Sharp Advantage (HMO) 2016 Formulary

Transcription

Sharp Advantage (HMO)
2016 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
Sharp Advantage 2016 Part D Formulary Effective 07/01/2016
Formulary ID: 16490.000, Version: 15
This formulary was updated on 06/27/2016. For more recent information or other questions, please contact
Sharp Advantage Customer Care at 1-855-820-2112 or visit www.sharphealthplan.com/sharpadvantage for
additional information. (TTY users should call 711.) Hours are 8:00 a.m. to 6:00 p.m. Pacific Time, Monday
to Friday.
Note to existing members: This formulary has changed since last year. Please review this document to
make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Sharp Health Plan. When it refers to
“plan” or “our plan,” it means Sharp Advantage.
This document includes the list of the drugs (formulary) for our plan which is current as of July 1, 2016.
For an updated formulary, please contact us. Our contact information, along with the date we last updated
the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. The Formulary may
change at any time. You will receive notice when necessary. Benefits may change on January 1 of each year.
H5386_SA COMP FORMULARY
i
What is the Sharp Advantage Formulary?
A formulary is a list of covered drugs selected by Sharp Advantage in consultation with a team of health care
providers, which represents the prescription therapies believed to be a necessary part of a quality treatment
program. Sharp Advantage will generally cover the drugs listed in our formulary as long as the drug is
medically necessary, the prescription is filled at a Sharp Advantage network pharmacy, and other plan rules
are followed. For more information on how to fill your prescriptions, please review your Evidence of
Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we
will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or effectiveness
of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will
not affect members who are currently taking the drug. It will remain available at the same cost-sharing for
those members taking it for the remainder of the coverage year. We feel it is important that you have
continued access for the remainder of the coverage year to the formulary drugs that were available when you
chose our plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the
change at least 60 days before the change becomes effective, or at the time the member requests a refill of
the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug
Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug
from the market, we will immediately remove the drug from our formulary and provide notice to members
who take the drug. The enclosed formulary is current as of July 1, 2016. To get updated information about
the drugs covered by Sharp Advantage, please contact us. Our contact information appears on the front and
back cover pages. In the event of mid-year non-maintenance formulary changes, we will notify in writing so
that you have the changes. We will post an updated version of the Sharp Advantage formulary on our website
at www.sharphealthplan.com/sharpadvantage. If you would like a printed version of the corrections, we will
mail it to you upon request.
ii
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on
the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, “Cardiovascular Agents”. If you know what your drug is used
for, look for the category name in the list that begins on page number 1. Then look under the category
name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on
page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next
to your drug, you will see the page number where you can find coverage information. Turn to the page
listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
Sharp Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the
FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less
than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:
•
Prior Authorization: Sharp Advantage requires you or your physician to get prior authorization for
certain drugs. This means that you will need to get approval from Sharp Advantage before you fill
your prescriptions. If you don’t get approval, Sharp Advantage may not cover the drug.
•
Quantity Limits: For certain drugs, Sharp Advantage limits the amount of the drug that Sharp
Advantage will cover. For example, Sharp Advantage provides 30 tablets for 30 days per
prescription for simvastatin. This may be in addition to a standard one-month or three-month supply.
•
Step Therapy: In some cases, Sharp Advantage requires you to first try certain drugs to treat your
medical condition before we will cover another drug for that condition. For example, if Drug A and
Drug B both treat your medical condition, Sharp Advantage may not cover Drug B unless you try
Drug A first. If Drug A does not work for you, Sharp Advantage will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 1. You can also get more information about the restrictions applied to specific covered drugs
by visiting our Web site. We have posted on line a document that explain our prior authorization and step
therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date
we last updated the formulary, appears on the front and back cover pages.
iii
You can ask Sharp Advantage to make an exception to these restrictions or limits or for a list of other,
similar drugs that may treat your health condition. See the section, “How do I request an exception to the
Sharp Advantage formulary?” on page iv for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Member
Services and ask if your drug is covered.
If you learn that Sharp Advantage does not cover your drug, you have two options:
•
You can ask Member Services for a list of similar drugs that are covered by Sharp Advantage. When
you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is
covered by Sharp Advantage.
•
You can ask Sharp Advantage to make an exception and cover your drug. See below for information
about how to request an exception.
How do I request an exception to the Sharp Advantage Formulary?
You can ask Sharp Advantage to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.
•
•
•
You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be
covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the
drug at a lower cost-sharing level.
You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the
specialty tier. If approved this would lower the amount you must pay for your drug.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
Sharp Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit,
you can ask us to waive the limit and cover a greater amount.
Generally, Sharp Advantage will only approve your request for an exception if the alternative drugs included
on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as
effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you request a formulary, tiering or utilization restriction exception you
should submit a statement from your prescriber or physician supporting your request. Generally, we
must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request
an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by
waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no
later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need
a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide
iv
if you should switch to an appropriate drug that we cover or request a formulary exception so that we will
cover the drug you take. While you talk to your doctor to determine the right course of action for you, we
may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a
network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a
member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with 98-day transition supply, consistent with dispensing increment, (unless you have a
prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days
you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your
drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary
exception.
If you are a member entering a long-term care (LTC) facility from other care settings and have a level of care
change, we will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer
days.
For more information
For more detailed information about your Sharp Advantage prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about Sharp Advantage, please contact us. Our contact information, along with the date
we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or,
visit http://www.medicare.gov.
Sharp Advantage’s Formulary
The formulary that begins on page 1 provides coverage information about the drugs covered by Sharp
Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) and
generic drugs are listed in lower-case italics (e.g., lisinopril).
The information in the Requirements/Limits column tells you if Sharp Advantage has any special
requirements for coverage of your drug.
v
The following abbreviations may be found within the body of this document
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION DESCRIPTION
PA
Prior Authorization
Restriction
PA BvD
Prior Authorization
Restriction for
Part B vs Part D
Determination
EXPLANATION
You (or your provider) are required to get prior authorization
from Sharp Advantage before you fill your prescription for
this drug. Without prior approval, we may not cover this
drug.
This drug may be eligible for payment under Medicare Part
B or Part D. You (or your provider) are required to get
authorization from us to determine that this drug is covered
under Medicare Part D before you fill your prescription for
this drug. Without prior approval, we may not cover this
drug.
PA-HRM
Prior Authorization
If you are 65 years or older, you (or your provider) are
Restrictions for members required to get prior authorization from us before you fill your
65 years and older
prescription for this drug. Without prior authorization, we
may not cover this drug.
PA NSO
Prior Authorization
If you are a new member or you have not taken this drug
Restriction for New Starts previously, you (or your provider) are required to get prior
Only
authorization from us before you fill your prescription for this
drug. Without prior approval, we may not cover this drug.
QL
Quantity Limit
Restrictions
ST
Step Therapy Restriction Before we will provide coverage for this drug, you must first
try another drug(s) to treat your medical condition. This drug
may only be covered if the other drug(s) does not work for
you.
LA
Limited Access Drugs
This prescription may be available only at certain pharmacies.
For more information consult your Pharmacy Directory or call
Member Services at 1-855-820-2112 (TTY 711) 8:00 a.m. to
6:00 p.m. Pacific Time, Monday-Friday.
NM
No Mail Order
This drug is not available through mail order.
We limit the amount of this drug that is covered per
prescription, or within a specific time frame.
vi
Table of Contents
Contents
of
Table
Analgesics ........................................................................................................................................................................................................................................................................................................ 3
Anesthetics ................................................................................................................................................................................................................................................................................................. 10
Anti-Addiction/Substance Abuse Treatment Agents ................................................................................................................................................................... 11
Antianxiety Agents ........................................................................................................................................................................................................................................................................ 12
Antibacterials ......................................................................................................................................................................................................................................................................................... 13
Anticancer Agents ........................................................................................................................................................................................................................................................................... 23
Anticholinergic Agents ............................................................................................................................................................................................................................................................. 33
Anticonvulsants .................................................................................................................................................................................................................................................................................. 34
Antidementia Agents .................................................................................................................................................................................................................................................................. 38
Antidepressants ................................................................................................................................................................................................................................................................................... 39
Antidiabetic Agents ...................................................................................................................................................................................................................................................................... 42
Antifungals ................................................................................................................................................................................................................................................................................................ 47
Antihistamines ...................................................................................................................................................................................................................................................................................... 50
Anti-Infectives (Skin And Mucous Membrane) .................................................................................................................................................................................. 50
Antimigraine Agents ................................................................................................................................................................................................................................................................... 50
Antimycobacterials ........................................................................................................................................................................................................................................................................ 51
Antinausea Agents ......................................................................................................................................................................................................................................................................... 52
Antiparasite Agents ...................................................................................................................................................................................................................................................................... 53
Antiparkinsonian Agents ...................................................................................................................................................................................................................................................... 54
Antipsychotic Agents ................................................................................................................................................................................................................................................................. 55
Antivirals (Systemic) ................................................................................................................................................................................................................................................................... 59
Blood Products/Modifiers/Volume Expanders ..................................................................................................................................................................................... 65
Caloric Agents ...................................................................................................................................................................................................................................................................................... 69
Cardiovascular Agents ............................................................................................................................................................................................................................................................. 73
Central Nervous System Agents ................................................................................................................................................................................................................................. 86
Contraceptives ...................................................................................................................................................................................................................................................................................... 88
Dental And Oral Agents ........................................................................................................................................................................................................................................................ 95
Dermatological Agents ............................................................................................................................................................................................................................................................ 95
Devices ......................................................................................................................................................................................................................................................................................................... 101
Enzyme Replacement/Modifiers ............................................................................................................................................................................................................................ 102
Eye, Ear, Nose, Throat Agents ................................................................................................................................................................................................................................. 104
Gastrointestinal Agents ....................................................................................................................................................................................................................................................... 109
Genitourinary Agents ............................................................................................................................................................................................................................................................. 113
Heavy Metal Antagonists ................................................................................................................................................................................................................................................. 114
Hormonal Agents, Stimulant/Replacement/Modifying ....................................................................................................................................................... 114
Immunological Agents .......................................................................................................................................................................................................................................................... 121
Inflammatory Bowel Disease Agents ............................................................................................................................................................................................................... 129
Irrigating Solutions .................................................................................................................................................................................................................................................................... 129
Metabolic Bone Disease Agents .............................................................................................................................................................................................................................. 130
Miscellaneous Therapeutic Agents ..................................................................................................................................................................................................................... 132
Sharp Advantage 2016 Part D Formulary
1
Effective: July 01, 2016
Contents
of
Table
Ophthalmic Agents .................................................................................................................................................................................................................................................................... 137
Replacement Preparations .............................................................................................................................................................................................................................................. 138
Respiratory Tract Agents ................................................................................................................................................................................................................................................. 143
Skeletal Muscle Relaxants ............................................................................................................................................................................................................................................... 147
Sleep Disorder Agents ........................................................................................................................................................................................................................................................... 147
Vasodilating Agents .................................................................................................................................................................................................................................................................. 148
Vitamins And Minerals ....................................................................................................................................................................................................................................................... 149
2
Drug Name
Drug Tier
Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen-codeine 120 mg-12 mg/5
ml solution 120-12 mg/5 ml
acetaminophen-codeine oral solution 300
mg-30 mg /12.5 ml
acetaminophen-codeine oral tablet 300-15
mg, 300-30 mg
acetaminophen-codeine oral tablet 300-60
mg
ALLZITAL ORAL TABLET 25-325
MG
ascomp with codeine oral capsule
30-50-325-40 mg
BELBUCA BUCCAL FILM 150
MCG, 300 MCG, 450 MCG, 600 MCG,
75 MCG, 750 MCG, 900 MCG
buprenorphine hcl injection syringe 0.3
mg/ml
butalbital compound w/codeine oral
capsule 30-50-325-40 mg
butalbital-acetaminop-caf-cod oral
capsule 50-300-40-30 mg, 50-325-40-30
mg
butalbital-acetaminophen oral tablet
50-325 mg
butalbital-acetaminophen-caff oral
capsule 50-325-40 mg
butalbital-acetaminophen-caff oral tablet
50-325-40 mg
butalbital-aspirin-caffeine oral capsule
50-325-40 mg
butorphanol tartrate nasal
spray,non-aerosol 10 mg/ml
(Acetaminophen with
Codeine)
(Acetaminophen with
Codeine)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
2
QL (2700 per 30 days)
2
2
2
2
(Fiorinal with Codeine
#3)
2
4
ST; QL (60 per 30 days)
(Buprenorphine HCl)
2
(Fiorinal with Codeine
#3)
(Fioricet with Codeine)
2
2
(Tencon)
2
(Esgic)
2
(Esgic)
2
(Fiorinal)
2
(Butorphanol Tartrate)
2
QL (5 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
3
Drug Name
Drug Tier
BUTRANS TRANSDERMAL
PATCH WEEKLY 10 MCG/HOUR,
15 MCG/HOUR, 20 MCG/HOUR, 5
MCG/HOUR, 7.5 MCG/HOUR
capacet oral capsule 50-325-40 mg
codeine sulfate oral tablet 15 mg, 30 mg,
60 mg
EMBEDA ORAL CAPSULE,ORAL
ONLY,EXT.REL PELL 100-4 MG,
20-0.8 MG, 30-1.2 MG, 50-2 MG,
60-2.4 MG, 80-3.2 MG
endocet oral tablet 10-325 mg, 2.5-325
mg, 5-325 mg, 7.5-325 mg
endodan oral tablet 4.8355-325 mg
fentanyl citrate buccal lozenge on a
handle 1,200 mcg, 1,600 mcg, 200 mcg,
400 mcg, 600 mcg, 800 mcg
fentanyl transdermal patch 72 hour 100
mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5
mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75
mcg/hr, 87.5 mcg/hour
hydrocodone-acetaminophen oral solution
10-325 mg/15 ml(15 ml), 2.5-167 mg/5
ml, 7.5-325 mg/15 ml
hydrocodone-acetaminophen oral tablet
10-300 mg, 5-300 mg, 7.5-300 mg
3
QL (4 per 28 days)
2
2
4
QL (60 per 30 days)
(Xolox)
2
(Percodan)
(Actiq)
2
5
PA; QL (120 per 30
days)
(Duragesic)
2
QL (10 per 30 days)
(Hycet)
2
(Norco)
2
(Norco)
2
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
(Ibudone)
2
(Dilaudid-HP)
2
(Dilaudid)
2
hydrocodone-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg,
7.5-325 mg
hydrocodone-ibuprofen oral tablet 10-200
mg, 2.5-200 mg, 5-200 mg, 7.5-200 mg
hydromorphone (pf) injection solution 10
mg/ml
hydromorphone (pf) injection solution 4
mg/ml
(Esgic)
(Codeine Sulfate)
Requirements/Limits
4
Drug Name
hydromorphone injection solution 2
mg/ml
hydromorphone injection syringe 2 mg/ml
hydromorphone oral liquid 1 mg/ml
hydromorphone oral tablet 2 mg, 4 mg
hydromorphone oral tablet 8 mg
HYSINGLA ER ORAL
TABLET,ORAL ONLY,EXT.REL.24
HR 100 MG, 120 MG, 20 MG, 30 MG,
40 MG, 60 MG, 80 MG
LAZANDA NASAL
SPRAY,NON-AEROSOL 100
MCG/SPRAY, 400 MCG/SPRAY
lorcet (hydrocodone) oral tablet 5-325
mg
lorcet hd oral tablet 10-325 mg
lorcet plus oral tablet 7.5-325 mg
margesic oral capsule 50-325-40 mg
methadone injection solution 10 mg/ml
methadone oral solution 10 mg/5 ml, 5
mg/5 ml
methadone oral tablet 10 mg, 5 mg
methadose oral tablet,soluble 40 mg
morphine (pf) in 0.9 % nacl intravenous
pt controlled analgesia syring 50 mg/25
ml (2 mg/ml)
morphine 10 mg/ml carpuject 10 mg/ml
morphine 8 mg/ml syringe 8 mg/ml
morphine concentrate oral solution 100
mg/5 ml (20 mg/ml)
morphine concentrate oral syringe 20
mg/ml
Drug Tier
(Hydromorphone HCl)
2
(Hydromorphone HCl)
(Dilaudid)
(Dilaudid)
(Dilaudid)
2
2
2
2
3
Requirements/Limits
QL (30 per 30 days)
5
PA; QL (30 per 30
days)
(Norco)
2
(Norco)
(Norco)
(Esgic)
(Methadone HCl)
(Methadone HCl)
2
2
2
2
2
(Diskets)
(Diskets)
(Morphine
Sulfate/0.9% Nacl/PF)
2
2
2
QL (90 per 30 days)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
2
2
2
2
2
(Morphine Sulfate)
2
5
Drug Name
morphine in dextrose 5 % injection pt
controlled analgesia syring 100 mg/50 ml
(2 mg/ml), 50 mg/25 ml (2 mg/ml)
morphine injection solution 15 mg/ml, 8
mg/ml
morphine injection syringe 10 mg/ml
morphine intramuscular pen injector 10
mg/0.7 ml
morphine intravenous cartridge 15 mg/ml
morphine intravenous solution 25 mg/ml,
50 mg/ml
morphine intravenous syringe 10 mg/ml, 2
mg/ml, 4 mg/ml, 8 mg/ml
morphine oral solution 10 mg/5 ml
morphine oral solution 20 mg/5 ml (4
mg/ml)
MORPHINE ORAL TABLET 15 MG,
30 MG
morphine oral tablet extended release 100
mg, 30 mg, 60 mg
morphine oral tablet extended release 15
mg, 200 mg
morphine rectal suppository 10 mg, 20
mg, 30 mg, 5 mg
NUCYNTA ER ORAL TABLET
EXTENDED RELEASE 12 HR 100
MG, 150 MG, 200 MG, 250 MG, 50
MG
NUCYNTA ORAL TABLET 100 MG,
50 MG, 75 MG
oxycodone oral capsule 5 mg
oxycodone oral concentrate 20 mg/ml
oxycodone oral solution 5 mg/5 ml
oxycodone oral tablet 10 mg, 15 mg, 20
mg, 30 mg, 5 mg
Drug Tier
Requirements/Limits
(Morphine
Sulfate/D5W)
2
(Morphine Sulfate)
2
(Morphine Sulfate)
(Morphine Sulfate)
2
2
(Morphine Sulfate)
(Morphine Sulfate)
2
2
(Morphine Sulfate)
2
(Morphine Sulfate)
(Morphine Sulfate)
2
2
4
(MS Contin)
2
(MS Contin)
2
(Morphine Sulfate)
2
(Oxycodone HCl)
(Oxycodone HCl)
(Oxycodone HCl)
(Roxicodone)
3
QL (60 per 30 days)
3
2
2
2
2
6
Drug Name
oxycodone oral tablet,oral only,ext.rel.12
hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg,
60 mg
oxycodone oral tablet,oral only,ext.rel.12
hr 80 mg
oxycodone-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg,
7.5-325 mg
10-650 mg
7.5-500 mg
oxycodone-aspirin oral tablet 4.8355-325
mg
OXYCONTIN ORAL
HR 10 MG, 15 MG, 20 MG, 30 MG, 40
MG, 60 MG
OXYCONTIN ORAL
HR 80 MG
oxymorphone oral tablet 10 mg, 5 mg
oxymorphone oral tablet extended release
12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
oxymorphone oral tablet extended release
12 hr 30 mg, 40 mg
reprexain oral tablet 10-200 mg, 2.5-200
mg, 5-200 mg
roxicet oral solution 5-325 mg/5 ml
tencon oral tablet 50-325 mg
tramadol oral tablet 50 mg
tramadol-acetaminophen oral tablet
37.5-325 mg
Drug Tier
Requirements/Limits
(Oxycontin)
2
QL (60 per 30 days)
(Oxycontin)
5
(Xolox)
2
(Xolox)
2
(Xolox)
2
(Percodan)
2
3
QL (60 per 30 days)
3
(Opana)
(Opana ER)
2
2
QL (60 per 30 days)
(Opana ER)
2
(Ibudone)
2
(Oxycodone
HCl/Acetaminophen)
(Tencon)
(Ultram)
(Ultracet)
2
2
2
2
7
Drug Name
Drug Tier
vicodin es oral tablet 7.5-300 mg
(Norco)
2
vicodin hp oral tablet 10-300 mg
(Norco)
2
vicodin oral tablet 5-300 mg
(Norco)
2
XARTEMIS XR ORAL TAB,ORAL
ONLY,IR - ER, BIPHASE 7.5-325 MG
xylon 10 oral tablet 10-200 mg
zebutal oral capsule 50-325-40 mg
ZOHYDRO ER ORAL CAPSULE,
ORAL ONLY, ER 12HR 10 MG, 15
MG, 20 MG, 30 MG, 40 MG, 50 MG
Nonsteroidal Anti-Inflammatory
Agents
CALDOLOR INTRAVENOUS
RECON SOLN 400 MG/4 ML (100
MG/ML)
celecoxib oral capsule 100 mg, 200 mg,
400 mg, 50 mg
choline,magnesium salicylate oral liquid
500 mg/5 ml
diclofenac potassium oral tablet 50 mg
diclofenac sodium oral tablet extended
release 24 hr 100 mg
diclofenac sodium oral tablet,delayed
release (dr/ec) 25 mg, 50 mg, 75 mg
diclofenac sodium topical gel 3 %
diclofenac-misoprostol oral
tablet,ir,delayed rel,biphasic 50-200
mg-mcg, 75-200 mg-mcg
(Ibudone)
(Esgic)
Requirements/Limits
3
(includes Vicodin,
Vicodin ES and
per 30 days)
(includes Vicodin,
Vicodin ES and
per 30 days)
(includes Vicodin,
Vicodin ES and
per 30 days)
2
2
4
QL (60 per 30 days)
4
(Celebrex)
2
(Choline Sal/Mag
Salicylate)
(Diclofenac Potassium)
(Voltaren-XR)
2
(Diclofenac Sodium)
2
(Voltaren)
(Arthrotec 50)
5
2
QL (60 per 30 days)
2
2
8
Drug Name
diflunisal oral tablet 500 mg
etodolac oral capsule 200 mg, 300 mg
etodolac oral tablet 400 mg, 500 mg
etodolac oral tablet extended release 24
hr 400 mg, 500 mg, 600 mg
fenoprofen oral tablet 600 mg
FLECTOR TRANSDERMAL
PATCH 12 HOUR 1.3 %
flurbiprofen oral tablet 100 mg, 50 mg
ibuprofen oral suspension 100 mg/5 ml
ibuprofen oral tablet 400 mg, 600 mg,
800 mg
indomethacin oral capsule 25 mg
indomethacin oral capsule 50 mg
indomethacin oral capsule, extended
release 75 mg
indomethacin sodium intravenous recon
soln 1 mg
ketoprofen oral capsule 50 mg, 75 mg
ketoprofen oral capsule,ext rel. pellets 24
hr 200 mg
ketorolac 30 mg/ml carpuject luer lock,
10's,l/f 30 mg/ml
ketorolac injection cartridge 15 mg/ml
Drug Tier
(Diflunisal)
(Etodolac)
(Etodolac)
(Etodolac)
2
2
2
2
(Fenoprofen Calcium)
2
3
(Flurbiprofen)
(Ibuprofen)
(Ibuprofen)
2
2
1
(Indomethacin)
(Indomethacin)
(Indomethacin)
2
2
2
(Indomethacin
Sodium)
(Ketoprofen)
(Ketoprofen)
2
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
ketorolac injection cartridge 30 mg/ml
(Ketorolac
Tromethamine)
ketorolac injection solution 15 mg/ml
(Ketorolac
Tromethamine)
ketorolac injection solution 30 mg/ml (1 (Ketorolac
ml)
Tromethamine)
ketorolac intramuscular solution 60 mg/2 (Ketorolac
ml
Tromethamine)
ketorolac oral tablet 10 mg
(Ketorolac
Tromethamine)
mefenamic acid oral capsule 250 mg
(Ponstel)
Requirements/Limits
PA
QL (60 per 30 days)
2
2
2
2
QL (40 per 30 days)
2
QL (20 per 30 days)
2
QL (40 per 30 days)
2
QL (20 per 30 days)
2
QL (20 per 30 days)
2
QL (20 per 30 days)
2
9
Drug Name
meloxicam oral suspension 7.5 mg/5 ml
meloxicam oral tablet 15 mg, 7.5 mg
nabumetone oral tablet 500 mg, 750 mg
naproxen oral suspension 125 mg/5 ml
naproxen oral tablet 250 mg, 375 mg, 500
mg
naproxen oral tablet,delayed release
(dr/ec) 375 mg, 500 mg
naproxen sodium oral tablet 275 mg, 550
mg
piroxicam oral capsule 10 mg, 20 mg
sulindac oral tablet 150 mg, 200 mg
tolmetin oral capsule 400 mg
tolmetin oral tablet 200 mg, 600 mg
VOLTAREN TOPICAL GEL 1 %
Drug Tier
(Mobic)
(Mobic)
(Nabumetone)
(Naprosyn)
(Naprosyn)
2
1
2
2
1
(Ec-Naprosyn)
2
(Anaprox)
1
(Feldene)
(Sulindac)
(Tolmetin Sodium)
(Tolmetin Sodium)
2
2
2
2
2
(Lidocaine HCl)
2
(Xylocaine-MPF)
2
(Lidocaine HCl/PF)
2
(Xylocaine)
(Xylocaine)
2
2
(Xylocaine)
2
(Lidocaine HCl)
(Lidocaine HCl)
2
2
(Xylocaine)
2
(Lidocaine HCl)
2
Requirements/Limits
Anesthetics
Local Anesthetics
glydo mucous membrane jelly in
applicator 2 %
lidocaine (pf) injection solution 15 mg/ml
(1.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5
%)
lidocaine (pf) intravenous syringe 100
mg/5 ml (2 %)
lidocaine 2% viscous soln 2 %
lidocaine hcl injection solution 10 mg/ml
(1 %), 20 mg/ml (2 %)
lidocaine hcl laryngotracheal solution 4
%
lidocaine hcl mucous membrane gel 2 %
lidocaine hcl mucous membrane jelly in
applicator 2 %
lidocaine hcl mucous membrane solution
2 %, 4 % (40 mg/ml)
lidocaine hcl urethral gel 2 %
10
Drug Name
Drug Tier
lidocaine topical adhesive
(Lidoderm)
patch,medicated 5 %
lidocaine topical ointment 5 %
(Lidocaine)
lidocaine-prilocaine topical cream 2.5-2.5 (EMLA)
%
2
Requirements/Limits
PA
2
2
Anti-Addiction/Substance Abuse
Treatment Agents
Anti-Addiction/Substance Abuse
Treatment Agents
acamprosate oral tablet,delayed release
(dr/ec) 333 mg
buprenorphine hcl sublingual tablet 2 mg,
8 mg
buprenorphine-naloxone sublingual tablet
2-0.5 mg, 8-2 mg
bupropion hcl sr 150 mg tablet f/c 150 mg
CHANTIX CONTINUING MONTH
BOX ORAL TABLET 1 MG
CHANTIX ORAL TABLET 0.5 MG, 1
MG
CHANTIX STARTING MONTH
BOX ORAL TABLETS,DOSE PACK
0.5 MG (11)- 1 MG (42)
disulfiram oral tablet 250 mg, 500 mg
naloxone injection solution 0.4 mg/ml
naloxone injection syringe 0.4 mg/ml, 1
mg/ml
naltrexone oral tablet 50 mg
NARCAN NASAL
SPRAY,NON-AEROSOL 4
MG/ACTUATION
NICOTROL INHALATION
CARTRIDGE 10 MG
ZUBSOLV SUBLINGUAL TABLET
1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71
MG, 5.7-1.4 MG, 8.6-2.1 MG
(Acamprosate
Calcium)
(Buprenorphine HCl)
2
(Buprenorphine
HCl/Naloxone HCl)
(Zyban)
2
2
PA; QL (90 per 30
days)
PA; QL (90 per 30
days)
2
3
3
3
QL (53 per 28 days)
(Antabuse)
(Naloxone HCl)
(Naloxone HCl)
2
2
2
(Revia)
2
4
QL (4 per 30 days)
4
3
PA; QL (90 per 30
days)
11
Drug Name
Drug Tier
Requirements/Limits
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet 0.25 mg, 0.5 mg, 1
mg, 2 mg
alprazolam oral tablet extended release
24 hr 0.5 mg, 1 mg, 2 mg
alprazolam oral tablet extended release
24 hr 3 mg
chlordiazepoxide hcl oral capsule 10 mg,
25 mg, 5 mg
clonazepam oral tablet 0.5 mg, 1 mg
clonazepam oral tablet 2 mg
clonazepam oral tablet,disintegrating
0.125 mg, 0.25 mg, 0.5 mg, 1 mg
clonazepam oral tablet,disintegrating 2
mg
clorazepate dipotassium oral tablet 15 mg
clorazepate dipotassium oral tablet 3.75
mg, 7.5 mg
diazepam injection syringe 5 mg/ml
diazepam intensol oral concentrate 5
mg/ml
diazepam oral solution 5 mg/5 ml (1
mg/ml)
diazepam oral tablet 10 mg, 2 mg, 5 mg
diazepam rectal kit 12.5-15-17.5-20 mg,
2.5 mg, 5-7.5-10 mg
estazolam oral tablet 1 mg
estazolam oral tablet 2 mg
flurazepam oral capsule 15 mg
flurazepam oral capsule 30 mg
lorazepam intensol oral concentrate 2
mg/ml
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg
midazolam oral syrup 2 mg/ml
(Xanax)
2
(Xanax XR)
2
(Xanax XR)
2
QL (90 per 30 days)
(Chlordiazepoxide
HCl)
(Klonopin)
(Klonopin)
(Clonazepam)
2
2
2
2
QL (90 per 30 days)
QL (90 per 30 days)
(Clonazepam)
2
(Tranxene T-Tab)
(Tranxene T-Tab)
2
2
QL (60 per 30 days)
(Diazepam)
(Diazepam)
2
2
QL (10 per 28 days)
(Diazepam)
2
(Valium)
(Diastat)
2
2
(Estazolam)
(Estazolam)
(Flurazepam HCl)
(Flurazepam HCl)
(Ativan)
2
2
2
2
2
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
(Ativan)
(Midazolam HCl)
2
2
QL (90 per 30 days)
QL (10 per 30 days)
12
Drug Name
Drug Tier
ONFI ORAL SUSPENSION 2.5
MG/ML
temazepam oral capsule 15 mg, 22.5 mg,
30 mg
temazepam oral capsule 7.5 mg
triazolam oral tablet 0.125 mg
triazolam oral tablet 0.25 mg
4
Requirements/Limits
(Restoril)
2
PA NSO; QL (480 per
30 days)
QL (30 per 30 days)
(Restoril)
(Halcion)
(Halcion)
2
2
2
QL (60 per 30 days)
5
PA BvD
Antibacterials
Aminoglycosides
BETHKIS INHALATION
SOLUTION FOR NEBULIZATION
300 MG/4 ML
gentamicin in nacl (iso-osm) intravenous
piggyback 100 mg/100 ml, 100 mg/50 ml,
60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml,
80 mg/50 ml, 90 mg/100 ml
gentamicin injection solution 40 mg/ml
gentamicin ped 20 mg/2 ml vial
25's,pedi,latex-free 20 mg/2 ml
gentamicin sulfate (pf) intravenous
solution 80 mg/8 ml
neomycin oral tablet 500 mg
streptomycin intramuscular recon soln 1
gram
TOBI PODHALER INHALATION
CAPSULE, W/INHALATION
DEVICE 28 MG
tobramycin in 0.225 % nacl inhalation
solution for nebulization 300 mg/5 ml
tobramycin in 0.9 % nacl intravenous
piggyback 60 mg/50 ml, 80 mg/100 ml
tobramycin sulfate injection solution 10
mg/ml, 40 mg/ml
Antibacterials, Miscellaneous
baciim intramuscular recon soln 50,000
unit
(Gentamicin In Nacl,
Iso-Osm)
2
(Gentamicin Sulfate)
(Gentamicin
Sulfate/PF)
(Gentamicin
Sulfate/PF)
(Neomycin Sulfate)
(Streptomycin Sulfate)
2
2
2
2
2
5
(Tobi)
5
PA BvD
(Tobramycin/Sodium
Chloride)
(Tobramycin Sulfate)
2
(Bacitracin)
2
2
13
Drug Name
bacitracin intramuscular recon soln
50,000 unit
chloramphenicol sod succinate
intravenous recon soln 1 gram
clindamycin 75 mg/5 ml soln 75 mg/5 ml
clindamycin hcl oral capsule 150 mg, 300
mg, 75 mg
clindamycin in 5 % dextrose intravenous
piggyback 300 mg/50 ml, 600 mg/50 ml,
900 mg/50 ml
clindamycin pediatric oral recon soln 75
mg/5 ml
clindamycin phosphate injection solution
150 mg/ml
clindamycin phosphate intravenous
solution 600 mg/4 ml
colistin (colistimethate na) injection
recon soln 150 mg
CUBICIN INTRAVENOUS RECON
SOLN 500 MG
linezolid intravenous parenteral solution
600 mg/300 ml
linezolid oral suspension for
reconstitution 100 mg/5 ml
linezolid oral tablet 600 mg
methenamine hippurate oral tablet 1
gram
metronidazole in nacl (iso-os)
intravenous piggyback 500 mg/100 ml
metronidazole oral capsule 375 mg
metronidazole oral tablet 250 mg, 500 mg
nitrofurantoin macrocrystal oral capsule
100 mg, 25 mg, 50 mg
nitrofurantoin monohyd/m-cryst oral
capsule 100 mg
Drug Tier
(Bacitracin)
2
(Chloramphenicol Sod
Succ)
(Cleocin Palmitate)
(Cleocin HCl)
2
(Cleocin Phosphate In
D5w)
2
(Cleocin Palmitate)
2
(Cleocin Phosphate)
2
(Cleocin Phosphate)
2
(Coly-Mycin M
Parenteral)
5
Requirements/Limits
2
2
5
(Zyvox)
5
(Zyvox)
5
(Zyvox)
(Hiprex)
5
2
(Metronidazole/Sodiu
m Chloride)
(Flagyl)
(Flagyl)
(Macrodantin/Macrobi
d)
(Macrobid)
2
2
2
2
2
14
Drug Name
nitrofurantoin monohyd/m-cryst oral
capsule 100 mg (75/25)
nitrofurantoin oral suspension 25 mg/5 ml
polymyxin b sulfate injection recon soln
500,000 unit
SYNERCID INTRAVENOUS
RECON SOLN 500 MG
trimethoprim oral tablet 100 mg
vancomycin hcl 1g/200 ml bag 1
gram/200 ml
vancomycin intravenous recon soln 1,000
mg, 10 gram, 750 mg
vancomycin intravenous recon soln 500
mg
vancomycin oral capsule 125 mg, 250 mg
XIFAXAN ORAL TABLET 200 MG
XIFAXAN ORAL TABLET 550 MG
ZYVOX ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML
Cephalosporins
cefaclor oral capsule 250 mg, 500 mg
cefaclor oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
cefaclor oral tablet extended release 12
hr 500 mg
cefadroxil oral capsule 500 mg
cefadroxil oral suspension for
reconstitution 250 mg/5 ml, 500 mg/5 ml
cefadroxil oral tablet 1 gram
CEFAZOLIN IN DEXTROSE
(ISO-OS) INTRAVENOUS
PIGGYBACK 1 GRAM/50 ML
cefazolin in dextrose (iso-os) intravenous
piggyback 2 gram/50 ml
cefazolin injection recon soln 1 gram, 10
gram, 500 mg
Drug Tier
Requirements/Limits
(Macrobid)
2
(Furadantin)
(Polymyxin B Sulfate)
2
2
5
(Trimethoprim)
(Vancomycin
HCl/D5W)
(Vancomycin HCl)
2
2
(Vancomycin
HCl/D5W)
(Vancocin HCl)
2
2
5
5
5
5
(Cefaclor)
(Cefaclor)
2
2
(Cefaclor)
2
(Cefadroxil)
(Cefadroxil)
2
2
(Cefadroxil)
2
2
(Cefazolin
Sodium/Dextrose, Iso)
(Cefazolin Sodium)
2
PA; QL (9 per 30 days)
PA
2
15
Drug Name
cefdinir oral capsule 300 mg
cefdinir oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml
cefditoren pivoxil oral tablet 200 mg, 400
mg
CEFEPIME 2 GM INJECTION 2
GRAM/100 ML
CEFEPIME IN DEXTROSE 5 %
INTRAVENOUS PIGGYBACK 1
GRAM/50 ML, 2 GRAM/50 ML
cefepime injection recon soln 1 gram, 2
gram
cefixime oral suspension for
cefotaxime injection recon soln 1 gram,
10 gram, 2 gram, 500 mg
cefoxitin in dextrose, iso-osm intravenous
piggyback 2 gram/50 ml
cefoxitin intravenous recon soln 1 gram,
10 gram, 2 gram
cefpodoxime oral suspension for
cefpodoxime oral tablet 100 mg, 200 mg
cefprozil oral suspension for
cefprozil oral tablet 250 mg, 500 mg
ceftazidime injection recon soln 2 gram, 6
gram
ceftibuten oral capsule 400 mg
ceftibuten oral suspension for
ceftriaxone 1 gm piggyback 50ml
galaxycontainer 1 gram/50 ml
ceftriaxone 1 gm vial 10's, fliptop,l/f 1
gram
Drug Tier
(Cefdinir)
(Cefdinir)
2
2
(Spectracef)
2
Requirements/Limits
4
4
(Maxipime)
2
(Suprax)
2
(Claforan)
2
(Cefoxitin
(Cefoxitin Sodium)
2
(Cefpodoxime Proxetil)
2
(Cefpodoxime Proxetil)
(Cefprozil)
2
2
(Cefprozil)
(Fortaz)
2
2
(Cedax)
(Cedax)
2
2
(Ceftriaxone
Na/Dextrose, Iso)
(Rocephin)
2
2
2
16
Drug Name
ceftriaxone 2 gm piggyback 50ml
galaxycontainer 2 gram/50 ml
ceftriaxone injection recon soln 10 gram,
250 mg, 500 mg
ceftriaxone intravenous recon soln 1
gram, 2 gram
cefuroxime axetil oral tablet 250 mg, 500
mg
cefuroxime sodium injection recon soln
1.5 gram, 750 mg
cefuroxime sodium intravenous recon soln
7.5 gram
cephalexin oral capsule 250 mg, 500 mg,
750 mg
cephalexin oral suspension for
cephalexin oral tablet 250 mg, 500 mg
MEFOXIN IN DEXTROSE
(ISO-OSM) INTRAVENOUS
PIGGYBACK 1 GRAM/50 ML, 2
GRAM/50 ML
SUPRAX ORAL SUSPENSION FOR
SUPRAX ORAL
TABLET,CHEWABLE 100 MG, 200
MG
tazicef injection recon soln 2 gram, 6
gram
TEFLARO INTRAVENOUS RECON
SOLN 400 MG, 600 MG
Macrolides
azithromycin intravenous recon soln 500
mg
azithromycin oral packet 1 gram
azithromycin oral suspension for
Drug Tier
(Ceftriaxone
Na/Dextrose, Iso)
(Rocephin)
2
(Ceftriaxone
Na/Dextrose, Iso)
(Ceftin)
2
(Zinacef)
2
(Zinacef)
2
(Keflex)
1
(Cephalexin)
1
(Cephalexin)
1
4
Requirements/Limits
2
2
4
4
(Fortaz)
2
4
(Zithromax)
2
(Zithromax)
(Zithromax)
2
2
17
Drug Name
azithromycin oral tablet 250 mg, 250 mg
(6 pack), 600 mg
azithromycin oral tablet 500 mg
clarithromycin oral suspension for
clarithromycin oral tablet 250 mg, 500
mg
clarithromycin oral tablet extended
release 24 hr 500 mg
DIFICID ORAL TABLET 200 MG
e.e.s. 400 oral tablet 400 mg
e.e.s. granules oral suspension for
ery-tab oral tablet,delayed release
(dr/ec) 250 mg, 500 mg
ERY-TAB ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
erythrocin (as stearate) oral tablet 250
mg
ERYTHROCIN INTRAVENOUS
RECON SOLN 1,000 MG, 500 MG
erythromycin ethylsuccinate oral tablet
400 mg
erythromycin oral capsule,delayed
release(dr/ec) 250 mg
erythromycin oral tablet 250 mg, 500 mg
Miscellaneous B-Lactam
Antibiotics
aztreonam injection recon soln 1 gram
CAYSTON INHALATION
SOLUTION FOR NEBULIZATION
75 MG/ML
imipenem-cilastatin intravenous recon
soln 250 mg, 500 mg
Drug Tier
(Zithromax)
2
(Zithromax)
(Biaxin)
2
2
(Biaxin)
2
(Clarithromycin)
2
(Erythromycin
Ethylsuccinate)
(Eryped 200)
(Erythromycin Base)
5
2
Requirements/Limits
QL (20 per 10 days)
2
2
4
(Erythromycin
Stearate)
2
4
(Erythromycin
Ethylsuccinate)
(Erythromycin Base)
2
(Erythromycin Base)
2
(Azactam)
2
5
(Primaxin)
2
LA
2
18
Drug Name
Drug Tier
INVANZ INJECTION RECON SOLN
1 GRAM
meropenem intravenous recon soln 500
mg
meropenem iv 1 gm vial outer, latex-free
1 gram
Penicillins
amoxicillin oral capsule 250 mg, 500 mg
amoxicillin oral suspension for
reconstitution 125 mg/5 ml, 200 mg/5 ml,
250 mg/5 ml, 400 mg/5 ml
amoxicillin oral tablet 500 mg, 875 mg
amoxicillin oral tablet,chewable 125 mg,
250 mg
amoxicillin-pot clavulanate oral
suspension for reconstitution 200-28.5
mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5
ml, 600-42.9 mg/5 ml
amoxicillin-pot clavulanate oral tablet
250-125 mg, 500-125 mg, 875-125 mg
amoxicillin-pot clavulanate oral tablet
extended release 12 hr 1,000-62.5 mg
amoxicillin-pot clavulanate oral
tablet,chewable 200-28.5 mg, 400-57 mg
ampicillin 2 gm vial 10's, latex-free 2
gram
ampicillin oral capsule 250 mg, 500 mg
ampicillin oral suspension for
ampicillin sodium injection recon soln 1
gram, 10 gram, 125 mg
ampicillin sodium intravenous recon soln
2 gram
ampicillin-sulbactam 1.5 gm vl p/f,
latex-free 1.5 gram
ampicillin-sulbactam injection recon soln
15 gram, 3 gram
4
(Merrem)
2
(Merrem)
2
(Amoxicillin)
(Amoxicillin)
1
1
(Amoxicillin)
(Amoxicillin)
1
1
(Augmentin)
2
(Augmentin)
2
(Augmentin XR)
2
(Amoxicillin/Potassium
Clav)
(Ampicillin Sodium)
2
(Ampicillin Trihydrate)
(Ampicillin Trihydrate)
1
1
(Ampicillin Sodium)
2
(Ampicillin Sodium)
2
(Unasyn)
2
(Unasyn)
2
Requirements/Limits
2
19
Drug Name
ampicillin-sulbactam intravenous recon
soln 1.5 gram
BICILLIN C-R INTRAMUSCULAR
SYRINGE 1,200,000 UNIT/ 2
ML(600K/600K), 1,200,000 UNIT/ 2
ML(900K/300K)
BICILLIN L-A INTRAMUSCULAR
SYRINGE 1,200,000 UNIT/2 ML,
2,400,000 UNIT/4 ML, 600,000
UNIT/ML
dicloxacillin oral capsule 250 mg, 500 mg
nafcillin 2 gm vial sterile, latex-free 2
gram
nafcillin injection recon soln 1 gram, 10
gram
nafcillin intravenous recon soln 2 gram
oxacillin 1 gm add-vantage vl
add-vantage, inner 1 gram
oxacillin in dextrose(iso-osm)
intravenous piggyback 1 gram/50 ml, 2
gram/50 ml
oxacillin injection recon soln 10 gram
oxacillin intravenous recon soln 2 gram
penicillin g pot in dextrose intravenous
piggyback 1 million unit/50 ml, 2 million
unit/50 ml, 3 million unit/50 ml
penicillin g potassium injection recon soln
5 million unit
penicillin g procaine intramuscular
syringe 1.2 million unit/2 ml, 600,000
unit/ml
penicillin gk 20 million unit 20 million
unit
penicillin v potassium oral recon soln 125
mg/5 ml, 250 mg/5 ml
penicillin v potassium oral tablet 250 mg,
500 mg
Drug Tier
(Unasyn)
Requirements/Limits
2
4
4
(Dicloxacillin Sodium)
(Nafcillin Sodium)
2
2
(Nafcillin Sodium)
2
(Nafcillin Sodium)
(Oxacillin Sodium)
2
2
(Oxacillin
2
(Oxacillin Sodium)
(Oxacillin Sodium)
(Pen G
Pot/Dextrose-Water)
2
2
2
(Penicillin G
Potassium)
(Penicillin G Procaine)
2
(Penicillin G
Potassium)
(Penicillin V
Potassium)
(Penicillin V
Potassium)
2
2
2
2
20
Drug Name
pfizerpen-g injection recon soln 20 million
unit
piperacillin-tazobactam intravenous
recon soln 2.25 gram, 3.375 gram, 4.5
gram
piperacil-tazobact 40.5 gram p/f,
pharmacy bulk 40.5 gram
Quinolones
ciprofloxacin (mixture) oral tablet, er
multiphase 24 hr 1,000 mg, 500 mg
ciprofloxacin 200 mg/20 ml vl
sdv,latex-free 200 mg/20 ml
ciprofloxacin hcl oral tablet 100 mg, 250
mg, 500 mg, 750 mg
ciprofloxacin in 5 % dextrose intravenous
piggyback 200 mg/100 ml
ciprofloxacin lactate intravenous solution
400 mg/40 ml
ciprofloxacin oral
suspension,microcapsule recon 250 mg/5
ml, 500 mg/5 ml
ciprofloxacn-d5w 400 mg/200 ml
p/f,latex/f, in d5w 400 mg/200 ml
levofloxacin in d5w intravenous
levofloxacin intravenous solution 25
mg/ml
levofloxacin oral solution 250 mg/10 ml
levofloxacin oral tablet 250 mg, 500 mg,
750 mg
moxifloxacin oral tablet 400 mg
ofloxacin oral tablet 400 mg
Sulfonamides
sulfadiazine oral tablet 500 mg
sulfamethoxazole-trimethoprim
intravenous solution 400-80 mg/5 ml
Drug Tier
(Penicillin G
Potassium)
(Zosyn)
2
(Zosyn)
2
(Cipro XR)
2
(Ciprofloxacin Lactate)
2
(Cipro)
1
(Cipro I.V.)
2
(Ciprofloxacin Lactate)
2
(Cipro)
2
(Cipro I.V.)
2
(Levaquin)
2
(Levofloxacin)
2
(Levaquin)
(Levaquin)
2
1
(Avelox)
(Ofloxacin)
2
2
(Sulfadiazine)
(Sulfamethoxazole/Tri
methoprim)
2
2
Requirements/Limits
2
21
Drug Name
sulfamethoxazole-trimethoprim oral
suspension 200-40 mg/5 ml
sulfamethoxazole-trimethoprim oral
tablet 400-80 mg, 800-160 mg
sulfasalazine oral tablet 500 mg
sulfasalazine oral tablet,delayed release
(dr/ec) 500 mg
sulfatrim oral suspension 200-40 mg/5 ml
Tetracyclines
demeclocycline oral tablet 150 mg, 300
mg
doxy 100 vial 10's, p/f 100 mg
doxycycline hyclate 100 mg cap 100 mg
doxycycline hyclate 100 mg tab f/c 100
mg
doxycycline hyclate intravenous recon
soln 100 mg
doxycycline hyclate oral capsule 100 mg
doxycycline hyclate oral capsule 50 mg
doxycycline hyclate oral tablet 100 mg,
50 mg
doxycycline hyclate oral tablet 20 mg
doxycycline hyclate oral tablet,delayed
release (dr/ec) 100 mg, 150 mg, 75 mg
doxycycline mono 100 mg cap 100 mg
doxycycline mono 100 mg tablet f/c 100
mg
doxycycline mono 50 mg tablet 50 mg
doxycycline monohydrate oral capsule
150 mg, 50 mg, 75 mg
doxycycline monohydrate oral suspension
for reconstitution 25 mg/5 ml
doxycycline monohydrate oral tablet 150
mg, 75 mg
Drug Tier
methoprim)
(Bactrim)
2
(Azulfidine)
(Azulfidine)
2
2
methoprim)
2
(Demeclocycline HCl)
2
(Doxycycline Hyclate)
(Morgidox)
(Doryx)
2
2
2
(Doxycycline Hyclate)
2
(Adoxa)
(Morgidox)
(Avidoxy)
2
2
2
(Doryx)
(Doryx)
2
2
(Adoxa)
(Avidoxy)
2
2
(Avidoxy)
(Adoxa)
2
2
(Vibramycin)
2
(Avidoxy)
2
Requirements/Limits
1
22
Drug Name
Drug Tier
MINOCIN INTRAVENOUS RECON
SOLN 100 MG
minocycline oral capsule 100 mg, 50 mg,
75 mg
minocycline oral tablet 100 mg, 50 mg,
75 mg
minocycline oral tablet extended release
24 hr 135 mg, 45 mg, 90 mg
tetracycline oral capsule 250 mg, 500 mg
TYGACIL INTRAVENOUS RECON
SOLN 50 MG
5
(Minocin)
2
(Minocycline HCl)
2
(Minocycline HCl)
2
(Tetracycline HCl)
2
5
Requirements/Limits
Anticancer Agents
Anticancer Agents
ABRAXANE INTRAVENOUS
SUSPENSION FOR
RECONSTITUTION 100 MG
ADCETRIS INTRAVENOUS
RECON SOLN 50 MG
adriamycin intravenous recon soln 10 mg,
20 mg, 50 mg
adriamycin intravenous solution 10 mg/5
ml
adrucil 2,500 mg/50 ml vial outer,
latex-free 2.5 gram/50 ml
adrucil intravenous solution 500 mg/10 ml
AFINITOR DISPERZ ORAL
TABLET FOR SUSPENSION 2 MG, 3
MG, 5 MG
AFINITOR ORAL TABLET 10 MG
5
5
(Doxorubicin HCl)
2
PA NSO; QL (4 per 21
days)
PA BvD
(Doxorubicin HCl)
2
PA BvD
(Fluorouracil)
2
PA BvD
(Fluorouracil)
2
5
PA BvD
PA NSO; QL (112 per
28 days)
5
days)
days)
PA NSO; QL (240 per
30 days)
AFINITOR ORAL TABLET 2.5 MG,
5 MG, 7.5 MG
ALECENSA ORAL CAPSULE 150
MG
ALIMTA INTRAVENOUS RECON
SOLN 500 MG
5
5
5
23
Drug Name
Drug Tier
anastrozole oral tablet 1 mg
AVASTIN INTRAVENOUS
SOLUTION 25 MG/ML, 25 MG/ML
(16 ML)
azacitidine injection recon soln 100 mg
BELEODAQ INTRAVENOUS
RECON SOLN 500 MG
BENDEKA INTRAVENOUS
SOLUTION 25 MG/ML
bexarotene oral capsule 75 mg
(Arimidex)
bicalutamide oral tablet 50 mg
bleomycin injection recon soln 30 unit
bleomycin sulfate 15 unit vial latex-free
15 unit
BLINCYTO INTRAVENOUS KIT 35
MCG
BOSULIF ORAL TABLET 100 MG
2
5
PA NSO
5
5
PA NSO
5
PA NSO
(Targretin)
5
PA NSO; QL (420 per
30 days)
(Casodex)
(Bleomycin Sulfate)
(Bleomycin Sulfate)
2
2
2
(Vidaza)
5
5
BOSULIF ORAL TABLET 500 MG
5
CABOMETYX ORAL TABLET 20
MG, 60 MG
CABOMETYX ORAL TABLET 40
MG
CAPRELSA ORAL TABLET 100 MG
5
CAPRELSA ORAL TABLET 300 MG
5
carboplatin intravenous solution 10
mg/ml
cladribine intravenous solution 10 mg/10
ml
COMETRIQ ORAL CAPSULE 100
MG/DAY(80 MG[1]-20 MG[1]), 140
MG/DAY(80 MG[1]-20 MG[3]), 60
MG/DAY (20 MG [3]/DAY)
Requirements/Limits
5
5
PA BvD
PA BvD
PA NSO; QL (140 per
365 days)
PA NSO; QL (120 per
30 days)
days)
days)
days)
days)
days)
(Carboplatin)
2
(Cladribine)
2
PA BvD
5
PA NSO; QL (112 per
28 days)
24
Drug Name
Drug Tier
COTELLIC ORAL TABLET 20 MG
cyclophosphamide intravenous recon soln
1 gram, 2 gram, 500 mg
CYCLOPHOSPHAMIDE ORAL
CAPSULE 25 MG, 50 MG
cyclophosphamide oral tablet 25 mg, 50
mg
CYRAMZA INTRAVENOUS
(50 ML)
dactinomycin intravenous recon soln 0.5
mg
DARZALEX INTRAVENOUS
SOLUTION 20 MG/ML
DAUNOXOME INTRAVENOUS
SOLUTION 2 MG/ML
decitabine intravenous recon soln 50 mg
docetaxel 160 mg/16 ml vial mdv 160
mg/16 ml (10 mg/ml)
docetaxel intravenous solution 20 mg/2
ml (final), 80 mg/4 ml (20 mg/ml), 80
mg/8 ml (10 mg/ml)
doxorubicin, peg-liposomal intravenous
suspension 2 mg/ml
DROXIA ORAL CAPSULE 200 MG,
300 MG, 400 MG
ELIGARD SUBCUTANEOUS
SYRINGE 22.5 MG (3 MONTH)
SYRINGE 30 MG (4 MONTH)
SYRINGE 45 MG (6 MONTH)
SYRINGE 7.5 MG (1 MONTH)
EMCYT ORAL CAPSULE 140 MG
5
(Cyclophosphamide)
(Cyclophosphamide)
(Dactinomycin)
Requirements/Limits
2
PA NSO; LA; QL (63
per 28 days)
PA BvD
4
PA BvD; ST
2
PA BvD; ST
5
PA NSO
2
5
PA NSO; LA
3
(Dacogen)
(Taxotere)
5
5
(Taxotere)
5
(Doxil)
5
PA BvD
3
4
QL (1 per 84 days)
4
QL (1 per 112 days)
4
QL (1 per 168 days)
4
3
25
Drug Name
Drug Tier
Requirements/Limits
EMPLICITI INTRAVENOUS
RECON SOLN 300 MG, 400 MG
ERIVEDGE ORAL CAPSULE 150
MG
ETOPOPHOS INTRAVENOUS
RECON SOLN 100 MG
etoposide intravenous solution 20 mg/ml
exemestane oral tablet 25 mg
FARESTON ORAL TABLET 60 MG
FARYDAK ORAL CAPSULE 10
MG, 15 MG, 20 MG
FASLODEX INTRAMUSCULAR
SYRINGE 250 MG/5 ML
floxuridine injection recon soln 0.5 gram
fluorouracil 5,000 mg/100 ml latex-free 5
gram/100 ml
fluorouracil intravenous solution 2.5
gram/50 ml
flutamide oral capsule 125 mg
GAZYVA INTRAVENOUS
SOLUTION 1,000 MG/40 ML
gemcitabine intravenous recon soln 1
gram
GILOTRIF ORAL TABLET 20 MG,
30 MG, 40 MG
GLEEVEC ORAL TABLET 100 MG
5
PA NSO
5
days)
4
(Etoposide)
(Aromasin)
2
2
5
5
PA NSO
5
(Floxuridine)
(Fluorouracil)
2
2
PA BvD
PA BvD
(Fluorouracil)
2
PA BvD
(Flutamide)
2
5
PA NSO
(Gemzar)
5
5
5
GLEEVEC ORAL TABLET 400 MG
5
GLEOSTINE ORAL CAPSULE 10
MG, 100 MG, 40 MG
HERCEPTIN INTRAVENOUS
RECON SOLN 440 MG
HEXALEN ORAL CAPSULE 50 MG
hydroxyurea oral capsule 500 mg
4
5
days)
days)
days)
PA NSO
5
2
(Hydrea)
26
Drug Name
Drug Tier
Requirements/Limits
IBRANCE ORAL CAPSULE 100 MG,
125 MG, 75 MG
ICLUSIG ORAL TABLET 15 MG
5
ICLUSIG ORAL TABLET 45 MG
5
ifosfamide 1 gm/20 ml vial sd polymer
vial 1 gram/20 ml
ifosfamide intravenous recon soln 1 gram
ifosfamide-mesna intravenous kit 1-1
gram, 3,000-1,000 mg
IMBRUVICA ORAL CAPSULE 140
MG
IMLYGIC INJECTION
SUSPENSION 10EXP6 (1 MILLION)
PFU/ML
IMLYGIC INJECTION
SUSPENSION 10EXP8 (100
MILLION) PFU/ML
INLYTA ORAL TABLET 1 MG
(Ifex)
2
days)
days)
days)
PA BvD
(Ifex)
(Ifosfamide/Mesna)
2
5
PA BvD
PA BvD
5
PA NSO
5
days)
5
days)
5
PA NSO; QL (180 per
30 days)
days)
days)
5
INLYTA ORAL TABLET 5 MG
5
IRESSA ORAL TABLET 250 MG
5
irinotecan intravenous solution 100 mg/5 (Camptosar)
ml, 500 mg/25 ml
IXEMPRA 15 MG KIT WITH
DILUENT 15 MG
IXEMPRA INTRAVENOUS RECON
SOLN 45 MG
JAKAFI ORAL TABLET 10 MG, 15
MG, 20 MG, 25 MG, 5 MG
KEYTRUDA INTRAVENOUS
RECON SOLN 50 MG
2
5
5
5
5
days)
PA NSO
27
Drug Name
Drug Tier
KEYTRUDA INTRAVENOUS
SOLUTION 100 MG/4 ML (25
MG/ML)
KYPROLIS INTRAVENOUS
RECON SOLN 60 MG
LENVIMA ORAL CAPSULE 10
MG/DAY (10 MG X 1/DAY), 14
MG/DAY(10 MG X 1-4 MG X 1), 20
MG/DAY (10 MG X 2), 24
MG/DAY(10 MG X 2-4 MG X 1)
letrozole oral tablet 2.5 mg
LEUKERAN ORAL TABLET 2 MG
leuprolide subcutaneous kit 1 mg/0.2 ml
lipodox intravenous suspension 2 mg/ml
lomustine oral capsule 10 mg, 100 mg, 40
mg
LONSURF ORAL TABLET 15-6.14
MG
LONSURF ORAL TABLET 20-8.19
MG
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT
11.25 MG, 22.5 MG
30 MG
45 MG
LUPRON DEPOT
3.75 MG, 7.5 MG
LYNPARZA ORAL CAPSULE 50
MG
LYSODREN ORAL TABLET 500 MG
MARQIBO INTRAVENOUS KIT 5
MG/31 ML(0.16 MG/ML) FINAL
5
PA NSO
5
days)
PA NSO
5
(Femara)
(Leuprolide Acetate)
(Doxil)
(Lomustine)
2
4
2
5
2
5
Requirements/Limits
PA BvD
5
PA NSO; QL (100 per
28 days)
days)
QL (1 per 84 days)
5
QL (1 per 84 days)
5
QL (1 per 168 days)
5
5
5
3
5
PA NSO; QL (480 per
30 days)
days)
28
Drug Name
MATULANE ORAL CAPSULE 50
MG
megestrol oral tablet 20 mg, 40 mg
MEKINIST ORAL TABLET 0.5 MG
Drug Tier
5
(Megestrol Acetate)
MEKINIST ORAL TABLET 2 MG
melphalan hcl intravenous recon soln 50
mg
mercaptopurine oral tablet 50 mg
methotrexate 50 mg/2 ml vial latex-free,
5's, mdv 25 mg/ml
methotrexate sodium (pf) injection recon
soln 1 gram
methotrexate sodium (pf) injection
solution 25 mg/ml
methotrexate sodium oral tablet 2.5 mg
mitoxantrone intravenous concentrate 2
mg/ml
NEXAVAR ORAL TABLET 200 MG
Requirements/Limits
2
5
5
days)
days)
(Alkeran)
5
(Mercaptopurine)
(Methotrexate Sodium)
2
2
PA BvD
(Methotrexate
Sodium/PF)
2
PA BvD
2
PA BvD
(Mitoxantrone HCl)
2
2
PA BvD; ST
5
PA NSO; QL (120 per
30 days)
NILANDRON ORAL TABLET 150
MG
NINLARO ORAL CAPSULE 2.3 MG,
3 MG, 4 MG
ODOMZO ORAL CAPSULE 200 MG
ONCASPAR INJECTION
SOLUTION 750 UNIT/ML
onxol intravenous concentrate 6 mg/ml
(Paclitaxel)
OPDIVO INTRAVENOUS
SOLUTION 40 MG/4 ML
oxaliplatin intravenous solution 100
(Eloxatin)
mg/20 ml
paclitaxel intravenous concentrate 6
(Paclitaxel)
mg/ml
3
5
5
5
days)
PA NSO; LA
PA NSO
2
5
PA NSO
5
2
29
Drug Name
Drug Tier
PERJETA INTRAVENOUS
MG/ML)
POMALYST ORAL CAPSULE 1 MG,
2 MG, 3 MG, 4 MG
PORTRAZZA INTRAVENOUS
MG/ML)
PROLEUKIN INTRAVENOUS
RECON SOLN 22 MILLION UNIT
PURIXAN ORAL SUSPENSION 20
MG/ML
REVLIMID ORAL CAPSULE 10
MG, 15 MG, 2.5 MG, 20 MG, 25 MG,
5 MG
RITUXAN INTRAVENOUS
CONCENTRATE 10 MG/ML
SOLTAMOX ORAL SOLUTION 10
MG/5 ML
SPRYCEL ORAL TABLET 100 MG,
140 MG, 50 MG, 70 MG, 80 MG
SPRYCEL ORAL TABLET 20 MG
5
PA NSO
5
days)
PA NSO; QL (100 per
21 days)
STIVARGA ORAL TABLET 40 MG
5
SUTENT ORAL CAPSULE 12.5 MG,
25 MG, 37.5 MG, 50 MG
SYLVANT INTRAVENOUS RECON
SOLN 100 MG, 400 MG
SYNRIBO SUBCUTANEOUS
RECON SOLN 3.5 MG
TABLOID ORAL TABLET 40 MG
TAFINLAR ORAL CAPSULE 50
MG, 75 MG
TAGRISSO ORAL TABLET 40 MG,
80 MG
tamoxifen oral tablet 10 mg, 20 mg
(Tamoxifen Citrate)
5
5
Requirements/Limits
5
5
5
PA NSO; LA
5
PA NSO
4
5
5
5
5
3
5
5
days)
days)
days)
days)
PA NSO
days)
PA NSO; QL (120 per
30 days)
PA NSO; LA; QL (30
per 30 days)
2
30
Drug Name
Drug Tier
Requirements/Limits
TARCEVA ORAL TABLET 100 MG,
25 MG
TARCEVA ORAL TABLET 150 MG
5
TARGRETIN ORAL CAPSULE 75
MG
TARGRETIN TOPICAL GEL 1 %
5
TASIGNA ORAL CAPSULE 150 MG,
200 MG
TECENTRIQ INTRAVENOUS
SOLUTION 1,200 MG/20 ML (60
MG/ML)
TEMODAR INTRAVENOUS
RECON SOLN 100 MG
teniposide intravenous solution 50 mg/5
ml
thiotepa injection recon soln 15 mg
toposar intravenous solution 20 mg/ml
topotecan hcl 4 mg/4 ml vial
suv,latex-free 4 mg/4 ml (1 mg/ml)
topotecan intravenous recon soln 4 mg
TORISEL INTRAVENOUS RECON
SOLN 30 MG/3 ML (10 MG/ML)
(FIRST)
TREANDA 25 MG VIAL 25 MG
TREANDA INTRAVENOUS
RECON SOLN 100 MG
TREANDA INTRAVENOUS
SOLUTION 180 MG/2 ML, 45 MG/0.5
ML
TRELSTAR 22.5 MG SYRINGE
WITH MIXJECT 22.5 MG/2 ML
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 22.5 MG
5
days)
days)
PA NSO; QL (420 per
30 days)
days)
PA NSO; QL (112 per
28 days)
days)
5
5
5
5
(Teniposide)
5
(Thiotepa)
(Etoposide)
(Hycamtin)
5
2
5
(Hycamtin)
5
5
PA NSO; (vial only)
PA BvD; QL (4 per 28
days)
5
5
5
5
QL (1 per 168 days)
5
QL (1 per 168 days)
31
Drug Name
Drug Tier
SYRINGE 11.25 MG/2 ML
SYRINGE 3.75 MG/2 ML
tretinoin (chemotherapy) oral capsule 10
mg
TREXALL ORAL TABLET 10 MG,
15 MG, 5 MG, 7.5 MG
TYKERB ORAL TABLET 250 MG
UNITUXIN INTRAVENOUS
SOLUTION 3.5 MG/ML
VALSTAR INTRAVESICAL
SOLUTION 40 MG/ML
VECTIBIX INTRAVENOUS
MG/ML)
VELCADE INJECTION RECON
SOLN 3.5 MG
VENCLEXTA ORAL TABLET 10
MG, 50 MG
VENCLEXTA ORAL TABLET 100
MG
VENCLEXTA STARTING PACK
ORAL TABLETS,DOSE PACK 10
MG-50 MG- 100 MG
vinblastine intravenous solution 1 mg/ml
vincasar pfs 2 mg/2 ml vial 2 mg/2 ml
vincasar pfs intravenous solution 1 mg/ml
vincristine 2 mg/2 ml vial p/f, sdv 2 mg/2
ml
vincristine intravenous solution 1 mg/ml
vinorelbine intravenous solution 50 mg/5
ml
VOTRIENT ORAL TABLET 200 MG
5
Requirements/Limits
QL (1 per 84 days)
5
(Tretinoin)
5
(capsule: 10mg)
4
PA BvD; ST
5
5
PA NSO
5
5
PA NSO
5
PA NSO
4
PA NSO; LA
5
PA NSO; LA
5
PA NSO; LA
(Vinblastine Sulfate)
(Vincristine Sulfate)
2
2
2
2
PA BvD
PA BvD
PA BvD
PA BvD
(Navelbine)
2
2
PA BvD
5
PA NSO; QL (120 per
30 days)
32
Drug Name
Drug Tier
Requirements/Limits
XALKORI ORAL CAPSULE 200
MG, 250 MG
XTANDI ORAL CAPSULE 40 MG
5
YERVOY INTRAVENOUS
MG/ML)
YONDELIS INTRAVENOUS
RECON SOLN 1 MG
ZALTRAP INTRAVENOUS
MG/ML)
ZELBORAF ORAL TABLET 240 MG
5
days)
PA NSO; QL (120 per
30 days)
PA NSO
5
PA NSO
5
PA NSO
5
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG
ZOLADEX SUBCUTANEOUS
IMPLANT 3.6 MG
ZOLINZA ORAL CAPSULE 100 MG
ZYDELIG ORAL TABLET 100 MG,
150 MG
ZYKADIA ORAL CAPSULE 150 MG
4
PA NSO; QL (240 per
30 days)
QL (1 per 84 days)
4
QL (1 per 28 days)
ZYTIGA ORAL TABLET 250 MG
5
5
5
5
5
days)
PA NSO; QL (140 per
28 days)
PA NSO; QL (120 per
30 days)
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine injection solution 0.4 mg/ml, 1
(Atropine Sulfate)
mg/ml
atropine injection syringe 0.05 mg/ml, 0.1 (Atropine Sulfate)
mg/ml
propantheline oral tablet 15 mg
(Propantheline
Bromide)
STIOLTO RESPIMAT
INHALATION MIST 2.5-2.5
MCG/ACTUATION
2
2
2
3
QL (4 per 28 days)
33
Drug Name
Drug Tier
Requirements/Limits
Anticonvulsants
Anticonvulsants
APTIOM ORAL TABLET 200 MG,
400 MG, 600 MG, 800 MG
BANZEL ORAL SUSPENSION 40
MG/ML
BANZEL ORAL TABLET 200 MG,
400 MG
BRIVIACT INTRAVENOUS
SOLUTION 50 MG/5 ML
BRIVIACT ORAL SOLUTION 10
MG/ML
BRIVIACT ORAL TABLET 10 MG,
100 MG, 25 MG, 50 MG, 75 MG
carbamazepine oral capsule, er
multiphase 12 hr 100 mg, 200 mg, 300 mg
carbamazepine oral suspension 100 mg/5
ml
carbamazepine oral tablet 200 mg
carbamazepine oral tablet extended
release 12 hr 100 mg, 200 mg, 400 mg
carbamazepine oral tablet,chewable 100
mg
CELONTIN ORAL CAPSULE 300
MG
DILANTIN ORAL CAPSULE 30 MG
divalproex oral capsule, sprinkle 125 mg
divalproex oral tablet extended release 24
hr 250 mg, 500 mg
divalproex oral tablet,delayed release
(dr/ec) 125 mg, 250 mg, 500 mg
epitol oral tablet 200 mg
ethosuximide oral capsule 250 mg
ethosuximide oral solution 250 mg/5 ml
felbamate oral suspension 600 mg/5 ml
felbamate oral tablet 400 mg, 600 mg
4
4
4
4
4
5
(Carbatrol)
2
(Tegretol)
2
(Tegretol)
(Tegretol XR)
2
2
(Carbamazepine)
2
days)
PA NSO; QL (600 per
30 days)
days)
3
(Depakote Sprinkle)
(Depakote ER)
2
2
2
(Depakote)
2
(Tegretol)
(Zarontin)
(Zarontin)
(Felbatol)
(Felbatol)
2
2
2
2
2
34
Drug Name
fosphenytoin 500 mg pe/10 ml
10's,sdv,latex-free 500 mg pe/10 ml
fosphenytoin injection solution 100 mg
pe/2 ml
FYCOMPA ORAL TABLET 10 MG,
12 MG, 2 MG, 4 MG, 6 MG, 8 MG
gabapentin oral capsule 100 mg, 300 mg,
400 mg
gabapentin oral solution 250 mg/5 ml
gabapentin oral tablet 600 mg, 800 mg
GABITRIL ORAL TABLET 12 MG,
16 MG
GRALISE 30-DAY STARTER PACK
ORAL TABLET EXTENDED
RELEASE 24 HR 300 MG (9)- 600 MG
(69)
GRALISE ORAL TABLET
MG, 600 MG
LAMICTAL ODT STARTER (BLUE)
ORAL TABLET DISINTEGRATING,
DOSE PK 25 MG (21) -50 MG (7)
LAMICTAL ODT STARTER
(GREEN) ORAL TABLET
DISINTEGRATING, DOSE PK 50
MG (42) -100 MG (14)
(ORANGE) ORAL TABLET
DISINTEGRATING, DOSE PK 25
MG(14)-50 MG (14)-100 MG (7)
LAMICTAL ORAL TABLET,
CHEWABLE DISPERSIBLE 2 MG
lamotrigine oral tablet 100 mg, 150 mg,
200 mg, 25 mg
Drug Tier
(Cerebyx)
2
(Cerebyx)
2
Requirements/Limits
4
(Neurontin)
2
(Neurontin)
(Neurontin)
2
2
3
4
4
4
4
4
4
(Lamictal)
2
35
Drug Name
lamotrigine oral tablet disintegrating,
dose pk 25 mg (21) -50 mg (7), 25
mg(14)-50 mg (14)-100 mg (7), 50 mg
(42) -100 mg (14)
lamotrigine oral tablet extended release
24hr 100 mg, 200 mg, 25 mg, 250 mg,
300 mg, 50 mg
lamotrigine oral tablet, chewable
dispersible 25 mg, 5 mg
lamotrigine oral tablet,disintegrating 100
mg, 200 mg, 25 mg, 50 mg
lamotrigine oral tablets,dose pack 25 mg
(35)
levetiracetam in nacl (iso-os) intravenous
piggyback 1,000 mg/100 ml, 1,500
mg/100 ml, 500 mg/100 ml
levetiracetam intravenous solution 500
mg/5 ml
levetiracetam oral solution 100 mg/ml
levetiracetam oral tablet 1,000 mg, 250
mg, 500 mg, 750 mg
levetiracetam oral tablet extended release
24 hr 500 mg, 750 mg
LYRICA ORAL CAPSULE 100 MG,
150 MG, 200 MG, 225 MG, 25 MG,
300 MG, 50 MG, 75 MG
LYRICA ORAL SOLUTION 20
MG/ML
oxcarbazepine oral suspension 300 mg/5
ml
oxcarbazepine oral tablet 150 mg, 300
mg, 600 mg
OXTELLAR XR ORAL TABLET
MG, 300 MG, 600 MG
PEGANONE ORAL TABLET 250
MG
Drug Tier
(Lamictal Odt (Blue))
2
(Lamictal XR)
2
(Lamictal)
2
(Lamictal Odt)
2
(Lamictal (Blue))
2
(Levetiracetam In Nacl
(Iso-Os))
2
(Keppra)
2
(Keppra)
(Keppra)
2
2
(Keppra XR)
2
Requirements/Limits
3
QL (90 per 30 days)
3
(Trileptal)
2
(Trileptal)
2
4
3
36
Drug Name
phenobarbital oral elixir 20 mg/5 ml (4
mg/ml)
phenobarbital oral tablet 100 mg, 15 mg,
16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2
mg
phenobarbital oral tablet 30 mg
phenobarbital sodium injection solution
130 mg/ml, 65 mg/ml
phenytoin oral suspension 125 mg/5 ml
phenytoin oral tablet,chewable 50 mg
phenytoin sodium extended oral capsule
100 mg, 200 mg, 300 mg
phenytoin sodium intravenous solution 50
mg/ml
phenytoin sodium intravenous syringe 50
mg/ml
POTIGA ORAL TABLET 200 MG,
300 MG, 400 MG
POTIGA ORAL TABLET 50 MG
primidone oral tablet 250 mg, 50 mg
SABRIL ORAL POWDER IN
PACKET 500 MG
SABRIL ORAL TABLET 500 MG
SPRITAM ORAL TABLET FOR
SUSPENSION 1,000 MG
SPRITAM ORAL TABLET FOR
SUSPENSION 250 MG, 500 MG, 750
MG
TEGRETOL XR ORAL TABLET
MG
tiagabine oral tablet 2 mg, 4 mg
topiragen oral tablet 100 mg, 200 mg, 25
mg, 50 mg
topiramate oral capsule, sprinkle 15 mg,
25 mg
Drug Tier
Requirements/Limits
(Phenobarbital)
2
(Phenobarbital)
2
QL (90 per 30 days)
(Phenobarbital)
(Phenobarbital
Sodium)
(Dilantin-125)
(Dilantin)
(Dilantin)
2
2
QL (2 per 30 days)
(Phenytoin Sodium)
2
(Phenytoin Sodium)
2
(Mysoline)
2
2
2
4
QL (90 per 30 days)
4
2
5
5
4
4
ST ; QL (60 per 30
days)
ST ; QL (120 per 30
days)
3
(Gabitril)
(Topamax)
2
2
(Topamax)
2
37
Drug Name
topiramate oral capsule,sprinkle,er 24hr
100 mg, 150 mg, 200 mg, 25 mg, 50 mg
topiramate oral tablet 100 mg, 200 mg,
25 mg, 50 mg
TROKENDI XR ORAL
CAPSULE,EXTENDED RELEASE
24HR 100 MG, 200 MG, 25 MG, 50
MG
valproate sodium intravenous solution
500 mg/5 ml (100 mg/ml)
valproic acid (as sodium salt) oral
solution 250 mg/5 ml
valproic acid oral capsule 250 mg
VIMPAT INTRAVENOUS
SOLUTION 200 MG/20 ML
VIMPAT ORAL SOLUTION 10
MG/ML
VIMPAT ORAL TABLET 100 MG,
150 MG, 200 MG, 50 MG
zonisamide oral capsule 100 mg, 25 mg,
50 mg
Drug Tier
(Qudexy XR)
2
(Topamax)
2
Requirements/Limits
4
(Depacon)
2
(Depakene)
2
(Depakene)
2
4
QL (200 per 5 days)
4
4
QL (60 per 30 days)
(Zonegran)
2
(Aricept)
(Donepezil HCl)
2
2
QL (30 per 30 days)
QL (30 per 30 days)
(Razadyne ER)
2
QL (30 per 30 days)
(Galantamine Hbr)
(Razadyne)
2
2
QL (60 per 30 days)
(Namenda)
(Namenda)
(Namenda)
2
2
2
QL (60 per 30 days)
QL (49 per 28 days)
Antidementia Agents
Antidementia Agents
donepezil oral tablet 10 mg, 23 mg, 5 mg
donepezil oral tablet,disintegrating 10
mg, 5 mg
galantamine oral capsule,ext rel. pellets
24 hr 16 mg, 24 mg, 8 mg
galantamine oral solution 4 mg/ml
galantamine oral tablet 12 mg, 4 mg, 8
mg
memantine oral solution 2 mg/ml
memantine oral tablet 10 mg, 5 mg
memantine oral tablets,dose pack 5-10
mg
38
Drug Name
Drug Tier
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE
PACK 7-14-21-28 MG
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR 14
MG, 21 MG, 28 MG, 7 MG
NAMZARIC ORAL
CAPSULE,SPRINKLE,ER 24HR
14-10 MG, 28-10 MG
rivastigmine tartrate oral capsule 1.5 mg, (Exelon)
3 mg, 4.5 mg, 6 mg
rivastigmine transdermal patch 24 hour
(Exelon)
13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24
hr
Requirements/Limits
3
QL (28 per 28 days)
3
QL (30 per 30 days)
3
2
QL (60 per 30 days)
2
QL (30 per 30 days)
Antidepressants
Antidepressants
amitriptyline oral tablet 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75 mg
amoxapine oral tablet 100 mg, 150 mg,
25 mg, 50 mg
BRINTELLIX ORAL TABLET 10
MG, 20 MG, 5 MG
buproban oral tablet extended release 150
mg
bupropion hcl oral tablet 100 mg, 75 mg
bupropion hcl oral tablet extended release
100 mg, 150 mg, 200 mg
bupropion hcl oral tablet extended release
24 hr 150 mg, 300 mg
citalopram oral solution 10 mg/5 ml
citalopram oral tablet 10 mg, 20 mg, 40
mg
clomipramine oral capsule 25 mg, 50 mg,
75 mg
desipramine oral tablet 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75 mg
(Amitriptyline HCl)
2
(Amoxapine)
2
4
(Wellbutrin SR)
2
(Wellbutrin)
(Wellbutrin SR)
2
2
(Wellbutrin XL)
2
(Citalopram
Hydrobromide)
(Celexa)
2
(Anafranil)
2
(Norpramin)
2
1
QL (30 per 30 days)
39
Drug Name
Drug Tier
DESVENLAFAXINE FUMARATE
ORAL TABLET EXTENDED
RELEASE 24HR 100 MG, 50 MG
doxepin oral capsule 10 mg, 100 mg, 150
mg, 25 mg, 50 mg, 75 mg
doxepin oral concentrate 10 mg/ml
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
EMSAM TRANSDERMAL PATCH
24 HOUR 12 MG/24 HR, 6 MG/24
HR, 9 MG/24 HR
escitalopram oxalate oral solution 5 mg/5
ml
escitalopram oxalate oral tablet 10 mg,
20 mg, 5 mg
FETZIMA ORAL CAPSULE,EXT
REL 24HR DOSE PACK 20 MG (2)40 MG (26)
FETZIMA ORAL
CAPSULE,EXTENDED RELEASE 24
HR 120 MG, 20 MG, 40 MG, 80 MG
fluoxetine oral capsule 10 mg, 20 mg, 40
mg
fluoxetine oral capsule,delayed
fluoxetine oral solution 20 mg/5 ml (4
mg/ml)
fluoxetine oral tablet 10 mg, 20 mg
FLUOXETINE ORAL TABLET 60
MG
fluvoxamine oral capsule,extended
release 24hr 100 mg, 150 mg
3
(Doxepin HCl)
2
(Doxepin HCl)
(Duloxetine)
2
2
(Duloxetine)
2
(Duloxetine)
2
4
(Lexapro)
2
(Lexapro)
2
Requirements/Limits
QL (30 per 30 days)
(Cymbalta); QL (60 per
30 days)
(Cymbalta); QL (30 per
30 days)
(Irenka); QL (30 per 30
days)
QL (30 per 30 days)
4
4
(Prozac)
1
(Prozac Weekly)
2
(Fluoxetine HCl)
2
(Fluoxetine HCl)
2
4
(Fluvoxamine Maleate)
2
40
Drug Name
fluvoxamine oral tablet 100 mg, 25 mg,
50 mg
imipramine hcl oral tablet 10 mg, 25 mg,
50 mg
imipramine pamoate oral capsule 100 mg,
125 mg, 150 mg, 75 mg
maprotiline oral tablet 25 mg, 50 mg, 75
mg
MARPLAN ORAL TABLET 10 MG
mirtazapine oral tablet 15 mg, 30 mg, 45
mg, 7.5 mg
mirtazapine oral tablet,disintegrating 15
mg, 30 mg, 45 mg
nefazodone oral tablet 100 mg, 150 mg,
200 mg, 250 mg, 50 mg
nortriptyline oral capsule 10 mg, 25 mg,
50 mg, 75 mg
nortriptyline oral solution 10 mg/5 ml
olanzapine-fluoxetine oral capsule 12-25
mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50
mg
paroxetine hcl oral tablet 10 mg, 20 mg,
30 mg, 40 mg
paroxetine hcl oral tablet extended
release 24 hr 12.5 mg, 25 mg, 37.5 mg
PAXIL ORAL SUSPENSION 10
MG/5 ML
perphenazine-amitriptyline oral tablet
2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg,
4-50 mg
phenelzine oral tablet 15 mg
PRISTIQ ORAL TABLET
MG, 25 MG, 50 MG
protriptyline oral tablet 10 mg, 5 mg
sertraline oral concentrate 20 mg/ml
Drug Tier
(Fluvoxamine Maleate)
2
(Tofranil)
2
(Tofranil-Pm)
2
(Maprotiline HCl)
2
(Remeron)
4
2
(Remeron)
2
(Nefazodone HCl)
2
(Pamelor)
2
(Nortriptyline HCl)
(Symbyax)
2
2
(Paxil)
2
(Paxil CR)
2
Requirements/Limits
4
(Perphenazine/Amitript
yline HCl)
2
(Nardil)
2
4
(Protriptyline HCl)
(Zoloft)
QL (30 per 30 days)
2
2
41
Drug Name
sertraline oral tablet 100 mg, 25 mg, 50
mg
SILENOR ORAL TABLET 3 MG, 6
MG
SURMONTIL ORAL CAPSULE 100
MG, 25 MG, 50 MG
tranylcypromine oral tablet 10 mg
trazodone oral tablet 100 mg, 150 mg,
300 mg, 50 mg
trimipramine oral capsule 100 mg, 25 mg,
50 mg
TRINTELLIX ORAL TABLET 10
MG, 20 MG, 5 MG
venlafaxine oral capsule,extended release
24hr 150 mg, 37.5 mg, 75 mg
venlafaxine oral tablet 100 mg, 25 mg,
37.5 mg, 50 mg, 75 mg
venlafaxine oral tablet extended release
24hr 150 mg, 37.5 mg, 75 mg
venlafaxine oral tablet extended release
24hr 225 mg
VIIBRYD ORAL TABLET 10 MG, 20
MG, 40 MG
VIIBRYD ORAL TABLETS,DOSE
PACK 10 MG (7)- 20 MG (23), 10 MG
(7)-20 MG (7)-40 MG (16)
Drug Tier
(Zoloft)
Requirements/Limits
1
3
QL (30 per 30 days)
4
(Parnate)
(Trazodone HCl)
2
1
(Trimipramine
Maleate)
2
4
(Effexor XR)
2
(Venlafaxine HCl)
2
(Venlafaxine HCl)
2
(Venlafaxine HCl)
3
4
4
Antidiabetic Agents
Antidiabetic Agents,
Miscellaneous
acarbose oral tablet 100 mg, 25 mg, 50
mg
ACTOPLUS MET XR ORAL
TABLET, ER MULTIPHASE 24 HR
15-1,000 MG, 30-1,000 MG
alogliptin oral tablet 12.5 mg, 25 mg,
6.25 mg
(Precose)
(Nesina)
2
QL (90 per 30 days)
3
QL (60 per 30 days)
4
QL (30 per 30 days)
42
Drug Name
Drug Tier
alogliptin-metformin oral tablet
(Kazano)
12.5-1,000 mg, 12.5-500 mg
alogliptin-pioglitazone oral tablet 12.5-15 (Oseni)
mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg,
25-30 mg, 25-45 mg
CYCLOSET ORAL TABLET 0.8 MG
GLYSET ORAL TABLET 100 MG, 25
MG, 50 MG
GLYXAMBI ORAL TABLET 10-5
MG, 25-5 MG
INVOKAMET ORAL TABLET
150-1,000 MG, 150-500 MG, 50-1,000
MG, 50-500 MG
INVOKANA ORAL TABLET 100
MG, 300 MG
JANUMET ORAL TABLET 50-1,000
MG, 50-500 MG
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 100-1,000 MG,
50-1,000 MG, 50-500 MG
JANUVIA ORAL TABLET 100 MG,
25 MG, 50 MG
JARDIANCE ORAL TABLET 10
MG, 25 MG
JENTADUETO ORAL TABLET
2.5-1,000 MG, 2.5-500 MG, 2.5-850
MG
KAZANO ORAL TABLET 12.5-1,000
MG, 12.5-500 MG
KORLYM ORAL TABLET 300 MG
metformin oral tablet 1,000 mg
metformin oral tablet 500 mg
metformin oral tablet 850 mg
metformin oral tablet extended release 24
hr 500 mg
(Glucophage)
(Glucophage)
(Glucophage)
(Glucophage XR)
Requirements/Limits
4
QL (60 per 30 days)
4
QL (30 per 30 days)
4
3
QL (90 per 30 days)
3
ST
3
ST
3
ST
3
3
3
3
ST
3
4
QL (60 per 30 days)
5
PA; QL (112 per 28
days)
QL (75 per 30 days)
QL (90 per 30 days)
1
1
1
2
43
Drug Name
metformin oral tablet extended release 24
hr 750 mg
metformin oral tablet extended release
24hr 1,000 mg
metformin oral tablet extended release
24hr 500 mg
miglitol oral tablet 100 mg, 25 mg, 50 mg
nateglinide oral tablet 120 mg, 60 mg
NESINA ORAL TABLET 12.5 MG, 25
MG, 6.25 MG
OSENI ORAL TABLET 12.5-15 MG,
12.5-30 MG, 12.5-45 MG, 25-15 MG,
25-30 MG, 25-45 MG
pioglitazone oral tablet 15 mg, 30 mg, 45
mg
pioglitazone-glimepiride oral tablet 30-2
mg, 30-4 mg
pioglitazone-metformin oral tablet
15-500 mg, 15-850 mg
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg
repaglinide-metformin oral tablet 1-500
mg, 2-500 mg
SYMLINPEN 120 SUBCUTANEOUS
PEN INJECTOR 2,700 MCG/2.7 ML
SYMLINPEN 60 SUBCUTANEOUS
PEN INJECTOR 1,500 MCG/1.5 ML
SYNJARDY ORAL TABLET
12.5-1,000 MG, 12.5-500 MG, 5-1,000
MG, 5-500 MG
TRADJENTA ORAL TABLET 5 MG
TRULICITY SUBCUTANEOUS PEN
INJECTOR 0.75 MG/0.5 ML, 1.5
MG/0.5 ML
VICTOZA 3-PAK SUBCUTANEOUS
PEN INJECTOR 0.6 MG/0.1 ML (18
MG/3 ML)
Drug Tier
Requirements/Limits
(Glucophage XR)
2
QL (90 per 30 days)
(Fortamet)
2
QL (60 per 30 days)
(Fortamet)
2
(Glyset)
(Starlix)
2
2
4
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
4
QL (30 per 30 days)
(Actos)
2
QL (30 per 30 days)
(Duetact)
2
QL (30 per 30 days)
(Actoplus Met)
2
QL (90 per 30 days)
(Prandin)
(Prandimet)
2
2
4
QL (10.8 per 28 days)
4
QL (6 per 28 days)
3
ST
3
3
3
44
Drug Name
Drug Tier
Insulins
HUMALOG 100 UNITS/ML
CARTRIDGE 5'S, OUTER 100
UNIT/ML
HUMALOG KWIKPEN
SUBCUTANEOUS INSULIN PEN
100 UNIT/ML
HUMALOG KWIKPEN
200 UNIT/ML (3 ML)
HUMALOG MIX 50-50 KWIKPEN
100 UNIT/ML (50-50)
HUMALOG MIX 50-50
SUBCUTANEOUS SUSPENSION 100
UNIT/ML (50-50)
HUMALOG MIX 75-25 KWIKPEN
100 UNIT/ML (75-25)
HUMALOG MIX 75-25
SUBCUTANEOUS SUSPENSION 100
UNIT/ML (75-25)
HUMALOG SUBCUTANEOUS
HUMALOG SUBCUTANEOUS
(PREFILLED SYRINGE)
HUMULIN 70/30 KWIKPEN
100 UNIT/ML (70-30)
HUMULIN 70/30 SUBCUTANEOUS
SUSPENSION 100 UNIT/ML (70-30)
HUMULIN N KWIKPEN
100 UNIT/ML (3 ML)
HUMULIN N SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
Requirements/Limits
3
QL (30 per 28 days)
3
QL (30 per 28 days)
3
QL (12 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
45
Drug Name
Drug Tier
Requirements/Limits
HUMULIN R INJECTION
HUMULIN R U-500 (CONC)
KWIKPEN SUBCUTANEOUS
INSULIN PEN 500 UNIT/ML (3 ML)
HUMULIN R U-500
(CONCENTRATED)
SUBCUTANEOUS SOLUTION 500
UNIT/ML
LANTUS SOLOSTAR
100 UNIT/ML (3 ML)
LANTUS SUBCUTANEOUS
NOVOLIN 70/30 SUBCUTANEOUS
SUSPENSION 100 UNIT/ML (70-30)
NOVOLIN N SUBCUTANEOUS
NOVOLIN R INJECTION
NOVOLOG FLEXPEN
100 UNIT/ML
NOVOLOG MIX 70-30 FLEXPEN
100 UNIT/ML (70-30)
NOVOLOG MIX 70-30
SUBCUTANEOUS SOLUTION 100
UNIT/ML (70-30)
NOVOLOG PENFILL
SUBCUTANEOUS CARTRIDGE 100
UNIT/ML
NOVOLOG SUBCUTANEOUS
TOUJEO SOLOSTAR
300 UNIT/ML (1.5 ML)
3
QL (40 per 28 days)
3
QL (24 per 28 days)
3
QL (40 per 28 days)
3
3
3
QL (40 per 28 days)
3
QL (40 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
46
Drug Name
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg
glimepiride oral tablet 4 mg
glipizide oral tablet 10 mg
glipizide oral tablet 5 mg
glipizide oral tablet extended release 24hr
10 mg
2.5 mg
5 mg
glipizide-metformin oral tablet 2.5-250
mg
glipizide-metformin oral tablet 2.5-500
mg, 5-500 mg
glyburide micronized oral tablet 1.5 mg
glyburide micronized oral tablet 3 mg
glyburide micronized oral tablet 6 mg
glyburide oral tablet 1.25 mg
glyburide oral tablet 2.5 mg
glyburide oral tablet 5 mg
glyburide-metformin oral tablet 1.25-250
mg
glyburide-metformin oral tablet 2.5-500
mg, 5-500 mg
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide oral tablet 500 mg
Drug Tier
(Amaryl)
(Amaryl)
(Glucotrol)
(Glucotrol)
(Glucotrol XL)
Requirements/Limits
1
1
1
1
2
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
2
QL (30 per 30 days)
(Glucotrol XL)
2
QL (30 per 30 days)
(Glipizide/Metformin
HCl)
(Glipizide/Metformin
HCl)
(Glynase)
(Glynase)
(Glynase)
(Glyburide)
(Glyburide)
(Glyburide)
(Glucovance)
2
2
2
2
2
2
2
2
2
(Glucovance)
2
(Tolazamide)
(Tolazamide)
(Tolbutamide)
2
2
2
QL (60 per 30 days)
5
PA BvD
5
PA BvD
2
PA BvD
Antifungals
Antifungals
ABELCET INTRAVENOUS
SUSPENSION 5 MG/ML
AMBISOME INTRAVENOUS
SUSPENSION FOR
RECONSTITUTION 50 MG
amphotericin b injection recon soln 50 mg (Amphotericin B)
47
Drug Name
Drug Tier
CANCIDAS INTRAVENOUS
ciclopirox topical cream 0.77 %
ciclopirox topical gel 0.77 %
ciclopirox topical shampoo 1 %
ciclopirox topical solution 8 %
ciclopirox topical suspension 0.77 %
ciclopirox-ure-camph-menth-euc topical
solution 8 %
clotrimazole mucous membrane troche 10
mg
clotrimazole topical cream 1 %
clotrimazole topical solution 1 %
clotrimazole-betamethasone topical
cream 1-0.05 %
clotrimazole-betamethasone topical
lotion 1-0.05 %
econazole topical cream 1 %
EXELDERM TOPICAL CREAM 1 %
EXELDERM TOPICAL SOLUTION
1%
fluconazole in dextrose(iso-o)
fluconazole in nacl (iso-osm) intravenous
fluconazole oral suspension for
reconstitution 10 mg/ml, 40 mg/ml
fluconazole oral tablet 100 mg, 150 mg,
200 mg, 50 mg
fluconazole-nacl 400 mg/200 ml
10's,latex-free, p/f 400 mg/200 ml
flucytosine oral capsule 250 mg, 500 mg
griseofulvin microsize oral suspension 125
mg/5 ml
griseofulvin microsize oral tablet 500 mg
5
(Ciclodan)
(Loprox)
(Loprox)
(Penlac)
(Ciclopirox Olamine)
(Ciclodan)
2
2
2
2
2
2
(Clotrimazole)
2
(Clotrimazole)
(Clotrimazole)
(Lotrisone)
2
2
2
(Clotrimazole/Betamet
hasone Dip)
(Econazole Nitrate)
2
(Fluconazole In
Nacl,Iso-Osm)
(Fluconazole In
Nacl,Iso-Osm)
(Diflucan)
2
(Diflucan)
2
(Fluconazole In
Nacl,Iso-Osm)
(Ancobon)
(Griseofulvin,
Microsize)
(Grifulvin V)
2
Requirements/Limits
2
4
4
2
2
5
2
2
48
Drug Name
griseofulvin ultramicrosize oral tablet 125
mg, 250 mg
itraconazole oral capsule 100 mg
ketoconazole oral tablet 200 mg
ketoconazole topical cream 2 %
ketoconazole topical shampoo 2 %
miconazole-3 vaginal suppository 200 mg
NOXAFIL INTRAVENOUS
SOLUTION 300 MG/16.7 ML
NOXAFIL ORAL SUSPENSION 200
MG/5 ML (40 MG/ML)
NOXAFIL ORAL
(DR/EC) 100 MG
nyamyc topical powder 100,000
unit/gram
nystatin oral suspension 100,000 unit/ml
nystatin oral tablet 500,000 unit
nystatin topical cream 100,000 unit/gram
nystatin topical ointment 100,000
unit/gram
nystatin topical powder 100,000
unit/gram
nystatin-triamcinolone topical cream
100,000-0.1 unit/g-%
nystatin-triamcinolone topical ointment
100,000-0.1 unit/gram-%
nystop topical powder 100,000 unit/gram
SPORANOX ORAL SOLUTION 10
MG/ML
terbinafine hcl oral tablet 250 mg
voriconazole intravenous solution 200 mg
voriconazole oral suspension for
reconstitution 200 mg/5 ml (40 mg/ml)
voriconazole oral tablet 200 mg, 50 mg
Drug Tier
(Gris-Peg)
2
(Sporanox)
(Ketoconazole)
(Ketoconazole)
(Nizoral)
(Miconazole Nitrate)
2
2
2
2
2
5
Requirements/Limits
5
5
(Nystatin)
2
(Nystatin)
(Nystatin)
(Nystatin)
(Nystatin)
2
2
2
2
(Nystatin)
2
(Nystatin/Triamcin)
2
(Nystatin/Triamcin)
2
(Nystatin)
2
4
(Lamisil)
(Vfend IV)
(Vfend)
2
2
5
(Vfend)
5
49
Drug Name
Drug Tier
Requirements/Limits
Antihistamines
Antihistamines
carbinoxamine maleate oral liquid 4 mg/5 (Carbinoxamine
ml
Maleate)
carbinoxamine maleate oral tablet 4 mg (Carbinoxamine
Maleate)
clemastine oral tablet 2.68 mg
(Clemastine Fumarate)
cyproheptadine oral syrup 2 mg/5 ml
(Cyproheptadine HCl)
cyproheptadine oral tablet 4 mg
(Cyproheptadine HCl)
diphenhydramine hcl injection solution 50 (Diphenhydramine
mg/ml
HCl)
diphenhydramine hcl injection syringe 50 (Diphenhydramine
mg/ml
HCl)
levocetirizine oral solution 2.5 mg/5 ml
(Xyzal)
levocetirizine oral tablet 5 mg
(Xyzal)
promethazine oral syrup 6.25 mg/5 ml
(Promethazine HCl)
2
2
2
2
2
2
2
2
2
2
Anti-Infectives (Skin And Mucous
Membrane)
Anti-Infectives (Skin And Mucous
Membrane)
AVC VAGINAL VAGINAL CREAM
15 %
clindamycin phosphate vaginal cream 2 %
metronidazole vaginal gel 0.75 %
terconazole vaginal cream 0.4 %, 0.8 %
terconazole vaginal suppository 80 mg
3
(Cleocin)
(Metrogel-Vaginal)
(Terazol 7)
(Terconazole)
2
2
2
2
(Axert)
2
QL (12 per 28 days)
(D.H.E.45)
2
QL (30 per 28 days)
(Migranal)
2
QL (8 per 28 days)
Antimigraine Agents
Antimigraine Agents
almotriptan malate oral tablet 12.5 mg,
6.25 mg
dihydroergotamine injection solution 1
mg/ml
dihydroergotamine nasal
spray,non-aerosol 0.5 mg/pump act. (4
mg/ml)
50
Drug Name
Drug Tier
Requirements/Limits
ERGOMAR SUBLINGUAL TABLET
2 MG
naratriptan oral tablet 1 mg, 2.5 mg
rizatriptan oral tablet 10 mg, 5 mg
rizatriptan oral tablet,disintegrating 10
mg, 5 mg
sumatriptan 6 mg/0.5 ml syrng
p/f,dehp/f,pvc/f 6 mg/0.5 ml
sumatriptan nasal spray,non-aerosol 20
mg/actuation, 5 mg/actuation
sumatriptan succinate oral tablet 100 mg,
25 mg, 50 mg
sumatriptan succinate subcutaneous
cartridge 4 mg/0.5 ml
cartridge 6 mg/0.5 ml
sumatriptan succinate subcutaneous pen
injector 4 mg/0.5 ml
sumatriptan succinate subcutaneous pen
injector 6 mg/0.5 ml, 6 mg/0.5 ml
(auto-injector)
solution 6 mg/0.5 ml
zolmitriptan oral tablet 2.5 mg, 5 mg
zolmitriptan oral tablet,disintegrating 2.5
mg, 5 mg
4
QL (40 per 28 days)
(Amerge)
(Maxalt)
(Maxalt Mlt)
2
2
2
QL (18 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
(Sumatriptan
Succinate)
(Imitrex)
2
QL (4 per 28 days)
2
QL (12 per 28 days)
(Imitrex)
2
QL (18 per 28 days)
(Sumatriptan
Succinate)
(Imitrex)
2
QL (4 per 28 days)
2
QL (4 per 28 days)
(Sumatriptan
Succinate)
(Sumatriptan
Succinate)
2
QL (4 per 28 days)
2
QL (4 per 28 days)
(Imitrex)
2
QL (4 per 28 days)
(Zomig)
(Zomig Zmt)
2
2
QL (12 per 28 days)
QL (12 per 28 days)
Antimycobacterials
Antimycobacterials
CAPASTAT INJECTION RECON
SOLN 1 GRAM
dapsone oral tablet 100 mg, 25 mg
ethambutol oral tablet 100 mg, 400 mg
isoniazid oral solution 50 mg/5 ml
isoniazid oral tablet 100 mg, 300 mg
PASER ORAL GRANULES DR FOR
SUSP IN PACKET 4 GRAM
4
(Dapsone)
(Myambutol)
(Isoniazid)
(Isoniazid)
2
2
2
1
4
51
Drug Name
Drug Tier
PRIFTIN ORAL TABLET 150 MG
pyrazinamide oral tablet 500 mg
rifabutin oral capsule 150 mg
rifampin intravenous recon soln 600 mg
rifampin oral capsule 150 mg, 300 mg
RIFATER ORAL TABLET 50-120-300
MG
SIRTURO ORAL TABLET 100 MG
4
2
2
2
2
4
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifadin)
5
TRECATOR ORAL TABLET 250 MG
Requirements/Limits
PA; QL (188 per 168
days)
4
Antinausea Agents
Antinausea Agents
AKYNZEO ORAL CAPSULE 300-0.5
MG
compro rectal suppository 25 mg
dimenhydrinate injection solution 50
mg/ml
dronabinol oral capsule 10 mg, 2.5 mg, 5
mg
EMEND INTRAVENOUS RECON
SOLN 115 MG, 150 MG
EMEND ORAL CAPSULE 125 MG,
80 MG
EMEND ORAL CAPSULE 40 MG
EMEND ORAL CAPSULE,DOSE
PACK 125 MG (1)- 80 MG (2)
granisetron (pf) intravenous solution 100
mcg/ml
granisetron hcl intravenous solution 1
mg/ml (1 ml)
granisetron hcl oral tablet 1 mg
granisol oral solution 1 mg/5 ml
meclizine oral tablet 12.5 mg, 25 mg
ondansetron hcl (pf) injection solution 4
mg/2 ml
3
(Compazine)
(Dimenhydrinate)
2
2
(Marinol)
2
PA BvD
4
QL (2 per 28 days)
4
PA BvD
4
4
PA BvD
(Granisetron HCl/PF)
2
(Granisetron HCl)
2
(Granisetron HCl)
(Granisetron HCl)
(Antivert)
(Ondansetron HCl/PF)
2
2
2
2
PA BvD
PA BvD
52
Drug Name
ondansetron hcl (pf) injection syringe 4
mg/2 ml
ondansetron hcl oral solution 4 mg/5 ml
ondansetron hcl oral tablet 24 mg, 4 mg,
8 mg
ondansetron oral tablet,disintegrating 4
mg, 8 mg
phenadoz rectal suppository 12.5 mg, 25
mg
prochlorperazine edisylate injection
solution 10 mg/2 ml (5 mg/ml)
prochlorperazine maleate oral tablet 10
mg, 5 mg
prochlorperazine rectal suppository 25
mg
promethazine oral tablet 12.5 mg, 25 mg,
50 mg
promethazine rectal suppository 12.5 mg,
25 mg, 50 mg
promethegan rectal suppository 12.5 mg,
25 mg, 50 mg
TRANSDERM-SCOP
TRANSDERMAL PATCH 3 DAY 1.5
MG (1 MG OVER 3 DAYS)
Drug Tier
Requirements/Limits
(Ondansetron HCl/PF)
2
(Zofran)
(Zofran)
2
2
PA BvD
PA BvD
(Zofran Odt)
2
PA BvD
(Phenergan)
2
(Prochlorperazine
Edisylate)
(Compazine)
2
(Compazine)
2
(Promethazine HCl)
2
(Phenergan)
2
(Phenergan)
2
1
4
QL (10 per 30 days)
Antiparasite Agents
Antiparasite Agents
ALBENZA ORAL TABLET 200 MG
ALINIA ORAL SUSPENSION FOR
ALINIA ORAL TABLET 500 MG
atovaquone oral suspension 750 mg/5 ml
atovaquone-proguanil oral tablet 250-100
mg, 62.5-25 mg
chloroquine phosphate oral tablet 250
mg, 500 mg
4
4
(Mepron)
(Malarone)
(Chloroquine
Phosphate)
4
5
2
2
53
Drug Name
Drug Tier
COARTEM ORAL TABLET 20-120
MG
DARAPRIM ORAL TABLET 25 MG
EMVERM ORAL
TABLET,CHEWABLE 100 MG
hydroxychloroquine oral tablet 200 mg
ivermectin oral tablet 3 mg
mefloquine oral tablet 250 mg
NEBUPENT INHALATION RECON
SOLN 300 MG
paromomycin oral capsule 250 mg
PENTAM INJECTION RECON
SOLN 300 MG
PRIMAQUINE ORAL TABLET 26.3
MG
quinine sulfate oral capsule 324 mg
tinidazole oral tablet 250 mg, 500 mg
4
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Paromomycin Sulfate)
Requirements/Limits
4
2
QL (6 per 21 days)
2
2
2
4
PA BvD
2
4
4
QL (90 per 30 days)
(Qualaquin)
(Tindamax)
2
2
(Amantadine HCl)
(Amantadine HCl)
(Amantadine HCl)
2
2
2
5
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl oral capsule 100 mg
amantadine hcl oral solution 50 mg/5 ml
amantadine hcl oral tablet 100 mg
APOKYN SUBCUTANEOUS
CARTRIDGE 10 MG/ML
AZILECT ORAL TABLET 0.5 MG, 1
MG
benztropine injection solution 2 mg/2 ml
benztropine oral tablet 0.5 mg, 1 mg, 2
mg
bromocriptine oral capsule 5 mg
bromocriptine oral tablet 2.5 mg
cabergoline oral tablet 0.5 mg
carbidopa oral tablet 25 mg
carbidopa-levodopa oral tablet 10-100
mg, 25-100 mg, 25-250 mg
QL (60 per 30 days)
3
(Cogentin)
(Benztropine Mesylate)
2
2
(Parlodel)
(Parlodel)
(Cabergoline)
(Lodosyn)
(Sinemet CR)
2
2
2
2
2
54
Drug Name
carbidopa-levodopa oral tablet extended
release 25-100 mg, 50-200 mg
carbidopa-levodopa oral
tablet,disintegrating 10-100 mg, 25-100
mg, 25-250 mg
carbidopa-levodopa-entacapone oral
tablet 12.5-50-200 mg, 18.75-75-200 mg,
25-100-200 mg, 31.25-125-200 mg,
37.5-150-200 mg, 50-200-200 mg
entacapone oral tablet 200 mg
NEUPRO TRANSDERMAL PATCH
24 HOUR 1 MG/24 HOUR, 2 MG/24
HOUR, 3 MG/24 HOUR, 4 MG/24
HOUR, 6 MG/24 HOUR, 8 MG/24
HOUR
pramipexole oral tablet 0.125 mg, 0.25
mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg
ropinirole oral tablet 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg, 5 mg
ropinirole oral tablet extended release 24
hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg
selegiline hcl oral capsule 5 mg
selegiline hcl oral tablet 5 mg
trihexyphenidyl oral elixir 0.4 mg/ml
trihexyphenidyl oral tablet 2 mg, 5 mg
Drug Tier
(Sinemet CR)
2
(Carbidopa/Levodopa)
2
(Stalevo 50)
2
(Comtan)
2
3
(Mirapex)
2
(Requip)
2
(Requip XL)
2
(Eldepryl)
(Selegiline HCl)
(Trihexyphenidyl HCl)
(Trihexyphenidyl HCl)
2
2
2
2
Requirements/Limits
Antipsychotic Agents
Antipsychotic Agents
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON 300 MG
ABILIFY MAINTENA
INTRAMUSCULAR
RECON 400 MG
5
5
QL (1 per 28 days)
55
Drug Name
Drug Tier
Requirements/Limits
ABILIFY MAINTENA
INTRAMUSCULAR
SYRING 300 MG, 400 MG
aripiprazole oral solution 1 mg/ml
aripiprazole oral tablet 10 mg, 15 mg, 20
mg, 30 mg, 5 mg
aripiprazole oral tablet 2 mg
aripiprazole oral tablet,disintegrating 10
mg
aripiprazole oral tablet,disintegrating 15
mg
ARISTADA INTRAMUSCULAR
SYRING 441 MG/1.6 ML
chlorpromazine injection solution 25
mg/ml
chlorpromazine oral tablet 10 mg, 100
mg, 200 mg, 25 mg, 50 mg
clozapine oral tablet 100 mg
clozapine oral tablet 200 mg
clozapine oral tablet 25 mg, 50 mg
clozapine oral tablet,disintegrating 100
mg, 12.5 mg, 150 mg, 200 mg, 25 mg
FANAPT ORAL TABLET 1 MG, 10
MG, 12 MG, 2 MG, 4 MG, 6 MG, 8
MG
FANAPT ORAL TABLETS,DOSE
PACK 1MG(2)-2MG(2)4MG(2)-6MG(2)
5
QL (1 per 28 days)
(Abilify)
(Abilify)
2
2
QL (30 per 30 days)
(Abilify)
(Abilify Discmelt)
2
2
QL (60 per 30 days)
QL (90 per 30 days)
(Abilify Discmelt)
2
QL (60 per 30 days)
5
5
5
(Chlorpromazine HCl)
2
(Chlorpromazine HCl)
2
(Clozaril)
(Clozaril)
(Clozaril)
(Fazaclo)
2
2
2
2
QL (90 per 30 days)
ST
4
ST ; QL (60 per 30
days)
4
ST ; QL (8 per 28 days)
56
Drug Name
fluphenazine decanoate injection solution
25 mg/ml
fluphenazine hcl injection solution 2.5
mg/ml
fluphenazine hcl oral concentrate 5 mg/ml
fluphenazine hcl oral elixir 2.5 mg/5 ml
fluphenazine hcl oral tablet 1 mg, 10 mg,
2.5 mg, 5 mg
GEODON INTRAMUSCULAR
RECON SOLN 20 MG/ML (FINAL
CONC.)
haloperidol decanoate intramuscular
solution 100 mg/ml
haloperidol decanoate intramuscular
solution 50 mg/ml
haloperidol lactate injection solution 5
mg/ml
haloperidol lactate oral concentrate 2
mg/ml
haloperidol oral tablet 0.5 mg, 1 mg, 10
mg, 2 mg, 20 mg, 5 mg
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 117
MG/0.75 ML, 156 MG/ML, 234
MG/1.5 ML
INVEGA SUSTENNA
MG/0.25 ML, 78 MG/0.5 ML
INVEGA TRINZA
MG/0.875 ML, 410 MG/1.315 ML, 546
MG/1.75 ML, 819 MG/2.625 ML
LATUDA ORAL TABLET 120 MG,
20 MG, 40 MG, 60 MG, 80 MG
loxapine succinate oral capsule 10 mg, 25
mg, 5 mg, 50 mg
molindone oral tablet 10 mg
Drug Tier
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
2
(Fluphenazine HCl)
(Fluphenazine HCl)
(Fluphenazine HCl)
2
2
2
Requirements/Limits
2
4
(Haloperidol
Decanoate)
(Haldol Decanoate 50)
2
(Haloperidol Lactate)
2
(Haloperidol Lactate)
2
(Haloperidol)
2
QL (6 per 28 days)
2
5
3
5
4
(Loxapine Succinate)
2
(Moban)
2
57
Drug Name
Drug Tier
Requirements/Limits
NUPLAZID ORAL TABLET 17 MG
(Moban)
(Moban)
2
2
5
olanzapine intramuscular recon soln 10
mg
olanzapine oral tablet 10 mg, 15 mg, 2.5
mg, 20 mg, 5 mg, 7.5 mg
olanzapine oral tablet,disintegrating 10
mg, 15 mg, 5 mg
olanzapine oral tablet,disintegrating 20
mg
paliperidone oral tablet extended release
24hr 1.5 mg, 3 mg, 9 mg
paliperidone oral tablet extended release
24hr 6 mg
perphenazine oral tablet 16 mg, 2 mg, 4
mg, 8 mg
pimozide oral tablet 1 mg, 2 mg
quetiapine oral tablet 100 mg, 200 mg, 25
mg, 300 mg, 400 mg, 50 mg
REXULTI ORAL TABLET 0.25 MG
REXULTI ORAL TABLET 0.5 MG
REXULTI ORAL TABLET 1 MG, 2
MG, 3 MG, 4 MG
RISPERDAL CONSTA
INTRAMUSCULAR SYRINGE 12.5
MG/2 ML, 25 MG/2 ML, 37.5 MG/2
ML, 50 MG/2 ML
risperidone oral solution 1 mg/ml
risperidone oral tablet 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg
risperidone oral tablet,disintegrating 0.25
mg, 0.5 mg, 1 mg, 2 mg
risperidone oral tablet,disintegrating 3
mg, 4 mg
(Zyprexa)
2
days)
QL (30 per 30 days)
(Zyprexa)
2
QL (30 per 30 days)
(Zyprexa Zydis)
2
QL (30 per 30 days)
(Zyprexa Zydis)
2
QL (31 per 30 days)
(Invega)
2
QL (30 per 30 days)
(Invega)
2
QL (60 per 30 days)
(Perphenazine)
2
(Orap)
(Seroquel)
2
2
QL (90 per 30 days)
5
5
5
QL (60 per 30 days)
QL (30 per 30 days)
4
QL (4 per 28 days)
(Risperdal)
(Risperdal)
2
2
QL (60 per 30 days)
(Risperdal M-Tab)
2
QL (60 per 30 days)
(Risperdal M-Tab)
2
58
Drug Name
Drug Tier
SAPHRIS (BLACK CHERRY)
SUBLINGUAL TABLET 10 MG, 2.5
MG, 5 MG
SEROQUEL XR ORAL TABLET
MG, 300 MG, 400 MG, 50 MG
SEROQUEL XR ORAL TABLET
MG
thioridazine oral tablet 10 mg, 100 mg,
25 mg, 50 mg
thiothixene oral capsule 1 mg, 10 mg, 2
mg, 5 mg
trifluoperazine oral tablet 1 mg, 10 mg, 2
mg, 5 mg
VERSACLOZ ORAL SUSPENSION
50 MG/ML
VRAYLAR ORAL CAPSULE 1.5
MG, 3 MG, 4.5 MG, 6 MG
VRAYLAR ORAL CAPSULE,DOSE
PACK 1.5 MG (1)- 3 MG (6)
ziprasidone hcl oral capsule 20 mg, 40
mg, 60 mg, 80 mg
ZYPREXA RELPREVV 405 MG VL
KIT W/ DILUENT, OUTER 405 MG
ZYPREXA RELPREVV
INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 210 MG
4
ST ; QL (60 per 30
days)
4
ST ; QL (60 per 30
days)
4
ST ; QL (30 per 30
days)
(Thioridazine HCl)
2
(Thiothixene)
2
(Trifluoperazine HCl)
2
5
(Geodon)
Requirements/Limits
5
ST ; QL (540 per 30
days)
QL (30 per 30 days)
4
QL (7 per 30 days)
2
QL (60 per 30 days)
5
5
Antivirals (Systemic)
Antiretrovirals
abacavir oral tablet 300 mg
abacavir-lamivudine-zidovudine oral
tablet 300-150-300 mg
APTIVUS ORAL CAPSULE 250 MG
APTIVUS ORAL SOLUTION 100
MG/ML
(Ziagen)
(Trizivir)
2
5
5
4
59
Drug Name
Drug Tier
ATRIPLA ORAL TABLET
600-200-300 MG
COMPLERA ORAL TABLET
200-25-300 MG
CRIXIVAN ORAL CAPSULE 200
MG, 400 MG
DESCOVY ORAL TABLET 200-25
MG
didanosine oral capsule,delayed
(Videx EC)
release(dr/ec) 125 mg, 200 mg, 250 mg,
400 mg
EDURANT ORAL TABLET 25 MG
EMTRIVA ORAL CAPSULE 200 MG
EMTRIVA ORAL SOLUTION 10
MG/ML
EPIVIR HBV ORAL SOLUTION 25
MG/5 ML (5 MG/ML)
EPZICOM ORAL TABLET 600-300
MG
EVOTAZ ORAL TABLET 300-150
MG
FUZEON SUBCUTANEOUS
RECON SOLN 90 MG
GENVOYA ORAL TABLET
150-150-200-10 MG
INTELENCE ORAL TABLET 100
MG, 200 MG
INTELENCE ORAL TABLET 25 MG
INVIRASE ORAL CAPSULE 200 MG
INVIRASE ORAL TABLET 500 MG
ISENTRESS ORAL POWDER IN
PACKET 100 MG
ISENTRESS ORAL TABLET 400 MG
ISENTRESS ORAL
TABLET,CHEWABLE 100 MG, 25
MG
Requirements/Limits
5
5
4
5
2
5
3
3
4
5
5
5
5
5
3
5
5
3
5
3
60
Drug Name
Drug Tier
KALETRA ORAL SOLUTION
400-100 MG/5 ML
KALETRA ORAL TABLET 100-25
MG
KALETRA ORAL TABLET 200-50
MG
lamivudine oral solution 10 mg/ml
lamivudine oral tablet 100 mg, 150 mg,
300 mg
lamivudine-zidovudine oral tablet
150-300 mg
LEXIVA ORAL SUSPENSION 50
MG/ML
LEXIVA ORAL TABLET 700 MG
nevirapine oral suspension 50 mg/5 ml
nevirapine oral tablet 200 mg
nevirapine oral tablet extended release 24
hr 100 mg, 400 mg
NORVIR ORAL CAPSULE 100 MG
NORVIR ORAL SOLUTION 80
MG/ML
NORVIR ORAL TABLET 100 MG
ODEFSEY ORAL TABLET 200-25-25
MG
PREZCOBIX ORAL TABLET 800-150
MG-MG
PREZISTA ORAL SUSPENSION 100
MG/ML
PREZISTA ORAL TABLET 150 MG,
75 MG
PREZISTA ORAL TABLET 400 MG,
600 MG, 800 MG
RESCRIPTOR ORAL TABLET 200
MG
RESCRIPTOR ORAL TABLET,
DISPERSIBLE 100 MG
5
Requirements/Limits
3
5
(Epivir)
(Epivir)
2
2
(Combivir)
5
3
(Viramune)
(Viramune)
(Viramune XR)
5
2
2
2
3
3
3
5
5
4
3
5
4
4
61
Drug Name
Drug Tier
RETROVIR INTRAVENOUS
SOLUTION 10 MG/ML
REYATAZ ORAL CAPSULE 150
MG, 200 MG, 300 MG
REYATAZ ORAL POWDER IN
PACKET 50 MG
SELZENTRY ORAL TABLET 150
MG, 300 MG
stavudine oral capsule 15 mg, 20 mg, 30
(Zerit)
mg, 40 mg
stavudine oral recon soln 1 mg/ml
(Zerit)
STRIBILD ORAL TABLET
150-150-200-300 MG
SUSTIVA ORAL CAPSULE 200 MG,
50 MG
SUSTIVA ORAL TABLET 600 MG
TIVICAY ORAL TABLET 50 MG
TRIUMEQ ORAL TABLET
600-50-300 MG
TRUVADA ORAL TABLET 100-150
MG, 133-200 MG, 167-250 MG,
200-300 MG
VIDEX 2 GRAM PEDIATRIC ORAL
RECON SOLN 10 MG/ML (FINAL)
VIDEX 4 GM PEDIATRIC SOLN 10
MG/ML (FINAL)
VIRACEPT ORAL TABLET 250 MG,
625 MG
VIRAMUNE XR ORAL TABLET
MG
VIREAD ORAL POWDER 40
MG/SCOOP (40 MG/GRAM)
VIREAD ORAL TABLET 150 MG,
200 MG, 250 MG, 300 MG
VITEKTA ORAL TABLET 150 MG,
85 MG
Requirements/Limits
3
5
5
5
2
2
5
4
4
5
5
5
3
3
4
3
5
5
5
62
Drug Name
Drug Tier
ZIAGEN ORAL SOLUTION 20
MG/ML
zidovudine oral capsule 100 mg
zidovudine oral syrup 10 mg/ml
zidovudine oral tablet 300 mg
Antivirals, Miscellaneous
foscarnet intravenous solution 24 mg/ml
RELENZA DISKHALER
INHALATION BLISTER WITH
DEVICE 5 MG/ACTUATION
rimantadine oral tablet 100 mg
SYNAGIS 100 MG/1 ML VIAL 100
MG/ML
SYNAGIS INTRAMUSCULAR
TAMIFLU ORAL CAPSULE 30 MG,
45 MG, 75 MG
TAMIFLU ORAL SUSPENSION
FOR RECONSTITUTION 6 MG/ML
Hcv Antivirals
DAKLINZA ORAL TABLET 30 MG,
60 MG, 90 MG
HARVONI ORAL TABLET 90-400
MG
OLYSIO ORAL CAPSULE 150 MG
4
(Retrovir)
(Retrovir)
(Zidovudine)
2
2
2
(Foscavir)
2
4
(Flumadine)
2
5
Requirements/Limits
PA BvD
5
3
3
5
5
5
SOVALDI ORAL TABLET 400 MG
5
TECHNIVIE ORAL TABLET
12.5-75-50 MG
VIEKIRA PAK ORAL
TABLETS,DOSE PACK 12.5 MG-75
MG -50 MG/250 MG
ZEPATIER ORAL TABLET 50-100
MG
5
5
5
PA; QL (28 per 28
days)
PA; QL (30 per 30
days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
PA; QL (56 per 28
days)
PA; QL (112 per 28
days)
PA; QL (30 per 30
days)
63
Drug Name
Interferons
INTRON A 25 MILLION UNIT/2.5
ML 10 MILLION UNIT/ML
INTRON A INJECTION RECON
SOLN 10 MILLION UNIT (1 ML)
INTRON A INJECTION RECON
SOLN 18 MILLION UNIT (1 ML), 50
MILLION UNIT (1 ML)
INTRON A INJECTION SOLUTION
6 MILLION UNIT/ML
PEGASYS PROCLICK
SUBCUTANEOUS PEN INJECTOR
135 MCG/0.5 ML, 180 MCG/0.5 ML
PEGASYS SUBCUTANEOUS
SOLUTION 180 MCG/ML
PEGASYS SUBCUTANEOUS
SYRINGE 180 MCG/0.5 ML
PEGINTRON SUBCUTANEOUS
KIT 120 MCG/0.5 ML, 150 MCG/0.5
ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML
SYLATRON SUBCUTANEOUS KIT
200 MCG, 300 MCG, 600 MCG
Nucleosides And Nucleotides
acyclovir oral capsule 200 mg
acyclovir oral suspension 200 mg/5 ml
acyclovir oral tablet 400 mg, 800 mg
acyclovir sodium intravenous solution 50
mg/ml
adefovir oral tablet 10 mg
BARACLUDE ORAL SOLUTION
0.05 MG/ML
cidofovir intravenous solution 75 mg/ml
entecavir oral tablet 0.5 mg, 1 mg
famciclovir oral tablet 125 mg, 250 mg,
500 mg
Drug Tier
Requirements/Limits
4
PA NSO
4
PA NSO
4
PA NSO
4
PA NSO
5
PA
5
PA
5
PA
5
PA
5
days)
(Zovirax)
(Zovirax)
(Zovirax)
(Acyclovir Sodium)
2
2
2
2
(Hepsera)
5
4
(Vistide)
(Baraclude)
(Famvir)
5
5
2
PA BvD
64
Drug Name
ganciclovir sodium intravenous recon soln
500 mg
ribasphere oral capsule 200 mg
ribasphere oral tablet 200 mg, 400 mg,
600 mg
ribasphere ribapak oral tablets,dose pack
200 mg (7)- 400 mg (7), 400-400 mg
(28)-mg (28), 600-400 mg (28)-mg
(28)
ribavirin oral capsule 200 mg
ribavirin oral tablet 200 mg
TYZEKA ORAL TABLET 600 MG
valacyclovir oral tablet 1 gram, 500 mg
VALCYTE ORAL RECON SOLN 50
MG/ML
valganciclovir oral tablet 450 mg
VIRAZOLE INHALATION RECON
SOLN 6 GRAM
Drug Tier
(Cytovene)
2
(Rebetol)
(Copegus)
2
2
(Ribatab)
5
(Rebetol)
(Copegus)
2
2
5
2
4
(Valtrex)
(Valcyte)
5
5
Requirements/Limits
PA BvD
PA BvD
Blood Products/Modifiers/Volume
Expanders
Anticoagulants
CEPROTIN (BLUE BAR)
INTRAVENOUS RECON SOLN 500
UNIT
ELIQUIS ORAL TABLET 2.5 MG, 5
MG
enoxaparin subcutaneous solution 300
mg/3 ml
enoxaparin subcutaneous syringe 100
mg/ml, 120 mg/0.8 ml, 150 mg/ml
enoxaparin subcutaneous syringe 30
mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml,
80 mg/0.8 ml
fondaparinux subcutaneous syringe 10
mg/0.8 ml
5
3
(Lovenox)
2
(Lovenox)
5
(Lovenox)
2
(Arixtra)
2
QL (24 per 30 days)
65
Drug Name
fondaparinux subcutaneous syringe 2.5
mg/0.5 ml
fondaparinux subcutaneous syringe 5
mg/0.4 ml
fondaparinux subcutaneous syringe 7.5
mg/0.6 ml
heparin (porcine) in 5 % dex intravenous
parenteral solution 12,500 unit/250 ml,
20,000 unit/500 ml (40 unit/ml), 25,000
unit/500 ml (50 unit/ml)
heparin (porcine) in 5 % dex intravenous
parenteral solution 25,000 unit/250
ml(100 unit/ml)
heparin (porcine) in nacl (pf)
intravenous parenteral solution 1,000
unit/500 ml
heparin (porcine) injection solution 1,000
unit/ml, 10,000 unit/ml, 20,000 unit/ml,
5,000 unit/ml
heparin, porcine (pf) injection solution
5,000 unit/0.5 ml
heparin, porcine (pf) injection syringe
5,000 unit/0.5 ml
heparin-0.45% nacl 25,000 units/250 ml
(100 units/ml) bag latex-free, inner
25,000 unit/250 ml
heparin-d5w 25,000 units/250 ml (100
units/ml) bag excel container 25,000
unit/250 ml(100 unit/ml)
IPRIVASK SUBCUTANEOUS
RECON SOLN 15 MG
jantoven oral tablet 1 mg, 10 mg, 2 mg,
2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
PRADAXA ORAL CAPSULE 110
MG, 150 MG, 75 MG
SAVAYSA ORAL TABLET 15 MG,
30 MG, 60 MG
Drug Tier
Requirements/Limits
(Arixtra)
2
QL (15 per 30 days)
(Arixtra)
2
QL (12 per 30 days)
(Arixtra)
2
QL (18 per 30 days)
(Heparin
Sodium,Porcine/D5W)
2
(Heparin Sod,Pork In
0.45% NaCl)
2
(Heparin
Sodium,Porcine/Ns/PF
)
(Heparin
Sodium,Porcine)
2
(Heparin
Sodium,Porcine/PF)
(Monoject Prefill
Advanced)
(Heparin Sod,Pork In
0.45% NaCl)
2
(Heparin
Sodium,Porcine/D5W)
2
2
2
2
5
(Coumadin)
PA; QL (24 per 28
days)
1
4
4
66
Drug Name
warfarin oral tablet 1 mg, 10 mg, 2 mg,
2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
XARELTO ORAL TABLET 10 MG,
15 MG, 20 MG
XARELTO ORAL TABLETS,DOSE
PACK 15 MG (42)- 20 MG (9)
Blood Formation Modifiers
CINRYZE INTRAVENOUS RECON
SOLN 500 UNIT (5 ML)
EPOGEN 10,000 UNITS/ML VIAL
SDV, P/F, OUTER 10,000 UNIT/ML
EPOGEN INJECTION SOLUTION
2,000 UNIT/ML, 20,000 UNIT/2 ML,
20,000 UNIT/ML, 3,000 UNIT/ML,
4,000 UNIT/ML
GRANIX SUBCUTANEOUS
SYRINGE 300 MCG/0.5 ML, 480
MCG/0.8 ML
LEUKINE INJECTION RECON
SOLN 250 MCG
MIRCERA INJECTION SYRINGE
100 MCG/0.3 ML, 200 MCG/0.3 ML,
50 MCG/0.3 ML, 75 MCG/0.3 ML
MOZOBIL SUBCUTANEOUS
SOLUTION 24 MG/1.2 ML (20
MG/ML)
NEULASTA SUBCUTANEOUS
SYRINGE 6 MG/0.6ML
NEULASTA SUBCUTANEOUS
SYRINGE, W/ WEARABLE
INJECTOR 6 MG/0.6 ML
NEUMEGA SUBCUTANEOUS
RECON SOLN 5 MG
NEUPOGEN INJECTION
SOLUTION 300 MCG/ML, 480
MCG/1.6 ML
Drug Tier
(Coumadin)
Requirements/Limits
1
3
3
5
PA
3
PA; QL (12 per 28
days)
PA; QL (12 per 28
days)
3
5
5
4
PA; QL (0.6 per 28
days)
5
5
5
5
5
67
Drug Name
Drug Tier
NEUPOGEN INJECTION SYRINGE
300 MCG/0.5 ML, 480 MCG/0.8 ML
PROCRIT 10,000 UNITS/ML VIAL
4'S, MDV, OUTER 20,000 UNIT/2 ML
PROCRIT INJECTION SOLUTION
10,000 UNIT/ML, 2,000 UNIT/ML,
3,000 UNIT/ML, 4,000 UNIT/ML
20,000 UNIT/ML
40,000 UNIT/ML
PROMACTA ORAL TABLET 12.5
MG, 25 MG, 50 MG, 75 MG
ZARXIO INJECTION SYRINGE 300
MCG/0.5 ML, 480 MCG/0.8 ML
Hematologic Agents,
Miscellaneous
aminocaproic acid oral solution 250
mg/ml (25 %)
aminocaproic acid oral tablet 1,000 mg,
500 mg
anagrelide oral capsule 0.5 mg, 1 mg
protamine intravenous solution 10 mg/ml
tranexamic acid intravenous solution
1,000 mg/10 ml (100 mg/ml)
tranexamic acid oral tablet 650 mg
Platelet-Aggregation Inhibitors
aspirin-dipyridamole oral capsule, er
multiphase 12 hr 25-200 mg
BRILINTA ORAL TABLET 60 MG,
90 MG
cilostazol oral tablet 100 mg, 50 mg
clopidogrel oral tablet 300 mg, 75 mg
dipyridamole oral tablet 25 mg, 50 mg,
75 mg
5
3
3
5
5
5
Requirements/Limits
PA; QL (12 per 28
days)
PA; QL (12 per 28
days)
PA; QL (12 per 28
days)
PA; QL (30 per 30
days)
5
(Aminocaproic Acid)
2
(Aminocaproic Acid)
2
(Agrylin)
(Protamine Sulfate)
(Tranexamic Acid)
2
2
2
(Lysteda)
2
(Aggrenox)
2
QL (30 per 30 days)
3
(Pletal)
(Plavix)
(Persantine)
2
2
2
68
Drug Name
EFFIENT ORAL TABLET 10 MG, 5
MG
pentoxifylline oral tablet extended
release 400 mg
Drug Tier
3
(Pentoxifylline)
Requirements/Limits
QL (30 per 30 days)
2
Caloric Agents
Caloric Agents
AMINO ACIDS 15 %
INTRAVENOUS PARENTERAL
SOLUTION 15 %
AMINOSYN 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
AMINOSYN 3.5 % INTRAVENOUS
PARENTERAL SOLUTION 3.5 %
AMINOSYN 7 % INTRAVENOUS
AMINOSYN 7 % WITH
ELECTROLYTES INTRAVENOUS
AMINOSYN 8.5 % INTRAVENOUS
AMINOSYN 8.5 %-ELECTROLYTES
SOLUTION 8.5 %
AMINOSYN II 10 %
SOLUTION 10 %
AMINOSYN II 15 %
SOLUTION 15 %
AMINOSYN II 7 % INTRAVENOUS
AMINOSYN II 8.5 %
SOLUTION 8.5 %
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
69
Drug Name
Drug Tier
Requirements/Limits
AMINOSYN II 8.5
%-ELECTROLYTES
SOLUTION 8.5 %
AMINOSYN M 3.5 %
SOLUTION 3.5 %
AMINOSYN-HBC 7%
SOLUTION 7 %
AMINOSYN-PF 10 %
SOLUTION 10 %
AMINOSYN-PF 7 %
(SULFITE-FREE) INTRAVENOUS
AMINOSYN-RF 5.2 %
SOLUTION 5.2 %
CLINIMIX 5%/D15W SULFITE
FREE INTRAVENOUS
CLINIMIX 5%/D25W
SULFITE-FREE INTRAVENOUS
CLINIMIX 2.75%/D5W SULFIT
FREE INTRAVENOUS
CLINIMIX 4.25%/D10W SULF FREE
SOLUTION 4.25 %
CLINIMIX 4.25%/D5W SULFIT
FREE INTRAVENOUS
CLINIMIX 4.25%-D20W SULF-FREE
SOLUTION 4.25 %
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
70
Drug Name
Drug Tier
CLINIMIX 4.25%-D25W SULF-FREE
SOLUTION 4.25 %
CLINIMIX
5%-D20W(SULFITE-FREE)
SOLUTION 5 %
CLINIMIX E 2.75%/D10W SUL
FREE INTRAVENOUS
CLINIMIX E 2.75%/D5W SULF
FREE INTRAVENOUS
FREE INTRAVENOUS
FREE INTRAVENOUS
CLINIMIX E 4.25%/D5W SULF
FREE INTRAVENOUS
CLINIMIX E 5%/D15W SULFIT
FREE INTRAVENOUS
FREE INTRAVENOUS
FREE INTRAVENOUS
CLINISOL SF 15 % INTRAVENOUS
cysteine (l-cysteine) intravenous solution (Cysteine HCl)
50 mg/ml
dextrose 10 % in water (d10w)
(Dextrose 10 % in
intravenous parenteral solution 10 %
Water)
Requirements/Limits
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
2
PA BvD
2
PA BvD
71
Drug Name
intravenous syringe
dextrose 5 % in ringers intravenous
parenteral solution 5 %
dextrose 5 % in water (d5w) intravenous
parenteral solution
intravenous parenteral solution
intravenous syringe
FREAMINE HBC 6.9 %
SOLUTION 6.9 %
FREAMINE III 10 %
SOLUTION 10 %
HEPATAMINE 8% INTRAVENOUS
HEPATASOL 8 % INTRAVENOUS
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
KABIVEN INTRAVENOUS
EMULSION 3.31-9.8-3.9 %
LIPOSYN II INTRAVENOUS
EMULSION 20 %
LIPOSYN III INTRAVENOUS
EMULSION 10 %, 20 %, 30 %
NEPHRAMINE 5.4 %
SOLUTION 5.4 %
Drug Tier
(Dextrose 20 % in
Water)
(Dextrose 25 % in
Water)
(Dextrose 40 % in
Water)
(Dextrose 5 % In
Ringers)
(Dextrose 5 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 70 % in
Water)
Requirements/Limits
2
PA BvD
2
PA BvD
2
PA BvD
2
2
2
PA BvD
2
PA BvD
2
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
72
Drug Name
Drug Tier
Requirements/Limits
NUTRILIPID INTRAVENOUS
EMULSION 20 %
PERIKABIVEN INTRAVENOUS
EMULSION 2.36-6.8-3.5 %
PREMASOL 10 % INTRAVENOUS
PREMASOL 6 % INTRAVENOUS
PROCALAMINE 3%
SOLUTION 3 %
PROSOL 20 % INTRAVENOUS
PARENTERAL SOLUTION
TRAVASOL 10 % INTRAVENOUS
TROPHAMINE 10 %
SOLUTION 10 %
TROPHAMINE 6% INTRAVENOUS
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet 0.1 mg, 0.2 mg,
0.3 mg
clonidine transdermal patch weekly 0.1
mg/24 hr, 0.2 mg/24 hr
clonidine transdermal patch weekly 0.3
mg/24 hr
clorpres oral tablet 0.1-15 mg, 0.2-15 mg,
0.3-15 mg
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8
mg
guanfacine oral tablet 1 mg, 2 mg
midodrine oral tablet 10 mg, 2.5 mg, 5
mg
(Catapres)
1
(Catapres-Tts 1)
2
QL (4 per 28 days)
(Catapres-Tts 1)
2
QL (8 per 28 days)
(Clonidine
HCl/Chlorthalidone)
(Cardura)
2
(Tenex)
(Midodrine HCl)
2
2
2
73
Drug Name
Drug Tier
NORTHERA ORAL CAPSULE 100
MG, 200 MG, 300 MG
phenylephrine hcl injection solution 10
mg/ml
prazosin oral capsule 1 mg, 2 mg, 5 mg
Angiotensin Ii Receptor
Antagonists
BENICAR HCT ORAL TABLET
20-12.5 MG, 40-12.5 MG, 40-25 MG
BENICAR ORAL TABLET 20 MG, 40
MG, 5 MG
candesartan oral tablet 16 mg, 32 mg, 4
mg, 8 mg
candesartan-hydrochlorothiazid oral
tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg
EDARBI ORAL TABLET 40 MG, 80
MG
EDARBYCLOR ORAL TABLET
40-12.5 MG, 40-25 MG
ENTRESTO ORAL TABLET 24-26
MG, 49-51 MG, 97-103 MG
eprosartan oral tablet 600 mg
irbesartan oral tablet 150 mg, 300 mg, 75
mg
irbesartan-hydrochlorothiazide oral
tablet 150-12.5 mg, 300-12.5 mg
losartan oral tablet 100 mg, 25 mg, 50
mg
losartan-hydrochlorothiazide oral tablet
100-12.5 mg, 100-25 mg, 50-12.5 mg
telmisartan oral tablet 20 mg, 40 mg, 80
mg
telmisartan-hydrochlorothiazid oral
tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg
TEVETEN HCT ORAL TABLET
600-12.5 MG, 600-25 MG
5
(Vazculep)
2
(Minipress)
2
Requirements/Limits
PA; QL (180 per 30
days)
3
3
(Atacand)
2
(Atacand HCT)
2
4
ST
4
ST
3
PA; QL (60 per 30
days)
(Teveten)
(Avapro)
2
2
(Avalide)
2
(Cozaar)
1
(Hyzaar)
2
(Micardis)
2
(Micardis HCT)
2
3
ST
74
Drug Name
Drug Tier
TRIBENZOR ORAL TABLET
20-5-12.5 MG, 40-10-12.5 MG, 40-10-25
MG, 40-5-12.5 MG, 40-5-25 MG
valsartan oral tablet 160 mg, 320 mg, 40
mg, 80 mg
valsartan-hydrochlorothiazide oral tablet
160-12.5 mg, 160-25 mg, 320-12.5 mg,
320-25 mg, 80-12.5 mg
Angiotensin-Converting Enzyme
Inhibitors
benazepril oral tablet 10 mg, 20 mg, 40
mg, 5 mg
benazepril-hydrochlorothiazide oral
tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg,
5-6.25 mg
captopril oral tablet 100 mg, 12.5 mg, 25
mg, 50 mg
captopril-hydrochlorothiazide oral tablet
25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg
enalapril maleate oral tablet 10 mg, 2.5
mg, 20 mg, 5 mg
enalaprilat intravenous solution 1.25
mg/ml
enalapril-hydrochlorothiazide oral tablet
10-25 mg, 5-12.5 mg
fosinopril oral tablet 10 mg, 20 mg, 40
mg
fosinopril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg
lisinopril oral tablet 10 mg, 2.5 mg, 20
mg, 30 mg, 40 mg, 5 mg
lisinopril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg
moexipril oral tablet 15 mg, 7.5 mg
moexipril-hydrochlorothiazide oral tablet
15-12.5 mg, 15-25 mg, 7.5-12.5 mg
3
(Diovan)
2
(Diovan HCT)
2
(Lotensin)
1
(Lotensin HCT)
2
(Captopril)
2
(Captopril/Hydrochlor
othiazide)
(Vasotec)
2
(Enalaprilat Dihydrate)
2
(Vaseretic)
2
(Fosinopril Sodium)
2
(Fosinopril/Hydrochlor
othiazide)
(Zestril)
2
(Zestoretic)
1
(Moexipril HCl)
(Moexipril/Hydrochlor
othiazide)
2
2
Requirements/Limits
ST
1
1
75
Drug Name
perindopril erbumine oral tablet 2 mg, 4
mg, 8 mg
quinapril oral tablet 10 mg, 20 mg, 40
mg, 5 mg
quinapril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg
ramipril oral capsule 1.25 mg, 10 mg, 2.5
mg, 5 mg
trandolapril oral tablet 1 mg, 2 mg, 4 mg
Antiarrhythmic Agents
amiodarone intravenous solution 50
mg/ml
amiodarone intravenous syringe 150 mg/3
ml
amiodarone oral tablet 100 mg, 200 mg,
400 mg
disopyramide phosphate oral capsule 100
mg, 150 mg
flecainide oral tablet 100 mg, 150 mg, 50
mg
lidocaine (pf) intravenous syringe 50
mg/5 ml (1 %)
lidocaine in 5 % dextrose (pf)
intravenous parenteral solution 8 mg/ml
(0.8 %)
mexiletine oral capsule 150 mg, 200 mg,
250 mg
MULTAQ ORAL TABLET 400 MG
pacerone oral tablet 100 mg, 200 mg, 400
mg
procainamide injection solution 100
mg/ml, 500 mg/ml
propafenone oral capsule,extended
propafenone oral tablet 150 mg, 225 mg,
300 mg
Drug Tier
(Aceon)
2
(Accupril)
2
(Accuretic)
2
(Altace)
2
(Mavik)
2
(Amiodarone HCl)
2
(Amiodarone HCl)
2
(Cordarone)
2
(Norpace)
2
(Tambocor)
2
(Lidocaine HCl/PF)
2
(Lidocaine
HCl/D5w/PF)
2
(Mexiletine HCl)
2
(Cordarone)
3
2
(Procainamide HCl)
2
(Rythmol SR)
2
(Rythmol)
2
Requirements/Limits
76
Drug Name
quinidine gluconate oral tablet extended
release 324 mg
quinidine sulfate oral tablet 200 mg, 300
mg
quinidine sulfate oral tablet extended
release 300 mg
TIKOSYN ORAL CAPSULE 125
MCG, 250 MCG, 500 MCG
Beta-Adrenergic Blocking Agents
acebutolol oral capsule 200 mg, 400 mg
atenolol oral tablet 100 mg, 25 mg, 50 mg
atenolol-chlorthalidone oral tablet 100-25
mg, 50-25 mg
betaxolol oral tablet 10 mg, 20 mg
bisoprolol fumarate oral tablet 10 mg, 5
mg
bisoprolol-hydrochlorothiazide oral tablet
10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg
BYSTOLIC ORAL TABLET 10 MG,
2.5 MG, 20 MG, 5 MG
carvedilol oral tablet 12.5 mg, 25 mg,
3.125 mg, 6.25 mg
esmolol intravenous solution 100 mg/10
ml (10 mg/ml)
labetalol intravenous solution 5 mg/ml
labetalol oral tablet 100 mg, 200 mg, 300
mg
metoprolol succinate oral tablet extended
release 24 hr 100 mg, 200 mg, 25 mg, 50
mg
metoprolol ta-hydrochlorothiaz oral
tablet 100-25 mg, 100-50 mg, 50-25 mg
metoprolol tartrate intravenous solution 5
mg/5 ml
metoprolol tartrate oral tablet 100 mg, 25
mg, 50 mg
Drug Tier
(Quinidine Gluconate)
2
(Quinidine Sulfate)
2
(Quinidine Sulfate)
2
Requirements/Limits
3
(Sectral)
(Tenormin)
(Tenoretic 50)
2
1
1
(Kerlone)
(Zebeta)
2
2
(Ziac)
2
3
(Coreg)
1
(Brevibloc)
2
(Labetalol HCl)
(Trandate)
2
2
(Toprol XL)
2
(Lopressor HCT)
2
(Lopressor)
2
(Lopressor)
1
PA BvD
77
Drug Name
metoprolol tartrate oral tablet 37.5 mg,
75 mg
nadolol oral tablet 20 mg, 40 mg, 80 mg
pindolol oral tablet 10 mg, 5 mg
propranolol intravenous solution 1 mg/ml
propranolol oral capsule,extended release
24 hr 120 mg, 160 mg, 60 mg, 80 mg
propranolol oral solution 20 mg/5 ml (4
mg/ml), 40 mg/5 ml (8 mg/ml)
propranolol oral tablet 10 mg, 20 mg, 40
mg, 60 mg, 80 mg
propranolol-hydrochlorothiazid oral
tablet 40-25 mg, 80-25 mg
sorine oral tablet 120 mg, 160 mg, 240
mg, 80 mg
sotalol 120 mg tablet 120 mg
sotalol af oral tablet 120 mg
sotalol oral tablet 160 mg, 240 mg, 80 mg
timolol maleate oral tablet 10 mg, 20 mg,
5 mg
Calcium-Channel Blocking Agents
cartia xt oral capsule,extended release
24hr 120 mg, 180 mg, 240 mg, 300 mg
diltiazem 24hr er 180 mg cap 180 mg
diltiazem 24hr er 360 mg cap once a day
dosage 360 mg
diltiazem hcl intravenous recon soln 100
mg
diltiazem hcl intravenous solution 5
mg/ml
diltiazem hcl oral capsule, extended
release 180 mg, 360 mg, 420 mg
diltiazem hcl oral capsule,extended
diltiazem hcl oral capsule,extended
release 24hr 120 mg, 240 mg, 300 mg
Drug Tier
(Lopressor)
2
(Corgard)
(Pindolol)
(Propranolol HCl)
(Inderal LA)
2
2
2
2
(Propranolol HCl)
2
(Propranolol HCl)
2
(Propranolol/Hydrochl
orothiazid)
(Betapace)
2
(Betapace)
(Betapace)
(Betapace)
(Timolol Maleate)
2
2
2
2
(Cardizem CD)
2
(Cardizem CD)
(Cardizem CD)
2
2
(Cardizem CD)
2
(Cardizem CD)
2
(Cardizem CD)
2
(Cardizem CD)
2
(Cardizem CD)
2
Requirements/Limits
2
78
Drug Name
diltiazem hcl oral tablet 120 mg, 30 mg,
60 mg, 90 mg
diltiazem hcl oral tablet extended release
24 hr 180 mg, 240 mg, 300 mg, 360 mg,
420 mg
dilt-xr oral capsule,ext release
degradable 120 mg, 180 mg, 240 mg
matzim la oral tablet extended release 24
hr 180 mg, 240 mg, 300 mg, 360 mg, 420
mg
taztia xt oral capsule, extended release
120 mg, 180 mg, 240 mg, 300 mg, 360 mg
verapamil intravenous syringe 2.5 mg/ml
verapamil oral capsule, 24 hr er pellet ct
100 mg, 200 mg, 300 mg
verapamil oral capsule,ext rel. pellets 24
hr 120 mg, 180 mg, 240 mg, 360 mg
verapamil oral tablet 120 mg, 40 mg, 80
mg
verapamil oral tablet extended release
120 mg, 180 mg, 240 mg
Cardiovascular Agents,
Miscellaneous
CORLANOR ORAL TABLET 5 MG,
7.5 MG
DEMSER ORAL CAPSULE 250 MG
digitek oral tablet 125 mcg, 250 mcg
digox 125 mcg tablet 125 mcg
digox 250 mcg tablet 250 mcg
digoxin 0.25 mg/ml syringe 250 mcg/ml
digoxin injection solution 250 mcg/ml
DIGOXIN ORAL SOLUTION 50
MCG/ML
digoxin oral tablet 125 mcg, 250 mcg
Drug Tier
(Cardizem CD)
1
(Cardizem LA)
2
(Cardizem CD)
2
(Cardizem CD)
2
(Cardizem CD)
2
(Verapamil HCl)
(Verelan Pm)
2
2
(Verelan)
2
(Calan)
1
(Calan SR)
2
3
(Lanoxin)
(Lanoxin)
(Lanoxin)
(Digoxin)
(Digoxin)
(Lanoxin)
5
2
2
2
2
2
3
2
Requirements/Limits
ST
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
79
Drug Name
dobutamine in d5w intravenous
parenteral solution 1,000 mg/250 ml
(4,000 mcg/ml), 250 mg/250 ml (1
mg/ml), 500 mg/250 ml (2,000 mcg/ml)
dobutamine intravenous solution 250
mg/20 ml (12.5 mg/ml)
dopamine in 5 % dextrose intravenous
solution 200 mg/250 ml (800 mcg/ml),
400 mg/250 ml (1,600 mcg/ml), 800
mg/250 ml (3,200 mcg/ml)
dopamine intravenous solution 200 mg/5
ml (40 mg/ml), 400 mg/5 ml (80 mg/ml),
800 mg/10 ml (80 mg/ml), 800 mg/5 ml
(160 mg/ml)
ephedrine sulfate injection solution 50
mg/ml
epinephrine hcl (pf) intravenous solution
1 mg/ml (1 ml)
epinephrine injection auto-injector 0.15
mg/0.15 ml, 0.3 mg/0.3 ml
epinephrine injection solution 1 mg/ml (1
ml)
epinephrine injection syringe 0.1 mg/ml
EPIPEN 2-PAK INJECTION
AUTO-INJECTOR 0.3 MG/0.3 ML
EPIPEN JR 2-PAK INJECTION
AUTO-INJECTOR 0.15 MG/0.3 ML
ethamolin intravenous solution 5 %
FIRAZYR SUBCUTANEOUS
SYRINGE 30 MG/3 ML
hydralazine injection solution 20 mg/ml
hydralazine oral tablet 10 mg, 100 mg, 25
mg, 50 mg
LANOXIN ORAL TABLET 187.5
MCG, 62.5 MCG
milrinone in 5 % dextrose intravenous
piggyback 40 mg/200 ml (200 mcg/ml)
Drug Tier
Requirements/Limits
(Dobutamine
HCl/D5W)
2
PA BvD
(Dobutamine HCl)
2
PA BvD
(Dopamine HCl/D5W)
2
PA BvD
(Dopamine HCl)
2
PA BvD
(Ephedrine Sulfate)
2
(Epinephrine HCl/PF)
2
(Adrenaclick)
2
(Epinephrine)
2
(Epinephrine)
2
3
3
(Ethanolamine Oleate)
2
5
(Hydralazine HCl)
(Hydralazine HCl)
2
2
(Milrinone
Lactate/D5W)
4
QL (30 per 30 days)
5
PA BvD
80
Drug Name
milrinone intravenous solution 1 mg/ml
norepinephrine bitartrate intravenous
solution 1 mg/ml
papaverine injection solution 30 mg/ml
papaverine oral capsule, extended release
150 mg
RANEXA ORAL TABLET
EXTENDED RELEASE 12 HR 1,000
MG, 500 MG
Dihydropyridines
afeditab cr oral tablet extended release
30 mg, 60 mg
amlodipine oral tablet 10 mg, 2.5 mg, 5
mg
amlodipine-benazepril oral capsule 10-20
mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20
mg, 5-40 mg
amlodipine-valsartan oral tablet 10-160
mg, 10-320 mg, 5-160 mg, 5-320 mg
amlodipine-valsartan-hcthiazid oral
tablet 10-160-12.5 mg, 10-160-25 mg,
10-320-25 mg, 5-160-12.5 mg, 5-160-25
mg
AZOR ORAL TABLET 10-20 MG,
10-40 MG, 5-20 MG, 5-40 MG
CLEVIPREX INTRAVENOUS
EMULSION 50 MG/100 ML
felodipine oral tablet extended release 24
hr 10 mg, 2.5 mg, 5 mg
isradipine oral capsule 2.5 mg, 5 mg
nicardipine oral capsule 20 mg, 30 mg
nifedical xl oral tablet extended release
24hr 30 mg, 60 mg
nifedipine er 30 mg tablet f/c 30 mg
nifedipine oral tablet extended release
24hr 30 mg
Drug Tier
Requirements/Limits
(Milrinone Lactate)
(Levophed Bitartrate)
5
2
PA BvD
PA BvD
(Papaverine HCl)
(Papaverine HCl)
2
2
PA
PA
3
(Adalat CC)
2
(Norvasc)
1
(Lotrel)
2
(Exforge)
2
(Exforge HCT)
2
3
ST
4
(Felodipine)
2
(Isradipine)
(Nicardipine HCl)
(Procardia XL)
2
2
2
(Adalat CC)
(Adalat CC)
2
2
81
Drug Name
nifedipine oral tablet extended release
24hr 60 mg, 90 mg
Diuretics
amiloride oral tablet 5 mg
amiloride-hydrochlorothiazide oral tablet
5-50 mg
bumetanide injection solution 0.25 mg/ml
bumetanide oral tablet 0.5 mg, 1 mg, 2
mg
chlorothiazide oral tablet 250 mg, 500 mg
chlorothiazide sodium intravenous recon
soln 500 mg
chlorthalidone oral tablet 25 mg, 50 mg
DYRENIUM ORAL CAPSULE 100
MG, 50 MG
furosemide injection solution 10 mg/ml
furosemide injection syringe 10 mg/ml
furosemide oral solution 10 mg/ml, 40
mg/5 ml (8 mg/ml)
furosemide oral tablet 20 mg, 40 mg, 80
mg
hydrochlorothiazide oral capsule 12.5 mg
hydrochlorothiazide oral tablet 12.5 mg,
25 mg, 50 mg
indapamide oral tablet 1.25 mg, 2.5 mg
methyclothiazide oral tablet 5 mg
metolazone oral tablet 10 mg, 2.5 mg, 5
mg
torsemide oral tablet 10 mg, 100 mg, 20
mg, 5 mg
triamterene-hydrochlorothiazid oral
capsule 37.5-25 mg, 50-25 mg
triamterene-hydrochlorothiazid oral
tablet 37.5-25 mg, 75-50 mg
Drug Tier
(Procardia XL)
2
(Amiloride HCl)
(Amiloride/Hydrochlor
othiazide)
(Bumetanide)
(Bumetanide)
2
2
(Chlorothiazide)
(Sodium Diuril)
1
2
(Chlorthalidone)
1
4
(Furosemide)
(Furosemide)
(Furosemide)
2
2
2
(Lasix)
1
(Microzide)
(Hydrochlorothiazide)
1
1
(Indapamide)
(Methyclothiazide)
(Zaroxolyn)
1
2
2
(Demadex)
2
(Dyazide)
2
(Maxzide)
2
Requirements/Limits
2
2
82
Drug Name
Dyslipidemics
ALTOPREV ORAL TABLET
MG, 40 MG, 60 MG
amlodipine-atorvastatin oral tablet 10-10
mg, 10-20 mg, 10-40 mg, 10-80 mg,
2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10
mg, 5-20 mg, 5-40 mg, 5-80 mg
atorvastatin oral tablet 10 mg, 20 mg, 40
mg, 80 mg
cholestyramine light oral powder in
packet 4 gram
cholestyramine packet 4 gram
colestipol hcl granules packet 5 gram
colestipol oral granules 5 gram
colestipol oral tablet 1 gram
CRESTOR ORAL TABLET 10 MG,
20 MG, 40 MG, 5 MG
fenofibrate micronized oral capsule 130
mg, 134 mg, 200 mg, 43 mg, 67 mg
fenofibrate nanocrystallized oral tablet
145 mg, 48 mg
fenofibrate oral tablet 120 mg, 160 mg,
40 mg, 54 mg
fenofibric acid (choline) oral
capsule,delayed release(dr/ec) 135 mg,
45 mg
fenofibric acid oral tablet 105 mg, 35 mg
fluvastatin oral capsule 20 mg, 40 mg
gemfibrozil oral tablet 600 mg
JUXTAPID ORAL CAPSULE 10 MG,
20 MG, 30 MG, 40 MG, 5 MG, 60 MG
KYNAMRO SUBCUTANEOUS
SYRINGE 200 MG/ML
lovastatin oral tablet 10 mg, 20 mg, 40
mg
Drug Tier
Requirements/Limits
4
(Caduet)
2
(Lipitor)
1
(Questran)
2
(Questran)
(Colestid)
(Colestid)
(Colestid)
2
2
2
2
2
(Lofibra)
2
(Tricor)
2
(Lofibra)
2
(Trilipix)
2
(Fibricor)
(Lescol)
(Lopid)
2
2
2
5
PA
5
(Mevacor)
1
83
Drug Name
niacin oral tablet extended release 24 hr
1,000 mg, 500 mg, 750 mg
niacor oral tablet 500 mg
omega-3 acid ethyl esters oral capsule 1
gram
PRALUENT PEN SUBCUTANEOUS
PEN INJECTOR 150 MG/ML, 75
MG/ML
PRALUENT SYRINGE
SUBCUTANEOUS SYRINGE 150
MG/ML, 75 MG/ML
pravastatin oral tablet 10 mg, 20 mg, 40
mg, 80 mg
prevalite oral powder 4 gram
prevalite packet outer 4 gram
REPATHA SURECLICK
140 MG/ML
REPATHA SYRINGE
MG/ML
simvastatin oral tablet 10 mg, 20 mg, 40
mg, 5 mg
simvastatin oral tablet 80 mg
VASCEPA ORAL CAPSULE 1
GRAM
VYTORIN 10-10 ORAL TABLET
10-10 MG
10-20 MG
10-40 MG
10-80 MG
Drug Tier
(Niaspan)
2
(Niacin)
(Lovaza)
2
2
Requirements/Limits
5
5
(Pravachol)
1
(Cholestyramine/Aspar
tame)
(Cholestyramine/Aspar
tame)
2
2
5
5
(Zocor)
1
(Zocor)
1
3
QL (30 per 30 days)
4
4
4
4
84
Drug Name
Drug Tier
WELCHOL ORAL POWDER IN
PACKET 3.75 GRAM
WELCHOL ORAL TABLET 625 MG
ZETIA ORAL TABLET 10 MG
Renin-Angiotensin-Aldosterone
System Inhibitors
eplerenone oral tablet 25 mg, 50 mg
spironolactone oral tablet 100 mg, 25 mg,
50 mg
spironolacton-hydrochlorothiaz oral
tablet 25-25 mg
Vasodilators
BIDIL ORAL TABLET 20-37.5 MG
isosorbide dinitrate oral tablet 10 mg, 20
mg, 30 mg, 5 mg
isosorbide dinitrate oral tablet extended
release 40 mg
isosorbide dinitrate sublingual tablet 2.5
mg, 5 mg
isosorbide mononitrate oral tablet 10 mg,
20 mg
isosorbide mononitrate oral tablet
extended release 24 hr 120 mg, 30 mg, 60
mg
minitran transdermal patch 24 hour 0.1
mg/hr, 0.2 mg/hr, 0.6 mg/hr
minitran transdermal patch 24 hour 0.4
mg/hr
minoxidil oral tablet 10 mg, 2.5 mg
NITRO-BID TRANSDERMAL
OINTMENT 2 %
nitroglycerin in 5 % dextrose intravenous
solution 100 mg/250 ml (400 mcg/ml), 25
mg/250 ml (100 mcg/ml), 50 mg/250 ml
(200 mcg/ml)
nitroglycerin intravenous solution 50
mg/10 ml (5 mg/ml)
3
Requirements/Limits
3
4
(Inspra)
(Aldactone)
2
2
(Aldactazide)
2
(Isochron)
3
2
(Isochron)
2
(Isosorbide Dinitrate)
1
(Isosorbide
Mononitrate)
(Imdur)
2
(Nitro-Dur)
2
QL (30 per 30 days)
(Nitro-Dur)
2
QL (60 per 30 days)
(Minoxidil)
2
2
(Nitroglycerin/D5W)
2
(Nitroglycerin)
2
2
85
Drug Name
nitroglycerin transdermal patch 24 hour
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
nitroglycerin transdermal patch 24 hour
0.4 mg/hr
NITROSTAT SUBLINGUAL
TABLET 0.3 MG, 0.4 MG, 0.6 MG
PROGLYCEM ORAL SUSPENSION
50 MG/ML
Drug Tier
Requirements/Limits
(Nitro-Dur)
2
QL (30 per 30 days)
(Nitro-Dur)
2
QL (60 per 30 days)
3
4
Central Nervous System Agents
Central Nervous System Agents
AMPYRA ORAL TABLET
MG
caffeine citrated intravenous solution 60
mg/3 ml (20 mg/ml)
caffeine citrated oral solution 60 mg/3 ml
(20 mg/ml)
caffeine-sodium benzoate injection
solution 250 mg/ml (125 mg/ml caffeine)
clonidine hcl oral tablet extended release
12 hr 0.1 mg
dexmethylphenidate oral tablet 10 mg,
2.5 mg, 5 mg
dextroamphetamine oral capsule,
extended release 10 mg, 15 mg, 5 mg
dextroamphetamine oral tablet 10 mg, 5
mg
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 10 mg, 15
mg, 5 mg
capsule,extended release 24hr 20 mg, 25
mg, 30 mg
tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30
mg, 5 mg, 7.5 mg
flumazenil intravenous solution 0.1 mg/ml
5
PA; QL (60 per 30
days)
(Cafcit)
2
(Cafcit)
2
(Caffeine/Sodium
Benzoate)
(Kapvay)
2
(Focalin)
2
QL (60 per 30 days)
(Dexedrine)
2
(Dexedrine)
2
(Adderall XR)
2
QL (30 per 30 days)
(Adderall XR)
2
QL (60 per 30 days)
(Adderall)
2
QL (60 per 30 days)
(Romazicon)
2
2
86
Drug Name
guanfacine oral tablet extended release
24 hr 1 mg, 2 mg, 3 mg, 4 mg
lithium carbonate oral capsule 150 mg,
300 mg, 600 mg
lithium carbonate oral tablet 300 mg
lithium carbonate oral tablet extended
release 300 mg, 450 mg
lithium citrate oral solution 8 meq/5 ml
methylphenidate cd 20 mg cap 20 mg
methylphenidate cd 40 mg cap 40 mg
methylphenidate oral capsule, er biphasic
30-70 10 mg, 50 mg, 60 mg
methylphenidate oral capsule, er biphasic
30-70 30 mg
methylphenidate oral capsule,er biphasic
50-50 20 mg, 40 mg
methylphenidate oral solution 10 mg/5
ml, 5 mg/5 ml
methylphenidate oral tablet 10 mg, 20
mg, 5 mg
methylphenidate oral tablet extended
release 10 mg, 20 mg
release 24hr 36 mg
NUEDEXTA ORAL CAPSULE 20-10
MG
QUILLIVANT XR ORAL
SUSPENSION,EXT REL
24HR,RECON 5 MG/ML (25 MG/5
ML)
riluzole oral tablet 50 mg
SAVELLA ORAL TABLET 100 MG,
12.5 MG, 25 MG, 50 MG
Drug Tier
Requirements/Limits
(Intuniv)
2
(Lithium Carbonate)
2
(Lithobid)
(Lithobid)
2
2
(Lithium Citrate)
(Metadate Cd)
(Metadate Cd)
(Metadate Cd)
2
2
2
2
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
(Metadate Cd)
2
QL (60 per 30 days)
(Metadate Cd)
2
QL (30 per 30 days)
(Methylin)
2
(Ritalin)
2
QL (90 per 30 days)
(Methylphenidate HCl)
2
QL (90 per 30 days)
(Concerta)
2
QL (30 per 30 days)
(Concerta)
2
QL (60 per 30 days)
3
QL (60 per 30 days)
3
(Rilutek)
2
3
QL (60 per 30 days)
87
Drug Name
Drug Tier
SAVELLA ORAL TABLETS,DOSE
PACK 12.5 MG (5)-25 MG(8)-50
MG(42)
STRATTERA ORAL CAPSULE 10
MG, 100 MG, 18 MG, 25 MG, 40 MG,
60 MG, 80 MG
tetrabenazine oral tablet 12.5 mg, 25 mg (Xenazine)
3
Requirements/Limits
QL (60 per 30 days)
3
5
PA; QL (112 per 28
days)
Contraceptives
Contraceptives
altavera (28) oral tablet 0.15-0.03 mg
alyacen 1/35 (28) oral tablet 1-35
mg-mcg
alyacen 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
amethia lo oral tablets,dose pack,3 month
0.10 mg-20 mcg (84)/10 mcg (7)
amethia oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
apri oral tablet 0.15-0.03 mg
aranelle (28) oral tablet 0.5/1/0.5-35
mg-mcg
ashlyna oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
aubra oral tablet 0.1-20 mg-mcg
aviane oral tablet 0.1-20 mg-mcg
azurette (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
balziva (28) oral tablet 0.4-35 mg-mcg
bekyree (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
blisovi 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
blisovi fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
(Amethyst)
(Modicon)
2
2
(Modicon)
2
(Seasonique)
2
QL (91 per 84 days)
(Seasonique)
2
QL (91 per 84 days)
(Desogen)
(Modicon)
2
2
(Seasonique)
2
(Amethyst)
(Amethyst)
(Mircette)
2
2
2
(Modicon)
(Mircette)
2
2
(Loestrin Fe)
2
(Loestrin Fe)
2
88
Drug Name
blisovi fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
briellyn oral tablet 0.4-35 mg-mcg
camila oral tablet 0.35 mg
camrese lo oral tablets,dose pack,3 month
0.10 mg-20 mcg (84)/10 mcg (7)
camrese oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
caziant (28) oral tablet 0.1/.125/.15-25
mg-mcg
cryselle (28) oral tablet 0.3-30 mg-mcg
cyclafem 1/35 (28) oral tablet 1-35
mg-mcg
cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
cyred oral tablet 0.15-0.03 mg
dasetta 1/35 (28) oral tablet 1-35
mg-mcg
dasetta 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
daysee oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
deblitane oral tablet 0.35 mg
delyla (28) oral tablet 0.1-20 mg-mcg
desog-e.estradiol/e.estradiol oral tablet
0.15-0.02 mgx21 /0.01 mg x 5
desogestrel-ethinyl estradiol oral tablet
0.15-0.03 mg
drospirenone-ethinyl estradiol oral tablet
3-0.02 mg, 3-0.03 mg
elinest oral tablet 0.3-30 mg-mcg
ELLA ORAL TABLET 30 MG
emoquette oral tablet 0.15-0.03 mg
Drug Tier
Requirements/Limits
(Loestrin Fe)
2
(Modicon)
(Nor-Q-D)
(Seasonique)
2
2
2
QL (91 per 84 days)
(Seasonique)
2
QL (91 per 84 days)
(Desogen)
2
(Norgestrel-Ethinyl
Estradiol)
(Modicon)
2
(Modicon)
2
(Desogen)
(Modicon)
2
2
(Modicon)
2
(Seasonique)
2
(Nor-Q-D)
(Amethyst)
(Mircette)
2
2
2
(Desogen)
2
(Yaz)
2
(Norgestrel-Ethinyl
Estradiol)
2
(Desogen)
2
4
2
QL (91 per 84 days)
QL (6 per 365 days)
89
Drug Name
enpresse oral tablet 50-30 (6)/75-40
(5)/125-30(10)
enskyce oral tablet 0.15-0.03 mg
errin oral tablet 0.35 mg
estarylla oral tablet 0.25-35 mg-mcg
falmina (28) oral tablet 0.1-20 mg-mcg
gianvi (28) oral tablet 3-0.02 mg
gildagia oral tablet 0.4-35 mg-mcg
gildess 1.5/30 (21) oral tablet 1.5-30
mg-mcg
gildess 1/20 (21) oral tablet 1-20 mg-mcg
gildess 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
gildess fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
gildess fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
heather oral tablet 0.35 mg
introvale oral tablets,dose pack,3 month
0.15-30 mg-mcg
jencycla oral tablet 0.35 mg
jolessa oral tablets,dose pack,3 month
0.15-30 mg-mcg
jolivette oral tablet 0.35 mg
juleber oral tablet 0.15-0.03 mg
junel 1.5/30 (21) oral tablet 1.5-30
mg-mcg
junel 1/20 (21) oral tablet 1-20 mg-mcg
junel fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
junel fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
junel fe 24 oral tablet 1 mg-20 mcg
(24)/75 mg (4)
kariva (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
Drug Tier
Requirements/Limits
(Amethyst)
2
(Desogen)
(Nor-Q-D)
(Ortho-Cyclen)
(Amethyst)
(Yaz)
(Modicon)
(Loestrin)
2
2
2
2
2
2
2
(Loestrin)
(Loestrin Fe)
2
2
(Loestrin Fe)
2
(Loestrin Fe)
2
(Nor-Q-D)
(Levonorgestrel-Ethin
Estradiol)
(Nor-Q-D)
Estradiol)
(Nor-Q-D)
(Desogen)
(Loestrin)
2
2
QL (91 per 84 days)
2
2
QL (91 per 84 days)
(Loestrin)
(Loestrin Fe)
2
2
(Loestrin Fe)
2
(Loestrin Fe)
2
(Mircette)
2
2
2
2
90
Drug Name
kelnor 1/35 (28) oral tablet 1-35 mg-mcg
kimidess (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
kurvelo oral tablet 0.15-0.03 mg
l norgest/e.estradiol-e.estrad oral
tablets,dose pack,3 month 0.10 mg-20
mcg (84)/10 mcg (7), 0.15 mg-30 mcg
(84)/10 mcg (7)
larin 1.5/30 (21) oral tablet 1.5-30
mg-mcg
larin 1/20 (21) oral tablet 1-20 mg-mcg
larin 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
larin fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
larin fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
leena 28 oral tablet 0.5/1/0.5-35 mg-mcg
lessina oral tablet 0.1-20 mg-mcg
levonest (28) oral tablet 50-30 (6)/75-40
(5)/125-30(10)
levonor-eth estrad 0.15-0.03 outer
0.15-0.03 mg
levonorgestrel oral tablet 0.75 mg
levonorgestrel oral tablet 1.5 mg
levonorgestrel-ethinyl estrad oral tablet
0.1-20 mg-mcg
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month 0.15-30
mg-mcg
levonorg-eth estrad triphasic oral tablet
50-30 (6)/75-40 (5)/125-30(10)
levora-28 oral tablet 0.15-0.03 mg
lomedia 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
loryna (28) oral tablet 3-0.02 mg
Drug Tier
Requirements/Limits
(Demulen 1-50-21)
(Mircette)
2
2
(Amethyst)
(Seasonique)
2
2
(Loestrin)
2
(Loestrin)
(Loestrin Fe)
2
2
(Loestrin Fe)
2
(Loestrin Fe)
2
(Modicon)
(Amethyst)
(Amethyst)
2
2
2
(Amethyst)
2
QL (91 per 84 days)
(Plan B One-Step)
(Plan B One-Step)
(Amethyst)
2
2
2
QL (6 per 365 days)
(Amethyst)
2
QL (91 per 84 days)
(Amethyst)
2
QL (91 per 84 days)
(Amethyst)
(Loestrin Fe)
2
2
(Yaz)
2
QL (91 per 84 days)
91
Drug Name
low-ogestrel (28) oral tablet 0.3-30
mg-mcg
lutera (28) oral tablet 0.1-20 mg-mcg
lyza oral tablet 0.35 mg
marlissa oral tablet 0.15-0.03 mg
microgestin 1.5/30 (21) oral tablet 1.5-30
mg-mcg
microgestin 1/20 (21) oral tablet 1-20
mg-mcg
microgestin fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
microgestin fe 1/20 (28) oral tablet 1
mg-20 mcg (21)/75 mg (7)
mono-linyah oral tablet 0.25-35 mg-mcg
mononessa (28) oral tablet 0.25-35
mg-mcg
myzilra oral tablet 50-30 (6)/75-40
(5)/125-30(10)
necon 0.5/35 (28) oral tablet 0.5-35
mg-mcg
necon 1/35 (28) oral tablet 1-35 mg-mcg
necon 1/50 (28) oral tablet 1-50 mg-mcg
necon 10/11 (28) oral tablet 0.5-35/1-35
mg-mcg/mg-mcg
necon 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
next choice one dose oral tablet 1.5 mg
nikki (28) oral tablet 3-0.02 mg
nora-be oral tablet 0.35 mg
norethindrone (contraceptive) oral tablet
0.35 mg
norethindrone ac-eth estradiol oral tablet
1-20 mg-mcg
norethindrone-e.estradiol-iron oral tablet
1 mg-20 mcg (24)/75 mg (4)
Drug Tier
(Norgestrel-Ethinyl
Estradiol)
(Amethyst)
(Nor-Q-D)
(Amethyst)
(Loestrin)
2
(Loestrin)
2
(Loestrin Fe)
2
(Loestrin Fe)
2
(Ortho-Cyclen)
(Ortho-Cyclen)
2
2
(Amethyst)
2
(Modicon)
2
(Modicon)
(Norinyl 1+50)
(Modicon)
2
2
2
(Modicon)
2
(Plan B One-Step)
(Yaz)
(Nor-Q-D)
(Nor-Q-D)
2
2
2
2
(Loestrin)
2
(Loestrin Fe)
2
Requirements/Limits
2
2
2
2
QL (6 per 365 days)
92
Drug Name
norg-ee 0.18-0.215-0.25/0.035
0.18/0.215/0.25 mg-35 mcg (28)
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-25 mcg, 0.25-35
mg-mcg
norlyroc oral tablet 0.35 mg
nortrel 0.5/35 (28) oral tablet 0.5-35
mg-mcg
nortrel 1/35 (21) oral tablet 1-35
mg-mcg
nortrel 1/35 (28) oral tablet 1-35
mg-mcg
nortrel 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
NUVARING VAGINAL RING
0.12-0.015 MG/24 HR
ocella oral tablet 3-0.03 mg
ogestrel (28) oral tablet 0.5-50 mg-mcg
Drug Tier
(Ortho-Cyclen)
2
(Ortho-Cyclen)
2
(Nor-Q-D)
(Modicon)
2
2
(Modicon)
2
(Modicon)
2
(Modicon)
2
3
(Yaz)
(Norgestrel-Ethinyl
Estradiol)
orsythia oral tablet 0.1-20 mg-mcg
(Amethyst)
philith oral tablet 0.4-35 mg-mcg
(Modicon)
pimtrea (28) oral tablet 0.15-0.02 mgx21 (Mircette)
/0.01 mg x 5
pirmella oral tablet 0.5/0.75/1 mg- 35
(Modicon)
mcg, 1-35 mg-mcg
portia oral tablet 0.15-0.03 mg
(Amethyst)
previfem oral tablet 0.25-35 mg-mcg
(Ortho-Cyclen)
quasense oral tablets,dose pack,3 month (Levonorgestrel-Ethin
0.15-30 mg-mcg
Estradiol)
reclipsen (28) oral tablet 0.15-0.03 mg
(Desogen)
setlakin oral tablets,dose pack,3 month
0.15-30 mg-mcg
Estradiol)
sharobel oral tablet 0.35 mg
(Nor-Q-D)
sprintec (28) oral tablet 0.25-35 mg-mcg (Ortho-Cyclen)
sronyx oral tablet 0.1-20 mg-mcg
(Amethyst)
syeda oral tablet 3-0.03 mg
(Yaz)
Requirements/Limits
QL (1 per 28 days)
2
2
2
2
2
2
2
2
2
QL (91 per 84 days)
2
2
QL (91 per 84 days)
2
2
2
2
93
Drug Name
tarina fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
tilia fe oral tablet 1-20(5)/1-30(7)
/1mg-35mcg (9)
tri-estarylla oral tablet 0.18/0.215/0.25
mg-35 mcg (28)
tri-legest fe oral tablet 1-20(5)/1-30(7)
/1mg-35mcg (9)
tri-linyah oral tablet 0.18/0.215/0.25
mg-35 mcg (28)
tri-lo-estarylla oral tablet 0.18/0.215/0.25
mg-25 mcg
tri-lo-marzia oral tablet 0.18/0.215/0.25
mg-25 mcg
tri-lo-sprintec oral tablet 0.18/0.215/0.25
mg-25 mcg
trinessa (28) oral tablet 0.18/0.215/0.25
mg-35 mcg (28)
tri-previfem (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
tri-sprintec (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
trivora (28) oral tablet 50-30 (6)/75-40
(5)/125-30(10)
velivet triphasic regimen (28) oral tablet
0.1/.125/.15-25 mg-mcg
vestura (28) oral tablet 3-0.02 mg
vienva oral tablet 0.1-20 mg-mcg
viorele (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
vyfemla (28) oral tablet 0.4-35 mg-mcg
wera (28) oral tablet 0.5-35 mg-mcg
wymzya fe oral tablet,chewable
0.4mg-35mcg(21) and 75 mg (7)
xulane transdermal patch weekly 150-35
mcg/24 hr
Drug Tier
(Loestrin Fe)
2
(Loestrin Fe)
2
(Ortho-Cyclen)
2
(Loestrin Fe)
2
(Ortho-Cyclen)
2
(Ortho-Cyclen)
2
(Ortho-Cyclen)
2
(Ortho-Cyclen)
2
(Ortho-Cyclen)
2
(Ortho-Cyclen)
2
(Ortho-Cyclen)
2
(Amethyst)
2
(Desogen)
2
(Yaz)
(Amethyst)
(Mircette)
2
2
2
(Modicon)
(Modicon)
(Femcon Fe)
2
2
2
(Ortho Evra)
2
Requirements/Limits
QL (3 per 28 days)
94
Drug Name
zarah oral tablet 3-0.03 mg
zenchent (28) oral tablet 0.4-35 mg-mcg
zenchent fe oral tablet,chewable
0.4mg-35mcg(21) and 75 mg (7)
zeosa oral tablet,chewable
0.4mg-35mcg(21) and 75 mg (7)
zovia 1/35e (28) oral tablet 1-35 mg-mcg
zovia 1/50e (28) oral tablet 1-50 mg-mcg
Drug Tier
(Yaz)
(Modicon)
(Femcon Fe)
2
2
2
(Femcon Fe)
2
(Demulen 1-50-21)
(Demulen 1-50-21)
2
2
(Evoxac)
(Peridex)
2
2
(Triamcinolone
Acetonide)
(Peridex)
2
(Salagen)
(Sodium Fluoride)
2
2
(Triamcinolone
Acetonide)
2
Requirements/Limits
Dental And Oral Agents
Dental And Oral Agents
cevimeline oral capsule 30 mg
chlorhexidine gluconate mucous
membrane mouthwash 0.12 %
oralone dental paste 0.1 %
periogard mucous membrane mouthwash
0.12 %
pilocarpine hcl oral tablet 5 mg, 7.5 mg
sodium fluoride oral tablet,chewable 0.25
mg fluorid (0.55 mg)
triamcinolone acetonide dental paste 0.1
%
2
Dermatological Agents
Dermatological Agents, Other
8-MOP ORAL CAPSULE 10 MG
acitretin oral capsule 10 mg, 17.5 mg, 25
mg
acyclovir topical ointment 5 %
ALCOHOL PADS TOPICAL PADS,
MEDICATED
ALCOHOL PREP PADS
ammonium lactate topical cream 12 %
ammonium lactate topical lotion 12 %
ANACAINE TOPICAL OINTMENT
10 %
calcipotriene scalp solution 0.005 %
(Soriatane)
(Zovirax)
4
5
2
1
(Lac-Hydrin)
(Lac-Hydrin)
1
2
2
4
(Calcipotriene)
2
QL (30 per 30 days)
95
Drug Name
Drug Tier
calcipotriene topical cream 0.005 %
calcipotriene topical ointment 0.005 %
calcitrene topical ointment 0.005 %
calcitriol topical ointment 3 mcg/gram
CONDYLOX TOPICAL GEL 0.5 %
COSENTYX (150 MG/ML) 300 MG
DOSE-2 PENS 150 MG/ML
COSENTYX (150 MG/ML) 300 MG
DOSE-2 SYRINGES 150 MG/ML
COSENTYX PEN SUBCUTANEOUS
PEN INJECTOR 150 MG/ML
COSENTYX SUBCUTANEOUS
SYRINGE 150 MG/ML
DENAVIR TOPICAL CREAM 1 %
fluorouracil topical cream 0.5 %, 5 %
fluorouracil topical solution 2 %, 5 %
imiquimod topical cream in packet 5 %
(Dovonex)
(Calcipotriene)
(Calcipotriene)
(Vectical)
methoxsalen rapid oral capsule 10 mg
PANRETIN TOPICAL GEL 0.1 %
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
podocon topical liquid 25 %
podofilox topical solution 0.5 %
potassium hydroxide topical solution 5 %
REGRANEX TOPICAL GEL 0.01 %
(Oxsoralen-Ultra)
(Carac)
(Fluorouracil)
(Aldara)
(Podophyllum Resin)
(Condylox)
(Potassium Hydroxide)
SANTYL TOPICAL OINTMENT 250
UNIT/GRAM
TALTZ AUTOINJECTOR
SUBCUTANEOUS
AUTO-INJECTOR 80 MG/ML
TALTZ SYRINGE
MG/ML
TOLAK TOPICAL CREAM 4 %
Requirements/Limits
2
2
2
2
4
5
PA
5
PA
5
PA
5
PA
4
2
2
2
5
5
3
3
2
2
2
4
days)
QL (3 per 56 days)
QL (2 per 56 days)
PA; QL (30 per 30
days)
4
5
PA
5
PA
4
96
Drug Name
Drug Tier
VALCHLOR TOPICAL GEL 0.016 %
VEREGEN TOPICAL OINTMENT
15 %
zenatane oral capsule 10 mg, 20 mg, 30
mg, 40 mg
ZOVIRAX TOPICAL CREAM 5 %
Dermatological Antibacterials
clindamycin phosphate topical foam 1 %
clindamycin phosphate topical gel 1 %
clindamycin phosphate topical lotion 1 %
clindamycin phosphate topical solution 1
%
clindamycin phosphate topical swab 1 %
clindamycin-benzoyl peroxide topical gel
1-5 %, 1.2 %(1 % base) -5 %
ery pads topical swab 2 %
5
4
(Isotretinoin)
2
3
(Evoclin)
(Cleocin T)
(Cleocin T)
(Cleocin T)
2
2
2
2
(Cleocin T)
(Duac)
2
2
(Erythromycin
Base/Ethanol)
erythromycin with ethanol topical gel 2 % (Emgel)
erythromycin with ethanol topical
(Erythromycin
solution 2 %
Base/Ethanol)
erythromycin with ethanol topical swab 2 (Erythromycin
%
Base/Ethanol)
erythromycin-benzoyl peroxide topical
(Benzamycin)
gel 3-5 %
gentamicin topical cream 0.1 %
gentamicin topical ointment 0.1 %
metronidazole topical cream 0.75 %
(Metrocream)
metronidazole topical gel 0.75 %, 1 %
(Rosadan)
metronidazole topical lotion 0.75 %
(Metrolotion)
mupirocin calcium topical cream 2 %
(Bactroban)
mupirocin topical ointment 2 %
(Centany)
neomycin-polymyxin b gu irrigation
(Neosporin G.U.
solution 40 mg-200,000 unit/ml
Irrigant)
neuac topical gel 1.2 %(1 % base) -5 %
(Duac)
rosadan topical cream 0.75 %
(Metrocream)
selenium sulfide topical lotion 2.5 %
(Selenium Sulfide)
Requirements/Limits
QL (15 per 30 days)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
97
Drug Name
selenium sulfide topical shampoo 2.25 %
silver nitrate topical ointment 10 %
silver nitrate topical solution 0.5 %, 10 %,
25 %, 50 %
silver sulfadiazine topical cream 1 %
ssd topical cream 1 %
sulfacetamide sodium (acne) topical
suspension 10 %
Dermatological
Anti-Inflammatory Agents
ala-cort topical cream 1 %
ala-scalp topical lotion 2 %
alclometasone topical cream 0.05 %
Drug Tier
(Selenium Sulfide)
(Silver Nitrate)
(Silver Nitrate)
2
2
2
(Silvadene)
(Silvadene)
(Klaron)
2
2
2
(Anusol-HC)
(Scalacort)
(Alclometasone
Dipropionate)
alclometasone topical ointment 0.05 %
(Alclometasone
Dipropionate)
betamethasone dipropionate topical
(Betamethasone
cream 0.05 %
Dipropionate)
(Betamethasone
lotion 0.05 %
Dipropionate)
(Betamethasone
ointment 0.05 %
Dipropionate)
betamethasone valerate topical cream 0.1 (Betamethasone
%
Valerate)
betamethasone valerate topical foam 0.12 (Luxiq)
%
betamethasone valerate topical lotion 0.1 (Betamethasone
%
Valerate)
betamethasone valerate topical ointment (Betamethasone
0.1 %
Valerate)
betamethasone, augmented topical cream (Diprolene AF)
0.05 %
betamethasone, augmented topical gel
(Betamethasone
0.05 %
Dipropionate)
betamethasone, augmented topical lotion (Diprolene)
0.05 %
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
98
Drug Name
betamethasone, augmented topical
ointment 0.05 %
clobetasol 0.05% cream 0.05 %
clobetasol scalp solution 0.05 %
Drug Tier
(Diprolene)
(Temovate)
(Clobetasol
Propionate)
clobetasol topical foam 0.05 %
(Olux)
clobetasol topical gel 0.05 %
(Clobetasol
Propionate)
clobetasol topical lotion 0.05 %
(Clobex)
clobetasol topical ointment 0.05 %
(Temovate)
clobetasol topical shampoo 0.05 %
(Clobex)
clobetasol-emollient topical cream 0.05 % (Temovate)
clocortolone pivalate topical cream 0.1 % (Cloderm)
colocort rectal enema 100 mg/60 ml
(Cortenema)
cormax scalp solution 0.05 %
(Clobetasol
Propionate)
desonide topical cream 0.05 %
(Desowen)
desonide topical lotion 0.05 %
(Desowen)
desonide topical ointment 0.05 %
(Desonide)
desoximetasone topical cream 0.05 %,
(Topicort)
0.25 %
desoximetasone topical gel 0.05 %
(Topicort)
desoximetasone topical ointment 0.05 %, (Topicort)
0.25 %
diflorasone topical cream 0.05 %
(Psorcon)
diflorasone topical ointment 0.05 %
(Diflorasone Diacetate)
ELIDEL TOPICAL CREAM 1 %
fluocinonide 0.05% cream 0.05 %
(Vanos)
fluocinonide topical gel 0.05 %
(Fluocinonide)
fluocinonide topical ointment 0.05 %
(Fluocinonide)
fluocinonide topical solution 0.05 %
(Fluocinonide)
fluocinonide-e topical cream 0.05 %
(Vanos)
fluticasone topical cream 0.05 %
(Cutivate)
fluticasone topical ointment 0.005 %
(Fluticasone
Propionate)
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
2
2
2
2
2
2
2
99
Drug Name
halobetasol propionate topical cream 0.05
%
halobetasol propionate topical ointment
0.05 %
hydrocortisone 1% ointment carton (otc)
1%
hydrocortisone acet-aloe vera topical gel
2%
hydrocortisone buty 0.1% cream 0.1 %
hydrocortisone butyrate topical ointment
0.1 %
hydrocortisone butyrate topical solution
0.1 %
hydrocortisone butyr-emollient topical
cream 0.1 %
hydrocortisone rectal enema 100 mg/60
ml
hydrocortisone topical cream 1 %, 2.5 %
hydrocortisone topical lotion 2.5 %
hydrocortisone topical ointment 1 %, 2.5
%
hydrocortisone valerate topical cream 0.2
%
hydrocortisone valerate topical ointment
0.2 %
mometasone topical cream 0.1 %
mometasone topical ointment 0.1 %
mometasone topical solution 0.1 %
ONFI ORAL TABLET 10 MG, 20 MG
prednicarbate topical cream 0.1 %
prednicarbate topical ointment 0.1 %
procto-med hc rectal cream 2.5 %
procto-pak rectal cream 1 %
proctosol hc rectal cream 2.5 %
Drug Tier
(Ultravate)
2
(Ultravate)
2
(Hydrocortisone)
2
(Hydrocortisone
Acetate/Aloe V)
(Hydrocortisone
Butyrate)
(Locoid)
2
(Locoid)
2
(Hydrocortisone
Butyrate)
(Cortenema)
2
(Anusol-HC)
(Scalacort)
(Hydrocortisone)
2
2
2
(Hydrocortisone
Valerate)
(Westcort)
2
(Elocon)
(Elocon)
(Elocon)
2
2
2
4
(Dermatop)
(Dermatop)
(Hydrocortisone)
(Anusol-HC)
(Hydrocortisone)
Requirements/Limits
2
2
2
2
days)
2
2
2
2
2
100
Drug Name
proctozone-hc rectal cream 2.5 %
tacrolimus topical ointment 0.03 %, 0.1
%
triamcinolone acetonide topical cream
0.025 %, 0.1 %, 0.5 %
triamcinolone acetonide topical lotion
0.025 %, 0.1 %
triamcinolone acetonide topical ointment
0.025 %, 0.1 %, 0.5 %
trianex topical ointment 0.05 %
u-cort topical cream 1-10 %
Dermatological Retinoids
adapalene topical cream 0.1 %
adapalene topical gel 0.1 %
TAZORAC TOPICAL CREAM 0.05
%, 0.1 %
tretinoin gel micro 0.04% tube 0.04 %
tretinoin gel micro 0.1% tube 0.1 %
tretinoin microspheres topical gel with
pump 0.04 %, 0.1 %
tretinoin topical cream 0.025 %, 0.05 %,
0.1 %
tretinoin topical gel 0.01 %, 0.025 %,
0.05 %
Scabicides And Pediculicides
EURAX TOPICAL CREAM 10 %
EURAX TOPICAL LOTION 10 %
malathion topical lotion 0.5 %
permethrin topical cream 5 %
spinosad topical suspension 0.9 %
Drug Tier
Requirements/Limits
(Hydrocortisone)
(Protopic)
2
2
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Hydrocortisone
Acetate/Urea)
2
(Differin)
(Differin)
2
2
4
(Retin-A Micro)
(Retin-A Micro)
(Retin-A Micro)
2
2
2
PA
PA
PA
(Retin-A)
2
PA
(Retin-A)
2
PA
(Ovide)
(Elimite)
(Natroba)
3
3
2
2
2
2
2
2
2
Devices
Devices
ASSURE ID INSULIN SAFETY
SYRINGE 1 ML 29 GAUGE X 1/2"
2
101
Drug Name
Drug Tier
BD INSULIN SYR 0.3 ML 31GX5/16
0.3 ML 31 GAUGE X 5/16
BD INSULIN SYR 0.5 ML 31GX5/16"
0.5 ML 31 GAUGE X 5/16
BD INSULIN SYR 1 ML 31GX5/16" 1
ML 31 GAUGE X 5/16
BD ULTRA-FINE PEN NDL
8MMX31G SHORT 31 GAUGE X
5/16"
INSULIN SYRINGE-NEEDLE U-100
SYRINGE 0.3 ML 29, 1 ML 29
GAUGE X 1/2", 1/2 ML 28 GAUGE
PEN NEEDLE, DIABETIC NEEDLE
29 GAUGE X 1/2 "
VGO 40 DISPOSABLE DEVICE
2
Requirements/Limits
2
2
2
2
2
2
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN INTRAMUSCULAR
ALDURAZYME INTRAVENOUS
SOLUTION 2.9 MG/5 ML
CEREZYME INTRAVENOUS
RECON SOLN 400 UNIT
CREON ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000
-60,000 UNIT, 24,000-76,000 -120,000
UNIT, 3,000-9,500- 15,000 UNIT,
36,000-114,000- 180,000 UNIT,
6,000-19,000 -30,000 UNIT
ELAPRASE INTRAVENOUS
SOLUTION 6 MG/3 ML
ELITEK INTRAVENOUS RECON
SOLN 1.5 MG
FABRAZYME INTRAVENOUS
RECON SOLN 35 MG
5
5
5
3
5
5
5
102
Drug Name
Drug Tier
KANUMA INTRAVENOUS
SOLUTION 2 MG/ML
KRYSTEXXA INTRAVENOUS
SOLUTION 8 MG/ML
KUVAN ORAL TABLET,SOLUBLE
100 MG
MYOZYME INTRAVENOUS
RECON SOLN 50 MG
NAGLAZYME INTRAVENOUS
SOLUTION 5 MG/5 ML
ORFADIN ORAL CAPSULE 10 MG,
2 MG, 5 MG
pancrelipase 5000 oral capsule,delayed
(Lipase/Protease/Amyl
release(dr/ec) 5,000-17,000 -27,000 unit ase)
PERTZYE ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 16,000-57,50060,500 UNIT, 8,000-28,750- 30,250
UNIT
PULMOZYME INHALATION
SOLUTION 1 MG/ML
STRENSIQ SUBCUTANEOUS
VIMIZIM INTRAVENOUS
SOLUTION 5 MG/5 ML (1 MG/ML)
VPRIV INTRAVENOUS RECON
SOLN 400 UNIT
ZAVESCA ORAL CAPSULE 100 MG
ZENPEP ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-34,000
-55,000 UNIT, 15,000-51,000 -82,000
UNIT, 20,000-68,000 -109,000 UNIT,
25,000-85,000- 136,000 UNIT,
3,000-10,000- 16,000 UNIT,
40,000-136,000- 218,000 UNIT,
5,000-17,000 -27,000 UNIT
5
Requirements/Limits
PA
5
5
5
5
5
2
4
5
PA BvD
5
PA; LA
5
PA
5
5
3
QL (90 per 30 days)
103
Drug Name
Drug Tier
Requirements/Limits
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents,
Miscellaneous
AKTEN (PF) OPHTHALMIC GEL
3.5 %
alcaine ophthalmic drops 0.5 %
altacaine ophthalmic drops 0.5 %
apraclonidine ophthalmic drops 0.5 %
atropine ophthalmic drops 1 %
atropine ophthalmic ointment 1 %
atropine-care ophthalmic drops 1 %
azelastine nasal aerosol,spray 137 mcg
(0.1 %)
azelastine nasal spray,non-aerosol 0.15 %
(205.5 mcg)
azelastine ophthalmic drops 0.05 %
BEPREVE OPHTHALMIC DROPS
1.5 %
carteolol ophthalmic drops 1 %
cromolyn ophthalmic drops 4 %
cyclopentolate ophthalmic drops 0.5 %, 1
%, 2 %
CYSTARAN OPHTHALMIC DROPS
0.44 %
epinastine ophthalmic drops 0.05 %
flucaine ophthalmic drops 0.25-0.5 %
homatropaire ophthalmic drops 5 %
homatropine hbr ophthalmic drops 5 %
ipratropium bromide nasal
spray,non-aerosol 0.03 %
ipratropium bromide nasal
spray,non-aerosol 0.06 %
LACRISERT OPHTHALMIC
INSERT 5 MG
naphazoline ophthalmic drops 0.1 %
4
(Proparacaine HCl)
(Tetravisc)
(Iopidine)
(Isopto Atropine)
(Atropine Sulfate)
(Isopto Atropine)
(Astepro)
2
2
2
2
2
2
2
QL (30 per 25 days)
(Astepro)
2
QL (30 per 25 days)
(Azelastine HCl)
2
4
ST
(Carteolol HCl)
(Cromolyn Sodium)
(Cyclogyl)
2
2
2
5
(Elestat)
(Proparacaine/Fluoresc
ein Sod)
(Isopto Homatropine)
(Isopto Homatropine)
(Atrovent)
2
2
2
2
2
QL (30 per 28 days)
(Atrovent)
2
QL (15 per 10 days)
3
(Naphazoline HCl)
1
104
Drug Name
olopatadine nasal spray,non-aerosol 0.6
%
olopatadine ophthalmic drops 0.1 %
PATADAY OPHTHALMIC DROPS
0.2 %
phenylephrine hcl ophthalmic drops 10 %,
2.5 %
proparacaine ophthalmic drops 0.5 %
tetracaine hcl (pf) ophthalmic drops 0.5
%
TYZINE NASAL DROPS 0.1 %
TYZINE NASAL
SPRAY,NON-AEROSOL 0.1 %
Eye, Ear, Nose, Throat
Anti-Infectives Agents
acetasol hc otic drops 1-2 %
acetic acid otic solution 2 %
bacitracin ophthalmic ointment 500
unit/gram
bacitracin-polymyxin b ophthalmic
ointment 500-10,000 unit/gram
bleph-10 ophthalmic drops 10 %
Drug Tier
Requirements/Limits
(Patanase)
2
(Patanol)
2
4
ST
(Mydfrin)
2
(Proparacaine HCl)
(Tetracaine HCl/PF)
2
2
4
4
(Vosol HC)
(Acetic Acid)
(Bacitracin)
2
2
2
(Bacitracin/Polymyxin
B Sulfate)
(Sulfacetamide
Sodium)
2
BLEPHAMIDE OPHTHALMIC
DROPS,SUSPENSION 10-0.2 %
BLEPHAMIDE S.O.P.
OPHTHALMIC OINTMENT 10-0.2 %
CILOXAN OPHTHALMIC
OINTMENT 0.3 %
CIPRODEX OTIC
DROPS,SUSPENSION 0.3-0.1 %
ciprofloxacin hcl ophthalmic drops 0.3 % (Ciloxan)
ciprofloxacin hcl otic dropperette 0.2 %
(Cetraxal)
COLY-MYCIN S OTIC
DROPS,SUSPENSION 3.3-3-10-0.5
MG/ML
2
3
2
4
3
2
2
4
105
Drug Name
Drug Tier
CORTISPORIN-TC OTIC
DROPS,SUSPENSION 3.3-3-10-0.5
MG/ML
erythromycin ophthalmic ointment 5
mg/gram (0.5 %)
gatifloxacin ophthalmic drops 0.5 %
gentak ophthalmic ointment 0.3 % (3
mg/gram)
gentamicin ophthalmic drops 0.3 %
gentamicin ophthalmic ointment 0.3 % (3
mg/gram)
hydrocortisone-acetic acid otic drops 1-2
%
levofloxacin ophthalmic drops 0.5 %
MOXEZA OPHTHALMIC DROPS,
VISCOUS 0.5 %
NATACYN OPHTHALMIC
DROPS,SUSPENSION 5 %
neomycin-bacitracin-poly-hc ophthalmic
ointment 3.5-400-10,000 mg-unit/g-1%
neomycin-bacitracin-polymyxin
ophthalmic ointment 3.5-400-10,000
mg-unit-unit/g
neomycin-polymyxin b-dexameth
ophthalmic drops,suspension
3.5mg/ml-10,000 unit/ml-0.1 %
ophthalmic ointment 3.5 mg/g-10,000
unit/g-0.1 %
neomycin-polymyxin-gramicidin
ophthalmic drops 1.75 mg-10,000
unit-0.025mg/ml
neomycin-polymyxin-hc ophthalmic
drops,suspension 3.5-10,000-10
mg-unit-mg/ml
3
(Ilotycin)
2
(Zymaxid)
(Garamycin)
2
2
(Garamycin)
(Garamycin)
2
2
(Vosol HC)
2
(Levofloxacin)
2
3
Requirements/Limits
3
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
Su/Bacitra/Polymyxin)
2
(Maxitrol)
2
(Maxitrol)
2
(Neosporin)
2
(Neomycin/Polymyxin
B Sulf/HC)
2
2
106
Drug Name
neomycin-polymyxin-hc otic
drops,suspension 3.5-10,000-1
mg/ml-unit/ml-%
neomycin-polymyxin-hc otic solution
3.5-10,000-1 mg/ml-unit/ml-%
neo-polycin hc ophthalmic ointment
3.5-400-10,000 mg-unit/g-1%
neo-polycin ophthalmic ointment
3.5-400-10,000 mg-unit-unit/g
ofloxacin ophthalmic drops 0.3 %
ofloxacin otic drops 0.3 %
polymyxin b sulf-trimethoprim
ophthalmic drops 10,000 unit- 1 mg/ml
sulfacetamide sodium ophthalmic drops
10 %
sulfacetamide sodium ophthalmic
ointment 10 %
sulfacetamide-prednisolone ophthalmic
drops 10 %-0.23 % (0.25 %)
TOBRADEX OPHTHALMIC
OINTMENT 0.3-0.1 %
TOBRADEX ST OPHTHALMIC
tobramycin ophthalmic drops 0.3 %
tobramycin-dexamethasone ophthalmic
drops,suspension 0.3-0.1 %
trifluridine ophthalmic drops 1 %
VIGAMOX OPHTHALMIC DROPS
0.5 %
ZIRGAN OPHTHALMIC GEL 0.15 %
ZYLET OPHTHALMIC
Eye, Ear, Nose, Throat
Anti-Inflammatory Agents
ALREX OPHTHALMIC
DROPS,SUSPENSION 0.2 %
Drug Tier
(Neomycin/Polymyxin
B Sulf/HC)
2
(Cortisporin)
2
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
Su/Bacitra/Polymyxin)
(Ocuflox)
(Ocuflox)
(Polytrim)
2
(Sulfacetamide
Sodium)
(Sulfacetamide
Sodium)
(Sulfacetamide/Prednis
olone Sp)
2
Requirements/Limits
2
2
2
2
2
2
4
3
(Tobrex)
(Tobradex)
2
2
(Viroptic)
2
3
4
3
3
ST
107
Drug Name
bromfenac ophthalmic drops 0.09 %
dexamethasone sodium phosphate
ophthalmic drops 0.1 %
diclofenac sodium ophthalmic drops 0.1
%
DUREZOL OPHTHALMIC DROPS
0.05 %
flunisolide nasal spray,non-aerosol 25
mcg (0.025 %)
fluocinolone acetonide oil otic drops 0.01
%
fluorometholone ophthalmic
drops,suspension 0.1 %
flurbiprofen sodium ophthalmic drops
0.03 %
fluticasone nasal spray,suspension 50
mcg/actuation
ILEVRO OPHTHALMIC
ketorolac ophthalmic drops 0.4 %, 0.5 %
LOTEMAX OPHTHALMIC
DROPS,GEL 0.5 %
LOTEMAX OPHTHALMIC
LOTEMAX OPHTHALMIC
OINTMENT 0.5 %
NEVANAC OPHTHALMIC
prednisolone acetate ophthalmic
drops,suspension 1 %
prednisolone sodium phosphate
ophthalmic drops 1 %
PROLENSA OPHTHALMIC DROPS
0.07 %
RESTASIS OPHTHALMIC
DROPPERETTE 0.05 %
Drug Tier
(Bromfenac Sodium)
(Dexasol)
2
2
(Diclofenac Sodium)
2
Requirements/Limits
3
(Flunisolide)
2
(Dermotic)
2
(FML)
2
(Ocufen)
2
(Fluticasone
Propionate)
1
QL (50 per 25 days)
3
(Acular)
2
3
3
3
3
(Omnipred)
2
(Prednisolone Sod
Phosphate)
2
3
3
QL (60 per 30 days)
108
Drug Name
triamcinolone acetonide nasal
aerosol,spray 55 mcg
Drug Tier
(Triamcinolone
Acetonide)
2
(Prevpac)
2
Requirements/Limits
Gastrointestinal Agents
Antiulcer Agents And Acid
Suppressants
amoxicil-clarithromy-lansopraz oral
combo pack 500-500-30 mg
CARAFATE ORAL SUSPENSION
100 MG/ML
cimetidine hcl oral solution 300 mg/5 ml
cimetidine oral tablet 200 mg, 300 mg,
400 mg, 800 mg
DEXILANT ORAL
CAPSULE,BIPHASE DELAYED
RELEAS 30 MG, 60 MG
esomeprazole sodium intravenous recon
soln 20 mg, 40 mg
famotidine (pf) intravenous solution 20
mg/2 ml
famotidine (pf)-nacl (iso-os)
famotidine 40 mg/4 ml vial 25's,outer 10
mg/ml
famotidine oral suspension 40 mg/5 ml (8
mg/ml)
famotidine oral tablet 20 mg, 40 mg
lansoprazole oral capsule,delayed
release(dr/ec) 15 mg, 30 mg
misoprostol oral tablet 100 mcg, 200 mcg
nizatidine oral capsule 150 mg, 300 mg
nizatidine oral solution 150 mg/10 ml
omeprazole oral capsule,delayed
release(dr/ec) 10 mg, 20 mg, 40 mg
pantoprazole oral tablet,delayed release
(dr/ec) 20 mg, 40 mg
3
(Cimetidine HCl)
(Cimetidine)
2
2
(Rx Product Only)
3
ST
(Nexium I.V.)
2
(Famotidine)
2
(Famotidine In
Nacl,Iso-Osm/PF)
(Famotidine)
2
(Pepcid)
2
(Rx Product Only)
(Pepcid)
(Prevacid)
1
2
(Rx Product Only)
(Rx Product Only)
(Cytotec)
(Nizatidine)
(Nizatidine)
(Prilosec)
2
2
2
2
(Protonix)
2
2
109
Drug Name
ranitidine hcl 50 mg/2 ml vial sdv 50 mg/2
ml (25 mg/ml)
ranitidine hcl injection solution 25 mg/ml
ranitidine hcl oral capsule 150 mg, 300
mg
ranitidine hcl oral syrup 15 mg/ml
ranitidine hcl oral tablet 150 mg, 300 mg
sucralfate oral suspension 100 mg/ml
sucralfate oral tablet 1 gram
Gastrointestinal Agents, Other
AMITIZA ORAL CAPSULE 24 MCG,
8 MCG
BUPHENYL ORAL TABLET 500 MG
CARBAGLU ORAL TABLET,
DISPERSIBLE 200 MG
constulose oral solution 10 gram/15 ml
cromolyn oral concentrate 100 mg/5 ml
dicyclomine oral capsule 10 mg
dicyclomine oral solution 10 mg/5 ml
dicyclomine oral tablet 20 mg
diphenoxylate-atropine oral liquid
2.5-0.025 mg/5 ml
diphenoxylate-atropine oral tablet
2.5-0.025 mg
enulose oral solution 10 gram/15 ml
GATTEX 5 MG 30-VIAL KIT 5 MG
GATTEX ONE-VIAL
SUBCUTANEOUS KIT 5 MG
generlac oral solution 10 gram/15 ml
glycopyrrolate injection solution 0.2
mg/ml
glycopyrrolate oral tablet 1 mg, 2 mg
kionex 15 gm/60 ml suspension 15
gram/60 ml
kionex oral powder
Drug Tier
Requirements/Limits
(Zantac)
2
(Rx Product Only)
(Zantac)
(Ranitidine HCl)
2
2
(Rx Product Only)
(Rx Product Only)
(Ranitidine HCl)
(Zantac)
(Sucralfate)
(Carafate)
2
1
2
2
(Rx Product Only)
(Rx Product Only)
3
QL (60 per 30 days)
5
5
(Lactulose)
(Gastrocrom)
(Bentyl)
(Dicyclomine HCl)
(Bentyl)
(Diphenoxylate
HCl/Atropine)
(Lomotil)
2
5
2
2
2
2
(Lactulose)
2
5
5
2
(Lactulose)
(Robinul)
2
2
(Robinul)
(Sodium Polystyrene
Sulfonate)
(Sodium Polystyrene
Sulfonate)
2
2
PA
PA
2
110
Drug Name
Drug Tier
lactulose oral solution 10 gram/15 ml
(Lactulose)
LINZESS ORAL CAPSULE 145
MCG, 290 MCG
loperamide oral capsule 2 mg
(Loperamide HCl)
LOTRONEX ORAL TABLET 0.5
MG, 1 MG
methscopolamine oral tablet 2.5 mg, 5 mg (Methscopolamine
Bromide)
metoclopramide hcl injection solution 5
(Metoclopramide HCl)
mg/ml
metoclopramide hcl oral solution 5 mg/5 (Metoclopramide HCl)
ml
metoclopramide hcl oral tablet 10 mg, 5 (Reglan)
mg
MOVANTIK ORAL TABLET 12.5
MG, 25 MG
NUTRESTORE ORAL POWDER IN
PACKET 5 GRAM
RAVICTI ORAL LIQUID 1.1
GRAM/ML
RELISTOR SUBCUTANEOUS
RELISTOR SUBCUTANEOUS
SYRINGE 12 MG/0.6 ML, 8 MG/0.4
ML
sodium polystyrene (sorb free) oral
(Sodium Polystyrene
suspension 15 gram/60 ml
Sulfonate)
sodium polystyrene sulfonate rectal
(Sodium Polystyrene
enema 30 gram/120 ml
Sulfonate)
sps 15 gm/60 ml suspension 15 gram/60
(Sodium Polystyrene
ml
Sulfonate)
ursodiol oral capsule 300 mg
(Actigall)
ursodiol oral tablet 250 mg, 500 mg
(Urso)
VELPHORO ORAL
TABLET,CHEWABLE 500 MG
2
3
Requirements/Limits
QL (30 per 30 days)
2
5
2
2
2
1
3
4
5
PA
4
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
4
2
2
2
2
2
4
111
Drug Name
VIBERZI ORAL TABLET 100 MG, 75
MG
Laxatives
gavilyte-c oral recon soln 240-22.72-6.72 (Golytely)
-5.84 gram
gavilyte-g oral recon soln 236-22.74-6.74 (Golytely)
-5.86 gram
gavilyte-n oral recon soln 420 gram
(Nulytely with Flavor
Packs)
MOVIPREP ORAL POWDER IN
PACKET 100-7.5-2.691 GRAM
peg 3350-electrolytes oral recon soln
(Golytely)
236-22.74-6.74 -5.86 gram,
240-22.72-6.72 -5.84 gram
peg-electrolyte soln oral recon soln 420
(Nulytely with Flavor
gram
Packs)
polyethylene glycol 3350 oral powder 17 (Gavilyte-N)
gram/dose
polyethylene glycol 3350 oral powder in
(Polyethylene Glycol
packet 17 gram
3350)
PREPOPIK ORAL POWDER IN
PACKET 10 MG-3.5 GRAM-12
GRAM
trilyte with flavor packets oral recon soln (Nulytely with Flavor
420 gram
Packs)
Phosphate Binders
AURYXIA ORAL TABLET 210 MG
IRON
calcium acetate oral capsule 667 mg
(Phoslo)
calcium acetate oral tablet 667 mg
(Calcium Acetate)
eliphos oral tablet 667 mg
(Calcium Acetate)
FOSRENOL ORAL POWDER IN
PACKET 1,000 MG, 750 MG
FOSRENOL ORAL
TABLET,CHEWABLE 1,000 MG, 500
MG, 750 MG
Drug Tier
Requirements/Limits
5
2
2
2
3
2
2
2
2
4
2
4
2
2
2
4
4
112
Drug Name
magnebind 400 oral tablet 400-200-1 mg
Drug Tier
(Calcium
Carbonate/Mag
Carb/Fa)
PHOSLYRA ORAL SOLUTION 667
MG (169 MG CALCIUM)/5 ML
RENAGEL ORAL TABLET 400 MG,
800 MG
RENVELA ORAL POWDER IN
PACKET 0.8 GRAM, 2.4 GRAM
RENVELA ORAL TABLET 800 MG
Requirements/Limits
2
4
3
3
3
Genitourinary Agents
Antispasmodics, Urinary
flavoxate oral tablet 100 mg
MYRBETRIQ ORAL TABLET
MG, 50 MG
oxybutynin chloride oral syrup 5 mg/5 ml
oxybutynin chloride oral tablet 5 mg
oxybutynin chloride oral tablet extended
tolterodine oral capsule,extended release
24hr 2 mg, 4 mg
tolterodine oral tablet 1 mg, 2 mg
TOVIAZ ORAL TABLET
EXTENDED RELEASE 24 HR 4 MG,
8 MG
trospium oral capsule,extended release
24hr 60 mg
trospium oral tablet 20 mg
VESICARE ORAL TABLET 10 MG, 5
MG
Genitourinary Agents,
Miscellaneous
alfuzosin oral tablet extended release 24
hr 10 mg
(Flavoxate HCl)
2
3
(Oxybutynin Chloride)
(Oxybutynin Chloride)
(Ditropan XL)
2
2
2
(Detrol LA)
2
(Detrol)
2
3
(Trospium Chloride)
2
(Trospium Chloride)
2
3
(Uroxatral)
2
113
Drug Name
Drug Tier
tamsulosin oral capsule,extended release (Flomax)
24hr 0.4 mg
terazosin oral capsule 1 mg, 10 mg, 2 mg, (Terazosin HCl)
5 mg
Requirements/Limits
2
1
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine injection recon soln 2 gram, (Desferal)
500 mg
DEPEN TITRATABS ORAL
TABLET 250 MG
EXJADE ORAL TABLET,
DISPERSIBLE 125 MG
EXJADE ORAL TABLET,
DISPERSIBLE 250 MG, 500 MG
FERRIPROX ORAL SOLUTION 100
MG/ML
FERRIPROX ORAL TABLET 500
MG
sodium thiosulfate intravenous solution 1 (Sodium Thiosulfate)
gram/10 ml (100 mg/ml), 12.5 gram/50
ml (250 mg/ml)
SYPRINE ORAL CAPSULE 250 MG
2
PA BvD
5
4
5
5
5
2
5
Hormonal Agents,
Stimulant/Replacement/Modifying
Androgens
ANDRODERM TRANSDERMAL
PATCH 24 HOUR 2 MG/24 HOUR, 4
MG/24 HR
ANDROGEL TRANSDERMAL GEL
IN METERED-DOSE PUMP 20.25
MG/1.25 GRAM (1.62 %)
ANDROGEL TRANSDERMAL GEL
IN PACKET 1.62 % (20.25 MG/1.25
GRAM), 1.62 % (40.5 MG/2.5 GRAM)
androxy oral tablet 10 mg
(Fluoxymesterone)
3
PA; QL (30 per 30
days)
3
PA; QL (150 per 30
days)
3
PA; QL (150 per 30
days)
2
114
Drug Name
Drug Tier
AXIRON TRANSDERMAL
SOLUTION IN METERED PUMP
W/APP 30 MG/ACTUATION (1.5
ML)
danazol oral capsule 100 mg, 200 mg, 50
mg
oxandrolone oral tablet 10 mg, 2.5 mg
testosterone cypionate intramuscular oil
100 mg/ml, 200 mg/ml
testosterone enanthate intramuscular oil
200 mg/ml
testosterone transdermal gel 50 mg/5
gram (1 %)
testosterone transdermal gel in
metered-dose pump 1.25 gram/ actuation
(1 %)
testosterone transdermal gel in packet 1
% (25 mg/2.5gram)
testosterone transdermal gel in packet 1
% (50 mg/5 gram)
Estrogens And Antiestrogens
COMBIPATCH TRANSDERMAL
PATCH SEMIWEEKLY 0.05-0.14
MG/24 HR, 0.05-0.25 MG/24 HR
DUAVEE ORAL TABLET 0.45-20
MG
ESTRACE VAGINAL CREAM 0.01
% (0.1 MG/GRAM)
estradiol oral tablet 0.5 mg, 1 mg, 2 mg
estradiol transdermal patch semiweekly
0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05
mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr
estradiol transdermal patch weekly 0.025
mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24
hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1
mg/24 hr
3
Requirements/Limits
PA; QL (180 per 28
days)
(Danazol)
2
(Oxandrin)
(Depo-Testosterone)
2
2
PA
(Testosterone
Enanthate)
(Testim)
2
2
(Vogelxo)
2
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
(Androgel)
2
(Testim)
2
3
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
QL (8 per 28 days)
3
3
(Estrace)
(Vivelle-Dot)
2
2
QL (8 per 28 days)
(Climara)
2
QL (4 per 28 days)
115
Drug Name
estradiol valerate intramuscular oil 10
mg/ml, 20 mg/ml, 40 mg/ml
estradiol-norethindrone acet oral tablet
0.5-0.1 mg, 1-0.5 mg
ESTRING VAGINAL RING 2 MG
estropipate oral tablet 0.75 mg, 1.5 mg, 3
mg
FEMRING VAGINAL RING 0.05
MG/24 HR, 0.1 MG/24 HR
fyavolv oral tablet 1-5 mg-mcg
jinteli oral tablet 1-5 mg-mcg
MENEST ORAL TABLET 0.3 MG,
0.625 MG, 1.25 MG, 2.5 MG
mimvey lo oral tablet 0.5-0.1 mg
mimvey oral tablet 1-0.5 mg
norethindrone ac-eth estradiol oral tablet
1-5 mg-mcg
PREMARIN INJECTION RECON
SOLN 25 MG
PREMARIN ORAL TABLET 0.3 MG,
0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG
PREMARIN VAGINAL CREAM
0.625 MG/GRAM
PREMPHASE ORAL TABLET 0.625
MG (14)/ 0.625MG-5MG(14)
PREMPRO ORAL TABLET 0.3-1.5
MG, 0.45-1.5 MG, 0.625-2.5 MG,
0.625-5 MG
raloxifene oral tablet 60 mg
VAGIFEM VAGINAL TABLET 10
MCG
Glucocorticoids/Mineralocorticoid
s
a-hydrocort injection recon soln 100 mg
Drug Tier
Requirements/Limits
(Delestrogen)
2
(Activella)
2
QL (1 per 84 days)
(Estropipate)
4
2
4
QL (1 per 84 days)
(Femhrt)
(Femhrt)
2
2
4
(Activella)
(Activella)
(Femhrt)
2
2
2
3
3
3
3
3
(Evista)
2
3
(Hydrocortisone Sod
Succinate)
QL (18 per 28 days)
2
116
Drug Name
betamethasone acet,sod phos injection
suspension 6 mg/ml
cortisone oral tablet 25 mg
dexamethasone oral elixir 0.5 mg/5 ml
dexamethasone oral tablet 0.5 mg, 0.75
mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg
injection solution 10 mg/ml, 4 mg/ml
fludrocortisone oral tablet 0.1 mg
hydrocortisone oral tablet 10 mg, 20 mg,
5 mg
methylprednisolone 125 mg vial 2ml sdv,
25's,l/f 125 mg
methylprednisolone acetate injection
suspension 40 mg/ml, 80 mg/ml
methylprednisolone oral tablet 16 mg, 32
mg, 4 mg, 8 mg
methylprednisolone oral tablets,dose pack
4 mg
methylprednisolone sodium succ injection
recon soln 125 mg, 40 mg
methylprednisolone ss 1 gm vl
mdv,latex-free 1,000 mg
prednisolone sodium phosphate oral
solution 15 mg/5 ml (3 mg/ml), 25 mg/5
ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5
ml)
PREDNISONE INTENSOL ORAL
CONCENTRATE 5 MG/ML
prednisone oral solution 5 mg/5 ml
prednisone oral tablet 1 mg, 2.5 mg, 20
mg, 5 mg, 50 mg
prednisone oral tablet 10 mg
prednisone oral tablets,dose pack 10 mg,
5 mg
Drug Tier
Requirements/Limits
(Celestone)
2
(Cortisone Acetate)
(Dexamethasone)
(Dexamethasone)
2
2
1
(Dexamethasone Sod
Phosphate)
(Fludrocortisone
Acetate)
(Cortef)
2
(Solu-Medrol)
2
(Depo-Medrol)
2
(Medrol)
2
PA BvD
(Medrol)
2
PA BvD
(Solu-Medrol)
2
(Solu-Medrol)
2
(Pediapred)
2
PA BvD
3
PA BvD
(Prednisone)
(Prednisone)
2
1
PA BvD
PA BvD
(Prednisone)
(Prednisone)
1
2
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
2
2
PA BvD
117
Drug Name
Drug Tier
SOLU-CORTEF (PF) INJECTION
RECON SOLN 100 MG/2 ML, 250
MG/2 ML
triamcinolone acetonide injection
suspension 10 mg/ml, 40 mg/ml
Pituitary
desmopressin injection solution 4 mcg/ml
4
desmopressin nasal solution 0.1 mg/ml
(refrigerate)
desmopressin nasal spray,non-aerosol 10
mcg/spray (0.1 ml)
desmopressin oral tablet 0.1 mg, 0.2 mg
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE 0.2
MG/0.25 ML
SUBCUTANEOUS SYRINGE 0.4
MG/0.25 ML, 0.6 MG/0.25 ML, 0.8
MG/0.25 ML, 1 MG/0.25 ML, 1.2
MG/0.25 ML, 1.4 MG/0.25 ML, 1.6
MG/0.25 ML, 1.8 MG/0.25 ML, 2
MG/0.25 ML
GENOTROPIN SUBCUTANEOUS
CARTRIDGE 12 MG/ML (36
UNIT/ML), 5 MG/ML (15 UNIT/ML)
INCRELEX SUBCUTANEOUS
SOLUTION 10 MG/ML
LUPRON DEPOT-PED (3 MONTH)
30 MG
LUPRON DEPOT-PED
INTRAMUSCULAR KIT 11.25 MG,
15 MG, 7.5 MG (PED)
Requirements/Limits
(Triamcinolone
Acetonide)
2
(Desmopressin
Acetate)
(DDAVP)
2
2
QL (15 per 30 days)
(Desmopressin
Acetate)
(DDAVP)
2
QL (15 per 30 days)
2
4
PA
5
PA
5
PA
5
5
QL (1 per 84 days)
5
118
Drug Name
Drug Tier
NORDITROPIN FLEXPRO
10 MG/1.5 ML (6.7 MG/ML), 15
MG/1.5 ML (10 MG/ML), 30 MG/3
ML (10 MG/ML), 5 MG/1.5 ML (3.3
MG/ML)
octreotide acet 50 mcg/ml syr
outer,single-dose,10 50 mcg/ml (1 ml)
octreotide acetate injection solution 1,000
mcg/ml
octreotide acetate injection solution 100
mcg/ml, 200 mcg/ml, 500 mcg/ml
octreotide acetate injection solution 50
mcg/ml
SAIZEN CLICK.EASY
SUBCUTANEOUS CARTRIDGE 8.8
MG/1.5 ML (FNL)
SAIZEN SUBCUTANEOUS RECON
SOLN 5 MG, 8.8 MG
SANDOSTATIN LAR 10 MG KIT 10
MG
MG
MG
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR
RECON 10 MG, 20 MG, 30 MG
SEROSTIM SUBCUTANEOUS
RECON SOLN 4 MG, 5 MG, 6 MG
SOMATULINE DEPOT
MG/0.5 ML, 60 MG/0.2 ML, 90
MG/0.3 ML
5
(Octreotide Acetate)
2
(Sandostatin)
5
(Sandostatin)
2
(Octreotide Acetate)
2
Requirements/Limits
PA
5
PA
5
PA
5
5
5
5
5
PA
5
QL (1 per 28 days)
119
Drug Name
Drug Tier
SOMAVERT SUBCUTANEOUS
RECON SOLN 10 MG, 15 MG, 20
MG, 25 MG, 30 MG
STIMATE NASAL
MCG/SPRAY (0.1 ML)
SUPPRELIN LA IMPLANT KIT 50
MG (65 MCG/DAY)
Progestins
DEPO-PROVERA
INTRAMUSCULAR SOLUTION 400
MG/ML
medroxyprogesterone intramuscular
suspension 150 mg/ml
medroxyprogesterone intramuscular
syringe 150 mg/ml
medroxyprogesterone oral tablet 10 mg,
2.5 mg, 5 mg
MEGACE ES ORAL SUSPENSION
625 MG/5 ML
megestrol oral suspension 400 mg/10 ml
(40 mg/ml), 625 mg/5 ml
norethindrone acetate oral tablet 5 mg
progesterone in oil intramuscular oil 50
mg/ml
progesterone micronized oral capsule 100
mg, 200 mg
Thyroid And Antithyroid Agents
levothyroxine intravenous recon soln 100
mcg, 200 mcg, 500 mcg
levothyroxine oral tablet 100 mcg, 112
mcg, 125 mcg, 137 mcg, 150 mcg, 175
mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg,
75 mcg, 88 mcg
liothyronine intravenous solution 10
mcg/ml
5
Requirements/Limits
4
5
QL (1 per 360 days)
4
QL (10 per 28 days)
(Depo-Provera)
2
QL (1 per 84 days)
(Depo-Provera)
2
QL (1 per 84 days)
(Provera)
2
5
(Megace Es)
2
(Aygestin)
(Progesterone)
2
2
(Prometrium)
2
(Levothyroxine
Sodium)
(Levoxyl)
2
(Triostat)
2
1
120
Drug Name
Drug Tier
liothyronine oral tablet 25 mcg, 5 mcg, 50 (Cytomel)
mcg
methimazole oral tablet 10 mg, 5 mg
(Tapazole)
propylthiouracil oral tablet 50 mg
(Propylthiouracil)
Requirements/Limits
2
2
2
Immunological Agents
Immunological Agents
ARCALYST SUBCUTANEOUS
RECON SOLN 220 MG
ASTAGRAF XL ORAL
24HR 0.5 MG, 1 MG, 5 MG
AUBAGIO ORAL TABLET 14 MG, 7
MG
azathioprine oral tablet 50 mg
azathioprine sodium injection recon soln
100 mg
CARIMUNE NF NANOFILTERED
GRAM
CELLCEPT INTRAVENOUS
MG
CIMZIA POWDER FOR RECONST
SUBCUTANEOUS KIT 400 MG (200
MG X 2 VIALS)
CIMZIA SUBCUTANEOUS
SYRINGE KIT 400 MG/2 ML (200
MG/ML X 2)
cyclosporine intravenous solution 250
mg/5 ml
cyclosporine modified oral capsule 100
mg, 25 mg, 50 mg
cyclosporine modified oral solution 100
mg/ml
cyclosporine oral capsule 100 mg, 25 mg
5
4
PA BvD
5
2
2
PA; QL (28 per 28
days)
PA BvD
PA BvD
5
PA BvD
4
PA BvD
5
PA
5
PA
(Sandimmune)
2
PA BvD
(Neoral)
2
PA BvD
(Neoral)
2
PA BvD
(Sandimmune)
2
PA BvD
(Imuran)
(Azathioprine Sodium)
121
Drug Name
Drug Tier
ENBREL SUBCUTANEOUS RECON
SOLN 25 MG (1 ML)
ENBREL SUBCUTANEOUS
SYRINGE 25 MG/0.5ML (0.51), 50
MG/ML (0.98 ML)
ENBREL SURECLICK
50 MG/ML (0.98 ML)
ENVARSUS XR ORAL TABLET
EXTENDED RELEASE 24 HR 0.75
MG, 1 MG, 4 MG
FLEBOGAMMA DIF
INTRAVENOUS SOLUTION 10 %, 5
%
GAMASTAN S/D
INTRAMUSCULAR SOLUTION
15-18 % RANGE
GAMMAGARD LIQUID
INJECTION SOLUTION 10 %
GAMMAPLEX INTRAVENOUS
SOLUTION 5 %
GAMUNEX-C 20 GRAM/200 ML
VIAL P/F,LTX-FR,SUV,OUTER 20
GRAM/200 ML (10 %)
GAMUNEX-C INJECTION
SOLUTION 1 GRAM/10 ML (10 %)
gengraf oral capsule 100 mg, 25 mg
(Neoral)
gengraf oral solution 100 mg/ml
(Neoral)
HUMIRA PEN CROHN'S-UC-HS
START SUBCUTANEOUS PEN
INJECTOR KIT 40 MG/0.8 ML
HUMIRA PEN SUBCUTANEOUS
PEN INJECTOR KIT 40 MG/0.8 ML
HUMIRA SUBCUTANEOUS
SYRINGE KIT 10 MG/0.2 ML, 20
MG/0.4 ML, 40 MG/0.8 ML
Requirements/Limits
5
PA
5
PA
5
PA
4
PA BvD
5
PA BvD
3
PA BvD
5
PA BvD
5
PA BvD
5
PA BvD
5
PA BvD
2
2
5
PA BvD
PA BvD
PA
5
PA
5
PA
122
Drug Name
Drug Tier
HYPERRAB S/D (PF)
UNIT/ML, 150 UNIT/ML (10 ML)
HYQVIA SUBCUTANEOUS
SOLUTION 10 GRAM /100 ML (10
%), 2.5 GRAM /25 ML (10 %), 20
GRAM /200 ML (10 %), 30 GRAM
/300 ML (10 %), 5 GRAM /50 ML (10
%)
ILARIS (PF) SUBCUTANEOUS
RECON SOLN 180 MG/1.2 ML (150
MG/ML)
IMOGAM RABIES-HT (PF)
UNIT/ML
KINERET SUBCUTANEOUS
SYRINGE 100 MG/0.67 ML
leflunomide oral tablet 10 mg, 20 mg
mycophenolate mofetil oral capsule 250
mg
mycophenolate mofetil oral suspension
for reconstitution 200 mg/ml
mycophenolate mofetil oral tablet 500 mg
mycophenolate sodium oral
tablet,delayed release (dr/ec) 180 mg,
360 mg
NULOJIX INTRAVENOUS RECON
SOLN 250 MG
OCTAGAM INTRAVENOUS
SOLUTION 10 %, 5 %
ORENCIA (WITH MALTOSE)
MG
ORENCIA SUBCUTANEOUS
SYRINGE 125 MG/ML
PRIVIGEN INTRAVENOUS
SOLUTION 10 %
4
Requirements/Limits
5
PA BvD
5
PA
4
5
PA; QL (18.76 per 28
days)
(Arava)
(Cellcept)
2
2
PA BvD
(Cellcept)
5
PA BvD
(Cellcept)
(Myfortic)
2
2
PA BvD
PA BvD
5
PA BvD
5
PA BvD
5
PA
5
PA
5
PA BvD
123
Drug Name
Drug Tier
Requirements/Limits
PROGRAF INTRAVENOUS
SOLUTION 5 MG/ML
RAPAMUNE ORAL SOLUTION 1
MG/ML
RIDAURA ORAL CAPSULE 3 MG
sirolimus oral tablet 0.5 mg, 1 mg
(Rapamune)
sirolimus oral tablet 2 mg
(Rapamune)
tacrolimus oral capsule 0.5 mg, 1 mg, 5
(Hecoria)
mg
TYSABRI INTRAVENOUS
ZORTRESS ORAL TABLET 0.25 MG
4
PA BvD
5
PA BvD
5
2
5
2
PA BvD
PA BvD
PA BvD
ZORTRESS ORAL TABLET 0.5 MG,
0.75 MG
Vaccines
ACTHIB (PF) INTRAMUSCULAR
RECON SOLN 10 MCG/0.5 ML
ADACEL(TDAP
ADOLESN/ADULT)(PF)
INTRAMUSCULAR SUSPENSION 2
LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
ADACEL(TDAP
ADOLESN/ADULT)(PF)
LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
BCG (TICE STRAIN) VIAL 50 MG
BCG VACCINE, LIVE (PF)
PERCUTANEOUS SUSPENSION
FOR RECONSTITUTION 50 MG
BEXSERO (PF) INTRAMUSCULAR
SYRINGE 50-50-50-25 MCG/0.5 ML
BOOSTRIX TDAP
2.5-8-5 LF-MCG-LF/0.5ML
5
5
4
PA; LA; QL (15 per 28
days)
PA BvD; QL (120 per
30 days)
PA BvD; QL (120 per
30 days)
3
3
3
3
3
PA BvD
PA BvD
3
3
124
Drug Name
Drug Tier
BOOSTRIX TDAP
INTRAMUSCULAR SYRINGE
2.5-8-5 LF-MCG-LF/0.5ML
CERVARIX VACCINE (PF)
INTRAMUSCULAR SYRINGE 20-20
MCG/0.5 ML
COMVAX (PF) INTRAMUSCULAR
SUSPENSION 5-7.5-125 MCG/0.5 ML
DAPTACEL (DTAP PEDIATRIC)
(PF) INTRAMUSCULAR
SUSPENSION 15-10-5
LF-MCG-LF/0.5ML
ENGERIX-B (PF)
MCG/ML
ENGERIX-B 20 MCG/ML VIAL
10'S,ADULT,P/F,OUTER 20
MCG/ML
ENGERIX-B PEDIATRIC (PF)
10 MCG/0.5 ML
MCG/0.5 ML
GARDASIL (PF)
20-40-40-20 MCG/0.5 ML
GARDASIL (PF)
INTRAMUSCULAR SYRINGE
20-40-40-20 MCG/0.5 ML
GARDASIL 9 (PF)
0.5 ML
GARDASIL 9 (PF)
INTRAMUSCULAR SYRINGE 0.5
ML
3
Requirements/Limits
3
3
3
3
days)
3
days)
3
days)
3
days)
3
3
3
3
125
Drug Name
Drug Tier
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA
UNIT/ML
HAVRIX (PF) INTRAMUSCULAR
SYRINGE 1,440 ELISA UNIT/ML,
720 ELISA UNIT/0.5 ML
IMOVAX RABIES VACCINE (PF)
INTRAMUSCULAR RECON SOLN
2.5 UNIT
INFANRIX (DTAP) (PF)
25-58-10 LF-MCG-LF/0.5ML
IPOL INJECTION SUSPENSION
40-8-32 UNIT/0.5 ML
IPOL INJECTION SYRINGE 40-8-32
UNIT/0.5 ML
IXIARO (PF) INTRAMUSCULAR
KINRIX (PF) INTRAMUSCULAR
SUSPENSION 25 LF-58 MCG-10
LF/0.5 ML
KINRIX (PF) INTRAMUSCULAR
SYRINGE 25 LF-58 MCG-10 LF/0.5
ML
MENACTRA (PF)
MCG/0.5 ML
MENHIBRIX (PF)
INTRAMUSCULAR RECON SOLN
5-2.5 MCG/0.5 ML
MENOMUNE - A/C/Y/W-135 (PF)
SUBCUTANEOUS RECON SOLN 50
MCG
MENVEO A-C-Y-W-135-DIP (PF)
INTRAMUSCULAR KIT 10-5
MCG/0.5 ML
3
Requirements/Limits
3
3
PA BvD
3
3
3
3
3
3
3
3
3
3
126
Drug Name
Drug Tier
MENVEO MENA COMPONENT
(PF) INTRAMUSCULAR RECON
SOLN 10 MCG /0.5 ML (FINAL)
MENVEO MENCYW-135 COMPNT
SOLN 5 MCG X 3/ 0.5 ML (FINAL)
M-M-R II (PF) SUBCUTANEOUS
RECON SOLN 1,000-12,500
TCID50/0.5 ML
PEDIARIX (PF) INTRAMUSCULAR
SYRINGE 10 MCG-25LF-25
MCG-10LF/0.5 ML
PEDVAX HIB (PF)
INTRAMUSCULAR SOLUTION 7.5
MCG/0.5 ML
PENTACEL (PF)
INTRAMUSCULAR KIT 15 LF
UNIT-20 MCG-5 LF/0.5 ML
PENTACEL ACTHIB COMPONENT
SOLN 10 MCG/0.5 ML
PROQUAD (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 10EXP3-4.3-33.99 TCID50/0.5
QUADRACEL (PF)
15 LF-48 MCG- 5 LF UNIT/0.5ML
RABAVERT (PF)
FOR RECONSTITUTION 2.5 UNIT
RECOMBIVAX HB (PF)
10 MCG/ML, 40 MCG/ML
RECOMBIVAX HB (PF)
MCG/ML, 5 MCG/0.5 ML
3
Requirements/Limits
3
3
QL (2 per 365 days)
3
3
3
3
3
QL (2 per 365 days)
3
3
PA BvD
3
days)
3
days)
127
Drug Name
Drug Tier
ROTARIX ORAL SUSPENSION
FOR RECONSTITUTION 10EXP6
CCID50/ML
ROTATEQ VACCINE ORAL
SUSPENSION 2 ML
TENIVAC (PF) INTRAMUSCULAR
SYRINGE 5-2 LF UNIT/0.5 ML
TETANUS TOXOID,ADSORBED
(PF) INTRAMUSCULAR
SUSPENSION 5 LF UNIT/0.5 ML
TETANUS,DIPHTHERIA TOX
PED(PF) INTRAMUSCULAR
SUSPENSION 5-25 LF UNIT/0.5 ML
tetanus-diphtheria toxoids-td
intramuscular suspension 2-2 lf unit/0.5
ml
TRUMENBA INTRAMUSCULAR
TWINRIX (PF) INTRAMUSCULAR
SUSPENSION 720 ELISA UNIT -20
MCG/ML
TWINRIX (PF) INTRAMUSCULAR
SYRINGE 720 ELISA UNIT -20
MCG/ML
TYPHIM VI INTRAMUSCULAR
SOLUTION 25 MCG/0.5 ML
TYPHIM VI INTRAMUSCULAR
VAQTA (PF) INTRAMUSCULAR
VAQTA (PF) INTRAMUSCULAR
SYRINGE 25 UNIT/0.5 ML, 50
UNIT/ML
VAQTA 25 UNITS/0.5 ML VIAL
SDV, OUTER 25 UNIT/0.5 ML
3
Requirements/Limits
3
3
3
PA BvD
3
(Tetanus, Diphtheria
Tox,Adult)
3
3
3
3
3
3
3
3
3
128
Drug Name
Drug Tier
VARIVAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 1,350 UNIT/0.5
ML
YF-VAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 10 EXP4.74
UNIT/0.5 ML
ZOSTAVAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 19,400
UNIT/0.65 ML
3
Requirements/Limits
QL (2 per 365 days)
3
3
QL (1 per 365 days)
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease
Agents
alosetron oral tablet 0.5 mg, 1 mg
APRISO ORAL
24HR 0.375 GRAM
ASACOL HD ORAL
(DR/EC) 800 MG
balsalazide oral capsule 750 mg
budesonide oral
capsule,delayed,extend.release 3 mg
DELZICOL ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 400 MG
DIPENTUM ORAL CAPSULE 250
MG
(Alosetron HCl)
5
3
3
(Colazal)
(Entocort EC)
2
5
3
4
ST
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation solution 0.25 %
LACTATED RINGERS
IRRIGATION SOLUTION
ringers irrigation solution
(Acetic Acid)
2
3
(Tis-U-Sol)
2
129
Drug Name
sodium chloride irrigation solution 0.9 %
sorbitol irrigation solution 3 %, 3.3 %
sorbitol-mannitol urethral solution
2.7-0.54 g/100 ml
water for irrigation, sterile irrigation
solution
Drug Tier
Requirements/Limits
(Sodium Chloride Irrig
Solution)
(Sorbitol Solution)
(Mannitol/Sorbitol
Solution)
(Water For
Irrigation,Sterile)
2
(Alendronate Sodium)
(Fosamax)
2
1
(Fosamax)
(Miacalcin)
1
2
QL (4 per 28 days)
(Calcitriol)
(Rocaltrol)
(Rocaltrol)
(Doxercalciferol)
2
2
2
2
(Hectorol)
2
(Etidronate Disodium)
2
2
2
2
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate oral solution 70 mg/75 ml
alendronate oral tablet 10 mg, 40 mg, 5
mg
alendronate oral tablet 35 mg, 70 mg
calcitonin (salmon) nasal
spray,non-aerosol 200 unit/actuation
calcitriol intravenous solution 1 mcg/ml
calcitriol oral capsule 0.25 mcg, 0.5 mcg
calcitriol oral solution 1 mcg/ml
doxercalciferol intravenous solution 4
mcg/2 ml
doxercalciferol oral capsule 0.5 mcg, 1
mcg, 2.5 mcg
etidronate disodium oral tablet 200 mg,
400 mg
FORTEO SUBCUTANEOUS PEN
INJECTOR 20 MCG/DOSE - 600
MCG/2.4 ML
FORTICAL NASAL
UNIT/ACTUATION
ibandronate intravenous solution 3 mg/3
ml
ibandronate intravenous syringe 3 mg/3
ml
ibandronate oral tablet 150 mg
4
4
(Ibandronate Sodium)
2
QL (3 per 84 days)
(Boniva)
2
QL (3 per 84 days)
(Boniva)
2
QL (1 per 28 days)
130
Drug Name
Drug Tier
MIACALCIN INJECTION
NATPARA SUBCUTANEOUS
CARTRIDGE 100 MCG/DOSE, 25
MCG/DOSE, 50 MCG/DOSE, 75
MCG/DOSE
pamidronate intravenous solution 30
mg/10 ml (3 mg/ml), 60 mg/10 ml (6
mg/ml), 90 mg/10 ml (9 mg/ml)
paricalcitol oral capsule 1 mcg, 2 mcg, 4
mcg
PROLIA SUBCUTANEOUS
SYRINGE 60 MG/ML
risedronate oral tablet 150 mg
risedronate oral tablet 30 mg, 5 mg
risedronate oral tablet 35 mg (12 pack),
35 mg (4 pack)
risedronate sodium 35 mg tab f/c,
once-a-week 35 mg
XGEVA SUBCUTANEOUS
SOLUTION 120 MG/1.7 ML (70
MG/ML)
ZEMPLAR INTRAVENOUS
SOLUTION 2 MCG/ML, 5 MCG/ML
zoledronic acid intravenous solution 4
mg/5 ml
zoledronic acid-mannitol-water
3
intravenous solution 5 mg/100 ml
ZOMETA INTRAVENOUS
5
(Pamidronate
Disodium)
2
(Zemplar)
2
Requirements/Limits
3
QL (1 per 180 days)
(Actonel)
(Actonel)
(Actonel)
2
2
2
QL (1 per 28 days)
QL (30 per 28 days)
QL (4 per 28 days)
(Actonel)
2
QL (4 per 28 days)
5
PA
3
(Zometa)
2
(Zoledronic
Acid/Mannitol and
Water)
(Reclast)
2
2
5
131
Drug Name
Drug Tier
Requirements/Limits
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA INTRAVENOUS
MG/ML), 400 MG/20 ML (20
MG/ML), 80 MG/4 ML (20 MG/ML)
ACTEMRA SUBCUTANEOUS
SYRINGE 162 MG/0.9 ML
ACTIMMUNE SUBCUTANEOUS
SOLUTION 100 MCG/0.5 ML
allopurinol oral tablet 100 mg, 300 mg
allopurinol sodium intravenous recon soln
500 mg
amifostine crystalline intravenous recon
soln 500 mg
ammonium chloride intravenous solution
5 meq/ml
anticoag citrate phos dextrose solution
2.63-222 gram-mg/100ml
AVONEX (WITH ALBUMIN)
INTRAMUSCULAR KIT 30 MCG
AVONEX INTRAMUSCULAR PEN
INJECTOR KIT 30 MCG/0.5 ML
AVONEX INTRAMUSCULAR
SYRINGE KIT 30 MCG/0.5 ML
BENLYSTA INTRAVENOUS
BETASERON SUBCUTANEOUS
KIT 0.3 MG
bethanechol chloride oral tablet 10 mg,
25 mg, 5 mg, 50 mg
BOTOX INJECTION RECON SOLN
100 UNIT
BOTOX INJECTION RECON SOLN
200 UNIT
5
PA
5
PA
5
(Zyloprim)
(Allopurinol Sodium)
2
2
(Amifostine
Crystalline)
(Ammonium Chloride)
2
(Citrate Phosphate
Dextros Soln)
2
(Urecholine)
2
5
ST
5
ST
5
ST
5
PA
5
ST
2
3
3
132
Drug Name
buspirone oral tablet 10 mg, 15 mg, 30
mg, 5 mg, 7.5 mg
CERDELGA ORAL CAPSULE 84
MG
colchicine oral tablet 0.6 mg
colchicine-probenecid oral tablet 0.5-500
mg
COPAXONE SUBCUTANEOUS
SYRINGE 20 MG/ML, 40 MG/ML
CYSTADANE ORAL POWDER 1
GRAM/1.7 ML
dexrazoxane hcl intravenous recon soln
250 mg
droperidol injection solution 2.5 mg/ml
dutasteride oral capsule 0.5 mg
dutasteride-tamsulosin oral capsule, er
multiphase 24 hr 0.5-0.4 mg
ELMIRON ORAL CAPSULE 100 MG
ergoloid oral tablet 1 mg
EXTAVIA SUBCUTANEOUS KIT
0.3 MG
finasteride oral tablet 5 mg
fomepizole intravenous solution 1
gram/ml
FUSILEV INTRAVENOUS RECON
SOLN 50 MG
GAUZE PAD TOPICAL BANDAGE
2X2"
GILENYA ORAL CAPSULE 0.5 MG
GLUCAGEN HYPOKIT INJECTION
RECON SOLN 1 MG
GLUCAGON EMERGENCY KIT
(HUMAN) INJECTION KIT 1 MG
guanidine oral tablet 125 mg
hydroxyzine hcl intramuscular solution
25 mg/ml, 50 mg/ml
Drug Tier
(Buspirone HCl)
2
5
(Colcrys)
(Colchicine/Probenecid
)
Requirements/Limits
PA
2
2
5
5
(Totect)
2
(Droperidol)
(Avodart)
(Jalyn)
2
2
2
QL (30 per 30 days)
(Ergoloid Mesylates)
4
2
5
ST
(Proscar)
(Fomepizole)
2
5
5
1
5
3
QL (28 per 28 days)
4
(Guanidine HCl)
(Hydroxyzine HCl)
2
2
133
Drug Name
Drug Tier
hydroxyzine hcl oral solution 10 mg/5 ml (Hydroxyzine HCl)
hydroxyzine hcl oral tablet 10 mg, 25 mg, (Hydroxyzine HCl)
50 mg
hydroxyzine pamoate oral capsule 100
(Vistaril)
mg, 25 mg, 50 mg
KEVEYIS ORAL TABLET 50 MG
2
2
LEMTRADA INTRAVENOUS
leucovorin calcium 200 mg vial sdv, p/f,
latex-free 200 mg
leucovorin calcium injection recon soln
100 mg, 350 mg
leucovorin calcium oral tablet 10 mg, 15
mg, 25 mg, 5 mg
levocarnitine (with sugar) oral solution
100 mg/ml
levocarnitine intravenous solution 200
mg/ml
levocarnitine oral tablet 330 mg
mesna intravenous solution 100 mg/ml
MESNEX ORAL TABLET 400 MG
MESTINON ORAL SYRUP 60 MG/5
ML
MESTINON TIMESPAN ORAL
TABLET EXTENDED RELEASE 180
MG
methylergonovine injection solution 0.2
mg/ml (1 ml)
methylergonovine oral tablet 0.2 mg
morrhuate sodium intravenous solution 5
%
MYOBLOC INTRAMUSCULAR
SOLUTION 10,000 UNIT/2 ML, 2,500
UNIT/0.5 ML, 5,000 UNIT/ML
5
Requirements/Limits
2
5
(Leucovorin Calcium)
2
2
2
(Levocarnitine (With
Sugar))
(Carnitor)
2
(Carnitor)
(Mesnex)
2
2
5
4
PA NSO; QL (120 per
30 days)
PA
2
4
(Methylergonovine
Maleate)
(Methergine)
(Sodium Morrhuate)
2
2
2
4
QL (1 per 90 days)
134
Drug Name
Drug Tier
Requirements/Limits
NPLATE SUBCUTANEOUS RECON
SOLN 250 MCG, 500 MCG
OTEZLA ORAL TABLET 30 MG
5
5
OTEZLA STARTER ORAL
TABLETS,DOSE PACK 10 MG (4)-20
MG (4)-30 MG (47), 10 MG (4)-20 MG
(4)-30 MG(19)
OTREXUP (PF) SUBCUTANEOUS
AUTO-INJECTOR 10 MG/0.4 ML, 15
MG/0.4 ML, 17.5 MG/0.4 ML, 20
MG/0.4 ML, 22.5 MG/0.4 ML, 25
MG/0.4 ML, 7.5 MG/0.4 ML
PLEGRIDY SUBCUTANEOUS PEN
INJECTOR 125 MCG/0.5 ML, 63
MCG/0.5 ML- 94 MCG/0.5 ML
PLEGRIDY SUBCUTANEOUS
SYRINGE 125 MCG/0.5 ML, 63
MCG/0.5 ML- 94 MCG/0.5 ML
probenecid oral tablet 500 mg
(Probenecid)
PROCYSBI ORAL CAPSULE,
DELAYED REL SPRINKLE 25 MG,
75 MG
pyridostigmine bromide oral tablet 60 mg (Mestinon)
pyridostigmine bromide oral tablet
(Mestinon)
extended release 180 mg
RASUVO (PF) SUBCUTANEOUS
AUTO-INJECTOR 10 MG/0.2 ML,
12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5
MG/0.35 ML, 20 MG/0.4 ML, 22.5
MG/0.45 ML, 25 MG/0.5 ML, 27.5
MG/0.55 ML, 30 MG/0.6 ML, 7.5
MG/0.15 ML
REBIF (WITH ALBUMIN)
MCG/0.5 ML, 44 MCG/0.5 ML
5
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
3
5
ST
5
ST
2
5
2
2
3
5
135
Drug Name
Drug Tier
REBIF REBIDOSE
22 MCG/0.5 ML, 44 MCG/0.5 ML,
8.8MCG/0.2ML-22 MCG/0.5ML (6)
REBIF TITRATION PACK
SUBCUTANEOUS SYRINGE
8.8MCG/0.2ML-22 MCG/0.5ML (6)
REMICADE INTRAVENOUS
RECON SOLN 100 MG
SENSIPAR ORAL TABLET 30 MG
SENSIPAR ORAL TABLET 60 MG,
90 MG
SIGNIFOR SUBCUTANEOUS
SOLUTION 0.3 MG/ML (1 ML), 0.6
MG/ML (1 ML), 0.9 MG/ML (1 ML)
SIMPONI ARIA INTRAVENOUS
SOLUTION 12.5 MG/ML
SIMPONI SUBCUTANEOUS PEN
INJECTOR 100 MG/ML, 50 MG/0.5
ML
SIMPONI SUBCUTANEOUS
SYRINGE 100 MG/ML, 50 MG/0.5
ML
STELARA SUBCUTANEOUS
SYRINGE 45 MG/0.5 ML, 90 MG/ML
STERILE PADS 2" X 2" 2 X 2 "
SYNAREL NASAL
SPRAY,NON-AEROSOL 2 MG/ML
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)- 240
MG (46), 240 MG
THALOMID ORAL CAPSULE 100
MG, 150 MG, 200 MG, 50 MG
5
Requirements/Limits
5
5
PA
3
5
5
QL (60 per 30 days)
5
PA
5
PA
5
PA
5
PA
1
5
5
QL (14 per 30 days)
5
QL (60 per 30 days)
5
days)
136
Drug Name
Drug Tier
Requirements/Limits
TYBOST ORAL TABLET 150 MG
ULORIC ORAL TABLET 40 MG, 80
MG
XELJANZ ORAL TABLET 5 MG
4
3
QL (30 per 30 days)
QL (30 per 30 days)
5
XELJANZ XR ORAL TABLET
MG
5
PA; QL (60 per 30
days)
PA; QL (30 per 30
days)
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule, extended
release 500 mg
acetazolamide oral tablet 125 mg, 250 mg
acetazolamide sodium injection recon
soln 500 mg
ALPHAGAN P OPHTHALMIC
DROPS 0.1 %
AZOPT OPHTHALMIC
DROPS,SUSPENSION 1 %
betaxolol ophthalmic drops 0.5 %
BETOPTIC S OPHTHALMIC
bimatoprost ophthalmic drops 0.03 %
brimonidine ophthalmic drops 0.15 %, 0.2
%
COMBIGAN OPHTHALMIC DROPS
0.2-0.5 %
dorzolamide ophthalmic drops 2 %
dorzolamide-timolol ophthalmic drops
22.3-6.8 mg/ml
latanoprost ophthalmic drops 0.005 %
levobunolol ophthalmic drops 0.25 %, 0.5
%
LUMIGAN OPHTHALMIC DROPS
0.01 %
methazolamide oral tablet 25 mg, 50 mg
(Diamox Sequels)
2
(Acetazolamide)
(Acetazolamide
Sodium)
2
2
3
3
(Betaxolol HCl)
2
4
(Bimatoprost)
(Alphagan P)
2
2
(drops: 0.15%, 0.20%)
3
(Trusopt)
(Cosopt)
2
2
(Xalatan)
(Betagan)
2
2
3
(Neptazane)
2
137
Drug Name
metipranolol ophthalmic drops 0.3 %
PHOSPHOLINE IODIDE
OPHTHALMIC DROPS 0.125 %
pilocarpine hcl ophthalmic drops 1 %, 2
%, 4 %
SIMBRINZA OPHTHALMIC
DROPS,SUSPENSION 1-0.2 %
timolol maleate ophthalmic drops 0.25 %,
0.5 %
timolol maleate ophthalmic gel forming
solution 0.25 %, 0.5 %
TRAVATAN Z OPHTHALMIC
DROPS 0.004 %
travoprost (benzalkonium) ophthalmic
drops 0.004 %
ZIOPTAN (PF) OPHTHALMIC
DROPPERETTE 0.0015 %
Drug Tier
(Metipranolol)
2
3
(Isopto Carpine)
2
Requirements/Limits
3
(Timoptic)
2
(Timoptic-Xe)
2
(Travoprost
(Benzalkonium))
3
2
4
QL (30 per 30 days)
Replacement Preparations
Replacement Preparations
calcium chloride intravenous solution 100
mg/ml (10 %)
calcium chloride intravenous syringe 100
mg/ml (10 %)
calcium gluconate intravenous solution
100 mg/ml (10%)
d10 %-0.45 % sodium chloride
d2.5 %-0.45 % sodium chloride
d5 % and 0.9 % sodium chloride
d5 %-0.45 % sodium chloride intravenous
parenteral solution
dextrose 10 % and 0.2 % nacl intravenous
parenteral solution
(Calcium Chloride)
2
(Calcium Chloride)
2
(Calcium Gluconate)
2
(Dextrose 10 % and
0.45 % NaCl)
(Dextrose 2.5 % and
0.45 % NaCl)
(Dextrose 5 % and 0.9
% NaCl)
(Dextrose 5 %-0.45 %
NaCl)
% NaCl)
2
2
2
2
2
138
Drug Name
dextrose 5 %-lactated ringers intravenous
parenteral solution
dextrose 5%-0.2 % sod chloride
dextrose 5%-0.3 % sod.chloride
dextrose with sodium chloride
intravenous parenteral solution 5-0.2 %
effer-k oral tablet, effervescent 25 meq
electrolyte-48 in d5w intravenous
parenteral solution
HYPERLYTE CR INTRAVENOUS
SOLUTION 25-20-5-5-30-30 MEQ/20
ML
IONOSOL-B IN D5W
SOLUTION 5 %
IONOSOL-MB IN D5W
SOLUTION 5 %
ISOLYTE M IN 5 % DEXTROSE
SOLUTION
ISOLYTE-H IN 5 % DEXTROSE
SOLUTION 5 %
ISOLYTE-P IN 5 % DEXTROSE
SOLUTION 5 %
ISOLYTE-S INTRAVENOUS
PARENTERAL SOLUTION
k-effervescent oral tablet, effervescent 25
meq
klor-con 10 oral tablet extended release
10 meq
klor-con m10 tablet 10 meq
Drug Tier
(Dextrose 5%-Lactated
Ringers)
(Dextrose 5 %-0.2 %
NaCl)
% NaCl)
(Dextrose 5 %-0.2 %
NaCl)
(Klor-Con-Ef)
(Electrolyte-48
Solution/D5W)
Requirements/Limits
2
2
2
2
2
2
4
4
4
4
4
4
4
(Klor-Con-Ef)
2
(Potassium Chloride)
2
2
139
Drug Name
klor-con m15 oral tablet,er
particles/crystals 15 meq
klor-con m20 oral tablet,er
klor-con sprinkle oral capsule, extended
release 10 meq, 8 meq
magnesium chloride injection solution 200
mg/ml (20 %)
magnesium sulf in 0.45% nacl intravenous
solution 20 gram/500 ml (40 mg/ml)
magnesium sulfate in d5w intravenous
piggyback 1 gram/100 ml, 4 gram/100 ml
magnesium sulfate in water intravenous
parenteral solution 20 gram/500 ml (4
%), 40 gram/1,000 ml (4 %)
magnesium sulfate in water intravenous
piggyback 2 gram/50 ml (4 %), 4
gram/100 ml (4 %), 4 gram/50 ml (8 %)
magnesium sulfate injection solution 4
meq/ml (50 %)
magnesium sulfate injection syringe 4
meq/ml
NORMOSOL-M IN 5 % DEXTROSE
SOLUTION
NORMOSOL-R PH 7.4
SOLUTION
NUTRILYTE II INTRAVENOUS
SOLUTION 35-20-5 MEQ/20 ML
NUTRILYTE INTRAVENOUS
SOLUTION 25-40.6-5 MEQ/20 ML
phospha 250 neutral oral tablet 250 mg
PLASMA-LYTE 148 INTRAVENOUS
PARENTERAL SOLUTION
PLASMA-LYTE A INTRAVENOUS
PARENTERAL SOLUTION
Drug Tier
2
2
2
(Magnesium Chloride)
2
(Magnesium Sulf In
0.45% NaCl)
(Magnesium
Sulfate/D5W)
(Magnesium Sulfate in
Water)
2
(Magnesium Sulfate in
Water)
2
(Magnesium Sulfate)
2
(Magnesium Sulfate)
2
Requirements/Limits
2
2
4
4
4
4
(K-Phos Neutral)
2
4
4
140
Drug Name
Drug Tier
PLASMA-LYTE-56 IN 5 %
DEXTROSE INTRAVENOUS
potassium acetate intravenous solution 2
meq/ml, 4 meq/ml
potassium bicarb and chloride oral tablet,
effervescent 25 meq
potassium bicarb-citric acid oral tablet,
effervescent 25 meq
potassium chlorid-d5-0.45%nacl
intravenous parenteral solution 10 meq/l,
20 meq/l, 30 meq/l, 40 meq/l
potassium chloride in 0.9%nacl
40 meq/l
potassium chloride in 5 % dex
30 meq/l, 40 meq/l
potassium chloride in lr-d5 intravenous
parenteral solution 20 meq/l
potassium chloride intravenous piggyback
10 meq/100 ml, 20 meq/100 ml, 30
meq/100 ml, 40 meq/100 ml
potassium chloride intravenous solution 2
meq/ml
potassium chloride oral capsule, extended
release 10 meq, 8 meq
potassium chloride oral liquid 20 meq/15
ml, 40 meq/15 ml
potassium chloride oral packet 20 meq
potassium chloride oral tablet extended
release 8 meq
potassium chloride oral tablet,er
potassium chloride oral tablet,er
4
(Potassium Acetate)
2
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
2
(Potassium
Chloride/D5-0.45nacl)
2
(Potassium Chloride In
0.9%NaCl)
2
D5w)
2
Lr-D5)
2
2
2
2
(Klor-Con)
(K-Tab ER)
2
2
(K-Tab ER)
2
2
Requirements/Limits
2
2
141
Drug Name
potassium chloride-0.45 % nacl
intravenous parenteral solution 20 meq/l
potassium chloride-d5-0.2%nacl
20 meq/l, 30 meq/l, 40 meq/l
intravenous parenteral solution 20 meq/l
40 meq/l
potassium citrate oral tablet extended
release 10 meq (1,080 mg), 15 meq, 5
meq (540 mg)
potassium citrate-citric acid oral packet
3,300-1,002 mg
potassium cl 10 meq/50 ml sol 10 meq/50
ml
potassium cl 20 meq/50 ml sol 20 meq/50
ml
potassium cl er 10 meq tablet f/c 10 meq
potassium phosphate m-/d-basic
intravenous solution 3 mmol/ml
ringers intravenous parenteral solution
sodium acetate intravenous solution 2
meq/ml, 4 meq/ml
sodium bicarbonate intravenous solution
1 meq/ml (8.4 %)
sodium bicarbonate intravenous syringe
10 meq/10 ml (8.4 %), 4.2 % (0.5
meq/ml), 7.5 % (0.9 meq/ml), 8.4 % (1
meq/ml)
sodium chloride 0.45 % intravenous
parenteral solution 0.45 %
sodium chloride 0.9 % intravenous
parenteral solution 0.9 %
Drug Tier
(Potassium
Chloride-0.45% NaCl)
(Potassium
Chloride/D5-0.2%NaC
l)
(Potassium
Chloride/D5-0.3%NaC
l)
(Potassium
Chloride/D5-0.9%NaC
l)
(Urocit-K)
2
(Potassium
Citrate/Citric Acid)
2
2
(K-Tab ER)
(Potassium
Phos,M-Basic-D-Basic)
(Ringers Solution)
(Sodium Acetate)
2
2
(Sodium Bicarbonate)
2
(Sodium Bicarbonate)
2
(Sodium Chloride 0.45
%)
(0.9 % Sodium
Chloride)
2
Requirements/Limits
2
2
2
2
2
2
2
2
142
Drug Name
sodium chloride 3 % intravenous
sodium chloride 5 % intravenous
sodium chloride intravenous parenteral
solution 2.5 meq/ml, 4 meq/ml
sodium lactate intravenous parenteral
solution 167 meq/l
sodium lactate intravenous solution 5
meq/ml
sodium phosphate intravenous solution 3
mmol/ml
TPN ELECTROLYTES II IV SOLN
25'S,20ML/50ML FTV 18-18-5-4.5-35
MEQ/20 ML
TPN ELECTROLYTES
INTRAVENOUS SOLUTION 35-20-5
MEQ/20 ML
virt-phos 250 neutral oral tablet 250 mg
Drug Tier
(Sodium Chloride 3 %)
2
(Sodium Chloride 5 %)
2
(Sodium Chloride)
2
(Sodium Lactate)
2
(Sodium Lactate)
2
(Sodium
Phos,M-Basic-D-Basic)
2
Requirements/Limits
4
4
(K-Phos Neutral)
2
Respiratory Tract Agents
Anti-Inflammatories, Inhaled
Corticosteroids
ADVAIR DISKUS INHALATION
BLISTER WITH DEVICE 100-50
MCG/DOSE, 250-50 MCG/DOSE,
500-50 MCG/DOSE
ADVAIR HFA INHALATION HFA
AEROSOL INHALER 115-21
MCG/ACTUATION, 230-21
MCG/ACTUATION
BREO ELLIPTA INHALATION
BLISTER WITH DEVICE 100-25
MCG/DOSE, 200-25 MCG/DOSE
3
QL (60 per 30 days)
3
QL (12 per 28 days)
3
QL (60 per 30 days)
143
Drug Name
Drug Tier
DULERA INHALATION HFA
AEROSOL INHALER 100-5
MCG/ACTUATION
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 100
MCG/ACTUATION, 50
MCG/ACTUATION
FLOVENT DISKUS INHALATION
MCG/ACTUATION
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 110
MCG/ACTUATION
AEROSOL INHALER 220
MCG/ACTUATION
AEROSOL INHALER 44
MCG/ACTUATION
QVAR INHALATION AEROSOL 40
MCG/ACTUATION, 80
MCG/ACTUATION
Antileukotrienes
montelukast oral granules in packet 4 mg
montelukast oral tablet 10 mg
montelukast oral tablet,chewable 4 mg, 5
mg
zafirlukast oral tablet 10 mg, 20 mg
Bronchodilators
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml,
2.5 mg /3 ml (0.083 %), 5 mg/ml
albuterol sulfate oral syrup 2 mg/5 ml
albuterol sulfate oral tablet 2 mg, 4 mg
albuterol sulfate oral tablet extended
release 12 hr 4 mg, 8 mg
3
QL (13 per 28 days)
3
QL (60 per 30 days)
3
3
QL (12 per 28 days)
3
QL (24 per 28 days)
3
3
(Singulair)
(Singulair)
(Singulair)
2
2
2
(Accolate)
2
(Albuterol Sulfate)
2
(Albuterol Sulfate)
(Albuterol Sulfate)
(Vospire ER)
2
2
2
Requirements/Limits
PA BvD
144
Drug Name
ATROVENT HFA INHALATION
HFA AEROSOL INHALER 17
MCG/ACTUATION
COMBIVENT RESPIMAT
INHALATION MIST 20-100
MCG/ACTUATION
elixophyllin oral elixir 80 mg/15 ml
FORADIL AEROLIZER
INHALATION CAPSULE,
W/INHALATION DEVICE 12 MCG
ipratropium bromide inhalation solution
0.02 %
ipratropium-albuterol inhalation solution
for nebulization 0.5 mg-3 mg(2.5 mg
base)/3 ml
metaproterenol oral syrup 10 mg/5 ml
metaproterenol oral tablet 10 mg, 20 mg
Drug Tier
(Theophylline
Anhydrous)
Requirements/Limits
3
3
QL (8 per 30 days)
2
3
(Ipratropium Bromide)
2
(Ipratropium/Albuterol
Sulfate)
2
(Metaproterenol
Sulfate)
(Metaproterenol
Sulfate)
2
PROAIR HFA INHALATION HFA
AEROSOL INHALER 90
MCG/ACTUATION
PROAIR RESPICLICK
INHALATION AEROSOL POWDR
BREATH ACTIVATED 90
MCG/ACTUATION
SEREVENT DISKUS INHALATION
MCG/DOSE
SPIRIVA RESPIMAT INHALATION
MIST 1.25 MCG/ACTUATION, 2.5
MCG/ACTUATION
SPIRIVA WITH HANDIHALER
INHALATION CAPSULE,
W/INHALATION DEVICE 18 MCG
2
3
3
3
3
3
145
Drug Name
Drug Tier
STRIVERDI RESPIMAT
INHALATION MIST 2.5
MCG/ACTUATION
terbutaline oral tablet 2.5 mg, 5 mg
terbutaline subcutaneous solution 1
mg/ml
theochron oral tablet extended release 12
hr 100 mg, 200 mg, 300 mg
theophylline in dextrose 5 % intravenous
parenteral solution 200 mg/100 ml, 200
mg/50 ml, 400 mg/250 ml, 400 mg/500
ml, 800 mg/250 ml
theophylline oral solution 80 mg/15 ml
3
theophylline oral tablet extended release
12 hr 100 mg, 200 mg, 300 mg, 450 mg
theophylline oral tablet extended release
400 mg, 600 mg
TUDORZA PRESSAIR
INHALATION AEROSOL POWDR
BREATH ACTIVATED 400
MCG/ACTUATION, 400
MCG/ACTUATION (30 ACTUAT)
VENTOLIN HFA INHALATION
HFA AEROSOL INHALER 90
MCG/ACTUATION
Respiratory Tract Agents, Other
acetylcysteine intravenous solution 200
mg/ml (20 %)
acetylcysteine solution 100 mg/ml (10
%), 200 mg/ml (20 %)
CINQAIR INTRAVENOUS
SOLUTION 10 MG/ML
cromolyn inhalation solution for
nebulization 20 mg/2 ml
DALIRESP ORAL TABLET 500
MCG
(Terbutaline Sulfate)
(Terbutaline Sulfate)
2
2
(Theophylline
Anhydrous)
(Theophylline/D5W)
2
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
2
Requirements/Limits
2
2
2
3
QL (2 per 28 days)
3
(Acetadote)
2
PA BvD
(Acetadote)
2
PA BvD
5
PA
2
PA BvD
3
QL (30 per 30 days)
(Cromolyn Sodium)
146
Drug Name
Drug Tier
ESBRIET ORAL CAPSULE 267 MG
5
KALYDECO ORAL GRANULES IN
PACKET 50 MG, 75 MG
KALYDECO ORAL TABLET 150
MG
NUCALA SUBCUTANEOUS
RECON SOLN 100 MG
OFEV ORAL CAPSULE 100 MG, 150
MG
ORKAMBI ORAL TABLET 200-125
MG
PROLASTIN-C INTRAVENOUS
RECON SOLN 1,000 MG
XOLAIR SUBCUTANEOUS RECON
SOLN 150 MG
5
5
5
5
5
Requirements/Limits
PA; QL (270 per 30
days)
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
days)
PA
PA; QL (120 per 30
days)
5
5
PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen oral tablet 10 mg, 20 mg
carisoprodol oral tablet 250 mg, 350 mg
chlorzoxazone oral tablet 500 mg
cyclobenzaprine oral tablet 10 mg, 5 mg,
7.5 mg
dantrolene oral capsule 100 mg, 25 mg,
50 mg
metaxall oral tablet 800 mg
metaxalone oral tablet 400 mg, 800 mg
methocarbamol oral tablet 500 mg, 750
mg
revonto intravenous recon soln 20 mg
tizanidine oral capsule 2 mg, 4 mg, 6 mg
tizanidine oral tablet 2 mg, 4 mg
(Baclofen)
(Soma)
(Parafon Forte DSC)
(Fexmid)
2
2
2
2
(Dantrium)
2
(Skelaxin)
(Skelaxin)
(Robaxin)
2
2
2
(Zanaflex)
(Zanaflex)
2
2
2
Sleep Disorder Agents
Sleep Disorder Agents
BELSOMRA ORAL TABLET 10 MG,
15 MG, 20 MG, 5 MG
3
QL (30 per 30 days)
147
Drug Name
eszopiclone oral tablet 1 mg, 2 mg, 3 mg
HETLIOZ ORAL CAPSULE 20 MG
NUVIGIL ORAL TABLET 150 MG,
200 MG, 250 MG, 50 MG
ROZEREM ORAL TABLET 8 MG
XYREM ORAL SOLUTION 500
MG/ML
zaleplon oral capsule 10 mg, 5 mg
zolpidem oral tablet 10 mg, 5 mg
zolpidem oral tablet,ext release
multiphase 12.5 mg, 6.25 mg
Drug Tier
(Lunesta)
(Sonata)
(Ambien)
(Ambien CR)
Requirements/Limits
2
5
3
QL (30 per 30 days)
PA
PA
3
5
LA
2
2
2
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
5
2
PA; QL (60 per 30
days)
PA; QL (90 per 30
days)
PA; QL (30 per 30
days)
PA BvD
5
PA BvD
5
Vasodilating Agents
Vasodilating Agents
ADCIRCA ORAL TABLET 20 MG
ADEMPAS ORAL TABLET 0.5 MG,
1 MG, 1.5 MG, 2 MG, 2.5 MG
CIALIS ORAL TABLET 2.5 MG, 5
MG
epoprostenol (glycine) intravenous recon (Flolan)
soln 0.5 mg
epoprostenol (glycine) intravenous recon (Flolan)
soln 1.5 mg
LETAIRIS ORAL TABLET 10 MG, 5
MG
OPSUMIT ORAL TABLET 10 MG
5
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.125 MG
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.25 MG, 1
MG, 2.5 MG
REMODULIN INJECTION
SOLUTION 1 MG/ML, 10 MG/ML,
2.5 MG/ML, 5 MG/ML
3
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
PA
5
PA
5
PA BvD
3
5
148
Drug Name
Drug Tier
Requirements/Limits
sildenafil intravenous solution 10 mg/12.5 (Revatio)
ml
sildenafil oral tablet 20 mg
(Revatio)
5
PA; QL (37.5 per 1 day)
2
TRACLEER ORAL TABLET 125
MG, 62.5 MG
TYVASO INHALATION SOLUTION
FOR NEBULIZATION 1.74 MG/2.9
ML (0.6 MG/ML)
TYVASO REFILL KIT
INHALATION SOLUTION FOR
NEBULIZATION 1.74 MG/2.9 ML
(0.6 MG/ML)
TYVASO STARTER KIT
INHALATION SOLUTION FOR
NEBULIZATION 1.74 MG/2.9 ML
UPTRAVI ORAL TABLET 1,000
MCG, 1,200 MCG, 1,400 MCG, 1,600
MCG, 400 MCG, 600 MCG, 800 MCG
UPTRAVI ORAL TABLET 200 MCG
5
5
PA; QL (90 per 30
days)
days)
PA BvD
5
PA BvD
5
PA BvD
5
PA; QL (60 per 30
days)
5
UPTRAVI ORAL TABLETS,DOSE
PACK 200 MCG (140)- 800 MCG (60)
5
PA; QL (240 per 30
days)
PA; QL (200 per 365
days)
Vitamins And Minerals
Vitamins And Minerals
multivit-fluor 0.5 mg tab chew chewable,
d/f, s/f 0.5 mg
pnv prenatal plus multivit tab s/f,
gluten-free 27 mg iron- 1 mg
prenatal vitamin plus low iron oral tablet
27 mg iron- 1 mg
sodium fluoride 1 mg (2.2 mg) 1 mg
fluoride (2.2 mg)
sodium fluoride oral tablet 1 mg fluoride
(2.2 mg)
(Pedi M.Vit No.17 with
Fluoride)
(Pnv with
Ca,No.72/Iron/Fa)
(Pnv with
Ca,No.72/Iron/Fa)
(Sodium Fluoride)
2
(Pedi M.Vit No.17 with
Fluoride)
2
3
3
(All Rx Prenatal
Vitamins Covered)
(All Rx Prenatal
Vitamins Covered)
2
149
Drug Name
Drug Tier
VITAFOL FE+ (WITH DOCUSATE)
ORAL CAPSULE 90 MG IRON-1 MG
-50 MG-200 MG
3
Requirements/Limits
150
INDEX
I-1
AMINOSYN 7 % WITH
ELECTROLYTES ................................. 69
AMINOSYN 8.5 % ............................... 69
AMINOSYN 8.5
%-ELECTROLYTES ........................ 69
AMINOSYN II 10 % .......................... 69
AMINOSYN II 15 % .......................... 69
AMINOSYN II 7 % ............................. 69
AMINOSYN II 8.5 % ........................ 69
AMINOSYN II 8.5
%-ELECTROLYTES ........................ 70
AMINOSYN M 3.5 % ...................... 70
AMINOSYN-HBC 7% .................... 70
AMINOSYN-PF 10 % ..................... 70
AMINOSYN-PF 7 %
(SULFITE-FREE) ................................. 70
AMINOSYN-RF 5.2 % .................. 70
amiodarone .......................................................... 76
AMITIZA ........................................................ 110
amitriptyline ...................................................... 39
amlodipine ............................................................. 81
amlodipine-atorvastatin ..................... 83
amlodipine-benazepril ........................... 81
amlodipine-valsartan .............................. 81
amlodipine-valsartan-hcthiazid
............................................................................................... 81
ammonium chloride .............................. 132
ammonium lactate ..................................... 95
amoxapine ............................................................ 39
amoxicil-clarithromy-lansopraz
........................................................................................... 109
amoxicillin ............................................................ 19
amoxicillin-pot clavulanate ........... 19
amphotericin b ................................................ 47
ampicillin ................................................................ 19
ampicillin sodium ........................................ 19
ampicillin-sulbactam ................... 19, 20
AMPYRA ........................................................... 86
ANACAINE .................................................... 95
anagrelide .............................................................. 68
anastrozole ........................................................... 24
ANDRODERM ..................................... 114
Index
ala-scalp ................................................................... 98
ALBENZA ......................................................... 53
albuterol sulfate ......................................... 144
alcaine ..................................................................... 104
alclometasone ................................................... 98
ALCOHOL PADS ................................. 95
ALCOHOL PREP PADS ............ 95
ALDURAZYME ................................. 102
ALECENSA .................................................... 23
alendronate ...................................................... 130
alfuzosin ............................................................... 113
ALIMTA ............................................................... 23
ALINIA .................................................................. 53
allopurinol ......................................................... 132
allopurinol sodium .................................. 132
ALLZITAL ........................................................... 3
almotriptan malate ................................... 50
alogliptin ................................................................. 42
alogliptin-metformin ............................... 43
alogliptin-pioglitazone ......................... 43
alosetron .............................................................. 129
ALPHAGAN P ....................................... 137
alprazolam ............................................................ 12
ALREX ............................................................... 107
altacaine ............................................................... 104
altavera (28) .................................................... 88
ALTOPREV .................................................... 83
alyacen 1/35 (28) ....................................... 88
alyacen 7/7/7 (28) ..................................... 88
amantadine hcl ................................................ 54
AMBISOME ................................................... 47
amethia ..................................................................... 88
amethia lo .............................................................. 88
amifostine crystalline ......................... 132
amiloride ................................................................. 82
amiloride-hydrochlorothiazide
............................................................................................... 82
AMINO ACIDS 15 % ....................... 69
aminocaproic acid ...................................... 68
AMINOSYN 10 % ................................. 69
AMINOSYN 3.5 % ............................... 69
AMINOSYN 7 % ..................................... 69
Index
Index
8-MOP ...................................................................... 95
abacavir .................................................................... 59
abacavir-lamivudine-zidovudine
............................................................................................... 59
ABELCET .......................................................... 47
ABILIFY MAINTENA ..... 55, 56
ABRAXANE .................................................. 23
acamprosate ....................................................... 11
acarbose ................................................................... 42
acebutolol ............................................................... 77
acetaminophen-codeine ........................... 3
acetasol hc ......................................................... 105
acetazolamide ............................................... 137
acetazolamide sodium ....................... 137
acetic acid ........................................... 105, 129
acetylcysteine ................................................ 146
acitretin .................................................................... 95
ACTEMRA ................................................... 132
ACTHIB (PF) ............................................ 124
ACTIMMUNE ........................................ 132
ACTOPLUS MET XR ..................... 42
acyclovir ....................................................... 64, 95
acyclovir sodium ........................................... 64
ADACEL(TDAP
ADOLESN/ADULT)(PF) ...... 124
ADAGEN ........................................................ 102
adapalene ............................................................ 101
ADCETRIS ...................................................... 23
ADCIRCA ...................................................... 148
adefovir ..................................................................... 64
ADEMPAS .................................................... 148
adriamycin ............................................................ 23
adrucil ......................................................................... 23
ADVAIR DISKUS ............................ 143
ADVAIR HFA ........................................ 143
afeditab cr ............................................................. 81
AFINITOR ....................................................... 23
AFINITOR DISPERZ .................... 23
a-hydrocort ...................................................... 116
AKTEN (PF) .............................................. 104
AKYNZEO ....................................................... 52
ala-cort ...................................................................... 98
I-2
bicalutamide ....................................................... 24
BICILLIN C-R ............................................ 20
BICILLIN L-A ............................................ 20
BIDIL ........................................................................ 85
bimatoprost ..................................................... 137
bisoprolol fumarate .................................. 77
bisoprolol-hydrochlorothiazide
............................................................................................... 77
bleomycin ............................................................... 24
bleph-10 ................................................................ 105
BLEPHAMIDE ...................................... 105
BLEPHAMIDE S.O.P. ................ 105
BLINCYTO ...................................................... 24
blisovi 24 fe .......................................................... 88
blisovi fe 1.5/30 (28) .............................. 88
blisovi fe 1/20 (28) ................................... 89
BOOSTRIX TDAP ............. 124, 125
BOSULIF ............................................................ 24
BOTOX ............................................................... 132
BREO ELLIPTA .................................. 143
briellyn ....................................................................... 89
BRILINTA ........................................................ 68
brimonidine ...................................................... 137
BRINTELLIX .............................................. 39
BRIVIACT ........................................................ 34
bromfenac .......................................................... 108
bromocriptine ................................................... 54
budesonide ......................................................... 129
bumetanide ........................................................... 82
BUPHENYL ............................................... 110
buprenorphine hcl ................................ 3, 11
buprenorphine-naloxone .................... 11
buproban ................................................................. 39
bupropion hcl ......................................... 11, 39
buspirone ............................................................. 133
butalbital compound w/codeine .... 3
butalbital-acetaminop-caf-cod ...... 3
butalbital-acetaminophen .................... 3
butalbital-acetaminophen-caff ...... 3
butalbital-aspirin-caffeine ................... 3
butorphanol tartrate ................................... 3
BUTRANS ............................................................ 4
BYSTOLIC ........................................................ 77
cabergoline ........................................................... 54
CABOMETYX ............................................ 24
Index
azithromycin ........................................... 17, 18
AZOPT ................................................................. 137
AZOR ........................................................................ 81
aztreonam .............................................................. 18
azurette (28) .................................................... 88
baciim .......................................................................... 13
bacitracin ................................................ 14, 105
bacitracin-polymyxin b ................... 105
baclofen ................................................................. 147
balsalazide ........................................................ 129
balziva (28) ........................................................ 88
BANZEL .............................................................. 34
BARACLUDE ............................................. 64
BCG VACCINE, LIVE (PF)
........................................................................................... 124
BD INSULIN PEN NEEDLE
UF SHORT ................................................... 102
BD INSULIN SYRINGE
ULTRA-FINE .......................................... 102
bekyree (28) ..................................................... 88
BELBUCA ............................................................. 3
BELEODAQ ................................................... 24
BELSOMRA ............................................... 147
benazepril ............................................................... 75
benazepril-hydrochlorothiazide
............................................................................................... 75
BENDEKA ....................................................... 24
BENICAR .......................................................... 74
BENICAR HCT ........................................ 74
BENLYSTA ................................................. 132
benztropine .......................................................... 54
BEPREVE ....................................................... 104
betamethasone acet,sod phos
........................................................................................... 117
betamethasone dipropionate ........ 98
betamethasone valerate ...................... 98
betamethasone, augmented
.................................................................................... 98, 99
BETASERON ........................................... 132
betaxolol .................................................. 77, 137
bethanechol chloride ............................ 132
BETHKIS ............................................................ 13
BETOPTIC S .............................................. 137
bexarotene ............................................................ 24
BEXSERO (PF) ...................................... 124
Index
Index
ANDROGEL ............................................. 114
androxy ................................................................. 114
anticoag citrate phos dextrose
........................................................................................... 132
APOKYN ............................................................ 54
apraclonidine ................................................. 104
apri .................................................................................. 88
APRISO .............................................................. 129
APTIOM ............................................................... 34
APTIVUS ............................................................. 59
aranelle (28) ..................................................... 88
ARCALYST ................................................ 121
aripiprazole ......................................................... 56
ARISTADA ..................................................... 56
ASACOL HD ............................................. 129
ascomp with codeine ................................... 3
ashlyna ....................................................................... 88
aspirin-dipyridamole ............................... 68
ASSURE ID INSULIN
SAFETY ............................................................ 101
ASTAGRAF XL ................................... 121
atenolol ..................................................................... 77
atenolol-chlorthalidone ....................... 77
atorvastatin ......................................................... 83
atovaquone ........................................................... 53
atovaquone-proguanil ............................ 53
ATRIPLA ............................................................ 60
atropine ...................................................... 33, 104
atropine-care ................................................. 104
ATROVENT HFA ............................ 145
AUBAGIO ..................................................... 121
aubra ............................................................................ 88
AURYXIA ..................................................... 112
AVASTIN ........................................................... 24
AVC VAGINAL ....................................... 50
aviane .......................................................................... 88
AVONEX ......................................................... 132
AVONEX (WITH ALBUMIN)
........................................................................................... 132
AXIRON ........................................................... 115
azacitidine ............................................................. 24
azathioprine .................................................... 121
azathioprine sodium ............................. 121
azelastine ............................................................ 104
AZILECT ............................................................ 54
I-3
chlorzoxazone .............................................. 147
cholestyramine (with sugar) ....... 83
cholestyramine light ................................ 83
choline,magnesium salicylate ......... 8
CIALIS ................................................................. 148
ciclopirox ............................................................... 48
ciclopirox-ure-camph-menth-euc
............................................................................................... 48
cidofovir ................................................................... 64
cilostazol ................................................................. 68
CILOXAN ...................................................... 105
cimetidine ........................................................... 109
cimetidine hcl ................................................ 109
CIMZIA ............................................................. 121
CIMZIA POWDER FOR
RECONST ...................................................... 121
CINQAIR ........................................................ 146
CINRYZE .......................................................... 67
CIPRODEX .................................................. 105
ciprofloxacin ...................................................... 21
ciprofloxacin (mixture) .................... 21
ciprofloxacin hcl ............................ 21, 105
ciprofloxacin in 5 % dextrose ..... 21
ciprofloxacin lactate ............................... 21
citalopram ............................................................. 39
cladribine ................................................................ 24
clarithromycin ................................................. 18
clemastine .............................................................. 50
CLEVIPREX .................................................. 81
clindamycin hcl ............................................... 14
clindamycin in 5 % dextrose ........ 14
clindamycin palmitate hcl ................ 14
clindamycin pediatric ............................. 14
clindamycin phosphate
........................................................................ 14, 50, 97
clindamycin-benzoyl peroxide ... 97
CLINIMIX 5%/D15W
SULFITE FREE ....................................... 70
CLINIMIX 5%/D25W
SULFITE-FREE ...................................... 70
CLINIMIX 2.75%/D5W
SULFIT FREE ............................................ 70
CLINIMIX 4.25%/D10W SULF
FREE ......................................................................... 70
Index
cefdinir ....................................................................... 16
cefditoren pivoxil ......................................... 16
cefepime ................................................................... 16
CEFEPIME IN DEXTROSE 5
% ........................................................................................ 16
CEFEPIME IN
DEXTROSE,ISO-OSM .................. 16
cefixime .................................................................... 16
cefotaxime ............................................................ 16
cefoxitin ................................................................... 16
cefoxitin in dextrose, iso-osm ..... 16
cefpodoxime ....................................................... 16
cefprozil .................................................................... 16
ceftazidime ........................................................... 16
ceftibuten ................................................................ 16
ceftriaxone ................................................ 16, 17
ceftriaxone in dextrose,iso-os
.................................................................................... 16, 17
cefuroxime axetil ........................................ 17
cefuroxime sodium .................................... 17
celecoxib ..................................................................... 8
CELLCEPT INTRAVENOUS
........................................................................................... 121
CELONTIN ..................................................... 34
cephalexin ............................................................. 17
CEPROTIN (BLUE BAR) ........ 65
CERDELGA ............................................... 133
CEREZYME ............................................... 102
CERVARIX VACCINE (PF)
........................................................................................... 125
cevimeline .............................................................. 95
CHANTIX ......................................................... 11
CHANTIX CONTINUING
MONTH BOX .............................................. 11
CHANTIX STARTING
MONTH BOX .............................................. 11
chloramphenicol sod succinate
............................................................................................... 14
chlordiazepoxide hcl ............................... 12
chlorhexidine gluconate ...................... 95
chloroquine phosphate .......................... 53
chlorothiazide ................................................... 82
chlorothiazide sodium ........................... 82
chlorpromazine ............................................... 56
chlorthalidone .................................................. 82
Index
Index
caffeine citrated ............................................ 86
caffeine-sodium benzoate ................. 86
calcipotriene ............................................ 95, 96
calcitonin (salmon) .............................. 130
calcitrene ................................................................ 96
calcitriol .................................................... 96, 130
calcium acetate ........................................... 112
calcium chloride ........................................ 138
calcium gluconate ................................... 138
CALDOLOR ...................................................... 8
camila .......................................................................... 89
camrese ..................................................................... 89
camrese lo .............................................................. 89
CANCIDAS ..................................................... 48
candesartan ......................................................... 74
candesartan-hydrochlorothiazid
............................................................................................... 74
capacet .......................................................................... 4
CAPASTAT ..................................................... 51
CAPRELSA ..................................................... 24
captopril ................................................................... 75
captopril-hydrochlorothiazide ... 75
CARAFATE ............................................... 109
CARBAGLU .............................................. 110
carbamazepine ................................................ 34
carbidopa ................................................................ 54
carbidopa-levodopa ....................... 54, 55
carbidopa-levodopa-entacapone
............................................................................................... 55
carbinoxamine maleate ....................... 50
carboplatin ........................................................... 24
CARIMUNE NF
NANOFILTERED ........................... 121
carisoprodol .................................................... 147
carteolol ............................................................... 104
cartia xt .................................................................... 78
carvedilol ................................................................ 77
CAYSTON ........................................................ 18
caziant (28) ....................................................... 89
cefaclor ...................................................................... 15
cefadroxil ............................................................... 15
cefazolin ................................................................... 15
CEFAZOLIN IN DEXTROSE
(ISO-OS) ................................................................ 15
cefazolin in dextrose (iso-os) .... 15
I-4
Index
colocort ..................................................................... 99
COLY-MYCIN S ................................. 105
COMBIGAN .............................................. 137
COMBIPATCH ...................................... 115
COMBIVENT RESPIMAT
........................................................................................... 145
COMETRIQ .................................................... 24
COMPLERA .................................................. 60
compro ....................................................................... 52
COMVAX (PF) ....................................... 125
CONDYLOX ................................................. 96
constulose ........................................................... 110
COPAXONE ............................................... 133
CORLANOR ................................................. 79
cormax ....................................................................... 99
cortisone ............................................................... 117
CORTISPORIN-TC ........................ 106
COSENTYX .................................................... 96
COSENTYX (2 SYRINGES)
............................................................................................... 96
COSENTYX PEN .................................. 96
COSENTYX PEN (2 PENS)
............................................................................................... 96
COTELLIC ....................................................... 25
CREON ............................................................... 102
CRESTOR .......................................................... 83
CRIXIVAN ...................................................... 60
cromolyn ................................ 104, 110, 146
cryselle (28) ...................................................... 89
CUBICIN ............................................................. 14
cyclafem 1/35 (28) ................................... 89
cyclafem 7/7/7 (28) ................................. 89
cyclobenzaprine ......................................... 147
cyclopentolate .............................................. 104
cyclophosphamide ...................................... 25
CYCLOPHOSPHAMIDE ......... 25
CYCLOSET ..................................................... 43
cyclosporine .................................................... 121
cyclosporine modified ........................ 121
cyproheptadine ............................................... 50
CYRAMZA ...................................................... 25
cyred ............................................................................. 89
CYSTADANE .......................................... 133
CYSTARAN ............................................... 104
cysteine (l-cysteine) ............................... 71
Index
Index
CLINIMIX 4.25%/D5W
SULFIT FREE ............................................ 70
CLINIMIX 4.25%-D20W
SULF-FREE ................................................... 70
CLINIMIX 4.25%-D25W
SULF-FREE ................................................... 71
CLINIMIX
5%-D20W(SULFITE-FREE)
............................................................................................... 71
CLINIMIX E 2.75%/D10W
SUL FREE ......................................................... 71
SULF FREE .................................................... 71
SUL FREE ......................................................... 71
SUL FREE ......................................................... 71
SULF FREE .................................................... 71
CLINIMIX E 5%/D15W
SULFIT FREE ............................................ 71
CLINIMIX E 5%/D20W
SULFIT FREE ............................................ 71
CLINIMIX E 5%/D25W
SULFIT FREE ............................................ 71
CLINISOL SF 15 % ............................. 71
clobetasol ............................................................... 99
clobetasol-emollient ................................. 99
clocortolone pivalate ............................... 99
clomipramine .................................................... 39
clonazepam .......................................................... 12
clonidine ................................................................... 73
clonidine hcl ............................................. 73, 86
clopidogrel ............................................................ 68
clorazepate dipotassium ..................... 12
clorpres ...................................................................... 73
clotrimazole ........................................................ 48
clotrimazole-betamethasone ........ 48
clozapine ................................................................. 56
COARTEM ...................................................... 54
codeine sulfate ..................................................... 4
colchicine ............................................................ 133
colchicine-probenecid ......................... 133
colestipol ................................................................. 83
colistin (colistimethate na) ........... 14
138
d2.5 %-0.45 % sodium chloride
........................................................................................... 138
d5 % and 0.9 % sodium chloride
........................................................................................... 138
........................................................................................... 138
dactinomycin ..................................................... 25
DAKLINZA .................................................... 63
DALIRESP .................................................... 146
danazol ................................................................... 115
dantrolene .......................................................... 147
dapsone ..................................................................... 51
DAPTACEL (DTAP
PEDIATRIC) (PF) ............................. 125
DARAPRIM .................................................. 54
DARZALEX .................................................. 25
dasetta 1/35 (28) ........................................ 89
dasetta 7/7/7 (28) ...................................... 89
DAUNOXOME ......................................... 25
daysee .......................................................................... 89
deblitane .................................................................. 89
decitabine ............................................................... 25
deferoxamine ................................................. 114
delyla (28) ........................................................... 89
DELZICOL ................................................... 129
demeclocycline ................................................ 22
DEMSER ............................................................. 79
DENAVIR ......................................................... 96
DEPEN TITRATABS .................. 114
DEPO-PROVERA ............................. 120
DESCOVY ......................................................... 60
desipramine ......................................................... 39
desmopressin .................................................. 118
desog-e.estradiol/e.estradiol ......... 89
desogestrel-ethinyl estradiol ......... 89
desonide .................................................................... 99
desoximetasone .............................................. 99
DESVENLAFAXINE
FUMARATE ................................................. 40
dexamethasone ........................................... 117
............................................................................ 108, 117
DEXILANT ................................................. 109
...........................................................................................
I-5
ELAPRASE .................................................. 102
electrolyte-48 in d5w ........................... 139
ELIDEL ................................................................. 99
ELIGARD .......................................................... 25
elinest .......................................................................... 89
eliphos ..................................................................... 112
ELIQUIS ............................................................... 65
ELITEK .............................................................. 102
elixophyllin ...................................................... 145
ELLA ......................................................................... 89
ELMIRON ..................................................... 133
EMBEDA ................................................................ 4
EMCYT .................................................................. 25
EMEND ................................................................. 52
emoquette ............................................................... 89
EMPLICITI ...................................................... 26
EMSAM ................................................................. 40
EMTRIVA ......................................................... 60
EMVERM .......................................................... 54
enalapril maleate ......................................... 75
enalaprilat ............................................................. 75
enalapril-hydrochlorothiazide .... 75
ENBREL ........................................................... 122
ENBREL SURECLICK ............ 122
endocet .......................................................................... 4
endodan ........................................................................ 4
ENGERIX-B (PF) .............................. 125
........................................................................................... 125
enoxaparin ............................................................ 65
enpresse .................................................................... 90
enskyce ...................................................................... 90
entacapone ............................................................ 55
entecavir .................................................................. 64
ENTRESTO ..................................................... 74
enulose .................................................................... 110
ENVARSUS XR ................................... 122
ephedrine sulfate .......................................... 80
epinastine ............................................................ 104
epinephrine ........................................................... 80
epinephrine hcl (pf) ................................. 80
EPIPEN 2-PAK .......................................... 80
EPIPEN JR 2-PAK ............................... 80
epitol ............................................................................. 34
EPIVIR HBV .................................................. 60
Index
DILANTIN ...................................................... 34
diltiazem hcl ............................................ 78, 79
dilt-xr .......................................................................... 79
dimenhydrinate ............................................... 52
DIPENTUM ................................................ 129
diphenhydramine hcl ............................... 50
diphenoxylate-atropine .................... 110
dipyridamole ...................................................... 68
disopyramide phosphate ..................... 76
disulfiram ............................................................... 11
divalproex .............................................................. 34
dobutamine .......................................................... 80
dobutamine in d5w ..................................... 80
docetaxel ................................................................. 25
donepezil ................................................................. 38
dopamine ................................................................. 80
dopamine in 5 % dextrose ................ 80
dorzolamide ..................................................... 137
dorzolamide-timolol ............................. 137
doxazosin ............................................................... 73
doxepin ...................................................................... 40
doxercalciferol ............................................ 130
doxorubicin, peg-liposomal ........... 25
doxy-100 ................................................................. 22
doxycycline hyclate .................................. 22
doxycycline monohydrate ................ 22
dronabinol ............................................................. 52
droperidol ........................................................... 133
drospirenone-ethinyl estradiol ... 89
DROXIA .............................................................. 25
DUAVEE ......................................................... 115
DULERA ......................................................... 144
duloxetine .............................................................. 40
DUREZOL .................................................... 108
dutasteride ........................................................ 133
dutasteride-tamsulosin ..................... 133
DYRENIUM ................................................. 82
e.e.s. 400 .................................................................. 18
e.e.s. granules ................................................... 18
econazole ................................................................ 48
EDARBI ................................................................ 74
EDARBYCLOR ....................................... 74
EDURANT ...................................................... 60
effer-k ...................................................................... 139
EFFIENT ............................................................ 69
Index
Index
dexmethylphenidate ................................. 86
dexrazoxane hcl ........................................ 133
dextroamphetamine ................................. 86
dextroamphetamine-amphetamine
............................................................................................... 86
dextrose 10 % and 0.2 % nacl
........................................................................................... 138
............................................................................................... 71
............................................................................................... 72
............................................................................................... 72
............................................................................................... 72
dextrose 5 % in ringers ........................ 72
dextrose 5 % in water (d5w) ...... 72
dextrose 5 %-lactated ringers
........................................................................................... 139
dextrose 5%-0.2 % sod chloride
........................................................................................... 139
dextrose 5%-0.3 % sod.chloride
........................................................................................... 139
............................................................................................... 72
............................................................................................... 72
dextrose with sodium chloride
........................................................................................... 139
diazepam ................................................................. 12
diazepam intensol ........................................ 12
diclofenac potassium .................................. 8
diclofenac sodium ............................ 8, 108
diclofenac-misoprostol ............................. 8
dicloxacillin ......................................................... 20
dicyclomine ...................................................... 110
didanosine .............................................................. 60
DIFICID ............................................................... 18
diflorasone ............................................................ 99
diflunisal ...................................................................... 9
digitek ......................................................................... 79
digox ............................................................................. 79
digoxin ....................................................................... 79
DIGOXIN ........................................................... 79
dihydroergotamine .................................... 50
I-6
fluorometholone ........................................ 108
fluorouracil ............................................... 26, 96
fluoxetine ............................................................... 40
FLUOXETINE ........................................... 40
fluphenazine decanoate ....................... 57
fluphenazine hcl ............................................. 57
flurazepam ............................................................ 12
flurbiprofen ............................................................. 9
flurbiprofen sodium .............................. 108
flutamide ................................................................. 26
fluticasone .............................................. 99, 108
fluvastatin .............................................................. 83
fluvoxamine ............................................. 40, 41
fomepizole ......................................................... 133
fondaparinux .......................................... 65, 66
FORADIL AEROLIZER ....... 145
FORTEO .......................................................... 130
FORTICAL .................................................. 130
foscarnet .................................................................. 63
fosinopril ................................................................. 75
fosinopril-hydrochlorothiazide
............................................................................................... 75
fosphenytoin ....................................................... 35
FOSRENOL ................................................ 112
FREAMINE HBC 6.9 % .............. 72
FREAMINE III 10 % ........................ 72
furosemide ............................................................. 82
FUSILEV ......................................................... 133
FUZEON ............................................................. 60
fyavolv .................................................................... 116
FYCOMPA ....................................................... 35
gabapentin ............................................................ 35
GABITRIL ........................................................ 35
galantamine ........................................................ 38
GAMASTAN S/D ............................... 122
GAMMAGARD LIQUID .... 122
GAMMAPLEX ...................................... 122
GAMUNEX-C ......................................... 122
ganciclovir sodium ..................................... 65
GARDASIL (PF) ................................. 125
GARDASIL 9 (PF) ........................... 125
gatifloxacin ...................................................... 106
GATTEX 30-VIAL ............................ 110
GATTEX ONE-VIAL .................. 110
GAUZE PAD ............................................ 133
Index
FABRAZYME ........................................ 102
falmina (28) ...................................................... 90
famciclovir ............................................................ 64
famotidine .......................................................... 109
famotidine (pf) .......................................... 109
famotidine (pf)-nacl (iso-os)
........................................................................................... 109
FANAPT .............................................................. 56
FARESTON .................................................... 26
FARYDAK ...................................................... 26
FASLODEX .................................................... 26
felbamate ................................................................ 34
felodipine ................................................................ 81
FEMRING .................................................... 116
fenofibrate ............................................................ 83
fenofibrate micronized ......................... 83
fenofibrate nanocrystallized ......... 83
fenofibric acid .................................................. 83
fenofibric acid (choline) ................... 83
fenoprofen ................................................................. 9
fentanyl ......................................................................... 4
fentanyl citrate ................................................... 4
FERRIPROX ............................................. 114
FETZIMA .......................................................... 40
finasteride .......................................................... 133
FIRAZYR .......................................................... 80
flavoxate .............................................................. 113
FLEBOGAMMA DIF ................. 122
flecainide ................................................................. 76
FLECTOR ............................................................. 9
FLOVENT DISKUS ...................... 144
FLOVENT HFA ................................... 144
floxuridine ............................................................. 26
flucaine .................................................................. 104
fluconazole ........................................................... 48
fluconazole in dextrose(iso-o)
............................................................................................... 48
fluconazole in nacl (iso-osm) ..... 48
flucytosine ............................................................. 48
fludrocortisone ............................................ 117
flumazenil .............................................................. 86
flunisolide ........................................................... 108
fluocinolone acetonide oil ............. 108
fluocinonide ......................................................... 99
fluocinonide-e ................................................... 99
Index
Index
eplerenone ............................................................. 85
EPOGEN .............................................................. 67
epoprostenol (glycine) ..................... 148
eprosartan ............................................................. 74
EPZICOM .......................................................... 60
ergoloid ................................................................. 133
ERGOMAR ..................................................... 51
ERIVEDGE ..................................................... 26
errin ............................................................................... 90
ery pads .................................................................... 97
ery-tab ........................................................................ 18
ERY-TAB ............................................................ 18
ERYTHROCIN ......................................... 18
erythrocin (as stearate) .................... 18
erythromycin ...................................... 18, 106
erythromycin ethylsuccinate ........ 18
erythromycin with ethanol .............. 97
erythromycin-benzoyl peroxide
............................................................................................... 97
ESBRIET .......................................................... 147
escitalopram oxalate .............................. 40
esmolol ....................................................................... 77
esomeprazole sodium .......................... 109
estarylla ................................................................... 90
estazolam ............................................................... 12
ESTRACE ....................................................... 115
estradiol ................................................................ 115
estradiol valerate ...................................... 116
estradiol-norethindrone acet .... 116
ESTRING ........................................................ 116
estropipate ........................................................ 116
eszopiclone ........................................................ 148
ethambutol ............................................................ 51
ethamolin ................................................................ 80
ethosuximide ...................................................... 34
etidronate disodium .............................. 130
etodolac ........................................................................ 9
ETOPOPHOS ................................................ 26
etoposide ................................................................. 26
EURAX .............................................................. 101
EVOTAZ .............................................................. 60
EXELDERM ................................................. 48
exemestane ........................................................... 26
EXJADE ............................................................ 114
EXTAVIA ....................................................... 133
I-7
HUMULIN N ............................................... 45
HUMULIN N KWIKPEN ....... 45
HUMULIN R ............................................... 46
HUMULIN R U-500 (CONC)
KWIKPEN ........................................................ 46
HUMULIN R U-500
(CONCENTRATED) ....................... 46
hydralazine .......................................................... 80
hydrochlorothiazide ................................. 82
hydrocodone-acetaminophen ........... 4
hydrocodone-ibuprofen ........................... 4
hydrocortisone .............................. 100, 117
hydrocortisone acet-aloe vera
........................................................................................... 100
hydrocortisone butyrate ................. 100
hydrocortisone butyr-emollient
........................................................................................... 100
hydrocortisone valerate ................... 100
hydrocortisone-acetic acid .......... 106
hydromorphone .................................................. 5
hydromorphone (pf) .................................. 4
hydroxychloroquine ................................. 54
hydroxyurea ....................................................... 26
hydroxyzine hcl ........................... 133, 134
hydroxyzine pamoate ......................... 134
HYPERLYTE CR .............................. 139
HYPERRAB S/D (PF) ................. 123
HYQVIA ........................................................... 123
HYSINGLA ER ............................................ 5
ibandronate ...................................................... 130
IBRANCE .......................................................... 27
ibuprofen ..................................................................... 9
ICLUSIG .............................................................. 27
ifosfamide .............................................................. 27
ifosfamide-mesna ......................................... 27
ILARIS (PF) ................................................ 123
ILEVRO ............................................................. 108
IMBRUVICA ................................................ 27
imipenem-cilastatin .................................. 18
imipramine hcl ................................................. 41
imipramine pamoate ............................... 41
imiquimod .............................................................. 96
IMLYGIC ........................................................... 27
IMOGAM RABIES-HT (PF)
........................................................................................... 123
Index
granisetron (pf) ............................................ 52
granisetron hcl ................................................ 52
granisol ..................................................................... 52
GRANIX .............................................................. 67
griseofulvin microsize ............................ 48
griseofulvin ultramicrosize ............. 49
guanfacine .................................................. 73, 87
guanidine ............................................................. 133
halobetasol propionate ..................... 100
haloperidol ............................................................ 57
haloperidol decanoate ........................... 57
haloperidol lactate ..................................... 57
HARVONI ......................................................... 63
HAVRIX (PF) ........................................... 126
heather ....................................................................... 90
heparin (porcine) ....................................... 66
heparin (porcine) in 5 % dex ...... 66
heparin (porcine) in nacl (pf)
............................................................................................... 66
heparin(porcine) in 0.45% nacl
............................................................................................... 66
heparin, porcine (pf) ............................. 66
HEPATAMINE 8% ............................. 72
HEPATASOL 8 % .................................. 72
HERCEPTIN ................................................. 26
HETLIOZ ........................................................ 148
HEXALEN ........................................................ 26
homatropaire ................................................. 104
homatropine hbr ........................................ 104
HUMALOG .................................................... 45
HUMALOG KWIKPEN ............ 45
HUMALOG MIX 50-50 ............... 45
HUMALOG MIX 50-50
KWIKPEN ........................................................ 45
HUMALOG MIX 75-25 ............... 45
HUMALOG MIX 75-25
KWIKPEN ........................................................ 45
HUMIRA ......................................................... 122
HUMIRA PEN ....................................... 122
HUMIRA PEN
CROHN'S-UC-HS START
........................................................................................... 122
HUMULIN 70/30 .................................... 45
HUMULIN 70/30 KWIKPEN
............................................................................................... 45
Index
Index
gavilyte-c ............................................................. 112
gavilyte-g ............................................................ 112
gavilyte-n ............................................................ 112
GAZYVA ............................................................. 26
gemcitabine ......................................................... 26
gemfibrozil ........................................................... 83
generlac ................................................................. 110
gengraf ................................................................... 122
GENOTROPIN ...................................... 118
........................................................................................... 118
gentak ...................................................................... 106
gentamicin .................................. 13, 97, 106
gentamicin in nacl (iso-osm) ...... 13
gentamicin sulfate (ped) (pf) ... 13
gentamicin sulfate (pf) ....................... 13
GENVOYA ...................................................... 60
GEODON ........................................................... 57
gianvi (28) ........................................................... 90
gildagia ..................................................................... 90
gildess 1.5/30 (21) .................................... 90
gildess 1/20 (21) .......................................... 90
gildess 24 fe ......................................................... 90
gildess fe 1.5/30 (28) ............................. 90
gildess fe 1/20 (28) .................................. 90
GILENYA ...................................................... 133
GILOTRIF ........................................................ 26
GLEEVEC .......................................................... 26
GLEOSTINE ................................................. 26
glimepiride ............................................................ 47
glipizide .................................................................... 47
glipizide-metformin .................................. 47
GLUCAGEN HYPOKIT ....... 133
GLUCAGON EMERGENCY
KIT (HUMAN) ...................................... 133
glyburide ................................................................. 47
glyburide micronized .............................. 47
glyburide-metformin ............................... 47
glycopyrrolate .............................................. 110
glydo ............................................................................. 10
GLYSET ............................................................... 43
GLYXAMBI ................................................... 43
GRALISE ............................................................ 35
GRALISE 30-DAY STARTER
PACK ........................................................................ 35
I-8
KUVAN ............................................................. 103
KYNAMRO .................................................... 83
KYPROLIS ...................................................... 28
l norgest/e.estradiol-e.estrad ....... 91
labetalol ................................................................... 77
LACRISERT .............................................. 104
LACTATED RINGERS ........... 129
lactulose ............................................................... 111
LAMICTAL .................................................... 35
(BLUE) .................................................................... 35
(GREEN) ............................................................. 35
(ORANGE) ....................................................... 35
lamivudine ............................................................. 61
lamivudine-zidovudine .......................... 61
lamotrigine ................................................ 35, 36
LANOXIN ......................................................... 80
lansoprazole .................................................... 109
LANTUS .............................................................. 46
LANTUS SOLOSTAR .................... 46
larin 1.5/30 (21) .......................................... 91
larin 1/20 (21) ................................................ 91
larin 24 fe ............................................................... 91
larin fe 1.5/30 (28) ................................... 91
larin fe 1/20 (28) ......................................... 91
latanoprost ....................................................... 137
LATUDA ............................................................. 57
LAZANDA ........................................................... 5
leena 28 ..................................................................... 91
leflunomide ....................................................... 123
LEMTRADA ............................................. 134
LENVIMA ......................................................... 28
lessina .......................................................................... 91
LETAIRIS ...................................................... 148
letrozole .................................................................... 28
leucovorin calcium .................................. 134
LEUKERAN .................................................. 28
LEUKINE .......................................................... 67
leuprolide ................................................................ 28
levetiracetam ..................................................... 36
levetiracetam in nacl (iso-os) .... 36
levobunolol ........................................................ 137
levocarnitine ................................................... 134
Index
IXEMPRA ......................................................... 27
IXIARO (PF) .............................................. 126
JAKAFI ................................................................. 27
jantoven .................................................................... 66
JANUMET ........................................................ 43
JANUMET XR .......................................... 43
JANUVIA ........................................................... 43
JARDIANCE ................................................ 43
jencycla ..................................................................... 90
JENTADUETO ......................................... 43
jinteli ......................................................................... 116
jolessa .......................................................................... 90
jolivette ...................................................................... 90
juleber ......................................................................... 90
junel 1.5/30 (21) .......................................... 90
junel 1/20 (21) ................................................ 90
junel fe 1.5/30 (28) .................................. 90
junel fe 1/20 (28) ........................................ 90
junel fe 24 ............................................................... 90
JUXTAPID ....................................................... 83
KABIVEN .......................................................... 72
KALETRA ........................................................ 61
KALYDECO .............................................. 147
KANUMA ..................................................... 103
kariva (28) .......................................................... 90
KAZANO ............................................................ 43
k-effervescent ................................................ 139
kelnor 1/35 (28) ........................................... 91
ketoconazole ...................................................... 49
ketoprofen ................................................................. 9
ketorolac ...................................................... 9, 108
KEVEYIS ........................................................ 134
KEYTRUDA ...................................... 27, 28
kimidess (28) ................................................... 91
KINERET ....................................................... 123
KINRIX (PF) ............................................. 126
kionex ...................................................................... 110
klor-con 10 ....................................................... 139
klor-con m10 .................................................. 139
klor-con m15 .................................................. 140
klor-con m20 .................................................. 140
klor-con sprinkle ....................................... 140
KORLYM ........................................................... 43
KRYSTEXXA .......................................... 103
kurvelo ....................................................................... 91
Index
Index
IMOVAX RABIES VACCINE
(PF) ............................................................................ 126
INCRELEX .................................................. 118
indapamide ........................................................... 82
indomethacin ......................................................... 9
indomethacin sodium ................................. 9
INFANRIX (DTAP) (PF) ...... 126
INLYTA ................................................................ 27
INSULIN SYRINGE-NEEDLE
U-100 ....................................................................... 102
INTELENCE ................................................. 60
INTRALIPID ................................................ 72
INTRON A ....................................................... 64
introvale ................................................................... 90
INVANZ ............................................................... 19
INVEGA SUSTENNA ................... 57
INVEGA TRINZA ............................... 57
INVIRASE ........................................................ 60
INVOKAMET ............................................. 43
INVOKANA .................................................. 43
IONOSOL-B IN D5W .................. 139
IONOSOL-MB IN D5W ........... 139
IPOL ........................................................................ 126
ipratropium bromide ............ 104, 145
ipratropium-albuterol ........................ 145
IPRIVASK ......................................................... 66
irbesartan ............................................................... 74
irbesartan-hydrochlorothiazide
............................................................................................... 74
IRESSA ................................................................... 27
irinotecan ............................................................... 27
ISENTRESS .................................................... 60
ISOLYTE M IN 5 %
DEXTROSE ................................................ 139
ISOLYTE-H IN 5 %
DEXTROSE ................................................ 139
ISOLYTE-P IN 5 %
DEXTROSE ................................................ 139
ISOLYTE-S ................................................... 139
isoniazid ................................................................... 51
isosorbide dinitrate ................................... 85
isosorbide mononitrate ........................ 85
isradipine ................................................................ 81
itraconazole ........................................................ 49
ivermectin .............................................................. 54
I-9
MENHIBRIX (PF) ............................ 126
MENOMUNE - A/C/Y/W-135
(PF) ............................................................................ 126
MENVEO A-C-Y-W-135-DIP
(PF) ............................................................................ 126
MENVEO MENA
COMPONENT (PF) ........................ 127
MENVEO MENCYW-135
COMPNT (PF) ........................................ 127
mercaptopurine .............................................. 29
meropenem ........................................................... 19
mesna ....................................................................... 134
MESNEX ......................................................... 134
MESTINON ................................................ 134
MESTINON TIMESPAN ...... 134
metaproterenol ............................................ 145
metaxall ............................................................... 147
metaxalone ....................................................... 147
metformin ................................................... 43, 44
methadone ................................................................. 5
methadose ................................................................. 5
methazolamide ............................................ 137
methenamine hippurate ....................... 14
methimazole .................................................... 121
methocarbamol ........................................... 147
methotrexate sodium .............................. 29
methotrexate sodium (pf) .............. 29
methoxsalen rapid ...................................... 96
methscopolamine ...................................... 111
methyclothiazide .......................................... 82
methylergonovine .................................... 134
methylphenidate ............................................ 87
methylprednisolone ............................... 117
methylprednisolone acetate ....... 117
methylprednisolone sodium succ
........................................................................................... 117
metipranolol .................................................... 138
metoclopramide hcl ............................... 111
metolazone ........................................................... 82
metoprolol succinate ............................... 77
metoprolol ta-hydrochlorothiaz
............................................................................................... 77
metoprolol tartrate ........................ 77, 78
metronidazole ............................ 14, 50, 97
Index
LUMIGAN ................................................... 137
LUPRON DEPOT ................................. 28
............................................................................................... 28
............................................................................................... 28
............................................................................................... 28
LUPRON DEPOT-PED ........... 118
LUPRON DEPOT-PED (3
MONTH) .......................................................... 118
lutera (28) ........................................................... 92
LYNPARZA ................................................... 28
LYRICA ................................................................ 36
LYSODREN ................................................... 28
lyza ................................................................................. 92
magnebind 400 ............................................ 113
magnesium chloride .............................. 140
magnesium sulf in 0.45% nacl
........................................................................................... 140
magnesium sulfate .................................. 140
magnesium sulfate in d5w ............ 140
magnesium sulfate in water ....... 140
malathion ............................................................ 101
maprotiline ........................................................... 41
margesic ...................................................................... 5
marlissa .................................................................... 92
MARPLAN ...................................................... 41
MARQIBO ........................................................ 28
MATULANE ................................................ 29
matzim la ................................................................ 79
meclizine .................................................................. 52
medroxyprogesterone ........................ 120
mefenamic acid .................................................. 9
mefloquine ............................................................. 54
MEFOXIN IN DEXTROSE
(ISO-OSM) ......................................................... 17
MEGACE ES ............................................. 120
megestrol ................................................. 29, 120
MEKINIST ....................................................... 29
meloxicam ............................................................. 10
melphalan hcl .................................................... 29
memantine ............................................................. 38
MENACTRA (PF) ............................ 126
MENEST .......................................................... 116
Index
Index
levocarnitine (with sugar) .......... 134
levocetirizine ...................................................... 50
levofloxacin .......................................... 21, 106
levofloxacin in d5w ................................... 21
levonest (28) ..................................................... 91
levonorgestrel ................................................... 91
levonorgestrel-ethinyl estrad ....... 91
levonorg-eth estrad triphasic ....... 91
levora-28 ................................................................. 91
levothyroxine ................................................. 120
LEXIVA ................................................................. 61
lidocaine ................................................................... 11
lidocaine (pf) ........................................ 10, 76
lidocaine hcl ........................................................ 10
lidocaine in 5 % dextrose (pf)
............................................................................................... 76
lidocaine viscous ........................................... 10
lidocaine-prilocaine .................................. 11
linezolid .................................................................... 14
LINZESS .......................................................... 111
liothyronine ....................................... 120, 121
lipodox ....................................................................... 28
LIPOSYN II ..................................................... 72
LIPOSYN III .................................................. 72
lisinopril ................................................................... 75
lisinopril-hydrochlorothiazide .... 75
lithium carbonate ........................................ 87
lithium citrate ................................................... 87
lomedia 24 fe ..................................................... 91
lomustine ................................................................. 28
LONSURF ........................................................ 28
loperamide ........................................................ 111
lorazepam .............................................................. 12
lorazepam intensol ..................................... 12
lorcet (hydrocodone) ................................ 5
lorcet hd ....................................................................... 5
lorcet plus .................................................................. 5
loryna (28) .......................................................... 91
losartan ..................................................................... 74
losartan-hydrochlorothiazide ...... 74
LOTEMAX ................................................... 108
LOTRONEX ............................................... 111
lovastatin ................................................................ 83
low-ogestrel (28) ........................................ 92
loxapine succinate ...................................... 57
14
mexiletine .............................................................. 76
MIACALCIN ............................................ 131
miconazole-3 ...................................................... 49
microgestin 1.5/30 (21) ..................... 92
microgestin 1/20 (21) ........................... 92
microgestin fe 1.5/30 (28) .............. 92
microgestin fe 1/20 (28) ................... 92
midazolam ............................................................. 12
midodrine ............................................................... 73
miglitol ...................................................................... 44
milrinone ................................................................. 81
milrinone in 5 % dextrose ................ 80
mimvey ................................................................... 116
mimvey lo ........................................................... 116
minitran .................................................................... 85
MINOCIN .......................................................... 23
minocycline .......................................................... 23
minoxidil ................................................................. 85
MIRCERA ........................................................ 67
mirtazapine .......................................................... 41
misoprostol ....................................................... 109
mitoxantrone ..................................................... 29
M-M-R II (PF) ......................................... 127
moexipril ................................................................. 75
moexipril-hydrochlorothiazide
............................................................................................... 75
molindone ................................................... 57, 58
mometasone .................................................... 100
mono-linyah ........................................................ 92
mononessa (28) ............................................ 92
montelukast ..................................................... 144
morphine .............................................................. 5, 6
MORPHINE ....................................................... 6
morphine (pf) in 0.9 % nacl ............. 5
morphine concentrate ................................ 5
morphine in dextrose 5 % .................... 6
morrhuate sodium ................................... 134
MOVANTIK .............................................. 111
MOVIPREP .................................................. 112
MOXEZA ........................................................ 106
moxifloxacin ...................................................... 21
MOZOBIL .......................................................... 67
MULTAQ ........................................................... 76
...............................................................................................
I-10
NEPHRAMINE 5.4 % ..................... 72
NESINA ................................................................ 44
neuac ............................................................................ 97
NEULASTA .................................................... 67
NEUMEGA ..................................................... 67
NEUPOGEN ...................................... 67, 68
NEUPRO ............................................................. 55
NEVANAC ................................................... 108
nevirapine ............................................................... 61
NEXAVAR ....................................................... 29
next choice one dose ................................ 92
niacin ............................................................................ 84
niacor ........................................................................... 84
nicardipine ............................................................ 81
NICOTROL ..................................................... 11
nifedical xl ............................................................ 81
nifedipine ..................................................... 81, 82
nikki (28) .............................................................. 92
NILANDRON ............................................. 29
NINLARO ......................................................... 29
NITRO-BID .................................................... 85
nitrofurantoin ................................................... 15
nitrofurantoin macrocrystal ......... 14
nitrofurantoin monohyd/m-cryst
.................................................................................... 14, 15
nitroglycerin ............................................ 85, 86
nitroglycerin in 5 % dextrose ...... 85
NITROSTAT ................................................. 86
nizatidine ............................................................. 109
nora-be ....................................................................... 92
NORDITROPIN FLEXPRO
........................................................................................... 119
norepinephrine bitartrate ................. 81
norethindrone (contraceptive)
............................................................................................... 92
norethindrone acetate ........................ 120
norethindrone ac-eth estradiol
................................................................................ 92, 116
norethindrone-e.estradiol-iron ... 92
norgestimate-ethinyl estradiol ... 93
norlyroc .................................................................... 93
NORMOSOL-M IN 5 %
DEXTROSE ................................................ 140
NORMOSOL-R PH 7.4 ............. 140
NORTHERA ................................................. 74
Index
multivitamin with fluoride ........... 149
mupirocin ............................................................... 97
mupirocin calcium ...................................... 97
mycophenolate mofetil ..................... 123
mycophenolate sodium ..................... 123
MYOBLOC ................................................... 134
MYOZYME ................................................. 103
MYRBETRIQ ........................................... 113
myzilra ....................................................................... 92
nabumetone ......................................................... 10
nadolol ....................................................................... 78
nafcillin ..................................................................... 20
NAGLAZYME ....................................... 103
naloxone .................................................................. 11
naltrexone ............................................................. 11
NAMENDA XR ....................................... 39
NAMZARIC .................................................. 39
naphazoline ...................................................... 104
naproxen ................................................................. 10
naproxen sodium .......................................... 10
naratriptan ........................................................... 51
NARCAN ........................................................... 11
NATACYN ................................................... 106
nateglinide ............................................................. 44
NATPARA .................................................... 131
NEBUPENT .................................................... 54
necon 0.5/35 (28) ....................................... 92
necon 1/35 (28) ............................................. 92
necon 1/50 (28) ............................................. 92
necon 10/11 (28) ......................................... 92
necon 7/7/7 (28) ........................................... 92
nefazodone ............................................................ 41
neomycin ................................................................. 13
neomycin-bacitracin-poly-hc ... 106
neomycin-bacitracin-polymyxin
........................................................................................... 106
neomycin-polymyxin b gu ................ 97
........................................................................................... 106
neomycin-polymyxin-gramicidin
........................................................................................... 106
neomycin-polymyxin-hc
............................................................................ 106, 107
neo-polycin ....................................................... 107
neo-polycin hc .............................................. 107
Index
Index
metronidazole in nacl (iso-os)
I-11
paroxetine hcl ................................................... 41
PASER ..................................................................... 51
PATADAY .................................................... 105
PAXIL ...................................................................... 41
PEDIARIX (PF) .................................... 127
PEDVAX HIB (PF) .......................... 127
peg 3350-electrolytes .......................... 112
PEGANONE .................................................. 36
PEGASYS ........................................................... 64
PEGASYS PROCLICK ................. 64
peg-electrolyte soln ............................... 112
PEGINTRON ............................................... 64
PEN NEEDLE, DIABETIC
........................................................................................... 102
penicillin g pot in dextrose .............. 20
penicillin g potassium ............................ 20
penicillin g procaine ................................. 20
penicillin v potassium ............................. 20
PENTACEL (PF) ................................. 127
PENTACEL ACTHIB
COMPONENT (PF) ........................ 127
PENTAM ............................................................. 54
pentoxifylline .................................................... 69
PERIKABIVEN ........................................ 73
perindopril erbumine ............................... 76
periogard ................................................................. 95
PERJETA ............................................................ 30
permethrin ......................................................... 101
perphenazine ...................................................... 58
perphenazine-amitriptyline ............ 41
PERTZYE ....................................................... 103
pfizerpen-g ............................................................ 21
phenadoz ................................................................. 53
phenelzine .............................................................. 41
phenobarbital .................................................... 37
phenobarbital sodium ............................ 37
phenylephrine hcl .......................... 74, 105
phenytoin ................................................................ 37
phenytoin sodium ......................................... 37
phenytoin sodium extended ........... 37
philith .......................................................................... 93
PHOSLYRA ................................................ 113
phospha 250 neutral ............................. 140
PHOSPHOLINE IODIDE ..... 138
PICATO ................................................................. 96
Index
omega-3 acid ethyl esters ................. 84
omeprazole ....................................................... 109
ONCASPAR ................................................... 29
ondansetron ......................................................... 53
ondansetron hcl .............................................. 53
ondansetron hcl (pf) ................... 52, 53
ONFI ........................................................... 13, 100
onxol ............................................................................. 29
OPDIVO ................................................................ 29
OPSUMIT ....................................................... 148
oralone ....................................................................... 95
ORENCIA ...................................................... 123
ORENCIA (WITH MALTOSE)
........................................................................................... 123
ORENITRAM ......................................... 148
ORFADIN ..................................................... 103
ORKAMBI .................................................... 147
orsythia ..................................................................... 93
OSENI ...................................................................... 44
OTEZLA ........................................................... 135
OTEZLA STARTER ..................... 135
OTREXUP (PF) ..................................... 135
oxacillin .................................................................... 20
oxacillin in dextrose(iso-osm)
............................................................................................... 20
oxaliplatin ............................................................. 29
oxandrolone .................................................... 115
oxcarbazepine .................................................. 36
OXTELLAR XR ...................................... 36
oxybutynin chloride .............................. 113
oxycodone ......................................................... 6, 7
oxycodone-acetaminophen ................. 7
oxycodone-aspirin .......................................... 7
OXYCONTIN .................................................. 7
oxymorphone ........................................................ 7
pacerone ................................................................... 76
paclitaxel ................................................................ 29
paliperidone ........................................................ 58
pamidronate .................................................... 131
pancrelipase 5000 .................................... 103
PANRETIN ..................................................... 96
pantoprazole ................................................... 109
papaverine ............................................................. 81
paricalcitol ........................................................ 131
paromomycin .................................................... 54
Index
Index
nortrel 0.5/35 (28) .................................... 93
nortrel 1/35 (21) .......................................... 93
nortrel 1/35 (28) .......................................... 93
nortrel 7/7/7 (28) ....................................... 93
nortriptyline ........................................................ 41
NORVIR ............................................................... 61
NOVOLIN 70/30 ....................................... 46
NOVOLIN N ................................................. 46
NOVOLIN R .................................................. 46
NOVOLOG ...................................................... 46
NOVOLOG FLEXPEN ................. 46
NOVOLOG MIX 70-30 .................. 46
NOVOLOG MIX 70-30
FLEXPEN .......................................................... 46
NOVOLOG PENFILL .................... 46
NOXAFIL .......................................................... 49
NPLATE ........................................................... 135
NUCALA ........................................................ 147
NUCYNTA .......................................................... 6
NUCYNTA ER ............................................. 6
NUEDEXTA .................................................. 87
NULOJIX ........................................................ 123
NUPLAZID ..................................................... 58
NUTRESTORE ..................................... 111
NUTRILIPID ............................................... 73
NUTRILYTE ............................................ 140
NUTRILYTE II ..................................... 140
NUVARING .................................................. 93
NUVIGIL ........................................................ 148
nyamyc ...................................................................... 49
nystatin ..................................................................... 49
nystatin-triamcinolone ......................... 49
nystop .......................................................................... 49
ocella ............................................................................ 93
OCTAGAM .................................................. 123
octreotide acetate .................................... 119
ODEFSEY .......................................................... 61
ODOMZO ........................................................... 29
OFEV ..................................................................... 147
ofloxacin .................................................. 21, 107
ogestrel (28) ..................................................... 93
olanzapine ............................................................. 58
olanzapine-fluoxetine ............................ 41
olopatadine ....................................................... 105
OLYSIO ................................................................. 63
I-12
procto-med hc ............................................... 100
procto-pak ......................................................... 100
proctosol hc ..................................................... 100
proctozone-hc ............................................... 101
PROCYSBI .................................................... 135
progesterone in oil .................................. 120
progesterone micronized ................ 120
PROGLYCEM ............................................ 86
PROGRAF .................................................... 124
PROLASTIN-C ...................................... 147
PROLENSA ................................................. 108
PROLEUKIN ............................................... 30
PROLIA ............................................................. 131
PROMACTA ................................................. 68
promethazine .......................................... 50, 53
promethegan ...................................................... 53
propafenone ........................................................ 76
propantheline .................................................... 33
proparacaine .................................................. 105
propranolol .......................................................... 78
propranolol-hydrochlorothiazid
............................................................................................... 78
propylthiouracil ......................................... 121
PROQUAD (PF) ................................... 127
PROSOL 20 % .............................................. 73
protamine ............................................................... 68
protriptyline ........................................................ 41
PULMOZYME ....................................... 103
PURIXAN ......................................................... 30
pyrazinamide ..................................................... 52
pyridostigmine bromide .................. 135
QUADRACEL (PF) ........................ 127
quasense ................................................................... 93
quetiapine ............................................................... 58
QUILLIVANT XR ............................... 87
quinapril ................................................................... 76
quinapril-hydrochlorothiazide ... 76
quinidine gluconate ................................... 77
quinidine sulfate ............................................ 77
quinine sulfate .................................................. 54
QVAR .................................................................... 144
RABAVERT (PF) ............................... 127
raloxifene ........................................................... 116
ramipril ..................................................................... 76
RANEXA ............................................................ 81
Index
potassium citrate-citric acid ..... 142
potassium hydroxide ............................... 96
potassium phosphate m-/d-basic
........................................................................................... 142
POTIGA ................................................................ 37
PRADAXA ....................................................... 66
PRALUENT PEN .................................. 84
PRALUENT SYRINGE .............. 84
pramipexole ........................................................ 55
pravastatin ............................................................ 84
prazosin .................................................................... 74
prednicarbate ................................................ 100
prednisolone acetate ............................ 108
prednisolone sodium phosphate
............................................................................ 108, 117
prednisone .......................................................... 117
PREDNISONE INTENSOL
........................................................................................... 117
PREMARIN ................................................ 116
PREMASOL 10 % .................................. 73
PREMASOL 6 % ...................................... 73
PREMPHASE ........................................... 116
PREMPRO .................................................... 116
prenatal plus (calcium carb) ... 149
prenatal vitamin plus low iron
........................................................................................... 149
PREPOPIK .................................................... 112
prevalite .................................................................... 84
previfem .................................................................... 93
PREZCOBIX ................................................. 61
PREZISTA ........................................................ 61
PRIFTIN .............................................................. 52
PRIMAQUINE .......................................... 54
primidone ............................................................... 37
PRISTIQ ............................................................... 41
PRIVIGEN .................................................... 123
PROAIR HFA .......................................... 145
PROAIR RESPICLICK ............ 145
probenecid ......................................................... 135
procainamide ..................................................... 76
PROCALAMINE 3% ........................ 73
prochlorperazine ........................................... 53
prochlorperazine edisylate .............. 53
prochlorperazine maleate ................. 53
PROCRIT ........................................................... 68
Index
Index
pilocarpine hcl .................................. 95, 138
pimozide ................................................................... 58
pimtrea (28) ...................................................... 93
pindolol ..................................................................... 78
pioglitazone ......................................................... 44
pioglitazone-glimepiride .................... 44
pioglitazone-metformin ....................... 44
piperacillin-tazobactam ...................... 21
pirmella ..................................................................... 93
piroxicam ............................................................... 10
PLASMA-LYTE 148 ...................... 140
PLASMA-LYTE A ............................ 140
PLASMA-LYTE-56 IN 5 %
DEXTROSE ................................................ 141
PLEGRIDY .................................................. 135
podocon ..................................................................... 96
podofilox ................................................................. 96
polyethylene glycol 3350 ............... 112
polymyxin b sulfate .................................. 15
polymyxin b sulf-trimethoprim
........................................................................................... 107
POMALYST ................................................... 30
portia ............................................................................ 93
PORTRAZZA .............................................. 30
potassium acetate .................................... 141
potassium bicarb and chloride
........................................................................................... 141
potassium bicarb-citric acid ...... 141
potassium chlorid-d5-0.45%nacl
........................................................................................... 141
potassium chloride .................. 141, 142
potassium chloride in 0.9%nacl
........................................................................................... 141
potassium chloride in 5 % dex
........................................................................................... 141
potassium chloride in lr-d5 ......... 141
potassium chloride-0.45 % nacl
........................................................................................... 142
........................................................................................... 142
........................................................................................... 142
........................................................................................... 142
potassium citrate ...................................... 142
I-13
sodium chloride 5 % ............................. 143
sodium fluoride ................................ 95, 149
sodium lactate .............................................. 143
sodium phosphate .................................... 143
sodium polystyrene (sorb free)
........................................................................................... 111
sodium polystyrene sulfonate
........................................................................................... 111
sodium thiosulfate ................................... 114
SOLTAMOX .................................................. 30
SOLU-CORTEF (PF) ................... 118
SOMATULINE DEPOT .......... 119
SOMAVERT ............................................... 120
sorbitol ................................................................... 130
sorbitol-mannitol ...................................... 130
sorine ............................................................................ 78
sotalol .......................................................................... 78
sotalol af .................................................................. 78
SOVALDI ........................................................... 63
spinosad ................................................................ 101
SPIRIVA RESPIMAT .................. 145
SPIRIVA WITH
HANDIHALER .................................... 145
spironolactone ................................................. 85
spironolacton-hydrochlorothiaz
............................................................................................... 85
SPORANOX ................................................... 49
sprintec (28) ..................................................... 93
SPRITAM ........................................................... 37
SPRYCEL ........................................................... 30
sps ................................................................................. 111
sronyx ......................................................................... 93
ssd ..................................................................................... 98
stavudine ................................................................. 62
STELARA ...................................................... 136
STERILE PADS .................................... 136
STIMATE ........................................................ 120
STIOLTO RESPIMAT ................... 33
STIVARGA ...................................................... 30
STRATTERA ............................................... 88
STRENSIQ .................................................... 103
streptomycin ...................................................... 13
STRIBILD .......................................................... 62
STRIVERDI RESPIMAT ...... 146
sucralfate ............................................................ 110
Index
rivastigmine tartrate ............................... 39
rizatriptan ............................................................. 51
ropinirole ................................................................ 55
rosadan ...................................................................... 97
ROTARIX ...................................................... 128
ROTATEQ VACCINE ............... 128
roxicet ............................................................................ 7
ROZEREM ................................................... 148
SABRIL .................................................................. 37
SAIZEN .............................................................. 119
SAIZEN CLICK.EASY ............. 119
SANDOSTATIN LAR DEPOT
........................................................................................... 119
SANTYL ............................................................... 96
SAPHRIS (BLACK CHERRY)
............................................................................................... 59
SAVAYSA .......................................................... 66
SAVELLA ............................................... 87, 88
selegiline hcl ....................................................... 55
selenium sulfide ................................... 97, 98
SELZENTRY ................................................ 62
SENSIPAR .................................................... 136
SEREVENT DISKUS .................. 145
SEROQUEL XR ....................................... 59
SEROSTIM ................................................... 119
sertraline ...................................................... 41, 42
setlakin ...................................................................... 93
sharobel .................................................................... 93
SIGNIFOR .................................................... 136
sildenafil ............................................................... 149
SILENOR ............................................................ 42
silver nitrate ........................................................ 98
silver sulfadiazine ........................................ 98
SIMBRINZA .............................................. 138
SIMPONI ......................................................... 136
SIMPONI ARIA ................................... 136
simvastatin ........................................................... 84
sirolimus ............................................................... 124
SIRTURO ........................................................... 52
sodium acetate ............................................. 142
sodium bicarbonate ............................... 142
sodium chloride ........................... 130, 143
sodium chloride 0.45 % .................... 142
sodium chloride 0.9 % ....................... 142
sodium chloride 3 % ............................. 143
Index
Index
ranitidine hcl .................................................. 110
RAPAMUNE ............................................ 124
RASUVO (PF) .......................................... 135
RAVICTI .......................................................... 111
REBIF (WITH ALBUMIN)
........................................................................................... 135
REBIF REBIDOSE .......................... 136
REBIF TITRATION PACK
........................................................................................... 136
reclipsen (28) ................................................... 93
RECOMBIVAX HB (PF) ........ 127
REGRANEX ................................................. 96
RELENZA DISKHALER ......... 63
RELISTOR ................................................... 111
REMICADE ............................................... 136
REMODULIN ......................................... 148
RENAGEL .................................................... 113
RENVELA ..................................................... 113
repaglinide ............................................................ 44
repaglinide-metformin .......................... 44
REPATHA SURECLICK ......... 84
REPATHA SYRINGE ................... 84
reprexain .................................................................... 7
RESCRIPTOR ............................................. 61
RESTASIS ...................................................... 108
RETROVIR ..................................................... 62
REVLIMID ...................................................... 30
revonto ................................................................... 147
REXULTI ........................................................... 58
REYATAZ ........................................................ 62
ribasphere .............................................................. 65
ribasphere ribapak ..................................... 65
ribavirin .................................................................... 65
RIDAURA .................................................... 124
rifabutin ................................................................... 52
rifampin .................................................................... 52
RIFATER ........................................................... 52
riluzole ....................................................................... 87
rimantadine ......................................................... 63
ringers ...................................................... 129, 142
risedronate ........................................................ 131
RISPERDAL CONSTA ................ 58
risperidone ............................................................ 58
RITUXAN ......................................................... 30
rivastigmine ......................................................... 39
I-14
TOBRADEX ............................................... 107
TOBRADEX ST .................................... 107
tobramycin ........................................................ 107
tobramycin in 0.225 % nacl ........... 13
tobramycin in 0.9 % nacl .................. 13
tobramycin sulfate ..................................... 13
tobramycin-dexamethasone ...... 107
TOLAK ................................................................... 96
tolazamide ............................................................. 47
tolbutamide .......................................................... 47
tolmetin ..................................................................... 10
tolterodine ......................................................... 113
topiragen ................................................................. 37
topiramate ................................................. 37, 38
toposar ....................................................................... 31
topotecan ................................................................ 31
TORISEL ............................................................. 31
torsemide ................................................................ 82
TOUJEO SOLOSTAR ..................... 46
TOVIAZ ............................................................. 113
TPN ELECTROLYTES ............ 143
TPN ELECTROLYTES II .... 143
TRACLEER ................................................ 149
TRADJENTA ............................................... 44
tramadol ...................................................................... 7
tramadol-acetaminophen ...................... 7
trandolapril .......................................................... 76
tranexamic acid ............................................. 68
TRANSDERM-SCOP ..................... 53
tranylcypromine ............................................ 42
TRAVASOL 10 % ................................... 73
TRAVATAN Z ....................................... 138
travoprost (benzalkonium) ....... 138
trazodone ................................................................ 42
TREANDA ....................................................... 31
TRECATOR ................................................... 52
TRELSTAR .......................................... 31, 32
tretinoin ................................................................ 101
tretinoin (chemotherapy) ................ 32
tretinoin microspheres ...................... 101
TREXALL ......................................................... 32
triamcinolone acetonide
.................................................. 95, 101, 109, 118
triamterene-hydrochlorothiazid
............................................................................................... 82
Index
TECHNIVIE ................................................... 63
TEFLARO ......................................................... 17
TEGRETOL XR ....................................... 37
telmisartan ........................................................... 74
telmisartan-hydrochlorothiazid
............................................................................................... 74
temazepam ........................................................... 13
TEMODAR ...................................................... 31
tencon .............................................................................. 7
teniposide ............................................................... 31
TENIVAC (PF) ....................................... 128
terazosin ............................................................... 114
terbinafine hcl .................................................. 49
terbutaline ......................................................... 146
terconazole ........................................................... 50
testosterone ...................................................... 115
testosterone cypionate ...................... 115
testosterone enanthate ...................... 115
TETANUS
TOXOID,ADSORBED (PF)
........................................................................................... 128
TETANUS,DIPHTHERIA
TOX PED(PF) .......................................... 128
tetanus-diphtheria toxoids-td
........................................................................................... 128
tetrabenazine ..................................................... 88
tetracaine hcl (pf) .................................. 105
tetracycline .......................................................... 23
TEVETEN HCT ........................................ 74
THALOMID ............................................... 136
theochron ............................................................ 146
theophylline ..................................................... 146
theophylline in dextrose 5 % .... 146
thioridazine .......................................................... 59
thiotepa ..................................................................... 31
thiothixene ............................................................ 59
tiagabine .................................................................. 37
TICE BCG ...................................................... 124
TIKOSYN ........................................................... 77
tilia fe .......................................................................... 94
timolol maleate ................................ 78, 138
tinidazole ................................................................ 54
TIVICAY ............................................................. 62
tizanidine ............................................................. 147
TOBI PODHALER .............................. 13
Index
Index
sulfacetamide sodium ......................... 107
sulfacetamide sodium (acne) ..... 98
sulfacetamide-prednisolone ........ 107
sulfadiazine .......................................................... 21
sulfamethoxazole-trimethoprim
.................................................................................... 21, 22
sulfasalazine ....................................................... 22
sulfatrim .................................................................. 22
sulindac ..................................................................... 10
sumatriptan ......................................................... 51
sumatriptan succinate ........................... 51
SUPPRELIN LA .................................. 120
SUPRAX .............................................................. 17
SURMONTIL .............................................. 42
SUSTIVA ............................................................. 62
SUTENT ............................................................... 30
syeda ............................................................................. 93
SYLATRON ................................................... 64
SYLVANT ......................................................... 30
SYMLINPEN 120 ................................... 44
SYMLINPEN 60 ...................................... 44
SYNAGIS ........................................................... 63
SYNAREL ..................................................... 136
SYNERCID ..................................................... 15
SYNJARDY .................................................... 44
SYNRIBO ........................................................... 30
SYPRINE ........................................................ 114
TABLOID ........................................................... 30
tacrolimus ........................................... 101, 124
TAFINLAR ..................................................... 30
TAGRISSO ....................................................... 30
TALTZ AUTOINJECTOR ...... 96
TALTZ SYRINGE ............................... 96
TAMIFLU ......................................................... 63
tamoxifen ............................................................... 30
tamsulosin .......................................................... 114
TARCEVA ........................................................ 31
TARGRETIN ............................................... 31
tarina fe 1/20 (28) .................................... 94
TASIGNA ........................................................... 31
tazicef .......................................................................... 17
TAZORAC .................................................... 101
taztia xt .................................................................... 79
TECENTRIQ ................................................. 31
TECFIDERA ............................................. 136
I-15
VIMPAT ............................................................... 38
vinblastine ............................................................. 32
vincasar pfs .......................................................... 32
vincristine ............................................................... 32
vinorelbine ............................................................. 32
viorele (28) ......................................................... 94
VIRACEPT ....................................................... 62
VIRAMUNE XR ..................................... 62
VIRAZOLE ...................................................... 65
VIREAD ............................................................... 62
virt-phos 250 neutral ........................... 143
VITAFOL FE+ (WITH
DOCUSATE) ............................................. 150
VITEKTA ........................................................... 62
VOLTAREN ................................................... 10
voriconazole ........................................................ 49
VOTRIENT ...................................................... 32
VPRIV ................................................................... 103
VRAYLAR ....................................................... 59
vyfemla (28) ..................................................... 94
VYTORIN 10-10 ....................................... 84
VYTORIN 10-20 ....................................... 84
VYTORIN 10-40 ....................................... 84
VYTORIN 10-80 ....................................... 84
warfarin .................................................................... 67
water for irrigation, sterile ......... 130
WELCHOL ....................................................... 85
wera (28) ............................................................... 94
wymzya fe ............................................................. 94
XALKORI ......................................................... 33
XARELTO ........................................................ 67
XARTEMIS XR ........................................... 8
XELJANZ ....................................................... 137
XELJANZ XR .......................................... 137
XGEVA ............................................................... 131
XIFAXAN ......................................................... 15
XOLAIR ............................................................ 147
XTANDI ............................................................... 33
xulane .......................................................................... 94
xylon 10 ....................................................................... 8
XYREM ............................................................. 148
YERVOY ............................................................. 33
YF-VAX (PF) ............................................ 129
YONDELIS ...................................................... 33
zafirlukast ......................................................... 144
Index
VAGIFEM ..................................................... 116
valacyclovir ......................................................... 65
VALCHLOR .................................................. 97
VALCYTE ......................................................... 65
valganciclovir .................................................... 65
valproate sodium .......................................... 38
valproic acid ....................................................... 38
valproic acid (as sodium salt) ... 38
valsartan .................................................................. 75
valsartan-hydrochlorothiazide ... 75
VALSTAR .......................................................... 32
vancomycin .......................................................... 15
vancomycin in dextrose 5 % ......... 15
VAQTA (PF) ............................................... 128
VARIVAX (PF) ...................................... 129
VASCEPA .......................................................... 84
VECTIBIX ......................................................... 32
VELCADE ......................................................... 32
velivet triphasic regimen (28) ... 94
VELPHORO ............................................... 111
VENCLEXTA .............................................. 32
VENCLEXTA STARTING
PACK ........................................................................ 32
venlafaxine ........................................................... 42
VENTOLIN HFA ............................... 146
verapamil ................................................................ 79
VEREGEN ........................................................ 97
VERSACLOZ ............................................... 59
VESICARE ................................................... 113
vestura (28) ....................................................... 94
VGO 40 ................................................................ 102
VIBERZI ........................................................... 112
vicodin ............................................................................ 8
vicodin es .................................................................... 8
vicodin hp ................................................................... 8
VICTOZA 3-PAK ................................... 44
VIDEX 2 GRAM PEDIATRIC
............................................................................................... 62
VIDEX 4 GRAM PEDIATRIC
............................................................................................... 62
VIEKIRA PAK .......................................... 63
vienva ........................................................................... 94
VIGAMOX .................................................... 107
VIIBRYD ............................................................. 42
VIMIZIM ......................................................... 103
Index
Index
trianex .................................................................... 101
triazolam ................................................................. 13
TRIBENZOR ................................................ 75
tri-estarylla .......................................................... 94
trifluoperazine ................................................. 59
trifluridine ......................................................... 107
trihexyphenidyl .............................................. 55
tri-legest fe ........................................................... 94
tri-linyah ................................................................. 94
tri-lo-estarylla .................................................. 94
tri-lo-marzia ....................................................... 94
tri-lo-sprintec .................................................... 94
trilyte with flavor packets ............ 112
trimethoprim ...................................................... 15
trimipramine ...................................................... 42
trinessa (28) ...................................................... 94
TRINTELLIX .............................................. 42
tri-previfem (28) ......................................... 94
tri-sprintec (28) ............................................ 94
TRIUMEQ ........................................................ 62
trivora (28) ......................................................... 94
TROKENDI XR ...................................... 38
TROPHAMINE 10 % ....................... 73
TROPHAMINE 6% ............................. 73
trospium ............................................................... 113
TRULICITY ................................................... 44
TRUMENBA ............................................. 128
TRUVADA ...................................................... 62
TUDORZA PRESSAIR ............ 146
TWINRIX (PF) ....................................... 128
TYBOST ............................................................ 137
TYGACIL .......................................................... 23
TYKERB .............................................................. 32
TYPHIM VI ................................................. 128
TYSABRI ........................................................ 124
TYVASO ........................................................... 149
TYVASO REFILL KIT ............. 149
TYVASO STARTER KIT ..... 149
TYZEKA .............................................................. 65
TYZINE ............................................................. 105
u-cort ........................................................................ 101
ULORIC ............................................................ 137
UNITUXIN ..................................................... 32
UPTRAVI ....................................................... 149
ursodiol .................................................................. 111
Index
zaleplon ................................................................. 148
ZALTRAP .......................................................... 33
zarah ............................................................................. 95
ZARXIO ............................................................... 68
ZAVESCA ...................................................... 103
zebutal ............................................................................ 8
ZELBORAF .................................................... 33
ZEMPLAR .................................................... 131
zenatane ................................................................... 97
zenchent (28) ................................................... 95
zenchent fe ............................................................ 95
ZENPEP ............................................................ 103
zeosa ............................................................................. 95
ZEPATIER ........................................................ 63
ZETIA ....................................................................... 85
ZIAGEN ............................................................... 63
zidovudine .............................................................. 63
ZIOPTAN (PF) ....................................... 138
ziprasidone hcl ................................................. 59
ZIRGAN ........................................................... 107
ZOHYDRO ER ............................................. 8
ZOLADEX ........................................................ 33
zoledronic acid ............................................ 131
........................................................................................... 131
ZOLINZA ........................................................... 33
zolmitriptan ........................................................ 51
zolpidem ............................................................... 148
ZOMETA ......................................................... 131
zonisamide ............................................................ 38
ZORTRESS .................................................. 124
ZOSTAVAX (PF) ................................ 129
zovia 1/35e (28) ........................................... 95
zovia 1/50e (28) ........................................... 95
ZOVIRAX .......................................................... 97
ZUBSOLV .......................................................... 11
ZYDELIG .......................................................... 33
ZYKADIA ......................................................... 33
ZYLET ................................................................. 107
ZYPREXA RELPREVV .............. 59
ZYTIGA ................................................................ 33
ZYVOX ................................................................... 15
I-16
This formulary was updated on 06/27/2016. For more recent information or other questions, please contact
Sharp Advantage Customer Care at 1-855-820-2112 or visit www.sharphealthplan.com/sharpadvantage for
additional information. (TTY users should call 711.) Hours are 8:00 a.m. to 6:00 p.m. Pacific Time, Monday to
Friday.
Sharp Advantage is offered by Sharp Health Plan. Sharp Advantage is an HMO plan with a Medicare contract.
Enrollment in Sharp Advantage depends on contract renewal.
This information is available for free in other languages. Please call our Customer Care number at
1-855-820-2112 for additional information. (TTY users should call 711.) Hours are 8:00 a.m. to 6:00 p.m.,
Monday to Friday. Customer Care also has free language interpreter services available for non-English
speakers. Please contact Sharp Advantage if you need information in another format.
Esta información puede obtenerse sin cargo en otros idiomas. Si desea más información, llame a nuestro
servicio de atención a los miembros al 1-855-820-2112. (Los usuarios de TTY deben llamar al 711.) El horario
es de 8:00 de la mañana a 6:00 de la tarde de lunes a viernes. Alguien que hable español le podrá ayudar. Este
es un servicio gratuito. Por favor, póngase en contacto con Sharp Advantage si usted necesita información en
otro forma.
The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice
when necessary.

Sharp Advantage (HMO) 2016 Formulary

Transcription

Similar documents

Printable Formulary for 2016 (effective 9/1/16)

HealthPartners EnhancedRx

2015 Prescription Drug Formular and Network Pharmacies

List of Covered Drugs - Inland Empire Health Plan

(PDP) 2016 Formulary - Blue Cross and Blue Shield of Illinois

mhccr Formulary

SilverScript 2016 Choice Formulary

Kaiser Permanente comprehensive formulary

2016 MDWise HIEx Formulary

Formulary - Cloudfront.net

Comprehensive Formulary - Medicare Part D Plans

Fidelis Care 2016 Formulary (List of Covered Drugs)

2016 Formulary (List of Covered Drugs)

Tiếng Việt - Santa Clara Family Health Plan

Comprehensive Formulary

CCHH ITEM Description 22797 STRIP INDICATOR STEAM