OC Preferred (HMO) - Inter Valley Health Plan

Transcription

It’s Personal.
2016
PLEASE READ:
This document contains information
about the drugs we cover in the
Plans Service To Seniors (HMO) and
OC Preferred (HMO).
This formulary was updated on
08/19/2015.
For more recent information or other
questions, please contact Inter Valley
Health Plan’s Pharmacy Specialist at
800-523-3142, 7:30 am to 8 pm,
7 days a week. TTY/TDD users should
call 800-505-7150.
Formulary ID 16149, Version 16
H0545_FUY2016_26 Accepted
Comprehensive
Formulary
LIST OF
COVERED DRUGS
Service To Seniors (HMO)
OC Preferred (HMO)
Table of Contents
What is the Inter Valley Health Plan Service To Seniors (HMO) or
OC Preferred (HMO) Formulary?...........................................................pg 2
Can the Formulary (drug list) change?.................................................pg 2
How do I use the Formulary?................................................................pg 3
What are generic drugs?.......................................................................pg 3
Are there any restrictions on my coverage?.........................................pg 3
What if my drug is not on the Formulary?...........................................pg 4
How do I request an exception to the Inter Valley Health Plan
Service To Seniors (HMO) or OC Preferred (HMO) Formulary?...........pg 5
What do I do before I can talk to my doctor about
changing my drugs or requesting an exception?.................................pg 5
For more information............................................................................pg 6
Inter Valley Health Plan Service To Seniors (HMO) Copay Amounts...pg 7
Inter Valley Health Plan OC Preferred (HMO) Copay Amounts...........pg 8
Drugs Requiring Prior Authorization..................................................pg 98
Drugs with Quantity Limits................................................................pg 103
Drugs Requiring Step Therapy..........................................................pg 112
Index of Drugs....................................................................................pg 114
1
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 Inter Valley
Health Plan Service To Seniors (HMO) or OC
Preferred (HMO). When it refers to “plan” or
“our plan,” it means Inter Valley Health Plan
Service To Seniors (HMO) or OC Preferred
(HMO).
This document includes a list of the drugs
(formulary) for our plan which is current as of
August 19, 2015. 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.
Benefits, formulary, pharmacy network, and/
or copayments/coinsurance may change on
January 1, 2016, and from time to time during
the year.
What is the Inter Valley Health Plan
Service To Seniors (HMO) or
OC Preferred (HMO) Formulary?
A formulary is a list of covered drugs selected by
Inter Valley Health Plan Service To Seniors (HMO)
or OC Preferred (HMO) in consultation with a
team of healthcare providers, which represents
the prescription therapies believed to be a
necessary part of a quality treatment program.
The Plan will generally cover the drugs listed in
our formulary as long as the drug is medically
necessary, the prescription is filled at an Inter
Valley Health Plan network pharmacy, and other
plan rules are followed. For more information on
how to fill your prescriptions, please review your
2
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.
category, “Cardiovascular Agents.” If you know
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 (FDA) 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.
name in the list that begins on page 11. Then
The enclosed formulary is current as of August
19, 2015. To get updated information about
the drugs covered by Inter Valley Health Plan,
please visit our web site at http://www.ivhp.
com/Site/PrescriptionDrugSearch.aspx or
call our Pharmacy Specialist at 800-523-3142,
7:30 am to 8 pm, 7 days a week. TTY/TDD
users should call 800-505-7150. Inter Valley
Health Plan provides updates to the Formulary
in our quarterly newsletter, InterView, or on
our website at http://www.ivhp.com/Site/
PrescriptionDrugSearch.aspx.
How do I use the Formulary?
There are two ways to find your drug within
the formulary:
MEDICAL CONDITION
The formulary begins on page 11. 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
what your drug is used for, look for the category
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 114. 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?
Inter Valley Health Plan Service To Seniors (HMO)
or OC Preferred (HMO) 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: Inter Valley Health Plan
Service To Seniors (HMO) or OC Preferred (HMO)
requires you or your physician to get prior
authorization for certain drugs. This means that
you will need to get approval from us before you
fill your prescriptions. If you don’t get approval,
we may not cover the drug.
3
Quantity Limits: For certain drugs, Inter
Valley Health Plan Service To Seniors (HMO) or
OC Preferred (HMO) limits the amount of the
drug that the Plan will cover. For example, Inter
Valley Health Plan Service To Seniors (HMO) or
OC Preferred (HMO) provides 30 tablets per 30
days prescription for Atorvastatin. This may be
in addition to a standard one-month or threemonth supply.
Step Therapy: In some cases, Inter Valley Health
Plan Service To Seniors (HMO) or OC Preferred
(HMO) 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 1 and Drug 2 both treat your medical
condition, the Plan may not cover Drug 2 unless
you try Drug 1 first. If Drug 1 does not work for
you, the Plan will then cover Drug 2.
You can find out if your drug has any addi
tional requirements or limits by looking in
the formulary that begins on page 11. You
can also get more information about the
restrictions applied to specific covered drugs
by visiting our Web site. We have posted
online documents 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.
You can ask us 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 Inter Valley
Preferred (HMO) formulary?” on page 5
for information about how to request an
exception.
4
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 our Pharmacy Specialist and ask if
your drug is covered.
If you learn that Inter Valley Health Plan
(HMO) does not cover your drug, you have
two options:
You can ask our Pharmacy Specialist for a
list of similar drugs that are covered by the
Plan. When you receive the list, show it to
your doctor and ask him or her to prescribe a
similar drug that is covered by the Plan.
You can ask us to make an exception
and cover your drug. See page 5 for
information about how to request an
exception.
How do I request an exception
to the Inter Valley Health Plan
Service To Seniors (HMO) or
OC Preferred (HMO) Formulary?
You can ask us 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 costsharing level, and you would not be able to
ask us to provide the drug at a lower costsharing 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, Inter Valley Health Plan
(HMO) 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, Inter Valley Health Plan Service To
Seniors (HMO) or OC Preferred (HMO) 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 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.
5
If you are a resident of a long-term care
facility, we will allow you to refill your
prescription until we have provided you with
a 91-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 31day emergency supply of that drug (unless you
have a prescription for fewer days) while you
pursue a formulary exception.
Exceptions are also available when you have
experienced a change in the level of care you
are receiving which requires you to transition
from one facility or treatment center to
another. Examples of situations in which you
would be eligible for the one-time temporary
fill exception when you are outside of the
three month effective date with the Plan are
as follows:
If you are discharged from
the hospital and provided a
discharge list of medications
based upon the Formulary
of the hospital.
If you end your skilled
nursing facility Medicare
Part A stay (where payments
include all pharmacy charges)
and you need to revert back
to the Inter Valley Health
Plan Service To Seniors
(HMO) or OC Preferred
(HMO) formulary.
6
If you give up hospice status to revert back to
standard Medicare Part A and Part B benefits.
If you are discharged from Chronic Psychiatric
Hospitals with medication regimens that are
highly individualized.
All of these situations would warrant a
temporary one-time fill exception regardless
of your effective date with the Plan.
For more information
For more detailed information about your
Inter Valley Health Plan Service To Seniors
(HMO) or OC Preferred (HMO) prescription
drug coverage, please review your Evidence of
Coverage and other plan materials.
If you have questions about Inter Valley
Preferred (HMO), 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 1-800-MEDICARE (1800-633-4227) 24 hours a day/7
days a week. TTY users should
call 1-877-486-2048. Or, visit
http://www.medicare.gov.
Inter Valley Health Plan Service To Seniors (HMO) Copay Amounts
INITIAL
COVERAGE
LIMIT
TIER
1
Preferred
Generic Drugs
$5 Copay
$15 Copay
$5 Copay
$10 Copay
$5 Copay
TIER
2
Generic Drugs
$17.50 Copay
$52.50 Copay
$17.50 Copay
$35 Copay
$17.50 Copay
TIER
3
Preferred
Brand Drugs
$47 Copay
$141 Copay
$47 Copay
$117.50 Copay
$47 Copay
TIER
4
Non-Preferred
Brand Drugs
$95 Copay
$285 Copay
$95 Copay
$237.50 Copay
$95 Copay
TIER
5
Specialty Drugs
33%
Coinsurance
N/A
33%
Coinsurance
N/A
33%
Coinsurance
TIER
1
Preferred
Generic Drugs
58%
Coinsurance
58%
Coinsurance
58%
Coinsurance
58%
Coinsurance
58%
Coinsurance
TIER
2
Non-Preferred
Generic Drugs
58%
Coinsurance
58%
Coinsurance
58%
Coinsurance
58%
Coinsurance
58%
Coinsurance
TIER
3
Preferred
Brand Drugs
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
TIER
4
Retail
Retail
Network LongMail Order
Out of Network
Copayment / Copayment /
Term Care
Copayment /
Copayment/
Coinsurance
Coinsurance
Cost-Sharing
Coinsurance
Coinsurance
(30 day Supply) (90 day Supply) (30 day Supply) (90 day Supply) (30 day Supply)*
Non-Preferred
Brand Drugs
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
TIER
5
Drug Tier
$3310, the total yearly drug cost in the initial coverage limit paid by both you
and Inter Valley Health Plan
Specialty Drugs
**
N/A
**
N/A
**
COVERAGE GAP
CATASTROPHIC After your yearly out-of-pocket drug cost reach $4,850 you pay the greater of a
$2.95 copay for generic (including brand drugs treated as generic) and $7.40 for
COVERAGE
all other drugs, or a 5% coinsurance.
*You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out of network pharmacy.
**You pay 58% for the total cost of the generic or 45% for the brand.
7
Inter Valley Health Plan OC Preferred (HMO) Copay Amounts
INITIAL
COVERAGE
LIMIT
TIER
1
Preferred
Generic Drugs
$5 Copay
$15 Copay
$5 Copay
$10 Copay
$5 Copay
TIER
2
Generic Drugs
$15 Copay
$45 Copay
$15 Copay
$30 Copay
$15 Copay
TIER
3
Preferred
Brand Drugs
$39 Copay
$117 Copay
$39 Copay
$78 Copay
$39 Copay
TIER
4
Non-Preferred
Brand Drugs
$89 Copay
$267 Copay
$89 Copay
$178 Copay
$89 Copay
TIER
5
Specialty Drugs
33%
Coinsurance
N/A
33%
Coinsurance
N/A
33%
Coinsurance
TIER
1
Preferred
Generic Drugs
$5 Copay
$15 Copay
$5 Copay
$10 Copay
$5 Copay
TIER
2
Non-Preferred
Generic Drugs
58%
Coinsurance
58%
Coinsurance
58%
Coinsurance
58%
Coinsurance
58%
Coinsurance
TIER
3
Preferred
Brand Drugs
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
TIER
4
Retail
Retail
Network LongMail Order
Out of Network
Copayment / Copayment /
Term Care
Copayment /
Copayment/
Coinsurance
Coinsurance
Cost-Sharing
Coinsurance
Coinsurance
(30 day Supply) (90 day Supply) (30 day Supply) (90 day Supply) (30 day Supply)*
Non-Preferred
Brand Drugs
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
TIER
5
Drug Tier
$3310, the total yearly drug cost in the initial coverage limit paid by both you
and Inter Valley Health Plan
Specialty Drugs
**
N/A
**
N/A
**
COVERAGE GAP
CATASTROPHIC After your yearly out-of-pocket drug cost reach $4,850 you pay the greater of a
COVERAGE
$2.95 copay for generic (including brand drugs treated as generic) and $7.40 for
all other drugs, or a 5% coinsurance
*You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out of network pharmacy.
**You pay 58% for the total cost of the generic or 45% for the brand.
8
Inter Valley Health Plan Service To Seniors (HMO) or
OC Preferred (HMO) Formulary
The formulary that begins on page 11 provides coverage information about some of the
drugs covered by Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO). If
you have trouble finding your drug in the list, turn to the Index that begins on page 114.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,
ZETIA) and generic drugs are listed in lower-case italics (e.g., simvastatin).
The second column of the chart lists the alternate drug name (this is for reference only and if
the drug name is in this column it is NOT a covered benefit).
The third column of the chart lists the Tier number for each covered medication. Please refer
to page 7 for Inter Valley Health Plan Service To Seniors (HMO) copay chart or page 8
for the Inter Valley Health Plan OC Preferred (HMO) copay chart. This copay chart will show
you what the copayment is for each Tier.
The fourth column of the chart will let you see if the listed medication is available to be filled
for 90 days with one of our Mail Order Pharmacies. Please refer to page 7 for Inter Valley
Health Plan Service To Seniors (HMO) copay chart or page 8 for the Inter Valley Health
Plan OC Preferred (HMO) copay chart for the Mail Order 90 day copayment.
The fifth column of the chart will let you see if the listed medication is available to be
filled for 90 days at a local retail Pharmacy. Please refer to page 7 for Inter Valley
Health Plan Service To Seniors (HMO) copay chart or page 8 for the Inter Valley Health
Plan OC Preferred (HMO) copay chart for the Retail 90 day copayment.
The sixth column of the chart will show you if the listed medication has any special
requirements or limits. The information in the Requirements/Limits column tells you if
Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) has any special
requirements for coverage of your drug.
The seventh column of the chart will show you the route of the listed medication.
9
The following explains the abbreviations used in the Formulary: PA-Prior Authorization;
QL‑Quantity Limits; ST-Step Therapy; Inj-Injection; TD-Transdermal; Rec-Rectal; Top-Topical;
NS-Nasal; Vag-Vaginal; Inh-Inhalation; OP-Ophthalmic; OT-Otic; MT-Mucus Membrane Topical;
SL-Sublingual; IR-Irrigation; BU-Buccal; TL-Translingual.
Drugs marked with “**” indicates the prescription drug is not normally covered in a Medicare
Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does
not count towards your total drug costs (that is, the amount you pay does not help you
qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your
prescriptions, you will not get any extra help to pay for this drug.
10
Formulary
Covered Drug Name
Alternate Drug Name
Tier
*90-Day *90-Day Requirements/
Mail Retail
Route
Limits
Order Store
ANALGESICS
Analgesics, Other
but-50 / apap-300 / caf-40 cap
butalbital - acetaminophen - caffeine
Tier 2
No
No
but-50 / apap-325 / caf-40 / codeine-30 cap
FIORICET - CODEINE
Tier 2
No
No
Tier 2
No
No
but-50 / apap-325 / caf-40 tab
Tier 2
No
No
but-50 / apap-325 tab
butalbital - acetaminophen
Tier 2
No
No
but-50 / asa-325 / caff-40 cap
butalbital - aspirin - caffeine
Tier 2
No
No
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Nonsteroidal Anti-inflammatory Drugs
celecoxib cap 100mg
CELEBREX
celecoxib cap 200mg
CELEBREX
celecoxib cap 400mg
CELEBREX
celecoxib cap 50mg
CELEBREX
diclofen pot tab 50mg
CATAFLAM
diclofenac tab 100mg er
VOLTAREN - XR
diclofenac tab 25mg dr
VOLTAREN
VOLTAREN
VOLTAREN
diflunisal tab 500mg
diflunisal
etodolac cap 200mg
LODINE
etodolac cap 300mg
LODINE
etodolac er tab 400mg
LODINE XL
LODINE XL
LODINE XL
etodolac tab 400mg
LODINE
etodolac tab 500mg
LODINE
fenoprofen tab 600mg
FENOPROFEN
flurbiprofen tab 100mg
ANSAID
flurbiprofen tab 50mg
ANSAID
ibuprofen sus 100/5ml
MOTRIN
ibuprofen tab 400mg
MOTRIN
ibuprofen tab 600mg
MOTRIN
ibuprofen tab 800mg
MOTRIN
PA, QL (120 per 30
days)
PA, QL (180 per 30
days)
PA, QL (120 per 30
days)
PA, QL (120 per 30
days)
PA, QL (180 per 30
days)
PA, QL (180 per 30
days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
Please go to page 7 or 8 to confirm copays, to find the meaning of symbols or abbreviations go to page 10.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
11
Formulary
Covered Drug Name
ketoprofen cap 200mg er
ketoprofen cap 50mg
ketoprofen cap 75mg
meclofen sod cap 100mg
meclofen sod cap 50mg
meloxicam tab 15mg
meloxicam tab 7.5mg
nabumetone tab 500mg
nabumetone tab 750mg
naproxen dr tab 375mg
naproxen dr tab 500mg
naproxen sod tab 275mg
naproxen sod tab 500mg cr
naproxen sod tab 550mg
naproxen sus 125/5ml
naproxen tab 250mg
naproxen tab 375mg
naproxen tab 500mg
oxaprozin tab 600mg
piroxicam cap 10mg
piroxicam cap 20mg
sulindac tab 150mg
sulindac tab 200mg
tolmetin sod cap 400mg
tolmetin sod tab 600mg
Alternate Drug Name
ORUVAIL
KETOPROFEN
KETOPROFEN
meclofenamate
meclofenamate
MOBIC
MOBIC
RELAFEN
RELAFEN
NAPROSYN
NAPROSYN
ANAPROX
naproxen er
ANAPROX DS
NAPROSYN
NAPROXYN
NAPROSYN
NAPROSYN
DAYPRO
FELDENE
FELDENE
CLINORIL
CLINORIL
TOLECTIN DS
TOLECTIN
Opioid Analgesics, Long-acting
fentanyl dis 100mcg/hr
DURAGESIC
DURAGESIC
DURAGESIC
DURAGESIC
DURAGESIC
levorphanol tab 2mg
LEVO-DROMORAN
methadone inj 10mg/ml
methadone
morphine sul tab 100mg er
12
MS CONTIN
MS CONTIN
MS CONTIN
MS CONTIN
MS CONTIN
Tier
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Mail Retail
Route
Limits
Order Store
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes QL (30 per 30 days)
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (120 per 30 days)
PA, QL (120 per 30
days)
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
TD
TD
TD
TD
TD
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
OXYCONTIN TAB 10MG CR
Alternate Drug Name
oxycodone er
oxycodone er
oxycodone er
oxycodone er
oxycodone er
oxycodone er
oxycodone er
Opioid Analgesics, Short-acting
apap/codeine sol 120-12/5ml
TYLENOL WITH CODEINE SOLN
apap/codeine tab 300-15mg
TYLENOL WITH CODEINE
butorphanol sol 10mg/ml
butorphanol
DURAMORPH INJ 0.5MG/ML
morphine
DURAMORPH INJ 1MG/ML
morphine
endocet tab 10-325mg
ENDOCET, PERCOCET
endocet tab 5-325mg
ENDOCET, PERCOCET
endocet tab 7.5-325mg
ENDOCET, PERCOCET
fentanyl ot loz 1200mcg
ACTIQ
Tier
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 5
No
No
No
No
No
No
No
No
No
No
No
No QL (4500 per 30 days)
No
PA
No
PA
No PA, QL (120 per 30
days)
days)
days)
days)
days)
days)
No
No
ACTIQ
Tier 5
No
ACTIQ
Tier 2
No
ACTIQ
Tier 5
No
ACTIQ
Tier 5
No
ACTIQ
Tier 5
No
hydroco/apap tab 10-325mg
hydroco/apap tab 7.5-300mg
hydromorphon inj 500/50ml
hydromorphon tab 2mg
morphine sul sol 10mg/5ml
NORCO
XODOL
NORCO
XODOL
NORCO
DILAUDID
DILAUDID
DILAUDID
DILAUDID
morphine soln
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 3
No
No
No
No
No
No
No
No
No
No
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
NS
Inj
Inj
Oral
Oral
Oral
BU
BU
BU
BU
BU
BU
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
13
Formulary
Covered Drug Name
Alternate Drug Name
Tier
morphine sul sol 20mg/5ml
morphine sul sol 20mg/ml
morphine sul tab 15mg
nalbuphine inj 10mg/ml
morphine soln
morphine
morphine
morphine
NUBAIN
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
NUBAIN
oxycod/apap tab 10-325mg
oxycod/apap tab 2.5-325mg
oxycodone cap 5mg
oxycodone con 100/5ml
oxycodone tab 10mg
oxycodone tab 15mg
oxycodone tab 20mg
oxycodone tab 30mg
oxycodone tab 5mg
tramadl/apap tab 37.5-325mg
tramadol hcl tab 50mg
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
Tier 2
No
No
ENDOCET, PERCOCET
PERCOCET
ENDOCET, PERCOCET
ENDOCET, PERCOCET
ROXICODONE
ROXICODONE
ROXICODONE
ROXICODONE
ROXICODONE
ROXICODONE
ROXICODONE
ULTRCET
ULTRAM
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Local Anesthetics
lido/prilocn cre 2.5-2.5%
lidocaine gel 2% jelly
lidocaine gel 2% jelly
lidocaine inj 0.5%
lidocaine oin 5%
lidocaine pad 5%
EMLA
lidocaine
XYLOCAINE
XYLOCAINE
XYLOCAINE
LIDODERM
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
lidocaine sol 2% visc
lidocaine sol 4%
XYLOCAINE
XYLOCAINE
Tier 1
Tier 2
No
No
No
No
101
102
PA, QL (120 per 30
days)
PA, QL (120 per 30
days)
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
ANESTHETICS
120
121
122
PA
123
124
PA, QL (90 per 30
days)
125
126
127
Top
Top
Top
Inj
Top
Top
MT
Top
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
Alcohol Deterrents/Anti-craving
acampro cal tab 333mg
acamprosate
disulfiram tab 250mg
ANTABUSE
disulfiram tab 500mg
ANTABUSE
14
Tier 1
Tier 2
Tier 2
No
No
No
No
No
No
128
129
130
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
Opioid Dependence Treatments
buprenorphin inj 0.3mg/ml
BUPRENEX
buprenorphin sub 2mg
SUBUTEX
SUBUTEX
SUBOXONE MIS 12-3MG
buprenorphine - naloxone
SUBOXONE MIS 2-0.5MG
SUBOXONE MIS 4-1MG
SUBOXONE MIS 8-2MG
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Opioid Reversal Agents
naloxone inj 1mg/ml
naltrexone tab 50mg
NARCAN
naltrexone
Tier 2
Tier 2
No
No
No
No
Smoking Cessation Agents
buproban tab 150mg
CHANTIX PAK 0.5& 1MG
CHANTIX PAK 1MG
CHANTIX TAB 0.5MG
CHANTIX TAB 1MG
NICOTROL NS SPR 10MG/ML
bupropion
varenicline
varenicline
varenicline
varenicline
nicotine
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
No
No
No
No
No
No
No
No
No
No
No
No
QL (90 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (40 per 30 days)
amikacin
GENTAK
GENTAMICIN
GENTAMICIN
gentamicin
gentamicin
GENTAK
NEOMYCIN
PARAMOMYCIN
streptomycin
tobramycin - dexamethasone
tobramycin
TOBREX
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 2
Tier 4
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
PA
PA
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
Inj
SL
SL
SL
SL
SL
SL
Inj
Oral
Oral
Oral
Oral
Oral
Oral
NS
ANTIBACTERIALS
Aminoglycosides
amikacin inj 500/2ml
gentak oin 0.3%
gentam/nacl inj 100mg
gentamicin cre 0.1%
gentamicin oin 0.1%
gentamicin sol 0.3%
neomycin tab 500mg
paromomycin cap 250mg
streptomycin inj 1gm
TOBRADEX OIN 0.3-0.1%
tobramycin inj 80mg/2ml
tobramycin sol 0.3%
146
147
PA
PA
148
149
150
151
152
153
154
PA
155
156
PA
157
158
Inj
OP
Inj
Inj
Top
Top
OP
Oral
Oral
Inj
OP
Inj
OP
15
Formulary
Covered Drug Name
16
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
Antibacterials, Other
acetic acid sol 2%
baciim inj 50000unt
bacitracin oin
BACTROBAN OIN NASAL 2%
chloramphen inj 1gm
clindamycin aer 1%
clindamycin cap 150mg
clindamycin cap 300mg
clindamycin cre 2%
clindamycin gel 1%
clindamycin inj 150mg/ml
clindamycin inj 300mg
clindamycin inj 600mg
clindamycin lot 1%
clindamycin pad 1%
clindamycin sol 1%
colistimeth inj 150mg
CUBICIN SOL 500MG
linezolid inj 2mg/ml
linezolid tab 600mg
ACETIC ACID
BACITRACIN
bacitracin
mupirocin
chloramphenicol
CLEOCIN-T
CLEOCIN
CLEOCIN
CLEOCIN
CLEOCIN-T
CLEOCIN
CLEOCIN
CLEOCIN
CLEOCIN-T
CLEOCIN-T
CLEOCIN-T
colistimethate
daptomycin
ZYVOX
ZYVOX
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
methenam hip tab 1gm
metron/nacl inj 500mg
metronidazol cre 0.75%
metronidazol gel 0.75%
metronidazol gel 0.75%
metronidazol gel 1%
metronidazol lot 0.75%
metronidazol tab 250mg
metronidazol tab 500mg
mupirocin oin 2%
neo/poly gu sol 40/ml
nitrofur mac cap 50mg
nitrofurantn cap 100mg
SULFAMYLON CRE 85MG/GM
SULFAMYLON PAK 5%
SYNERCID INJ 500MG
trimethoprim tab 100mg
TYGACIL INJ 50MG
HIPREX
FLAGYL
metronidazole
METROGEL-VAG, VANDAZOLE
metronidazole
FLAGYL
metronidazole
FLAGYL
FLAGYL
BACTROBAN
NEOSPORIN GU
MACRODANTIN
MACROBID
mafenide
mafenide
dalfopristin - quinupristin
PROLOPRIM
tigecycline
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 5
Tier 2
Tier 5
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
159
PA
160
161
162
PA
163
164
165
166
167
168
PA
169
170
171
172
173
174
PA
PA
PA
PA, QL (28 per 14
days)
175
176
177
178
179
PA
180
181
182
183
184
185
186
187
188
189
PA
PA
190
191
192
193
PA
194
195
PA
196
OT
Inj
OP
NS
Inj
Top
Oral
Oral
Vag
Top
Inj
Inj
Inj
Top
Top
Top
Inj
Inj
Inj
Oral
Oral
Inj
Top
Vag
Top
Top
Top
Oral
Oral
Top
IR
Oral
Oral
Top
Top
Inj
Oral
Inj
Formulary
Covered Drug Name
Alternate Drug Name
Tier
VANCOCIN HCL CAP 125MG
vancomycin inj 1000mg
ZYVOX SUS 100MG/5ML
vancomycin
vancomycin
VANCOMYCIN
VANCOCIN
linezolid
Tier 5
Tier 5
Tier 2
Tier 2
Tier 5
Beta-lactam, Cephalosporins
cefaclor cap 250mg
cefaclor cap 500mg
cefaclor er tab 500mg
cefadroxil cap 500mg
cefadroxil sus 250/5ml
cefadroxil sus 500/5ml
cefadroxil tab 1gm
cefazolin inj 1gm
cefazolin inj 500mg
cefdinir cap 300mg
cefdinir sus 125/5ml
cefdinir sus 250/5ml
cefepime inj 1gm
cefepime inj 2gm
cefoxitin inj 1gm
cefoxitin inj 2gm
cefpodo prox sus 100/5ml
cefpodo prox sus 50mg/5ml
cefpodoxime tab 100mg
cefpodoxime tab 200mg
cefprozil sus 125/5ml
cefprozil sus 250/5ml
cefprozil tab 250mg
cefprozil tab 500mg
ceftriaxone inj 1gm
ceftriaxone inj 250mg
ceftriaxone inj 2gm
cefuroxime inj 1.5gm
cefuroxime inj 750mg
cefuroxime tab 250mg
cefuroxime tab 500mg
CECLOR
CECLOR
CECLOR
DURICEF
DURICEF
DURICEF
DURICEF
ANCEF
ANCEF
OMNICEF
OMNICEF
OMNICEF
MAXIPIME
MAXIPIME
MEFOXIN
MEFOXIN
VANTIN
VANTIN
VANTIN
VANTIN
CEFZIL
CEFZIL
CEFZIL
CEFZIL
ROCEPHIN
ROCEPHIN
ROCEPHIN
ROCEPHIN
ZINACEF
ZINACEF
ZINACEF
CEFTIN
CEFTIN
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
PA
PA
PA
PA
PA
197
198
199
200
201
202
203
204
205
206
207
208
PA
PA
209
210
211
212
213
PA
PA
PA
PA
214
215
216
217
218
219
220
221
222
223
224
225
PA
PA
PA
PA
PA
PA
PA
226
227
228
229
230
231
232
233
234
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
17
Formulary
Covered Drug Name
18
Alternate Drug Name
Tier
cephalexin cap 250mg
cephalexin cap 500mg
cephalexin sus 125/5ml
cephalexin sus 250/5ml
cephalexin tab 250mg
cephalexin tab 500mg
SUPRAX CAP 400MG
TEFLARO INJ 400MG
TEFLARO INJ 600MG
KEFLEX
KEFLEX
KEFLEX
KEFLEX
KEFLEX
KEFLEX
cefixime
ceftaroline
ceftaroline
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 5
Tier 5
Beta-lactam, Other
aztreonam inj 1gm
imipenem/cil inj 500mg
INVANZ INJ 1GM
MERREM INJ 500MG
AZACTAM
imipenem-cilastatin
ertapenem
meropenem
Beta-lactam, Penicillins
amox-pot cla tab er
amox/k clav chw 200mg
amox/k clav chw 400mg
amox/k clav sus 200/5ml
amox/k clav tab 250mg
amoxicillin cap 250mg
amoxicillin cap 500mg
amoxicillin chw 125mg
amoxicillin chw 250mg
amoxicillin sus 125/5ml
amoxicillin tab 500mg
amoxicillin tab 875mg
amp-sulbacta inj 15gm
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AMOXIL
AMOXIL
AMOXIL
AMOXIL
AMOXIL
AMOXIL
AMOXIL
AMOXIL
AMOXIL
AMOXIL
UNASYN
UNASYN
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Tier 4
Tier 2
Tier 4
Tier 4
No
No
No
No
No
No
No
No
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
235
236
237
238
239
240
241
PA
PA
PA
PA
242
243
244
245
246
PA
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
PA
PA
268
269
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Tier 1
Tier 1
Tier 2
Tier 2
Tier 1
Tier 1
Tier 4
BICILLIN L-A INJ 1200000
dicloxacill cap 250mg
dicloxacill cap 500mg
nafcillin inj 1gm
NALLPEN/DEX INJ 1GM/50ML
pen g sod inj 5000000
penicilln gk inj 5mu
penicilln vk sol 125/5ml
penicilln vk sol 250/5ml
penicilln vk tab 250mg
penicilln vk tab 500mg
piper/tazoba inj 3-0.375gm
ampicillin
ampicillin
ampicillin
ampicillin
ampicillin
ampicillin
penicillin g benzathine - penicillin g
procaine
penicillin g benzathine - penicillin g
procaine
penicillin g benzathine
DYCIL, DYNAPEN
DYCIL, DYNAPEN
NAFCILLIN
nafcillin
pen g sod
penicillin g
VEETIDS
VEETIDS
VEETIDS
VEETIDS
ZOSYN
ZOSYN
Cystic Fibrosis Agents
tobramycin neb 300/5ml
Macrolides
AZASITE SOL 1%
azithromycin inj 500mg
azithromycin sus 100/5ml
azithromycin tab 250mg
clarithromyc sus 125/5ml
clarithromyc sus 250/5ml
ampicillin cap 250mg
ampicillin cap 500mg
AMPICILLIN INJ 125MG
ampicillin inj 1gm
ampicillin sus 125/5ml
ampicillin sus 250/5ml
BICILLIN C-R INJ 1200000
BICILLIN C-R INJ 900/300
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Tier 4
No
No
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 2
Tier 5
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
TOBI
Tier 5
No
No
azithromycin
ZITHROMAX
ZITHROMAX
ZITHROMAX
ZITHROMAX
ZITHROMAX
ZITHROMAX
BIAXIN
BIAXIN
Tier 4
Tier 2
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
270
271
PA
PA
272
273
274
275
276
277
278
279
280
281
282
PA
PA
PA
PA
283
284
285
286
287
288
289
290
PA
PA
PA
291
292
293
294
PA
QL (30 per 5 days)
QL (90 per 5 days)
QL (6 per 5 days)
QL (6 per 5 days)
QL (6 per 5 days)
295
296
297
298
299
300
301
302
Oral
Oral
Inj
Inj
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Inj
Inj
Inh
OP
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
19
Formulary
Covered Drug Name
20
Alternate Drug Name
Tier
clarithromyc tab 250mg
clarithromyc tab 500mg er
ery pad 2%
ery-tab tab 250mg ec
erythrocin inj 500mg
erythrocin tab 250mg
erythromycin gel 2%
erythromycin oin
erythromycin sol 2%
erythromycin tab 250mg bs
erythromycin tab 500mg bs
BIAXIN
BIAXIN
BIAXIN XL
ERY
erythromycin
erythromycin
erythromycin
erythromycin
ERYTHROCIN
ERYGEL
ROMYCIN
ERYGEL
ERY-TAB, E.E.S.
ERY-TAB, E.E.S.
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Quinolones
BESIVANCE SUS 0.6%
ciprofloxacn inj 200mg
ciprofloxacn sol 0.3%
ciprofloxacn tab 1000mg
ciprofloxacn tab 500mg er
gatifloxacin sol 0.5%
levoflox/d5w inj 500/100ml
levofloxacin inj 25mg/ml
levofloxacin sol 0.5%
levofloxacin sol 25mg/ml
levofloxacin tab 250mg
moxifloxacin tab 400mg
ofloxacin dro 0.3%
ofloxacin dro 0.3%
ofloxacin tab 400mg
VIGAMOX DRO 0.5%
besifloxacin
CIPRO
CIPRO
CILOXAN
CIPRO XR
CIPRO
CIPRO
CIPRO
CIPRO XR
CIPRO
ZYMAXID
LEVAQUIN
LEVAQUIN
QUIXIN
LEVAQUIN
LEVAQUIN
LEVAQUIN
LEVAQUIN
AVELOX
FLOXIN OTIC
OCUFLOX
FLOXIN
moxifloxacin
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
QL (28 per 14 days)
QL (28 per 14 days)
QL (28 per 14 days)
303
304
305
306
307
308
309
PA
310
311
312
313
314
315
316
317
PA
PA
318
319
320
321
322
323
324
325
326
327
PA
PA
328
329
330
331
QL (14 per 14 days)
QL (14 per 14 days)
QL (14 per 14 days)
QL (14 per 14 days)
332
333
334
335
336
337
338
339
Oral
Oral
Oral
Top
Oral
Oral
Oral
Inj
Oral
Top
OP
Top
Oral
Oral
OP
Inj
Inj
OP
Oral
Oral
Oral
Oral
Oral
Oral
OP
Inj
Inj
OP
Oral
Oral
Oral
Oral
Oral
OT
OP
Oral
OP
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
Sulfonamides
silver sulfa cre 1%
smz-tmp inj 400-80/5ml
smz-tmp sus 200-40/5ml
smz-tmp tab 400-80mg
smz/tmp ds tab 800-160mg
sod sulfacet sol 10%
ssd cre 1%
sulfacet sod oin 10%
sulfacetamid sus 10%
sulfadiazine tab 500mg
SILVADENE - SSD
BACTRIM, SEPTRA
BACTRIM, SEPTRA
BACTRIM, SEPTRA
BACTRAM DS, SEPTRA DS
BLEPH-10
SILVADENE - SSD
BLEPH-10
KLARON
sulfadiazine
Tier 1
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Tetracyclines
demeclocycl tab 150mg
demeclocycl tab 300mg
doxy 100 inj 100mg
doxycyc mono tab 150mg
doxycycl hyc cap 100mg
doxycycl hyc cap 50mg
doxycycl hyc inj 100mg
doxycycl hyc tab 100mg
minocycline cap 100mg
minocycline tab 100mg
minocycline tab 135mg er
DECLOMYCIN
DECLOMYCIN
vibramycin
VIBRATAB
VIBRATAB
VIBRATAB
ADOXA
ADOXA
vibramycin
ADOXA
MINOCIN
MINOCIN
MINOCIN
DYNACIN
SOLODYN
SOLODYN
DYNACIN
DYNACIN
SOLODYN
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
KEPPRA
KEPPRA
Tier 4
Tier 4
No
No
No
No
340
PA
341
342
343
344
345
346
347
348
349
350
351
PA
352
353
354
355
356
357
PA
358
359
360
361
362
363
364
365
366
367
368
Top
Inj
Oral
Oral
Oral
OP
Top
OP
Top
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
ANTICONVULSANTS
Anticonvulsants, Other
levetiraceta inj 10mg/ml
369
370
Inj
Inj
21
Formulary
Covered Drug Name
levetiraceta sol 100mg/ml
levetiraceta tab 1000mg
levetiraceta tab 500mg er
levetiraceta tab 750mg er
levetiracetm inj 500/5ml
POTIGA TAB 200MG
POTIGA TAB 300MG
POTIGA TAB 400MG
POTIGA TAB 50MG
22
Alternate Drug Name
KEPPRA
KEPPRA
KEPPRA
KEPPRA
KEPPRA
KEPPRA XR
KEPPRA
KEPPRA XR
KEPPRA
ezogabine
ezogabine
ezogabine
ezogabine
Tier
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Mail Retail
Route
Limits
Order Store
No
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
Yes
Yes
Calcium Channel Modifying Agents
CELONTIN CAP 300MG
methsuximide
ethosuximide cap 250mg
ZARONTIN
ethosuximide sol 250/5ml
ZARONTIN
LYRICA CAP 100MG
pregabalin
LYRICA CAP 150MG
pregabalin
LYRICA CAP 200MG
pregabalin
LYRICA CAP 225MG
pregabalin
LYRICA CAP 25MG
pregabalin
LYRICA CAP 300MG
pregabalin
LYRICA CAP 50MG
pregabalin
LYRICA CAP 75MG
pregabalin
LYRICA SOL 20MG/ML
pregabalin
zonisamide cap 100mg
ZONEGRAN
zonisamide cap 25mg
ZONEGRAN
zonisamide cap 50mg
ZONEGRAN
Tier 4
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
No
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazep odt tab 0.125mg
KLONOPIN ODT
KLONOPIN ODT
KLONOPIN ODT
clonazep odt tab 1mg
KLONOPIN ODT
KLONOPIN ODT
clonazepam tab 0.5mg
KLONOPIN
clonazepam tab 1mg
KLONOPIN
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
No
No
371
372
373
374
375
376
377
378
379
QL (90 per 30 days)
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
PA
PA
PA
PA
PA
PA
PA
399
400
401
402
403
404
405
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
clonazepam tab 2mg
cloraz dipot tab 15mg
KLONOPIN
TRANXENE
Tier 2
Tier 2
cloraz dipot tab 3.75mg
TRANXENE
Mail Retail
Route
Limits
Order Store
No
No
No
No
Tier 2
No
No
TRANXENE
Tier 2
No
No
DIASTAT ACDL GEL 12.5-20MG
DIASTAT ACDL GEL 5-10MG
diazepam gel
diazepam gel
Tier 4
Tier 4
No
No
No
No
DIASTAT PED GEL 2.5M GEL
diazepam gel
Tier 4
No
No
diazepam con 5mg/ml
VALIUM
Tier 2
No
No
diazepam sol 1mg/ml
VALIUM
Tier 2
No
No
diazepam tab 10mg
VALIUM
Tier 2
No
No
diazepam tab 2mg
VALIUM
Tier 2
No
No
diazepam tab 5mg
VALIUM
Tier 2
No
No
divalproex cap 125mg
divalproex tab 125mg dr
divalproex tab 250mg er
divalproex tab 500mg er
FYCOMPA TAB 10MG
FYCOMPA TAB 12MG
FYCOMPA TAB 2MG
FYCOMPA TAB 4MG
FYCOMPA TAB 6MG
FYCOMPA TAB 8MG
gabapentin cap 100mg
gabapentin sol 250/5ml
gabapentin tab 600mg
GABITRIL TAB 12MG
GABITRIL TAB 16MG
lorazepam tab 0.5mg
DEPAKOTE
DEPAKOTE
DEPAKOTE
DEPAKOTE
DEPAKOTE
DEPAKOTE
perampanel
perampanel
perampanel
perampanel
perampanel
perampanel
NEURONTIN
NEURONTIN
NEURONTIN
NEURONTIN
NEURONTIN
NEURONTIN
tiagabine
tiagabine
ATIVAN
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
PA
PA, QL (90 per 30
days)
PA, QL (90 per 30
days)
PA, QL (90 per 30
days)
PA
PA, QL (30 per 30
days)
PA, QL (30 per 30
days)
PA, QL (240 per 30
days)
PA, QL (1200 per 30
days)
PA, QL (180 per 30
days)
PA, QL (90 per 30
days)
PA, QL (240 per 30
days)
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
424
425
426
427
428
429
430
431
432
433
434
435
436
437
QL (60 per 30 days)
438
Oral
Oral
Oral
Oral
Rec
Rec
Rec
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
23
Formulary
Covered Drug Name
24
Alternate Drug Name
Tier
lorazepam tab 1mg
lorazepam tab 2mg
ONFI SUS 2.5MG/ML
ONFI TAB 10MG
ONFI TAB 20MG
phenobarb elx 20mg/5ml
ATIVAN
ATIVAN
clobazam
clobazam
clobazam
phenobarbital
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 2
phenobarb tab 100mg
phenobarbital
phenobarb tab 15mg
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
Tier 2
No
No
phenobarbital
Tier 2
No
No
phenobarb tab 16.2mg
phenobarbital
Tier 2
No
No
phenobarb tab 30mg
phenobarbital
Tier 2
No
No
phenobarbital
Tier 2
No
No
phenobarb tab 60mg
phenobarbital
Tier 2
No
No
PHENOBARB TAB 64.8MG
phenobarbital
Tier 2
No
No
phenobarbital
Tier 2
No
No
primidone tab 250mg
primidone tab 50mg
SABRIL POW 500MG
MYSOLINE
MYSOLINE
vigabatrin
Tier 1
Tier 1
Tier 5
Yes
Yes
No
Yes
Yes
No
SABRIL TAB 500MG
vigabatrin
Tier 5
No
No
tiagabine tab 2mg
tiagabine tab 4mg
valproate inj 100mg/ml
valproic acd cap 250mg
valproic acd syp 250/5ml
GABITRIL
GABITRIL
DEPAKENE
DEPAKENE
DEPAKENE
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
No
No
No
Yes
Yes
No
No
No
Yes
Yes
Glutamate Reducing Agents
felbamate sus 600/5ml
felbamate tab 400mg
felbamate tab 600mg
lamotrigine chw 25mg
lamotrigine chw 5mg
lamotrigine tab 100mg
FELBATOL
FELBATOL
FELBATOL
LAMICTAL CHEWABLE
LAMICTAL CHEWABLE
LAMICTAL
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
QL (60 per 30 days)
QL (60 per 30 days)
439
440
441
QL (60 per 30 days)
QL (60 per 30 days)
PA, QL (1500 per 30
days)
PA, QL (90 per 30
days)
PA, QL (120 per 30
days)
PA, QL (360 per 30
days)
PA, QL (195 per 30
days)
PA, QL (180 per 30
days)
PA, QL (60 per 30
days)
PA, QL (90 per 30
days)
PA, QL (60 per 30
days)
442
443
444
445
446
447
448
449
450
451
452
453
454
PA, QL (180 per 30
days)
PA, QL (180 per 30
days)
455
456
457
458
459
460
461
462
463
464
465
466
467
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
lamotrigine tab odt 25mg
lamotrigine tab odt 50mg
lamotrigine tab odt/100mg
lamotrigine tab odt/200mg
topiramate cap 15mg
topiramate cap 25mg
topiramate tab 100mg
topiramate tab 200mg
topiramate tab 25mg
topiramate tab 50mg
LAMICTAL
LAMICTAL
LAMICTAL
LAMICTAL ODT
LAMICTAL ODT
LAMICTAL ODT
LAMICTAL ODT
TOPAMAX
TOPAMAX
TOPAMAX
TOPAMAX
TOPAMAX
TOPAMAX
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Sodium Channel Agents
APTIOM TAB 200MG
APTIOM TAB 400MG
APTIOM TAB 600MG
APTIOM TAB 800MG
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
carbamazepin cap 100mg er
carbamazepin chw 100mg
carbamazepin sus 100/5ml
carbamazepin tab 200mg
carbamazepin tab 200mg er
carbamazepin tab 400mg er
DILANTIN CAP 100MG
DILANTIN CAP 30MG
DILANTIN CHW 50MG
DILANTIN-125 SUS 125/5ML
epitol tab 200mg
EQUETRO CAP 100MG
EQUETRO CAP 200MG
EQUETRO CAP 300MG
oxcarbazepin sus 300mg/5ml
oxcarbazepin tab 150mg
eslicarbazepine
eslicarbazepine
eslicarbazepine
eslicarbazepine
rufinamide
rufinamide
rufinamide
TEGRETOL XR
TEGRETOL XR
TEGRETOL XR
TEGRETOL
TEGRETOL
TEGRETOL
TEGRETOL XR
TEGRETOL XR
phenytoin
phenytoin
phenytoin
phenytoin
TEGRETOL
carbamazepine sr
carbamazepine sr
carbamazepine sr
TRILEPTAL
TRILEPTAL
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 4
Tier 5
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 1
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Mail Retail
Route
Limits
Order Store
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
468
469
470
471
472
473
474
475
476
477
478
479
480
QL (90 per 30 days)
QL (60 per 30 days)
QL (45 per 30 days)
481
482
483
484
485
486
487
488
489
490
491
492
493
494
495
496
497
498
499
500
501
502
503
504
505
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
25
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Tier 3
No
No
Tier 1
Tier 2
Tier 1
Tier 2
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
TRILEPTAL
TRILEPTAL
oxcarbazepine
oxcarbazepine
oxcarbazepine
ethotoin
DILANTIN CHEWABLE
DILANTIN
DILANTIN
DILANTIN
DILANTIN
lacosamide
lacosamide
lacosamide
lacosamide
lacosamide
lacosamide
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Antidementia Agents, Other
ergoloid mes tab 1mg
ergoloid mesylates
Cholinesterase Inhibitors
donepezil tab 10mg
donepezil tab 10mg odt
donepezil tab 5mg
EXELON DIS 13.3/24HR
EXELON DIS 4.6MG/24HR
EXELON DIS 9.5MG/24HR
galantamine cap 16mg er
galantamine sol 4mg/ml
galantamine tab 12mg
galantamine tab 4mg
galantamine tab 8mg
rivastigmine cap 1.5mg
rivastigmine cap 3mg
ARICEPT
ARICEPT ODT
ARICEPT
ARICEPT ODT
rivastigmine patch
rivastigmine patch
rivastigmine patch
RAZADYNE ER
RAZADYNE ER
RAZADYNE ER
REMINYL, RAZADYNE
REMINYL, RAZADYNE
REMINYL, RAZADYNE
REMINYL, RAZADYNE
EXELON
EXELON
OXTELLAR XR TAB 150MG
PEGANONE TAB 250MG
phenytoin chw 50mg
phenytoin ex cap 100mg
phenytoin sus 125/5ml
VIMPAT INJ 200MG/20ML
VIMPAT SOL 10MG/ML
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
VIMPAT TAB 50MG
Mail Retail
Route
Limits
Order Store
Oral
Oral
QL (480 per 30 days) Oral
Oral
Oral
Oral
Oral
Oral
Oral
QL (1200 per 30 days) Inj
506
507
508
509
510
511
512
513
514
515
516
517
518
519
520
521
522
ANTIDEMENTIA AGENTS
26
523
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
524
525
526
527
528
529
530
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
531
532
533
534
535
536
537
538
539
Oral
Oral
Oral
Oral
Oral
TD
TD
TD
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
EXELON
EXELON
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA SOL 10MG/5ML
memantine
NAMENDA TAB 10MG
memantine
NAMENDA TAB 5MG
memantine
Tier
Mail Retail
Route
Limits
Order Store
Yes
Yes
Tier 3
Tier 3
Tier 3
Yes
No
No
Tier 2
Tier 2
540
541
542
543
544
Oral
Oral
Oral
Oral
Oral
ANTIDEPRESSANTS
Antidepressants, Other
ABILIFY DISC TAB 10MG
aripiprazole disintegrating
Tier 4
No
Yes
ABILIFY MAIN INJ 300MG
aripiprazole tab 10mg
aripiprazole
aripiprazole
ABILIFY
Tier 5
Tier 5
Tier 2
No
No
No
No
No
Yes
ABILIFY
Tier 2
No
Yes
ABILIFY
Tier 2
No
Yes
ABILIFY
Tier 2
No
Yes
ABILIFY
Tier 2
No
Yes
ABILIFY
Tier 2
No
Yes
bupropion tab 100mg
bupropion tab 100mg sr
bupropion tab 75mg
bupropn hcl tab 150mg xl
maprotiline tab 25mg
mirtazapine tab 15mg
mirtazapine tab 15mg odt
WELLBUTRIN
WELLBUTRIN SR, BUDEPRION SR
WELLBUTRIN
WELLBUTRIN XL
WELLBUTRIN XL
LUDIOMIL
LUDIOMIL
LUDIOMIL
REMERON
REMERON
REMERON
REMERON
REMERON
Tier 1
Tier 2
Tier 2
Tier 2
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
PA, QL (90 per 30
days)
PA
PA
PA, QL (90 per 30
days)
PA, QL (60 per 30
days)
PA, QL (60 per 30
days)
PA, QL (450 per 30
days)
PA, QL (30 per 30
days)
PA, QL (180 per 30
days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (45 per 30 days)
545
546
547
548
549
550
551
552
553
554
555
556
557
558
559
560
561
562
563
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
564
565
566
567
568
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
27
Formulary
Covered Drug Name
mirtazapine tab 7.5mg
olanza/fluox cap 12-25mg
perphen/amit tab 2-10mg
quetiapine tab 100mg
quetiapine tab 25mg
quetiapine tab 50mg
Alternate Drug Name
REMERON
REMERON
SYMBYAX
SYMBYAX
SYMBYAX
SYMBYAX
SYMBYAX
perphenazine - amitriptyline
SEROQUEL
SEROQUEL
SEROQUEL
SEROQUEL
SEROQUEL
SEROQUEL
Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Mail Retail
Route
Limits
Order Store
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Monoamine Oxidase Inhibitors
EMSAM DIS 12MG/24HR
selegiline
Tier 5
No
Yes
EMSAM DIS 6MG/24HR
selegiline
Tier 5
No
Yes
EMSAM DIS 9MG/24HR
selegiline
Tier 5
No
Yes
MARPLAN TAB 10MG
phenelzine tab 15mg
tranylcyprom tab 10mg
isocarboxazid
NARDIL
PARNATE
Tier 4
Tier 1
Tier 1
No
No
Yes
No
No
Yes
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
569
570
571
572
573
574
575
576
577
578
579
580
QL (90 per 30 days)
QL (60 per 30 days)
PA, QL (30 per 30
days)
PA, QL (30 per 30
days)
PA, QL (30 per 30
days)
581
582
583
584
585
586
587
588
589
590
591
592
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
TD
TD
TD
Oral
Oral
Oral
SSRIs/SNRIs-Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake
Inhibitors
BRINTELLIX TAB 10MG
vortioxetine
Tier 4 No No QL (60 per 30 days) Oral
BRINTELLIX TAB 20MG
vortioxetine
BRINTELLIX TAB 5MG
vortioxetine
citalopram sol 10mg/5ml
CELEXA
Tier 1 Yes Yes QL (600 per 30 days) Oral
citalopram tab 10mg
CELEXA
citalopram tab 20mg
CELEXA
citalopram tab 40mg
CELEXA
DULOXETINE CAP 20MG
CYMBALTA
duloxetine cap 30mg
CYMBALTA
593
594
595
596
597
598
599
600
601
28
Formulary
Covered Drug Name
duloxetine cap 40mg
duloxetine cap 60mg
escitalopram sol 5mg/5ml
escitalopram tab 10mg
FETZIMA CAP 120MG
FETZIMA CAP 20MG
FETZIMA CAP 40MG
FETZIMA CAP 80MG
FETZIMA CAP TITRATION
fluoxetine cap 10mg
fluoxetine cap 20mg
fluoxetine cap 40mg
fluoxetine sol 20mg/5ml
fluoxetine tab 10mg
fluoxetine tab 20mg
fluvoxamine tab 100mg
KHEDEZLA TAB 100MG ER
nefazodone tab 100mg
nefazodone tab 50mg
paroxetin er tab 12.5mg
paroxetine tab 10mg
paroxetine tab 20mg
paroxetine tab 25mg er
paroxetine tab 30mg
paroxetine tab 40mg
PAXIL SUS 10MG/5ML
PRISTIQ TAB 100MG
PRISTIQ TAB 25MG
PRISTIQ TAB 50MG
sertraline con 20mg/ml
sertraline tab 100mg
sertraline tab 25mg
sertraline tab 50mg
Alternate Drug Name
CYMBALTA
CYMBALTA
LEXAPRO
LEXAPRO
LEXAPRO
LEXAPRO
levomilnacipran
levomilnacipran
levomilnacipran
levomilnacipran
levomilnacipran
PROZAC
PROZAC
PROZAC
PROZAC
PROZAC
PROZAC
LUVOX
LUVOX
LUVOX
desvenlafaxine er
desvenlafaxine er
SERZONE
SERZONE
SERZONE
SERZONE
SERZONE
PAXIL CR
PAXIL CR
PAXIL
PAXIL
PAXIL CR
PAXIL
PAXIL
paroxetine
desvenlafaxine
desvenlafaxine
desvenlafaxine
ZOLOFT
ZOLOFT
ZOLOFT
ZOLOFT
Tier
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Mail Retail
Route
Limits
Order Store
No
No
No
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
QL (90 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (28 per 28 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
602
603
604
605
606
607
608
609
610
611
612
613
614
615
616
QL (30 per 30 days)
617
618
QL (90 per 30 days)
619
620
621
622
623
624
625
626
627
628
QL (60 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (45 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
629
630
631
632
633
634
635
636
637
638
639
640
641
642
643
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
29
Formulary
Covered Drug Name
30
Alternate Drug Name
Tier
trazodone tab 100mg
trazodone tab 150mg
trazodone tab 300mg
trazodone tab 50mg
venlafaxine cap 150mg er
venlafaxine cap 37.5mg
venlafaxine tab 100mg
venlafaxine tab 150mg er
venlafaxine tab 37.5 er
venlafaxine tab 37.5mg
VIIBRYD KIT
VIIBRYD TAB 10MG
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG
DESYREL,OLEPTRO
DESYREL,OLEPTRO
DESYREL,OLEPTRO
DESYREL,OLEPTRO
EFFEXOR ER
EFFEXOR ER
EFFEXOR ER
EFFEXOR
EFFEXOR ER
EFFEXOR ER
EFFEXOR
EFFEXOR XR
EFFEXOR
EFFEXOR
EFFEXOR
EFFEXOR ER
vilazodone
vilazodone
vilazodone
vilazodone
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tricyclics
amitriptylin tab 100mg
amoxapine tab 100mg
amoxapine tab 150mg
amoxapine tab 25mg
amoxapine tab 50mg
clomipramine cap 25mg
desipramine tab 100mg
ELAVIL
ELAVIL
ELAVIL
ELAVIL
ELAVIL
ELAVIL
ASENDIN
ASENDIN
ASENDIN
ASENDIN
ANAFRANIL
ANAFRANIL
ANAFRANIL
NORPRAMIN
NORPRAMIN
NORPRAMIN
NORPRAMIN
NORPRAMIN
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Mail Retail
Route
Limits
Order Store
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
644
645
646
647
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
648
649
650
651
652
653
654
655
656
657
658
659
660
QL (60 per 30 days)
QL (30 per 30 days)
661
662
663
664
665
666
667
668
669
670
671
672
673
674
675
676
677
678
679
680
681
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
doxepin hcl cap 100mg
doxepin hcl con 10mg/ml
imipram hcl tab 10mg
imipram pam cap 100mg
nortriptylin cap 10mg
nortriptylin sol 10mg/5ml
protriptylin tab 10mg
protriptylin tab 5mg
SURMONTIL CAP 100MG
SURMONTIL CAP 25MG
SURMONTIL CAP 50MG
Alternate Drug Name
Tier
NORPRAMIN
SINEQUAN
SINEQUAN
SINEQUAN
SINEQUAN
SINEQUAN
SINEQUAN
SINEQUAN
TOFRANIL
TOFRANIL
TOFRANIL
TOFRANIL-PM
TOFRANIL-PM
TOFRANIL-PM
TOFRANIL-PM
PAMELOR
PAMELOR
PAMELOR
PAMELOR
PAMELOR
VIVACTIL
VIVACTIL
trimipramine
trimipramine
trimipramine
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
THORAZINE
THORAZINE
THORAZINE
THORAZINE
THORAZINE
THORAZINE
prochlorperazine
BENADRYL
ANTIVERT
ANTIVERT
REGLAN
REGLAN
REGLAN
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 2
Mail Retail
Route
Limits
Order Store
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
682
683
684
685
686
687
688
689
690
691
692
693
694
695
696
697
698
699
700
701
702
703
704
705
706
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
ANTIEMETICS
Antiemetics, Other
chlorpromaz inj 25mg/ml
chlorpromaz tab 100mg
compro sup 25mg
diphenhydram inj 50mg/ml
meclizine tab 12.5mg
meclizine tab 25mg
metoclopram inj 5mg/ml
metoclopram sol 5mg/5ml
metoclopram tab 10mg
707
708
709
710
711
712
713
PA
714
715
716
PA
717
718
719
Inj
Oral
Oral
Oral
Oral
Oral
Rec
Inj
Oral
Oral
Inj
Oral
Oral
31
Formulary
Covered Drug Name
metoclopram tab 5mg
perphenazine tab 16mg
prochlorper inj 5mg/ml
prochlorper sup 25mg
prochlorper tab 10mg
prochlorper tab 5mg
promethazine inj 25mg/ml
promethazine tab 12.5mg
TRANSDERM-SC DIS 1.5MG
32
Alternate Drug Name
REGLAN
TRILAFON
TRILAFON
TRILAFON
TRILAFON
COMPAZINE
COMPRO
COMPAZINE
COMPAZINE
PHENERGAN
PHENERGAN
scopolamine transdermal patch
Tier
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Mail Retail
Route
Limits
Order Store
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
PA
No
Emetogenic Therapy Adjuncts
ANZEMET TAB 100MG
dolasetron
Tier 4
No
No
ANZEMET TAB 50MG
dolasetron
Tier 4
No
No
dronabinol cap 10mg
dronabinol cap 2.5mg
dronabinol cap 5mg
EMEND CAP 125MG
MARINOL
MARINOL
MARINOL
aprepitant
Tier 5
Tier 2
Tier 2
Tier 3
No
No
No
No
No
No
No
No
EMEND CAP 40MG
aprepitant
Tier 3
No
No
EMEND CAP 80MG
aprepitant
Tier 3
No
No
granisetron inj 0.1mg/ml
granisetron inj 1mg/ml
granisetron tab 1mg
KYTRIL
KYTRIL
KYTRIL
Tier 2
Tier 2
Tier 2
No
No
No
No
No
No
ondansetron inj 4mg/2ml
ondansetron sol 4mg/5ml
ZOFRAN
ZOFRAN
Tier 2
Tier 1
No
No
No
No
ondansetron tab 24mg
ZOFRAN
Tier 1
No
No
ondansetron tab 4mg
ondansetron tab 4mg odt
ondansetron tab 8mg
ZOFRAN
ZOFRAN ODT
ZOFRAN
ZOFRAN ODT
Tier 1
Tier 1
Tier 1
Tier 1
No
No
No
No
No
No
No
No
PA, QL (30 per 30
days)
PA, QL (30 per 30
days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
PA, QL (30 per 30
days)
PA, QL (30 per 30
days)
PA, QL (30 per 30
days)
PA
PA
PA, QL (30 per 30
days)
PA
PA, QL (150 per 5
days)
PA, QL (30 per 30
days)
PA, QL (12 per 5 days)
720
721
722
723
724
725
726
727
728
729
730
731
732
733
734
735
736
737
738
739
740
741
742
743
744
745
746
747
748
749
Oral
Oral
Oral
Oral
Oral
Inj
Rec
Oral
Oral
Inj
Oral
TD
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
amphotericin b liposomal
amphotericin b liposomal 4 mg/ml
FUNGIZONE
caspofungin
caspofungin
LOPROX
LOPROX
LOPROX
PENLAC
LOPROX
LOTRIMIN
clotrimazole
MYCELEX
SPECTAZOLE
anidulafungin
DIFLUCAN
DIFLUCAN
DIFLUCAN
DIFLUCAN
DIFLUCAN
DIFLUCAN
DIFLUCAN - DEXTROSE
ANCOBON
ANCOBON
GRIFULVIN V
GRIFULVIN V
SPORANOX
NIZORAL
NIZORAL
NIZORAL
MICONAZOLE
natamycin
posaconazole
nystatin
NYSTATIN - TRIAMCINOLONE
NYSTATIN - TRIAMCINOLONE
MYCOSTATIN
MYCOSTATIN
Tier 5
Tier 5
Tier 2
Tier 5
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 5
Tier 5
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 5
Tier 1
Tier 2
Tier 2
Tier 1
Tier 1
Mail Retail
Route
Limits
Order Store
ANTIFUNGALS
Antifungals
ABELCET INJ 5MG/ML
AMBISOME INJ 50MG
amphotericin inj 50mg
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
ciclopirox cre 0.77%
ciclopirox gel 0.77%
ciclopirox sha 1%
ciclopirox sol 8%
ciclopirox sus 0.77%
clotrimazole cre 1%
clotrimazole sol 1%
clotrimazole tro 10mg
econazole cre 1%
ERAXIS INJ 100MG
fluconazole sus 10mg/ml
fluconazole sus 40mg/ml
fluconazole tab 100mg
fluconazole/ inj dex 400mg
flucytosine cap 250mg
flucytosine cap 500mg
griseofulvin sus 125/5ml
griseofulvin tab micr 500mg
itraconazole cap 100mg
ketoconazole cre 2%
ketoconazole sha 2%
ketoconazole tab 200mg
miconazole 3 sup 200mg
NATACYN SUS 5%
NOXAFIL SUS 40MG/ML
nyamyc pow 100000
nystat/triam cre
nystat/triam oin
nystatin cre 100000
nystatin oin 100000
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
PA
PA
PA
PA
PA
750
751
752
753
754
755
756
757
758
759
760
761
762
763
PA
764
765
766
767
768
769
770
PA
771
772
773
774
775
PA
776
777
778
779
QL (3 per 3 days)
780
781
PA
782
783
784
785
786
787
Inj
Inj
Inj
Inj
Inj
Top
Top
Top
Top
Top
Top
Top
MT
Top
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Top
Top
Oral
Vag
OP
Oral
Top
Top
Top
Top
Top
33
Formulary
Covered Drug Name
Alternate Drug Name
Tier
MYCOSTATIN
NYSTATIN
NYSTATIN
MYCOSTATIN
LAMISIL
TERAZOL, ZAZOLE
TERAZOL, ZAZOLE
TERAZOL, ZAZOLE
VFEND
VFEND
VFEND
VFEND
TERAZOL, ZAZOLE
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
Tier 1
Tier 1
Tier 4
Tier 5
Tier 5
Tier 5
Tier 2
ZYLOPRIM
ZYLOPRIM
colchicine
COLCHICINE - PROBENECID
PROBENECID
Ergot Alkaloids
ergomar sub 2mg
migergot sup 2/100
MIGRANAL SPR 4MG/ML
Prophylactic
timolol mal tab 10mg
timolol mal tab 20mg
timolol mal tab 5mg
nystatin pow 100000
nystatin sus 100000
nystatin tab 500000
nystop pow 100000
terbinafine tab 250mg
terconazole cre 0.4%
terconazole cre 0.8%
terconazole sup 80mg
voriconazole inj 200mg
voriconazole sus 40mg/ml
voriconazole tab 200mg
zazole cre 0.4%
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
ergotamine
caffeine-ergotamine
dihydroergotamine nasal spray
Tier 2
Tier 2
Tier 4
No
No
No
No
No
No
BLOCADREN
BLOCADREN
BLOCADREN
Tier 1
Tier 1
Tier 1
Yes
Yes
Yes
Yes
Yes
Yes
Tier 2
Tier 2
Tier 2
No
No
No
No
No
No
788
789
790
791
QL (30 per 30 days)
792
793
794
QL (3 per 3 days)
PA
PA
PA
PA
795
796
797
798
799
800
Top
MT
Oral
Top
Oral
Vag
Vag
Vag
Inj
Oral
Oral
Oral
Vag
ANTIGOUT AGENTS
Antigout Agents
allopurinol tab 100mg
allopurinol tab 300mg
COLCRYS TAB 0.6MG
proben/colch tab 500-0.5mg
probenecid tab 500mg
801
802
803
804
805
Oral
Oral
Oral
Oral
Oral
ANTIMIGRAINE AGENTS
Serotonin (5-HT) 1b/1d Receptor Agonists
rizatriptan tab 10mg
MAXALT
rizatriptan tab 10mg odt
MAXALT
rizatriptan tab 5mg
MAXALT
34
806
807
QL (16 per 30 days)
808
809
810
811
QL (15 per 5 days)
QL (12 per 30 days)
QL (15 per 5 days)
812
813
814
SL
Rec
NS
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
sumatriptan inj 6mg/0.5ml
sumatriptan tab 100mg
Alternate Drug Name
MAXALT
IMITREX
IMITREX
IMITREX
IMITREX
IMITREX
Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Mail Retail
Route
Limits
Order Store
No
No
No
Yes
Yes
Yes
815
816
817
818
819
820
Oral
Inj
Inj
Oral
Oral
Oral
ANTIMYASTHENIC AGENTS
Parasympathomimetics
GUANIDINE TAB 125MG
MESTINON SYP 60MG/5ML
MESTINON TAB TIMESPAN
pyridostigm tab 60mg
guanidine
pyridostigmine
pyridostigmine
MESTINON
Tier 4
Tier 4
Tier 4
Tier 2
No
No
No
No
No
Yes
Yes
Yes
Antimycobacterials, Other
dapsone tab 100mg
dapsone tab 25mg
MYCOBUTIN CAP 150MG
dapsone
dapsone
rifabutin
Tier 2
Tier 2
Tier 4
No
No
No
No
No
No
Antituberculars
CAPASTAT SUL INJ 1GM
ethambutol tab 100mg
ethambutol tab 400mg
isoniazid syp 50mg/5ml
isoniazid tab 100mg
isoniazid tab 300mg
pyrazinamide tab 500mg
rifabutin cap 150mg
rifampin cap 150mg
rifampin cap 300mg
rifampin inj 600 mg
RIFATER TAB
SIRTURO TAB 100MG
TRECATOR TAB 250MG
capreomycin
MYAMBUTOL
MYAMBUTOL
TUBIZID
TUBIZID
TUBIZID
PYRAZINAMIDE
MYCOBUTIN
RIFADIN
RIFADIN
RIFADIN
isoniazid - rifampin
bedaquiline
ethionamide
Tier 4
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 5
Tier 4
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
821
822
823
824
Oral
Oral
Oral
Oral
ANTIMYCOBACTERIALS
825
826
827
PA
828
829
830
831
832
833
834
835
836
837
PA
838
839
PA
840
841
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
35
Formulary
Covered Drug Name
Sulfonamides
PASER GRA 4GM
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
aminosalicylic acid
Tier 2
No
No
Alkylating Agents
cyclophosph cap 25mg
HEXALEN CAP 50MG
LEUKERAN TAB 2MG
lomustine cap 100mg
lomustine cap 10mg
lomustine cap 40mg
MATULANE CAP 50MG
CYTOXAN
CYTOXAN
altretamine
chlorambucil
CEENU
CEENU
CEENU
procarbazine
Tier 4
Tier 4
Tier 5
Tier 4
Tier 3
Tier 3
Tier 3
Tier 5
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
PA
PA
PA
Antiandrogens
bicalutamide tab 50mg
flutamide cap 125mg
NILANDRON TAB 150MG
XTANDI CAP 40MG
CASODEX
EULEXIN
nilutamide
enzalutamide
Tier 2
Tier 2
Tier 4
Tier 5
No
No
No
No
No
No
No
No
QL (30 per 30 days)
ZYTIGA TAB 250MG
abiraterone
Tier 5
No
No
Antiangiogenic Agents
POMALYST CAP 1MG
POMALYST CAP 2MG
POMALYST CAP 3MG
POMALYST CAP 4MG
REVLIMID CAP 10MG
REVLIMID CAP 15MG
REVLIMID CAP 2.5MG
REVLIMID CAP 20MG
REVLIMID CAP 25MG
REVLIMID CAP 5MG
THALOMID CAP 100MG
THALOMID CAP 150MG
pomalidomide
pomalidomide
pomalidomide
pomalidomide
lenalidomide
lenalidomide
lenalidomide
lenalidomide
lenalidomide
lenalidomide
thalidomide
thalidomide
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
842
Oral
ANTINEOPLASTICS
36
843
844
845
846
847
848
849
850
851
852
853
PA, QL (120 per 30
days)
PA, QL (120 per 30
days)
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
854
855
856
857
858
859
860
861
862
863
864
865
866
867
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
THALOMID CAP 200MG
THALOMID CAP 50MG
thalidomide
thalidomide
Tier 5
Tier 5
Antiestrogens/Modifiers
EMCYT CAP 140MG
FARESTON TAB 60MG
SOLTAMOX SOL 10MG/5ML
tamoxifen tab 10mg
tamoxifen tab 20mg
estramustine
toremifene
tamoxifen
NOLVADEX
NOLVADEX
Antimetabolites
DROXIA CAP 200MG
DROXIA CAP 300MG
DROXIA CAP 400MG
hydroxyurea cap 500mg
mercaptopur tab 50mg
PURIXAN SUS 20MG/ML
TABLOID TAB 40MG
Antineoplastics, Other
ALIMTA INJ 500MG
amifostine inj 500mg
azacitidine inj 100mg
BELEODAQ INJ 500MG
bleomycin inj 30unit
DOCEFREZ INJ 20MG
ELITEK INJ 1.5MG
ERWINAZE INJ 10000UNT
FARYDAK CAP 10MG
FARYDAK CAP 15MG
FARYDAK CAP 20MG
FASLODEX INJ 250MG
IBRANCE CAP 100MG
IBRANCE CAP 125MG
IBRANCE CAP 75MG
ISTODAX INJ 10MG
KADCYLA INJ 100MG
leucovor ca inj 100mg
Mail Retail
Route
Limits
Order Store
No
No
No
No
PA
PA
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
No
No
No
Yes
Yes
No
No
No
Yes
Yes
PA
hydroxyurea
hydroxyurea
hydroxyurea
HYDREA
PURINETHOL
mercaptopurine
thioguanine
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 4
Tier 4
No
No
No
No
No
No
No
No
No
No
No
No
No
No
PA
pemetrexed
ETHYOL
VIDAZA
belinostat
BLENOXANE
docetaxel
rasburicase
erwinia asparaginase
panobinostat
panobinostat
panobinostat
fulvestrant
palbociclib
palbociclib
palbociclib
romidepsin
ado-trastuzumab
LEUCOVORIN
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
868
869
870
871
872
873
874
875
876
877
878
879
880
881
882
883
884
885
886
887
888
889
890
891
892
893
894
895
896
897
898
899
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Inj
Inj
Inj
37
Formulary
Covered Drug Name
leucovor ca tab 10mg
leucovor ca tab 5mg
levoleucovor inj 50mg
mesna inj 1gm
MESNEX TAB 400MG
mitoxantron inj 2mg/ml
ONCASPAR INJ 750/ML
paclitaxel inj 300/50ml
PROLEUKIN INJ 22MU
SYNRIBO INJ 3.5MG
VALCHLOR GEL 0.016%
ZOLINZA CAP 100MG
38
Alternate Drug Name
LEUCOVORIN
LEUCOVORIN
LEUCOVORIN
LEUCOVORIN
LEUCOVORIN
FUSILEV
MESNEX
mesna
NOVANTRONE
pegaspargase
TAXOL
aldesleukin
omacetaxine
mechlorethamine
vorinostat
Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 2
Tier 5
Tier 2
Tier 5
Tier 5
Tier 5
Tier 5
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
PA
900
901
902
903
904
PA
PA
905
906
907
PA
PA
PA
PA
PA
PA
PA
Aromatase Inhibitors, 3rd Generation
anastrozole tab 1mg
ARIMIDEX
exemestane tab 25mg
AROMASIN
letrozole tab 2.5mg
FEMARA
Tier 2
Tier 2
Tier 2
Yes
No
No
No
Enzyme Inhibitors
etoposide inj 20mg/ml
topotecan inj 4mg
VEPESID
HYCAMTIN
Tier 2
Tier 5
No
No
No
No
PA
PA
Molecular Target Inhibitors
AFINITOR DIS TAB 2MG
everolimus
Tier 5
No
No
everolimus
Tier 5
No
No
everolimus
Tier 5
No
No
AFINITOR TAB 10MG
everolimus
Tier 5
No
No
AFINITOR TAB 2.5MG
everolimus
Tier 5
No
No
AFINITOR TAB 5MG
everolimus
Tier 5
No
No
PA, QL (150 per 30
days)
PA, QL (90 per 30
days)
PA, QL (60 per 30
days)
PA, QL (60 per 30
days)
PA, QL (60 per 30
days)
PA, QL (60 per 30
days)
908
909
910
911
912
913
914
915
916
917
918
919
920
921
922
923
924
925
Inj
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Inj
Inj
Inj
Inj
Inj
Top
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
AFINITOR TAB 7.5MG
everolimus
Tier 5
BOSULIF TAB 100MG
bosutinib
BOSULIF TAB 500MG
Mail Retail
Route
Limits
Order Store
No
No
Tier 5
No
No
bosutinib
Tier 5
No
No
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
COMETRIQ KIT 100MG
vandetanib
vandetanib
cabozantinib
Tier 5
Tier 5
Tier 5
No
No
No
No
No
No
COMETRIQ KIT 140MG
cabozantinib
Tier 5
No
No
COMETRIQ KIT 60MG
cabozantinib
Tier 5
No
No
ERIVEDGE CAP 150MG
GILOTRIF TAB 20MG
vismodegib
afatinib
Tier 5
Tier 5
No
No
No
No
GILOTRIF TAB 30MG
afatinib
Tier 5
No
No
GILOTRIF TAB 40MG
afatinib
Tier 5
No
No
GLEEVEC TAB 100MG
imatinib
Tier 5
No
No
GLEEVEC TAB 400MG
imatinib
Tier 5
No
No
ICLUSIG TAB 15MG
ponatinib
Tier 5
No
No
ICLUSIG TAB 45MG
ponatinib
Tier 5
No
No
IMBRUVICA CAP 140MG
ibrutinib
Tier 5
No
No
INLYTA TAB 1MG
INLYTA TAB 5MG
JAKAFI TAB 10MG
axitinib
axitinib
ruxolitinib
Tier 5
Tier 5
Tier 5
No
No
No
No
No
No
JAKAFI TAB 15MG
ruxolitinib
Tier 5
No
No
JAKAFI TAB 20MG
ruxolitinib
Tier 5
No
No
JAKAFI TAB 25MG
ruxolitinib
Tier 5
No
No
JAKAFI TAB 5MG
ruxolitinib
Tier 5
No
No
LENVIMA CAP 10MG
LENVIMA CAP 14MG
lenvatinib
lenvatinib
Tier 5
Tier 5
No
No
No
No
PA, QL (60 per 30
days)
PA, QL (120 per 30
days)
PA, QL (30 per 30
days)
QL (60 per 30 days)
QL (30 per 30 days)
PA, QL (56 per 28
days)
PA, QL (112 per 28
days)
PA, QL (84 per 28
days)
PA
PA, QL (30 per 30
days)
PA, QL (30 per 30
days)
PA, QL (30 per 30
days)
PA, QL (90 per 30
days)
PA, QL (60 per 30
days)
PA, QL (60 per 30
days)
PA, QL (30 per 30
days)
PA, QL (120 per 30
days)
PA
PA
PA, QL (60 per 30
days)
PA, QL (60 per 30
days)
PA, QL (60 per 30
days)
PA, QL (60 per 30
days)
PA, QL (60 per 30
days)
PA
PA
926
927
928
929
930
931
932
933
934
935
936
937
938
939
940
941
942
943
944
945
946
947
948
949
950
951
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
39
Formulary
Covered Drug Name
40
Alternate Drug Name
Tier
LENVIMA CAP 20MG
LENVIMA CAP 24MG
LYNPARZA CAP 50MG
MEKINIST TAB 0.5MG
lenvatinib
lenvatinib
olaparib
trametinib
Tier 5
Tier 5
Tier 5
Tier 5
MEKINIST TAB 2MG
trametinib
NEXAVAR TAB 200MG
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
Tier 5
No
No
sorafenib
Tier 5
No
No
SPRYCEL TAB 100MG
SPRYCEL TAB 140MG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 80MG
STIVARGA TAB 40MG
dasatinib
dasatinib
dasatinib
dasatinib
dasatinib
dasatinib
sorafenib
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
No
No
No
No
No
No
No
No
No
No
No
No
No
No
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 37.5MG
SUTENT CAP 50MG
TAFINLAR CAP 50MG
sunitinib
sunitinib
sunitinib
sunitinib
dabrafenib
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
No
No
No
No
No
No
No
No
No
No
TAFINLAR CAP 75MG
dabrafenib
Tier 5
No
No
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TARCEVA TAB 25MG
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TRISENOX SOL 10MG/10ML
TYKERB TAB 250MG
VELCADE INJ 3.5MG
VOTRIENT TAB 200MG
XALKORI CAP 200MG
erlotinib
erlotinib
erlotinib
nilotinib
nilotinib
arsenic trioxide
lapatinib
bortezomib
pazopanib
crizotinib
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
XALKORI CAP 250MG
crizotinib
Tier 5
No
No
ZELBORAF TAB 240MG
vemurafenib
Tier 5
No
No
ZYDELIG TAB 100MG
idelalisib
Tier 5
No
No
ZYDELIG TAB 150MG
idelalisib
Tier 5
No
No
PA
PA
PA
PA, QL (120 per 30
days)
PA, QL (30 per 30
days)
PA, QL (120 per 30
days)
PA
PA
PA
PA
PA
PA
PA, QL (84 per 28
days)
PA
PA
PA
PA
PA, QL (180 per 30
days)
PA, QL (120 per 30
days)
PA
PA
PA
PA
PA
PA
PA
PA
952
953
954
955
956
957
958
959
960
961
962
963
964
965
966
967
968
969
970
971
972
973
974
975
976
977
978
979
PA, QL (60 per 30
days)
PA, QL (60 per 30
days)
PA, QL (240 per 30
days)
PA, QL (90 per 30
days)
PA, QL (60 per 30
days)
980
981
982
983
984
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
ZYKADIA CAP 150MG
ceritinib
Tier 5
Monoclonal Antibodies
AVASTIN INJ
HERCEPTIN INJ 440MG
KEYTRUDA SOL 50MG
OPDIVO INJ 40MG/4ML
PERJETA INJ 420/14ML
RITUXAN INJ 500MG
YERVOY INJ 50MG
ZALTRAP INJ 100/4ML
bevacizumab
trastuzumab
pembrolizumab
nivolumab
pertuzumab
rituximab
ipilimumab
ziv-aflibercept
Retinoids
PANRETIN GEL 0.1%
TARGRETIN CAP 75MG
TARGRETIN GEL 1%
tretinoin cap 10mg
Mail Retail
Route
Limits
Order Store
No
No
PA, QL (150 per 30
days)
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
PA
PA
PA
PA
PA
PA
PA
PA
alitretinoin
bexarotene
bexarotene
Tier 5
Tier 5
Tier 5
No
No
No
No
No
No
VESANOID
Tier 5
No
No
Antihelminthics
ALBENZA TAB 200MG
BILTRICIDE TAB 600MG
STROMECTOL TAB 3MG
albendazole
praziquantel
ivermectin
Tier 5
Tier 4
Tier 3
No
No
No
No
No
No
Antiprotozoals
ALINIA SUS 100/5ML
ALINIA TAB 500MG
atovaq/progu tab 250-100mg
atovaq/progu tab 62.5-25mg
chloroquine tab 250mg
chloroquine tab 500mg
COARTEM TAB 20-120MG
DARAPRIM TAB 25MG
hydroxychlor tab 200mg
mefloquine tab 250mg
nitazoxanide
nitazoxanide
MALARONE
MALARONE
ARALEN
ARALEN
artemether - lumefantrine
pyrimethamine
PLAQUENIL
LARIAM
Tier 4
Tier 4
Tier 2
Tier 2
Tier 1
Tier 1
Tier 4
Tier 4
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
985
986
987
988
989
990
991
992
993
994
PA
PA, QL (60 per 30
days)
PA
995
996
997
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Top
Oral
Top
Oral
ANTIPARASITICS
998
999
1000
1001
1002
1003
1004
1005
1006
1007
1008
1009
1010
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
41
Formulary
Covered Drug Name
Alternate Drug Name
Tier
MEPRON SUS
NEBUPENT INH 300MG
PENTAM 300 INJ 300MG
PRIMAQUINE TAB 26.3MG
quinine sulf cap 324mg
atovaquone
pentamidine neb
pentamidine
primaquine
QUALAQUIN
Tier 5
Tier 4
Tier 4
Tier 4
Tier 2
Pediculicides/Scabicides
EURAX CRE 10%
EURAX LOT 10%
malathion lot 0.5%
permethrin cre 5%
crotamiton
crotamiton
OVIDE
ELIMITE
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
Tier 3
Tier 3
Tier 1
Tier 2
No
No
No
No
No
No
No
No
PA
PA
PA
1011
1012
1013
1014
PA
1015
1016
1017
1018
1019
Oral
Inh
Inj
Oral
Oral
Top
Top
Top
Top
ANTIPARKINSON AGENTS
42
Anticholinergics
benztropine inj 1mg/ml
benztropine tab 0.5mg
benztropine tab 1mg
benztropine tab 2mg
trihexyphen elx 0.4mg/ml
trihexyphen tab 2mg
trihexyphen tab 5mg
COGENTIN
COGENTIN
COGENTIN
COGENTIN
ARTANE, TRIHEXANE
ARTANE, TRIHEXANE
ARTANE, TRIHEXANE
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Antiparkinson Agents, Other
amantadine cap 100mg
amantadine syp 50mg/5ml
amantadine tab 100mg
entacapone tab 200mg
TASMAR TAB 100MG
SYMMETREL
SYMMETREL
SYMMETREL
COMTAN
tolcapone
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Dopamine Agonists
APOKYN INJ 10MG/ML
bromocriptin cap 5mg
bromocriptin tab 2.5mg
NEUPRO DIS 1MG/24HR
NEUPRO DIS 2MG/24HR
NEUPRO DIS 3MG/24HR
NEUPRO DIS 4MG/24HR
apomorphine
PARLODEL
PARLODEL
rotigotine transdermal patch
Tier 5
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
No
Yes
Yes
No
No
No
No
No
Yes
Yes
No
No
No
No
1020
PA
PA
PA
PA
PA
PA
PA
1021
1022
1023
1024
1025
1026
1027
1028
1029
1030
1031
1032
1033
1034
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
1035
1036
1037
1038
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
TD
TD
TD
TD
Formulary
Covered Drug Name
NEUPRO DIS 6MG/24HR
NEUPRO DIS 8MG/24HR
pramipexole tab 0.125mg
pramipexole tab 1mg
ropinirole tab 0.25mg
ropinirole tab 0.5mg
ropinirole tab 1mg
ropinirole tab 2mg
ropinirole tab 3mg
ropinirole tab 4mg
ropinirole tab 5mg
Alternate Drug Name
Tier
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors
carb/levo er tab 25-100mg
SINEMET CR
Tier 1
carb/levo er tab 50-200mg
SINEMET CR
Tier 1
carb/levo tab 10-100mg
PERCOPA
Tier 1
SINEMET
Tier 1
PERCOPA
Tier 1
SINEMET
Tier 1
PERCOPA
Tier 1
SINEMET
Tier 1
carbidopa tab 25mg
LODOSYN
Tier 1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT TAB 0.5MG
rasagiline
AZILECT TAB 1MG
rasagiline
selegiline cap 5mg
ELDEPRYL
selegiline tab 5mg
ELDEPRYL
Tier 4
Tier 4
Tier 1
Tier 1
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Tier 2
Tier 2
Tier 2
No
Yes
Yes
No
Yes
Yes
MIRAPEX
MIRAPEX
MIRAPEX
MIRAPEX
MIRAPEX
MIRAPEX
REQUIP
REQUIP
REQUIP
REQUIP
REQUIP
REQUIP
REQUIP
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Mail Retail
Route
Limits
Order Store
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
1039
1040
1041
1042
1043
1044
1045
1046
1047
1048
1049
1050
1051
1052
1053
1054
1055
1056
1057
1058
1059
1060
1061
1062
1063
1064
1065
1066
TD
TD
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
ANTIPSYCHOTICS
1st Generation/Typical
fluphenaz de inj 25mg/ml
fluphenazine con 5mg/ml
fluphenazine elx 2.5/5ml
PROLIXIN
PROLIXIN
PROLIXIN
1067
1068
1069
Inj
Oral
Oral
43
Formulary
Covered Drug Name
44
Alternate Drug Name
Tier
fluphenazine inj 2.5mg/ml
fluphenazine tab 10mg
fluphenazine tab 2.5mg
haloper dec inj 100mg/ml
haloper lac inj 5mg/ml
haloperidol con 2mg/ml
haloperidol tab 0.5mg
haloperidol tab 10mg
haloperidol tab 1mg
haloperidol tab 20mg
haloperidol tab 2mg
haloperidol tab 5mg
loxapine cap 10mg
loxapine cap 25mg
loxapine cap 50mg
loxapine cap 5mg
ORAP TAB 1MG
ORAP TAB 2MG
thioridazine tab 100mg
thiothixene cap 10mg
thiothixene cap 1mg
thiothixene cap 2mg
thiothixene cap 5mg
trifluoperaz tab 10mg
PROLIXIN
PROLIXIN
PROLIXIN
PROLIXIN
PROLIXIN
HALDOL DEC
HALDOL DEC
HALDOL LAC
HALDOL LAC
HALDOL
HALDOL
HALDOL
HALDOL
HALDOL
HALDOL
LOXITANE
LOXITANE
LOXITANE
LOXITANE
pimozide
pimozide
MELLARIL
MELLARIL
MELLARIL
MELLARIL
NAVANE
NAVANE
NAVANE
NAVANE
STELAZINE
STELAZINE
STELAZINE
STELAZINE
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
2nd Generation/Atypical
FANAPT PAK
FANAPT TAB 10MG
FANAPT TAB 12MG
FANAPT TAB 1MG
FANAPT TAB 2MG
iloperidone
iloperidone
iloperidone
iloperidone
iloperidone
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Mail Retail
Route
Limits
Order Store
No
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
1070
1071
1072
1073
1074
PA
PA
1075
1076
1077
1078
1079
1080
1081
1082
1083
1084
1085
1086
1087
1088
1089
1090
1091
1092
1093
1094
1095
1096
1097
1098
1099
1100
1101
1102
QL (60 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
1103
1104
1105
1106
1107
Inj
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
FANAPT TAB 4MG
FANAPT TAB 6MG
FANAPT TAB 8MG
GEODON INJ 20MG
INVEGA SUST INJ 117/0.75ML
INVEGA SUST INJ 156MG/ML
INVEGA TAB 1.5MG
INVEGA TAB 3MG
INVEGA TAB 6MG
INVEGA TAB 9MG
LATUDA TAB 120MG
LATUDA TAB 20MG
LATUDA TAB 40MG
LATUDA TAB 60MG
LATUDA TAB 80MG
olanzapine inj 10mg
iloperidone
iloperidone
iloperidone
ziprasidone
paliperidone palmitate im
paliperidone
paliperidone
paliperidone
paliperidone
lurasidone
lurasidone
lurasidone
lurasidone
lurasidone
ZYPREXA
Tier 4
Tier 4
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
olanzapine tab 10mg
olanzapine tab 10mg odt
olanzapine tab 15mg
olanzapine tab 2.5mg
olanzapine tab 20mg
olanzapine tab 5mg
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
risperidone sol 1mg/ml
risperidone tab 0.25 odt
risperidone tab 0.25mg
risperidone tab 0.5mg odt
risperidone tab 1mg
risperidone tab 1mg odt
risperidone tab 2mg
ZYPREXA
ZYPREXA ZYDIS
ZYPREXA
ZYPREXA ZYDIS
ZYPREXA
ZYPREXA
ZYPREXA ZYDIS
ZYPREXA
ZYPREXA ZYDIS
ZYPREXA
risperidone
risperidone
risperidone
risperidone
RISPERDAL
RISPERDAL M
RISPERDAL
RISPERDAL
RISPERDAL M
RISPERDAL
RISPERDAL M
RISPERDAL
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 5
Tier 5
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
QL (90 per 30 days)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
1108
1109
1110
1111
PA
PA
PA
PA
PA
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
PA, QL (30 per 30
days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
1112
1113
1114
1115
1116
1117
1118
1119
1120
1121
1122
1123
1124
1125
1126
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
1127
1128
1129
1130
1131
1132
1133
1134
1135
1136
1137
1138
1139
1140
1141
1142
1143
1144
1145
1146
1147
1148
45
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
No
QL (60 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
PA
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
QL (90 per 30 days)
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
risperidone tab 3mg
risperidone tab 4mg
SAPHRIS SUB 10MG
SAPHRIS SUB 2.5MG
SAPHRIS SUB 5MG
ziprasidone cap 20mg
ZYPREXA RELP INJ 210MG
RISPERDAL M
RISPERDAL
RISPERDAL M
RISPERDAL
RISPERDAL M
asenapine
asenapine
asenapine
GEODON
GEODON
GEODON
GEODON
olanzapine susp
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Treatment-Resistant
clozapine tab 100mg
clozapine tab 200mg
clozapine tab 25mg
clozapine tab 50mg
FAZACLO TAB 100/ODT
FAZACLO TAB 12.5/ODT
FAZACLO TAB 150MG
FAZACLO TAB 200MG
FAZACLO TAB 25MG ODT
VERSACLOZ SUS 50MG/ML
CLOZARIL
CLOZARIL
CLOZARIL
CLOZARIL
clozapine
clozapine
clozapine
clozapine
clozapine
clozapine
1149
1150
1151
1152
1153
1154
1155
1156
1157
1158
1159
1160
1161
1162
1163
1164
1165
1166
1167
1168
1169
1170
1171
Oral
Oral
Oral
Oral
Oral
SL
SL
SL
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
ANTISPASTICITY AGENTS
Antispasticity Agents
baclofen tab 10mg
baclofen tab 20mg
dantrolene cap 100mg
dantrolene cap 25mg
dantrolene cap 50mg
tizanidine cap 2mg
tizanidine cap 4mg
tizanidine cap 6mg
tizanidine tab 2mg
tizanidine tab 4mg
46
KEMSTRO, LIORESAL
KEMSTRO, LIORESAL
DANTRIUM
DANTRIUM
DANTRIUM
ZANAFLEX
ZANAFLEX
ZANAFLEX
ZANAFLEX
ZANAFLEX
1172
1173
1174
1175
1176
1177
1178
1179
1180
1181
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
ANTIVIRALS
Anti-cytomegalovirus (CMV) Agents
FOSCARNET INJ 24MG/ML
foscarnet
ganciclovir inj 500mg
CYTOVENE
VALCYTE SOL 50MG/ML
valganciclovir
valganciclov tab 450mg
VALCYTE
ZIRGAN GEL 0.15%
ganciclovir
Tier 2
Tier 4
Tier 5
Tier 5
Tier 4
No
No
No
No
No
No
No
No
No
No
Anti-hepatitis B (HBV) Agents
BARACLUDE SOL .05MG/ML
entecavir
Tier 5
No
No
entecavir tab 0.5mg
BARACLUDE
Tier 5
No
No
entecavir tab 1mg
BARACLUDE
Tier 5
No
No
EPIVIR HBV SOL 5MG/ML
HEPSERA TAB 10MG
INTRON-A INJ 10MU
INTRON-A INJ 18MU
PEG-INTRON KIT 120 RP
PEG-INTRON KIT 50MCG
PEG-INTRON KIT 50MCG RP
PEGASYS INJ 180MCG/0.5ML
PEGASYS INJ 180MCG/ML
ribapak pak 1200/day
ribapak pak 800/day
ribasphere cap 200mg
ribasphere tab 200mg
ribavirin cap 200mg
ribavirin tab 200mg
SYLATRON KIT 296MCG
lamivudine
adefovir
interferon alfa-2b
interferon alfa-2b
peginterferon alfa-2b
peginterferon alfa-2a
peginterferon alfa-2a
ribavirin
ribavirin
REBETOL
REBETOL-COPEGUS
RIBASPHERE, REBETOL
RIBASPHERE, REBETOL-COPEGUS
Tier 4
Tier 5
Tier 5
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
Tier 2
Tier 4
Tier 4
Tier 5
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
SYLATRON KIT 444MCG
SYLATRON KIT 888MCG
Tier 5
Tier 5
No
No
TYZEKA TAB 600MG
telbivudine
Tier 5
No
1182
PA
1183
1184
1185
1186
PA, QL (600 per 30
days)
PA, QL (30 per 30
days)
PA, QL (30 per 30
days)
1187
1188
1189
1190
PA
PA
PA
1191
1192
1193
1194
1195
1196
1197
1198
1199
1200
1201
1202
1203
1204
1205
1206
Inj
Inj
Oral
Oral
OP
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Inj
PA, QL (25 per 28
days)
No PA, QL (5 per 28 days) Inj
No
PA, QL (25 per 28
Inj
days)
No
PA
Oral
1207
1208
1209
1210
47
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
Anti-hepatitis C (HCV) Agents
SOVALDI TAB 400MG
sofosbuvir 400 mg
Tier 5
No
No
VIEKIRA PAK TAB
Tier 5
No
No
Tier 5
Tier 3
Tier 3
Tier 5
Tier 5
No
No
No
No
No
No
No
No
No
No
Tier 5
Tier 5
Tier 5
No
No
No
No
No
No
dasabuvir - ombitasvir - paritaprevir ritonavir
Anti-HIV Agents, Integrase Inhibitors (INSTI)
ISENTRESS CHW 100MG
raltegravir
ISENTRESS CHW 25MG
raltegravir
ISENTRESS POW 100MG
raltegravir
ISENTRESS TAB 400MG
raltegravir
STRIBILD TAB
cobicistat-elvitegravir-emtricitabinetenofovir
TIVICAY TAB 50MG
dolutegravir
VITEKTA TAB 150MG
elvitegravir
VITEKTA TAB 85MG
elvitegravir
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
COMPLERA TAB
emtricitabine-rilpivirine-tenofovir
Tier 5 No No
EDURANT TAB 25MG
rilpivirine
Tier 5 No No
INTELENCE TAB 100MG
etravirine
Tier 5 No No
INTELENCE TAB 200MG
etravirine
Tier 5 No No
INTELENCE TAB 25MG
etravirine
Tier 4 No No
nevirapine 400 mg extended release
VIRAMUNE XR
Tier 2 No No
nevirapine sus 50mg/5ml
VIRAMUNE
Tier 4 No No
nevirapine tab 200mg
VIRAMUNE
Tier 2 No No
RESCRIPTOR TAB 100 MG
delavirdine
Tier 4 No No
RESCRIPTOR TAB 200MG
delavirdine
Tier 4 No No
SUSTIVA CAP 200MG
efavirenz
Tier 3 No No
SUSTIVA CAP 50MG
efavirenz
Tier 3 No No
SUSTIVA TAB 600MG
efavirenz
Tier 3 No No
VIRAMUNE SUS 50MG/5ML
nevirapine
Tier 4 No No
VIRAMUNE XR TAB 100MG
nevirapine xr
Tier 4 No No
PA, QL (30 per 30
days)
PA
1212
1213
1214
1215
1216
QL (30 per 30 days)
QL (60 per 30 days)
1217
1218
1219
1220
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
abacav/lamiv/zidovud
TRIZIVIR
Tier 5 No No
48
1211
1221
1222
1223
1224
1225
1226
1227
1228
1229
1230
1231
1232
1233
1234
1235
1236
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
abacavir tab 300mg
ATRIPLA TAB
didanosine cap 125mg
EMTRIVA CAP 200MG
EMTRIVA SOL 10MG/ML
EPZICOM TAB 600-300MG
lamivud/zido tab 150-300mg
lamivudine sol 10mg/ml
lamivudine tab 100mg
RETROVIR INJ 10MG/ML
stavudine cap 15mg
stavudine cap 20mg
stavudine cap 30mg
stavudine cap 40mg
stavudine sol 1mg/ml
TRUVADA TAB 200-300MG
VIDEX SOL 2GM
VIREAD POW 40MG/GM
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
ZIAGEN SOL 20MG/ML
zidovudine cap 100mg
zidovudine syp 50mg/5ml
zidovudine tab 300mg
ZIAGEN
efavirenz - emtricitabine -tenofovir
VIDEX EC
VIDEX EC
VIDEX EC
VIDEX EC
emtricitabine
emtricitabine
abacavir-lamivudine
COMBIVIR
EPIVIR
EPIVIR
EPIVIR
EPIVIR
zidovudine
ZERIT
ZERIT
ZERIT
ZERIT
ZERIT
emtricitabine - tenofovir
didanosine
tenofovir
tenofovir
tenofovir
tenofovir
tenofovir
abacavir
RETROVIR
RETROVIR
RETROVIR
Tier 2
Tier 5
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 3
Tier 2
Tier 2
Tier 2
Anti-HIV Agents, Other
EVOTAZ TAB 300-150MG
FUZEON INJ 90MG
PREZCOBIX TAB 800-150MG
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
TRIUMEQ TAB
TYBOST TAB 150MG
atazanavir - cobicistat
enfuvirtide
cobicistat - darunavir
maraviroc
maraviroc
abacavir - dolutegravir - lamivudine
cobicistat
Tier 5
Tier 5
Tier 3
Tier 5
Tier 5
Tier 5
Tier 3
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
1237
1238
1239
1240
1241
1242
1243
1244
1245
1246
1247
1248
1249
1250
1251
1252
1253
1254
1255
1256
1257
1258
1259
1260
1261
1262
1263
1264
1265
1266
1267
1268
1269
1270
1271
1272
QL (30 per 30 days)
QL (30 per 30 days)
1273
1274
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
49
Formulary
Covered Drug Name
50
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
Anti-HIV Agents, Protease Inhibitors
APTIVUS CAP 250MG
tipranavir
APTIVUS SOL
tipranavir
CRIXIVAN CAP 200MG
indinavir
CRIXIVAN CAP 400MG
indinavir
INVIRASE CAP 200MG
saquinavir
INVIRASE TAB 500MG
saquinavir
KALETRA SOL
lopinavir - ritonavir
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
LEXIVA SUS 50MG/ML
fosamprenavir
LEXIVA TAB 700MG
fosamprenavir
NORVIR CAP 100MG
ritonavir
NORVIR SOL 80MG/ML
ritonavir
NORVIR TAB 100MG
ritonavir
PREZISTA SUS 100MG/ML
darunavir
PREZISTA TAB 150MG
darunavir
PREZISTA TAB 600MG
darunavir
PREZISTA TAB 75MG
darunavir
PREZISTA TAB 800MG
darunavir
REYATAZ CAP 150MG
atazanavir
REYATAZ CAP 200MG
atazanavir
REYATAZ CAP 300MG
atazanavir
REYATAZ POW 50MG
atazanavir
VIRACEPT TAB 250MG
nelfinavir
VIRACEPT TAB 625MG
nelfinavir
Tier 5
Tier 5
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 4
Tier 5
Tier 3
Tier 5
Tier 4
Tier 4
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 3
Tier 5
Tier 5
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Anti-influenza Agents
RELENZA MIS DISKHALE
rimantadine tab 100mg
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
VIRAZOLE INH 6GM
Tier 4
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 5
No
No
No
No
No
No
No
No
No
zanamivir
FLUMADINE
oseltamivir
oseltamivir
oseltamivir
oseltamivir
ribavirin 20 mg/ml inhalant
1275
1276
1277
1278
1279
1280
1281
1282
1283
1284
1285
1286
1287
1288
1289
1290
1291
1292
1293
1294
1295
1296
1297
1298
1299
1300
1301
1302
1303
1304
1305
1306
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inh
Oral
Oral
Oral
Oral
Oral
Inh
Formulary
Covered Drug Name
Antiherpetic Agents
acyclovir cap 200mg
acyclovir na inj 500mg
acyclovir oin 5%
acyclovir sus 200/5ml
acyclovir tab 400mg
acyclovir tab 800mg
DENAVIR CRE 1%
famciclovir tab 125mg
trifluridine sol 1%
valacyclovir tab 1gm
valacyclovir tab 500mg
ZOVIRAX CRE 5%
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
ZOVIRAX
ZOVIRAX
ZOVIRAX
ZOVIRAX
ZOVIRAX
ZOVIRAX
penciclovir
FAMVIR
FAMVIR
FAMVIR
VIROPTIC
VALTREX
VALTREX
acyclovir
Tier 1
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Anxiolytics, Other
buspirone tab 10mg
buspirone tab 15mg
buspirone tab 30mg
buspirone tab 5mg
buspirone tab 7.5mg
hydroxyz hcl inj 50mg/ml
hydroxyz hcl tab 50mg
hydroxyz pam cap 25mg
BUSPAR
BUSPAR
BUSPAR
BUSPAR
BUSPAR
VISTARIL
VISTARIL
hydroxyzine
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
Benzodiazepines
alprazolam tab 0.25mg
alprazolam tab 0.5mg
alprazolam tab 1mg
alprazolam tab 2mg
oxazepam cap 10mg
oxazepam cap 15mg
triazolam tab 0.125mg
triazolam tab 0.25mg
XANAX
XANAX
XANAX
XANAX
SERAX
SERAX
HALCION
HALCION
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
1307
PA
QL (30 per 30 days)
1308
1309
1310
1311
1312
QL (1.5 per 28 days)
QL (21 per 10 days)
QL (60 per 30 days)
QL (21 per 7 days)
1313
1314
1315
1316
1317
QL (30 per 30 days)
QL (30 per 30 days)
QL (10 per 30 days)
1318
1319
1320
Oral
Inj
Top
Oral
Oral
Oral
Top
Oral
Oral
Oral
OP
Oral
Oral
Top
ANXIOLYTICS
1321
1322
1323
1324
1325
PA
1326
1327
1328
1329
1330
1331
1332
1333
1334
1335
1336
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
51
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
BIPOLAR AGENTS
Mood Stabilizers
lithium carb cap 150mg
lithium carb tab 300mg
lithium carb tab 300mg er
lithium carb tab 450mg er
LITHIUM CITR SOL 8MEQ/5ML
LITHOBID
LITHOBID
LITHOBID
LITHOBID
LITHOBID
LITHOBID
lithium citr
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
1337
1338
1339
1340
1341
1342
1343
Oral
Oral
Oral
Oral
Oral
Oral
Oral
BLOOD GLUCOSE REGULATORS
52
Antidiabetic Agents
acarbose tab 100mg
acarbose tab 25mg
acarbose tab 50mg
AVANDAMET TAB 2-1000MG
AVANDIA TAB 2MG
AVANDIA TAB 4MG
AVANDIA TAB 8MG
BYDUREON INJ
BYETTA INJ 10MCG
PRECOSE
PRECOSE
PRECOSE
metformin - rosiglitazone
rosiglitazone
rosiglitazone
rosiglitazone
exenatide
exenatide
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
BYETTA INJ 5MCG
exenatide
Tier 4
No
Yes
CYCLOSET TAB 0.8MG
glimepiride tab 1mg
glimepiride tab 2mg
glimepiride tab 4mg
glip/metform tab 2.5-250mg
glip/metform tab 5-500mg
glipizide er tab 10mg
glipizide er tab 2.5mg
glipizide tab 10mg
glipizide tab 5mg
GLYSET TAB 100MG
GLYSET TAB 25MG
GLYSET TAB 50MG
bromocriptine
AMARYL
AMARYL
AMARYL
METAGLIP
METAGLIP
METAGLIP
GLUCOTROL XL
GLUCOTROL XL
GLUCOTROL XL
GLUCOTROL
GLUCOTROL
miglitol
miglitol
miglitol
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
PA
PA, QL (2.4 per 30
days)
PA, QL (2.4 per 30
days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
1344
1345
1346
1347
1348
1349
1350
1351
1352
1353
1354
1355
1356
1357
1358
1359
1360
1361
1362
1363
1364
1365
1366
1367
1368
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
INVOKANA TAB 100MG
canagliflozin
Tier 4
INVOKANA TAB 300MG
JANUMET TAB 50-1000MG
JANUMET XR TAB 100-1000MG
JANUVIA TAB 100MG
JANUVIA TAB 25MG
JANUVIA TAB 50MG
JENTADUETO TAB 2.5-1000MG
KOMBIGLYZE TAB 2.5-1000MG
KOMBIGLYZE TAB 5-1000MG
metformin tab 1000mg
metformin tab 500mg
metformin tab 500mg er
metformin tab 850mg
nateglinide tab 120mg
ONGLYZA TAB 2.5MG
ONGLYZA TAB 5MG
pioglita/met tab 15-500mg
pioglitazone tab 15mg
repaglinide tab 0.5mg
repaglinide tab 1mg
repaglinide tab 2mg
SYMLINPEN 60 INJ 1000MCG
canagliflozin
metformin - sitagliptin
metformin - sitagliptin
metformin - sitagliptin sr
sitagliptin
sitagliptin
sitagliptin
linagliptin - metformin
saxagliptin - metformin
GLUCOPHAGE
GLUCOPHAGE
GLUCOPHAGE XL
GLUCOPHAGE XL
GLUCOPHAGE
STARLIX
STARLIX
saxagliptin
saxagliptin
ACTOPLUS
ACTOPLUS
ACTOS
ACTOS
ACTOS
PRANDIN
PRANDIN
PRANDIN
pramlintide
SYMLNPEN 120 INJ 1000MCG
tolazamide tab 250mg
tolazamide tab 500mg
tolbutamide tab 500mg
TRADJENTA TAB 5MG
Mail Retail
Route
Limits
Order Store
No
No
PA, QL (90 per 30
days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
pramlintide
Tier 4
No
Yes
tolazamide
tolazamide
tolazamide
miglitol
Tier 2
Tier 2
Tier 2
Tier 4
No
No
No
No
No
No
No
1369
1370
1371
1372
1373
1374
1375
1376
1377
1378
1379
1380
1381
1382
1383
1384
1385
1386
1387
1388
1389
1390
1391
1392
1393
1394
1395
1396
1397
1398
1399
1400
1401
PA, QL (10.8 per 30
days)
PA, QL (10.8 per 30
days)
1402
1403
1404
1405
1406
1407
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
53
Formulary
Covered Drug Name
Alternate Drug Name
Tier
No
Yes PA, QL (9 per 30 days)
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
glucagon
glucagon rdna
mifepristone
diazoxide
Tier 3
Tier 3
Tier 5
Tier 5
No
No
No
No
No
PA
Yes
insulin lispro
insulin lispro
insulin lispro
insulin lispro
insulin lispro
insulin lispro
nph insulin, human unt/ml - regular
insulin
insulin human, isophane (nph)
insulin human, isophane (nph)
insulin human (regular) - insulin human,
isophane
insulin human (regular)
insulin glargine
insulin detemir
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Tier 3
Tier 3
Tier 3
Yes
Yes
Yes
Tier 3
Tier 4
Tier 4
Yes
Yes
Yes
VICTOZA INJ 18MG/3ML
liraglutide
Tier 4
Blood Glucose Regulators
ALCOHOL PREP PAD
GAUZE PAD 2X2
insulin syrg mis 0.3/31g
insulin syrg mis 1ml/29g
pen needles mis 29gx1/2
isopropyl alcohol pad
GAUZE PADS AND DRESSING - 2X2
insulin syringe (disp) u-100
insulin pen needle
Glycemic Agents
GLUCAGEN INJ HYPOKIT
GLUCAGON KIT 1MG
KORLYM TAB 300MG
PROGLYCEM SUS 50MG/ML
Insulins
HUMALOG INJ 100/ML
HUMALOG INJ 100/ML
HUMALOG MIX INJ 50/50
HUMALOG MIX INJ 50/50KWP
HUMALOG MIX SUS 75/25
HUMULIN INJ 70/30
HUMULIN N INJ U-100
HUMULIN N PN INJ U-100
HUMULIN PEN INJ 70/30
HUMULIN R INJ U-100
LANTUS INJ 100/ML
LEVEMIR INJ
Mail Retail
Route
Limits
Order Store
1408
1409
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
1410
1411
1412
1413
1414
1415
1416
1417
1418
1419
1420
1421
1422
1423
1424
1425
1426
1427
1428
1429
1430
1431
1432
Inj
Top
Top
Top
Top
Top
Top
Top
Inj
Inj
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
Anticoagulants
COUMADIN TAB 10MG
54
warfarin
Tier 3
No
Yes
1433
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Tier 4
No
No
LOVENOX
Tier 5
No
No
enoxaparin inj 120/0.8ml
LOVENOX
Tier 5
No
No
enoxaparin inj 150mg/ml
LOVENOX
Tier 5
No
No
LOVENOX
Tier 2
No
No
LOVENOX
Tier 2
No
No
LOVENOX
Tier 2
No
No
LOVENOX
Tier 5
No
No
fondaparinux sol 10/0.8ml
fondaparinux sol 2.5/0.5ml
FRAGMIN INJ 10000/ML
ARIXTRA
ARIXTRA
ARIXTRA
ARIXTRA
dalteparin
Tier 5
Tier 4
Tier 5
Tier 5
Tier 5
No
No
No
No
No
No
No
No
No
No
FRAGMIN INJ 12500UNT
dalteparin
Tier 5
No
No
dalteparin
Tier 5
No
No
dalteparin
Tier 5
No
No
FRAGMIN INJ 2500/0.2ML
dalteparin
Tier 4
No
No
dalteparin
Tier 4
No
No
HEP SOD/D5W INJ 25000UNT
heparin
heparin
Tier 4
Tier 4
No
No
No
No
COUMADIN TAB 1MG
COUMADIN TAB 2.5MG
COUMADIN TAB 2MG
COUMADIN TAB 3MG
COUMADIN TAB 4MG
COUMADIN TAB 5MG
COUMADIN TAB 6MG
COUMADIN TAB 7.5MG
ELIQUIS TAB 2.5MG
warfarin
warfarin
warfarin
warfarin
warfarin
warfarin
warfarin
warfarin
apixaban
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
ELIQUIS TAB 5MG
apixaban
1434
1435
1436
1437
1438
1439
1440
1441
PA, QL (60 per 30
days)
PA, QL (60 per 30
days)
PA, QL (28 per 30
days)
PA, QL (22.4 per 30
days)
PA, QL (28 per 30
days)
PA, QL (8.4 per 30
days)
PA, QL (11.2 per 30
days)
PA, QL (16.8 per 30
days)
PA, QL (22.4 per 30
days)
QL (20 per 30 days)
QL (15 per 30 days)
QL (20 per 30 days)
QL (20 per 30 days)
PA, QL (20 per 30
days)
PA, QL (20 per 30
days)
PA, QL (20 per 30
days)
PA, QL (20 per 30
days)
PA, QL (20 per 30
days)
PA, QL (20 per 30
days)
PA
PA
1442
1443
1444
1445
1446
1447
1448
1449
1450
1451
1452
1453
1454
1455
1456
1457
1458
1459
1460
1461
1462
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
55
Formulary
Covered Drug Name
56
Alternate Drug Name
Tier
heparin sod inj 1000/ml
jantoven tab 10mg
jantoven tab 1mg
jantoven tab 2.5mg
jantoven tab 2mg
jantoven tab 3mg
jantoven tab 4mg
jantoven tab 5mg
jantoven tab 6mg
jantoven tab 7.5mg
PRADAXA CAP 150MG
heparin
heparin
heparin
heparin
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
dabigatran
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
PRADAXA CAP 75MG
dabigatran
warfarin tab 10mg
warfarin tab 1mg
warfarin tab 2.5mg
warfarin tab 2mg
warfarin tab 3mg
warfarin tab 4mg
warfarin tab 5mg
warfarin tab 6mg
warfarin tab 7.5mg
XARELTO TAB 10MG
Mail Retail
Route
Limits
Order Store
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
PA
PA
PA
PA
Tier 4
No
Yes
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
rivaroxaban
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
XARELTO TAB 15MG
rivaroxaban
Tier 4
No
No
XARELTO TAB 20MG
rivaroxaban
Tier 4
No
No
Blood Formation Modifiers
anagrelide cap 0.5mg
anagrelide cap 1mg
ARANESP INJ 100MCG/0.5ML
ARANESP INJ 100MCG/1ML
AGRYLIN
AGRYLIN
darbepoetin alfa
darbepoetin alfa
darbepoetin alfa
Tier 2
Tier 2
Tier 5
Tier 5
Tier 5
Yes
Yes
No
No
No
darbepoetin alfa
Tier 5
No
Yes
Oral
Yes
Oral
No PA, QL (1.2 per 28
Inj
days)
Inj
days)
1463
1464
1465
1466
1467
1468
1469
1470
1471
1472
1473
1474
1475
PA, QL (60 per 30
days)
PA, QL (60 per 30
days)
1476
1477
1478
1479
1480
1481
1482
1483
1484
1485
1486
PA, QL (30 per 30
days)
PA, QL (30 per 30
days)
PA, QL (30 per 30
days)
1487
1488
1489
1490
1491
1492
1493
1494
1495
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
darbepoetin alfa
darbepoetin alfa
Tier 5
Tier 4
No
No
darbepoetin alfa
darbepoetin alfa
Tier 4
Tier 5
No
No
darbepoetin alfa
darbepoetin alfa
Tier 5
Tier 4
No
No
darbepoetin alfa
darbepoetin alfa
darbepoetin alfa
Tier 4
Tier 5
Tier 4
No
No
No
EPOGEN INJ 10000/ML
EPOGEN INJ 2000/ML
darbepoetin alfa
epoetin alfa
epoetin alfa
Tier 4
Tier 4
Tier 4
No
No
No
EPOGEN INJ 20000/ML
EPOGEN INJ 3000/ML
epoetin alfa
epoetin alfa
Tier 5
Tier 4
No
No
EPOGEN INJ 4000/ML
epoetin alfa
Tier 4
No
GRANIX INJ 300/0.5ML
LEUKINE INJ 250MCG
MOZOBIL INJ
NEULASTA INJ 6MG/0.6ML
NEUMEGA INJ 5MG
filgrastim
filgrastim
sargramostim
plerixafor
pegfilgrastim
oprelvekin
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
No
No
No
No
No
No
NEUPOGEN INJ 300/0.5ML
NEUPOGEN INJ 480MCG
PROCRIT INJ 10000/ML
PROCRIT INJ 2000/ML
filgrastim
filgrastim
filgrastim
epoetin alfa
epoetin alfa
Tier 5
Tier 5
Tier 5
Tier 4
Tier 4
No
No
No
No
No
PROCRIT INJ 3000/ML
epoetin alfa
epoetin alfa
Tier 5
Tier 4
No
No
PROCRIT INJ 4000/ML
epoetin alfa
Tier 4
No
PROMACTA TAB 12.5MG
PROMACTA TAB 25MG
PROMACTA TAB 50MG
epoetin alfa
eltrombopag
eltrombopag
eltrombopag
Tier 5
Tier 5
Tier 5
Tier 5
No
No
No
No
No PA, QL (1.68 per 28 Inj
days)
Inj
days)
Inj
days)
Inj
days)
No
PA
Inj
No
PA, QL (12 per 28
Inj
days)
No
PA
Inj
No
PA, QL (12 per 28
Inj
days)
No
PA, QL (12 per 28
Inj
days)
No
PA
Inj
No
PA
Inj
No
PA
Inj
No
PA
Inj
No
PA, QL (21 per 21
Inj
days)
No
PA
Inj
No
PA
Inj
No
PA
Inj
No
PA
Inj
No
PA, QL (12 per 28
Inj
days)
No
PA
Inj
No
PA, QL (12 per 28
Inj
days)
No
PA, QL (12 per 28
Inj
days)
No
PA
Inj
Yes QL (90 per 30 days) Oral
1496
1497
1498
1499
1500
1501
1502
1503
1504
1505
1506
1507
1508
1509
1510
1511
1512
1513
1514
1515
1516
1517
1518
1519
1520
1521
1522
1523
1524
1525
1526
1527
1528
57
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
No
Tier 4
Tier 2
No
No
No
No
aspirin - dipyridamole
ticagrelor
PLETAL
PLETAL
PLAVIX
prasugrel
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 4
Yes
No
Yes
Yes
Yes
No
prasugrel
Tier 4
No
Yes
Yes
Yes PA, QL (30 per 30
days)
Yes PA, QL (30 per 30
days)
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
QL (4 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
PROMACTA TAB 75MG
eltrombopag
Tier 5
Coagulants
tranex acid inj 100mg/ml
tranex acid tab 650mg
tranexamic
tranexamic acid
Platelet Modifying Agents
AGGRENOX CAP 25-200MG
BRILINTA TAB 90MG
cilostazol tab 100mg
cilostazol tab 50mg
clopidogrel tab 75mg
EFFIENT TAB 10MG
EFFIENT TAB 5MG
PA
1529
1530
1531
1532
1533
1534
1535
1536
1537
1538
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
CARDIOVASCULAR AGENTS
Alpha-adrenergic Agonists
clonidine dis 0.1/24hr
clonidine tab 0.1mg
clonidine tab 0.2mg
clonidine tab 0.3mg
midodrine tab 10mg
midodrine tab 2.5mg
midodrine tab 5mg
CATAPRES TTS
CATAPRES TTS
CATAPRES TTS
CATAPRES
CATAPRES
CATAPRES
PROAMATINE
PROAMATINE
PROAMATINE
Alpha-adrenergic Blocking Agents
doxazosin tab 1mg
CARDURA
doxazosin tab 2mg
CARDURA
doxazosin tab 4mg
CARDURA
doxazosin tab 8mg
CARDURA
prazosin hcl cap 1mg
MINIPRESS
MINIPRESS
MINIPRESS
58
1539
1540
1541
1542
1543
1544
1545
1546
1547
1548
1549
1550
1551
1552
1553
1554
TD
TD
TD
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
terazosin cap 10mg
terazosin cap 1mg
terazosin cap 2mg
terazosin cap 5mg
Alternate Drug Name
HYTRIN
HYTRIN
HYTRIN
HYTRIN
Tier
Tier 1
Tier 1
Tier 1
Tier 1
Mail Retail
Route
Limits
Order Store
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Angiotensin II Receptor Antagonists
candesa/hctz tab 16-12.5mg
ATACAND HCT
ATACAND HCT
candesa/hctz tab 32-25mg
ATACAND HCT
candesartan tab 16mg
ATACAND
ATACAND
candesartan tab 4mg
ATACAND
candesartan tab 8mg
ATACAND
irbesar/hctz tab 150-12.5mg
AVALIDE
AVALIDE
irbesartan tab 150mg
AVAPRO
AVAPRO
irbesartan tab 75mg
AVAPRO
losartan pot tab 100mg
COZAAR
COZAAR
COZAAR
losartan/hct tab 100-12.5mg
HYZAAR
losartan/hct tab 100-25mg
HYZAAR
HYZAAR
telmisartan tab 20mg
MICARDIS
MICARDIS
MICARDIS
valsart/hctz tab 160-12.5mg
DIOVAN HCT
valsart/hctz tab 160-25mg
DIOVAN HCT
DIOVAN HCT
DIOVAN HCT
DIOVAN HCT
valsartan tab 160mg
DIOVAN
valsartan tab 320mg
DIOVAN
valsartan tab 40mg
DIOVAN
valsartan tab 80mg
DIOVAN
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
No
No
No
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Angiotensin-converting Enzyme (ACE) Inhibitors
amlod/benazp cap 10-20mg
LOTREL
Tier 1
Yes
1555
1556
1557
1558
1559
1560
1561
1562
1563
1564
1565
1566
1567
1568
1569
1570
1571
1572
1573
1574
1575
1576
1577
1578
1579
1580
1581
1582
1583
1584
1585
1586
1587
1588
1589
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
59
Formulary
Covered Drug Name
amlod/benazp cap 2.5-10mg
benazep/hctz tab 10-12.5mg
benazep/hctz tab 20-25mg
benazepril tab 10mg
benazepril tab 20mg
benazepril tab 40mg
benazepril tab 5mg
captopr/hctz tab 25-15mg
captopril tab 100mg
captopril tab 12.5mg
captopril tab 25mg
captopril tab 50mg
enalapr/hctz tab 10-25mg
enalapr/hctz tab 5-12.5mg
enalapril tab 10mg
enalapril tab 2.5mg
enalapril tab 20mg
enalapril tab 5mg
fosinop/hctz tab 10/12.5mg
fosinop/hctz tab 20/12.5mg
fosinopril tab 10mg
fosinopril tab 20mg
fosinopril tab 40mg
lisinop/hctz tab 10-12.5mg
lisinop/hctz tab 20-12.5mg
lisinop/hctz tab 20-25mg
lisinopril tab 10mg
lisinopril tab 2.5mg
lisinopril tab 20mg
lisinopril tab 30mg
lisinopril tab 40mg
lisinopril tab 5mg
moexipr/hctz tab 15-12.5mg
60
Alternate Drug Name
LOTREL
LOTREL
LOTREL
LOTREL
LOTREL
LOTENSIN HCT
LOTENSIN HCT
LOTENSIN HCT
LOTENSIN HCT
LOTENSIN
LOTENSIN
LOTENSIN
LOTENSIN
CAPOZIDE
CAPOZIDE
CAPOZIDE
CAPOZIDE
CAPOTEN
CAPOTEN
CAPOTEN
CAPOTEN
VASERETIC
VASERETIC
VASOTEC
VASOTEC
VASOTEC
VASOTEC
MONOPRIL HCT
MONOPRIL HCT
MONOPRIL
MONOPRIL
MONOPRIL
ZESTORETIC, PRINZIDE
ZESTRIL, PRINIVIL
ZESTRIL, PRINIVIL
ZESTRIL, PRINIVIL
ZESTRIL, PRINIVIL
ZESTRIL, PRINIVIL
ZESTRIL, PRINIVIL
UNIRETIC
Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Mail Retail
Route
Limits
Order Store
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
1590
1591
1592
1593
1594
1595
1596
1597
1598
1599
1600
1601
1602
1603
1604
1605
1606
1607
1608
1609
1610
1611
1612
1613
1614
1615
1616
1617
1618
1619
1620
1621
1622
1623
1624
1625
1626
1627
1628
1629
1630
1631
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
moexipr/hctz tab 15-25mg
moexipr/hctz tab 7.5-12.5mg
moexipril tab 15mg
moexipril tab 7.5mg
perindopril tab 2mg
perindopril tab 4mg
perindopril tab 8mg
qnapril/hctz tab 10-12.5mg
qnapril/hctz tab 20-12.5mg
qnapril/hctz tab 20-25mg
quinapril tab 10mg
quinapril tab 20mg
quinapril tab 40mg
quinapril tab 5mg
ramipril cap 1.25mg
ramipril cap 10mg
ramipril cap 2.5mg
ramipril cap 5mg
trandolapril tab 1mg
UNIRETIC
UNIRETIC
UNIVASC
UNIVASC
ACEON
ACEON
ACEON
ACCURETIC
ACCURETIC
ACCURETIC
ACCUPRIL
ACCUPRIL
ACCUPRIL
ACCUPRIL
ALTACE
ALTACE
ALTACE
ALTACE
MAVIK
MAVIK
MAVIK
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Antiarrhythmics
amiodarone inj 50mg/ml
amiodarone tab 200mg
amiodarone tab 400mg
flecainide tab 100mg
flecainide tab 150mg
flecainide tab 50mg
mexiletine cap 150mg
MULTAQ TAB 400MG
pacerone tab 100mg
pacerone tab 200mg
propafenone tab 150mg
quinidine gl tab 324mg cr
quinidine su tab 200mg
CORDARONE, PACERONE
CORDARONE, PACERONE
CORDARONE, PACERONE
TAMBOCOR
TAMBOCOR
TAMBOCOR
MEXITIL
MEXITIL
MEXITIL
dronedarone
CORDARONE
CORDARONE
RYTHMOL
RYTHMOL
RYTHMOL
quinidine gl
quinidine su
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Mail Retail
Route
Limits
Order Store
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
PA
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1632
1633
1634
1635
1636
1637
1638
1639
1640
1641
1642
1643
1644
1645
1646
1647
1648
1649
1650
1651
1652
1653
1654
1655
1656
1657
1658
1659
1660
1661
1662
1663
1664
1665
1666
1667
1668
1669
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
61
Formulary
Covered Drug Name
quinidine su tab 300mg
sorine tab 120mg
sorine tab 160mg
sorine tab 240mg
sorine tab 80mg
sotalol af tab 120mg
sotalol hcl tab 160mg
TIKOSYN CAP 125MCG
TIKOSYN CAP 250MCG
TIKOSYN CAP 500MCG
Alternate Drug Name
quinidine su
SORINE, BETAPACE
SORINE, BETAPACE
SORINE, BETAPACE
SORINE, BETAPACE
SORINE, BETAPACE
SORINE, BETAPACE
SORINE, BETAPACE
SORINE, BETAPACE
dofetilide
dofetilide
dofetilide
Beta-adrenergic Blocking Agents
acebutolol cap 200mg
SECTRAL
acebutolol cap 400mg
SECTRAL
atenol/chlor tab 100-25mg
TENORETIC
atenol/chlor tab 50-25mg
TENORETIC
atenolol tab 100mg
TENORMIN
atenolol tab 25mg
TENORMIN
atenolol tab 50mg
TENORMIN
betaxolol tab 10mg
KERLONE
betaxolol tab 20mg
KERLONE
bisoprl/hctz tab 10/6.25mg
ZIAC
bisoprl/hctz tab 2.5/6.25mg
ZIAC
bisoprl/hctz tab 5-6.25mg
ZIAC
bisoprol fum tab 10mg
ZEBETA
bisoprol fum tab 5mg
ZEBETA
carvedilol tab 12.5mg
COREG
carvedilol tab 25mg
COREG
COREG
COREG
labetalol inj 5mg/ml
TRANDATE
labetalol tab 100mg
TRANDATE
labetalol tab 200mg
TRANDATE
labetalol tab 300mg
TRANDATE
metoprl/hctz tab 100-25mg
LOPRESSOR HCT
LOPRESSOR HCT
LOPRESSOR HCT
metoprol tar tab 100mg
LOPRESSOR
62
Tier
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Mail Retail
Route
Limits
Order Store
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1670
1671
1672
1673
1674
1675
1676
1677
1678
1679
1680
1681
1682
1683
1684
1685
1686
1687
1688
1689
1690
1691
1692
1693
1694
1695
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
PA
1696
1697
1698
1699
1700
1701
1702
1703
1704
1705
1706
1707
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
metoprolol inj 1mg/ml
metoprolol tab 100mg er
nadolol tab 20mg
nadolol tab 40mg
nadolol tab 80mg
nadolol/bend tab 40-5mg
nadolol/bend tab 80-5mg
pindolol tab 10mg
pindolol tab 5mg
propranolol cap 120mg er
propranolol tab 10mg
Alternate Drug Name
LOPRESSOR
LOPRESSOR
LOPRESSOR
TOPROL XL
TOPROL XL
TOPROL XL
TOPROL XL
CORGARD
CORGARD
CORGARD
CORZIDE
CORZIDE
VISKEN
VISKEN
INDERAL LA
INDERAL LA
INDERAL LA
INDERAL LA
INDERAL
INDERAL
INDERAL
INDERAL
INDERAL
Calcium Channel Blocking Agents
afeditab tab 30mg cr
PROCARDIA XL, ADALAT CC
afeditab tab 60mg cr
amlodipine tab 10mg
NORVASC
amlodipine tab 2.5mg
NORVASC
amlodipine tab 5mg
NORVASC
cartia xt cap 120/24hr
DILT-CD
DILT-CD
DILT-CD
DILT-CD
dilt-xr cap 120mg
DILT-CD
dilt-xr cap 180mg
DILTIAZEM CD
dilt-xr cap 240mg
DILTIAZEM CD
diltiazem cap 120mg cd
DILT-CD
diltiazem cap 120mg er
CARDIZEM SR
diltiazem cap 180mg/24hr
TAZTIA XT, DILTZAC
Tier
Tier 1
Tier 1
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Mail Retail
Route
Limits
Order Store
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1708
1709
PA
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
1710
1711
1712
1713
1714
1715
1716
1717
1718
1719
1720
1721
1722
1723
1724
1725
1726
1727
1728
1729
1730
1731
1732
1733
1734
1735
1736
1737
1738
1739
1740
1741
1742
1743
1744
1745
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
63
Formulary
Covered Drug Name
diltiazem cap 240mg cd
diltiazem inj 100mg
diltiazem inj 50/10ml
diltiazem tab 120mg
diltiazem tab 30mg
diltiazem tab 60mg
diltiazem tab 90mg
felodipine tab 10mg er
felodipine tab 2.5mg er
felodipine tab 5mg er
isradipine cap 2.5mg
isradipine cap 5mg
matzim la tab 180mg/24hr
nicardipine cap 20mg
nicardipine cap 30mg
nifedical xl tab 30mg
nifedical xl tab 60mg
nifedipine tab 30mg er
nimodipine cap 30mg
nisoldipine tab 17mg er
nisoldipine tab 20mg
nisoldipine tab 25.5mg
nisoldipine tab 34mg er
nisoldipine tab 8.5mg er
taztia xt cap 120mg/24hr
64
Alternate Drug Name
DILT-CD
DILT-CD
TAZTIA XT, DILTZAC
TAZTIA XT, DILTZAC
CARDIZEM SR
CARDIZEM SR
CARDIZEM
CARDIZEM
CARDIZEM
CARDIZEM
CARDIZEM
CARDIZEM
PLENDIL
PLENDIL
PLENDIL
DYNACIRC
DYNACIRC
CARDIZEM LA
CARDIZEM LA
CARDIZEM LA
CARDIZEM LA
CARDIZEM LA
CARDENE
CARDENE
NIMOTOP
SULAR
SULAR
SULAR
SULAR
SULAR
SULAR
SULAR
TAZTIA XT, DILTZAC
TAZTIA XT, DILTZAC
TAZTIA XT, DILTZAC
TAZTIA XT, DILTZAC
TAZTIA XT, DILTZAC
Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Mail Retail
Route
Limits
Order Store
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1746
1747
1748
1749
1750
1751
PA
PA
1752
1753
1754
1755
1756
1757
1758
1759
1760
1761
1762
1763
1764
1765
1766
1767
1768
1769
1770
1771
1772
1773
1774
1775
1776
1777
1778
1779
1780
1781
1782
1783
1784
1785
1786
1787
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
No
No
No
No
No
No
No
No
No
No
No
No
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
Tier 5
Tier 1
Tier 3
Tier 3
No
Yes
Yes
No
No
No
Yes
No
No
No
Yes
Yes
No
No
No
Yes
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
verapamil cap 100mg er
verapamil cap 360mg sr
verapamil tab 120mg
verapamil tab 120mg er
verapamil tab 40mg
verapamil tab 80mg
VERELAN PM
VERELAN
VERELAN
VERELAN PM
VERELAN
VERELAN PM
VERELAN PM
CALAN
CALAN SR
CALAN SR
CALAN SR
CALAN
CALAN
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Cardiovascular Agents, Other
ADEMPAS TAB 0.5MG
ADEMPAS TAB 1.5MG
ADEMPAS TAB 1MG
ADEMPAS TAB 2.5MG
ADEMPAS TAB 2MG
DEMSER CAP 250MG
riociguat
riociguat
riociguat
riociguat
riociguat
metyrosine
digoxin inj 0.25mg/1
digoxin sol 50mcg/ml
digoxin tab 0.125mg
NORTHERA CAP 100MG
NORTHERA CAP 200MG
NORTHERA CAP 300MG
pentoxifylli tab 400mg er
RANEXA TAB 1000MG
RANEXA TAB 500MG
LANOXIN
LANOXIN
LANOXIN
droxidopa
droxidopa
droxidopa
TRENTAL
ranolazine
ranolazine
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamid cap 500mg er
DIAMOX SEQUELS
acetazolamid tab 125mg
DIAMOX
acetazolamid tab 250mg
DIAMOX
methazolamid tab 25mg
METHAZOLAMIDE
methazolamid tab 50mg
METHAZOLAMIDE
Mail Retail
Route
Limits
Order Store
1788
1789
1790
1791
1792
1793
1794
1795
1796
1797
1798
1799
1800
PA
PA
PA
PA
PA
PA, QL (480 per 30
days)
PA
PA
PA
PA
PA
PA
1801
1802
1803
1804
1805
1806
1807
1808
1809
1810
1811
1812
1813
1814
1815
1816
1817
1818
1819
1820
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
65
Formulary
Covered Drug Name
66
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
Diuretics, Loop
amilor/hctz tab 5-50mg
bumetanide tab 0.5mg
bumetanide tab 1mg
bumetanide tab 2mg
furosemide inj 10mg/ml
furosemide sol 10mg/ml
furosemide sol 8mg/ml
furosemide tab 20mg
furosemide tab 40mg
furosemide tab 80mg
torsemide tab 100mg
torsemide tab 10mg
torsemide tab 20mg
torsemide tab 5mg
MODURETIC
BUMEX
BUMEX
BUMEX
LASIX
LASIX
LASIX
LASIX
LASIX
LASIX
DEMADEX
DEMADEX
DEMADEX
DEMADEX
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Diuretics, Potassium-sparing
amiloride tab 5mg
eplerenone tab 25mg
eplerenone tab 50mg
spironolact tab 100mg
MIDAMOR
INSPRA
INSPRA
ALDACTONE
ALDACTONE
ALDACTONE
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Diuretics, Thiazide
chlorothiaz tab 250mg
chlorothiaz tab 500mg
chlorthalid tab 25mg
chlorthalid tab 50mg
hydrochlorot cap 12.5mg
hydrochlorot tab 12.5mg
hydrochlorot tab 25mg
hydrochlorot tab 50mg
indapamide tab 1.25mg
indapamide tab 2.5mg
methyclothia tab 5mg
metolazone tab 10mg
DIURIL
DIURIL
THALITONE
THALITONE
MICROZIDE
HYDRODIURIL
HYDRODIURIL
HYDRODIURIL
LOZOL
LOZOL
AQUATENSEN, ENDURON
ZAROXOLYN
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1821
1822
1823
1824
PA
1825
1826
1827
1828
1829
1830
1831
1832
1833
1834
1835
1836
1837
1838
1839
1840
1841
1842
1843
1844
1845
1846
1847
1848
1849
1850
1851
1852
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
metolazone tab 2.5mg
metolazone tab 5mg
spirono/hctz tab 25/25mg
triamt/hctz cap 37.5-25mg
triamt/hctz tab 37.5-25mg
triamt/hctz tab 75-50mg
Alternate Drug Name
ZAROXOLYN
ZAROXOLYN
ALDACTAZIDE
DYAZIDE
MAXZIDE, DYAZIDE
MAXZIDE, DYAZIDE
Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Mail Retail
Route
Limits
Order Store
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1853
1854
1855
1856
1857
1858
Dyslipidemics, Fibric Acid Derivatives
fenofibrate cap 130mg
fenofibrate
LOFIBRA
LOFIBRA
fenofibrate
LOFIBRA
fenofibrate tab 145mg
fenofibrate
TRICOR
TRICOR
TRICOR
fenofibric cap 135mg dr
TRILIPIX
TRILIPIX
gemfibrozil tab 600mg
LOPID
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin tab 10mg
LIPITOR
LIPITOR
LIPITOR
LIPITOR
lovastatin tab 10mg
MEVACOR
lovastatin tab 20mg
MEVACOR
lovastatin tab 40mg
MEVACOR
pravastatin tab 10mg
PRAVACHOL
PRAVACHOL
PRAVACHOL
PRAVACHOL
simvastatin tab 10mg
ZOCOR
ZOCOR
ZOCOR
simvastatin tab 5mg
ZOCOR
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
1859
1860
1861
1862
1863
1864
1865
1866
1867
1868
1869
1870
1871
1872
1873
1874
1875
1876
1877
1878
1879
1880
1881
1882
1883
1884
1885
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
67
Formulary
Covered Drug Name
Dyslipidemics, Other
cholestyram pow 4gm lite
colestipol gra 5gm
colestipol tab 1gm
JUXTAPID CAP 5MG
KYNAMRO INJ 200MG/ML
niacin er tab 1000mg
niacin er tab 500mg
niacin er tab 750mg
omega-3-acid cap 1gm
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG
ZETIA TAB 10MG
68
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
Tier 1
Tier 1
Tier 1
Tier 5
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
Yes
Vasodilators, Direct-acting Arterial
hydralazine tab 100mg
APRESOLINE
APRESOLINE
APRESOLINE
APRESOLINE
minoxidil tab 10mg
LONITEN
minoxidil tab 2.5mg
LONITEN
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Vasodilators, Direct-acting Arterial/Venous
isosorb din tab 10mg
ISORDIL
ISORDIL
ISORDIL
isosorb din tab 40mg er
DILATRATE-SR
isosorb din tab 5mg
ISORDIL
isosorb mono tab 10mg
ISMO, MONOKET
isosorb mono tab 120mg er
IMDUR
isosorb mono tab 20mg
ISMO, MONOKET
IMDUR
IMDUR
nitroglycer dis 0.1mg/hr
NITRO-DUR
NITRO-DUR
NITRO-DUR
nitroglyceri dis 0.6mg/hr
NITRO-DUR
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
QUESTRAN
COLESTID
COLESTID
lomitapide
mipomersen sodium
NIASPAN
NIASPAN
NIASPAN
LOVAZA
colesevelam
colesevelam
ezetimibe
1886
1887
1888
PA
PA
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
1889
1890
1891
1892
1893
1894
1895
1896
QL (30 per 30 days)
1897
1898
1899
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
1914
1915
1916
1917
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
TD
TD
TD
TD
Formulary
Covered Drug Name
Alternate Drug Name
Tier 2
Tier 3
Tier 3
Tier 3
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
dexmethylph tab 10mg
FOCALIN
Tier 2 No
dexmethylph tab 2.5mg
FOCALIN
Tier 2 No
dexmethylph tab 5mg
FOCALIN
Tier 2 No
guanfacine tab 1mg er
INTUNIV
Tier 2 No
INTUNIV
Tier 2 No
INTUNIV
Tier 2 No
INTUNIV
Tier 2 No
methylphenid tab 10mg
RITALIN
Tier 2 No
RITALIN
Tier 2 No
RITALIN
Tier 2 No
STRATTERA CAP 100MG
atomoxetine
Tier 4 No
STRATTERA CAP 10MG
atomoxetine
Tier 4 No
STRATTERA CAP 18MG
atomoxetine
Tier 4 No
STRATTERA CAP 25MG
atomoxetine
Tier 4 No
STRATTERA CAP 40MG
atomoxetine
Tier 4 No
STRATTERA CAP 60MG
atomoxetine
Tier 4 No
STRATTERA CAP 80MG
atomoxetine
Tier 4 No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
Central Nervous System, Other
NUEDEXTA CAP 20-10MG
dextromethorphan - quinidine sulfate
No
QL (60 per 30 days)
nitroglycrn spr 0.4mg
NITROSTAT SUB 0.3MG
NITROSTAT SUB 0.4MG
NITROSTAT SUB 0.6MG
NITROMIST
nitroglycerin
nitroglycerin
nitroglycerin
Tier
1918
1919
1920
1921
TL
SL
SL
SL
CENTRAL NERVOUS SYSTEM AGENTS
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine tab 10mg
ADDERALL
Tier 2
amphetamine tab 12.5mg
ADDERALL
Tier 2
ADDERALL
Tier 2
ADDERALL
Tier 2
ADDERALL
Tier 2
amphetamine tab 5mg
ADDERALL
Tier 2
ADDERALL
Tier 2
dextroamphet tab 10mg
DEXEDRINE
Tier 2
DEXEDRINE
Tier 2
Tier 5
No
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
69
Formulary
Covered Drug Name
Alternate Drug Name
Tier
riluzole tab 50mg
XENAZINE TAB 12.5MG
XENAZINE TAB 25MG
RILUTEK
tetrabenazine
tetrabenazine
Tier 3
Tier 5
Tier 5
Multiple Sclerosis Agents
AMPYRA TAB 10MG
AVONEX KIT 30MCG
AVONEX PREFL KIT 30MCG
BETASERON INJ 0.3MG
DALFAMPRIDINE ER
interferon beta-1a
interferon beta-1a
interferon beta-1b
COPAXONE INJ 40MG/ML
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
PA
Tier 5
Tier 5
Tier 5
Tier 5
No
No
No
No
glatiramer
Tier 5
No
COPAXONE KIT 20MG/ML
glatiramer
Tier 5
No
GILENYA CAP 0.5MG
fingolimod
Tier 5
No
PLEGRIDY INJ
peginterferon beta-1a
Tier 5
No
PLEGRIDY PEN INJ STARTER
peginterferon beta-1a
Tier 5
No
REBIF INJ 22/0.5ML
interferon beta-1a
Tier 5
No
REBIF INJ 44/0.5ML
interferon beta-1a
Tier 5
No
REBIF TITRTN SOL PACK
TYSABRI INJ 300/15ML
interferon beta-1a
natalizumab
Tier 5
Tier 5
No
No
No
PA
Oral
No
PA, QL (15 per 30
Inj
days)
No
PA, QL (30 per 30
Inj
days)
No
PA, QL (30 per 30
Inj
days)
No
PA, QL (30 per 30 Oral
days)
No
PA, QL (21 per 28
Inj
days)
No
PA, QL (21 per 28
Inj
days)
No
PA, QL (12 per 30
Inj
days)
No
PA, QL (12 per 30
Inj
days)
No
Inj
1949
1950
1951
Oral
Oral
Oral
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
DENTAL AND ORAL AGENTS
70
Antibacterials
doxycycline tab 20mg
VIBRATAB
Tier 2
No
No
Dental and Oral Agents
chlorhex glu sol 0.12%
periogard sol 0.12%
pilocarpine tab 5mg
pilocarpine tab 7.5mg
triamcin/ora pst 0.1%
PERIDEX ORAL RINSE
PERIDEX ORAL RINSE
SALAGEN
SALAGEN
KENALOG-ORABORALONE
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
1965
1966
1967
1968
1969
1970
Oral
MT
MT
Oral
Oral
MT
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
DERMATOLOGICAL AGENTS
Dermatological Agents
8-MOP CAP 10MG
acitretin cap 10mg
acitretin cap 17.5mg
acitretin cap 25mg
adapalene cre 0.1%
adapalene gel 0.1%
adapalene gel 0.3%
ammonium lac cre 12%
ammonium lac lot 12%
amnesteem cap 10mg
amnesteem cap 20mg
amnesteem cap 40mg
calcipotrien cre 0.005%
calcipotrien sol 0.005%
clotrim/beta cre diprop
clotrim/beta lot diprop
CONDYLOX GEL 0.5%
diclofenac gel 3%
ELIDEL CRE 1%
methoxsalen
SORIATANE
SORIATANE
SORIATANE
DIFFERIN
DIFFERIN
DIFFERIN
LAC-HYDRIN
LAC-HYDRIN
isotretinoin
isotretinoin
isotretinoin
DOVONEX
DOVONEX
LOTRISONE
LOTRISONE
podofilox
SOLARAZE
pimecrolimus
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 2
Tier 4
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
erythromycin gel /benzoyl
fluorouracil cre 5%
fluorouracil sol 2%
fluorouracil sol 5%
imiquimod cre 5%
podofilox sol 0.5%
SANTYL OIN 250/GM
selenium sul lot 2.5%
tacrolimus oin 0.03%
BENZAMYCIN
EFUDEX
EFUDEX
EFUDEX
ALDARA
CONDYLOX
collagenase
SELSUN
PROTOPIC
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
tacrolimus oin 0.1%
PROTOPIC
Tier 2
No
No
TAZORAC CRE 0.05%
TAZORAC CRE 0.1%
TAZORAC GEL 0.05%
TAZORAC GEL 0.1%
tretinoin cre 0.025%
tretinoin cre 0.05%
tazarotene
tazarotene
tazarotene
tazarotene
RETIN-A, AVITA
RETIN-A
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
PA
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
PA
PA, QL (30 per 30
days)
1988
1989
1990
1991
1992
1993
1994
1995
QL (30 per 30 days)
1996
1997
PA, QL (30 per 30
days)
PA, QL (30 per 30
days)
1998
1999
2000
2001
2002
2003
2004
2005
Oral
Oral
Oral
Oral
Top
Top
Top
Top
Top
Oral
Oral
Oral
Top
Top
Top
Top
Top
TD
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
71
Formulary
Covered Drug Name
tretinoin cre 0.1%
tretinoin gel 0.01%
tretinoin gel 0.025%
tretinoin gel 0.04%
tretinoin gel 0.1%
VOLTAREN GEL 1%
Alternate Drug Name
RETIN-A
RETIN-A
RETIN-A, AVITA
RETIN-A
RETIN-A
diclofenac sodium topical gel
Tier
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 4
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
2006
2007
2008
2009
2010
2011
Top
Top
Top
Top
Top
TD
ENZYME REPLACEMENT/ MODIFIERS
Enzyme Replacement/ Modifiers
ADAGEN INJ 250/ML
pegademase bovine
ALDURAZYME INJ 2.9MG/5ML
laronidase
CEREZYME INJ 400UNIT
imiglucerase
CYSTADANE POW
betaine (trimethylglycine)
CYSTAGON CAP 150MG
cysteamine
CYSTAGON CAP 50MG
cysteamine
ELAPRASE INJ 6MG/3ML
idursulfase
FABRAZYME INJ 35MG
agalsidase beta
KUVAN TAB 100MG
sapropterin
NAGLAZYME INJ 1MG/ML
galsulfase
phenylbutyra pow sodium
sodium phenylbutyrate
RAVICTI LIQ 1.1GM/ML
glycerol phenylbutyrate
VPRIV INJ 400UNIT
velaglucerase alfa
ZAVESCA CAP 100MG
miglustat
Tier 5
Tier 5
Tier 5
Tier 5
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
Tier 5
Tier 5
Tier 5
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
PA
PA
PA
Enzyme Replacements/ Modifiers
LUMIZYME INJ 50MG
alglucosidase alfa
Tier 5
No
No
PA
Antispasmodics, Gastrointestinal
dicyclomine cap 10mg
BENTYL
glycopyrrol tab 1mg
ROBINUL
Tier 2
Tier 2
No
No
No
No
Gastrointestinal Agents, Other
CREON CAP 12000UNT
amylases - endopeptidase - lipase
CREON CAP 24000UNT
CREON CAP 3000UNIT
CREON CAP 36000UNT
Tier 3
Tier 3
Tier 3
Tier 3
No
No
No
No
Yes
Yes
Yes
Yes
2012
2013
2014
2015
2016
2017
PA
PA
PA
PA
PA
PA
PA
PA
2018
2019
2020
2021
2022
2023
2024
2025
2026
Inj
Inj
Inj
Oral
Oral
Oral
Inj
Inj
Oral
Inj
Oral
Oral
Inj
Oral
Inj
GASTROINTESTINAL AGENTS
72
2027
2028
2029
2030
2031
2032
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
CREON CAP 6000UNIT
GATTEX KIT 5MG
loperamide cap 2mg
PANCREAZE CAP 10500UNT
PANCREAZE CAP 4200UNIT
RELISTOR INJ 12/0.6ML
RELISTOR KIT 12/0.6ML
SUCRAID SOL 8500/ML
ursodiol cap 300mg
ursodiol tab 250mg
ursodiol tab 500mg
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
ZENPEP CAP 20000UNT
ZENPEP CAP 25000UNT
ZENPEP CAP 3000UNIT
ZENPEP CAP 5000UNIT
Alternate Drug Name
Tier
teduglutide
IMODIUM
METHYLNALTREXONE
methylnaltrexone
methylnaltrexone
sacrosidase
ACTIGALL
URSO 250
URSO FORTE
Tier 3
Tier 5
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 5
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Histamine2 (H2) Receptor Antagonists
cimetidine sol 300/5ml
TAGAMET
cimetidine tab 200mg
TAGAMET
TAGAMET
TAGAMET
TAGAMET
famotidine inj 10mg/ml
PEPCID I.V.
famotidine inj 20mg/50ml
PEPCID I.V.
famotidine sus 40mg/5ml
PEPCID
famotidine tab 20mg
PEPCID
famotidine tab 40mg
PEPCID
nizatidine cap 150mg
AXID
nizatidine cap 300mg
AXID
nizatidine sol 15mg/ml
AXID
ranitidine cap 150mg
ZANTAC
ranitidine cap 300mg
ZANTAC
ranitidine inj 150/6ml
ZANTAC
ranitidine syp 15mg/ml
ZANTAC
ranitidine tab 150mg
ZANTAC
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
2033
PA
2034
2035
2036
2037
2038
2039
PA
PA
PA
PA
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
2056
2057
PA
PA
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
PA
2068
2069
2070
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
73
Formulary
Covered Drug Name
ranitidine tab 300mg
74
Alternate Drug Name
ZANTAC
Tier
Tier 2
Mail Retail
Route
Limits
Order Store
Yes
Yes
Irritable Bowel Syndrome Agents
LINZESS CAP 145MCG
linaclotide
LINZESS CAP 290MCG
linaclotide
LOTRONEX TAB 0.5MG
alosetron
Tier 3
Tier 3
Tier 5
No
No
Yes
No
No
Yes
LOTRONEX TAB 1MG
alosetron
Tier 5
Yes
Yes
Laxatives
constulose sol 10gm/15ml
enulose sol 10gm/15ml
gavilyte-c sol
gavilyte-g sol
gavilyte-n sol flav pk
generlac sol 10gm/15ml
lactulose sol 10gm/15ml
peg-3350 sol electrol
polyeth glyc pow 3350 nf
trilyte sol
CONSTULOSE, CEPHULAC, ENULOSE
LACTULOSE
COLYTE-FLAVR
GOLYTELY
TRILYTE, GAVILYTE-N
lactulose
CONSTULOSE, CEPHULAC, ENULOSE
peg-3350
MIRALAX
TRILYTE, GAVILYTE-N
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
Tier 2
Tier 1
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Protectants
misoprostol tab 100mcg
misoprostol tab 200mcg
sucralfate tab 1gm
CYTOTEC
CYTOTEC
CARAFATE
Tier 2
Tier 2
Tier 1
No
No
Yes
No
No
Yes
Proton Pump Inhibitors
esomeprazole inj 40mg
lansoprazole cap 15mg dr
omeprazole cap 10mg
omeprazole cap 20mg
omeprazole cap 40mg
pantoprazole tab 20mg
PROTONIX INJ 40MG
NEXIUM
PREVACID
PREVACID
PRILOSEC
PRILOSEC
PRILOSEC
PROTONIX
PROTONIX
pantoprazole
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
2071
2072
2073
PA, QL (60 per 30
days)
PA, QL (60 per 30
days)
2074
2075
2076
2077
2078
2079
2080
2081
2082
2083
2084
2085
2086
2087
2088
PA
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
2089
2090
2091
2092
2093
2094
2095
2096
2097
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
GENITOURINARY AGENTS
Antispasmodics, Urinary
ENABLEX TAB 15MG
darifenacin
Tier 4
No
No
ENABLEX TAB 7.5MG
darifenacin
Tier 4
No
No
flavoxate tab 100mg
MYRBETRIQ TAB 25MG
URISPAS
mirabegron er
Tier 2
Tier 4
No
No
No
No
MYRBETRIQ TAB 50MG
mirabegron er
Tier 4
No
No
oxybutynin tab 10mg er
oxybutynin tab 5mg
tolterodine tab 1mg
tolterodine tab 2mg
TOVIAZ TAB 4MG
TOVIAZ TAB 8MG
trospium chl cap 60mg er
trospium cl tab 20mg
VESICARE TAB 10MG
DITROPAN XL
DITROPAN XL
DITROPAN
DITROPAN XL
DETROL
DETROL
fesoterodine
fesoterodine
SANCTURA
SANCTURA
solifenacin
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 2
Tier 2
Tier 4
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
VESICARE TAB 5MG
solifenacin
Tier 4
No
No
Tier 1
Tier 4
Yes
Yes
Benign Prostatic Hypertrophy Agents
alfuzosin tab 10mg
UROXATRAL
AVODART CAP 0.5MG
dutasteride
QL (30 per 30 days),
ST
ST
2098
2099
2100
ST
ST
QL (90 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
ST
ST
finasteride tab 5mg
tamsulosin cap 0.4mg
PROSCAR
FLOMAX
Tier 1
Tier 1
Yes
Yes
Yes QL (30 per 30 days),
ST
Genitourinary Agents, Other
bethanechol tab 10mg
bethanechol tab 5mg
URECHOLINE
URECHOLINE
URECHOLINE
URECHOLINE
Tier 2
Tier 2
Tier 2
Tier 2
No
No
No
No
No
No
No
No
2101
2102
2103
2104
2105
2106
2107
2108
2109
2110
2111
2112
2113
2114
2115
2116
2117
2118
2119
2120
2121
2122
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
75
Formulary
Covered Drug Name
Alternate Drug Name
Tier
DEPEN TITRA TAB 250MG
VIAGRA TAB 100MG *
VIAGRA TAB 25MG *
VIAGRA TAB 50MG *
penicillamine
sildenafil
sildenafil
sildenafil
Tier 5
Tier 4
Tier 4
Tier 4
Phosphate Binders
calc acetate cap 667mg
FOSRENOL CHW 1000MG
FOSRENOL CHW 500MG
FOSRENOL CHW 750MG
PHOSLYRA SOL
RENAGEL TAB 400MG
RENAGEL TAB 800MG
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
PHOSLO
lanthanum
lanthanum
lanthanum
calcium acetate
sevelamer
sevelamer
sevelamer
sevelamer
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
2123
QL (4 per 30 days)
QL (4 per 30 days)
QL (4 per 30 days)
2124
2125
2126
2127
2128
2129
2130
2131
2132
2133
2134
2135
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
a-hydrocort inj 100mg
CORTEF
Tier 2
ala cort cre 1%
PROCTOCORT, ALA-CORT
Tier 1
alclometason cre 0.05%
ACLOVATE
Tier 1
alclometason oin 0.05%
ACLOVATE
Tier 1
amcinonide cre 0.1%
CYCLOCORT
Tier 2
amcinonide lot 0.1%
CYCLOCORT
Tier 2
amcinonide oin 0.1%
CYCLOCORT
Tier 2
aug betamet cre 0.05%
DIPROLENE
Tier 1
aug betamet gel 0.05%
DIPROLENE
Tier 1
aug betamet lot 0.05%
DIPROLENE
Tier 1
aug betamet oin 0.05%
DIPROLENE
Tier 1
betameth dip cre 0.05%
DEL-BETA
Tier 2
betameth dip lot 0.05%
DEL-BETA
Tier 2
betameth dip oin 0.05%
DEL-BETA
Tier 2
betameth val aer 0.12%
LUXIQ
Tier 1
betameth val cre 0.1%
BETA-VAL
Tier 1
betameth val lot 0.1%
BETA-VAL
Tier 1
betameth val oin 0.1%
BETA-VAL
Tier 1
budesonide cap 3mg/24hr
ENTOCORT EC
Tier 2
colocort ene 100mg
COLOCORT
Tier 2
CORTISONE AC TAB 25MG
cortisone
Tier 1
76
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
PA
2136
2137
2138
2139
2140
2141
2142
2143
2144
2145
2146
2147
2148
2149
2150
2151
2152
2153
2154
2155
2156
Inj
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Oral
Rec
Oral
Formulary
Covered Drug Name
desonide cre 0.05%
desonide lot 0.05%
desonide oin 0.05%
desoximetas cre 0.05%
desoximetas cre 0.25%
desoximetas gel 0.05%
desoximetas oin 0.25%
dexameth pho inj 120mg/30ml
dexamethason con 1mg/ml
dexamethason elx 0.5/5ml
dexamethason tab 0.5mg
dexamethason tab 1mg
diflorasone cre 0.05%
diflorasone oin 0.05%
fludrocort tab 0.1mg
fluocin acet cre 0.01%
fluocin acet cre 0.025%
fluocin acet oil body
fluocin acet oin 0.025%
fluocin acet sol 0.01%
fluocinonide cre -e 0.05%
fluocinonide cre 0.1%
fluocinonide gel 0.05%
fluocinonide oin 0.05%
fluocinonide sol 0.05%
fluticasone cre 0.05%
fluticasone lot 0.05%
fluticasone oin 0.005%
halobetasol cre 0.05%
halobetasol oin 0.05%
hc valerate cre 0.2%
hc valerate oin 0.2%
hydrocort cre 1%
hydrocort cre 2.5%
hydrocort ene 100mg
hydrocort lot 2.5%
hydrocort oin 1%
Alternate Drug Name
DESOWEN
DESOWEN
DESOWEN
TOPICORT
TOPICORT
TOPICORT
TOPICORT
DECADRON, DEXASONE
BAYCADRON
BAYCADRON
DECADRON, DEXASONE
DECADRON, DEXASONE
DECADRON, DEXASONE
DECADRON, DEXASONE
DECADRON, DEXASONE
DECADRON, DEXASONE
DECADRON, DEXASONE
PSORCON
PSORCON
FLORINEF
SYNALAR
SYNALAR
DERMA-SMOOTH
SYNALAR
SYNALAR
LIDEX-E
LIDEX
LIDEX
LIDEX
LIDEX
CUTIVATE
CUTIVATE
CUTIVATE
ULTRAVATE
ULTRAVATE
hydrocortisone
hydrocortisone
PROCTOCORT, ALA-CORT
HYTONE
COLOCORT
HYTONE
HYTONE
Tier
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 1
Tier 1
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
2157
2158
2159
2160
2161
2162
2163
PA
2164
2165
2166
2167
2168
2169
2170
2171
2172
2173
2174
2175
2176
2177
2178
2179
2180
2181
2182
2183
2184
2185
2186
2187
2188
2189
2190
2191
2192
2193
2194
2195
2196
2197
2198
Top
Top
Top
Top
Top
Top
Top
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Top
Top
Oral
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Rec
Top
Top
77
Formulary
Covered Drug Name
hydrocort oin 2.5%
hydrocort tab 10mg
hydrocort tab 20mg
hydrocort tab 5mg
lokara lot 0.05%
methylpr ace inj 40mg/ml
methylpr ss inj 125mg
methylpred pak 4mg
methylpred tab 16mg
methylpred tab 32mg
methylpred tab 4mg
methylpred tab 8mg
mometasone cre 0.1%
mometasone oin 0.1%
mometasone sol 0.1%
pred sod pho sol 5mg/5ml
prednicarbat oin 0.1%
prednisolone sol 15mg/5ml
prednisone tab 10mg
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 20mg
prednisone tab 50mg
prednisone tab 5mg
procto-pak cre 1%
proctozone cre -hc 2.5%
triamcinolon cre 0.025%
triamcinolon lot 0.025%
triamcinolon lot 0.1%
triamcinolon oin 0.025%
triderm cre 0.1%
Alternate Drug Name
HYTONE
CORTEF
CORTEF
CORTEF
DESOWEN
DEPO-MEDROL
DEPO-MEDROL
SOLU-MEDROL
SOLU-MEDROL
MEDROL
MEDROL
MEDROL
MEDROL
MEDROL
ELOCON
ELOCON
ELOCON
ORAPRED
DERMATOP
ORAPRED
prednisone
prednisone
prednisone
prednisone
prednisone
prednisone
PROCTO-PAK
hydrocortisone
triamcinolone
triamcinolone
triamcinolone
triamcinolone
triamcinolone
triamcinolone
triamcinolone
triamcinolone
triamcinolone
Tier
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
2199
2200
2201
2202
2203
PA
PA
PA
PA
2204
2205
2206
2207
2208
2209
2210
2211
2212
2213
2214
2215
2216
2217
2218
2219
2220
2221
2222
2223
2224
2225
2226
2227
2228
2229
2230
2231
2232
2233
2234
2235
Top
Oral
Oral
Oral
Top
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Top
Top
Top
Oral
Top
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Rec
Rec
Top
Top
Top
Top
Top
Top
Top
Top
Top
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin inj 4mcg/ml
DDAVP
Tier 2 No
78
No
PA
2236
Inj
Formulary
Covered Drug Name
desmopressin spr 0.01%
desmopressin tab 0.1mg
desmopressin tab 0.2mg
GENOTROPIN INJ 0.2MG
GENOTROPIN INJ 12MG
GENOTROPIN INJ 1MG
GENOTROPIN INJ 2MG
GENOTROPIN INJ 5MG
INCRELEX INJ 40MG/4ML
NUTROPIN AQ INJ 10MG/2ML
Alternate Drug Name
DDAVP
DDAVP
DDAVP
somatropin
somatropin
somatropin
somatropin
somatropin
somatropin
somatropin
somatropin
somatropin
somatropin
somatropin
somatropin
mecasermin
somatropin
somatropin
Tier
Tier 2
Tier 2
Tier 2
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
2237
2238
2239
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
2240
2241
2242
2243
2244
2245
2246
2247
2248
2249
2250
2251
2252
PA
PA
2253
2254
NS
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING
(SEX HORMONES/MODIFIERS)
Anabolic Steroids
ANADROL-50 TAB 50MG
oxandrolone tab 10mg
oxandrolone tab 2.5mg
oxymetholone
OXANDRIN
OXANDRIN
Tier 4
Tier 2
Tier 2
No
No
No
No
No
No
Androgens
ANDROGEL GEL 1.62%
ANDROGEL GEL 1.62%
ANDROGEL GEL 1%(25MG)
ANDROGEL GEL PUMP 1.62%
danazol cap 100mg
danazol cap 200mg
danazol cap 50mg
TESTIM GEL 1%(50MG)
testost cyp inj 100mg/ml
testosterone
testosterone
testosterone
testosterone
testosterone
testosterone
DANOCRINE
DANOCRINE
DANOCRINE
testosterone
testosterone cypionate
testosterone cypionate
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
2255
2256
2257
2258
2259
2260
2261
2262
2263
2264
2265
2266
PA
PA
2267
2268
2269
Oral
Oral
Oral
TD
TD
TD
TD
TD
TD
Oral
Oral
Oral
TD
Inj
Inj
79
Formulary
Covered Drug Name
Estrogens
apri
aranelle
aviane
cryselle-28
enpresse-28
ESTRACE VAG CRE 0.1MG/GM
estrad val inj 20mg/ml
estradiol tab 0.5mg
estradiol tab 1mg
estradiol tab 2mg
junel 1.5/30
junel 1/20
junel fe tab 1.5/30
junel fe tab 1/20
kariva tab 28 day
kelnor tab 1/35
lessina
levora-28 tab 0.15/30
lutera
menest tab 0.3mg
menest tab 0.625mg
menest tab 1.25mg
menest tab 2.5mg
microgestin tab 1.5/30
microgestin tab 1/20
microgestin tab fe 1/20
microgestin tab fe1.5/30
necon tab 0.5/35
necon tab 1/35
necon tab 10/11-28
nortrel tab 0.5/35
nortrel tab 1/35
nortrel tab 7/7/7
portia-28
PREMARIN TAB 0.625MG
PREMARIN VAG CRE 0.625MG
PREMPRO TAB .625-2.5MG
80
Alternate Drug Name
ORTHO-CEPT
LEENA, ARANELLE
ALESSE, AVIANE, LESSINA, LUTERA
LO/OVRAL, CRYSELLE
ENPRESSE, TRIVORA, TRI-LEVEN
estradiol vaginal cream
estradiol
estradiol
ESTRACE
ESTRACE
ESTRACE
ethinyl estradiol - norethindrone
ORTHO-CEPT
DEMULEN, KELNOR, ZOVIA
PORTIA, LEVORA
esterified estrogens
ethinyl - norethindrone
BREVICON, NORTREL, NECON
NORTREL, NECON
ORTHO-NOVUM, NORTREL, NECON
PORTIA, LEVORA
estrogens, conjugated
estrogens, conjugated
estrogens, conjugatedmedroxyprogesterone
Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 3
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Yes
2270
2271
2272
2273
2274
2275
PA
PA
PA
PA
PA
2276
2277
2278
2279
2280
2281
2282
2283
2284
2285
2286
2287
2288
2289
2290
2291
2292
2293
2294
2295
2296
2297
2298
2299
2300
2301
2302
2303
2304
2305
2306
2307
Oral
Oral
Oral
Oral
Oral
Vag
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Vag
Oral
Formulary
Covered Drug Name
PREMPRO TAB 0.3-1.5MG
Alternate Drug Name
Tier
Yes
Yes
Tier 3
Yes
Yes
Tier 3
Yes
Yes
Tier 1
Tier 1
No
No
No
No
Tier 1
No
No
Tier 1
No
No
Tier 1
Tier 1
Tier 1
Tier 1
No
No
No
No
No
No
No
No
Tier 1
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 1
Tier 2
Tier 2
No
No
Yes
Yes
Yes
No
No
No
No
No
No
Yes
No
Yes
Yes
Yes
No
No
No
No
No
No
Tier 2
No
No
Tier 3
trivora-28
velivet pak
zovia 1/35e
zovia 1/50e
SEASONALE
ORTHO-CYCLEN, SPRINTEC,
MONONESSA
ORTHO TRI-CYCLEN LO, TRI-SPRINTEC,
TRINESSA, TRI-PREVIFEM
ORTHO TRI-CYCLEN LO, TRI-SPRINTEC,
ENPRESSE, TRIVORA, TRI-LEVEN
CYCLESSA, VELIVET, CESIA
DEMULEN, KELNOR, ZOVIA
DEMULEN
Progestins
errin tab 0.35mg
medroxypr ac inj 150mg/ml
medroxypr ac tab 10mg
medroxypr ac tab 2.5mg
medroxypr ac tab 5mg
megestrol ac sus 40mg/ml
megestrol ac tab 20mg
norethin ace tab 5mg
progesterone cap 100mg
progesterone cap 200mg
ORTHO MICRONOR
DEPO-PROVERA
PROVERA
PROVERA
PROVERA
MEGACE
MEGACE
MEGACE
AYGESTIN
progesterone
progesterone
PREMPRO TAB 0.45-1.5MG
PREMPRO TAB 0.625-5MG
quasense
sprintec 28 day
tri-previfem
tri-sprintec
Selective Estrogen Receptor Modifying Agents
raloxifene tab 60mg
EVISTA
Mail Retail
Route
Limits
Order Store
2308
2309
2310
2311
2312
2313
2314
2315
2316
2317
2318
2319
2320
2321
2322
2323
PA
PA
PA
2324
2325
2326
2327
2328
2329
QL (30 per 30 days)
2330
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
CYTOMEL TAB 25MCG
liothyronine
Tier 4
CYTOMEL TAB 50MCG
liothyronine
Tier 4
CYTOMEL TAB 5MCG
liothyronine
Tier 4
No
No
No
No
No
No
2331
2332
2333
Oral
Oral
Oral
81
Formulary
Covered Drug Name
levothyroxin tab 100mcg
levoxyl tab 100mcg
levoxyl tab 112mcg
levoxyl tab 125mcg
levoxyl tab 137mcg
levoxyl tab 150mcg
levoxyl tab 175mcg
levoxyl tab 200mcg
levoxyl tab 25mcg
levoxyl tab 50mcg
levoxyl tab 75mcg
levoxyl tab 88mcg
liothyronine tab 25mcg
SYNTHROID TAB 100MCG
SYNTHROID TAB 25MCG
SYNTHROID TAB 50MCG
SYNTHROID TAB 75MCG
SYNTHROID TAB 88MCG
UNITHROID TAB 100MCG
82
Alternate Drug Name
LEVOTHROID, SYNTHROID
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
CYTOMEL
CYTOMEL
CYTOMEL
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Mail Retail
Route
Limits
Order Store
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
2334
2335
2336
2337
2338
2339
2340
2341
2342
2343
2344
2345
2346
2347
2348
2349
2350
2351
2352
2353
2354
2355
2356
2357
2358
2359
2360
2361
2362
2363
2364
2365
2366
2367
2368
2369
2370
2371
2372
2373
2374
2375
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
UNITHROID TAB 25MCG
UNITHROID TAB 50MCG
UNITHROID TAB 75MCG
UNITHROID TAB 88MCG
Alternate Drug Name
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
Tier
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Mail Retail
Route
Limits
Order Store
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
2376
2377
2378
2379
2380
2381
2382
Oral
Oral
Oral
Oral
Oral
Oral
Oral
HORMONAL AGENTS, SUPPRESSANT (ADRENAL)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN TAB 500MG
mitotane
Tier 3
2383
Oral
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TAB 30MG
cinacalcet
SENSIPAR TAB 60MG
cinacalcet
SENSIPAR TAB 90MG
cinacalcet
Tier 3
Tier 5
Tier 5
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
2384
2385
2386
Oral
Oral
Oral
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
Hormonal Agents, Suppressant (Pituitary)
cabergoline tab 0.5mg
DOSTINEX
leuprolide inj 1mg/0.2ml
LUPRON SC
LUPR DEP-PED INJ 11.25MG
leuprolide acetate
LUPR DEP-PED INJ 15MG
leuprolide dep ped
LUPRON DEPOT INJ 3.75MG
leuprolide acetate
leuprolide depot
octreotide inj 1000mcg
SANDOSTATIN
SANDOSTATIN
SANDOSTATIN
SANDOSTATIN
octreotide inj 50mcg/ml
SANDOSTATIN
SANDOSTATIN KIT LAR 10MG
octreotide
octreotide
octreotide
SIGNIFOR INJ 0.3MG/ML
pasireotide
pasireotide
pasireotide
SOMATULINE INJ 120/.5ML
lanreotide
SOMATULINE INJ 60/0.2ML
lanreotide
Tier 2
Tier 2
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
2387
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
2388
2389
2390
2391
2392
2393
2394
2395
2396
2397
2398
2399
2400
PA
PA
PA
2401
2402
2403
2404
2405
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
83
Formulary
Covered Drug Name
SOMATULINE INJ 90/0.3ML
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
SOMAVERT INJ 20MG
SOMAVERT INJ 25MG
SOMAVERT INJ 30MG
SYNAREL SOL 2MG/ML
Alternate Drug Name
lanreotide
pegvisomant
pegvisomant
pegvisomant
pegvisomant
pegvisomant
nafarelin
Tier
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Tier 1
Tier 1
Tier 1
No
No
No
No
No
No
2406
PA
PA
PA
PA
PA
2407
2408
2409
2410
2411
2412
Inj
Inj
Inj
Inj
Inj
Inj
NS
HORMONAL AGENTS, SUPPRESSANT (THYROID)
Antithyroid Agents
methimazole tab 10mg
methimazole tab 5mg
propylthiour tab 50mg
TAPAZOLE
TAPAZOLE
propylthiouracil
2413
2414
2415
Oral
Oral
Oral
IMMUNOLOGICAL AGENTS
84
Angioedema (HAE) Agents
CINRYZE SOL 500 UNIT
FIRAZYR INJ 30MG/3ML
c1 inhibitor (human)
icatibant
Tier 5
Tier 5
No
No
No
No
Immune Suppressants
ASTAGRAF XL CAP 0.5MG
ASTAGRAF XL CAP 1MG
ASTAGRAF XL CAP 5MG
AZASAN TAB 100MG
AZASAN TAB 75 MG
azathioprine tab 50mg
CELLCEPT IV INJ 500MG
cyclosporine cap 100mg
cyclosporine cap 100mg md
cyclosporine cap 25mg mod
cyclosporine inj 50mg/ml
cyclosporine sol modified
ENBREL INJ 25/0.5ML
ENBREL INJ 25MG
tacrolimus er
tacrolimus er
tacrolimus er
azathioprine
azathioprine
IMURAN
mycophenolate
SANDIMMUNE
NEORAL
SANDIMMUNE
NEORAL
NEORAL
SANDIMMUNE
NEORAL
etanercept
etanercept
Tier 4
Tier 4
Tier 5
Tier 2
Tier 2
Tier 2
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
ENBREL INJ 50MG/ML
etanercept
Tier 5
No
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No PA, QL (8 per 28 days)
No
PA, QL (16 per 28
days)
PA
PA, QL (29 per 30
days)
2416
2417
2418
2419
2420
2421
2422
2423
2424
2425
2426
2427
2428
2429
2430
2431
2432
2433
2434
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Inj
Inj
Inj
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
gengraf cap 100mg
gengraf cap 25mg
gengraf sol 100mg/ml
HUMIRA KIT 20MG/0.4ML
HUMIRA PEN KIT CROHNS
KINERET INJ
methotrexate inj 1gm
methotrexate inj 25mg/ml
methotrexate tab 2.5mg
mycophenolat cap 250mg
mycophenolat sus 200mg/ml
mycophenolat tab 500mg
mycophenolic tab 180mg dr
NULOJIX INJ 250MG
ORENCIA INJ 125MG/ML
ORENCIA INJ 250MG
PROGRAF INJ 5MG/ML
RAPAMUNE SOL 1MG/ML
REMICADE INJ 100MG
SANDIMMUNE SOL 100MG/ML
sirolimus tab 0.5mg
sirolimus tab 1mg
sirolimus tab 2mg
tacrolimus cap 0.5mg
tacrolimus cap 1mg
tacrolimus cap 5mg
TORISEL SOL 25MG/ML
TREXALL TAB 10MG
TREXALL TAB 15MG
TREXALL TAB 5MG
TREXALL TAB 7.5MG
ZORTRESS TAB 0.25MG
NEORAL
NEORAL
NEORAL
adalimumab
adalimumab
adalimumab penfill
anakinra
TREXALL
TREXALL
TREXALL
CELLCEPT
CELLCEPT
CELLCEPT
CELLCEPT
CELLCEPT
belatacept
abatacept
abatacept
tacrolimus
sirolimus
infliximab
cyclosporine
RAPAMUNE
RAPAMUNE
RAPAMUNE
PROGRAF
PROGRAF
PROGRAF
temsirolimus
methotrexate
methotrexate
methotrexate
methotrexate
everolimus
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
Tier 2
Tier 2
Tier 4
Tier 5
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 4
Tier 5
Tier 5
Tier 4
Tier 4
Tier 4
Tier 5
Tier 2
Tier 2
Tier 2
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
ZORTRESS TAB 0.5MG
everolimus
Tier 5
No
ZORTRESS TAB 0.75MG
everolimus
Tier 5
No
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
Yes
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
Yes
Yes
Yes
Yes
No
PA, QL (60 per 30
days)
No
PA, QL (60 per 30
days)
No
PA, QL (60 per 30
days)
2435
2436
2437
2438
2439
2440
2441
2442
2443
2444
2445
2446
2447
2448
2449
2450
2451
2452
2453
2454
2455
2456
2457
2458
2459
2460
2461
2462
2463
2464
2465
2466
2467
2468
2469
2470
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
85
Formulary
Covered Drug Name
Immunizing Agents, Passive
CARIMUNE NF INJ 3GM
GAMASTAN S/D INJ
GAMMAGARD INJ 2.5GM/25ML
THYMOGLOBULN INJ 25MG
Immunomodulators
ACTIMMUNE INJ 2MU/0.5ML
ARCALYST INJ 220MG
BENLYSTA INJ 120MG
ILARIS INJ 180MG
leflunomide tab 10mg
RIDAURA CAP 3MG
SYNAGIS INJ 50MG
Vaccines
ACTHIB INJ
ADACEL INJ
BCG VACCINE INJ
BOOSTRIX INJ
CERVARIX INJ
COMVAX INJ
DAPTACEL INJ
ENGERIX-B INJ 10/0.5ML
ENGERIX-B INJ 20MCG/ML
GARDASIL 9 INJ
GARDASIL 9 INJ
GARDASIL INJ
HAVRIX INJ 1440UNIT
HAVRIX INJ 720UNIT
86
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
globulin, immune
immune globulin (human)
globulin, immune
rabbit anti-human t-lymphocyte
globulin
Tier 5
Tier 3
Tier 5
Tier 5
No
No
No
No
No
No
No
No
PA
PA
PA
PA
interferon gamma-1b
rilonacept
belimumab
canakinumab
ARAVA
ARAVA
auranofin
palivizumab
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
Tier 2
Tier 5
Tier 5
No
No
No
No
No
No
No
No
No
PA
No
PA
No
PA
No
PA
Yes
No
PA
haemophilus b conjugate vaccine
bordetella pertussis filamentous
hemagglutinin vaccine
bcg, live, tice strain 50 mg/ml injectable
suspension
boostrix
human papillomavirus
haemophilus b polysaccharide conj vacc
- hepatitis
bordetella pertussis
hepatitis b virus vaccine
uman papillomavirus - quadrivalent hpv
(6,11,16,18) vac
(6,11,16,18) vac
(6,11,16,18) vac
hepatitis a virus vaccine
Tier 4
Tier 1
No
No
No
No
Tier 3
No
No
Tier 1
Tier 4
Tier 4
No
No
No
No
No
No
Tier 1
Tier 4
Tier 4
Tier 4
No
No
No
No
No
No
No
No
PA
PA
PA
Tier 4
No
No
PA
Tier 4
No
No
PA
Tier 4
Tier 4
No
No
No
No
2471
2472
2473
2474
2475
2476
2477
2478
2479
2480
2481
2482
2483
2484
2485
2486
2487
2488
2489
2490
2491
2492
2493
2494
2495
2496
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Formulary
Covered Drug Name
IMOVAX RABIE INJ 2.5/ML
INFANRIX INJ
IPOL INJ INACTIVE
IXIARO INJ
M-M-R II INJ LIVE
MENACTRA INJ
MENOMUNE INJ A/C/Y/W
MENVEO INJ
PEDVAX HIB INJ
PROQUAD INJ
RABAVERT INJ
RECOMBIVA HB INJ 10MCG/ML
RECOMBIVA HB INJ 5MCG/0.5ML
RECOMBIVA-HB INJ 40MCG/ML
ROTARIX SUS
ROTATEQ SOL
TET/DIP TOX INJ 2-2 LF
TWINRIX INJ
TYPHIM VI INJ
VAQTA INJ 25/0.5ML
VARIVAX INJ
YF-VAX INJ
ZOSTAVAX INJ
Alternate Drug Name
rabies vaccine human diploid cell
diphtheria - tetanus toxoids - acellular
pertussis
poliovirus vaccine
japanese encephalitis virus vaccine
measles virus - mumps virus vaccine
meningococcal polysaccharide vac a-cy-w
meningococcal polysaccharide vac a-cy-w
meninggococcal oligosaccharide
conjugate vaccine
haemophilus b polysaccharide conj
vaccine
measles virus vaccine - mumps virus
vaccine - rubella virus vaccine varicella-zoster virus vaccine
rabies virus vaccine
rotavirus vaccine
rotavirus vaccine
diphtheria toxoid - tetanus toxoid
hepatitis a - hepatitis b virus vaccine
typhoid vi polysaccharide vaccine
varicella virus vaccine
yellow fever vaccine
varicella-zoster virus vaccine
Tier
Tier 4
Tier 1
Mail Retail
Route
Limits
Order Store
No
No
No
No
Tier 4
Tier 4
Tier 4
Tier 4
No
No
No
No
No
No
No
No
Tier 4
No
No
Tier 4
No
No
Tier 4
No
No
Tier 4
No
No
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Tier 4
Tier 2
Tier 5
Tier 4
Tier 5
Tier 2
Tier 4
Tier 5
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
2497
2498
2499
2500
2501
2502
2503
2504
2505
2506
PA
PA
PA
PA
2507
2508
2509
2510
2511
2512
PA
PA
2513
2514
2515
2516
2517
2518
2519
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
INFLAMMATORY BOWEL DISEASE AGENTS
Aminosalicylates
ASACOL HD TAB 800MG
balsalazide cap 750mg
CANASA SUP 1000MG
DELZICOL CAP 400MG
DIPENTUM CAP 250MG
mesalamine kit 4gm
PENTASA CAP 250MG CR
PENTASA CAP 500MG CR
mesalamine (5-asa)
COLAZAL
mesalamine (5-asa)
mesalamine ec
olsalazine
ROWASA
mesalamine (5-asa)
mesalamine (5-asa)
2520
2521
2522
2523
2524
2525
2526
2527
Oral
Oral
Rec
Oral
Oral
Rec
Oral
Oral
87
Formulary
Covered Drug Name
Sulfonamides
sulfasalazin tab 500mg
sulfazine ec tab 500mg
Alternate Drug Name
AZULFIDINE
AZULFIDINE
Tier
Mail Retail
Route
Limits
Order Store
Tier 1
Tier 1
No
No
No
No
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
Tier 1
Tier 2
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 2
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 5
Tier 4
Tier 4
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
PA
Yes
No
No
No
No
Yes
Yes
No
PA
No
PA, QL (1 per 30
days), ST
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No
PA
No QL (1 per 30 days), ST
No
PA
No
PA
No
PA
2528
2529
Oral
Oral
METABOLIC BONE DISEASE AGENTS
Metabolic Bone Disease Agents
alendronate tab 10mg
FOSAMAX
FOSAMAX
FOSAMAX
alendronate tab 5mg
FOSAMAX
FOSAMAX
calcitonin spr 200/act
MIACALCIN
calcitriol cap 0.25mcg
ROCALTROL
calcitriol cap 0.5mcg
ROCALTROL
calcitriol inj 1mcg/ml
CALCIJEX
calcitriol sol 1mcg/ml
ROCALTROL
doxercalcif cap 0.5mcg
HECTOROL
doxercalcif cap 1mcg
HECTOROL
doxercalcif cap 2.5mcg
HECTOROL
doxercalcif inj 4mcg/2ml
HECTOROL
etidron disd tab 200mg
DIDRONEL
etidron disd tab 400mg
DIDRONEL
FORTEO SOL 600/2.4ML
teriparatide
ibandronate inj 3mg/3ml
BONIVA
ibandronate tab 150mg
MIACALCIN INJ 200/ML
pamidronate inj 30/10ml
paricalcitol cap 1 mcg
PROLIA SOL 60MG/ML
risedronate tab 150mg
XGEVA INJ
zoledronic inj 4mg/5ml
zoledronic inj 5/100ml
88
BONIVA
salmon calcitonin
AREDIA
AREDIA
ZEMPLAR
ZEMPLAR
ZEMPLAR
denosumab
actonel
denosumab
ZOMETA
RECLAST
2530
2531
2532
2533
2534
2535
2536
2537
2538
2539
2540
2541
2542
2543
2544
2545
2546
2547
2548
2549
2550
2551
2552
2553
2554
2555
2556
2557
2558
2559
Oral
Oral
Oral
Oral
Oral
NS
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Inj
Inj
Oral
Inj
Inj
Inj
Oral
Oral
Oral
Inj
Oral
Inj
Inj
Inj
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
MISCELLANEOUS THERAPEUTIC AGENTS
Hormonal Agents, Stimulant/Replacement/Modifying (Parathyroid)
NATPARA INJ 100MCG
parathyroid hormone
Tier 5 No
NATPARA INJ 25MCG
parathyroid hormone
Tier 5 No
NATPARA INJ 50MCG
parathyroid hormone
Tier 5 No
NATPARA INJ 75MCG
parathyroid hormone
Tier 5 No
No
No
No
No
PA
PA
PA
PA
2560
2561
2562
2563
Inj
Inj
Inj
Inj
OPHTHALMIC AGENTS
Ophthalmic Agents, Other
bacit/polymy oin
NAPHAZOLINE SOL 0.1%
neo/bac/poly oin
neo/poly/bac oin /hc 1%
neo/poly/dex oin 0.1%
neo/poly/dex sus 0.1%
neo/poly/gra sol
neo/poly/hc sus
polymyxin b/ sol trimethp
RESTASIS EMU 0.05%
sulf/pred na sol
tobra/dexame sus 0.3-0.1%
POLYSPORIN
naphazoline
TRIPLE ANTIBIOTIC
CORTISPORIN
MAXITROL
MAXITROL
NEOSPORIN
CORTISPORIN
POLYTRIM
cyclosporine
BLEPHAMIDE
TOBRADEX
Tier 2
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 1
No
Yes
No
No
Yes
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
No
Yes
No
Yes
Yes
Ophthalmic Anti-allergy Agents
ALOMIDE SOL 0.1%
lodoxamide
cromolyn sod sol 4%
CROLOM
epinastine dro 0.05%
ELESTAT
PATANOL SOL 0.1%
olopatadine
Tier 4
Tier 2
Tier 2
Tier 4
No
Yes
No
No
Yes
Yes
No
No
Ophthalmic Anti-inflammatories
ALREX SUS 0.2%
loteprednol etabonate
bromfenac sol 0.09%
XIBROM
dexameth pho sol 0.1%
DEXASOL
diclofenac sol 0.1%
VOLTAREN
DUREZOL EMU 0.05%
difluprednate
fluoromethol sus 0.1%
FML
flurbiprofen sol 0.03%
OCUFEN
Tier 3
Tier 2
Tier 1
Tier 2
Tier 3
Tier 3
Tier 2
No
Yes
No
Yes
No
No
Yes
Yes
Yes
No
Yes
No
No
Yes
2564
2565
2566
2567
2568
2569
2570
2571
2572
2573
2574
2575
2576
2577
2578
2579
2580
2581
2582
2583
2584
2585
2586
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
89
Formulary
Covered Drug Name
FML FORTE SUS 0.25%
FML OIN 0.1%
ketorolac sol 0.4%
ketorolac sol 0.5%
LOTEMAX SUS 0.5%
NEVANAC SUS 0.1%
pred sod pho sol 1%
prednisolone sus 1%
fluorometholone
fluorometholone
KETOROLAC
KETOROLAC
loteprednol
nepafenac
INFLAMASE
PRED MILD / PRED FORTE
Tier
Tier 3
Tier 3
Tier 2
Tier 2
Tier 3
Tier 4
Tier 2
Tier 3
Mail Retail
Route
Limits
Order Store
No
No
Yes
Yes
No
No
Yes
No
No
No
Yes
Yes
Yes
No
Yes
No
2587
2588
2589
2590
2591
2592
2593
2594
Ophthalmic Antiglaucoma Agents
ALPHAGAN P SOL 0.1%
brimonidine
ALPHAGAN P SOL 0.15%
brimonidine
apraclonidin sol 0.5%
IOPIDINE
AZOPT SUS 1%
brinzolamide
betaxolol sol 0.5%
BETAXOLOL
BETOPTIC-S SUS 0.25%
betaxolol
brimonidine sol 0.15%
ALPHAGAN
brimonidine sol 0.2%
ALPHAGAN
carteolol sol 1%
OCUPRESS
COMBIGAN SOL 0.2/0.5%
brimonidine - timolol
dorzol/timol sol 2-0.5%
COSOPT
dorzolamide sol 2%
TRUSOPT
levobunolol sol 0.5%
BETAGAN
metipranolol sol 0.3%
OPTIPRANOLOL
PHOSPHOLINE SOL 0.125%
phospholine
PILOCARPINE SOL 1%
pilocarpine hydrochloride
PILOCARPINE SOL 2%
PILOCARPINE SOL 4%
SIMBRINZA SUS 1-0.2%
brimonidine - brinzolamide
timolol gel sol 0.25%
TIMOPTIC-XE
timolol gel sol 0.5%
TIMOPTIC-XE
timolol mal sol 0.25%
TIMOPTIC
timolol mal sol 0.5%
TIMOPTIC
Tier 4
Tier 4
Tier 2
Tier 4
Tier 1
Tier 4
Tier 3
Tier 2
Tier 1
Tier 4
Tier 2
Tier 2
Tier 1
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 3
Tier 3
Tier 2
Tier 2
No
No
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost sol 0.005%
XALATAN
LUMIGAN SOL 0.01%
bimatoprost
Tier 1
Tier 4
Yes
Yes
Tier 2
No
Yes QL (7.5 per 30 days),
ST
No
travoprost dro 0.004%
90
Alternate Drug Name
TRAVATAN
ST
ST
2595
2596
2597
2598
2599
ST
2600
2601
2602
2603
2604
2605
2606
2607
2608
2609
2610
2611
2612
2613
2614
2615
2616
2617
2618
2619
2620
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
Formulary
Covered Drug Name
ZIOPTAN DRO 0.0015%
Alternate Drug Name
Tier
tafluprost
Tier 4
ACETASOL HC, VOSOL HC
ciprofloxacin hc
DERMOTIC
ACETASOL HC, VOSOL HC
CORTISPORIN
CORTISPORIN
Mail Retail
Route
Limits
Order Store
No
No
ST
Tier 3
Tier 3
Tier 2
Tier 2
Tier 1
Tier 1
No
No
No
No
No
No
No
No
No
No
No
No
Tier 2
Tier 2
Tier 2
No
No
No
No
No
No
Anti-inflammatories, Inhaled Corticosteroids
budesonide sus 0.25mg/2ml
PULMICORT
PULMICORT
FLOVENT DISK AER 100MCG
fluticasone
fluticasone
fluticasone
FLOVENT HFA AER 110MCG
fluticasone
fluticasone
fluticasone
flunisolide spr 0.025%
NASALIDE
fluticasone spr 50mcg
FLONASE
NASONEX SPR 50MCG/AC
mometasone
PULMICORT INH 180MCG
budesonide
QVAR AER 40MCG
beclomethasone
QVAR AER 80MCG
beclomethasone
triamcinolon spr 55mcg/ac
NASACORT AQ
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 4
Tier 3
Tier 4
Tier 4
Tier 1
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
No
No
No
PA
PA
QL (24 per 30 days)
QL (24 per 30 days)
QL (50 per 30 days)
QL (16 per 30 days)
QL (34 per 30 days)
QL (2 per 30 days)
QL (33 per 30 days)
Antihistamines
azelastine spr 0.1%
Tier 2
No
No
QL (30 per 30 days)
2621
OP
OTIC AGENTS
Otic Agents
acetasol hc sol
CIPRO HC SUS
fluocin acet oil 0.01%
hc/acet acid sol
neo/poly/hc sol 1%
neo/poly/hc sus 1%
2622
2623
2624
2625
2626
2627
OT
OT
OT
OT
OT
OT
RESPIRATORY TRACT AGENTS
Respiratory Tract Agents, Other
benzonatate cap 100mg *
TESSALON
benzonatate cap 200mg *
TESSALON
tussigon tab 5mg *
TUSSIGON
2628
2629
2630
Oral
Oral
Oral
RESPIRATORY TRACT/PULMONARY AGENTS
ASTELIN
2631
2632
2633
2634
2635
2636
2637
2638
2639
2640
2641
2642
2643
2644
2645
2646
Inh
Inh
Inh
Inh
Inh
Inh
Inh
Inh
NS
NS
NS
Inh
Inh
Inh
NS
NS
91
Formulary
Covered Drug Name
92
Alternate Drug Name
Tier
azelastine spr 0.15%
cyproheptad tab 4mg
levocetirizi tab 5mg
astepro
PERIACTIN
XYZAL
Tier 2
Tier 2
Tier 2
Antileukotrienes
montelukast chw 4mg
montelukast chw 5mg
montelukast gra 4mg
montelukast tab 10mg
zafirlukast tab 10mg
SINGULAIR
SINGULAIR
SINGULAIR
SINGULAIR
ACCOLATE
ACCOLATE
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
QL (30 per 30 days)
PA
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
No
No
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
Bronchodilators, Anticholinergic
ATROVENT HFA AER 17MCG
ipratropium
INCRUSE ELPT INH 62.5MCG
umeclidinium
ipratropium sol 0.02%inh
IPRATROPIUM
ipratropium spr 0.03%
IPRATROPIUM
IPRATROPIUM
TUDORZA PRES AER 400/ACT
aclidinium
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 4
No
No
No
No
No
No
No QL (25.8 per 30 days)
No
No
PA
Bronchodilators, Sympathomimetic
albuterol neb 0.083%
VENTOLIN NEB
albuterol neb 0.5%
VENTOLIN NEB
albuterol neb 0.63mg/3ml
ACCUNEB
ACCUNEB
albuterol syp 2mg/5ml
PROVENTIL - VENTOLIN
albuterol tab 2mg
albuterol tab 4mg
albuterol tab 4mg er
VOSPIRE ER
albuterol tab 8mg er
VOSPIRE ER
ARCAPTA CAP 75MCG
indacaterol
BROVANA NEB 15MCG
arformoterol
COMBIVENT AER RESPIMAT
albuterol-apratropium
EPIPEN 2-PAK INJ 0.3MG
epinephrine
EPIPEN-JR INJ 2-PAK
epinephrine
levalbuterol neb 0.31mg
XOPENEX
XOPENEX
levalbuterol neb 1.25/0.5ml
XOPENEX
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
PA
Yes
PA
Yes
PA
Yes
PA
Yes
Yes
Yes
Yes
Yes
No
PA
No
PA
No
PA
No
PA
2647
2648
2649
2650
2651
2652
2653
2654
2655
2656
2657
2658
2659
2660
2661
2662
2663
2664
2665
2666
2667
2668
2669
2670
2671
2672
2673
2674
2675
2676
2677
2678
NS
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inh
Inh
Inh
NS
NS
Inh
Inh
Inh
Inh
Inh
Oral
Oral
Oral
Oral
Oral
Inh
Inh
Inh
Inj
Inj
Inh
Inh
Inh
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
Yes
No
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
No
No
No
No
No
No
No
No
No
No
Tier 2
Tier 2
No
No
No
No
Phosphodiesterase Inhibitors, Airways Disease
DALIRESP TAB 500MCG
roflumilast
theophylline tab 100mg cr
THEO-DUR
theophylline tab 200mg cr
THEOCHRON SR
theophylline tab 300mg er
THEOCHRON SR
THEO-DUR
THEO-DUR
THEO-DUR
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Pulmonary Antihypertensives
ADCIRCA TAB 20MG
tadalafil
Tier 5
No
No
LETAIRIS TAB 10MG
ambrisentan
Tier 5
No
No
LETAIRIS TAB 5MG
ambrisentan
Tier 5
No
No
OPSUMIT TAB 10MG
macitentan
Tier 5
No
No
metaproteren syp 10mg/5ml
PROAIR HFA AER
PROVENTIL AER HFA
SEREVENT DIS AER 50MCG
STRIVERDI AER RESPIMAT
VENTOLIN HFA AER
XOPENEX HFA AER
METAPROTERENOL
albuterol
albuterol
salmeterol
olodaterol
albuterol
levalbuterol hfa
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Cystic Fibrosis Agents
CAYSTON INH 75MG
KALYDECO PAK 50MG
KALYDECO PAK 75MG
KALYDECO TAB 150MG
TOBI PODHALR CAP 28MG
aztreonam
ivacaftor
ivacaftor
ivacaftor
tobramycin inhalant powder
Mast Cell Stabilizers
cromolyn sod con 100/5ml
cromolyn sod neb 20mg/2ml
GASTROCROM
INTAL
Oral
QL (17 per 30 days) Inh
QL (13.4 per 30 days) Inh
Inh
2679
2680
2681
2682
2683
2684
2685
PA
PA
PA
PA
2686
2687
2688
2689
2690
2691
PA
PA, QL (60 per 30
days)
PA, QL (30 per 30
days)
PA, QL (60 per 30
days)
PA, QL (30 per 30
days)
2692
2693
2694
2695
2696
2697
2698
2699
2700
2701
2702
2703
Inh
Oral
Oral
Oral
Inh
Oral
Inh
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
93
Formulary
Covered Drug Name
Alternate Drug Name
Tier
sildenafil tab 20mg
REVATIO
Tier 2
TRACLEER TAB 125MG
bosentan
TRACLEER TAB 62.5MG
VENTAVIS SOL 10MCG/ML
Mail Retail
Route
Limits
Order Store
No
No
Tier 5
No
No
bosentan
Tier 5
No
No
iloprost
iloprost
Tier 5
Tier 5
No
No
No
No
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 5
Tier 3
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 3
Tier 3
Tier 5
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Yes
No
No
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
No
No
No
No
No
No
No
No
No
No
Respiratory Tract Agents, Other
acetylcyst sol 10%
MUCOMYST-10
acetylcyst sol 20%
MUCOMYST
ADVAIR DISKU AER 100/50
fluticasone - salmeterol
ADVAIR HFA AER 115/21
ANORO ELLIPT AER 62.5-25
umeclidinium - vilanterol
ARALAST NP INJ 400MG
alpha-1-proteinase inhibitor
BREO ELLIPTA INH 100-25
fluticasone - vilanterol
DULERA AER 100-5MCG
formoterol - mometasone
DULERA AER 200-5MCG
formoterol - mometasone
ESBRIET CAP 267MG
pirfenidone
OFEV CAP 100MG
nintedanib
OFEV CAP 150MG
nintedanib
PROLASTIN-C INJ 1000MG
alpha-1-proteinase inhibitor
PULMOZYME SOL 1MG/ML
dornase alfa
SYMBICORT AER 160-4.5
budesonide - formoterol
budesonide - formoterol
XOLAIR SOL 150MG
omalizumab
PA, QL (90 per 30
days)
PA, QL (60 per 30
days)
PA, QL (120 per 30
days)
PA
PA
PA
PA
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (12 per 30 days)
QL (12 per 30 days)
QL (12 per 30 days)
QL (60 per 30 days)
PA
2704
2705
2706
2707
2708
Oral
Oral
Oral
Inh
Inh
Inh
Inh
Inh
Inh
Inh
Inh
Inh
Inh
Inh
Inj
Inh
PA
Oral
PA
Oral
PA
Oral
PA
Inj
PA
Inh
PA
Inj
2709
2710
2711
2712
2713
2714
2715
2716
2717
2718
2719
2720
2721
2722
2723
2724
2725
2726
2727
2728
2729
SKELETAL MUSCLE RELAXANTS
Skeletal Muscle Relaxants
carisoprodol tab 350mg
chlorzoxazon tab 500mg
cyclobenzapr tab 10mg
methocarbam tab 500mg
94
SOMA
chlorzoxazone
FLEXERIL
ROBAXIN
ROBAXIN-750
PA
2730
2731
PA
PA
PA
2732
2733
2734
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Mail Retail
Route
Limits
Order Store
SLEEP DISORDER AGENTS
GABA Receptor Modulators
temazepam cap 15mg
zaleplon cap 10mg
RESTORIL
SONATA
Tier 2
Tier 2
No
No
No
No
zaleplon cap 5mg
SONATA
Tier 2
No
No
Sleep Disorders, Other
HETLIOZ CAP 20MG
modafinil tab 100mg
tasimelteon
PROVIGIL
Tier 5
Tier 2
No
No
No
No
modafinil tab 200mg
PROVIGIL
Tier 2
No
No
ROZEREM TAB 8MG
XYREM SOL 500MG/ML
ramelteon
sodium oxybate
Tier 4
Tier 5
No
No
No
No
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
Tier 1
Tier 1
Tier 2
Tier 5
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
PA
PA
PA
PA
PA
PA
Tier 4
Tier 4
Tier 2
Tier 4
Tier 4
No
No
No
No
No
No
No
No
No
No
PA
PA
PA
PA
PA
2735
PA, QL (60 per 30
days)
PA, QL (30 per 30
days)
PA
PA, QL (60 per 30
days)
PA, QL (60 per 30
days)
QL (30 per 30 days)
PA
2736
2737
2738
2739
2740
2741
2742
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
Electrolyte/Mineral Modifiers
CARBAGLU TAB 200MG
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
FERRIPROX TAB 500MG
fomepizole inj 1gm/ml
kionex pow
levocarnitin sol 1gm/10ml
levocarnitin tab 330mg
sod poly sul sus 15gm/60ml
SYPRINE CAP 250MG
carglumic acid
deferasirox
deferasirox
deferasirox
deferiprone
ANTIZOL
KAYEXALATE - SPS
CARNITOR
CARNITOR
KAYEXALATE - SPS
trientine
Electrolyte/Mineral Replacement
aminosyn ii inj 8.5/lyte
AMINOSYN
aminosyn inj 8.5/lyte
AMINOSYN
clinisol sf inj 15%
CLINISOL SF
d2.5w/nacl inj 0.45%
dextrose 2.5% - sodium chloride 0.45%
d5w/lr
kcl/d5w/lr
2743
2744
2745
2746
2747
2748
2749
2750
2751
2752
2753
2754
2755
2756
2757
2758
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
95
Formulary
Covered Drug Name
d5w/nacl inj 0.2%
D5W/NACL INJ 0.225%
d5w/nacl inj 0.33%
d5w/nacl inj 0.45%
d5w/nacl inj 0.9%
dextrose inj 10%
dextrose inj 5%
hepatamine sol 8%
intralipid inj 20%
kcl in nacl
kcl/d5w inj 0.15%
kcl/d5w inj 0.3%
kcl/d5w/lr inj 0.15%
kcl/d5w/nacl inj .075/.45%
kcl/d5w/nacl inj 0.15/0.2%
kcl/nacl inj 0.15-0.9%
klor-con 10 tab 10meq er
klor-con 8 tab 8meq er
klor-con m20 tab 20meq er
lactated rin
lactated rin sol
magnesium su inj 50%
pot chloride cap 10meq er
pot chloride cap 8meq er
POT CHLORIDE INJ 10MEQ
pot chloride inj 2meq/ml
pot chloride liq 10%
pot chloride liq 20%
pot citrate tab 1080mg
pot citrate tab 540mg
pot cl micro tab 10meq er
pot cl micro tab 20meq er
premasol sol 6%
ringers
ringers sol
sod chloride inj 0.45%
96
Alternate Drug Name
dextrose 5% - sodium chloride 0.2%
dextrose 10%
dextrose 5%
HEPATASOL
intralipid
kcl/sodium chloride
kcl/d5w
kcl/d5w
kcl/d5w/lr
kcl/d5w/nacl
kcl/d5w/nacl
kcl/d5w/nacl
kcl/d5w/nacl
kcl/d5w/nacl
kcl/d5w/nacl
kcl/d5w/nacl
kcl / sodium chloride
MICRO-K / KLOR-CON / K-TAB
lactated rigners
LACTATED RINGERS
MAGNESIUM SULF
potassium chloride
potassium chloride
potassium chloride
potassium chloride
potassium chloride
UROCIT-K
UROCIT-K
PREMASOL
lactated ringers
ringers irrigation soln
sod chloride 0.45%
Tier
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 4
Tier 2
Tier 2
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
2759
2760
2761
2762
2763
2764
2765
2766
2767
2768
2769
2770
2771
2772
2773
2774
2775
2776
2777
2778
2779
2780
2781
2782
PA
2783
2784
PA
2785
2786
2787
PA
PA
PA
2788
2789
2790
2791
2792
2793
2794
2795
2796
PA
PA
2797
2798
2799
PA
2800
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Inj
IR
Inj
Oral
Oral
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
IR
Inj
Formulary
Covered Drug Name
Alternate Drug Name
Tier
sodium chlor sol 0.9%
sodium fluoride tab 1mg f
steril water sol
tpn electrol
sod chloride 0.9%
SODIUM CHLORIDE IRRIGATION
sod fluoride
STERILE WATER IRRIGATION
tpn multilyte
Tier 4
Tier 4
Tier 1
Tier 4
Tier 4
Vitamins
prenatabs tab obn
prenatal rx vitamin
Tier 2
Mail Retail
Route
Limits
Order Store
No
No
No
No
No
No
No
No
No
No
No
No
PA
2801
2802
2803
2804
PA
2805
2806
Inj
IR
Top
IR
Inj
Oral
97
Drugs Requiring Prior Authorization
8-MOP CAP 10MG
a-hydrocort inj 100mg
ABELCET INJ 5MG/ML
acetylcyst sol 10%
acetylcyst sol 20%
ACTIMMUNE INJ 2MU/0.5ML
acyclovir na inj 500mg
ADAGEN INJ 250/ML
ADCIRCA TAB 20MG
ADEMPAS TAB 0.5MG
ADEMPAS TAB 1.5MG
ADEMPAS TAB 1MG
ADEMPAS TAB 2.5MG
ADEMPAS TAB 2MG
AFINITOR TAB 10MG
AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
albuterol neb 0.083%
albuterol neb 0.5%
ALDURAZYME INJ 2.9MG/5ML
ALIMTA INJ 500MG
AMBISOME INJ 50MG
amifostine inj 500mg
amikacin inj 500/2ml
aminosyn ii inj 8.5/lyte
aminosyn inj 8.5/lyte
amiodarone inj 50mg/ml
amphotericin inj 50mg
AMPICILLIN INJ 125MG
ampicillin inj 1gm
AMPYRA TAB 10MG
ANZEMET TAB 100MG
ANZEMET TAB 50MG
APOKYN INJ 10MG/ML
ARALAST NP INJ 400MG
98
ARCALYST INJ 220MG
ASTAGRAF XL CAP 0.5MG
ASTAGRAF XL CAP 1MG
ASTAGRAF XL CAP 5MG
AVASTIN INJ
AVONEX KIT 30MCG
azacitidine inj 100mg
AZASAN TAB 100MG
AZASAN TAB 75 MG
azathioprine tab 50mg
azithromycin inj 500mg
aztreonam inj 1gm
baciim inj 50000unt
BELEODAQ INJ 500MG
BENLYSTA INJ 120MG
benztropine tab 0.5mg
benztropine tab 1mg
benztropine tab 2mg
BETASERON INJ 0.3MG
bleomycin inj 30unit
BOSULIF TAB 100MG
BOSULIF TAB 500MG
BROVANA NEB 15MCG
buprenorphin inj 0.3mg/ml
BYDUREON INJ
BYETTA INJ 10MCG
BYETTA INJ 5MCG
calcitriol inj 1mcg/ml
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
CAPASTAT SUL INJ 1GM
CARBAGLU TAB 200MG
CARIMUNE NF INJ 3GM
carisoprodol tab 350mg
CAYSTON INH 75MG
cefazolin inj 1gm
cefazolin inj 500mg
cefepime inj 1gm
cefepime inj 2gm
cefoxitin inj 1gm
cefoxitin inj 2gm
ceftriaxone inj 1gm
ceftriaxone inj 2gm
cefuroxime inj 750mg
CELLCEPT IV INJ 500MG
CEREZYME INJ 400UNIT
chloramphen inj 1gm
CINRYZE SOL 500 UNIT
clindamycin inj 150mg/ml
clinisol sf inj 15%
clonazepam tab 0.5mg
clonazepam tab 1mg
clonazepam tab 2mg
colistimeth inj 150mg
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
COMETRIQ KIT 60MG
cromolyn sod neb 20mg/2ml
CUBICIN SOL 500MG
cyclobenzapr tab 10mg
cyclosporine cap 100mg md
cyclosporine inj 50mg/ml
cyclosporine sol modified
cyproheptad tab 4mg
d2.5w/nacl inj 0.45%
d5w/lr
d5w/nacl inj 0.2%
D5W/NACL INJ 0.225%
d5w/nacl inj 0.33%
d5w/nacl inj 0.45%
d5w/nacl inj 0.9%
DEMSER CAP 250MG
desmopressin inj 4mcg/ml
dexameth pho inj 120mg/30ml
dextrose inj 10%
dextrose inj 5%
DIASTAT ACDL GEL 12.5-20MG
diazepam con 5mg/ml
diazepam sol 1mg/ml
diazepam tab 10mg
diazepam tab 2mg
diazepam tab 5mg
diclofenac gel 3%
digoxin inj 0.25mg/1
digoxin sol 50mcg/ml
digoxin tab 0.125mg
diltiazem inj 100mg
diltiazem inj 50/10ml
diphenhydram inj 50mg/ml
DOCEFREZ INJ 20MG
doxy 100 inj 100mg
doxycycl hyc inj 100mg
DURAMORPH INJ 0.5MG/ML
DURAMORPH INJ 1MG/ML
EFFIENT TAB 10MG
EFFIENT TAB 5MG
ELAPRASE INJ 6MG/3ML
ELIDEL CRE 1%
ELIQUIS TAB 2.5MG
ELIQUIS TAB 5MG
ELITEK INJ 1.5MG
EMCYT CAP 140MG
EMEND CAP 125MG
EMEND CAP 40MG
EMEND CAP 80MG
EMSAM DIS 12MG/24HR
EMSAM DIS 6MG/24HR
EMSAM DIS 9MG/24HR
ENBREL INJ 25/0.5ML
ENBREL INJ 25MG
ENBREL INJ 50MG/ML
ENGERIX-B INJ 10/0.5ML
ENGERIX-B INJ 20MCG/ML
entecavir tab 0.5mg
entecavir tab 1mg
EPOGEN INJ 10000/ML
EPOGEN INJ 2000/ML
EPOGEN INJ 20000/ML
EPOGEN INJ 3000/ML
EPOGEN INJ 4000/ML
ERAXIS INJ 100MG
ERIVEDGE CAP 150MG
ERWINAZE INJ 10000UNT
erythrocin inj 500mg
ESBRIET CAP 267MG
esomeprazole inj 40mg
estradiol tab 0.5mg
estradiol tab 1mg
estradiol tab 2mg
etoposide inj 20mg/ml
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
FABRAZYME INJ 35MG
famotidine inj 10mg/ml
famotidine inj 20mg/50ml
FARYDAK CAP 10MG
FARYDAK CAP 15MG
FARYDAK CAP 20MG
FASLODEX INJ 250MG
FERRIPROX TAB 500MG
fluconazole/ inj dex 400mg
fomepizole inj 1gm/ml
FORTEO SOL 600/2.4ML
furosemide inj 10mg/ml
GAMASTAN S/D INJ
GAMMAGARD INJ 2.5GM/25ML
ganciclovir inj 500mg
GARDASIL 9 INJ
GARDASIL INJ
GATTEX KIT 5MG
gengraf cap 100mg
gengraf cap 25mg
gengraf sol 100mg/ml
GENOTROPIN INJ 12MG
GENOTROPIN INJ 1MG
GENOTROPIN INJ 2MG
GENOTROPIN INJ 5MG
GILENYA CAP 0.5MG
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
99
GLEEVEC TAB 100MG
GLEEVEC TAB 400MG
granisetron inj 0.1mg/ml
granisetron inj 1mg/ml
granisetron tab 1mg
hepatamine sol 8%
HEPSERA TAB 10MG
HERCEPTIN INJ 440MG
HETLIOZ CAP 20MG
HEXALEN CAP 50MG
hydroxyz hcl inj 50mg/ml
IBRANCE CAP 100MG
IBRANCE CAP 125MG
IBRANCE CAP 75MG
ICLUSIG TAB 15MG
ICLUSIG TAB 45MG
ILARIS INJ 180MG
IMBRUVICA CAP 140MG
imipenem/cil inj 500mg
INLYTA TAB 1MG
INLYTA TAB 5MG
intralipid inj 20%
INTRON-A INJ 10MU
INTRON-A INJ 18MU
INVEGA SUST INJ 156MG/ML
INVOKANA TAB 100MG
ipratropium sol 0.02%inh
ISTODAX INJ 10MG
itraconazole cap 100mg
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
100
JAKAFI TAB 25MG
JAKAFI TAB 5MG
JUXTAPID CAP 5MG
KADCYLA INJ 100MG
KALYDECO PAK 50MG
KALYDECO PAK 75MG
KALYDECO TAB 150MG
kcl in nacl
kcl/d5w inj 0.15%
kcl/d5w inj 0.3%
kcl/d5w/lr inj 0.15%
kcl/nacl inj 0.15-0.9%
KEYTRUDA SOL 50MG
KINERET INJ
KORLYM TAB 300MG
KUVAN TAB 100MG
KYNAMRO INJ 200MG/ML
labetalol inj 5mg/ml
lactated rin
LENVIMA CAP 10MG
LENVIMA CAP 14MG
LENVIMA CAP 20MG
LENVIMA CAP 24MG
LETAIRIS TAB 10MG
LETAIRIS TAB 5MG
LEUKINE INJ 250MCG
leuprolide inj 1mg/0.2ml
levalbuterol neb 1.25/0.5ml
levoflox/d5w inj 500/100ml
levofloxacin inj 25mg/ml
levoleucovor inj 50mg
lidocaine inj 0.5%
lidocaine pad 5%
linezolid inj 2mg/ml
linezolid tab 600mg
LOTRONEX TAB 0.5MG
LOTRONEX TAB 1MG
LUMIZYME INJ 50MG
LUPR DEP-PED INJ 11.25MG
LUPR DEP-PED INJ 15MG
LYNPARZA CAP 50MG
magnesium su inj 50%
megestrol ac sus 40mg/ml
MEKINIST TAB 0.5MG
MEKINIST TAB 2MG
MEPRON SUS
MERREM INJ 500MG
mesna inj 1gm
methotrexate inj 1gm
methotrexate inj 25mg/ml
metoclopram inj 5mg/ml
metoprolol inj 1mg/ml
metron/nacl inj 500mg
MIACALCIN INJ 200/ML
mitoxantron inj 2mg/ml
modafinil tab 100mg
modafinil tab 200mg
MOZOBIL INJ
mycophenolat cap 250mg
mycophenolat sus 200mg/ml
mycophenolat tab 500mg
nafcillin inj 1gm
NAGLAZYME INJ 1MG/ML
NALLPEN/DEX INJ 1GM/50ML
NATPARA INJ 100MCG
NATPARA INJ 25MCG
NATPARA INJ 50MCG
NATPARA INJ 75MCG
NEBUPENT INH 300MG
NEUMEGA INJ 5MG
NEUPOGEN INJ 480MCG
NEXAVAR TAB 200MG
nitrofur mac cap 50mg
nitrofurantn cap 100mg
NORTHERA CAP 100MG
NORTHERA CAP 200MG
NORTHERA CAP 300MG
NOXAFIL SUS 40MG/ML
NULOJIX INJ 250MG
octreotide inj 50mcg/ml
OFEV CAP 100MG
OFEV CAP 150MG
olanzapine inj 10mg
ONCASPAR INJ 750/ML
ondansetron inj 4mg/2ml
ondansetron tab 4mg
ondansetron tab 8mg
OPDIVO INJ 40MG/4ML
OPSUMIT TAB 10MG
ORENCIA INJ 125MG/ML
ORENCIA INJ 250MG
paclitaxel inj 300/50ml
pen g sod inj 5000000
penicilln gk inj 5mu
PENTAM 300 INJ 300MG
PERJETA INJ 420/14ML
phenobarb tab 100mg
phenobarb tab 15mg
phenobarb tab 30mg
phenobarb tab 60mg
phenylbutyra pow sodium
PLEGRIDY INJ
POMALYST CAP 1MG
POMALYST CAP 2MG
POMALYST CAP 3MG
POMALYST CAP 4MG
pot chloride inj 2meq/ml
PRADAXA CAP 150MG
PRADAXA CAP 75MG
premasol sol 6%
PROCRIT INJ 2000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROGRAF INJ 5MG/ML
PROLASTIN-C INJ 1000MG
PROLEUKIN INJ 22MU
PROLIA SOL 60MG/ML
promethazine inj 25mg/ml
PULMOZYME SOL 1MG/ML
quinine sulf cap 324mg
RABAVERT INJ
ranitidine inj 150/6ml
RAPAMUNE SOL 1MG/ML
RAVICTI LIQ 1.1GM/ML
REBIF INJ 22/0.5ML
REBIF INJ 44/0.5ML
RECOMBIVA HB INJ 10MCG/ML
RECOMBIVA HB INJ 5MCG/0.5ML
RECOMBIVA-HB INJ 40MCG/ML
RELISTOR KIT 12/0.6ML
REMICADE INJ 100MG
REVLIMID CAP 10MG
REVLIMID CAP 15MG
REVLIMID CAP 2.5MG
REVLIMID CAP 20MG
REVLIMID CAP 25MG
REVLIMID CAP 5MG
rifampin inj 600 mg
riluzole tab 50mg
ringers
RITUXAN INJ 500MG
SABRIL POW 500MG
SABRIL TAB 500MG
SANDIMMUNE SOL 100MG/ML
sildenafil tab 20mg
sirolimus tab 0.5mg
sirolimus tab 1mg
sirolimus tab 2mg
SIRTURO TAB 100MG
smz-tmp inj 400-80/5ml
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
SOMAVERT INJ 20MG
SOMAVERT INJ 25MG
SOMAVERT INJ 30MG
SOVALDI TAB 400MG
SPRYCEL TAB 100MG
SPRYCEL TAB 140MG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 80MG
STIVARGA TAB 40MG
streptomycin inj 1gm
SUCRAID SOL 8500/ML
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 37.5MG
SUTENT CAP 50MG
SYLATRON KIT 296MCG
SYLATRON KIT 444MCG
SYLATRON KIT 888MCG
101
SYNAGIS INJ 50MG
SYNERCID INJ 500MG
SYNRIBO INJ 3.5MG
TABLOID TAB 40MG
tacrolimus cap 0.5mg
tacrolimus cap 1mg
tacrolimus cap 5mg
tacrolimus oin 0.1%
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TARCEVA TAB 25MG
TARGRETIN CAP 75MG
TARGRETIN GEL 1%
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TEFLARO INJ 400MG
TEFLARO INJ 600MG
TET/DIP TOX INJ 2-2 LF
THALOMID CAP 100MG
THALOMID CAP 150MG
THALOMID CAP 200MG
THALOMID CAP 50MG
THYMOGLOBULN INJ 25MG
tobramycin inj 80mg/2ml
tobramycin neb 300/5ml
topotecan inj 4mg
tpn electrol
TRACLEER TAB 125MG
TRACLEER TAB 62.5MG
tranex acid inj 100mg/ml
tretinoin cap 10mg
trihexyphen elx 0.4mg/ml
trihexyphen tab 2mg
trihexyphen tab 5mg
TRISENOX SOL 10MG/10ML
TWINRIX INJ
TYGACIL INJ 50MG
TYKERB TAB 250MG
TYZEKA TAB 600MG
VALCHLOR GEL 0.016%
102
VELCADE INJ 3.5MG
VIEKIRA PAK TAB
voriconazole inj 200mg
voriconazole sus 40mg/ml
VPRIV INJ 400UNIT
XALKORI CAP 200MG
XALKORI CAP 250MG
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
XGEVA INJ
XOLAIR SOL 150MG
XTANDI CAP 40MG
XYREM SOL 500MG/ML
YERVOY INJ 50MG
zaleplon cap 10mg
zaleplon cap 5mg
ZALTRAP INJ 100/4ML
ZAVESCA CAP 100MG
ZELBORAF TAB 240MG
zoledronic inj 4mg/5ml
zoledronic inj 5/100ml
ZOLINZA CAP 100MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.75MG
ZYDELIG TAB 100MG
ZYDELIG TAB 150MG
ZYKADIA CAP 150MG
ZYPREXA RELP INJ 210MG
ZYTIGA TAB 250MG
ZYVOX SUS 100MG/5ML
Drugs With Quantity Limits
Covered Drug
Quantity Limit Covered Drug
Quantity Limit
acarbose tab 100mg
acarbose tab 25mg
acarbose tab 50mg
acyclovir oin 5%
ADCIRCA TAB 20MG
AFINITOR TAB 10MG
AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
AGGRENOX CAP 25-200MG
alendronate tab 5mg
alfuzosin tab 10mg
amlod/benazp cap 2.5-10mg
amlodipine tab 10mg
amlodipine tab 2.5mg
amlodipine tab 5mg
amphetamine tab 5mg
anastrozole tab 1mg
ANDROGEL GEL 1.62%
ANORO ELLIPT AER 62.5-25
90/30 days
90/30 days
90/30 days
90/30 days
30/30 days
60/30 days
60/30 days
60/30 days
60/30 days
12/30 days
12/30 days
12/30 days
150/30 days
90/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
120/30 days
5/30 days
30/30 days
240/30 days
5/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
30/30 days
300/30 days
300/30 days
300/30 days
300/30 days
60/30 days
30/30 days
30/30 days
4500/30 days
400/30 days
400/30 days
400/30 days
180/30 days
90/30 days
60/30 days
45/30 days
300/30 days
2/28 days
4/28 days
1.2/28 days
1.6/28 days
4/28 days
1.68/28 days
4/28 days
2.4/28 days
4/28 days
1.6/28 days
4/28 days
4/28 days
1.2/28 days
4/28 days
30/30 days
90/30 days
60/30 days
60/30 days
450/30 days
30/30 days
180/30 days
30/30 days
30/30 days
30/30 days
30/30 days
25.8/30 days
60/30 days
60/30 days
60/30 days
60/30 days
30/30 days
4/28 days
4/28 days
30/30 days
30/30 days
30/5 days
90/5 days
ANZEMET TAB 100MG
ANZEMET TAB 50MG
apap/codeine sol 120-12/5ml
APTIOM TAB 200MG
APTIOM TAB 400MG
APTIOM TAB 600MG
APTIOM TAB 800MG
APTIVUS SOL
ARCAPTA CAP 75MCG
ATROVENT HFA AER 17MCG
AVANDAMET TAB 2-1000MG
AVANDIA TAB 2MG
AVANDIA TAB 4MG
AVANDIA TAB 8MG
AVODART CAP 0.5MG
AVONEX KIT 30MCG
azelastine spr 0.1%
azelastine spr 0.15%
103
104
Covered Drug
Quantity Limit
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
BETASERON INJ 0.3MG
bicalutamide tab 50mg
BOSULIF TAB 100MG
BOSULIF TAB 500MG
BRILINTA TAB 90MG
BRINTELLIX TAB 10MG
BRINTELLIX TAB 20MG
BRINTELLIX TAB 5MG
buproban tab 150mg
bupropion tab 100mg
bupropion tab 75mg
butorphanol sol 10mg/ml
BYETTA INJ 10MCG
BYETTA INJ 5MCG
calcipotrien cre 0.005%
calcipotrien sol 0.005%
candesa/hctz tab 32-25mg
candesartan tab 4mg
candesartan tab 8mg
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
carvedilol tab 25mg
6/5 days
6/5 days
6/5 days
2400/30 days
240/30 days
240/30 days
600/30 days
15/30 days
30/30 days
120/30 days
30/30 days
60/30 days
60/30 days
30/30 days
120/30 days
120/30 days
120/30 days
90/30 days
120/30 days
60/30 days
90/30 days
30/30 days
180/30 days
30/30 days
45/30 days
120/30 days
180/30 days
120/30 days
120/30 days
180/30 days
180/30 days
10/30 days
2.4/30 days
2.4/30 days
120/30 days
120/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
30/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
600/30 days
30/30 days
30/30 days
30/30 days
28/14 days
28/14 days
28/14 days
4/28 days
4/28 days
4/28 days
30/30 days
90/30 days
90/30 days
90/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
29/30 days
56/28 days
112/28 days
84/28 days
30/30 days
30/30 days
30/30 days
180/30 days
30/30 days
480/30 days
1.5/28 days
90/30 days
90/30 days
90/30 days
180/30 days
180/30 days
30/30 days
30/30 days
240/30 days
1200/30 days
celecoxib cap 100mg
celecoxib cap 200mg
celecoxib cap 400mg
celecoxib cap 50mg
CHANTIX PAK 0.5& 1MG
CHANTIX PAK 1MG
CHANTIX TAB 0.5MG
CHANTIX TAB 1MG
citalopram sol 10mg/5ml
citalopram tab 10mg
citalopram tab 20mg
citalopram tab 40mg
clarithromyc tab 500mg er
clopidogrel tab 75mg
clozapine tab 100mg
clozapine tab 200mg
clozapine tab 25mg
clozapine tab 50mg
COLCRYS TAB 0.6MG
COMBIVENT AER RESPIMAT
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
COMETRIQ KIT 60MG
COMPLERA TAB
CYCLOSET TAB 0.8MG
DALIRESP TAB 500MCG
DEMSER CAP 250MG
DENAVIR CRE 1%
dexmethylph tab 10mg
dexmethylph tab 2.5mg
dexmethylph tab 5mg
diazepam con 5mg/ml
diazepam sol 1mg/ml
Covered Drug
Quantity Limit
diazepam tab 10mg
diazepam tab 2mg
diazepam tab 5mg
donepezil tab 10mg
donepezil tab 5mg
doxazosin tab 1mg
doxazosin tab 2mg
doxazosin tab 4mg
doxazosin tab 8mg
dronabinol cap 10mg
dronabinol cap 2.5mg
dronabinol cap 5mg
DULERA AER 100-5MCG
DULERA AER 200-5MCG
DULOXETINE CAP 20MG
duloxetine cap 30mg
duloxetine cap 40mg
duloxetine cap 60mg
EDURANT TAB 25MG
EFFIENT TAB 10MG
EFFIENT TAB 5MG
ELIDEL CRE 1%
ELIQUIS TAB 2.5MG
ELIQUIS TAB 5MG
EMEND CAP 125MG
EMEND CAP 40MG
EMEND CAP 80MG
EMSAM DIS 12MG/24HR
EMSAM DIS 6MG/24HR
EMSAM DIS 9MG/24HR
ENABLEX TAB 15MG
ENABLEX TAB 7.5MG
ENBREL INJ 25/0.5ML
ENBREL INJ 25MG
ENBREL INJ 50MG/ML
endocet tab 10-325mg
endocet tab 5-325mg
endocet tab 7.5-325mg
entacapone tab 200mg
180/30 days
90/30 days
240/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
60/30 days
60/30 days
13/30 days
13/30 days
180/30 days
120/30 days
90/30 days
60/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
8/28 days
16/28 days
8/28 days
120/30 days
120/30 days
120/30 days
28/30 days
22.4/30 days
28/30 days
8.4/30 days
11.2/30 days
16.8/30 days
22.4/30 days
270/30 days
30/30 days
30/30 days
1/30 days
1/30 days
12/28 days
12/28 days
12/28 days
620/30 days
60/30 days
30/30 days
120/30 days
21/10 days
60/30 days
21/7 days
60/30 days
90/30 days
60/30 days
720/30 days
360/30 days
180/30 days
120/30 days
90/30 days
270/30 days
90/30 days
180/30 days
120/30 days
270/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
entecavir tab 0.5mg
entecavir tab 1mg
EPIPEN 2-PAK INJ 0.3MG
EPIPEN-JR INJ 2-PAK
EPOGEN INJ 2000/ML
EPOGEN INJ 3000/ML
EPOGEN INJ 4000/ML
escitalopram sol 5mg/5ml
FANAPT PAK
FANAPT TAB 10MG
FANAPT TAB 12MG
FANAPT TAB 1MG
FANAPT TAB 2MG
FANAPT TAB 4MG
FANAPT TAB 6MG
FANAPT TAB 8MG
FAZACLO TAB 100/ODT
FAZACLO TAB 12.5/ODT
FAZACLO TAB 150MG
FAZACLO TAB 200MG
FAZACLO TAB 25MG ODT
105
106
Covered Drug
Quantity Limit
FETZIMA CAP 120MG
FETZIMA CAP 20MG
FETZIMA CAP 40MG
FETZIMA CAP 80MG
FETZIMA CAP TITRATION
finasteride tab 5mg
flunisolide spr 0.025%
fluoxetine cap 10mg
fluoxetine cap 20mg
fluoxetine cap 40mg
fluoxetine tab 10mg
fluticasone spr 50mcg
fondaparinux sol 10/0.8ml
FYCOMPA TAB 10MG
FYCOMPA TAB 12MG
FYCOMPA TAB 2MG
FYCOMPA TAB 4MG
FYCOMPA TAB 6MG
FYCOMPA TAB 8MG
galantamine sol 4mg/ml
120/30 days
30/30 days
180/30 days
120/30 days
30/30 days
28/28 days
30/30 days
29/30 days
120/30 days
300/30 days
120/30 days
24/30 days
24/30 days
21.2/30 days
50/30 days
30/30 days
30/30 days
60/30 days
30/30 days
16/30 days
90/30 days
360/30 days
180/30 days
20/30 days
15/30 days
20/30 days
20/30 days
20/30 days
20/30 days
20/30 days
20/30 days
20/30 days
20/30 days
30/30 days
30/30 days
120/30 days
90/30 days
60/30 days
30/30 days
360/30 days
360/30 days
270/30 days
180/30 days
120/30 days
30/30 days
30/30 days
30/30 days
180/30 days
60/30 days
60/30 days
60/30 days
90/30 days
30/30 days
30/30 days
30/30 days
30/30 days
90/30 days
60/30 days
60/30 days
60/30 days
60/30 days
240/30 days
120/30 days
120/30 days
60/30 days
240/30 days
120/30 days
120/30 days
240/30 days
30/30 days
2/30 days
90/30 days
90/30 days
90/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
8/28 days
8/28 days
8/28 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
240/30 days
360/30 days
360/30 days
240/30 days
galantamine tab 12mg
galantamine tab 4mg
galantamine tab 8mg
GAUZE PAD 2X2
GILENYA CAP 0.5MG
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
GLEEVEC TAB 100MG
GLEEVEC TAB 400MG
glimepiride tab 1mg
glimepiride tab 2mg
glimepiride tab 4mg
glip/metform tab 5-500mg
glipizide er tab 2.5mg
glipizide tab 10mg
glipizide tab 5mg
GLUCAGEN INJ HYPOKIT
GLUCAGON KIT 1MG
GLYSET TAB 100MG
GLYSET TAB 25MG
GLYSET TAB 50MG
granisetron tab 1mg
HUMALOG INJ 100/ML
HUMALOG MIX INJ 50/50
HUMALOG MIX SUS 75/25
HUMULIN INJ 70/30
HUMULIN N INJ U-100
HUMULIN N PN INJ U-100
HUMULIN PEN INJ 70/30
HUMULIN R INJ U-100
Covered Drug
Quantity Limit
ibandronate tab 150mg
ICLUSIG TAB 15MG
ICLUSIG TAB 45MG
IMBRUVICA CAP 140MG
INTELENCE TAB 100MG
INTELENCE TAB 200MG
INVEGA TAB 1.5MG
INVEGA TAB 3MG
INVEGA TAB 6MG
INVEGA TAB 9MG
INVOKANA TAB 100MG
INVOKANA TAB 300MG
irbesartan tab 75mg
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
JAKAFI TAB 5MG
JANUVIA TAB 100MG
JANUVIA TAB 25MG
JANUVIA TAB 50MG
KOMBIGLYZE TAB 2.5-1000MG
240/30 days
120/30 days
120/30 days
120/30 days
1/30 days
1/30 days
60/30 days
30/30 days
120/30 days
100/30 days
100/30 days
100/30 days
100/30 days
120/30 days
60/30 days
240/30 days
120/30 days
60/30 days
60/30 days
90/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
60/30 days
120/30 days
240/30 days
60/30 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
5/30 days
30/30 days
120/30 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
30/30 days
30/30 days
14/14 days
14/14 days
14/14 days
120/30 days
90/30 days
28/14 days
60/30 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
30/30 days
30/30 days
60/30 days
7.5/30 days
120/30 days
30/30 days
30/30 days
30/30 days
90/30 days
150/30 days
120/30 days
90/30 days
90/30 days
120/30 days
90/30 days
LANTUS INJ 100/ML
latanoprost sol 0.005%
LATUDA TAB 120MG
LATUDA TAB 20MG
LATUDA TAB 40MG
LATUDA TAB 60MG
LATUDA TAB 80MG
LETAIRIS TAB 10MG
LETAIRIS TAB 5MG
letrozole tab 2.5mg
LEVEMIR INJ
levorphanol tab 2mg
lidocaine pad 5%
linezolid tab 600mg
lorazepam tab 0.5mg
lorazepam tab 1mg
lorazepam tab 2mg
losartan/hct tab 100-25mg
LOTRONEX TAB 0.5MG
LOTRONEX TAB 1MG
lovastatin tab 10mg
lovastatin tab 20mg
lovastatin tab 40mg
LUMIGAN SOL 0.01%
MEKINIST TAB 0.5MG
MEKINIST TAB 2MG
meloxicam tab 15mg
meloxicam tab 7.5mg
metformin tab 1000mg
metformin tab 500mg
metformin tab 850mg
107
108
Covered Drug
Quantity Limit
miconazole 3 sup 200mg
MIGRANAL SPR 4MG/ML
mirtazapine tab 7.5mg
modafinil tab 100mg
modafinil tab 200mg
montelukast chw 4mg
montelukast chw 5mg
montelukast gra 4mg
montelukast tab 10mg
moxifloxacin tab 400mg
MULTAQ TAB 400MG
MYRBETRIQ TAB 25MG
MYRBETRIQ TAB 50MG
NAMENDA SOL 10MG/5ML
NAMENDA TAB 10MG
NAMENDA TAB 5MG
NASONEX SPR 50MCG/AC
NEUMEGA INJ 5MG
NEUPRO DIS 1MG/24HR
NEUPRO DIS 2MG/24HR
NEUPRO DIS 3MG/24HR
NEUPRO DIS 4MG/24HR
NEUPRO DIS 6MG/24HR
NEUPRO DIS 8MG/24HR
90/30 days
90/30 days
60/30 days
60/30 days
60/30 days
60/30 days
3/3 days
16/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
30/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
14/14 days
60/30 days
30/30 days
30/30 days
120/30 days
120/30 days
360/30 days
60/30 days
60/30 days
34/30 days
90/30 days
90/30 days
2/30 days
21/21 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
120/30 days
60/30 days
60/30 days
60/30 days
40/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
30/30 days
30/30 days
90/30 days
90/30 days
30/30 days
30/30 days
60/30 days
60/30 days
60/30 days
60/30 days
240/30 days
30/30 days
30/30 days
120/30 days
120/30 days
90/30 days
120/30 days
60/30 days
60/30 days
30/30 days
150/5 days
30/30 days
12/5 days
12/5 days
12/5 days
12/5 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
480/30 days
240/30 days
120/30 days
90/30 days
60/30 days
180/30 days
180/30 days
NEXAVAR TAB 200MG
niacin er tab 1000mg
niacin er tab 500mg
niacin er tab 750mg
NICOTROL NS SPR 10MG/ML
nitroglyceri dis 0.6mg/hr
NUEDEXTA CAP 20-10MG
olanzapine inj 10mg
olanzapine tab 10mg
olanzapine tab 15mg
olanzapine tab 20mg
olanzapine tab 5mg
omega-3-acid cap 1gm
omeprazole cap 10mg
omeprazole cap 20mg
omeprazole cap 40mg
ondansetron tab 4mg
ondansetron tab 8mg
ONFI TAB 10MG
ONFI TAB 20MG
ONGLYZA TAB 2.5MG
ONGLYZA TAB 5MG
OPSUMIT TAB 10MG
oxybutynin tab 5mg
Covered Drug
Quantity Limit
oxycodone cap 5mg
oxycodone tab 10mg
oxycodone tab 15mg
oxycodone tab 20mg
oxycodone tab 30mg
oxycodone tab 5mg
paroxetine tab 10mg
paroxetine tab 20mg
paroxetine tab 25mg er
paroxetine tab 30mg
paroxetine tab 40mg
PAXIL SUS 10MG/5ML
pen needles mis 29gx1/2
phenobarb tab 100mg
phenobarb tab 15mg
phenobarb tab 30mg
phenobarb tab 60mg
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
90/30 days
90/30 days
90/30 days
90/30 days
90/30 days
90/30 days
90/30 days
30/30 days
30/30 days
150/30 days
60/30 days
90/30 days
60/30 days
90/30 days
60/30 days
45/30 days
900/30 days
4/28 days
4/28 days
5/28 days
4/28 days
4/28 days
2/28 days
4/28 days
100/30 days
1500/30 days
90/30 days
120/30 days
360/30 days
195/30 days
180/30 days
60/30 days
90/30 days
60/30 days
90/30 days
90/30 days
30/30 days
30/30 days
30/30 days
21/28 days
21/28 days
180/30 days
120/30 days
90/30 days
720/30 days
60/30 days
60/30 days
90/30 days
90/30 days
90/30 days
90/30 days
90/30 days
90/30 days
30/30 days
30/30 days
60/30 days
30/30 days
30/30 days
240/30 days
240/30 days
17/30 days
12/28 days
12/28 days
12/28 days
90/30 days
90/30 days
90/30 days
90/30 days
13.4/30 days
2/30 days
240/30 days
120/30 days
960/30 days
90/30 days
60/30 days
480/30 days
21.9/30 days
21.9/30 days
30/30 days
120/30 days
120/30 days
12/30 days
12/30 days
6/30 days
60/180 days
60/30 days
PLEGRIDY INJ
POTIGA TAB 200MG
POTIGA TAB 300MG
POTIGA TAB 400MG
POTIGA TAB 50MG
PRADAXA CAP 150MG
PRADAXA CAP 75MG
pramipexole tab 1mg
PRISTIQ TAB 100MG
PRISTIQ TAB 25MG
PRISTIQ TAB 50MG
PROAIR HFA AER
PROCRIT INJ 2000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROMACTA TAB 12.5MG
PROMACTA TAB 25MG
PROMACTA TAB 50MG
PROMACTA TAB 75MG
PROVENTIL AER HFA
PULMICORT INH 180MCG
quetiapine tab 25mg
quetiapine tab 50mg
QVAR AER 40MCG
QVAR AER 80MCG
raloxifene tab 60mg
RANEXA TAB 1000MG
RANEXA TAB 500MG
REBIF INJ 22/0.5ML
REBIF INJ 44/0.5ML
RELENZA MIS DISKHALE
RESTASIS EMU 0.05%
109
110
Covered Drug
Quantity Limit
risedronate tab 150mg
risperidone sol 1mg/ml
risperidone tab 0.25 odt
risperidone tab 0.5mg odt
risperidone tab 1mg
risperidone tab 2mg
risperidone tab 3mg
risperidone tab 4mg
rizatriptan tab 10mg
rizatriptan tab 5mg
ROZEREM TAB 8MG
SABRIL POW 500MG
SABRIL TAB 500MG
SANTYL OIN 250/GM
SAPHRIS SUB 10MG
SAPHRIS SUB 2.5MG
SAPHRIS SUB 5MG
SEREVENT DIS AER 50MCG
sertraline con 20mg/ml
sertraline tab 100mg
sertraline tab 25mg
sertraline tab 50mg
sildenafil tab 20mg
SOVALDI TAB 400MG
STIVARGA TAB 40MG
STRATTERA CAP 100MG
STRATTERA CAP 10MG
STRATTERA CAP 18MG
STRATTERA CAP 25MG
STRATTERA CAP 40MG
STRATTERA CAP 60MG
STRATTERA CAP 80MG
STRIBILD TAB
SUBOXONE MIS 12-3MG
SUBOXONE MIS 2-0.5MG
SUBOXONE MIS 4-1MG
1/30 days
480/30 days
1920/30 days
1920/30 days
960/30 days
960/30 days
480/30 days
480/30 days
240/30 days
240/30 days
180/30 days
180/30 days
120/30 days
120/30 days
60/30 days
60/30 days
60/30 days
60/30 days
15/5 days
12/30 days
15/5 days
12/30 days
30/30 days
180/30 days
180/30 days
30/30 days
60/30 days
240/30 days
120/30 days
60/30 days
300/30 days
60/30 days
240/30 days
120/30 days
90/30 days
30/30 days
84/28 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
30/30 days
60/30 days
90/30 days
90/30 days
90/30 days
6/30 days
9/30 days
9/30 days
9/30 days
25/28 days
5/28 days
25/28 days
10.2/30 days
10.2/30 days
10.8/30 days
10.8/30 days
30/30 days
30/30 days
180/30 days
120/30 days
84/180 days
42/180 days
42/180 days
900/180 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
60/30 days
30/30 days
30/30 days
30/30 days
30/30 days
3/3 days
300/30 days
60/30 days
60/30 days
60/30 days
30/30 days
30/30 days
60/30 days
120/30 days
30/30 days
240/30 days
240/30 days
10/30 days
33/30 days
30/30 days
30/30 days
60/30 days
1/30 days
SUBOXONE MIS 8-2MG
SYLATRON KIT 296MCG
SYLATRON KIT 444MCG
SYLATRON KIT 888MCG
tacrolimus oin 0.1%
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
tamsulosin cap 0.4mg
TARGRETIN GEL 1%
terazosin cap 10mg
terazosin cap 1mg
terazosin cap 2mg
terazosin cap 5mg
terbinafine tab 250mg
terconazole sup 80mg
TESTIM GEL 1%(50MG)
TIVICAY TAB 50MG
tolterodine tab 1mg
tolterodine tab 2mg
TOVIAZ TAB 4MG
TOVIAZ TAB 8MG
TRACLEER TAB 125MG
TRACLEER TAB 62.5MG
TRADJENTA TAB 5MG
tramadl/apap tab 37.5-325mg
tramadol hcl tab 50mg
TRANSDERM-SC DIS 1.5MG
triamcinolon spr 55mcg/ac
TRIUMEQ TAB
trospium chl cap 60mg er
trospium cl tab 20mg
TUDORZA PRES AER 400/ACT
Covered Drug
Quantity Limit
TYBOST TAB 150MG
valacyclovir tab 1gm
valacyclovir tab 500mg
valsartan tab 160mg
valsartan tab 320mg
valsartan tab 40mg
valsartan tab 80mg
venlafaxine cap 37.5mg
venlafaxine tab 37.5 er
venlafaxine tab 37.5mg
VENTOLIN HFA AER
VERSACLOZ SUS 50MG/ML
VESICARE TAB 10MG
VESICARE TAB 5MG
VIAGRA TAB 100MG
VIAGRA TAB 25MG
VIAGRA TAB 50MG
VIIBRYD TAB 10MG
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG
VIMPAT INJ 200MG/20ML
VIMPAT SOL 10MG/ML
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
VIMPAT TAB 50MG
XALKORI CAP 200MG
XALKORI CAP 250MG
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
XOPENEX HFA AER
XTANDI CAP 40MG
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
180/30 days
90/30 days
90/30 days
60/30 days
30/30 days
270/30 days
180/30 days
180/30 days
150/30 days
150/30 days
90/30 days
36/30 days
540/30 days
30/30 days
30/30 days
4/30 days
4/30 days
4/30 days
9/30 days
120/30 days
60/30 days
30/30 days
1200/30 days
1200/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
30/30 days
120/30 days
60/30 days
60/30 days
60/30 days
30/30 days
240/30 days
30/30 days
30/30 days
240/30 days
120/30 days
90/30 days
60/30 days
60/30 days
60/30 days
60/30 days
10/30 days
90/30 days
60/30 days
150/30 days
120/30 days
zaleplon cap 10mg
zaleplon cap 5mg
ZELBORAF TAB 240MG
ZETIA TAB 10MG
ZIOPTAN DRO 0.0015%
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.75MG
ZOVIRAX CRE 5%
ZYDELIG TAB 100MG
ZYDELIG TAB 150MG
ZYKADIA CAP 150MG
ZYTIGA TAB 250MG
111
Step Therapy Criteria
Metabolic Bone Disease Agents
A three month trial of a Step 1 drug is required to use this Step 2 drug.
Step 1 Drugs
Step 2 Drugs
alendronate 5mg Tablet
Ibandronate 3mg/ml Injection
alendronate 10mg Tablets
Genitourinary Agents, Benign Prostatic Hypertrophy Agents
A one month trial of a Step 1 drug is required to use this Step 2 drug.
Step 1 Drugs
Step 2 Drugs
Finasteride 5mg Tablets
AVODART 0.5MG CAPSULES
Genitourinary Agents, Antispasmodics
Step 1 Drugs
Step 2 Drugs
oxybutynin 5mg Tablets
ENABLEX 7.5MG TABLETS
ENABLEX 15MG TABLETS
MYRBETRIQ 25MG TABLETS
oxybutynin 5mg ER Tablets
MYRBETRIQ 50MG TABLETS
VESICARE 5MG TABLETS
VESICARE 10MG TABLETS
trospium 20mg Tablets
trospium 60mg ER Capsules
Pharmacy claims will be reviewed using a look back period of 180 days.
112
Step Therapy Criteria
Ophthalmic Agents, Antiglaucoma Agents
Step 1 Drugs
Step 2 Drugs
betaxolol 0.5% Solution
BETOPTIC-S 0.25% SUSPENSION
Ophthalmic Agents, Ophthalmic Prostaglandin and Prostamide Analogs
Step 1 Drugs
Step 2 Drugs
Latanoprost 0.005% Solution
LUMIGAN 0.01% SOLUTION
ZIOPTAN 0.0015% DROPS
Ophthalmic Agents, Antiglaucoma Agents
Step 1 Drugs
Step 2 Drugs
brimonidine 0.2% Solution
ALPHAGAN P 0.1% SOLUTION
brimonidine 0.15% Solution
ALPHAGAN P 0.15% SOLUTION
Pharmacy claims will be reviewed using a look back period of 180 days.
113
Index of Drugs
A
a-hydrocort inj 100mg . . . . . . . . . . . . . 76
abacav/lamiv/zidovud . . . . . . . . . . . . . . 48
abacavir . . . . . . . . . . . . . . . . . . . . . . . . . 49
abacavir - dolutegravir - . . . . . . . . . . . 49
lamivudine
abacavir tab 300mg . . . . . . . . . . . . . . . 49
abacavir-lamivudine . . . . . . . . . . . . . . . 49
abatacept . . . . . . . . . . . . . . . . . . . . . . . 85
ABELCET INJ 5MG/ML . . . . . . . . . . . . . . 33
ABILIFY . . . . . . . . . . . . . . . . . . . . . . . . . 27
ABILIFY DISC TAB 10MG . . . . . . . . . . . . 27
ABILIFY MAIN INJ 300MG . . . . . . . . . . 27
ABILIFY MAIN INJ 400MG . . . . . . . . . . 27
abiraterone . . . . . . . . . . . . . . . . . . . . . . 36
acampro cal tab 333mg . . . . . . . . . . . . 14
acamprosate . . . . . . . . . . . . . . . . . . . . . 14
acarbose tab 100mg . . . . . . . . . . . . . . . 52
acarbose tab 25mg . . . . . . . . . . . . . . . . 52
acarbose tab 50mg . . . . . . . . . . . . . . . . 52
ACCOLATE . . . . . . . . . . . . . . . . . . . . . . . 92
ACCUNEB . . . . . . . . . . . . . . . . . . . . . . . 92
ACCUPRIL . . . . . . . . . . . . . . . . . . . . . . . 61
ACCURETIC . . . . . . . . . . . . . . . . . . . . . . 61
acebutolol cap 200mg . . . . . . . . . . . . . 62
acebutolol cap 400mg . . . . . . . . . . . . . 62
ACEON . . . . . . . . . . . . . . . . . . . . . . . . . 61
acetasol hc sol . . . . . . . . . . . . . . . . . . . . 91
ACETASOL HC, VOSOL HC . . . . . . . . . . 91
acetazolamid cap 500mg er . . . . . . . . . 65
acetazolamid tab 125mg . . . . . . . . . . . 65
acetazolamid tab 250mg . . . . . . . . . . . 65
ACETIC ACID . . . . . . . . . . . . . . . . . . . . . 16
acetic acid sol 2% . . . . . . . . . . . . . . . . . 16
acetylcyst sol 10% . . . . . . . . . . . . . . . . 94
acetylcyst sol 20% . . . . . . . . . . . . . . . . 94
acitretin cap 10mg . . . . . . . . . . . . . . . . 71
acitretin cap 17.5mg . . . . . . . . . . . . . . 71
acitretin cap 25mg . . . . . . . . . . . . . . . . 71
aclidinium . . . . . . . . . . . . . . . . . . . . . . . 92
ACLOVATE . . . . . . . . . . . . . . . . . . . . . . . 76
ACTHIB INJ . . . . . . . . . . . . . . . . . . . . . . 86
ACTIGALL . . . . . . . . . . . . . . . . . . . . . . . 73
ACTIMMUNE INJ 2MU/0.5ML . . . . . . . . 86
ACTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 13
actonel . . . . . . . . . . . . . . . . . . . . . . . . . 88
ACTOPLUS . . . . . . . . . . . . . . . . . . . . . . . 53
ACTOS . . . . . . . . . . . . . . . . . . . . . . . . . . 53
acyclovir . . . . . . . . . . . . . . . . . . . . . . . . 51
acyclovir cap 200mg . . . . . . . . . . . . . . . 51
acyclovir na inj 500mg . . . . . . . . . . . . . 51
acyclovir oin 5% . . . . . . . . . . . . . . . . . . 51
114
acyclovir sus 200/5ml . . . . . . . . . . . . . . 51
acyclovir tab 400mg . . . . . . . . . . . . . . . 51
acyclovir tab 800mg . . . . . . . . . . . . . . . 51
ADACEL INJ . . . . . . . . . . . . . . . . . . . . . . 86
ADAGEN INJ 250/ML . . . . . . . . . . . . . . 72
adalimumab . . . . . . . . . . . . . . . . . . . . . 85
adalimumab penfill . . . . . . . . . . . . . . . 85
adapalene cre 0.1% . . . . . . . . . . . . . . . 71
adapalene gel 0.1% . . . . . . . . . . . . . . . 71
adapalene gel 0.3% . . . . . . . . . . . . . . . 71
ADCIRCA TAB 20MG . . . . . . . . . . . . . . . 93
ADDERALL . . . . . . . . . . . . . . . . . . . . . . 69
adefovir . . . . . . . . . . . . . . . . . . . . . . . . . 47
ADEMPAS TAB 0.5MG . . . . . . . . . . . . . 65
ADEMPAS TAB 1.5MG . . . . . . . . . . . . . 65
ADEMPAS TAB 1MG . . . . . . . . . . . . . . . 65
ADEMPAS TAB 2.5MG . . . . . . . . . . . . . 65
ADEMPAS TAB 2MG . . . . . . . . . . . . . . . 65
ado-trastuzumab . . . . . . . . . . . . . . . . . 37
ADOXA . . . . . . . . . . . . . . . . . . . . . . . . . 21
ADVAIR DISKU AER 100/50 . . . . . . . . . 94
ADVAIR DISKU AER 250/50 . . . . . . . . . 94
ADVAIR DISKU AER 500/50 . . . . . . . . . 94
ADVAIR HFA AER 115/21 . . . . . . . . . . . 94
ADVAIR HFA AER 230/21 . . . . . . . . . . . 94
ADVAIR HFA AER 45/21 . . . . . . . . . . . . 94
afatinib . . . . . . . . . . . . . . . . . . . . . . . . . 39
afeditab tab 30mg cr . . . . . . . . . . . . . . 63
afeditab tab 60mg cr . . . . . . . . . . . . . . 63
AFINITOR DIS TAB 2MG . . . . . . . . . . . . 38
AFINITOR TAB 10MG . . . . . . . . . . . . . . 38
AFINITOR TAB 2.5MG . . . . . . . . . . . . . . 38
AFINITOR TAB 5MG . . . . . . . . . . . . . . . 38
AFINITOR TAB 7.5MG . . . . . . . . . . . . . . 39
agalsidase beta . . . . . . . . . . . . . . . . . . . 72
AGGRENOX CAP 25-200MG . . . . . . . . . 58
AGRYLIN . . . . . . . . . . . . . . . . . . . . . . . . 56
ala cort cre 1% . . . . . . . . . . . . . . . . . . . 76
albendazole . . . . . . . . . . . . . . . . . . . . . 41
ALBENZA TAB 200MG . . . . . . . . . . . . . 41
albuterol . . . . . . . . . . . . . . . . . . . . . . . . 93
albuterol neb 0.083% . . . . . . . . . . . . . 92
albuterol neb 0.5% . . . . . . . . . . . . . . . 92
albuterol neb 0.63mg/3ml . . . . . . . . . . 92
albuterol neb 1.25mg/3ml . . . . . . . . . . 92
albuterol syp 2mg/5ml . . . . . . . . . . . . . 92
albuterol tab 2mg . . . . . . . . . . . . . . . . 92
albuterol tab 4mg . . . . . . . . . . . . . . . . 92
albuterol tab 4mg er . . . . . . . . . . . . . . 92
albuterol tab 8mg er . . . . . . . . . . . . . . 92
albuterol-apratropium . . . . . . . . . . . . . 92
alclometason cre 0.05% . . . . . . . . . . . . 76
alclometason oin 0.05% . . . . . . . . . . . 76
ALCOHOL PREP PAD . . . . . . . . . . . . . . . 54
ALDACTAZIDE . . . . . . . . . . . . . . . . . . . . 67
ALDACTONE . . . . . . . . . . . . . . . . . . . . . 66
ALDARA . . . . . . . . . . . . . . . . . . . . . . . . 71
aldesleukin . . . . . . . . . . . . . . . . . . . . . . 38
ALDURAZYME INJ 2.9MG/5ML . . . . . . 72
alendronate tab 10mg . . . . . . . . . . . . . 88
alendronate tab 5mg . . . . . . . . . . . . . . 88
ALESSE, AVIANE, LESSINA, LUTERA . . . 80
alfuzosin tab 10mg . . . . . . . . . . . . . . . 75
alglucosidase alfa . . . . . . . . . . . . . . . . . 72
ALIMTA INJ 500MG . . . . . . . . . . . . . . . 37
ALINIA SUS 100/5ML . . . . . . . . . . . . . . . 41
ALINIA TAB 500MG . . . . . . . . . . . . . . . 41
alitretinoin . . . . . . . . . . . . . . . . . . . . . . 41
allopurinol tab 100mg . . . . . . . . . . . . . 34
allopurinol tab 300mg . . . . . . . . . . . . . 34
ALOMIDE SOL 0.1% . . . . . . . . . . . . . . . 89
alosetron . . . . . . . . . . . . . . . . . . . . . . . . 74
alpha-1-proteinase inhibitor . . . . . . . . 94
ALPHAGAN . . . . . . . . . . . . . . . . . . . . . . 90
ALPHAGAN P SOL 0.1% . . . . . . . . . . . . 90
ALPHAGAN P SOL 0.15% . . . . . . . . . . . 90
alprazolam tab 0.25mg . . . . . . . . . . . . 51
alprazolam tab 0.5mg . . . . . . . . . . . . . 51
alprazolam tab 1mg . . . . . . . . . . . . . . . 51
alprazolam tab 2mg . . . . . . . . . . . . . . . 51
ALREX SUS 0.2% . . . . . . . . . . . . . . . . . . 89
ALTACE . . . . . . . . . . . . . . . . . . . . . . . . . 61
altretamine . . . . . . . . . . . . . . . . . . . . . . 36
amantadine cap 100mg . . . . . . . . . . . . 42
amantadine syp 50mg/5ml . . . . . . . . . 42
amantadine tab 100mg . . . . . . . . . . . . 42
AMARYL . . . . . . . . . . . . . . . . . . . . . . . . 52
AMBISOME INJ 50MG . . . . . . . . . . . . . 33
ambrisentan . . . . . . . . . . . . . . . . . . . . . 93
amcinonide cre 0.1% . . . . . . . . . . . . . . 76
amcinonide lot 0.1% . . . . . . . . . . . . . . 76
amcinonide oin 0.1% . . . . . . . . . . . . . . 76
amifostine inj 500mg . . . . . . . . . . . . . . 37
amikacin . . . . . . . . . . . . . . . . . . . . . . . . 15
amikacin inj 500/2ml . . . . . . . . . . . . . . 15
amilor/hctz tab 5-50mg . . . . . . . . . . . . 66
amiloride tab 5mg . . . . . . . . . . . . . . . . 66
aminosalicylic acid . . . . . . . . . . . . . . . . 36
AMINOSYN . . . . . . . . . . . . . . . . . . . . . . 95
aminosyn ii inj 8.5/lyte . . . . . . . . . . . . . 95
aminosyn inj 8.5/lyte . . . . . . . . . . . . . . 95
Index of Drugs
amiodarone inj 50mg/ml . . . . . . . . . . . 61
amiodarone tab 200mg . . . . . . . . . . . . 61
amiodarone tab 400mg . . . . . . . . . . . . 61
amitriptylin tab 100mg . . . . . . . . . . . . 30
amitriptylin tab 10mg . . . . . . . . . . . . . 30
amitriptylin tab 150mg . . . . . . . . . . . . 30
amlod/benazp cap 10-20mg . . . . . . . . 59
amlod/benazp cap 10-40mg . . . . . . . . 60
amlod/benazp cap 2.5-10mg . . . . . . . . 60
amlod/benazp cap 5-10mg . . . . . . . . . 60
amlodipine tab 10mg . . . . . . . . . . . . . . 63
amlodipine tab 2.5mg . . . . . . . . . . . . . 63
amlodipine tab 5mg . . . . . . . . . . . . . . . 63
ammonium lac cre 12% . . . . . . . . . . . . 71
ammonium lac lot 12% . . . . . . . . . . . . 71
amnesteem cap 10mg . . . . . . . . . . . . . 71
amnesteem cap 20mg . . . . . . . . . . . . . 71
amnesteem cap 40mg . . . . . . . . . . . . . 71
amox-pot cla tab er . . . . . . . . . . . . . . . 18
amox/k clav chw 200mg . . . . . . . . . . . . 18
amox/k clav chw 400mg . . . . . . . . . . . . 18
amox/k clav sus 200/5ml . . . . . . . . . . . . 18
amox/k clav sus 250/5ml . . . . . . . . . . . . 18
amox/k clav sus 400/5ml . . . . . . . . . . . . 18
amox/k clav sus 600/5ml . . . . . . . . . . . . 18
amox/k clav tab 250mg . . . . . . . . . . . . 18
amox/k clav tab 500mg . . . . . . . . . . . . 18
amox/k clav tab 875mg . . . . . . . . . . . . 18
amoxapine tab 100mg . . . . . . . . . . . . . 30
amoxapine tab 150mg . . . . . . . . . . . . . 30
amoxapine tab 25mg . . . . . . . . . . . . . . 30
amoxapine tab 50mg . . . . . . . . . . . . . . 30
amoxicillin cap 250mg . . . . . . . . . . . . . 18
amoxicillin cap 500mg . . . . . . . . . . . . . 18
amoxicillin chw 125mg . . . . . . . . . . . . 18
amoxicillin chw 250mg . . . . . . . . . . . . 18
amoxicillin sus 125/5ml . . . . . . . . . . . . 18
amoxicillin tab 500mg . . . . . . . . . . . . . 18
amoxicillin tab 875mg . . . . . . . . . . . . . 18
AMOXIL . . . . . . . . . . . . . . . . . . . . . . . . . 18
amp-sulbacta inj 15gm . . . . . . . . . . . . . 18
amp-sulbacta inj 3gm . . . . . . . . . . . . . . 18
amphetamine tab 10mg . . . . . . . . . . . 69
amphetamine tab 12.5mg . . . . . . . . . . 69
amphetamine tab 5mg . . . . . . . . . . . . 69
amphetamine tab 7.5mg . . . . . . . . . . . 69
amphotericin b liposomal . . . . . . . . . . 33
amphotericin b liposomal 4 mg/ml . . . 33
amphotericin inj 50mg . . . . . . . . . . . . . 33
ampicillin . . . . . . . . . . . . . . . . . . . . . . . 19
ampicillin cap 250mg . . . . . . . . . . . . . . 19
ampicillin cap 500mg . . . . . . . . . . . . . . 19
AMPICILLIN INJ 125MG . . . . . . . . . . . . 19
ampicillin inj 1gm . . . . . . . . . . . . . . . . . 19
ampicillin sus 125/5ml . . . . . . . . . . . . . 19
ampicillin sus 250/5ml . . . . . . . . . . . . . 19
AMPYRA TAB 10MG . . . . . . . . . . . . . . . 70
amylases - endopeptidase - lipase . . . . 72
ANADROL-50 TAB 50MG . . . . . . . . . . . 79
ANAFRANIL . . . . . . . . . . . . . . . . . . . . . . 30
anagrelide cap 0.5mg . . . . . . . . . . . . . 56
anagrelide cap 1mg . . . . . . . . . . . . . . . 56
anakinra . . . . . . . . . . . . . . . . . . . . . . . . 85
ANAPROX . . . . . . . . . . . . . . . . . . . . . . . 12
ANAPROX DS . . . . . . . . . . . . . . . . . . . . 12
anastrozole tab 1mg . . . . . . . . . . . . . . 38
ANCEF . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ANCOBON . . . . . . . . . . . . . . . . . . . . . . . 33
ANDROGEL GEL 1.62% . . . . . . . . . . . . 79
ANDROGEL GEL 1%(25MG) . . . . . . . . . 79
ANDROGEL GEL 1%(50MG) . . . . . . . . . 79
ANDROGEL GEL PUMP 1.62% . . . . . . . 79
anidulafungin . . . . . . . . . . . . . . . . . . . . 33
ANORO ELLIPT AER 62.5-25 . . . . . . . . . 94
ANSAID . . . . . . . . . . . . . . . . . . . . . . . . . 11
ANTABUSE . . . . . . . . . . . . . . . . . . . . . . 14
ANTIVERT . . . . . . . . . . . . . . . . . . . . . . . 31
ANTIZOL . . . . . . . . . . . . . . . . . . . . . . . . 95
ANZEMET TAB 100MG . . . . . . . . . . . . . 32
ANZEMET TAB 50MG . . . . . . . . . . . . . . 32
apap/codeine sol 120-12/5ml . . . . . . . . 13
apap/codeine tab 300-15mg . . . . . . . . 13
apixaban . . . . . . . . . . . . . . . . . . . . . . . . 55
APOKYN INJ 10MG/ML . . . . . . . . . . . . . 42
apomorphine . . . . . . . . . . . . . . . . . . . . 42
apraclonidin sol 0.5% . . . . . . . . . . . . . 90
aprepitant . . . . . . . . . . . . . . . . . . . . . . . 32
APRESOLINE . . . . . . . . . . . . . . . . . . . . . 68
apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
APTIOM TAB 200MG . . . . . . . . . . . . . . 25
APTIOM TAB 400MG . . . . . . . . . . . . . . 25
APTIOM TAB 600MG . . . . . . . . . . . . . . 25
APTIOM TAB 800MG . . . . . . . . . . . . . . 25
APTIVUS CAP 250MG . . . . . . . . . . . . . . 50
APTIVUS SOL . . . . . . . . . . . . . . . . . . . . . 50
AQUATENSEN, ENDURON . . . . . . . . . . 66
ARALAST NP INJ 400MG . . . . . . . . . . . 94
ARALEN . . . . . . . . . . . . . . . . . . . . . . . . . 41
aranelle . . . . . . . . . . . . . . . . . . . . . . . . . 80
ARANESP INJ 100MCG/0.5ML . . . . . . . 56
ARANESP INJ 100MCG/1ML . . . . . . . . . 56
ARANESP INJ 25MCG/1ML . . . . . . . . . . 57
ARANESP INJ 40MCG/0.4ML . . . . . . . . 57
ARANESP INJ 60MCG/0.3ML . . . . . . . . 57
ARAVA . . . . . . . . . . . . . . . . . . . . . . . . . 86
ARCALYST INJ 220MG . . . . . . . . . . . . . 86
ARCAPTA CAP 75MCG . . . . . . . . . . . . . 92
AREDIA . . . . . . . . . . . . . . . . . . . . . . . . . 88
arformoterol . . . . . . . . . . . . . . . . . . . . . 92
ARICEPT . . . . . . . . . . . . . . . . . . . . . . . . . 26
ARICEPT ODT . . . . . . . . . . . . . . . . . . . . 26
ARIMIDEX . . . . . . . . . . . . . . . . . . . . . . . 38
aripiprazole . . . . . . . . . . . . . . . . . . . . . 27
aripiprazole disintegrating . . . . . . . . . 27
aripiprazole tab 10mg . . . . . . . . . . . . . 27
aripiprazole tab 2mg . . . . . . . . . . . . . . 27
aripiprazole tab 5mg . . . . . . . . . . . . . . 27
ARIXTRA . . . . . . . . . . . . . . . . . . . . . . . . 55
AROMASIN . . . . . . . . . . . . . . . . . . . . . . 38
arsenic trioxide . . . . . . . . . . . . . . . . . . . 40
ARTANE, TRIHEXANE . . . . . . . . . . . . . . 42
artemether - lumefantrine . . . . . . . . . 41
ASACOL HD TAB 800MG . . . . . . . . . . . 87
asenapine . . . . . . . . . . . . . . . . . . . . . . . 46
ASENDIN . . . . . . . . . . . . . . . . . . . . . . . . 30
aspirin - dipyridamole . . . . . . . . . . . . . 58
ASTAGRAF XL CAP 0.5MG . . . . . . . . . . 84
ASTAGRAF XL CAP 1MG . . . . . . . . . . . . 84
ASTAGRAF XL CAP 5MG . . . . . . . . . . . . 84
ASTELIN . . . . . . . . . . . . . . . . . . . . . . . . . 91
astepro . . . . . . . . . . . . . . . . . . . . . . . . . 92
ATACAND . . . . . . . . . . . . . . . . . . . . . . . 59
ATACAND HCT . . . . . . . . . . . . . . . . . . . 59
atazanavir . . . . . . . . . . . . . . . . . . . . . . . 50
115
Index of Drugs
atazanavir - cobicistat . . . . . . . . . . . . . 49
atenol/chlor tab 100-25mg . . . . . . . . . 62
atenol/chlor tab 50-25mg . . . . . . . . . . 62
atenolol tab 100mg . . . . . . . . . . . . . . . 62
atenolol tab 25mg . . . . . . . . . . . . . . . . 62
atenolol tab 50mg . . . . . . . . . . . . . . . . 62
ATIVAN . . . . . . . . . . . . . . . . . . . . . . . . . 23
atomoxetine . . . . . . . . . . . . . . . . . . . . . 69
atorvastatin tab 10mg . . . . . . . . . . . . . 67
atovaq/progu tab 250-100mg . . . . . . . 41
atovaq/progu tab 62.5-25mg . . . . . . . . 41
atovaquone . . . . . . . . . . . . . . . . . . . . . 42
ATRIPLA TAB . . . . . . . . . . . . . . . . . . . . . 49
ATROVENT HFA AER 17MCG . . . . . . . . 92
aug betamet cre 0.05% . . . . . . . . . . . . 76
aug betamet gel 0.05% . . . . . . . . . . . . 76
aug betamet lot 0.05% . . . . . . . . . . . . 76
aug betamet oin 0.05% . . . . . . . . . . . . 76
AUGMENTIN . . . . . . . . . . . . . . . . . . . . . 18
auranofin . . . . . . . . . . . . . . . . . . . . . . . 86
AVALIDE . . . . . . . . . . . . . . . . . . . . . . . . 59
AVANDAMET TAB 2-1000MG . . . . . . . 52
AVANDIA TAB 2MG . . . . . . . . . . . . . . . 52
AVANDIA TAB 4MG . . . . . . . . . . . . . . . 52
AVANDIA TAB 8MG . . . . . . . . . . . . . . . 52
AVAPRO . . . . . . . . . . . . . . . . . . . . . . . . 59
AVASTIN INJ . . . . . . . . . . . . . . . . . . . . . 41
AVELOX . . . . . . . . . . . . . . . . . . . . . . . . . 20
aviane . . . . . . . . . . . . . . . . . . . . . . . . . . 80
AVODART CAP 0.5MG . . . . . . . . . . . . . 75
AVONEX KIT 30MCG . . . . . . . . . . . . . . 70
AVONEX PREFL KIT 30MCG . . . . . . . . . 70
AXID . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
axitinib . . . . . . . . . . . . . . . . . . . . . . . . . 39
AYGESTIN . . . . . . . . . . . . . . . . . . . . . . . 81
azacitidine inj 100mg . . . . . . . . . . . . . . 37
AZACTAM . . . . . . . . . . . . . . . . . . . . . . . 18
AZASAN TAB 100MG . . . . . . . . . . . . . . 84
AZASAN TAB 75 MG . . . . . . . . . . . . . . . 84
AZASITE SOL 1% . . . . . . . . . . . . . . . . . . 19
azathioprine . . . . . . . . . . . . . . . . . . . . . 84
azathioprine tab 50mg . . . . . . . . . . . . 84
azelastine spr 0.1% . . . . . . . . . . . . . . . 91
azelastine spr 0.15% . . . . . . . . . . . . . . 92
AZILECT TAB 0.5MG . . . . . . . . . . . . . . . 43
AZILECT TAB 1MG . . . . . . . . . . . . . . . . 43
azithromycin . . . . . . . . . . . . . . . . . . . . . 19
azithromycin inj 500mg . . . . . . . . . . . . 19
azithromycin sus 100/5ml . . . . . . . . . . . 19
azithromycin sus 200/5ml . . . . . . . . . . . 19
116
azithromycin tab 250mg . . . . . . . . . . . 19
AZOPT SUS 1% . . . . . . . . . . . . . . . . . . . 90
aztreonam . . . . . . . . . . . . . . . . . . . . . . 93
aztreonam inj 1gm . . . . . . . . . . . . . . . . 18
AZULFIDINE . . . . . . . . . . . . . . . . . . . . . . 88
B
baciim inj 50000unt . . . . . . . . . . . . . . . 16
bacit/polymy oin . . . . . . . . . . . . . . . . . . 89
bacitracin . . . . . . . . . . . . . . . . . . . . . . . 16
bacitracin oin . . . . . . . . . . . . . . . . . . . . 16
baclofen tab 10mg . . . . . . . . . . . . . . . . 46
baclofen tab 20mg . . . . . . . . . . . . . . . . 46
BACTRAM DS, SEPTRA DS . . . . . . . . . . 21
BACTRIM, SEPTRA . . . . . . . . . . . . . . . . 21
BACTROBAN . . . . . . . . . . . . . . . . . . . . . 16
BACTROBAN OIN NASAL 2% . . . . . . . . 16
balsalazide cap 750mg . . . . . . . . . . . . . 87
BANZEL SUS 40MG/ML . . . . . . . . . . . . . 25
BANZEL TAB 200MG . . . . . . . . . . . . . . . 25
BANZEL TAB 400MG . . . . . . . . . . . . . . . 25
BARACLUDE . . . . . . . . . . . . . . . . . . . . . 47
BARACLUDE SOL .05MG/ML . . . . . . . . 47
BAYCADRON . . . . . . . . . . . . . . . . . . . . . 77
BCG VACCINE INJ . . . . . . . . . . . . . . . . . 86
bcg, live, tice strain 50 mg/ml . . . . . . . 86
injectable suspension
beclomethasone . . . . . . . . . . . . . . . . . . 91
bedaquiline . . . . . . . . . . . . . . . . . . . . . . 35
belatacept . . . . . . . . . . . . . . . . . . . . . . . 85
BELEODAQ INJ 500MG . . . . . . . . . . . . . 37
belimumab . . . . . . . . . . . . . . . . . . . . . . 86
belinostat . . . . . . . . . . . . . . . . . . . . . . . 37
BENADRYL . . . . . . . . . . . . . . . . . . . . . . 31
benazep/hctz tab 10-12.5mg . . . . . . . . 60
benazep/hctz tab 20-12.5mg . . . . . . . . 60
benazep/hctz tab 20-25mg . . . . . . . . . 60
benazep/hctz tab 5-6.25mg . . . . . . . . . 60
benazepril tab 10mg . . . . . . . . . . . . . . 60
benazepril tab 5mg . . . . . . . . . . . . . . . 60
BENLYSTA INJ 120MG . . . . . . . . . . . . . . 86
BENTYL . . . . . . . . . . . . . . . . . . . . . . . . . 72
BENZAMYCIN . . . . . . . . . . . . . . . . . . . . 71
benzonatate cap 100mg . . . . . . . . . . . 91
benzonatate cap 200mg . . . . . . . . . . . 91
benztropine inj 1mg/ml . . . . . . . . . . . . 42
benztropine tab 0.5mg . . . . . . . . . . . . 42
benztropine tab 1mg . . . . . . . . . . . . . . 42
benztropine tab 2mg . . . . . . . . . . . . . . 42
besifloxacin . . . . . . . . . . . . . . . . . . . . . . 20
BESIVANCE SUS 0.6% . . . . . . . . . . . . . . 20
BETA-VAL . . . . . . . . . . . . . . . . . . . . . . . 76
BETAGAN . . . . . . . . . . . . . . . . . . . . . . . 90
betaine (trimethylglycine) . . . . . . . . . 72
betameth dip cre 0.05% . . . . . . . . . . . 76
betameth dip lot 0.05% . . . . . . . . . . . . 76
betameth dip oin 0.05% . . . . . . . . . . . 76
betameth val aer 0.12% . . . . . . . . . . . 76
betameth val cre 0.1% . . . . . . . . . . . . . 76
betameth val lot 0.1% . . . . . . . . . . . . . 76
betameth val oin 0.1% . . . . . . . . . . . . 76
BETASERON INJ 0.3MG . . . . . . . . . . . . . 70
betaxolol . . . . . . . . . . . . . . . . . . . . . . . . 90
betaxolol sol 0.5% . . . . . . . . . . . . . . . . 90
betaxolol tab 10mg . . . . . . . . . . . . . . . 62
betaxolol tab 20mg . . . . . . . . . . . . . . . 62
bethanechol tab 10mg . . . . . . . . . . . . . 75
bethanechol tab 5mg . . . . . . . . . . . . . . 75
BETOPTIC-S SUS 0.25% . . . . . . . . . . . . . 90
bevacizumab . . . . . . . . . . . . . . . . . . . . . 41
bexarotene . . . . . . . . . . . . . . . . . . . . . . 41
BIAXIN . . . . . . . . . . . . . . . . . . . . . . . . . . 19
BIAXIN XL . . . . . . . . . . . . . . . . . . . . . . . 20
bicalutamide tab 50mg . . . . . . . . . . . . 36
BICILLIN C-R INJ 1200000 . . . . . . . . . . . 19
BICILLIN C-R INJ 900/300 . . . . . . . . . . . 19
BICILLIN L-A INJ 1200000 . . . . . . . . . . . 19
BICILLIN L-A INJ 2400000 . . . . . . . . . . . 19
BICILLIN L-A INJ 600000 . . . . . . . . . . . . 19
BILTRICIDE TAB 600MG . . . . . . . . . . . . 41
bimatoprost . . . . . . . . . . . . . . . . . . . . . 90
bisoprl/hctz tab 10/6.25mg . . . . . . . . . 62
bisoprl/hctz tab 2.5/6.25mg . . . . . . . . . 62
bisoprl/hctz tab 5-6.25mg . . . . . . . . . . 62
bisoprol fum tab 10mg . . . . . . . . . . . . 62
bisoprol fum tab 5mg . . . . . . . . . . . . . 62
BLENOXANE . . . . . . . . . . . . . . . . . . . . . 37
bleomycin inj 30unit . . . . . . . . . . . . . . 37
BLEPH-10 . . . . . . . . . . . . . . . . . . . . . . . . 21
BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . 89
BLOCADREN . . . . . . . . . . . . . . . . . . . . . 34
BONIVA . . . . . . . . . . . . . . . . . . . . . . . . . 88
boostrix . . . . . . . . . . . . . . . . . . . . . . . . . 86
BOOSTRIX INJ . . . . . . . . . . . . . . . . . . . . 86
bordetella pertussis . . . . . . . . . . . . . . . 86
bordetella pertussis filamentous . . . . . 86
hemagglutinin vaccine
bortezomib . . . . . . . . . . . . . . . . . . . . . . 40
bosentan . . . . . . . . . . . . . . . . . . . . . . . . 94
BOSULIF TAB 100MG . . . . . . . . . . . . . . 39
Index of Drugs
BOSULIF TAB 500MG . . . . . . . . . . . . . . 39
bosutinib . . . . . . . . . . . . . . . . . . . . . . . . 39
BREO ELLIPTA INH 100-25 . . . . . . . . . . 94
BREVICON, NORTREL, NECON . . . . . . . 80
BRILINTA TAB 90MG . . . . . . . . . . . . . . . 58
brimonidine . . . . . . . . . . . . . . . . . . . . . 90
brimonidine - brinzolamide . . . . . . . . . 90
brimonidine - timolol . . . . . . . . . . . . . . 90
brimonidine sol 0.15% . . . . . . . . . . . . . 90
brimonidine sol 0.2% . . . . . . . . . . . . . . 90
BRINTELLIX TAB 10MG . . . . . . . . . . . . . 28
BRINTELLIX TAB 20MG . . . . . . . . . . . . . 28
BRINTELLIX TAB 5MG . . . . . . . . . . . . . . 28
brinzolamide . . . . . . . . . . . . . . . . . . . . 90
bromfenac sol 0.09% . . . . . . . . . . . . . . 89
bromocriptin cap 5mg . . . . . . . . . . . . . 42
bromocriptin tab 2.5mg . . . . . . . . . . . . 42
bromocriptine . . . . . . . . . . . . . . . . . . . . 52
BROVANA NEB 15MCG . . . . . . . . . . . . 92
budesonide . . . . . . . . . . . . . . . . . . . . . . 91
budesonide - formoterol . . . . . . . . . . . 94
budesonide cap 3mg/24hr . . . . . . . . . . 76
budesonide sus 0.25mg/2ml . . . . . . . . 91
budesonide sus 0.5mg/2ml . . . . . . . . . 91
bumetanide tab 0.5mg . . . . . . . . . . . . 66
bumetanide tab 1mg . . . . . . . . . . . . . . 66
bumetanide tab 2mg . . . . . . . . . . . . . . 66
BUMEX . . . . . . . . . . . . . . . . . . . . . . . . . 66
BUPRENEX . . . . . . . . . . . . . . . . . . . . . . . 15
buprenorphin inj 0.3mg/ml . . . . . . . . . 15
buprenorphin sub 2mg . . . . . . . . . . . . 15
buprenorphin sub 8mg . . . . . . . . . . . . 15
buprenorphine - naloxone . . . . . . . . . 15
buproban tab 150mg . . . . . . . . . . . . . . 15
bupropion . . . . . . . . . . . . . . . . . . . . . . . 15
bupropion tab 100mg . . . . . . . . . . . . . 27
bupropion tab 100mg sr . . . . . . . . . . . 27
bupropion tab 75mg . . . . . . . . . . . . . . 27
bupropn hcl tab 150mg xl . . . . . . . . . . 27
bupropn hcl tab 300mg xl . . . . . . . . . . 27
BUSPAR . . . . . . . . . . . . . . . . . . . . . . . . . 51
buspirone tab 10mg . . . . . . . . . . . . . . . 51
buspirone tab 15mg . . . . . . . . . . . . . . . 51
buspirone tab 30mg . . . . . . . . . . . . . . . 51
buspirone tab 5mg . . . . . . . . . . . . . . . . 51
buspirone tab 7.5mg . . . . . . . . . . . . . . 51
but-50 / apap-300 / caf-40 cap . . . . . . . 11
but-50 / apap-325 / caf-40 / . . . . . . . . . 11
codeine-30 cap
but-50 / apap-325 / caf-40 cap . . . . . . . 11
but-50 / apap-325 / caf-40 tab . . . . . . . 11
but-50 / apap-325 tab . . . . . . . . . . . . . 11
but-50 / asa-325 / caff-40 cap . . . . . . . . 11
butalbital - acetaminophen . . . . . . . . . 11
butalbital - acetaminophen - . . . . . . . . 11
caffeine
butalbital - aspirin - caffeine . . . . . . . . 11
butorphanol . . . . . . . . . . . . . . . . . . . . . 13
butorphanol sol 10mg/ml . . . . . . . . . . 13
BYDUREON INJ . . . . . . . . . . . . . . . . . . . 52
BYETTA INJ 10MCG . . . . . . . . . . . . . . . 52
BYETTA INJ 5MCG . . . . . . . . . . . . . . . . 52
C
c1 inhibitor (human) . . . . . . . . . . . . . . 84
cabergoline tab 0.5mg . . . . . . . . . . . . . 83
cabozantinib . . . . . . . . . . . . . . . . . . . . . 39
caffeine-ergotamine . . . . . . . . . . . . . . 34
CALAN . . . . . . . . . . . . . . . . . . . . . . . . . . 65
CALAN SR . . . . . . . . . . . . . . . . . . . . . . . 65
calc acetate cap 667mg . . . . . . . . . . . . 76
CALCIJEX . . . . . . . . . . . . . . . . . . . . . . . . 88
calcipotrien cre 0.005% . . . . . . . . . . . . 71
calcipotrien sol 0.005% . . . . . . . . . . . . 71
calcitonin spr 200/act . . . . . . . . . . . . . . 88
calcitriol cap 0.25mcg . . . . . . . . . . . . . . 88
calcitriol cap 0.5mcg . . . . . . . . . . . . . . . 88
calcitriol inj 1mcg/ml . . . . . . . . . . . . . . 88
calcitriol sol 1mcg/ml . . . . . . . . . . . . . . 88
calcium acetate . . . . . . . . . . . . . . . . . . . 76
canagliflozin . . . . . . . . . . . . . . . . . . . . . 53
canakinumab . . . . . . . . . . . . . . . . . . . . 86
CANASA SUP 1000MG . . . . . . . . . . . . . 87
CANCIDAS INJ 50MG . . . . . . . . . . . . . . 33
CANCIDAS INJ 70MG . . . . . . . . . . . . . . 33
candesa/hctz tab 16-12.5mg . . . . . . . . 59
candesa/hctz tab 32-12.5mg . . . . . . . . 59
candesa/hctz tab 32-25mg . . . . . . . . . . 59
candesartan tab 16mg . . . . . . . . . . . . . 59
candesartan tab 32mg . . . . . . . . . . . . . 59
candesartan tab 4mg . . . . . . . . . . . . . . 59
candesartan tab 8mg . . . . . . . . . . . . . . 59
CAPASTAT SUL INJ 1GM . . . . . . . . . . . . 35
CAPOTEN . . . . . . . . . . . . . . . . . . . . . . . 60
CAPOZIDE . . . . . . . . . . . . . . . . . . . . . . . 60
CAPRELSA TAB 100MG . . . . . . . . . . . . . 39
CAPRELSA TAB 300MG . . . . . . . . . . . . . 39
capreomycin . . . . . . . . . . . . . . . . . . . . . 35
captopr/hctz tab 25-15mg . . . . . . . . . . 60
captopril tab 100mg . . . . . . . . . . . . . . . 60
captopril tab 12.5mg . . . . . . . . . . . . . . 60
captopril tab 25mg . . . . . . . . . . . . . . . . 60
captopril tab 50mg . . . . . . . . . . . . . . . . 60
CARAFATE . . . . . . . . . . . . . . . . . . . . . . . 74
carb/levo er tab 25-100mg . . . . . . . . . . 43
carb/levo er tab 50-200mg . . . . . . . . . . 43
carb/levo tab 10-100mg . . . . . . . . . . . . 43
carb/levo tab 25-100mg . . . . . . . . . . . . 43
carb/levo tab 25-250mg . . . . . . . . . . . . 43
CARBAGLU TAB 200MG . . . . . . . . . . . . 95
carbamazepin cap 100mg er . . . . . . . . 25
carbamazepin chw 100mg . . . . . . . . . . 25
carbamazepin sus 100/5ml . . . . . . . . . . 25
carbamazepin tab 200mg . . . . . . . . . . 25
carbamazepin tab 200mg er . . . . . . . . 25
carbamazepin tab 400mg er . . . . . . . . 25
carbamazepine sr . . . . . . . . . . . . . . . . . 25
carbidopa tab 25mg . . . . . . . . . . . . . . . 43
CARDENE . . . . . . . . . . . . . . . . . . . . . . . 64
CARDIZEM . . . . . . . . . . . . . . . . . . . . . . . 64
CARDIZEM LA . . . . . . . . . . . . . . . . . . . . 64
CARDIZEM SR . . . . . . . . . . . . . . . . . . . . 63
CARDURA . . . . . . . . . . . . . . . . . . . . . . . 58
carglumic acid . . . . . . . . . . . . . . . . . . . . 95
CARIMUNE NF INJ 3GM . . . . . . . . . . . . 86
carisoprodol tab 350mg . . . . . . . . . . . . 94
CARNITOR . . . . . . . . . . . . . . . . . . . . . . . 95
carteolol sol 1% . . . . . . . . . . . . . . . . . . 90
cartia xt cap 120/24hr . . . . . . . . . . . . . . 63
cartia xt cap 180/24hr . . . . . . . . . . . . . . 63
cartia xt cap 240/24hr . . . . . . . . . . . . . . 63
cartia xt cap 300/24hr . . . . . . . . . . . . . . 63
carvedilol tab 12.5mg . . . . . . . . . . . . . 62
carvedilol tab 25mg . . . . . . . . . . . . . . . 62
carvedilol tab 3.125mg . . . . . . . . . . . . 62
carvedilol tab 6.25mg . . . . . . . . . . . . . 62
CASODEX . . . . . . . . . . . . . . . . . . . . . . . 36
caspofungin . . . . . . . . . . . . . . . . . . . . . 33
CATAFLAM . . . . . . . . . . . . . . . . . . . . . . 11
CATAPRES . . . . . . . . . . . . . . . . . . . . . . . 58
CATAPRES TTS . . . . . . . . . . . . . . . . . . . . 58
CAYSTON INH 75MG . . . . . . . . . . . . . . 93
CECLOR . . . . . . . . . . . . . . . . . . . . . . . . . 17
CEENU . . . . . . . . . . . . . . . . . . . . . . . . . . 36
cefaclor cap 250mg . . . . . . . . . . . . . . . 17
cefaclor cap 500mg . . . . . . . . . . . . . . . 17
cefaclor er tab 500mg . . . . . . . . . . . . . 17
cefadroxil cap 500mg . . . . . . . . . . . . . . 17
cefadroxil sus 250/5ml . . . . . . . . . . . . . 17
cefadroxil sus 500/5ml . . . . . . . . . . . . . 17
cefadroxil tab 1gm . . . . . . . . . . . . . . . . 17
cefazolin inj 1gm . . . . . . . . . . . . . . . . . 17
117
Index of Drugs
cefazolin inj 500mg . . . . . . . . . . . . . . . 17
cefdinir cap 300mg . . . . . . . . . . . . . . . . 17
cefdinir sus 125/5ml . . . . . . . . . . . . . . . 17
cefdinir sus 250/5ml . . . . . . . . . . . . . . . 17
cefepime inj 1gm . . . . . . . . . . . . . . . . . 17
cefepime inj 2gm . . . . . . . . . . . . . . . . . 17
cefixime . . . . . . . . . . . . . . . . . . . . . . . . . 18
cefoxitin inj 1gm . . . . . . . . . . . . . . . . . 17
cefoxitin inj 2gm . . . . . . . . . . . . . . . . . 17
cefpodo prox sus 100/5ml . . . . . . . . . . 17
cefpodo prox sus 50mg/5ml . . . . . . . . . 17
cefpodoxime tab 100mg . . . . . . . . . . . 17
cefpodoxime tab 200mg . . . . . . . . . . . 17
cefprozil sus 125/5ml . . . . . . . . . . . . . . 17
cefprozil sus 250/5ml . . . . . . . . . . . . . . 17
cefprozil tab 250mg . . . . . . . . . . . . . . . 17
cefprozil tab 500mg . . . . . . . . . . . . . . . 17
ceftaroline . . . . . . . . . . . . . . . . . . . . . . 18
CEFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ceftriaxone inj 1gm . . . . . . . . . . . . . . . 17
ceftriaxone inj 250mg . . . . . . . . . . . . . 17
ceftriaxone inj 2gm . . . . . . . . . . . . . . . 17
ceftriaxone inj 500mg . . . . . . . . . . . . . 17
cefuroxime inj 1.5gm . . . . . . . . . . . . . . 17
cefuroxime inj 7.5gm . . . . . . . . . . . . . . 17
cefuroxime inj 750mg . . . . . . . . . . . . . 17
cefuroxime tab 250mg . . . . . . . . . . . . . 17
cefuroxime tab 500mg . . . . . . . . . . . . . 17
CEFZIL . . . . . . . . . . . . . . . . . . . . . . . . . . 17
CELEBREX . . . . . . . . . . . . . . . . . . . . . . . 11
celecoxib cap 100mg . . . . . . . . . . . . . . 11
celecoxib cap 200mg . . . . . . . . . . . . . . 11
celecoxib cap 400mg . . . . . . . . . . . . . . 11
celecoxib cap 50mg . . . . . . . . . . . . . . . 11
CELEXA . . . . . . . . . . . . . . . . . . . . . . . . . 28
CELLCEPT . . . . . . . . . . . . . . . . . . . . . . . . 85
CELLCEPT IV INJ 500MG . . . . . . . . . . . . 84
CELONTIN CAP 300MG . . . . . . . . . . . . . 22
cephalexin cap 250mg . . . . . . . . . . . . . 18
cephalexin cap 500mg . . . . . . . . . . . . . 18
cephalexin sus 125/5ml . . . . . . . . . . . . 18
cephalexin sus 250/5ml . . . . . . . . . . . . 18
cephalexin tab 250mg . . . . . . . . . . . . . 18
cephalexin tab 500mg . . . . . . . . . . . . . 18
CEREZYME INJ 400UNIT . . . . . . . . . . . . 72
ceritinib . . . . . . . . . . . . . . . . . . . . . . . . . 41
CERVARIX INJ . . . . . . . . . . . . . . . . . . . . 86
CHANTIX PAK 0.5& 1MG . . . . . . . . . . . 15
CHANTIX PAK 1MG . . . . . . . . . . . . . . . 15
CHANTIX TAB 0.5MG . . . . . . . . . . . . . . 15
CHANTIX TAB 1MG . . . . . . . . . . . . . . . . 15
chlorambucil . . . . . . . . . . . . . . . . . . . . . 36
chloramphen inj 1gm . . . . . . . . . . . . . . 16
118
chloramphenicol . . . . . . . . . . . . . . . . . . 16
chlorhex glu sol 0.12% . . . . . . . . . . . . . 70
chloroquine tab 250mg . . . . . . . . . . . . 41
chloroquine tab 500mg . . . . . . . . . . . . 41
chlorothiaz tab 250mg . . . . . . . . . . . . . 66
chlorothiaz tab 500mg . . . . . . . . . . . . . 66
chlorpromaz inj 25mg/ml . . . . . . . . . . . 31
chlorpromaz tab 100mg . . . . . . . . . . . 31
chlorpromaz tab 10mg . . . . . . . . . . . . 31
chlorpromaz tab 200mg . . . . . . . . . . . 31
chlorthalid tab 25mg . . . . . . . . . . . . . . 66
chlorthalid tab 50mg . . . . . . . . . . . . . . 66
chlorzoxazon tab 500mg . . . . . . . . . . . 94
chlorzoxazone . . . . . . . . . . . . . . . . . . . 94
cholestyram pow 4gm lite . . . . . . . . . . 68
ciclopirox cre 0.77% . . . . . . . . . . . . . . . 33
ciclopirox gel 0.77% . . . . . . . . . . . . . . . 33
ciclopirox sha 1% . . . . . . . . . . . . . . . . . 33
ciclopirox sol 8% . . . . . . . . . . . . . . . . . 33
ciclopirox sus 0.77% . . . . . . . . . . . . . . . 33
cilostazol tab 100mg . . . . . . . . . . . . . . 58
cilostazol tab 50mg . . . . . . . . . . . . . . . 58
CILOXAN . . . . . . . . . . . . . . . . . . . . . . . . 20
cimetidine sol 300/5ml . . . . . . . . . . . . . 73
cimetidine tab 200mg . . . . . . . . . . . . . 73
cinacalcet . . . . . . . . . . . . . . . . . . . . . . . 83
CINRYZE SOL 500 UNIT . . . . . . . . . . . . . 84
CIPRO . . . . . . . . . . . . . . . . . . . . . . . . . . 20
CIPRO HC SUS . . . . . . . . . . . . . . . . . . . . 91
CIPRO XR . . . . . . . . . . . . . . . . . . . . . . . . 20
ciprofloxacin hc . . . . . . . . . . . . . . . . . . 91
ciprofloxacn inj 200mg . . . . . . . . . . . . 20
ciprofloxacn inj 400mg . . . . . . . . . . . . 20
ciprofloxacn sol 0.3% . . . . . . . . . . . . . . 20
ciprofloxacn tab 1000mg . . . . . . . . . . . 20
ciprofloxacn tab 100mg . . . . . . . . . . . . 20
ciprofloxacn tab 500mg er . . . . . . . . . . 20
citalopram sol 10mg/5ml . . . . . . . . . . . 28
citalopram tab 10mg . . . . . . . . . . . . . . 28
clarithromyc sus 125/5ml . . . . . . . . . . . 19
clarithromyc sus 250/5ml . . . . . . . . . . . 19
clarithromyc tab 250mg . . . . . . . . . . . . 20
clarithromyc tab 500mg . . . . . . . . . . . . 20
clarithromyc tab 500mg er . . . . . . . . . 20
CLEOCIN . . . . . . . . . . . . . . . . . . . . . . . . 16
CLEOCIN-T . . . . . . . . . . . . . . . . . . . . . . . 16
clindamycin aer 1% . . . . . . . . . . . . . . . 16
clindamycin cap 150mg . . . . . . . . . . . . 16
clindamycin cap 300mg . . . . . . . . . . . . 16
clindamycin cre 2% . . . . . . . . . . . . . . . 16
clindamycin gel 1% . . . . . . . . . . . . . . . 16
clindamycin inj 150mg/ml . . . . . . . . . . 16
clindamycin inj 300mg . . . . . . . . . . . . . 16
clindamycin inj 600mg . . . . . . . . . . . . . 16
clindamycin lot 1% . . . . . . . . . . . . . . . . 16
clindamycin pad 1% . . . . . . . . . . . . . . . 16
clindamycin sol 1% . . . . . . . . . . . . . . . . 16
CLINISOL SF . . . . . . . . . . . . . . . . . . . . . . 95
clinisol sf inj 15% . . . . . . . . . . . . . . . . . 95
CLINORIL . . . . . . . . . . . . . . . . . . . . . . . . 12
clobazam . . . . . . . . . . . . . . . . . . . . . . . . 24
clomipramine cap 25mg . . . . . . . . . . . 30
clonazep odt tab 0.125mg . . . . . . . . . . 22
clonazep odt tab 0.25mg . . . . . . . . . . . 22
clonazep odt tab 0.5mg . . . . . . . . . . . . 22
clonazep odt tab 1mg . . . . . . . . . . . . . 22
clonazep odt tab 2mg . . . . . . . . . . . . . 22
clonazepam tab 0.5mg . . . . . . . . . . . . 22
clonazepam tab 1mg . . . . . . . . . . . . . . 22
clonazepam tab 2mg . . . . . . . . . . . . . . 23
clonidine dis 0.1/24hr . . . . . . . . . . . . . . 58
clonidine dis 0.2/24hr . . . . . . . . . . . . . . 58
clonidine dis 0.3/24hr . . . . . . . . . . . . . . 58
clonidine tab 0.1mg . . . . . . . . . . . . . . . 58
clonidine tab 0.2mg . . . . . . . . . . . . . . . 58
clonidine tab 0.3mg . . . . . . . . . . . . . . . 58
clopidogrel tab 75mg . . . . . . . . . . . . . . 58
cloraz dipot tab 15mg . . . . . . . . . . . . . 23
cloraz dipot tab 3.75mg . . . . . . . . . . . . 23
cloraz dipot tab 7.5mg . . . . . . . . . . . . . 23
clotrim/beta cre diprop . . . . . . . . . . . . 71
clotrim/beta lot diprop . . . . . . . . . . . . 71
clotrimazole . . . . . . . . . . . . . . . . . . . . . 33
clotrimazole cre 1% . . . . . . . . . . . . . . . 33
clotrimazole sol 1% . . . . . . . . . . . . . . . 33
clotrimazole tro 10mg . . . . . . . . . . . . . 33
clozapine . . . . . . . . . . . . . . . . . . . . . . . . 46
clozapine tab 100mg . . . . . . . . . . . . . . 46
clozapine tab 200mg . . . . . . . . . . . . . . 46
clozapine tab 25mg . . . . . . . . . . . . . . . 46
clozapine tab 50mg . . . . . . . . . . . . . . . 46
CLOZARIL . . . . . . . . . . . . . . . . . . . . . . . 46
COARTEM TAB 20-120MG . . . . . . . . . . 41
cobicistat . . . . . . . . . . . . . . . . . . . . . . . . 49
Index of Drugs
cobicistat - darunavir . . . . . . . . . . . . . . 49
cobicistat-elvitegravir-emtricitabinetenofovir . . . . . . . . . . . . . . . . . . . . . 48
COGENTIN . . . . . . . . . . . . . . . . . . . . . . . 42
COLAZAL . . . . . . . . . . . . . . . . . . . . . . . . 87
colchicine . . . . . . . . . . . . . . . . . . . . . . . 34
COLCHICINE - PROBENECID . . . . . . . . . 34
COLCRYS TAB 0.6MG . . . . . . . . . . . . . . 34
colesevelam . . . . . . . . . . . . . . . . . . . . . 68
COLESTID . . . . . . . . . . . . . . . . . . . . . . . 68
colestipol gra 5gm . . . . . . . . . . . . . . . . 68
colestipol tab 1gm . . . . . . . . . . . . . . . . 68
colistimeth inj 150mg . . . . . . . . . . . . . . 16
colistimethate . . . . . . . . . . . . . . . . . . . . 16
collagenase . . . . . . . . . . . . . . . . . . . . . . 71
COLOCORT . . . . . . . . . . . . . . . . . . . . . . 76
colocort ene 100mg . . . . . . . . . . . . . . . 76
COLYTE-FLAVR . . . . . . . . . . . . . . . . . . . 74
COMBIGAN SOL 0.2/0.5% . . . . . . . . . . 90
COMBIVENT AER RESPIMAT . . . . . . . . 92
COMBIVIR . . . . . . . . . . . . . . . . . . . . . . . 49
COMETRIQ KIT 100MG . . . . . . . . . . . . . 39
COMETRIQ KIT 140MG . . . . . . . . . . . . . 39
COMETRIQ KIT 60MG . . . . . . . . . . . . . . 39
COMPAZINE . . . . . . . . . . . . . . . . . . . . . 32
COMPLERA TAB . . . . . . . . . . . . . . . . . . 48
COMPRO . . . . . . . . . . . . . . . . . . . . . . . . 32
compro sup 25mg . . . . . . . . . . . . . . . . . 31
COMTAN . . . . . . . . . . . . . . . . . . . . . . . . 42
COMVAX INJ . . . . . . . . . . . . . . . . . . . . . 86
CONDYLOX . . . . . . . . . . . . . . . . . . . . . . 71
CONDYLOX GEL 0.5% . . . . . . . . . . . . . 71
constulose sol 10gm/15ml . . . . . . . . . . 74
CONSTULOSE, CEPHULAC, ENULOSE . . 74
COPAXONE INJ 40MG/ML . . . . . . . . . . 70
COPAXONE KIT 20MG/ML . . . . . . . . . . 70
CORDARONE . . . . . . . . . . . . . . . . . . . . . 61
CORDARONE, PACERONE . . . . . . . . . . 61
COREG . . . . . . . . . . . . . . . . . . . . . . . . . . 62
CORGARD . . . . . . . . . . . . . . . . . . . . . . . 63
CORTEF . . . . . . . . . . . . . . . . . . . . . . . . . 76
cortisone . . . . . . . . . . . . . . . . . . . . . . . . 76
CORTISONE AC TAB 25MG . . . . . . . . . . 76
CORTISPORIN . . . . . . . . . . . . . . . . . . . . 89
CORZIDE . . . . . . . . . . . . . . . . . . . . . . . . 63
COSOPT . . . . . . . . . . . . . . . . . . . . . . . . . 90
COUMADIN . . . . . . . . . . . . . . . . . . . . . . 56
COUMADIN TAB 10MG . . . . . . . . . . . . 54
COUMADIN TAB 1MG . . . . . . . . . . . . . 55
COUMADIN TAB 2.5MG . . . . . . . . . . . . 55
COUMADIN TAB 2MG . . . . . . . . . . . . . 55
COUMADIN TAB 3MG . . . . . . . . . . . . . 55
COUMADIN TAB 4MG . . . . . . . . . . . . . 55
COUMADIN TAB 5MG . . . . . . . . . . . . . 55
COUMADIN TAB 6MG . . . . . . . . . . . . . 55
COUMADIN TAB 7.5MG . . . . . . . . . . . . 55
COZAAR . . . . . . . . . . . . . . . . . . . . . . . . 59
CREON CAP 12000UNT . . . . . . . . . . . . . 72
CREON CAP 24000UNT . . . . . . . . . . . . . 72
CREON CAP 3000UNIT . . . . . . . . . . . . . 72
CREON CAP 36000UNT . . . . . . . . . . . . . 72
CREON CAP 6000UNIT . . . . . . . . . . . . . 73
CRIXIVAN CAP 200MG . . . . . . . . . . . . . 50
CRIXIVAN CAP 400MG . . . . . . . . . . . . . 50
crizotinib . . . . . . . . . . . . . . . . . . . . . . . . 40
CROLOM . . . . . . . . . . . . . . . . . . . . . . . . 89
cromolyn sod con 100/5ml . . . . . . . . . . 93
cromolyn sod neb 20mg/2ml . . . . . . . . 93
cromolyn sod sol 4% . . . . . . . . . . . . . . 89
crotamiton . . . . . . . . . . . . . . . . . . . . . . 42
cryselle-28 . . . . . . . . . . . . . . . . . . . . . . . 80
CUBICIN SOL 500MG . . . . . . . . . . . . . . 16
CUTIVATE . . . . . . . . . . . . . . . . . . . . . . . 77
CYCLESSA, VELIVET, CESIA . . . . . . . . . . 81
cyclobenzapr tab 10mg . . . . . . . . . . . . 94
CYCLOCORT . . . . . . . . . . . . . . . . . . . . . 76
cyclophosph cap 25mg . . . . . . . . . . . . . 36
cyclophosph cap 50mg . . . . . . . . . . . . . 36
CYCLOSET TAB 0.8MG . . . . . . . . . . . . . 52
cyclosporine . . . . . . . . . . . . . . . . . . . . . 85
cyclosporine cap 100mg . . . . . . . . . . . . 84
cyclosporine cap 100mg md . . . . . . . . 84
cyclosporine cap 25mg . . . . . . . . . . . . . 84
cyclosporine cap 25mg mod . . . . . . . . 84
cyclosporine cap 50mg mod . . . . . . . . 84
cyclosporine inj 50mg/ml . . . . . . . . . . . 84
cyclosporine sol modified . . . . . . . . . . 84
CYMBALTA . . . . . . . . . . . . . . . . . . . . . . 28
cyproheptad tab 4mg . . . . . . . . . . . . . 92
CYSTADANE POW . . . . . . . . . . . . . . . . . 72
CYSTAGON CAP 150MG . . . . . . . . . . . . 72
CYSTAGON CAP 50MG . . . . . . . . . . . . . 72
cysteamine . . . . . . . . . . . . . . . . . . . . . . 72
CYTOMEL . . . . . . . . . . . . . . . . . . . . . . . 82
CYTOMEL TAB 25MCG . . . . . . . . . . . . . 81
CYTOMEL TAB 50MCG . . . . . . . . . . . . . 81
CYTOMEL TAB 5MCG . . . . . . . . . . . . . . 81
CYTOTEC . . . . . . . . . . . . . . . . . . . . . . . . 74
CYTOVENE . . . . . . . . . . . . . . . . . . . . . . 47
CYTOXAN . . . . . . . . . . . . . . . . . . . . . . . 36
D
d2.5w/nacl inj 0.45% . . . . . . . . . . . . . . 95
d5w/lr . . . . . . . . . . . . . . . . . . . . . . . . . . 95
d5w/nacl inj 0.2% . . . . . . . . . . . . . . . . . 96
D5W/NACL INJ 0.225% . . . . . . . . . . . . . 96
d5w/nacl inj 0.33% . . . . . . . . . . . . . . . . 96
d5w/nacl inj 0.45% . . . . . . . . . . . . . . . . 96
d5w/nacl inj 0.9% . . . . . . . . . . . . . . . . . 96
dabigatran . . . . . . . . . . . . . . . . . . . . . . 56
dabrafenib . . . . . . . . . . . . . . . . . . . . . . 40
DALFAMPRIDINE ER . . . . . . . . . . . . . . . 70
dalfopristin - quinupristin . . . . . . . . . . 16
DALIRESP TAB 500MCG . . . . . . . . . . . . 93
dalteparin . . . . . . . . . . . . . . . . . . . . . . . 55
danazol cap 100mg . . . . . . . . . . . . . . . 79
danazol cap 200mg . . . . . . . . . . . . . . . 79
danazol cap 50mg . . . . . . . . . . . . . . . . 79
DANOCRINE . . . . . . . . . . . . . . . . . . . . . 79
DANTRIUM . . . . . . . . . . . . . . . . . . . . . . 46
dantrolene cap 100mg . . . . . . . . . . . . . 46
dantrolene cap 25mg . . . . . . . . . . . . . . 46
dantrolene cap 50mg . . . . . . . . . . . . . . 46
dapsone . . . . . . . . . . . . . . . . . . . . . . . . 35
dapsone tab 100mg . . . . . . . . . . . . . . . 35
dapsone tab 25mg . . . . . . . . . . . . . . . . 35
DAPTACEL INJ . . . . . . . . . . . . . . . . . . . . 86
daptomycin . . . . . . . . . . . . . . . . . . . . . . 16
DARAPRIM TAB 25MG . . . . . . . . . . . . . 41
darbepoetin alfa . . . . . . . . . . . . . . . . . 56
darifenacin . . . . . . . . . . . . . . . . . . . . . . 75
darunavir . . . . . . . . . . . . . . . . . . . . . . . 50
dasabuvir - ombitasvir - . . . . . . . . . . . . 48
paritaprevir - ritonavir
dasatinib . . . . . . . . . . . . . . . . . . . . . . . . 40
DAYPRO . . . . . . . . . . . . . . . . . . . . . . . . 12
DDAVP . . . . . . . . . . . . . . . . . . . . . . . . . 78
DECADRON, DEXASONE . . . . . . . . . . . 77
DECLOMYCIN . . . . . . . . . . . . . . . . . . . . 21
deferasirox . . . . . . . . . . . . . . . . . . . . . . 95
deferiprone . . . . . . . . . . . . . . . . . . . . . . 95
DEL-BETA . . . . . . . . . . . . . . . . . . . . . . . 76
delavirdine . . . . . . . . . . . . . . . . . . . . . . 48
DELZICOL CAP 400MG . . . . . . . . . . . . . 87
DEMADEX . . . . . . . . . . . . . . . . . . . . . . . 66
demeclocycl tab 150mg . . . . . . . . . . . . 21
demeclocycl tab 300mg . . . . . . . . . . . . 21
DEMSER CAP 250MG . . . . . . . . . . . . . . 65
DEMULEN . . . . . . . . . . . . . . . . . . . . . . . 81
DEMULEN, KELNOR, ZOVIA . . . . . . . . . 80
DENAVIR CRE 1% . . . . . . . . . . . . . . . . . 51
denosumab . . . . . . . . . . . . . . . . . . . . . . 88
DEPAKENE . . . . . . . . . . . . . . . . . . . . . . 24
DEPAKOTE . . . . . . . . . . . . . . . . . . . . . . 23
DEPEN TITRA TAB 250MG . . . . . . . . . . 76
DEPO-MEDROL . . . . . . . . . . . . . . . . . . . 78
DEPO-PROVERA . . . . . . . . . . . . . . . . . . 81
DERMA-SMOOTH . . . . . . . . . . . . . . . . . 77
DERMATOP . . . . . . . . . . . . . . . . . . . . . . 78
119
Index of Drugs
DERMOTIC . . . . . . . . . . . . . . . . . . . . . . 91
desipramine tab 100mg . . . . . . . . . . . . 30
desipramine tab 10mg . . . . . . . . . . . . . 30
desipramine tab 150mg . . . . . . . . . . . . 30
desmopressin inj 4mcg/ml . . . . . . . . . . 78
desmopressin spr 0.01% . . . . . . . . . . . 79
desmopressin tab 0.1mg . . . . . . . . . . . 79
desmopressin tab 0.2mg . . . . . . . . . . . 79
desonide cre 0.05% . . . . . . . . . . . . . . . 77
desonide lot 0.05% . . . . . . . . . . . . . . . 77
desonide oin 0.05% . . . . . . . . . . . . . . . 77
DESOWEN . . . . . . . . . . . . . . . . . . . . . . . 77
desoximetas cre 0.05% . . . . . . . . . . . . 77
desoximetas cre 0.25% . . . . . . . . . . . . 77
desoximetas gel 0.05% . . . . . . . . . . . . 77
desoximetas oin 0.25% . . . . . . . . . . . . 77
desvenlafaxine . . . . . . . . . . . . . . . . . . . 29
desvenlafaxine er . . . . . . . . . . . . . . . . . 29
DESYREL,OLEPTRO . . . . . . . . . . . . . . . . 30
DETROL . . . . . . . . . . . . . . . . . . . . . . . . . 75
dexameth pho inj 120mg/30ml . . . . . . 77
dexameth pho sol 0.1% . . . . . . . . . . . . 89
dexamethason con 1mg/ml . . . . . . . . . 77
dexamethason elx 0.5/5ml . . . . . . . . . . 77
dexamethason tab 0.5mg . . . . . . . . . . 77
dexamethason tab 0.75mg . . . . . . . . . 77
dexamethason tab 1.5mg . . . . . . . . . . 77
dexamethason tab 1mg . . . . . . . . . . . . 77
DEXASOL . . . . . . . . . . . . . . . . . . . . . . . . 89
DEXEDRINE . . . . . . . . . . . . . . . . . . . . . . 69
dexmethylph tab 10mg . . . . . . . . . . . . 69
dexmethylph tab 2.5mg . . . . . . . . . . . . 69
dexmethylph tab 5mg . . . . . . . . . . . . . 69
dextroamphet tab 10mg . . . . . . . . . . . 69
dextroamphet tab 5mg . . . . . . . . . . . . 69
dextromethorphan - quinidine . . . . . . 69
sulfate
dextrose 10% . . . . . . . . . . . . . . . . . . . . 96
dextrose 2.5% - sodium chloride . . . . . 95
0.45%
dextrose 5% . . . . . . . . . . . . . . . . . . . . . 96
dextrose 5% - sodium chloride 0.2% . 96
dextrose 5% - sodium chloride . . . . . . 96
0.225%
0.33%
120
0.45%
dextrose 5% - sodium chloride 0.9% . 96
dextrose inj 10% . . . . . . . . . . . . . . . . . 96
dextrose inj 5% . . . . . . . . . . . . . . . . . . 96
DIAMOX . . . . . . . . . . . . . . . . . . . . . . . . 65
DIAMOX SEQUELS . . . . . . . . . . . . . . . . 65
DIASTAT ACDL GEL 12.5-20MG . . . . . . 23
DIASTAT ACDL GEL 5-10MG . . . . . . . . . 23
DIASTAT PED GEL 2.5M GEL . . . . . . . . . 23
diazepam con 5mg/ml . . . . . . . . . . . . . 23
diazepam gel . . . . . . . . . . . . . . . . . . . . 23
diazepam sol 1mg/ml . . . . . . . . . . . . . . 23
diazepam tab 10mg . . . . . . . . . . . . . . . 23
diazepam tab 2mg . . . . . . . . . . . . . . . . 23
diazepam tab 5mg . . . . . . . . . . . . . . . . 23
diazoxide . . . . . . . . . . . . . . . . . . . . . . . 54
diclofen pot tab 50mg . . . . . . . . . . . . . 11
diclofenac gel 3% . . . . . . . . . . . . . . . . . 71
diclofenac sodium topical gel . . . . . . . 72
diclofenac sol 0.1% . . . . . . . . . . . . . . . 89
diclofenac tab 100mg er . . . . . . . . . . . 11
diclofenac tab 25mg dr . . . . . . . . . . . . 11
dicloxacill cap 250mg . . . . . . . . . . . . . . 19
dicloxacill cap 500mg . . . . . . . . . . . . . . 19
dicyclomine cap 10mg . . . . . . . . . . . . . 72
didanosine . . . . . . . . . . . . . . . . . . . . . . 49
didanosine cap 125mg . . . . . . . . . . . . . 49
DIDRONEL . . . . . . . . . . . . . . . . . . . . . . . 88
DIFFERIN . . . . . . . . . . . . . . . . . . . . . . . . 71
diflorasone cre 0.05% . . . . . . . . . . . . . 77
diflorasone oin 0.05% . . . . . . . . . . . . . 77
DIFLUCAN . . . . . . . . . . . . . . . . . . . . . . . 33
DIFLUCAN - DEXTROSE . . . . . . . . . . . . 33
diflunisal . . . . . . . . . . . . . . . . . . . . . . . . 11
diflunisal tab 500mg . . . . . . . . . . . . . . 11
difluprednate . . . . . . . . . . . . . . . . . . . . 89
digoxin inj 0.25mg/1 . . . . . . . . . . . . . . 65
digoxin sol 50mcg/ml . . . . . . . . . . . . . . 65
digoxin tab 0.125mg . . . . . . . . . . . . . . 65
dihydroergotamine nasal spray . . . . . . 34
DILANTIN . . . . . . . . . . . . . . . . . . . . . . . 26
DILANTIN CAP 100MG . . . . . . . . . . . . . 25
DILANTIN CAP 30MG . . . . . . . . . . . . . . 25
DILANTIN CHEWABLE . . . . . . . . . . . . . 26
DILANTIN CHW 50MG . . . . . . . . . . . . . 25
DILANTIN-125 SUS 125/5ML . . . . . . . . . 25
DILATRATE-SR . . . . . . . . . . . . . . . . . . . . 68
DILAUDID . . . . . . . . . . . . . . . . . . . . . . . 13
DILT-CD . . . . . . . . . . . . . . . . . . . . . . . . . 63
dilt-xr cap 120mg . . . . . . . . . . . . . . . . . 63
dilt-xr cap 180mg . . . . . . . . . . . . . . . . . 63
dilt-xr cap 240mg . . . . . . . . . . . . . . . . . 63
diltiazem cap 120mg cd . . . . . . . . . . . . 63
diltiazem cap 120mg er . . . . . . . . . . . . 63
diltiazem cap 180mg/24hr . . . . . . . . . . 63
diltiazem cap 240mg cd . . . . . . . . . . . . 64
diltiazem cap 300mg er . . . . . . . . . . . . 64
diltiazem cap 60mg er . . . . . . . . . . . . . 64
diltiazem cap 90mg er . . . . . . . . . . . . . 64
DILTIAZEM CD . . . . . . . . . . . . . . . . . . . . 63
diltiazem inj 100mg . . . . . . . . . . . . . . . 64
diltiazem inj 50/10ml . . . . . . . . . . . . . . 64
diltiazem tab 120mg . . . . . . . . . . . . . . 64
diltiazem tab 30mg . . . . . . . . . . . . . . . 64
diltiazem tab 60mg . . . . . . . . . . . . . . . 64
diltiazem tab 90mg . . . . . . . . . . . . . . . 64
DIOVAN . . . . . . . . . . . . . . . . . . . . . . . . . 59
DIOVAN HCT . . . . . . . . . . . . . . . . . . . . . 59
DIPENTUM CAP 250MG . . . . . . . . . . . . 87
diphenhydram inj 50mg/ml . . . . . . . . . 31
diphtheria - tetanus toxoids - . . . . . . . 87
acellular pertussis
diphtheria toxoid - tetanus toxoid . . . 87
DIPROLENE . . . . . . . . . . . . . . . . . . . . . . 76
disulfiram tab 250mg . . . . . . . . . . . . . . 14
disulfiram tab 500mg . . . . . . . . . . . . . . 14
DITROPAN . . . . . . . . . . . . . . . . . . . . . . . 75
DITROPAN XL . . . . . . . . . . . . . . . . . . . . 75
DIURIL . . . . . . . . . . . . . . . . . . . . . . . . . . 66
divalproex cap 125mg . . . . . . . . . . . . . 23
divalproex tab 125mg dr . . . . . . . . . . . 23
divalproex tab 250mg er . . . . . . . . . . . 23
divalproex tab 500mg er . . . . . . . . . . . 23
DOCEFREZ INJ 20MG . . . . . . . . . . . . . . 37
docetaxel . . . . . . . . . . . . . . . . . . . . . . . 37
dofetilide . . . . . . . . . . . . . . . . . . . . . . . 62
dolasetron . . . . . . . . . . . . . . . . . . . . . . . 32
dolutegravir . . . . . . . . . . . . . . . . . . . . . 48
donepezil tab 10mg . . . . . . . . . . . . . . . 26
donepezil tab 10mg odt . . . . . . . . . . . 26
donepezil tab 5mg . . . . . . . . . . . . . . . . 26
donepezil tab 5mg odt . . . . . . . . . . . . 26
dornase alfa . . . . . . . . . . . . . . . . . . . . . 94
dorzol/timol sol 2-0.5% . . . . . . . . . . . . 90
dorzolamide sol 2% . . . . . . . . . . . . . . . 90
DOSTINEX . . . . . . . . . . . . . . . . . . . . . . . 83
DOVONEX . . . . . . . . . . . . . . . . . . . . . . . 71
Index of Drugs
doxazosin tab 1mg . . . . . . . . . . . . . . . . 58
doxazosin tab 2mg . . . . . . . . . . . . . . . . 58
doxazosin tab 4mg . . . . . . . . . . . . . . . . 58
doxazosin tab 8mg . . . . . . . . . . . . . . . . 58
doxepin hcl cap 100mg . . . . . . . . . . . . 31
doxepin hcl cap 10mg . . . . . . . . . . . . . 31
doxepin hcl cap 150mg . . . . . . . . . . . . 31
doxepin hcl con 10mg/ml . . . . . . . . . . . 31
doxercalcif cap 0.5mcg . . . . . . . . . . . . . 88
doxercalcif cap 1mcg . . . . . . . . . . . . . . 88
doxercalcif cap 2.5mcg . . . . . . . . . . . . . 88
doxercalcif inj 4mcg/2ml . . . . . . . . . . . 88
doxy 100 inj 100mg . . . . . . . . . . . . . . . 21
doxycyc mono tab 150mg . . . . . . . . . . 21
doxycyc mono tab 50mg . . . . . . . . . . . 21
doxycyc mono tab 75mg . . . . . . . . . . . 21
doxycycl hyc cap 100mg . . . . . . . . . . . . 21
doxycycl hyc cap 50mg . . . . . . . . . . . . . 21
doxycycl hyc inj 100mg . . . . . . . . . . . . 21
doxycycl hyc tab 100mg . . . . . . . . . . . . 21
doxycycline tab 20mg . . . . . . . . . . . . . 70
dronabinol cap 10mg . . . . . . . . . . . . . . 32
dronabinol cap 2.5mg . . . . . . . . . . . . . 32
dronabinol cap 5mg . . . . . . . . . . . . . . . 32
dronedarone . . . . . . . . . . . . . . . . . . . . . 61
DROXIA CAP 200MG . . . . . . . . . . . . . . 37
DROXIA CAP 300MG . . . . . . . . . . . . . . 37
DROXIA CAP 400MG . . . . . . . . . . . . . . 37
droxidopa . . . . . . . . . . . . . . . . . . . . . . . 65
DULERA AER 100-5MCG . . . . . . . . . . . . 94
DULERA AER 200-5MCG . . . . . . . . . . . . 94
DULOXETINE CAP 20MG . . . . . . . . . . . 28
duloxetine cap 30mg . . . . . . . . . . . . . . 28
DURAGESIC . . . . . . . . . . . . . . . . . . . . . . 12
DURAMORPH INJ 0.5MG/ML . . . . . . . . 13
DURAMORPH INJ 1MG/ML . . . . . . . . . 13
DUREZOL EMU 0.05% . . . . . . . . . . . . . 89
DURICEF . . . . . . . . . . . . . . . . . . . . . . . . 17
dutasteride . . . . . . . . . . . . . . . . . . . . . . 75
DYAZIDE . . . . . . . . . . . . . . . . . . . . . . . . 67
DYCIL, DYNAPEN . . . . . . . . . . . . . . . . . 19
DYNACIN . . . . . . . . . . . . . . . . . . . . . . . . 21
DYNACIRC . . . . . . . . . . . . . . . . . . . . . . . 64
efavirenz - emtricitabine . . . . . . . . . . . 49
-tenofovir
EFFEXOR . . . . . . . . . . . . . . . . . . . . . . . . 30
EFFEXOR ER . . . . . . . . . . . . . . . . . . . . . 30
EFFEXOR XR . . . . . . . . . . . . . . . . . . . . . 30
EFFIENT TAB 10MG . . . . . . . . . . . . . . . . 58
EFFIENT TAB 5MG . . . . . . . . . . . . . . . . . 58
8-MOP CAP 10MG . . . . . . . . . . . . . . . . 71
EFUDEX . . . . . . . . . . . . . . . . . . . . . . . . . 71
ELAPRASE INJ 6MG/3ML . . . . . . . . . . . 72
ELAVIL . . . . . . . . . . . . . . . . . . . . . . . . . . 30
ELDEPRYL . . . . . . . . . . . . . . . . . . . . . . . 43
ELESTAT . . . . . . . . . . . . . . . . . . . . . . . . . 89
ELIDEL CRE 1% . . . . . . . . . . . . . . . . . . . 71
ELIMITE . . . . . . . . . . . . . . . . . . . . . . . . . 42
ELIQUIS TAB 2.5MG . . . . . . . . . . . . . . . 55
ELIQUIS TAB 5MG . . . . . . . . . . . . . . . . . 55
ELITEK INJ 1.5MG . . . . . . . . . . . . . . . . . 37
ELOCON . . . . . . . . . . . . . . . . . . . . . . . . 78
eltrombopag . . . . . . . . . . . . . . . . . . . . . 57
elvitegravir . . . . . . . . . . . . . . . . . . . . . . 48
EMCYT CAP 140MG . . . . . . . . . . . . . . . 37
EMEND CAP 125MG . . . . . . . . . . . . . . . 32
EMEND CAP 40MG . . . . . . . . . . . . . . . . 32
EMEND CAP 80MG . . . . . . . . . . . . . . . . 32
EMLA . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
EMSAM DIS 12MG/24HR . . . . . . . . . . . 28
EMSAM DIS 6MG/24HR . . . . . . . . . . . . 28
EMSAM DIS 9MG/24HR . . . . . . . . . . . . 28
emtricitabine . . . . . . . . . . . . . . . . . . . . 49
emtricitabine - tenofovir . . . . . . . . . . . 49
emtricitabine-rilpivirine-tenofovir . . . 48
EMTRIVA CAP 200MG . . . . . . . . . . . . . 49
EMTRIVA SOL 10MG/ML . . . . . . . . . . . . 49
ENABLEX TAB 15MG . . . . . . . . . . . . . . 75
ENABLEX TAB 7.5MG . . . . . . . . . . . . . . 75
enalapr/hctz tab 10-25mg . . . . . . . . . . 60
enalapr/hctz tab 5-12.5mg . . . . . . . . . . 60
enalapril tab 10mg . . . . . . . . . . . . . . . . 60
enalapril tab 2.5mg . . . . . . . . . . . . . . . 60
enalapril tab 20mg . . . . . . . . . . . . . . . . 60
enalapril tab 5mg . . . . . . . . . . . . . . . . . 60
ENBREL INJ 25/0.5ML . . . . . . . . . . . . . . 84
ENBREL INJ 25MG . . . . . . . . . . . . . . . . . 84
ENBREL INJ 50MG/ML . . . . . . . . . . . . . . 84
endocet tab 10-325mg . . . . . . . . . . . . . 13
endocet tab 5-325mg . . . . . . . . . . . . . . 13
endocet tab 7.5-325mg . . . . . . . . . . . . 13
ENDOCET, PERCOCET . . . . . . . . . . . . . . 13
enfuvirtide . . . . . . . . . . . . . . . . . . . . . . 49
E
econazole cre 1% . . . . . . . . . . . . . . . . . 33 ENGERIX-B INJ 10/0.5ML . . . . . . . . . . . 86
EDURANT TAB 25MG . . . . . . . . . . . . . . 48 ENGERIX-B INJ 20MCG/ML . . . . . . . . . . 86
efavirenz . . . . . . . . . . . . . . . . . . . . . . . . 48 enoxaparin inj 100mg/ml . . . . . . . . . . . 55
enoxaparin inj 120/0.8ml . . . . . . . . . . . 55
enoxaparin inj 150mg/ml . . . . . . . . . . . 55
enoxaparin inj 30/0.3ml . . . . . . . . . . . . 55
enpresse-28 . . . . . . . . . . . . . . . . . . . . . . 80
ENPRESSE, TRIVORA, TRI-LEVEN . . . . . 80
entacapone tab 200mg . . . . . . . . . . . . 42
entecavir . . . . . . . . . . . . . . . . . . . . . . . . 47
entecavir tab 0.5mg . . . . . . . . . . . . . . . 47
entecavir tab 1mg . . . . . . . . . . . . . . . . 47
ENTOCORT EC . . . . . . . . . . . . . . . . . . . . 76
enulose sol 10gm/15ml . . . . . . . . . . . . 74
enzalutamide . . . . . . . . . . . . . . . . . . . . 36
epinastine dro 0.05% . . . . . . . . . . . . . . 89
epinephrine . . . . . . . . . . . . . . . . . . . . . 92
EPIPEN 2-PAK INJ 0.3MG . . . . . . . . . . . 92
EPIPEN-JR INJ 2-PAK . . . . . . . . . . . . . . . 92
epitol tab 200mg . . . . . . . . . . . . . . . . . 25
EPIVIR . . . . . . . . . . . . . . . . . . . . . . . . . . 49
EPIVIR HBV SOL 5MG/ML . . . . . . . . . . . 47
eplerenone tab 25mg . . . . . . . . . . . . . 66
eplerenone tab 50mg . . . . . . . . . . . . . 66
epoetin alfa . . . . . . . . . . . . . . . . . . . . . 57
EPOGEN INJ 10000/ML . . . . . . . . . . . . . 57
EPOGEN INJ 2000/ML . . . . . . . . . . . . . . 57
EPOGEN INJ 20000/ML . . . . . . . . . . . . . 57
EPOGEN INJ 3000/ML . . . . . . . . . . . . . . 57
EPOGEN INJ 4000/ML . . . . . . . . . . . . . . 57
EPZICOM TAB 600-300MG . . . . . . . . . . 49
EQUETRO CAP 100MG . . . . . . . . . . . . . 25
EQUETRO CAP 200MG . . . . . . . . . . . . . 25
EQUETRO CAP 300MG . . . . . . . . . . . . . 25
ERAXIS INJ 100MG . . . . . . . . . . . . . . . . 33
ergoloid mes tab 1mg . . . . . . . . . . . . . 26
ergoloid mesylates . . . . . . . . . . . . . . . . 26
ergomar sub 2mg . . . . . . . . . . . . . . . . . 34
ergotamine . . . . . . . . . . . . . . . . . . . . . . 34
ERIVEDGE CAP 150MG . . . . . . . . . . . . . 39
erlotinib . . . . . . . . . . . . . . . . . . . . . . . . 40
errin tab 0.35mg . . . . . . . . . . . . . . . . . . 81
ertapenem . . . . . . . . . . . . . . . . . . . . . . 18
ERWINAZE INJ 10000UNT . . . . . . . . . . 37
erwinia asparaginase . . . . . . . . . . . . . . 37
ERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
ery pad 2% . . . . . . . . . . . . . . . . . . . . . . 20
ery-tab tab 250mg ec . . . . . . . . . . . . . . 20
ery-tab tab 333mg ec . . . . . . . . . . . . . . 20
ery-tab tab 500mg ec . . . . . . . . . . . . . . 20
ERY-TAB, E.E.S. . . . . . . . . . . . . . . . . . . . 20
ERYGEL . . . . . . . . . . . . . . . . . . . . . . . . . 20
ERYTHROCIN . . . . . . . . . . . . . . . . . . . . . 20
121
Index of Drugs
erythrocin inj 500mg . . . . . . . . . . . . . . 20
erythrocin tab 250mg . . . . . . . . . . . . . 20
erythromycin . . . . . . . . . . . . . . . . . . . . 20
erythromycin gel /benzoyl . . . . . . . . . . 71
erythromycin gel 2% . . . . . . . . . . . . . . 20
erythromycin oin . . . . . . . . . . . . . . . . . 20
erythromycin sol 2% . . . . . . . . . . . . . . 20
erythromycin tab 250mg bs . . . . . . . . . 20
erythromycin tab 500mg bs . . . . . . . . . 20
ESBRIET CAP 267MG . . . . . . . . . . . . . . . 94
escitalopram sol 5mg/5ml . . . . . . . . . . 29
escitalopram tab 10mg . . . . . . . . . . . . 29
escitalopram tab 20mg . . . . . . . . . . . . 29
escitalopram tab 5mg . . . . . . . . . . . . . 29
eslicarbazepine . . . . . . . . . . . . . . . . . . . 25
esomeprazole inj 40mg . . . . . . . . . . . . 74
esterified estrogens . . . . . . . . . . . . . . . 80
ESTRACE . . . . . . . . . . . . . . . . . . . . . . . . 80
ESTRACE VAG CRE 0.1MG/GM . . . . . . . 80
estrad val inj 20mg/ml . . . . . . . . . . . . . 80
estrad val inj 40mg/ml . . . . . . . . . . . . . 80
estradiol . . . . . . . . . . . . . . . . . . . . . . . . 80
estradiol tab 0.5mg . . . . . . . . . . . . . . . 80
estradiol tab 1mg . . . . . . . . . . . . . . . . . 80
estradiol tab 2mg . . . . . . . . . . . . . . . . . 80
estradiol vaginal cream . . . . . . . . . . . . 80
estramustine . . . . . . . . . . . . . . . . . . . . . 37
estrogens, conjugated . . . . . . . . . . . . . 80
estrogens, . . . . . . . . . . . . . . . . . . . . . . . 80
conjugated-medroxyprogesterone
etanercept . . . . . . . . . . . . . . . . . . . . . . 84
ethambutol tab 100mg . . . . . . . . . . . . 35
ethambutol tab 400mg . . . . . . . . . . . . 35
ethinyl - norethindrone . . . . . . . . . . . . 80
ethinyl estradiol - norethindrone . . . . 80
ethionamide . . . . . . . . . . . . . . . . . . . . . 35
ethosuximide cap 250mg . . . . . . . . . . . 22
ethosuximide sol 250/5ml . . . . . . . . . . 22
ethotoin . . . . . . . . . . . . . . . . . . . . . . . . 26
ETHYOL . . . . . . . . . . . . . . . . . . . . . . . . . 37
etidron disd tab 200mg . . . . . . . . . . . . 88
etidron disd tab 400mg . . . . . . . . . . . . 88
etodolac cap 200mg . . . . . . . . . . . . . . . 11
etodolac cap 300mg . . . . . . . . . . . . . . . 11
etodolac er tab 400mg . . . . . . . . . . . . . 11
etodolac tab 400mg . . . . . . . . . . . . . . . 11
etodolac tab 500mg . . . . . . . . . . . . . . . 11
etoposide inj 20mg/ml . . . . . . . . . . . . . 38
etravirine . . . . . . . . . . . . . . . . . . . . . . . 48
EULEXIN . . . . . . . . . . . . . . . . . . . . . . . . 36
EURAX CRE 10% . . . . . . . . . . . . . . . . . . 42
122
EURAX LOT 10% . . . . . . . . . . . . . . . . . . 42
everolimus . . . . . . . . . . . . . . . . . . . . . . 38
EVISTA . . . . . . . . . . . . . . . . . . . . . . . . . . 81
EVOTAZ TAB 300-150MG . . . . . . . . . . . 49
EXELON . . . . . . . . . . . . . . . . . . . . . . . . . 26
EXELON DIS 13.3/24HR . . . . . . . . . . . . . 26
EXELON DIS 4.6MG/24HR . . . . . . . . . . . 26
EXELON DIS 9.5MG/24HR . . . . . . . . . . . 26
exemestane tab 25mg . . . . . . . . . . . . . 38
exenatide . . . . . . . . . . . . . . . . . . . . . . . 52
EXJADE TAB 125MG . . . . . . . . . . . . . . . 95
EXJADE TAB 250MG . . . . . . . . . . . . . . . 95
EXJADE TAB 500MG . . . . . . . . . . . . . . . 95
ezetimibe . . . . . . . . . . . . . . . . . . . . . . . 68
ezogabine . . . . . . . . . . . . . . . . . . . . . . . 22
F
FABRAZYME INJ 35MG . . . . . . . . . . . . . 72
famciclovir tab 125mg . . . . . . . . . . . . . 51
famotidine inj 10mg/ml . . . . . . . . . . . . 73
famotidine inj 20mg/50ml . . . . . . . . . . 73
famotidine sus 40mg/5ml . . . . . . . . . . 73
famotidine tab 20mg . . . . . . . . . . . . . . 73
famotidine tab 40mg . . . . . . . . . . . . . . 73
FAMVIR . . . . . . . . . . . . . . . . . . . . . . . . . 51
FANAPT PAK . . . . . . . . . . . . . . . . . . . . . 44
FANAPT TAB 10MG . . . . . . . . . . . . . . . 44
FANAPT TAB 12MG . . . . . . . . . . . . . . . 44
FANAPT TAB 1MG . . . . . . . . . . . . . . . . 44
FANAPT TAB 2MG . . . . . . . . . . . . . . . . 44
FANAPT TAB 4MG . . . . . . . . . . . . . . . . 45
FANAPT TAB 6MG . . . . . . . . . . . . . . . . 45
FANAPT TAB 8MG . . . . . . . . . . . . . . . . 45
FARESTON TAB 60MG . . . . . . . . . . . . . 37
FARYDAK CAP 10MG . . . . . . . . . . . . . . 37
FARYDAK CAP 15MG . . . . . . . . . . . . . . 37
FARYDAK CAP 20MG . . . . . . . . . . . . . . 37
FASLODEX INJ 250MG . . . . . . . . . . . . . 37
FAZACLO TAB 100/ODT . . . . . . . . . . . . 46
FAZACLO TAB 12.5/ODT . . . . . . . . . . . . 46
FAZACLO TAB 150MG . . . . . . . . . . . . . 46
FAZACLO TAB 200MG . . . . . . . . . . . . . 46
FAZACLO TAB 25MG ODT . . . . . . . . . . 46
felbamate sus 600/5ml . . . . . . . . . . . . . 24
felbamate tab 400mg . . . . . . . . . . . . . 24
felbamate tab 600mg . . . . . . . . . . . . . 24
FELBATOL . . . . . . . . . . . . . . . . . . . . . . . 24
FELDENE . . . . . . . . . . . . . . . . . . . . . . . . 12
felodipine tab 10mg er . . . . . . . . . . . . 64
felodipine tab 2.5mg er . . . . . . . . . . . . 64
felodipine tab 5mg er . . . . . . . . . . . . . 64
FEMARA . . . . . . . . . . . . . . . . . . . . . . . . 38
fenofibrate . . . . . . . . . . . . . . . . . . . . . . 67
fenofibrate cap 130mg . . . . . . . . . . . . 67
fenofibrate cap 43mg . . . . . . . . . . . . . 67
fenofibrate cap 67mg . . . . . . . . . . . . . 67
fenofibrate tab 145mg . . . . . . . . . . . . 67
fenofibrate tab 160mg . . . . . . . . . . . . 67
fenofibrate tab 48mg . . . . . . . . . . . . . 67
fenofibrate tab 54mg . . . . . . . . . . . . . 67
fenofibric cap 135mg dr . . . . . . . . . . . 67
fenofibric cap 45mg dr . . . . . . . . . . . . 67
FENOPROFEN . . . . . . . . . . . . . . . . . . . . 11
fenoprofen tab 600mg . . . . . . . . . . . . 11
fentanyl dis 100mcg/hr . . . . . . . . . . . . 12
fentanyl dis 12mcg/hr . . . . . . . . . . . . . 12
fentanyl ot loz 1200mcg . . . . . . . . . . . 13
fentanyl ot loz 1600mcg . . . . . . . . . . . 13
fentanyl ot loz 200mcg . . . . . . . . . . . . 13
FERRIPROX TAB 500MG . . . . . . . . . . . . 95
fesoterodine . . . . . . . . . . . . . . . . . . . . . 75
FETZIMA CAP 120MG . . . . . . . . . . . . . . 29
FETZIMA CAP 20MG . . . . . . . . . . . . . . . 29
FETZIMA CAP 40MG . . . . . . . . . . . . . . . 29
FETZIMA CAP 80MG . . . . . . . . . . . . . . . 29
FETZIMA CAP TITRATION . . . . . . . . . . . 29
filgrastim . . . . . . . . . . . . . . . . . . . . . . . . 57
finasteride tab 5mg . . . . . . . . . . . . . . . 75
fingolimod . . . . . . . . . . . . . . . . . . . . . . 70
FIORICET - CODEINE . . . . . . . . . . . . . . . 11
FIRAZYR INJ 30MG/3ML . . . . . . . . . . . . 84
FLAGYL . . . . . . . . . . . . . . . . . . . . . . . . . 16
flavoxate tab 100mg . . . . . . . . . . . . . . 75
flecainide tab 100mg . . . . . . . . . . . . . . 61
flecainide tab 150mg . . . . . . . . . . . . . . 61
flecainide tab 50mg . . . . . . . . . . . . . . . 61
FLEXERIL . . . . . . . . . . . . . . . . . . . . . . . . 94
FLOMAX . . . . . . . . . . . . . . . . . . . . . . . . 75
FLONASE . . . . . . . . . . . . . . . . . . . . . . . . 91
FLORINEF . . . . . . . . . . . . . . . . . . . . . . . . 77
FLOVENT DISK AER 100MCG . . . . . . . . 91
FLOVENT DISK AER 250MCG . . . . . . . . 91
FLOVENT DISK AER 50MCG . . . . . . . . . 91
FLOVENT HFA AER 110MCG . . . . . . . . 91
FLOVENT HFA AER 220MCG . . . . . . . . 91
FLOVENT HFA AER 44MCG . . . . . . . . . 91
Index of Drugs
FLOXIN . . . . . . . . . . . . . . . . . . . . . . . . . 20
FLOXIN OTIC . . . . . . . . . . . . . . . . . . . . . 20
fluconazole sus 10mg/ml . . . . . . . . . . . 33
fluconazole sus 40mg/ml . . . . . . . . . . . 33
fluconazole tab 100mg . . . . . . . . . . . . 33
fluconazole tab 50mg . . . . . . . . . . . . . 33
fluconazole/ inj dex 400mg . . . . . . . . . 33
flucytosine cap 250mg . . . . . . . . . . . . . 33
flucytosine cap 500mg . . . . . . . . . . . . . 33
fludrocort tab 0.1mg . . . . . . . . . . . . . . 77
FLUMADINE . . . . . . . . . . . . . . . . . . . . . 50
flunisolide spr 0.025% . . . . . . . . . . . . . 91
fluocin acet cre 0.01% . . . . . . . . . . . . . 77
fluocin acet cre 0.025% . . . . . . . . . . . . 77
fluocin acet oil 0.01% . . . . . . . . . . . . . 91
fluocin acet oil body . . . . . . . . . . . . . . 77
fluocin acet oin 0.025% . . . . . . . . . . . . 77
fluocin acet sol 0.01% . . . . . . . . . . . . . 77
fluocinonide cre -e 0.05% . . . . . . . . . . 77
fluocinonide cre 0.1% . . . . . . . . . . . . . 77
fluocinonide gel 0.05% . . . . . . . . . . . . 77
fluocinonide oin 0.05% . . . . . . . . . . . . 77
fluocinonide sol 0.05% . . . . . . . . . . . . 77
fluoromethol sus 0.1% . . . . . . . . . . . . . 89
fluorometholone . . . . . . . . . . . . . . . . . 90
fluorouracil cre 5% . . . . . . . . . . . . . . . 71
fluorouracil sol 2% . . . . . . . . . . . . . . . . 71
fluorouracil sol 5% . . . . . . . . . . . . . . . . 71
fluoxetine cap 10mg . . . . . . . . . . . . . . 29
fluoxetine sol 20mg/5ml . . . . . . . . . . . 29
fluoxetine tab 10mg . . . . . . . . . . . . . . 29
fluoxetine tab 20mg . . . . . . . . . . . . . . 29
fluphenaz de inj 25mg/ml . . . . . . . . . . 43
fluphenazine con 5mg/ml . . . . . . . . . . 43
fluphenazine elx 2.5/5ml . . . . . . . . . . . 43
fluphenazine inj 2.5mg/ml . . . . . . . . . . 44
fluphenazine tab 10mg . . . . . . . . . . . . 44
fluphenazine tab 1mg . . . . . . . . . . . . . 44
fluphenazine tab 2.5mg . . . . . . . . . . . 44
fluphenazine tab 5mg . . . . . . . . . . . . . 44
flurbiprofen sol 0.03% . . . . . . . . . . . . . 89
flurbiprofen tab 100mg . . . . . . . . . . . . 11
flurbiprofen tab 50mg . . . . . . . . . . . . . 11
flutamide cap 125mg . . . . . . . . . . . . . . 36
fluticasone . . . . . . . . . . . . . . . . . . . . . . 91
fluticasone - vilanterol . . . . . . . . . . . . 94
fluticasone - salmeterol . . . . . . . . . . . . 94
fluticasone cre 0.05% . . . . . . . . . . . . . . 77
fluticasone lot 0.05% . . . . . . . . . . . . . . 77
fluticasone oin 0.005% . . . . . . . . . . . . 77
fluticasone spr 50mcg . . . . . . . . . . . . . 91
fluvoxamine tab 100mg . . . . . . . . . . . . 29
fluvoxamine tab 25mg . . . . . . . . . . . . . 29
fluvoxamine tab 50mg . . . . . . . . . . . . . 29
FML . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
FML FORTE SUS 0.25% . . . . . . . . . . . . . 90
FML OIN 0.1% . . . . . . . . . . . . . . . . . . . . 90
FOCALIN . . . . . . . . . . . . . . . . . . . . . . . . 69
fomepizole inj 1gm/ml . . . . . . . . . . . . . 95
fondaparinux sol 10/0.8ml . . . . . . . . . . 55
fondaparinux sol 2.5/0.5ml . . . . . . . . . 55
formoterol - mometasone . . . . . . . . . . 94
FORTEO SOL 600/2.4ML . . . . . . . . . . . . 88
FOSAMAX . . . . . . . . . . . . . . . . . . . . . . . 88
fosamprenavir . . . . . . . . . . . . . . . . . . . 50
foscarnet . . . . . . . . . . . . . . . . . . . . . . . . 47
FOSCARNET INJ 24MG/ML . . . . . . . . . . 47
fosinop/hctz tab 10/12.5mg . . . . . . . . . 60
fosinop/hctz tab 20/12.5mg . . . . . . . . . 60
fosinopril tab 10mg . . . . . . . . . . . . . . . 60
FOSRENOL CHW 1000MG . . . . . . . . . . 76
FOSRENOL CHW 500MG . . . . . . . . . . . 76
FOSRENOL CHW 750MG . . . . . . . . . . . 76
FRAGMIN INJ 10000/ML . . . . . . . . . . . . 55
FRAGMIN INJ 12500UNT . . . . . . . . . . . 55
FRAGMIN INJ 15000UNT . . . . . . . . . . . 55
FRAGMIN INJ 18000UNT . . . . . . . . . . . 55
FRAGMIN INJ 2500/0.2ML . . . . . . . . . . 55
FRAGMIN INJ 5000/0.2ML . . . . . . . . . . 55
fulvestrant . . . . . . . . . . . . . . . . . . . . . . 37
FUNGIZONE . . . . . . . . . . . . . . . . . . . . . . 33
furosemide inj 10mg/ml . . . . . . . . . . . . 66
furosemide sol 10mg/ml . . . . . . . . . . . 66
furosemide sol 8mg/ml . . . . . . . . . . . . 66
furosemide tab 20mg . . . . . . . . . . . . . . 66
FUSILEV . . . . . . . . . . . . . . . . . . . . . . . . . 38
FUZEON INJ 90MG . . . . . . . . . . . . . . . . 49
FYCOMPA TAB 10MG . . . . . . . . . . . . . . 23
FYCOMPA TAB 12MG . . . . . . . . . . . . . . 23
FYCOMPA TAB 2MG . . . . . . . . . . . . . . . 23
FYCOMPA TAB 4MG . . . . . . . . . . . . . . . 23
FYCOMPA TAB 6MG . . . . . . . . . . . . . . . 23
FYCOMPA TAB 8MG . . . . . . . . . . . . . . . 23
gabapentin cap 300mg . . . . . . . . . . . . 23
gabapentin cap 400mg . . . . . . . . . . . . 23
gabapentin sol 250/5ml . . . . . . . . . . . . 23
gabapentin tab 600mg . . . . . . . . . . . . 23
gabapentin tab 800mg . . . . . . . . . . . . 23
GABITRIL . . . . . . . . . . . . . . . . . . . . . . . . 24
GABITRIL TAB 12MG . . . . . . . . . . . . . . . 23
GABITRIL TAB 16MG . . . . . . . . . . . . . . . 23
galantamine cap 16mg er . . . . . . . . . . 26
galantamine cap 24mg er . . . . . . . . . . 26
galantamine cap 8mg er . . . . . . . . . . . 26
galantamine sol 4mg/ml . . . . . . . . . . . 26
galantamine tab 12mg . . . . . . . . . . . . 26
galantamine tab 4mg . . . . . . . . . . . . . 26
galantamine tab 8mg . . . . . . . . . . . . . 26
galsulfase . . . . . . . . . . . . . . . . . . . . . . . 72
GAMASTAN S/D INJ . . . . . . . . . . . . . . . 86
GAMMAGARD INJ 2.5GM/25ML . . . . . 86
ganciclovir . . . . . . . . . . . . . . . . . . . . . . . 47
ganciclovir inj 500mg . . . . . . . . . . . . . . 47
GARDASIL 9 INJ . . . . . . . . . . . . . . . . . . 86
GARDASIL INJ . . . . . . . . . . . . . . . . . . . . 86
GASTROCROM . . . . . . . . . . . . . . . . . . . 93
gatifloxacin sol 0.5% . . . . . . . . . . . . . . 20
GATTEX KIT 5MG . . . . . . . . . . . . . . . . . 73
GAUZE PAD 2X2 . . . . . . . . . . . . . . . . . . 54
GAUZE PADS AND DRESSING - 2X2 . . . 54
gavilyte-c sol . . . . . . . . . . . . . . . . . . . . . 74
gavilyte-g sol . . . . . . . . . . . . . . . . . . . . 74
gavilyte-n sol flav pk . . . . . . . . . . . . . . 74
gemfibrozil tab 600mg . . . . . . . . . . . . 67
generlac sol 10gm/15ml . . . . . . . . . . . . 74
gengraf cap 100mg . . . . . . . . . . . . . . . 85
gengraf cap 25mg . . . . . . . . . . . . . . . . 85
gengraf sol 100mg/ml . . . . . . . . . . . . . 85
GENOTROPIN INJ 0.2MG . . . . . . . . . . . 79
GENOTROPIN INJ 12MG . . . . . . . . . . . . 79
GENOTROPIN INJ 1MG . . . . . . . . . . . . . 79
GENTAK . . . . . . . . . . . . . . . . . . . . . . . . . 15
gentak oin 0.3% . . . . . . . . . . . . . . . . . . 15
gentam/nacl inj 100mg . . . . . . . . . . . . 15
gentam/nacl inj 80mg . . . . . . . . . . . . . 15
gentamicin . . . . . . . . . . . . . . . . . . . . . . 15
G
gabapentin cap 100mg . . . . . . . . . . . . 23 gentamicin cre 0.1% . . . . . . . . . . . . . . 15
123
Index of Drugs
gentamicin oin 0.1% . . . . . . . . . . . . . . 15
gentamicin sol 0.3% . . . . . . . . . . . . . . . 15
GEODON . . . . . . . . . . . . . . . . . . . . . . . . 46
GEODON INJ 20MG . . . . . . . . . . . . . . . 45
GILENYA CAP 0.5MG . . . . . . . . . . . . . . 70
GILOTRIF TAB 20MG . . . . . . . . . . . . . . . 39
GILOTRIF TAB 30MG . . . . . . . . . . . . . . . 39
GILOTRIF TAB 40MG . . . . . . . . . . . . . . . 39
glatiramer . . . . . . . . . . . . . . . . . . . . . . . 70
GLEEVEC TAB 100MG . . . . . . . . . . . . . . 39
GLEEVEC TAB 400MG . . . . . . . . . . . . . . 39
glimepiride tab 1mg . . . . . . . . . . . . . . 52
glip/metform tab 2.5-250mg . . . . . . . . 52
glip/metform tab 2.5-500mg . . . . . . . . 52
glip/metform tab 5-500mg . . . . . . . . . 52
glipizide er tab 10mg . . . . . . . . . . . . . . 52
glipizide er tab 2.5mg . . . . . . . . . . . . . 52
glipizide er tab 5mg . . . . . . . . . . . . . . . 52
glipizide tab 10mg . . . . . . . . . . . . . . . . 52
glipizide tab 5mg . . . . . . . . . . . . . . . . . 52
globulin, immune . . . . . . . . . . . . . . . . . 86
GLUCAGEN INJ HYPOKIT . . . . . . . . . . . 54
glucagon . . . . . . . . . . . . . . . . . . . . . . . . 54
GLUCAGON KIT 1MG . . . . . . . . . . . . . . 54
glucagon rdna . . . . . . . . . . . . . . . . . . . 54
GLUCOPHAGE . . . . . . . . . . . . . . . . . . . . 53
GLUCOPHAGE XL . . . . . . . . . . . . . . . . . 53
GLUCOTROL . . . . . . . . . . . . . . . . . . . . . 52
GLUCOTROL XL . . . . . . . . . . . . . . . . . . . 52
glycerol phenylbutyrate . . . . . . . . . . . . 72
glycopyrrol tab 1mg . . . . . . . . . . . . . . . 72
GLYSET TAB 100MG . . . . . . . . . . . . . . . 52
GLYSET TAB 25MG . . . . . . . . . . . . . . . . 52
GLYSET TAB 50MG . . . . . . . . . . . . . . . . 52
GOLYTELY . . . . . . . . . . . . . . . . . . . . . . . 74
granisetron inj 0.1mg/ml . . . . . . . . . . . 32
granisetron inj 1mg/ml . . . . . . . . . . . . 32
granisetron tab 1mg . . . . . . . . . . . . . . 32
GRANIX INJ 300/0.5ML . . . . . . . . . . . . . 57
GRANIX INJ 480/0.8ML . . . . . . . . . . . . . 57
GRIFULVIN V . . . . . . . . . . . . . . . . . . . . . 33
griseofulvin sus 125/5ml . . . . . . . . . . . . 33
griseofulvin tab micr 500mg . . . . . . . . 33
guanfacine tab 1mg er . . . . . . . . . . . . 69
guanidine . . . . . . . . . . . . . . . . . . . . . . . 35
GUANIDINE TAB 125MG . . . . . . . . . . . 35
124
H
HUMIRA KIT 40MG/0.8ML . . . . . . . . . . 85
HUMIRA PEN KIT CROHNS . . . . . . . . . . 85
HUMULIN INJ 70/30 . . . . . . . . . . . . . . . 54
HUMULIN N INJ U-100 . . . . . . . . . . . . . 54
HUMULIN N PN INJ U-100 . . . . . . . . . . 54
HUMULIN PEN INJ 70/30 . . . . . . . . . . . 54
HUMULIN R INJ U-100 . . . . . . . . . . . . . 54
HYCAMTIN . . . . . . . . . . . . . . . . . . . . . . 38
hydralazine tab 100mg . . . . . . . . . . . . 68
hydralazine tab 10mg . . . . . . . . . . . . . 68
HYDREA . . . . . . . . . . . . . . . . . . . . . . . . 37
hydrochlorot cap 12.5mg . . . . . . . . . . . 66
hydrochlorot tab 12.5mg . . . . . . . . . . . 66
hydrochlorot tab 25mg . . . . . . . . . . . . 66
hydrochlorot tab 50mg . . . . . . . . . . . . 66
hydroco/apap tab 10-325mg . . . . . . . . 13
hydroco/apap tab 5-300mg . . . . . . . . . 13
hydroco/apap tab 5-325mg . . . . . . . . . 13
hydroco/apap tab 7.5-300mg . . . . . . . 13
hydroco/apap tab 7.5-325mg . . . . . . . 13
hydrocort cre 1% . . . . . . . . . . . . . . . . . 77
hydrocort cre 2.5% . . . . . . . . . . . . . . . . 77
hydrocort ene 100mg . . . . . . . . . . . . . . 77
hydrocort lot 2.5% . . . . . . . . . . . . . . . . 77
hydrocort oin 1% . . . . . . . . . . . . . . . . . 77
hydrocort oin 2.5% . . . . . . . . . . . . . . . 78
hydrocort tab 10mg . . . . . . . . . . . . . . . 78
hydrocort tab 20mg . . . . . . . . . . . . . . . 78
hydrocort tab 5mg . . . . . . . . . . . . . . . . 78
hydrocortisone . . . . . . . . . . . . . . . . . . . 77
HYDRODIURIL . . . . . . . . . . . . . . . . . . . . 66
hydromorphon inj 500/50ml . . . . . . . . 13
hydromorphon tab 2mg . . . . . . . . . . . 13
hydroxychlor tab 200mg . . . . . . . . . . . 41
hydroxyurea . . . . . . . . . . . . . . . . . . . . . 37
hydroxyurea cap 500mg . . . . . . . . . . . 37
hydroxyz hcl inj 50mg/ml . . . . . . . . . . . 51
hydroxyz hcl tab 50mg . . . . . . . . . . . . . 51
hydroxyz pam cap 25mg . . . . . . . . . . . 51
hydroxyzine . . . . . . . . . . . . . . . . . . . . . 51
HYTONE . . . . . . . . . . . . . . . . . . . . . . . . 77
HYTRIN . . . . . . . . . . . . . . . . . . . . . . . . . 59
HYZAAR . . . . . . . . . . . . . . . . . . . . . . . . 59
haemophilus b conjugate vaccine . . . . 86
haemophilus b polysaccharide conj . . 86
vacc - hepatitis
haemophilus b polysaccharide conj . . 87
vaccine
HALCION . . . . . . . . . . . . . . . . . . . . . . . . 51
HALDOL . . . . . . . . . . . . . . . . . . . . . . . . 44
HALDOL DEC . . . . . . . . . . . . . . . . . . . . . 44
HALDOL LAC . . . . . . . . . . . . . . . . . . . . . 44
halobetasol cre 0.05% . . . . . . . . . . . . . 77
halobetasol oin 0.05% . . . . . . . . . . . . . 77
haloper dec inj 100mg/ml . . . . . . . . . . 44
haloper dec inj 50mg/ml . . . . . . . . . . . 44
haloper lac inj 5mg/ml . . . . . . . . . . . . . 44
haloperidol con 2mg/ml . . . . . . . . . . . . 44
haloperidol tab 0.5mg . . . . . . . . . . . . . 44
haloperidol tab 10mg . . . . . . . . . . . . . 44
haloperidol tab 1mg . . . . . . . . . . . . . . 44
haloperidol tab 20mg . . . . . . . . . . . . . 44
HAVRIX INJ 1440UNIT . . . . . . . . . . . . . 86
HAVRIX INJ 720UNIT . . . . . . . . . . . . . . 86
hc valerate cre 0.2% . . . . . . . . . . . . . . . 77
hc valerate oin 0.2% . . . . . . . . . . . . . . 77
hc/acet acid sol . . . . . . . . . . . . . . . . . . . 91
HECTOROL . . . . . . . . . . . . . . . . . . . . . . 88
HEP SOD/D5W INJ 25000UNT . . . . . . . 55
heparin . . . . . . . . . . . . . . . . . . . . . . . . . 55
heparin sod inj 1000/ml . . . . . . . . . . . . 56
heparin sod inj 10000/ml . . . . . . . . . . . 56
heparin sod inj 20000/ml . . . . . . . . . . . 56
heparin sod inj 5000/ml . . . . . . . . . . . . 56
hepatamine sol 8% . . . . . . . . . . . . . . . 96
HEPATASOL . . . . . . . . . . . . . . . . . . . . . . 96
hepatitis a - hepatitis b virus . . . . . . . . 87
vaccine
hepatitis a virus vaccine . . . . . . . . . . . . 86
hepatitis b virus vaccine . . . . . . . . . . . . 86
HEPSERA TAB 10MG . . . . . . . . . . . . . . . 47
HERCEPTIN INJ 440MG . . . . . . . . . . . . . 41
HETLIOZ CAP 20MG . . . . . . . . . . . . . . . 95
HEXALEN CAP 50MG . . . . . . . . . . . . . . 36
HIPREX . . . . . . . . . . . . . . . . . . . . . . . . . 16
HUMALOG INJ 100/ML . . . . . . . . . . . . . 54
HUMALOG MIX INJ 50/50 . . . . . . . . . . 54
HUMALOG MIX INJ 50/50KWP . . . . . . 54
HUMALOG MIX INJ 75/25KWP . . . . . . 54 I
HUMALOG MIX SUS 75/25 . . . . . . . . . . 54 ibandronate inj 3mg/3ml . . . . . . . . . . . 88
human papillomavirus . . . . . . . . . . . . . 86 ibandronate tab 150mg . . . . . . . . . . . . 88
HUMIRA KIT 20MG/0.4ML . . . . . . . . . . 85 IBRANCE CAP 100MG . . . . . . . . . . . . . . 37
IBRANCE CAP 125MG . . . . . . . . . . . . . . 37
Index of Drugs
IBRANCE CAP 75MG . . . . . . . . . . . . . . . 37
ibrutinib . . . . . . . . . . . . . . . . . . . . . . . . 39
ibuprofen sus 100/5ml . . . . . . . . . . . . . 11
ibuprofen tab 400mg . . . . . . . . . . . . . . 11
ibuprofen tab 600mg . . . . . . . . . . . . . . 11
ibuprofen tab 800mg . . . . . . . . . . . . . . 11
icatibant . . . . . . . . . . . . . . . . . . . . . . . . 84
ICLUSIG TAB 15MG . . . . . . . . . . . . . . . . 39
ICLUSIG TAB 45MG . . . . . . . . . . . . . . . . 39
idelalisib . . . . . . . . . . . . . . . . . . . . . . . . 40
idursulfase . . . . . . . . . . . . . . . . . . . . . . 72
ILARIS INJ 180MG . . . . . . . . . . . . . . . . . 86
iloperidone . . . . . . . . . . . . . . . . . . . . . . 44
iloprost . . . . . . . . . . . . . . . . . . . . . . . . . 94
imatinib . . . . . . . . . . . . . . . . . . . . . . . . . 39
IMBRUVICA CAP 140MG . . . . . . . . . . . 39
IMDUR . . . . . . . . . . . . . . . . . . . . . . . . . . 68
imiglucerase . . . . . . . . . . . . . . . . . . . . . 72
imipenem-cilastatin . . . . . . . . . . . . . . . 18
imipenem/cil inj 500mg . . . . . . . . . . . . 18
imipram hcl tab 10mg . . . . . . . . . . . . . 31
imipram pam cap 100mg . . . . . . . . . . . 31
imipram pam cap 75mg . . . . . . . . . . . . 31
imiquimod cre 5% . . . . . . . . . . . . . . . . 71
IMITREX . . . . . . . . . . . . . . . . . . . . . . . . . 35
immune globulin (human) . . . . . . . . . . 86
IMODIUM . . . . . . . . . . . . . . . . . . . . . . . 73
IMOVAX RABIE INJ 2.5/ML . . . . . . . . . . 87
IMURAN . . . . . . . . . . . . . . . . . . . . . . . . 84
INCRELEX INJ 40MG/4ML . . . . . . . . . . . 79
INCRUSE ELPT INH 62.5MCG . . . . . . . . 92
indacaterol . . . . . . . . . . . . . . . . . . . . . . 92
indapamide tab 1.25mg . . . . . . . . . . . . 66
indapamide tab 2.5mg . . . . . . . . . . . . . 66
INDERAL . . . . . . . . . . . . . . . . . . . . . . . . 63
INDERAL LA . . . . . . . . . . . . . . . . . . . . . 63
indinavir . . . . . . . . . . . . . . . . . . . . . . . . 50
INFANRIX INJ . . . . . . . . . . . . . . . . . . . . 87
INFLAMASE . . . . . . . . . . . . . . . . . . . . . . 90
infliximab . . . . . . . . . . . . . . . . . . . . . . . 85
INLYTA TAB 1MG . . . . . . . . . . . . . . . . . 39
INLYTA TAB 5MG . . . . . . . . . . . . . . . . . 39
INSPRA . . . . . . . . . . . . . . . . . . . . . . . . . 66
insulin detemir . . . . . . . . . . . . . . . . . . . 54
insulin glargine . . . . . . . . . . . . . . . . . . . 54
insulin human (regular) . . . . . . . . . . . . 54
insulin human (regular) - insulin . . . . . 54
human, isophane
insulin human, isophane (nph) . . . . . . 54
insulin lispro . . . . . . . . . . . . . . . . . . . . . 54
insulin pen needle . . . . . . . . . . . . . . . . 54
insulin syrg mis 0.3/31g . . . . . . . . . . . . 54
insulin syrg mis 0.5/30g . . . . . . . . . . . . 54
insulin syrg mis 1ml/29g . . . . . . . . . . . . 54
insulin syrg mis 1ml/31g . . . . . . . . . . . . 54
insulin syringe (disp) u-100 . . . . . . . . . 54
INTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
INTELENCE TAB 100MG . . . . . . . . . . . . 48
INTELENCE TAB 200MG . . . . . . . . . . . . 48
INTELENCE TAB 25MG . . . . . . . . . . . . . 48
interferon alfa-2b . . . . . . . . . . . . . . . . . 47
interferon beta-1a . . . . . . . . . . . . . . . . 70
interferon beta-1b . . . . . . . . . . . . . . . . 70
interferon gamma-1b . . . . . . . . . . . . . 86
intralipid . . . . . . . . . . . . . . . . . . . . . . . . 96
intralipid inj 20% . . . . . . . . . . . . . . . . . 96
INTRON-A INJ 10MU . . . . . . . . . . . . . . . 47
INTRON-A INJ 18MU . . . . . . . . . . . . . . . 47
INTUNIV . . . . . . . . . . . . . . . . . . . . . . . . 69
INVANZ INJ 1GM . . . . . . . . . . . . . . . . . 18
INVEGA SUST INJ 117/0.75ML . . . . . . . 45
INVEGA SUST INJ 156MG/ML . . . . . . . . 45
INVEGA SUST INJ 234/1.5ML . . . . . . . . 45
INVEGA SUST INJ 39/0.25ML . . . . . . . . 45
INVEGA SUST INJ 78/0.5ML . . . . . . . . . 45
INVEGA TAB 1.5MG . . . . . . . . . . . . . . . 45
INVEGA TAB 3MG . . . . . . . . . . . . . . . . . 45
INVEGA TAB 6MG . . . . . . . . . . . . . . . . . 45
INVEGA TAB 9MG . . . . . . . . . . . . . . . . . 45
INVIRASE CAP 200MG . . . . . . . . . . . . . 50
INVIRASE TAB 500MG . . . . . . . . . . . . . 50
INVOKANA TAB 100MG . . . . . . . . . . . . 53
INVOKANA TAB 300MG . . . . . . . . . . . . 53
IOPIDINE . . . . . . . . . . . . . . . . . . . . . . . . 90
ipilimumab . . . . . . . . . . . . . . . . . . . . . . 41
IPOL INJ INACTIVE . . . . . . . . . . . . . . . . 87
IPRATROPIUM . . . . . . . . . . . . . . . . . . . . 92
ipratropium sol 0.02%inh . . . . . . . . . . 92
ipratropium spr 0.03% . . . . . . . . . . . . . 92
ipratropium spr 0.06% . . . . . . . . . . . . . 92
irbesar/hctz tab 150-12.5mg . . . . . . . . 59
irbesar/hctz tab 300-12.5mg . . . . . . . . 59
irbesartan tab 150mg . . . . . . . . . . . . . . 59
irbesartan tab 300mg . . . . . . . . . . . . . . 59
irbesartan tab 75mg . . . . . . . . . . . . . . . 59
ISENTRESS CHW 100MG . . . . . . . . . . . . 48
ISENTRESS CHW 25MG . . . . . . . . . . . . . 48
ISENTRESS POW 100MG . . . . . . . . . . . . 48
ISENTRESS TAB 400MG . . . . . . . . . . . . . 48
ISMO, MONOKET . . . . . . . . . . . . . . . . . 68
isocarboxazid . . . . . . . . . . . . . . . . . . . . 28
isoniazid - rifampin . . . . . . . . . . . . . . . 35
isoniazid syp 50mg/5ml . . . . . . . . . . . . 35
isoniazid tab 100mg . . . . . . . . . . . . . . . 35
isoniazid tab 300mg . . . . . . . . . . . . . . . 35
isopropyl alcohol pad . . . . . . . . . . . . . . 54
ISORDIL . . . . . . . . . . . . . . . . . . . . . . . . . 68
isosorb din tab 10mg . . . . . . . . . . . . . . 68
isosorb din tab 40mg er . . . . . . . . . . . . 68
isosorb din tab 5mg . . . . . . . . . . . . . . . 68
isosorb mono tab 10mg . . . . . . . . . . . . 68
isosorb mono tab 120mg er . . . . . . . . . 68
isosorb mono tab 20mg . . . . . . . . . . . . 68
isosorb mono tab 30mg er . . . . . . . . . . 68
isosorb mono tab 60mg er . . . . . . . . . . 68
isotretinoin . . . . . . . . . . . . . . . . . . . . . . 71
isradipine cap 2.5mg . . . . . . . . . . . . . . 64
isradipine cap 5mg . . . . . . . . . . . . . . . . 64
ISTODAX INJ 10MG . . . . . . . . . . . . . . . 37
itraconazole cap 100mg . . . . . . . . . . . . 33
ivacaftor . . . . . . . . . . . . . . . . . . . . . . . . 93
ivermectin . . . . . . . . . . . . . . . . . . . . . . . 41
IXIARO INJ . . . . . . . . . . . . . . . . . . . . . . . 87
J
JAKAFI TAB 10MG . . . . . . . . . . . . . . . . 39
JAKAFI TAB 15MG . . . . . . . . . . . . . . . . 39
JAKAFI TAB 20MG . . . . . . . . . . . . . . . . 39
JAKAFI TAB 25MG . . . . . . . . . . . . . . . . 39
JAKAFI TAB 5MG . . . . . . . . . . . . . . . . . 39
jantoven tab 10mg . . . . . . . . . . . . . . . . 56
jantoven tab 1mg . . . . . . . . . . . . . . . . . 56
jantoven tab 2.5mg . . . . . . . . . . . . . . . 56
jantoven tab 2mg . . . . . . . . . . . . . . . . . 56
jantoven tab 3mg . . . . . . . . . . . . . . . . . 56
jantoven tab 4mg . . . . . . . . . . . . . . . . . 56
jantoven tab 5mg . . . . . . . . . . . . . . . . . 56
jantoven tab 6mg . . . . . . . . . . . . . . . . . 56
jantoven tab 7.5mg . . . . . . . . . . . . . . . 56
JANUMET TAB 50-1000MG . . . . . . . . . 53
JANUMET TAB 50-500MG . . . . . . . . . . 53
JANUMET XR TAB 100-1000MG . . . . . . 53
JANUMET XR TAB 50-1000MG . . . . . . . 53
JANUMET XR TAB 50-500MG . . . . . . . . 53
JANUVIA TAB 100MG . . . . . . . . . . . . . . 53
JANUVIA TAB 25MG . . . . . . . . . . . . . . . 53
JANUVIA TAB 50MG . . . . . . . . . . . . . . . 53
japanese encephalitis virus . . . . . . . . . 87
vaccine
JENTADUETO TAB 2.5-1000MG . . . . . . 53
JENTADUETO TAB 2.5-500MG . . . . . . . 53
JENTADUETO TAB 2.5-850MG . . . . . . . 53
junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . 80
125
Index of Drugs
junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . 80
junel fe tab 1.5/30 . . . . . . . . . . . . . . . . 80
junel fe tab 1/20 . . . . . . . . . . . . . . . . . . 80
JUXTAPID CAP 5MG . . . . . . . . . . . . . . . 68
K
KADCYLA INJ 100MG . . . . . . . . . . . . . . 37
KALETRA SOL . . . . . . . . . . . . . . . . . . . . 50
KALETRA TAB 100-25MG . . . . . . . . . . . 50
KALETRA TAB 200-50MG . . . . . . . . . . . 50
KALYDECO PAK 50MG . . . . . . . . . . . . . 93
KALYDECO PAK 75MG . . . . . . . . . . . . . 93
KALYDECO TAB 150MG . . . . . . . . . . . . 93
kariva tab 28 day . . . . . . . . . . . . . . . . . 80
KAYEXALATE - SPS . . . . . . . . . . . . . . . . 95
kcl / sodium chloride . . . . . . . . . . . . . . 96
kcl in nacl . . . . . . . . . . . . . . . . . . . . . . . 96
kcl/d5w . . . . . . . . . . . . . . . . . . . . . . . . . 96
kcl/d5w inj 0.15% . . . . . . . . . . . . . . . . . 96
kcl/d5w inj 0.3% . . . . . . . . . . . . . . . . . . 96
kcl/d5w/lr . . . . . . . . . . . . . . . . . . . . . . . 95
kcl/d5w/lr inj 0.15% . . . . . . . . . . . . . . . 96
kcl/d5w/nacl . . . . . . . . . . . . . . . . . . . . . 96
kcl/d5w/nacl inj .075/.45% . . . . . . . . . . 96
kcl/d5w/nacl inj .15/.33% . . . . . . . . . . . 96
kcl/d5w/nacl inj .15/.45% . . . . . . . . . . . 96
kcl/d5w/nacl inj .22/.45% . . . . . . . . . . . 96
kcl/d5w/nacl inj 0.15/0.2% . . . . . . . . . . 96
kcl/d5w/nacl inj 0.15/0.9% . . . . . . . . . . 96
kcl/d5w/nacl inj 0.3/0.45% . . . . . . . . . . 96
kcl/nacl inj 0.15-0.9% . . . . . . . . . . . . . . 96
kcl/sodium chloride . . . . . . . . . . . . . . . 96
KEFLEX . . . . . . . . . . . . . . . . . . . . . . . . . 18
kelnor tab 1/35 . . . . . . . . . . . . . . . . . . . 80
KEMSTRO, LIORESAL . . . . . . . . . . . . . . 46
KENALOG-ORABORALONE . . . . . . . . . 70
KEPPRA . . . . . . . . . . . . . . . . . . . . . . . . . 21
KEPPRA XR . . . . . . . . . . . . . . . . . . . . . . 22
KERLONE . . . . . . . . . . . . . . . . . . . . . . . . 62
ketoconazole cre 2% . . . . . . . . . . . . . . 33
ketoconazole sha 2% . . . . . . . . . . . . . . 33
ketoconazole tab 200mg . . . . . . . . . . . 33
KETOPROFEN . . . . . . . . . . . . . . . . . . . . 12
ketoprofen cap 200mg er . . . . . . . . . . 12
ketoprofen cap 50mg . . . . . . . . . . . . . 12
ketoprofen cap 75mg . . . . . . . . . . . . . 12
KETOROLAC . . . . . . . . . . . . . . . . . . . . . 90
ketorolac sol 0.4% . . . . . . . . . . . . . . . . 90
ketorolac sol 0.5% . . . . . . . . . . . . . . . . 90
KEYTRUDA SOL 50MG . . . . . . . . . . . . . 41
KHEDEZLA TAB 100MG ER . . . . . . . . . . 29
KHEDEZLA TAB 50MG ER . . . . . . . . . . . 29
KINERET INJ . . . . . . . . . . . . . . . . . . . . . 85
126
kionex pow . . . . . . . . . . . . . . . . . . . . . . 95
KLARON . . . . . . . . . . . . . . . . . . . . . . . . 21
KLONOPIN . . . . . . . . . . . . . . . . . . . . . . . 22
KLONOPIN ODT . . . . . . . . . . . . . . . . . . 22
klor-con 10 tab 10meq er . . . . . . . . . . 96
klor-con 8 tab 8meq er . . . . . . . . . . . . 96
klor-con m20 tab 20meq er . . . . . . . . . 96
KOMBIGLYZE TAB 2.5-1000MG . . . . . . 53
KOMBIGLYZE TAB 5-1000MG . . . . . . . 53
KOMBIGLYZE TAB 5-500MG . . . . . . . . 53
KORLYM TAB 300MG . . . . . . . . . . . . . . 54
KUVAN TAB 100MG . . . . . . . . . . . . . . . 72
KYNAMRO INJ 200MG/ML . . . . . . . . . . 68
KYTRIL . . . . . . . . . . . . . . . . . . . . . . . . . . 32
L
labetalol inj 5mg/ml . . . . . . . . . . . . . . . 62
labetalol tab 100mg . . . . . . . . . . . . . . . 62
labetalol tab 200mg . . . . . . . . . . . . . . . 62
labetalol tab 300mg . . . . . . . . . . . . . . . 62
LAC-HYDRIN . . . . . . . . . . . . . . . . . . . . . 71
lacosamide . . . . . . . . . . . . . . . . . . . . . . 26
lactated rigners . . . . . . . . . . . . . . . . . . 96
lactated rin . . . . . . . . . . . . . . . . . . . . . . 96
lactated rin sol . . . . . . . . . . . . . . . . . . . 96
lactated ringers . . . . . . . . . . . . . . . . . . 96
lactulose . . . . . . . . . . . . . . . . . . . . . . . . 74
lactulose sol 10gm/15ml . . . . . . . . . . . . 74
LAMICTAL . . . . . . . . . . . . . . . . . . . . . . . 24
LAMICTAL CHEWABLE . . . . . . . . . . . . . 24
LAMICTAL ODT . . . . . . . . . . . . . . . . . . . 25
LAMISIL . . . . . . . . . . . . . . . . . . . . . . . . . 34
lamivud/zido tab 150-300mg . . . . . . . . 49
lamivudine . . . . . . . . . . . . . . . . . . . . . . 47
lamivudine sol 10mg/ml . . . . . . . . . . . . 49
lamivudine tab 100mg . . . . . . . . . . . . . 49
lamotrigine chw 25mg . . . . . . . . . . . . . 24
lamotrigine chw 5mg . . . . . . . . . . . . . . 24
lamotrigine tab 100mg . . . . . . . . . . . . 24
lamotrigine tab 25mg . . . . . . . . . . . . . 25
lamotrigine tab odt 25mg . . . . . . . . . . 25
lamotrigine tab odt 50mg . . . . . . . . . . 25
lamotrigine tab odt/100mg . . . . . . . . . 25
lamotrigine tab odt/200mg . . . . . . . . . 25
LANOXIN . . . . . . . . . . . . . . . . . . . . . . . . 65
lanreotide . . . . . . . . . . . . . . . . . . . . . . . 83
lansoprazole cap 15mg dr . . . . . . . . . . 74
lansoprazole cap 30mg dr . . . . . . . . . . 74
lanthanum . . . . . . . . . . . . . . . . . . . . . . 76
LANTUS INJ 100/ML . . . . . . . . . . . . . . . 54
lapatinib . . . . . . . . . . . . . . . . . . . . . . . . 40
LARIAM . . . . . . . . . . . . . . . . . . . . . . . . . 41
laronidase . . . . . . . . . . . . . . . . . . . . . . . 72
LASIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
latanoprost sol 0.005% . . . . . . . . . . . . 90
LATUDA TAB 120MG . . . . . . . . . . . . . . 45
LATUDA TAB 20MG . . . . . . . . . . . . . . . 45
LATUDA TAB 40MG . . . . . . . . . . . . . . . 45
LATUDA TAB 60MG . . . . . . . . . . . . . . . 45
LATUDA TAB 80MG . . . . . . . . . . . . . . . 45
LEENA, ARANELLE . . . . . . . . . . . . . . . . 80
leflunomide tab 10mg . . . . . . . . . . . . . 86
leflunomide tab 20mg . . . . . . . . . . . . . 86
lenalidomide . . . . . . . . . . . . . . . . . . . . . 36
lenvatinib . . . . . . . . . . . . . . . . . . . . . . . 39
LENVIMA CAP 10MG . . . . . . . . . . . . . . 39
LENVIMA CAP 14MG . . . . . . . . . . . . . . 39
LENVIMA CAP 20MG . . . . . . . . . . . . . . 40
LENVIMA CAP 24MG . . . . . . . . . . . . . . 40
lessina . . . . . . . . . . . . . . . . . . . . . . . . . . 80
LETAIRIS TAB 10MG . . . . . . . . . . . . . . . 93
LETAIRIS TAB 5MG . . . . . . . . . . . . . . . . 93
letrozole tab 2.5mg . . . . . . . . . . . . . . . 38
leucovor ca inj 100mg . . . . . . . . . . . . . 37
leucovor ca inj 350mg . . . . . . . . . . . . . 38
leucovor ca tab 10mg . . . . . . . . . . . . . . 38
leucovor ca tab 5mg . . . . . . . . . . . . . . . 38
LEUCOVORIN . . . . . . . . . . . . . . . . . . . . 37
LEUKERAN TAB 2MG . . . . . . . . . . . . . . 36
LEUKINE INJ 250MCG . . . . . . . . . . . . . . 57
leuprolide acetate . . . . . . . . . . . . . . . . 83
leuprolide dep ped . . . . . . . . . . . . . . . . 83
leuprolide depot . . . . . . . . . . . . . . . . . 83
leuprolide inj 1mg/0.2ml . . . . . . . . . . . 83
levalbuterol hfa . . . . . . . . . . . . . . . . . . 93
levalbuterol neb 0.31mg . . . . . . . . . . . 92
levalbuterol neb 0.63mg . . . . . . . . . . . 92
levalbuterol neb 1.25/0.5ml . . . . . . . . . 92
LEVAQUIN . . . . . . . . . . . . . . . . . . . . . . . 20
LEVEMIR INJ . . . . . . . . . . . . . . . . . . . . . 54
levetiraceta inj 10mg/ml . . . . . . . . . . . 21
levetiraceta inj 15mg/ml . . . . . . . . . . . 21
levetiraceta inj 5mg/ml . . . . . . . . . . . . 22
levetiraceta sol 100mg/ml . . . . . . . . . . 22
levetiraceta tab 1000mg . . . . . . . . . . . 22
levetiraceta tab 250mg . . . . . . . . . . . . 22
levetiraceta tab 500mg er . . . . . . . . . . 22
levetiraceta tab 750mg er . . . . . . . . . . 22
Index of Drugs
levetiracetm inj 500/5ml . . . . . . . . . . . 22
LEVO-DROMORAN . . . . . . . . . . . . . . . . 12
levobunolol sol 0.5% . . . . . . . . . . . . . . 90
levocarnitin sol 1gm/10ml . . . . . . . . . . 95
levocarnitin tab 330mg . . . . . . . . . . . . 95
levocetirizi tab 5mg . . . . . . . . . . . . . . . 92
levoflox/d5w inj 500/100ml . . . . . . . . . 20
levofloxacin inj 25mg/ml . . . . . . . . . . . 20
levofloxacin sol 0.5% . . . . . . . . . . . . . . 20
levofloxacin sol 25mg/ml . . . . . . . . . . . 20
levofloxacin tab 250mg . . . . . . . . . . . . 20
levoleucovor inj 50mg . . . . . . . . . . . . . 38
levomilnacipran . . . . . . . . . . . . . . . . . . 29
levora-28 tab 0.15/30 . . . . . . . . . . . . . . 80
levorphanol tab 2mg . . . . . . . . . . . . . . 12
LEVOTHROID, SYNTHROID . . . . . . . . . 82
levothyroxin tab 100mcg . . . . . . . . . . . 82
levothyroxin tab 25mcg . . . . . . . . . . . . 82
levothyroxine . . . . . . . . . . . . . . . . . . . . 82
levoxyl tab 100mcg . . . . . . . . . . . . . . . 82
levoxyl tab 112mcg . . . . . . . . . . . . . . . 82
levoxyl tab 125mcg . . . . . . . . . . . . . . . 82
levoxyl tab 137mcg . . . . . . . . . . . . . . . 82
levoxyl tab 150mcg . . . . . . . . . . . . . . . 82
levoxyl tab 175mcg . . . . . . . . . . . . . . . 82
levoxyl tab 200mcg . . . . . . . . . . . . . . . 82
levoxyl tab 25mcg . . . . . . . . . . . . . . . . 82
levoxyl tab 50mcg . . . . . . . . . . . . . . . . 82
levoxyl tab 75mcg . . . . . . . . . . . . . . . . 82
levoxyl tab 88mcg . . . . . . . . . . . . . . . . 82
LEXAPRO . . . . . . . . . . . . . . . . . . . . . . . . 29
LEXIVA SUS 50MG/ML . . . . . . . . . . . . . 50
LEXIVA TAB 700MG . . . . . . . . . . . . . . . 50
LIDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
LIDEX-E . . . . . . . . . . . . . . . . . . . . . . . . . 77
lido/prilocn cre 2.5-2.5% . . . . . . . . . . . 14
lidocaine . . . . . . . . . . . . . . . . . . . . . . . . 14
lidocaine gel 2% jelly . . . . . . . . . . . . . . 14
lidocaine inj 0.5% . . . . . . . . . . . . . . . . . 14
lidocaine oin 5% . . . . . . . . . . . . . . . . . 14
lidocaine pad 5% . . . . . . . . . . . . . . . . . 14
lidocaine sol 2% visc . . . . . . . . . . . . . . 14
lidocaine sol 4% . . . . . . . . . . . . . . . . . . 14
LIDODERM . . . . . . . . . . . . . . . . . . . . . . 14
linaclotide . . . . . . . . . . . . . . . . . . . . . . . 74
linagliptin - metformin . . . . . . . . . . . . 53
linezolid . . . . . . . . . . . . . . . . . . . . . . . . 17
linezolid inj 2mg/ml . . . . . . . . . . . . . . . 16
linezolid tab 600mg . . . . . . . . . . . . . . . 16
LINZESS CAP 145MCG . . . . . . . . . . . . . . 74
LINZESS CAP 290MCG . . . . . . . . . . . . . . 74
liothyronine . . . . . . . . . . . . . . . . . . . . . 81
liothyronine tab 25mcg . . . . . . . . . . . . 82
liothyronine tab 50mcg . . . . . . . . . . . . 82
liothyronine tab 5mcg . . . . . . . . . . . . . 82
LIPITOR . . . . . . . . . . . . . . . . . . . . . . . . . 67
liraglutide . . . . . . . . . . . . . . . . . . . . . . . 54
lisinop/hctz tab 10-12.5mg . . . . . . . . . 60
lisinop/hctz tab 20-12.5mg . . . . . . . . . 60
lisinop/hctz tab 20-25mg . . . . . . . . . . . 60
lisinopril tab 10mg . . . . . . . . . . . . . . . . 60
lisinopril tab 2.5mg . . . . . . . . . . . . . . . 60
lisinopril tab 5mg . . . . . . . . . . . . . . . . . 60
lithium carb cap 150mg . . . . . . . . . . . . 52
lithium carb tab 300mg . . . . . . . . . . . . 52
lithium carb tab 300mg er . . . . . . . . . . 52
lithium carb tab 450mg er . . . . . . . . . . 52
lithium citr . . . . . . . . . . . . . . . . . . . . . . 52
LITHIUM CITR SOL 8MEQ/5ML . . . . . . . 52
LITHOBID . . . . . . . . . . . . . . . . . . . . . . . . 52
LO/OVRAL, CRYSELLE . . . . . . . . . . . . . . 80
LODINE . . . . . . . . . . . . . . . . . . . . . . . . . 11
LODINE XL . . . . . . . . . . . . . . . . . . . . . . . 11
LODOSYN . . . . . . . . . . . . . . . . . . . . . . . 43
lodoxamide . . . . . . . . . . . . . . . . . . . . . . 89
LOFIBRA . . . . . . . . . . . . . . . . . . . . . . . . 67
lokara lot 0.05% . . . . . . . . . . . . . . . . . . 78
lomitapide . . . . . . . . . . . . . . . . . . . . . . 68
lomustine cap 100mg . . . . . . . . . . . . . . 36
lomustine cap 10mg . . . . . . . . . . . . . . . 36
lomustine cap 40mg . . . . . . . . . . . . . . . 36
LONITEN . . . . . . . . . . . . . . . . . . . . . . . . 68
loperamide cap 2mg . . . . . . . . . . . . . . 73
LOPID . . . . . . . . . . . . . . . . . . . . . . . . . . 67
lopinavir - ritonavir . . . . . . . . . . . . . . . 50
LOPRESSOR . . . . . . . . . . . . . . . . . . . . . . 62
LOPRESSOR HCT . . . . . . . . . . . . . . . . . . 62
LOPROX . . . . . . . . . . . . . . . . . . . . . . . . . 33
lorazepam tab 0.5mg . . . . . . . . . . . . . . 23
lorazepam tab 1mg . . . . . . . . . . . . . . . 24
lorazepam tab 2mg . . . . . . . . . . . . . . . 24
losartan pot tab 100mg . . . . . . . . . . . . 59
losartan pot tab 25mg . . . . . . . . . . . . . 59
losartan pot tab 50mg . . . . . . . . . . . . . 59
losartan/hct tab 100-12.5mg . . . . . . . . 59
losartan/hct tab 100-25mg . . . . . . . . . . 59
losartan/hct tab 50-12.5mg . . . . . . . . . 59
LOTEMAX SUS 0.5% . . . . . . . . . . . . . . . 90
LOTENSIN . . . . . . . . . . . . . . . . . . . . . . . 60
LOTENSIN HCT . . . . . . . . . . . . . . . . . . . 60
loteprednol . . . . . . . . . . . . . . . . . . . . . . 90
loteprednol etabonate . . . . . . . . . . . . 89
LOTREL . . . . . . . . . . . . . . . . . . . . . . . . . 59
LOTRIMIN . . . . . . . . . . . . . . . . . . . . . . . 33
LOTRISONE . . . . . . . . . . . . . . . . . . . . . . 71
LOTRONEX TAB 0.5MG . . . . . . . . . . . . 74
LOTRONEX TAB 1MG . . . . . . . . . . . . . . 74
lovastatin tab 10mg . . . . . . . . . . . . . . . 67
LOVAZA . . . . . . . . . . . . . . . . . . . . . . . . 68
LOVENOX . . . . . . . . . . . . . . . . . . . . . . . 55
loxapine cap 10mg . . . . . . . . . . . . . . . . 44
loxapine cap 25mg . . . . . . . . . . . . . . . . 44
loxapine cap 50mg . . . . . . . . . . . . . . . . 44
loxapine cap 5mg . . . . . . . . . . . . . . . . . 44
LOXITANE . . . . . . . . . . . . . . . . . . . . . . . 44
LOZOL . . . . . . . . . . . . . . . . . . . . . . . . . . 66
LUDIOMIL . . . . . . . . . . . . . . . . . . . . . . . 27
LUMIGAN SOL 0.01% . . . . . . . . . . . . . . 90
LUMIZYME INJ 50MG . . . . . . . . . . . . . . 72
LUPR DEP-PED INJ 11.25MG . . . . . . . . . 83
LUPR DEP-PED INJ 15MG . . . . . . . . . . . 83
LUPRON DEPOT INJ 3.75MG . . . . . . . . 83
LUPRON DEPOT INJ 7.5MG . . . . . . . . . 83
LUPRON SC . . . . . . . . . . . . . . . . . . . . . . 83
lurasidone . . . . . . . . . . . . . . . . . . . . . . . 45
lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
LUVOX . . . . . . . . . . . . . . . . . . . . . . . . . . 29
LUXIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 76
LYNPARZA CAP 50MG . . . . . . . . . . . . . 40
LYRICA CAP 100MG . . . . . . . . . . . . . . . 22
LYRICA CAP 150MG . . . . . . . . . . . . . . . 22
LYRICA CAP 200MG . . . . . . . . . . . . . . . 22
LYRICA CAP 225MG . . . . . . . . . . . . . . . 22
LYRICA CAP 25MG . . . . . . . . . . . . . . . . 22
LYRICA CAP 300MG . . . . . . . . . . . . . . . 22
LYRICA CAP 50MG . . . . . . . . . . . . . . . . 22
LYRICA CAP 75MG . . . . . . . . . . . . . . . . 22
LYRICA SOL 20MG/ML . . . . . . . . . . . . . 22
LYSODREN TAB 500MG . . . . . . . . . . . . 83
127
Index of Drugs
M
M-M-R II INJ LIVE . . . . . . . . . . . . . . . . . 87
macitentan . . . . . . . . . . . . . . . . . . . . . . 93
MACROBID . . . . . . . . . . . . . . . . . . . . . . 16
MACRODANTIN . . . . . . . . . . . . . . . . . . 16
mafenide . . . . . . . . . . . . . . . . . . . . . . . . 16
magnesium su inj 50% . . . . . . . . . . . . . 96
MAGNESIUM SULF . . . . . . . . . . . . . . . . 96
MALARONE . . . . . . . . . . . . . . . . . . . . . . 41
malathion lot 0.5% . . . . . . . . . . . . . . . 42
maprotiline tab 25mg . . . . . . . . . . . . . 27
maraviroc . . . . . . . . . . . . . . . . . . . . . . . 49
MARINOL . . . . . . . . . . . . . . . . . . . . . . . 32
MARPLAN TAB 10MG . . . . . . . . . . . . . . 28
MATULANE CAP 50MG . . . . . . . . . . . . 36
matzim la tab 180mg/24hr . . . . . . . . . 64
MAVIK . . . . . . . . . . . . . . . . . . . . . . . . . . 61
MAXALT . . . . . . . . . . . . . . . . . . . . . . . . 34
MAXIPIME . . . . . . . . . . . . . . . . . . . . . . . 17
MAXITROL . . . . . . . . . . . . . . . . . . . . . . 89
MAXZIDE, DYAZIDE . . . . . . . . . . . . . . . 67
measles virus - mumps virus . . . . . . . . . 87
vaccine
measles virus vaccine - mumps . . . . . . 87
virus vaccine - rubella virus vaccine varicella-zoster virus vaccine
mecasermin . . . . . . . . . . . . . . . . . . . . . . 79
mechlorethamine . . . . . . . . . . . . . . . . . 38
meclizine tab 12.5mg . . . . . . . . . . . . . . 31
meclizine tab 25mg . . . . . . . . . . . . . . . 31
meclofen sod cap 100mg . . . . . . . . . . . 12
meclofen sod cap 50mg . . . . . . . . . . . . 12
meclofenamate . . . . . . . . . . . . . . . . . . 12
MEDROL . . . . . . . . . . . . . . . . . . . . . . . . 78
medroxypr ac inj 150mg/ml . . . . . . . . . 81
medroxypr ac tab 10mg . . . . . . . . . . . . 81
medroxypr ac tab 2.5mg . . . . . . . . . . . 81
medroxypr ac tab 5mg . . . . . . . . . . . . . 81
mefloquine tab 250mg . . . . . . . . . . . . 41
MEFOXIN . . . . . . . . . . . . . . . . . . . . . . . . 17
MEGACE . . . . . . . . . . . . . . . . . . . . . . . . 81
megestrol ac sus 40mg/ml . . . . . . . . . . 81
megestrol ac tab 20mg . . . . . . . . . . . . 81
megestrol ac tab 40mg . . . . . . . . . . . . 81
MEKINIST TAB 0.5MG . . . . . . . . . . . . . . 40
MEKINIST TAB 2MG . . . . . . . . . . . . . . . 40
128
MELLARIL . . . . . . . . . . . . . . . . . . . . . . . 44
meloxicam tab 15mg . . . . . . . . . . . . . . 12
meloxicam tab 7.5mg . . . . . . . . . . . . . . 12
memantine . . . . . . . . . . . . . . . . . . . . . . 27
MENACTRA INJ . . . . . . . . . . . . . . . . . . . 87
menest tab 0.3mg . . . . . . . . . . . . . . . . 80
menest tab 0.625mg . . . . . . . . . . . . . . 80
menest tab 1.25mg . . . . . . . . . . . . . . . 80
menest tab 2.5mg . . . . . . . . . . . . . . . . 80
meninggococcal oligosaccharide . . . . 87
conjugate vaccine
meningococcal polysaccharide vac . . . 87
a-c-y-w
MENOMUNE INJ A/C/Y/W . . . . . . . . . . 87
MENVEO INJ . . . . . . . . . . . . . . . . . . . . . 87
MEPRON SUS . . . . . . . . . . . . . . . . . . . . 42
mercaptopur tab 50mg . . . . . . . . . . . . 37
mercaptopurine . . . . . . . . . . . . . . . . . . 37
meropenem . . . . . . . . . . . . . . . . . . . . . 18
MERREM INJ 500MG . . . . . . . . . . . . . . 18
mesalamine (5-asa) . . . . . . . . . . . . . . . . 87
mesalamine ec . . . . . . . . . . . . . . . . . . . 87
mesalamine kit 4gm . . . . . . . . . . . . . . . 87
mesna . . . . . . . . . . . . . . . . . . . . . . . . . . 38
mesna inj 1gm . . . . . . . . . . . . . . . . . . . 38
MESNEX . . . . . . . . . . . . . . . . . . . . . . . . 38
MESNEX TAB 400MG . . . . . . . . . . . . . . 38
MESTINON . . . . . . . . . . . . . . . . . . . . . . 35
MESTINON SYP 60MG/5ML . . . . . . . . . 35
MESTINON TAB TIMESPAN . . . . . . . . . . 35
METAGLIP . . . . . . . . . . . . . . . . . . . . . . . 52
metaproteren syp 10mg/5ml . . . . . . . . 93
METAPROTERENOL . . . . . . . . . . . . . . . 93
metformin - rosiglitazone . . . . . . . . . . 52
metformin - sitagliptin . . . . . . . . . . . . . 53
metformin - sitagliptin sr . . . . . . . . . . . 53
metformin tab 1000mg . . . . . . . . . . . . 53
metformin tab 500mg . . . . . . . . . . . . . 53
metformin tab 500mg er . . . . . . . . . . . 53
metformin tab 750mg er . . . . . . . . . . . 53
metformin tab 850mg . . . . . . . . . . . . . 53
methadone . . . . . . . . . . . . . . . . . . . . . . 12
methadone inj 10mg/ml . . . . . . . . . . . 12
methazolamid tab 25mg . . . . . . . . . . . 65
methazolamid tab 50mg . . . . . . . . . . . 65
METHAZOLAMIDE . . . . . . . . . . . . . . . . 65
methenam hip tab 1gm . . . . . . . . . . . . 16
methimazole tab 10mg . . . . . . . . . . . . 84
methimazole tab 5mg . . . . . . . . . . . . . 84
methocarbam tab 500mg . . . . . . . . . . 94
methocarbam tab 750mg . . . . . . . . . . 94
methotrexate . . . . . . . . . . . . . . . . . . . . 85
methotrexate inj 1gm . . . . . . . . . . . . . 85
methotrexate inj 25mg/ml . . . . . . . . . . 85
methotrexate tab 2.5mg . . . . . . . . . . . 85
methoxsalen . . . . . . . . . . . . . . . . . . . . . 71
methsuximide . . . . . . . . . . . . . . . . . . . . 22
methyclothia tab 5mg . . . . . . . . . . . . . 66
methylnaltrexone . . . . . . . . . . . . . . . . . 73
methylphenid tab 10mg . . . . . . . . . . . 69
methylphenid tab 20mg . . . . . . . . . . . 69
methylphenid tab 5mg . . . . . . . . . . . . 69
methylpr ace inj 40mg/ml . . . . . . . . . . 78
methylpr ace inj 80mg/ml . . . . . . . . . . 78
methylpr ss inj 125mg . . . . . . . . . . . . . 78
methylpr ss inj 40mg . . . . . . . . . . . . . . 78
methylpred pak 4mg . . . . . . . . . . . . . . 78
methylpred tab 16mg . . . . . . . . . . . . . 78
methylpred tab 32mg . . . . . . . . . . . . . 78
methylpred tab 4mg . . . . . . . . . . . . . . 78
methylpred tab 8mg . . . . . . . . . . . . . . 78
metipranolol sol 0.3% . . . . . . . . . . . . . 90
metoclopram inj 5mg/ml . . . . . . . . . . . 31
metoclopram sol 5mg/5ml . . . . . . . . . . 31
metoclopram tab 10mg . . . . . . . . . . . . 31
metoclopram tab 5mg . . . . . . . . . . . . . 32
metolazone tab 10mg . . . . . . . . . . . . . 66
metolazone tab 2.5mg . . . . . . . . . . . . . 67
metolazone tab 5mg . . . . . . . . . . . . . . 67
metoprl/hctz tab 100-25mg . . . . . . . . . 62
metoprl/hctz tab 100-50mg . . . . . . . . . 62
metoprl/hctz tab 50-25mg . . . . . . . . . . 62
metoprol tar tab 100mg . . . . . . . . . . . 62
metoprol tar tab 25mg . . . . . . . . . . . . 63
metoprol tar tab 50mg . . . . . . . . . . . . 63
metoprolol inj 1mg/ml . . . . . . . . . . . . . 63
metoprolol tab 100mg er . . . . . . . . . . 63
metoprolol tab 200mg er . . . . . . . . . . 63
metoprolol tab 25mg er . . . . . . . . . . . 63
metoprolol tab 50mg er . . . . . . . . . . . 63
METROGEL-VAG, VANDAZOLE . . . . . . 16
metron/nacl inj 500mg . . . . . . . . . . . . . 16
metronidazol cre 0.75% . . . . . . . . . . . 16
metronidazol gel 0.75% . . . . . . . . . . . 16
metronidazol gel 1% . . . . . . . . . . . . . . 16
metronidazol lot 0.75% . . . . . . . . . . . . 16
metronidazol tab 250mg . . . . . . . . . . . 16
metronidazol tab 500mg . . . . . . . . . . . 16
metronidazole . . . . . . . . . . . . . . . . . . . 16
metyrosine . . . . . . . . . . . . . . . . . . . . . . 65
MEVACOR . . . . . . . . . . . . . . . . . . . . . . . 67
mexiletine cap 150mg . . . . . . . . . . . . . 61
MEXITIL . . . . . . . . . . . . . . . . . . . . . . . . . 61
MIACALCIN . . . . . . . . . . . . . . . . . . . . . . 88
Index of Drugs
MIACALCIN INJ 200/ML . . . . . . . . . . . . 88
MICARDIS . . . . . . . . . . . . . . . . . . . . . . . 59
MICONAZOLE . . . . . . . . . . . . . . . . . . . . 33
miconazole 3 sup 200mg . . . . . . . . . . . 33
MICRO-K / KLOR-CON / K-TAB . . . . . . . 96
microgestin tab 1.5/30 . . . . . . . . . . . . . 80
microgestin tab 1/20 . . . . . . . . . . . . . . 80
microgestin tab fe 1/20 . . . . . . . . . . . . 80
microgestin tab fe1.5/30 . . . . . . . . . . . 80
MICROZIDE . . . . . . . . . . . . . . . . . . . . . . 66
MIDAMOR . . . . . . . . . . . . . . . . . . . . . . . 66
midodrine tab 10mg . . . . . . . . . . . . . . 58
midodrine tab 2.5mg . . . . . . . . . . . . . . 58
midodrine tab 5mg . . . . . . . . . . . . . . . 58
mifepristone . . . . . . . . . . . . . . . . . . . . . 54
migergot sup 2/100 . . . . . . . . . . . . . . . 34
miglitol . . . . . . . . . . . . . . . . . . . . . . . . . 52
miglustat . . . . . . . . . . . . . . . . . . . . . . . . 72
MIGRANAL SPR 4MG/ML . . . . . . . . . . . 34
MINIPRESS . . . . . . . . . . . . . . . . . . . . . . . 58
MINOCIN . . . . . . . . . . . . . . . . . . . . . . . . 21
minocycline cap 100mg . . . . . . . . . . . . 21
minocycline cap 50mg . . . . . . . . . . . . . 21
minocycline cap 75mg . . . . . . . . . . . . . 21
minocycline tab 100mg . . . . . . . . . . . . 21
minocycline tab 135mg er . . . . . . . . . . 21
minocycline tab 45mg er . . . . . . . . . . . 21
minocycline tab 50mg . . . . . . . . . . . . . 21
minocycline tab 75mg . . . . . . . . . . . . . 21
minocycline tab 90mg er . . . . . . . . . . . 21
minoxidil tab 10mg . . . . . . . . . . . . . . . 68
minoxidil tab 2.5mg . . . . . . . . . . . . . . . 68
mipomersen sodium . . . . . . . . . . . . . . . 68
mirabegron er . . . . . . . . . . . . . . . . . . . 75
MIRALAX . . . . . . . . . . . . . . . . . . . . . . . . 74
MIRAPEX . . . . . . . . . . . . . . . . . . . . . . . . 43
mirtazapine tab 15mg . . . . . . . . . . . . . 27
mirtazapine tab 15mg odt . . . . . . . . . . 27
mirtazapine tab 7.5mg . . . . . . . . . . . . 28
misoprostol tab 100mcg . . . . . . . . . . . 74
misoprostol tab 200mcg . . . . . . . . . . . 74
mitotane . . . . . . . . . . . . . . . . . . . . . . . . 83
mitoxantron inj 2mg/ml . . . . . . . . . . . . 38
MOBIC . . . . . . . . . . . . . . . . . . . . . . . . . . 12
modafinil tab 100mg . . . . . . . . . . . . . . 95
modafinil tab 200mg . . . . . . . . . . . . . . 95
MODURETIC . . . . . . . . . . . . . . . . . . . . . 66
moexipr/hctz tab 15-12.5mg . . . . . . . . 60
moexipr/hctz tab 15-25mg . . . . . . . . . . 61
moexipr/hctz tab 7.5-12.5mg . . . . . . . . 61
moexipril tab 15mg . . . . . . . . . . . . . . . 61
moexipril tab 7.5mg . . . . . . . . . . . . . . . 61
mometasone . . . . . . . . . . . . . . . . . . . . . 91
mometasone cre 0.1% . . . . . . . . . . . . . 78
mometasone oin 0.1% . . . . . . . . . . . . . 78
mometasone sol 0.1% . . . . . . . . . . . . . 78
MONOPRIL . . . . . . . . . . . . . . . . . . . . . . 60
MONOPRIL HCT . . . . . . . . . . . . . . . . . . 60
montelukast chw 4mg . . . . . . . . . . . . . 92
montelukast chw 5mg . . . . . . . . . . . . . 92
montelukast gra 4mg . . . . . . . . . . . . . . 92
montelukast tab 10mg . . . . . . . . . . . . . 92
morphine . . . . . . . . . . . . . . . . . . . . . . . 13
morphine soln . . . . . . . . . . . . . . . . . . . 13
morphine sul sol 10mg/5ml . . . . . . . . . 13
morphine sul sol 20mg/5ml . . . . . . . . . 14
morphine sul sol 20mg/ml . . . . . . . . . . 14
morphine sul tab 100mg er . . . . . . . . . 12
morphine sul tab 15mg . . . . . . . . . . . . 14
morphine sul tab 15mg er . . . . . . . . . . 12
morphine sul tab 200mg er . . . . . . . . . 12
morphine sul tab 30mg . . . . . . . . . . . . 14
MOTRIN . . . . . . . . . . . . . . . . . . . . . . . . . 11
moxifloxacin . . . . . . . . . . . . . . . . . . . . . 20
moxifloxacin tab 400mg . . . . . . . . . . . 20
MOZOBIL INJ . . . . . . . . . . . . . . . . . . . . . 57
MS CONTIN . . . . . . . . . . . . . . . . . . . . . . 12
MUCOMYST . . . . . . . . . . . . . . . . . . . . . 94
MUCOMYST-10 . . . . . . . . . . . . . . . . . . . 94
MULTAQ TAB 400MG . . . . . . . . . . . . . . 61
mupirocin . . . . . . . . . . . . . . . . . . . . . . . 16
mupirocin oin 2% . . . . . . . . . . . . . . . . . 16
MYAMBUTOL . . . . . . . . . . . . . . . . . . . . 35
MYCELEX . . . . . . . . . . . . . . . . . . . . . . . 33
MYCOBUTIN . . . . . . . . . . . . . . . . . . . . . 35
MYCOBUTIN CAP 150MG . . . . . . . . . . . 35
mycophenolat cap 250mg . . . . . . . . . . 85
mycophenolat sus 200mg/ml . . . . . . . . 85
mycophenolat tab 500mg . . . . . . . . . . 85
mycophenolate . . . . . . . . . . . . . . . . . . . 84
mycophenolic tab 180mg dr . . . . . . . . 85
mycophenolic tab 360mg dr . . . . . . . . 85
MYCOSTATIN . . . . . . . . . . . . . . . . . . . . 33
MYRBETRIQ TAB 25MG . . . . . . . . . . . . 75
MYRBETRIQ TAB 50MG . . . . . . . . . . . . 75
MYSOLINE . . . . . . . . . . . . . . . . . . . . . . . 24
nadolol tab 20mg . . . . . . . . . . . . . . . . . 63
nadolol tab 40mg . . . . . . . . . . . . . . . . . 63
nadolol tab 80mg . . . . . . . . . . . . . . . . . 63
nadolol/bend tab 40-5mg . . . . . . . . . . 63
nadolol/bend tab 80-5mg . . . . . . . . . . 63
nafarelin . . . . . . . . . . . . . . . . . . . . . . . . 84
nafcillin . . . . . . . . . . . . . . . . . . . . . . . . . 19
nafcillin inj 1gm . . . . . . . . . . . . . . . . . . 19
NAGLAZYME INJ 1MG/ML . . . . . . . . . . 72
nalbuphine inj 10mg/ml . . . . . . . . . . . . 14
nalbuphine inj 20mg/ml . . . . . . . . . . . . 14
NALLPEN/DEX INJ 1GM/50ML . . . . . . . 19
naloxone inj 1mg/ml . . . . . . . . . . . . . . 15
naltrexone . . . . . . . . . . . . . . . . . . . . . . 15
naltrexone tab 50mg . . . . . . . . . . . . . . 15
NAMENDA SOL 10MG/5ML . . . . . . . . . 27
NAMENDA TAB 10MG . . . . . . . . . . . . . 27
NAMENDA TAB 5MG . . . . . . . . . . . . . . 27
naphazoline . . . . . . . . . . . . . . . . . . . . . 89
NAPHAZOLINE SOL 0.1% . . . . . . . . . . . 89
NAPROSYN . . . . . . . . . . . . . . . . . . . . . . 12
naproxen dr tab 375mg . . . . . . . . . . . . 12
naproxen dr tab 500mg . . . . . . . . . . . . 12
naproxen er . . . . . . . . . . . . . . . . . . . . . 12
naproxen sod tab 275mg . . . . . . . . . . . 12
naproxen sod tab 500mg cr . . . . . . . . . 12
naproxen sod tab 550mg . . . . . . . . . . . 12
naproxen sus 125/5ml . . . . . . . . . . . . . 12
naproxen tab 250mg . . . . . . . . . . . . . . 12
naproxen tab 375mg . . . . . . . . . . . . . . 12
naproxen tab 500mg . . . . . . . . . . . . . . 12
NAPROXYN . . . . . . . . . . . . . . . . . . . . . . 12
NARCAN . . . . . . . . . . . . . . . . . . . . . . . . 15
NARDIL . . . . . . . . . . . . . . . . . . . . . . . . . 28
NASACORT AQ . . . . . . . . . . . . . . . . . . . 91
NASALIDE . . . . . . . . . . . . . . . . . . . . . . . 91
NASONEX SPR 50MCG/AC . . . . . . . . . . 91
NATACYN SUS 5% . . . . . . . . . . . . . . . . 33
natalizumab . . . . . . . . . . . . . . . . . . . . . 70
natamycin . . . . . . . . . . . . . . . . . . . . . . . 33
nateglinide tab 120mg . . . . . . . . . . . . 53
nateglinide tab 60mg . . . . . . . . . . . . . 53
NATPARA INJ 100MCG . . . . . . . . . . . . . 89
NATPARA INJ 25MCG . . . . . . . . . . . . . . 89
NATPARA INJ 50MCG . . . . . . . . . . . . . . 89
NATPARA INJ 75MCG . . . . . . . . . . . . . . 89
NAVANE . . . . . . . . . . . . . . . . . . . . . . . . 44
NEBUPENT INH 300MG . . . . . . . . . . . . 42
necon tab 0.5/35 . . . . . . . . . . . . . . . . . . 80
necon tab 1/35 . . . . . . . . . . . . . . . . . . . 80
necon tab 10/11-28 . . . . . . . . . . . . . . . . 80
N
nabumetone tab 500mg . . . . . . . . . . . 12 nefazodone tab 100mg . . . . . . . . . . . . 29
nabumetone tab 750mg . . . . . . . . . . . 12 nefazodone tab 150mg . . . . . . . . . . . . 29
129
Index of Drugs
nefazodone tab 200mg . . . . . . . . . . . . 29
nefazodone tab 250mg . . . . . . . . . . . . 29
nefazodone tab 50mg . . . . . . . . . . . . . 29
nelfinavir . . . . . . . . . . . . . . . . . . . . . . . . 50
neo/bac/poly oin . . . . . . . . . . . . . . . . . . 89
neo/poly gu sol 40/ml . . . . . . . . . . . . . . 16
neo/poly/bac oin /hc 1% . . . . . . . . . . . 89
neo/poly/dex oin 0.1% . . . . . . . . . . . . . 89
neo/poly/dex sus 0.1% . . . . . . . . . . . . . 89
neo/poly/gra sol . . . . . . . . . . . . . . . . . . 89
neo/poly/hc sol 1% . . . . . . . . . . . . . . . . 91
neo/poly/hc sus . . . . . . . . . . . . . . . . . . . 89
neo/poly/hc sus 1% . . . . . . . . . . . . . . . . 91
NEOMYCIN . . . . . . . . . . . . . . . . . . . . . . 15
neomycin tab 500mg . . . . . . . . . . . . . . 15
NEORAL . . . . . . . . . . . . . . . . . . . . . . . . . 84
NEOSPORIN . . . . . . . . . . . . . . . . . . . . . . 89
NEOSPORIN GU . . . . . . . . . . . . . . . . . . . 16
nepafenac . . . . . . . . . . . . . . . . . . . . . . . 90
NEULASTA INJ 6MG/0.6ML . . . . . . . . . . 57
NEUMEGA INJ 5MG . . . . . . . . . . . . . . . 57
NEUPOGEN INJ 300/0.5ML . . . . . . . . . . 57
NEUPOGEN INJ 480/0.8ML . . . . . . . . . . 57
NEUPOGEN INJ 480MCG . . . . . . . . . . . 57
NEUPRO DIS 1MG/24HR . . . . . . . . . . . . 42
NEUPRO DIS 2MG/24HR . . . . . . . . . . . . 42
NEUPRO DIS 3MG/24HR . . . . . . . . . . . . 42
NEUPRO DIS 4MG/24HR . . . . . . . . . . . . 42
NEUPRO DIS 6MG/24HR . . . . . . . . . . . . 43
NEUPRO DIS 8MG/24HR . . . . . . . . . . . . 43
NEURONTIN . . . . . . . . . . . . . . . . . . . . . 23
NEVANAC SUS 0.1% . . . . . . . . . . . . . . . 90
nevirapine . . . . . . . . . . . . . . . . . . . . . . . 48
nevirapine 400 mg extended release . 48
nevirapine sus 50mg/5ml . . . . . . . . . . . 48
nevirapine tab 200mg . . . . . . . . . . . . . 48
nevirapine xr . . . . . . . . . . . . . . . . . . . . . 48
NEXAVAR TAB 200MG . . . . . . . . . . . . . 40
NEXIUM . . . . . . . . . . . . . . . . . . . . . . . . . 74
niacin er tab 1000mg . . . . . . . . . . . . . . 68
niacin er tab 500mg . . . . . . . . . . . . . . . 68
niacin er tab 750mg . . . . . . . . . . . . . . . 68
NIASPAN . . . . . . . . . . . . . . . . . . . . . . . . 68
nicardipine cap 20mg . . . . . . . . . . . . . . 64
nicardipine cap 30mg . . . . . . . . . . . . . . 64
nicotine . . . . . . . . . . . . . . . . . . . . . . . . . 15
NICOTROL NS SPR 10MG/ML . . . . . . . . 15
nifedical xl tab 30mg . . . . . . . . . . . . . . 64
nifedical xl tab 60mg . . . . . . . . . . . . . . 64
nifedipine tab 30mg er . . . . . . . . . . . . 64
NILANDRON TAB 150MG . . . . . . . . . . . 36
130
nilotinib . . . . . . . . . . . . . . . . . . . . . . . . 40
nilutamide . . . . . . . . . . . . . . . . . . . . . . 36
nimodipine cap 30mg . . . . . . . . . . . . . 64
NIMOTOP . . . . . . . . . . . . . . . . . . . . . . . 64
nintedanib . . . . . . . . . . . . . . . . . . . . . . 94
nisoldipine tab 17mg er . . . . . . . . . . . . 64
nisoldipine tab 20mg . . . . . . . . . . . . . . 64
nisoldipine tab 25.5mg . . . . . . . . . . . . 64
nisoldipine tab 34mg er . . . . . . . . . . . . 64
nisoldipine tab 8.5mg er . . . . . . . . . . . 64
nitazoxanide . . . . . . . . . . . . . . . . . . . . . 41
NITRO-DUR . . . . . . . . . . . . . . . . . . . . . . 68
nitrofur mac cap 50mg . . . . . . . . . . . . 16
nitrofurantn cap 100mg . . . . . . . . . . . 16
nitroglycer dis 0.1mg/hr . . . . . . . . . . . . 68
nitroglyceri dis 0.6mg/hr . . . . . . . . . . . 68
nitroglycerin . . . . . . . . . . . . . . . . . . . . . 69
nitroglycrn spr 0.4mg . . . . . . . . . . . . . . 69
NITROMIST . . . . . . . . . . . . . . . . . . . . . . 69
NITROSTAT SUB 0.3MG . . . . . . . . . . . . 69
NITROSTAT SUB 0.4MG . . . . . . . . . . . . 69
NITROSTAT SUB 0.6MG . . . . . . . . . . . . 69
nivolumab . . . . . . . . . . . . . . . . . . . . . . . 41
nizatidine cap 150mg . . . . . . . . . . . . . . 73
nizatidine cap 300mg . . . . . . . . . . . . . . 73
nizatidine sol 15mg/ml . . . . . . . . . . . . . 73
NIZORAL . . . . . . . . . . . . . . . . . . . . . . . . 33
NOLVADEX . . . . . . . . . . . . . . . . . . . . . . 37
NORCO . . . . . . . . . . . . . . . . . . . . . . . . . 13
norethin ace tab 5mg . . . . . . . . . . . . . 81
NORPRAMIN . . . . . . . . . . . . . . . . . . . . . 30
NORTHERA CAP 100MG . . . . . . . . . . . . 65
NORTHERA CAP 200MG . . . . . . . . . . . . 65
NORTHERA CAP 300MG . . . . . . . . . . . . 65
nortrel tab 0.5/35 . . . . . . . . . . . . . . . . . 80
nortrel tab 1/35 . . . . . . . . . . . . . . . . . . 80
nortrel tab 7/7/7 . . . . . . . . . . . . . . . . . . 80
NORTREL, NECON . . . . . . . . . . . . . . . . . 80
nortriptylin cap 10mg . . . . . . . . . . . . . 31
nortriptylin sol 10mg/5ml . . . . . . . . . . 31
NORVASC . . . . . . . . . . . . . . . . . . . . . . . 63
NORVIR CAP 100MG . . . . . . . . . . . . . . . 50
NORVIR SOL 80MG/ML . . . . . . . . . . . . . 50
NORVIR TAB 100MG . . . . . . . . . . . . . . . 50
NOVANTRONE . . . . . . . . . . . . . . . . . . . 38
NOXAFIL SUS 40MG/ML . . . . . . . . . . . . 33
nph insulin, human unt/ml - . . . . . . . . 54
regular insulin
NUBAIN . . . . . . . . . . . . . . . . . . . . . . . . . 14
NUEDEXTA CAP 20-10MG . . . . . . . . . . 69
NULOJIX INJ 250MG . . . . . . . . . . . . . . . 85
NUTROPIN AQ INJ 10MG/2ML . . . . . . . 79
NUTROPIN AQ INJ 20MG/2ML . . . . . . . 79
nyamyc pow 100000 . . . . . . . . . . . . . . . 33
nystat/triam cre . . . . . . . . . . . . . . . . . . 33
nystat/triam oin . . . . . . . . . . . . . . . . . . 33
nystatin . . . . . . . . . . . . . . . . . . . . . . . . . 33
NYSTATIN - TRIAMCINOLONE . . . . . . . 33
nystatin cre 100000 . . . . . . . . . . . . . . . 33
nystatin oin 100000 . . . . . . . . . . . . . . . 33
nystatin pow 100000 . . . . . . . . . . . . . . 34
nystatin sus 100000 . . . . . . . . . . . . . . . 34
nystatin tab 500000 . . . . . . . . . . . . . . . 34
nystop pow 100000 . . . . . . . . . . . . . . . 34
O
octreotide . . . . . . . . . . . . . . . . . . . . . . . 83
octreotide inj 1000mcg . . . . . . . . . . . . 83
octreotide inj 100mcg . . . . . . . . . . . . . 83
octreotide inj 50mcg/ml . . . . . . . . . . . . 83
OCUFEN . . . . . . . . . . . . . . . . . . . . . . . . . 89
OCUFLOX . . . . . . . . . . . . . . . . . . . . . . . 20
OCUPRESS . . . . . . . . . . . . . . . . . . . . . . . 90
OFEV CAP 100MG . . . . . . . . . . . . . . . . . 94
OFEV CAP 150MG . . . . . . . . . . . . . . . . . 94
ofloxacin dro 0.3% . . . . . . . . . . . . . . . . 20
ofloxacin tab 400mg . . . . . . . . . . . . . . 20
olanza/fluox cap 12-25mg . . . . . . . . . . 28
olanza/fluox cap 12-50mg . . . . . . . . . . 28
olanza/fluox cap 3-25mg . . . . . . . . . . . 28
olanzapine inj 10mg . . . . . . . . . . . . . . 45
olanzapine susp . . . . . . . . . . . . . . . . . . 46
olanzapine tab 10mg . . . . . . . . . . . . . . 45
olanzapine tab 10mg odt . . . . . . . . . . 45
olanzapine tab 2.5mg . . . . . . . . . . . . . 45
olanzapine tab 5mg . . . . . . . . . . . . . . . 45
olanzapine tab 5mg odt . . . . . . . . . . . 45
olanzapine tab 7.5mg . . . . . . . . . . . . . 45
olaparib . . . . . . . . . . . . . . . . . . . . . . . . . 40
olodaterol . . . . . . . . . . . . . . . . . . . . . . . 93
olopatadine . . . . . . . . . . . . . . . . . . . . . 89
Index of Drugs
olsalazine . . . . . . . . . . . . . . . . . . . . . . . 87
omacetaxine . . . . . . . . . . . . . . . . . . . . . 38
omalizumab . . . . . . . . . . . . . . . . . . . . . 94
omega-3-acid cap 1gm . . . . . . . . . . . . . 68
omeprazole cap 10mg . . . . . . . . . . . . . 74
OMNICEF . . . . . . . . . . . . . . . . . . . . . . . . 17
ONCASPAR INJ 750/ML . . . . . . . . . . . . . 38
ondansetron inj 4mg/2ml . . . . . . . . . . 32
ondansetron sol 4mg/5ml . . . . . . . . . . 32
ondansetron tab 24mg . . . . . . . . . . . . 32
ondansetron tab 4mg . . . . . . . . . . . . . 32
ondansetron tab 4mg odt . . . . . . . . . . 32
ondansetron tab 8mg . . . . . . . . . . . . . 32
ondansetron tab 8mg odt . . . . . . . . . . 32
ONFI SUS 2.5MG/ML . . . . . . . . . . . . . . . 24
ONFI TAB 10MG . . . . . . . . . . . . . . . . . . 24
ONFI TAB 20MG . . . . . . . . . . . . . . . . . . 24
ONGLYZA TAB 2.5MG . . . . . . . . . . . . . 53
ONGLYZA TAB 5MG . . . . . . . . . . . . . . . 53
OPDIVO INJ 40MG/4ML . . . . . . . . . . . . 41
oprelvekin . . . . . . . . . . . . . . . . . . . . . . . 57
OPSUMIT TAB 10MG . . . . . . . . . . . . . . 93
OPTIPRANOLOL . . . . . . . . . . . . . . . . . . 90
ORAP TAB 1MG . . . . . . . . . . . . . . . . . . 44
ORAP TAB 2MG . . . . . . . . . . . . . . . . . . 44
ORAPRED . . . . . . . . . . . . . . . . . . . . . . . 78
ORENCIA INJ 125MG/ML . . . . . . . . . . . 85
ORENCIA INJ 250MG . . . . . . . . . . . . . . 85
ORTHO MICRONOR . . . . . . . . . . . . . . . 81
ORTHO TRI-CYCLEN LO, TRI-SPRINTEC, 81
ORTHO-CEPT . . . . . . . . . . . . . . . . . . . . . 80
ORTHO-CYCLEN, SPRINTEC,
MONONESSA . . . . . . . . . . . . . . . . . . 81
ORTHO-NOVUM, NORTREL, NECON . . 80
ORUVAIL . . . . . . . . . . . . . . . . . . . . . . . . 12
oseltamivir . . . . . . . . . . . . . . . . . . . . . . 50
OVIDE . . . . . . . . . . . . . . . . . . . . . . . . . . 42
OXANDRIN . . . . . . . . . . . . . . . . . . . . . . 79
oxandrolone tab 10mg . . . . . . . . . . . . 79
oxandrolone tab 2.5mg . . . . . . . . . . . . 79
oxaprozin tab 600mg . . . . . . . . . . . . . . 12
oxazepam cap 10mg . . . . . . . . . . . . . . 51
oxazepam cap 15mg . . . . . . . . . . . . . . 51
oxcarbazepin sus 300mg/5ml . . . . . . . . 25
oxcarbazepin tab 150mg . . . . . . . . . . . 25
oxcarbazepine . . . . . . . . . . . . . . . . . . . 26
OXTELLAR XR TAB 150MG . . . . . . . . . . 26
oxybutynin tab 10mg er . . . . . . . . . . . 75
oxybutynin tab 15mg er . . . . . . . . . . . 75
oxybutynin tab 5mg . . . . . . . . . . . . . . . 75
oxybutynin tab 5mg er . . . . . . . . . . . . 75
oxycod/apap tab 10-325mg . . . . . . . . . 14
oxycod/apap tab 2.5-325mg . . . . . . . . 14
oxycod/apap tab 5-325mg . . . . . . . . . . 14
oxycod/apap tab 7.5-325mg . . . . . . . . 14
oxycodone cap 5mg . . . . . . . . . . . . . . . 14
oxycodone con 100/5ml . . . . . . . . . . . . 14
oxycodone er . . . . . . . . . . . . . . . . . . . . 13
oxycodone tab 10mg . . . . . . . . . . . . . . 14
oxycodone tab 15mg . . . . . . . . . . . . . . 14
oxycodone tab 20mg . . . . . . . . . . . . . . 14
oxycodone tab 30mg . . . . . . . . . . . . . . 14
oxycodone tab 5mg . . . . . . . . . . . . . . . 14
OXYCONTIN TAB 10MG CR . . . . . . . . . 13
oxymetholone . . . . . . . . . . . . . . . . . . . 79
P
pacerone tab 100mg . . . . . . . . . . . . . . 61
pacerone tab 200mg . . . . . . . . . . . . . . 61
paclitaxel inj 300/50ml . . . . . . . . . . . . . 38
palbociclib . . . . . . . . . . . . . . . . . . . . . . . 37
paliperidone . . . . . . . . . . . . . . . . . . . . . 45
paliperidone palmitate im . . . . . . . . . . 45
palivizumab . . . . . . . . . . . . . . . . . . . . . 86
PAMELOR . . . . . . . . . . . . . . . . . . . . . . . 31
pamidronate inj 30/10ml . . . . . . . . . . . 88
pamidronate inj 90/10ml . . . . . . . . . . . 88
PANCREAZE CAP 10500UNT . . . . . . . . 73
PANCREAZE CAP 4200UNIT . . . . . . . . . 73
panobinostat . . . . . . . . . . . . . . . . . . . . 37
PANRETIN GEL 0.1% . . . . . . . . . . . . . . . 41
pantoprazole . . . . . . . . . . . . . . . . . . . . 74
pantoprazole tab 20mg . . . . . . . . . . . . 74
pantoprazole tab 40mg . . . . . . . . . . . . 74
PARAMOMYCIN . . . . . . . . . . . . . . . . . . 15
parathyroid hormone . . . . . . . . . . . . . 89
paricalcitol cap 1 mcg . . . . . . . . . . . . . 88
PARLODEL . . . . . . . . . . . . . . . . . . . . . . . 42
PARNATE . . . . . . . . . . . . . . . . . . . . . . . . 28
paromomycin cap 250mg . . . . . . . . . . 15
paroxetin er tab 12.5mg . . . . . . . . . . . 29
paroxetin er tab 37.5mg . . . . . . . . . . . 29
paroxetine . . . . . . . . . . . . . . . . . . . . . . 29
paroxetine tab 10mg . . . . . . . . . . . . . . 29
paroxetine tab 25mg er . . . . . . . . . . . . 29
PASER GRA 4GM . . . . . . . . . . . . . . . . . . 36
pasireotide . . . . . . . . . . . . . . . . . . . . . . 83
PATANOL SOL 0.1% . . . . . . . . . . . . . . . 89
PAXIL . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
PAXIL CR . . . . . . . . . . . . . . . . . . . . . . . . 29
PAXIL SUS 10MG/5ML . . . . . . . . . . . . . 29
pazopanib . . . . . . . . . . . . . . . . . . . . . . . 40
PEDVAX HIB INJ . . . . . . . . . . . . . . . . . . 87
peg-3350 . . . . . . . . . . . . . . . . . . . . . . . . 74
peg-3350 sol electrol . . . . . . . . . . . . . . 74
PEG-INTRON KIT 120 RP . . . . . . . . . . . . 47
PEG-INTRON KIT 150 RP . . . . . . . . . . . . 47
PEG-INTRON KIT 50MCG . . . . . . . . . . . 47
PEG-INTRON KIT 50MCG RP . . . . . . . . . 47
PEG-INTRON KIT 80MCG RP . . . . . . . . . 47
pegademase bovine . . . . . . . . . . . . . . . 72
PEGANONE TAB 250MG . . . . . . . . . . . . 26
pegaspargase . . . . . . . . . . . . . . . . . . . . 38
PEGASYS INJ 180MCG/0.5ML . . . . . . . . 47
PEGASYS INJ 180MCG/ML . . . . . . . . . . 47
pegfilgrastim . . . . . . . . . . . . . . . . . . . . 57
peginterferon alfa-2a . . . . . . . . . . . . . 47
peginterferon alfa-2b . . . . . . . . . . . . . 47
peginterferon beta-1a . . . . . . . . . . . . . 70
pegvisomant . . . . . . . . . . . . . . . . . . . . . 84
pembrolizumab . . . . . . . . . . . . . . . . . . 41
pemetrexed . . . . . . . . . . . . . . . . . . . . . 37
pen g sod . . . . . . . . . . . . . . . . . . . . . . . 19
pen g sod inj 5000000 . . . . . . . . . . . . . 19
pen needles mis 29gx1/2 . . . . . . . . . . . 54
penciclovir . . . . . . . . . . . . . . . . . . . . . . . 51
penicillamine . . . . . . . . . . . . . . . . . . . . 76
penicillin g . . . . . . . . . . . . . . . . . . . . . . 19
penicillin g benzathine . . . . . . . . . . . . 19
penicillin g benzathine - . . . . . . . . . . . 19
penicillin g procaine
penicilln gk inj 5mu . . . . . . . . . . . . . . . 19
penicilln vk sol 125/5ml . . . . . . . . . . . . 19
penicilln vk sol 250/5ml . . . . . . . . . . . . 19
penicilln vk tab 250mg . . . . . . . . . . . . . 19
penicilln vk tab 500mg . . . . . . . . . . . . . 19
PENLAC . . . . . . . . . . . . . . . . . . . . . . . . . 33
PENTAM 300 INJ 300MG . . . . . . . . . . . 42
pentamidine . . . . . . . . . . . . . . . . . . . . . 42
131
Index of Drugs
pentamidine neb . . . . . . . . . . . . . . . . . 42
PENTASA CAP 250MG CR . . . . . . . . . . . 87
PENTASA CAP 500MG CR . . . . . . . . . . . 87
pentoxifylli tab 400mg er . . . . . . . . . . 65
PEPCID . . . . . . . . . . . . . . . . . . . . . . . . . . 73
PEPCID I.V. . . . . . . . . . . . . . . . . . . . . . . . 73
perampanel . . . . . . . . . . . . . . . . . . . . . 23
PERCOCET . . . . . . . . . . . . . . . . . . . . . . . 14
PERCOPA . . . . . . . . . . . . . . . . . . . . . . . . 43
PERIACTIN . . . . . . . . . . . . . . . . . . . . . . . 92
PERIDEX ORAL RINSE . . . . . . . . . . . . . . 70
perindopril tab 2mg . . . . . . . . . . . . . . . 61
periogard sol 0.12% . . . . . . . . . . . . . . . 70
PERJETA INJ 420/14ML . . . . . . . . . . . . . 41
permethrin cre 5% . . . . . . . . . . . . . . . . 42
perphen/amit tab 2-10mg . . . . . . . . . . 28
perphenazine - amitriptyline . . . . . . . . 28
perphenazine tab 16mg . . . . . . . . . . . 32
perphenazine tab 2mg . . . . . . . . . . . . 32
pertuzumab . . . . . . . . . . . . . . . . . . . . . 41
phenelzine tab 15mg . . . . . . . . . . . . . . 28
PHENERGAN . . . . . . . . . . . . . . . . . . . . . 32
phenobarb elx 20mg/5ml . . . . . . . . . . . 24
phenobarb tab 100mg . . . . . . . . . . . . . 24
phenobarb tab 15mg . . . . . . . . . . . . . . 24
phenobarb tab 16.2mg . . . . . . . . . . . . 24
phenobarb tab 30mg . . . . . . . . . . . . . . 24
phenobarb tab 32.4mg . . . . . . . . . . . . 24
phenobarb tab 60mg . . . . . . . . . . . . . . 24
PHENOBARB TAB 64.8MG . . . . . . . . . . 24
PHENOBARB TAB 97.2MG . . . . . . . . . . 24
phenobarbital . . . . . . . . . . . . . . . . . . . . 24
phenylbutyra pow sodium . . . . . . . . . . 72
phenytoin . . . . . . . . . . . . . . . . . . . . . . . 25
phenytoin chw 50mg . . . . . . . . . . . . . . 26
phenytoin ex cap 100mg . . . . . . . . . . . 26
phenytoin sus 125/5ml . . . . . . . . . . . . . 26
PHOSLO . . . . . . . . . . . . . . . . . . . . . . . . . 76
PHOSLYRA SOL . . . . . . . . . . . . . . . . . . . 76
phospholine . . . . . . . . . . . . . . . . . . . . . 90
PHOSPHOLINE SOL 0.125% . . . . . . . . . 90
pilocarpine hydrochloride . . . . . . . . . . 90
PILOCARPINE SOL 1% . . . . . . . . . . . . . 90
132
PILOCARPINE SOL 2% . . . . . . . . . . . . . 90
PILOCARPINE SOL 4% . . . . . . . . . . . . . 90
pilocarpine tab 5mg . . . . . . . . . . . . . . . 70
pilocarpine tab 7.5mg . . . . . . . . . . . . . 70
pimecrolimus . . . . . . . . . . . . . . . . . . . . 71
pimozide . . . . . . . . . . . . . . . . . . . . . . . . 44
pindolol tab 10mg . . . . . . . . . . . . . . . . 63
pindolol tab 5mg . . . . . . . . . . . . . . . . . 63
pioglita/met tab 15-500mg . . . . . . . . . 53
pioglita/met tab 15-850mg . . . . . . . . . 53
pioglitazone tab 15mg . . . . . . . . . . . . 53
piper/tazoba inj 3-0.375gm . . . . . . . . . 19
piper/tazoba inj 4-0.5gm . . . . . . . . . . . 19
pirfenidone . . . . . . . . . . . . . . . . . . . . . . 94
piroxicam cap 10mg . . . . . . . . . . . . . . . 12
piroxicam cap 20mg . . . . . . . . . . . . . . . 12
PLAQUENIL . . . . . . . . . . . . . . . . . . . . . . 41
PLAVIX . . . . . . . . . . . . . . . . . . . . . . . . . 58
PLEGRIDY INJ . . . . . . . . . . . . . . . . . . . . 70
PLEGRIDY PEN INJ STARTER . . . . . . . . . 70
PLENDIL . . . . . . . . . . . . . . . . . . . . . . . . . 64
plerixafor . . . . . . . . . . . . . . . . . . . . . . . 57
PLETAL . . . . . . . . . . . . . . . . . . . . . . . . . . 58
podofilox . . . . . . . . . . . . . . . . . . . . . . . 71
podofilox sol 0.5% . . . . . . . . . . . . . . . . 71
poliovirus vaccine . . . . . . . . . . . . . . . . . 87
polyeth glyc pow 3350 nf . . . . . . . . . . 74
polymyxin b/ sol trimethp . . . . . . . . . . 89
POLYSPORIN . . . . . . . . . . . . . . . . . . . . . 89
POLYTRIM . . . . . . . . . . . . . . . . . . . . . . . 89
pomalidomide . . . . . . . . . . . . . . . . . . . 36
POMALYST CAP 1MG . . . . . . . . . . . . . . 36
POMALYST CAP 2MG . . . . . . . . . . . . . . 36
POMALYST CAP 3MG . . . . . . . . . . . . . . 36
POMALYST CAP 4MG . . . . . . . . . . . . . . 36
ponatinib . . . . . . . . . . . . . . . . . . . . . . . 39
portia-28 . . . . . . . . . . . . . . . . . . . . . . . . 80
PORTIA, LEVORA . . . . . . . . . . . . . . . . . 80
posaconazole . . . . . . . . . . . . . . . . . . . . 33
pot chloride cap 10meq er . . . . . . . . . . 96
pot chloride cap 8meq er . . . . . . . . . . . 96
POT CHLORIDE INJ 10MEQ . . . . . . . . . 96
pot chloride inj 2meq/ml . . . . . . . . . . . 96
POT CHLORIDE INJ 40MEQ . . . . . . . . . 96
pot chloride liq 10% . . . . . . . . . . . . . . 96
pot chloride liq 20% . . . . . . . . . . . . . . 96
pot citrate tab 1080mg . . . . . . . . . . . . 96
pot citrate tab 540mg . . . . . . . . . . . . . 96
pot cl micro tab 10meq er . . . . . . . . . . 96
pot cl micro tab 20meq er . . . . . . . . . . 96
potassium chloride . . . . . . . . . . . . . . . . 96
POTIGA TAB 200MG . . . . . . . . . . . . . . . 22
POTIGA TAB 300MG . . . . . . . . . . . . . . . 22
POTIGA TAB 400MG . . . . . . . . . . . . . . . 22
POTIGA TAB 50MG . . . . . . . . . . . . . . . . 22
PRADAXA CAP 150MG . . . . . . . . . . . . . 56
PRADAXA CAP 75MG . . . . . . . . . . . . . . 56
pramipexole tab 0.125mg . . . . . . . . . . 43
pramipexole tab 0.25mg . . . . . . . . . . . 43
pramipexole tab 0.5mg . . . . . . . . . . . . 43
pramipexole tab 0.75mg . . . . . . . . . . . 43
pramipexole tab 1.5mg . . . . . . . . . . . . 43
pramipexole tab 1mg . . . . . . . . . . . . . . 43
pramlintide . . . . . . . . . . . . . . . . . . . . . . 53
PRANDIN . . . . . . . . . . . . . . . . . . . . . . . . 53
prasugrel . . . . . . . . . . . . . . . . . . . . . . . . 58
PRAVACHOL . . . . . . . . . . . . . . . . . . . . . 67
pravastatin tab 10mg . . . . . . . . . . . . . . 67
praziquantel . . . . . . . . . . . . . . . . . . . . . 41
prazosin hcl cap 1mg . . . . . . . . . . . . . . 58
PRECOSE . . . . . . . . . . . . . . . . . . . . . . . . 52
PRED MILD / PRED FORTE . . . . . . . . . . 90
pred sod pho sol 1% . . . . . . . . . . . . . . 90
pred sod pho sol 5mg/5ml . . . . . . . . . . 78
prednicarbat oin 0.1% . . . . . . . . . . . . . 78
prednisolone sol 15mg/5ml . . . . . . . . . 78
prednisolone sus 1% . . . . . . . . . . . . . . 90
prednisone . . . . . . . . . . . . . . . . . . . . . . 78
prednisone tab 10mg . . . . . . . . . . . . . . 78
prednisone tab 1mg . . . . . . . . . . . . . . . 78
prednisone tab 2.5mg . . . . . . . . . . . . . 78
prednisone tab 5mg . . . . . . . . . . . . . . . 78
pregabalin . . . . . . . . . . . . . . . . . . . . . . 22
PREMARIN TAB 0.625MG . . . . . . . . . . . 80
PREMARIN VAG CRE 0.625MG . . . . . . . 80
PREMASOL . . . . . . . . . . . . . . . . . . . . . . 96
premasol sol 6% . . . . . . . . . . . . . . . . . . 96
PREMPRO TAB .625-2.5MG . . . . . . . . . 80
PREMPRO TAB 0.3-1.5MG . . . . . . . . . . 81
PREMPRO TAB 0.45-1.5MG . . . . . . . . . 81
PREMPRO TAB 0.625-5MG . . . . . . . . . . 81
prenatabs tab obn . . . . . . . . . . . . . . . . 97
prenatal rx vitamin . . . . . . . . . . . . . . . . 97
PREVACID . . . . . . . . . . . . . . . . . . . . . . . 74
PREZCOBIX TAB 800-150MG . . . . . . . . 49
PREZISTA SUS 100MG/ML . . . . . . . . . . . 50
PREZISTA TAB 150MG . . . . . . . . . . . . . . 50
Index of Drugs
PREZISTA TAB 600MG . . . . . . . . . . . . . . 50
PREZISTA TAB 75MG . . . . . . . . . . . . . . . 50
PREZISTA TAB 800MG . . . . . . . . . . . . . . 50
PRILOSEC . . . . . . . . . . . . . . . . . . . . . . . . 74
primaquine . . . . . . . . . . . . . . . . . . . . . . 42
PRIMAQUINE TAB 26.3MG . . . . . . . . . . 42
primidone tab 250mg . . . . . . . . . . . . . 24
primidone tab 50mg . . . . . . . . . . . . . . 24
PRISTIQ TAB 100MG . . . . . . . . . . . . . . . 29
PRISTIQ TAB 25MG . . . . . . . . . . . . . . . . 29
PRISTIQ TAB 50MG . . . . . . . . . . . . . . . . 29
PROAIR HFA AER . . . . . . . . . . . . . . . . . 93
PROAMATINE . . . . . . . . . . . . . . . . . . . . 58
proben/colch tab 500-0.5mg . . . . . . . . 34
PROBENECID . . . . . . . . . . . . . . . . . . . . . 34
probenecid tab 500mg . . . . . . . . . . . . . 34
procarbazine . . . . . . . . . . . . . . . . . . . . . 36
PROCARDIA XL, ADALAT CC . . . . . . . . 63
prochlorper inj 5mg/ml . . . . . . . . . . . . 32
prochlorper sup 25mg . . . . . . . . . . . . . 32
prochlorper tab 10mg . . . . . . . . . . . . . 32
prochlorper tab 5mg . . . . . . . . . . . . . . 32
prochlorperazine . . . . . . . . . . . . . . . . . 31
PROCRIT INJ 10000/ML . . . . . . . . . . . . . 57
PROCRIT INJ 2000/ML . . . . . . . . . . . . . . 57
PROCRIT INJ 20000/ML . . . . . . . . . . . . . 57
PROCRIT INJ 3000/ML . . . . . . . . . . . . . . 57
PROCRIT INJ 4000/ML . . . . . . . . . . . . . . 57
PROCRIT INJ 40000/ML . . . . . . . . . . . . . 57
PROCTO-PAK . . . . . . . . . . . . . . . . . . . . 78
procto-pak cre 1% . . . . . . . . . . . . . . . . 78
PROCTOCORT, ALA-CORT . . . . . . . . . . 76
proctozone cre -hc 2.5% . . . . . . . . . . . 78
progesterone . . . . . . . . . . . . . . . . . . . . 81
progesterone cap 100mg . . . . . . . . . . . 81
progesterone cap 200mg . . . . . . . . . . . 81
PROGLYCEM SUS 50MG/ML . . . . . . . . . 54
PROGRAF . . . . . . . . . . . . . . . . . . . . . . . 85
PROGRAF INJ 5MG/ML . . . . . . . . . . . . . 85
PROLASTIN-C INJ 1000MG . . . . . . . . . . 94
PROLEUKIN INJ 22MU . . . . . . . . . . . . . 38
PROLIA SOL 60MG/ML . . . . . . . . . . . . . 88
PROLIXIN . . . . . . . . . . . . . . . . . . . . . . . . 43
PROLOPRIM . . . . . . . . . . . . . . . . . . . . . 16
PROMACTA TAB 12.5MG . . . . . . . . . . . 57
PROMACTA TAB 25MG . . . . . . . . . . . . 57
PROMACTA TAB 50MG . . . . . . . . . . . . 57
PROMACTA TAB 75MG . . . . . . . . . . . . 58
promethazine inj 25mg/ml . . . . . . . . . 32
promethazine tab 12.5mg . . . . . . . . . . 32
propafenone tab 150mg . . . . . . . . . . . 61
propranolol cap 120mg er . . . . . . . . . . 63
propranolol cap 160mg er . . . . . . . . . . 63
propranolol cap 60mg er . . . . . . . . . . . 63
propranolol cap 80mg er . . . . . . . . . . . 63
propranolol tab 10mg . . . . . . . . . . . . . 63
propylthiour tab 50mg . . . . . . . . . . . . 84
propylthiouracil . . . . . . . . . . . . . . . . . . 84
PROQUAD INJ . . . . . . . . . . . . . . . . . . . . 87
PROSCAR . . . . . . . . . . . . . . . . . . . . . . . . 75
PROTONIX . . . . . . . . . . . . . . . . . . . . . . . 74
PROTONIX INJ 40MG . . . . . . . . . . . . . . 74
PROTOPIC . . . . . . . . . . . . . . . . . . . . . . . 71
protriptylin tab 10mg . . . . . . . . . . . . . 31
protriptylin tab 5mg . . . . . . . . . . . . . . 31
PROVENTIL - VENTOLIN . . . . . . . . . . . . 92
PROVENTIL AER HFA . . . . . . . . . . . . . . 93
PROVERA . . . . . . . . . . . . . . . . . . . . . . . 81
PROVIGIL . . . . . . . . . . . . . . . . . . . . . . . . 95
PROZAC . . . . . . . . . . . . . . . . . . . . . . . . . 29
PSORCON . . . . . . . . . . . . . . . . . . . . . . . 77
PULMICORT . . . . . . . . . . . . . . . . . . . . . . 91
PULMICORT INH 180MCG . . . . . . . . . . 91
PULMOZYME SOL 1MG/ML . . . . . . . . . 94
PURINETHOL . . . . . . . . . . . . . . . . . . . . . 37
PURIXAN SUS 20MG/ML . . . . . . . . . . . . 37
PYRAZINAMIDE . . . . . . . . . . . . . . . . . . 35
pyrazinamide tab 500mg . . . . . . . . . . . 35
pyridostigm tab 60mg . . . . . . . . . . . . . 35
pyridostigmine . . . . . . . . . . . . . . . . . . . 35
pyrimethamine . . . . . . . . . . . . . . . . . . . 41
Q
qnapril/hctz tab 10-12.5mg . . . . . . . . . 61
qnapril/hctz tab 20-12.5mg . . . . . . . . . 61
qnapril/hctz tab 20-25mg . . . . . . . . . . 61
QUALAQUIN . . . . . . . . . . . . . . . . . . . . . 42
quasense . . . . . . . . . . . . . . . . . . . . . . . . 81
QUESTRAN . . . . . . . . . . . . . . . . . . . . . . 68
quetiapine tab 100mg . . . . . . . . . . . . . 28
quetiapine tab 25mg . . . . . . . . . . . . . . 28
quetiapine tab 50mg . . . . . . . . . . . . . . 28
quinapril tab 10mg . . . . . . . . . . . . . . . 61
quinapril tab 20mg . . . . . . . . . . . . . . . 61
quinapril tab 40mg . . . . . . . . . . . . . . . 61
quinapril tab 5mg . . . . . . . . . . . . . . . . 61
quinidine gl . . . . . . . . . . . . . . . . . . . . . 61
quinidine gl tab 324mg cr . . . . . . . . . . 61
quinidine su . . . . . . . . . . . . . . . . . . . . . 61
quinidine su tab 200mg . . . . . . . . . . . . 61
quinidine su tab 300mg . . . . . . . . . . . . 62
quinine sulf cap 324mg . . . . . . . . . . . . 42
QUIXIN . . . . . . . . . . . . . . . . . . . . . . . . . 20
QVAR AER 40MCG . . . . . . . . . . . . . . . . 91
QVAR AER 80MCG . . . . . . . . . . . . . . . . 91
R
RABAVERT INJ . . . . . . . . . . . . . . . . . . . . 87
rabbit anti-human t-lymphocyte . . . . . 86
globulin
rabies vaccine human diploid cell . . . . 87
rabies virus vaccine . . . . . . . . . . . . . . . . 87
raloxifene tab 60mg . . . . . . . . . . . . . . . 81
raltegravir . . . . . . . . . . . . . . . . . . . . . . . 48
ramelteon . . . . . . . . . . . . . . . . . . . . . . . 95
ramipril cap 1.25mg . . . . . . . . . . . . . . . 61
ramipril cap 10mg . . . . . . . . . . . . . . . . 61
ramipril cap 2.5mg . . . . . . . . . . . . . . . . 61
ramipril cap 5mg . . . . . . . . . . . . . . . . . 61
RANEXA TAB 1000MG . . . . . . . . . . . . . 65
RANEXA TAB 500MG . . . . . . . . . . . . . . 65
ranitidine cap 150mg . . . . . . . . . . . . . . 73
ranitidine cap 300mg . . . . . . . . . . . . . . 73
ranitidine inj 150/6ml . . . . . . . . . . . . . . 73
ranitidine syp 15mg/ml . . . . . . . . . . . . 73
ranitidine tab 150mg . . . . . . . . . . . . . . 73
ranitidine tab 300mg . . . . . . . . . . . . . . 74
ranolazine . . . . . . . . . . . . . . . . . . . . . . . 65
RAPAMUNE . . . . . . . . . . . . . . . . . . . . . . 85
RAPAMUNE SOL 1MG/ML . . . . . . . . . . 85
rasagiline . . . . . . . . . . . . . . . . . . . . . . . 43
rasburicase . . . . . . . . . . . . . . . . . . . . . . 37
RAVICTI LIQ 1.1GM/ML . . . . . . . . . . . . 72
RAZADYNE ER . . . . . . . . . . . . . . . . . . . 26
REBETOL . . . . . . . . . . . . . . . . . . . . . . . . 47
REBETOL-COPEGUS . . . . . . . . . . . . . . . 47
REBIF INJ 22/0.5ML . . . . . . . . . . . . . . . . 70
REBIF INJ 44/0.5ML . . . . . . . . . . . . . . . . 70
REBIF TITRTN SOL PACK . . . . . . . . . . . . 70
RECLAST . . . . . . . . . . . . . . . . . . . . . . . . 88
RECOMBIVA HB INJ 10MCG/ML . . . . . . 87
RECOMBIVA HB INJ 5MCG/0.5ML . . . . 87
RECOMBIVA-HB INJ 40MCG/ML . . . . . . 87
REGLAN . . . . . . . . . . . . . . . . . . . . . . . . . 31
RELAFEN . . . . . . . . . . . . . . . . . . . . . . . . 12
RELENZA MIS DISKHALE . . . . . . . . . . . 50
RELISTOR INJ 12/0.6ML . . . . . . . . . . . . . 73
RELISTOR INJ 8/0.4ML . . . . . . . . . . . . . . 73
RELISTOR KIT 12/0.6ML . . . . . . . . . . . . 73
REMERON . . . . . . . . . . . . . . . . . . . . . . . 27
133
Index of Drugs
REMICADE INJ 100MG . . . . . . . . . . . . . 85
REMINYL, RAZADYNE . . . . . . . . . . . . . 26
RENAGEL TAB 400MG . . . . . . . . . . . . . 76
RENAGEL TAB 800MG . . . . . . . . . . . . . 76
RENVELA PAK 0.8GM . . . . . . . . . . . . . . 76
RENVELA PAK 2.4GM . . . . . . . . . . . . . . 76
repaglinide tab 0.5mg . . . . . . . . . . . . . 53
repaglinide tab 1mg . . . . . . . . . . . . . . 53
repaglinide tab 2mg . . . . . . . . . . . . . . 53
REQUIP . . . . . . . . . . . . . . . . . . . . . . . . . 43
RESCRIPTOR TAB 100 MG . . . . . . . . . . . 48
RESCRIPTOR TAB 200MG . . . . . . . . . . . 48
RESTASIS EMU 0.05% . . . . . . . . . . . . . . 89
RESTORIL . . . . . . . . . . . . . . . . . . . . . . . . 95
RETIN-A . . . . . . . . . . . . . . . . . . . . . . . . . 71
RETIN-A, AVITA . . . . . . . . . . . . . . . . . . . 71
RETROVIR . . . . . . . . . . . . . . . . . . . . . . . 49
RETROVIR INJ 10MG/ML . . . . . . . . . . . . 49
REVATIO . . . . . . . . . . . . . . . . . . . . . . . . 94
REVLIMID CAP 10MG . . . . . . . . . . . . . . 36
REVLIMID CAP 15MG . . . . . . . . . . . . . . 36
REVLIMID CAP 2.5MG . . . . . . . . . . . . . 36
REVLIMID CAP 20MG . . . . . . . . . . . . . . 36
REVLIMID CAP 25MG . . . . . . . . . . . . . . 36
REVLIMID CAP 5MG . . . . . . . . . . . . . . . 36
REYATAZ CAP 150MG . . . . . . . . . . . . . . 50
REYATAZ CAP 200MG . . . . . . . . . . . . . . 50
REYATAZ CAP 300MG . . . . . . . . . . . . . . 50
REYATAZ POW 50MG . . . . . . . . . . . . . . 50
ribapak pak 1200/day . . . . . . . . . . . . . . 47
ribapak pak 800/day . . . . . . . . . . . . . . . 47
ribasphere cap 200mg . . . . . . . . . . . . . 47
ribasphere tab 200mg . . . . . . . . . . . . . 47
RIBASPHERE, REBETOL . . . . . . . . . . . . . 47
RIBASPHERE, REBETOL-COPEGUS . . . . 47
ribavirin . . . . . . . . . . . . . . . . . . . . . . . . . 47
ribavirin 20 mg/ml inhalant . . . . . . . . . 50
ribavirin cap 200mg . . . . . . . . . . . . . . . 47
ribavirin tab 200mg . . . . . . . . . . . . . . . 47
RIDAURA CAP 3MG . . . . . . . . . . . . . . . 86
rifabutin . . . . . . . . . . . . . . . . . . . . . . . . 35
rifabutin cap 150mg . . . . . . . . . . . . . . . 35
RIFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 35
rifampin cap 150mg . . . . . . . . . . . . . . . 35
rifampin cap 300mg . . . . . . . . . . . . . . . 35
rifampin inj 600 mg . . . . . . . . . . . . . . . 35
RIFATER TAB . . . . . . . . . . . . . . . . . . . . . 35
rilonacept . . . . . . . . . . . . . . . . . . . . . . . 86
rilpivirine . . . . . . . . . . . . . . . . . . . . . . . . 48
RILUTEK . . . . . . . . . . . . . . . . . . . . . . . . . 70
riluzole tab 50mg . . . . . . . . . . . . . . . . . 70
rimantadine tab 100mg . . . . . . . . . . . . 50
ringers . . . . . . . . . . . . . . . . . . . . . . . . . . 96
134
ringers irrigation soln . . . . . . . . . . . . . 96
ringers sol . . . . . . . . . . . . . . . . . . . . . . . 96
riociguat . . . . . . . . . . . . . . . . . . . . . . . . 65
risedronate tab 150mg . . . . . . . . . . . . 88
RISPERDAL . . . . . . . . . . . . . . . . . . . . . . 45
RISPERDAL INJ 12.5MG . . . . . . . . . . . . 45
RISPERDAL INJ 25MG . . . . . . . . . . . . . . 45
RISPERDAL INJ 37.5MG . . . . . . . . . . . . 45
RISPERDAL INJ 50MG . . . . . . . . . . . . . . 45
RISPERDAL M . . . . . . . . . . . . . . . . . . . . 45
risperidone . . . . . . . . . . . . . . . . . . . . . . 45
risperidone sol 1mg/ml . . . . . . . . . . . . 45
risperidone tab 0.25 odt . . . . . . . . . . . 45
risperidone tab 0.25mg . . . . . . . . . . . . 45
risperidone tab 0.5mg . . . . . . . . . . . . . 45
risperidone tab 0.5mg odt . . . . . . . . . . 45
risperidone tab 1mg . . . . . . . . . . . . . . . 45
risperidone tab 1mg odt . . . . . . . . . . . 45
RITALIN . . . . . . . . . . . . . . . . . . . . . . . . . 69
ritonavir . . . . . . . . . . . . . . . . . . . . . . . . 50
RITUXAN INJ 500MG . . . . . . . . . . . . . . 41
rituximab . . . . . . . . . . . . . . . . . . . . . . . 41
rivaroxaban . . . . . . . . . . . . . . . . . . . . . . 56
rivastigmine cap 1.5mg . . . . . . . . . . . . 26
rivastigmine cap 3mg . . . . . . . . . . . . . . 26
rivastigmine cap 4.5mg . . . . . . . . . . . . 27
rivastigmine cap 6mg . . . . . . . . . . . . . . 27
rivastigmine patch . . . . . . . . . . . . . . . . 26
rizatriptan tab 10mg . . . . . . . . . . . . . . 34
rizatriptan tab 10mg odt . . . . . . . . . . . 34
rizatriptan tab 5mg . . . . . . . . . . . . . . . 34
rizatriptan tab 5mg odt . . . . . . . . . . . . 35
ROBAXIN . . . . . . . . . . . . . . . . . . . . . . . . 94
ROBAXIN-750 . . . . . . . . . . . . . . . . . . . . 94
ROBINUL . . . . . . . . . . . . . . . . . . . . . . . . 72
ROCALTROL . . . . . . . . . . . . . . . . . . . . . 88
ROCEPHIN . . . . . . . . . . . . . . . . . . . . . . . 17
roflumilast . . . . . . . . . . . . . . . . . . . . . . 93
romidepsin . . . . . . . . . . . . . . . . . . . . . . 37
ROMYCIN . . . . . . . . . . . . . . . . . . . . . . . 20
ropinirole tab 0.25mg . . . . . . . . . . . . . 43
ropinirole tab 0.5mg . . . . . . . . . . . . . . 43
ropinirole tab 1mg . . . . . . . . . . . . . . . . 43
rosiglitazone . . . . . . . . . . . . . . . . . . . . . 52
ROTARIX SUS . . . . . . . . . . . . . . . . . . . . 87
ROTATEQ SOL . . . . . . . . . . . . . . . . . . . . 87
rotavirus vaccine . . . . . . . . . . . . . . . . . . 87
rotigotine transdermal patch . . . . . . . 42
ROWASA . . . . . . . . . . . . . . . . . . . . . . . . 87
ROXICODONE . . . . . . . . . . . . . . . . . . . . 14
ROZEREM TAB 8MG . . . . . . . . . . . . . . . 95
rufinamide . . . . . . . . . . . . . . . . . . . . . . 25
ruxolitinib . . . . . . . . . . . . . . . . . . . . . . . 39
RYTHMOL . . . . . . . . . . . . . . . . . . . . . . . 61
S
SABRIL POW 500MG . . . . . . . . . . . . . . . 24
SABRIL TAB 500MG . . . . . . . . . . . . . . . 24
sacrosidase . . . . . . . . . . . . . . . . . . . . . . 73
SALAGEN . . . . . . . . . . . . . . . . . . . . . . . . 70
salmeterol . . . . . . . . . . . . . . . . . . . . . . . 93
salmon calcitonin . . . . . . . . . . . . . . . . . 88
SANCTURA . . . . . . . . . . . . . . . . . . . . . . 75
SANDIMMUNE . . . . . . . . . . . . . . . . . . . 84
SANDIMMUNE SOL 100MG/ML . . . . . . 85
SANDOSTATIN . . . . . . . . . . . . . . . . . . . . 83
SANDOSTATIN KIT LAR 10MG . . . . . . . 83
SANTYL OIN 250/GM . . . . . . . . . . . . . . 71
SAPHRIS SUB 10MG . . . . . . . . . . . . . . . 46
SAPHRIS SUB 2.5MG . . . . . . . . . . . . . . . 46
SAPHRIS SUB 5MG . . . . . . . . . . . . . . . . 46
sapropterin . . . . . . . . . . . . . . . . . . . . . . 72
saquinavir . . . . . . . . . . . . . . . . . . . . . . . 50
sargramostim . . . . . . . . . . . . . . . . . . . . 57
saxagliptin . . . . . . . . . . . . . . . . . . . . . . 53
saxagliptin - metformin . . . . . . . . . . . . 53
scopolamine transdermal patch . . . . . 32
SEASONALE . . . . . . . . . . . . . . . . . . . . . . 81
SECTRAL . . . . . . . . . . . . . . . . . . . . . . . . 62
selegiline . . . . . . . . . . . . . . . . . . . . . . . . 28
selegiline cap 5mg . . . . . . . . . . . . . . . . 43
selegiline tab 5mg . . . . . . . . . . . . . . . . 43
selenium sul lot 2.5% . . . . . . . . . . . . . . 71
SELSUN . . . . . . . . . . . . . . . . . . . . . . . . . 71
SELZENTRY TAB 150MG . . . . . . . . . . . . 49
SELZENTRY TAB 300MG . . . . . . . . . . . . 49
SENSIPAR TAB 30MG . . . . . . . . . . . . . . 83
SENSIPAR TAB 60MG . . . . . . . . . . . . . . 83
SENSIPAR TAB 90MG . . . . . . . . . . . . . . 83
SERAX . . . . . . . . . . . . . . . . . . . . . . . . . . 51
SEREVENT DIS AER 50MCG . . . . . . . . . 93
SEROQUEL . . . . . . . . . . . . . . . . . . . . . . . 28
sertraline con 20mg/ml . . . . . . . . . . . . 29
sertraline tab 100mg . . . . . . . . . . . . . . 29
Index of Drugs
sertraline tab 25mg . . . . . . . . . . . . . . . 29
sertraline tab 50mg . . . . . . . . . . . . . . . 29
SERZONE . . . . . . . . . . . . . . . . . . . . . . . . 29
sevelamer . . . . . . . . . . . . . . . . . . . . . . . 76
SIGNIFOR INJ 0.3MG/ML . . . . . . . . . . . . 83
sildenafil . . . . . . . . . . . . . . . . . . . . . . . . 76
sildenafil tab 20mg . . . . . . . . . . . . . . . 94
SILVADENE - SSD . . . . . . . . . . . . . . . . . . 21
silver sulfa cre 1% . . . . . . . . . . . . . . . . 21
SIMBRINZA SUS 1-0.2% . . . . . . . . . . . . 90
simvastatin tab 10mg . . . . . . . . . . . . . . 67
simvastatin tab 5mg . . . . . . . . . . . . . . . 67
SINEMET . . . . . . . . . . . . . . . . . . . . . . . . 43
SINEMET CR . . . . . . . . . . . . . . . . . . . . . 43
SINEQUAN . . . . . . . . . . . . . . . . . . . . . . . 31
SINGULAIR . . . . . . . . . . . . . . . . . . . . . . 92
sirolimus . . . . . . . . . . . . . . . . . . . . . . . . 85
sirolimus tab 0.5mg . . . . . . . . . . . . . . . 85
sirolimus tab 1mg . . . . . . . . . . . . . . . . . 85
sirolimus tab 2mg . . . . . . . . . . . . . . . . . 85
SIRTURO TAB 100MG . . . . . . . . . . . . . . 35
sitagliptin . . . . . . . . . . . . . . . . . . . . . . . 53
smz-tmp inj 400-80/5ml . . . . . . . . . . . . 21
smz-tmp sus 200-40/5ml . . . . . . . . . . . . 21
smz-tmp tab 400-80mg . . . . . . . . . . . . 21
smz/tmp ds tab 800-160mg . . . . . . . . . 21
sod chloride 0.45% . . . . . . . . . . . . . . . 96
sod chloride 0.9% . . . . . . . . . . . . . . . . 97
sod chloride inj 0.45% . . . . . . . . . . . . . 96
sod chloride inj 0.9% . . . . . . . . . . . . . . 97
sod fluoride . . . . . . . . . . . . . . . . . . . . . 97
sod poly sul sus 15gm/60ml . . . . . . . . . 95
sod sulfacet sol 10% . . . . . . . . . . . . . . . 21
sodium chlor sol 0.9% . . . . . . . . . . . . . 97
SODIUM CHLORIDE IRRIGATION . . . . . 97
sodium fluoride tab 1mg f . . . . . . . . . . 97
sodium oxybate . . . . . . . . . . . . . . . . . . 95
sodium phenylbutyrate . . . . . . . . . . . . 72
sofosbuvir 400 mg . . . . . . . . . . . . . . . . 48
SOLARAZE . . . . . . . . . . . . . . . . . . . . . . . 71
solifenacin . . . . . . . . . . . . . . . . . . . . . . . 75
SOLODYN . . . . . . . . . . . . . . . . . . . . . . . 21
SOLTAMOX SOL 10MG/5ML . . . . . . . . . 37
SOLU-MEDROL . . . . . . . . . . . . . . . . . . . 78
SOMA . . . . . . . . . . . . . . . . . . . . . . . . . . 94
somatropin . . . . . . . . . . . . . . . . . . . . . . 79
SOMATULINE INJ 120/.5ML . . . . . . . . . 83
SOMATULINE INJ 60/0.2ML . . . . . . . . . 83
SOMATULINE INJ 90/0.3ML . . . . . . . . . 84
SOMAVERT INJ 10MG . . . . . . . . . . . . . . 84
SOMAVERT INJ 15MG . . . . . . . . . . . . . . 84
SOMAVERT INJ 20MG . . . . . . . . . . . . . . 84
SOMAVERT INJ 25MG . . . . . . . . . . . . . . 84
SOMAVERT INJ 30MG . . . . . . . . . . . . . . 84
SONATA . . . . . . . . . . . . . . . . . . . . . . . . . 95
sorafenib . . . . . . . . . . . . . . . . . . . . . . . . 40
SORIATANE . . . . . . . . . . . . . . . . . . . . . . 71
sorine tab 120mg . . . . . . . . . . . . . . . . . 62
sorine tab 160mg . . . . . . . . . . . . . . . . . 62
sorine tab 240mg . . . . . . . . . . . . . . . . . 62
sorine tab 80mg . . . . . . . . . . . . . . . . . . 62
SORINE, BETAPACE . . . . . . . . . . . . . . . . 62
sotalol af tab 120mg . . . . . . . . . . . . . . 62
sotalol hcl tab 160mg . . . . . . . . . . . . . . 62
sotalol hcl tab 240mg . . . . . . . . . . . . . . 62
sotalol hcl tab 80mg . . . . . . . . . . . . . . . 62
SOVALDI TAB 400MG . . . . . . . . . . . . . . 48
SPECTAZOLE . . . . . . . . . . . . . . . . . . . . . 33
spirono/hctz tab 25/25mg . . . . . . . . . . 67
spironolact tab 100mg . . . . . . . . . . . . . 66
spironolact tab 25mg . . . . . . . . . . . . . . 66
spironolact tab 50mg . . . . . . . . . . . . . . 66
SPORANOX . . . . . . . . . . . . . . . . . . . . . . 33
sprintec 28 day . . . . . . . . . . . . . . . . . . . 81
SPRYCEL TAB 100MG . . . . . . . . . . . . . . 40
SPRYCEL TAB 140MG . . . . . . . . . . . . . . 40
SPRYCEL TAB 20MG . . . . . . . . . . . . . . . 40
SPRYCEL TAB 50MG . . . . . . . . . . . . . . . 40
SPRYCEL TAB 70MG . . . . . . . . . . . . . . . 40
SPRYCEL TAB 80MG . . . . . . . . . . . . . . . 40
ssd cre 1% . . . . . . . . . . . . . . . . . . . . . . . 21
STARLIX . . . . . . . . . . . . . . . . . . . . . . . . . 53
stavudine cap 15mg . . . . . . . . . . . . . . . 49
stavudine cap 20mg . . . . . . . . . . . . . . . 49
stavudine cap 30mg . . . . . . . . . . . . . . . 49
stavudine cap 40mg . . . . . . . . . . . . . . . 49
stavudine sol 1mg/ml . . . . . . . . . . . . . . 49
STELAZINE . . . . . . . . . . . . . . . . . . . . . . . 44
steril water sol . . . . . . . . . . . . . . . . . . . 97
STERILE WATER IRRIGATION . . . . . . . . 97
STIVARGA TAB 40MG . . . . . . . . . . . . . . 40
STRATTERA CAP 100MG . . . . . . . . . . . . 69
STRATTERA CAP 10MG . . . . . . . . . . . . . 69
STRATTERA CAP 18MG . . . . . . . . . . . . . 69
STRATTERA CAP 25MG . . . . . . . . . . . . . 69
STRATTERA CAP 40MG . . . . . . . . . . . . . 69
STRATTERA CAP 60MG . . . . . . . . . . . . . 69
STRATTERA CAP 80MG . . . . . . . . . . . . . 69
streptomycin . . . . . . . . . . . . . . . . . . . . . 15
streptomycin inj 1gm . . . . . . . . . . . . . . 15
STRIBILD TAB . . . . . . . . . . . . . . . . . . . . 48
STRIVERDI AER RESPIMAT . . . . . . . . . . 93
STROMECTOL TAB 3MG . . . . . . . . . . . . 41
SUBOXONE MIS 12-3MG . . . . . . . . . . . 15
SUBOXONE MIS 2-0.5MG . . . . . . . . . . . 15
SUBOXONE MIS 4-1MG . . . . . . . . . . . . 15
SUBOXONE MIS 8-2MG . . . . . . . . . . . . 15
SUBUTEX . . . . . . . . . . . . . . . . . . . . . . . . 15
SUCRAID SOL 8500/ML . . . . . . . . . . . . . 73
sucralfate tab 1gm . . . . . . . . . . . . . . . . 74
SULAR . . . . . . . . . . . . . . . . . . . . . . . . . . 64
sulf/pred na sol . . . . . . . . . . . . . . . . . . . 89
sulfacet sod oin 10% . . . . . . . . . . . . . . 21
sulfacetamid sus 10% . . . . . . . . . . . . . . 21
sulfadiazine . . . . . . . . . . . . . . . . . . . . . 21
sulfadiazine tab 500mg . . . . . . . . . . . . 21
SULFAMYLON CRE 85MG/GM . . . . . . . 16
SULFAMYLON PAK 5% . . . . . . . . . . . . . 16
sulfasalazin tab 500mg . . . . . . . . . . . . 88
sulfazine ec tab 500mg . . . . . . . . . . . . 88
sulindac tab 150mg . . . . . . . . . . . . . . . 12
sulindac tab 200mg . . . . . . . . . . . . . . . 12
sumatriptan inj 6mg/0.5ml . . . . . . . . . 35
sumatriptan tab 100mg . . . . . . . . . . . . 35
sumatriptan tab 25mg . . . . . . . . . . . . . 35
sumatriptan tab 50mg . . . . . . . . . . . . . 35
sunitinib . . . . . . . . . . . . . . . . . . . . . . . . 40
SUPRAX CAP 400MG . . . . . . . . . . . . . . 18
SURMONTIL CAP 100MG . . . . . . . . . . . 31
SURMONTIL CAP 25MG . . . . . . . . . . . . 31
SURMONTIL CAP 50MG . . . . . . . . . . . . 31
SUSTIVA CAP 200MG . . . . . . . . . . . . . . 48
SUSTIVA CAP 50MG . . . . . . . . . . . . . . . 48
SUSTIVA TAB 600MG . . . . . . . . . . . . . . 48
SUTENT CAP 12.5MG . . . . . . . . . . . . . . 40
SUTENT CAP 25MG . . . . . . . . . . . . . . . . 40
SUTENT CAP 37.5MG . . . . . . . . . . . . . . 40
SUTENT CAP 50MG . . . . . . . . . . . . . . . . 40
SYLATRON KIT 296MCG . . . . . . . . . . . . 47
SYLATRON KIT 444MCG . . . . . . . . . . . . 47
SYLATRON KIT 888MCG . . . . . . . . . . . . 47
SYMBICORT AER 160-4.5 . . . . . . . . . . . 94
SYMBICORT AER 80-4.5 . . . . . . . . . . . . 94
SYMBYAX . . . . . . . . . . . . . . . . . . . . . . . 28
SYMLINPEN 60 INJ 1000MCG . . . . . . . . 53
SYMLNPEN 120 INJ 1000MCG . . . . . . . 53
SYMMETREL . . . . . . . . . . . . . . . . . . . . . 42
SYNAGIS INJ 50MG . . . . . . . . . . . . . . . . 86
SYNALAR . . . . . . . . . . . . . . . . . . . . . . . . 77
SYNAREL SOL 2MG/ML . . . . . . . . . . . . . 84
SYNERCID INJ 500MG . . . . . . . . . . . . . . 16
SYNRIBO INJ 3.5MG . . . . . . . . . . . . . . . 38
SYNTHROID TAB 100MCG . . . . . . . . . . 82
135
Index of Drugs
SYNTHROID TAB 25MCG . . . . . . . . . . . 82
SYPRINE CAP 250MG . . . . . . . . . . . . . . 95
T
TABLOID TAB 40MG . . . . . . . . . . . . . . . 37
tacrolimus . . . . . . . . . . . . . . . . . . . . . . . 85
tacrolimus cap 0.5mg . . . . . . . . . . . . . . 85
tacrolimus cap 1mg . . . . . . . . . . . . . . . 85
tacrolimus cap 5mg . . . . . . . . . . . . . . . 85
tacrolimus er . . . . . . . . . . . . . . . . . . . . . 84
tacrolimus oin 0.03% . . . . . . . . . . . . . . 71
tacrolimus oin 0.1% . . . . . . . . . . . . . . . 71
tadalafil . . . . . . . . . . . . . . . . . . . . . . . . . 93
TAFINLAR CAP 50MG . . . . . . . . . . . . . . 40
TAFINLAR CAP 75MG . . . . . . . . . . . . . . 40
tafluprost . . . . . . . . . . . . . . . . . . . . . . . 91
TAGAMET . . . . . . . . . . . . . . . . . . . . . . . 73
TAMBOCOR . . . . . . . . . . . . . . . . . . . . . . 61
TAMIFLU CAP 30MG . . . . . . . . . . . . . . . 50
TAMIFLU CAP 45MG . . . . . . . . . . . . . . . 50
TAMIFLU CAP 75MG . . . . . . . . . . . . . . . 50
TAMIFLU SUS 6MG/ML . . . . . . . . . . . . . 50
tamoxifen . . . . . . . . . . . . . . . . . . . . . . . 37
tamoxifen tab 10mg . . . . . . . . . . . . . . 37
tamoxifen tab 20mg . . . . . . . . . . . . . . 37
tamsulosin cap 0.4mg . . . . . . . . . . . . . 75
TAPAZOLE . . . . . . . . . . . . . . . . . . . . . . . 84
TARCEVA TAB 100MG . . . . . . . . . . . . . 40
TARCEVA TAB 150MG . . . . . . . . . . . . . 40
TARCEVA TAB 25MG . . . . . . . . . . . . . . 40
TARGRETIN CAP 75MG . . . . . . . . . . . . . 41
TARGRETIN GEL 1% . . . . . . . . . . . . . . . 41
TASIGNA CAP 150MG . . . . . . . . . . . . . . 40
TASIGNA CAP 200MG . . . . . . . . . . . . . . 40
tasimelteon . . . . . . . . . . . . . . . . . . . . . . 95
TASMAR TAB 100MG . . . . . . . . . . . . . . 42
TAXOL . . . . . . . . . . . . . . . . . . . . . . . . . . 38
tazarotene . . . . . . . . . . . . . . . . . . . . . . 71
TAZORAC CRE 0.05% . . . . . . . . . . . . . . 71
TAZORAC CRE 0.1% . . . . . . . . . . . . . . . 71
TAZORAC GEL 0.05% . . . . . . . . . . . . . . 71
TAZORAC GEL 0.1% . . . . . . . . . . . . . . . 71
taztia xt cap 120mg/24hr . . . . . . . . . . . 64
136
TAZTIA XT, DILTZAC . . . . . . . . . . . . . . . 63
teduglutide . . . . . . . . . . . . . . . . . . . . . . 73
TEFLARO INJ 400MG . . . . . . . . . . . . . . 18
TEFLARO INJ 600MG . . . . . . . . . . . . . . 18
TEGRETOL . . . . . . . . . . . . . . . . . . . . . . . 25
TEGRETOL XR . . . . . . . . . . . . . . . . . . . . 25
telbivudine . . . . . . . . . . . . . . . . . . . . . . 47
telmisartan tab 20mg . . . . . . . . . . . . . . 59
temazepam cap 15mg . . . . . . . . . . . . . 95
temsirolimus . . . . . . . . . . . . . . . . . . . . . 85
tenofovir . . . . . . . . . . . . . . . . . . . . . . . . 49
TENORETIC . . . . . . . . . . . . . . . . . . . . . . 62
TENORMIN . . . . . . . . . . . . . . . . . . . . . . 62
TERAZOL, ZAZOLE . . . . . . . . . . . . . . . . 34
terazosin cap 10mg . . . . . . . . . . . . . . . 59
terazosin cap 1mg . . . . . . . . . . . . . . . . 59
terazosin cap 2mg . . . . . . . . . . . . . . . . 59
terazosin cap 5mg . . . . . . . . . . . . . . . . 59
terbinafine tab 250mg . . . . . . . . . . . . . 34
terconazole cre 0.4% . . . . . . . . . . . . . . 34
terconazole cre 0.8% . . . . . . . . . . . . . . 34
terconazole sup 80mg . . . . . . . . . . . . . 34
teriparatide . . . . . . . . . . . . . . . . . . . . . . 88
TESSALON . . . . . . . . . . . . . . . . . . . . . . . 91
TESTIM GEL 1%(50MG) . . . . . . . . . . . . 79
testost cyp inj 100mg/ml . . . . . . . . . . . 79
testost cyp inj 200mg/ml . . . . . . . . . . . 79
testosterone . . . . . . . . . . . . . . . . . . . . . 79
testosterone cypionate . . . . . . . . . . . . 79
TET/DIP TOX INJ 2-2 LF . . . . . . . . . . . . . 87
tetrabenazine . . . . . . . . . . . . . . . . . . . . 70
thalidomide . . . . . . . . . . . . . . . . . . . . . 36
THALITONE . . . . . . . . . . . . . . . . . . . . . . 66
THALOMID CAP 100MG . . . . . . . . . . . . 36
THALOMID CAP 150MG . . . . . . . . . . . . 36
THALOMID CAP 200MG . . . . . . . . . . . . 37
THALOMID CAP 50MG . . . . . . . . . . . . . 37
THEO-DUR . . . . . . . . . . . . . . . . . . . . . . . 93
THEOCHRON SR . . . . . . . . . . . . . . . . . . 93
theophylline tab 100mg cr . . . . . . . . . 93
theophylline tab 200mg cr . . . . . . . . . 93
theophylline tab 300mg er . . . . . . . . . 93
thioguanine . . . . . . . . . . . . . . . . . . . . . 37
thioridazine tab 100mg . . . . . . . . . . . . 44
thioridazine tab 10mg . . . . . . . . . . . . . 44
thiothixene cap 10mg . . . . . . . . . . . . . 44
thiothixene cap 1mg . . . . . . . . . . . . . . 44
THORAZINE . . . . . . . . . . . . . . . . . . . . . . 31
THYMOGLOBULN INJ 25MG . . . . . . . . 86
tiagabine . . . . . . . . . . . . . . . . . . . . . . . . 23
tiagabine tab 2mg . . . . . . . . . . . . . . . . 24
tiagabine tab 4mg . . . . . . . . . . . . . . . . 24
ticagrelor . . . . . . . . . . . . . . . . . . . . . . . 58
tigecycline . . . . . . . . . . . . . . . . . . . . . . . 16
TIKOSYN CAP 125MCG . . . . . . . . . . . . . 62
TIKOSYN CAP 250MCG . . . . . . . . . . . . . 62
TIKOSYN CAP 500MCG . . . . . . . . . . . . . 62
timolol gel sol 0.25% . . . . . . . . . . . . . . 90
timolol gel sol 0.5% . . . . . . . . . . . . . . . 90
timolol mal sol 0.25% . . . . . . . . . . . . . 90
timolol mal sol 0.5% . . . . . . . . . . . . . . 90
timolol mal tab 10mg . . . . . . . . . . . . . 34
timolol mal tab 20mg . . . . . . . . . . . . . 34
timolol mal tab 5mg . . . . . . . . . . . . . . 34
TIMOPTIC . . . . . . . . . . . . . . . . . . . . . . . 90
TIMOPTIC-XE . . . . . . . . . . . . . . . . . . . . . 90
tipranavir . . . . . . . . . . . . . . . . . . . . . . . 50
TIVICAY TAB 50MG . . . . . . . . . . . . . . . . 48
tizanidine cap 2mg . . . . . . . . . . . . . . . . 46
tizanidine tab 2mg . . . . . . . . . . . . . . . . 46
tizanidine tab 4mg . . . . . . . . . . . . . . . . 46
TOBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
TOBI PODHALR CAP 28MG . . . . . . . . . 93
tobra/dexame sus 0.3-0.1% . . . . . . . . . 89
TOBRADEX . . . . . . . . . . . . . . . . . . . . . . 89
TOBRADEX OIN 0.3-0.1% . . . . . . . . . . . 15
tobramycin . . . . . . . . . . . . . . . . . . . . . . 15
tobramycin - dexamethasone . . . . . . . 15
tobramycin inhalant powder . . . . . . . . 93
tobramycin inj 80mg/2ml . . . . . . . . . . . 15
tobramycin neb 300/5ml . . . . . . . . . . . 19
tobramycin sol 0.3% . . . . . . . . . . . . . . 15
TOBREX . . . . . . . . . . . . . . . . . . . . . . . . . 15
TOFRANIL . . . . . . . . . . . . . . . . . . . . . . . 31
TOFRANIL-PM . . . . . . . . . . . . . . . . . . . . 31
tolazamide . . . . . . . . . . . . . . . . . . . . . . 53
tolazamide tab 250mg . . . . . . . . . . . . . 53
tolazamide tab 500mg . . . . . . . . . . . . . 53
tolbutamide tab 500mg . . . . . . . . . . . . 53
tolcapone . . . . . . . . . . . . . . . . . . . . . . . 42
TOLECTIN . . . . . . . . . . . . . . . . . . . . . . . 12
TOLECTIN DS . . . . . . . . . . . . . . . . . . . . . 12
tolmetin sod cap 400mg . . . . . . . . . . . 12
Index of Drugs
tolmetin sod tab 600mg . . . . . . . . . . . 12
tolterodine tab 1mg . . . . . . . . . . . . . . . 75
tolterodine tab 2mg . . . . . . . . . . . . . . . 75
TOPAMAX . . . . . . . . . . . . . . . . . . . . . . . 25
TOPICORT . . . . . . . . . . . . . . . . . . . . . . . 77
topiramate cap 15mg . . . . . . . . . . . . . . 25
topiramate cap 25mg . . . . . . . . . . . . . . 25
topiramate tab 100mg . . . . . . . . . . . . . 25
topiramate tab 200mg . . . . . . . . . . . . . 25
topiramate tab 25mg . . . . . . . . . . . . . . 25
topiramate tab 50mg . . . . . . . . . . . . . . 25
topotecan inj 4mg . . . . . . . . . . . . . . . . 38
TOPROL XL . . . . . . . . . . . . . . . . . . . . . . 63
toremifene . . . . . . . . . . . . . . . . . . . . . . 37
TORISEL SOL 25MG/ML . . . . . . . . . . . . 85
torsemide tab 100mg . . . . . . . . . . . . . . 66
torsemide tab 10mg . . . . . . . . . . . . . . . 66
torsemide tab 20mg . . . . . . . . . . . . . . . 66
torsemide tab 5mg . . . . . . . . . . . . . . . . 66
TOVIAZ TAB 4MG . . . . . . . . . . . . . . . . . 75
TOVIAZ TAB 8MG . . . . . . . . . . . . . . . . . 75
tpn electrol . . . . . . . . . . . . . . . . . . . . . . 97
tpn multilyte . . . . . . . . . . . . . . . . . . . . . 97
TRACLEER TAB 125MG . . . . . . . . . . . . . 94
TRACLEER TAB 62.5MG . . . . . . . . . . . . 94
TRADJENTA TAB 5MG . . . . . . . . . . . . . 53
tramadl/apap tab 37.5-325mg . . . . . . . 14
tramadol hcl tab 50mg . . . . . . . . . . . . 14
trametinib . . . . . . . . . . . . . . . . . . . . . . . 40
TRANDATE . . . . . . . . . . . . . . . . . . . . . . 62
trandolapril tab 1mg . . . . . . . . . . . . . . 61
tranex acid inj 100mg/ml . . . . . . . . . . . 58
tranex acid tab 650mg . . . . . . . . . . . . . 58
tranexamic . . . . . . . . . . . . . . . . . . . . . . 58
tranexamic acid . . . . . . . . . . . . . . . . . . 58
TRANSDERM-SC DIS 1.5MG . . . . . . . . . 32
TRANXENE . . . . . . . . . . . . . . . . . . . . . . 23
tranylcyprom tab 10mg . . . . . . . . . . . . 28
trastuzumab . . . . . . . . . . . . . . . . . . . . . 41
TRAVATAN . . . . . . . . . . . . . . . . . . . . . . 90
travoprost dro 0.004% . . . . . . . . . . . . . 90
trazodone tab 100mg . . . . . . . . . . . . . 30
trazodone tab 150mg . . . . . . . . . . . . . 30
trazodone tab 300mg . . . . . . . . . . . . . 30
trazodone tab 50mg . . . . . . . . . . . . . . 30
TRECATOR TAB 250MG . . . . . . . . . . . . 35
TRENTAL . . . . . . . . . . . . . . . . . . . . . . . . 65
tretinoin cap 10mg . . . . . . . . . . . . . . . . 41
tretinoin cre 0.025% . . . . . . . . . . . . . . 71
tretinoin cre 0.05% . . . . . . . . . . . . . . . 71
tretinoin cre 0.1% . . . . . . . . . . . . . . . . 72
tretinoin gel 0.01% . . . . . . . . . . . . . . . 72
tretinoin gel 0.025% . . . . . . . . . . . . . . 72
tretinoin gel 0.04% . . . . . . . . . . . . . . . 72
tretinoin gel 0.1% . . . . . . . . . . . . . . . . 72
TREXALL . . . . . . . . . . . . . . . . . . . . . . . . 85
TREXALL TAB 10MG . . . . . . . . . . . . . . . 85
TREXALL TAB 15MG . . . . . . . . . . . . . . . 85
TREXALL TAB 5MG . . . . . . . . . . . . . . . . 85
TREXALL TAB 7.5MG . . . . . . . . . . . . . . 85
tri-previfem . . . . . . . . . . . . . . . . . . . . . . 81
tri-sprintec . . . . . . . . . . . . . . . . . . . . . . 81
triamcin/ora pst 0.1% . . . . . . . . . . . . . . 70
triamcinolon cre 0.025% . . . . . . . . . . . 78
triamcinolon cre 0.1% . . . . . . . . . . . . . 78
triamcinolon cre 0.5% . . . . . . . . . . . . . 78
triamcinolon lot 0.025% . . . . . . . . . . . 78
triamcinolon lot 0.1% . . . . . . . . . . . . . 78
triamcinolon oin 0.025% . . . . . . . . . . . 78
triamcinolon oin 0.1% . . . . . . . . . . . . . 78
triamcinolon oin 0.5% . . . . . . . . . . . . . 78
triamcinolon spr 55mcg/ac . . . . . . . . . . 91
triamcinolone . . . . . . . . . . . . . . . . . . . . 78
triamt/hctz cap 37.5-25mg . . . . . . . . . . 67
triamt/hctz tab 37.5-25mg . . . . . . . . . . 67
triamt/hctz tab 75-50mg . . . . . . . . . . . 67
triazolam tab 0.125mg . . . . . . . . . . . . . 51
triazolam tab 0.25mg . . . . . . . . . . . . . . 51
TRICOR . . . . . . . . . . . . . . . . . . . . . . . . . 67
triderm cre 0.1% . . . . . . . . . . . . . . . . . 78
trientine . . . . . . . . . . . . . . . . . . . . . . . . 95
trifluoperaz tab 10mg . . . . . . . . . . . . . 44
trifluoperaz tab 1mg . . . . . . . . . . . . . . 44
trifluridine sol 1% . . . . . . . . . . . . . . . . 51
trihexyphen elx 0.4mg/ml . . . . . . . . . . 42
trihexyphen tab 2mg . . . . . . . . . . . . . . 42
trihexyphen tab 5mg . . . . . . . . . . . . . . 42
TRILAFON . . . . . . . . . . . . . . . . . . . . . . . 32
TRILEPTAL . . . . . . . . . . . . . . . . . . . . . . . 25
TRILIPIX . . . . . . . . . . . . . . . . . . . . . . . . . 67
trilyte sol . . . . . . . . . . . . . . . . . . . . . . . . 74
TRILYTE, GAVILYTE-N . . . . . . . . . . . . . . 74
trimethoprim tab 100mg . . . . . . . . . . . 16
trimipramine . . . . . . . . . . . . . . . . . . . . . 31
TRIPLE ANTIBIOTIC . . . . . . . . . . . . . . . . 89
TRISENOX SOL 10MG/10ML . . . . . . . . . 40
TRIUMEQ TAB . . . . . . . . . . . . . . . . . . . . 49
trivora-28 . . . . . . . . . . . . . . . . . . . . . . . 81
TRIZIVIR . . . . . . . . . . . . . . . . . . . . . . . . . 48
trospium chl cap 60mg er . . . . . . . . . . 75
trospium cl tab 20mg . . . . . . . . . . . . . . 75
TRUSOPT . . . . . . . . . . . . . . . . . . . . . . . . 90
TRUVADA TAB 200-300MG . . . . . . . . . 49
TUBIZID . . . . . . . . . . . . . . . . . . . . . . . . . 35
TUDORZA PRES AER 400/ACT . . . . . . . 92
TUSSIGON . . . . . . . . . . . . . . . . . . . . . . . 91
tussigon tab 5mg . . . . . . . . . . . . . . . . . 91
TWINRIX INJ . . . . . . . . . . . . . . . . . . . . . 87
TYBOST TAB 150MG . . . . . . . . . . . . . . . 49
TYGACIL INJ 50MG . . . . . . . . . . . . . . . . 16
TYKERB TAB 250MG . . . . . . . . . . . . . . . 40
TYLENOL WITH CODEINE . . . . . . . . . . . 13
TYLENOL WITH CODEINE SOLN . . . . . . 13
TYPHIM VI INJ . . . . . . . . . . . . . . . . . . . . 87
typhoid vi polysaccharide vaccine . . . . 87
TYSABRI INJ 300/15ML . . . . . . . . . . . . . 70
TYZEKA TAB 600MG . . . . . . . . . . . . . . . 47
U
ULTRAM . . . . . . . . . . . . . . . . . . . . . . . . 14
ULTRAVATE . . . . . . . . . . . . . . . . . . . . . . 77
ULTRCET . . . . . . . . . . . . . . . . . . . . . . . . 14
uman papillomavirus - quadrivalent . . 86
hpv (6,11,16,18) vac
umeclidinium . . . . . . . . . . . . . . . . . . . . 92
umeclidinium - vilanterol . . . . . . . . . . . 94
UNASYN . . . . . . . . . . . . . . . . . . . . . . . . 18
UNIRETIC . . . . . . . . . . . . . . . . . . . . . . . . 60
UNITHROID TAB 100MCG . . . . . . . . . . 82
UNITHROID TAB 25MCG . . . . . . . . . . . 83
UNIVASC . . . . . . . . . . . . . . . . . . . . . . . . 61
URECHOLINE . . . . . . . . . . . . . . . . . . . . . 75
URISPAS . . . . . . . . . . . . . . . . . . . . . . . . . 75
UROCIT-K . . . . . . . . . . . . . . . . . . . . . . . 96
UROXATRAL . . . . . . . . . . . . . . . . . . . . . 75
URSO 250 . . . . . . . . . . . . . . . . . . . . . . . 73
URSO FORTE . . . . . . . . . . . . . . . . . . . . . 73
ursodiol cap 300mg . . . . . . . . . . . . . . . 73
ursodiol tab 250mg . . . . . . . . . . . . . . . 73
ursodiol tab 500mg . . . . . . . . . . . . . . . 73
V
valacyclovir tab 1gm . . . . . . . . . . . . . . 51
valacyclovir tab 500mg . . . . . . . . . . . . 51
VALCHLOR GEL 0.016% . . . . . . . . . . . . 38
VALCYTE . . . . . . . . . . . . . . . . . . . . . . . . 47
137
Index of Drugs
VALCYTE SOL 50MG/ML . . . . . . . . . . . . 47
valganciclov tab 450mg . . . . . . . . . . . . 47
valganciclovir . . . . . . . . . . . . . . . . . . . . 47
VALIUM . . . . . . . . . . . . . . . . . . . . . . . . . 23
valproate inj 100mg/ml . . . . . . . . . . . . 24
valproic acd cap 250mg . . . . . . . . . . . . 24
valproic acd syp 250/5ml . . . . . . . . . . . 24
valsart/hctz tab 160-12.5mg . . . . . . . . 59
valsart/hctz tab 160-25mg . . . . . . . . . . 59
valsart/hctz tab 320-12.5mg . . . . . . . . 59
valsart/hctz tab 320-25mg . . . . . . . . . . 59
valsart/hctz tab 80-12.5mg . . . . . . . . . 59
valsartan tab 160mg . . . . . . . . . . . . . . 59
valsartan tab 320mg . . . . . . . . . . . . . . 59
valsartan tab 40mg . . . . . . . . . . . . . . . 59
valsartan tab 80mg . . . . . . . . . . . . . . . 59
VALTREX . . . . . . . . . . . . . . . . . . . . . . . . 51
VANCOCIN . . . . . . . . . . . . . . . . . . . . . . 17
VANCOCIN HCL CAP 125MG . . . . . . . . 17
VANCOCIN HCL CAP 250MG . . . . . . . . 17
VANCOMYCIN . . . . . . . . . . . . . . . . . . . 17
vancomycin inj 1000mg . . . . . . . . . . . . 17
vancomycin inj 500mg . . . . . . . . . . . . . 17
vandetanib . . . . . . . . . . . . . . . . . . . . . . 39
VANTIN . . . . . . . . . . . . . . . . . . . . . . . . . 17
VAQTA INJ 25/0.5ML . . . . . . . . . . . . . . 87
varenicline . . . . . . . . . . . . . . . . . . . . . . 15
varicella virus vaccine . . . . . . . . . . . . . . 87
varicella-zoster virus vaccine . . . . . . . . 87
VARIVAX INJ . . . . . . . . . . . . . . . . . . . . . 87
VASERETIC . . . . . . . . . . . . . . . . . . . . . . 60
VASOTEC . . . . . . . . . . . . . . . . . . . . . . . . 60
VEETIDS . . . . . . . . . . . . . . . . . . . . . . . . . 19
velaglucerase alfa . . . . . . . . . . . . . . . . . 72
VELCADE INJ 3.5MG . . . . . . . . . . . . . . . 40
velivet pak . . . . . . . . . . . . . . . . . . . . . . 81
vemurafenib . . . . . . . . . . . . . . . . . . . . . 40
venlafaxine cap 150mg er . . . . . . . . . . 30
venlafaxine cap 37.5mg . . . . . . . . . . . . 30
venlafaxine cap 75mg er . . . . . . . . . . . 30
venlafaxine tab 100mg . . . . . . . . . . . . 30
venlafaxine tab 150mg er . . . . . . . . . . 30
venlafaxine tab 225mg er . . . . . . . . . . 30
venlafaxine tab 25mg . . . . . . . . . . . . . 30
venlafaxine tab 37.5 er . . . . . . . . . . . . 30
venlafaxine tab 37.5mg . . . . . . . . . . . . 30
venlafaxine tab 75mg er . . . . . . . . . . . 30
VENTAVIS SOL 10MCG/ML . . . . . . . . . . 94
VENTAVIS SOL 20MCG/ML . . . . . . . . . . 94
VENTOLIN HFA AER . . . . . . . . . . . . . . . 93
VENTOLIN NEB . . . . . . . . . . . . . . . . . . . 92
138
VEPESID . . . . . . . . . . . . . . . . . . . . . . . . . 38
verapamil cap 100mg er . . . . . . . . . . . 65
verapamil cap 360mg sr . . . . . . . . . . . . 65
verapamil tab 120mg . . . . . . . . . . . . . . 65
verapamil tab 120mg er . . . . . . . . . . . . 65
verapamil tab 40mg . . . . . . . . . . . . . . . 65
verapamil tab 80mg . . . . . . . . . . . . . . . 65
VERELAN . . . . . . . . . . . . . . . . . . . . . . . . 65
VERELAN PM . . . . . . . . . . . . . . . . . . . . . 65
VERSACLOZ SUS 50MG/ML . . . . . . . . . 46
VESANOID . . . . . . . . . . . . . . . . . . . . . . . 41
VESICARE TAB 10MG . . . . . . . . . . . . . . 75
VESICARE TAB 5MG . . . . . . . . . . . . . . . 75
VFEND . . . . . . . . . . . . . . . . . . . . . . . . . . 34
VIAGRA TAB 100MG . . . . . . . . . . . . . . . 76
VIAGRA TAB 25MG . . . . . . . . . . . . . . . . 76
VIAGRA TAB 50MG . . . . . . . . . . . . . . . . 76
vibramycin . . . . . . . . . . . . . . . . . . . . . . 21
VIBRATAB . . . . . . . . . . . . . . . . . . . . . . . 21
VICTOZA INJ 18MG/3ML . . . . . . . . . . . 54
VIDAZA . . . . . . . . . . . . . . . . . . . . . . . . . 37
VIDEX EC . . . . . . . . . . . . . . . . . . . . . . . . 49
VIDEX SOL 2GM . . . . . . . . . . . . . . . . . . 49
VIEKIRA PAK TAB . . . . . . . . . . . . . . . . . 48
vigabatrin . . . . . . . . . . . . . . . . . . . . . . . 24
VIGAMOX DRO 0.5% . . . . . . . . . . . . . . 20
VIIBRYD KIT . . . . . . . . . . . . . . . . . . . . . 30
VIIBRYD TAB 10MG . . . . . . . . . . . . . . . 30
VIIBRYD TAB 20MG . . . . . . . . . . . . . . . 30
VIIBRYD TAB 40MG . . . . . . . . . . . . . . . 30
vilazodone . . . . . . . . . . . . . . . . . . . . . . 30
VIMPAT INJ 200MG/20ML . . . . . . . . . . 26
VIMPAT SOL 10MG/ML . . . . . . . . . . . . . 26
VIMPAT TAB 100MG . . . . . . . . . . . . . . . 26
VIMPAT TAB 150MG . . . . . . . . . . . . . . . 26
VIMPAT TAB 200MG . . . . . . . . . . . . . . . 26
VIMPAT TAB 50MG . . . . . . . . . . . . . . . . 26
VIRACEPT TAB 250MG . . . . . . . . . . . . . 50
VIRACEPT TAB 625MG . . . . . . . . . . . . . 50
VIRAMUNE . . . . . . . . . . . . . . . . . . . . . . 48
VIRAMUNE SUS 50MG/5ML . . . . . . . . . 48
VIRAMUNE XR . . . . . . . . . . . . . . . . . . . 48
VIRAMUNE XR TAB 100MG . . . . . . . . . 48
VIRAZOLE INH 6GM . . . . . . . . . . . . . . . 50
VIREAD POW 40MG/GM . . . . . . . . . . . 49
VIREAD TAB 150MG . . . . . . . . . . . . . . . 49
VIREAD TAB 200MG . . . . . . . . . . . . . . . 49
VIREAD TAB 250MG . . . . . . . . . . . . . . . 49
VIREAD TAB 300MG . . . . . . . . . . . . . . . 49
VIROPTIC . . . . . . . . . . . . . . . . . . . . . . . . 51
VISKEN . . . . . . . . . . . . . . . . . . . . . . . . . 63
vismodegib . . . . . . . . . . . . . . . . . . . . . . 39
VISTARIL . . . . . . . . . . . . . . . . . . . . . . . . 51
VITEKTA TAB 150MG . . . . . . . . . . . . . . 48
VITEKTA TAB 85MG . . . . . . . . . . . . . . . 48
VIVACTIL . . . . . . . . . . . . . . . . . . . . . . . . 31
VOLTAREN . . . . . . . . . . . . . . . . . . . . . . . 11
VOLTAREN - XR . . . . . . . . . . . . . . . . . . . 11
VOLTAREN GEL 1% . . . . . . . . . . . . . . . . 72
voriconazole inj 200mg . . . . . . . . . . . . 34
voriconazole sus 40mg/ml . . . . . . . . . . 34
voriconazole tab 200mg . . . . . . . . . . . 34
voriconazole tab 50mg . . . . . . . . . . . . 34
vorinostat . . . . . . . . . . . . . . . . . . . . . . . 38
vortioxetine . . . . . . . . . . . . . . . . . . . . . 28
VOSPIRE ER . . . . . . . . . . . . . . . . . . . . . . 92
VOTRIENT TAB 200MG . . . . . . . . . . . . . 40
VPRIV INJ 400UNIT . . . . . . . . . . . . . . . . 72
W
warfarin . . . . . . . . . . . . . . . . . . . . . . . . 54
warfarin tab 10mg . . . . . . . . . . . . . . . . 56
warfarin tab 1mg . . . . . . . . . . . . . . . . . 56
warfarin tab 2.5mg . . . . . . . . . . . . . . . 56
warfarin tab 2mg . . . . . . . . . . . . . . . . . 56
warfarin tab 3mg . . . . . . . . . . . . . . . . . 56
warfarin tab 4mg . . . . . . . . . . . . . . . . . 56
warfarin tab 5mg . . . . . . . . . . . . . . . . . 56
warfarin tab 6mg . . . . . . . . . . . . . . . . . 56
warfarin tab 7.5mg . . . . . . . . . . . . . . . 56
WELCHOL PAK 3.75GM . . . . . . . . . . . . 68
WELCHOL TAB 625MG . . . . . . . . . . . . . 68
WELLBUTRIN . . . . . . . . . . . . . . . . . . . . . 27
WELLBUTRIN SR, BUDEPRION SR . . . . . 27
WELLBUTRIN XL . . . . . . . . . . . . . . . . . . 27
X
XALATAN . . . . . . . . . . . . . . . . . . . . . . . 90
XALKORI CAP 200MG . . . . . . . . . . . . . . 40
XALKORI CAP 250MG . . . . . . . . . . . . . . 40
XANAX . . . . . . . . . . . . . . . . . . . . . . . . . 51
XARELTO TAB 10MG . . . . . . . . . . . . . . 56
XARELTO TAB 15MG . . . . . . . . . . . . . . 56
XARELTO TAB 20MG . . . . . . . . . . . . . . 56
XENAZINE TAB 12.5MG . . . . . . . . . . . . 70
XENAZINE TAB 25MG . . . . . . . . . . . . . . 70
XGEVA INJ . . . . . . . . . . . . . . . . . . . . . . . 88
XIBROM . . . . . . . . . . . . . . . . . . . . . . . . . 89
XODOL . . . . . . . . . . . . . . . . . . . . . . . . . 13
Index of Drugs
XOLAIR SOL 150MG . . . . . . . . . . . . . . . 94
XOPENEX . . . . . . . . . . . . . . . . . . . . . . . 92
XOPENEX HFA AER . . . . . . . . . . . . . . . . 93
XTANDI CAP 40MG . . . . . . . . . . . . . . . . 36
XYLOCAINE . . . . . . . . . . . . . . . . . . . . . . 14
XYREM SOL 500MG/ML . . . . . . . . . . . . 95
XYZAL . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Y
yellow fever vaccine . . . . . . . . . . . . . . . 87
YERVOY INJ 50MG . . . . . . . . . . . . . . . . 41
YF-VAX INJ . . . . . . . . . . . . . . . . . . . . . . 87
Z
zafirlukast tab 10mg . . . . . . . . . . . . . . 92
zafirlukast tab 20mg . . . . . . . . . . . . . . 92
zaleplon cap 10mg . . . . . . . . . . . . . . . . 95
zaleplon cap 5mg . . . . . . . . . . . . . . . . . 95
ZALTRAP INJ 100/4ML . . . . . . . . . . . . . 41
ZANAFLEX . . . . . . . . . . . . . . . . . . . . . . . 46
zanamivir . . . . . . . . . . . . . . . . . . . . . . . 50
ZANTAC . . . . . . . . . . . . . . . . . . . . . . . . . 73
ZARONTIN . . . . . . . . . . . . . . . . . . . . . . . 22
ZAROXOLYN . . . . . . . . . . . . . . . . . . . . . 66
ZAVESCA CAP 100MG . . . . . . . . . . . . . 72
zazole cre 0.4% . . . . . . . . . . . . . . . . . . 34
ZEBETA . . . . . . . . . . . . . . . . . . . . . . . . . 62
ZELBORAF TAB 240MG . . . . . . . . . . . . . 40
ZEMPLAR . . . . . . . . . . . . . . . . . . . . . . . . 88
ZENPEP CAP 10000UNT . . . . . . . . . . . . 73
ZENPEP CAP 15000UNT . . . . . . . . . . . . 73
ZENPEP CAP 20000UNT . . . . . . . . . . . . 73
ZENPEP CAP 25000UNT . . . . . . . . . . . . 73
ZENPEP CAP 3000UNIT . . . . . . . . . . . . . 73
ZENPEP CAP 5000UNIT . . . . . . . . . . . . . 73
ZERIT . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
ZESTORETIC, PRINZIDE . . . . . . . . . . . . . 60
ZESTRIL, PRINIVIL . . . . . . . . . . . . . . . . . 60
ZETIA TAB 10MG . . . . . . . . . . . . . . . . . 68
ZIAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
ZIAGEN . . . . . . . . . . . . . . . . . . . . . . . . . 49
ZIAGEN SOL 20MG/ML . . . . . . . . . . . . . 49
zidovudine . . . . . . . . . . . . . . . . . . . . . . 49
zidovudine cap 100mg . . . . . . . . . . . . . 49
zidovudine syp 50mg/5ml . . . . . . . . . . 49
zidovudine tab 300mg . . . . . . . . . . . . . 49
ZINACEF . . . . . . . . . . . . . . . . . . . . . . . . 17
ZIOPTAN DRO 0.0015% . . . . . . . . . . . . 91
ziprasidone . . . . . . . . . . . . . . . . . . . . . . 45
ziprasidone cap 20mg . . . . . . . . . . . . . 46
ZIRGAN GEL 0.15% . . . . . . . . . . . . . . . . 47
ZITHROMAX . . . . . . . . . . . . . . . . . . . . . 19
ziv-aflibercept . . . . . . . . . . . . . . . . . . . . 41
ZOCOR . . . . . . . . . . . . . . . . . . . . . . . . . . 67
ZOFRAN . . . . . . . . . . . . . . . . . . . . . . . . . 32
ZOFRAN ODT . . . . . . . . . . . . . . . . . . . . 32
zoledronic inj 4mg/5ml . . . . . . . . . . . . 88
zoledronic inj 5/100ml . . . . . . . . . . . . . 88
ZOLINZA CAP 100MG . . . . . . . . . . . . . . 38
ZOLOFT . . . . . . . . . . . . . . . . . . . . . . . . . 29
ZOMETA . . . . . . . . . . . . . . . . . . . . . . . . 88
ZONEGRAN . . . . . . . . . . . . . . . . . . . . . . 22
zonisamide cap 100mg . . . . . . . . . . . . 22
zonisamide cap 25mg . . . . . . . . . . . . . 22
zonisamide cap 50mg . . . . . . . . . . . . . 22
ZORTRESS TAB 0.25MG . . . . . . . . . . . . 85
ZORTRESS TAB 0.5MG . . . . . . . . . . . . . 85
ZORTRESS TAB 0.75MG . . . . . . . . . . . . 85
ZOSTAVAX INJ . . . . . . . . . . . . . . . . . . . 87
ZOSYN . . . . . . . . . . . . . . . . . . . . . . . . . . 19
zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . 81
zovia 1/50e . . . . . . . . . . . . . . . . . . . . . . 81
ZOVIRAX . . . . . . . . . . . . . . . . . . . . . . . . 51
ZOVIRAX CRE 5% . . . . . . . . . . . . . . . . . 51
ZYDELIG TAB 100MG . . . . . . . . . . . . . . 40
ZYDELIG TAB 150MG . . . . . . . . . . . . . . 40
ZYKADIA CAP 150MG . . . . . . . . . . . . . 41
ZYLOPRIM . . . . . . . . . . . . . . . . . . . . . . . 34
ZYMAXID . . . . . . . . . . . . . . . . . . . . . . . 20
ZYPREXA . . . . . . . . . . . . . . . . . . . . . . . . 45
ZYPREXA RELP INJ 210MG . . . . . . . . . . 46
ZYPREXA ZYDIS . . . . . . . . . . . . . . . . . . 45
ZYTIGA TAB 250MG . . . . . . . . . . . . . . . 36
ZYVOX . . . . . . . . . . . . . . . . . . . . . . . . . . 16
ZYVOX SUS 100MG/5ML . . . . . . . . . . . 17
139
It’s Personal.
800-523-3142
TTY/TDD 800-505-7150
7:30 am to 8 pm, 7 days a week.
300 S. Park Avenue
P.O. Box 6002, Pomona, CA 91769-6002
www.ivhp.com
www.facebook.com/intervalley
MED337 STS/OC 09/15

OC Preferred (HMO) - Inter Valley Health Plan

Transcription

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