kỳ quy định hạn chế hoặc giới hạn nào đối với thuốc được đài thọ không? Hoặc có cần làm
gì để nhận một số loại thuốc nhất định hay không?
Đúng vậy, một số loại thuốc có những quy tắc đài thọ hoặc có giới hạn về số lượng quý vị có thể nhận được. Trong một số trường hợp, bác
sĩ hoặc người kê đơn khác của quý vị phải thực hiện một vài việc trước thì quý vị mới có thể nhận thuốc. Ví dụ:
 Sự chấp thuận trước (hoặc sự cho phép trước): Đối với một số loại thuốc, quý vị hoặc bác sĩ của quý vị hoặc người kê toa khác
phải có sự chấp thuận từ Care1st Cal MediConnect Plan trước khi quý vị mua thuốc theo toa. Nếu quý vị không có sự chấp thuận,
Care1st Cal MediConnect Plan có thể sẽ không bao trả cho thuốc này.
 Giới hạn số lượng: Đôi khi Care1st Cal MediConnect Plan giới hạn số lượng một loại thuốc quý vị có thể nhận.
 Trị liệu từng bước: Đôi khi Care1st Cal MediConnect Plan yêu cầu quý vị thực hiện phương pháp trị liệu từng bước. Điều này có
nghĩa là quý vị sẽ phải dùng thử các thuốc theo một thứ tự nhất định cho tình trạng sức khỏe của mình. Quý vị có thể phải dùng thử
một loại thuốc trước khi chúng tôi đài thọ cho một loại thuốc khác. Nếu bác sĩ của quý vị cho rằng loại thuốc đầu tiên không có tác dụng
với quý vị, chúng tôi sẽ đài thọ cho loại thuốc thứ hai.
Quý vị có thể tìm hiểu xem thuốc của quý vị có bất kỳ yêu cầu hoặc giới hạn bổ sung nào hay không bằng cách xem các bảng ở trang 9-23.
Quý vị cũng có thể biết thêm thông tin bằng cách vào trang mạng của chúng tôi tại www.care1st.com/ca/calmediconnect. Chúng tôi đã đăng
tải trên mạng các tài liệu giải thích các hạn chế về sự cho phép trước và phương pháp trị liệu từng bước. Quý vị cũng có thể yêu cầu chúng
tôi gửi cho quý vị một bản sao.
Quý vị có thể yêu cầu “trường hợp ngoại lệ” cho các giới hạn này. Vui lòng xem Câu hỏi 11 để biết thêm thông tin về các trường hợp ngoại
lệ.

Nếu quý vị đang sống trong nhà điều dưỡng hoặc một cơ sở chăm sóc dài hạn khác và cần loại thuốc không có trong Danh sách thuốc,
hoặc nếu quý vị không thể dễ dàng nhận được loại thuốc quý vị cần, chúng tôi có thể giúp đỡ. Chúng tôi sẽ đài thọ số lượng thuốc khẩn
cấp quý vị cần để đủ dùng trong 31 ngày (trừ khi quý vị có toa thuốc kê cho số ngày ít hơn), bất kể quý vị là thành viên mới của Care1st
Cal MediConnect Plan hay không. Như thế, quý vị có thời gian trao đổi với bác sĩ hoặc người kê toa khác của quý vị. Người này có thể
giúp quý vị quyết định liệu có một loại thuốc tương tự trong Danh sách thuốc quý vị có thể dùng để thay thế hoặc liệu có cần yêu cầu
trường hợp ngoại lệ hay không. Vui lòng xem Câu hỏi 11 để biết thêm thông tin về các trường hợp ngoại lệ.
6. Làm thế nào quý vị biết loại thuốc quý vị có giới hạn hoặc liệu quý vị bắt buộc phải làm gì để nhận
thuốc hay không?
Danh sách thuốc được đài thọ ở trang 25 có một cột tên là “Hành động cần thiết, quy định hạn chế hoặc giới hạn sử dụng.”
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7. Điều gì sẽ xảy ra nếu chúng tôi thay đổi quy tắc về cách thức đài thọ cho một số loại thuốc? Ví dụ:
nếu chúng tôi yêu cầu phải có thêm sự cho phép (chấp thuận) trước, giới hạn số lượng và/hoặc
quy định hạn chế về phương pháp trị liệu từng bước đối với một loại thuốc.
Chúng tôi sẽ thông báo cho quý vị biết nếu chúng tôi yêu cầu phải có thêm sự chấp thuận trước, giới hạn số lượng và/hoặc quy định hạn chế
về phương pháp trị liệu từng bước đối với một loại thuốc. Chúng tôi sẽ thông báo cho quý vị biết ít nhất 60 ngày trước khi quy định hạn chế
được thêm vào hoặc khi quý vị yêu cầu nhà thuốc của mình bán thêm thuốc. Sau đó, quý vị có thể nhận được một lượng thuốc đủ dùng trong
60 ngày trước khi các thay đổi đối về quy tắc đài thọ được thực hiện. Điều này sẽ cho quý vị thời gian trao đổi với bác sĩ của mình hoặc
người kê toa khác về điều cần làm tiếp theo.
8. Làm thế để tìm một loại thuốc trong Danh sách thuốc?
Có hai cách để tìm kiếm một loại thuốc:
 Quý vị có thể tìm theo thứ tự bảng chữ cái (nếu quý vị biết đánh vần tên thuốc), hoặc
 Quý vị có thể tìm theo bệnh trạng.
Để tìm theo thứ tự bảng chữ cái, vui lòng tới mục Danh sách theo thứ tự bảng chữ cái. Quý vị có thể thấy danh sách này ở bảng chú dẫn
bắt đầu từ trang 167. Bảng chú dẫn này cung cấp một danh sách theo thứ tự bảng chữ cái bao gồm tất cả các loại thuốc có trong tài liệu này.
Cả hai loại thuốc chính hiệu và thuốc gốc được liệt kê trong Bảng chú dẫn này. Tìm tên thuốc của quý vị trong Bảng chú dẫn. Bên cạnh tên
thuốc là số trang nơi quý vị có thể xem thông tin đài thọ cho loại thuốc này. Lật đến trang ghi trong Bảng chú dẫn này và tìm tên thuốc của
quý vị ở cột đầu tiên trong danh sách.
Để tìm theo bệnh trạng, tìm mục có tên “Danh sách thuốc theo bệnh trạng” ở trang xi. Các thuốc trong mục này được xếp nhóm với nhau
theo các loại bệnh mà chúng được dùng để điều trị. Ví dụ: nếu quý vị bị bệnh tim, quý vị sẽ tìm trong loại Cardiovascular Agents. Đó là nơi
quý vị sẽ tìm thấy thuốc điều trị bệnh tim.
9.
Nếu loại thuốc quý vị muốn dùng không có trong Danh sách thuốc thì sao?
Nếu quý vị không thấy loại thuốc của mình trong Danh sách thuốc, xin gọi phòng Phụ vụ thành viên theo số 1-855-905-3825 (TTY: 711) và
hỏi về vấn đề này. Nếu quý vị biết rằng Care1st Cal MediConnect Plan sẽ không đài thọ cho loại thuốc đó, quý vị có thể thực hiện một trong
những điều sau đây:
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 Yêu cầu phòng Phục vụ thành viên cho một danh sách các loại thuốc giống loại quý vị muốn dùng. Sau đó cho bác sĩ hoặc người kê
toa khác của quý vị xem danh sách đó. Người đó có thể kê một loại thuốc có trong Danh sách thuốc giống loại thuốc quý vị muốn dùng.
Hoặc
 Quý vị có thể yêu cầu chương trình bảo hiểm y tế cấp trường hợp ngoại lệ để đài thọ cho thuốc của quý vị. Vui lòng xem câu hỏi 11 để
biết thêm thông tin về các trường hợp ngoại lệ.
10. Nếu quý vị là thành viên mới của Care1st Cal MediConnect Plan và không thể tìm thấy loại thuốc
của mình trong Danh sách thuốc hoặc có vấn đề trong việc lấy thuốc thì sao?
Chúng tôi có thể giúp đỡ. Chúng tôi có thể đài thọ lượng thuốc tạm thời đủ dùng trong 30 ngày cho quý vị trong suốt 90 ngày đầu tiên quý vị
là thành viên của Care1st Cal MediConnect Plan. Điều này sẽ cho quý vị thời gian để trao đổi với bác sĩ của quý vị hoặc người kê toa khác.
Người này có thể giúp quý vị quyết định liệu có một loại thuốc tương tự trong Danh sách thuốc mà quý vị có thể dùng để thay thế hoặc liệu có
cần yêu cầu trường hợp ngoại lệ hay không.
Chúng tôi sẽ đài thọ cho một số lượng thuốc để quý vị đủ dùng trong 30 ngày nếu:
 quý vị đang dùng một loại thuốc không có trong Danh sách thuốc của chúng tôi, hoặc
 các quy tắc của chương trình bảo hiểm y tế không cho phép quý vị nhận được số lượng do người kê toa của quý vị chỉ định, hoặc
 loại thuốc phải có sự chấp thuận trước của Care1st Cal MediConnect Plan, hoặc
 quý vị đang dùng một loại thuốc là một phần trong quy định hạn chế về phương pháp trị liệu từng bước.
Nếu quý vị sống trong nhà điều dưỡng hoặc cơ sở chăm sóc dài hạn khác, quý vị có thể mua thêm thuốc theo toa trong vòng 91 ngày. Quý vị
có thể mua thêm thuốc nhiều lần trong 90 ngày đầu tiên trong chương trình. Điều này cho phép người kê toa của quý vị có thời gian để
chuyển các loại thuốc của quý vị sang những loại có trong Danh sách thuốc hoặc yêu cầu trường hợp ngoại lệ.
Chính sách chuyển tiếp
Trong trường hợp người có bảo hiểmđổi cơ sở điều trị sang cơ sở khác, Care1st Cal MediConnect Plan sẽ bảo đảm thực hiện thủ tục chấp
thuận nhanh chóng cho các loại thuốc thuộc Phần D không có trong danh mục. Thủ tục này cũng sẽ áp dụng cho các loại thuốc Phần D
trong danh mục cần được cho phép trước hoặc thuộc phương pháp trị liệu từng bước. Ví dụ về những thay đổi trong mức độ chăm sóc là:
người có bảo hiểm được xuất viện về nhà; người có bảo hiểm vừa chấm dứt thời gian ở tại cơ sở điều dưỡng chuyên môn được đài thọ qua
Medicare Phần A và cần được chuyển trở lại danh mục thuốc của chương trình Phần D; người có bảo hiểm vừa chấm dứt thời gian ở tại cơ
sở chăm sóc dài hạn và trở về sống trong cộng đồng; và người có bảo hiểm được xuất viện từ bệnh viện tâm thần với chương trình điều trị
bằng những loại thuốc đặc biệt dành riêng cho bệnh nhân.
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Dịch vụ ngoài giờ làm việc của Care1st Cal MediConnect Plan cho phép các nhà thuốc liên lạc với nhân viên đại diện của chương trình có
quyền quyết định những vấn đề bảo hiểm của nhà thuốc. Cách tiếp cận này sẽ cho phép các nhà thuốc có được quyết định về bảo hiểm toa
thuốc vào lúc bán thuốc và bảo đảm người có bảo hiểm được lấy thuốc họ cần một cách đáng tin cậy.
11. Quý vị có thể yêu cầu trường hợp ngoại lệ để bao trả cho loại thuốc của mình hay không?
Có. Quý vị có thể yêu cầu Care1st Cal MediConnect Plan cấp trường hợp ngoại lệ để bao trả cho thuốc không có trong Danh sách thuốc.
Quý vị cũng có thể yêu cầu chúng tôi thay đổi quy tắc về loại thuốc quý vị dùng.
 Ví dụ: Care1st Cal MediConnect Plan có thể giới hạn số lượng một loại thuốc chúng tôi sẽ đài thọ. Nếu loại thuốc của quý vị có giới
hạn, quý vị có thể yêu cầu chúng tôi thay đổi giới hạn và đài thọ thêm.
 Các ví dụ khác: Quý vị có thể yêu cầu chúng tôi hủy bỏ quy định hạn chế về phương pháp trị liệu từng bước hoặc yêu cầu về sự chấp
thuận trước.
12. Mất bao lâu để được cấp trường hợp ngoại lệ?
Đầu tiên, chúng tôi phải nhận được giấy từ người kê toa của quý vị ủng hộ việc yêu cầu trường hợp ngoại lệ của quý vị. Sau khi chúng tôi
nhận được giấy đó, chúng tôi sẽ quyết định về yêu cầu trường hợp ngoại lệ của quý vị trong vòng 72 giờ.
Nếu quý vị hoặc người kê toa của quý vị cho rằng sức khỏe của quý vị có thể bị tổn hại nếu quý vị phải chờ 72 giờ để nhận được quyết định,
quý vị có thể yêu cầu quyết định cấp tốc. Đây là quyết định nhanh hơn. Nếu người kê toa của quý vị ủng hộ đề nghị của quý vị, chúng tôi sẽ
ra quyết định cho quý vị trong vòng 24 giờ kể từ khi nhận được giấy ủng hộ của người kê toa của quý vị.
13. Làm thế nào quý vị có thể yêu cầu trường hợp ngoại lệ?
Để yêu cầu trường hợp ngoại lệ, xin gọi phòng Phục vụ thành viên. Phòng Phục vụ thành viên sẽ làm việc với quý vị và nhà cung cấp dịch vụ
của quý vị để giúp quý vị yêu cầu trường hợp ngoại lệ.
14. Thuốc gốc là gì?
Thuốc gốc được sản xuất từ những thành phần tương tự như thuốc chính hiệu. Chúng thường rẻ hơn thuốc chính hiệu và tên của chúng ít
phổ biến hơn. Thuốc gốc được Cục quản lý Thực phẩm và Dược phẩm (Food and Drug Administration - FDA) chấp thuận.
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Chương trình Care1st Cal MediConnect Plan đài thọ cả thuốc chính hiệu lẫn thuốc gốc.
15. Thuốc mua không cần toa (over-the-counter - OTC) là gì?
OTC là viết tắt của từ “over-the-counter” (“không cần toa”). Care1st Cal MediConnect Plan đài thọmột số loại thuốc OTC khi các thuốc này được nhà cung cấp dịch vụ của quý vị kê toa.
Quý vị có thể đọc Danh sách thuốc của Care1st Cal MediConnect Plan để xem loại thuốc OTC nào được đài thọ. 16. Care1st Cal MediConnect Plan có đài thọ các sản phẩm OTC không phải là thuốc hay không?
Care1st Cal MediConnect Plan đài thọ một số sản phẩm OTC không phải là thuốc khi các sản phẩm này được nhà cung cấp dịch vụ của quý
vị kê toa.
Quý vị có thể đọc Danh sách thuốc của Care1st Cal MediConnect Plan để xem loại sản phẩm OTC không phải là thuốc nào được đài thọ.
17. Tiền đồng trả của quý vị là gì?
Quý vị có thể đọc Danh sách thuốc của Care1st Cal MediConnect Plan để tìm hiểu về tiền đồng trả cho mỗi loại thuốc.
Các thành viên Care1st Cal MediConnect Plan sống tại các nhà điều dưỡng hoặc các cơ sở chăm sóc dài hạn khác sẽ không phải trả tiền
đồng trả. Một số thành viên được chăm sóc dài hạn tại cộng đồng cũng sẽ không phải trả tiền đồng trả.
Tiền đồng trả được liệt kê theo bậc. Bậc là các nhóm thuốc có chung tiền đồng trả. Số tiền đồng trả sẽ thay đổi dựa trên tiêu chuẩn bảo hiểm
Medi-Cal của quý vị.
Bậc
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Mô tả
Tiền đồng trả
số lượng đủ dùng trong 30
ngày
số lượng đủ dùng trong 90
ngày
Bậc 1
Thuốc gốc
$0 đến $2.95 tiền đồng trả
Bậc 2
Thuốc chính hiệu
Bậc 3
Thuốc theo toa (Rx) không thuộc
Medicare / Thuốc mua không cần
toa (Over-the-counter - OTC)
$0 tiền đồng trả
$0 tiền đồng trả
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Danh sách thuốc được đài thọ
Danh sách thuốc được đài thọ bắt đầu từ trang kế cung cấp cho quý vị thông tin về các thuốc được Care1st Cal MediConnect Plan đài thọ.
Nếu quý vị không tìm được thuốc của quý vị trong danh sách, xin lật sang Bảng chú dẫn bắt đầu từ trang 167.
Cột đầu tiên của bảng này ghi tên thuốc. Thuốc chính hiệu được viết hoa (ví dụ: IMITREX) và thuốc gốc được ghi bằng chữ thường, viết
nghiêng (ví dụ: simvastatin).
Thông tin trong cột “Hành động cần thiết, quy định hạn chế hoặc giới hạn sử dụng” cho quý vị biết Care1st Cal MediConnect Plan có quy tắc
nào đối với việc đài thọ thuốc của quý vị hay không.
Chú thích về Chữ viết tắt được sử dụng để Yêu cầu/Giới hạn trong Danh sách thuốc
Chữ viết tắt
Mô tả
PA
Phải có sự cho phép trước.
QL
Giới hạn số lượng
ST
Trị liệu từng bước
BvD
Phải có sự cho phép trước
để xác định bảo hiểm thuộc
Phần B hay Phần D
PA>65 y/o
Phải có sự Cho phép trước
đối với hội viên trên 65 tuổi
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Giải thích
Quý vị (hoặc bác sĩ của quý vị) bắt buộc phải có sự cho phép trước từ
Care1st Cal MediConnect Plan trước khi quý vị mua thuốc này theo toa. Nếu không có sự
chấp thuận trước, Care1st Cal MediConnect Plan có thể không bao trả cho thuốc này.
Care1st Cal MediConnect Plan giới hạn số lượng được đài thọ trong một khoảng thời gian
cụ thể cho thuốc này.
Trước khi Care1st Cal MediConnect Plan đài thọ thuốc này, đầu tiên quý vị phải thử một
loại thuốc khác trong danh mục thuốc để điều trị bệnh trạng của quý vị. Thuốc này chỉ có
thể được đài thọ nếu (các) thuốc khác không có tác dụng với quý vị.
Thuốc này có thể đủ tiêu chuẩn được bao trả theo Medicare Phần B hoặc Phần D. Quý vị
(hoặc bác sĩ của quý vị) bắt buộc phải có sự cho phép trước từ
Care1st Cal MediConnect Plan để quyết định thuốc này có được đài thọ theo Medicare
Phần D hay không trước khi quý vị mua thuốc này theo toa. Nếu không có sự chấp thuận
trước, Care1st Cal MediConnect Plan có thể không đài thọ cho loại thuốc này.
Quý vị (hoặc bác sĩ của quý vị) bắt buộc phải có sự cho phép trước từ
Care1st Cal MediConnect Plan trước khi quý vị mua thuốc này theo toa, nếu quý vị trên 65
tuổi.
x
Chú thích các ký hiệu trong Danh sách thuốc
Ký
hiệu
~
+
*
Ghi chú
Toa thuốc này có thể chỉ mua được tại một số nhà thuốc nào thôi. Để biết thêm thông tin, xin gọi phòng Phục vụ thành viên của
Care1st Cal MediConnect Plan.
Đây là thuốc duy trì. Số lượng thuốc này đủ dùng cho đến 90 ngày được cung cấp qua nhà thuốc bán qua bưu điện trong mạng
lưới và qua một số các nhà thuốc bán lẻ trong mạng lưới của chúng tôi. Để biết thêm thông tin, xin gọi phòng Phục vụ thành viên
của Care1st Cal MediConnect Plan.
Thuốc này được Medi-Cal đài thọ và không phải là “thuốc Phần D.” Nếu quý vị có thắc mắc, xin gọi phòng Phục vụ thành viên của
Care1st Cal MediConnect Plan.
Lưu ý: Dấu sao (*) cạnh một loaị thuôć có nghĩa là thuôć đó không phaỉ “thuốc Phân
̀ D.” Quý vị không cần phải trả khoản tiền đồng trả cho các
thuốc này. Các loại thuốc này cũng có những quy tăć khác nhau về trường hợp kháng cáo. Kháng cáo là một cách chính thưć yêu câu
̀ chúng tôi
xem xét quyết đinh
̣ về mức bảo hiểm của quý vị và thay đổi nó nếu quý vị nghĩ răng
̀ chúng tôi đã làm sai. Ví dụ: chúng tôi có thể quyêt́ đinh
̣ Medicare
hoặc Medi-Cal không đài thọ hay không còn đài thọ cho loại thuốc quý vị cân.
̀ Nêu
́ quý vị hoăc̣ bác sĩ cuả quý vị không đông
̀ ý với quyết định cuả
chúng tôi, quý vị có thể kháng cáo. Nếu quý vị có thắc mắc, xin goị phòng Phục vụ thành viên theo số 1-855-905-3825 (TTY: 711). Quý vị cũng có
thể đọc Sổ tay thành viên để biết cách kháng cáo môṭ quyết định.
Danh sách thuốc theo Bệnh trạng
Các thuốc trong danh mục này được xếp nhóm với nhau thành các loại theo bệnh mà chúng được dùng để điều trị. Ví dụ: nếu quý vị bị bệnh
tim, quý vị sẽ tìm trong loại Cardiovascular Agents. Đó là nơi quý vị sẽ tìm thấy thuốc điều trị bệnh tim.
?
xi
Table of Contents
QUANTITY LIMITS TABLE
......................................................................................................................................................................................................... 9
ANALGESICS
ANALGESICS, MISCELLANEOUS ......................................................................................................................................................... 25
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS ............................................................................................................................... 28
ANESTHETICS
LOCAL ANESTHETICS ........................................................................................................................................................................ 30
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS .............................................................................................................. 30
ANTIANXIETY AGENTS
BENZODIAZEPINES ............................................................................................................................................................................ 31
ANTIBACTERIALS
AMINOGLYCOSIDES ......................................................................................................................................................................... 32
ANTIBACTERIALS, MISCELLANEOUS ................................................................................................................................................... 32
CEPHALOSPORINS ............................................................................................................................................................................ 34
MACROLIDES .................................................................................................................................................................................... 35
MISCELLANEOUS B-LACTAM ANTIBIOTICS ......................................................................................................................................... 36
PENICILLINS ...................................................................................................................................................................................... 37
QUINOLONES .................................................................................................................................................................................. 38
SULFONAMIDES ................................................................................................................................................................................ 39
TETRACYCLINES ................................................................................................................................................................................ 39
ANTICANCER AGENTS
ANTICANCER AGENTS....................................................................................................................................................................... 40
ANTICONVULSANTS
ANTICONVULSANTS .......................................................................................................................................................................... 47
If you have questions, please call Care1st Cal MediConnect Plan at 1-855-905-3825 (TTY:711), 8:00 a.m. - 8:00 p.m., seven days a week. The call is free. For more information, visit www.care1st.com/ca/calmediconnect.
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Table of Contents
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS .................................................................................................................................................................... 52
ANTIDEPRESSANTS
ANTIDEPRESSANTS ............................................................................................................................................................................ 53
ANTIDIABETIC AGENTS
ANTIDIABETIC AGENTS, MISCELLANEOUS ......................................................................................................................................... 56
INSULINS........................................................................................................................................................................................... 58
SULFONYLUREAS ............................................................................................................................................................................... 59
ANTIFUNGALS
ANTIFUNGALS ................................................................................................................................................................................... 60
ANTIHISTAMINES
ANTIHISTAMINES ............................................................................................................................................................................... 63
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) .......................................................................................................................... 64
ANTIMIGRAINE AGENTS
ANTIMIGRAINE AGENTS .................................................................................................................................................................... 64
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS ..................................................................................................................................................................... 65
ANTINAUSEA AGENTS
ANTINAUSEA AGENTS ....................................................................................................................................................................... 66
ANTIPARASITE AGENTS
ANTIPARASITE AGENTS ...................................................................................................................................................................... 67
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ANTIPARKINSONIAN AGENTS
ANTIPARKINSONIAN AGENTS ............................................................................................................................................................ 68
ANTIPSYCHOTIC AGENTS
ANTIPSYCHOTIC AGENTS ................................................................................................................................................................. 69
ANTIVIRALS (SYSTEMIC)
ANTIRETROVIRALS ............................................................................................................................................................................. 73
ANTIVIRALS, MISCELLANEOUS ........................................................................................................................................................... 77
HCV ANTIVIRALS ................................................................................................................................................................................ 77
INTERFERONS ................................................................................................................................................................................... 78
NUCLEOSIDES AND NUCLEOTIDES ................................................................................................................................................... 78
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS ........................................................................................................................................................................... 79
BLOOD FORMATION MODIFIERS ...................................................................................................................................................... 80
HEMATOLOGIC AGENTS, MISCELLANEOUS ...................................................................................................................................... 82
PLATELET-AGGREGATION INHIBITORS............................................................................................................................................... 83
CALORIC AGENTS
CALORIC AGENTS ............................................................................................................................................................................. 83
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGENTS ............................................................................................................................................................ 84
ANGIOTENSIN II RECEPTOR ANTAGONISTS ...................................................................................................................................... 85
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ........................................................................................................................... 85
ANTIARRHYTHMIC AGENTS ............................................................................................................................................................... 86
BETA-ADRENERGIC BLOCKING AGENTS ............................................................................................................................................ 87
CALCIUM-CHANNEL BLOCKING AGENTS .......................................................................................................................................... 88
CARDIOVASCULAR AGENTS, MISCELLANEOUS .................................................................................................................................. 89
DIHYDROPYRIDINES .......................................................................................................................................................................... 90
DIURETICS ......................................................................................................................................................................................... 91
DYSLIPIDEMICS .................................................................................................................................................................................. 92
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RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ............................................................................................................... 93
VASODILATORS ................................................................................................................................................................................. 93
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS ................................................................................................................................................ 94
CONTRACEPTIVES
CONTRACEPTIVES ............................................................................................................................................................................. 95
DENTAL AND ORAL AGENTS
DENTAL AND ORAL AGENTS ........................................................................................................................................................... 100
DERMATOLOGICAL AGENTS
DERMATOLOGICAL AGENTS, OTHER .............................................................................................................................................. 101
DERMATOLOGICAL ANTIBACTERIALS ............................................................................................................................................... 103
DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS ......................................................................................................................... 104
DERMATOLOGICAL RETINOIDS ....................................................................................................................................................... 108
SCABICIDES AND PEDICULICIDES .................................................................................................................................................... 108
DEVICES
DEVICES .......................................................................................................................................................................................... 109
ENZYME REPLACEMENT/MODIFIERS
ENZYME REPLACEMENT/MODIFIERS ................................................................................................................................................ 109
EYE, EAR, NOSE, THROAT AGENTS
EYE, EAR, NOSE, THROAT AGENTS, MISCELLANEOUS ...................................................................................................................... 111
EYE, EAR, NOSE, THROAT ANTI-INFECTIVES AGENTS ....................................................................................................................... 112
EYE, EAR, NOSE, THROAT ANTI-INFLAMMATORY AGENTS ............................................................................................................... 114
GASTROINTESTINAL AGENTS
ANTIULCER AGENTS AND ACID SUPPRESSANTS ............................................................................................................................... 115
GASTROINTESTINAL AGENTS, OTHER .............................................................................................................................................. 116
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LAXATIVES ....................................................................................................................................................................................... 117
PHOSPHATE BINDERS ...................................................................................................................................................................... 117
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY ........................................................................................................................................................... 118
GENITOURINARY AGENTS, MISCELLANEOUS .................................................................................................................................. 118
HEAVY METAL ANTAGONISTS
HEAVY METAL ANTAGONISTS .......................................................................................................................................................... 119
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING
ANDROGENS .................................................................................................................................................................................. 119
ESTROGENS AND ANTIESTROGENS ................................................................................................................................................ 120
GLUCOCORTICOIDS/MINERALOCORTICOIDS ................................................................................................................................ 121
PITUITARY ........................................................................................................................................................................................ 122
PROGESTINS ................................................................................................................................................................................... 123
THYROID AND ANTITHYROID AGENTS ............................................................................................................................................ 123
IMMUNOLOGICAL AGENTS
IMMUNOLOGICAL AGENTS ............................................................................................................................................................ 124
VACCINES ....................................................................................................................................................................................... 127
INFLAMMATORY BOWEL DISEASE AGENTS
INFLAMMATORY BOWEL DISEASE AGENTS ...................................................................................................................................... 130
IRRIGATING SOLUTIONS
IRRIGATING SOLUTIONS ................................................................................................................................................................. 131
METABOLIC BONE DISEASE AGENTS
METABOLIC BONE DISEASE AGENTS ............................................................................................................................................... 131
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS ......................................................................................................................................... 133
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OPHTHALMIC AGENTS
ANTIGLAUCOMA AGENTS............................................................................................................................................................... 136
REPLACEMENT PREPARATIONS
REPLACEMENT PREPARATIONS ......................................................................................................................................................... 137
RESPIRATORY TRACT AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS .................................................................................................................... 140
ANTILEUKOTRIENES......................................................................................................................................................................... 141
BRONCHODILATORS ...................................................................................................................................................................... 141
RESPIRATORY TRACT AGENTS, OTHER ............................................................................................................................................. 143
SKELETAL MUSCLE RELAXANTS
SKELETAL MUSCLE RELAXANTS ......................................................................................................................................................... 143
SLEEP DISORDER AGENTS
SLEEP DISORDER AGENTS ................................................................................................................................................................ 144
VASODILATING AGENTS
VASODILATING AGENTS ................................................................................................................................................................. 145
VITAMINS AND MINERALS
VITAMINS AND MINERALS ................................................................................................................................................................ 145
ANALGESICS
ANALGESICS, MISCELLANEOUS ....................................................................................................................................................... 147
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS ............................................................................................................................. 148
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ............................................................................................................ 149
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ANTIFUNGALS
ANTIFUNGALS ................................................................................................................................................................................. 149
ANTIHISTAMINES
ANTIHISTAMINES ............................................................................................................................................................................. 150
ANTINAUSEA AGENTS
ANTINAUSEA AGENTS ..................................................................................................................................................................... 151
ANTICOAGULANTS ......................................................................................................................................................................... 151
DYSLIPIDEMICS ................................................................................................................................................................................ 151
CENTRAL NERVOUS SYSTEM AGENTS .............................................................................................................................................. 152
CONTRACEPTIVES
CONTRACEPTIVES ........................................................................................................................................................................... 152
COUGH AND COLD PRODUCTS
COUGH AND COLD PRODUCTS ..................................................................................................................................................... 153
DERMATOLOGICAL AGENTS, OTHER .............................................................................................................................................. 154
DERMATOLOGICAL ANTIBACTERIALS ............................................................................................................................................... 155
DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS ......................................................................................................................... 155
SCABICIDES AND PEDICULICIDES .................................................................................................................................................... 155
DEVICES
DEVICES .......................................................................................................................................................................................... 156
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EYE, EAR, NOSE, THROAT AGENTS, MISCELLANEOUS ...................................................................................................................... 157
EYE, EAR, NOSE, THROAT ANTI-INFECTIVES AGENTS ....................................................................................................................... 158
ANTIFLATULENTS ............................................................................................................................................................................. 158
ANTIULCER AGENTS AND ACID SUPPRESSANTS ............................................................................................................................... 158
GASTROINTESTINAL AGENTS, OTHER .............................................................................................................................................. 159
LAXATIVES ....................................................................................................................................................................................... 160
REPLACEMENT PREPARATIONS ......................................................................................................................................................... 161
RESPIRATORY TRACT AGENTS, OTHER ............................................................................................................................................. 162
VITAMINS AND MINERALS ................................................................................................................................................................ 162
INDEX OF DRUGS
..................................................................................................................................................................................................... 167
8
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
ARIPIPRAZOLE
ORAL SOLUTION
900 ML IN 30 DAYS
ABILIFY DISCMELT 10 MG
ARIPIPRAZOLE
TAB RAPDIS
30 TABS IN 30 DAYS
ABILIFY DISCMELT 15 MG
ARIPIPRAZOLE
TAB RAPDIS
60 TABS IN 30 DAYS
ACARBOSE 100 MG
ACARBOSE
TABLET
90 TABS IN 30 DAYS
ACARBOSE 25 MG
ACARBOSE
TABLET
360 TABS IN 30 DAYS
ACARBOSE 50 MG
ACARBOSE
TABLET
180 TABS IN 30 DAYS
ACE AEROSOL CLOUD ENHANCER
INHALER, ASSIST DEVICES
SPACER
2 DEVICE IN 365 DAYS
ACEPHEN 650 MG
ACETAMINOPHEN
SUPP.RECT
30 SUPP IN 30 DAYS
ACETAMINOPHEN 100 MG/ML
ACETAMINOPHEN
ORAL DROPS
30 ML IN 30 DAYS
ACETAMINOPHEN 120 MG
ACETAMINOPHEN
SUPP.RECT
30 SUPP IN 30 DAYS
ACETAMINOPHEN 160 MG/5ML
ACETAMINOPHEN
ELIXIR
240 ML IN 30 DAYS
ACETAMINOPHEN
SUPP.RECT
30 SUPP IN 30 DAYS
ACETAMINOPHEN
SUPP.RECT
60 SUPP IN 30 DAYS
ACETAMINOPHEN 80MG/0.8ML
ACETAMINOPHEN
DROPS SUSP
30 ML IN 30 DAYS
ACETAMINOPHEN-CODEINE
ACETAMINOPHEN WITH CODEINE
TABLET
120 TABS IN 30 DAYS
ACETAMINOPHEN-CODEINE
ACETAMINOPHEN WITH CODEINE
ORAL SOLUTION
1800 ML IN 30 DAYS
ACTONEL 35 MG
RISEDRONATE SODIUM
TABLET
4 TABS IN 28 DAYS
ACTONEL 5 MG
RISEDRONATE SODIUM
TABLET
30 TABS IN 30 DAYS
9
ABILIFY
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
ACYCLOVIR
ACYCLOVIR
TOPICAL OINT.
30 GM IN 30 DAYS
ADVAIR DISKUS
FLUTICASONE/SALMETEROL
INHALATION DISK
60 DISK IN 30 DAYS
ADVAIR HFA
FLUTICASONE/SALMETEROL
AEROSOL
12 GM IN 30 DAYS
ALENDRONATE SODIUM 35MG, 70MG
ALENDRONATE SODIUM
TABLET
4 TABS IN 28 DAYS
ALENDRONATE SODIUM 5MG, 10MG, 40MG
ALENDRONATE SODIUM
TABLET
30 TABS IN 30 DAYS
ALFUZOSIN HCL ER
ALFUZOSIN HCL
TAB ER 24
30 TABS IN 30 DAYS
ALPRAZOLAM 0.25MG, 0.5MG, 1MG
ALPRAZOLAM
TABLET
120 TABS IN 30 DAYS
ALPRAZOLAM 2MG
ALPRAZOLAM
TABLET
90 TABS IN 30 DAYS
AMLODIPINE BESYLATE-BENAZEPRIL '10 MG-20MG,5 MG-20 MG AMLODIPINE BESYLATE/BENAZEPRIL CAPSULE
30 CAPS IN 30 DAYS
AMLODIPINE BESYLATE-BENAZEPRIL 10 MG-40MG, 5 MG-40 MG AMLODIPINE BESYLATE/BENAZEPRIL CAPSULE
30 CAPS IN 30 DAYS
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG, 5 MG-10 MG AMLODIPINE BESYLATE/BENAZEPRIL CAPSULE
30 CAPS IN 30 DAYS
ANORO ELLIPTA
UMECLIDINIUM BRM/VILANTEROL TR
INHALATION DISK
60 DISK IN 30 DAYS
APTIOM 200 MG, 400 MG
ESLICARBAZEPINE ACETATE
TABLET
30 TABS IN 30 DAYS
APTIOM 600 MG
ESLICARBAZEPINE ACETATE
TABLET
60 TABS IN 30 DAYS
ARIPIPRAZOLE 2 MG, 5 MG, 10 MG, 15 MG
ARIPIPRAZOLE
TABLET
30 TABS IN 30 DAYS
ASCOMP WITH CODEINE
CODEINE/BUTALBITAL/ASA/CAFFEIN
CAPSULE
180 CAPS IN 30 DAYS
AVODART
DUTASTERIDE
CAPSULE
30 CAPS IN 30 DAYS
AZELASTINE HCL
AZELASTINE HCL
NASAL SPRAY
30 ML IN 30 DAYS
10
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
RASAGILINE MESYLATE
TABLET
30 TABS IN 30 DAYS
AZITHROMYCIN
AZITHROMYCIN
ORAL SUSP
2 ML IN 30 DAYS
AZITHROMYCIN
AZITHROMYCIN
ORAL SUSP
67.5 ML IN 30 DAYS
AZITHROMYCIN
AZITHROMYCIN
ORAL PACKETS
3 GM IN 30 DAYS
AZITHROMYCIN 250 MG, 500 MG
AZITHROMYCIN
TABLET
6 TABS IN 30 DAYS
AZITHROMYCIN 600 MG
AZITHROMYCIN
TABLET
8 TABS IN 30 DAYS
AZOPT
BRINZOLAMIDE
OPHT SUSP
15 ML IN 30 DAYS
BREATHERITE
SPACER
2 IN 365 DAYS
BREATHRITE
BUPROPION XL 150 MG
BUPROPION HCL
TAB ER 24
30 TABS IN 30 DAYS
BUTALB-CAFF-ACETAMINOPH-CODEIN
BUTALBIT/ACETAMIN/CAFF/CODEINE
CAPSULE
180 CAPS IN 30 DAYS
BUTALBITAL COMPOUND-CODEINE
CODEINE/BUTALBITAL/ASA/CAFFEIN
CAPSULE
120 CAPS IN 30 DAYS
CALCIPOTRIENE
CALCIPOTRIENE
CREAM
60 GM IN 30 DAYS
CALCIPOTRIENE
CALCIPOTRIENE
TOPICAL SOLUTION
60 ML IN 30 DAYS
CARISOPRODOL
CARISOPRODOL
TABLET
90 TABS IN 30 DAYS
CHILDREN'S NON-ASPIRIN 80 MG
ACETAMINOPHEN
TAB CHEW
30 TABS IN 30 DAYS
CHILDREN'S PAIN AND FEVER 160 MG/5ML
ACETAMINOPHEN
ORAL SUSP
240 ML IN 30 DAYS
CHILDREN'S SILAPAP 160 MG/5ML
ACETAMINOPHEN
LIQUID
240 ML IN 30 DAYS
2 IN 365 DAYS
11
AZILECT 0.5 MG
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
CHLORZOXAZONE
CHLORZOXAZONE
TABLET
180 TABS IN 30 DAYS
CLEARLAX 17G/DOSE
POLYETHYLENE GLYCOL 3350
POWDER
527 GM IN 23 DAYS
CLORAZEPATE DIPOTASSIUM 15 MG
CLORAZEPATE DIPOTASSIUM
TABLET
180 TABS IN 30 DAYS
CLORAZEPATE DIPOTASSIUM 3.75 MG, 7.5 MG CLORAZEPATE DIPOTASSIUM
TABLET
120 TABS IN 30 DAYS
CODEINE SULFATE
CODEINE SULFATE
TABLET
120 TABS IN 30 DAYS
COMBIVENT RESPIMAT
IPRATROPIUM/ALBUTEROL SULFATE
AEROSOL
8 GM IN 30 DAYS
COMPACT SPACE CHAMBER PLUS
SPACER
2 IN 365 DAYS
CONDOMS, LATEX, LUBRICATED
CONDOMS, LATEX, LUBRICATED
CYCLOBENZAPRINE HCL
CYCLOBENZAPRINE HCL
TABLET
90 TABS IN 30 DAYS
DIAZEPAM
DIAZEPAM
TABLET
120 TABS IN 30 DAYS
DIAZEPAM
DIAZEPAM
ORAL SOLUTION
1200 ML IN 30 DAYS
DIAZEPAM 2.5 MG
DIAZEPAM
RECTAL KIT
5 UNIT IN 30 DAYS
DIGITEK 125 MCG
DIGOXIN
TABLET
30 TABS IN 30 DAYS
DIGOX 125 MCG
DIGOXIN
TABLET
30 TABS IN 30 DAYS
DORZOLAMIDE HCL
DORZOLAMIDE HCL
OPHT DROPS
10 ML IN 30 DAYS
DORZOLAMIDE-TIMOLOL
DORZOLAMIDE HCL/TIMOLOL MALEAT
OPHT DROPS
10 ML IN 30 DAYS
DOXERCALCIFEROL 0.5 MCG
DOXERCALCIFEROL
CAPSULE
30 CAPS IN 30 DAYS
DOXERCALCIFEROL 1 MCG
DOXERCALCIFEROL
CAPSULE
90 CAPS IN 30 DAYS
24 IN 30 DAYS
12
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
SPACER
2 IN 365 DAYS
EDURANT
RILPIVIRINE HCL
TABLET
30 TABS IN 30 DAYS
ELIDEL
PIMECROLIMUS
CREAM
30 GM IN 30 DAYS
ELLA
ULIPRISTAL ACETATE
TABLET
1 TABS IN 30 DAYS
ENDOCET
OXYCODONE HCL/ACETAMINOPHEN
TABLET
120 TABS IN 30 DAYS
ENDODAN
OXYCODONE HCL/ASPIRIN
TABLET
120 TABS IN 30 DAYS
E-Z SPACER
SPACER
2 IN 365 DAYS
FENTANYL
FENTANYL
PATCH
10 PATCH IN 30 DAYS
FENTANYL CITRATE 1200 MCG
FENTANYL CITRATE
ORAL LOZENGE
120 LOZ IN 30 DAYS
FENTANYL CITRATE
ORAL LOZENGE
120 LOZ IN 30 DAYS
FENTANYL CITRATE 200 MCG, 400 MCG
FENTANYL CITRATE
ORAL LOZENGE
120 LOZ IN 30 DAYS
FENTANYL CITRATE 600 MCG, 800 MCG
FENTANYL CITRATE
ORAL LOZENGE
120 LOZ IN 30 DAYS
FINASTERIDE
FINASTERIDE
TABLET
30 TABS IN 30 DAYS
FORTEO
TERIPARATIDE
INJECTION
3 ML IN 28 DAYS
FYCOMPA 2 MG, 4 MG
PERAMPANEL
TABLET
30 TABS IN 30 DAYS
FYCOMPA 6 MG
PERAMPANEL
TABLET
60 TABS IN 30 DAYS
FYCOMPA 8 MG, 10 MG, 12 MG
PERAMPANEL
TABLET
30 TABS IN 30 DAYS
GLIMEPIRIDE 1 MG
GLIMEPIRIDE
TABLET
240 TABS IN 30 DAYS
13
EASIVENT
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
GLIMEPIRIDE 2 MG
GLIMEPIRIDE
TABLET
120 TABS IN 30 DAYS
GLIMEPIRIDE 4 MG
GLIMEPIRIDE
TABLET
60 TABS IN 30 DAYS
GLIPIZIDE 10 MG
GLIPIZIDE
TABLET
120 TABS IN 30 DAYS
GLIPIZIDE 5 MG
GLIPIZIDE
TABLET
60 TABS IN 30 DAYS
GLIPIZIDE ER 2.5 MG
GLIPIZIDE
TAB ER 24
240 TABS IN 30 DAYS
GLIPIZIDE ER 5 MG
GLIPIZIDE
TAB ER 24
120 TABS IN 30 DAYS
GLIPIZIDE XL
GLIPIZIDE
TAB ER 24
60 TABS IN 30 DAYS
GLIPIZIDE-METFORMIN 2.5-250 MG
GLIPIZIDE/METFORMIN HCL
TABLET
240 TABS IN 30 DAYS
GLIPIZIDE-METFORMIN 2.5-500 MG, 5 MG-500MG GLIPIZIDE/METFORMIN HCL
TABLET
120 TABS IN 30 DAYS
GLUCAGON EMERGENCY KIT
GLUCAGON,HUMAN RECOMBINANT
INJECTION
2 ML IN 30 DAYS
GLYBURIDE 1.25 MG
GLYBURIDE
TABLET
480 TABS IN 30 DAYS
GLYBURIDE 2.5 MG
GLYBURIDE
TABLET
240 TABS IN 30 DAYS
GLYBURIDE 5 MG
GLYBURIDE
TABLET
120 TABS IN 30 DAYS
GLYBURIDE MICRONIZED 1.5 MG
GLYBURIDE,MICRONIZED
TABLET
240 TABS IN 30 DAYS
GLYBURIDE MICRONIZED 3 MG
TABLET
120 TABS IN 30 DAYS
GLYBURIDE MICRONIZED 6 MG
TABLET
60 TABS IN 30 DAYS
GLYBURIDE-METFORMIN HCL 1.25-250MG
GLYBURIDE/METFORMIN HCL
TABLET
240 TABS IN 30 DAYS
TABLET
120 TABS IN 30 DAYS
GLYBURIDE-METFORMIN HCL 2.5-500 MG, 5 MG-500MG GLYBURIDE/METFORMIN HCL
14
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
MIGLITOL
TABLET
90 TABS IN 30 DAYS
GLYSET 25 MG
MIGLITOL
TABLET
360 TABS IN 30 DAYS
GLYSET 50 MG
MIGLITOL
TABLET
180 TABS IN 30 DAYS
HOMATROPAIRE
HOMATROPINE HBR
OPHT DROPS
5 ML IN 30 DAYS
HOMATROPINE HYDROBROMIDE
HOMATROPINE HBR
OPHT DROPS
5 ML IN 30 DAYS
HYDROCODONE-ACETAMINOPHEN
HYDROCODONE/ACETAMINOPHEN
ORAL SOLUTION
1800 ML IN 30 DAYS
HYDROCODONE-ACETAMINOPHEN
TABLET
120 TABS IN 30 DAYS
HYDROCODONE-IBUPROFEN
HYDROCODONE/IBUPROFEN
TABLET
120 TABS IN 30 DAYS
HYDROMORPHONE HCL
HYDROMORPHONE HCL
TABLET
120 TABS IN 30 DAYS
IBANDRONATE SODIUM
IBANDRONATE SODIUM
TABLET
1 TABS IN 30 DAYS
IMIQUIMOD
IMIQUIMOD
CREAM PACK
12 GM IN 30 DAYS
INFANT'S ACETAMINOPHEN 80MG/0.8ML
ACETAMINOPHEN
ORAL DROPS
30 ML IN 30 DAYS
INVEGA 1.5 MG
PALIPERIDONE
TAB ER 24
240 TABS IN 30 DAYS
INVEGA 3 MG
PALIPERIDONE
TAB ER 24
120 TABS IN 30 DAYS
INVEGA 6 MG, 9 MG
PALIPERIDONE
TAB ER 24
60 TABS IN 30 DAYS
INVIRASE
SAQUINAVIR MESYLATE
CAPSULE
300 CAPS IN 30 DAYS
ISENTRESS
RALTEGRAVIR POTASSIUM
ORAL PACKETS
300 GM IN 30 DAYS
ISENTRESS 100 MG
TAB CHEW
180 TABS IN 30 DAYS
15
GLYSET 100 MG
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
ISENTRESS 25 MG
TAB CHEW
120 TABS IN 30 DAYS
JANUMET
SITAGLIPTIN PHOS/METFORMIN HCL
TABLET
60 TABS IN 30 DAYS
JANUMET XR 50-1000 MG, 100-1000MG
TAB SR 24H
60 TABS IN 30 DAYS
JANUMET XR 50MG-500MG
TAB SR 24H
30 TABS IN 30 DAYS
JANUVIA
SITAGLIPTIN PHOSPHATE
TABLET
30 TABS IN 30 DAYS
JENTADUETO
LINAGLIPTIN/METFORMIN HCL
TABLET
60 TABS IN 30 DAYS
KETOROLAC TROMETHAMINE
TABLET
20 TABS IN 30 DAYS
INJECTION
20 ML IN 30 DAYS
LAZANDA
FENTANYL CITRATE
NASAL SPRAY
75 ML IN 30 DAYS
LEVETIRACETAM ER 500 MG
LEVETIRACETAM
TAB ER 24
180 TABS IN 30 DAYS
LEVETIRACETAM ER 750 MG
LEVETIRACETAM
TAB ER 24
120 TABS IN 30 DAYS
LITEAIRE
SPACER
2 IN 365 DAYS
LORAZEPAM
LORAZEPAM
TABLET
120 TABS IN 30 DAYS
LORCET
TABLET
120 TABS IN 30 DAYS
LORCET HD
TABLET
120 TABS IN 30 DAYS
LORCET PLUS
TABLET
120 TABS IN 30 DAYS
MAPAP 325 MG
ACETAMINOPHEN
TABLET
60 TABS IN 30 DAYS
MAPAP 500 MG
ACETAMINOPHEN
CAPSULE
60 CAPS IN 30 DAYS
16
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
ACETAMINOPHEN
TABLET
60 TABS IN 30 DAYS
MAPAP 500MG/15ML
ACETAMINOPHEN
LIQUID
120 ML IN 30 DAYS
MEPERIDINE HCL
MEPERIDINE HCL
ORAL SOLUTION
600 ML IN 30 DAYS
MEPERIDINE HCL
MEPERIDINE HCL
TABLET
120 TABS IN 30 DAYS
MEPERITAB
MEPERIDINE HCL
TABLET
120 TABS IN 30 DAYS
METFORMIN HCL 1000 MG
METFORMIN HCL
TABLET
60 TABS IN 30 DAYS
METFORMIN HCL
TABLET
150 TABS IN 30 DAYS
METFORMIN HCL
TABLET
90 TABS IN 30 DAYS
METFORMIN HCL ER 500 MG
METFORMIN HCL
TAB ER 24
120 TABS IN 30 DAYS
METFORMIN HCL ER 750 MG, 1000 MG
METFORMIN HCL
TAB ER 24
60 TABS IN 30 DAYS
METHADONE HCL
METHADONE HCL
ORAL SOLUTION
1800 ML IN 30 DAYS
METHADONE HCL
METHADONE HCL
TABLET
120 TABS IN 30 DAYS
METHADONE INTENSOL
METHADONE HCL
ORAL CONC
1800 ML IN 30 DAYS
METHADOSE
METHADONE HCL
TAB DISPER
120 TABS IN 30 DAYS
METHOCARBAMOL 500 MG
METHOCARBAMOL
TABLET
240 TABS IN 30 DAYS
METHOCARBAMOL 750 MG
METHOCARBAMOL
TABLET
180 TABS IN 30 DAYS
METOPROLOL SUCCINATE 100 MG
METOPROLOL SUCCINATE
TAB ER 24
30 TABS IN 30 DAYS
METOPROLOL SUCCINATE 200 MG
TAB ER 24
60 TABS IN 30 DAYS
17
MAPAP 500 MG
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
METOPROLOL SUCCINATE 25 MG, 50 MG
TAB ER 24
30 TABS IN 30 DAYS
MICROCHAMBER
SPACER
2 IN 365 DAYS
MICROSPACER
SPACER
2 IN 365 DAYS
MORPHINE SULFATE
MORPHINE SULFATE
ORAL SOLUTION
1800 ML IN 30 DAYS
MORPHINE SULFATE
MORPHINE SULFATE
TABLET
120 TABS IN 30 DAYS
MORPHINE SULFATE
MORPHINE SULFATE
RECTAL SUPP
120 SUPP IN 30 DAYS
MORPHINE SULFATE ER
MORPHINE SULFATE
TAB ER
90 TABS IN 30 DAYS
MUPIROCIN
MUPIROCIN
TOPICAL OINT.
22 GM IN 30 DAYS
NAMENDA XR
MEMANTINE HCL
CAP D SPK
30 CAPS IN 30 DAYS
NAMENDA XR
MEMANTINE HCL
CAP SPR 24
30 CAPS IN 30 DAYS
NESSI SPACER
SPACER
2 IN 365 DAYS
OLANZAPINE 15 MG
OLANZAPINE
TABLET
30 TABS IN 30 DAYS
OLANZAPINE 2.5 MG , 5 MG
OLANZAPINE
TABLET
30 TABS IN 30 DAYS
OLANZAPINE 20 MG
OLANZAPINE
TABLET
30 TABS IN 30 DAYS
OLANZAPINE 7.5 MG, 10 MG
OLANZAPINE
TABLET
30 TABS IN 30 DAYS
OLANZAPINE ODT
OLANZAPINE
TAB RAPDIS
30 TABS IN 30 DAYS
OMEPRAZOLE 10 MG, 20 MG
OMEPRAZOLE
CAPSULE CR
60 CAPS IN 30 DAYS
OMEPRAZOLE 40 MG
OMEPRAZOLE
CAPSULE CR
30 CAPS IN 30 DAYS
18
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
INHALER,ASSIST DEVICE,ACCESORY
SPACER
2 IN 365 DAYS
OPTICHAMBER
SPACER
2 DEVICE IN 365 DAYS
ORALYTE
ELECTROLYTE,ORAL
SOLUTION
4000 ML IN 15 DAYS
OXYCODONE HCL
OXYCODONE HCL
ORAL CONC
250 ML IN 30 DAYS
OXYCODONE HCL
OXYCODONE HCL
ORAL SOLUTION
250 ML IN 30 DAYS
OXYCODONE HCL
OXYCODONE HCL
TABLET
120 TABS IN 30 DAYS
OXYCODONE HCL
OXYCODONE HCL
CAPSULE
120 CAPS IN 30 DAYS
OXYCODONE HCL ER
OXYCODONE HCL
TAB ER 12H
60 TABS IN 30 DAYS
OXYCODONE HCL-ASPIRIN
OXYCODONE HCL/ASPIRIN
TABLET
120 TABS IN 30 DAYS
OXYCODONE-ACETAMINOPHEN
TABLET
120 TABS IN 30 DAYS
OXYCONTIN 10 MG, 15 MG
OXYCODONE HCL
TAB ER 12H
60 TABS IN 30 DAYS
OXYCODONE HCL
TAB ER 12H
60 TABS IN 30 DAYS
OXYCODONE HCL
TAB ER 12H
60 TABS IN 30 DAYS
PAIN RELIEVER JUNIOR STRENGTH 160 MG
ACETAMINOPHEN
TAB CHEW
30 TABS IN 30 DAYS
PEG 3350-ELECTROLYTE
PEG 3350/NA SULF,BICARB,CL/KCL
ORAL SOLUTION
4000 ML IN 30 DAYS
PEG-3350
SODIUM CHLORIDE/NAHCO3/KCL/PEG
ORAL SOLUTION
4000 ML IN 30 DAYS
PENTASA
MESALAMINE
ER CAPSULE
480 CAPS IN 30 DAYS
PHENYLEPHRINE HCL
PHENYLEPHRINE HCL
OPHT DROPS
15 ML IN 30 DAYS
19
OPTICHAMBER
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
PIOGLITAZONE HCL
PIOGLITAZONE HCL
TABLET
30 TABS IN 30 DAYS
POLYETHYLENE GLYCOL 3350 17G
POLYETHYLENE GLYCOL 3350
POWD PACK
527 GM IN 23 DAYS
POTIGA 50 MG
EZOGABINE
TABLET
270 TABS IN 30 DAYS
PREZISTA
DARUNAVIR ETHANOLATE
ORAL SUSP
360 ML IN 30 DAYS
PREZISTA 75 MG
DARUNAVIR ETHANOLATE
TABLET
60 TABS IN 30 DAYS
PRIMEAIRE
SPACER
2 IN 365 DAYS
PROAIR HFA
ALBUTEROL SULFATE
AEROSOL
17 GM IN 30 DAYS
PROAIR RESPICLICK
ALBUTEROL SULFATE
AEROSOL
1 AEROSOL IN 30 DAYS
PROMETHAZINE-CODEINE 6.25-10/5
PROMETHAZINE HCL/CODEINE
SYRUP
240 ML IN 30 DAYS
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE
TABLET
90 TABS IN 30 DAYS
RALOXIFENE HCL
RALOXIFENE HCL
TABLET
30 TABS IN 30 DAYS
REGRANEX
BECAPLERMIN
TOPICAL GEL
15 GM IN 30 DAYS
RELENZA
ZANAMIVIR
INHALATION DISK
56 DISK IN 180 DAYS
REPREXAIN
HYDROCODONE/IBUPROFEN
TABLET
120 TABS IN 30 DAYS
RESTASIS
CYCLOSPORINE
OPHT DROPS
64 ML IN 30 DAYS
RISEDRONATE SODIUM 35 MG, 150 MG
RISEDRONATE SODIUM
TABLET
1 TABS IN 30 DAYS
RISEDRONATE SODIUM 5 MG, 30 MG
RISEDRONATE SODIUM
TABLET
1 TABS IN 30 DAYS
RISEDRONATE SODIUM DR
RISEDRONATE SODIUM
TABLET DR
4 TABS IN 28 DAYS
20
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
RISPERIDONE
TABLET
60 TABS IN 30 DAYS
RISPERIDONE
RISPERIDONE
TAB RAPDIS
60 TABS IN 30 DAYS
RISPERIDONE
RISPERIDONE
ORAL SOLUTION
240 ML IN 30 DAYS
RISPERIDONE ODT
RISPERIDONE
TAB RAPDIS
60 TABS IN 30 DAYS
RITEFLO
SPACER
2 IN 365 DAYS
RIZATRIPTAN
RIZATRIPTAN BENZOATE
TAB RAPDIS
12 TABS IN 30 DAYS
RIZATRIPTAN
RIZATRIPTAN BENZOATE
TABLET
12 TABS IN 30 DAYS
ROXICET
TABLET
120 TABS IN 30 DAYS
SENSIPAR 30 MG
CINACALCET HCL
TABLET
30 TABS IN 30 DAYS
SIROLIMUS 0.5 MG
SIROLIMUS
TABLET
30 TABS IN 30 DAYS
SPACE CHAMBER PLUS
SPACER
2 IN 365 DAYS
SPIRIVA
TIOTROPIUM BROMIDE
INHALATION CAPSULE
30 CAPS IN 30 DAYS
SPIRIVA RESPIMAT
TIOTROPIUM BROMIDE
AEROSOL
4 GM IN 30 DAYS
SUMATRIPTAN
SUMATRIPTAN
NASAL SPRAY
9 ML IN 30 DAYS
SUMATRIPTAN SUCCINATE
INJECTION
4 ML IN 30 DAYS
TABLET
9 TABS IN 30 DAYS
TAMIFLU 30 MG
OSELTAMIVIR PHOSPHATE
CAPSULE
56 CAPS IN 180 DAYS
TAMIFLU 45 MG, 75 MG
CAPSULE
28 CAPS IN 180 DAYS
21
RISPERIDONE
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
TAMIFLU 6 MG/ML
ORAL SUSP
360 ML IN 180 DAYS
TAMSULOSIN HCL
TAMSULOSIN HCL
CAP.ER 24H
60 CAPS IN 30 DAYS
TEMAZEPAM
TEMAZEPAM
CAPSULE
30 CAPS IN 30 DAYS
TOLAZAMIDE
TOLAZAMIDE
TABLET
60 TABS IN 30 DAYS
TOLBUTAMIDE
TOLBUTAMIDE
TABLET
180 TABS IN 30 DAYS
TOLTERODINE TARTRATE
TABLET
60 TABS IN 30 DAYS
TOLTERODINE TARTRATE ER
CAP.ER 24H
30 CAPS IN 30 DAYS
TRADJENTA
LINAGLIPTIN
TABLET
30 TABS IN 30 DAYS
TRAMADOL HCL
TRAMADOL HCL
TABLET
240 TABS IN 30 DAYS
TRAMADOL HCL-ACETAMINOPHEN
TRAMADOL HCL/ACETAMINOPHEN
TABLET
240 TABS IN 30 DAYS
TRAVATAN Z
TRAVOPROST
OPHT DROPS
5 ML IN 30 DAYS
TRAVOPROST
TRAVOPROST (BENZALKONIUM)
OPHT DROPS
5 ML IN 30 DAYS
TRIAZOLAM
TRIAZOLAM
TABLET
30 TABS IN 30 DAYS
TROKENDI XR 100 MG
TOPIRAMATE
CAP.ER 24H
90 CAPS IN 30 DAYS
TROKENDI XR 200 MG
TOPIRAMATE
CAP.ER 24H
240 CAPS IN 30 DAYS
TROKENDI XR 25 MG, 50 MG
TOPIRAMATE
CAP.ER 24H
90 CAPS IN 30 DAYS
VENTOLIN HFA
ALBUTEROL SULFATE
AEROSOL
36 GM IN 30 DAYS
VIMPAT
LACOSAMIDE
INTRAVENOUS (IV)
200 ML IN 5 DAYS
22
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
SPACER
2 IN 365 DAYS
VORTEX FROG MASK
SPACER
2 IN 365 DAYS
VORTEX LADYBUG MASK
SPACER
2 IN 365 DAYS
VORTEX VHC FROG MASK
SPACER
2 IN 365 DAYS
WATCHHALER
SPACER
2 IN 365 DAYS
ZAFIRLUKAST
ZAFIRLUKAST
TABLET
60 TABS IN 30 DAYS
ZIPRASIDONE HCL 20 MG, 40 MG
ZIPRASIDONE HCL
CAPSULE
60 CAPS IN 30 DAYS
ZIPRASIDONE HCL 60 MG, 80 MG
ZIPRASIDONE HCL
CAPSULE
120 CAPS IN 30 DAYS
ZMAX
AZITHROMYCIN
ORAL SUSP
60 ML IN 30 DAYS
ZOLPIDEM TARTRATE
ZOLPIDEM TARTRATE
TABLET
30 TABS IN 30 DAYS
ZOVIRAX
ACYCLOVIR
CREAM
10 GM IN 30 DAYS
23
VORTEX
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
COST YOU (TIER LEVEL)
NECESSARY ACTIONS,
RESTRICTIONS/LIMITS ON USE
ANALGESICS
ANALGESICS, MISCELLANEOUS
Acetaminophen With Codeine
TABLET
($0.00 - $2.95) Tier 1
QL
Acetaminophen-Codeine
Acetaminophen With Codeine
ORAL SOLUTION
($0.00 - $2.95) Tier 1
QL
Ascomp With Codeine
Codeine/Butalbital/Asa/Caffein
CAPSULE
($0.00 - $2.95) Tier 1
QL
Butalb-Caff-Acetaminoph-Codein
Butalbit/Acetamin/Caff/Codeine
CAPSULE
($0.00 - $2.95) Tier 1
PA, QL
Butalbital Compound-Codeine
Codeine/Butalbital/Asa/Caffein
CAPSULE
($0.00 - $2.95) Tier 1
QL
Codeine Sulfate
Codeine Sulfate
TABLET
($0.00 - $2.95) Tier 1
QL
Endocet
Oxycodone Hcl/Acetaminophen
TABLET
($0.00 - $2.95) Tier 1
QL
Endodan
Oxycodone Hcl/Aspirin
TABLET
($0.00 - $2.95) Tier 1
QL
Fentanyl
Fentanyl
PATCH
($0.00 - $2.95) Tier 1
QL,ST
Fentanyl Citrate
ORAL LOZENGE
($0.00 - $7.40) Tier 2
PA, QL
Fentanyl Citrate
ORAL LOZENGE
($0.00 - $7.40) Tier 2
PA, QL
FENTANYL CITRATE 200 MCG, 400 MCG Fentanyl Citrate
ORAL LOZENGE
($0.00 - $7.40) Tier 2
PA, QL
FENTANYL CITRATE 600 MCG, 800 MCG Fentanyl Citrate
ORAL LOZENGE
($0.00 - $7.40) Tier 2
PA, QL
Hydrocodone-Acetaminophen
Hydrocodone/Acetaminophen
TABLET
($0.00 - $2.95) Tier 1
QL
Hydrocodone-Acetaminophen
ORAL SOLUTION
($0.00 - $2.95) Tier 1
QL
PART D DRUGS
Acetaminophen-Codeine
(You can find information on what the symbols and abbreviations in this table mean by going to pages x-xi and reading the explanation provided in the legends).
25
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Hydrocodone-Ibuprofen
Hydrocodone/Ibuprofen
TABLET
($0.00 - $2.95) Tier 1
QL
Hydromorphone Hcl
Hydromorphone Hcl
TABLET
($0.00 - $2.95) Tier 1
QL
Hydromorphone Hcl
Hydromorphone Hcl
INJECTION
($0.00 - $2.95) Tier 1
BvD
LAZANDA
Fentanyl Citrate
NASAL SPRAY
($0.00 - $7.40) Tier 2
PA, QL
Lorcet
TABLET
($0.00 - $2.95) Tier 1
QL
Lorcet Hd
TABLET
($0.00 - $2.95) Tier 1
QL
Lorcet Plus
TABLET
($0.00 - $2.95) Tier 1
QL
Meperidine Hcl
Meperidine Hcl
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
Meperidine Hcl
Meperidine Hcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
Meperitab
Meperidine Hcl
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
Methadone Hcl
Methadone Hcl
TABLET
($0.00 - $2.95) Tier 1
QL
Methadone Hcl
Methadone Hcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
QL
Methadone Hcl
Methadone Hcl
INJECTION
($0.00 - $2.95) Tier 1
BvD
Methadone Intensol
Methadone Hcl
ORAL CONC
($0.00 - $2.95) Tier 1
QL
Methadose
Methadone Hcl
TAB DISPER
($0.00 - $2.95) Tier 1
QL
Morphine Sulfate
Morphine Sulfate
RECTAL SUPP
($0.00 - $2.95) Tier 1
QL
Morphine Sulfate
Morphine Sulfate
INJECTION
($0.00 - $2.95) Tier 1
BvD
26
WHAT THE DRUG WILL
NECESSARY ACTIONS,
GENERIC DRUG NAME
Morphine Sulfate
Morphine Sulfate
ORAL SOLUTION
($0.00 - $2.95) Tier 1
QL
Morphine Sulfate
Morphine Sulfate
TABLET
($0.00 - $2.95) Tier 1
QL
Morphine Sulfate Er
Morphine Sulfate
TAB ER
($0.00 - $2.95) Tier 1
QL
Oxycodone Hcl
Oxycodone Hcl
TABLET
($0.00 - $2.95) Tier 1
QL
Oxycodone Hcl
Oxycodone Hcl
ORAL CONC
($0.00 - $2.95) Tier 1
QL
Oxycodone Hcl
Oxycodone Hcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
QL
Oxycodone Hcl
Oxycodone Hcl
CAPSULE
($0.00 - $2.95) Tier 1
QL
OXYCODONE HCL ER
Oxycodone Hcl
TAB ER 12H
($0.00 - $7.40) Tier 2
PA, QL
Oxycodone Hcl-Aspirin
Oxycodone Hcl/Aspirin
TABLET
($0.00 - $2.95) Tier 1
QL
Oxycodone-Acetaminophen
TABLET
($0.00 - $2.95) Tier 1
QL
Oxycodone Hcl
TAB ER 12H
($0.00 - $7.40) Tier 2
PA, QL
Oxycodone Hcl
TAB ER 12H
($0.00 - $7.40) Tier 2
PA, QL
Oxycodone Hcl
TAB ER 12H
($0.00 - $7.40) Tier 2
PA, QL
Reprexain
Hydrocodone/Ibuprofen
TABLET
($0.00 - $2.95) Tier 1
QL
Roxicet
TABLET
($0.00 - $2.95) Tier 1
QL
Tramadol Hcl
Tramadol Hcl
TABLET
($0.00 - $2.95) Tier 1
QL
Tramadol Hcl-Acetaminophen
Tramadol Hcl/Acetaminophen
TABLET
($0.00 - $2.95) Tier 1
QL
FORMULATION
PART D DRUGS
BRAND DRUG NAME
27
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
PART D DRUGS
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
+Celecoxib
Celecoxib
CAPSULE
($0.00 - $2.95) Tier 1
PA +Choline Mag Trisalicylate
Choline Sal/Mag Salicylate
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Diclofenac Potassium
Diclofenac Potassium
TABLET
($0.00 - $2.95) Tier 1
+Diclofenac Sodium
Diclofenac Sodium
TABLET DR
($0.00 - $2.95) Tier 1
DICLOFENAC SODIUM
Diclofenac Sodium
TOPICAL GEL
($0.00 - $7.40) Tier 2
PA +Diclofenac Sodium Er
Diclofenac Sodium
TAB ER 24
($0.00 - $2.95) Tier 1
+Diflunisal
Diflunisal
TABLET
($0.00 - $2.95) Tier 1
+Etodolac
Etodolac
TABLET
($0.00 - $2.95) Tier 1
+Etodolac
Etodolac
CAPSULE
($0.00 - $2.95) Tier 1
+Etodolac Er
Etodolac
TAB ER 24
($0.00 - $2.95) Tier 1
+Fenoprofen Calcium
Fenoprofen Calcium
TABLET
($0.00 - $2.95) Tier 1
+Flurbiprofen
Flurbiprofen
TABLET
($0.00 - $2.95) Tier 1
+Ibuprofen
Ibuprofen
TABLET
($0.00 - $2.95) Tier 1
Indomethacin
Indomethacin
CAPSULE
($0.00 - $2.95) Tier 1
PA>65 y/o Indomethacin
Indomethacin
ER CAPSULE
($0.00 - $2.95) Tier 1
PA>65 y/o
+Ketoprofen
Ketoprofen
CAPSULE
($0.00 - $2.95) Tier 1
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies.
For more information call Care1st Cal MediConnect Plan Member Services.
28
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Ketoprofen
CAP24H PEL
($0.00 - $2.95) Tier 1
Ketorolac Tromethamine
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
INJECTION
($0.00 - $2.95) Tier 1
BvD,QL
+Meclofenamate Sodium
Meclofenamate Sodium
CAPSULE
($0.00 - $2.95) Tier 1
+Meloxicam
Meloxicam
TABLET
($0.00 - $2.95) Tier 1
+Nabumetone
Nabumetone
TABLET
($0.00 - $2.95) Tier 1
+Naproxen
Naproxen
TABLET
($0.00 - $2.95) Tier 1
+Naproxen
Naproxen
ORAL SUSP
($0.00 - $2.95) Tier 1
+Naproxen
Naproxen
TABLET DR
($0.00 - $2.95) Tier 1
+Naproxen Sodium
Naproxen Sodium
TABLET
($0.00 - $2.95) Tier 1
+Oxaprozin
Oxaprozin
TABLET
($0.00 - $2.95) Tier 1
+Piroxicam
Piroxicam
CAPSULE
($0.00 - $2.95) Tier 1
+Sulindac
Sulindac
TABLET
($0.00 - $2.95) Tier 1
+Tolmetin Sodium
Tolmetin Sodium
CAPSULE
($0.00 - $2.95) Tier 1
+Tolmetin Sodium
Tolmetin Sodium
TABLET
($0.00 - $2.95) Tier 1
+VOLTAREN
Diclofenac Sodium
TOPICAL GEL
($0.00 - $7.40) Tier 2
PART D DRUGS
+Ketoprofen
PA
29
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
ANESTHETICS
PART D DRUGS
LOCAL ANESTHETICS
Lidocaine
Lidocaine
TOPICAL OINT.
($0.00 - $2.95) Tier 1
BvD
LIDOCAINE
Lidocaine
PATCH
($0.00 - $7.40) Tier 2
PA
+Lidocaine Hcl
Lidocaine Hcl
TOPICAL GEL
($0.00 - $2.95) Tier 1
Lidocaine Hcl
Lidocaine Hcl
INJECTION
($0.00 - $2.95) Tier 1
+Lidocaine Hcl
Lidocaine Hcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Lidocaine Hcl Viscous
Lidocaine Hcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
Lidocaine-Prilocaine
Lidocaine/Prilocaine
CREAM
($0.00 - $2.95) Tier 1
BvD
BvD, PA
+ACAMPROSATE CALCIUM
Acamprosate Calcium
TABLET DR
($0.00 - $7.40) Tier 2
BUPRENORPHINE HCL
Buprenorphine Hcl
TAB SUBL
($0.00 - $7.40) Tier 2
PA BUPRENORPHINE-NALOXONE
Buprenorphine Hcl/Naloxone Hcl
TAB SUBL
($0.00 - $7.40) Tier 2
PA CHANTIX
Varenicline Tartrate
TABLET
($0.00 - $7.40) Tier 2
PA +Depade
Naltrexone Hcl
TABLET
($0.00 - $2.95) Tier 1
30
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Disulfiram
Disulfiram
TABLET
($0.00 - $2.95) Tier 1
NALOXONE HCL
Naloxone Hcl
INJECTION
($0.00 - $7.40) Tier 2
+Naltrexone Hcl
Naltrexone Hcl
TABLET
($0.00 - $2.95) Tier 1
NICOTROL
Nicotine
INHALATION CARTRIDGE ($0.00 - $7.40) Tier 2
PA
NICOTROL NS
Nicotine
NASAL SPRAY
($0.00 - $7.40) Tier 2
PA
SUBOXONE
Buprenorphine Hcl/Naloxone Hcl
SUBLINGUAL FILM
($0.00 - $7.40) Tier 2
PA
Alprazolam 0.25Mg, 0.5Mg, 1Mg
Alprazolam
TABLET
($0.00 - $2.95) Tier 1
QL Alprazolam 2Mg
Alprazolam
TABLET
($0.00 - $2.95) Tier 1
QL +Clonazepam
Clonazepam
TAB RAPDIS
($0.00 - $2.95) Tier 1
+Clonazepam
Clonazepam
TABLET
($0.00 - $2.95) Tier 1
Clorazepate Dipotassium 15 Mg
Clorazepate Dipotassium
TABLET
($0.00 - $2.95) Tier 1
QL Clorazepate Dipotassium 3.75 Mg, 7.5 Mg Clorazepate Dipotassium
TABLET
($0.00 - $2.95) Tier 1
QL Diazepam
Diazepam
ORAL SOLUTION
($0.00 - $2.95) Tier 1
QL Diazepam
Diazepam
TABLET
($0.00 - $2.95) Tier 1
QL
+Diazepam 12.5-15-20
Diazepam
RECTAL KIT
($0.00 - $2.95) Tier 1
BvD
ANTIANXIETY AGENTS
BENZODIAZEPINES
PART D DRUGS
31
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Diazepam 2.5 Mg
Diazepam
RECTAL KIT
($0.00 - $2.95) Tier 1
QL
+Diazepam 5-7.5-10Mg
Diazepam
RECTAL KIT
($0.00 - $2.95) Tier 1
Lorazepam
Lorazepam
TABLET
($0.00 - $2.95) Tier 1
QL
Temazepam
Temazepam
CAPSULE
($0.00 - $2.95) Tier 1
QL
Triazolam
Triazolam
TABLET
($0.00 - $2.95) Tier 1
QL
Amikacin Sulfate
Amikacin Sulfate
INJECTION
($0.00 - $2.95) Tier 1
BvD
Gentamicin Sulfate
Gentamicin Sulfate
INJECTION
($0.00 - $2.95) Tier 1
BvD
+Neomycin Sulfate
Neomycin Sulfate
TABLET
($0.00 - $2.95) Tier 1
Streptomycin Sulfate
Streptomycin Sulfate
INJECTION
($0.00 - $2.95) Tier 1
BvD
+TOBRAMYCIN
Tobramycin In 0.225% Nacl
INHALATION SOLN
($0.00 - $7.40) Tier 2
BvD, PA
Tobramycin Sulfate
Tobramycin Sulfate
INJECTION
($0.00 - $2.95) Tier 1
BvD
CHLORAMPHENICOL SOD SUCCINATE Chloramphenicol Sod Succ
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD +Clindamycin Hcl
CAPSULE
($0.00 - $2.95) Tier 1
ANTIBACTERIALS
PART D DRUGS
AMINOGLYCOSIDES
ANTIBACTERIALS, MISCELLANEOUS
Clindamycin Hcl
32
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Clindamycin Phosphate
INJECTION
($0.00 - $2.95) Tier 1
BvD
+Colistimethate
Colistin (Colistimethate Na)
INJECTION
($0.00 - $2.95) Tier 1
CUBICIN
Daptomycin
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
LINEZOLID
Linezolid
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
PA
+Methenamine Hippurate
Methenamine Hippurate
TABLET
($0.00 - $2.95) Tier 1
+Metronidazole
Metronidazole
TABLET
($0.00 - $2.95) Tier 1
Metronidazole
Metronidazole/Sodium Chloride
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
Nitrofurantoin
Nitrofurantoin Macrocrystal
CAPSULE
($0.00 - $2.95) Tier 1
PA>65 y/o
Nitrofurantoin
Nitrofurantoin Macrocrystal
CAPSULE
($0.00 - $2.95) Tier 1
PA>65 y/o
Nitrofurantoin Mono-Macro
Nitrofurantoin Monohyd/M-Cryst
CAPSULE
($0.00 - $2.95) Tier 1
PA>65 y/o
SIVEXTRO
Tedizolid Phosphate
TABLET
($0.00 - $7.40) Tier 2
PA
SIVEXTRO
Tedizolid Phosphate
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
SYNERCID
Quinupristin/Dalfopristin
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
Trimethoprim
Trimethoprim
TABLET
($0.00 - $2.95) Tier 1
Vancomycin Hcl
Vancomycin Hcl
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
VANCOMYCIN HCL
Vancomycin Hcl
CAPSULE
($0.00 - $7.40) Tier 2
ZYVOX
Linezolid
TABLET
($0.00 - $7.40) Tier 2
PART D DRUGS
BvD
PA
33
BRAND DRUG NAME
ZYVOX
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Linezolid
ORAL SUSP
($0.00 - $7.40) Tier 2
PA
+Cefaclor
Cefaclor
CAPSULE
($0.00 - $2.95) Tier 1
+Cefaclor
Cefaclor
ORAL SUSP
($0.00 - $2.95) Tier 1
+Cefaclor Er
Cefaclor
TAB ER 12H
($0.00 - $2.95) Tier 1
+Cefadroxil
Cefadroxil
TABLET
($0.00 - $2.95) Tier 1
+Cefadroxil
Cefadroxil
ORAL SUSP
($0.00 - $2.95) Tier 1
+Cefadroxil
Cefadroxil
CAPSULE
($0.00 - $2.95) Tier 1
Cefazolin
Cefazolin Sodium/Dextrose,Iso
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD Cefazolin Sodium
Cefazolin Sodium
INJECTION
($0.00 - $2.95) Tier 1
BvD +Cefdinir
Cefdinir
CAPSULE
($0.00 - $2.95) Tier 1
Cefepime Hcl
Cefepime Hcl
INJECTION
($0.00 - $2.95) Tier 1
BvD Cefotaxime Sodium
Cefotaxime Sodium
INJECTION
($0.00 - $2.95) Tier 1
BvD +Cefpodoxime Proxetil
Cefpodoxime Proxetil
ORAL SUSP
($0.00 - $2.95) Tier 1
+Cefpodoxime Proxetil
Cefpodoxime Proxetil
TABLET
($0.00 - $2.95) Tier 1
+Cefprozil
Cefprozil
ORAL SUSP
($0.00 - $2.95) Tier 1
+Cefprozil
Cefprozil
TABLET
($0.00 - $2.95) Tier 1
PART D DRUGS
CEPHALOSPORINS
34
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Ceftazidime In Dextrose5%Water
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
Ceftazidime
Ceftazidime
INJECTION
($0.00 - $2.95) Tier 1
BvD
Ceftriaxone
Ceftriaxone Na/Dextrose,Iso
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
Ceftriaxone
Ceftriaxone Sodium
INJECTION
($0.00 - $2.95) Tier 1
BvD
+Cefuroxime
Cefuroxime Axetil
TABLET
($0.00 - $2.95) Tier 1
Cefuroxime Sodium
Cefuroxime Sodium
INJECTION
($0.00 - $2.95) Tier 1
BvD
Cefuroxime Sodium
Cefuroxime Sodium
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
+Cephalexin
Cephalexin
CAPSULE
($0.00 - $2.95) Tier 1
+Cephalexin
Cephalexin
ORAL SUSP
($0.00 - $2.95) Tier 1
+Cephalexin
Cephalexin
TABLET
($0.00 - $2.95) Tier 1
FORTAZ IN ISO-OSMOTIC DEXTROSE Ceftazidime Na/Dextrose,Iso
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
Tazicef
Ceftazidime
INJECTION
($0.00 - $2.95) Tier 1
BvD
Tazicef
Ceftazidime
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
TEFLARO
Ceftaroline Fosamil Acetate
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
Azithromycin
Azithromycin
ORAL PACKETS
($0.00 - $2.95) Tier 1
QL Azithromycin
Azithromycin
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
PART D DRUGS
CEFTAZIDIME
MACROLIDES
35
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Azithromycin
Azithromycin
ORAL SUSP
($0.00 - $2.95) Tier 1
QL
Azithromycin
Azithromycin
ORAL SUSP
($0.00 - $2.95) Tier 1
QL
Azithromycin 250 Mg, 500 Mg
Azithromycin
TABLET
($0.00 - $2.95) Tier 1
QL
Azithromycin 600 Mg
Azithromycin
TABLET
($0.00 - $2.95) Tier 1
QL
+Clarithromycin
Clarithromycin
ORAL SUSP
($0.00 - $2.95) Tier 1
+Clarithromycin
Clarithromycin
TABLET
($0.00 - $2.95) Tier 1
+Clarithromycin Er
Clarithromycin
TAB ER 24
($0.00 - $2.95) Tier 1
+E.E.S. 400
Erythromycin Ethylsuccinate
TABLET
($0.00 - $2.95) Tier 1
ERYTHROCIN LACTOBIONATE
Erythromycin Lactobionate
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
+Erythrocin Stearate
Erythromycin Stearate
TABLET
($0.00 - $2.95) Tier 1
+Erythromycin
Erythromycin Base
CAPSULE CR
($0.00 - $2.95) Tier 1
+Erythromycin
Erythromycin Base
TABLET
($0.00 - $2.95) Tier 1
+Erythromycin Ethylsuccinate
Erythromycin Ethylsuccinate
TABLET
($0.00 - $2.95) Tier 1
KETEK
Telithromycin
TABLET
($0.00 - $7.40) Tier 2
ST
ZMAX
Azithromycin
ORAL SUSP
($0.00 - $7.40) Tier 2
QL
INJECTION
($0.00 - $2.95) Tier 1
BvD
BvD
MISCELLANEOUS B-LACTAM ANTIBIOTICS
Aztreonam
Aztreonam
36
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
CAYSTON
Aztreonam Lysine
INHALATION SOLN
($0.00 - $7.40) Tier 2
BvD, PA
Imipenem-Cilastatin Sodium
Imipenem/Cilastatin Sodium
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
INVANZ
Ertapenem Sodium
INJECTION
($0.00 - $7.40) Tier 2
BvD
MEROPENEM
Meropenem
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+Amox Tr-Potassium Clavulanate
Amoxicillin/Potassium Clav
ORAL SUSP
($0.00 - $2.95) Tier 1
TAB CHEW
($0.00 - $2.95) Tier 1
TABLET
($0.00 - $2.95) Tier 1
+Amoxicillin
Amoxicillin
TABLET
($0.00 - $2.95) Tier 1
+Amoxicillin
Amoxicillin
TAB CHEW
($0.00 - $2.95) Tier 1
+Amoxicillin
Amoxicillin
ORAL SUSP
($0.00 - $2.95) Tier 1
+Amoxicillin
Amoxicillin
CAPSULE
($0.00 - $2.95) Tier 1
AMPICILLIN SODIUM
Ampicillin Sodium
INJECTION
($0.00 - $7.40) Tier 2
+Ampicillin Trihydrate
Ampicillin Trihydrate
ORAL SUSP
($0.00 - $2.95) Tier 1
+Ampicillin Trihydrate
Ampicillin Trihydrate
CAPSULE
($0.00 - $2.95) Tier 1
Ampicillin-Sulbactam
Ampicillin Sodium/Sulbactam Na
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD Ampicillin-Sulbactam
Ampicillin Sodium/Sulbactam Na
INJECTION
($0.00 - $2.95) Tier 1
BvD
PENICILLINS
PART D DRUGS
BvD + Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies.
37
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
BICILLIN C-R
Pen G Benz/Pen G Procaine
INJECTION
($0.00 - $7.40) Tier 2
BvD
BICILLIN L-A
Penicillin G Benzathine
INJECTION
($0.00 - $7.40) Tier 2
BvD
+Dicloxacillin Sodium
Dicloxacillin Sodium
CAPSULE
($0.00 - $2.95) Tier 1
Nafcillin Sodium
Nafcillin Sodium
INJECTION
($0.00 - $2.95) Tier 1
BvD
Nafcillin Sodium
Nafcillin Sodium
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
Penicillin G Potassium
INJECTION
($0.00 - $2.95) Tier 1
BvD
Penicillin G Sodium
Penicillin G Sodium
INJECTION
($0.00 - $2.95) Tier 1
BvD
Penicillin Gk-Iso-Osm Dextrose
Pen G Pot/Dextrose-Water
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
Penicillin V Potassium
TABLET
($0.00 - $2.95) Tier 1
ORAL SOLUTION
($0.00 - $2.95) Tier 1
Pfizerpen
INJECTION
($0.00 - $2.95) Tier 1
BvD
PIPERACILLIN-TAZOBACTAM
Piperacillin Sodium/Tazobactam
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
TIMENTIN
Ticarcillin/K Clavulanate
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
Ciprofloxacin
Ciprofloxacin Lactate
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD +Ciprofloxacin
Ciprofloxacin
ORAL SUSP
($0.00 - $2.95) Tier 1
+Ciprofloxacin Er
Ciprofloxacin/Ciprofloxa Hcl
TAB SR 24H
($0.00 - $2.95) Tier 1
QUINOLONES
38
WHAT THE DRUG WILL
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
+Ciprofloxacin Hcl
Ciprofloxacin Hcl
TABLET
($0.00 - $2.95) Tier 1
+Levofloxacin
Levofloxacin
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Levofloxacin
Levofloxacin
TABLET
($0.00 - $2.95) Tier 1
Levofloxacin-D5W
Levofloxacin/D5W
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
MOXIFLOXACIN HCL
Moxifloxacin Hcl
TABLET
($0.00 - $7.40) Tier 2
+Ofloxacin
Ofloxacin
TABLET
($0.00 - $2.95) Tier 1
Sulfadiazine
Sulfadiazine
TABLET
($0.00 - $2.95) Tier 1
Sulfamethoxazole-Trimethoprim
Sulfamethoxazole/Trimethoprim
TABLET
($0.00 - $2.95) Tier 1
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
ORAL SUSP
($0.00 - $2.95) Tier 1
+Sulfasalazine
Sulfasalazine
TABLET
($0.00 - $2.95) Tier 1
+Sulfasalazine Dr
Sulfasalazine
TABLET DR
($0.00 - $2.95) Tier 1
Sulfatrim
ORAL SUSP
($0.00 - $2.95) Tier 1
+Sulfazine
Sulfasalazine
TABLET
($0.00 - $2.95) Tier 1
Demeclocycline Hcl
TABLET
($0.00 - $2.95) Tier 1
NECESSARY ACTIONS,
BvD
SULFONAMIDES
PART D DRUGS
BvD
TETRACYCLINES
+Demeclocycline Hcl
39
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Doxy 100
Doxycycline Hyclate
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
+Doxycycline Hyclate
Doxycycline Hyclate
TABLET
($0.00 - $2.95) Tier 1
+Doxycycline Hyclate
Doxycycline Hyclate
CAPSULE
($0.00 - $2.95) Tier 1
+Doxycycline Monohydrate
Doxycycline Monohydrate
CAPSULE
($0.00 - $2.95) Tier 1
+Doxycycline Monohydrate
Doxycycline Monohydrate
TABLET
($0.00 - $2.95) Tier 1
+Minocycline Hcl
Minocycline Hcl
CAPSULE
($0.00 - $2.95) Tier 1
+Minocycline Hcl
Minocycline Hcl
TABLET
($0.00 - $2.95) Tier 1
Tetracycline Hcl
Tetracycline Hcl
CAPSULE
($0.00 - $2.95) Tier 1
TYGACIL
Tigecycline
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
ADCETRIS
Brentuximab Vedotin
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+AFINITOR
Everolimus
TABLET
($0.00 - $7.40) Tier 2
PA +AFINITOR DISPERZ
Everolimus
BLISTER PACK
($0.00 - $7.40) Tier 2
PA ALIMTA
Pemetrexed Disodium
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+Anastrozole
Anastrozole
TABLET
($0.00 - $2.95) Tier 1
ARZERRA
Ofatumumab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
ANTICANCER AGENTS
ANTICANCER AGENTS
BvD, PA
40
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
AVASTIN
Bevacizumab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
AZACITIDINE
Azacitidine
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+BELEODAQ
Belinostat
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+Bicalutamide
Bicalutamide
TABLET
($0.00 - $2.95) Tier 1
Bleomycin Sulfate
Bleomycin Sulfate
INJECTION
($0.00 - $2.95) Tier 1
BvD, PA
BLINCYTO
Blinatumomab
INTRAVENOUS (IV) KIT
($0.00 - $7.40) Tier 2
BvD, PA +BOSULIF
Bosutinib
TABLET
($0.00 - $7.40) Tier 2
PA CAPRELSA
Vandetanib
TABLET
($0.00 - $7.40) Tier 2
PA COMETRIQ
Cabozantinib S-Malate
CAPSULE
($0.00 - $7.40) Tier 2
PA CYCLOPHOSPHAMIDE
Cyclophosphamide
CAPSULE
($0.00 - $7.40) Tier 2
BvD, PA
+CYRAMZA
Ramucirumab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
DAUNOXOME
Daunorubicin Citrate Liposomal
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
DECITABINE
Decitabine
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
DOCETAXEL
Docetaxel
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+DROXIA
Hydroxyurea
CAPSULE
($0.00 - $7.40) Tier 2
ELIGARD 22.5 MG, 30 MG, 45 MG
Leuprolide Acetate
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
ELIGARD 7.5 MG
Leuprolide Acetate
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
PART D DRUGS
41
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
EMCYT
Estramustine Phosphate Sodium
CAPSULE
($0.00 - $7.40) Tier 2
PA
+ERIVEDGE
Vismodegib
CAPSULE
($0.00 - $7.40) Tier 2
PA
ERWINAZE
Asparaginase (Erwinia Chrysan)
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+Exemestane
Exemestane
TABLET
($0.00 - $2.95) Tier 1
+FARESTON
Toremifene Citrate
TABLET
($0.00 - $7.40) Tier 2
FARYDAK
Panobinostat Lactate
CAPSULE
($0.00 - $7.40) Tier 2
PA
+FASLODEX
Fulvestrant
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
FIRMAGON 120 MG
Degarelix Acetate
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+FIRMAGON 80 MG
Degarelix Acetate
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
FLUOROURACIL
Fluorouracil
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+Flutamide
Flutamide
CAPSULE
($0.00 - $2.95) Tier 1
FOLOTYN
Pralatrexate
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
GAZYVA
Obinutuzumab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
GEMCITABINE HCL
Gemcitabine Hcl
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+GILOTRIF
Afatinib Dimaleate
TABLET
($0.00 - $7.40) Tier 2
PA
+GLEEVEC
Imatinib Mesylate
TABLET
($0.00 - $7.40) Tier 2
PA
HALAVEN
Eribulin Mesylate
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
42
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
HERCEPTIN
Trastuzumab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
HEXALEN
Altretamine
CAPSULE
($0.00 - $7.40) Tier 2
PA +Hydroxyurea
Hydroxyurea
CAPSULE
($0.00 - $2.95) Tier 1
+IBRANCE
Palbociclib
CAPSULE
($0.00 - $7.40) Tier 2
PA +ICLUSIG
Ponatinib Hcl
TABLET
($0.00 - $7.40) Tier 2
PA IMBRUVICA
Ibrutinib
CAPSULE
($0.00 - $7.40) Tier 2
PA INLYTA
Axitinib
TABLET
($0.00 - $7.40) Tier 2
PA ISTODAX
Romidepsin
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+JAKAFI
Ruxolitinib Phosphate
TABLET
($0.00 - $7.40) Tier 2
PA JEVTANA
Cabazitaxel
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
KADCYLA
Ado-Trastuzumab Emtansine
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+KEYTRUDA
Pembrolizumab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
KYPROLIS
Carfilzomib
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
PA +LENVIMA
Lenvatinib Mesylate
CAPSULE
($0.00 - $7.40) Tier 2
PA +Letrozole
Letrozole
TABLET
($0.00 - $2.95) Tier 1
LEUKERAN
Chlorambucil
TABLET
($0.00 - $7.40) Tier 2 LEUPROLIDE ACETATE
Leuprolide Acetate
INJECTION
($0.00 - $7.40) Tier 2
PART D DRUGS
BvD, PA
43
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
LIPODOX
Doxorubicin Hcl Peg-Liposomal
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
LOMUSTINE
Lomustine
CAPSULE
($0.00 - $7.40) Tier 2
PA LUPRON DEPOT 3.75 MG
Leuprolide Acetate
INJECTION: IM KIT
($0.00 - $7.40) Tier 2
BvD, PA LUPRON DEPOT ALL OTHER STRENGTHS Leuprolide Acetate
INJECTION: IM KIT
($0.00 - $7.40) Tier 2
BvD, PA LYNPARZA
Olaparib
CAPSULE
($0.00 - $7.40) Tier 2
PA LYSODREN
Mitotane
TABLET
($0.00 - $7.40) Tier 2 MARQIBO
Vincristine Sulfate Liposomal
INTRAVENOUS (IV) KIT
($0.00 - $7.40) Tier 2
MATULANE
Procarbazine Hcl
CAPSULE
($0.00 - $7.40) Tier 2 Megestrol Acetate
Megestrol Acetate
TABLET
($0.00 - $2.95) Tier 1
PA +MEKINIST
Trametinib Dimethyl Sulfoxide
TABLET
($0.00 - $7.40) Tier 2
PA MELPHALAN HCL
Melphalan Hcl
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+Mercaptopurine
Mercaptopurine
TABLET
($0.00 - $2.95) Tier 1
Methotrexate
Methotrexate Sodium
INJECTION
($0.00 - $2.95) Tier 1
+Methotrexate
Methotrexate Sodium
TABLET
($0.00 - $2.95) Tier 1
+Mitoxantrone Hcl
Mitoxantrone Hcl
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD, PA
NEXAVAR
Sorafenib Tosylate
TABLET
($0.00 - $7.40) Tier 2
PA +NILANDRON
Nilutamide
TABLET
($0.00 - $7.40) Tier 2
PA BvD, PA BvD + Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies.
44
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
ONCASPAR
Pegaspargase
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+OPDIVO
Nivolumab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
OXALIPLATIN
Oxaliplatin
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
PACLITAXEL
Paclitaxel
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
PERJETA
Pertuzumab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
PA +POMALYST
Pomalidomide
CAPSULE
($0.00 - $7.40) Tier 2
PA PROLEUKIN
Aldesleukin
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
PURIXAN
Mercaptopurine
ORAL SUSP
($0.00 - $7.40) Tier 2
PA +~REVLIMID
Lenalidomide
CAPSULE
($0.00 - $7.40) Tier 2
PA
RITUXAN
Rituximab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+SOLTAMOX
Tamoxifen Citrate
ORAL SOLUTION
($0.00 - $7.40) Tier 2
PA +SPRYCEL
Dasatinib
TABLET
($0.00 - $7.40) Tier 2
PA STIVARGA
Regorafenib
TABLET
($0.00 - $7.40) Tier 2
BvD, PA
SUTENT
Sunitinib Malate
CAPSULE
($0.00 - $7.40) Tier 2
PA +SYLVANT
Siltuximab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+SYNRIBO
Omacetaxine Mepesuccinate
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
TABLOID
Thioguanine
TABLET
($0.00 - $7.40) Tier 2
PA PART D DRUGS
~ This prescription may be available only at certain pharmacies. For more information, call Care1st Cal MediConnect Plan Member Services.
45
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
TAFINLAR
Dabrafenib Mesylate
CAPSULE
($0.00 - $7.40) Tier 2
PA
+Tamoxifen Citrate
Tamoxifen Citrate
TABLET
($0.00 - $2.95) Tier 1
+TARCEVA
Erlotinib Hcl
TABLET
($0.00 - $7.40) Tier 2
+TARGRETIN
Bexarotene
CAPSULE
($0.00 - $7.40) Tier 2
TARGRETIN
Bexarotene
TOPICAL GEL
($0.00 - $7.40) Tier 2
+TASIGNA
Nilotinib Hcl
CAPSULE
($0.00 - $7.40) Tier 2
PA
TEMODAR
Temozolomide
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
TENIPOSIDE
Teniposide
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
TOPOTECAN HCL
Topotecan Hcl
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
TREANDA
Bendamustine Hcl
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
TRELSTAR
Triptorelin Pamoate
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
TRETINOIN
Tretinoin
CAPSULE
($0.00 - $7.40) Tier 2
PA
TRISENOX
Arsenic Trioxide
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+TYKERB
Lapatinib Ditosylate
TABLET
($0.00 - $7.40) Tier 2
PA
VELCADE
Bortezomib
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
VOTRIENT
Pazopanib Hcl
TABLET
($0.00 - $7.40) Tier 2
PA
+XALKORI
Crizotinib
CAPSULE
($0.00 - $7.40) Tier 2
PA
PA
46
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Enzalutamide
CAPSULE
($0.00 - $7.40) Tier 2
PA
YERVOY
Ipilimumab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+ZALTRAP
Ziv-Aflibercept
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+ZELBORAF
Vemurafenib
TABLET
($0.00 - $7.40) Tier 2
PA
ZOLADEX
Goserelin Acetate
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
ZOLINZA
Vorinostat
CAPSULE
($0.00 - $7.40) Tier 2
PA
ZYDELIG
Idelalisib
TABLET
($0.00 - $7.40) Tier 2
BvD, PA
ZYKADIA
Ceritinib
CAPSULE
($0.00 - $7.40) Tier 2
PA
+ZYTIGA
Abiraterone Acetate
TABLET
($0.00 - $7.40) Tier 2
PA
+APTIOM 200 MG, 400 MG
Eslicarbazepine Acetate
TABLET
($0.00 - $7.40) Tier 2
PA, QL
+APTIOM 600 MG
TABLET
($0.00 - $7.40) Tier 2
PA, QL
+APTIOM 800 MG
TABLET
($0.00 - $7.40) Tier 2
PA +BANZEL
Rufinamide
ORAL SUSP
($0.00 - $7.40) Tier 2
PA +BANZEL 200 MG
Rufinamide
TABLET
($0.00 - $7.40) Tier 2
PA +BANZEL 400 MG
Rufinamide
TABLET
($0.00 - $7.40) Tier 2
PA PART D DRUGS
+XTANDI
ANTICONVULSANTS
ANTICONVULSANTS
47
PART D DRUGS
WHAT THE DRUG WILL
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
+Carbamazepine
Carbamazepine
CAPSULE
($0.00 - $2.95) Tier 1
+Carbamazepine
Carbamazepine
TAB CHEW
($0.00 - $2.95) Tier 1
+Carbamazepine
Carbamazepine
ORAL SUSP
($0.00 - $2.95) Tier 1
+Carbamazepine
Carbamazepine
TABLET
($0.00 - $2.95) Tier 1
+Carbamazepine Er
Carbamazepine
TAB ER 12H
($0.00 - $2.95) Tier 1
+Carbamazepine Xr
Carbamazepine
TAB ER 12H
($0.00 - $2.95) Tier 1
+CELONTIN
Methsuximide
CAPSULE
($0.00 - $7.40) Tier 2
+DILANTIN
Phenytoin
TAB CHEW
($0.00 - $7.40) Tier 2
+DILANTIN
Phenytoin Sodium Extended
CAPSULE
($0.00 - $7.40) Tier 2
+DILANTIN-125
Phenytoin
ORAL SUSP
($0.00 - $7.40) Tier 2
+Divalproex Sodium
Divalproex Sodium
CAP SPRINK
($0.00 - $2.95) Tier 1
+Divalproex Sodium
Divalproex Sodium
TABLET DR
($0.00 - $2.95) Tier 1
+Divalproex Sodium Er
Divalproex Sodium
TAB ER 24
($0.00 - $2.95) Tier 1
+Epitol
Carbamazepine
TABLET
($0.00 - $2.95) Tier 1
+Ethosuximide
Ethosuximide
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Ethosuximide
Ethosuximide
CAPSULE
($0.00 - $2.95) Tier 1
+FELBAMATE
Felbamate
TABLET
($0.00 - $7.40) Tier 2
NECESSARY ACTIONS,
PA
48
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+FELBAMATE
Felbamate
ORAL SUSP
($0.00 - $7.40) Tier 2
PA
FOSPHENYTOIN SODIUM
Fosphenytoin Sodium
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+FYCOMPA 2 MG, 4 MG
Perampanel
TABLET
($0.00 - $7.40) Tier 2
PA, QL
+FYCOMPA 6 MG
Perampanel
TABLET
($0.00 - $7.40) Tier 2
PA, QL
+FYCOMPA 8 MG, 10 MG, 12 MG
Perampanel
TABLET
($0.00 - $7.40) Tier 2
PA, QL
+Gabapentin
Gabapentin
TABLET
($0.00 - $2.95) Tier 1
+Gabapentin
Gabapentin
CAPSULE
($0.00 - $2.95) Tier 1
+Gabapentin
Gabapentin
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+GABITRIL
Tiagabine Hcl
TABLET
($0.00 - $7.40) Tier 2
+Lamotrigine
Lamotrigine
TAB DS PK
($0.00 - $2.95) Tier 1
+Lamotrigine
Lamotrigine
TAB CHW DSP
($0.00 - $2.95) Tier 1
+Lamotrigine
Lamotrigine
TABLET
($0.00 - $2.95) Tier 1
Levetiracetam
Levetiracetam
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
+Levetiracetam
Levetiracetam
TABLET
($0.00 - $2.95) Tier 1
+Levetiracetam
Levetiracetam
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Levetiracetam Er 500 Mg
Levetiracetam
TAB ER 24
($0.00 - $2.95) Tier 1
QL +Levetiracetam Er 750 Mg
Levetiracetam
TAB ER 24
($0.00 - $2.95) Tier 1
QL PART D DRUGS
BvD, PA
49
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Levetiracetam-Nacl
Levetiracetam In Nacl (Iso-Os)
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD, PA
+LYRICA
Pregabalin
ORAL SOLUTION
($0.00 - $7.40) Tier 2
+LYRICA
Pregabalin
CAPSULE
($0.00 - $7.40) Tier 2
+Oxcarbazepine
Oxcarbazepine
ORAL SUSP
($0.00 - $2.95) Tier 1
+Oxcarbazepine
Oxcarbazepine
TABLET
($0.00 - $2.95) Tier 1
+OXTELLAR XR
Oxcarbazepine
TAB ER 24
($0.00 - $7.40) Tier 2
+PEGANONE
Ethotoin
TABLET
($0.00 - $7.40) Tier 2
+Phenobarbital
Phenobarbital
ORAL SOLUTION
($0.00 - $2.95) Tier 1
PA +Phenobarbital
Phenobarbital
TABLET
($0.00 - $2.95) Tier 1
PA
+PHENYTEK
CAPSULE
($0.00 - $7.40) Tier 2
+Phenytoin
Phenytoin
ORAL SUSP
($0.00 - $2.95) Tier 1
+Phenytoin
Phenytoin
TAB CHEW
($0.00 - $2.95) Tier 1
Phenytoin Sodium
Phenytoin Sodium
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
+Phenytoin Sodium Extended
CAPSULE
($0.00 - $2.95) Tier 1
+POTIGA 200 MG, 400 MG
Ezogabine
TABLET
($0.00 - $7.40) Tier 2
PA +POTIGA 300 MG
Ezogabine
TABLET
($0.00 - $7.40) Tier 2
PA +POTIGA 50 MG
Ezogabine
TABLET
($0.00 - $7.40) Tier 2
PA, QL
PA BvD, PA
50
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Primidone
TABLET
($0.00 - $2.95) Tier 1
SABRIL
Vigabatrin
TABLET
($0.00 - $7.40) Tier 2
PA SABRIL
Vigabatrin
ORAL PACKETS
($0.00 - $7.40) Tier 2
PA
+TEGRETOL XR
Carbamazepine
TAB ER 12H
($0.00 - $7.40) Tier 2
+TIAGABINE HCL
Tiagabine Hcl
TABLET
($0.00 - $7.40) Tier 2
+Topiramate
Topiramate
CAP SPRINK
($0.00 - $2.95) Tier 1
+Topiramate
Topiramate
TABLET
($0.00 - $2.95) Tier 1
+TOPIRAMATE ER
Topiramate
CAP SPR 24
($0.00 - $7.40) Tier 2
PA +TROKENDI XR 100 MG
Topiramate
CAP.ER 24H
($0.00 - $7.40) Tier 2
PA, QL
+TROKENDI XR 200 MG
Topiramate
CAP.ER 24H
($0.00 - $7.40) Tier 2
PA, QL
+TROKENDI XR 25 MG, 50 MG
Topiramate
CAP.ER 24H
($0.00 - $7.40) Tier 2
PA, QL
Valproate Sodium
Valproic Acid (As Sodium Salt)
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD, PA
+Valproic Acid
Valproic Acid
CAPSULE
($0.00 - $2.95) Tier 1
+Valproic Acid
Valproic Acid (As Sodium Salt)
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+VIMPAT
Lacosamide
ORAL SOLUTION
($0.00 - $7.40) Tier 2
PA VIMPAT
Lacosamide
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
PA, QL
+VIMPAT 100 MG, 150 MG
Lacosamide
TABLET
($0.00 - $7.40) Tier 2
PA PART D DRUGS
+Primidone
51
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+VIMPAT 200 MG
Lacosamide
TABLET
($0.00 - $7.40) Tier 2
PA
+VIMPAT 50 MG
Lacosamide
TABLET
($0.00 - $7.40) Tier 2
PA
+Zonisamide
Zonisamide
CAPSULE
($0.00 - $2.95) Tier 1
ANTIDEMENTIA AGENTS
PART D DRUGS
ANTIDEMENTIA AGENTS
+DONEPEZIL HCL 23 MG
Donepezil Hcl
TABLET
($0.00 - $7.40) Tier 2
+Donepezil Hcl 5 Mg, 10 Mg
Donepezil Hcl
TABLET
($0.00 - $2.95) Tier 1
+Donepezil Hcl Odt
Donepezil Hcl
TAB RAPDIS
($0.00 - $2.95) Tier 1
+EXELON
Rivastigmine
PATCH
($0.00 - $7.40) Tier 2
+Memantine Hcl
Memantine Hcl
TABLET
($0.00 - $2.95) Tier 1
+Memantine Hcl
Memantine Hcl
TAB DS PK
($0.00 - $2.95) Tier 1
+NAMENDA
Memantine Hcl
TABLET
($0.00 - $7.40) Tier 2
NAMENDA
Memantine Hcl
TAB DS PK
($0.00 - $7.40) Tier 2
+NAMENDA
Memantine Hcl
ORAL SOLUTION
($0.00 - $7.40) Tier 2
NAMENDA XR
Memantine Hcl
CAP D SPK
($0.00 - $7.40) Tier 2
QL +NAMENDA XR
Memantine Hcl
CAP SPR 24
($0.00 - $7.40) Tier 2
QL
+Rivastigmine
Rivastigmine Tartrate
CAPSULE
($0.00 - $2.95) Tier 1
52
BRAND DRUG NAME
WHAT THE DRUG WILL
NECESSARY ACTIONS,
GENERIC DRUG NAME
FORMULATION
+Amitriptyline Hcl
Amitriptyline Hcl
TABLET
($0.00 - $2.95) Tier 1
+Amoxapine
Amoxapine
TABLET
($0.00 - $2.95) Tier 1
+BRINTELLIX
Vortioxetine Hydrobromide
TABLET
($0.00 - $7.40) Tier 2
+Buproban
Bupropion Hcl
TAB ER
($0.00 - $2.95) Tier 1
+Bupropion Hcl
Bupropion Hcl
TABLET
($0.00 - $2.95) Tier 1
+Bupropion Hcl Sr
Bupropion Hcl
TAB ER
($0.00 - $2.95) Tier 1
+Bupropion Xl 150 Mg
Bupropion Hcl
TAB ER 24
($0.00 - $2.95) Tier 1
+Bupropion Xl 300 Mg
Bupropion Hcl
TAB ER 24
($0.00 - $2.95) Tier 1
+Chlordiazepoxide-Amitriptyline
Amitrip Hcl/Chlordiazepoxide
TABLET
($0.00 - $2.95) Tier 1
+Citalopram Hbr
Citalopram Hydrobromide
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Citalopram Hbr
Citalopram Hydrobromide
TABLET
($0.00 - $2.95) Tier 1
+Clomipramine Hcl
Clomipramine Hcl
CAPSULE
($0.00 - $2.95) Tier 1
+Desipramine Hcl
Desipramine Hcl
TABLET
($0.00 - $2.95) Tier 1
+DESVENLAFAXINE ER
Desvenlafaxine
TAB ER 24
($0.00 - $7.40) Tier 2
PA +Doxepin Hcl
Doxepin Hcl
CAPSULE
($0.00 - $2.95) Tier 1
PA ANTIDEPRESSANTS
ANTIDEPRESSANTS
PA PA PART D DRUGS
QL PA + Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies.
53
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Doxepin Hcl
Doxepin Hcl
ORAL CONC
($0.00 - $2.95) Tier 1
PA
+DULOXETINE HCL
Duloxetine Hcl
CAPSULE CR
($0.00 - $7.40) Tier 2
ST
+Duloxetine Hcl
Duloxetine Hcl
CAPSULE CR
($0.00 - $2.95) Tier 1
+Duloxetine Hcl 20 Mg, 30 Mg
Duloxetine Hcl
CAPSULE CR
($0.00 - $2.95) Tier 1
+EMSAM
Selegiline
PATCH
($0.00 - $7.40) Tier 2
+Escitalopram Oxalate
Escitalopram Oxalate
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Escitalopram Oxalate
Escitalopram Oxalate
TABLET
($0.00 - $2.95) Tier 1
+FETZIMA
Levomilnacipran Hydrochloride
CAP SA 24HR
($0.00 - $7.40) Tier 2
PA
FETZIMA
Levomilnacipran Hydrochloride
TITRATION PAK
($0.00 - $7.40) Tier 2
PA
+Fluoxetine Dr
Fluoxetine Hcl
CAPSULE CR
($0.00 - $2.95) Tier 1
+Fluoxetine Hcl
Fluoxetine Hcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Fluoxetine Hcl
Fluoxetine Hcl
CAPSULE
($0.00 - $2.95) Tier 1
+Fluoxetine Hcl
Fluoxetine Hcl
TABLET
($0.00 - $2.95) Tier 1
+Fluvoxamine Maleate
Fluvoxamine Maleate
TABLET
($0.00 - $2.95) Tier 1
+Imipramine Hcl
Imipramine Hcl
TABLET
($0.00 - $2.95) Tier 1
PA
+Imipramine Pamoate
Imipramine Pamoate
CAPSULE
($0.00 - $2.95) Tier 1
PA
+Maprotiline Hcl
Maprotiline Hcl
TABLET
($0.00 - $2.95) Tier 1
PA
54
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
Isocarboxazid
TABLET
($0.00 - $7.40) Tier 2
+Mirtazapine
Mirtazapine
TAB RAPDIS
($0.00 - $2.95) Tier 1
+Mirtazapine
Mirtazapine
TABLET
($0.00 - $2.95) Tier 1
+Nefazodone Hcl
Nefazodone Hcl
TABLET
($0.00 - $2.95) Tier 1
+Nortriptyline Hcl
Nortriptyline Hcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Nortriptyline Hcl
Nortriptyline Hcl
CAPSULE
($0.00 - $2.95) Tier 1
+Paroxetine Hcl
Paroxetine Hcl
TABLET
($0.00 - $2.95) Tier 1
+PAXIL
Paroxetine Hcl
ORAL SUSP
($0.00 - $7.40) Tier 2
+Perphenazine-Amitriptyline
Perphenazine/Amitriptyline Hcl
TABLET
($0.00 - $2.95) Tier 1
+Phenelzine Sulfate
Phenelzine Sulfate
TABLET
($0.00 - $2.95) Tier 1
+PRISTIQ ER
Desvenlafaxine Succinate
TAB ER 24
($0.00 - $7.40) Tier 2
+Protriptyline Hcl
Protriptyline Hcl
TABLET
($0.00 - $2.95) Tier 1
+Sertraline Hcl
Sertraline Hcl
TABLET
($0.00 - $2.95) Tier 1
+Sertraline Hcl
Sertraline Hcl
ORAL CONC
($0.00 - $2.95) Tier 1
+SURMONTIL
Trimipramine Maleate
CAPSULE
($0.00 - $7.40) Tier 2
+Tranylcypromine Sulfate
Tranylcypromine Sulfate
TABLET
($0.00 - $2.95) Tier 1
+Trazodone Hcl
Trazodone Hcl
TABLET
($0.00 - $2.95) Tier 1
PA
PART D DRUGS
+MARPLAN
NECESSARY ACTIONS,
PA
PA
55
WHAT THE DRUG WILL
NECESSARY ACTIONS,
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
+Venlafaxine Hcl
Venlafaxine Hcl
TABLET
($0.00 - $2.95) Tier 1
+VENLAFAXINE HCL ER
Venlafaxine Hcl
TAB ER 24
($0.00 - $7.40) Tier 2
+Venlafaxine Hcl Er
Venlafaxine Hcl
CAP.ER 24H
($0.00 - $2.95) Tier 1
VIIBRYD
Vilazodone Hydrochloride
TAB DS PK
($0.00 - $7.40) Tier 2
PA
+VIIBRYD
Vilazodone Hydrochloride
TABLET
($0.00 - $7.40) Tier 2
PA
ANTIDIABETIC AGENTS
PART D DRUGS
ANTIDIABETIC AGENTS, MISCELLANEOUS
+Acarbose 100 Mg
Acarbose
TABLET
($0.00 - $2.95) Tier 1
QL +Acarbose 25 Mg
Acarbose
TABLET
($0.00 - $2.95) Tier 1
QL +Acarbose 50 Mg
Acarbose
TABLET
($0.00 - $2.95) Tier 1
QL +AVANDIA
Rosiglitazone Maleate
TABLET
($0.00 - $7.40) Tier 2
PA +BYDUREON
Exenatide Microspheres
INJECTION
($0.00 - $7.40) Tier 2
PA +BYDUREON PEN
Exenatide Microspheres
INJECTION
($0.00 - $7.40) Tier 2
PA +BYETTA
Exenatide
INJECTION
($0.00 - $7.40) Tier 2
PA +CYCLOSET
Bromocriptine Mesylate
TABLET
($0.00 - $7.40) Tier 2
PA +GLYSET 100 MG
Miglitol
TABLET
($0.00 - $7.40) Tier 2
QL
+GLYSET 25 MG
Miglitol
TABLET
($0.00 - $7.40) Tier 2
QL
56
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Miglitol
TABLET
($0.00 - $7.40) Tier 2
QL
+INVOKAMET
Canagliflozin/Metformin Hcl
TABLET
($0.00 - $7.40) Tier 2
PA
+INVOKANA
Canagliflozin
TABLET
($0.00 - $7.40) Tier 2
PA
+JANUMET
Sitagliptin Phos/Metformin Hcl
TABLET
($0.00 - $7.40) Tier 2
QL
+JANUMET XR 50-1000 MG, 100-1000MG Sitagliptin Phos/Metformin Hcl
TAB SR 24H
($0.00 - $7.40) Tier 2
QL
+JANUMET XR 50MG-500MG
Sitagliptin Phos/Metformin Hcl
TAB SR 24H
($0.00 - $7.40) Tier 2
QL
+JANUVIA
Sitagliptin Phosphate
TABLET
($0.00 - $7.40) Tier 2
QL
+JENTADUETO
Linagliptin/Metformin Hcl
TABLET
($0.00 - $7.40) Tier 2
QL
+KORLYM
Mifepristone
TABLET
($0.00 - $7.40) Tier 2
PA
+Metformin Hcl 1000 Mg
Metformin Hcl
TABLET
($0.00 - $2.95) Tier 1
QL
Metformin Hcl
TABLET
($0.00 - $2.95) Tier 1
QL
Metformin Hcl
TABLET
($0.00 - $2.95) Tier 1
QL
+Metformin Hcl Er 500 Mg
Metformin Hcl
TAB ER 24
($0.00 - $2.95) Tier 1
QL
+Metformin Hcl Er 750 Mg, 1000 Mg Metformin Hcl
TAB ER 24
($0.00 - $2.95) Tier 1
QL
+Nateglinide
Nateglinide
TABLET
($0.00 - $2.95) Tier 1
+Pioglitazone Hcl
Pioglitazone Hcl
TABLET
($0.00 - $2.95) Tier 1
+Repaglinide
Repaglinide
TABLET
($0.00 - $2.95) Tier 1
PART D DRUGS
+GLYSET 50 MG
QL
57
WHAT THE DRUG WILL
NECESSARY ACTIONS,
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
+SYMLINPEN 120
Pramlintide Acetate
INJECTION
($0.00 - $7.40) Tier 2
PA
+SYMLINPEN 60
Pramlintide Acetate
INJECTION
($0.00 - $7.40) Tier 2
PA
+TANZEUM
Albiglutide
INJECTION
($0.00 - $7.40) Tier 2
ST
+TRADJENTA
Linagliptin
TABLET
($0.00 - $7.40) Tier 2
QL
+VICTOZA 3-PAK
Liraglutide
INJECTION
($0.00 - $7.40) Tier 2
PA
+HUMALOG
Insulin Lispro
INJECTION
($0.00 - $7.40) Tier 2
+HUMALOG KWIKPEN
Insulin Lispro
INSULN PEN
($0.00 - $7.40) Tier 2
+HUMALOG MIX 50-50
Insulin Npl/Insulin Lispro
INJECTION
($0.00 - $7.40) Tier 2
+HUMALOG MIX 50-50 KWIKPEN
INSULN PEN
($0.00 - $7.40) Tier 2
+HUMALOG MIX 75-25
INJECTION
($0.00 - $7.40) Tier 2
+HUMALOG MIX 75-25 KWIKPEN
INSULN PEN
($0.00 - $7.40) Tier 2
+HUMULIN 70/30 KWIKPEN
Insulin Nph Hum/Reg Insulin Hm
INSULN PEN
($0.00 - $7.40) Tier 2
+HUMULIN 70-30
INJECTION
($0.00 - $7.40) Tier 2
+HUMULIN N
Insulin Nph Human Isophane
INJECTION
($0.00 - $7.40) Tier 2
+HUMULIN N KWIKPEN
INSULN PEN
($0.00 - $7.40) Tier 2
+HUMULIN R
Insulin Regular, Human
INJECTION
($0.00 - $7.40) Tier 2
PART D DRUGS
INSULINS
58
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
INJECTION
($0.00 - $7.40) Tier 2
+LANTUS
Insulin Glargine,Hum.Rec.Anlog
INJECTION
($0.00 - $7.40) Tier 2
+LANTUS SOLOSTAR
Insulin Glargine,Hum.Rec.Anlog
INSULN PEN
($0.00 - $7.40) Tier 2
+NOVOLIN 70-30
INJECTION
($0.00 - $7.40) Tier 2
+NOVOLIN N
INJECTION
($0.00 - $7.40) Tier 2
+NOVOLIN R
INJECTION
($0.00 - $7.40) Tier 2
+NOVOLOG
Insulin Aspart
INJECTION
($0.00 - $7.40) Tier 2
+NOVOLOG FLEXPEN
Insulin Aspart
INSULN PEN
($0.00 - $7.40) Tier 2
+NOVOLOG MIX 70-30
Insulin Aspart Protam And Aspart
INJECTION
($0.00 - $7.40) Tier 2
+NOVOLOG MIX 70-30 FLEXPEN
Insulin Aspart Protam And Aspart
INSULN PEN
($0.00 - $7.40) Tier 2
+Glimepiride 1 Mg
Glimepiride
TABLET
($0.00 - $2.95) Tier 1
QL
+Glimepiride 2 Mg
Glimepiride
TABLET
($0.00 - $2.95) Tier 1
QL
+Glimepiride 4 Mg
Glimepiride
TABLET
($0.00 - $2.95) Tier 1
QL
+Glipizide 10 Mg
Glipizide
TABLET
($0.00 - $2.95) Tier 1
QL +Glipizide 5 Mg
Glipizide
TABLET
($0.00 - $2.95) Tier 1
QL +Glipizide Er 2.5 Mg
Glipizide
TAB ER 24
($0.00 - $2.95) Tier 1
QL PART D DRUGS
+HUMULIN R U-500
SULFONYLUREAS
59
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Glipizide Er 5 Mg
Glipizide
TAB ER 24
($0.00 - $2.95) Tier 1
QL
+Glipizide Xl
Glipizide
TAB ER 24
($0.00 - $2.95) Tier 1
QL
+Glipizide-Metformin 2.5-250 Mg
Glipizide/Metformin Hcl
TABLET
($0.00 - $2.95) Tier 1
QL
+Glipizide-Metformin 2.5-500 Mg, 5 Mg-500Mg Glipizide/Metformin Hcl
TABLET
($0.00 - $2.95) Tier 1
QL
+Glyburide 1.25 Mg
Glyburide
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
+Glyburide 2.5 Mg
Glyburide
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
+Glyburide 5 Mg
Glyburide
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
+Glyburide Micronized 1.5 Mg
Glyburide,Micronized
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
+Glyburide Micronized 3 Mg
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
+Glyburide Micronized 6 Mg
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
+Glyburide-Metformin Hcl 2.5-500 Mg, 5 Mg-500Mg Glyburide/Metformin Hcl TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
+Tolazamide
Tolazamide
TABLET
($0.00 - $2.95) Tier 1
QL
+Tolbutamide
Tolbutamide
TABLET
($0.00 - $2.95) Tier 1
QL
Amphotericin B Lipid Complex
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+Glyburide-Metformin Hcl 1.25-250Mg Glyburide/Metformin Hcl
ANTIFUNGALS
ANTIFUNGALS
ABELCET
60
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
AMBISOME
Amphotericin B Liposome
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD Amphotericin B
Amphotericin B
INJECTION
($0.00 - $2.95) Tier 1
BvD CANCIDAS
Caspofungin Acetate
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2 Ciclopirox
Ciclopirox
TOPICAL SOLUTION
($0.00 - $2.95) Tier 1
+Ciclopirox
Ciclopirox Olamine
TOPICAL SUSP
($0.00 - $2.95) Tier 1
+Ciclopirox
Ciclopirox
TOPICAL GEL
($0.00 - $2.95) Tier 1
+Ciclopirox
Ciclopirox Olamine
CREAM
($0.00 - $2.95) Tier 1
+Clotrimazole
Clotrimazole
ORAL TROCHE
($0.00 - $2.95) Tier 1
+Clotrimazole
Clotrimazole
TOPICAL SOLUTION
($0.00 - $2.95) Tier 1
+Clotrimazole
Clotrimazole
CREAM
($0.00 - $2.95) Tier 1
+Clotrimazole-Betamethasone
Clotrimazole/Betamethasone Dip
CREAM
($0.00 - $2.95) Tier 1
+Clotrimazole-Betamethasone
Clotrimazole/Betamethasone Dip
TOPICAL LOTION
($0.00 - $2.95) Tier 1
+Econazole Nitrate
Econazole Nitrate
CREAM
($0.00 - $2.95) Tier 1
ERAXIS (WATER DILUENT)
Anidulafungin
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2 +Fluconazole
Fluconazole
ORAL SUSP
($0.00 - $2.95) Tier 1
+Fluconazole
Fluconazole
TABLET
($0.00 - $2.95) Tier 1
Fluconazole-Nacl
Fluconazole In Nacl,Iso-Osm
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
PA PART D DRUGS
61
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Flucytosine
Flucytosine
CAPSULE
($0.00 - $2.95) Tier 1
+Griseofulvin
Griseofulvin, Microsize
TABLET
($0.00 - $2.95) Tier 1
+Griseofulvin
Griseofulvin, Microsize
ORAL SUSP
($0.00 - $2.95) Tier 1
+Griseofulvin Ultramicrosize
Griseofulvin Ultramicrosize
TABLET
($0.00 - $2.95) Tier 1
Itraconazole
Itraconazole
CAPSULE
($0.00 - $2.95) Tier 1
+Ketoconazole
Ketoconazole
CREAM
($0.00 - $2.95) Tier 1
+Ketoconazole
Ketoconazole
SHAMPOO
($0.00 - $2.95) Tier 1
+Ketoconazole
Ketoconazole
TABLET
($0.00 - $2.95) Tier 1
+Miconazole 3
Miconazole Nitrate
VAGINAL SUPP
($0.00 - $2.95) Tier 1
+Nyamyc
Nystatin
TOPICAL POWDER
($0.00 - $2.95) Tier 1
+Nystatin
Nystatin
CREAM
($0.00 - $2.95) Tier 1
+Nystatin
Nystatin
ORAL SUSP
($0.00 - $2.95) Tier 1
+Nystatin
Nystatin
TABLET
($0.00 - $2.95) Tier 1
+Nystatin
Nystatin
TOPICAL POWDER
($0.00 - $2.95) Tier 1
+Nystatin
Nystatin
TOPICAL OINT.
($0.00 - $2.95) Tier 1
+Nystatin-Triamcinolone
Nystatin/Triamcin
CREAM
($0.00 - $2.95) Tier 1
+Nystatin-Triamcinolone
Nystatin/Triamcin
TOPICAL OINT.
($0.00 - $2.95) Tier 1
PA + Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies.
62
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Nystop
Nystatin
TOPICAL POWDER
($0.00 - $2.95) Tier 1
Terbinafine Hcl
Terbinafine Hcl
TABLET
($0.00 - $2.95) Tier 1
VORICONAZOLE
Voriconazole
ORAL SUSP
($0.00 - $7.40) Tier 2
PA
VORICONAZOLE
Voriconazole
TABLET
($0.00 - $7.40) Tier 2
PA
VORICONAZOLE
Voriconazole
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
Clemastine Fumarate
Clemastine Fumarate
TABLET
($0.00 - $2.95) Tier 1
PA>65 y/o
Clemastine Fumarate
Clemastine Fumarate
ORAL SYRUP
($0.00 - $2.95) Tier 1
PA>65 y/o
+Cyproheptadine Hcl
Cyproheptadine Hcl
TABLET
($0.00 - $2.95) Tier 1
PA>65 y/o
+Desloratadine
Desloratadine
TABLET
($0.00 - $2.95) Tier 1
ST
+Desloratadine
Desloratadine
TAB RAPDIS
($0.00 - $2.95) Tier 1
ST
Diphenhydramine Hcl
Diphenhydramine Hcl
INJECTION
($0.00 - $2.95) Tier 1
BvD
Promethazine Hcl
Promethazine Hcl
ORAL SYRUP
($0.00 - $2.95) Tier 1
PA>65 y/o
ANTIHISTAMINES
ANTIHISTAMINES
PART D DRUGS
63
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Clindamycin Phosphate
VAGINAL CREAM
($0.00 - $2.95) Tier 1
+Metronidazole
Metronidazole
VAGINAL GEL
($0.00 - $2.95) Tier 1
Terconazole
Terconazole
VAGINAL SUPP
($0.00 - $2.95) Tier 1
Terconazole
Terconazole
VAGINAL CREAM
($0.00 - $2.95) Tier 1
ANTIMIGRAINE AGENTS
PART D DRUGS
ANTIMIGRAINE AGENTS
Dihydroergotamine Mesylate
Dihydroergotamine Mesylate
INJECTION
($0.00 - $2.95) Tier 1
BvD ERGOMAR
Ergotamine Tartrate
TAB SUBL
($0.00 - $7.40) Tier 2 +Migergot
Ergotamine Tartrate/Caffeine
RECTAL SUPP
($0.00 - $2.95) Tier 1
Rizatriptan
Rizatriptan Benzoate
TABLET
($0.00 - $2.95) Tier 1
QL Rizatriptan
Rizatriptan Benzoate
TAB RAPDIS
($0.00 - $2.95) Tier 1
QL
Sumatriptan
Sumatriptan
NASAL SPRAY
($0.00 - $2.95) Tier 1
QL Sumatriptan Succinate
Sumatriptan Succinate
INJECTION
($0.00 - $2.95) Tier 1
QL Sumatriptan Succinate
Sumatriptan Succinate
TABLET
($0.00 - $2.95) Tier 1
QL
64
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS
CAPASTAT SULFATE
Capreomycin Sulfate
INJECTION
($0.00 - $7.40) Tier 2
PA CYCLOSERINE
Cycloserine
CAPSULE
($0.00 - $7.40) Tier 2 +DAPSONE
Dapsone
TABLET
($0.00 - $7.40) Tier 2
+Ethambutol Hcl
Ethambutol Hcl
TABLET
($0.00 - $2.95) Tier 1
+Isoniazid
Isoniazid
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Isoniazid
Isoniazid
TABLET
($0.00 - $2.95) Tier 1
+PASER
Aminosalicylic Acid
GRANULATED PACKET
($0.00 - $7.40) Tier 2
PRIFTIN
Rifapentine
TABLET
($0.00 - $7.40) Tier 2 +Pyrazinamide
Pyrazinamide
TABLET
($0.00 - $2.95) Tier 1
Rifabutin
Rifabutin
CAPSULE
($0.00 - $2.95) Tier 1 Rifampin
Rifampin
CAPSULE
($0.00 - $2.95) Tier 1 RIFAMPIN
Rifampin
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
RIFATER
Rifamp/Isoniazid/Pyrazinamide
TABLET
($0.00 - $7.40) Tier 2 TRECATOR
Ethionamide
TABLET
($0.00 - $7.40) Tier 2 PART D DRUGS
65
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
ANTINAUSEA AGENTS
PART D DRUGS
ANTINAUSEA AGENTS
+Compro
Prochlorperazine
RECTAL SUPP
($0.00 - $2.95) Tier 1
DRONABINOL
Dronabinol
CAPSULE
($0.00 - $7.40) Tier 2
PA EMEND
Fosaprepitant Dimeglumine
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD EMEND
Aprepitant
CAPSULE
($0.00 - $7.40) Tier 2
BvD
EMEND
Aprepitant
CAP DS PK
($0.00 - $7.40) Tier 2
BvD
Granisetron Hcl
Granisetron Hcl
TABLET
($0.00 - $2.95) Tier 1
BvD Granisetron Hcl 1 Mg/Ml
Granisetron Hcl
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD GRANISETRON HCL 100 MCG/ML Granisetron Hcl/Pf
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD +Meclizine Hcl
Meclizine Hcl
TABLET
($0.00 - $2.95) Tier 1
Ondansetron Hcl
Ondansetron Hcl/Pf
INJECTION
($0.00 - $2.95) Tier 1
BvD Ondansetron Hcl
Ondansetron Hcl
TABLET
($0.00 - $2.95) Tier 1
BvD
Ondansetron Hcl
Ondansetron Hcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
BvD
Ondansetron Odt
Ondansetron
TAB RAPDIS
($0.00 - $2.95) Tier 1
BvD Phenadoz
Promethazine Hcl
RECTAL SUPP
($0.00 - $2.95) Tier 1
PA>65 y/o Prochlorperazine
Prochlorperazine
RECTAL SUPP
($0.00 - $2.95) Tier 1 + Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies.
66
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Prochlorperazine Edisylate
Prochlorperazine Edisylate
INJECTION
($0.00 - $2.95) Tier 1
BvD
Prochlorperazine Maleate
Prochlorperazine Maleate
TABLET
($0.00 - $2.95) Tier 1
Promethazine Hcl
Promethazine Hcl
INJECTION
($0.00 - $2.95) Tier 1
BvD
Promethazine Hcl
Promethazine Hcl
TABLET
($0.00 - $2.95) Tier 1
PA>65 y/o
Promethazine Hcl
Promethazine Hcl
RECTAL SUPP
($0.00 - $2.95) Tier 1
PA>65 y/o
Promethegan
Promethazine Hcl
RECTAL SUPP
($0.00 - $2.95) Tier 1
PA>65 y/o
TRANSDERM-SCOP
Scopolamine
PATCH
($0.00 - $7.40) Tier 2
PA
ALBENZA
Albendazole
TABLET
($0.00 - $7.40) Tier 2 ALINIA
Nitazoxanide
TABLET
($0.00 - $7.40) Tier 2
ATOVAQUONE
Atovaquone
ORAL SUSP
($0.00 - $7.40) Tier 2 ATOVAQUONE-PROGUANIL HCL
Atovaquone/Proguanil Hcl
TABLET
($0.00 - $7.40) Tier 2 BILTRICIDE
Praziquantel
TABLET
($0.00 - $7.40) Tier 2 +Chloroquine Phosphate
Chloroquine Phosphate
TABLET
($0.00 - $2.95) Tier 1
DARAPRIM
Pyrimethamine
TABLET
($0.00 - $7.40) Tier 2 +Hydroxychloroquine Sulfate
Hydroxychloroquine Sulfate
TABLET
($0.00 - $2.95) Tier 1
ANTIPARASITE AGENTS
PART D DRUGS
ANTIPARASITE AGENTS
67
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
IVERMECTIN
Ivermectin
TABLET
($0.00 - $7.40) Tier 2
+Mefloquine Hcl
Mefloquine Hcl
TABLET
($0.00 - $2.95) Tier 1
NEBUPENT
Pentamidine Isethionate
INHALATION SOLN
($0.00 - $7.40) Tier 2
+Paromomycin Sulfate
Paromomycin Sulfate
CAPSULE
($0.00 - $2.95) Tier 1
PENTAM 300
Pentamidine Isethionate
INJECTION
($0.00 - $7.40) Tier 2
+PRIMAQUINE
Primaquine Phosphate
TABLET
($0.00 - $7.40) Tier 2
NECESSARY ACTIONS,
BvD, PA
BvD, PA
PART D DRUGS
+Amantadine
Amantadine Hcl
TABLET
($0.00 - $2.95) Tier 1
+Amantadine
Amantadine Hcl
CAPSULE
($0.00 - $2.95) Tier 1
+Amantadine
Amantadine Hcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+APOKYN
Apomorphine Hcl
INJECTION
($0.00 - $7.40) Tier 2
PA +AZILECT 0.5 MG
Rasagiline Mesylate
TABLET
($0.00 - $7.40) Tier 2
PA, QL
+AZILECT 1 MG
Rasagiline Mesylate
TABLET
($0.00 - $7.40) Tier 2
PA +Benztropine Mesylate
Benztropine Mesylate
TABLET
($0.00 - $2.95) Tier 1
PA>65 y/o +Bromocriptine Mesylate
CAPSULE
($0.00 - $2.95) Tier 1
+Bromocriptine Mesylate
TABLET
($0.00 - $2.95) Tier 1
68
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Cabergoline
TABLET
($0.00 - $2.95) Tier 1
+Carbidopa-Levodopa
Carbidopa/Levodopa
TABLET
($0.00 - $2.95) Tier 1
+Carbidopa-Levodopa Er
Carbidopa/Levodopa
TAB ER
($0.00 - $2.95) Tier 1
+Carbidopa-Levodopa-Entacapone
Carbidopa/Levodopa/Entacapone
TABLET
($0.00 - $2.95) Tier 1
ST
+ENTACAPONE
Entacapone
TABLET
($0.00 - $7.40) Tier 2
ST
+Pramipexole Dihydrochloride
Pramipexole Di-Hcl
TABLET
($0.00 - $2.95) Tier 1
+Ropinirole Hcl
Ropinirole Hcl
TABLET
($0.00 - $2.95) Tier 1
+Selegiline Hcl
Selegiline Hcl
CAPSULE
($0.00 - $2.95) Tier 1
+Selegiline Hcl
Selegiline Hcl
TABLET
($0.00 - $2.95) Tier 1
+TOLCAPONE
Tolcapone
TABLET
($0.00 - $7.40) Tier 2
ST
+Trihexyphenidyl Hcl
Trihexyphenidyl Hcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
PA>65 y/o
+Trihexyphenidyl Hcl
Trihexyphenidyl Hcl
TABLET
($0.00 - $2.95) Tier 1
PA>65 y/o
PART D DRUGS
+Cabergoline
+ABILIFY
Aripiprazole
ORAL SOLUTION
($0.00 - $7.40) Tier 2
QL ABILIFY
Aripiprazole
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ABILIFY DISCMELT 10 MG
Aripiprazole
TAB RAPDIS
($0.00 - $7.40) Tier 2
QL + Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies.
69
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ABILIFY DISCMELT 15 MG
Aripiprazole
TAB RAPDIS
($0.00 - $7.40) Tier 2
QL
+ABILIFY MAINTENA
Aripiprazole
VIAL
($0.00 - $7.40) Tier 2
BvD, PA
+ABILIFY MAINTENA
Aripiprazole
SUSER SYRINGE
($0.00 - $7.40) Tier 2
BvD, PA
ADASUVE
Loxapine
AEROSOL
($0.00 - $7.40) Tier 2
BvD, PA
+Aripiprazole 2 Mg, 5 Mg, 10 Mg, 15 Mg Aripiprazole
TABLET
($0.00 - $2.95) Tier 1
QL
+ARIPIPRAZOLE 20 MG, 30 MG
Aripiprazole
TABLET
($0.00 - $7.40) Tier 2
+Chlorpromazine Hcl
Chlorpromazine Hcl
TABLET
($0.00 - $2.95) Tier 1
Chlorpromazine Hcl
Chlorpromazine Hcl
INJECTION
($0.00 - $2.95) Tier 1
+Clozapine
Clozapine
TABLET
($0.00 - $2.95) Tier 1
+CLOZAPINE ODT
Clozapine
TAB RAPDIS
($0.00 - $7.40) Tier 2
FANAPT
Iloperidone
TAB DS PK
($0.00 - $7.40) Tier 2
PA
+FANAPT
Iloperidone
TABLET
($0.00 - $7.40) Tier 2
PA
Fluphenazine Decanoate
Fluphenazine Decanoate
INJECTION
($0.00 - $2.95) Tier 1
BvD, PA
+Fluphenazine Hcl
Fluphenazine Hcl
ORAL CONC
($0.00 - $2.95) Tier 1
Fluphenazine Hcl
Fluphenazine Hcl
INJECTION
($0.00 - $2.95) Tier 1
+Fluphenazine Hcl
Fluphenazine Hcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Fluphenazine Hcl
Fluphenazine Hcl
TABLET
($0.00 - $2.95) Tier 1
BvD, PA
BvD, PA
70
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
GEODON
Ziprasidone Mesylate
INJECTION
($0.00 - $7.40) Tier 2
PA
+Haloperidol
Haloperidol
TABLET
($0.00 - $2.95) Tier 1
+Haloperidol Decanoate
Haloperidol Decanoate
INJECTION
($0.00 - $2.95) Tier 1
+Haloperidol Lactate
Haloperidol Lactate
ORAL CONC
($0.00 - $2.95) Tier 1
Haloperidol Lactate
Haloperidol Lactate
INJECTION
($0.00 - $2.95) Tier 1
BvD, PA
+INVEGA 1.5 MG
Paliperidone
TAB ER 24
($0.00 - $7.40) Tier 2
BvD,QL
+INVEGA 3 MG
Paliperidone
TAB ER 24
($0.00 - $7.40) Tier 2
BvD,QL
+INVEGA 6 MG, 9 MG
Paliperidone
TAB ER 24
($0.00 - $7.40) Tier 2
BvD,QL
+INVEGA SUSTENNA 117MG/0.75 Paliperidone Palmitate
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+INVEGA SUSTENNA 156 MG/ML, 234MG/1.5 Paliperidone Palmitate
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+INVEGA SUSTENNA 39MG/0.25, 78MG/0.5ML Paliperidone Palmitate
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+LATUDA
Lurasidone Hcl
TABLET
($0.00 - $7.40) Tier 2
PA
+Loxapine
Loxapine Succinate
CAPSULE
($0.00 - $2.95) Tier 1
Olanzapine
Olanzapine
INJECTION
($0.00 - $2.95) Tier 1
BvD, PA
+Olanzapine 15 Mg
Olanzapine
TABLET
($0.00 - $2.95) Tier 1
QL
+Olanzapine 2.5 Mg , 5 Mg
Olanzapine
TABLET
($0.00 - $2.95) Tier 1
QL
+OLANZAPINE 20 MG
Olanzapine
TABLET
($0.00 - $7.40) Tier 2
QL
BvD, PA
PART D DRUGS
71
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Olanzapine 7.5 Mg, 10 Mg
Olanzapine
TABLET
($0.00 - $2.95) Tier 1
QL
+Olanzapine Odt
Olanzapine
TAB RAPDIS
($0.00 - $2.95) Tier 1
QL
+ORAP
Pimozide
TABLET
($0.00 - $7.40) Tier 2
+Perphenazine
Perphenazine
TABLET
($0.00 - $2.95) Tier 1
+Quetiapine Fumarate
Quetiapine Fumarate
TABLET
($0.00 - $2.95) Tier 1
QL
+RISPERDAL CONSTA 12.5MG/2ML Risperidone Microspheres
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+RISPERDAL CONSTA 25 MG/2 ML Risperidone Microspheres
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+RISPERDAL CONSTA 37.5MG/2ML Risperidone Microspheres
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+RISPERDAL CONSTA 50 MG/2 ML Risperidone Microspheres
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+Risperidone
Risperidone
TAB RAPDIS
($0.00 - $2.95) Tier 1
QL
+Risperidone
Risperidone
TABLET
($0.00 - $2.95) Tier 1
QL
+Risperidone
Risperidone
ORAL SOLUTION
($0.00 - $2.95) Tier 1
QL
+Risperidone Odt
Risperidone
TAB RAPDIS
($0.00 - $2.95) Tier 1
QL
+SAPHRIS
Asenapine Maleate
TAB SUBL
($0.00 - $7.40) Tier 2
PA
+Thioridazine Hcl
Thioridazine Hcl
TABLET
($0.00 - $2.95) Tier 1
PA
+Thiothixene
Thiothixene
CAPSULE
($0.00 - $2.95) Tier 1
+Trifluoperazine Hcl
Trifluoperazine Hcl
TABLET
($0.00 - $2.95) Tier 1
72
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+VERSACLOZ
Clozapine
ORAL SUSP
($0.00 - $7.40) Tier 2
PA
+Ziprasidone Hcl 20 Mg, 40 Mg
Ziprasidone Hcl
CAPSULE
($0.00 - $2.95) Tier 1
QL
+Ziprasidone Hcl 60 Mg, 80 Mg
Ziprasidone Hcl
CAPSULE
($0.00 - $2.95) Tier 1
QL
+ZYPREXA RELPREVV
Olanzapine Pamoate
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
Abacavir Sulfate
TABLET
($0.00 - $2.95) Tier 1
+ABACAVIR-LAMIVUDINE-ZIDOVUDINE Abacavir/Lamivudine/Zidovudine TABLET
($0.00 - $7.40) Tier 2
+APTIVUS
Tipranavir
CAPSULE
($0.00 - $7.40) Tier 2
+APTIVUS
Tipranavir/Vitamin E Tpgs
ORAL SOLUTION
($0.00 - $7.40) Tier 2
+ATRIPLA
Efavirenz/Emtricitab/Tenofovir
TABLET
($0.00 - $7.40) Tier 2
+COMPLERA
Emtricitab/Rilpivirine/Tenofov
TABLET
($0.00 - $7.40) Tier 2
+CRIXIVAN
Indinavir Sulfate
CAPSULE
($0.00 - $7.40) Tier 2
+Didanosine
Didanosine
CAPSULE CR
($0.00 - $2.95) Tier 1
+EDURANT
Rilpivirine Hcl
TABLET
($0.00 - $7.40) Tier 2
+EMTRIVA
Emtricitabine
ORAL SOLUTION
($0.00 - $7.40) Tier 2
+EMTRIVA
Emtricitabine
CAPSULE
($0.00 - $7.40) Tier 2
ANTIVIRALS (SYSTEMIC)
ANTIRETROVIRALS
+Abacavir
PART D DRUGS
73
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+EPIVIR HBV
Lamivudine
ORAL SOLUTION
($0.00 - $7.40) Tier 2
PA
+EPZICOM
Abacavir Sulfate/Lamivudine
TABLET
($0.00 - $7.40) Tier 2
+EVOTAZ
Atazanavir Sulfate/Cobicistat
TABLET
($0.00 - $7.40) Tier 2
+FUZEON
Enfuvirtide
INJECTION
($0.00 - $7.40) Tier 2
+INTELENCE 100 MG, 200 MG
Etravirine
TABLET
($0.00 - $7.40) Tier 2
+INTELENCE 25 MG
Etravirine
TABLET
($0.00 - $7.40) Tier 2
+INVIRASE
Saquinavir Mesylate
CAPSULE
($0.00 - $7.40) Tier 2
+INVIRASE
Saquinavir Mesylate
TABLET
($0.00 - $7.40) Tier 2
+ISENTRESS
Raltegravir Potassium
TABLET
($0.00 - $7.40) Tier 2
+ISENTRESS
ORAL PACKETS
($0.00 - $7.40) Tier 2
QL
+ISENTRESS 100 MG
TAB CHEW
($0.00 - $7.40) Tier 2
QL
+ISENTRESS 25 MG
TAB CHEW
($0.00 - $7.40) Tier 2
QL
+KALETRA
Lopinavir/Ritonavir
ORAL SOLUTION
($0.00 - $7.40) Tier 2
+KALETRA 100MG-25MG
Lopinavir/Ritonavir
TABLET
($0.00 - $7.40) Tier 2
+KALETRA 200MG-50MG
Lopinavir/Ritonavir
TABLET
($0.00 - $7.40) Tier 2
+Lamivudine
Lamivudine
TABLET
($0.00 - $2.95) Tier 1
+LAMIVUDINE
Lamivudine
ORAL SOLUTION
($0.00 - $7.40) Tier 2
QL
74
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Lamivudine Hbv
Lamivudine
TABLET
($0.00 - $2.95) Tier 1
+LAMIVUDINE-ZIDOVUDINE
Lamivudine/Zidovudine
TABLET
($0.00 - $7.40) Tier 2
+LEXIVA
Fosamprenavir Calcium
ORAL SUSP
($0.00 - $7.40) Tier 2
+LEXIVA
Fosamprenavir Calcium
TABLET
($0.00 - $7.40) Tier 2
+Nevirapine
Nevirapine
TABLET
($0.00 - $2.95) Tier 1
+Nevirapine
Nevirapine
ORAL SUSP
($0.00 - $2.95) Tier 1
+Nevirapine Er
Nevirapine
TAB ER 24
($0.00 - $2.95) Tier 1
+NORVIR
Ritonavir
TABLET
($0.00 - $7.40) Tier 2
+NORVIR
Ritonavir
ORAL SOLUTION
($0.00 - $7.40) Tier 2
+NORVIR
Ritonavir
CAPSULE
($0.00 - $7.40) Tier 2
+PREZCOBIX
Darunavir/Cobicistat
TABLET
($0.00 - $7.40) Tier 2
+PREZISTA
Darunavir Ethanolate
ORAL SUSP
($0.00 - $7.40) Tier 2
+PREZISTA 150 MG,
TABLET
($0.00 - $7.40) Tier 2
+PREZISTA 400 MG, 600 MG
TABLET
($0.00 - $7.40) Tier 2
+PREZISTA 75 MG
TABLET
($0.00 - $7.40) Tier 2
QL
+PREZISTA 800 MG
TABLET
($0.00 - $7.40) Tier 2
+RESCRIPTOR
Delavirdine Mesylate
TAB DISPER
($0.00 - $7.40) Tier 2
PART D DRUGS
75
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
+RESCRIPTOR
Delavirdine Mesylate
TABLET
($0.00 - $7.40) Tier 2
RETROVIR
Zidovudine
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
+REYATAZ
Atazanavir Sulfate
ORAL PACKETS
($0.00 - $7.40) Tier 2
+REYATAZ
Atazanavir Sulfate
CAPSULE
($0.00 - $7.40) Tier 2
+SELZENTRY
Maraviroc
TABLET
($0.00 - $7.40) Tier 2
+Stavudine
Stavudine
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Stavudine
Stavudine
CAPSULE
($0.00 - $2.95) Tier 1
+STRIBILD
Elvitegr/Cobicist/Emtric/Tenof
TABLET
($0.00 - $7.40) Tier 2
+SUSTIVA 50 MG, 200 MG
Efavirenz
CAPSULE
($0.00 - $7.40) Tier 2
+SUSTIVA 600 MG
Efavirenz
TABLET
($0.00 - $7.40) Tier 2
+TIVICAY
Dolutegravir Sodium
TABLET
($0.00 - $7.40) Tier 2
+TRIUMEQ
Abacavir/Dolutegravir/Lamivudi
TABLET
($0.00 - $7.40) Tier 2
+TRUVADA
Emtricitabine/Tenofovir
TABLET
($0.00 - $7.40) Tier 2
+VIDEX
Didanosine
ORAL SOLUTION
($0.00 - $7.40) Tier 2
+VIRACEPT
Nelfinavir Mesylate
TABLET
($0.00 - $7.40) Tier 2
+VIRAMUNE XR
Nevirapine
TAB ER 24
($0.00 - $7.40) Tier 2
+VIREAD
Tenofovir Disoproxil Fumarate
ORAL POWDER
($0.00 - $7.40) Tier 2
NECESSARY ACTIONS,
76
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
+VIREAD
Tenofovir Disoproxil Fumarate
TABLET
($0.00 - $7.40) Tier 2
+VITEKTA
Elvitegravir
TABLET
($0.00 - $7.40) Tier 2
+ZIAGEN
Abacavir Sulfate
ORAL SOLUTION
($0.00 - $7.40) Tier 2
+Zidovudine
Zidovudine
ORAL SYRUP
($0.00 - $2.95) Tier 1
+Zidovudine
Zidovudine
TABLET
($0.00 - $2.95) Tier 1
+Zidovudine
Zidovudine
CAPSULE
($0.00 - $2.95) Tier 1
NECESSARY ACTIONS,
ANTIVIRALS, MISCELLANEOUS
Zanamivir
INHALATION DISK
($0.00 - $7.40) Tier 2
QL
Rimantadine Hcl
Rimantadine Hcl
TABLET
($0.00 - $2.95) Tier 1
SYNAGIS
Palivizumab
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
TAMIFLU 30 MG
Oseltamivir Phosphate
CAPSULE
($0.00 - $7.40) Tier 2
QL
TAMIFLU 45 MG, 75 MG
CAPSULE
($0.00 - $7.40) Tier 2
QL
TAMIFLU 6 MG/ML
ORAL SUSP
($0.00 - $7.40) Tier 2
QL
HARVONI
Ledipasvir/Sofosbuvir
TABLET
($0.00 - $7.40) Tier 2
PA OLYSIO
Simeprevir Sodium
CAPSULE
($0.00 - $7.40) Tier 2
PA SOVALDI
Sofosbuvir
TABLET
($0.00 - $7.40) Tier 2
PA PART D DRUGS
RELENZA
HCV ANTIVIRALS
77
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
INTERFERONS
INTRON A
Interferon Alfa-2B,Recomb.
INJECTION
($0.00 - $7.40) Tier 2
PA
PEGASYS
Peginterferon Alfa-2A
INJECTION
($0.00 - $7.40) Tier 2
PA
PEGASYS PROCLICK
Peginterferon Alfa-2A
INJECTION
($0.00 - $7.40) Tier 2
PA
PEGINTRON
Peginterferon Alfa-2B
INJECTION
($0.00 - $7.40) Tier 2
PA
PEGINTRON REDIPEN
INJECTION KIT
($0.00 - $7.40) Tier 2
PA
+SYLATRON
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
PART D DRUGS
NUCLEOSIDES AND NUCLEOTIDES
+Acyclovir
Acyclovir
CAPSULE
($0.00 - $2.95) Tier 1
+Acyclovir
Acyclovir
TABLET
($0.00 - $2.95) Tier 1
+Acyclovir
Acyclovir
ORAL SUSP
($0.00 - $2.95) Tier 1
Acyclovir Sodium
Acyclovir Sodium
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD ADEFOVIR DIPIVOXIL
Adefovir Dipivoxil
TABLET
($0.00 - $7.40) Tier 2
PA +BARACLUDE
Entecavir
ORAL SOLUTION
($0.00 - $7.40) Tier 2
PA +ENTECAVIR
Entecavir
TABLET
($0.00 - $7.40) Tier 2
PA GANCICLOVIR SODIUM
Ganciclovir Sodium
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD Ribasphere
Ribavirin
TABLET
($0.00 - $2.95) Tier 1
78
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Ribasphere
Ribavirin
CAPSULE
($0.00 - $2.95) Tier 1
PA
Ribavirin
Ribavirin
CAPSULE
($0.00 - $2.95) Tier 1
PA
Ribavirin
Ribavirin
TABLET
($0.00 - $2.95) Tier 1
PA
+TYZEKA
Telbivudine
TABLET
($0.00 - $7.40) Tier 2
PA
+Valacyclovir
Valacyclovir Hcl
TABLET
($0.00 - $2.95) Tier 1
+VALGANCICLOVIR HCL
Valganciclovir Hcl
TABLET
($0.00 - $7.40) Tier 2
VIRAZOLE
Ribavirin
INHALATION SOLN
($0.00 - $7.40) Tier 2
BvD
+COUMADIN
Warfarin Sodium
TABLET
($0.00 - $7.40) Tier 2
+ELIQUIS
Apixaban
TABLET
($0.00 - $7.40) Tier 2
PA ENOXAPARIN SODIUM 120MG/.8ML, 150 MG/ML Enoxaparin Sodium
INJECTION
($0.00 - $7.40) Tier 2
PA ENOXAPARIN SODIUM 300MG/3ML Enoxaparin Sodium
INJECTION
($0.00 - $7.40) Tier 2
PA ENOXAPARIN SODIUM 30MG/0.3ML Enoxaparin Sodium
INJECTION
($0.00 - $7.40) Tier 2
PA ENOXAPARIN SODIUM 40MG/0.4ML, 60MG/0.6ML Enoxaparin Sodium
INJECTION
($0.00 - $7.40) Tier 2
PA ENOXAPARIN SODIUM 80MG/0.8ML, 100 MG/ML Enoxaparin Sodium
INJECTION
($0.00 - $7.40) Tier 2
PA FONDAPARINUX SODIUM
INJECTION
($0.00 - $7.40) Tier 2
PA Fondaparinux Sodium
PART D DRUGS
ANTICOAGULANTS
79
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
FRAGMIN
Dalteparin Sodium,Porcine
INJECTION
($0.00 - $7.40) Tier 2
PA
Heparin Sodium
Heparin Sodium,Porcine
INJECTION
($0.00 - $2.95) Tier 1
BvD
Heparin Sodium In 0.45% Nacl
Heparin Sod,Pork In 0.45% Nacl
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
Heparin Sodium-0.9% Nacl
Heparin Sodium,Porcine/Ns/Pf
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
Heparin Sodium-D5W
Heparin Sodium,Porcine/D5W
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
+Jantoven
Warfarin Sodium
TABLET
($0.00 - $2.95) Tier 1
+PRADAXA
Dabigatran Etexilate Mesylate
CAPSULE
($0.00 - $7.40) Tier 2
+Warfarin Sodium
Warfarin Sodium
TABLET
($0.00 - $2.95) Tier 1
+XARELTO
Rivaroxaban
TABLET
($0.00 - $7.40) Tier 2
PA
XARELTO
Rivaroxaban
TAB DS PK
($0.00 - $7.40) Tier 2
PA
PA
BLOOD FORMATION MODIFIERS
+ARANESP 100 MCG/ML
Darbepoetin Alfa In Polysorbat
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ARANESP 100MCG/0.5
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ARANESP 10MCG/0.4
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ARANESP 150MCG/0.3
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ARANESP 200 MCG/ML
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ARANESP 200MCG/0.4
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
80
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ARANESP 25MCG/0.42
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ARANESP 300 MCG/ML
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ARANESP 300MCG/0.6
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ARANESP 40 MCG/0.4
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ARANESP 40 MCG/ML
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ARANESP 500 MCG/ML
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ARANESP 60MCG/0.3
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ARANESP 60MCG/ML
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+EPOGEN 2000/ML, 10000/ML
Epoetin Alfa
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+EPOGEN 20000/ML
Epoetin Alfa
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+EPOGEN 3000/ML, 4000/ML
Epoetin Alfa
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
GRANIX
Tbo-Filgrastim
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
LEUKINE
Sargramostim
INJECTION
($0.00 - $7.40) Tier 2
PA
+MIRCERA
Methoxy Peg-Epoetin Beta
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
MOZOBIL
Plerixafor
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
NEULASTA
Pegfilgrastim
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
PART D DRUGS
+ARANESP 25 MCG/ML
81
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
NEUMEGA
Oprelvekin
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
NEUPOGEN
Filgrastim
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+PROCRIT 2000/ML
Epoetin Alfa
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+PROCRIT 20000/2ML
Epoetin Alfa
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+PROCRIT 20000/ML
Epoetin Alfa
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+PROCRIT 3000/ML
Epoetin Alfa
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+PROCRIT 4000/ML
Epoetin Alfa
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+PROCRIT 40000/ML
Epoetin Alfa
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+PROMACTA
Eltrombopag Olamine
TABLET
($0.00 - $7.40) Tier 2
PA
RUCONEST
C1 Esterase Inhibitor, Recomb
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
HEMATOLOGIC AGENTS, MISCELLANEOUS
Aminocaproic Acid
Aminocaproic Acid
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD Aminocaproic Acid
Aminocaproic Acid
TABLET
($0.00 - $2.95) Tier 1
PA
Aminocaproic Acid
Aminocaproic Acid
ORAL SOLUTION
($0.00 - $2.95) Tier 1
PA
+Anagrelide Hcl
Anagrelide Hcl
CAPSULE
($0.00 - $2.95) Tier 1
TRANEXAMIC ACID
Tranexamic Acid
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+TRANEXAMIC ACID
Tranexamic Acid
TABLET
($0.00 - $7.40) Tier 2
PA
82
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
PLATELET-AGGREGATION INHIBITORS
+AGGRENOX
Aspirin/Dipyridamole
CAPSULE
($0.00 - $7.40) Tier 2
+ASPIRIN-DIPYRIDAMOLE ER
Aspirin/Dipyridamole
CAPSULE
($0.00 - $7.40) Tier 2
+BRILINTA
Ticagrelor
TABLET
($0.00 - $7.40) Tier 2
+Cilostazol
Cilostazol
TABLET
($0.00 - $2.95) Tier 1
+Clopidogrel
Clopidogrel Bisulfate
TABLET
($0.00 - $2.95) Tier 1
+Dipyridamole
Dipyridamole
TABLET
($0.00 - $2.95) Tier 1
+Pentoxifylline
Pentoxifylline
TAB ER
($0.00 - $2.95) Tier 1
+Ticlopidine Hcl
Ticlopidine Hcl
TABLET
($0.00 - $2.95) Tier 1
PA>65 y/o
AMINOSYN
Parenteral Amino Acid 3.5% No1
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD Aminosyn Ii
Parenteral Amino Acid 15% No.2
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD AMINOSYN II
Parenteral Amino Acid 7 % No.2
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD AMINOSYN-HBC
Amino Acids 7 %
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD AMINOSYN-PF
Parent. Amino Acid 7 % #1(Ped)
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD Dextrose In Ringers Injection
Dextrose 5% In Ringers
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD PA>65 y/o
PART D DRUGS
CALORIC AGENTS
CALORIC AGENTS
83
WHAT THE DRUG WILL
NECESSARY ACTIONS,
BRAND DRUG NAME
GENERIC DRUG NAME
Dextrose In Water
Dextrose In Water
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
FREAMINE HBC
Amino Acids 6.9 %
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
INTRALIPID
Fat Emulsions
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
NEPHRAMINE
Amino Acids 5.4 %
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
Premasol
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
Travasol
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
Trophamine
Amino Acids 10 %
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
FORMULATION
PART D DRUGS
ALPHA-ADRENERGIC AGENTS
+Clonidine Hcl
Clonidine Hcl
TABLET
($0.00 - $2.95) Tier 1
+Doxazosin Mesylate
Doxazosin Mesylate
TABLET
($0.00 - $2.95) Tier 1
+Guanfacine Hcl
Guanfacine Hcl
TABLET
($0.00 - $2.95) Tier 1
PA>65 y/o +Methyldopa
Methyldopa
TABLET
($0.00 - $2.95) Tier 1
PA>65 y/o +Methyldopa-Hydrochlorothiazide
Methyldopa/Hydrochlorothiazide
TABLET
($0.00 - $2.95) Tier 1
PA>65 y/o +Midodrine Hcl
Midodrine Hcl
TABLET
($0.00 - $2.95) Tier 1
+Prazosin Hcl
Prazosin Hcl
CAPSULE
($0.00 - $2.95) Tier 1
84
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
ANGIOTENSIN II RECEPTOR ANTAGONISTS
+Losartan Potassium
Losartan Potassium
TABLET
($0.00 - $2.95) Tier 1
+Losartan-Hydrochlorothiazide
Losartan/Hydrochlorothiazide
TABLET
($0.00 - $2.95) Tier 1
+Valsartan
Valsartan
TABLET
($0.00 - $2.95) Tier 1
+Valsartan-Hydrochlorothiazide
Valsartan/Hydrochlorothiazide
TABLET
($0.00 - $2.95) Tier 1
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
Benazepril Hcl
TABLET
($0.00 - $2.95) Tier 1
+Benazepril-Hydrochlorothiazide
Benazepril/Hydrochlorothiazide
TABLET
($0.00 - $2.95) Tier 1
+Captopril
Captopril
TABLET
($0.00 - $2.95) Tier 1
+Captopril-Hydrochlorothiazide
Captopril/Hydrochlorothiazide
TABLET
($0.00 - $2.95) Tier 1
+Enalapril Maleate
Enalapril Maleate
TABLET
($0.00 - $2.95) Tier 1
+Enalapril-Hydrochlorothiazide
Enalapril/Hydrochlorothiazide
TABLET
($0.00 - $2.95) Tier 1
+Fosinopril Sodium
Fosinopril Sodium
TABLET
($0.00 - $2.95) Tier 1
+Fosinopril-Hydrochlorothiazide
Fosinopril/Hydrochlorothiazide
TABLET
($0.00 - $2.95) Tier 1
+Lisinopril
Lisinopril
TABLET
($0.00 - $2.95) Tier 1
+Lisinopril-Hydrochlorothiazide
Lisinopril/Hydrochlorothiazide
TABLET
($0.00 - $2.95) Tier 1
+Moexipril Hcl
Moexipril Hcl
TABLET
($0.00 - $2.95) Tier 1
PART D DRUGS
+Benazepril Hcl
85
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Quinapril Hcl
Quinapril Hcl
TABLET
($0.00 - $2.95) Tier 1
+Quinapril-Hydrochlorothiazide
Quinapril/Hydrochlorothiazide
TABLET
($0.00 - $2.95) Tier 1
+Ramipril
Ramipril
CAPSULE
($0.00 - $2.95) Tier 1
+Trandolapril
Trandolapril
TABLET
($0.00 - $2.95) Tier 1
+Amiodarone Hcl
Amiodarone Hcl
TABLET
($0.00 - $2.95) Tier 1
+Disopyramide Phosphate
Disopyramide Phosphate
CAPSULE
($0.00 - $2.95) Tier 1
+Flecainide Acetate
Flecainide Acetate
TABLET
($0.00 - $2.95) Tier 1
Lidocaine Hcl In 5% Dextrose
Lidocaine Hcl/D5W/Pf
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
+Mexiletine Hcl
Mexiletine Hcl
CAPSULE
($0.00 - $2.95) Tier 1
+MULTAQ
Dronedarone Hcl
TABLET
($0.00 - $7.40) Tier 2
+Pacerone
Amiodarone Hcl
TABLET
($0.00 - $2.95) Tier 1
+Propafenone Hcl
Propafenone Hcl
TABLET
($0.00 - $2.95) Tier 1
+Quinidine Gluconate
Quinidine Gluconate
TAB ER
($0.00 - $2.95) Tier 1
+Quinidine Sulfate
Quinidine Sulfate
TAB ER
($0.00 - $2.95) Tier 1
+Quinidine Sulfate
Quinidine Sulfate
TABLET
($0.00 - $2.95) Tier 1
+TIKOSYN
Dofetilide
CAPSULE
($0.00 - $7.40) Tier 2
PART D DRUGS
ANTIARRHYTHMIC AGENTS
PA>65 y/o BvD PA PA + Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies.
86
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
BETA-ADRENERGIC BLOCKING AGENTS
+Acebutolol Hcl
Acebutolol Hcl
CAPSULE
($0.00 - $2.95) Tier 1
+Atenolol
Atenolol
TABLET
($0.00 - $2.95) Tier 1
+Atenolol-Chlorthalidone
Atenolol/Chlorthalidone
TABLET
($0.00 - $2.95) Tier 1
+Betaxolol Hcl
Betaxolol Hcl
TABLET
($0.00 - $2.95) Tier 1
+Bisoprolol Fumarate
Bisoprolol Fumarate
TABLET
($0.00 - $2.95) Tier 1
+Bisoprolol-Hydrochlorothiazide
Bisoprolol Fumarate/Hctz
TABLET
($0.00 - $2.95) Tier 1
BREVIBLOC
Esmolol In Sodium Chloride,Iso
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
+Carvedilol
Carvedilol
TABLET
($0.00 - $2.95) Tier 1
Esmolol Hcl
Esmolol Hcl
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
+Labetalol Hcl
Labetalol Hcl
TABLET
($0.00 - $2.95) Tier 1
+Metoprolol Succinate 100 Mg
Metoprolol Succinate
TAB ER 24
($0.00 - $2.95) Tier 1
QL +Metoprolol Succinate 200 Mg
Metoprolol Succinate
TAB ER 24
($0.00 - $2.95) Tier 1
QL +Metoprolol Succinate 25 Mg, 50 Mg Metoprolol Succinate
TAB ER 24
($0.00 - $2.95) Tier 1
QL +Metoprolol Tartrate
Metoprolol Tartrate
TABLET
($0.00 - $2.95) Tier 1
+Metoprolol-Hydrochlorothiazide
Metoprolol/Hydrochlorothiazide
TABLET
($0.00 - $2.95) Tier 1
+Nadolol
Nadolol
TABLET
($0.00 - $2.95) Tier 1
BvD PART D DRUGS
87
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
+Pindolol
Pindolol
TABLET
($0.00 - $2.95) Tier 1
+Propranolol Hcl
Propranolol Hcl
TABLET
($0.00 - $2.95) Tier 1
+Propranolol Hcl Er
Propranolol Hcl
CAP SA 24HR
($0.00 - $2.95) Tier 1
+Propranolol-Hydrochlorothiazid
Propranolol/Hydrochlorothiazid
TABLET
($0.00 - $2.95) Tier 1
+Sorine
Sotalol Hcl
TABLET
($0.00 - $2.95) Tier 1
+Sotalol
Sotalol Hcl
TABLET
($0.00 - $2.95) Tier 1
+Timolol Maleate
Timolol Maleate
TABLET
($0.00 - $2.95) Tier 1
NECESSARY ACTIONS,
PART D DRUGS
CALCIUM-CHANNEL BLOCKING AGENTS
+Cartia Xt
Diltiazem Hcl
CAP.ER 24H
($0.00 - $2.95) Tier 1
+Diltiazem 12Hr Er
Diltiazem Hcl
CAP.ER 12H
($0.00 - $2.95) Tier 1
+Diltiazem 24Hr Er
Diltiazem Hcl
CAP.ER 24H
($0.00 - $2.95) Tier 1
+Diltiazem Er
Diltiazem Hcl
ER CAPSULE
($0.00 - $2.95) Tier 1
+Diltiazem Hcl
Diltiazem Hcl
TABLET
($0.00 - $2.95) Tier 1
+Dilt-Xr
Diltiazem Hcl
ER CAPSULE
($0.00 - $2.95) Tier 1
+Taztia Xt
Diltiazem Hcl
ER CAPSULE
($0.00 - $2.95) Tier 1
+Verapamil Er
Verapamil Hcl
TAB ER
($0.00 - $2.95) Tier 1
+Verapamil Er
Verapamil Hcl
CAP24H PEL
($0.00 - $2.95) Tier 1
88
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
+Verapamil Er Pm
Verapamil Hcl
CAP24HR
($0.00 - $2.95) Tier 1
+Verapamil Hcl
Verapamil Hcl
CAP24H PEL
($0.00 - $2.95) Tier 1
+Verapamil Hcl
Verapamil Hcl
TABLET
($0.00 - $2.95) Tier 1
NECESSARY ACTIONS,
CARDIOVASCULAR AGENTS, MISCELLANEOUS
DEMSER
Metyrosine
CAPSULE
($0.00 - $7.40) Tier 2
PA DIGIFAB
Digoxin Immune Fab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD +Digitek 125 Mcg
Digoxin
TABLET
($0.00 - $2.95) Tier 1
QL +Digitek 250 Mcg
Digoxin
TABLET
($0.00 - $2.95) Tier 1
+Digox 125 Mcg
Digoxin
TABLET
($0.00 - $2.95) Tier 1
QL +Digox 250 Mcg
Digoxin
TABLET
($0.00 - $2.95) Tier 1
PA>65 y/o +DIGOXIN
Digoxin
ORAL SOLUTION
($0.00 - $7.40) Tier 2
Digoxin
Digoxin
INJECTION
($0.00 - $2.95) Tier 1
+Epinephrine
Epinephrine
AUTO INJCT
($0.00 - $2.95) Tier 1
+Epinephrine
Epinephrine
INJECTION
($0.00 - $2.95) Tier 1
EPIPEN 2-PAK
Epinephrine
AUTO INJCT
($0.00 - $7.40) Tier 2 FIRAZYR
Icatibant Acetate
INJECTION
($0.00 - $7.40) Tier 2
PA +Hydralazine Hcl
Hydralazine Hcl
TABLET
($0.00 - $2.95) Tier 1
PART D DRUGS
89
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+LANOXIN
Digoxin
TABLET
($0.00 - $7.40) Tier 2
LANOXIN PEDIATRIC
Digoxin
INJECTION
($0.00 - $7.40) Tier 2
BvD
Milrinone In 5% Dextrose
Milrinone Lactate/D5W
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
+RANEXA
Ranolazine
TAB ER 12H
($0.00 - $7.40) Tier 2
+Reserpine
Reserpine
TABLET
($0.00 - $2.95) Tier 1
+Reserpine
Reserpine
TABLET
($0.00 - $2.95) Tier 1
+Afeditab Cr
Nifedipine
TAB ER
($0.00 - $2.95) Tier 1
+Amlodipine Besylate
Amlodipine Besylate
TABLET
($0.00 - $2.95) Tier 1
PA>65 y/o
PART D DRUGS
DIHYDROPYRIDINES
+Amlodipine Besylate-Benazepril '10 Mg-20Mg,5 Mg-20 Mg Amlodipine Besylate/Benazepril CAPSULE
($0.00 - $2.95) Tier 1
QL +Amlodipine Besylate-Benazepril 10 Mg-40Mg, 5 Mg-40 Mg Amlodipine Besylate/Benazepril CAPSULE
($0.00 - $2.95) Tier 1
QL +Amlodipine Besylate-Benazepril 2.5Mg-10Mg, 5 Mg-10 Mg Amlodipine Besylate/Benazepril CAPSULE
($0.00 - $2.95) Tier 1
QL +Felodipine Er
Felodipine
TAB ER 24
($0.00 - $2.95) Tier 1
+Isradipine
Isradipine
CAPSULE
($0.00 - $2.95) Tier 1
+Nicardipine Hcl
Nicardipine Hcl
CAPSULE
($0.00 - $2.95) Tier 1
+Nifedical Xl
Nifedipine
TAB ER 24
($0.00 - $2.95) Tier 1
+Nifedipine Er
Nifedipine
TAB ER
($0.00 - $2.95) Tier 1
90
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
DIURETICS
+Amiloride Hcl
Amiloride Hcl
TABLET
($0.00 - $2.95) Tier 1
+Amiloride-Hydrochlorothiazide
Amiloride/Hydrochlorothiazide
TABLET
($0.00 - $2.95) Tier 1
+Bumetanide
Bumetanide
TABLET
($0.00 - $2.95) Tier 1
Bumetanide
Bumetanide
INJECTION
($0.00 - $2.95) Tier 1
+Chlorothiazide
Chlorothiazide
TABLET
($0.00 - $2.95) Tier 1
+Chlorthalidone
Chlorthalidone
TABLET
($0.00 - $2.95) Tier 1
+Furosemide
Furosemide
ORAL SOLUTION
($0.00 - $2.95) Tier 1
Furosemide
Furosemide
INJECTION
($0.00 - $2.95) Tier 1
+Furosemide
Furosemide
TABLET
($0.00 - $2.95) Tier 1
+Hydrochlorothiazide
Hydrochlorothiazide
TABLET
($0.00 - $2.95) Tier 1
+Hydrochlorothiazide
Hydrochlorothiazide
CAPSULE
($0.00 - $2.95) Tier 1
+Indapamide
Indapamide
TABLET
($0.00 - $2.95) Tier 1
+Methyclothiazide
Methyclothiazide
TABLET
($0.00 - $2.95) Tier 1
+Metolazone
Metolazone
TABLET
($0.00 - $2.95) Tier 1
+Torsemide
Torsemide
TABLET
($0.00 - $2.95) Tier 1
+Triamterene-Hydrochlorothiazid
Triamterene/Hydrochlorothiazid
CAPSULE
($0.00 - $2.95) Tier 1
BvD
BvD
PART D DRUGS
91
BRAND DRUG NAME
+Triamterene-Hydrochlorothiazid
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Triamterene/Hydrochlorothiazid
TABLET
($0.00 - $2.95) Tier 1
+Atorvastatin Calcium
Atorvastatin Calcium
TABLET
($0.00 - $2.95) Tier 1
+Cholestyramine
Cholestyramine (With Sugar)
ORAL PACKETS
($0.00 - $2.95) Tier 1
+Colestipol Hcl
Colestipol Hcl
TABLET
($0.00 - $2.95) Tier 1
+Colestipol Hcl
Colestipol Hcl
ORAL PACKETS
($0.00 - $2.95) Tier 1
+Fenofibrate
Fenofibrate,Micronized
CAPSULE
($0.00 - $2.95) Tier 1
+Fenofibrate
Fenofibrate
TABLET
($0.00 - $2.95) Tier 1
+Fenofibrate Nanocrystallized
Fenofibrate Nanocrystallized
TABLET
($0.00 - $2.95) Tier 1
+Gemfibrozil
Gemfibrozil
TABLET
($0.00 - $2.95) Tier 1
+KYNAMRO
Mipomersen Sodium
INJECTION
($0.00 - $7.40) Tier 2
+Lovastatin
Lovastatin
TABLET
($0.00 - $2.95) Tier 1
+NIACIN ER
Niacin
TAB ER 24
($0.00 - $7.40) Tier 2
+OMEGA-3 ACID ETHYL ESTERS
Omega-3 Acid Ethyl Esters
CAPSULE
($0.00 - $7.40) Tier 2
+Pravastatin Sodium
Pravastatin Sodium
TABLET
($0.00 - $2.95) Tier 1
+Prevalite
Cholestyramine/Aspartame
ORAL PACKETS
($0.00 - $2.95) Tier 1
+Simvastatin
Simvastatin
TABLET
($0.00 - $2.95) Tier 1
PART D DRUGS
DYSLIPIDEMICS
PA PA + Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies.
92
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+VASCEPA
Icosapent Ethyl
CAPSULE
($0.00 - $7.40) Tier 2
PA
+WELCHOL
Colesevelam Hcl
ORAL PACKETS
($0.00 - $7.40) Tier 2
PA
+WELCHOL
Colesevelam Hcl
TABLET
($0.00 - $7.40) Tier 2
PA
+ZETIA
Ezetimibe
TABLET
($0.00 - $7.40) Tier 2
PA
PA
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
Eplerenone
TABLET
($0.00 - $7.40) Tier 2
+Spironolactone
Spironolactone
TABLET
($0.00 - $2.95) Tier 1
+Spironolactone-Hctz
Spironolact/Hydrochlorothiazid
TABLET
($0.00 - $2.95) Tier 1
+TEKTURNA
Aliskiren Hemifumarate
TABLET
($0.00 - $7.40) Tier 2
PA
+TEKTURNA HCT
Aliskiren/Hydrochlorothiazide
TABLET
($0.00 - $7.40) Tier 2
PA
+Isosorbide Dinitrate
Isosorbide Dinitrate
TAB ER
($0.00 - $2.95) Tier 1
+Isosorbide Dinitrate
Isosorbide Dinitrate
TABLET
($0.00 - $2.95) Tier 1
+Isosorbide Mononitrate
Isosorbide Mononitrate
TABLET
($0.00 - $2.95) Tier 1
+Isosorbide Mononitrate Er
Isosorbide Mononitrate
TAB ER 24
($0.00 - $2.95) Tier 1
+Minitran
Nitroglycerin
PATCH
($0.00 - $2.95) Tier 1
+Minoxidil
Minoxidil
TABLET
($0.00 - $2.95) Tier 1
PART D DRUGS
+EPLERENONE
VASODILATORS
93
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Nitroglycerin Patch
Nitroglycerin
PATCH
($0.00 - $2.95) Tier 1
+NITROSTAT
Nitroglycerin
TAB SUBL
($0.00 - $7.40) Tier 2
+PROGLYCEM
Diazoxide
ORAL SUSP
($0.00 - $7.40) Tier 2
PA
PART D DRUGS
+Amphetamine Salt Combo
Dextroamphetamine/Amphetamine
TABLET
($0.00 - $2.95) Tier 1
+AMPYRA
Dalfampridine
TAB ER 12H
($0.00 - $7.40) Tier 2
PA +CLONIDINE HCL ER
Clonidine Hcl
TAB ER 12H
($0.00 - $7.40) Tier 2
PA +Dexmethylphenidate Hcl
Dexmethylphenidate Hcl
TABLET
($0.00 - $2.95) Tier 1
ST +DEXMETHYLPHENIDATE HCL ER Dexmethylphenidate Hcl
CAP-ER 24HR
($0.00 - $7.40) Tier 2
ST
+Dextroamphetamine Sulfate
Dextroamphetamine Sulfate
TABLET
($0.00 - $2.95) Tier 1
+Dextroamphetamine Sulfate Er
Dextroamphetamine Sulfate
ER CAPSULE
($0.00 - $2.95) Tier 1
+Dextroamphetamine-Amphet Er
Dextroamphetamine/Amphetamine
CAP.ER 24H
($0.00 - $2.95) Tier 1
+FOCALIN XR
Dexmethylphenidate Hcl
CAP-ER 24 HR
($0.00 - $7.40) Tier 2
ST
+GUANFACINE HCL ER
Guanfacine Hcl
TAB ER 24
($0.00 - $7.40) Tier 2
PA +Lithium
Lithium Citrate
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Lithium Carbonate
Lithium Carbonate
CAPSULE
($0.00 - $2.95) Tier 1
94
BRAND DRUG NAME
WHAT THE DRUG WILL
NECESSARY ACTIONS,
GENERIC DRUG NAME
FORMULATION
+Lithium Carbonate
Lithium Carbonate
TABLET
($0.00 - $2.95) Tier 1
+Lithium Carbonate Er
Lithium Carbonate
TAB ER
($0.00 - $2.95) Tier 1
+METHYLPHENIDATE ER
Methylphenidate Hcl
TAB ER 24
($0.00 - $7.40) Tier 2
+Methylphenidate Er 10 Mg, 20 Mg
Methylphenidate Hcl
TAB ER
($0.00 - $2.95) Tier 1
+Methylphenidate Hcl
Methylphenidate Hcl
TABLET
($0.00 - $2.95) Tier 1
NUEDEXTA
Dextromethorphan Hbr/Quinidine
CAPSULE
($0.00 - $7.40) Tier 2
PA
+Riluzole
Riluzole
TABLET
($0.00 - $2.95) Tier 1
PA
SAVELLA
Milnacipran Hcl
TAB DS PK
($0.00 - $7.40) Tier 2
PA
+SAVELLA
Milnacipran Hcl
TABLET
($0.00 - $7.40) Tier 2
PA
+STRATTERA
Atomoxetine Hcl
CAPSULE
($0.00 - $7.40) Tier 2
PA
+XENAZINE
Tetrabenazine
TABLET
($0.00 - $7.40) Tier 2
+Altavera
Levonorgestrel-Ethin Estradiol
TABLET
($0.00 - $2.95) Tier 1
+Alyacen
Norethindrone-Ethinyl Estrad
TABLET
($0.00 - $2.95) Tier 1
+Apri
Desogestrel-Ethinyl Estradiol
TABLET
($0.00 - $2.95) Tier 1
+Aranelle
TABLET
($0.00 - $2.95) Tier 1
ST
PART D DRUGS
CONTRACEPTIVES
CONTRACEPTIVES
95
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
+Aubra
TABLET
($0.00 - $2.95) Tier 1
+Aviane
TABLET
($0.00 - $2.95) Tier 1
+Azurette
Desog-E.Estradiol/E.Estradiol
TABLET
($0.00 - $2.95) Tier 1
+Balziva
TABLET
($0.00 - $2.95) Tier 1
+Briellyn
TABLET
($0.00 - $2.95) Tier 1
+Camila
Norethindrone
TABLET
($0.00 - $2.95) Tier 1
+Caziant
TABLET
($0.00 - $2.95) Tier 1
+Cryselle
Norgestrel-Ethinyl Estradiol
TABLET
($0.00 - $2.95) Tier 1
+Cyclafem
TABLET
($0.00 - $2.95) Tier 1
+Dasetta
TABLET
($0.00 - $2.95) Tier 1
+Desogestrel-Ethinyl Estradiol
TABLET
($0.00 - $2.95) Tier 1
+Desogestr-Eth Estrad Eth Estra
TABLET
($0.00 - $2.95) Tier 1
+Drospirenone-Ethinyl Estradiol
Ethinyl Estradiol/Drospirenone
TABLET
($0.00 - $2.95) Tier 1
ELLA
Ulipristal Acetate
TABLET
($0.00 - $7.40) Tier 2
+Emoquette
TABLET
($0.00 - $2.95) Tier 1
+Enpresse
TABLET
($0.00 - $2.95) Tier 1
+Enskyce
TABLET
($0.00 - $2.95) Tier 1
NECESSARY ACTIONS,
QL
96
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Norethindrone
TABLET
($0.00 - $2.95) Tier 1
+Falmina
TABLET
($0.00 - $2.95) Tier 1
+Gildagia
TABLET
($0.00 - $2.95) Tier 1
+Gildess
Norethindrone Ac-Eth Estradiol
TABLET
($0.00 - $2.95) Tier 1
+Gildess 24 Fe
Norethindrone-E.Estradiol-Iron
TABLET
($0.00 - $2.95) Tier 1
+Gildess Fe
TABLET
($0.00 - $2.95) Tier 1
+Heather
Norethindrone
TABLET
($0.00 - $2.95) Tier 1
+Introvale
TABLET
($0.00 - $2.95) Tier 1
+Jolessa
TABLET
($0.00 - $2.95) Tier 1
+Jolivette
Norethindrone
TABLET
($0.00 - $2.95) Tier 1
+Junel
TABLET
($0.00 - $2.95) Tier 1
+Junel Fe
TABLET
($0.00 - $2.95) Tier 1
+Junel Fe 24
TABLET
($0.00 - $2.95) Tier 1
+Kariva
TABLET
($0.00 - $2.95) Tier 1
+Kelnor 1-35
Ethynodiol D-Ethinyl Estradiol
TABLET
($0.00 - $2.95) Tier 1
+Kurvelo
TABLET
($0.00 - $2.95) Tier 1
+Larin 24 Fe
TABLET
($0.00 - $2.95) Tier 1
PART D DRUGS
+Errin
97
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Larin Fe
TABLET
($0.00 - $2.95) Tier 1
+Leena
TABLET
($0.00 - $2.95) Tier 1
+Lessina
TABLET
($0.00 - $2.95) Tier 1
+Levonest
TABLET
($0.00 - $2.95) Tier 1
+Levonorgestrel
Levonorgestrel
TABLET
($0.00 - $2.95) Tier 1
+Levonorgestrel-Eth Estradiol
TABLET
($0.00 - $2.95) Tier 1
+Levora-28
TABLET
($0.00 - $2.95) Tier 1
+Low-Ogestrel
TABLET
($0.00 - $2.95) Tier 1
+Lutera
TABLET
($0.00 - $2.95) Tier 1
+Marlissa
TABLET
($0.00 - $2.95) Tier 1
+Microgestin
TABLET
($0.00 - $2.95) Tier 1
+Microgestin Fe
TABLET
($0.00 - $2.95) Tier 1
+Mono-Linyah
Norgestimate-Ethinyl Estradiol
TABLET
($0.00 - $2.95) Tier 1
+Mononessa
TABLET
($0.00 - $2.95) Tier 1
+Myzilra
TABLET
($0.00 - $2.95) Tier 1
+Necon
TABLET
($0.00 - $2.95) Tier 1
+Nora-Be
Norethindrone
TABLET
($0.00 - $2.95) Tier 1
98
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Norethindrone
TABLET
($0.00 - $2.95) Tier 1
+Norethin-Eth Estra Ferrous Fum
TABLET
($0.00 - $2.95) Tier 1
+Norgestimate-Ethinyl Estradiol
TABLET
($0.00 - $2.95) Tier 1
+Norlyroc
Norethindrone
TABLET
($0.00 - $2.95) Tier 1
+Nortrel
TABLET
($0.00 - $2.95) Tier 1
+Ogestrel
TABLET
($0.00 - $2.95) Tier 1
+Orsythia
TABLET
($0.00 - $2.95) Tier 1
+Philith
TABLET
($0.00 - $2.95) Tier 1
+Pirmella
TABLET
($0.00 - $2.95) Tier 1
+Portia
TABLET
($0.00 - $2.95) Tier 1
+Previfem
TABLET
($0.00 - $2.95) Tier 1
+Quasense
TABLET
($0.00 - $2.95) Tier 1
+Reclipsen
TABLET
($0.00 - $2.95) Tier 1
+Sprintec
TABLET
($0.00 - $2.95) Tier 1
+Sronyx
TABLET
($0.00 - $2.95) Tier 1
+Tilia Fe
TABLET
($0.00 - $2.95) Tier 1
+Tri-Legest Fe
TABLET
($0.00 - $2.95) Tier 1
PART D DRUGS
+Norethindrone
99
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
+Tri-Linyah
TABLET
($0.00 - $2.95) Tier 1
+Trinessa
TABLET
($0.00 - $2.95) Tier 1
+Tri-Previfem
TABLET
($0.00 - $2.95) Tier 1
+Tri-Sprintec
TABLET
($0.00 - $2.95) Tier 1
+Trivora-28
TABLET
($0.00 - $2.95) Tier 1
+Velivet
TABLET
($0.00 - $2.95) Tier 1
+Viorele
TABLET
($0.00 - $2.95) Tier 1
+Vyfemla
TABLET
($0.00 - $2.95) Tier 1
+Wera
TABLET
($0.00 - $2.95) Tier 1
+Zenchent
TABLET
($0.00 - $2.95) Tier 1
+Zenchent Fe
Noreth-Ethinyl Estradiol/Iron
TAB CHEW
($0.00 - $2.95) Tier 1
+Zovia 1-35E
TABLET
($0.00 - $2.95) Tier 1
+Zovia 1-50E
TABLET
($0.00 - $2.95) Tier 1
NECESSARY ACTIONS,
+Chlorhexidine Gluconate
Chlorhexidine Gluconate
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Denta 5000 Plus
Sodium Fluoride
DENTAL CREAM
($0.00 - $2.95) Tier 1
100
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
+Dentagel
Sodium Fluoride
DENTAL GEL
($0.00 - $2.95) Tier 1
+Oralone
Triamcinolone Acetonide
DENTAL PASTE
($0.00 - $2.95) Tier 1
Periogard
Chlorhexidine Gluconate
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Pilocarpine Hcl
Pilocarpine Hcl
TABLET
($0.00 - $2.95) Tier 1
+Sf 5000 Plus
Sodium Fluoride
DENTAL CREAM
($0.00 - $2.95) Tier 1
+Sodium Fluoride
Sodium Fluoride
DENTAL SOLN
($0.00 - $2.95) Tier 1
+Stannous Fluoride
Stannous Fluoride
DENTAL SOLN
($0.00 - $2.95) Tier 1
DENTAL PASTE
($0.00 - $2.95) Tier 1
NECESSARY ACTIONS,
PART D DRUGS
DERMATOLOGICAL AGENTS, OTHER
8-MOP
Methoxsalen
CAPSULE
($0.00 - $7.40) Tier 2
PA ACITRETIN 10 MG, 25 MG
Acitretin
CAPSULE
($0.00 - $7.40) Tier 2
PA ACITRETIN 17.5 MG
Acitretin
CAPSULE
($0.00 - $7.40) Tier 2 ACYCLOVIR
Acyclovir
TOPICAL OINT.
($0.00 - $7.40) Tier 2
QL +Alcohol Prep Pads
Alcohol Antiseptic Pads
TOPICAL MED. PAD
($0.00 - $2.95) Tier 1
+Ammonium Lactate
Ammonium Lactate
TOPICAL LOTION
($0.00 - $2.95) Tier 1
AMNESTEEM
Isotretinoin
CAPSULE
($0.00 - $7.40) Tier 2
101
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Anacaine
Benzocaine
TOPICAL OINT.
($0.00 - $2.95) Tier 1
Calcipotriene
Calcipotriene
TOPICAL SOLUTION
($0.00 - $2.95) Tier 1
PA, QL
Calcipotriene
Calcipotriene
CREAM
($0.00 - $2.95) Tier 1
PA, QL
CLARAVIS
Isotretinoin
CAPSULE
($0.00 - $7.40) Tier 2
PA
DENAVIR
Penciclovir
CREAM
($0.00 - $7.40) Tier 2
PA
+Fluorouracil
Fluorouracil
TOPICAL SOLUTION
($0.00 - $2.95) Tier 1
+Fluorouracil
Fluorouracil
CREAM
($0.00 - $2.95) Tier 1
Imiquimod
Imiquimod
CREAM PACK
($0.00 - $2.95) Tier 1
PA, QL
LEVULAN
Aminolevulinic Acid Hcl
TOPICAL SOLUTION
($0.00 - $7.40) Tier 2
PA
METHOXSALEN
Methoxsalen, Rapid
CAPSULE
($0.00 - $7.40) Tier 2
PA
OXSORALEN
Methoxsalen
TOPICAL LOTION
($0.00 - $7.40) Tier 2
PA
PANRETIN
Alitretinoin
TOPICAL GEL
($0.00 - $7.40) Tier 2
PA
PICATO
Ingenol Mebutate
TOPICAL GEL
($0.00 - $7.40) Tier 2
PA
PODOCON-25
Podophyllum Resin
TOPICAL LIQUID
($0.00 - $7.40) Tier 2
Podofilox
Podofilox
TOPICAL SOLUTION
($0.00 - $2.95) Tier 1
REGRANEX
Becaplermin
TOPICAL GEL
($0.00 - $7.40) Tier 2
SANTYL
Collagenase Clostridium Hist.
TOPICAL OINT.
($0.00 - $7.40) Tier 2
PA, QL
102
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+VALCHLOR
Mechlorethamine Hcl
TOPICAL GEL
($0.00 - $7.40) Tier 2
PA
ZONALON
Doxepin Hcl
CREAM
($0.00 - $7.40) Tier 2
ZOVIRAX
Acyclovir
CREAM
($0.00 - $7.40) Tier 2
QL
ZYCLARA
Imiquimod
CREAM
($0.00 - $7.40) Tier 2
PA
DERMATOLOGICAL ANTIBACTERIALS
TOPICAL GEL
($0.00 - $2.95) Tier 1
TOPICAL LOTION
($0.00 - $2.95) Tier 1
TOPICAL MED. SWAB
($0.00 - $2.95) Tier 1
TOPICAL SOLUTION
($0.00 - $2.95) Tier 1
+Ery
Erythromycin Base/Ethanol
TOPICAL MED. SWAB
($0.00 - $2.95) Tier 1
+Erythromycin
TOPICAL MED. SWAB
($0.00 - $2.95) Tier 1
+Erythromycin
TOPICAL GEL
($0.00 - $2.95) Tier 1
+Erythromycin
TOPICAL SOLUTION
($0.00 - $2.95) Tier 1
+Erythromycin-Benzoyl Peroxide
Erythromycin/Benzoyl Peroxide
TOPICAL GEL
($0.00 - $2.95) Tier 1
+Metronidazole
Metronidazole
CREAM
($0.00 - $2.95) Tier 1
+Metronidazole
Metronidazole
TOPICAL GEL
($0.00 - $2.95) Tier 1
+Metronidazole
Metronidazole
TOPICAL LOTION
($0.00 - $2.95) Tier 1
PART D DRUGS
103
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
Mupirocin
Mupirocin
TOPICAL OINT.
($0.00 - $2.95) Tier 1
Selenium Sulfide
Selenium Sulfide
SHAMPOO
($0.00 - $2.95) Tier 1
Selenium Sulfide
Selenium Sulfide
TOPICAL SUSP
($0.00 - $2.95) Tier 1
Silver Sulfadiazine
Silver Sulfadiazine
CREAM
($0.00 - $2.95) Tier 1
Ssd
Silver Sulfadiazine
CREAM
($0.00 - $2.95) Tier 1
NECESSARY ACTIONS,
QL
PART D DRUGS
DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS
+Ala-Cort
Hydrocortisone
CREAM
($0.00 - $2.95) Tier 1
+Ala-Scalp
Hydrocortisone
TOPICAL LOTION
($0.00 - $2.95) Tier 1
+Alclometasone Dipropionate
Alclometasone Dipropionate
CREAM
($0.00 - $2.95) Tier 1
+Alclometasone Dipropionate
Alclometasone Dipropionate
TOPICAL OINT.
($0.00 - $2.95) Tier 1
+Amcinonide
Amcinonide
TOPICAL OINT.
($0.00 - $2.95) Tier 1
+Amcinonide
Amcinonide
TOPICAL LOTION
($0.00 - $2.95) Tier 1
+Amcinonide
Amcinonide
CREAM
($0.00 - $2.95) Tier 1
+Apexicon E
Diflorasone Diacetate/Emoll
CREAM
($0.00 - $2.95) Tier 1
+Betamethasone Dipropionate
Betamethasone Dipropionate
TOPICAL OINT.
($0.00 - $2.95) Tier 1
CREAM
($0.00 - $2.95) Tier 1
TOPICAL GEL
($0.00 - $2.95) Tier 1
104
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
TOPICAL LOTION
($0.00 - $2.95) Tier 1
+Betamethasone Valerate
Betamethasone Valerate
TOPICAL OINT.
($0.00 - $2.95) Tier 1
CREAM
($0.00 - $2.95) Tier 1
TOPICAL LOTION
($0.00 - $2.95) Tier 1
+Clobetasol Propionate
Clobetasol Propionate
TOPICAL OINT.
($0.00 - $2.95) Tier 1
TOPICAL SOLUTION
($0.00 - $2.95) Tier 1
TOPICAL FOAM
($0.00 - $2.95) Tier 1
CREAM
($0.00 - $2.95) Tier 1
TOPICAL GEL
($0.00 - $2.95) Tier 1
+Colocort
Hydrocortisone
RECTAL ENEMA
($0.00 - $2.95) Tier 1
+Cormax
TOPICAL SOLUTION
($0.00 - $2.95) Tier 1
DESONATE
Desonide
TOPICAL GEL
($0.00 - $7.40) Tier 2 +Desonide
Desonide
TOPICAL OINT.
($0.00 - $2.95) Tier 1
+Desonide
Desonide
CREAM
($0.00 - $2.95) Tier 1
+Desonide
Desonide
TOPICAL LOTION
($0.00 - $2.95) Tier 1
+Desoximetasone
Desoximetasone
TOPICAL OINT.
($0.00 - $2.95) Tier 1
+Desoximetasone
Desoximetasone
TOPICAL GEL
($0.00 - $2.95) Tier 1
PART D DRUGS
NECESSARY ACTIONS,
105
PART D DRUGS
WHAT THE DRUG WILL
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
+Desoximetasone
Desoximetasone
CREAM
($0.00 - $2.95) Tier 1
+Diflorasone Diacetate
Diflorasone Diacetate
CREAM
($0.00 - $2.95) Tier 1
+Diflorasone Diacetate
Diflorasone Diacetate
TOPICAL OINT.
($0.00 - $2.95) Tier 1
ELIDEL
Pimecrolimus
CREAM
($0.00 - $7.40) Tier 2
+Fluocinolone Acetonide
Fluocinolone Acetonide
CREAM
($0.00 - $2.95) Tier 1
TOPICAL OINT.
($0.00 - $2.95) Tier 1
TOPICAL SOLUTION
($0.00 - $2.95) Tier 1
+Fluocinonide
Fluocinonide
TOPICAL OINT.
($0.00 - $2.95) Tier 1
+Fluocinonide
Fluocinonide
TOPICAL SOLUTION
($0.00 - $2.95) Tier 1
+Fluocinonide
Fluocinonide
TOPICAL GEL
($0.00 - $2.95) Tier 1
+Fluocinonide
Fluocinonide
CREAM
($0.00 - $2.95) Tier 1
+Fluticasone Propionate
Fluticasone Propionate
CREAM
($0.00 - $2.95) Tier 1
TOPICAL OINT.
($0.00 - $2.95) Tier 1
+Halobetasol Propionate
Halobetasol Propionate
TOPICAL OINT.
($0.00 - $2.95) Tier 1
+Halobetasol Propionate
Halobetasol Propionate
CREAM
($0.00 - $2.95) Tier 1
+Hydrocortisone
Hydrocortisone
CREAM
($0.00 - $2.95) Tier 1
+Hydrocortisone
Hydrocortisone
TOPICAL LOTION
($0.00 - $2.95) Tier 1
NECESSARY ACTIONS,
PA, QL + Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies.
106
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Hydrocortisone
Hydrocortisone
TOPICAL OINT.
($0.00 - $2.95) Tier 1
+Hydrocortisone
Hydrocortisone
RECTAL ENEMA
($0.00 - $2.95) Tier 1
+Hydrocortisone Butyrate
Hydrocortisone Butyrate
CREAM
($0.00 - $2.95) Tier 1
TOPICAL SOLUTION
($0.00 - $2.95) Tier 1
TOPICAL OINT.
($0.00 - $2.95) Tier 1
+Hydrocortisone Valerate
Hydrocortisone Valerate
CREAM
($0.00 - $2.95) Tier 1
+Hydrocortisone Valerate
Hydrocortisone Valerate
TOPICAL OINT.
($0.00 - $2.95) Tier 1
+Mometasone Furoate
Mometasone Furoate
TOPICAL OINT.
($0.00 - $2.95) Tier 1
+Mometasone Furoate
Mometasone Furoate
CREAM
($0.00 - $2.95) Tier 1
+Mometasone Furoate
Mometasone Furoate
TOPICAL SOLUTION
($0.00 - $2.95) Tier 1
+ONFI
Clobazam
ORAL SUSP
($0.00 - $7.40) Tier 2
PA +ONFI
Clobazam
TABLET
($0.00 - $7.40) Tier 2
PA
Procto-Pak
Hydrocortisone
RECTAL CREAM
($0.00 - $2.95) Tier 1 Proctosol-Hc
Hydrocortisone
RECTAL CREAM
($0.00 - $2.95) Tier 1 Proctozone-Hc
Hydrocortisone
RECTAL CREAM
($0.00 - $2.95) Tier 1 Triamcinolone Acetonide
TOPICAL LOTION
($0.00 - $2.95) Tier 1 Triamcinolone Acetonide
CREAM
($0.00 - $2.95) Tier 1
PART D DRUGS
107
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
TOPICAL OINT.
($0.00 - $2.95) Tier 1
Triderm
CREAM
($0.00 - $2.95) Tier 1
U-Cort
Hydrocortisone Acetate/Urea
CREAM
($0.00 - $2.95) Tier 1
VERDESO
Desonide
TOPICAL FOAM
($0.00 - $7.40) Tier 2
NECESSARY ACTIONS,
PART D DRUGS
DERMATOLOGICAL RETINOIDS
+Adapalene
Adapalene
TOPICAL GEL
($0.00 - $2.95) Tier 1
ADAPALENE
Adapalene
TOPICAL LOTION
($0.00 - $7.40) Tier 2
+Adapalene
Adapalene
CREAM
($0.00 - $2.95) Tier 1
Avita
Tretinoin
TOPICAL GEL
($0.00 - $2.95) Tier 1
PA
TAZORAC
Tazarotene
TOPICAL GEL
($0.00 - $7.40) Tier 2
PA
TAZORAC
Tazarotene
CREAM
($0.00 - $7.40) Tier 2
PA
Tretinoin
Tretinoin
TOPICAL GEL
($0.00 - $2.95) Tier 1
PA
Tretinoin
Tretinoin
CREAM
($0.00 - $2.95) Tier 1
PA
SCABICIDES AND PEDICULICIDES
+Lindane
Lindane
SHAMPOO
($0.00 - $2.95) Tier 1
+Lindane
Lindane
TOPICAL LOTION
($0.00 - $2.95) Tier 1
Permethrin
Permethrin
CREAM
($0.00 - $2.95) Tier 1 + Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies.
108
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
DEVICES
DEVICES
+Bd Ultra-Fine Pen Needle
Needles, Insulin Disposable
SYRINGES
($0.00 - $2.95) Tier 1
+Insulin Syringe
Syring W-Ndl,Disp,Insul,0.3 Ml
SYRINGES
($0.00 - $2.95) Tier 1
+Vgo 40
Sub-Q Insulin Device, 40 Unit
DEVICE
($0.00 - $2.95) Tier 1
Pegademase Bovine
INJECTION
($0.00 - $7.40) Tier 2
BvD ALDURAZYME
Laronidase
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD +CEREZYME
Imiglucerase
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+CREON 12K-38K-60, 24-76-120K
Lipase/Protease/Amylase
CAPSULE CR
($0.00 - $7.40) Tier 2
+CREON 36-114-180
CAPSULE CR
($0.00 - $7.40) Tier 2
+CREON 3-9.5-15K, 6K-19K-30K
CAPSULE CR
($0.00 - $7.40) Tier 2
+CYSTAGON
Cysteamine Bitartrate
CAPSULE
($0.00 - $7.40) Tier 2
PA +ELAPRASE
Idursulfase
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
PA +ELELYSO
Taliglucerase Alfa
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
PART D DRUGS
ADAGEN
109
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
ELITEK
Rasburicase
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+FABRAZYME
Agalsidase Beta
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+KUVAN
Sapropterin Dihydrochloride
TAB DISPER
($0.00 - $7.40) Tier 2
PA
+KUVAN
Sapropterin Dihydrochloride
ORAL PACKETS
($0.00 - $7.40) Tier 2
PA
+MYOZYME
Alglucosidase Alfa
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+NAGLAZYME
Galsulfase
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+ORFADIN
Nitisinone
CAPSULE
($0.00 - $7.40) Tier 2
PA
+PANCRELIPASE 5,000
CAPSULE CR
($0.00 - $7.40) Tier 2
+PULMOZYME
Dornase Alfa
INHALATION SOLN
($0.00 - $7.40) Tier 2
BvD
+SUCRAID
Sacrosidase
ORAL SOLUTION
($0.00 - $7.40) Tier 2
PA
+VPRIV
Velaglucerase Alfa
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+ZAVESCA
Miglustat
CAPSULE
($0.00 - $7.40) Tier 2
PA
+ZENPEP 15-51-82K, 20-68-109K
CAPSULE CR
($0.00 - $7.40) Tier 2
+ZENPEP 25-85-136K
CAPSULE CR
($0.00 - $7.40) Tier 2
+ZENPEP 3K-10K-16K, 10-34-55K
CAPSULE CR
($0.00 - $7.40) Tier 2
+ZENPEP 40K-136K
CAPSULE CR
($0.00 - $7.40) Tier 2
110
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
EYE, EAR, NOSE, THROAT AGENTS, MISCELLANEOUS
Proparacaine Hcl
OPHT DROPS
($0.00 - $2.95) Tier 1
+Altacaine
Tetracaine Hcl
OPHT DROPS
($0.00 - $2.95) Tier 1
+Azelastine Hcl
Azelastine Hcl
OPHT DROPS
($0.00 - $2.95) Tier 1
+Azelastine Hcl
Azelastine Hcl
NASAL SPRAY
($0.00 - $2.95) Tier 1
QL
+Carteolol Hcl
Carteolol Hcl
OPHT DROPS
($0.00 - $2.95) Tier 1
+Cromolyn Sodium
Cromolyn Sodium
OPHT DROPS
($0.00 - $2.95) Tier 1
+Cyclopentolate Hcl
Cyclopentolate Hcl
OPHT DROPS
($0.00 - $2.95) Tier 1
+Homatropaire
Homatropine Hbr
OPHT DROPS
($0.00 - $2.95) Tier 1
QL +Homatropine Hydrobromide
Homatropine Hbr
OPHT DROPS
($0.00 - $2.95) Tier 1
QL +Ipratropium Bromide
Ipratropium Bromide
NASAL SPRAY
($0.00 - $2.95) Tier 1
LACRISERT
Hydroxypropyl Cellulose
OPHT INSERT
($0.00 - $7.40) Tier 2 +Naphazoline Hcl
Naphazoline Hcl
OPHT DROPS
($0.00 - $2.95) Tier 1
PATADAY
Olopatadine Hcl
OPHT DROPS
($0.00 - $7.40) Tier 2 Phenylephrine Hcl
Phenylephrine Hcl
OPHT DROPS
($0.00 - $2.95) Tier 1
Proparacaine Hcl
Proparacaine Hcl
OPHT DROPS
+Alcaine
111
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
Tetracaine Hcl
Tetracaine Hcl/Pf
OPHT DROPS
($0.00 - $2.95) Tier 1
+Tropicamide
Tropicamide
OPHT DROPS
($0.00 - $2.95) Tier 1
TYZINE
Tetrahydrozoline Hcl
NASAL SPRAY
($0.00 - $7.40) Tier 2
NECESSARY ACTIONS,
PART D DRUGS
EYE, EAR, NOSE, THROAT ANTI-INFECTIVES AGENTS
+Acetasol Hc
Acetic Acid/Hydrocortisone
OTIC DROPS
($0.00 - $2.95) Tier 1
+Bacitracin
Bacitracin
OPHT OINTMENT
($0.00 - $2.95) Tier 1
+Bacitracin-Polymyxin
Bacitracin/Polymyxin B Sulfate
OPHT OINTMENT
($0.00 - $2.95) Tier 1
+Bleph-10
Sulfacetamide Sodium
OPHT DROPS
($0.00 - $2.95) Tier 1
+Ciprofloxacin Hcl
Ciprofloxacin Hcl
OTIC DROPS
($0.00 - $2.95) Tier 1
+Ciprofloxacin Hcl
Ciprofloxacin Hcl
OPHT DROPS
($0.00 - $2.95) Tier 1
+Erythromycin
Erythromycin Base
OPHT OINTMENT
($0.00 - $2.95) Tier 1
+Gentak
Gentamicin Sulfate
OPHT OINTMENT
($0.00 - $2.95) Tier 1
+Gentamicin Sulfate
Gentamicin Sulfate
OPHT OINTMENT
($0.00 - $2.95) Tier 1
+Gentamicin Sulfate
Gentamicin Sulfate
OPHT DROPS
($0.00 - $2.95) Tier 1
+Hydrocortisone-Acetic Acid
Acetic Acid/Hydrocortisone
OTIC DROPS
($0.00 - $2.95) Tier 1
+Neomycin-Bacitracin-Poly-Hc
Neomycin Su/Baci Zn/Poly/Hc
OPHT OINTMENT
($0.00 - $2.95) Tier 1
+Neomycin-Bacitracin-Polymyxin
Neomycin Su/Bacitra/Polymyxin
OPHT OINTMENT
($0.00 - $2.95) Tier 1
112
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
Neo/Polymyx B Sulf/Dexameth
OPHT OINTMENT
($0.00 - $2.95) Tier 1
+Neomycin-Polymyxin-Dexameth
Neo/Polymyx B Sulf/Dexameth
OPHT SUSP
($0.00 - $2.95) Tier 1
+Neomycin-Polymyxin-Gramicidin
Neomycin/Polymyxn B/Gramicidin
OPHT DROPS
($0.00 - $2.95) Tier 1
+Neomycin-Polymyxin-Hc
Neomycin/Polymyxin B Sulf/Hc
OTIC SUSP
($0.00 - $2.95) Tier 1
+Neomycin-Polymyxin-Hc
OPHT SUSP
($0.00 - $2.95) Tier 1
+Neomycin-Polymyxin-Hydrocort
OTIC SOLN
($0.00 - $2.95) Tier 1
+Neo-Polycin Hc
Neomycin Su/Baci Zn/Poly/Hc
OPHT OINTMENT
($0.00 - $2.95) Tier 1
+Ofloxacin
Ofloxacin
OPHT DROPS
($0.00 - $2.95) Tier 1
+Ofloxacin
Ofloxacin
OTIC DROPS
($0.00 - $2.95) Tier 1
Polymyxin B Sul-Trimethoprim
Polymyxin B Sulf/Trimethoprim
OPHT DROPS
($0.00 - $2.95) Tier 1 Sulfacetamide Sodium
OPHT DROPS
($0.00 - $2.95) Tier 1 Sulfacetamide Sodium
OPHT OINTMENT
($0.00 - $2.95) Tier 1
Sulfacetamide-Prednisolone
Sulfacetamide/Prednisolone Sp
OPHT DROPS
($0.00 - $2.95) Tier 1 Tobramycin
Tobramycin
OPHT DROPS
($0.00 - $2.95) Tier 1 Tobramycin-Dexamethasone
Tobramycin/Dexamethasone
OPHT SUSP
($0.00 - $2.95) Tier 1 Trifluridine
Trifluridine
OPHT DROPS
($0.00 - $2.95) Tier 1 VIGAMOX
Moxifloxacin Hcl
OPHT DROPS
+Neomycin-Polymyxin-Dexameth
NECESSARY ACTIONS,
113
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
EYE, EAR, NOSE, THROAT ANTI-INFLAMMATORY AGENTS
PART D DRUGS
BROMFENAC SODIUM
OPHT DROPS
($0.00 - $7.40) Tier 2
+Dexamethasone Sodium Phosphate Dexamethasone Sod Phosphate
OPHT DROPS
($0.00 - $2.95) Tier 1
+Diclofenac Sodium
Diclofenac Sodium
OPHT DROPS
($0.00 - $2.95) Tier 1
+Flunisolide
Flunisolide
NASAL SPRAY
($0.00 - $2.95) Tier 1
FLUOCINOLONE ACETONIDE OIL Fluocinolone Acetonide Oil
OTIC DROPS
($0.00 - $7.40) Tier 2
FLUOROMETHOLONE
Fluorometholone
OPHT SUSP
($0.00 - $7.40) Tier 2
+Flurbiprofen Sodium
Flurbiprofen Sodium
OPHT DROPS
($0.00 - $2.95) Tier 1
NASAL SPRAY
($0.00 - $2.95) Tier 1
+Ketorolac Tromethamine
OPHT DROPS
($0.00 - $2.95) Tier 1
LOTEMAX
Loteprednol Etabonate
OPHT SUSP
($0.00 - $7.40) Tier 2
MAXIDEX
Dexamethasone
OPHT SUSP
($0.00 - $7.40) Tier 2
Prednisolone Acetate
Prednisolone Acetate
OPHT SUSP
($0.00 - $2.95) Tier 1
Prednisolone Sodium Phosphate
Prednisolone Sod Phosphate
OPHT DROPS
($0.00 - $2.95) Tier 1
+RESTASIS
Cyclosporine
OPHT DROPS
($0.00 - $7.40) Tier 2
Bromfenac Sodium
PA, QL
114
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
ANTIULCER AGENTS AND ACID SUPPRESSANTS
+Cimetidine
Cimetidine
TABLET
($0.00 - $2.95) Tier 1
+Cimetidine
Cimetidine Hcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
Famotidine
Famotidine
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
+Famotidine
Famotidine
TABLET
($0.00 - $2.95) Tier 1
+Lansoprazole
Lansoprazole
CAPSULE CR
($0.00 - $2.95) Tier 1
+Misoprostol
Misoprostol
TABLET
($0.00 - $2.95) Tier 1
+Nizatidine
Nizatidine
CAPSULE
($0.00 - $2.95) Tier 1
+Omeprazole 10 Mg, 20 Mg
Omeprazole
CAPSULE CR
($0.00 - $2.95) Tier 1
QL +Omeprazole 40 Mg
Omeprazole
CAPSULE CR
($0.00 - $2.95) Tier 1
QL +Pantoprazole Sodium
Pantoprazole Sodium
TABLET DR
($0.00 - $2.95) Tier 1
PROTONIX IV
Pantoprazole Sodium
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD Ranitidine Hcl
Ranitidine Hcl
INJECTION
($0.00 - $2.95) Tier 1
BvD +Ranitidine Hcl
Ranitidine Hcl
TABLET
($0.00 - $2.95) Tier 1
+Ranitidine Hcl
Ranitidine Hcl
CAPSULE
($0.00 - $2.95) Tier 1
+Ranitidine Hcl
Ranitidine Hcl
ORAL SYRUP
($0.00 - $2.95) Tier 1
BvD PART D DRUGS
115
BRAND DRUG NAME
+Sucralfate
GENERIC DRUG NAME
Sucralfate
FORMULATION
WHAT THE DRUG WILL
TABLET
($0.00 - $2.95) Tier 1
NECESSARY ACTIONS,
PART D DRUGS
GASTROINTESTINAL AGENTS, OTHER
+AMITIZA
Lubiprostone
CAPSULE
($0.00 - $7.40) Tier 2
PA BUPHENYL
Sodium Phenylbutyrate
TABLET
($0.00 - $7.40) Tier 2
PA +CARBAGLU
Carglumic Acid
TAB DISPER
($0.00 - $7.40) Tier 2
PA +Constulose
Lactulose
ORAL SOLUTION
($0.00 - $2.95) Tier 1
CROMOLYN SODIUM
Cromolyn Sodium
ORAL SOLUTION
($0.00 - $7.40) Tier 2 +Dicyclomine Hcl
Dicyclomine Hcl
TABLET
($0.00 - $2.95) Tier 1
+Dicyclomine Hcl
Dicyclomine Hcl
CAPSULE
($0.00 - $2.95) Tier 1
+Diphenoxylate-Atropine
Diphenoxylate Hcl/Atropine
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Diphenoxylate-Atropine
Diphenoxylate Hcl/Atropine
TABLET
($0.00 - $2.95) Tier 1
+Generlac
Lactulose
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Glycopyrrolate
Glycopyrrolate
TABLET
($0.00 - $2.95) Tier 1
+Kionex
Sodium Polystyrene Sulfonate
ORAL SUSP
($0.00 - $2.95) Tier 1
+Lactulose
Lactulose
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Loperamide
Loperamide Hcl
CAPSULE
($0.00 - $2.95) Tier 1
+LOTRONEX
Alosetron Hcl
TABLET
($0.00 - $7.40) Tier 2
116
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Metoclopramide Hcl
Metoclopramide Hcl
TABLET
($0.00 - $2.95) Tier 1
+Metoclopramide Hcl
Metoclopramide Hcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
Metoclopramide Hcl
Metoclopramide Hcl
INJECTION
($0.00 - $2.95) Tier 1
BvD
RELISTOR
Methylnaltrexone Bromide
INJECTION
($0.00 - $7.40) Tier 2
PA
Sps
Sodium Polystyrene Sulfonate
ORAL SUSP
($0.00 - $2.95) Tier 1
+Ursodiol
Ursodiol
CAPSULE
($0.00 - $2.95) Tier 1
+Gavilyte-C
Peg 3350/Na Sulf,Bicarb,Cl/Kcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Gavilyte-N
Sodium Chloride/Nahco3/Kcl/Peg
ORAL SOLUTION
($0.00 - $2.95) Tier 1
Peg 3350-Electrolyte
ORAL SOLUTION
($0.00 - $2.95) Tier 1
QL
Peg-3350
ORAL SOLUTION
($0.00 - $2.95) Tier 1
QL
+Peg-3350 And Electrolytes
ORAL SOLUTION
($0.00 - $2.95) Tier 1
Polyethylene Glycol 3350
ORAL PACKETS
($0.00 - $2.95) Tier 1
Trilyte With Flavor Packets
ORAL SOLUTION
($0.00 - $2.95) Tier 1
+Calcium Acetate
Calcium Acetate
CAPSULE
($0.00 - $2.95) Tier 1
+Calcium Acetate
Calcium Acetate
TABLET
($0.00 - $2.95) Tier 1
LAXATIVES
PART D DRUGS
PHOSPHATE BINDERS
117
BRAND DRUG NAME
WHAT THE DRUG WILL
GENERIC DRUG NAME
FORMULATION
+Eliphos
Calcium Acetate
TABLET
($0.00 - $2.95) Tier 1
+RENAGEL
Sevelamer Hcl
TABLET
($0.00 - $7.40) Tier 2
+RENVELA
Sevelamer Carbonate
TABLET
($0.00 - $7.40) Tier 2
NECESSARY ACTIONS,
GENITOURINARY AGENTS
PART D DRUGS
ANTISPASMODICS, URINARY
+MYRBETRIQ
Mirabegron
TAB ER 24
($0.00 - $7.40) Tier 2
PA
+Oxybutynin Chloride
Oxybutynin Chloride
TABLET
($0.00 - $2.95) Tier 1
+Oxybutynin Chloride
Oxybutynin Chloride
ORAL SYRUP
($0.00 - $2.95) Tier 1
+Oxybutynin Chloride Er
Oxybutynin Chloride
TAB ER 24
($0.00 - $2.95) Tier 1
+Tolterodine Tartrate
Tolterodine Tartrate
TABLET
($0.00 - $2.95) Tier 1
QL,ST
+Tolterodine Tartrate Er
Tolterodine Tartrate
CAP.ER 24H
($0.00 - $2.95) Tier 1
QL,ST
GENITOURINARY AGENTS, MISCELLANEOUS
+Alfuzosin Hcl Er
Alfuzosin Hcl
TAB ER 24
($0.00 - $2.95) Tier 1
QL +Tamsulosin Hcl
Tamsulosin Hcl
CAP.ER 24H
($0.00 - $2.95) Tier 1
QL +Terazosin Hcl
Terazosin Hcl
CAPSULE
($0.00 - $2.95) Tier 1
118
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+CUPRIMINE
Penicillamine
CAPSULE
($0.00 - $7.40) Tier 2
PA
Deferoxamine Mesylate
Deferoxamine Mesylate
INJECTION
($0.00 - $2.95) Tier 1
BvD
+DEPEN
Penicillamine
TABLET
($0.00 - $7.40) Tier 2
+EXJADE
Deferasirox
TAB DISPER
($0.00 - $7.40) Tier 2
PA
SYPRINE
Trientine Hcl
CAPSULE
($0.00 - $7.40) Tier 2
PA
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING
PART D DRUGS
ANDROGENS
ANADROL-50
Oxymetholone
TABLET
($0.00 - $7.40) Tier 2
PA +ANDRODERM
Testosterone
PATCH
($0.00 - $7.40) Tier 2
PA +Android
Methyltestosterone
CAPSULE
($0.00 - $2.95) Tier 1
PA +Androxy
Fluoxymesterone
TABLET
($0.00 - $2.95) Tier 1
PA +AVEED
Testosterone Undecanoate
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+Danazol
Danazol
CAPSULE
($0.00 - $2.95) Tier 1
+Oxandrolone
Oxandrolone
TABLET
($0.00 - $2.95) Tier 1
119
BRAND DRUG NAME
+Testosterone Cypionate
GENERIC DRUG NAME
Testosterone Cypionate
FORMULATION
WHAT THE DRUG WILL
INJECTION
($0.00 - $2.95) Tier 1
NECESSARY ACTIONS,
BvD, PA
PART D DRUGS
ESTROGENS AND ANTIESTROGENS
+ALORA
Estradiol
PATCH
($0.00 - $7.40) Tier 2
+COMBIPATCH
Estradiol/Norethindrone Acet
PATCH
($0.00 - $7.40) Tier 2
+Estradiol
Estradiol
PATCH
($0.00 - $2.95) Tier 1
PA>65 y/o +Estradiol
Estradiol
TABLET
($0.00 - $2.95) Tier 1
PA>65 y/o
+Estradiol-Norethindrone Acetat
TABLET
($0.00 - $2.95) Tier 1
+Estropipate
Estropipate
TABLET
($0.00 - $2.95) Tier 1
PA>65 y/o +MENEST
Estrogens,Esterified
TABLET
($0.00 - $7.40) Tier 2
PA>65 y/o +Mimvey
TABLET
($0.00 - $2.95) Tier 1
+Mimvey Lo
TABLET
($0.00 - $2.95) Tier 1
+Norethindron-Ethinyl Estradiol
TABLET
($0.00 - $2.95) Tier 1
+PREMARIN
Estrogens, Conjugated
TABLET
($0.00 - $7.40) Tier 2
+PREMARIN
Estrogens, Conjugated
VAGINAL CREAM
($0.00 - $7.40) Tier 2
+PREMPHASE
Estrogen,Con/M-Progest Acet
TABLET
($0.00 - $7.40) Tier 2
PA>65 y/o +PREMPRO
Estrogen,Con/M-Progest Acet
TABLET
($0.00 - $7.40) Tier 2
PA>65 y/o +Raloxifene Hcl
Raloxifene Hcl
TABLET
($0.00 - $2.95) Tier 1
QL
PA>65 y/o + Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies.
120
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
GLUCOCORTICOIDS/MINERALOCORTICOIDS
Hydrocortisone Sod Succinate
INJECTION
($0.00 - $2.95) Tier 1
BvD Cortisone Acetate
Cortisone Acetate
TABLET
($0.00 - $2.95) Tier 1
BvD DEPO-MEDROL
Methylprednisolone Acetate
INJECTION
($0.00 - $7.40) Tier 2
BvD Dexamethasone
Dexamethasone
ORAL SOLUTION
($0.00 - $2.95) Tier 1
BvD Dexamethasone
Dexamethasone
TABLET
($0.00 - $2.95) Tier 1
BvD
Dexamethasone Sodium Phosphate Dexamethasone Sod Phosphate
INJECTION
($0.00 - $2.95) Tier 1
BvD +Fludrocortisone Acetate
Fludrocortisone Acetate
TABLET
($0.00 - $2.95) Tier 1
+Hydrocortisone
Hydrocortisone
TABLET
($0.00 - $2.95) Tier 1
BvD
Methylprednisolone
Methylprednisolone
TABLET
($0.00 - $2.95) Tier 1
BvD Methylprednisolone
Methylprednisolone
TAB DS PK
($0.00 - $2.95) Tier 1
BvD
INJECTION
($0.00 - $2.95) Tier 1
BvD Methylprednisolone Sod Succ
Methylprednisolone Sod Succ
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD Methylprednisolone Sod Succ
Methylprednisolone Sod Succ
INJECTION
($0.00 - $2.95) Tier 1
BvD
Prednisolone Sodium Phosphate
ORAL SOLUTION
($0.00 - $2.95) Tier 1
BvD Prednisone
Prednisone
TAB DS PK
($0.00 - $2.95) Tier 1 Prednisone
Prednisone
TABLET
($0.00 - $2.95) Tier 1
PART D DRUGS
A-Hydrocort
BvD
121
BRAND DRUG NAME
Veripred 20
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
ORAL SOLUTION
($0.00 - $2.95) Tier 1
BvD
Chorionic Gonadotropin
Chorionic Gonadotropin, Human
INJECTION
($0.00 - $2.95) Tier 1
BvD, PA
+Desmopressin Acetate
Desmopressin Acetate
NASAL SPRAY
($0.00 - $2.95) Tier 1
INJECTION
($0.00 - $2.95) Tier 1
PA
TABLET
($0.00 - $2.95) Tier 1
NASAL SOLN
($0.00 - $2.95) Tier 1
+GENOTROPIN 0.2MG/0.25
Somatropin
INJECTION
($0.00 - $7.40) Tier 2
PA +GENOTROPIN ALL OTHER STRENGHTS Somatropin
INJECTION
($0.00 - $7.40) Tier 2
PA +HUMATROPE 12 MG, 24 MG
Somatropin
INJECTION
($0.00 - $7.40) Tier 2
PA +HUMATROPE 5 MG
Somatropin
INJECTION
($0.00 - $7.40) Tier 2
PA +HUMATROPE 6 MG
Somatropin
INJECTION
($0.00 - $7.40) Tier 2
PA INCRELEX
Mecasermin
INJECTION
($0.00 - $7.40) Tier 2
PA LUPRON DEPOT-PED
Leuprolide Acetate
INJECTION: IM KIT
($0.00 - $7.40) Tier 2
BvD, PA LUPRON DEPOT-PED
Leuprolide Acetate
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+NORDITROPIN FLEXPRO
Somatropin
INJECTION
($0.00 - $7.40) Tier 2
PA +NORDITROPIN NORDIFLEX
Somatropin
INJECTION
($0.00 - $7.40) Tier 2
PA PART D DRUGS
PITUITARY
122
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+NUTROPIN AQ NUSPIN
Somatropin
INJECTION
($0.00 - $7.40) Tier 2
PA
+SAIZEN
Somatropin
INJECTION
($0.00 - $7.40) Tier 2
PA
+SANDOSTATIN LAR
Octreotide Acetate,Mi-Spheres
INJECTION
($0.00 - $7.40) Tier 2
BvD
+SEROSTIM
Somatropin
INJECTION
($0.00 - $7.40) Tier 2
PA
+SOMATULINE DEPOT
Lanreotide Acetate
INJECTION
($0.00 - $7.40) Tier 2
PA
+SOMAVERT
Pegvisomant
INJECTION
($0.00 - $7.40) Tier 2
PA
+ZORBTIVE
Somatropin
INJECTION
($0.00 - $7.40) Tier 2
PA
+DEPO-PROVERA
Medroxyprogesterone Acetate
INJECTION
($0.00 - $7.40) Tier 2
BvD
+Medroxyprogesterone Acetate
INJECTION
($0.00 - $2.95) Tier 1
BvD
+Medroxyprogesterone Acetate
TABLET
($0.00 - $2.95) Tier 1
+Megestrol Acetate
Megestrol Acetate
ORAL SUSP
($0.00 - $2.95) Tier 1
+Norethindrone Acetate
Norethindrone Acetate
TABLET
($0.00 - $2.95) Tier 1
+Progesterone
Progesterone,Micronized
CAPSULE
($0.00 - $2.95) Tier 1
PROGESTINS
PART D DRUGS
PA
THYROID AND ANTITHYROID AGENTS
+Levothyroxine Sodium
Levothyroxine Sodium
TABLET
($0.00 - $2.95) Tier 1
+LEVOXYL
TABLET
($0.00 - $7.40) Tier 2
123
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Liothyronine Sodium
Liothyronine Sodium
TABLET
($0.00 - $2.95) Tier 1
+Methimazole
Methimazole
TABLET
($0.00 - $2.95) Tier 1
+Propylthiouracil
Propylthiouracil
TABLET
($0.00 - $2.95) Tier 1
+SYNTHROID
TABLET
($0.00 - $7.40) Tier 2
+THYROLAR-1
Liotrix
TABLET
($0.00 - $7.40) Tier 2
+THYROLAR-1/2
Liotrix
TABLET
($0.00 - $7.40) Tier 2
+THYROLAR-1/4
Liotrix
TABLET
($0.00 - $7.40) Tier 2
+THYROLAR-2
Liotrix
TABLET
($0.00 - $7.40) Tier 2
+THYROLAR-3
Liotrix
TABLET
($0.00 - $7.40) Tier 2
+TIROSINT
CAPSULE
($0.00 - $7.40) Tier 2
+UNITHROID
TABLET
($0.00 - $7.40) Tier 2
ANTIVENIN LATRODECTUS MACTANS Antivenin,Latrodectus Mactans
INJECTION
($0.00 - $7.40) Tier 2
BvD ANTIVENIN MICRURUS FULVIUS
Antivenin,Micrurus Fulvius
INJECTION
($0.00 - $7.40) Tier 2
BvD +ARCALYST
Rilonacept
INJECTION
($0.00 - $7.40) Tier 2
PA +ASTAGRAF XL
Tacrolimus
CAP.ER 24H
($0.00 - $7.40) Tier 2
PA IMMUNOLOGICAL AGENTS
IMMUNOLOGICAL AGENTS
124
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Lymphocyte Immune Globulin
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+AUBAGIO
Teriflunomide
TABLET
($0.00 - $7.40) Tier 2
PA
+Azathioprine
Azathioprine
TABLET
($0.00 - $2.95) Tier 1
BvD
BIVIGAM
Immun Glob G (Igg)/Gly/Iga 50+
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
CARIMUNE NF NANOFILTERED
Immune Globulin,Gamma(Igg)
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
CROFAB
Antivenin,Crotalidae Fab(Ovin)
INJECTION
($0.00 - $7.40) Tier 2
BvD
Cyclosporine
Cyclosporine
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD, PA
+Cyclosporine
Cyclosporine, Modified
ORAL SOLUTION
($0.00 - $2.95) Tier 1
BvD
+Cyclosporine
Cyclosporine
CAPSULE
($0.00 - $2.95) Tier 1
BvD
+Cyclosporine Modified
CAPSULE
($0.00 - $2.95) Tier 1
BvD
CYTOGAM
Cytomegalovirus Immune Globuln
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+ENBREL
Etanercept
INJECTION
($0.00 - $7.40) Tier 2
PA
GAMUNEX-C
Immune Glob,Gam Caprylate(Igg)
INJECTION
($0.00 - $7.40) Tier 2
BvD
+Gengraf
CAPSULE
($0.00 - $2.95) Tier 1
BvD
+Gengraf
ORAL SOLUTION
($0.00 - $2.95) Tier 1
BvD
HEPAGAM B
Hepatitis B Immun Glob/Maltose
INJECTION
($0.00 - $7.40) Tier 2
BvD
+HUMIRA
Adalimumab
INJECTION KIT
($0.00 - $7.40) Tier 2
PA
PART D DRUGS
ATGAM
125
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+HUMIRA CROHN'S
Adalimumab
INJECTION KIT
($0.00 - $7.40) Tier 2
PA
HYPERHEP B S-D
Hepatitis B Immune Globulin
INJECTION
($0.00 - $7.40) Tier 2
BvD
HYPERRAB S-D
Rabies Immune Globulin/Pf
INJECTION
($0.00 - $7.40) Tier 2
BvD
HYPERRHO S-D 1500 UNIT
Rho(D) Immune Globulin
INJECTION
($0.00 - $7.40) Tier 2
BvD
HYPERRHO S-D 250 UNIT
INJECTION
($0.00 - $7.40) Tier 2
BvD
HYPERTET S-D
Tetanus Immune Globulin/Pf
INJECTION
($0.00 - $7.40) Tier 2
BvD
+HYQVIA
Igg/Hyaluronidase,Recombinant
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
IMOGAM RABIES-HT
Rabies Immune Globulin/Pf
INJECTION
($0.00 - $7.40) Tier 2
BvD
+KINERET
Anakinra
INJECTION
($0.00 - $7.40) Tier 2
PA
+Leflunomide
Leflunomide
TABLET
($0.00 - $2.95) Tier 1
MICRHOGAM ULTRA-FILTERED PLUS Rho(D) Immune Globulin
INJECTION
($0.00 - $7.40) Tier 2
BvD
+Mycophenolate Mofetil
Mycophenolate Mofetil
ORAL SUSP
($0.00 - $2.95) Tier 1
BvD
TABLET
($0.00 - $2.95) Tier 1
BvD
CAPSULE
($0.00 - $2.95) Tier 1
BvD
+Mycophenolic Acid
Mycophenolate Sodium
TABLET DR
($0.00 - $2.95) Tier 1
BvD
NABI-HB
Hepatitis B Immune Globulin
INJECTION
($0.00 - $7.40) Tier 2
BvD
+NULOJIX
Belatacept
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
126
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Abatacept/Maltose
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
PROGRAF
Tacrolimus
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+RAPAMUNE
Sirolimus
ORAL SOLUTION
($0.00 - $7.40) Tier 2
BvD
RHOGAM ULTRA-FILTERED PLUS Rho(D) Immune Globulin
INJECTION
($0.00 - $7.40) Tier 2
BvD
RHOPHYLAC
INJECTION
($0.00 - $7.40) Tier 2
BvD
+RIDAURA
Auranofin
CAPSULE
($0.00 - $7.40) Tier 2
+Sirolimus 0.5 Mg
Sirolimus
TABLET
($0.00 - $2.95) Tier 1
BvD,QL
+SIROLIMUS 1 MG
Sirolimus
TABLET
($0.00 - $7.40) Tier 2
BvD
+SIROLIMUS 2 MG
Sirolimus
TABLET
($0.00 - $7.40) Tier 2
BvD
+Tacrolimus 0.5 Mg, 1 Mg
Tacrolimus
CAPSULE
($0.00 - $2.95) Tier 1
BvD
+TACROLIMUS 5 MG
Tacrolimus
CAPSULE
($0.00 - $7.40) Tier 2
BvD
+TYSABRI
Natalizumab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
WINRHO SDF
Rho(D) Immune Globulin/Maltose
INJECTION
($0.00 - $7.40) Tier 2
BvD
+ZORTRESS 0.25 MG
Everolimus
TABLET
($0.00 - $7.40) Tier 2
BvD, PA
+ZORTRESS 0.5 MG, 0.75 MG
Everolimus
TABLET
($0.00 - $7.40) Tier 2
BvD, PA
Haemoph B Poly Conj-Tet Tox/Pf
INJECTION
($0.00 - $7.40) Tier 2
PART D DRUGS
+ORENCIA
VACCINES
ACTHIB
127
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
ADACEL TDAP
Diph,Pertuss(Acell),Tet Vac/Pf
INJECTION
($0.00 - $7.40) Tier 2
BCG (TICE STRAIN)
Bcg Live
INJECTION
($0.00 - $7.40) Tier 2
BEXSERO
Meningococcal B Vacc,4-Comp/Pf
INJECTION
($0.00 - $7.40) Tier 2
BOOSTRIX TDAP
Diphth,Pertuss(Acell),Tet Vac
INJECTION
($0.00 - $7.40) Tier 2
CERVARIX
Human Papillomav Vacc Bival/Pf
INJECTION
($0.00 - $7.40) Tier 2
COMVAX
Hep B Vaccine/Hib Conj-Meng/Pf
INJECTION
($0.00 - $7.40) Tier 2
DAPTACEL DTAP
Diph,Pertuss(Acell),Tet Ped/Pf
INJECTION
($0.00 - $7.40) Tier 2
DIPHTHERIA-TETANUS TOXOIDS-PED Tetanus,Diphtheria Toxd Ped/Pf
INJECTION
($0.00 - $7.40) Tier 2
ENGERIX-B ADULT
INJECTION
($0.00 - $7.40) Tier 2
BvD
ENGERIX-B PEDIATRIC-ADOLESCENT Hepatitis B Virus Vaccine/Pf
INJECTION
($0.00 - $7.40) Tier 2
BvD
GARDASIL
Human Papilomvirus Vac,Qval/Pf
INJECTION
($0.00 - $7.40) Tier 2
GARDASIL 9
Hpv Vaccine 9-Valent/Pf
INJECTION
($0.00 - $7.40) Tier 2
HAVRIX
Hepatitis A Virus Vaccine/Pf
INJECTION
($0.00 - $7.40) Tier 2
IMOVAX RABIES VACCINE
Rabies Vacc, Human Diploid/Pf
INJECTION
($0.00 - $7.40) Tier 2
INFANRIX DTAP
Diph,Pertuss(Acell),Tet Ped/Pf
INJECTION
($0.00 - $7.40) Tier 2
IPOL
Poliomyelitis Vaccine, Killed
INJECTION
($0.00 - $7.40) Tier 2
IXIARO
Japanese Encephalitis Vacc/Pf
INJECTION
($0.00 - $7.40) Tier 2
Hepatitis B Virus Vaccine/Pf
128
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
Diph,Pertus(Acel),Tet,Polio/Pf
INJECTION
($0.00 - $7.40) Tier 2
MENACTRA
Mening Vac A,C,Y,W-135 Dip/Pf
INJECTION
($0.00 - $7.40) Tier 2
MENHIBRIX
Meningococcal Vac C,Y/Hib/Pf
INJECTION
($0.00 - $7.40) Tier 2
MENOMUNE-A-C-Y-W-135
Meningococ Vac A,C,Y,W-135/Pf
INJECTION
($0.00 - $7.40) Tier 2
MENVEO A-C-Y-W-135-DIP
Mening Vac A,C,Y,W-135 Dip/Pf
INJECTION
($0.00 - $7.40) Tier 2
MENVEO MENA COMPONENT
Mening A Conj Vacc, 1 Of 2/Pf
INJECTION
($0.00 - $7.40) Tier 2
INJECTION
($0.00 - $7.40) Tier 2
M-M-R II VACCINE
Measles,Mumps And Rubella Vacc/Pf INJECTION
($0.00 - $7.40) Tier 2
PEDIARIX
Hep B Vaccine/Dp(A)T-Polio/Pf
INJECTION
($0.00 - $7.40) Tier 2
PEDVAXHIB
Haemph B Polysac Conj-Menin/Pf
INJECTION
($0.00 - $7.40) Tier 2
PENTACEL ACTHIB COMPONENT Haemoph B Poly Conj-Tet Tox/Pf
INJECTION
($0.00 - $7.40) Tier 2
PENTACEL DTAP-IPV COMPONENT Diph,Pertus(Acel),Tet,Polio/Pf
INJECTION
($0.00 - $7.40) Tier 2
PROQUAD
Measles,Mumps,Rub,Varicella/Pf
INJECTION
($0.00 - $7.40) Tier 2
QUADRACEL DTAP-IPV
Diph,Pertus(Acel),Tet,Polio/Pf
INJECTION
($0.00 - $7.40) Tier 2
RABAVERT
Rabies Vaccine (Pcec)/Pf
INJECTION
($0.00 - $7.40) Tier 2
RECOMBIVAX HB
Hepatitis B Virus Vaccine/Pf
INJECTION
($0.00 - $7.40) Tier 2
ROTARIX
Rotavirus Vac,Live Att, 89-12
ORAL SUSP
($0.00 - $7.40) Tier 2
MENVEO MENCYW-135 COMPONENT Mening C,Y,W-135 Vac 2 Of 2/Pf
BvD
PART D DRUGS
KINRIX
NECESSARY ACTIONS,
BvD
129
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
ROTATEQ
Rotavirus Vaccine,Live Oral Pv
ORAL SUSP
($0.00 - $7.40) Tier 2
TENIVAC
Tetanus And Diphtheria Tox/Pf
INJECTION
($0.00 - $7.40) Tier 2
TETANUS DIPHTHERIA TOXOIDS
Tetanus And Diphtheria Tox,Adult
INJECTION
($0.00 - $7.40) Tier 2
Tetanus Toxoid Adsorbed
Tetanus Toxoid, Adsorbed/Pf
INJECTION
($0.00 - $2.95) Tier 1
THERACYS
Bcg Live
INJECTION
($0.00 - $7.40) Tier 2
TRUMENBA
N.Meningitidis B,Lipid Fhbp Rc
INJECTION
($0.00 - $7.40) Tier 2
TWINRIX
Hepatitis A And B Vaccine/Pf
INJECTION
($0.00 - $7.40) Tier 2
TYPHIM VI
Typhoid Vacc Vi Capsulr Polys
INJECTION
($0.00 - $7.40) Tier 2
VAQTA
Hepatitis A Virus Vaccine/Pf
INJECTION
($0.00 - $7.40) Tier 2
VARIVAX VACCINE
Varicella Vaccine Live/Pf
INJECTION
($0.00 - $7.40) Tier 2
YF-VAX
Yellow Fever Vaccine Live/Pf
INJECTION
($0.00 - $7.40) Tier 2
ZOSTAVAX
Zoster Vaccine Live/Pf
INJECTION
($0.00 - $7.40) Tier 2
NECESSARY ACTIONS,
BvD
+ALOSETRON HCL
Alosetron Hcl
TABLET
($0.00 - $7.40) Tier 2
+Balsalazide Disodium
Balsalazide Disodium
CAPSULE
($0.00 - $2.95) Tier 1
BUDESONIDE EC
Budesonide
CAPSULE
($0.00 - $7.40) Tier 2 PA + Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies.
130
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+CANASA
Mesalamine
RECTAL SUPP
($0.00 - $7.40) Tier 2
+DELZICOL
Mesalamine
CAPSULE CR
($0.00 - $7.40) Tier 2
+DIPENTUM
Olsalazine Sodium
CAPSULE
($0.00 - $7.40) Tier 2
+Mesalamine
Mesalamine
RECTAL ENEMA
($0.00 - $2.95) Tier 1
+PENTASA
Mesalamine
ER CAPSULE
($0.00 - $7.40) Tier 2
QL
Sodium Chloride Irrig Solution
IRRIGATION
($0.00 - $2.95) Tier 1
BvD
Water
Water For Irrigation,Sterile
IRRIGATION
($0.00 - $2.95) Tier 1
BvD
PART D DRUGS
Sodium Chloride
+ACTONEL 35 MG
Risedronate Sodium
TABLET
($0.00 - $7.40) Tier 2
QL
+ACTONEL 5 MG
Risedronate Sodium
TABLET
($0.00 - $7.40) Tier 2
QL
+Alendronate Sodium 35Mg, 70Mg
Alendronate Sodium
TABLET
($0.00 - $2.95) Tier 1
QL +Alendronate Sodium 5Mg, 10Mg, 40Mg Alendronate Sodium
TABLET
($0.00 - $2.95) Tier 1
QL
+CALCITONIN-SALMON
NASAL SPRAY
($0.00 - $7.40) Tier 2
PA Calcitonin,Salmon,Synthetic
131
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Calcitriol
Calcitriol
CAPSULE
($0.00 - $2.95) Tier 1
BvD
+DOXERCALCIFEROL
Doxercalciferol
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+DOXERCALCIFEROL 0.5 MCG
Doxercalciferol
CAPSULE
($0.00 - $7.40) Tier 2
BvD,QL
+DOXERCALCIFEROL 1 MCG
Doxercalciferol
CAPSULE
($0.00 - $7.40) Tier 2
BvD,QL
+DOXERCALCIFEROL 2.5 MCG
Doxercalciferol
CAPSULE
($0.00 - $7.40) Tier 2
BvD
+Etidronate Disodium
Etidronate Disodium
TABLET
($0.00 - $2.95) Tier 1
+FORTEO
Teriparatide
INJECTION
($0.00 - $7.40) Tier 2
PA, QL
+FORTICAL
Calcitonin,Salmon,Synthetic
NASAL SPRAY
($0.00 - $7.40) Tier 2
PA
+Ibandronate Sodium
Ibandronate Sodium
TABLET
($0.00 - $2.95) Tier 1
QL
MIACALCIN
Calcitonin,Salmon,Synthetic
INJECTION
($0.00 - $7.40) Tier 2
PA
+NATPARA
Parathyroid Hormone
INJECTION
($0.00 - $7.40) Tier 2
PA
Pamidronate Disodium
Pamidronate Disodium
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
+PARICALCITOL
Paricalcitol
CAPSULE
($0.00 - $7.40) Tier 2
BvD
+PARICALCITOL
Paricalcitol
INJECTION
($0.00 - $7.40) Tier 2
BvD
+PROLIA
Denosumab
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+RISEDRONATE SODIUM 35 MG, 150 MG Risedronate Sodium
TABLET
($0.00 - $7.40) Tier 2
QL
+RISEDRONATE SODIUM 5 MG, 30 MG Risedronate Sodium
TABLET
($0.00 - $7.40) Tier 2
QL
132
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+RISEDRONATE SODIUM DR
Risedronate Sodium
TABLET DR
($0.00 - $7.40) Tier 2
PA, QL
XGEVA
Denosumab
INJECTION
($0.00 - $7.40) Tier 2
PA
+ZEMPLAR
Paricalcitol
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
ZOLEDRONIC ACID 4 MG/5 ML
Zoledronic Acid
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+ZOLEDRONIC ACID 5 MG/100ML Zoledronic Acid/Mannitol And Water
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+ZOMETA
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
BvD, PA
Zoledronic Acid/Mannitol And Water
Interferon Gamma-1B,Recomb.
INJECTION
($0.00 - $7.40) Tier 2
+Allopurinol
Allopurinol
TABLET
($0.00 - $2.95) Tier 1
AMIFOSTINE
Amifostine Crystalline
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
PA +AVODART
Dutasteride
CAPSULE
($0.00 - $7.40) Tier 2
QL +AVONEX
Interferon Beta-1A
INJECTION: IM KIT
($0.00 - $7.40) Tier 2
PA +AVONEX ADMINISTRATION PACK Interferon Beta-1A/Albumin
INJECTION
($0.00 - $7.40) Tier 2
PA +AVONEX PEN
Interferon Beta-1A
INJECTION: IM KIT
($0.00 - $7.40) Tier 2
PA +BENLYSTA
Belimumab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+BETASERON
Interferon Beta-1B
INJECTION
($0.00 - $7.40) Tier 2
PART D DRUGS
ACTIMMUNE
133
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Bethanechol Chloride
Bethanechol Chloride
TABLET
($0.00 - $2.95) Tier 1
+Buspirone Hcl
Buspirone Hcl
TABLET
($0.00 - $2.95) Tier 1
+COLCHICINE
Colchicine
TABLET
($0.00 - $7.40) Tier 2
+COPAXONE
Glatiramer Acetate
INJECTION
($0.00 - $7.40) Tier 2
CYSTADANE
Betaine
ORAL POWDER
($0.00 - $7.40) Tier 2
+ENTYVIO
Vedolizumab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+Ergoloid Mesylates
Ergoloid Mesylates
TABLET
($0.00 - $2.95) Tier 1
PA
+EXTAVIA
Interferon Beta-1B
INJECTION
($0.00 - $7.40) Tier 2
PA
+Finasteride
Finasteride
TABLET
($0.00 - $2.95) Tier 1
QL
FOMEPIZOLE
Fomepizole
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+GILENYA
Fingolimod Hcl
CAPSULE
($0.00 - $7.40) Tier 2
PA
GLUCAGEN
Glucagon,Human Recombinant
INJECTION
($0.00 - $7.40) Tier 2
GLUCAGON EMERGENCY KIT
Glucagon,Human Recombinant
INJECTION
($0.00 - $7.40) Tier 2
+Guanidine Hcl
Guanidine Hcl
TABLET
($0.00 - $2.95) Tier 1
Hydroxyzine Hcl
Hydroxyzine Hcl
TABLET
($0.00 - $2.95) Tier 1
PA>65 y/o
Hydroxyzine Hcl
Hydroxyzine Hcl
ORAL SOLUTION
($0.00 - $2.95) Tier 1
PA>65 y/o
KEPIVANCE
Palifermin
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
PA
QL
134
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Leucovorin Calcium
Leucovorin Calcium
TABLET
($0.00 - $2.95) Tier 1
Leucovorin Calcium
Leucovorin Calcium
INJECTION
($0.00 - $2.95) Tier 1
BvD, PA
LEVOLEUCOVORIN CALCIUM
Levoleucovorin Calcium
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
MESNEX
Mesna
TABLET
($0.00 - $7.40) Tier 2 MIFEPREX
Mifepristone
TABLET
($0.00 - $7.40) Tier 2 +OTEZLA
Apremilast
TABLET
($0.00 - $7.40) Tier 2
PA OTEZLA
Apremilast
TAB DS PK
($0.00 - $7.40) Tier 2
PA
+PLEGRIDY
Peginterferon Beta-1A
INJECTION
($0.00 - $7.40) Tier 2
PA +PLEGRIDY PEN
Peginterferon Beta-1A
INJECTION
($0.00 - $7.40) Tier 2
PA +Probenecid
Probenecid
TABLET
($0.00 - $2.95) Tier 1
Probenecid-Colchicine
Colchicine/Probenecid
TABLET
($0.00 - $2.95) Tier 1 +Pyridostigmine Bromide
Pyridostigmine Bromide
TABLET
($0.00 - $2.95) Tier 1
+REBIF
Interferon Beta-1A/Albumin
INJECTION
($0.00 - $7.40) Tier 2
PA +REBIF REBIDOSE
Interferon Beta-1A/Albumin
INJECTION
($0.00 - $7.40) Tier 2
PA +REMICADE
Infliximab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+SENSIPAR 30 MG
Cinacalcet Hcl
TABLET
($0.00 - $7.40) Tier 2
PA, QL
+SENSIPAR 60 MG, 90 MG
Cinacalcet Hcl
TABLET
($0.00 - $7.40) Tier 2
PA PART D DRUGS
135
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+SIGNIFOR
Pasireotide Diaspartate
AMPUL
($0.00 - $7.40) Tier 2
PA
+SIGNIFOR LAR
Pasireotide Pamoate
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
SIMULECT
Basiliximab
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
Sterile Pads
Gauze Bandage
BANDAGE
($0.00 - $2.95) Tier 1
SYNAREL
Nafarelin Acetate
NASAL SPRAY
($0.00 - $7.40) Tier 2
PA
+TECFIDERA
Dimethyl Fumarate
CAPSULE CR
($0.00 - $7.40) Tier 2
PA
+THALOMID
Thalidomide
CAPSULE
($0.00 - $7.40) Tier 2
PA
THIOLA
Tiopronin
TABLET
($0.00 - $7.40) Tier 2
+TYBOST
Cobicistat
TABLET
($0.00 - $7.40) Tier 2
VORAXAZE
Glucarpidase
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+XELJANZ
Tofacitinib Citrate
TABLET
($0.00 - $7.40) Tier 2
PA
+ACETAZOLAMIDE
Acetazolamide
ER CAPSULE
($0.00 - $7.40) Tier 2
+Acetazolamide
Acetazolamide
TABLET
($0.00 - $2.95) Tier 1
+ALPHAGAN P
Brimonidine Tartrate
OPHT DROPS
($0.00 - $7.40) Tier 2
+AZOPT
Brinzolamide
OPHT SUSP
($0.00 - $7.40) Tier 2
OPHTHALMIC AGENTS
ANTIGLAUCOMA AGENTS
136
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Betaxolol Hcl
OPHT DROPS
($0.00 - $2.95) Tier 1
+Brimonidine Tartrate
Brimonidine Tartrate
OPHT DROPS
($0.00 - $2.95) Tier 1
+Dorzolamide Hcl
Dorzolamide Hcl
OPHT DROPS
($0.00 - $2.95) Tier 1
QL
+Dorzolamide-Timolol
Dorzolamide Hcl/Timolol Maleat
OPHT DROPS
($0.00 - $2.95) Tier 1
QL
+Latanoprost
Latanoprost
OPHT DROPS
($0.00 - $2.95) Tier 1
+Levobunolol Hcl
Levobunolol Hcl
OPHT DROPS
($0.00 - $2.95) Tier 1
+Methazolamide
Methazolamide
TABLET
($0.00 - $2.95) Tier 1
+Metipranolol
Metipranolol
OPHT DROPS
($0.00 - $2.95) Tier 1
+PHOSPHOLINE IODIDE
Echothiophate Iodide
OPHT DROPS
($0.00 - $7.40) Tier 2
+Pilocarpine Hcl
Pilocarpine Hcl
OPHT DROPS
($0.00 - $2.95) Tier 1
+Timolol Maleate
Timolol Maleate
OPHT DROPS
($0.00 - $2.95) Tier 1
+Timolol Maleate
Timolol Maleate
OPHT GEL
($0.00 - $2.95) Tier 1
+TRAVATAN Z
Travoprost
OPHT DROPS
($0.00 - $7.40) Tier 2
QL
+TRAVOPROST
Travoprost (Benzalkonium)
OPHT DROPS
($0.00 - $7.40) Tier 2
QL
ORAL SOLUTION
($0.00 - $2.95) Tier 1
PART D DRUGS
+Betaxolol Hcl
+Cytra-2
Citric Acid/Sodium Citrate
137
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Dextrose 2.5%-0.45% Nacl
Dextrose 2.5 % And 0.45 % Nacl
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD Dextrose 5%-0.2% Nacl
Dextrose 5 %-0.2 % Nacl
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD Dextrose 5%-0.2% Nacl-Kcl
Potassium Chloride/D5-0.2%Nacl
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
Dextrose 5 % And 0.3 % Nacl
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
Potassium Chloride/D5-0.45Nacl
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD Dextrose 5%-1/2Ns-Kcl
Potassium Chloride/D5-0.45Nacl
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD Dextrose 5%-1/4Ns-Kcl
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD Dextrose 5%-Ns-Kcl
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD Dextrose 5%-Potassium Chloride
Potassium Chloride In D5W
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD Dextrose In Lactated Ringers
Dextrose 5%-Lactated Ringers
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD +Effer-K
Potassium Bicarbonate/Cit Ac
TABLET EFF
($0.00 - $2.95) Tier 1
138
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Sodium/K+/Mag/Ca/Chlor/Acetate
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD +K Effervescent
TABLET EFF
($0.00 - $2.95) Tier 1
+Klor-Con M10
Potassium Chloride
TAB PRT ER
($0.00 - $2.95) Tier 1
+Klor-Con M15
Potassium Chloride
TAB PRT ER
($0.00 - $2.95) Tier 1
+Klor-Con M20
Potassium Chloride
TAB PRT ER
($0.00 - $2.95) Tier 1
LACTATED RINGERS
Ringers Solution,Lactated
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD Magnesium Sulfate
Magnesium Sulfate
INJECTION
($0.00 - $2.95) Tier 1
BvD NUTRILYTE II
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD Phospha 250 Neutral
Phosphorus #1
TABLET
($0.00 - $2.95) Tier 1 +Potassium Bicarbonate
TABLET EFF
($0.00 - $2.95) Tier 1
Potassium Chl-Normal Saline
Potassium Chloride In 0.9%Nacl
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
+Potassium Chloride
Potassium Chloride
TAB ER
($0.00 - $2.95) Tier 1
+Potassium Chloride
Potassium Chloride
ORAL PACKETS
($0.00 - $2.95) Tier 1
+Potassium Chloride
Potassium Chloride
TAB PRT ER
($0.00 - $2.95) Tier 1
+Potassium Chloride
Potassium Chloride
ER CAPSULE
($0.00 - $2.95) Tier 1
+Potassium Chloride
Potassium Chloride
ORAL SOLUTION
($0.00 - $2.95) Tier 1
Potassium Chloride
Potassium Chloride
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
PART D DRUGS
HYPERLYTE CR
BvD BvD
139
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
+Potassium Chloride
Pot Chloride/Pot Bicarb/Cit Ac
TABLET EFF
($0.00 - $2.95) Tier 1
Potassium Chloride In D5Lr
Potassium Chloride In Lr-D5
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
+Potassium Citrate Er
Potassium Citrate
TAB ER
($0.00 - $2.95) Tier 1
Potassium Citrate-Citric Acid
Potassium Citrate/Citric Acid
ORAL PACKETS
($0.00 - $2.95) Tier 1
Ringers Injection
Ringers Solution
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
Shohl'S Modified
ORAL SOLUTION
($0.00 - $2.95) Tier 1
Sodium Bicarbonate
Sodium Bicarbonate
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
Sodium Chloride
0.9 % Sodium Chloride
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
Sodium Citrate And Citric Acid
ORAL SOLUTION
($0.00 - $2.95) Tier 1
TPN ELECTROLYTES II
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
Virt-Phos 250 Neutral
Phosphorus #1
TABLET
($0.00 - $2.95) Tier 1
NECESSARY ACTIONS,
BvD
BvD
BvD
BvD
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
+ADVAIR DISKUS
Fluticasone/Salmeterol
INHALATION DISK
($0.00 - $7.40) Tier 2
QL,ST
+ADVAIR HFA
Fluticasone/Salmeterol
AEROSOL
($0.00 - $7.40) Tier 2
QL,ST
+Budesonide
Budesonide
INHALATION SOLN
($0.00 - $2.95) Tier 1
BvD, PA
+FLOVENT DISKUS
INHALATION DISK
($0.00 - $7.40) Tier 2
140
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+FLOVENT HFA
AEROSOL
($0.00 - $7.40) Tier 2
+PULMICORT FLEXHALER
Budesonide
AEROSOL
($0.00 - $7.40) Tier 2
+QVAR
Beclomethasone Dipropionate
AEROSOL
($0.00 - $7.40) Tier 2
+Montelukast Sodium
Montelukast Sodium
TABLET
($0.00 - $2.95) Tier 1
+Montelukast Sodium
Montelukast Sodium
TAB CHEW
($0.00 - $2.95) Tier 1
+Zafirlukast
Zafirlukast
TABLET
($0.00 - $2.95) Tier 1
QL
+Albuterol Sulfate
Albuterol Sulfate
TABLET
($0.00 - $2.95) Tier 1
+Albuterol Sulfate
Albuterol Sulfate
TAB ER 12H
($0.00 - $2.95) Tier 1
+Albuterol Sulfate
Albuterol Sulfate
ORAL SYRUP
($0.00 - $2.95) Tier 1
+Albuterol Sulfate
Albuterol Sulfate
INHALATION SOLN
($0.00 - $2.95) Tier 1
BvD
+Albuterol Sulfate
Albuterol Sulfate
INHALATION SOLN
($0.00 - $2.95) Tier 1
BvD
+ANORO ELLIPTA
Umeclidinium Brm/Vilanterol Tr
INHALATION DISK
($0.00 - $7.40) Tier 2
PA, QL
+ATROVENT HFA
Ipratropium Bromide
AEROSOL
($0.00 - $7.40) Tier 2
+COMBIVENT RESPIMAT
Ipratropium/Albuterol Sulfate
AEROSOL
($0.00 - $7.40) Tier 2
+Elixophyllin
Theophylline Anhydrous
ORAL SOLUTION
($0.00 - $2.95) Tier 1
ANTILEUKOTRIENES
BRONCHODILATORS
PART D DRUGS
141
PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Ipratropium Bromide
Ipratropium Bromide
INHALATION SOLN
($0.00 - $2.95) Tier 1
BvD
+Ipratropium-Albuterol
Ipratropium/Albuterol Sulfate
INHALATION SOLN
($0.00 - $2.95) Tier 1
BvD
+Levalbuterol Hcl
Levalbuterol Hcl
INHALATION SOLN
($0.00 - $2.95) Tier 1
BvD, PA
+Metaproterenol Sulfate
Metaproterenol Sulfate
TABLET
($0.00 - $2.95) Tier 1
+Metaproterenol Sulfate
Metaproterenol Sulfate
ORAL SYRUP
($0.00 - $2.95) Tier 1
+PROAIR HFA
Albuterol Sulfate
AEROSOL
($0.00 - $7.40) Tier 2
QL
+PROAIR RESPICLICK
Albuterol Sulfate
AEROSOL
($0.00 - $7.40) Tier 2
QL
+SEREVENT DISKUS
Salmeterol Xinafoate
INHALATION DISK
($0.00 - $7.40) Tier 2
PA
+SPIRIVA
Tiotropium Bromide
INHALATION CAPSULE
($0.00 - $7.40) Tier 2
QL
+SPIRIVA RESPIMAT
Tiotropium Bromide
AEROSOL
($0.00 - $7.40) Tier 2
QL
+STRIVERDI RESPIMAT
Olodaterol Hcl
AEROSOL
($0.00 - $7.40) Tier 2
+Terbutaline Sulfate
Terbutaline Sulfate
TABLET
($0.00 - $2.95) Tier 1
Terbutaline Sulfate
Terbutaline Sulfate
INJECTION
($0.00 - $2.95) Tier 1
+THEO-24
CAP.ER 24H
($0.00 - $7.40) Tier 2
+Theochron
TAB ER 12H
($0.00 - $2.95) Tier 1
+Theophylline
TAB ER
($0.00 - $2.95) Tier 1
+Theophylline
ORAL SOLUTION
($0.00 - $2.95) Tier 1
142
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+Theophylline Anhydrous
TAB ER 12H
($0.00 - $2.95) Tier 1
Theophylline In 5% Dextrose
Theophylline/D5W
INTRAVENOUS (IV)
($0.00 - $2.95) Tier 1
BvD
+TUDORZA PRESSAIR
Aclidinium Bromide
AEROSOL
($0.00 - $7.40) Tier 2
ST
+VENTOLIN HFA
Albuterol Sulfate
AEROSOL
($0.00 - $7.40) Tier 2
QL
RESPIRATORY TRACT AGENTS, OTHER
Acetylcysteine
SOLN
($0.00 - $2.95) Tier 1
BvD
+Cromolyn Sodium
Cromolyn Sodium
INHALATION SOLN
($0.00 - $2.95) Tier 1
BvD
+DALIRESP
Roflumilast
TABLET
($0.00 - $7.40) Tier 2
PA
+ESBRIET
Pirfenidone
CAPSULE
($0.00 - $7.40) Tier 2
PA
+KALYDECO
Ivacaftor
TABLET
($0.00 - $7.40) Tier 2
PA
+OFEV
Nintedanib Esylate
CAPSULE
($0.00 - $7.40) Tier 2
PA
+XOLAIR
Omalizumab
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
+ZEMAIRA
Alpha-1-Proteinase Inhibitor
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
PA
TABLET
($0.00 - $2.95) Tier 1
PART D DRUGS
Acetylcysteine
+Baclofen
Baclofen
143
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Carisoprodol
Carisoprodol
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
Chlorzoxazone
Chlorzoxazone
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
Cyclobenzaprine Hcl
Cyclobenzaprine Hcl
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
+Dantrolene Sodium
Dantrolene Sodium
CAPSULE
($0.00 - $2.95) Tier 1
Methocarbamol 500 Mg
Methocarbamol
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
Methocarbamol 750 Mg
Methocarbamol
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
+Tizanidine Hcl
Tizanidine Hcl
TABLET
($0.00 - $2.95) Tier 1
PART D DRUGS
+HETLIOZ
Tasimelteon
CAPSULE
($0.00 - $7.40) Tier 2
PA
+MODAFINIL
Modafinil
TABLET
($0.00 - $7.40) Tier 2
PA
ROZEREM
Ramelteon
TABLET
($0.00 - $7.40) Tier 2
PA
~XYREM
Sodium Oxybate
ORAL SOLUTION
($0.00 - $7.40) Tier 2
PA
Zaleplon
Zaleplon
CAPSULE
($0.00 - $2.95) Tier 1
PA>65 y/o
Zolpidem Tartrate
Zolpidem Tartrate
TABLET
($0.00 - $2.95) Tier 1
QL,PA 65 y/o
144
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
VASODILATING AGENTS
VASODILATING AGENTS
Tadalafil
TABLET
($0.00 - $7.40) Tier 2
PA
+ADEMPAS
Riociguat
TABLET
($0.00 - $7.40) Tier 2
PA
EPOPROSTENOL SODIUM
Epoprostenol Sodium (Glycine)
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
+LETAIRIS
Ambrisentan
TABLET
($0.00 - $7.40) Tier 2
PA
REMODULIN
Treprostinil Sodium
INJECTION
($0.00 - $7.40) Tier 2
BvD, PA
Sildenafil
Sildenafil Citrate
TABLET
($0.00 - $2.95) Tier 1
PA
SILDENAFIL CITRATE
Sildenafil Citrate
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD, PA
+~TRACLEER
Bosentan
TABLET
($0.00 - $7.40) Tier 2
PA
VELETRI
Epoprostenol Sodium (Arginine)
INTRAVENOUS (IV)
($0.00 - $7.40) Tier 2
BvD
TABLET
($0.00 - $2.95) Tier 1
PART D DRUGS
+ADCIRCA
Prenatal Plus
Pnv With Ca,No.72/Iron/Fa
145
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
ANALGESICS
ANALGESICS, MISCELLANEOUS
Acetaminophen
SUPP.RECT
($0.00) Tier 3
QL
*Acetaminophen 100 MG/ML
Acetaminophen
DROPS
($0.00) Tier 3
QL
*Acetaminophen 120 MG
Acetaminophen
SUPP.RECT
($0.00) Tier 3
QL
*Acetaminophen 160 MG/5ML
Acetaminophen
ELIXIR
($0.00) Tier 3
QL
Acetaminophen
SUPP.RECT
($0.00) Tier 3
QL
Acetaminophen
SUPP.RECT
($0.00) Tier 3
QL
*Acetaminophen 80MG/0.8ML
Acetaminophen
DROPS SUSP
($0.00) Tier 3
QL
*Children'S Non-Aspirin 80 MG
Acetaminophen
TAB CHEW
($0.00) Tier 3
QL
*Children'S Pain And Fever 160 MG/5ML Acetaminophen
ORAL SUSP
($0.00) Tier 3
QL
*Children'S Silapap 160 MG/5ML
LIQUID
($0.00) Tier 3
QL
*Infant'S Acetaminophen 80MG/0.8ML Acetaminophen
DROPS
($0.00) Tier 3
QL
*Mapap 325 MG
Acetaminophen
TABLET
($0.00) Tier 3
QL
*Mapap 500 MG
Acetaminophen
TABLET
($0.00) Tier 3
QL
*Mapap 500 MG
Acetaminophen
CAPSULE
($0.00) Tier 3
QL
*Mapap 500MG/15ML
Acetaminophen
LIQUID
($0.00) Tier 3
QL
Acetaminophen
NON PART D DRUGS
*Acephen 650 MG
* This drug is covered by Medi-Cal and is not a "Part D drug." If you have questions, call Care1st Cal MediConnect Plan Member Services.
147
BRAND DRUG NAME
GENERIC DRUG NAME
*Pain Reliever Junior Strength 160 MG Acetaminophen
FORMULATION
WHAT THE DRUG WILL
TAB CHEW
($0.00) Tier 3
NECESSARY ACTIONS,
QL
NON PART D DRUGS
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
*Aspirin 300 MG
Aspirin
SUPP.RECT
($0.00) Tier 3
*Aspirin 325 MG
Aspirin
TABLET
($0.00) Tier 3
*Aspirin 500 MG
Aspirin
TABLET
($0.00) Tier 3
*Aspirin 600 MG
Aspirin
SUPP.RECT
($0.00) Tier 3
*Aspirin 81 MG
Aspirin
TAB CHEW
($0.00) Tier 3
*Aspirin Buffered 325 MG
Aspirin/Calcium Carbonate/Mag
TABLET
($0.00) Tier 3
*Aspirin Ec 325 MG
Aspirin
TABLET DR
($0.00) Tier 3
*Aspirin Ec 500 MG
Aspirin
TABLET DR
($0.00) Tier 3
*Aspirin Ec 650 MG
Aspirin
TABLET DR
($0.00) Tier 3
*Aspirin Ec 81 MG
Aspirin
TABLET DR
($0.00) Tier 3
*Bufferin 500 MG
Aspirin/Calcium Carbonate/Mag
TABLET
($0.00) Tier 3
*Children'S Advil 100 MG/5ML
Ibuprofen
ORAL SUSP
($0.00) Tier 3
*Ibuprofen 100 MG
Ibuprofen
TABLET
($0.00) Tier 3
*Ibuprofen 100 MG
Ibuprofen
TAB CHEW
($0.00) Tier 3
*Ibuprofen 200 MG
Ibuprofen
TABLET
($0.00) Tier 3
148
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
*Ibuprofen 200 MG
Ibuprofen
CAPSULE
($0.00) Tier 3
*Infant'S Ibuprofen 50 MG/1.25
Ibuprofen
DROPS SUSP
($0.00) Tier 3
NECESSARY ACTIONS,
Nicotine Polacrilex
GUM
($0.00) Tier 3
PA
*Nicorelief 4 MG
Nicotine Polacrilex
GUM
($0.00) Tier 3
PA
*Nicotine Patch 14MG/24HR
Nicotine
PATCH TD24
($0.00) Tier 3
PA
*Nicotine Patch 21 MG/24HR
Nicotine
PATCH TD24
($0.00) Tier 3
PA
*Nicotine Patch 22 MG/24HR
Nicotine
PATCH TD24
($0.00) Tier 3
PA
*Nicotine Patch 7MG/24HR
Nicotine
PATCH TD24
($0.00) Tier 3
PA
*Baza Antifungal 2 %
Miconazole Nitrate
CREAM (G)
($0.00) Tier 3
*Clotrimazole 1 %
Clotrimazole
CREAM (G)
($0.00) Tier 3
*Clotrimazole 1 %
Clotrimazole
CREAM/APPL
($0.00) Tier 3
*Clotrimazole 100 MG
Clotrimazole
TABLET
($0.00) Tier 3
NON PART D DRUGS
*Nicorelief 2 MG
ANTIFUNGALS
ANTIFUNGALS
149
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Clotrimazole 3 2 %
Clotrimazole
CREAM/APPL
($0.00) Tier 3
*Desenex 2 %
Miconazole Nitrate
SPRAY
($0.00) Tier 3
*Miconazole 7 100 MG
Miconazole Nitrate
SUPP.VAG
($0.00) Tier 3
*Miconazole Nitrate 2 %
Miconazole Nitrate
CREAM/APPL
($0.00) Tier 3
*Tioconazole 1 6.5 %
Tioconazole
OIN/PF APP
($0.00) Tier 3
*Tolnaftate 1 %
Tolnaftate
CREAM (G)
($0.00) Tier 3
*Tolnaftate 1 %
Tolnaftate
SOLUTION
($0.00) Tier 3
*Aller-Chlor 2 MG/5 ML
Chlorpheniramine Maleate
SYRUP
($0.00) Tier 3
PA>65 y/o
*Allergy 25 MG
Diphenhydramine Hcl
TABLET
($0.00) Tier 3
PA>65 y/o
*Aprodine 60MG-2.5MG
Pseudoephedrine/Triprolidine
TABLET
($0.00) Tier 3
PA>65 y/o
*Cetirizine Hcl 10 MG
Cetirizine Hcl
TABLET
($0.00) Tier 3
*Cetirizine Hcl 5 MG
Cetirizine Hcl
TABLET
($0.00) Tier 3
*Diphenhydramine Hcl 12.5MG/5ML Diphenhydramine Hcl
LIQUID
($0.00) Tier 3
*Diphenhydramine Hcl 25 MG
Diphenhydramine Hcl
CAPSULE
($0.00) Tier 3
PA>65 y/o
*Diphenhydramine Hcl 50 MG
Diphenhydramine Hcl
TABLET
($0.00) Tier 3
PA>65 y/o
ANTIHISTAMINES
NON PART D DRUGS
ANTIHISTAMINES
150
BRAND DRUG NAME
*Q-Tapp 15-1MG/5ML
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
Pseudoephedrine/Brompheniramin
LIQUID
($0.00) Tier 3
*Ambizine 25 MG
Meclizine Hcl
TABLET
($0.00) Tier 3
*Meclizine Hcl 12.5 MG
Meclizine Hcl
TABLET
($0.00) Tier 3
*Travel Sickness 25 MG
Meclizine Hcl
TAB CHEW
($0.00) Tier 3
NECESSARY ACTIONS,
ANTINAUSEA AGENTS
ANTINAUSEA AGENTS
ANTICOAGULANTS
SYRINGE
($0.00) Tier 3
PA
NON PART D DRUGS
*Monoject Prefill Advanced 500/5 ML Heparin Sodium,Porcine/Pf
DYSLIPIDEMICS
*Endur-Acin 250 MG
Niacin
TABLET ER
($0.00) Tier 3
*Endur-Acin 500 MG
Niacin
TABLET ER
($0.00) Tier 3
*Niacin 100 MG
Niacin
TABLET
($0.00) Tier 3
*Niacin 1000 MG
Niacin
TABLET ER
($0.00) Tier 3
151
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
*Niacin 125 MG
Niacin
CAPSULE ER
($0.00) Tier 3
*Niacin 250 MG
Niacin
CAPSULE ER
($0.00) Tier 3
*Niacin 250 MG
Niacin
TABLET
($0.00) Tier 3
*Niacin 400 MG
Niacin
CAPSULE ER
($0.00) Tier 3
*Niacin 50 MG
Niacin
TABLET
($0.00) Tier 3
*Niacin 500 MG
Niacin
TABLET
($0.00) Tier 3
*Niacin 500 MG
Niacin
CAPSULE ER
($0.00) Tier 3
*Niacin 750 MG
Niacin
TABLET ER
($0.00) Tier 3
NECESSARY ACTIONS,
NON PART D DRUGS
*Phentermine Hcl 15 MG
Phentermine Hcl
CAPSULE
($0.00) Tier 3
PA
*Phentermine Hcl 30 MG
Phentermine Hcl
CAPSULE
($0.00) Tier 3
PA
*Conceptrol 4 %
Nonoxynol 9
GEL/PF APP
($0.00) Tier 3
*Condoms
Condoms, Latex, Lubricated
EACH
($0.00) Tier 3
CONTRACEPTIVES
CONTRACEPTIVES
QL
152
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
*Econtra Ez 1.5 MG
Levonorgestrel
TABLET
($0.00) Tier 3
*Gynol Ii 3 %
Nonoxynol 9
JELLY/APPL
($0.00) Tier 3
*Vcf 12.5 %
Nonoxynol 9
FOAM/APPL
($0.00) Tier 3
*Adult Nasal Decongestant 15 MG/5 ML Pseudoephedrine Hcl
LIQUID
($0.00) Tier 3
*Adult Robitussin Peak Cold 100-10MG/5 Guaifenesin/Dextromethorphan
LIQUID
($0.00) Tier 3
*Adult Wal-Tussin 100 MG/5ML
Guaifenesin
LIQUID
($0.00) Tier 3
*Adult Wal-Tussin Dm 100-10MG/5
Guaifenesin/Dextromethorphan
SYRUP
($0.00) Tier 3
*Benzonatate 100 MG
Benzonatate
CAPSULE
($0.00) Tier 3
*Benzonatate 200 MG
Benzonatate
CAPSULE
($0.00) Tier 3
*Cheratussin Ac 100-10MG/5
Guaifenesin/Codeine Phosphate
LIQUID
($0.00) Tier 3
*Cold And Cough Childrens 5-15-1MG/5 D-Methorphan Hb/P-Epd Hcl/Bpm
ELIXIR
($0.00) Tier 3
*Expectorant Max Strength 15-30MG/5 Dextromethorphan/Pseudoephed
LIQUID
($0.00) Tier 3
*Nasal And Sinus Decongestant 30 MG Pseudoephedrine Hcl
TABLET
($0.00) Tier 3
*Neo-Tuss 200-30MG/5
Guaifenesin/Dextromethorphan
LIQUID
($0.00) Tier 3
*Pedia Relief 2.5-7.5/.8
Dextromethorphan/Pseudoephed
DROPS
($0.00) Tier 3
NECESSARY ACTIONS,
NON PART D DRUGS
153
NON PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Pedia Relief Cough-Cold 5-15-1MG/5 D-Methorphan Hb/P-Ephed Hcl/Cp
LIQUID
($0.00) Tier 3
*Phenylhistine Dh 30-10-2/5
LIQUID
($0.00) Tier 3
PA>65 y/o
*Promethazine Vc-Codeine 6.25-5-10 Promethazine/Phenyleph/Codeine
SYRUP
($0.00) Tier 3
PA>65 y/o
*Promethazine-Codeine 6.25-10/5
Promethazine Hcl/Codeine
SYRUP
($0.00) Tier 3
QL, PA>65 y/o
*Promethazine-Dm 15-6.25/5
D-Methorphan Hb/Prometh Hcl
SYRUP
($0.00) Tier 3
PA>65 y/o
*Pseudoephedrine Hcl 30 MG/5 ML
Pseudoephedrine Hcl
LIQUID
($0.00) Tier 3
*Sudogest 120 MG
Pseudoephedrine Hcl
TABLET ER
($0.00) Tier 3
*Sudogest 60 MG
Pseudoephedrine Hcl
TABLET
($0.00) Tier 3
*Valu-Tapp Decongestant 9.4MG/ML Pseudoephedrine Hcl
DROPS
($0.00) Tier 3
P-Ephed Hcl/Cod/Chlorphenir
DERMATOLOGICAL AGENTS, OTHER
*Allergy Cream 2 %
Diphenhydramine Hcl
CREAM (G)
($0.00) Tier 3
*Amlactin 12 %
Ammonium Lactate
LOTION
($0.00) Tier 3
*Benzoyl Peroxide 10 %
Benzoyl Peroxide
CLEANSER
($0.00) Tier 3
*Benzoyl Peroxide 10 %
Benzoyl Peroxide
GEL (GRAM)
($0.00) Tier 3
*Itch Relief 2 %-0.1 %
Diphenhydramine Hcl/Zinc Acet
CREAM (G)
($0.00) Tier 3
*Scalp Itch-Dandruff Relief 3 %
Salicylic Acid
LIQUID
($0.00) Tier 3
154
BRAND DRUG NAME
*T-Gel 1 %
GENERIC DRUG NAME
Coal Tar
FORMULATION
WHAT THE DRUG WILL
SHAMPOO
($0.00) Tier 3
NECESSARY ACTIONS,
DERMATOLOGICAL ANTIBACTERIALS
*Antibiotic Plus 3.5-10K-10
Neomycin Su/Plymx B Su/Pram
CREAM (G)
($0.00) Tier 3
*Bacitracin 500 UNIT/G
Bacitracin
OINT. (G)
($0.00) Tier 3
*Bacitracin-Polymyxin 500-10K/G
Bacitracin/Polymyxin B Sulfate
OINT. (G)
($0.00) Tier 3
*Neosporin 3.5-400-5K
Neomycin Su/Bacitrac Zn/Poly
OINT. (G)
($0.00) Tier 3
DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS
Hydrocortisone
LOTION
($0.00) Tier 3
*Cortaid 1 %
Hydrocortisone
CREAM (G)
($0.00) Tier 3
*Cortizone-10 1 %
Hydrocortisone
OINT. (G)
($0.00) Tier 3
*Hydrocortisone 0.5 %
Hydrocortisone
OINT. (G)
($0.00) Tier 3
*Hydrocortisone 0.5 %
Hydrocortisone
CREAM (G)
($0.00) Tier 3
*Nu-Derm Tolereen 0.5 %
Hydrocortisone
LOTION
($0.00) Tier 3
NON PART D DRUGS
*Aquanil Hc 1 %
SCABICIDES AND PEDICULICIDES
*Bedding Spray 0.5 %
Permethrin
SPRAY
($0.00) Tier 3
*Lice Cream Rinse 1 %
Permethrin
LIQUID
($0.00) Tier 3
*Lice Killing 4%-0.33%
Piperonyl Butoxide/Pyrethrins
SHAMPOO
($0.00) Tier 3
* This drug is covered by Medi-Cal and is not a "Part D drug." If you have questions, call Care1st Cal MediConnect Plan Member Services
155
BRAND DRUG NAME
*Lice Treatment
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Piperonyl Butoxide/Pyrethrins
LIQUID
($0.00) Tier 3
*Ace Aerosol Cloud Enhancer
Inhaler, Assist Devices
SPACER
($0.00) Tier 3
QL
*Ace Aerosol Cloud Enhancer
SPACER
($0.00) Tier 3
QL
*Breatherite
SPACER
($0.00) Tier 3
QL
*Breathrite
SPACER
($0.00) Tier 3
QL
*Compact Space Chamber Plus
SPACER
($0.00) Tier 3
QL
*Easivent
SPACER
($0.00) Tier 3
QL
*E-Z Spacer
SPACER
($0.00) Tier 3
QL
*Liteaire
SPACER
($0.00) Tier 3
QL
*Microchamber
SPACER
($0.00) Tier 3
QL
*Microspacer
SPACER
($0.00) Tier 3
QL
*Nessi Spacer
SPACER
($0.00) Tier 3
QL
*Optichamber
Inhaler,Assist Device,Accesory
SPACER
($0.00) Tier 3
QL
*Optichamber
SPACER
($0.00) Tier 3
QL
*Primeaire
SPACER
($0.00) Tier 3
QL
DEVICES
NON PART D DRUGS
DEVICES
156
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Riteflo
SPACER
($0.00) Tier 3
QL
*Space Chamber Plus
SPACER
($0.00) Tier 3
QL
*Vortex
SPACER
($0.00) Tier 3
QL
*Vortex Frog Mask
SPACER
($0.00) Tier 3
QL
*Vortex Ladybug Mask
SPACER
($0.00) Tier 3
QL
*Vortex Vhc Frog Mask
SPACER
($0.00) Tier 3
QL
*Watchhaler
SPACER
($0.00) Tier 3
QL
EYE, EAR, NOSE, THROAT AGENTS, MISCELLANEOUS
Ketotifen Fumarate
DROPS
($0.00) Tier 3
*Altamist 0.65 %
Sodium Chloride
SPRAY
($0.00) Tier 3
*Artificial Tears 1.4 %
Polyvinyl Alcohol
DROPS
($0.00) Tier 3
*Ephrine Nose Drops 1 %
Phenylephrine Hcl
DROPS
($0.00) Tier 3
*Eye Wash
Sodium/Potassium/Sod Chl
DROPS
($0.00) Tier 3
*Little Noses 0.125 %
Phenylephrine Hcl
DROPS
($0.00) Tier 3
*Muro-128 2 %
Sodium Chloride
DROPS
($0.00) Tier 3
*Muro-128 5 %
Sodium Chloride
DROPS
($0.00) Tier 3
NON PART D DRUGS
*Alaway 0.025 %
157
BRAND DRUG NAME
*Wal-Four 1 %
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
Phenylephrine Hcl
SPRAY
($0.00) Tier 3
DROPS
($0.00) Tier 3
NECESSARY ACTIONS,
EYE, EAR, NOSE, THROAT ANTI-INFECTIVES AGENTS
*Auraphene-B 6.5 %
Carbamide Peroxide
NON PART D DRUGS
ANTIFLATULENTS
*Anti-Gas 166MG
Simethicone
CAPSULE
($0.00) Tier 3
*Gas Relief 125 MG
Simethicone
CAPSULE
($0.00) Tier 3
*Gas Relief 125 MG
Simethicone
TAB CHEW
($0.00) Tier 3
*Gas Relief 80 MG
Simethicone
TAB CHEW
($0.00) Tier 3
*Simethicone 40MG/0.6ML
Simethicone
DROPS SUSP
($0.00) Tier 3
ANTIULCER AGENTS AND ACID SUPPRESSANTS
*Acid Reducer 10 MG
Famotidine
TABLET
($0.00) Tier 3
*Acid Reducer 20 MG
Famotidine
TABLET
($0.00) Tier 3
*Acid Relief 200 MG
Cimetidine
TABLET
($0.00) Tier 3
*Omeprazole Magnesium 20 MG
Omeprazole Magnesium
CAPSULE DR
($0.00) Tier 3
*Ranitidine Hcl 150 MG
Ranitidine Hcl
TABLET
($0.00) Tier 3
158
BRAND DRUG NAME
*Ranitidine Hcl 75 MG
GENERIC DRUG NAME
Ranitidine Hcl
FORMULATION
WHAT THE DRUG WILL
TABLET
($0.00) Tier 3
NECESSARY ACTIONS,
GASTROINTESTINAL AGENTS, OTHER
Magnesium Carbonate/Al Hydrox
TAB CHEW
($0.00) Tier 3
*Almacone 200-200-20
Mag Hydrox/Al Hydrox/Simeth
ORAL SUSP
($0.00) Tier 3
*Almacone-2 400-400-40
ORAL SUSP
($0.00) Tier 3
*Aluminum Hydroxide 320 MG/5ML
Aluminum Hydroxide
ORAL SUSP
($0.00) Tier 3
*Aluminum Hydroxide 600 MG/5ML
Aluminum Hydroxide
ORAL SUSP
($0.00) Tier 3
*Anti-Diarrheal 2 MG
Loperamide Hcl
CAPSULE
($0.00) Tier 3
*Anti-Diarrheal 2 MG
Loperamide Hcl
TABLET
($0.00) Tier 3
*Bismuth Subsalicylate 262 MG
Bismuth Subsalicylate
TAB CHEW
($0.00) Tier 3
*Bismuth Subsalicylate 262 MG
Bismuth Subsalicylate
TABLET
($0.00) Tier 3
*Bismuth Subsalicylate 525MG/15ML Bismuth Subsalicylate
ORAL SUSP
($0.00) Tier 3
*Calci-Chew 500(1250)
Calcium Carbonate
TAB CHEW
($0.00) Tier 3
*Calcium Antacid 200(500)MG
Calcium Carbonate
TAB CHEW
($0.00) Tier 3
*Calcium Antacid 300MG(750)
Calcium Carbonate
TAB CHEW
($0.00) Tier 3
*Children'S Pepto 400 MG
Calcium Carbonate
TAB CHEW
($0.00) Tier 3
*Foaming Antacid 20-80MG
Mg Trisilicate/Alh/Nahco3/Aa
TAB CHEW
($0.00) Tier 3
NON PART D DRUGS
*Acid Gone 105-160MG
159
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
*Loperamide 1 MG/5 ML
Loperamide Hcl
LIQUID
($0.00) Tier 3
*Loperamide 1MG/7.5ML
Loperamide Hcl
LIQUID
($0.00) Tier 3
*Riginic 131-31.7/5
Mag Carb/Al Hydrox/Alginic Ac
ORAL SUSP
($0.00) Tier 3
*Ri-Mag 540MG/5ML
Magaldrate
ORAL SUSP
($0.00) Tier 3
*Ri-Mox Plus 200-225-25
ORAL SUSP
($0.00) Tier 3
*Sodium Bicarbonate 325 MG
Sodium Bicarbonate
TABLET
($0.00) Tier 3
*Sodium Bicarbonate 650 MG
Sodium Bicarbonate
TABLET
($0.00) Tier 3
*Adult Glycerin ADULT
Glycerin
SUPP.RECT
($0.00) Tier 3
*Bisacodyl 10 MG
Bisacodyl
SUPP.RECT
($0.00) Tier 3
*Bisacodyl 5 MG
Bisacodyl
TABLET DR
($0.00) Tier 3
*Child Suppository PEDIATRIC
Glycerin
SUPP.RECT
($0.00) Tier 3
*Citrate Of Magnesia
Magnesium Citrate
SOLUTION
($0.00) Tier 3
*Clearlax 17G/DOSE
POWDER
($0.00) Tier 3
*Colace 100 MG
Docusate Sodium
CAPSULE
($0.00) Tier 3
*Colace Clear 50 MG
Docusate Sodium
CAPSULE
($0.00) Tier 3
*Docu Liquid 50 MG/5 ML
Docusate Sodium
LIQUID
($0.00) Tier 3
NECESSARY ACTIONS,
NON PART D DRUGS
LAXATIVES
QL
160
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
*Docusate Sodium 250 MG
Docusate Sodium
CAPSULE
($0.00) Tier 3
*Polyethylene Glycol 3350 17G
POWD PACK
($0.00) Tier 3
*Silace 60 MG/15ML
Docusate Sodium
SYRUP
($0.00) Tier 3
BRAND DRUG NAME
NECESSARY ACTIONS,
QL
Calcium Carbonate/Vitamin D3
TABLET
($0.00) Tier 3
*Calcium 500 + Vit D3 500 MG-600
TABLET
($0.00) Tier 3
*Calcium 500 + Vitamin D 500 MG-125 Calcium Carbonate/Vitamin D3
TABLET
($0.00) Tier 3
*Calcium 600 MG
Calcium Carbonate
TABLET
($0.00) Tier 3
*Calcium Carbonate 260MG(648)
Calcium Carbonate
TABLET
($0.00) Tier 3
*Calcium Gluconate 45(500) MG
Calcium Gluconate
TABLET
($0.00) Tier 3
*Calcium Gluconate 61(648) MG
Calcium Gluconate
TABLET
($0.00) Tier 3
*Calcium Lactate 84 MG(650)
Calcium Lactate
TABLET
($0.00) Tier 3
*Calcium With Vitamin D 500 MG-200 Calcium Carbonate/Vitamin D3
TABLET
($0.00) Tier 3
*Mag-G 27 MG(500)
Magnesium Gluconate
TABLET
($0.00) Tier 3
*Magnesium 300 MG
Magnesium Oxide/Mag Aa Chelate
CAPSULE
($0.00) Tier 3
*Oralyte
Electrolyte,Oral
SOLUTION
($0.00) Tier 3
NON PART D DRUGS
*Calcium 500 + Vit D3 500 MG-400
QL
161
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
*Oysco D 250 MG-125
TABLET
($0.00) Tier 3
*Oysco-500 500(1250)
Calcium Carbonate
TABLET
($0.00) Tier 3
*Oyster Shell Calcium W-Vit D 250 MG-125 Calcium Carbonate/Vitamin D2 TABLET
($0.00) Tier 3
NECESSARY ACTIONS,
RESPIRATORY TRACT AGENTS, OTHER
*Cromolyn Sodium 5.2 MG
Cromolyn Sodium
SPRAY/PUMP
($0.00) Tier 3
NON PART D DRUGS
*B-12 5000 MCG
Mecobalamin
TAB RAPDIS
($0.00) Tier 3
*B-12 Dots 500 MCG
Cyanocobalamin (Vitamin B-12)
TABLET
($0.00) Tier 3
*Calcidol 8000/ML
Ergocalciferol (Vitamin D2)
DROPS
($0.00) Tier 3
*Children'S Ferrous Sulfate 15 MG/ML Ferrous Sulfate
DROPS
($0.00) Tier 3
*Feosol 325(65) MG
Ferrous Sulfate
TABLET
($0.00) Tier 3
*Ferrous Sulfate 220(44)/5
Ferrous Sulfate
SOLUTION
($0.00) Tier 3
*Ferrous Sulfate 300 MG/5ML
Ferrous Sulfate
LIQUID
($0.00) Tier 3
*Ferrous Sulfate 324(65)MG
Ferrous Sulfate
TABLET DR
($0.00) Tier 3
162
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
*Folic Acid 0.4 MG
Folic Acid
TABLET
($0.00) Tier 3
*Folic Acid 0.8 MG
Folic Acid
TABLET
($0.00) Tier 3
*Folic Acid 1 MG
Folic Acid
TABLET
($0.00) Tier 3
*Fruit C-100 100 MG
Ascorbic Acid
TAB CHEW
($0.00) Tier 3
*High Potency Iron 134MG
Ferrous Sulfate
TABLET
($0.00) Tier 3
*Iron 325(65) MG
Ferrous Sulfate
CAPSULE ER
($0.00) Tier 3
*KPN
Prenatal Vit W-Ca,Fe,Fa( Less Than 1 Mg) TABLET
*Perry Prenatal 13.5-0.4MG
Pnv With Ca No.36/Iron/Fa
CAPSULE
($0.00) Tier 3
*Prenatal 19 29 MG-1 MG
Pnv No.118/Iron Fumarate/Fa
TAB CHEW
($0.00) Tier 3
*Prenatal 19 29-1-25 MG
Pnv119/Iron Fumarate/Fa/Dss
TABLET
($0.00) Tier 3
*Prenatal 27MG-0.8MG
Prenatal Vit#96/Ferrous Fum/Fa
TABLET
($0.00) Tier 3
Prenatal Vit/Iron Fumarate/Fa
TABLET
($0.00) Tier 3
Prenatal Vit/Iron Fumarate/Fa
TABLET
($0.00) Tier 3
Pnv95/Ferrous Fumarate/Fa
TABLET
($0.00) Tier 3
*Pyridoxine Hcl 250 MG
Pyridoxine Hcl
TABLET
($0.00) Tier 3
*Pyridoxine Hcl 500 MG
Pyridoxine Hcl
TABLET
($0.00) Tier 3
*Riboflavin 100 MG
Riboflavin
TABLET
($0.00) Tier 3
NECESSARY ACTIONS,
($0.00) Tier 3
NON PART D DRUGS
163
NON PART D DRUGS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
*Riboflavin 50 MG
Riboflavin
TABLET
($0.00) Tier 3
*Slow Release Iron 47.5 IRON
Ferrous Sulfate
TABLET ER
($0.00) Tier 3
*Tri-Vi-Sol 750-35/ML
Vit A Palmitate/Vit C/Vit D3
DROPS
($0.00) Tier 3
*Tri-Vitamin 1500-35/ML
Pedi Multivits A,C, And D3 No.21
DROPS
($0.00) Tier 3
*Vitamin A 10000 UNIT
Vitamin A
CAPSULE
($0.00) Tier 3
Vitamin A
CAPSULE
($0.00) Tier 3
Vitamin A
CAPSULE
($0.00) Tier 3
*Vitamin B-1 100 MG
Thiamine Hcl
TABLET
($0.00) Tier 3
*Vitamin B-6 100 MG
Pyridoxine Hcl
TABLET
($0.00) Tier 3
*Vitamin B-6 200 MG
Pyridoxine Hcl
TABLET ER
($0.00) Tier 3
*Vitamin B-6 200 MG
Pyridoxine Hcl
TABLET
($0.00) Tier 3
*Vitamin B-6 25 MG
Pyridoxine Hcl
TABLET
($0.00) Tier 3
*Vitamin B-6 50 MG
Pyridoxine Hcl
TABLET
($0.00) Tier 3
*Vitamin C 100 MG
Ascorbic Acid
TABLET
($0.00) Tier 3
*Vitamin C 1000 MG
Ascorbic Acid
TABLET
($0.00) Tier 3
*Vitamin C 1000 MG
Ascorbic Acid
TAB CHEW
($0.00) Tier 3
*Vitamin C 1000 MG
Ascorbic Acid
TABLET ER
($0.00) Tier 3
NECESSARY ACTIONS,
164
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
Ascorbic Acid
TABLET ER
($0.00) Tier 3
*Vitamin C 250 MG
Ascorbic Acid
TAB CHEW
($0.00) Tier 3
*Vitamin C 250 MG
Ascorbic Acid
TABLET
($0.00) Tier 3
*Vitamin C 500 MG
Ascorbic Acid
CAPSULE ER
($0.00) Tier 3
*Vitamin C 500 MG
Ascorbic Acid
TABLET
($0.00) Tier 3
*Vitamin C 500 MG
Ascorbic Acid
TABLET ER
($0.00) Tier 3
*Vitamin C 500 MG
Ascorbic Acid
TAB CHEW
($0.00) Tier 3
*Vitamin C 500 MG/5ML
Ascorbic Acid
SYRUP
($0.00) Tier 3
*Vitamin D 400 UNIT
Cholecalciferol (Vitamin D3)
CAPSULE
($0.00) Tier 3
*Vitamin D2 400 UNIT
TABLET
($0.00) Tier 3
*Vitamin D2 50000 UNIT
CAPSULE
($0.00) Tier 3
*Vitamin E 400 UNIT
Vitamin E (Dl,Tocopheryl Acet)
CAPSULE
($0.00) Tier 3
*Vitamin E 400 UNIT
Vitamin E
CAPSULE
($0.00) Tier 3
*Vitamin K 100 MCG
Phytonadione
TABLET
($0.00) Tier 3
NON PART D DRUGS
*Vitamin C 1500 MG
NECESSARY ACTIONS,
165
Index of Drugs
8
8-MOP ............................................................ 101
A
ABACAVIR ....................................................... 73
ABACAVIR-LAMIVUDINEZIDOVUDINE ................................................... 73
ABELCET ......................................................... 60
ABILIFY ........................................................ 9, 69
ABILIFY DISCMELT 10 MG ......................... 9, 69
ABILIFY DISCMELT 15 MG ......................... 9, 70
ABILIFY MAINTENA ........................................ 70
ACAMPROSATE CALCIUM ............................. 30
ACARBOSE 100 MG .......................................... 9
ACARBOSE 100 MG ........................................ 56
ACARBOSE 25 MG ............................................ 9
ACARBOSE 25 MG .......................................... 56
ACARBOSE 50 MG ............................................ 9
ACARBOSE 50 MG .......................................... 56
ACE AEROSOL CLOUD ENHANCER ...................................................... 9
ACE AEROSOL CLOUD ENHANCER ................................................... 156
ACEBUTOLOL HCL ......................................... 87
ACEPHEN 650 MG ............................................ 9
ACEPHEN 650 MG ........................................ 147
ACETAMINOPHEN 100 MG/ML ........................ 9
ACETAMINOPHEN 100 MG/ML .................... 147
ACETAMINOPHEN 120 MG ...............................9
ACETAMINOPHEN 120 MG ...........................147
ACETAMINOPHEN 160 MG/5ML .......................9
ACETAMINOPHEN 160 MG/5ML ...................147
ACETAMINOPHEN 80MG/0.8ML .......................9
ACETAMINOPHEN 80MG/0.8ML ...................147
ACETAMINOPHEN-CODEINE ...........................9
ACETAMINOPHEN-CODEINE .........................25
ACETASOL HC .............................................. 112
ACETAZOLAMIDE .........................................136
ACETYLCYSTEINE ........................................143
ACID GONE 105-160MG ................................159
ACID REDUCER 10 MG .................................158
ACID REDUCER 20 MG .................................158
ACID RELIEF 200 MG ....................................158
ACITRETIN 10 MG, 25 MG ............................101
ACITRETIN 17.5 MG ......................................101
ACTHIB ...........................................................127
ACTIMMUNE ..................................................133
ACTONEL 35 MG .......................................9, 131
ACTONEL 5 MG .........................................9, 131
ACYCLOVIR .....................................................10
ACYCLOVIR .....................................................78
ACYCLOVIR ...................................................101
ACYCLOVIR SODIUM ..................................... 78
ADACEL TDAP .............................................. 128
ADAGEN ........................................................ 109
ADAPALENE .................................................. 108
ADASUVE ........................................................ 70
ADCETRIS ....................................................... 40
ADCIRCA ....................................................... 145
ADEFOVIR DIPIVOXIL .................................... 78
ADEMPAS ...................................................... 145
ADULT GLYCERIN ADULT ........................... 160
ADULT NASAL DECONGESTANT 15 MG/5 ML ................................................... 153
ADULT ROBITUSSIN PEAK COLD 100-10MG/5 ................................................... 153
ADULT WAL-TUSSIN 100 MG/5ML .............. 153
ADULT WAL-TUSSIN DM 10010MG/5 .......................................................... 153
ADVAIR DISKUS ..................................... 10, 140
ADVAIR HFA ............................................ 10, 140
AFEDITAB CR ................................................. 90
AFINITOR ........................................................ 40
AFINITOR DISPERZ ........................................ 40
AGGRENOX .................................................... 83
A-HYDROCORT ............................................ 121
ALA-CORT ..................................................... 104
ALA-SCALP ................................................... 104
ALAWAY 0.025 % .......................................... 157
ALBENZA ......................................................... 67
ALBUTEROL SULFATE ................................. 141
167
Index of Drugs
ALCAINE .........................................................111
ALCLOMETASONE DIPROPIONATE ............................................ 104
ALCOHOL PREP PADS ................................. 101
ALDURAZYME ............................................... 109
ALENDRONATE SODIUM 35MG, 70MG ................................................................ 10
ALENDRONATE SODIUM 35MG, 70MG .............................................................. 131
ALENDRONATE SODIUM 5MG, 10MG, 40MG .................................................... 10
ALENDRONATE SODIUM 5MG, 10MG, 40MG .................................................. 131
ALFUZOSIN HCL ER ....................................... 10
ALFUZOSIN HCL ER ......................................118
ALIMTA ............................................................ 40
ALINIA .............................................................. 67
ALLER-CHLOR 2 MG/5 ML ........................... 150
ALLERGY 25 MG ........................................... 150
ALLERGY CREAM 2 % .................................. 154
ALLOPURINOL .............................................. 133
ALMACONE 200-200-20 ................................ 159
ALMACONE-2 400-400-40 ............................. 159
ALORA ........................................................... 120
ALOSETRON HCL ......................................... 130
ALPHAGAN P ................................................ 136
ALPRAZOLAM 0.25MG, 0.5MG, 1MG .................................................................. 10
ALPRAZOLAM 0.25MG, 0.5MG, 1MG .................................................................. 31
ALPRAZOLAM 2MG .........................................10
ALPRAZOLAM 2MG .........................................31
ALTACAINE .................................................... 111
ALTAMIST 0.65 % ..........................................157
ALTAVERA .......................................................95
ALUMINUM HYDROXIDE 320 MG/
5ML .................................................................159
ALUMINUM HYDROXIDE 600 MG/
5ML .................................................................159
ALYACEN .........................................................95
AMANTADINE ..................................................68
AMBISOME ......................................................61
AMBIZINE 25 MG ...........................................151
AMCINONIDE .................................................104
AMIFOSTINE ..................................................133
AMIKACIN SULFATE .......................................32
AMILORIDE HCL ..............................................91
AMILORIDEHYDROCHLOROTHIAZIDE .............................91
AMINOCAPROIC ACID ....................................82
AMINOSYN .......................................................83
AMINOSYN II ....................................................83
AMINOSYN-HBC ..............................................83
AMINOSYN-PF .................................................83
AMIODARONE HCL .........................................86
AMITIZA .......................................................... 116
AMITRIPTYLINE HCL ......................................53
AMLACTIN 12 % ............................................154
AMLODIPINE BESYLATE ................................90
AMLODIPINE BESYLATEBENAZEPRIL '10 MG-20MG,5 MG20 MG .............................................................. 10
AMLODIPINE BESYLATEBENAZEPRIL '10 MG-20MG,5 MG20 MG .............................................................. 90
AMLODIPINE BESYLATEBENAZEPRIL 10 MG-40MG, 5 MG40 MG .............................................................. 10
AMLODIPINE BESYLATEBENAZEPRIL 10 MG-40MG, 5 MG40 MG .............................................................. 90
AMLODIPINE BESYLATEBENAZEPRIL 2.5MG-10MG, 5 MG10 MG .............................................................. 10
AMLODIPINE BESYLATEBENAZEPRIL 2.5MG-10MG, 5 MG10 MG .............................................................. 90
AMMONIUM LACTATE .................................. 101
AMNESTEEM ................................................ 101
AMOX TR-POTASSIUM CLAVULANATE ............................................... 37
AMOXAPINE .................................................... 53
AMOXICILLIN .................................................. 37
AMPHETAMINE SALT COMBO ...................... 94
AMPHOTERICIN B .......................................... 61
AMPICILLIN SODIUM ...................................... 37
AMPICILLIN TRIHYDRATE ............................. 37
AMPICILLIN-SULBACTAM .............................. 37
AMPYRA .......................................................... 94
ANACAINE ..................................................... 102
168
Index of Drugs
ANADROL-50 ..................................................119
ANAGRELIDE HCL .......................................... 82
ANASTROZOLE ............................................... 40
ANDRODERM .................................................119
ANDROID ........................................................119
ANDROXY .......................................................119
ANORO ELLIPTA ..................................... 10, 141
ANTIBIOTIC PLUS 3.5-10K-10 ...................... 155
ANTI-DIARRHEAL 2 MG ................................ 159
ANTI-GAS 166MG .......................................... 158
ANTIVENIN LATRODECTUS MACTANS ...................................................... 124
ANTIVENIN MICRURUS FULVIUS ................ 124
APEXICON E ................................................. 104
APOKYN .......................................................... 68
APRI ................................................................. 95
APRODINE 60MG-2.5MG .............................. 150
APTIOM 200 MG, 400 MG ......................... 10, 47
APTIOM 600 MG ........................................ 10, 47
APTIOM 800 MG .............................................. 47
APTIVUS .......................................................... 73
AQUANIL HC 1 % .......................................... 155
ARANELLE ....................................................... 95
ARANESP 100 MCG/ML .................................. 80
ARANESP 100MCG/0.5 ................................... 80
ARANESP 10MCG/0.4 ..................................... 80
ARANESP 150MCG/0.3 ................................... 80
ARANESP 200 MCG/ML .................................. 80
ARANESP 200MCG/0.4 ................................... 80
ARANESP 25 MCG/ML ....................................81
ARANESP 25MCG/0.42 ...................................81
ARANESP 300 MCG/ML ..................................81
ARANESP 300MCG/0.6 ...................................81
ARANESP 40 MCG/0.4 ....................................81
ARANESP 40 MCG/ML ....................................81
ARANESP 500 MCG/ML ..................................81
ARANESP 60MCG/0.3 .....................................81
ARANESP 60MCG/ML .....................................81
ARCALYST .....................................................124
ARIPIPRAZOLE 2 MG, 5 MG, 10 MG, 15 MG ...............................................................10
ARIPIPRAZOLE 2 MG, 5 MG, 10 MG, 15 MG ...............................................................70
ARIPIPRAZOLE 20 MG, 30 MG .......................70
ARTIFICIAL TEARS 1.4 % .............................157
ARZERRA .........................................................40
ASCOMP WITH CODEINE ...............................10
ASCOMP WITH CODEINE ...............................25
ASPIRIN 300 MG ............................................148
ASPIRIN 325 MG ............................................148
ASPIRIN 500 MG ............................................148
ASPIRIN 600 MG ............................................148
ASPIRIN 81 MG ..............................................148
ASPIRIN BUFFERED 325 MG .......................148
ASPIRIN EC 325 MG ......................................148
ASPIRIN EC 500 MG ......................................148
ASPIRIN EC 650 MG ......................................148
ASPIRIN EC 81 MG ........................................148
ASPIRIN-DIPYRIDAMOLE ER ........................ 83
ASTAGRAF XL .............................................. 124
ATENOLOL ...................................................... 87
ATENOLOL-CHLORTHALIDONE .................... 87
ATGAM .......................................................... 125
ATORVASTATIN CALCIUM ............................ 92
ATOVAQUONE ................................................ 67
ATOVAQUONE-PROGUANIL HCL ................. 67
ATRIPLA .......................................................... 73
ATROVENT HFA ........................................... 141
AUBAGIO ....................................................... 125
AUBRA ............................................................. 96
AURAPHENE-B 6.5 % ................................... 158
AVANDIA ......................................................... 56
AVASTIN .......................................................... 41
AVEED ............................................................119
AVIANE ............................................................ 96
AVITA ............................................................. 108
AVODART ................................................ 10, 133
AVONEX ........................................................ 133
AVONEX ADMINISTRATION PACK .............. 133
AVONEX PEN ................................................ 133
AZACITIDINE ................................................... 41
AZATHIOPRINE ............................................. 125
AZELASTINE HCL ........................................... 10
AZELASTINE HCL ..........................................111
AZILECT 0.5 MG .........................................11, 68
AZILECT 1 MG ................................................. 68
169
Index of Drugs
AZITHROMYCIN ...............................................11
AZITHROMYCIN .............................................. 35
AZITHROMYCIN 250 MG, 500 MG ..................11
AZITHROMYCIN 250 MG, 500 MG ................. 36
AZITHROMYCIN 600 MG .................................11
AZITHROMYCIN 600 MG ................................ 36
AZOPT ......................................................11, 136
AZTREONAM ................................................... 36
AZURETTE ...................................................... 96
B
B-12 5000 MCG ............................................. 162
B-12 DOTS 500 MCG .................................... 162
BACITRACIN ...................................................112
BACITRACIN 500 UNIT/G ............................. 155
BACITRACIN-POLYMYXIN ............................112
BACITRACIN-POLYMYXIN 50010K/G ............................................................. 155
BACLOFEN .................................................... 143
BALSALAZIDE DISODIUM ............................ 130
BALZIVA ........................................................... 96
BANZEL ........................................................... 47
BANZEL 200 MG .............................................. 47
BANZEL 400 MG .............................................. 47
BARACLUDE ................................................... 78
BAZA ANTIFUNGAL 2 % ............................... 149
BCG (TICE STRAIN) ...................................... 128
BD ULTRA-FINE PEN NEEDLE .................... 109
BEDDING SPRAY 0.5 % ................................ 155
BELEODAQ ......................................................41
BENAZEPRIL HCL ...........................................85
BENAZEPRILHYDROCHLOROTHIAZIDE .............................85
BENLYSTA .....................................................133
BENZONATATE 100 MG ...............................153
BENZONATATE 200 MG ...............................153
BENZOYL PEROXIDE 10 % ..........................154
BENZTROPINE MESYLATE ............................68
BETAMETHASONE DIPROPIONATE .............................................104
BETAMETHASONE VALERATE ....................105
BETASERON ..................................................133
BETAXOLOL HCL ....................................87, 137
BETHANECHOL CHLORIDE .........................134
BEXSERO ......................................................128
BICALUTAMIDE ...............................................41
BICILLIN C-R ....................................................38
BICILLIN L-A .....................................................38
BILTRICIDE ......................................................67
BISACODYL 10 MG .......................................160
BISACODYL 5 MG .........................................160
BISMUTH SUBSALICYLATE 262 MG ..................................................................159
BISMUTH SUBSALICYLATE 525MG/15ML ..................................................159
BISOPROLOL FUMARATE ..............................87
BISOPROLOLHYDROCHLOROTHIAZIDE .............................87
BIVIGAM ........................................................ 125
BLEOMYCIN SULFATE ................................... 41
BLEPH-10 .......................................................112
BLINCYTO ....................................................... 41
BOOSTRIX TDAP .......................................... 128
BOSULIF .......................................................... 41
BREATHERITE ................................................11
BREATHERITE .............................................. 156
BREATHRITE ..................................................11
BREATHRITE ................................................ 156
BREVIBLOC ..................................................... 87
BRIELLYN ........................................................ 96
BRILINTA ......................................................... 83
BRIMONIDINE TARTRATE ........................... 137
BRINTELLIX ..................................................... 53
BROMFENAC SODIUM ..................................114
BROMOCRIPTINE MESYLATE ....................... 68
BUDESONIDE ............................................... 140
BUDESONIDE EC ......................................... 130
BUFFERIN 500 MG ....................................... 148
BUMETANIDE .................................................. 91
BUPHENYL .....................................................116
BUPRENORPHINE HCL .................................. 30
BUPRENORPHINE-NALOXONE ..................... 30
BUPROBAN ..................................................... 53
BUPROPION HCL ........................................... 53
BUPROPION HCL SR ..................................... 53
BUPROPION XL 150 MG .................................11
170
Index of Drugs
CALCIUM ANTACID 300MG(750) ..................159
CALCIUM CARBONATE 260MG(648) ....................................................161
CALCIUM GLUCONATE 45(500)
MG ..................................................................161
CALCIUM GLUCONATE 61(648)
MG ..................................................................161
CALCIUM LACTATE 84 MG(650) ..................161
CALCIUM WITH VITAMIN D 500 MG-200 ...........................................................161
CAMILA ............................................................96
CANASA .........................................................131
CANCIDAS .......................................................61
CAPASTAT SULFATE ......................................65
CAPRELSA .......................................................41
CAPTOPRIL .....................................................85
CABERGOLINE ............................................... 69
CAPTOPRILCALCI-CHEW 500(1250) ............................... 159
HYDROCHLOROTHIAZIDE .............................85
CALCIDOL 8000/ML ...................................... 162
CARBAGLU .................................................... 116
CALCIPOTRIENE .............................................11
CARBAMAZEPINE ...........................................48
CALCIPOTRIENE .......................................... 102
CARBAMAZEPINE ER .....................................48
CALCITONIN-SALMON ................................. 131
CARBAMAZEPINE XR .....................................48
CALCITRIOL .................................................. 132
CARBIDOPA-LEVODOPA ................................69
CALCIUM 500 + VIT D3 500 MG-400............. 161
CARBIDOPA-LEVODOPA ER ..........................69
CALCIUM 500 + VIT D3 500 MG-600............. 161
CARBIDOPA-LEVODOPAENTACAPONE .................................................69
CALCIUM 500 + VITAMIN D 500 MG125 ................................................................. 161
CARIMUNE NF NANOFILTERED ..................125
CALCIUM 600 MG ......................................... 161
CARISOPRODOL ............................................. 11
CALCIUM ACETATE .......................................117
CARISOPRODOL ...........................................144
CALCIUM ANTACID 200(500)MG ................. 159
CARTEOLOL HCL .......................................... 111
BUPROPION XL 150 MG ................................. 53
BUPROPION XL 300 MG ................................. 53
BUSPIRONE HCL .......................................... 134
BUTALB-CAFF-ACETAMINOPHCODEIN ............................................................11
BUTALB-CAFF-ACETAMINOPHCODEIN ........................................................... 25
BUTALBITAL COMPOUNDCODEINE ..........................................................11
BUTALBITAL COMPOUNDCODEINE ......................................................... 25
BYDUREON ..................................................... 56
BYDUREON PEN ............................................. 56
BYETTA ........................................................... 56
C
CARTIA XT ...................................................... 88
CARVEDILOL .................................................. 87
CAYSTON ........................................................ 37
CAZIANT .......................................................... 96
CEFACLOR ...................................................... 34
CEFACLOR ER ................................................ 34
CEFADROXIL .................................................. 34
CEFAZOLIN ..................................................... 34
CEFAZOLIN SODIUM ...................................... 34
CEFDINIR ........................................................ 34
CEFEPIME HCL ............................................... 34
CEFOTAXIME SODIUM .................................. 34
CEFPODOXIME PROXETIL ............................ 34
CEFPROZIL ..................................................... 34
CEFTAZIDIME ................................................. 35
CEFTRIAXONE ................................................ 35
CEFUROXIME ................................................. 35
CEFUROXIME SODIUM .................................. 35
CELECOXIB ..................................................... 28
CELONTIN ....................................................... 48
CEPHALEXIN .................................................. 35
CEREZYME ................................................... 109
CERVARIX ..................................................... 128
CETIRIZINE HCL 10 MG ............................... 150
CETIRIZINE HCL 5 MG ................................. 150
CHANTIX ......................................................... 30
CHERATUSSIN AC 100-10MG/5 .................. 153
CHILD SUPPOSITORY PEDIATRIC ............. 160
171
Index of Drugs
CHILDREN'S ADVIL 100 MG/5ML ................. 148
CHILDREN'S FERROUS SULFATE 15 MG/ML ....................................................... 162
CHILDREN'S NON-ASPIRIN 80 MG.................11
CHILDREN'S NON-ASPIRIN 80 MG.............. 147
CHILDREN'S PAIN AND FEVER 160 MG/5ML .............................................................11
CHILDREN'S PAIN AND FEVER 160 MG/5ML .......................................................... 147
CHILDREN'S PEPTO 400 MG ....................... 159
CHILDREN'S SILAPAP 160 MG/5ML................11
CHILDREN'S SILAPAP 160 MG/5ML............. 147
CHLORAMPHENICOL SOD SUCCINATE ..................................................... 32
CHLORDIAZEPOXIDEAMITRIPTYLINE .............................................. 53
CHLORHEXIDINE GLUCONATE .................. 100
CHLOROQUINE PHOSPHATE ....................... 67
CHLOROTHIAZIDE .......................................... 91
CHLORPROMAZINE HCL ............................... 70
CHLORTHALIDONE ........................................ 91
CHLORZOXAZONE ......................................... 12
CHLORZOXAZONE ....................................... 144
CHOLESTYRAMINE ........................................ 92
CHOLINE MAG TRISALICYLATE .................... 28
CHORIONIC GONADOTROPIN .................... 122
CICLOPIROX ................................................... 61
CILOSTAZOL ................................................... 83
CIMETIDINE ....................................................115
CIPROFLOXACIN ............................................38
CIPROFLOXACIN ER ......................................38
CIPROFLOXACIN HCL ............................ 39, 112
CITALOPRAM HBR ..........................................53
CITRATE OF MAGNESIA .............................160
CLARAVIS ......................................................102
CLARITHROMYCIN .........................................36
CLARITHROMYCIN ER ...................................36
CLEARLAX 17G/DOSE ....................................12
CLEARLAX 17G/DOSE ..................................160
CLEMASTINE FUMARATE ..............................63
CLINDAMYCIN HCL .........................................32
CLINDAMYCIN PHOSPHATE ............33, 64, 103
CLOBETASOL PROPIONATE .......................105
CLOMIPRAMINE HCL ......................................53
CLONAZEPAM .................................................31
CLONIDINE HCL ..............................................84
CLONIDINE HCL ER ........................................94
CLOPIDOGREL ................................................83
CLORAZEPATE DIPOTASSIUM 15 MG ....................................................................12
CLORAZEPATE DIPOTASSIUM 15 MG ....................................................................31
CLORAZEPATE DIPOTASSIUM 3.75 MG, 7.5 MG ..............................................12
CLORAZEPATE DIPOTASSIUM 3.75 MG, 7.5 MG ..............................................31
CLOTRIMAZOLE ..............................................61
CLOTRIMAZOLE 1 % .....................................149
CLOTRIMAZOLE 100 MG ............................. 149
CLOTRIMAZOLE 3 2 % ................................. 150
CLOTRIMAZOLEBETAMETHASONE ......................................... 61
CLOZAPINE ..................................................... 70
CLOZAPINE ODT ............................................ 70
CODEINE SULFATE ........................................ 12
CODEINE SULFATE ........................................ 25
COLACE 100 MG ........................................... 160
COLACE CLEAR 50 MG ................................ 160
COLCHICINE ................................................. 134
COLD AND COUGH CHILDRENS 515-1MG/5 ....................................................... 153
COLESTIPOL HCL .......................................... 92
COLISTIMETHATE .......................................... 33
COLOCORT ................................................... 105
COMBIPATCH ............................................... 120
COMBIVENT RESPIMAT ........................ 12, 141
COMETRIQ ...................................................... 41
COMPACT SPACE CHAMBER PLUS ............................................................... 12
COMPACT SPACE CHAMBER PLUS .............................................................. 156
COMPLERA ..................................................... 73
COMPRO ......................................................... 66
COMVAX ........................................................ 128
CONCEPTROL 4 % ....................................... 152
CONDOMS .................................................... 152
CONDOMS, LATEX, LUBRICATED ............... 12
172
Index of Drugs
CONSTULOSE ................................................116
COPAXONE ................................................... 134
CORMAX ........................................................ 105
CORTAID 1 % ................................................ 155
CORTISONE ACETATE ................................ 121
CORTIZONE-10 1 % ...................................... 155
COUMADIN ...................................................... 79
CREON 12K-38K-60, 24-76-120K ................. 109
CREON 36-114-180 ....................................... 109
CREON 3-9.5-15K, 6K-19K-30K .................... 109
CRIXIVAN ........................................................ 73
CROFAB ........................................................ 125
CROMOLYN SODIUM ....................................111
CROMOLYN SODIUM ....................................116
CROMOLYN SODIUM ................................... 143
CROMOLYN SODIUM 5.2 MG ...................... 162
CRYSELLE ....................................................... 96
CUBICIN ........................................................... 33
CUPRIMINE ....................................................119
CYCLAFEM ...................................................... 96
CYCLOBENZAPRINE HCL .............................. 12
CYCLOBENZAPRINE HCL ............................ 144
CYCLOPENTOLATE HCL ..............................111
CYCLOPHOSPHAMIDE .................................. 41
CYCLOSERINE ................................................ 65
CYCLOSET ...................................................... 56
CYCLOSPORINE ........................................... 125
CYCLOSPORINE MODIFIED ........................ 125
CYPROHEPTADINE HCL ................................63
CYRAMZA ........................................................41
CYSTADANE ..................................................134
CYSTAGON ....................................................109
CYTOGAM ......................................................125
CYTRA-2 ........................................................137
D
DALIRESP ......................................................143
DANAZOL ....................................................... 119
DANTROLENE SODIUM ................................144
DAPSONE ........................................................65
DAPTACEL DTAP ..........................................128
DARAPRIM .......................................................67
DASETTA .........................................................96
DAUNOXOME ..................................................41
DECITABINE ....................................................41
DEFEROXAMINE MESYLATE ....................... 119
DELZICOL ......................................................131
DEMECLOCYCLINE HCL ................................39
DEMSER ..........................................................89
DENAVIR ........................................................102
DENTA 5000 PLUS ........................................100
DENTAGEL ....................................................101
DEPADE ...........................................................30
DEPEN ........................................................... 119
DEPO-MEDROL .............................................121
DEPO-PROVERA ...........................................123
DESENEX 2 % ...............................................150
DESIPRAMINE HCL ........................................ 53
DESLORATADINE ........................................... 63
DESMOPRESSIN ACETATE ......................... 122
DESOGESTREL-ETHINYL ESTRADIOL ..................................................... 96
DESOGESTR-ETH ESTRAD ETH
ESTRA ............................................................. 96
DESONATE ................................................... 105
DESONIDE .................................................... 105
DESOXIMETASONE ..................................... 105
DESVENLAFAXINE ER ................................... 53
DEXAMETHASONE ....................................... 121
DEXAMETHASONE SODIUM PHOSPHATE ..........................................114, 121
DEXMETHYLPHENIDATE HCL ...................... 94
DEXMETHYLPHENIDATE HCL ER ................ 94
DEXTROAMPHETAMINE SULFATE ............... 94
DEXTROAMPHETAMINE SULFATE ER .................................................................... 94
DEXTROAMPHETAMINE-AMPHET ER .................................................................... 94
DEXTROSE 2.5%-0.45% NACL .................... 138
DEXTROSE 5%-0.2% NACL ......................... 138
DEXTROSE 5%-0.2% NACL-KCL ................. 138
DEXTROSE 5%-0.225% NACL ..................... 138
DEXTROSE 5%-0.3% NACL ......................... 138
DEXTROSE 5%-0.3% NACL-KCL ................. 138
DEXTROSE 5%-0.33% NACL ....................... 138
DEXTROSE 5%-0.33% NACL-KCL ............... 138
173
Index of Drugs
DEXTROSE 5%-0.45% NACL ....................... 138
DEXTROSE 5%-0.45% NACL-KCL ............... 138
DEXTROSE 5%-0.9% NACL ......................... 138
DEXTROSE 5%-1/2NS-KCL .......................... 138
DEXTROSE 5%-1/4NS-KCL .......................... 138
DEXTROSE 5%-NS-KCL ............................... 138
DEXTROSE 5%-POTASSIUM CHLORIDE ..................................................... 138
DEXTROSE IN LACTATED RINGERS ....................................................... 138
DEXTROSE IN RINGERS INJECTION ...................................................... 83
DEXTROSE IN WATER ................................... 84
DIAZEPAM ....................................................... 12
DIAZEPAM ....................................................... 31
DIAZEPAM 12.5-15-20 ..................................... 31
DIAZEPAM 2.5 MG .......................................... 12
DIAZEPAM 2.5 MG .......................................... 32
DIAZEPAM 5-7.5-10MG ................................... 32
DICLOFENAC POTASSIUM ............................ 28
DICLOFENAC SODIUM ............................28, 114
DICLOFENAC SODIUM ER ............................. 28
DICLOXACILLIN SODIUM ............................... 38
DICYCLOMINE HCL .......................................116
DIDANOSINE ................................................... 73
DIFLORASONE DIACETATE ........................ 106
DIFLUNISAL ..................................................... 28
DIGIFAB ........................................................... 89
DIGITEK 125 MCG ........................................... 12
DIGITEK 125 MCG ...........................................89
DIGITEK 250 MCG ...........................................89
DIGOX 125 MCG ..............................................12
DIGOX 125 MCG ..............................................89
DIGOX 250 MCG ..............................................89
DIGOXIN ...........................................................89
DIHYDROERGOTAMINE MESYLATE .......................................................64
DILANTIN .........................................................48
DILANTIN-125 ..................................................48
DILTIAZEM 12HR ER .......................................88
DILTIAZEM 24HR ER .......................................88
DILTIAZEM ER .................................................88
DILTIAZEM HCL ...............................................88
DILT-XR ............................................................88
DIPENTUM .....................................................131
DIPHENHYDRAMINE HCL ..............................63
DIPHENHYDRAMINE HCL 12.5MG/
5ML .................................................................150
DIPHENHYDRAMINE HCL 25 MG .................150
DIPHENHYDRAMINE HCL 50 MG .................150
DIPHENOXYLATE-ATROPINE ...................... 116
DIPHTHERIA-TETANUS TOXOIDSPED ................................................................128
DIPYRIDAMOLE ...............................................83
DISOPYRAMIDE PHOSPHATE .......................86
DISULFIRAM ....................................................31
DIVALPROEX SODIUM ...................................48
DIVALPROEX SODIUM ER .............................48
DOCETAXEL ................................................... 41
DOCU LIQUID 50 MG/5 ML ........................... 160
DOCUSATE SODIUM 250 MG ...................... 161
DONEPEZIL HCL 23 MG ................................. 52
DONEPEZIL HCL 5 MG, 10 MG ...................... 52
DONEPEZIL HCL ODT .................................... 52
DORZOLAMIDE HCL ....................................... 12
DORZOLAMIDE HCL ..................................... 137
DORZOLAMIDE-TIMOLOL .............................. 12
DORZOLAMIDE-TIMOLOL ............................ 137
DOXAZOSIN MESYLATE ................................ 84
DOXEPIN HCL ................................................. 53
DOXERCALCIFEROL .................................... 132
DOXERCALCIFEROL 0.5 MCG .............. 12, 132
DOXERCALCIFEROL 1 MCG ................. 12, 132
DOXERCALCIFEROL 2.5 MCG .................... 132
DOXY 100 ........................................................ 40
DOXYCYCLINE HYCLATE .............................. 40
DOXYCYCLINE MONOHYDRATE .................. 40
DRONABINOL ................................................. 66
DROSPIRENONE-ETHINYL
ESTRADIOL ..................................................... 96
DROXIA ........................................................... 41
DULOXETINE HCL .......................................... 54
DULOXETINE HCL 20 MG, 30 MG ................. 54
E
E.E.S. 400 ........................................................ 36
EASIVENT ...................................................... 13
174
Index of Drugs
EASIVENT ...................................................... 156
ECONAZOLE NITRATE ................................... 61
ECONTRA EZ 1.5 MG ................................... 153
EDURANT .................................................. 13, 73
EFFER-K ........................................................ 138
ELAPRASE .................................................... 109
ELELYSO ....................................................... 109
ELIDEL ..................................................... 13, 106
ELIGARD 22.5 MG, 30 MG, 45 MG ................. 41
ELIGARD 7.5 MG ............................................. 41
ELIPHOS .........................................................118
ELIQUIS ........................................................... 79
ELITEK ............................................................110
ELIXOPHYLLIN .............................................. 141
ELLA ........................................................... 13, 96
EMCYT ............................................................. 42
EMEND ............................................................ 66
EMOQUETTE ................................................... 96
EMSAM ............................................................ 54
EMTRIVA ......................................................... 73
ENALAPRIL MALEATE .................................... 85
ENALAPRILHYDROCHLOROTHIAZIDE ............................. 85
ENBREL ......................................................... 125
ENDOCET ........................................................ 13
ENDOCET ........................................................ 25
ENDODAN ....................................................... 13
ENDODAN ....................................................... 25
ENDUR-ACIN 250 MG ................................... 151
ENDUR-ACIN 500 MG ...................................151
ENGERIX-B ADULT .......................................128
ENGERIX-B PEDIATRICADOLESCENT ...............................................128
ENOXAPARIN SODIUM 120MG/
.8ML, 150 MG/ML .............................................79
3ML ...................................................................79
0.3ML ................................................................79
0.4ML, 60MG/0.6ML .........................................79
0.8ML, 100 MG/ML ...........................................79
ENPRESSE ......................................................96
ENSKYCE .........................................................96
ENTACAPONE .................................................69
ENTECAVIR .....................................................78
ENTYVIO ........................................................134
EPHRINE NOSE DROPS 1 % ........................157
EPINEPHRINE .................................................89
EPIPEN 2-PAK .................................................89
EPITOL .............................................................48
EPIVIR HBV ......................................................74
EPLERENONE .................................................93
EPOGEN 2000/ML, 10000/ML .........................81
EPOGEN 20000/ML .........................................81
EPOGEN 3000/ML, 4000/ML ...........................81
EPOPROSTENOL SODIUM ...........................145
EPZICOM .........................................................74
ERAXIS (WATER DILUENT) ........................... 61
ERGOLOID MESYLATES .............................. 134
ERGOMAR ....................................................... 64
ERIVEDGE ....................................................... 42
ERRIN .............................................................. 97
ERWINAZE ...................................................... 42
ERY ................................................................ 103
ERYTHROCIN LACTOBIONATE ..................... 36
ERYTHROCIN STEARATE ............................. 36
ERYTHROMYCIN .............................36, 103, 112
ERYTHROMYCIN
ETHYLSUCCINATE ......................................... 36
ERYTHROMYCIN-BENZOYL PEROXIDE ..................................................... 103
ESBRIET ........................................................ 143
ESCITALOPRAM OXALATE ........................... 54
ESMOLOL HCL ................................................ 87
ESTRADIOL ................................................... 120
ESTRADIOL-NORETHINDRONE ACETAT ......................................................... 120
ESTROPIPATE .............................................. 120
ETHAMBUTOL HCL ........................................ 65
ETHOSUXIMIDE .............................................. 48
ETIDRONATE DISODIUM ............................. 132
ETODOLAC ..................................................... 28
ETODOLAC ER ............................................... 28
EVOTAZ ........................................................... 74
EXELON ........................................................... 52
EXEMESTANE ................................................. 42
175
Index of Drugs
EXJADE ..........................................................119
EXPECTORANT MAX STRENGTH 15-30MG/5 ..................................................... 153
EXTAVIA ........................................................ 134
EYE WASH ................................................... 157
E-Z SPACER ................................................... 13
E-Z SPACER .................................................. 156
F
FABRAZYME ..................................................110
FALMINA .......................................................... 97
FAMOTIDINE ..................................................115
FANAPT ........................................................... 70
FARESTON ...................................................... 42
FARYDAK ........................................................ 42
FASLODEX ...................................................... 42
FELBAMATE .................................................... 48
FELODIPINE ER .............................................. 90
FENOFIBRATE ................................................ 92
FENOFIBRATE NANOCRYSTALLIZED .................................... 92
FENOPROFEN CALCIUM ............................... 28
FENTANYL ....................................................... 13
FENTANYL ....................................................... 25
FENTANYL CITRATE 1200 MCG .............. 13, 25
FENTANYL CITRATE 1600 MCG .............. 13, 25
FENTANYL CITRATE 200 MCG, 400 MCG ........................................................... 13, 25
FENTANYL CITRATE 600 MCG, 800 MCG ........................................................... 13, 25
FEOSOL 325(65) MG .....................................162
FERROUS SULFATE 220(44)/5 .....................162
FERROUS SULFATE 300 MG/5ML ...............162
FERROUS SULFATE 324(65)MG ..................162
FETZIMA ..........................................................54
FINASTERIDE ..................................................13
FINASTERIDE ................................................134
FIRAZYR ..........................................................89
FIRMAGON 120 MG .........................................42
FIRMAGON 80 MG ...........................................42
FLECAINIDE ACETATE ...................................86
FLOVENT DISKUS .........................................140
FLOVENT HFA ...............................................141
FLUCONAZOLE ...............................................61
FLUCONAZOLE-NACL ....................................61
FLUCYTOSINE .................................................62
FLUDROCORTISONE ACETATE ..................121
FLUNISOLIDE ................................................ 114
FLUOCINOLONE ACETONIDE .....................106
FLUOCINOLONE ACETONIDE OIL ............... 114
FLUOCINONIDE .............................................106
FLUOROMETHOLONE .................................. 114
FLUOROURACIL ..............................................42
FLUOROURACIL ............................................102
FLUOXETINE DR .............................................54
FLUOXETINE HCL ...........................................54
FLUPHENAZINE DECANOATE .......................70
FLUPHENAZINE HCL ......................................70
FLURBIPROFEN ............................................. 28
FLURBIPROFEN SODIUM .............................114
FLUTAMIDE ..................................................... 42
FLUTICASONE PROPIONATE ..............106, 114
FLUVOXAMINE MALEATE .............................. 54
FOAMING ANTACID 20-80MG ...................... 159
FOCALIN XR .................................................... 94
FOLIC ACID 0.4 MG ...................................... 163
FOLIC ACID 0.8 MG ...................................... 163
FOLIC ACID 1 MG ......................................... 163
FOLOTYN ........................................................ 42
FOMEPIZOLE ................................................ 134
FONDAPARINUX SODIUM ............................. 79
FORTAZ IN ISO-OSMOTIC DEXTROSE ..................................................... 35
FORTEO .................................................. 13, 132
FORTICAL ..................................................... 132
FOSINOPRIL SODIUM .................................... 85
FOSINOPRILHYDROCHLOROTHIAZIDE ............................ 85
FOSPHENYTOIN SODIUM ............................. 49
FRAGMIN ......................................................... 80
FREAMINE HBC .............................................. 84
FRUIT C-100 100 MG .................................... 163
FUROSEMIDE ................................................. 91
FUZEON .......................................................... 74
FYCOMPA 2 MG, 4 MG ............................. 13, 49
FYCOMPA 6 MG ........................................ 13, 49
FYCOMPA 8 MG, 10 MG, 12 MG .............. 13, 49
176
Index of Drugs
G
GABAPENTIN .................................................. 49
GABITRIL ......................................................... 49
GAMUNEX-C ................................................. 125
GANCICLOVIR SODIUM ................................. 78
GARDASIL ..................................................... 128
GARDASIL 9 .................................................. 128
GAS RELIEF 125 MG .................................... 158
GAS RELIEF 80 MG ...................................... 158
GAVILYTE-C ...................................................117
GAVILYTE-N ...................................................117
GAZYVA ........................................................... 42
GEMCITABINE HCL ........................................ 42
GEMFIBROZIL ................................................. 92
GENERLAC .....................................................116
GENGRAF ...................................................... 125
GENOTROPIN 0.2MG/0.25 ........................... 122
GENOTROPIN ALL OTHER STRENGHTS ................................................. 122
GENTAK ..........................................................112
GENTAMICIN SULFATE ...........................32, 112
GEODON ......................................................... 71
GILDAGIA ........................................................ 97
GILDESS .......................................................... 97
GILDESS 24 FE ............................................... 97
GILDESS FE .................................................... 97
GILENYA ........................................................ 134
GILOTRIF ......................................................... 42
GLEEVEC .........................................................42
GLIMEPIRIDE 1 MG .........................................13
GLIMEPIRIDE 1 MG .........................................59
GLIMEPIRIDE 2 MG .........................................14
GLIMEPIRIDE 2 MG .........................................59
GLIMEPIRIDE 4 MG .........................................14
GLIMEPIRIDE 4 MG .........................................59
GLIPIZIDE 10 MG .............................................14
GLIPIZIDE 10 MG .............................................59
GLIPIZIDE 5 MG ...............................................14
GLIPIZIDE 5 MG ...............................................59
GLIPIZIDE ER 2.5 MG ......................................14
GLIPIZIDE ER 2.5 MG ......................................59
GLIPIZIDE ER 5 MG .........................................14
GLIPIZIDE ER 5 MG .........................................60
GLIPIZIDE XL ...................................................14
GLIPIZIDE XL ...................................................60
GLIPIZIDE-METFORMIN 2.5-250 MG ....................................................................14
GLIPIZIDE-METFORMIN 2.5-250 MG ....................................................................60
GLIPIZIDE-METFORMIN 2.5-500 MG, 5 MG-500MG ............................................14
GLIPIZIDE-METFORMIN 2.5-500 MG, 5 MG-500MG ............................................60
GLUCAGEN ....................................................134
GLUCAGON EMERGENCY KIT ..............14, 134
GLYBURIDE 1.25 MG ......................................14
GLYBURIDE 1.25 MG ......................................60
GLYBURIDE 2.5 MG ........................................ 14
GLYBURIDE 2.5 MG ........................................ 60
GLYBURIDE 5 MG ........................................... 14
GLYBURIDE 5 MG ........................................... 60
GLYBURIDE MICRONIZED 1.5 MG ................ 14
GLYBURIDE MICRONIZED 1.5 MG ................ 60
GLYBURIDE MICRONIZED 3 MG ................... 14
GLYBURIDE-METFORMIN HCL 1.25-250MG ..................................................... 14
GLYBURIDE-METFORMIN HCL 1.25-250MG ..................................................... 60
GLYBURIDE-METFORMIN HCL 2.5500 MG, 5 MG-500MG ..................................... 14
GLYBURIDE-METFORMIN HCL 2.5500 MG, 5 MG-500MG ..................................... 60
GLYCOPYRROLATE ......................................116
GLYSET 100 MG ....................................... 15, 56
GLYSET 25 MG ......................................... 15, 56
GLYSET 50 MG ......................................... 15, 57
GRANISETRON HCL ....................................... 66
GRANISETRON HCL 1 MG/ML ....................... 66
GRANISETRON HCL 100 MCG/ML ................ 66
GRANIX ........................................................... 81
GRISEOFULVIN .............................................. 62
GRISEOFULVIN
ULTRAMICROSIZE ......................................... 62
177
Index of Drugs
GUANFACINE HCL .......................................... 84
GUANFACINE HCL ER .................................... 94
GUANIDINE HCL ........................................... 134
GYNOL II 3 % ................................................. 153
H
HALAVEN ......................................................... 42
HALOBETASOL PROPIONATE .................... 106
HALOPERIDOL ................................................ 71
HALOPERIDOL DECANOATE ........................ 71
HALOPERIDOL LACTATE ............................... 71
HARVONI ......................................................... 77
HAVRIX .......................................................... 128
HEATHER ........................................................ 97
HEPAGAM B .................................................. 125
HEPARIN SODIUM .......................................... 80
HEPARIN SODIUM IN 0.45% NACL ................ 80
HEPARIN SODIUM-0.9% NACL ...................... 80
HEPARIN SODIUM-D5W ................................. 80
HERCEPTIN ..................................................... 43
HETLIOZ ........................................................ 144
HEXALEN ......................................................... 43
HIGH POTENCY IRON 134MG ..................... 163
HOMATROPAIRE ............................................ 15
HOMATROPAIRE ...........................................111
HOMATROPINE HYDROBROMIDE ................ 15
HOMATROPINE HYDROBROMIDE ...............111
HUMALOG ....................................................... 58
HUMALOG KWIKPEN ...................................... 58
HUMALOG MIX 50-50 ......................................58
HUMALOG MIX 50-50 KWIKPEN ....................58
HUMALOG MIX 75-25 ......................................58
HUMALOG MIX 75-25 KWIKPEN ....................58
HUMATROPE 12 MG, 24 MG ........................122
HUMATROPE 5 MG .......................................122
HUMATROPE 6 MG .......................................122
HUMIRA ..........................................................125
HUMIRA CROHN'S ........................................126
HUMULIN 70/30 KWIKPEN ..............................58
HUMULIN 70-30 ...............................................58
HUMULIN N ......................................................58
HUMULIN N KWIKPEN ....................................58
HUMULIN R ......................................................58
HUMULIN R U-500 ...........................................59
HYDRALAZINE HCL ........................................89
HYDROCHLOROTHIAZIDE .............................91
HYDROCODONEACETAMINOPHEN ..........................................15
HYDROCODONEACETAMINOPHEN ..........................................25
HYDROCODONE-IBUPROFEN .......................15
HYDROCODONE-IBUPROFEN .......................26
HYDROCORTISONE .............................106, 121
HYDROCORTISONE 0.5 % ...........................155
HYDROCORTISONE BUTYRATE .................107
HYDROCORTISONE VALERATE ..................107
HYDROCORTISONE-ACETIC ACID ............. 112
HYDROMORPHONE HCL ...............................15
HYDROMORPHONE HCL ............................... 26
HYDROXYCHLOROQUINE SULFATE ......................................................... 67
HYDROXYUREA ............................................. 43
HYDROXYZINE HCL ..................................... 134
HYPERHEP B S-D ......................................... 126
HYPERLYTE CR ............................................ 139
HYPERRAB S-D ............................................ 126
HYPERRHO S-D 1500 UNIT ......................... 126
HYPERRHO S-D 250 UNIT ........................... 126
HYPERTET S-D ............................................. 126
HYQVIA .......................................................... 126
I
IBANDRONATE SODIUM ................................ 15
IBANDRONATE SODIUM .............................. 132
IBRANCE ......................................................... 43
IBUPROFEN .................................................... 28
IBUPROFEN 100 MG .................................... 148
IBUPROFEN 200 MG .................................... 148
ICLUSIG ........................................................... 43
IMBRUVICA ..................................................... 43
IMIPENEM-CILASTATIN SODIUM .................. 37
IMIPRAMINE HCL ............................................ 54
IMIPRAMINE PAMOATE ................................. 54
IMIQUIMOD ..................................................... 15
IMIQUIMOD ................................................... 102
IMOGAM RABIES-HT .................................... 126
IMOVAX RABIES VACCINE .......................... 128
178
Index of Drugs
INCRELEX ..................................................... 122
INDAPAMIDE ................................................... 91
INDOMETHACIN .............................................. 28
INFANRIX DTAP ............................................ 128
INFANT'S ACETAMINOPHEN 80MG/0.8ML ..................................................... 15
INFANT'S ACETAMINOPHEN 80MG/0.8ML ................................................... 147
INFANT'S IBUPROFEN 50 MG/1.25.............. 149
INLYTA ............................................................. 43
INSULIN SYRINGE ........................................ 109
INTELENCE 100 MG, 200 MG ......................... 74
INTELENCE 25 MG ......................................... 74
INTRALIPID ...................................................... 84
INTRON A ........................................................ 78
INTROVALE ..................................................... 97
INVANZ ............................................................ 37
INVEGA 1.5 MG ......................................... 15, 71
INVEGA 3 MG ............................................ 15, 71
INVEGA 6 MG, 9 MG ................................. 15, 71
INVEGA SUSTENNA 117MG/0.75 .................. 71
INVEGA SUSTENNA 156 MG/ML, 234MG/1.5 ........................................................ 71
INVEGA SUSTENNA 39MG/0.25, 78MG/0.5ML ..................................................... 71
INVIRASE ................................................... 15, 74
INVOKAMET .................................................... 57
INVOKANA ....................................................... 57
IPOL ............................................................... 128
IPRATROPIUM BROMIDE ..................... 111, 142
IPRATROPIUM-ALBUTEROL ........................142
IRON 325(65) MG ...........................................163
ISENTRESS ...............................................15, 74
ISENTRESS 100 MG ..................................15, 74
ISENTRESS 25 MG ....................................16, 74
ISONIAZID ........................................................65
ISOSORBIDE DINITRATE ...............................93
ISOSORBIDE MONONITRATE ........................93
ISOSORBIDE MONONITRATE ER ..................93
ISRADIPINE .....................................................90
ISTODAX ..........................................................43
ITCH RELIEF 2 %-0.1 % ................................154
ITRACONAZOLE ..............................................62
IVERMECTIN ....................................................68
IXIARO ............................................................128
J
JAKAFI ..............................................................43
JANTOVEN .......................................................80
JANUMET ...................................................16, 57
JANUMET XR 50-1000 MG, 1001000MG ......................................................16, 57
JANUMET XR 50MG-500MG .....................16, 57
JANUVIA .....................................................16, 57
JENTADUETO ............................................16, 57
JEVTANA ..........................................................43
JOLESSA ..........................................................97
JOLIVETTE .......................................................97
JUNEL .............................................................. 97
JUNEL FE ........................................................ 97
JUNEL FE 24 ................................................... 97
K
K EFFERVESCENT ....................................... 139
KADCYLA ........................................................ 43
KALETRA ......................................................... 74
KALETRA 100MG-25MG ................................. 74
KALETRA 200MG-50MG ................................. 74
KALYDECO .................................................... 143
KARIVA ............................................................ 97
KELNOR 1-35 .................................................. 97
KEPIVANCE ................................................... 134
KETEK ............................................................. 36
KETOCONAZOLE ............................................ 62
KETOPROFEN ................................................ 28
KETOROLAC TROMETHAMINE ..................... 16
KETOROLAC TROMETHAMINE ..............29, 114
KEYTRUDA ...................................................... 43
KINERET ........................................................ 126
KINRIX ........................................................... 129
KIONEX ...........................................................116
KLOR-CON M10 ............................................ 139
KLOR-CON M15 ............................................ 139
KLOR-CON M20 ............................................ 139
KORLYM .......................................................... 57
KPN ................................................................ 163
KURVELO ........................................................ 97
179
Index of Drugs
KUVAN ............................................................110
KYNAMRO ....................................................... 92
KYPROLIS ....................................................... 43
L
LABETALOL HCL ............................................. 87
LACRISERT ....................................................111
LACTATED RINGERS ................................... 139
LACTULOSE ...................................................116
LAMIVUDINE ................................................... 74
LAMIVUDINE HBV ........................................... 75
LAMIVUDINE-ZIDOVUDINE ............................ 75
LAMOTRIGINE ................................................. 49
LANOXIN .......................................................... 90
LANOXIN PEDIATRIC ..................................... 90
LANSOPRAZOLE ...........................................115
LANTUS ........................................................... 59
LANTUS SOLOSTAR ....................................... 59
LARIN 24 FE .................................................... 97
LARIN FE ......................................................... 98
LATANOPROST ............................................. 137
LATUDA ........................................................... 71
LAZANDA ................................................... 16, 26
LEENA .............................................................. 98
LEFLUNOMIDE .............................................. 126
LENVIMA .......................................................... 43
LESSINA .......................................................... 98
LETAIRIS ....................................................... 145
LETROZOLE .................................................... 43
LEUCOVORIN CALCIUM ...............................135
LEUKERAN ......................................................43
LEUKINE ..........................................................81
LEUPROLIDE ACETATE .................................43
LEVALBUTEROL HCL ...................................142
LEVETIRACETAM ............................................49
LEVETIRACETAM ER 500 MG ........................16
LEVETIRACETAM-NACL .................................50
LEVOBUNOLOL HCL .....................................137
LEVOFLOXACIN ..............................................39
LEVOFLOXACIN-D5W .....................................39
LEVOLEUCOVORIN CALCIUM .....................135
LEVONEST .......................................................98
LEVONORGESTREL .......................................98
LEVONORGESTREL-ETH ESTRADIOL .....................................................98
LEVORA-28 ......................................................98
LEVOTHYROXINE SODIUM ..........................123
LEVOXYL .......................................................123
LEVULAN .......................................................102
LEXIVA .............................................................75
LICE CREAM RINSE 1 % ...............................155
LICE KILLING 4%-0.33% ...............................155
LICE TREATMENT ........................................156
LIDOCAINE ......................................................30
LIDOCAINE HCL ..............................................30
LIDOCAINE HCL IN 5% DEXTROSE .............. 86
LIDOCAINE HCL VISCOUS ............................ 30
LIDOCAINE-PRILOCAINE ............................... 30
LINDANE ........................................................ 108
LINEZOLID ....................................................... 33
LIOTHYRONINE SODIUM ............................. 124
LIPODOX ......................................................... 44
LISINOPRIL ..................................................... 85
LISINOPRILHYDROCHLOROTHIAZIDE ............................ 85
LITEAIRE ........................................................ 16
LITEAIRE ....................................................... 156
LITHIUM ........................................................... 94
LITHIUM CARBONATE ................................... 94
LITHIUM CARBONATE ER ............................. 95
LITTLE NOSES 0.125 % ................................ 157
LOMUSTINE .................................................... 44
LOPERAMIDE .................................................116
LOPERAMIDE 1 MG/5 ML ............................. 160
LOPERAMIDE 1MG/7.5ML ............................ 160
LORAZEPAM ................................................... 16
LORAZEPAM ................................................... 32
LORCET ........................................................... 16
LORCET ........................................................... 26
LORCET HD .................................................... 16
LORCET HD .................................................... 26
LORCET PLUS ................................................ 16
LORCET PLUS ................................................ 26
LOSARTAN POTASSIUM ................................ 85
180
Index of Drugs
LOSARTANHYDROCHLOROTHIAZIDE ............................. 85
LOTEMAX .......................................................114
LOTRONEX .....................................................116
LOVASTATIN ................................................... 92
LOW-OGESTREL ............................................ 98
LOXAPINE ....................................................... 71
LUPRON DEPOT 3.75 MG .............................. 44
LUPRON DEPOT ALL OTHER STRENGTHS ................................................... 44
LUPRON DEPOT-PED .................................. 122
LUTERA ........................................................... 98
LYNPARZA ...................................................... 44
LYRICA ............................................................ 50
LYSODREN ...................................................... 44
M
MAG-G 27 MG(500) ....................................... 161
MAGNESIUM 300 MG ................................... 161
MAGNESIUM SULFATE ................................ 139
MAPAP 325 MG ............................................... 16
MAPAP 325 MG ............................................. 147
MAPAP 500 MG ............................................... 16
MAPAP 500 MG ............................................. 147
MAPAP 500MG/15ML ...................................... 17
MAPAP 500MG/15ML .................................... 147
MAPROTILINE HCL ......................................... 54
MARLISSA ....................................................... 98
MARPLAN ........................................................ 55
MARQIBO .........................................................44
MATULANE ......................................................44
MAXIDEX ........................................................ 114
MECLIZINE HCL ..............................................66
MECLIZINE HCL 12.5 MG ..............................151
MECLOFENAMATE SODIUM ..........................29
MEDROXYPROGESTERONE ACETATE .......................................................123
MEFLOQUINE HCL ..........................................68
MEGESTROL ACETATE ..........................44, 123
MEKINIST .........................................................44
MELOXICAM ....................................................29
MELPHALAN HCL ............................................44
MEMANTINE HCL ............................................52
MENACTRA ....................................................129
MENEST .........................................................120
MENHIBRIX ....................................................129
MENOMUNE-A-C-Y-W-135 ............................129
MENVEO A-C-Y-W-135-DIP ..........................129
MENVEO MENA COMPONENT ....................129
MENVEO MENCYW-135
COMPONENT ................................................129
MEPERIDINE HCL ...........................................17
MEPERIDINE HCL ...........................................26
MEPERITAB .....................................................17
MEPERITAB .....................................................26
MERCAPTOPURINE ........................................44
MEROPENEM ..................................................37
MESALAMINE ................................................131
MESNEX ........................................................ 135
METAPROTERENOL SULFATE ................... 142
METFORMIN HCL 1000 MG ........................... 17
METFORMIN HCL 1000 MG ........................... 57
METFORMIN HCL 500 MG ............................. 17
METFORMIN HCL 500 MG ............................. 57
METFORMIN HCL 850 MG ............................. 17
METFORMIN HCL 850 MG ............................. 57
METFORMIN HCL ER 500 MG ....................... 17
METFORMIN HCL ER 500 MG ....................... 57
METFORMIN HCL ER 750 MG, 1000 MG ................................................................... 17
METFORMIN HCL ER 750 MG, 1000 MG ................................................................... 57
METHADONE HCL .......................................... 17
METHADONE HCL .......................................... 26
METHADONE INTENSOL ............................... 17
METHADONE INTENSOL ............................... 26
METHADOSE .................................................. 17
METHADOSE .................................................. 26
METHAZOLAMIDE ........................................ 137
METHENAMINE HIPPURATE ......................... 33
METHIMAZOLE ............................................. 124
METHOCARBAMOL 500 MG .......................... 17
METHOCARBAMOL 500 MG ........................ 144
METHOCARBAMOL 750 MG .......................... 17
METHOCARBAMOL 750 MG ........................ 144
METHOTREXATE ............................................ 44
METHOXSALEN ............................................ 102
181
Index of Drugs
METHYCLOTHIAZIDE ..................................... 91
METHYLDOPA ................................................. 84
METHYLDOPAHYDROCHLOROTHIAZIDE ............................. 84
METHYLPHENIDATE ER ................................ 95
METHYLPHENIDATE ER 10 MG, 20 MG .................................................................... 95
METHYLPHENIDATE HCL .............................. 95
METHYLPREDNISOLONE ............................ 121
METHYLPREDNISOLONE ACETATE ....................................................... 121
METHYLPREDNISOLONE SOD SUCC ............................................................. 121
METIPRANOLOL ........................................... 137
METOCLOPRAMIDE HCL ..............................117
METOLAZONE ................................................. 91
METOPROLOL SUCCINATE 100 MG .................................................................... 17
METOPROLOL SUCCINATE 25 MG, 50 MG ............................................................... 18
METOPROLOL SUCCINATE 25 MG, 50 MG ............................................................... 87
METOPROLOL TARTRATE ............................ 87
METOPROLOLHYDROCHLOROTHIAZIDE ............................. 87
METRONIDAZOLE .............................33, 64, 103
MEXILETINE HCL ............................................86
MIACALCIN ....................................................132
MICONAZOLE 3 ...............................................62
MICONAZOLE 7 100 MG ...............................150
MICONAZOLE NITRATE 2 % ........................150
MICRHOGAM ULTRA-FILTERED PLUS ..............................................................126
MICROCHAMBER ...........................................18
MICROCHAMBER ..........................................156
MICROGESTIN ................................................98
MICROGESTIN FE ...........................................98
MICROSPACER ..............................................18
MICROSPACER .............................................156
MIDODRINE HCL .............................................84
MIFEPREX .....................................................135
MIGERGOT ......................................................64
MILRINONE IN 5% DEXTROSE ......................90
MIMVEY ..........................................................120
MIMVEY LO ....................................................120
MINITRAN ........................................................93
MINOCYCLINE HCL .........................................40
MINOXIDIL .......................................................93
MIRCERA .........................................................81
MIRTAZAPINE ..................................................55
MISOPROSTOL ............................................. 115
MITOXANTRONE HCL .....................................44
M-M-R II VACCINE .........................................129
MODAFINIL ....................................................144
MOEXIPRIL HCL ............................................. 85
MOMETASONE FUROATE ........................... 107
MONOJECT PREFILL ADVANCED
500/5 ML ........................................................ 151
MONO-LINYAH ................................................ 98
MONONESSA .................................................. 98
MONTELUKAST SODIUM ............................. 141
MORPHINE SULFATE ..................................... 18
MORPHINE SULFATE ..................................... 26
MORPHINE SULFATE ER ............................... 18
MORPHINE SULFATE ER ............................... 27
MOXIFLOXACIN HCL ...................................... 39
MOZOBIL ......................................................... 81
MULTAQ .......................................................... 86
MUPIROCIN ..................................................... 18
MUPIROCIN ................................................... 104
MURO-128 2 % .............................................. 157
MURO-128 5 % .............................................. 157
MYCOPHENOLATE MOFETIL ...................... 126
MYCOPHENOLIC ACID ................................ 126
MYOZYME ......................................................110
MYRBETRIQ ...................................................118
MYZILRA .......................................................... 98
N
NABI-HB ......................................................... 126
NABUMETONE ................................................ 29
NADOLOL ........................................................ 87
NAFCILLIN SODIUM ....................................... 38
182
Index of Drugs
NAGLAZYME ..................................................110
NALOXONE HCL ............................................. 31
NALTREXONE HCL ......................................... 31
NAMENDA ....................................................... 52
NAMENDA XR ........................................... 18, 52
NAPHAZOLINE HCL .......................................111
NAPROXEN ..................................................... 29
NAPROXEN SODIUM ...................................... 29
NASAL AND SINUS DECONGESTANT 30 MG .............................. 153
NATEGLINIDE ................................................. 57
NATPARA ...................................................... 132
NEBUPENT ...................................................... 68
NECON ............................................................ 98
NEFAZODONE HCL ........................................ 55
NEOMYCIN SULFATE ..................................... 32
NEOMYCIN-BACITRACIN-POLYHC ...................................................................112
NEOMYCIN-BACITRACINPOLYMYXIN ...................................................112
NEOMYCIN-POLYMYXINDEXAMETH ....................................................113
NEOMYCIN-POLYMYXINGRAMICIDIN ...................................................113
NEOMYCIN-POLYMYXIN-HC ........................113
NEOMYCIN-POLYMYXINHYDROCORT .................................................113
NEO-POLYCIN HC .........................................113
NEOSPORIN 3.5-400-5K ............................... 155
NEO-TUSS 200-30MG/5 ................................ 153
NEPHRAMINE ..................................................84
NESSI SPACER ..............................................18
NESSI SPACER .............................................156
NEULASTA .......................................................81
NEUMEGA ........................................................82
NEUPOGEN .....................................................82
NEVIRAPINE ....................................................75
NEVIRAPINE ER ..............................................75
NEXAVAR .........................................................44
NIACIN 100 MG ..............................................151
NIACIN 1000 MG ............................................151
NIACIN 125 MG ..............................................152
NIACIN 250 MG ..............................................152
NIACIN 400 MG ..............................................152
NIACIN 50 MG ................................................152
NIACIN 500 MG ..............................................152
NIACIN 750 MG ..............................................152
NIACIN ER ........................................................92
NICARDIPINE HCL ..........................................90
NICORELIEF 2 MG ........................................149
NICORELIEF 4 MG ........................................149
NICOTINE PATCH 14MG/24HR ....................149
NICOTINE PATCH 21 MG/24HR ...................149
NICOTINE PATCH 22 MG/24HR ...................149
NICOTINE PATCH 7MG/24HR ......................149
NICOTROL .......................................................31
NICOTROL NS .................................................31
NIFEDICAL XL ..................................................90
NIFEDIPINE ER ............................................... 90
NILANDRON .................................................... 44
NITROFURANTOIN ......................................... 33
NITROFURANTOIN MONO-MACRO .............. 33
NITROGLYCERIN PATCH .............................. 94
NITROSTAT ..................................................... 94
NIZATIDINE ....................................................115
NORA-BE ......................................................... 98
NORDITROPIN FLEXPRO ............................ 122
NORDITROPIN NORDIFLEX ........................ 122
NORETHINDRONE ......................................... 99
NORETHINDRONE ACETATE ...................... 123
NORETHINDRON-ETHINYL ESTRADIOL ................................................... 120
NORETHIN-ETH ESTRA FERROUS FUM ................................................................. 99
NORGESTIMATE-ETHINYL ESTRADIOL ..................................................... 99
NORLYROC ..................................................... 99
NORTREL ........................................................ 99
NORTRIPTYLINE HCL .................................... 55
NORVIR ........................................................... 75
NOVOLIN 70-30 ............................................... 59
NOVOLIN N ..................................................... 59
NOVOLIN R ..................................................... 59
NOVOLOG ....................................................... 59
NOVOLOG FLEXPEN ...................................... 59
NOVOLOG MIX 70-30 ..................................... 59
NOVOLOG MIX 70-30 FLEXPEN .................... 59
183
Index of Drugs
NU-DERM TOLEREEN 0.5 % ........................ 155
NUEDEXTA ...................................................... 95
NULOJIX ........................................................ 126
NUTRILYTE II ................................................ 139
NUTROPIN AQ NUSPIN ................................ 123
NYAMYC .......................................................... 62
NYSTATIN ........................................................ 62
NYSTATIN-TRIAMCINOLONE ........................ 62
NYSTOP ........................................................... 63
O
OFEV .............................................................. 143
OFLOXACIN ..............................................39, 113
OGESTREL ...................................................... 99
OLANZAPINE ................................................... 71
OLANZAPINE 15 MG ....................................... 18
OLANZAPINE 15 MG ....................................... 71
OLANZAPINE 2.5 MG , 5 MG .......................... 18
OLANZAPINE 2.5 MG , 5 MG .......................... 71
OLANZAPINE 20 MG ................................. 18, 71
OLANZAPINE 7.5 MG, 10 MG ......................... 18
OLANZAPINE 7.5 MG, 10 MG ......................... 72
OLANZAPINE ODT .......................................... 18
OLANZAPINE ODT .......................................... 72
OLYSIO ............................................................ 77
OMEGA-3 ACID ETHYL ESTERS ................... 92
OMEPRAZOLE 10 MG, 20 MG ........................ 18
OMEPRAZOLE 10 MG, 20 MG .......................115
OMEPRAZOLE 40 MG ..................................... 18
OMEPRAZOLE 40 MG ................................... 115
OMEPRAZOLE MAGNESIUM 20 MG ..................................................................158
ONCASPAR ......................................................45
ONDANSETRON HCL ......................................66
ONDANSETRON ODT .....................................66
ONFI ...............................................................107
OPDIVO ............................................................45
OPTICHAMBER ..............................................19
OPTICHAMBER .............................................156
ORALONE ......................................................101
ORALYTE ........................................................19
ORALYTE ......................................................161
ORAP ................................................................72
ORENCIA .......................................................127
ORFADIN ........................................................ 110
ORSYTHIA .......................................................99
OTEZLA ..........................................................135
OXALIPLATIN ...................................................45
OXANDROLONE ............................................ 119
OXAPROZIN .....................................................29
OXCARBAZEPINE ...........................................50
OXSORALEN .................................................102
OXTELLAR XR .................................................50
OXYBUTYNIN CHLORIDE ............................. 118
OXYBUTYNIN CHLORIDE ER ....................... 118
OXYCODONE HCL ..........................................19
OXYCODONE HCL ..........................................27
OXYCODONE HCL ER ..............................19, 27
OXYCODONE HCL-ASPIRIN .......................... 19
OXYCODONE HCL-ASPIRIN .......................... 27
OXYCODONE-ACETAMINOPHEN ................. 19
OXYCODONE-ACETAMINOPHEN ................. 27
OXYCONTIN 10 MG, 15 MG ..................... 19, 27
OXYCONTIN 20 MG, 30 MG ..................... 19, 27
OXYCONTIN 40 MG, 60 MG ..................... 19, 27
OYSCO D 250 MG-125 .................................. 162
OYSCO-500 500(1250) .................................. 162
OYSTER SHELL CALCIUM W-VIT D 250 MG-125 ................................................... 162
P
PACERONE ..................................................... 86
PACLITAXEL ................................................... 45
PAIN RELIEVER JUNIOR
STRENGTH 160 MG ........................................ 19
PAIN RELIEVER JUNIOR
STRENGTH 160 MG ...................................... 148
PAMIDRONATE DISODIUM .......................... 132
PANCRELIPASE 5,000 ...................................110
PANRETIN ..................................................... 102
PANTOPRAZOLE SODIUM ............................115
PARICALCITOL ............................................. 132
PAROMOMYCIN SULFATE ............................ 68
PAROXETINE HCL .......................................... 55
PASER ............................................................. 65
PATADAY .......................................................111
PAXIL ............................................................... 55
184
Index of Drugs
PEDIA RELIEF 2.5-7.5/.8 ............................... 153
PEDIA RELIEF COUGH-COLD 5-151MG/5 ............................................................. 154
PEDIARIX ....................................................... 129
PEDVAXHIB ................................................... 129
PEG 3350-ELECTROLYTE .............................. 19
PEG 3350-ELECTROLYTE .............................117
PEG-3350 ......................................................... 19
PEG-3350 ........................................................117
PEG-3350 AND ELECTROLYTES ..................117
PEGANONE ..................................................... 50
PEGASYS ........................................................ 78
PEGASYS PROCLICK ..................................... 78
PEGINTRON .................................................... 78
PEGINTRON REDIPEN ................................... 78
PENICILLIN G POTASSIUM ............................ 38
PENICILLIN G SODIUM ................................... 38
PENICILLIN GK-ISO-OSM DEXTROSE ...................................................... 38
PENICILLIN V POTASSIUM ............................ 38
PENTACEL ACTHIB COMPONENT .............. 129
PENTACEL DTAP-IPV COMPONENT ................................................ 129
PENTAM 300 ................................................... 68
PENTASA ................................................. 19, 131
PENTOXIFYLLINE ........................................... 83
PERIOGARD .................................................. 101
PERJETA ......................................................... 45
PERMETHRIN ................................................ 108
PERPHENAZINE ..............................................72
PERPHENAZINE-AMITRIPTYLINE .................55
PERRY PRENATAL 13.5-0.4MG ...................163
PFIZERPEN ......................................................38
PHENADOZ ......................................................66
PHENELZINE SULFATE ..................................55
PHENOBARBITAL ............................................50
PHENTERMINE HCL 15 MG ..........................152
PHENTERMINE HCL 30 MG ..........................152
PHENYLEPHRINE HCL ...................................19
PHENYLEPHRINE HCL ................................. 111
PHENYLHISTINE DH 30-10-2/5 .....................154
PHENYTEK ......................................................50
PHENYTOIN .....................................................50
PHENYTOIN SODIUM .....................................50
PHENYTOIN SODIUM EXTENDED .................50
PHILITH ............................................................99
PHOSPHA 250 NEUTRAL .............................139
PHOSPHOLINE IODIDE ................................137
PICATO ..........................................................102
PILOCARPINE HCL ...............................101, 137
PINDOLOL ........................................................88
PIOGLITAZONE HCL .......................................20
PIOGLITAZONE HCL .......................................57
PIPERACILLIN-TAZOBACTAM ........................38
PIRMELLA ........................................................99
PIROXICAM ......................................................29
PLEGRIDY ......................................................135
PLEGRIDY PEN ............................................. 135
PODOCON-25 ............................................... 102
PODOFILOX .................................................. 102
POLYETHYLENE GLYCOL 3350 ...................117
POLYETHYLENE GLYCOL 3350 17G .................................................................. 20
POLYETHYLENE GLYCOL 3350 17G ................................................................ 161
POLYMYXIN B SULTRIMETHOPRIM ............................................113
POMALYST ...................................................... 45
PORTIA ............................................................ 99
POTASSIUM BICARBONATE ....................... 139
POTASSIUM CHL-NORMAL SALINE .......................................................... 139
POTASSIUM CHLORIDE .............................. 139
POTASSIUM CHLORIDE IN D5LR ................ 140
POTASSIUM CITRATE ER ............................ 140
POTASSIUM CITRATE-CITRIC ACID ............................................................... 140
POTIGA 200 MG, 400 MG ............................... 50
POTIGA 300 MG .............................................. 50
POTIGA 50 MG .......................................... 20, 50
PRADAXA ........................................................ 80
PRAMIPEXOLE DIHYDROCHLORIDE ...................................... 69
PRAVASTATIN SODIUM ................................. 92
PRAZOSIN HCL ............................................... 84
PREDNISOLONE ACETATE ..........................114
185
Index of Drugs
PREDNISOLONE SODIUM PHOSPHATE ..........................................114, 121
PREDNISONE ................................................ 121
PREMARIN .................................................... 120
PREMASOL ..................................................... 84
PREMPHASE ................................................. 120
PREMPRO ..................................................... 120
PRENATAL 19 29 MG-1 MG .......................... 163
PRENATAL 19 29-1-25 MG ........................... 163
PRENATAL 27MG-0.8MG .............................. 163
PRENATAL 28MG-0.8MG .............................. 163
PRENATAL PLUS .......................................... 145
PREVALITE ...................................................... 92
PREVIFEM ....................................................... 99
PREZCOBIX ..................................................... 75
PREZISTA .................................................. 20, 75
PREZISTA 150 MG, ......................................... 75
PREZISTA 400 MG, 600 MG ........................... 75
PREZISTA 75 MG ...................................... 20, 75
PREZISTA 800 MG .......................................... 75
PRIFTIN ........................................................... 65
PRIMAQUINE ................................................... 68
PRIMEAIRE ..................................................... 20
PRIMEAIRE .................................................... 156
PRIMIDONE ..................................................... 51
PRISTIQ ER ..................................................... 55
PROAIR HFA ........................................... 20, 142
PROAIR RESPICLICK ............................. 20, 142
PROBENECID ................................................ 135
PROBENECID-COLCHICINE .........................135
PROCHLORPERAZINE ...................................66
PROCHLORPERAZINE EDISYLATE ......................................................67
PROCHLORPERAZINE MALEATE ..................67
PROCRIT 2000/ML ...........................................82
PROCRIT 20000/2ML .......................................82
PROCRIT 20000/ML .........................................82
PROCRIT 3000/ML ...........................................82
PROCRIT 4000/ML ...........................................82
PROCRIT 40000/ML .........................................82
PROCTO-PAK ................................................107
PROCTOSOL-HC ...........................................107
PROCTOZONE-HC ........................................107
PROGESTERONE .........................................123
PROGLYCEM ...................................................94
PROGRAF ......................................................127
PROLEUKIN .....................................................45
PROLIA ...........................................................132
PROMACTA .....................................................82
PROMETHAZINE HCL ...............................63, 67
PROMETHAZINE VC-CODEINE
6.25-5-10 ........................................................154
PROMETHAZINE-CODEINE 6.2510/5 ...................................................................20
PROMETHAZINE-CODEINE 6.2510/5 .................................................................154
PROMETHAZINE-DM 15-6.25/5 ....................154
PROMETHEGAN ..............................................67
PROPAFENONE HCL ..................................... 86
PROPARACAINE HCL ...................................111
PROPRANOLOL HCL ...................................... 88
PROPRANOLOL HCL ER ................................ 88
PROPRANOLOLHYDROCHLOROTHIAZID ............................... 88
PROPYLTHIOURACIL ................................... 124
PROQUAD ..................................................... 129
PROTONIX IV .................................................115
PROTRIPTYLINE HCL .................................... 55
PSEUDOEPHEDRINE HCL 30 MG/5 ML .................................................................. 154
PULMICORT FLEXHALER ............................ 141
PULMOZYME .................................................110
PURIXAN ......................................................... 45
PYRAZINAMIDE .............................................. 65
PYRIDOSTIGMINE BROMIDE ...................... 135
PYRIDOXINE HCL 250 MG ........................... 163
PYRIDOXINE HCL 500 MG ........................... 163
Q
Q-TAPP 15-1MG/5ML .................................... 151
QUADRACEL DTAP-IPV ............................... 129
QUASENSE ..................................................... 99
QUETIAPINE FUMARATE ............................... 20
QUETIAPINE FUMARATE ............................... 72
QUINAPRIL HCL .............................................. 86
QUINAPRILHYDROCHLOROTHIAZIDE ............................ 86
186
Index of Drugs
QUINIDINE GLUCONATE ............................... 86
RESERPINE .....................................................90
QUINIDINE SULFATE ...................................... 86
RESTASIS ................................................ 20, 114
QVAR ............................................................. 141
RETROVIR .......................................................76
REVLIMID .........................................................45
REYATAZ .........................................................76
RABAVERT .................................................... 129
RHOGAM ULTRA-FILTERED PLUS ..............127
RALOXIFENE HCL .......................................... 20
RHOPHYLAC .................................................127
RALOXIFENE HCL ........................................ 120
RIBASPHERE ...................................................78
RAMIPRIL ........................................................ 86
RIBAVIRIN ........................................................79
RANEXA ........................................................... 90
RIBOFLAVIN 100 MG .....................................163
RANITIDINE HCL ............................................115
RIBOFLAVIN 50 MG .......................................164
RANITIDINE HCL 150 MG ............................. 158
RIDAURA ........................................................127
RANITIDINE HCL 75 MG ............................... 159
RIFABUTIN .......................................................65
RAPAMUNE ................................................... 127
RIFAMPIN .........................................................65
REBIF ............................................................. 135
RIFATER ..........................................................65
REBIF REBIDOSE ......................................... 135
RIGINIC 131-31.7/5 ........................................160
RECLIPSEN ..................................................... 99
RILUZOLE ........................................................95
RECOMBIVAX HB ......................................... 129
RI-MAG 540MG/5ML ......................................160
REGRANEX ............................................. 20, 102
RIMANTADINE HCL .........................................77
RELENZA ................................................... 20, 77
RI-MOX PLUS 200-225-25 .............................160
RELISTOR ......................................................117
RINGERS INJECTION ...................................140
REMICADE .................................................... 135
RISEDRONATE SODIUM 35 MG, REMODULIN .................................................. 145
150 MG .....................................................20, 132
RENAGEL .......................................................118
RISEDRONATE SODIUM 5 MG, 30 RENVELA ........................................................118
MG ............................................................20, 132
REPAGLINIDE ................................................. 57
RISEDRONATE SODIUM DR ..................20, 133
REPREXAIN ..................................................... 20
RISPERDAL CONSTA 12.5MG/2ML ................72
REPREXAIN ..................................................... 27
RISPERDAL CONSTA 25 MG/2 ML .................72
RESCRIPTOR .................................................. 75
RISPERDAL CONSTA 37.5MG/2ML ................72
R
RISPERDAL CONSTA 50 MG/2 ML ................ 72
RISPERIDONE ................................................ 21
RISPERIDONE ................................................ 72
RISPERIDONE ODT ........................................ 21
RISPERIDONE ODT ........................................ 72
RITEFLO ......................................................... 21
RITEFLO ........................................................ 157
RITUXAN ......................................................... 45
RIVASTIGMINE ............................................... 52
RIZATRIPTAN .................................................. 21
RIZATRIPTAN .................................................. 64
ROPINIROLE HCL ........................................... 69
ROTARIX ....................................................... 129
ROTATEQ ...................................................... 130
ROXICET ......................................................... 21
ROXICET ......................................................... 27
ROZEREM ..................................................... 144
RUCONEST ..................................................... 82
S
SABRIL ............................................................ 51
SAIZEN .......................................................... 123
SANDOSTATIN LAR ...................................... 123
SANTYL ......................................................... 102
SAPHRIS ......................................................... 72
SAVELLA ......................................................... 95
SCALP ITCH-DANDRUFF RELIEF 3 % .................................................................... 154
SELEGILINE HCL ............................................ 69
187
Index of Drugs
SELENIUM SULFIDE ..................................... 104
SELZENTRY .................................................... 76
SENSIPAR 30 MG ................................... 21, 135
SENSIPAR 60 MG, 90 MG ............................. 135
SEREVENT DISKUS ...................................... 142
SEROSTIM ..................................................... 123
SERTRALINE HCL ........................................... 55
SF 5000 PLUS ............................................... 101
SHOHL'S MODIFIED ..................................... 140
SIGNIFOR ...................................................... 136
SIGNIFOR LAR .............................................. 136
SILACE 60 MG/15ML ..................................... 161
SILDENAFIL ................................................... 145
SILDENAFIL CITRATE .................................. 145
SILVER SULFADIAZINE ................................ 104
SIMETHICONE 40MG/0.6ML ......................... 158
SIMULECT ..................................................... 136
SIMVASTATIN ................................................. 92
SIROLIMUS 0.5 MG ......................................... 21
SIROLIMUS 0.5 MG ....................................... 127
SIROLIMUS 1 MG .......................................... 127
SIROLIMUS 2 MG .......................................... 127
SIVEXTRO ....................................................... 33
SLOW RELEASE IRON 47.5 IRON ............... 164
SODIUM BICARBONATE .............................. 140
SODIUM BICARBONATE 325 MG ................ 160
SODIUM BICARBONATE 650 MG ................ 160
SODIUM CHLORIDE ............................. 131, 140
SODIUM CITRATE AND CITRIC ACID ...............................................................140
SODIUM FLUORIDE ......................................101
SOLTAMOX ......................................................45
SOMATULINE DEPOT ...................................123
SOMAVERT ....................................................123
SORINE ............................................................88
SOTALOL .........................................................88
SOVALDI ..........................................................77
SPACE CHAMBER PLUS ...............................21
SPACE CHAMBER PLUS ..............................157
SPIRIVA ....................................................21, 142
SPIRIVA RESPIMAT ................................21, 142
SPIRONOLACTONE ........................................93
SPIRONOLACTONE-HCTZ .............................93
SPRINTEC ........................................................99
SPRYCEL .........................................................45
SPS ................................................................. 117
SRONYX ...........................................................99
SSD ................................................................104
STANNOUS FLUORIDE .................................101
STAVUDINE .....................................................76
STERILE PADS ..............................................136
STIVARGA ........................................................45
STRATTERA ....................................................95
STREPTOMYCIN SULFATE ............................32
STRIBILD ..........................................................76
STRIVERDI RESPIMAT .................................142
SUBOXONE .....................................................31
SUCRAID ........................................................110
SUCRALFATE ................................................116
SUDOGEST 120 MG ..................................... 154
SUDOGEST 60 MG ....................................... 154
SULFACETAMIDE SODIUM ...........................113
SULFACETAMIDEPREDNISOLONE ............................................113
SULFADIAZINE ............................................... 39
SULFAMETHOXAZOLETRIMETHOPRIM ............................................. 39
SULFASALAZINE ............................................ 39
SULFASALAZINE DR ...................................... 39
SULFATRIM ..................................................... 39
SULFAZINE ..................................................... 39
SULINDAC ....................................................... 29
SUMATRIPTAN ............................................... 21
SUMATRIPTAN ............................................... 64
SUMATRIPTAN SUCCINATE .......................... 21
SUMATRIPTAN SUCCINATE .......................... 64
SURMONTIL .................................................... 55
SUSTIVA 50 MG, 200 MG ............................... 76
SUSTIVA 600 MG ............................................ 76
SUTENT ........................................................... 45
SYLATRON ...................................................... 78
SYLVANT ......................................................... 45
SYMLINPEN 120 ............................................. 58
SYMLINPEN 60 ............................................... 58
SYNAGIS ......................................................... 77
SYNAREL ...................................................... 136
188
Index of Drugs
SYNERCID ....................................................... 33
SYNRIBO ......................................................... 45
SYNTHROID .................................................. 124
SYPRINE .........................................................119
T
TABLOID .......................................................... 45
TACROLIMUS 0.5 MG, 1 MG ........................ 127
TACROLIMUS 5 MG ...................................... 127
TAFINLAR ........................................................ 46
TAMIFLU 30 MG ........................................ 21, 77
TAMIFLU 45 MG, 75 MG ........................... 21, 77
TAMIFLU 6 MG/ML .................................... 22, 77
TAMOXIFEN CITRATE .................................... 46
TAMSULOSIN HCL .......................................... 22
TAMSULOSIN HCL .........................................118
TANZEUM ........................................................ 58
TARCEVA ........................................................ 46
TARGRETIN ..................................................... 46
TASIGNA .......................................................... 46
TAZICEF .......................................................... 35
TAZORAC ...................................................... 108
TAZTIA XT ....................................................... 88
TECFIDERA ................................................... 136
TEFLARO ......................................................... 35
TEGRETOL XR ................................................ 51
TEKTURNA ...................................................... 93
TEKTURNA HCT .............................................. 93
TEMAZEPAM ................................................... 22
TEMAZEPAM ...................................................32
TEMODAR ........................................................46
TENIPOSIDE ....................................................46
TENIVAC ........................................................130
TERAZOSIN HCL ........................................... 118
TERBINAFINE HCL ..........................................63
TERBUTALINE SULFATE ..............................142
TERCONAZOLE ...............................................64
TESTOSTERONE CYPIONATE .....................120
TETANUS DIPHTHERIA TOXOIDS ...............130
TETANUS TOXOID ADSORBED ...................130
TETRACAINE HCL ......................................... 112
TETRACYCLINE HCL ......................................40
T-GEL 1 % ......................................................155
THALOMID .....................................................136
THEO-24 .........................................................142
THEOCHRON .................................................142
THEOPHYLLINE ............................................142
THEOPHYLLINE ANHYDROUS ....................143
THEOPHYLLINE IN 5% DEXTROSE .............143
THERACYS ....................................................130
THIOLA ...........................................................136
THIORIDAZINE HCL ........................................72
THIOTHIXENE ..................................................72
THYROLAR-1 .................................................124
THYROLAR-1/2 ..............................................124
THYROLAR-1/4 ..............................................124
THYROLAR-2 .................................................124
THYROLAR-3 ................................................ 124
TIAGABINE HCL .............................................. 51
TICLOPIDINE HCL .......................................... 83
TIKOSYN ......................................................... 86
TILIA FE ........................................................... 99
TIMENTIN ........................................................ 38
TIMOLOL MALEATE ................................ 88, 137
TIOCONAZOLE 1 6.5 % ................................ 150
TIROSINT ...................................................... 124
TIVICAY ........................................................... 76
TIZANIDINE HCL ........................................... 144
TOBRAMYCIN ................................................. 32
TOBRAMYCIN ................................................113
TOBRAMYCIN SULFATE ................................ 32
TOBRAMYCIN-DEXAMETHASONE ..............113
TOLAZAMIDE .................................................. 22
TOLAZAMIDE .................................................. 60
TOLBUTAMIDE ................................................ 22
TOLBUTAMIDE ................................................ 60
TOLCAPONE ................................................... 69
TOLMETIN SODIUM ........................................ 29
TOLNAFTATE 1 % ......................................... 150
TOLTERODINE TARTRATE ............................ 22
TOLTERODINE TARTRATE ...........................118
TOLTERODINE TARTRATE ER ...................... 22
TOLTERODINE TARTRATE ER .....................118
TOPIRAMATE .................................................. 51
TOPIRAMATE ER ............................................ 51
189
Index of Drugs
TOPOTECAN HCL ........................................... 46
TORSEMIDE .................................................... 91
TPN ELECTROLYTES II ................................ 140
TRACLEER .................................................... 145
TRADJENTA .............................................. 22, 58
TRAMADOL HCL ............................................. 22
TRAMADOL HCL ............................................. 27
TRAMADOL HCLACETAMINOPHEN .......................................... 22
TRAMADOL HCLACETAMINOPHEN .......................................... 27
TRANDOLAPRIL .............................................. 86
TRANEXAMIC ACID ........................................ 82
TRANSDERM-SCOP ....................................... 67
TRANYLCYPROMINE SULFATE .................... 55
TRAVASOL ...................................................... 84
TRAVATAN Z ........................................... 22, 137
TRAVEL SICKNESS 25 MG .......................... 151
TRAVOPROST ......................................... 22, 137
TRAZODONE HCL ........................................... 55
TREANDA ........................................................ 46
TRECATOR ...................................................... 65
TRELSTAR ....................................................... 46
TRETINOIN ...................................................... 46
TRETINOIN .................................................... 108
TRIAMCINOLONE ACETONIDE ........... 101, 107
TRIAMTERENEHYDROCHLOROTHIAZID ............................... 91
TRIAZOLAM ..................................................... 22
TRIAZOLAM .....................................................32
TRIDERM .......................................................108
TRIFLUOPERAZINE HCL ................................72
TRIFLURIDINE ............................................... 113
TRIHEXYPHENIDYL HCL ................................69
TRI-LEGEST FE ...............................................99
TRI-LINYAH ....................................................100
TRILYTE WITH FLAVOR PACKETS .............. 117
TRIMETHOPRIM ..............................................33
TRINESSA ......................................................100
TRI-PREVIFEM ..............................................100
TRISENOX .......................................................46
TRI-SPRINTEC ...............................................100
TRIUMEQ .........................................................76
TRI-VI-SOL 750-35/ML ...................................164
TRI-VITAMIN 1500-35/ML ..............................164
TRIVORA-28 ...................................................100
TROKENDI XR 100 MG .............................22, 51
TROKENDI XR 200 MG .............................22, 51
TROKENDI XR 25 MG, 50 MG ...................22, 51
TROPHAMINE ..................................................84
TROPICAMIDE ............................................... 112
TRUMENBA ....................................................130
TRUVADA .........................................................76
TUDORZA PRESSAIR ...................................143
TWINRIX .........................................................130
TYBOST .........................................................136
TYGACIL ..........................................................40
TYKERB ........................................................... 46
TYPHIM VI ..................................................... 130
TYSABRI ........................................................ 127
TYZEKA ........................................................... 79
TYZINE ...........................................................112
U
U-CORT ......................................................... 108
UNITHROID ................................................... 124
URSODIOL .....................................................117
V
VALACYCLOVIR .............................................. 79
VALCHLOR .................................................... 103
VALGANCICLOVIR HCL ................................. 79
VALPROATE SODIUM .................................... 51
VALPROIC ACID ............................................. 51
VALSARTAN .................................................... 85
VALSARTANHYDROCHLOROTHIAZIDE ............................ 85
VALU-TAPP DECONGESTANT
9.4MG/ML ...................................................... 154
VANCOMYCIN HCL ......................................... 33
VAQTA ........................................................... 130
VARIVAX VACCINE ....................................... 130
VASCEPA ........................................................ 93
VCF 12.5 % .................................................... 153
VELCADE ........................................................ 46
VELETRI ........................................................ 145
190
Index of Drugs
VELIVET ......................................................... 100
VENLAFAXINE HCL ........................................ 56
VENLAFAXINE HCL ER .................................. 56
VENTOLIN HFA ....................................... 22, 143
VERAPAMIL ER ............................................... 88
VERAPAMIL ER PM ........................................ 89
VERAPAMIL HCL ............................................. 89
VERDESO ...................................................... 108
VERIPRED 20 ................................................ 122
VERSACLOZ .................................................... 73
VGO 40 .......................................................... 109
VICTOZA 3-PAK .............................................. 58
VIDEX ............................................................... 76
VIGAMOX ........................................................113
VIIBRYD ........................................................... 56
VIMPAT ...................................................... 22, 51
VIMPAT 100 MG, 150 MG ............................... 51
VIMPAT 200 MG .............................................. 52
VIMPAT 50 MG ................................................ 52
VIORELE ........................................................ 100
VIRACEPT ....................................................... 76
VIRAMUNE XR ................................................ 76
VIRAZOLE ........................................................ 79
VIREAD ............................................................ 76
VIRT-PHOS 250 NEUTRAL ........................... 140
VITAMIN A 10000 UNIT ................................. 164
VITAMIN A 25000 UNIT ................................. 164
VITAMIN A 8000 UNIT ................................... 164
VITAMIN B-1 100 MG .....................................164
VITAMIN B-6 100 MG .....................................164
VITAMIN B-6 200 MG .....................................164
VITAMIN B-6 25 MG .......................................164
VITAMIN B-6 50 MG .......................................164
VITAMIN C 100 MG ........................................164
VITAMIN C 1000 MG ......................................164
VITAMIN C 1500 MG ......................................165
VITAMIN C 250 MG ........................................165
VITAMIN C 500 MG ........................................165
VITAMIN C 500 MG/5ML ................................165
VITAMIN D 400 UNIT .....................................165
VITAMIN D2 400 UNIT ...................................165
VITAMIN D2 50000 UNIT ...............................165
VITAMIN E 400 UNIT .....................................165
VITAMIN K 100 MCG .....................................165
VITEKTA ...........................................................77
VOLTAREN ......................................................29
VORAXAZE ....................................................136
VORICONAZOLE .............................................63
VORTEX ..........................................................23
VORTEX .........................................................157
VORTEX FROG MASK ...................................23
VORTEX FROG MASK ..................................157
VORTEX LADYBUG MASK .............................23
VORTEX LADYBUG MASK ............................157
VORTEX VHC FROG MASK ...........................23
VORTEX VHC FROG MASK ..........................157
VOTRIENT ....................................................... 46
VPRIV .............................................................110
VYFEMLA ...................................................... 100
W
WAL-FOUR 1 % ............................................. 158
WARFARIN SODIUM ....................................... 80
WATCHHALER ............................................... 23
WATCHHALER .............................................. 157
WATER .......................................................... 131
WELCHOL ....................................................... 93
WERA ............................................................ 100
WINRHO SDF ................................................ 127
X
XALKORI .......................................................... 46
XARELTO ........................................................ 80
XELJANZ ....................................................... 136
XENAZINE ....................................................... 95
XGEVA ........................................................... 133
XOLAIR .......................................................... 143
XTANDI ............................................................ 47
XYREM .......................................................... 144
Y
YERVOY .......................................................... 47
YF-VAX .......................................................... 130
Z
ZAFIRLUKAST ................................................. 23
191
Index of Drugs
ZAFIRLUKAST ............................................... 141
ZALEPLON ..................................................... 144
ZALTRAP ......................................................... 47
ZAVESCA ........................................................110
ZELBORAF ...................................................... 47
ZEMAIRA ....................................................... 143
ZEMPLAR ...................................................... 133
ZENCHENT .................................................... 100
ZENCHENT FE .............................................. 100
ZENPEP 15-51-82K, 20-68-109K ...................110
ZENPEP 25-85-136K ......................................110
ZENPEP 3K-10K-16K, 10-34-55K ...................110
ZENPEP 40K-136K .........................................110
ZETIA ............................................................... 93
ZIAGEN ............................................................ 77
ZIDOVUDINE ................................................... 77
ZIPRASIDONE HCL 20 MG, 40 MG ................ 23
ZMAX ......................................................... 23, 36
ZOLADEX ......................................................... 47
ZOLEDRONIC ACID 4 MG/5 ML ................... 133
ZOLEDRONIC ACID 5 MG/100ML ................ 133
ZOLINZA .......................................................... 47
ZOLPIDEM TARTRATE ................................... 23
ZOLPIDEM TARTRATE ................................. 144
ZOMETA ........................................................ 133
ZONALON ......................................................103
ZONISAMIDE ...................................................52
ZORBTIVE ......................................................123
ZORTRESS 0.25 MG .....................................127
ZORTRESS 0.5 MG, 0.75 MG ........................127
ZOSTAVAX .....................................................130
ZOVIA 1-35E ..................................................100
ZOVIA 1-50E ..................................................100
ZOVIRAX ..................................................23, 103
ZYCLARA .......................................................103
ZYDELIG ..........................................................47
ZYKADIA ..........................................................47
ZYPREXA RELPREVV .....................................73
ZYTIGA .............................................................47
ZYVOX ..............................................................33
192
CARE1ST CAl MEdiConnECT plAn
Danh sách thuốc được bảo hiểm (Danh mục) năm 2016
Quận: Los AngeLes và sAn Diego
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Danh sách thuốc được bảo hiểm (Danh mục) năm 2016

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