2013 Formulary (List of covered drugs)

Transcription

ODS Advantage
Comprehensive Formulary
2013 Formulary (List of covered drugs)
PLEASE READ: THIS DOCUMENT
CONTAINS INFORMATION ABOUT
THE DRUGS WE COVER IN THIS PLAN
Note to existing members: This formulary has
changed since last year. Please review this document
to make sure that it still contains the drugs you take.
Beneficiaries must use network pharmacies to
access their prescription drug benefit. Benefits,
formulary, pharmacy network, premium and/or
copayments/coinsurance may change on
January 1, 2014.
To receive this document in an alternate format
or language, please contact Pharmacy Customer
Service at 1-888-786-7509 from 7 am to 8 pm,
Pacific time, seven days a week.
H3813-003
H3813-006
www.odscompanies.com/odsadvantage
Formulary ID 00013384, Version 14
H3813_1085PPORXS13A Accepted
Next year, you can get these
documents delivered to you online
Online documents give you easy access to
all your Medicare information.
The Centers for Medicare and Medicaid
Services (CMS) require that we send you
important plan documents every year.
These documents contain information
specific to your ODS Advantage plan:
�
Combined Annual Notice of Changes
(ANOC) and Evidence of Coverage
(EOC)
�
Comprehensive Formulary
(if applicable)
�
Provider and/or Pharmacy Directory
(if applicable)
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electronically through your myODS account.
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when new materials are available, simply
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in is on the right side of your screen. You can
also create an account on this page. Once
logged in, select the “Account” tab. Next,
click on “Change account settings.” From
here, you can update your email and make
your electronic delivery preference.
Once you request electronic delivery you
will no longer receive these documents
in the mail. For questions or help please
contact Member Services at 877-299-9062.
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902427 (8/12)
ODS Advantage Comprehensive Formulary
2013 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE
COVER IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this document to
make sure that it still contains the drugs you take.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary,
pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2014.
ODS Advantage PPORX plan is a PPO plan with a Medicare contract.
To receive document in an alternate format or language, please contact Customer Service at 1-888-786-7509
from 7 am to 8 pm, Pacific time, seven days a week.
Last updated 9/2012
Formulary ID 00013384, Version 14
H3813_1085PPORXS13A Accepted
I
What is the ODS Advantage Formulary?
A formulary is a list of covered drugs selected by ODS Advantage in consultation with a team of health
care providers, which represents the prescription therapies believed to be a necessary part of a quality
treatment program. ODS Advantage will generally cover the drugs listed in our formulary as long as the
drug is medically necessary, the prescription is filled at a ODS Advantage network pharmacy, and other
plan rules are followed. For more information on how to fill your prescriptions, please review your
Evidence of Coverage.
Can the Formulary change?
Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year,
we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a
new, less expensive generic drug becomes available or when new adverse information about the safety
or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from
our formulary, will not affect members who are currently taking the drug. It will remain available at the
same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is
important that you have continued access for the remainder of the coverage year to the formulary drugs
that were available when you chose our plan, except for cases in which you can save additional money
or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of
the change at least 60 days before the change becomes effective, or at the time the member requests a
refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and
Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes
the drug from the market, we will immediately remove the drug from our formulary and provide notice
to members who take the drug. The enclosed formulary is current as of August 2012. To get updated
information about the drugs covered by ODS Advantage, please visit our Web site at
www.odscompanies.com/odsadvantage or call Customer Service at 1-888-786-7509, from 7 am to 8 pm,
Pacific time, seven days a week. (TTY/TDD users should call 711.)
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending
on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, Cardiac Drugs. If you know what your drug is used for, look
for the category name in the list that begins on page 1. Then look under the category name for your
drug.
II
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that
begins on page I-1 (at the back of this booklet). The Index provides an alphabetical list of all of the
drugs included in this document. Both brand name drugs and generic drugs are listed in the Index.
Look in the Index and find your drug. Next to your drug, you will see the page number where you
can find coverage information. Turn to the page listed in the Index and find the name of your drug
in the first column of the list.
What are generic drugs?
ODS Advantage covers both brand name drugs and generic drugs. A generic drug is approved by
the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost
less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and
limits may include:
•
Prior Authorization: ODS Advantage requires you or your physician to get prior authorization
for certain drugs. This means that you will need to get approval from ODS Advantage before
you fill your prescriptions. If you don’t get approval, ODS Advantage may not cover the drug.
•
Quantity Limits: For certain drugs, ODS Advantage limits the amount of the drug that ODS
Advantage will cover. For example, ODS Advantage provides 9 tablets in 28 days per
prescription for sumatriptan (Imitrex) tablets. This may be in addition to a standard one month
or three month supply.
•
Step Therapy: In some cases, ODS Advantage requires you to first try certain drugs to treat
your medical condition before we will cover another drug for that condition. For example, if
Drug A and Drug B both treat your medical condition, ODS Advantage may not cover Drug B
unless you try Drug A first. If Drug A does not work for you, ODS Advantage will then cover
Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 1. You can also get more information about the restrictions applied to specific covered
drugs by visiting our Web site at www.odscompanies.com/odsadvantage.
You can ask ODS Advantage to make an exception to these restrictions or limits. See the section, “How
do I request an exception to the ODS Advantage formulary?” on page IV for information about how to
request an exception.
III
What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Customer Service and confirm
that your drug is not covered. If you learn that ODS Advantage does not cover your drug, you have two
options:
•
You can ask Customer Service for a list of similar drugs that are covered by ODS Advantage.
When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug
that is covered by ODS Advantage.
•
You can ask ODS Advantage to make an exception and cover your drug. See below for
information about how to request an exception.
How do I request an exception to the ODS Advantage Formulary?
You can ask ODS Advantage to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.
•
You can ask us to cover your drug even if it is not on our formulary.
•
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain
drugs, ODS Advantage limits the amount of the drug that we will cover. If your drug has a
quantity limit, you can ask us to waive the limit and cover more.
•
You can ask us to provide a higher level of coverage for your drug. If your drug is contained in
one of our non-preferred/highest tiers subject to the tiering exceptions process tier (Tier 2 or Tier
4), you can ask us to cover it at the cost-sharing amount that applies to drugs in the
preferred/lowest tier subject to the tiering exceptions process tier instead. This would lower the
amount you must pay for your drug. Please note, if we grant your request to cover a drug that is
not on our formulary, you may not ask us to provide a higher level of coverage for the drug.
Also, you may not ask us to provide a higher level of coverage for drugs that are in the tier
designated as the high-cost/unique drug tier (Specialty tier – Tier 5).
Generally, ODS Advantage will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be
as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you are requesting a formulary, tiering or utilization restriction
exception you should submit a statement from your physician supporting your request. Generally,
we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s
IV
supporting statement. You can request an expedited (fast) exception if you or your doctor believe that
your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to
expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or
prescribing physician’s supporting statement.
What do I do before I can talk to my doctor about changing my drugs or requesting
an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or,
you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you
may need a prior authorization from us before you can fill your prescription. You should talk to your
doctor to decide if you should switch to an appropriate drug that we cover or request a formulary
exception so that we will cover the drug you take. While you talk to your doctor to determine the right
course of action for you, we may cover your drug in certain cases during the first 90 days you are a
member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will
cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to
a network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have
been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we
have provided you with a 93-day transition supply, consistent with the dispensing increment, (unless
you have a prescription written for fewer days). We will cover more than one refill of these drugs for the
first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your
ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will
cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you
pursue a formulary exception.
If you have a level of care change, (going into or coming out of a skilled nursing facility or long term
care home) we will provide you with a 31-day transition supply (unless you have a prescription written
for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member
of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited,
but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply
of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
For more information
For more detailed information about your ODS Advantage prescription drug coverage, please review
your Evidence of Coverage and other plan materials.
If you have questions about ODS Advantage, please call Customer Service at 1-888-786-7509, 7 am to 8
pm, Pacific time, seven days a week. (TTY/TDD users should call 711.) Or visit
www.odscompanies.com/odsadvantage.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-4862048. Or, visit www.medicare.gov.
V
ODS Advantage Formulary
The formulary that begins on page 1 provides coverage information about some of the drugs covered by
ODS Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page
I-1.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ASMANEX)
and generic drugs are listed in lower-case italics (e.g., sumatriptan).
The information in the Requirements/Limits column tells you if ODS Advantage has any special
requirements for coverage of your drug.
o LA – This prescription may be available only at certain pharmacies. For more information call
Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY
users should call 711.)
o PA for Ages 65 and Older; May be High Risk Medication – The Centers for Medicare and
Medicaid Services (CMS) considers this medication to be of high risk for patients 65 years old or
older. Please contact your provider for more information.
o PA – Prior authorization is required for these drugs. This means you or your provider will need
to get approval from ODS Advantage before you can fill your prescription. If you don’t get
approval, ODS Advantage may not cover the drug. See page IV for how to request an exception.
If you need help requesting an exception please call Customer Service at 1-888-786-7509 from 7
am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)
o PA for Part B vs Part D Only - This drug may be covered under Medicare Part B or D
depending upon the circumstances. Information may need to be submitted describing the use and
setting of the drug to make the determination. If you need help requesting an exception please
call Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week.
(TTY users should call 711.)
o PA for ESRD only – These drugs are also prescribed for members who have End-Stage Renal
Disease (ESRD). If you have ESRD then you may need to receive these drugs from your dialysis
facility. If you don’t have ESRD, see page IV for how to request an exception. If you need help
requesting an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm,
Pacific time, seven days a week. (TTY users should call 711.)
o QL – These drugs have a quantity limit. This means you will receive a limited amount of these
drugs unless you or your provider asks for an exception to the quantity limit. See page IV for
how to request an exception. The maximum dosage allowed for the drug is noted first, then the
days supply (e.g., sumatriptan tablets QL 9 in 28 days, this means a maximum of 9 tablets are
allowed within 28 days). If you need help asking for an exception please call Customer Service
at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call
711.)
VI
o Rx Product Only - This drug is now available as a generic over-the-counter (OTC) medication.
OTC products are not covered under your Part D benefit. The prescription strength is only
covered under your Part D benefit. If you have questions please call Customer Service at 1-888786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)
o ST – These drugs require you to first try certain other drugs to treat your medical condition
before we will cover this drug. See page IV for how to request an exception. If you need help
asking for an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm,
Pacific time, seven days a week. (TTY users should call 711.)
Below is your cost sharing by plan and tier.
Deductible
Drug Tier
Tier 1
Tier 2
Tier 3
Tier 4
Tier 5
ODS Advantage PPORX
$120.00
up to a 31-day
up to a 93-day
supply
supply
$5.00
$15.00
$33.00
$99.00
$41.00
$123.00
50%
50%
30%
drugs on this tier
are limited to a 31day supply
VII
ODS Advantage PPORX Select
$120.00
up to a 31-day
up to a 93-day
supply
supply
$5.00
$15.00
$33.00
$99.00
$41.00
$123.00
50%
50%
30%
drugs on this tier
are limited to a 31day supply
Drug
Tier
Drug Name
Requirements/Limits
Adrenals
Adrenals
ADVAIR DISKUS
3
ADVAIR HFA
3
AEROBID-M
4
A-HYDROCORT
4
ALVESCO
4
ASMANEX
4
ASMANEX
4
ASMANEX
4
betamet acet/betamet na
ph
budesonide
cortisone acetate
(Celestone)
1
(Entocort EC)
(Cortisone Acetate)
2
1
dexamethasone acetate
(Dexamethasone Acetate)
1
dexamethasone sod
phosphate
(Dexamethasone Sod Phosphate)
1
dexamethasone sod
phosphate
(Dexamethasone Sod Phosphate)
1
dexamethasone
(Dexamethasone)
1
dexamethasone
(Dexamethasone)
1
DULERA
3
1
QL: 62 in
31 days
QL: 12 in
28 days
QL: 14 in
25 days
PA
(PA for Part B vs
Part D Only)
QL: 12.2
in 25
days
QL: 1 in aer pow ba:
14 days 220mcg(60)
25 days 110mcg(30),
220mcg120
7 days
220mcg(30)
PA
(PA for Part B vs
Part D Only)
capdr & er
PA
(PA for Part B vs
Part D Only)
PA
(PA for Part B vs
Part D Only)
PA
vial: 10mg/ml, (PA
for Part B vs Part D
Only)
PA
vial: 4mg/ml, (PA
Only)
PA
elixir, tablet, (PA
Only)
PA
tab ds pk, (PA for
Part B vs Part D
Only)
QL: 13 in
28 days
Drug
Tier
Drug Name
FLOVENT DISKUS
3
FLOVENT DISKUS
3
FLOVENT HFA
3
FLOVENT HFA
3
FLOVENT HFA
3
Requirements/Limits
QL: 120
in 30
days
QL: 60 in
30 days
QL: 12 in
28 days
QL: 21.2
in 28
days
QL: 24 in
28 days
disk w/dev: 250mcg
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
vial: 1000mg, (PA
Only)
vial: 125mg/2ml,
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
solution, tablet,
(PA for Part B vs
Part D Only)
tab ds pk, (PA for
Part B vs Part D
Only)
fludrocortisone acetate
hydrocortisone sod
succinate
hydrocortisone
(Fludrocortisone Acetate)
(Hydrocortisone Sod Succinate)
1
1
PA
(Cortef)
1
PA
methylprednisolone
acetate
methylprednisolone sod
succ
(Depo-medrol)
1
PA
(Solu-medrol)
1
PA
methylprednisolone sod
succ
(Solu-medrol)
1
PA
methylprednisolone
(Medrol)
1
PA
prednisolone acetate
(Prednisolone Acetate)
1
PA
prednisolone sod
phosphate
prednisolone
(Orapred)
1
PA
(Prednisolone)
1
PA
4
PA
PREDNISONE
INTENSOL
prednisone
(Prednisone)
1
PA
prednisone
(Prednisone)
1
PA
2
disk w/dev: 50mcg,
100mcg
aer w/adap: 110mcg
aer w/adap: 44mcg
aer w/adap: 220mcg
Drug
Tier
Drug Name
QVAR
3
SOLU-CORTEF (PF)
4
SOLU-MEDROL (PF)
4
SYMBICORT
4
triamcinolone acetonide
(Kenalog-40)
1
VERIPRED 20
1
Requirements/Limits
QL: 17.4
in 25
days
PA
(PA for Part B vs
Part D Only)
PA
vial: 40mg/ml, (PA
Only)
ST, QL:
11 in 25
days
PA
(PA for Part B vs
Part D Only)
PA
(PA for Part B vs
Part D Only)
Alpha-Adrenergic Blocking Agents
doxazosin mesylate
(Cardura)
prazosin hcl
(Minipress)
terazosin hcl
(Hytrin)
1
1
1
Ammonia Detoxicants
Ammonia Detoxicants
BUPHENYL
CARBAGLU
lactulose
(Lactulose)
lactulose
(Lactulose)
LITHOSTAT
3
5
1
1
3
solution
syrup
Analgesics and Antipyretics
Analgesics And Antipyretics, Miscellaneous
acetaminophen/phenyltolx (Staflex)
cit
ACUFLEX
FLEXTRA PLUS
mg sal/acetaminophn/p(Durabac Forte)
tlox/caf
OFIRMEV
RELAGESIC
sal-amide/acetamin/p-tlox/ (Durabac)
caff
sal-amide/acetaminophn/ (Asp)
p-tlox
3
1
4
4
1
4
4
1
1
liquid
Drug
Tier
Drug Name
salicylamide/
(Salicylamide/acetaminophen)
acetaminophen
Nonsteroidal Anti-inflammatory Agents
CALDOLOR
CELEBREX
1
choline sal/mag salicylate
diclofenac potassium
diclofenac sodium
diflunisal
etodolac
(Choline Sal/mag Salicylate)
(Cataflam)
(Voltaren)
(Diflunisal)
(Etodolac)
1
1
1
1
1
etodolac
etodolac
fenoprofen calcium
FLECTOR
flurbiprofen
ibuprofen
indomethacin sodium
trihydrate
(Etodolac)
(Etodolac)
(Fenoprofen Calcium)
(Ansaid)
(Motrin)
(Indocin I.v.)
1
2
1
4
1
1
1
indomethacin
(Indocin SR)
2
indomethacin
(Indomethacin)
1
ketoprofen
ketoprofen
ketorolac tromethamine
(Ketoprofen)
(Ketoprofen)
(Ketorolac Tromethamine)
1
2
1
(Ketorolac Tromethamine)
1
(Toradol)
1
(Toradol)
1
(Magnesium Salicylate)
(Meclofenamate Sodium)
(Ponstel)
(Mobic)
4
1
2
2
1
LEVACET
magnesium salicylate
meclofenamate sodium
mefenamic acid
meloxicam
4
4
3
Requirements/Limits
ST, QL:
62 in 31
days
capsule: 200mg;
tablet
capsule: 300mg
tab er 24h
ST
(May be High Risk
Med for Ages 65
and Older)
capsule er, (May be
High Risk Med for
Ages 65 and Older)
capsule, (May be
High Risk Med for
Ages 65 and Older)
capsule
cap24h pel
QL: 20 in vial: 60mg/2ml
31 days
QL: 40 in vial: 15mg/ml
31 days
QL: 20 in cartridge: 30mg/ml
31 days
QL: 40 in cartridge: 15mg/ml
31 days
Drug
Tier
Drug Name
nabumetone
naproxen sodium
naproxen
oxaprozin
piroxicam
salsalate
SOLARAZE
sulindac
tolmetin sodium
VOLTAREN
Opiate Agonists
acetaminophen with
codeine
(Relafen)
(Anaprox)
(Naprosyn)
(Oxaprozin)
(Feldene)
(Salflex)
1
1
1
1
1
1
4
1
2
3
(Clinoril)
(Tolmetin Sodium)
(Tylenol-codeine No.3)
1
acetaminophen with
codeine
1
acetaminophen with
codeine
1
codeine phos/
acetaminophen
(Codeine Phos/acetaminophen)
1
codeine phosphate
codeine sulfate
(Codeine Phosphate)
(Codeine Sulfate)
1
1
CODEINE SULFATE
1
dhcodeine bt/
acetaminophn/caff
(Dhcodeine Bt/acetaminophn/
caff)
1
dhcodeine bt/
acetaminophn/caff
(Panlor SS)
1
fentanyl citrate
(Actiq)
5
fentanyl
(Duragesic)
2
5
Requirements/Limits
ST
gel (gram),
(Topical Gel)
QL: 180
in 30
days
QL: 180
in 30
days
QL: 360
in 30
days
QL: 2500
in 30
days
tablet: 300mg-60mg
tablet: 650mg30mg, 650mg-60mg
tablet: 300mg15mg, 300mg-30mg
(Injection)
QL: 180
in 30
days
QL: 1800
in 30
days
QL: 300
in 30
days
QL: 150
in 30
days
PA, QL:
120 in 30
days
PA, QL:
10 in 30
days
capsule
tablet
patch td72: 12mcg/
hr, 25mcg/hr,
50mcg/hr, 75mcg/hr
Drug
Tier
Drug Name
fentanyl
(Duragesic)
2
hydrocodone bit/
acetaminophen
(Hycet)
1
hydrocodone bit/
acetaminophen
(Hycet)
1
hydrocodone bit/
acetaminophen
(Hycet)
1
hydrocodone bit/
acetaminophen
(Vicodin)
1
hydrocodone bit/
acetaminophen
(Vicodin)
1
hydrocodone bit/
acetaminophen
(Vicodin)
1
hydrocodone bit/
acetaminophen
(Vicodin)
1
hydrocodone bit/
acetaminophen
(Vicodin)
1
hydrocodone bit/
acetaminophen
(Vicodin)
1
hydrocodone/ibuprofen
(Vicoprofen)
1
hydromorphone hcl
(Dilaudid)
1
hydromorphone hcl
(Dilaudid)
1
hydromorphone hcl
(Dilaudid)
2
6
Requirements/Limits
PA, QL:
20 in 30
days
QL: 2025
in 30
days
QL: 2700
in 30
days
QL: 2700
in 30
days
QL: 150
in 30
days
QL: 180
in 30
days
QL: 240
in 30
days
QL: 360
in 30
days
QL: 360
in 30
days
QL: 390
in 30
days
QL: 150
in 30
days
QL: 180
in 30
days
QL: 240
in 30
days
patch td72: 100mcg/
hr
solution: 10-300/15
solution: 5-163/7.5
solution: 7.5-325/
15, 7.5-500/15
tablet: 7.5-750mg,
10-750mg
tablet: 7.5-650mg,
10-660mg, 10mg650mg
capsule, tablet: 2.5500mg, 5mg500mg, 7.5-500mg,
10mg-500mg
tablet: 2.5-325mg
tablet: 5mg-325mg,
7.5-325mg, 10mg325mg
tablet: 5mg-300mg,
7.5-300mg, 10mg300mg
tablet: 2mg, 4mg
tablet: 8mg
vial
Drug
Tier
Drug Name
hydromorphone hcl
(Dilaudid-5)
1
hydromorphone hcl/pf
hydromorphone hcl/pf
ibuprofen/oxycodone hcl
(Hydromorphone HCl/PF)
(Hydromorphone HCl/PF)
(Combunox)
2
2
1
KADIAN
3
KADIAN
5
levorphanol tartrate
(Levo-dromoran)
2
methadone hcl
methadone hcl
(Methadone HCl)
(Methadone HCl)
1
1
methadone hcl
(Methadose)
1
methadone hcl
(Methadose)
1
morphine sulfate in 0.9 %
nacl
morphine sulfate
(Morphine Sulfate In 0.9 %
NaCl)
(Kadian)
1
morphine sulfate
(Kadian)
5
morphine sulfate
(Morphine Sulfate)
1
morphine sulfate
(MS Contin)
1
morphine sulfate
(MS Contin)
1
7
2
Requirements/Limits
QL: 1200 liquid
in 30
days
ampul, disp syrin
vial
QL: 28 in
30 days
ST, QL: cap er pel: 10mg
60 in 30
days
ST, QL: cap er pel: 200mg
120 in 30
days
QL: 180
in 30
days
vial
QL: 1800 oral conc, solution
in 30
days
QL: 360 tablet
in 30
days
QL: 90 in tablet sol
30 days
ST, QL:
60 in 30
days
ST, QL:
60 in 30
days
QL: 120
in 30
days
QL: 180
in 30
days
cap er pel: 20mg,
30mg, 50mg, 60mg,
80mg
cap er pel: 100mg
disp syrin, pen
injctr, supp.rect, vial
tablet er: 30mg,
60mg, 100mg
tablet, tablet er:
15mg, 200mg
Drug
Tier
Drug Name
morphine sulfate
(MSIR)
1
morphine sulfate
(MSIR)
1
morphine sulfate
(MSIR)
1
morphine sulfate/d5w
morphine sulfate/pf
(Morphine Sulfate/D5W)
(Morphine Sulfate/PF)
1
1
morphine sulfate/pf
(Morphine Sulfate/PF)
1
NUCYNTA ER
3
NUCYNTA
3
oxycodone hcl
(Oxycodone HCl)
1
oxycodone hcl
(Oxycodone HCl)
1
oxycodone hcl
(Oxycodone HCl)
1
oxycodone hcl
(Roxicodone)
1
oxycodone hcl
(Roxicodone)
1
oxycodone hcl/
acetaminophen
(Oxycodone HCl/
acetaminophen)
1
oxycodone hcl/
acetaminophen
(Percocet)
1
oxycodone hcl/
acetaminophen
(Percocet)
1
8
Requirements/Limits
QL: 200
in 30
days
QL: 300
in 30
days
QL: 700
in 30
days
solution: 100mg/
5ml
solution: 20mg/5ml
solution: 10mg/5ml
pca vial, vial: 25mg/
ml
vial: 0.5mg/ml,
1mg/ml
QL: 60 in
30 days
QL: 181
in 30
days
QL: 120
in 30
days
QL: 1300
in 30
days
QL: 60 in
30 days
QL: 180
in 30
days
QL: 180
in 30
days
QL: 1800
in 30
days
QL: 180
in 30
days
QL: 240
in 30
days
tab er 12h: 80mg
solution
tab er 12h: 10mg,
20mg, 40mg
capsule, oral conc,
tablet: 5mg, 15mg,
30mg
tablet: 10mg, 20mg
solution
tablet: 10mg-650mg
capsule, tablet:
5mg-500mg, 7.5500mg
Drug
Tier
Drug Name
Requirements/Limits
oxycodone hcl/
acetaminophen
(Percocet)
1
QL: 360
in 30
days
oxycodone hcl/aspirin
(Percodan)
1
oxycodone hcl/oxycodon
ter/asa
(Oxycodone HCl/oxycodon Ter/
asa)
1
QL: 360
in 30
days
QL: 360
in 30
days
QL: 120 tab er 12h: 80mg
in 30
days
QL: 60 in tab er 12h: 10mg,
30 days 15mg, 20mg, 30mg,
40mg, 60mg
QL: 60 in tab er 12h
30 days
QL: 180 tablet
in 30
days
QL: 30 in tab er 24h: 200mg,
30 days 300mg
QL: 90 in tab er 24h: 100mg
30 days
QL: 240 tablet
in 30
days
QL: 240
in 30
days
OXYCONTIN
3
OXYCONTIN
3
oxymorphone hcl
(Opana ER)
2
oxymorphone hcl
(Opana)
2
tramadol hcl
(Ultram ER)
1
tramadol hcl
(Ultram ER)
1
tramadol hcl
(Ultram)
1
tramadol hcl/
acetaminophen
(Ultracet)
1
9
tablet: 2.5-325mg,
5mg-325mg, 7.5325mg, 10mg325mg
Drug
Tier
Drug Name
Opiate Partial Agonists
buprenorphine hcl
(Buprenorphine HCl)
buprenorphine hcl
(Subutex)
2
2
buprenorphine hcl
(Subutex)
2
butorphanol tartrate
butorphanol tartrate
(Butorphanol Tartrate)
(Butorphanol Tartrate)
2
2
nalbuphine hcl
SUBOXONE
(Nalbuphine HCl)
1
4
Requirements/Limits
PA, QL:
20 in 30
days
PA, QL:
5 in 30
days
QL: 5 in
28 days
disp syrin
tab subl: 2mg
tab subl: 8mg
disp syrin
spray
PA, QL:
90 in 30
days
Androgens
Androgens
ANADROL-50
ANDRODERM
5
4
ANDROGEL
3
ANDROGEL
3
AXIRON
3
danazol
fluoxymesterone
oxandrolone
TESTIM
(Danocrine)
(Fluoxymesterone)
(Oxandrin)
testosterone cypionate
testosterone enanthate
(Depo-testosterone)
(Delatestryl)
2
2
2
4
1
1
10
QL: 30 in
30 days
QL: 150
in 30
days
QL: 300
in 30
days
QL: 180
in 28
days
PA, QL:
300 in 30
days
PA
PA, QL:
5 in 28
days
patch td24: 2mg/
24hr, 4mg/24hr
gel md pmp
gel packet
Drug
Tier
Drug Name
Requirements/Limits
Anorexigenics, Respiratory, Cerebral Stimulants
Amphetamines
amphet asp/amphet/damphet
(Adderall XR)
2
cap er 24h, (PA for
Ages 65 and Older;
May be High Risk
Med)
amphet asp/amphet/d(Adderall)
1
PA, QL: tablet, (PA for
amphet
60 in 30 Ages 65 and Older;
days
May be High Risk
Med)
dextroamphetamine
(Dexedrine)
2
PA, QL: capsule er, (PA for
sulfate
days
May be High Risk
Med)
dextroamphetamine
(Dextrostat)
1
sulfate
days
May be High Risk
Med)
methamphetamine hcl
(Desoxyn)
1
QL: 150 (May be High Risk
in 30
Med for Ages 65
days
and Older)
VYVANSE
4
PA, QL: (PA for Ages 65 and
30 in 30 Older; May be High
days
Risk Med)
Anorexigenics, Respiratory, Cerebral Stimulants, Miscellaneous
caffeine citrated
(Cafcit)
1
caffeine/sodium benzoate (Caffeine/sodium Benzoate)
1
dexmethylphenidate hcl
(Focalin)
1
days
Risk Med)
FOCALIN XR
4
days
Risk Med)
METADATE CD
4
days
Risk Med)
METHYLIN
4
PA, QL: tab chew: 10mg,
180 in 30 (PA for Ages 65 and
days
Older; May be High
Risk Med)
11
PA, QL:
30 in 30
days
Drug
Tier
Drug Name
METHYLIN
4
methylphenidate hcl
(Concerta)
2
methylphenidate hcl
(Methylin)
1
methylphenidate hcl
(Ritalin LA)
2
methylphenidate hcl
(Ritalin LA)
2
methylphenidate hcl
(Ritalin)
1
methylphenidate hcl
(Ritalin)
1
NUVIGIL
4
NUVIGIL
4
RITALIN LA
4
12
Requirements/Limits
PA, QL:
90 in 30
days
tab chew: 2.5mg,
5mg, (PA for Ages
65 and Older; May
be High Risk Med)
PA, QL: tab er 24, (PA for
days
May be High Risk
Med)
PA, QL: solution, (PA for
days
May be High Risk
Med)
PA, QL: cpmp 50-50: 20mg,
30 in 30 40mg, (PA for
days
Ages 65 and Older;
May be High Risk
Med)
days
Older; May be High
Risk Med)
PA, QL: tablet er: 10mg,
days
Older; May be High
Risk Med)
PA, QL: tablet, tablet er:
90 in 30 20mg, (PA for
days
Ages 65 and Older;
May be High Risk
Med)
PA, QL: tablet: 150mg,
30 in 30 250mg
days
PA, QL: tablet: 50mg
90 in 30
days
days
Older; May be High
Risk Med)
Drug
Tier
Drug Name
Requirements/Limits
Anthelmintics
Anthelmintics
ALBENZA
BILTRICIDE
mebendazole
STROMECTOL
3
4
1
3
(Mebendazole)
Antiallergic Agents
Antiallergic Agents
ALOMIDE
ASTEPRO
4
3
azelastine hcl
(Astelin)
1
azelastine hcl
BEPREVE
epinastine hcl
PATADAY
PATANASE
(Optivar)
2
4
2
3
4
(Elestat)
PATANOL
3
QL: 30 in
25 days
QL: 30 in spray/pump
25 days
drops
ST
ST
QL: 30.5
in 30
days
ST
Antibacterials
Aminoglycosides
amikacin sulfate
gentamicin in nacl, isoosm
gentamicin in nacl, isoosm
gentamicin sulfate
gentamicin sulfate/pf
kanamycin sulfate
kanamycin sulfate
NEBCIN IN DEXTROSE
NEBCIN
neomycin sulfate
neomycin sulfate
streptomycin sulfate
TOBI
(Amikacin Sulfate)
(Gentamicin In Nacl, Iso-osm)
1
1
(Gentamicin In Nacl, Iso-osm)
1
(Garamycin)
(Gentamicin Sulfate/PF)
(Kanamycin Sulfate)
(Kanamycin Sulfate)
1
1
1
1
4
4
1
1
2
5
(Neomycin Sulfate)
(Neomycin Sulfate)
(Streptomycin Sulfate)
13
piggyback: 60mg/
100ml, 100mg/50ml
piggyback: 60mg/
50ml, 70mg/50ml,
80mg/100ml, 80mg/
50ml, 90mg/100ml,
100mg/0.1l
vial: 1g/3ml
vial: 500mg/2ml
vial: 80mg
solution
tablet
PA
(PA for Part B vs
Part D Only)
Drug
Tier
Drug Name
tobramycin sulfate
(Nebcin)
tobramycin sulfate
(Nebcin)
tobramycin/sodium
(Tobramycin/sodium Chloride)
chloride
Antibacterials, Miscellaneous
bacitracin
(Bacitracin)
chloramphenicol na succ (Chloramphenicol Na Succ)
clindamycin hcl
(Cleocin HCl)
1
2
1
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate
colistin (colistimethate na)
CUBICIN
(Cleocin HCl)
(Cleocin Palmitate)
(Cleocin Phosphate)
(Coly-mycin M Parenteral)
1
2
1
2
5
polymyxin b sulfate
SYNERCID
vancomycin hcl
vancomycin hcl
(Polymyxin B Sulfate)
vancomycin hcl/d5w
VANCOMYCIN HCL
XIFAXAN
(Vancomycin HCl/D5W)
(Vancocin HCl)
(Vancomycin HCl)
Requirements/Limits
vial port
vial
2
1
1
1
5
5
2
2
4
3
XIFAXAN
3
ZYVOX
Cephalosporins
CEDAX
CEDAX
cefaclor
cefaclor
cefadroxil hydrate
cefazolin sodium
cefazolin sodium/
dextrose,iso
cefazolin sodium/
dextrose,iso
cefdinir
cefditoren pivoxil
cefepime hcl
5
capsule: 150mg,
300mg
capsule: 75mg
PA
PA
PA, QL:
60 in 30
days
PA, QL:
9 in 30
days
(PA for ESRD
Only)
capsule
vial, (PA for ESRD
Only)
tablet: 550mg
tablet: 200mg
(Ceclor)
(Ceclor)
(Cefadroxil Hydrate)
(Ancef)
(Cefazolin Sodium/dextrose, Iso)
4
4
1
2
1
2
2
capsule
susp recon
susp recon
capsule, tab er 12h
(Cefazolin Sodium/dextrose, Iso)
2
piggyback
(Omnicef)
(Spectracef)
(Maxipime)
2
2
2
14
froz.piggy
Drug
Tier
Drug Name
CEFEPIME
CEFEPIME-DEXTROSE
cefotaxime sodium
cefotaxime sodium
cefpodoxime proxetil
(Claforan)
(Claforan)
(Cefpodoxime Proxetil)
3
3
1
1
1
cefpodoxime proxetil
(Vantin)
2
cefprozil
ceftazidime pentahydrate
ceftazidime pentahydrate
CEFTAZIDIME
ceftriaxone na/
dextrose,iso
ceftriaxone sodium
cefuroxime axetil
cefuroxime axetil
cefuroxime sodium
cefuroxime sodium
cefuroxime sodium/
dextrose,iso
cephalexin
SUPRAX
TAZICEF IN
DEXTROSE
Macrolides
azithromycin hydrogen
citrate
azithromycin
azithromycin
(Cefzil)
(Fortaz)
(Fortaz)
2
2
2
2
2
(Ceftriaxone Na/dextrose, Iso)
(Rocephin)
(Ceftin)
(Cefuroxime Axetil)
(Zinacef)
(Zinacef)
(Cefuroxime Sodium/dextrose,
Iso)
(Keflex)
2
1
1
1
2
1
(Azithromycin Hydrogen
Citrate)
(Zithromax)
(Zithromax)
1
clarithromycin
(Biaxin XL)
2
clarithromycin
DIFICID
(Biaxin)
1
5
ery e-succ/sulfisoxazole
ERY-TAB
ERYTHROCIN
LACTOBIONATE
ERYTHROCIN
LACTOBIONATE
erythromycin base
(Pediazole)
(Eryc)
15
Requirements/Limits
vial: 1g, 2g, 10g
vial: 500mg
susp recon: 50mg/
5ml
susp recon: 100mg/
5ml; tablet
vial: 1g; vial port
vial: 2g, 6g, 500mg
tablet
susp recon
vial: 7.5g
vial: 1.5g, 750mg
1
4
3
1
1
packet
susp recon, tablet,
vial
susp recon, tab er
24h
tablet
QL: 20 in
10 days
1
1
3
vial port: 1g
3
vial port: 500mg
1
capsule dr
Drug
Tier
Drug Name
Requirements/Limits
erythromycin base
(Erythromycin Base)
erythromycin
(Erythromycin Ethylsuccinate)
ethylsuccinate
erythromycin
(Erythromycin Ethylsuccinate)
ethylsuccinate
erythromycin stearate
(Erythromycin Stearate)
erythromycin stearate
(Erythromycin Stearate)
KETEK
Miscellaneous B-lactam Antibiotics
AZACTAM-ISOOSMOTIC DEXTROSE
aztreonam
(Azactam)
CAYSTON
cefotetan disod/
(Cefotetan Disod/dextrose, Iso)
dextrose,iso
cefotetan disodium
(Cefotetan Disodium)
cefoxitin sodium
(Mefoxin)
cefoxitin sodium
(Mefoxin)
cefoxitin sodium/
(Cefoxitin Sodium/dextrose, Iso)
dextrose,iso
imipenem/cilastatin
(Primaxin)
sodium
INVANZ
INVANZ
meropenem
(Merrem)
Penicillins
amoxicillin
(Amoxil)
1
1
amoxicillin
(Amoxil)
1
amoxicillin/potassium clav
ampicillin sodium
ampicillin sodium
ampicillin sodium
ampicillin sodium/
sulbactam na
ampicillin sodium/
sulbactam na
ampicillin sodium/
sulbactam na
ampicillin trihydrate
BACTOCILL
(Augmentin)
(Totacillin-N)
(Totacillin-N)
(Totacillin-N)
(Unasyn)
1
1
2
2
1
vial: 125mg
vial port
vial: 2g, 10g
vial: 15g
(Unasyn)
2
vial port
(Unasyn)
2
vial: 3g
(Ampicillin Trihydrate)
1
4
16
tablet, tablet dr
oral susp: 200mg/
5ml
tablet
1
1
1
4
tablet: 250mg
tablet: 500mg
ST
4
2
5
2
2
1
2
1
LA
vial: 10g
vial: 1g, 2g
2
4
4
2
vial
vial port
1
capsule, susp recon,
tab chew: 125mg,
250mg; tablet
tab chew: 200mg,
400mg
Drug Name
Drug
Tier
Requirements/Limits
vial
vial port
BICILLIN C-R
BICILLIN L-A
dicloxacillin sodium
nafcillin sodium
nafcillin sodium
nafcillin sodium/d2.4w
oxacillin sodium
oxacillin sodium/
dextrose,iso
pen g pot/dextrose-water
(Dicloxacillin Sodium)
(Unipen)
(Unipen)
(Nafcillin Sodium/d2.4w)
(Oxacillin Sodium)
(Oxacillin Sodium/dextrose, Iso)
3
3
1
2
2
2
2
2
(Pen G Pot/dextrose-water)
2
pen g pot/dextrose-water
(Pen G Pot/dextrose-water)
2
penicillin g potassium
(Penicillin G Potassium)
penicillin g potassium/d5w (Penicillin G Potassium/D5W)
penicillin g procaine
(Penicillin G Procaine)
2
2
2
penicillin g procaine
(Penicillin G Procaine)
2
penicillin v potassium
piperacillin sodium
piperacillin sodium/
tazobactam
PIPRACIL IN
DEXTROSE
TIMENTIN
ZOSYN
(Veetids 500)
(Piperacillin Sodium)
(Zosyn)
1
2
2
froz.piggy: 1mm/
50ml
froz.piggy: 2mm/
50ml, 3mm/50ml
disp syrin: 1.2mm/
2ml
disp syrin: 600000/
ml
4
4
4
17
froz.piggy
Drug
Tier
Drug Name
Quinolones
AVELOX ABC PACK
AVELOX IV
AVELOX
ciprofloxacin hcl
(Cipro)
ciprofloxacin lactate
(Cipro I.V.)
ciprofloxacin lactate/d5w (Cipro I.V.)
ciprofloxacin/ciprofloxa
(Cipro XR)
hcl
FACTIVE
levofloxacin
(Levaquin)
levofloxacin
(Levaquin)
levofloxacin/d5w
(Levaquin)
nalidixic acid
(Nalidixic Acid)
NOROXIN
ofloxacin
(Floxin)
Sulfonamides (Systemic)
sulfadiazine
(Sulfadiazine)
sulfamethoxazole/
(Septra)
trimethoprim
sulfasalazine
(Azulfidine)
Tetracyclines
demeclocycline hcl
(Declomycin)
doxycycline hyclate
(Doryx)
doxycycline hyclate
(Vibramycin)
doxycycline hyclate
(Vibramycin)
doxycycline hyclate
(Vibra-tabs)
doxycycline monohydrate (Adoxa)
Requirements/Limits
3
3
3
1
1
1
2
4
1
2
1
1
4
2
vial
solution, tablet
2
1
1
2
2
1
2
1
1
doxycycline monohydrate
(Adoxa)
2
doxycycline monohydrate
MINOCIN
minocycline hcl
minocycline hcl
tetracycline hcl
tetracycline hcl
TYGACIL
(Monodox)
2
5
1
2
1
1
5
(Dynacin)
(Dynacin)
(Ala-tet)
(Tetracycline HCl)
18
tablet dr, vial
capsule
capsule dr
tablet
tablet: 50mg,
100mg
capsule: 75mg;
tablet: 75mg,
150mg
capsule: 150mg
vial
capsule
tab er 24h, tablet
capsule
oral susp
Drug
Tier
Drug Name
Requirements/Limits
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine sulfate
(Atropine Sulfate)
atropine sulfate
(Atropine Sulfate)
ATROVENT HFA
1
1
3
dicyclomine hcl
(Bentyl)
1
glycopyrrolate
glycopyrrolate
isopropamide/
prochlorperazine
methscopolamine bromide
(Robinul)
(Robinul)
(Isopropamide/prochlorperazine)
1
2
1
(Pamine)
1
PA
3
QL: 30 in
30 days
SPIRIVA
ampul, vial
disp syrin
QL: 25.8
in 28
days
PA
capsule, syrup,
tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
vial
tablet
(PA for Ages 65 and
Older; May be High
Risk Med)
Anticonvulsants
Anticonvulsants, Miscellaneous
BANZEL
carbamazepine
(Carbatrol)
4
2
carbamazepine
carbamazepine
divalproex sodium
(Tegretol XR)
(Tegretol)
(Depakote ER)
2
1
2
divalproex sodium
felbamate
gabapentin
gabapentin
GABITRIL
LAMICTAL (BLUE)
LAMICTAL (ORANGE)
LAMICTAL ODT
(BLUE)
LAMICTAL ODT
(GREEN)
LAMICTAL ODT
(ORANGE)
(Depakote)
(Felbatol)
(Neurontin)
(Neurontin)
1
2
1
2
3
4
4
4
4
4
19
cpmp 12hr, oral
susp
tab er 12h
tab chew, tablet
cap sprink, tab er
24h
tablet dr
capsule
solution, tablet
Drug
Tier
Drug Name
LAMICTAL ODT
LAMICTAL XR (BLUE)
LAMICTAL XR
(GREEN)
LAMICTAL XR
(ORANGE)
LAMICTAL XR
LAMICTAL XR
lamotrigine
lamotrigine
levetiracetam
levetiracetam
Requirements/Limits
4
4
4
4
4
tab er 24: 25mg,
50mg, 100mg,
200mg, 250mg
tab er 24: 300mg
tab ds pk
tablet, tb chw dsp
vial
solution, tab er 24h,
tablet
4
2
1
1
2
(Lamictal (green))
(Lamictal)
(Keppra)
(Keppra)
LYRICA
3
magnesium chloride
magnesium sulfate
magnesium sulfate
(Magnesium Chloride)
(Magnesium Sulfate)
(Magnesium Sulfate)
1
1
1
magnesium sulfate/d5w
oxcarbazepine
oxcarbazepine
POTIGA
(Magnesium Sulfate/D5W)
(Trileptal)
(Trileptal)
1
1
2
4
POTIGA
4
SABRIL
TEGRETOL XR
topiramate
topiramate
TRILEPTAL
valproate sodium
valproic acid
VIMPAT
5
3
1
2
4
1
1
4
(Topamax)
(Topamax)
(Depakene)
(Depakene)
VIMPAT
4
VIMPAT
4
20
QL: 93 in
31 days
disp syrin
infus. btl,
piggyback, vial
tablet
oral susp
tablet: 50mg
QL: 270
in 30
days
QL: 90 in tablet: 200mg,
30 days 300mg, 400mg
tab er 12h: 100mg
tablet
cap sprink
oral susp
QL: 1200 solution
in 30
days
QL: 200 vial
in 5 days
QL: 60 in tablet
30 days
Drug
Tier
Drug Name
zonisamide
Hydantoins
DILANTIN
DILANTIN
fosphenytoin sodium
PEGANONE
PHENYTEK
phenytoin sodium
extended
phenytoin sodium
phenytoin sodium
phenytoin
Succinimides
CELONTIN
ethosuximide
ethosuximide
(Zonegran)
Requirements/Limits
1
capsule: 30mg
tab chew
(Dilantin)
3
3
1
3
3
1
(Phenytoin Sodium)
(Phenytoin Sodium)
(Dilantin-125)
1
1
1
ampul
disp syrin
(Zarontin)
(Zarontin)
3
1
2
(Cerebyx)
syrup
capsule
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
acarbose
(Precose)
2
BYDUREON
3
BYETTA
3
BYETTA
3
GLYSET
4
JANUMET XR
3
JANUMET XR
3
JANUMET
3
JANUVIA
3
JENTADUETO
3
21
QL: 90 in
30 days
ST, QL:
4 in 28
days
ST, QL:
1.2 in 28
days
ST, QL:
2.4 in 28
days
QL: 90 in
30 days
QL: 30 in
30 days
pen injctr: 5mcg/
0.02
pen injctr: 10mcg/
0.04
tbmp 24hr: 50mg500mg, 1001000mg
QL: 60 in tbmp 24hr: 5030 days 1000mg
QL: 60 in
30 days
QL: 30 in
30 days
QL: 60 in
30 days
Drug
Tier
Drug Name
JUVISYNC
3
KORLYM
5
metformin hcl
(Fortamet)
1
metformin hcl
(Glucophage)
1
metformin hcl
(Glucophage)
1
metformin hcl
(Glucophage)
1
nateglinide
(Starlix)
2
PRANDIMET
3
PRANDIN
3
SYMLIN
4
SYMLINPEN 120
4
SYMLINPEN 60
4
TRADJENTA
3
VICTOZA 3-PAK
4
Insulins
HUMALOG MIX 50-50
3
HUMALOG MIX 50-50
3
HUMALOG MIX 75-25
3
HUMALOG MIX 75-25
3
22
Requirements/Limits
QL: 30 in
30 days
PA, QL:
112 in 28
days
QL: 60 in
30 days
QL: 120
in 30
days
QL: 60 in
30 days
QL: 90 in
30 days
QL: 90 in
30 days
QL: 150
in 30
days
QL: 240
in 30
days
QL: 20 in
28 days
QL: 16.2
in 28
days
QL: 9 in
28 days
QL: 30 in
30 days
PA, QL:
9 in 28
days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
tab er 24
tab er 24h: 500mg;
tablet: 500mg
tablet: 1000mg
tab er 24h: 750mg;
tablet: 850mg
insuln pen
vial
insuln pen
vial
Drug
Tier
Drug Name
HUMALOG
3
HUMALOG
3
HUMULIN 70-30
3
HUMULIN 70-30
3
HUMULIN N
3
HUMULIN N
3
HUMULIN R
3
LANTUS SOLOSTAR
3
LANTUS
3
LEVEMIR
3
LEVEMIR
3
NOVOLIN 70-30
INNOLET
NOVOLIN 70-30
3
NOVOLIN N INNOLET
3
NOVOLIN N
3
NOVOLIN R
3
NOVOLIN R
3
NOVOLOG MIX 70-30
3
NOVOLOG MIX 70-30
3
NOVOLOG
3
3
23
Requirements/Limits
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
ST, QL:
30 in 28
days
ST, QL:
40 in 28
days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
insuln pen
vial
insuln pen
vial
insuln pen
vial
insuln pen
vial
insuln pen
vial
insuln pen
vial
insuln pen
Drug
Tier
Drug Name
NOVOLOG
3
QL: 40 in vial
28 days
QL: 30 in
30 days
QL: 60 in
30 days
QL: 30 in
30 days
QL: 120
in 30
days
QL: 60 in
30 days
QL: 120
in 30
days
QL: 60 in
30 days
PA, QL:
120 in 30
days
Sulfonylureas
glimepiride
(Amaryl)
1
glimepiride
(Amaryl)
1
glipizide
(Glucotrol XL)
1
glipizide
(Glucotrol)
1
glipizide
(Glucotrol)
1
glipizide/metformin hcl
(Metaglip)
2
glipizide/metformin hcl
(Metaglip)
2
glyburide
(Micronase)
1
glyburide
(Micronase)
1
glyburide,micronized
(Glynase)
1
glyburide,micronized
(Glynase)
1
glyburide/metformin hcl
(Glucovance)
1
24
Requirements/Limits
tablet: 1mg, 2mg
tablet: 4mg
tab er 24: 2.5mg,
5mg
tablet: 10mg
tab er 24: 10mg;
tablet: 5mg
tablet: 2.5-500mg,
5mg-500mg
tablet: 2.5-250mg
tablet: 5mg, (PA
for Ages 65 and
Older; May be High
Risk Med)
PA, QL: tablet: 1.25mg,
30 in 30 2.5mg, (PA for
days
Ages 65 and Older;
May be High Risk
Med)
PA, QL: tablet: 1.5mg, 3mg,
days
Older; May be High
Risk Med)
PA, QL: tablet: 6mg, (PA
60 in 30 for Ages 65 and
days
Older; May be High
Risk Med)
PA, QL: tablet: 2.5-500mg,
120 in 30 5mg-500mg, (PA
days
for Ages 65 and
Older; May be High
Risk Med)
Drug
Tier
Drug Name
Requirements/Limits
glyburide/metformin hcl
(Glucovance)
1
PA, QL:
60 in 30
days
tolazamide
(Tolazamide)
1
tolazamide
(Tolazamide)
1
tolbutamide
(Tolbutamide)
1
QL: 120
in 30
days
QL: 60 in tablet: 500mg
30 days
QL: 180
in 30
days
Thiazolidinediones
ACTOPLUS MET XR
3
ACTOPLUS MET
3
ACTOS
4
AVANDAMET
3
AVANDARYL
3
AVANDIA
3
DUETACT
3
tablet: 1.25-250mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
tablet: 250mg
QL: 60 in
30 days
QL: 90 in
30 days
QL: 30 in
30 days
PA, QL:
60 in 30
days
PA, QL:
30 in 30
days
PA, QL:
30 in 30
days
QL: 30 in
30 days
Antidiarrhea Agents
Antidiarrhea Agents
diphenoxylate hcl/atropine (Lomotil)
1
loperamide hcl
paregoric
1
2
(Loperamide HCl)
(Paregoric)
(May be High Risk
Med for Ages 65
and Older)
Antiemetics
5-ht3 Receptor Antagonists
ALOXI
granisetron hcl
(Kytril)
4
2
25
vial
Drug
Tier
Drug Name
Requirements/Limits
granisetron hcl
(Kytril)
2
PA
granisetron hcl/pf
ondansetron hcl
ondansetron hcl
(Kytril)
(Zofran)
(Zofran)
1
1
1
PA
ondansetron hcl
(Zofran)
2
PA
ondansetron
(Zofran Odt)
1
PA
Antiemetics, Miscellaneous
CESAMET
dronabinol
(Marinol)
EMEND
4
2
3
EMEND
3
PA, QL:
2 per fill
EMEND
3
PA, QL:
3 per fill
EMEND
3
QL: 2 in
28 days
Antihistamines (GI Drugs)
dimenhydrinate
(Dimenhydrinate)
meclizine hcl
(Antivert)
prochlorperazine edisylate (Compazine)
prochlorperazine maleate (Compazine)
1
1
1
1
PA, QL:
1 per fill
solution, tablet,
(PA for Part B vs
Part D Only)
vial
tablet, (PA for Part
B vs Part D Only)
solution, (PA for
Part B vs Part D
Only)
(PA for Part B vs
Part D Only)
capsule: 40mg,
125mg, (PA for
Part B vs Part D
Only)
capsule: 80mg, (PA
Only)
cap ds pk, (PA for
Part B vs Part D
Only)
vial
Antifungal (Systemic)
Antifungals, Miscellaneous
ABELCET
5
PA
amphotericin b
(Amphotericin B)
2
PA
flucytosine
griseofulvin,microsize
GRIS-PEG
nystatin
nystatin
(Ancobon)
(Grifulvin V)
5
1
4
1
1
(Mycostatin)
(Nystatin)
26
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
powder(ea), tablet
powder
Drug
Tier
Drug Name
terbinafine hcl
triacetin
Azoles
fluconazole in nacl,isoosm
fluconazole
itraconazole
ketoconazole
NOXAFIL
SPORANOX
VFEND IV
VFEND
voriconazole
Echinocandins
CANCIDAS
ERAXIS (WATER
DILUENT)
(Lamisil)
(Triacetin)
1
1
(Fluconazole In Nacl,iso-osm)
1
(Diflucan)
(Sporanox)
(Nizoral)
1
2
1
5
3
4
5
5
(Vfend)
Requirements/Limits
solution
susp recon
tablet
5
5
Antiglaucoma Agents
Antiglaucoma Agents
acetazolamide sodium
(Acetazolamide Sodium)
acetazolamide
(Acetazolamide)
acetazolamide
(Diamox Sequels)
ALPHAGAN P
AZOPT
betaxolol hcl
(Betaxolol HCl)
BETIMOL
BETOPTIC S
brimonidine tartrate
(Alphagan P)
brimonidine tartrate
(Alphagan P)
COMBIGAN
dorzolamide hcl
(Trusopt)
dorzolamide hcl/timolol
(Cosopt)
maleat
ISOPTO CARPINE
ISTALOL
latanoprost
(Xalatan)
levobunolol hcl
(Betagan)
levobunolol hcl
(Betagan)
LUMIGAN
methazolamide
(Neptazane)
1
1
2
3
3
1
4
4
1
1
3
1
1
3
4
1
1
1
3
1
27
tablet
capsule er
drops: 0.1%
(Drops 0.15%)
drops: 8%
drops: 0.25%
drops: 0.5%
QL: 2.5
in 25
days
Drug
Tier
Drug Name
metipranolol
(Optipranolol)
PHOSPHOLINE IODIDE
pilocarpine hcl
(Isopto Carpine)
PILOPINE HS
timolol maleate
(Timoptic)
TRAVATAN Z
1
4
1
4
1
3
Requirements/Limits
QL: 2.5
in 25
days
Antihistamines
Antihistamines
carbinoxamine maleate
(Palgic)
1
PA
clemastine fumarate
(Clemastine Fumarate)
1
PA
clemastine fumarate
(Clemastine Fumarate)
1
PA
diphenhydramine hcl
diphenhydramine hcl
levocetirizine
dihydrochloride
p-epd tan/chlor-tan
phenyleph/acetaminop/ptlox/cp
phenylephrine/chlor-tan
promethazine hcl
(Benadryl)
(Diphenhydramine HCl)
(Xyzal)
1
1
2
(P-epd Tan/chlor-tan)
(Phenyleph/acetaminop/p-tlox/
cp)
(Rynatan)
(Promethazine HCl)
1
1
tripelennamine hcl
(Tripelennamine HCl)
1
1
1
Anti-infectives (EENT)
Anti-infectives (EENT)
acetic acid
(Vosol)
acetic acid/aluminum
(Domeboro)
acetate
acetic acid/hydrocortisone (Vosol HC)
AZASITE
bacitracin
(Bacitracin)
1
1
2
4
1
28
PA
(PA for Ages 65 and
Older; May be High
Risk Med)
syrup, tablet:
2.68mg, (PA for
Ages 65 and Older;
May be High Risk
Med)
tablet: 1.34mg, (PA
for Ages 65 and
Older; May be High
Risk Med)
vial
disp syrin
(PA for Ages 65 and
Older; May be High
Risk Med)
Drug
Tier
Drug Name
bacitracin/polymyxin b
sulfate
BACTROBAN NASAL
BESIVANCE
BLEPHAMIDE S.O.P.
BLEPHAMIDE
CETRAXAL
chlorhexidine gluconate
CILOXAN
CIPRO HC
CIPRODEX
ciprofloxacin hcl
COLY-MYCIN S
CORTISPORIN-TC
cresyl ace/ben alc/
butanol/ipa
doxycycline hyclate
erythromycin base
gentamicin sulfate
levofloxacin
MOXEZA
NATACYN
neo/polymyx b sulf/
dexameth
neomy sulf/bacitra/
polymyxin b
neomy sulf/bacitra/
polymyxin b
neomy sulf/bacitrac zn/
poly/hc
neomycin sulfate/dex na
ph
neomycin/polymyxin b
sulf/hc
neomycin/polymyxn b/
gramicidin
ofloxacin
polymyxin b sulfate/tmp
sulfacetamide sodium
sulfacetamide/
prednisolone sp
TOBRADEX
(Polycin-b)
Requirements/Limits
1
(Peridex)
(Ciloxan)
(Cresyl Ace/ben Alc/butanol/ipa)
(Periostat)
(Romycin)
(Garamycin)
(Quixin)
4
4
3
4
4
1
4
3
3
1
4
4
1
ST
oint. (g)
1
1
1
1
3
3
1
(Maxitrol)
(Neomy Sulf/bacitra/polymyxin
B)
(Neo-polycin)
1
packet
1
oint. (g)
(Triple Antibiotic HC)
1
(Neomycin Sulfate/dex Na Ph)
1
(Oticin HC)
1
(Neosporin)
1
(Floxin)
(Polytrim)
(Sulfac)
(Sulfacetamide/prednisolone Sp)
1
1
1
1
4
29
oint. (g)
Drug
Tier
Drug Name
tobramycin sulf/
dexamethasone
tobramycin sulfate
trifluridine
VIGAMOX
ZIRGAN
ZYLET
ZYMAR
ZYMAXID
(Tobradex)
1
(Tobrex)
(Viroptic)
1
2
3
4
3
3
3
Requirements/Limits
Anti-infectives (Skin and Mucous Membrane)
Antibacterials (Skin and Mucous Membrane)
ALTABAX
clindamycin phos/benzoyl (Benzaclin)
perox
clindamycin phos/benzoyl (Duac)
perox
clindamycin phosphate
(Cleocin T)
erythromycin base/ethanol (Emgel)
erythromycin/benzoyl
(Benzamycin)
peroxide
gentamicin sulfate
(Gentamicin Sulfate)
metronidazole
(Nydamax)
metronidazole
(Vitazol)
mupirocin
(Centany)
neomy sulf/polymyxin b
(Neosporin G.U. Irrigant)
sulfate
Antifungals (Skin and Mucous Membrane)
ciclopirox olamine
(Loprox)
ciclopirox olamine
(Loprox)
ciclopirox
(Penlac)
clotrimazole
(Lotrimin)
clotrimazole/
(Lotrisone)
betamethasone dip
econazole nitrate
(Spectazole)
EXELDERM
GYNAZOLE-1
ketoconazole
(Extina)
ketoconazole
(Kuric)
LAMISIL
miconazole nitrate
(Monistat 3)
30
4
2
gel (gram)
2
gel er (g)
1
1
1
1
1
2
1
1
1
2
2
1
1
1
4
3
2
1
3
1
gel (gram), gel w/
appl
cream (g), lotion
suspension
cream (g)
foam
cream (g), shampoo
Drug
Tier
Drug Name
nystatin
(Mycostatin)
Requirements/Limits
1
nystatin
(Nystatin)
nystatin/triamcin
(Mycogen II)
sod propionate/inosi/aa14/ (Sod Propionate/inosi/aa14/urea)
urea
sodium thiosulfate/sal acid (Sodium Thiosulfate/sal Acid)
terconazole
(Terazol 7)
XOLEGEL
Antivirals (Skin and Mucous Membrane)
DENAVIR
VEREGEN
ZOVIRAX
Local Anti-infectives, Miscellaneous
acetic ac/ricinoleic/
(Acetic Ac/ricinoleic/oxyquinol)
oxyquinol
alcohol antiseptic pads
(Alcohol Antiseptic Pads)
AVC
selenium sulfide
(Selenium Sulfide)
selenium sulfide
(Selseb)
silver nitrate
(Silver Nitrate)
silver sulfadiazine
(Silvadene)
sulfacetamide sodium
(Klaron)
SULFAMYLON
Scabicides and Pediculicides
EURAX
lindane
(Lindane)
malathion
(Ovide)
permethrin
(Elimite)
cream (g), oint. (g),
powder
tablet
1
1
1
1
1
4
3
4
4
1
1
3
1
1
1
1
2
4
suspension
shampoo
3
2
1
1
Anti-infectives (systemic), Miscellaneous
Anti-infectives (systemic), Miscellaneous
FUROXONE
3
Anti-inflammatory Agents (EENT)
Anti-inflammatory Agents (EENT)
ALREX
BECONASE AQ
BROMDAY
bromfenac sodium
dexamethasone sod
phosphate
diclofenac sodium
3
4
(Bromfenac Sodium)
(Ak-dex)
3
2
1
(Voltaren)
1
31
QL: 50 in
28 days
Drug
Tier
Drug Name
DUREZOL
flunisolide
(Nasarel)
3
1
fluocinolone acetonide oil
fluorometholone
flurbiprofen sodium
fluticasone propionate
(Dermotic)
(Fluorometholone)
(Ocufen)
(Flonase)
1
1
1
1
LOTEMAX
NASONEX
(Acular LS)
(Acular LS)
1
2
3
3
NEVANAC
OMNARIS
prednisolone acetate
prednisolone sod
phosphate
QNASL
3
4
(Pred Forte)
(Prednisol)
QL: 50 in
25 days
QL: 16 in
30 days
drops: 0.5%
drops: 0.4%
QL: 34 in
28 days
QL: 13 in
30 days
1
1
4
RESTASIS
4
RHINOCORT AQUA
4
Requirements/Limits
(Nasacort Aq)
2
VERAMYST
4
ZETONNA
4
Anti-inflammatory Agents (GI Drugs)
Anti-inflammatory Agents (GI Drugs)
APRISO
ASACOL HD
ASACOL
balsalazide disodium
(Colazal)
DIPENTUM
3
4
4
2
3
32
QL: 8.7
in 28
days
PA, QL:
64 in 31
days
QL: 17.2
in 30
days
QL: 16.5
in 30
days
QL: 10 in
30 days
QL: 6.1
in 30
days
Drug
Tier
Drug Name
LIALDA
mesalamine w/cleansing
wipes
PENTASA
Requirements/Limits
4
2
(Rowasa)
4
Anti-inflammatory Agents (Respiratory)
Anti-inflammatory Agents (Respiratory)
ALOCRIL
cromolyn sodium
(Cromolyn Sodium)
cromolyn sodium
(Gastrocrom)
cromolyn sodium
(Intal)
4
1
2
1
SINGULAIR
zafirlukast
4
1
(Accolate)
PA
drops
solution
ampul-neb, (PA for
Part B vs Part D
Only)
Anti-inflammatory Agents (Skin and Mucous)
Anti-inflammatory Agents (Skin and Mucous)
alclometasone
(Aclovate)
dipropionate
amcinonide
(Amcinonide)
APEXICON E
betamet diprop/prop gly
(Diprolene AF)
betamethasone
(Betamethasone Dipropionate)
dipropionate
betamethasone
(Del-beta)
dipropionate
betamethasone valerate
(Betamethasone Valerate)
clobetasol propionate
(Olux)
clobetasol propionate
1
1
4
1
1
1
1
2
(Temovate)
1
CLODERM
CORDRAN SP
CORDRAN
CORDRAN
desonide
(Desowen)
4
4
4
4
1
desoximetasone
(Topicort)
2
desoximetasone
diflorasone diacetate
(Topicort)
(Psorcon)
2
1
33
gel (gram)
cream (g), lotion,
oint. (g)
foam, lotion,
shampoo
cream (g), gel
(gram), oint. (g),
solution
lotion, med. tape
oint. (g)
cream (g), lotion,
oint. (g): 0.05%
cream (g), gel
(gram), oint. (g):
0.25%
oint. (g): 0.05%
Drug
Tier
Drug Name
fluocinolone acetonide
fluocinolone/shower cap
fluocinonide
halobetasol propionate
hydrocortisone acetate
hydrocortisone acetate/
aloe v
hydrocortisone acetate/
urea
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone
hydrocortisone
(Fluocinolone Acetonide)
(Derma-smoothe-fs)
(Fluocinonide)
(Cutivate)
(Cutivate)
(Ultravate)
(Hydrocortisone Acetate)
(Nuzon)
1
1
1
1
2
1
1
1
(Carmol HC)
1
(Locoid)
(Hydrocortisone Valerate)
(Cortenema)
(Proctocort)
1
1
2
1
KENALOG
LOCOID
mometasone furoate
prednicarbate
(Elocon)
(Dermatop)
(Triamcinolone Acetonide)
4
4
1
1
1
(Triderm)
1
Requirements/Limits
cream (g), oint. (g)
lotion
enema
cream (g),
cream(gm), lotion,
oint. (g)
aerosol
cream (g)
cream (g), lotion,
oint. (g): 0.025%,
0.1%, 0.5%; paste
(g)
cream, oint. (g):
0.05%
Antilipemic Agents
Antilipemic Agents, Miscellaneous
LOVAZA
niacin
(Niacin)
NIASPAN
ZETIA
Bile Acid Sequestrants
cholestyramine (with
(Questran)
sugar)
cholestyramine/aspartame (Questran Light)
colestipol hcl
(Colestid)
WELCHOL
Fibric Acid Derivatives
fenofibrate
(Lofibra)
fenofibrate,micronized
(Lofibra)
3
1
3
4
2
2
2
3
1
1
34
tablet: 500mg
Drug
Tier
Drug Name
fenofibric acid
(Fibricor)
gemfibrozil
(Lopid)
TRICOR
TRILIPIX
HMG-CoA Reductase Inhibitors
ADVICOR
ALTOPREV
amlodipine/atorvastatin
(Caduet)
atorvastatin calcium
(Lipitor)
CRESTOR
fluvastatin sodium
(Lescol)
lovastatin
(Mevacor)
pravastatin sodium
(Pravachol)
SIMCOR
1
1
4
3
SIMCOR
4
simvastatin
4
4
2
2
4
2
1
1
4
(Zocor)
Requirements/Limits
ST
ST
tbmp 24hr: 100020mg
tbmp 24hr: 500mg20mg, 500mg40mg, 750mg20mg, 1000-40mg
1
QL: 30 in
30 days
Selective Serotonin Agonists
AXERT
4
FROVA
4
QL: 12 in
28 days
QL: 18 in
28 days
QL: 9 in
28 days
QL: 9 in
28 days
QL: 4 in
28 days
QL: 4 in
28 days
QL: 12 in
28 days
QL: 18 in
28 days
QL: 9 in
28 days
QL: 6 in
28 days
Antimigraine Agents
naratriptan hcl
(Amerge)
2
sumatriptan succinate
(Imitrex)
1
(Imitrex)
2
(Imitrex)
2
sumatriptan
(Imitrex)
2
sumatriptan
(Imitrex)
2
ZOMIG ZMT
4
ZOMIG
4
35
tablet
cartridge, vial
pen injctr
spray: 20mg
spray: 5mg
spray
Drug
Tier
Drug Name
ZOMIG
4
Requirements/Limits
QL: 9 in
28 days
tablet
Antimycobacterials
Antimycobacterials
CAPASTAT SULFATE
dapsone
(Dapsone)
ethambutol hcl
(Myambutol)
isoniazid
(Isoniazid)
MYCOBUTIN
PASER
PRIFTIN
pyrazinamide
(Pyrazinamide)
rifampin
(Rifadin)
rifampin/isoniazid
(Rifamate)
SEROMYCIN
TRECATOR
3
1
2
1
4
3
4
1
2
1
4
3
Antineoplastic Agents
Antineoplastic Agents
ABRAXANE
ADCETRIS
AFINITOR
5
5
5
ALIMTA
anastrozole
ARRANON
ARZERRA
5
1
5
5
AVASTIN
BEXXAR
bicalutamide
BICNU
bleomycin sulfate
BUSULFEX
CAMPATH
CAPRELSA
(Arimidex)
5
5
2
4
1
5
5
5
(Casodex)
(Bleomycin Sulfate)
CAPRELSA
5
36
PA, QL:
28 in 28
days
PA, QL:
80 in 30
days
PA
PA, QL:
30 in 30
days
PA, QL:
60 in 30
days
tablet: 300mg
tablet: 100mg
Drug
Tier
Drug Name
carboplatin
CEENU
cisplatin
cladribine
(Paraplatin)
Requirements/Limits
(Cisplatin)
(Leustatin)
2
3
1
2
PA
(PA for Part B vs
Part D Only)
CLOLAR
cyclophosphamide
(Cyclophosphamide)
5
2
PA, ST
cyclophosphamide
(Cytoxan)
2
PA
cytarabine/pf
(Cytarabine/PF)
1
PA
B vs Part D Only)
vial, (PA for Part B
vs Part D Only)
(PA for Part B vs
Part D Only)
dacarbazine
DACOGEN
dactinomycin
daunorubicin hcl
DAUNOXOME
DOCEFREZ
docetaxel
(Dtic-Dome IV)
(Taxotere)
1
5
1
2
4
5
5
docetaxel
(Taxotere)
doxorubicin hcl liposomal (Doxil)
5
5
doxorubicin hcl
DROXIA
ELIGARD
2
3
4
(Cosmegen)
(Cerubidine)
(Adriamycin RDF)
ELIGARD
4
ELIGARD
4
ELIGARD
5
ELSPAR
EMCYT
epirubicin hcl
ERBITUX
ERIVEDGE
3
3
1
4
5
(Ellence)
ERWINAZE
5
37
PA
PA
QL: 1 in
112 days
QL: 1 in
28 days
QL: 1 in
84 days
QL: 1 in
168 days
PA, QL:
30 in 30
days
PA, QL:
60 in 30
days
vial: 20mg/2ml,
20mg/ml(1)
vial: fnl20mg/2
(PA for Part B vs
Part D Only)
vial: 50mg
disp syrin: 30mg
disp syrin: 7.5mg
disp syrin: 22.5mg
disp syrin: 45mg
Drug
Tier
Drug Name
ETOPOPHOS
etoposide
exemestane
FARESTON
FASLODEX
4
2
2
5
5
(Etoposide)
(Aromasin)
FASLODEX
5
FIRMAGON
floxuridine
4
1
fludarabine phosphate
fluorouracil
flutamide
FOLOTYN
gemcitabine hcl
gemcitabine hcl
GLEEVEC
Requirements/Limits
(FUDR)
(Fludara)
(Fluorouracil)
(Flutamide)
5
2
2
5
5
5
5
(Gemzar)
(Gemzar)
disp syrin: 125mg/
2.5
disp syrin: 250mg/
5ml
PA
(PA for Part B vs
Part D Only)
PA
vial: 1g
vial: 200mg
QL: 60 in
30 days
PA, QL:
24 in 28
days
PA
(PA for Part B vs
Part D Only)
HALAVEN
5
HERCEPTIN
5
HEXALEN
hydroxyurea
idarubicin hcl
ifosfamide
(Hydrea)
(Idamycin Pfs)
(Ifex)
5
1
2
2
PA
ifosfamide/mesna
(Ifex-mesnex)
5
PA
INLYTA
5
INLYTA
5
IRESSA
5
PA, QL:
180 in 30
days
PA, QL: tablet: 5mg
60 in 30
days
PA, QL:
30 in 30
days
irinotecan hcl
ISTODAX
(Camptosar)
5
5
38
PA
(PA for Part B vs
Part D Only)
kit: 1g-1g, 3g-1g,
(PA for Part B vs
Part D Only)
tablet: 1mg
Drug
Tier
Drug Name
IXEMPRA
JAKAFI
5
5
JEVTANA
letrozole
LEUKERAN
leuprolide acetate
5
2
4
2
(Femara)
(Lupron)
LUPRON DEPOT
5
LUPRON DEPOT
5
LUPRON DEPOT
5
LUPRON DEPOT
5
LUPRON DEPOT-PED
5
LYSODREN
MATULANE
MEGACE ES
3
5
3
Requirements/Limits
PA, QL:
60 in 30
days
QL: 2 in
28 days
QL: 1 in
112 days
QL: 1 in
168 days
QL: 1 in
28 days
QL: 1 in
84 days
QL: 1 in
28 days
(Megace)
1
melphalan hcl
mercaptopurine
methotrexate sodium
(Alkeran)
(Purinethol)
(Methotrexate Sodium)
5
2
1
PA, ST
methotrexate sodium
(Methotrexate Sodium)
1
PA
methotrexate sodium/pf
(Methotrexate Sodium/PF)
1
PA
mitomycin
mitoxantrone hcl
MUSTARGEN
NEXAVAR
(Mitomycin)
(Novantrone)
1
1
3
5
PA
3
5
39
syringekit: 45mg
syringekit: 3.75mg
syringekit:
11.25mg, 22.5mg
(May be High Risk
Med for Ages 65
and Older)
(May be High Risk
Med for Ages 65
and Older)
megestrol acetate
NILANDRON
ONCASPAR
syringekit: 30mg
PA, QL:
120 in 30
days
B vs Part D Only)
vs Part D Only)
(PA for Part B vs
Part D Only)
Drug
Tier
Drug Name
ONTAK
oxaliplatin
paclitaxel
pentostatin
PROLEUKIN
REVLIMID
5
5
2
5
5
5
(Oxaliplatin)
(Taxol)
(Nipent)
RITUXAN
SPRYCEL
SUTENT
5
5
5
TABLOID
tamoxifen citrate
TARCEVA
3
1
5
TARGRETIN
TASIGNA
thiotepa
topotecan hcl
TORISEL
(Nolvadex)
5
5
2
5
5
(Thiotepa)
(Hycamtin)
TREANDA
TRELSTAR
5
5
TRELSTAR
5
TRELSTAR
5
tretinoin
TREXALL
(Tretinoin)
5
3
TRISENOX
TYKERB
VALSTAR
VANDETANIB
5
5
5
5
VANDETANIB
5
40
Requirements/Limits
LA, QL:
30 in 30
days
PA
PA, QL:
30 in 30
days
PA, QL:
30 in 30
days
PA
(PA for Part B vs
Part D Only)
QL: 1 in
168 days
QL: 1 in
28 days
QL: 1 in
84 days
disp syrin: 22.5mg/
2ml
disp syrin: 3.75mg/
2ml
disp syrin: 11.25/
2ml
PA, ST
(PA for Part B vs
Part D Only)
PA, QL:
30 in 30
days
PA, QL:
60 in 30
days
tablet: 300mg
tablet: 100mg
Drug
Tier
Drug Name
VECTIBIX
VELCADE
VIDAZA
vinblastine sulfate
Requirements/Limits
(Vinblastine Sulfate)
5
5
5
2
PA
vincristine sulfate
(Vincristine Sulfate)
1
PA
vinorelbine tartrate
VOTRIENT
(Navelbine)
1
5
VUMON
XALKORI
4
5
YERVOY
5
ZANOSAR
ZELBORAF
5
5
ZOLADEX
4
ZOLADEX
4
ZOLINZA
ZYTIGA
5
5
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
PA, QL:
120 in 30
days
PA, QL:
60 in 30
days
PA, QL:
30 in 21
days
PA, QL:
240 in 30
days
QL: 1 in implant: 3.6mg
28 days
QL: 1 in implant: 10.8mg
84 days
PA, QL:
120 in 30
days
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
(Amantadine HCl)
APOKYN
AZILECT
benztropine mesylate
(Benztropine Mesylate)
1
5
3
1
PA
benztropine mesylate
2
PA
(Cogentin)
41
tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
ampul, (PA for
Ages 65 and Older;
May be High Risk
Med)
Drug
Tier
Drug Name
bromocriptine mesylate
cabergoline
carbidopa/levodopa
COMTAN
pramipexole di-hcl
ropinirole hcl
ropinirole hcl
selegiline hcl
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
TASMAR
trihexyphenidyl hcl
(Parlodel)
(Cabergoline)
(Sinemet 25-100)
(Mirapex)
(Requip XL)
(Requip)
(Eldepryl)
(Trihexyphenidyl HCl)
42
2
2
1
3
2
2
1
1
3
3
3
3
3
3
3
1
Requirements/Limits
tab er 24h
tablet
PA
(PA for Ages 65 and
Older; May be High
Risk Med)
Drug
Tier
Drug Name
Requirements/Limits
Antiprotozoal Agents
Antiprotozoal Agents
ALINIA
atovaquone/proguanil hcl (Malarone)
atovaquone/proguanil hcl (Malarone)
chloroquine phosphate
(Aralen Phosphate)
COARTEM
DARAPRIM
HALFAN
hydroxychloroquine
(Plaquenil)
sulfate
mefloquine hcl
(Lariam)
MEPRON
metronidazole
(Flagyl)
metronidazole/sodium
(Metro IV)
chloride
paromomycin sulfate
(Paromomycin Sulfate)
pentamidine isethionate
(Pentam 300)
PRIMAQUINE
QUALAQUIN
tinidazole
YODOXIN
4
2
2
1
4
3
3
1
1
5
1
1
1
1
3
4
(Tindamax)
tablet: 250-100mg
tablet: 62.5-25mg
QL: 93 in
31 days
PA, QL:
42 in 30
days
1
3
Antipruritics and Local Anesthetics
Antipruritics and Local Anesthetics
AMERICAINE
ANACAINE
lidocaine
(Lidocaine)
3
3
1
PA
lidocaine/prilocaine
1
PA
(EMLA)
LIDODERM
PRUDOXIN
ZONALON
(PA for ESRD
Only)
(PA for ESRD
Only)
4
4
4
Antiulcer Agents
Antiulcer Agents
CARAFATE
cimetidine hcl
cimetidine in 0.9 % nacl
cimetidine
(Cimetidine HCl)
(Cimetidine In 0.9 % NaCl)
(Tagamet)
43
3
1
1
1
oral susp
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
Drug
Tier
Drug Name
Requirements/Limits
famotidine in nacl,isoosm/pf
famotidine
lansoprazole
(Famotidine In Nacl,iso-osm/PF)
1
(Pepcid)
(Prevacid)
1
2
ST
lansoprazole
(Prevacid)
2
ST
misoprostol
misoprostol
nizatidine
nizatidine
omeprazole
(Cytotec)
(Cytotec)
(Axid)
(Axid)
(Prilosec)
1
1
1
2
1
omeprazole/sodium
bicarbonate
pantoprazole sodium
PROTONIX IV
ranitidine hcl
sucralfate
sucralfate
(Zegerid)
1
(Rx Product Only)
capsule dr, (Rx
Product Only)
tab rap dr, (Rx
Product Only)
tablet: 100mcg
tablet: 200mcg
capsule
solution
capsule dr: 10mg,
20mg, 40mg, (Rx
Product Only)
(Rx Product Only)
(Protonix)
1
4
1
1
2
(Rx Product Only)
tablet
oral susp
(Zantac)
(Carafate)
(Sucralfate)
Antivirals (Systemic)
Antiretrovirals
APTIVUS
APTIVUS
ATRIPLA
COMPLERA
CRIXIVAN
CRIXIVAN
didanosine
EDURANT
EMTRIVA
EPIVIR HBV
EPIVIR
EPZICOM
FUZEON
INTELENCE
INTELENCE
4
5
5
5
4
4
(Videx EC)
2
5
3
4
4
5
5
3
5
INVIRASE
ISENTRESS
5
5
44
solution
capsule
capsule: 100mg
capsule: 200mg,
400mg
solution
tablet: 25mg
tablet: 100mg,
200mg
Drug
Tier
Drug Name
KALETRA
KALETRA
lamivudine
lamivudine/zidovudine
LEXIVA
LEXIVA
nevirapine
NORVIR
PREZISTA
PREZISTA
3
5
(Epivir)
(Combivir)
2
5
3
5
2
4
3
5
(Viramune)
RESCRIPTOR
RETROVIR
REYATAZ
REYATAZ
4
3
3
5
SELZENTRY
stavudine
stavudine
SUSTIVA
SUSTIVA
5
2
2
4
4
TRIZIVIR
TRUVADA
VIDEX
VIRACEPT
VIRACEPT
VIRAMUNE XR
VIRAMUNE
VIREAD
ZERIT
ZIAGEN
zidovudine
zidovudine
(Zerit)
(Zerit)
5
5
3
4
4
3
3
5
4
4
1
2
(Retrovir)
(Retrovir)
45
Requirements/Limits
tablet: 100mg-25mg
solution, tablet:
200mg-50mg
oral susp
tablet
tablet
tablet: 75mg
tablet: 150mg,
400mg, 600mg
vial
capsule: 100mg
capsule: 150mg,
200mg, 300mg
capsule
soln recon
capsule: 100mg
capsule: 50mg,
200mg; tablet
powder
tablet
oral susp
soln recon
syrup
capsule, tablet
Drug
Tier
Drug Name
Antivirals, Miscellaneous
foscarnet sodium
(Foscavir)
1
RELENZA
rimantadine hcl
SYNAGIS
TAMIFLU
4
1
4
3
(Flumadine)
Requirements/Limits
PA
capsule, susp recon:
6mg/ml
Hcv Protease Inhibitors
INCIVEK
5
VICTRELIS
5
Interferons
ALFERON N
INTRON A
5
3
PA
INTRON A
5
PA
INTRON A
5
PA
PEGASYS PROCLICK
PEGASYS
PEGINTRON REDIPEN
PEGINTRON
PEGINTRON
5
5
5
5
5
PA
PA
PA
PA
PA
SYLATRON
5
PA, QL:
1 in 28
days
Nucleosides and Nucleotides
acyclovir sodium
(Acyclovir Sodium)
1
PA
acyclovir
acyclovir
BARACLUDE
BARACLUDE
famciclovir
1
2
4
5
2
(Zovirax)
(Zovirax)
(Famvir)
46
(PA for Part B vs
Part D Only)
PA, QL:
168 in 28
days
PA, QL:
336 in 28
days
pen ij kit: 3mm/
0.2ml; vial: 10mm/
ml
pen ij kit: 5mm/
0.2ml, 10mm/0.2ml;
vial: 6mmunit/ml
vial: 18mmunit,
50mmunit
kit: 50mcg/0.5
kit: 80mcg/0.5,
120mcg/0.5,
150mcg/0.5
(PA for Part B vs
Part D Only)
capsule, tablet
oral susp
solution
tablet
Drug
Tier
Drug Name
ganciclovir sodium
(Cytovene)
1
ganciclovir
ganciclovir
HEPSERA
RIBATAB
(Cytovene)
(Cytovene)
2
5
5
5
ribavirin
ribavirin
(Copegus)
(Ribatab)
2
5
ribavirin
(Ribatab)
5
TYZEKA
valacyclovir hcl
VALCYTE
VALCYTE
VISTIDE
Requirements/Limits
PA
tab ds pk: 600600mg
capsule, tablet
tab ds pk: 200400mg
tab ds pk: 400400mg, 600-400mg
5
2
4
5
5
(Valtrex)
(PA for Part B vs
Part D Only)
capsule: 250mg
capsule: 500mg
soln recon
tablet
Anxiolytics, Sedatives and Hypnotics
Anxiolytics, Sedatives and Hypnotics, Miscellaneous
buspirone hcl
(Buspar)
droperidol
(Inapsine)
glutethimide
(Glutethimide)
hydroxyzine hcl
(Hydroxyzine HCl)
1
1
1
1
PA
hydroxyzine pamoate
(Vistaril)
1
PA
ROZEREM
zaleplon
(Sonata)
3
1
zolpidem tartrate
(Ambien CR)
2
zolpidem tartrate
(Ambien)
1
(Drysol)
1
Astringents
Astringents
aluminum chloride
47
PA, QL:
90 in 365
days
PA, QL:
90 in 365
days
(PA for Ages 65 and
Older; May be High
Risk Med)
(PA for Ages 65 and
Older; May be High
Risk Med)
(PA/QL for Ages 65
and Older; May be
High Risk Med)
tab mphase, (PA/
QL for Ages 65 and
Older; May be High
Risk Med)
PA, QL: tablet, (PA/QL for
days
May be High Risk
Med)
Drug
Tier
Drug Name
XERAC AC
Requirements/Limits
3
Benzodiazepines
Benzodiazepines
alprazolam
(Xanax XR)
1
alprazolam
(Xanax XR)
1
alprazolam
(Xanax)
1
clonazepam
(Klonopin)
1
clonazepam
(Klonopin)
1
clorazepate dipotassium
(Tranxene T-tab)
1
clorazepate dipotassium
(Tranxene T-tab)
1
DIASTAT ACUDIAL
diazepam
diazepam
(Diastat)
(Diazepam)
4
2
1
diazepam
(Valium)
1
estazolam
(Prosom)
1
lorazepam
(Ativan)
1
lorazepam
(Ativan)
1
48
QL: 30 in
30 days
QL: 60 in
30 days
QL: 90 in
30 days
QL: 300
in 30
days
QL: 90 in
30 days
tab er 24h: 0.5mg,
1mg
tab er 24h: 2mg,
3mg
tab rapdis, tablet
tab rapdis: 2mg;
tablet: 2mg
tab rapdis: 0.125mg,
0.25mg, 0.5mg,
1mg; tablet: 0.5mg,
1mg
days
Older; May be High
Risk Med)
60 in 30 7.5mg, (PA for
days
Ages 65 and Older;
May be High Risk
Med)
kit
oral conc, solution,
(PA for Ages 65 and
Older; May be High
Risk Med)
days
May be High Risk
Med)
QL: 30 in
30 days
QL: 2 in disp syrin, vial
30 days
QL: 90 in tablet
30 days
PA, QL:
1200 in
30 days
Drug
Tier
Drug Name
ONFI
4
oxazepam
(Oxazepam)
1
temazepam
(Restoril)
1
triazolam
(Halcion)
1
Requirements/Limits
PA, QL:
60 in 30
days
QL: 120
in 30
days
QL: 30 in
30 days
QL: 30 in
30 days
Beta-Adrenergic Blocking Agents
Beta-Adrenergic Blocking Agents
acebutolol hcl
(Sectral)
atenolol
(Tenormin)
atenolol/chlorthalidone
(Tenoretic 100)
betaxolol hcl
(Kerlone)
bisoprolol fumarate
(Zebeta)
bisoprolol fumarate/hctz
(Ziac)
BYSTOLIC
carvedilol
(Coreg)
COREG CR
DUTOPROL
esmolol hcl
(Brevibloc)
INNOPRAN XL
labetalol hcl
(Trandate)
labetalol hcl
(Trandate)
metoprolol succinate
(Toprol XL)
metoprolol tartrate
(Lopressor)
metoprolol/
(Lopressor HCT)
hydrochlorothiazide
nadolol
(Corgard)
nadolol/
(Corzide)
bendroflumethiazide
pindolol
(Pindolol)
propranolol hcl
(Propranolol HCl)
propranolol/
(Propranolol/hydrochlorothiazid)
hydrochlorothiazid
sotalol hcl
(Betapace)
SOTALOL HCL
timolol maleate
(Timolol Maleate)
Blood Derivatives
Blood Derivatives
49
1
1
1
1
1
1
3
1
3
3
1
4
1
1
1
1
1
1
1
1
1
1
1
4
1
PA
disp syrin
tablet, vial
Drug
Tier
Drug Name
ALBUKED-25
ALBUKED-5
ALBUMIN (HUMAN)
ALBUMINAR-25
ALBUMINAR-5
ALBURX
ALBUTEIN
BUMINATE
FLEXBUMIN
KEDBUMIN
PLASBUMIN-25
PLASBUMIN-5
STERILE DILUENT
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
3
3
3
Calcium-Channel Blocking Agents
Calcium-Channel Blocking Agents, Miscellaneous
diltiazem hcl
(Cardizem CD)
1
diltiazem hcl
verapamil hcl
(Tiazac)
(Calan)
1
1
verapamil hcl
(Verelan)
1
(Norvasc)
(Lotrel)
1
2
(Plendil)
(Dynacirc)
(Nicardipine HCl)
(Procardia XL)
(Nimotop)
(Sular)
4
4
4
4
4
3
3
1
2
1
1
2
2
Dihydropyridines
amlodipine besylate
amlodipine besylate/
benazepril
AZOR
CARDENE I.V.
CARDENE SR
CLEVIPREX
DYNACIRC CR
EXFORGE HCT
EXFORGE
felodipine
isradipine
nicardipine hcl
nifedipine
nimodipine
nisoldipine
50
various dosage and/
or strengths are
available
capsule er: 420mg
cap24h pct, cap24h
pel: 120mg, 180mg,
240mg; tablet, tablet
er, vial
cap24h pel: 360mg;
disp syrin
ST
piggyback
ST
ST
tab er 24, tablet er
Drug
Tier
Drug Name
Requirements/Limits
Caloric Agents
Caloric Agents
AMINO ACIDS
AMINOSYN II 3.5% MDEXTROSE 5%
AMINOSYN II 3.5%DEXTROSE 25%
AMINOSYN II 4.25% MDEXT 10%
AMINOSYN II 5% IN
25% DEXTROSE
AMINOSYN II IN
DEXTROSE
AMINOSYN II with
LYTES-CA-DW
3
3
PA
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
AMINOSYN II with
LYTES-CA-DW
3
PA
AMINOSYN II
3
PA
AMINOSYN II
3
PA
AMINOSYN II
3
PA
AMINOSYN II
3
PA
AMINOSYN M
3
PA
AMINOSYN with
ELECTROLYTES
AMINOSYN
3
PA
3
PA
51
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
iv soln: 3.5%, (PA
Only)
iv soln: 4.25%, (PA
Only)
iv soln: 10%, (PA
Only)
iv soln: 15%, (PA
Only)
iv soln: 7%, (PA
Only)
iv soln: 8.5%, (PA
Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
iv soln: 10%, (PA
Only)
Drug
Tier
Drug Name
Requirements/Limits
AMINOSYN
3
PA
AMINOSYN
3
PA
AMINOSYN
3
PA
AMINOSYN
3
PA
AMINOSYN
3
PA
AMINOSYN-HBC
3
PA
AMINOSYN-HF
3
PA
AMINOSYN-PF
3
PA
AMINOSYN-PF
3
PA
AMINOSYN-RF
3
PA
BRANCHAMIN
3
PA
CLINIMIX E
3
PA
CLINIMIX E
3
PA
CLINIMIX E
3
PA
CLINIMIX
3
PA
52
iv soln: 3.5%, (PA
Only)
iv soln: 5%, (PA
Only)
iv soln: 7%, (PA
Only)
iv soln: 8.5%, (PA
Only)
iv soln: 8.5%, (PA
Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
iv soln: 10%, (PA
Only)
iv soln: 7%, (PA
Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
iv soln: 2.75%, (PA
Only)
iv soln: 4.25%, (PA
Only)
iv soln: 5%, (PA
Only)
iv soln: 2.75%, (PA
Only)
Drug
Tier
Drug Name
Requirements/Limits
CLINIMIX
3
PA
CLINIMIX
3
PA
CLINISOL
3
PA
PA
cysteine hcl
(Cysteine HCl)
1
dextrose 10 % and 0.225
% nacl
dextrose 10 % and 0.225
% nacl
dextrose 10 % and 0.9 %
nacl
dextrose 10%-0.5 normal
saline
dextrose 10%-water
(Dextrose 10 % and 0.225 %
NaCl)
(Dextrose 10 % and 0.225 %
NaCl)
(Dextrose 10 % and 0.9 % NaCl)
1
(Dextrose 10%-0.5 Normal
Saline)
(Dextrose 10%-water)
1
1
PA
dextrose 2.5 %-water
(Dextrose 2.5 %-water)
1
PA
dextrose 2.5%-0.5normal
saline
dextrose 20 % in water
(Dextrose 2.5%-0.5 Normal
Saline)
(Dextrose 20 % in Water)
1
1
PA
dextrose 20%-water
1
PA
dextrose 25%-water
1
PA
dextrose 40%-water
1
PA
nacl
nacl
dextrose 5 %-0.225 %
nacl
dextrose 5 %-0.45 % nacl
dextrose 5 %-water
1
1
(Dextrose 5 %-0.225 % NaCl)
1
(Dextrose 5 %-0.45 % NaCl)
(Dextrose 5 %-water)
1
1
1
53
1
iv soln: 4.25%, (PA
Only)
iv soln: 5%, (PA
Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
iv soln
1
PA
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
Drug
Tier
Drug Name
Requirements/Limits
1
PA
1
PA
ethyl alcohol/d5w
FREAMINE HBC
(Ethyl Alcohol/D5W)
1
3
PA
FREAMINE III with
ELECTROLYTES
FREAMINE III
3
PA
3
PA
FREAMINE III
3
PA
1
PA
HEPATAMINE
3
PA
HEPATASOL
3
PA
INTRALIPID
3
PA
INTRALIPID
3
PA
LIPOSYN II
3
PA
LIPOSYN III
3
PA
LIPOSYN III
3
PA
NEPHRAMINE
3
PA
NOVAMINE
3
PA
PREMASOL
3
PA
fructose 10%
(Fructose 10%)
54
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
iv soln: 10%, (PA
Only)
iv soln: 8.5%, (PA
Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
emulsion: 10%,
(PA for Part B vs
Part D Only)
emulsion: 20%,
30%, (PA for Part
B vs Part D Only)
(PA for Part B vs
Part D Only)
emulsion: 10%,
20%, (PA for Part
B vs Part D Only)
emulsion: 30%,
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
iv soln: 10%, (PA
Only)
Drug
Tier
Drug Name
Requirements/Limits
PREMASOL
3
PA
PROCALAMINE
3
PA
PROSOL
3
PA
QUICK MIX with LYTES
3
PA
RENAMIN
3
PA
TRAVAMULSION
3
PA
TRAVASOL W/
DEXTROSE
TRAVASOL W/
ELECTROLYTES
3
PA
3
PA
TRAVASOL W/
ELECTROLYTES
3
PA
TRAVASOL with
DEXTROSE
3
PA
TRAVASOL with
ELECTROLYTES
TRAVASOL
3
PA
3
PA
TRAVASOL
3
PA
TRAVASOL
3
PA
TRAVERT IN NORMAL
SALINE
TRAVERT
3
PA
3
PA
TRAVERT
3
PA
55
iv soln: 6%, (PA
Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
iv soln.: 5.5%, (PA
Only)
iv soln.: 8.5%, (PA
Only)
iv soln: 8.5%, (PA
Only)
(PA for Part B vs
Part D Only)
iv soln: 10%, (PA
Only)
iv soln: 5.5%, (PA
Only)
iv soln: 8.5%, (PA
Only)
(PA for Part B vs
Part D Only)
iv soln: 10%, (PA
Only)
iv soln: 5%, (PA
Only)
Drug
Tier
Drug Name
Requirements/Limits
TROPHAMINE
3
PA
TROPHAMINE
3
PA
iv soln: 10%, (PA
Only)
iv soln: 6%, (PA
Only)
Cardiac Drugs
Antiarrhythmic Agents
amiodarone hcl
(Amiodarone HCl)
amiodarone hcl
(Cordarone)
disopyramide phosphate
(Norpace)
1
1
1
PA
disopyramide phosphate
(Norpace)
1
PA
flecainide acetate
lidocaine hcl
lidocaine hcl/d5w/pf
(Tambocor)
(Lidocaine HCl)
(Lidocaine HCl/d5w/PF)
1
1
1
lidocaine hcl/pf
(Lidocaine HCl/PF)
mexiletine hcl
(Mexitil)
MULTAQ
procainamide hcl
(Procainamide HCl)
procainamide hcl
(Procainamide HCl)
PRONESTYL
propafenone hcl
(Rythmol)
quinidine gluconate
(Quinidine Gluconate)
quinidine sulfate
(Quinidine Sulfate)
TIKOSYN
Cardiac Drugs, Miscellaneous
digoxin
(Lanoxin)
1
1
3
1
1
3
2
1
1
3
digoxin
1
(Lanoxin)
DIGOXIN
1
3
56
disp syrin
tablet, vial
capsule er, (PA for
Ages 65 and Older;
May be High Risk
Med)
capsule, (PA for
Ages 65 and Older;
May be High Risk
Med)
iv soln: 2mg/ml,
8mg/ml
capsule, tablet sa
vial
PA, QL:
30 in 30
days
PA
PA, QL:
75 in 30
days
tablet, (PAfor Ages
65 and Older; May
be High Risk Med)
ampul, (PA/QL for
Ages 65 and Older;
May be High Risk
Med)
(PA/QL for Ages 65
and Older; May be
High Risk Med)
Drug
Tier
Drug Name
Requirements/Limits
inamrinone lactate
(Inamrinone Lactate)
1
PA
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
tab er 12h: 500mg
milrinone lactate
(Milrinone Lactate)
5
PA
milrinone lactate/d5w
(Primacor in 5% Dextrose)
5
PA
RANEXA
3
RANEXA
3
QL: 120
in 30
days
QL: 60 in tab er 12h: 1000mg
30 days
Cathartics and Laxatives
Cathartics and Laxatives
AMITIZA
3
peg 3350/na sulf,bicarb,cl/ (Colyte with Flavor Packets)
kcl
polyethylene glycol 3350 (Polyethylene Glycol 3350)
sodium chloride/nahco3/ (Nulytely)
kcl/peg
QL: 60 in
30 days
1
1
1
Cell Stimulants and Proliferants
Cell Stimulants and Proliferants
KEPIVANCE
RETIN-A MICRO
tretinoin
(Retin-A)
5
4
1
PA
PA
Central Nervous System Agents, Miscellaneous
Central Nervous System Agents, Miscellaneous
BUTISOL SODIUM
4
BUTISOL SODIUM
4
BUTISOL SODIUM
4
CAMPRAL
CAMPRAL
flumazenil
3
3
1
(Romazicon)
57
PA, QL: tablet: 30mg, (May
120 in 30 be High Risk Med
days
for Ages 65 and
Older)
PA, QL: elixir: 30mg/5ml,
473 in 30 (May be High Risk
days
Med for Ages 65
and Older)
days
for Ages 65 and
Older)
tab ds pk
tablet dr
Drug
Tier
Drug Name
INTUNIV
lithium carbonate
lithium citrate
LODOSYN
LUMINAL SODIUM
4
(Eskalith)
(Lithium Citrate)
1
1
3
4
NAMENDA
3
NAMENDA
3
NAMENDA
3
NUEDEXTA
3
phenobarbital sodium
(Phenobarbital Sodium)
1
phenobarbital
(Phenobarbital)
1
phenobarbital
(Phenobarbital)
1
phenobarbital
(Phenobarbital)
1
phenobarbital
(Phenobarbital)
1
primidone
RILUTEK
SAVELLA
(Mysoline)
1
5
3
STRATTERA
3
58
Requirements/Limits
QL: 30 in
30 days
PA, QL:
2 in 30
days
QL: 360
in 30
days
QL: 49 in
28 days
QL: 62 in
31 days
QL: 60 in
30 days
PA, QL:
2 in 30
days
PA, QL:
1500 in
30 days
disp syrin: 60mg/
ml, 130mg/ml
solution
tab ds pk
tablet
vial: 65mg/ml,
130mg/ml
elixir: 20mg/5ml,
(May be High Risk
Med for Ages 65
and Older)
days
for Ages 65 and
Older)
PA, QL: tablet: 15mg, 60mg,
90 in 30 100mg, (May be
days
High Risk Med for
Ages 65 and Older)
90 in 30 32.4mg, 64.8mg,
days
97.2mg, (May be
High Risk Med for
Ages 65 and Older)
QL: 60 in
30 days
Drug
Tier
Drug Name
XENAZINE
5
XYREM
5
59
Requirements/Limits
PA, QL:
112 in 28
days
LA
Drug
Tier
Drug Name
Requirements/Limits
Contraceptives
Contraceptives
desogestrel-ethinyl
estradiol
desog-et estra/ethin estra
ethinyl estradiol/
drospirenone
ethynodiol d-ethinyl
estradiol
levonorgestrel
levonorgestrel-eth
estradiol
levonorgestrel-eth
estradiol
levonorgestrel-eth
estradiol
l-norgest-eth estr/ethin
estra
l-norgest-eth estr/ethin
estra
noreth a-et estra/fe
fumarate
noreth-ethinyl estradiol/
iron
norethindrone a-e
estradiol
norethindrone
norethindrone-ethinyl
estrad
norethindrone-mestranol
norgestimate-ethinyl
estradiol
norgestrel-ethinyl
estradiol
NUVARING
(Desogen)
1
(Mircette)
(Yaz)
1
2
(Demulen 1-50-21)
1
(Plan B)
(Lybrel)
1
1
(Lybrel)
2
(Seasonale)
1
(Seasonique)
2
(Seasonique)
2
(Loestrin Fe)
1
(Femcon Fe)
2
(Loestrin)
1
(Nor-Q-D)
(Ovcon-35)
1
1
(Ortho-novum)
(Ortho Tri-cyclen)
1
1
(Lo-ovral-28)
1
3
ORTHO EVRA
4
60
tablet: 0.1-0.02,
0.15-0.03, 6-5-10
tablet: 90-20mcg
QL: 91 in
84 days
QL: 91 in
84 days
QL: 91 in
84 days
QL: 1 in
28 days
QL: 3 in
28 days
tbdspk 3mo
tbdspk 3mo: 10020(84)
tbdspk 3mo: 15030(84)
Drug
Tier
Drug Name
Requirements/Limits
Devices
Devices
needles, insulin disp.,
safety
needles, insulin disposable
syring wndl,disp,insul,0.3ml
syring wndl,disp,insul,0.5ml
syringe & needle,insulin,1
ml
(Needles, Insulin Disp., Safety)
1
(Needles, Insulin Disposable)
(Syring W-ndl,disp,insul,0.3ml)
1
1
(Syring W-ndl,disp,insul,0.5ml)
1
(Syringe & Needle,insulin,1 Ml)
1
Diuretics
Diuretics, Miscellaneous
chlorothiazide
(Chlorothiazide)
chlorthalidone
(Chlorthalidone)
hydrochlorothiazide
(Hydrochlorothiazide)
indapamide
(Lozol)
methyclothiazide
(Methyclothiazide)
metolazone
(Zaroxolyn)
SAMSCA
1
1
1
1
1
1
5
SAMSCA
5
Loop Diuretics
bumetanide
(Bumex)
furosemide
(Furosemide)
furosemide
(Lasix)
torsemide
(Demadex)
Potassium-sparing Diuretics
amiloride hcl
(Midamor)
amiloride/
(Amiloride/hydrochlorothiazide)
hydrochlorothiazide
DYRENIUM
triamterene/
(Maxzide-25mg)
hydrochlorothiazid
1
1
1
1
30 days
30 days
disp syrin
solution, tablet, vial
1
1
4
1
EENT Drugs, Miscellaneous
EENT Drugs, Miscellaneous
apraclonidine hcl
(Iopidine)
atropine sulfate
(Isopto Atropine)
carteolol hcl
(Carteolol HCl)
CYCLOGYL
cyclopentolate hcl
(Cyclogyl)
1
1
1
3
1
61
drops: 0.5%
drops: 1%
Drug
Tier
Drug Name
homatropine hbr
IOPIDINE
ipratropium bromide
(Isopto Homatropine)
(Atrovent)
1
4
1
ipratropium bromide
(Atrovent)
1
ISOPTO
HOMATROPINE
LACRISERT
naphazoline hcl
naphazoline hcl/antazoline
phenylephrine hcl
PROPINE
tropicamide
TYZINE
TYZINE
3
(Albalon)
(Naphazoline HCl/antazoline)
(Mydfrin)
(Mydral)
Requirements/Limits
droperette
QL: 15 in spray: 42mcg
10 days
QL: 30 in spray: 21mcg
28 days
drops: 2%
3
1
1
1
3
1
3
3
drops
spray
Enzymes
Enzymes
ADAGEN
ALDURAZYME
CEREDASE
CEREZYME
ELAPRASE
ELITEK
FABRAZYME
KRYSTEXXA
LUMIZYME
MYOZYME
NAGLAZYME
PULMOZYME
5
5
5
5
5
5
5
5
5
5
5
5
VPRIV
XIAFLEX
5
5
62
PA
PA, QL:
1 in 28
days
(PA for Part B vs
Part D Only)
Drug
Tier
Drug Name
Requirements/Limits
Estrogens and Antiestrogens
Estrogens and Antiestrogens
ALORA
4
ANGELIQ
4
PA, QL:
8 in 28
days
PA
CENESTIN
4
PA
COMBIPATCH
3
DEPO-ESTRADIOL
ESTRACE
estradiol valerate
estradiol
(Delestrogen)
(Climara)
4
3
1
1
PA, QL:
8 in 28
days
PA
PA
PA
PA, QL:
4 in 28
days
estradiol
(Estrace)
1
PA
estradiol/noreth ac
(Activella)
1
PA
estradiol/noreth ac
(Activella)
2
PA
ESTRASORB
4
ESTRING
4
PA, QL:
97.44 in
28 days
PA, QL:
1 in 84
days
PA
estropipate
(Ogen)
1
EVISTA
3
63
(PA for Ages 65 and
Older; May be High
Risk Med)
(PA for Ages 65 and
Older; May be High
Risk Med)
(PA for Ages 65 and
Older; May be High
Risk Med)
(PA for Ages 65 and
Older; May be High
Risk Med)
cream/appl
patch tdwk, (PA for
Ages 65 and Older;
May be High Risk
Med)
tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
tablet: 1-0.5mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
tablet: 0.5-0.1mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
(PA for Ages 65 and
Older; May be High
Risk Med)
(PA for Ages 65 and
Older; May be High
Risk Med)
Drug
Tier
Drug Name
FEMHRT
FEMRING
4
4
MENEST
4
norethind ac/ethinyl
estradiol
PREFEST
(Femhrt)
Requirements/Limits
tablet: 0.5mg-2.5
PA, QL:
1 in 84
days
PA
(PA for Ages 65 and
Older; May be High
Risk Med)
2
4
PA
PREMARIN
3
PA
PREMPHASE
3
PA
PREMPRO
3
PA
VAGIFEM
3
VAGIFEM
3
VIVELLE-DOT
3
PA, QL:
18 in 28
days
PA, QL:
8 in 28
days
PA, QL:
8 in 28
days
(PA for Ages 65 and
Older; May be High
Risk Med)
(PA for Ages 65 and
Older; May be High
Risk Med)
(PA for Ages 65 and
Older; May be High
Risk Med)
(PA for Ages 65 and
Older; May be High
Risk Med)
tablet: 10mcg
tablet: 25mcg
(PA for Ages 65 and
Older; May be High
Risk Med)
Genitourinary Smooth Muscle Relaxants
Genitourinary Smooth Muscle Relaxants
DETROL LA
flavoxate hcl
(Urispas)
GELNIQUE
3
2
4
GELNIQUE
4
oxybutynin chloride
OXYTROL
SANCTURA XR
tolterodine tartrate
(Ditropan)
1
4
4
2
(Detrol)
64
QL: 30 in gel packet
30 days
QL: 92 in gel md pmp
30 days
QL: 8 in
28 days
Drug
Tier
Drug Name
TOVIAZ
trospium chloride
VESICARE
Requirements/Limits
3
2
3
(Sanctura)
GI Drugs, Miscellaneous
GI Drugs, Miscellaneous
CHENODAL
5
CIMZIA
5
CREON
lipase/protease/amylase
LOTRONEX
metoclopramide hcl
(Metoclopramide HCl)
3
2
5
1
PA
(Reglan)
1
PA
metoclopramide hcl
(Zenpep)
NUTRESTORE
PANCREAZE
RELISTOR
3
4
4
RELISTOR
4
ursodiol
ZENPEP
(Actigall)
2
3
65
PA, QL:
120 in 30
days
PA, QL:
3 in 28
days
PA, QL:
28 in 28
days
PA, QL:
28 in 28
days
disp syrin, (PA for
Ages 65 and Older;
May be High Risk
Med)
solution, tablet, vial,
(PA for Ages 65 and
Older; May be High
Risk Med)
disp syrin
vial
Drug
Tier
Drug Name
Requirements/Limits
Heavy Metal Antagonists
Heavy Metal Antagonists
BAL IN OIL
CALCIUM DISODIUM
VERSENATE
deferoxamine mesylate
(Desferal)
edetate disodium
(Edetate Disodium)
ENDRATE
EXJADE
EXJADE
FERRIPROX
GALZIN
na nitrite/na thiosul/amyl
nit
sodium thiosulfate
SYPRINE
3
3
1
1
3
3
5
(Na Nitrite/na Thiosul/amyl Nit)
(Sodium Thiosulfate)
PA
tab disper: 125mg
tab disper: 250mg,
500mg
5
4
1
2
5
Hematologic Agents
Anticoagulants
CEPROTIN
citrate-phos-dex solution
enoxaparin sodium
(Citrate-phos-dex Solution)
(Lovenox)
5
1
2
enoxaparin sodium
(Lovenox)
2
enoxaparin sodium
(Lovenox)
2
enoxaparin sodium
(Lovenox)
2
enoxaparin sodium
(Lovenox)
5
enoxaparin sodium
(Lovenox)
5
enoxaparin sodium
(Lovenox)
5
fondaparinux sodium
(Arixtra)
2
66
QL: 13.6
in 30
days
QL: 18 in
30 days
QL: 20.4
in 30
days
QL: 27.2
in 30
days
QL: 27.2
in 30
days
QL: 34 in
30 days
QL: 36 in
30 days
QL: 11.2
in 28
days
disp syrin: 40mg/
0.4ml
disp syrin: 30mg/
0.3ml
disp syrin: 60mg/
0.6ml
disp syrin: 80mg/
0.8ml
disp syrin: 120mg/
.8ml
disp syrin: 150mg/
ml
disp syrin: 100mg/
ml
disp syrin: 10mg/
0.8ml
Drug
Tier
Drug Name
Requirements/Limits
fondaparinux sodium
(Arixtra)
2
fondaparinux sodium
(Arixtra)
2
fondaparinux sodium
(Arixtra)
2
heparin sodium,porcine
(Hep-lock)
1
heparin sodium,porcine/
d5w
heparin sodium,porcine/
ns/pf
heparin sodium,porcine/pf
heparin sodium,porcine/pf
(Heparin Sodium, porcine/D5W)
1
(Heparin Sodium, porcine/ns/PF)
1
(Hep-lock)
(Hep-lock)
1
1
PA
heparin sodium,porcine/pf (Monoject Prefill Advanced)
1
PA
IPRIVASK
5
LOVENOX
3
PRADAXA
4
PA, QL:
24 in 28
days
QL: 36 in vial
30 days
PA, QL:
60 in 30
days
warfarin sodium
XARELTO
(Coumadin)
1
4
Hematologic Agents, Miscellaneous
aminocaproic acid
(Amicar)
aminocaproic acid
(Aminocaproic Acid)
anagrelide hcl
(Agrylin)
LYSTEDA
2
1
2
4
pentoxifylline
protamine sulfate
(Trental)
(Protamine Sulfate)
1
1
tranexamic acid
(Tranexamic Acid)
Platelet-aggregation Inhibitors
2
67
QL: 5.6
in 28
days
QL: 7 in
28 days
QL: 8.4
in 28
days
PA
disp syrin: 5mg/
0.4ml
disp syrin: 2.5mg/
0.5
disp syrin: 7.5mg/
0.6
(PA for ESRD
Only)
vial port
vial, (PA for ESRD
Only)
disp syrin, (PA for
ESRD Only)
PA, QL:
30 in 30
days
solution, tablet
vial
QL: 30 in
30 days
PA
(PA for ESRD
Only)
Drug
Tier
Drug Name
BRILINTA
cilostazol
clopidogrel bisulfate
EFFIENT
4
(Pletal)
(Plavix)
1
1
3
Requirements/Limits
QL: 60 in
30 days
QL: 30 in
30 days
Hematopoietic Agents
Hematopoietic Agents
ARANESP
3
ARANESP
3
ARANESP
3
ARANESP
3
ARANESP
5
ARANESP
5
ARANESP
5
ARANESP
5
ARANESP
5
EPOGEN
3
EPOGEN
5
LEUKINE
5
68
PA, QL:
1.2 in 28
days
PA, QL:
1.6 in 28
days
PA, QL:
1.68 in
28 days
PA, QL:
4 in 28
days
PA, QL:
1.2 in 28
days
PA, QL:
1.6 in 28
days
PA, QL:
2 in 28
days
PA, QL:
2.4 in 28
days
PA, QL:
4 in 28
days
PA, QL:
12 in 28
days
PA, QL:
6 in 28
days
disp syrin: 60mcg/
0.3
disp syrin: 40mcg/
0.4
disp syrin: 25mcg/
0.42
vial: 25mcg/ml,
40mcg/ml, 60mcg/
ml
disp syrin: 150mcg/
0.3
disp syrin: 200mcg/
0.4
disp syrin: 100mcg/
0.5
disp syrin: 300mcg/
0.6
disp syrin: 500mcg/
ml; vial: 100mcg/
ml, 200mcg/ml,
300mcg/ml
vial: 2000/ml, 3000/
ml, 4000/ml, 10000/
ml, 20000/ml
vial: 40000/ml
Drug
Tier
Drug Name
MOZOBIL
5
NEULASTA
NEUMEGA
NEUPOGEN
PROCRIT
5
5
5
3
PROCRIT
5
PROCRIT
5
PROMACTA
5
Requirements/Limits
PA, QL:
9.6 per
fill
PA, QL:
12 in 28
days
PA, QL:
12 in 28
days
PA, QL:
6 in 28
days
PA, QL:
30 in 30
days
vial: 2000/ml, 3000/
ml, 4000/ml, 10000/
ml
vial: 20000/ml
patch tdwk: 0.1mg/
24hr, 0.2mg/24hr
patch tdwk: 0.3mg/
24hr
(PA for Part B vs
Part D Only)
(PA for Ages 65 and
Older; May be High
Risk Med)
vial: 40000/ml
Hypotensive Agents
Hypotensive Agents, Miscellaneous
clonidine hcl
(Catapres)
clonidine hcl/
(Clonidine HCl/chlorthalidone)
chlorthalidone
clonidine
(Catapres-TTS 3)
1
2
clonidine
(Catapres-TTS 3)
2
fenoldopam mesylate
(Corlopam)
1
QL: 4 in
28 days
QL: 8 in
28 days
PA
guanfacine hcl
(Tenex)
1
PA
hydralazine hcl
hydralazine/
hydrochlorothiazid
hydralazine/reserpin/hctz
(Apresoline)
(Hydralazine/
hydrochlorothiazid)
(Hydralazine/reserpin/hctz)
1
1
minoxidil
PROGLYCEM
reserpine
(Minoxidil)
1
3
1
(Reserpine)
69
2
1
PA, QL:
30 in 30
days
(PA/QL for Ages 65
and Older; May be
High Risk Med)
PA, QL:
30 in 30
days
(PA/QL for Ages 65
and Older; May be
High Risk Med)
Drug
Tier
Drug Name
reserpine/
hydrochlorothiazide
(Reserpine/hydrochlorothiazide)
1
Requirements/Limits
PA, QL:
30 in 30
days
(PA/QL for Ages 65
and Older; May be
High Risk Med)
Ion-Removing Agents
Ion-Removing Agents
calcium acetate
(Phoslo)
calcium carbonate/mag
(Calcium Carbonate/mag Carb/
carb/fa
fa)
FOSRENOL
PHOSLYRA
RENAGEL
RENVELA
sodium polystyrene
sulfonate
(Sodium Polystyrene Sulfonate)
2
1
4
4
3
3
powd pack: 2.4g;
tablet
1
Irrigating Solutions
Irrigating Solutions
acetic acid
(Acetic Acid)
glycine
(Aminoacetic Acid)
LACTATED RINGERS
mannitol/sorbitol solution (Mannitol/sorbitol Solution)
ringers solution
(Tis-u-sol)
sod chloride 0.45% irrig. (Sod Chloride 0.45% Irrig. Soln)
soln
sodium chloride irrig
(Sodium Chloride Irrig Solution)
solution
sorbitol solution
(Sorbitol Solution)
UROLOGIC SOLUTION
G
water for irrigation,sterile (Water for Irrigation, Sterile)
1
1
3
1
1
1
1
1
3
1
Keratolytic Agents
Keratolytic Agents
benzoyl peroxide
(Neobenz Micro)
microspheres
benzoyl peroxide
(Acne Medication-5)
benzoyl peroxide/aloe
vera
benzoyl peroxide/
hydrocortison
benzoyl peroxide/urea
potassium hydroxide
1
1
(Benziq)
1
(Benzoyl Peroxide/
hydrocortison)
(Zoderm)
(Potassium Hydroxide)
1
70
1
1
cleanser, gel (gram),
lotion, med. pad
Drug
Tier
Drug Name
salicylic acid
salicylic acid/ammon lact/
aloe
salicylic acid/ceramide
cmb #1
silver nitrate applicator
(Salacyn)
(Salkera)
1
1
(Salex)
1
(Silver Nitrate Applicator)
1
Requirements/Limits
Keratoplastic Agents
Keratoplastic Agents
DRITHO-SCALP
sulfacetamide sodium/urea (Rosula Ns)
3
1
med. pad
Local Anesthetics
Local Anesthetics
aa/antipyrn/bcaine/
polico#1/al
aa/antpy/bcaine/polico/al
acet
AKTEN
antipyrine/benzocaine/
glycerin
benzocaine
chloroprocaine hcl/pf
chloroxylenol/pramoxine
hcl
cocaine hcl
lidocaine hcl
(Auralgan)
2
(Aa/antpy/bcaine/polico/al Acet)
2
(Otra Nr)
4
1
(Omedia Otic)
(Nesacaine-MPF)
(Oticin)
1
1
1
(Cocaine HCl)
(Xylocaine)
2
1
lidocaine hcl
(Xylocaine)
1
PA
lidocaine hcl/pf
(Xylocaine-MPF)
1
PA
mepivacaine hcl/pf
phenylephrine/antipy/bcaine
proparacaine hcl
proparacaine/fluorescein
sod
tetracaine hcl/pf
XYLOCAINE
(Mepivacaine HCl/PF)
(Otogesic)
1
1
(Ophthetic)
(Proparacaine/fluorescein Sod)
1
1
(Tetracaine HCl/PF)
1
1
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
71
jel (ml), jel/pf app,
solution
vial, (PA for ESRD
Only)
ampul, ampul luer,
(PA for ESRD
Only)
vial: 20mg/ml
Drug
Tier
Drug Name
ACTEMRA
5
ACTHAR H.P.
5
ACTIMMUNE
ACTONEL with
CALCIUM
ACTONEL
5
3
ACTONEL
3
ACTONEL
3
3
alendronate sodium
(Fosamax)
1
alendronate sodium
(Fosamax)
1
allopurinol sodium
allopurinol
amifostine crystalline
ammonium chloride
AMPYRA
(Aloprim)
(Zyloprim)
(Ethyol)
(Ammonium Chloride)
1
1
1
1
5
Requirements/Limits
PA, QL:
40 in 30
days
PA, QL:
35 in 28
days
QL: 28 in
28 days
28 days
QL: 31 in tablet: 5mg, 30mg
31 days
28 days
tablet: 5mg, 10mg,
40mg
QL: 4 in tablet: 35mg, 70mg
28 days
PA, QL:
60 in 30
days
ARCALYST
ATELVIA
5
4
AVODART
AVONEX
ADMINISTRATION
PACK
AVONEX
azathioprine sodium
3
5
ST
(Azathioprine Sodium)
5
1
ST
PA
azathioprine
(Imuran)
1
PA
5
PA, QL:
2 in 28
days
BENLYSTA
72
QL: 4 in
28 days
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
Drug
Tier
Drug Name
Requirements/Limits
BERINERT
5
BETASERON
BONIVA
5
3
BONIVA
3
BOTOX
4
BOTOX
4
CELLCEPT
4
PA, QL:
4 in 300
days
ST
PA, QL:
3 in 84
days
QL: 31 in
31 days
PA, QL:
1 in 90
days
PA, QL:
4 in 90
days
PA
CELLCEPT
5
PA
CINRYZE
5
PA, QL:
20 in 28
days
citric acid/sodium citrate
colchicine/probenecid
COLCRYS
COPAXONE
cyclosporine
(Bicitra)
(Colchicine/probenecid)
(Sandimmune)
1
1
3
5
2
PA
cyclosporine
(Sandimmune)
2
PA
cyclosporine, modified
(Neoral)
2
PA
CYSTADANE
dexrazoxane
disulfiram
DUODOTE
DYSPORT
4
1
2
3
4
(Totect)
(Antabuse)
ELMIRON
3
73
PA, QL:
2 in 90
days
disp syrin, (PA for
ESRD Only)
tablet: 2.5mg
vial: 200unit
vial: 100unit
vs Part D Only)
susp recon, (PA for
Part B vs Part D
Only)
capsule, vial, (PA
Only)
solution, (PA for
Part B vs Part D
Only)
(PA for Part B vs
Part D Only)
Drug
Tier
Drug Name
ENBREL
5
ENBREL
5
ENBREL
5
etidronate disodium
EXTAVIA
finasteride
FIRAZYR
FLUORITAB
FLURA-DROPS
fomepizole
FUSILEV
gauze bandage
GILENYA
GLUCAGEN
GLUCAGON
EMERGENCY KIT
gold sodium thiomalate
HUMIRA
(Didronel)
2
5
1
5
4
4
5
5
1
5
(Proscar)
(Antizol)
(Gauze Bandage)
PA, QL:
7.84 in
28 days
PA, QL:
8 in 28
days
PA, QL:
8.16 in
28 days
pen injctr
kit
disp syrin
ST
PA, QL:
28 in 28
days
3
3
(Myochrysine)
1
5
HUMIRA
ibandronate sodium
Requirements/Limits
5
(Boniva)
2
ILARIS
KALBITOR
KINERET
5
5
5
K-PHOS M.F.
K-PHOS NO.2
KUVAN
leflunomide
leucovorin calcium
3
3
5
2
1
(Arava)
(Leucovorin Calcium)
74
PA, QL:
4 in 28
days
PA, QL:
6 in 28
days
QL: 1 in
28 days
PA, QL:
18.76 in
28 days
kit, pen ij kit: 40mg/
0.8ml
pen ij kit: 40mg/
0.8ml, (Starter Kit)
Drug
Tier
Drug Name
Requirements/Limits
levocarnitine (with sugar) (Carnitor)
2
PA
levocarnitine
(Carnitor)
2
PA
mesna
MESNEX
methylene blue
methylergonovine maleate
methylergonovine maleate
mycophenolate mofetil
(Mesnex)
1
5
1
1
1
2
PA
MYFORTIC
4
PA
MYOBLOC
4
NPLATE
5
NULOJIX
5
PA, QL:
1 in 90
days
PA, QL:
8 in 28
days
PA
(Methylene Blue)
(Methergine)
(Methylergonovine Maleate)
(Cellcept)
octreotide acetate
(Sandostatin)
2
octreotide acetate
(Sandostatin)
5
tablet
ORENCIA
5
ORENCIA
5
ORFADIN
pamidronate disodium
(Aredia)
3
1
PA
pamidronate disodium
(Aredia)
2
PA
phosphorus #1
potassium citrate
potassium citrate/citric
acid
(K-phos Neutral)
(Urocit-K)
(Polycitra-k)
1
1
1
75
(PA for ESRD
Only)
(PA for ESRD
Only)
PA, QL:
4 in 28
days
PA, QL:
4 in 28
days
tablet
vial
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
vial: 50mcg/ml,
100mcg/ml,
200mcg/ml
vial: 500mcg/ml,
1000mcg/ml
disp syrin
vial
vial: 60mg/10ml,
90mg/10ml, (PA
for ESRD Only)
vial: 30mg/10ml,
(PA for ESRD
Only)
Drug
Tier
Drug Name
PRALIDOXIME
CHLORIDE
probenecid
PROGRAF
Requirements/Limits
3
(Probenecid)
1
4
PA
PROLIA
4
PROTOPAM CHLORIDE
RAPAMUNE
4
3
PA
RAPAMUNE
5
PA
REBIF
RECLAST
5
4
REMICADE
REVLIMID
5
5
RIDAURA
SANDOSTATIN LAR
SENSIPAR
SENSIPAR
SIMPONI
4
5
3
5
5
SIMULECT
3
SKELID
sod/pot/k cit/sod cit/cit
acid
sodium bicarbonate
sodium fluoride
sodium lactate
SOLIRIS
SOMATULINE DEPOT
ampul, (PA for Part
B vs Part D Only)
PA, QL:
1 in 180
days
solution, tablet:
0.5mg, (PA for Part
B vs Part D Only)
tablet: 1mg, 2mg,
(PA for Part B vs
Part D Only)
QL: 100
in 300
days
PA
LA, QL:
30 in 30
days
tablet: 30mg
tablet: 60mg, 90mg
PA, QL:
0.5 in 28
days
PA
(PA for Part B vs
Part D Only)
4
1
(Polycitra-lc)
(Sodium Bicarbonate)
(Sodium Fluoride)
(Sodium Lactate)
76
1
4
1
5
5
drops, tab chew
QL: 1 in
28 days
Drug
Tier
Drug Name
STELARA
5
STELARA
5
SUPPRELIN LA
5
SUPPRELIN
SYNAREL
tacrolimus
4
5
2
(Prograf)
THALOMID
5
TYSABRI
5
ULORIC
3
VANTAS
4
XEOMIN
4
XGEVA
5
ZAVESCA
ZOMETA
ZOMETA
ZORTRESS
5
4
4
4
ZORTRESS
5
Requirements/Limits
PA, QL: vial
10 in 360
days
PA, QL: disp syrin
5 in 360
days
QL: 1 in
360 days
PA
(PA for Part B vs
Part D Only)
QL: 60 in
30 days
LA, PA,
QL: 15 in
28 days
ST, QL:
31 in 31
days
QL: 1 in
360 days
PA, QL:
2 in 90
days
PA, QL:
1.7 in 28
days
PA, QL:
60 in 30
days
PA, QL:
60 in 30
days
infus. btl
vial
tablet: 0.25mg, (PA
Only)
tablet: 0.5mg,
0.75mg, (PA for
Part B vs Part D
Only)
Opiate Antagonists
Opiate Antagonists
naloxone hcl
(Naloxone HCl)
1
naloxone hcl
1
(Naloxone HCl)
77
ampul, disp syrin:
0.4mg/ml; vial
disp syrin: 1mg/ml
Drug
Tier
Drug Name
naltrexone hcl
(Revia)
Requirements/Limits
1
Parasympathomimetics (Cholinergic Agents)
Parasympathomimetics (Cholinergic Agents)
ARICEPT
3
bethanechol chloride
CHANTIX
2
3
(Urecholine)
CHANTIX
3
donepezil hcl
(Aricept Odt)
2
donepezil hcl
(Aricept)
1
EXELON
4
EXELON
4
galantamine hbr
(Razadyne ER)
2
galantamine hbr
(Razadyne)
2
galantamine hbr
(Razadyne)
2
MESTINON
MYTELASE
neostigmine methylsulfate (Neostigmine Methylsulfate)
NICOTROL NS
4
3
1
4
NICOTROL
4
physostigmine salicylate
pilocarpine hcl
PROSTIGMIN
pyridostigmine bromide
(Physostigmine Salicylate)
(Salagen)
(Mestinon)
78
1
2
3
1
PA, QL:
31 in 31
days
tablet: 23mg
PA, QL:
168 in 84
days
PA, QL:
53 in 28
days
QL: 31 in
31 days
QL: 31 in
31 days
PA, QL:
30 in 30
days
QL: 240
in 31
days
QL: 30 in
30 days
QL: 200
in 30
days
QL: 60 in
30 days
tablet
tab ds pk
tab rapdis
tablet
patch td24
solution
cap24h pel
solution
tablet
syrup, tablet er
QL: 240
in 180
days
QL: 2016
in 365
days
Drug
Tier
Drug Name
REGONOL
rivastigmine tartrate
4
2
(Exelon)
Requirements/Limits
QL: 62 in
31 days
Parathyroid
Parathyroid
calcitonin,salmon,syntheti (Miacalcin)
c
2
FORTEO
4
FORTICAL
3
MIACALCIN
3
QL: 3.7
in 28
days
QL: 3 in
28 days
QL: 3.7
in 28
days
PA
vial, (PA for ESRD
Only)
Pituitary
Pituitary
DDAVP
desmopressin acetate
(DDAVP)
(DDAVP)
(Desmopressin Acetate)
3
1
2
2
(Desmopressin Acetate)
2
GENOTROPIN
3
GENOTROPIN
5
HUMATROPE
NORDITROPIN
FLEXPRO
NORDITROPIN
NORDIFLEX
NORDITROPIN
NUTROPIN AQ NUSPIN
NUTROPIN AQ NUSPIN
NUTROPIN AQ
NUTROPIN
OMNITROPE
5
5
ampul: 15mcg/ml
ampul
tablet
QL: 15 in solution
30 days
QL: 15 in spray/pump
30 days
PA
disp syrin: 0.2mg/
0.25
PA
various dosage and/
or strengths are
available
PA
PA
5
PA
5
5
5
5
5
3
PA
PA
PA
PA
PA
PA
OMNITROPE
5
PA
79
cartridge: 10mg/2ml
cartridge: 5mg/2ml
cartridge: 10mg/
1.5ml
cartridge: 5mg/
1.5ml; vial
Drug
Tier
Drug Name
SAIZEN
SAIZEN
SEROSTIM
STIMATE
TEV-TROPIN
vasopressin
ZORBTIVE
(Pitressin)
Requirements/Limits
5
5
5
4
3
1
5
PA
PA
PA
cartridge, vial: 5mg
vial: 8.8mg
3
QL: 10 in vial: 400mg/ml
28 days
QL: 1 in disp syrin
84 days
QL: 1 in vial
84 days
tablet
PA
PA
Progestins
Progestins
DEPO-PROVERA
medroxyprogesterone
acetate
medroxyprogesterone
acetate
medroxyprogesterone
acetate
norethindrone acetate
progesterone
progesterone,micronized
(Depo-provera)
1
(Depo-provera)
1
(Provera)
1
(Aygestin)
(Progesterone In Oil)
(Prometrium)
1
1
1
Psychotherapeutic Agents
Antidepressants
amitriptyline hcl
(Amitriptyline HCl)
1
amoxapine
bupropion hcl
citalopram hydrobromide
citalopram hydrobromide
(Amoxapine)
(Wellbutrin SR)
(Celexa)
(Celexa)
1
1
1
1
clomipramine hcl
(Anafranil)
1
CYMBALTA
3
CYMBALTA
3
desipramine hcl
doxepin hcl
(Norpramin)
(Doxepin HCl)
2
1
EMSAM
4
80
PA
(PA for Ages 65 and
Older; May be High
Risk Med)
solution
QL: 30 in tablet
30 days
PA
(PA for Ages 65 and
Older; May be High
Risk Med)
QL: 30 in capsule dr: 30mg
30 days
QL: 60 in capsule dr: 20mg,
30 days 60mg
PA
QL: 30 in
30 days
(PA for Ages 65 and
Older; May be High
Risk Med)
Drug
Tier
Drug Name
Requirements/Limits
escitalopram oxalate
fluoxetine hcl
(Lexapro)
(Prozac)
2
1
fluoxetine hcl
fluoxetine hcl
fluvoxamine maleate
imipramine hcl
(Prozac)
(Rapiflux)
(Fluvoxamine Maleate)
(Tofranil)
2
2
1
1
PA
imipramine pamoate
(Tofranil-PM)
2
PA
LEXAPRO
LUVOX CR
maprotiline hcl
MARPLAN
mirtazapine
nefazodone hcl
nortriptyline hcl
paroxetine hcl
paroxetine hcl
PAXIL
perphenazine/
amitriptyline hcl
(Maprotiline HCl)
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Paroxetine HCl)
(Paxil)
(Perphenazine/amitriptyline
HCl)
phenelzine sulfate
PRISTIQ ER
(Nardil)
protriptyline hcl
sertraline hcl
SILENOR
(Vivactil)
(Zoloft)
4
4
1
4
1
1
1
1
1
4
1
1
4
2
1
3
SURMONTIL
4
SYMBYAX
4
tranylcypromine sulfate
trazodone hcl
trimipramine maleate
(Parnate)
(Trazodone HCl)
(Surmontil)
2
1
2
81
capsule, solution,
tablet: 10mg, 20mg
capsule dr
tablet: 60mg
PA
(PA for Ages 65 and
Older; May be High
Risk Med)
(PA for Ages 65 and
Older; May be High
Risk Med)
solution
oral susp
tab er 24h, tablet
oral susp
(PA for Ages 65 and
Older; May be High
Risk Med)
QL: 31 in
31 days
QL: 30 in
30 days
PA
(PA for Ages 65 and
Older; May be High
Risk Med)
QL: 30 in
30 days
PA
(PA for Ages 65 and
Older; May be High
Risk Med)
Drug
Tier
Drug Name
VENLAFAXINE HCL
ER
venlafaxine hcl
venlafaxine hcl
VIIBRYD
Requirements/Limits
2
(Effexor XR)
(Effexor)
2
1
4
Antipsychotic Agents
ABILIFY DISCMELT
3
ABILIFY DISCMELT
3
ABILIFY
3
ABILIFY
3
ABILIFY
3
chlorpromazine hcl
chlorpromazine hcl
clozapine
(Chlorpromazine HCl)
(Chlorpromazine HCl)
(Clozaril)
1
1
1
clozapine
(Clozaril)
1
clozapine
(Clozaril)
1
FANAPT
4
FANAPT
4
FAZACLO
4
82
cap er 24h
tablet
QL: 30 in
30 days
ST, QL:
62 in 31
days
ST, QL:
93 in 31
days
ST, QL:
161.2 in
28 days
ST, QL:
31 in 31
days
ST, QL:
930 in 31
days
QL: 140
in 31
days
QL: 279
in 31
days
QL: 93 in
31 days
ST, QL:
60 in 30
days
ST, QL:
8 in 28
days
ST, QL:
124 in 31
days
tab rapdis: 15mg
tab rapdis: 10mg
vial
tablet
solution
ampul, tablet
oral conc.
tablet: 200mg
tablet: 100mg
tablet: 25mg, 50mg
tablet
tab ds pk
tab rapdis: 200mg
Drug
Tier
Drug Name
FAZACLO
4
FAZACLO
4
fluphenazine decanoate
fluphenazine hcl
GEODON
(Fluphenazine Decanoate)
(Fluphenazine HCl)
haloperidol decanoate
haloperidol lactate
haloperidol
INVEGA SUSTENNA
(Haloperidol Decanoate)
(Haloperidol Lactate)
(Haloperidol)
1
1
4
1
1
1
3
INVEGA SUSTENNA
3
INVEGA SUSTENNA
5
INVEGA SUSTENNA
5
INVEGA SUSTENNA
5
INVEGA
4
INVEGA
4
LATUDA
4
loxapine succinate
MOBAN
NAVANE
olanzapine
ORAP
perphenazine
(Loxitane)
(Zyprexa)
1
4
4
2
(Perphenazine)
4
1
83
Requirements/Limits
ST, QL: tab rapdis: 150mg
186 in 31
days
ST, QL: tab rapdis: 12.5mg,
93 in 31 25mg, 100mg
days
QL: 6 in
28 days
vial
QL: 0.25
in 28
days
QL: 0.5
in 28
days
QL: 0.75
in 28
days
QL: 1 in
28 days
QL: 1.5
in 28
days
ST, QL:
31 in 31
days
ST, QL:
62 in 31
days
ST, QL:
30 in 30
days
disp syrin: 39mg/
0.25
disp syrin: 78mg/
0.5ml
disp syrin: 117mg/
0.75
disp syrin: 156mg/
ml
disp syrin: 234mg/
1.5
tab er 24: 1.5mg,
3mg, 9mg
tab er 24: 6mg
capsule: 20mg
QL: 31 in
31 days
Drug
Tier
Drug Name
quetiapine fumarate
(Seroquel)
2
Requirements/Limits
thioridazine hcl
(Thioridazine HCl)
1
QL: 93 in
31 days
QL: 4 in
28 days
QL: 124
in 31
days
QL: 62 in
31 days
QL: 496
in 31
days
QL: 62 in
31 days
ST, QL:
60 in 30
days
ST, QL:
31 in 31
days
ST, QL:
62 in 31
days
PA
thioridazine hcl
(Thioridazine HCl)
1
PA
thiothixene
trifluoperazine hcl
ziprasidone hcl
(Navane)
(Trifluoperazine HCl)
(Geodon)
1
1
2
RISPERDAL CONSTA
4
risperidone
(Risperdal M-tab)
2
risperidone
(Risperdal M-tab)
2
risperidone
(Risperdal)
1
risperidone
(Risperdal)
1
SAPHRIS
4
SEROQUEL XR
4
SEROQUEL XR
4
ZYPREXA RELPREVV
5
ZYPREXA
4
84
tab rapdis: 3mg,
4mg
tab rapdis: 0.25mg,
0.5mg, 1mg, 2mg
solution
tablet
tab er 24h: 200mg
tab er 24h: 50mg,
150mg, 300mg,
400mg
oral conc., (PA for
Ages 65 and Older;
May be High Risk
Med)
tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
QL: 62 in
31 days
QL: 2 in
28 days
QL: 31 in vial
31 days
Drug
Tier
Drug Name
Requirements/Limits
Renin-Angiotensin-Aldosterone System Inhibitors
Angiotensin II Receptor Antagonists
BENICAR HCT
BENICAR
DIOVAN HCT
DIOVAN
eprosartan mesylate
(Teveten)
irbesartan
(Avapro)
irbesartan/
(Avalide)
hydrochlorothiazide
losartan potassium
(Cozaar)
losartan/
(Hyzaar)
hydrochlorothiazide
MICARDIS HCT
MICARDIS
TEVETEN HCT
TEVETEN
TRIBENZOR
Angiotensin-Converting Enzyme Inhibitors
benazepril hcl
(Lotensin)
benazepril/
(Lotensin HCT)
hydrochlorothiazide
captopril
(Capoten)
captopril/
(Capozide)
hydrochlorothiazide
enalapril maleate
(Vasotec)
enalapril/
(Vaseretic)
hydrochlorothiazide
enalaprilat dihydrate
(Enalaprilat Dihydrate)
fosinopril sodium
(Monopril)
fosinopril/
(Monopril HCT)
hydrochlorothiazide
lisinopril
(Zestril)
lisinopril/
(Prinzide)
hydrochlorothiazide
moexipril hcl
(Univasc)
moexipril/
(Uniretic)
hydrochlorothiazide
perindopril erbumine
(Aceon)
quinapril hcl
(Accupril)
quinapril/
(Accuretic)
hydrochlorothiazide
85
3
3
4
4
2
2
2
ST
ST
ST
ST
1
1
4
4
4
4
4
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
ST
ST
ST
ST
ST
tablet: 400mg
Drug
Tier
Drug Name
ramipril
(Altace)
trandolapril
(Mavik)
trandolapril/verapamil hcl (Trandolapril/verapamil HCl)
Renin-Angiotensin-Aldosterone System Inhibitors
AMTURNIDE
eplerenone
(Inspra)
spironolact/
(Aldactazide)
hydrochlorothiazid
spironolactone
(Aldactone)
TEKAMLO
TEKTURNA HCT
TEKTURNA
VALTURNA
Requirements/Limits
1
1
1
4
2
1
1
4
4
4
4
ST
ST
ST
ST
ST
Replacement Preparations
Replacement Preparations
0.9 % sodium chloride
(0.9 % Sodium Chloride)
calcium chloride
(Calcium Chloride)
calcium gluconate
(Calcium Gluconate)
dex 2.5%-half str
(Dex 2.5%-half Str Lact.ringers)
lact.ringers
dextrose 2.5% in half
(Dextrose 2.5% In Half Ringers)
ringers
dextrose 5% in ringers
(Dextrose 5% In Ringers)
dextrose 5%-lactated
(Dextrose 5%-Lactated Ringers)
ringers
DEXTROSE W/
ELECTROLYTE A
DEXTROSE W/
ELECTROLYTE B
EFFER-K
electrolyte-48 solution/
(Electrolyte-48 Solution/d10w)
d10w
(Electrolyte-48 Solution/D5W)
d5w
electrolyte-48/fructose
(Electrolyte-48/fructose 10%)
10%
electrolyte-48/fructose 5% (Electrolyte-48/fructose 5%)
(Electrolyte-75 Solution/D5W)
d5w
electrolyte-75/fructose 5% (Electrolyte-75/fructose 5%)
electrolyte-r solution/d5w (Normosol-r and Dextrose)
HYPERLYTE CR
HYPERLYTE R
86
1
1
1
1
1
1
1
3
3
4
1
1
1
1
1
1
1
3
3
PA
Drug
Tier
Drug Name
IONOSOL B with
DEXTROSE 5%
IONOSOL MBDEXTROSE 5%
IONOSOL T-DEXTROSE
5%
ISOLYTE E
ISOLYTE H W/
DEXTROSE
ISOLYTE M W/
DEXTROSE
ISOLYTE P with
DEXTROSE
ISOLYTE S with
DEXTROSE
ISOLYTE S
LACTATED RINGERS
NORMOSOL-M and
DEXTROSE
NORMOSOL-R PH 7.4
NUTRILYTE II
NUTRILYTE
PLASMA-LYTE 148
PLASMA-LYTE 56 IN
DEXTROSE
PLASMA-LYTE A PH
7.4
PLASMA-LYTE M IN
DEXTROSE
pot chloride/pot bicarb/cit
ac
potassium acetate
potassium bicarbonate/cit
ac
potassium chlorid/d100.2%nacl
potassium chlorid/d50.225nacl
potassium chlorid/d50.225nacl
potassium chloride in
0.9%nacl
Requirements/Limits
3
3
3
3
3
3
3
3
3
4
3
3
3
3
3
3
3
3
(K-lyte-cl)
1
(Potassium Acetate)
(K-lyte)
1
1
(Potassium Chlorid/d100.2%NaCl)
(Potassium Chlorid/d50.225NaCl)
(Potassium Chlorid/d50.225NaCl)
(Potassium Chloride In
0.9%NaCl)
1
87
1
1
1
iv soln: 10meq/l,
30meq/l, 40meq/l
iv soln: 20meq/l
Drug
Tier
Drug Name
potassium chloride
(Kaochlor)
1
potassium chloride
(K-dur)
1
potassium chloride/d50.25ns
potassium chloride/d50.33nacl
potassium chloride/d50.45nacl
potassium chloride/d50.9%nacl
potassium chloride/d5lr
potassium chloride/d5w
potassium chloride/d5w
(Potassium Chloride/D5-0.25
NS)
(Potassium Chloride/d50.33NaCl)
(Potassium Chloride/d50.45NaCl)
(Potassium Chloride/d50.9%NaCl)
(Potassium Chloride/D5 LR)
(Potassium Chloride/D5W)
(Potassium Chloride/D5W)
1
potassium chloride-0.45%
nacl
potassium gluconate
potassium phos,m-basic-dbasic
ringers solution
sodium acetate
sodium chloride 0.45 %
sodium chloride 3%
sodium chloride 5%
sodium chloride
sodium chloride
sodium phos,m-basic-dbasic
TPN ELECTROLYTES
TRAVERTELECTROLYTE NO.1
(Potassium Chloride-0.45%
NaCl)
(Potassium Gluconate)
(Potassium Phos,m-basic-dbasic)
(Ringers Solution)
(Sodium Acetate)
(Sodium Chloride 0.45 %)
(Sodium Chloride 3%)
(Sodium Chloride 5%)
(Sodium Chloride)
(Sodium Chloride)
(Sodium Phos,m-basic-d-basic)
1
Requirements/Limits
liquid, packet, tablet
sa
capsule er,
piggyback, tab er
prt, tablet er, vial
1
1
1
1
1
1
iv soln: 10meq/l
iv soln: 20meq/l,
30meq/l, 40meq/l
1
1
1
1
1
1
1
1
1
1
iv soln
vial
3
3
3
iv soln: 10%
3
iv soln: 5%
3
3
Respiratory Tract Agents, Miscellaneous
88
Drug
Tier
Drug Name
Respiratory Tract Agents, Miscellaneous
acetylcysteine
(Acetylcysteine)
1
aminophylline
aminophylline
ARALAST
DALIRESP
(Aminophylline)
(Aminophylline)
1
1
5
3
guaifen/theop anhyd/pephed
KALYDECO
(Guaifen/theop Anhyd/p-ephed)
PROLASTIN C
PROLASTIN
theophylline anhydrous
(Theochron)
5
5
1
theophylline anhydrous
(Theochron)
1
theophylline/d5w
XOLAIR
(Theophylline/D5W)
1
5
5
89
PA
(PA for Part B vs
Part D Only)
liquid, tablet
vial
ST, QL:
30 in 30
days
1
5
ZEMAIRA
Requirements/Limits
PA, QL:
60 in 30
days
elixir, tab er 12h:
100mg, 200mg,
300mg, 450mg;
tablet er
solution, tab er 12h:
200mg
PA, QL:
6 in 28
days
Drug
Tier
Drug Name
Requirements/Limits
Sclerosing Agents
Sclerosing Agents
ethanolamine oleate
(Ethanolamine Oleate)
sodium morrhuate
(Sodium Morrhuate)
sodium tetradecyl sulfate (Sodium Tetradecyl Sulfate)
1
1
1
Serums
Serums
ANASCORP
ANTIVENIN
LATRODECTUS
MACTANS
ANTIVENIN
MICRURUS FULVIUS
CARIMUNE NF
NANOFILTERED
CROFAB
CYTOGAM
DIGIBIND
DIGIFAB
FLEBOGAMMA DIF
5
3
5
5
PA
(PA for Part B vs
Part D Only)
5
5
3
3
5
PA
FLEBOGAMMA
5
PA
GAMMAGARD LIQUID
5
PA
GAMMAPLEX
5
PA
GAMUNEX-C
5
PA
HIZENTRA
5
PA
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
HYPERRAB S-D
HYPERRHO S-D
IMOGAM RABIES-HT
MICRHOGAM PLUS
OCTAGAM
3
3
3
3
5
PA
PRIVIGEN
5
PA
RHOGAM PLUS
RHOPHYLAC
3
3
90
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
Drug
Tier
Drug Name
VIVAGLOBIN
5
WINRHO SDF
3
Requirements/Limits
PA
(PA for Part B vs
Part D Only)
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
(Baclofen)
carisoprodol
(Soma)
1
1
carisoprodol
(Soma)
1
chlorzoxazone
(Parafon Forte DSC)
1
chlorzoxazone/
acetaminophen
(Chlorzoxazone/acetaminophen)
1
cyclobenzaprine hcl
(Flexeril)
1
dantrolene sodium
dantrolene sodium
metaxalone
(Dantrium)
(Dantrium)
(Skelaxin)
1
2
1
methocarbamol
(Robaxin-750)
1
tizanidine hcl
tizanidine hcl
(Zanaflex)
(Zanaflex)
1
2
days
Older; May be High
Risk Med)
days
Older; May be High
Risk Med)
PA
(PA for Ages 65 and
Older; May be High
Risk Med)
PA
(PA for Ages 65 and
Older; May be High
Risk Med)
PA
tablet: 5mg, 10mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
vial
capsule
PA
(PA for Ages 65 and
Older; May be High
Risk Med)
PA
(PA for Ages 65 and
Older; May be High
Risk Med)
tablet
capsule
Skin and Mucous Membrane Agents, Miscellaneous
Skin and Mucous Membrane Agents, Miscellaneous
8-MOP
adapalene
AMEVIVE
ammonium lactate
AZELEX
3
2
5
(Differin)
(Lac-hydrin)
1
4
91
PA, QL:
4 in 28
days
Drug
Tier
Drug Name
calcipotriene
calcipotriene
calcitriol
CARAC
CONDYLOX
DIFFERIN
DOVONEX
ELIDEL
EPIDUO
FLUOROPLEX
fluorouracil
fluorouracil
imiquimod
isotretinoin
LEVULAN
METVIXIA
OXSORALEN
OXSORALEN-ULTRA
PANRETIN
PICATO
(Calcipotriene)
(Dovonex)
(Vectical)
1
2
2
3
4
4
3
3
4
3
2
2
2
(Efudex)
(Efudex)
(Aldara)
(Accutane)
2
3
3
4
5
5
4
PICATO
podofilox
podophyllum resin
PROTOPIC
RECTIV
Requirements/Limits
4
(Condylox)
(Pododerm)
2
2
4
4
REGRANEX
4
SANTYL
SORIATANE
3
5
SORIATANE
STELARA
5
5
92
oint. (g)
solution
gel (gram)
gel (gram): 0.3%;
lotion
cream
PA
cream (g)
solution
PA, QL:
24 in 30
days
PA, QL:
2 in 56
days
PA, QL:
3 in 56
days
gel (ea): 0.05%
gel (ea): 0.015%
PA
QL: 30 in
30 days
PA, QL:
30 in 30
days
capsule: 10mg,
17.5mg, 25mg
capsule: 22.5mg
PA, QL:
10 in 360
days
Drug
Tier
Drug Name
TACLONEX SCALP
TACLONEX
TARGRETIN
TAZORAC
UVADEX
ZYCLARA
3
2
5
3
4
3
Requirements/Limits
PA, QL:
28 in 28
days
Somatotropin Agonists and Antagonists
Somatotropin Agonists and Antagonists
INCRELEX
SOMAVERT
5
5
Sympatholytic Adrenergic Blocking Agents
alfuzosin hcl
(Uroxatral)
dihydroergotamine
(D.H.E. 45)
mesylate
ergotamine tartrate/
(Ergotamine Tartrate/caffeine)
caffeine
phentolamine mesylate
(Phentolamine Mesylate)
PHENTOLAMINE
MESYLATE
tamsulosin hcl
(Flomax)
2
2
1
2
2
PA
PA
1
Sympathomimetic (Adrenergic) Agents
Sympathomimetic (Adrenergic) Agents
albuterol sulfate
(Accuneb)
1
albuterol sulfate
albuterol sulfate
albuterol
COMBIVENT
RESPIMAT
COMBIVENT
(Proventil)
(Vospire ER)
(Ventolin)
1
2
1
3
dobutamine hcl
(Dobutamine HCl)
2
dobutamine hcl/d5w
(Dobutamine HCl/D5W)
1
3
93
PA
solution, vial-neb:
0.63mg/3ml,
1.25mg/3ml, 2.5mg/
3ml, (PA for Part B
vs Part D Only)
syrup, tablet
tab er 12h
QL: 8 in
30 days
QL: 29.4
in 30
days
PA
(PA for Part B vs
Part D Only)
PA
(PA for Part B vs
Part D Only)
Drug
Tier
Drug Name
Requirements/Limits
dopamine hcl
(Dopamine HCl)
1
PA
dopamine hcl/d5w
(Dopamine HCl/D5W)
1
PA
ephedrine sulfate
epinephrine
(Ephedrine Sulfate)
(Adrenaclick)
1
2
epinephrine
(Epinephrine)
1
epinephrine/pf
EPIPEN JR
(Epinephrine/PF)
1
4
QL: 2 in
30 days
4
FORADIL
3
isoproterenol hcl
(Isoproterenol HCl)
MAXAIR AUTOHALER
1
4
metaproterenol sulfate
midodrine hcl
NEO-SYNEPHRINE
norepinephrine bit/0.9 %
nacl
norepinephrine bitartrate
(Metaproterenol Sulfate)
(Proamatine)
1
2
4
1
PA
1
PA
phenylephrine hcl
phenylephrine tannate
PROAIR HFA
(Phenylephrine HCl)
(Phenylephrine Tannate)
SEREVENT DISKUS
terbutaline sulfate
VENTOLIN HFA
1
1
3
3
(Brethine)
1
4
disp syrin: 0.3mg/
0.3; pen injctr
disp syrin: 0.1mg/
ml
QL: 2 in
30 days
QL: 2 in
30 days
QL: 62 in
31 days
EPIPEN
(Norepinephrine Bit/0.9 %
NaCl)
(Norepinephrine Bitartrate)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
QL: 14 in
30 days
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
QL: 17 in
25 days
QL: 62 in
31 days
QL: 36 in
25 days
Thyroid and Antithyroid Agents
Thyroid and Antithyroid Agents
levothyroxine sodium
(Levothyroxine Sodium)
levothyroxine sodium
(Synthroid)
liothyronine sodium
(Cytomel)
methimazole
(Tapazole)
methimazole
(Tapazole)
propylthiouracil
(Propylthiouracil)
94
2
1
1
1
1
1
vial
tablet
tablet: 20mg
tablet: 5mg, 10mg
Drug
Tier
Drug Name
Requirements/Limits
Toxoids
Toxoids
ADACEL
ADACEL
BOOSTRIX
DAPTACEL
DIPHTHERIATETANUS TOXOID
INFANRIX PF
INFANRIX
TE ANATOXAL BERNA
3
3
3
3
3
3
3
3
TENIVAC
TETANUS DIPHTHERIA
TOXOIDS
TETANUS-DIPHTERIADECAVAC
TRIHIBIT
TRIPEDIA
disp syrin
vial
PA
(PA for Part B vs
Part D Only)
3
3
3
3
3
Urinary Anti-infectives
Urinary Anti-infectives
methenamine mandelate
(Mandelamine)
methenamine mandelate
(Mandelamine)
nitrofurantoin
(Macrobid)
macrocrystal
1
2
1
trimethoprim
1
(Trimethoprim)
tablet: 500mg
tablet: 1g
PA, QL: (PA/QL for Ages 65
90 in 365 and Older; May be
days
High Risk Med)
Vaccines
Vaccines
ACTHIB
ATTENUVAX
VACCINE with
DILUENT
BCG VACCINE (TICE
STRAIN)
BIOTHRAX
CERVARIX
CERVARIX
COMVAX
ENGERIX-B
3
3
PA
(PA for Part B vs
Part D Only)
3
PA
(PA for Part B vs
Part D Only)
3
4
4
3
3
GARDASIL
4
95
disp syrin
vial
PA
(PA for Part B vs
Part D Only)
disp syrin
Drug
Tier
Drug Name
Requirements/Limits
GARDASIL
HAVRIX
4
3
IPOL
IXIARO
JE-VAX
KINRIX
MENACTRA
MENACTRA
MENOMUNE-A-C-Y-W135
MENVEO A-C-Y-W-135DIP
MERUVAX II VACCINE
W-DILUENT
M-M-R II VACCINE
MUMPSVAX VACCINE
W-DILUENT
PEDIARIX
PEDVAXHIB
PENTACEL
PROQUAD
RABAVERT
3
3
3
3
3
3
3
3
3
3
4
3
PA
RECOMBIVAX HB
RECOMBIVAX HB
3
3
PA
PA
RECOMBIVAX HB
3
PA
ROTARIX
ROTATEQ
THERACYS
3
3
3
PA
TWINRIX
TWINRIX
TYPHIM VI
VAQTA
3
3
3
3
(PA for Part B vs
Part D Only)
disp syrin
vial
PA
VAQTA
3
PA
disp syrin, (PA for
Part B vs Part D
Only)
vs Part D Only)
VARIVAX VACCINE
3
PA
vial
(PA for Part B vs
Part D Only)
disp syrin
vial
3
3
3
3
96
(PA for Part B vs
Part D Only)
disp syrin
disp syrin, (PA for
Part B vs Part D
Only)
vs Part D Only)
Drug
Tier
Drug Name
YF-VAX
ZOSTAVAX
Requirements/Limits
3
3
Vasodilating Agents
Vasodilating Agents
ADCIRCA
5
AGGRENOX
3
alprostadil
amyl nitrite
epoprostenol sodium
(glycine)
(Alprostadil)
(Amyl Nitrite)
(Flolan)
2
1
2
epoprostenol sodium
(glycine)
(Flolan)
5
isosorbide dinitrate
isosorbide mononitrate
(Isordil)
(Imdur)
1
1
isosorbide mononitrate
ISOVEX
LETAIRIS
(Ismo)
1
3
5
NITRO-BID
nitroglycerin
(Nitro-dur)
3
1
nitroglycerin
(Nitro-dur)
1
nitroglycerin
nitroglycerin
nitroglycerin/d5w
NITROSTAT
nylidrin hcl
papaverine hcl
REMODULIN
(Nitroglycerin)
(Nitrolingual)
(Nitroglycerin/D5W)
1
2
1
3
1
1
5
(Nylidrin HCl)
(Papaverine HCl)
REVATIO
5
97
PA, QL:
60 in 30
days
QL: 60 in
30 days
PA
PA
PA
vial: 0.5mg, (PA
Only)
vial: 1.5mg, (PA
Only)
tab er 24h, tablet:
20mg
tablet: 10mg
PA, QL:
30 in 30
days
QL: 30 in patch td24: 0.1mg/
30 days hr, 0.2mg/hr, 0.6mg/
hr
QL: 60 in patch td24: 0.4mg/
30 days hr
vial
spray
tablet: 12mg
PA
PA
PA, QL:
37.5 in 1
day
(PA for Part B vs
Part D Only)
vial
Drug
Tier
Drug Name
REVATIO
5
TRACLEER
5
Requirements/Limits
PA, QL: tablet
90 in 30
days
LA, PA,
QL: 60 in
30 days
Vitamins and Minerals
Vitamins and Minerals
calcitriol
(Rocaltrol)
1
PA
(PA for ESRD
Only)
FLUOR-A-DAY
fluoride/iron/vit a,c&d
FLURA
HECTOROL
4
4
4
3
PA
(PA for ESRD
Only)
LOZI-FLUR
multivitamins with
fluoride
ped mv a,c,d3 #21 wfluoride
pnv with ca,no.72/iron/fa
sodium fluoride
sodium fluoride
ZEMPLAR
(Fluoride/iron/vit A,c&d)
(Multivitamins with Fluoride)
4
4
(Ped Mv A,c,d3 #21 W-fluoride)
4
(Pnv with Ca,no.72/iron/fa)
3
(Luride)
(Luride)
4
4
4
98
PA
(All Pre-Natal
Vitamins are
Covered)
drops
tab chew
(PA for ESRD
Only)
INDEX
0.9 % sodium chloride ....... 86
8-MOP................................ 91
aa/antipyrn/bcaine/polico#1/
al .................................... 71
aa/antpy/bcaine/polico/al
acet ................................. 71
ABELCET.......................... 26
ABILIFY ............................ 82
ABILIFY DISCMELT ....... 82
ABRAXANE ..................... 36
acarbose ............................. 21
acebutolol hcl ..................... 49
acetaminophen with codeine 5
acetaminophen/phenyltolx cit
.......................................... 3
acetazolamide .................... 27
acetazolamide sodium ........ 27
acetic ac/ricinoleic/oxyquinol
........................................ 31
acetic acid .................... 28, 70
acetic acid/aluminum acetate
........................................ 28
acetic acid/hydrocortisone . 28
acetylcysteine ..................... 89
ACTEMRA ........................ 72
ACTHAR H.P. ................... 72
ACTHIB ............................. 95
ACTIMMUNE ................... 72
ACTONEL ......................... 72
ACTONEL with CALCIUM
........................................ 72
ACTOPLUS MET ............. 25
ACTOPLUS MET XR ....... 25
ACTOS .............................. 25
ACUFLEX ........................... 3
acyclovir ............................. 46
acyclovir sodium ................ 46
ADACEL ........................... 95
ADAGEN ........................... 62
adapalene ........................... 91
ADCETRIS ........................ 36
ADCIRCA .......................... 97
ADVAIR DISKUS ............... 1
ADVAIR HFA ..................... 1
ADVICOR .......................... 35
AEROBID-M ....................... 1
AFINITOR ......................... 36
AGGRENOX ..................... 97
A-HYDROCORT ................. 1
AKTEN .............................. 71
ALBENZA ......................... 13
ALBUKED-25 ................... 50
ALBUKED-5 ..................... 50
ALBUMIN HUMAN ......... 50
ALBUMINAR-25 .............. 50
ALBUMINAR-5 ................ 50
ALBURX ........................... 50
ALBUTEIN ........................ 50
albuterol ............................. 93
albuterol sulfate.................. 93
alclometasone dipropionate
........................................ 33
alcohol antiseptic pads ....... 31
ALDURAZYME ................ 62
alendronate sodium ............ 72
ALFERON N...................... 46
alfuzosin hcl........................ 93
ALIMTA ............................ 36
ALINIA .............................. 43
allopurinol .......................... 72
allopurinol sodium ............. 72
ALOCRIL........................... 33
ALOMIDE ......................... 13
ALORA .............................. 63
ALOXI ............................... 25
ALPHAGAN P ................... 27
alprazolam.......................... 48
alprostadil .......................... 97
ALREX............................... 31
ALTABAX ......................... 30
ALTOPREV ....................... 35
aluminum chloride.............. 47
I-1
ALVESCO ........................... 1
amantadine hcl .................. 41
amcinonide......................... 33
AMERICAINE .................. 43
AMEVIVE ......................... 91
amifostine crystalline ......... 72
amikacin sulfate ................. 13
amiloride hcl ...................... 61
amiloride/
hydrochlorothiazide ....... 61
AMINO ACIDS ................. 51
aminocaproic acid ............. 67
aminophylline .................... 89
AMINOSYN ................ 51, 52
AMINOSYN II .................. 51
AMINOSYN II 3.5% MDEXTROSE 5% ............ 51
AMINOSYN II 3.5%DEXTROSE 25% .......... 51
AMINOSYN II 3.5%DEXTROSE 5% ............ 51
AMINOSYN II 4.25% MDEXT 10% .................... 51
AMINOSYN II 4.25%DEXTROSE 25% .......... 51
AMINOSYN II 5% IN 25%
DEXTROSE .................. 51
AMINOSYN II IN
DEXTROSE .................. 51
AMINOSYN II with LYTESCA-DW .......................... 51
AMINOSYN M ................. 51
AMINOSYN with
ELECTROLYTES ......... 51
AMINOSYN-HBC ............ 52
AMINOSYN-HF ............... 52
AMINOSYN-PF ................ 52
AMINOSYN-RF ............... 52
amiodarone hcl .................. 56
AMITIZA .......................... 57
amitriptyline hcl ................. 80
amlodipine besylate ........... 50
amlodipine besylate/
benazepril ....................... 50
amlodipine/atorvastatin ..... 35
ammonium chloride ........... 72
ammonium lactate .............. 91
amoxapine .......................... 80
amoxicillin.......................... 16
amoxicillin/potassium clav. 16
amphet asp/amphet/d-amphet
........................................ 11
amphotericin b ................... 26
ampicillin sodium ............... 16
ampicillin sodium/sulbactam
na.................................... 16
ampicillin trihydrate .......... 16
AMPYRA .......................... 72
AMTURNIDE.................... 86
amyl nitrite ......................... 97
ANACAINE ....................... 43
ANADROL-50 ................... 10
anagrelide hcl .................... 67
ANASCORP ...................... 90
anastrozole ......................... 36
ANDRODERM .................. 10
ANDROGEL...................... 10
ANGELIQ .......................... 63
antipyrine/benzocaine/
glycerin .......................... 71
ANTIVENIN
LATRODECTUS
MACTANS .................... 90
ANTIVENIN MICRURUS
FULVIUS ....................... 90
APEXICON E .................... 33
APOKYN ........................... 41
apraclonidine hcl ............... 61
APRISO ............................. 32
APTIVUS ........................... 44
ARALAST ......................... 89
ARANESP ......................... 68
ARCALYST ...................... 72
ARICEPT ........................... 78
ARRANON ........................ 36
ARZERRA ......................... 36
ASACOL ............................ 32
ASACOL HD ..................... 32
ASMANEX .......................... 1
ASTEPRO .......................... 13
ATELVIA........................... 72
atenolol ............................... 49
atenolol/chlorthalidone ...... 49
atorvastatin calcium ........... 35
atovaquone/proguanil hcl .. 43
ATRIPLA ........................... 44
atropine sulfate............. 19, 61
ATROVENT HFA ............. 19
ATTENUVAX VACCINE
with DILUENT .............. 95
AVANDAMET .................. 25
AVANDARYL................... 25
AVANDIA ......................... 25
AVASTIN .......................... 36
AVC ................................... 31
AVELOX ........................... 18
AVELOX ABC PACK....... 18
AVELOX IV ...................... 18
AVODART ........................ 72
AVONEX ........................... 72
AVONEX
ADMINISTRATION
PACK ............................. 72
AXERT............................... 35
AXIRON ............................ 10
AZACTAM-ISO-OSMOTIC
DEXTROSE ................... 16
AZASITE ........................... 28
azathioprine........................ 72
azathioprine sodium ........... 72
azelastine hcl ...................... 13
AZELEX ............................ 91
AZILECT ........................... 41
azithromycin ....................... 15
azithromycin hydrogen citrate
........................................ 15
AZOPT ............................... 27
AZOR ................................. 50
aztreonam ........................... 16
I-2
bacitracin ..................... 14, 28
bacitracin/polymyxin b sulfate
....................................... 29
baclofen ............................. 91
BACTOCILL ..................... 16
BACTROBAN NASAL .... 29
BAL IN OIL ...................... 66
balsalazide disodium ......... 32
BANZEL ........................... 19
BARACLUDE ................... 46
BCG VACCINE TICE
STRAIN ......................... 95
BECONASE AQ ............... 31
benazepril hcl .................... 85
benazepril/
BENICAR .......................... 85
BENICAR HCT ................. 85
BENLYSTA ...................... 72
benzocaine ......................... 71
benzoyl peroxide ................ 70
benzoyl peroxide
microspheres .................. 70
benzoyl peroxide/aloe vera 70
benzoyl peroxide/
hydrocortison ................. 70
benzoyl peroxide/urea........ 70
benztropine mesylate ......... 41
BEPREVE ......................... 13
BERINERT ........................ 73
BESIVANCE ..................... 29
betamet acet/betamet na ph . 1
betamet diprop/prop gly .... 33
betamethasone dipropionate
....................................... 33
betamethasone valerate ..... 33
BETASERON .................... 73
betaxolol hcl ................ 27, 49
bethanechol chloride ......... 78
BETIMOL ......................... 27
BETOPTIC S ..................... 27
BEXXAR ........................... 36
bicalutamide ...................... 36
BICILLIN C-R .................. 17
BICILLIN L-A ................... 17
BICNU ............................... 36
BILTRICIDE ..................... 13
BIOTHRAX ....................... 95
bisoprolol fumarate............ 49
bisoprolol fumarate/hctz .... 49
bleomycin sulfate ............... 36
BLEPHAMIDE .................. 29
BLEPHAMIDE S.O.P. ...... 29
BONIVA ............................ 73
BOOSTRIX........................ 95
BOTOX .............................. 73
BRANCHAMIN ................ 52
BRILINTA ......................... 68
brimonidine tartrate ........... 27
BROMDAY ....................... 31
bromfenac sodium .............. 31
bromocriptine mesylate ...... 42
budesonide ........................... 1
bumetanide ......................... 61
BUMINATE ...................... 50
BUPHENYL ........................ 3
buprenorphine hcl .............. 10
bupropion hcl ..................... 80
buspirone hcl ...................... 47
BUSULFEX ....................... 36
BUTISOL SODIUM .......... 57
butorphanol tartrate........... 10
BYDUREON ..................... 21
BYETTA ............................ 21
BYSTOLIC ........................ 49
cabergoline ........................ 42
caffeine citrated ................. 11
caffeine/sodium benzoate ... 11
calcipotriene ...................... 92
calcitonin,salmon,synthetic 79
calcitriol ....................... 92, 98
calcium acetate .................. 70
calcium carbonate/mag carb/
fa .................................... 70
calcium chloride................. 86
CALCIUM DISODIUM
VERSENATE ................ 66
calcium gluconate .............. 86
CALDOLOR ........................ 4
CAMPATH ........................ 36
CAMPRAL......................... 57
CANCIDAS ....................... 27
CAPASTAT SULFATE ..... 36
CAPRELSA ....................... 36
captopril ............................. 85
captopril/hydrochlorothiazide
........................................ 85
CARAC .............................. 92
CARAFATE ....................... 43
CARBAGLU ........................ 3
carbamazepine ................... 19
carbidopa/levodopa ............ 42
carbinoxamine maleate ...... 28
carboplatin ......................... 37
CARDENE I.V. .................. 50
CARDENE SR ................... 50
CARIMUNE NF
NANOFILTERED ......... 90
carisoprodol ....................... 91
carteolol hcl........................ 61
carvedilol ............................ 49
CAYSTON ......................... 16
CEDAX .............................. 14
CEENU............................... 37
cefaclor ............................... 14
cefadroxil hydrate .............. 14
cefazolin sodium ................. 14
cefazolin sodium/dextrose,iso
........................................ 14
cefdinir ............................... 14
cefditoren pivoxil ................ 14
CEFEPIME......................... 15
cefepime hcl ........................ 14
CEFEPIME-DEXTROSE .. 15
cefotaxime sodium .............. 15
cefotetan disod/dextrose,iso16
cefotetan disodium.............. 16
cefoxitin sodium.................. 16
cefoxitin sodium/dextrose,iso
........................................ 16
cefpodoxime proxetil .......... 15
cefprozil .............................. 15
I-3
CEFTAZIDIME................. 15
ceftazidime pentahydrate ... 15
ceftriaxone na/dextrose,iso 15
ceftriaxone sodium ............. 15
cefuroxime axetil................ 15
cefuroxime sodium ............. 15
cefuroxime sodium/
dextrose,iso .................... 15
CELEBREX......................... 4
CELLCEPT ....................... 73
CELONTIN ....................... 21
CENESTIN ........................ 63
cephalexin .......................... 15
CEPROTIN ........................ 66
CEREDASE....................... 62
CEREZYME ...................... 62
CERVARIX ....................... 95
CESAMET......................... 26
CETRAXAL ...................... 29
CHANTIX ......................... 78
CHENODAL ..................... 65
chloramphenicol na succ ... 14
chlorhexidine gluconate .... 29
chloroprocaine hcl/pf ........ 71
chloroquine phosphate ...... 43
chlorothiazide .................... 61
chloroxylenol/pramoxine hcl
....................................... 71
chlorpromazine hcl ............ 82
chlorthalidone .................... 61
chlorzoxazone .................... 91
chlorzoxazone/acetaminophen
....................................... 91
cholestyramine (with sugar)
....................................... 34
cholestyramine/aspartame . 34
choline sal/mag salicylate ... 4
ciclopirox ........................... 30
ciclopirox olamine ............. 30
cilostazol ............................ 68
CILOXAN ......................... 29
cimetidine........................... 43
cimetidine hcl ..................... 43
cimetidine in 0.9 % nacl .... 43
CIMZIA ............................. 65
CINRYZE .......................... 73
CIPRO HC ......................... 29
CIPRODEX........................ 29
ciprofloxacin hcl .......... 18, 29
ciprofloxacin lactate .......... 18
ciprofloxacin lactate/d5w... 18
ciprofloxacin/ciprofloxa hcl
........................................ 18
cisplatin .............................. 37
citalopram hydrobromide .. 80
citrate-phos-dex solution ... 66
citric acid/sodium citrate ... 73
cladribine ........................... 37
clarithromycin .................... 15
clemastine fumarate ........... 28
CLEVIPREX...................... 50
clindamycin hcl .................. 14
clindamycin palmitate hcl .. 14
clindamycin phos/benzoyl
perox .............................. 30
clindamycin phosphate. 14, 30
CLINIMIX ................... 52, 53
CLINIMIX E ...................... 52
CLINISOL ......................... 53
clobetasol propionate......... 33
CLODERM ........................ 33
CLOLAR............................ 37
clomipramine hcl ............... 80
clonazepam ........................ 48
clonidine ............................. 69
clonidine hcl ....................... 69
clonidine hcl/chlorthalidone
........................................ 69
clopidogrel bisulfate .......... 68
clorazepate dipotassium..... 48
clotrimazole........................ 30
clotrimazole/betamethasone
dip .................................. 30
clozapine ............................ 82
COARTEM ........................ 43
cocaine hcl ......................... 71
codeine phos/acetaminophen5
codeine phosphate ................ 5
codeine sulfate ...................... 5
CODEINE SULFATE .......... 5
colchicine/probenecid ........ 73
COLCRYS ......................... 73
colestipol hcl ...................... 34
colistin (colistimethate na) . 14
COLY-MYCIN S ............... 29
COMBIGAN ...................... 27
COMBIPATCH .................. 63
COMBIVENT .................... 93
COMBIVENT RESPIMAT93
COMPLERA ...................... 44
COMTAN........................... 42
COMVAX .......................... 95
CONDYLOX ..................... 92
COPAXONE ...................... 73
CORDRAN ........................ 33
CORDRAN SP ................... 33
COREG CR ........................ 49
cortisone acetate .................. 1
CORTISPORIN-TC ........... 29
CREON .............................. 65
CRESTOR .......................... 35
cresyl ace/ben alc/butanol/ipa
........................................ 29
CRIXIVAN ........................ 44
CROFAB ............................ 90
cromolyn sodium ................ 33
CUBICIN ........................... 14
cyclobenzaprine hcl ............ 91
CYCLOGYL ...................... 61
cyclopentolate hcl ............... 61
cyclophosphamide .............. 37
cyclosporine ....................... 73
cyclosporine, modified ....... 73
CYMBALTA ..................... 80
CYSTADANE .................... 73
cysteine hcl ......................... 53
cytarabine/pf....................... 37
CYTOGAM ........................ 90
dacarbazine ........................ 37
DACOGEN ........................ 37
dactinomycin ...................... 37
DALIRESP ......................... 89
I-4
danazol............................... 10
dantrolene sodium ............. 91
dapsone .............................. 36
DAPTACEL ...................... 95
DARAPRIM ...................... 43
daunorubicin hcl ................ 37
DAUNOXOME ................. 37
DDAVP ............................. 79
deferoxamine mesylate ...... 66
demeclocycline hcl ............. 18
DENAVIR ......................... 31
DEPO-ESTRADIOL ......... 63
DEPO-PROVERA ............. 80
desipramine hcl.................. 80
desmopressin acetate ......... 79
desogestrel-ethinyl estradiol
....................................... 60
desog-et estra/ethin estra... 60
desonide ............................. 33
desoximetasone .................. 33
DETROL LA ..................... 64
dex 2.5%-half str lact.ringers
....................................... 86
dexamethasone..................... 1
dexamethasone acetate ........ 1
dexamethasone sod phosphate
................................... 1, 31
dexmethylphenidate hcl ..... 11
dexrazoxane ....................... 73
dextroamphetamine sulfate 11
nacl ................................ 53
dextrose 10 % and 0.9 % nacl
....................................... 53
dextrose 10%-0.5 normal
saline.............................. 53
dextrose 10%-water ........... 53
dextrose 2.5 %-water ......... 53
dextrose 2.5% in half ringers
....................................... 86
dextrose 2.5%-0.5normal
saline.............................. 53
dextrose 20 % in water ...... 53
dextrose 20%-water ........... 53
dextrose 25%-water ........... 53
dextrose 40%-water ........... 53
........................................ 53
........................................ 53
dextrose 5 %-0.225 % nacl 53
dextrose 5 %-0.45 % nacl .. 53
dextrose 5 %-water ............ 53
dextrose 5% in ringers ....... 86
dextrose 5%-lactated ringers
........................................ 86
DEXTROSE W/
ELECTROLYTE A ....... 86
DEXTROSE W/
ELECTROLYTE B ........ 86
dhcodeine bt/acetaminophn/
caff.................................... 5
DIASTAT ACUDIAL ....... 48
diazepam ............................ 48
diclofenac potassium ............ 4
diclofenac sodium .......... 4, 31
dicloxacillin sodium ........... 17
dicyclomine hcl .................. 19
didanosine .......................... 44
DIFFERIN.......................... 92
DIFICID ............................. 15
diflorasone diacetate .......... 33
diflunisal .............................. 4
DIGIBIND ......................... 90
DIGIFAB ........................... 90
digoxin................................ 56
DIGOXIN .......................... 56
dihydroergotamine mesylate
........................................ 93
DILANTIN ........................ 21
diltiazem hcl ....................... 50
dimenhydrinate .................. 26
DIOVAN ............................ 85
DIOVAN HCT ................... 85
DIPENTUM ....................... 32
diphenhydramine hcl .......... 28
diphenoxylate hcl/atropine . 25
DIPHTHERIA-TETANUS
TOXOID......................... 95
disopyramide phosphate..... 56
disulfiram ........................... 73
divalproex sodium .............. 19
dobutamine hcl ................... 93
dobutamine hcl/d5w ........... 93
DOCEFREZ ....................... 37
docetaxel............................. 37
donepezil hcl ....................... 78
dopamine hcl ...................... 94
dopamine hcl/d5w .............. 94
dorzolamide hcl .................. 27
dorzolamide hcl/timolol
maleat ............................. 27
DOVONEX ........................ 92
doxazosin mesylate ............... 3
doxepin hcl ......................... 80
doxorubicin hcl ................... 37
doxorubicin hcl liposomal .. 37
doxycycline hyclate ...... 18, 29
doxycycline monohydrate ... 18
DRITHO-SCALP ............... 71
dronabinol .......................... 26
droperidol ........................... 47
DROXIA ............................ 37
DUETACT ......................... 25
DULERA .............................. 1
DUODOTE......................... 73
DUREZOL ......................... 32
DUTOPROL....................... 49
DYNACIRC CR................. 50
DYRENIUM ...................... 61
DYSPORT.......................... 73
econazole nitrate ................ 30
edetate disodium ................. 66
EDURANT ......................... 44
EFFER-K............................ 86
EFFIENT ............................ 68
ELAPRASE ........................ 62
electrolyte-48 solution/d10w
........................................ 86
I-5
electrolyte-48 solution/d5w 86
electrolyte-48/fructose 10%86
electrolyte-48/fructose 5% . 86
electrolyte-75 solution/d5w 86
electrolyte-75/fructose 5% . 86
electrolyte-r solution/d5w .. 86
ELIDEL ............................. 92
ELIGARD .......................... 37
ELITEK ............................. 62
ELMIRON ......................... 73
ELSPAR ............................ 37
EMCYT ............................. 37
EMEND ............................. 26
EMSAM............................. 80
EMTRIVA ......................... 44
enalapril maleate ............... 85
enalapril/hydrochlorothiazide
....................................... 85
enalaprilat dihydrate ......... 85
ENBREL ............................ 74
ENDRATE......................... 66
ENGERIX-B ...................... 95
enoxaparin sodium ............ 66
ephedrine sulfate................ 94
EPIDUO............................. 92
epinastine hcl ..................... 13
epinephrine ........................ 94
epinephrine/pf .................... 94
EPIPEN .............................. 94
EPIPEN JR ........................ 94
epirubicin hcl ..................... 37
EPIVIR .............................. 44
EPIVIR HBV ..................... 44
eplerenone ......................... 86
EPOGEN ........................... 68
epoprostenol sodium (glycine)
....................................... 97
eprosartan mesylate ........... 85
EPZICOM .......................... 44
ERAXIS WATER DILUENT
....................................... 27
ERBITUX .......................... 37
ergotamine tartrate/caffeine
....................................... 93
ERIVEDGE........................ 37
ERWINAZE ....................... 37
ery e-succ/sulfisoxazole ..... 15
ERY-TAB .......................... 15
ERYTHROCIN
LACTOBIONATE ......... 15
erythromycin base .. 15, 16, 29
erythromycin base/ethanol . 30
erythromycin ethylsuccinate
........................................ 16
erythromycin stearate ........ 16
erythromycin/benzoyl
peroxide.......................... 30
escitalopram oxalate .......... 81
esmolol hcl ......................... 49
estazolam............................ 48
ESTRACE .......................... 63
estradiol ............................. 63
estradiol valerate ............... 63
estradiol/noreth ac ............. 63
ESTRASORB .................... 63
ESTRING ........................... 63
estropipate.......................... 63
ethambutol hcl .................... 36
ethanolamine oleate ........... 90
ethinyl estradiol/drospirenone
........................................ 60
ethosuximide ...................... 21
ethyl alcohol/d5w ............... 54
ethynodiol d-ethinyl estradiol
........................................ 60
etidronate disodium ........... 74
etodolac ................................ 4
ETOPOPHOS .................... 38
etoposide ............................ 38
EURAX .............................. 31
EVISTA ............................. 63
EXELDERM ...................... 30
EXELON............................ 78
exemestane ......................... 38
EXFORGE ......................... 50
EXFORGE HCT ................ 50
EXJADE ............................ 66
EXTAVIA .......................... 74
FABRAZYME ................... 62
FACTIVE ........................... 18
famciclovir .......................... 46
famotidine ........................... 44
famotidine in nacl,iso-osm/pf
........................................ 44
FANAPT ............................ 82
FARESTON ....................... 38
FASLODEX ....................... 38
FAZACLO ................... 82, 83
felbamate ............................ 19
felodipine ............................ 50
FEMHRT ............................ 64
FEMRING .......................... 64
fenofibrate .......................... 34
fenofibrate,micronized........ 34
fenofibric acid .................... 35
fenoldopam mesylate .......... 69
fenoprofen calcium ............... 4
fentanyl ............................. 5, 6
fentanyl citrate...................... 5
FERRIPROX ...................... 66
finasteride ........................... 74
FIRAZYR ........................... 74
FIRMAGON....................... 38
flavoxate hcl ....................... 64
FLEBOGAMMA ............... 90
FLEBOGAMMA DIF ........ 90
flecainide acetate................ 56
FLECTOR ............................ 4
FLEXBUMIN..................... 50
FLEXTRA PLUS ................. 3
FLOVENT DISKUS ............ 2
FLOVENT HFA ................... 2
floxuridine .......................... 38
fluconazole ......................... 27
fluconazole in nacl,iso-osm 27
flucytosine........................... 26
fludarabine phosphate ........ 38
fludrocortisone acetate......... 2
flumazenil ........................... 57
flunisolide ........................... 32
fluocinolone acetonide ....... 34
fluocinolone acetonide oil .. 32
I-6
fluocinolone/shower cap .... 34
fluocinonide ....................... 34
FLUOR-A-DAY ................ 98
fluoride/iron/vit a,c&d ....... 98
FLUORITAB ..................... 74
fluorometholone ................. 32
FLUOROPLEX ................. 92
fluorouracil .................. 38, 92
fluoxetine hcl...................... 81
fluoxymesterone ................. 10
fluphenazine decanoate ..... 83
fluphenazine hcl ................. 83
FLURA .............................. 98
FLURA-DROPS ................ 74
flurbiprofen .......................... 4
flurbiprofen sodium ........... 32
flutamide ............................ 38
fluticasone propionate . 32, 34
fluvastatin sodium .............. 35
fluvoxamine maleate .......... 81
FOCALIN XR ................... 11
FOLOTYN......................... 38
fomepizole .......................... 74
fondaparinux sodium ... 66, 67
FORADIL .......................... 94
FORTEO ............................ 79
FORTICAL ........................ 79
foscarnet sodium ................ 46
fosinopril sodium ............... 85
fosinopril/
fosphenytoin sodium .......... 21
FOSRENOL....................... 70
FREAMINE HBC.............. 54
FREAMINE III .................. 54
FREAMINE III with
FROVA .............................. 35
fructose 10% ...................... 54
furosemide ......................... 61
FUROXONE ..................... 31
FUSILEV ........................... 74
FUZEON ........................... 44
gabapentin ......................... 19
GABITRIL ......................... 19
galantamine hbr ................. 78
GALZIN ............................. 66
GAMMAGARD LIQUID .. 90
GAMMAPLEX .................. 90
GAMUNEX-C ................... 90
ganciclovir ......................... 47
ganciclovir sodium ............. 47
GARDASIL ................. 95, 96
gauze bandage ................... 74
GELNIQUE ....................... 64
gemcitabine hcl .................. 38
gemfibrozil ......................... 35
GENOTROPIN .................. 79
gentamicin in nacl, iso-osm 13
gentamicin sulfate .. 13, 29, 30
gentamicin sulfate/pf .......... 13
GEODON ........................... 83
GILENYA .......................... 74
GLEEVEC ......................... 38
glimepiride ......................... 24
glipizide .............................. 24
glipizide/metformin hcl ...... 24
GLUCAGEN...................... 74
GLUCAGON EMERGENCY
KIT ................................. 74
glutethimide........................ 47
glyburide ............................ 24
glyburide,micronized ......... 24
glyburide/metformin hcl .... 24,
25
glycine ................................ 70
glycopyrrolate .................... 19
GLYSET ............................ 21
gold sodium thiomalate ...... 74
granisetron hcl ............. 25, 26
granisetron hcl/pf ............... 26
griseofulvin,microsize ........ 26
GRIS-PEG.......................... 26
guaifen/theop anhyd/p-ephed
........................................ 89
guanfacine hcl .................... 69
GYNAZOLE-1 .................. 30
HALAVEN ........................ 38
HALFAN ............................ 43
halobetasol propionate....... 34
haloperidol ......................... 83
haloperidol decanoate ........ 83
haloperidol lactate ............. 83
HAVRIX ............................ 96
HECTOROL....................... 98
heparin sodium,porcine ...... 67
heparin sodium,porcine/d5w
........................................ 67
heparin sodium,porcine/ns/pf
........................................ 67
heparin sodium,porcine/pf . 67
HEPATAMINE .................. 54
HEPATASOL..................... 54
HEPSERA .......................... 47
HERCEPTIN ...................... 38
HEXALEN ......................... 38
HIZENTRA ........................ 90
homatropine hbr ................. 62
HUMALOG ....................... 23
HUMALOG MIX 50-50 .... 22
HUMALOG MIX 75-25 .... 22
HUMATROPE ................... 79
HUMIRA ............................ 74
HUMULIN 70-30 ............... 23
HUMULIN N ..................... 23
HUMULIN R ..................... 23
hydralazine hcl ................... 69
hydralazine/
hydrochlorothiazid ......... 69
hydralazine/reserpin/hctz ... 69
hydrochlorothiazide ........... 61
hydrocodone bit/
acetaminophen ................. 6
hydrocodone/ibuprofen ........ 6
hydrocortisone................ 2, 34
hydrocortisone acetate ....... 34
hydrocortisone acetate/aloe v
........................................ 34
hydrocortisone acetate/urea
........................................ 34
hydrocortisone butyrate ..... 34
I-7
hydrocortisone sod succinate
......................................... 2
hydrocortisone valerate ..... 34
hydromorphone hcl .......... 6, 7
hydromorphone hcl/pf.......... 7
hydroxychloroquine sulfate 43
hydroxyurea ....................... 38
hydroxyzine hcl .................. 47
hydroxyzine pamoate ......... 47
HYPERLYTE CR.............. 86
HYPERLYTE R ................ 86
HYPERRAB S-D .............. 90
HYPERRHO S-D .............. 90
ibandronate sodium ........... 74
ibuprofen.............................. 4
ibuprofen/oxycodone hcl...... 7
idarubicin hcl ..................... 38
ifosfamide........................... 38
ifosfamide/mesna ............... 38
ILARIS .............................. 74
imipenem/cilastatin sodium 16
imipramine hcl ................... 81
imipramine pamoate .......... 81
imiquimod .......................... 92
IMOGAM RABIES-HT .... 90
inamrinone lactate ............. 57
INCIVEK ........................... 46
INCRELEX ....................... 93
indapamide ........................ 61
indomethacin ....................... 4
indomethacin sodium
trihydrate ......................... 4
INFANRIX ........................ 95
INFANRIX PF ................... 95
INLYTA ............................ 38
INNOPRAN XL ................ 49
INTELENCE ..................... 44
INTRALIPID ..................... 54
INTRON A ........................ 46
INTUNIV........................... 58
INVANZ ............................ 16
INVEGA ............................ 83
INVEGA SUSTENNA ...... 83
INVIRASE......................... 44
IONOSOL B with
DEXTROSE 5% ............ 87
IONOSOL MB-DEXTROSE
5% .................................. 87
IONOSOL T-DEXTROSE
5% .................................. 87
IOPIDINE .......................... 62
IPOL ................................... 96
ipratropium bromide .......... 62
IPRIVASK ......................... 67
irbesartan ........................... 85
irbesartan/
IRESSA .............................. 38
irinotecan hcl ..................... 38
ISENTRESS ....................... 44
ISOLYTE E ....................... 87
ISOLYTE H W/DEXTROSE
........................................ 87
ISOLYTE M W/DEXTROSE
........................................ 87
ISOLYTE P with
DEXTROSE ................... 87
ISOLYTE S ........................ 87
ISOLYTE S with
DEXTROSE ................... 87
isoniazid ............................. 36
isopropamide/
prochlorperazine ............ 19
isoproterenol hcl ................ 94
ISOPTO CARPINE ........... 27
ISOPTO HOMATROPINE 62
isosorbide dinitrate ............ 97
isosorbide mononitrate ...... 97
isotretinoin ......................... 92
ISOVEX ............................. 97
isradipine ........................... 50
ISTALOL ........................... 27
ISTODAX .......................... 38
itraconazole........................ 27
IXEMPRA.......................... 39
IXIARO.............................. 96
JAKAFI .............................. 39
JANUMET ......................... 21
JANUMET XR................... 21
JANUVIA........................... 21
JENTADUETO .................. 21
JE-VAX .............................. 96
JEVTANA .......................... 39
JUVISYNC......................... 22
KADIAN .............................. 7
KALBITOR ........................ 74
KALETRA ......................... 45
KALYDECO ...................... 89
kanamycin sulfate ............... 13
KEDBUMIN ...................... 50
KENALOG......................... 34
KEPIVANCE ..................... 57
KETEK ............................... 16
ketoconazole ................. 27, 30
ketoprofen ............................. 4
ketorolac tromethamine.. 4, 32
KINERET ........................... 74
KINRIX .............................. 96
KORLYM........................... 22
K-PHOS M.F. ..................... 74
K-PHOS NO.2 .................... 74
KRYSTEXXA.................... 62
KUVAN ............................. 74
labetalol hcl ........................ 49
LACRISERT ...................... 62
LACTATED RINGERS .... 70,
87
lactulose ............................... 3
LAMICTAL BLUE ............ 19
LAMICTAL ODT .............. 20
LAMICTAL ODT BLUE... 19
LAMICTAL ODT GREEN 19
LAMICTAL ODT ORANGE
........................................ 19
LAMICTAL ORANGE...... 19
LAMICTAL XR ................. 20
LAMICTAL XR BLUE ..... 20
LAMICTAL XR GREEN .. 20
LAMICTAL XR ORANGE
........................................ 20
LAMISIL............................ 30
lamivudine .......................... 45
I-8
lamivudine/zidovudine ....... 45
lamotrigine......................... 20
lansoprazole....................... 44
LANTUS ........................... 23
LANTUS SOLOSTAR ...... 23
latanoprost ......................... 27
LATUDA ........................... 83
leflunomide ........................ 74
LETAIRIS ......................... 97
letrozole ............................. 39
leucovorin calcium ............ 74
LEUKERAN ...................... 39
LEUKINE .......................... 68
leuprolide acetate .............. 39
LEVACET ........................... 4
LEVEMIR ......................... 23
levetiracetam ..................... 20
levobunolol hcl .................. 27
levocarnitine ...................... 75
levocarnitine (with sugar) . 75
levocetirizine dihydrochloride
....................................... 28
levofloxacin .................. 18, 29
levofloxacin/d5w ................ 18
levonorgestrel .................... 60
levonorgestrel-eth estradiol60
levorphanol tartrate ............. 7
levothyroxine sodium ......... 94
LEVULAN ........................ 92
LEXAPRO ......................... 81
LEXIVA ............................ 45
LIALDA ............................ 33
lidocaine ............................ 43
lidocaine hcl ................ 56, 71
lidocaine hcl/d5w/pf .......... 56
lidocaine hcl/pf ............ 56, 71
lidocaine/prilocaine ........... 43
LIDODERM ...................... 43
lindane ............................... 31
liothyronine sodium ........... 94
lipase/protease/amylase..... 65
LIPOSYN II....................... 54
LIPOSYN III ..................... 54
lisinopril............................. 85
lisinopril/hydrochlorothiazide
........................................ 85
lithium carbonate ............... 58
lithium citrate ..................... 58
LITHOSTAT........................ 3
l-norgest-eth estr/ethin estra
........................................ 60
LOCOID ............................ 34
LODOSYN ........................ 58
loperamide hcl ................... 25
lorazepam ........................... 48
losartan potassium ............. 85
losartan/hydrochlorothiazide
........................................ 85
LOTEMAX ........................ 32
LOTRONEX ...................... 65
lovastatin ............................ 35
LOVAZA ........................... 34
LOVENOX ........................ 67
loxapine succinate .............. 83
LOZI-FLUR ....................... 98
LUMIGAN ......................... 27
LUMINAL SODIUM ........ 58
LUMIZYME ...................... 62
LUPRON DEPOT .............. 39
LUPRON DEPOT-PED ..... 39
LUVOX CR ....................... 81
LYRICA ............................. 20
LYSODREN ...................... 39
LYSTEDA ......................... 67
magnesium chloride ........... 20
magnesium salicylate ........... 4
magnesium sulfate.............. 20
magnesium sulfate/d5w ...... 20
malathion ........................... 31
mannitol/sorbitol solution .. 70
maprotiline hcl ................... 81
MARPLAN ........................ 81
MATULANE ..................... 39
MAXAIR AUTOHALER .. 94
mebendazole ....................... 13
meclizine hcl....................... 26
meclofenamate sodium ......... 4
medroxyprogesterone acetate
........................................ 80
mefenamic acid ..................... 4
mefloquine hcl .................... 43
MEGACE ES ..................... 39
megestrol acetate................ 39
meloxicam............................. 4
melphalan hcl ..................... 39
MENACTRA ..................... 96
MENEST ............................ 64
MENOMUNE-A-C-Y-W-135
........................................ 96
MENVEO A-C-Y-W-135DIP ................................. 96
mepivacaine hcl/pf.............. 71
MEPRON ........................... 43
mercaptopurine .................. 39
meropenem ......................... 16
MERUVAX II VACCINE
W-DILUENT ................. 96
mesalamine w/cleansing
wipes ............................... 33
mesna .................................. 75
MESNEX ........................... 75
MESTINON ....................... 78
METADATE CD ............... 11
metaproterenol sulfate........ 94
metaxalone ......................... 91
metformin hcl...................... 22
methadone hcl ...................... 7
methamphetamine hcl ......... 11
methazolamide.................... 27
methenamine mandelate ..... 95
methimazole........................ 94
methocarbamol ................... 91
methotrexate sodium .......... 39
methotrexate sodium/pf ...... 39
methscopolamine bromide.. 19
methyclothiazide ................. 61
methylene blue .................... 75
methylergonovine maleate.. 75
METHYLIN ................. 11, 12
methylphenidate hcl............ 12
methylprednisolone .............. 2
I-9
methylprednisolone acetate . 2
methylprednisolone sod succ 2
metipranolol....................... 28
metoclopramide hcl ........... 65
metolazone ......................... 61
metoprolol succinate.......... 49
metoprolol tartrate ............ 49
metoprolol/
metronidazole .............. 30, 43
metronidazole/sodium
chloride .......................... 43
METVIXIA ....................... 92
mexiletine hcl ..................... 56
mg sal/acetaminophn/p-tlox/
caf .................................... 3
MIACALCIN..................... 79
MICARDIS ........................ 85
MICARDIS HCT ............... 85
miconazole nitrate ............. 30
MICRHOGAM PLUS ....... 90
midodrine hcl ..................... 94
milrinone lactate ................ 57
milrinone lactate/d5w ........ 57
MINOCIN .......................... 18
minocycline hcl .................. 18
minoxidil ............................ 69
mirtazapine ........................ 81
misoprostol ........................ 44
mitomycin........................... 39
mitoxantrone hcl ................ 39
M-M-R II VACCINE ........ 96
MOBAN ............................ 83
moexipril hcl ...................... 85
moexipril/
mometasone furoate ........... 34
morphine sulfate .............. 7, 8
morphine sulfate in 0.9 %
nacl .................................. 7
morphine sulfate/d5w .......... 8
morphine sulfate/pf .............. 8
MOXEZA .......................... 29
MOZOBIL ......................... 69
MULTAQ .......................... 56
multivitamins with fluoride 98
MUMPSVAX VACCINE WDILUENT ...................... 96
mupirocin ........................... 30
MUSTARGEN ................... 39
MYCOBUTIN ................... 36
mycophenolate mofetil ....... 75
MYFORTIC ....................... 75
MYOBLOC........................ 75
MYOZYME ....................... 62
MYTELASE ...................... 78
na nitrite/na thiosul/amyl nit
........................................ 66
nabumetone .......................... 5
nadolol ............................... 49
nadolol/bendroflumethiazide
........................................ 49
nafcillin sodium.................. 17
nafcillin sodium/d2.4w ....... 17
NAGLAZYME .................. 62
nalbuphine hcl .................... 10
nalidixic acid ...................... 18
naloxone hcl ....................... 77
naltrexone hcl..................... 78
NAMENDA ....................... 58
naphazoline hcl .................. 62
naphazoline hcl/antazoline 62
naproxen .............................. 5
naproxen sodium .................. 5
naratriptan hcl ................... 35
NASONEX ........................ 32
NATACYN ........................ 29
nateglinide.......................... 22
NAVANE ........................... 83
NEBCIN ............................. 13
NEBCIN IN DEXTROSE.. 13
needles, insulin disp., safety
........................................ 61
needles, insulin disposable. 61
nefazodone hcl ................... 81
neo/polymyx b sulf/dexameth
........................................ 29
neomy sulf/bacitra/polymyxin
b ...................................... 29
neomy sulf/bacitrac zn/poly/
hc .................................... 29
neomy sulf/polymyxin b
sulfate ............................. 30
neomycin sulfate ................. 13
neomycin sulfate/dex na ph 29
neomycin/polymyxin b sulf/hc
........................................ 29
neomycin/polymyxn b/
gramicidin ...................... 29
neostigmine methylsulfate .. 78
NEO-SYNEPHRINE ......... 94
NEPHRAMINE.................. 54
NEULASTA ....................... 69
NEUMEGA ........................ 69
NEUPOGEN ...................... 69
NEVANAC ........................ 32
nevirapine ........................... 45
NEXAVAR ........................ 39
niacin .................................. 34
NIASPAN........................... 34
nicardipine hcl.................... 50
NICOTROL........................ 78
NICOTROL NS.................. 78
nifedipine ............................ 50
NILANDRON .................... 39
nimodipine .......................... 50
nisoldipine .......................... 50
NITRO-BID ....................... 97
nitrofurantoin macrocrystal
........................................ 95
nitroglycerin ....................... 97
nitroglycerin/d5w ............... 97
NITROSTAT...................... 97
nizatidine ............................ 44
NORDITROPIN ................. 79
NORDITROPIN FLEXPRO
........................................ 79
NORDITROPIN
NORDIFLEX ................. 79
norepinephrine bit/0.9 % nacl
........................................ 94
I-10
norepinephrine bitartrate .. 94
noreth a-et estra/fe fumarate
....................................... 60
noreth-ethinyl estradiol/iron
....................................... 60
norethind ac/ethinyl estradiol
....................................... 64
norethindrone .................... 60
norethindrone acetate ........ 80
norethindrone a-e estradiol 60
norethindrone-ethinyl estrad
....................................... 60
norethindrone-mestranol ... 60
norgestimate-ethinyl estradiol
....................................... 60
norgestrel-ethinyl estradiol 60
NORMOSOL-M and
DEXTROSE .................. 87
NORMOSOL-R PH 7.4 ..... 87
NOROXIN ......................... 18
nortriptyline hcl ................. 81
NORVIR ............................ 45
NOVAMINE ..................... 54
NOVOLIN 70-30 ............... 23
NOVOLIN 70-30 INNOLET
....................................... 23
NOVOLIN N ..................... 23
NOVOLIN N INNOLET ... 23
NOVOLIN R ..................... 23
NOVOLOG ................. 23, 24
NOVOLOG MIX 70-30 .... 23
NOXAFIL .......................... 27
NPLATE ............................ 75
NUCYNTA .......................... 8
NUCYNTA ER.................... 8
NUEDEXTA ..................... 58
NULOJIX .......................... 75
NUTRESTORE ................. 65
NUTRILYTE ..................... 87
NUTRILYTE II ................. 87
NUTROPIN ....................... 79
NUTROPIN AQ ................ 79
NUTROPIN AQ NUSPIN . 79
NUVARING ...................... 60
NUVIGIL ........................... 12
nylidrin hcl ......................... 97
nystatin ......................... 26, 31
nystatin/triamcin ................ 31
OCTAGAM ....................... 90
octreotide acetate ............... 75
OFIRMEV............................ 3
ofloxacin ....................... 18, 29
olanzapine .......................... 83
omeprazole ......................... 44
omeprazole/sodium
bicarbonate .................... 44
OMNARIS ......................... 32
OMNITROPE .................... 79
ONCASPAR ...................... 39
ondansetron........................ 26
ondansetron hcl .................. 26
ONFI .................................. 49
ONTAK.............................. 40
ORAP ................................. 83
ORENCIA .......................... 75
ORFADIN .......................... 75
ORTHO EVRA .................. 60
oxacillin sodium ................. 17
oxacillin sodium/dextrose,iso
........................................ 17
oxaliplatin .......................... 40
oxandrolone ....................... 10
oxaprozin.............................. 5
oxazepam............................ 49
oxcarbazepine .................... 20
OXSORALEN ................... 92
OXSORALEN-ULTRA ..... 92
oxybutynin chloride ............ 64
oxycodone hcl....................... 8
oxycodone hcl/acetaminophen
...................................... 8, 9
oxycodone hcl/aspirin .......... 9
oxycodone hcl/oxycodon ter/
asa .................................... 9
OXYCONTIN ...................... 9
oxymorphone hcl .................. 9
OXYTROL ........................ 64
paclitaxel ............................ 40
pamidronate disodium ........ 75
PANCREAZE .................... 65
PANRETIN ........................ 92
pantoprazole sodium .......... 44
papaverine hcl .................... 97
paregoric ............................ 25
paromomycin sulfate .......... 43
paroxetine hcl ..................... 81
PASER ............................... 36
PATADAY ......................... 13
PATANASE ....................... 13
PATANOL ......................... 13
PAXIL ................................ 81
ped mv a,c,d3 #21 w-fluoride
........................................ 98
PEDIARIX ......................... 96
PEDVAXHIB ..................... 96
peg 3350/na sulf,bicarb,cl/kcl
........................................ 57
PEGANONE ...................... 21
PEGASYS .......................... 46
PEGASYS PROCLICK ..... 46
PEGINTRON ..................... 46
PEGINTRON REDIPEN ... 46
pen g pot/dextrose-water .... 17
penicillin g potassium......... 17
penicillin g potassium/d5w . 17
penicillin g procaine........... 17
penicillin v potassium ......... 17
PENTACEL ....................... 96
pentamidine isethionate...... 43
PENTASA .......................... 33
pentostatin .......................... 40
pentoxifylline ...................... 67
p-epd tan/chlor-tan ............. 28
perindopril erbumine.......... 85
permethrin .......................... 31
perphenazine ...................... 83
perphenazine/amitriptyline
hcl ................................... 81
phenelzine sulfate ............... 81
phenobarbital ..................... 58
phenobarbital sodium......... 58
phentolamine mesylate ....... 93
I-11
PHENTOLAMINE
MESYLATE .................. 93
phenyleph/acetaminop/p-tlox/
cp ................................... 28
phenylephrine hcl ........ 62, 94
phenylephrine tannate ....... 94
phenylephrine/antipy/b-caine
....................................... 71
phenylephrine/chlor-tan .... 28
PHENYTEK ...................... 21
phenytoin ........................... 21
phenytoin sodium ............... 21
phenytoin sodium extended 21
PHOSLYRA ...................... 70
PHOSPHOLINE IODIDE . 28
phosphorus #1.................... 75
physostigmine salicylate .... 78
PICATO ............................. 92
pilocarpine hcl ............. 28, 78
PILOPINE HS ................... 28
pindolol .............................. 49
piperacillin sodium ............ 17
piperacillin sodium/
tazobactam ..................... 17
PIPRACIL IN DEXTROSE
....................................... 17
piroxicam ............................. 5
PLASBUMIN-25 ............... 50
PLASBUMIN-5 ................. 50
PLASMA-LYTE 148 ........ 87
PLASMA-LYTE 56 IN
DEXTROSE .................. 87
PLASMA-LYTE A PH 7.4 87
PLASMA-LYTE M IN
DEXTROSE .................. 87
pnv with ca,no.72/iron/fa ... 98
podofilox ............................ 92
podophyllum resin ............. 92
polyethylene glycol 3350 ... 57
polymyxin b sulfate ............ 14
polymyxin b sulfate/tmp ..... 29
pot chloride/pot bicarb/cit ac
....................................... 87
potassium acetate .............. 87
potassium bicarbonate/cit ac
........................................ 87
potassium chlorid/d100.2%nacl ........................ 87
potassium chlorid/d50.225nacl ........................ 87
potassium chloride ............. 88
potassium chloride in
0.9%nacl ........................ 87
potassium chloride/d5-0.25ns
........................................ 88
potassium chloride/d50.33nacl .......................... 88
potassium chloride/d50.45nacl .......................... 88
potassium chloride/d50.9%nacl ........................ 88
potassium chloride/d5lr ..... 88
potassium chloride/d5w ..... 88
potassium chloride-0.45%
nacl ................................. 88
potassium citrate ................ 75
potassium citrate/citric acid
........................................ 75
potassium gluconate........... 88
potassium hydroxide .......... 70
potassium phos,m-basic-dbasic ............................... 88
POTIGA ............................. 20
PRADAXA ........................ 67
PRALIDOXIME
CHLORIDE ................... 76
pramipexole di-hcl ............. 42
PRANDIMET .................... 22
PRANDIN .......................... 22
pravastatin sodium ............. 35
prazosin hcl .......................... 3
prednicarbate ..................... 34
prednisolone......................... 2
prednisolone acetate ...... 2, 32
prednisolone sod phosphate 2,
32
prednisone ............................ 2
PREDNISONE INTENSOL 2
PREFEST ........................... 64
PREMARIN ....................... 64
PREMASOL................. 54, 55
PREMPHASE .................... 64
PREMPRO ......................... 64
PREZISTA ......................... 45
PRIFTIN ............................. 36
PRIMAQUINE ................... 43
primidone ........................... 58
PRISTIQ ER ....................... 81
PRIVIGEN ......................... 90
PROAIR HFA .................... 94
probenecid .......................... 76
procainamide hcl ................ 56
PROCALAMINE ............... 55
prochlorperazine edisylate . 26
prochlorperazine maleate .. 26
PROCRIT ........................... 69
progesterone ....................... 80
progesterone,micronized .... 80
PROGLYCEM ................... 69
PROGRAF ......................... 76
PROLASTIN ...................... 89
PROLASTIN C .................. 89
PROLEUKIN ..................... 40
PROLIA ............................. 76
PROMACTA...................... 69
promethazine hcl ................ 28
PRONESTYL ..................... 56
propafenone hcl .................. 56
proparacaine hcl ................ 71
proparacaine/fluorescein sod
........................................ 71
PROPINE ........................... 62
propranolol hcl................... 49
propranolol/
hydrochlorothiazid ......... 49
propylthiouracil.................. 94
PROQUAD......................... 96
PROSOL............................. 55
PROSTIGMIN ................... 78
protamine sulfate ................ 67
PROTONIX IV .................. 44
PROTOPAM CHLORIDE . 76
I-12
PROTOPIC ........................ 92
protriptyline hcl ................. 81
PRUDOXIN....................... 43
PULMOZYME .................. 62
pyrazinamide ..................... 36
pyridostigmine bromide ..... 78
QNASL .............................. 32
QUALAQUIN ................... 43
quetiapine fumarate ........... 84
QUICK MIX with LYTES 55
quinapril hcl ...................... 85
quinapril/hydrochlorothiazide
....................................... 85
quinidine gluconate ........... 56
quinidine sulfate ................ 56
QVAR .................................. 3
RABAVERT ...................... 96
ramipril .............................. 86
RANEXA........................... 57
ranitidine hcl...................... 44
RAPAMUNE ..................... 76
REBIF ................................ 76
RECLAST ......................... 76
RECOMBIVAX HB .......... 96
RECTIV ............................. 92
REGONOL ........................ 79
REGRANEX ..................... 92
RELAGESIC ....................... 3
RELENZA ......................... 46
RELISTOR ........................ 65
REMICADE ...................... 76
REMODULIN ................... 97
RENAGEL......................... 70
RENAMIN......................... 55
RENVELA......................... 70
RESCRIPTOR ................... 45
reserpine ............................ 69
reserpine/hydrochlorothiazide
....................................... 70
RESTASIS ......................... 32
RETIN-A MICRO ............. 57
RETROVIR ....................... 45
REVATIO .................... 97, 98
REVLIMID .................. 40, 76
REYATAZ ......................... 45
RHINOCORT AQUA ........ 32
RHOGAM PLUS ............... 90
RHOPHYLAC ................... 90
RIBATAB .......................... 47
ribavirin ............................. 47
RIDAURA ......................... 76
rifampin .............................. 36
rifampin/isoniazid .............. 36
RILUTEK .......................... 58
rimantadine hcl .................. 46
ringers solution ............ 70, 88
RISPERDAL CONSTA ..... 84
risperidone ......................... 84
RITALIN LA ..................... 12
RITUXAN.......................... 40
rivastigmine tartrate .......... 79
ropinirole hcl ..................... 42
ROTARIX .......................... 96
ROTATEQ ......................... 96
ROZEREM ........................ 47
SABRIL ............................. 20
SAIZEN ............................. 80
sal-amide/acetamin/p-tlox/
caff.................................... 3
sal-amide/acetaminophn/ptlox.................................... 3
salicylamide/acetaminophen 4
salicylic acid ...................... 71
salicylic acid/ammon lact/
aloe................................. 71
salicylic acid/ceramide cmb
#1.................................... 71
salsalate ............................... 5
SAMSCA ........................... 61
SANCTURA XR ............... 64
SANDOSTATIN LAR....... 76
SANTYL ............................ 92
SAPHRIS ........................... 84
SAVELLA ......................... 58
selegiline hcl ...................... 42
selenium sulfide .................. 31
SELZENTRY ..................... 45
SENSIPAR ......................... 76
SEREVENT DISKUS ........ 94
SEROMYCIN .................... 36
SEROQUEL XR ................ 84
SEROSTIM ........................ 80
sertraline hcl ...................... 81
SILENOR ........................... 81
silver nitrate ....................... 31
silver nitrate applicator...... 71
silver sulfadiazine............... 31
SIMCOR............................. 35
SIMPONI ........................... 76
SIMULECT ........................ 76
simvastatin.......................... 35
SINGULAIR ...................... 33
SKELID .............................. 76
sod chloride 0.45% irrig. soln
........................................ 70
sod propionate/inosi/aa14/
urea................................. 31
sod/pot/k cit/sod cit/cit acid 76
sodium acetate .................... 88
sodium bicarbonate ............ 76
sodium chloride .................. 88
sodium chloride 0.45 % ...... 88
sodium chloride 3% ............ 88
sodium chloride 5% ............ 88
sodium chloride irrig solution
........................................ 70
sodium chloride/nahco3/kcl/
peg .................................. 57
sodium fluoride............. 76, 98
sodium lactate .................... 76
sodium morrhuate .............. 90
sodium phos,m-basic-d-basic
........................................ 88
sodium polystyrene sulfonate
........................................ 70
sodium tetradecyl sulfate .... 90
sodium thiosulfate .............. 66
sodium thiosulfate/sal acid . 31
SOLARAZE ......................... 5
SOLIRIS ............................. 76
SOLU-CORTEF PF ............. 3
SOLU-MEDROL PF ............ 3
I-13
SOMATULINE DEPOT ... 76
SOMAVERT ..................... 93
sorbitol solution ................. 70
SORIATANE..................... 92
sotalol hcl .......................... 49
SOTALOL HCL ................ 49
SPIRIVA ............................ 19
spironolact/
hydrochlorothiazid......... 86
spironolactone ................... 86
SPORANOX ...................... 27
SPRYCEL.......................... 40
STALEVO 100 .................. 42
STALEVO 125 .................. 42
STALEVO 150 .................. 42
STALEVO 200 .................. 42
STALEVO 50 .................... 42
STALEVO 75 .................... 42
stavudine ............................ 45
STELARA ................... 77, 92
STERILE DILUENT ......... 50
STIMATE .......................... 80
STRATTERA .................... 58
streptomycin sulfate ........... 13
STROMECTOL................. 13
SUBOXONE ..................... 10
sucralfate ........................... 44
sulfacetamide sodium .. 29, 31
sulfacetamide sodium/urea 71
sulfacetamide/prednisolone
sp .................................... 29
sulfadiazine ........................ 18
sulfamethoxazole/
trimethoprim .................. 18
SULFAMYLON ................ 31
sulfasalazine ...................... 18
sulindac................................ 5
sumatriptan ........................ 35
sumatriptan succinate ........ 35
SUPPRELIN ...................... 77
SUPPRELIN LA................ 77
SUPRAX ........................... 15
SURMONTIL .................... 81
SUSTIVA .......................... 45
SUTENT ............................ 40
SYLATRON ...................... 46
SYMBICORT ...................... 3
SYMBYAX........................ 81
SYMLIN ............................ 22
SYMLINPEN 120 .............. 22
SYMLINPEN 60 ................ 22
SYNAGIS .......................... 46
SYNAREL ......................... 77
SYNERCID........................ 14
SYPRINE ........................... 66
syring w-ndl,disp,insul,0.3ml
........................................ 61
syring w-ndl,disp,insul,0.5ml
........................................ 61
syringe & needle,insulin,1 ml
........................................ 61
TABLOID .......................... 40
TACLONEX ...................... 93
TACLONEX SCALP......... 93
tacrolimus .......................... 77
TAMIFLU .......................... 46
tamoxifen citrate ................ 40
tamsulosin hcl .................... 93
TARCEVA......................... 40
TARGRETIN ............... 40, 93
TASIGNA .......................... 40
TASMAR ........................... 42
TAZICEF IN DEXTROSE 15
TAZORAC ......................... 93
TE ANATOXAL BERNA . 95
TEGRETOL XR ................ 20
TEKAMLO ........................ 86
TEKTURNA ...................... 86
TEKTURNA HCT ............. 86
temazepam.......................... 49
TENIVAC .......................... 95
terazosin hcl ......................... 3
terbinafine hcl .................... 27
terbutaline sulfate .............. 94
terconazole ......................... 31
TESTIM ............................. 10
testosterone cypionate ........ 10
testosterone enanthate ....... 10
TETANUS DIPHTHERIA
TOXOIDS ...................... 95
TETANUS-DIPHTERIADECAVAC..................... 95
tetracaine hcl/pf.................. 71
tetracycline hcl ................... 18
TEVETEN .......................... 85
TEVETEN HCT ................. 85
TEV-TROPIN .................... 80
THALOMID....................... 77
theophylline anhydrous ...... 89
theophylline/d5w ................ 89
THERACYS ....................... 96
thioridazine hcl................... 84
thiotepa ............................... 40
thiothixene .......................... 84
TIKOSYN .......................... 56
TIMENTIN......................... 17
timolol maleate ............. 28, 49
tinidazole ............................ 43
tizanidine hcl ...................... 91
TOBI................................... 13
TOBRADEX ...................... 29
tobramycin sulf/
dexamethasone ............... 30
tobramycin sulfate ........ 14, 30
tobramycin/sodium chloride
........................................ 14
tolazamide .......................... 25
tolbutamide ......................... 25
tolmetin sodium .................... 5
tolterodine tartrate ............. 64
topiramate .......................... 20
topotecan hcl ...................... 40
TORISEL ........................... 40
torsemide ............................ 61
TOVIAZ ............................. 65
TPN ELECTROLYTES ..... 88
TRACLEER ....................... 98
TRADJENTA ..................... 22
tramadol hcl ......................... 9
tramadol hcl/acetaminophen 9
trandolapril ........................ 86
trandolapril/verapamil hcl . 86
I-14
tranexamic acid ................. 67
tranylcypromine sulfate ..... 81
TRAVAMULSION ........... 55
TRAVASOL ...................... 55
TRAVASOL W/DEXTROSE
....................................... 55
TRAVASOL W/
TRAVASOL with
DEXTROSE .................. 55
TRAVASOL with
TRAVATAN Z .................. 28
TRAVERT ......................... 55
TRAVERT IN NORMAL
SALINE ......................... 55
TRAVERT-ELECTROLYTE
NO.1 .............................. 88
TRAVERT-ELECTROLYTE
NO.2 .............................. 88
TRAVERT-ELECTROLYTE
NO.3 .............................. 88
TRAVERT-ELECTROLYTE
NO.4 .............................. 88
trazodone hcl ..................... 81
TREANDA ........................ 40
TRECATOR ...................... 36
TRELSTAR ....................... 40
tretinoin ....................... 40, 57
TREXALL ......................... 40
triacetin .............................. 27
triamcinolone acetonide 3, 32,
34
triamterene/
hydrochlorothiazid......... 61
triazolam ............................ 49
TRIBENZOR ..................... 85
TRICOR............................. 35
trifluoperazine hcl.............. 84
trifluridine.......................... 30
trihexyphenidyl hcl ............ 42
TRIHIBIT .......................... 95
TRILEPTAL ...................... 20
TRILIPIX........................... 35
trimethoprim ...................... 95
trimipramine maleate ......... 81
TRIPEDIA ......................... 95
tripelennamine hcl ............. 28
TRISENOX ........................ 40
TRIZIVIR .......................... 45
TROPHAMINE ................. 56
tropicamide ........................ 62
trospium chloride ............... 65
TRUVADA ........................ 45
TWINRIX .......................... 96
TYGACIL .......................... 18
TYKERB............................ 40
TYPHIM VI ....................... 96
TYSABRI .......................... 77
TYZEKA............................ 47
TYZINE ............................. 62
ULORIC ............................. 77
UROLOGIC SOLUTION G
........................................ 70
ursodiol .............................. 65
UVADEX ........................... 93
VAGIFEM ......................... 64
valacyclovir hcl .................. 47
VALCYTE ......................... 47
valproate sodium ................ 20
valproic acid ...................... 20
VALSTAR ......................... 40
VALTURNA...................... 86
vancomycin hcl................... 14
VANCOMYCIN HCL ....... 14
vancomycin hcl/d5w ........... 14
VANDETANIB ................. 40
VANTAS ........................... 77
VAQTA.............................. 96
VARIVAX VACCINE ...... 96
vasopressin ......................... 80
VECTIBIX ......................... 41
VELCADE ......................... 41
venlafaxine hcl ................... 82
VENLAFAXINE HCL ER 82
VENTOLIN HFA .............. 94
VERAMYST...................... 32
verapamil hcl ...................... 50
VEREGEN ......................... 31
VERIPRED 20 ..................... 3
VESICARE ........................ 65
VFEND............................... 27
VFEND IV ......................... 27
VICTOZA 3-PAK .............. 22
VICTRELIS ....................... 46
VIDAZA............................. 41
VIDEX ............................... 45
VIGAMOX......................... 30
VIIBRYD ........................... 82
VIMPAT............................. 20
vinblastine sulfate............... 41
vincristine sulfate ............... 41
vinorelbine tartrate ............ 41
VIRACEPT ........................ 45
VIRAMUNE ...................... 45
VIRAMUNE XR ................ 45
VIREAD ............................. 45
VISTIDE ............................ 47
VIVAGLOBIN ................... 91
VIVELLE-DOT ................. 64
VOLTAREN ........................ 5
voriconazole ....................... 27
VOTRIENT ........................ 41
VPRIV ................................ 62
VUMON ............................. 41
VYVANSE ......................... 11
warfarin sodium ................. 67
water for irrigation,sterile.. 70
WELCHOL ........................ 34
WINRHO SDF ................... 91
XALKORI .......................... 41
XARELTO ......................... 67
XENAZINE ........................ 59
XEOMIN ............................ 77
XERAC AC ........................ 48
XGEVA .............................. 77
XIAFLEX ........................... 62
XIFAXAN .......................... 14
XOLAIR ............................. 89
XOLEGEL ......................... 31
I-15
XYLOCAINE .................... 71
XYREM ............................. 59
YERVOY........................... 41
YF-VAX ............................ 97
YODOXIN......................... 43
zafirlukast .......................... 33
zaleplon .............................. 47
ZANOSAR ........................ 41
ZAVESCA ......................... 77
ZELBORAF....................... 41
ZEMAIRA ......................... 89
ZEMPLAR......................... 98
ZENPEP............................. 65
ZERIT ................................ 45
ZETIA ................................ 34
ZETONNA ........................ 32
ZIAGEN ............................ 45
zidovudine .......................... 45
ziprasidone hcl ................... 84
ZIRGAN ............................ 30
ZOLADEX ........................ 41
ZOLINZA .......................... 41
zolpidem tartrate................ 47
ZOMETA........................... 77
ZOMIG ........................ 35, 36
ZOMIG ZMT ..................... 35
ZONALON ........................ 43
zonisamide ......................... 21
ZORBTIVE ....................... 80
ZORTRESS ....................... 77
ZOSTAVAX ...................... 97
ZOSYN .............................. 17
ZOVIRAX ......................... 31
ZYCLARA ........................ 93
ZYLET............................... 30
ZYMAR ............................. 30
ZYMAXID ........................ 30
ZYPREXA ......................... 84
ZYPREXA RELPREVV ... 84
ZYTIGA ............................ 41
ZYVOX ............................. 14
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2013 Formulary (List of covered drugs)

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