2015 Aetna Pharmacy Plan Drug List - Four Tier Open

Transcription

Quality health plans & benefits
Healthier living
Financial well-being
Intelligent solutions
2015 Aetna Pharmacy Plan Drug List
Four Tier Open Value Plus Plan
www.aetna.com
©2015 Aetna Inc.
05.05.352.1 G (8/15)
Do you have questions?
Call the toll-free number on your member ID card. Or visit
www.aetna.com/formulary for the most up-to-date information.
Dear Member:
What pharmacy benefits plan do I have?
To help you know how drugs are covered by your plan, we
are pleased to provide you with a copy of our 2015 Aetna
Pharmacy Plan Drug List.
You are enrolled in the Aetna Four Tier Open Value Plus
formulary plan.
This guide provides helpful information about your pharmacy
benefits plan. You may want to take this guide with you when
you see your doctor to talk about what is covered under your
plan and what you can expect to pay for your medicine.
Many commonly prescribed drugs are listed in this guide. Please
remember this is not a complete list of drugs covered under your
plan. Because thousands of drugs are included in your pharmacy
benefits plan, we only list the most commonly prescribed ones.
Here’s what that means to you:
Think of tier as a level. Four Tier means you could pay four
different amounts, depending on the drug you take.
A formulary is a list of generic and brand-name drugs that your
health plan covers. An open formulary means your plan covers
most prescription drugs. But it may not cover some others.
What can I expect to pay?
With this health benefits and health insurance plan, the amount
you pay depends on the drug your doctor prescribes. It’s either
a flat fee or a percent of the prescription’s price.
What you pay falls into one of these tiers or levels:
Tier One: Preferred Generic – You pay the lowest cost for
drugs in this level. Your plan may include an additional benefit
where some Tier 1 drugs would be provided at an even lower
cost to you. These are considered Value Drugs/Tier 1a and
include generics and some over-the-counter brand and generic
products. These would be available at the lowest cost share
indicated in your plan materials.
Tier Two: Preferred Brand – You pay a slightly higher cost
for drugs in this level.
Tier Three: Non-Preferred Brand and Generic – You pay
the highest cost for drugs in this level.
Tier Four: All Specialty – You pay the highest cost for specialty
drugs in this level. Specialty drugs may be injected, infused or
taken by mouth.
To find your exact costs
Check your Plan Design and Benefits summary. This should be
in your enrollment kit.
Your pharmacy benefits plan may include a program that
encourages you to choose a generic drug over a brand-name
drug, in order to help reduce what you pay. This means that
if you fill a brand-name drug when a generic is available, that
in addition to your standard copay or coinsurance, you must
also pay the difference in cost between the brand-name and
generic drug.
For a summary of your pharmacy benefits plan, including
out-of-pocket costs, visit www.aetna.com and log in to Aetna
Navigator. Or call the toll-free number on your member ID card.
www.aetna.com/formulary
Where can I find more formulary information?
Why is the formulary subject to change?
You and your doctor can search for a drug, find out if it’s covered
and see what tier it falls under. You can also see if there are
alternatives that cost less. Make sure your doctor knows that
you pay more for two, three and four tier drugs. He or she
can consider this before writing a prescription.
We may add or remove drugs for certain reasons. We might
also move a drug from one coverage tier to another.
Take these steps:
1.Visit www.aetna.com/formulary. You arrive at a page that
says “Medication Search.”
2.This is where you can learn more about the types of
drug coverage reviews your drug requires; things like
precertification, step therapy or quantity limits. You will
arrive at a menu page where you can view various drug lists,
including your Aetna Pharmacy Plan Drug List and more.
How is the formulary developed?
Aetna’s Pharmacy and Therapeutics (P&T) Committee meets
regularly to review new drugs and new information about
drugs that are already on the market. It reviews available
information concerning safety, effectiveness and current use
in therapy. The P&T Committee reviews scientific evidence,
including relevant findings of federal government agencies,
pharmaceutical manufacturers, medical professional
associations, national commissions and peer-reviewed journals.
Our P&T Committee includes licensed pharmacists and doctors,
including those who are currently in practice and others who are
Aetna employees. All committee members must tell us if they
are in a situation that can create a conflict of interest or if they
have a financial stake that might affect their decisions.
Once the P&T Committee completes its clinical review, we
also consider overall value (including cost and manufacturer
rebate arrangements) and other factors before adding or
removing a drug from the formulary. Aetna Pharmacy Plan
Drug List shows you recent changes to the guide. For example,
it could show what drugs started requiring coverage reviews like
precertification, step therapy or quantity limits. Or which drugs
no longer do. The P&T Committee can make recommendations
to change the tier level of a drug or to place it on our Formulary
Exclusions List, designating it as a drug that is no longer covered.
Here are some reasons why:
•As brand-name drugs lose their patents and generic versions
become available, the brand-name may be covered at a higher
out-of-pocket cost while the generic may be covered at a lower
out-of-pocket cost.
•The Food and Drug Administration (FDA) approves many
new drugs throughout the year.
•Drugs can be withdrawn from the market or may become
available without a prescription.
Our website, www.aetna.com/formulary, reflects the most
up-to-date formulary information – so please visit it often.
Why do some drugs require prior authorization
or precertification?
This drug coverage review encourages appropriate and costeffective use of prescription drugs by allowing coverage only
when certain conditions are met.
Reasons for precertification include:
•Compliance with dosing guidelines
•Avoiding duplicate therapies
•Helping health care providers check that a drug is being
used based on generally accepted medical criteria
The precertification program is based upon current medical
findings, FDA-approved manufacturer labeling information,
and cost and manufacturer rebate arrangements.
If your plan requires precertification, you will find a list of drugs
that are subject to precertification with this guide. Please keep
the following in mind:
•Your doctor must contact Aetna to request approval of
coverage for these drugs.
•If we approve the request, we will notify your doctor. The
drug will then be covered at the applicable out-of-pocket
cost under your plan. You will also be notified of approvals
where the state requires notification to members.
If the request is denied, you and your doctor will be notified.
You can still purchase the drug, but for the full price.
Why do some drugs have quantity limits?
Saving on prescriptions
This drug coverage review limits coverage of quantities for
certain drugs. These limits help your doctor and pharmacist
check that your prescribed drug is used correctly and safely.
Here are some other tips to pay less out of pocket for your
prescription drugs:
We use medical guidelines and FDA-approved recommendations
from drug makers to set these coverage limits. The quantity limit
program includes:
•Dose Efficiency Edits – Limit coverage of prescriptions to one
dose per day for drugs that are approved for once-daily dosing.
•Maximum Daily Dose – A message is sent to the pharmacy
if a prescription is less than the minimum or higher than the
maximum allowed dose.
•Quantity Limits Over Time – Limit coverage of prescriptions
to a specific number of units in a defined amount of time.
What is step therapy?
This drug coverage review promotes the appropriate use
of equally effective but lower-cost drugs first. Prerequisite
drugs are FDA-approved and treat the same condition as
the corresponding step therapy drugs.
What is therapeutic duplication?
Therapeutic duplication means that two or more drugs of
the same type are prescribed at the same time. This can occur
when two doctors prescribe similar drugs or when your doctor
switches from one drug to another drug in the same class
without cancelling the first prescription.
It is rare that you should ever need two drugs from the same
class to treat a medical condition. Since serious side effects
may occur, we help bring such duplications to your pharmacist’s
and doctor’s attention.
Learn more about drug coverage reviews
If you have a medical need for a drug that requires precertification,
quantity limits or step therapy, your doctor can ask for a medical
exception. The list of drugs requiring precertification, quantity
limits or step therapy is subject to change. Find the most
up-to-date information at www.aetna.com/formulary.
You may be able to save with generic drugs
Generic drugs are approved by the U.S. Food and Drug
Administration (FDA) and proven to be just as safe and effective
as brand-name drugs. They contain the same active ingredients
in the same amounts as the brand-name products. The
difference is that generics may be a different color, shape or size.
When appropriate, your doctor may decide to prescribe, or allow
substitution with, a generic drug. Please talk to your doctor to
find out if a generic is right for you.
•Ask your doctor to consider prescribing generic drugs
instead of brand-name drugs.
•Ask your doctor to consider prescribing drugs that are
on the Aetna Pharmacy Plan Drug List.
•Check to see if your plan includes our mail-order pharmacy
service. Depending upon your plan, mail order may save you
money. See Aetna Rx Home Delivery® in this guide for details.
•Remind your doctor to check your plan to make sure you
get maximum coverage.
What is Aetna Rx Home Delivery?
Check your plan documents to see if your plan includes
our Aetna Rx Home Delivery mail-order pharmacy. It fills
prescriptions for maintenance medicine. This type of medicine
is used regularly, to treat conditions like arthritis, asthma,
diabetes or high cholesterol. If you need this type of drug, you
can get up to a 90-day supply, or the maximum supply allowed
by your plan, and free delivery right to your mailbox.
You also get:
•Quick, confidential service
•Free standard shipping
•Pharmacists who check all prescriptions for accuracy
and can answer questions any time
It’s easy and fast to order – choose one of these ways:
1. Mail – Get a new prescription from your doctor. Mail
your new prescription to Aetna Rx Home Delivery with
a completed order form. You can access the form online.
Visit www.aetna.com and log in to Aetna Navigator,
your secure member website. Or you can go right to
www.aetnanavigator.com. Once logged in, click the
link to “Aetna Pharmacy”.
2. F
ax – Give your doctor the Aetna Rx Home Delivery fax
number: 1-877-270-3317. Your doctor can fax in the
prescription. Make sure your doctor includes your member
ID number, your date of birth and your mailing address on
the fax cover sheet. Only a doctor may fax a prescription.
3. Phone – To help make it easy to get started, you can also
choose to use our Aetna Rx Courtesy Start SM program. Call
the toll-free number on your member ID card. Ask us to reach
out to your doctor. We can request a new 90-day prescription
on your behalf. Your doctor may need you to schedule a visit
before he or she will write you a new prescription. After we
reach out to your doctor, please allow time (up to 7 days) for
us to receive a reply. To help this process move quickly, please
alert your doctor to expect our call.
If your prescription is for a controlled medicine, a written
prescription from your doctor may be needed.
Generally, if your order is complete, you will receive your
medicine within 10-14 days from when Aetna Rx Home Delivery
receives your order. You can request expedited delivery for an
additional charge.
What is Aetna Specialty Pharmacy?
Aetna Specialty Pharmacy is Aetna’s in-house specialty
pharmacy. It can fill your prescription specialty medicine.
These types of drugs may be injected, infused or taken by
mouth. Specialty medicine often needs special storage and
handling. It must be delivered quickly. And a nurse or pharmacist
should monitor you during your treatment. Use Aetna Specialty
Pharmacy to get this medicine sent right to your mailbox.
You also get:
•Free delivery that is reliable, secure and sent anywhere
you choose
•Extra help when you need it – like injection training and
side effect monitoring
•Proactive outreach to confirm your refills
•Free standard supplies
•Nurses and pharmacists who can help you 24 hours a day,
every day
It’s easy and fast to order – choose one of these ways:
•Fax – Your doctor may fax your prescription to
1-866-FAX-ASRX (1-866-329-2779).
•Mail – You or your doctor may mail your prescription order to:
Aetna Specialty Pharmacy, 503 Sunport Lane, Orlando, FL 32809.
If you mail in your own prescription, please send it along with
a completed Patient Profile Form. To access this form, visit
www.AetnaSpecialtyRx.com and click “Specialty pharmacy:
How to enroll.”
•Phone – Your doctor may also call and speak to one
of our registered pharmacists at 1-866-782-ASRX
(1-866-782-2779) during normal business hours of
8 a.m. until 7 p.m. ET.
To transfer an existing prescription order to be filled by
Aetna Specialty Pharmacy, call toll-free at 1-866-353-1892.
Need more information?
Visit www.aetna.com/formulary or call the
appropriate toll-free number on your member ID card.
Please note that if your prescription drug benefits plan changes, the information herein may no longer apply.
A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor for covered prescriptions except as required by law
to be otherwise. Some drugs on the Preferred Drug List are subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That
means it may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug.
Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York,
Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In
Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. Aetna Pharmacy
Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary
of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment.
Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features
and availability may vary by location and are subject to change.
SP – Drugs listed are managed by our Aetna’s Specialty Health Care Management SM nurse team. Members receive the support of this team throughout the entire
course of therapy. This team employs a “split fill” dispensing provision. This means that half of a one month’s supply of medicine is filled at a time. Split fill
dispensing allows the nurse team to offer more support, including more follow up to monitor response to treatment and potential reactions or side-effects. This
helps prevent wasted medicine and saves members money if their medicine or dose changes between fills. This list is not all-inclusive and is subject to change.
Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna’s Preferred Drug List. Rebates do not reduce the amount a
member pays the pharmacy for covered prescriptions. Information is subject to change. For more information about Aetna plans, refer to www.aetna.com.
The drugs on the Preferred Drug List, Formulary Exclusions, Precertification, Quantity Limit and Step Therapy Lists are subject to change. The quantity limits and
step therapy drug coverage review programs are not available in all service areas. For example, step therapy programs do not apply to fully-insured members in
Indiana. Step therapy does not apply to fully-insured members in New Jersey. However, these programs are available to self-funded plans.
In accordance with state law, commercial fully-insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving
coverage for medications that are added or removed from the Preferred Drug List, Precertification, Quantity Limits or Step-Therapy Lists during the plan year will
continue to have those medications covered at the same benefit level until their plan’s renewal date. In Texas, precertification approval is known as “pre-service
utilization review.” It is not “verification” as defined by Texas law.
In accordance with state law, fully-insured Commercial California HMO members (except Federal Employee Health Benefit Plan members) who are receiving
coverage for medications that are added to the Precertification or Step-therapy Lists will continue to have those medications covered, for as long as the treating
physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical
condition. In accordance with state law, fully-insured Commercial Connecticut PPO members (except Federal Employee Health Benefit Plan members) who are
receiving coverage for medications that are added to the Precertification or Step-therapy Lists will continue to have those medications covered for as long as the
treating physician prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall
preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this
section be construed to prohibit generic drug substitutions.
This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan
documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are
subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide
care or guarantee access to health services. Information is subject to change. For more information about Aetna plans, refer to www.aetna.com.
www.aetna.com
©2015 Aetna Inc.
05.05.352.1 G (8/15)
2015 Aetna Pharmacy Plan Drug List ‐ Four Tier Open Value Plus Plan
Table of Contents
Table of Contents
*ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS* ....................................................................................................................................................................................... 3
*AMEBICIDES* ........................................................................................................................................................................................................................................................................................................................ 5
*AMINOGLYCOSIDES* .................................................................................................................................................................................................................................................................................................. 5
*ANALGESICS ‐ ANTI‐INFLAMMATORY* ................................................................................................................................................................................................................................................ 6
*ANALGESICS ‐ NONNARCOTIC* ..................................................................................................................................................................................................................................................................... 8
*ANALGESICS ‐ OPIOID* ............................................................................................................................................................................................................................................................................................. 8
*ANDROGENS‐ANABOLIC* .................................................................................................................................................................................................................................................................................. 11
*ANORECTAL AGENTS* ........................................................................................................................................................................................................................................................................................... 12
*ANTHELMINTICS* ........................................................................................................................................................................................................................................................................................................ 12
*ANTIANGINAL AGENTS* ...................................................................................................................................................................................................................................................................................... 12
*ANTIANXIETY AGENTS* ........................................................................................................................................................................................................................................................................................ 13
*ANTIARRHYTHMICS* ............................................................................................................................................................................................................................................................................................... 13
*ANTIASTHMATIC AND BRONCHODILATOR AGENTS* .................................................................................................................................................................................................... 14
*ANTICOAGULANTS* ................................................................................................................................................................................................................................................................................................. 16
*ANTICONVULSANTS* .............................................................................................................................................................................................................................................................................................. 16
*ANTIDEPRESSANTS* ................................................................................................................................................................................................................................................................................................. 19
*ANTIDIABETICS* ............................................................................................................................................................................................................................................................................................................ 21
*ANTIDIARRHEALS* ..................................................................................................................................................................................................................................................................................................... 24
*ANTIDOTES* ....................................................................................................................................................................................................................................................................................................................... 25
*ANTIEMETICS* ................................................................................................................................................................................................................................................................................................................. 25
*ANTIFUNGALS* ............................................................................................................................................................................................................................................................................................................... 25
*ANTIHISTAMINES* ..................................................................................................................................................................................................................................................................................................... 26
*ANTIHYPERLIPIDEMICS* ..................................................................................................................................................................................................................................................................................... 27
*ANTIHYPERTENSIVES* ........................................................................................................................................................................................................................................................................................... 28
*ANTI‐INFECTIVE AGENTS ‐ MISC.* .......................................................................................................................................................................................................................................................... 31
*ANTIMALARIALS* ........................................................................................................................................................................................................................................................................................................ 32
*ANTIMYASTHENIC/CHOLINERGIC AGENTS* .............................................................................................................................................................................................................................. 32
*ANTIMYCOBACTERIAL AGENTS* .............................................................................................................................................................................................................................................................. 32
*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* ........................................................................................................................................................................................................... 33
*ANTIPARKINSON AGENTS* .............................................................................................................................................................................................................................................................................. 35
*ANTIPSYCHOTICS/ANTIMANIC AGENTS* ...................................................................................................................................................................................................................................... 36
*ANTIVIRALS* ...................................................................................................................................................................................................................................................................................................................... 38
*ASSORTED CLASSES* ............................................................................................................................................................................................................................................................................................... 41
*BETA BLOCKERS* .......................................................................................................................................................................................................................................................................................................... 42
*CALCIUM CHANNEL BLOCKERS* ............................................................................................................................................................................................................................................................... 43
*CARDIOTONICS* ........................................................................................................................................................................................................................................................................................................... 45
*CARDIOVASCULAR AGENTS ‐ MISC.* .................................................................................................................................................................................................................................................. 45
*CEPHALOSPORINS* ................................................................................................................................................................................................................................................................................................... 46
*CHEMICALS* ...................................................................................................................................................................................................................................................................................................................... 46
*CONTRACEPTIVES* .................................................................................................................................................................................................................................................................................................... 46
*CORTICOSTEROIDS* ................................................................................................................................................................................................................................................................................................. 51
*COUGH/COLD/ALLERGY* .................................................................................................................................................................................................................................................................................. 51
*DERMATOLOGICALS* ............................................................................................................................................................................................................................................................................................. 52
*DIAGNOSTIC PRODUCTS* ................................................................................................................................................................................................................................................................................. 60
*DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS* ................................................................................................................................................................................ 61
*DIGESTIVE AIDS* .......................................................................................................................................................................................................................................................................................................... 62
*DIURETICS* .......................................................................................................................................................................................................................................................................................................................... 63
*ENDOCRINE AND METABOLIC AGENTS ‐ MISC.* ................................................................................................................................................................................................................. 64
*ESTROGENS* ..................................................................................................................................................................................................................................................................................................................... 66
*FLUOROQUINOLONES* ........................................................................................................................................................................................................................................................................................ 67
1
Table of Contents
*GASTROINTESTINAL AGENTS ‐ MISC.* .............................................................................................................................................................................................................................................. 68
*GENITOURINARY AGENTS ‐ MISCELLANEOUS* ...................................................................................................................................................................................................................... 69
*GOUT AGENTS* .............................................................................................................................................................................................................................................................................................................. 70
*HEMATOLOGICAL AGENTS ‐ MISC.* .................................................................................................................................................................................................................................................... 70
*HEMATOPOIETIC AGENTS* ............................................................................................................................................................................................................................................................................. 71
*HEMOSTATICS* .............................................................................................................................................................................................................................................................................................................. 72
*HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS* ...................................................................................................................................................................................................... 72
*LAXATIVES* ......................................................................................................................................................................................................................................................................................................................... 73
*MACROLIDES* ................................................................................................................................................................................................................................................................................................................. 74
*MEDICAL DEVICES* ................................................................................................................................................................................................................................................................................................... 74
*MIGRAINE PRODUCTS* ........................................................................................................................................................................................................................................................................................ 79
*MINERALS & ELECTROLYTES* ...................................................................................................................................................................................................................................................................... 80
*MOUTH/THROAT/DENTAL AGENTS* .................................................................................................................................................................................................................................................. 80
*MULTIVITAMINS* ........................................................................................................................................................................................................................................................................................................ 81
*MUSCULOSKELETAL THERAPY AGENTS* ........................................................................................................................................................................................................................................ 82
*NASAL AGENTS ‐ SYSTEMIC AND TOPICAL* ............................................................................................................................................................................................................................... 82
*NEUROMUSCULAR AGENTS* ........................................................................................................................................................................................................................................................................ 83
*OPHTHALMIC AGENTS* ....................................................................................................................................................................................................................................................................................... 83
*OTIC AGENTS* ................................................................................................................................................................................................................................................................................................................. 86
*OXYTOCICS* ....................................................................................................................................................................................................................................................................................................................... 87
*PASSIVE IMMUNIZING AGENTS* ............................................................................................................................................................................................................................................................. 87
*PENICILLINS* ..................................................................................................................................................................................................................................................................................................................... 87
*PHARMACEUTICAL ADJUVANTS* ............................................................................................................................................................................................................................................................ 87
*PROGESTINS* ................................................................................................................................................................................................................................................................................................................... 87
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC.* ........................................................................................................................................................................ 88
*RESPIRATORY AGENTS ‐ MISC.* ................................................................................................................................................................................................................................................................ 90
*SULFONAMIDES* ......................................................................................................................................................................................................................................................................................................... 90
*TETRACYCLINES* .......................................................................................................................................................................................................................................................................................................... 90
*THYROID AGENTS* .................................................................................................................................................................................................................................................................................................... 91
*ULCER DRUGS* ............................................................................................................................................................................................................................................................................................................... 92
*URINARY ANTI‐INFECTIVES* .......................................................................................................................................................................................................................................................................... 94
*URINARY ANTISPASMODICS* ....................................................................................................................................................................................................................................................................... 94
*VACCINES* ........................................................................................................................................................................................................................................................................................................................... 95
*VAGINAL PRODUCTS* ............................................................................................................................................................................................................................................................................................ 95
*VASOPRESSORS* .......................................................................................................................................................................................................................................................................................................... 95
*VITAMINS* ........................................................................................................................................................................................................................................................................................................................... 96
2
2015 Aetna Pharmacy Plan Drug List ‐ Four Tier Open Value Plus Plan
lowercase italics = Generic drugs
UPPERCASE = Brand name drugs
Drug Name
Drug Details
# = Brand‐name drug expected to become available generically in the near future
AL = Age Limit
Drug Status
CE = Available to some members at = no cost with a prescription from your = provider when obtained at an = in‐network pharmacy. Certain CE = Copay Exception: limitations may apply.
Available to some N1 = 3 Copays Required
members at no cost with a N2 = Not Available for 90 day supply
prescription from your N3 = Step Therapy Not Applicable in provider when obtained at NJ
an in‐network pharmacy. N4 = Covered in NJ, IN
Certain limitations may PA = Prior Authorization Applies
apply.
QL = Quantity Limit
LA = Limited Access ‐ Select OTC = Select OTC Program if Covered In Listed States
your pharmacy plan includes this Tier 1 = Preferred Generic program you may have coverage for Tier 2 = Preferred Brand
products noted with a doctors Tier 3 = Non Preferred prescription. Please see your plan Drug
benefit information for specific Tier 4 = Specialty
coverage details.
Tier 6 = Not Covered SF = Split Fill Applies
Unless Noted Otherwise
ST = Step Therapy
Drug Status
Drug Details
*ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXI
ANTS*
ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG
Tier 3
QL
ADDERALL XR
Tier 3
ST; N3; QL; AL
ADIPEX‐P ORAL TABLET
Tier 3
ALLI
Tier 3
amphetamine‐dextroamphet er
Tier 1
PA; QL
2015 Aetna Pharmacy Plan Drug List‐ Four Tier Open Value Plus Plan
(Updated 08/01/2015)
3
Drug Name
Drug Status
Drug Details
amphetamine‐dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg
Tier 1
QL
APTENSIO XR
Tier 3
PA; ST; QL
BELVIQ
Tier 6
benzphetamine hcl
LA
Covered in DC
CAFCIT ORAL
Tier 3
clonidine hcl er
Tier 1
PA; QL
CONCERTA ORAL TABLET EXTENDEDRELEASE* 18 MG, 27 MG, 36 MG, 54 MG
Tier 3
ST; N2; N3; QL; AL
CONTRAVE
LA
DAYTRANA
Tier 3
PA; ST; N2; N3; #; QL; AL
DESOXYN
Tier 3
N2; QL
DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR
Tier 3
PA; ST; N2; N3; QL
dexmethylphenidate hcl
Tier 1
N2; QL
dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 5 mg
Tier 1
PA; QL
dexmethylphenidate hcl er oral capsule extended release 24 hour 15 mg, 30 mg, 40 mg
Tier 1
PA; N2; QL; AL
dextroamphetamine sulfate er
Tier 1
N2; QL
dextroamphetamine sulfate oral solution
Tier 1
QL
dextroamphetamine sulfate oral tablet
Tier 1
PA; N2; QL
DIDREX
Tier 3
diethylpropion hcl er
LA
Covered in DC
diethylpropion hcl oral
LA
Covered in DC
EVEKEO
Tier 3
PA; ST; QL
FOCALIN
Tier 3
PA; ST; N2; N3; QL
FOCALIN XR
Tier 3
ST; N2; N3; #; QL; AL
INTUNIV
Tier 3
PA; ST; N3; #; QL
KAPVAY ORAL TABLET EXTENDED RELEASE 12 HR*
Tier 3
PA; N3; QL
METADATE CD ORAL CAPSULE EXTENDED RELEASE* 10 MG, 20 MG, 30 MG, 40 MG, 50 MG
Tier 3
ST; N2; N3; QL
METADATE CD ORAL CAPSULE EXTENDED RELEASE* 60 MG
Tier 3
ST; N2; N3; QL; AL
METADATE ER
Tier 1
N2; QL
methamphetamine hcl
Tier 1
QL
METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML
Tier 3
QL
METHYLIN ORAL TABLET CHEWABLE
Tier 3
ST; N3; QL
methylphenidate hcl er (cd)
Tier 1
N2; QL; AL
methylphenidate hcl er (la)
Tier 1
(Updated 08/01/2015)
4
QL
Drug Name
Drug Status
Drug Details
methylphenidate hcl er oral tablet extendedrelease*
18 mg, 27 mg, 36 mg, 54 mg
Tier 1
N2; QL; AL
methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml
Tier 1
QL
methylphenidate hcl oral tablet
Tier 1
N2; QL
methylphenidate hcl oral tablet chewable
Tier 3
PA; QL
modafinil
Tier 1
PA; N2; QL
NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG
Tier 3
PA; N2; QL
phendimetrazine tartrate
LA
Covered in DC
phendimetrazine tartrate er
LA
Covered in DC
phentermine hcl oral
LA
Covered in DC
PROCENTRA
Tier 3
PA; N3; QL
PROVIGIL
Tier 3
PA; N2; QL
QSYMIA
LA
QUILLIVANT XR
N2; Covered in DC
Tier 3
PA; N2; N3; QL
REGIMEX
LA
Covered in DC
RITALIN
Tier 3
PA; ST; N2; N3; QL
RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 30 MG, 40 MG
Tier 3
N2; N3; QL; AL
RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 60 MG
Tier 3
QL
RITALIN SR
Tier 3
PA; ST; N2; N3; QL
SAXENDA
CE
PA
Tier 2
QL
STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG
SUPRENZA
LA
Covered in DC
VYVANSE ORAL CAPSULE 10 MG
Tier 2
QL
VYVANSE ORAL CAPSULE 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG
Tier 2
N2; QL
XENICAL
LA
Covered in DC
ZENZEDI ORAL TABLET 10 MG, 5 MG
Tier 1
N2; QL
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG
Tier 6
N4
Tier 2
N2
*AMEBICIDES*
YODOXIN
*AMINOGLYCOSIDES*
BETHKIS
Tier 4
neomycin sulfate oral
Tier 1
N2
paromomycin sulfate oral
Tier 1
N2
(Updated 08/01/2015)
5
Drug Name
Drug Status
Drug Details
TOBI
Tier 4
N2; QL
TOBI PODHALER
Tier 4
PA; N2; QL
tobramycin inhalation
Tier 4
N2; QL
ACTEMRA SUBCUTANEOUS*
Tier 4
PA; N2; QL
ANAPROX
Tier 3
ANAPROX DS
Tier 3
ARAVA
Tier 3
QL
ARCALYST
Tier 4
PA; N2
ARTHROTEC
Tier 3
CATAFLAM
Tier 3
CELEBREX
Tier 3
ST; #; QL
celecoxib oral
Tier 3
ST; QL
childrens ibuprofen 100
Tier 1
DAYPRO
Tier 3
diclofenac potassium
Tier 1
diclofenac sodium er
Tier 1
diclofenac sodium oral tablet delayed release 25 mg, 50 mg
Tier 1
diclofenac sodium oral tablet delayed release 75 mg
Tier 1
diclofenac‐misoprostol
Tier 1
DUEXIS
Tier 6
EC‐NAPROSYN
Tier 3
ENBREL SUBCUTANEOUS* 25 MG/0.5ML, 50 MG/ML
Tier 4
PA; QL
ENBREL SUBCUTANEOUS* KIT
Tier 4
PA; N2; QL
ENBREL SURECLICK
Tier 4
PA; QL
etodolac er
Tier 1
etodolac oral
Tier 1
FELDENE
Tier 3
fenoprofen calcium oral
Tier 1
flurbiprofen oral
Tier 1
HUMIRA PEDIATRIC CROHNS START
Tier 4
PA; QL
HUMIRA PEN
Tier 4
PA; QL
HUMIRA PEN‐CROHNS STARTER
Tier 4
PA; QL
HUMIRA PEN‐PSORIASIS STARTER
Tier 4
PA; QL
HUMIRA SUBCUTANEOUS* 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML
Tier 4
PA; QL
IBUPROFEN COMFORT PAC
Tier 6
N4
*ANALGESICS ‐ ANTI‐INFLAMMATORY*
(Updated 08/01/2015)
6
Lowest Generic Copay Applies
N4; QL
Drug Name
Drug Status
Drug Details
ibuprofen oral suspension
Tier 1
ibuprofen oral tablet 200 mg
Tier 1
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
Tier 1
IC 400
Tier 6
N4
IC 800
Tier 6
N4
ILARIS
Tier 4
PA; N2; QL
INDOCIN
Tier 3
INDOCIN ORAL
Tier 2
indomethacin er
Tier 1
indomethacin oral
Tier 1
ketoprofen er
Tier 1
ketoprofen oral
Tier 1
ketorolac tromethamine oral
Tier 1
N2; QL
leflunomide oral
Tier 1
N2; QL
meclofenamate sodium oral
Tier 1
mefenamic acid oral
Tier 3
MELOXICAM COMFORT PAC
Tier 6
meloxicam oral suspension
Tier 1
meloxicam oral tablet
Tier 1
MOBIC
Tier 3
nabumetone oral
Tier 1
NALFON
Tier 3
NAPRELAN
Tier 3
NAPROSYN
Tier 3
NAPROXEN COMFORT PAC
Tier 6
naproxen dr
Tier 1
naproxen oral suspension
Tier 1
naproxen oral tablet
Tier 1
naproxen sodium er
Tier 3
naproxen sodium oral tablet 275 mg
Tier 1
naproxen sodium oral tablet 550 mg
Tier 1
OTEZLA ORAL
Tier 4
PA; N2; QL
OTEZLA ORAL TABLET
Tier 4
PA; N2; QL
OTREXUP
Tier 4
PA; ST; N4
oxaprozin
Tier 1
piroxicam oral
Tier 1
PONSTEL
Tier 3
RASUVO
Tier 4
N4
N4
PA; ST
(Updated 08/01/2015)
7
Drug Name
Drug Status
Drug Details
RIDAURA
Tier 2
SIMPONI
Tier 4
PA; QL
SPRIX
Tier 3
N2; QL
sulindac oral
Tier 1
TIVORBEX
Tier 3
tolmetin sodium
Tier 1
VIMOVO
Tier 6
VOLTAREN‐XR
Tier 3
XELJANZ
Tier 4
PA; N2; QL
ZIPSOR
Tier 3
N4
ZORVOLEX
Tier 3
QL
ANACIN ORAL TABLET DELAYED RELEASE
CE
CE
ARTHRITIS PAIN REGIMEN EX ST
CE
CE
BAYER ADVANCED ASPIRIN EX ST
CE
CE
BAYER ADVANCED ASPIRIN REG ST
CE
CE
BAYER ASPIRIN REGIMEN
CE
CE
BAYER LOW DOSE ORAL TABLET DELAYED RELEASE
CE
CE
BAYER LOW STRENGTH
CE
QL
N4
*ANALGESICS ‐ NONNARCOTIC*
butalbital‐acetaminophen
Tier 1
butalbital‐apap‐caffeine oral capsule 50‐300‐40 mg
Tier 1
N2
butalbital‐apap‐caffeine oral tablet 50‐325‐40 mg
Tier 1
N2
butalbital‐asa‐caffeine
Tier 1
N2
choline‐mag trisalicylate
Tier 1
diflunisal oral
Tier 1
ECOTRIN
CE
CE
eq aspirin low dose
CE
CE
Tier 3
N2
CE
CE
FIORINAL
HALFPRIN ORAL TABLET DELAYED RELEASE 162 MG
salsalate oral
Tier 1
TYLENOL ORAL TABLET
Tier 3
*ANALGESICS ‐ OPIOID*
ABSTRAL
Tier 3
PA; N2
acetaminophen‐codeine
Tier 1
N2
acetaminophen‐codeine #2
Tier 1
N2
Tier 1
N2
Tier 1
N2
ACTIQ
Tier 3
PA; N2; QL
(Updated 08/01/2015)
8
Drug Name
Drug Status
Drug Details
AVINZA
Tier 3
PA; ST; N2; N3; QL
BUNAVAIL BUCCAL FILM 2.1‐0.3 MG, 4.2‐0.7 MG, 6.3‐1 MG
Tier 3
PA; QL
buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg
Tier 1
PA; N2; QL
buprenorphine hcl‐naloxone hcl
Tier 1
PA; N2; QL
butalbital‐apap‐caff‐cod
Tier 1
N2
butorphanol tartrate nasal
Tier 3
N2; QL
BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR
Tier 2
N2; QL
BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR
Tier 2
QL
codeine sulfate oral solution 30 mg/5ml
Tier 1
N2
codeine sulfate oral tablet
Tier 1
N2
CONZIP
Tier 6
N4
DEMEROL ORAL
Tier 3
N2
DILAUDID ORAL TABLET
Tier 3
N2
DOLOPHINE
Tier 3
N2
DURAGESIC‐100
Tier 3
PA; N2; QL
DURAGESIC‐12
Tier 3
PA; N2; QL
DURAGESIC‐25
Tier 3
PA; N2; QL
DURAGESIC‐50
Tier 3
PA; N2; QL
DURAGESIC‐75
Tier 3
PA; N2; QL
EMBEDA
Tier 3
PA; ST; QL
EXALGO
Tier 3
PA; N2; QL
fentanyl citrate buccal
Tier 3
PA; N2; QL
fentanyl transdermal patch 72 hr 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
Tier 3
N2; QL
fentanyl transdermal patch 72 hr 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr
Tier 3
QL
FENTORA
Tier 3
PA; N2; QL
FIORINAL/CODEINE #3
Tier 3
N2
hydrocodone‐acetaminophen oral tablet 10‐325 mg, 2.5‐325 mg, 5‐325 mg, 7.5‐325 mg
Tier 1
N2
hydrocodone‐acetaminophen oral tablet 5‐300 mg, 7.5‐300 mg
Tier 3
N2
hydrocodone‐ibuprofen oral tablet 7.5‐200 mg
Tier 1
N2
hydromorphone hcl er oral 32 mg
Tier 3
PA; QL
hydromorphone hcl oral liquid†
Tier 3
N2
hydromorphone hcl oral tablet
Tier 1
N2
(Updated 08/01/2015)
9
Drug Name
Drug Status
Drug Details
HYSINGLA ER
Tier 3
PA; ST; QL
KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG
Tier 3
PA; N2; N3; QL
LAZANDA
Tier 3
PA; N2; QL
levorphanol tartrate oral
Tier 3
meperidine hcl oral tablet
Tier 1
N2
meperitab oral tablet 50 mg
Tier 1
N2
methadone hcl oral tablet
Tier 1
N2
methadone hcl oral tablet soluble
Tier 1
N2
METHADOSE ORAL TABLET
Tier 1
N2
morphine sulfate er
Tier 1
N2
morphine sulfate er beads
Tier 1
morphine sulfate oral solution 10 mg/5ml
Tier 1
N2
morphine sulfate oral tablet 15 mg
Tier 1
N2
MS CONTIN
Tier 3
N2
NUCYNTA
Tier 3
ST; N2; N3; QL
NUCYNTA ER
Tier 3
PA; N2; N3; QL
OPANA ER ORAL
Tier 2
QL
OPANA ORAL
Tier 3
ST; N2; N3
oxycodone hcl er
Tier 1
QL
oxycodone hcl oral capsule
Tier 1
N2
oxycodone hcl oral tablet
Tier 1
N2
OXYCONTIN
Tier 3
PA; N2; N3; QL
oxymorphone hcl
Tier 3
ST; N3
oxymorphone hcl er
Tier 1
QL
PERCOCET ORAL TABLET 10‐325 MG, 2.5‐325 MG, 5‐325 MG, 7.5‐325 MG
Tier 3
N2
PERCODAN
Tier 3
N2
PRIMLEV
Tier 3
N2
SUBOXONE SUBLINGUAL FILM
Tier 3
PA; N2; QL
SUBSYS
Tier 3
PA; N2; QL
SYNALGOS‐DC
Tier 3
tramadol hcl er oral capsule extended release 24 hour
100 mg, 200 mg, 300 mg
Tier 6
QL
tramadol hcl er oral capsule extended release 24 hour
150 mg
Tier 1
N4
tramadol hcl er oral tablet extended release 24 hr*
Tier 1
N2
tramadol hcl oral
Tier 1
N2
(Updated 08/01/2015)
10
Drug Name
Drug Status
Drug Details
tramadol‐acetaminophen
Tier 1
QL
TREZIX
Tier 3
QL
TYLENOL WITH CODEINE #3
Tier 3
N2
TYLENOL WITH CODEINE #4
Tier 3
N2
ULTRACET
Tier 3
QL
ULTRAM
Tier 3
N2
ULTRAM ER
Tier 3
N2
VICOPROFEN
Tier 3
N2
XARTEMIS XR
Tier 3
ST; N2; N3; QL
XODOL
Tier 3
N2
ZOHYDRO ER ORAL
Tier 3
PA; QL
ZOHYDRO ER ORAL CAPSULE EXTENDED RELEASE 12 HOUR
Tier 3
PA; ST; N2; QL
ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4‐0.36 MG, 5.7‐1.4 MG
Tier 3
PA; N2; N3; QL
ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 8.6‐2.1 MG
Tier 3
PA; ST; QL
*ANDROGENS‐ANABOLIC*
ANADROL‐50
Tier 3
ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR, 4 MG/24HR
Tier 3
PA; ST; N2; N3; N4; #; QL
ANDRODERM TRANSDERMAL PATCH 24 HR 2.5 MG/24HR, 5 MG/24HR
Tier 3
PA; ST
ANDROGEL PUMP TRANSDERMAL 12.5 MG/ACT (1%)
Tier 2
PA; N2; #; QL
ANDROGEL PUMP TRANSDERMAL 20.25 MG/ACT (1.62%)
Tier 2
PA; N2; QL
ANDROGEL TRANSDERMAL 20.25 MG/1.25GM (1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM (1.62%), 50 MG/5GM (1%)
Tier 2
PA; N2; QL
ANDROID
Tier 2
N2
ANDROXY
Tier 1
AXIRON
Tier 3
danazol oral
Tier 1
FORTESTA
Tier 3
PA; ST; N3; N4; QL
NATESTO
Tier 3
PA; ST; QL
OXANDRIN
Tier 3
STRIANT
Tier 3
PA; ST; N3; N4; QL
TESTIM
Tier 2
PA; N2; QL
testosterone cypionate intramuscular* solution 250 mg/ml
Tier 1
QL
PA; N2; N3; N4; QL
(Updated 08/01/2015)
11
Drug Name
Drug Status
Drug Details
testosterone transdermal 10 mg/act (2%), 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)
Tier 3
PA; QL
VOGELXO
Tier 3
PA; ST; N3; N4; QL
VOGELXO PUMP
Tier 3
PA; ST; N3; N4; QL
*ANORECTAL AGENTS*
ANALPRAM‐HC CREAM 1‐1 %
Tier 3
ANALPRAM‐HC LOTION
Tier 3
ANUSOL‐HC CREAM
Tier 3
CORTIFOAM
Tier 2
hydrocortisone cream
Tier 1
lidocaine‐hydrocortisone ace cream
Tier 1
lidocaine‐hydrocortisone ace kit 3‐0.5 %, 3‐1 %
Tier 1
PROCTOCORT CREAM
Tier 3
PROCTOFOAM HC
Tier 3
PROCTOZONE‐HC
Tier 1
RECTIV
Tier 3
QL
UCERIS
Tier 3
ST; QL
*ANTHELMINTICS*
ALBENZA
Tier 3
BILTRICIDE
Tier 2
ivermectin oral
Tier 3
STROMECTOL
Tier 3
*ANTIANGINAL AGENTS*
DILATRATE‐SR
Tier 3
IMDUR
Tier 3
isoditrate er
Tier 1
ISORDIL TITRADOSE
Tier 3
isosorbide dinitrate er
Tier 1
isosorbide dinitrate oral
Tier 1
isosorbide mononitrate
Tier 1
isosorbide mononitrate er
Tier 1
MINITRAN
Tier 1
MONOKET
Tier 3
NITRO‐BID
Tier 3
NITRO‐DUR
Tier 3
nitroglycerin er oral capsule extended release* 9 mg
Tier 1
nitroglycerin transdermal
Tier 1
nitroglycerin translingual aerosol, solution
Tier 3
(Updated 08/01/2015)
12
N2
N2
Drug Name
Drug Status
Drug Details
nitroglycerin translingual solution
Tier 1
NITROLINGUAL
Tier 3
NITROMIST
Tier 3
NITROSTAT
Tier 2
NITRO‐TIME ORAL CAPSULE EXTENDED RELEASE* 9 MG
Tier 1
RANEXA
Tier 2
QL
alprazolam er
Tier 1
N2; QL; AL
ALPRAZOLAM INTENSOL
Tier 3
alprazolam oral
Tier 1
N2; AL
alprazolam xr
Tier 1
N2; QL; AL
ATIVAN ORAL
Tier 3
N2
buspirone hcl oral tablet 10 mg, 5 mg
Tier 1
buspirone hcl oral tablet 15 mg, 30 mg, 7.5 mg
Tier 1
chlordiazepoxide hcl
Tier 1
N2; AL
clorazepate dipotassium
Tier 1
N2; AL
diazepam oral concentrate
Tier 3
diazepam oral solution
Tier 1
diazepam oral tablet
Tier 1
N2
hydroxyzine hcl oral syrup
Tier 1
hydroxyzine hcl oral tablet
Tier 1
hydroxyzine pamoate Tier 1
hydroxyzine pamoate oral capsule 25 mg, 50 mg
Tier 1
lorazepam oral concentrate
Tier 1
lorazepam oral tablet
Tier 1
meprobamate
Tier 1
NIRAVAM
Tier 3
AL
oxazepam
Tier 1
N2; AL
TRANXENE‐T
Tier 3
N2; AL
VALIUM
Tier 3
N2
VISTARIL
Tier 3
XANAX
Tier 3
N2; AL
XANAX XR
Tier 3
N2; QL; AL
*ANTIANXIETY AGENTS*
N2
*ANTIARRHYTHMICS*
amiodarone hcl oral
Tier 1
CORDARONE
Tier 3
disopyramide phosphate oral
Tier 1
(Updated 08/01/2015)
13
Drug Name
Drug Status
flecainide acetate
Tier 1
mexiletine hcl oral
Tier 1
MULTAQ
Tier 3
NORPACE
Tier 3
NORPACE CR
Tier 2
propafenone hcl
Tier 1
propafenone hcl er
Tier 1
quinidine gluconate er
Tier 1
quinidine sulfate er
Tier 1
quinidine sulfate oral
Tier 1
RYTHMOL
Tier 3
RYTHMOL SR
Tier 3
TIKOSYN
Tier 2
Drug Details
QL
QL
QL
*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*
ACCOLATE
Tier 3
ADVAIR DISKUS
Tier 3
PA; ST; N3; QL
ADVAIR HFA
Tier 3
PA; ST; N3; QL
AEROSPAN
Tier 3
PA; N3; QL
albuterol sulfate er
Tier 1
albuterol sulfate inhalation
Tier 1
albuterol sulfate oral
Tier 1
ALVESCO
Tier 3
PA; N3; QL
ANORO ELLIPTA
Tier 3
PA; QL
ARCAPTA NEOHALER
Tier 3
PA; ST; N3; QL
ARNUITY ELLIPTA
Tier 3
PA; ST; QL
ASMANEX 120 METERED DOSES
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
ASMANEX HFA
Tier 2
ATROVENT HFA
Tier 2
QL
BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 100‐25 MCG/INH
Tier 3
PA; ST; N3; QL
BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 200‐25 MCG/INH
Tier 3
PA; ST; QL
BROVANA
Tier 3
PA; ST; N3; QL
budesonide inhalation
Tier 1
PA; AL
(Updated 08/01/2015)
14
Drug Name
Drug Status
Drug Details
COMBIVENT RESPIMAT
Tier 2
QL
cromolyn sodium inhalation
Tier 1
DALIRESP
Tier 3
QL
DULERA
Tier 2
QL
DUONEB
Tier 3
ELIXOPHYLLIN
Tier 3
epinephrine hcl injection solution 1 mg/ml
Tier 1
N2
FLOVENT DISKUS
Tier 3
PA; QL
FLOVENT HFA
Tier 3
PA; ST; N3; QL
FORADIL AEROLIZER
Tier 2
QL
INCRUSE ELLIPTA
Tier 3
PA; ST; QL
ipratropium bromide inhalation
Tier 1
ipratropium‐albuterol
Tier 1
levalbuterol hcl inhalation
Tier 1
LUFYLLIN
Tier 3
metaproterenol sulfate oral
Tier 1
montelukast sodium oral
Tier 1
QL
PERFOROMIST
Tier 3
PA; N3; QL
PROAIR HFA
Tier 2
QL
PROAIR RESPICLICK
Tier 2
QL
PROVENTIL HFA
Tier 3
PA; N3; QL
PULMICORT
Tier 3
PA; ST; N3; AL
PULMICORT FLEXHALER
Tier 3
PA; N3; QL
QVAR
Tier 2
SEREVENT DISKUS
Tier 2
QL
SINGULAIR
Tier 3
QL
SPIRIVA HANDIHALER
Tier 2
QL
SPIRIVA RESPIMAT
Tier 2
QL
STIOLTO RESPIMAT
Tier 2
QL
STRIVERDI RESPIMAT
Tier 3
QL
SYMBICORT
Tier 2
QL
THEO‐24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG
Tier 2
QL
THEO‐24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG, 400 MG
Tier 2
THEOCHRON
Tier 1
theophylline er
Tier 1
theophylline oral solution
Tier 3
(Updated 08/01/2015)
15
Drug Name
Drug Status
Drug Details
TUDORZA PRESSAIR
Tier 3
PA; N3; QL
VENTOLIN HFA
Tier 2
QL
VOSPIRE ER
Tier 3
XOPENEX
Tier 3
XOPENEX CONCENTRATE
Tier 3
XOPENEX HFA
Tier 3
zafirlukast
Tier 1
ZYFLO
Tier 3
ZYFLO CR
Tier 3
PA; ST; N3; QL
*ANTICOAGULANTS*
ARIXTRA
Tier 3
PA; N2; QL
COUMADIN ORAL
Tier 3
ELIQUIS
Tier 2
QL
enoxaparin sodium
Tier 1
PA; N2; QL
fondaparinux sodium
Tier 3
PA; N2; QL
FRAGMIN SUBCUTANEOUS* SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 25000 UNIT/ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML
Tier 3
PA; N2; QL
FRAGMIN SUBCUTANEOUS* SOLUTION 95000 UNIT/3.8ML
Tier 3
PA; QL
heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml
Tier 1
N2; Tier 1 for DE
IPRIVASK
Tier 3
PA
LOVENOX
Tier 3
PA; N2; QL
PRADAXA
Tier 3
ST; N3; QL
SAVAYSA
Tier 3
ST; QL
warfarin sodium oral
Tier 1
XARELTO ORAL TABLET 10 MG, 20 MG
Tier 2
QL
XARELTO ORAL TABLET 15 MG
Tier 2
N3; QL
XARELTO STARTER PACK
Tier 2
QL
APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG
Tier 3
QL
BANZEL ORAL TABLET
Tier 3
QL
carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg
Tier 1
carbamazepine er oral tablet extended release 12 hr*
Tier 1
carbamazepine oral suspension
Tier 1
*ANTICONVULSANTS*
carbamazepine oral tablet
Tier 1
(Updated 08/01/2015)
16
Drug Name
Drug Status
Drug Details
carbamazepine oral tablet chewable
Tier 1
CARBATROL
Tier 2
CELONTIN
Tier 2
clonazepam oral
Tier 1
DEPAKENE
Tier 3
DEPAKOTE
Tier 3
DEPAKOTE ER
Tier 3
DEPAKOTE SPRINKLES
Tier 3
DIASTAT ACUDIAL
Tier 2
QL
DIASTAT PEDIATRIC
Tier 2
QL
diazepam
Tier 1
QL
DILANTIN
Tier 2
DILANTIN INFATABS
Tier 2
divalproex sodium
Tier 1
divalproex sodium er
Tier 1
EPITOL
Tier 1
ethosuximide oral
Tier 1
felbamate
Tier 1
FELBATOL
Tier 3
FYCOMPA
Tier 3
QL
gabapentin oral capsule
Tier 1
QL
gabapentin oral solution
Tier 1
QL
gabapentin oral tablet
Tier 1
QL
GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG
Tier 3
QL
KEPPRA
Tier 3
KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR* 500 MG, 750 MG
Tier 3
QL
KLONOPIN
Tier 3
N2
LAMICTAL
Tier 3
LAMICTAL ODT ORAL KIT
Tier 3
LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 MG, 25 MG, 50 MG
Tier 3
LAMICTAL STARTER
Tier 3
LAMICTAL XR ORAL KIT
Tier 3
LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG
Tier 3
QL
lamotrigine er oral tablet extended release 24 hr* 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg
Tier 1
QL
N2
QL
(Updated 08/01/2015)
17
Drug Name
Drug Status
Drug Details
lamotrigine oral tablet
Tier 1
lamotrigine oral tablet chewable
Tier 3
lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg
Tier 3
QL
levetiracetam er oral tablet extended release 24 hr*
500 mg, 750 mg
Tier 1
QL
levetiracetam oral
Tier 1
LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG
Tier 3
PA; N2; N3; QL
LYRICA ORAL SOLUTION
Tier 3
PA; ST; N2; N3; QL
MYSOLINE
Tier 3
NEURONTIN ORAL CAPSULE
Tier 3
NEURONTIN ORAL SOLUTION
Tier 3
NEURONTIN ORAL TABLET
Tier 3
ONFI ORAL SUSPENSION
Tier 3
ONFI ORAL TABLET 10 MG, 20 MG
Tier 3
oxcarbazepine
Tier 1
OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 300 MG, 600 MG
Tier 3
PEGANONE
Tier 3
PHENYTEK
Tier 2
PHENYTOIN INFATABS
Tier 1
phenytoin oral suspension 125 mg/5ml
Tier 1
phenytoin oral tablet chewable
Tier 1
phenytoin sodium extended
Tier 1
POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG
Tier 3
primidone oral
Tier 1
QUDEXY XR
Tier 3
QL
SABRIL
Tier 4
PA; N2; QL
STAVZOR
Tier 6
N4
TEGRETOL ORAL SUSPENSION
Tier 2
TEGRETOL ORAL TABLET
Tier 2
TEGRETOL‐XR
Tier 2
tiagabine hcl oral tablet 2 mg, 4 mg
Tier 1
TOPAMAX
Tier 3
TOPAMAX SPRINKLE
Tier 3
TOPIRAGEN
Tier 1
topiramate oral capsule sprinkle
Tier 1
(Updated 08/01/2015)
18
QL
QL
QL
QL
QL
QL
QL
QL
Drug Name
Drug Status
Drug Details
topiramate oral tablet
Tier 1
TRILEPTAL
Tier 3
TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG
Tier 3
valproic acid oral
Tier 1
VIMPAT ORAL SOLUTION
Tier 3
QL
VIMPAT ORAL TABLET
Tier 3
QL
ZARONTIN
Tier 3
ZONEGRAN
Tier 3
zonisamide oral
Tier 1
QL
*ANTIDEPRESSANTS*
amitriptyline hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg, 75 mg
Tier 1
amitriptyline hcl oral tablet 150 mg
Tier 1
amoxapine
Tier 1
ANAFRANIL
Tier 3
APLENZIN
Tier 6
N4
BRINTELLIX
Tier 3
PA; ST; N3; QL
BUDEPRION XL
Tier 1
QL
bupropion hcl er (sr)
Tier 1
QL
bupropion hcl er (xl)
Tier 1
QL
bupropion hcl oral
Tier 1
QL
CELEXA
Tier 3
QL
citalopram hydrobromide oral solution
Tier 1
citalopram hydrobromide oral tablet
Tier 1
clomipramine hcl oral
Tier 1
CYMBALTA ORAL CAPSULE DELAYED RELEASE PARTICLES 20 MG, 30 MG, 60 MG
Tier 3
desipramine hcl oral
Tier 1
desvenlafaxine er
Tier 3
ST; N3; QL
desvenlafaxine fumarate er
Tier 3
ST; N3; QL
doxepin hcl oral
Tier 1
duloxetine hcl oral capsule delayed release particles
20 mg, 30 mg, 60 mg
Tier 1
N3; QL
duloxetine hcl oral capsule delayed release particles
40 mg
Tier 1
QL
EFFEXOR XR
Tier 3
QL
EMSAM
Tier 3
QL
escitalopram oxalate oral solution
Tier 1
Lowest Generic Copay Applies; QL
N3; QL
(Updated 08/01/2015)
19
Drug Name
Drug Status
Drug Details
escitalopram oxalate oral tablet
Tier 1
QL
FETZIMA
Tier 3
PA; ST; N3; QL
FETZIMA TITRATION
Tier 3
PA; ST; N3; QL
fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg
Tier 1
fluoxetine hcl oral capsule delayed release
Tier 1
QL
fluoxetine hcl oral tablet 10 mg
Tier 1
Tier 1
QL
Tier 3
QL
fluvoxamine maleate er
Tier 1
QL
fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg
Tier 1
QL
FORFIVO XL
Tier 6
N4
imipramine hcl oral
Tier 1
imipramine pamoate
Tier 3
IRENKA
Tier 3
QL
KHEDEZLA
Tier 3
PA; ST; N3; QL
LEXAPRO ORAL SOLUTION
Tier 3
LEXAPRO ORAL TABLET
Tier 3
QL
LUVOX CR
Tier 3
QL
maprotiline hcl
Tier 1
mirtazapine oral tablet
Tier 1
mirtazapine oral tablet dispersible
Tier 3
NARDIL
Tier 2
nefazodone hcl
Tier 3
NORPRAMIN
Tier 3
nortriptyline hcl oral capsule 10 mg, 25 mg
Tier 1
nortriptyline hcl oral capsule 50 mg, 75 mg
Tier 1
OLEPTRO ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 300 MG
Tier 3
PAMELOR
Tier 3
PARNATE
Tier 3
paroxetine hcl er
Tier 1
N2; QL
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg
Tier 1
PAXIL CR
Tier 3
QL
PAXIL ORAL SUSPENSION
Tier 3
QL
PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG
Tier 3
QL
PEXEVA
Tier 6
N4
(Updated 08/01/2015)
20
QL
N3; QL
Drug Name
Drug Status
Drug Details
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 50 MG
Tier 3
PA; ST; N3; QL
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 25 MG
Tier 3
PA; ST; QL
protriptyline hcl
Tier 1
PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG
Tier 3
QL
PROZAC WEEKLY
Tier 3
QL
REMERON
Tier 3
REMERON SOLTAB
Tier 3
QL
sertraline hcl oral concentrate
Tier 1
QL
sertraline hcl oral tablet 100 mg, 25 mg, 50 mg
Tier 1
SURMONTIL
Tier 3
TOFRANIL
Tier 3
TOFRANIL‐PM
Tier 3
tranylcypromine sulfate
Tier 1
trazodone hcl oral
Tier 1
venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg
Tier 1
QL
venlafaxine hcl er oral tablet extended release 24 hr*
150 mg, 225 mg, 37.5 mg, 75 mg
Tier 3
N3; QL
venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg
Tier 1
QL
VIIBRYD ORAL KIT
Tier 3
PA; ST; N3; QL
VIIBRYD ORAL TABLET
Tier 3
PA; ST; N3; QL
VIVACTIL
Tier 3
WELLBUTRIN
Tier 3
QL
WELLBUTRIN SR
Tier 3
QL
WELLBUTRIN XL
Tier 3
QL
ZOLOFT ORAL CONCENTRATE
Tier 3
QL
ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG
Tier 3
QL
*ANTIDIABETICS*
acarbose
Tier 1
ACTOPLUS MET
Tier 3
QL
ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HR* 15‐1000 MG, 30‐1000 MG
Tier 2
QL
ACTOS
Tier 3
QL
AFREZZA INHALATION POWDER 4 (60) & 8 (30) UNIT, 4 UNIT, 8 (60)& 12 (30) UNIT
Tier 3
PA; ST
AMARYL
Tier 3
APIDRA
Tier 3
(Updated 08/01/2015)
ST; N3
21
Drug Name
Drug Status
Drug Details
APIDRA SOLOSTAR
Tier 3
ST; N3
AVANDAMET ORAL TABLET 2‐1000 MG, 2‐500 MG, 4‐500 MG
Tier 3
PA; QL
AVANDARYL ORAL TABLET 4‐1 MG, 4‐2 MG, 4‐4 MG, 8‐4 MG
Tier 3
PA; QL
AVANDIA
Tier 3
PA; QL
BYDUREON
Tier 2
ST; N3; QL
BYETTA 10 MCG PEN
Tier 3
ST; N3; QL
BYETTA 5 MCG PEN
Tier 3
ST; N3; QL
chlorpropamide oral tablet 100 mg
Tier 1
Lowest generic copay applies
chlorpropamide oral tablet 250 mg
Tier 1
CYCLOSET
Tier 3
DIABETA
Tier 3
DUETACT
Tier 3
QL
FARXIGA
Tier 3
ST; N3; QL
FORTAMET
Tier 3
glimepiride
Tier 1
glipizide er oral tablet extended release 24 hr* 10 mg, 5 mg
Tier 1
glipizide er oral tablet extended release 24 hr* 2.5 mg
Tier 1
glipizide oral
Tier 1
GLIPIZIDE XL
Tier 1
glipizide‐metformin hcl
Tier 1
GLUCAGEN HYPOKIT
Tier 2
QL
GLUCAGON EMERGENCY
Tier 2
QL
GLUCOPHAGE
Tier 3
GLUCOPHAGE XR
Tier 3
GLUCOTROL
Tier 3
GLUCOTROL XL
Tier 3
GLUCOVANCE ORAL TABLET 2.5‐500 MG, 5‐500 MG
Tier 3
GLUMETZA
Tier 3
glyburide micronized oral tablet 1.5 mg
Tier 1
glyburide micronized oral tablet 3 mg, 6 mg
Tier 1
glyburide oral tablet 1.25 mg
Tier 1
glyburide oral tablet 2.5 mg, 5 mg
Tier 1
glyburide‐metformin
Tier 1
GLYNASE
Tier 3
GLYSET
Tier 3
GLYXAMBI
Tier 3
(Updated 08/01/2015)
22
QL
PA; ST; QL
Drug Name
Drug Status
Drug Details
HUMALOG
Tier 2
HUMALOG KWIKPEN
Tier 2
HUMALOG MIX 50/50
Tier 2
HUMALOG MIX 50/50 KWIKPEN
Tier 2
HUMALOG MIX 75/25
Tier 2
HUMALOG MIX 75/25 KWIKPEN
Tier 2
HUMULIN 70/30
Tier 2
HUMULIN 70/30 KWIKPEN
Tier 2
HUMULIN N
Tier 2
HUMULIN N KWIKPEN
Tier 2
HUMULIN R
Tier 2
HUMULIN R U‐500 (CONCENTRATED)
Tier 2
INVOKAMET
Tier 2
ST; N3; QL
INVOKANA
Tier 2
ST; N3; QL
JANUMET
Tier 2
N3; QL
JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100‐1000 MG, 50‐1000 MG, 50‐500 MG
Tier 2
N3; QL
JANUVIA
Tier 2
N3; QL
JARDIANCE
Tier 3
ST; QL
JENTADUETO
Tier 3
PA; ST; N3; QL
KAZANO
Tier 3
PA; ST; N3; QL
KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* 2.5‐1000 MG, 5‐1000 MG, 5‐500 MG
Tier 2
N3; QL
KORLYM
Tier 4
PA; N2; QL
LANTUS
Tier 3
ST; N3
LANTUS SOLOSTAR
Tier 3
ST; N3
LEVEMIR
Tier 2
LEVEMIR FLEXPEN
Tier 2
LEVEMIR FLEXTOUCH
Tier 2
metformin hcl er (osm)
Tier 3
metformin hcl er oral tablet extended release 24 hr*
500 mg
Tier 1
metformin hcl er oral tablet extended release 24 hr*
750 mg
Tier 1
metformin hcl oral
Tier 1
nateglinide
Tier 3
NESINA
Tier 3
PA; ST; N3; QL
NOVOLIN 70/30
Tier 3
ST; N3
NOVOLIN 70/30 RELION
Tier 3
ST; N3
(Updated 08/01/2015)
23
Drug Name
Drug Status
Drug Details
NOVOLIN N
Tier 3
ST
NOVOLIN N RELION
Tier 3
ST
NOVOLIN R
Tier 3
ST; N3
NOVOLIN R RELION
Tier 3
ST; N3
NOVOLOG
Tier 3
ST; N3
NOVOLOG FLEXPEN
Tier 3
ST; N3
NOVOLOG MIX 70/30
Tier 3
ST; N3
NOVOLOG MIX 70/30 FLEXPEN
Tier 3
ST; N3
ONGLYZA
Tier 2
N3; QL
OSENI
Tier 3
PA; ST; N3; QL
pioglitazone hcl
Tier 1
QL
pioglitazone hcl‐glimepiride
Tier 1
QL
pioglitazone hcl‐metformin hcl
Tier 1
QL
PRANDIMET
Tier 3
QL
PRANDIN
Tier 3
PRECOSE
Tier 3
PROGLYCEM
Tier 3
repaglinide
Tier 3
RIOMET
Tier 3
STARLIX
Tier 3
SYMLINPEN 120
Tier 3
PA; QL
SYMLINPEN 60
Tier 3
PA; QL
TANZEUM
Tier 3
PA; QL
tolazamide
Tier 1
tolbutamide
Tier 1
TOUJEO SOLOSTAR
Tier 3
PA; ST
TRADJENTA
Tier 3
PA; ST; N3; QL
TRULICITY
Tier 3
PA; ST; QL
VICTOZA
Tier 3
PA; N3; QL
XIGDUO XR
Tier 3
ST; QL
diphenatol
Tier 1
N2
diphenoxylate‐atropine
Tier 1
N2
FULYZAQ
Tier 3
PA; QL
LOMOTIL
Tier 3
N2
MOTOFEN
Tier 3
opium
Tier 3
N2
opium tincture (paregoric)
Tier 3
N2
*ANTIDIARRHEALS*
(Updated 08/01/2015)
24
Drug Name
Drug Status
Drug Details
*ANTIDOTES*
EVZIO
Tier 2
PA
EXJADE
Tier 4
PA; N2
FERRIPROX
Tier 4
PA; N2
JADENU
Tier 4
PA
naltrexone hcl oral
Tier 1
N2
REVIA
Tier 3
*ANTIEMETICS*
AKYNZEO
Tier 3
PA; QL
ANZEMET ORAL
Tier 3
N2; QL
CESAMET
Tier 3
QL
DICLEGIS
Tier 3
QL
dronabinol
Tier 3
PA; QL
EMEND ORAL
Tier 3
#; QL
MARINOL
Tier 3
PA; N2; QL
ondansetron
Tier 1
N2; QL
ondansetron hcl oral solution
Tier 1
N2; QL
ondansetron hcl oral tablet 24 mg
Tier 3
N2; QL
ondansetron hcl oral tablet 4 mg, 8 mg
Tier 1
N2; QL
SANCUSO
Tier 3
QL
TIGAN ORAL
Tier 3
trimethobenzamide hcl oral
Tier 1
ZOFRAN ODT
Tier 3
N2; QL
ZOFRAN ORAL SOLUTION
Tier 3
N2; QL
ZOFRAN ORAL TABLET
Tier 3
N2; QL
ZUPLENZ
Tier 6
N4
ANCOBON
Tier 3
N2
CRESEMBA ORAL
Tier 3
DIFLUCAN ORAL SUSPENSION RECONSTITUTED
Tier 3
DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG
Tier 3
DIFLUCAN ORAL TABLET 150 MG
Tier 3
QL
fluconazole oral suspension reconstituted
Tier 1
AL
fluconazole oral tablet 100 mg, 200 mg, 50 mg
Tier 1
fluconazole oral tablet 150 mg
Tier 1
QL
GRIFULVIN V
Tier 2
N2
griseofulvin microsize oral
Tier 1
N2
griseofulvin ultramicrosize
Tier 1
N2
*ANTIFUNGALS*
(Updated 08/01/2015)
25
Drug Name
Drug Status
Drug Details
GRIS‐PEG
Tier 2
N2
itraconazole oral
Tier 1
QL
ketoconazole oral
Tier 1
N2; QL
LAMISIL ORAL PACKET 125 MG, 187.5 MG
Tier 3
N2; QL
LAMISIL ORAL TABLET
Tier 3
N2
NOXAFIL ORAL SUSPENSION
Tier 3
N2; QL
NOXAFIL ORAL TABLET DELAYED RELEASE
Tier 3
N2
nystatin oral tablet
Tier 1
N2
ONMEL
Tier 6
N4
SPORANOX ORAL CAPSULE
Tier 3
QL
SPORANOX ORAL SOLUTION
Tier 2
N2
SPORANOX PULSEPAK
Tier 3
QL
terbinafine hcl oral
Tier 1
N2
TERBINEX
Tier 6
N4
VFEND
Tier 3
N2
voriconazole oral tablet
Tier 1
N2
ALAVERT ORAL TABLET
Tier 1
ALAVERT ORAL TABLET DISPERSIBLE
Tier 1
Select OTC
ALLEGRA ALLERGY CHILDRENS
Tier 1
Select OTC
ALLEGRA ALLERGY ORAL TABLET 180 MG, 60 MG
Tier 1
Select OTC; QL
cetirizine hcl oral syrup 5 mg/5ml
Tier 1
cetirizine hcl oral tablet 10 mg
Tier 1
Lowest Generic Copay Applies; Select OTC
cetirizine hcl oral tablet 5 mg
Tier 1
cetirizine hcl oral tablet chewable
Tier 1
Select OTC
childrens loratadine
Tier 1
Select OTC
CLARINEX ORAL SYRUP
Tier 3
CLARINEX ORAL TABLET
Tier 3
QL
CLARITIN ORAL SYRUP
Tier 1
CLARITIN ORAL TABLET
Tier 1
Select OTC
CLARITIN ORAL TABLET CHEWABLE
Tier 1
Select OTC
CLARITIN REDITABS
Tier 1
clemastine fumarate oral tablet 2.68 mg
Tier 1
cyproheptadine hcl oral
Tier 1
fexofenadine hcl childrens
Tier 1
Select OTC
fexofenadine hcl oral
Tier 1
Select OTC
KARBINAL ER
Tier 3
ST
*ANTIHISTAMINES*
(Updated 08/01/2015)
26
Drug Name
Drug Status
Drug Details
levocetirizine dihydrochloride oral solution
Tier 3
levocetirizine dihydrochloride oral tablet
Tier 3
QL
loratadine allergy relief
Tier 1
Select OTC
loratadine childrens
Tier 1
Select OTC
loratadine oral syrup
Tier 1
loratadine oral tablet
Tier 1
Select OTC
promethazine hcl oral
Tier 1
XYZAL
Tier 3
ZYRTEC ALLERGY ORAL CAPSULE
Tier 1
ZYRTEC ALLERGY ORAL TABLET
Tier 1
Select OTC
ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR* 1000‐20 MG, 1000‐40 MG, 500‐20 MG, 750‐20 MG
Tier 3
QL
ALTOPREV
Tier 3
ST; N3; QL
ANTARA ORAL CAPSULE 30 MG, 90 MG
Tier 3
QL
atorvastatin calcium oral
Tier 1
QL
cholestyramine light oral packet
Tier 1
cholestyramine oral packet
Tier 1
COLESTID
Tier 3
COLESTID FLAVORED
Tier 3
colestipol hcl
Tier 1
CRESTOR
Tier 2
QL
fenofibrate micronized oral capsule 130 mg, 43 mg
Tier 3
QL
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg
Tier 1
QL
fenofibrate oral tablet 145 mg, 48 mg
Tier 3
QL
fenofibrate oral tablet 160 mg, 54 mg
Tier 1
QL
fenofibric acid oral capsule delayed release
Tier 1
QL
fenofibric acid oral tablet
Tier 1
FENOGLIDE
Tier 3
#; QL
FIBRICOR
Tier 3
QL
fluvastatin sodium
Tier 1
QL
gemfibrozil oral
Tier 1
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG
Tier 4
PA; N2; QL
JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG
Tier 4
PA; QL
LESCOL
Tier 3
N3; QL
LESCOL XL
Tier 3
N3; QL
LIPITOR
Tier 3
N3; QL
QL
*ANTIHYPERLIPIDEMICS*
(Updated 08/01/2015)
27
Drug Name
Drug Status
Drug Details
LIPOFEN
Tier 3
#; QL
LIPTRUZET
Tier 3
N3; QL
LIVALO
Tier 3
ST; N3; QL
LOFIBRA
Tier 3
QL
LOPID
Tier 3
lovastatin
Tier 1
LOVAZA
Tier 3
N3; QL
MEVACOR
Tier 3
QL
micronized colestipol hcl
Tier 1
niacin er (antihyperlipidemic)
Tier 1
NIASPAN
Tier 3
omega‐3‐acid ethyl esters
Tier 1
QL
PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG
Tier 3
QL
pravastatin sodium
Tier 1
PREVALITE
Tier 1
QUESTRAN
Tier 3
QUESTRAN LIGHT
Tier 3
SIMCOR
Tier 3
QL
simvastatin oral
Tier 1
TRICOR
Tier 3
QL
TRIGLIDE ORAL TABLET 160 MG
Tier 3
QL
TRILIPIX
Tier 3
QL
VASCEPA
Tier 2
ST; QL
VYTORIN
Tier 3
N3; QL
WELCHOL
Tier 2
#
ZETIA
Tier 2
QL
ZOCOR
Tier 3
QL
N2
*ANTIHYPERTENSIVES*
ACCUPRIL
Tier 3
ACCURETIC
Tier 3
ACEON ORAL TABLET 4 MG, 8 MG
Tier 3
ALTACE
Tier 3
amlodipine besy‐benazepril hcl
Tier 3
QL
amlodipine besylate‐valsartan
Tier 3
QL
amlodipine‐valsartan‐hctz
Tier 3
ST; QL
AMTURNIDE
Tier 3
PA; QL
ATACAND
Tier 3
QL
ATACAND HCT
Tier 3
QL
(Updated 08/01/2015)
28
QL
Drug Name
Drug Status
Drug Details
atenolol‐chlorthalidone
Tier 1
AVALIDE ORAL TABLET 150‐12.5 MG, 300‐12.5 MG
Tier 3
QL
AVAPRO
Tier 3
QL
AZOR
Tier 3
ST; N3; QL
benazepril hcl oral
Tier 1
benazepril‐hydrochlorothiazide
Tier 1
BENICAR
Tier 3
ST; N3; QL
BENICAR HCT
Tier 3
N3; QL
bisoprolol‐hydrochlorothiazide
Tier 1
candesartan cilexetil
Tier 1
QL
candesartan cilexetil‐hctz
Tier 1
QL
captopril oral
Tier 1
captopril‐hydrochlorothiazide
Tier 1
CARDURA
Tier 3
CATAPRES
Tier 3
CATAPRES‐TTS‐1
Tier 3
QL
CATAPRES‐TTS‐2
Tier 3
QL
CATAPRES‐TTS‐3
Tier 3
QL
clonidine hcl oral
Tier 1
clonidine hcl transdermal patch weekly 0.1 mg/24hr, 0.3 mg/24hr
Tier 3
QL
clonidine hcl transdermal patch weekly 0.2 mg/24hr
Tier 3
CLORPRES
Tier 3
CORZIDE
Tier 3
COZAAR
Tier 3
DEMSER
Tier 3
DIBENZYLINE
Tier 2
DIOVAN
Tier 3
ST; N3; QL
DIOVAN HCT
Tier 3
QL
doxazosin mesylate
Tier 1
DUTOPROL
Tier 3
EDARBI
Tier 3
ST; N3; QL
EDARBYCLOR
Tier 3
ST; N3; QL
enalapril maleate oral
Tier 1
enalapril‐hydrochlorothiazide
Tier 1
EPANED
Tier 3
QL; AL
eprosartan mesylate
Tier 3
QL
EXFORGE HCT
Tier 3
ST; N3; #; QL
(Updated 08/01/2015)
29
Drug Name
Drug Status
Drug Details
EXFORGE ORAL TABLET 10‐160 MG, 5‐160 MG
Tier 3
ST; N3; #; QL
EXFORGE ORAL TABLET 10‐320 MG, 5‐320 MG
Tier 3
ST; N3; #
fosinopril sodium
Tier 1
fosinopril sodium‐hctz
Tier 1
guanfacine hcl oral
Tier 1
hydralazine hcl oral tablet 10 mg, 100 mg, 50 mg
Tier 1
hydralazine hcl oral tablet 25 mg
Tier 1
HYZAAR
Tier 3
INSPRA ORAL TABLET 25 MG, 50 MG
Tier 3
QL
irbesartan
Tier 1
QL
irbesartan‐hydrochlorothiazide
Tier 1
QL
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg
Tier 1
lisinopril oral tablet 30 mg, 40 mg
Tier 1
lisinopril‐hydrochlorothiazide
Tier 1
LOPRESSOR HCT ORAL TABLET 50‐25 MG
Tier 3
losartan potassium
Tier 1
losartan potassium‐hctz
Tier 1
LOTENSIN ORAL TABLET 20 MG, 40 MG
Tier 3
LOTREL
Tier 3
MAVIK
Tier 3
methyldopa oral
Tier 1
methyldopa‐hydrochlorothiazide
Tier 1
metoprolol‐hydrochlorothiazide
Tier 1
MICARDIS
Tier 3
QL
MICARDIS HCT
Tier 3
QL
MINIPRESS
Tier 3
minoxidil oral
Tier 1
moexipril hcl
Tier 1
moexipril‐hydrochlorothiazide
Tier 1
perindopril erbumine oral tablet 2 mg, 8 mg
Tier 3
perindopril erbumine oral tablet 4 mg
Tier 3
prazosin hcl oral
Tier 1
PRINIVIL
Tier 3
propranolol‐hctz
Tier 1
quinapril hcl
Tier 1
quinapril‐hydrochlorothiazide
Tier 1
ramipril
Tier 1
reserpine oral
Tier 3
(Updated 08/01/2015)
30
QL
QL
Drug Name
Drug Status
Drug Details
TARKA
Tier 3
#
TEKAMLO
Tier 3
PA; QL
TEKTURNA
Tier 3
PA; QL
TEKTURNA HCT
Tier 3
PA; QL
telmisartan
Tier 1
QL
telmisartan‐amlodipine
Tier 3
ST; N3; QL
telmisartan‐hctz
Tier 1
QL
TENEX
Tier 3
TENORETIC 100
Tier 3
TENORETIC 50
Tier 3
terazosin hcl oral
Tier 1
TEVETEN HCT
Tier 3
ST; N3; #; QL
TEVETEN ORAL TABLET 600 MG
Tier 3
QL
trandolapril
Tier 1
trandolapril‐verapamil hcl er
Tier 1
TRIBENZOR
Tier 3
ST; N3; QL
TWYNSTA
Tier 3
ST; N3; QL
UNIRETIC ORAL TABLET 15‐12.5 MG
Tier 3
UNIVASC
Tier 3
valsartan
Tier 1
valsartan‐hydrochlorothiazide
Tier 1
VASERETIC
Tier 3
VASOTEC
Tier 3
VECAMYL
Tier 4
ZESTORETIC
Tier 3
ZESTRIL
Tier 3
ZIAC
Tier 3
QL
PA; N2; QL
*ANTI‐INFECTIVE AGENTS ‐ MISC.*
ALINIA ORAL SUSPENSION RECONSTITUTED
Tier 3
QL
ALINIA ORAL TABLET
Tier 3
QL
atovaquone oral
Tier 1
BACTRIM
Tier 3
N2
BACTRIM DS
Tier 3
N2
CAYSTON
Tier 4
N2; QL
CLEOCIN ORAL
Tier 3
clindamycin hcl oral
Tier 1
dapsone oral
Tier 2
FLAGYL
Tier 3
N2
(Updated 08/01/2015)
31
Drug Name
Drug Status
Drug Details
FLAGYL ER
Tier 3
KETEK
Tier 3
QL
MEPRON
Tier 3
N2; QL
metronidazole oral
Tier 1
N2
NEBUPENT
Tier 2
N2
SIVEXTRO ORAL
Tier 3
PA; QL
smz‐tmp ds
Tier 1
Lowest Generic Copay Applies; N2
sulfamethoxazole‐tmp ds
Tier 1
sulfamethoxazole‐trimethoprim oral suspension
200‐40 mg/5ml
Tier 1
sulfamethoxazole‐trimethoprim oral tablet
Tier 1
TINDAMAX ORAL TABLET 250 MG, 500 MG
Tier 3
QL
trimethoprim oral
Tier 1
VANCOCIN HCL ORAL CAPSULE 125 MG, 250 MG
Tier 3
vancomycin hcl intravenous*
Tier 1
XIFAXAN ORAL TABLET 200 MG
Tier 3
N2; QL
XIFAXAN ORAL TABLET 550 MG
Tier 3
PA; N2; QL
ZYVOX ORAL SUSPENSION RECONSTITUTED
Tier 2
N2; QL
ZYVOX ORAL TABLET
Tier 2
N2; #; QL
ARALEN
Tier 3
N2
atovaquone‐proguanil hcl
Tier 3
PA; N2; QL
chloroquine phosphate oral
Tier 1
N2
COARTEM
Tier 2
PA; N2; QL
DARAPRIM
Tier 2
N2
hydroxychloroquine sulfate oral
Tier 1
N2
MALARONE
Tier 3
PA; QL
PLAQUENIL
Tier 3
N2
primaquine phosphate oral
Tier 3
N2
QUALAQUIN
Tier 3
PA; N2; QL
QL
*ANTIMALARIALS*
*ANTIMYASTHENIC/CHOLINERGIC AGENTS*
MESTINON ORAL SYRUP
Tier 3
MESTINON ORAL TABLET
Tier 3
pyridostigmine bromide oral
Tier 1
*ANTIMYCOBACTERIAL AGENTS*
ethambutol hcl oral
Tier 1
N2
isoniazid oral
Tier 1
N2
MYAMBUTOL ORAL TABLET 400 MG
Tier 3
N2
(Updated 08/01/2015)
32
Drug Name
Drug Status
MYCOBUTIN
Tier 2
PASER
Tier 3
PRIFTIN
Tier 3
pyrazinamide oral
Tier 1
rifabutin
Tier 1
RIFADIN
Tier 3
RIFAMATE
Tier 3
rifampin oral
Tier 1
RIFATER
Tier 3
SIRTURO
Tier 4
TRECATOR
Tier 3
Drug Details
N2
N2
N2
PA; N2; QL
*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*
ACTIMMUNE
Tier 4
PA; N2
AFINITOR
Tier 4
PA; N2; SF; QL
AFINITOR DISPERZ
Tier 4
PA; N2; SF; QL
ALKERAN ORAL
Tier 4
N2
anastrozole oral
Tier 1
PA; N2
ARIMIDEX
Tier 3
PA; N2
AROMASIN
Tier 3
PA; N2; QL
bicalutamide
Tier 1
QL
BOSULIF ORAL TABLET 100 MG, 500 MG
Tier 4
PA; ST; N2; N3; QL
capecitabine
Tier 4
PA; N2
CAPRELSA ORAL TABLET 100 MG, 300 MG
Tier 4
PA; N2; Tier 2 for DE; QL
CASODEX
Tier 3
QL
COMETRIQ (100 MG DAILY DOSE)
Tier 4
PA; N2; QL
Tier 4
PA; N2; QL
Tier 4
PA; N2; QL
cyclophosphamide oral capsule
Tier 4
cyclophosphamide oral tablet
Tier 4
N2
EMCYT
Tier 2
N2
ERIVEDGE
Tier 4
PA; N2; QL
etoposide oral
Tier 4
N2
exemestane
Tier 1
PA; N2; QL
FARESTON
Tier 2
FARYDAK
Tier 4
PA; QL
FEMARA
Tier 3
PA
flutamide
Tier 1
GILOTRIF
Tier 4
PA; N2; QL
(Updated 08/01/2015)
33
Drug Name
Drug Status
Drug Details
GLEEVEC
Tier 4
GLEOSTINE
Tier 4
HEXALEN
Tier 4
N2
HYCAMTIN ORAL
Tier 4
PA; N2
HYDREA
Tier 1
N2
hydroxyurea oral
Tier 1
N2
IBRANCE
Tier 4
PA; QL
ICLUSIG ORAL TABLET 15 MG, 45 MG
Tier 4
PA; ST; N2; N3; QL
IMBRUVICA
Tier 4
PA; N2
INLYTA
Tier 4
PA; N2; SF; QL
INTRON A INJECTION SOLUTION
Tier 4
PA; N2
JAKAFI
Tier 4
PA; N2; SF; QL
LENVIMA 10 MG DAILY DOSE
Tier 4
PA; QL
Tier 4
PA; QL
Tier 4
PA; QL
Tier 4
PA; QL
letrozole oral
Tier 1
PA
leucovorin calcium oral
Tier 1
LEUKERAN
Tier 2
N2
leuprolide acetate injection
Tier 4
PA
lomustine
Tier 4
LYNPARZA
Tier 4
LYSODREN
Tier 2
MATULANE
Tier 4
MEGACE ORAL
Tier 3
megestrol acetate oral tablet
Tier 1
MEKINIST ORAL TABLET 0.5 MG, 2 MG
Tier 4
PA; N2; SF; QL
mercaptopurine oral
Tier 1
N2
methotrexate oral
Tier 1
N2
methotrexate sodium (pf)
Tier 1
methotrexate sodium injection solution
Tier 1
N2
MYLERAN
Tier 4
N2
NEXAVAR
Tier 4
PA; N2; SF; QL
NILANDRON
Tier 2
POMALYST
Tier 4
PURINETHOL
Tier 3
PURIXAN
Tier 4
SOLTAMOX
Tier 3
(Updated 08/01/2015)
34
PA; N2; Tier 2 for DE
PA; QL
N2
PA; N2; QL
PA; QL
Drug Name
Drug Status
Drug Details
SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG
Tier 4
PA; ST; N2; N3; SF; QL
STIVARGA
Tier 4
PA; N2; QL
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG
Tier 4
PA; N2; SF; QL
SUTENT ORAL CAPSULE 37.5 MG
Tier 4
PA; QL
TABLOID
Tier 2
TAFINLAR
Tier 4
tamoxifen citrate oral
CE
PA; N2; SF; QL
CE
TARCEVA
Tier 4
PA; N2; SF; QL
TARGRETIN ORAL
Tier 4
N2
TASIGNA
Tier 4
PA; ST; N2; N3; QL
TEMODAR ORAL
Tier 4
PA; N2
temozolomide
Tier 4
PA; N2
tretinoin oral
Tier 4
N2; Tier 1 for DE
TYKERB
Tier 4
PA; N2
VOTRIENT
Tier 4
PA; N2; SF; QL
XALKORI
Tier 4
PA; N2; QL
XELODA
Tier 4
PA
XTANDI
Tier 4
PA; N2; QL
ZELBORAF
Tier 4
PA; N2; SF; QL
ZOLINZA
Tier 4
PA; N2; QL
ZYDELIG
Tier 4
PA
ZYKADIA
Tier 4
PA; QL
ZYTIGA
Tier 4
PA; N2; QL
*ANTIPARKINSON AGENTS*
amantadine hcl oral
Tier 1
APOKYN
Tier 4
N2
AZILECT
Tier 2
QL
benztropine mesylate oral
Tier 1
bromocriptine mesylate oral
Tier 1
carbidopa oral
Tier 3
carbidopa‐levodopa
Tier 1
carbidopa‐levodopa er
Tier 1
carbidopa‐levodopa‐entacapone
Tier 3
COMTAN
Tier 3
DUOPA
Tier 4
ELDEPRYL
Tier 3
entacapone
Tier 1
PA; ST; QL
(Updated 08/01/2015)
35
Drug Name
Drug Status
Drug Details
LODOSYN
Tier 3
MIRAPEX
Tier 3
MIRAPEX ER
Tier 3
QL
NEUPRO
Tier 3
QL
PARCOPA
Tier 3
PARLODEL
Tier 3
pramipexole dihydrochloride
Tier 1
pramipexole dihydrochloride er
Tier 3
REQUIP
Tier 3
REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HR* 12 MG, 2 MG, 4 MG, 6 MG, 8 MG
Tier 3
ropinirole hcl
Tier 1
ropinirole hcl er oral tablet extended release 24 hr* 12 mg, 2 mg, 4 mg, 6 mg, 8 mg
Tier 3
RYTARY
Tier 3
selegiline hcl oral
Tier 1
SINEMET
Tier 3
SINEMET CR
Tier 3
STALEVO 100
Tier 3
STALEVO 125
Tier 3
STALEVO 150
Tier 3
STALEVO 200
Tier 3
STALEVO 50
Tier 3
STALEVO 75
Tier 3
TASMAR
Tier 3
tolcapone
Tier 3
trihexyphenidyl hcl oral elixir
Tier 1
trihexyphenidyl hcl oral tablet 2 mg
Tier 1
trihexyphenidyl hcl oral tablet 5 mg
Tier 1
ZELAPAR
Tier 3
QL
ABILIFY DISCMELT
Tier 3
ST; N3; #; QL
ABILIFY ORAL SOLUTION
Tier 3
ST; N3; QL
ABILIFY ORAL TABLET
Tier 3
PA; ST; N3; #; QL
aripiprazole
Tier 1
QL
chlorpromazine hcl oral
Tier 1
clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg
Tier 1
QL
QL
QL
*ANTIPSYCHOTICS/ANTIMANIC AGENTS*
clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 Tier 1
mg, 200 mg, 25 mg
(Updated 08/01/2015)
36
N2; QL
QL
Drug Name
Drug Status
Drug Details
CLOZARIL ORAL TABLET 100 MG, 25 MG
Tier 3
QL
COMPAZINE
Tier 3
EQUETRO
Tier 3
FANAPT
Tier 3
ST; N3; QL
FANAPT TITRATION PACK
Tier 3
ST; N3; QL
FAZACLO ORAL TABLET DISPERSIBLE 100 MG, 12.5 MG, 150 MG, 200 MG, 25 MG
Tier 3
#; QL
fluphenazine hcl oral concentrate
Tier 1
fluphenazine hcl oral tablet
Tier 1
GEODON ORAL
Tier 3
haloperidol lactate oral
Tier 1
haloperidol oral
Tier 1
INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 1.5 MG, 3 MG, 6 MG, 9 MG
Tier 3
ST; N3; QL
LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG
Tier 2
N3; QL
lithium carbonate er oral tablet extendedrelease* 450 mg
Tier 1
lithium carbonate oral
Tier 1
LITHOBID
Tier 3
loxapine succinate oral
Tier 1
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg
Tier 1
QL
olanzapine oral tablet dispersible 15 mg, 20 mg, 5 mg
Tier 1
QL
perphenazine oral
Tier 1
prochlorperazine
Tier 1
prochlorperazine edisylate injection
Tier 1
prochlorperazine maleate oral
Tier 1
quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg
Tier 1
QL
RISPERDAL M‐TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG
Tier 3
QL
RISPERDAL ORAL SOLUTION
Tier 3
RISPERDAL ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG
Tier 3
QL
RISPERIDONE M‐TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG
Tier 3
QL
risperidone oral solution
Tier 3
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
Tier 1
ST; N3; QL
QL
(Updated 08/01/2015)
37
Drug Name
Drug Status
Drug Details
risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
Tier 1
QL
SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG
Tier 3
ST; N3; QL
SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG
Tier 3
ST; QL
SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG
Tier 3
N3; QL
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 200 MG, 300 MG, 50 MG
Tier 3
PA; N3; QL
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 400 MG
Tier 3
PA; ST; N3; QL
thioridazine hcl oral
Tier 1
thiothixene oral
Tier 1
trifluoperazine hcl oral
Tier 1
VERSACLOZ
Tier 3
N3
ziprasidone hcl
Tier 1
QL
ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG
Tier 3
N3; QL
ZYPREXA ORAL TABLET 7.5 MG
Tier 3
QL
ZYPREXA ZYDIS
Tier 3
N3; QL
*ANTIVIRALS*
abacavir sulfate
Tier 1
abacavir‐lamivudine‐zidovudine
Tier 1
acyclovir oral capsule
Tier 1
acyclovir oral suspension
Tier 1
acyclovir oral tablet 400 mg
Tier 1
acyclovir oral tablet 800 mg
Tier 1
adefovir dipivoxil
Tier 4
N2; QL
APTIVUS ORAL CAPSULE
Tier 2
QL
APTIVUS ORAL SOLUTION
Tier 2
ATRIPLA
Tier 3
#
BARACLUDE ORAL SOLUTION
Tier 4
N2; #
BARACLUDE ORAL TABLET
Tier 4
N2; #; QL
COMBIVIR
Tier 3
COMPLERA
Tier 3
QL
COPEGUS
Tier 4
PA; N2
CRIXIVAN ORAL CAPSULE 100 MG
Tier 3
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
Tier 3
didanosine
Tier 1
(Updated 08/01/2015)
38
Tier 2 for DE
Drug Name
Drug Status
Drug Details
EDURANT
Tier 3
QL
EMTRIVA
Tier 2
QL
entecavir
Tier 4
QL
EPIVIR HBV
Tier 4
EPIVIR ORAL SOLUTION
Tier 2
EPIVIR ORAL TABLET
Tier 3
EPZICOM
Tier 3
EVOTAZ
Tier 3
famciclovir oral
Tier 1
N2; QL
FAMVIR
Tier 3
QL
FLUMADINE
Tier 3
FUZEON SUBCUTANEOUS* KIT
Tier 3
FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED
Tier 3
N2; #; Tier 2 for DE
HARVONI
Tier 4
PA; QL
HEPSERA
Tier 4
N2; QL
INCIVEK
Tier 4
PA; N2; QL
INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG
Tier 3
QL
INVIRASE
Tier 3
ISENTRESS ORAL PACKET
Tier 3
ISENTRESS ORAL TABLET
Tier 3
ISENTRESS ORAL TABLET CHEWABLE
Tier 3
KALETRA
Tier 2
lamivudine
Tier 1
lamivudine‐zidovudine
Tier 1
LEXIVA
Tier 2
MODERIBA 1200 DOSE PACK
Tier 6
N4
MODERIBA 800 DOSE PACK
Tier 6
N4
MODERIBA ORAL TABLET
Tier 6
Tier 1 for DE
nevirapine
Tier 1
Tier 1 for DE
nevirapine er
Tier 1
QL
NORVIR
Tier 2
OLYSIO
Tier 4
PA; ST; N2; QL
PEGASYS
Tier 4
PA; N2
PEGASYS PROCLICK
Tier 4
PA
PEG‐INTRON
Tier 6
N4
PEG‐INTRON REDIPEN
Tier 6
N4
PEG‐INTRON REDIPEN PAK 4
Tier 6
N4
QL
(Updated 08/01/2015)
39
Drug Name
Drug Status
PREZCOBIX
Tier 3
PREZISTA ORAL SUSPENSION
Tier 2
QL
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG
Tier 2
QL
PREZISTA ORAL TABLET 400 MG
Tier 2
REBETOL ORAL CAPSULE
Tier 4
PA; N2
REBETOL ORAL SOLUTION
Tier 4
PA; N2; QL
RELENZA DISKHALER
Tier 3
#; QL
RESCRIPTOR
Tier 3
RETROVIR INTRAVENOUS*
Tier 3
RETROVIR ORAL CAPSULE
Tier 3
N2
RETROVIR ORAL SYRUP
Tier 3
N2
RETROVIR ORAL TABLET
Tier 3
REYATAZ ORAL CAPSULE 100 MG
Tier 2
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG
Tier 2
REYATAZ ORAL PACKET
Tier 2
RIBASPHERE ORAL CAPSULE
Tier 4
N2; Tier 1 for DE
RIBASPHERE ORAL TABLET 200 MG
Tier 4
N2; Tier 1 for DE
RIBASPHERE ORAL TABLET 400 MG, 600 MG
Tier 4
N2
RIBASPHERE RIBAPAK
Tier 6
N4
ribavirin oral
Tier 4
N2; Tier 1 for DE
rimantadine hcl
Tier 1
N2
SELZENTRY
Tier 3
QL
SITAVIG
Tier 6
N4
SOVALDI
Tier 4
PA; N2; QL
stavudine
Tier 1
STRIBILD
Tier 3
SUSTIVA
Tier 2
TAMIFLU ORAL CAPSULE
Tier 3
N2; QL
TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML
Tier 3
N2; QL
TIVICAY
Tier 3
QL
TRIUMEQ
Tier 3
TRIZIVIR
Tier 3
TRUVADA
Tier 2
PA
TYBOST
Tier 3
QL
TYZEKA
Tier 4
N2; QL
valacyclovir hcl oral tablet 1 gm, 500 mg
Tier 1
N2; QL
(Updated 08/01/2015)
40
Drug Details
QL
PA; QL
Drug Name
Drug Status
Drug Details
VALCYTE ORAL SOLUTION RECONSTITUTED
Tier 2
PA; N2
VALCYTE ORAL TABLET
Tier 4
PA; N2; QL
valganciclovir hcl
Tier 4
PA; QL
VALTREX ORAL TABLET 1 GM, 500 MG
Tier 3
N2; QL
VICTRELIS
Tier 4
PA; N2; QL
VIDEX
Tier 2
VIDEX EC
Tier 3
VIEKIRA PAK
Tier 4
PA; ST
VIRACEPT
Tier 3
#
VIRAMUNE
Tier 3
VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 400 MG
Tier 3
VIREAD ORAL POWDER
Tier 2
VIREAD ORAL TABLET
Tier 2
VITEKTA
Tier 3
ZERIT
Tier 3
ZIAGEN
Tier 3
zidovudine
Tier 1
ZOVIRAX ORAL
Tier 3
QL
QL
N2
Tier 1 for DE
*ASSORTED CLASSES*
ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG
Tier 4
ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 5 MG
Tier 4
azathioprine oral
Tier 1
CELLCEPT
Tier 4
CUPRIMINE
Tier 2
cyclosporine modified
Tier 4
N2
cyclosporine oral
Tier 4
N2
DEPEN TITRATABS
Tier 2
GENGRAF
Tier 4
N2
HECORIA
Tier 4
N2
IMURAN
Tier 3
N2
KAYEXALATE
Tier 3
KIONEX
Tier 1
mycophenolate mofetil oral capsule
Tier 4
mycophenolate mofetil oral suspension reconstituted
Tier 1
mycophenolate mofetil oral tablet
Tier 4
N2
mycophenolic acid
Tier 4
(Updated 08/01/2015)
N2
QL
N2
N2
41
Drug Name
Drug Status
Drug Details
MYFORTIC
Tier 4
N2
NEORAL
Tier 4
N2
PROGRAF
Tier 4
N2
RAPAMUNE
Tier 4
N2
REVLIMID
Tier 4
PA; N2; QL
SANDIMMUNE ORAL
Tier 4
N2
sirolimus oral tablet 0.5 mg
Tier 4
N2
sirolimus oral tablet 1 mg, 2 mg
Tier 4
sodium polystyrene sulfonate oral powder
Tier 1
sodium polystyrene sulfonate oral suspension
Tier 1
sodium polystyrene sulfonate suspension 30 gm/120ml
Tier 1
sodium polystyrene sulfonate suspension 50 gm/200ml
Tier 2
SPS
Tier 1
SYPRINE
Tier 3
tacrolimus oral
Tier 4
N2
THALOMID
Tier 4
ZORTRESS
Tier 4
N2
N2
*BETA BLOCKERS*
acebutolol hcl oral
Tier 1
atenolol oral
Tier 1
BETAPACE
Tier 3
BETAPACE AF
Tier 3
bisoprolol fumarate
Tier 1
BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG
Tier 3
QL
carvedilol
Tier 1
COREG
Tier 3
COREG CR
Tier 3
CORGARD
Tier 3
HEMANGEOL
Tier 3
INDERAL LA
Tier 3
INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG
Tier 3
labetalol hcl oral
Tier 1
metoprolol succinate er oral tablet extended release 24 hr* 100 mg, 200 mg, 25 mg, 50 mg
Tier 1
QL
metoprolol tartrate oral
Tier 1
nadolol oral
Tier 1
(Updated 08/01/2015)
42
QL
PA
QL
Drug Name
Drug Status
Drug Details
pindolol
Tier 1
propranolol hcl er
Tier 1
propranolol hcl oral solution
Tier 1
propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80 mg
Tier 1
propranolol hcl oral tablet 60 mg
Tier 1
SECTRAL
Tier 3
sotalol hcl (af) oral tablet 120 mg
Tier 1
sotalol hcl (af) oral tablet 160 mg, 80 mg
Tier 1
sotalol hcl oral tablet 120 mg, 80 mg
Tier 1
sotalol hcl oral tablet 160 mg, 240 mg
Tier 1
SOTYLIZE
Tier 3
TENORMIN
Tier 3
timolol maleate oral
Tier 1
TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 200 MG, 25 MG
Tier 3
QL
TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR* 50 MG
Tier 1
QL
TRANDATE
Tier 3
ZEBETA
Tier 3
*CALCIUM CHANNEL BLOCKERS*
ADALAT CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG, 90 MG
Tier 3
QL
AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG
Tier 1
QL
amlodipine besylate oral
Tier 1
CALAN
Tier 3
CALAN SR
Tier 3
CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG
Tier 3
QL
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR* 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG
Tier 3
QL
CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG
Tier 3
CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG
Tier 1
QL
diltiazem hcl cd
Tier 1
QL
diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg
Tier 1
QL
(Updated 08/01/2015)
43
Drug Name
Drug Status
Drug Details
diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg
Tier 1
QL
diltiazem hcl er coated beads oral tablet extended release 24 hr* 180 mg, 240 mg, 300 mg, 360 mg, 420 mg
Tier 3
QL
diltiazem hcl er oral capsule extended release 12 hour
Tier 1
diltiazem hcl er oral capsule extended release 24 hour
240 mg
Tier 1
QL
diltiazem hcl oral
Tier 1
felodipine er
Tier 1
QL
MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180 MG, 240 MG, 300 MG, 360 MG, 420 MG
Tier 3
QL
nicardipine hcl oral
Tier 1
NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG
Tier 1
QL
nifedipine er oral tablet extended release 24 hr* 30 mg, 60 mg, 90 mg
Tier 1
QL
nifedipine er osmotic oral tablet extended release 24 hr* 30 mg, 60 mg, 90 mg
Tier 1
QL
nifedipine oral
Tier 1
nimodipine oral
Tier 1
nisoldipine er oral tablet extended release 24 hr* 17 mg, 20 mg, 30 mg, 34 mg, 40 mg, 8.5 mg
Tier 1
nisoldipine er oral tablet extended release 24 hr* 25.5 mg
Tier 1
NORVASC
Tier 3
NYMALIZE
Tier 3
PROCARDIA
Tier 3
PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG, 90 MG
Tier 3
QL
SULAR ORAL TABLET EXTENDED RELEASE 24 HR* 17 MG, 34 MG, 8.5 MG
Tier 3
QL
TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG
Tier 1
QL
TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG
Tier 3
QL
verapamil hcl er oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg
Tier 1
QL
verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg
Tier 1
verapamil hcl er oral tablet extendedrelease* 120 mg
Tier 1
(Updated 08/01/2015)
44
QL
PA
Drug Name
Drug Status
verapamil hcl er oral tablet extendedrelease* 180 mg, 240 mg
Tier 1
verapamil hcl oral
Tier 1
VERELAN
Tier 3
VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG
Tier 3
Drug Details
QL
*CARDIOTONICS*
DIGOX
Tier 1
digoxin oral solution
Tier 1
digoxin oral tablet
Tier 1
LANOXIN ORAL TABLET 0.0625 MG, 187.5 MCG
Tier 3
LANOXIN ORAL TABLET 0.125 MG, 0.25 MG
Tier 1
LANOXIN PEDIATRIC
Tier 3
*CARDIOVASCULAR AGENTS ‐ MISC.*
ADCIRCA
Tier 4
PA; N2; QL
ADEMPAS
Tier 4
PA; N2; QL
BIDIL
Tier 3
CADUET
Tier 6
N4
CAVERJECT
LA
N2; #; Covered in DC; QL
CAVERJECT IMPULSE
LA
N2; #; Covered in DC; QL
CIALIS ORAL TABLET 10 MG, 20 MG, 5 MG
LA
N2; Covered in DC, NY; QL
CIALIS ORAL TABLET 2.5 MG
LA
N2; N4; Covered in DC, NY; QL
CORLANOR
EDEX
LETAIRIS
Tier 3
LA
Tier 4
PA; ST; QL
N2; Covered in DC; QL
PA; N2
LEVITRA ORAL TABLET 10 MG, 20 MG, 5 MG
LA
ST; N2; N3; Covered in DC, NY; QL
LEVITRA ORAL TABLET 2.5 MG
LA
ST; N2; N3; Covered in DC; QL
MUSE
LA
Covered in DC; QL
OPSUMIT
Tier 4
PA
ORENITRAM
Tier 4
PA; N2
REVATIO ORAL SUSPENSION RECONSTITUTED
Tier 4
PA; QL
REVATIO ORAL TABLET
Tier 4
PA; N2; QL
sildenafil citrate oral
Tier 4
STAXYN
LA
ST; N2; N3; Covered in DC; QL
STENDRA
LA
TRACLEER
Tier 4
PA; N2; #
TYVASO
Tier 4
PA; N2; QL
TYVASO REFILL
Tier 4
PA; N2; QL
(Updated 08/01/2015)
45
Drug Name
Drug Status
Drug Details
TYVASO STARTER
Tier 4
PA; N2; QL
VENTAVIS
Tier 4
PA; N2
VIAGRA
LA
*CEPHALOSPORINS*
CEDAX
Tier 3
cefaclor
Tier 1
N2
cefaclor er
Tier 1
N2; QL
cefadroxil
Tier 1
N2
cefdinir
Tier 1
N2
cefixime
Tier 3
QL
cefprozil
Tier 1
N2
CEFTIN
Tier 3
cefuroxime axetil oral tablet
Tier 1
N2
cephalexin oral capsule
Tier 1
N2
cephalexin oral tablet
Tier 1
N2
KEFLEX
Tier 3
N2
SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML
Tier 3
QL
SUPRAX ORAL TABLET CHEWABLE
Tier 3
QL
*CHEMICALS*
cyclopentolate hcl Tier 1
hydroxyzine hcl Tier 1
*CONTRACEPTIVES*
ALTAVERA
Tier 1
QL
alyacen 1/35
Tier 1
QL
alyacen 7/7/7
Tier 1
QL
AMETHIA
CE
N1; QL
AMETHIA LO
CE
N1; QL
AMETHYST
CE
QL
APRI
Tier 1
QL
ARANELLE
Tier 1
QL
AVIANE
Tier 1
QL
AZURETTE
Tier 1
QL
BALZIVA
Tier 1
QL
BEYAZ
Tier 3
QL
BREVICON (28)
Tier 3
QL
briellyn
Tier 1
QL
CAMRESE
CE
(Updated 08/01/2015)
46
N1; QL
Drug Name
Drug Status
Drug Details
CAMRESE LO
CE
N1; QL
CAZIANT
CE
CE; QL
CHATEAL
CE
CE; QL
CRYSELLE‐28
Tier 1
QL
CYCLAFEM 1/35
Tier 1
QL
CYCLESSA
Tier 3
QL
DASETTA 1/35
Tier 1
QL
DASETTA 7/7/7
Tier 1
QL
DAYSEE
CE
N1; QL
DELYLA
CE
CE
DEPO‐PROVERA INTRAMUSCULAR* SUSPENSION 150 MG/ML
Tier 3
QL
DEPO‐SUBQ PROVERA 104
Tier 3
QL
DESOGEN
Tier 3
QL
desogestrel‐ethinyl estradiol oral tablet 0.15‐30 mg‐mcg
Tier 1
QL
drospirenone‐ethinyl estradiol
Tier 1
QL
ELINEST
CE
CE; QL
ELLA
CE
QL
EMOQUETTE
Tier 1
QL
ENPRESSE‐28
Tier 1
QL
ENSKYCE
CE
CE; QL
ERRIN
Tier 1
QL
ESTARYLLA
Tier 1
QL
ESTROSTEP FE
Tier 3
QL
CE
CE
FALMINA
Tier 1
QL
FEMCON FE
Tier 3
QL
GENERESS FE
Tier 3
#; QL
GIANVI
Tier 1
QL
GILDAGIA
Tier 1
QL
GILDESS FE 1.5/30
Tier 1
QL
GILDESS FE 1/20
Tier 1
QL
IMPLANON
CE
CE
INTROVALE
CE
N1; QL
FALLBACK SOLO
JENCYCLA
JOLESSA
JOLIVETTE
Tier 1
CE
Tier 1
QL
N1; QL
QL
(Updated 08/01/2015)
47
Drug Name
Drug Status
Drug Details
JUNEL 1.5/30
Tier 1
QL
JUNEL 1/20
Tier 1
QL
JUNEL FE 1.5/30
Tier 1
QL
JUNEL FE 1/20
Tier 1
QL
KARIVA
Tier 1
QL
KELNOR 1/35
KURVELO
CE
CE; QL
Tier 1
QL
LARIN 1.5/30
CE
CE
LARIN 1/20
CE
CE
LARIN FE 1.5/30
CE
CE
LARIN FE 1/20
CE
CE
LEENA
CE
CE; QL
LESSINA
LEVONEST
Tier 1
QL
CE
CE; QL
levonorgest‐eth estrad 91‐day oral tablet 0.1‐0.02 & 0.01 mg
Tier 1
N1; QL
levonorgest‐eth estrad 91‐day oral tablet 0.15‐0.03 mg
CE
N1; QL
levonorgestrel oral tablet 0.75 mg
CE
CE; QL
levonorgestrel oral tablet 1.5 mg
CE
QL
levonorgestrel‐ethinyl estrad oral tablet 0.1‐20 mg‐mcg, 90‐20 mcg
Tier 1
QL
levonorgestrel‐ethinyl estrad oral tablet 0.15‐30 mg‐mcg
Tier 3
N1; QL
LEVORA 0.15/30 (28)
Tier 1
QL
LILETTA
CE
LO LOESTRIN FE
Tier 3
QL
LO/OVRAL (28)
Tier 3
QL
LOESTRIN 1.5/30 (21)
Tier 3
QL
LOESTRIN 1/20 (21)
Tier 3
QL
LOESTRIN FE 1.5/30
Tier 3
QL
LOESTRIN FE 1/20
Tier 3
QL
LOMEDIA 24 FE
Tier 3
QL
LORYNA
Tier 1
QL
LOSEASONIQUE
Tier 3
N1; QL
LOW‐OGESTREL
Tier 1
QL
LUTERA
Tier 1
QL
LYZA
Tier 1
QL
marlissa
Tier 1
QL
(Updated 08/01/2015)
48
Drug Name
medroxyprogesterone acetate intramuscular*
Drug Status
CE
Drug Details
CE; QL
MICROGESTIN 1.5/30
Tier 1
QL
MICROGESTIN 1/20
Tier 1
QL
MICROGESTIN FE 1.5/30
Tier 1
QL
MICROGESTIN FE 1/20
Tier 1
QL
MINASTRIN 24 FE
Tier 3
QL
MIRCETTE
Tier 3
QL
MIRENA
CE
CE; QL
MODICON (28)
Tier 3
QL
MONO‐LINYAH
Tier 1
QL
MONONESSA
Tier 1
QL
NATAZIA
Tier 3
QL
NECON 0.5/35 (28)
Tier 1
QL
NECON 1/35 (28)
Tier 1
QL
NECON 1/50 (28)
Tier 1
QL
NECON 10/11 (28)
Tier 1
QL
NEXPLANON
CE
CE; QL
NEXT CHOICE
CE
CE
NEXT CHOICE ONE DOSE
Tier 1
QL
NORA‐BE
Tier 1
QL
NORDETTE (28)
Tier 3
QL
norethin ace‐eth estrad‐fe oral tablet 1‐20 mg‐mcg
norethindrone oral
CE
Tier 1
QL
CE
QL
norgestimate‐eth estradiol
Tier 1
QL
norgestim‐eth estrad triphasic
Tier 1
QL
CE
CE
NORINYL 1+35 (28)
Tier 3
QL
NORINYL 1+50 (28)
Tier 3
QL
NOR‐QD
Tier 3
QL
NORTREL 0.5/35 (28)
Tier 1
QL
NORTREL 1/35 (21)
Tier 1
QL
NORTREL 1/35 (28)
Tier 1
QL
NORTREL 7/7/7
Tier 1
QL
CE
QL
OCELLA
Tier 1
QL
OGESTREL
Tier 3
QL
ORSYTHIA
Tier 1
QL
norethin‐eth estradiol‐fe
norgestrel‐ethinyl estradiol
NUVARING
(Updated 08/01/2015)
49
Drug Name
Drug Status
Drug Details
ORTHO EVRA
Tier 3
QL
ORTHO MICRONOR
Tier 3
QL
ORTHO TRI‐CYCLEN (28)
Tier 3
QL
ORTHO TRI‐CYCLEN LO
Tier 3
#; QL
ORTHO‐CEPT (28)
Tier 3
QL
ORTHO‐CYCLEN (28)
Tier 3
QL
ORTHO‐NOVUM 1/35 (28)
Tier 3
QL
ORTHO‐NOVUM 7/7/7 (28)
Tier 3
QL
OVCON‐35 (28)
Tier 3
QL
PARAGARD INTRAUTERINE COPPER
Tier 3
CE; QL
PHILITH
Tier 1
QL
PIMTREA
CE
CE
PIRMELLA 1/35
CE
CE; QL
PLAN B ONE‐STEP
Tier 1
QL
PORTIA‐28
Tier 1
QL
PREVIFEM
Tier 1
QL
QUARTETTE
Tier 3
N1; QL
QUASENSE
CE
N1; QL
RECLIPSEN
Tier 1
QL
SAFYRAL
Tier 3
QL
SEASONALE
Tier 3
QL
SEASONIQUE
Tier 3
N1; QL
SKYLA
CE
QL
SPRINTEC 28
Tier 1
QL
SRONYX
Tier 1
QL
SYEDA
Tier 1
QL
TAKE ACTION
CE
QL
TILIA FE
CE
CE; QL
TRI‐ESTARYLLA
Tier 1
QL
TRI‐LEGEST FE
Tier 1
QL
TRI‐LINYAH
Tier 1
QL
TRINESSA (28)
Tier 1
QL
TRI‐NORINYL (28)
Tier 3
QL
TRI‐PREVIFEM
Tier 1
QL
TRI‐SPRINTEC
Tier 1
QL
TRIVORA (28)
Tier 1
QL
VELIVET
Tier 1
QL
VESTURA
Tier 1
QL
(Updated 08/01/2015)
50
Drug Name
Drug Status
Drug Details
VYFEMLA
CE
CE
WERA
CE
CE; QL
WYMZYA FE
CE
CE; QL
XULANE
CE
CE; QL
YASMIN 28
Tier 3
QL
YAZ
Tier 3
QL
ZARAH
Tier 1
QL
ZENCHENT
Tier 1
QL
CE
QL
ZOVIA 1/35E (28)
Tier 1
QL
ZOVIA 1/50E (28)
Tier 1
QL
ZENCHENT FE
*CORTICOSTEROIDS*
budesonide er
Tier 1
CORTEF
Tier 3
cortisone acetate oral
Tier 1
dexamethasone oral
Tier 1
ENTOCORT EC
Tier 3
fludrocortisone acetate oral
Tier 1
hydrocortisone oral
Tier 1
MEDROL
Tier 3
MEDROL (PAK)
Tier 3
methylprednisolone (pak)
Tier 1
methylprednisolone oral
Tier 1
ORAPRED ODT
Tier 3
prednisolone sodium phosphate Tier 3
prednisolone sodium phosphate oral tablet dispersible
Tier 3
prednisone (pak)
Tier 1
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg
Tier 1
prednisone oral tablet 50 mg
Tier 1
RAYOS
Tier 3
N3
UCERIS ORAL
Tier 3
ST; N3; QL
*COUGH/COLD/ALLERGY*
acetylcysteine inhalation
Tier 1
ALAVERT ALLERGY/SINUS
Tier 1
Select OTC
ALLEGRA‐D ALLERGY & CONGESTION
Tier 6
N4
benzonatate oral capsule 100 mg, 200 mg
Tier 1
benzonatate oral capsule 150 mg
Tier 6
(Updated 08/01/2015)
51
Drug Name
Drug Status
Drug Details
BROMFED DM
Tier 3
N2
cetirizine‐pseudoephedrine er
Tier 1
Select OTC
cheratussin ac oral syrup
Tier 1
N2
CLARINEX‐D 12 HOUR
Tier 3
QL
CLARITIN‐D 12 HOUR
Tier 1
N2; Select OTC
CLARITIN‐D 24 HOUR
Tier 1
N2; Select OTC
fexofenadine‐pseudoephed er
Tier 1
Select OTC
guaifenesin‐codeine
Tier 1
N2
hydrocodone‐homatropine
Tier 1
N2
loratadine‐d 12hr
Tier 1
Select OTC
loratadine‐d 24hr
Tier 1
Select OTC
NEBUSAL INHALATION NEBULIZATION SOLUTION 3 %
Tier 1
OBREDON
Tier 3
promethazine vc
Tier 1
promethazine vc plain
Tier 1
promethazine vc/codeine
Tier 1
N2
promethazine‐codeine
Tier 1
N2
promethazine‐dm
Tier 1
pseudoeph‐chlorphen‐hydrocod
Tier 3
REZIRA
Tier 3
SEMPREX‐D
Tier 3
sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 %
Tier 1
TESSALON PERLES
Tier 3
TUSSICAPS
Tier 3
QL
TUSSIONEX PENNKINETIC ER
Tier 3
N2; QL
TUZISTRA XR
Tier 3
VITUZ
Tier 3
QL
ZONATUSS
Tier 6
N4
ZUTRIPRO
Tier 3
ZYRTEC‐D ALLERGY & CONGESTION
Tier 1
Select OTC
ABREVA
Tier 1
N2; Select OTC; QL
ABSORICA
Tier 6
N4
ACANYA
Tier 6
N4
acitretin
Tier 1
QL
acyclovir external
Tier 3
ACZONE
Tier 3
*DERMATOLOGICALS*
(Updated 08/01/2015)
52
Drug Name
Drug Status
Drug Details
adapalene external 0.1 %
Tier 3
adapalene external 0.3 %
Tier 3
adapalene external cream
Tier 3
adapalene external lotion
Tier 3
alclometasone dipropionate
Tier 1
ALDARA
Tier 3
ALTABAX
Tier 3
aluminum acetate external
Tier 1
AMNESTEEM
Tier 3
PA; ST; N2; N3; QL
ATRALIN
Tier 3
#; QL
AVAR CLEANSER
Tier 1
AVAR‐E EMOLLIENT
Tier 3
AVAR‐E GREEN
Tier 3
AVITA
Tier 3
AZELEX
Tier 2
BACTROBAN
Tier 3
BENZACLIN
Tier 3
QL
BENZACLIN WITH PUMP
Tier 6
N4
BENZAMYCIN
Tier 3
BENZAMYCINPAK
Tier 3
benzoyl peroxide‐erythromycin
Tier 1
betamethasone dipropionate aug external cream
Tier 1
betamethasone dipropionate aug external lotion
Tier 1
betamethasone dipropionate aug external ointment
Tier 1
betamethasone valerate external cream
Tier 1
betamethasone valerate external lotion
Tier 1
betamethasone valerate external ointment
Tier 1
bp 10‐1
Tier 1
calcipotriene external
Tier 3
calcipotriene‐betameth diprop
Tier 3
CALCITRENE
Tier 3
ST; N3
calcitriol external
Tier 3
ST; N3
CAPEX
Tier 2
CICLODAN CREAM
Tier 6
N4
CICLODAN SOLUTION
Tier 6
N4
ciclopirox external
Tier 3
N2
ciclopirox external shampoo
Tier 3
ciclopirox olamine external cream
Tier 1
ST; N3
ST
QL
QL
N2
(Updated 08/01/2015)
53
Drug Name
Drug Status
Drug Details
CLARAVIS
Tier 1
CLARIFOAM EF
Tier 2
CLEOCIN‐T
Tier 3
CLINDACIN PAC
Tier 6
CLINDAGEL
Tier 3
clindamycin phos‐benzoyl perox external 1‐5 %
Tier 3
QL
clindamycin phosphate external lotion
Tier 1
N2
clindamycin phosphate external solution
Tier 1
N2
clindamycin phosphate external swab
Tier 3
N2
clobetasol propionate e
Tier 1
clobetasol propionate external cream
Tier 1
clobetasol propionate external liquid†
Tier 1
clobetasol propionate external ointment
Tier 1
CLOBEX
Tier 3
CLOBEX SPRAY
Tier 3
CLODERM
Tier 3
CLODERM PUMP
Tier 3
clotrimazole af
Tier 1
clotrimazole anti‐fungal
Tier 1
clotrimazole external cream
Tier 1
CNL8 NAIL
Tier 6
CONDYLOX
Tier 3
CORDRAN EXTERNAL TAPE
Tier 3
QL
COSENTYX
Tier 4
PA
COSENTYX SENSOREADY PEN
Tier 4
PA
CUTIVATE EXTERNAL CREAM
Tier 3
CUTIVATE EXTERNAL LOTION
Tier 3
cvs clotrimazole
Tier 1
cvs permethrin
Tier 1
DENAVIR
Tier 3
DERMA‐SMOOTHE/FS BODY
Tier 2
DERMA‐SMOOTHE/FS SCALP
Tier 2
DERMATOP
Tier 3
DERMAZENE
Tier 3
DESONATE
Tier 3
desonide external cream
Tier 1
desonide external ointment
Tier 1
DESOWEN EXTERNAL CREAM
Tier 3
(Updated 08/01/2015)
54
PA; ST; N3; QL
N4
N4
N2
Drug Name
Drug Status
Drug Details
diclofenac sodium transdermal
Tier 1
diclofenac sodium transdermal solution
Tier 1
QL
DIFFERIN EXTERNAL
Tier 3
ST; N3
DIFFERIN EXTERNAL CREAM
Tier 3
DIFFERIN EXTERNAL LOTION
Tier 3
DIPROLENE
Tier 3
DIPROLENE AF
Tier 3
DOVONEX EXTERNAL CREAM
Tier 3
doxycycline
Tier 6
DRYSOL
Tier 3
DUAC
Tier 3
econazole nitrate external
Tier 1
ECOZA
Tier 6
EFUDEX
Tier 3
ELIDEL
Tier 3
ELIMITE
Tier 3
ELOCON
Tier 3
EMLA
Tier 3
N2
EPIDUO
Tier 3
QL
ERTACZO
Tier 3
erythromycin external solution
Tier 1
EURAX
Tier 2
EVOCLIN
Tier 3
EXELDERM
Tier 2
EXTINA
Tier 3
FABIOR
Tier 3
FINACEA
Tier 3
FLECTOR
Tier 6
fluocinolone acetonide body
Tier 1
fluocinolone acetonide scalp
Tier 1
fluocinonide external
Tier 1
fluocinonide external cream 0.05 %
Tier 1
fluocinonide external cream 0.1 %
Tier 1
fluocinonide external ointment
Tier 1
fluocinonide‐e
Tier 1
FLUOROPLEX
Tier 3
fluorouracil external cream 0.5 %
Tier 3
fluorouracil external cream 5 %
Tier 1
QL
N4
PA; N2; QL
N4
(Updated 08/01/2015)
55
Drug Name
Drug Status
Drug Details
fluorouracil external solution
Tier 1
fluticasone propionate external cream
Tier 1
fluticasone propionate external lotion
Tier 3
fluticasone propionate external ointment
Tier 1
gentamicin sulfate external
Tier 1
halobetasol propionate
Tier 1
HALOG
Tier 3
HALONATE
Tier 6
N4
HALONATE PAC
Tier 6
N4
hydrocortisone ace‐pramoxine external
Tier 1
hydrocortisone butyr lipo base
Tier 1
hydrocortisone butyrate external
Tier 1
hydrocortisone external cream 2.5 %
Tier 1
hydrocortisone external lotion 2.5 %
Tier 1
hydrocortisone external ointment 2.5 %
Tier 1
hydrocortisone valerate
Tier 1
hydrocortisone‐iodoquinol
Tier 3
HYLATOPIC
Tier 3
imiquimod external
Tier 1
JUBLIA
Tier 3
KENALOG EXTERNAL
Tier 3
KERYDIN
Tier 3
KETODAN EXTERNAL KIT
Tier 6
KLARON
Tier 3
kp clotrimazole
Tier 1
LAC‐HYDRIN
Tier 3
LEVULAN KERASTICK
Tier 3
lidocaine external patch
Tier 1
lidocaine‐prilocaine external cream
Tier 1
LIDODERM
Tier 3
lidorx
Tier 3
QL
lindane external lotion
Tier 1
N2; QL
lindane external shampoo
Tier 2
N2; QL
LOCOID EXTERNAL CREAM
Tier 3
LOCOID EXTERNAL LOTION
Tier 3
LOCOID EXTERNAL OINTMENT
Tier 3
LOCOID LIPOCREAM
Tier 3
LOPROX EXTERNAL SHAMPOO
Tier 3
(Updated 08/01/2015)
56
QL
N4
N2
Drug Name
Drug Status
Drug Details
LOTRISONE
Tier 3
LUXIQ
Tier 3
LUZU
Tier 3
MENTAX
Tier 3
methoxsalen rapid
Tier 1
METROCREAM
Tier 3
METROGEL
Tier 3
METROLOTION
Tier 3
metronidazole external 0.75 %
Tier 1
N2
metronidazole external 1 %
Tier 3
N2
metronidazole external cream
Tier 1
N2
metronidazole external lotion
Tier 1
N2
MIRVASO
Tier 3
mometasone furoate external
Tier 1
mupirocin calcium
Tier 1
mupirocin external
Tier 1
MYORISAN
Tier 3
naftifine hcl
Tier 3
NAFTIN
Tier 3
NATROBA
Tier 3
NORITATE
Tier 3
nystatin external cream
Tier 1
N2
nystatin external ointment
Tier 1
N2
nystatin‐triamcinolone
Tier 1
N2
OLUX
Tier 3
OLUX‐E
Tier 3
ONEXTON
Tier 6
ORACEA
Tier 6
OVACE WASH
Tier 3
OVIDE
Tier 3
OXISTAT
Tier 3
OXSORALEN
Tier 2
OXSORALEN ULTRA
Tier 3
PANDEL
Tier 3
PANRETIN
Tier 3
PEDIADERM HC
Tier 6
PENLAC
Tier 3
PENNSAID TRANSDERMAL SOLUTION 1.5 %
Tier 6
PA; ST; N3; QL
N4
QL
N4
N4
(Updated 08/01/2015)
57
Drug Name
Drug Status
Drug Details
PENNSAID TRANSDERMAL SOLUTION 2 %
Tier 3
ST; N4; QL
permethrin external
Tier 1
N2
PICATO
Tier 2
N2; QL
PLEXION
Tier 3
PLEXION CLEANSER EXTERNAL LIQUID†
Tier 3
PLEXION CLEANSING CLOTH EXTERNAL PAD
Tier 3
podocon
Tier 3
podofilox external
Tier 1
PRAMOSONE EXTERNAL CREAM 1‐1 %
Tier 3
PRAMOSONE EXTERNAL LOTION
Tier 3
PROTOPIC
Tier 3
PRUDOXIN
Tier 3
qc clotrimazole
Tier 1
ra clotrimazole
Tier 1
REGRANEX
Tier 3
RETIN‐A
Tier 3
QL
RETIN‐A MICRO
Tier 3
QL
RETIN‐A MICRO PUMP
Tier 3
ST; QL
ROSADAN EXTERNAL
Tier 3
ROSADAN EXTERNAL CREAM
Tier 1
ROSADAN EXTERNAL KIT
Tier 6
ROSANIL CLEANSER
Tier 3
SALEX EXTERNAL SHAMPOO
Tier 3
salicylic acid external solution 28.5 %
Tier 1
SANTYL
Tier 3
selenium sulfide external lotion
Tier 1
selenium sulf‐pyrithione‐urea
Tier 1
SELRX
Tier 6
SELSUN BLUE MEDICATED
Tier 6
SILVADENE
Tier 3
silver sulfadiazine external
Tier 1
sm antifungal clotrimazole
Tier 1
SOLARAZE
Tier 3
SOOLANTRA
Tier 3
ST
SORIATANE
Tier 2
QL
SORILUX
Tier 6
N4
STELARA
Tier 4
sulfacetamide sodium‐sulfur external cream 9.8‐4.8 %
Tier 3
(Updated 08/01/2015)
58
PA; N2; #; QL
N4
N4
N2
ST
Drug Name
Drug Status
Drug Details
sulfacetamide sodium‐sulfur external emulsion
Tier 1
sulfacetamide sodium‐sulfur external liquid† 9.8‐4.8 %
Tier 3
sulfacetamide sodium‐sulfur external liquid† 9‐4.5 %
Tier 1
sulfacetamide sodium‐sulfur external lotion 10‐5 %
Tier 1
sulfacetamide sodium‐sulfur external lotion 9.8‐4.8 %
Tier 3
sulfacetamide sodium‐sulfur external suspension 10‐5 %
Tier 1
sulfacetamide sod‐sulfur wash
Tier 6
sulfacetamide‐sulfur in urea
Tier 1
SULFAMYLON
Tier 3
SUMADAN
Tier 6
N4
SUMADAN WASH
Tier 6
N4
SUMADAN XLT
Tier 6
N4
SUMAXIN CP
Tier 6
N4
SYNALAR
Tier 3
SYNALAR (CREAM)
Tier 3
SYNALAR (OINTMENT)
Tier 3
SYNALAR TS
Tier 6
SYNERA
Tier 3
TACLONEX EXTERNAL OINTMENT
Tier 3
tacrolimus external
Tier 3
PA; QL
TARGRETIN EXTERNAL
Tier 4
N2
TAZORAC
Tier 3
TEMOVATE EXTERNAL CREAM
Tier 3
TEMOVATE EXTERNAL OINTMENT
Tier 3
tgt clotrimazole
Tier 1
th clotrimazole
Tier 1
TOPICORT
Tier 3
TOPICORT SPRAY
Tier 6
tretinoin external 0.01 %
Tier 1
tretinoin external 0.025 %
Tier 1
QL
tretinoin external cream
Tier 1
QL
tretinoin microsphere
Tier 1
QL
tretinoin microsphere pump
Tier 1
QL
TRETIN‐X EXTERNAL CREAM 0.0375 %
Tier 3
QL
TRETIN‐X EXTERNAL KIT 0.025 % CREAM, 0.05 % CREAM, 0.1 % CREAM
Tier 6
N4
triamcinolone acetonide external aerosol, solution
Tier 1
ST
ST
N4
N4
N4
(Updated 08/01/2015)
59
Drug Name
Drug Status
Drug Details
triamcinolone acetonide external cream
Tier 1
triamcinolone acetonide external ointment
Tier 1
ULESFIA
Tier 3
QL
ULTRASAL‐ER
Tier 1
ULTRAVATE
Tier 3
ULTRAVATE X (CREAM)
Tier 6
N4
ULTRAVATE X (OINTMENT)
Tier 6
N4
VALCHLOR
Tier 4
PA; N2; QL
VANIQA
Tier 3
VANOS
Tier 3
VANOXIDE‐HC
Tier 3
VECTICAL
Tier 3
VELTIN
Tier 3
VERDESO
Tier 3
VEREGEN
Tier 3
VOLTAREN TRANSDERMAL
Tier 2
WESTCORT
Tier 3
XERAC AC
Tier 2
XOLEGEL
Tier 3
ZENATANE ORAL CAPSULE 10 MG, 20 MG, 40 MG
Tier 3
PA; ST; N3; QL
ZENATANE ORAL CAPSULE 30 MG
Tier 3
PA; ST; QL
ZIANA
Tier 3
ZITHRANOL
Tier 3
ZOVIRAX EXTERNAL CREAM
Tier 3
ZOVIRAX EXTERNAL OINTMENT
Tier 3
N2
ZYCLARA
Tier 6
PA; N4
ZYCLARA PUMP
Tier 6
PA; N4
ACCU‐CHEK AVIVA IN VITRO STRIP
Tier 3
PA; ST; N3; N4; QL
ACCU‐CHEK COMFORT CURVE IN VITRO STRIP
Tier 3
PA; ST; N3; N4; QL
ACCU‐CHEK SMARTVIEW
Tier 3
PA; ST; N3; N4; QL
FREESTYLE INSULINX TEST
Tier 3
PA; ST; N3; QL
FREESTYLE LITE TEST
Tier 3
PA; ST; N3; QL
FREESTYLE TEST
Tier 3
PA; ST; N3; QL
NOVA MAX GLUCOSE TEST
Tier 3
PA; ST; N3; QL
ONETOUCH ULTRA BLUE
Tier 2
QL
ONETOUCH VERIO IN VITRO STRIP
Tier 2
QL
PRECISION XTRA BLOOD GLUCOSE
Tier 3
PA; ST; N3; QL
#
QL
*DIAGNOSTIC PRODUCTS*
(Updated 08/01/2015)
60
Drug Name
Drug Status
Drug Details
RA TRUETEST TEST
Tier 3
PA; ST; N3; QL
TRUETEST TEST
Tier 3
PA; ST; N3; QL
TRUETRACK TEST
Tier 3
PA; ST; N3; QL
APPTRIM
LA
Covered in TX
APPTRIM‐D
LA
Covered in TX
AVAILNEX
LA
Covered in TX
AXONA
LA
Covered in TX
CARDIOTEK RX
LA
Covered in TX
CEREFOLIN
LA
Covered in TX
CEREFOLIN NAC
LA
Covered in TX
DEPLIN 15
LA
Covered in TX
DEPLIN 7.5
LA
Covered in TX
DERMANIC
Tier 3
*DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS*
ENLYTE
LA
Covered in TX
ENTERAGAM
LA
Covered in TX
FOLBEE AR
LA
Covered in TX
FOLBIC
LA
Covered in TX
FOLBIC RF
LA
Covered in TX
FOLTANX
LA
Covered in TX
FOLTANX RF
LA
Covered in TX
FOLTX
LA
Covered in TX
FOSTEUM
LA
Covered in TX
FOSTEUM PLUS
LA
Covered in TX
FOVEX
LA
Covered in TX
GABADONE
LA
Covered in TX
HYPERTENSA
LA
Covered in TX
LIMBREL
LA
Covered in TX
LIMBREL250
LA
Covered in TX
LIMBREL500
LA
Covered in TX
LIPICHOL 540
LA
Covered in TX
LISTER‐V
LA
Covered in TX
l‐methylfolate
LA
Covered in TX
l‐methylfolate ca me‐cbl nac
LA
Covered in TX
l‐methylfolate formula 15
LA
Covered in TX
l‐methylfolate formula 7.5
LA
Covered in TX
l‐methylfolate forte
LA
Covered in TX
(Updated 08/01/2015)
61
Drug Name
Drug Status
Drug Details
l‐methylfolate‐algae‐b12‐b6
LA
Covered in TX
l‐methylfolate‐b6‐b12
LA
Covered in TX
l‐methyl‐mc
LA
Covered in TX
l‐methyl‐mc nac
LA
Covered in TX
LUKAID GLA
LA
Covered in TX
MACUTEK
LA
Covered in TX
METAFOLBIC
LA
Covered in TX
METAFOLBIC PLUS
LA
Covered in TX
METAFOLBIC PLUS RF
LA
Covered in TX
METANX ORAL CAPSULE
LA
Covered in TX
PERCURA
LA
Covered in TX
PODIAPN
LA
Covered in TX
PROTEOLIN DS
LA
Covered in TX
PROTEOLIN ORAL TABLET
LA
Covered in TX
PULMONA
LA
Covered in TX
SENTRA AM
LA
Covered in TX
SENTRA PM
LA
Covered in TX
THERAMINE
LA
Covered in TX
TOZAL
LA
Covered in TX
TREPADONE
LA
Covered in TX
VASCAZEN
LA
Covered in TX
VASCULERA
LA
Covered in TX
VAYACOG
LA
Covered in TX
VAYARIN
LA
Covered in TX
VIRILEX
LA
Covered in TX
virt‐vite forte
LA
Covered in TX
VITA‐RESPA
LA
Covered in TX
vp‐gstn
LA
Covered in TX
VSL#3 JUNIOR
LA
Covered in TX
*DIGESTIVE AIDS*
CREON
Tier 2
PANCREAZE
Tier 3
PERTZYE
Tier 3
SUCRAID
Tier 4
ULTRESA
Tier 3
VIOKACE
Tier 3
ZENPEP
Tier 2
(Updated 08/01/2015)
62
N2
Drug Name
Drug Status
Drug Details
*DIURETICS*
acetazolamide er
Tier 1
acetazolamide oral
Tier 1
ALDACTAZIDE
Tier 3
ALDACTONE
Tier 3
amiloride hcl oral
Tier 1
amiloride‐hydrochlorothiazide
Tier 1
bumetanide oral tablet 0.5 mg, 1 mg
Tier 1
bumetanide oral tablet 2 mg
Tier 1
chlorothiazide oral
Tier 1
N2
chlorthalidone oral tablet 25 mg, 50 mg
Tier 1
DEMADEX
Tier 3
DIAMOX SEQUELS
Tier 3
DIURIL
Tier 3
DYAZIDE
Tier 3
DYRENIUM
Tier 3
EDECRIN
Tier 3
furosemide oral tablet
Tier 1
hydrochlorothiazide oral capsule
Tier 1
hydrochlorothiazide oral tablet 12.5 mg
Tier 1
hydrochlorothiazide oral tablet 25 mg, 50 mg
Tier 1
indapamide oral
Tier 1
LASIX
Tier 3
MAXZIDE
Tier 3
MAXZIDE‐25
Tier 3
methazolamide oral
Tier 1
metolazone
Tier 1
MICROZIDE
Tier 3
NEPTAZANE
Tier 3
spironolactone oral tablet 100 mg, 50 mg
Tier 1
spironolactone oral tablet 25 mg
Tier 1
spironolactone‐hctz
Tier 1
torsemide oral
Tier 1
triamterene‐hctz oral capsule 37.5‐25 mg
Tier 1
triamterene‐hctz oral capsule 50‐25 mg
Tier 1
triamterene‐hctz oral tablet
Tier 1
ZAROXOLYN
Tier 3
(Updated 08/01/2015)
63
Drug Name
Drug Status
Drug Details
*ENDOCRINE AND METABOLIC AGENTS ‐ MISC.*
ACTONEL ORAL TABLET 150 MG
Tier 3
N3; #; QL
ACTONEL ORAL TABLET 30 MG, 35 MG, 5 MG
Tier 3
#; QL
alendronate sodium oral solution
Tier 1
QL
alendronate sodium oral tablet 10 mg, 35 mg, 40 mg, 5 mg
Tier 1
QL
alendronate sodium oral tablet 70 mg
Tier 1
ATELVIA
Tier 3
QL
BINOSTO
Tier 6
N4
BONIVA ORAL
Tier 3
QL
BRAVELLE
LA
BUPHENYL
Tier 4
cabergoline
Tier 1
calcitonin (salmon)
Tier 1
calcitriol oral capsule
Tier 1
CARBAGLU
Tier 4
CARNITOR ORAL
Tier 3
CARNITOR SF
Tier 3
PA; N2; Covered in VA
PA; N2
N2; QL
PA; N2
CETROTIDE SUBCUTANEOUS* KIT 0.25 MG
LA
PA; N2
chorionic gonadotropin intramuscular*
LA
clomiphene citrate oral
LA
Covered in VA
CYSTADANE
Tier 4
DDAVP NASAL
Tier 3
DDAVP ORAL
Tier 3
DDAVP RHINAL TUBE
Tier 3
desmopressin ace rhinal tube
Tier 1
desmopressin ace spray refrig
Tier 1
desmopressin acetate oral
Tier 1
desmopressin acetate spray
Tier 1
DIDRONEL
Tier 3
doxercalciferol oral
Tier 3
ST; N3
EGRIFTA SUBCUTANEOUS* SOLUTION RECONSTITUTED 2 MG
Tier 4
PA; N2
etidronate disodium
Tier 3
EVISTA
Tier 3
FOLLISTIM AQ
LA
N2
FORTEO
Tier 4
PA; N2
FORTICAL
Tier 1
QL
(Updated 08/01/2015)
64
Drug Name
Drug Status
Drug Details
FOSAMAX ORAL TABLET 10 MG
Tier 3
FOSAMAX ORAL TABLET 70 MG
Tier 3
QL
FOSAMAX PLUS D
Tier 3
QL
ganirelix acetate
LA
PA; N2
GENOTROPIN
Tier 6
N4
GENOTROPIN MINIQUICK
Tier 6
N4
GONAL‐F
LA
GONAL‐F RFF
LA
GONAL‐F RFF PEN
LA
Covered in VA
GONAL‐F RFF REDIJECT
LA
Covered in VA
HECTOROL ORAL
Tier 3
ST; N3
HUMATROPE
Tier 6
N4
ibandronate sodium oral
Tier 3
PA; QL
INCRELEX
Tier 4
PA; N2
KUVAN ORAL PACKET
Tier 4
PA
KUVAN ORAL TABLET SOLUBLE
Tier 4
PA; N2
MENOPUR
LA
MIACALCIN INJECTION
Tier 3
MIACALCIN NASAL
Tier 3
QL
MYALEPT
Tier 4
PA; QL
NATPARA
Tier 4
PA; QL
NORDITROPIN FLEXPRO SUBCUTANEOUS* SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 5 MG/1.5ML
Tier 6
N4
NORDITROPIN NORDIFLEX PEN
Tier 6
N4
NOVAREL
LA
NUTROPIN AQ NUSPIN 10
Tier 6
N4
Tier 6
N4
Tier 6
N4
NUTROPIN AQ PEN
Tier 6
N4
octreotide acetate
Tier 4
PA; N2
OMNITROPE
Tier 4
PA; N2
ORFADIN
Tier 4
N2
OSPHENA
Tier 3
ST; N3; QL
OVIDREL
LA
paricalcitol intravenous*
Tier 4
paricalcitol oral
Tier 1
PREGNYL
raloxifene hcl
LA
Tier 1
PA; N2
CE
(Updated 08/01/2015)
65
Drug Name
RAVICTI
REPRONEX
Drug Status
Tier 4
LA
Drug Details
PA; N2; QL
risedronate sodium oral tablet 150 mg
Tier 3
N3; QL
risedronate sodium oral tablet 30 mg, 35 mg, 5 mg
Tier 3
QL
risedronate sodium oral tablet delayed release
Tier 3
PA; ST; QL
ROCALTROL
Tier 3
SAIZEN
Tier 6
N4
SAIZEN CLICK.EASY
Tier 6
N4
SAMSCA ORAL TABLET 15 MG, 30 MG
Tier 4
PA; N2; QL
SANDOSTATIN
Tier 4
PA; N2
SENSIPAR
Tier 3
ST; N3
SEROPHENE
LA
N2; Covered in VA
SEROSTIM
Tier 6
N4
SIGNIFOR
Tier 4
PA; N2; QL
SIGNIFOR LAR
Tier 4
PA; QL
SKELID
Tier 3
QL
sodium phenylbutyrate oral
Tier 4
PA; N2
SOMATULINE DEPOT
Tier 4
PA; N2
SOMAVERT SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG
Tier 4
PA; N2
SOMAVERT SUBCUTANEOUS* SOLUTION RECONSTITUTED 25 MG, 30 MG
Tier 4
PA
STIMATE
Tier 4
PA
SYNAREL
Tier 2
TEV‐TROPIN
Tier 6
N4
ZEMPLAR ORAL
Tier 3
ST; N3; QL
ZOMACTON
Tier 6
PA
ZORBTIVE
Tier 4
PA; N2
ACTIVELLA
Tier 3
QL
ALORA
Tier 3
QL
ANGELIQ
Tier 3
QL
CENESTIN ORAL TABLET 0.45 MG, 0.625 MG, 0.9 MG
Tier 3
QL
CLIMARA
Tier 3
QL
CLIMARA PRO
Tier 3
#; QL
COMBIPATCH
Tier 3
#; QL
DIVIGEL
Tier 3
DUAVEE
Tier 2
*ESTROGENS*
(Updated 08/01/2015)
66
QL
Drug Name
Drug Status
Drug Details
ELESTRIN
Tier 3
QL
ENJUVIA
Tier 3
QL
ESTRACE ORAL
Tier 3
estradiol oral
Tier 1
estradiol transdermal patch weekly
Tier 1
QL
estradiol‐norethindrone acet
Tier 1
QL
ESTROGEL
Tier 3
QL
estropipate oral tablet 0.75 mg, 1.5 mg
Tier 1
estropipate oral tablet 3 mg
Tier 1
EVAMIST
Tier 3
QL
FEMHRT LOW DOSE
Tier 3
QL
JINTELI
Tier 1
MENEST
Tier 3
MENOSTAR
Tier 3
QL
MIMVEY
Tier 1
QL
MINIVELLE
Tier 3
QL
norethindrone‐eth estradiol oral tablet 0.5‐2.5 mg‐mcg
Tier 3
QL
PREFEST
Tier 3
QL
PREMARIN ORAL
Tier 2
PREMPHASE
Tier 2
PREMPRO
Tier 2
VIVELLE‐DOT
Tier 3
QL
AVELOX ORAL
Tier 3
N2; QL
CIPRO ORAL SUSPENSION RECONSTITUTED
Tier 3
N2
CIPRO ORAL TABLET 250 MG, 500 MG
Tier 3
N2
CIPRO XR ORAL TABLET EXTENDED RELEASE 24 HR* 1000 MG, 500 MG
Tier 3
QL
ciprofloxacin hcl oral
Tier 1
N2
FACTIVE
Tier 3
N2; #; QL
LEVAQUIN ORAL SOLUTION
Tier 3
N2; QL
LEVAQUIN ORAL TABLET
Tier 3
N2; QL
levofloxacin oral solution
Tier 1
N2; QL
levofloxacin oral tablet
Tier 1
N2; QL
moxifloxacin hcl oral
Tier 1
N2; QL
NOROXIN
Tier 3
N2; QL
ofloxacin oral tablet 400 mg
Tier 1
N2; QL
*FLUOROQUINOLONES*
(Updated 08/01/2015)
67
Drug Name
Drug Status
Drug Details
*GASTROINTESTINAL AGENTS ‐ MISC.*
ACTIGALL
Tier 3
alosetron hcl
Tier 1
AMITIZA
Tier 2
ST; N2; N3; QL
APRISO
Tier 3
ST; N3; QL
ASACOL HD
Tier 2
#; QL
AZULFIDINE
Tier 3
ST; N3; QL
AZULFIDINE EN‐TABS
Tier 3
ST; N3; QL
balsalazide disodium
Tier 1
QL
calcium acetate (phos binder)
Tier 1
calcium acetate oral capsule
Tier 1
CANASA
Tier 2
QL
CHENODAL
Tier 4
PA; N2
CHOLBAM
Tier 4
PA
CIMZIA
Tier 4
CIMZIA PREFILLED
Tier 4
CIMZIA STARTER KIT
Tier 4
COLAZAL
Tier 3
QL
DELZICOL
Tier 2
QL
DIPENTUM
Tier 3
ST; N3; QL
ELIPHOS
Tier 1
FOSRENOL
Tier 3
GATTEX
Tier 4
PA; Tier 2 for DE; QL
GIAZO
Tier 3
PA; ST; N3; QL
lactulose encephalopathy
Tier 1
LIALDA
Tier 2
QL
LINZESS ORAL CAPSULE 145 MCG
Tier 3
ST; N3; QL; AL
LINZESS ORAL CAPSULE 290 MCG
Tier 3
ST; N3; QL
LOTRONEX
Tier 2
N2
mesalamine enema
Tier 1
metoclopramide hcl injection
Tier 1
metoclopramide hcl oral solution 5 mg/5ml
Tier 1
metoclopramide hcl oral tablet 10 mg
Tier 1
metoclopramide hcl oral tablet 5 mg
Tier 1
metoclopramide hcl oral tablet dispersible
Tier 6
METOZOLV ODT ORAL TABLET DISPERSIBLE 5 MG
Tier 6
N4
MOVANTIK
Tier 3
PA; QL
(Updated 08/01/2015)
68
Drug Name
Drug Status
Drug Details
PENTASA ORAL CAPSULE EXTENDED RELEASE* 250 MG, 500 MG
Tier 2
PHOSLO
Tier 3
REGLAN ORAL
Tier 3
RELISTOR
Tier 3
REMICADE
Tier 4
PA
RENAGEL
Tier 3
#
RENVELA
Tier 3
sevelamer carbonate
Tier 1
sulfasalazine oral
Tier 1
QL
SULFAZINE
Tier 1
QL
URSO 250
Tier 3
URSO FORTE
Tier 3
ursodiol oral capsule
Tier 1
ursodiol oral tablet
Tier 3
VELPHORO
Tier 3
QL
*GENITOURINARY AGENTS ‐ MISCELLANEOUS*
acetic acid irrigation
Tier 1
alfuzosin hcl er
Tier 1
QL
AVODART
Tier 3
#; QL
CARDURA XL
Tier 3
QL
citric acid‐sodium citrate
Tier 1
CYSTAGON
Tier 4
CYTRA‐3
Tier 1
cytra‐k
Tier 1
ELMIRON
Tier 2
finasteride oral tablet 5 mg
Tier 1
FLOMAX
Tier 3
JALYN
Tier 3
PHENAZO ORAL TABLET 200 MG
Tier 1
phenazopyridine hcl oral tablet 100 mg
Tier 1
phenazopyridine hcl oral tablet 200 mg
Tier 1
potassium citrate er
Tier 1
PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 MG, 75 MG
Tier 4
PROSCAR
Tier 3
RAPAFLO
Tier 3
SHOHLS MODIFIED
Tier 3
PA; N2
#; QL
PA; N2; QL
QL
(Updated 08/01/2015)
69
Drug Name
Drug Status
Drug Details
tamsulosin hcl
Tier 1
tricitrates
Tier 1
UROCIT‐K 10
Tier 3
UROCIT‐K 15
Tier 3
UROCIT‐K 5
Tier 3
UROXATRAL
Tier 3
QL
allopurinol oral
Tier 1
colchicine oral tablet
Tier 1
QL
colchicine‐probenecid
Tier 1
COLCRYS
Tier 3
N2; QL
MITIGARE
Tier 3
QL
probenecid oral
Tier 1
ULORIC
Tier 3
ZYLOPRIM
Tier 3
*GOUT AGENTS*
QL
*HEMATOLOGICAL AGENTS ‐ MISC.*
ADVATE
Tier 4
PA
AGGRENOX
Tier 2
#
AGRYLIN
Tier 3
ALPHANATE/VWF COMPLEX/HUMAN
Tier 4
PA
ALPHANINE SD
Tier 4
PA
ALPROLIX
Tier 4
PA
anagrelide hcl
Tier 1
BEBULIN
Tier 4
PA
BENEFIX
Tier 4
PA
BERINERT
Tier 4
BRILINTA
Tier 2
QL
cilostazol
Tier 1
CINRYZE
Tier 4
PA; N2
clopidogrel bisulfate
Tier 1
QL
CORIFACT
Tier 4
PA
dipyridamole oral
Tier 1
EFFIENT
Tier 3
PA; QL
ELOCTATE
Tier 4
PA
FEIBA NF
Tier 4
PA
FEIBA VH IMMUNO
Tier 4
PA
FIRAZYR
Tier 4
PA; N2; QL
HELIXATE FS
Tier 4
PA
(Updated 08/01/2015)
70
Drug Name
Drug Status
Drug Details
HEMOFIL M
Tier 4
PA
HUMATE‐P
Tier 4
PA
IXINITY
Tier 4
PA
KCENTRA
Tier 4
PA
KOATE‐DVI
Tier 4
PA
KOGENATE FS
Tier 4
PA
KOGENATE FS BIO‐SET
Tier 4
PA
MONOCLATE‐P
Tier 4
PA
MONONINE
Tier 4
PA
NOVOEIGHT
Tier 4
PA
NOVOSEVEN RT
Tier 4
PA
pentoxifylline er
Tier 1
PERSANTINE
Tier 3
PLAVIX
Tier 3
PLETAL
Tier 3
PROFILNINE SD
Tier 4
PA
RECOMBINATE
Tier 4
PA
RIASTAP
Tier 4
PA
rixubis
Tier 4
PA
RUCONEST
Tier 4
PA
ticlopidine hcl
Tier 1
TRETTEN
Tier 4
PA
WILATE
Tier 4
PA
XYNTHA
Tier 4
PA
XYNTHA SOLOFUSE
Tier 4
PA
ZONTIVITY
Tier 3
ST; QL
ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML
Tier 4
PA
ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/0.5ML, 100 MCG/ML, 150 MCG/0.3ML, 150 MCG/0.75ML, 200 MCG/0.4ML, 200 MCG/ML, 25 MCG/0.42ML, 25 MCG/ML, 300 MCG/0.6ML, 300 MCG/ML, 40 MCG/0.4ML, 40 MCG/ML, 500 MCG/ML, 60 MCG/0.3ML, 60 MCG/ML
Tier 4
PA; N2
QL
*HEMATOPOIETIC AGENTS*
BPROTECTED PEDIA IRON
CE
CERDELGA
Tier 4
cvs folic acid oral tablet 400 mcg
Tier 1
cyanocobalamin injection
Tier 3
CE
PA; QL
(Updated 08/01/2015)
71
Drug Name
Drug Status
EPOGEN
Tier 4
eql folic acid
Tier 1
FER‐IN‐SOL
CE
FERIVAFA
PA; N2
CE
Tier 3
ferrous sulfate oral solution
CE
folic acid oral capsule 20 mg
Tier 1
folic acid oral tablet 1 mg
Drug Details
CE
folic acid oral tablet 400 mcg
Tier 1
gnp folic acid
Tier 1
GRANIX
Tier 4
hm folic acid
Tier 1
ICAR‐C PLUS
Tier 3
kp folic acid
CE
CE
Lowest Generic Copay Applies; CE
PA; N2
CE
LEUKINE INTRAVENOUS*
Tier 4
PA; N2
MIRCERA
Tier 4
PA
NEULASTA
Tier 4
PA; N2
NEUPOGEN
Tier 4
PA; N2
PROCRIT
Tier 4
PA; N2
PROMACTA
Tier 4
PA; N2; QL
px folic acid
Tier 1
ra folic acid oral tablet 400 mcg
Tier 1
revesta
Tier 3
sm folic acid
Tier 1
th folic acid
CE
ZAVESCA
Tier 4
CE
PA; N2; #; QL
*HEMOSTATICS*
aminocaproic acid oral
Tier 1
LYSTEDA
Tier 3
QL
AMBIEN
Tier 3
N2; QL; AL
AMBIEN CR
Tier 3
PA; N2; QL; AL
BELSOMRA
Tier 3
ST; QL
BUTISOL SODIUM
Tier 3
N2
DORAL
Tier 3
N2
EDLUAR
Tier 6
N4; AL
estazolam
Tier 1
N2; AL
eszopiclone
Tier 3
PA; ST; N3; QL; AL
flurazepam hcl
Tier 1
N2; AL
*HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS*
(Updated 08/01/2015)
72
Drug Name
Drug Status
Drug Details
HALCION
Tier 3
N2; AL
HETLIOZ
Tier 4
PA; N2
INTERMEZZO
Tier 6
N4; AL
LUNESTA
Tier 3
PA; ST; N2; N3; QL; AL
phenobarbital oral
Tier 1
N2
RESTORIL ORAL CAPSULE 15 MG, 30 MG
Tier 3
N2; AL
RESTORIL ORAL CAPSULE 22.5 MG, 7.5 MG
Tier 3
N2; QL; AL
ROZEREM
Tier 3
QL; AL
SILENOR
Tier 6
N4; AL
SONATA
Tier 3
QL
temazepam oral capsule 15 mg, 30 mg
Tier 1
N2; AL
temazepam oral capsule 22.5 mg, 7.5 mg
Tier 3
N2; QL; AL
triazolam
Tier 1
N2; AL
zolpidem tartrate er
Tier 3
PA; N2; QL; AL
zolpidem tartrate oral tablet 10 mg
Tier 3
N2; QL; AL
zolpidem tartrate oral tablet 5 mg
Tier 1
N2; QL; AL
ZOLPIMIST
Tier 6
N4
Tier 3
QL
fematrol
CE
CE
gavilax oral packet
CE
CE
*LAXATIVES*
COLYTE WITH FLAVOR PACKS
GAVILYTE‐H
Tier 1
GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM
Tier 3
KRISTALOSE
Tier 3
lactulose oral solution 10 gm/15ml
Tier 1
lactulose oral solution 20 gm/30ml
Tier 1
MIRALAX ORAL PACKET
Tier 1
MIRALAX ORAL POWDER
Tier 1
MOVIPREP
Tier 3
NULYTELY WITH FLAVOR PACKS
Tier 3
OSMOPREP
Tier 3
peg 3350
Tier 1
peg 3350/electrolytes
Tier 3
peg 3350‐kcl‐na bicarb‐nacl
Tier 1
peg‐3350/electrolytes
Tier 1
PEG‐PREP
Tier 1
polyethylene glycol 3350 oral packet
Tier 1
polyethylene glycol 3350 oral powder
Tier 1
N2; QL
Select OTC
QL
N2; QL
Select OTC
(Updated 08/01/2015)
73
Drug Name
saline laxative oral solution 2.7‐7.2 gm/15ml
Drug Status
CE
sb polyethylene glycol 3350
Tier 1
TRILYTE
Tier 1
Drug Details
CE
*MACROLIDES*
azithromycin oral packet
Tier 3
azithromycin oral suspension reconstituted
Tier 1
N2
azithromycin oral tablet 250 mg, 500 mg
Tier 1
N2
azithromycin oral tablet 600 mg
Tier 1
BIAXIN ORAL SUSPENSION RECONSTITUTED
Tier 3
N2; QL
BIAXIN ORAL TABLET
Tier 3
N2; QL
BIAXIN XL
Tier 3
N2; QL
BIAXIN XL PAC
Tier 3
N2; QL
clarithromycin er
Tier 1
N2; QL
clarithromycin oral suspension reconstituted 125 mg/5ml
Tier 1
N2
clarithromycin oral suspension reconstituted 250 mg/5ml
Tier 1
N2; QL
clarithromycin oral tablet
Tier 1
N2
DIFICID
Tier 3
N2; QL
E.E.S. 400
Tier 1
N2
E.E.S. GRANULES
Tier 2
N2
ERY‐TAB
Tier 1
N2
ERYTHROCIN STEARATE
Tier 1
N2
erythromycin base oral tablet
Tier 1
N2
erythromycin ethylsuccinate oral
Tier 1
N2
erythromycin stearate oral
Tier 1
N2
PCE
Tier 3
N2
ZITHROMAX ORAL PACKET
Tier 3
ZITHROMAX ORAL SUSPENSION RECONSTITUTED
Tier 3
ZITHROMAX ORAL TABLET 250 MG
Tier 3
ZITHROMAX ORAL TABLET 500 MG, 600 MG
Tier 3
N2
ZITHROMAX TRI‐PAK
Tier 3
N2
ZITHROMAX Z‐PAK
Tier 3
ZMAX
Tier 3
*MEDICAL DEVICES*
1st choice lancets super thin
Tier 1
1st choice lancets thin
Tier 1
1st choice lancets ultra thin
Tier 1
(Updated 08/01/2015)
74
N2
N2
Drug Name
Drug Status
Drug Details
ACCU‐CHEK COMPACT PLUS CARE
Tier 6
N4
acti‐lance lite lancets 28g
Tier 1
acti‐lance special lancets 17g
Tier 1
ADVOCATE BLOOD GLUCOSE MONITOR
Tier 6
N4
ADVOCATE BLOOD GLUCOSE SYSTEM
Tier 6
N4
AEROCHAMBER MV
Tier 2
QL
af lancets super thin
Tier 1
assure comfort lancets 28g
Tier 1
assure comfort lancets 30g
Tier 1
BD AUTOSHIELD
Tier 2
BD CATHETER TIP SYRINGE
Tier 2
BD ECLIPSE SYRINGE 23G X 1" 3 ML, 25G X 5/8" 3 ML, 27G X 1/2" 1 ML, 30G X 1/2" 1 ML
Tier 2
BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, U‐100 1 ML
Tier 2
BD INSULIN SYRINGE HALF‐UNIT
Tier 2
BD INSULIN SYRINGE MICROFINE 28G X 1/2" 0.3 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML
Tier 2
BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 31G X 15/64" 0.3 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
Tier 2
BD INTEGRA INSULIN SYRINGE
Tier 2
BD INTEGRA SYRINGE 21G X 1‐1/2" 3 ML, 22G X 1‐1/2" 3 ML, 23G X 1" 3 ML, 25G X 1" 3 ML, 25G X 5/8" 1 ML, 25G X 5/8" 3 ML
Tier 2
BD LUER‐LOK SYRINGE 18G X 1‐1/2" 3 ML, 20G X 1" 1 ML, 20G X 1" 10 ML, 20G X 1" 3 ML, 20G X 1" 5 ML, 20G X 1‐1/2" 10 ML, 20G X 1‐1/2" 3 ML, 20G X 1‐1/2" 5 ML, 21G X 1" 10 ML, 21G X 1" 3 ML, 21G X 1" 5 ML, 21G X 1‐1/2" 10 ML, 21G X 1‐1/2" 3 ML, 21G X 1‐1/2" 5 ML, 21G X 1‐1/4" 3 ML, 22G X 1" 10 ML, 22G X 1" 3 ML, 22G X 1" 5 ML, 22G X 1‐1/2" 10 ML, 22G X 1‐1/2" 3 ML, 22G X 1‐1/2" 5 ML, 23G X 1" 3 ML, 23G X 1" 5 ML, 23G X 1‐1/2" 3 ML, 23G X 1‐1/4" 10 ML, 23G X 1‐1/4" 3 ML, 23G X 1‐1/4" 5 ML, 24G X 1" 3 ML, 25G X 1" 3 ML, 25G X 1‐1/2" 3 ML, 25G X 5/8" 3 ML, 26G X 5/8" 3 ML, 2G X 1‐1/4" 3 ML
Tier 2
BD PEN
Tier 2
BD PEN MINI
Tier 2
BD PEN NEEDLE MINI U/F
Tier 2
BD PEN NEEDLE NANO U/F
Tier 2
BD PEN NEEDLE SHORT U/F
Tier 2
(Updated 08/01/2015)
75
Drug Name
Drug Status
BD PEN NEEDLE ULTRAFINE
Tier 2
BD SAFETYGLIDE INSULIN SYRINGE
Tier 2
BD SAFETYGLIDE NEEDLE
Tier 2
BD SAFETYGLIDE SHIELDED NEEDLE 21G X 1‐1/2" , 22G X 1‐1/2" , 22G X 1‐1/2" 10 ML, 23G X 1" , 25G X 1"
Tier 2
BD SAFETYGLIDE SYRINGE/NEEDLE
Tier 2
BD SAFETY‐LOK INSULIN SYRINGE
Tier 2
BD SYRINGE 20 ML , 60 ML
Tier 2
BD SYRINGE 50‐60 ML
Tier 2
BD SYRINGE DUAL CANNULA
Tier 2
BD SYRINGE LUER SLIP TIP 3 ML , 5 ML
Tier 2
BD SYRINGE LUER‐LOK 1 ML , 20 ML
Tier 2
BD SYRINGE SLIP TIP 1 ML , 3 ML
Tier 2
BD SYRINGE/NEEDLE 22G X 1‐1/2" 3 ML, 25G X 5/8" 1 ML
Tier 2
BD SYRINGE/NEEDLE SLIP TIP 26G X 5/8" 1 ML
Tier 2
bullseye mini safety lancets
Tier 1
comfort assured lancets 28g
Tier 1
comfort assured lancets 33g
Tier 1
comfort lancets
Tier 1
cvs lancets 21g
Tier 1
cvs lancets micro thin 33g
Tier 1
cvs lancets original
Tier 1
cvs lancets thin
Tier 1
cvs lancets thin 26g
Tier 1
cvs lancets ultra thin 30g
Tier 1
cvs ultra thin lancets
Tier 1
drug mart lancets thin 26g
Tier 1
drug mart lancets ultra thin
Tier 1
easy comfort lancets
Tier 1
eql color lancets 21g
Tier 1
eql color lancets micro 33g
Tier 1
eql super thin lancets 30g
Tier 1
eql thin lancets 26g
Tier 1
Drug Details
FC2 FEMALE CONDOM
CE
CE
FEMCAP
CE
CE
Tier 3
PA
FREESTYLE FREEDOM LITE
GLASPAK TB SYRINGE
Tier 2
(Updated 08/01/2015)
76
Drug Name
Drug Status
global inject ease lancets 28g
Tier 1
global inject ease lancets 30g
Tier 1
gnp lancets
Tier 1
gnp lancets 21g
Tier 1
gnp lancets micro thin 33g
Tier 1
gnp lancets super thin 30g
Tier 1
gnp lancets thin
Tier 1
gnp lancets thin 26g
Tier 1
gnp micro thin lancets 33g
Tier 1
gnp super thin lancets 30g
Tier 1
healthwise lancets 30g
Tier 1
healthy accents unilet lancets
Tier 1
h‐e‐b incontrol lancets 28g
Tier 1
h‐e‐b incontrol lancets 30g
Tier 1
hm lancets micro thin 33g
Tier 1
hm lancets ultra thin 30g
Tier 1
hy‐vee thin lancets
Tier 1
kinney lancets
Tier 1
kinney thin lancets
Tier 1
kroger lancets
Tier 1
kroger lancets 21g
Tier 1
kroger lancets micro thin 33g
Tier 1
kroger lancets super thin
Tier 1
kroger lancets thin
Tier 1
kroger lancets thin 26g
Tier 1
kroger lancets ultrathin 30g
Tier 1
lady lite lancets
Tier 1
lancets
Tier 1
lancets 28g
Tier 1
lancets 30g
Tier 1
lancets micro thin 33g
Tier 1
lancets super thin 28g
Tier 1
lancets thin
Tier 1
lancets ultra thin 30g
Tier 1
lite touch lancets
Tier 1
longs lancets standard
Tier 1
longs lancets thin
Tier 1
longs lancets ultra thin
Tier 1
Drug Details
(Updated 08/01/2015)
77
Drug Name
Drug Status
Drug Details
major comfort lancets
Tier 1
medicine shoppe lancets
Tier 1
medicine shoppe lancets thin
Tier 1
medi‐lance lancets
Tier 1
MICROCHAMBER
Tier 2
OMNITROPE PEN 5 INJ DEVICE
Tier 4
PA; N2
ONETOUCH VERIO IQ SYSTEM
Tier 2
QL
ORTHO ALL‐FLEX FITTING SET
CE
CE
ORTHO DIAPHRAGM ALL‐FLEX
CE
CE
pc lancets super thin 30g
Tier 1
pharmacist choice lancets
Tier 1
preferred plus lancets colored
Tier 1
preferred plus lancets thin
Tier 1
PRODIGY AUTOCODE BLOOD GLUCOSE
Tier 3
PA; QL
PRODIGY POCKET BLOOD GLUCOSE
Tier 3
PA; QL
PRODIGY VOICE BLOOD GLUCOSE
Tier 3
PA; QL
px lancets
Tier 1
px lancets ultra thin
Tier 1
qc lancets super thin 30g
Tier 1
qc lancets ultra thin
Tier 1
reality lancets
Tier 1
reality trigger lancets
Tier 1
safety lancets 28g
Tier 1
SAFETY‐GLIDE SYRINGE
Tier 2
sb lancets thin
Tier 1
sb lancets ultra thin
Tier 1
select‐lite device/lancets
Tier 1
sm lancets 21g
Tier 1
sm lancets 33g
Tier 1
sm super thin lancets 30g
Tier 1
sm thin lancets 26g
Tier 1
super thin lancets
Tier 1
sure comfort lancets 28g
Tier 1
sure comfort lancets 30g
Tier 1
syringe disposable 10 ml , 3 ml , 5 ml , 60 ml Tier 2
syringe disposable 50‐60ml
Tier 2
todays health thin lancets 28g
Tier 1
todays health thin lancets 30g
Tier 1
(Updated 08/01/2015)
78
Drug Name
Drug Status
Drug Details
ultra thin lancets 28g
Tier 1
ultra thin lancets 30g
Tier 1
value plus lancets super thin
Tier 1
value plus lancets thin 26g
Tier 1
walgreens adv travel lancets
Tier 1
walgreens lancets micro thin
Tier 1
walgreens lancets super thin
Tier 1
WIDE‐SEAL DIAPHRAGM 60
CE
CE
CE
CE
CE
CE
CE
CE
CE
CE
CE
CE
CE
CE
CE
CE
ALSUMA
Tier 6
N4
AMERGE
Tier 3
N2; QL
AXERT
Tier 3
ST; N2; N3; #; QL
CAFERGOT
Tier 2
N2
CAMBIA
Tier 6
N4
D.H.E. 45
Tier 3
QL
dihydroergotamine mesylate injection
Tier 3
QL
dihydroergotamine mesylate nasal
Tier 1
N2; QL
FROVA
Tier 3
ST; N2; N3; #; QL
IMITREX NASAL
Tier 3
N2; QL
IMITREX ORAL
Tier 3
N2; QL
IMITREX STATDOSE REFILL
Tier 3
N2; QL
IMITREX SUBCUTANEOUS*
Tier 3
N2; QL
MAXALT
Tier 3
N2; QL
MAXALT‐MLT
Tier 3
N2; QL
MIGRANAL
Tier 3
QL
naratriptan hcl
Tier 1
N2; QL
RELPAX
Tier 3
N2; N3; QL
rizatriptan benzoate
Tier 1
N2; QL
sumatriptan nasal
Tier 1
N2; QL
sumatriptan succinate oral
Tier 1
N2; QL
sumatriptan succinate refill
Tier 1
N2; QL
*MIGRAINE PRODUCTS*
(Updated 08/01/2015)
79
Drug Name
Drug Status
Drug Details
sumatriptan succinate subcutaneous*
Tier 1
N2; QL
SUMAVEL DOSEPRO SUBCUTANEOUS* 6 MG/0.5ML
Tier 6
N4
TREXIMET
Tier 6
N4; QL
zolmitriptan oral
Tier 1
N2; QL
ZOMIG NASAL
Tier 3
N2; N3; QL
ZOMIG ORAL
Tier 3
N2; QL
ZOMIG ZMT
Tier 3
N2; QL
*MINERALS & ELECTROLYTES*
EPIFLUR
CE
CE
FLUORABON
CE
CE
FLUOR‐A‐DAY ORAL TABLET CHEWABLE 0.25 (F)‐236.79 MG, 0.5 (F)‐236.79 MG
CE
CE
FLURA‐DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP
CE
CE
K‐PHOS‐NEUTRAL
Tier 3
LURIDE ORAL SOLUTION
CE
CE
LURIDE ORAL TABLET CHEWABLE 1.1 (0.5 F) MG
CE
CE
potassium chloride crys er oral tablet extendedrelease* 10 meq
Tier 1
potassium chloride er oral capsule extended release*
10 meq
Tier 1
potassium chloride er oral capsule extended release*
8 meq
Tier 1
potassium chloride er oral tablet extendedrelease* 10 meq, 8 meq
Tier 1
potassium chloride er oral tablet extendedrelease* 20 meq
Tier 1
potassium chloride oral liquid† 20 meq/15ml (10%)
Tier 1
sodium chloride injection solution 0.9 %
Tier 1
sodium fluoride oral solution
CE
sodium fluoride oral tablet
Tier 1
sodium fluoride oral tablet chewable
Tier 1
SSKI
Tier 2
CE
*MOUTH/THROAT/DENTAL AGENTS*
CAPHOSOL
Tier 3
clotrimazole mouth/throat
Tier 1
EVOXAC
Tier 2
GELCLAIR
Tier 3
lidocaine viscous
Tier 1
nystatin mouth/throat
Tier 1
(Updated 08/01/2015)
80
QL
Drug Name
ORALONE
ORAVIG
PERIOGARD
SALAGEN
Drug Status
Drug Details
LA
Tier 3
N2; QL
LA
Tier 3
*MULTIVITAMINS*
CITRANATAL 90 DHA
Tier 3
CITRANATAL B‐CALM
Tier 3
CITRANATAL DHA
Tier 3
CITRANATAL HARMONY ORAL CAPSULE 27‐1‐260 MG
Tier 3
CITRANATAL RX
Tier 3
cvs prenatal
Tier 1
levomefolate dha
Tier 3
MYNATAL
Tier 1
NEEVO DHA ORAL CAPSULE 27‐1.13 MG
Tier 3
NESTABS
Tier 3
NICOMIDE
Tier 3
OBTREX
Tier 3
O‐CAL PRENATAL
Tier 3
OCUVEL
Tier 3
pnv fe fum/docusate/folic acid
Tier 3
POLY‐VI‐FLOR FS ORAL STRIP 1 MG
CE
POLY‐VI‐FLOR ORAL TABLET CHEWABLE
Tier 2
PREFERAOB ONE
Tier 3
prenatabs fa
Tier 3
PRENATABS RX
Tier 3
prenatal oral tablet 27‐0.8 mg
Tier 1
prenatal vitamins oral tablet 0.8 mg
Tier 1
prenatal/iron
Tier 1
PRENATE DHA ORAL CAPSULE 28‐0.6‐0.4‐300 MG
Tier 3
PRENATE ELITE ORAL TABLET 26‐0.6‐0.4 MG
Tier 3
PRENATE ESSENTIAL ORAL CAPSULE 29‐0.6‐0.4‐340 MG
Tier 3
PRENATE MINI
Tier 3
PREQUE 10 ORAL TABLET 15‐25‐0.5‐50 MG
Tier 3
QUFLORA PEDIATRIC
Tier 3
SELECT‐OB+DHA
Tier 3
TRICARE PRENATAL DHA ONE
Tier 3
TRINATE
Tier 1
QL
(Updated 08/01/2015)
81
Drug Name
Drug Status
TRI‐VI‐FLOR ORAL SUSPENSION 0.25 MG/ML
Tier 2
TRI‐VI‐FLOR ORAL SUSPENSION 0.5 MG/ML
Tier 3
VINATE DHA RF
Tier 3
virt‐caps
Tier 3
VITAPEARL
Tier 3
VIVA DHA
Tier 3
Drug Details
*MUSCULOSKELETAL THERAPY AGENTS*
AMRIX
Tier 6
N4
baclofen oral tablet 10 mg
Tier 1
baclofen oral tablet 20 mg
Tier 1
carisoprodol oral tablet 350 mg
Tier 1
N2
carisoprodol‐aspirin
Tier 1
N2
chlorzoxazone oral
Tier 1
CYCLOBENZAPRINE COMFORT PAC
Tier 6
N4
cyclobenzaprine hcl oral tablet 10 mg, 5 mg
Tier 1
cyclobenzaprine hcl oral tablet 7.5 mg
Tier 1
N2
DANTRIUM ORAL CAPSULE 25 MG, 50 MG
Tier 3
dantrolene sodium oral
Tier 1
LIORESAL
Tier 3
LORZONE
Tier 6
N4
metaxalone
Tier 3
QL
methocarbamol oral
Tier 1
orphenadrine citrate er
Tier 1
PARAFON FORTE DSC
Tier 3
ROBAXIN ORAL
Tier 3
SKELAXIN
Tier 3
QL
SOMA
Tier 6
N4
TIZANIDINE COMFORT PAC
Tier 6
N4
tizanidine hcl oral tablet
Tier 1
ZANAFLEX
Tier 6
N4
*NASAL AGENTS ‐ SYSTEMIC AND TOPICAL*
ADRENALIN NASAL
Tier 2
ASTEPRO
Tier 3
ATROVENT
Tier 3
azelastine hcl nasal solution 0.1 %
Tier 1
azelastine hcl nasal solution 0.15 %
Tier 3
BACTROBAN NASAL
Tier 3
BECONASE AQ
Tier 3
(Updated 08/01/2015)
82
QL
ST; N3
Drug Name
Drug Status
Drug Details
DYMISTA
Tier 6
N4
FLONASE
Tier 3
ST; N3
FLONASE ALLERGY RELIEF
Tier 1
Select OTC
flunisolide nasal solution 25 mcg/act (0.025%)
Tier 1
fluticasone propionate nasal
Tier 1
ipratropium bromide nasal
Tier 1
QL
NASACORT ALLERGY 24HR
Tier 1
Select OTC
NASONEX
Tier 2
QL
olopatadine hcl
Tier 3
OMNARIS
Tier 3
PATANASE
Tier 3
QNASL
Tier 3
QNASL CHILDRENS
Tier 3
RHINOCORT AQUA
Tier 3
ST; N3
VERAMYST
Tier 3
ST; N3
ZETONNA
Tier 3
ST; N3
RILUTEK
Tier 3
PA
riluzole
Tier 1
PA
ST
ST; N3
*NEUROMUSCULAR AGENTS*
*OPHTHALMIC AGENTS*
ACULAR
Tier 3
ACULAR LS
Tier 3
ACUVAIL
Tier 3
QL
ALAWAY
Tier 1
ALAWAY CHILDRENS ALLERGY
Tier 1
ALOCRIL
Tier 3
ALOMIDE
Tier 3
ALPHAGAN P
Tier 3
ALREX
Tier 2
apraclonidine hcl
Tier 1
atropine sulfate ophthalmic
Tier 1
AZASITE
Tier 3
AZOPT
Tier 2
bacitracin ophthalmic
Tier 1
bacitracin‐polymyxin b ophthalmic
Tier 1
BEPREVE
Tier 3
QL
(Updated 08/01/2015)
83
Drug Name
Drug Status
BESIVANCE
Tier 3
BETAGAN
Tier 3
betaxolol hcl ophthalmic
Tier 1
BETIMOL OPHTHALMIC SOLUTION 0.5 %
Tier 2
BETOPTIC‐S
Tier 2
bimatoprost ophthalmic
Tier 3
BLEPH‐10
Tier 3
BLEPHAMIDE
Tier 2
BLEPHAMIDE S.O.P.
Tier 2
brimonidine tartrate ophthalmic solution 0.2 %
Tier 1
carteolol hcl
Tier 1
CILOXAN OPHTHALMIC OINTMENT
Tier 2
CILOXAN OPHTHALMIC SOLUTION
Tier 3
COMBIGAN
Tier 3
COSOPT
Tier 3
COSOPT PF
Tier 3
cromolyn sodium ophthalmic
Tier 1
CYCLOGYL
Tier 3
CYCLOMYDRIL
Tier 3
cyclopentolate hcl ophthalmic
Tier 1
CYSTARAN
Tier 4
dexamethasone sodium phosphate ophthalmic
Tier 1
diclofenac sodium ophthalmic
Tier 1
dorzolamide hcl
Tier 1
dorzolamide hcl‐timolol mal
Tier 1
DUREZOL
Tier 2
ELESTAT
Tier 3
FLAREX
Tier 3
fluorometholone ophthalmic
Tier 1
flurbiprofen sodium
Tier 1
FML
Tier 2
FML FORTE
Tier 3
FML LIQUIFILM
Tier 3
GARAMYCIN OPHTHALMIC SOLUTION
Tier 3
gatifloxacin
Tier 3
gentamicin sulfate ophthalmic
Tier 1
ILOTYCIN
Tier 3
IOPIDINE
Tier 3
(Updated 08/01/2015)
84
Drug Details
QL
PA; N2; QL
Drug Name
Drug Status
Drug Details
ISOPTO ATROPINE
Tier 3
ISOPTO CARBACHOL OPHTHALMIC SOLUTION 1.5 %
Tier 3
ISOPTO CARPINE
Tier 3
ISOPTO HYOSCINE
Tier 3
ketorolac tromethamine ophthalmic
Tier 3
LACRISERT
Tier 3
LASTACAFT
Tier 3
QL
latanoprost ophthalmic
Tier 1
QL
levobunolol hcl
Tier 1
levofloxacin ophthalmic
Tier 1
LOTEMAX
Tier 2
LUMIGAN OPHTHALMIC SOLUTION 0.01 %
Tier 3
MAXIDEX
Tier 3
MAXITROL
Tier 3
metipranolol
Tier 1
MOXEZA
Tier 3
NATACYN
Tier 3
neomycin‐polymyxin‐dexameth ophthalmic ointment
Tier 1
neomycin‐polymyxin‐dexameth ophthalmic suspension 3.5‐10000‐0.1 Tier 1
NEOSPORIN
Tier 3
NEVANAC
Tier 3
OCUFEN
Tier 3
OCUFLOX
Tier 3
ofloxacin ophthalmic
Tier 1
OMNIPRED
Tier 3
OPTIVAR
Tier 3
PATADAY
Tier 3
PATANOL
Tier 3
PAZEO
Tier 3
PHOSPHOLINE IODIDE
Tier 2
pilocarpine hcl ophthalmic
Tier 1
polymyxin b‐trimethoprim
Tier 1
POLYTRIM
Tier 3
PRED FORTE
Tier 3
PRED MILD
Tier 3
PRED‐G
Tier 3
PRED‐G S.O.P.
Tier 3
N2
PA; N3; #; QL
N2
#
(Updated 08/01/2015)
85
Drug Name
Drug Status
Drug Details
prednisolone acetate ophthalmic
Tier 1
prednisolone sodium phosphate ophthalmic
Tier 1
PROLENSA
Tier 3
QL
RESCULA
Tier 3
PA; ST; N3; QL
RESTASIS
Tier 3
QL
SIMBRINZA
Tier 3
QL
sulfacetamide sodium ophthalmic
Tier 1
sulfacetamide‐prednisolone ophthalmic solution
Tier 1
sulfacetamide‐prednisolone ophthalmic suspension
Tier 2
timolol maleate ophthalmic
Tier 1
TIMOPTIC
Tier 3
TIMOPTIC‐XE
Tier 3
TOBRADEX
Tier 3
TOBRADEX ST
Tier 3
TOBREX
Tier 3
TRAVATAN Z
Tier 2
QL
travoprost
Tier 3
PA
trifluridine ophthalmic
Tier 1
TRUSOPT
Tier 3
VEXOL
Tier 3
VIGAMOX
Tier 3
VIROPTIC
Tier 3
XALATAN
Tier 3
PA; ST; N3; QL
ZADITOR
Tier 1
Select OTC
ZIOPTAN
Tier 3
PA; N3; QL
ZIRGAN
Tier 3
QL
ZYLET
Tier 3
ZYMAXID
Tier 3
N2
QL
*OTIC AGENTS*
ACETASOL HC
Tier 1
acetic acid otic
Tier 1
acetic acid‐aluminum acetate
Tier 1
antipyrine‐benzocaine
Tier 1
CETRAXAL
Tier 3
CIPRO HC
Tier 3
CIPRODEX
Tier 2
COLY‐MYCIN S
Tier 3
CORTISPORIN OTIC
Tier 3
(Updated 08/01/2015)
86
#
Drug Name
Drug Status
CORTISPORIN‐TC
Tier 3
hydrocortisone‐acetic acid
Tier 1
ofloxacin otic
Tier 1
VOSOL HC
Tier 3
Drug Details
N2
*OXYTOCICS*
CERVIDIL
Tier 3
methylergonovine maleate oral
Tier 1
PREPIDIL
Tier 3
*PASSIVE IMMUNIZING AGENTS*
GAMMAGARD
Tier 4
PA; N2
GAMMAKED
Tier 4
PA; N2
GAMUNEX‐C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML
Tier 4
GAMUNEX‐C INJECTION SOLUTION 40 GM/400ML
Tier 4
PA
HIZENTRA
Tier 4
PA; N2
HYQVIA
Tier 4
PA
WINRHO SDF
Tier 3
N2; QL
amoxicillin
Tier 1
N2
amoxicillin‐pot clavulanate oral
Tier 1
N2
ampicillin
Tier 1
N2
AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125‐31.25 MG/5ML
Tier 2
AUGMENTIN ORAL SUSPENSION RECONSTITUTED 250‐62.5 MG/5ML
Tier 3
AUGMENTIN ORAL TABLET
Tier 3
AUGMENTIN XR
Tier 3
QL
dicloxacillin sodium
Tier 1
N2
penicillin v potassium
Tier 1
N2
*PENICILLINS*
*PHARMACEUTICAL ADJUVANTS*
polyethylene glycol 3350 powder
Tier 1
*PROGESTINS*
AYGESTIN
Tier 3
medroxyprogesterone acetate oral
Tier 1
MEGACE ES
Tier 3
PROMETRIUM
Tier 2
PROVERA
Tier 3
QL
(Updated 08/01/2015)
87
Drug Name
Drug Status
Drug Details
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC.*
acamprosate calcium
Tier 3
QL
AMPYRA
Tier 4
PA; N2; QL
ANTABUSE
Tier 3
ARICEPT ODT
Tier 3
AL
ARICEPT ORAL TABLET 10 MG
Tier 3
AL
ARICEPT ORAL TABLET 23 MG, 5 MG
Tier 3
QL; AL
AUBAGIO
Tier 4
PA; N2; QL
AVONEX
Tier 4
PA; N2; QL
AVONEX PEN
Tier 4
PA; N2; QL
AVONEX PREFILLED
Tier 4
PA; N2; QL
BETASERON
Tier 4
PA; N2; QL
BRISDELLE
Tier 6
N4
BUPROBAN
CE
QL
bupropion hcl er (smoking det)
CE
QL
CAMPRAL
Tier 3
QL
CHANTIX
CE
QL
CHANTIX CONTINUING MONTH PAK
CE
QL
CHANTIX STARTING MONTH PAK
CE
QL
chlordiazepoxide‐amitriptyline
Tier 3
COPAXONE SUBCUTANEOUS* 40 MG/ML
Tier 4
cvs nicotine
PA; N2
LA
disulfiram oral
Tier 1
donepezil hcl oral tablet 10 mg
Tier 1
AL
donepezil hcl oral tablet 23 mg, 5 mg
Tier 1
QL; AL
donepezil hcl oral tablet dispersible
Tier 1
AL
eq nicotine transdermal patch 24 hr 14 mg/24hr, 21 mg/24hr
LA
eql nicotine
LA
ergoloid mesylates oral
Tier 3
EXELON ORAL CAPSULE
Tier 3
QL
EXELON TRANSDERMAL
Tier 3
QL
EXTAVIA
Tier 4
fluoxetine hcl (pmdd) oral capsule 10 mg, 20 mg
Tier 1
galantamine hydrobromide
Tier 3
galantamine hydrobromide er
Tier 3
QL; AL
GILENYA
Tier 4
PA; N2; QL
(Updated 08/01/2015)
88
Drug Name
Drug Status
Drug Details
GLATOPA
Tier 4
PA
GRALISE ORAL TABLET 300 MG, 600 MG
Tier 3
PA; ST; N3; QL
GRALISE STARTER
Tier 3
PA; ST; N3; QL
hm nicotine
LA
HORIZANT ORAL TABLET EXTENDEDRELEASE* 300 MG, 600 MG
Tier 3
PA; QL
NAMENDA ORAL SOLUTION
Tier 2
#; AL
NAMENDA ORAL TABLET
Tier 2
QL
NAMENDA TITRATION PAK
Tier 2
QL
NAMENDA XR
Tier 2
ST; N3; #; QL; AL
NAMENDA XR TITRATION PACK
Tier 2
ST; N3; #; QL; AL
NAMZARIC
Tier 2
PA; QL; AL
NICODERM CQ
LA
NICORELIEF MOUTH/THROAT GUM
LA
NICORETTE
LA
NICORETTE MINI
LA
NICORETTE STARTER KIT
LA
nicotine
CE
QL
nicotine polacrilex mouth/throat gum
CE
QL
nicotine polacrilex mouth/throat lozenge
CE
QL
nicotine step 1
LA
nicotine step 2
LA
nicotine step 3
LA
NICOTROL
CE
QL
NICOTROL NS
CE
QL
NUEDEXTA
Tier 3
QL
ORAP
Tier 3
perphenazine‐amitriptyline oral tablet 2‐10 mg, 2‐25 mg, 4‐25 mg
Tier 1
PLEGRIDY
Tier 4
PA; ST; QL
PLEGRIDY STARTER PACK
Tier 4
PA; ST; QL
ra nicotine transdermal
LA
RAZADYNE ER
Tier 3
QL; AL
RAZADYNE ORAL TABLET
Tier 3
AL
REBIF REBIDOSE
Tier 4
PA; N2; QL
REBIF REBIDOSE TITRATION PACK
Tier 4
PA; N2; QL
REBIF SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML
Tier 4
PA; N2; QL
REBIF SUBCUTANEOUS* SOLUTION 44 MCG/0.5ML
Tier 4
PA; N2
(Updated 08/01/2015)
89
Drug Name
Drug Status
Drug Details
REBIF TITRATION PACK
Tier 4
PA; N2; QL
SARAFEM
Tier 1
QL
SAVELLA
Tier 3
PA; ST; N3; QL
SAVELLA TITRATION PACK
Tier 3
PA; ST; N3; QL
sm nicotine transdermal
LA
SYMBYAX
Tier 3
QL
TECFIDERA
Tier 4
PA; N2; QL
tgt nicotine step one
LA
tgt nicotine step three
LA
tgt nicotine step two
LA
XENAZINE ORAL TABLET 12.5 MG, 25 MG
Tier 4
PA; N2; #; QL
XYREM
Tier 4
PA; N2
ZYBAN
LA
*RESPIRATORY AGENTS ‐ MISC.*
ESBRIET
Tier 4
PA; QL
KALYDECO ORAL PACKET
Tier 4
PA; QL
KALYDECO ORAL TABLET
Tier 4
PA; N2; QL
OFEV
Tier 4
PA; QL
PULMOZYME
Tier 4
PA; N2; QL
*SULFONAMIDES*
sulfadiazine oral
Tier 3
sulfisoxizole
Tier 1
*TETRACYCLINES*
ACTICLATE
Tier 6
ADOXA
Tier 6
N4
ADOXA PAK 1/100
Tier 6
N4
ADOXA PAK 1/150
Tier 6
N4
ADOXA PAK 2/100
Tier 6
N4
avidoxy
Tier 1
AVIDOXY DK
Tier 6
N4
DORYX ORAL TABLET DELAYED RELEASE 150 MG, 200 MG
Tier 6
N4
DORYX ORAL TABLET DELAYED RELEASE 50 MG
Tier 6
doxycycline hyclate oral capsule
Tier 1
doxycycline hyclate oral tablet 100 mg
Tier 1
doxycycline hyclate oral tablet 20 mg
LA
doxycycline hyclate oral tablet delayed release
Tier 6
(Updated 08/01/2015)
90
N4
Drug Name
Drug Status
Drug Details
doxycycline monohydrate oral capsule 100 mg, 150 mg
Tier 6
doxycycline monohydrate oral capsule 50 mg
Tier 1
doxycycline monohydrate oral capsule 75 mg
Tier 6
doxycycline monohydrate oral suspension reconstituted
Tier 1
doxycycline monohydrate oral tablet 100 mg
Tier 1
doxycycline monohydrate oral tablet 50 mg, 75 mg
Tier 6
N4
MINOCIN COMBINATION
Tier 6
N4
MINOCIN ORAL CAPSULE 100 MG, 50 MG
Tier 3
minocycline hcl er
Tier 6
N4
minocycline hcl oral capsule
Tier 1
N2; N4
minocycline hcl oral tablet
Tier 6
N4
MONODOX ORAL CAPSULE 100 MG
Tier 3
N2
MONODOX ORAL CAPSULE 75 MG
Tier 6
N4
MORGIDOX COMBINATION
Tier 6
N4
OCUDOX
Tier 6
N4
SOLODYN
Tier 6
N4
TARGADOX
Tier 6
tetracycline hcl oral
Tier 1
VIBRAMYCIN
Tier 3
N4
*THYROID AGENTS*
ARMOUR THYROID
Tier 3
CYTOMEL
Tier 3
LEVOTHROID
Tier 1
levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
Tier 1
levothyroxine sodium oral tablet 300 mcg
Tier 1
LEVOXYL
Tier 1
liothyronine sodium oral
Tier 1
methimazole oral
Tier 1
NATURE‐THROID
Tier 3
np thyroid
Tier 1
propylthiouracil oral
Tier 1
SYNTHROID
Tier 2
TAPAZOLE
Tier 3
THYROLAR‐1
Tier 3
THYROLAR‐1/2
Tier 3
(Updated 08/01/2015)
91
Drug Name
Drug Status
THYROLAR‐1/4
Tier 3
THYROLAR‐2
Tier 3
THYROLAR‐3
Tier 3
TIROSINT
Tier 3
UNITHROID
Tier 1
UNITHROID DIRECT
Tier 1
WESTHROID
Tier 3
WESTHROID‐P
Tier 3
Drug Details
*ULCER DRUGS*
ACIPHEX
Tier 3
amoxicill‐clarithro‐lansopraz
Tier 1
ANASPAZ
Tier 3
BENTYL ORAL CAPSULE
Tier 3
BENTYL ORAL TABLET
Tier 3
CARAFATE
Tier 3
cimetidine 200
Tier 1
cimetidine hcl oral
Tier 1
cimetidine oral tablet 200 mg, 300 mg, 400 mg
Tier 1
cimetidine oral tablet 800 mg
Tier 1
CUVPOSA
Tier 3
cvs heartburn relief oral tablet
Tier 1
CYTOTEC
Tier 3
DEXILANT
Tier 3
PA; QL
dicyclomine hcl oral capsule
Tier 1
dicyclomine hcl oral tablet
Tier 1
eq lansoprazole
Tier 6
esomeprazole magnesium
Tier 1
QL
esomeprazole strontium oral capsule delayed release
49.3 mg
Tier 6
N4
famotidine oral tablet 10 mg
Tier 1
famotidine oral tablet 20 mg, 40 mg
Tier 1
FIRST‐LANSOPRAZOLE
Tier 2
FIRST‐OMEPRAZOLE
Tier 2
gnp heartburn relief
Tier 1
HELIDAC
Tier 3
hm famotidine
Tier 1
hyoscyamine sulfate oral tablet
Tier 1
hyoscyamine sulfate oral tablet dispersible
Tier 1
(Updated 08/01/2015)
92
PA; QL
Drug Name
Drug Status
Drug Details
lansoprazole oral capsule delayed release 15 mg
Tier 1
N4; Select OTC
lansoprazole oral capsule delayed release 30 mg
Tier 6
N4
LEVSIN ORAL
Tier 3
misoprostol oral
Tier 1
NEXIUM 24HR
Tier 1
Select OTC
NEXIUM ORAL CAPSULE DELAYED RELEASE
Tier 2
#; QL
NEXIUM ORAL PACKET 10 MG, 2.5 MG, 5 MG
Tier 2
#
NEXIUM ORAL PACKET 20 MG, 40 MG
Tier 2
#; QL
nizatidine
Tier 1
OMECLAMOX‐PAK
Tier 3
N4
omeprazole magnesium
Tier 1
omeprazole oral capsule delayed release 10 mg, 40 mg
Tier 1
omeprazole oral capsule delayed release 20 mg
Tier 1
omeprazole oral tablet delayed release
Tier 1
Select OTC
PAMINE
Tier 3
PAMINE FORTE
Tier 3
pantoprazole sodium oral
Tier 1
PEPCID
Tier 3
PREVACID 24HR
Tier 1
Select OTC; QL
PREVACID ORAL CAPSULE DELAYED RELEASE 15 MG
Tier 6
PA; N4; QL; AL
PREVACID ORAL CAPSULE DELAYED RELEASE 30 MG
Tier 6
N4
PREVACID SOLUTAB
Tier 3
PA; QL; AL
PREVPAC
Tier 3
PRILOSEC ORAL CAPSULE DELAYED RELEASE
Tier 3
PRILOSEC ORAL PACKET
Tier 6
N4
PRILOSEC OTC
Tier 1
propantheline bromide oral
Tier 1
PROTONIX ORAL
Tier 3
px acid reducer max st oral tablet 20 mg
Tier 1
PYLERA
Tier 3
rabeprazole sodium
Tier 3
ranitidine hcl oral capsule
Tier 1
ranitidine hcl oral tablet 150 mg, 300 mg
Tier 1
ROBINUL ORAL
Tier 3
ROBINUL‐FORTE
Tier 3
sucralfate oral
Tier 1
PA; QL
(Updated 08/01/2015)
93
Drug Name
Drug Status
Drug Details
th famotidine 10
Tier 1
ZANTAC 150 MAXIMUM STRENGTH
Tier 3
ZANTAC ORAL TABLET
Tier 3
ZEGERID
Tier 6
N4
ZEGERID OTC
Tier 1
N4; Select OTC; QL
FURADANTIN
Tier 3
N2
HIPREX
Tier 3
MACROBID
Tier 3
MACRODANTIN
Tier 3
methenamine hippurate
Tier 1
methenamine mandelate oral
Tier 1
nitrofurantoin
Tier 1
N2
nitrofurantoin macrocrystal oral
Tier 1
N2
nitrofurantoin monohyd macro
Tier 1
N2
*URINARY ANTI‐INFECTIVES*
*URINARY ANTISPASMODICS*
bethanechol chloride oral
Tier 1
DETROL
Tier 3
DETROL LA
Tier 3
ST; N3; QL
DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 15 MG, 5 MG
Tier 3
ST; N3; QL
ENABLEX
Tier 3
ST; N3; QL
flavoxate hcl
Tier 1
GELNIQUE
Tier 3
ST; N3; QL
MYRBETRIQ
Tier 2
N3; QL
oxybutynin chloride er
Tier 1
N2
oxybutynin chloride oral syrup
Tier 1
oxybutynin chloride oral tablet
Tier 1
Lowest Generic Copay Applies; N2; QL
OXYTROL
Tier 6
N4; #
OXYTROL FOR WOMEN
Tier 1
Select OTC; QL
SANCTURA XR
Tier 3
N3; QL
tolterodine tartrate
Tier 1
tolterodine tartrate er
Tier 1
QL
TOVIAZ
Tier 3
N3; QL
trospium chloride
Tier 1
QL
trospium chloride er
Tier 1
QL
URECHOLINE
Tier 3
VESICARE
Tier 2
(Updated 08/01/2015)
94
N3; QL
Drug Name
Drug Status
Drug Details
*VACCINES*
AFLURIA
LA
FLUBLOK
LA
FLULAVAL QUADRIVALENT INTRAMUSCULAR* SUSPENSION
LA
FLUZONE QUADRIVALENT INTRAMUSCULAR* SUSPENSION 0.5 ML
LA
*VAGINAL PRODUCTS*
AVC VAGINAL
Tier 3
CLEOCIN VAGINAL CREAM
Tier 3
CLEOCIN VAGINAL SUPPOSITORY
Tier 2
clindamycin phosphate vaginal
Tier 1
CLINDESSE
Tier 3
clotrimazole vaginal cream 1 %
Tier 1
CRINONE VAGINAL 4 %
Tier 3
ESTRACE VAGINAL
Tier 3
ESTRING
Tier 3
FEM PH
Tier 3
FEMRING
Tier 3
#; QL
GYNAZOLE‐1
Tier 3
QL
METROGEL‐VAGINAL
Tier 3
metronidazole vaginal
Tier 1
miconazole 3 vaginal suppository
Tier 3
NUVESSA
Tier 3
PREMARIN VAGINAL
Tier 2
ra clotrimazole 7
Tier 1
RELAGARD
Tier 3
sm clotrimazole vaginal
Tier 1
TERAZOL 3 VAGINAL CREAM
Tier 3
TERAZOL 7
Tier 3
terconazole
Tier 1
TODAY SPONGE
CE
VAGIFEM
Tier 3
VANDAZOLE
Tier 1
VCF VAGINAL CONTRACEPTIVE
CE
N2
CE
CE
*VASOPRESSORS*
ADRENACLICK
Tier 3
PA; ST; N2; N3; QL
ADRENALIN INJECTION SOLUTION 1 MG/ML
Tier 3
N2
(Updated 08/01/2015)
95
Drug Name
Drug Status
Drug Details
AUVI‐Q INJECTION 0.15 MG/0.15ML, 0.3 MG/0.3ML
Tier 2
N2; QL
epinephrine injection 0.15 mg/0.15ml, 0.3 mg/0.3ml
Tier 1
N2; QL
EPIPEN 2‐PAK
Tier 2
N2; QL
EPIPEN JR 2‐PAK
Tier 2
N2; QL
midodrine hcl
Tier 3
NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG
Tier 4
PA; QL
*VITAMINS*
BPROTECTED PEDIA D‐VITE
CALCIFEROL
CE
CE
Tier 1
cvs d3 oral capsule 400 unit
CE
d 400 oral tablet
CE
CE
d3‐1000 oral tablet
CE
CE
D‐VI‐SOL
CE
CE
Tier 1
N2
CE
CE
hm niacin
Tier 1
N2
MEPHYTON
Tier 2
niacin er
Tier 1
niacin oral tablet
Tier 1
sm niacin cr
Tier 1
N2
CE
CE
gnp niacin tr
gnp vitamin d oral tablet chewable
vitamin d‐3 oral capsule
(Updated 08/01/2015)
96
N2
Index
ALPHANATE/VWF COMPLEX/HUMAN
....................................................................................................... 70
ALPHANINE SD .......................................................... 70
alprazolam ..................................................................... 13
alprazolam er .............................................................. 13
ALPRAZOLAM INTENSOL .............................. 13
alprazolam xr .............................................................. 13
ALPROLIX .......................................................................... 70
ALREX .................................................................................... 83
ALSUMA ............................................................................. 79
ALTABAX ........................................................................... 53
ALTACE ................................................................................ 28
ALTAVERA ........................................................................ 46
ALTOPREV ....................................................................... 27
aluminum acetate ................................................. 53
ALVESCO ........................................................................... 14
alyacen 1/35 ................................................................ 46
alyacen 7/7/7 ............................................................. 46
amantadine hcl ......................................................... 35
AMARYL ............................................................................. 21
AMBIEN .............................................................................. 72
AMBIEN CR ..................................................................... 72
AMERGE ............................................................................ 79
AMETHIA .......................................................................... 46
AMETHIA LO ................................................................. 46
AMETHYST ...................................................................... 46
amiloride hcl ................................................................ 63
amiloride‐hydrochlorothiazide .............. 63
aminocaproic acid ................................................. 72
amiodarone hcl ......................................................... 13
AMITIZA ............................................................................. 68
amitriptyline hcl ....................................................... 19
amlodipine besy‐benazepril hcl ............ 28
amlodipine besylate ........................................... 43
amlodipine besylate‐valsartan ............. 28
amlodipine‐valsartan‐hctz ......................... 28
AMNESTEEM ................................................................ 53
amoxapine ...................................................................... 19
amoxicill‐clarithro‐lansopraz .................. 92
amoxicillin ....................................................................... 87
amoxicillin‐pot clavulanate ....................... 87
amphetamine‐dextroamphet er ............. 3
amphetamine‐dextroamphetamine
........................................................................................................... 4
ampicillin .......................................................................... 87
AMPYRA ............................................................................. 88
AMRIX .................................................................................. 82
AMTURNIDE ................................................................. 28
ANACIN ................................................................................... 8
ANADROL‐50 ............................................................... 11
ANAFRANIL .................................................................... 19
anagrelide hcl ............................................................. 70
ANALPRAM‐HC ......................................................... 12
ANAPROX ............................................................................. 6
ANAPROX DS ................................................................... 6
ANASPAZ ........................................................................... 92
Index
Index
Index
1st choice lancets super thin ................... 74 ADDERALL XR .................................................................. 3
1st choice lancets thin ..................................... 74 adefovir dipivoxil .................................................... 38
1st choice lancets ultra thin ...................... 74 ADEMPAS ......................................................................... 45
abacavir sulfate ....................................................... 38 ADIPEX‐P ............................................................................... 3
abacavir‐lamivudine‐zidovudine ......... 38 ADOXA ................................................................................. 90
ABILIFY ................................................................................. 36 ADOXA PAK 1/100 ................................................ 90
ABILIFY DISCMELT ................................................. 36 ADOXA PAK 1/150 ................................................ 90
ABREVA .............................................................................. 52 ADOXA PAK 2/100 ................................................ 90
ABSORICA ........................................................................ 52 ADRENACLICK ............................................................. 95
ABSTRAL ................................................................................ 8 ADRENALIN ......................................................... 82, 95
acamprosate calcium ....................................... 88 ADVAIR DISKUS ......................................................... 14
ACANYA .............................................................................. 52 ADVAIR HFA .................................................................. 14
acarbose ............................................................................ 21 ADVATE .............................................................................. 70
ACCOLATE ....................................................................... 14 ADVICOR ........................................................................... 27
ACCU‐CHEK AVIVA ................................................ 60 ADVOCATE BLOOD GLUCOSE ACCU‐CHEK COMFORT CURVE .............. 60 MONITOR ......................................................................... 75
ADVOCATE BLOOD GLUCOSE SYSTEM
ACCU‐CHEK COMPACT PLUS CARE
....................................................................................................... 75
....................................................................................................... 75
ACCU‐CHEK SMARTVIEW ............................. 60 AEROCHAMBER MV ............................................ 75
ACCUPRIL ......................................................................... 28 AEROSPAN ...................................................................... 14
ACCURETIC ..................................................................... 28 af lancets super thin ........................................... 75
acebutolol hcl ............................................................. 42 AFEDITAB CR ................................................................ 43
ACEON ................................................................................. 28 AFINITOR .......................................................................... 33
acetaminophen‐codeine ................................... 8 AFINITOR DISPERZ ................................................ 33
acetaminophen‐codeine #2 .......................... 8 AFLURIA ............................................................................. 95
acetaminophen‐codeine #3 .......................... 8 AFREZZA ............................................................................ 21
acetaminophen‐codeine #4 .......................... 8 AGGRENOX .................................................................... 70
ACETASOL HC .............................................................. 86 AGRYLIN ............................................................................. 70
acetazolamide ........................................................... 63 AKYNZEO .......................................................................... 25
acetazolamide er .................................................... 63 ALAVERT ............................................................................ 26
acetic acid ............................................................ 69, 86 ALAVERT ALLERGY/SINUS ............................ 51
acetic acid‐aluminum acetate ............... 86 ALAWAY ............................................................................. 83
acetylcysteine ............................................................. 51 ALAWAY CHILDRENS ALLERGY .............. 83
ACIPHEX ............................................................................. 92 ALBENZA ........................................................................... 12
acitretin .............................................................................. 52 albuterol sulfate ...................................................... 14
ACTEMRA ............................................................................. 6 albuterol sulfate er .............................................. 14
ACTICLATE ....................................................................... 90 alclometasone dipropionate .................... 53
ACTIGALL .......................................................................... 68 ALDACTAZIDE .............................................................. 63
acti‐lance lite lancets 28g ............................ 75 ALDACTONE .................................................................. 63
acti‐lance special lancets 17g ................. 75 ALDARA .............................................................................. 53
ACTIMMUNE ................................................................ 33 alendronate sodium ........................................... 64
ACTIQ ........................................................................................ 8 alfuzosin hcl er ........................................................... 69
ACTIVELLA ....................................................................... 66 ALINIA ................................................................................... 31
ACTONEL ........................................................................... 64 ALKERAN ........................................................................... 33
ACTOPLUS MET ........................................................ 21 ALLEGRA ALLERGY ................................................ 26
ACTOPLUS MET XR ............................................... 21 ALLEGRA ALLERGY CHILDRENS ............. 26
ACTOS ................................................................................... 21 ALLEGRA‐D ALLERGY & CONGESTION
ACULAR .............................................................................. 83 ....................................................................................................... 51
ACULAR LS ...................................................................... 83 ALLI .............................................................................................. 3
ACUVAIL ............................................................................ 83 allopurinol ....................................................................... 70
acyclovir .................................................................. 38, 52 ALOCRIL .............................................................................. 83
ACZONE .............................................................................. 52 ALOMIDE .......................................................................... 83
ADALAT CC ..................................................................... 43 ALORA .................................................................................. 66
adapalene ....................................................................... 53 alosetron hcl ................................................................. 68
ADCIRCA ............................................................................ 45 ALPHAGAN P ................................................................ 83
ADDERALL ........................................................................... 3
(Updated 08/01/2015)
97
(Updated 08/01/2015)
98
BARACLUDE .................................................................. 38
BAYER ADVANCED ASPIRIN EX ST ......... 8
BAYER ADVANCED ASPIRIN REG ST .... 8
BAYER ASPIRIN REGIMEN ................................ 8
BAYER LOW DOSE ..................................................... 8
BAYER LOW STRENGTH ...................................... 8
BD AUTOSHIELD ...................................................... 75
BD CATHETER TIP SYRINGE ........................ 75
BD ECLIPSE SYRINGE .......................................... 75
BD INSULIN SYRINGE ......................................... 75
BD INSULIN SYRINGE HALF‐UNIT ....... 75
BD INSULIN SYRINGE MICROFINE ..... 75
BD INSULIN SYRINGE ULTRAFINE ....... 75
BD INTEGRA INSULIN SYRINGE ............. 75
BD INTEGRA SYRINGE ....................................... 75
BD LUER‐LOK SYRINGE .................................... 75
BD PEN ................................................................................ 75
BD PEN MINI ................................................................ 75
BD PEN NEEDLE MINI U/F ........................... 75
BD PEN NEEDLE NANO U/F ....................... 75
BD PEN NEEDLE SHORT U/F ...................... 75
BD PEN NEEDLE ULTRAFINE ..................... 76
BD SAFETYGLIDE INSULIN SYRINGE
....................................................................................................... 76
BD SAFETYGLIDE NEEDLE ............................. 76
BD SAFETYGLIDE SHIELDED NEEDLE
....................................................................................................... 76
BD SAFETYGLIDE SYRINGE/NEEDLE
....................................................................................................... 76
BD SAFETY‐LOK INSULIN SYRINGE .... 76
BD SYRINGE ................................................................... 76
BD SYRINGE 50‐60 ML ..................................... 76
BD SYRINGE DUAL CANNULA .................. 76
BD SYRINGE LUER SLIP TIP .......................... 76
BD SYRINGE LUER‐LOK .................................... 76
BD SYRINGE SLIP TIP .......................................... 76
BD SYRINGE/NEEDLE ......................................... 76
BD SYRINGE/NEEDLE SLIP TIP ................. 76
BEBULIN ............................................................................. 70
BECONASE AQ ............................................................ 82
BELSOMRA ..................................................................... 72
BELVIQ ..................................................................................... 4
benazepril hcl .............................................................. 29
benazepril‐hydrochlorothiazide ........... 29
BENEFIX .............................................................................. 70
BENICAR ............................................................................ 29
BENICAR HCT ............................................................... 29
BENTYL ................................................................................ 92
BENZACLIN ..................................................................... 53
BENZACLIN WITH PUMP ............................... 53
BENZAMYCIN .............................................................. 53
BENZAMYCINPAK ................................................... 53
benzonatate ................................................................. 51
benzoyl peroxide‐erythromycin ............ 53
benzphetamine hcl .................................................. 4
benztropine mesylate ....................................... 35
BEPREVE ............................................................................ 83
BERINERT ......................................................................... 70
Index
ATIVAN ................................................................................ 13
atorvastatin calcium .......................................... 27
atovaquone ................................................................... 31
atovaquone‐proguanil hcl ........................... 32
ATRALIN ............................................................................. 53
ATRIPLA .............................................................................. 38
atropine sulfate ........................................................ 83
ATROVENT ...................................................................... 82
ATROVENT HFA ........................................................ 14
AUBAGIO .......................................................................... 88
AUGMENTIN ................................................................ 87
AUGMENTIN XR ....................................................... 87
AUVI‐Q ................................................................................ 96
AVAILNEX ......................................................................... 61
AVALIDE ............................................................................. 29
AVANDAMET ............................................................... 22
AVANDARYL .................................................................. 22
AVANDIA ........................................................................... 22
AVAPRO ............................................................................. 29
AVAR CLEANSER ...................................................... 53
AVAR‐E EMOLLIENT ............................................ 53
AVAR‐E GREEN .......................................................... 53
AVC VAGINAL .............................................................. 95
AVELOX ............................................................................... 67
AVIANE ................................................................................ 46
avidoxy ................................................................................ 90
AVIDOXY DK .................................................................. 90
AVINZA .................................................................................... 9
AVITA ..................................................................................... 53
AVODART ......................................................................... 69
AVONEX ............................................................................. 88
AVONEX PEN ................................................................ 88
AVONEX PREFILLED ............................................. 88
AXERT ................................................................................... 79
AXIRON ............................................................................... 11
AXONA ................................................................................. 61
AYGESTIN ......................................................................... 87
AZASITE .............................................................................. 83
azathioprine ................................................................. 41
azelastine hcl ............................................................... 82
AZELEX ................................................................................. 53
AZILECT ............................................................................... 35
azithromycin ................................................................ 74
AZOPT ................................................................................... 83
AZOR ...................................................................................... 29
AZULFIDINE ................................................................... 68
AZULFIDINE EN‐TABS ........................................ 68
AZURETTE ........................................................................ 46
bacitracin ......................................................................... 83
bacitracin‐polymyxin b .................................... 83
baclofen ............................................................................. 82
BACTRIM ........................................................................... 31
BACTRIM DS ................................................................. 31
BACTROBAN ................................................................. 53
BACTROBAN NASAL ............................................ 82
balsalazide disodium ......................................... 68
BALZIVA .............................................................................. 46
BANZEL ................................................................................ 16
Index
Index
anastrozole .................................................................... 33
ANCOBON ....................................................................... 25
ANDRODERM .............................................................. 11
ANDROGEL ..................................................................... 11
ANDROGEL PUMP ................................................. 11
ANDROID .......................................................................... 11
ANDROXY ......................................................................... 11
ANGELIQ ............................................................................ 66
ANORO ELLIPTA ....................................................... 14
ANTABUSE ...................................................................... 88
ANTARA .............................................................................. 27
antipyrine‐benzocaine ..................................... 86
ANUSOL‐HC ................................................................... 12
ANZEMET ......................................................................... 25
APIDRA ................................................................................ 21
APIDRA SOLOSTAR ............................................... 22
APLENZIN ......................................................................... 19
APOKYN .............................................................................. 35
APPTRIM ........................................................................... 61
APPTRIM‐D .................................................................... 61
apraclonidine hcl .................................................... 83
APRI ......................................................................................... 46
APRISO ................................................................................. 68
APTENSIO XR ................................................................... 4
APTIOM .............................................................................. 16
APTIVUS ............................................................................. 38
ARALEN ............................................................................... 32
ARANELLE ........................................................................ 46
ARANESP (ALBUMIN FREE) ........................ 71
ARAVA ..................................................................................... 6
ARCALYST ............................................................................ 6
ARCAPTA NEOHALER ......................................... 14
ARICEPT .............................................................................. 88
ARICEPT ODT ............................................................... 88
ARIMIDEX ......................................................................... 33
aripiprazole ................................................................... 36
ARIXTRA ............................................................................. 16
ARMOUR THYROID .............................................. 91
ARNUITY ELLIPTA ................................................... 14
AROMASIN ..................................................................... 33
ARTHRITIS PAIN REGIMEN EX ST ............ 8
ARTHROTEC ...................................................................... 6
ASACOL HD .................................................................... 68
ASMANEX 120 METERED DOSES ........ 14
ASMANEX 14 METERED DOSES ............ 14
ASMANEX 7 METERED DOSES ............... 14
ASMANEX HFA ........................................................... 14
assure comfort lancets 28g ....................... 75
assure comfort lancets 30g ....................... 75
ASTAGRAF XL ............................................................... 41
ASTEPRO ........................................................................... 82
ATACAND ......................................................................... 28
ATACAND HCT ............................................................ 28
ATELVIA .............................................................................. 64
atenolol .............................................................................. 42
atenolol‐chlorthalidone ................................. 29
carvedilol .......................................................................... 42
CASODEX .......................................................................... 33
CATAFLAM ......................................................................... 6
CATAPRES ........................................................................ 29
CATAPRES‐TTS‐1 ..................................................... 29
CATAPRES‐TTS‐2 ..................................................... 29
CATAPRES‐TTS‐3 ..................................................... 29
CAVERJECT ..................................................................... 45
CAVERJECT IMPULSE ......................................... 45
CAYSTON .......................................................................... 31
CAZIANT ............................................................................. 47
CEDAX ................................................................................... 46
cefaclor ............................................................................... 46
cefaclor er ....................................................................... 46
cefadroxil .......................................................................... 46
cefdinir ................................................................................ 46
cefixime .............................................................................. 46
cefprozil .............................................................................. 46
CEFTIN .................................................................................. 46
cefuroxime axetil .................................................... 46
CELEBREX ............................................................................. 6
celecoxib ............................................................................... 6
CELEXA ................................................................................ 19
CELLCEPT .......................................................................... 41
CELONTIN ........................................................................ 17
CENESTIN ......................................................................... 66
cephalexin ....................................................................... 46
CERDELGA ....................................................................... 71
CEREFOLIN ...................................................................... 61
CEREFOLIN NAC ....................................................... 61
CERVIDIL ............................................................................ 87
CESAMET .......................................................................... 25
cetirizine hcl .................................................................. 26
cetirizine‐pseudoephedrine er ............... 52
CETRAXAL ........................................................................ 86
CETROTIDE ..................................................................... 64
CHANTIX ............................................................................ 88
CHANTIX CONTINUING MONTH PAK
....................................................................................................... 88
CHANTIX STARTING MONTH PAK ...... 88
CHATEAL ........................................................................... 47
CHENODAL ..................................................................... 68
cheratussin ac ............................................................ 52
childrens ibuprofen 100 ..................................... 6
childrens loratadine ............................................ 26
chlordiazepoxide hcl ........................................... 13
chlordiazepoxide‐amitriptyline ............. 88
chloroquine phosphate ................................... 32
chlorothiazide ............................................................. 63
chlorpromazine hcl ............................................... 36
chlorpropamide ........................................................ 22
chlorthalidone ............................................................ 63
chlorzoxazone ............................................................ 82
CHOLBAM ........................................................................ 68
cholestyramine ......................................................... 27
cholestyramine light ........................................... 27
choline‐mag trisalicylate .................................. 8
chorionic gonadotropin .................................. 64
Index
butalbital‐apap‐caff‐cod .................................. 9
butalbital‐apap‐caffeine ................................... 8
butalbital‐asa‐caffeine ....................................... 8
BUTISOL SODIUM .................................................. 72
butorphanol tartrate ............................................. 9
BUTRANS .............................................................................. 9
BYDUREON ..................................................................... 22
BYETTA 10 MCG PEN ......................................... 22
BYETTA 5 MCG PEN ............................................. 22
BYSTOLIC .......................................................................... 42
cabergoline .................................................................... 64
CADUET .............................................................................. 45
CAFCIT ..................................................................................... 4
CAFERGOT ....................................................................... 79
CALAN .................................................................................. 43
CALAN SR ......................................................................... 43
CALCIFEROL ................................................................... 96
calcipotriene ................................................................. 53
calcipotriene‐betameth diprop ............. 53
calcitonin (salmon) ............................................... 64
CALCITRENE .................................................................. 53
calcitriol .................................................................. 53, 64
calcium acetate ........................................................ 68
calcium acetate (phos binder) ............... 68
CAMBIA .............................................................................. 79
CAMPRAL ......................................................................... 88
CAMRESE .......................................................................... 46
CAMRESE LO ................................................................ 47
CANASA .............................................................................. 68
candesartan cilexetil .......................................... 29
candesartan cilexetil‐hctz ............................ 29
capecitabine ................................................................. 33
CAPEX ................................................................................... 53
CAPHOSOL ...................................................................... 80
CAPRELSA ........................................................................ 33
captopril ............................................................................ 29
captopril‐hydrochlorothiazide ............... 29
CARAFATE ........................................................................ 92
CARBAGLU ...................................................................... 64
carbamazepine .............................................. 16, 17
carbamazepine er .................................................. 16
CARBATROL ................................................................... 17
carbidopa ......................................................................... 35
carbidopa‐levodopa ............................................ 35
carbidopa‐levodopa er .................................... 35
carbidopa‐levodopa‐entacapone ...... 35
CARDIOTEK RX ........................................................... 61
CARDIZEM ....................................................................... 43
CARDIZEM CD ............................................................. 43
CARDIZEM LA .............................................................. 43
CARDURA ......................................................................... 29
CARDURA XL ................................................................. 69
carisoprodol .................................................................. 82
carisoprodol‐aspirin ............................................ 82
CARNITOR ........................................................................ 64
CARNITOR SF ............................................................... 64
carteolol hcl .................................................................. 84
CARTIA XT ........................................................................ 43
Index
Index
BESIVANCE ..................................................................... 84
BETAGAN .......................................................................... 84
betamethasone dipropionate aug .... 53
betamethasone valerate .............................. 53
BETAPACE ........................................................................ 42
BETAPACE AF ............................................................... 42
BETASERON ................................................................... 88
betaxolol hcl ................................................................. 84
bethanechol chloride ......................................... 94
BETHKIS .................................................................................. 5
BETIMOL ........................................................................... 84
BETOPTIC‐S .................................................................... 84
BEYAZ .................................................................................... 46
BIAXIN .................................................................................. 74
BIAXIN XL .......................................................................... 74
BIAXIN XL PAC ............................................................ 74
bicalutamide ................................................................ 33
BIDIL ....................................................................................... 45
BILTRICIDE ....................................................................... 12
bimatoprost .................................................................. 84
BINOSTO ........................................................................... 64
bisoprolol fumarate ............................................ 42
bisoprolol‐hydrochlorothiazide ............. 29
BLEPH‐10 .......................................................................... 84
BLEPHAMIDE ............................................................... 84
BLEPHAMIDE S.O.P. ............................................ 84
BONIVA ............................................................................... 64
BOSULIF ............................................................................. 33
bp 10‐1 ................................................................................ 53
BPROTECTED PEDIA D‐VITE ....................... 96
BPROTECTED PEDIA IRON ........................... 71
BRAVELLE ......................................................................... 64
BREO ELLIPTA .............................................................. 14
BREVICON (28) .......................................................... 46
briellyn ................................................................................. 46
BRILINTA ........................................................................... 70
brimonidine tartrate .......................................... 84
BRINTELLIX ..................................................................... 19
BRISDELLE ........................................................................ 88
BROMFED DM ............................................................ 52
bromocriptine mesylate ................................ 35
BROVANA ........................................................................ 14
BUDEPRION XL .......................................................... 19
budesonide ..................................................................... 14
budesonide er ............................................................. 51
bullseye mini safety lancets ...................... 76
bumetanide ................................................................... 63
BUNAVAIL ........................................................................... 9
BUPHENYL ....................................................................... 64
buprenorphine hcl ..................................................... 9
buprenorphine hcl‐naloxone hcl ............. 9
BUPROBAN .................................................................... 88
bupropion hcl .............................................................. 19
bupropion hcl er (smoking det) ............ 88
bupropion hcl er (sr) ........................................... 19
bupropion hcl er (xl) ............................................ 19
buspirone hcl ............................................................... 13
butalbital‐acetaminophen ............................. 8
(Updated 08/01/2015)
99
(Updated 08/01/2015)
100
CREON .................................................................................. 62
CRESEMBA ...................................................................... 25
CRESTOR ........................................................................... 27
CRINONE ........................................................................... 95
CRIXIVAN .......................................................................... 38
cromolyn sodium ......................................... 15, 84
CRYSELLE‐28 ................................................................. 47
CUPRIMINE .................................................................... 41
CUTIVATE ......................................................................... 54
CUVPOSA .......................................................................... 92
cvs clotrimazole ....................................................... 54
cvs d3 .................................................................................... 96
cvs folic acid .................................................................. 71
cvs heartburn relief ............................................. 92
cvs lancets 21g .......................................................... 76
cvs lancets micro thin 33g .......................... 76
cvs lancets original ............................................... 76
cvs lancets thin .......................................................... 76
cvs lancets thin 26g ............................................. 76
cvs lancets ultra thin 30g ............................. 76
cvs nicotine .................................................................... 88
cvs permethrin ........................................................... 54
cvs prenatal ................................................................... 81
cvs ultra thin lancets .......................................... 76
cyanocobalamin ...................................................... 71
CYCLAFEM 1/35 ....................................................... 47
CYCLESSA .......................................................................... 47
CYCLOBENZAPRINE COMFORT PAC
....................................................................................................... 82
cyclobenzaprine hcl ............................................. 82
CYCLOGYL ........................................................................ 84
CYCLOMYDRIL ............................................................ 84
cyclopentolate hcl ...................................... 46, 84
cyclophosphamide ................................................ 33
CYCLOSET ......................................................................... 22
cyclosporine .................................................................. 41
cyclosporine modified ...................................... 41
CYMBALTA ...................................................................... 19
cyproheptadine hcl .............................................. 26
CYSTADANE ................................................................... 64
CYSTAGON ...................................................................... 69
CYSTARAN ....................................................................... 84
CYTOMEL .......................................................................... 91
CYTOTEC ............................................................................ 92
CYTRA‐3 ............................................................................. 69
cytra‐k .................................................................................. 69
d 400 ...................................................................................... 96
D.H.E. 45 ........................................................................... 79
d3‐1000 .............................................................................. 96
DALIRESP .......................................................................... 15
danazol ............................................................................... 11
DANTRIUM ..................................................................... 82
dantrolene sodium ............................................... 82
dapsone ............................................................................. 31
DARAPRIM ...................................................................... 32
DASETTA 1/35 ............................................................ 47
DASETTA 7/7/7 ......................................................... 47
DAYPRO ................................................................................. 6
Index
clopidogrel bisulfate ........................................... 70
clorazepate dipotassium ............................... 13
CLORPRES ........................................................................ 29
clotrimazole ............................................. 54, 80, 95
clotrimazole af ........................................................... 54
clotrimazole anti‐fungal ................................ 54
clozapine ........................................................................... 36
CLOZARIL .......................................................................... 37
CNL8 NAIL ........................................................................ 54
COARTEM ........................................................................ 32
codeine sulfate .............................................................. 9
COLAZAL ............................................................................ 68
colchicine .......................................................................... 70
colchicine‐probenecid ....................................... 70
COLCRYS ............................................................................ 70
COLESTID .......................................................................... 27
COLESTID FLAVORED ......................................... 27
colestipol hcl ................................................................ 27
COLY‐MYCIN S ............................................................ 86
COLYTE WITH FLAVOR PACKS ................ 73
COMBIGAN .................................................................... 84
COMBIPATCH .............................................................. 66
COMBIVENT RESPIMAT .................................. 15
COMBIVIR ........................................................................ 38
COMETRIQ (100 MG DAILY DOSE) .... 33
COMETRIQ (140 MG DAILY DOSE) .... 33
COMETRIQ (60 MG DAILY DOSE) ....... 33
comfort assured lancets 28g ................... 76
comfort assured lancets 33g ................... 76
comfort lancets ........................................................ 76
COMPAZINE .................................................................. 37
COMPLERA ..................................................................... 38
COMTAN ........................................................................... 35
CONCERTA .......................................................................... 4
CONDYLOX ..................................................................... 54
CONTRAVE ......................................................................... 4
CONZIP .................................................................................... 9
COPAXONE ..................................................................... 88
COPEGUS .......................................................................... 38
CORDARONE ................................................................ 13
CORDRAN ........................................................................ 54
COREG .................................................................................. 42
COREG CR ........................................................................ 42
CORGARD ......................................................................... 42
CORIFACT ......................................................................... 70
CORLANOR ..................................................................... 45
CORTEF ............................................................................... 51
CORTIFOAM .................................................................. 12
cortisone acetate ................................................... 51
CORTISPORIN .............................................................. 86
CORTISPORIN‐TC .................................................... 87
CORZIDE ............................................................................. 29
COSENTYX ....................................................................... 54
COSENTYX SENSOREADY PEN ................. 54
COSOPT .............................................................................. 84
COSOPT PF ...................................................................... 84
COUMADIN .................................................................... 16
COZAAR .............................................................................. 29
Index
Index
CIALIS .................................................................................... 45
CICLODAN CREAM ................................................ 53
CICLODAN SOLUTION ....................................... 53
ciclopirox ........................................................................... 53
ciclopirox olamine ................................................. 53
cilostazol ........................................................................... 70
CILOXAN ............................................................................ 84
cimetidine ........................................................................ 92
cimetidine 200 ........................................................... 92
cimetidine hcl .............................................................. 92
CIMZIA ................................................................................. 68
CIMZIA PREFILLED ................................................. 68
CIMZIA STARTER KIT ........................................... 68
CINRYZE .............................................................................. 70
CIPRO .................................................................................... 67
CIPRO HC .......................................................................... 86
CIPRO XR ........................................................................... 67
CIPRODEX ........................................................................ 86
ciprofloxacin hcl ....................................................... 67
citalopram hydrobromide ........................... 19
CITRANATAL 90 DHA ......................................... 81
CITRANATAL B‐CALM ........................................ 81
CITRANATAL DHA .................................................. 81
CITRANATAL HARMONY ................................ 81
CITRANATAL RX ........................................................ 81
citric acid‐sodium citrate .............................. 69
CLARAVIS .......................................................................... 54
CLARIFOAM EF .......................................................... 54
CLARINEX .......................................................................... 26
CLARINEX‐D 12 HOUR ...................................... 52
clarithromycin ............................................................ 74
clarithromycin er .................................................... 74
CLARITIN ........................................................................... 26
CLARITIN REDITABS ............................................. 26
CLARITIN‐D 12 HOUR ........................................ 52
CLARITIN‐D 24 HOUR ........................................ 52
clemastine fumarate ......................................... 26
CLEOCIN .................................................................. 31, 95
CLEOCIN‐T ....................................................................... 54
CLIMARA ........................................................................... 66
CLIMARA PRO ............................................................. 66
CLINDACIN PAC ........................................................ 54
CLINDAGEL ..................................................................... 54
clindamycin hcl ......................................................... 31
clindamycin phos‐benzoyl perox ......... 54
clindamycin phosphate ........................ 54, 95
CLINDESSE ....................................................................... 95
clobetasol propionate ...................................... 54
clobetasol propionate e ................................. 54
CLOBEX ............................................................................... 54
CLOBEX SPRAY ........................................................... 54
CLODERM ......................................................................... 54
CLODERM PUMP .................................................... 54
clomiphene citrate ................................................ 64
clomipramine hcl .................................................... 19
clonazepam ................................................................... 17
clonidine hcl .................................................................. 29
clonidine hcl er .............................................................. 4
DUAVEE .............................................................................. 66
DUETACT ........................................................................... 22
DUEXIS ..................................................................................... 6
DULERA ............................................................................... 15
duloxetine hcl .............................................................. 19
DUONEB ............................................................................ 15
DUOPA ................................................................................. 35
DURAGESIC‐100 .......................................................... 9
DURAGESIC‐12 .............................................................. 9
DURAGESIC‐25 .............................................................. 9
DURAGESIC‐50 .............................................................. 9
DURAGESIC‐75 .............................................................. 9
DUREZOL ........................................................................... 84
DUTOPROL ..................................................................... 29
D‐VI‐SOL ............................................................................ 96
DYAZIDE ............................................................................. 63
DYMISTA ........................................................................... 83
DYRENIUM ...................................................................... 63
E.E.S. 400 .......................................................................... 74
E.E.S. GRANULES ..................................................... 74
easy comfort lancets .......................................... 76
EC‐NAPROSYN ............................................................... 6
econazole nitrate ................................................... 55
ECOTRIN ................................................................................ 8
ECOZA ................................................................................... 55
EDARBI ................................................................................ 29
EDARBYCLOR ............................................................... 29
EDECRIN ............................................................................. 63
EDEX ....................................................................................... 45
EDLUAR ............................................................................... 72
EDURANT ......................................................................... 39
EFFEXOR XR ................................................................... 19
EFFIENT ............................................................................... 70
EFUDEX ............................................................................... 55
EGRIFTA ............................................................................. 64
ELDEPRYL .......................................................................... 35
ELESTAT .............................................................................. 84
ELESTRIN ........................................................................... 67
ELIDEL ................................................................................... 55
ELIMITE ............................................................................... 55
ELINEST ............................................................................... 47
ELIPHOS .............................................................................. 68
ELIQUIS ............................................................................... 16
ELIXOPHYLLIN ............................................................. 15
ELLA ......................................................................................... 47
ELMIRON .......................................................................... 69
ELOCON .............................................................................. 55
ELOCTATE ........................................................................ 70
EMBEDA ................................................................................ 9
EMCYT .................................................................................. 33
EMEND ................................................................................ 25
EMLA ..................................................................................... 55
EMOQUETTE ................................................................ 47
EMSAM ............................................................................... 19
EMTRIVA ........................................................................... 39
ENABLEX ............................................................................ 94
enalapril maleate ................................................... 29
enalapril‐hydrochlorothiazide ................ 29
Index
diclofenac‐misoprostol ....................................... 6
dicloxacillin sodium ............................................. 87
dicyclomine hcl .......................................................... 92
didanosine ...................................................................... 38
DIDREX .................................................................................... 4
DIDRONEL ........................................................................ 64
diethylpropion hcl ..................................................... 4
diethylpropion hcl er .............................................. 4
DIFFERIN ........................................................................... 55
DIFICID ................................................................................. 74
DIFLUCAN ........................................................................ 25
diflunisal ............................................................................... 8
DIGOX ................................................................................... 45
digoxin ................................................................................. 45
dihydroergotamine mesylate .................. 79
DILANTIN .......................................................................... 17
DILANTIN INFATABS ........................................... 17
DILATRATE‐SR ............................................................. 12
DILAUDID ............................................................................. 9
diltiazem hcl ................................................................. 44
diltiazem hcl cd ......................................................... 43
diltiazem hcl er .......................................................... 44
diltiazem hcl er beads ....................................... 43
diltiazem hcl er coated beads ................. 44
DIOVAN .............................................................................. 29
DIOVAN HCT ................................................................. 29
DIPENTUM ...................................................................... 68
diphenatol ....................................................................... 24
diphenoxylate‐atropine .................................. 24
DIPROLENE ..................................................................... 55
DIPROLENE AF ............................................................ 55
dipyridamole ................................................................ 70
disopyramide phosphate .............................. 13
disulfiram ......................................................................... 88
DITROPAN XL ............................................................... 94
DIURIL ................................................................................... 63
divalproex sodium ................................................. 17
divalproex sodium er ......................................... 17
DIVIGEL ............................................................................... 66
DOLOPHINE ....................................................................... 9
donepezil hcl ................................................................ 88
DORAL .................................................................................. 72
DORYX .................................................................................. 90
dorzolamide hcl ........................................................ 84
dorzolamide hcl‐timolol mal .................... 84
DOVONEX ........................................................................ 55
doxazosin mesylate ............................................. 29
doxepin hcl ..................................................................... 19
doxercalciferol ........................................................... 64
doxycycline ..................................................................... 55
doxycycline hyclate .............................................. 90
doxycycline monohydrate ........................... 91
dronabinol ...................................................................... 25
drospirenone‐ethinyl estradiol .............. 47
drug mart lancets thin 26g ........................ 76
drug mart lancets ultra thin ..................... 76
DRYSOL ............................................................................... 55
DUAC ..................................................................................... 55
Index
Index
DAYSEE ................................................................................ 47
DAYTRANA ......................................................................... 4
DDAVP ................................................................................. 64
DDAVP RHINAL TUBE ........................................ 64
DELYLA ................................................................................. 47
DELZICOL .......................................................................... 68
DEMADEX ........................................................................ 63
DEMEROL ............................................................................. 9
DEMSER ............................................................................. 29
DENAVIR ............................................................................ 54
DEPAKENE ....................................................................... 17
DEPAKOTE ....................................................................... 17
DEPAKOTE ER .............................................................. 17
DEPAKOTE SPRINKLES ...................................... 17
DEPEN TITRATABS ................................................. 41
DEPLIN 15 ........................................................................ 61
DEPLIN 7.5 ...................................................................... 61
DEPO‐PROVERA ....................................................... 47
DEPO‐SUBQ PROVERA 104 ........................ 47
DERMANIC ...................................................................... 61
DERMA‐SMOOTHE/FS BODY ................... 54
DERMA‐SMOOTHE/FS SCALP .................. 54
DERMATOP .................................................................... 54
DERMAZENE ................................................................. 54
desipramine hcl ........................................................ 19
desmopressin ace rhinal tube ................. 64
desmopressin ace spray refrig ............... 64
desmopressin acetate ...................................... 64
desmopressin acetate spray .................... 64
DESOGEN ......................................................................... 47
desogestrel‐ethinyl estradiol ................... 47
DESONATE ...................................................................... 54
desonide ............................................................................ 54
DESOWEN ........................................................................ 54
DESOXYN .............................................................................. 4
desvenlafaxine er ................................................... 19
desvenlafaxine fumarate er ...................... 19
DETROL ............................................................................... 94
DETROL LA ...................................................................... 94
dexamethasone ....................................................... 51
dexamethasone sodium phosphate
....................................................................................................... 84
DEXEDRINE ........................................................................ 4
DEXILANT ......................................................................... 92
dexmethylphenidate hcl .................................... 4
dexmethylphenidate hcl er ............................ 4
dextroamphetamine sulfate ........................ 4
dextroamphetamine sulfate er ................ 4
DIABETA ............................................................................. 22
DIAMOX SEQUELS ................................................. 63
DIASTAT ACUDIAL ................................................. 17
DIASTAT PEDIATRIC ............................................. 17
diazepam ............................................................... 13, 17
DIBENZYLINE ................................................................ 29
DICLEGIS ............................................................................ 25
diclofenac potassium ............................................ 6
diclofenac sodium ............................... 6, 55, 84
diclofenac sodium er ............................................. 6
(Updated 08/01/2015)
101
(Updated 08/01/2015)
102
FER‐IN‐SOL ..................................................................... 72
FERIVAFA .......................................................................... 72
FERRIPROX ...................................................................... 25
ferrous sulfate ............................................................ 72
FETZIMA ............................................................................ 20
FETZIMA TITRATION ........................................... 20
fexofenadine hcl ...................................................... 26
fexofenadine hcl childrens .......................... 26
fexofenadine‐pseudoephed er ............... 52
FIBRICOR ........................................................................... 27
FINACEA ............................................................................. 55
finasteride ....................................................................... 69
FIORINAL .............................................................................. 8
FIORINAL/CODEINE #3 ........................................ 9
FIRAZYR .............................................................................. 70
FIRST‐LANSOPRAZOLE ..................................... 92
FIRST‐OMEPRAZOLE ........................................... 92
FLAGYL ................................................................................. 31
FLAGYL ER ........................................................................ 32
FLAREX ................................................................................. 84
flavoxate hcl ................................................................. 94
flecainide acetate .................................................. 14
FLECTOR ............................................................................ 55
FLOMAX ............................................................................. 69
FLONASE ........................................................................... 83
FLONASE ALLERGY RELIEF ........................... 83
FLOVENT DISKUS .................................................... 15
FLOVENT HFA .............................................................. 15
FLUBLOK ............................................................................ 95
fluconazole ..................................................................... 25
fludrocortisone acetate .................................. 51
FLULAVAL QUADRIVALENT ........................ 95
FLUMADINE .................................................................. 39
flunisolide ........................................................................ 83
fluocinolone acetonide body .................... 55
fluocinolone acetonide scalp ................... 55
fluocinonide .................................................................. 55
fluocinonide‐e ............................................................. 55
FLUORABON ................................................................. 80
FLUOR‐A‐DAY .............................................................. 80
fluorometholone ..................................................... 84
FLUOROPLEX ................................................................ 55
fluorouracil .......................................................... 55, 56
fluoxetine hcl ............................................................... 20
fluoxetine hcl (pmdd) ........................................ 88
fluphenazine hcl ....................................................... 37
FLURA‐DROPS ............................................................. 80
flurazepam hcl ........................................................... 72
flurbiprofen ....................................................................... 6
flurbiprofen sodium ............................................ 84
flutamide .......................................................................... 33
fluticasone propionate ......................... 56, 83
fluvastatin sodium ................................................ 27
fluvoxamine maleate ........................................ 20
fluvoxamine maleate er ................................. 20
FLUZONE QUADRIVALENT .......................... 95
FML .......................................................................................... 84
FML FORTE ..................................................................... 84
Index
ethambutol hcl .......................................................... 32
ethosuximide ............................................................... 17
etidronate disodium ........................................... 64
etodolac ................................................................................. 6
etodolac er ......................................................................... 6
etoposide .......................................................................... 33
EURAX .................................................................................. 55
EVAMIST ............................................................................ 67
EVEKEO ................................................................................... 4
EVISTA .................................................................................. 64
EVOCLIN ............................................................................ 55
EVOTAZ ............................................................................... 39
EVOXAC .............................................................................. 80
EVZIO ..................................................................................... 25
EXALGO .................................................................................. 9
EXELDERM ...................................................................... 55
EXELON ............................................................................... 88
exemestane ................................................................... 33
EXFORGE ........................................................................... 30
EXFORGE HCT ............................................................. 29
EXJADE ................................................................................. 25
EXTAVIA ............................................................................. 88
EXTINA ................................................................................. 55
FABIOR ................................................................................ 55
FACTIVE .............................................................................. 67
FALLBACK SOLO ....................................................... 47
FALMINA ........................................................................... 47
famciclovir ...................................................................... 39
famotidine ...................................................................... 92
FAMVIR ............................................................................... 39
FANAPT ............................................................................... 37
FANAPT TITRATION PACK ............................ 37
FARESTON ....................................................................... 33
FARXIGA ............................................................................. 22
FARYDAK ........................................................................... 33
FAZACLO ............................................................................ 37
FC2 FEMALE CONDOM ................................... 76
FEIBA NF ............................................................................ 70
FEIBA VH IMMUNO ............................................. 70
felbamate ........................................................................ 17
FELBATOL ......................................................................... 17
FELDENE ................................................................................ 6
felodipine er .................................................................. 44
FEM PH ............................................................................... 95
FEMARA ............................................................................. 33
fematrol ............................................................................. 73
FEMCAP ............................................................................. 76
FEMCON FE ................................................................... 47
FEMHRT LOW DOSE ............................................ 67
FEMRING .......................................................................... 95
fenofibrate ...................................................................... 27
fenofibrate micronized .................................... 27
fenofibric acid ............................................................. 27
FENOGLIDE ..................................................................... 27
fenoprofen calcium ................................................. 6
fentanyl .................................................................................. 9
fentanyl citrate ............................................................. 9
FENTORA .............................................................................. 9
Index
Index
ENBREL ................................................................................... 6
ENBREL SURECLICK .................................................. 6
ENJUVIA ............................................................................. 67
ENLYTE ................................................................................. 61
enoxaparin sodium .............................................. 16
ENPRESSE‐28 ............................................................... 47
ENSKYCE ............................................................................ 47
entacapone .................................................................... 35
entecavir ........................................................................... 39
ENTERAGAM ................................................................ 61
ENTOCORT EC ............................................................. 51
EPANED .............................................................................. 29
EPIDUO ............................................................................... 55
EPIFLUR .............................................................................. 80
epinephrine ................................................................... 96
epinephrine hcl ......................................................... 15
EPIPEN 2‐PAK .............................................................. 96
EPIPEN JR 2‐PAK ...................................................... 96
EPITOL .................................................................................. 17
EPIVIR ................................................................................... 39
EPIVIR HBV ..................................................................... 39
EPOGEN ............................................................................. 72
eprosartan mesylate .......................................... 29
EPZICOM ........................................................................... 39
eq aspirin low dose .................................................. 8
eq lansoprazole ........................................................ 92
eq nicotine ...................................................................... 88
eql color lancets 21g .......................................... 76
eql color lancets micro 33g ........................ 76
eql folic acid .................................................................. 72
eql nicotine .................................................................... 88
eql super thin lancets 30g ........................... 76
eql thin lancets 26g ............................................. 76
EQUETRO ......................................................................... 37
ergoloid mesylates ............................................... 88
ERIVEDGE ......................................................................... 33
ERRIN .................................................................................... 47
ERTACZO ........................................................................... 55
ERY‐TAB ............................................................................. 74
ERYTHROCIN STEARATE ................................. 74
erythromycin ............................................................... 55
erythromycin base ................................................ 74
erythromycin ethylsuccinate ................... 74
erythromycin stearate ..................................... 74
ESBRIET ............................................................................... 90
escitalopram oxalate .............................. 19, 20
esomeprazole magnesium ......................... 92
esomeprazole strontium ............................... 92
ESTARYLLA ...................................................................... 47
estazolam ........................................................................ 72
ESTRACE .................................................................. 67, 95
estradiol ............................................................................. 67
estradiol‐norethindrone acet .................. 67
ESTRING ............................................................................. 95
ESTROGEL ........................................................................ 67
estropipate ..................................................................... 67
ESTROSTEP FE ............................................................. 47
eszopiclone .................................................................... 72
guaifenesin‐codeine ........................................... 52
guanfacine hcl ............................................................ 30
GYNAZOLE‐1 ................................................................. 95
HALCION ........................................................................... 73
HALFPRIN ............................................................................. 8
halobetasol propionate .................................. 56
HALOG ................................................................................. 56
HALONATE ...................................................................... 56
HALONATE PAC ........................................................ 56
haloperidol ..................................................................... 37
haloperidol lactate ............................................... 37
HARVONI .......................................................................... 39
healthwise lancets 30g ................................... 77
healthy accents unilet lancets ................ 77
h‐e‐b incontrol lancets 28g ........................ 77
h‐e‐b incontrol lancets 30g ........................ 77
HECORIA ............................................................................ 41
HECTOROL ...................................................................... 65
HELIDAC ............................................................................. 92
HELIXATE FS .................................................................. 70
HEMANGEOL ............................................................... 42
HEMOFIL M ................................................................... 71
heparin sodium (porcine) ............................. 16
HEPSERA ............................................................................ 39
HETLIOZ .............................................................................. 73
HEXALEN ........................................................................... 34
HIPREX ................................................................................. 94
HIZENTRA ......................................................................... 87
hm famotidine ........................................................... 92
hm folic acid ................................................................. 72
hm lancets micro thin 33g .......................... 77
hm lancets ultra thin 30g ............................. 77
hm niacin .......................................................................... 96
hm nicotine .................................................................... 89
HORIZANT ....................................................................... 89
HUMALOG ...................................................................... 23
HUMALOG KWIKPEN ......................................... 23
HUMALOG MIX 50/50 ...................................... 23
HUMALOG MIX 50/50 KWIKPEN ........ 23
HUMALOG MIX 75/25 ...................................... 23
HUMALOG MIX 75/25 KWIKPEN ........ 23
HUMATE‐P ...................................................................... 71
HUMATROPE ............................................................... 65
HUMIRA ................................................................................. 6
HUMIRA PEDIATRIC CROHNS START
........................................................................................................... 6
HUMIRA PEN ................................................................... 6
HUMIRA PEN‐CROHNS STARTER ............ 6
HUMIRA PEN‐PSORIASIS STARTER ....... 6
HUMULIN 70/30 ...................................................... 23
HUMULIN 70/30 KWIKPEN ........................ 23
HUMULIN N .................................................................. 23
HUMULIN N KWIKPEN ..................................... 23
HUMULIN R ................................................................... 23
HUMULIN R U‐500 (CONCENTRATED)
....................................................................................................... 23
HYCAMTIN ...................................................................... 34
hydralazine hcl .......................................................... 30
Index
gentamicin sulfate ..................................... 56, 84
GEODON ............................................................................ 37
GIANVI ................................................................................. 47
GIAZO .................................................................................... 68
GILDAGIA .......................................................................... 47
GILDESS FE 1.5/30 ................................................. 47
GILDESS FE 1/20 ...................................................... 47
GILENYA ............................................................................. 88
GILOTRIF ........................................................................... 33
GLASPAK TB SYRINGE ....................................... 76
GLATOPA .......................................................................... 89
GLEEVEC ............................................................................ 34
GLEOSTINE ..................................................................... 34
glimepiride ..................................................................... 22
glipizide .............................................................................. 22
glipizide er ....................................................................... 22
GLIPIZIDE XL .................................................................. 22
glipizide‐metformin hcl ................................... 22
global inject ease lancets 28g ................ 77
global inject ease lancets 30g ................ 77
GLUCAGEN HYPOKIT .......................................... 22
GLUCAGON EMERGENCY ............................. 22
GLUCOPHAGE ............................................................. 22
GLUCOPHAGE XR ................................................... 22
GLUCOTROL .................................................................. 22
GLUCOTROL XL .......................................................... 22
GLUCOVANCE ............................................................. 22
GLUMETZA ..................................................................... 22
glyburide ........................................................................... 22
glyburide micronized ......................................... 22
glyburide‐metformin ......................................... 22
GLYNASE ........................................................................... 22
GLYSET ................................................................................. 22
GLYXAMBI ....................................................................... 22
gnp folic acid ............................................................... 72
gnp heartburn relief ........................................... 92
gnp lancets ..................................................................... 77
gnp lancets 21g ........................................................ 77
gnp lancets micro thin 33g ........................ 77
gnp lancets super thin 30g ......................... 77
gnp lancets thin ....................................................... 77
gnp lancets thin 26g ........................................... 77
gnp micro thin lancets 33g ........................ 77
gnp niacin tr ................................................................. 96
gnp super thin lancets 30g ......................... 77
gnp vitamin d .............................................................. 96
GOLYTELY ......................................................................... 73
GONAL‐F ............................................................................ 65
GONAL‐F RFF ............................................................... 65
GONAL‐F RFF PEN .................................................. 65
GONAL‐F RFF REDIJECT .................................. 65
GRALISE .............................................................................. 89
GRALISE STARTER .................................................. 89
GRANIX ............................................................................... 72
GRIFULVIN V ................................................................. 25
griseofulvin microsize ....................................... 25
griseofulvin ultramicrosize ......................... 25
GRIS‐PEG ........................................................................... 26
Index
Index
FML LIQUIFILM ......................................................... 84
FOCALIN ................................................................................ 4
FOCALIN XR ....................................................................... 4
FOLBEE AR ...................................................................... 61
FOLBIC .................................................................................. 61
FOLBIC RF ......................................................................... 61
folic acid ............................................................................ 72
FOLLISTIM AQ ............................................................. 64
FOLTANX ........................................................................... 61
FOLTANX RF .................................................................. 61
FOLTX .................................................................................... 61
fondaparinux sodium ........................................ 16
FORADIL AEROLIZER ........................................... 15
FORFIVO XL .................................................................... 20
FORTAMET ..................................................................... 22
FORTEO .............................................................................. 64
FORTESTA ........................................................................ 11
FORTICAL .......................................................................... 64
FOSAMAX ......................................................................... 65
FOSAMAX PLUS D .................................................. 65
fosinopril sodium .................................................... 30
fosinopril sodium‐hctz ...................................... 30
FOSRENOL ....................................................................... 68
FOSTEUM ......................................................................... 61
FOSTEUM PLUS ......................................................... 61
FOVEX ................................................................................... 61
FRAGMIN .......................................................................... 16
FREESTYLE FREEDOM LITE .......................... 76
FREESTYLE INSULINX TEST .......................... 60
FREESTYLE LITE TEST .......................................... 60
FREESTYLE TEST ....................................................... 60
FROVA .................................................................................. 79
FULYZAQ ........................................................................... 24
FURADANTIN ............................................................... 94
furosemide ..................................................................... 63
FUZEON .............................................................................. 39
FYCOMPA ......................................................................... 17
GABADONE .................................................................... 61
gabapentin ..................................................................... 17
GABITRIL ........................................................................... 17
galantamine hydrobromide ...................... 88
galantamine hydrobromide er .............. 88
GAMMAGARD ............................................................ 87
GAMMAKED ................................................................. 87
GAMUNEX‐C ................................................................. 87
ganirelix acetate ..................................................... 65
GARAMYCIN ................................................................. 84
gatifloxacin .................................................................... 84
GATTEX ............................................................................... 68
gavilax .................................................................................. 73
GAVILYTE‐H ................................................................... 73
GELCLAIR .......................................................................... 80
GELNIQUE ........................................................................ 94
gemfibrozil ..................................................................... 27
GENERESS FE ............................................................... 47
GENGRAF .......................................................................... 41
GENOTROPIN .............................................................. 65
GENOTROPIN MINIQUICK ........................... 65
(Updated 08/01/2015)
103
(Updated 08/01/2015)
104
KEPPRA ............................................................................... 17
KEPPRA XR ...................................................................... 17
KERYDIN ............................................................................. 56
KETEK .................................................................................... 32
ketoconazole ................................................................ 26
KETODAN ......................................................................... 56
ketoprofen .......................................................................... 7
ketoprofen er .................................................................. 7
ketorolac tromethamine ........................ 7, 85
KHEDEZLA ........................................................................ 20
kinney lancets ............................................................. 77
kinney thin lancets ............................................... 77
KIONEX ................................................................................ 41
KLARON .............................................................................. 56
KLONOPIN ....................................................................... 17
KOATE‐DVI ...................................................................... 71
KOGENATE FS ............................................................. 71
KOGENATE FS BIO‐SET .................................... 71
KOMBIGLYZE XR ...................................................... 23
KORLYM ............................................................................. 23
kp clotrimazole ......................................................... 56
kp folic acid .................................................................... 72
K‐PHOS‐NEUTRAL .................................................. 80
KRISTALOSE ................................................................... 73
kroger lancets ............................................................. 77
kroger lancets 21g ................................................ 77
kroger lancets micro thin 33g ................ 77
kroger lancets super thin ............................. 77
kroger lancets thin ............................................... 77
kroger lancets thin 26g ................................... 77
kroger lancets ultrathin 30g ..................... 77
KURVELO ........................................................................... 48
KUVAN ................................................................................. 65
labetalol hcl ................................................................... 42
LAC‐HYDRIN .................................................................. 56
LACRISERT ....................................................................... 85
lactulose ............................................................................ 73
lactulose encephalopathy ........................... 68
lady lite lancets ......................................................... 77
LAMICTAL ........................................................................ 17
LAMICTAL ODT .......................................................... 17
LAMICTAL STARTER ............................................. 17
LAMICTAL XR ............................................................... 17
LAMISIL ............................................................................... 26
lamivudine ...................................................................... 39
lamivudine‐zidovudine .................................... 39
lamotrigine .................................................................... 18
lamotrigine er ............................................................. 17
lancets .................................................................................. 77
lancets 28g ..................................................................... 77
lancets 30g ..................................................................... 77
lancets micro thin 33g ..................................... 77
lancets super thin 28g ...................................... 77
lancets thin .................................................................... 77
lancets ultra thin 30g ........................................ 77
LANOXIN ........................................................................... 45
LANOXIN PEDIATRIC ........................................... 45
lansoprazole ................................................................. 93
Index
INTROVALE ..................................................................... 47
INTUNIV ................................................................................. 4
INVEGA ............................................................................... 37
INVIRASE ........................................................................... 39
INVOKAMET .................................................................. 23
INVOKANA ...................................................................... 23
IOPIDINE ............................................................................ 84
ipratropium bromide .............................. 15, 83
ipratropium‐albuterol ...................................... 15
IPRIVASK ............................................................................ 16
irbesartan ........................................................................ 30
irbesartan‐hydrochlorothiazide ........... 30
IRENKA ................................................................................ 20
ISENTRESS ....................................................................... 39
isoditrate er ................................................................... 12
isoniazid ............................................................................. 32
ISOPTO ATROPINE ................................................ 85
ISOPTO CARBACHOL .......................................... 85
ISOPTO CARPINE ..................................................... 85
ISOPTO HYOSCINE ................................................. 85
ISORDIL TITRADOSE ............................................ 12
isosorbide dinitrate .............................................. 12
isosorbide dinitrate er ...................................... 12
isosorbide mononitrate .................................. 12
isosorbide mononitrate er .......................... 12
itraconazole .................................................................. 26
ivermectin ....................................................................... 12
IXINITY ................................................................................. 71
JADENU ............................................................................... 25
JAKAFI ................................................................................... 34
JALYN ..................................................................................... 69
JANUMET ......................................................................... 23
JANUMET XR ................................................................ 23
JANUVIA ............................................................................ 23
JARDIANCE ..................................................................... 23
JENCYCLA ......................................................................... 47
JENTADUETO ............................................................... 23
JINTELI .................................................................................. 67
JOLESSA .............................................................................. 47
JOLIVETTE ........................................................................ 47
JUBLIA .................................................................................. 56
JUNEL 1.5/30 ............................................................... 48
JUNEL 1/20 ..................................................................... 48
JUNEL FE 1.5/30 ....................................................... 48
JUNEL FE 1/20 ............................................................ 48
JUXTAPID .......................................................................... 27
KADIAN ............................................................................... 10
KALETRA ............................................................................ 39
KALYDECO ....................................................................... 90
KAPVAY ................................................................................... 4
KARBINAL ER ................................................................ 26
KARIVA ................................................................................ 48
KAYEXALATE ................................................................. 41
KAZANO ............................................................................. 23
KCENTRA ........................................................................... 71
KEFLEX ................................................................................. 46
KELNOR 1/35 ............................................................... 48
KENALOG .......................................................................... 56
Index
Index
HYDREA .............................................................................. 34
hydrochlorothiazide ............................................ 63
hydrocodone‐acetaminophen .................... 9
hydrocodone‐homatropine ........................ 52
hydrocodone‐ibuprofen ..................................... 9
hydrocortisone ..................................... 12, 51, 56
hydrocortisone ace‐pramoxine ............. 56
hydrocortisone butyr lipo base ............. 56
hydrocortisone butyrate ............................... 56
hydrocortisone valerate ................................ 56
hydrocortisone‐acetic acid ......................... 87
hydrocortisone‐iodoquinol ......................... 56
hydromorphone hcl ................................................. 9
hydromorphone hcl er ......................................... 9
hydroxychloroquine sulfate ....................... 32
hydroxyurea .................................................................. 34
hydroxyzine hcl .............................................. 13, 46
hydroxyzine pamoate ....................................... 13
HYLATOPIC ..................................................................... 56
hyoscyamine sulfate .......................................... 92
HYPERTENSA ................................................................ 61
HYQVIA ............................................................................... 87
HYSINGLA ER ................................................................ 10
hy‐vee thin lancets ............................................... 77
HYZAAR ............................................................................... 30
ibandronate sodium ........................................... 65
IBRANCE ............................................................................ 34
ibuprofen .............................................................................. 7
IBUPROFEN COMFORT PAC .......................... 6
IC 400 ........................................................................................ 7
IC 800 ........................................................................................ 7
ICAR‐C PLUS .................................................................. 72
ICLUSIG ............................................................................... 34
ILARIS ........................................................................................ 7
ILOTYCIN ........................................................................... 84
IMBRUVICA .................................................................... 34
IMDUR ................................................................................. 12
imipramine hcl ........................................................... 20
imipramine pamoate ........................................ 20
imiquimod ....................................................................... 56
IMITREX .............................................................................. 79
IMITREX STATDOSE REFILL ......................... 79
IMPLANON ..................................................................... 47
IMURAN ............................................................................. 41
INCIVEK ............................................................................... 39
INCRELEX .......................................................................... 65
INCRUSE ELLIPTA .................................................... 15
indapamide ................................................................... 63
INDERAL LA .................................................................... 42
INDOCIN ................................................................................ 7
indomethacin .................................................................. 7
indomethacin er .......................................................... 7
INLYTA .................................................................................. 34
INNOPRAN XL ............................................................. 42
INSPRA ................................................................................. 30
INTELENCE ...................................................................... 39
INTERMEZZO ............................................................... 73
INTRON A ......................................................................... 34
LOSEASONIQUE ........................................................ 48
LOTEMAX ......................................................................... 85
LOTENSIN ......................................................................... 30
LOTREL ................................................................................ 30
LOTRISONE ..................................................................... 57
LOTRONEX ...................................................................... 68
lovastatin ......................................................................... 28
LOVAZA ............................................................................... 28
LOVENOX .......................................................................... 16
LOW‐OGESTREL ....................................................... 48
loxapine succinate ................................................ 37
LUFYLLIN ........................................................................... 15
LUKAID GLA ................................................................... 62
LUMIGAN ......................................................................... 85
LUNESTA ........................................................................... 73
LURIDE ................................................................................. 80
LUTERA ............................................................................... 48
LUVOX CR ......................................................................... 20
LUXIQ .................................................................................... 57
LUZU ....................................................................................... 57
LYNPARZA ........................................................................ 34
LYRICA .................................................................................. 18
LYSODREN ....................................................................... 34
LYSTEDA ............................................................................. 72
LYZA ........................................................................................ 48
MACROBID ..................................................................... 94
MACRODANTIN ........................................................ 94
MACUTEK ......................................................................... 62
major comfort lancets ..................................... 78
MALARONE .................................................................... 32
maprotiline hcl .......................................................... 20
MARINOL .......................................................................... 25
marlissa .............................................................................. 48
MATULANE .................................................................... 34
MATZIM LA .................................................................... 44
MAVIK .................................................................................. 30
MAXALT ............................................................................. 79
MAXALT‐MLT .............................................................. 79
MAXIDEX ........................................................................... 85
MAXITROL ....................................................................... 85
MAXZIDE ........................................................................... 63
MAXZIDE‐25 ................................................................. 63
meclofenamate sodium ..................................... 7
medicine shoppe lancets .............................. 78
medicine shoppe lancets thin ................. 78
medi‐lance lancets ............................................... 78
MEDROL ............................................................................ 51
MEDROL (PAK) ........................................................... 51
medroxyprogesterone acetate ... 49, 87
mefenamic acid ........................................................... 7
MEGACE ES .................................................................... 87
MEGACE ORAL ........................................................... 34
megestrol acetate ................................................. 34
MEKINIST .......................................................................... 34
meloxicam .......................................................................... 7
MELOXICAM COMFORT PAC ....................... 7
MENEST .............................................................................. 67
MENOPUR ....................................................................... 65
Index
LILETTA ................................................................................ 48
LIMBREL ............................................................................. 61
LIMBREL250 .................................................................. 61
LIMBREL500 .................................................................. 61
lindane ................................................................................. 56
LINZESS ............................................................................... 68
LIORESAL ........................................................................... 82
liothyronine sodium ............................................ 91
LIPICHOL 540 ............................................................... 61
LIPITOR ................................................................................ 27
LIPOFEN ............................................................................. 28
LIPTRUZET ....................................................................... 28
lisinopril .............................................................................. 30
lisinopril‐hydrochlorothiazide ................. 30
LISTER‐V ............................................................................. 61
lite touch lancets .................................................... 77
lithium carbonate .................................................. 37
lithium carbonate er .......................................... 37
LITHOBID .......................................................................... 37
LIVALO ................................................................................. 28
l‐methylfolate ............................................................. 61
l‐methylfolate ca me‐cbl nac ................... 61
l‐methylfolate formula 15 ........................... 61
l‐methylfolate formula 7.5 ......................... 61
l‐methylfolate forte ............................................. 61
l‐methylfolate‐algae‐b12‐b6 ................... 62
l‐methylfolate‐b6‐b12 ...................................... 62
l‐methyl‐mc ................................................................... 62
l‐methyl‐mc nac ....................................................... 62
LO LOESTRIN FE ........................................................ 48
LO/OVRAL (28) .......................................................... 48
LOCOID ................................................................................ 56
LOCOID LIPOCREAM ........................................... 56
LODOSYN .......................................................................... 36
LOESTRIN 1.5/30 (21) ....................................... 48
LOESTRIN 1/20 (21) ............................................. 48
LOESTRIN FE 1.5/30 ............................................ 48
LOESTRIN FE 1/20 .................................................. 48
LOFIBRA ............................................................................. 28
LOMEDIA 24 FE ......................................................... 48
LOMOTIL ........................................................................... 24
lomustine ......................................................................... 34
longs lancets standard .................................... 77
longs lancets thin ................................................... 77
longs lancets ultra thin ................................... 77
LOPID ..................................................................................... 28
LOPRESSOR HCT ...................................................... 30
LOPROX .............................................................................. 56
loratadine ........................................................................ 27
loratadine allergy relief .................................. 27
loratadine childrens ............................................ 27
loratadine‐d 12hr ................................................... 52
loratadine‐d 24hr ................................................... 52
lorazepam ....................................................................... 13
LORYNA .............................................................................. 48
LORZONE .......................................................................... 82
losartan potassium .............................................. 30
losartan potassium‐hctz ................................ 30
Index
Index
LANTUS ............................................................................... 23
LANTUS SOLOSTAR .............................................. 23
LARIN 1.5/30 ................................................................ 48
LARIN 1/20 ..................................................................... 48
LARIN FE 1.5/30 ....................................................... 48
LARIN FE 1/20 ............................................................. 48
LASIX ...................................................................................... 63
LASTACAFT ..................................................................... 85
latanoprost .................................................................... 85
LATUDA .............................................................................. 37
LAZANDA .......................................................................... 10
LEENA ................................................................................... 48
leflunomide ....................................................................... 7
LENVIMA 10 MG DAILY DOSE ................. 34
LESCOL ................................................................................. 27
LESCOL XL ........................................................................ 27
LESSINA .............................................................................. 48
LETAIRIS ............................................................................. 45
letrozole ............................................................................. 34
leucovorin calcium ................................................ 34
LEUKERAN ....................................................................... 34
LEUKINE ............................................................................. 72
leuprolide acetate ................................................. 34
levalbuterol hcl ......................................................... 15
LEVAQUIN ....................................................................... 67
LEVEMIR ............................................................................ 23
LEVEMIR FLEXPEN ................................................. 23
LEVEMIR FLEXTOUCH ....................................... 23
levetiracetam .............................................................. 18
levetiracetam er ...................................................... 18
LEVITRA .............................................................................. 45
levobunolol hcl .......................................................... 85
levocetirizine dihydrochloride ................ 27
levofloxacin ......................................................... 67, 85
levomefolate dha ................................................... 81
LEVONEST ........................................................................ 48
levonorgest‐eth estrad 91‐day .............. 48
levonorgestrel ............................................................ 48
levonorgestrel‐ethinyl estrad .................. 48
LEVORA 0.15/30 (28) ......................................... 48
levorphanol tartrate ........................................... 10
LEVOTHROID ................................................................ 91
levothyroxine sodium ........................................ 91
LEVOXYL ............................................................................. 91
LEVSIN .................................................................................. 93
LEVULAN KERASTICK .......................................... 56
LEXAPRO ........................................................................... 20
LEXIVA .................................................................................. 39
LIALDA .................................................................................. 68
lidocaine ............................................................................ 56
lidocaine viscous ..................................................... 80
lidocaine‐hydrocortisone ace .................. 12
lidocaine‐prilocaine ............................................. 56
LIDODERM ...................................................................... 56
lidorx ...................................................................................... 56
(Updated 08/01/2015)
105
(Updated 08/01/2015)
106
mupirocin ......................................................................... 57
mupirocin calcium ................................................. 57
MUSE ..................................................................................... 45
MYALEPT ........................................................................... 65
MYAMBUTOL .............................................................. 32
MYCOBUTIN ................................................................. 33
mycophenolate mofetil .................................. 41
mycophenolic acid ................................................ 41
MYFORTIC ....................................................................... 42
MYLERAN ......................................................................... 34
MYNATAL ......................................................................... 81
MYORISAN ...................................................................... 57
MYRBETRIQ ................................................................... 94
MYSOLINE ....................................................................... 18
nabumetone ..................................................................... 7
nadolol ................................................................................ 42
naftifine hcl ................................................................... 57
NAFTIN ................................................................................ 57
NALFON ................................................................................. 7
naltrexone hcl ............................................................. 25
NAMENDA ...................................................................... 89
NAMENDA TITRATION PAK ....................... 89
NAMENDA XR ............................................................. 89
NAMENDA XR TITRATION PACK .......... 89
NAMZARIC ...................................................................... 89
NAPRELAN .......................................................................... 7
NAPROSYN ......................................................................... 7
naproxen .............................................................................. 7
NAPROXEN COMFORT PAC ........................... 7
naproxen dr ...................................................................... 7
naproxen sodium ....................................................... 7
naproxen sodium er ................................................ 7
naratriptan hcl .......................................................... 79
NARDIL ................................................................................ 20
NASACORT ALLERGY 24HR ......................... 83
NASONEX ......................................................................... 83
NATACYN .......................................................................... 85
NATAZIA ............................................................................ 49
nateglinide ..................................................................... 23
NATESTO ........................................................................... 11
NATPARA .......................................................................... 65
NATROBA ......................................................................... 57
NATURE‐THROID .................................................... 91
NEBUPENT ...................................................................... 32
NEBUSAL ........................................................................... 52
NECON 0.5/35 (28) .............................................. 49
NECON 1/35 (28) .................................................... 49
NECON 1/50 (28) .................................................... 49
NECON 10/11 (28) ................................................ 49
NEEVO DHA ................................................................... 81
nefazodone hcl .......................................................... 20
neomycin sulfate ........................................................ 5
neomycin‐polymyxin‐dexameth .......... 85
NEORAL .............................................................................. 42
NEOSPORIN ................................................................... 85
NEPTAZANE ................................................................... 63
NESINA ................................................................................ 23
NESTABS ............................................................................ 81
Index
MICARDIS ......................................................................... 30
MICARDIS HCT ........................................................... 30
miconazole 3 ................................................................ 95
MICROCHAMBER ................................................... 78
MICROGESTIN 1.5/30 ....................................... 49
MICROGESTIN 1/20 ............................................. 49
MICROGESTIN FE 1.5/30 ............................... 49
MICROGESTIN FE 1/20 .................................... 49
micronized colestipol hcl ............................... 28
MICROZIDE .................................................................... 63
midodrine hcl .............................................................. 96
MIGRANAL ...................................................................... 79
MIMVEY ............................................................................. 67
MINASTRIN 24 FE ................................................... 49
MINIPRESS ...................................................................... 30
MINITRAN ....................................................................... 12
MINIVELLE ....................................................................... 67
MINOCIN .......................................................................... 91
minocycline hcl .......................................................... 91
minocycline hcl er .................................................. 91
minoxidil ............................................................................ 30
MIRALAX ........................................................................... 73
MIRAPEX ........................................................................... 36
MIRAPEX ER .................................................................. 36
MIRCERA ........................................................................... 72
MIRCETTE ........................................................................ 49
MIRENA .............................................................................. 49
mirtazapine ................................................................... 20
MIRVASO .......................................................................... 57
misoprostol .................................................................... 93
MITIGARE ......................................................................... 70
MOBIC ..................................................................................... 7
modafinil .............................................................................. 5
MODERIBA ..................................................................... 39
MODERIBA 1200 DOSE PACK .................. 39
MODERIBA 800 DOSE PACK ...................... 39
MODICON (28) .......................................................... 49
moexipril hcl ................................................................. 30
moexipril‐hydrochlorothiazide .............. 30
mometasone furoate ........................................ 57
MONOCLATE‐P .......................................................... 71
MONODOX ..................................................................... 91
MONOKET ....................................................................... 12
MONO‐LINYAH .......................................................... 49
MONONESSA ............................................................... 49
MONONINE ................................................................... 71
montelukast sodium .......................................... 15
MORGIDOX .................................................................... 91
morphine sulfate .................................................... 10
morphine sulfate er ............................................. 10
morphine sulfate er beads .......................... 10
MOTOFEN ....................................................................... 24
MOVANTIK ..................................................................... 68
MOVIPREP ...................................................................... 73
MOXEZA ............................................................................ 85
moxifloxacin hcl ....................................................... 67
MS CONTIN .................................................................... 10
MULTAQ ............................................................................ 14
Index
Index
MENOSTAR .................................................................... 67
MENTAX ............................................................................ 57
meperidine hcl ........................................................... 10
meperitab ........................................................................ 10
MEPHYTON .................................................................... 96
meprobamate ............................................................ 13
MEPRON ........................................................................... 32
mercaptopurine ....................................................... 34
mesalamine ................................................................... 68
MESTINON ...................................................................... 32
METADATE CD ............................................................... 4
METADATE ER ................................................................ 4
METAFOLBIC ................................................................ 62
METAFOLBIC PLUS ................................................ 62
METAFOLBIC PLUS RF ....................................... 62
METANX ............................................................................ 62
metaproterenol sulfate .................................. 15
metaxalone .................................................................... 82
metformin hcl ............................................................. 23
metformin hcl er ..................................................... 23
metformin hcl er (osm) ................................... 23
methadone hcl ........................................................... 10
METHADOSE ................................................................ 10
methamphetamine hcl ....................................... 4
methazolamide ......................................................... 63
methenamine hippurate ............................... 94
methenamine mandelate ............................ 94
methimazole ................................................................ 91
methocarbamol ....................................................... 82
methotrexate .............................................................. 34
methotrexate sodium ....................................... 34
methotrexate sodium (pf) ........................... 34
methoxsalen rapid ................................................ 57
methyldopa ................................................................... 30
methyldopa‐hydrochlorothiazide ...... 30
methylergonovine maleate ....................... 87
METHYLIN ........................................................................... 4
methylphenidate hcl .............................................. 5
methylphenidate hcl er ...................................... 5
methylphenidate hcl er (cd) .......................... 4
methylphenidate hcl er (la) ........................... 4
methylprednisolone ............................................ 51
methylprednisolone (pak) ........................... 51
metipranolol ................................................................. 85
metoclopramide hcl ............................................ 68
metolazone .................................................................... 63
metoprolol succinate er ................................. 42
metoprolol tartrate ............................................. 42
metoprolol‐hydrochlorothiazide ......... 30
METOZOLV ODT ...................................................... 68
METROCREAM ........................................................... 57
METROGEL ..................................................................... 57
METROGEL‐VAGINAL ........................................ 95
METROLOTION .......................................................... 57
metronidazole ...................................... 32, 57, 95
MEVACOR ........................................................................ 28
mexiletine hcl .............................................................. 14
MIACALCIN ..................................................................... 65
OCUVEL .............................................................................. 81
OFEV ....................................................................................... 90
ofloxacin ...................................................... 67, 85, 87
OGESTREL ........................................................................ 49
olanzapine ...................................................................... 37
OLEPTRO ........................................................................... 20
olopatadine hcl ......................................................... 83
OLUX ...................................................................................... 57
OLUX‐E ................................................................................ 57
OLYSIO ................................................................................. 39
OMECLAMOX‐PAK ................................................ 93
omega‐3‐acid ethyl esters .......................... 28
omeprazole .................................................................... 93
omeprazole magnesium ................................ 93
OMNARIS ......................................................................... 83
OMNIPRED ..................................................................... 85
OMNITROPE ................................................................. 65
OMNITROPE PEN 5 INJ DEVICE ............. 78
ondansetron ................................................................. 25
ondansetron hcl ....................................................... 25
ONETOUCH ULTRA BLUE .............................. 60
ONETOUCH VERIO ................................................ 60
ONETOUCH VERIO IQ SYSTEM .............. 78
ONEXTON ......................................................................... 57
ONFI ........................................................................................ 18
ONGLYZA .......................................................................... 24
ONMEL ................................................................................ 26
OPANA ................................................................................. 10
OPANA ER ........................................................................ 10
opium .................................................................................... 24
opium tincture (paregoric) ......................... 24
OPSUMIT .......................................................................... 45
OPTIVAR ............................................................................ 85
ORACEA .............................................................................. 57
ORALONE ......................................................................... 81
ORAP ...................................................................................... 89
ORAPRED ODT ........................................................... 51
ORAVIG ............................................................................... 81
ORENITRAM .................................................................. 45
ORFADIN ........................................................................... 65
orphenadrine citrate er .................................. 82
ORSYTHIA ......................................................................... 49
ORTHO ALL‐FLEX FITTING SET ................ 78
ORTHO DIAPHRAGM ALL‐FLEX ............. 78
ORTHO EVRA ............................................................... 50
ORTHO MICRONOR ............................................. 50
ORTHO TRI‐CYCLEN (28) ................................ 50
ORTHO TRI‐CYCLEN LO ................................... 50
ORTHO‐CEPT (28) .................................................. 50
ORTHO‐CYCLEN (28) ........................................... 50
ORTHO‐NOVUM 1/35 (28) ......................... 50
ORTHO‐NOVUM 7/7/7 (28) ...................... 50
OSENI .................................................................................... 24
OSMOPREP .................................................................... 73
OSPHENA .......................................................................... 65
OTEZLA .................................................................................... 7
OTREXUP .............................................................................. 7
OVACE WASH .............................................................. 57
Index
norethin‐eth estradiol‐fe .............................. 49
norgestimate‐eth estradiol ........................ 49
norgestim‐eth estrad triphasic ............. 49
norgestrel‐ethinyl estradiol ....................... 49
NORINYL 1+35 (28) .............................................. 49
NORINYL 1+50 (28) .............................................. 49
NORITATE ........................................................................ 57
NOROXIN .......................................................................... 67
NORPACE .......................................................................... 14
NORPACE CR ................................................................ 14
NORPRAMIN ................................................................ 20
NOR‐QD ............................................................................. 49
NORTHERA ..................................................................... 96
NORTREL 0.5/35 (28) ........................................ 49
NORTREL 1/35 (21) .............................................. 49
NORTREL 1/35 (28) .............................................. 49
NORTREL 7/7/7 ......................................................... 49
nortriptyline hcl ........................................................ 20
NORVASC ......................................................................... 44
NORVIR ............................................................................... 39
NOVA MAX GLUCOSE TEST ........................ 60
NOVAREL .......................................................................... 65
NOVOEIGHT .................................................................. 71
NOVOLIN 70/30 ....................................................... 23
NOVOLIN 70/30 RELION ................................ 23
NOVOLIN N .................................................................... 24
NOVOLIN N RELION ............................................. 24
NOVOLIN R ..................................................................... 24
NOVOLIN R RELION ............................................. 24
NOVOLOG ........................................................................ 24
NOVOLOG FLEXPEN ............................................ 24
NOVOLOG MIX 70/30 ....................................... 24
NOVOLOG MIX 70/30 FLEXPEN ........... 24
NOVOSEVEN RT ........................................................ 71
NOXAFIL ............................................................................. 26
np thyroid ........................................................................ 91
NUCYNTA ......................................................................... 10
NUCYNTA ER ................................................................ 10
NUEDEXTA ...................................................................... 89
NULYTELY WITH FLAVOR PACKS ......... 73
NUTROPIN AQ NUSPIN 10 .......................... 65
NUTROPIN AQ NUSPIN 20 .......................... 65
NUTROPIN AQ NUSPIN 5 .............................. 65
NUTROPIN AQ PEN .............................................. 65
NUVARING ...................................................................... 49
NUVESSA ........................................................................... 95
NUVIGIL ................................................................................. 5
NYMALIZE ........................................................................ 44
nystatin ......................................................... 26, 57, 80
nystatin‐triamcinolone .................................... 57
OBREDON ........................................................................ 52
OBTREX ............................................................................... 81
O‐CAL PRENATAL .................................................... 81
OCELLA ................................................................................ 49
octreotide acetate ................................................ 65
OCUDOX ............................................................................ 91
OCUFEN .............................................................................. 85
OCUFLOX .......................................................................... 85
Index
Index
NEULASTA ....................................................................... 72
NEUPOGEN .................................................................... 72
NEUPRO ............................................................................. 36
NEURONTIN .................................................................. 18
NEVANAC ......................................................................... 85
nevirapine ....................................................................... 39
nevirapine er ................................................................ 39
NEXAVAR .......................................................................... 34
NEXIUM .............................................................................. 93
NEXIUM 24HR ............................................................ 93
NEXPLANON ................................................................. 49
NEXT CHOICE ............................................................... 49
NEXT CHOICE ONE DOSE .............................. 49
niacin ..................................................................................... 96
niacin er ............................................................................. 96
niacin er (antihyperlipidemic) ................. 28
NIASPAN ............................................................................ 28
nicardipine hcl ............................................................ 44
NICODERM CQ ........................................................... 89
NICOMIDE ....................................................................... 81
NICORELIEF .................................................................... 89
NICORETTE ..................................................................... 89
NICORETTE MINI ..................................................... 89
NICORETTE STARTER KIT ............................... 89
nicotine ............................................................................... 89
nicotine polacrilex ................................................. 89
nicotine step 1 ............................................................ 89
nicotine step 2 ............................................................ 89
nicotine step 3 ............................................................ 89
NICOTROL ........................................................................ 89
NICOTROL NS .............................................................. 89
NIFEDICAL XL ............................................................... 44
nifedipine ......................................................................... 44
nifedipine er .................................................................. 44
nifedipine er osmotic ......................................... 44
NILANDRON .................................................................. 34
nimodipine ...................................................................... 44
NIRAVAM ......................................................................... 13
nisoldipine er ............................................................... 44
NITRO‐BID ....................................................................... 12
NITRO‐DUR .................................................................... 12
nitrofurantoin ............................................................. 94
nitrofurantoin macrocrystal ..................... 94
nitrofurantoin monohyd macro ........... 94
nitroglycerin ...................................................... 12, 13
nitroglycerin er .......................................................... 12
NITROLINGUAL ......................................................... 13
NITROMIST ..................................................................... 13
NITROSTAT ..................................................................... 13
NITRO‐TIME .................................................................. 13
nizatidine .......................................................................... 93
NORA‐BE ........................................................................... 49
NORDETTE (28) ......................................................... 49
NORDITROPIN FLEXPRO ................................ 65
NORDITROPIN NORDIFLEX PEN ........... 65
norethin ace‐eth estrad‐fe ......................... 49
norethindrone ............................................................ 49
norethindrone‐eth estradiol ..................... 67
(Updated 08/01/2015)
107
(Updated 08/01/2015)
108
POLY‐VI‐FLOR FS ..................................................... 81
POMALYST ...................................................................... 34
PONSTEL ............................................................................... 7
PORTIA‐28 ....................................................................... 50
potassium chloride ............................................... 80
potassium chloride crys er .......................... 80
potassium chloride er ....................................... 80
potassium citrate er ........................................... 69
POTIGA ................................................................................ 18
PRADAXA .......................................................................... 16
pramipexole dihydrochloride .................. 36
pramipexole dihydrochloride er ........... 36
PRAMOSONE ............................................................... 58
PRANDIMET .................................................................. 24
PRANDIN ........................................................................... 24
PRAVACHOL .................................................................. 28
pravastatin sodium .............................................. 28
prazosin hcl .................................................................... 30
PRECISION XTRA BLOOD GLUCOSE
....................................................................................................... 60
PRECOSE ............................................................................ 24
PRED FORTE .................................................................. 85
PRED MILD ..................................................................... 85
PRED‐G ................................................................................ 85
PRED‐G S.O.P. ............................................................. 85
prednisolone acetate ........................................ 86
prednisolone sodium phosphate
............................................................................................. 51, 86
prednisone ...................................................................... 51
prednisone (pak) ..................................................... 51
PREFERAOB ONE ..................................................... 81
preferred plus lancets colored ............... 78
preferred plus lancets thin ......................... 78
PREFEST ............................................................................. 67
PREGNYL ........................................................................... 65
PREMARIN ........................................................... 67, 95
PREMPHASE .................................................................. 67
PREMPRO ........................................................................ 67
prenatabs fa ................................................................. 81
PRENATABS RX .......................................................... 81
prenatal ............................................................................. 81
prenatal vitamins ................................................... 81
prenatal/iron ............................................................... 81
PRENATE DHA ............................................................ 81
PRENATE ELITE .......................................................... 81
PRENATE ESSENTIAL .......................................... 81
PRENATE MINI ........................................................... 81
PREPIDIL ............................................................................ 87
PREQUE 10 ..................................................................... 81
PREVACID ......................................................................... 93
PREVACID 24HR ....................................................... 93
PREVACID SOLUTAB ........................................... 93
PREVALITE ....................................................................... 28
PREVIFEM ........................................................................ 50
PREVPAC ........................................................................... 93
PREZCOBIX ...................................................................... 40
PREZISTA ........................................................................... 40
PRIFTIN ............................................................................... 33
Index
penicillin v potassium ....................................... 87
PENLAC ............................................................................... 57
PENNSAID ............................................................. 57, 58
PENTASA ........................................................................... 69
pentoxifylline er ....................................................... 71
PEPCID ................................................................................. 93
PERCOCET ........................................................................ 10
PERCODAN ..................................................................... 10
PERCURA .......................................................................... 62
PERFOROMIST ........................................................... 15
perindopril erbumine ......................................... 30
PERIOGARD ................................................................... 81
permethrin ..................................................................... 58
perphenazine ............................................................... 37
perphenazine‐amitriptyline ....................... 89
PERSANTINE ................................................................. 71
PERTZYE ............................................................................. 62
PEXEVA ............................................................................... 20
pharmacist choice lancets .......................... 78
PHENAZO ......................................................................... 69
phenazopyridine hcl ............................................ 69
phendimetrazine tartrate ............................... 5
phendimetrazine tartrate er ........................ 5
phenobarbital ............................................................. 73
phentermine hcl .......................................................... 5
PHENYTEK ....................................................................... 18
phenytoin ......................................................................... 18
PHENYTOIN INFATABS ..................................... 18
phenytoin sodium extended ..................... 18
PHILITH ............................................................................... 50
PHOSLO .............................................................................. 69
PHOSPHOLINE IODIDE ..................................... 85
PICATO ................................................................................ 58
pilocarpine hcl ............................................................ 85
PIMTREA ........................................................................... 50
pindolol ............................................................................... 43
pioglitazone hcl ........................................................ 24
pioglitazone hcl‐glimepiride ..................... 24
pioglitazone hcl‐metformin hcl ............. 24
PIRMELLA 1/35 ......................................................... 50
piroxicam ............................................................................. 7
PLAN B ONE‐STEP .................................................. 50
PLAQUENIL ..................................................................... 32
PLAVIX .................................................................................. 71
PLEGRIDY .......................................................................... 89
PLEGRIDY STARTER PACK ............................. 89
PLETAL ................................................................................. 71
PLEXION ............................................................................. 58
PLEXION CLEANSER ............................................. 58
PLEXION CLEANSING CLOTH .................... 58
pnv fe fum/docusate/folic acid ............. 81
PODIAPN ........................................................................... 62
podocon ............................................................................. 58
podofilox ........................................................................... 58
polyethylene glycol 3350 ................... 73, 87
polymyxin b‐trimethoprim .......................... 85
POLYTRIM ........................................................................ 85
POLY‐VI‐FLOR .............................................................. 81
Index
Index
OVCON‐35 (28) ......................................................... 50
OVIDE .................................................................................... 57
OVIDREL ............................................................................. 65
OXANDRIN ...................................................................... 11
oxaprozin ............................................................................. 7
oxazepam ........................................................................ 13
oxcarbazepine ............................................................ 18
OXISTAT ............................................................................. 57
OXSORALEN .................................................................. 57
OXSORALEN ULTRA ............................................. 57
OXTELLAR XR ............................................................... 18
oxybutynin chloride ............................................. 94
oxybutynin chloride er ..................................... 94
oxycodone hcl ............................................................. 10
oxycodone hcl er ..................................................... 10
OXYCONTIN ................................................................... 10
oxymorphone hcl .................................................... 10
oxymorphone hcl er ............................................ 10
OXYTROL ........................................................................... 94
OXYTROL FOR WOMEN .................................. 94
PAMELOR ......................................................................... 20
PAMINE .............................................................................. 93
PAMINE FORTE ......................................................... 93
PANCREAZE ................................................................... 62
PANDEL ............................................................................... 57
PANRETIN ........................................................................ 57
pantoprazole sodium ........................................ 93
PARAFON FORTE DSC ....................................... 82
PARAGARD INTRAUTERINE COPPER
....................................................................................................... 50
PARCOPA .......................................................................... 36
paricalcitol ...................................................................... 65
PARLODEL ........................................................................ 36
PARNATE ........................................................................... 20
paromomycin sulfate ............................................ 5
paroxetine hcl ............................................................. 20
paroxetine hcl er ..................................................... 20
PASER .................................................................................... 33
PATADAY .......................................................................... 85
PATANASE ....................................................................... 83
PATANOL .......................................................................... 85
PAXIL ...................................................................................... 20
PAXIL CR ............................................................................ 20
PAZEO ................................................................................... 85
pc lancets super thin 30g ............................. 78
PCE ........................................................................................... 74
PEDIADERM HC ........................................................ 57
peg 3350 ........................................................................... 73
peg 3350/electrolytes ...................................... 73
peg 3350‐kcl‐na bicarb‐nacl ..................... 73
peg‐3350/electrolytes ...................................... 73
PEGANONE ..................................................................... 18
PEGASYS ............................................................................ 39
PEGASYS PROCLICK .............................................. 39
PEG‐INTRON ................................................................. 39
PEG‐INTRON REDIPEN ..................................... 39
PEG‐INTRON REDIPEN PAK 4 ................... 39
PEG‐PREP ......................................................................... 73
RECLIPSEN ....................................................................... 50
RECOMBINATE .......................................................... 71
RECTIV .................................................................................. 12
REGIMEX ............................................................................... 5
REGLAN .............................................................................. 69
REGRANEX ...................................................................... 58
RELAGARD ...................................................................... 95
RELENZA DISKHALER .......................................... 40
RELISTOR .......................................................................... 69
RELPAX ................................................................................ 79
REMERON ........................................................................ 21
REMERON SOLTAB ............................................... 21
REMICADE ....................................................................... 69
RENAGEL ........................................................................... 69
RENVELA ........................................................................... 69
repaglinide ..................................................................... 24
REPRONEX ...................................................................... 66
REQUIP ................................................................................ 36
REQUIP XL ....................................................................... 36
RESCRIPTOR .................................................................. 40
RESCULA ............................................................................ 86
reserpine ........................................................................... 30
RESTASIS ........................................................................... 86
RESTORIL .......................................................................... 73
RETIN‐A .............................................................................. 58
RETIN‐A MICRO ........................................................ 58
RETIN‐A MICRO PUMP .................................... 58
RETROVIR ......................................................................... 40
REVATIO ............................................................................ 45
revesta ................................................................................. 72
REVIA ..................................................................................... 25
REVLIMID ......................................................................... 42
REYATAZ ............................................................................ 40
REZIRA .................................................................................. 52
RHINOCORT AQUA ............................................... 83
RIASTAP .............................................................................. 71
RIBASPHERE .................................................................. 40
RIBASPHERE RIBAPAK ...................................... 40
ribavirin .............................................................................. 40
RIDAURA ............................................................................... 8
rifabutin ............................................................................. 33
RIFADIN .............................................................................. 33
RIFAMATE ........................................................................ 33
rifampin ............................................................................. 33
RIFATER .............................................................................. 33
RILUTEK .............................................................................. 83
riluzole ................................................................................. 83
rimantadine hcl ........................................................ 40
RIOMET ............................................................................... 24
risedronate sodium .............................................. 66
RISPERDAL ...................................................................... 37
RISPERDAL M‐TAB ................................................. 37
risperidone ........................................................... 37, 38
RISPERIDONE M‐TAB ......................................... 37
RITALIN ................................................................................... 5
RITALIN LA .......................................................................... 5
RITALIN SR .......................................................................... 5
rixubis ................................................................................... 71
Index
PULMICORT ................................................................... 15
PULMICORT FLEXHALER ................................ 15
PULMONA ....................................................................... 62
PULMOZYME ............................................................... 90
PURINETHOL ................................................................ 34
PURIXAN ............................................................................ 34
px acid reducer max st .................................... 93
px folic acid .................................................................... 72
px lancets ......................................................................... 78
px lancets ultra thin ............................................ 78
PYLERA ................................................................................ 93
pyrazinamide ............................................................... 33
pyridostigmine bromide ................................ 32
qc clotrimazole .......................................................... 58
qc lancets super thin 30g ............................. 78
qc lancets ultra thin ............................................ 78
QNASL .................................................................................. 83
QNASL CHILDRENS ............................................... 83
QSYMIA .................................................................................. 5
QUALAQUIN ................................................................. 32
QUARTETTE ................................................................... 50
QUASENSE ...................................................................... 50
QUDEXY XR .................................................................... 18
QUESTRAN ...................................................................... 28
QUESTRAN LIGHT .................................................. 28
quetiapine fumarate .......................................... 37
QUFLORA PEDIATRIC ......................................... 81
QUILLIVANT XR ............................................................. 5
quinapril hcl .................................................................. 30
quinapril‐hydrochlorothiazide ............... 30
quinidine gluconate er ..................................... 14
quinidine sulfate ...................................................... 14
quinidine sulfate er .............................................. 14
QVAR ..................................................................................... 15
ra clotrimazole .......................................................... 58
ra clotrimazole 7 ..................................................... 95
ra folic acid .................................................................... 72
ra nicotine ....................................................................... 89
RA TRUETEST TEST ............................................... 61
rabeprazole sodium ............................................ 93
raloxifene hcl ............................................................... 65
ramipril ............................................................................... 30
RANEXA .............................................................................. 13
ranitidine hcl ................................................................ 93
RAPAFLO ........................................................................... 69
RAPAMUNE ................................................................... 42
RASUVO ................................................................................. 7
RAVICTI ............................................................................... 66
RAYOS ................................................................................... 51
RAZADYNE ...................................................................... 89
RAZADYNE ER ............................................................. 89
reality lancets ............................................................. 78
reality trigger lancets ....................................... 78
REBETOL ............................................................................ 40
REBIF ...................................................................................... 89
REBIF REBIDOSE ....................................................... 89
REBIF REBIDOSE TITRATION PACK .... 89
REBIF TITRATION PACK ................................... 90
Index
Index
PRILOSEC .......................................................................... 93
PRILOSEC OTC ............................................................ 93
primaquine phosphate .................................... 32
primidone ........................................................................ 18
PRIMLEV ............................................................................ 10
PRINIVIL ............................................................................. 30
PRISTIQ ............................................................................... 21
PROAIR HFA .................................................................. 15
PROAIR RESPICLICK ............................................. 15
probenecid ...................................................................... 70
PROCARDIA ................................................................... 44
PROCARDIA XL ........................................................... 44
PROCENTRA ...................................................................... 5
prochlorperazine ..................................................... 37
prochlorperazine edisylate ......................... 37
prochlorperazine maleate ........................... 37
PROCRIT ............................................................................. 72
PROCTOCORT .............................................................. 12
PROCTOFOAM HC ................................................. 12
PROCTOZONE‐HC ................................................... 12
PROCYSBI ......................................................................... 69
PRODIGY AUTOCODE BLOOD GLUCOSE ........................................................................... 78
PRODIGY POCKET BLOOD GLUCOSE
....................................................................................................... 78
PRODIGY VOICE BLOOD GLUCOSE ... 78
PROFILNINE SD ......................................................... 71
PROGLYCEM ................................................................. 24
PROGRAF .......................................................................... 42
PROLENSA ....................................................................... 86
PROMACTA .................................................................... 72
promethazine hcl .................................................... 27
promethazine vc ...................................................... 52
promethazine vc plain ..................................... 52
promethazine vc/codeine ............................ 52
promethazine‐codeine ..................................... 52
promethazine‐dm .................................................. 52
PROMETRIUM ............................................................ 87
propafenone hcl ....................................................... 14
propafenone hcl er ............................................... 14
propantheline bromide ................................... 93
propranolol hcl .......................................................... 43
propranolol hcl er .................................................. 43
propranolol‐hctz ...................................................... 30
propylthiouracil ........................................................ 91
PROSCAR ........................................................................... 69
PROTEOLIN .................................................................... 62
PROTEOLIN DS ........................................................... 62
PROTONIX ....................................................................... 93
PROTOPIC ........................................................................ 58
protriptyline hcl ........................................................ 21
PROVENTIL HFA ....................................................... 15
PROVERA .......................................................................... 87
PROVIGIL .............................................................................. 5
PROZAC .............................................................................. 21
PROZAC WEEKLY ..................................................... 21
PRUDOXIN ...................................................................... 58
pseudoeph‐chlorphen‐hydrocod ......... 52
(Updated 08/01/2015)
109
(Updated 08/01/2015)
110
SPORANOX PULSEPAK ..................................... 26
SPRINTEC 28 ................................................................. 50
SPRIX ......................................................................................... 8
SPRYCEL ............................................................................. 35
SPS ............................................................................................ 42
SRONYX .............................................................................. 50
SSKI .......................................................................................... 80
STALEVO 100 ............................................................... 36
STALEVO 125 ............................................................... 36
STALEVO 150 ............................................................... 36
STALEVO 200 ............................................................... 36
STALEVO 50 ................................................................... 36
STALEVO 75 ................................................................... 36
STARLIX ............................................................................... 24
stavudine .......................................................................... 40
STAVZOR ........................................................................... 18
STAXYN ............................................................................... 45
STELARA ............................................................................. 58
STENDRA ........................................................................... 45
STIMATE ............................................................................ 66
STIOLTO RESPIMAT ............................................. 15
STIVARGA ......................................................................... 35
STRATTERA ........................................................................ 5
STRIANT ............................................................................. 11
STRIBILD ............................................................................ 40
STRIVERDI RESPIMAT ........................................ 15
STROMECTOL .............................................................. 12
SUBOXONE ..................................................................... 10
SUBSYS ................................................................................ 10
SUCRAID ............................................................................ 62
sucralfate ......................................................................... 93
SULAR ................................................................................... 44
sulfacetamide sodium ...................................... 86
sulfacetamide sodium‐sulfur ........ 58, 59
sulfacetamide sod‐sulfur wash ............. 59
sulfacetamide‐prednisolone ..................... 86
sulfacetamide‐sulfur in urea .................... 59
sulfadiazine ................................................................... 90
sulfamethoxazole‐tmp ds ............................ 32
sulfamethoxazole‐trimethoprim ......... 32
SULFAMYLON .............................................................. 59
sulfasalazine ................................................................. 69
SULFAZINE ...................................................................... 69
sulfisoxizole ................................................................... 90
sulindac .................................................................................. 8
SUMADAN ....................................................................... 59
SUMADAN WASH .................................................. 59
SUMADAN XLT ........................................................... 59
sumatriptan .................................................................. 79
sumatriptan succinate .......................... 79, 80
sumatriptan succinate refill ...................... 79
SUMAVEL DOSEPRO ........................................... 80
SUMAXIN CP ................................................................ 59
super thin lancets .................................................. 78
SUPRAX ............................................................................... 46
SUPRENZA ........................................................................... 5
sure comfort lancets 28g .............................. 78
sure comfort lancets 30g .............................. 78
Index
SEROQUEL XR ............................................................. 38
SEROSTIM ........................................................................ 66
sertraline hcl ................................................................ 21
sevelamer carbonate ......................................... 69
SHOHLS MODIFIED ............................................... 69
SIGNIFOR .......................................................................... 66
SIGNIFOR LAR ............................................................. 66
sildenafil citrate ....................................................... 45
SILENOR ............................................................................. 73
SILVADENE ...................................................................... 58
silver sulfadiazine .................................................. 58
SIMBRINZA ..................................................................... 86
SIMCOR .............................................................................. 28
SIMPONI ................................................................................ 8
simvastatin .................................................................... 28
SINEMET ............................................................................ 36
SINEMET CR .................................................................. 36
SINGULAIR ...................................................................... 15
sirolimus ............................................................................ 42
SIRTURO ............................................................................ 33
SITAVIG ............................................................................... 40
SIVEXTRO .......................................................................... 32
SKELAXIN .......................................................................... 82
SKELID .................................................................................. 66
SKYLA ..................................................................................... 50
sm antifungal clotrimazole ........................ 58
sm clotrimazole vaginal ................................. 95
sm folic acid .................................................................. 72
sm lancets 21g ........................................................... 78
sm lancets 33g ........................................................... 78
sm niacin cr ................................................................... 96
sm nicotine ..................................................................... 90
sm super thin lancets 30g ........................... 78
sm thin lancets 26g ............................................. 78
smz‐tmp ds ..................................................................... 32
sodium chloride ............................................. 52, 80
sodium fluoride ......................................................... 80
sodium phenylbutyrate .................................. 66
sodium polystyrene sulfonate ................ 42
SOLARAZE ........................................................................ 58
SOLODYN .......................................................................... 91
SOLTAMOX ..................................................................... 34
SOMA .................................................................................... 82
SOMATULINE DEPOT ......................................... 66
SOMAVERT ..................................................................... 66
SONATA .............................................................................. 73
SOOLANTRA .................................................................. 58
SORIATANE .................................................................... 58
SORILUX ............................................................................. 58
sotalol hcl ......................................................................... 43
sotalol hcl (af) ............................................................. 43
SOTYLIZE ........................................................................... 43
SOVALDI ............................................................................. 40
SPIRIVA HANDIHALER ....................................... 15
SPIRIVA RESPIMAT ............................................... 15
spironolactone ........................................................... 63
spironolactone‐hctz ............................................ 63
SPORANOX ..................................................................... 26
Index
Index
rizatriptan benzoate ........................................... 79
ROBAXIN ........................................................................... 82
ROBINUL ........................................................................... 93
ROBINUL‐FORTE ...................................................... 93
ROCALTROL ................................................................... 66
ropinirole hcl ................................................................ 36
ropinirole hcl er ........................................................ 36
ROSADAN ......................................................................... 58
ROSANIL CLEANSER ............................................. 58
ROZEREM ......................................................................... 73
RUCONEST ...................................................................... 71
RYTARY ................................................................................ 36
RYTHMOL ......................................................................... 14
RYTHMOL SR ................................................................ 14
SABRIL .................................................................................. 18
safety lancets 28g ................................................. 78
SAFETY‐GLIDE SYRINGE .................................. 78
SAFYRAL ............................................................................. 50
SAIZEN ................................................................................. 66
SAIZEN CLICK.EASY ............................................... 66
SALAGEN ........................................................................... 81
SALEX ..................................................................................... 58
salicylic acid .................................................................. 58
saline laxative ............................................................. 74
salsalate ................................................................................ 8
SAMSCA ............................................................................. 66
SANCTURA XR ............................................................. 94
SANCUSO .......................................................................... 25
SANDIMMUNE ........................................................... 42
SANDOSTATIN ............................................................ 66
SANTYL ................................................................................ 58
SAPHRIS ............................................................................. 38
SARAFEM .......................................................................... 90
SAVAYSA ........................................................................... 16
SAVELLA ............................................................................. 90
SAVELLA TITRATION PACK .......................... 90
SAXENDA .............................................................................. 5
sb lancets thin ............................................................ 78
sb lancets ultra thin ............................................ 78
sb polyethylene glycol 3350 ..................... 74
SEASONALE .................................................................... 50
SEASONIQUE ................................................................ 50
SECTRAL ............................................................................. 43
select‐lite device/lancets .............................. 78
SELECT‐OB+DHA ...................................................... 81
selegiline hcl ................................................................. 36
selenium sulfide ....................................................... 58
selenium sulf‐pyrithione‐urea ................ 58
SELRX ..................................................................................... 58
SELSUN BLUE MEDICATED .......................... 58
SELZENTRY ...................................................................... 40
SEMPREX‐D .................................................................... 52
SENSIPAR .......................................................................... 66
SENTRA AM ................................................................... 62
SENTRA PM .................................................................... 62
SEREVENT DISKUS ................................................. 15
SEROPHENE ................................................................... 66
SEROQUEL ....................................................................... 38
tolcapone ......................................................................... 36
tolmetin sodium .......................................................... 8
tolterodine tartrate ............................................. 94
tolterodine tartrate er ..................................... 94
TOPAMAX ........................................................................ 18
TOPAMAX SPRINKLE .......................................... 18
TOPICORT ........................................................................ 59
TOPICORT SPRAY .................................................... 59
TOPIRAGEN ................................................................... 18
topiramate .......................................................... 18, 19
TOPROL XL ...................................................................... 43
torsemide ......................................................................... 63
TOUJEO SOLOSTAR .............................................. 24
TOVIAZ ................................................................................. 94
TOZAL ................................................................................... 62
TRACLEER ......................................................................... 45
TRADJENTA .................................................................... 24
tramadol hcl ................................................................. 10
tramadol hcl er ......................................................... 10
tramadol‐acetaminophen ........................... 11
TRANDATE ...................................................................... 43
trandolapril .................................................................... 31
trandolapril‐verapamil hcl er .................. 31
TRANXENE‐T ................................................................. 13
tranylcypromine sulfate ................................ 21
TRAVATAN Z ................................................................. 86
travoprost ........................................................................ 86
trazodone hcl .............................................................. 21
TRECATOR ....................................................................... 33
TREPADONE .................................................................. 62
tretinoin .................................................................. 35, 59
tretinoin microsphere ....................................... 59
tretinoin microsphere pump .................... 59
TRETIN‐X ........................................................................... 59
TRETTEN ............................................................................ 71
TREXIMET ........................................................................ 80
TREZIX .................................................................................. 11
triamcinolone acetonide .................... 59, 60
triamterene‐hctz ..................................................... 63
triazolam .......................................................................... 73
TRIBENZOR ..................................................................... 31
TRICARE PRENATAL DHA ONE ............... 81
tricitrates .......................................................................... 70
TRICOR ................................................................................ 28
TRI‐ESTARYLLA .......................................................... 50
trifluoperazine hcl ................................................. 38
trifluridine ....................................................................... 86
TRIGLIDE ............................................................................ 28
trihexyphenidyl hcl ............................................... 36
TRI‐LEGEST FE ............................................................. 50
TRILEPTAL ........................................................................ 19
TRI‐LINYAH ..................................................................... 50
TRILIPIX ............................................................................... 28
TRILYTE ............................................................................... 74
trimethobenzamide hcl .................................. 25
trimethoprim ............................................................... 32
TRINATE ............................................................................. 81
TRINESSA (28) ............................................................. 50
Index
TERBINEX .......................................................................... 26
terconazole .................................................................... 95
TESSALON PERLES ................................................. 52
TESTIM ................................................................................ 11
testosterone ................................................................. 12
testosterone cypionate ................................... 11
tetracycline hcl .......................................................... 91
TEVETEN ............................................................................ 31
TEVETEN HCT .............................................................. 31
TEV‐TROPIN .................................................................. 66
tgt clotrimazole ........................................................ 59
tgt nicotine step one .......................................... 90
tgt nicotine step three ..................................... 90
tgt nicotine step two .......................................... 90
th clotrimazole .......................................................... 59
th famotidine 10 ..................................................... 94
th folic acid ..................................................................... 72
THALOMID ...................................................................... 42
THEO‐24 ............................................................................ 15
THEOCHRON ................................................................ 15
theophylline .................................................................. 15
theophylline er ........................................................... 15
THERAMINE .................................................................. 62
thioridazine hcl ......................................................... 38
thiothixene ..................................................................... 38
THYROLAR‐1 ................................................................. 91
THYROLAR‐1/2 .......................................................... 91
THYROLAR‐1/4 .......................................................... 92
THYROLAR‐2 ................................................................. 92
THYROLAR‐3 ................................................................. 92
tiagabine hcl ................................................................ 18
TIAZAC ................................................................................. 44
ticlopidine hcl .............................................................. 71
TIGAN .................................................................................... 25
TIKOSYN ............................................................................. 14
TILIA FE ............................................................................... 50
timolol maleate ............................................. 43, 86
TIMOPTIC ......................................................................... 86
TIMOPTIC‐XE ............................................................... 86
TINDAMAX ..................................................................... 32
TIROSINT ........................................................................... 92
TIVICAY ............................................................................... 40
TIVORBEX ............................................................................. 8
TIZANIDINE COMFORT PAC ....................... 82
tizanidine hcl ................................................................ 82
TOBI ............................................................................................ 6
TOBI PODHALER .......................................................... 6
TOBRADEX ...................................................................... 86
TOBRADEX ST .............................................................. 86
tobramycin ......................................................................... 6
TOBREX ............................................................................... 86
TODAY SPONGE ....................................................... 95
todays health thin lancets 28g .............. 78
todays health thin lancets 30g .............. 78
TOFRANIL ......................................................................... 21
TOFRANIL‐PM ............................................................. 21
tolazamide ...................................................................... 24
tolbutamide .................................................................. 24
Index
Index
SURMONTIL .................................................................. 21
SUSTIVA ............................................................................. 40
SUTENT ............................................................................... 35
SYEDA ................................................................................... 50
SYMBICORT ................................................................... 15
SYMBYAX .......................................................................... 90
SYMLINPEN 120 ....................................................... 24
SYMLINPEN 60 ........................................................... 24
SYNALAR ........................................................................... 59
SYNALAR (CREAM) ................................................ 59
SYNALAR (OINTMENT) .................................... 59
SYNALAR TS ................................................................... 59
SYNALGOS‐DC ............................................................ 10
SYNAREL ............................................................................ 66
SYNERA ............................................................................... 59
SYNTHROID .................................................................... 91
SYPRINE .............................................................................. 42
syringe disposable ................................................ 78
syringe disposable 50‐60ml ...................... 78
TABLOID ............................................................................. 35
TACLONEX ....................................................................... 59
tacrolimus ............................................................. 42, 59
TAFINLAR .......................................................................... 35
TAKE ACTION ............................................................... 50
TAMIFLU ............................................................................ 40
tamoxifen citrate .................................................... 35
tamsulosin hcl ............................................................ 70
TANZEUM ........................................................................ 24
TAPAZOLE ........................................................................ 91
TARCEVA ........................................................................... 35
TARGADOX ..................................................................... 91
TARGRETIN .......................................................... 35, 59
TARKA ................................................................................... 31
TASIGNA ............................................................................ 35
TASMAR ............................................................................. 36
TAZORAC .......................................................................... 59
TAZTIA XT ......................................................................... 44
TECFIDERA ...................................................................... 90
TEGRETOL ........................................................................ 18
TEGRETOL‐XR .............................................................. 18
TEKAMLO ......................................................................... 31
TEKTURNA ....................................................................... 31
TEKTURNA HCT ......................................................... 31
telmisartan .................................................................... 31
telmisartan‐amlodipine ................................. 31
telmisartan‐hctz ...................................................... 31
temazepam ................................................................... 73
TEMODAR ........................................................................ 35
TEMOVATE ..................................................................... 59
temozolomide ............................................................ 35
TENEX ................................................................................... 31
TENORETIC 100 ........................................................ 31
TENORETIC 50 ............................................................ 31
TENORMIN ..................................................................... 43
TERAZOL 3 ....................................................................... 95
TERAZOL 7 ....................................................................... 95
terazosin hcl ................................................................. 31
terbinafine hcl ............................................................ 26
(Updated 08/01/2015)
111
(Updated 08/01/2015)
112
VIRAMUNE ..................................................................... 41
VIRAMUNE XR ............................................................ 41
VIREAD ................................................................................ 41
VIRILEX ................................................................................ 62
VIROPTIC ........................................................................... 86
virt‐caps ............................................................................. 82
virt‐vite forte ................................................................ 62
VISTARIL ............................................................................. 13
vitamin d‐3 ..................................................................... 96
VITAPEARL ...................................................................... 82
VITA‐RESPA .................................................................... 62
VITEKTA .............................................................................. 41
VITUZ ..................................................................................... 52
VIVA DHA ......................................................................... 82
VIVACTIL ............................................................................ 21
VIVELLE‐DOT ................................................................ 67
VOGELXO .......................................................................... 12
VOGELXO PUMP ...................................................... 12
VOLTAREN ....................................................................... 60
VOLTAREN‐XR ................................................................ 8
voriconazole ................................................................. 26
VOSOL HC ........................................................................ 87
VOSPIRE ER .................................................................... 16
VOTRIENT ........................................................................ 35
vp‐gstn ................................................................................. 62
VSL#3 JUNIOR ............................................................. 62
VYFEMLA .......................................................................... 51
VYTORIN ............................................................................ 28
VYVANSE ............................................................................... 5
walgreens adv travel lancets .................. 79
walgreens lancets micro thin .................. 79
walgreens lancets super thin .................. 79
warfarin sodium ...................................................... 16
WELCHOL ......................................................................... 28
WELLBUTRIN ................................................................ 21
WELLBUTRIN SR ....................................................... 21
WELLBUTRIN XL ....................................................... 21
WERA .................................................................................... 51
WESTCORT ..................................................................... 60
WESTHROID .................................................................. 92
WESTHROID‐P ............................................................ 92
WIDE‐SEAL DIAPHRAGM 60 ..................... 79
WILATE ................................................................................ 71
WINRHO SDF ............................................................... 87
WYMZYA FE ................................................................... 51
XALATAN ........................................................................... 86
XALKORI ............................................................................. 35
XANAX .................................................................................. 13
XANAX XR ........................................................................ 13
XARELTO ............................................................................ 16
XARELTO STARTER PACK ............................... 16
Index
valganciclovir hcl .................................................... 41
VALIUM .............................................................................. 13
valproic acid ................................................................. 19
valsartan ........................................................................... 31
valsartan‐hydrochlorothiazide .............. 31
VALTREX ............................................................................ 41
value plus lancets super thin ................... 79
value plus lancets thin 26g ........................ 79
VANCOCIN HCL ......................................................... 32
vancomycin hcl ......................................................... 32
VANDAZOLE .................................................................. 95
VANIQA .............................................................................. 60
VANOS ................................................................................. 60
VANOXIDE‐HC ............................................................ 60
VASCAZEN ....................................................................... 62
VASCEPA ........................................................................... 28
VASCULERA ................................................................... 62
VASERETIC ...................................................................... 31
VASOTEC ........................................................................... 31
VAYACOG ......................................................................... 62
VAYARIN ............................................................................ 62
VCF VAGINAL CONTRACEPTIVE ............ 95
VECAMYL .......................................................................... 31
VECTICAL .......................................................................... 60
VELIVET ............................................................................... 50
VELPHORO ...................................................................... 69
VELTIN .................................................................................. 60
venlafaxine hcl ........................................................... 21
venlafaxine hcl er ................................................... 21
VENTAVIS ......................................................................... 46
VENTOLIN HFA .......................................................... 16
VERAMYST ...................................................................... 83
verapamil hcl ............................................................... 45
verapamil hcl er ............................................ 44, 45
VERDESO ........................................................................... 60
VEREGEN .......................................................................... 60
VERELAN ........................................................................... 45
VERELAN PM ................................................................ 45
VERSACLOZ .................................................................... 38
VESICARE .......................................................................... 94
VESTURA ........................................................................... 50
VEXOL ................................................................................... 86
VFEND .................................................................................. 26
VIAGRA ................................................................................ 46
VIBRAMYCIN ................................................................ 91
VICOPROFEN ................................................................ 11
VICTOZA ............................................................................. 24
VICTRELIS ......................................................................... 41
VIDEX ..................................................................................... 41
VIDEX EC ............................................................................ 41
VIEKIRA PAK .................................................................. 41
VIGAMOX ......................................................................... 86
VIIBRYD ............................................................................... 21
VIMOVO ................................................................................ 8
VIMPAT ............................................................................... 19
VINATE DHA RF ......................................................... 82
VIOKACE ............................................................................ 62
VIRACEPT .......................................................................... 41
Index
Index
TRI‐NORINYL (28) ................................................... 50
TRI‐PREVIFEM ............................................................. 50
TRI‐SPRINTEC .............................................................. 50
TRIUMEQ .......................................................................... 40
TRI‐VI‐FLOR .................................................................... 82
TRIVORA (28) ............................................................... 50
TRIZIVIR .............................................................................. 40
TROKENDI XR .............................................................. 19
trospium chloride ................................................... 94
trospium chloride er ........................................... 94
TRUETEST TEST ......................................................... 61
TRUETRACK TEST .................................................... 61
TRULICITY ......................................................................... 24
TRUSOPT ........................................................................... 86
TRUVADA ......................................................................... 40
TUDORZA PRESSAIR ............................................ 16
TUSSICAPS ....................................................................... 52
TUSSIONEX PENNKINETIC ER .................. 52
TUZISTRA XR ................................................................. 52
TWYNSTA ......................................................................... 31
TYBOST ................................................................................ 40
TYKERB ................................................................................ 35
TYLENOL ................................................................................ 8
TYLENOL WITH CODEINE #3 ..................... 11
TYLENOL WITH CODEINE #4 ..................... 11
TYVASO ............................................................................... 45
TYVASO REFILL .......................................................... 45
TYVASO STARTER ................................................... 46
TYZEKA ................................................................................ 40
UCERIS ...................................................................... 12, 51
ULESFIA .............................................................................. 60
ULORIC ................................................................................ 70
ultra thin lancets 28g ........................................ 79
ultra thin lancets 30g ........................................ 79
ULTRACET ........................................................................ 11
ULTRAM ............................................................................. 11
ULTRAM ER .................................................................... 11
ULTRASAL‐ER ............................................................... 60
ULTRAVATE .................................................................... 60
ULTRAVATE X (CREAM) .................................. 60
ULTRAVATE X (OINTMENT) ....................... 60
ULTRESA ............................................................................ 62
UNIRETIC .......................................................................... 31
UNITHROID .................................................................... 92
UNITHROID DIRECT ............................................. 92
UNIVASC ............................................................................ 31
URECHOLINE ................................................................ 94
UROCIT‐K 10 ................................................................. 70
UROCIT‐K 15 ................................................................. 70
UROCIT‐K 5 .................................................................... 70
UROXATRAL .................................................................. 70
URSO 250 ......................................................................... 69
URSO FORTE ................................................................. 69
ursodiol ............................................................................... 69
VAGIFEM ........................................................................... 95
valacyclovir hcl .......................................................... 40
VALCHLOR ....................................................................... 60
VALCYTE ............................................................................. 41
ZITHROMAX TRI‐PAK ......................................... 74
ZITHROMAX Z‐PAK ............................................... 74
ZMAX ..................................................................................... 74
ZOCOR .................................................................................. 28
ZOFRAN .............................................................................. 25
ZOFRAN ODT ................................................................ 25
ZOHYDRO ER ................................................................ 11
ZOLINZA ............................................................................. 35
zolmitriptan ................................................................... 80
ZOLOFT ............................................................................... 21
zolpidem tartrate ................................................... 73
zolpidem tartrate er ........................................... 73
ZOLPIMIST ....................................................................... 73
ZOMACTON ................................................................... 66
ZOMIG .................................................................................. 80
ZOMIG ZMT ................................................................... 80
ZONATUSS ...................................................................... 52
ZONEGRAN ..................................................................... 19
zonisamide ..................................................................... 19
ZONTIVITY ....................................................................... 71
ZORBTIVE ......................................................................... 66
ZORTRESS ......................................................................... 42
ZORVOLEX ........................................................................... 8
ZOVIA 1/35E (28) .................................................... 51
ZOVIA 1/50E (28) .................................................... 51
ZOVIRAX ................................................................. 41, 60
ZUBSOLV ........................................................................... 11
ZUPLENZ ............................................................................ 25
ZUTRIPRO ......................................................................... 52
ZYBAN ................................................................................... 90
ZYCLARA ............................................................................ 60
ZYCLARA PUMP ........................................................ 60
ZYDELIG .............................................................................. 35
ZYFLO .................................................................................... 16
ZYFLO CR ........................................................................... 16
ZYKADIA ............................................................................. 35
ZYLET ..................................................................................... 86
ZYLOPRIM ........................................................................ 70
ZYMAXID ........................................................................... 86
ZYPREXA ............................................................................ 38
ZYPREXA ZYDIS .......................................................... 38
ZYRTEC ALLERGY ..................................................... 27
ZYRTEC‐D ALLERGY & CONGESTION
....................................................................................................... 52
ZYTIGA ................................................................................. 35
ZYVOX ................................................................................... 32
Index
Index
XARTEMIS XR ............................................................... 11
XELJANZ ................................................................................. 8
XELODA ............................................................................... 35
XENAZINE ......................................................................... 90
XENICAL ................................................................................. 5
XERAC AC ......................................................................... 60
XIFAXAN ............................................................................. 32
XIGDUO XR ..................................................................... 24
XODOL .................................................................................. 11
XOLEGEL ............................................................................ 60
XOPENEX ........................................................................... 16
XOPENEX CONCENTRATE ............................. 16
XOPENEX HFA ............................................................. 16
XTANDI ................................................................................ 35
XULANE .............................................................................. 51
XYNTHA .............................................................................. 71
XYNTHA SOLOFUSE .............................................. 71
XYREM ................................................................................. 90
XYZAL .................................................................................... 27
YASMIN 28 ...................................................................... 51
YAZ ........................................................................................... 51
YODOXIN .............................................................................. 5
ZADITOR ............................................................................ 86
zafirlukast ........................................................................ 16
ZANAFLEX ........................................................................ 82
ZANTAC ............................................................................... 94
ZANTAC 150 MAXIMUM STRENGTH
....................................................................................................... 94
ZARAH .................................................................................. 51
ZARONTIN ....................................................................... 19
ZAROXOLYN .................................................................. 63
ZAVESCA ............................................................................ 72
ZEBETA ................................................................................ 43
ZEGERID ............................................................................. 94
ZEGERID OTC ............................................................... 94
ZELAPAR ............................................................................ 36
ZELBORAF ........................................................................ 35
ZEMPLAR .......................................................................... 66
ZENATANE ....................................................................... 60
ZENCHENT ....................................................................... 51
ZENCHENT FE .............................................................. 51
ZENPEP ................................................................................ 62
ZENZEDI ................................................................................. 5
ZERIT ...................................................................................... 41
ZESTORETIC ................................................................... 31
ZESTRIL ................................................................................ 31
ZETIA ...................................................................................... 28
ZETONNA .......................................................................... 83
ZIAC ......................................................................................... 31
ZIAGEN ................................................................................ 41
ZIANA .................................................................................... 60
zidovudine ....................................................................... 41
ZIOPTAN ............................................................................ 86
ziprasidone hcl ........................................................... 38
ZIPSOR ..................................................................................... 8
ZIRGAN ................................................................................ 86
ZITHRANOL .................................................................... 60
ZITHROMAX .................................................................. 74
(Updated 08/01/2015)
113

2015 Aetna Pharmacy Plan Drug List - Four Tier Open

Transcription

Similar documents

3-tier QHP forumulary

PDL—Medication Categories Guide

3-Tier Formulary - Total Health Care

drug formulary - Health Alliance

MCD-IL CAID 2 - Harmony Health Plan

Drug Formulary

GPI DRUG CLASSIFICATION REPORT

2016 LIST OF COVERED DRUGS - WellCare Advocate Complete