Danh sách thuốc được bảo hiểm (Danh mục) năm 2014

Transcription

CARE1ST CAL MEDICONNECT PLAN
Danh sách thuốc được bảo
hiểm (Danh mục) năm 2014
QUẬN: LOS ANGELES VÀ SAN DIEGO
VUI LÒNG ĐỌC KỸ: TÀI LIỆU NÀY CÓ THÔNG TIN VỀ CÁC LOẠI
THUỐC ĐƯỢC BẢO HIỂM TRONG CHƯƠNG TRÌNH NÀY
Danh mục này được cập nhật vào tháng 2 năm 2014. Để biết thêm thông tin mới nhất hoặc
nếu có các thắc mắc khác, vui lòng gọi Care1st Cal MediConnect Plan theo số 1-855-905-3825
(TTY: 711), từ 8:00 sáng – 8:00 tối, bảy ngày trong tuần, hoặc truy cập: www.care1st.com/ca/
calmediconnect
Formulary ID: 00014480, Version: 7
H0148_14_002_RX3_FINAL_VIET Approved
H0148_14_002_RX3_FINAL_VIET Approved
Care1st Cal MediConnect Plan (Medicare-Medicaid Plan) | Danh sách thuốc được bảo hiểm (Danh mục thuốc) năm 2014
Đây là danh sách thuốc mà hội viên có thể nhận được từ Care1st Cal MediConnect Plan.
 Care1st Health Plan là chương trình bảo hiểm y tế ký hợp đồng với cả Medicare và Medi-Cal nhằm cung cấp quyền lợi của cả hai
chương trình cho người ghi danh.
 Quyền lợi, Danh sách thuốc được bảo hiểm, các nhà thuốc và nhà cung cấp dịch vụ được bao gồm trong mạng lưới của Care1st Cal
MediConnect Plan và tiền đồng trả đôi khi có thể thay đổi trong cả năm và vào ngày 1 tháng 1 hàng năm.
 Quý vị luôn có thể kiểm tra Danh sách thuốc được bảo hiểm đã cập nhật của Care1st Cal MediConnect Plan trực tuyến tại
www.care1st.com/ca/calmediconnect hoặc bằng cách gọi số 1-855-905-3825 (TTY: 711).
 Quý vị có thể yêu cầu thông tin này dưới các định dạng khác, như chữ nổi Braille hoặc bản in cỡ lớn. Xin gọi 1-855-905-3825 (TTY:
711). Cuộc gọi này miễn phí.
 Những giới hạn và quy định hạn chế có thể áp dụng. Để biết thêm thông tin, xin gọi Dịch vụ hội viên của Care1st Cal MediConnect Plan.
 Tiền đồng trả cho các loại thuốc theo toa có thể thay đổi theo mức trợ giúp phụ trội Extra Help quý vị được cấp. Vui lòng liên lạc với
chương trình để biết thêm chi tiết
 You can get this information for free in other languages. Call 1-855-905-3825 (TTY users should call 711). The call is free.
Puede recibir esta información sin cargo en otros idiomas. Llame al 1-855-905-3825. Los usuarios de TTY deben llamar al
711. La llamada es gratuita.
您可免费获得本资讯的其他语言版本。请致电免费电话 1-855-905-3825，听障及语障人士请致电711。
您可免費獲得本資訊的其他語言版本。請致電免費電話 1-855-905-3825。聽障及語障人士請致電 711。
.‫ﻤﺎ‬ѧѧ‫ﻮﻧﺎ ﯼم ﺷ‬ѧѧѧ‫ﻪ ار اﻃﻼﻋﺎت نﯼا دﯼﺗ‬ѧѧѧ‫ﻮﺗﺮ ﺑ‬ѧѧѧѧ‫ﺎنﯼار ﺻ‬ѧѧѧ‫ﺎن رد ﮔ‬ѧѧѧ‫ﺮﯼد ﯼﻩﺎ زﺑ‬ѧѧѧ‫ﺖﯼرد ﮔ‬ѧѧѧѧ‫ﻦ اﻓ‬ѧѧѧ‫دﯼﮐ‬
‫( ﺗﻠﻔﻦ‬1-855-905-3825) .‫ارﻳﮕﺎن اﺳﺖ‬
‫ﺎ‬ѧѧѧ‫ﻤﺎرﻩ ﺑ‬ѧѧ‫ﻦ ﺷ‬ѧѧ ѧѧѧѧѧѧѧ‫ ﺗﻠﻔ‬711 .‫ﺎس‬ѧѧѧ‫ﮓ ﺗﻤ‬ѧѧ‫( دﯼرﯼﺑ‬TTY) ‫ﺮا‬ѧѧѧ‫ﺧﺪﻣﺎت ﯼﺑ‬
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Nếu quý vị có thắc mắc, vui lòng gọi cho Care1st Cal MediConnect Plan theo số 1-855-905-3825 (TTY: 711), 8:00 sáng – 8:00 tối,
bảy ngày trong tuần. Cuộc gọi này miễn phí. Để biết thêm thông tin, hãy truy cập www.care1st.com/ca/calmediconnect.
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Դուք կարող եք անվճար ստանալ այս տեղեկությունն այլ լեզուներով: Զանգահարեք 1-855-905-3825 հեռախոսահամարներով: TTY օգտվողները
պետք է զանգահարել 711: Զանգն անվճար է:
អ្នកអាចយកព័ត៌មានេនះេដាយឥតគិតៃថ្លេនៅក្នុងភាសាេផ ងេទៀត។ េហៅ 1-855-905-3825 េលាកអ្នកែដលេ្រលើ TTY េលតាទូរស័ព្ទេលៅលលខ
711។ ការេហៅេនះគឺឥតគិតៃថ្ល។
본 정보를 무료로 다른 언어로 받아보실 수 있습니다. 1-855-905-3825 번으로 전화해 주십시오. TTY 사용자는 711번으로
전화해 주십시오. 통화는 무료입니다.
Эту информацию вы можете получить бесплатно в переводе на другие языки. Позвоните по телефону 1-855-9053825. Пользователи TTY должны позвонить 711. Звонки по этому телефону бесплатные.
Maaari ninyong makuha nang libre ang impormasyon na ito sa ibang mga wika. Tawagan ang 1-855-905-3825. Ang
gumagamit ng TTY ay dapat tumawag sa 711. Libre ang tawag.
.3825-905-855-1‫ اﺗﺼﻞ‬.‫ﻳﻤﻜﻨﻚ اﻟﺤﺼﻮل ﻋﻠﻰ هﺬﻩ اﻟﻤﻌﻠﻮﻣﺎت ﻣﺠﺎﻧﺎ ﻓﻲ ﻟﻐﺎت أﺧﺮى‬
. ‫ اﻟﻤﻜﺎﻟﻤﺔ ﻣﺠﺎﻧﻴﺔ‬. 711 ‫( ﻳﺠﺐ ﻋﻠﻰ اﻟﻤﺴﺘﺨﺪﻣﻴﻦ اﻻﺗﺼﺎل ب‬TTY) ‫واﻟﻨﻄﻖ اﻟﺴﻤﻊ ﺿﻌﺎف‬
Quý vị có thể nhận thông tin này miễn phí bằng các ngôn ngữ khác. Hãy gọi 1-855-905-3825. Người sử dụng TTY nên gọi 711. Cuộc gọi
này được miễn phí.
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Các câu hỏi thường gặp (FAQ)
Hãy tìm các câu trả lời cho các câu hỏi của quý vị về Danh sách thuốc được bảo hiểm tại đây. Quý vị có thể đọc tất cả các câu hỏi thường
gặp để biết thêm hoặc tìm một câu hỏi và đáp cụ thể.
Loại thuốc theo toa nào thuộc Danh sách thuốc được bảo hiểm?
(Chúng tôi gọi tắt Danh sách thuốc được bảo hiểm là “Danh sách thuốc”.)
1.
Thuốc có trong Danh sách thuốc là những thuốc được Care1st Cal MediConnect Plan bảo hiểm. Thuốc có sẵn tại các nhà thuốc trong mạng
lưới của chúng tôi. Một nhà thuốc được xem là nằm trong mạng lưới của chúng tôi nếu chúng tôi có thỏa thuận làm việc với họ và họ cung
cấp dịch vụ cho quý vị. Chúng tôi gọi những nhà thuốc này là “nhà thuốc trong mạng lưới.”
Care1st Cal MediConnect Plan sẽ bảo hiểm cho tất cả các loại thuốc cần thiết về mặt y tế có trong Danh sách thuốc nếu:
 bác sĩ hoặc người kê toa của quý vị nói rằng quý vị cần những loại thuốc này để phục hồi hoặc để giữ gìn sức khỏe; và
 quý vị mua thuốc theo toa tại một nhà thuốc trong mạng lưới của Care1st Cal MediConnect Plan.
 Trong một số trường hợp, quý vị cần làm gì đó trước khi quý vị có thể nhận được thuốc (xem câu hỏi số 5 bên dưới).
 Quý vị cũng có thể xem danh sách thuốc được chúng tôi bảo hiểm đã cập nhật trên trang mạng của chúng tôi tại
www.care1st.com/ca/calmediconnect hoặc gọi Dịch vụ hội viên theo số 1-855-905-3825 (TTY: 711).
Danh sách thuốc có bao giờ thay đổi không?
2.
Có Care1st Cal MediConnect Plan có thể thêm vào hoặc loại bỏ thuốc ra khỏi Danh sách thuốc trong cả năm. Nhìn chung, Danh sách thuốc
sẽ chỉ thay đổi nếu:
 một loại thuốc rẻ hơn xuất hiện có hiệu quả như thuốc trong Danh sách thuốc hiện tại; hoặc
 chúng tôi phát hiện ra rằng loại thuốc đó không an toàn.
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Chúng tôi cũng có thể thay đổi quy tắc về thuốc. Ví dụ, chúng tôi có thể:
 Quyết định yêu cầu hoặc không yêu cầu sự chấp thuận trước cho một thuốc nào đó. (Chấp thuận trước là sự cho phép của Care1st Cal
MediConnect Plan trước khi quý vị có thể nhận thuốc.)
 Bổ sung hoặc thay đổi số lượng thuốc của một thuốc nào đó quý vị có thể nhận được (gọi là “giới hạn số lượng”).
 Bổ sung hoặc thay đổi quy định hạn chế về trị liệu từng bước đối với một thuốc nào đó. (Trị liệu từng bước nghĩa là quý vị phải thử một
loại thuốc trước khi chúng tôi bảo hiểm cho một loại thuốc khác.)
(Để biết thêm thông tin về những quy tắc thuốc này, hãy xem trang 5.)
Chúng tôi sẽ cho quý vị biết khi thuốc quý vị đang dùng bị loại ra khỏi Danh sách thuốc. Chúng tôi cũng sẽ cho quý vị biết khi nào chúng tôi
thay đổi quy tắc về việc bảo hiểm cho một loại thuốc. Các câu hỏi 3, 4 và 7 ở trang 4 - 6 có thêm thông tin về điều gì sẽ xảy ra khi Danh sách
thuốc thay đổi.
 Quý vị luôn có thể kiểm tra Danh sách thuốc cập nhật của Care1st Cal MediConnect Plan trực tuyến tại
www.care1st.com/ca/calmediconnect.
 Quý vị cũng có thể gọi Dịch vụ hội viên để kiểm tra Danh sách thuốc hiện tại theo số 1-855-905-3825 (TTY: 711).
3.
Điều gì sẽ xảy ra khi một loại thuốc rẻ hơn xuất hiện có hiệu quả như thuốc có trong Danh sách
thuốc hiện tại?
Nếu quý vị đang dùng một loại thuốc bị loại bỏ vì một loại thuốc rẻ hơn có hiệu quả tương tự xuất hiện, chúng tôi sẽ thông báo cho quý vị
biết. Chúng tôi sẽ thông báo cho quý vị ít nhất 60 ngày trước khi chúng tôi loại bỏ thuốc đó ra khỏi Danh sách thuốc hoặc khi quý vị yêu cầu
mua thêm thuốc. Khi đó quý vị có thể nhận được một lượng thuốc đủ dùng trong 60 ngày trước khi thuốc đó bị loại ra khỏi danh sách thuốc.
Mỗi tháng Care1st Cal MediConnect Plan gửi cho quý vị qua đường bưu điện bản báo cáo có tên là “Bản giải thích về quyền lợi”
(“Explanation of Benefits”) hay gọi tắt là “EOB”. Bản EOB cho quý vị biết tổng số tiền quý vị đã trả cho thuốc theo toa và tổng số tiền chúng tôi
đã trả cho mỗi loại thuốc theo toa của quý vị trong tháng. Cùng với bản EOB, chúng tôi sẽ gửi cho quý vị “Phụ bản về thay đổi danh mục
thuốc” nếu gần đây có bất kỳ thay đổi nào đối với danh mục thuốc của chúng tôi. Ngay cả khi quý vị không có mua thuốc theo toa nào cả
trong thời gian gần đây, khi nhận được tài liệu này, xin quý vị hãy đọc kỹ để biết xem danh mục thuốc có gì thay đổi hay không.
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Điều gì sẽ xảy ra khi chúng tôi phát hiện một loại thuốc không an toàn?
4.
Nếu Cục quản lý Thực phẩm và Dược phẩm Hoa Kỳ (Food and Drug Administration - FDA) nói rằng loại thuốc quý vị đang dùng không an
toàn, chúng tôi sẽ loại bỏ thuốc đó ra khỏi Danh sách thuốc ngay lập tức. Chúng tôi cũng sẽ gửi thư cho quý vị để thông báo rằng thuốc đó
đã bị loại bỏ ra khỏi Danh sách thuốc và hướng dẫn quý vị điều cần làm tiếp theo.
Có bất kỳ quy định hạn chế hoặc giới hạn nào đối với bảo hiểm thuốc không? Hoặc có cần thực
hiện hành động bắt buộc nào để nhận một số loại thuốc nhất định hay không?
5.
Đúng vậy, một số loại thuốc có những quy tắc bảo hiểm hoặc có giới hạn về số lượng quý vị có thể nhận được. Trong một số trường hợp,
quý vị phải thực hiện vài điều trước khi quý vị có thể nhận được thuốc. Ví dụ:
 Sự chấp thuận trước (hoặc sự cho phép trước): Đối với một số loại thuốc, quý vị hoặc bác sĩ của quý vị phải nhận được sự chấp
thuận từ Care1st Cal MediConnect Plan trước khi quý vị mua thuốc theo toa. Nếu quý vị không được chấp thuận, Care1st Cal
MediConnect Plan có thể không bảo hiểm cho thuốc này.
 Giới hạn số lượng: Đôi khi Care1st Cal MediConnect Plan giới hạn số lượng một loại thuốc quý vị có thể nhận.
 Trị liệu từng bước: Đôi khi Care1st Cal MediConnect Plan yêu cầu quý vị thực hiện trị liệu từng bước. Điều này có nghĩa là quý vị sẽ
phải dùng thử các thuốc theo một thứ tự nhất định cho tình trạng sức khỏe của mình. Quý vị có thể phải dùng thử một loại thuốc trước
khi chúng tôi bảo hiểm cho một loại thuốc khác. Nếu bác sĩ của quý vị cho rằng loại thuốc đầu tiên không có tác dụng với quý vị, chúng
tôi sẽ bảo hiểm cho loại thuốc thứ hai.
Quý vị có thể tìm hiểu liệu thuốc của quý vị có bất kỳ yêu cầu bổ sung hoặc giới hạn nào không bằng cách tra cứu trong các bảng ở trang 31174. Quý vị cũng có thể lấy thêm thông tin bằng cách truy cập trang mạng của chúng tôi tại www.care1st.com/ca/calmediconnect. Quý vị
cũng có thể yêu cầu “trường hợp ngoại lệ” cho những giới hạn này. Vui lòng xem Câu hỏi 11 để biết thêm thông tin về các trường hợp ngoại
lệ.
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Nếu quý vị đang sống trong nhà điều dưỡng hoặc một cơ sở chăm sóc dài hạn khác và cần loại thuốc không có trong Danh sách thuốc,
hoặc nếu quý vị không thể dễ dàng nhận được loại thuốc quý vị cần, chúng tôi có thể giúp đỡ. Chúng tôi sẽ bảo hiểm số lượng thuốc cấp
cứu quý vị cần đủ dùng trong 31 ngày (trừ khi quý vị có toa thuốc kê cho số ngày ít hơn), dù quý vị có phải là hội viên mới của Care1st
Cal MediConnect Plan hay không. Như thế, quý vị có thời gian trao đổi với bác sĩ hoặc người kê toa khác của quý vị. Người này có thể
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giúp quý vị quyết định liệu có một loại thuốc tương tự trong Danh sách thuốc quý vị có thể dùng thay thế hoặc liệu có cần yêu cầu trường
hợp ngoại lệ hay không. Vui lòng xem Câu hỏi 11 để biết thêm thông tin về các trường hợp ngoại lệ.
Làm thế nào quý vị biết liệu loại thuốc quý vị cần có giới hạn hoặc liệu có bắt buộc làm gì để nhận
được thuốc hay không?
6.
Danh sách thuốc được bảo hiểm ở trang 47-174 có một cột tên là “Hành động cần thiết, quy định hạn chế hoặc giới hạn sử dụng.”
Điều gì sẽ xảy ra nếu chúng tôi thay đổi quy tắc về cách thức chúng tôi bảo hiểm cho một số loại
thuốc? Ví dụ: nếu chúng tôi yêu cầu phải có thêm sự cho phép (chấp thuận) trước, giới hạn số
lượng và/hoặc quy định hạn chế về trị liệu từng bước đối với một loại thuốc.
7.
Chúng tôi sẽ thông báo cho quý vị biết nếu chúng tôi yêu cầu phải có thêm sự chấp thuận trước, giới hạn số lượng và/hoặc quy định hạn chế
về trị liệu từng bước đối với một loại thuốc. Chúng tôi sẽ thông báo cho quý vị biết ít nhất 60 ngày trước khi quy định hạn chế được thêm vào
hoặc khi quý vị yêu cầu nhà thuốc của mình bán thêm thuốc. Sau đó, quý vị có thể nhận được một lượng thuốc đủ dùng trong 60 ngày trước
khi thay đổi đối với các quy tắc bảo hiểm được thực hiện. Như thế, quý vị có thời gian trao đổi với bác sĩ của mình về điều cần làm tiếp theo.
Làm thế nào quý vị có thể tìm thấy một loại thuốc trong Danh sách thuốc?
8.
Có hai cách để tìm kiếm một loại thuốc:
 Quý vị có thể tìm theo thứ tự bảng chữ cái (nếu quý vị biết đánh vần tên thuốc); hoặc
 Quý vị có thể tìm theo bệnh trạng.
Để tìm theo thứ tự bảng chữ cái, vui lòng tới mục Danh sách theo thứ tự bảng chữ cái. Quý vị có thể thấy danh sách này ở bảng chú dẫn
bắt đầu từ trang 175. Bảng chú dẫn này cung cấp một danh sách theo thứ tự bảng chữ cái của tất cả các loại thuốc có trong tài liệu này. Cả
hai loại thuốc chính hiệu và thuốc gốc được liệt kê trong Bảng chú dẫn này. Tìm tên thuốc của quý vị trong Bảng chú dẫn. Bên cạnh tên thuốc
là số trang nơi quý vị có thể xem thông tin về bảo hiểm cho loại thuốc này. Lật đến trang ghi trong Bảng chú dẫn này và tìm tên thuốc của quý
vị ở cột đầu tiên trong danh sách.
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6
Để tìm theo bệnh trạng, tìm mục có tên “Danh sách thuốc theo bệnh trạng” ở trang 47 - 174. Sau đó tìm bệnh trạng của quý vị. Ví dụ: nếu
quý vị bị bệnh tim, quý vị cần tìm tại mục đó. Đó là nơi quý vị sẽ tìm thấy thuốc điều trị bệnh tim.
Điều gì xảy ra nếu loại thuốc quý vị muốn dùng không có trong Danh sách thuốc?
9.
Nếu quý vị không thấy loại thuốc của mình trong Danh sách thuốc, xin gọi Dịch vụ hội viên theo số 1-855-905-3825 (TTY: 711) và hỏi về vấn
đề này. Nếu quý vị biết rằng Care1st Cal MediConnect Plan sẽ không bảo hiểm cho loại thuốc đó, quý vị có thể thực hiện một trong những
điều sau đây:
 Yêu cầu Dịch vụ hội viên cho một danh sách các loại thuốc giống loại quý vị muốn dùng. Sau đó cho bác sĩ hoặc người kê toa khác của
quý vị xem danh sách đó. Người đó có thể kê một loại thuốc có trong Danh sách thuốc giống loại thuốc quý vị muốn dùng. Hoặc
 Quý vị có thể yêu cầu chương trình bảo hiểm y tế cấp trường hợp ngoại lệ để bảo hiểm cho thuốc của quý vị. Vui lòng xem câu hỏi 11
để biết thêm thông tin về các trường hợp ngoại lệ.
10. Điều gì xảy ra nếu quý vị là hội viên mới của Care1st Cal MediConnect Plan và không thể tìm thấy
loại thuốc của mình trong Danh sách thuốc hoặc có vấn đề trong việc nhận loại thuốc của mình?
Chúng tôi có thể giúp đỡ. Chúng tôi có thể bảo hiểm cho số lượng thuốc của quý vị đủ dùng tạm thời trong 30 ngày trong thời hạn 90 ngày
đầu tiên quý vị là hội viên của Care1st Cal MediConnect Plan. Như thế, quý vị có thời gian trao đổi với bác sĩ hoặc người kê toa khác của quý
vị. Người này có thể giúp quý vị quyết định liệu có một loại thuốc tương tự trong Danh sách thuốc mà quý vị có thể dùng thay thế hoặc liệu có
phải yêu cầu trường hợp ngoại lệ hay không.
Chúng tôi sẽ bảo hiểm cho một số lượng thuốc của quý vị đủ dùng trong 30 ngày nếu:
 quý vị đang dùng một loại thuốc không có trong Danh sách thuốc của chúng tôi; hoặc
 các quy tắc của chương trình bảo hiểm y tế không cho phép quý vị nhận được số lượng do người kê toa của quý vị chỉ định; hoặc
 loại thuốc phải có sự chấp thuận trước của Care1st Cal MediConnect Plan; hoặc
 quý vị đang dùng một loại thuốc là một phần trong quy định hạn chế về trị liệu từng bước.
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Nếu quý vị sống trong nhà điều dưỡng hoặc cơ sở chăm sóc dài hạn khác, quý vị có thể mua thêm thuốc theo toa trong vòng 91 ngày. Quý vị
có thể mua thêm thuốc nhiều lần trong vòng 91 ngày. Điều này cho phép người kê toa của quý vị có thời gian để chuyển các loại thuốc của
quý vị sang những loại có trong Danh sách thuốc hoặc yêu cầu trường hợp ngoại lệ.
Chính sách chuyển tiếp
Trong trường hợp người hưởng lợi đổi cơ sở điều trị sang cơ sở khác, Care1st Cal MediConnect Plan sẽ đảm bảo thực hiện thủ tục chấp
thuận nhanh chóng các loại thuốc Phần D không có trong danh mục. Thủ tục này cũng sẽ áp dụng cho các loại thuốc Phần D trong danh
mục mà cần được cho phép trước hoặc thuộc loại trị liệu từng bước. Ví dụ về những thay đổi cấp bậc chăm sóc là: người hưởng lợi được
xuất viện về nhà; người hưởng lợi vừa chấm dứt thời gian ở tại cơ sở điều dưỡng chuyên môn được bảo hiểm qua Medicare Phần A và cần
được chuyển trở lại vào nhóm quyền lợi thuốc trong danh mục chương trình thuộc Phần D; người hưởng lợi vừa chấm dứt thời gian ở tại cơ
sở chăm sóc dài hạn và trở về sống trong cộng đồng; và người hưởng lợi được xuất viện từ bệnh viện tâm thần với chương trình điều trị
bằng những loại thuốc thật đặc biệt dành riêng cho bệnh nhân.
Dịch vụ ngoài giờ làm việc của Care1st Cal MediConnect Plan sẽ cho phép các nhà thuốc liên lạc với nhân viên đại diện của chương trình có
quyền quyết định những vấn đề xử lý yêu cầu bảo hiểm của nhà thuốc. Cách tiếp cận này sẽ cho phép các nhà thuốc có được quyết định yêu
cầu bảo hiểm toa thuốc tại điểm bán thuốc và đảm bảo người hưởng lợi được tiếp cận thuốc họ cần một cách đáng tin cậy.
11. Quý vị có thể yêu cầu trường hợp ngoại lệ để bảo hiểm cho loại thuốc của mình hay không?
Có Quý vị có thể yêu cầu Care1st Cal MediConnect Plan cấp trường hợp ngoại lệ để bảo hiểm cho thuốc không có trong Danh sách thuốc.
Quý vị cũng có thể yêu cầu chúng tôi thay đổi quy tắc về loại thuốc quý vị dùng.
 Ví dụ: Care1st Cal MediConnect Plan có thể giới hạn số lượng một loại thuốc chúng tôi sẽ bảo hiểm. Nếu loại thuốc của quý vị có giới
hạn, quý vị có thể yêu cầu chúng tôi thay đổi giới hạn và bảo hiểm thêm.
 Các ví dụ khác: Quý vị có thể yêu cầu chúng tôi hủy bỏ quy định hạn chế về trị liệu từng bước hoặc yêu cầu về sự chấp thuận trước.
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12. Mất bao lâu để được cấp trường hợp ngoại lệ?
Đầu tiên, chúng tôi phải nhận được bản tuyên bố từ người kê toa của quý vị ủng hộ việc quý vị yêu cầu trường hợp ngoại lệ. Sau khi chúng
tôi nhận được bản tuyên bố đó, chúng tôi sẽ quyết định về yêu cầu trường hợp ngoại lệ của quý vị trong vòng 72 giờ.
Nếu quý vị hoặc người kê toa của quý vị cho rằng sức khỏe của quý vị có thể bị tổn hại nếu quý vị phải chờ 72 giờ để nhận được quyết định,
quý vị có thể yêu cầu quyết định khẩn. Đây là quyết định nhanh hơn. Nếu người kê toa của quý vị ủng hộ đề nghị của quý vị, chúng tôi sẽ ra
quyết định cho quý vị trong vòng 24 giờ kể từ khi nhận được tuyên bố ủng hộ của người kê toa của quý vị.
13. Làm thế nào quý vị có thể yêu cầu trường hợp ngoại lệ?
Để yêu cầu trường hợp ngoại lệ, xin gọi Dịch vụ hội viên. Dịch vụ hội viên sẽ làm việc với quý vị và nhà cung cấp dịch vụ của quý vị để giúp
quý vị yêu cầu trường hợp ngoại lệ.
14. Thuốc gốc là gì?
Thuốc gốc được sản xuất từ những thành phần tương tự như thuốc chính hiệu. Chúng thường rẻ hơn thuốc chính hiệu và tên của chúng ít
phổ dụng hơn. Thuốc gốc được Cục quản lý Thực phẩm và Dược phẩm (Food and Drug Administration - FDA) chấp thuận.
Chương trình Care1st Cal MediConnect Plan bảo hiểm cho cả thuốc chính hiệu lẫn thuốc gốc.
15. Thuốc mua không cần toa (OTC) là gì?
OTC là viết tắt của từ “over-the-counter” (“không cần toa”). Quý vị có thể mua thuốc OTC mà không cần đến toa thuốc.
Care1st Cal MediConnect Plan bảo hiểm cho một số loại thuốc OTC. Care1st Cal MediConnect Plan sẽ cung cấp miễn phí những loại thuốc
OTC này cho quý vị.
Quý vị có thể đọc Danh sách thuốc của Care1st Cal MediConnect Plan để xem loại thuốc OTC nào được bảo hiểm.
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16. Care1st Cal MediConnect Plan có bảo hiểm cho các sản phẩm OTC không phải thuốc hay không?
Care1st Cal MediConnect Plan bảo hiểm cho một số sản phẩm OTC không phải thuốc.
Quý vị có thể đọc Danh sách thuốc của Care1st Cal MediConnect Plan để xem loại sản phẩm OTC không phải thuốc nào được bảo hiểm.
17. Tiền đồng trả của quý vị là gì?
Quý vị có thể đọc Danh sách thuốc của Care1st Cal MediConnect Plan để biết về tiền đồng trả cho mỗi loại thuốc. Hội viên của Care1st Cal
MediConnect Plan sống trong các nhà điều dưỡng hoặc các cơ sở chăm sóc dài hạn sẽ không phải trả tiền đồng trả. Một số hội viên được
chăm sóc dài hạn tại cộng đồng cũng sẽ không phải trả tiền đồng trả.
Tiền đồng trả được liệt kê theo bậc. Số tiền đồng trả sẽ thay đổi dựa trên mức đủ tiêu chuẩn tham gia Medicaid của quý vị.
Bậc
Mô tả
Tiền đồng trả
số lượng đủ dùng
trong 30 ngày
?
số lượng đủ dùng
trong 90 ngày
Bậc 1
Thuốc gốc
$0 đến $2.55 tiền
đồng trả
đồng trả
Bậc 2
Thuốc chính hiệu
đồng trả
đồng trả
Bậc 3
Thuốc theo toa (Rx) không
phải Medicare / Thuốc mua
không cần toa (OTC)
$0.00 tiền đồng trả
$0.00 tiền đồng trả
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Danh sách thuốc được bảo hiểm
Danh sách thuốc được bảo hiểm bắt đầu từ trang kế cung cấp cho quý vị thông tin về các thuốc được Care1st Cal MediConnect Plan bảo
hiểm. Nếu quý vị không tìm được thuốc của quý vị trong danh sách, xin lật sang Bảng chú dẫn bắt đầu từ trang 175.
Cột đầu tiên của bảng này ghi tên thuốc. Thuốc chính hiệu được viết hoa (ví dụ: IMITREX) và thuốc gốc được ghi bằng chữ thường, viết
nghiêng (ví dụ: simvastatin).
Thông tin trong cột “Hành động cần thiết, quy định hạn chế hoặc giới hạn sử dụng” cho quý vị biết Care1st Cal MediConnect Plan có quy tắc
nào về việc bảo hiểm thuốc của quý vị hay không.
Chú thích về Chữ viết tắt được sử dụng để Yêu cầu/Giới hạn trong Danh sách thuốc
Chữ viết tắt
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Mô tả
PA
Phải có sự cho phép trước.
QL
Giới hạn số lượng
ST
Trị liệu từng bước
BvD
Phải có sự cho phép trước
để xác định bảo hiểm thuộc
Phần B hay Phần D
PA>65
Phải có sự cho phép trước
đối với hội viên trên 65 tuổi
Giải thích
Quý vị (hoặc bác sĩ của quý vị) được yêu cầu phải có sự cho phép trước từ Care1st Cal
MediConnect Plan trước khi quý vị mua thuốc này theo toa. Nếu không có sự chấp thuận
trước, Care1st Cal MediConnect Plan có thể không bảo hiểm cho thuốc này.
Care1st Cal MediConnect Plan giới hạn số lượng được bảo hiểm trong một khoảng thời
gian cụ thể cho thuốc này.
Trước khi Care1st Cal MediConnect Plan cung cấp bảo hiểm cho thuốc này, đầu tiên quý vị
phải thử một loại thuốc khác trong danh mục thuốc để điều trị bệnh trạng của quý vị. Thuốc
này chỉ có thể được bảo hiểm nếu (các) thuốc khác không có tác dụng với quý vị.
Thuốc này có thể đủ tiêu chuẩn được chi trả theo Medicare Phần B hoặc Phần D. Quý vị
(hoặc bác sĩ của quý vị) được yêu cầu phải có sự cho phép trước từ Care1st Cal
MediConnect Plan để quyết định thuốc này có được bảo hiểm theo Medicare Phần D hay
không trước khi quý vị mua thuốc này theo toa. Nếu không có sự chấp thuận trước,
Care1st Cal MediConnect Plan có thể không bảo hiểm cho loại thuốc này.
Quý vị (hoặc bác sĩ của quý vị) được yêu cầu phải có sự cho phép trước từ Care1st Cal
MediConnect Plan trước khi quý vị mua thuốc này theo toa, nếu quý vị trên 65 tuổi.
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Chú thích các biểu tượng trong Danh sách thuốc
Biểu
tượng
Ghi chú
~
Toa thuốc này có thể chỉ mua được tại một số nhà thuốc nào thôi. Để biết thêm thông tin, xin gọi Dịch vụ hội viên của Care1st Cal
MediConnect Plan.
+
Đây là thuốc duy trì. Số lượng thuốc này đủ dùng cho đến 90 ngày được cung cấp qua nhà thuốc bán qua bưu điện trong mạng
lưới và qua một số các nhà thuốc bán lẻ trong mạng lưới của chúng tôi. Để biết thêm thông tin, xin gọi Dịch vụ hội viên của
Care1st Cal MediConnect Plan.
*
Thuốc này được Medicaid bảo hiểm và không phải là “thuốc Phần D.” Nếu quý vị có thắc mắc, xin gọi Dịch vụ hội viên của
Care1st Cal MediConnect Plan.
Lưu ý: Dấu sao (*) cạnh một loại thuốc có nghĩa là thuốc đó không phải “thuốc Phần D.” Số tiền quý vị phải trả khi quý vị mua thuốc này theo
toa không được tính vào tổng chi phí thuốc của quý vị (có nghĩa là, số tiền quý vị trả không giúp quý vị đủ điều kiện nhận bảo hiểm tai ương).
Các loại thuốc này cũng có những quy tắc khác nhau về kháng cáo. Kháng cáo là một cách chính thức yêu cầu chúng tôi xem xét quyết định
chúng tôi đã đưa ra về bảo hiểm của quý vị và thay đổi bảo hiểm nếu quý vị nghĩ rằng chúng tôi đã làm sai. Ví dụ: chúng tôi có thể quyết định
Medicare hoặc Medi-Cal không bảo hiểm hay không còn bảo hiểm cho loại thuốc quý vị cần. Nếu quý vị hoặc bác sĩ của quý vị không đồng ý
với quyết định của chúng tôi, quý vị có thể kháng cáo. Nếu quý vị có thắc mắc, xin gọi Dịch vụ hội viên theo số 1-855-905-3825 (TTY: 711).
Quý vị cũng có thể đọc Sổ tay hội viên để biết cách kháng cáo một quyết định.
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Table of Contents
QUANTITY LIMITS TABLE ....................................................................................................................................................19
QUANTITY LIMITS TABLE .................................................................................................................................................................... 19
ANALGESICS .......................................................................................................................................................................33
ANALGESICS, MISCELLANEOUS ......................................................................................................................................................... 33
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS ............................................................................................................................... 35
ANESTHETICS ......................................................................................................................................................................37
LOCAL ANESTHETICS ........................................................................................................................................................................ 37
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS .............................................................................................38
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS .............................................................................................................. 38
ANTIANXIETY AGENTS .......................................................................................................................................................39
BENZODIAZEPINES ............................................................................................................................................................................ 39
ANTIBACTERIALS ................................................................................................................................................................40
AMINOGLYCOSIDES ......................................................................................................................................................................... 40
ANTIBACTERIALS, MISCELLANEOUS ................................................................................................................................................... 40
CEPHALOSPORINS ............................................................................................................................................................................ 41
MACROLIDES .................................................................................................................................................................................... 43
MISCELLANEOUS B-LACTAM ANTIBIOTICS ......................................................................................................................................... 44
PENICILLINS ...................................................................................................................................................................................... 44
QUINOLONES .................................................................................................................................................................................. 46
SULFONAMIDES ................................................................................................................................................................................ 47
TETRACYCLINES ................................................................................................................................................................................ 47
ANTICANCER AGENTS.........................................................................................................................................................48
ANTICANCER AGENTS....................................................................................................................................................................... 48
ANTICONVULSANTS ...........................................................................................................................................................54
ANTICONVULSANTS .......................................................................................................................................................................... 54
ANTIDEMENTIA AGENTS ....................................................................................................................................................58
ANTIDEMENTIA AGENTS .................................................................................................................................................................... 58
ANTIDEPRESSANTS .............................................................................................................................................................59
ANTIDEPRESSANTS ............................................................................................................................................................................ 59
If you have questions, please call Care1st Cal MediConnect Plan at 1-855-905-3825 (TTY:711), 8:00 a.m. - 8:00 p.m., seven days a week.
The call is free. For more information, visit www.care1st.com/ca/calmediconnect.
13
Table of Contents
ANTIDIABETIC AGENTS .......................................................................................................................................................62
ANTIDIABETIC AGENTS, MISCELLANEOUS ......................................................................................................................................... 62
INSULINS........................................................................................................................................................................................... 63
SULFONYLUREAS ............................................................................................................................................................................... 65
THIAZOLIDINEDIONES ...................................................................................................................................................................... 65
ANTIFUNGALS ....................................................................................................................................................................66
ANTIFUNGALS ................................................................................................................................................................................... 66
ANTIHISTAMINES ...............................................................................................................................................................68
ANTIHISTAMINES ............................................................................................................................................................................... 68
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE).........................................................................................................69
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) .......................................................................................................................... 69
ANTIMIGRAINE AGENTS .....................................................................................................................................................69
ANTIMIGRAINE AGENTS .................................................................................................................................................................... 69
ANTIMYCOBACTERIALS .......................................................................................................................................................70
ANTIMYCOBACTERIALS ..................................................................................................................................................................... 70
ANTINAUSEA AGENTS ........................................................................................................................................................71
ANTINAUSEA AGENTS ....................................................................................................................................................................... 71
ANTIPARASITE AGENTS ......................................................................................................................................................72
ANTIPARASITE AGENTS ...................................................................................................................................................................... 72
ANTIPARKINSONIAN AGENTS ...........................................................................................................................................73
ANTIPARKINSONIAN AGENTS ............................................................................................................................................................ 73
ANTIPSYCHOTIC AGENTS ...................................................................................................................................................75
ANTIPSYCHOTIC AGENTS ................................................................................................................................................................. 75
ANTIVIRALS (SYSTEMIC) ......................................................................................................................................................78
ANTIRETROVIRALS ............................................................................................................................................................................. 78
ANTIVIRALS, MISCELLANEOUS ........................................................................................................................................................... 81
HCV PROTEASE INHIBITORS .............................................................................................................................................................. 82
INTERFERONS ................................................................................................................................................................................... 82
14
Table of Contents
NUCLEOSIDES AND NUCLEOTIDES ................................................................................................................................................... 82
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS ......................................................................................................83
ANTICOAGULANTS ........................................................................................................................................................................... 83
BLOOD FORMATION MODIFIERS ...................................................................................................................................................... 84
HEMATOLOGIC AGENTS, MISCELLANEOUS ...................................................................................................................................... 85
PLATELET-AGGREGATION INHIBITORS............................................................................................................................................... 85
CALORIC AGENTS ...............................................................................................................................................................86
CALORIC AGENTS ............................................................................................................................................................................. 86
CARDIOVASCULAR AGENTS ................................................................................................................................................87
ALPHA-ADRENERGIC AGENTS ............................................................................................................................................................ 87
ANGIOTENSIN II RECEPTOR ANTAGONISTS ...................................................................................................................................... 88
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ........................................................................................................................... 88
ANTIARRHYTHMIC AGENTS ............................................................................................................................................................... 89
BETA-ADRENERGIC BLOCKING AGENTS ............................................................................................................................................ 90
CALCIUM-CHANNEL BLOCKING AGENTS .......................................................................................................................................... 91
CARDIOVASCULAR AGENTS, MISCELLANEOUS .................................................................................................................................. 92
DIHYDROPYRIDINES .......................................................................................................................................................................... 94
DIURETICS ......................................................................................................................................................................................... 94
DYSLIPIDEMICS .................................................................................................................................................................................. 95
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ............................................................................................................... 97
VASODILATORS ................................................................................................................................................................................. 97
CENTRAL NERVOUS SYSTEM AGENTS .................................................................................................................................98
CENTRAL NERVOUS SYSTEM AGENTS ................................................................................................................................................ 98
CONTRACEPTIVES ...............................................................................................................................................................99
CONTRACEPTIVES ............................................................................................................................................................................. 99
DENTAL AND ORAL AGENTS ............................................................................................................................................104
DENTAL AND ORAL AGENTS ........................................................................................................................................................... 104
DERMATOLOGICAL AGENTS .............................................................................................................................................105
DERMATOLOGICAL AGENTS, OTHER .............................................................................................................................................. 105
DERMATOLOGICAL ANTIBACTERIALS ............................................................................................................................................... 106
15
Table of Contents
DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS ......................................................................................................................... 107
DERMATOLOGICAL RETINOIDS ....................................................................................................................................................... 111
SCABICIDES AND PEDICULICIDES .................................................................................................................................................... 112
DEVICES ............................................................................................................................................................................112
DEVICES .......................................................................................................................................................................................... 112
ENZYME REPLACEMENT/MODIFIERS .................................................................................................................................112
ENZYME REPLACEMENT/MODIFIERS ................................................................................................................................................ 112
EYE, EAR, NOSE, THROAT AGENTS ...................................................................................................................................114
EYE, EAR, NOSE, THROAT ANTI-INFECTIVES AGENTS ....................................................................................................................... 114
EYE, EAR, NOSE, THROAT ANTI-INFLAMMATORY AGENTS ............................................................................................................... 116
EYE, EAR, NOSE, THROAT DRUGS, MISCELLANEOUS ....................................................................................................................... 116
GASTROINTESTINAL AGENTS ...........................................................................................................................................118
ANTIULCER AGENTS AND ACID SUPPRESSANTS ............................................................................................................................... 118
GASTROINTESTINAL AGENTS, OTHER .............................................................................................................................................. 119
LAXATIVES ....................................................................................................................................................................................... 120
PHOSPHATE BINDERS ...................................................................................................................................................................... 120
GENITOURINARY AGENTS ................................................................................................................................................121
ANTISPASMODICS, URINARY ........................................................................................................................................................... 121
HEAVY METAL ANTAGONISTS ..........................................................................................................................................121
HEAVY METAL ANTAGONISTS .......................................................................................................................................................... 121
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING .....................................................................................122
ANDROGENS .................................................................................................................................................................................. 122
ESTROGENS AND ANTIESTROGENS ................................................................................................................................................ 122
GLUCOCORTICOIDS/MINERALOCORTICOIDS ................................................................................................................................ 123
PITUITARY ........................................................................................................................................................................................ 124
PROGESTINS ................................................................................................................................................................................... 126
THYROID AND ANTITHYROID AGENTS ............................................................................................................................................ 126
IMMUNOLOGICAL AGENTS ..............................................................................................................................................127
IMMUNOLOGICAL AGENTS ............................................................................................................................................................ 127
VACCINES ....................................................................................................................................................................................... 130
16
Table of Contents
INFLAMMATORY BOWEL DISEASE AGENTS ......................................................................................................................133
INFLAMMATORY BOWEL DISEASE AGENTS ...................................................................................................................................... 133
IRRIGATING SOLUTIONS ..................................................................................................................................................134
IRRIGATING SOLUTIONS ................................................................................................................................................................. 134
METABOLIC BONE DISEASE AGENTS ................................................................................................................................134
METABOLIC BONE DISEASE AGENTS ............................................................................................................................................... 134
MISCELLANEOUS THERAPEUTIC AGENTS .........................................................................................................................135
MISCELLANEOUS THERAPEUTIC AGENTS ......................................................................................................................................... 135
OPTHALMIC AGENTS ........................................................................................................................................................138
ANTIGLAUCOMA AGENTS............................................................................................................................................................... 138
REPLACEMENT PREPARATIONS .........................................................................................................................................140
REPLACEMENT PREPARATIONS ......................................................................................................................................................... 140
RESPIRATORY TRACT AGENTS ...........................................................................................................................................142
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS .................................................................................................................... 142
ANTILEUKOTRIENES......................................................................................................................................................................... 142
BRONCHODILATORS ...................................................................................................................................................................... 143
RESPIRATORY TRACT AGENTS, OTHER ............................................................................................................................................. 144
SKELETAL MUSCLE RELAXANTS .........................................................................................................................................145
SKELETAL MUSCLE RELAXANTS ......................................................................................................................................................... 145
SLEEP DISORDER AGENTS .................................................................................................................................................145
SLEEP DISORDER AGENTS ................................................................................................................................................................ 145
SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS ........................................................................................................146
ALPHA-ADRENERGIC BLOCKING AGENTS ....................................................................................................................................... 146
VASODILATING AGENTS ..................................................................................................................................................146
VASODILATING AGENTS ................................................................................................................................................................. 146
VITAMINS AND MINERALS ...............................................................................................................................................147
VITAMINS AND MINERALS ................................................................................................................................................................ 147
17
Table of Contents
INDEX OF DRUGS .............................................................................................................................................................171
..................................................................................................................................................................................................... 171
18
QUANTITY LIMITS TABLE
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
Aripiprazole
TABLET
30 TABS IN 30 DAYS
ABILIFY
Aripiprazole
ORAL SOLUTION
900 ML IN 30 DAYS
ABILIFY DISCMELT 10MG
Aripiprazole
TAB RAPDIS
30 TABS IN 30 DAYS
ABILIFY DISCMELT 15MG
Aripiprazole
TAB RAPDIS
60 TABS IN 30 DAYS
Acarbose 100MG
Acarbose
TABLET
90 TABS IN 30 DAYS
Acarbose 25MG
Acarbose
TABLET
360 TABS IN 30 DAYS
Acarbose 50MG
Acarbose
TABLET
180 TABS IN 30 DAYS
Acetaminophen 100 MG/ML
Acetaminophen 100MG/ML
ORAL DROPS
30ML IN 30 DAYS
Acetaminophen 120 MG
Acetaminophen 120MG
SUPP.RECT
30 SUPP IN 30 DAYS
Acetaminophen 160 MG/5ML
Acetaminophen 160MG/5ML
SOLUTION
240ML IN 30 DAYS
ELIXIR
240ML IN 30 DAYS
LIQUID
240ML IN 30 DAYS
Acetaminophen 325 MG
Acetaminophen 325MG
SUPP.RECT
30 SUPP IN 30 DAYS
Acetaminophen 325MG
Acetaminophen 325MG
TABLET
60 TABS IN 30 DAYS
Acetaminophen 500MG
Acetaminophen 500MG
CAPSULE
60 CAPS IN 30 DAYS
Acetaminophen 500MG
Acetaminophen 500MG
TABLET
60 TABS IN 30 DAYS
Acetaminophen 650MG
Acetaminophen 650MG
SUPP.RECT
60 SUPP IN 30 DAYS
Acetaminophen W/Codeine
Codeine Phos/Acetaminophen
ORAL SOLUTION
1800 ML IN 30 DAYS
Acetaminophen-Codeine
Acetaminophen With Codeine
TABLET
120 TABS IN 30 DAYS
19
ABILIFY
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
ACTONEL 150MG
Risedronate Sodium
TABLET
1 TABS IN 30 DAYS
ACTONEL 35MG
Risedronate Sodium
TABLET
4 TABS IN 28 DAYS
ACTONEL 5MG
Risedronate Sodium
TABLET
30 TABS IN 30 DAYS
ACYCLOVIR
Acyclovir
TOPICAL OINT.
30 GM IN 30 DAYS
ADVAIR DISKUS
Fluticasone/Salmeterol
INHALATION DISK
60 CAP IN 30 DAYS
ADVAIR HFA 120 ACTU
AEROSOL
12 GM IN 30 DAYS
ADVAIR HFA 60 ACTU
AEROSOL
8 GM IN 30 DAYS
Alendronate Sodium 35MG, 70MG
Alendronate Sodium
TABLET
4 TABS IN 28 DAYS
Alendronate Sodium 5MG, 10MG, 40MG
Alendronate Sodium
TABLET
30 TABS IN 30 DAYS
Alfuzosin HCL
Alfuzosin HCL
TAB ER 24H
30 TABS IN 30 DAYS
ALPHAGAN P
Brimonidine Tartrate
OPHT DROPS
15 ML IN 30 DAYS
Alprazolam 0.25MG, 0.5MG, 1MG
Alprazolam
TABLET
120 TABS IN 30 DAYS
Alprazolam 2MG
Alprazolam
TABLET
60 TABS IN 30 DAYS
Americet 325-40-50
Acetaminophen/Caffeine/Butalb
TABLET
60 TABS IN 30 DAYS
Amlodipine Besylate-Benazepril
Amlodipine Besylate/Benazepril
CAPSULE
30 CAPS IN 30 DAYS
Ascomp With Codeine
Codeine/Butalbital/Asa/Caffein
CAPSULE
120 CAPS IN 30 DAYS
ATELVIA
Risedronate Sodium
TABLET DR
4 TABS IN 28 DAYS
AVODART
Dutasteride
CAPSULE
30 CAPS IN 30 DAYS
Azelastine HCL
Azelastine HCL
NASAL SPRAY
30 ML IN 30 DAYS
20
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
Rasagiline Mesylate
TABLET
30 TABS IN 30 DAYS
Azithromycin 100MG/5Ml
Azithromycin
ORAL SUSP
2 ML IN 30 DAYS
Azithromycin 1Gm
Azithromycin
ORAL PACKETS
2 GM IN 30 DAYS
Azithromycin 200MG/5Ml
Azithromycin
ORAL SUSP
67.5 ML IN 30 DAYS
Azithromycin 250MG, 500MG
Azithromycin
TABLET
6 TABS IN 30 DAYS
Azithromycin 600MG
Azithromycin
TABLET
8 TABS IN 30 DAYS
AZOPT
Brinzolamide
OPHT SUSP
15 ML IN 30 DAYS
BROMFENAC SODIUM
Bromfenac Sodium
OPHT DROPS
5 ML IN 30 DAYS
Bupropion XL
Bupropion HCL
TAB ER 24H
30 TABS IN 30 DAYS
Butalb-Caff-Acetaminoph-Codein
Butalbit/Acetamin/Caff/Codeine
CAPSULE
120 CAPS IN 30 DAYS
Butalbital Compound-Codeine
CAPSULE
120 CAPS IN 30 DAYS
Calcipotriene
Calcipotriene
TOPICAL CREAM
60 GM IN 30 DAYS
Calcipotriene
Calcipotriene
TOPICAL SOLUTION
60 GM IN 30 DAYS
Carisoprodol
Carisoprodol
TABLET
90 TABS IN 30 DAYS
Children'S Q-Pap 160 MG/5ML
ORAL SUSP
240ML IN 30 DAYS
Chlorzoxazone
Chlorzoxazone
TABLET
120 TABS IN 30 DAYS
Clorazepate Dipotassium 15MG
Clorazepate Dipotassium
TABLET
180 TABS IN 30 DAYS
Clorazepate Dipotassium 3.75MG, 7.5MG
TABLET
120 TABS IN 30 DAYS
Codeine Sulfate
Codeine Sulfate
TABLET
120 TABS IN 30 DAYS
21
AZILECT
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
Co-Gesic
Hydrocodone Bit/Acetaminophen
TABLET
120 TABS IN 30 DAYS
COMBIVENT
Ipratropium/Albuterol Sulfate
AEROSOL
30 GM IN 30 DAYS
COMBIVENT RESPIMAT
AEROSOL
8 GM IN 30 DAYS
Cyclobenzaprine HCL
Cyclobenzaprine HCL
TABLET
90 TABS IN 30 DAYS
DETROL LA
Tolterodine Tartrate
CAP ER 24H
30 CAPS IN 30 DAYS
Diazepam
Diazepam
ORAL SOLUTION
1200 ML IN 30 DAYS
Diazepam
Diazepam
RECTAL KIT
5 UNIT IN 30 DAYS
Diazepam
Diazepam
TABLET
120 TABS IN 30 DAYS
DIFFERIN
Adapalene
MED. SWAB
45 GM IN 30 DAYS
DIFFERIN
Adapalene
TOPICAL GEL
45 GM IN 30 DAYS
Digitek
Digoxin
TABLET
30 TABS IN 30 DAYS
Digoxin
Digoxin
TABLET
30 TABS IN 30 DAYS
Dorzolamide HCL
Dorzolamide HCL
OPHT DROPS
10 ML IN 30 DAYS
Dorzolamide-Timolol
Dorzolamide HCL/Timolol Maleat
OPHT DROPS
10 ML IN 30 DAYS
EDURANT
Rilpivirine HCL
TABLET
30 TABS IN 30 DAYS
ELIDEL
Pimecrolimus
TOPICAL CREAM
30 GM IN 30 DAYS
Endocet
Oxycodone HCL/Acetaminophen
TABLET
120 TABS IN 30 DAYS
Endodan
Oxycodone HCL/Aspirin
TABLET
120 TABS IN 30 DAYS
EVISTA
Raloxifene HCL
TABLET
30 TABS IN 30 DAYS
22
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
Condoms, Female
EACH
24 IN 30 DAYS
Fentanyl
Fentanyl
PATCH
10 PATCHS IN 30 DAYS
FENTANYL CITRATE
Fentanyl Citrate
LOZENGE HD
120 LOZ IN 30 DAYS
Finasteride
Finasteride
TABLET
30 TABS IN 30 DAYS
FORTEO
Teriparatide
INJECTION PEN
3 ML IN 28 DAYS
FYCOMPA 2MG, 4MG, 8MG
Perampanel
TABLET
30 TABS IN 30 DAYS
FYCOMPA 6MG
Perampanel
TABLET
60 TABS IN 30 DAYS
Gavilyte-C
Peg 3350/Na Sulf,Bicarb,Cl/Kcl
ORAL SOLUTION
4000 ML IN 30 DAYS
Gavilyte-N
Sodium Chloride/Nahco3/Kcl/Peg
ORAL SOLUTION
4000 ML IN 30 DAYS
Gentamicin Sulfate
Gentamicin Sulfate
OPHT OINTMENT
5 ML IN 30 DAYS
Glimepiride 1MG
Glimepiride
TABLET
240 TABS IN 30 DAYS
Glimepiride 2MG
Glimepiride
TABLET
120 TABS IN 30 DAYS
Glimepiride 4MG
Glimepiride
TABLET
60 TABS IN 30 DAYS
Glipizide 10MG
Glipizide
TABLET
120 TABS IN 30 DAYS
Glipizide 5MG
Glipizide
TABLET
60 TABS IN 30 DAYS
Glipizide ER 10MG
Glipizide
TAB ER 24
60 TABS IN 30 DAYS
Glipizide ER 2.5MG
Glipizide
TAB ER 24
240 TABS IN 30 DAYS
Glipizide ER 5MG
Glipizide
TAB ER 24
120 TABS IN 30 DAYS
Glipizide-Metformin 2.5-250MG
Glipizide/Metformin HCL
TABLET
240 TABS IN 30 DAYS
23
FC Condom, Female N/A
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
Glipizide-Metformin 2.5-500MG, 5-500MG
TABLET
120 TABS IN 30 DAYS
GLUCAGON EMERGENCY KIT
Glucagon,Human Recombinant
INJECTION KIT
2 UNIT IN 30 DAYS
Glyburide 1.25MG
Glyburide
TABLET
480 TABS IN 30 DAYS
Glyburide 2.5MG
Glyburide
TABLET
240 TABS IN 30 DAYS
Glyburide 5MG
Glyburide
TABLET
120 TABS IN 30 DAYS
Glyburide Micronized 1.5MG
Glyburide,Micronized
TABLET
240 TABS IN 30 DAYS
Glyburide Micronized 3MG
TABLET
120 TABS IN 30 DAYS
Glyburide Micronized 6MG
TABLET
60 TABS IN 30 DAYS
Glyburide-Metformin HCL 1.25-250MG
Glyburide/Metformin HCL
TABLET
240 TABS IN 30 DAYS
Glyburide-Metformin HCL 2.5-500MG, 5-500MG Glyburide/Metformin HCL
TABLET
120 TABS IN 30 DAYS
GLYSET 100MG
Miglitol
TABLET
90 TABS IN 30 DAYS
GLYSET 25MG
Miglitol
TABLET
360 TABS IN 30 DAYS
GLYSET 50MG
Miglitol
TABLET
180 TABS IN 30 DAYS
HECTOROL 0.5MCG
Doxercalciferol
CAPSULE
30 CAPS IN 30 DAYS
HECTOROL 1MG
Doxercalciferol
CAPSULE
90 CAPS IN 30 DAYS
Homatropaire
Homatropine Hbr
OPHT DROPS
5 ML IN 30 DAYS
Hydrocodone Bit-Ibuprofen
Hydrocodone/Ibuprofen
TABLET
120 TABS IN 30 DAYS
Hydrocodone-Acetaminophen
TABLET
120 TABS IN 30 DAYS
ORAL SOLUTION
1800 ML IN 30 DAYS
24
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
TABLET
120 TABS IN 30 DAYS
Hydromorphone HCL
Hydromorphone HCL
TABLET
120 TABS IN 30 DAYS
IBANDRONATE SODIUM
Ibandronate Sodium
TABLET
1 TABS IN 30 DAYS
Imiquimod
Imiquimod
TOPICAL CREAM
12 GM IN 30 DAYS
Infant'S Pain Relief 100 MG/ML
Acetaminophen 100 MG/ML
DROPS SUSP
30 ML IN 30 DAYS
Infant'S Pain Relief 80MG/0.8ML
Acetaminophen 80MG/0.8ML
DROPS SUSP
30 ML IN 30 DAYS
INVEGA
Paliperidone
TAB ER 24
30 TABS IN 30 DAYS
INVIRASE
Saquinavir Mesylate
CAPSULE
120 CAPS IN 30 DAYS
ISENTRESS 100MG
Raltegravir Potassium
TAB CHEW
180 TABS IN 30 DAYS
ISENTRESS 25MG
TAB CHEW
120 TABS IN 30 DAYS
Isopto Homatropine
Homatropine Hbr
OPHT DROPS
15 ML IN 30 DAYS
JANUMET
Sitagliptin Phos/Metformin HCL
TABLET
60 TABS IN 30 DAYS
JANUMET XR 100-1000MG, 50-1000MG
TBMP 24HR
60 TABS IN 30 DAYS
JANUMET XR 50-500MG
TBMP 24HR
30 TABS IN 30 DAYS
JANUVIA
Sitagliptin Phosphate
TABLET
30 TABS IN 30 DAYS
JENTADUETO
Linagliptin/Metformin HCL
TABLET
60 TABS IN 30 DAYS
JUVISYNC
Sitagliptin/Simvastatin
TABLET
30 TABS IN 30 DAYS
Ketorolac Tromethamine
INJECTION
20 ML IN 30 DAYS
INJECTION CART
20 ML IN 30 DAYS
25
Hydrocodone-Ibuprofen
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
TABLET
20 TABS IN 30 DAYS
Laxa Clear 17G/Dose
Polyethylene Glycol 3350
ORAL POWDER
527GM IN 23 DAYS
LAZANDA
Fentanyl Citrate
NASAL SPRAY
75 ML IN 30 DAYS
Levetiracetam 500MG
Levetiracetam
TAB ER 24H
180 TABS IN 30 DAYS
Levetiracetam 750MG
Levetiracetam
TAB ER 24H
120 TABS IN 30 DAYS
Levobunolol HCL
Levobunolol HCL
OPHT DROPS
15 ML IN 30 DAYS
Lifestyles XS N/A
Condoms, Latex, Non-Lubricated
EACH
24 IN 30 DAYS
Lorazepam
Lorazepam
TABLET
120 TABS IN 30 DAYS
Mapap 500MG/15ML
LIQUID
120ML IN 30 DAYS
Meperidine HCL
Meperidine HCL
ORAL SOLUTION
600 ML IN 30 DAYS
Meperidine HCL
Meperidine HCL
TABLET
120 TABS IN 30 DAYS
Metformin HCL 1000MG
Metformin HCL
TABLET
60 TABS IN 30 DAYS
Metformin HCL 500MG
Metformin HCL
TABLET
150 TABS IN 30 DAYS
Metformin HCL 850MG
Metformin HCL
TABLET
90 TABS IN 30 DAYS
Metformin HCL ER 500MG
Metformin HCL
TAB ER 24H
120 TABS IN 30 DAYS
Metformin HCL ER 750MG, 1000MG
Metformin HCL
TAB ER 24
60 TABS IN 30 DAYS
Methadone HCL
Methadone HCL
ORAL SOLUTION
1800 ML IN 30 DAYS
Methadone HCL
Methadone HCL
TABLET
120 TABS IN 30 DAYS
Methadone Intensol
Methadone HCL
ORAL CONC
1800 ML IN 30 DAYS
26
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
Methadone HCL
TABLET SOL
120 TABS IN 30 DAYS
Methocarbamol 500MG
Methocarbamol
TABLET
240 TABS IN 30 DAYS
Methocarbamol 750MG
Methocarbamol
TABLET
180 TABS IN 30 DAYS
Metoprolol Succinate 200MG
Metoprolol Succinate
TAB ER 24H
60 TABS IN 30 DAYS
Metoprolol Succinate 25MG, 50MG,100MG
TAB ER 24H
30 TABS IN 30 DAYS
Morphine Sulfate
Morphine Sulfate
ORAL SOLUTION
1800 ML IN 30 DAYS
Morphine Sulfate
Morphine Sulfate
RECTAL SUPP
120 SUPP IN 30 DAYS
Morphine Sulfate
Morphine Sulfate
TABLET
120 TABS IN 30 DAYS
Morphine Sulfate Er
Morphine Sulfate
TABLET ER
90 TABS IN 30 DAYS
Mupirocin
Mupirocin
TOPICAL OINT.
22 GM IN 30 DAYS
Naphazoline HCL W/Antazoline
Naphazoline HCL/Antazoline
OPHT DROPS
15 ML IN 30 DAYS
Neomycin W/Dexamethasone
Neomycin Sulfate/Dex Na Ph
OPHT DROPS
5 ML IN 30 DAYS
Nitrofurantoin
Nitrofurantoin Macrocrystal
CAPSULE
90 CAPS IN 365 DAYS
Non-Aspirin 160 MG
Acetaminophen 160MG
TAB CHEW
30 TABS IN 30 DAYS
Non-Aspirin 80 MG
Acetaminophen 80MG
TAB CHEW
30 TABS IN 30 DAYS
Olanzapine
Olanzapine
TABLET
30 TABS IN 30 DAYS
Olanzapine Odt
Olanzapine
TAB RAPDIS
30 TABS IN 30 DAYS
Omeprazole 10MG, 20MG
Omeprazole
CAPSULE DR
60 CAPS IN 30 DAYS
Omeprazole 40MG
Omeprazole
CAPSULE DR
30 CAPS IN 30 DAYS
27
Methadose
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
Oralyte N/A
Electrolyte,Oral
SOLUTION
4000ML IN 15 DAYS
ORTHO ALL-FLEX 65MM
Diaphragms, Arc-Spring
VAGINAL KIT
2 KITS IN 365 DAYS
ORTHO ALL-FLEX 70MM
VAGINAL KIT
2 KITS IN 365 DAYS
ORTHO ALL-FLEX 75MM
VAGINAL KIT
2 KITS IN 365 DAYS
ORTHO ALL-FLEX 80MM
VAGINAL KIT
2 KITS IN 365 DAYS
ORTHO ALL-FLEX N/A
Diaphragm Fitting Set,Arcsprng
EACH
2 KITS IN 365 DAYS
Oxycodone Concentrate
Oxycodone HCL
ORAL CONC
250 ML IN 30 DAYS
Oxycodone HCL
Oxycodone HCL
CAPSULE
120 CAPS IN 30 DAYS
Oxycodone HCL
Oxycodone HCL
ORAL SOLUTION
250 ML IN 30 DAYS
Oxycodone HCL
Oxycodone HCL
TABLET
120 TABS IN 30 DAYS
Oxycodone HCL-Acetaminophen
TABLET
120 TABS IN 30 DAYS
Oxycodone HCL-Aspirin
TABLET
120 TABS IN 30 DAYS
Oxycodone-Acetaminophen
TABLET
120 TABS IN 30 DAYS
CAPSULE
120 CAPS IN 30 DAYS
OXYCONTIN
Oxycodone HCL
TAB ER 12H
60 TABS IN 30 DAYS
PATANOL
Olopatadine HCL
OPHT DROPS
5 ML IN 30 DAYS
Peg 3350-Electrolyte
ORAL SOLUTION
4000 ML IN 30 DAYS
Peg-3350 And Electrolytes
ORAL SOLUTION
4000 ML IN 30 DAYS
Peg-3350 With Flavor Packs
ORAL SOLUTION
4000 ML IN 30 DAYS
28
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
Mesalamine
CAPSULE ER
480 CAPS IN 30 DAYS
PENTAZOCINE-ACETAMINOPHEN
Pentazocine HCL/Acetaminophen
TABLET
120 TABS IN 30 DAYS
Phenylephrine HCL
Phenylephrine HCL
OPHT DROPS
15 ML IN 30 DAYS
Pilocarpine HCL
Pilocarpine HCL
OPHT DROPS
15 ML IN 30 DAYS
Pioglitazone HCL
Pioglitazone HCL
TABLET
30 TABS IN 30 DAYS
POTIGA
Ezogabine
TABLET
270 TABS IN 30 DAYS
PREZISTA
Darunavir Ethanolate
TABLET
60 TABS IN 30 DAYS
PREZISTA
ORAL SUSP
360 ML IN 30 DAYS
PROAIR HFA
Albuterol Sulfate
AEROSOL
17 GM IN 30 DAYS
Promethazine W/Codeine 6.25-10/5
Promethazine W/Codeine 6.25-10/5
SYRUP
240ML IN 30 DAYS
Q-Pap 80MG/0.8ML
Acetaminophen 80MG/0.8ML
ORAL DROPS
30ML IN 30 DAYS
Quetiapine Fumarate
Quetiapine Fumarate
TABLET
90 TABS IN 30 DAYS
Reality N/A
Condoms, Latex, Lubricated
EACH
24 IN 30 DAYS
RELENZA
Zanamivir
INHALATION DISK
56 CAP IN 180 DAYS
Reprexain
TABLET
120 TABS IN 30 DAYS
RESTASIS
Cyclosporine
OPHT DROPS
64 ML IN 30 DAYS
Risperidone
Risperidone
ORAL SOLUTION
240 ML IN 30 DAYS
Risperidone
Risperidone
TABLET
60 TABS IN 30 DAYS
Risperidone M-Tab
Risperidone
TAB RAPDIS
60 TABS IN 30 DAYS
29
PENTASA
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
Risperidone Odt
Risperidone
TAB RAPDIS
60 TABS IN 30 DAYS
Rizatriptan
Rizatriptan Benzoate
TAB RAPDIS
12 TABS IN 30 DAYS
Roxicet
TABLET
120 TABS IN 30 DAYS
SENSIPAR
Cinacalcet HCL
TABLET
30 TABS IN 30 DAYS
SPIRIVA
Tiotropium Bromide
INHALATION CAPSULE
30 CAP IN 30 DAYS
Stagesic
CAPSULE
120 CAPS IN 30 DAYS
Sumatriptan
Sumatriptan
NASAL SPRAY
9 ML IN 30 DAYS
Sumatriptan Succinate
INJECTION CART
4 ML IN 30 DAYS
TABLET
9 TABS IN 30 DAYS
TAMIFLU
Oseltamivir Phosphate
ORAL SUSP
175 ML IN 180 DAYS
TAMIFLU 30MG
CAPSULE
56 CAPS IN 180 DAYS
TAMIFLU 45MG, 75MG
CAPSULE
28 CAPS IN 180 DAYS
Tamsulosin HCL
Tamsulosin HCL
CAP ER 24H
60 CAPS IN 30 DAYS
Temazepam
Temazepam
CAPSULE
30 CAPS IN 30 DAYS
Tolazamide
Tolazamide
TABLET
60 TABS IN 30 DAYS
Tolbutamide
Tolbutamide
TABLET
180 TABS IN 30 DAYS
TOLTERODINE TARTRATE
TABLET
60 TABS IN 30 DAYS
TRADJENTA
Linagliptin
TABLET
30 TABS IN 30 DAYS
Tramadol HCL
Tramadol HCL
TABLET
240 TABS IN 30 DAYS
30
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
QUANTITY LIMIT
Tramadol HCL/Acetaminophen
TABLET
120 TABS IN 30 DAYS
TRAVATAN Z
Travoprost
OPHT DROPS
5 ML IN 30 DAYS
TRAVOPROST
Travoprost (Benzalkonium)
OPHT DROPS
5 ML IN 30 DAYS
Triazolam
Triazolam
TABLET
30 TABS IN 30 DAYS
Trojan Naturalamb N/A
Condoms, Non-Latex, Non-Lubri
EACH
24 IN 30 DAYS
Trojan Supra Na
Condoms, Non-Latex, Lubricated
EACH
24 IN 30 DAYS
VENTOLIN
Albuterol
AEROSOL
36 GM IN 30 DAYS
VIMPAT
Lacosamide
INTRAVENOUS (IV)
200 ML IN 5 DAYS
VORTEX FROG MASK N/A
VORTEX FROG MASK N/A
EACH
2 KITS IN 365 DAYS
VORTEX N/A
VORTEX N/A
SPACER
2 KITS IN 365 DAYS
Zafirlukast
Zafirlukast
TABLET
60 TABS IN 30 DAYS
Ziprasidone HCL 20MG, 40MG
Ziprasidone HCL
CAPSULE
60 CAPS IN 30 DAYS
Ziprasidone HCL 60MG, 80MG
Ziprasidone HCL
CAPSULE
120 CAPS IN 30 DAYS
ZMAX
Azithromycin
ORAL SUS ER REC
60 ML IN 30 DAYS
Zolpidem Tartrate
Zolpidem Tartrate
TABLET
30 TABS IN 30 DAYS
ZOVIRAX
Acyclovir
TOPICAL CREAM
10 GM IN 30 DAYS
31
Tramadol HCL-Acetaminophen
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
COST YOU (TIER LEVEL)
NECESSARY ACTIONS,
RESTRICTIONS/LIMITS ON USE
ANALGESICS
ANALGESICS, MISCELLANEOUS
TABLET
$0.00 - $2.55 (Tier 1)
QL
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
QL
Ascomp With Codeine
CAPSULE
$0.00 - $2.55 (Tier 1)
QL
Butalb-Caff-Acetaminoph-Codein
Butalbit/Acetamin/Caff/Codeine
CAPSULE
$0.00 - $2.55 (Tier 1)
QL, PA>65 yrs old
Codeine Sulfate
Codeine Sulfate
TABLET
$0.00 - $2.55 (Tier 1)
QL
Fentanyl
Fentanyl
PATCH
$0.00 - $2.55 (Tier 1)
QL, ST
FENTANYL CITRATE
Fentanyl Citrate
LOZENGE HD
$0.00 - $2.55 (Tier 1)
QL, PA
Hydrocodone Bit-Ibuprofen
TABLET
$0.00 - $2.55 (Tier 1)
QL
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
QL
TABLET
$0.00 - $2.55 (Tier 1)
QL
Hydromorphone HCL
Hydromorphone HCL
TABLET
$0.00 - $2.55 (Tier 1)
QL
Hydromorphone HCL
Hydromorphone HCL/PF
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
LAZANDA
Fentanyl Citrate
NASAL SPRAY
$0.00 - $6.35 (Tier 2)
QL, PA
Meperidine HCL
Meperidine HCL
TABLET
$0.00 - $2.55 (Tier 1)
QL, PA>65 yrs old
ANALGESICS
* This drug is covered by Medicaid and is not a "Part D drug." If you have questions, call Care1st Cal MediConnect Plan Member Services.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies.
For more information call Care1st Cal MediConnect Plan Member Services.
~ This prescription may be available only at certain pharmacies. For more information, call Care1st Cal MediConnect Plan Member Services.
PA = Prior authorization required
PA>65 = Requires a Prior Authorization for members greater than 65 years old.
QL = Quantity limit
BvD = Requires a prior authorization to perform a Part B vs. Part D coverage determination.
ST = Step Therapy
PART D
33
ANALGESICS
WHAT THE DRUG WILL
NECESSARY ACTIONS,
BRAND DRUG NAME
GENERIC DRUG NAME
Meperidine HCL
Meperidine HCL
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
QL, PA>65 yrs old
Methadone HCL
Methadone HCL
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Methadone HCL
Methadone HCL
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
QL
Methadone HCL
Methadone HCL
TABLET
$0.00 - $2.55 (Tier 1)
QL
Methadone HCL
Methadone HCL
TABLET SOL
$0.00 - $2.55 (Tier 1)
QL
Methadone Intensol
Methadone HCL
ORAL CONC
$0.00 - $2.55 (Tier 1)
QL
Morphine Sulfate
Morphine Sulfate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Morphine Sulfate
Morphine Sulfate
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
QL
Morphine Sulfate
Morphine Sulfate
RECTAL SUPP
$0.00 - $2.55 (Tier 1)
QL
Morphine Sulfate
Morphine Sulfate
TABLET
$0.00 - $2.55 (Tier 1)
QL
Morphine Sulfate ER All Other Strengths Morphine Sulfate
TABLET ER
$0.00 - $2.55 (Tier 1)
QL
Oxycodone Concentrate
Oxycodone HCL
ORAL CONC
$0.00 - $2.55 (Tier 1)
QL
Oxycodone HCL
Oxycodone HCL
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
QL
Oxycodone HCL
Oxycodone HCL
TABLET
$0.00 - $2.55 (Tier 1)
QL
Oxycodone HCL
Oxycodone HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
QL
Oxycodone HCL-Aspirin
TABLET
$0.00 - $2.55 (Tier 1)
QL
FORMULATION
QL = Quantity limit
ST = Step Therapy
34
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
CAPSULE
$0.00 - $2.55 (Tier 1)
QL
TABLET
$0.00 - $2.55 (Tier 1)
QL
OXYCONTIN
Oxycodone HCL
TAB ER 12H
$0.00 - $6.35 (Tier 2)
QL, PA
PENTAZOCINE-ACETAMINOPHEN Pentazocine HCL/Acetaminophen
TABLET
$0.00 - $2.55 (Tier 1)
QL, PA>65 yrs old
Stagesic
CAPSULE
$0.00 - $2.55 (Tier 1)
QL
Tramadol HCL
Tramadol HCL
TABLET
$0.00 - $2.55 (Tier 1)
QL
Tramadol HCL-Acetaminophen
Tramadol HCL/Acetaminophen
TABLET
$0.00 - $2.55 (Tier 1)
QL
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
Celecoxib
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ Choline Mag Trisalicylate
Choline Sal/Mag Salicylate
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
Diclofenac Potassium
Diclofenac Potassium
TABLET
$0.00 - $2.55 (Tier 1)
+ Diclofenac Sodium
Diclofenac Sodium
TABLET DR
$0.00 - $2.55 (Tier 1)
DICLOFENAC SODIUM
Diclofenac Sodium
TOPICAL GEL
$0.00 - $6.35 (Tier 2)
PA
+ Diclofenac Sodium
Diclofenac Sodium
TAB ER 24H
$0.00 - $2.55 (Tier 1)
+ Diflunisal
Diflunisal
TABLET
$0.00 - $2.55 (Tier 1)
+ Etodolac
Etodolac
CAPSULE
$0.00 - $2.55 (Tier 1)
ANALGESICS
+ CELEBREX
QL = Quantity limit
ST = Step Therapy
PART D
35
ANALGESICS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Etodolac
Etodolac
TAB ER 24H
$0.00 - $2.55 (Tier 1)
+ Etodolac
Etodolac
TABLET
$0.00 - $2.55 (Tier 1)
+ Fenoprofen Calcium
Fenoprofen Calcium
TABLET
$0.00 - $2.55 (Tier 1)
+ Flurbiprofen
Flurbiprofen
TABLET
$0.00 - $2.55 (Tier 1)
+ Ibuprofen
Ibuprofen
TABLET
$0.00 - $2.55 (Tier 1)
Indomethacin
Indomethacin
CAPSULE ER
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
Indomethacin
Indomethacin
CAPSULE
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Ketoprofen
Ketoprofen
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Ketoprofen
Ketoprofen
CAP24H PEL
$0.00 - $2.55 (Tier 1)
INJECTION
$0.00 - $2.55 (Tier 1)
QL, BvD
TABLET
$0.00 - $2.55 (Tier 1)
QL, PA>65 yrs old
+ Meclofenamate Sodium
Meclofenamate Sodium
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Meloxicam
Meloxicam
TABLET
$0.00 - $2.55 (Tier 1)
+ Nabumetone
Nabumetone
TABLET
$0.00 - $2.55 (Tier 1)
+ Naproxen
Naproxen
ORAL SUSP
$0.00 - $2.55 (Tier 1)
+ Naproxen
Naproxen
TABLET
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
36
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Naproxen
Naproxen
TABLET DR
$0.00 - $2.55 (Tier 1)
+ Naproxen Sodium
Naproxen Sodium
TABLET
$0.00 - $2.55 (Tier 1)
+ Oxaprozin
Oxaprozin
TABLET
$0.00 - $2.55 (Tier 1)
+ Piroxicam
Piroxicam
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Salsalate
Salsalate
TABLET
$0.00 - $2.55 (Tier 1)
+ Sulindac
Sulindac
TABLET
$0.00 - $2.55 (Tier 1)
+ Tolmetin Sodium
Tolmetin Sodium
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Tolmetin Sodium
Tolmetin Sodium
TABLET
$0.00 - $2.55 (Tier 1)
Lidocaine
Lidocaine
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
BvD
Lidocaine
Lidocaine
TOPICAL PATCH
$0.00 - $2.55 (Tier 1)
PA
Lidocaine HCL
Lidocaine HCL
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Lidocaine HCL
Lidocaine HCL
INJECTION DISP SYR
$0.00 - $2.55 (Tier 1)
BvD
Lidocaine HCL
Lidocaine HCL
ORAL JEL
$0.00 - $2.55 (Tier 1)
Lidocaine HCL
Lidocaine HCL/PF
INJECTION
$0.00 - $2.55 (Tier 1)
ANESTHETICS
ANALGESICS
LOCAL ANESTHETICS
BvD
QL = Quantity limit
ST = Step Therapy
PART D
37
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Lidocaine HCL Viscous
Lidocaine HCL
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
Lidocaine-Prilocaine
Lidocaine/Prilocaine
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
PA
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ANESTHETICS
+Acamprosate Calcium
Acamprosate Calcium
TABLET DR
$0.00 - $2.55 (Tier 1)
BUPRENORPHINE HCL
Buprenorphine HCL
TAB SUBL
$0.00 - $2.55 (Tier 1)
PA
BUPRENORPHINE-NALOXONE
Buprenorphine HCL/Naloxone HCL
TAB SUBL
$0.00 - $2.55 (Tier 1)
PA
+ CAMPRAL
Acamprosate Calcium
TAB DS PK
$0.00 - $6.35 (Tier 2)
CHANTIX
Varenicline Tartrate
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ Disulfiram
Disulfiram
TABLET
$0.00 - $2.55 (Tier 1)
NALOXONE HCL
Naloxone HCL
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
NALOXONE HCL
Naloxone HCL
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BvD
NALOXONE HCL
Naloxone HCL
INJECTION VIAL
$0.00 - $6.35 (Tier 2)
Naltrexone HCL
Naltrexone HCL
TABLET
$0.00 - $2.55 (Tier 1)
NICOTROL
Nicotine
INHALATION CARTRIDGE $0.00 - $6.35 (Tier 2)
PA
NICOTROL NS
Nicotine
NASAL SPRAY
PA
$0.00 - $6.35 (Tier 2)
QL = Quantity limit
ST = Step Therapy
38
PART D
BRAND DRUG NAME
SUBOXONE
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Buprenorphine HCL/Naloxone HCL
SUBLINGUAL FILM
$0.00 - $6.35 (Tier 2)
PA
Alprazolam
Alprazolam
TABLET
$0.00 - $2.55 (Tier 1)
QL
+ Clonazepam
Clonazepam
TAB RAPDIS
$0.00 - $2.55 (Tier 1)
+ Clonazepam
Clonazepam
TABLET
$0.00 - $2.55 (Tier 1)
TABLET
$0.00 - $2.55 (Tier 1)
QL
Diazepam
Diazepam
RECTAL KIT
$0.00 - $2.55 (Tier 1)
QL
Diazepam
Diazepam
TABLET
$0.00 - $2.55 (Tier 1)
QL
Diazepam
Diazepam
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
QL
Lorazepam
Lorazepam
TABLET
$0.00 - $2.55 (Tier 1)
QL
+ ONFI
Clobazam
ORAL SUSP
$0.00 - $6.35 (Tier 2)
PA
+ ONFI
Clobazam
TABLET
$0.00 - $6.35 (Tier 2)
PA
Temazepam
Temazepam
CAPSULE
$0.00 - $2.55 (Tier 1)
QL
Triazolam
Triazolam
TABLET
$0.00 - $2.55 (Tier 1)
QL
ANTIANXIETY AGENTS
BENZODIAZEPINES
ANTI-ADDICTION/SUBSTANCE ABUSE
QL = Quantity limit
ST = Step Therapy
PART D
39
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
ANTIBACTERIALS
ANTIBACTERIALS
AMINOGLYCOSIDES
Amikacin Sulfate
Amikacin Sulfate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Gentamicin Sulfate
Gentamicin Sulfate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Neomycin Sulfate
Neomycin Sulfate
TABLET
$0.00 - $2.55 (Tier 1)
Streptomycin Sulfate
Streptomycin Sulfate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
TOBI
Tobramycin In 0.225% Nacl
INHALATION SOLN
$0.00 - $6.35 (Tier 2)
PA
Tobramycin Sulfate
Tobramycin Sulfate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
CHLORAMPHENICOL SOD SUCCINATE Chloramphenicol Sod Succ
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Clindamycin HCL
Clindamycin HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
Clindamycin Phosphate
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
Colistimethate Sodium
Colistin (Colistimethate Na)
INJECTION
$0.00 - $2.55 (Tier 1)
CUBICIN
Daptomycin
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
Methenamine Hippurate
Methenamine Hippurate
TABLET
$0.00 - $2.55 (Tier 1)
Nitrofurantoin
Nitrofurantoin Macrocrystal
CAPSULE
$0.00 - $2.55 (Tier 1)
ANTIBACTERIALS, MISCELLANEOUS
BvD
PA
QL, PA>65 yrs old
QL = Quantity limit
ST = Step Therapy
40
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Trimethoprim
Trimethoprim
TABLET
$0.00 - $2.55 (Tier 1)
VANCOMYCIN HCL
Vancomycin HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
Vancomycin HCL
Vancomycin HCL
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
ZYVOX
Linezolid
TABLET
$0.00 - $6.35 (Tier 2)
PA
ZYVOX
Linezolid
ORAL SUSP
$0.00 - $6.35 (Tier 2)
PA
ZYVOX
Linezolid
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
Cefaclor
Cefaclor
CAPSULE
$0.00 - $2.55 (Tier 1)
Cefaclor
Cefaclor
ORAL SUSP
$0.00 - $2.55 (Tier 1)
Cefaclor ER
Cefaclor
TAB ER 12H
$0.00 - $2.55 (Tier 1)
Cefadroxil
Cefadroxil Hydrate
CAPSULE
$0.00 - $2.55 (Tier 1)
Cefadroxil
Cefadroxil Hydrate
ORAL SUSP
$0.00 - $2.55 (Tier 1)
Cefadroxil
Cefadroxil Hydrate
TABLET
$0.00 - $2.55 (Tier 1)
Cefazolin
Cefazolin Sodium/Dextrose,Iso
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Cefazolin Sodium
Cefazolin Sodium
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Cefdinir
Cefdinir
CAPSULE
$0.00 - $2.55 (Tier 1)
CEPHALOSPORINS
ANTIBACTERIALS
QL = Quantity limit
ST = Step Therapy
PART D
41
ANTIBACTERIALS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Cefepime HCL
Cefepime HCL
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Cefotaxime Sodium
Cefotaxime Sodium
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Cefpodoxime Proxetil
ORAL SUSP
$0.00 - $2.55 (Tier 1)
TABLET
$0.00 - $2.55 (Tier 1)
Cefprozil
Cefprozil
ORAL SUSP
$0.00 - $2.55 (Tier 1)
Cefprozil
Cefprozil
TABLET
$0.00 - $2.55 (Tier 1)
Ceftazidime
Ceftazidime Pentahydrate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
CEFTAZIDIME
Ceftazidime Pentahydrate/D5W
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
Ceftriaxone
Ceftriaxone Na/Dextrose,Iso
IV- FROZ.PIGGY
$0.00 - $2.55 (Tier 1)
BvD
Ceftriaxone
Ceftriaxone Sodium
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Ceftriaxone
Ceftriaxone Sodium
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Cefuroxime
Cefuroxime Axetil
TABLET
$0.00 - $2.55 (Tier 1)
Cefuroxime Sodium
Cefuroxime Sodium
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Cefuroxime Sodium
Cefuroxime Sodium
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Cephalexin
Cephalexin
TABLET
$0.00 - $2.55 (Tier 1)
Cephalexin
Cephalexin
CAPSULE
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
42
PART D
BRAND DRUG NAME
Cephalexin
GENERIC DRUG NAME
Cephalexin
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
ORAL SUSP
$0.00 - $2.55 (Tier 1)
FORTAZ IN ISO-OSMOTIC DEXTROSE Ceftazidime Na/Dextrose,Iso
IV- FROZ.PIGGY
$0.00 - $6.35 (Tier 2)
SUPRAX
Cefixime
TABLET
$0.00 - $6.35 (Tier 2)
Tazicef
Ceftazidime Pentahydrate
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Tazicef In Dextrose
Ceftazidime P-Hyd/Dextrose,Iso
IV- FROZ.PIGGY
$0.00 - $2.55 (Tier 1)
BvD
Azithromycin
Azithromycin
TABLET
$0.00 - $2.55 (Tier 1)
QL
Azithromycin
Azithromycin
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Azithromycin
Azithromycin
ORAL PACKETS
$0.00 - $2.55 (Tier 1)
QL
Azithromycin
Azithromycin
ORAL SUSP
$0.00 - $2.55 (Tier 1)
QL
Clarithromycin
Clarithromycin
TABLET
$0.00 - $2.55 (Tier 1)
Clarithromycin
Clarithromycin
ORAL SUSP
$0.00 - $2.55 (Tier 1)
Clarithromycin ER
Clarithromycin
TAB ER 24H
$0.00 - $2.55 (Tier 1)
Erythrocin Stearate
Erythromycin Stearate
TABLET
$0.00 - $2.55 (Tier 1)
Erythromycin
Erythromycin Base
CAPSULE DR
$0.00 - $2.55 (Tier 1)
Erythromycin
Erythromycin Base
TABLET
$0.00 - $2.55 (Tier 1)
BvD
MACROLIDES
ANTIBACTERIALS
QL = Quantity limit
ST = Step Therapy
PART D
43
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Erythromycin Ethylsuccinate
Erythromycin Ethylsuccinate
TABLET
$0.00 - $2.55 (Tier 1)
Erythromycin-Sulfisoxazole
Ery E-Succ/Sulfisoxazole
ORAL SUSP
$0.00 - $2.55 (Tier 1)
KETEK
Telithromycin
TABLET
$0.00 - $6.35 (Tier 2)
ST
ZMAX
Azithromycin
ORAL SUS ER REC
$0.00 - $6.35 (Tier 2)
QL
ANTIBACTERIALS
MISCELLANEOUS B-LACTAM ANTIBIOTICS
Aztreonam
Aztreonam
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
CAYSTON
Aztreonam Lysine
INHALATION SOLN
$0.00 - $6.35 (Tier 2)
PA
Imipenem-Cilastatin Sodium
Imipenem/Cilastatin Sodium
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
PRIMAXIN I.M.
Imipenem/Cilastatin Sodium
INJECTION
$0.00 - $6.35 (Tier 2)
Amox Tr-Potassium Clavulanate
Amoxicillin/Potassium Clav
ORAL SUSP
$0.00 - $2.55 (Tier 1)
TABLET
$0.00 - $2.55 (Tier 1)
TAB CHEW
$0.00 - $2.55 (Tier 1)
Amoxicillin
Amoxicillin
CAPSULE
$0.00 - $2.55 (Tier 1)
Amoxicillin
Amoxicillin
TABLET
$0.00 - $2.55 (Tier 1)
Amoxicillin
Amoxicillin
ORAL SUSP
$0.00 - $2.55 (Tier 1)
PENICILLINS
QL = Quantity limit
ST = Step Therapy
44
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Amoxicillin
Amoxicillin
TAB CHEW
$0.00 - $2.55 (Tier 1)
AMPICILLIN SODIUM
Ampicillin Sodium
INJECTION
$0.00 - $6.35 (Tier 2)
Ampicillin Trihydrate
CAPSULE
$0.00 - $2.55 (Tier 1)
ORAL SUSP
$0.00 - $2.55 (Tier 1)
Ampicillin-Sulbactam
Ampicillin Sodium/Sulbactam Na
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Ampicillin-Sulbactam
Ampicillin Sodium/Sulbactam Na
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
BICILLIN C-R
Pen G Benz/Pen G Procaine
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BvD
BICILLIN L-A
Penicillin G Benzathine
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BvD
Dicloxacillin Sodium
Dicloxacillin Sodium
CAPSULE
$0.00 - $2.55 (Tier 1)
Nafcillin Sodium
Nafcillin Sodium
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Nafcillin Sodium
Nafcillin Sodium
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Nallpen-Iso-Osmotic Dextrose
Nafcillin In Dextrose,Iso-Osm
IV- FROZ.PIGGY
$0.00 - $2.55 (Tier 1)
BvD
Penicillin G Potassium
Penicillin G Potassium
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Penicillin G Sodium
Penicillin G Sodium
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Penicillin Gk-Iso-Osm Dextrose
Pen G Pot/Dextrose-Water
IV- FROZ.PIGGY
$0.00 - $2.55 (Tier 1)
BvD
Penicillin V Potassium
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
BvD
ANTIBACTERIALS
QL = Quantity limit
ST = Step Therapy
PART D
45
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
TABLET
$0.00 - $2.55 (Tier 1)
TICAR
Ticarcillin Disodium
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
TICAR
Ticarcillin Disodium
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
TICAR IN DEXTROSE
Ticarcillin Disodium/D5W
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
TIMENTIN
Ticarcillin/K Clavulanate
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
AVELOX
Moxifloxacin HCL
TABLET
$0.00 - $6.35 (Tier 2)
AVELOX ABC PACK
Moxifloxacin HCL
TABLET
$0.00 - $6.35 (Tier 2)
Ciprofloxacin
Ciprofloxacin Lactate
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
Ciprofloxacin ER
Ciprofloxacin/Ciprofloxa HCL
TBMP 24HR
$0.00 - $2.55 (Tier 1)
Ciprofloxacin HCL
Ciprofloxacin HCL
TABLET
$0.00 - $2.55 (Tier 1)
Levofloxacin
Levofloxacin
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
Levofloxacin
Levofloxacin
TABLET
$0.00 - $2.55 (Tier 1)
Levofloxacin-D5W
Levofloxacin/D5W
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
Nalidixic Acid
Nalidixic Acid
TABLET
$0.00 - $2.55 (Tier 1)
Ofloxacin
Ofloxacin
TABLET
$0.00 - $2.55 (Tier 1)
ANTIBACTERIALS
QUINOLONES
BvD
BvD
QL = Quantity limit
ST = Step Therapy
46
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
SULFONAMIDES
Sulfadiazine
Sulfadiazine
TABLET
$0.00 - $2.55 (Tier 1)
Sulfamethoxazole-Trimethoprim
Sulfamethoxazole/Trimethoprim
TABLET
$0.00 - $2.55 (Tier 1)
ORAL SUSP
$0.00 - $2.55 (Tier 1)
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
Sulfasalazine
Sulfasalazine
TABLET
$0.00 - $2.55 (Tier 1)
Sulfasalazine DR
Sulfasalazine
TABLET DR
$0.00 - $2.55 (Tier 1)
Demeclocycline HCL
Demeclocycline HCL
TABLET
$0.00 - $2.55 (Tier 1)
Doxycycline Hyclate
Doxycycline Hyclate
CAPSULE
$0.00 - $2.55 (Tier 1)
Doxycycline Hyclate
Doxycycline Hyclate
CAPSULE DR
$0.00 - $2.55 (Tier 1)
Doxycycline Hyclate
Doxycycline Hyclate
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
Doxycycline Hyclate
Doxycycline Hyclate
TABLET
$0.00 - $2.55 (Tier 1)
Doxycycline Monohydrate
Doxycycline Monohydrate
TABLET
$0.00 - $2.55 (Tier 1)
Minocycline HCL
Minocycline HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
Minocycline HCL
Minocycline HCL
TABLET
$0.00 - $2.55 (Tier 1)
BvD
TETRACYCLINES
ANTIBACTERIALS
QL = Quantity limit
ST = Step Therapy
PART D
47
WHAT THE DRUG WILL
NECESSARY ACTIONS,
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
Tetracycline HCL
Tetracycline HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
TYGACIL
Tigecycline
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
ADCETRIS
Brentuximab Vedotin
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
GILOTRIF
Afatinib Dimaleate
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ AFINITOR
Everolimus
TABLET
$0.00 - $6.35 (Tier 2)
PA
ALIMTA
Pemetrexed Disodium
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ Anastrozole
Anastrozole
TABLET
$0.00 - $2.55 (Tier 1)
ARZERRA
Ofatumumab
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
AVASTIN
Bevacizumab
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
AZACITIDINE
Azacitidine
INJECTION VIAL
$0.00 - $6.35 (Tier 2)
PA
+ Bicalutamide
Bicalutamide
TABLET
$0.00 - $2.55 (Tier 1)
Bleomycin Sulfate
Bleomycin Sulfate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
+ BOSULIF
Bosutinib
TABLET
$0.00 - $6.35 (Tier 2)
PA
CAPRELSA
Vandetanib
TABLET
$0.00 - $6.35 (Tier 2)
PA
ANTICANCER AGENTS
ANTIBACTERIALS
ANTICANCER AGENTS
QL = Quantity limit
ST = Step Therapy
48
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Cabozantinib S-Malate
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
Cyclophosphamide
Cyclophosphamide
TABLET
$0.00 - $2.55 (Tier 1)
DECITABINE
Decitabine
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
DOCETAXEL
Docetaxel
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
ELIGARD
Leuprolide Acetate
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
EMCYT
Estramustine Phosphate Sodium
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ ERIVEDGE
Vismodegib
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
ERWINAZE
Asparaginase (Erwinia Chrysan)
INJECTION
$0.00 - $6.35 (Tier 2)
PA
AFINITOR DISPERZ
Everolimus
TAB SUSP
$0.00 - $6.35 (Tier 2)
PA
+ Exemestane
Exemestane
TABLET
$0.00 - $2.55 (Tier 1)
+ FARESTON
Toremifene Citrate
TABLET
$0.00 - $6.35 (Tier 2)
+ FASLODEX
Fulvestrant
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BvD
FIRMAGON
Degarelix Acetate
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ Flutamide
Flutamide
CAPSULE
$0.00 - $2.55 (Tier 1)
FOLOTYN
Pralatrexate
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
GEMCITABINE HCL
Gemcitabine HCL
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
PA
ANTICANCER AGENTS
COMETRIQ
QL = Quantity limit
ST = Step Therapy
PART D
49
ANTICANCER AGENTS
BRAND DRUG NAME
WHAT THE DRUG WILL
NECESSARY ACTIONS,
GENERIC DRUG NAME
FORMULATION
+ GLEEVEC
Imatinib Mesylate
TABLET
$0.00 - $6.35 (Tier 2)
PA
HALAVEN
Eribulin Mesylate
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
+ HEXALEN
Altretamine
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ Hydroxyurea
Hydroxyurea
CAPSULE
$0.00 - $2.55 (Tier 1)
+ ICLUSIG
Ponatinib HCL
TABLET
$0.00 - $6.35 (Tier 2)
PA
IMBRUVICA
Ibrutinib
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
INLYTA
Axitinib
TABLET
$0.00 - $6.35 (Tier 2)
PA
ISTODAX
Romidepsin
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ JAKAFI
Ruxolitinib Phosphate
TABLET
$0.00 - $6.35 (Tier 2)
PA
JEVTANA
Cabazitaxel
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
KADCYLA
Ado-Trastuzumab Emtansine
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
KYPROLIS
Carfilzomib
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
+ Letrozole
Letrozole
TABLET
$0.00 - $2.55 (Tier 1)
LEUKERAN
Chlorambucil
TABLET
$0.00 - $6.35 (Tier 2)
LEUPROLIDE ACETATE
Leuprolide Acetate
INJECTION KIT
$0.00 - $2.55 (Tier 1)
PA
LIPODOX
Doxorubicin HCL Peg-Liposomal
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
QL = Quantity limit
ST = Step Therapy
50
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Lomustine
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
LUPRON DEPOT
Leuprolide Acetate
INJECTION KIT
$0.00 - $6.35 (Tier 2)
PA
LUPRON DEPOT-PED
Leuprolide Acetate
INJECTION KIT
$0.00 - $6.35 (Tier 2)
PA
LYSODREN
Mitotane
TABLET
$0.00 - $6.35 (Tier 2)
+ MATULANE
Procarbazine HCL
CAPSULE
$0.00 - $6.35 (Tier 2)
Megestrol Acetate
Megestrol Acetate
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
Megestrol Acetate
Megestrol Acetate
ORAL SUSP
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ MEKINIST
Trametinib Dimethyl Sulfoxide
TABLET
$0.00 - $6.35 (Tier 2)
PA
MELPHALAN HCL
Melphalan HCL
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Mercaptopurine
Mercaptopurine
TABLET
$0.00 - $2.55 (Tier 1)
+ Methotrexate
Methotrexate Sodium
TABLET
$0.00 - $2.55 (Tier 1)
Mitoxantrone HCL
Mitoxantrone HCL
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
+ NEXAVAR
Sorafenib Tosylate
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ NILANDRON
Nilutamide
TABLET
$0.00 - $6.35 (Tier 2)
PA
GAZYVA
Obinutuzumab
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
ONTAK
Denileukin Diftitox
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
ANTICANCER AGENTS
LOMUSTINE
QL = Quantity limit
ST = Step Therapy
PART D
51
ANTICANCER AGENTS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
OXALIPLATIN
Oxaliplatin
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
PERJETA
Pertuzumab
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
+ POMALYST
Pomalidomide
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
PROLEUKIN
Aldesleukin
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
~+ REVLIMID
Lenalidomide
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
RITUXAN
Rituximab
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ SOLTAMOX
Tamoxifen Citrate
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
PA
+ SPRYCEL
Dasatinib
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ STIVARGA
Regorafenib
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ SUTENT
Sunitinib Malate
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ SYNRIBO
Omacetaxine Mepesuccinate
INJECTION
$0.00 - $6.35 (Tier 2)
PA
TABLOID
Thioguanine
TABLET
$0.00 - $6.35 (Tier 2)
PA
TAFINLAR
Dabrafenib Mesylate
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ Tamoxifen Citrate
Tamoxifen Citrate
TABLET
$0.00 - $2.55 (Tier 1)
+ TARCEVA
Erlotinib HCL
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ TARGRETIN
Bexarotene
CAPSULE
$0.00 - $6.35 (Tier 2)
QL = Quantity limit
ST = Step Therapy
52
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Nilotinib HCL
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
TEMODAR
Temozolomide
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
TENIPOSIDE
Teniposide
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
TOPOTECAN HCL
Topotecan HCL
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
TRELSTAR
Triptorelin Pamoate
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
TRELSTAR
Triptorelin Pamoate
INJECTION
$0.00 - $6.35 (Tier 2)
PA
TRETINOIN
Tretinoin
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
TRISENOX
Arsenic Trioxide
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
+ TYKERB
Lapatinib Ditosylate
TABLET
$0.00 - $6.35 (Tier 2)
PA
VELCADE
Bortezomib
INJECTION
$0.00 - $6.35 (Tier 2)
PA
MARQIBO
Vincristine Sulfate Liposomal
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
VOTRIENT
Pazopanib HCL
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ XALKORI
Crizotinib
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ XTANDI
Enzalutamide
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
YERVOY
Ipilimumab
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
ZALTRAP
Ziv-Aflibercept
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
ANTICANCER AGENTS
+ TASIGNA
QL = Quantity limit
ST = Step Therapy
PART D
53
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ ZELBORAF
Vemurafenib
TABLET
$0.00 - $6.35 (Tier 2)
PA
ZOLADEX
Goserelin Acetate
IMPLANT
$0.00 - $6.35 (Tier 2)
PA
ZOLINZA
Vorinostat
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ ZYTIGA
Abiraterone Acetate
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ BANZEL
Rufinamide
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ BANZEL
Rufinamide
ORAL SUSP
$0.00 - $6.35 (Tier 2)
PA
+ Carbamazepine
Carbamazepine
ORAL SUSP
$0.00 - $2.55 (Tier 1)
+ Carbamazepine
Carbamazepine
TABLET
$0.00 - $2.55 (Tier 1)
+ Carbamazepine
Carbamazepine
TAB CHEW
$0.00 - $2.55 (Tier 1)
+ Carbamazepine
Carbamazepine
CPMP 12HR
$0.00 - $2.55 (Tier 1)
+ Carbamazepine XR
Carbamazepine
TAB ER 12H
$0.00 - $2.55 (Tier 1)
+ CELONTIN
Methsuximide
CAPSULE
$0.00 - $6.35 (Tier 2)
+ DILANTIN
Phenytoin Sodium Extended
CAPSULE
$0.00 - $6.35 (Tier 2)
+ DILANTIN
Phenytoin
TAB CHEW
$0.00 - $6.35 (Tier 2)
ANTICONVULSANTS
ANTICANCER AGENTS
ANTICONVULSANTS
QL = Quantity limit
ST = Step Therapy
54
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Phenytoin
ORAL SUSP
$0.00 - $6.35 (Tier 2)
+ Divalproex Sodium
Divalproex Sodium
CAP SPRINK
$0.00 - $2.55 (Tier 1)
+ Divalproex Sodium
Divalproex Sodium
TABLET DR
$0.00 - $2.55 (Tier 1)
+ Divalproex Sodium ER
Divalproex Sodium
TAB ER 24H
$0.00 - $2.55 (Tier 1)
+ Ethosuximide
Ethosuximide
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Ethosuximide
Ethosuximide
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ FELBAMATE
Felbamate
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ FELBAMATE
Felbamate
ORAL SUSP
$0.00 - $6.35 (Tier 2)
PA
+ FYCOMPA
Perampanel
TABLET
$0.00 - $6.35 (Tier 2)
QL, PA
+ Gabapentin
Gabapentin
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Gabapentin
Gabapentin
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Gabapentin
Gabapentin
TABLET
$0.00 - $2.55 (Tier 1)
+ Lamotrigine
Lamotrigine
TAB DS PK
$0.00 - $2.55 (Tier 1)
+ Lamotrigine
Lamotrigine
TABLET
$0.00 - $2.55 (Tier 1)
+ Lamotrigine
Lamotrigine
TB CHW DSP
$0.00 - $2.55 (Tier 1)
Levetiracetam
Levetiracetam
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
ANTICONVULSANTS
+ DILANTIN-125
PA
QL = Quantity limit
ST = Step Therapy
PART D
55
ANTICONVULSANTS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Levetiracetam
Levetiracetam
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Levetiracetam
Levetiracetam
TAB ER 24H
$0.00 - $2.55 (Tier 1)
+ Levetiracetam
Levetiracetam
TABLET
$0.00 - $2.55 (Tier 1)
Levetiracetam-Nacl
Levetiracetam In Nacl (Iso-Os)
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
PA
+ LYRICA
Pregabalin
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
+ LYRICA
Pregabalin
CAPSULE
$0.00 - $6.35 (Tier 2)
+ Oxcarbazepine
Oxcarbazepine
TABLET
$0.00 - $2.55 (Tier 1)
+ Oxcarbazepine
Oxcarbazepine
ORAL SUSP
$0.00 - $2.55 (Tier 1)
+ OXTELLAR XR
Oxcarbazepine
TAB ER 24H
$0.00 - $6.35 (Tier 2)
PA
+ PEGANONE
Ethotoin
TABLET
$0.00 - $6.35 (Tier 2)
+ Phenobarbital
Phenobarbital
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Phenobarbital
Phenobarbital
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Phenytoin
Phenytoin
TAB CHEW
$0.00 - $2.55 (Tier 1)
+ Phenytoin
Phenytoin
ORAL SUSP
$0.00 - $2.55 (Tier 1)
+ Phenytoin Sodium
Phenytoin Sodium
IV- DISP SYRIN
$0.00 - $2.55 (Tier 1)
PA
+ Phenytoin Sodium
Phenytoin Sodium
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
PA
QL
QL = Quantity limit
ST = Step Therapy
56
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Phenytoin Sodium Extended
CAPSULE
$0.00 - $2.55 (Tier 1)
+ POTIGA
Ezogabine
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ POTIGA 50MG
Ezogabine
TABLET
$0.00 - $6.35 (Tier 2)
QL, PA
+ Primidone
Primidone
TABLET
$0.00 - $2.55 (Tier 1)
+ SABRIL
Vigabatrin
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ SABRIL
Vigabatrin
ORAL PACKETS
$0.00 - $6.35 (Tier 2)
PA
+ TEGRETOL XR
Carbamazepine
TAB ER 12H
$0.00 - $6.35 (Tier 2)
+ TIAGABINE HCL
Tiagabine HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ TROKENDI XR
Topiramate
CAP ER 24H
$0.00 - $6.35 (Tier 2)
QL, PA
+ Topiramate
Topiramate
CAP SPRINK
$0.00 - $2.55 (Tier 1)
+ Topiramate
Topiramate
TABLET
$0.00 - $2.55 (Tier 1)
+ TRILEPTAL
Oxcarbazepine
ORAL SUSP
$0.00 - $6.35 (Tier 2)
Valproate Sodium
Valproate Sodium
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
+ Valproic Acid
Valproate Sodium
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Valproic Acid
Valproic Acid
CAPSULE
$0.00 - $2.55 (Tier 1)
+ VIMPAT
Lacosamide
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
ANTICONVULSANTS
+ Phenytoin Sodium Extended
PA
QL = Quantity limit
ST = Step Therapy
PART D
57
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ VIMPAT
Lacosamide
TABLET
$0.00 - $6.35 (Tier 2)
PA
VIMPAT
Lacosamide
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
QL, PA
+ Zonisamide
Zonisamide
CAPSULE
$0.00 - $2.55 (Tier 1)
ANTIDEMENTIA AGENTS
ANTICONVULSANTS
ANTIDEMENTIA AGENTS
+ Donepezil HCL
Donepezil HCL
TAB RAPDIS
$0.00 - $2.55 (Tier 1)
+ Donepezil HCL
Donepezil HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ DONEPEZIL HCL 23MG
Donepezil Hcl
TABLET
$0.00 - $6.35 (Tier 2)
+ EXELON
Rivastigmine Tartrate
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
+ EXELON
Rivastigmine
PATCH
$0.00 - $6.35 (Tier 2)
+ NAMENDA XR
Memantine HCL
CAP24 DSPK
$0.00 - $6.35 (Tier 2)
+ NAMENDA XR
Memantine HCL
CAP SPR 24
$0.00 - $6.35 (Tier 2)
+ NAMENDA
Memantine HCL
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
+ NAMENDA
Memantine HCL
TABLET
$0.00 - $6.35 (Tier 2)
+ NAMENDA
Memantine HCL
TAB DS PK
$0.00 - $6.35 (Tier 2)
+ Rivastigmine
Rivastigmine Tartrate
CAPSULE
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
58
PART D
BRAND DRUG NAME
WHAT THE DRUG WILL
NECESSARY ACTIONS,
GENERIC DRUG NAME
FORMULATION
+ Amitriptyline HCL
Amitriptyline HCL
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Amoxapine
Amoxapine
TABLET
$0.00 - $2.55 (Tier 1)
+ Bupropion HCL
Bupropion HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Bupropion SR
Bupropion HCL
TABLET ER
$0.00 - $2.55 (Tier 1)
+ Bupropion XL
Bupropion HCL
TAB ER 24H
$0.00 - $2.55 (Tier 1)
+ Bupropion XL 150MG
Bupropion HCL
TAB ER 24H
$0.00 - $2.55 (Tier 1)
QL
+ Chlordiazepoxide-Amitriptyline
Amitrip HCL/Chlordiazepoxide
TABLET
$0.00 - $2.55 (Tier 1)
+ Citalopram Hbr
Citalopram Hydrobromide
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Citalopram Hbr
Citalopram Hydrobromide
TABLET
$0.00 - $2.55 (Tier 1)
+ Clomipramine HCL
Clomipramine HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Desipramine HCL
Desipramine HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ DESVENLAFAXINE ER
Desvenlafaxine
TAB ER 24H
$0.00 - $2.55 (Tier 1)
PA
+ Doxepin HCL
Doxepin HCL
ORAL CONC
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Doxepin HCL
Doxepin HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
ANTIDEPRESSANTS
ANTIDEPRESSANTS
ANTIDEPRESSANTS
QL = Quantity limit
ST = Step Therapy
PART D
59
ANTIDEPRESSANTS
WHAT THE DRUG WILL
NECESSARY ACTIONS,
BRAND DRUG NAME
GENERIC DRUG NAME
+ Duloxetine HCL
Duloxetine HCL
CAPSULE DR
$0.00 - $2.55 (Tier 1)
+ EMSAM
Selegiline
PATCH
$0.00 - $6.35 (Tier 2)
PA
+ Escitalopram Oxalate
Escitalopram Oxalate
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Escitalopram Oxalate
Escitalopram Oxalate
TABLET
$0.00 - $2.55 (Tier 1)
+ Fluoxetine Dr
Fluoxetine HCL
CAPSULE DR
$0.00 - $2.55 (Tier 1)
+ Fluoxetine HCL
Fluoxetine HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Fluoxetine HCL
Fluoxetine HCL
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Fluoxetine HCL
Fluoxetine HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Fluvoxamine Maleate
Fluvoxamine Maleate
TABLET
$0.00 - $2.55 (Tier 1)
+ Imipramine HCL
Imipramine HCL
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Imipramine Pamoate
Imipramine Pamoate
CAPSULE
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ KHEDEZLA
Desvenlafaxine
TAB ER 24
$0.00 - $6.35 (Tier 2)
PA
+FETZIMA
Levomilnacipran Hydrochloride
CAP24HDSPK
$0.00 - $6.35 (Tier 2)
PA
+FETZIMA
Levomilnacipran Hydrochloride
CAP SA 24H
$0.00 - $6.35 (Tier 2)
PA
+ Maprotiline HCL
Maprotiline HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ MARPLAN
Isocarboxazid
TABLET
$0.00 - $6.35 (Tier 2)
FORMULATION
QL = Quantity limit
ST = Step Therapy
60
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Mirtazapine
TAB RAPDIS
$0.00 - $2.55 (Tier 1)
+ Mirtazapine
Mirtazapine
TABLET
$0.00 - $2.55 (Tier 1)
+ Nefazodone HCL
Nefazodone HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Nortriptyline HCL
Nortriptyline HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Nortriptyline HCL
Nortriptyline HCL
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Paroxetine HCL
Paroxetine HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ PAXIL
Paroxetine HCL
ORAL SUSP
$0.00 - $6.35 (Tier 2)
+ Perphenazine-Amitriptyline
Perphenazine/Amitriptyline HCL
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Phenelzine Sulfate
Phenelzine Sulfate
TABLET
$0.00 - $2.55 (Tier 1)
+ Protriptyline HCL
Protriptyline HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Sertraline HCL
Sertraline HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Sertraline HCL
Sertraline HCL
ORAL CONC
$0.00 - $2.55 (Tier 1)
+ Tranylcypromine Sulfate
Tranylcypromine Sulfate
TABLET
$0.00 - $2.55 (Tier 1)
+ Trazodone HCL
Trazodone HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Trimipramine Maleate
Trimipramine Maleate
CAPSULE
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Venlafaxine HCL
Venlafaxine HCL
TABLET
$0.00 - $2.55 (Tier 1)
ANTIDEPRESSANTS
+ Mirtazapine
QL = Quantity limit
ST = Step Therapy
PART D
61
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Venlafaxine HCL ER
Venlafaxine HCL
CAP ER 24H
$0.00 - $2.55 (Tier 1)
+ VENLAFAXINE HCL ER
Venlafaxine HCL
TAB ER 24
$0.00 - $2.55 (Tier 1)
+ VIIBRYD
Vilazodone Hydrochloride
TAB DS PK
$0.00 - $6.35 (Tier 2)
PA
+ VIIBRYD
Vilazodone Hydrochloride
TABLET
$0.00 - $6.35 (Tier 2)
PA
+BRINTELLIX
Vortioxetine Hydrobromide
TABLET
$0.00 - $6.35 (Tier 2)
PA
ANTIDIABETIC AGENTS
ANTIDEPRESSANTS
ANTIDIABETIC AGENTS, MISCELLANEOUS
+ Acarbose
Acarbose
TABLET
$0.00 - $2.55 (Tier 1)
QL
+ BYDUREON
Exenatide Microspheres
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ BYETTA
Exenatide
INJECTION PEN
$0.00 - $6.35 (Tier 2)
PA
+ CYCLOSET
Bromocriptine Mesylate
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ GLYSET
Miglitol
TABLET
$0.00 - $6.35 (Tier 2)
QL
+ INVOKANA
Canagliflozin
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ JANUMET
TABLET
$0.00 - $6.35 (Tier 2)
QL
+ JANUMET XR
TBMP 24HR
$0.00 - $6.35 (Tier 2)
QL
+ JANUVIA
Sitagliptin Phosphate
TABLET
$0.00 - $6.35 (Tier 2)
QL
QL = Quantity limit
ST = Step Therapy
62
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Linagliptin/Metformin HCL
TABLET
$0.00 - $6.35 (Tier 2)
QL
+ JUVISYNC
Sitagliptin/Simvastatin
TABLET
$0.00 - $6.35 (Tier 2)
QL
+ Metformin HCL
Metformin HCL
TABLET
$0.00 - $2.55 (Tier 1)
QL
+ Metformin HCL ER
Metformin HCL
TAB ER 24H
$0.00 - $2.55 (Tier 1)
QL
+ Nateglinide
Nateglinide
TABLET
$0.00 - $2.55 (Tier 1)
+ Repaglinide
Repaglinide
TABLET
$0.00 - $2.55 (Tier 1)
+ SYMLIN
Pramlintide Acetate
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ SYMLINPEN
Pramlintide Acetate
INJECTION PEN
$0.00 - $6.35 (Tier 2)
PA
+ TRADJENTA
Linagliptin
TABLET
$0.00 - $6.35 (Tier 2)
QL
+ VICTOZA 3-PAK
Liraglutide
INJECTION PEN
$0.00 - $6.35 (Tier 2)
PA
+ HUMALOG
Insulin Lispro
INJECTION
$0.00 - $6.35 (Tier 2)
+ HUMALOG
Insulin Lispro
INSULN PEN
$0.00 - $6.35 (Tier 2)
+ HUMALOG MIX 50-50
Insulin Npl/Insulin Lispro
INJECTION
$0.00 - $6.35 (Tier 2)
+ HUMALOG MIX 50-50
INSULN PEN
$0.00 - $6.35 (Tier 2)
+ HUMALOG MIX 75-25
INJECTION
$0.00 - $6.35 (Tier 2)
ANTIDIABETIC AGENTS
+ JENTADUETO
INSULINS
QL = Quantity limit
ST = Step Therapy
PART D
63
ANTIDIABETIC AGENTS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ HUMALOG MIX 75-25
INSULN PEN
$0.00 - $6.35 (Tier 2)
+ HUMULIN 70-30
Hum Insulin Nph/Reg Insulin Hm
INSULN PEN
$0.00 - $6.35 (Tier 2)
+ HUMULIN 70-30
INJECTION
$0.00 - $6.35 (Tier 2)
+ HUMULIN N
Nph, Human Insulin Isophane
INJECTION
$0.00 - $6.35 (Tier 2)
+ HUMULIN N
INSULN PEN
$0.00 - $6.35 (Tier 2)
+ HUMULIN R
Insulin Regular, Human
INJECTION
$0.00 - $6.35 (Tier 2)
+ HUMULIN R
INSULN PEN
$0.00 - $6.35 (Tier 2)
+ HUMULIN R 500/ML
INJECTION
$0.00 - $6.35 (Tier 2)
+ LANTUS
Insulin Glargine,Hum.Rec.Anlog
INJECTION
$0.00 - $6.35 (Tier 2)
+ LANTUS SOLOSTAR
Insulin Glargine,Hum.Rec.Anlog
INSULN PEN
$0.00 - $6.35 (Tier 2)
+ NOVOLIN 70-30
INJECTION
$0.00 - $6.35 (Tier 2)
+ NOVOLIN 70-30 INNOLET
INSULN PEN
$0.00 - $6.35 (Tier 2)
+ NOVOLIN N
INJECTION
$0.00 - $6.35 (Tier 2)
+ NOVOLIN N INNOLET
INSULN PEN
$0.00 - $6.35 (Tier 2)
+ NOVOLIN R
INJECTION
$0.00 - $6.35 (Tier 2)
+ NOVOLIN R
INSULN PEN
$0.00 - $6.35 (Tier 2)
QL = Quantity limit
ST = Step Therapy
64
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ NOVOLOG
Insulin Aspart
INJECTION
$0.00 - $6.35 (Tier 2)
+ NOVOLOG FLEXPEN
Insulin Aspart
INSULN PEN
$0.00 - $6.35 (Tier 2)
+ NOVOLOG MIX 70-30
Insuln Asp Prt/Insulin Aspart
INJECTION
$0.00 - $6.35 (Tier 2)
+ NOVOLOG MIX 70-30 FLEXPEN
Insuln Asp Prt/Insulin Aspart
INSULN PEN
$0.00 - $6.35 (Tier 2)
+ Glimepiride
Glimepiride
TABLET
$0.00 - $2.55 (Tier 1)
QL
+ Glipizide
Glipizide
TABLET
$0.00 - $2.55 (Tier 1)
QL
+ Glipizide ER
Glipizide
TAB ER 24
$0.00 - $2.55 (Tier 1)
QL
+ Glipizide-Metformin
TABLET
$0.00 - $2.55 (Tier 1)
QL
+ Glyburide
Glyburide
TABLET
$0.00 - $2.55 (Tier 1)
QL, PA>65 yrs old
+ Glyburide Micronized
TABLET
$0.00 - $2.55 (Tier 1)
QL, PA>65 yrs old
+ Glyburide-Metformin HCL
Glyburide/Metformin HCL
TABLET
$0.00 - $2.55 (Tier 1)
QL, PA>65 yrs old
+ Tolazamide
Tolazamide
TABLET
$0.00 - $2.55 (Tier 1)
QL
+ Tolbutamide
Tolbutamide
TABLET
$0.00 - $2.55 (Tier 1)
QL
Rosiglitazone Maleate
TABLET
$0.00 - $6.35 (Tier 2)
PA
SULFONYLUREAS
+ AVANDIA
QL = Quantity limit
ST = Step Therapy
PART D
65
ANTIDIABETIC AGENTS
THIAZOLIDINEDIONES
BRAND DRUG NAME
WHAT THE DRUG WILL
NECESSARY ACTIONS,
GENERIC DRUG NAME
FORMULATION
Pioglitazone HCL
TABLET
$0.00 - $2.55 (Tier 1)
QL
ABELCET
Amphotericin B Lipid Complex
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
AMBISOME
Amphotericin B Liposome
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
Amphotericin B
Amphotericin B
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
CANCIDAS
Caspofungin Acetate
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
Ciclopirox
Ciclopirox
TOPICAL GEL
$0.00 - $2.55 (Tier 1)
Ciclopirox
Ciclopirox
TOPICAL SOLUTION
$0.00 - $2.55 (Tier 1)
Ciclopirox
Ciclopirox Olamine
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Ciclopirox
Ciclopirox Olamine
TOPICAL SUSP
$0.00 - $2.55 (Tier 1)
Clotrimazole
Clotrimazole
ORAL TROCHE
$0.00 - $2.55 (Tier 1)
Clotrimazole
Clotrimazole
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Clotrimazole
Clotrimazole
TOPICAL SOLUTION
$0.00 - $2.55 (Tier 1)
Clotrimazole-Betamethasone
Clotrimazole/Betamethasone Dip
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Clotrimazole-Betamethasone
Clotrimazole/Betamethasone Dip
TOPICAL LOTION
$0.00 - $2.55 (Tier 1)
+ Pioglitazone HCL
ANTIFUNGALS
ANTIDIABETIC AGENTS
ANTIFUNGALS
PA
QL = Quantity limit
ST = Step Therapy
66
PART D
WHAT THE DRUG WILL
NECESSARY ACTIONS,
BRAND DRUG NAME
GENERIC DRUG NAME
Econazole Nitrate
Econazole Nitrate
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
ERAXIS (ALCOHOL DILUENT)
Anidulafungin
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
Fluconazole
Fluconazole
ORAL SUSP
$0.00 - $2.55 (Tier 1)
Fluconazole
Fluconazole
TABLET
$0.00 - $2.55 (Tier 1)
Fluconazole In Saline
Fluconazole In Nacl,Iso-Osm
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
Flucytosine
Flucytosine
CAPSULE
$0.00 - $2.55 (Tier 1)
Griseofulvin
Griseofulvin,Microsize
ORAL SUSP
$0.00 - $2.55 (Tier 1)
PA
Griseofulvin
Griseofulvin,Microsize
TABLET
$0.00 - $2.55 (Tier 1)
PA
Griseofulvin Ultramicrosize
Griseofulvin Ultramicrosize
TABLET
$0.00 - $2.55 (Tier 1)
PA
Itraconazole
Itraconazole
CAPSULE
$0.00 - $2.55 (Tier 1)
PA
Ketoconazole
Ketoconazole
SHAMPOO
$0.00 - $2.55 (Tier 1)
Ketoconazole
Ketoconazole
TABLET
$0.00 - $2.55 (Tier 1)
Ketoconazole
Ketoconazole
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Nyamyc
Nystatin
TOPICAL POWDER
$0.00 - $2.55 (Tier 1)
Nystatin
Nystatin
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
Nystatin
Nystatin
TOPICAL POWDER
$0.00 - $2.55 (Tier 1)
FORMULATION
BvD
ANTIFUNGALS
QL = Quantity limit
ST = Step Therapy
PART D
67
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Nystatin
Nystatin
ORAL POWDER
$0.00 - $2.55 (Tier 1)
Nystatin
Nystatin
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Nystatin
Nystatin
TABLET
$0.00 - $2.55 (Tier 1)
Nystatin-Triamcinolone
Nystatin/Triamcin
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Nystatin-Triamcinolone
Nystatin/Triamcin
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
Terbinafine HCL
Terbinafine HCL
TABLET
$0.00 - $2.55 (Tier 1)
VORICONAZOLE
Voriconazole
TABLET
$0.00 - $2.55 (Tier 1)
PA
Clemastine Fumarate
Clemastine Fumarate
ORAL SYRUP
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
Clemastine Fumarate
Clemastine Fumarate
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Cyproheptadine HCL
Cyproheptadine HCL
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Desloratadine
Desloratadine
TAB RAPDIS
$0.00 - $2.55 (Tier 1)
ST
+ Desloratadine
Desloratadine
TABLET
$0.00 - $2.55 (Tier 1)
ST
Diphenhydramine HCL
Diphenhydramine HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
Diphenhydramine HCL
Diphenhydramine HCL
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
ANTIFUNGALS
ANTIHISTAMINES
ANTIHISTAMINES
QL = Quantity limit
ST = Step Therapy
68
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
Promethazine HCL
Promethazine HCL
FORMULATION
ORAL SYRUP
WHAT THE DRUG WILL
$0.00 - $2.55 (Tier 1)
NECESSARY ACTIONS,
PA>65 yrs old
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)
VAGINAL CREAM
$0.00 - $2.55 (Tier 1)
Metronidazole
Metronidazole
VAGINAL GEL
$0.00 - $2.55 (Tier 1)
Miconazole 3
Miconazole Nitrate
VAGINAL SUPP
$0.00 - $2.55 (Tier 1)
Terconazole
Terconazole
VAGINAL CREAM
$0.00 - $2.55 (Tier 1)
Terconazole
Terconazole
VAGINAL SUPP
$0.00 - $2.55 (Tier 1)
ANTIHISTAMINES
ANTIMIGRAINE AGENTS
ANTIMIGRAINE AGENTS
Dihydroergotamine Mesylate
Dihydroergotamine Mesylate
INJECTION
$0.00 - $2.55 (Tier 1)
ERGOMAR
Ergotamine Tartrate
TAB SUBL
$0.00 - $6.35 (Tier 2)
Ergotamine-Caffeine
Ergotamine Tartrate/Caffeine
TABLET
$0.00 - $2.55 (Tier 1)
Migergot
Ergotamine Tartrate/Caffeine
RECTAL SUPP
$0.00 - $2.55 (Tier 1)
Rizatriptan
TABLET
$0.00 - $2.55 (Tier 1)
BvD
QL
QL = Quantity limit
ST = Step Therapy
PART D
69
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Rizatriptan
TAB RAPDIS
$0.00 - $2.55 (Tier 1)
QL
Sumatriptan
Sumatriptan
NASAL SPRAY
$0.00 - $2.55 (Tier 1)
QL
TABLET
$0.00 - $2.55 (Tier 1)
QL
INJECTION CART
$0.00 - $2.55 (Tier 1)
QL
CAPASTAT SULFATE
Capreomycin Sulfate
INJECTION
$0.00 - $6.35 (Tier 2)
PA
CYCLOSERINE
Cycloserine
CAPSULE
$0.00 - $2.55 (Tier 1)
+ DAPSONE
Dapsone
TABLET
$0.00 - $6.35 (Tier 2)
+ Ethambutol HCL
Ethambutol HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Isoniazid
Isoniazid
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Isoniazid
Isoniazid
TABLET
$0.00 - $2.55 (Tier 1)
MYCOBUTIN
Rifabutin
CAPSULE
$0.00 - $6.35 (Tier 2)
+ PASER
Aminosalicylic Acid
ORAL PACKETS
$0.00 - $6.35 (Tier 2)
PRIFTIN
Rifapentine
TABLET
$0.00 - $6.35 (Tier 2)
+ Pyrazinamide
Pyrazinamide
TABLET
$0.00 - $2.55 (Tier 1)
ANTIMYCOBACTERIALS
ANTIMIGRAINE AGENTS
ANTIMYCOBACTERIALS
QL = Quantity limit
ST = Step Therapy
70
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Rifampin
Rifampin
CAPSULE
$0.00 - $2.55 (Tier 1)
RIFAMPIN
Rifampin
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
RIFATER
Rifampin/Isoniazid/Pyrazinamid
TABLET
$0.00 - $6.35 (Tier 2)
+ TRECATOR
Ethionamide
TABLET
$0.00 - $6.35 (Tier 2)
DRONABINOL
Dronabinol
CAPSULE
$0.00 - $2.55 (Tier 1)
PA
EMEND
Aprepitant
CAP DS PK
$0.00 - $6.35 (Tier 2)
BvD
EMEND
Aprepitant
CAPSULE
$0.00 - $6.35 (Tier 2)
BvD
EMEND
Fosaprepitant Dimeglumine
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
Granisetron HCL
Granisetron HCL
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Granisetron HCL
Granisetron HCL
TABLET
$0.00 - $2.55 (Tier 1)
BvD
GRANISETRON HCL
Granisetron HCL/PF
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Meclizine HCL
Meclizine HCL
TABLET
$0.00 - $2.55 (Tier 1)
Ondansetron HCL
Ondansetron HCL
TABLET
$0.00 - $2.55 (Tier 1)
BvD
Ondansetron HCL
Ondansetron HCL
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
BvD
BvD
ANTINAUSEA AGENTS
ANTINAUSEA AGENTS
ANTIMYCOBACTERIALS
QL = Quantity limit
ST = Step Therapy
PART D
71
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Ondansetron Odt
Ondansetron
TAB RAPDIS
$0.00 - $2.55 (Tier 1)
BvD
Prochlorperazine Edisylate
Prochlorperazine Edisylate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Prochlorperazine Maleate
RECTAL SUPP
$0.00 - $2.55 (Tier 1)
TABLET
$0.00 - $2.55 (Tier 1)
Promethazine HCL
Promethazine HCL
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Promethazine Hcl
Promethazine Hcl
RECTAL SUPP
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
Promethazine HCL
Promethazine HCL
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
ALBENZA
Albendazole
TABLET
$0.00 - $6.35 (Tier 2)
ALINIA
Nitazoxanide
TABLET
$0.00 - $6.35 (Tier 2)
ATOVAQUONE-PROGUANIL HCL
Atovaquone/Proguanil HCL
TABLET
$0.00 - $2.55 (Tier 1)
BILTRICIDE
Praziquantel
TABLET
$0.00 - $6.35 (Tier 2)
+ Chloroquine Phosphate
Chloroquine Phosphate
TABLET
$0.00 - $2.55 (Tier 1)
DARAPRIM
Pyrimethamine
TABLET
$0.00 - $6.35 (Tier 2)
+ Hydroxychloroquine Sulfate
Hydroxychloroquine Sulfate
TABLET
$0.00 - $2.55 (Tier 1)
ANTINAUSEA AGENTS
ANTIPARASITE AGENTS
ANTIPARASITE AGENTS
PA
QL = Quantity limit
ST = Step Therapy
72
PART D
WHAT THE DRUG WILL
NECESSARY ACTIONS,
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
+ Mefloquine HCL
Mefloquine HCL
TABLET
$0.00 - $2.55 (Tier 1)
MEPRON
Atovaquone
ORAL SUSP
$0.00 - $6.35 (Tier 2)
Metronidazole
Metronidazole
TABLET
$0.00 - $2.55 (Tier 1)
Metronidazole
Metronidazole/Sodium Chloride
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
NEBUPENT
Pentamidine Isethionate
INHALATION SOLN
$0.00 - $6.35 (Tier 2)
BvD
Paromomycin Sulfate
Paromomycin Sulfate
CAPSULE
$0.00 - $2.55 (Tier 1)
PENTAMIDINE ISETHIONATE
Pentamidine Isethionate
INJECTION
$0.00 - $2.55 (Tier 1)
PRIMAQUINE
Primaquine Phosphate
TABLET
$0.00 - $6.35 (Tier 2)
STROMECTOL
Ivermectin
TABLET
$0.00 - $6.35 (Tier 2)
Yodoxin
Iodoquinol
TABLET
$0.00 - $2.55 (Tier 1)
PA
ANTIPARASITE AGENTS
ANTIPARKINSONIAN AGENTS
+ Amantadine
Amantadine HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Amantadine
Amantadine HCL
ORAL SYRUP
$0.00 - $2.55 (Tier 1)
+ Amantadine
Amantadine HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
+ APOKYN
Apomorphine HCL
INJECTION CART
$0.00 - $6.35 (Tier 2)
PA
QL = Quantity limit
ST = Step Therapy
PART D
73
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ AZILECT
Rasagiline Mesylate
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ AZILECT 0.5MG
Rasagiline Mesylate
TABLET
$0.00 - $6.35 (Tier 2)
QL, PA
+ Benztropine Mesylate
Benztropine Mesylate
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Bromocriptine Mesylate
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Bromocriptine Mesylate
TABLET
$0.00 - $2.55 (Tier 1)
+ Cabergoline
Cabergoline
TABLET
$0.00 - $2.55 (Tier 1)
+ Carbidopa-Levodopa
Carbidopa/Levodopa
TABLET
$0.00 - $2.55 (Tier 1)
+ Carbidopa-Levodopa
Carbidopa/Levodopa
TABLET ER
$0.00 - $2.55 (Tier 1)
+ CARBIDOPA-LEVODOPA-ENTACAPONE Carbidopa/Levodopa/Entacapone TABLET
$0.00 - $2.55 (Tier 1)
ST
+ ENTACAPONE
Entacapone
TABLET
$0.00 - $2.55 (Tier 1)
ST
+ Pramipexole Dihydrochloride
Pramipexole Di-Hcl
TABLET
$0.00 - $2.55 (Tier 1)
+ Ropinirole HCL
Ropinirole HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Selegiline HCL
Selegiline HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Selegiline HCL
Selegiline HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
+ TASMAR
Tolcapone
TABLET
$0.00 - $6.35 (Tier 2)
ST
+ Trihexyphenidyl HCL
Trihexyphenidyl HCL
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
QL = Quantity limit
ST = Step Therapy
74
PART D
BRAND DRUG NAME
+ Trihexyphenidyl HCL
GENERIC DRUG NAME
Trihexyphenidyl HCL
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
ANTIPSYCHOTIC AGENTS
Aripiprazole
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ ABILIFY
Aripiprazole
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
QL, ST
+ ABILIFY
Aripiprazole
TABLET
$0.00 - $6.35 (Tier 2)
QL, ST
+ ABILIFY DISCMELT
Aripiprazole
TAB RAPDIS
$0.00 - $6.35 (Tier 2)
QL, ST
+ ABILIFY MAINTENA
Aripiprazole
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ Chlorpromazine HCL
Chlorpromazine HCL
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Chlorpromazine HCL
ORAL CONC
$0.00 - $2.55 (Tier 1)
Chlorpromazine HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Clozapine
Clozapine
TABLET
$0.00 - $2.55 (Tier 1)
+ CLOZAPINE ODT
Clozapine
TAB RAPDIS
$0.00 - $6.35 (Tier 2)
+ FANAPT
Iloperidone
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ FANAPT
Iloperidone
TAB DS PK
$0.00 - $6.35 (Tier 2)
PA
Fluphenazine Decanoate
Fluphenazine Decanoate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
+ ABILIFY
QL = Quantity limit
ST = Step Therapy
PART D
75
WHAT THE DRUG WILL
NECESSARY ACTIONS,
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
Fluphenazine HCL
Fluphenazine HCL
INJECTION
$0.00 - $2.55 (Tier 1)
+ Fluphenazine HCL
Fluphenazine HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Fluphenazine HCL
Fluphenazine HCL
ORAL CONC
$0.00 - $2.55 (Tier 1)
+ Fluphenazine HCL
Fluphenazine HCL
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
GEODON
Ziprasidone Mesylate
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ Haloperidol
Haloperidol
TABLET
$0.00 - $2.55 (Tier 1)
Haloperidol Decanoate
Haloperidol Decanoate
INJECTION
$0.00 - $2.55 (Tier 1)
PA
Haloperidol Lactate
Haloperidol Lactate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
+ Haloperidol Lactate
Haloperidol Lactate
ORAL CONC
$0.00 - $2.55 (Tier 1)
+ INVEGA
Paliperidone
TAB ER 24
$0.00 - $6.35 (Tier 2)
QL, PA
+ INVEGA SUSTENNA
Paliperidone Palmitate
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
+ LATUDA
Lurasidone HCL
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ Loxapine
Loxapine Succinate
CAPSULE
$0.00 - $2.55 (Tier 1)
+ OLANZAPINE
Olanzapine
TABLET
$0.00 - $2.55 (Tier 1)
QL
+ Olanzapine
Olanzapine
INJECTION
$0.00 - $2.55 (Tier 1)
PA
+ Olanzapine Odt
Olanzapine
TAB RAPDIS
$0.00 - $2.55 (Tier 1)
QL
BvD
QL = Quantity limit
ST = Step Therapy
76
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Pimozide
TABLET
$0.00 - $6.35 (Tier 2)
+ Perphenazine
Perphenazine
TABLET
$0.00 - $2.55 (Tier 1)
+ Quetiapine Fumarate
Quetiapine Fumarate
TABLET
$0.00 - $2.55 (Tier 1)
QL
+ RISPERDAL CONSTA
Risperidone Microspheres
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
+ Risperidone
Risperidone
TABLET
$0.00 - $2.55 (Tier 1)
QL
+ Risperidone
Risperidone
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
QL
+ Risperidone M-Tab
Risperidone
TAB RAPDIS
$0.00 - $2.55 (Tier 1)
QL
+ SAPHRIS
Asenapine Maleate
TAB SUBL
$0.00 - $6.35 (Tier 2)
PA
+ Thioridazine HCL
Thioridazine HCL
ORAL CONC
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Thioridazine HCL
Thioridazine HCL
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Thiothixene
Thiothixene
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Trifluoperazine HCL
Trifluoperazine HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ VERSACLOZ
Clozapine
ORAL SUSP
$0.00 - $6.35 (Tier 2)
PA
+ Ziprasidone HCL
Ziprasidone HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
QL
+ ORAP
QL = Quantity limit
ST = Step Therapy
PART D
77
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
ANTIVIRALS (SYSTEMIC)
ANTIRETROVIRALS
TABLET
$0.00 - $2.55 (Tier 1)
+ABACAVIR-LAMIVUDINE-ZIDOVUDINE Abacavir/Lamivudine/Zidovudine TABLET
$0.00 - $6.35 (Tier 2)
+ APTIVUS
Tipranavir/Vitamin E Tpgs
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
+ APTIVUS
Tipranavir
CAPSULE
$0.00 - $6.35 (Tier 2)
+ ATRIPLA
Efavirenz/Emtricitab/Tenofovir
TABLET
$0.00 - $6.35 (Tier 2)
+ COMPLERA
Emtricitab/Rilpivirine/Tenofov
TABLET
$0.00 - $6.35 (Tier 2)
+ CRIXIVAN
Indinavir Sulfate
CAPSULE
$0.00 - $6.35 (Tier 2)
+ Didanosine
Didanosine
CAPSULE DR
$0.00 - $2.55 (Tier 1)
+TIVICAY
Dolutegravir Sodium
TABLET
$0.00 - $6.35 (Tier 2)
+ EDURANT
Rilpivirine HCL
TABLET
$0.00 - $6.35 (Tier 2)
QL
+ EMTRIVA
Emtricitabine
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
+ EMTRIVA
Emtricitabine
CAPSULE
$0.00 - $6.35 (Tier 2)
+ EPIVIR
Lamivudine
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
+ EPIVIR HBV
Lamivudine
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
PA
+ Abacavir
Abacavir Sulfate
QL = Quantity limit
ST = Step Therapy
78
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Lamivudine
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ EPZICOM
Abacavir Sulfate/Lamivudine
TABLET
$0.00 - $6.35 (Tier 2)
+ FUZEON
Enfuvirtide
INJECTION
$0.00 - $6.35 (Tier 2)
+ INTELENCE
Etravirine
TABLET
$0.00 - $6.35 (Tier 2)
+ INVIRASE
Saquinavir Mesylate
TABLET
$0.00 - $6.35 (Tier 2)
+ INVIRASE
Saquinavir Mesylate
CAPSULE
$0.00 - $6.35 (Tier 2)
QL
+ ISENTRESS
TAB CHEW
$0.00 - $6.35 (Tier 2)
QL
+ ISENTRESS
TABLET
$0.00 - $6.35 (Tier 2)
+ KALETRA
Lopinavir/Ritonavir
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
+ KALETRA
Lopinavir/Ritonavir
TABLET
$0.00 - $6.35 (Tier 2)
+ Lamivudine
Lamivudine
TABLET
$0.00 - $2.55 (Tier 1)
+ LAMIVUDINE-ZIDOVUDINE
Lamivudine/Zidovudine
TABLET
$0.00 - $2.55 (Tier 1)
+ LEXIVA
Fosamprenavir Calcium
TABLET
$0.00 - $6.35 (Tier 2)
+ LEXIVA
Fosamprenavir Calcium
ORAL SUSP
$0.00 - $6.35 (Tier 2)
+ Nevirapine
Nevirapine
ORAL SUSP
$0.00 - $2.55 (Tier 1)
+ Nevirapine
Nevirapine
TABLET
$0.00 - $2.55 (Tier 1)
+ EPIVIR HBV
QL = Quantity limit
ST = Step Therapy
PART D
79
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ NORVIR
Ritonavir
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
+ NORVIR
Ritonavir
CAPSULE
$0.00 - $6.35 (Tier 2)
+ NORVIR
Ritonavir
TABLET
$0.00 - $6.35 (Tier 2)
+ PREZISTA
ORAL SUSP
$0.00 - $6.35 (Tier 2)
+ PREZISTA
TABLET
$0.00 - $6.35 (Tier 2)
+ PREZISTA 75MG
TABLET
$0.00 - $6.35 (Tier 2)
QL
+ RESCRIPTOR
Delavirdine Mesylate
TAB DISPER
$0.00 - $6.35 (Tier 2)
+ RESCRIPTOR
Delavirdine Mesylate
TABLET
$0.00 - $6.35 (Tier 2)
RETROVIR
Zidovudine
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
+ REYATAZ
Atazanavir Sulfate
CAPSULE
$0.00 - $6.35 (Tier 2)
+ SELZENTRY
Maraviroc
TABLET
$0.00 - $6.35 (Tier 2)
+ Stavudine
Stavudine
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Stavudine
Stavudine
CAPSULE
$0.00 - $2.55 (Tier 1)
+ STRIBILD
Elvitegr/Cobicist/Emtric/Tenof
TABLET
$0.00 - $6.35 (Tier 2)
+ SUSTIVA
Efavirenz
CAPSULE
$0.00 - $6.35 (Tier 2)
+ SUSTIVA
Efavirenz
TABLET
$0.00 - $6.35 (Tier 2)
QL
QL = Quantity limit
ST = Step Therapy
80
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Emtricitabine/Tenofovir
TABLET
$0.00 - $6.35 (Tier 2)
+ VIDEX
Didanosine
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
+ VIRACEPT
Nelfinavir Mesylate
TABLET
$0.00 - $6.35 (Tier 2)
+ VIRAMUNE XR
Nevirapine
TAB ER 24H
$0.00 - $6.35 (Tier 2)
+ VIREAD
Tenofovir Disoproxil Fumarate
ORAL POWDER
$0.00 - $6.35 (Tier 2)
+ VIREAD
Tenofovir Disoproxil Fumarate
TABLET
$0.00 - $6.35 (Tier 2)
+ ZIAGEN
Abacavir Sulfate
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
+ Zidovudine
Zidovudine
ORAL SYRUP
$0.00 - $2.55 (Tier 1)
+ Zidovudine
Zidovudine
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Zidovudine
Zidovudine
TABLET
$0.00 - $2.55 (Tier 1)
+ TRUVADA
ANTIVIRALS, MISCELLANEOUS
RELENZA
Zanamivir
INHALATION DISK
$0.00 - $6.35 (Tier 2)
QL
Rimantadine HCL
Rimantadine HCL
TABLET
$0.00 - $2.55 (Tier 1)
TAMIFLU
CAPSULE
$0.00 - $6.35 (Tier 2)
QL
TAMIFLU
ORAL SUSP
$0.00 - $6.35 (Tier 2)
QL
QL = Quantity limit
ST = Step Therapy
PART D
81
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
HCV PROTEASE INHIBITORS
INCIVEK
Telaprevir
TABLET
$0.00 - $6.35 (Tier 2)
PA
VICTRELIS
Boceprevir
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
INFERGEN
Interferon Alfacon-1
INJECTION
$0.00 - $6.35 (Tier 2)
PA
INTRON A
Interferon Alfa-2B,Recomb.
INJECTION
$0.00 - $6.35 (Tier 2)
PA
INTRON A
Interferon Alfa-2B,Recomb.
INJECTION KIT
$0.00 - $6.35 (Tier 2)
PA
PEGASYS
Peginterferon Alfa-2A
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
PEGASYS
INJECTION
$0.00 - $6.35 (Tier 2)
PA
PEGASYS PROCLICK
INJECTION PEN
$0.00 - $6.35 (Tier 2)
PA
PEGINTRON
Peginterferon Alfa-2B
INJECTION KIT
$0.00 - $6.35 (Tier 2)
PA
PEGINTRON REDIPEN
INJECTION KIT
$0.00 - $6.35 (Tier 2)
PA
SYLATRON 4-PACK
INJECTION KIT
$0.00 - $6.35 (Tier 2)
PA
INTERFERONS
NUCLEOSIDES AND NUCLEOTIDES
+ Acyclovir
Acyclovir
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Acyclovir
Acyclovir
ORAL SUSP
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
82
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Acyclovir
TABLET
$0.00 - $2.55 (Tier 1)
Acyclovir Sodium
Acyclovir Sodium
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
ADEFOVIR DIPIVOXIL
Adefovir Dipivoxil
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ BARACLUDE
Entecavir
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
PA
+ BARACLUDE
Entecavir
TABLET
$0.00 - $6.35 (Tier 2)
PA
GANCICLOVIR SODIUM
Ganciclovir Sodium
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
Ribavirin
Ribavirin
CAPSULE
$0.00 - $2.55 (Tier 1)
PA
Ribavirin
Ribavirin
TABLET
$0.00 - $2.55 (Tier 1)
PA
+ TYZEKA
Telbivudine
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ Valacyclovir
Valacyclovir HCL
TABLET
$0.00 - $2.55 (Tier 1)
PA
+ VALCYTE
Valganciclovir HCL
TABLET
$0.00 - $6.35 (Tier 2)
+ Acyclovir
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
+ COUMADIN
Warfarin Sodium
TABLET
$0.00 - $6.35 (Tier 2)
+ ELIQUIS
Apixaban
TABLET
$0.00 - $6.35 (Tier 2)
PA
Enoxaparin Sodium
Enoxaparin Sodium
INJECTION
$0.00 - $2.55 (Tier 1)
PA
QL = Quantity limit
ST = Step Therapy
PART D
83
BLOOD PRODUCTS/MODIFIERS/VOLUME
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Enoxaparin Sodium
Enoxaparin Sodium
INJECTION DISP SYR
$0.00 - $2.55 (Tier 1)
PA
FONDAPARINUX SODIUM
Fondaparinux Sodium
INJECTION DISP SYR
$0.00 - $2.55 (Tier 1)
PA
FRAGMIN
Dalteparin Sodium,Porcine
INJECTION
$0.00 - $6.35 (Tier 2)
PA
FRAGMIN
Dalteparin Sodium,Porcine
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
Heparin Sodium
Heparin Sodium,Porcine/PF
INJECTION DISP SYR
$0.00 - $2.55 (Tier 1)
BvD
Heparin Sodium
Heparin Sodium,Porcine/PF
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Heparin Sodium In 0.45% Nacl
Heparin Sod,Pork In 0.45% Nacl
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Heparin Sodium-D5W
Heparin Sodium,Porcine/D5W
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Heparin Sodium-Ns
Heparin Sodium,Porcine/Ns/PF
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
+ PRADAXA
Dabigatran Etexilate Mesylate
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ Warfarin Sodium
Warfarin Sodium
TABLET
$0.00 - $2.55 (Tier 1)
+ XARELTO
Rivaroxaban
TABLET
$0.00 - $6.35 (Tier 2)
PA
BLOOD FORMATION MODIFIERS
+ ARANESP
Darbepoetin Alfa In Polysorbat
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ ARANESP
Darbepoetin Alfa In Polysorbat
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
+ EPOGEN
Epoetin Alfa
INJECTION
$0.00 - $6.35 (Tier 2)
PA
QL = Quantity limit
ST = Step Therapy
84
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Sargramostim
INJECTION
$0.00 - $6.35 (Tier 2)
PA
NEULASTA
Pegfilgrastim
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
NEUMEGA
Oprelvekin
INJECTION
$0.00 - $6.35 (Tier 2)
PA
NEUPOGEN
Filgrastim
INJECTION
$0.00 - $6.35 (Tier 2)
PA
NEUPOGEN
Filgrastim
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
+ PROCRIT
Epoetin Alfa
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ PROMACTA
Eltrombopag Olamine
TABLET
$0.00 - $6.35 (Tier 2)
PA
LEUKINE
HEMATOLOGIC AGENTS, MISCELLANEOUS
Aminocaproic Acid
Aminocaproic Acid
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Aminocaproic Acid
Aminocaproic Acid
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
PA
Aminocaproic Acid
Aminocaproic Acid
TABLET
$0.00 - $2.55 (Tier 1)
PA
+ Anagrelide HCL
Anagrelide HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
TRANEXAMIC ACID
Tranexamic Acid
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
+ TRANEXAMIC ACID
Tranexamic Acid
TABLET
$0.00 - $6.35 (Tier 2)
PA
CPMP 12HR
$0.00 - $6.35 (Tier 2)
PLATELET-AGGREGATION INHIBITORS
+ AGGRENOX
Aspirin/Dipyridamole
QL = Quantity limit
ST = Step Therapy
PART D
85
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Cilostazol
Cilostazol
TABLET
$0.00 - $2.55 (Tier 1)
+ Clopidogrel
Clopidogrel Bisulfate
TABLET
$0.00 - $2.55 (Tier 1)
+ Dipyridamole
Dipyridamole
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Pentoxifylline
Pentoxifylline
TABLET ER
$0.00 - $2.55 (Tier 1)
+ Ticlopidine HCL
Ticlopidine HCL
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
AMINOSYN
Parenteral Amino Acid 3.5% No1
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
Aminosyn Ii
Parenteral Amino Acid 15% No.2
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
AMINOSYN II
Amino Acids 7 %
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
AMINOSYN-HBC
Amino Acids 7 %
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
AMINOSYN-PF
Parent. Amino Acid 7 % #1(Ped)
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
Dextrose In Lactated Ringers
Dextrose 5%-Lactated Ringers
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Dextrose In Ringers Injection
Dextrose 5% In Ringers
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
Dextrose In Water
Dextrose 70%-Water
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Dextrose In Water
Dextrose 50 % In Water
IV- DISP SYRIN
$0.00 - $2.55 (Tier 1)
BvD
CALORIC AGENTS
CALORIC AGENTS
QL = Quantity limit
ST = Step Therapy
86
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Dextrose With Sodium Chloride
Dextrose 5 %-0.2 % Nacl
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
FREAMINE HBC
Amino Acids 6.9%
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
FRUCTOSE
Fructose 10%
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
Hepatasol
Amino Acids 8%
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
INTRALIPID
Fat Emulsions
IV- EMULSION
$0.00 - $6.35 (Tier 2)
BvD
NEPHRAMINE
Amino Acids 5.4%
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
Premasol
Parenteral Amino Acid 10% No.7
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Travasol
Amino Acids 8.5 %
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Trophamine
Amino Acids 10 %
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
CALORIC AGENTS
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGENTS
+ Clonidine HCL
Clonidine HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Doxazosin Mesylate
Doxazosin Mesylate
TABLET
$0.00 - $2.55 (Tier 1)
+ Guanfacine HCL
Guanfacine HCL
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Methyldopa
Methyldopa
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Methyldopa-Hydrochlorothiazide
Methyldopa/Hydrochlorothiazide
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
QL = Quantity limit
ST = Step Therapy
PART D
87
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Midodrine HCL
Midodrine HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Prazosin HCL
Prazosin HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
ANGIOTENSIN II RECEPTOR ANTAGONISTS
+ DIOVAN
Valsartan
TABLET
$0.00 - $6.35 (Tier 2)
+ Losartan Potassium
Losartan Potassium
TABLET
$0.00 - $2.55 (Tier 1)
+ Losartan-Hydrochlorothiazide
Losartan/Hydrochlorothiazide
TABLET
$0.00 - $2.55 (Tier 1)
+ Valsartan-Hydrochlorothiazide
Valsartan/Hydrochlorothiazide
TABLET
$0.00 - $2.55 (Tier 1)
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
+ Benazepril HCL
Benazepril HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Benazepril-Hydrochlorothiazide
Benazepril/Hydrochlorothiazide
TABLET
$0.00 - $2.55 (Tier 1)
+ Captopril
Captopril
TABLET
$0.00 - $2.55 (Tier 1)
+ Captopril-Hydrochlorothiazide
Captopril/Hydrochlorothiazide
TABLET
$0.00 - $2.55 (Tier 1)
+ Enalapril Maleate
Enalapril Maleate
TABLET
$0.00 - $2.55 (Tier 1)
+ Enalapril-Hydrochlorothiazide
Enalapril/Hydrochlorothiazide
TABLET
$0.00 - $2.55 (Tier 1)
+ Fosinopril Sodium
Fosinopril Sodium
TABLET
$0.00 - $2.55 (Tier 1)
+ Fosinopril-Hydrochlorothiazide
Fosinopril/Hydrochlorothiazide
TABLET
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
88
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Lisinopril
Lisinopril
TABLET
$0.00 - $2.55 (Tier 1)
+ Lisinopril-Hydrochlorothiazide
Lisinopril/Hydrochlorothiazide
TABLET
$0.00 - $2.55 (Tier 1)
+ Moexipril HCL
Moexipril HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Quinapril HCL
Quinapril HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Quinapril-Hydrochlorothiazide
Quinapril/Hydrochlorothiazide
TABLET
$0.00 - $2.55 (Tier 1)
+ Ramipril
Ramipril
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Trandolapril
Trandolapril
TABLET
$0.00 - $2.55 (Tier 1)
+ Amiodarone HCL
Amiodarone HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Disopyramide Phosphate
Disopyramide Phosphate
CAPSULE
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Flecainide Acetate
Flecainide Acetate
TABLET
$0.00 - $2.55 (Tier 1)
Lidocaine HCL
Lidocaine HCL/PF
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Lidocaine HCL In 5% Dextrose
Lidocaine HCL/D5W/PF
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
+ Mexiletine HCL
Mexiletine HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
+ MULTAQ
Dronedarone HCL
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ Procainamide HCL
Procainamide HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
ANTIARRHYTHMIC AGENTS
QL = Quantity limit
ST = Step Therapy
PART D
89
BRAND DRUG NAME
WHAT THE DRUG WILL
NECESSARY ACTIONS,
GENERIC DRUG NAME
FORMULATION
+ Procainamide HCL
Procainamide HCL
TABLET SA
$0.00 - $2.55 (Tier 1)
+ Propafenone HCL
Propafenone HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Quinidine Gluconate
Quinidine Gluconate
TABLET ER
$0.00 - $2.55 (Tier 1)
+ Quinidine Sulfate
Quinidine Sulfate
TABLET
$0.00 - $2.55 (Tier 1)
+ Quinidine Sulfate
Quinidine Sulfate
TABLET ER
$0.00 - $2.55 (Tier 1)
+ TIKOSYN
Dofetilide
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
BETA-ADRENERGIC BLOCKING AGENTS
+ Acebutolol HCL
Acebutolol HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Atenolol
Atenolol
TABLET
$0.00 - $2.55 (Tier 1)
+ Atenolol-Chlorthalidone
Atenolol/Chlorthalidone
TABLET
$0.00 - $2.55 (Tier 1)
+ Betaxolol HCL
Betaxolol HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Bisoprolol Fumarate
Bisoprolol Fumarate
TABLET
$0.00 - $2.55 (Tier 1)
+ Bisoprolol-Hydrochlorothiazide
Bisoprolol Fumarate/Hctz
TABLET
$0.00 - $2.55 (Tier 1)
BREVIBLOC
Esmolol In Sodium Chloride,Iso
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ Carvedilol
Carvedilol
TABLET
$0.00 - $2.55 (Tier 1)
Esmolol HCL
Esmolol HCL
IV- DISP SYRIN
$0.00 - $2.55 (Tier 1)
BvD
QL = Quantity limit
ST = Step Therapy
90
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Labetalol HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Metoprolol Succinate
TAB ER 24H
$0.00 - $2.55 (Tier 1)
QL
+ Metoprolol Tartrate
Metoprolol Tartrate
TABLET
$0.00 - $2.55 (Tier 1)
+ Metoprolol-Hydrochlorothiazide
Metoprolol/Hydrochlorothiazide
TABLET
$0.00 - $2.55 (Tier 1)
+ Nadolol
Nadolol
TABLET
$0.00 - $2.55 (Tier 1)
+ Pindolol
Pindolol
TABLET
$0.00 - $2.55 (Tier 1)
+ Propranolol HCL
Propranolol HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Propranolol HCL
Propranolol HCL
CAP SA 24H
$0.00 - $2.55 (Tier 1)
+ Propranolol-Hydrochlorothiazid
Propranolol/Hydrochlorothiazid
TABLET
$0.00 - $2.55 (Tier 1)
+ Sorine
Sotalol HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Sotalol
Sotalol HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Sotalol AF
Sotalol HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Timolol Maleate
Timolol Maleate
TABLET
$0.00 - $2.55 (Tier 1)
+ Labetalol HCL
CALCIUM-CHANNEL BLOCKING AGENTS
+ Cartia XT
Diltiazem HCL
CAP ER 24H
$0.00 - $2.55 (Tier 1)
+ Dilt-CD
Diltiazem HCL
CAP ER 24H
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
PART D
91
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Diltia XT
Diltiazem HCL
CAP ER DEG
$0.00 - $2.55 (Tier 1)
+ Diltiazem 24Hr CD
Diltiazem HCL
CAP ER 24H
$0.00 - $2.55 (Tier 1)
+ Diltiazem 24Hr ER
Diltiazem HCL
CAP ER 24H
$0.00 - $2.55 (Tier 1)
+ Diltiazem ER
Diltiazem HCL
CAP ER 12H
$0.00 - $2.55 (Tier 1)
+ Diltiazem ER
Diltiazem HCL
CAPSULE ER
$0.00 - $2.55 (Tier 1)
+ Diltiazem HCL
Diltiazem HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Dilt-XR
Diltiazem HCL
CAP ER DEG
$0.00 - $2.55 (Tier 1)
+ Diltzac ER
Diltiazem HCL
CAPSULE ER
$0.00 - $2.55 (Tier 1)
+ Taztia XT
Diltiazem HCL
CAPSULE ER
$0.00 - $2.55 (Tier 1)
+ Verapamil ER
Verapamil HCL
CAP24H PEL
$0.00 - $2.55 (Tier 1)
+ Verapamil ER
Verapamil HCL
TABLET ER
$0.00 - $2.55 (Tier 1)
+ Verapamil ER PM
Verapamil HCL
CAP24H PCT
$0.00 - $2.55 (Tier 1)
+ Verapamil HCL
Verapamil HCL
CAP24H PEL
$0.00 - $2.55 (Tier 1)
+ Verapamil HCL
Verapamil HCL
TABLET
$0.00 - $2.55 (Tier 1)
AUTO INJCT
$0.00 - $6.35 (Tier 2)
CARDIOVASCULAR AGENTS, MISCELLANEOUS
+ AUVI-Q
Epinephrine
QL = Quantity limit
ST = Step Therapy
92
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Digoxin Immune Fab
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ Digoxin
Digoxin
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
+ DIGOXIN
Digoxin
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
+ Digoxin 125MCG
Digoxin
TABLET
$0.00 - $2.55 (Tier 1)
QL
+ Digoxin 250MCG
Digoxin
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Epinephrine
Epinephrine
INJECTION DISP SYR
$0.00 - $2.55 (Tier 1)
+ Epinephrine
Epinephrine
PEN INJCTR
$0.00 - $2.55 (Tier 1)
+ EPIPEN 2-PAK
Epinephrine
PEN INJCTR
$0.00 - $6.35 (Tier 2)
+ Hctz/Reserpine/Hydralazine
Hydralazine/Reserpin/Hctz
TABLET
$0.00 - $2.55 (Tier 1)
+ Hydralazine HCL
Hydralazine HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Hydralazine W/Hctz
Hydralazine/Hydrochlorothiazid
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Hydrochlorothiazide/Reserpine
Reserpine/Hydrochlorothiazide
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ LANOXIN PEDIATRIC
Digoxin
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
Milrinone In 5% Dextrose
Milrinone Lactate/D5W
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
+ RANEXA
Ranolazine
TAB ER 12H
$0.00 - $6.35 (Tier 2)
+ Reserpine 0.1MG
Reserpine
TABLET
$0.00 - $2.55 (Tier 1)
DIGIFAB
QL = Quantity limit
ST = Step Therapy
PART D
93
BRAND DRUG NAME
+ Reserpine 0.25MG
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Reserpine
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Afeditab CR
Nifedipine
TABLET ER
$0.00 - $2.55 (Tier 1)
+ Amlodipine Besylate
Amlodipine Besylate
TABLET
$0.00 - $2.55 (Tier 1)
+ Amlodipine Besylate-Benazepril
Amlodipine Besylate/Benazepril
CAPSULE
$0.00 - $2.55 (Tier 1)
QL
+ Felodipine ER
Felodipine
TAB ER 24H
$0.00 - $2.55 (Tier 1)
+ Isradipine
Isradipine
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Nicardipine HCL
Nicardipine HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Nifediac CC
Nifedipine
TABLET ER
$0.00 - $2.55 (Tier 1)
+ Nifedical XL
Nifedipine
TAB ER 24
$0.00 - $2.55 (Tier 1)
+ Nifedipine ER
Nifedipine
TAB ER 24
$0.00 - $2.55 (Tier 1)
+ Amiloride HCL
Amiloride HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Amiloride-Hydrochlorothiazide
Amiloride/Hydrochlorothiazide
TABLET
$0.00 - $2.55 (Tier 1)
+ Bumetanide
Bumetanide
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
+ Bumetanide
Bumetanide
TABLET
$0.00 - $2.55 (Tier 1)
DIHYDROPYRIDINES
DIURETICS
QL = Quantity limit
ST = Step Therapy
94
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Chlorothiazide
Chlorothiazide
TABLET
$0.00 - $2.55 (Tier 1)
+ Chlorthalidone
Chlorthalidone
TABLET
$0.00 - $2.55 (Tier 1)
+ Furosemide
Furosemide
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
+ Furosemide
Furosemide
INJECTION DISP SYR
$0.00 - $2.55 (Tier 1)
BvD
+ Furosemide
Furosemide
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Furosemide
Furosemide
TABLET
$0.00 - $2.55 (Tier 1)
+ Hydrochlorothiazide
Hydrochlorothiazide
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Hydrochlorothiazide
Hydrochlorothiazide
TABLET
$0.00 - $2.55 (Tier 1)
+ Indapamide
Indapamide
TABLET
$0.00 - $2.55 (Tier 1)
+ Methyclothiazide
Methyclothiazide
TABLET
$0.00 - $2.55 (Tier 1)
+ Metolazone
Metolazone
TABLET
$0.00 - $2.55 (Tier 1)
+ Torsemide
Torsemide
TABLET
$0.00 - $2.55 (Tier 1)
+ Triamterene-HCTZ
Triamterene/Hydrochlorothiazid
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Triamterene-HCTZ
Triamterene/Hydrochlorothiazid
TABLET
$0.00 - $2.55 (Tier 1)
Atorvastatin Calcium
TABLET
$0.00 - $2.55 (Tier 1)
DYSLIPIDEMICS
+ Atorvastatin Calcium
QL = Quantity limit
ST = Step Therapy
PART D
95
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Cholestyramine
Cholestyramine (With Sugar)
ORAL PACKETS
$0.00 - $2.55 (Tier 1)
+ Colestipol HCL
Colestipol HCL
ORAL PACKETS
$0.00 - $2.55 (Tier 1)
+ Colestipol HCL
Colestipol HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Fenofibrate
Fenofibrate Nanocrystallized
TABLET
$0.00 - $2.55 (Tier 1)
+ Fenofibrate
Fenofibrate,Micronized
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Gemfibrozil
Gemfibrozil
TABLET
$0.00 - $2.55 (Tier 1)
+ Lovastatin
Lovastatin
TABLET
$0.00 - $2.55 (Tier 1)
+ LOVAZA
Omega-3 Acid Ethyl Esters
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ Niacin
Niacin
TAB ER 24H
$0.00 - $2.55 (Tier 1)
PA
+ Pravastatin Sodium
Pravastatin Sodium
TABLET
$0.00 - $2.55 (Tier 1)
+ Prevalite
Cholestyramine/Aspartame
ORAL PACKETS
$0.00 - $2.55 (Tier 1)
+ Simvastatin
Simvastatin
TABLET
$0.00 - $2.55 (Tier 1)
+ VASCEPA
Icosapent Ethyl
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ WELCHOL
Colesevelam HCL
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ WELCHOL
Colesevelam HCL
ORAL PACKETS
$0.00 - $6.35 (Tier 2)
PA
+ ZETIA
Ezetimibe
TABLET
$0.00 - $6.35 (Tier 2)
PA
QL = Quantity limit
ST = Step Therapy
96
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
+ EPLERENONE
Eplerenone
TABLET
$0.00 - $2.55 (Tier 1)
PA
+ Spironolactone
Spironolactone
TABLET
$0.00 - $2.55 (Tier 1)
+ Spironolactone-HCTZ
Spironolact/Hydrochlorothiazid
TABLET
$0.00 - $2.55 (Tier 1)
+ TEKTURNA
Aliskiren Hemifumarate
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ TEKTURNA HCT
Aliskiren/Hydrochlorothiazide
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ Isosorbide Dinitrate
Isosorbide Dinitrate
TAB SUBL
$0.00 - $2.55 (Tier 1)
TABLET
$0.00 - $2.55 (Tier 1)
TABLET ER
$0.00 - $2.55 (Tier 1)
+ Isosorbide Mononitrate
Isosorbide Mononitrate
TABLET
$0.00 - $2.55 (Tier 1)
+ Isosorbide Mononitrate ER
Isosorbide Mononitrate
TAB ER 24H
$0.00 - $2.55 (Tier 1)
+ Minoxidil
Minoxidil
TABLET
$0.00 - $2.55 (Tier 1)
+ Nitroglycerin Patch
Nitroglycerin
PATCH
$0.00 - $2.55 (Tier 1)
+ NITROSTAT
Nitroglycerin
TAB SUBL
$0.00 - $6.35 (Tier 2)
+ PROGLYCEM
Diazoxide
ORAL SUSP
$0.00 - $6.35 (Tier 2)
PA
VASODILATORS
QL = Quantity limit
ST = Step Therapy
PART D
97
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
CENTRAL NERVOUS SYSTEM AGENTS
+ Amphetamine Salt Combo
Dextroamphetamine/Amphetamine
TABLET
$0.00 - $2.55 (Tier 1)
+ AMPYRA
Dalfampridine
TAB ER 12H
$0.00 - $6.35 (Tier 2)
PA
+CLONIDINE HCL ER
Clonidine HCL
TAB ER 12H
$0.00 - $2.55 (Tier 1)
PA
+ Dexmethylphenidate HCL
Dexmethylphenidate HCL
CPMP 50-50
$0.00 - $2.55 (Tier 1)
ST
+ Dexmethylphenidate HCL
Dexmethylphenidate HCL
TABLET
$0.00 - $2.55 (Tier 1)
ST
+ Dextroamphetamine Sulfate
Dextroamphetamine Sulfate
CAPSULE ER
$0.00 - $2.55 (Tier 1)
+ Dextroamphetamine Sulfate
Dextroamphetamine Sulfate
TABLET
$0.00 - $2.55 (Tier 1)
+ Dextroamphetamine-Amphetamine Dextroamphetamine/Amphetamine
CAP ER 24H
$0.00 - $2.55 (Tier 1)
+ INTUNIV
Guanfacine HCL
TAB ER 24H
$0.00 - $6.35 (Tier 2)
PA
+ Lithium
Lithium Citrate
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Lithium Carbonate
Lithium Carbonate
TABLET
$0.00 - $2.55 (Tier 1)
+ Lithium Carbonate
Lithium Carbonate
TABLET ER
$0.00 - $2.55 (Tier 1)
+ Lithium Carbonate
Lithium Carbonate
CAPSULE
$0.00 - $2.55 (Tier 1)
+ METHYLPHENIDATE ER
Methylphenidate HCL
TAB ER 24
$0.00 - $6.35 (Tier 2)
ST
QL = Quantity limit
ST = Step Therapy
98
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Methylphenidate HCL
TABLET ER
$0.00 - $2.55 (Tier 1)
+ Methylphenidate HCL
Methylphenidate HCL
TABLET
$0.00 - $2.55 (Tier 1)
NUEDEXTA
Dextromethorphan Hbr/Quinidine
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ Riluzole
Riluzole
TABLET
$0.00 - $2.55 (Tier 1)
PA
+ SAVELLA
Milnacipran HCL
TAB DS PK
$0.00 - $6.35 (Tier 2)
PA
+ SAVELLA
Milnacipran HCL
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ STRATTERA
Atomoxetine HCL
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ XENAZINE
Tetrabenazine
TABLET
$0.00 - $6.35 (Tier 2)
+ Altavera
Levonorgestrel-Eth Estradiol
TABLET
$0.00 - $2.55 (Tier 1)
+ Alyacen
Norethindrone-Ethinyl Estrad
TABLET
$0.00 - $2.55 (Tier 1)
+ Apri
Desogestrel-Ethinyl Estradiol
TABLET
$0.00 - $2.55 (Tier 1)
+ Aranelle
TABLET
$0.00 - $2.55 (Tier 1)
+ Aviane
TABLET
$0.00 - $2.55 (Tier 1)
+ Azurette
Desog-Et Estra/Ethin Estra
TABLET
$0.00 - $2.55 (Tier 1)
+ Methylphenidate ER
CONTRACEPTIVES
CONTRACEPTIVES
QL = Quantity limit
ST = Step Therapy
PART D
99
CONTRACEPTIVES
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Balziva
TABLET
$0.00 - $2.55 (Tier 1)
+ Briellyn
TABLET
$0.00 - $2.55 (Tier 1)
+ Camila
Norethindrone
TABLET
$0.00 - $2.55 (Tier 1)
+ Caziant
TABLET
$0.00 - $2.55 (Tier 1)
+ Cryselle
Norgestrel-Ethinyl Estradiol
TABLET
$0.00 - $2.55 (Tier 1)
+ Cyclafem
TABLET
$0.00 - $2.55 (Tier 1)
+ Dasetta
TABLET
$0.00 - $2.55 (Tier 1)
+ Drospirenone-Ethinyl Estradiol
Ethinyl Estradiol/Drospirenone
TABLET
$0.00 - $2.55 (Tier 1)
+ Emoquette
TABLET
$0.00 - $2.55 (Tier 1)
+ Enpresse
TABLET
$0.00 - $2.55 (Tier 1)
+ Enskyce
TABLET
$0.00 - $2.55 (Tier 1)
+ Errin
Norethindrone
TABLET
$0.00 - $2.55 (Tier 1)
+ Falmina
TABLET
$0.00 - $2.55 (Tier 1)
+ Gildagia
TABLET
$0.00 - $2.55 (Tier 1)
+ Gildess
Norethindrone A-E Estradiol
TABLET
$0.00 - $2.55 (Tier 1)
+ Gildess Fe
Noreth A-Et Estra/Fe Fumarate
TABLET
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
100
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Norethindrone
TABLET
$0.00 - $2.55 (Tier 1)
+ Introvale
TABLET
$0.00 - $2.55 (Tier 1)
+ Jolessa
TABLET
$0.00 - $2.55 (Tier 1)
+ Jolivette
Norethindrone
TABLET
$0.00 - $2.55 (Tier 1)
+ Junel
TABLET
$0.00 - $2.55 (Tier 1)
+ Junel Fe
TABLET
$0.00 - $2.55 (Tier 1)
+ Kariva
TABLET
$0.00 - $2.55 (Tier 1)
+ Kelnor 1-35
Ethynodiol D-Ethinyl Estradiol
TABLET
$0.00 - $2.55 (Tier 1)
+ Kurvelo
TABLET
$0.00 - $2.55 (Tier 1)
+ Leena
TABLET
$0.00 - $2.55 (Tier 1)
+ Lessina
TABLET
$0.00 - $2.55 (Tier 1)
+ Levlen 28
TABLET
$0.00 - $2.55 (Tier 1)
+ Levonest
TABLET
$0.00 - $2.55 (Tier 1)
+ Levonorgestrel
Levonorgestrel
TABLET
$0.00 - $2.55 (Tier 1)
+ Levonorgestrel-Eth Estradiol
TABLET
$0.00 - $2.55 (Tier 1)
+ Levora-28
TABLET
$0.00 - $2.55 (Tier 1)
CONTRACEPTIVES
+ Heather
QL = Quantity limit
ST = Step Therapy
PART D
101
CONTRACEPTIVES
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Low-Ogestrel
TABLET
$0.00 - $2.55 (Tier 1)
+ Lutera
TABLET
$0.00 - $2.55 (Tier 1)
+ Marlissa
TABLET
$0.00 - $2.55 (Tier 1)
+ Microgestin
TABLET
$0.00 - $2.55 (Tier 1)
+ Microgestin Fe
TABLET
$0.00 - $2.55 (Tier 1)
+ Mono-Linyah
Norgestimate-Ethinyl Estradiol
TABLET
$0.00 - $2.55 (Tier 1)
+ Mononessa
TABLET
$0.00 - $2.55 (Tier 1)
+ Myzilra
TABLET
$0.00 - $2.55 (Tier 1)
+ Necon
TABLET
$0.00 - $2.55 (Tier 1)
+ Nora-Be
Norethindrone
TABLET
$0.00 - $2.55 (Tier 1)
+ Norethindrone
Norethindrone
TABLET
$0.00 - $2.55 (Tier 1)
+ Norgestimate-Ethinyl Estradiol
TABLET
$0.00 - $2.55 (Tier 1)
+ Nortrel
TABLET
$0.00 - $2.55 (Tier 1)
+ Ogestrel
TABLET
$0.00 - $2.55 (Tier 1)
+ Orsythia
TABLET
$0.00 - $2.55 (Tier 1)
+ Philith
TABLET
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
102
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
TABLET
$0.00 - $2.55 (Tier 1)
+ Portia
TABLET
$0.00 - $2.55 (Tier 1)
+ Previfem
TABLET
$0.00 - $2.55 (Tier 1)
+ Quasense
TABLET
$0.00 - $2.55 (Tier 1)
+ Reclipsen
TABLET
$0.00 - $2.55 (Tier 1)
+ Sprintec
TABLET
$0.00 - $2.55 (Tier 1)
+ Sronyx
TABLET
$0.00 - $2.55 (Tier 1)
+ Tilia Fe
TABLET
$0.00 - $2.55 (Tier 1)
+ Tri-Legest Fe
TABLET
$0.00 - $2.55 (Tier 1)
+ Tri-Linyah
TABLET
$0.00 - $2.55 (Tier 1)
+ Trinessa
TABLET
$0.00 - $2.55 (Tier 1)
+ Tri-Previfem
TABLET
$0.00 - $2.55 (Tier 1)
+ Tri-Sprintec
TABLET
$0.00 - $2.55 (Tier 1)
+ Trivora-28
TABLET
$0.00 - $2.55 (Tier 1)
+ Velivet
TABLET
$0.00 - $2.55 (Tier 1)
+ Viorele
TABLET
$0.00 - $2.55 (Tier 1)
CONTRACEPTIVES
+ Pirmella
QL = Quantity limit
ST = Step Therapy
PART D
103
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Wera
TABLET
$0.00 - $2.55 (Tier 1)
+ Zenchent
TABLET
$0.00 - $2.55 (Tier 1)
+ Zenchent Fe
Noreth-Ethinyl Estradiol/Iron
TAB CHEW
$0.00 - $2.55 (Tier 1)
+ Zovia 1-35E
TABLET
$0.00 - $2.55 (Tier 1)
+ Zovia 1-50E
TABLET
$0.00 - $2.55 (Tier 1)
DENTAL AND ORAL AGENTS
CONTRACEPTIVES
DENTAL AND ORAL AGENTS
Chlorhexidine Gluconate
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Dentagel
Sodium Fluoride
DENTAL CREAM
$0.00 - $2.55 (Tier 1)
KEPIVANCE
Palifermin
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ Pilocarpine HCL
Pilocarpine HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ SF 5000 Plus
Sodium Fluoride
DENTAL GEL
$0.00 - $2.55 (Tier 1)
+ Sodium Fluoride
Sodium Fluoride
DENTAL SOLN
$0.00 - $2.55 (Tier 1)
+ Stannous Fluoride
Stannous Fluoride
DENTAL SOLN
$0.00 - $2.55 (Tier 1)
Triamcinolone Acetonide
DENTAL PASTE
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
104
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
DERMATOLOGICAL AGENTS
DERMATOLOGICAL AGENTS, OTHER
Methoxsalen
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
ACYCLOVIR
Acyclovir
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
QL
Ammonium Lactate
Ammonium Lactate
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Ammonium Lactate
Ammonium Lactate
TOPICAL LOTION
$0.00 - $2.55 (Tier 1)
Anacaine
Benzocaine
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
REGRANEX
Becaplermin
TOPICAL GEL
$0.00 - $6.35 (Tier 2)
QL, PA
Calcipotriene
Calcipotriene
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
QL, PA
Calcipotriene
Calcipotriene
TOPICAL SOLUTION
$0.00 - $2.55 (Tier 1)
QL, PA
DENAVIR
Penciclovir
TOPICAL CREAM
$0.00 - $6.35 (Tier 2)
PA
Fluorouracil
Fluorouracil
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Fluorouracil
Fluorouracil
TOPICAL SOLUTION
$0.00 - $2.55 (Tier 1)
Imiquimod
Imiquimod
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
QL, PA
AMNESTEEM
Isotretinoin
CAPSULE
$0.00 - $2.55 (Tier 1)
PA
LEVULAN
Aminolevulinic Acid HCL
TOPICAL SOLUTION
$0.00 - $6.35 (Tier 2)
PA
8-MOP
QL = Quantity limit
ST = Step Therapy
PART D
105
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
VALCHLOR
Mechlorethamine HCL
TOPICAL GEL
$0.00 - $6.35 (Tier 2)
PA
OXSORALEN
Methoxsalen
TOPICAL LOTION
$0.00 - $6.35 (Tier 2)
PA
OXSORALEN-ULTRA
Methoxsalen, Rapid
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
PANRETIN
Alitretinoin
TOPICAL GEL
$0.00 - $6.35 (Tier 2)
PA
PICATO
Ingenol Mebutate
TOPICAL GEL
$0.00 - $6.35 (Tier 2)
PA
PODOCON-25
Podophyllum Resin
TOPICAL LIQ
$0.00 - $6.35 (Tier 2)
Podofilox
Podofilox
TOPICAL SOLUTION
$0.00 - $2.55 (Tier 1)
SANTYL
Collagenase Clostridium Hist.
TOPICAL OINT.
$0.00 - $6.35 (Tier 2)
Selenos
Selenium Sulfide
SHAMPOO
$0.00 - $2.55 (Tier 1)
Single Use Swab
Alcohol Antiseptic Pads
TOPICAL MED. PAD
$0.00 - $2.55 (Tier 1)
SORIATANE
Acitretin
CAPSULE
$0.00 - $6.35 (Tier 2)
ZONALON
Doxepin HCL
TOPICAL CREAM
$0.00 - $6.35 (Tier 2)
ZOVIRAX
Acyclovir
TOPICAL CREAM
$0.00 - $6.35 (Tier 2)
PA
QL
DERMATOLOGICAL ANTIBACTERIALS
TOPICAL GEL
$0.00 - $2.55 (Tier 1)
TOPICAL SOLUTION
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
106
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
TOPICAL LOTION
$0.00 - $2.55 (Tier 1)
TOPICAL MED. SWAB
$0.00 - $2.55 (Tier 1)
Erythromycin
Erythromycin Base/Ethanol
TOPICAL GEL
$0.00 - $2.55 (Tier 1)
Erythromycin
TOPICAL MED. SWAB
$0.00 - $2.55 (Tier 1)
Erythromycin
TOPICAL SOLUTION
$0.00 - $2.55 (Tier 1)
Erythromycin-Benzoyl Peroxide
Erythromycin/Benzoyl Peroxide
TOPICAL GEL
$0.00 - $2.55 (Tier 1)
Metronidazole
Metronidazole
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Metronidazole
Metronidazole
TOPICAL GEL
$0.00 - $2.55 (Tier 1)
Metronidazole
Metronidazole
TOPICAL LOTION
$0.00 - $2.55 (Tier 1)
Mupirocin
Mupirocin
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
Selenium Sulfide
Selenium Sulfide
TOPICAL SUSP
$0.00 - $2.55 (Tier 1)
Silver Sulfadiazine
Silver Sulfadiazine
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
NECESSARY ACTIONS,
QL
DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS
Alclometasone Dipropionate
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
Amcinonide
Amcinonide
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
PART D
107
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
Amcinonide
Amcinonide
TOPICAL LOTION
$0.00 - $2.55 (Tier 1)
Amcinonide
Amcinonide
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
Apexicon E
Diflorasone Diacetate/Emoll
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Betamethasone Dipropionate
Betamethasone/Propylene Glyc
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
TOPICAL GEL
$0.00 - $2.55 (Tier 1)
TOPICAL LOTION
$0.00 - $2.55 (Tier 1)
Betamethasone Valerate
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
TOPICAL LOTION
$0.00 - $2.55 (Tier 1)
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Clobetasol Propionate
TOPICAL FOAM
$0.00 - $2.55 (Tier 1)
TOPICAL GEL
$0.00 - $2.55 (Tier 1)
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
TOPICAL SOLUTION
$0.00 - $2.55 (Tier 1)
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
DESONATE
Desonide
TOPICAL GEL
$0.00 - $6.35 (Tier 2)
NECESSARY ACTIONS,
QL = Quantity limit
ST = Step Therapy
108
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
Desonide
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
Desonide
Desonide
TOPICAL LOTION
$0.00 - $2.55 (Tier 1)
Desonide
Desonide
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Desoximetasone
Desoximetasone
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Desoximetasone
Desoximetasone
TOPICAL GEL
$0.00 - $2.55 (Tier 1)
Desoximetasone
Desoximetasone
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
Diflorasone Diacetate
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
ELIDEL
Pimecrolimus
TOPICAL CREAM
$0.00 - $6.35 (Tier 2)
Fluocinolone Acetonide
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
TOPICAL SOLUTION
$0.00 - $2.55 (Tier 1)
Fluocinonide
Fluocinonide
TOPICAL SOLUTION
$0.00 - $2.55 (Tier 1)
Fluocinonide
Fluocinonide
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Fluocinonide
Fluocinonide
TOPICAL GEL
$0.00 - $2.55 (Tier 1)
Fluocinonide
Fluocinonide
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
Desonide
NECESSARY ACTIONS,
QL, PA
QL = Quantity limit
ST = Step Therapy
PART D
109
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
Fluticasone Propionate
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Halobetasol Propionate
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
Anusol-Hc
Hydrocortisone
RECTAL CREAM
$0.00 - $2.55 (Tier 1)
Colocort
Hydrocortisone
RECTAL ENEMA
$0.00 - $2.55 (Tier 1)
Hydrocortisone
Hydrocortisone
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Hydrocortisone
Hydrocortisone
TOPICAL LOTION
$0.00 - $2.55 (Tier 1)
Hydrocortisone
Hydrocortisone
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
Hydrocortisone Butyrate
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
TOPICAL SOLUTION
$0.00 - $2.55 (Tier 1)
Hydrocortisone Valerate
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
Mometasone Furoate
Mometasone Furoate
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Mometasone Furoate
Mometasone Furoate
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
NECESSARY ACTIONS,
QL = Quantity limit
ST = Step Therapy
110
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
Mometasone Furoate
Mometasone Furoate
TOPICAL SOLUTION
$0.00 - $2.55 (Tier 1)
Rectasol-Hc
Hydrocortisone Acetate
RECTAL SUPP
$0.00 - $2.55 (Tier 1)
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
TOPICAL LOTION
$0.00 - $2.55 (Tier 1)
TOPICAL OINT.
$0.00 - $2.55 (Tier 1)
U-Cort
Hydrocortisone Acetate/Urea
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
VERDESO
Desonide
TOPICAL FOAM
$0.00 - $6.35 (Tier 2)
NECESSARY ACTIONS,
Adapalene
Adapalene
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
Adapalene
Adapalene
TOPICAL GEL
$0.00 - $2.55 (Tier 1)
DIFFERIN
Adapalene
TOPICAL GEL
$0.00 - $6.35 (Tier 2)
DIFFERIN
Adapalene
TOPICAL LOTION
$0.00 - $6.35 (Tier 2)
DIFFERIN
Adapalene
TOPICAL MED. SWAB
$0.00 - $6.35 (Tier 2)
TARGRETIN
Bexarotene
TOPICAL GEL
$0.00 - $6.35 (Tier 2)
TAZORAC
Tazarotene
TOPICAL CREAM
$0.00 - $6.35 (Tier 2)
PA
TAZORAC
Tazarotene
TOPICAL GEL
$0.00 - $6.35 (Tier 2)
PA
DERMATOLOGICAL RETINOIDS
QL
QL
QL = Quantity limit
ST = Step Therapy
PART D
111
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Tretinoin
Tretinoin
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
PA
Tretinoin
Tretinoin
TOPICAL GEL
$0.00 - $2.55 (Tier 1)
PA
SCABICIDES AND PEDICULICIDES
Lindane
Lindane
SHAMPOO
$0.00 - $2.55 (Tier 1)
Lindane
Lindane
TOPICAL LOTION
$0.00 - $2.55 (Tier 1)
Permethrin
Permethrin
TOPICAL CREAM
$0.00 - $2.55 (Tier 1)
+ Insulin Syringe
Syring W-Ndl,Disp,Insul,0.3Ml
SYRINGES
$0.00 - $2.55 (Tier 1)
+ Pen Needle
Needles, Insulin Disposable
SYRINGES
$0.00 - $2.55 (Tier 1)
+ Sure Comfort
Syring W-Ndl,Disp,Insul,0.5Ml
SYRINGES
$0.00 - $2.55 (Tier 1)
DEVICES
DEVICES
ENZYME REPLACEMENT/MODIFIERS
ADAGEN
Pegademase Bovine
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
ALDURAZYME
Laronidase
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
QL = Quantity limit
ST = Step Therapy
112
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Imiglucerase
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ CREON
Lipase/Protease/Amylase
CAPSULE DR
$0.00 - $6.35 (Tier 2)
+ CYSTAGON
Cysteamine Bitartrate
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ ELAPRASE
Idursulfase
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
ELELYSO
Taliglucerase Alfa
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
ELITEK
Rasburicase
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
FABRAZYME
Agalsidase Beta
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ KUVAN
Sapropterin Dihydrochloride
TABLET SOL
$0.00 - $6.35 (Tier 2)
PA
+ LOTRONEX
Alosetron HCL
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ NAGLAZYME
Galsulfase
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ ORFADIN
Nitisinone
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ PANCREAZE
CAPSULE DR
$0.00 - $6.35 (Tier 2)
+ PANCRELIPASE 5,000
CAPSULE DR
$0.00 - $6.35 (Tier 2)
+ PULMOZYME
Dornase Alfa
INHALATION SOLN
$0.00 - $6.35 (Tier 2)
BvD
+ SUCRAID
Sacrosidase
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
PA
VPRIV
Velaglucerase Alfa
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ CEREZYME
QL = Quantity limit
ST = Step Therapy
PART D
113
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ ZAVESCA
Miglustat
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
+ ZENPEP
CAPSULE DR
$0.00 - $6.35 (Tier 2)
EYE, EAR, NOSE, THROAT AGENTS
EYE, EAR, NOSE, THROAT ANTI-INFECTIVES AGENTS
Acetasol Hc
Acetic Acid/Hydrocortisone
OTIC DROPS
$0.00 - $2.55 (Tier 1)
Bacitracin
Bacitracin
OPHT OINTMENT
$0.00 - $2.55 (Tier 1)
Bacitracin-Polymyxin
Bacitracin/Polymyxin B Sulfate
OPHT OINTMENT
$0.00 - $2.55 (Tier 1)
Ciprofloxacin HCL
Ciprofloxacin HCL
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Ciprofloxacin HCL
Ciprofloxacin HCL
OTIC DROPS
$0.00 - $2.55 (Tier 1)
Erythromycin
Erythromycin Base
OPHT OINTMENT
$0.00 - $2.55 (Tier 1)
Gentak
Gentamicin Sulfate
OPHT OINTMENT
$0.00 - $2.55 (Tier 1)
Gentamicin Sulfate
Gentamicin Sulfate
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Gentamicin Sulfate
Gentamicin Sulfate
OPHT OINTMENT
$0.00 - $2.55 (Tier 1)
QL
Neomycin W/Dexamethasone
Neomycin Sulfate/Dex Na Ph
OPHT DROPS
$0.00 - $2.55 (Tier 1)
QL
Neomycin-Bacitracin-Poly-Hc
Neomy Sulf/Bacitrac Zn/Poly/Hc
OPHT OINTMENT
$0.00 - $2.55 (Tier 1)
Neomycin-Bacitracin-Polymyxin
Neomy Sulf/Bacitra/Polymyxin B
OPHT OINTMENT
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
114
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
Neo/Polymyx B Sulf/Dexameth
OPHT SUSP
$0.00 - $2.55 (Tier 1)
Neomycin-Polymyxin-Dexameth
Neo/Polymyx B Sulf/Dexameth
OPHT OINTMENT
$0.00 - $2.55 (Tier 1)
Neomycin-Polymyxin-Gramicidin
Neomycin/Polymyxn B/Gramicidin
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Neomycin-Polymyxin-Hc
Neomycin/Polymyxin B Sulf/Hc
OTIC SUSP
$0.00 - $2.55 (Tier 1)
Neomycin-Polymyxin-Hc
OPHT SUSP
$0.00 - $2.55 (Tier 1)
Neomycin-Polymyxin-Hydrocort
OTIC SOLN
$0.00 - $2.55 (Tier 1)
Ofloxacin
Ofloxacin
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Ofloxacin
Ofloxacin
OTIC DROPS
$0.00 - $2.55 (Tier 1)
Polymyxin B Sul-Trimethoprim
Polymyxin B Sulf/Trimethoprim
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Sulfacetamide Sodium
OPHT DROPS
$0.00 - $2.55 (Tier 1)
OPHT OINTMENT
$0.00 - $2.55 (Tier 1)
Sulfacetamide-Prednisolone
Sulfacetamide/Prednisolone Sp
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Tobramycin
Tobramycin
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Tobramycin-Dexamethasone
Tobramycin/Dexamethasone
OPHT SUSP
$0.00 - $2.55 (Tier 1)
Trifluridine
Trifluridine
OPHT DROPS
$0.00 - $2.55 (Tier 1)
VIGAMOX
Moxifloxacin HCL
OPHT DROPS
$0.00 - $6.35 (Tier 2)
Neomycin-Polymyxin-Dexameth
NECESSARY ACTIONS,
QL = Quantity limit
ST = Step Therapy
PART D
115
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
EYE, EAR, NOSE, THROAT ANTI-INFLAMMATORY AGENTS
BROMFENAC SODIUM
Bromfenac Sodium
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Dexamethasone Sodium Phosphate Dexamethasone Sod Phosphate
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Diclofenac Sodium
OPHT DROPS
$0.00 - $2.55 (Tier 1)
FLUOCINOLONE ACETONIDE OIL Fluocinolone Acetonide Oil
OTIC DROPS
$0.00 - $2.55 (Tier 1)
FLUOROMETHOLONE
Fluorometholone
OPHT SUSP
$0.00 - $2.55 (Tier 1)
Flurbiprofen Sodium
Flurbiprofen Sodium
OPHT DROPS
$0.00 - $2.55 (Tier 1)
OPHT DROPS
$0.00 - $2.55 (Tier 1)
LOTEMAX
Loteprednol Etabonate
OPHT SUSP
$0.00 - $6.35 (Tier 2)
MAXIDEX
Dexamethasone
OPHT SUSP
$0.00 - $6.35 (Tier 2)
Prednisolone Acetate
Prednisolone Acetate
OPHT SUSP
$0.00 - $2.55 (Tier 1)
Prednisolone Sodium Phosphate
Prednisolone Sod Phosphate
OPHT DROPS
$0.00 - $2.55 (Tier 1)
RESTASIS
Cyclosporine
OPHT DROPS
$0.00 - $6.35 (Tier 2)
QL, PA
QL
Diclofenac Sodium
QL
EYE, EAR, NOSE, THROAT DRUGS, MISCELLANEOUS
Azelastine HCL
Azelastine HCL
NASAL SPRAY
$0.00 - $2.55 (Tier 1)
Azelastine HCL
Azelastine HCL
OPHT DROPS
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
116
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Carteolol HCL
Carteolol HCL
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Cromolyn Sodium
Cromolyn Sodium
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Cyclopentolate HCL
Cyclopentolate HCL
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Homatropaire
Homatropine Hbr
OPHT DROPS
$0.00 - $2.55 (Tier 1)
LACRISERT
Hydroxypropyl Cellulose
OPTH INSERTS
$0.00 - $6.35 (Tier 2)
Naphazoline HCL
Naphazoline HCL
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Naphazoline HCL W/Antazoline
Naphazoline HCL/Antazoline
OPHT DROPS
$0.00 - $2.55 (Tier 1)
QL
PATANOL
Olopatadine HCL
OPHT DROPS
$0.00 - $6.35 (Tier 2)
QL
Phenylephrine HCL
Phenylephrine HCL
OPHT DROPS
$0.00 - $2.55 (Tier 1)
QL
Proparacaine HCL
Proparacaine HCL
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Tetracaine HCL
Tetracaine HCL
OPHT DROPS
$0.00 - $2.55 (Tier 1)
Tropicamide
Tropicamide
OPHT DROPS
$0.00 - $2.55 (Tier 1)
TYZINE
Tetrahydrozoline HCL
NASAL SPRAY
$0.00 - $6.35 (Tier 2)
TYZINE
Tetrahydrozoline HCL
NASAL DROPS
$0.00 - $6.35 (Tier 2)
QL
QL = Quantity limit
ST = Step Therapy
PART D
117
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
GASTROINTESTINAL AGENTS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
Cimetidine
Cimetidine HCL
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
+ Cimetidine
Cimetidine
TABLET
$0.00 - $2.55 (Tier 1)
+ Cimetidine HCL
Cimetidine HCL
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Famotidine
Famotidine
TABLET
$0.00 - $2.55 (Tier 1)
Famotidine
Famotidine In Nacl,Iso-Osm/PF
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
+ Lansoprazole
Lansoprazole
CAPSULE DR
$0.00 - $2.55 (Tier 1)
+ Misoprostol
Misoprostol
TABLET
$0.00 - $2.55 (Tier 1)
+ Nizatidine
Nizatidine
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Omeprazole
Omeprazole
CAPSULE DR
$0.00 - $2.55 (Tier 1)
QL
+ Pantoprazole Sodium
Pantoprazole Sodium
TABLET DR
$0.00 - $2.55 (Tier 1)
PROTONIX IV
Pantoprazole Sodium
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ Ranitidine HCL
Ranitidine HCL
ORAL SYRUP
$0.00 - $2.55 (Tier 1)
+ Ranitidine HCL
Ranitidine HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ Ranitidine HCL
Ranitidine HCL
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
QL = Quantity limit
ST = Step Therapy
118
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
+ Ranitidine HCL
Ranitidine HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Sucralfate
Sucralfate
TABLET
$0.00 - $2.55 (Tier 1)
+ Sucralfate
Sucralfate
ORAL SUSP
$0.00 - $2.55 (Tier 1)
NECESSARY ACTIONS,
GASTROINTESTINAL AGENTS, OTHER
Lubiprostone
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
BUPHENYL
Sodium Phenylbutyrate
TABLET
$0.00 - $6.35 (Tier 2)
PA
CROMOLYN SODIUM
Cromolyn Sodium
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
Dicyclomine HCL
Dicyclomine HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
Dicyclomine HCL
Dicyclomine HCL
TABLET
$0.00 - $2.55 (Tier 1)
Diphenoxylate-Atropine
Diphenoxylate HCL/Atropine
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
Diphenoxylate-Atropine
Diphenoxylate HCL/Atropine
TABLET
$0.00 - $2.55 (Tier 1)
Glycopyrrolate
Glycopyrrolate
TABLET
$0.00 - $2.55 (Tier 1)
+ Lactulose
Lactulose
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Lactulose
Lactulose
ORAL SYRUP
$0.00 - $2.55 (Tier 1)
Loperamide
Loperamide HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
Metoclopramide HCL
Metoclopramide HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ AMITIZA
QL = Quantity limit
ST = Step Therapy
PART D
119
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Metoclopramide HCL
Metoclopramide HCL
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Metoclopramide HCL
Metoclopramide HCL
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
RELISTOR
Methylnaltrexone Bromide
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
SODIUM PHENYLBUTYRATE
Sodium Phenylbutyrate
ORAL POWDER
$0.00 - $6.35 (Tier 2)
PA
+ Ursodiol
Ursodiol
CAPSULE
$0.00 - $2.55 (Tier 1)
Peg-3350 And Electrolytes
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
QL
Peg-3350 With Flavor Packs
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
QL
ORAL POWDER
$0.00 - $2.55 (Tier 1)
Trilyte With Flavor Packets
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Calcium Acetate
Calcium Acetate
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Calcium Acetate
Calcium Acetate
TABLET
$0.00 - $2.55 (Tier 1)
+ RENAGEL
Sevelamer HCL
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ RENVELA
Sevelamer Carbonate
TABLET
$0.00 - $6.35 (Tier 2)
PA
Sps
Sodium Polystyrene Sulfonate
ORAL SUSP
$0.00 - $2.55 (Tier 1)
LAXATIVES
PHOSPHATE BINDERS
QL = Quantity limit
ST = Step Therapy
120
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
CAP ER 24H
$0.00 - $6.35 (Tier 2)
QL, ST
+ MYRBETRIQ
Mirabegron
TAB ER 24H
$0.00 - $6.35 (Tier 2)
PA
+ Oxybutynin Chloride
Oxybutynin Chloride
ORAL SYRUP
$0.00 - $2.55 (Tier 1)
+ Oxybutynin Chloride
Oxybutynin Chloride
TABLET
$0.00 - $2.55 (Tier 1)
+ Oxybutynin Chloride ER
Oxybutynin Chloride
TAB ER 24
$0.00 - $2.55 (Tier 1)
+ TOLTERODINE TARTRATE
TABLET
$0.00 - $2.55 (Tier 1)
QL, ST
GENITOURINARY AGENTS
+ DETROL LA
HEAVY METAL ANTAGONISTS
HEAVY METAL ANTAGONISTS
+ CUPRIMINE
Penicillamine
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
Deferoxamine Mesylate
Deferoxamine Mesylate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
+ DEPEN
Penicillamine
TABLET
$0.00 - $6.35 (Tier 2)
+ EXJADE
Deferasirox
TAB DISPER
$0.00 - $6.35 (Tier 2)
PA
QL = Quantity limit
ST = Step Therapy
PART D
121
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING
HORMONAL AGENTS, STIMULANT/
ANDROGENS
+ ANADROL-50
Oxymetholone
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ ANDRODERM
Testosterone
PATCH
$0.00 - $6.35 (Tier 2)
PA
+ Android
Methyltestosterone
CAPSULE
$0.00 - $2.55 (Tier 1)
PA
+ Androxy
Fluoxymesterone
TABLET
$0.00 - $2.55 (Tier 1)
PA
Danazol
Danazol
CAPSULE
$0.00 - $2.55 (Tier 1)
+ Oxandrolone
Oxandrolone
TABLET
$0.00 - $2.55 (Tier 1)
PA
ESTROGENS AND ANTIESTROGENS
+ ALORA
Estradiol
PATCH
$0.00 - $6.35 (Tier 2)
+ CENESTIN
Estrogens,Conj.,Synthetic A
TABLET
$0.00 - $6.35 (Tier 2)
PA>65 yrs old
+ COMBIPATCH
Estradiol/Norethindrone Acet
PATCH
$0.00 - $6.35 (Tier 2)
+ Estradiol
Estradiol
PATCH
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Estradiol
Estradiol
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
+ Estradiol-Norethindrone Acetat
TABLET
$0.00 - $2.55 (Tier 1)
+ Estropipate
Estropipate
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
QL = Quantity limit
ST = Step Therapy
122
PART D
BRAND DRUG NAME
WHAT THE DRUG WILL
NECESSARY ACTIONS,
FORMULATION
+ EVISTA
Raloxifene HCL
TABLET
$0.00 - $6.35 (Tier 2)
QL
+ MENEST
Estrogens,Esterified
TABLET
$0.00 - $6.35 (Tier 2)
PA>65 yrs old
+ Mimvey
TABLET
$0.00 - $2.55 (Tier 1)
+ PREMARIN
Estrogens, Conjugated
TABLET
$0.00 - $6.35 (Tier 2)
PA>65 yrs old
+ PREMARIN
Estrogens, Conjugated
VAGINAL CREAM
$0.00 - $6.35 (Tier 2)
+ PREMPHASE
Estrogen,Con/M-Progest Acet
TABLET
$0.00 - $6.35 (Tier 2)
PA>65 yrs old
+ PREMPRO
Estrogen,Con/M-Progest Acet
TABLET
$0.00 - $6.35 (Tier 2)
PA>65 yrs old
BvD
GENERIC DRUG NAME
GLUCOCORTICOIDS/MINERALOCORTICOIDS
A-Hydrocort
Hydrocortisone Sod Succinate
INJECTION
$0.00 - $2.55 (Tier 1)
CELESTONE
Betamethasone
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
Cortisone Acetate
Cortisone Acetate
TABLET
$0.00 - $2.55 (Tier 1)
BvD
Dexamethasone
Dexamethasone
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
BvD
Dexamethasone
Dexamethasone
TABLET
$0.00 - $2.55 (Tier 1)
BvD
Dexamethasone Acetate
Dexamethasone Acetate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Dexamethasone Sodium Phosphate Dexamethasone Sod Phosphate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Fludrocortisone Acetate
TABLET
$0.00 - $2.55 (Tier 1)
Fludrocortisone Acetate
QL = Quantity limit
ST = Step Therapy
PART D
123
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Hydrocortisone
Hydrocortisone
TABLET
$0.00 - $2.55 (Tier 1)
BvD
Methylprednisolone
Methylprednisolone
TABLET
$0.00 - $2.55 (Tier 1)
BvD
Methylprednisolone
Methylprednisolone
TAB DS PK
$0.00 - $2.55 (Tier 1)
BvD
Methylprednisolone Acetate
Methylprednisolone Acetate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
Methylprednisolone Sod Succ
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Prednisolone Sodium Phosphate
Prednisolone Sod Phosphate
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
BvD
Prednisone
Prednisone
TAB DS PK
$0.00 - $2.55 (Tier 1)
Prednisone
Prednisone
TABLET
$0.00 - $2.55 (Tier 1)
BvD
Chorionic Gonadotropin
Chorionic Gonadotropin, Human
INJECTION
$0.00 - $2.55 (Tier 1)
PA
+ Desmopressin Acetate
Desmopressin Acetate
TABLET
$0.00 - $2.55 (Tier 1)
NASAL SOLN
$0.00 - $2.55 (Tier 1)
NASAL SPRAY
$0.00 - $2.55 (Tier 1)
+ GENOTROPIN
Somatropin
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
+ GENOTROPIN
Somatropin
INJECTION CART
$0.00 - $6.35 (Tier 2)
PA
PITUITARY
QL = Quantity limit
ST = Step Therapy
124
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Somatropin
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ INCRELEX
Mecasermin
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ NORDITROPIN
Somatropin
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ NORDITROPIN FLEXPRO
Somatropin
INJECTION PEN
$0.00 - $6.35 (Tier 2)
PA
+ NORDITROPIN NORDIFLEX
Somatropin
INJECTION PEN
$0.00 - $6.35 (Tier 2)
PA
+ NUTROPIN
Somatropin
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ NUTROPIN AQ
Somatropin
INJECTION CART
$0.00 - $6.35 (Tier 2)
PA
+ NUTROPIN AQ NUSPIN
Somatropin
INJECTION CART
$0.00 - $6.35 (Tier 2)
PA
+ SAIZEN
Somatropin
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ SAIZEN
Somatropin
INJECTION CART
$0.00 - $6.35 (Tier 2)
PA
+ SANDOSTATIN LAR
Octreotide Acetate
INJECTION KIT
$0.00 - $6.35 (Tier 2)
BvD
+ SEROSTIM
Somatropin
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ SOMATULINE DEPOT
Lanreotide Acetate
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
+ SOMAVERT
Pegvisomant
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ ZORBTIVE
Somatropin
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ HUMATROPE
QL = Quantity limit
ST = Step Therapy
PART D
125
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
PROGESTINS
+ Medroxyprogesterone Acetate
Medroxyprogesterone Acetate
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
INJECTION DISP SYR
$0.00 - $2.55 (Tier 1)
BvD
TABLET
$0.00 - $2.55 (Tier 1)
+ Norethindrone Acetate
Norethindrone Acetate
TABLET
$0.00 - $2.55 (Tier 1)
+ Progesterone
Progesterone,Micronized
CAPSULE
$0.00 - $2.55 (Tier 1)
THYROID AND ANTITHYROID AGENTS
+ LEVOTHROID
Levothyroxine Sodium
TABLET
$0.00 - $6.35 (Tier 2)
+ Levothyroxine Sodium
TABLET
$0.00 - $2.55 (Tier 1)
+ LEVOXYL
TABLET
$0.00 - $6.35 (Tier 2)
+ Liothyronine Sodium
Liothyronine Sodium
TABLET
$0.00 - $2.55 (Tier 1)
+ Methimazole
Methimazole
TABLET
$0.00 - $2.55 (Tier 1)
+ Propylthiouracil
Propylthiouracil
TABLET
$0.00 - $2.55 (Tier 1)
+ SYNTHROID
TABLET
$0.00 - $6.35 (Tier 2)
+ THYROLAR-1
Liotrix
TABLET
$0.00 - $6.35 (Tier 2)
+ THYROLAR-1/2
Liotrix
TABLET
$0.00 - $6.35 (Tier 2)
QL = Quantity limit
ST = Step Therapy
126
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ THYROLAR-1/4
Liotrix
TABLET
$0.00 - $6.35 (Tier 2)
+ THYROLAR-2
Liotrix
TABLET
$0.00 - $6.35 (Tier 2)
+ THYROLAR-3
Liotrix
TABLET
$0.00 - $6.35 (Tier 2)
+ TIROSINT
CAPSULE
$0.00 - $6.35 (Tier 2)
+ UNITHROID
TABLET
$0.00 - $6.35 (Tier 2)
TABLET DR
$0.00 - $6.35 (Tier 2)
BvD
ANTIVENIN LATRODECTUS MACTANS Antivenin,Latrodectus Mactans
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
ANTIVENIN MICRURUS FULVIUS
Antivenin,Micrurus Fulvius
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
+ ARCALYST
Rilonacept
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ ASTAGRAF XL
Tacrolimus
CAP ER 24H
$0.00 - $6.35 (Tier 2)
PA
ATGAM
Lymphocyte Immune Globulin
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ AUBAGIO
Teriflunomide
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ Azathioprine
Azathioprine
TABLET
$0.00 - $2.55 (Tier 1)
BvD
BIVIGAM
Immune Globulin,Gamma(Igg)
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
IMMUNOLOGICAL AGENTS
+ MYFORTIC
Mycophenolate Sodium
QL = Quantity limit
ST = Step Therapy
PART D
127
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
CARIMUNE NF NANOFILTERED
Immune Globulin,Gamma(Igg)
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ CELLCEPT
Mycophenolate Mofetil
ORAL SUSP
$0.00 - $6.35 (Tier 2)
BvD
CROFAB
Antivenin,Crotalidae Fab(Ovin)
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
+ Cyclosporine
Cyclosporine, Modified
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
BvD
+ Cyclosporine
Cyclosporine
CAPSULE
$0.00 - $2.55 (Tier 1)
BvD
+ Cyclosporine Modified
Cyclosporine, Modified
CAPSULE
$0.00 - $2.55 (Tier 1)
BvD
CYTOGAM
Cytomegalovirus Immune Glob
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ ENBREL
Etanercept
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
+ ENBREL
Etanercept
INJECTION PEN
$0.00 - $6.35 (Tier 2)
PA
+ ENBREL
Etanercept
INJECTION
$0.00 - $6.35 (Tier 2)
PA
GAMUNEX-C
Immune Glob,Gam Caprylate(Igg)
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
HEPAGAM B
Hepatitis B Immun Glob/Maltose
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
+ HUMIRA
Adalimumab
INJECTION KIT
$0.00 - $6.35 (Tier 2)
PA
HYPERHEP B S-D
Hepatitis B Immune Globulin
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BvD
HYPERHEP B S-D
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
HYPERRAB S-D
Rabies Immune Globulin/PF
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BvD
QL = Quantity limit
ST = Step Therapy
128
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Rho(D) Immune Globulin
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BvD
HYPERRHO S-D
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BvD
HYPERTET S-D
Tetanus Immune Globulin/PF
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BvD
IMOGAM RABIES-HT
Rabies Immune Globulin/PF
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
+ KINERET
Anakinra
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
+ Leflunomide
Leflunomide
TABLET
$0.00 - $2.55 (Tier 1)
MICRHOGAM PLUS
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BvD
+ Mycophenolate Mofetil
CAPSULE
$0.00 - $2.55 (Tier 1)
BvD
+ Mycophenolate Mofetil
TABLET
$0.00 - $2.55 (Tier 1)
BvD
NABI-HB
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
+ NULOJIX
Belatacept
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
+ ORENCIA
Abatacept/Maltose
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ PROGRAF
Tacrolimus
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ RAPAMUNE
Sirolimus
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
BvD
+ RAPAMUNE
Sirolimus
TABLET
$0.00 - $6.35 (Tier 2)
BvD
RHOGAM PLUS
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BvD
HYPERRHO S-D
QL = Quantity limit
ST = Step Therapy
PART D
129
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
RHOPHYLAC
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BvD
+ RIDAURA
Auranofin
CAPSULE
$0.00 - $6.35 (Tier 2)
+ Tacrolimus
Tacrolimus
CAPSULE
$0.00 - $2.55 (Tier 1)
BvD
+ TACROLIMUS 5MG
Tacrolimus
CAPSULE
$0.00 - $6.35 (Tier 2)
BvD
TYSABRI
Natalizumab
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
WINRHO SDF
Rho(D) Immune Globulin/Maltose
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
+ ZORTRESS
Everolimus
TABLET
$0.00 - $6.35 (Tier 2)
PA
ACTHIB
Haemoph B Poly Conj-Tet Tox/PF
INJECTION
$0.00 - $6.35 (Tier 2)
ADACEL
Diph,Pertuss(Acell),Tet Vac/PF
INJECTION
$0.00 - $6.35 (Tier 2)
ADACEL
Diph,Pertuss(Acell),Tet Vac/PF
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BCG VACCINE (TICE STRAIN)
Bcg Live
INJECTION
$0.00 - $6.35 (Tier 2)
BOOSTRIX
Diphth,Pertuss(Acell),Tet Vac
INJECTION
$0.00 - $6.35 (Tier 2)
BOOSTRIX
Diphth,Pertuss(Acell),Tet Vac
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
CERVARIX
Human Papillomav Vacc Bival/PF
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
COMVAX
Hep B Vaccine/Hib Conj-Meng/PF
INJECTION
$0.00 - $6.35 (Tier 2)
VACCINES
QL = Quantity limit
ST = Step Therapy
130
PART D
BRAND DRUG NAME
DAPTACEL
GENERIC DRUG NAME
Diph,Pertuss(Acell),Tet Ped/PF
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
$0.00 - $6.35 (Tier 2)
DIPHTHERIA-TETANUS TOXOIDS-PED Tetanus,Diphtheria Toxd Ped/PF
INJECTION
$0.00 - $6.35 (Tier 2)
ENGERIX-B
Hepatitis B Virus Vaccine/PF
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BvD
ENGERIX-B
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
GARDASIL
Human Papilomvirus Vac,Qval/PF
INJECTION
$0.00 - $6.35 (Tier 2)
GARDASIL
Human Papilomvirus Vac,Qval/PF
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
HAVRIX
Hepatitis A Virus Vaccine/PF
INJECTION
$0.00 - $6.35 (Tier 2)
HAVRIX
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
IMOVAX RABIES VACCINE
Rabies Vacc, Human Diploid/PF
INJECTION
$0.00 - $6.35 (Tier 2)
INFANRIX
INJECTION
$0.00 - $6.35 (Tier 2)
INFANRIX PF
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
IPOL
Poliomyelitis Vaccine, Killed
INJECTION
$0.00 - $6.35 (Tier 2)
IXIARO
Japanese Encephalitis Vacc/PF
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
JE-VAX
Japanese Encephalitis Vaccine
INJECTION
$0.00 - $6.35 (Tier 2)
KINRIX
Diph,Pertus(Acel),Tet,Polio/PF
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
KINRIX
Diph,Pertus(Acel),Tet,Polio/PF
INJECTION
$0.00 - $6.35 (Tier 2)
INJECTION
QL = Quantity limit
ST = Step Therapy
PART D
131
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
MENACTRA
Mening Vac A,C,Y,W-135 Dip/PF
INJECTION
$0.00 - $6.35 (Tier 2)
MENHIBRIX
Meningococcal Vac C,Y/Hib/Pf
INJECTION VIAL
$0.00 - $6.35 (Tier 2)
MENOMUNE-A-C-Y-W-135
Meningococ Vac A,C,Y,W-135/PF
INJECTION
$0.00 - $6.35 (Tier 2)
MENVEO A-C-Y-W-135-DIP
Mening Vac A,C,Y,W-135 Dip/PF
INJECTION KIT
$0.00 - $6.35 (Tier 2)
M-M-R II VACCINE
Measles,Mumps&Rubella Vacc/PF
INJECTION
$0.00 - $6.35 (Tier 2)
PEDIARIX
Hep B Vaccine/Dp(A)T-Polio/PF
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PEDVAXHIB
Haemph B Polysac Conj-Menin/PF
INJECTION
$0.00 - $6.35 (Tier 2)
PROQUAD
Measles,Mumps,Rub,Varicella/PF
INJECTION
$0.00 - $6.35 (Tier 2)
RABAVERT
Rabies Vaccine (Pcec)/PF
INJECTION KIT
$0.00 - $6.35 (Tier 2)
RECOMBIVAX HB
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
BvD
RECOMBIVAX HB
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
ROTATEQ
Rotavirus Vac,Live Pentav
ORAL SUSP
$0.00 - $6.35 (Tier 2)
TE ANATOXAL BERNA
Tetanus Toxoid, Adsorbed
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
TENIVAC
Tetanus And Diphtheria Tox/PF
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
TETANUS DIPHTHERIA TOXOIDS
Tetanus & Diphtheria Tox,Adult
INJECTION
$0.00 - $6.35 (Tier 2)
Tetanus Toxoid Adsorbed
Tetanus Toxoid,Adsorbed/PF
INJECTION
$0.00 - $2.55 (Tier 1)
BvD
QL = Quantity limit
ST = Step Therapy
132
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
Bcg Live
INJECTION
$0.00 - $6.35 (Tier 2)
TWINRIX
Hepatitis A & B Vaccine/PF
INJECTION
$0.00 - $6.35 (Tier 2)
TYPHIM VI
Typhoid Vacc Vi Capsu Polysacc
INJECTION
$0.00 - $6.35 (Tier 2)
VAQTA
INJECTION
$0.00 - $6.35 (Tier 2)
VAQTA
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
VARIVAX VACCINE
Varicella Vaccine Live/PF
INJECTION
$0.00 - $6.35 (Tier 2)
VIVOTIF BERNA
Typhoid Vacc,Live,Attenuated
CAPSULE DR
$0.00 - $6.35 (Tier 2)
YF-VAX
Yellow Fever Vaccine/PF
INJECTION
$0.00 - $6.35 (Tier 2)
ZOSTAVAX
Zoster Vaccine Live/PF
INJECTION
$0.00 - $6.35 (Tier 2)
BvD
THERACYS
NECESSARY ACTIONS,
INFLAMMATORY BOWEL DISEASE AGENTS
+ BALSALAZIDE DISODIUM
Balsalazide Disodium
CAPSULE
$0.00 - $2.55 (Tier 1)
+ BUDESONIDE EC
Budesonide
CAPDR & ER
$0.00 - $2.55 (Tier 1)
+ CANASA
Mesalamine
RECTAL SUPP
$0.00 - $6.35 (Tier 2)
+ DELZICOL
Mesalamine
CAPSULE DR
$0.00 - $6.35 (Tier 2)
+ DIPENTUM
Olsalazine Sodium
CAPSULE
$0.00 - $6.35 (Tier 2)
QL = Quantity limit
ST = Step Therapy
PART D
133
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Mesalamine
Mesalamine W/Cleansing Wipes
RECTAL KIT
$0.00 - $2.55 (Tier 1)
+ PENTASA
Mesalamine
CAPSULE ER
$0.00 - $6.35 (Tier 2)
QL, PA
IRRIGATING SOLUTIONS
IRRIGATING SOLUTIONS
Sodium Chloride
Sodium Chloride Irrig Solution
IRRIGATION
$0.00 - $2.55 (Tier 1)
BvD
Water
Water For Irrigation,Sterile
IRRIGATION
$0.00 - $2.55 (Tier 1)
BvD
METABOLIC BONE DISEASE AGENTS
+ ACTONEL
Risedronate Sodium
TABLET
$0.00 - $6.35 (Tier 2)
QL
+ Alendronate Sodium
Alendronate Sodium
TABLET
$0.00 - $2.55 (Tier 1)
QL
+ ATELVIA
Risedronate Sodium
TABLET DR
$0.00 - $6.35 (Tier 2)
QL, PA
+ CALCITONIN-SALMON
Calcitonin,Salmon,Synthetic
NASAL SPRAY
$0.00 - $2.55 (Tier 1)
PA
+ Calcitriol
Calcitriol
CAPSULE
$0.00 - $2.55 (Tier 1)
BvD
+ Etidronate Disodium
Etidronate Disodium
TABLET
$0.00 - $2.55 (Tier 1)
+ FORTEO
Teriparatide
INJECTION PEN
$0.00 - $2.55 (Tier 1)
QL, PA
QL = Quantity limit
ST = Step Therapy
134
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Doxercalciferol
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ HECTOROL 0.5MCG, 1MCG
Doxercalciferol
CAPSULE
$0.00 - $6.35 (Tier 2)
QL, BvD
+ HECTOROL 2.5MCG
Doxercalciferol
CAPSULE
$0.00 - $6.35 (Tier 2)
BvD
+ IBANDRONATE SODIUM
Ibandronate Sodium
TABLET
$0.00 - $2.55 (Tier 1)
QL
Pamidronate Disodium
Pamidronate Disodium
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
+ PARICALCITOL
Paricalcitol
CAPSULE
$0.00 - $6.35 (Tier 2)
BvD
+ PROLIA
Denosumab
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
XGEVA
Denosumab
INJECTION
$0.00 - $6.35 (Tier 2)
PA
ZEMPLAR
Paricalcitol
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
ZOLEDRONIC ACID
Zoledronic Acid/Mannitol&Water
IV- INFUS. BTL
$0.00 - $6.35 (Tier 2)
BvD
ZOLEDRONIC ACID
Zoledronic Acid
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ ZOLEDRONIC ACID
Zoledronic Acid/Mannitol&Water
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
PA
HECTOROL
MISCELLANEOUS THERAPEUTIC AGENTS
+ ACTIMMUNE
Interferon Gamma-1B,Recomb.
INJECTION
$0.00 - $6.35 (Tier 2)
PA
+ Allopurinol
Allopurinol
TABLET
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
PART D
135
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
AMIFOSTINE
Amifostine Crystalline
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
PA
+ AVODART
Dutasteride
CAPSULE
$0.00 - $6.35 (Tier 2)
QL
+ AVONEX
Interferon Beta-1A
INJECTION KIT
$0.00 - $6.35 (Tier 2)
PA
+ AVONEX ADMINISTRATION PACK Interferon Beta-1A/Albumin
INJECTION KIT
$0.00 - $6.35 (Tier 2)
PA
+ BETASERON
Interferon Beta-1B
INJECTION KIT
$0.00 - $6.35 (Tier 2)
PA
Bethanechol Chloride
Bethanechol Chloride
TABLET
$0.00 - $2.55 (Tier 1)
+ Buspirone HCL
Buspirone HCL
TABLET
$0.00 - $2.55 (Tier 1)
+ COLCRYS
Colchicine
TABLET
$0.00 - $6.35 (Tier 2)
+ COPAXONE
Glatiramer Acetate
INJECTION KIT
$0.00 - $6.35 (Tier 2)
PA
CYSTADANE
Betaine
ORAL POWDER
$0.00 - $6.35 (Tier 2)
+ EXTAVIA
Interferon Beta-1B
INJECTION KIT
$0.00 - $6.35 (Tier 2)
PA
+ Finasteride
Finasteride
TABLET
$0.00 - $2.55 (Tier 1)
QL
FOMEPIZOLE
Fomepizole
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
+ GILENYA
Fingolimod HCL
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
GLUCAGEN
INJECTION KIT
$0.00 - $6.35 (Tier 2)
GLUCAGON EMERGENCY KIT
INJECTION KIT
$0.00 - $6.35 (Tier 2)
QL
QL = Quantity limit
ST = Step Therapy
136
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Guanidine HCL
Guanidine HCL
TABLET
$0.00 - $2.55 (Tier 1)
Hydroxyzine HCL
Hydroxyzine HCL
ORAL SYRUP
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
Hydroxyzine HCL
Hydroxyzine HCL
TABLET
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
Leucovorin Calcium
Leucovorin Calcium
TABLET
$0.00 - $2.55 (Tier 1)
Leucovorin Calcium
Leucovorin Calcium
INJECTION
$0.00 - $2.55 (Tier 1)
MESNEX
Mesna
TABLET
$0.00 - $6.35 (Tier 2)
MIFEPREX
Mifepristone
TABLET
$0.00 - $6.35 (Tier 2)
MYTELASE
Ambenonium Chloride
TABLET
$0.00 - $6.35 (Tier 2)
+ Probenecid
Probenecid
TABLET
$0.00 - $2.55 (Tier 1)
+ Probenecid-Colchicine
Colchicine/Probenecid
TABLET
$0.00 - $2.55 (Tier 1)
PROSTIGMIN
Neostigmine Bromide
TABLET
$0.00 - $6.35 (Tier 2)
+ Pyridostigmine Bromide
Pyridostigmine Bromide
TABLET
$0.00 - $2.55 (Tier 1)
+ REBIF
Interferon Beta-1A/Albumin
INJECTION DISP SYR
$0.00 - $6.35 (Tier 2)
PA
+ REBIF REBIDOSE
Interferon Beta-1A/Albumin
INJECTION PEN
$0.00 - $6.35 (Tier 2)
PA
+ REMICADE
Infliximab
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
+ SENSIPAR 30MG
Cinacalcet HCL
TABLET
$0.00 - $6.35 (Tier 2)
QL, PA
BvD
QL = Quantity limit
ST = Step Therapy
PART D
137
BRAND DRUG NAME
WHAT THE DRUG WILL
NECESSARY ACTIONS,
GENERIC DRUG NAME
FORMULATION
+ SENSIPAR 60MG, 90MG
Cinacalcet HCL
TABLET
$0.00 - $6.35 (Tier 2)
PA
SIMULECT
Basiliximab
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
Sterile Pads
Gauze Bandage
BANDAGE
$0.00 - $2.55 (Tier 1)
SYNAREL
Nafarelin Acetate
NASAL SPRAY
$0.00 - $6.35 (Tier 2)
PA
+ TECFIDERA
Dimethyl Fumarate
CAPSULE DR
$0.00 - $6.35 (Tier 2)
PA
+ THALOMID
Thalidomide
CAPSULE
$0.00 - $6.35 (Tier 2)
PA
THIOLA
Tiopronin
TABLET
$0.00 - $6.35 (Tier 2)
VORAXAZE
Glucarpidase
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ XELJANZ
Tofacitinib Citrate
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ ACETAZOLAMIDE
Acetazolamide
CAPSULE ER
$0.00 - $6.35 (Tier 2)
+ Acetazolamide
Acetazolamide
TABLET
$0.00 - $2.55 (Tier 1)
+ ALPHAGAN P
OPHT DROPS
$0.00 - $6.35 (Tier 2)
QL
+ AZOPT
Brinzolamide
OPHT SUSP
$0.00 - $6.35 (Tier 2)
QL
+ Betaxolol HCL
Betaxolol HCL
OPHT DROPS
$0.00 - $2.55 (Tier 1)
OPTHALMIC AGENTS
ANTIGLAUCOMA AGENTS
QL = Quantity limit
ST = Step Therapy
138
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
OPHT DROPS
$0.00 - $2.55 (Tier 1)
+ Dorzolamide HCL
Dorzolamide HCL
OPHT DROPS
$0.00 - $2.55 (Tier 1)
QL
+ Dorzolamide-Timolol
Dorzolamide HCL/Timolol Maleat
OPHT DROPS
$0.00 - $2.55 (Tier 1)
QL
+ HUMORSOL
Demecarium Bromide
OPHT DROPS
$0.00 - $6.35 (Tier 2)
+ Latanoprost
Latanoprost
OPHT DROPS
$0.00 - $2.55 (Tier 1)
+ Levobunolol HCL 0.25%
Levobunolol HCL
OPHT DROPS
$0.00 - $2.55 (Tier 1)
QL
+ Levobunolol HCL 0.5%
Levobunolol HCL
OPHT DROPS
$0.00 - $2.55 (Tier 1)
+ Methazolamide
Methazolamide
TABLET
$0.00 - $2.55 (Tier 1)
+ Metipranolol
Metipranolol
OPHT DROPS
$0.00 - $2.55 (Tier 1)
+ PHOSPHOLINE IODIDE
Echothiophate Iodide
OPHT DROPS
$0.00 - $6.35 (Tier 2)
+ Pilocarpine HCL
Pilocarpine HCL
OPHT DROPS
$0.00 - $2.55 (Tier 1)
QL
+ PILOPINE HS
Pilocarpine HCL
OPHT GEL (G)
$0.00 - $6.35 (Tier 2)
+ Timolol Maleate
Timolol Maleate
OPHT DROPS
$0.00 - $2.55 (Tier 1)
+ Timolol Maleate
Timolol Maleate
OPHT GEL (G)
$0.00 - $2.55 (Tier 1)
+ TRAVATAN Z
Travoprost
OPHT DROPS
$0.00 - $6.35 (Tier 2)
QL
+ TRAVOPROST
Travoprost (Benzalkonium)
OPHT DROPS
$0.00 - $6.35 (Tier 2)
QL
OPTHALMIC AGENTS
+ Brimonidine Tartrate
QL = Quantity limit
ST = Step Therapy
PART D
139
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
REPLACEMENT PREPARATIONS
Cytra-3
Sod/Pot/K Cit/Sod Cit/Cit Acid
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Cytra-K
Potassium Citrate/Citric Acid
ORAL PACKETS
$0.00 - $2.55 (Tier 1)
Dextrose 5%-1/2Ns-Kcl
Potassium Chloride/D5-0.45Nacl
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Potassium Chloride/D5-0.3%Nacl
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Dextrose 5%-Ns-Kcl
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Dextrose 5%-Potassium Chloride
Potassium Chloride In D5W
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
+ Ed K+10
Potassium Chloride
TABLET SA
$0.00 - $2.55 (Tier 1)
+ Effer-K
Potassium Bicarbonate/Cit Ac
TABLET EFF
$0.00 - $2.55 (Tier 1)
HYPERLYTE CR
+/Mag/Ca/Chlor/Acetate
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
HYPERLYTE R
Electrolyte Solution,Inj
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
+ K Effervescent
Potassium Bicarbonate/Cit Ac
TABLET EFF
$0.00 - $2.55 (Tier 1)
+ Klor-Con
Potassium Chloride
ORAL PACKETS
$0.00 - $2.55 (Tier 1)
+ Klor-Con 10
Potassium Chloride
TABLET ER
$0.00 - $2.55 (Tier 1)
QL = Quantity limit
ST = Step Therapy
140
PART D
BRAND DRUG NAME
WHAT THE DRUG WILL
NECESSARY ACTIONS,
FORMULATION
+ Klor-Con 8
Potassium Chloride
TABLET ER
$0.00 - $2.55 (Tier 1)
+ Klor-Con M15
Potassium Chloride
TAB ER PRT
$0.00 - $2.55 (Tier 1)
+ Klor-Con M20
Potassium Chloride
TAB ER PRT
$0.00 - $2.55 (Tier 1)
LACTATED RINGERS
Ringers Solution,Lactated
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
NUTRILYTE II
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
Phospha 250 Neutral
Phosphorus #1
TABLET
$0.00 - $2.55 (Tier 1)
Potassium Chl-Normal Saline
Potassium Chloride In 0.9%Nacl
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
+ Potassium Chloride
Potassium Chloride
TAB ER PRT
$0.00 - $2.55 (Tier 1)
Potassium Chloride
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
Potassium Chloride
CAPSULE ER
$0.00 - $2.55 (Tier 1)
Pot Chloride/Pot Bicarb/Cit Ac
TABLET EFF
$0.00 - $2.55 (Tier 1)
Potassium Chloride
TABLET ER
$0.00 - $2.55 (Tier 1)
Potassium Chloride In D5Lr
Potassium Chloride In Lr-D5
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
+ Potassium Citrate
Potassium Citrate
TABLET ER
$0.00 - $2.55 (Tier 1)
Ringers Injection
Ringers Solution
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
Sodium Bicarbonate
Sodium Bicarbonate
IV- DISP SYRIN
$0.00 - $2.55 (Tier 1)
GENERIC DRUG NAME
QL = Quantity limit
ST = Step Therapy
PART D
141
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Sodium Bicarbonate
Sodium Bicarbonate
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
Sodium Chloride
Sodium Chloride 0.45 %
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
Sodium Citrate & Citric Acid
Citric Acid/Sodium Citrate
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
TPN ELECTROLYTES
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
BvD
RESPIRATORY TRACT AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
+ ADVAIR DISKUS
INHALATION DISK
$0.00 - $6.35 (Tier 2)
QL, ST
+ ADVAIR HFA
AEROSOL
$0.00 - $6.35 (Tier 2)
QL, ST
+ ASMANEX
Mometasone Furoate
AEROSOL
$0.00 - $6.35 (Tier 2)
+ FLOVENT HFA
AEROSOL
$0.00 - $6.35 (Tier 2)
+ Flunisolide
Flunisolide
NASAL SPRAY
$0.00 - $2.55 (Tier 1)
+ Fluticasone Propionate
NASAL SPRAY
$0.00 - $2.55 (Tier 1)
+ PULMICORT FLEXHALER
Budesonide
AEROSOL
$0.00 - $6.35 (Tier 2)
+ QVAR
Beclomethasone Dipropionate
AEROSOL
$0.00 - $6.35 (Tier 2)
Montelukast Sodium
TAB CHEW
$0.00 - $2.55 (Tier 1)
ANTILEUKOTRIENES
+ Montelukast Sodium
QL = Quantity limit
ST = Step Therapy
142
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
+ Montelukast Sodium
Montelukast Sodium
TABLET
$0.00 - $2.55 (Tier 1)
+ Zafirlukast
Zafirlukast
TABLET
$0.00 - $2.55 (Tier 1)
QL
+ Albuterol Sulfate
Albuterol Sulfate
INHALATION SOLN
$0.00 - $2.55 (Tier 1)
BvD
+ Albuterol Sulfate
Albuterol Sulfate
ORAL SYRUP
$0.00 - $2.55 (Tier 1)
+ Albuterol Sulfate
Albuterol Sulfate
TAB ER 12H
$0.00 - $2.55 (Tier 1)
+ Albuterol Sulfate
Albuterol Sulfate
TABLET
$0.00 - $2.55 (Tier 1)
+ Aminophylline
Aminophylline
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ ATROVENT HFA
Ipratropium Bromide
AEROSOL
$0.00 - $6.35 (Tier 2)
+ COMBIVENT
AEROSOL
$0.00 - $6.35 (Tier 2)
QL
+ COMBIVENT RESPIMAT
AEROSOL
$0.00 - $6.35 (Tier 2)
QL
+ Ipratropium Bromide
Ipratropium Bromide
INHALATION SOLN
$0.00 - $2.55 (Tier 1)
BvD
+ Ipratropium Bromide
Ipratropium Bromide
NASAL SPRAY
$0.00 - $2.55 (Tier 1)
+ Ipratropium-Albuterol
INHALATION SOLN
$0.00 - $2.55 (Tier 1)
BvD
+ Metaproterenol Sulfate
Metaproterenol Sulfate
ORAL SYRUP
$0.00 - $2.55 (Tier 1)
+ Metaproterenol Sulfate
Metaproterenol Sulfate
TABLET
$0.00 - $2.55 (Tier 1)
BRONCHODILATORS
QL = Quantity limit
ST = Step Therapy
PART D
143
WHAT THE DRUG WILL
NECESSARY ACTIONS,
BRAND DRUG NAME
GENERIC DRUG NAME
+ PROAIR HFA
Albuterol Sulfate
AEROSOL
$0.00 - $6.35 (Tier 2)
QL
+ SEREVENT DISKUS
Salmeterol Xinafoate
INHALATION DISK
$0.00 - $6.35 (Tier 2)
PA
+ SPIRIVA
Tiotropium Bromide
INHALATION CAPSULE
$0.00 - $6.35 (Tier 2)
QL
+ Terbutaline Sulfate
Terbutaline Sulfate
INJECTION
$0.00 - $2.55 (Tier 1)
+ Terbutaline Sulfate
Terbutaline Sulfate
TABLET
$0.00 - $2.55 (Tier 1)
+ THEO-24
Theophylline Anhydrous
CAP ER 24H
$0.00 - $6.35 (Tier 2)
+ Theophylline
TABLET ER
$0.00 - $2.55 (Tier 1)
+ Theophylline
ORAL SOLUTION
$0.00 - $2.55 (Tier 1)
+ Theophylline Anhydrous
TAB ER 12H
$0.00 - $2.55 (Tier 1)
+ Theophylline In 5% Dextrose
Theophylline/D5W
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
+ TUDORZA PRESSAIR
Aclidinium Bromide
AEROSOL
$0.00 - $6.35 (Tier 2)
ST
+ VENTOLIN
Albuterol
RESPIRATORY TRACT AGENTS, OTHER
AEROSOL
$0.00 - $6.35 (Tier 2)
QL
+ Cromolyn Sodium
Cromolyn Sodium
INHALATION SOLN
$0.00 - $2.55 (Tier 1)
BvD
+ DALIRESP
Roflumilast
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ XOLAIR
Omalizumab
INJECTION
$0.00 - $6.35 (Tier 2)
PA
FORMULATION
QL = Quantity limit
ST = Step Therapy
144
PART D
BRAND DRUG NAME
+ ZEMAIRA
GENERIC DRUG NAME
Alpha-1-Proteinase Inhibitor
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
SKELETAL MUSCLE RELAXANTS
SKELETAL MUSCLE RELAXANTS
Baclofen
TABLET
$0.00 - $2.55 (Tier 1)
Carisoprodol
Carisoprodol
TABLET
$0.00 - $2.55 (Tier 1)
QL, PA>65 yrs old
Chlorzoxazone
Chlorzoxazone
TABLET
$0.00 - $2.55 (Tier 1)
QL, PA>65 yrs old
Cyclobenzaprine HCL
Cyclobenzaprine HCL
TABLET
$0.00 - $2.55 (Tier 1)
QL, PA>65 yrs old
+ Dantrolene Sodium
Dantrolene Sodium
CAPSULE
$0.00 - $2.55 (Tier 1)
Methocarbamol
Methocarbamol
TABLET
$0.00 - $2.55 (Tier 1)
QL, PA>65 yrs old
+ Tizanidine HCL
Tizanidine HCL
TABLET
$0.00 - $2.55 (Tier 1)
SLEEP DISORDER AGENTS
+ MODAFINIL
Modafinil
TABLET
$0.00 - $2.55 (Tier 1)
PA
~ XYREM
Sodium Oxybate
ORAL SOLUTION
$0.00 - $6.35 (Tier 2)
PA
Zaleplon
Zaleplon
CAPSULE
$0.00 - $2.55 (Tier 1)
PA>65 yrs old
QL = Quantity limit
ST = Step Therapy
PART D
145
+ Baclofen
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
Zolpidem Tartrate
Zolpidem Tartrate
TABLET
WHAT THE DRUG WILL
NECESSARY ACTIONS,
$0.00 - $2.55 (Tier 1)
QL, PA>65 yrs old
SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS
ALPHA-ADRENERGIC BLOCKING AGENTS
+ Alfuzosin HCL
Alfuzosin HCL
TAB ER 24H
$0.00 - $2.55 (Tier 1)
QL
+ Tamsulosin HCL
Tamsulosin HCL
CAP ER 24H
$0.00 - $2.55 (Tier 1)
QL
+ Terazosin HCL
Terazosin HCL
CAPSULE
$0.00 - $2.55 (Tier 1)
VASODILATING AGENTS
VASODILATING AGENTS
+ ADCIRCA
Tadalafil
TABLET
$0.00 - $6.35 (Tier 2)
PA
EPOPROSTENOL SODIUM
Epoprostenol Sodium (Glycine)
INTRAVENOUS (IV)
$0.00 - $2.55 (Tier 1)
BvD
+ LETAIRIS
Ambrisentan
TABLET
$0.00 - $6.35 (Tier 2)
PA
+ REMODULIN
Treprostinil Sodium
INJECTION
$0.00 - $6.35 (Tier 2)
PA
REVATIO
Sildenafil Citrate
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
PA
+ADEMPAS
Riociguat
TABLET
$0.00 - $6.35 (Tier 2)
PA
Sildenafil
Sildenafil Citrate
TABLET
$0.00 - $2.55 (Tier 1)
PA
QL = Quantity limit
ST = Step Therapy
146
PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
~+ TRACLEER
Bosentan
TABLET
$0.00 - $6.35 (Tier 2)
PA
VELETRI
Epoprostenol Sodium (Arginine)
INTRAVENOUS (IV)
$0.00 - $6.35 (Tier 2)
BvD
TABLET
$0.00 - $2.55 (Tier 1)
VITAMINS AND MINERALS
+ Prenatal Plus
Pnv With Ca,No.72/Iron/Fa
VASODILATING AGENTS
QL = Quantity limit
ST = Step Therapy
PART D
147
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
ANALGESICS
ANALGESICS, MISCELLANEOUS
Acetaminophen
ORAL DROPS
$0.00 (Tier 3)
QL
*Acetaminophen 120 MG
Acetaminophen
SUPP.RECT
$0.00 (Tier 3)
QL
*Acetaminophen 160 MG/5ML
Acetaminophen
SOLUTION
$0.00 (Tier 3)
QL
*Acetaminophen 160MG/5ML
Acetaminophen
ELIXIR
$0.00 (Tier 3)
QL
*Acetaminophen 160MG/5ML
Acetaminophen
LIQUID
$0.00 (Tier 3)
QL
*Acetaminophen 325 MG
Acetaminophen
SUPP.RECT
$0.00 (Tier 3)
QL
*Acetaminophen 325MG
Acetaminophen
TABLET
$0.00 (Tier 3)
QL
Acetaminophen
TABLET
$0.00 (Tier 3)
QL
Acetaminophen
CAPSULE
$0.00 (Tier 3)
QL
Acetaminophen
SUPP.RECT
$0.00 (Tier 3)
QL
*Americet 325-40-50
Acetaminophen/Caffeine/Butalb
TABLET
$0.00 (Tier 3)
QL
*Children'S Q-Pap 160 MG/5ML
Acetaminophen
ORAL SUSP
$0.00 (Tier 3)
QL
*Infant'S Pain Relief 100 MG/ML
Acetaminophen
DROPS SUSP
$0.00 (Tier 3)
QL
*Infant'S Pain Relief 80MG/0.8ML
Acetaminophen
DROPS SUSP
$0.00 (Tier 3)
QL
*Mapap 500MG/15ML
Acetaminophen
LIQUID
$0.00 (Tier 3)
QL
*Non-Aspirin 160 MG
Acetaminophen
TAB CHEW
$0.00 (Tier 3)
QL
*Non-Aspirin 80 MG
Acetaminophen
TAB CHEW
$0.00 (Tier 3)
QL
ANALGESICS
*Acetaminophen 100 MG/ML
QL = Quantity limit
ST = Step Therapy
NON PART D
149
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Q-Pap 80MG/0.8ML
Acetaminophen
ORAL DROPS
$0.00 (Tier 3)
QL
*Tension Headache Relief 500MG-65MG
Acetaminophen/Caffeine
TABLET
$0.00 (Tier 3)
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
*Aspirin 300 MG
Aspirin
SUPP.RECT
$0.00 (Tier 3)
*Aspirin 325 MG
Aspirin
TABLET
$0.00 (Tier 3)
*Aspirin 500 MG
Aspirin
TABLET
$0.00 (Tier 3)
*Aspirin 600 MG
Aspirin
SUPP.RECT
$0.00 (Tier 3)
*Aspirin EC 325 MG
Aspirin
TABLET DR
$0.00 (Tier 3)
*Aspirin EC 500 MG
Aspirin
TABLET DR
$0.00 (Tier 3)
*Aspirin EC 650 MG
Aspirin
TABLET DR
$0.00 (Tier 3)
*Aspirin EC 81 MG
Aspirin
TABLET DR
$0.00 (Tier 3)
*Aspridrox 325 MG
ASA/Calcium Carb/Mag/Al Hydrox
TABLET
$0.00 (Tier 3)
*Buffered Aspirin 324 MG
Aspirin/Calcium Carbonate/Mag
TABLET
$0.00 (Tier 3)
*Cap-Profen 200 MG
Ibuprofen
TABLET
$0.00 (Tier 3)
*Children's Aspirin 81 MG
Aspirin
TAB CHEW
$0.00 (Tier 3)
*Children's Profen Ib 100 MG/5ML
Ibuprofen
ORAL SUSP
$0.00 (Tier 3)
*Ibuprofen 100 MG
Ibuprofen
TABLET
$0.00 (Tier 3)
*Ibuprofen 200 MG
Ibuprofen
CAPSULE
$0.00 (Tier 3)
*Ibuprofen IB 100 MG
Ibuprofen
TAB CHEW
$0.00 (Tier 3)
QL = Quantity limit
ST = Step Therapy
150
NON PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Infants Profenib 50 MG/1.25
Ibuprofen
DROPS SUSP
$0.00 (Tier 3)
*Migraine Formula 250-250-65
Aspirin/Acetaminophen/Caffeine
TABLET
$0.00 (Tier 3)
*Tri-Buffered Aspirin 325 MG
Aspirin/Calcium Carbonate/Mag
TABLET
$0.00 (Tier 3)
*Eq Nicotine Gum 2MG
Nicotine Polacrilex
GUM
$0.00 (Tier 3)
PA
*Nicotine Gum 4MG
Nicotine Polacrilex
GUM
$0.00 (Tier 3)
PA
*Nicotine Patch 14MG/24Hr
Nicotine
PATCH TD24
$0.00 (Tier 3)
PA
*Nicotine Patch 21 MG/24Hr
Nicotine
PATCH TD24
$0.00 (Tier 3)
PA
*Nicotine Transdermal 7MG/24Hr
Nicotine
PATCH TD24
$0.00 (Tier 3)
PA
ANTICHOLINERGIC AGENTS
ANALGESICS
ANTIMUSCARINICS/ANTISPASMODICS
*Belladonna-Phenobarbital 16.2 MG
Phenobarb/Hyoscy/Atropine/Scop
TABLET
$0.00 (Tier 3)
*Spasmolin 16.2MG
Belladonna Alkaloids/Phenobarb
TABLET
$0.00 (Tier 3)
Tioconazole
VAGINAL OINT/APPL $0.00 (Tier 3)
ANTIFUNGALS
ANTIFUNGALS
*1-Day 6.5 %
QL = Quantity limit
ST = Step Therapy
NON PART D
151
ANTIFUNGALS
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Antifungal 1 %
Clotrimazole
CREAM
$0.00 (Tier 3)
*Antifungal Cream 1 %
Tolnaftate
CREAM
$0.00 (Tier 3)
*Clotrimazole 3 2 %
Clotrimazole
VAGINAL CR/APPL
$0.00 (Tier 3)
*Clotrimazole-7 1 %
Clotrimazole
VAGINAL CR/APPL
$0.00 (Tier 3)
*Fungi-Guard 1 %
Tolnaftate
SOLUTION
$0.00 (Tier 3)
*Jock Itch 1 %
Terbinafine Hcl
CREAM
$0.00 (Tier 3)
*Micatin 2 %
Miconazole Nitrate
CREAM
$0.00 (Tier 3)
*Miconazole 7 2 %
Miconazole Nitrate
VAGINAL CR/APPL
$0.00 (Tier 3)
*Miconazole Nitrate 2 %
Miconazole Nitrate
SPRAY
$0.00 (Tier 3)
*Mycelex-7 100 MG
Clotrimazole
TABLET
$0.00 (Tier 3)
*Tolnaftate 1%
Tolnaftate
CREAM
$0.00 (Tier 3)
*Vaginal 3-Day 200 MG-1 %
Clotrimazole
VAGINAL COMBO. PKG $0.00 (Tier 3)
*Acta-Tabs 60-2.5MG
P-Ephed Hcl/Triprolidine Hcl
TABLET
$0.00 (Tier 3)
PA
*Aller-Chlor 2 MG/5 ML
Chlorpheniramine Maleate
SYRUP
$0.00 (Tier 3)
PA
*Aphedrid 60MG-2.5MG
Pseudoephedrine/Triprolidine
TABLET
$0.00 (Tier 3)
PA
*Brofed 30-4MG/5ML
Pseudoephedrine/Brompheniramin
SYRUP
$0.00 (Tier 3)
PA
ANTIHISTAMINES
ANTIHISTAMINES
QL = Quantity limit
ST = Step Therapy
152
NON PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Cetirizine 10 MG
Cetirizine Hcl
TABLET
$0.00 (Tier 3)
*Cetirizine Hcl 5 MG
Cetirizine Hcl
TABLET
$0.00 (Tier 3)
*Children's Allergy 12.5MG/5ML
Diphenhydramine HCL
LIQUID
$0.00 (Tier 3)
*Children's Cetirizine Hcl 1 MG/ML
Cetirizine Hcl
SOLUTION
$0.00 (Tier 3)
*Diphenhydramine 25 MG
Diphenhydramine HCL
CAPSULE
$0.00 (Tier 3)
PA
*Diphenhydramine 50 MG
Diphenhydramine HCL
CAPSULE
$0.00 (Tier 3)
PA
*Diphenhydramine Hcl 12.5MG/5ML
Diphenhydramine HCL
ELIXIR
$0.00 (Tier 3)
*Diphenhydramine Hcl 50 MG
Diphenhydramine HCL
TABLET
$0.00 (Tier 3)
PA
*Elixir 15-1MG/5ML
Pseudoephedrine/Brompheniramin
LIQUID
$0.00 (Tier 3)
*Fexofenadine HCL
Fexofenadine HCL
TABLET
$0.00 (Tier 3)
*Fexofenadine HCL
Fexofenadine HCL
TABLET
$0.00 (Tier 3)
*Loratadine
Loratadine
ORAL SOLUTION
$0.00 (Tier 3)
*Loratadine
Loratadine
TABLET
$0.00 (Tier 3)
*Silphen 12.5MG/5ML
Diphenhydramine HCL
SYRUP
$0.00 (Tier 3)
*Sleep Tablet 25MG
Diphenhydramine HCL
TABLET
$0.00 (Tier 3)
PA
*Triotann-S 5-12.5-2/5
Phenylephrine/Pyril Tan/Cp
ORAL SUSP
$0.00 (Tier 3)
PA
ANTIHISTAMINES
QL = Quantity limit
ST = Step Therapy
NON PART D
153
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Miconazole Nitrate
SUPP.VAG
$0.00 (Tier 3)
*Meclizine Hcl 12.5MG
Meclizine HCL
TABLET
$0.00 (Tier 3)
*Meclizine Hcl 25MG
Meclizine HCL
TAB CHEW
$0.00 (Tier 3)
*Travel Motion Sickness 25 MG
Meclizine HCL
TABLET
$0.00 (Tier 3)
IV SYRINGE
$0.00 (Tier 3)
PA
P-Ephed Hcl/Acetaminophen
TABLET
$0.00 (Tier 3)
*Niacin 1000 MG
Niacin
TABLET ER
$0.00 (Tier 3)
*Niacin 125 MG
Niacin
CAPSULE ER
$0.00 (Tier 3)
*Miconazole 7 100 MG
ANTINAUSEA AGENTS
ANTI-INFECTIVES (SKIN AND MUCOUS
ANTINAUSEA AGENTS
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
*Heparin Lock 100/ML (1)
Heparin Sodium,Porcine
CARDIOVASCULAR AGENTS, MISCELLANEOUS
*Sudafed Sinus 30MG-500MG
DYSLIPIDEMICS
QL = Quantity limit
ST = Step Therapy
154
NON PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Niacin 250 MG
Niacin
CAPSULE ER
$0.00 (Tier 3)
*Niacin 250 MG
Niacin
TABLET
$0.00 (Tier 3)
*Niacin 250 MG
Niacin
TABLET ER
$0.00 (Tier 3)
*Niacin 400 MG
Niacin
CAPSULE ER
$0.00 (Tier 3)
*Niacin 50 MG
Niacin
TABLET
$0.00 (Tier 3)
*Niacin 500 MG
Niacin
TABLET ER
$0.00 (Tier 3)
*Niacin 500 MG
Niacin
CAPSULE ER
$0.00 (Tier 3)
*Niacin 500 MG
Niacin
TABLET
$0.00 (Tier 3)
*Niacin 750 MG
Niacin
TABLET ER
$0.00 (Tier 3)
CONTRACEPTIVES (E.G., FOAMS, DEVICES)
*FC Condom, Female N/A
Condoms, Female
EACH
$0.00 (Tier 3)
QL
*Lifestyles Xs N/A
Condoms, Latex, Non-Lubricated
EACH
$0.00 (Tier 3)
QL
*ORTHO ALL-FLEX 65MM
VAGINAL KIT
$0.00 (Tier 3)
QL
VAGINAL KIT
$0.00 (Tier 3)
QL
VAGINAL KIT
$0.00 (Tier 3)
QL
VAGINAL KIT
$0.00 (Tier 3)
QL
*Reality N/A
Condoms, Latex, Lubricated
EACH
$0.00 (Tier 3)
QL
QL = Quantity limit
ST = Step Therapy
NON PART D
155
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Trojan Naturalamb N/A
Condoms, Non-Latex, Non-Lubri
EACH
$0.00 (Tier 3)
QL
*Trojan Supra Na
Condoms, Non-Latex, Lubricated
EACH
$0.00 (Tier 3)
QL
*Vcf 12.5%
Nonoxynol 9
VAGINAL FOAM/APPL $0.00 (Tier 3)
COUGH AND COLD PRODUCTS
*Antitussive Dm 100-15MG/5
Guaifenesin/Dextromethorphan
SYRUP
$0.00 (Tier 3)
*Benzonatate 100 MG
Benzonatate
CAPSULE
$0.00 (Tier 3)
*Benzonatate 200 MG
Benzonatate
CAPSULE
$0.00 (Tier 3)
*Brotapp Dm 5-15-1MG/5
D-Methorphan Hb/P-Epd Hcl/Bpm
ELIXIR
$0.00 (Tier 3)
*Children'S Silfedrine 15 MG/5 ML
Pseudoephedrine Hcl
LIQUID
$0.00 (Tier 3)
*Childs Allergy 5-15-1MG/5
D-Methorphan Hb/P-Ephed Hcl/Cp
LIQUID
$0.00 (Tier 3)
*Guaifenesin 100MG/5ML
Guaifenesin
LIQUID
$0.00 (Tier 3)
*Guaifenesin Er 600 MG
Guaifenesin
TABLET ER
$0.00 (Tier 3)
*Guaifenesin 100MG/5ML
Guaifenesin
SYRUP
$0.00 (Tier 3)
*Hydrocodone Cp 5-2.5-2
Phenylephrine/Hydrocodone/Cp
SYRUP
$0.00 (Tier 3)
*Infant Decongestant 9.4MG/ML
Pseudoephedrine Hcl
ORAL DROPS
$0.00 (Tier 3)
*Kosher Care Dm 100-10MG/5
LIQUID
$0.00 (Tier 3)
LIQUID
$0.00 (Tier 3)
*Nasal Decon (Pseudoephedrine) 30 MG/5 ML Pseudoephedrine Hcl
QL = Quantity limit
ST = Step Therapy
156
NON PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
LIQUID
$0.00 (Tier 3)
*Non-Asa Sinus 30MG-500MG
Pseudoephedrine/Acetaminophen
TABLET
$0.00 (Tier 3)
*Pedia Relief 2.5-7.5/.8
Dextromethorphan/Pseudoephed
ORAL DROPS
$0.00 (Tier 3)
*Phenylhistine Dh 30-10-2/5
P-Ephed Hcl/Cod/Chlorphenir
LIQUID
$0.00 (Tier 3)
PA
*Profed 600MG-60MG
Guaifenesin/P-Ephed Hcl
TAB.SR 12H
$0.00 (Tier 3)
*Promethazine Vc-Codeine 6.25-5-10
Promethazine/Phenyleph/Codeine
SYRUP
$0.00 (Tier 3)
PA
*Promethazine W/Codeine 6.25-10/5
Promethazine Hcl/Codeine
SYRUP
$0.00 (Tier 3)
QL, PA
*Promethazine-Dm 15-6.25/5
D-Methorphan Hb/Prometh Hcl
SYRUP
$0.00 (Tier 3)
PA
*Pseudoephedrine 120 MG
Pseudoephedrine Hcl
TABLET ER
$0.00 (Tier 3)
*Pseudogest 30MG/5ML
Pseudoephedrine Hcl
SYRUP
$0.00 (Tier 3)
*Sudogest 60 MG
Pseudoephedrine Hcl
TABLET
$0.00 (Tier 3)
*Suphedrine Sinus Congestion 30 MG
Pseudoephedrine Hcl
TABLET
$0.00 (Tier 3)
*Tussin Dm 100-10MG/5
SYRUP
$0.00 (Tier 3)
*Tussin Max Strength Cough/Cold 15-30MG/5 Dextromethorphan/Pseudoephed
LIQUID
$0.00 (Tier 3)
*Virtussin Ac 100-10MG/5
LIQUID
$0.00 (Tier 3)
GEL
$0.00 (Tier 3)
Guaifenesin/Codeine Phosphate
*Neo-Tuss 200-30MG/5
DERMATOLOGICAL AGENTS, OTHER
*Acneclear 10 %
Benzoyl Peroxide
QL = Quantity limit
ST = Step Therapy
NON PART D
157
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Amlactin 12 %
Ammonium Lactate
LOTION
$0.00 (Tier 3)
*Anti-Itch 2 %
Diphenhydramine HCL
CREAM
$0.00 (Tier 3)
*Anti-Itch 2 %-0.1 %
Diphenhydramine HCL/Zinc Acet
CREAM
$0.00 (Tier 3)
*Benzoyl Peroxide 10 %
Benzoyl Peroxide
TOP CLEANSER
$0.00 (Tier 3)
*Benzoyl Peroxide 5 %
Benzoyl Peroxide
TOP CLEANSER
$0.00 (Tier 3)
*Caldyphen 1 %-8 %
Pramoxine Hcl/Calamine
LOTION
$0.00 (Tier 3)
*Calohist N/A
Diphenhydramine HCL/Calamine
LOTION
$0.00 (Tier 3)
*Chlorhexidine Gluconate 4 %
TOPICAL LIQUID
$0.00 (Tier 3)
*Clear Medicated Lotion N/A
Pramoxine Hcl/Camph/Zinc Acet
LOTION
$0.00 (Tier 3)
*D.R. Benzide 5%
Benzoyl Peroxide
GEL
$0.00 (Tier 3)
*Geri-Hydrolac 12 %
Ammonium Lactate
CREAM
$0.00 (Tier 3)
*Scalp Itch-Dandruff Relief 3 %
Salicylic Acid
TOPICAL LIQUID
$0.00 (Tier 3)
*T-Gel 1 %
Coal Tar
SHAMPOO
$0.00 (Tier 3)
*Urogesic 95MG
Phenazopyridine Hcl
TABLET
$0.00 (Tier 3)
DERMATOLOGICAL ANTIBACTERIALS
*Antibiotic Plus 3.5-10K-10
Neomy Sulf/Polymyx B Sulf/Pram
CREAM
$0.00 (Tier 3)
*Bacitracin 500 Unit/G
Bacitracin
OINT.
$0.00 (Tier 3)
*Bacitracin 500 Unit/G
Bacitracin
PACKET
$0.00 (Tier 3)
*Poly Bacitracin 500-10K/G
Bacitracin/Polymyxin B Sulfate
OINT.
$0.00 (Tier 3)
QL = Quantity limit
ST = Step Therapy
158
NON PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Triple Antibiotic 3.5-400-5K
Neomy Sulf/Bacitrac Zn/Poly
OINT.
$0.00 (Tier 3)
*Triple Antibiotic Plus 3.5-10K-10
Neomycn/Baci Zn/Pmyx Bs/Pramox
OINT.
$0.00 (Tier 3)
DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS
*Anusert Hc-1 1 %
RECTAL OINT.
$0.00 (Tier 3)
*Cortisone 1 %
Hydrocortisone/Aloe Vera
CREAM
$0.00 (Tier 3)
*Cortizone-10 1 %
Hydrocortisone
OINT.
$0.00 (Tier 3)
*Hydrocortisone 0.5 %
Hydrocortisone
LOTION
$0.00 (Tier 3)
Hydrocortisone
OINT.
$0.00 (Tier 3)
Hydrocortisone
CREAM
$0.00 (Tier 3)
*Hydrocortisone 1 %
OINT.
$0.00 (Tier 3)
*Hydrocortisone 1 %
Hydrocortisone
LOTION
$0.00 (Tier 3)
*Hydrocortisone Acetate 0.5 %
CREAM
$0.00 (Tier 3)
*Hydrocortisone Acetate 0.5%
LOTION
$0.00 (Tier 3)
*Medi-Cortisone 1 %
CREAM
$0.00 (Tier 3)
*Noble Formula Hc 1 %
Hydrocortisone
CREAM
$0.00 (Tier 3)
*Lice Solution 4-.33-.5%
Pip Butox/Pyrethrins/Permeth
TOPIACAL KIT
$0.00 (Tier 3)
*Permethrin 1 %
Permethrin
TOPICAL LIQUID
$0.00 (Tier 3)
*Pyrethrin Lice Treatment N/A
Piperonyl Butoxide/Pyrethrins
TOPICAL LIQUID
$0.00 (Tier 3)
SCABICIDES AND PEDICULICIDES
QL = Quantity limit
ST = Step Therapy
NON PART D
159
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Rid 0.5 %
Permethrin
SPRAY
$0.00 (Tier 3)
*Rid 4%-0.33%
Piperonyl Butoxide/Pyrethrins
SHAMPOO
$0.00 (Tier 3)
*ORTHO ALL-FLEX N/A
Diaphragm Fitting Set,Arcsprng
EACH
$0.00 (Tier 3)
QL
*VORTEX FROG MASK N/A
Inhaler,Assist Device,Accesory
EACH
$0.00 (Tier 3)
QL
*VORTEX N/A
Inhaler, Assist Devices
SPACER
$0.00 (Tier 3)
QL
OTIC DROPS
$0.00 (Tier 3)
DEVICES
DEVICES
EYE, EAR, NOSE, THROAT ANTI-INFECTIVES AGENTS
*Ear System 6.5 %
Carbamide Peroxide
EYE, EAR, NOSE, THROAT DRUGS, MISCELLANEOUS
*Alconefrin 25 0.25 %
Phenylephrine Hcl
NASAL DROPS
$0.00 (Tier 3)
*Alconefrin 50 0.5 %
Phenylephrine Hcl
NASAL DROPS
$0.00 (Tier 3)
*Allergy Eye 0.025 %
Ketotifen Fumarate
OTIC DROPS
$0.00 (Tier 3)
*Altachlore 5 %
Sodium Chloride
OPHTHALMIC DROPS $0.00 (Tier 3)
*Altafrin 0.12 %
Phenylephrine Hcl
*Little Noses 0.125 %
Phenylephrine Hcl
NASAL DROPS
$0.00 (Tier 3)
QL = Quantity limit
ST = Step Therapy
160
NON PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Muro-128 2 %
Sodium Chloride
*Nose Drops 1 %
Phenylephrine Hcl
NASAL DROPS
$0.00 (Tier 3)
*Nu-Way 1 %
Phenylephrine Hcl
SPRAY
$0.00 (Tier 3)
ANTIFLATULENTS
Simethicone
CAPSULE
$0.00 (Tier 3)
*Gas Relief 125 MG
Simethicone
CAPSULE
$0.00 (Tier 3)
*Gas Relief 125 MG
Simethicone
TAB CHEW
$0.00 (Tier 3)
*Gas Relief 40MG/0.6ML
Simethicone
DROPS SUSP
$0.00 (Tier 3)
*Gas Relief 80 MG
Simethicone
TAB CHEW
$0.00 (Tier 3)
*Major-Con 40MG/0.6ML
Simethicone
ORAL DROPS
$0.00 (Tier 3)
*Anti-Gas 166MG
ANTIULCER AGENTS AND ACID SUPPRESSANTS
*+ Acid Control 150 MG
Ranitidine Hcl
TABLET
$0.00 (Tier 3)
*+ Acid Controller 10 MG
Famotidine
TABLET
$0.00 (Tier 3)
*+ Acid Controller 20 MG
Famotidine
TABLET
$0.00 (Tier 3)
*+ Cimetidine 200 MG
Cimetidine
TABLET
$0.00 (Tier 3)
*+ Lansoprazole 15 MG
Lansoprazole
CAPSULE DR
$0.00 (Tier 3)
*+ Omeprazole Magnesium 20 MG
Omeprazole Magnesium
CAPSULE DR
$0.00 (Tier 3)
QL = Quantity limit
ST = Step Therapy
NON PART D
161
BRAND DRUG NAME
GENERIC DRUG NAME
*+ Ranitidine Hcl 75 MG
FORMULATION
Ranitidine Hcl
WHAT THE DRUG WILL
NECESSARY ACTIONS,
TABLET
$0.00 (Tier 3)
GASTROINTESTINAL AGENTS, OTHER
*Aluminum Hydroxide 320MG/5ML
Aluminum Hydroxide
ORAL SUSP
$0.00 (Tier 3)
*Aluminum Hydroxide 600MG/5ML
Aluminum Hydroxide
ORAL SUSP
$0.00 (Tier 3)
*Antacid 200(500)MG
Calcium Carbonate
TAB CHEW
$0.00 (Tier 3)
*Antacid 200-225/5
Magnesium Hydroxide/Al Hydrox
ORAL SUSP
$0.00 (Tier 3)
*Antacid 750MG
Calcium Carbonate
TAB CHEW
$0.00 (Tier 3)
*Antacid Extra Strength 300MG(750)
Calcium Carbonate
TAB CHEW
$0.00 (Tier 3)
*Antacid Tablet 20-80MG
Mg Trisilicate/Alh/Nahco3/Aa
TAB CHEW
$0.00 (Tier 3)
*Anti-Diarrheal 2 MG
Loperamide HCL
CAPSULE
$0.00 (Tier 3)
*Anti-Diarrheal 2MG
Loperamide HCL
TABLET
$0.00 (Tier 3)
*Calcium 500 MG-100
Calcium Carbonate/Vitamin D3
TAB CHEW
$0.00 (Tier 3)
*Calcium 500(1250)
Calcium Carbonate
TAB CHEW
$0.00 (Tier 3)
*Children's Pepto 400 MG
Calcium Carbonate
TAB CHEW
$0.00 (Tier 3)
*Fast-Acting Heartburn Relief 237.5-254
Mag Carb/Al Hydrox/Alginic Ac
ORAL SUSP
$0.00 (Tier 3)
*Foaming Antacid Max Strength 105-160MG Magnesium Carbonate/Al Hydrox
TAB CHEW
$0.00 (Tier 3)
*Ka-Pec 750MG/15ML
Attapulgite
ORAL SUSP
$0.00 (Tier 3)
*Liquid Antacid 200-200-20
Mag Hydrox/Al Hydrox/Simeth
ORAL SUSP
$0.00 (Tier 3)
*Liquid Antacid 400-400-40
ORAL SUSP
$0.00 (Tier 3)
QL = Quantity limit
ST = Step Therapy
162
NON PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
Loperamide HCL
LIQUID
$0.00 (Tier 3)
*Loperamide Hcl 1MG/5ML
Loperamide HCL
LIQUID
$0.00 (Tier 3)
*Maldroxal Antacid-Anti-Gas 450-500-40
ORAL SUSP
$0.00 (Tier 3)
*Masanti Antacid 311-232MG
Calcium Carbonate/Mag Carb
TABLET
$0.00 (Tier 3)
*Pink Bismuth 262 MG
Bismuth Subsalicylate
TABLET
$0.00 (Tier 3)
*Pink Bismuth 262MG
TAB CHEW
$0.00 (Tier 3)
*Pink Bismuth 525MG/15ML
ORAL SUSP
$0.00 (Tier 3)
*Riginic 131-31.7/5
Mag Carb/Al Hydrox/Alginic Ac
ORAL SUSP
$0.00 (Tier 3)
*Ri-Mag 540MG/5ML
Magaldrate
ORAL SUSP
$0.00 (Tier 3)
*Sodium Bicarbonate 325 MG
Sodium Bicarbonate
TABLET
$0.00 (Tier 3)
*Sodium Bicarbonate 650 MG
Sodium Bicarbonate
TABLET
$0.00 (Tier 3)
*Child Suppository Pediatric
Glycerin
SUPP.RECT
$0.00 (Tier 3)
*Colace 50 MG
Docusate Sodium
CAPSULE
$0.00 (Tier 3)
*Duosol 250MG
Docusate Sodium
CAPSULE
$0.00 (Tier 3)
*Laxa Clear 17G/Dose
ORAL POWDER
$0.00 (Tier 3)
QL
*Laxative Suppository 10 MG
Bisacodyl
SUPP.RECT
$0.00 (Tier 3)
*Magnesium Citrate N/A
Magnesium Citrate
SOLUTION
$0.00 (Tier 3)
*Silace 50 MG/5 ML
Docusate Sodium
LIQUID
$0.00 (Tier 3)
*Loperamide 1MG/7.5ML
LAXATIVES
QL = Quantity limit
ST = Step Therapy
NON PART D
163
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Stool Softener 100MG
Docusate Sodium
CAPSULE
$0.00 (Tier 3)
*Stool Softener 60 MG/15ML
Docusate Sodium
SYRUP
$0.00 (Tier 3)
*Suppository Adult
Glycerin
SUPP.RECT
$0.00 (Tier 3)
*Woman's Laxative 5 MG
Bisacodyl
TABLET DR
$0.00 (Tier 3)
*Calcium 500 + Vitamin D 500 MG-125
TABLET
$0.00 (Tier 3)
*Calcium 600 MG
Calcium Carbonate
TABLET
$0.00 (Tier 3)
*Calcium Carbonate 648 MG
Calcium Carbonate
TABLET
$0.00 (Tier 3)
*Calcium Gluconate 45(500) MG
Calcium Gluconate
TABLET
$0.00 (Tier 3)
Calcium Gluconate
TABLET
$0.00 (Tier 3)
Calcium Gluconate
TABLET
$0.00 (Tier 3)
*Calcium Lactate 650 MG
Calcium Lactate
TABLET
$0.00 (Tier 3)
*Calcium Lactate 85 MG(650)
Calcium Lactate
TABLET
$0.00 (Tier 3)
*Calcium With Vitamin D 600 MG-400
TABLET
$0.00 (Tier 3)
*Hi-Calcium 1.25G
Calcium Carbonate
TABLET
$0.00 (Tier 3)
*Mag-G 27 MG(500)
Magnesium Gluconate
TABLET
$0.00 (Tier 3)
*Magnesium 300 MG
Magnesium Oxide/Mag Aa Chelate
CAPSULE
$0.00 (Tier 3)
QL = Quantity limit
ST = Step Therapy
164
NON PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Oralyte N/A
Electrolyte,Oral
SOLUTION
$0.00 (Tier 3)
QL
*Oyster Shell Calcium 500(1250)
Calcium Carbonate
TABLET
$0.00 (Tier 3)
*Oyster Shell Calcium W/Vit D 500 MG-125
TABLET
$0.00 (Tier 3)
*Oyster Shell Calcium W-Vit D 250 MG-125
TABLET
$0.00 (Tier 3)
TABLET
$0.00 (Tier 3)
TABLET
$0.00 (Tier 3)
*Oyster Shell Calcium-Vitamin D 500 MG-400 Calcium Carbonate/Vitamin D3
TABLET
$0.00 (Tier 3)
*Potassium Gluconate 595(99)MG
Potassium Gluconate
TABLET
$0.00 (Tier 3)
*Sodium Chloride 0.9 %
Bacteriostatic Sodium Chloride
INJECTION VIAL
$0.00 (Tier 3)
Cromolyn Sodium
SPRAY/PUMP
$0.00 (Tier 3)
*Ascorbic Acid 100MG
Ascorbic Acid
TABLET
$0.00 (Tier 3)
*B-12 Dots 500 Mcg
Cyanocobalamin (Vitamin B-12)
TABLET
$0.00 (Tier 3)
*Children's Iron 15 MG/ML
Ferrous Sulfate
ORAL DROPS
$0.00 (Tier 3)
*Ergocalciferol 8000/ML
Ergocalciferol (Vitamin D2)
ORAL DROPS
$0.00 (Tier 3)
RESPIRATORY TRACT AGENTS, OTHER
*Nasal Allergy Spray 5.2 MG
QL = Quantity limit
ST = Step Therapy
NON PART D
165
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Ferosul 220(44)/5
Ferrous Sulfate
SOLUTION
$0.00 (Tier 3)
*Ferrous Sulfate 134MG
Ferrous Sulfate
TABLET
$0.00 (Tier 3)
*Ferrous Sulfate 15MG/0.6ML
Ferrous Sulfate
ORAL DROPS
$0.00 (Tier 3)
*Ferrous Sulfate 220MG/5ML
Ferrous Sulfate
ELIXIR
$0.00 (Tier 3)
*Ferrous Sulfate 250 MG
Ferrous Sulfate
CAPSULE ER
$0.00 (Tier 3)
*Ferrous Sulfate 300MG/5ML
Ferrous Sulfate
LIQUID
$0.00 (Tier 3)
*Ferrous Sulfate 324(65)MG
Ferrous Sulfate
TABLET DR
$0.00 (Tier 3)
*Ferrous Sulfate 325(65) MG
Ferrous Sulfate
TABLET DR
$0.00 (Tier 3)
*Fluoride 0.25(0.55)
Sodium Fluoride
TAB CHEW
$0.00 (Tier 3)
*Folic Acid 0.4 MG
Folic Acid
TABLET
$0.00 (Tier 3)
*Folic Acid 0.8 MG
Folic Acid
TABLET
$0.00 (Tier 3)
*Folic Acid 1 MG
Folic Acid
TABLET
$0.00 (Tier 3)
*Iron 325(65) MG
Ferrous Sulfate
TABLET
$0.00 (Tier 3)
*Iron 325(65) MG
Ferrous Sulfate
CAPSULE ER
$0.00 (Tier 3)
*Niacin 100MG
Niacin
TABLET
$0.00 (Tier 3)
*Niacin 250MG
Niacin
CAPSULE SA
$0.00 (Tier 3)
*Niacin 500MG
Niacin
CAPSULE SA
$0.00 (Tier 3)
*Niacin 50MG
Niacin
TABLET
$0.00 (Tier 3)
*Perry Prenatal 13.5-0.4MG
PNV With Ca No.36/Iron/Fa
CAPSULE
$0.00 (Tier 3)
QL = Quantity limit
ST = Step Therapy
166
NON PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
PNV No.118/Iron Fumarate/Fa
TAB CHEW
$0.00 (Tier 3)
*Prenatal 28MG-0.8MG
PNV95/Ferrous Fumarate/Fa
TABLET
$0.00 (Tier 3)
*Prenatal Formula 28MG-0.8MG
Prenatal Vit/Iron Fumarate/Fa
TABLET
$0.00 (Tier 3)
*Prenatal Vitamin N/A
Prenatal Vits W-Ca,Fe,Fa(<1Mg)
TABLET
$0.00 (Tier 3)
*Prenatal Vitamins 60MG-0.8MG
Prenatal Vit/Iron Fumarate/Fa
TABLET
$0.00 (Tier 3)
*Pyri 500 500 MG
Pyridoxine Hcl
TABLET ER
$0.00 (Tier 3)
*Pyridoxine Hcl 500 MG
Pyridoxine Hcl
TABLET
$0.00 (Tier 3)
*Right Step Prenatal Vitamins 27MG-0.8MG Prenatal Vit/Iron Fumarate/Fa
TABLET
$0.00 (Tier 3)
*Slow Release Iron 47.5 Iron
Ferrous Sulfate
TABLET ER
$0.00 (Tier 3)
*Tri-Vitamin 1500-35/ML
Pedi Multivits A,C,&D3 No.21
ORAL DROPS
$0.00 (Tier 3)
*Vitamin A 10000 Unit
Vitamin A
CAPSULE
$0.00 (Tier 3)
Vitamin A
TABLET
$0.00 (Tier 3)
Vitamin A
CAPSULE
$0.00 (Tier 3)
Vitamin A
CAPSULE
$0.00 (Tier 3)
*Vitamin B-12 1000 Mcg
Cyanocobalamin (Vitamin B-12)
TABLET
$0.00 (Tier 3)
*Vitamin B-6 100MG
Pyridoxine Hcl
TABLET
$0.00 (Tier 3)
*Vitamin B-6 200 MG
Pyridoxine Hcl
TABLET ER
$0.00 (Tier 3)
*Vitamin B-6 200 MG
Pyridoxine Hcl
TABLET
$0.00 (Tier 3)
*Vitamin B-6 250 MG
Pyridoxine Hcl
TABLET
$0.00 (Tier 3)
*Prenatal 19 29 MG-1 MG
QL = Quantity limit
ST = Step Therapy
NON PART D
167
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Vitamin B-6 25MG
Pyridoxine Hcl
TABLET
$0.00 (Tier 3)
*Vitamin B-6 50 MG
Pyridoxine Hcl
TABLET
$0.00 (Tier 3)
*Vitamin B-6 50MG
Pyridoxine Hcl
TABLET
$0.00 (Tier 3)
*Vitamin C 100 MG
Ascorbic Acid
TAB CHEW
$0.00 (Tier 3)
*Vitamin C 1000 MG
Ascorbic Acid
TAB CHEW
$0.00 (Tier 3)
*Vitamin C 1000 MG
Ascorbic Acid
TABLET ER
$0.00 (Tier 3)
*Vitamin C 1500 MG
Ascorbic Acid
TABLET ER
$0.00 (Tier 3)
*Vitamin C 250 MG
Ascorbic Acid/Ascorbate Sodium
TAB CHEW
$0.00 (Tier 3)
*Vitamin C 250 MG
Ascorbic Acid
TAB CHEW
$0.00 (Tier 3)
*Vitamin C 250 MG
Ascorbic Acid
TABLET
$0.00 (Tier 3)
*Vitamin C 300 MG
Ascorbic Acid
TAB CHEW
$0.00 (Tier 3)
*Vitamin C 500 MG
Ascorbic Acid
CAPSULE ER
$0.00 (Tier 3)
*Vitamin C 500 MG
Ascorbic Acid
TABLET
$0.00 (Tier 3)
*Vitamin C 500 MG
Ascorbic Acid
TAB CHEW
$0.00 (Tier 3)
*Vitamin C 500 MG
Ascorbic Acid
TABLET ER
$0.00 (Tier 3)
*Vitamin C 500 MG/5ML
Ascorbic Acid
SYRUP
$0.00 (Tier 3)
*Vitamin D 1000 Unit
Cholecalciferol (Vitamin D3)
TABLET
$0.00 (Tier 3)
*Vitamin D 400 Unit
TABLET
$0.00 (Tier 3)
*Vitamin D 400 Unit
CAPSULE
$0.00 (Tier 3)
QL = Quantity limit
ST = Step Therapy
168
NON PART D
BRAND DRUG NAME
GENERIC DRUG NAME
FORMULATION
WHAT THE DRUG WILL
NECESSARY ACTIONS,
*Vitamin D2 400 Unit
TABLET
$0.00 (Tier 3)
*Vitamin D2 50000 Unit
CAPSULE
$0.00 (Tier 3)
*Vitamin K 100 Mcg
Phytonadione
TABLET
$0.00 (Tier 3)
QL = Quantity limit
ST = Step Therapy
NON PART D
169
Index of Drugs
+
+ MYFORTIC.................................................. 127
1
1-DAY 6.5 % ................................................... 151
8
8-MOP ............................................................ 105
A
ABACAVIR ....................................................... 78
ABACAVIR/LAMIVUDINE/
ZIDOVUDINE ................................................... 78
ABELCET ......................................................... 66
ABILIFY ...................................................... 19, 75
ABILIFY DISCMELT ......................................... 75
ABILIFY DISCMELT 10MG .............................. 19
ABILIFY DISCMELT 15MG .............................. 19
ABILIFY MAINTENA ........................................ 75
ACAMPROSATE CALCIUM ............................. 38
ACARBOSE ..................................................... 62
ACARBOSE 100MG ......................................... 19
ACARBOSE 25MG ........................................... 19
ACARBOSE 50MG ........................................... 19
ACEBUTOLOL HCL ......................................... 90
ACETAMINOPHEN 100 MG/ML .............. 19, 149
ACETAMINOPHEN 120 MG .....................19, 149
ACETAMINOPHEN 160 MG/5ML .............19, 149
ACETAMINOPHEN 160MG/5ML ..............19, 149
ACETAMINOPHEN 325 MG .....................19, 149
ACETAMINOPHEN 325MG ......................19, 149
ACETAMINOPHEN W/CODEINE .....................19
ACETAMINOPHEN-CODEINE ...................19, 33
ACETASOL HC .............................................. 114
ACETAZOLAMIDE .........................................138
ACID CONTROL 150 MG ...............................161
ACID CONTROLLER 10 MG ..........................161
ACID CONTROLLER 20 MG ..........................161
ACNECLEAR 10 % .........................................157
ACTA-TABS 60-2.5MG ...................................152
ACTHIB ...........................................................130
ACTIMMUNE ..................................................135
ACTONEL .......................................................134
ACTONEL 150MG ............................................20
ACTONEL 35MG ..............................................20
ACTONEL 5MG ................................................20
ACYCLOVIR .....................................................20
ACYCLOVIR .....................................................82
ACYCLOVIR ...................................................105
ACYCLOVIR SODIUM ..................................... 83
ADACEL ......................................................... 130
ADAGEN .........................................................112
ADAPALENE ...................................................111
ADCETRIS ....................................................... 48
ADCIRCA ....................................................... 146
ADEFOVIR DIPIVOXIL .................................... 83
ADVAIR DISKUS ..................................... 20, 142
ADVAIR HFA .................................................. 142
ADVAIR HFA 120 ACTU .................................. 20
ADVAIR HFA 60 ACTU .................................... 20
AFATINIB DIMALEATE .................................... 48
AFEDITAB CR ................................................. 94
AFINITOR ........................................................ 48
AGGRENOX .................................................... 85
A-HYDROCORT ............................................ 123
ALBENZA ......................................................... 72
ALBUTEROL SULFATE ................................. 143
ALCLOMETASONE
DIPROPIONATE ............................................ 107
ALCONEFRIN 25 0.25 % ............................... 160
ALCONEFRIN 50 0.5 % ................................. 160
ALDURAZYME ................................................112
ALENDRONATE SODIUM ............................. 134
ALENDRONATE SODIUM 35MG,
70MG ............................................................... 20
171
Index of Drugs
ALENDRONATE SODIUM 5MG,
10MG, 40MG .................................................... 20
ALFUZOSIN HCL ..................................... 20, 146
ALIMTA ............................................................ 48
ALINIA .............................................................. 72
ALLER-CHLOR 2 MG/5 ML ........................... 152
ALLERGY EYE 0.025 % ................................ 160
ALLOPURINOL .............................................. 135
ALORA ........................................................... 122
ALPHAGAN P .......................................... 20, 138
ALPRAZOLAM ................................................. 39
ALPRAZOLAM 0.25MG, 0.5MG,
1MG .................................................................. 20
ALPRAZOLAM 2MG ........................................ 20
ALTACHLORE 5 % ........................................ 160
ALTAFRIN 0.12 % .......................................... 160
ALTAVERA ....................................................... 99
ALUMINUM HYDROXIDE 320MG/
5ML ................................................................ 162
ALUMINUM HYDROXIDE 600MG/
5ML ................................................................ 162
ALYACEN ......................................................... 99
AMANTADINE .................................................. 73
AMBISOME ...................................................... 66
AMCINONIDE ................................................ 107
AMERICET 325-40-50 ............................. 20, 149
AMIFOSTINE ..................................................136
AMIKACIN SULFATE .......................................40
AMILORIDE HCL ..............................................94
AMILORIDEHYDROCHLOROTHIAZIDE .............................94
AMINOCAPROIC ACID ....................................85
AMINOPHYLLINE ...........................................143
AMINOSYN .......................................................86
AMINOSYN II ....................................................86
AMINOSYN-HBC ..............................................86
AMINOSYN-PF .................................................86
AMIODARONE HCL .........................................89
AMITIZA .......................................................... 119
AMITRIPTYLINE HCL ......................................59
AMLACTIN 12 % ............................................158
AMLODIPINE BESYLATE ................................94
AMLODIPINE BESYLATEBENAZEPRIL .............................................20, 94
AMMONIUM LACTATE ..................................105
AMOX TR-POTASSIUM
CLAVULANATE ................................................44
AMOXAPINE ....................................................59
AMOXICILLIN ...................................................44
AMPHETAMINE SALT COMBO .......................98
AMPHOTERICIN B ...........................................66
AMPICILLIN SODIUM ......................................45
AMPICILLIN TRIHYDRATE ............................. 45
AMPICILLIN-SULBACTAM .............................. 45
AMPYRA .......................................................... 98
ANACAINE ..................................................... 105
ANADROL-50 ................................................. 122
ANAGRELIDE HCL .......................................... 85
ANASTROZOLE .............................................. 48
ANDRODERM ................................................ 122
ANDROID ....................................................... 122
ANDROXY ..................................................... 122
ANTACID 200(500)MG .................................. 162
ANTACID 200-225/5 ...................................... 162
ANTACID 750MG ........................................... 162
ANTACID EXTRA STRENGTH
300MG(750) ................................................... 162
ANTACID TABLET 20-80MG ......................... 162
ANTIBIOTIC PLUS 3.5-10K-10 ...................... 158
ANTI-DIARRHEAL 2 MG ............................... 162
ANTI-DIARRHEAL 2MG ................................ 162
ANTIFUNGAL 1 % ......................................... 152
ANTIFUNGAL CREAM 1 % ........................... 152
ANTI-GAS 166MG ......................................... 161
ANTI-ITCH 2 % .............................................. 158
ANTI-ITCH 2 %-0.1 % .................................... 158
ANTITUSSIVE DM 100-15MG/5 .................... 156
172
Index of Drugs
ANTIVENIN LATRODECTUS
MACTANS ...................................................... 127
ANTIVENIN MICRURUS FULVIUS ................ 127
ANUSERT HC-1 1 % ...................................... 159
APEXICON E ................................................. 108
APHEDRID 60MG-2.5MG .............................. 152
APOKYN .......................................................... 73
APRI ................................................................. 99
APTIVUS .......................................................... 78
ARANELLE ....................................................... 99
ARANESP ........................................................ 84
ARCALYST .................................................... 127
ARZERRA ........................................................ 48
ASCOMP WITH CODEINE ........................ 20, 33
ASCORBIC ACID 100MG .............................. 165
ASMANEX ...................................................... 142
ASPIRIN 300 MG ........................................... 150
ASPIRIN 325 MG ........................................... 150
ASPIRIN 500 MG ........................................... 150
ASPIRIN 600 MG ........................................... 150
ASPIRIN EC 325 MG ..................................... 150
ASPIRIN EC 500 MG ..................................... 150
ASPIRIN EC 650 MG ..................................... 150
ASPIRIN EC 81 MG ....................................... 150
ASPRIDROX 325 MG .................................... 150
ASTAGRAF XL ...............................................127
ATELVIA ...................................................20, 134
ATENOLOL .......................................................90
ATENOLOL-CHLORTHALIDONE ....................90
ATGAM ...........................................................127
ATORVASTATIN CALCIUM .............................95
ATOVAQUONE-PROGUANIL HCL ..................72
ATRIPLA ...........................................................78
ATROVENT HFA ............................................143
AUBAGIO .......................................................127
AUVI-Q .............................................................92
AVANDIA ..........................................................65
AVASTIN ..........................................................48
AVELOX ...........................................................46
AVELOX ABC PACK ........................................46
AVIANE .............................................................99
AVODART ................................................20, 136
AVONEX .........................................................136
AVONEX ADMINISTRATION PACK ..............136
AZACITIDINE ...................................................48
AZATHIOPRINE .............................................127
AZELASTINE HCL .................................... 20, 116
AZILECT .....................................................21, 74
AZILECT 0.5MG ...............................................74
AZITHROMYCIN ..............................................43
AZITHROMYCIN 100MG/5ML ......................... 21
AZITHROMYCIN 1GM ..................................... 21
AZITHROMYCIN 200MG/5ML ......................... 21
AZITHROMYCIN 250MG, 500MG ................... 21
AZITHROMYCIN 600MG ................................. 21
AZOPT ..................................................... 21, 138
AZTREONAM ................................................... 44
AZURETTE ...................................................... 99
B
B-12 DOTS 500 MCG .................................... 165
BACITRACIN ..................................................114
BACITRACIN 500 UNIT/G ............................. 158
BACITRACIN-POLYMYXIN ............................114
BACLOFEN .................................................... 145
BALSALAZIDE DISODIUM ............................ 133
BALZIVA ........................................................ 100
BANZEL ........................................................... 54
BARACLUDE ................................................... 83
BCG VACCINE (TICE STRAIN) ..................... 130
BECAPLERMIN ............................................. 105
BELLADONNA-PHENOBARBITAL
16.2 MG ......................................................... 151
BENAZEPRIL HCL ........................................... 88
BENAZEPRILHYDROCHLOROTHIAZIDE ............................ 88
173
Index of Drugs
BENZONATATE 100 MG ............................... 156
BENZONATATE 200 MG ............................... 156
BENZOYL PEROXIDE 10 % .......................... 158
BENZOYL PEROXIDE 5 % ............................ 158
BENZTROPINE MESYLATE ............................ 74
BETAMETHASONE
DIPROPIONATE ............................................ 108
BETAMETHASONE VALERATE ................... 108
BETASERON ................................................. 136
BETAXOLOL HCL .................................... 90, 138
BETHANECHOL CHLORIDE ......................... 136
BICALUTAMIDE ............................................... 48
BICILLIN C-R ................................................... 45
BICILLIN L-A .................................................... 45
BILTRICIDE ...................................................... 72
BISOPROLOL FUMARATE ............................. 90
BISOPROLOLHYDROCHLOROTHIAZIDE ............................. 90
BIVIGAM ........................................................ 127
BLEOMYCIN SULFATE ................................... 48
BOOSTRIX ..................................................... 130
BOSULIF .......................................................... 48
BREVIBLOC ..................................................... 90
BRIELLYN ...................................................... 100
BRIMONIDINE TARTRATE ........................... 139
BROFED 30-4MG/5ML .................................. 152
BROMFENAC SODIUM ........................... 21, 116
BROMOCRIPTINE MESYLATE .......................74
BROTAPP DM 5-15-1MG/5 ............................156
BUDESONIDE EC ..........................................133
BUFFERED ASPIRIN 324 MG .......................150
BUMETANIDE ..................................................94
BUPHENYL .................................................... 119
BUPRENORPHINE HCL ..................................38
BUPRENORPHINE-NALOXONE .....................38
BUPROPION HCL ............................................59
BUPROPION SR ..............................................59
BUPROPION XL ...............................................21
BUPROPION XL .............................................59
BUPROPION XL 150MG ..................................59
BUSPIRONE HCL ..........................................136
BUTALB-CAFF-ACETAMINOPHCODEIN ......................................................21, 33
BUTALBITAL COMPOUNDCODEINE .........................................................21
BYDUREON .....................................................62
BYETTA ............................................................62
C
CABERGOLINE ................................................74
CALCIPOTRIENE .....................................21, 105
CALCITONIN-SALMON ..................................134
CALCITRIOL .................................................. 134
CALCIUM 500 + VITAMIN D 500 MG125 ................................................................. 164
CALCIUM 500 MG-100 .................................. 162
CALCIUM 500(1250) ...................................... 162
CALCIUM 600 MG ......................................... 164
CALCIUM ACETATE ..................................... 120
CALCIUM CARBONATE 648 MG .................. 164
CALCIUM GLUCONATE 45(500)
MG ................................................................. 164
MG ................................................................. 164
MG ................................................................. 164
CALCIUM LACTATE 650 MG ........................ 164
CALCIUM LACTATE 85 MG(650) .................. 164
CALCIUM WITH VITAMIN D 600
MG-400 .......................................................... 164
CALDYPHEN 1 %-8 % ................................... 158
CALOHIST N/A .............................................. 158
CAMILA .......................................................... 100
CAMPRAL ........................................................ 38
CANASA ........................................................ 133
CANCIDAS ....................................................... 66
CAPASTAT SULFATE ..................................... 70
CAP-PROFEN 200 MG .................................. 150
CAPRELSA ...................................................... 48
174
Index of Drugs
CAPTOPRIL ..................................................... 88
CAPTOPRILHYDROCHLOROTHIAZIDE ............................. 88
CARBAMAZEPINE ........................................... 54
CARBAMAZEPINE XR ..................................... 54
CARBIDOPA-LEVODOPA ............................... 74
CARBIDOPA-LEVODOPAENTACAPONE ................................................. 74
CARIMUNE NF NANOFILTERED .................. 128
CARISOPRODOL .................................... 21, 145
CARTEOLOL HCL ..........................................117
CARTIA XT ....................................................... 91
CARVEDILOL ................................................... 90
CAYSTON ........................................................ 44
CAZIANT ........................................................ 100
CEFACLOR ...................................................... 41
CEFACLOR ER ................................................ 41
CEFADROXIL .................................................. 41
CEFAZOLIN ..................................................... 41
CEFAZOLIN SODIUM ...................................... 41
CEFDINIR ........................................................ 41
CEFEPIME HCL ............................................... 42
CEFOTAXIME SODIUM ................................... 42
CEFPODOXIME PROXETIL ............................ 42
CEFPROZIL ..................................................... 42
CEFTAZIDIME ................................................. 42
CEFTRIAXONE ................................................42
CEFUROXIME ..................................................42
CEFUROXIME SODIUM ..................................42
CELEBREX .......................................................35
CELESTONE ..................................................123
CELLCEPT .....................................................128
CELONTIN ........................................................54
CENESTIN ......................................................122
CEPHALEXIN ...................................................42
CEREZYME .................................................... 113
CERVARIX .....................................................130
CETIRIZINE 10 MG ........................................153
CETIRIZINE HCL 5 MG ..................................153
CHANTIX ..........................................................38
CHILD SUPPOSITORY PEDIATRIC ..............163
CHILDREN'S ALLERGY 12.5MG/
5ML .................................................................153
CHILDREN'S ASPIRIN 81 MG .......................150
CHILDREN'S CETIRIZINE HCL 1
MG/ML ............................................................153
CHILDREN'S IRON 15 MG/ML.......................165
CHILDREN'S PEPTO 400 MG .......................162
CHILDREN'S PROFEN IB 100 MG/
5ML .................................................................150
CHILDREN'S Q-PAP 160 MG/5ML ..........21, 149
CHILDREN'S SILFEDRINE 15 MG/5
ML .................................................................. 156
CHILDS ALLERGY 5-15-1MG/5 .................... 156
CHLORAMPHENICOL SOD
SUCCINATE .................................................... 40
CHLORDIAZEPOXIDEAMITRIPTYLINE .............................................. 59
CHLORHEXIDINE GLUCONATE .................. 104
CHLORHEXIDINE GLUCONATE 4
% .................................................................... 158
CHLOROQUINE PHOSPHATE ....................... 72
CHLOROTHIAZIDE ......................................... 95
CHLORPROMAZINE HCL ............................... 75
CHLORTHALIDONE ........................................ 95
CHLORZOXAZONE ................................. 21, 145
CHOLESTYRAMINE ........................................ 96
CHOLINE MAG TRISALICYLATE ................... 35
CHORIONIC GONADOTROPIN .................... 124
CICLOPIROX ................................................... 66
CILOSTAZOL ................................................... 86
CIMETIDINE ...................................................118
CIMETIDINE 200 MG ..................................... 161
CIMETIDINE HCL ...........................................118
CIPROFLOXACIN ............................................ 46
CIPROFLOXACIN ER ...................................... 46
CIPROFLOXACIN HCL .............................46, 114
175
Index of Drugs
CITALOPRAM HBR ......................................... 59
CLARITHROMYCIN ......................................... 43
CLARITHROMYCIN ER ................................... 43
CLEAR MEDICATED LOTION N/A ................ 158
CLEMASTINE FUMARATE .............................. 68
CLINDAMYCIN HCL ........................................ 40
CLINDAMYCIN PHOSPHATE ........... 40, 69, 106
CLOBETASOL PROPIONATE ....................... 108
CLOMIPRAMINE HCL ..................................... 59
CLONAZEPAM ................................................. 39
CLONIDINE HCL .............................................. 87
CLONIDINE HCL .............................................. 98
CLOPIDOGREL ............................................... 86
CLORAZEPATE DIPOTASSIUM ..................... 39
CLORAZEPATE DIPOTASSIUM
15MG ................................................................ 21
CLORAZEPATE DIPOTASSIUM
3.75MG, 7.5MG ................................................ 21
CLOTRIMAZOLE ............................................. 66
CLOTRIMAZOLE 3 2 % ................................. 152
CLOTRIMAZOLE-7 1 % ................................. 152
CLOTRIMAZOLEBETAMETHASONE ......................................... 66
CLOZAPINE ..................................................... 75
CLOZAPINE ODT ............................................ 75
CODEINE SULFATE .................................. 21, 33
CO-GESIC ........................................................22
COLACE 50 MG .............................................163
COLCRYS ......................................................136
COLESTIPOL HCL ...........................................96
COLISTIMETHATE SODIUM ...........................40
COMBIPATCH ................................................122
COMBIVENT ............................................22, 143
COMBIVENT RESPIMAT .........................22, 143
COMETRIQ ......................................................49
COMPLERA ......................................................78
COMVAX ........................................................130
COPAXONE ...................................................136
CORTISONE 1 % ...........................................159
CORTISONE ACETATE .................................123
CORTIZONE-10 1 % ......................................159
COUMADIN ......................................................83
CREON ........................................................... 113
CRIXIVAN .........................................................78
CROFAB .........................................................128
CROMOLYN SODIUM .................................... 117
CROMOLYN SODIUM .................................... 119
CROMOLYN SODIUM ....................................144
CRYSELLE .....................................................100
CUBICIN ...........................................................40
CUPRIMINE ....................................................121
CYCLAFEM .................................................... 100
CYCLOBENZAPRINE HCL ...................... 22, 145
CYCLOPENTOLATE HCL ..............................117
CYCLOPHOSPHAMIDE .................................. 49
CYCLOSERINE ............................................... 70
CYCLOSET ...................................................... 62
CYCLOSPORINE ........................................... 128
CYCLOSPORINE MODIFIED ........................ 128
CYPROHEPTADINE HCL ................................ 68
CYSTADANE ................................................. 136
CYSTAGON ....................................................113
CYTOGAM ..................................................... 128
CYTRA-3 ........................................................ 140
CYTRA-K ....................................................... 140
D
D.R. BENZIDE 5% ......................................... 158
DALIRESP ..................................................... 144
DANAZOL ...................................................... 122
DANTROLENE SODIUM ............................... 145
DAPSONE ........................................................ 70
DAPTACEL .................................................... 131
DARAPRIM ...................................................... 72
DASETTA ....................................................... 100
DECITABINE .................................................... 49
DEFEROXAMINE MESYLATE ...................... 121
176
Index of Drugs
DELZICOL ...................................................... 133
DEMECLOCYCLINE HCL ................................ 47
DENAVIR ....................................................... 105
DENTAGEL .................................................... 104
DEPEN ........................................................... 121
DESIPRAMINE HCL ........................................ 59
DESLORATADINE ........................................... 68
DESMOPRESSIN ACETATE ......................... 124
DESONATE .................................................... 108
DESONIDE ..................................................... 109
DESOXIMETASONE ...................................... 109
DESVENLAFAXINE ER ................................... 59
DETROL LA ............................................. 22, 121
DEXAMETHASONE ....................................... 123
DEXAMETHASONE ACETATE ..................... 123
DEXAMETHASONE SODIUM
PHOSPHATE ..........................................116, 123
DEXMETHYLPHENIDATE HCL ....................... 98
DEXTROAMPHETAMINE SULFATE ............... 98
DEXTROAMPHETAMINEAMPHETAMINE ............................................... 98
DEXTROSE 5%-1/2NS-KCL .......................... 140
DEXTROSE 5%-1/3NS-KCL .......................... 140
DEXTROSE 5%-1/4NS-KCL .......................... 140
DEXTROSE 5%-NS-KCL ............................... 140
DEXTROSE 5%-POTASSIUM
CHLORIDE .....................................................140
DEXTROSE IN LACTATED
RINGERS .........................................................86
DEXTROSE IN RINGERS
INJECTION .......................................................86
DEXTROSE IN WATER ...................................86
DEXTROSE WITH SODIUM
CHLORIDE .......................................................87
DIAZEPAM .................................................22, 39
DICLOFENAC POTASSIUM ............................35
DICLOFENAC SODIUM ........................... 35, 116
DICLOXACILLIN SODIUM ...............................45
DICYCLOMINE HCL ....................................... 119
DIDANOSINE ...................................................78
DIFFERIN ................................................. 22, 111
DIFLORASONE DIACETATE .........................109
DIFLUNISAL .....................................................35
DIGIFAB ...........................................................93
DIGITEK ...........................................................22
DIGOXIN ...........................................................22
DIGOXIN ...........................................................93
DIGOXIN 125MCG ...........................................93
DIGOXIN 250MCG ...........................................93
DIHYDROERGOTAMINE
MESYLATE .......................................................69
DILANTIN .........................................................54
DILANTIN-125 .................................................. 55
DILT-CD ........................................................... 91
DILTIA XT ........................................................ 92
DILTIAZEM 24HR CD ...................................... 92
DILTIAZEM 24HR ER ...................................... 92
DILTIAZEM ER ................................................ 92
DILTIAZEM HCL .............................................. 92
DILT-XR ........................................................... 92
DILTZAC ER .................................................... 92
DIOVAN ........................................................... 88
DIPENTUM .................................................... 133
DIPHENHYDRAMINE 25 MG ........................ 153
DIPHENHYDRAMINE 50 MG ........................ 153
DIPHENHYDRAMINE HCL .............................. 68
DIPHENHYDRAMINE HCL 12.5MG/
5ML ................................................................ 153
DIPHENHYDRAMINE HCL 50 MG ................ 153
DIPHENOXYLATE-ATROPINE ......................119
DIPHTHERIA-TETANUS TOXOIDSPED ................................................................ 131
DIPYRIDAMOLE .............................................. 86
DISOPYRAMIDE PHOSPHATE ...................... 89
DISULFIRAM ................................................... 38
DIVALPROEX SODIUM ................................... 55
DIVALPROEX SODIUM ER ............................. 55
DOCETAXEL ................................................... 49
177
Index of Drugs
DOLUTEGRAVIR SODIUM .............................. 78
DONEPEZIL HCL ............................................. 58
DORZOLAMIDE HCL ............................... 22, 139
DORZOLAMIDE-TIMOLOL ...................... 22, 139
DOXAZOSIN MESYLATE ................................ 87
DOXEPIN HCL ................................................. 59
DOXYCYCLINE HYCLATE .............................. 47
DOXYCYCLINE MONOHYDRATE .................. 47
DRONABINOL .................................................. 71
DROSPIRENONE-ETHINYL
ESTRADIOL ................................................... 100
DULOXETINE HCL .......................................... 60
DUOSOL 250MG ........................................... 163
E
EAR SYSTEM 6.5 % ...................................... 160
ECONAZOLE NITRATE ................................... 67
ED K+10 ......................................................... 140
EDURANT .................................................. 22, 78
EFFER-K ........................................................ 140
ELAPRASE .....................................................113
ELELYSO ........................................................113
ELIDEL ..................................................... 22, 109
ELIGARD .......................................................... 49
ELIQUIS ........................................................... 83
ELITEK ............................................................113
ELIXIR 15-1MG/5ML ......................................153
EMCYT .............................................................49
EMEND .............................................................71
EMOQUETTE .................................................100
EMSAM .............................................................60
EMTRIVA ..........................................................78
ENALAPRIL MALEATE ....................................88
ENALAPRILHYDROCHLOROTHIAZIDE .............................88
ENBREL .........................................................128
ENDOCET ........................................................22
ENDODAN ........................................................22
ENGERIX-B ....................................................131
ENOXAPARIN SODIUM ...................................83
ENPRESSE ....................................................100
ENSKYCE .......................................................100
ENTACAPONE .................................................74
EPINEPHRINE .................................................93
EPIPEN 2-PAK .................................................93
EPIVIR ..............................................................78
EPIVIR HBV ......................................................78
EPLERENONE .................................................97
EPOGEN .........................................................84
EPOPROSTENOL SODIUM ...........................146
EPZICOM .........................................................79
EQ NICOTINE GUM 2MG .............................. 151
ERAXIS (ALCOHOL DILUENT) ....................... 67
ERGOCALCIFEROL 8000/ML ....................... 165
ERGOMAR ....................................................... 69
ERGOTAMINE-CAFFEINE .............................. 69
ERIVEDGE ....................................................... 49
ERRIN ............................................................ 100
ERWINAZE ...................................................... 49
ERYTHROCIN STEARATE ............................. 43
ERYTHROMYCIN .............................43, 107, 114
ERYTHROMYCIN
ETHYLSUCCINATE ......................................... 44
ERYTHROMYCIN-BENZOYL
PEROXIDE ..................................................... 107
ERYTHROMYCINSULFISOXAZOLE ............................................ 44
ESCITALOPRAM OXALATE ........................... 60
ESMOLOL HCL ................................................ 90
ESTRADIOL ................................................... 122
ESTRADIOL-NORETHINDRONE
ACETAT ......................................................... 122
ESTROPIPATE .............................................. 122
ETHAMBUTOL HCL ........................................ 70
ETHOSUXIMIDE .............................................. 55
ETIDRONATE DISODIUM ............................. 134
ETODOLAC ..................................................... 35
178
Index of Drugs
EVEROLIMUS .................................................. 49
EVISTA ..................................................... 22, 123
EXELON ........................................................... 58
EXEMESTANE ................................................. 49
EXJADE ......................................................... 121
EXTAVIA ........................................................ 136
F
FABRAZYME ..................................................113
FALMINA ........................................................ 100
FAMOTIDINE ..................................................118
FANAPT ........................................................... 75
FARESTON ...................................................... 49
FASLODEX ...................................................... 49
FAST-ACTING HEARTBURN
RELIEF 237.5-254 .......................................... 162
FC CONDOM, FEMALE N/A .................... 23, 155
FELBAMATE .................................................... 55
FELODIPINE ER .............................................. 94
FENOFIBRATE ................................................ 96
FENOPROFEN CALCIUM ............................... 36
FENTANYL ................................................. 23, 33
FENTANYL CITRATE ................................ 23, 33
FEROSUL 220(44)/5 ...................................... 166
FERROUS SULFATE 134MG ........................ 166
FERROUS SULFATE 15MG/0.6ML ............... 166
FERROUS SULFATE 220MG/5ML ................166
FERROUS SULFATE 250 MG .......................166
FERROUS SULFATE 300MG/5ML ................166
FERROUS SULFATE 324(65)MG ..................166
FERROUS SULFATE 325(65) MG .................166
FEXOFENADINE HCL ....................................153
FINASTERIDE ..........................................23, 136
FIRMAGON ......................................................49
FLECAINIDE ACETATE ...................................89
FLOVENT HFA ...............................................142
FLUCONAZOLE ...............................................67
FLUCONAZOLE IN SALINE .............................67
FLUCYTOSINE .................................................67
FLUDROCORTISONE ACETATE ..................123
FLUNISOLIDE ................................................142
FLUOCINOLONE ACETONIDE .....................109
FLUOCINOLONE ACETONIDE OIL ............... 116
FLUOCINONIDE .............................................109
FLUORIDE 0.25(0.55) ....................................166
FLUOROMETHOLONE .................................. 116
FLUOROURACIL ............................................105
FLUOXETINE DR .............................................60
FLUOXETINE HCL ...........................................60
FLUPHENAZINE DECANOATE .......................75
FLUPHENAZINE HCL ......................................76
FLURBIPROFEN ............................................. 36
FLURBIPROFEN SODIUM .............................116
FLUTAMIDE ..................................................... 49
FLUTICASONE PROPIONATE ..............110, 142
FLUVOXAMINE MALEATE .............................. 60
FOAMING ANTACID MAX
STRENGTH 105-160MG ............................... 162
FOLIC ACID 0.4 MG ...................................... 166
FOLIC ACID 0.8 MG ...................................... 166
FOLIC ACID 1 MG ......................................... 166
FOLOTYN ........................................................ 49
FOMEPIZOLE ................................................ 136
FONDAPARINUX SODIUM ............................. 84
FORTAZ IN ISO-OSMOTIC
DEXTROSE ..................................................... 43
FORTEO .................................................. 23, 134
FOSINOPRIL SODIUM .................................... 88
FOSINOPRILHYDROCHLOROTHIAZIDE ............................ 88
FRAGMIN ......................................................... 84
FREAMINE HBC .............................................. 87
FRUCTOSE ..................................................... 87
FUNGI-GUARD 1 % ....................................... 152
FUROSEMIDE ................................................. 95
FUZEON .......................................................... 79
FYCOMPA ...................................................... 55
179
Index of Drugs
FYCOMPA 2MG, 4MG, 8MG ........................... 23
FYCOMPA 6MG ............................................... 23
G
GABAPENTIN .................................................. 55
GAMUNEX-C ................................................. 128
GANCICLOVIR SODIUM ................................. 83
GARDASIL ..................................................... 131
GAS RELIEF 125 MG .................................... 161
GAS RELIEF 40MG/0.6ML ............................ 161
GAS RELIEF 80 MG ...................................... 161
GAVILYTE-C .................................................... 23
GAVILYTE-N .................................................... 23
GEMCITABINE HCL ........................................ 49
GEMFIBROZIL ................................................. 96
GENOTROPIN .............................................. 124
GENTAK ..........................................................114
GENTAMICIN SULFATE .....................23, 40, 114
GEODON ......................................................... 76
GERI-HYDROLAC 12 % ................................ 158
GILDAGIA ...................................................... 100
GILDESS ........................................................ 100
GILDESS FE .................................................. 100
GILENYA ........................................................ 136
GLEEVEC ........................................................ 50
GLIMEPIRIDE .................................................. 65
GLIMEPIRIDE 1MG ..........................................23
GLIMEPIRIDE 2MG ..........................................23
GLIMEPIRIDE 4MG ..........................................23
GLIPIZIDE ........................................................65
GLIPIZIDE 10MG ..............................................23
GLIPIZIDE 5MG ................................................23
GLIPIZIDE ER ..................................................65
GLIPIZIDE ER 10MG ........................................23
GLIPIZIDE ER 2.5MG .......................................23
GLIPIZIDE ER 5MG ..........................................23
GLIPIZIDE-METFORMIN .................................65
GLIPIZIDE-METFORMIN 2.5250MG ..............................................................23
GLIPIZIDE-METFORMIN 2.5500MG, 5-500MG .............................................24
GLUCAGEN ....................................................136
GLUCAGON EMERGENCY KIT ..............24, 136
GLYBURIDE .....................................................65
GLYBURIDE 1.25MG .......................................24
GLYBURIDE 2.5MG .........................................24
GLYBURIDE 5MG ............................................24
GLYBURIDE MICRONIZED .............................65
GLYBURIDE MICRONIZED 1.5MG .................24
GLYBURIDE MICRONIZED 3MG ....................24
GLYBURIDE MICRONIZED 6MG ....................24
GLYBURIDE-METFORMIN HCL ......................65
GLYBURIDE-METFORMIN HCL
1.25-250MG ..................................................... 24
GLYBURIDE-METFORMIN HCL 2.5500MG, 5-500MG ............................................ 24
GLYCOPYRROLATE ......................................119
GLYSET ........................................................... 62
GLYSET 100MG .............................................. 24
GLYSET 25MG ................................................ 24
GLYSET 50MG ................................................ 24
GRANISETRON HCL ....................................... 71
GRISEOFULVIN .............................................. 67
GRISEOFULVIN
ULTRAMICROSIZE ......................................... 67
GUAIFENESIN 100MG/5ML ......................... 156
GUAIFENESIN ER 600 MG .......................... 156
GUAIFENESIN 100MG/5ML .......................... 156
GUANFACINE HCL ......................................... 87
GUANIDINE HCL ........................................... 137
H
HALAVEN ........................................................ 50
HALOBETASOL PROPIONATE .....................110
HALOPERIDOL ................................................ 76
HALOPERIDOL DECANOATE ........................ 76
HALOPERIDOL LACTATE .............................. 76
HAVRIX .......................................................... 131
HCTZ/RESERPINE/HYDRALAZINE ................ 93
180
Index of Drugs
HEATHER ...................................................... 101
HECTOROL ................................................... 135
HECTOROL 0.5MCG ....................................... 24
HECTOROL 0.5MCG, 1MCG ......................... 135
HECTOROL 1MG ............................................. 24
HECTOROL 2.5MCG ..................................... 135
HEPAGAM B .................................................. 128
HEPARIN LOCK 100/ML (1) .......................... 154
HEPARIN SODIUM .......................................... 84
HEPARIN SODIUM IN 0.45% NACL ................ 84
HEPARIN SODIUM-D5W ................................. 84
HEPARIN SODIUM-NS .................................... 84
HEPATASOL .................................................... 87
HEXALEN ......................................................... 50
HI-CALCIUM 1.25G ........................................ 164
HOMATROPAIRE .....................................24, 117
HUMALOG ....................................................... 63
HUMALOG MIX 50-50 ...................................... 63
HUMALOG MIX 75-25 ...................................... 63
HUMATROPE ............................................... 125
HUMIRA ......................................................... 128
HUMORSOL ................................................... 139
HUMULIN 70-30 ............................................... 64
HUMULIN N ..................................................... 64
HUMULIN R ..................................................... 64
HUMULIN R 500/ML .........................................64
HYDRALAZINE HCL ........................................93
HYDRALAZINE W/HCTZ ..................................93
HYDROCHLOROTHIAZIDE .............................95
HYDROCHLOROTHIAZIDE/
RESERPINE .....................................................93
HYDROCODONE BIT-IBUPROFEN ..........24, 33
HYDROCODONE CP 5-2.5-2 .........................156
HYDROCODONEACETAMINOPHEN ....................................24, 33
HYDROCODONE-IBUPROFEN .......................25
HYDROCORTISONE ............................. 110, 124
HYDROCORTISONE 0.5 % ..........................159
HYDROCORTISONE 0.5 % ...........................159
HYDROCORTISONE 1 % ..............................159
HYDROCORTISONE ACETATE 0.5
% .....................................................................159
HYDROCORTISONE ACETATE
0.5% ................................................................159
HYDROCORTISONE BUTYRATE ................. 110
HYDROCORTISONE VALERATE .................. 110
HYDROMORPHONE HCL .........................25, 33
HYDROXYCHLOROQUINE
SULFATE ..........................................................72
HYDROXYUREA ..............................................50
HYDROXYZINE HCL ......................................137
HYPERHEP B S-D .........................................128
HYPERLYTE CR ............................................ 140
HYPERLYTE R .............................................. 140
HYPERRAB S-D ............................................ 128
HYPERRHO S-D ............................................ 129
HYPERTET S-D ............................................. 129
I
IBANDRONATE SODIUM ........................ 25, 135
IBUPROFEN .................................................... 36
IBUPROFEN 100 MG .................................... 150
IBUPROFEN 200 MG .................................... 150
IBUPROFEN IB 100 MG ................................ 150
ICLUSIG ........................................................... 50
IMBRUVICA ..................................................... 50
IMIPENEM-CILASTATIN SODIUM .................. 44
IMIPRAMINE HCL ............................................ 60
IMIPRAMINE PAMOATE ................................. 60
IMIQUIMOD ............................................. 25, 105
IMOGAM RABIES-HT .................................... 129
IMOVAX RABIES VACCINE .......................... 131
INCIVEK ........................................................... 82
INCRELEX ..................................................... 125
INDAPAMIDE ................................................... 95
INDOMETHACIN ............................................. 36
INFANRIX ...................................................... 131
INFANRIX PF ................................................. 131
181
Index of Drugs
INFANT DECONGESTANT 9.4MG/
ML .................................................................. 156
INFANT'S PAIN RELIEF 100 MG/ML....... 25, 149
INFANT'S PAIN RELIEF 80MG/
0.8ML ....................................................... 25, 149
INFANTS PROFENIB 50 MG/1.25 ................. 151
INFERGEN ....................................................... 82
INLYTA ............................................................. 50
INSULIN SYRINGE .........................................112
INTELENCE ..................................................... 79
INTRALIPID ...................................................... 87
INTRON A ....................................................... 82
INTROVALE ................................................... 101
INTUNIV ........................................................... 98
INVEGA ............................................................ 25
INVEGA ........................................................... 76
INVEGA SUSTENNA ...................................... 76
INVIRASE ................................................... 25, 79
INVOKANA ....................................................... 62
IPOL ............................................................... 131
IPRATROPIUM BROMIDE ............................. 143
IPRATROPIUM-ALBUTEROL ........................ 143
IRON 325(65) MG .......................................... 166
ISENTRESS ..................................................... 79
ISENTRESS 100MG ........................................ 25
ISENTRESS 25MG .......................................... 25
ISONIAZID ........................................................70
ISOPTO HOMATROPINE ................................25
ISOSORBIDE DINITRATE ...............................97
ISOSORBIDE MONONITRATE ........................97
ISOSORBIDE MONONITRATE ER ..................97
ISOTRETINOIN ..............................................105
ISRADIPINE .....................................................94
ISTODAX ..........................................................50
ITRACONAZOLE ..............................................67
IXIARO ............................................................131
J
JAKAFI ..............................................................50
JANUMET ...................................................25, 62
JANUMET XR ...................................................62
JANUMET XR 100-1000MG, 501000MG ............................................................25
JANUMET XR 50-500MG .................................25
JANUVIA .....................................................25, 62
JENTADUETO ............................................25, 63
JE-VAX ...........................................................131
JEVTANA ..........................................................50
JOCK ITCH 1 % ..............................................152
JOLESSA ........................................................101
JOLIVETTE .....................................................101
JUNEL ............................................................101
JUNEL FE ...................................................... 101
JUVISYNC ................................................. 25, 63
K
K EFFERVESCENT ....................................... 140
KADCYLA ........................................................ 50
KALETRA ......................................................... 79
KA-PEC 750MG/15ML ................................... 162
KARIVA .......................................................... 101
KELNOR 1-35 ................................................ 101
KEPIVANCE ................................................... 104
KETEK ............................................................. 44
KETOCONAZOLE ............................................ 67
KETOPROFEN ................................................ 36
KETOROLAC TROMETHAMINE ........25, 36, 116
KHEDEZLA ...................................................... 60
KINERET ........................................................ 129
KINRIX ........................................................... 131
KLOR-CON .................................................... 140
KLOR-CON 10 ............................................... 140
KLOR-CON 8 ................................................. 141
KLOR-CON M15 ............................................ 141
KLOR-CON M20 ............................................ 141
KOSHER CARE DM 100-10MG/5 ................. 156
KURVELO ...................................................... 101
KUVAN ............................................................113
182
Index of Drugs
KYPROLIS ....................................................... 50
L
LABETALOL HCL ............................................. 91
LACRISERT ....................................................117
LACTATED RINGERS ................................... 141
LACTULOSE ...................................................119
LAMIVUDINE ................................................... 79
LAMIVUDINE-ZIDOVUDINE ............................ 79
LAMOTRIGINE ................................................. 55
LANOXIN PEDIATRIC ..................................... 93
LANSOPRAZOLE ...........................................118
LANSOPRAZOLE 15 MG ............................... 161
LANTUS ........................................................... 64
LANTUS SOLOSTAR ....................................... 64
LATANOPROST ............................................. 139
LATUDA ........................................................... 76
LAXA CLEAR 17G/DOSE ........................ 26, 163
LAXATIVE SUPPOSITORY 10 MG ............... 163
LAZANDA ................................................... 26, 33
LEENA ............................................................ 101
LEFLUNOMIDE .............................................. 129
LESSINA ........................................................ 101
LETAIRIS ....................................................... 146
LETROZOLE .................................................... 50
LEUCOVORIN CALCIUM .............................. 137
LEUKERAN ......................................................50
LEUKINE ..........................................................85
LEUPROLIDE ACETATE .................................50
LEVETIRACETAM ............................................55
LEVETIRACETAM 500MG ...............................26
LEVETIRACETAM 750MG ...............................26
LEVETIRACETAM-NACL .................................56
LEVLEN 28 .....................................................101
LEVOBUNOLOL HCL .......................................26
LEVOBUNOLOL HCL 0.25% ..........................139
LEVOBUNOLOL HCL 0.5% ............................139
LEVOFLOXACIN ..............................................46
LEVOFLOXACIN-D5W .....................................46
LEVOMILNACIPRAN
HYDROCHLORIDE ..........................................60
LEVONEST .....................................................101
LEVONORGESTREL .....................................101
LEVONORGESTREL-ETH
ESTRADIOL ...................................................101
LEVORA-28 ....................................................101
LEVOTHROID ................................................126
LEVOTHYROXINE SODIUM ..........................126
LEVOXYL .......................................................126
LEVULAN .......................................................105
LEXIVA .............................................................79
LICE SOLUTION 4-.33-.5% ............................159
LIDOCAINE ...................................................... 37
LIDOCAINE HCL ........................................ 37, 89
LIDOCAINE HCL IN 5% DEXTROSE .............. 89
LIDOCAINE HCL VISCOUS ............................ 38
LIDOCAINE-PRILOCAINE ............................... 38
LIFESTYLES XS N/A ....................................... 26
LIFESTYLES XS N/A ..................................... 155
LINDANE .........................................................112
LIOTHYRONINE SODIUM ............................. 126
LIPODOX ......................................................... 50
LIQUID ANTACID 200-200-20 ....................... 162
LIQUID ANTACID 400-400-40 ....................... 162
LISINOPRIL ..................................................... 89
LISINOPRILHYDROCHLOROTHIAZIDE ............................ 89
LITHIUM ........................................................... 98
LITHIUM CARBONATE ................................... 98
LITTLE NOSES 0.125 % ................................ 160
LOMUSTINE .................................................... 51
LOPERAMIDE .................................................119
LOPERAMIDE 1MG/7.5ML ............................ 163
LOPERAMIDE HCL 1MG/5ML ....................... 163
LORATADINE ................................................ 153
LORAZEPAM ............................................. 26, 39
LOSARTAN POTASSIUM ................................ 88
183
Index of Drugs
LOSARTANHYDROCHLOROTHIAZIDE ............................. 88
LOTEMAX .......................................................116
LOTRONEX .....................................................113
LOVASTATIN ................................................... 96
LOVAZA ........................................................... 96
LOW-OGESTREL .......................................... 102
LOXAPINE ....................................................... 76
LUPRON DEPOT ............................................. 51
LUPRON DEPOT-PED .................................... 51
LUTERA ......................................................... 102
LYRICA ............................................................ 56
LYSODREN ...................................................... 51
M
MAG-G 27 MG(500) ....................................... 164
MAGNESIUM 300 MG ................................... 164
MAGNESIUM CITRATE N/A .......................... 163
MAJOR-CON 40MG/0.6ML ............................ 161
MALDROXAL ANTACID-ANTI-GAS
450-500-40 ..................................................... 163
MAPAP 500MG/15ML .............................. 26, 149
MAPROTILINE HCL ......................................... 60
MARLISSA ..................................................... 102
MARPLAN ........................................................ 60
MASANTI ANTACID 311-232MG ................... 163
MATULANE ......................................................51
MAXIDEX ........................................................ 116
MECHLORETHAMINE HCL ...........................106
MECLIZINE HCL ..............................................71
MECLIZINE HCL 12.5MG ...............................154
MECLIZINE HCL 25MG ..................................154
MECLOFENAMATE SODIUM ..........................36
MEDI-CORTISONE 1 % .................................159
MEDROXYPROGESTERONE
ACETATE .......................................................126
MEFLOQUINE HCL ..........................................73
MEGESTROL ACETATE ..................................51
MEKINIST .........................................................51
MELOXICAM ....................................................36
MELPHALAN HCL ............................................51
MEMANTINE HCL ............................................58
MENACTRA ....................................................132
MENEST .........................................................123
MENINGOCOCCAL VAC C,Y/HIB/
PF ...................................................................132
MENOMUNE-A-C-Y-W-135 ............................132
MENVEO A-C-Y-W-135-DIP ..........................132
MEPERIDINE HCL .....................................26, 33
MEPRON ..........................................................73
MERCAPTOPURINE ........................................51
MESALAMINE ................................................134
MESNEX ........................................................ 137
METAPROTERENOL SULFATE ................... 143
METFORMIN HCL ........................................... 63
METFORMIN HCL 1000MG ............................ 26
METFORMIN HCL 500MG .............................. 26
METFORMIN HCL 850MG .............................. 26
METFORMIN HCL ER ..................................... 63
METFORMIN HCL ER 500MG ........................ 26
METFORMIN HCL ER 750MG,
1000MG ........................................................... 26
METHADONE HCL .................................... 26, 34
METHADONE INTENSOL ......................... 26, 34
METHADOSE .................................................. 27
METHAZOLAMIDE ........................................ 139
METHENAMINE HIPPURATE ......................... 40
METHIMAZOLE ............................................. 126
METHOCARBAMOL ...................................... 145
METHOCARBAMOL 500MG ........................... 27
METHOCARBAMOL 750MG ........................... 27
METHOTREXATE ............................................ 51
METHYCLOTHIAZIDE ..................................... 95
METHYLDOPA ................................................ 87
METHYLDOPAHYDROCHLOROTHIAZIDE ............................ 87
METHYLPHENIDATE ER ................................ 98
METHYLPHENIDATE ER ................................ 99
184
Index of Drugs
METHYLPHENIDATE HCL .............................. 99
METHYLPREDNISOLONE ............................ 124
METHYLPREDNISOLONE
ACETATE ....................................................... 124
METHYLPREDNISOLONE SOD
SUCC ............................................................. 124
METIPRANOLOL ........................................... 139
METOCLOPRAMIDE HCL ..............................119
METOLAZONE ................................................. 95
METOPROLOL SUCCINATE ........................... 91
METOPROLOL SUCCINATE
200MG .............................................................. 27
METOPROLOL SUCCINATE 25MG,
50MG,100MG ................................................... 27
METOPROLOL TARTRATE ............................ 91
METOPROLOLHYDROCHLOROTHIAZIDE ............................. 91
METRONIDAZOLE ............................ 69, 73, 107
MEXILETINE HCL ............................................ 89
MICATIN 2 % ................................................. 152
MICONAZOLE 3 ............................................... 69
MICONAZOLE 7 100 MG ............................... 154
MICONAZOLE 7 2 % ..................................... 152
MICONAZOLE NITRATE 2 % ........................ 152
MICRHOGAM PLUS ...................................... 129
MICROGESTIN .............................................. 102
MICROGESTIN FE ........................................ 102
MIDODRINE HCL .............................................88
MIFEPREX .....................................................137
MIGERGOT ......................................................69
MIGRAINE FORMULA 250-250-65 ................151
MILRINONE IN 5% DEXTROSE ......................93
MIMVEY ..........................................................123
MINOCYCLINE HCL .........................................47
MINOXIDIL .......................................................97
MIRTAZAPINE ..................................................61
MISOPROSTOL ............................................. 118
MITOXANTRONE HCL .....................................51
M-M-R II VACCINE .........................................132
MODAFINIL ....................................................145
MOEXIPRIL HCL ..............................................89
MOMETASONE FUROATE ............................ 110
MONO-LINYAH ..............................................102
MONONESSA ................................................102
MONTELUKAST SODIUM .............................142
MORPHINE SULFATE ...............................27, 34
MORPHINE SULFATE ER ...............................27
MORPHINE SULFATE ER ALL
OTHER STRENGTHS ......................................34
MULTAQ ...........................................................89
MUPIROCIN .............................................27, 107
MURO-128 2 % ..............................................161
MYCELEX-7 100 MG ..................................... 152
MYCOBUTIN .................................................... 70
MYCOPHENOLATE MOFETIL ...................... 129
MYRBETRIQ .................................................. 121
MYTELASE .................................................... 137
MYZILRA ........................................................ 102
N
NABI-HB ......................................................... 129
NABUMETONE ................................................ 36
NADOLOL ........................................................ 91
NAFCILLIN SODIUM ....................................... 45
NAGLAZYME ..................................................113
NALIDIXIC ACID .............................................. 46
NALLPEN-ISO-OSMOTIC
DEXTROSE ..................................................... 45
NALOXONE HCL ............................................. 38
NALTREXONE HCL ......................................... 38
NAMENDA ....................................................... 58
NAPHAZOLINE HCL .......................................117
NAPHAZOLINE HCL W/
ANTAZOLINE ............................................27, 117
NAPROXEN ..................................................... 36
NAPROXEN SODIUM ...................................... 37
NASAL ALLERGY SPRAY 5.2 MG ................ 165
NASAL DECON
(PSEUDOEPHEDRINE) 30 MG/5 ML ............ 156
185
Index of Drugs
NATEGLINIDE ................................................. 63
NEBUPENT ...................................................... 73
NECON .......................................................... 102
NEFAZODONE HCL ........................................ 61
NEOMYCIN SULFATE ..................................... 40
NEOMYCIN W/DEXAMETHASONE .........27, 114
NEOMYCIN-BACITRACIN-POLYHC ...................................................................114
NEOMYCIN-BACITRACINPOLYMYXIN ...................................................114
NEOMYCIN-POLYMYXINDEXAMETH ....................................................115
NEOMYCIN-POLYMYXINGRAMICIDIN ...................................................115
NEOMYCIN-POLYMYXIN-HC ........................115
NEOMYCIN-POLYMYXINHYDROCORT .................................................115
NEO-TUSS 200-30MG/5 ................................ 157
NEPHRAMINE ................................................. 87
NEULASTA ...................................................... 85
NEUMEGA ....................................................... 85
NEUPOGEN ..................................................... 85
NEVIRAPINE .................................................... 79
NEXAVAR ........................................................ 51
NIACIN ............................................................. 96
NIACIN 1000 MG ........................................... 154
NIACIN 100MG .............................................. 166
NIACIN 125 MG ..............................................154
NIACIN 250 MG ..............................................155
NIACIN 250MG ...............................................166
NIACIN 400 MG ..............................................155
NIACIN 50 MG ................................................155
NIACIN 500 MG ..............................................155
NIACIN 500MG ...............................................166
NIACIN 50MG .................................................166
NIACIN 750 MG ..............................................155
NICARDIPINE HCL ..........................................94
NICOTINE GUM 4MG ....................................151
NICOTINE PATCH 14MG/24HR ....................151
NICOTINE PATCH 21 MG/24HR ...................151
NICOTINE TRANSDERMAL 7MG/
24HR ...............................................................151
NICOTROL .......................................................38
NICOTROL NS .................................................38
NIFEDIAC CC ...................................................94
NIFEDICAL XL ..................................................94
NIFEDIPINE ER ................................................94
NILANDRON .....................................................51
NITROFURANTOIN ....................................27, 40
NITROGLYCERIN PATCH ...............................97
NITROSTAT .....................................................97
NIZATIDINE .................................................... 118
NOBLE FORMULA HC 1 % ........................... 159
NON-ASA SINUS 30MG-500MG ................... 157
NON-ASPIRIN 160 MG ............................ 27, 149
NON-ASPIRIN 80 MG .............................. 27, 149
NORA-BE ....................................................... 102
NORDITROPIN .............................................. 125
NORDITROPIN FLEXPRO ............................ 125
NORDITROPIN NORDIFLEX ........................ 125
NORETHINDRONE ....................................... 102
NORETHINDRONE ACETATE ...................... 126
NORGESTIMATE-ETHINYL
ESTRADIOL ................................................... 102
NORTREL ...................................................... 102
NORTRIPTYLINE HCL .................................... 61
NORVIR ........................................................... 80
NOSE DROPS 1 % ........................................ 161
NOVOLIN 70-30 ............................................... 64
NOVOLIN 70-30 INNOLET .............................. 64
NOVOLIN N ..................................................... 64
NOVOLIN N INNOLET ..................................... 64
NOVOLIN R ..................................................... 64
NOVOLOG ....................................................... 65
NOVOLOG FLEXPEN ...................................... 65
NOVOLOG MIX 70-30 ..................................... 65
NOVOLOG MIX 70-30 FLEXPEN .................... 65
186
Index of Drugs
NUEDEXTA ...................................................... 99
NULOJIX ........................................................ 129
NUTRILYTE II ................................................ 141
NUTROPIN ..................................................... 125
NUTROPIN AQ .............................................. 125
NUTROPIN AQ NUSPIN ................................ 125
NU-WAY 1 % .................................................. 161
NYAMYC .......................................................... 67
NYSTATIN ........................................................ 67
NYSTATIN-TRIAMCINOLONE ........................ 68
O
OBINUTUZUMAB ............................................. 51
OFLOXACIN ..............................................46, 115
OGESTREL .................................................... 102
OLANZAPINE ................................................... 27
OLANZAPINE ................................................... 76
OLANZAPINE ODT .................................... 27, 76
OMEPRAZOLE ...............................................118
OMEPRAZOLE 10MG, 20MG .......................... 27
OMEPRAZOLE 40MG ...................................... 27
OMEPRAZOLE MAGNESIUM 20
MG .................................................................. 161
ONDANSETRON HCL ..................................... 71
ONDANSETRON ODT ..................................... 72
ONFI ................................................................. 39
ONTAK .............................................................51
ORALYTE N/A ..........................................28, 165
ORAP ................................................................77
ORENCIA .......................................................129
ORFADIN ........................................................ 113
ORSYTHIA .....................................................102
ORTHO ALL-FLEX 65MM ........................28, 155
ORTHO ALL-FLEX 70MM ........................28, 155
ORTHO ALL-FLEX 75MM ........................28, 155
ORTHO ALL-FLEX 80MM ........................28, 155
ORTHO ALL-FLEX N/A ............................28, 160
OXALIPLATIN ...................................................52
OXANDROLONE ............................................122
OXAPROZIN .....................................................37
OXCARBAZEPINE ...........................................56
OXSORALEN .................................................106
OXSORALEN-ULTRA ....................................106
OXTELLAR XR .................................................56
OXYBUTYNIN CHLORIDE .............................121
OXYBUTYNIN CHLORIDE ER .......................121
OXYCODONE CONCENTRATE ................28, 34
OXYCODONE HCL ....................................28, 34
OXYCODONE HCLACETAMINOPHEN ..........................................28
OXYCODONE HCL-ASPIRIN .....................28, 34
OXYCODONE-ACETAMINOPHEN ........... 28, 35
OXYCONTIN .............................................. 28, 35
OYSTER SHELL CALCIUM
500(1250) ....................................................... 165
OYSTER SHELL CALCIUM W/VIT D
500 MG-125 ................................................... 165
OYSTER SHELL CALCIUM W-VIT D
250 MG-125 ................................................... 165
OYSTER SHELL CALCIUM W-VIT D
500 MG-200 ................................................... 165
OYSTER SHELL CALCIUMVITAMIN D 500 MG-400 ................................ 165
P
PAMIDRONATE DISODIUM .......................... 135
PANCREAZE ..................................................113
PANCRELIPASE 5,000 ...................................113
PANRETIN ..................................................... 106
PANTOPRAZOLE SODIUM ............................118
PARICALCITOL ............................................. 135
PAROMOMYCIN SULFATE ............................ 73
PAROXETINE HCL .......................................... 61
PASER ............................................................. 70
PATANOL .................................................28, 117
PAXIL ............................................................... 61
PEDIA RELIEF 2.5-7.5/.8 ............................... 157
PEDIARIX ...................................................... 132
187
Index of Drugs
PEDVAXHIB ................................................... 132
PEG 3350-ELECTROLYTE .............................. 28
PEG-3350 AND ELECTROLYTES ........... 28, 120
PEG-3350 WITH FLAVOR PACKS .......... 28, 120
PEGANONE ..................................................... 56
PEGASYS ........................................................ 82
PEGASYS PROCLICK ..................................... 82
PEGINTRON .................................................... 82
PEGINTRON REDIPEN ................................... 82
PEN NEEDLE ..................................................112
PENICILLIN G POTASSIUM ............................ 45
PENICILLIN G SODIUM ................................... 45
PENICILLIN GK-ISO-OSM
DEXTROSE ...................................................... 45
PENICILLIN V POTASSIUM ............................ 45
PENTAMIDINE ISETHIONATE ........................ 73
PENTASA ................................................. 29, 134
PENTAZOCINE-ACETAMINOPHEN ......... 29, 35
PENTOXIFYLLINE ........................................... 86
PERJETA ......................................................... 52
PERMETHRIN .................................................112
PERMETHRIN 1 % ........................................ 159
PERPHENAZINE ............................................. 77
PERPHENAZINE-AMITRIPTYLINE ................. 61
PERRY PRENATAL 13.5-0.4MG ................... 166
PHENELZINE SULFATE ..................................61
PHENOBARBITAL ............................................56
PHENYLEPHRINE HCL ........................... 29, 117
PHENYLHISTINE DH 30-10-2/5 .....................157
PHENYTOIN .....................................................56
PHENYTOIN SODIUM .....................................56
PHENYTOIN SODIUM EXTENDED .................57
PHILITH ..........................................................102
PHOSPHA 250 NEUTRAL .............................141
PHOSPHOLINE IODIDE ................................139
PICATO ..........................................................106
PILOCARPINE HCL .........................29, 104, 139
PILOPINE HS .................................................139
PINDOLOL ........................................................91
PINK BISMUTH 262 MG ................................163
PINK BISMUTH 262MG .................................163
PINK BISMUTH 525MG/15ML .......................163
PIOGLITAZONE HCL .................................29, 66
PIRMELLA ......................................................103
PIROXICAM ......................................................37
PODOCON-25 ................................................106
PODOFILOX ...................................................106
POLY BACITRACIN 500-10K/G .....................158
POLYETHYLENE GLYCOL 3350 ...................120
POLYMYXIN B SULTRIMETHOPRIM ............................................115
POMALYST ...................................................... 52
PORTIA .......................................................... 103
POTASSIUM CHL-NORMAL
SALINE .......................................................... 141
POTASSIUM CHLORIDE .............................. 141
POTASSIUM CHLORIDE IN D5LR ................ 141
POTASSIUM CITRATE .................................. 141
POTASSIUM GLUCONATE
595(99)MG ..................................................... 165
POTIGA ............................................................ 29
POTIGA ........................................................... 57
POTIGA 50MG ................................................. 57
PRADAXA ........................................................ 84
PRAMIPEXOLE
DIHYDROCHLORIDE ...................................... 74
PRAVASTATIN SODIUM ................................. 96
PRAZOSIN HCL ............................................... 88
PREDNISOLONE ACETATE ..........................116
PREDNISOLONE SODIUM
PHOSPHATE ..........................................116, 124
PREDNISONE ............................................... 124
PREMARIN .................................................... 123
PREMASOL ..................................................... 87
PREMPHASE ................................................. 123
PREMPRO ..................................................... 123
188
Index of Drugs
PRENATAL 19 29 MG-1 MG .......................... 167
PRENATAL 28MG-0.8MG .............................. 167
PRENATAL FORMULA 28MG0.8MG ............................................................. 167
PRENATAL PLUS .......................................... 147
PRENATAL VITAMIN N/A .............................. 167
PRENATAL VITAMINS 60MG0.8MG ............................................................. 167
PREVALITE ...................................................... 96
PREVIFEM ..................................................... 103
PREZISTA .................................................. 29, 80
PREZISTA 75MG ............................................. 80
PRIFTIN ........................................................... 70
PRIMAQUINE ................................................... 73
PRIMAXIN I.M. ................................................. 44
PRIMIDONE ..................................................... 57
PROAIR HFA ........................................... 29, 144
PROBENECID ................................................ 137
PROBENECID-COLCHICINE ........................ 137
PROCAINAMIDE HCL ..................................... 89
PROCHLORPERAZINE
EDISYLATE ...................................................... 72
PROCHLORPERAZINE MALEATE ................. 72
PROCRIT ........................................................ 85
PROFED 600MG-60MG ................................. 157
PROGESTERONE ......................................... 126
PROGLYCEM ...................................................97
PROGRAF ......................................................129
PROLEUKIN .....................................................52
PROLIA ...........................................................135
PROMACTA .....................................................85
PROMETHAZINE HCL ...............................69, 72
PROMETHAZINE VC-CODEINE
6.25-5-10 ........................................................157
PROMETHAZINE W/CODEINE 6.2510/5 ...........................................................29, 157
PROMETHAZINE-DM 15-6.25/5 ....................157
PROPAFENONE HCL ......................................90
PROPARACAINE HCL ................................... 117
PROPRANOLOL HCL ......................................91
PROPRANOLOLHYDROCHLOROTHIAZID ...............................91
PROPYLTHIOURACIL ...................................126
PROQUAD ......................................................132
PROSTIGMIN .................................................137
PROTONIX IV ................................................. 118
PROTRIPTYLINE HCL .....................................61
PSEUDOEPHEDRINE 120 MG ......................157
PSEUDOGEST 30MG/5ML ............................157
PULMICORT FLEXHALER .............................142
PULMOZYME ................................................. 113
PYRAZINAMIDE ...............................................70
PYRETHRIN LICE TREATMENT N/
A ..................................................................... 159
PYRI 500 500 MG .......................................... 167
PYRIDOSTIGMINE BROMIDE ...................... 137
PYRIDOXINE HCL 500 MG ........................... 167
Q
Q-PAP 80MG/0.8ML ................................ 29, 150
QUASENSE ................................................... 103
QUETIAPINE FUMARATE ......................... 29, 77
QUINAPRIL HCL .............................................. 89
QUINAPRILHYDROCHLOROTHIAZIDE ............................ 89
QUINIDINE GLUCONATE ............................... 90
QUINIDINE SULFATE ..................................... 90
QVAR ............................................................. 142
R
RABAVERT .................................................... 132
RAMIPRIL ........................................................ 89
RANEXA .......................................................... 93
RANITIDINE HCL ............................................118
RANITIDINE HCL 75 MG ............................... 162
RAPAMUNE ................................................... 129
REALITY N/A ........................................... 29, 155
REBIF ............................................................. 137
REBIF REBIDOSE ......................................... 137
189
Index of Drugs
RECLIPSEN ................................................... 103
RECOMBIVAX HB ......................................... 132
RECTASOL-HC ...............................................111
RELENZA ................................................... 29, 81
RELISTOR ..................................................... 120
REMICADE .................................................... 137
REMODULIN .................................................. 146
RENAGEL ...................................................... 120
RENVELA ....................................................... 120
REPAGLINIDE ................................................. 63
REPREXAIN ..................................................... 29
RESCRIPTOR .................................................. 80
RESERPINE 0.1MG ......................................... 93
RESERPINE 0.25MG ....................................... 94
RESTASIS .................................................29, 116
RETROVIR ....................................................... 80
REVATIO ........................................................ 146
REVLIMID ........................................................ 52
REYATAZ ........................................................ 80
RHOGAM PLUS ............................................. 129
RHOPHYLAC ................................................. 130
RIBAVIRIN ....................................................... 83
RID 0.5 % ....................................................... 160
RID 4%-0.33% ................................................ 160
RIDAURA ....................................................... 130
RIFAMPIN .........................................................71
RIFATER ..........................................................71
RIGHT STEP PRENATAL VITAMINS
27MG-0.8MG ..................................................167
RIGINIC 131-31.7/5 ........................................163
RILUZOLE ........................................................99
RI-MAG 540MG/5ML ......................................163
RIMANTADINE HCL .........................................81
RINGERS INJECTION ...................................141
RIOCIGUAT ....................................................146
RISPERDAL CONSTA .....................................77
RISPERIDONE ...........................................29, 77
RISPERIDONE M-TAB ...............................29, 77
RISPERIDONE ODT ........................................30
RITUXAN ..........................................................52
RIVASTIGMINE ................................................58
RIZATRIPTAN ............................................30, 69
ROPINIROLE HCL ...........................................74
ROTATEQ ......................................................132
ROXICET ..........................................................30
S
SABRIL .............................................................57
SAIZEN ...........................................................125
SALSALATE .....................................................37
SANDOSTATIN LAR ......................................125
SANTYL ......................................................... 106
SAPHRIS ......................................................... 77
SAVELLA ......................................................... 99
SCALP ITCH-DANDRUFF RELIEF 3
% .................................................................... 158
SELEGILINE HCL ............................................ 74
SELENIUM SULFIDE ..................................... 107
SELENOS ...................................................... 106
SELZENTRY .................................................... 80
SENSIPAR ....................................................... 30
SENSIPAR 30MG .......................................... 137
SENSIPAR 60MG, 90MG .............................. 138
SEREVENT DISKUS ..................................... 144
SEROSTIM .................................................... 125
SERTRALINE HCL .......................................... 61
SF 5000 PLUS ............................................... 104
SILACE 50 MG/5 ML ...................................... 163
SILDENAFIL ................................................... 146
SILPHEN 12.5MG/5ML .................................. 153
SILVER SULFADIAZINE ................................ 107
SIMULECT ..................................................... 138
SIMVASTATIN ................................................. 96
SINGLE USE SWAB ...................................... 106
SLEEP TABLET 25MG .................................. 153
SLOW RELEASE IRON 47.5 IRON ............... 167
190
Index of Drugs
SODIUM BICARBONATE .............................. 141
SODIUM BICARBONATE 325 MG ................ 163
SODIUM BICARBONATE 650 MG ................ 163
SODIUM CHLORIDE ............................. 134, 142
SODIUM CHLORIDE 0.9 % ........................... 165
SODIUM CITRATE & CITRIC ACID ............... 142
SODIUM FLUORIDE ...................................... 104
SODIUM PHENYLBUTYRATE ...................... 120
SOLTAMOX ..................................................... 52
SOMATULINE DEPOT ................................... 125
SOMAVERT ................................................... 125
SORIATANE ................................................... 106
SORINE ............................................................ 91
SOTALOL ......................................................... 91
SOTALOL AF ................................................... 91
SPASMOLIN 16.2MG ..................................... 151
SPIRIVA ................................................... 30, 144
SPIRONOLACTONE ........................................ 97
SPIRONOLACTONE-HCTZ ............................. 97
SPRINTEC ..................................................... 103
SPRYCEL ......................................................... 52
SPS ................................................................ 120
SRONYX ........................................................ 103
STAGESIC ................................................. 30, 35
STANNOUS FLUORIDE ................................ 104
STAVUDINE .....................................................80
STERILE PADS ..............................................138
STIVARGA ........................................................52
STOOL SOFTENER 100MG ..........................164
STOOL SOFTENER 60 MG/15ML .................164
STRATTERA ....................................................99
STREPTOMYCIN SULFATE ............................40
STRIBILD ..........................................................80
STROMECTOL .................................................73
SUBOXONE .....................................................39
SUCRAID ........................................................ 113
SUCRALFATE ................................................ 119
SUDAFED SINUS 30MG-500MG ...................154
SUDOGEST 60 MG ........................................157
SULFACETAMIDE SODIUM .......................... 115
SULFACETAMIDEPREDNISOLONE ........................................... 115
SULFADIAZINE ................................................47
SULFAMETHOXAZOLETRIMETHOPRIM ..............................................47
SULFASALAZINE .............................................47
SULFASALAZINE DR .......................................47
SULINDAC ........................................................37
SUMATRIPTAN ..........................................30, 70
SUMATRIPTAN SUCCINATE ....................30, 70
SUPHEDRINE SINUS
CONGESTION 30 MG ................................... 157
SUPPOSITORY ADULT ................................ 164
SUPRAX .......................................................... 43
SURE COMFORT ...........................................112
SUSTIVA .......................................................... 80
SUTENT ........................................................... 52
SYLATRON 4-PACK ........................................ 82
SYMLIN ............................................................ 63
SYMLINPEN .................................................... 63
SYNAREL ...................................................... 138
SYNRIBO ......................................................... 52
SYNTHROID .................................................. 126
T
TABLOID .......................................................... 52
TACROLIMUS ............................................... 130
TACROLIMUS 5MG ....................................... 130
TAFINLAR ........................................................ 52
TAMIFLU .................................................... 30, 81
TAMIFLU 30MG ............................................... 30
TAMIFLU 45MG, 75MG ................................... 30
TAMOXIFEN CITRATE .................................... 52
TAMSULOSIN HCL .................................. 30, 146
TARCEVA ........................................................ 52
TARGRETIN .............................................52, 111
191
Index of Drugs
TASIGNA .......................................................... 53
TASMAR .......................................................... 74
TAZICEF .......................................................... 43
TAZICEF IN DEXTROSE ................................. 43
TAZORAC .......................................................111
TAZTIA XT ....................................................... 92
TE ANATOXAL BERNA ................................. 132
TECFIDERA ................................................... 138
TEGRETOL XR ................................................ 57
TEKTURNA ...................................................... 97
TEKTURNA HCT .............................................. 97
TEMAZEPAM ............................................. 30, 39
TEMODAR ....................................................... 53
TENIPOSIDE .................................................... 53
TENIVAC ........................................................ 132
TENSION HEADACHE RELIEF
500MG-65MG ................................................. 150
TERAZOSIN HCL ........................................... 146
TERBINAFINE HCL ......................................... 68
TERBUTALINE SULFATE ............................. 144
TERCONAZOLE .............................................. 69
TETANUS DIPHTHERIA TOXOIDS ............... 132
TETANUS TOXOID ADSORBED ................... 132
TETRACAINE HCL .........................................117
TETRACYCLINE HCL ...................................... 48
T-GEL 1 % ......................................................158
THALOMID .....................................................138
THEO-24 .........................................................144
THEOPHYLLINE ............................................144
THEOPHYLLINE ANHYDROUS ....................144
THEOPHYLLINE IN 5% DEXTROSE .............144
THERACYS ....................................................133
THIOLA ...........................................................138
THIORIDAZINE HCL ........................................77
THIOTHIXENE ..................................................77
THYROLAR-1 .................................................126
THYROLAR-1/2 ..............................................126
THYROLAR-1/4 ..............................................127
THYROLAR-2 .................................................127
THYROLAR-3 .................................................127
TIAGABINE HCL ..............................................57
TICAR ...............................................................46
TICAR IN DEXTROSE ......................................46
TICLOPIDINE HCL ...........................................86
TIKOSYN ..........................................................90
TILIA FE ..........................................................103
TIMENTIN .........................................................46
TIMOLOL MALEATE ................................91, 139
TIROSINT .......................................................127
TIZANIDINE HCL ............................................145
TOBI ................................................................. 40
TOBRAMYCIN ................................................115
TOBRAMYCIN SULFATE ................................ 40
TOBRAMYCIN-DEXAMETHASONE ..............115
TOLAZAMIDE ............................................ 30, 65
TOLBUTAMIDE .......................................... 30, 65
TOLMETIN SODIUM ........................................ 37
TOLNAFTATE 1% .......................................... 152
TOLTERODINE TARTRATE .................... 30, 121
TOPIRAMATE .................................................. 57
TOPOTECAN HCL ........................................... 53
TORSEMIDE .................................................... 95
TPN ELECTROLYTES ................................... 142
TRACLEER .................................................... 147
TRADJENTA .............................................. 30, 63
TRAMADOL HCL ....................................... 30, 35
TRAMADOL HCLACETAMINOPHEN .................................... 31, 35
TRANDOLAPRIL .............................................. 89
TRANEXAMIC ACID ........................................ 85
TRANYLCYPROMINE SULFATE .................... 61
TRAVASOL ...................................................... 87
TRAVATAN Z ........................................... 31, 139
TRAVEL MOTION SICKNESS 25
MG ................................................................. 154
TRAVOPROST ........................................ 31, 139
192
Index of Drugs
TRAZODONE HCL ........................................... 61
TRECATOR ...................................................... 71
TRELSTAR ....................................................... 53
TRETINOIN ...................................................... 53
TRETINOIN .....................................................112
TRIAMCINOLONE ACETONIDE ............104, 111
TRIAMTERENE-HCTZ ..................................... 95
TRIAZOLAM ............................................... 31, 39
TRI-BUFFERED ASPIRIN 325 MG ................ 151
TRIFLUOPERAZINE HCL ................................ 77
TRIFLURIDINE ................................................115
TRIHEXYPHENIDYL HCL ................................ 74
TRI-LEGEST FE ............................................. 103
TRILEPTAL ...................................................... 57
TRI-LINYAH ................................................... 103
TRILYTE WITH FLAVOR PACKETS ............. 120
TRIMETHOPRIM .............................................. 41
TRIMIPRAMINE MALEATE ............................. 61
TRINESSA ..................................................... 103
TRIOTANN-S 5-12.5-2/5 ................................ 153
TRIPLE ANTIBIOTIC 3.5-400-5K ................... 159
TRIPLE ANTIBIOTIC PLUS 3.5-10K10 ................................................................... 159
TRI-PREVIFEM .............................................. 103
TRISENOX ....................................................... 53
TRI-SPRINTEC ...............................................103
TRI-VITAMIN 1500-35/ML ..............................167
TRIVORA-28 ...................................................103
TROJAN NATURALAMB N/A ...................31, 156
TROJAN SUPRA NA ................................31, 156
TROPHAMINE ..................................................87
TROPICAMIDE ............................................... 117
TRUVADA .........................................................81
TUDORZA PRESSAIR ...................................144
TUSSIN DM 100-10MG/5 ...............................157
TUSSIN MAX STRENGTH COUGH/
COLD 15-30MG/5 ...........................................157
TWINRIX .........................................................133
TYGACIL ..........................................................48
TYKERB ...........................................................53
TYPHIM VI ......................................................133
TYSABRI ........................................................130
TYZEKA ............................................................83
TYZINE ........................................................... 117
U
U-CORT .......................................................... 111
UNITHROID ....................................................127
UROGESIC 95MG ..........................................158
URSODIOL .....................................................120
V
VAGINAL 3-DAY 200 MG-1 % ....................... 152
VALACYCLOVIR .............................................. 83
VALCYTE ......................................................... 83
VALPROATE SODIUM .................................... 57
VALPROIC ACID ............................................. 57
VALSARTANHYDROCHLOROTHIAZIDE ............................ 88
VANCOMYCIN HCL ......................................... 41
VAQTA ........................................................... 133
VARIVAX VACCINE ....................................... 133
VASCEPA ........................................................ 96
VCF 12.5% ..................................................... 156
VELCADE ........................................................ 53
VELETRI ........................................................ 147
VELIVET ........................................................ 103
VENLAFAXINE HCL ........................................ 61
VENLAFAXINE HCL ER .................................. 62
VENTOLIN ............................................... 31, 144
VERAPAMIL ER ............................................... 92
VERAPAMIL ER PM ........................................ 92
VERAPAMIL HCL ............................................ 92
VERDESO .......................................................111
VERSACLOZ ................................................... 77
VICTOZA 3-PAK .............................................. 63
193
Index of Drugs
VICTRELIS ....................................................... 82
VIDEX ............................................................... 81
VIGAMOX ........................................................115
VIIBRYD ........................................................... 62
VIMPAT ...................................................... 31, 57
VINCRISTINE SULFATE
LIPOSOMAL ..................................................... 53
VIORELE ........................................................ 103
VIRACEPT ....................................................... 81
VIRAMUNE XR ................................................ 81
VIREAD ............................................................ 81
VIRTUSSIN AC 100-10MG/5 ......................... 157
VITAMIN A 10000 UNIT ................................. 167
VITAMIN A 25000 UNIT ................................. 167
VITAMIN A 8000 UNIT ................................... 167
VITAMIN B-12 1000 MCG .............................. 167
VITAMIN B-6 100MG ..................................... 167
VITAMIN B-6 200 MG .................................... 167
VITAMIN B-6 250 MG .................................... 167
VITAMIN B-6 25MG ....................................... 168
VITAMIN B-6 50 MG ...................................... 168
VITAMIN B-6 50MG ....................................... 168
VITAMIN C 100 MG ....................................... 168
VITAMIN C 1000 MG ..................................... 168
VITAMIN C 1500 MG ..................................... 168
VITAMIN C 250 MG ........................................168
VITAMIN C 300 MG ........................................168
VITAMIN C 500 MG ........................................168
VITAMIN C 500 MG/5ML ................................168
VITAMIN D 1000 UNIT ...................................168
VITAMIN D 400 UNIT .....................................168
VITAMIN D2 400 UNIT ...................................169
VITAMIN D2 50000 UNIT ...............................169
VITAMIN K 100 MCG .....................................169
VIVOTIF BERNA ............................................133
VORAXAZE ....................................................138
VORICONAZOLE .............................................68
VORTEX FROG MASK N/A .....................31, 160
VORTEX N/A ............................................31, 160
VORTIOXETINE HYDROBROMIDE ................62
VOTRIENT ........................................................53
VPRIV ............................................................. 113
W
WARFARIN SODIUM .......................................84
WATER ...........................................................134
WELCHOL ........................................................96
WERA .............................................................104
WINRHO SDF .................................................130
WOMAN'S LAXATIVE 5 MG...........................164
X
XALKORI .......................................................... 53
XARELTO ........................................................ 84
XELJANZ ....................................................... 138
XENAZINE ....................................................... 99
XGEVA ........................................................... 135
XOLAIR .......................................................... 144
XTANDI ............................................................ 53
XYREM .......................................................... 145
Y
YERVOY .......................................................... 53
YF-VAX .......................................................... 133
YODOXIN ......................................................... 73
Z
ZAFIRLUKAST ......................................... 31, 143
ZALEPLON .................................................... 145
ZALTRAP ......................................................... 53
ZAVESCA .......................................................114
ZELBORAF ...................................................... 54
ZEMAIRA ....................................................... 145
ZEMPLAR ...................................................... 135
ZENCHENT .................................................... 104
ZENCHENT FE .............................................. 104
ZENPEP ..........................................................114
194
Index of Drugs
ZETIA ............................................................... 96
ZIAGEN ............................................................ 81
ZIDOVUDINE ................................................... 81
ZIPRASIDONE HCL ......................................... 77
ZIPRASIDONE HCL 20MG, 40MG .................. 31
ZIPRASIDONE HCL 60MG, 80MG .................. 31
ZMAX ......................................................... 31, 44
ZOLADEX ......................................................... 54
ZOLEDRONIC ACID ...................................... 135
ZOLEDRONIC ACID/
MANNITOL&WATER ..................................... 135
ZOLINZA .......................................................... 54
ZOLPIDEM TARTRATE ........................... 31, 146
ZONALON ...................................................... 106
ZONISAMIDE ................................................... 58
ZORBTIVE ..................................................... 125
ZORTRESS .................................................... 130
ZOSTAVAX .................................................... 133
ZOVIA 1-35E .................................................. 104
ZOVIA 1-50E .................................................. 104
ZOVIRAX .................................................. 31, 106
ZYTIGA ............................................................ 54
ZYVOX ............................................................. 41
195
CARE1ST CAL MEDICONNECT PLAN
Danh sách thuốc được bảo hiểm (Danh mục) năm 2014
QUẬN: LOS ANGELES VÀ SAN DIEGO
CARE1ST HEALTH PLAN
601 Potrero Grande Dr., Monterey Park, CA 91755
DỊCH VỤ HỘI VIÊN
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ĐƯỜNG DÂY TRỢ GIÚP NGƯỜI KHIẾM THÍNH TTY
711
8:00 sáng – 8:00 tối, 7 ngày trong tuần
www.care1st.com/ca/calmediconnect
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Danh sách thuốc được bảo hiểm (Danh mục) năm 2014

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