2016 AlohaCare Advantage Plus Formulary

Transcription

ALOHACARE ADVANTAGE PLUS (HMO SNP) PLAN
2016 FORMULARY
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT
THE DRUGS WE COVER IN THIS PLAN
Formulary ID 00016449 Version 27
This formulary was updated on September 1, 2016. For more recent information or other questions,
please contact AlohaCare Advantage Plus (HMO SNP) Member Services at 1-866-973-6395, or, for
TTY/TDD users, 1-877-447-5990, 8 a.m. to 8 p.m., 7 days a week, or visit www.AlohaCare.org.
AlohaCare Advantage Plus is an HMO plan with a Medicare contract and a contract with the Hawaii
Medicaid Program. Enrollment in AlohaCare Advantage Plus depends on contract renewal. The
Formulary may change at any time. You will receive notice when necessary.
H5969_108505_1 Accepted
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 AlohaCare. When it refers
to “plan” or “our plan,” it means AlohaCare
Advantage Plus (HMO SNP).
This document includes a list of the drugs
(formulary) for our plan which is current as of
September 1, 2016. For an updated formulary,
please
contact us. Our contact information, along with
the date we last updated the formulary, appears on
the front and back cover pages.
You must generally use network pharmacies to
use your prescription drug benefit. Benefits,
formulary, pharmacy network, and/or copayments/
coinsurance may change on January 1, 2017, and
from time to time during the year.
What is the AlohaCare Advantage Plus
Formulary?
A formulary is a list of covered drugs selected by
AlohaCare Advantage Plus 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. AlohaCare
Advantage Plus will generally cover the drugs
listed in our formulary as long as the drug is
medically necessary, the prescription is filled at an
AlohaCare Advantage Plus network pharmacy,
and other plan rules are followed. For more
information on how to fill your prescriptions,
please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2016
formulary that was covered at the beginning of the
year, we will not discontinue or reduce coverage
of the drug during the 2016 coverage year except
when a new, less expensive generic drug becomes
available or when new adverse information about
the safety or effectiveness of a drug is released.
Other types of formulary changes, such as
removing a drug from our formulary, will not
affect members who are currently taking the drug.
It will remain available at the same cost-sharing
for those members taking it for the remainder of
the coverage year. We feel it is important that you
have continued access for the remainder of the
coverage year to the formulary drugs that were
available when you chose our plan, except for
cases in which you can save additional money or
we can ensure your safety.
If we remove drugs from our formulary, or add
prior authorization, quantity limits and/or step
therapy restrictions on a drug, we must notify
affected members of the change at least 60 days
before the change becomes effective, or at the
time the member requests a refill of the drug, at
which time the member will receive a 60-day
supply of the drug. If the Food and Drug
Administration deems a drug on our formulary to
be unsafe or the drug’s manufacturer removes the
drug from the market, we will immediately
remove the drug from our formulary and provide
notice to members who take the drug. The
enclosed formulary is current as of September 1,
2016. To get updated information about the drugs
covered by AlohaCare Advantage Plus, please
contact us. Our contact information appears on the
front and back cover pages.
If we make any mid-year non-maintenance
changes to the AlohaCare Advantage Plus
formulary, we will mail you a copy of the
formulary changes via errata sheets to ensure that
you have a complete and updated formulary.
How do I use the Formulary?
There are two ways to find your drug within the
formulary:
Medical Condition
The formulary begins on page 1. The drugs in
this formulary are grouped into categories
depending on the type of medical conditions
that they are used to treat. For example, drugs
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Page i
Advantage Plus will cover. For example,
AlohaCare Advantage Plus provides 60
capsules per prescription for Celebrex.
This may be in addition to a standard onemonth or three-month supply.
used to treat a heart condition are listed under
the category, “Cardiovascular, Hypertension/
Lipids”. If you know what your drug is used
for, look for the category name in the list that
begins on page 1. Then look under the
category name for your drug.
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 118. 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?
AlohaCare Advantage Plus covers both brand
name drugs and generic drugs. A generic drug is
approved by the FDA as having the same active
ingredient as the brand name drug. Generally,
generic drugs cost less than brand name drugs.
Are there any restrictions on my
coverage?
Some covered drugs may have additional
requirements or limits on coverage. These
requirements and limits may include:
•
•
Prior Authorization: AlohaCare
Advantage Plus requires you or your
physician to get prior authorization for
certain drugs. This means that you will
need to get approval from AlohaCare
Advantage Plus before you fill your
prescriptions. If you don’t get approval,
AlohaCare Advantage Plus may not cover
the drug.
Quantity Limits: For certain drugs,
AlohaCare Advantage Plus limits the
amount of the drug that AlohaCare
•
Step Therapy: In some cases, AlohaCare
Advantage Plus requires you to first try
certain drugs to treat your medical
condition before we will cover another
drug for that condition. For example, if
Drug A and Drug B both treat your
medical condition, AlohaCare Advantage
Plus may not cover Drug B unless you try
Drug A first. If Drug A does not work for
you, AlohaCare Advantage Plus will then
cover Drug B.
You can find out if your drug has any additional
requirements or limits by looking in the formulary
that begins on page 1. You can also get more
information about the restrictions applied to
specific covered drugs by visiting our Web site.
We have posted on line documents that explains
our prior authorization and step therapy
restrictions. You may also ask us to send you a
copy. Our contact information, along with the date
we last updated the formulary, appears on the
front and back cover pages.
You can ask AlohaCare Advantage Plus 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 AlohaCare Advantage
Plus formulary?” on page iii
iv for information about
how to request an exception.
What are over-the counter
counter (OTC)
(OTC)
drugs?
OTC drugs are non-prescription drugs that are not
normally covered by a Medicare Prescription Drug
Plan. AlohaCare Advantage Plus pays for certain
OTC drugs: Prilosec OTC, Prevacid 24Hr,
Allegra Allergy OTC, loratadine OTC, and
cetirizine. AlohaCare Advantage Plus will provide
iii
Page ii
these OTC drugs at no cost to you. The cost to
AlohaCare Advantage Plus of these OTC drugs
will not count toward your total Part D drug costs
(that is, the amount you pay does not count for the
coverage gap.)
What if my drug is not on the
Formulary?
If your drug is not included in this formulary (list
of covered drugs), you should first contact
Member Services and ask if your drug is covered.
If you learn that AlohaCare Advantage Plus does
not cover your drug, you have two options:
•
You can ask Member Services for a list of
similar drugs that are covered by
AlohaCare Advantage Plus. When you
receive the list, show it to your doctor and
ask him or her to prescribe a similar drug
that is covered by AlohaCare Advantage
Plus.
•
You can ask AlohaCare Advantage Plus to
make an exception and cover your drug.
See below for information about how to
request an exception.
How do I request an exception to the
AlohaCare Advantage Plus Formulary?
You can ask AlohaCare Advantage Plus to make
an exception to our coverage rules. There are
several types of exceptions that you can ask us to
make.
• You can ask us to cover a drug even if it is
not on our formulary. If approved, this
drug will be covered at a pre-determined
cost-sharing level, and you would not be
able to ask us to provide the drug at a
lower cost-sharing level.
•
You can ask us to waive coverage
restrictions or limits on your drug. For
example, for certain drugs, AlohaCare
Advantage Plus 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, AlohaCare Advantage Plus will only
approve your request for an exception if the
alternative drugs included on the plan’s formulary,
or additional utilization restrictions would not be
as effective in treating your condition and/or
would cause you to have adverse medical effects.
You should contact us to ask us for an initial
coverage decision for a formulary, or utilization
restriction exception. When you request a
formulary or utilization restriction exception
you should submit a statement from your
prescriber or physician supporting your
request. Generally, we must make our decision
within 72 hours of getting your prescriber’s
supporting statement. You can request an
expedited (fast) exception if you or your doctor
believe that your health could be seriously harmed
by waiting up to 72 hours for a decision. If your
request to expedite is granted, we must give you a
decision no later than 24 hours after we get a
supporting statement from your doctor or other
prescriber.
What do I do before I can talk to my
doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan you
may be taking drugs that are not on our formulary.
Or, you may be taking a drug that is on our
formulary but your ability to get it is limited. For
example, you may need a prior authorization from
us before you can fill your prescription. You
should talk to your doctor to decide if you should
switch to an appropriate drug that we cover or
request a formulary exception so that we will
cover the drug you take. While you talk to your
doctor to determine the right course of action for
you, we may cover your drug in certain cases
during the first 90 days you are a member of our
plan.
iv
Page iii
For each of your drugs that is not on our formulary
• if your hospice status reve
your
to get your drugs is• limited,
For each of your drugs thatoris ifnot
on ability
our formulary
Medicare
Part A and B be
if yourwe
hospice status reverts
to standard
will
cover
a
temporary
30-day
supply
(unless
you
or if your ability to get your drugs is limited, we
Medicare Part A and B benefits; or,
havesupply
a prescription
written for fewer days) when
will cover a temporary 30-day
(unless you
• if you are discharged from
go to adays)
network
your
first
have a prescription written you
for fewer
whenpharmacy. After
with a drug regim
• if you are discharged from hospital
a psychiatric
30-day
supply,
will not pay for these
drugs, with a drug regimen
you go to a network pharmacy.
After
yourwe
first
individualized.
hospital
that is highly
if you
have
been a member of the individualized.
plan less
30-day supply, we will not even
pay for
these
drugs,
than 90ofdays.
even if you have been a member
the plan less
For more information
than 90 days.
For more informationFor more detailed information abo
If you are a resident of a long-term care facility,
AlohaCare
Advantage Plus prescr
For more detailed information
about your
we will allow
you to refill your prescription until
If you are a resident of a long-term
care facility,
please
AlohaCare Advantage Pluscoverage,
prescription
drugreview your Evi
we have
provideduntil
you with a 91-day transition
we will allow you to refill your
prescription
Coverage
andofother plan material
coverage, please review your
Evidence
consistent
we have provided you withsupply,
a 91-day
transitionwith dispensing increment,
Coverage and other plan materials.
supply, consistent with dispensing
increment,
(unless you
have a prescription written for fewer
If you have questions about Aloh
days).written
We will
(unless you have a prescription
for cover
fewer more than one refill of these
If you have questions aboutPlus,
AlohaCare
Advantage
please contact
us. Our conta
days). We will cover moredrugs
than one
refill
of 90
these
for the
first
days you are a member of
with
the date we last update
Plus, please contact us. Ouralong
contact
information,
our are
plan.
If you need
drugs for the first 90 days you
a member
of a drug that is not on our
along with the date we last appears
updated on
thethe
formulary,
front and back cov
our plan. If you need a drugformulary
that is notoronif our
your ability to get your drugs is
appears on the front and back cover pages.
formulary or if your abilitylimited,
to get your
drugsareis past the first 90 days of
but you
If you have general questions abo
limited, but you are past themembership
first 90 daysinofour plan, we will cover a 31-day
If you have general questions
about Medicare
prescription
drug coverage, please
membership in our plan, weemergency
will coversupply
a 31-day
of that drug (unless you have a
prescription drug coverage,atplease
call Medicare (1-800-633
1-800-MEDICARE
emergency supply of that drug
(unless you
have adays) while you pursue a
prescription
for fewer
at 1-800-MEDICARE (1-800-633-4227)
hoursTTY/TDD
a day/7 days a24
week.
prescription for fewer days)formulary
while youexception.
pursue a
a day/7 days a week. TTY/TDD
users shouldOr,
callvisit
1-877-486-2048.
formulary exception.
1-877-486-2048. Or, visit http://www.medicare.gov.
Transition policy for levelhttp://www.medicare.gov.
of care
Transition policy for level
of care
changes
AlohaCare Advantage Plus
changes
Upon notification, AlohaCare Advantage
Plus
will
AlohaCare Advantage Plus’ Formulary
The formulary that begins on pag
Upon notification, AlohaCare
Advantage
Plus will
cover
up to a 60-day
supply of aThe
prescription
formularydrug
that begins on
page 1 information
provides about the dr
coverage
cover up to a 60-day supply(unless
of a prescription
you have adrug
prescription coverage
written forinformation
fewer
aboutAlohaCare
the drugs covered
by Plus. If yo
Advantage
(unless you have a prescription
for fewer
days)written
for current
members who AlohaCare
have a levelAdvantage
of
Plus.finding
If youyour
havedrug
trouble
in the list, turn
days) for current members care
who change.
have a level
of of care change includes the
A level
finding your drug in the list,begins
turn toonthe
Index
that page numb
page
<index
care change. A level of care
change
includes
the
following situations:
begins on page 118.
100.
following situations:
• if you enter a long-term care facility from a
The first column of the chart lists
• if you enter a long-term care
facilityorfrom
hospital
othera setting;The first column of the chart
lists name
the drug
name.
Brand
drugs
are capitalized
hospital or other setting;
Brand name drugs are capitalized
(e.g.,
ACTOS)
and generic drugs are listed in low
• if you leave a long-termand
caregeneric
facilitydrugs
to are listed(e.g.,
in lower-case
italics
pioglitazone).
• if you leave a long-term care
facility
return
to atocommunity/home
(e.g., setting;
pioglitazone).
return to a community/home setting;
The information in the Requireme
• if you are discharged from
hospital to ain the Requirements/Limits
Thea information
column tells you if AlohaCare Ad
• if you are discharged from community/home
a hospital to a
setting;
column tells you if AlohaCare
Plus has for cove
any Advantage
special requirements
community/home setting;
any special requirements for
coverage of your
drug.
• if you end your skilled nursing
drug. facility stay
• if you end your skilled nursing
facility
stay
covered
under
Medicare Part A and need
BvsD = Part B versus Part D: Thi
covered under Medicare Part
A and to
need
to revert
coverage under
AlohaCare
BvsD
= Part B versus Part D:
This drug
be
covered
undermay
Medicare
Part B or
to revert to coverage underAdvantage
AlohaCarePlus;
covered under Medicare Part
B or Parton
D,the circumstances
depending
Advantage Plus;
depending on the circumstances
v
Page iv
MO = Mail Order service available: This service
helps you save money on your prescription drug
costs and your drugs will be conveniently mailed
to your home.
PA = Prior Authorization
QL = Quantity Limit
LA = Limited Access: This prescription may be
available only at certain pharmacies.
For more information consult your Provider &
Pharmacy Directory or call Member Services at 1866-973-6395, 8 a.m. to 8 p.m., 7 days a week.
TTY users should call 1-877-447-5990.
ST = Step Therapy
LA = Limited Access: This prescription may be
available only at certain pharmacies.
vi
Page v
LEGEND
SYMBOL
NAME
DESCRIPTION
Quantity Limit
For certain drugs, AlohaCare Advantage Plus limits the
amount of drug that AlohaCare Advantage Plus will
cover.
Prior Authorization
AlohaCare Advantage Plus requires you or your
physician to get prior authorization for certain drugs.
This means that you will need to get approval from
AlohaCare Advantage Plus before you fill your
prescriptions. If you don't get approval, AlohaCare
Advantage Plus may not cover the drug.
ST
Step Therapy
In some cases, AlohaCare Advantage Plus requires
you to first try certain drugs to treat your medical
condition before we will cover another drug for that
condition.
LA
Limited Access
This drug may be available only at certain pharmacies.
PA B vs D
Prior Authorization- Part B
vs. Part D
Medicare Part B vs. Part D determination required.
QL
PA
1
2016 AlohaCare Advantage Plus Formulary (HMO SNP) (List of
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
ABELCET 100 MG/20 ML VIAL
PA B vs D
AMBISOME 50 MG VIAL
PA B vs D
amphotericin b 50 mg vial
PA B vs D
ANCOBON (250 MG CAPSULE, 500 MG CAPSULE)
CANCIDAS (50 MG VIAL, 70 MG VIAL)
PA B vs D
clotrimazole 10 mg troche
ERAXIS (WATER DILUENT) (DIL) 50 MG VIAL, DIL)
100 MG VIAL)
PA B vs D
fluconazole (10 mg/ml susp recon, 40 mg/ml susp
recon, 50 mg tablet, 100 mg tablet, 200 mg tablet)
fluconazole 150 mg tablet
QL (2 PER 30 DAYS)
fluconazole in dextrose,iso-os 200mg/0.1l piggyback
fluconazole in dextrose,iso-os 400mg/0.2l piggyback
PA B vs D
fluconazole in sodium chloride, iso-osmotic (200mg/0.1l
pggybk btl, 200mg/0.1l piggyback)
flucytosine (250 mg capsule, 500 mg capsule)
GRIS-PEG (125 MG TABLET, 250 MG TABLET)
griseofulvin ultramicrosize (125 mg tablet, 250 mg
tablet)
griseofulvin, microsize (125 mg/5ml oral susp, 500 mg
tablet)
griseofulvin,microsize 125 mg/5ml oral susp
itraconazole 100 mg capsule
QL (120 PER 30 DAYS)
ketoconazole 200 mg tablet
MYCAMINE (50 MG VIAL, 100 MG VIAL)
PA B vs D
NOXAFIL 40 MG/ML SUSPENSION
nystatin (50mm unit powder(ea), 150mm unit
powder(ea), 500mm unit powder(ea), 500k unit tablet,
100000/ml oral susp)
You can find information on what the symbols and abbreviations
on this table mean by going to page 1.
2
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ONMEL 200 MG TABLET
SPORANOX 10 MG/ML SOLUTION
terbinafine hcl 250 mg tablet
VFEND (40 MG/ML SUSPENSION, 50 MG TABLET,
200 MG TABLET)
VFEND IV 200 MG VIAL
PA B vs D
voriconazole (50 mg tablet, 200 mg tablet, 200 mg/5ml
susp recon)
voriconazole 200 mg vial
PA B vs D
ANTIVIRALS
abacavir sulfate 300 mg tablet
abacavir/lamivudine/zidovudine 150-300mg tablet
acyclovir (5 % oint. (g), 200 mg capsule, 200 mg/5ml
oral susp, 400 mg tablet, 800 mg tablet)
acyclovir sodium (50 mg/ml vial, 500 mg vial, 1000 mg
vial)
adefovir dipivoxil 10 mg tablet
amantadine hcl (50 mg/5 ml syrup, 50 mg/5 ml solution,
100 mg tablet, 100 mg capsule)
APTIVUS (100 MG/ML SOLUTION, 250 MG
CAPSULE)
ATRIPLA TABLET
BARACLUDE (0.05 MG/ML SOLUTION, 0.5 MG
TABLET, 1 MG TABLET)
cidofovir 75 mg/ml vial
COMBIVIR TABLET
COMPLERA TABLET
CRIXIVAN (200 MG CAPSULE, 400 MG CAPSULE)
CYTOVENE 500 MG VIAL
PA B vs D
DESCOVY 200-25 MG TABLET
didanosine (125 mg capsule dr, 200 mg capsule dr, 250
mg capsule dr, 400 mg capsule dr)
3
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
EDURANT 25 MG TABLET
EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE)
entecavir (0.5 mg tablet, 1 mg tablet)
EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET,
300 MG TABLET)
EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET)
EPZICOM TABLET
EVOTAZ 300 MG-150 MG TABLET
famciclovir (125 mg tablet, 250 mg tablet, 500 mg
tablet)
foscarnet sodium 24 mg/ml infus. btl
FUZEON (90 MG VIAL, CONVENIENCE KIT)
ganciclovir sodium 500 mg vial
PA B vs D
GENVOYA TABLET
HEPSERA 10 MG TABLET
QL (30 PER 30 DAYS)
INTELENCE (25 MG TABLET, 100 MG TABLET, 200
MG TABLET)
INVIRASE (200 MG CAPSULE, 500 MG TABLET)
ISENTRESS (25 MG TABLET CHEW, 100 MG
POWDER PACKET, 100 MG TABLET CHEW, 400 MG
TABLET)
KALETRA (100-25 MG TABLET, 200-50 MG TABLET,
400-100/5 ML ORAL SOLU)
lamivudine (10 mg/ml solution, 100 mg tablet, 150 mg
tablet, 300 mg tablet)
lamivudine/zidovudine 150-300mg tablet
LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET)
MODERIBA (200 MG TABLET, 400-400 MG
DOSEPACK, 600-600 MG DOSEPACK)
nevirapine (50 mg/5 ml oral susp, 100 mg tab er 24h,
200 mg tablet, 400 mg tab er 24h)
NORVIR (80 MG/ML SOLUTION, 100 MG TABLET,
100 MG SOFTGEL CAP)
4
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ODEFSEY TABLET
OLYSIO 150 MG CAPSULE
PA
PREZCOBIX 800 MG-150 MG TABLET
PREZISTA (75 MG TABLET, 100 MG/ML
SUSPENSION, 150 MG TABLET, 600 MG TABLET,
800 MG TABLET)
RAPIVAB 200 MG/20 ML VIAL
REBETOL 40 MG/ML SOLUTION
RELENZA 5 MG DISKHALER
RESCRIPTOR (100 MG TABLET, 200 MG TABLET)
RETROVIR (200 MG/20 ML VIAL, IV INFUSION VIAL)
REYATAZ (50 MG POWDER PACKET, 150 MG
CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE)
RIBAPAK (400-600 MG, 400-400 MG, 600-600 MG)
RIBASPHERE (200 MG TABLET, 200 MG CAPSULE,
400 MG TABLET, 600 MG TABLET)
RIBASPHERE RIBAPAK (400-400 MG, 600-600 MG,
600-400 MG)
RIBATAB 600-600 MG DOSEPACK
ribavirin (200 mg capsule, 200 mg tablet)
rimantadine hcl 100 mg tablet
SELZENTRY (150 MG TABLET, 300 MG TABLET)
SOVALDI 400 MG TABLET
PA
stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg
capsule, 30 mg capsule, 40 mg capsule)
STRIBILD TABLET
SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600
MG TABLET)
SYNAGIS (50 MG/0.5 ML VIAL, 100 MG/1 ML VIAL)
TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE,
45 MG CAPSULE, 75 MG CAPSULE)
TECHNIVIE DOSE PACK
5
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
TIVICAY (10 MG TABLET, 25 MG TABLET, 50 MG
TABLET)
TRIUMEQ TABLET
TRIZIVIR TABLET
TRUVADA (100 MG-150 MG TABLET, 133 MG-200
MG TABLET, 167 MG-250 MG TABLET, 200 MG-300
MG TABLET)
TYZEKA 600 MG TABLET
valacyclovir hcl (500 mg tablet, 1000 mg tablet)
QL (60 PER 30 DAYS)
VALCYTE 450 MG TABLET
valganciclovir hcl 450 mg tablet
VALTREX (1 GM, 500 MG)
QL (60 PER 30 DAYS)
VIDEX (2 GM SOLN, 4 GM SOLN)
VIDEX EC 125 MG CAPSULE
VIEKIRA PAK
PA
VIRACEPT (250 MG TABLET, 625 MG TABLET)
VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET)
VIRAMUNE XR 400 MG TABLET
VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG
TABLET, 300 MG TABLET, POWDER)
VISTIDE 75 MG/ML VIAL
PA B vs D
VITEKTA (85 MG TABLET, 150 MG TABLET)
ZERIT (1 MG/ML SOLUTION, 15 MG CAPSULE, 20
MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE)
ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET)
zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg
tablet)
ZOVIRAX 800 MG TABLET
CEPHALOSPORINS
CEDAX (90 MG/5 ML SUSPENSION, 180 MG/5 ML
SUSPENSION, 400 MG CAPSULE)
6
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
cefaclor (250 mg capsule, 500 mg tab er 12h, 500 mg
capsule)
cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg
capsule, 500 mg/5ml susp recon)
cefadroxil hydrate (1 g tablet, 250 mg/5ml susp recon,
500 mg capsule, 500 mg/5ml susp recon)
cefazolin sodium (1 g vial, 1 g vial port, 10 g vial, 20 g
vial, 100 g bulkbaginj, 300g bulkbaginj, 500 mg vial)
cefazolin sodium/dextrose, iso-osmotic
(sodium/dextrose,iso 1 g/50 ml froz.piggy,
sodium/dextrose,iso 1 g/50 ml piggyback)
cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp
recon, 300 mg capsule)
cefepime hcl (1 vial, 2 vial)
cefepime hcl/dextrose 5 % in water (hcl/d5w 2 g/50 ml,
hcl/d5w 1 g/50 ml)
cefixime (100 mg/5ml, 200 mg/5ml)
cefotaxime sodium (1 g vial, 2 g vial, 500 mg vial)
cefotetan disodium (1 vial, 2 vial, 10 vial)
cefoxitin sodium (1 vial, 2 vial, 10 vial)
cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg
tablet, 100 mg/5ml susp recon, 200 mg tablet)
cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250
mg/5ml susp recon, 500 mg tablet)
ceftazidime (1 vial, 2 vial, 6 vial)
ceftazidime in dextrose 5% and water ( 1 g/50 ml, 2
g/50 ml)
ceftazidime pentahydrate (1 g vial, 2 g vial, 6g vial)
CEFTIN (125 MG/5 ML ORAL SUSP, 250 MG/5 ML
ORAL SUSP, 250 MG TABLET, 500 MG TABLET)
ceftriaxone sodium (1 g vial, 1 g vial port, 1 g pggybk
btl, 2 g vial port, 2 g pggybk btl, 2 g vial, 10 g vial, 100 g
bulkbaginj, 250 mg vial, 500 mg vial)
cefuroxime axetil (250 mg tablet, 500 mg tablet)
7
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
cefuroxime sodium (1.5 g vial, 750 mg vial)
PA B vs D
cefuroxime sodium (7.5g vial, 7.5 g vial, 75 g
bulkbaginj)
cephalexin (125 mg/5ml susp recon, 250 mg tablet, 250
mg capsule, 250 mg/5ml susp recon, 500 mg tablet,
500 mg capsule)
CLAFORAN (1 GM VIAL, 2 GM ADD-VANTAGE VL)
CLAFORAN 1 GM ADD-VANTAGE VL
PA B vs D
FORTAZ (1 GM ADD-VANTAGE VIAL, 1 GM
TWISTVIAL, 2 GM TWISTVIAL, 2 GM ADD-VANTAGE
VIAL, 6 GM VIAL)
KEFLEX 750 MG CAPSULE
SUPRAX (100 MG/5 ML SUSPENSION, 100 MG
TABLET CHEWABLE, 200 MG/5 ML SUSPENSION,
200 MG TABLET CHEWABLE, 400 MG CAPSULE, 500
MG/5 ML SUSPENSION)
TEFLARO (400 MG VIAL, 600 MG VIAL)
ZINACEF (1.5 GM TWISTVIAL, 1.5 GM VIAL, 7.5 GM
VIAL, 750 MG VIAL)
ERYTHROMYCINS / OTHER MACROLIDES
azithromycin (1 g packet, 100 mg/5ml susp recon, 200
mg/5ml susp recon, 250 mg tablet, 500 mg vial port,
500 mg tablet, 500 mg vial, 600 mg tablet)
clarithromycin (125 mg/5ml susp recon, 250 mg/5ml
susp recon, 250 mg tablet, 500 mg tab er 24h, 500 mg
tablet)
E.E.S. 400 FILMTAB
ERY-TAB (EC 250 MG TABLET, EC 333 MG TABLET,
EC 500 MG TABLET)
ERYPED 200 (200 MG/5 ML GRANULES, 200 MG/5
ML SUSPENSION)
ERYTHROCIN 250 MG FILMTAB
ERYTHROCIN LACTOBIONATE (500 MG VIAL, 500
MG ADDVNT VL)
PA B vs D
erythromycin base (250 mg tablet, 250 mg capsule dr,
500 mg tablet)
8
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
erythromycin ethylsuccinate 400 mg tablet
ZMAX (2 G/60 ML SUSP SR, 2 G/60 ML ORAL
SUSPENSION)
MISCELLANEOUS ANTIINFECTIVES
ALBENZA 200 MG TABLET
ALINIA 100 MG/5 ML SUSPENSION
ALINIA 500 MG TABLET
QL (6 PER 30 DAYS)
amikacin sulfate (500 mg/2ml vial, 1000mg/4ml vial)
atovaquone 750 mg/5ml oral susp
atovaquone/proguanil hcl (atovaquone/proguanil 62.525 mg tablet, atovaquone/proguanil 250-100 mg tablet)
AZACTAM (1 GM VIAL, 2 GM VIAL)
AZACTAM-ISO-OSMOTIC DEXTROSE (1 GM/50 ML,
2 GM/50 ML)
aztreonam (1 vial, 2 vial)
BACIIM (STRL VIAL, VIAL)
bacitracin 50000 unit vial
BILTRICIDE 600 MG TABLET
CAPASTAT SULFATE 1 GM VIAL
PA B vs D
CAYSTON 75 MG INHAL SOLUTION
chloramphenicol sod succ 1 g vial
PA B vs D
chloroquine phosphate (250 mg tablet, 500 mg tablet)
CLEOCIN 75 MG/5 ML GRANULES
CLEOCIN HCL 75 MG CAPSULE
CLEOCIN PHOSPHATE IN D5W (300, 600, 900)
PA B vs D
clindamycin hcl (75 mg capsule, 150 mg capsule, 300
mg capsule)
clindamycin palmitate hcl 75 mg/5 ml soln recon
clindamycin phosphate (150 mg/ml vial, 300 mg/2ml vial
port, 600 mg/4ml vial port, 900mg/6ml vial port)
9
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
clindamycin phosphate/dextrose 5 % in water
(phosphate/d5w 300mg/50ml, phosphate/d5w
900mg/50ml, phosphate/d5w 600mg/50ml)
COARTEM TABLETS
colistin (colistimethate na) 150 mg vial
CUBICIN 500 MG VIAL
PA B vs D
dapsone (25 mg tablet, 100 mg tablet)
DARAPRIM 25 MG TABLET
DORIBAX 500 MG VIAL
PA B vs D
EMVERM 100 MG TABLET CHEW
ethambutol hcl (100 mg tablet, 400 mg tablet)
FLAGYL ER 750 MG TABLET
gentamicin sulfate 40 mg/ml vial
gentamicin sulfate in sodium chloride, iso-osmotic (60
mg/50ml, 70 mg/50ml, 80 mg/50ml, 90mg/100ml,
120mg/0.1l)
gentamicin sulfate in sodium chloride, iso-osmotic
(80mg/100ml, 100mg/0.1l)
PA B vs D
hydroxychloroquine sulfate 200 mg tablet
imipenem/cilastatin sodium (imipenem/cilastatin 250 mg
vial, imipenem/cilastatin 500 mg vial)
PA B vs D
INVANZ 1 GM VIAL
PA B vs D
ISONARIF CAPSULE
isoniazid (50 mg/5 ml solution, 100 mg/ml vial, 100 mg
ivermectin 3 mg tablet
KETEK (300 MG TABLET, 400 MG TABLET)
KORLYM 300 MG TABLET
PA, QL (120 PER 30 OVER TIME)
linezolid (100 mg/5ml susp recon, 600mg/300 iv soln,
600 mg tablet)
linezolid-0.9% sodium chloride 600mg/300 iv soln
MALARONE (62.5-25 MG PED TAB, 250-100 MG
TABLET)
10
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
mefloquine hcl 250 mg tablet
MEPRON 750 MG/5 ML SUSPENSION
meropenem 1 g vial
meropenem 500 mg vial
PA B vs D
MERREM IV 1 GM VIAL
MERREM IV 500 MG VIAL
PA B vs D
metronidazole (250 mg tablet, 375 mg capsule, 500 mg
tablet)
metronidazole/sodium chloride 500mg/0.1l piggyback
NEBUPENT 300 MG INHAL POWDER
PA B vs D
neomycin sulfate 500 mg tablet
paromomycin sulfate 250 mg capsule
PASER GRANULES 4 GM PACKET
PENTAM 300 VIAL
PA B vs D
polymyxin b sulfate 500k unit vial
primaquine phosphate 26.3 mg tablet
PRIMAXIN (250 MG VIAL, 500 MG VIAL)
pyrazinamide 500 mg tablet
QUALAQUIN 324 MG CAPSULE
quinine sulfate 324 mg capsule
rifabutin 150 mg capsule
RIFAMATE CAPSULE
rifampin (150 mg capsule, 300 mg capsule, 600 mg
vial)
RIFATER TABLET
SIRTURO 100 MG TABLET
PA
streptomycin sulfate 1 g vial
STROMECTOL 3 MG TABLET
SYNERCID 500 MG VIAL
PA B vs D
tinidazole (250 mg tablet, 500 mg tablet)
11
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
TOBI 300 MG/5 ML SOLUTION
PA B vs D
tobramycin in 0.225% nacl 300 mg/5ml ampul-neb
PA B vs D
tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml
vial, 80 mg/8 ml vial port)
tobramycin/sodium chloride 80mg/100ml piggyback
PA B vs D
TRECATOR 250 MG TABLET
TYGACIL 50 MG VIAL
PA B vs D
XIFAXAN (200 MG TABLET, 550 MG TABLET)
ZYVOX (100 MG/5 ML SUSPENSION, 200 MG/100 ML
IV SOLN, 600 MG TABLET)
ZYVOX 600 MG/300 ML IV SOLN
PA B vs D
PENICILLINS
amoxicillin (125 mg tab chew, 125 mg/5ml susp recon,
200 mg/5ml susp recon, 250 mg capsule, 250 mg tab
chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon,
500 mg tablet, 500 mg capsule, 875mg tablet, 875 mg
tablet)
amoxicillin/potassium clavulanate
(amoxicillin/potassium 200-28.5mg tab chew,
amoxicillin/potassium 200-28.5/5 susp recon,
amoxicillin/potassium 250-125 mg tablet,
amoxicillin/potassium 400-57mg tab chew,
amoxicillin/potassium 400-57mg/5 susp recon,
amoxicillin/potassium 500-125 mg tablet,
amoxicillin/potassium 875-125 mg tablet)
ampicillin sodium (1 g vial, 1 g vial port, 2 g vial, 10 g
vial, 125 mg vial, 250 mg vial, 500 mg vial)
ampicillin sodium/sulbactam sodium (sodium/sulbactam
1.5 vial port, sodium/sulbactam 1.5 vial,
sodium/sulbactam 3 vial, sodium/sulbactam 3 vial port,
sodium/sulbactam 15 vial)
ampicillin trihydrate (125 mg/5ml susp recon, 250 mg
capsule, 250 mg/5ml susp recon, 500 mg capsule)
BICILLIN C-R (1.2 MILLION UNIT, 900-300 SYRINGE)
BICILLIN L-A (600,000 UNIT/ML, 1,200,000 UNITS,
2,400,000 UNITS)
12
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
dicloxacillin sodium (250 mg capsule, 500 mg capsule)
MOXATAG ER 775 MG TABLET
nafcillin in dextrose, iso-osmotic ( 1 g/50 ml, 2 g/100 ml)
nafcillin sodium (1 vial, 2 vial, 10 vial)
OMECLAMOX-PAK COMBO PACK
oxacillin sodium (1 vial, 2 vial port, 2 vial, 10 vial)
oxacillin sodium/dextrose, iso-osmotic
(sodium/dextrose,iso 1 g/50 ml, sodium/dextrose,iso 2
g/50 ml)
penicillin g potassium (5mm vial, 20mm vial)
penicillin g potassium/dextrose-water (pot/dextrosewater 2mm/50ml froz.piy, pot/dextrose-water 3mm/50ml
froz.piy)
PA B vs D
penicillin g procaine 1.2mm/2 ml syringe
PA B vs D
penicillin g sodium 5mm unit vial
PA B vs D
penicillin v potassium (125 mg/5ml soln recon, 250 mg
tablet, 250 mg/5ml soln recon, 500 mg tablet)
piperacillin sodium/tazobactam 2.25 g vial
piperacillin sodium/tazobactam sodium
(sodium/tazobactam 3.375 vial, sodium/tazobactam
3.375 vial port, sodium/tazobactam 4.5 vial,
sodium/tazobactam 4.5 vial port, sodium/tazobactam
40.5 vial)
PA B vs D
ZOSYN (2.25 GM/50 ML GALAXY BAG, 3.375 GRAM
VIAL, 3.375 GM/50 ML GALAXY, 40.5 GRAM BULK
VIAL)
PA B vs D
ZOSYN (2.25 GRAM VIAL, 4.5 GRAM VIAL, 4.5
GM/100 ML GALAXY BAG)
QUINOLONES
AVELOX 400 MG TABLET
AVELOX ABC PACK 400 MG TAB
AVELOX IV 400 MG/250 ML
PA B vs D
CIPRO (5%, 10%)
13
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ciprofloxacin (250 mg/5ml, 500 mg/5ml)
ciprofloxacin hcl (100 mg tablet, 250 mg tablet, 500 mg
ciprofloxacin lactate (200mg/20ml vial, 400mg/40ml
vial)
ciprofloxacin lactate/dextrose 5 % in water (lactate/d5w
400mg/0.2l, lactate/d5w 200mg/0.1l)
ciprofloxacin/ciprofloxacin hcl (ciprofloxacin/ciprofloxa
500 mg, ciprofloxacin/ciprofloxa 1000 mg)
FACTIVE 320 MG TABLET
gatifloxacin 0.5 % drops
LEVAQUIN (25 MG/ML SOLUTION, 250 MG TABLET,
levofloxacin (250mg/10ml solution, 250 mg tablet, 500
mg tablet, 500mg/20ml solution, 750 mg tablet)
levofloxacin 25 mg/ml vial
PA B vs D
levofloxacin/d5w 250mg/50ml piggyback
levofloxacin/dextrose 5 % in water (levofloxacin/d5w
750mg/.15l, levofloxacin/d5w 500mg/0.1l)
PA B vs D
moxifloxacin hcl 400 mg tablet
moxifloxacin/sod.ace,sul/water 400mg/.25l piggyback
ofloxacin 400 mg tablet
SULFA'S / RELATED AGENTS
sulfadiazine 500 mg tablet
sulfamethoxazole/trimethoprim
(sulfamethoxazole/trimethoprim 80-16mg/ml vial,
sulfamethoxazole/trimethoprim 200-40mg/5 oral susp,
sulfamethoxazole/trimethoprim 400mg-80mg tablet,
sulfamethoxazole/trimethoprim 800-160/20 oral susp,
sulfamethoxazole/trimethoprim 800-160 mg tablet)
TETRACYCLINES
demeclocycline hcl (150 mg tablet, 300 mg tablet)
14
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
doxycycline hyclate (20 mg tablet, 50 mg tablet dr, 50
mg capsule, 100 mg capsule, 100 mg tablet, 100 mg
vial, 200 mg tablet dr)
doxycycline monohydrate (25 mg/5 ml susp recon, 50
mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet,
100 mg tablet, 100 mg capsule, 150 mg tablet)
minocycline hcl (45 mg tab er 24h, 50 mg tablet, 50 mg
capsule, 75 mg capsule, 75 mg tablet, 90 mg tab er
24h, 100 mg capsule, 100 mg tablet, 135 mg tab er
24h)
ORACEA 40 MG CAPSULE
tetracycline hcl (250 mg capsule, 500 mg capsule)
VIBRAMYCIN 50 MG/5 ML SYRUP
URINARY TRACT AGENTS
FURADANTIN 25 MG/5 ML SUSP
MACRODANTIN 25 MG CAPSULE
methenamine hippurate 1 g tablet
MONUROL 3 GM SACHET
nitrofurantoin (25 mg/5 ml oral susp, 50 mg capsule)
nitrofurantoin macrocrystal (25 mg capsule, 50 mg
capsule, 100 mg capsule)
nitrofurantoin monohyd/m-cryst 100 mg capsule
PRIMSOL 50 MG/5 ML ORAL SOLN
trimethoprim 100 mg tablet
VANCOMYCIN
VANCOCIN HCL (125 MG PULVULE, 125 MG
CAPSULE, 250 MG PULVULE, 250 MG CAPSULE)
vancomycin hcl (1 g vial, 1 g vial port, 5 g vial, 125 mg
capsule, 250 mg capsule, 750 mg vial)
vancomycin hcl (10 g vial, 500 mg vial, 500 mg vial
port)
PA B vs D
15
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
amifostine crystalline 500 mg vial
dexrazoxane hcl (250 mg vial, 500 mg vial)
PA B vs D
ELITEK (1.5 MG VIAL, 7.5 MG VIAL)
PA B vs D
FUSILEV I.V. 50 MG VIAL
PA B vs D
KEPIVANCE 6.25 MG VIAL
PA B vs D
leucovorin calcium (10 mg/ml vial, 50 mg vial, 100 mg
vial, 200 mg vial, 350 mg vial, 500mg/50ml vial, 500 mg
vial)
PA B vs D
leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg
levoleucovorin calcium 10 mg/ml vial
PA B vs D
mesna 100 mg/ml vial
PA B vs D
MESNEX 400 MG TABLET
XGEVA 120 MG/1.7 ML VIAL
PA B vs D
ZINECARD (250 MG VIAL, 500 MG VIAL)
PA B vs D
ABRAXANE 100 MG VIAL
PA B vs D
ADRUCIL (5 GRAM/100 ML VIAL, 500 MG/10 ML VIAL,
2,500 MG/50 ML VIAL)
PA B vs D
AFINITOR (2.5 MG TABLET, 5 MG TABLET, 7.5 MG
AFINITOR DISPERZ (2 MG TABLET, 3 MG TABLET, 5
MG TABLET)
ALECENSA 150 MG CAPSULE
ALIMTA 100 MG VIAL
ALIMTA 500 MG VIAL
PA B vs D
ALKERAN 50 MG VIAL
PA B vs D
anastrozole 1 mg tablet
ARIMIDEX 1 MG TABLET
16
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
AROMASIN 25 MG TABLET
ARRANON 250 MG VIAL
PA B vs D
ARZERRA (100 MG/5 ML VIAL, 1,000 MG/50 ML VIAL)
ASTAGRAF XL (0.5 MG CAPSULE, 1 MG CAPSULE, 5
MG CAPSULE)
PA B vs D
AVASTIN (100 MG/4 ML VIAL, 400 MG/16 ML VIAL)
PA B vs D
azacitidine 100 mg vial
PA B vs D
AZASAN (75 MG TABLET, 100 MG TABLET)
PA B vs D
azathioprine 50 mg tablet
PA B vs D
azathioprine sodium 100 mg vial
PA B vs D
BELEODAQ 500 MG VIAL
PA B vs D
bexarotene 75 mg capsule
bicalutamide 50 mg tablet
BICNU 100 MG VIAL
PA B vs D
bleomycin sulfate (15 vial, 30 vial)
PA B vs D
BOSULIF (100 MG TABLET, 500 MG TABLET)
BUSULFEX (6 MG/ML AMPUL, 60 MG/10 ML AMPUL,
60 MG/10 ML VIAL)
PA B vs D
CABOMETYX (20 MG TABLET, 40 MG TABLET, 60
MG TABLET)
CAPRELSA (100 MG TABLET, 300 MG TABLET)
carboplatin (10 mg/ml vial, 50 mg vial, 150 mg vial, 450
mg vial)
PA B vs D
CASODEX 50 MG TABLET
CELLCEPT (200 MG/ML ORAL SUSP, 250 MG
CAPSULE, 500 MG TABLET, 500 MG VIAL)
PA B vs D
cisplatin 1 mg/ml vial
PA B vs D
cladribine 10 mg/10ml vial
PA B vs D
CLOLAR 20 MG/20 ML VIAL
PA B vs D
COMETRIQ (60 MG PACK, 100 MG PK, 140 MG PK)
COSMEGEN 0.5 MG VIAL
PA B vs D
17
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
COTELLIC 20 MG TABLET
LA
cyclophosphamide (25 mg capsule, 50 mg capsule)
PA B vs D
cyclosporine (25 mg capsule, 100 mg capsule, 100
mg/ml solution, 250 mg/5ml vial, 250 mg/5ml ampul)
PA B vs D
cyclosporine, modified (25 mg capsule, 50 mg capsule,
100 mg/ml solution, 100 mg capsule)
PA B vs D
CYRAMZA (100 MG/10 ML VIAL, 500 MG/50 ML VIAL)
cytarabine 20 mg/ml vial
PA B vs D
cytarabine/pf (cytarabine/pf 1 g vial, cytarabine/pf 2
g/20 ml vial, cytarabine/pf 2 g vial, cytarabine/pf 20
mg/ml vial, cytarabine/pf 100 mg/5ml vial)
PA B vs D
dacarbazine 100 mg vial
dacarbazine 200 mg vial
PA B vs D
DACOGEN 50 MG VIAL
PA B vs D
DARZALEX (100 MG/5 ML VIAL, 400 MG/20 ML VIAL)
LA
daunorubicin hcl (5 mg/ml vial, 20 mg vial)
PA B vs D
DAUNOXOME (2 MG/ML VIAL, 50 MG (2 MG/ML)
VIAL)
PA B vs D
decitabine 50 mg vial
PA B vs D
DOCEFREZ 20 MG VIAL
PA B vs D
docetaxel (20 mg/2 ml vial, 20mg/ml(1) vial, 80 mg/8 ml
vial, 80 mg/4 ml vial, 140 mg/7ml vial, 160 mg/8ml vial,
160mg/16ml vial, 200mg/20ml vial)
PA B vs D
DOXIL 2 MG/ML VIAL
PA B vs D
doxorubicin hcl (2 mg/ml vial, 10 mg vial, 10 mg/5 ml
vial, 20 mg/10ml vial, 50 mg vial, 50 mg/25ml vial)
PA B vs D
doxorubicin hcl peg-liposomal 2 mg/ml vial
DROXIA (200 MG CAPSULE, 300 MG CAPSULE, 400
MG CAPSULE)
ELIGARD (7.5 MG B, 7.5 MG KIT, 22.5 MG B, 22.5 MG
KIT, 30 MG B, 30 MG KIT, 45 MG B, 45 MG KIT)
PA B vs D
ELLENCE 2 MG/ML VIAL
PA B vs D
ELOXATIN (50 MG/10 ML VIAL, 100 MG/20 ML VIAL,
200 MG/40 ML VIAL)
18
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
EMCYT 140 MG CAPSULE
EMPLICITI (300 MG VIAL, 400 MG VIAL)
ENVARSUS XR (0.75 MG TABLET, 1 MG TABLET, 4
MG TABLET)
epirubicin hcl (50 mg vial, 50 mg/25ml vial, 200 mg vial,
200mg/0.1l vial)
PA B vs D
ERBITUX 100 MG/50 ML VIAL
PA B vs D
ERBITUX 200 MG/100 ML VIAL
ERIVEDGE 150 MG CAPSULE
ERWINAZE 10,000 UNITS VIAL
PA B vs D
ETOPOPHOS 100 MG VIAL
PA B vs D
etoposide 20 mg/ml vial
PA B vs D
exemestane 25 mg tablet
FARESTON 60 MG TABLET
FARYDAK (10 MG CAPSULE, 15 MG CAPSULE, 20
MG CAPSULE)
FASLODEX 250 MG/5 ML SYRINGE
PA B vs D
FEMARA 2.5 MG TABLET
fludarabine phosphate (50 mg vial, 50 mg/2 ml vial)
PA B vs D
fluorouracil (1 g/20 ml vial, 2.5 g/50ml vial, 5 g/100 ml
vial, 500mg/10ml vial)
PA B vs D
flutamide 125 mg capsule
gemcitabine hcl (1 g vial, 200 mg vial)
PA B vs D
gemcitabine hcl (1 g/26.3ml vial, 2 g vial, 2 g/52.6ml
vial, 200mg/5.26 vial)
GEMZAR 1 GRAM VIAL
PA B vs D
GEMZAR 200 MG VIAL
GENGRAF (25 MG CAPSULE, 100 MG/ML
SOLUTION, 100 MG CAPSULE)
PA B vs D
GILOTRIF (20 MG TABLET, 30 MG TABLET, 40 MG
TABLET)
GLEEVEC (100 MG TABLET, 400 MG TABLET)
19
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
GLEOSTINE (5 MG CAPSULE, 10 MG CAPSULE, 40
MG CAPSULE, 100 MG CAPSULE)
HALAVEN 1 MG/2 ML VIAL
PA B vs D
HERCEPTIN 440 MG VIAL
PA B vs D
HEXALEN 50 MG CAPSULE
HYCAMTIN 4 MG VIAL
PA B vs D
hydroxyurea 500 mg capsule
IBRANCE (75 MG CAPSULE, 100 MG CAPSULE, 125
MG CAPSULE)
ICLUSIG (15 MG TABLET, 45 MG TABLET)
idarubicin hcl 1 mg/ml vial
PA B vs D
IFEX (1 GM VIAL, 3 GM VIAL)
PA B vs D
ifosfamide (1 g/20 ml vial, 1 g vial, 3g/60ml vial, 3 g vial)
PA B vs D
imatinib mesylate (100 mg tablet, 400 mg tablet)
IMBRUVICA 140 MG CAPSULE
INLYTA (1 MG TABLET, 5 MG TABLET)
IRESSA 250 MG TABLET
irinotecan hcl (40 mg/2 ml vial, 100 mg/5ml vial,
500mg/25ml vial)
IXEMPRA 15 MG KIT
IXEMPRA 45 MG KIT
PA B vs D
JAKAFI (5 MG TABLET, 10 MG TABLET, 15 MG
TABLET, 20 MG TABLET, 25 MG TABLET)
JEVTANA 60 MG/1.5 ML KIT
KEYTRUDA (50 MG VIAL, 100 MG/4 ML VIAL)
PA B vs D
LENVIMA (8 MG, 10 MG, 14 MG, 18 MG, 20 MG, 24
MG)
letrozole 2.5 mg tablet
LEUKERAN 2 MG TABLET
leuprolide acetate (1 mg/0.2ml kit, 1 mg/0.2ml vial)
lomustine (10 mg capsule, 40 mg capsule, 100 mg
capsule)
20
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
LONSURF (15 MG-6.14 MG TABLET, 20 MG-8.19 MG
TABLET)
LUPRON DEPOT (DEPOT 3.75 MG, DEPOT-4
MONTH, DEPOT 7.5 MG, DEPOT 11.25 MG 3MO,
DEPOT 22.5 MG 3MO, DEPOT 45 MG 6MO)
PA B vs D
LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO,
11.25 MG KIT, 15 MG KIT, 30 MG 3MO KIT)
PA B vs D
LYNPARZA 50 MG CAPSULE
LYSODREN 500 MG TABLET
MATULANE 50 MG CAPSULE
megestrol acetate (20 mg tablet, 40 mg tablet,
400mg/10ml oral susp, 625mg/5ml oral susp,
800mg/20ml oral susp)
MEKINIST (0.5 MG TABLET, 2 MG TABLET)
melphalan hcl 50 mg vial
PA B vs D
mercaptopurine 50 mg tablet
methotrexate sodium 2.5 mg tablet
PA B vs D
methotrexate sodium/pf (sodium/pf 1 g vial, sodium/pf
25 mg/ml vial)
PA B vs D
mitomycin (5 mg vial, 20 mg vial, 40 mg vial)
PA B vs D
mitoxantrone hcl 2 mg/ml vial
PA B vs D
MUSTARGEN 10 MG VIAL
PA B vs D
mycophenolate mofetil (200 mg/ml susp recon, 250 mg
capsule, 500 mg tablet)
PA B vs D
mycophenolate sodium (180 mg tablet dr, 360 mg tablet
dr)
PA B vs D
MYFORTIC (180 MG TABLET, 360 MG TABLET)
PA B vs D
NEORAL (25 MG GELATIN CAPSULE, 100 MG/ML
SOLUTION, 100 MG GELATIN CAPSULE)
PA B vs D
NEXAVAR 200 MG TABLET
NILANDRON 150 MG TABLET
NINLARO (2.3 MG CAPSULE, 3 MG CAPSULE, 4 MG
CAPSULE)
21
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
NULOJIX 250 MG VIAL
PA B vs D
octreotide acetate (50 mcg/ml vial, 50 mcg/ml ampul,
100 mcg/ml ampul, 100 mcg/ml vial, 200 mcg/ml vial,
500 mcg/ml ampul, 500 mcg/ml vial, 1000mcg/ml vial)
PA B vs D
ODOMZO 200 MG CAPSULE
LA
ONCASPAR (750 UNIT/ML VIAL, 3,750 UNIT/5 ML
VIAL)
PA B vs D
OPDIVO 100 MG/10 ML VIAL
OPDIVO 40 MG/4 ML VIAL
PA B vs D
OTREXUP 7.5 MG/0.4 ML AUTO-INJ
oxaliplatin (50 mg vial, 50 mg/10ml vial, 100 mg vial,
100mg/20ml vial)
PA B vs D
paclitaxel 6 mg/ml vial
PA B vs D
PERJETA 420 MG/14 ML VIAL
PA B vs D
POMALYST (1 MG CAPSULE, 2 MG CAPSULE, 3 MG
CAPSULE, 4 MG CAPSULE)
PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5
MG/ML AMPULE, 5 MG CAPSULE)
PA B vs D
PURIXAN 20 MG/ML ORAL SUSP
RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1
MG/ML ORAL SOLN, 2 MG TABLET)
PA B vs D
REVLIMID (2.5 MG CAPSULE, 20 MG CAPSULE)
REVLIMID (5 MG CAPSULE, 10 MG CAPSULE, 15 MG
LA
RHEUMATREX 2.5 MG TABLET
PA B vs D
RITUXAN 10 MG/ML VIAL
PA B vs D
SANDIMMUNE (25 MG CAPSULE, 50 MG/ML AMPUL,
100 MG/ML SOLN, 100 MG CAPSULE)
PA B vs D
SIMULECT 10 MG VIAL
SIMULECT 20 MG VIAL
PA B vs D
sirolimus (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
PA B vs D
SOLTAMOX 10 MG/5 ML SOLN
22
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
SOMATULINE DEPOT (DEPOT 90 MG/0.3 ML, 120
MG/0.5 ML SYRGE, DEPOT 120 MG/0.5 ML)
PA B vs D
SPRYCEL (20 MG TABLET, 50 MG TABLET, 70 MG
TABLET, 80 MG TABLET, 100 MG TABLET, 140 MG
TABLET)
STIVARGA 40 MG TABLET
SUTENT (12.5 MG CAPSULE, 25 MG CAPSULE, 37.5
SYLVANT (100 MG VIAL, 400 MG VIAL)
SYNRIBO 3.5 MG/ML VIAL
PA B vs D
TABLOID 40 MG TABLET
tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg
capsule)
PA B vs D
TAFINLAR (50 MG CAPSULE, 75 MG CAPSULE)
TAGRISSO (40 MG TABLET, 80 MG TABLET)
LA
tamoxifen citrate (10 mg tablet, 20 mg tablet)
TARCEVA (25 MG TABLET, 100 MG TABLET, 150 MG
TABLET)
TARGRETIN (1% GEL, 75 MG SOFTGEL, 75 MG
CAPSULE)
TASIGNA (150 MG CAPSULE, 200 MG CAPSULE)
TECENTRIQ 1,200 MG/20 ML VIAL
THALOMID (50 MG CAPSULE, 100 MG CAPSULE,
thiotepa 15 mg vial
TOLAK 4% CREAM
topotecan hcl (4 mg/4 ml vial, 4 mg vial)
PA B vs D
TORISEL 25 MG KIT
PA B vs D
TREANDA (25 MG VIAL, 45 MG/0.5 ML VIAL, 100 MG
VIAL, 180 MG/2 ML VIAL)
PA B vs D
TRELSTAR (3.75 MG, 11.25 MG)
PA B vs D
TRELSTAR DEPOT 3.75 MG VIAL
PA B vs D
23
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
TRELSTAR LA 11.25 MG VIAL
PA B vs D
tretinoin 10 mg capsule
TREXALL (5 MG TABLET, 7.5 MG TABLET, 10 MG
PA B vs D
TRISENOX 10 MG/10 ML AMPULE
PA B vs D
TYKERB 250 MG TABLET
VECTIBIX (200 MG/10 ML VIAL, 400 MG/20 ML VIAL)
VECTIBIX 100 MG/5 ML VIAL
PA B vs D
VELCADE 3.5 MG VIAL
PA B vs D
VENCLEXTA (10 MG TABLET, 50 MG TABLET, 100
MG TABLET)
VENCLEXTA STARTING PACK
VIDAZA 100 MG VIAL
PA B vs D
vinblastine sulfate (1 mg/ml vial, 10 mg vial)
PA B vs D
VINCASAR PFS (1 MG/ML VIAL, 2 MG/2 ML VIAL)
PA B vs D
vincristine sulfate (1 mg/ml vial, 2 mg/2 ml vial)
PA B vs D
vinorelbine tartrate (10 mg/ml vial, 50 mg/5 ml vial)
PA B vs D
VOTRIENT 200 MG TABLET
XALKORI (200 MG CAPSULE, 250 MG CAPSULE)
XTANDI 40 MG CAPSULE
YERVOY 200 MG/40 ML VIAL
YERVOY 50 MG/10 ML VIAL
PA B vs D
ZALTRAP 100 MG/4 ML VIAL
PA B vs D
ZALTRAP 200 MG/8 ML VIAL
ZANOSAR 1 GM POWDER VIAL
PA B vs D
ZELBORAF 240 MG TABLET
ZOLINZA 100 MG CAPSULE
ZORTRESS (0.25 MG TABLET, 0.5 MG TABLET, 0.75
MG TABLET)
PA B vs D
ZYDELIG (100 MG TABLET, 150 MG TABLET)
24
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ZYKADIA 150 MG CAPSULE
ZYTIGA 250 MG TABLET
AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG
BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET,
400 MG TABLET)
BRIVIACT (10 MG/ML ORAL SOLN, 10 MG TABLET,
25 MG TABLET, 50 MG TABLET, 50 MG/5 ML VIAL,
carbamazepine (100 mg tab er 12h, 100 mg cpmp 12hr,
100 mg/5ml oral susp, 100 mg tab chew, 200mg/10ml
oral susp, 200 mg tablet, 200 mg tab er 12h, 200 mg
cpmp 12hr, 300 mg cpmp 12hr)
CARBATROL (ER 100 MG CAPSULE, ER 200 MG
CAPSULE, ER 300 MG CAPSULE)
CELONTIN 300 MG KAPSEAL
CEREBYX (100 MG PE/2 ML VIAL, 500 MG PE/10 ML
VIAL)
DEPAKOTE (DR 125 MG TABLET, DR 250 MG
TABLET, DR 500 MG TABLET)
DEPAKOTE 125 MG SPRINKLE CAP
DEPAKOTE ER (ER 250 MG TABLET, ER 500 MG
TABLET)
DILANTIN (30 MG CAPSULE, 50 MG INFATAB)
divalproex sodium (125 mg tablet dr, 125 mg cap
sprink, 250 mg tab er 24h, 250 mg tablet dr, 500 mg
tablet dr, 500 mg tab er 24h)
EPITOL 200 MG TABLET
EQUETRO (100 MG CAPSULE, 200 MG CAPSULE,
300 MG CAPSULE)
ethosuximide (250 mg/5ml solution, 250 mg capsule)
25
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml
oral susp)
FELBATOL (400 MG TABLET, 600 MG TABLET, 600
MG/5 ML SUSP)
fosphenytoin sodium (100mg pe/2 vial, 500 pe/10 vial)
FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4
MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG
gabapentin (100 mg capsule, 250 mg/5ml solution, 300
mg/6ml solution, 300 mg capsule, 400 mg capsule, 600
mg tablet, 800 mg tablet)
GABITRIL (2 MG TABLET, 4 MG TABLET, 12 MG
GRALISE (30-DAY STARTER PACK, ER 300 MG
TABLET, ER 600 MG TABLET)
KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET,
500 MG TABLET, 750 MG TABLET, 1,000 MG
TABLET)
KEPPRA XR (500 MG TABLET, 750 MG TABLET)
LAMICTAL (25 MG TABLET, 100 MG TABLET, 150
MG TABLET, 200 MG TABLET)
LAMICTAL TAB START KIT (BLUE)
LAMICTAL TAB START KIT (GREEN)
LAMICTAL TB START KIT (ORANGE)
LAMICTAL XR (25 MG TABLET, 50 MG TABLET, 100
MG TABLET, 200 MG TABLET, 250 MG TABLET, 300
MG TABLET)
LAMICTAL XR START KIT (BLUE)
LAMICTAL XR START KIT (GREEN)
LAMICTAL XR START KIT (ORANGE)
26
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
lamotrigine (5 mg tb chw dsp, 25 mg tablet, 25 mg tab
er 24, 25 mg tab rapdis, 25 mg tb chw dsp, 50 mg tab
rapdis, 50 mg tab er 24, 100 mg tab er 24, 100 mg tab
rapdis, 100 mg tablet, 150 mg tablet, 200 mg tablet, 200
mg tab er 24, 200 mg tab rapdis, 250 mg tab er 24, 300
mg tab er 24)
levetiracetam (100 mg/ml solution, 250 mg tablet, 500
mg/5ml solution, 500 mg tab er 24h, 500 mg tablet, 750
mg tablet, 750 mg tab er 24h, 1000 mg tablet)
levetiracetam 500 mg/5ml vial
PA B vs D
levetiracetam in sodium chloride, iso-osmotic ((iso-os)
500mg/0.1l, (iso-os) 1000mg/100, (iso-os) 1500mg/100)
PA B vs D
LYRICA (20 MG/ML ORAL SOLUTION, 25 MG
CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100
MG CAPSULE, 150 MG CAPSULE, 200 MG
CAPSULE, 225 MG CAPSULE, 300 MG CAPSULE)
NEURONTIN 250 MG/5 ML SOLN
ONFI (2.5 MG/ML SUSPENSION, 10 MG TABLET, 20
MG TABLET)
oxcarbazepine (150 mg tablet, 300 mg tablet, 300
mg/5ml oral susp, 600 mg tablet)
OXTELLAR XR (150 MG TABLET, 300 MG TABLET,
600 MG TABLET)
PEGANONE 250 MG TABLET
phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml
elixir, 30 mg tablet, 32.4mg tablet, 32.4 mg tablet, 60
mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet)
PHENYTEK (200 MG CAPSULE, 300 MG CAPSULE)
phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125
mg/5ml oral susp)
phenytoin sodium (50 mg/ml vial, 50 mg/ml ampul)
phenytoin sodium extended (100 mg capsule, 200 mg
POTIGA (50 MG TABLET, 200 MG TABLET, 300 MG
primidone (50 mg tablet, 250 mg tablet)
27
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE,
100 MG CAPSULE, 150 MG CAPSULE, 200 MG
CAPSULE)
ROWEEPRA 500 MG TABLET
SABRIL (500 MG TABLET, 500 MG POWDER
PACKET)
LA
SPRITAM (250 MG TABLET, 500 MG TABLET, 750
MG TABLET, 1,000 MG TABLET)
TEGRETOL XR (100 MG TABLET, 200 MG TABLET,
400 MG TABLET)
tiagabine hcl (2 mg tablet, 4 mg tablet)
TOPAMAX (15 MG SPRINKLE CAP, 25 MG TABLET,
25 MG SPRINKLE CAP, 50 MG TABLET, 100 MG
topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg
tablet, 25 mg cap spr 24, 50 mg cap spr 24, 50 mg
tablet, 100 mg cap spr 24, 100 mg tablet, 150 mg cap
spr 24, 200 mg tablet, 200 mg cap spr 24)
TRILEPTAL (150 MG TABLET, 300 MG/5 ML SUSP,
TROKENDI XR (25 MG CAPSULE, 50 MG CAPSULE,
valproate sodium 250 mg/5ml solution
valproic acid (as sodium salt) (valproate sodium) (salt)
250 mg/5ml solution, salt) 500 mg/5ml vial, salt)
500mg/10ml solution)
valproic acid 250 mg capsule
VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100
MG TABLET, 150 MG TABLET, 200 MG/20 ML VIAL,
200 MG TABLET)
ZONEGRAN 100 MG CAPSULE
zonisamide (25 mg capsule, 50 mg capsule, 100 mg
capsule)
ANTIPARKINSONISM AGENTS
APOKYN 30 MG/3 ML CARTRIDGE
PA B vs D
28
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
AZILECT (0.5 MG TABLET, 1 MG TABLET)
benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2
mg/2 ml vial, 2 mg/2 ml ampul, 2 mg tablet)
bromocriptine mesylate (2.5 mg tablet, 5 mg capsule)
carbidopa 25 mg tablet
carbidopa/levodopa (carbidopa/levodopa 10mg-100mg
tab rapdis, carbidopa/levodopa 10mg-100mg tablet,
carbidopa/levodopa 25mg-250mg tab rapdis,
carbidopa/levodopa 25mg-250mg tablet,
carbidopa/levodopa 25mg-100mg tab rapdis,
carbidopa/levodopa 25mg-100mg tablet er,
carbidopa/levodopa 25mg-100mg tablet,
carbidopa/levodopa 50mg-200mg tablet er)
carbidopa/levodopa/entacapone
(carbidopa/levodopa/entacapone 12.5-50 mg tablet,
carbidopa/levodopa/entacapone 18.75-75mg tablet,
carbidopa/levodopa/entacapone 25-100-200 tablet,
carbidopa/levodopa/entacapone 31.25-125 tablet,
carbidopa/levodopa/entacapone 37.5-150mg tablet,
carbidopa/levodopa/entacapone 50-200-200 tablet)
COMTAN 200 MG TABLET
entacapone 200 mg tablet
MIRAPEX (0.125 MG TABLET, 0.25 MG TABLET, 0.5
MG TABLET, 0.75 MG TABLET, 1 MG TABLET, 1.5
MG TABLET)
MIRAPEX ER (ER 0.375 MG TABLET, ER 0.75 MG
TABLET, ER 1.5 MG TABLET, ER 2.25 MG TABLET,
ER 3 MG TABLET, ER 3.75 MG TABLET, ER 4.5 MG
TABLET)
NEUPRO (1 MG/24 HR PATCH, 2 MG/24 HR PATCH,
3 MG/24 HR PATCH, 4 MG/24 HR PATCH, 6 MG/24
HR PATCH, 8 MG/24 HR PATCH)
pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet,
0.375 mg tab er 24h, 0.5 mg tablet, 0.75 mg tab er 24h,
0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 1.5 mg tab er
24h, 2.25 mg tab er 24h, 3 mg tab er 24h, 4.5 mg tab er
24h)
29
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet,
2 mg tab er 24h, 2 mg tablet, 3 mg tablet, 4 mg tablet, 4
mg tab er 24h, 5 mg tablet, 6 mg tab er 24h, 8 mg tab
er 24h, 12 mg tab er 24h)
selegiline hcl (5 mg tablet, 5 mg capsule)
STALEVO 100 TABLET
STALEVO 125 TABLET
STALEVO 150 TABLET
STALEVO 200 TABLET
STALEVO 50 TABLET
STALEVO 75 TABLET
TASMAR 100 MG TABLET
tolcapone 100 mg tablet
trihexyphenidyl hcl (2 mg/5 ml elixir, 2 mg tablet, 5 mg
tablet)
ZELAPAR 1.25 MG ODT TABLET
MIGRAINE / CLUSTER HEADACHE THERAPY
almotriptan malate (6.25 mg tablet, 12.5 mg tablet)
QL (8 PER 30 DAYS)
dihydroergotamine mesylate (0.5mg/spry spray/pump, 1
mg/ml ampul, 1 mg/ml vial)
frovatriptan succinate 2.5 mg tablet
QL (12 PER 30 DAYS)
MAXALT (5 MG TABLET, 10 MG TABLET)
QL (36 PER 30 OVER TIME)
MAXALT MLT (5 MG TABLET, 10 MG TABLET)
MIGRANAL NASAL SPRAY
rizatriptan benzoate (5 mg tablet, 5 mg tab rapdis, 10
mg tablet, 10 mg tab rapdis)
sumatriptan (5 mg, 20 mg)
QL (12 PER 30 DAYS)
sumatriptan succinate (4 mg/0.5ml pen injctr, 4
mg/0.5ml cartridge, 4 mg/0.5ml vial, 6 mg/0.5ml pen
injctr, 6 mg/0.5ml syringe, 6 mg/0.5ml cartridge, 6
mg/0.5ml vial, 25 mg tablet)
sumatriptan succinate 100 mg tablet
QL (9 PER 30 DAYS)
30
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
sumatriptan succinate 50 mg tablet
QL (18 PER 30 DAYS)
zolmitriptan (2.5 mg tab rapdis, 2.5 mg tablet)
QL (12 PER 30 DAYS)
zolmitriptan (5 mg tab rapdis, 5 mg tablet)
QL (8 PER 30 DAYS)
MISCELLANEOUS NEUROLOGICAL THERAPY
AMPYRA ER 10 MG TABLET
ARICEPT (5 MG TABLET, 10 MG TABLET, 23 MG
TABLET)
ST, QL (30 PER 30 DAYS)
COPAXONE 40 MG/ML SYRINGE
dalfampridine powder
donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg
tablet, 10 mg tab rapdis, 23 mg tablet)
QL (30 PER 30 DAYS)
EXELON (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG
EXELON (4.6 MG/24HR PATCH, 9.5 MG/24HR
PATCH, 13.3 MG/24HR PATCH)
ST
galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg
galantamine hbr (8 mg, 16 mg, 24 mg)
QL (30 PER 30 DAYS)
HETLIOZ 20 MG CAPSULE
memantine hcl (2 mg/ml solution, 5 mg-10 mg tab ds
pk)
memantine hcl 10 mg tablet
QL (60 PER 30 DAYS)
memantine hcl 5 mg tablet
QL (90 PER 30 DAYS)
NAMENDA (2 MG/ML SOLUTION, 5-10 MG
TITRATION PK)
NAMENDA 10 MG TABLET
NAMENDA 5 MG TABLET
NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE,
21 MG CAPSULE, 28 MG CAPSULE, TITRATION
PACK)
NUEDEXTA 20-10 MG CAPSULE
RAVICTI 1.1 GRAM/ML LIQUID
31
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
rivastigmine (4.6mg/24hr patch, 9.5mg/24hr patch,
13.3mg/24h patch)
rivastigmine tartrate (1.5 mg capsule, 3 mg capsule, 4.5
mg capsule, 6 mg capsule)
QL (60 PER 30 DAYS)
tetrabenazine (12.5 mg tablet, 25 mg tablet)
TYSABRI 300 MG/15 ML VIAL
PA B vs D, LA
XENAZINE (12.5 MG TABLET, 25 MG TABLET)
LA
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
AMRIX (ER 15 MG CAPSULE, ER 30 MG CAPSULE)
PA
baclofen (10 mg tablet, 20 mg tablet)
carisoprodol (250 mg tablet, 350 mg tablet)
PA
carisoprodol/aspirin 200-325 mg tablet
PA
chlorzoxazone 500 mg tablet
PA
codeine/carisoprodol/aspirin 16-200-325 tablet
PA, QL (2490 PER 30 DAYS)
cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet, 10 mg
tablet)
PA
dantrolene sodium (25 mg capsule, 50 mg capsule, 100
mg capsule)
guanidine hcl 125 mg tablet
LORZONE (375 MG TABLET, 750 MG TABLET)
meprobamate (200 mg tablet, 400 mg tablet)
MESTINON (60 MG/5 ML SYRUP, 180 MG
TIMESPAN)
METAXALL 800 MG TABLET
metaxalone (400 mg tablet, 800 mg tablet)
PA
methocarbamol (500 mg tablet, 750 mg tablet)
PA
orphenadrine citrate 100 mg tablet er
PA
pyridostigmine bromide (60 mg tablet, 180 mg tablet er)
SKELAXIN 800 MG TABLET
SOMA 250 MG TABLET
PA
tizanidine hcl (2 mg capsule, 2 mg tablet, 4 mg tablet, 4
32
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ZANAFLEX (2 MG CAPSULE, 4 MG CAPSULE, 6 MG
CAPSULE)
NARCOTIC ANALGESICS
acetaminophen with codeine 300mg-60mg tablet
acetaminophen with codeine phosphate (120-12mg/5
elixir, 120-12mg/5 solution, 240-24/10 solution,
300mg/12.5 solution, 360-36/15 solution)
acetaminophen with codeine phosphate (300mg-30mg
tablet, 300mg-15mg tablet)
ASCOMP WITH CODEINE CAPSULE
buprenorphine hcl (0.3 mg/ml vial, 0.3 mg/ml syringe)
buprenorphine hcl 2 mg tab subl
buprenorphine hcl 8 mg tab subl
QL (75 PER 30 DAYS)
buprenorphine hcl/naloxone hcl (/naloxone 2 mg-0.5mg
tab, /naloxone 8 mg-2 mg tab)
butalbit/acetamin/caff/codeine 50-325-30 capsule
codeine sulfate (15 mg tablet, 30 mg tablet, 60 mg
tablet)
DILAUDID 1 MG/ML LIQUID
DURAMORPH (0.5 MG/ML, 5 MG/10 ML)
DURAMORPH (1 MG/ML, 10 MG/10 ML)
ENDOCET (5-325 TABLET, 7.5-325 MG TABLET, 10325 MG TABLET)
fentanyl (12 mcg/hr patch, 25 mcg/hr patch, 25mcg/hr
patch, 50mcg/hr patch, 75mcg/hr patch)
QL (10 PER 30 DAYS)
fentanyl 100 mcg/hr patch td72
QL (9 PER 30 DAYS)
fentanyl 37.5mcg/hr patch td72
QL (25 PER 30 DAYS)
QL (15 PER 30 DAYS)
QL (11 PER 30 DAYS)
fentanyl citrate 1200 mcg lozenge hd
QL (39 PER 30 DAYS)
QL (29 PER 30 DAYS)
33
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
QL (77 PER 30 DAYS)
QL (58 PER 30 DAYS)
hydrocodone bit/acetaminophen (bit/acetaminophen
5mg-325mg tablet, bit/acetaminophen 10mg-325mg
tablet)
hydrocodone bitartrate/acetaminophen
(hydrocodone/acetaminophen 2.5-108/5,
hydrocodone/acetaminophen 5-217mg/10,
hydrocodone/acetaminophen 7.5-325/15)
(hydrocodone/acetaminophen 2.5-325mg tablet,
hydrocodone/acetaminophen 5 mg-325mg tablet,
hydrocodone/acetaminophen 5mg-300mg tablet,
hydrocodone/acetaminophen 7.5-325mg tablet,
hydrocodone/acetaminophen 7.5-300mg tablet,
hydrocodone/acetaminophen 10mg-325mg tablet,
hydrocodone/acetaminophen 10mg-300mg tablet)
hydrocodone/ibuprofen (hydrocodone/ibuprofen 5mg200mg tablet, hydrocodone/ibuprofen 10mg-200mg
tablet)
QL (57 PER 23 DAYS)
hydrocodone/ibuprofen 7.5-200 mg tablet
QL (50 PER 30 DAYS)
hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mg
tablet)
hydromorphone hcl (8 mg tab er, 12 mg tab er, 16 mg
tab er)
QL (60 PER 30 DAYS)
hydromorphone hcl 1 mg/ml liquid
hydromorphone hcl 2 mg/ml syringe
hydromorphone hcl 32 mg tab er 24h
QL (47 PER 30 DAYS)
hydromorphone hcl/pf (hcl/pf 10 mg/ml ampul, hcl/pf 10
mg/ml vial)
ibuprofen/oxycodone hcl 400mg-5mg tablet
QL (28 PER 30 DAYS)
levorphanol tartrate 2 mg tablet
LORCET 5-325 MG TABLET
LORCET HD 10-325 MG TABLET
LORTAB (5-325 MG TABLET, 7.5-325 MG TABLET,
10-325 MG TABLET)
34
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
meperidine hcl (50 mg tablet, 50 mg/5 ml solution, 100
mg tablet)
methadone hcl (10 mg/ml vial, 10 mg/ml syringe)
methadone hcl 10 mg tablet
methadone hcl 10 mg/5 ml solution
methadone hcl 5 mg tablet
methadone hcl 5 mg/5 ml solution
morphine sulfate (10 mg cap er, 20 mg cap er, 30 mg
cap er, 50 mg cap er, 60 mg cap er)
QL (90 PER 30 DAYS)
morphine sulfate (10 mg/5 ml, 20 mg/5 ml)
morphine sulfate (15 mg tablet er, 30 mg tablet er)
morphine sulfate (15 mg tablet, 30 mg tablet, 100
mg/5ml solution)
morphine sulfate (30 mg cpmp 24hr, 45 mg cpmp 24hr,
60 mg cpmp 24hr, 75 mg cpmp 24hr, 90 mg cpmp 24hr,
100 mg tablet er, 100 mg cap er pel)
QL (60 PER 30 DAYS)
morphine sulfate 120 mg cpmp 24hr
QL (50 PER 30 DAYS)
morphine sulfate 200 mg tablet er
QL (30 PER 30 DAYS)
morphine sulfate 60 mg tablet er
morphine sulfate 80 mg cap er pel
QL (75 PER 30 DAYS)
OPANA 10 MG TABLET
OPANA 5 MG TABLET
OPANA ER (ER 5 MG TABLET, ER 7.5 MG TABLET,
ER 10 MG TABLET, ER 15 MG TABLET, ER 20 MG
TABLET)
QL (90 PER 30 DAYS)
OPANA ER 30 MG TABLET
QL (67 PER 30 DAYS)
OPANA ER 40 MG TABLET
QL (50 PER 30 DAYS)
oxycodone hcl (10 mg tab er, 15 mg tab er, 20 mg tab
er, 30 mg tab er, 40 mg tab er, 60 mg tab er)
QL (90 PER 30 DAYS)
oxycodone hcl (10 mg tablet, 15 mg tablet, 20 mg/ml
oral conc, 20 mg tablet)
oxycodone hcl (5 mg capsule, 5 mg tablet)
35
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
oxycodone hcl 30 mg tablet
oxycodone hcl 5 mg/5 ml solution
oxycodone hcl 80 mg tab er 12h
oxycodone hcl/acetaminophen (hcl/acetaminophen 2.5325mg tablet, hcl/acetaminophen 5mg-325mg tablet,
hcl/acetaminophen 5 mg-325mg tablet,
hcl/acetaminophen 7.5-325mg tablet,
hcl/acetaminophen 10mg-325mg tablet)
oxycodone hcl/acetaminophen 5-325/5ml solution
oxycodone hcl/aspirin 4.8355-325 tablet
oxymorphone hcl (5 mg tab er, 7.5 mg tab er, 10 mg tab
er, 15 mg tab er, 20 mg tab er)
QL (90 PER 30 DAYS)
oxymorphone hcl 10 mg tablet
oxymorphone hcl 30 mg tab er 12h
QL (67 PER 30 DAYS)
oxymorphone hcl 40 mg tab er 12h
QL (50 PER 30 DAYS)
oxymorphone hcl 5 mg tablet
REPREXAIN (2.5-200 MG TABLET, 5-200 MG
TABLET, 10-200 MG TABLET)
QL (50 PER 30 DAYS)
tramadol hcl 300 mg cpbp 17-83
NON-NARCOTIC ANALGESICS
ARTHROTEC 50 MG-200 MCG TAB
ARTHROTEC 75 MG-200 MCG TAB
BUNAVAIL (2.1-0.3 MG, 4.2-0.7 MG, 6.3-1 MG)
butorphanol tartrate (1 mg/ml vial, 1 mg/ml disp syrin)
butorphanol tartrate 10 mg/ml spray
QL (5 PER 28 DAYS)
butorphanol tartrate 2 mg/ml vial
celecoxib (50 mg capsule, 100 mg capsule, 200 mg
QL (60 PER 30 DAYS)
diclofenac potassium 50 mg tablet
diclofenac sodium (1 % gel (gram), 1.5 % drops, 3 %
gel (gram), 25 mg tablet dr, 50 mg tablet dr, 75 mg
tablet dr, 100 mg tab er 24h)
36
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
diclofenac sodium/misoprostol (sodium/misoprostol 50
tab ir dr, sodium/misoprostol 75 tab ir dr)
diflunisal 500 mg tablet
etodolac (200 mg capsule, 400 mg tab er 24h, 400 mg
tablet, 500 mg tablet, 500 mg tab er 24h, 600 mg tab er
24h)
fenoprofen calcium 600 mg tablet
flurbiprofen (50 mg tablet, 100 mg tablet)
ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600
INDOCIN 25 MG/5 ML SUSPENSION
ketoprofen (50 mg capsule, 75 mg capsule, 200 mg
cap24h pel)
ketorolac tromethamine (15 mg/ml vial, 30mg/ml(1) vial,
30 mg/ml vial, 60 mg/2 ml vial)
ketorolac tromethamine 10 mg tablet
QL (20 PER 30 DAYS)
meclofenamate sodium (50 mg capsule, 100 mg
capsule)
mefenamic acid 250 mg capsule
meloxicam (7.5 mg tablet, 15 mg tablet)
nabumetone (500 mg tablet, 750 mg tablet)
nalbuphine hcl (10 mg/ml vial, 10 mg/ml ampul)
nalbuphine hcl (20 mg/ml vial, 20 mg/ml ampul)
naloxone hcl (0.4 mg/ml vial, 0.4 mg/ml ampul, 1 mg/ml
syringe)
naltrexone hcl 50 mg tablet
naproxen (125 mg/5ml oral susp, 250 mg tablet, 375
mg tablet, 375 mg tablet dr, 500 mg tablet dr, 500 mg
tablet)
naproxen sodium (275 mg tablet, 500 mg tbmp 24hr,
550 mg tablet)
oxaprozin 600 mg tablet
pentazocine hcl/naloxone hcl 50mg-0.5mg tablet
37
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
piroxicam (10 mg capsule, 20 mg capsule)
SUBOXONE (4 MG-1 MG, 8 MG-2 MG)
QL (90 PER 30 DAYS)
SUBOXONE 12 MG-3 MG SL FILM
QL (60 PER 30 DAYS)
SUBOXONE 2 MG-0.5 MG SL FILM
sulindac (150 mg tablet, 200 mg tablet)
TALWIN (30 MG/ML VIAL, 30 MG/ML AMPUL)
PA B vs D
tolmetin sodium (400 mg capsule, 600 mg tablet)
tramadol hcl (100 mg 25-75, 200 mg 25-75)
tramadol hcl (100 mg tbmp 24hr, 100 mg tab er 24h,
200 mg tbmp 24hr, 200 mg tab er 24h, 300 mg tab er
24h, 300 mg tbmp 24hr)
QL (30 PER 30 DAYS)
tramadol hcl 50 mg tablet
tramadol hcl/acetaminophen 37.5-325mg tablet
VIVITROL (380 MG VIAL + DILUENT, 380 MG VIAL)
PA B vs D
VOLTAREN 1% GEL
PSYCHOTHERAPEUTIC DRUGS
ABILIFY (2 MG TABLET, 5 MG TABLET, 9.7 MG/1.3
ML VIAL, 10 MG TABLET, 15 MG TABLET, 20 MG
ABILIFY DISCMELT (10 MG TABLET, 15 MG TABLET)
ABILIFY MAINTENA (ER 300 MG SYR, ER 400 MG
VL, ER 400 MG SYR)
ABILIFY MAINTENA ER 300 MG VL
PA B vs D
ADDERALL XR (5 MG CAPSULE, 10 MG CAPSULE,
alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg
tab rapdis, 0.5 mg tab er 24h, 0.5 mg tablet, 1 mg
tablet, 1 mg tab rapdis, 1 mg tab er 24h, 2 mg tab
rapdis, 2 mg tablet, 2 mg tab er 24h, 3 mg tab er 24h)
ALPRAZOLAM 1 MG/ML ORAL CONC
amitriptyline hcl (10 mg tablet, 25 mg tablet, 50 mg
tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet)
38
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
amitriptyline hcl/chlordiazepoxide (amitrip
hcl/chlordiazepoxide 12.5mg-5mg tablet, amitrip
hcl/chlordiazepoxide 25 mg-10mg tablet,
amitriptyline/chlordiazepoxide 12.5mg-5mg tablet,
amitriptyline/chlordiazepoxide 25 mg-10mg tablet)
amoxapine (25 mg tablet, 50 mg tablet, 100 mg tablet,
150 mg tablet)
APLENZIN (ER 174 MG TABLET, ER 348 MG
TABLET, ER 522 MG TABLET)
aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 10
mg tab rapdis, 15 mg tablet, 15 mg tab rapdis, 20 mg
ARISTADA (ER 441 MG/1.6 ML, ER 662 MG/2.4 ML,
ER 882 MG/3.2 ML)
armodafinil (50 mg tablet, 150 mg tablet, 200 mg tablet,
250 mg tablet)
PA
BRINTELLIX (5 MG TABLET, 10 MG TABLET, 20 MG
TABLET)
BRISDELLE 7.5 MG CAPSULE
bupropion hcl (75 mg tablet, 100 mg tablet er, 100 mg
tablet, 150 mg tab er 24h, 150 mg tablet er, 200 mg
tablet er, 300 mg tab er 24h)
buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet,
15 mg tablet, 30 mg tablet)
carbamazepine 400 mg tab er 12h
chlordiazepoxide hcl (5 mg capsule, 10 mg capsule, 25
mg capsule)
chlorpromazine hcl (10 mg tablet, 25 mg tablet, 25
mg/ml ampul, 50 mg tablet, 100 mg tablet, 200 mg
tablet)
citalopram hydrobromide (10 mg tablet, 10 mg/5 ml
solution, 20 mg tablet, 40 mg tablet)
clomipramine hcl (25 mg capsule, 50 mg capsule, 75
mg capsule)
clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis,
0.5 mg tablet, 0.5 mg tab rapdis, 1 mg tab rapdis, 1 mg
tablet, 2 mg tab rapdis, 2 mg tablet)
39
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
clorazepate dipotassium (3.75 mg tablet, 7.5 mg tablet,
15 mg tablet)
clozapine (12.5 mg tab rapdis, 25 mg tablet, 25 mg tab
rapdis, 50 mg tablet, 100 mg tablet, 100 mg tab rapdis,
150 mg tab rapdis, 200 mg tablet, 200 mg tab rapdis)
CLOZARIL (25 MG TABLET, 100 MG TABLET)
CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET,
ER 36 MG TABLET, ER 54 MG TABLET)
CYMBALTA (20 MG CAPSULE, 30 MG CAPSULE, 60
MG CAPSULE)
desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg
DESOXYN 5 MG TABLET
desvenlafaxine (50 mg tab er 24h, 50 mg tab er 24, 100
mg tab er 24h, 100 mg tab er 24)
dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10
mg cpbp 50-50, 10 mg tablet, 15 mg cpbp 50-50, 20 mg
cpbp 50-50, 30 mg cpbp 50-50, 40 mg cpbp 50-50)
40
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate (dextroamphetamine/amphetamine 5 mg cap
er 24h, dextroamphetamine/amphetamine 5 mg tablet,
dextroamphetamine/amphetamine 7.5 mg tablet,
dextroamphetamine/amphetamine 10 mg tablet,
dextroamphetamine/amphetamine 10 mg cap er 24h,
dextroamphetamine/amphetamine 12.5 mg tablet,
dextroamphetamine/amphetamine 30 mg cap er 24h)
dextroamphetamine sulfate (5 mg tablet, 5 mg capsule
er, 10 mg tablet, 10 mg capsule er, 15 mg capsule er)
DIASTAT 2.5 MG PEDI SYSTEM
DIASTAT ACUDIAL (5-7.5-10 MG KT, 12.5-15-20 MG)
diazepam (2 mg tablet, 2.5 mg kit, 5 mg/5 ml solution,
5-7.5-10mg kit, 5 mg/ml oral conc, 5 mg tablet, 10 mg
tablet, 12.5-15-20 kit)
doxepin hcl (10 mg/ml oral conc, 10 mg capsule, 25 mg
capsule, 50 mg capsule, 75 mg capsule, 100 mg
duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 40
mg capsule dr, 60 mg capsule dr)
EFFEXOR XR (37.5 MG CAPSULE, 75 MG CAPSULE,
150 MG CAPSULE)
EMSAM (6 MG/24 PATCH, 9 MG/24 PATCH, 12 MG/24
PATCH)
ergoloid mesylates 1 mg tablet
escitalopram oxalate (5 mg/5 ml solution, 5 mg tablet,
estazolam (1 mg tablet, 2 mg tablet)
eszopiclone (1 mg tablet, 2 mg tablet, 3 mg tablet)
PA
FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG
TABLET, 12 MG TABLET, TITRATION PACK)
41
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
FAZACLO (12.5 MG TABLET, 12.5 MG ODT, 25 MG
TABLET, 25 MG ODT, 100 MG ODT, 100 MG TABLET,
150 MG ODT, 200 MG ODT)
FETZIMA (20-40 MG TITRATION PAK, ER 20 MG
CAPSULE, ER 40 MG CAPSULE, ER 80 MG
CAPSULE, ER 120 MG CAPSULE)
fluoxetine hcl (10 mg tablet, 10 mg capsule, 20 mg
tablet, 20 mg/5 ml solution, 20 mg capsule, 40 mg
capsule, 60 mg tablet, 90 mg capsule dr)
fluphenazine decanoate 25 mg/ml vial
fluphenazine hcl (1 mg tablet, 2.5 mg/5ml elixir, 2.5 mg
tablet, 2.5 mg/ml vial, 5 mg tablet, 5 mg/ml oral conc, 10
mg tablet)
flurazepam hcl (15 mg capsule, 30 mg capsule)
fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100
mg cap er 24h, 100 mg tablet, 150 mg cap er 24h)
FOCALIN (2.5 MG TABLET, 5 MG TABLET, 10 MG
TABLET)
FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15
MG CAPSULE, 20 MG CAPSULE, 25 MG CAPSULE,
CAPSULE)
FORFIVO XL 450 MG TABLET
GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60
GEODON 20 MG/ML VIAL
PA B vs D
guanfacine hcl (1 mg tab er, 2 mg tab er, 3 mg tab er, 4
mg tab er)
HALDOL 5 MG/ML AMPUL
HALDOL DECANOATE 100 AMPUL
HALDOL DECANOATE 50 AMPUL
haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5
mg tablet, 10 mg tablet, 20 mg tablet)
haloperidol decanoate (50 mg/ml vial, 50 mg/ml ampul,
100 mg/ml ampul, 100 mg/ml vial)
haloperidol lactate (2 mg/ml oral conc, 5 mg/ml vial, 5
mg/ml ampul)
42
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg
tablet)
imipramine pamoate (75 mg capsule, 100 mg capsule,
125 mg capsule, 150 mg capsule)
INVEGA (ER 1.5 MG TABLET, ER 3 MG TABLET, ER
6 MG TABLET, ER 9 MG TABLET)
INVEGA SUSTENNA (39 MG/0.25 ML, 78 MG/0.5 ML,
117 MG/0.75 ML, 156 MG/ML SYRG, 234 MG/1.5 ML)
PA B vs D
INVEGA TRINZA (273 MG/0.875 ML, 410 MG/1.315
ML, 546 MG/1.75 ML, 819 MG/2.625 ML)
IRENKA DR 40 MG CAPSULE
KHEDEZLA (ER 50 MG TABLET, ER 100 MG TABLET)
LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG
TABLET, 80 MG TABLET, 120 MG TABLET)
LEXAPRO (5 MG TABLET, 5 MG/5 ML SOLUTION, 10
lithium carbonate (150 mg capsule, 300 mg tablet er,
300 mg tablet, 300 mg capsule, 450 mg tablet er, 600
mg capsule)
lithium citrate 8 meq/5 ml solution
lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
LORAZEPAM INTENSOL 2 MG/ML
loxapine succinate (5 mg capsule, 10 mg capsule, 25
maprotiline hcl (25 mg tablet, 50 mg tablet, 75 mg
tablet)
MARPLAN 10 MG TABLET
METADATE CD (10 MG CAPSULE, 20 MG CAPSULE,
METADATE ER 20 MG TABLET
methamphetamine hcl 5 mg tablet
METHYLIN (2.5 MG CHEWABLE TAB, 5 MG/5 ML
SOLUTION, 5 MG CHEWABLE TABLET, 10 MG/5 ML
SOLUTION, 10 MG CHEWABLE TABLET)
43
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
methylphenidate hcl (2.5 mg tab chew, 5 mg tablet, 5
mg/5 ml solution, 5 mg tab chew, 10 mg tablet, 10 mg/5
ml solution, 10 mg cpbp 30-70, 10 mg tab chew, 18 mg
tab er 24, 20 mg cpbp 30-70, 20 mg tablet, 20 mg cpbp
50-50, 20 mg tablet er, 27 mg tab er 24, 30 mg cpbp
50-50, 30 mg cpbp 30-70, 40 mg cpbp 50-50, 40 mg
cpbp 30-70, 50 mg cpbp 30-70, 60 mg cpbp 30-70)
mirtazapine (7.5 mg tablet, 15 mg tablet, 15 mg tab
rapdis, 30 mg tablet, 30 mg tab rapdis, 45 mg tablet, 45
mg tab rapdis)
modafinil (100 mg tablet, 200 mg tablet)
PA
molindone hcl (5 mg tablet, 10 mg tablet, 25 mg tablet)
NARDIL 15 MG TABLET
nefazodone hcl (50 mg tablet, 100 mg tablet, 150 mg
tablet, 200 mg tablet, 250 mg tablet)
nortriptyline hcl (10 mg/5 ml solution, 10 mg capsule, 25
mg capsule, 50 mg capsule, 75 mg capsule)
NUPLAZID 17 MG TABLET
NUVIGIL (50 MG TABLET, 150 MG TABLET, 200 MG
PA
olanzapine (2.5 mg tablet, 5 mg tablet, 5 mg tab rapdis,
7.5 mg tablet, 10 mg tab rapdis, 10 mg tablet, 10 mg
vial, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 20
mg tab rapdis)
olanzapine/fluoxetine hcl (olanzapine/fluoxetine 3 mg25 mg capsule, olanzapine/fluoxetine 6mg-50mg
capsule, olanzapine/fluoxetine 6mg-25mg capsule,
olanzapine/fluoxetine 12mg-25mg capsule,
olanzapine/fluoxetine 12mg-50mg capsule)
ORAP (1 MG TABLET, 2 MG TABLET)
oxazepam (10 mg capsule, 15 mg capsule, 30 mg
capsule)
paliperidone (1.5 mg tab er 24, 3 mg tab er 24, 6 mg tab
er 24, 9 mg tab er 24)
paroxetine hcl (10 mg tablet, 12.5 mg tab er 24h, 20 mg
tablet, 25 mg tab er 24h, 30 mg tablet, 37.5 mg tab er
24h, 40 mg tablet)
PAXIL 10 MG/5 ML SUSPENSION
44
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet, 16
mg tablet)
perphenazine/amitriptyline hcl
(perphenazine/amitriptyline 2 mg-10 mg tablet,
perphenazine/amitriptyline 2 mg-25 mg tablet,
perphenazine/amitriptyline 4 mg-25 mg tablet,
perphenazine/amitriptyline 4mg-10mg tablet,
perphenazine/amitriptyline 4 mg-50 mg tablet)
PEXEVA (10 MG TABLET, 20 MG TABLET, 30 MG
phenelzine sulfate 15 mg tablet
pimozide (1 mg tablet, 2 mg tablet)
PRISTIQ ER (ER 25 MG TABLET, ER 50 MG TABLET,
ER 100 MG TABLET)
protriptyline hcl (5 mg tablet, 10 mg tablet)
PROVIGIL (100 MG TABLET, 200 MG TABLET)
PA
PROZAC WEEKLY 90 MG CAPSULE
quetiapine fumarate (25 mg tablet, 50 mg tablet, 100
mg tablet, 200 mg tablet, 300 mg tablet, 400 mg tablet)
RESTORIL (7.5 MG CAPSULE, 15 MG CAPSULE,
22.5 MG CAPSULE, 30 MG CAPSULE)
REXULTI (0.25 MG TABLET, 0.5 MG TABLET, 1 MG
TABLET)
RISPERDAL CONSTA (12.5 MG, 25 MG, 37.5 MG, 50
MG)
PA B vs D
RISPERDAL M-TAB (0.5 MG ODT, 1 MG ODT, 2 MG
ODT, 3 MG ODT, 4 MG ODT)
risperidone (0.25 mg tablet, 0.25 mg tab rapdis, 0.5 mg
tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg/ml
solution, 1 mg tablet, 2 mg tablet, 2 mg tab rapdis, 3 mg
tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet)
ROZEREM 8 MG TABLET
PA
SAPHRIS (2.5 MG TAB SL BLK CHRY, 5 MG TAB SL
BLK CHERRY, 5 MG TABLET SUBLINGUAL, 10 MG
TAB SUBLINGUAL, 10 MG TAB SL BLK CHERY)
45
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
SARAFEM (10 MG TABLET, 20 MG TABLET)
SEROQUEL (25 MG TABLET, 50 MG TABLET, 100
MG TABLET, 200 MG TABLET, 300 MG TABLET, 400
MG TABLET)
SEROQUEL XR (50 MG TABLET, 150 MG TABLET,
200 MG TABLET, 300 MG TABLET, 400 MG TABLET)
sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg
STRATTERA (10 MG CAPSULE, 18 MG CAPSULE, 25
SURMONTIL (25 MG CAPSULE, 50 MG CAPSULE,
100 MG CAPSULE)
SYMBYAX (3-25 MG CAPSULE, 6-25 MG CAPSULE,
6-50 MG CAPSULE, 12-25 MG CAPSULE, 12-50 MG
CAPSULE)
temazepam (7.5 mg capsule, 15 mg capsule, 22.5 mg
thioridazine hcl (10 mg tablet, 25 mg tablet, 50 mg
thiothixene (1 mg capsule, 2 mg capsule, 5 mg capsule,
10 mg capsule)
TOFRANIL-PM (75 MG CAPSULE, 100 MG CAPSULE,
tranylcypromine sulfate 10 mg tablet
trazodone hcl (50 mg tablet, 100 mg tablet, 150 mg
triazolam (0.125 mg tablet, 0.25 mg tablet)
trifluoperazine hcl (1 mg tablet, 2 mg tablet, 5 mg tablet,
10 mg tablet)
trimipramine maleate (25 mg capsule, 50 mg capsule,
100 mg capsule)
TRINTELLIX (5 MG TABLET, 10 MG TABLET, 20 MG
TABLET)
46
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
venlafaxine hcl (25 mg tablet, 37.5 mg cap er 24h, 37.5
mg tab er 24, 37.5 mg tablet, 50 mg tablet, 75 mg tab er
24, 75 mg cap er 24h, 75 mg tablet, 100 mg tablet, 150
mg cap er 24h, 150 mg tab er 24, 225 mg tab er 24)
VERSACLOZ 50 MG/ML SUSPENSION
VIIBRYD (10-20 MG STARTER PACK, 10 MG
TABLET, 10-20-40 MG STARTER PK, 20 MG TABLET,
40 MG TABLET)
VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK, 3
MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE)
VYVANSE (20 MG CAPSULE, 30 MG CAPSULE, 40
70 MG CAPSULE)
XYREM 500 MG/ML ORAL SOLUTION
LA
zaleplon (5 mg capsule, 10 mg capsule)
ziprasidone hcl (20 mg capsule, 40 mg capsule, 60 mg
zolpidem tartrate (1.75 mg tab subl, 3.5 mg tab subl, 5
mg tablet, 6.25 mg tab mphase, 10 mg tablet, 12.5 mg
tab mphase)
ZYPREXA (2.5 MG TABLET, 5 MG TABLET, 7.5 MG
TABLET, 10 MG VIAL, 10 MG TABLET, 15 MG
ZYPREXA RELPREVV (210 MG VIAL, 210 MG VL KIT)
PA B vs D
ZYPREXA RELPREVV (300 MG VL KIT, 300 MG VIAL,
405 MG VL KIT, 405 MG VIAL)
ZYPREXA ZYDIS (5 MG TABLET, 10 MG TABLET, 15
CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone hcl (50 mg/ml vial, 50 mg/ml ampul, 200
disopyramide phosphate (100 mg capsule, 150 mg
capsule)
dofetilide (125 mcg capsule, 250 mcg capsule, 500 mcg
capsule)
47
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
flecainide acetate (50 mg tablet, 100 mg tablet, 150 mg
tablet)
mexiletine hcl (150 mg capsule, 200 mg capsule, 250
mg capsule)
MULTAQ 400 MG TABLET
QL (60 PER 30 DAYS)
PACERONE (100 MG TABLET, 200 MG TABLET, 400
MG TABLET)
procainamide hcl (100 mg/ml vial, 500 mg/ml vial)
propafenone hcl (150 mg tablet, 225 mg cap er 12h,
225 mg tablet, 300 mg tablet, 325 mg cap er 12h, 425
mg cap er 12h)
quinidine gluconate (80 mg/ml vial, 324 mg tablet er)
quinidine sulfate (200 mg tablet, 300 mg tablet er, 300
mg tablet)
SORINE (80 MG TABLET, 120 MG TABLET, 160 MG
sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet,
240 mg tablet)
TIKOSYN (125 MCG CAPSULE, 250 MCG CAPSULE,
500 MCG CAPSULE)
ANTIHYPERTENSIVE THERAPY
acebutolol hcl (200 mg capsule, 400 mg capsule)
ADCIRCA 20 MG TABLET
PA
AFEDITAB CR (30 MG TABLET, 60 MG TABLET)
ALDACTAZIDE 50-50 TABLET
amiloride hcl 5 mg tablet
amiloride/hydrochlorothiazide 5 mg-50 mg tablet
amlodipine besylate (2.5 mg tablet, 5 mg tablet, 10 mg
tablet)
48
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
amlodipine besylate/atorvastatin calcium
(amlodipine/atorvastatin 2.5mg-20mg tablet,
amlodipine/atorvastatin 2.5mg-40mg tablet,
amlodipine/atorvastatin 2.5mg-10mg tablet,
amlodipine/atorvastatin 5 mg-20 mg tablet,
amlodipine/atorvastatin 10 mg-80mg tablet,
amlodipine/atorvastatin 10 mg-10mg tablet)
amlodipine besylate/benazepril hcl (besylate/benazepril
2.5mg-10mg capsule, besylate/benazepril 5 mg-40 mg
capsule, besylate/benazepril 5 mg-10 mg capsule,
besylate/benazepril 5 mg-20 mg capsule,
besylate/benazepril 10 mg-40mg capsule,
besylate/benazepril 10 mg-20mg capsule)
amlodipine besylate/valsartan (amlodipine/valsartan
5mg-320mg tablet, amlodipine/valsartan 5 mg-160mg
tablet, amlodipine/valsartan 10mg-160mg tablet,
amlodipine/valsartan 10mg-320mg tablet)
QL (30 PER 30 DAYS)
amlodipine besylate/valsartan/hydrochlorothiazide
(amlodipine/valsartan/hcthiazid 5-160-25mg tablet,
amlodipine/valsartan/hcthiazid 5-160-12.5 tablet,
amlodipine/valsartan/hcthiazid 10mg-160mg tablet,
amlodipine/valsartan/hcthiazid 10-320-25 tablet,
amlodipine/valsartan/hcthiazid 10-160-25 tablet)
QL (30 PER 30 DAYS)
atenolol (25 mg tablet, 50 mg tablet, 100 mg tablet)
atenolol/chlorthalidone (atenolol/chlorthalidone 50 mg25mg tablet, atenolol/chlorthalidone 100mg-25mg
tablet)
AZOR (5-20 MG TABLET, 5-40 MG TABLET, 10-20
MG TABLET, 10-40 MG TABLET)
benazepril hcl (5 mg tablet, 10 mg tablet, 20 mg tablet,
40 mg tablet)
49
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
benazepril hcl/hydrochlorothiazide
(benazepril/hydrochlorothiazide 5-6.25mg tablet,
benazepril/hydrochlorothiazide 10-12.5mg tablet,
benazepril/hydrochlorothiazide 20-12.5 mg tablet,
benazepril/hydrochlorothiazide 20-25mg tablet,
benazepril/hydrochlorothiazide 20 mg-25mg tablet)
betaxolol hcl (10 mg tablet, 20 mg tablet)
bisoprolol fumarate (5 mg tablet, 10 mg tablet)
bisoprolol fumarate/hydrochlorothiazide (fumarate/hctz
2.5-6.25mg tablet, fumarate/hctz 5-6.25mg tablet,
fumarate/hctz 10-6.25mg tablet)
bumetanide (0.25 mg/ml vial, 0.5 mg tablet, 1 mg tablet,
2 mg tablet)
BYSTOLIC (2.5 MG TABLET, 5 MG TABLET, 10 MG
candesartan cilexetil (4 mg tablet, 8 mg tablet, 16 mg
candesartan cilexetil/hydrochlorothiazide
(candesartan/hydrochlorothiazid 16-12.5mg tablet,
candesartan/hydrochlorothiazid 32-12.5mg tablet,
candesartan/hydrochlorothiazid 32mg-25mg tablet)
captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet,
100 mg tablet)
captopril/hydrochlorothiazide
(captopril/hydrochlorothiazide 25 mg-25mg tablet,
captopril/hydrochlorothiazide 25 mg-15mg tablet,
captopril/hydrochlorothiazide 50 mg-15mg tablet,
captopril/hydrochlorothiazide 50 mg-25mg tablet)
CARDURA XL (4 MG TABLET, 8 MG TABLET)
QL (60 PER 30 DAYS)
CARTIA XT (120 MG CAPSULE, 180 MG CAPSULE,
carvedilol (3.125 mg tablet, 6.25 mg tablet, 12.5 mg
chlorothiazide (250 mg tablet, 500 mg tablet)
chlorothiazide sodium 500 mg vial
PA B vs D
chlorthalidone (25 mg tablet, 50 mg tablet)
clonidine (0.1mg/24hr patch, 0.2mg/24hr patch,
0.3mg/24hr patch)
50
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
clonidine hcl (0.1 mg tab er 12h, 0.1 mg tablet, 0.2 mg
tablet, 0.3 mg tablet)
CLORPRES (0.1-15 TABLET, 0.2-15 TABLET, 0.3-15
TABLET)
COREG CR (10 MG CAPSULE, 20 MG CAPSULE, 40
COZAAR (25 MG TABLET, 50 MG TABLET)
COZAAR 100 MG TABLET
DEMSER 250 MG CAPSULE
DIBENZYLINE 10 MG CAPSULE
DILT-CD (180 MG CAPSULE, 240 MG CAPSULE)
DILT-XR (180 MG CAPSULE, 240 MG CAPSULE)
diltiazem hcl (5 mg/ml vial, 30 mg tablet, 60 mg cap er
12h, 60 mg tablet, 90 mg cap er 12h, 90 mg tablet, 100
mg vial port, 120 mg cap er 12h, 120 mg cap er 24h,
120 mg cap er deg, 120 mg capsule er, 120 mg tablet,
180 mg cap er 24h, 180 mg capsule er, 180 mg cap er
deg, 240 mg cap er deg, 240 mg cap er 24h, 240 mg
capsule er, 300 mg capsule er, 300 mg cap er 24h, 360
mg cap er 24h, 360 mg capsule er, 420mg capsule er,
420 mg capsule er)
DIOVAN (40 MG TABLET, 80 MG TABLET, 160 MG
TABLET)
DIOVAN 320 MG TABLET
DIOVAN HCT (80-12.5 MG TABLET, 160-25 MG
TABLET, 160-12.5 MG TAB, 320-12.5 MG TAB, 320-25
MG TABLET)
DIURIL 250 MG/5 ML ORAL SUSP
DIURIL SODIUM 500 MG VIAL
PA B vs D
doxazosin mesylate (1 mg tablet, 2 mg tablet, 4 mg
QL (60 PER 30 DAYS)
EDARBI (40 MG TABLET, 80 MG TABLET)
ST
EDARBYCLOR (40-12.5 MG TABLET, 40-25 MG
TABLET)
ST
enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mg
51
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
enalapril maleate/hydrochlorothiazide
(enalapril/hydrochlorothiazide 5mg-12.5mg tablet,
enalapril/hydrochlorothiazide 10mg-25mg tablet,
enalapril/hydrochlorothiazide 10 mg-25mg tablet)
eplerenone (25 mg tablet, 50 mg tablet)
eprosartan mesylate 600 mg tablet
EXFORGE (5-320 MG TABLET, 5-160 MG TABLET,
10-320 MG TABLET, 10-160 MG TABLET)
EXFORGE HCT (5-160-25 MG TAB, 5-160-12.5 MG
TAB, 10-320-25 MG TAB, 10-160-12.5 MG TAB, 10160-25 MG TAB)
felodipine (2.5 mg tab er, 5 mg tab er, 10 mg tab er)
fosinopril sodium (10 mg tablet, 20 mg tablet, 40 mg
tablet)
fosinopril sodium/hydrochlorothiazide
(fosinopril/hydrochlorothiazide 10-12.5mg tablet,
fosinopril/hydrochlorothiazide 20-12.5 mg tablet)
furosemide (10 mg/ml syringe, 10 mg/ml disp syrin, 10
mg/ml solution, 10 mg/ml vial, 20 mg tablet, 40 mg
tablet, 40mg/5ml solution, 80 mg tablet)
guanfacine hcl (1 mg tablet, 2 mg tablet)
hydralazine hcl (10 mg tablet, 20 mg/ml vial, 25 mg
hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet,
HYZAAR (50-12.5 TABLET, 100-12.5 TABLET, 100-25
TABLET)
indapamide (1.25 mg tablet, 2.5 mg tablet)
INTUNIV (ER 1 MG TABLET, ER 2 MG TABLET, ER 3
MG TABLET, ER 4 MG TABLET)
irbesartan (75 mg tablet, 150 mg tablet, 300 mg tablet)
irbesartan/hydrochlorothiazide
(irbesartan/hydrochlorothiazide 150-12.5mg tablet,
irbesartan/hydrochlorothiazide 300-12.5mg tablet)
isradipine (2.5 mg capsule, 5 mg capsule)
labetalol hcl (5 mg/ml vial, 100 mg tablet, 200 mg tablet,
300 mg tablet)
52
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
lisinopril (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20
mg tablet, 30 mg tablet, 40 mg tablet)
lisinopril/hydrochlorothiazide
(lisinopril/hydrochlorothiazide 10-12.5mg tablet,
lisinopril/hydrochlorothiazide 20-12.5 mg tablet,
lisinopril/hydrochlorothiazide 20 mg-25mg tablet,
lisinopril/hydrochlorothiazide 20-25mg tablet)
losartan potassium (25 mg tablet, 50 mg tablet, 100 mg
tablet)
losartan potassium/hydrochlorothiazide
(losartan/hydrochlorothiazide 50-12.5 mg tablet,
losartan/hydrochlorothiazide 100-12.5mg tablet,
losartan/hydrochlorothiazide 100mg-25mg tablet)
methyclothiazide 5 mg tablet
methyldopa (250 mg tablet, 500 mg tablet)
methyldopa/hydrochlorothiazide
(methyldopa/hydrochlorothiazide 250mg-25mg tablet,
methyldopa/hydrochlorothiazide 250mg-15mg tablet)
metolazone (2.5 mg tablet, 5 mg tablet, 10 mg tablet)
metoprolol succinate (25 mg tab er, 50 mg tab er, 100
mg tab er, 200 mg tab er)
metoprolol tartrate (5 mg/5 ml ampul, 5 mg/5 ml vial)
PA B vs D
metoprolol tartrate (5 mg/5 ml syringe, 25 mg tablet, 50
metoprolol tartrate/hydrochlorothiazide
(metoprolol/hydrochlorothiazide 50 mg-25mg tablet,
metoprolol/hydrochlorothiazide 100mg-50mg tablet,
metoprolol/hydrochlorothiazide 100mg-25mg tablet)
MICARDIS (20 MG TABLET, 40 MG TABLET, 80 MG
TABLET)
MICARDIS HCT (40-12.5 MG TABLET, 80-12.5 MG
minoxidil (2.5 mg tablet, 10 mg tablet)
moexipril hcl 15 mg tablet
53
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
moexipril hcl/hydrochlorothiazide
(moexipril/hydrochlorothiazide 7.5-12.5mg tablet,
moexipril/hydrochlorothiazide 15-25mg tablet,
moexipril/hydrochlorothiazide 15-12.5mg tablet)
nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet)
nadolol/bendroflumethiazide
(nadolol/bendroflumethiazide 40 mg tablet,
nadolol/bendroflumethiazide 80 mg tablet)
nicardipine hcl (20 mg capsule, 30 mg capsule)
NIFEDICAL XL (30 MG TABLET, 60 MG TABLET)
nifedipine (10 mg capsule, 20 mg capsule, 30 mg tab er
24, 30 mg tablet er, 60 mg tablet er, 60 mg tab er 24, 90
mg tab er 24, 90 mg tablet er)
nimodipine 30 mg capsule
nisoldipine (20 mg tab er, 30 mg tab er, 40 mg tab er)
phenoxybenzamine hcl 10 mg capsule
pindolol (5 mg tablet, 10 mg tablet)
prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg
capsule)
propranolol hcl (1 mg/ml vial, 10 mg tablet, 20 mg/5 ml
solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution,
60 mg cap sa 24h, 60 mg tablet, 80 mg tablet, 80 mg
cap sa 24h, 120 mg cap sa 24h, 160 mg cap sa 24h)
propranolol hcl/hydrochlorothiazide
(propranolol/hydrochlorothiazid 40 tablet,
propranolol/hydrochlorothiazid 80 tablet)
quinapril hcl (5 mg tablet, 10 mg tablet, 20 mg tablet, 40
mg tablet)
quinapril hcl/hydrochlorothiazide
(quinapril/hydrochlorothiazide 10-12.5mg tablet,
quinapril/hydrochlorothiazide 20 mg-25mg tablet,
quinapril/hydrochlorothiazide 20-12.5 mg tablet)
ramipril (1.25 mg capsule, 2.5 mg capsule, 5 mg
REMODULIN (1 MG/ML VIAL, 2.5 MG/ML VIAL, 5
MG/ML VIAL, 10 MG/ML VIAL)
PA B vs D
54
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
reserpine (0.1 mg tablet, 0.25 mg tablet)
SODIUM DIURIL 0.5 GRAM VIAL
PA B vs D
spironolact/hydrochlorothiazid 25 mg-25mg tablet
spironolactone (25 mg tablet, 50 mg tablet, 100 mg
tablet)
SULAR (ER 8.5 MG TABLET, ER 34 MG TABLET)
TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE,
CAPSULE)
TEKTURNA (150 MG TABLET, 300 MG TABLET)
TEKTURNA HCT (150-12.5 MG TAB, 150-25 MG
TABLET, 300-12.5 MG TAB, 300-25 MG TABLET)
telmisartan (20 mg tablet, 40 mg tablet, 80 mg tablet)
telmisartan/amlodipine besylate (telmisartan/amlodipine
40 mg-10mg tablet, telmisartan/amlodipine 40 mg-5 mg
tablet, telmisartan/amlodipine 80 mg-10mg tablet,
telmisartan/amlodipine 80 mg-5 mg tablet)
telmisartan/hydrochlorothiazide
(telmisartan/hydrochlorothiazid 40-12.5 mg tablet,
telmisartan/hydrochlorothiazid 80-12.5mg tablet,
telmisartan/hydrochlorothiazid 80 mg-25mg tablet)
terazosin hcl (1 mg capsule, 2 mg capsule, 5 mg
timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet)
torsemide (5 mg tablet, 10 mg tablet, 20 mg tablet, 100
mg tablet)
trandolapril (1 mg tablet, 2 mg tablet, 4 mg tablet)
trandolapril/verapamil hcl (trandolapril/verapamil 1240mg tab, trandolapril/verapamil 2-240mg tab,
trandolapril/verapamil 2 mg-180mg tab,
trandolapril/verapamil 4-240mg tab)
55
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
triamterene/hydrochlorothiazide
(triamterene/hydrochlorothiazid 37.5-25 mg capsule,
triamterene/hydrochlorothiazid 37.5-25 mg tablet,
triamterene/hydrochlorothiazid 50 mg-25mg capsule,
triamterene/hydrochlorothiazid 75 mg-50mg tablet)
valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet,
320 mg tablet)
valsartan/hydrochlorothiazide
(valsartan/hydrochlorothiazide 80-12.5mg tablet,
valsartan/hydrochlorothiazide 160-12.5mg tablet,
valsartan/hydrochlorothiazide 160-25mg tablet,
valsartan/hydrochlorothiazide 320mg-25mg tablet,
valsartan/hydrochlorothiazide 320-12.5mg tablet)
QL (30 PER 30 DAYS)
verapamil hcl (2.5 mg/ml ampul, 2.5 mg/ml vial, 40 mg
tablet, 80 mg tablet, 100 mg cap24h pct, 120 mg
cap24h pel, 120 mg tablet, 120 mg tablet er, 180 mg
tablet er, 180 mg cap24h pel, 200 mg cap24h pct, 240
mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct,
360 mg cap24h pel)
CARDIAC GLYCOSIDES
DIGITEK (125 MCG TABLET, 250 MCG TABLET)
digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg
tablet)
LANOXIN (0.25 MG/ML AMPUL, 500 MCG/2 ML
AMPULE)
PA B vs D
COAGULATION THERAPY
AGGRENOX 25 MG-200 MG CAPSULE
ARIXTRA (2.5 MG, 2.5 MG/0.5 ML, 5 MG, 5 MG/0.4
ML, 7.5 MG, 7.5 MG/0.6 ML, 10 MG, 10 MG/0.8 ML)
PA B vs D
aspirin/dipyridamole 25mg-200mg cpmp 12hr
BRILINTA (60 MG TABLET, 90 MG TABLET)
cilostazol (50 mg tablet, 100 mg tablet)
clopidogrel bisulfate 300 mg tablet
clopidogrel bisulfate 75 mg tablet
QL (30 PER 30 DAYS)
CYKLOKAPRON (100 MG/ML AMPUL, 1,000 MG/10
ML VL)
56
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet)
ELIQUIS (2.5 MG TABLET, 5 MG TABLET)
enoxaparin sodium (100 mg/ml syringe, 300mg/3ml
vial)
enoxaparin sodium (30mg/0.3ml, 40mg/0.4ml,
60mg/0.6ml, 80mg/0.8ml, 120mg/.8ml, 150 mg/ml)
PA B vs D
fondaparinux sodium (2.5 mg/0.5, 5mg/0.4ml,
7.5mg/0.6, 10mg/0.8ml)
PA B vs D
FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2
ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML
SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML,
18,000 UNITS/0.72 ML, 25,000 UNITS/ML VIAL,
95,000 UNITS/3.8 ML VL)
PA B vs D
heparin sodium,porcine (1000/ml vial, 5000/ml vial,
5000/ml(1) cartridge, 10000/ml vial, 20000/ml vial)
heparin sodium,porcine/d5w 20k/500ml iv soln
PA B vs D
heparin sodium,porcine/dextrose 5 % in water
(sodium,porcine/d5w 25000/250 soln,
sodium,porcine/d5w 12500/250 soln,
sodium,porcine/d5w 25000/500 soln,
sodium,porcine/d5w 10k/100ml soln)
JANTOVEN (1 MG TABLET, 2 MG TABLET, 2.5 MG
TABLET, 6 MG TABLET, 7.5 MG TABLET, 10 MG
TABLET)
LOVENOX (30 MG/0.3 ML, 40 MG/0.4 ML, 60 MG/0.6
ML, 80 MG/0.8 ML, 100 MG/ML, 120 MG/0.8 ML, 150
MG/ML)
PA B vs D
LOVENOX 300 MG/3 ML VIAL
LYSTEDA 650 MG TABLET
pentoxifylline 400 mg tablet er
PLAVIX 300 MG TABLET
PLAVIX 75 MG TABLET
QL (30 PER 30 DAYS)
PRADAXA (75 MG CAPSULE, 110 MG CAPSULE, 150
MG CAPSULE)
PROMACTA (12.5 MG TABLET, 25 MG TABLET, 50
57
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ticlopidine hcl 250 mg tablet
tranexamic acid 650 mg tablet
warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet,
3 mg tablet, 4 mg tablet, 5 mg tablet, 6 mg tablet, 7.5
LIPID/CHOLESTEROL LOWERING AGENTS
ADVICOR (500 MG-20 MG TABLET, 750 MG-20 MG
TABLET, 1,000 MG-40 MG TABLET, 1,000 MG-20 MG
TABLET)
atorvastatin calcium (10 mg tablet, 20 mg tablet, 40 mg
CADUET (2.5 MG-40 MG TABLET, 2.5 MG-20 MG
TABLET, 2.5 MG-10 MG TABLET, 5 MG-80 MG
TABLET, 5 MG-10 MG TABLET, 5 MG-40 MG
TABLET, 10 MG-40 MG TABLET)
QL (30 PER 30 DAYS)
cholestyramine/aspartame (cholestyramine/aspartame
4 powd pack, cholestyramine/aspartame 4 powder)
colestipol hcl (1 tablet, 5 packet, 5 ranules)
CRESTOR (5 MG TABLET, 10 MG TABLET, 20 MG
ST
fenofibrate (40 mg tablet, 50 mg capsule, 54 mg tablet,
120 mg tablet, 150 mg capsule, 160 mg tablet)
fenofibrate nanocrystallized (48 mg tablet, 145mg
tablet)
fenofibrate,micronized (43 mg capsule, 67 mg capsule,
130 mg capsule, 134mg capsule, 200 mg capsule)
fenofibric acid (35 mg tablet, 105 mg tablet)
fenofibric acid (choline) ((choline) 45 mg capsule dr,
(choline) 135 mg capsule dr)
FIBRICOR (35 MG TABLET, 105 MG TABLET)
fluvastatin sodium (20 mg capsule, 40 mg capsule)
fluvastatin sodium 80 mg tab er 24h
QL (30 PER 30 DAYS)
gemfibrozil 600 mg tablet
58
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE, 20
60 MG CAPSULE)
PA
lovastatin (10 mg tablet, 20 mg tablet, 40 mg tablet)
LOVAZA 1 GM CAPSULE
niacin (500 mg tab er, 750 mg tab er, 1000 mg tab er)
NIACOR 500 MG TABLET
NIASPAN (ER 500 MG TABLET, ER 750 MG TABLET,
ER 1,000 MG TABLET)
omega-3 acid ethyl esters 1 g capsule
PRALUENT PEN (75 MG/ML, 150 MG/ML)
N/A
PRALUENT SYRINGE (75 MG/ML, 150 MG/ML)
N/A
pravastatin sodium (10 mg tablet, 20 mg tablet, 40 mg
PREVALITE (PACKET, POWDER)
REPATHA 140 MG/ML SURECLICK
N/A
REPATHA 140 MG/ML SYRINGE
N/A
rosuvastatin calcium (5 mg tablet, 10 mg tablet, 20 mg
simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40
VYTORIN (10-80 MG TABLET, 10-10 MG TABLET, 1040 MG TABLET, 10-20 MG TABLET)
QL (30 PER 30 DAYS)
WELCHOL (3.75G PACKET, 625 MG TABLET)
ZETIA 10 MG TABLET
QL (30 PER 30 DAYS)
MISCELLANEOUS CARDIOVASCULAR AGENTS
ADEMPAS (0.5 MG TABLET, 1 MG TABLET, 1.5 MG
TABLET, 2 MG TABLET, 2.5 MG TABLET)
ENTRESTO (24 MG-26 MG TABLET, 49 MG-51 MG
TABLET, 97 MG-103 MG TABLET)
N/A
RANEXA (ER 500 MG TABLET, ER 1,000 MG
TABLET)
PA
sildenafil citrate 10 mg/12.5 vial
59
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
UPTRAVI (200 MCG TABLET, 200-800 TITRATION
PACK, 400 MCG TABLET, 600 MCG TABLET, 800
MCG TABLET, 1,000 MCG TABLET, 1,200 MCG
TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET)
N/A
NITRATES
isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg
tablet, 30 mg tablet, 40 mg tablet er)
isosorbide mononitrate (10 mg tablet, 20 mg tablet, 30
mg tab er 24h, 60 mg tab er 24h, 120 mg tab er 24h)
MINITRAN (0.1 MG/HR PATCH, 0.2 MG/HR PATCH,
0.4 MG/HR PATCH, 0.6 MG/HR PATCH)
NITRO-BID 2% OINTMENT
nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24,
0.4mg/hr patch td24, 0.6mg/hr patch td24, 50 mg/10ml
vial, 400mcg/spr spray)
NITROLINGUAL 0.4 MG SPRAY
NITROSTAT (0.3 MG TABLET, 0.4 MG TABLET, 0.6
MG TABLET)
Central Nervous System Agents
MISCELLANEOUS AGENTS
riluzole 50 mg tablet
DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
acitretin (10 mg capsule, 17.5 mg capsule, 25 mg
capsule)
calcipotriene (0.005 % cream (g), 0.005 % oint. (g),
0.005 % solution)
calcipotriene/betamethasone 0.005-.064 oint. (g)
calcitriol 3 mcg/g oint. (g)
DOVONEX 0.005% CREAM
selenium sulfide (2.5 % suspension, 2.5 % lotion)
60
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
SORIATANE (10 MG CAPSULE, 17.5 MG CAPSULE,
25 MG CAPSULE)
TACLONEX 0.005%-0.064% SUSPENS
TACLONEX SCALP SUSPENSION
BURN THERAPY
silver sulfadiazine 1 % cream (g)
SSD 1% CREAM
SSD AF 1% CREAM
MISCELLANEOUS DERMATOLOGICALS
8-MOP 10 MG CAPSULE
ALDARA 5% CREAM
ammonium lactate (12 % lotion, 12 % cream (g))
CARAC (, 0.5%)
doxepin hcl 5 % cream (g)
ELIDEL 1% CREAM
fluorouracil (0.5 % cream (g), 2 % solution, 5 %
solution, 5 % cream (g))
imiquimod 5 % cream pack
methoxsalen, rapid 10 mg capsule
OXSORALEN-ULTRA 10 MG CAP
PANRETIN 0.1% GEL
podofilox 0.5 % solution
PROTOPIC (0.03%, 0.1%)
PRUDOXIN 5% CREAM
SOLARAZE 3% GEL
tacrolimus (0.03 % (g), 0.1 % (g))
tretinoin 0.05 % gel (gram)
UVADEX 20 MCG/ML VIAL
PA B vs D
VALCHLOR 0.016% GEL
61
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
VEREGEN 15% OINTMENT
THERAPY FOR ACNE
ACANYA (GEL, GEL PUMP)
adapalene (0.1 % gel (gram), 0.1 % cream (g))
AMNESTEEM (10 MG CAPSULE, 20 MG CAPSULE,
40 MG CAPSULE)
AVITA 0.025% CREAM
AZELEX 20% CREAM
BENZACLIN (GEL, GEL 35G PUMP, GEL 50G PUMP)
CLARAVIS (10 MG CAPSULE, 20 MG CAPSULE, 30
clindamycin phosphate (1 % lotion, 1 % med. swab, 1
% gel (gram), 1 % solution)
clindamycin phosphate/benzoyl peroxide (phos/benzoyl
1 %-5 % gel (gram), phos/benzoyl 1 %-5 % gel w/pump,
phos/benzoyl 1.2(1)%-5% gel (gram))
ERY 2% PADS
ERYGEL 2% GEL
erythromycin base/ethyl alcohol (base/ethanol 2 %
solution, base/ethanol 2 % gel (gram))
erythromycin/benzoyl peroxide 3 %-5 % gel (gram)
FINACEA 15% GEL
METROGEL (GEL, PUMP)
metronidazole (0.75 % gel (gram), 0.75 % cream (g),
0.75 % lotion)
MYORISAN 30 MG CAPSULE
NORITATE 1% CREAM
TAZORAC (0.05% CREAM, 0.05% GEL, 0.1% GEL,
0.1% CREAM)
tretinoin (0.01 % gel (gram), 0.025 % gel (gram), 0.025
% cream (g), 0.05 % cream (g), 0.1 % cream (g))
tretinoin microspheres (0.04 % gel w/pump, 0.04 % gel
(gram), 0.1 % gel (gram), 0.1 % gel w/pump)
62
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
TOPICAL ANESTHETICS
lidocaine (5 % adh. patch, 5 % oint. (g))
lidocaine hcl (2 % solution, 2 % jel/pf app, 2 % jel (ml),
5 mg/ml vial, 40 mg/ml solution)
lidocaine hcl/pf 5 mg/ml vial
lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g),
lidocaine/prilocaine 2.5 kit)
LIDODERM 5% PATCH
TOPICAL ANTIBACTERIALS
ALTABAX 1% OINTMENT
BACTROBAN 2% CREAM
CORTISPORIN CREAM
gentamicin sulfate (0.1 % oint. (g), 0.1 % cream (g))
mupirocin 2 % oint. (g)
mupirocin calcium 2 % cream (g)
sulfacetamide sodium 10 % suspension
SULFAMYLON (8.5% CREAM, POWDER PACKET)
TOPICAL ANTIFUNGALS
ciclopirox (0.77 % gel (gram), 8 % solution)
ciclopirox olamine (0.77 % cream (g), 0.77 %
suspension)
clotrimazole (1 % cream (g), 1 % solution)
clotrimazole/betamethasone dipropionate
(clotrimazole/betamethasone 1 % lotion,
clotrimazole/betamethasone 1 % cream (g))
econazole nitrate 1 % cream (g)
ERTACZO 2% CREAM
EXELDERM (CREAM, SOLUTION)
EXTINA 2% FOAM
ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo)
63
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
naftifine hcl (1 % (g), 2 % (g))
NYAMYC 100,000 UNITS/GM POWDER
nystatin (100000/g powder, 100000/g cream (g),
100000/g oint. (g))
nystatin/triamcinolone acetonide (nystatin/triamcin
100000-0.1 cream (g), nystatin/triamcin 100000-0.1
oint. (g))
NYSTOP 100,000 UNITS/GM POWDER
oxiconazole nitrate 1 % cream (g)
TOPICAL ANTIVIRALS
DENAVIR 1% CREAM
ZOVIRAX (CREAM, OINTMENT)
TOPICAL CORTICOSTEROIDS
ALA-CORT 1% CREAM
ALA-SCALP 2% LOTION
alclometasone dipropionate (0.05 % oint. (g), 0.05 %
cream (g))
amcinonide (0.1 % cream (g), 0.1 % lotion, 0.1 % oint.
(g))
betamethasone dipropionate (0.05 % lotion, 0.05 % gel
(gram), 0.05 % cream (g), 0.05 % oint. (g))
betamethasone dipropionate/propylene glycol
(betamethasone/propylene 0.05 % cream (g),
betamethasone/propylene 0.05 % oint. (g),
betamethasone/propylene 0.05 % lotion)
betamethasone valerate (0.1 % cream (g), 0.1 % lotion,
0.1 % oint. (g), 0.12 % foam)
CAPEX SHAMPOO
clobetasol propionate (0.05 % solution, 0.05 % lotion,
0.05 % shampoo, 0.05 % spray, 0.05 % foam, 0.05 %
oint. (g), 0.05 % gel (gram))
DESONATE 0.05% GEL
desonide (0.05 % lotion, 0.05 % cream (g), 0.05 % oint.
(g))
64
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
desoximetasone (0.05 % cream (g), 0.05 % gel (gram),
0.05 % oint. (g), 0.25 % oint. (g), 0.25 % cream (g))
diflorasone diacetate (0.05 % oint. (g), 0.05 % cream
(g))
fluocinolone acetonide (0.01 % cream (g), 0.01 % oil,
0.01 % solution, 0.025 % oint. (g), 0.025 % cream (g))
fluocinonide (0.05 % gel (gram), 0.05 % solution, 0.05
% oint. (g), 0.1 % cream (g))
fluocinonide/emollient base 0.05 % cream (g)
flurandrenolide 0.05 % cream (g)
fluticasone propionate (0.005 % oint. (g), 0.05 % lotion,
0.05 % cream (g))
halobetasol propionate (0.05 % oint. (g), 0.05 % cream
(g))
HALOG (CREAM, OINTMENT)
hydrocortisone (1 % oint. (g), 1 % cream (g), 2.5 %
lotion, 2.5 % cream (g), 2.5 % oint. (g))
hydrocortisone butyrate (0.1 % oint. (g), 0.1 % solution)
hydrocortisone butyrate/emoll 0.1 % cream (g)
hydrocortisone valerate (0.2 % cream (g), 0.2 % oint.
(g))
KENALOG (0.147 MG/GRAM, AEROSOL)
mometasone furoate (0.1 % cream (g), 0.1 % oint. (g),
0.1 % solution)
prednicarbate 0.1 % oint. (g)
PROCTO-PAK 1% CREAM
PROCTOZONE-HC 2.5% CREAM
triamcinolone acetonide (0.025 % cream (g), 0.025 %
oint. (g), 0.025 % lotion, 0.1 % lotion, 0.1 % oint. (g), 0.1
% cream (g), 0.147mg/g aerosol, 0.5 % oint. (g), 0.5 %
cream (g))
TRIDERM 0.1% CREAM
65
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
TOPICAL ENZYMES
SANTYL OINTMENT
TOPICAL SCABICIDES / PEDICULICIDES
EURAX (CREAM, LOTION)
lindane (1 % lotion, 1 % shampoo)
malathion 0.5 % lotion
permethrin 5 % cream (g)
DIAGNOSTICS / MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
neomycin sulfate/polymyxin b sulfate (su/polymyx 40200k/ml ampul, su/polymyx 40-200k/ml vial)
ringers solution irrig soln
ringers solution,lactated irrig soln
0.9 % sodium chloride (0.9 % 0.9 % iv soln, 0.9 % 0.9
% syringe, 0.9 % 0.9 % disp syrin, 0.9 % pggybk prt,
0.9 % 0.9 % vial, 0.9 % pgy vl prt)
PA B vs D
acamprosate calcium 333 mg tablet dr
ACTONEL 30 MG TABLET
ADAGEN 250 UNITS/ML VIAL
PA B vs D
alendronate sodium 40 mg tablet
anagrelide hcl (0.5 mg capsule, 1 mg capsule)
ANTABUSE (250 MG TABLET, 500 MG TABLET)
ARALAST 1,000 MG VIAL
PA B vs D
ARALAST NP (500 MG VIAL, 1,000 MG VIAL)
PA B vs D
BUPHENYL (500 MG TABLET, POWDER)
CARNITOR 1 GM/5 ML VIAL
PA B vs D
cevimeline hcl 30 mg capsule
66
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
CHEMET 100 MG CAPSULE
CLINIMIX 4.25%-5% SOLUTION
PA B vs D
CLINIMIX E (2.75%-5%, 2.75%-10%)
PA B vs D
dextrose 10 % and 0.2 % sodium chloride (10 % 0.2 %
10 % dehp fr bg, 10 % 0.2 % 10 % iv soln)
PA B vs D
dextrose 10 % and 0.45 % nacl 10%-0.45% iv soln
PA B vs D
dextrose 10 % in water (10 %10 % ampul, 10 %10 % iv
soln, 10 %10 % dehp fr bg)
PA B vs D
dextrose 2.5 % and 0.45 % nacl 2.5%-0.45% iv soln
PA B vs D
dextrose 5 % and 0.3 % nacl 5 %-0.3 % iv soln
PA B vs D
dextrose 5 % and 0.9 % nacl 5 %-0.9 % iv soln
PA B vs D
dextrose 5 % in water (5 %5 % iv soln, 5 % pgy vl prt, 5
%5 % vial, 5 % pggybk prt)
PA B vs D
dextrose 5 %-0.2 % nacl 5 %-0.2 % iv soln
PA B vs D
dextrose 5 %-0.45 % nacl 5 %-0.45 % iv soln
PA B vs D
disulfiram (250 mg tablet, 500 mg tablet)
etidronate disodium (200 mg tablet, 400 mg tablet)
EVOXAC 30 MG CAPSULE
EXJADE (125 MG TABLET, 250 MG TABLET, 500 MG
TABLET)
FOSRENOL (500 MG TABLET, 750 MG TABLET,
1,000 MG TABLET)
INCRELEX 40 MG/4 ML VIAL
PA B vs D
JADENU (90 MG TABLET, 180 MG TABLET, 360 MG
TABLET)
KIONEX (15 GM/60 ML SUSPENSION, POWDER)
KUVAN 500 MG POWDER PACKET
levocarnitine (with sugar) 100 mg/ml solution
levocarnitine 200 mg/ml vial
PA B vs D
levocarnitine 330 mg tablet
midodrine hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet)
67
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ORFADIN 4 MG/ML SUSPENSION
pilocarpine hcl (5 mg tablet, 7.5 mg tablet)
potassium citrate (5 tablet er, 10 tablet er)
PROLASTIN C 1,000 MG VIAL
PA B vs D
RENAGEL (400 MG TABLET, 800 MG TABLET)
RENVELA (0.8 GM POWDER PACKET, 2.4 GM
POWDER PACKET, 800 MG TABLET)
RILUTEK 50 MG TABLET
risedronate sodium 30 mg tablet
ST
sodium chloride irrig solution 0.9 % irrig soln
sodium polystyrene sulfonate (15 g/60 ml oral susp, 30
g/120ml enema, 50 g/200ml enema, powder)
SYPRINE 250 MG CAPSULE
VELTASSA (8.4 GM, 16.8 GM, 25.2 GM)
water for irrigation,sterile irrig soln
ZEMAIRA 1,000 MG VIAL
PA B vs D
SMOKING DETERRENTS
BUPROBAN 150 MG TABLET
CHANTIX (0.5 MG TABLET, 1 MG TABLET,
STARTING MONTH BOX, STARTING MONTH PAK)
PA
CHANTIX (1 MG BOX, 1 MG PAK)
NICOTROL CARTRIDGE INHALER
NICOTROL NS 10 MG/ML SPRAY
ZYBAN SR 150 MG TABLET
EAR, NOSE / THROAT MEDICATIONS
azelastine hcl (137 mcg spray/pump, 205.5mcg
spray/pump)
BACTROBAN NASAL 2% OINTMENT
68
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
chlorhexidine gluconate 0.12 % mouthwash
ipratropium bromide (21 mcg, 42 mcg, 42mcg)
olopatadine hcl 0.6 % spray/pump
PATANASE 665 MCG NASAL SPRAY
PERIOGARD 0.12% ORAL RINSE
triamcinolone acetonide 0.1 % paste (g)
TYZINE PEDIATRIC 0.05% DROP
MISCELLANEOUS OTIC PREPARATIONS
ACETASOL HC EAR DROPS
acetic acid 2 % solution
acetic acid/hydrocortisone 2 %-1 % drops
fluocinolone acetonide oil 0.01 % drops
ofloxacin 0.3 % drops
OTIC STEROID / ANTIBIOTIC
CIPRO HC OTIC SUSPENSION
CIPRODEX OTIC SUSPENSION
COLY-MYCIN S (EAR DROP, OTIC UP DROP)
CORTISPORIN-TC EAR SUSPENSION
neomycin sulfate/polymyxin b sulfate/hydrocortisone
(neomycin/polymyxin sulf/hc 3.5-10k-1 solution,
neomycin/polymyxin sulf/hc 3.5-10k-1 drops susp)
ENDOCRINE/DIABETES
ADRENAL HORMONES
A-HYDROCORT 100 MG VIAL
PA B vs D
cortisone acetate 25 mg tablet
dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5
mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg
DEXAMETHASONE INTENSOL 1MG/1ML
69
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
dexamethasone sod phosphate (4 mg/ml vial, 4 mg/ml
syringe)
dexamethasone sod phosphate 10 mg/ml vial
PA B vs D
dexamethasone sodium phosp/pf 10 mg/ml vial
PA B vs D
DEXPAK 13 DAY 1.5 MG TABLET
fludrocortisone acetate 0.1 mg tablet
hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet)
KENALOG-10 10 MG/ML VIAL
PA B vs D
KENALOG-40 40 MG/ML VIAL
PA B vs D
methylprednisolone (4 mg tablet, 4 mg tab ds pk, 8 mg
methylprednisolone acetate (40 mg/ml vial, 80 mg/ml
vial)
PA B vs D
methylprednisolone sodium succinate (40 mg vial, 125
mg vial, 500 mg vial, 1000 mg vial)
PA B vs D
MILLIPRED 10 MG/5 ML SOLUTION
NATPARA (25 MCG, 50 MCG, 75 MCG, 100 MCG)
ORAPRED ODT (ODT 15 MG TABLET, ODT 30 MG
TABLET)
prednisolone 15 mg/5 ml solution
prednisolone sod phosphate (5 mg/5 ml solution, 10 mg
tab rapdis, 15 mg tab rapdis, 15 mg/5 ml solution, 25
mg/5 ml solution, 30 mg tab rapdis)
prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tablet, 5
mg/5 ml solution, 5 mg tab ds pk, 10 mg tablet, 10 mg
tab ds pk, 20 mg tablet, 50 mg tablet)
PREDNISONE 5 MG/ML SOLUTION
PA B vs D
SIGNIFOR (0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML)
SIGNIFOR LAR (20 MG VIAL, 20 MG KIT, 40 MG KIT,
40 MG VIAL, 60 MG VIAL, 60 MG KIT)
PA B vs D
SOLU-CORTEF (100 MG VIAL, 250 MG VIAL, 250 MG
ACT-O-VL, 500 MG VIAL, 500 MG ACT-O-VL, 1,000
MG VIAL)
PA B vs D
SOLU-MEDROL (40 MG VIAL, 500 MG VIAL, 1,000
MG VIAL, 2,000 MG VIAL)
PA B vs D
70
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
VERIPRED 20 20 MG/5 ML SOLN
Antithyroid Agents
methimazole (5 mg tablet, 10 mg tablet)
propylthiouracil 50 mg tablet
DIABETES THERAPY
acarbose (25 mg tablet, 50 mg tablet, 100 mg tablet)
ACTOPLUS MET (15 MG-500 MG TAB, 15 MG-850
MG TAB)
ACTOPLUS MET XR (15-1,000 MG, 30-1,000 MG)
ACTOS (15 MG TABLET, 30 MG TABLET, 45 MG
TABLET)
QL (30 PER 30 DAYS)
BYDUREON 2 MG PEN INJECT
BYDUREON 2 MG VIAL
BYETTA (5 MCG, 10 MCG)
chlorpropamide (100 mg tablet, 250 mg tablet)
CYCLOSET 0.8 MG TABLET
DUETACT (30-4 MG TABLET, 30-2 MG TABLET)
FARXIGA (5 MG TABLET, 10 MG TABLET)
ST
glimepiride (1 mg tablet, 2 mg tablet, 4 mg tablet)
glipizide (2.5 mg tab er 24, 5 mg tablet, 5 mg tab er 24,
10 mg tab er 24, 10 mg tablet)
glipizide/metformin hcl (glipizide/metformin 2.5-250 mg
tablet, glipizide/metformin 2.5-500 mg tablet,
glipizide/metformin 5 mg-500mg tablet)
GLUCAGEN (1 MG HYPOKIT, DIAGNOSTIC 1 MG
VIAL, 1 MG HYPOKIT 2-PACK)
GLUCAGON 1 MG EMERGENCY KIT
glyburide (1.25 mg tablet, 2.5 mg tablet, 5 mg tablet)
glyburide,micronized (1.5 mg tablet, 3 mg tablet, 6 mg
tablet)
71
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
glyburide/metformin hcl (glyburide/metformin 1.25250mg tablet, glyburide/metformin 2.5-500 mg tablet,
glyburide/metformin 5 mg-500mg tablet)
HUMALOG 100 UNITS/ML CARTRIDGE
HUMALOG 100 UNITS/ML KWIKPEN
HUMALOG 200 UNITS/ML KWIKPEN
HUMALOG MIX 50-50 KWIKPEN
HUMALOG MIX 50-50 VIAL
HUMALOG MIX 75-25 VIAL
INVOKAMET (50-1,000 MG TABLET, 50-500 MG
TABLET, 150-500 MG TABLET, 150-1,000 MG
TABLET)
ST
INVOKANA (100 MG TABLET, 300 MG TABLET)
ST
JANUMET (50-1,000 MG TABLET, 50-500 MG
TABLET)
JANUMET XR (50-500 MG TABLET, 50-1,000 MG
TABLET, 100-1,000 MG TABLET)
JANUVIA (25 MG TABLET, 50 MG TABLET, 100 MG
TABLET)
JARDIANCE (10 MG TABLET, 25 MG TABLET)
ST
JENTADUETO (2.5 MG-850 MG TAB, 2.5 MG-1000
MG TAB, 2.5 MG-500 MG TAB)
KAZANO (12.5-500 MG TABLET, 12.5-1,000 MG
TABLET)
KOMBIGLYZE XR (2.5-1,000 MG TAB, 5-1,000 MG
TAB, 5-500 MG TABLET)
LANTUS (100 UNITS/ML CARTRIDGE, 100 UNITS/ML
VIAL)
LANTUS SOLOSTAR 100 UNITS/ML
metformin hcl (500 mg tabergr24h, 500 mg tab er 24,
500 mg tablet, 500 mg tab er 24h, 750 mg tab er 24h,
850 mg tablet, 1000 mg tab er 24, 1000 mg tablet)
miglitol (25 mg tablet, 50 mg tablet, 100 mg tablet)
72
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
nateglinide (60 mg tablet, 120 mg tablet)
NESINA (6.25 MG TABLET, 12.5 MG TABLET, 25 MG
TABLET)
NOVOLOG (100 UNIT/ML CARTRIDGE, 100 UNIT/ML
VIAL)
NOVOLOG 100 UNITS/ML FLEXPEN
NOVOLOG MIX 70-30 FLEXPEN SYRN
NOVOLOG MIX 70-30 VIAL
ONGLYZA (2.5 MG TABLET, 5 MG TABLET)
OSENI (12.5-15 MG TABLET, 12.5-30 MG TABLET,
12.5-45 MG TABLET, 25-30 MG TABLET, 25-15 MG
pioglitazone hcl (15 mg tablet, 30 mg tablet, 45 mg
tablet)
pioglitazone hcl/glimepiride (hcl/glimepiride 30 mg-4 mg
tablet, hcl/glimepiride 30 mg-2 mg tablet)
pioglitazone hcl/metformin hcl (/metformin 15mg-500mg
tablet, /metformin 15mg-850mg tablet)
PRANDIMET (1 MG TABLET, 2 MG TABLET)
PRANDIN (0.5 MG TABLET, 1 MG TABLET, 2 MG
TABLET)
PROGLYCEM 50 MG/ML ORAL SUSP
repaglinide (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
repaglinide/metformin hcl (repaglinide/metformin 1mg500mg tablet, repaglinide/metformin 2 mg-500mg
tablet)
RIOMET 500 MG/5 ML SOLUTION
SYMLINPEN 120 PEN INJECTOR
PA
SYMLINPEN 60 PEN INJECTOR
PA
tolazamide (250 mg tablet, 500 mg tablet)
tolbutamide 500 mg tablet
TOUJEO SOLOSTAR 300 UNITS/ML
TRADJENTA 5 MG TABLET
73
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
VICTOZA 2-PAK 18 MG/3 ML PEN
VICTOZA 3-PAK 18 MG/3 ML PEN
MISCELLANEOUS HORMONES
ALDURAZYME 2.9 MG/5 ML VIAL
PA B vs D
ANADROL-50 TABLET
ANDRODERM (2 MG/24HR PATCH, 4 MG/24HR
PATCH)
ANDROGEL (1%(5G) GEL PACKET, 1%(2.5G) GEL
PACKET, 1% GEL PUMP, 1.62%(1.25G) GEL PCKT,
1.62% GEL PUMP, 1.62%(2.5G) GEL PCKT)
cabergoline 0.5 mg tablet
calcitonin,salmon,synthetic 200/spray spray/pump
calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml
solution, 1 mcg/ml vial, 1 mcg/ml ampul)
CEREZYME 200 UNITS VIAL
CEREZYME 400 UNITS VIAL
PA B vs D
danazol (50 mg capsule, 100 mg capsule, 200 mg
capsule)
desmopressin acetate (0.1 mg tablet, 0.1 mg/ml
solution, 0.2 mg tablet)
desmopressin acetate (4mcg/ml ampul, 4mcg/ml vial)
PA B vs D
doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5
mcg capsule)
doxercalciferol (4mcg/2ml ampul, 4mcg/2ml vial)
PA B vs D
ELAPRASE 6 MG/3 ML VIAL
PA B vs D
FABRAZYME (5 MG VIAL, 35 MG VIAL)
PA B vs D
FORTICAL 200 UNITS NASAL SPRAY
KUVAN 100 MG TABLET
METHITEST 10 MG TABLET
methyltestosterone 10 mg capsule
MIACALCIN (200 UNIT/ML VIAL, 400 UNIT/2 ML VIAL)
74
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
MYOZYME 50 MG VIAL
PA B vs D
NAGLAZYME 5 MG/5 ML VIAL
PA B vs D
NORDITROPIN FLEXPRO 30 MG/3 ML
PA
NORDITROPIN NORDIFLEX 30 MG/3
PA
oxandrolone (2.5 mg tablet, 10 mg tablet)
pamidronate disodium (30 mg vial, 30mg/10ml vial, 60
mg/10ml vial, 90 mg vial, 90 mg/10ml vial)
paricalcitol (1 mcg capsule, 2 mcg capsule, 4mcg
capsule)
SENSIPAR (30 MG TABLET, 60 MG TABLET, 90 MG
TABLET)
SOMAVERT (10 MG VIAL, 15 MG VIAL, 20 MG VIAL)
PA B vs D
STIMATE 1.5 MG/ML NASAL SPRAY
SYNAREL 2 MG/ML NASAL SPRAY
TESTIM 1% (50MG) GEL
testosterone (1.25 g(1%) gel md pmp, 10 mg (2%) gel
md pmp, 25mg(1%) gel packet, 50 mg (1%) gel (gram),
50 mg (1%) gel packet)
testosterone cypionate 200 mg/ml vial
PA B vs D
testosterone enanthate 200 mg/ml vial
TESTRED 10 MG CAPSULE
ZAVESCA 100 MG CAPSULE
ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE)
ZEMPLAR (2 MCG/ML VIAL, 5 MCG/ML VIAL, 10
MCG/2 ML VIAL)
PA B vs D
zoledronic acid (4 mg/5 ml vial, 4 mg vial)
PA B vs D
ZOMETA 4 MG/5 ML VIAL
75
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
THYROID HORMONES
levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75
mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg
tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet,
175mcg tablet, 200 mcg tablet, 300 mcg tablet)
LEVOXYL (25 MCG TABLET, 50 MCG TABLET, 75
MCG TABLET, 88 MCG TABLET, 100 MCG TABLET,
112 MCG TABLET, 125 MCG TABLET, 137 MCG
TABLET, 150 MCG TABLET, 175 MCG TABLET, 200
MCG TABLET)
liothyronine sodium (5 mcg tablet, 10 mcg/ml vial, 25
mcg tablet, 50 mcg tablet)
SYNTHROID (25 MCG TABLET, 50 MCG TABLET, 75
MCG TABLET, 88 MCG TABLET, 100 MCG TABLET,
112 MCG TABLET, 125 MCG TABLET, 137 MCG
TABLET, 150 MCG TABLET, 175 MCG TABLET, 200
MCG TABLET, 300 MCG TABLET)
GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
atropine sulfate (0.05mg/ml syringe, 0.1 mg/ml disp
syrin, 0.1 mg/ml syringe)
BENTYL 10 MG/ML AMPUL
PA B vs D
CANTIL 25 MG TABLET
dicyclomine hcl (10 mg/ml vial, 10 mg capsule, 10 mg/5
ml solution, 20 mg tablet)
diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5.025mg tablet, hcl/atropine 2.5-.025/5 liquid)
glycopyrrolate (0.2 mg/ml vial, 1 mg tablet, 2 mg tablet)
loperamide hcl 2 mg capsule
methscopolamine bromide (2.5 mg tablet, 5 mg tablet)
propantheline bromide 15 mg tablet
TRANSDERM-SCOP 1.5 MG/3 DAY
76
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
MISCELLANEOUS GASTROINTESTINAL AGENTS
alosetron hcl (0.5 mg tablet, 1 mg tablet)
ALOXI (0.075 MG/1.5 ML VIAL, 0.25 MG/5 ML VIAL)
PA B vs D
AMITIZA (8 MCG CAPSULE, 24 MCG CAPSULES)
PA
ANZEMET (50 MG TABLET, 100 MG TABLET)
PA B vs D, QL (7 PER 30 DAYS)
ANZEMET 20 MG/ML VIAL
PA B vs D
APRISO ER 0.375 GRAM CAPSULE
ASACOL HD DR 800 MG TABLET
balsalazide disodium 750 mg capsule
budesonide 3 mg capdr - er
CANASA 1,000 MG SUPPOSITORY
CARBAGLU 200 MG DISPER TABLET
CESAMET 1 MG CAPSULE
PA B vs D
COMPRO 25 MG SUPPOSITORY
CONSTULOSE 10 GM/15 ML SOLN
CREON (DR 3,000 CAPSULE, DR 6,000 CAPSULE,
DR 12,000 CAPSULE, DR 24,000 CAPSULE, DR
36,000 CAPSULE)
cromolyn sodium 20 mg/ml oral conc
CYSTADANE POWDER
DELZICOL DR 400 MG CAPSULE
DIPENTUM 250 MG CAPSULE
dronabinol (2.5 mg capsule, 5 mg capsule, 10 mg
capsule)
PA B vs D
EMEND 125 MG CAPSULE
EMEND 150 MG VIAL
EMEND 40 MG CAPSULE
PA B vs D
EMEND 80 MG CAPSULE
EMEND TRIPACK
ENTOCORT EC 3 MG CAPSULE
77
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ENULOSE 10 GM/15 ML SOLUTION
GATTEX (5 MG ONE-VIAL, 5 MG 30-VIAL)
PA
GAVILYTE-C SOLUTION
GAVILYTE-H AND BISACODYL KIT
GAVILYTE-N SOLUTION
GENERLAC 10 GM/15 ML SOLUTION
GOLYTELY (PACKET, SOLUTION)
granisetron hcl (1 mg tablet, 1 mg/ml(1) vial, 1 mg/ml
vial)
PA B vs D
granisetron hcl/pf (hcl/pf 1 mg/ml(1) vial, hcl/pf 100
mcg/ml vial)
PA B vs D
hydrocortisone 100mg/60ml enema
lactulose (10 g/15 ml, 20 g/30 ml)
lansoprazole/amoxiciln/clarith 30-500-500 combo. pkg
LIALDA DR 1.2 GM TABLET
LINZESS (145 MCG CAPSULE, 290 MCG CAPSULE)
LOTRONEX (0.5 MG TABLET, 1 MG TABLET)
QL (60 PER 30 DAYS)
meclizine hcl (12.5 mg tablet, 25 mg tablet)
mesalamine w/cleansing wipes 4 g/60 ml enema kit
metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10
mg tablet, 10 mg/10ml solution, 10 mg tab rapdis)
metoclopramide hcl (5 mg/ml ampul, 5 mg/ml vial)
PA B vs D
MOVIPREP POWDER PACKET
NULYTELY SOLUTION
NULYTELY WITH FLAVOR PACKS SOL
ondansetron (4 mg tab rapdis, 8 mg tab rapdis)
PA B vs D
ondansetron hcl (4 mg/5 ml solution, 4 mg tablet, 8 mg
PA B vs D
ondansetron hcl/pf (hcl/pf 4 mg/2 ml ampul, hcl/pf 4
mg/2 ml vial)
PA B vs D
OSMOPREP TABLET
78
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
PANCREAZE (DR 4,200 CAP, DR 10,500 CAP, DR
16,800 CAP, DR 21,000 CAP)
PENTASA (250 MG CAPSULE, 500 MG CAPSULE)
PERTZYE (DR 8,000 CAPSULE, DR 16,000 CAPS)
polyethylene glycol 3350 (3350 17g powd pack, 3350
17g/dose powder)
PREVPAC PATIENT PACK
prochlorperazine 25 mg supp.rect
prochlorperazine edisylate (5 mg/ml vial, 10 mg/2 ml
vial)
prochlorperazine maleate (5 mg tablet, 10 mg tablet)
PROCTO-MED HC 2.5% CREAM
PROCTOSOL-HC 2.5% CREAM
RECTIV 0.4% OINTMENT
RELISTOR (12 MG/0.6 ML KIT, 12 MG/0.6 ML VIAL)
REMICADE 100 MG VIAL
PA B vs D
sodium chloride/nahco3/kcl/peg 420g soln recon
SUCRAID 8,500 UNITS/ML SOLN
sulfasalazine (500 mg tablet, 500 mg tablet dr)
TRILYTE WITH FLAVOR PACKETS
ULTRESA (DR 13,800 CAPSULE, DR 20,700
CAPSULE, DR 23,000 CAPSULE)
URSO 250 MG TABLET
URSO FORTE 500 MG TABLET
ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet)
VARUBI 90 MG TABLET
VIOKACE (10,440-39,150, 20,880-78,300)
ZENPEP (DR 3,000 CAPSULE, DR 5,000 CAPSULE,
DR 10,000 CAPSULE, DR 15,000 CAPSULE, DR
20,000 CAPSULE, DR 25,000 CAPSULE)
79
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ULCER THERAPY
CARAFATE 1 GM/10 ML SUSP
cimetidine (200 mg tablet, 300 mg tablet, 400 mg tablet,
800 mg tablet)
cimetidine hcl 300 mg/5ml solution
DEXILANT (DR 30 MG CAPSULE, DR 60 MG
CAPSULE)
esomeprazole magnesium (20 mg capsule dr, 40 mg
capsule dr)
esomeprazole strontium 49.3 mg capsule dr
famotidine (20 mg tablet, 40mg/5ml oral susp, 40 mg
tablet)
famotidine in nacl,iso-osm/pf 20 mg/50ml piggyback
famotidine/pf 20 mg/2 ml vial
KAPIDEX (DR 30 MG CAPSULE, DR 60 MG
CAPSULE)
lansoprazole (15 mg capsule dr, 30 mg capsule dr)
metoclopramide hcl 5 mg tab rapdis
misoprostol (100 mcg tablet, 200 mcg tablet)
nizatidine (150mg/10ml solution, 150 mg capsule, 300
mg capsule)
omeprazole (10 mg capsule dr, 20 mg capsule dr, 40
mg capsule dr)
pantoprazole sodium (20 mg tablet dr, 40 mg vial, 40
mg tablet dr)
PEPCID 40 MG/5 ML ORAL SUSP
PREVACID (15 MG, 30 MG)
PREVPAC PATIENT PACK
PROTONIX IV 40 MG VIAL
PYLERA CAPSULE
rabeprazole sodium 20 mg tablet dr
80
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ranitidine hcl (15 mg/ml syrup, 25 mg/ml vial, 50 mg/2
ml vial, 150 mg capsule, 150 mg tablet, 300 mg tablet,
300 mg capsule)
sucralfate 1 g tablet
IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ACTIMMUNE 100 MCG/0.5 ML VIAL
ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/ML
VIAL, 25 MCG/0.42 ML SYRING, 40 MCG/ML VIAL, 40
MCG/0.4 ML SYRINGE, 60 MCG/0.3 ML SYRINGE, 60
MCG/ML VIAL, 100 MCG/ML VIAL, 100 MCG/0.5 ML
SYRINGE, 150 MCG/0.3 ML SYRINGE, 200 MCG/0.4
ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML
SYRINGE, 300 MCG/ML VIAL, 500 MCG/1 ML
SYRINGE)
PA B vs D
ARANESP 150 MCG/0.75 ML VIAL
ARCALYST 220 MG INJECTION
PA B vs D, LA
AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30
MCG KT, PREFILLED SYR 30 MCG)
PA B vs D
AVONEX PEN (30 MCG/0.5 ML, 30 MCG/0.5 ML KIT)
BETASERON (0.3 MG VIAL, 0.3 MG KIT)
PA B vs D
COPAXONE 20 MG/ML SYRINGE
COSENTYX 150 MG/ML SYRINGE
COSENTYX 300 MG DOSE-2 PENS
COSENTYX 300 MG DOSE-2 SYRINGE
EPOGEN (2,000 UNITS/ML VIAL, 3,000 UNITS/ML
VIAL, 4,000 UNITS/ML VIAL, 20,000 UNITS/2 ML VIAL,
20,000 UNITS/ML VIAL)
PA B vs D
EPOGEN 10,000 UNITS/ML VIAL
81
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4
MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG,
MINIQUICK 1 MG, MINIQUICK 1.2 MG, MINIQUICK
1.4 MG, MINIQUICK 1.6 MG, MINIQUICK 1.8 MG,
MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MG
CARTRIDGE)
PA
GILENYA 0.5 MG CAPSULE
GLATOPA 20 MG/ML SYRINGE
HUMATROPE (12 MG, 24 MG)
PA
INTRON A (10 MILLION UNITS VIL, 18 MILLION
UNITS VIL, 18 MILLION UNIT/3 ML, 25 MILLION
UNIT/2.5ML, 50 MILLION UNITS VIL)
PA B vs D
LEUKINE 250 MCG VIAL
PA B vs D
NEULASTA (6 MG/0.6 ML SYRINGE, ONPRO 6
MG/0.6 ML KIT)
PA B vs D
NEUMEGA 5 MG VIAL
NEUPOGEN (300 MCG/ML VIAL, 300 MCG/0.5 ML
SYR, 480 MCG/1.6 ML VIAL, 480 MCG/0.8 ML SYR)
PA B vs D
NORDITROPIN FLEXPRO (5 MG/1.5, 10 MG/1.5, 15
MG/1.5)
PA
NORDITROPIN NORDIFLEX (NORDIFLEX 5 MG/1.5,
NORDIFLX 15 MG/1.5)
PA
NUTROPIN AQ 20 MG/2ML PEN CART
PA
NUTROPIN AQ NUSPIN (5, 20)
PA
NUTROPIN AQ NUSPIN 10 INJECTOR
OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10
MG/1.5 ML CRTG)
PA
PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 ML
SYRINGE)
PEGASYS PROCLICK (135 MCG/0.5, 180 MCG/0.5)
PEGINTRON (50 MCG, 80 MCG, 120 MCG, 150 MCG)
PEGINTRON REDIPEN (50 MCG, 50 MCG 4PK, 80
MCG, 80 MCG 4PK, 120 MCG 4PK, 120 MCG, 150
MCG, 150 MCG 4PK)
82
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
PROCRIT (2,000 UNITS/ML VIAL, 3,000 UNITS/ML
VIAL, 4,000 UNITS/ML VIAL, 10,000 UNITS/ML VIAL,
20,000 UNITS/ML VIAL, 40,000 UNITS/ML VIAL)
PA B vs D
PROLEUKIN 22 MILLION UNIT VIAL
PA B vs D
REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML
SYRINGE, TITRATION PACK)
REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML,
TITRATION PACK)
SAIZEN (5 MG VIAL, 8.8 MG CLICK.EASY CARTG)
PA
SEROSTIM (4 MG VIAL, 5 MG VIAL, 6 MG VIAL)
PA
SYLATRON (200 MCG, 300 MCG, 600 MCG)
SYLATRON 4-PACK (200 MCG, 300 MCG, 888 MCG)
ZARXIO (300 MCG/0.5 ML, 480 MCG/0.8 ML)
ZOMACTON (5 MG VIAL, 10 MG VIAL)
ZORBTIVE 8.8 MG VIAL
PA
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
ACTHIB (VIAL, WITH DILUENT)
ADACEL TDAP VIAL
ATGAM 50 MG/ML AMPUL
bcg vaccine, live/pf 50 mg vial
PA B vs D
BEXSERO PREFILLED SYRINGE
BOOSTRIX TDAP (SYRINGE, VIAL)
BOOSTRIX VACCINE SYRINGE
CARIMUNE NF NANOFILTERED (3 GM VIAL, 6 GM
VIAL, 12 GM VIAL)
PA B vs D
CERVARIX VACCINE SYRINGE
CINRYZE 500 UNIT VIAL
PA B vs D
COMVAX VACCINE VIAL
DAPTACEL DTAP VACCINE
ENGERIX-B 20 MCG/ML SYRN
PA B vs D
ENGERIX-B 20 MCG/ML SYRN
PA B vs D
83
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ENGERIX-B 20 MCG/ML VIAL
ENGERIX-B PEDIATRIC-ADOLESCENT (10 MCG/0.5
ML PED VL, PEDI 10 MCG/0.5 SYRN)
PA B vs D
FIRAZYR 30 MG/3 ML SYRINGE
fomepizole 1 g/ml vial
GAMASTAN S-D VIAL
PA B vs D
GAMASTAN S/D SYRINGE
GAMMAGARD LIQUID 10% VIAL
PA B vs D
GAMMAGARD S-D (0.5 GM VL W-ST, 2.5 GM VL
W/ST, 5 G (IGA<1) SOLN, 5 GM VL W/SET, 10 G
(IGA<1) SOL, 10 GM VL W/ST)
GAMUNEX 10% VIAL
PA B vs D
GAMUNEX-C (1 GRAM/10 ML VIAL, 2.5 GRAM/25 ML
VIAL, 5 GRAM/50 ML VIAL, 10 GRAM/100 ML VIAL, 20
GRAM/200 ML VIAL, 40 GRAM/400 ML VIAL)
PA B vs D
GARDASIL (SYRINGE, VIAL)
GARDASIL 9 (9 VIAL, 9 SYRINGE)
HAVRIX (720 UNITS/0.5 ML VIAL, 720 UNIT/0.5 ML
SYRINGE, 1,440 UNITS/ML VIAL)
HIBERIX (VIAL, WITH DILUENT)
IMOVAX RABIES VACCINE (VACCINE VIAL,
VACCINE+DILUENT)
INFANRIX DTAP VIAL
INFANRIX VACCINE VIAL
IPOL (SINGLE DOSE SYRINGE, VIAL)
IXIARO 6 MCG/0.5 ML SYRINGE
KANUMA 20 MG/10 ML VIAL
M-M-R II VACCINE (VIAL, WITH DILUENT)
MENACTRA VIAL
MENHIBRIX VACCINE VIAL
MENOMUNE-A-C-Y-W-135 (VIAL, W-DILUENT)
MENVEO A-C-Y-W-135-DIP VIAL KT
84
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
PEDVAXHIB VACCINE VIAL
PENTACEL ACTHIB COMPONENT VIAL
PROQUAD VIAL
RABAVERT RABIES VACCINE VIAL
PA B vs D
RECOMBIVAX HB (5 MCG/0.5 ML SYR, 10 MCG/ML
VIAL, 10 MCG/ML SYR, 40 MCG/ML VIAL)
PA B vs D
RECOMBIVAX HB 5 MCG/0.5 ML VL
ROTARIX (10E6/ML, VACCINE)
ROTATEQ VACCINE
SAIZEN 8.8 MG VIAL
PA
STRENSIQ (18 MG/0.45 ML VIAL, 28 MG/0.7 ML VIAL,
40 MG/ML VIAL, 80 MG/0.8 ML VIAL)
TENIVAC SYRINGE
PA B vs D
tetanus and diphtheria toxoids, adult (tetanus, 2-2 lf/0.5
vial, tetanus & 2-2lf/0.5 vial)
PA B vs D
tetanus,diphtheria toxd ped/pf 5-25/0.5ml vial
PA B vs D
THYMOGLOBULIN 25 MG VIAL
PA B vs D
TWINRIX VACCINE VIAL
PA B vs D
TYPHIM VI (25 MCG/0.5 ML SYRNG, 25 MCG/0.5 ML
AL)
VAQTA 25 UNITS/0.5 ML SYRINGE
VARIVAX VACCINE (VIAL, WITH DILUENT)
YF-VAX (1 VIAL, 5 VIAL)
ZOSTAVAX VIAL
MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
allopurinol (100 mg tablet, 300 mg tablet)
ALOPRIM 500 MG VIAL
colchicine (0.6 mg capsule, 0.6 mg tablet)
85
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
colchicine/probenecid 0.5-500mg tablet
COLCRYS 0.6 MG TABLET
probenecid 500 mg tablet
ULORIC (40 MG TABLET, 80 MG TABLET)
OSTEOPOROSIS THERAPY
ACTONEL 5 MG TABLET
alendronate sodium (35 mg tablet, 70 mg tablet)
QL (4 PER 28 DAYS)
QL (60 PER 30 DAYS)
QL (30 PER 30 DAYS)
alendronate sodium 70 mg/75ml solution
ATELVIA DR 35 MG TABLET
ST
BONIVA 150 MG TABLET
QL (1 PER 30 DAYS)
BONIVA 3 MG/3 ML SYRINGE
PA B vs D
FORTEO 600 MCG/2.4 ML PEN INJ
PA
FOSAMAX PLUS D (70 MG-5,600, 70 MG-2,800)
ST
ibandronate sodium (3 mg/3 ml syringe, 3 mg/3 ml vial)
PA B vs D
ibandronate sodium 150 mg tablet
QL (1 PER 30 DAYS)
raloxifene hcl 60 mg tablet
risedronate sodium (5 mg tablet, 35 mg tablet dr, 35 mg
tablet)
ST
risedronate sodium 150 mg tablet
OTHER RHEUMATOLOGICALS
ACTEMRA (80 MG/4 ML VIAL, 400 MG/20 ML VIAL)
BENLYSTA 120 MG VIAL
PA B vs D
BENLYSTA 400 MG VIAL
CUPRIMINE 250 MG CAPSULE
DEPEN 250 MG TITRATAB
86
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50
MG/ML SYRINGE, 50 MG/ML SURECLICK SYR)
PA B vs D
HUMIRA (20 MG/0.4 ML, 40 MG/0.8 ML)
PA B vs D
HUMIRA 10 MG/0.2 ML SYRINGE
HUMIRA 40 MG/0.8 ML PEN
HUMIRA PEN CROHN-UC-HS STARTER
HUMIRA PEN PSORIASIS-UVEITIS
ILARIS 180 MG VIAL
PA
KINERET (100 MG/0.67 ML SYRINGE, 100 MG/0.67
ML SYR)
leflunomide (10 mg tablet, 20 mg tablet)
ORENCIA (125 MG/ML SYRINGE, 250 MG VIAL)
PA
RIDAURA 3 MG CAPSULE
XELJANZ XR 11 MG TABLET
N/A
OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
CAMILA 0.35 MG TABLET
CRINONE (4% GEL, 8% GEL)
DEPO-ESTRADIOL 5 MG/ML VIAL
DEPO-PROVERA 400 MG/ML VIAL
PA B vs D
DEPO-SUBQ PROVERA 104 SYRINGE
DIVIGEL (0.25 MG GEL, 0.5 MG GEL, 1 MG GEL)
ENJUVIA (0.3 MG TABLET, 0.45 MG TABLET, 0.625
MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET)
ERRIN 0.35 MG TABLET
ESTRACE 0.01% CREAM
87
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
estradiol (.025mg/24h patch tdwk, .025mg/24h patch
tdsw, .0375mg/24 patch tdwk, .0375mg/24 patch tdsw,
0.05mg/24h patch tdsw, 0.05mg/24h patch tdwk,
0.06mg/24h patch tdwk, .075mg/24h patch tdwk,
.075mg/24h patch tdsw, 0.1mg/24hr patch tdwk,
0.1mg/24hr patch tdsw, 0.5 mg tablet, 1 mg tablet, 2 mg
tablet)
estradiol valerate 20 mg/ml vial
estradiol/norethindrone acet 1 mg-0.5mg tablet
ESTRING 2 MG VAGINAL RING
QL (1 PER 90 DAYS)
estropipate (0.75 mg tablet, 1.5 mg tablet, 3 mg tablet)
EVAMIST 1.53 MG/SPRAY
FEMRING (FEM0.05 MG, FEM0.10 MG)
QL (1 PER 90 DAYS)
FYAVOLV (0.5 MG-2.5 MCG TABLET, 1 MG-5 MCG
TABLET)
hydroxyprogesterone caproate 250 mg/ml vial
JOLIVETTE TABLET
LYZA 0.35 MG TABLET
medroxyprogesterone acetate (2.5 mg tablet, 5 mg
tablet, 10 mg tablet, 150 mg/ml vial, 150 mg/ml syringe)
MENEST (0.3 MG TABLET, 0.625 MG TABLET, 1.25
MG TABLET, 2.5 MG TABLET)
MENOSTAR 14 MCG/DAY PATCH
MIMVEY LO 0.5-0.1 MG TABLET
MINIVELLE (0.025 MG PATCH, 0.0375 MG PATCH,
0.05 MG PATCH, 0.075 MG PATCH, 0.1 MG PATCH)
norethindrone 0.35 mg tablet
norethindrone acetate 5 mg tablet
PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625
MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET,
VAGINAL CREAM-APPL)
PREMARIN 25 MG VIAL
PA B vs D
PREMPHASE 0.625-5 MG TABLET
progesterone,micronized (100 mg capsule, 200 mg
capsule)
88
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
VIVELLE (0.05 MG PATCH, 0.1 MG PATCH)
VIVELLE-DOT (0.025 MG PATCH, 0.0375 MG PATCH,
0.05 MG PATCH, 0.075 MG PATCH, 0.1 MG PATCH)
MISCELLANEOUS OB/GYN
clindamycin phosphate 2 % cream/appl
metronidazole (0.75 % gel w/appl, 1 % gel w/pump, 1 %
gel (gram))
miconazole nitrate 200 mg supp.vag
terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80
mg supp.vag)
VANDAZOLE VAGINAL 0.75% GEL
ORAL CONTRACEPTIVES / RELATED AGENTS
AMETHIA 0.15-0.03-0.01 MG TAB
AMETHYST 90-20 MCG TABLET
APRI 28 DAY TABLET
ARANELLE 28 TABLET
AVIANE-28 TABLET
BALZIVA 28 TABLET
BRIELLYN TABLET
CRYSELLE-28 TABLET
CYCLAFEM (1-35-28 TABLET, 7-7-7-28 TABLET)
EMOQUETTE 28 DAY TABLET
ENPRESSE-28 TABLET
estradiol/norethindrone acet 0.5-0.1mg tablet
ethinyl estradiol/drospirenone 0.03mg-3mg tablet
FEMCON FE (MCON CHEWABLE TABLET, MCON
TABLET)
GILDAGIA 0.4 MG-0.035 MG TAB
INTROVALE 0.15-0.03 MG TABLET
JUNEL (1 MG-20 MCG TABLET, 1.5 MG-30 MCG
TABLET)
89
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
JUNEL FE (1 MG-20 MCG TABLET, 1.5 MG-30 MCG
TABLET)
JUNEL FE 24 TABLET
KARIVA 28 DAY TABLET
KELNOR 1-35 28 TABLET
l-norgest/e.estradiol-e.estrad 150-30(84) tbdspk 3mo
LARIN 21 1-20 TABLET
LARIN FE (1-20 TABLET, 1.5-30 TABLET)
LESSINA-28 TABLET
LEVONEST-28 TABLET
levonorgestrel-ethinyl estradiol (0.1-0.02 tablet, 0.150.03 tbdspk 3mo, 0.15-0.03 tablet, 90-20mcg tablet)
LEVORA-28 TABLET
LOESTRIN (21 1-20 TABLET, 21 1.5-30 TABLET)
LOESTRIN FE (1-20 TABLET, 1.5-30 TABLET)
LUTERA-28 TABLET
MARLISSA-28 TABLET
MICROGESTIN (21 1.5-30 TAB, 21 1-20 TABLET)
MICROGESTIN FE (1-20 TABLET, 1.5-30 TAB)
MONONESSA 28 TABLET
NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 7-7-728 TABLET, 10-11-28 TABLET)
noreth-ethinyl estradiol/iron 0.8-25(24) tab chew
norethindrone acetate-ethinyl estradiol (0.5mg-2.5
tablet, 1mg-5mcg tablet)
norethindrone acetate-ethinyl estradiol/ferrous fumarate
(1mg-20(24) tablet, 1mg-20(21) tablet)
NORTREL (0.5-35 TABLET, 1-35 TABLET, 7-7-7-28
TABLET)
OGESTREL TABLET
ORSYTHIA-28 TABLET
90
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ORTHO TRI-CYCLEN LO TABLET
PIMTREA 28 DAY TABLET
PIRMELLA 1-35-28 TABLET
PORTIA-28 TABLET
PREVIFEM TABLET
QUASENSE 0.15-0.03 MG TABLET
RECLIPSEN 28 DAY TABLET
SEASONIQUE 0.15-0.03-0.01 TAB
SPRINTEC 28 DAY TABLET
SRONYX 0.10-0.02 MG TABLET
TRI-LEGEST FE-28 DAY TABLET
TRI-PREVIFEM TABLET
TRI-SPRINTEC TABLET
TRINESSA TABLET
TRIVORA-28 TABLET
VELIVET 28 DAY TABLET
VESTURA 3 MG-0.02 MG TABLET
XULANE PATCH
ZENCHENT 0.4 MG-35 MCG TABLET
ZOVIA 1-35E TABLET
ZOVIA 1-50E TABLET
OXYTOCICS
methylergonovine maleate 0.2 mg tablet
OPHTHALMOLOGY
ANTIBIOTICS
AZASITE 1% EYE DROPS
bacitracin 500 unit/g oint. (g)
bacitracin/polymyxin b sulfate 500-10k/g oint. (g)
91
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
CILOXAN 0.3% OINTMENT
ciprofloxacin hcl 0.3 % drops
erythromycin base (5 mg/g (g), 5mg/g (g))
GARAMYCIN (0.3% DROPS, 3 MG/ML DROPS)
GENTAK 0.3 % EYE OINTMENT
gentamicin sulfate (0.3 % oint. (g), 0.3 % drops)
levofloxacin 0.5 % drops
MOXEZA 0.5% EYE DROPS
NATACYN EYE DROPS
neomycin sulfate/bacitracin/polymyxin b (neomy
sulf/bacitra/polymyxin b (g), neomycin
su/bacitra/polymyxin (g))
neomycin/polymyxn b/gramicidin 1.75mg-10k drops
ofloxacin 0.3 % drops
polymyxin b sulf/trimethoprim 10000-1/ml drops
tobramycin 0.3 % drops
TOBREX 0.3% EYE OINTMENT
VIGAMOX 0.5% EYE DROPS
ANTIVIRALS
trifluridine 1 % drops
VIROPTIC 1% EYE DROPS
ZIRGAN 0.15% OPHTHALMIC GEL
BETA-BLOCKERS
betaxolol hcl 0.5 % drops
BETOPTIC S 0.25% EYE DROPS
carteolol hcl 1 % drops
levobunolol hcl 0.5 % drops
metipranolol 0.3 % drops
timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 %
sol-gel, 0.5 % drops)
92
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
CHOLINESTERASE INHIBITOR MIOTICS
PHOSPHOLINE IODIDE 0.125%
DIRECT ACTING MIOTICS
ISOPTO CARPINE (1% DROPS, 2% DROPS, 4%
DROPS)
pilocarpine hcl (1 % drops, 2 % drops, 4 % drops)
MISCELLANEOUS OPHTHALMOLOGICS
ALOCRIL 2% EYE DROPS
ALOMIDE 0.1% EYE DROPS
azelastine hcl 0.05 % drops
cromolyn sodium 4 % drops
DUREZOL 0.05% EYE DROPS
ELESTAT 0.05% EYE DROPS
EMADINE 0.05% EYE DROPS
epinastine hcl 0.05 % drops
olopatadine hcl 0.1 % drops
PATADAY 0.2% EYE DROPS
PATANOL 0.1% EYE DROPS
proparacaine hcl 0.5 % drops
RESTASIS 0.05% EYE EMULSION
QL (60 PER 30 DAYS)
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
ACUVAIL 0.45% OPHTH SOLUTION
bromfenac sodium 0.09% drops
diclofenac sodium 0.1 % drops
flurbiprofen sodium 0.03 % drops
ketorolac tromethamine (0.4 % drops, 0.5 % drops)
NEVANAC 0.1% DROPTAINER
93
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ORAL DRUGS FOR GLAUCOMA
acetazolamide (125 mg tablet, 250 mg tablet, 500 mg
capsule er)
acetazolamide sodium 500 mg vial
methazolamide (25 mg tablet, 50 mg tablet)
OTHER GLAUCOMA DRUGS
AZOPT 1% EYE DROPS
bimatoprost 0.03 % drops
COMBIGAN 0.2%-0.5% EYE DROPS
dorzolamide hcl 2 % drops
dorzolamide hcl/timolol maleat 22.3-6.8/1 drops
latanoprost 0.005 % drops
LUMIGAN 0.01% EYE DROPS
TRAVATAN Z 0.004% EYE DROP
travoprost (benzalkonium) 0.004 % drops
XALATAN 0.005% EYE DROPS
STEROID-ANTIBIOTIC COMBINATIONS
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone (neomy sulf/bacitrac zn/poly/hc 3.510k-1 (g), neomycin su/baci zn/poly/hc 3.5-10k-1 (g))
neomycin/polymyxin b sulf/hc 3.5-10k-10 drops susp
neomycin/polymyxin b sulfate/dexamethasone
(neo/polymyx sulf/dexameth 0.1 % drops susp,
neo/polymyx sulf/dexameth 3.5-10k-.1 oint. (g))
PRED-G (1% DROPS, S.O.P. OINTMENT)
TOBRADEX EYE OINTMENT
tobramycin/dexamethasone 0.3 %-0.1% drops susp
ZYLET EYE DROPS
STEROID-SULFONAMIDE COMBINATIONS
BLEPHAMIDE EYE DROPS
94
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
BLEPHAMIDE EYE OINTMENT
sulfacetamide/prednisolone sp 10 %-0.23% drops
STEROIDS
ALREX 0.2% EYE DROPS
dexamethasone sod phosphate 0.1 % drops
FLAREX 0.1% EYE DROPS
fluorometholone 0.1 % drops susp
FML FORTE 0.25% EYE DROPS
FML S.O.P. 0.1% OINTMENT
LOTEMAX (EYE DROPS, EYE OINTMENT,
OPHTHALMIC GEL)
MAXIDEX 0.1% EYE DROPS
PRED FORTE 1% EYE DROPS
prednisolone sod phosphate 1 % drops
VEXOL 1% EYE DROPS
SULFONAMIDES
BLEPH-10 10% EYE DROPS
sulfacetamide sodium (10 % drops, 10 % oint. (g))
SYMPATHOMIMETICS
ALPHAGAN P (ALHAGAN 0.1% DROS, ALHAGAN
0.15% EYE DROS)
apraclonidine hcl 0.5 % drops
brimonidine tartrate (0.15 % drops, 0.2 % drops)
IOPIDINE (0.5% DROPS, 1% DROPS)
VASOCONSTRICTOR DECONGESTANTS
naphazoline hcl 0.1 % drops
OTC-Product
pen needle, diabetic (, 30gx 5/16", , 31 gx3/16", , 31
gx5/16")
95
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
syring-needl,disp,insul,0.3 ml 30gx 5/16" disp syrin
syringe with needle, insulin, safety, 0.3 ml
(ge,needle,insuln,sf,0.3ml 30gx 5/16" disp,
ge,needle,insuln,sf,0.3ml 29 g x1/2" disp)
syringe with needle, insulin, safety, 0.5 ml (29 g x1/2"
disp, 30gx 5/16" disp)
syringe with needle, insulin, safety, 1 ml (29 g x1/2"
disp, 30gx 5/16" disp)
syringe with needle,disposable,insulin 1 ml (ge &
needle,insulin,1 ml 30gx1/2" disp, ge & needle,insulin,1
ml 27gx1/2" disp, ge & needle,insulin,1 ml 26gx1/2"
disp, ge & needle,insulin,1 ml 28gx1/2" disp, ge &
needle,insulin,1 ml 29gx1/2" disp, ge and
needle,insulin,1ml 30gx 5/16" disp, ge and
needle,insulin,1ml 30gx1/2" disp, ge and
needle,insulin,1ml disp, ge and needle,insulin,1ml 29 g
x1/2" disp, ge and needle,insulin,1ml 28gx1/2" disp)
syringe with needle,insulin disposable,0.3 ml (29gx1/2"
disp, 30gx1/2" disp)
syringe with needle,insulin disposable,0.5 ml (28gx1/2"
disp, 29gx1/2" disp, 30gx1/2" disp)
syringe with needle,insulin,0.5 ml (ml 28 gauge disp, ml
29 g x1/2" disp, ml 30gx 5/16" disp, ml 30gx1/2" disp)
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
carbinoxamine maleate (4 mg tablet, 4 mg/5 ml liquid)
cetirizine hcl 1 mg/ml solution
CLARINEX (0.5 MG/ML (2.5 MG/5), 5 MG TABLET)
ST
CLARINEX-D 12 HOUR TABLET
desloratadine (2.5 mg tab rapdis, 5 mg tablet, 5 mg tab
rapdis)
diphenhydramine hcl 50 mg/ml vial
epinephrine 0.3mg/0.3 auto injct
EPIPEN 0.3 MG AUTO-INJECTOR
96
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
EPIPEN 2-PAK 0.3 MG AUTO-INJCT
EPIPEN JR 0.15 MG AUTO-INJCT
EPIPEN JR 2-PAK 0.15 MG INJCTR
hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25
mg tablet, 50 mg/25ml solution, 50 mg tablet)
hydroxyzine pamoate (25 mg capsule, 50 mg capsule,
100 mg capsule)
levocetirizine dihydrochloride (2.5 mg/5ml solution, 5
mg tablet)
PHENADOZ 12.5 MG SUPPOSITORY
PHENERGAN (12.5 MG, 25 MG, 50 MG)
promethazine hcl (12.5 mg tablet, 25 mg tablet, 50 mg
supp.rect, 50 mg tablet)
PROMETHEGAN (25 MG, 50 MG)
XYZAL (2.5 MG/5 ML SOLUTION, 5 MG TABLET)
ST
PULMONARY AGENTS
ACCOLATE (10 MG TABLET, 20 MG TABLET)
acetylcysteine (100 mg/ml vial, 200 mg/ml vial)
PA B vs D
ADVAIR DISKUS (100-50, 250-50, 500-50)
ADVAIR HFA (45-21 MCG, 115-21 MCG, 230-21 MCG)
albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vialneb, 2.5 mg/3ml vial-neb, 2.5 mg/0.5 vial-neb, 5 mg/ml
solution)
PA B vs D
albuterol sulfate (2 mg/5 ml syrup, 2 mg tablet, 4 mg tab
er 12h, 4 mg tablet, 8 mg tab er 12h)
aminophylline (250mg/10ml vial, 250mg/10ml ampul,
500mg/20ml vial, 500mg/20ml ampul)
ANORO ELLIPTA 62.5-25 MCG INH
ASMANEX TWISTHALER 110 MCG #30
ATROVENT HFA INHALER
BECONASE AQ 0.042% SPRAY
BREO ELLIPTA (100-25 MCG, 200-25 MCG)
97
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
BROVANA 15 MCG/2 ML SOLUTION
PA B vs D
budesonide (0.25mg/2ml, 0.5 mg/2ml)
PA B vs D
budesonide (1 mg/2 ml ampul-neb, 32mcg spray/pump)
COMBIVENT RESPIMAT INHAL SPRAY
cromolyn sodium 20 mg/2 ml ampul-neb
PA B vs D
DALIRESP 500 MCG TABLET
DULERA (100 MCG/5 MCG, 200 MCG/5 MCG)
ELIXOPHYLLIN 80 MG/15 ML ELIX
FLOVENT HFA (44 MCG, 110 MCG, 220 MCG)
fluticasone propionate 50 mcg spray susp
INCRUSE ELLIPTA 62.5 MCG INH
ipratropium bromide 0.2 mg/ml solution
PA B vs D
ipratropium/albuterol sulfate 0.5-3mg/3 ampul-neb
PA B vs D
KALYDECO (50 MG GRANULES PACKET, 75 MG
GRANULES PACKET, 150 MG TABLET)
LETAIRIS (5 MG TABLET, 10 MG TABLET)
levalbuterol hcl (0.31mg/3ml, 0.63mg/3ml, 1.25mg/0.5,
1.25mg/3ml)
PA B vs D
metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup,
20 mg tablet)
mometasone furoate 50 mcg spray/pump
montelukast sodium (4 mg gran pack, 4 mg tab chew, 5
mg tab chew, 10 mg tablet)
NASONEX 50 MCG NASAL SPRAY
NUCALA 100 MG VIAL
N/A
OFEV (100 MG CAPSULE, 150 MG CAPSULE)
OMNARIS 50 MCG NASAL SPRAY
ORKAMBI 200 MG-125 MG TABLET
PERFOROMIST 20 MCG/2 ML SOLN
PA B vs D
PROAIR HFA 90 MCG INHALER
QL (17 PER 30 DAYS)
98
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
PROVENTIL HFA 90 MCG INHALER
PULMICORT 1 MG/2 ML RESPULE
PA B vs D
PULMICORT FLEXHALER (90 MCG, 180 MCG)
PULMOZYME 1 MG/ML AMPUL
PA B vs D
QVAR (40 MCG, 80 MCG)
REVATIO (10 MG/ML ORAL SUSP, 20 MG TABLET)
PA
SEREVENT DISKUS 50 MCG
sildenafil citrate 20 mg tablet
PA
SINGULAIR (4 MG GRANULES, 4 MG TABLET
CHEW, 5 MG TABLET CHEW, 10 MG TABLET)
SPIRIVA 18 MCG CP-HANDIHALER
SPIRIVA RESPIMAT (1.25 MCG, 2.5 MCG)
terbutaline sulfate (1 mg/ml vial, 1 mg/ml ampul)
PA B vs D
terbutaline sulfate (2.5 mg tablet, 5 mg tablet)
theophylline anhydrous (100 mg tab er 12h, 200 mg tab
er 12h, 300 mg tab er 12h, 400 mg tablet er, 400 mg
tab er 24h, 450 mg tab er 12h, 600 mg tab er 24h)
TRACLEER (62.5 MG TABLET, 125 MG TABLET)
PA, LA
triamcinolone acetonide 55 mcg spray
TUDORZA PRESSAIR 400 MCG INH
VENTOLIN HFA (90 MCG INHALER, RELION 90 MCG
INH)
QL (36 PER 30 DAYS)
XOLAIR 150 MG VIAL
PA B vs D
XOPENEX (0.31 MG/3 ML, 0.63 MG/3 ML, 1.25 MG/3
ML)
PA B vs D
XOPENEX CONC 1.25 MG/0.5 ML
PA B vs D
XOPENEX HFA 45 MCG INHALER
zafirlukast (10 mg tablet, 20 mg tablet)
ZYFLO 600 MG FILMTAB
ZYFLO CR 600 MG TABLET
99
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
UROLOGICALS
ANTICHOLINERGICS / ANTISPASMODICS
darifenacin hydrobromide (7.5 mg tab er, 15 mg tab er)
QL (30 PER 30 DAYS)
DETROL (1 MG TABLET, 2 MG TABLET)
ENABLEX (7.5 MG TABLET, 15 MG TABLET)
QL (30 PER 30 DAYS)
flavoxate hcl 100 mg tablet
MYRBETRIQ (ER 25 MG TABLET, ER 50 MG
TABLET)
oxybutynin chloride (5 mg/5 ml syrup, 5 mg tablet, 5 mg
tab er 24, 10 mg tab er 24, 15 mg tab er 24)
tolterodine tartrate (1 mg tablet, 2 mg tablet, 2 mg cap
er 24h, 4 mg cap er 24h)
trospium chloride 20 mg tablet
QL (60 PER 30 DAYS)
trospium chloride 60 mg cap er 24h
QL (30 PER 30 DAYS)
VESICARE (5 MG TABLET, 10 MG TABLET)
QL (30 PER 30 DAYS)
BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY
alfuzosin hcl 10 mg tab er 24h
QL (30 PER 30 DAYS)
AVODART 0.5 MG SOFTGEL
QL (30 PER 30 DAYS)
dutasteride 0.5 mg capsule
QL (30 PER 30 DAYS)
dutasteride/tamsulosin hcl 0.5-0.4 mg cpmp 24hr
finasteride 5 mg tablet
QL (30 PER 30 DAYS)
JALYN 0.5-0.4 MG CAPSULE
tamsulosin hcl 0.4 mg cap er 24h
QL (60 PER 30 DAYS)
UROXATRAL 10 MG TABLET
QL (30 PER 30 DAYS)
CHOLINERGIC STIMULANTS
bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg
MISCELLANEOUS UROLOGICALS
ammonium chloride 5 meq/ml vial
PA B vs D
100
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
CYSTAGON (50 MG CAPSULE, 150 MG CAPSULE)
ELMIRON 100 MG CAPSULE
potassium citrate 15 meq tablet er
sodium phenylbutyrate 0.94 g/g powder
Uncategorized
Unclassified
sodium phenylbutyrate 100 % powder
XELJANZ 5 MG TABLET
N/A
VACCINES and MISCELLANEOUS IMMUNOLOGICALS
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
QUADRACEL DTAP-IPV VIAL
VARIZIG 125 UNIT/1.2 ML VIAL
VITAMINS and HEMATINICS
ELECTROLYTES
potassium chloride (20meq/15ml, 40meq/15ml)
VITAMINS, HEMATINICS / ELECTROLYTES
calcium acetate 667 mg capsule
dextrose 5%-lactated ringers 5 % iv soln
ELIPHOS 667 MG TABLET
KLOR-CON 10 MEQ TABLET
KLOR-CON 8 MEQ TABLET
KLOR-CON M10 TABLET
KLOR-CON M15 TABLET
KLOR-CON M20 TABLET
KLOR-CON SPRINKLE (ER 8 CAP, ER 10 CP)
101
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
magnesium sulfate (4 meq/ml syringe, 4 meq/ml disp
syrin)
PA B vs D
magnesium sulfate 4 meq/ml vial
NORMOSOL-R-DEXTROSE 5% IV SOLN
PA B vs D
potassium chloride (2 meq/ml vial, 2 meq/ml iv soln,
10meq/0.1l piggyback, 10meq/50ml piggyback,
20meq/50ml piggyback, 20meq/0.1l piggyback,
40meq/0.1l piggyback)
PA B vs D
potassium chloride (8 capsule er, 8 tablet er, 10 tablet
er, 10 tab er prt, 10 capsule er, 20 tablet er, 20 tab er
prt)
potassium chloride in 0.9 % sodium chloride (20 meq/l
soln, 40 meq/l soln)
PA B vs D
potassium chloride in 5 % dextrose in water (20 meq/l
soln, 40 meq/l soln)
PA B vs D
potassium chloride in dextrose 5 % and 0.9 % sodium
chloride (chloride/d5-0.9%nacl 40 meq/l soln,
chloride/d5-0.9%nacl 20 meq/l soln)
PA B vs D
potassium chloride in dextrose 5 %-0.45 % sodium
chloride (chloride/d5-0.45nacl 10 meq/l soln,
chloride/d5-0.45nacl 20 meq/l soln, chloride/d5-0.45nacl
40 meq/l soln, chloride/d5-0.45nacl 30 meq/l soln)
PA B vs D
potassium chloride in lr-d5 20 meq/l iv soln
potassium chloride-0.45% nacl 20 meq/l iv soln
PA B vs D
potassium chloride/d5-0.2%nacl 20 meq/l iv soln
PA B vs D
potassium chloride/d5-0.3%nacl 20 meq/l iv soln
PA B vs D
ringers solution iv soln
ringers solution,lactated iv soln
PA B vs D
sodium chloride (2.5 meq/ml vial, 2.5 meq/ml iv soln)
PA B vs D
sodium chloride 0.45 % (0.45 % pggybk prt, 0.45 %
0.45 % iv soln)
PA B vs D
sodium chloride 3 % 3 % iv soln
PA B vs D
sodium chloride 5 % 5 % iv soln
PA B vs D
sodium lactate 5 meq/ml vial
PA B vs D
102
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
MISCELLANEOUS NUTRITION PRODUCTS
AMINOSYN 7%-ELECTROLYTE SOL
PA B vs D
AMINOSYN II (7%, 8.5%, 10%, 15%)
PA B vs D
AMINOSYN M 3.5% IV SOLUTION
PA B vs D
AMINOSYN-HBC 7% IV SOLUTION
PA B vs D
AMINOSYN-PF (7%, 10%)
PA B vs D
AMINOSYN-RF 5.2% IV SOLUTION
PA B vs D
CLINIMIX (2.75%-5%, 4.25%-20%, 4.25%-10%, 5%20%, 5%-25%, 5%-15%)
PA B vs D
CLINIMIX E (4.25%-25%, 4.25%-5%, 5%-15%, 5%25%, 5%-20%)
PA B vs D
HEPATAMINE 8% IV SOLUTION
PA B vs D
INTRALIPID (20%, 30%)
PA B vs D
IONOSOL B-D5W IV SOLUTION
PA B vs D
IONOSOL MB-D5W IV SOLUTION
PA B vs D
ISOLYTE P-DEXTROSE 5% SOLN
PA B vs D
ISOLYTE S IV SOLUTION-EXCEL
PA B vs D
NEPHRAMINE 5.4% IV SOLUTION
PA B vs D
NORMOSOL-R PH 7.4 IV SOLUTION
PA B vs D
PLASMA-LYTE 148 IV SOLUTION
PA B vs D
PLASMA-LYTE 56-DEXTROSE 5%
PA B vs D
PLASMA-LYTE A PH 7.4 SOLN.
PA B vs D
PREMASOL (6%, 10%)
PA B vs D
PROCALAMINE IV SOLUTION
PA B vs D
PROSOL 20% INJECTION
PA B vs D
TRAVASOL 10% SOLN VIAFLEX
PA B vs D
TROPHAMINE (6%, 10%)
PA B vs D
VITAMINS / HEMATINICS
ACTIVE OB SOFTGEL
103
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ADVANCED CARE PLUS TABLET
ATABEX EC CAPLET
B-NEXA TABLET
BAL-CARE DHA COMBO PACK
BAL-CARE DHA ESSENTIAL PACK
BP FOLINATAL PLUS B TABLET
C-NATE DHA SOFTGEL
CADEAU DHA SOFTGEL
CALCIUM-PNV 28-1-250 MG SFTGL
CAVAN ONE OMEGA SOFTGEL
CAVAN-ALPHA KIT COMBO PACK
CAVAN-EC SOD DHA VITAMINS
CAVAN-FOLATE DHA COMBO PACK
CAVAN-FOLATE OB TABLET
CAVAN-HEME OB TABLET
CAVAN-HEME OMEGA COMBO PACK
CHOICE-OB + DHA COMBO PACK
CITRANATAL 90 DHA (90, 90 COMBO)
CITRANATAL ASSURE COMBO PACK
CITRANATAL B-CALM (, COMBO)
CITRANATAL DHA PACK
CITRANATAL HARMONY CAPSULE
CITRANATAL RX TABLET
CO-NATAL FA TABLET
COMPLETE NATAL DHA
COMPLETE-RF PRENATAL TABLET
COMPLETENATE TABLET CHEW
CONCEPT DHA CAPSULE
CONCEPT OB CAPSULE
104
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
CORENATE-DHA COMBO PACK
DOCOSAVIT SOFTGEL
DOTHELLE DHA SOFTGEL
DUET DHA (400 MG COMBO PACK, 430 MG COMBO
PACK, VITAMINS)
DUET DHA 400 COMBO PACK
DUET DHA BALANCED ((24 MG IRON), (25 MG
IRON), (26 MG IRON), COMBO PACK)
DUET DHA COMPLETE COMBO PACK
DUET DHA EC (400 EC COMBO PACK, EC 400 MG
COMBO PACK, EC 430 MG COMBO PACK, 430 EC
COMBO PACK, EC PRENATAL VITS)
DUET DHA FERRAZONE EC OMEGA-3
DUET STUARTNATAL (STUART NATAL CHEWABLE
TAB, STUARTNATAL TABLET)
ED CYTE F TABLET
EDGE OB CAPLET
ELITE OB DHA SOFTGEL
ELITE-OB 400 CAPSULE
ELITE-OB CAPLET
ENBRACE HR SOFTGEL
EXTRA-VIRT PLUS DHA SOFTGEL
FEMECAL OB PLUS DHA COMBO PACK
FEMECAL OB TABLET
FOCALGIN 90 DHA COMBO PACK
FOCALGIN CA COMBO PACK
FOCALGIN-B TABLET
FOLBECAL TABLET
FOLCAL DHA (CAPSULE, SOFTGEL)
FOLCAPS CARE ONE CAPSULE
FOLCAPS OMEGA-3 CAPSULE
105
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
FOLET DHA COMBO PACK
FOLET ONE SOFTGEL
FOLIVANE-EC CALCIUM DHA COMBO
FOLIVANE-OB CAPSULE
FOLIVANE-PRX DHA NF CAPSULE
FOLTABS 90 PLUS DHA PACK
FOLTABS PRENATAL PLUS DHA
FOLTABS PRENATAL TABLET
GENTEX ADE TABLET
GESTICARE DHA COMBO PACK
GESTICARE TABLET
HEMENATAL OB + DHA COMBO PACK
HEMENATAL OB TABLET
HIP PRENATAL TABLET
ICAR-C PLUS SR CAPSULE
INATAL ADVANCE TABLET
INATAL GT TABLET
INATAL ULTRA TABLET
INFANATE BALANCE SOFTGEL
INFANATE DHA CAPSULE
INFANATE PLUS SOFTGEL
KOLNATAL DHA DR COMBO PACK
KOSHER PRENATAL PLUS IRON TAB
L-METHYLFOLATE PNV DHA SOFTGEL
LACTOCAL-F TABLET
LEVOMEFOLATEPNV COMBO PACK
M-VIT CAPLET
MACNATAL CN DHA SOFTGEL
MARNATAL-F CAPSULE
106
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
MARNATAL-F PLUS COMBO PACK
MATERNITY VITAMIN
MAXINATE TABLET
MULTI-NATE 30 DHA (30 PRENATAL, 30 430 MG)
MULTI-NATE 30 TABLET
MULTI-NATE DHA EXTRA PRENATAL
MULTINATAL PLUS (CHEW TABLET, TABLET)
MYNATAL (CAPSULE, ULTRACAPLET)
MYNATAL ADVANCE TABLET
MYNATAL PLUS CAPTAB
MYNATAL-Z CAPTAB
MYNATE 90 PLUS CAPLET SA
NATA KOMPLETE PRENATAL TABLET
NATACHEW (TABLET, TABLET CHEW)
NATAFORT TABLET
NATAL-V RX TABLET
NATALVIRT 90 DHA COMBO PACK
NATALVIRT CA COMBO PACK
NATALVIT TABLET
NATELLE C TABLET
NATELLE ONE CAPSULE
NATELLE PLUS COMBO PACK
NATELLE PREFER TABLET
NATELLE TABLET
NATELLE-EZ TABLET
NAVATAB + DHA PACK
NEEVO (CAPLET, COMBO PACK)
NEEVO DHA (CAPSULE, GELCAP)
NEEVODHA CAPSULE
107
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
NESTABS ABC PRENATAL COMBO PK
NESTABS DHA COMBO PACK
NESTABS TABLET
NEWGEN TABLET
NEXA PLUS SOFTGEL
NEXA SELECT (CAPSULE, SOFTGEL)
NIVA-PLUS TABLET
NOVANATAL TABLET
NOVASTART TABLET
NUTRI-TAB OB + DHA COMBO PACK
NUTRI-TAB OB TABLET
O-CAL FA TABLET
O-CAL PRENATAL TABLET
OB COMPLETE (CAPLET, CHEWABLE TABLET)
OB COMPLETE 400 (400 CAPSULE, 400 SOFTGEL)
OB COMPLETE DHA SOFTGEL
OB COMPLETE GOLD SOFTGEL
OB COMPLETE ONE SOFTGEL
OB COMPLETE PETITE SOFTGEL
OB COMPLETE PREMIER TABLET
OB COMPLETE WITH DHA SOFTGEL
OB-NATAL ONE PRENATAL CAPSULE
OBSTETRIX DHA COMBO PAK
OBSTETRIX EC CAPLET
OBTREX DHA PRENATAL VITAMIN
OBTREX PRENATAL CAPLET
PAIRE OB PLUS DHA COMBO PACK
pn vit.w-o ca #7, iron,fa,dha 28-1.25mg capsule
pnv #14/ferrous fum/folic acid 29 mg-1 mg tab chew
108
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
pnv #19/iron ps&heme/folic/dha 22-6-1-200 capsule
PNV 29-1 TABLET
pnv no.115/iron fumarate/fa 29 mg-1 mg tab chew
PNV OB+DHA COMBO PACK
pnv w-o ca no5/fe fumarate/fa 106.5-1mg capsule
pnv with ca,no.72/iron,carb/fa 29 mg-1 mg tablet
pnv with ca,no.72/iron/fa 27 mg-1 mg tablet
pnv#79/iron/fa/lmfolate ca/dha 27-1.13 mg capsule
PNV-DHA + DOCUSATE SOFTGEL
PNV-DHA PLUS SOFTGEL
PNV-DHA SOFTGEL
PNV-FIRST SOFTGEL
PNV-IRON TABLET
PNV-OB WITH DHA COMBO PACK
PNV-OMEGA SOFTGEL
PNV-SELECT TABLET
PNV-TOTAL SOFTGEL
PNV-VP-U CAPSULE
pnv115/iron fumarate/fa/dss 29-1-25 mg tablet
POLY IRON PN FORTE TABLET
POLY IRON PN TABLET
PR NATAL 400 COMBO PACK
PR NATAL 400 EC COMBO PACK
PR NATAL 430 COMBO PACK
PRECARE CHEWABLE TABLET
PRECARE CONCEIVE TABLET
PRECARE PREMIER CAPLETS
109
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
PREFERA OB TABLET
PREFERA-OB ONE SOFTGEL
PREFERA-OB PLUS DHA COMBO PACK
PREFERA-OB TABLET
PREFOL-DHA CAPSULE
PREMESIS RX TABLET
PRENA1 CHEW TABLET
PRENA1 PEARL SOFTGEL
PRENA1 PLUS COMBO PACK
PRENA1 SOFTGEL
PRENA1 TRUE COMBO PACK
PRENACARE TABLET
PRENAFIRST TABLET
PRENAISSANCE 90 DHA COMBO PACK
PRENAISSANCE BALANCE SOFTGEL
PRENAISSANCE CAPSULE
PRENAISSANCE DHA COMBO PACK
PRENAISSANCE DHA HARMONY CMBPK
PRENAISSANCE HARMONY DHA CMBPK
PRENAISSANCE NEXT TABLET
PRENAISSANCE NEXT-B TABLET
PRENAISSANCE PLUS SOFTGEL
PRENAISSANCE PROMISE COMBO PCK
PRENAPLUS TABLET
prenat vit comb.10/iron/fa/dha 65-1-250mg combo. pkg
PRENATA CHEWABLE TABLET
PRENATABS FA TABLET
PRENATABS RX TABLET
PRENATAL FORMULA TABLET
110
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
prenatal vit #60/iron fum/fa 27 mg-1 mg tablet
prenatal vit 15/iron cb/fa/dss 90-1-50 mg tablet
prenatal vits with calcium #74/ferrous fumarate/folic
acid (ca#74/iron/folic acid 27 mg tablet, ca,no.74/iron/fa
27 mg tablet)
PRENATE AM TABLET
PRENATE CHEWABLE TABLET
PRENATE DHA SOFTGEL
PRENATE ELITE TABLET
PRENATE ENHANCE SOFTGEL
PRENATE ESSENTIAL SOFTGEL
PRENATE MINI SOFTGEL
PRENATE PIXIE SOFTGEL
PRENATE PLUS TABLET
PRENATE RESTORE SOFTGEL
PRENATE STAR TABLET
PRENEXA CAPSULE
PRENEXA PREMIER CAPSULE
PREPLUS CA-FE 27 MG-FA 1 MG TB
PREQUE 10 TABLET
PRETAB 29 MG-1 MG TABLET
PREVITE RX TABLET
PRIMACARE ADVANTAGE COMBO PACK
PRIMACARE ONE SOFTGEL
PROTECT NATAL TABLET
PROVIDA DHA CAPSULE
PROVIDA OB CAPSULE
PRUET DHA (, PRENATAL)
PRUET DHA EC (EC VITAMINS, EC VITS)
PUREFE OB PLUS CAPSULE
111
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
PUREFE PLUS CAPSULE
R-NATAL OB SOFTGEL
RE DUALVIT OB CAPSULE
RE OB + DHA PACK
RE OB 90 + DHA PACK
RE-NATA 29 OB PRENATAL TABLET
RE-NATA 29 PRENATAL TABLET
REAPHIRM CAPSULE
RELNATE DHA PRENATAL SOFTGEL
RENATE CAPLET
RENATE DHA (430 MG VIT, VITAMINS)
RENATE DHA EXTRA (PRENATAL VITS, VITAMINS)
ROVIN-A DHA COMBO PACK
ROVIN-NV DHA CAPSULE
ROVIN-NV TABLET
RULAVITE DHA SOFTGEL
SE-CARE CHEWABLE TABLET
SE-CARE CONCEIVE TABLET
SE-CARE GESTURE TABLET
SE-NATAL 19 (19 CHEWABLE TABLET, 19 TABLET)
SE-NATAL 90 DR TABLET
SE-NATAL ONE TABLET
SE-PLETE DHA SOFTGEL
SE-TAN DHA CAPSULE
SELECT-OB + DHA PACK
SELECT-OB CHEWABLE CAPLET
SETONET PRENATAL VITAMIN
SETONET-EC PRENATAL VITAMINS
TANDEM DHA CAPSULE
112
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
TANDEM OB CAPSULE
TARON A PRENATAL DHA COMB PACK
TARON EC CALCIUM DHA COMB PACK
TARON-BC TABLET
TARON-C DHA CAPSULE
TARON-DUO EC COMB PACK
TARON-EC CAL TABLET
TARON-PREX PRENATAL DHA CAP
THRIVITE 19 TABLET
THRIVITE RX TABLET
TL FOLATE TABLET
TL-ASSURE + DHA COMBO PACK
TL-ASSURE ONE CAPSULE
TL-CARE DHA SOFTGEL
TL-SELECT CAPSULE
TL-SELECT DHA SOFTGEL
TRI RX TABLET
TRI-TABS DHA COMBO PACK
TRIADVANCE TABLET
TRICARE DHA 301 CAPSULE
TRICARE PRENATAL COMPLEAT PACK
TRICARE PRENATAL DHA ONE SFTGL
TRICARE PRENATAL TABLET
TRICARE PRENATAL WITH DHA PACK
TRIFERA OB TABLET
TRIMESIS RX TABLET
TRINATAL GT TABLET
TRINATAL RX 1 TABLET
TRINATAL ULTRA TABLET
113
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
TRINATE TABLET
TRISTART DHA SOFTGEL
TRIVEEN-DUO DHA COMBO PACK
TRIVEEN-ONE CAPSULE
TRIVEEN-PRX RNF CAPSULE
TRIVEEN-TEN TABLETS
TRIVEEN-U CAPSULE
TRUST NATAL DHA
ULTIMATE OB DHA COMBO PACK
ULTIMATECARE ADVANTAGE COMBO
ULTIMATECARE COMBO PACK
ULTIMATECARE ONE CAPSULE
ULTIMATECARE ONE NF CAPSULE
V-NATAL DHA COMBO PACK
V-NATAL TABLET
VEMAVITE-PRX 2 CAPSULE
VENA-BAL DHA COMBO PACK
VENATAL COMPLETE DHA COMBO
VENATAL-FA TABLET
VINACAL PRENATAL TABLET
VINATE AZ EXTRA TABLETS
VINATE AZ TABLET
VINATE C TABLET
VINATE CALCIUM PRENATAL TABLET
VINATE CARE CHEWABLE TABLET
VINATE DHA GELCAP
VINATE DHA RF GELCAP
VINATE GT TABLET
VINATE IC CAPSULE
114
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
VINATE II TABLET
VINATE III TABLET
VINATE ONE TABLET
VINATE PN CARE TABLET
VINATE ULTRA TABLET
VINATE-M TABLET
VIRT NATE TABLET
VIRT-ADVANCE TABLET
VIRT-BAL DHA COMBO PACK
VIRT-BAL DHA PLUS COMBO PACK
VIRT-C DHA SOFTGEL
VIRT-CARE ONE CAPSULE
VIRT-NATE DHA SOFTGEL
VIRT-NATE TABLET
VIRT-PN DHA SOFTGEL
VIRT-PN PLUS SOFTGEL
VIRT-PN TABLET
VIRT-SELECT CAPSULE
VIRT-VITE GT TABLET
VIRTPREX CAPSULE
VITAFOL FE+ DOCUSATE COMBO PCK
VITAFOL GUMMIES
VITAFOL NANO TABLET
VITAFOL ULTRA SOFTGEL
VITAFOL-OB CAPLET
VITAFOL-OB+DHA COMBO PACK
VITAFOL-ONE CAPSULE
VITAFOL-PLUS CAPSULE
VITAFOL-PN CAPLET
115
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
VITAMEDMD ONE RX SOFTGEL
VITAMEDMD PLUS RX COMBO PACK
VITAMEDMD REDICHEW RX TAB CHEW
VITAPEARL SOFTGEL
VITAPHIL + DHA 90 PACK
VITAPHIL + DHA PACK
VITAPHIL AIDE CAPLET
VITAPHIL CAPLET
VITASPIRE TABLET
VITATRUE COMBO PACK
VIVA CT PRENATAL CHEWABLE TAB
VIVA DHA PRENATAL SOFTGEL
VOL-NATE TABLET
VOL-PLUS TABLET
VOL-TAB RX TABLET
VP CH ULTRA SOFTGEL
VP-CH PLUS SOFTGEL
VP-CH-PNV PRENATAL SOFTGEL
VP-ERA OB PLUS TABLET
VP-GGR-B6 TABLET
VP-HEME OB + DHA COMBO PACK
VP-HEME OB TABLET
VP-HEME ONE SOFTGEL
VP-PNV-DHA (CAPSULE, SOFTGEL)
VYNATAL-FA TABLET
ZATEAN-CH CAPSULE
ZATEAN-PN DHA CAPSULE
ZATEAN-PN PLUS SOFTGEL
ZATEAN-PN TABLET
116
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ZINGIBER TABLET
117
Alphabetical Listing
0
0.9 % sodium chloride
66
8
8-MOP
61
A
A-HYDROCORT
69
abacavir sulfate
3
abacavir sulfate/lamivudine/zidovudine
3
ABELCET
2
ABILIFY
38
ABILIFY DISCMELT
38
ABILIFY MAINTENA
38
ABRAXANE
16
acamprosate calcium
66
ACANYA
62
acarbose
71
ACCOLATE
97
acebutolol hcl
48
acetaminophen with codeine phosphate
33
ACETASOL HC
69
acetazolamide
94
acetazolamide sodium
94
acetic acid
69
acetic acid/hydrocortisone
69
acetylcysteine
97
acitretin
60
ACTEMRA
86
ACTHIB
83
ACTIMMUNE
81
ACTIVE OB
103
ACTONEL
66,86
ACTOPLUS MET
71
ACTOPLUS MET XR
71
ACTOS
71
ACUVAIL
93
acyclovir
3
acyclovir sodium
3
ADACEL TDAP
83
118
ADAGEN
adapalene
ADCIRCA
ADDERALL XR
adefovir dipivoxil
ADEMPAS
ADRUCIL
ADVAIR DISKUS
ADVAIR HFA
ADVANCED CARE PLUS
ADVICOR
AFEDITAB CR
AFINITOR
AFINITOR DISPERZ
AGGRENOX
ALA-CORT
ALA-SCALP
ALBENZA
albuterol sulfate
alclometasone dipropionate
ALDACTAZIDE
ALDARA
ALDURAZYME
ALECENSA
alendronate sodium
alfuzosin hcl
ALIMTA
ALINIA
ALKERAN
allopurinol
almotriptan malate
ALOCRIL
ALOMIDE
ALOPRIM
alosetron hcl
ALOXI
ALPHAGAN P
alprazolam
ALPRAZOLAM INTENSOL
ALREX
ALTABAX
66
62
48
38
3
59
16
97
97
104
58
48
16
16
56
64
64
9
97
64
48
61
74
16
66,86
100
16
9
16
85
30
93
93
85
77
77
95
38
38
95
63
amantadine hcl
AMBISOME
amcinonide
AMETHIA
AMETHYST
amifostine crystalline
amikacin sulfate
amiloride hcl
amiloride hcl/hydrochlorothiazide
aminophylline
AMINOSYN II
AMINOSYN M
AMINOSYN WITH ELECTROLYTES
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-RF
amiodarone hcl
AMITIZA
amitriptyline hcl
amitriptyline hcl/chlordiazepoxide
amlodipine besylate
amlodipine besylate/atorvastatin calcium
amlodipine besylate/benazepril hcl
amlodipine besylate/valsartan
amlodipine
besylate/valsartan/hydrochlorothiazide
ammonium chloride
ammonium lactate
AMNESTEEM
amoxapine
amoxicillin
amoxicillin/potassium clavulanate
amphotericin b
ampicillin sodium
ampicillin sodium/sulbactam sodium
ampicillin trihydrate
AMPYRA
AMRIX
ANADROL-50
anagrelide hcl
anastrozole
3
2
64
89
89
16
9
48
48
97
103
103
103
103
103
103
47
77
38
39
48
49
49
49
49
100
61
62
39
12
12
2
12
12
12
31
32
74
66
16
119
ANCOBON
ANDRODERM
ANDROGEL
ANORO ELLIPTA
ANTABUSE
ANZEMET
APLENZIN
APOKYN
apraclonidine hcl
APRI
APRISO
APTIOM
APTIVUS
ARALAST
ARALAST NP
ARANELLE
ARANESP
ARCALYST
ARICEPT
ARIMIDEX
aripiprazole
ARISTADA
ARIXTRA
armodafinil
AROMASIN
ARRANON
ARTHROTEC 50
ARTHROTEC 75
ARZERRA
ASACOL HD
ASCOMP WITH CODEINE
ASMANEX
aspirin/dipyridamole
ASTAGRAF XL
ATABEX EC
ATELVIA
atenolol
atenolol/chlorthalidone
ATGAM
atorvastatin calcium
atovaquone
2
74
74
97
66
77
39
28
95
89
77
25
3
66
66
89
81
81
31
16
39
39
56
39
17
17
36
36
17
77
33
97
56
17
104
86
49
49
83
58
9
atovaquone/proguanil hcl
9
ATRIPLA
3
atropine sulfate
76
ATROVENT HFA
97
AVASTIN
17
AVELOX
13
AVELOX ABC PACK
13
AVELOX IV
13
AVIANE
89
AVITA
62
AVODART
100
AVONEX
81
AVONEX PEN
81
azacitidine
17
AZACTAM
9
AZACTAM-ISO-OSMOTIC DEXTROSE
9
AZASAN
17
AZASITE
91
azathioprine
17
azathioprine sodium
17
azelastine hcl
68,93
AZELEX
62
AZILECT
29
azithromycin
8
AZOPT
94
AZOR
49
aztreonam
9
B
B-NEXA
BACIIM
bacitracin
bacitracin/polymyxin b sulfate
baclofen
BACTROBAN
BACTROBAN NASAL
BAL-CARE DHA
BAL-CARE DHA ESSENTIAL
balsalazide disodium
BALZIVA
BANZEL
104
9
9,91
91
32
63
68
104
104
77
89
25
120
BARACLUDE
3
bcg vaccine, live/pf
83
BECONASE AQ
97
BELEODAQ
17
benazepril hcl
49
benazepril hcl/hydrochlorothiazide
50
BENLYSTA
86
BENTYL
76
BENZACLIN
62
benztropine mesylate
29
betamethasone dipropionate
64
betamethasone dipropionate/propylene
glycol
64
betamethasone valerate
64
BETASERON
81
betaxolol hcl
50,92
bethanechol chloride
100
BETOPTIC S
92
bexarotene
17
BEXSERO
83
bicalutamide
17
BICILLIN C-R
12
BICILLIN L-A
12
BICNU
17
BILTRICIDE
9
bimatoprost
94
bisoprolol fumarate
50
bisoprolol fumarate/hydrochlorothiazide
50
bleomycin sulfate
17
BLEPH-10
95
BLEPHAMIDE
94
BLEPHAMIDE S.O.P.
95
BONIVA
86
BOOSTRIX
83
BOOSTRIX TDAP
83
BOSULIF
17
BREO ELLIPTA
97
BRIELLYN
89
BRILINTA
56
brimonidine tartrate
95
BRINTELLIX
39
BRISDELLE
39
BRIVIACT
25
bromfenac sodium
93
bromocriptine mesylate
29
BROVANA
98
budesonide
77,98
bumetanide
50
BUNAVAIL
36
BUPHENYL
66
buprenorphine hcl
33
buprenorphine hcl/naloxone hcl
33
BUPROBAN
68
bupropion hcl
39
buspirone hcl
39
BUSULFEX
17
butalbital/acetaminophen/caffeine/codeine
phosphate
33
butorphanol tartrate
36
BYDUREON
71
BYDUREON PEN
71
BYETTA
71
BYSTOLIC
50
C
C-NATE DHA
104
cabergoline
74
CABOMETYX
17
CADEAU DHA
104
CADUET
58
calcipotriene
60
calcipotriene/betamethasone dipropionate 60
calcitonin,salmon,synthetic
74
calcitriol
60,74
calcium acetate
101
CALCIUM PNV
104
CAMILA
87
CANASA
77
CANCIDAS
2
candesartan cilexetil
50
candesartan cilexetil/hydrochlorothiazide 50
CANTIL
76
121
CAPASTAT SULFATE
9
CAPEX SHAMPOO
64
CAPRELSA
17
captopril
50
captopril/hydrochlorothiazide
50
CARAC
61
CARAFATE
80
CARBAGLU
77
carbamazepine
25,39
CARBATROL
25
carbidopa
29
carbidopa/levodopa
29
carbidopa/levodopa/entacapone
29
carbinoxamine maleate
96
carboplatin
17
CARDURA XL
50
CARIMUNE NF NANOFILTERED
83
carisoprodol
32
carisoprodol/aspirin
32
CARNITOR
66
carteolol hcl
92
CARTIA XT
50
carvedilol
50
CASODEX
17
CAVAN ONE OMEGA
104
CAVAN-ALPHA KIT
104
CAVAN-EC SOD DHA
104
CAVAN-FOLATE DHA
104
CAVAN-FOLATE OB
104
CAVAN-HEME OB
104
CAVAN-HEME OMEGA
104
CAYSTON
9
CEDAX
6
cefaclor
7
cefadroxil
7
cefadroxil hydrate
7
cefazolin sodium
7
cefazolin sodium/dextrose, iso-osmotic
7
cefdinir
7
cefepime hcl
7
cefepime hcl/dextrose 5 % in water
7
cefixime
cefotaxime sodium
cefotetan disodium
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime
ceftazidime in dextrose 5% and water
ceftazidime pentahydrate
CEFTIN
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
celecoxib
CELLCEPT
CELONTIN
cephalexin
CEREBYX
CEREZYME
CERVARIX
CESAMET
cetirizine hcl
cevimeline hcl
CHANTIX
CHEMET
chloramphenicol sod succ
chlordiazepoxide hcl
chlorhexidine gluconate
chloroquine phosphate
chlorothiazide
chlorothiazide sodium
chlorpromazine hcl
chlorpropamide
chlorthalidone
chlorzoxazone
CHOICE-OB + DHA
cholestyramine/aspartame
ciclopirox
ciclopirox olamine
cidofovir
cilostazol
7
7
7
7
7
7
7
7
7
7
7
7
8
36
17
25
8
25
74
83
77
96
66
68
67
9
39
69
9
50
50
39
71
50
32
104
58
63
63
3
56
122
CILOXAN
92
cimetidine
80
cimetidine hcl
80
CINRYZE
83
CIPRO
13
CIPRO HC
69
CIPRODEX
69
ciprofloxacin
14
ciprofloxacin hcl
14,92
ciprofloxacin lactate
14
ciprofloxacin lactate/dextrose 5 % in water 14
ciprofloxacin/ciprofloxacin hcl
14
cisplatin
17
citalopram hydrobromide
39
CITRANATAL 90 DHA
104
CITRANATAL ASSURE
104
CITRANATAL B-CALM
104
CITRANATAL DHA
104
CITRANATAL HARMONY
104
CITRANATAL RX
104
cladribine
17
CLAFORAN
8
CLARAVIS
62
CLARINEX
96
CLARINEX-D 12 HOUR
96
clarithromycin
8
CLEOCIN HCL
9
CLEOCIN PALMITATE
9
CLEOCIN PHOSPHATE IN D5W
9
clindamycin hcl
9
clindamycin palmitate hcl
9
clindamycin phosphate
9,62,89
clindamycin phosphate/benzoyl peroxide 62
clindamycin phosphate/dextrose 5 % in
water
10
CLINIMIX
67,103
CLINIMIX E
67,103
clobetasol propionate
64
CLOLAR
17
clomipramine hcl
39
clonazepam
39
clonidine
50
clonidine hcl
51
clopidogrel bisulfate
56
clorazepate dipotassium
40
CLORPRES
51
clotrimazole
2,63
clotrimazole/betamethasone dipropionate 63
clozapine
40
CLOZARIL
40
CO-NATAL FA
104
COARTEM
10
codeine phosphate/carisoprodol/aspirin
32
codeine sulfate
33
colchicine
85
colchicine/probenecid
86
COLCRYS
86
colestipol hcl
58
colistin (as colistimethate sodium)
10
COLY-MYCIN S
69
COMBIGAN
94
COMBIVENT RESPIMAT
98
COMBIVIR
3
COMETRIQ
17
COMPLERA
3
COMPLETE NATAL DHA
104
COMPLETE-RF PRENATAL
104
COMPLETENATE
104
COMPRO
77
COMTAN
29
COMVAX
83
CONCEPT DHA
104
CONCEPT OB
104
CONCERTA
40
CONSTULOSE
77
COPAXONE
31,81
COREG CR
51
CORENATE-DHA
105
cortisone acetate
69
CORTISPORIN
63
CORTISPORIN-TC
69
COSENTYX (2 SYRINGES)
81
123
COSENTYX PEN (2 PENS)
COSENTYX SYRINGE
COSMEGEN
COTELLIC
COZAAR
CREON
CRESTOR
CRINONE
CRIXIVAN
cromolyn sodium
CRYSELLE
CUBICIN
CUPRIMINE
CYCLAFEM
cyclobenzaprine hcl
cyclophosphamide
CYCLOSET
cyclosporine
cyclosporine, modified
CYKLOKAPRON
CYMBALTA
CYRAMZA
CYSTADANE
CYSTAGON
cytarabine
cytarabine/pf
CYTOVENE
81
81
17
18
51
77
58
87
3
77,93,98
89
10
86
89
32
18
71
18
18
56
40
18
77
101
18
18
3
D
dacarbazine
DACOGEN
dalfampridine
DALIRESP
danazol
dantrolene sodium
dapsone
DAPTACEL DTAP
DARAPRIM
darifenacin hydrobromide
DARZALEX
daunorubicin hcl
18
18
31
98
74
32
10
83
10
100
18
18
DAUNOXOME
18
decitabine
18
DELZICOL
77
demeclocycline hcl
14
DEMSER
51
DENAVIR
64
DEPAKOTE
25
DEPAKOTE ER
25
DEPAKOTE SPRINKLE
25
DEPEN
86
DEPO-ESTRADIOL
87
DEPO-PROVERA
87
DEPO-SUBQ PROVERA 104
87
DESCOVY
3
desipramine hcl
40
desloratadine
96
desmopressin acetate
74
DESONATE
64
desonide
64
desoximetasone
65
DESOXYN
40
desvenlafaxine
40
DETROL
100
dexamethasone
69
DEXAMETHASONE INTENSOL
69
dexamethasone sod phosphate
70,95
dexamethasone sodium phosphate/pf
70
DEXILANT
80
dexmethylphenidate hcl
40
DEXPAK
70
dexrazoxane hcl
16
dextroamphetamine sulfsaccharate/amphetamine sulf-aspartate
41
dextroamphetamine sulfate
41
dextrose 10 % and 0.2 % sodium chloride 67
dextrose 10 % in water
67
dextrose 2.5 % and 0.45 % sodium chloride67
124
dextrose 5 % in lactated ringers
101
dextrose 5 % in water
67
DIASTAT
41
DIASTAT ACUDIAL
41
diazepam
41
DIBENZYLINE
51
diclofenac potassium
36
diclofenac sodium
36,93
diclofenac sodium/misoprostol
37
dicloxacillin sodium
13
dicyclomine hcl
76
didanosine
3
diflorasone diacetate
65
diflunisal
37
DIGITEK
56
digoxin
56
dihydroergotamine mesylate
30
DILANTIN
25
DILAUDID
33
DILT-CD
51
DILT-XR
51
diltiazem hcl
51
DIOVAN
51
DIOVAN HCT
51
DIPENTUM
77
diphenhydramine hcl
96
diphenoxylate hcl/atropine sulfate
76
dipyridamole
57
disopyramide phosphate
47
disulfiram
67
DIURIL
51
DIURIL SODIUM
51
divalproex sodium
25
DIVIGEL
87
DOCEFREZ
18
docetaxel
18
DOCOSAVIT
105
dofetilide
47
donepezil hcl
31
DORIBAX
10
dorzolamide hcl
dorzolamide hcl/timolol maleate
DOTHELLE DHA
DOVONEX
doxazosin mesylate
doxepin hcl
doxercalciferol
DOXIL
doxorubicin hcl
doxorubicin hcl pegylated liposomal
doxycycline hyclate
doxycycline monohydrate
dronabinol
DROXIA
DUALVIT OB
DUET DHA
DUET DHA 400
DUET DHA BALANCED
DUET DHA COMPLETE
DUET DHA EC
DUET DHA WITH FERRAZONE
DUET STUARTNATAL
DUETACT
DULERA
duloxetine hcl
DURAMORPH
DUREZOL
dutasteride
dutasteride/tamsulosin hcl
94
94
105
60
51
41,61
74
18
18
18
15
15
77
18
112
105
105
105
105
105
105
105
71
98
41
33
93
100
100
E
E.E.S. 400
econazole nitrate
ED CYTE F
EDARBI
EDARBYCLOR
EDGE OB
EDURANT
EFFEXOR XR
ELAPRASE
ELESTAT
8
63
105
51
51
105
4
41
74
93
125
ELIDEL
61
ELIGARD
18
ELIPHOS
101
ELIQUIS
57
ELITE OB DHA
105
ELITE-OB
105
ELITE-OB 400
105
ELITEK
16
ELIXOPHYLLIN
98
ELLENCE
18
ELMIRON
101
ELOXATIN
18
EMADINE
93
EMCYT
19
EMEND
77
EMOQUETTE
89
EMPLICITI
19
EMSAM
41
EMTRIVA
4
EMVERM
10
ENABLEX
100
enalapril maleate
51
enalapril maleate/hydrochlorothiazide
52
ENBRACE HR
105
ENBREL
87
ENDOCET
33
ENGERIX-B
83
ENGERIX-B ADULT
83,84
ENGERIX-B PEDIATRIC-ADOLESCENT 84
ENJUVIA
87
enoxaparin sodium
57
ENPRESSE
89
entacapone
29
entecavir
4
ENTOCORT EC
77
ENTRESTO
59
ENULOSE
78
ENVARSUS XR
19
epinastine hcl
93
epinephrine
96
EPIPEN
96
EPIPEN 2-PAK
EPIPEN JR
EPIPEN JR 2-PAK
epirubicin hcl
EPITOL
EPIVIR
EPIVIR HBV
eplerenone
EPOGEN
eprosartan mesylate
EPZICOM
EQUETRO
ERAXIS (WATER DILUENT)
ERBITUX
ergoloid mesylates
ERIVEDGE
ERRIN
ERTACZO
ERWINAZE
ERY
ERY-TAB
ERYGEL
ERYPED 200
ERYTHROCIN LACTOBIONATE
ERYTHROCIN STEARATE
erythromycin base
erythromycin base/benzoyl peroxide
erythromycin base/ethyl alcohol
erythromycin ethylsuccinate
escitalopram oxalate
esomeprazole magnesium
esomeprazole strontium
estazolam
ESTRACE
estradiol
estradiol valerate
estradiol/norethindrone acetate
ESTRING
estropipate
eszopiclone
ethambutol hcl
97
97
97
19
25
4
4
52
81
52
4
25
2
19
41
19
87
63
19
62
8
62
8
8
8
8,92
62
62
9
41
80
80
41
87
88
88
88,89
88
88
41
10
126
ethinyl estradiol/drospirenone
ethosuximide
etidronate disodium
etodolac
ETOPOPHOS
etoposide
EURAX
EVAMIST
EVOTAZ
EVOXAC
EXELDERM
EXELON
exemestane
EXFORGE
EXFORGE HCT
EXJADE
EXTINA
EXTRA-VIRT PLUS DHA
89
25
67
37
19
19
66
88
4
67
63
31
19
52
52
67
63
105
F
FABRAZYME
FACTIVE
famciclovir
famotidine
famotidine in sodium chloride, isoosmotic/pf
famotidine/pf
FANAPT
FARESTON
FARXIGA
FARYDAK
FASLODEX
FAZACLO
felbamate
FELBATOL
felodipine
FEMARA
FEMCON FE
FEMECAL OB
FEMECAL OB PLUS DHA
FEMRING
74
14
4
80
80
80
41
19
71
19
19
42
26
26
52
19
89
105
105
88
fenofibrate
58
fenofibrate nanocrystallized
58
fenofibrate,micronized
58
fenofibric acid
58
fenofibric acid (choline)
58
fenoprofen calcium
37
fentanyl
33
fentanyl citrate
33,34
FETZIMA
42
FIBRICOR
58
FINACEA
62
finasteride
100
FIRAZYR
84
FLAGYL ER
10
FLAREX
95
flavoxate hcl
100
flecainide acetate
48
FLOVENT HFA
98
fluconazole
2
fluconazole in dextrose, iso-osmotic
2
fluconazole in sodium chloride, iso-osmotic 2
flucytosine
2
fludarabine phosphate
19
fludrocortisone acetate
70
fluocinolone acetonide
65
fluocinolone acetonide oil
69
fluocinonide
65
fluocinonide/emollient base
65
fluorometholone
95
fluorouracil
19,61
fluoxetine hcl
42
fluphenazine decanoate
42
fluphenazine hcl
42
flurandrenolide
65
flurazepam hcl
42
flurbiprofen
37
flurbiprofen sodium
93
flutamide
19
fluticasone propionate
65,98
fluvastatin sodium
58
fluvoxamine maleate
42
127
FML FORTE
FML S.O.P.
FOCALGIN 90 DHA
FOCALGIN CA
FOCALGIN-B
FOCALIN
FOCALIN XR
FOLBECAL
FOLCAL DHA
FOLCAPS CARE ONE
FOLCAPS OMEGA-3
FOLET DHA
FOLET ONE
FOLINATAL PLUS B
FOLIVANE-EC CALCIUM DHA NF
FOLIVANE-OB
FOLIVANE-PRX DHA NF
FOLTABS
FOLTABS 90 PLUS DHA
FOLTABS PRENATAL PLUS DHA
fomepizole
fondaparinux sodium
FORFIVO XL
FORTAZ
FORTEO
FORTICAL
FOSAMAX PLUS D
foscarnet sodium
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
fosphenytoin sodium
FOSRENOL
FRAGMIN
frovatriptan succinate
FURADANTIN
furosemide
FUSILEV
FUZEON
FYAVOLV
FYCOMPA
95
95
105
105
105
42
42
105
105
105
105
106
106
104
106
106
106
106
106
106
84
57
42
8
86
74
86
4
52
52
26
67
57
30
15
52
16
4
88
26
G
gabapentin
26
GABITRIL
26
galantamine hbr
31
GAMASTAN S-D
84
GAMMAGARD LIQUID
84
GAMMAGARD S-D
84
GAMUNEX
84
GAMUNEX-C
84
ganciclovir sodium
4
GARAMYCIN
92
GARDASIL
84
GARDASIL 9
84
gatifloxacin
14
GATTEX
78
GAVILYTE-C
78
GAVILYTE-H AND BISACODYL
78
GAVILYTE-N
78
gemcitabine hcl
19
gemfibrozil
58
GEMZAR
19
GENERLAC
78
GENGRAF
19
GENOTROPIN
82
GENTAK
92
gentamicin sulfate
10,63,92
gentamicin sulfate in sodium chloride, isoosmotic
10
GENTEX ADE
106
GENVOYA
4
GEODON
42
GESTICARE
106
GESTICARE DHA
106
GILDAGIA
89
GILENYA
82
GILOTRIF
19
GLATOPA
82
GLEEVEC
19
GLEOSTINE
20
glimepiride
71
128
glipizide
glipizide/metformin hcl
GLUCAGEN
GLUCAGON EMERGENCY KIT
glyburide
glyburide,micronized
glyburide/metformin hcl
glycopyrrolate
GOLYTELY
GRALISE
granisetron hcl
granisetron hcl/pf
GRIS-PEG
griseofulvin ultramicrosize
griseofulvin, microsize
griseofulvin,microsize
guanfacine hcl
guanidine hcl
71
71
71
71
71
71
72
76
78
26
78
78
2
2
2
2
42,52
32
H
HALAVEN
HALDOL
HALDOL DECANOATE 100
HALDOL DECANOATE 50
halobetasol propionate
HALOG
haloperidol
haloperidol decanoate
haloperidol lactate
HAVRIX
HEMENATAL OB
HEMENATAL OB + DHA
heparin sodium,porcine
heparin sodium,porcine/dextrose 5 % in
water
HEPATAMINE
HEPSERA
HERCEPTIN
HETLIOZ
HEXALEN
HIBERIX
20
42
42
42
65
65
42
42
42
84
106
106
57
57
103
4
20
31
20
84
HIP PRENATAL
106
HUMALOG
72
HUMALOG KWIKPEN U-100
72
HUMALOG KWIKPEN U-200
72
HUMALOG MIX 50-50
72
72
HUMALOG MIX 75-25
72
72
HUMATROPE
82
HUMIRA
87
HUMIRA PEN
87
HUMIRA PEN CROHN-UC-HS STARTER 87
HUMIRA PEN PSORIASIS-UVEITIS
87
HYCAMTIN
20
hydralazine hcl
52
hydrochlorothiazide
52
hydrocodone bit/acetaminophen
34
34
hydrocodone/ibuprofen
34
hydrocortisone
65,70,78
hydrocortisone butyrate
65
hydrocortisone butyrate/emollient base
65
hydrocortisone valerate
65
hydromorphone hcl
34
hydromorphone hcl/pf
34
hydroxychloroquine sulfate
10
hydroxyprogesterone caproate
88
hydroxyurea
20
hydroxyzine hcl
97
hydroxyzine pamoate
97
HYZAAR
52
I
ibandronate sodium
IBRANCE
ibuprofen
ibuprofen/oxycodone hcl
ICAR-C PLUS SR
ICLUSIG
idarubicin hcl
IFEX
86
20
37
34
106
20
20
20
129
ifosfamide
ILARIS
imatinib mesylate
IMBRUVICA
imipenem/cilastatin sodium
imipramine hcl
imipramine pamoate
imiquimod
IMOVAX RABIES VACCINE
INATAL ADVANCE
INATAL GT
INATAL ULTRA
INCRELEX
INCRUSE ELLIPTA
indapamide
INDOCIN
INFANATE BALANCE
INFANATE DHA
INFANATE PLUS
INFANRIX
INFANRIX DTAP
INLYTA
INTELENCE
INTRALIPID
INTRON A
INTROVALE
INTUNIV
INVANZ
INVEGA
INVEGA SUSTENNA
INVEGA TRINZA
INVIRASE
INVOKAMET
INVOKANA
IONOSOL B WITH DEXTROSE 5%
IONOSOL MB-DEXTROSE 5%
IOPIDINE
IPOL
ipratropium bromide
ipratropium bromide/albuterol sulfate
irbesartan
20
87
20
20
10
43
43
61
84
106
106
106
67
98
52
37
106
106
106
84
84
20
4
103
82
89
52
10
43
43
43
4
72
72
103
103
95
84
69,98
98
52
irbesartan/hydrochlorothiazide
IRENKA
IRESSA
irinotecan hcl
ISENTRESS
ISOLYTE P WITH DEXTROSE
ISOLYTE S
ISONARIF
isoniazid
ISOPTO CARPINE
isosorbide dinitrate
isosorbide mononitrate
isradipine
itraconazole
ivermectin
IXEMPRA
IXIARO
52
43
20
20
4
103
103
10
10
93
60
60
52
2
10
20
84
J
JADENU
JAKAFI
JALYN
JANTOVEN
JANUMET
JANUMET XR
JANUVIA
JARDIANCE
JENTADUETO
JEVTANA
JOLIVETTE
JUNEL
JUNEL FE
JUNEL FE 24
JUXTAPID
67
20
100
57
72
72
72
72
72
20
88
89
90
90
59
K
KALETRA
KALYDECO
KANUMA
KAPIDEX
KARIVA
4
98
84
80
90
130
KAZANO
KEFLEX
KELNOR 1-35
KENALOG
KENALOG-10
KENALOG-40
KEPIVANCE
KEPPRA
KEPPRA XR
KETEK
ketoconazole
ketoprofen
ketorolac tromethamine
KEYTRUDA
KHEDEZLA
KINERET
KIONEX
KLOR-CON 10
KLOR-CON 8
KLOR-CON M10
KLOR-CON M15
KLOR-CON M20
KLOR-CON SPRINKLE
KOLNATAL DHA
KOMBIGLYZE XR
KORLYM
KOSHER PRENATAL PLUS IRON
KUVAN
72
8
90
65
70
70
16
26
26
10
2,63
37
37,93
20
43
87
67
101
101
101
101
101
101
106
72
10
106
67,74
L
L-METHYLFOLATE PNV DHA
labetalol hcl
LACTOCAL-F
lactulose
LAMICTAL
LAMICTAL (BLUE)
LAMICTAL (GREEN)
LAMICTAL (ORANGE)
LAMICTAL XR
LAMICTAL XR (BLUE)
LAMICTAL XR (GREEN)
106
52
106
78
26
26
26
26
26
26
26
LAMICTAL XR (ORANGE)
26
lamivudine
4
lamivudine/zidovudine
4
lamotrigine
27
LANOXIN
56
lansoprazole
80
lansoprazole/amoxicillin
trihydrate/clarithromycin
78
LANTUS
72
LANTUS SOLOSTAR
72
LARIN
90
LARIN FE
90
latanoprost
94
LATUDA
43
leflunomide
87
LENVIMA
20
LESSINA
90
LETAIRIS
98
letrozole
20
leucovorin calcium
16
LEUKERAN
20
LEUKINE
82
leuprolide acetate
20
levalbuterol hcl
98
LEVAQUIN
14
levetiracetam
27
levetiracetam in sodium chloride, isoosmotic
27
levobunolol hcl
92
levocarnitine
67
levocarnitine (with sugar)
67
levocetirizine dihydrochloride
97
levofloxacin
14,92
levofloxacin/dextrose 5 % in water
14
levoleucovorin calcium
16
LEVOMEFOLATEPNV
106
LEVONEST
90
levonorgestrel-ethinyl estradiol
90
levonorgestrel/ethinyl estradiol and ethinyl
estradiol
90
LEVORA-28
90
131
levorphanol tartrate
levothyroxine sodium
LEVOXYL
LEXAPRO
LEXIVA
LIALDA
lidocaine
lidocaine hcl
lidocaine hcl/pf
lidocaine/prilocaine
LIDODERM
lindane
linezolid
linezolid in 0.9 % sodium chloride
LINZESS
liothyronine sodium
lisinopril
lisinopril/hydrochlorothiazide
lithium carbonate
lithium citrate
LOESTRIN
LOESTRIN FE
lomustine
LONSURF
loperamide hcl
lorazepam
LORAZEPAM INTENSOL
LORCET
LORCET HD
LORTAB
LORZONE
losartan potassium
losartan potassium/hydrochlorothiazide
LOTEMAX
LOTRONEX
lovastatin
LOVAZA
LOVENOX
loxapine succinate
LUMIGAN
LUPRON DEPOT
34
76
76
43
4
78
63
63
63
63
63
66
10
10
78
76
53
53
43
43
90
90
20
21
76
43
43
34
34
34
32
53
53
95
78
59
59
57
43
94
21
LUPRON DEPOT-PED
LUTERA
LYNPARZA
LYRICA
LYSODREN
LYSTEDA
LYZA
21
90
21
27
21
57
88
M
M-M-R II VACCINE
M-VIT
MACNATAL CN DHA
MACRODANTIN
magnesium sulfate
MALARONE
malathion
maprotiline hcl
MARLISSA
MARNATAL-F
MARNATAL-F PLUS
MARPLAN
MATERNITY
MATULANE
MAXALT
MAXALT MLT
MAXIDEX
MAXINATE
meclizine hcl
meclofenamate sodium
medroxyprogesterone acetate
mefenamic acid
mefloquine hcl
megestrol acetate
MEKINIST
meloxicam
melphalan hcl
memantine hcl
MENACTRA
MENEST
MENHIBRIX
MENOMUNE-A-C-Y-W-135
84
106
106
15
102
10
66
43
90
106
107
43
107
21
30
30
95
107
78
37
88
37
11
21
21
37
21
31
84
88
84
84
132
MENOSTAR
MENVEO A-C-Y-W-135-DIP
meperidine hcl
meprobamate
MEPRON
mercaptopurine
meropenem
MERREM
mesalamine with cleansing wipes
mesna
MESNEX
MESTINON
METADATE CD
METADATE ER
metaproterenol sulfate
METAXALL
metaxalone
metformin hcl
methadone hcl
methamphetamine hcl
methazolamide
methenamine hippurate
methimazole
METHITEST
methocarbamol
methotrexate sodium
methotrexate sodium/pf
methoxsalen, rapid
methscopolamine bromide
methyclothiazide
methyldopa
methyldopa/hydrochlorothiazide
methylergonovine maleate
METHYLIN
methylphenidate hcl
methylprednisolone
methylprednisolone acetate
methylprednisolone sodium succinate
methyltestosterone
metipranolol
metoclopramide hcl
88
84
35
32
11
21
11
11
78
16
16
32
43
43
98
32
32
72
35
43
94
15
71
74
32
21
21
61
76
53
53
53
91
43
44
70
70
70
74
92
78,80
metolazone
53
metoprolol succinate
53
metoprolol tartrate
53
metoprolol tartrate/hydrochlorothiazide
53
METROGEL
62
metronidazole
11,62,89
metronidazole in sodium chloride
11
mexiletine hcl
48
MIACALCIN
74
MICARDIS
53
MICARDIS HCT
53
miconazole nitrate
89
MICROGESTIN
90
MICROGESTIN FE
90
midodrine hcl
67
miglitol
72
MIGRANAL
30
MILLIPRED
70
MIMVEY LO
88
MINITRAN
60
MINIVELLE
88
minocycline hcl
15
minoxidil
53
MIRAPEX
29
MIRAPEX ER
29
mirtazapine
44
misoprostol
80
mitomycin
21
mitoxantrone hcl
21
modafinil
44
MODERIBA
4
moexipril hcl
53
moexipril hcl/hydrochlorothiazide
54
molindone hcl
44
mometasone furoate
65,98
MONONESSA
90
montelukast sodium
98
MONUROL
15
morphine sulfate
35
MOVIPREP
78
MOXATAG
13
133
MOXEZA
moxifloxacin hcl
moxifloxacin hcl in sodium acetate and
sulfate,water,iso-osm
MULTAQ
MULTI-NATE 30
MULTI-NATE 30 DHA
MULTI-NATE DHA EXTRA
MULTINATAL PLUS
mupirocin
mupirocin calcium
MUSTARGEN
MYCAMINE
mycophenolate mofetil
mycophenolate sodium
MYFORTIC
MYNATAL
MYNATAL ADVANCE
MYNATAL PLUS
MYNATAL-Z
MYNATE 90 PLUS
MYORISAN
MYOZYME
MYRBETRIQ
92
14
14
48
107
107
107
107
63
63
21
2
21
21
21
107
107
107
107
107
62
75
100
N
nabumetone
nadolol
nadolol/bendroflumethiazide
nafcillin in dextrose, iso-osmotic
nafcillin sodium
naftifine hcl
NAGLAZYME
nalbuphine hcl
naloxone hcl
naltrexone hcl
NAMENDA
NAMENDA XR
naphazoline hcl
naproxen
naproxen sodium
37
54
54
13
13
64
75
37
37
37
31
31
95
37
37
NARDIL
44
NASONEX
98
NATA KOMPLETE
107
NATACHEW
107
NATACYN
92
NATAFORT
107
NATAL-V RX
107
NATALVIRT 90 DHA
107
NATALVIRT CA
107
NATALVIT
107
nateglinide
73
NATELLE
107
NATELLE C
107
NATELLE ONE
107
NATELLE PLUS
107
NATELLE PREFER
107
NATELLE-EZ
107
NATPARA
70
NAVATAB + DHA
107
NEBUPENT
11
NECON
90
NEEVO
107
NEEVO DHA
107
NEEVODHA
107
nefazodone hcl
44
neomycin sulfate
11
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone
94
neomycin sulfate/bacitracin/polymyxin b
92
neomycin sulfate/polymyxin b sulfate
66
neomycin sulfate/polymyxin b
sulfate/gramicidin d
92
neomycin sulfate/polymyxin b
sulfate/hydrocortisone
69,94
neomycin/polymyxin b
sulfate/dexamethasone
94
NEORAL
21
NEPHRAMINE
103
NESINA
73
NESTABS
108
NESTABS ABC
108
134
NESTABS DHA
108
NEULASTA
82
NEUMEGA
82
NEUPOGEN
82
NEUPRO
29
NEURONTIN
27
NEVANAC
93
nevirapine
4
NEWGEN
108
NEXA PLUS
108
NEXA SELECT
108
NEXAVAR
21
niacin
59
NIACOR
59
NIASPAN
59
nicardipine hcl
54
NICOTROL
68
NICOTROL NS
68
NIFEDICAL XL
54
nifedipine
54
NILANDRON
21
nimodipine
54
NINLARO
21
nisoldipine
54
NITRO-BID
60
nitrofurantoin
15
nitrofurantoin macrocrystal
15
nitrofurantoin monohydrate/macrocrystals 15
nitroglycerin
60
NITROLINGUAL
60
NITROSTAT
60
NIVA-PLUS
108
nizatidine
80
NORDITROPIN FLEXPRO
75,82
NORDITROPIN NORDIFLEX
75,82
norethindrone
88
norethindrone acetate
88
norethindrone acetate-ethinyl estradiol
90
norethindrone acetate-ethinyl estradiol/ferrous
fumarate
90
norethindrone-ethinyl estradiol/ferrous
fumarate
NORITATE
NORMOSOL-R AND DEXTROSE
NORMOSOL-R PH 7.4
NORTREL
nortriptyline hcl
NORVIR
NOVANATAL
NOVASTART
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG MIX 70-30 FLEXPEN
NOXAFIL
NUCALA
NUEDEXTA
NULOJIX
NULYTELY
NULYTELY WITH FLAVOR PACKS
NUPLAZID
NUTRI-TAB OB
NUTRI-TAB OB + DHA
NUTROPIN AQ
NUTROPIN AQ NUSPIN
NUVIGIL
NYAMYC
nystatin
nystatin/triamcinolone acetonide
NYSTOP
90
62
102
103
90
44
4
108
108
73
73
73
73
2
98
31
22
78
78
44
108
108
82
82
44
64
2,64
64
64
O
O-CAL FA
O-CAL PRENATAL
OB + DHA
OB 90 + DHA
OB COMPLETE
OB COMPLETE 400
OB COMPLETE DHA
OB COMPLETE GOLD
OB COMPLETE ONE
108
108
112
112
108
108
108
108
108
135
OB COMPLETE PETITE
OB COMPLETE PREMIER
OB COMPLETE WITH DHA
OB-NATAL ONE
OBSTETRIX DHA
OBSTETRIX EC
OBTREX
OBTREX DHA
octreotide acetate
ODEFSEY
ODOMZO
OFEV
ofloxacin
OGESTREL
olanzapine
olanzapine/fluoxetine hcl
olopatadine hcl
OLYSIO
OMECLAMOX-PAK
omega-3 acid ethyl esters
omeprazole
OMNARIS
OMNITROPE
ONCASPAR
ondansetron
ondansetron hcl
ondansetron hcl/pf
ONFI
ONGLYZA
ONMEL
OPANA
OPANA ER
OPDIVO
ORACEA
ORAP
ORAPRED ODT
ORENCIA
ORFADIN
ORKAMBI
orphenadrine citrate
ORSYTHIA
108
108
108
108
108
108
108
108
22
5
22
98
14,69,92
90
44
44
69,93
5
13
59
80
98
82
22
78
78
78
27
73
3
35
35
22
15
44
70
87
68
98
32
90
ORTHO TRI-CYCLEN LO
OSENI
OSMOPREP
OTREXUP
oxacillin sodium
oxacillin sodium/dextrose, iso-osmotic
oxaliplatin
oxandrolone
oxaprozin
oxazepam
oxcarbazepine
oxiconazole nitrate
OXSORALEN-ULTRA
OXTELLAR XR
oxybutynin chloride
oxycodone hcl
oxycodone hcl/acetaminophen
oxycodone hcl/aspirin
oxymorphone hcl
91
73
78
22
13
13
22
75
37
44
27
64
61
27
100
35,36
36
36
36
P
PACERONE
paclitaxel
PAIRE OB PLUS DHA
paliperidone
pamidronate disodium
PANCREAZE
PANRETIN
pantoprazole sodium
paricalcitol
paromomycin sulfate
paroxetine hcl
PASER
PATADAY
PATANASE
PATANOL
PAXIL
PEDVAXHIB
PEGANONE
PEGASYS
PEGASYS PROCLICK
48
22
108
44
75
79
61
80
75
11
44
11
93
69
93
44
85
27
82
82
136
PEGINTRON
82
PEGINTRON REDIPEN
82
pen needle, diabetic
95
penicillin g potassium
13
penicillin g potassium/dextrose-water
13
penicillin g procaine
13
penicillin g sodium
13
penicillin v potassium
13
PENTACEL ACTHIB COMPONENT
85
PENTAM 300
11
PENTASA
79
pentazocine hcl/naloxone hcl
37
pentoxifylline
57
PEPCID
80
PERFOROMIST
98
PERIOGARD
69
PERJETA
22
permethrin
66
perphenazine
45
perphenazine/amitriptyline hcl
45
PERTZYE
79
PEXEVA
45
PHENADOZ
97
phenelzine sulfate
45
PHENERGAN
97
phenobarbital
27
phenoxybenzamine hcl
54
PHENYTEK
27
phenytoin
27
phenytoin sodium
27
phenytoin sodium extended
27
PHOSPHOLINE IODIDE
93
pilocarpine hcl
68,93
pimozide
45
PIMTREA
91
pindolol
54
pioglitazone hcl
73
pioglitazone hcl/glimepiride
73
pioglitazone hcl/metformin hcl
73
piperacillin sodium/tazobactam sodium
13
PIRMELLA
91
piroxicam
38
PLASMA-LYTE 148
103
PLASMA-LYTE 56 IN DEXTROSE
103
PLASMA-LYTE A PH 7.4
103
PLAVIX
57
PNV 29-1
109
PNV OB+DHA
109
PNV-DHA
109
PNV-DHA + DOCUSATE
109
PNV-DHA PLUS
109
PNV-FIRST
109
PNV-IRON
109
PNV-OB WITH DHA
109
PNV-OMEGA
109
PNV-SELECT
109
PNV-TOTAL
109
PNV-VP-U
109
podofilox
61
POLY IRON PN
109
POLY IRON PN FORTE
109
polyethylene glycol 3350
79
polymyxin b sulfate
11
polymyxin b sulfate/trimethoprim
92
POMALYST
22
PORTIA
91
potassium chloride
101,102
potassium chloride in 0.45 % sodium
chloride
102
potassium chloride in 0.9 % sodium
chloride
102
potassium chloride in 5 % dextrose in
water
102
potassium chloride in dextrose 5 % and 0.9 %
sodium chloride
102
potassium chloride in dextrose 5 %-0.2 %
sodium chloride
102
potassium chloride in dextrose 5 %-0.45 %
sodium chloride
102
potassium chloride in dextrose 5% and 0.3 %
sodium chloride
102
137
potassium chloride in lactated ringers and 5
% dextrose
102
potassium citrate
68,101
POTIGA
27
PR NATAL 400
109
PR NATAL 400 EC
109
PR NATAL 430
109
PR NATAL 430 EC
109
PR NATAL 440 EC
109
PRADAXA
57
PRALUENT PEN
59
PRALUENT SYRINGE
59
pramipexole di-hcl
29
PRANDIMET
73
PRANDIN
73
pravastatin sodium
59
prazosin hcl
54
PRECARE
109
PRECARE CONCEIVE
109
PRECARE PREMIER
109
PRED FORTE
95
PRED-G
94
prednicarbate
65
prednisolone
70
prednisolone sod phosphate
70,95
prednisone
70
PREDNISONE INTENSOL
70
PREFERA OB
110
PREFERA-OB
110
PREFERA-OB ONE
110
PREFERA-OB PLUS DHA
110
PREFOL-DHA
110
PREMARIN
88
PREMASOL
103
PREMESIS RX
110
PREMPHASE
88
PRENA1
110
PRENA1 CHEW
110
PRENA1 PEARL
110
PRENA1 PLUS
110
PRENA1 TRUE
110
PRENACARE
110
PRENAFIRST
110
PRENAISSANCE
110
PRENAISSANCE 90 DHA
110
PRENAISSANCE BALANCE
110
PRENAISSANCE DHA
110
PRENAISSANCE DHA HARMONY
110
PRENAISSANCE HARMONY DHA
110
PRENAISSANCE NEXT
110
PRENAISSANCE NEXT-B
110
PRENAISSANCE PLUS
110
PRENAISSANCE PROMISE
110
PRENAPLUS
110
PRENATA
110
PRENATABS FA
110
PRENATABS RX
110
PRENATAL FORMULA
110
prenatal vitamin comb no.79/iron
fumarat/fa/lmefolate ca/dha
109
prenatal vitamin no.15/iron,carbonyl/folic
acid/docusate sod
111
prenatal vitamin no.19/iron polysacc & iron
hem/folic ac/dha
109
prenatal vitamins comb 10/ferrous
fumarate/folic acid/dha
110
prenatal vitamins comb no.115/iron
fumarate/folic acid
109
prenatal vitamins comb no.115/iron
fumarate/folic acid/dss
109
prenatal vitamins combo no.14/ferrous
fumarate/folic acid
108
prenatal vitamins combo no.60/ferrous
fumarate/folic acid
111
prenatal vits w-o ca comb. no. 7 w/ iron & folic
acid & dha
108
prenatal vits with calcium #72/ferrous
fumarate/folic acid
109
prenatal vits with calcium
#72/iron,carbonyl/folic acid
109
prenatal vits with calcium #74/ferrous
fumarate/folic acid
111
138
prenatal vits without calc no5/ferrous
fumarate/folic acid
PRENATE AM
PRENATE CHEWABLE
PRENATE DHA
PRENATE ELITE
PRENATE ENHANCE
PRENATE ESSENTIAL
PRENATE MINI
PRENATE PIXIE
PRENATE PLUS
PRENATE RESTORE
PRENATE STAR
PRENEXA
PRENEXA PREMIER
PREPLUS
PREQUE 10
PRETAB
PREVACID
PREVALITE
PREVIFEM
PREVITE RX
PREVPAC
PREZCOBIX
PREZISTA
PRIMACARE ADVANTAGE
PRIMACARE ONE
primaquine phosphate
PRIMAXIN
primidone
PRIMSOL
PRISTIQ ER
PROAIR HFA
probenecid
procainamide hcl
PROCALAMINE
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
PROCRIT
PROCTO-MED HC
109
111
111
111
111
111
111
111
111
111
111
111
111
111
111
111
111
80
59
91
111
79,80
5
5
111
111
11
11
27
15
45
98
86
48
103
79
79
79
83
79
PROCTO-PAK
PROCTOSOL-HC
PROCTOZONE-HC
progesterone,micronized
PROGLYCEM
PROGRAF
PROLASTIN C
PROLEUKIN
PROMACTA
promethazine hcl
PROMETHEGAN
propafenone hcl
propantheline bromide
proparacaine hcl
propranolol hcl
propranolol hcl/hydrochlorothiazide
propylthiouracil
PROQUAD
PROSOL
PROTECT NATAL
PROTONIX IV
PROTOPIC
protriptyline hcl
PROVENTIL HFA
PROVIDA DHA
PROVIDA OB
PROVIGIL
PROZAC WEEKLY
PRUDOXIN
PRUET DHA
PRUET DHA EC
PULMICORT
PULMICORT FLEXHALER
PULMOZYME
PUREFE OB PLUS
PUREFE PLUS
PURIXAN
PYLERA
pyrazinamide
pyridostigmine bromide
65
79
65
88
73
22
68
83
57
97
97
48
76
93
54
54
71
85
103
111
80
61
45
99
111
111
45
45
61
111
111
99
99
99
111
112
22
80
11
32
139
Q
QUADRACEL DTAP-IPV
QUALAQUIN
QUASENSE
QUDEXY XR
quetiapine fumarate
quinapril hcl
quinapril hcl/hydrochlorothiazide
quinidine gluconate
quinidine sulfate
quinine sulfate
QVAR
101
11
91
28
45
54
54
48
48
11
99
R
R-NATAL OB
RABAVERT
rabeprazole sodium
raloxifene hcl
ramipril
RANEXA
ranitidine hcl
RAPAMUNE
RAPIVAB
RAVICTI
RE-NATA 29
RE-NATA 29 OB
REAPHIRM
REBETOL
REBIF
REBIF REBIDOSE
RECLIPSEN
RECOMBIVAX HB
RECTIV
RELENZA
RELISTOR
RELNATE DHA
REMICADE
REMODULIN
RENAGEL
RENATE
112
85
80
86
54
59
81
22
5
31
112
112
112
5
83
83
91
85
79
5
79
112
79
54
68
112
RENATE DHA
RENATE DHA EXTRA
RENVELA
repaglinide
repaglinide/metformin hcl
REPATHA SURECLICK
REPATHA SYRINGE
REPREXAIN
RESCRIPTOR
reserpine
RESTASIS
RESTORIL
RETROVIR
REVATIO
REVLIMID
REXULTI
REYATAZ
RHEUMATREX
RIBAPAK
RIBASPHERE
RIBASPHERE RIBAPAK
RIBATAB
ribavirin
RIDAURA
rifabutin
RIFAMATE
rifampin
RIFATER
RILUTEK
riluzole
rimantadine hcl
ringers solution
ringers solution,lactated
RIOMET
risedronate sodium
RISPERDAL CONSTA
RISPERDAL M-TAB
risperidone
RITUXAN
rivastigmine
rivastigmine tartrate
112
112
68
73
73
59
59
36
5
55
93
45
5
99
22
45
5
22
5
5
5
5
5
87
11
11
11
11
68
60
5
66,102
66,102
73
68,86
45
45
45
22
32
32
140
rizatriptan benzoate
ropinirole hcl
rosuvastatin calcium
ROTARIX
ROTATEQ
ROVIN-A DHA
ROVIN-NV
ROVIN-NV DHA
ROWEEPRA
ROZEREM
RULAVITE DHA
30
30
59
85
85
112
112
112
28
45
112
S
SABRIL
SAIZEN
SANDIMMUNE
SANTYL
SAPHRIS
SARAFEM
SE-CARE
SE-CARE CONCEIVE
SE-CARE GESTURE
SE-NATAL 19
SE-NATAL 90
SE-NATAL ONE
SE-PLETE DHA
SE-TAN DHA
SEASONIQUE
SELECT-OB
SELECT-OB + DHA
selegiline hcl
selenium sulfide
SELZENTRY
SENSIPAR
SEREVENT DISKUS
SEROQUEL
SEROQUEL XR
SEROSTIM
sertraline hcl
SETONET
SETONET-EC
28
83,85
22
66
45
46
112
112
112
112
112
112
112
112
91
112
112
30
60
5
75
99
46
46
83
46
112
112
SIGNIFOR
SIGNIFOR LAR
sildenafil citrate
silver sulfadiazine
SIMULECT
simvastatin
SINGULAIR
sirolimus
SIRTURO
SKELAXIN
sodium chloride
sodium chloride 0.45 %
sodium chloride 3 %
sodium chloride 5 %
sodium chloride irrigating solution
sodium chloride/sodium
bicarbonate/potassium chloride/peg
SODIUM DIURIL
sodium lactate
sodium phenylbutyrate
sodium polystyrene sulfonate
SOLARAZE
SOLTAMOX
SOLU-CORTEF
SOLU-MEDROL
SOMA
SOMATULINE DEPOT
SOMAVERT
SORIATANE
SORINE
sotalol hcl
SOVALDI
SPIRIVA
SPIRIVA RESPIMAT
spironolactone
spironolactone/hydrochlorothiazide
SPORANOX
SPRINTEC
SPRITAM
SPRYCEL
SRONYX
70
70
59,99
61
22
59
99
22
11
32
102
102
102
102
68
79
55
102
101
68
61
22
70
70
32
23
75
61
48
48
5
99
99
55
55
3
91
28
23
91
141
SSD
61
SSD AF
61
STALEVO 100
30
STALEVO 125
30
STALEVO 150
30
STALEVO 200
30
STALEVO 50
30
STALEVO 75
30
stavudine
5
STIMATE
75
STIVARGA
23
STRATTERA
46
STRENSIQ
85
streptomycin sulfate
11
STRIBILD
5
STROMECTOL
11
SUBOXONE
38
SUCRAID
79
sucralfate
81
SULAR
55
sulfacetamide sodium
63,95
sulfacetamide sodium/prednisolone sodium
phosphate
95
sulfadiazine
14
sulfamethoxazole/trimethoprim
14
SULFAMYLON
63
sulfasalazine
79
sulindac
38
sumatriptan
30
sumatriptan succinate
30,31
SUPRAX
8
SURMONTIL
46
SUSTIVA
5
SUTENT
23
SYLATRON
83
SYLATRON 4-PACK
83
SYLVANT
23
SYMBYAX
46
SYMLINPEN 120
73
SYMLINPEN 60
73
SYNAGIS
5
SYNAREL
SYNERCID
SYNRIBO
SYNTHROID
SYPRINE
syringe with needle, insulin, safety, 1 ml
syringe with needle,disposable,insulin 1 ml
syringe with needle,insulin disposable,0.3
ml
syringe with needle,insulin disposable,0.5
ml
syringe with needle,insulin,0.3 ml
syringe with needle,insulin,0.5 ml
75
11
23
76
68
96
96
96
96
96
96
96
96
T
TABLOID
TACLONEX
TACLONEX SCALP
tacrolimus
TAFINLAR
TAGRISSO
TALWIN
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TANDEM DHA
TANDEM OB
TARCEVA
TARGRETIN
TARON A PRENATAL
TARON EC CALCIUM
TARON-BC
TARON-C DHA
TARON-DUO EC
TARON-EC CAL
TARON-PREX PRENATAL
TASIGNA
TASMAR
TAZORAC
23
61
61
23,61
23
23
38
5
23
100
112
113
23
23
113
113
113
113
113
113
113
23
30
62
142
TAZTIA XT
TECENTRIQ
TECHNIVIE
TEFLARO
TEGRETOL XR
TEKTURNA
TEKTURNA HCT
telmisartan
telmisartan/amlodipine besylate
telmisartan/hydrochlorothiazide
temazepam
TENIVAC
terazosin hcl
terbinafine hcl
terbutaline sulfate
terconazole
TESTIM
testosterone
testosterone cypionate
testosterone enanthate
TESTRED
tetanus and diphtheria toxoids, adult
tetanus,diphtheria toxoid ped/pf
tetrabenazine
tetracycline hcl
THALOMID
theophylline anhydrous
thioridazine hcl
thiotepa
thiothixene
THRIVITE 19
THRIVITE RX
THYMOGLOBULIN
tiagabine hcl
ticlopidine hcl
TIKOSYN
timolol maleate
tinidazole
TIVICAY
tizanidine hcl
TL FOLATE
55
23
5
8
28
55
55
55
55
55
46
85
55
3
99
89
75
75
75
75
75
85
85
32
15
23
99
46
23
46
113
113
85
28
58
48
55,92
11
6
32
113
TL-ASSURE + DHA
113
TL-ASSURE ONE
113
TL-CARE DHA
113
TL-SELECT
113
TL-SELECT DHA
113
TOBI
12
TOBRADEX
94
tobramycin
92
tobramycin in 0.225 % sodium chloride
12
tobramycin sulfate
12
tobramycin sulfate/sodium chloride
12
tobramycin/dexamethasone
94
TOBREX
92
TOFRANIL-PM
46
TOLAK
23
tolazamide
73
tolbutamide
73
tolcapone
30
tolmetin sodium
38
tolterodine tartrate
100
TOPAMAX
28
topiramate
28
topotecan hcl
23
TORISEL
23
torsemide
55
TOUJEO SOLOSTAR
73
TRACLEER
99
TRADJENTA
73
tramadol hcl
36,38
tramadol hcl/acetaminophen
38
trandolapril
55
trandolapril/verapamil hcl
55
tranexamic acid
58
TRANSDERM-SCOP
76
tranylcypromine sulfate
46
TRAVASOL
103
TRAVATAN Z
94
travoprost (benzalkonium)
94
trazodone hcl
46
TREANDA
23
TRECATOR
12
143
TRELSTAR
23
TRELSTAR DEPOT
23
TRELSTAR LA
24
tretinoin
24,61,62
tretinoin microspheres
62
TREXALL
24
TRI RX
113
TRI-LEGEST FE
91
TRI-PREVIFEM
91
TRI-SPRINTEC
91
TRI-TABS DHA
113
TRIADVANCE
113
triamcinolone acetonide
65,69,99
triamterene/hydrochlorothiazide
56
triazolam
46
TRICARE
113
TRICARE DHA
113
TRICARE PRENATAL COMPLEAT
113
TRICARE PRENATAL DHA ONE
113
TRICARE PRENATAL WITH DHA
113
TRIDERM
65
TRIFERA OB
113
trifluoperazine hcl
46
trifluridine
92
trihexyphenidyl hcl
30
TRILEPTAL
28
TRILYTE WITH FLAVOR PACKETS
79
TRIMESIS RX
113
trimethoprim
15
trimipramine maleate
46
TRINATAL GT
113
TRINATAL RX 1
113
TRINATAL ULTRA
113
TRINATE
114
TRINESSA
91
TRINTELLIX
46
TRISENOX
24
TRISTART DHA
114
TRIUMEQ
6
TRIVEEN-DUO DHA
114
TRIVEEN-ONE
114
TRIVEEN-PRX RNF
TRIVEEN-TEN
TRIVEEN-U
TRIVORA-28
TRIZIVIR
TROKENDI XR
TROPHAMINE
trospium chloride
TRUST NATAL DHA
TRUVADA
TUDORZA PRESSAIR
TWINRIX
TYGACIL
TYKERB
TYPHIM VI
TYSABRI
TYZEKA
TYZINE
114
114
114
91
6
28
103
100
114
6
99
85
12
24
85
32
6
69
U
ULORIC
ULTIMATE OB DHA
ULTIMATECARE ADVANTAGE
ULTIMATECARE COMBO
ULTIMATECARE ONE
ULTIMATECARE ONE NF
ULTRESA
UPTRAVI
UROXATRAL
URSO
URSO FORTE
ursodiol
UVADEX
86
114
114
114
114
114
79
60
100
79
79
79
61
V
V-NATAL
V-NATAL DHA
valacyclovir hcl
VALCHLOR
VALCYTE
valganciclovir hcl
114
114
6
61
6
6
144
valproate sodium
valproic acid
valproic acid (as sodium salt) (valproate
sodium)
valsartan
valsartan/hydrochlorothiazide
VALTREX
VANCOCIN HCL
vancomycin hcl
VANDAZOLE
VAQTA
VARIVAX VACCINE
VARIZIG
VARUBI
VECTIBIX
VELCADE
VELIVET
VELTASSA
VEMAVITE-PRX 2
VENA-BAL DHA
VENATAL COMPLETE DHA
VENATAL-FA
VENCLEXTA
VENCLEXTA STARTING PACK
venlafaxine hcl
VENTOLIN HFA
verapamil hcl
VEREGEN
VERIPRED 20
VERSACLOZ
VESICARE
VESTURA
VEXOL
VFEND
VFEND IV
VIBRAMYCIN
VICTOZA 2-PAK
VICTOZA 3-PAK
VIDAZA
VIDEX
VIDEX EC
28
28
28
56
56
6
15
15
89
85
85
101
79
24
24
91
68
114
114
114
114
24
24
47
99
56
62
71
47
100
91
95
3
3
15
74
74
24
6
6
VIEKIRA PAK
VIGAMOX
VIIBRYD
VIMPAT
VINACAL
VINATE AZ
VINATE AZ EXTRA
VINATE C
VINATE CALCIUM
VINATE CARE
VINATE DHA
VINATE DHA RF
VINATE GT
VINATE IC
VINATE II
VINATE III
VINATE ONE
VINATE PN CARE
VINATE ULTRA
VINATE-M
vinblastine sulfate
VINCASAR PFS
vincristine sulfate
vinorelbine tartrate
VIOKACE
VIRACEPT
VIRAMUNE
VIRAMUNE XR
VIREAD
VIROPTIC
VIRT NATE
VIRT-ADVANCE
VIRT-BAL DHA
VIRT-BAL DHA PLUS
VIRT-C DHA
VIRT-CARE ONE
VIRT-NATE
VIRT-NATE DHA
VIRT-PN
VIRT-PN DHA
VIRT-PN PLUS
6
92
47
28
114
114
114
114
114
114
114
114
114
114
115
115
115
115
115
115
24
24
24
24
79
6
6
6
6
92
115
115
115
115
115
115
115
115
115
115
115
145
VIRT-SELECT
VIRT-VITE GT
VIRTPREX
VISTIDE
VITAFOL FE+
VITAFOL GUMMIES
VITAFOL NANO
VITAFOL ULTRA
VITAFOL-OB
VITAFOL-OB+DHA
VITAFOL-ONE
VITAFOL-PLUS
VITAFOL-PN
VITAMEDMD ONE RX
VITAMEDMD PLUS RX
VITAMEDMD REDICHEW RX
VITAPEARL
VITAPHIL
VITAPHIL + DHA
VITAPHIL + DHA 90
VITAPHIL AIDE
VITASPIRE
VITATRUE
VITEKTA
VIVA CT
VIVA DHA
VIVELLE
VIVELLE-DOT
VIVITROL
VOL-NATE
VOL-PLUS
VOL-TAB RX
VOLTAREN
voriconazole
VOTRIENT
VP CH ULTRA
VP-CH PLUS
VP-CH-PNV
VP-ERA OB PLUS
VP-GGR-B6
VP-HEME OB
115
115
115
6
115
115
115
115
115
115
115
115
115
116
116
116
116
116
116
116
116
116
116
6
116
116
89
89
38
116
116
116
38
3
24
116
116
116
116
116
116
VP-HEME OB + DHA
VP-HEME ONE
VP-PNV-DHA
VRAYLAR
VYNATAL-FA
VYTORIN
VYVANSE
116
116
116
47
116
59
47
W
warfarin sodium
water for irrigation,sterile
WELCHOL
58
68
59
X
XALATAN
XALKORI
XELJANZ
XELJANZ XR
XENAZINE
XGEVA
XIFAXAN
XOLAIR
XOPENEX
XOPENEX CONCENTRATE
XOPENEX HFA
XTANDI
XULANE
XYREM
XYZAL
94
24
101
87
32
16
12
99
99
99
99
24
91
47
97
Y
YERVOY
YF-VAX
24
85
Z
zafirlukast
zaleplon
ZALTRAP
ZANAFLEX
ZANOSAR
ZARXIO
99
47
24
33
24
83
146
ZATEAN-CH
ZATEAN-PN
ZATEAN-PN DHA
ZATEAN-PN PLUS
ZAVESCA
ZELAPAR
ZELBORAF
ZEMAIRA
ZEMPLAR
ZENCHENT
ZENPEP
ZERIT
ZETIA
ZIAGEN
zidovudine
ZINACEF
ZINECARD
ZINGIBER
ziprasidone hcl
ZIRGAN
ZMAX
zoledronic acid
ZOLINZA
zolmitriptan
zolpidem tartrate
ZOMACTON
ZOMETA
ZONEGRAN
zonisamide
ZORBTIVE
ZORTRESS
ZOSTAVAX
ZOSYN
ZOVIA 1-35E
ZOVIA 1-50E
ZOVIRAX
ZYBAN
ZYDELIG
ZYFLO
ZYFLO CR
ZYKADIA
116
116
116
116
75
30
24
68
75
91
79
6
59
6
6
8
16
117
47
92
9
75
24
31
47
83
75
28
28
83
24
85
13
91
91
6,64
68
24
99
99
25
ZYLET
ZYPREXA
ZYPREXA RELPREVV
ZYPREXA ZYDIS
ZYTIGA
ZYVOX
94
47
47
47
25
12
147
This was updated on September 1, 2016. For more recent information or other questions, please contact
AlohaCare Advantage Plus (HMO SNP) Member Services at 1-866-973-6395, or, for TTY/TDD users,
1-877-447-5990, 8 a.m. to 8 p.m., 7 days a week, or visit www.AlohaCare.org.
AlohaCare 1357 • Kapiolani Blvd, Suite 1250, Honolulu, HI 96814 • www.AlohaCare.org

2016 AlohaCare Advantage Plus Formulary

Transcription

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