2016 Formulary (List of Covered Drugs)

Transcription

2016 Formulary (List of Covered Drugs)
CareMore Value Plus (HMO), CareMore Breathe (HMO SNP),
CareMore ESRD (HMO SNP), CareMore Heart (HMO SNP), CareMore
Reliance (HMO SNP) and CareMore Touch (HMO SNP)
PLEASE READ: This document
contains information about the
drugs we cover in this plan.
This formulary was updated 10/2016. For more recent information or other questions, please contact
Member Services, at 1-800-499-2793 or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except
Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays)
from February 15 through September 30, or visit www.caremore.com.
FORMLAOCCVPSNPTCH16_WEB
Y0114_16_081568A CHP CMS Accepted
(09032015)
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Note to existing members:
This formulary has changed since last year. Please review this document
to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us” or “our,” it means
CareMore Health Plan. When it refers to “plan” or “our plan,” it means
CareMore Value Plus (HMO), CareMore Breathe (HMO SNP), CareMore
ESRD (HMO SNP), CareMore Heart (HMO SNP), CareMore Reliance
(HMO SNP) and CareMore Touch (HMO SNP).
This document includes a list of the drugs (formulary) for our plan which
is current as of 10/2016. For an updated formulary, please contact us. Our
contact information, along with the date we last updated the formulary,
appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug
benefit. Benefits, formulary, pharmacy network, and/or copayments/
coinsurance may change on January 1, 2017, and from time to time during
the year.
Effective Date November 1, 2016
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What is the CareMore Value Plus (HMO), contact us. Our contact information appears on the front
and back cover pages. If any other type of approved
CareMore Breathe (HMO SNP), CareMore formulary change (non-maintenance change) is made during
ESRD (HMO SNP), CareMore Heart (HMO the year, we will notify you by sending you a list of these
SNP), CareMore Reliance (HMO SNP) and changes, or by sending you an updated formulary.
CareMore Touch (HMO SNP) formulary? How do I use the formulary?
A formulary is a list of covered drugs selected by our plan
in consultation with a team of health care providers, which
represents the prescription therapies believed to be a
necessary part of a quality treatment program. Our plan
will generally cover the drugs listed in our formulary as long
as the drug is medically necessary, the prescription is filled
at a plan network pharmacy, and other plan rules are
followed. For more information on how to fill your
prescriptions, please review your Evidence of Coverage.
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 7. The drugs in this
formulary are grouped into categories depending on the
type of medical conditions that they are used to treat. For
example, drugs used to treat a heart condition are listed
under the category, “Antihypertensive Therapy.” If you
know what your drug is used for, look for the category name
in the list that begins on page 7. Then look under the
category name for your drug.
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.
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 54.
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?
Our plan 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.
If we remove drugs from our formulary, or 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. The enclosed
formulary is current as of 10/2016. To get updated
information about the drugs covered by our plan, please
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: Our plan requires you or your
physician to get prior authorization for certain drugs. This
means that you will need to get approval from our plan
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before you fill your prescriptions. If you don't get approval,
our plan may not cover the drug.
Breathe (HMO SNP), CareMore ESRD
(HMO SNP), CareMore Heart (HMO SNP),
CareMore Reliance (HMO SNP) and
CareMore Touch (HMO SNP)'s formulary?
Quantity Limits: For certain drugs, our plan limits the
amount of the drug that our plan will cover. For example,
our plan provides 30 tablets per month per prescription for
You can ask our plan to make an exception to our coverage
JANUVIA 100 MG. This may be in addition to a standard
rules. There are several types of exceptions that you can ask
one-month or three-month supply.
us to make.
You can find out if your drug has any additional
requirements or limits by looking in the formulary that
begins on page 7. You can also get more information about
the restrictions applied to specific covered drugs by visiting
our website. We have posted on-line documents that explain
our prior authorization restriction. 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 cover a drug even if it is not on our
formulary. If approved, this drug will be covered at a
predetermined cost-sharing level, and you would not be
able to ask us to provide the drug at a lower cost-sharing
level.
You can ask us to cover a formulary drug at a lower
cost-sharing level if this drug is not on the specialty tier.
If approved this would lower the amount you must pay for
your drug.
You can ask our plan 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 CareMore Value Plus (HMO),
CareMore Breathe (HMO SNP), CareMore ESRD (HMO
SNP), CareMore Heart (HMO SNP), CareMore Reliance
(HMO SNP) and CareMore Touch (HMO SNP)'s
formulary?” on page 4 for information about how to
request an exception.
You can ask us to waive coverage restrictions or limits
on your drug. For example, for certain drugs, our plan
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, our plan 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
What if my drug is not on the formulary? utilization restrictions would not be as effective in treating
If your drug is not included in this formulary (list of covered your condition and/or would cause you to have adverse
drugs), you should first contact Member Services and ask medical effects.
if your drug is covered.
You should contact us to ask us for an initial coverage
If you learn that our plan does not cover your drug, you
decision for a formulary, tiering or utilization restriction
have two options:
exception. When you request a formulary, tiering or
utilization restriction exception you should submit a
You can ask Member Services for a list of similar drugs that statement from your prescriber or physician supporting
are covered by our plan. When you receive the list, show it your request. Generally, we must make our decision within
to your doctor and ask him or her to prescribe a similar drug 72 hours of getting your prescriber’s supporting statement.
that is covered by our plan.
You can request an expedited (fast) exception if you or your
doctor believe that your health could be seriously harmed
You can ask our plan to make an exception and cover your by waiting up to 72 hours for a decision. If your request to
drug. See below for information about how to request an
expedite is granted, we must give you a decision no later
exception.
than 24 hours after we get a supporting statement from your
doctor or other prescriber.
How do I request an exception to the
CareMore Value Plus (HMO), CareMore
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What do I do before I can talk to my
doctor about changing my drugs or
requesting an exception?
For more information
For more detailed information about our plan prescription
drug coverage, please review your Evidence of Coverage and
other plan materials.
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.
If you have questions about our plan, 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
(1-800-633-4227), 24 hours a day/7 days a week. TTY
users should call 1-877-486-2048. Or, visit
http://www.medicare.gov.
Our plan’s formulary
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.
The formulary that begins on page 7 provides coverage
information about the drugs covered by our plan. If you
have trouble finding your drug in the list, turn to the Index
that begins on page 54.
The first column of the chart lists the drug name.
Brand-name drugs are capitalized (e.g., NOVOLOG) and
generic drugs are listed in lower-case italics (e.g., enalapril).
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 98-day transition supply, consistent
with dispensing increment (unless you have a prescription
written for fewer days). We will cover more than one refill
of these drugs for the first 90 days you are a member of our
plan. If you need a drug that is not on our formulary or if
your ability to get your drugs is limited, but you are past
the first 90 days of membership in our plan, we will cover
a 31-day emergency supply of that drug (unless you have a
prescription for fewer days) while you pursue a formulary
exception.
The information in the Requirements/Limits column tells
you if our plan has any special requirements for coverage of
your drug.
QLL - Quantity Limits: Restricts the frequency, amount
or dosage of medication for which you can obtain benefits
each time you get a prescription filled (most often set on a
monthly basis).
PAR - Prior Authorization: The process of obtaining
approval for certain prescriptions before benefits will be
approved. You, your doctor or other network provider will
During the time when you are getting a temporary supply need to request prior authorization before you fill the
of a drug, you should talk to your prescriber or prescribing prescription.
physician to decide what to do when your supply runs out.
B/D - Part B vs. Part D: This drug may be covered under
You can call Member Services to ask for a list of covered
either your Part D prescripton drug benefits or as a Part B
drugs that treat the same medical condition. This list can
help your doctor find a covered drug that might work for drug under your medical benefits, as determined by
you while you pursue a formulary exception. Please refer to Medicare.
the Evidence of Coverage for more information about
LA - Limited Access: This prescription may be available
exceptions.
only at certain pharmacies. For more information, consult
your Pharmacy Directory or call Member Services at
1-800-499-2793, 8 a.m. to 8 p.m., seven days a week (except
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Thanksgiving and Christmas) from October 1 through
February 14, and Monday to Friday (except holidays) from
February 15 through September 30. TTY users should call
711.
HI - Home Infusion: The drug may be covered through
the medical benefit as a home-infusion medication. For
more information, call Member Services at 1-800-499-2793,
8 a.m. to 8 p.m., seven days a week (except Thanksgiving
and Christmas) from October 1 through February 14, and
Monday to Friday (except holidays) from February 15
through September 30. TTY users should call 711.
INJ - Injectable: The drug is available in injectable form.
MO - Mail Orders: Prescription drugs available through
mail order.
Cost-sharing for a one-month supply of a covered Part D prescription drug
during the Initial Coverage Stage:
Cost-Sharing Tier 1: Preferred Generic
Standard Retail Cost-Sharing (30-day supply)
$0.00
Cost-Sharing Tier 2 Generic
$7.50
Cost-Sharing Tier 3 Preferred Brand
$37.50
Cost-Sharing Tier 4 Non-Preferred Brand
$85.00
Cost-Sharing Tier 5 Specialty Tier
33%
Cost-Sharing Tier 6 Select Care Drugs
$0.00
A 90-day supply of mail order drugs costs 2.5 times the amount of a 30-day supply. Drugs designated with MO are
available through mail order. Please refer to our Evidence of Coverage for more information for cost-sharing.
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Covered Medications by Therapeutic Category
Legend
Generic drugs are shown in lower-case italics (e.g. enalapril)
Brand-name drugs are shown in capital letters (e.g. NOVOLOG)
QLL - Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits
each time you get a prescription filled (most often set on a monthly basis).
PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved.
You, your doctor or other network provider will need to request prior authorization before you fill the prescription.
B/D - Part B vs Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B
drug under your medical benefits, as determined by Medicare.
LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your
Pharmacy Directory or call Member Services at 1-800-499-2793, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving
and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through
September 30. TTY users should call 711.
INJ - Injectable: The drug is available in injectable form.
MO - Mail Order: Prescription drugs available through mail order.
HI - Home Infusion: The drug may be covered through the medical benefit as a home-infusion medication. For more
information, call Member Services at 1-800-499-2793, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and
Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through
September 30. TTY users should call 711.
Drug Name
Drug Requirements/
Tier Limits
Anti - Infectives
abacavir
2
abacavir-lamivudine-zidovudine
2
ABELCET
acyclovir oral capsule
acyclovir oral suspension 200 mg/
5 ml
acyclovir oral tablet
acyclovir sodium intravenous
solution
5
2
2
MO; QLL (60 per
30 days)
MO; QLL (60 per
30 days)
B/D; PAR; HI
MO
MO
2
2
MO
B/D; PAR; MO
Drug Name
adefovir
ALBENZA
ALINIA ORAL
SUSPENSION FOR
RECONSTITUTION
ALINIA ORAL TABLET
amantadine hcl oral capsule
amantadine hcl oral tablet
AMBISOME
amikacin injection solution 1,
000 mg/4 ml, 500 mg/2 ml
amoxicillin oral capsule
Drug Requirements/
Tier Limits
5
3
4
MO
MO; QLL (180 per
3 days)
4
2
2
5
2
MO
MO
MO
B/D; PAR
MO
2
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this
table.
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Drug Name
amoxicillin oral suspension for
reconstitution
amoxicillin oral tablet
amoxicillin oral tablet,chewable
125 mg, 250 mg
amoxicillin-pot clavulanate
amphotericin b
ampicillin
ampicillin sodium injection
ampicillin sodium intravenous
recon soln 1 gram
ampicillin sodium intravenous
recon soln 2 gram
ampicillin-sulbactam injection
recon soln 1.5 gram, 3 gram
ampicillin-sulbactam injection
recon soln 15 gram
ampicillin-sulbactam intravenous
recon soln 3 gram
APTIVUS ORAL CAPSULE
Drug Requirements/
Tier Limits
2
MO
2
2
MO
MO
2
2
2
2
2
MO
B/D; PAR; MO
MO
MO; HI
HI
2
2
MO; HI
2
HI
2
MO
4
MO; QLL (120 per
30 days)
QLL (390 per 30
days)
PAR
MO
APTIVUS ORAL SOLUTION
4
atovaquone
atovaquone-proguanil oral tablet
250-100 mg
ATRIPLA
5
2
AZACTAM
AZACTAM IN DEXTROSE
(ISO-OSM)
azithromycin intravenous recon
soln 500 mg
azithromycin intravenous recon
soln 500 mg (2 mg/ml)
azithromycin oral suspension for
reconstitution
azithromycin oral tablet
baciim
bacitracin intramuscular
BARACLUDE ORAL
SOLUTION
3
3
MO; QLL (30 per
30 days)
MO; HI
HI
2
MO
4
2
2
MO
2
2
2
5
MO
MO
PAR; QLL (600 per
30 days)
Drug Name
BICILLIN C-R
INTRAMUSCULAR
SYRINGE 1,200,000 UNIT/
2 ML(600K/600K)
BILTRICIDE
CANCIDAS
CAPASTAT
CAYSTON
cefaclor oral capsule
cefaclor oral suspension for
reconstitution 125 mg/5 ml
cefaclor oral suspension for
reconstitution 250 mg/5 ml, 375
mg/5 ml
cefaclor oral tablet extended
release 12 hr
cefadroxil oral capsule
cefadroxil oral suspension for
reconstitution 250 mg/5 ml, 500
mg/5 ml
cefadroxil oral tablet
cefazolin in dextrose (iso-os)
intravenous piggyback 1 gram/50
ml
cefazolin injection recon soln 1
gram
gram, 100 gram, 20 gram, 300
g
mg
cefazolin intravenous
cefdinir
cefepime
cefoxitin in dextrose, iso-osm
cefoxitin intravenous recon soln
1 gram
cefoxitin intravenous recon soln
10 gram, 2 gram
cefpodoxime
cefprozil
ceftazidime injection recon soln
1 gram, 2 gram
Drug Requirements/
Tier Limits
4
MO
4
5
4
5
2
2
MO
B/D; PAR
2
MO
2
MO
2
2
MO
MO
2
2
MO
MO; HI
2
MO
2
HI
2
MO; HI
2
2
2
2
2
MO
MO; HI
HI
MO; HI
2
HI
2
2
2
MO
MO
MO; HI
PAR; LA
MO
table.
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Drug Name
ceftazidime injection recon soln
6 gram
ceftriaxone in dextrose,iso-os
ceftriaxone injection recon soln 1
gram, 2 gram, 250 mg, 500 mg
ceftriaxone injection recon soln
10 gram
ceftriaxone intravenous
cefuroxime axetil oral tablet
cefuroxime sodium intravenous
vial injection recon soln 1.5
gram, 750 mg
cefuroxime sodium intravenous
vial intravenous recon soln 7.5
gram
cephalexin oral capsule 250 mg,
500 mg
cephalexin oral suspension for
reconstitution
cephalexin oral tablet
chloramphenicol sod succinate
chloroquine phosphate oral
ciprofloxacin er
ciprofloxacin hcl oral
ciprofloxacin lactate intravenous
solution 200 mg/20 ml
ciprofloxacin lactate intravenous
clarithromycin oral suspension
for reconstitution
clarithromycin oral tablet
clarithromycin oral tablet
extended release 24 hr
clindamycin hcl
clindamycin phosphate injection
clindamycin phosphate
intravenous solution 300 mg/2
ml, 900 mg/6 ml
clindamycin phosphate
ml
clotrimazole mucous membrane
COARTEM
Drug Requirements/
Tier Limits
2
5
CRIXIVAN ORAL CAPSULE
200 MG
CRIXIVAN ORAL CAPSULE
400 MG
CUBICIN
dapsone
daptomycin
DARAPRIM
demeclocycline
DESCOVY
3
dicloxacillin
didanosine oral capsule,delayed
release(dr/ec) 125 mg
MO
MO
release(dr/ec) 250 mg, 400 mg
MO
doxy-100
MO
doxycycline hyclate intravenous
MO
doxycycline hyclate oral capsule
MO
doxycycline hyclate oral tablet
100 mg, 20 mg
doxycycline hyclate oral tablet 50
mg
MO
doxycycline hyclate oral tablet,
delayed release (dr/ec) 100 mg,
MO
150 mg, 75 mg
MO; QLL (28 per 2 doxycycline monohydrate oral
days)
capsule
MO
doxycycline monohydrate oral
tablet
MO
EDURANT
2
2
EMTRIVA ORAL CAPSULE
4
EMTRIVA ORAL
SOLUTION
entecavir
4
HI
2
2
MO
MO; HI
2
HI
2
2
2
MO; HI
MO
MO; HI
2
HI
2
MO
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
Drug Requirements/
Tier Limits
colistin (colistimethate na)
COMPLERA
2
2
Drug Name
3
5
2
5
4
2
5
2
2
2
2
2
2
MO
MO
MO
QLL (30 per 30
days)
MO
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO
MO
MO
2
2
MO
2
MO
2
MO
5
QLL (30 per 30
days)
MO; QLL (30 per
30 days)
MO; QLL (870 per
30 days)
PAR; QLL (30 per
30 days)
MO
MO
MO
MO; HI
QLL (30 per 30
days)
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
5
table.
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Drug Name
Drug Requirements/
Tier Limits
EPCLUSA
5
EPIVIR HBV ORAL
SOLUTION
EPIVIR ORAL SOLUTION
3
EPZICOM
3
3
ERAXIS(WATER DILUENT)
ery-tab
erythrocin (as stearate) oral tablet
250 mg
ERYTHROCIN
INTRAVENOUS RECON
SOLN 500 MG
erythromycin ethylsuccinate oral
tablet
erythromycin oral tablet
ethambutol
EVOTAZ
4
2
2
famciclovir oral tablet 125 mg,
250 mg
famciclovir oral tablet 500 mg
2
fluconazole
fluconazole in dextrose(iso-o)
fluconazole in nacl (iso-osm)
intravenous piggyback 100 mg/
50 ml, 400 mg/200 ml
fluconazole in nacl (iso-osm)
100 ml
flucytosine
foscarnet
FUZEON SUBCUTANEOUS
RECON SOLN
ganciclovir sodium
gentamicin injection
gentamicin sulfate (ped) (pf)
gentamicin sulfate (pf)
ml
2
2
2
PAR; QLL (30 per
30 days)
MO
MO; QLL (960 per
30 days)
MO; QLL (30 per
30 days)
PAR; MO
MO
MO
4
2
2
2
5
2
2
5
2
5
2
2
2
2
MO
MO
MO
QLL (30 per 30
days)
MO; QLL (60 per
30 days)
MO; QLL (21 per 7
days)
MO
MO
B/D; PAR
QLL (60 per 30
days)
MO
MO
MO
MO
Drug Name
Drug Requirements/
Tier Limits
gentamicin sulfate (pf)
intravenous solution 60 mg/6 ml,
80 mg/8 ml
GENVOYA
2
griseofulvin microsize oral
suspension
griseofulvin ultramicrosize
HARVONI
2
hydroxychloroquine oral
imipenem-cilastatin
INTELENCE ORAL TABLET
100 MG
200 MG
25 MG
INVANZ INJECTION
INVIRASE ORAL CAPSULE
2
2
4
INVIRASE ORAL TABLET
4
ISENTRESS ORAL
POWDER IN PACKET
ISENTRESS ORAL TABLET
4
ISENTRESS ORAL TABLET,
CHEWABLE 100 MG
ISENTRESS ORAL TABLET,
CHEWABLE 25 MG
isoniazid oral
itraconazole
KALETRA ORAL
SOLUTION
KALETRA ORAL TABLET
100-25 MG
KALETRA ORAL TABLET
200-50 MG
ketoconazole oral
lamivudine oral solution
5
lamivudine oral tablet 100 mg
2
5
2
5
4
4
4
4
5
4
2
2
3
3
3
2
2
QLL (30 per 30
days)
MO
MO
PAR; QLL (28 per
28 days)
MO
MO; HI
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (480 per
30 days)
MO; HI
MO; QLL (300 per
30 days)
MO; QLL (120 per
30 days)
MO
QLL (120 per 30
days)
QLL (180 per 30
days)
MO; QLL (720 per
30 days)
MO
MO
MO; QLL (480 per
30 days)
MO; QLL (300 per
30 days)
MO; QLL (120 per
30 days)
MO
MO; QLL (900 per
30 days)
MO
table.
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Drug Name
Drug Requirements/
Tier Limits
2
2
lamivudine-zidovudine
2
levofloxacin intravenous
levofloxacin oral
LEXIVA ORAL
SUSPENSION
LEXIVA ORAL TABLET
2
2
3
linezolid oral suspension for
reconstitution
linezolid oral tablet
2
MACRODANTIN ORAL
CAPSULE 25 MG, 50 MG
mefloquine
meropenem
methenamine hippurate
methenamine mandelate oral
tablet 1 gram
metro i.v.
metronidazole in nacl (iso-os)
metronidazole oral
minocycline oral capsule
minocycline oral tablet
moderiba
morgidox oral capsule 100 mg
morgidox oral capsule 50 mg
MYCOBUTIN
nafcillin injection recon soln 1
gram, 10 gram
nafcillin injection recon soln 2
gram
nafcillin intravenous recon soln
2 gram
NEBUPENT
neomycin
nevirapine oral suspension
4
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO
MO
MO; QLL (1800 per
30 days)
MO; QLL (120 per
30 days)
PAR; MO; QLL
(1800 per 2 days)
MO; QLL (28 per 2
days)
MO
2
2
2
2
MO
MO; HI
MO
MO
3
2
2
2
2
2
2
2
2
2
4
2
2
2
4
2
2
Drug Name
Drug Requirements/
Tier Limits
nevirapine oral tablet
2
nevirapine oral tablet extended
release 24 hr 100 mg
nevirapine oral tablet extended
NORVIR ORAL CAPSULE
2
NORVIR ORAL SOLUTION
4
NORVIR ORAL TABLET
4
NOXAFIL ORAL
SUSPENSION
nystatin oral suspension
nystatin oral tablet
ODEFSEY
5
ofloxacin oral tablet 400 mg
OLYSIO
oxacillin injection recon soln 1
gram, 2 gram
oxacillin injection recon soln 10
gram
MO
oxacillin intravenous recon soln
MO
1 gram
MO
oxacillin intravenous recon soln
MO
2 gram
MO
paromomycin
MO
paser
MO
PENICILLIN G POT IN
DEXTROSE
MO
INTRAVENOUS
MO; HI
PIGGYBACK 1 MILLION
UNIT/50 ML
MO
PENICILLIN G POT IN
DEXTROSE
MO
INTRAVENOUS
PIGGYBACK 2 MILLION
B/D; PAR; MO
UNIT/50 ML, 3 MILLION
MO
MO; QLL (1200 per UNIT/50 ML
penicillin g potassium injection
30 days)
recon soln 20 million unit
2
MO; QLL (60 per
30 days)
MO
2
5
2
MO; QLL (30 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (480 per
30 days)
MO; QLL (360 per
30 days)
QLL (630 per 30
days)
MO
MO
QLL (30 per 30
days)
MO
PAR
MO
2
MO; HI
4
2
2
5
2
2
HI
2
2
4
MO
MO
4
HI
2
MO
table.
11
00016274, V22
Drug Name
penicillin g potassium injection
recon soln 5 million unit
penicillin g procaine
intramuscular syringe 1.2 million
unit/2 ml
penicillin g procaine
intramuscular syringe 600,000
unit/ml
penicillin g sodium
penicillin v potassium
PENTAM
piperacillin-tazobactam
PREZCOBIX
Drug Requirements/
Tier Limits
2
MO; HI
2
MO
2
2
2
4
2
5
PREZISTA ORAL
SUSPENSION
PREZISTA ORAL TABLET
150 MG
600 MG, 800 MG
75 MG
PRIFTIN
PRIMAQUINE
pyrazinamide
quinine sulfate
RELENZA DISKHALER
5
RESCRIPTOR ORAL
TABLET
RESCRIPTOR ORAL
TABLET, DISPERSIBLE
RETROVIR INTRAVENOUS
REYATAZ ORAL CAPSULE
150 MG, 200 MG
REYATAZ ORAL CAPSULE
300 MG
REYATAZ ORAL POWDER
IN PACKET
ribasphere oral capsule
ribasphere oral tablet 200 mg
ribavirin oral capsule
ribavirin oral tablet 200 mg
4
4
4
4
4
4
2
2
4
4
4
3
3
3
2
2
2
2
MO; HI
MO
MO
MO; HI
QLL (30 per 30
days)
QLL (420 per 30
days)
MO; QLL (180 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (300 per
30 days)
MO
MO
MO
PAR; MO
MO; QLL (60 per
180 days)
MO; QLL (180 per
30 days)
MO; QLL (360 per
30 days)
MO
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (240 per
30 days)
MO
MO
MO
MO
Drug Name
Drug Requirements/
Tier Limits
rifampin
RIFATER
rimantadine
SELZENTRY
2
4
2
5
SIRTURO
SOVALDI
stavudine oral capsule 15 mg, 20
mg
stavudine oral capsule 30 mg, 40
mg
stavudine oral recon soln
5
5
2
STREPTOMYCIN
INTRAMUSCULAR
STRIBILD
4
STROMECTOL
sulfadiazine oral
sulfamethoxazole-trimethoprim
SUSTIVA ORAL CAPSULE
200 MG
SUSTIVA ORAL CAPSULE
50 MG
SUSTIVA ORAL TABLET
4
2
2
3
SYNAGIS
SYNERCID
TAMIFLU
TECHNIVIE
5
5
3
5
TEFLARO INTRAVENOUS
RECON SOLN 400 MG
TEFLARO INTRAVENOUS
RECON SOLN 600 MG
terbinafine hcl oral
4
tetracycline
TIVICAY ORAL TABLET 10
MG
TIVICAY ORAL TABLET 25
MG, 50 MG
2
4
2
2
3
3
3
MO
MO
MO
QLL (120 per 30
days)
PAR; LA
PAR
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (2400 per
30 days)
MO
MO; QLL (30 per
30 days)
MO
MO
MO
MO; QLL (120 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (30 per
30 days)
PAR; LA
MO
PAR; QLL (56 per
28 days)
MO
5
2
5
MO; QLL (30 per
30 days)
MO
QLL (60 per 30
days)
QLL (60 per 30
days)
table.
12
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
TOBI
5
tobramycin sulfate injection recon
soln
tobramycin sulfate injection
solution
TRECATOR
trimethoprim
TRIUMEQ
2
PAR; QLL (280 per
28 days)
HI
2
MO; HI
4
2
5
TRIZIVIR
3
TRUVADA ORAL TABLET
100-150 MG, 133-200 MG,
167-250 MG
TRUVADA ORAL TABLET
200-300 MG
TYBOST
3
MO
MO
QLL (30 per 30
days)
MO; QLL (60 per
30 days)
QLL (30 per 30
days)
Drug Name
Drug Requirements/
Tier Limits
VIDEX 4 GRAM
PEDIATRIC
VIEKIRA PAK
VIEKIRA XR
VIRACEPT ORAL TABLET
250 MG
VIRACEPT ORAL TABLET
625 MG
VIRAMUNE XR ORAL
TABLET EXTENDED
RELEASE 24 HR 100 MG
VIRAZOLE
VIREAD ORAL POWDER
4
VIREAD ORAL TABLET
4
VITEKTA
5
5
5
4
4
3
2
MO
zidovudine oral tablet
2
5
PAR; QLL (40 per 2
days)
PAR; QLL (80 per 2
days)
MO; QLL (1200 per
30 days)
ZOSYN IN DEXTROSE
(ISO-OSM) INTRAVENOUS
PIGGYBACK 2.25 GRAM/50
ML
ZOSYN IN DEXTROSE
(ISO-OSM) INTRAVENOUS
4
PAR
MO; QLL (240 per
30 days)
MO; QLL (30 per
30 days)
QLL (30 per 30
days)
MO
PAR; QLL (300 per
30 days)
PAR; QLL (60 per
30 days)
PAR; QLL (120 per
30 days)
PAR; QLL (84 per
28 days)
PAR; QLL (30 per
30 days)
MO; QLL (960 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (1920 per
30 days)
MO; QLL (60 per
30 days)
HI
4
MO; HI
3
3
TYGACIL
TYZEKA
valacyclovir
5
5
2
valganciclovir oral tablet
vancomycin in 0.9% sodium cl
intravenous piggyback
vancomycin in dextrose 5 %
intravenous piggyback 1 gram/
200 ml
vancomycin in dextrose 5 %
100 ml, 750 mg/150 ml
vancomycin intravenous recon
soln 1,000 mg, 10 gram, 500
mg, 750 mg
vancomycin intravenous recon
soln 5 gram
vancomycin oral capsule 125 mg
2
2
vancomycin oral capsule 250 mg
5
VIDEX 2 GRAM
PEDIATRIC
4
2
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
HI
voriconazole intravenous
voriconazole oral suspension for
reconstitution
MO; QLL (30 per 2 voriconazole oral tablet 200 mg
days)
voriconazole oral tablet 50 mg
MO
MO
2
2
5
4
MO; QLL (1200 per
30 days)
PAR
PAR
MO; QLL (300 per
30 days)
MO; QLL (120 per
30 days)
MO
2
5
5
5
XIFAXAN ORAL TABLET
550 MG
ZEPATIER
5
ZIAGEN ORAL SOLUTION
3
zidovudine oral capsule
2
zidovudine oral syrup
2
5
MO; HI
table.
13
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
PIGGYBACK 3.375 GRAM/
50 ML, 4.5 GRAM/100 ML
ZYVOX INTRAVENOUS
4 HI
PARENTERAL SOLUTION
200 MG/100 ML
ZYVOX INTRAVENOUS
4 MO; HI
PARENTERAL SOLUTION
600 MG/300 ML
ZYVOX ORAL
4 PAR; MO; QLL
SUSPENSION FOR
(1800 per 2 days)
RECONSTITUTION
Antineoplastic / Immunosuppressant Drugs
ABRAXANE
5
AFINITOR
5 PAR
AFINITOR DISPERZ
5 PAR
ALECENSA
5
ALIMTA
5
amifostine crystalline
5
anastrozole
2 MO; QLL (30 per
30 days)
ARRANON
5
ARZERRA
5
ASTAGRAF XL ORAL
4 B/D; PAR; MO
CAPSULE,EXTENDED
RELEASE 24HR 0.5 MG, 1
MG
ASTAGRAF XL ORAL
5 B/D; PAR
CAPSULE,EXTENDED
RELEASE 24HR 5 MG
AVASTIN
5
azacitidine
5
azasan
2 B/D; PAR; MO
azathioprine
2 B/D; PAR; MO
azathioprine sodium
2 B/D; PAR
BELEODAQ
5 PAR
BENDEKA
5 QLL (4 per 30 days)
bexarotene
5 PAR; QLL (300 per
30 days)
bicalutamide
2 MO
BICNU
4 MO
bleo 15k
2
bleomycin
2 MO
BLINCYTO
5 PAR
Drug Name
Drug Requirements/
Tier Limits
BOSULIF ORAL TABLET
100 MG
BOSULIF ORAL TABLET
500 MG
BUSULFEX
CABOMETYX ORAL
TABLET 20 MG
CABOMETYX ORAL
TABLET 40 MG, 60 MG
CAPRELSA ORAL TABLET
100 MG
CAPRELSA ORAL TABLET
300 MG
carboplatin intravenous solution
CELLCEPT INTRAVENOUS
cisplatin
cladribine
CLOLAR
COMETRIQ ORAL
CAPSULE 100 MG/DAY(80
MG X1-20 MG X1)
COMETRIQ ORAL
CAPSULE 140 MG/DAY(80
MG X1-20 MG X3)
COMETRIQ ORAL
CAPSULE 60 MG/DAY (20
MG X 3/DAY)
COTELLIC
5
cyclophosphamide oral capsule
cyclosporine intravenous
cyclosporine modified
cyclosporine oral capsule
CYRAMZA
cytarabine
cytarabine (pf) injection solution
100 mg/5 ml (20 mg/ml), 2
gram/20 ml (100 mg/ml)
cytarabine (pf) injection solution
20 mg/ml
dacarbazine
DACOGEN
DARZALEX
4
2
2
2
5
2
2
5
4
5
5
5
5
2
4
2
5
5
5
PAR; QLL (120 per
30 days)
PAR; QLL (30 per
30 days)
B/D; PAR
PAR; LA; QLL (90
per 30 days)
PAR; LA; QLL (30
per 30 days)
PAR; LA; QLL (90
per 30 days)
PAR; LA; QLL (30
per 30 days)
MO
B/D; PAR; MO
MO
PAR; QLL (56 per
28 days)
5
PAR; QLL (112 per
28 days)
5
PAR; QLL (84 per
28 days)
5
PAR; LA; QLL (90
per 30 days)
B/D; PAR; MO
B/D; PAR
B/D; PAR; MO
B/D; PAR; MO
PAR
MO
MO
2
2
5
5
MO
LA
table.
14
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
daunorubicin intravenous
solution
decitabine
dexrazoxane hcl intravenous
recon soln 250 mg
dexrazoxane hcl intravenous
recon soln 500 mg
DOCEFREZ
INTRAVENOUS RECON
SOLN 20 MG
DOCETAXEL
INTRAVENOUS
SOLUTION 10 MG/ML, 160
MG/16 ML (10 MG/ML), 160
MG/8 ML (20 MG/ML), 20
MG/2 ML (10 MG/ML)
docetaxel intravenous solution 20
mg/ml (1 ml), 80 mg/4 ml (20
mg/ml), 80 mg/8 ml (10 mg/ml)
doxorubicin intravenous recon
soln
doxorubicin intravenous solution
doxorubicin, peg-liposomal
DROXIA
ELITEK INTRAVENOUS
RECON SOLN 1.5 MG
elitek intravenous recon soln 7.5
mg
EMCYT
EMPLICITI
epirubicin intravenous solution
200 mg/100 ml
epirubicin intravenous solution
50 mg/25 ml
ERBITUX
ERIVEDGE
2
FARESTON
5
5
2
FARYDAK ORAL CAPSULE
10 MG
FARYDAK ORAL CAPSULE
15 MG, 20 MG
FASLODEX
FIRMAGON KIT W
DILUENT SYRINGE
SUBCUTANEOUS RECON
SOLN 120 MG
FIRMAGON KIT W
DILUENT SYRINGE
SUBCUTANEOUS RECON
SOLN 80 MG
fludarabine intravenous recon
soln
fludarabine intravenous solution
fluorouracil intravenous
flutamide
FOLOTYN
FUSILEV
GAZYVA
gemcitabine intravenous recon
soln 1 gram, 200 mg
gemcitabine intravenous recon
soln 2 gram
gemcitabine intravenous solution
1 gram/26.3 ml (38 mg/ml), 200
mg/5.26 ml (38 mg/ml)
gemcitabine intravenous solution
2 gram/52.6 ml (38 mg/ml)
gengraf oral capsule 100 mg, 25
mg
gengraf oral capsule 50 mg
gengraf oral solution
GILOTRIF
5
ERWINAZE
ETOPOPHOS
etoposide intravenous
EVOMELA
exemestane
5
4
2
5
2
GLEEVEC ORAL TABLET
100 MG
GLEEVEC ORAL TABLET
400 MG
GLEOSTINE
5
2
MO
5
5
5
2
2
5
4
5
MO
5
PAR
4
5
2
MO
B/D; PAR
2
MO
4
5
PAR; MO
PAR; QLL (30 per
30 days)
MO
PAR
MO
MO
MO; QLL (60 per
30 days)
5
QLL (30 per 30
days)
PAR; QLL (60 per
30 days)
PAR; QLL (30 per
30 days)
5
5
4
MO
2
MO
2
2
2
5
5
5
2
MO
MO
PAR
MO
2
2
MO
2
2
B/D; PAR; MO
2
2
5
B/D; PAR
B/D; PAR; MO
PAR; QLL (30 per
30 days)
PAR; QLL (240 per
30 days)
PAR; QLL (60 per
30 days)
MO
5
4
table.
15
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
HALAVEN
HERCEPTIN
HEXALEN
hydroxyurea
IBRANCE
5
5
5
2
5
ICLUSIG ORAL TABLET 15
MG
ICLUSIG ORAL TABLET 45
MG
idarubicin
ifosfamide intravenous recon soln
ifosfamide intravenous solution
imatinib oral tablet 100 mg
5
imatinib oral tablet 400 mg
5
2
2
2
5
5
IMBRUVICA
5
INLYTA ORAL TABLET 1
MG
INLYTA ORAL TABLET 5
MG
IRESSA
irinotecan intravenous solution
100 mg/5 ml, 40 mg/2 ml
irinotecan intravenous solution
500 mg/25 ml
ISTODAX
IXEMPRA
JAKAFI ORAL TABLET 10
MG
MG
MG
MG
MG
JEVTANA
KADCYLA
KEPIVANCE
5
5
5
2
PAR
MO
PAR; QLL (30 per
30 days)
PAR; QLL (60 per
30 days)
PAR; QLL (30 per
30 days)
MO
PAR; QLL (240 per
30 days)
PAR; QLL (60 per
30 days)
PAR; QLL (120 per
30 days)
PAR; QLL (240 per
30 days)
PAR; QLL (120 per
30 days)
MO
2
5
5
5
5
5
5
5
5
5
4
PAR; QLL (150 per
30 days)
PAR; QLL (100 per
30 days)
PAR; QLL (75 per
30 days)
PAR; QLL (60 per
30 days)
PAR; QLL (300 per
30 days)
PAR
Drug Name
Drug Requirements/
Tier Limits
KEYTRUDA
LENVIMA ORAL CAPSULE
10 MG/DAY (10 MG X 1/
DAY)
14 MG/DAY(10 MG X 1-4
MG X 1), 20 MG/DAY (10
MG X 2), 8 MG/DAY (4 MG
X 2), 8 MG/DAY (4 MG X 2)
(60 PACK)
18 MG/DAY (10 MG X 1-4
MG X2), 24 MG/DAY(10 MG
X 2-4 MG X 1)
letrozole
5
5
PAR
PAR; QLL (30 per
30 days)
5
PAR; QLL (60 per
30 days)
5
PAR; QLL (90 per
30 days)
2
leucovorin calcium injection
recon soln 100 mg, 200 mg, 350
mg, 50 mg
leucovorin calcium injection
recon soln 500 mg
leucovorin calcium oral
LEUKERAN
leuprolide subcutaneous kit
levoleucovorin calcium
intravenous recon soln
LONSURF
LUPRON DEPOT (3
MONTH)
INTRAMUSCULAR
SYRINGE KIT 22.5 MG
LUPRON DEPOT
INTRAMUSCULAR
SYRINGE KIT 3.75 MG
LUPRON DEPOT
INTRAMUSCULAR
SYRINGE KIT 7.5 MG
LYNPARZA
2
MO; QLL (30 per
30 days)
MO
LYSODREN
MARQIBO
MATULANE
3
5
5
2
2
3
2
5
MO
MO
MO
5
5
PAR
PAR
5
PAR; QLL (1 per 28
days)
5
PAR
5
PAR; QLL (480 per
30 days)
MO
table.
16
00016274, V22
Drug Name
megestrol oral suspension 400
mg/10 ml (10 ml), 800 mg/20
ml (20 ml)
megestrol oral suspension 400
mg/10 ml (40 mg/ml)
megestrol oral tablet
MEKINIST ORAL TABLET
0.5 MG
MEKINIST ORAL TABLET
2 MG
melphalan hcl
mercaptopurine
mesna
MESNEX ORAL
methotrexate sodium
methotrexate sodium (pf)
injection recon soln
methotrexate sodium (pf)
injection solution
mitomycin
mitoxantrone
MUSTARGEN
mycophenolate mofetil oral
capsule
mycophenolate mofetil oral
suspension for reconstitution
mycophenolate mofetil oral tablet
mycophenolate sodium
NEXAVAR
Drug Requirements/
Tier Limits
2
2
MO
2
5
MO
PAR; QLL (90 per
30 days)
PAR; QLL (30 per
30 days)
5
2
2
2
5
2
2
2
2
2
4
2
5
2
2
5
NILANDRON
5
NINLARO
5
NIPENT
NULOJIX
octreotide acetate injection
solution 1,000 mcg/ml, 500 mcg/
ml
solution 100 mcg/ml, 200 mcg/
ml, 50 mcg/ml
5
5
5
2
Drug Name
syringe 100 mcg/ml (1 ml), 50
mcg/ml (1 ml)
OCTREOTIDE ACETATE
INJECTION SYRINGE 500
MCG/ML (1 ML)
ODOMZO
ONCASPAR
OPDIVO
oxaliplatin intravenous recon soln
100 mg
MO
oxaliplatin intravenous recon soln
MO
50 mg
oxaliplatin intravenous solution
MO
paclitaxel
PERJETA
POMALYST ORAL
MO
CAPSULE 1 MG
POMALYST ORAL
MO
CAPSULE 2 MG
MO
POMALYST ORAL
MO
CAPSULE 3 MG, 4 MG
B/D; PAR; MO
PORTRAZZA
PROGRAF INTRAVENOUS
B/D; PAR
PURIXAN
RAPAMUNE
B/D; PAR; MO
REVLIMID ORAL CAPSULE
B/D; PAR; MO
PAR; LA; QLL (120 10 MG
REVLIMID ORAL CAPSULE
per 30 days)
15 MG, 2.5 MG, 20 MG, 25
QLL (30 per 30
MG
days)
PAR; QLL (3 per 28 REVLIMID ORAL CAPSULE
5 MG
days)
RITUXAN
SANDIMMUNE ORAL
B/D; PAR
SOLUTION
PAR
SIGNIFOR
SIMULECT
sirolimus
PAR; MO
SOLTAMOX
SOMATULINE DEPOT
Drug Requirements/
Tier Limits
2
PAR; MO
5
PAR
5
PAR; LA; QLL (30
per 30 days)
5
5
2
PAR
MO
2
2
2
5
5
5
5
5
4
5
4
5
5
5
5
4
5
5
2
4
5
MO
MO
PAR; QLL (120 per
30 days)
PAR; QLL (60 per
30 days)
PAR; QLL (30 per
30 days)
B/D; PAR; MO
PAR
B/D; PAR; MO
LA; QLL (60 per 30
days)
LA; QLL (30 per 30
days)
LA; QLL (150 per
30 days)
PAR
B/D; PAR; MO
B/D; PAR
B/D; PAR; MO
MO
table.
17
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
SPRYCEL
5
STIVARGA
5
SUTENT ORAL CAPSULE
12.5 MG
SUTENT ORAL CAPSULE
25 MG, 37.5 MG, 50 MG
SYNRIBO
TABLOID
tacrolimus oral
TAFINLAR
5
TAGRISSO ORAL TABLET
40 MG
TAGRISSO ORAL TABLET
80 MG
tamoxifen
TARCEVA ORAL TABLET
100 MG, 150 MG
TARCEVA ORAL TABLET
25 MG
TARGRETIN ORAL
5
TARGRETIN TOPICAL
TASIGNA
5
5
5
5
4
2
5
5
2
5
5
5
TECENTRIQ
5
THALOMID ORAL
THALOMID ORAL
thiotepa
toposar
topotecan intravenous recon soln
TOPOTECAN
INTRAVENOUS
SOLUTION
TORISEL
TREANDA INTRAVENOUS
RECON SOLN
TRELSTAR DEPOT
5
5
2
2
5
5
5
5
5
QLL (30 per 30
days)
PAR; QLL (120 per
30 days)
QLL (90 per 30
days)
QLL (30 per 30
days)
MO
B/D; PAR; MO
PAR; QLL (120 per
30 days)
PAR; LA; QLL (60
per 30 days)
PAR; LA; QLL (30
per 30 days)
MO
QLL (30 per 30
days)
QLL (90 per 30
days)
PAR; QLL (300 per
30 days)
PAR
QLL (120 per 30
days)
LA; QLL (20 per 21
days)
QLL (30 per 30
days)
QLL (60 per 30
days)
MO
MO
Drug Name
Drug Requirements/
Tier Limits
TRELSTAR
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION
TRELSTAR
INTRAMUSCULAR
SYRINGE 11.25 MG/2 ML,
3.75 MG/2 ML
TRELSTAR
INTRAMUSCULAR
SYRINGE 22.5 MG/2 ML
TRELSTAR LA
tretinoin (chemotherapy)
trexall
TRISENOX
TYKERB
5
UNITUXIN
VECTIBIX
VELCADE
VENCLEXTA ORAL
TABLET 10 MG
VENCLEXTA ORAL
TABLET 100 MG
VENCLEXTA ORAL
TABLET 50 MG
VENCLEXTA STARTING
PACK
vinblastine intravenous solution
vincasar pfs intravenous solution
1 mg/ml
vincasar pfs intravenous solution
2 mg/2 ml
vincristine
vinorelbine
VOTRIENT
5
3
5
4
XALKORI
5
XGEVA
5
XTANDI
5
QLL (1 per 168
days)
5
5
5
5
2
5
5
5
4
5
2
2
QLL (1 per 168
days)
MO
LA; QLL (180 per
30 days)
PAR; MO
PAR; LA; QLL (60
per 30 days)
PAR; LA; QLL (120
per 30 days)
PAR; LA; QLL (30
per 30 days)
PAR; LA; QLL (42
per 365 days)
MO
2
MO
2
2
5
MO
MO
QLL (120 per 30
days)
PAR; QLL (60 per
30 days)
PAR; QLL (1.7 per
28 days)
PAR; QLL (120 per
30 days)
table.
18
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
YERVOY
YONDELIS
ZALTRAP
ZANOSAR
ZELBORAF
5
5
5
4
5
ZOLINZA
5
ZORTRESS ORAL TABLET
0.25 MG
ZORTRESS ORAL TABLET
0.5 MG, 0.75 MG
ZYDELIG
4
PAR
MO
PAR; QLL (240 per
30 days)
QLL (120 per 30
days)
B/D; PAR; MO
5
B/D; PAR
PAR; QLL (60 per
30 days)
ZYKADIA
5 PAR; QLL (150 per
30 days)
ZYTIGA
5 PAR; QLL (120 per
30 days)
Autonomic / Cns Drugs, Neurology / Psych
ABILIFY MAINTENA
ABSTRAL SUBLINGUAL
4 PAR; MO; QLL
TABLET 100 MCG
(120 per 30 days)
ABSTRAL SUBLINGUAL
5 PAR; QLL (120 per
TABLET 200 MCG, 300
30 days)
MCG, 400 MCG, 600 MCG,
800 MCG
acetaminophen-codeine oral
2 QLL (4500 per 30
solution 120 mg-12 mg /5 ml (5
days)
ml), 240 mg-24 mg /10 ml (10
ml), 300 mg-30 mg /12.5 ml
2 MO; QLL (4500 per
solution 120-12 mg/5 ml
30 days)
2 MO; QLL (390 per
tablet 300-15 mg
30 days)
2 MO; QLL (360 per
tablet 300-30 mg
30 days)
2 MO; QLL (180 per
tablet 300-60 mg
30 days)
ADASUVE
4
alprazolam oral tablet
2 MO; QLL (90 per
30 days)
amitriptyline
2 MO
amoxapine
2 MO
Drug Name
Drug Requirements/
Tier Limits
AMPYRA
5
AMRIX
APOKYN
APTIOM
aripiprazole oral solution
5
5
4
5
aripiprazole oral tablet 10 mg
2
2
2
aripiprazole oral tablet 20 mg,
30 mg
2
aripiprazole oral tablet,
disintegrating 10 mg
aripiprazole oral tablet,
ARISTADA
INTRAMUSCULAR
SUSPENSION,EXTENDED
REL SYRING 441 MG/1.6
ML
ARISTADA
INTRAMUSCULAR
SUSPENSION,EXTENDED
ML
ARISTADA
INTRAMUSCULAR
SUSPENSION,EXTENDED
ML
AZILECT
baclofen
BANZEL ORAL
SUSPENSION
BANZEL ORAL TABLET 200
MG
2
5
2
2
5
PAR; LA; QLL (60
per 30 days)
PAR
PAR; LA
MO
QLL (900 per 30
days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (450 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
PAR; QLL (1.6 per
30 days)
5
PAR; QLL (2.4 per
30 days)
5
PAR; QLL (3.2 per
30 days)
3
2
5
MO
MO
PAR; QLL (2400 per
30 days)
PAR; MO; QLL
(480 per 30 days)
4
table.
19
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
BANZEL ORAL TABLET 400
MG
benztropine oral
BRIVIACT INTRAVENOUS
BRIVIACT ORAL
SOLUTION
BRIVIACT ORAL TABLET
10 MG
briviact oral tablet 100 mg
5
25 MG
50 MG
75 MG
bromocriptine
buprenorphine hcl injection
solution
buprenorphine hcl injection
syringe
buprenorphine hcl sublingual
tablet 2 mg
buprenorphine hcl sublingual
tablet 8 mg
buprenorphine-naloxone
sublingual tablet 2-0.5 mg
buprenorphine-naloxone
sublingual tablet 8-2 mg
bupropion hcl oral tablet 100 mg
5
bupropion hcl oral tablet 75 mg
2
bupropion hcl oral tablet
extended release 100 mg
extended release 150 mg, 200 mg
extended release 24 hr 150 mg
buspirone
2
4
5
5
5
5
5
2
2
2
2
2
2
2
2
2
2
2
2
2
PAR; QLL (240 per
30 days)
MO
PAR
PAR; QLL (600 per
30 days)
PAR; QLL (600 per
30 days)
PAR; QLL (60 per
30 days)
PAR; QLL (240 per
30 days)
PAR; QLL (120 per
30 days)
PAR; QLL (60 per
30 days)
MO
MO; QLL (150 per
30 days)
QLL (150 per 30
days)
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL
(360 per 30 days)
PAR; MO; QLL (90
per 30 days)
MO; QLL (135 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (45 per
30 days)
MO
Drug Name
Drug Requirements/
Tier Limits
butalbital-acetaminop-caf-cod
oral capsule 50-325-40-30 mg
butorphanol tartrate injection
solution 1 mg/ml
butorphanol tartrate injection
solution 2 mg/ml
butorphanol tartrate nasal
2
carbamazepine oral capsule, er
multiphase 12 hr
carbamazepine oral suspension
100 mg/5 ml
carbamazepine oral suspension
200 mg/10 ml
carbamazepine oral tablet
extended release 12 hr 200 mg,
400 mg
carbamazepine oral tablet,
chewable
carbidopa-levodopa
CELONTIN ORAL
CAPSULE 300 MG
chlorpromazine
citalopram oral solution
2
MO; QLL (180 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (5 per 28
days)
MO
2
MO
citalopram oral tablet 10 mg
2
2
2
clomipramine
clonazepam oral tablet 0.5 mg
2
2
clonazepam oral tablet 1 mg
2
clonazepam oral tablet 2 mg
2
clonazepam oral tablet,
disintegrating 0.125 mg
2
2
2
2
2
2
2
MO
2
MO
2
MO
2
4
MO
MO
2
2
MO
MO; QLL (600 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO
MO; QLL (1200 per
30 days)
MO; QLL (600 per
30 days)
MO; QLL (300 per
30 days)
MO; QLL (4800 per
30 days)
table.
20
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
disintegrating 1 mg
disintegrating 2 mg
clorazepate dipotassium
2
clozapine oral tablet 100 mg
2
2
2
2
clozapine oral tablet,
COPAXONE
SUBCUTANEOUS SYRINGE
20 MG/ML
COPAXONE
40 MG/ML
dantrolene
desipramine oral
DESVENLAFAXINE
FUMARATE ORAL TABLET
EXTENDED RELEASE
24HR 100 MG
DESVENLAFAXINE
FUMARATE ORAL TABLET
2
2
2
2
2
2
4
4
2
5
5
2
2
4
4
MO; QLL (2400 per
30 days)
MO; QLL (1200 per
30 days)
MO; QLL (600 per
30 days)
MO; QLL (300 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (270 per
30 days)
MO; QLL (135 per
30 days)
MO; QLL (1080 per
30 days)
MO; QLL (540 per
30 days)
QLL (270 per 30
days)
QLL (2160 per 30
days)
QLL (180 per 30
days)
QLL (135 per 30
days)
QLL (1080 per 30
days)
PAR; QLL (30 per
30 days)
PAR; QLL (12 per
28 days)
MO
MO
MO; QLL (120 per
30 days)
MO; QLL (240 per
30 days)
Drug Name
EXTENDED RELEASE
24HR 50 MG
DESVENLAFAXINE ORAL
TABLET EXTENDED
DESVENLAFAXINE ORAL
TABLET EXTENDED
RELEASE 24 HR 50 MG
desvenlafaxine oral tablet
extended release 24hr 100 mg
desvenlafaxine oral tablet
dextroamphetamine oral capsule,
extended release 10 mg, 5 mg
dextroamphetamine oral capsule,
extended release 15 mg
dextroamphetamine oral tablet
10 mg
dextroamphetamine oral tablet
5 mg
dextroamphetamineamphetamine oral tablet 10 mg,
12.5 mg, 15 mg, 20 mg, 5 mg,
7.5 mg
dextroamphetamineamphetamine oral tablet 30 mg
diazepam injection solution
diazepam injection syringe
diazepam intensol
Drug Requirements/
Tier Limits
4
MO; QLL (120 per
30 days)
4
MO; QLL (240 per
30 days)
4
QLL (120 per 30
days)
QLL (240 per 30
days)
MO; QLL (60 per
30 days)
MO; QLL (120 per
30 days)
PAR; MO; QLL
(180 per 30 days)
PAR; MO; QLL (90
per 30 days)
MO; QLL (90 per
30 days)
4
2
2
2
2
2
2
2
2
2
diazepam oral concentrate
2
diazepam oral solution 5 mg/5
ml (1 mg/ml)
diazepam oral solution 5 mg/5
ml (1 mg/ml, 5 ml)
diazepam oral tablet 10 mg
2
2
2
2
2
MO; QLL (60 per
30 days)
MO
MO; QLL (240 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (1200 per
30 days)
QLL (1200 per 30
days)
MO; QLL (120 per
30 days)
MO; QLL (600 per
30 days)
MO; QLL (240 per
30 days)
table.
21
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
diazepam rectal kit 12.5-1517.5-20 mg
diazepam rectal kit 2.5 mg, 57.5-10 mg
diclofenac potassium
diclofenac sodium oral
diflunisal
DILANTIN
DILANTIN EXTENDED
ORAL CAPSULES 100 MG
DILANTIN INFATABS
divalproex
donepezil oral tablet 10 mg
donepezil oral tablet 5 mg
2
MO
2
MO; QLL (2 per 2
days)
MO
MO
MO
MO
MO
donepezil oral tablet,
donepezil oral tablet,
disintegrating 5 mg
doxepin oral
duloxetine oral capsule,delayed
duramorph (pf) injection solution
0.5 mg/ml
duramorph (pf) injection solution
1 mg/ml
EMSAM
2
endocet oral tablet 10-325 mg,
5-325 mg, 7.5-325 mg
entacapone
epitol
EQUETRO ORAL
CAPSULE, ER
MULTIPHASE 12 HR 100
MG
2
2
2
2
3
3
3
2
2
2
2
2
2
2
2
2
2
2
5
2
2
4
MO
MO
MO
MO; QLL (30 per
30 days)
MO
MO; QLL (30 per
30 days)
MO
MO; QLL (180 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (180 per
30 days)
QLL (180 per 30
days)
QLL (30 per 30
days)
MO; QLL (360 per
30 days)
MO
MO
MO; QLL (480 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
EQUETRO ORAL
CAPSULE, ER
MG
EQUETRO ORAL
CAPSULE, ER
MG
ergoloid
ergomar
escitalopram oxalate oral solution
4
MO; QLL (240 per
30 days)
4
MO; QLL (180 per
30 days)
2
2
2
escitalopram oxalate oral tablet
10 mg
20 mg
5 mg
ethosuximide
etodolac
EXELON TRANSDERMAL
2
FANAPT ORAL TABLET 1
MG
MG
MG
MG
MG
MG
MG
FANAPT ORAL TABLETS,
DOSE PACK
FAZACLO ORAL TABLET,
DISINTEGRATING 100 MG
DISINTEGRATING 12.5
MG
4
MO
MO
MO; QLL (600 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (120 per
30 days)
MO
MO
MO; QLL (30 per
30 days)
QLL (720 per 30
days)
QLL (72 per 30
days)
MO; QLL (60 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (16 per
365 days)
QLL (270 per 30
days)
QLL (2160 per 30
days)
2
2
2
2
3
4
4
4
4
4
4
4
4
4
table.
22
00016274, V22
Drug Name
DISINTEGRATING 25 MG
felbamate
fenoprofen oral tablet
fentanyl citrate
Drug Requirements/
Tier Limits
4
2
2
5
fentanyl transdermal patch 72
hour 100 mcg/hr, 12 mcg/hr, 25
mcg/hr, 50 mcg/hr, 75 mcg/hr
FENTORA
2
FETZIMA ORAL CAPSULE,
EXT REL 24HR DOSE PACK
EXTENDED RELEASE 24
HR 120 MG, 80 MG
EXTENDED RELEASE 24
HR 20 MG
EXTENDED RELEASE 24
HR 40 MG
fluoxetine oral capsule 10 mg
4
5
4
4
4
2
2
2
fluoxetine oral solution
2
fluoxetine oral tablet 10 mg
2
fluoxetine oral tablet 20 mg
2
fluphenazine decanoate
fluphenazine hcl
flurbiprofen
fluvoxamine oral tablet 100 mg
2
2
2
2
2
2
Drug Name
Drug Requirements/
Tier Limits
fosphenytoin
FYCOMPA ORAL
SUSPENSION
FYCOMPA ORAL TABLET
10 MG, 12 MG
FYCOMPA ORAL TABLET
2 MG
FYCOMPA ORAL TABLET
4 MG
PAR; QLL (120 per FYCOMPA ORAL TABLET
30 days)
6 MG
PAR; MO; QLL (56 FYCOMPA ORAL TABLET
per 365 days)
8 MG
PAR; MO; QLL (30 gabapentin oral capsule 100 mg
per 30 days)
gabapentin oral capsule 300 mg
PAR; MO; QLL
(180 per 30 days)
gabapentin oral capsule 400 mg
2
4
PAR; MO; QLL (90 gabapentin oral solution 250 mg/
per 30 days)
5 ml
gabapentin oral solution 250 mg/
MO; QLL (240 per 5 ml (5 ml), 300 mg/6 ml (6 ml)
30 days)
gabapentin oral tablet 600 mg
MO; QLL (120 per
30 days)
gabapentin oral tablet 800 mg
MO; QLL (60 per
30 days)
GABITRIL ORAL TABLET
MO; QLL (600 per 12 MG, 16 MG
30 days)
galantamine oral capsule,ext rel.
MO; QLL (240 per pellets 24 hr
30 days)
galantamine oral solution
MO; QLL (120 per
30 days)
galantamine oral tablet
MO
MO
GEODON
MO
INTRAMUSCULAR
MO; QLL (90 per
GILENYA
30 days)
MO; QLL (360 per GLATOPA
30 days)
MO; QLL (180 per guanidine
30 days)
haloperidol
2
QLL (1080 per 30
days)
MO
MO
PAR; QLL (120 per
30 days)
MO; QLL (15 per
30 days)
4
4
4
4
4
2
2
2
2
2
2
4
2
2
2
4
5
5
3
2
MO
QLL (720 per 30
days)
MO; QLL (30 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (45 per
30 days)
MO; QLL (1080 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (270 per
30 days)
MO; QLL (2160 per
30 days)
QLL (2160 per 30
days)
MO; QLL (180 per
30 days)
MO; QLL (135 per
30 days)
MO
MO; QLL (30 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (60 per
30 days)
MO
PAR; QLL (30 per
30 days)
PAR; QLL (30 per
30 days)
MO
MO
table.
23
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
haloperidol decanoate
haloperidol lactate
HETLIOZ
2
2
5
hydrocodone-acetaminophen oral
solution 10-325 mg/15 ml(15
ml), 2.5-167 mg/5 ml, 5-163
mg/7.5ml(7.5ml)
solution 7.5-325 mg/15 ml
tablet 10-300 mg, 5-300 mg,
7.5-300 mg
tablet 10-325 mg, 5-325 mg,
7.5-325 mg
hydrocodone-ibuprofen oral
tablet 7.5-200 mg
hydromorphone oral tablet 2 mg,
4 mg
hydromorphone oral tablet 8 mg
2
ibuprofen oral suspension
ibuprofen oral tablet 400 mg,
600 mg, 800 mg
imipramine hcl
INTUNIV ER
2
2
INVEGA ORAL TABLET
EXTENDED RELEASE
24HR 1.5 MG
INVEGA ORAL TABLET
EXTENDED RELEASE
24HR 3 MG
INVEGA ORAL TABLET
EXTENDED RELEASE
24HR 6 MG
INVEGA ORAL TABLET
EXTENDED RELEASE
24HR 9 MG
INVEGA SUSTENNA
INTRAMUSCULAR
SYRINGE 117 MG/0.75 ML,
4
2
2
2
2
2
2
2
4
4
4
4
5
MO
MO
PAR; QLL (30 per
30 days)
QLL (2700 per 30
days)
Drug Name
156 MG/ML, 234 MG/1.5
ML, 78 MG/0.5 ML
INVEGA SUSTENNA
INTRAMUSCULAR
SYRINGE 39 MG/0.25 ML
INVEGA TRINZA
INTRAMUSCULAR
SYRINGE 273 MG/0.875 ML
MO; QLL (2700 per INVEGA TRINZA
INTRAMUSCULAR
30 days)
MO; QLL (390 per SYRINGE 410 MG/1.315 ML
INVEGA TRINZA
30 days)
INTRAMUSCULAR
INVEGA TRINZA
30 days)
INTRAMUSCULAR
KHEDEZLA ORAL TABLET
30 days)
MO; QLL (360 per EXTENDED RELEASE
24HR 100 MG
30 days)
MO; QLL (180 per KHEDEZLA ORAL TABLET
EXTENDED RELEASE
30 days)
24HR 50 MG
MO
lamotrigine oral tablet
MO
lamotrigine oral tablet, chewable
dispersible
MO
LATUDA ORAL TABLET
MO; QLL (30 per
120 MG
30 days)
MO; QLL (240 per LATUDA ORAL TABLET 20
MG
30 days)
LATUDA ORAL TABLET 40
MO; QLL (120 per MG
30 days)
MG
MO; QLL (60 per
MG
30 days)
LAZANDA
MO; QLL (30 per
levetiracetam intravenous
30 days)
levetiracetam oral solution 100
QLL (2 per 28 days) mg/ml
levetiracetam oral solution 500
mg/5 ml (5 ml)
Drug Requirements/
Tier Limits
4
MO; QLL (2 per 28
days)
5
QLL (0.875 per 90
days)
5
QLL (1.315 per 90
days)
5
QLL (1.75 per 90
days)
5
QLL (2.625 per 90
days)
4
MO; QLL (120 per
30 days)
4
MO; QLL (240 per
30 days)
2
2
MO
MO
4
MO; QLL (30 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (75 per
30 days)
MO; QLL (60 per
30 days)
PAR; QLL (30 per
30 days)
MO
MO
4
4
4
4
5
2
2
2
table.
24
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
levetiracetam oral tablet
levetiracetam oral tablet extended
levetiracetam oral tablet extended
levorphanol tartrate
2
2
lithium carbonate
lithium citrate oral solution 8
meq/5 ml
LODOSYN
lorazepam intensol
2
3
lorazepam oral tablet
2
lorcet (hydrocodone)
2
lorcet hd
2
lorcet plus oral tablet 7.5-325
mg
lortab 10-325
2
lortab 5-325
2
lortab 7.5-325
2
loxapine succinate
LUNESTA
2
4
LYRICA ORAL CAPSULE
100 MG
LYRICA ORAL CAPSULE
150 MG
LYRICA ORAL CAPSULE
200 MG
LYRICA ORAL CAPSULE
225 MG, 300 MG
LYRICA ORAL CAPSULE 25
MG
MG
2
2
4
2
2
3
3
3
3
3
3
MO
MO; QLL (180 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (180 per
30 days)
MO
MO
MO
MO; QLL (90 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (360 per
30 days)
MO
MO; QLL (30 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (720 per
30 days)
MO; QLL (360 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
MG
LYRICA ORAL SOLUTION
3
maprotiline oral tablet 25 mg
2
2
MARPLAN
meclofenamate oral
meloxicam oral suspension
2
4
2
3
meloxicam oral tablet
1
memantine oral solution
2
memantine oral tablet 10 mg
2
memantine oral tablet 5 mg
2
MESTINON ORAL SYRUP
MESTINON TIMESPAN
metadate er
4
4
2
methadone injection
4
methadone intensol
2
methadone oral concentrate
2
methadone oral solution 10 mg/
5 ml
methadone oral solution 5 mg/5
ml
methadone oral tablet 10 mg
2
methadone oral tablet 5 mg
2
methadose oral concentrate
2
methylphenidate oral capsule, er
biphasic 30-70 30 mg
2
3
2
2
MO; QLL (240 per
30 days)
MO; QLL (900 per
30 days)
MO; QLL (270 per
30 days)
MO; QLL (135 per
30 days)
MO
MO
MO
MO; QLL (300 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (300 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (90 per
30 days)
MO
MO
MO; QLL (90 per
30 days)
QLL (150 per 30
days)
MO; QLL (180 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (900 per
30 days)
MO; QLL (1800 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (60 per
30 days)
table.
25
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
methylphenidate oral capsule, er
methylphenidate oral capsule,er
methylphenidate oral capsule,er
methylphenidate oral tablet
2
extended release
MIGRANAL
2
mirtazapine oral tablet 15 mg
2
2
2
2
4
2
2
2
mirtazapine oral tablet 7.5 mg
2
mirtazapine oral tablet,
modafinil oral tablet 100 mg
2
modafinil oral tablet 200 mg
2
molindone
morphine (pf) injection solution
0.5 mg/ml
morphine (pf) injection solution
1 mg/ml
morphine (pf) intravenous
patient control.analgesia soln 150
mg/30 ml
morphine (pf) intravenous
patient control.analgesia soln 30
mg/30 ml
2
2
2
2
2
2
2
2
Drug Name
morphine concentrate oral
solution
morphine intravenous cartridge
2 mg/ml, 8 mg/ml
morphine intravenous solution
10 mg/ml, 50 mg/ml
morphine intravenous solution
100 mg/4 ml, 25 mg/ml, 250
mg/10 ml
morphine intravenous solution 4
mg/ml, 8 mg/ml
morphine intravenous syringe 2
MO; QLL (8 per 28 mg/ml, 4 mg/ml
morphine oral capsule, er
days)
multiphase 24 hr 30 mg, 60 mg
MO; QLL (90 per
morphine oral capsule,
30 days)
extend.release pellets 100 mg, 20
MO; QLL (45 per
mg, 30 mg, 50 mg, 60 mg, 80
30 days)
mg
MO; QLL (30 per
morphine oral solution 10 mg/5
30 days)
MO; QLL (180 per ml
morphine oral solution 20 mg/5
30 days)
ml (4 mg/ml)
MO; QLL (90 per
morphine oral tablet 15 mg
30 days)
MO; QLL (45 per
morphine oral tablet 30 mg
30 days)
MO; QLL (30 per
morphine oral tablet extended
30 days)
PAR; MO; QLL (30 release 100 mg, 15 mg, 30 mg,
60 mg
per 30 days)
PAR; MO; QLL (60 morphine oral tablet extended
release 200 mg
per 30 days)
nabumetone
nalbuphine injection solution 10
mg/ml
MO; QLL (180 per nalbuphine injection solution 20
mg/ml
30 days)
MO; QLL (120 per naloxone
naltrexone oral
30 days)
NAMENDA ORAL
SOLUTION
B/D; PAR; QLL
(180 per 30 days)
NAMENDA ORAL TABLET
10 MG
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (90 per
30 days)
MO
Drug Requirements/
Tier Limits
2
2
2
2
2
2
2
2
4
4
2
2
2
2
2
2
2
2
2
3
3
MO; QLL (270 per
30 days)
QLL (120 per 30
days)
MO; QLL (120 per
30 days)
QLL (120 per 30
days)
MO; QLL (180 per
30 days)
QLL (120 per 30
days)
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (2700 per
30 days)
MO; QLL (1350 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO
MO
MO; QLL (300 per
30 days)
MO; QLL (60 per
30 days)
table.
26
00016274, V22
Drug Name
NAMENDA ORAL TABLET
5 MG
NAMENDA TITRATION
PAK
NAMENDA XR ORAL CAP,
SPRINKLE,ER 24HR DOSE
PACK
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER
24HR
naproxen
naproxen sodium oral tablet 275
mg, 550 mg
NARCAN
nefazodone oral tablet 100 mg
Drug Requirements/
Tier Limits
3
3
3
3
2
2
3
2
2
2
2
2
NEUPRO
4
norco
2
nortriptyline
NUEDEXTA
2
3
NUPLAZID
5
olanzapine intramuscular
2
olanzapine oral tablet 10 mg
2
2
olanzapine oral tablet 2.5 mg
2
2
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (56 per
365 days)
MO; QLL (30 per
30 days)
MO
MO
MO
MO; QLL (180 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (72 per
30 days)
MO; QLL (360 per
30 days)
PAR; MO; QLL (30
per 30 days)
MO; QLL (360 per
30 days)
MO
MO; QLL (60 per
30 days)
PAR; LA; QLL (60
per 30 days)
MO; QLL (60 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (40 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (30 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
2
olanzapine oral tablet 7.5 mg
2
olanzapine oral tablet,
disintegrating 5 mg
olanzapine-fluoxetine oral
capsule 12-25 mg, 12-50 mg, 650 mg
olanzapine-fluoxetine oral
capsule 3-25 mg, 6-25 mg
ONFI ORAL SUSPENSION
2
ONFI ORAL TABLET 10
MG
ONFI ORAL TABLET 20
MG
ORAP
oxaprozin
oxcarbazepine oral tablet
OXTELLAR XR ORAL
TABLET EXTENDED
OXTELLAR XR ORAL
TABLET EXTENDED
OXTELLAR XR ORAL
TABLET EXTENDED
oxycodone oral capsule
4
oxycodone oral concentrate
2
oxycodone oral solution
2
oxycodone oral tablet 10 mg, 5
mg
2
2
2
2
2
2
4
4
4
2
2
4
MO; QLL (120 per
30 days)
MO; QLL (80 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (40 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (90 per
30 days)
PAR; MO; QLL
(480 per 30 days)
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL (60
per 30 days)
MO
MO
MO
MO; QLL (480 per
30 days)
4
MO; QLL (240 per
30 days)
4
MO; QLL (120 per
30 days)
2
MO; QLL (360 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (1800 per
30 days)
MO; QLL (360 per
30 days)
table.
27
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
oxycodone oral tablet 15 mg
2
oxycodone oral tablet 20 mg, 30
mg
oxycodone-acetaminophen oral
solution
oxycodone-acetaminophen oral
tablet 10-325 mg, 2.5-325 mg,
5-325 mg, 7.5-325 mg
oxycodone-aspirin
2
2
2
2
paliperidone oral tablet extended
release 24hr 1.5 mg
release 24hr 3 mg
release 24hr 6 mg
release 24hr 9 mg
paroxetine hcl oral tablet 10 mg
2
2
2
2
paroxetine hcl oral tablet
extended release 24 hr 12.5 mg
extended release 24 hr 37.5 mg
PAXIL ORAL SUSPENSION
2
PEGANONE
perphenazine
phenelzine
phenobarbital oral elixir
4
2
2
2
phenobarbital oral tablet 100 mg
2
2
2
2
2
2
2
4
MO; QLL (540 per
30 days)
MO; QLL (180 per
30 days)
QLL (1800 per 30
days)
MO; QLL (360 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (45 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (900 per
30 days)
MO
MO
MO
MO; QLL (3000 per
30 days)
MO; QLL (120 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
2
phenobarbital oral tablet 16.2
mg
2
mg
2
mg
mg
phenytoin oral suspension 100
mg/4 ml
phenytoin oral suspension 125
mg/5 ml
phenytoin oral tablet,chewable
phenytoin sodium extended
phenytoin sodium intravenous
solution
piroxicam
POTIGA ORAL TABLET 200
MG, 300 MG, 400 MG
POTIGA ORAL TABLET 50
MG
pramipexole oral tablet
primidone
PRISTIQ ORAL TABLET
EXTENDED RELEASE 24
HR 100 MG
PRISTIQ ORAL TABLET
EXTENDED RELEASE 24
HR 25 MG
PRISTIQ ORAL TABLET
EXTENDED RELEASE 24
HR 50 MG
protriptyline
pyridostigmine bromide
quetiapine oral tablet 100 mg
2
2
2
2
MO; QLL (800 per
30 days)
MO; QLL (741 per
30 days)
MO; QLL (400 per
30 days)
MO; QLL (370 per
30 days)
MO; QLL (200 per
30 days)
MO; QLL (185 per
30 days)
MO; QLL (123 per
30 days)
2
2
MO
2
2
2
MO
MO
MO
2
4
MO
MO; QLL (90 per
30 days)
MO; QLL (270 per
30 days)
MO
MO
MO; QLL (120 per
30 days)
4
2
2
4
4
MO; QLL (480 per
30 days)
4
MO; QLL (240 per
30 days)
2
2
2
MO
MO
MO; QLL (240 per
30 days)
table.
28
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
2
2
2
2
2
REXULTI ORAL TABLET
0.25 MG, 0.5 MG, 1 MG, 2
MG
REXULTI ORAL TABLET 3
MG, 4 MG
RISPERDAL CONSTA
INTRAMUSCULAR
SYRINGE 12.5 MG/2 ML, 25
MG/2 ML
RISPERDAL CONSTA
INTRAMUSCULAR
SYRINGE 37.5 MG/2 ML
RISPERDAL CONSTA
INTRAMUSCULAR
SYRINGE 50 MG/2 ML
risperidone oral solution
5
risperidone oral tablet 0.25 mg
2
5
4
5
5
2
risperidone oral tablet 0.5 mg
2
risperidone oral tablet 1 mg
2
2
2
2
risperidone oral tablet,
2
2
MO; QLL (120 per
30 days)
MO; QLL (960 per
30 days)
MO; QLL (80 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (480 per
30 days)
PAR; QLL (60 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
disintegrating 1 mg
disintegrating 2 mg
disintegrating 3 mg
disintegrating 4 mg
rivastigmine
2
rivastigmine tartrate
2
rizatriptan
2
PAR; QLL (30 per
30 days)
ropinirole oral tablet
MO; QLL (2 per 28 roweepra
days)
ROZEREM
2
2
2
2
2
2
4
SABRIL ORAL POWDER IN
QLL (2 per 28 days) PACKET
SABRIL ORAL TABLET
4
SAPHRIS (BLACK CHERRY)
SUBLINGUAL TABLET 10
MG
MO; QLL (480 per SAPHRIS (BLACK CHERRY)
30 days)
SUBLINGUAL TABLET 2.5
MO; QLL (1920 per MG
30 days)
SAPHRIS (BLACK CHERRY)
MO; QLL (960 per SUBLINGUAL TABLET 5
30 days)
MG
MO; QLL (480 per selegiline hcl
30 days)
SEROQUEL XR ORAL
MO; QLL (240 per TABLET EXTENDED
30 days)
MO; QLL (150 per SEROQUEL XR ORAL
30 days)
TABLET EXTENDED
MO; QLL (120 per RELEASE 24 HR 200 MG
30 days)
SEROQUEL XR ORAL
MO; QLL (1920 per TABLET EXTENDED
30 days)
MO; QLL (960 per
30 days)
4
5
MO; QLL (480 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (150 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (12 per
30 days)
MO
MO; QLL (30 per
30 days)
MO; LA; QLL (180
per 30 days)
LA; QLL (180 per
30 days)
MO; QLL (60 per
30 days)
4
MO; QLL (240 per
30 days)
4
MO; QLL (120 per
30 days)
2
4
MO
MO; QLL (150 per
30 days)
4
MO; QLL (120 per
30 days)
4
MO; QLL (80 per
30 days)
table.
29
00016274, V22
Drug Name
SEROQUEL XR ORAL
TABLET EXTENDED
SEROQUEL XR ORAL
TABLET EXTENDED
RELEASE 24 HR 50 MG
sertraline oral concentrate
Drug Requirements/
Tier Limits
4
MO; QLL (60 per
30 days)
4
MO; QLL (480 per
30 days)
2
sertraline oral tablet 100 mg
2
2
2
SPRITAM ORAL TABLET
FOR SUSPENSION 1,000
MG, 250 MG, 500 MG
SPRITAM ORAL TABLET
FOR SUSPENSION 750 MG
STRATTERA ORAL
CAPSULE 10 MG, 18 MG,
25 MG, 40 MG
STRATTERA ORAL
CAPSULE 100 MG, 60 MG,
80 MG
SUBSYS
4
MO; QLL (300 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
QLL (60 per 30
days)
Drug Name
Drug Requirements/
Tier Limits
SURMONTIL
temazepam oral capsule 15 mg,
22.5 mg, 30 mg
tetrabenazine oral tablet 12.5
mg
tetrabenazine oral tablet 25 mg
4
2
thioridazine
thiothixene
tiagabine
tizanidine oral tablet
tolcapone
tolmetin
topiramate oral capsule, sprinkle
topiramate oral tablet 100 mg
2
2
2
2
5
2
2
2
5
5
2
QLL (120 per 30
days)
MO; QLL (60 per
30 days)
2
2
3
MO; QLL (30 per
30 days)
tramadol oral tablet
2
tramadol-acetaminophen
2
5
PAR; QLL (120 per
30 days)
MO
MO; QLL (9 per 30
days)
MO; QLL (4 per 30
days)
MO; QLL (4 per 30
days)
4
3
sulindac oral
sumatriptan succinate oral
2
2
sumatriptan succinate
subcutaneous cartridge
subcutaneous pen injector 4 mg/
0.5 ml, 6 mg/0.5 ml
subcutaneous pen injector 6 mg/
0.5 ml (auto-injector)
subcutaneous solution
subcutaneous syringe 6 mg/0.5
ml
2
2
2
2
2
tranylcypromine
trazodone
trifluoperazine
trihexyphenidyl
TRILEPTAL ORAL
SUSPENSION
TRINTELLIX ORAL
TABLET 10 MG
TRINTELLIX ORAL
QLL (4 per 30 days) TABLET 20 MG
TRINTELLIX ORAL
TABLET 5 MG
MO; QLL (4 per 30 TYSABRI
days)
valproate sodium
QLL (4 per 30 days) valproic acid
valproic acid (as sodium salt) oral
2
2
2
2
4
4
4
4
5
2
2
2
MO
MO; QLL (30 per
30 days)
PAR; QLL (240 per
30 days)
PAR; QLL (120 per
30 days)
MO
MO
MO
MO
MO
MO
MO; QLL (480 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (1920 per
30 days)
MO; QLL (960 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (240 per
30 days)
MO
MO
MO
MO
MO
QLL (60 per 30
days)
QLL (30 per 30
days)
QLL (120 per 30
days)
PAR; LA
MO
MO
MO
table.
30
00016274, V22
Drug Name
valproic acid (as sodium salt) oral
solution 250 mg/5 ml (5 ml),
500 mg/10 ml (10 ml)
venlafaxine oral capsule,extended
release 24hr 150 mg
release 24hr 37.5 mg
release 24hr 75 mg
venlafaxine oral tablet 100 mg
Drug Requirements/
Tier Limits
2
2
2
2
2
2
venlafaxine oral tablet 37.5 mg
2
2
2
venlafaxine oral tablet extended
release 24hr 150 mg
release 24hr 37.5 mg
release 24hr 75 mg
VERSACLOZ
vicodin
2
2
2
5
2
vicodin es
2
vicodin hp
2
VIIBRYD ORAL TABLET 10
MG
MG
MG
VIMPAT INTRAVENOUS
VIMPAT ORAL SOLUTION
4
4
4
4
4
MO; QLL (60 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (113 per
30 days)
MO; QLL (450 per
30 days)
MO; QLL (300 per
30 days)
MO; QLL (225 per
30 days)
MO; QLL (150 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
QLL (600 per 30
days)
MO; QLL (390 per
30 days)
MO; QLL (390 per
30 days)
MO; QLL (390 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
QLL (1200 per 30
days)
MO; QLL (1200 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
VIMPAT ORAL TABLET 100
MG
MG
MG
MG
VOLTAREN TOPICAL GEL
1%
VRAYLAR ORAL CAPSULE
1.5 MG
VRAYLAR ORAL CAPSULE
3 MG, 4.5 MG, 6 MG
VRAYLAR ORAL CAPSULE,
DOSE PACK
XENAZINE ORAL TABLET
12.5 MG
XENAZINE ORAL TABLET
25 MG
xodol 10/300
4
xodol 5/300
2
xodol 7.5/300
2
XYREM
5
zaleplon oral capsule 10 mg
2
zaleplon oral capsule 5 mg
2
zenzedi oral tablet 10 mg
2
zenzedi oral tablet 5 mg
2
ziprasidone hcl oral capsule 20
mg
mg
mg, 80 mg
2
4
4
4
4
4
5
4
5
5
2
2
2
MO; QLL (120 per
30 days)
MO; QLL (80 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (1000 per
30 days)
PAR; QLL (30 per
30 days)
PAR; QLL (30 per
30 days)
PAR; QLL (7 per
365 days)
PAR; LA; QLL (240
per 30 days)
PAR; LA; QLL (120
per 30 days)
MO; QLL (390 per
30 days)
MO; QLL (390 per
30 days)
MO; QLL (390 per
30 days)
PAR; LA; QLL (540
per 30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
PAR; MO; QLL
(180 per 30 days)
PAR; MO; QLL (90
per 30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
table.
31
00016274, V22
Drug Name
zolmitriptan
Drug Requirements/
Tier Limits
2
MO; QLL (9 per 30
days)
ZOMIG NASAL
4 MO; QLL (6 per 30
days)
zonisamide
2 MO
ZYPREXA RELPREVV
Cardiovascular, Hypertension / Lipids
acebutolol
2 MO
afeditab cr
2 MO
AGGRENOX
4 MO; QLL (60 per
30 days)
amiloride
2 MO
amiloride-hydrochlorothiazide
2 MO
amiodarone intravenous solution 2 B/D; PAR; MO
amiodarone intravenous syringe 2 B/D; PAR
amiodarone oral
2 MO
amlodipine besylate oral tablet
1 MO; QLL (30 per
10 mg, 2.5 mg
30 days)
amlodipine besylate oral tablet 5 1 MO; QLL (45 per
mg
30 days)
amlodipine-benazepril
2 MO
atenolol
1 MO
atenolol-chlorthalidone
1 MO
atorvastatin
6 MO; QLL (30 per
30 days)
benazepril
6 MO
benazepril-hydrochlorothiazide
6 MO
betaxolol oral
2 MO
bisoprolol fumarate
2 MO
bisoprolol-hydrochlorothiazide
2 MO
BRILINTA
4 MO; QLL (60 per
30 days)
bumetanide
2 MO
candesartan oral tablet 16 mg, 4 2 MO; QLL (60 per
mg, 8 mg
30 days)
candesartan oral tablet 32 mg
2 MO; QLL (30 per
30 days)
candesartan-hydrochlorothiazid 2 MO; QLL (60 per
oral tablet 16-12.5 mg
30 days)
candesartan-hydrochlorothiazid 2 MO; QLL (30 per
oral tablet 32-12.5 mg, 32-25
30 days)
mg
captopril
6 MO
Drug Name
Drug Requirements/
Tier Limits
captopril-hydrochlorothiazide
cartia xt
carvedilol
chlorothiazide
chlorthalidone oral tablet 25 mg,
50 mg
cholestyramine (with sugar)
cholestyramine light
cilostazol
clonidine hcl oral tablet
clonidine transdermal patch
6
2
1
2
2
MO
MO
MO
MO
MO
2
2
2
2
2
clopidogrel oral tablet 300 mg
2
clopidogrel oral tablet 75 mg
2
colestipol
DEMSER
digox oral tablet 125 mcg
digoxin injection solution
digoxin oral solution 50 mcg/ml
digoxin oral tablet 125 mcg
dilt-xr
diltiazem hcl intravenous
solution
diltiazem hcl oral capsule,
extended release 120 mg, 180
mg, 240 mg, 300 mg, 360 mg
diltiazem hcl oral capsule,ext
release degradable
extended release 12 hr
extended release 24hr
diltiazem hcl oral tablet
diltiazem hcl oral tablet extended
release 24 hr
dofetilide
doxazosin
EFFIENT
2
4
2
2
3
2
2
2
MO
MO
MO
MO
MO; QLL (4 per 28
days)
MO; QLL (1 per 30
days)
MO; QLL (30 per
30 days)
MO
MO
MO
MO
MO
MO
MO
ELIQUIS ORAL TABLET 2.5
MG
4
2
MO
2
MO
2
MO
2
MO
2
2
MO
MO
4
2
3
MO
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
table.
32
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
ELIQUIS ORAL TABLET 5
MG
enalapril maleate
enalapril-hydrochlorothiazide
enoxaparin subcutaneous solution
4
enoxaparin subcutaneous syringe
100 mg/ml, 150 mg/ml
120 mg/0.8 ml, 80 mg/0.8 ml
30 mg/0.3 ml
40 mg/0.4 ml
60 mg/0.6 ml
eplerenone
eprosartan
2
felodipine oral er
fenofibrate micronized oral
capsule 134 mg, 200 mg, 67 mg
fenofibrate nanocrystallized 48
mg, 145 mg
fenofibrate oral tablet 160 mg,
54 mg
flecainide
fondaparinux subcutaneous
syringe 10 mg/0.8 ml
syringe 2.5 mg/0.5 ml
syringe 5 mg/0.4 ml
syringe 7.5 mg/0.6 ml
fosinopril
fosinopril-hydrochlorothiazide
FRAGMIN
2,500 ANTI-XA UNIT/0.2
ML, 5,000 ANTI-XA UNIT/
0.2 ML
furosemide injection solution
2
2
6
6
2
2
2
2
2
2
2
2
2
2
2
2
2
2
6
6
4
2
MO; QLL (74 per
30 days)
MO
MO
MO; QLL (84 per
30 days)
MO; QLL (28 per
30 days)
MO; QLL (22.4 per
30 days)
MO; QLL (8.4 per
30 days)
MO; QLL (11.2 per
30 days)
MO; QLL (16.8 per
30 days)
MO
MO; QLL (30 per
30 days)
MO
MO; QLL (30 per
30 days)
MO
MO; QLL (30 per
30 days)
MO
MO; QLL (24 per
30 days)
MO; QLL (15 per
30 days)
MO; QLL (12 per
30 days)
MO; QLL (18 per
30 days)
MO
MO
MO
MO
Drug Name
furosemide oral solution 10 mg/
ml, 40 mg/5 ml (8 mg/ml)
furosemide oral tablet
gemfibrozil oral
HEPARIN (PORCINE) IN 5
% DEX INTRAVENOUS
PARENTERAL SOLUTION
12,500 UNIT/250 ML
heparin (porcine) in 5 % dex
intravenous parenteral solution
25,000 unit/250 ml(100 unit/
ml)
heparin (porcine) in 5 % dex
25,000 unit/500 ml (50 unit/
ml)
heparin (porcine) in nacl (pf)
1,000 unit/500 ml, 2,000 unit/
1,000 ml
heparin (porcine) injection
cartridge
heparin (porcine) injection
solution
HEPARIN(PORCINE) IN
0.45% NACL
INTRAVENOUS
PARENTERAL SOLUTION
12,500 UNIT/250 ML
HEPARIN(PORCINE) IN
0.45% NACL
INTRAVENOUS
PARENTERAL SOLUTION
25,000 UNIT/250 ML
HEPARIN(PORCINE) IN
0.45% NACL
INTRAVENOUS
PARENTERAL SOLUTION
25,000 UNIT/500 ML
heparin, porcine (pf) injection
solution
hydralazine
hydrochlorothiazide
Drug Requirements/
Tier Limits
1
MO
1
2
4
MO
MO
B/D; PAR; HI
3
B/D; PAR; MO; HI
4
B/D; PAR; MO; HI
2
B/D; PAR; HI
2
B/D; PAR; MO; HI
2
B/D; PAR; MO; HI
4
B/D; PAR
3
B/D; PAR; MO
4
B/D; PAR; MO
2
B/D; PAR; MO
2
1
MO
MO
table.
33
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
indapamide
irbesartan
2
6
isosorbide dinitrate oral
isosorbide mononitrate
jantoven
JUXTAPID
KYNAMRO
labetalol intravenous solution
labetalol oral
LANOXIN INJECTION
LANOXIN ORAL TABLET
125 MCG, 62.5 MCG
lidocaine (pf) intravenous
solution
lidocaine (pf) intravenous syringe
100 mg/5 ml (2 %)
lisinopril
lisinopril-hydrochlorothiazide
losartan oral tablet 100 mg
2
2
1
5
5
2
2
4
3
losartan oral tablet 25 mg, 50
mg
losartan-hydrochlorothiazide
6
lovastatin oral tablet 10 mg, 20
mg
lovastatin oral tablet 40 mg
2
matzim la
methyclothiazide
methyldopa
methyldopa-hydrochlorothiazide
methyldopate
metolazone
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate intravenous
solution
metoprolol tartrate intravenous
syringe
metoprolol tartrate oral tablet
100 mg, 25 mg, 50 mg
2
2
2
2
2
2
2
2
2
2
MO
MO; QLL (30 per
30 days)
MO
MO
MO
PAR; LA
PAR; LA
MO
MO
MO
MO
2
6
6
6
6
2
MO
MO
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO
MO
MO
MO
MO
MO
MO
MO
2
1
MO
Drug Name
Drug Requirements/
Tier Limits
mexiletine
minoxidil oral
MULTAQ
2
2
4
nadolol
nadolol-bendroflumethiazide
niacin oral tablet extended release
24 hr 1,000 mg, 750 mg
niacin oral tablet extended release
24 hr 500 mg
niacor
NIASPAN EXTENDEDRELEASE ORAL TABLET
EXTENDED RELEASE 24
HR 1,000 MG, 750 MG
NIASPAN EXTENDEDRELEASE ORAL TABLET
EXTENDED RELEASE 24
HR 500 MG
nicardipine oral
nifedical xl
nifedipine oral tablet extended
release
nifedipine oral tablet extended
release 24hr
nitro-bid
nitroglycerin intravenous
nitroglycerin sublingual
nitroglycerin transdermal patch
24 hour
NITROSTAT
omega-3 acid ethyl esters
pacerone oral tablet 100 mg, 200
mg, 400 mg
pentoxifylline
pindolol
PRADAXA ORAL CAPSULE
110 MG
PRADAXA ORAL CAPSULE
150 MG, 75 MG
PRALUENT PEN
2
2
2
2
2
3
MO
MO
MO; QLL (60 per
30 days)
MO
MO
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO
MO; QLL (60 per
30 days)
3
MO; QLL (30 per
30 days)
2
2
2
MO
MO
MO
2
MO
2
2
6
2
MO
B/D; PAR
6
2
2
MO
MO
MO
2
2
4
MO
MO
MO
4
MO; QLL (60 per
30 days)
PAR; QLL (2 per 28
days)
5
MO
table.
34
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
PRALUENT SYRINGE
5
pravastatin
2
prazosin oral
prevalite
procainamide injection solution
100 mg/ml
procainamide injection solution
500 mg/ml
PROMACTA ORAL TABLET
12.5 MG, 25 MG, 75 MG
PROMACTA ORAL TABLET
50 MG
propafenone oral tablet
propranolol intravenous
propranolol oral
propranolol-hydrochlorothiazid
quinapril
quinapril-hydrochlorothiazide
quinidine gluconate oral
quinidine sulfate oral tablet
ramipril
RANEXA
REPATHA PUSHTRONEX
2
2
2
REPATHA SURECLICK
5
REPATHA SYRINGE
5
simvastatin
6
sorine oral tablet 120 mg, 160
mg, 80 mg
sorine oral tablet 240 mg
sotalol af
sotalol oral
spironolacton-hydrochlorothiaz
spironolactone
taztia xt
telmisartan oral tablet 20 mg, 40
mg
2
PAR; QLL (2 per 28
days)
MO; QLL (30 per
30 days)
MO
MO
MO
2
5
5
2
2
2
2
6
6
2
2
6
3
5
2
2
2
2
2
2
2
PAR; LA; QLL (30
per 30 days)
PAR; LA; QLL (60
per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
PAR; QLL (3.5 per
28 days)
PAR; QLL (3 per 28
days)
PAR; QLL (3 per 28
days)
MO; QLL (30 per
30 days)
MO
MO
MO
MO
MO
MO
MO; QLL (30 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
telmisartan oral tablet 80 mg
2
terazosin
TIKOSYN
timolol maleate oral
torsemide oral
trandolapril
tranexamic acid intravenous
triamterene-hydrochlorothiazid
valsartan oral tablet 160 mg
2
4
2
2
6
2
2
2
valsartan oral tablet 320 mg
2
valsartan oral tablet 40 mg, 80
mg
valsartan-hydrochlorothiazide
2
VECAMYL
verapamil intravenous solution
verapamil oral capsule, 24 hr er
pellet ct
verapamil oral capsule,ext rel.
pellets 24 hr
verapamil oral tablet
verapamil oral tablet extended
release 120 mg (24 hours)
verapamil oral tablet extended
release 120 mg, 180 mg, 240 mg
warfarin
WELCHOL
XARELTO ORAL TABLET
10 MG, 20 MG
XARELTO ORAL TABLET
15 MG
XARELTO ORAL TABLETS,
DOSE PACK
ZETIA
4
2
2
MO
MO
2
MO
2
2
MO
2
MO
1
4
4
MO
MO
MO; QLL (30 per
30 days)
MO; QLL (42 per
30 days)
MO; QLL (102 per
365 days)
MO; QLL (30 per
30 days)
6
4
4
4
MO; QLL (60 per
30 days)
MO
MO
MO
MO
MO
MO
MO
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (30 per
30 days)
Dermatologicals/Topical Therapy
8-MOP
3 PAR; MO
acyclovir topical
2 MO; QLL (30 per
30 days)
ala-cort topical cream
2 MO
table.
35
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
alclometasone
amcinonide
ammonium lactate
betamethasone dipropionate
betamethasone valerate topical
cream
lotion
ointment
betamethasone, augmented
topical cream
topical lotion
topical ointment
calcipotriene scalp
2
2
2
2
2
MO
MO
MO
MO
MO
2
MO
2
MO
2
MO
2
MO
2
MO
calcipotriene topical
2
CAPEX
ciclodan topical solution
ciclopirox topical cream
ciclopirox topical gel
ciclopirox topical shampoo
ciclopirox topical solution
ciclopirox topical suspension
clindamycin phosphate topical
clobetasol scalp
clobetasol topical cream
clobetasol topical gel
clobetasol topical ointment
clobetasol-emollient topical cream
clotrimazole topical
clotrimazole-betamethasone
cormax scalp
DENAVIR
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
desonide
desoximetasone
diclofenac sodium topical gel 3
%
2
2
2
2
MO; QLL (60 per
30 days)
MO; QLL (120 per
30 days)
MO
PAR; MO
MO
MO
MO
PAR; MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO; QLL (5 per 2
days)
MO
MO
PAR; MO; QLL
(100 per 30 days)
Drug Name
Drug Requirements/
Tier Limits
DIFFERIN TOPICAL GEL
0.3 %
DIFFERIN TOPICAL GEL
WITH PUMP
diflorasone
econazole topical
ELIDEL
4
ery pads
erythromycin with ethanol
erythromycin-benzoyl peroxide
fluocinolone
fluocinolone and shower cap
fluocinonide topical cream 0.05
%
fluocinonide topical gel
fluocinonide topical ointment
fluocinonide topical solution
fluocinonide-e topical cream 0.05
%
fluorouracil topical cream 5 %
fluticasone topical cream
fluticasone topical ointment
gentamicin topical
halobetasol propionate
HALOG
hydrocortisone topical cream 1
%, 2.5 %
hydrocortisone topical lotion 2.5
%
hydrocortisone topical ointment
1 %, 2.5 %
hydrocortisone valerate
hydrocortisone-min oil-wht pet
imiquimod
ketoconazole topical
lidocaine (pf) injection solution
10 mg/ml (1 %), 20 mg/ml (2
%), 40 mg/ml (4 %), 5 mg/ml
(0.5 %)
lidocaine (pf) injection solution
15 mg/ml (1.5 %)
4
MO
2
2
4
2
2
2
2
2
2
MO
MO
PAR; MO; QLL
(100 per 90 days)
MO
MO
MO
MO
MO
MO
2
2
2
2
MO
MO
MO
MO
2
2
2
2
2
4
2
MO
MO
MO
MO
MO
MO
MO
2
MO
2
MO
2
2
2
2
2
MO
MO
MO
MO
MO
2
table.
36
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
lidocaine hcl injection solution
10 mg/ml (1 %), 20 mg/ml (2
%)
lidocaine hcl injection solution 5
mg/ml (0.5 %)
lidocaine hcl laryngotracheal
lidocaine hcl mucous membrane
lidocaine hcl urethral
lidocaine topical adhesive patch,
medicated
lidocaine topical ointment
lidocaine viscous
lidocaine-prilocaine topical
cream
lindane topical shampoo
lokara
methoxsalen rapid
metronidazole topical cream
metronidazole topical gel 0.75
%
metronidazole topical lotion
mometasone topical
mupirocin topical ointment
nyamyc
nystatin topical
nystatin-triamcinolone
nystop
OXSORALEN
PANRETIN
permethrin topical cream
PICATO
podofilox
PROTOPIC
2
rosadan topical cream
SANTYL
2
4
selenium sulfide topical lotion
silver sulfadiazine
SORIATANE ORAL
CAPSULE 10 MG, 17.5 MG,
25 MG
2
2
5
MO
2
2
2
2
2
2
2
2
2
2
5
2
2
2
2
2
2
2
2
2
4
5
2
4
2
4
MO
MO
Drug Name
ssd
sulfacetamide sodium (acne)
SULFAMYLON
TAZORAC
thermazene
tretinoin topical cream
Drug Requirements/
Tier Limits
2
2
4
4
2
2
MO
MO
MO
MO
MO
MO; QLL (45 per
30 days)
MO; QLL (45 per
30 days)
MO
tretinoin topical gel 0.01 %,
2
PAR; MO; QLL (90 0.025 %
per 30 days)
triamcinolone acetonide topical 2
MO
cream
MO
triamcinolone acetonide topical 2 MO
lotion
MO
triamcinolone acetonide topical 2 MO
ointment 0.025 %, 0.1 %, 0.5
MO
%
trianex
2 MO
PAR
triderm topical cream
2 MO
MO
UVADEX
4
MO
VALCHLOR
5
MO
VECTICAL
4 MO
MO
Diagnostics / Miscellaneous Agents
acamprosate
MO
2 MO
acetylcysteine intravenous
MO
2 B/D; PAR; MO
MO
ADAGEN
5
alendronate oral tablet 40 mg
MO
2 MO; QLL (30 per
30 days)
MO
anagrelide
2 MO
MO
ARALAST NP
5 PAR; LA
buphenyl oral tablet
5 PAR
MO
bupropion hcl (smoking deter)
2 MO; QLL (60 per
MO
30 days)
MO
CARBAGLU
5
PAR; LA
PAR; MO; QLL
cevimeline
2 MO
(100 per 90 days)
CHANTIX
6 MO; QLL (60 per
MO
30 days)
MO; QLL (30 per
CHANTIX CONTINUING 6 MO; QLL (56 per
30 days)
MONTH BOX
28 days)
MO
CHANTIX STARTING
6 MO; QLL (106 per
MO
MONTH BOX
365 days)
CLINIMIX 4.25%/D5W
4 B/D; PAR; HI
SULFIT FREE
table.
37
00016274, V22
Drug Name
CLINIMIX E 2.75%/D10W
SUL FREE
SULF FREE
d10 %-0.45 % sodium chloride
d2.5 %-0.45 % sodium chloride
d5 % and 0.9 % sodium
chloride
d5 %-0.45 % sodium chloride
dextrose 10 % and 0.2 % nacl
dextrose 10 % in water (d10w)
dextrose 5 %-lactated ringers
dextrose 5%-0.2 % sod chloride
dextrose 5%-0.3 % sod.chloride
intravenous syringe
dextrose with sodium chloride
disulfiram
EXJADE
FERRIPROX
INCRELEX
kionex
kionex (with sorbitol)
lactated ringers irrigation
levocarnitine (with sugar)
levocarnitine oral tablet
midodrine
neomycin-polymyxin b gu
NICOTROL NS
ORFADIN ORAL CAPSULE
10 MG, 2 MG, 5 MG
ORFADIN ORAL CAPSULE
20 MG
Drug Requirements/
Tier Limits
4
B/D; PAR; HI
4
B/D; PAR; HI
4
2
2
HI
HI
MO; HI
2
4
2
2
2
2
2
2
2
2
2
MO; HI
HI
MO; HI
MO; HI
MO; HI
HI
HI
MO
2
2
2
2
5
5
5
2
2
2
2
2
2
2
3
5
5
MO
B/D; PAR; HI
MO
PAR; LA
PAR
PAR; LA
MO
MO
MO
B/D; PAR; MO
MO
MO
MO
MO; QLL (120 per
30 days)
LA
Drug Name
Drug Requirements/
Tier Limits
ORFADIN ORAL
SUSPENSION
pilocarpine hcl oral
RAVICTI
5
LA
2
5
RENAGEL
RENVELA ORAL POWDER
IN PACKET 0.8 GRAM
RENVELA ORAL POWDER
IN PACKET 2.4 GRAM
RENVELA ORAL TABLET
3
3
MO
PAR; QLL (525 per
30 days)
MO
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (270 per
30 days)
MO
B/D; PAR; MO
MO; HI
3
3
riluzole
2
ringers irrigation
2
sodium chloride 0.9 %
2
intravenous
sodium chloride irrigation
2
sodium polystyrene (sorb free)
2
sodium polystyrene sulfonate oral 2
powder
sodium polystyrene sulfonate oral 2
suspension
sodium polystyrene sulfonate
2
rectal
sps (with sorbitol) oral
2
sps (with sorbitol) rectal
2
SYPRINE
5
water for irrigation, sterile
2
ZEMAIRA
5
Ear, Nose / Throat Medications
acetic acid otic
2
acetic acid-aluminum acetate
2
ASTEPRO NASAL SPRAY,
3
NON-AEROSOL
azelastine nasal aerosol,spray
2
chlorhexidine gluconate mucous
membrane
CIPRODEX
COLY-MYCIN S
fluocinolone acetonide oil
hydrocortisone-acetic acid
MO
MO
MO
MO
MO
PAR; LA
2
MO
MO
MO; QLL (30 per
25 days)
MO; QLL (30 per
25 days)
MO
4
4
2
2
MO
MO
MO
MO
table.
38
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
ipratropium bromide nasal
2
neomycin-polymyxin-hc otic
ofloxacin otic
oralone
paroex oral rinse
periogard
triamcinolone acetonide dental
tyzine nasal drops 0.05 %
Endocrine/Diabetes
acarbose oral tablet 100 mg
2
2
2
2
2
2
2
2
2
2
ACTHAR H.P.
alcohol pads
ALDURAZYME
ANDRODERM
5
6
5
4
ANDROGEL
TRANSDERMAL GEL IN
METERED-DOSE PUMP
20.25 MG/1.25 GRAM (1.62
%)
ANDROGEL
TRANSDERMAL GEL IN
PACKET 1 % (25 MG/
2.5GRAM)
ANDROGEL
TRANSDERMAL GEL IN
PACKET 1 % (50 MG/5
GRAM)
ANDROGEL
TRANSDERMAL GEL IN
PACKET 1.62 % (20.25 MG/
1.25 GRAM)
ANDROGEL
TRANSDERMAL GEL IN
PACKET 1.62 % (40.5 MG/
2.5 GRAM)
ANDROXY
4
4
MO; QLL (30 per
30 days)
MO
MO
MO
MO
MO
MO
MO
MO; QLL (90 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
PAR
MO
PAR
MO; QLL (30 per
30 days)
MO; QLL (150 per
30 days)
MO; QLL (225 per
30 days)
4
MO; QLL (300 per
30 days)
4
MO; QLL (112.5
per 30 days)
4
MO; QLL (150 per
30 days)
4
Drug Name
Drug Requirements/
Tier Limits
AXIRON
4
BYDUREON
3
BYETTA SUBCUTANEOUS
PEN INJECTOR 10 MCG/
DOSE(250 MCG/ML) 2.4
ML
BYETTA SUBCUTANEOUS
PEN INJECTOR 5 MCG/
DOSE (250 MCG/ML) 1.2
ML
cabergoline
calcitonin (salmon)
3
calcitriol intravenous solution 1
mcg/ml
calcitriol oral capsule
CEREZYME
INTRAVENOUS RECON
SOLN 400 UNIT
cortisone
CYCLOSET
danazol oral
desmopressin injection
desmopressin nasal aerosol,spray
desmopressin nasal spray,nonaerosol
desmopressin oral
dexamethasone
dexamethasone sodium phos (pf)
dexamethasone sodium phosphate
injection
ELAPRASE
FABRAZYME
fludrocortisone
GAUZE PADS 2 X 2
glimepiride oral tablet 1 mg
6
MO; QLL (180 per
30 days)
MO; QLL (4 per 28
days)
MO; QLL (2.4 per
30 days)
3
MO; QLL (1.2 per
30 days)
2
2
2
MO
MO; QLL (4 per 30
days)
B/D; PAR; MO
2
5
B/D; PAR; MO
PAR
2
4
2
2
2
2
MO
MO; QLL (180 per
30 days)
MO
MO
MO
MO
2
2
2
2
MO
MO
MO
MO
5
5
2
6
6
PAR
PAR
MO
MO
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
PAR; MO
table.
39
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
6
glipizide oral tablet 10 mg
6
glipizide oral tablet 5 mg
6
Drug Name
Drug Requirements/
Tier Limits
JARDIANCE
4
KORLYM
KUVAN ORAL TABLET,
SOLUBLE
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXTOUCH
levothyroxine oral
levoxyl oral tablet 100 mcg, 112
mcg, 125 mcg, 137 mcg, 150
mcg, 175 mcg, 200 mcg, 25 mcg,
50 mcg, 75 mcg, 88 mcg
liothyronine oral
metformin oral tablet 1,000 mg
5
5
PAR; MO; QLL (30
per 30 days)
PAR
PAR
3
3
3
3
2
3
MO
MO
MO
MO
MO
MO
2
6
3
3
MO; QLL (60 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO
MO
metformin oral tablet 500 mg
6
2
6
6
MO
MO
MO
metformin oral tablet 850 mg
6
2
MO
MO; QLL (76 per
30 days)
MO; QLL (153 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (80 per
30 days)
MO; QLL (75 per
30 days)
MO
2
2
2
MO
MO
MO
2
MO
4
5
5
2
B/D; PAR; MO
glipizide oral tablet extended
release 24hr 10 mg
release 24hr 2.5 mg
release 24hr 5 mg
glipizide-metformin oral tablet
2.5-250 mg
glipizide-metformin oral tablet
2.5-500 mg, 5-500 mg
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY
KIT (HUMAN)
hydrocortisone oral
insulin pen needle
INSULIN SYRINGE (DISP)
U-100 0.3 ML, 1 ML, 1/2 ML
INVOKANA ORAL TABLET
100 MG
INVOKANA ORAL TABLET
300 MG
JANUMET
6
JANUMET XR ORAL
TABLET, ER MULTIPHASE
24 HR 100-1,000 MG
JANUMET XR ORAL
TABLET, ER MULTIPHASE
24 HR 50-1,000 MG, 50-500
MG
JANUVIA ORAL TABLET
100 MG
JANUVIA ORAL TABLET 25
MG
JANUVIA ORAL TABLET 50
MG
3
6
6
6
6
4
4
3
3
3
3
3
metformin oral tablet extended
PAR; MO; QLL (90 metformin oral tablet extended
per 30 days)
PAR; MO; QLL (30 metformin oral tablet extended
per 30 days)
release 24hr 1,000 mg
MO; QLL (60 per
methimazole oral tablet 10 mg,
30 days)
5 mg
MO; QLL (30 per
methylprednisolone acetate
30 days)
methylprednisolone oral tablets
methylprednisolone sodium succ
MO; QLL (60 per
injection recon soln 125 mg, 40
30 days)
mg
methylprednisolone sodium succ
intravenous
MO; QLL (30 per
MIACALCIN INJECTION
30 days)
MYOZYME
MO; QLL (120 per NAGLAZYME
30 days)
nateglinide oral tablet 120 mg
MO; QLL (60 per
30 days)
nateglinide oral tablet 60 mg
6
6
6
2
PAR; LA
MO; QLL (90 per
30 days)
MO; QLL (180 per
30 days)
table.
40
00016274, V22
Drug Name
NATPARA
needles, insulin disp.,safety
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG MIX 70-30
FLEXPEN
NOVOLOG PENFILL
oxandrolone oral tablet 10 mg
Drug Requirements/
Tier Limits
5
6
6
6
6
3
3
3
3
PAR; LA
MO
MO
MO
MO
MO
MO
MO
MO
3
2
oxandrolone oral tablet 2.5 mg
2
pamidronate
pioglitazone oral tablet 15 mg
2
2
2
2
pioglitazone-glimepiride
2
pioglitazone-metformin
2
prednisolone oral solution 15 mg/
5 ml
prednisolone sodium phosphate
oral solution 15 mg/5 ml (3 mg/
ml), 5 mg base/5 ml (6.7 mg/5
ml)
oral tablet,disintegrating
prednisone intensol
prednisone oral
PROGLYCEM
propylthiouracil
repaglinide oral tablet 0.5 mg
2
MO
MO; QLL (60 per
30 days)
MO; QLL (120 per
30 days)
B/D; PAR; MO
MO; QLL (90 per
30 days)
MO; QLL (45 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (90 per
30 days)
MO
2
MO
repaglinide oral tablet 1 mg
2
2
2
4
2
2
2
Drug Name
Drug Requirements/
Tier Limits
repaglinide oral tablet 2 mg
2
SENSIPAR ORAL TABLET
30 MG
60 MG
90 MG
SOMAVERT
SUBCUTANEOUS RECON
SOLN 10 MG, 15 MG, 20
MG
SOMAVERT
SUBCUTANEOUS RECON
SOLN 25 MG, 30 MG
STIMATE
SYMLINPEN 120
3
SYMLINPEN 60
4
SYNAREL
SYNTHROID
TESTIM
5
3
4
testosterone cypionate
testosterone enanthate
TOUJEO SOLOSTAR
triamcinolone acetonide injection
suspension 10 mg/ml
triamcinolone acetonide injection
suspension 40 mg/ml
TRULICITY
2
2
3
2
UNITHROID ORAL
TABLET 100 MCG, 112
175 MCG, 200 MCG, 25
75 MCG, 88 MCG
VICTOZA 2-PAK
3
VICTOZA 3-PAK
3
5
MO; QLL (240 per
30 days)
MO; QLL (60 per
30 days)
QLL (60 per 30
days)
QLL (120 per 30
days)
PAR; LA
5
PAR
4
4
MO
MO; QLL (11 per
30 days)
MO; QLL (6 per 30
days)
PAR
MO
MO; QLL (300 per
30 days)
MO
MO
MO
MO
5
5
2
4
MO
MO
MO
MO
MO
MO; QLL (960 per
30 days)
MO; QLL (480 per
30 days)
3
MO; QLL (2 per 28
days)
MO
MO; QLL (9 per 30
days)
MO; QLL (9 per 30
days)
table.
41
00016274, V22
Drug Name
VPRIV
ZAVESCA
zoledronic acid intravenous recon
soln 4 mg
zoledronic acid intravenous
solution 4 mg/5 ml
ZOMETA INTRAVENOUS
SOLUTION 4 MG/100 ML
Gastroenterology
alosetron
Drug Requirements/
Tier Limits
5
5
2
PAR
PAR; LA
2
MO
Drug Name
Drug Requirements/
Tier Limits
EMEND ORAL CAPSULE
125 MG
EMEND ORAL CAPSULE 40
MG
EMEND ORAL CAPSULE 80
MG
4
EMEND ORAL CAPSULE,
DOSE PACK
4
4
4
5
5
APRISO
ASACOL HD
atropine injection syringe 0.05
mg/ml, 0.1 mg/ml
balsalazide
budesonide oral
CANASA
CIMZIA
3
3
2
CIMZIA POWDER FOR
RECONST
CIMZIA STARTER KIT
5
colocort
compro
constulose
CREON
CYSTADANE
DELZICOL ORAL CAPSULE
(WITH DEL REL TABLETS)
DEXILANT
2
2
2
3
5
3
dicyclomine oral capsule
dicyclomine oral tablet
DIPENTUM
diphenoxylate-atropine oral
tablet
dronabinol oral capsule 10 mg
2
2
5
2
dronabinol oral capsule 2.5 mg,
5 mg
2
2
5
4
5
5
3
5
QLL (60 per 30
days)
MO
MO
EMEND ORAL
SUSPENSION FOR
RECONSTITUTION
enulose
famotidine (pf)
famotidine (pf)-nacl (iso-os)
MO
famotidine intravenous
famotidine oral suspension
MO
PAR; QLL (6 per 28 famotidine oral tablet 20 mg, 40
mg
days)
PAR; QLL (6 per 28 GATTEX 30-VIAL
GATTEX ONE-VIAL
days)
PAR; QLL (6 per 28 gavilyte-c
gavilyte-g
days)
gavilyte-n
MO
generlac
MO
glycopyrrolate oral
MO
hydrocortisone rectal cream 2.5
MO
%
hydrocortisone rectal enema
lactulose
lansoprazole oral capsule,delayed
MO; QLL (30 per
release(dr/ec)
30 days)
LINZESS
MO
loperamide oral capsule
MO
meclizine oral tablet 12.5 mg,
25 mg
MO
MESALAMINE ORAL
mesalamine rectal
B/D; PAR; QLL
mesalamine with cleansing wipe
(120 per 30 days)
metoclopramide hcl injection
B/D; PAR; MO;
solution
QLL (120 per 30
days)
4
2
2
2
2
2
2
5
5
2
2
2
2
2
2
2
2
2
B/D; PAR; MO;
QLL (5 per 30 days)
B/D; PAR; MO;
QLL (1 per 2 days)
B/D; PAR; MO;
QLL (10 per 30
days)
B/D; PAR; MO;
QLL (15 per 30
days)
B/D; PAR; QLL (15
per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
3
2
2
MO
MO
MO; QLL (30 per
30 days)
MO
MO
MO
3
2
2
2
MO
MO
MO
table.
42
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
metoclopramide hcl injection
syringe
metoclopramide hcl oral solution
metoclopramide hcl oral tablet
misoprostol
MOVIPREP
omeprazole oral capsule,delayed
release(dr/ec)
ondansetron hcl (pf) injection
solution
ondansetron hcl (pf) injection
syringe
ondansetron hcl intravenous
ondansetron hcl oral solution
2
ondansetron hcl oral tablet 24
mg
ondansetron hcl oral tablet 4 mg,
8 mg
2
ondansetron odt
2
PANCREAZE
pantoprazole
peg 3350-electrolytes oral recon
soln 236-22.74-6.74 -5.86 gram
peg 3350-electrolytes oral recon
soln 240-22.72-6.72 -5.84 gram
peg-electrolyte soln
PENTASA
polyethylene glycol 3350 oral
prochlorperazine edisylate
injection solution 10 mg/2 ml (5
mg/ml)
prochlorperazine maleate oral
tablet 10 mg, 5 mg
prochlorperazine maleate rectal
procto-pak
proctosol hc
proctozone-hc
3
2
2
2
2
2
3
2
MO
MO
MO
MO
MO
2
MO
2
2
2
2
2
2
4
2
2
2
2
2
2
2
Drug Name
PROTONIX
INTRAVENOUS
ranitidine hcl oral syrup
ranitidine hcl oral tablet 150
mg, 300 mg
RELISTOR
SUBCUTANEOUS
SOLUTION
REMICADE
sucralfate oral tablet
sulfasalazine
SUPREP BOWEL PREP KIT
TRANSDERM-SCOP
Drug Requirements/
Tier Limits
4
MO
2
2
MO
MO
4
PAR; MO
5
2
2
3
4
PAR
MO
MO
MO
MO
MO; QLL (4 per 12
days)
B/D; PAR; MO;
ursodiol
QLL (450 per 30
2 MO
days)
Immunology, Vaccines / Biotechnology
B/D; PAR; QLL (30 ACTHIB (PF)
3 MO
per 30 days)
ACTIMMUNE
5 PAR
B/D; PAR; MO;
ADACEL(TDAP ADOLESN/ 3 MO
QLL (90 per 30
ADULT)(PF)
days)
ARANESP (IN
5 PAR; QLL (4 per 28
B/D; PAR; MO;
POLYSORBATE)
days)
QLL (90 per 30
INJECTION SOLUTION
days)
100 MCG/ML, 200 MCG/
MO
ML, 300 MCG/ML
MO
ARANESP (IN
4 PAR; MO; QLL (4
MO
POLYSORBATE)
per 28 days)
INJECTION SOLUTION 25
MCG/ML, 40 MCG/ML, 60
MCG/ML
ARANESP (IN
4 PAR; MO; QLL (1.6
POLYSORBATE)
per 28 days)
MO
MO
MCG/0.4 ML, 40 MCG/0.4
MO
ML
ARANESP (IN
5 PAR; QLL (2 per 28
POLYSORBATE)
days)
MO
MCG/0.5 ML
MO
ARANESP (IN
5 PAR; QLL (1.2 per
MO
POLYSORBATE)
28 days)
MO
MCG/0.3 ML
table.
43
00016274, V22
Drug Name
ARANESP (IN
POLYSORBATE)
MCG/0.4 ML
ARANESP (IN
POLYSORBATE)
MCG/0.42 ML
ARANESP (IN
POLYSORBATE)
MCG/0.6 ML
ARANESP (IN
POLYSORBATE)
MCG/ML
ARANESP (IN
POLYSORBATE)
MCG/0.3 ML
ARCALYST
ATGAM
AVONEX (WITH
ALBUMIN)
AVONEX
INTRAMUSCULAR PEN
INJECTOR KIT
AVONEX
INTRAMUSCULAR
SYRINGE
AVONEX
INTRAMUSCULAR
SYRINGE KIT
BCG VACCINE, LIVE (PF)
BETASERON
SUBCUTANEOUS KIT
BEXSERO (PF)
BOOSTRIX TDAP
CARIMUNE NF
NANOFILTERED
INTRAVENOUS RECON
SOLN 12 GRAM, 6 GRAM
CERVARIX VACCINE (PF)
Drug Requirements/
Tier Limits
5
4
5
PAR; QLL (1.6 per
28 days)
PAR; MO; QLL
(1.68 per 28 days)
PAR; QLL (2.4 per
28 days)
5
PAR; QLL (4 per 28
days)
4
PAR; MO; QLL (1.2
per 28 days)
5
5
5
PAR
B/D; PAR
PAR; QLL (4 per 28
days)
PAR; QLL (4 per 28
days)
5
5
5
PAR; QLL (4 per 28
days)
PAR; QLL (4 per 28
days)
3
5
MO
PAR
4
3
5
MO
MO
PAR
3
MO
Drug Name
DAPTACEL (DTAP
PEDIATRIC) (PF)
ENGERIX-B (PF)
ENGERIX-B PEDIATRIC
(PF)
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAGARD S-D (IGA
< 1 MCG/ML)
GAMUNEX-C
GARDASIL (PF)
GARDASIL 9 (PF)
GENOTROPIN
GENOTROPIN
MINIQUICK
HAVRIX (PF)
INTRAMUSCULAR
SUSPENSION
HAVRIX (PF)
INTRAMUSCULAR
SYRINGE 1,440 ELISA
UNIT/ML
HAVRIX (PF)
INTRAMUSCULAR
SYRINGE 720 ELISA UNIT/
0.5 ML
HIBERIX (PF)
HUMATROPE INJECTION
CARTRIDGE 12 MG (36
UNIT), 24 MG (72 UNIT)
ILARIS (PF)
IMOVAX RABIES VACCINE
(PF)
INFANRIX (DTAP) (PF)
INTRAMUSCULAR
SUSPENSION
INTRON A INJECTION
IPOL INJECTION
SUSPENSION
IXIARO (PF)
LEUKINE INJECTION
RECON SOLN
Drug Requirements/
Tier Limits
3
MO
3
3
B/D; PAR; MO
B/D; PAR; MO
5
3
5
5
PAR
PAR; MO
PAR
PAR
5
3
3
5
4
PAR
MO
MO
PAR
PAR; MO
3
MO
4
MO
3
3
5
PAR
5
3
PAR; LA
MO
3
MO
5
3
PAR
MO
3
5
MO
table.
44
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
M-M-R II (PF)
MENACTRA (PF)
INTRAMUSCULAR
SOLUTION
MENOMUNE - A/C/Y/W135
MENOMUNE - A/C/Y/W135 (PF)
MENVEO A-C-Y-W-135-DIP
(PF)
MOZOBIL
NEULASTA
NEUPOGEN
NORDITROPIN FLEXPRO
SUBCUTANEOUS PEN
INJECTOR 10 MG/1.5 ML
(6.7 MG/ML), 15 MG/1.5 ML
(10 MG/ML), 5 MG/1.5 ML
(3.3 MG/ML)
PEDVAX HIB (PF)
PEGINTRON
PEGINTRON REDIPEN
3
3
PENTACEL ACTHIB
COMPONENT (PF)
PROCRIT
3
PROLEUKIN
PROQUAD (PF)
QUADRACEL (PF)
RABAVERT (PF)
REBIF (WITH ALBUMIN)
REBIF REBIDOSE
REBIF TITRATION PACK
RECOMBIVAX HB (PF)
INTRAMUSCULAR
SUSPENSION
RECOMBIVAX HB (PF)
INTRAMUSCULAR
SYRINGE 10 MCG/ML
5
3
3
3
5
5
5
3
3
3
3
5
5
5
5
3
5
5
3
3
MO
MO
Drug Name
Drug Requirements/
Tier Limits
RECOMBIVAX HB (PF)
3
INTRAMUSCULAR
SYRINGE 5 MCG/0.5 ML
ROTARIX
3
ROTATEQ VACCINE
3
SYLATRON
5
MO
tetanus,diphtheria tox ped(pf)
3
TETANUS-DIPHTHERIA
3
MO
TOXOIDS-TD
THYMOGLOBULIN
5
PAR
TICE BCG
3
PAR; QLL (2 per 28 TRUMENBA
3
days)
TWINRIX (PF)
3
PAR
INTRAMUSCULAR
PAR
SUSPENSION
TWINRIX (PF)
4
INTRAMUSCULAR
SYRINGE
TYPHIM VI
3
INTRAMUSCULAR
MO
SOLUTION
PAR
TYPHIM VI
3
PAR; QLL (4 per 28 INTRAMUSCULAR
days)
SYRINGE
VAQTA (PF)
3
VARIVAX (PF)
3
PAR; MO; QLL (12 VARIZIG
5
per 28 days)
YF-VAX (PF)
3
ZORBTIVE
5
MO
ZOSTAVAX (PF)
3
Musculoskeletal / Rheumatology
MO
ACTEMRA INTRAVENOUS 5
PAR
VIAL
PAR
alendronate oral tablet 10 mg, 5 2
PAR
mg
B/D; PAR; MO
alendronate oral tablet 35 mg,
2
70 mg
allopurinol
2
B/D; PAR; MO
BENLYSTA
5
BONIVA INTRAVENOUS
4
colchicine-probenecid
2
COLCRYS
4
DEPEN TITRATABS
5
B/D; PAR
MO
PAR
MO
MO
B/D; PAR
MO
MO
MO
MO
MO
MO
MO
MO
PAR
MO
PAR
MO; QLL (30 per
30 days)
MO; QLL (4 per 28
days)
MO
PAR
B/D; PAR; MO
MO
MO
table.
45
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
ENBREL SUBCUTANEOUS
RECON SOLN
ENBREL SUBCUTANEOUS
SYRINGE 25 MG/0.5ML
(0.51)
ENBREL SUBCUTANEOUS
SYRINGE 50 MG/ML (0.98
ML)
ENBREL SURECLICK
5
FORTEO
5
HUMIRA PEDIATRIC
CROHN'S START
HUMIRA PEN
5
HUMIRA PEN CROHN'SUC-HS START
HUMIRA PEN PSORIASISUVEITIS
HUMIRA SUBCUTANEOUS
SYRINGE KIT 10 MG/0.2
ML, 20 MG/0.4 ML
HUMIRA SUBCUTANEOUS
SYRINGE KIT 40 MG/0.8
ML
ibandronate intravenous
ibandronate oral
5
KINERET
5
leflunomide
ORENCIA
2
5
ORENCIA (WITH
MALTOSE)
ORENCIA CLICKJECT
5
probenecid
PROLIA
2
4
raloxifene
2
5
5
5
5
5
5
5
2
2
5
PAR; QLL (8 per 28
days)
PAR; QLL (4.08 per
28 days)
Drug Name
RIDAURA
SAVELLA ORAL TABLET
100 MG
SAVELLA ORAL TABLET
12.5 MG
PAR; QLL (8 per 28 SAVELLA ORAL TABLET 25
days)
MG
SAVELLA ORAL TABLET 50
PAR; QLL (8 per 28 MG
days)
SAVELLA ORAL TABLETS,
PAR; QLL (3 per 28 DOSE PACK
days)
SIMPONI
PAR; QLL (4.8 per
365 days)
Obstetrics / Gynecology
PAR; QLL (3.2 per altavera (28)
28 days)
alyacen 1/35 (28)
PAR; QLL (9.6 per alyacen 7/7/7 (28)
365 days)
apri
PAR; QLL (3.2 per aranelle (28)
28 days)
aubra
PAR; QLL (2 per 28 aviane
days)
azurette (28)
balziva (28)
PAR; QLL (3.2 per briellyn
28 days)
camila
caziant (28)
B/D; PAR; MO
clindamycin phosphate vaginal
MO; QLL (1 per 28 cryselle (28)
days)
cyclafem 7/7/7 (28)
PAR; QLL (28 per
dasetta 7/7/7 (28)
28 days)
deblitane
MO
delyla (28)
PAR; QLL (4 per 28 DEPO-PROVERA
days)
INTRAMUSCULAR
PAR
SOLUTION 400 MG/ML
desog-e.estradiol/e.estradiol
PAR; QLL (4 per 28 drospirenone-ethinyl estradiol
days)
oral tablet 3-0.03 mg
MO
elinest
PAR; MO; QLL (2 ELLA
per 365 days)
enpresse
MO; QLL (30 per
errin
30 days)
Drug Requirements/
Tier Limits
4
3
3
3
3
3
5
MO
MO; QLL (60 per
30 days)
MO; QLL (480 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (110 per
365 days)
PAR; QLL (1 per 28
days)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
2
MO
MO
2
3
2
2
MO
MO
MO
MO
MO
table.
46
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
ESTRACE VAGINAL
estradiol oral
estradiol transdermal patch
weekly
ESTRING
4
2
2
falmina (28)
gildagia
gildess 1.5/30 (21)
heather
hydroxyprogesterone caproate
jencycla
jolessa
jolivette
junel 1.5/30 (21)
junel 1/20 (21)
junel fe 1.5/30 (28)
junel fe 1/20 (28)
junel fe 24
kariva (28)
kelnor 1/35 (28)
kurvelo
larin 1.5/30 (21)
larin fe 1/20 (28)
lessina
levonest (28)
levonorg-eth estrad triphasic
levonorgestrel-ethinyl estrad oral
tablet 0.1-20 mg-mcg, 0.15-0.03
mg
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month
low-ogestrel (28)
lutera (28)
lyza
marlissa
medroxyprogesterone
intramuscular
medroxyprogesterone oral
menest
metronidazole vaginal
2
2
2
2
5
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
2
2
2
2
2
2
2
2
2
Drug Name
Drug Requirements/
Tier Limits
miconazole-3 vaginal suppository
2
microgestin 1.5/30 (21)
microgestin 1/20 (21)
microgestin fe 1.5/30 (28)
microgestin fe 1/20 (28)
mircette (28)
mono-linyah
mononessa (28)
myzilra
necon 0.5/35 (28)
MO
necon 1/35 (28)
MO
necon 10/11 (28)
MO
necon 7/7/7 (28)
MO
nora-be
MO
norethindrone (contraceptive)
MO
norethindrone acetate
MO
norethindrone-e.estradiol-iron
MO
norgestimate-ethinyl estradiol
oral tablet 0.18/0.215/0.25 mgMO
35 mcg (28)
MO
norgestimate-ethinyl estradiol
MO
oral tablet 0.25-35 mg-mcg
MO
norlyroc
MO
nortrel 0.5/35 (28)
MO
nortrel 1/35 (21)
MO
nortrel 1/35 (28)
MO
nortrel 7/7/7 (28)
MO
NUVARING
ocella
ogestrel (28)
MO
orsythia
MO
philith
MO
pimtrea (28)
MO
pirmella
MO
portia
MO; QLL (1 per 90 PREMARIN INJECTION
days)
PREMARIN ORAL
MO
PREMARIN VAGINAL
MO
PREMPHASE
MO
PREMPRO
previfem
2
2
2
2
2
2
4
2
2
2
2
4
2
2
2
2
2
MO
MO
MO; QLL (4 per 28
days)
MO; QLL (1 per 90
days)
MO
MO
MO
MO
MO; QLL (6 per 30
days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
MO
2
2
2
2
2
4
2
2
2
2
2
2
2
4
3
3
3
3
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
table.
47
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
reclipsen (28)
sharobel
sprintec (28)
sronyx
syeda
tarina fe 1/20 (28)
terconazole
tranexamic acid oral
tri-estarylla
tri-linyah
tri-previfem (28)
tri-sprintec (28)
trinessa (28)
trivora (28)
VAGIFEM
velivet triphasic regimen (28)
viorele (28)
VIVELLE-DOT
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
2
2
4
vyfemla (28)
zarah
zenchent (28)
zovia 1/35e (28)
zovia 1/50e (28)
Ophthalmology
acetazolamide
acetazolamide sodium
ALPHAGAN P
OPHTHALMIC DROPS 0.1
%
apraclonidine
atropine ophthalmic drops
azelastine ophthalmic
AZOPT
bacitracin ophthalmic
bacitracin-polymyxin b
ophthalmic
betaxolol ophthalmic
BLEPHAMIDE S.O.P.
brimonidine ophthalmic drops
0.2 %
carteolol
2
2
2
2
2
2
2
3
2
2
2
3
2
2
2
4
2
2
Drug Name
ciprofloxacin hcl ophthalmic
COMBIGAN
cromolyn ophthalmic
dexamethasone sodium phosphate
ophthalmic
MO
dorzolamide
MO
dorzolamide-timolol
MO
DUREZOL
MO
erythromycin ophthalmic
MO
fluorometholone
MO
flurbiprofen ophthalmic drops
MO
gentak ophthalmic ointment
MO
gentamicin ophthalmic
MO
ILEVRO
MO
ketorolac ophthalmic
MO
latanoprost
MO
levobunolol ophthalmic drops 0.5
MO
MO; QLL (8 per 28 %
LUMIGAN OPHTHALMIC
days)
DROPS 0.01 %
MO
methazolamide oral
MO
metipranolol
MO
NATACYN
MO
neo-polycin
MO
neo-polycin hc
neomycin-bacitracin-poly-hc
MO
neomycin-bacitracin-polymyxin
MO
neomycin-polymyxin b-dexameth
MO
neomycin-polymyxin-gramicidin
neomycin-polymyxin-hc
ophthalmic
MO
NEVANAC
MO
ofloxacin ophthalmic
MO
olopatadine ophthalmic
MO
PATADAY
MO
PATANOL
MO
PAZEO
MO
PHOSPHOLINE IODIDE
polycin
MO
polymyxin b sulf-trimethoprim
MO
prednisolone acetate
MO
MO
MO
MO
Drug Requirements/
Tier Limits
2
3
2
2
MO
MO
MO
MO
2
2
3
2
2
2
2
2
3
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
3
MO
2
2
4
2
2
2
2
2
2
2
MO
3
2
2
3
4
3
4
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
table.
48
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
ophthalmic
RESTASIS
2
MO
cromolyn inhalation
2
4
sulfacetamide sodium ophthalmic
drops
sulfacetamide-prednisolone
timolol maleate ophthalmic
tobramycin
tobramycin-dexamethasone
opthalmic suspension
TRAVATAN Z
travoprost (benzalkonium)
trifluridine
VIGAMOX
ZIRGAN
Respiratory And Allergy
acetylcysteine
ADEMPAS
ADVAIR DISKUS
2
MO; QLL (60 per
30 days)
MO
cyproheptadine oral tablet
DALIRESP
2
4
2
2
2
2
MO
MO
MO
MO
diphenhydramine hcl injection
solution 50 mg/ml
diphenhydramine hcl injection
syringe
DULERA
2
B/D; PAR; MO;
QLL (240 per 30
days)
MO
PAR; MO; QLL (30
per 30 days)
MO
2
MO
3
epinephrine injection syringe 0.1
mg/ml
EPIPEN 2-PAK
2
MO; QLL (13 per
30 days)
MO
EPIPEN JR 2-PAK
4
ESBRIET
5
3
2
2
3
4
2
5
3
ADVAIR HFA
3
albuterol sulfate inhalation
solution for nebulization 0.63
mg/3 ml, 1.25 mg/3 ml, 2.5 mg
/3 ml (0.083 %)
albuterol sulfate inhalation
solution for nebulization 2.5 mg/
0.5 ml, 5 mg/ml
albuterol sulfate oral
arbinoxa
ATROVENT HFA
1
budesonide inhalation suspension
for nebulization 0.25 mg/2 ml,
0.5 mg/2 ml
CINRYZE
clemastine oral tablet 2.68 mg
COMBIVENT RESPIMAT
2
1
2
2
3
5
2
3
MO
MO
MO
MO
MO
B/D; PAR; MO
PAR; LA
MO; QLL (60 per
30 days)
MO; QLL (12 per
30 days)
B/D; PAR; MO;
QLL (360 per 30
days)
FIRAZYR
FLOVENT DISKUS
INHALATION BLISTER
WITH DEVICE 100 MCG/
ACTUATION
FLOVENT DISKUS
INHALATION BLISTER
WITH DEVICE 250 MCG/
B/D; PAR; MO;
ACTUATION, 50 MCG/
QLL (60 per 30
ACTUATION
days)
FLOVENT HFA
MO
INHALATION HFA
MO
AEROSOL INHALER 110
MO; QLL (26 per
MCG/ACTUATION
30 days)
FLOVENT HFA
B/D; PAR; MO;
INHALATION HFA
QLL (120 per 30
AEROSOL INHALER 220
days)
MCG/ACTUATION
PAR
FLOVENT HFA
MO
MO; QLL (8 per 30 INHALATION HFA
AEROSOL INHALER 44
days)
MCG/ACTUATION
4
5
3
MO; QLL (2 per 2
days)
MO; QLL (2 per 2
days)
PAR; QLL (270 per
30 days)
MO; QLL (60 per
30 days)
3
MO; QLL (240 per
30 days)
3
MO; QLL (12 per
30 days)
3
MO; QLL (24 per
30 days)
3
MO; QLL (11 per
30 days)
table.
49
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
flunisolide nasal spray,nonaerosol 25 mcg (0.025 %)
fluticasone nasal
2
FORADIL AEROLIZER
4
ipratropium bromide inhalation
ipratropium-albuterol
2
2
2
KALYDECO ORAL TABLET
5
LETAIRIS
5
levalbuterol hcl inhalation
mg/3 ml, 1.25 mg/0.5 ml, 1.25
mg/3 ml
levalbuterol hcl inhalation
mg/3 ml
levocetirizine oral tablet
2
metaproterenol
montelukast
2
2
phenadoz
PROAIR HFA
2
3
PROAIR RESPICLICK
3
promethazine oral tablet
promethegan rectal suppository
12.5 mg
PULMOZYME
QVAR INHALATION
AEROSOL 40 MCG/
ACTUATION
QVAR INHALATION
AEROSOL 80 MCG/
ACTUATION
SEREVENT DISKUS
2
2
2
2
MO; QLL (75 per
30 days)
MO; QLL (16 per
30 days)
MO; QLL (60 per
30 days)
B/D; PAR; MO
B/D; PAR; MO;
QLL (540 per 30
days)
PAR; QLL (60 per
30 days)
PAR; LA; QLL (30
per 30 days)
B/D; PAR; MO;
QLL (270 per 30
days)
Drug Name
Drug Requirements/
Tier Limits
sildenafil oral
2
SPIRIVA RESPIMAT
3
SPIRIVA WITH
HANDIHALER
SYMBICORT
3
terbutaline oral
terbutaline subcutaneous
theophylline oral tablet extended
release 12 hr
theophylline oral tablet extended
release 24 hr
TRACLEER
2
2
2
PAR; MO; QLL (90
per 30 days)
MO; QLL (4 per 30
days)
MO; QLL (30 per
30 days)
MO; QLL (11 per
30 days)
MO
MO
MO
2
MO
5
TUDORZA PRESSAIR
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 400 MCG/
ACTUATION
TUDORZA PRESSAIR
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 400 MCG/
ACTUATION (30 ACTUAT)
VENTAVIS
VENTOLIN HFA
3
PAR; LA; QLL (60
per 30 days)
MO; QLL (1 per 30
days)
B/D; PAR; MO;
QLL (540 per 30
days)
MO; QLL (30 per
30 days)
MO
MO; QLL (30 per
30 days)
MO
MO; QLL (18 per
30 days)
MO; QLL (2 per 30 vospire er
days)
XOLAIR
PAR; MO
zafirlukast
MO
5
3
Urologicals
B/D; PAR
MO; QLL (9 per 30 alfuzosin
days)
AVODART
3
MO; QLL (18 per
30 days)
3
MO; QLL (60 per
30 days)
bethanechol chloride
CYSTAGON
dutasteride
3
3
QLL (1 per 30 days)
5
4
PAR
MO; QLL (36 per
30 days)
MO
PAR; LA; QLL (6
per 28 days)
MO; QLL (60 per
30 days)
2
5
2
2
3
2
4
2
MO
MO; QLL (30 per
30 days)
MO
MO; LA
MO; QLL (30 per
30 days)
table.
50
00016274, V22
Drug Name
Drug Requirements/
Tier Limits
dutasteride-tamsulosin
2
finasteride oral tablet 5 mg
JALYN
2
3
MYRBETRIQ
4
oxybutynin chloride oral syrup
2
oxybutynin chloride oral tablet
2
extended release 24hr 10 mg, 15
mg
potassium citrate oral tablet
extended release 10 meq (1,080
mg), 5 meq (540 mg)
tamsulosin
2
tolterodine oral capsule,extended
release 24hr
tolterodine oral tablet
2
TOVIAZ
3
VESICARE
4
2
2
2
2
MO; QLL (30 per
30 days)
MO
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (600 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
Vitamins, Hematinics / Electrolytes
AMINOSYN 8.5 %
4 B/D; PAR
AMINOSYN 8.5 %4 B/D; PAR; HI
ELECTROLYTES
AMINOSYN II 10 %
4 B/D; PAR; HI
AMINOSYN II 7 %
4 B/D; PAR; HI
AMINOSYN II 8.5 %
4 B/D; PAR; HI
AMINOSYN II 8.5 %4 B/D; PAR; HI
ELECTROLYTES
AMINOSYN M 3.5 %
4 B/D; PAR; HI
AMINOSYN-HBC 7%
4 B/D; PAR; HI
AMINOSYN-PF 10 %
4 B/D; PAR; HI
AMINOSYN-PF 7 %
4 B/D; PAR; HI
(SULFITE-FREE)
Drug Name
calcium acetate oral capsule
calcium acetate oral tablet 667
mg
CLINIMIX 5%/D15W
SULFITE FREE
CLINIMIX 5%/D25W
SULFITE-FREE
CLINIMIX 2.75%/D5W
SULFIT FREE
CLINIMIX 4.25%-D20W
SULF-FREE
CLINIMIX 4.25%-D25W
SULF-FREE
CLINIMIX 4.25%/D10W
SULF FREE
CLINIMIX 5%D20W(SULFITE-FREE)
SUL FREE
SULF FREE
CLINIMIX E 5%/D15W
SULFIT FREE
CLINIMIX E 5%/D20W
SULFIT FREE
CLINIMIX E 5%/D25W
SULFIT FREE
CLINISOL SF 15 %
dextrose-kcl-nacl
FREAMINE III 10 %
HEPATAMINE 8%
intralipid intravenous emulsion
20 %
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
lactated ringers intravenous
magnesium sulfate in water
Drug Requirements/
Tier Limits
2
2
MO
MO
4
B/D; PAR; HI
4
B/D; PAR; HI
4
B/D; PAR; HI
3
B/D; PAR; HI
3
B/D; PAR; HI
3
B/D; PAR; HI
4
B/D; PAR; HI
3
B/D; PAR; HI
4
B/D; PAR; HI
4
B/D; PAR; HI
4
B/D; PAR; HI
4
B/D; PAR; HI
4
2
3
4
2
B/D; PAR; MO; HI
B/D; PAR; HI
B/D; PAR
B/D; PAR; HI
B/D; PAR; MO
2
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO; HI
table.
51
00016274, V22
Drug Name
intravenous piggyback 2 gram/50
ml (4 %), 4 gram/50 ml (8 %)
intravenous piggyback 4 gram/
100 ml (4 %)
magnesium sulfate injection
solution
magnesium sulfate injection
syringe
NORMOSOL-M IN 5 %
DEXTROSE
NORMOSOL-R
NORMOSOL-R IN 5 %
DEXTROSE
NORMOSOL-R PH 7.4
PLASMA-LYTE 148
PLASMA-LYTE-56 IN 5 %
DEXTROSE
potassium chlorid-d5-0.45%nacl
10 meq/l, 30 meq/l, 40 meq/l
potassium chlorid-d5-0.45%nacl
20 meq/l
potassium chloride in 0.9%nacl
20 meq/l
potassium chloride in 5 % dex
20 meq/l, 40 meq/l
potassium chloride in 5 % dex
30 meq/l
potassium chloride in lr-d5
20 meq/l
potassium chloride in lr-d5
40 meq/l
potassium chloride intravenous
piggyback 10 meq/100 ml, 20
Drug Requirements/
Tier Limits
2
2
MO
2
MO
2
HI
4
HI
4
4
HI
4
3
3
HI
HI
HI
2
2
HI
MO; HI
2
HI
2
HI
2
2
MO; HI
2
2
HI
Drug Name
meq/100 ml, 20 meq/50 ml, 40
meq/100 ml
piggyback 10 meq/50 ml
piggyback 30 meq/100 ml
solution
potassium chloride oral capsule,
extended release
potassium chloride oral tablet
extended release
potassium chloride oral tablet,er
particles/crystals
potassium chloride-0.45 % nacl
potassium chloride-d5-0.2%nacl
20 meq/l
40 meq/l
20 meq/l
20 meq/l
40 meq/l
prenatal vitamin oral tablet
ringers intravenous
intravenous piggyback
sodium chloride 3 %
sodium chloride 5 %
sodium chloride intravenous
parenteral solution 2.5 meq/ml
sodium chloride intravenous
parenteral solution 4 meq/ml
sodium fluoride oral tablet
Drug Requirements/
Tier Limits
2
MO; HI
2
2
MO; HI
2
MO
2
MO
2
MO
2
2
HI
MO; HI
2
2
HI
2
MO; HI
2
HI
2
2
2
MO
B/D; PAR; HI
MO; HI
2
HI
2
2
2
MO; HI
HI
MO; HI
2
MO
2
MO
table.
52
00016274, V22
Drug Name
sodium fluoride oral tablet,
chewable 1 mg fluoride (2.2 mg)
tpn electrolytes
travasol 10 %
TROPHAMINE 10 %
TROPHAMINE 6%
Drug Requirements/
Tier Limits
2
MO
2
4
4
4
HI
B/D; PAR; MO; HI
B/D; PAR; MO; HI
B/D; PAR; HI
table.
53
00016274, V22
Index of Drugs:
Legend
Generic drugs are shown in lowercase italics (e.g. enalapril)
Brand-name drugs are shown in capital letters (e.g. NOVOLOG)
The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and
generic drugs are listed. 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.
Drug Name
Page
8-MOP.............................................................................35
abacavir..............................................................................7
abacavir-lamivudine-zidovudine..........................................7
ABELCET.........................................................................7
ABILIFY MAINTENA....................................................19
ABRAXANE....................................................................14
ABSTRAL SUBLINGUAL TABLET 100 MCG.............19
ABSTRAL SUBLINGUAL TABLET 200 MCG, 300
MCG, 400 MCG, 600 MCG, 800 MCG.....................19
acamprosate.......................................................................37
acarbose oral tablet 100 mg................................................39
acarbose oral tablet 25 mg..................................................39
acarbose oral tablet 50 mg..................................................39
acebutolol..........................................................................32
acetaminophen-codeine oral solution 120 mg-12 mg /5 ml
(5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /
12.5 ml..........................................................................19
acetaminophen-codeine oral solution 120-12 mg/5 ml.........19
acetaminophen-codeine oral tablet 300-15 mg.....................19
acetazolamide....................................................................48
acetazolamide sodium........................................................48
acetic acid otic...................................................................38
acetic acid-aluminum acetate.............................................38
acetylcysteine......................................................................49
acetylcysteine intravenous...................................................37
ACTEMRA INTRAVENOUS VIAL..............................45
ACTHAR H.P.................................................................39
ACTHIB (PF)..................................................................43
ACTIMMUNE...............................................................43
acyclovir oral capsule............................................................7
acyclovir oral suspension 200 mg/5 ml...................................7
acyclovir oral tablet..............................................................7
acyclovir sodium intravenous solution....................................7
54
Drug Name
Page
acyclovir topical.................................................................35
ADACEL(TDAP ADOLESN/ADULT)(PF)...................43
ADAGEN........................................................................37
ADASUVE......................................................................19
adefovir...............................................................................7
ADEMPAS......................................................................49
ADVAIR DISKUS...........................................................49
ADVAIR HFA.................................................................49
afeditab cr.........................................................................32
AFINITOR......................................................................14
AFINITOR DISPERZ.....................................................14
AGGRENOX..................................................................32
ala-cort topical cream.........................................................35
ALBENZA.........................................................................7
albuterol sulfate inhalation solution for nebulization 0.63
mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %)............49
albuterol sulfate inhalation solution for nebulization 2.5 mg/
0.5 ml, 5 mg/ml.............................................................49
albuterol sulfate oral..........................................................49
alclometasone.....................................................................36
alcohol pads.......................................................................39
ALDURAZYME..............................................................39
ALECENSA.....................................................................14
alendronate oral tablet 10 mg, 5 mg...................................45
alendronate oral tablet 35 mg, 70 mg.................................45
alendronate oral tablet 40 mg.............................................37
alfuzosin...........................................................................50
ALIMTA..........................................................................14
ALINIA ORAL SUSPENSION FOR
RECONSTITUTION....................................................7
ALINIA ORAL TABLET..................................................7
allopurinol........................................................................45
alosetron............................................................................42
ALPHAGAN P OPHTHALMIC DROPS 0.1 %............48
alprazolam oral tablet........................................................19
00016274, V22
Drug Name
Page
altavera (28).....................................................................46
alyacen 1/35 (28)..............................................................46
alyacen 7/7/7 (28).............................................................46
amantadine hcl oral capsule.................................................7
amantadine hcl oral tablet...................................................7
AMBISOME.....................................................................7
amcinonide.......................................................................36
amifostine crystalline..........................................................14
amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml......7
amiloride..........................................................................32
amiloride-hydrochlorothiazide............................................32
AMINOSYN 8.5 %.........................................................51
AMINOSYN 8.5 %-ELECTROLYTES..........................51
AMINOSYN II 10 %......................................................51
AMINOSYN II 7 %........................................................51
AMINOSYN II 8.5 %.....................................................51
AMINOSYN II 8.5 %-ELECTROLYTES......................51
AMINOSYN M 3.5 %....................................................51
AMINOSYN-HBC 7%...................................................51
AMINOSYN-PF 10 %....................................................51
AMINOSYN-PF 7 % (SULFITE-FREE)........................51
amiodarone intravenous solution........................................32
amiodarone intravenous syringe..........................................32
amiodarone oral................................................................32
amitriptyline.....................................................................19
amlodipine besylate oral tablet 10 mg, 2.5 mg.....................32
amlodipine besylate oral tablet 5 mg...................................32
amlodipine-benazepril.......................................................32
ammonium lactate.............................................................36
amoxapine........................................................................19
amoxicillin oral capsule........................................................7
amoxicillin oral suspension for reconstitution.........................8
amoxicillin oral tablet..........................................................8
amoxicillin oral tablet,chewable 125 mg, 250 mg..................8
amoxicillin-pot clavulanate..................................................8
amphotericin b....................................................................8
ampicillin...........................................................................8
ampicillin sodium injection..................................................8
ampicillin sodium intravenous recon soln 1 gram...................8
ampicillin sodium intravenous recon soln 2 gram...................8
ampicillin-sulbactam injection recon soln 1.5 gram, 3
gram................................................................................8
ampicillin-sulbactam injection recon soln 15 gram.................8
ampicillin-sulbactam intravenous recon soln 3 gram..............8
AMPYRA.........................................................................19
AMRIX............................................................................19
55
Drug Name
Page
anagrelide.........................................................................37
anastrozole........................................................................14
ANDRODERM..............................................................39
ANDROGEL TRANSDERMAL GEL IN METEREDDOSE PUMP 20.25 MG/1.25 GRAM (1.62 %).........39
ANDROGEL TRANSDERMAL GEL IN PACKET 1
% (25 MG/2.5GRAM).................................................39
ANDROGEL TRANSDERMAL GEL IN PACKET 1
% (50 MG/5 GRAM)...................................................39
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62
% (20.25 MG/1.25 GRAM).........................................39
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62
% (40.5 MG/2.5 GRAM).............................................39
ANDROXY.....................................................................39
APOKYN.........................................................................19
apraclonidine....................................................................48
apri..................................................................................46
APRISO...........................................................................42
APTIOM.........................................................................19
APTIVUS ORAL CAPSULE.............................................8
APTIVUS ORAL SOLUTION.........................................8
ARALAST NP.................................................................37
aranelle (28).....................................................................46
ARANESP (IN POLYSORBATE) INJECTION
SOLUTION 100 MCG/ML, 200 MCG/ML, 300
MCG/ML.....................................................................43
SOLUTION 25 MCG/ML, 40 MCG/ML, 60 MCG/
ML................................................................................43
SYRINGE 10 MCG/0.4 ML, 40 MCG/0.4 ML...........43
SYRINGE 100 MCG/0.5 ML......................................43
SYRINGE 150 MCG/0.3 ML......................................43
SYRINGE 200 MCG/0.4 ML......................................44
SYRINGE 25 MCG/0.42 ML......................................44
SYRINGE 300 MCG/0.6 ML......................................44
SYRINGE 500 MCG/ML............................................44
SYRINGE 60 MCG/0.3 ML........................................44
arbinoxa...........................................................................49
00016274, V22
Drug Name
Page
ARCALYST.....................................................................44
aripiprazole oral solution....................................................19
aripiprazole oral tablet 10 mg............................................19
aripiprazole oral tablet 15 mg............................................19
aripiprazole oral tablet 2 mg..............................................19
aripiprazole oral tablet 20 mg, 30 mg.................................19
aripiprazole oral tablet 5 mg..............................................19
aripiprazole oral tablet,disintegrating 10 mg.......................19
aripiprazole oral tablet,disintegrating 15 mg.......................19
ARISTADA INTRAMUSCULAR SUSPENSION,
EXTENDED REL SYRING 441 MG/1.6 ML.............19
ARRANON.....................................................................14
ARZERRA.......................................................................14
ASACOL HD..................................................................42
ASTAGRAF XL ORAL CAPSULE,EXTENDED
RELEASE 24HR 0.5 MG, 1 MG.................................14
ASTAGRAF XL ORAL CAPSULE,EXTENDED
RELEASE 24HR 5 MG................................................14
ASTEPRO NASAL SPRAY,NON-AEROSOL................38
atenolol.............................................................................32
atenolol-chlorthalidone.......................................................32
ATGAM..........................................................................44
atorvastatin.......................................................................32
atovaquone..........................................................................8
atovaquone-proguanil oral tablet 250-100 mg......................8
ATRIPLA...........................................................................8
atropine injection syringe 0.05 mg/ml, 0.1 mg/ml................42
atropine ophthalmic drops..................................................48
ATROVENT HFA..........................................................49
aubra................................................................................46
AVASTIN........................................................................14
aviane...............................................................................46
AVODART.....................................................................50
AVONEX (WITH ALBUMIN)......................................44
AVONEX INTRAMUSCULAR PEN INJECTOR
KIT...............................................................................44
AVONEX INTRAMUSCULAR SYRINGE....................44
AVONEX INTRAMUSCULAR SYRINGE KIT............44
AXIRON.........................................................................39
azacitidine........................................................................14
AZACTAM.......................................................................8
AZACTAM IN DEXTROSE (ISO-OSM)........................8
56
Drug Name
Page
azasan..............................................................................14
azathioprine......................................................................14
azathioprine sodium..........................................................14
azelastine nasal aerosol,spray..............................................38
azelastine ophthalmic.........................................................48
AZILECT........................................................................19
azithromycin intravenous recon soln 500 mg.........................8
azithromycin intravenous recon soln 500 mg (2 mg/ml).........8
azithromycin oral suspension for reconstitution......................8
azithromycin oral tablet.......................................................8
AZOPT...........................................................................48
azurette (28).....................................................................46
baciim................................................................................8
bacitracin intramuscular......................................................8
bacitracin ophthalmic........................................................48
bacitracin-polymyxin b ophthalmic.....................................48
baclofen............................................................................19
balsalazide........................................................................42
balziva (28)......................................................................46
BANZEL ORAL SUSPENSION.....................................19
BANZEL ORAL TABLET 200 MG................................19
BANZEL ORAL TABLET 400 MG................................20
BARACLUDE ORAL SOLUTION..................................8
BCG VACCINE, LIVE (PF)...........................................44
BELEODAQ...................................................................14
benazepril.........................................................................32
benazepril-hydrochlorothiazide...........................................32
BENDEKA......................................................................14
BENLYSTA.....................................................................45
benztropine oral................................................................20
betamethasone dipropionate................................................36
betamethasone valerate topical cream..................................36
betamethasone valerate topical lotion..................................36
betamethasone valerate topical ointment..............................36
betamethasone, augmented topical cream.............................36
betamethasone, augmented topical lotion.............................36
betamethasone, augmented topical ointment........................36
BETASERON SUBCUTANEOUS KIT.........................44
betaxolol ophthalmic..........................................................48
betaxolol oral.....................................................................32
bethanechol chloride...........................................................50
bexarotene.........................................................................14
BEXSERO (PF)...............................................................44
bicalutamide.....................................................................14
BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,
000 UNIT/ 2 ML(600K/600K)......................................8
00016274, V22
Drug Name
Page
BICNU............................................................................14
BILTRICIDE....................................................................8
bisoprolol fumarate............................................................32
bisoprolol-hydrochlorothiazide............................................32
bleo 15k............................................................................14
bleomycin..........................................................................14
BLEPHAMIDE S.O.P.....................................................48
BLINCYTO....................................................................14
BONIVA INTRAVENOUS............................................45
BOOSTRIX TDAP.........................................................44
BOSULIF ORAL TABLET 100 MG..............................14
BOSULIF ORAL TABLET 500 MG..............................14
briellyn.............................................................................46
BRILINTA......................................................................32
brimonidine ophthalmic drops 0.2 %.................................48
BRIVIACT INTRAVENOUS.........................................20
BRIVIACT ORAL SOLUTION.....................................20
BRIVIACT ORAL TABLET 10 MG..............................20
briviact oral tablet 100 mg.................................................20
bromocriptine....................................................................20
budesonide inhalation suspension for nebulization 0.25 mg/
2 ml, 0.5 mg/2 ml..........................................................49
budesonide oral..................................................................42
bumetanide.......................................................................32
buphenyl oral tablet...........................................................37
buprenorphine hcl injection solution...................................20
buprenorphine hcl injection syringe.....................................20
buprenorphine hcl sublingual tablet 2 mg............................20
buprenorphine hcl sublingual tablet 8 mg............................20
buprenorphine-naloxone sublingual tablet 2-0.5 mg............20
buprenorphine-naloxone sublingual tablet 8-2 mg...............20
bupropion hcl (smoking deter)............................................37
bupropion hcl oral tablet 100 mg........................................20
bupropion hcl oral tablet 75 mg..........................................20
bupropion hcl oral tablet extended release 100 mg................20
bupropion hcl oral tablet extended release 150 mg, 200
mg.................................................................................20
bupropion hcl oral tablet extended release 24 hr 150 mg......20
bupropion hcl oral tablet extended release 24 hr 300 mg......20
buspirone..........................................................................20
BUSULFEX.....................................................................14
butalbital-acetaminop-caf-cod oral capsule 50-325-40-30
mg.................................................................................20
57
Drug Name
Page
butorphanol tartrate injection solution 1 mg/ml...................20
butorphanol tartrate injection solution 2 mg/ml...................20
butorphanol tartrate nasal..................................................20
BYDUREON..................................................................39
BYETTA SUBCUTANEOUS PEN INJECTOR 10
MCG/DOSE(250 MCG/ML) 2.4 ML.........................39
BYETTA SUBCUTANEOUS PEN INJECTOR 5
MCG/DOSE (250 MCG/ML) 1.2 ML........................39
cabergoline........................................................................39
CABOMETYX ORAL TABLET 20 MG........................14
CABOMETYX ORAL TABLET 40 MG, 60 MG...........14
calcipotriene scalp..............................................................36
calcipotriene topical...........................................................36
calcitonin (salmon)............................................................39
calcitriol intravenous solution 1 mcg/ml..............................39
calcitriol oral capsule..........................................................39
calcium acetate oral capsule................................................51
calcium acetate oral tablet 667 mg......................................51
camila...............................................................................46
CANASA.........................................................................42
CANCIDAS......................................................................8
candesartan oral tablet 16 mg, 4 mg, 8 mg..........................32
candesartan oral tablet 32 mg.............................................32
candesartan-hydrochlorothiazid oral tablet 16-12.5 mg.......32
candesartan-hydrochlorothiazid oral tablet 32-12.5 mg, 3225 mg............................................................................32
CAPASTAT.......................................................................8
CAPEX............................................................................36
CAPRELSA ORAL TABLET 100 MG............................14
CAPRELSA ORAL TABLET 300 MG............................14
captopril............................................................................32
captopril-hydrochlorothiazide.............................................32
CARBAGLU....................................................................37
carbamazepine oral capsule, er multiphase 12 hr.................20
carbamazepine oral suspension 100 mg/5 ml.......................20
carbamazepine oral suspension 200 mg/10 ml.....................20
carbamazepine oral tablet..................................................20
carbamazepine oral tablet extended release 12 hr 100
mg.................................................................................20
carbamazepine oral tablet extended release 12 hr 200 mg,
400 mg..........................................................................20
carbamazepine oral tablet,chewable....................................20
carbidopa-levodopa............................................................20
carboplatin intravenous solution.........................................14
CARIMUNE NF NANOFILTERED INTRAVENOUS
RECON SOLN 12 GRAM, 6 GRAM..........................44
00016274, V22
Drug Name
Page
carteolol............................................................................48
cartia xt............................................................................32
carvedilol..........................................................................32
CAYSTON........................................................................8
caziant (28)......................................................................46
cefaclor oral capsule..............................................................8
cefaclor oral suspension for reconstitution 125 mg/5 ml..........8
cefaclor oral suspension for reconstitution 250 mg/5 ml, 375
mg/5 ml...........................................................................8
cefaclor oral tablet extended release 12 hr..............................8
cefadroxil oral capsule..........................................................8
cefadroxil oral suspension for reconstitution 250 mg/5 ml,
500 mg/5 ml....................................................................8
cefadroxil oral tablet............................................................8
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/
50 ml...............................................................................8
cefazolin injection recon soln 1 gram.....................................8
cefazolin injection recon soln 10 gram, 100 gram, 20 gram,
300 g...............................................................................8
cefazolin injection recon soln 500 mg....................................8
cefazolin intravenous...........................................................8
cefdinir...............................................................................8
cefepime..............................................................................8
cefoxitin in dextrose, iso-osm.................................................8
cefoxitin intravenous recon soln 1 gram.................................8
cefoxitin intravenous recon soln 10 gram, 2 gram..................8
cefpodoxime.........................................................................8
cefprozil..............................................................................8
ceftazidime injection recon soln 1 gram, 2 gram....................8
ceftazidime injection recon soln 6 gram.................................9
ceftriaxone in dextrose,iso-os.................................................9
ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg,
500 mg............................................................................9
ceftriaxone injection recon soln 10 gram................................9
ceftriaxone intravenous.........................................................9
cefuroxime axetil oral tablet..................................................9
cefuroxime sodium intravenous vial injection recon soln 1.5
gram, 750 mg..................................................................9
cefuroxime sodium intravenous vial intravenous recon soln
7.5 gram..........................................................................9
CELLCEPT INTRAVENOUS........................................14
CELONTIN ORAL CAPSULE 300 MG........................20
cephalexin oral capsule 250 mg, 500 mg...............................9
cephalexin oral suspension for reconstitution..........................9
cephalexin oral tablet...........................................................9
58
Drug Name
Page
CEREZYME INTRAVENOUS RECON SOLN 400
UNIT...........................................................................39
CERVARIX VACCINE (PF)...........................................44
cevimeline.........................................................................37
CHANTIX......................................................................37
CHANTIX CONTINUING MONTH BOX.................37
CHANTIX STARTING MONTH BOX........................37
chloramphenicol sod succinate...............................................9
chlorhexidine gluconate mucous membrane..........................38
chloroquine phosphate oral...................................................9
chlorothiazide....................................................................32
chlorpromazine..................................................................20
chlorthalidone oral tablet 25 mg, 50 mg..............................32
cholestyramine (with sugar)................................................32
cholestyramine light...........................................................32
ciclodan topical solution.....................................................36
ciclopirox topical cream......................................................36
ciclopirox topical gel...........................................................36
ciclopirox topical shampoo..................................................36
ciclopirox topical solution...................................................36
ciclopirox topical suspension................................................36
cilostazol...........................................................................32
CIMZIA..........................................................................42
CIMZIA POWDER FOR RECONST............................42
CIMZIA STARTER KIT................................................42
CINRYZE.......................................................................49
CIPRODEX....................................................................38
ciprofloxacin er....................................................................9
ciprofloxacin hcl ophthalmic...............................................48
ciprofloxacin hcl oral............................................................9
ciprofloxacin lactate intravenous solution 200 mg/20 ml........9
ciprofloxacin lactate intravenous solution 400 mg/40 ml........9
cisplatin............................................................................14
citalopram oral solution.....................................................20
citalopram oral tablet 10 mg..............................................20
cladribine..........................................................................14
clarithromycin oral suspension for reconstitution....................9
clarithromycin oral tablet.....................................................9
clarithromycin oral tablet extended release 24 hr....................9
clemastine oral tablet 2.68 mg............................................49
clindamycin hcl...................................................................9
clindamycin phosphate injection...........................................9
clindamycin phosphate intravenous solution 300 mg/2 ml,
900 mg/6 ml....................................................................9
00016274, V22
Drug Name
Page
clindamycin phosphate intravenous solution 600 mg/4 ml......9
clindamycin phosphate topical............................................36
clindamycin phosphate vaginal...........................................46
CLINIMIX 2.75%/D5W SULFIT FREE........................51
CLINIMIX 4.25%-D20W SULF-FREE.........................51
CLINIMIX 4.25%-D25W SULF-FREE.........................51
CLINIMIX 4.25%/D10W SULF FREE..........................51
CLINIMIX 4.25%/D5W SULFIT FREE........................37
CLINIMIX 5%-D20W(SULFITE-FREE).......................51
CLINIMIX 5%/D15W SULFITE FREE........................51
CLINIMIX 5%/D25W SULFITE-FREE........................51
CLINIMIX E 2.75%/D10W SUL FREE.........................38
CLINIMIX E 2.75%/D5W SULF FREE........................38
CLINIMIX E 4.25%/D25W SUL FREE.........................51
CLINIMIX E 4.25%/D5W SULF FREE........................51
CLINIMIX E 5%/D15W SULFIT FREE.......................51
CLINISOL SF 15 %........................................................51
clobetasol scalp...................................................................36
clobetasol topical cream......................................................36
clobetasol topical gel...........................................................36
clobetasol topical ointment..................................................36
clobetasol-emollient topical cream.......................................36
CLOLAR.........................................................................14
clomipramine....................................................................20
clonazepam oral tablet 0.5 mg............................................20
clonazepam oral tablet 1 mg...............................................20
clonazepam oral tablet 2 mg...............................................20
clonazepam oral tablet,disintegrating 0.125 mg...................20
clonazepam oral tablet,disintegrating 0.25 mg.....................21
clonazepam oral tablet,disintegrating 0.5 mg.......................21
clonazepam oral tablet,disintegrating 1 mg..........................21
clonazepam oral tablet,disintegrating 2 mg..........................21
clonidine hcl oral tablet......................................................32
clonidine transdermal patch...............................................32
clopidogrel oral tablet 300 mg............................................32
clopidogrel oral tablet 75 mg..............................................32
clorazepate dipotassium......................................................21
clotrimazole mucous membrane............................................9
clotrimazole topical............................................................36
clotrimazole-betamethasone................................................36
clozapine oral tablet 100 mg..............................................21
clozapine oral tablet 200 mg..............................................21
clozapine oral tablet 25 mg................................................21
clozapine oral tablet 50 mg................................................21
59
Drug Name
Page
clozapine oral tablet,disintegrating 100 mg.........................21
clozapine oral tablet,disintegrating 12.5 mg........................21
clozapine oral tablet,disintegrating 25 mg...........................21
COARTEM.......................................................................9
colchicine-probenecid.........................................................45
COLCRYS.......................................................................45
colestipol...........................................................................32
colistin (colistimethate na)....................................................9
colocort.............................................................................42
COLY-MYCIN S.............................................................38
COMBIGAN...................................................................48
COMBIVENT RESPIMAT............................................49
COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG
X1-20 MG X1).............................................................14
COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG
X1-20 MG X3).............................................................14
COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG
X 3/DAY).....................................................................14
COMPLERA.....................................................................9
compro..............................................................................42
constulose..........................................................................42
COPAXONE SUBCUTANEOUS SYRINGE 20 MG/
ML................................................................................21
COPAXONE SUBCUTANEOUS SYRINGE 40 MG/
ML................................................................................21
cormax scalp......................................................................36
cortisone............................................................................39
COTELLIC.....................................................................14
CREON..........................................................................42
CRIXIVAN ORAL CAPSULE 200 MG...........................9
CRIXIVAN ORAL CAPSULE 400 MG...........................9
cromolyn inhalation...........................................................49
cromolyn ophthalmic..........................................................48
cryselle (28).......................................................................46
CUBICIN..........................................................................9
cyclafem 7/7/7 (28)............................................................46
cyclophosphamide oral capsule.............................................14
CYCLOSET....................................................................39
cyclosporine intravenous.....................................................14
cyclosporine modified.........................................................14
cyclosporine oral capsule.....................................................14
cyproheptadine oral tablet..................................................49
CYRAMZA......................................................................14
CYSTADANE.................................................................42
00016274, V22
Drug Name
Page
CYSTAGON...................................................................50
cytarabine.........................................................................14
cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml),
2 gram/20 ml (100 mg/ml).............................................14
cytarabine (pf) injection solution 20 mg/ml.........................14
d10 %-0.45 % sodium chloride.........................................38
d2.5 %-0.45 % sodium chloride........................................38
d5 % and 0.9 % sodium chloride.......................................38
d5 %-0.45 % sodium chloride...........................................38
dacarbazine.......................................................................14
DACOGEN....................................................................14
DALIRESP......................................................................49
danazol oral......................................................................39
dantrolene.........................................................................21
dapsone...............................................................................9
DAPTACEL (DTAP PEDIATRIC) (PF)........................44
daptomycin.........................................................................9
DARAPRIM......................................................................9
DARZALEX....................................................................14
dasetta 7/7/7 (28)..............................................................46
daunorubicin intravenous solution......................................15
deblitane...........................................................................46
decitabine.........................................................................15
delyla (28)........................................................................46
DELZICOL ORAL CAPSULE (WITH DEL REL
TABLETS)....................................................................42
demeclocycline.....................................................................9
DEMSER.........................................................................32
DENAVIR.......................................................................36
DEPEN TITRATABS.....................................................45
DEPO-PROVERA INTRAMUSCULAR SOLUTION
400 MG/ML.................................................................46
DESCOVY........................................................................9
desipramine oral................................................................21
desmopressin injection........................................................39
desmopressin nasal aerosol,spray..........................................39
desmopressin nasal spray,non-aerosol...................................39
desmopressin oral...............................................................39
desog-e.estradiol/e.estradiol.................................................46
desonide............................................................................36
desoximetasone..................................................................36
DESVENLAFAXINE FUMARATE ORAL TABLET
EXTENDED RELEASE 24HR 100 MG.....................21
DESVENLAFAXINE FUMARATE ORAL TABLET
EXTENDED RELEASE 24HR 50 MG.......................21
60
Drug Name
Page
DESVENLAFAXINE ORAL TABLET EXTENDED
RELEASE 24 HR 100 MG...........................................21
DESVENLAFAXINE ORAL TABLET EXTENDED
RELEASE 24 HR 50 MG.............................................21
desvenlafaxine oral tablet extended release 24hr 100 mg......21
desvenlafaxine oral tablet extended release 24hr 50 mg........21
dexamethasone...................................................................39
dexamethasone sodium phos (pf).........................................39
dexamethasone sodium phosphate injection..........................39
dexamethasone sodium phosphate ophthalmic......................48
DEXILANT.....................................................................42
dexrazoxane hcl intravenous recon soln 250 mg...................15
dexrazoxane hcl intravenous recon soln 500 mg...................15
dextroamphetamine oral capsule, extended release 10 mg, 5
mg.................................................................................21
dextroamphetamine oral capsule, extended release 15 mg......21
dextroamphetamine oral tablet 10 mg.................................21
dextroamphetamine oral tablet 5 mg...................................21
dextroamphetamine-amphetamine oral tablet 10 mg, 12.5
mg, 15 mg, 20 mg, 5 mg, 7.5 mg....................................21
dextroamphetamine-amphetamine oral tablet 30 mg...........21
dextrose 10 % and 0.2 % nacl...........................................38
dextrose 10 % in water (d10w)..........................................38
dextrose 5 % in water (d5w)..............................................38
dextrose 5 %-lactated ringers..............................................38
dextrose 5%-0.2 % sod chloride..........................................38
dextrose 5%-0.3 % sod.chloride..........................................38
dextrose 50 % in water (d50w) intravenous parenteral
solution..........................................................................38
dextrose 50 % in water (d50w) intravenous syringe.............38
dextrose with sodium chloride.............................................38
dextrose-kcl-nacl................................................................51
diazepam injection solution................................................21
diazepam injection syringe..................................................21
diazepam intensol..............................................................21
diazepam oral concentrate..................................................21
diazepam oral solution 5 mg/5 ml (1 mg/ml).......................21
diazepam oral solution 5 mg/5 ml (1 mg/ml, 5 ml)..............21
diazepam oral tablet 10 mg................................................21
diazepam oral tablet 2 mg..................................................21
diazepam oral tablet 5 mg..................................................21
diazepam rectal kit 12.5-15-17.5-20 mg............................22
00016274, V22
Drug Name
Page
diazepam rectal kit 2.5 mg, 5-7.5-10 mg............................22
diclofenac potassium...........................................................22
diclofenac sodium oral........................................................22
diclofenac sodium topical gel 3 %.......................................36
dicloxacillin.........................................................................9
dicyclomine oral capsule.....................................................42
dicyclomine oral tablet.......................................................42
didanosine oral capsule,delayed release(dr/ec) 125 mg............9
didanosine oral capsule,delayed release(dr/ec) 200 mg............9
didanosine oral capsule,delayed release(dr/ec) 250 mg, 400
mg...................................................................................9
DIFFERIN TOPICAL GEL 0.3 %..................................36
DIFFERIN TOPICAL GEL WITH PUMP....................36
diflorasone.........................................................................36
diflunisal...........................................................................22
digox oral tablet 125 mcg...................................................32
digoxin injection solution...................................................32
digoxin oral solution 50 mcg/ml..........................................32
digoxin oral tablet 125 mcg................................................32
DILANTIN.....................................................................22
DILANTIN EXTENDED ORAL CAPSULES 100
MG...............................................................................22
DILANTIN INFATABS.................................................22
dilt-xr...............................................................................32
diltiazem hcl intravenous solution.......................................32
diltiazem hcl oral capsule, extended release 120 mg, 180 mg,
240 mg, 300 mg, 360 mg...............................................32
diltiazem hcl oral capsule,ext release degradable...................32
diltiazem hcl oral capsule,extended release 12 hr..................32
diltiazem hcl oral capsule,extended release 24hr...................32
diltiazem hcl oral tablet.....................................................32
diltiazem hcl oral tablet extended release 24 hr....................32
DIPENTUM...................................................................42
diphenhydramine hcl injection solution 50 mg/ml................49
diphenhydramine hcl injection syringe.................................49
diphenoxylate-atropine oral tablet.......................................42
disulfiram.........................................................................38
divalproex.........................................................................22
DOCEFREZ INTRAVENOUS RECON SOLN 20
MG...............................................................................15
DOCETAXEL INTRAVENOUS SOLUTION 10 MG/
ML, 160 MG/16 ML (10 MG/ML), 160 MG/8 ML
(20 MG/ML), 20 MG/2 ML (10 MG/ML)..................15
docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4
ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)..........................15
dofetilide...........................................................................32
61
Drug Name
Page
donepezil oral tablet 10 mg................................................22
donepezil oral tablet 5 mg..................................................22
donepezil oral tablet,disintegrating 10 mg...........................22
donepezil oral tablet,disintegrating 5 mg.............................22
dorzolamide......................................................................48
dorzolamide-timolol...........................................................48
doxazosin..........................................................................32
doxepin oral......................................................................22
doxorubicin intravenous recon soln.....................................15
doxorubicin intravenous solution........................................15
doxorubicin, peg-liposomal.................................................15
doxy-100.............................................................................9
doxycycline hyclate intravenous.............................................9
doxycycline hyclate oral capsule.............................................9
doxycycline hyclate oral tablet 100 mg, 20 mg.......................9
doxycycline hyclate oral tablet 50 mg.....................................9
doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg,
150 mg, 75 mg.................................................................9
doxycycline monohydrate oral capsule....................................9
doxycycline monohydrate oral tablet......................................9
dronabinol oral capsule 10 mg............................................42
dronabinol oral capsule 2.5 mg, 5 mg.................................42
drospirenone-ethinyl estradiol oral tablet 3-0.03 mg.............46
DROXIA.........................................................................15
DULERA.........................................................................49
duloxetine oral capsule,delayed release(dr/ec) 20 mg.............22
duramorph (pf) injection solution 0.5 mg/ml.......................22
duramorph (pf) injection solution 1 mg/ml..........................22
DUREZOL......................................................................48
dutasteride........................................................................50
dutasteride-tamsulosin.......................................................51
econazole topical................................................................36
EDURANT.......................................................................9
EFFIENT........................................................................32
ELAPRASE......................................................................39
ELIDEL...........................................................................36
elinest...............................................................................46
ELIQUIS ORAL TABLET 2.5 MG................................32
ELIQUIS ORAL TABLET 5 MG...................................33
ELITEK INTRAVENOUS RECON SOLN 1.5 MG.....15
elitek intravenous recon soln 7.5 mg....................................15
ELLA...............................................................................46
EMCYT...........................................................................15
00016274, V22
Drug Name
Page
EMEND ORAL CAPSULE 125 MG..............................42
EMEND ORAL CAPSULE 40 MG................................42
EMEND ORAL CAPSULE 80 MG................................42
EMEND ORAL CAPSULE,DOSE PACK......................42
EMEND ORAL SUSPENSION FOR
RECONSTITUTION..................................................42
EMPLICITI.....................................................................15
EMSAM..........................................................................22
EMTRIVA ORAL CAPSULE...........................................9
EMTRIVA ORAL SOLUTION........................................9
enalapril maleate...............................................................33
enalapril-hydrochlorothiazide.............................................33
ENBREL SUBCUTANEOUS RECON SOLN..............46
ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML
(0.51)............................................................................46
ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML
(0.98 ML).....................................................................46
ENBREL SURECLICK...................................................46
endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg........22
ENGERIX-B (PF)............................................................44
ENGERIX-B PEDIATRIC (PF)......................................44
enoxaparin subcutaneous solution.......................................33
enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml.....33
enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8
ml..................................................................................33
enoxaparin subcutaneous syringe 30 mg/0.3 ml....................33
enoxaparin subcutaneous syringe 40 mg/0.4 ml...................33
enoxaparin subcutaneous syringe 60 mg/0.6 ml....................33
enpresse.............................................................................46
entacapone........................................................................22
entecavir.............................................................................9
enulose..............................................................................42
EPCLUSA........................................................................10
epinephrine injection syringe 0.1 mg/ml..............................49
EPIPEN 2-PAK...............................................................49
EPIPEN JR 2-PAK..........................................................49
epirubicin intravenous solution 200 mg/100 ml..................15
epirubicin intravenous solution 50 mg/25 ml......................15
epitol................................................................................22
EPIVIR HBV ORAL SOLUTION..................................10
EPIVIR ORAL SOLUTION...........................................10
eplerenone.........................................................................33
eprosartan.........................................................................33
EPZICOM......................................................................10
EQUETRO ORAL CAPSULE, ER MULTIPHASE 12
HR 100 MG.................................................................22
62
Drug Name
Page
HR 200 MG.................................................................22
HR 300 MG.................................................................22
ERAXIS(WATER DILUENT)........................................10
ERBITUX........................................................................15
ergoloid.............................................................................22
ergomar.............................................................................22
ERIVEDGE.....................................................................15
errin.................................................................................46
ERWINAZE....................................................................15
ery pads.............................................................................36
ery-tab..............................................................................10
erythrocin (as stearate) oral tablet 250 mg...........................10
ERYTHROCIN INTRAVENOUS RECON SOLN 500
MG...............................................................................10
erythromycin ethylsuccinate oral tablet................................10
erythromycin ophthalmic....................................................48
erythromycin oral tablet.....................................................10
erythromycin with ethanol..................................................36
erythromycin-benzoyl peroxide............................................36
ESBRIET.........................................................................49
escitalopram oxalate oral solution........................................22
escitalopram oxalate oral tablet 10 mg................................22
escitalopram oxalate oral tablet 20 mg................................22
escitalopram oxalate oral tablet 5 mg..................................22
ESTRACE VAGINAL.....................................................47
estradiol oral.....................................................................47
estradiol transdermal patch weekly......................................47
ESTRING........................................................................47
ethambutol........................................................................10
ethosuximide.....................................................................22
etodolac.............................................................................22
ETOPOPHOS................................................................15
etoposide intravenous.........................................................15
EVOMELA......................................................................15
EVOTAZ.........................................................................10
EXELON TRANSDERMAL...........................................22
exemestane........................................................................15
EXJADE..........................................................................38
FABRAZYME..................................................................39
falmina (28).....................................................................47
famciclovir oral tablet 125 mg, 250 mg..............................10
famciclovir oral tablet 500 mg............................................10
famotidine (pf)..................................................................42
famotidine (pf)-nacl (iso-os)...............................................42
00016274, V22
Drug Name
Page
famotidine intravenous......................................................42
famotidine oral suspension..................................................42
famotidine oral tablet 20 mg, 40 mg...................................42
FANAPT ORAL TABLET 1 MG....................................22
FANAPT ORAL TABLET 10 MG..................................22
FANAPT ORAL TABLET 12 MG..................................22
FANAPT ORAL TABLETS,DOSE PACK.....................22
FARESTON....................................................................15
FARYDAK ORAL CAPSULE 10 MG.............................15
FARYDAK ORAL CAPSULE 15 MG, 20 MG...............15
FASLODEX....................................................................15
FAZACLO ORAL TABLET,DISINTEGRATING 100
MG...............................................................................22
FAZACLO ORAL TABLET,DISINTEGRATING 12.5
MG...............................................................................22
FAZACLO ORAL TABLET,DISINTEGRATING 25
MG...............................................................................23
felbamate..........................................................................23
felodipine oral er................................................................33
fenofibrate micronized oral capsule 134 mg, 200 mg, 67
mg.................................................................................33
fenofibrate nanocrystallized 48 mg, 145 mg........................33
fenofibrate oral tablet 160 mg, 54 mg.................................33
fenoprofen oral tablet.........................................................23
fentanyl citrate..................................................................23
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr,
25 mcg/hr, 50 mcg/hr, 75 mcg/hr....................................23
FENTORA......................................................................23
FERRIPROX...................................................................38
FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE
PACK...........................................................................23
FETZIMA ORAL CAPSULE,EXTENDED RELEASE
24 HR 120 MG, 80 MG..............................................23
24 HR 20 MG..............................................................23
24 HR 40 MG..............................................................23
finasteride oral tablet 5 mg.................................................51
FIRAZYR........................................................................49
FIRMAGON KIT W DILUENT SYRINGE
SUBCUTANEOUS RECON SOLN 120 MG.............15
63
Drug Name
Page
FIRMAGON KIT W DILUENT SYRINGE
SUBCUTANEOUS RECON SOLN 80 MG...............15
FLEBOGAMMA DIF.....................................................44
flecainide..........................................................................33
FLOVENT DISKUS INHALATION BLISTER WITH
DEVICE 100 MCG/ACTUATION............................49
FLOVENT DISKUS INHALATION BLISTER WITH
DEVICE 250 MCG/ACTUATION, 50 MCG/
ACTUATION..............................................................49
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 110 MCG/ACTUATION..........................49
INHALER 220 MCG/ACTUATION..........................49
INHALER 44 MCG/ACTUATION............................49
fluconazole........................................................................10
fluconazole in dextrose(iso-o)..............................................10
fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/
50 ml, 400 mg/200 ml...................................................10
fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/
100 ml...........................................................................10
flucytosine.........................................................................10
fludarabine intravenous recon soln......................................15
fludarabine intravenous solution.........................................15
fludrocortisone...................................................................39
flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)..........50
fluocinolone.......................................................................36
fluocinolone acetonide oil...................................................38
fluocinolone and shower cap...............................................36
fluocinonide topical cream 0.05 %.....................................36
fluocinonide topical gel.......................................................36
fluocinonide topical ointment.............................................36
fluocinonide topical solution...............................................36
fluocinonide-e topical cream 0.05 %...................................36
fluorometholone.................................................................48
fluorouracil intravenous.....................................................15
fluorouracil topical cream 5 %...........................................36
fluoxetine oral capsule 10 mg..............................................23
fluoxetine oral solution.......................................................23
fluoxetine oral tablet 10 mg................................................23
fluoxetine oral tablet 20 mg................................................23
fluphenazine decanoate......................................................23
fluphenazine hcl................................................................23
flurbiprofen.......................................................................23
00016274, V22
Drug Name
Page
flurbiprofen ophthalmic drops.............................................48
flutamide..........................................................................15
fluticasone nasal................................................................50
fluticasone topical cream....................................................36
fluticasone topical ointment................................................36
fluvoxamine oral tablet 100 mg..........................................23
fluvoxamine oral tablet 25 mg............................................23
fluvoxamine oral tablet 50 mg............................................23
FOLOTYN......................................................................15
fondaparinux subcutaneous syringe 10 mg/0.8 ml................33
fondaparinux subcutaneous syringe 2.5 mg/0.5 ml...............33
fondaparinux subcutaneous syringe 5 mg/0.4 ml..................33
fondaparinux subcutaneous syringe 7.5 mg/0.6 ml...............33
FORADIL AEROLIZER.................................................50
FORTEO........................................................................46
foscarnet............................................................................10
fosinopril...........................................................................33
fosinopril-hydrochlorothiazide............................................33
fosphenytoin......................................................................23
FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTIXA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2
ML................................................................................33
FREAMINE III 10 %......................................................51
furosemide injection solution..............................................33
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/
ml)................................................................................33
furosemide oral tablet.........................................................33
FUSILEV.........................................................................15
FUZEON SUBCUTANEOUS RECON SOLN.............10
FYCOMPA ORAL SUSPENSION.................................23
FYCOMPA ORAL TABLET 10 MG, 12 MG................23
FYCOMPA ORAL TABLET 2 MG................................23
gabapentin oral capsule 100 mg..........................................23
gabapentin oral solution 250 mg/5 ml.................................23
gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml
(6 ml)............................................................................23
gabapentin oral tablet 600 mg............................................23
gabapentin oral tablet 800 mg............................................23
GABITRIL ORAL TABLET 12 MG, 16 MG.................23
galantamine oral capsule,ext rel. pellets 24 hr......................23
galantamine oral solution...................................................23
64
Drug Name
Page
galantamine oral tablet......................................................23
GAMASTAN S/D...........................................................44
GAMMAGARD LIQUID...............................................44
GAMMAGARD S-D (IGA < 1 MCG/ML)................44
GAMUNEX-C................................................................44
ganciclovir sodium.............................................................10
GARDASIL (PF).............................................................44
GARDASIL 9 (PF)..........................................................44
GATTEX 30-VIAL..........................................................42
GATTEX ONE-VIAL.....................................................42
GAUZE PADS 2 X 2.......................................................39
gavilyte-c...........................................................................42
gavilyte-g...........................................................................42
gavilyte-n..........................................................................42
GAZYVA.........................................................................15
gemcitabine intravenous recon soln 1 gram, 200 mg............15
gemcitabine intravenous recon soln 2 gram..........................15
gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/
ml), 200 mg/5.26 ml (38 mg/ml)....................................15
gemcitabine intravenous solution 2 gram/52.6 ml (38 mg/
ml)................................................................................15
gemfibrozil oral.................................................................33
generlac.............................................................................42
gengraf oral capsule 100 mg, 25 mg....................................15
gengraf oral capsule 50 mg.................................................15
gengraf oral solution...........................................................15
GENOTROPIN..............................................................44
GENOTROPIN MINIQUICK......................................44
gentak ophthalmic ointment...............................................48
gentamicin injection..........................................................10
gentamicin ophthalmic.......................................................48
gentamicin sulfate (ped) (pf)...............................................10
gentamicin sulfate (pf) intravenous solution 100 mg/10
ml..................................................................................10
gentamicin sulfate (pf) intravenous solution 60 mg/6 ml, 80
mg/8 ml.........................................................................10
gentamicin topical.............................................................36
GENVOYA.....................................................................10
GEODON INTRAMUSCULAR....................................23
gildagia.............................................................................47
gildess 1.5/30 (21).............................................................47
GILENYA........................................................................23
GILOTRIF......................................................................15
GLATOPA......................................................................23
GLEEVEC ORAL TABLET 100 MG.............................15
GLEEVEC ORAL TABLET 400 MG.............................15
00016274, V22
Drug Name
Page
GLEOSTINE..................................................................15
glimepiride oral tablet 1 mg...............................................39
glipizide oral tablet 10 mg.................................................40
glipizide oral tablet 5 mg...................................................40
glipizide oral tablet extended release 24hr 10 mg.................40
glipizide oral tablet extended release 24hr 2.5 mg................40
glipizide oral tablet extended release 24hr 5 mg...................40
glipizide-metformin oral tablet 2.5-250 mg........................40
glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg........40
GLUCAGEN HYPOKIT................................................40
GLUCAGON EMERGENCY KIT (HUMAN)..............40
glycopyrrolate oral..............................................................42
griseofulvin microsize oral suspension..................................10
griseofulvin ultramicrosize..................................................10
guanidine..........................................................................23
HALAVEN......................................................................16
halobetasol propionate........................................................36
HALOG..........................................................................36
haloperidol........................................................................23
haloperidol decanoate.........................................................24
haloperidol lactate..............................................................24
HARVONI......................................................................10
HAVRIX (PF) INTRAMUSCULAR SUSPENSION......44
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440
ELISA UNIT/ML.........................................................44
HAVRIX (PF) INTRAMUSCULAR SYRINGE 720
ELISA UNIT/0.5 ML...................................................44
heather..............................................................................47
HEPARIN (PORCINE) IN 5 % DEX INTRAVENOUS
PARENTERAL SOLUTION 12,500 UNIT/250
ML................................................................................33
heparin (porcine) in 5 % dex intravenous parenteral solution
25,000 unit/250 ml(100 unit/ml)...................................33
heparin (porcine) in 5 % dex intravenous parenteral solution
25,000 unit/500 ml (50 unit/ml)....................................33
heparin (porcine) in nacl (pf) intravenous parenteral solution
1,000 unit/500 ml, 2,000 unit/1,000 ml........................33
heparin (porcine) injection cartridge...................................33
heparin (porcine) injection solution.....................................33
HEPARIN(PORCINE) IN 0.45% NACL
INTRAVENOUS PARENTERAL SOLUTION 12,
500 UNIT/250 ML......................................................33
65
Drug Name
Page
000 UNIT/250 ML......................................................33
000 UNIT/500 ML......................................................33
heparin, porcine (pf) injection solution................................33
HEPATAMINE 8%........................................................51
HERCEPTIN..................................................................16
HETLIOZ.......................................................................24
HEXALEN......................................................................16
HIBERIX (PF).................................................................44
HUMATROPE INJECTION CARTRIDGE 12 MG
(36 UNIT), 24 MG (72 UNIT)....................................44
HUMIRA PEDIATRIC CROHN'S START..................46
HUMIRA PEN................................................................46
HUMIRA PEN CROHN'S-UC-HS START..................46
HUMIRA PEN PSORIASIS-UVEITIS...........................46
HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/
0.2 ML, 20 MG/0.4 ML...............................................46
HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/
0.8 ML..........................................................................46
hydralazine.......................................................................33
hydrochlorothiazide...........................................................33
hydrocodone-acetaminophen oral solution 10-325 mg/15
ml(15 ml), 2.5-167 mg/5 ml, 5-163 mg/
7.5ml(7.5ml).................................................................24
hydrocodone-acetaminophen oral solution 7.5-325 mg/15
ml..................................................................................24
hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300
mg, 7.5-300 mg.............................................................24
hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325
mg, 7.5-325 mg.............................................................24
hydrocodone-ibuprofen oral tablet 7.5-200 mg....................24
hydrocortisone oral.............................................................40
hydrocortisone rectal cream 2.5 %......................................42
hydrocortisone rectal enema................................................42
hydrocortisone topical cream 1 %, 2.5 %............................36
hydrocortisone topical lotion 2.5 %.....................................36
hydrocortisone topical ointment 1 %, 2.5 %........................36
hydrocortisone valerate.......................................................36
hydrocortisone-acetic acid...................................................38
hydrocortisone-min oil-wht pet...........................................36
hydromorphone oral tablet 2 mg, 4 mg................................24
hydromorphone oral tablet 8 mg.........................................24
hydroxychloroquine oral.....................................................10
00016274, V22
Drug Name
Page
hydroxyprogesterone caproate..............................................47
hydroxyurea.......................................................................16
ibandronate intravenous....................................................46
ibandronate oral................................................................46
IBRANCE.......................................................................16
ibuprofen oral suspension....................................................24
ibuprofen oral tablet 400 mg, 600 mg, 800 mg...................24
ICLUSIG ORAL TABLET 15 MG.................................16
ICLUSIG ORAL TABLET 45 MG.................................16
idarubicin.........................................................................16
ifosfamide intravenous recon soln........................................16
ifosfamide intravenous solution...........................................16
ILARIS (PF).....................................................................44
ILEVRO..........................................................................48
imatinib oral tablet 100 mg...............................................16
imatinib oral tablet 400 mg...............................................16
IMBRUVICA..................................................................16
imipenem-cilastatin...........................................................10
imipramine hcl..................................................................24
imiquimod........................................................................36
IMOVAX RABIES VACCINE (PF)................................44
INCRELEX.....................................................................38
indapamide.......................................................................34
INFANRIX (DTAP) (PF) INTRAMUSCULAR
SUSPENSION.............................................................44
INLYTA ORAL TABLET 1 MG.....................................16
INLYTA ORAL TABLET 5 MG.....................................16
insulin pen needle..............................................................40
INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/
2 ML.............................................................................40
INTELENCE ORAL TABLET 100 MG........................10
INTELENCE ORAL TABLET 200 MG........................10
INTELENCE ORAL TABLET 25 MG..........................10
intralipid intravenous emulsion 20 %.................................51
INTRON A INJECTION...............................................44
INTUNIV ER.................................................................24
INVANZ INJECTION...................................................10
INVEGA ORAL TABLET EXTENDED RELEASE
24HR 1.5 MG..............................................................24
24HR 3 MG.................................................................24
24HR 6 MG.................................................................24
24HR 9 MG.................................................................24
66
Drug Name
Page
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE
117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML,
78 MG/0.5 ML.............................................................24
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE
39 MG/0.25 ML...........................................................24
INVEGA TRINZA INTRAMUSCULAR SYRINGE
273 MG/0.875 ML.......................................................24
410 MG/1.315 ML.......................................................24
546 MG/1.75 ML.........................................................24
819 MG/2.625 ML.......................................................24
INVIRASE ORAL CAPSULE.........................................10
INVIRASE ORAL TABLET...........................................10
INVOKANA ORAL TABLET 100 MG.........................40
INVOKANA ORAL TABLET 300 MG.........................40
IPOL INJECTION SUSPENSION................................44
ipratropium bromide inhalation.........................................50
ipratropium bromide nasal.................................................39
ipratropium-albuterol........................................................50
irbesartan..........................................................................34
IRESSA............................................................................16
irinotecan intravenous solution 100 mg/5 ml, 40 mg/2
ml..................................................................................16
irinotecan intravenous solution 500 mg/25 ml.....................16
ISENTRESS ORAL POWDER IN PACKET.................10
ISENTRESS ORAL TABLET.........................................10
ISENTRESS ORAL TABLET,CHEWABLE 100
MG...............................................................................10
ISENTRESS ORAL TABLET,CHEWABLE 25 MG......10
isoniazid oral....................................................................10
isosorbide dinitrate oral......................................................34
isosorbide mononitrate.......................................................34
ISTODAX.......................................................................16
itraconazole.......................................................................10
IXEMPRA.......................................................................16
IXIARO (PF)...................................................................44
JAKAFI ORAL TABLET 10 MG....................................16
JAKAFI ORAL TABLET 5 MG......................................16
JALYN.............................................................................51
jantoven............................................................................34
JANUMET......................................................................40
00016274, V22
Drug Name
Page
JANUMET XR ORAL TABLET, ER MULTIPHASE
24 HR 100-1,000 MG..................................................40
JANUMET XR ORAL TABLET, ER MULTIPHASE
24 HR 50-1,000 MG, 50-500 MG...............................40
JANUVIA ORAL TABLET 100 MG..............................40
JANUVIA ORAL TABLET 25 MG................................40
JANUVIA ORAL TABLET 50 MG................................40
JARDIANCE...................................................................40
jencycla.............................................................................47
JEVTANA.......................................................................16
jolessa................................................................................47
jolivette.............................................................................47
junel 1.5/30 (21)...............................................................47
junel 1/20 (21)..................................................................47
junel fe 1.5/30 (28)...........................................................47
junel fe 1/20 (28)..............................................................47
junel fe 24.........................................................................47
JUXTAPID......................................................................34
KADCYLA......................................................................16
KALETRA ORAL SOLUTION......................................10
KALETRA ORAL TABLET 100-25 MG........................10
KALETRA ORAL TABLET 200-50 MG........................10
KALYDECO ORAL TABLET........................................50
kariva (28).......................................................................47
kelnor 1/35 (28)................................................................47
KEPIVANCE..................................................................16
ketoconazole oral...............................................................10
ketoconazole topical...........................................................36
ketorolac ophthalmic..........................................................48
KEYTRUDA...................................................................16
KHEDEZLA ORAL TABLET EXTENDED RELEASE
24HR 100 MG.............................................................24
KHEDEZLA ORAL TABLET EXTENDED RELEASE
24HR 50 MG...............................................................24
KINERET.......................................................................46
kionex...............................................................................38
kionex (with sorbitol).........................................................38
klor-con 10.......................................................................51
klor-con 8.........................................................................51
klor-con m10.....................................................................51
klor-con m15.....................................................................51
klor-con m20.....................................................................51
KORLYM........................................................................40
kurvelo..............................................................................47
KUVAN ORAL TABLET,SOLUBLE.............................40
KYNAMRO....................................................................34
67
Drug Name
Page
labetalol intravenous solution.............................................34
labetalol oral.....................................................................34
lactated ringers intravenous................................................51
lactated ringers irrigation...................................................38
lactulose............................................................................42
lamivudine oral solution....................................................10
lamivudine oral tablet 100 mg...........................................10
lamivudine-zidovudine......................................................11
lamotrigine oral tablet........................................................24
lamotrigine oral tablet, chewable dispersible........................24
LANOXIN INJECTION................................................34
LANOXIN ORAL TABLET 125 MCG, 62.5 MCG......34
lansoprazole oral capsule,delayed release(dr/ec).....................42
LANTUS.........................................................................40
LANTUS SOLOSTAR....................................................40
larin 1.5/30 (21)...............................................................47
larin fe 1/20 (28)..............................................................47
latanoprost........................................................................48
LATUDA ORAL TABLET 120 MG...............................24
LATUDA ORAL TABLET 20 MG.................................24
LAZANDA......................................................................24
leflunomide.......................................................................46
LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X
1/DAY).........................................................................16
LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X
1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY
(4 MG X 2), 8 MG/DAY (4 MG X 2) (60 PACK).......16
LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X
1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X
1)..................................................................................16
lessina...............................................................................47
LETAIRIS........................................................................50
letrozole............................................................................16
leucovorin calcium injection recon soln 100 mg, 200 mg,
350 mg, 50 mg...............................................................16
leucovorin calcium injection recon soln 500 mg...................16
leucovorin calcium oral......................................................16
LEUKERAN....................................................................16
LEUKINE INJECTION RECON SOLN.......................44
leuprolide subcutaneous kit.................................................16
00016274, V22
Drug Name
Page
levalbuterol hcl inhalation solution for nebulization 0.31
mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml.........................50
levalbuterol hcl inhalation solution for nebulization 0.63
mg/3 ml.........................................................................50
LEVEMIR.......................................................................40
LEVEMIR FLEXTOUCH..............................................40
levetiracetam intravenous...................................................24
levetiracetam oral solution 100 mg/ml................................24
levetiracetam oral solution 500 mg/5 ml (5 ml)...................24
levetiracetam oral tablet.....................................................25
levetiracetam oral tablet extended release 24 hr 500 mg.......25
levetiracetam oral tablet extended release 24 hr 750 mg.......25
levobunolol ophthalmic drops 0.5 %...................................48
levocarnitine (with sugar)...................................................38
levocarnitine oral tablet......................................................38
levocetirizine oral tablet.....................................................50
levofloxacin intravenous.....................................................11
levofloxacin oral................................................................11
levoleucovorin calcium intravenous recon soln......................16
levonest (28)......................................................................47
levonorg-eth estrad triphasic...............................................47
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.150.03 mg.........................................................................47
levonorgestrel-ethinyl estrad oral tablets,dose pack,3
month............................................................................47
levorphanol tartrate...........................................................25
levothyroxine oral..............................................................40
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg,
150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg,
88 mcg...........................................................................40
LEXIVA ORAL SUSPENSION......................................11
LEXIVA ORAL TABLET................................................11
lidocaine (pf) injection solution 10 mg/ml (1 %), 20 mg/ml
(2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %).......................36
lidocaine (pf) injection solution 15 mg/ml (1.5 %)..............36
lidocaine (pf) intravenous solution......................................34
lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %).........34
lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml
(2 %)............................................................................37
lidocaine hcl injection solution 5 mg/ml (0.5 %).................37
lidocaine hcl laryngotracheal...............................................37
lidocaine hcl mucous membrane..........................................37
lidocaine hcl urethral.........................................................37
lidocaine topical adhesive patch,medicated..........................37
lidocaine topical ointment..................................................37
lidocaine viscous................................................................37
68
Drug Name
Page
lidocaine-prilocaine topical cream.......................................37
lindane topical shampoo.....................................................37
linezolid oral suspension for reconstitution...........................11
linezolid oral tablet............................................................11
LINZESS.........................................................................42
liothyronine oral................................................................40
lisinopril...........................................................................34
lisinopril-hydrochlorothiazide.............................................34
lithium carbonate..............................................................25
lithium citrate oral solution 8 meq/5 ml..............................25
LODOSYN.....................................................................25
lokara...............................................................................37
LONSURF......................................................................16
loperamide oral capsule......................................................42
lorazepam intensol.............................................................25
lorazepam oral tablet.........................................................25
lorcet (hydrocodone)...........................................................25
lorcet hd............................................................................25
lorcet plus oral tablet 7.5-325 mg.......................................25
lortab 10-325...................................................................25
lortab 5-325.....................................................................25
lortab 7.5-325..................................................................25
losartan oral tablet 100 mg................................................34
losartan oral tablet 25 mg, 50 mg.......................................34
losartan-hydrochlorothiazide..............................................34
lovastatin oral tablet 10 mg, 20 mg....................................34
lovastatin oral tablet 40 mg................................................34
low-ogestrel (28)................................................................47
loxapine succinate..............................................................25
LUMIGAN OPHTHALMIC DROPS 0.01 %...............48
LUNESTA.......................................................................25
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR
SYRINGE KIT 22.5 MG..............................................16
LUPRON DEPOT INTRAMUSCULAR SYRINGE
KIT 3.75 MG...............................................................16
LUPRON DEPOT INTRAMUSCULAR SYRINGE
KIT 7.5 MG.................................................................16
lutera (28)........................................................................47
LYNPARZA.....................................................................16
LYRICA ORAL CAPSULE 100 MG...............................25
LYRICA ORAL CAPSULE 225 MG, 300 MG...............25
LYRICA ORAL CAPSULE 25 MG.................................25
00016274, V22
Drug Name
Page
LYRICA ORAL SOLUTION..........................................25
LYSODREN....................................................................16
lyza...................................................................................47
M-M-R II (PF)................................................................45
MACRODANTIN ORAL CAPSULE 25 MG, 50
MG...............................................................................11
magnesium sulfate in water intravenous parenteral
solution..........................................................................51
magnesium sulfate in water intravenous piggyback 2 gram/
50 ml (4 %), 4 gram/50 ml (8 %)..................................52
magnesium sulfate in water intravenous piggyback 4 gram/
100 ml (4 %).................................................................52
magnesium sulfate injection solution...................................52
magnesium sulfate injection syringe.....................................52
maprotiline oral tablet 25 mg.............................................25
marlissa............................................................................47
MARPLAN......................................................................25
MARQIBO......................................................................16
MATULANE...................................................................16
matzim la.........................................................................34
meclizine oral tablet 12.5 mg, 25 mg..................................42
meclofenamate oral............................................................25
medroxyprogesterone intramuscular.....................................47
medroxyprogesterone oral....................................................47
mefloquine........................................................................11
megestrol oral suspension 400 mg/10 ml (10 ml), 800 mg/
20 ml (20 ml)................................................................17
megestrol oral suspension 400 mg/10 ml (40 mg/ml)............17
megestrol oral tablet...........................................................17
MEKINIST ORAL TABLET 0.5 MG.............................17
MEKINIST ORAL TABLET 2 MG................................17
meloxicam oral suspension..................................................25
meloxicam oral tablet.........................................................25
melphalan hcl....................................................................17
memantine oral solution.....................................................25
memantine oral tablet 10 mg.............................................25
memantine oral tablet 5 mg...............................................25
MENACTRA (PF) INTRAMUSCULAR
SOLUTION.................................................................45
menest...............................................................................47
MENOMUNE - A/C/Y/W-135......................................45
MENOMUNE - A/C/Y/W-135 (PF)..............................45
MENVEO A-C-Y-W-135-DIP (PF)................................45
mercaptopurine..................................................................17
69
Drug Name
Page
meropenem........................................................................11
MESALAMINE ORAL...................................................42
mesalamine rectal..............................................................42
mesalamine with cleansing wipe.........................................42
mesna...............................................................................17
MESNEX ORAL.............................................................17
MESTINON ORAL SYRUP...........................................25
MESTINON TIMESPAN..............................................25
metadate er.......................................................................25
metaproterenol...................................................................50
metformin oral tablet 1,000 mg..........................................40
metformin oral tablet 500 mg.............................................40
metformin oral tablet 850 mg.............................................40
metformin oral tablet extended release 24 hr 500 mg...........40
metformin oral tablet extended release 24 hr 750 mg...........40
metformin oral tablet extended release 24hr 1,000 mg.........40
methadone injection...........................................................25
methadone intensol............................................................25
methadone oral concentrate................................................25
methadone oral solution 10 mg/5 ml...................................25
methadone oral solution 5 mg/5 ml.....................................25
methadone oral tablet 10 mg..............................................25
methadone oral tablet 5 mg................................................25
methadose oral concentrate.................................................25
methazolamide oral...........................................................48
methenamine hippurate.....................................................11
methenamine mandelate oral tablet 1 gram.........................11
methimazole oral tablet 10 mg, 5 mg..................................40
methotrexate sodium..........................................................17
methotrexate sodium (pf) injection recon soln.......................17
methotrexate sodium (pf) injection solution.........................17
methoxsalen rapid..............................................................37
methyclothiazide................................................................34
methyldopa........................................................................34
methyldopa-hydrochlorothiazide.........................................34
methyldopate.....................................................................34
methylphenidate oral capsule, er biphasic 30-70 30 mg........25
methylphenidate oral capsule, er biphasic 30-70 40 mg........26
methylphenidate oral capsule,er biphasic 50-50 30 mg.........26
methylphenidate oral capsule,er biphasic 50-50 40 mg.........26
methylphenidate oral tablet................................................26
methylphenidate oral tablet extended release........................26
methylphenidate oral tablet extended release 24hr 18 mg.....26
methylprednisolone acetate..................................................40
methylprednisolone oral tablets...........................................40
00016274, V22
Drug Name
Page
methylprednisolone sodium succ injection recon soln 125 mg,
40 mg............................................................................40
methylprednisolone sodium succ intravenous........................40
metipranolol......................................................................48
metoclopramide hcl injection solution..................................42
metoclopramide hcl injection syringe...................................43
metoclopramide hcl oral solution.........................................43
metoclopramide hcl oral tablet............................................43
metolazone........................................................................34
metoprolol succinate...........................................................34
metoprolol ta-hydrochlorothiaz...........................................34
metoprolol tartrate intravenous solution..............................34
metoprolol tartrate intravenous syringe................................34
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg..........34
metro i.v...........................................................................11
metronidazole in nacl (iso-os).............................................11
metronidazole oral.............................................................11
metronidazole topical cream...............................................37
metronidazole topical gel 0.75 %........................................37
metronidazole topical lotion...............................................37
metronidazole vaginal........................................................47
mexiletine.........................................................................34
MIACALCIN INJECTION............................................40
miconazole-3 vaginal suppository........................................47
microgestin 1.5/30 (21).....................................................47
microgestin 1/20 (21)........................................................47
microgestin fe 1.5/30 (28)..................................................47
microgestin fe 1/20 (28).....................................................47
midodrine.........................................................................38
MIGRANAL....................................................................26
minocycline oral capsule.....................................................11
minocycline oral tablet.......................................................11
minoxidil oral...................................................................34
mircette (28).....................................................................47
mirtazapine oral tablet 15 mg............................................26
mirtazapine oral tablet 7.5 mg...........................................26
mirtazapine oral tablet,disintegrating 15 mg.......................26
misoprostol........................................................................43
mitomycin.........................................................................17
mitoxantrone.....................................................................17
modafinil oral tablet 100 mg..............................................26
modafinil oral tablet 200 mg..............................................26
70
Drug Name
Page
moderiba...........................................................................11
molindone.........................................................................26
mometasone topical............................................................37
mono-linyah......................................................................47
mononessa (28)..................................................................47
montelukast.......................................................................50
morgidox oral capsule 100 mg............................................11
morgidox oral capsule 50 mg..............................................11
morphine (pf) injection solution 0.5 mg/ml.........................26
morphine (pf) injection solution 1 mg/ml............................26
morphine (pf) intravenous patient control.analgesia soln 150
mg/30 ml.......................................................................26
morphine (pf) intravenous patient control.analgesia soln 30
mg/30 ml.......................................................................26
morphine concentrate oral solution......................................26
morphine intravenous cartridge 2 mg/ml, 8 mg/ml...............26
morphine intravenous solution 10 mg/ml, 50 mg/ml............26
morphine intravenous solution 100 mg/4 ml, 25 mg/ml, 250
mg/10 ml.......................................................................26
morphine intravenous solution 4 mg/ml, 8 mg/ml................26
morphine intravenous syringe 2 mg/ml, 4 mg/ml..................26
morphine oral capsule, er multiphase 24 hr 30 mg, 60
mg.................................................................................26
morphine oral capsule,extend.release pellets 100 mg, 20 mg,
30 mg, 50 mg, 60 mg, 80 mg..........................................26
morphine oral solution 10 mg/5 ml.....................................26
morphine oral solution 20 mg/5 ml (4 mg/ml).....................26
morphine oral tablet 15 mg................................................26
morphine oral tablet 30 mg................................................26
morphine oral tablet extended release 100 mg, 15 mg, 30
mg, 60 mg......................................................................26
morphine oral tablet extended release 200 mg......................26
MOVIPREP....................................................................43
MOZOBIL......................................................................45
MULTAQ.......................................................................34
mupirocin topical ointment................................................37
MUSTARGEN................................................................17
MYCOBUTIN................................................................11
mycophenolate mofetil oral capsule......................................17
mycophenolate mofetil oral suspension for reconstitution.......17
mycophenolate mofetil oral tablet........................................17
mycophenolate sodium........................................................17
MYOZYME.....................................................................40
MYRBETRIQ.................................................................51
myzilra.............................................................................47
nabumetone......................................................................26
00016274, V22
Drug Name
Page
nadolol..............................................................................34
nadolol-bendroflumethiazide..............................................34
nafcillin injection recon soln 1 gram, 10 gram.....................11
nafcillin injection recon soln 2 gram...................................11
nafcillin intravenous recon soln 2 gram...............................11
NAGLAZYME................................................................40
nalbuphine injection solution 10 mg/ml..............................26
nalbuphine injection solution 20 mg/ml..............................26
naloxone...........................................................................26
naltrexone oral..................................................................26
NAMENDA ORAL SOLUTION...................................26
NAMENDA ORAL TABLET 10 MG............................26
NAMENDA ORAL TABLET 5 MG..............................27
NAMENDA TITRATION PAK.....................................27
NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR
DOSE PACK................................................................27
NAMENDA XR ORAL CAPSULE,SPRINKLE,ER
24HR............................................................................27
naproxen...........................................................................27
naproxen sodium oral tablet 275 mg, 550 mg.....................27
NARCAN........................................................................27
NATACYN......................................................................48
nateglinide oral tablet 120 mg............................................40
nateglinide oral tablet 60 mg..............................................40
NATPARA......................................................................41
NEBUPENT...................................................................11
necon 0.5/35 (28)..............................................................47
necon 1/35 (28).................................................................47
necon 10/11 (28)...............................................................47
necon 7/7/7 (28)................................................................47
needles, insulin disp.,safety.................................................41
nefazodone oral tablet 100 mg............................................27
nefazodone oral tablet 50 mg..............................................27
neo-polycin........................................................................48
neo-polycin hc....................................................................48
neomycin...........................................................................11
neomycin-bacitracin-poly-hc...............................................48
neomycin-bacitracin-polymyxin..........................................48
neomycin-polymyxin b gu...................................................38
neomycin-polymyxin b-dexameth........................................48
neomycin-polymyxin-gramicidin.........................................48
neomycin-polymyxin-hc ophthalmic....................................48
neomycin-polymyxin-hc otic................................................39
71
Drug Name
Page
NEULASTA SUBCUTANEOUS SYRINGE..................45
NEUPOGEN..................................................................45
NEUPRO........................................................................27
NEVANAC.....................................................................48
nevirapine oral suspension..................................................11
nevirapine oral tablet.........................................................11
nevirapine oral tablet extended release 24 hr 100 mg...........11
nevirapine oral tablet extended release 24 hr 400 mg...........11
NEXAVAR......................................................................17
niacin oral tablet extended release 24 hr 1,000 mg, 750
mg.................................................................................34
niacin oral tablet extended release 24 hr 500 mg.................34
niacor...............................................................................34
NIASPAN EXTENDED-RELEASE ORAL TABLET
EXTENDED RELEASE 24 HR 1,000 MG, 750
MG...............................................................................34
NIASPAN EXTENDED-RELEASE ORAL TABLET
EXTENDED RELEASE 24 HR 500 MG....................34
nicardipine oral.................................................................34
NICOTROL NS.............................................................38
nifedical xl........................................................................34
nifedipine oral tablet extended release..................................34
nifedipine oral tablet extended release 24hr.........................34
NILANDRON................................................................17
NINLARO......................................................................17
NIPENT..........................................................................17
nitro-bid...........................................................................34
nitroglycerin intravenous....................................................34
nitroglycerin sublingual......................................................34
nitroglycerin transdermal patch 24 hour..............................34
NITROSTAT..................................................................34
nora-be.............................................................................47
norco.................................................................................27
NORDITROPIN FLEXPRO SUBCUTANEOUS PEN
INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/
1.5 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/
ML)..............................................................................45
norethindrone (contraceptive).............................................47
norethindrone acetate.........................................................47
norethindrone-e.estradiol-iron............................................47
norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25
mg-35 mcg (28).............................................................47
norgestimate-ethinyl estradiol oral tablet 0.25-35 mgmcg................................................................................47
norlyroc.............................................................................47
NORMOSOL-M IN 5 % DEXTROSE..........................52
00016274, V22
Drug Name
Page
NORMOSOL-R..............................................................52
NORMOSOL-R IN 5 % DEXTROSE...........................52
NORMOSOL-R PH 7.4.................................................52
nortrel 0.5/35 (28)............................................................47
nortrel 1/35 (21)...............................................................47
nortrel 1/35 (28)...............................................................47
nortrel 7/7/7 (28)..............................................................47
nortriptyline......................................................................27
NORVIR ORAL CAPSULE............................................11
NORVIR ORAL SOLUTION........................................11
NORVIR ORAL TABLET..............................................11
NOVOLIN 70/30...........................................................41
NOVOLIN N.................................................................41
NOVOLIN R..................................................................41
NOVOLOG....................................................................41
NOVOLOG FLEXPEN..................................................41
NOVOLOG MIX 70-30.................................................41
NOVOLOG MIX 70-30 FLEXPEN...............................41
NOVOLOG PENFILL...................................................41
NOXAFIL ORAL SUSPENSION...................................11
NUEDEXTA...................................................................27
NULOJIX........................................................................17
NUPLAZID....................................................................27
NUVARING...................................................................47
nyamyc..............................................................................37
nystatin oral suspension......................................................11
nystatin oral tablet.............................................................11
nystatin topical..................................................................37
nystatin-triamcinolone.......................................................37
nystop...............................................................................37
ocella................................................................................47
octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/
ml..................................................................................17
octreotide acetate injection solution 100 mcg/ml, 200 mcg/
ml, 50 mcg/ml................................................................17
octreotide acetate injection syringe 100 mcg/ml (1 ml), 50
mcg/ml (1 ml)................................................................17
OCTREOTIDE ACETATE INJECTION SYRINGE
500 MCG/ML (1 ML).................................................17
ODEFSEY.......................................................................11
ODOMZO......................................................................17
ofloxacin ophthalmic..........................................................48
ofloxacin oral tablet 400 mg...............................................11
ofloxacin otic.....................................................................39
ogestrel (28)......................................................................47
olanzapine intramuscular...................................................27
72
Drug Name
Page
olanzapine oral tablet 10 mg..............................................27
olanzapine oral tablet 2.5 mg.............................................27
olanzapine oral tablet 5 mg................................................27
olanzapine oral tablet 7.5 mg.............................................27
olanzapine oral tablet,disintegrating 10 mg.........................27
olanzapine oral tablet,disintegrating 5 mg...........................27
olanzapine-fluoxetine oral capsule 12-25 mg, 12-50 mg, 650 mg............................................................................27
olanzapine-fluoxetine oral capsule 3-25 mg, 6-25 mg..........27
olopatadine ophthalmic......................................................48
OLYSIO..........................................................................11
omega-3 acid ethyl esters.....................................................34
omeprazole oral capsule,delayed release(dr/ec)......................43
ONCASPAR....................................................................17
ondansetron hcl (pf) injection solution.................................43
ondansetron hcl (pf) injection syringe..................................43
ondansetron hcl intravenous...............................................43
ondansetron hcl oral solution..............................................43
ondansetron hcl oral tablet 24 mg.......................................43
ondansetron hcl oral tablet 4 mg, 8 mg...............................43
ondansetron odt.................................................................43
ONFI ORAL SUSPENSION..........................................27
ONFI ORAL TABLET 10 MG.......................................27
ONFI ORAL TABLET 20 MG.......................................27
OPDIVO.........................................................................17
oralone..............................................................................39
ORAP..............................................................................27
ORENCIA.......................................................................46
ORENCIA (WITH MALTOSE).....................................46
ORENCIA CLICKJECT.................................................46
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG.....38
ORFADIN ORAL CAPSULE 20 MG............................38
ORFADIN ORAL SUSPENSION..................................38
orsythia.............................................................................47
oxacillin injection recon soln 1 gram, 2 gram.......................11
oxacillin injection recon soln 10 gram.................................11
oxacillin intravenous recon soln 1 gram...............................11
oxacillin intravenous recon soln 2 gram...............................11
oxaliplatin intravenous recon soln 100 mg...........................17
oxaliplatin intravenous recon soln 50 mg.............................17
oxaliplatin intravenous solution..........................................17
oxandrolone oral tablet 10 mg............................................41
00016274, V22
Drug Name
Page
oxandrolone oral tablet 2.5 mg...........................................41
oxaprozin..........................................................................27
oxcarbazepine oral tablet....................................................27
OXSORALEN.................................................................37
OXTELLAR XR ORAL TABLET EXTENDED
RELEASE 24 HR 150 MG...........................................27
RELEASE 24 HR 300 MG...........................................27
RELEASE 24 HR 600 MG...........................................27
oxybutynin chloride oral syrup............................................51
oxybutynin chloride oral tablet............................................51
oxybutynin chloride oral tablet extended release 24hr 10 mg,
15 mg............................................................................51
oxybutynin chloride oral tablet extended release 24hr 5
mg.................................................................................51
oxycodone oral capsule........................................................27
oxycodone oral concentrate..................................................27
oxycodone oral solution.......................................................27
oxycodone oral tablet 10 mg, 5 mg......................................27
oxycodone oral tablet 15 mg...............................................28
oxycodone oral tablet 20 mg, 30 mg....................................28
oxycodone-acetaminophen oral solution...............................28
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325
mg, 5-325 mg, 7.5-325 mg.............................................28
oxycodone-aspirin..............................................................28
pacerone oral tablet 100 mg, 200 mg, 400 mg....................34
paclitaxel...........................................................................17
paliperidone oral tablet extended release 24hr 1.5 mg..........28
paliperidone oral tablet extended release 24hr 3 mg.............28
pamidronate......................................................................41
PANCREAZE..................................................................43
PANRETIN.....................................................................37
pantoprazole......................................................................43
paroex oral rinse................................................................39
paromomycin.....................................................................11
paroxetine hcl oral tablet 10 mg..........................................28
paroxetine hcl oral tablet 40 mg.........................................28
paroxetine hcl oral tablet extended release 24 hr 12.5
mg.................................................................................28
paroxetine hcl oral tablet extended release 24 hr 25 mg........28
73
Drug Name
Page
paroxetine hcl oral tablet extended release 24 hr 37.5
mg.................................................................................28
paser.................................................................................11
PATADAY.......................................................................48
PATANOL......................................................................48
PAXIL ORAL SUSPENSION.........................................28
PAZEO............................................................................48
PEDVAX HIB (PF).........................................................45
peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86
gram..............................................................................43
peg 3350-electrolytes oral recon soln 240-22.72-6.72 -5.84
gram..............................................................................43
peg-electrolyte soln..............................................................43
PEGANONE...................................................................28
PEGINTRON.................................................................45
PEGINTRON REDIPEN...............................................45
PENICILLIN G POT IN DEXTROSE
INTRAVENOUS PIGGYBACK 1 MILLION UNIT/
50 ML...........................................................................11
PENICILLIN G POT IN DEXTROSE
INTRAVENOUS PIGGYBACK 2 MILLION UNIT/
50 ML, 3 MILLION UNIT/50 ML.............................11
penicillin g potassium injection recon soln 20 million
unit...............................................................................11
penicillin g potassium injection recon soln 5 million unit......12
penicillin g procaine intramuscular syringe 1.2 million unit/
2 ml...............................................................................12
penicillin g procaine intramuscular syringe 600,000 unit/
ml..................................................................................12
penicillin g sodium.............................................................12
penicillin v potassium.........................................................12
PENTACEL ACTHIB COMPONENT (PF).................45
PENTAM........................................................................12
PENTASA.......................................................................43
pentoxifylline.....................................................................34
periogard...........................................................................39
PERJETA.........................................................................17
permethrin topical cream....................................................37
perphenazine.....................................................................28
phenadoz...........................................................................50
phenelzine.........................................................................28
phenobarbital oral elixir.....................................................28
phenobarbital oral tablet 100 mg.......................................28
phenobarbital oral tablet 15 mg.........................................28
phenobarbital oral tablet 16.2 mg......................................28
00016274, V22
Drug Name
Page
phenytoin oral suspension 100 mg/4 ml...............................28
phenytoin oral suspension 125 mg/5 ml...............................28
phenytoin oral tablet,chewable............................................28
phenytoin sodium extended.................................................28
phenytoin sodium intravenous solution................................28
philith...............................................................................47
PHOSPHOLINE IODIDE.............................................48
PICATO..........................................................................37
pilocarpine hcl oral............................................................38
pimtrea (28).....................................................................47
pindolol............................................................................34
pioglitazone oral tablet 15 mg............................................41
pioglitazone-glimepiride.....................................................41
pioglitazone-metformin......................................................41
piperacillin-tazobactam.....................................................12
pirmella............................................................................47
piroxicam..........................................................................28
PLASMA-LYTE 148........................................................52
PLASMA-LYTE-56 IN 5 % DEXTROSE.......................52
podofilox...........................................................................37
polycin..............................................................................48
polyethylene glycol 3350 oral..............................................43
polymyxin b sulf-trimethoprim............................................48
POMALYST ORAL CAPSULE 1 MG............................17
POMALYST ORAL CAPSULE 2 MG............................17
POMALYST ORAL CAPSULE 3 MG, 4 MG................17
portia................................................................................47
PORTRAZZA.................................................................17
potassium chlorid-d5-0.45%nacl intravenous parenteral
solution 10 meq/l, 30 meq/l, 40 meq/l..............................52
potassium chlorid-d5-0.45%nacl intravenous parenteral
solution 20 meq/l............................................................52
potassium chloride in 0.9%nacl intravenous parenteral
solution 20 meq/l............................................................52
potassium chloride in 5 % dex intravenous parenteral solution
20 meq/l, 40 meq/l.........................................................52
potassium chloride in 5 % dex intravenous parenteral solution
30 meq/l........................................................................52
potassium chloride in lr-d5 intravenous parenteral solution
20 meq/l........................................................................52
74
Drug Name
Page
potassium chloride in lr-d5 intravenous parenteral solution
40 meq/l........................................................................52
potassium chloride intravenous piggyback 10 meq/100 ml,
20 meq/100 ml, 20 meq/50 ml, 40 meq/100 ml..............52
potassium chloride intravenous piggyback 10 meq/50 ml......52
potassium chloride intravenous piggyback 30 meq/100
ml..................................................................................52
potassium chloride intravenous solution...............................52
potassium chloride oral capsule, extended release..................52
potassium chloride oral tablet extended release.....................52
potassium chloride oral tablet,er particles/crystals..................52
potassium chloride-0.45 % nacl..........................................52
potassium chloride-d5-0.2%nacl intravenous parenteral
solution 20 meq/l............................................................52
solution 40 meq/l............................................................52
solution 20 meq/l............................................................52
solution 20 meq/l............................................................52
solution 40 meq/l............................................................52
potassium citrate oral tablet extended release 10 meq (1,080
mg), 5 meq (540 mg)......................................................51
POTIGA ORAL TABLET 200 MG, 300 MG, 400
MG...............................................................................28
POTIGA ORAL TABLET 50 MG..................................28
PRADAXA ORAL CAPSULE 110 MG..........................34
PRADAXA ORAL CAPSULE 150 MG, 75 MG.............34
PRALUENT PEN...........................................................34
PRALUENT SYRINGE..................................................35
pramipexole oral tablet.......................................................28
pravastatin........................................................................35
prazosin oral.....................................................................35
prednisolone acetate...........................................................48
prednisolone oral solution 15 mg/5 ml.................................41
prednisolone sodium phosphate ophthalmic..........................49
prednisolone sodium phosphate oral solution 15 mg/5 ml (3
mg/ml), 5 mg base/5 ml (6.7 mg/5 ml).............................41
prednisolone sodium phosphate oral tablet,disintegrating......41
prednisone intensol.............................................................41
prednisone oral..................................................................41
PREMARIN INJECTION..............................................47
PREMARIN ORAL.........................................................47
PREMARIN VAGINAL..................................................47
PREMPHASE..................................................................47
00016274, V22
Drug Name
Page
PREMPRO......................................................................47
prenatal vitamin oral tablet...............................................52
prevalite............................................................................35
previfem............................................................................47
PREZCOBIX...................................................................12
PREZISTA ORAL SUSPENSION..................................12
PREZISTA ORAL TABLET 150 MG.............................12
PREZISTA ORAL TABLET 600 MG, 800 MG.............12
PREZISTA ORAL TABLET 75 MG...............................12
PRIFTIN.........................................................................12
PRIMAQUINE...............................................................12
primidone.........................................................................28
PRISTIQ ORAL TABLET EXTENDED RELEASE 24
HR 100 MG.................................................................28
HR 25 MG...................................................................28
HR 50 MG...................................................................28
PROAIR HFA.................................................................50
PROAIR RESPICLICK...................................................50
probenecid.........................................................................46
procainamide injection solution 100 mg/ml.........................35
procainamide injection solution 500 mg/ml.........................35
prochlorperazine edisylate injection solution 10 mg/2 ml (5
mg/ml)...........................................................................43
prochlorperazine maleate oral tablet 10 mg, 5 mg................43
prochlorperazine maleate rectal...........................................43
PROCRIT.......................................................................45
procto-pak.........................................................................43
proctosol hc........................................................................43
proctozone-hc....................................................................43
PROGLYCEM................................................................41
PROGRAF INTRAVENOUS.........................................17
PROLEUKIN..................................................................45
PROLIA..........................................................................46
PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75
MG...............................................................................35
PROMACTA ORAL TABLET 50 MG...........................35
promethazine oral tablet....................................................50
promethegan rectal suppository 12.5 mg..............................50
propafenone oral tablet.......................................................35
propranolol intravenous.....................................................35
propranolol oral.................................................................35
propranolol-hydrochlorothiazid...........................................35
propylthiouracil.................................................................41
PROQUAD (PF).............................................................45
75
Drug Name
Page
PROTONIX INTRAVENOUS......................................43
PROTOPIC....................................................................37
protriptyline......................................................................28
PULMOZYME...............................................................50
PURIXAN.......................................................................17
pyrazinamide....................................................................12
pyridostigmine bromide......................................................28
QUADRACEL (PF)........................................................45
quetiapine oral tablet 100 mg............................................28
quetiapine oral tablet 25 mg..............................................29
quetiapine oral tablet 50 mg..............................................29
quinapril...........................................................................35
quinapril-hydrochlorothiazide............................................35
quinidine gluconate oral.....................................................35
quinidine sulfate oral tablet................................................35
quinine sulfate...................................................................12
QVAR INHALATION AEROSOL 40 MCG/
ACTUATION..............................................................50
QVAR INHALATION AEROSOL 80 MCG/
ACTUATION..............................................................50
RABAVERT (PF)............................................................45
raloxifene..........................................................................46
ramipril............................................................................35
RANEXA.........................................................................35
ranitidine hcl oral syrup.....................................................43
ranitidine hcl oral tablet 150 mg, 300 mg..........................43
RAPAMUNE...................................................................17
RAVICTI.........................................................................38
REBIF (WITH ALBUMIN)............................................45
REBIF REBIDOSE.........................................................45
REBIF TITRATION PACK...........................................45
reclipsen (28).....................................................................48
RECOMBIVAX HB (PF) INTRAMUSCULAR
SUSPENSION.............................................................45
SYRINGE 10 MCG/ML..............................................45
SYRINGE 5 MCG/0.5 ML..........................................45
RELENZA DISKHALER................................................12
RELISTOR SUBCUTANEOUS SOLUTION...............43
REMICADE....................................................................43
RENAGEL......................................................................38
00016274, V22
Drug Name
Page
RENVELA ORAL POWDER IN PACKET 0.8
GRAM..........................................................................38
RENVELA ORAL POWDER IN PACKET 2.4
GRAM..........................................................................38
RENVELA ORAL TABLET............................................38
repaglinide oral tablet 0.5 mg.............................................41
repaglinide oral tablet 1 mg................................................41
repaglinide oral tablet 2 mg................................................41
REPATHA PUSHTRONEX...........................................35
REPATHA SURECLICK................................................35
REPATHA SYRINGE.....................................................35
RESCRIPTOR ORAL TABLET.....................................12
RESCRIPTOR ORAL TABLET, DISPERSIBLE...........12
RESTASIS.......................................................................49
RETROVIR INTRAVENOUS.......................................12
REVLIMID ORAL CAPSULE 10 MG...........................17
REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG,
25 MG..........................................................................17
REVLIMID ORAL CAPSULE 5 MG.............................17
REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG,
2 MG............................................................................29
REXULTI ORAL TABLET 3 MG, 4 MG......................29
REYATAZ ORAL CAPSULE 150 MG, 200 MG...........12
REYATAZ ORAL CAPSULE 300 MG...........................12
REYATAZ ORAL POWDER IN PACKET....................12
ribasphere oral capsule.......................................................12
ribasphere oral tablet 200 mg.............................................12
ribavirin oral capsule.........................................................12
ribavirin oral tablet 200 mg...............................................12
RIDAURA.......................................................................46
rifampin...........................................................................12
RIFATER........................................................................12
riluzole.............................................................................38
rimantadine......................................................................12
ringers intravenous.............................................................52
ringers irrigation................................................................38
RISPERDAL CONSTA INTRAMUSCULAR SYRINGE
12.5 MG/2 ML, 25 MG/2 ML.....................................29
37.5 MG/2 ML.............................................................29
50 MG/2 ML................................................................29
risperidone oral solution.....................................................29
risperidone oral tablet 0.25 mg...........................................29
risperidone oral tablet 0.5 mg.............................................29
risperidone oral tablet 1 mg................................................29
76
Drug Name
Page
risperidone oral tablet,disintegrating 0.25 mg......................29
risperidone oral tablet,disintegrating 0.5 mg........................29
risperidone oral tablet,disintegrating 1 mg...........................29
RITUXAN.......................................................................17
rivastigmine......................................................................29
rivastigmine tartrate..........................................................29
rizatriptan........................................................................29
ropinirole oral tablet..........................................................29
rosadan topical cream........................................................37
ROTARIX.......................................................................45
ROTATEQ VACCINE...................................................45
roweepra...........................................................................29
ROZEREM.....................................................................29
SABRIL ORAL POWDER IN PACKET........................29
SABRIL ORAL TABLET................................................29
SANDIMMUNE ORAL SOLUTION............................17
SANTYL..........................................................................37
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET
10 MG..........................................................................29
2.5 MG.........................................................................29
5 MG............................................................................29
SAVELLA ORAL TABLET 100 MG..............................46
SAVELLA ORAL TABLET 12.5 MG.............................46
SAVELLA ORAL TABLET 25 MG................................46
SAVELLA ORAL TABLET 50 MG................................46
SAVELLA ORAL TABLETS,DOSE PACK....................46
selegiline hcl......................................................................29
selenium sulfide topical lotion.............................................37
SELZENTRY..................................................................12
SENSIPAR ORAL TABLET 30 MG...............................41
SEREVENT DISKUS.....................................................50
SEROQUEL XR ORAL TABLET EXTENDED
RELEASE 24 HR 150 MG...........................................29
RELEASE 24 HR 200 MG...........................................29
00016274, V22
Drug Name
Page
RELEASE 24 HR 300 MG...........................................29
RELEASE 24 HR 400 MG...........................................30
RELEASE 24 HR 50 MG.............................................30
sertraline oral concentrate...................................................30
sertraline oral tablet 100 mg..............................................30
sertraline oral tablet 25 mg................................................30
sertraline oral tablet 50 mg................................................30
sharobel.............................................................................48
SIGNIFOR......................................................................17
sildenafil oral....................................................................50
silver sulfadiazine..............................................................37
SIMPONI........................................................................46
SIMULECT.....................................................................17
simvastatin........................................................................35
sirolimus...........................................................................17
SIRTURO.......................................................................12
sodium chloride 0.45 % intravenous parenteral solution......52
sodium chloride 0.45 % intravenous piggyback...................52
sodium chloride 0.9 % intravenous.....................................38
sodium chloride 3 %..........................................................52
sodium chloride 5 %..........................................................52
sodium chloride intravenous parenteral solution 2.5 meq/
ml..................................................................................52
sodium chloride intravenous parenteral solution 4 meq/
ml..................................................................................52
sodium chloride irrigation..................................................38
sodium fluoride oral tablet..................................................52
sodium fluoride oral tablet,chewable 1 mg fluoride (2.2
mg)................................................................................53
sodium polystyrene (sorb free)..............................................38
sodium polystyrene sulfonate oral powder.............................38
sodium polystyrene sulfonate oral suspension........................38
sodium polystyrene sulfonate rectal......................................38
SOLTAMOX...................................................................17
SOMATULINE DEPOT................................................17
SOMAVERT SUBCUTANEOUS RECON SOLN 10
MG, 15 MG, 20 MG....................................................41
SOMAVERT SUBCUTANEOUS RECON SOLN 25
MG, 30 MG.................................................................41
SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25
MG...............................................................................37
sorine oral tablet 120 mg, 160 mg, 80 mg...........................35
sorine oral tablet 240 mg...................................................35
77
Drug Name
Page
sotalol af............................................................................35
sotalol oral.........................................................................35
SOVALDI.......................................................................12
SPIRIVA RESPIMAT......................................................50
SPIRIVA WITH HANDIHALER...................................50
spironolacton-hydrochlorothiaz...........................................35
spironolactone....................................................................35
sprintec (28)......................................................................48
SPRITAM ORAL TABLET FOR SUSPENSION 1,000
MG, 250 MG, 500 MG................................................30
SPRITAM ORAL TABLET FOR SUSPENSION 750
MG...............................................................................30
SPRYCEL........................................................................18
sps (with sorbitol) oral........................................................38
sps (with sorbitol) rectal......................................................38
sronyx...............................................................................48
ssd.....................................................................................37
stavudine oral capsule 15 mg, 20 mg...................................12
stavudine oral capsule 30 mg, 40 mg..................................12
stavudine oral recon soln....................................................12
STIMATE.......................................................................41
STIVARGA.....................................................................18
STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25
MG, 40 MG.................................................................30
STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80
MG...............................................................................30
STREPTOMYCIN INTRAMUSCULAR.......................12
STRIBILD.......................................................................12
STROMECTOL.............................................................12
SUBSYS...........................................................................30
sucralfate oral tablet...........................................................43
sulfacetamide sodium (acne)...............................................37
sulfacetamide sodium ophthalmic drops...............................49
sulfacetamide-prednisolone.................................................49
sulfadiazine oral................................................................12
sulfamethoxazole-trimethoprim...........................................12
SULFAMYLON..............................................................37
sulfasalazine......................................................................43
sulindac oral......................................................................30
sumatriptan succinate oral..................................................30
sumatriptan succinate subcutaneous cartridge......................30
sumatriptan succinate subcutaneous pen injector 4 mg/0.5
ml, 6 mg/0.5 ml.............................................................30
sumatriptan succinate subcutaneous pen injector 6 mg/0.5
ml (auto-injector)...........................................................30
sumatriptan succinate subcutaneous solution........................30
00016274, V22
Drug Name
Page
sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml......30
SUPREP BOWEL PREP KIT.........................................43
SURMONTIL.................................................................30
SUSTIVA ORAL CAPSULE 200 MG............................12
SUSTIVA ORAL CAPSULE 50 MG..............................12
SUSTIVA ORAL TABLET.............................................12
SUTENT ORAL CAPSULE 12.5 MG............................18
SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50
MG...............................................................................18
syeda.................................................................................48
SYLATRON....................................................................45
SYMBICORT..................................................................50
SYMLINPEN 120...........................................................41
SYMLINPEN 60.............................................................41
SYNAGIS........................................................................12
SYNAREL.......................................................................41
SYNERCID.....................................................................12
SYNRIBO........................................................................18
SYNTHROID.................................................................41
SYPRINE.........................................................................38
TABLOID.......................................................................18
tacrolimus oral..................................................................18
TAFINLAR.....................................................................18
TAGRISSO ORAL TABLET 40 MG..............................18
TAGRISSO ORAL TABLET 80 MG..............................18
TAMIFLU.......................................................................12
tamoxifen..........................................................................18
tamsulosin.........................................................................51
TARCEVA ORAL TABLET 100 MG, 150 MG.............18
TARCEVA ORAL TABLET 25 MG...............................18
TARGRETIN ORAL......................................................18
TARGRETIN TOPICAL................................................18
tarina fe 1/20 (28)............................................................48
TASIGNA.......................................................................18
TAZORAC......................................................................37
taztia xt............................................................................35
TECENTRIQ..................................................................18
TECHNIVIE...................................................................12
TEFLARO INTRAVENOUS RECON SOLN 400
MG...............................................................................12
TEFLARO INTRAVENOUS RECON SOLN 600
MG...............................................................................12
telmisartan oral tablet 20 mg, 40 mg..................................35
telmisartan oral tablet 80 mg.............................................35
temazepam oral capsule 15 mg, 22.5 mg, 30 mg.................30
terazosin...........................................................................35
78
Drug Name
Page
terbinafine hcl oral............................................................12
terbutaline oral..................................................................50
terbutaline subcutaneous....................................................50
terconazole........................................................................48
TESTIM..........................................................................41
testosterone cypionate..........................................................41
testosterone enanthate.........................................................41
tetanus,diphtheria tox ped(pf).............................................45
TETANUS-DIPHTHERIA TOXOIDS-TD..................45
tetrabenazine oral tablet 12.5 mg.......................................30
tetrabenazine oral tablet 25 mg..........................................30
tetracycline........................................................................12
THALOMID ORAL CAPSULE 100 MG, 50 MG.........18
THALOMID ORAL CAPSULE 150 MG, 200 MG.......18
theophylline oral tablet extended release 12 hr.....................50
theophylline oral tablet extended release 24 hr.....................50
thermazene........................................................................37
thioridazine......................................................................30
thiotepa.............................................................................18
thiothixene........................................................................30
THYMOGLOBULIN.....................................................45
tiagabine...........................................................................30
TICE BCG......................................................................45
TIKOSYN.......................................................................35
timolol maleate ophthalmic................................................49
timolol maleate oral...........................................................35
TIVICAY ORAL TABLET 10 MG.................................12
TIVICAY ORAL TABLET 25 MG, 50 MG...................12
tizanidine oral tablet.........................................................30
TOBI...............................................................................13
tobramycin........................................................................49
tobramycin sulfate injection recon soln................................13
tobramycin sulfate injection solution...................................13
tobramycin-dexamethasone opthalmic suspension.................49
tolcapone...........................................................................30
tolmetin............................................................................30
tolterodine oral capsule,extended release 24hr......................51
tolterodine oral tablet.........................................................51
topiramate oral capsule, sprinkle.........................................30
topiramate oral tablet 100 mg............................................30
topiramate oral tablet 200 mg............................................30
topiramate oral tablet 25 mg..............................................30
topiramate oral tablet 50 mg..............................................30
toposar..............................................................................18
topotecan intravenous recon soln.........................................18
TOPOTECAN INTRAVENOUS SOLUTION.............18
00016274, V22
Drug Name
Page
TORISEL........................................................................18
torsemide oral....................................................................35
TOUJEO SOLOSTAR....................................................41
TOVIAZ..........................................................................51
tpn electrolytes...................................................................53
TRACLEER.....................................................................50
tramadol oral tablet...........................................................30
tramadol-acetaminophen....................................................30
trandolapril.......................................................................35
tranexamic acid intravenous...............................................35
tranexamic acid oral..........................................................48
TRANSDERM-SCOP.....................................................43
tranylcypromine.................................................................30
travasol 10 %....................................................................53
TRAVATAN Z................................................................49
travoprost (benzalkonium).................................................49
trazodone..........................................................................30
TREANDA INTRAVENOUS RECON SOLN..............18
TRECATOR...................................................................13
TRELSTAR DEPOT.......................................................18
TRELSTAR INTRAMUSCULAR SUSPENSION FOR
RECONSTITUTION..................................................18
TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/
2 ML, 3.75 MG/2 ML..................................................18
TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/
2 ML.............................................................................18
TRELSTAR LA...............................................................18
tretinoin (chemotherapy)....................................................18
tretinoin topical cream.......................................................37
tretinoin topical gel 0.01 %, 0.025 %................................37
trexall...............................................................................18
tri-estarylla........................................................................48
tri-linyah..........................................................................48
tri-previfem (28)...............................................................48
tri-sprintec (28).................................................................48
triamcinolone acetonide dental...........................................39
triamcinolone acetonide injection suspension 10 mg/ml........41
triamcinolone acetonide injection suspension 40 mg/ml........41
triamcinolone acetonide topical cream.................................37
triamcinolone acetonide topical lotion.................................37
triamcinolone acetonide topical ointment 0.025 %, 0.1 %,
0.5 %............................................................................37
triamterene-hydrochlorothiazid...........................................35
trianex..............................................................................37
triderm topical cream.........................................................37
trifluoperazine...................................................................30
79
Drug Name
Page
trifluridine........................................................................49
trihexyphenidyl..................................................................30
TRILEPTAL ORAL SUSPENSION...............................30
trimethoprim.....................................................................13
trinessa (28)......................................................................48
TRINTELLIX ORAL TABLET 10 MG..........................30
TRINTELLIX ORAL TABLET 20 MG..........................30
TRINTELLIX ORAL TABLET 5 MG............................30
TRISENOX.....................................................................18
TRIUMEQ......................................................................13
trivora (28).......................................................................48
TRIZIVIR.......................................................................13
TROPHAMINE 10 %....................................................53
TROPHAMINE 6%.......................................................53
TRULICITY....................................................................41
TRUMENBA..................................................................45
TRUVADA ORAL TABLET 100-150 MG, 133-200
MG, 167-250 MG........................................................13
TRUVADA ORAL TABLET 200-300 MG....................13
TUDORZA PRESSAIR INHALATION AEROSOL
POWDR BREATH ACTIVATED 400 MCG/
ACTUATION..............................................................50
TUDORZA PRESSAIR INHALATION AEROSOL
POWDR BREATH ACTIVATED 400 MCG/
ACTUATION (30 ACTUAT).....................................50
TWINRIX (PF) INTRAMUSCULAR
SUSPENSION.............................................................45
TWINRIX (PF) INTRAMUSCULAR SYRINGE...........45
TYBOST.........................................................................13
TYGACIL........................................................................13
TYKERB..........................................................................18
TYPHIM VI INTRAMUSCULAR SOLUTION............45
TYPHIM VI INTRAMUSCULAR SYRINGE................45
TYSABRI.........................................................................30
TYZEKA.........................................................................13
tyzine nasal drops 0.05 %..................................................39
UNITHROID ORAL TABLET 100 MCG, 112 MCG,
125 MCG, 150 MCG, 175 MCG, 200 MCG, 25
MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG........41
UNITUXIN....................................................................18
ursodiol.............................................................................43
UVADEX........................................................................37
VAGIFEM.......................................................................48
valacyclovir.......................................................................13
VALCHLOR...................................................................37
valganciclovir oral tablet....................................................13
00016274, V22
Drug Name
Page
valproate sodium...............................................................30
valproic acid......................................................................30
valproic acid (as sodium salt) oral solution 250 mg/5 ml......30
valproic acid (as sodium salt) oral solution 250 mg/5 ml (5
ml), 500 mg/10 ml (10 ml).............................................31
valsartan oral tablet 160 mg..............................................35
valsartan oral tablet 320 mg..............................................35
valsartan oral tablet 40 mg, 80 mg.....................................35
valsartan-hydrochlorothiazide.............................................35
vancomycin in 0.9% sodium cl intravenous piggyback.........13
vancomycin in dextrose 5 % intravenous piggyback 1 gram/
200 ml...........................................................................13
vancomycin in dextrose 5 % intravenous piggyback 500 mg/
100 ml, 750 mg/150 ml.................................................13
vancomycin intravenous recon soln 1,000 mg, 10 gram, 500
mg, 750 mg....................................................................13
vancomycin intravenous recon soln 5 gram..........................13
vancomycin oral capsule 125 mg.........................................13
vancomycin oral capsule 250 mg.........................................13
VAQTA (PF)...................................................................45
VARIVAX (PF)................................................................45
VARIZIG........................................................................45
VECAMYL......................................................................35
VECTIBIX......................................................................18
VECTICAL.....................................................................37
VELCADE.......................................................................18
velivet triphasic regimen (28).............................................48
VENCLEXTA ORAL TABLET 10 MG.........................18
VENCLEXTA ORAL TABLET 100 MG.......................18
VENCLEXTA ORAL TABLET 50 MG.........................18
VENCLEXTA STARTING PACK.................................18
venlafaxine oral capsule,extended release 24hr 150 mg.........31
venlafaxine oral capsule,extended release 24hr 37.5 mg........31
venlafaxine oral capsule,extended release 24hr 75 mg...........31
venlafaxine oral tablet 100 mg...........................................31
venlafaxine oral tablet 25 mg.............................................31
venlafaxine oral tablet 37.5 mg..........................................31
venlafaxine oral tablet extended release 24hr 150 mg...........31
venlafaxine oral tablet extended release 24hr 37.5 mg..........31
venlafaxine oral tablet extended release 24hr 75 mg.............31
VENTAVIS.....................................................................50
VENTOLIN HFA...........................................................50
verapamil intravenous solution...........................................35
verapamil oral capsule, 24 hr er pellet ct.............................35
80
Drug Name
Page
verapamil oral capsule,ext rel. pellets 24 hr..........................35
verapamil oral tablet..........................................................35
verapamil oral tablet extended release 120 mg (24
hours)............................................................................35
verapamil oral tablet extended release 120 mg, 180 mg, 240
mg.................................................................................35
VERSACLOZ..................................................................31
VESICARE......................................................................51
vicodin..............................................................................31
vicodin es..........................................................................31
vicodin hp.........................................................................31
VICTOZA 2-PAK...........................................................41
VICTOZA 3-PAK...........................................................41
VIDEX 2 GRAM PEDIATRIC.......................................13
VIDEX 4 GRAM PEDIATRIC.......................................13
VIEKIRA PAK.................................................................13
VIEKIRA XR...................................................................13
VIGAMOX......................................................................49
VIIBRYD ORAL TABLET 10 MG.................................31
VIMPAT INTRAVENOUS............................................31
VIMPAT ORAL SOLUTION........................................31
VIMPAT ORAL TABLET 100 MG................................31
VIMPAT ORAL TABLET 50 MG..................................31
vinblastine intravenous solution..........................................18
vincasar pfs intravenous solution 1 mg/ml...........................18
vincasar pfs intravenous solution 2 mg/2 ml........................18
vincristine.........................................................................18
vinorelbine........................................................................18
viorele (28).......................................................................48
VIRACEPT ORAL TABLET 250 MG............................13
VIRACEPT ORAL TABLET 625 MG............................13
VIRAMUNE XR ORAL TABLET EXTENDED
RELEASE 24 HR 100 MG...........................................13
VIRAZOLE.....................................................................13
VIREAD ORAL POWDER............................................13
VIREAD ORAL TABLET...............................................13
VITEKTA........................................................................13
VIVELLE-DOT..............................................................48
VOLTAREN TOPICAL GEL 1 %.................................31
voriconazole intravenous....................................................13
voriconazole oral suspension for reconstitution.....................13
voriconazole oral tablet 200 mg..........................................13
00016274, V22
Drug Name
Page
voriconazole oral tablet 50 mg............................................13
vospire er...........................................................................50
VOTRIENT....................................................................18
VPRIV.............................................................................42
VRAYLAR ORAL CAPSULE 1.5 MG............................31
VRAYLAR ORAL CAPSULE 3 MG, 4.5 MG, 6
MG...............................................................................31
VRAYLAR ORAL CAPSULE,DOSE PACK...................31
vyfemla (28)......................................................................48
warfarin...........................................................................35
water for irrigation, sterile..................................................38
WELCHOL.....................................................................35
XALKORI.......................................................................18
XARELTO ORAL TABLET 10 MG, 20 MG.................35
XARELTO ORAL TABLET 15 MG...............................35
XARELTO ORAL TABLETS,DOSE PACK...................35
XENAZINE ORAL TABLET 12.5 MG..........................31
XENAZINE ORAL TABLET 25 MG.............................31
XGEVA...........................................................................18
XIFAXAN ORAL TABLET 550 MG..............................13
xodol 10/300.....................................................................31
xodol 5/300.......................................................................31
xodol 7.5/300....................................................................31
XOLAIR..........................................................................50
XTANDI.........................................................................18
XYREM...........................................................................31
YERVOY.........................................................................19
YF-VAX (PF)...................................................................45
YONDELIS.....................................................................19
zafirlukast.........................................................................50
zaleplon oral capsule 10 mg................................................31
zaleplon oral capsule 5 mg..................................................31
ZALTRAP.......................................................................19
ZANOSAR......................................................................19
zarah................................................................................48
ZAVESCA.......................................................................42
ZELBORAF.....................................................................19
ZEMAIRA.......................................................................38
zenchent (28)....................................................................48
zenzedi oral tablet 10 mg...................................................31
81
Drug Name
Page
zenzedi oral tablet 5 mg.....................................................31
ZEPATIER......................................................................13
ZETIA.............................................................................35
ZIAGEN ORAL SOLUTION.........................................13
zidovudine oral capsule......................................................13
zidovudine oral syrup.........................................................13
zidovudine oral tablet........................................................13
ziprasidone hcl oral capsule 20 mg......................................31
ziprasidone hcl oral capsule 40 mg......................................31
ziprasidone hcl oral capsule 60 mg, 80 mg...........................31
ZIRGAN.........................................................................49
zoledronic acid intravenous recon soln 4 mg........................42
zoledronic acid intravenous solution 4 mg/5 ml...................42
ZOLINZA.......................................................................19
zolmitriptan......................................................................32
ZOMETA INTRAVENOUS SOLUTION 4 MG/100
ML................................................................................42
ZOMIG NASAL.............................................................32
zonisamide........................................................................32
ZORBTIVE.....................................................................45
ZORTRESS ORAL TABLET 0.25 MG..........................19
ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG...........19
ZOSTAVAX (PF)............................................................45
ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS
PIGGYBACK 2.25 GRAM/50 ML..............................13
ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS
PIGGYBACK 3.375 GRAM/50 ML, 4.5 GRAM/100
ML..........................................................................13–14
zovia 1/35e (28)................................................................48
zovia 1/50e (28)................................................................48
ZYDELIG........................................................................19
ZYKADIA.......................................................................19
ZYPREXA RELPREVV...................................................32
ZYTIGA..........................................................................19
ZYVOX INTRAVENOUS PARENTERAL SOLUTION
200 MG/100 ML..........................................................14
ZYVOX INTRAVENOUS PARENTERAL SOLUTION
600 MG/300 ML..........................................................14
ZYVOX ORAL SUSPENSION FOR
RECONSTITUTION..................................................14
00016274, V22
CareMore Health Plan is an HMO / HMO SNP plan with a Medicare contract. Enrollment in CareMore Health
Plan depends on contract renewal.
The Formulary may change at any time. You will receive notice when necessary.
This information is available for free in other languages. Please contact our Member Services at 1-800-499-2793
or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October
1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30.
Esta información esta disponible gratis en otros idiomas. Por favor comuníquese con el
departamento de servicios al cliente al 1-800-499-2793, TTY deben llamar al 711, de 8 a.m. a 8 p.m., los 7 días
de la semana (excepto el Día de Acción de Gracias y Navidad) desde el 1 de octubre hasta el 14 de febrero, y de
lunes a viernes (excepto los días feriados) desde el 15 de febrero hasta el 30 de septiembre.
This formulary was updated on 10/2016. For more recent information or other questions, please contact Member
Services, at 1-800-499-2793, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and
Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15
through September 30, or visit www.caremore.com.
Los Angeles & Orange Counties, CA
00016274, V22

2016 Formulary (List of Covered Drugs)

Transcription

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