Drug Formulary

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Drug Formulary
2016 Drug Formulary for
Qualified Health Plans
(HAP Personal Alliance® and
Small Group)
USE THIS DOCUMENT TO LEARN ABOUT THE PRESCRIPTION DRUGS WE COVER IN ALL
QUALIFIED HEALTH PLANS.
Qualified Health Plans (QHP) are Affordable Care Act-compliant plans that cover essential health
benefits and follow established limits on cost-sharing. This includes HAP Personal Alliance and small
group QHPs purchased through the Health Insurance Marketplace or directly from HAP.
For more information
If you have questions about your health plan, please call a Customer Service specialist at one of the
phone numbers listed below or log in at hap.org and send us a message.
Personal Alliance QHPs
HMO Plans: (800) 759-3436
PPO Plans: (800) 944-9399
Hours:
April 1 through September 30 – Monday through Friday 8 a.m. to 8 p.m.
October 1 through March 31 – Monday through Friday 8 a.m. to 8 p.m.; Saturday 8 a.m.
to noon
Small Group QHPs
HMO Plans: (800) 422-4641
Hours:
April 1 through September 30 – Monday through Friday 8 a.m. to 7 p.m.
October 1 through March 31 – Monday through Friday 8 a.m. to 7 p.m.; Saturday 8 a.m.
to noon
PPO Plans:
Hours:
(888) 999-4347
April 1 through September 30 – Monday through Friday 8 a.m. to 5 p.m.
October 1 through March 31 – Monday through Friday 8 a.m. to 5 p.m.; Saturday 8 a.m.
to noon
If you are deaf, hard of hearing or unable to speak, please call 711 for our TTY service.
Please note: The list of drugs we cover is current as of January 2016. A drug's formulary status
may change prior to being updated in this document. The listing of a drug does not imply
coverage for all benefits. Some dosage forms or strengths of an existing formulary drug may
not be covered. Please contact us for more details.
What is the drug formulary?
A formulary is a list of covered prescription drugs. Prescription drugs are self-administered medications
that you can obtain from pharmacies and that you use in the outpatient setting. The list of covered
prescription drugs is selected with a team of health care providers. This represents the prescription
therapies believed to be a necessary part of a quality treatment program. We will cover the drug listed
in our formulary as long as it is medically necessary, the prescription is filled at an in-network pharmacy
and other rules of the health plan are followed.
Formulary list can change over time. We may add new drugs as they are approved by the FDA and
likewise we may remove drugs as new information about safety and effectiveness is available. We may
also change the tier which reflects your cost-share for the drug. We may update our rules for coverage
meaning that we may add or remove the need for prior approval, quantity limits or criteria for coverage
(see page XX for recent formulary changes).
This list only includes “medical drugs” that are required to be obtained from HAP contracted Specialty
Pharmacy. Medical drugs are those that are administered in the doctor’s office or other health care
facility. These are generally supplied by your doctor or other health care provider. Drugs provided for
home infusion therapy are also considered medical. Please refer to your Medical Cost Share Rider for
information about your cost-sharing for Medical drugs.
The Qualified Health Plan Formulary is available at hap.org/formulary.
How do I use the drug formulary?
The formulary has a list of covered generic and brand name drugs and is organized by categories. Each
category depends on the type of medical conditions that the drugs are used to treat. For example, drugs
used to treat a heart condition are listed under the category “Cardiovascular Agents.” If you know what a
drug is used for, look for the category name in the list. Then look under the category name for the drug.
If you are not sure what category to look under, you should look for your drug in the Index that is at the
end of formulary list. The Index provides an alphabetical list of all of the drugs included in this document.
To search for a specific drug within the formulary, select Ctrl-F and enter the name of the drug in the
search box.
What is a generic substitution?
When an FDA approved generic drug is available, your prescription will be filled with the generic form of
the medication. Generic drugs contain the same active ingredients and are equivalent in strength and
dosage to the original brand name product. Generic drugs cost you and your health plan less money
than a brand name drug.
.
What are specialty drugs?
Specialty drugs are biologics or prescription drugs that require close monitoring for safety and efficacy.
For this reason we contract with Pharmacy Advantage, a specialty pharmacy, from whom you can obtain
specialty drugs. Specialty drugs require prior authorization and Pharmacy Advantage can help you and
your doctor submit a request. You or your doctor can contact Pharmacy Advantage at (800) 456-2112.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. The coverage
requirements are listed on the drug formulary. These requirements and limits may include:
 Prior Authorization – Some medications on our formulary have criteria you must meet before
we cover them. This means that you will need to get approval from us before you fill your
prescriptions for these drugs.


Step Therapy – In some cases, we require 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, we may not cover Drug B unless you try Drug A first. If Drug A
does not work for you, we will then cover Drug B.
Quantity Limits – Certain drugs have quantity limits. A quantity limit is the maximum quantity
that can be dispensed on each fill of medication or the maximum number of fills allowed for
treatment of certain conditions. Specialty/injectable drugs (except insulin) and select oral drugs
(e.g. opioid analgesics) are limited to a maximum 30-day supply per fill. Some specialty drugs
require a 15-day supply for the first fill.
Benefit limitations
Our drug formulary applies to drugs used in an outpatient setting. It does not include medication
administered in the doctor’s office or while in the hospital. These are known as medical drugs. Note that
some medical drugs are listed on this formulary because they are part of our Specialty Program. Please
refer to “what are specialty drug?” section for information about these medications
The following are general drug coverage exclusions that apply to all members:
• Over-the-counter (OTC) medications and their equivalents are not covered unless specified in
the formulary or on the rider
• Drug products used for cosmetic purposes are not covered
• Experimental drugs and/or any drug products used in an experimental manner are not covered
• Replacement of lost or stolen medication is not covered
Since the selected drug packages and coverage vary for each Qualified Health Plan, check your
Summary of Benefits and Coverage (SBC) for your cost-sharing and exclusions.
What if my drug is not on the drug formulary?
When your drug is not listed on the formulary it is considered non-formulary. You or your doctor can ask
us to make an exception and cover your drug and one of HAP clinical specialists will evaluate if the
medication will be covered by your plan. However it is best to first discuss with your doctor or pharmacist
if one of the formulary alternatives will work for you.
Exception approvals for standard non-formulary medications will process at the highest non specialty
(Tier three) copayment. Exception approvals for non-formulary specialty drugs will process at the
highest Specialty (Tier four) copayment. Non-formulary specialty drugs when approved for use by the
health plan can be required to be dispensed by Pharmacy Advantage.
How do I request prior authorization or drug formulary exception?
You or your doctor can ask us to make an exception to our requirements or limits. You may also ask us
to cover a drug not included on our formulary or ask us to exempt you from a formulary requirement
through the exception process. Your doctor must submit a request to us indicating why formulary
requirements should not apply. Your doctor may use the forms available at hap.org/mrf to send us
information when requesting either prior authorization or exception to the formulary.
What is included in the drug formulary?
The name of the covered drug is listed in the first column. Brand name drugs are capitalized (e.g.,
ADVAIR DISKUS) and generic drugs are listed in lower-case (e.g., gabapentin). When a generic drug
is listed on the formulary, only the generic is covered.
The second column represents the drug’s cost-sharing level, or Tier. Every drug on the formulary is in
one of four cost-sharing Tiers.
The following table will translate how the four Tiers shown on the formulary are applicable to your health
plan’s prescription drug benefit. Refer to your Summary of Benefits and Coverage for your costsharing information.
Description of Tier
Preventive (HCR) – generic prescription preventive drugs that
are mandated by the Affordable Care Act. These are covered
at zero copay when Health Care Reform rules are met.
Generic – non-brand name drugs that have the lowest copay
Preferred Brand – brand name formulary drugs that have
the lowest brand copay
Non-Preferred Brand – brand name formulary drugs that
are not in the Preferred Brand Tier
Specialty Drugs – biologics or drugs that require close
monitoring for safety and efficacy and as designated by us to
be a specialty drug
Medical Drugs - These are drugs that are infused or
administered in doctor’s office or facility and are covered
under the medical benefit of your plan.
Copay
Tier 0
Tier 1
Tier 2
Tier 3
Tier 4
Medical Coinsurance
The third column lists the Requirements/Limits that must be met for coverage of your drug. Please
refer to the abbreviations used in this column and their explanation.
The fourth column is the Comment section and may include specific information about strengths or
dosage forms that are covered.
The fifth column is the list of covered lower cost alternatives that you may be able to use.
Abbreviations for Requirements/Limits are as follows:
PA (Prior Authorization) – You or your doctor is required to get prior authorization from us before you
fill your prescription for this drug. Without prior approval, we may not cover this drug.
QL (Quantity Limit) – We limit the amount of these drugs that are covered for each prescription. For
example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit
coverage for your prescription to no more than one pill per day.
ST (Step Therapy) – Before we will provide coverage for this drug, you must first try another drug(s) to
treat your medical condition. This drug may only be covered if the other drug(s) does not work for you.
SP (Specialty Pharmacy) –This specialty drug can only be obtained from Pharmacy Advantage by
calling them at (800) 456 2112.
TABLE OF CONTENTS
ANTIHISTAMINE DRUGS
FIRST GENERATION ANTIHISTAMINES
ETHANOLAMINE DERIVATIVES
FIRST GEN. ANTIHIST. DERIVATIVES, MISC.
PHENOTHIAZINE DERIVATIVES
PROPYLAMINE DERIVATIVES
SECOND GENERATION ANTIHISTAMINES
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
ANTIBACTERIALS
AMINOGLYCOSIDES
ANTIBACTERIALS, MISCELLANEOUS
CEPHALOSPORINS
MACROLIDES
MISCELLANEOUS B-LACTAM ANTIBIOTICS
PENICILLINS
QUINOLONES
SULFONAMIDES (SYSTEMIC)
TETRACYCLINES
ANTIFUNGAL (SYSTEMIC)
ALLYLAMINES
ANTIFUNGALS, MISCELLANEOUS
AZOLES
POLYENES
PYRIMIDINES
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, MISCELLANEOUS
ANTITUBERCULOSIS AGENTS
ANTIPROTOZOALS
AMEBICIDES
ANTIMALARIALS
ANTIPROTOZOALS, MISCELLANEOUS
ANTIVIRALS (SYSTEMIC)
ADAMANTANES
ANTIRETROVIRALS
HCV ANTIVIRALS
INTERFERONS
MONOCLONAL ANTIBODIES
NEURAMINIDASE INHIBITORS
NUCLEOSIDES AND NUCLEOTIDES
URINARY ANTI-INFECTIVES
ANTINEOPLASTIC AGENTS
AUTONOMIC DRUGS
ANTICHOLINERGIC AGENTS
ANTIMUSCARINICS/ANTISPASMODICS
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TABLE OF CONTENTS
AUTONOMIC DRUGS
ANTICHOLINERGIC AGENTS
ANTIPARKINSONIAN AGENTS
AUTONOMIC DRUGS, MISCELLANEOUS
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
SKELETAL MUSCLE RELAXANTS
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT
DIRECT-ACTING SKELETAL MUSCLE RELAXANTS
GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT
SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS
SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS
ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ALPHA- AND BETA-ADRENERGIC AGONISTS
ALPHA-ADRENERGIC AGONISTS
BETA-ADRENERGIC AGONISTS
BLOOD FORMATION,COAGULATION & THROMBOSIS
ANTIANEMIA DRUGS
IRON PREPARATIONS
ANTIHEMORRHAGIC AGENTS
HEMOSTATICS
ANTITHROMBOTIC AGENTS
ANTICOAGULANTS
PLATELET-AGGREGATION INHIBITORS
PLATELET-REDUCING AGENTS
HEMATOPOIETIC AGENTS
HEMORRHEOLOGIC AGENTS
CARDIOVASCULAR DRUGS
ALPHA-ADRENERGIC BLOCKING AGENTS
ANTILIPEMIC AGENTS
ANTILIPEMIC AGENTS, MISCELLANEOUS
BILE ACID SEQUESTRANTS
CHOLESTEROL ABSORPTION INHIBITORS
FIBRIC ACID DERIVATIVES
HMG-COA REDUCTASE INHIBITORS
BETA-ADRENERGIC BLOCKING AGENTS
CALCIUM-CHANNEL BLOCKING AGENTS
CALCIUM-CHANNEL BLOCKING AGENTS, MISC.
DIHYDROPYRIDINES
CARDIAC DRUGS
ANTIARRHYTHMIC AGENTS
CARDIAC DRUGS, MISCELLANEOUS
CARDIOTONIC AGENTS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM
HYPOTENSIVE AGENTS
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TABLE OF CONTENTS
CARDIOVASCULAR DRUGS
HYPOTENSIVE AGENTS
CENTRAL ALPHA-AGONISTS
DIRECT VASODILATORS
DIURETICS (HYPOTENSIVE AGENTS)
PERIPHERAL ADRENERGIC INHIBITORS
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
ANGIOTENSIN II RECEPTOR ANTAGONISTS
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS
RENIN INHIBITORS
VASODILATING AGENTS
NITRATES AND NITRITES
PHOSPHODIESTERASE TYPE 5 INHIBITORS
VASODILATING AGENTS, MISCELLANEOUS
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
ANALGESICS AND ANTIPYRETICS, MISC.
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
OPIATE AGONISTS
OPIATE PARTIAL AGONISTS
ANOREXIGENICS AGENTS AND RESPIRATORY AND CNS
AMPHETAMINES
ANOREXIGENIC AGENTS
RESPIRATORY AND CNS STIMULANTS
WAKEFULNESS-PROMOTING AGENTS
ANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
BARBITURATES (ANTICONVULSANTS)
BENZODIAZEPINES (ANTICONVULSANTS)
HYDANTOINS
SUCCINIMIDES
ANTIMANIC AGENTS
ANTIMIGRAINE AGENTS
SELECTIVE SEROTONIN AGONISTS
ANTIPARKINSONIAN AGENTS (CNS)
ADAMANTANES (CNS)
ANTICHOLINERGIC AGENTS (CNS)
CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.
DOPAMINE PRECURSORS
DOPAMINE RECEPTOR AGONISTS
MONOAMINE OXIDASE B INHIBITORS
ANXIOLYTICS, SEDATIVES AND HYPNOTICS
ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
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TABLE OF CONTENTS
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES AND HYPNOTICS
BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
CENTRAL NERVOUS SYSTEM AGENTS, MISC.
FIBROMYALGIA AGENTS
OPIATE ANTAGONISTS
PSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
ANTIPSYCHOTIC AGENTS
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ALKALINIZING AGENTS
AMMONIA DETOXICANTS
DIURETICS
LOOP DIURETICS
POTASSIUM-SPARING DIURETICS
THIAZIDE DIURETICS
THIAZIDE-LIKE DIURETICS
VASOPRESSIN ANTAGONISTS
ION-REMOVING AGENTS
PHOSPHATE-REMOVING AGENTS
POTASSIUM-REMOVING AGENTS
REPLACEMENT PREPARATIONS
URICOSURIC AGENTS
EYE, EAR, NOSE AND THROAT (EENT) PREPS.
ANTIALLERGIC AGENTS
ANTIGLAUCOMA AGENTS
ALPHA-ADRENERGIC AGONISTS (EENT)
BETA-ADRENERGIC BLOCKING AGENTS (EENT)
CARBONIC ANHYDRASE INHIBITORS (EENT)
MIOTICS
PROSTAGLANDIN ANALOGS
ANTI-INFECTIVES (EENT)
ANTIBACTERIALS (EENT)
ANTIVIRALS (EENT)
EENT ANTI-INFECTIVES, MISCELLANEOUS
ANTI-INFLAMMATORY AGENTS (EENT)
CORTICOSTEROIDS (EENT)
EENT NONSTEROIDAL ANTI-INFLAM. AGENTS
EENT DRUGS, MISCELLANEOUS
LOCAL ANESTHETICS (EENT)
MYDRIATICS
VASOCONSTRICTORS
GASTROINTESTINAL DRUGS
ANTIDIARRHEA AGENTS
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TABLE OF CONTENTS
GASTROINTESTINAL DRUGS
ANTIEMETICS
5-HT3 RECEPTOR ANTAGONISTS
ANTIEMETICS, MISCELLANEOUS
ANTIHISTAMINES (GI DRUGS)
ANTI-INFLAMMATORY AGENTS (GI DRUGS)
ANTIULCER AGENTS AND ACID SUPPRESSANTS
HISTAMINE H2-ANTAGONISTS
PROSTAGLANDINS
PROTECTANTS
PROTON-PUMP INHIBITORS
CATHARTICS AND LAXATIVES
CHOLELITHOLYTIC AGENTS
DIGESTANTS
GI DRUGS, MISCELLANEOUS
PROKINETIC AGENTS
GOLD COMPOUNDS
HEAVY METAL ANTAGONISTS
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
ANDROGENS
ANTIDIABETIC AGENTS
ALPHA-GLUCOSIDASE INHIBITORS
AMYLINOMIMETICS
ANTIDIABETIC AGENTS, MISCELLANEOUS
BIGUANIDES
DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS
INCRETIN MIMETICS
INSULINS
MEGLITINIDES
SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBITORS
SULFONYLUREAS
THIAZOLIDINEDIONES
ANTIHYPOGLYCEMIC AGENTS
ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS
GLYCOGENOLYTIC AGENTS
CONTRACEPTIVES
ESTROGENS AND ANTIESTROGENS
ESTROGEN AGONIST-ANTAGONISTS
ESTROGENS
GONADOTROPINS
PARATHYROID
PITUITARY
PROGESTINS
SOMATOSTATIN AGONISTS AND ANTAGONISTS
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TABLE OF CONTENTS
HORMONES AND SYNTHETIC SUBSTITUTES
SOMATOSTATIN AGONISTS AND ANTAGONISTS
SOMATOSTATIN AGONISTS
SOMATOTROPIN AGONISTS AND ANTAGONISTS
SOMATOTROPIN AGONISTS
SOMATOTROPIN ANTAGONISTS
THYROID AND ANTITHYROID AGENTS
ANTITHYROID AGENTS
THYROID AGENTS
LOCAL ANESTHETICS (PARENTERAL)
MISCELLANEOUS THERAPEUTIC AGENTS
5-ALPHA-REDUCTASE INHIBITORS
ALCOHOL DETERRENTS
ANTIDOTES
ANTIGOUT AGENTS
BIOLOGIC RESPONSE MODIFIERS
BONE RESORPTION INHIBITORS
CARIOSTATIC AGENTS
COMPLEMENT INHIBITORS
DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
GONADOTROPIN-RELEASING HORMONE ANTAGNTS
IMMUNOSUPPRESSIVE AGENTS
OTHER MISCELLANEOUS THERAPEUTIC AGENTS
RESPIRATORY TRACT AGENTS
ANTIFIBROTIC AGENTS
ANTI-INFLAMMATORY AGENTS (RESPIRATORY)
LEUKOTRIENE MODIFIERS
MAST-CELL STABILIZERS
ANTITUSSIVES
CYSTIC FIBROSIS (CFTR) MODULATORS
CYSTIC FIBROSIS (CFTR) POTENTIATORS
MUCOLYTIC AGENTS
PHOSPHODIESTERASE TYPE 4 INHIBITORS
RESPIRATORY TRACT AGENTS, MISCELLANEOUS
VASODILATING AGENTS (RESPIRATORY TRACT)
SERUMS, TOXOIDS, AND VACCINES
SERUMS
TOXOIDS
VACCINES
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)
ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)
ANTIVIRALS (SKIN & MUCOUS MEMBRANE)
LOCAL ANTI-INFECTIVES, MISCELLANEOUS
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TABLE OF CONTENTS
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
SCABICIDES AND PEDICULICIDES
ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
ANTIPRURITICS AND LOCAL ANESTHETICS
ASTRINGENTS
CELL STIMULANTS AND PROLIFERANTS
DEPIGMENTING AND PIGMENTING AGENTS
PIGMENTING AGENTS
EMOLLIENTS, DEMULCENTS, AND PROTECTANTS
BASIC LOTIONS AND LINIMENTS
KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS, MISC.
SMOOTH MUSCLE RELAXANTS
GENITOURINARY SMOOTH MUSCLE RELAXANTS
ANTIMUSCARINICS
BETA-3-ADRENERGIC AGONISTS
RESPIRATORY SMOOTH MUSCLE RELAXANTS
VITAMINS
MULTIVITAMIN PREPARATIONS
VITAMIN B COMPLEX
VITAMIN D
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Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTIHISTAMINE DRUGS
FIRST GENERATION ANTIHISTAMINES
ETHANOLAMINE DERIVATIVES
clemastine syp 0.5/5ml
T1
clemastine tab 2.68mg
T1
FIRST GEN. ANTIHIST. DERIVATIVES, MISC.
cyproheptad syp 2mg/5ml
T1
cyproheptad tab 4mg
T1
PHENOTHIAZINE DERIVATIVES
phenadoz sup 25mg (promethazine)
T1
phenergan sup 25mg (promethazine)
T1
phenergan sup 50mg (promethazine)
T1
prometh vc syp 6.25-5/5 (promethazine)
T1
QL
prometh vc syp plain (promethazine)
T1
QL
prometh/pe syp 6.25-5/5
T1
QL
promethazine sol 6.25/5ml
T1
promethazine sup 25mg
T1
promethazine sup 50mg
T1
promethazine syp 6.25/5ml
T1
promethazine tab 12.5mg
T1
promethazine tab 25mg
T1
promethazine tab 50mg
T1
promethegan sup 25mg (promethazine)
T1
promethegan sup 50mg (promethazine)
T1
PROPYLAMINE DERIVATIVES
dexchlorphen syp 2mg/5ml
T1
SECOND GENERATION ANTIHISTAMINES
desloratadin tab 5mg
T1
levocetirizi sol 2.5/5ml
T1
levocetirizi tab 5mg
T1
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
ALBENZA TAB 200MG (albendazole)
T3
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
1
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
AMINOGLYCOSIDES
neomycin tab 500mg
T1
tobramycin neb 300/5ml
T4
PA, QL (2 nebulizers/day)
ANTIBACTERIALS, MISCELLANEOUS
baciim inj 50000unt (bacitracin)
T1
bacitracin inj 50000unt
T1
clindamycin cap 150mg
T1
clindamycin cap 300mg
T1
clindamycin cap 75mg
T1
clindamycin sol 75mg/5ml
T1
linezolid tab 600mg
T1
QL
vancomycin cap 125mg
T1
QL (112 caps/14 days)
vancomycin cap 250mg
T1
QL (112 caps/14 days)
VANCOMYCN 25 SOL 25MG/ML (vancomycin)
T2
VANCOMYCN 50 SOL 50MG/ML (vancomycin)
T2
XIFAXAN TAB 200MG (rifaximin)
T3
PA
XIFAXAN TAB 550MG (rifaximin)
T3
PA
ZYVOX SUS 100MG/5M (linezolid)
T3
QL (840ml/14 days)
ZYVOX TAB 600MG (linezolid)
T3
QL (28 tabs/14 days)
CEPHALOSPORINS
CEDAX CAP 400MG (ceftibuten)
T2
cefaclor cap 250mg
T1
cefaclor cap 500mg
T1
cefaclor er tab 500mg
T1
cefadroxil cap 500mg
T1
cefadroxil sus 250/5ml
T1
cefadroxil sus 500/5ml
T1
cefadroxil tab 1gm
T1
cefdinir cap 300mg
T1
cefdinir sus 125/5ml
T1
cefdinir sus 250/5ml
T1
cefditoren tab 200mg
T1
cefditoren tab 400mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
2
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
CEPHALOSPORINS
cefixime sus 100/5ml
T1
cefixime sus 200/5ml
T1
cefpodo prox sus 100/5ml
T1
cefpodo prox sus 50mg/5ml
T1
cefpodoxime tab 100mg
T1
cefpodoxime tab 200mg
T1
cefprozil sus 125/5ml
T1
cefprozil sus 250/5ml
T1
cefprozil tab 250mg
T1
cefprozil tab 500mg
T1
cefuroxime tab 250mg
T1
cefuroxime tab 500mg
T1
cephalexin cap 250mg
T1
cephalexin cap 500mg
T1
cephalexin cap 750mg
T1
cephalexin sus 125/5ml
T1
cephalexin sus 250/5ml
T1
SUPRAX SUS 100/5ML (cefixime)
T3
SUPRAX SUS 200/5ML (cefixime)
T3
SUPRAX SUS 500/5ML (cefixime)
T3
SUPRAX TAB 400MG (cefixime)
T3
MACROLIDES
azithromycin pow 1gm pak
T1
QL
azithromycin sus 100/5ml
T1
QL (120 ml/fill)
azithromycin sus 200/5ml
T1
QL (120 ml/fill)
azithromycin tab 250mg
T1
QL (8/5 days)
azithromycin tab 500mg
T1
QL (8/5 days)
azithromycin tab 600mg
T1
QL (8/5 days)
clarithromyc sus 125/5ml
T1
clarithromyc sus 250/5ml
T1
clarithromyc tab 250mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
3
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
MACROLIDES
clarithromyc tab 500mg
T1
clarithromyc tab 500mg er
T1
DIFICID TAB 200MG (fidaxomicin)
T3
e.e.s. 400 tab 400mg (erythromycin)
T1
E.E.S. GRAN SUS 200/5ML (erythromycin)
T2
ERYPED SUS 200/5ML (erythromycin)
T2
ERYPED SUS 400/5ML (erythromycin)
T2
erythrom eth tab 400mg
T1
erythromycin tab 250mg bs
T1
erythromycin tab 500mg bs
T1
KETEK TAB 300MG (telithromycin)
T3
QL (20 tabs/10 days)
KETEK TAB 400MG (telithromycin)
T3
QL (20 tabs/10 days)
PCE TAB 333MG EC (erythromycin)
T2
PCE TAB 500MG EC (erythromycin)
T2
QL (20/10 days)
MISCELLANEOUS B-LACTAM ANTIBIOTICS
CAYSTON INH 75MG (aztreonam)
T4
PA, QL (1 kit/28 days)
PENICILLINS
amox/k clav chw 200mg
T1
amox/k clav chw 400mg
T1
amox/k clav sus 200/5ml
T1
amox/k clav sus 250/5ml
T1
amox/k clav sus 400/5ml
T1
amox/k clav sus 600/5ml
T1
amox/k clav tab 250mg
T1
amox/k clav tab 500mg
T1
amox/k clav tab 875mg
T1
amoxicillin cap 250mg
T1
amoxicillin cap 500mg
T1
amoxicillin chw 125mg
T1
amoxicillin chw 250mg
T1
amoxicillin sus 125/5ml
T1
amoxicillin sus 200/5ml
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
4
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
PENICILLINS
amoxicillin sus 250/5ml
T1
amoxicillin sus 250mg/5m
T1
amoxicillin sus 400/5ml
T1
amoxicillin tab 500mg
T1
amoxicillin tab 875mg
T1
amox-pot cla tab er
T1
ampicillin cap 250mg
T1
ampicillin cap 500mg
T1
ampicillin sus 125/5ml
T1
ampicillin sus 250/5ml
T1
dicloxacill cap 250mg
T1
dicloxacill cap 500mg
T1
penicilln vk sol 125/5ml
T1
penicilln vk sol 250/5ml
T1
penicilln vk tab 250mg
T1
penicilln vk tab 500mg
T1
QUINOLONES
ciprofloxacn sus 250mg/5
T1
ciprofloxacn sus 500mg/5
T1
ciprofloxacn tab 1000mg
T1
ciprofloxacn tab 100mg
T1
ciprofloxacn tab 250mg
T1
ciprofloxacn tab 500mg
T1
ciprofloxacn tab 500mg er
T1
ciprofloxacn tab 750mg
T1
FACTIVE TAB 320MG (gemifloxacin)
T3
levofloxacin inj 25mg/ml
T1
levofloxacin sol 25mg/ml
T1
levofloxacin tab 250mg
T1
levofloxacin tab 500mg
T1
levofloxacin tab 750mg
T1
QL (14 tabs/Rx)
QL (14 tabs/Rx)
QL (7 tabs/7 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
5
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
QUINOLONES
moxifloxacin tab 400mg
T1
QL (14 tabs/Rx)
NOROXIN TAB 400MG (norfloxacin)
T3
QL (56 tabs/28 days)
ofloxacin tab 200mg
T1
ofloxacin tab 300mg
T1
ofloxacin tab 400mg
T1
SULFONAMIDES (SYSTEMIC)
smz/tmp ds tab 800-160
T1
smz-tmp sus 200-40/5
T1
smz-tmp tab 400-80mg
T1
smz-tmp ds tab 800-160 (sulfamethoxazoletrimethoprim)
T1
sulfadiazine tab 500mg
T1
sulfasalazin tab 500mg
T1
sulfasalazin tab 500mg dr
T1
sulfatrim pd sus 200-40/5 (sulfamethoxazoletrimethoprim)
T1
sulfazine tab 500mg (sulfasalazine)
T1
sulfazine ec tab 500mg (sulfasalazine)
T1
TETRACYCLINES
demeclocycl tab 150mg
T1
demeclocycl tab 300mg
T1
doxycyc mono cap 100mg
T1
doxycycl hyc cap 100mg
T1
doxycycl hyc cap 50mg
T1
QL (90 caps/30 days)
doxycycl hyc tab 100mg
T1
QL (90 caps/30 days)
minocycline cap 100mg
T1
minocycline cap 50mg
T1
minocycline cap 75mg
T1
minocycline tab 100mg
T1
minocycline tab 50mg
T1
minocycline tab 75mg
T1
tetracycline cap 250mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
6
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
TETRACYCLINES
tetracycline cap 500mg
T1
ANTIFUNGAL (SYSTEMIC)
ALLYLAMINES
terbinafine tab 250mg
T1
ANTIFUNGALS, MISCELLANEOUS
griseofulvin sus 125/5ml
T1
griseofulvin tab micr 500
T1
griseofulvin tab ultr 125
T1
griseofulvin tab ultr 250
T1
AZOLES
fluconazole sus 10mg/ml
T1
fluconazole sus 40mg/ml
T1
fluconazole tab 100mg
T1
fluconazole tab 150mg
T1
fluconazole tab 200mg
T1
fluconazole tab 50mg
T1
itraconazole cap 100mg
T1
ketoconazole tab 200mg
T1
NOXAFIL SUS 40MG/ML (posaconazole)
T3
SPORANOX SOL 10MG/ML (itraconazole)
T3
voriconazole tab 200mg
T1
PA
voriconazole tab 50mg
T1
PA
QL (2 bottles/fill)
POLYENES
nystatin pow
T1
nystatin pow 10bu
T1
nystatin pow 150mu
T1
nystatin pow 1bu
T1
nystatin pow 2bu
T1
nystatin pow 500mu
T1
nystatin pow 50mu
T1
nystatin pow 5bu
T1
nystatin sus 100000
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
7
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTI-INFECTIVE AGENTS
ANTIFUNGAL (SYSTEMIC)
POLYENES
nystatin tab 500000
T1
PYRIMIDINES
flucytosine cap 250mg
T1
flucytosine cap 500mg
T1
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, MISCELLANEOUS
dapsone tab 100mg
T1
dapsone tab 25mg
T1
ANTITUBERCULOSIS AGENTS
cycloserine cap 250mg
T1
ethambutol tab 100mg
T1
ethambutol tab 400mg
T1
isoniazid syp 50mg/5ml
T1
isoniazid tab 100mg
T1
isoniazid tab 300mg
T1
pyrazinamide tab 500mg
T1
rifabutin cap 150mg
T1
RIFAMATE CAP (isoniazid)
T2
rifampin cap 150mg
T1
rifampin cap 300mg
T1
rifampin inj 600 mg
T1
SIRTURO TAB 100MG (bedaquiline)
T4
PA
ANTIPROTOZOALS
AMEBICIDES
paromomycin cap 250mg
T1
ANTIMALARIALS
atovaq/progu tab 250-100
T1
QL
atovaq/progu tab 62.5-25
T1
QL
chloroquine tab 250mg
T1
chloroquine tab 500mg
T1
COARTEM TAB 20-120MG (artemetherlumefantrine)
T3
QL (24 tabs/fill)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
8
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTI-INFECTIVE AGENTS
ANTIPROTOZOALS
ANTIMALARIALS
DARAPRIM TAB 25MG (pyrimethamine)
T3
hydroxychlor tab 200mg
T1
mefloquine tab 250mg
T1
primaquine tab 26.3mg
T2
QL (90 tabs/30 days)
QL (5 tabs/30 days)
ANTIPROTOZOALS, MISCELLANEOUS
ALINIA SUS 100/5ML (nitazoxanide)
T3
QL (150ml/3 days)
ALINIA TAB 500MG (nitazoxanide)
T3
QL (6 tabs/3 days)
atovaquone sus 750/5ml
T1
metronidazol cap 375mg
T1
metronidazol tab 250mg
T1
metronidazol tab 500mg
T1
NEBUPENT INH 300MG (pentamidine)
T3
tinidazole tab 250mg
T1
tinidazole tab 500mg
T1
PA
ANTIVIRALS (SYSTEMIC)
ADAMANTANES
rimantadine tab 100mg
T1
ANTIRETROVIRALS
abacav/lamiv tab /zidovud
T4
abacavir tab 300mg
T4
APTIVUS CAP 250MG (tipranavir)
T4
APTIVUS SOL (tipranavir)
T4
ATRIPLA TAB (efavirenz-emtricitabine-tenofovir)
T4
QL (30 tabs/30 days)
COMPLERA TAB (emtricitabine-rilpivirinetenofovir)
T4
QL (30 tabs/30 days)
CRIXIVAN CAP 200MG (indinavir)
T4
QL (180 caps/30 days)
CRIXIVAN CAP 400MG (indinavir)
T4
QL (180 caps/30 days)
CRIXIVAN 100 MG CAPSULE (INDINAVIR)
T4
didanosine cap 125mg
T4
QL (60 caps/30 day)
didanosine cap 200mg
T4
QL (60 caps/30 day)
didanosine cap 250mg
T4
QL (60 caps/30 day)
didanosine cap 400mg
T4
QL (60 caps/30 day)
QL (60 tabs/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
9
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTI-INFECTIVE AGENTS
ANTIVIRALS (SYSTEMIC)
ANTIRETROVIRALS
EDURANT TAB 25MG (rilpivirine)
T4
QL (30 tabs/30 days)
EMTRIVA CAP 200MG (emtricitabine)
T4
QL (60 caps/30 days)
EMTRIVA SOL 10MG/ML (emtricitabine)
T4
QL (680ml/23 days)
EPIVIR HBV SOL 5MG/ML (lamivudine)
T4
QL
EPZICOM TAB (abacavir)
T4
QL (30 tabs/30 days)
EPZICOM TAB 600-300 (abacavir)
T4
QL (30 tabs/30 days)
FUZEON INJ 90MG (enfuvirtide)
T4
PA
FUZEON CONVENIENCE KIT (ENFUVIRTIDE)
T4
PA
INTELENCE TAB 100MG (etravirine)
T4
QL (60 tabs/30 days)
INTELENCE TAB 200MG (etravirine)
T4
QL (60 tabs/30 days)
INTELENCE TAB 25MG (etravirine)
T4
QL
ISENTRESS TAB 400MG (raltegravir)
T4
QL (60 tabs/30 days)
KALETRA SOL (lopinavir-ritonavir)
T4
QL (640ml/23 days)
KALETRA TAB 100-25MG (lopinavir-ritonavir)
T4
QL (60 tabs/30 days)
KALETRA TAB 200-50MG (lopinavir-ritonavir)
T4
QL (60 tabs/30 days)
lamivud/zido tab 150-300
T4
QL (60 tab/30 day)
lamivudine sol 10mg/ml
T4
lamivudine tab 100mg
T4
lamivudine tab 150mg
T4
lamivudine tab 300mg
T4
LEXIVA SUS 50MG/ML (fosamprenavir)
T4
QL (1800ml/30 days)
LEXIVA TAB 700MG (fosamprenavir)
T4
QL (120 tabs/30 days)
nevirapine sus 50mg/5ml
T4
nevirapine tab 200mg
T4
QL (60 tab/30 day)
nevirapine tab 400mg er
T4
QL (30 TABS/30 DAYS)
NORVIR CAP 100MG (ritonavir)
T4
QL (60 caps/30 days)
NORVIR SOL 80MG/ML (ritonavir)
T4
QL (240 ml/30 day)
NORVIR TAB 100MG (ritonavir)
T4
QL (60 tabs/30 days)
PREZISTA TAB 150MG (darunavir)
T4
QL (60 tabs/30 days)
PREZISTA TAB 400MG (darunavir)
T4
QL (60 tabs/30 days)
PREZISTA TAB 600MG (darunavir)
T4
QL (60 tabs/30 days)
PA, SP
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
10
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTI-INFECTIVE AGENTS
ANTIVIRALS (SYSTEMIC)
ANTIRETROVIRALS
PREZISTA TAB 75MG (darunavir)
T4
QL (60 tabs/30 days)
PREZISTA TAB 800MG (darunavir)
T4
QL (60 tabs/30 days)
RESCRIPTOR TAB 100 MG (delavirdine)
T4
QL (180 tabs/30 days)
RESCRIPTOR TAB 200MG (delavirdine)
T4
QL (180 tabs/30 days)
REYATAZ CAP 100MG (atazanavir)
T4
QL (30 caps/30 days)
REYATAZ CAP 150MG (atazanavir)
T4
QL (30 caps/30 days)
REYATAZ CAP 200MG (atazanavir)
T4
QL (30 caps/30 days)
REYATAZ CAP 300MG (atazanavir)
T4
QL (30 caps/30 days)
SELZENTRY TAB 150MG (maraviroc)
T4
QL (60 tabs/30 days)
SELZENTRY TAB 300MG (maraviroc)
T4
QL (60 tabs/30 days)
stavudine cap 15mg
T4
QL (60 caps/30 day)
stavudine cap 20mg
T4
QL (60 caps/30 day)
stavudine cap 30mg
T4
QL (60 caps/30 day)
stavudine cap 40mg
T4
QL (60 caps/30 day)
stavudine sol 1mg/ml
T4
QL (60 caps/30 day)
STRIBILD TAB (elvitegravir-cobicistatemtricitabine-tenofovir)
T4
QL (30 tabs/30 days)
SUSTIVA CAP 200MG (efavirenz)
T4
QL (30 caps/30 days)
SUSTIVA CAP 50MG (efavirenz)
T4
QL (30 caps/30 days)
SUSTIVA TAB 600MG (efavirenz)
T4
QL (30 tabs/30 days)
TIVICAY TAB 50MG (dolutegravir)
T4
QL (60 TABS/30 DAYS)
TRUVADA TAB (emtricitabine-tenofovir)
T4
PA, QL (30 tabs/30 days)
TRUVADA TAB 200-300 (emtricitabine-tenofovir)
T4
PA, QL (30 tabs/30 days)
VIDEX SOL 2GM (didanosine)
T4
QL (800ml/30 days)
VIDEX SOL 4GM (didanosine)
T4
QL (800ml/30 days)
VIRACEPT TAB 250MG (nelfinavir)
T4
QL (120 tabs/30 days)
VIRACEPT TAB 625MG (nelfinavir)
T4
QL (120 tabs/30 days)
VIRAMUNE SUS 50MG/5ML (nevirapine)
T4
QL (480 ml /30 day)
VIRAMUNE XR TAB 100MG (nevirapine)
T4
QL (30 tabs/30 days)
VIREAD POW 40MG/GM (tenofovir)
T4
VIREAD TAB 150MG (tenofovir)
T4
QL (30 tabs/30 days)
VIREAD TAB 200MG (tenofovir)
T4
QL (30 tabs/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
11
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTI-INFECTIVE AGENTS
ANTIVIRALS (SYSTEMIC)
ANTIRETROVIRALS
VIREAD TAB 250MG (tenofovir)
T4
QL (30 tabs/30 days)
VIREAD TAB 300MG (tenofovir)
T4
QL (30 tabs/30 days)
ZIAGEN SOL 20MG/ML (abacavir)
T4
QL (480ml/30 days)
zidovudine cap 100mg
T4
QL (60 caps/30 day)
zidovudine syp 50mg/5ml
T4
QL (480ml/30 day)
zidovudine tab 300mg
T4
QL (60 tab/30 day)
HARVONI TAB 90-400MG (ledipasvir-sofosbuvir)
T4
PA, SP
INCIVEK TAB 375MG (telaprevir)
T4
PA, SP
SOVALDI TAB 400MG (sofosbuvir)
T4
PA, SP
TECHNIVIE TAB (ombitasvir-paritaprevir-ritonavir)
T4
PA, SP
VICTRELIS CAP 200MG (boceprevir)
T4
PA, SP
VIEKIRA PAK TAB (ombitasvir-paritaprevirritonavir)
T4
PA, SP
INFERGEN INJ 15MCG (interferon)
T4
PA
INFERGEN INJ 9MCG (interferon)
T4
PA
PEGASYS 180 MCG/0.5 ML CONV.PK
(PEGINTERFERON)
T4
PA, SP
PEGINTRON KIT 120MCG (peginterferon)
T4
PA, SP
PEGINTRON KIT 150MCG (peginterferon)
T4
PA, SP
PEGINTRON KIT 50MCG (peginterferon)
T4
PA, SP
PEGINTRON KIT 80MCG (peginterferon)
T4
PA, SP
PEG-INTRON KIT 120 RP (peginterferon)
T4
PA, SP
PEG-INTRON KIT 120MCG (peginterferon)
T4
PA, SP
PEG-INTRON KIT 150 RP (peginterferon)
T4
PA, SP
PEG-INTRON KIT 150MCG (peginterferon)
T4
PA, SP
PEG-INTRON KIT 50MCG (peginterferon)
T4
PA, SP
PEG-INTRON KIT 50MCG RP (peginterferon)
T4
PA, SP
PEG-INTRON KIT 80MCG (peginterferon)
T4
PA, SP
PEG-INTRON KIT 80MCG RP (peginterferon)
T4
PA, SP
HCV ANTIVIRALS
INTERFERONS
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
12
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTI-INFECTIVE AGENTS
ANTIVIRALS (SYSTEMIC)
MONOCLONAL ANTIBODIES
SYNAGIS INJ 50MG (palivizumab)
MED
PA, SP
RELENZA AER DISKHALE (zanamivir)
T3
QL (20 inhalations/fill; 2 fills/365
days)
RELENZA MIS DISKHALE (zanamivir)
T3
QL (20 inhalations/fill; 2 fills/365
days)
TAMIFLU CAP 30MG (oseltamivir)
T3
QL (10 caps/fill; 2 fills/365 days)
TAMIFLU CAP 45MG (oseltamivir)
T3
QL (10 caps/fill; 2 fills/365 days)
TAMIFLU CAP 75MG (oseltamivir)
T3
QL (10 caps/fill; 2 fills/365 days)
TAMIFLU SUS 6MG/ML (oseltamivir)
T3
QL (120ml/fill; 2 fills/365 days)
Medical coinsurance
NEURAMINIDASE INHIBITORS
NUCLEOSIDES AND NUCLEOTIDES
acyclovir cap 200mg
T1
acyclovir sus 200/5ml
T1
acyclovir tab 400mg
T1
acyclovir tab 800mg
T1
adefov dipiv tab 10mg
T4
PA, SP
BARACLUDE SOL .05MG/ML (entecavir)
T4
PA, SP
entecavir tab 0.5mg
T4
PA, SP
entecavir tab 1mg
T4
PA, SP
famciclovir tab 125mg
T1
famciclovir tab 250mg
T1
famciclovir tab 500mg
T1
ganciclovir cap 250 mg
T1
moderiba tab 200mg (ribavirin)
T1
PA, SP
ribapak pak 1200/day (ribavirin)
T1
PA
ribapak pak 800/day (ribavirin)
T1
PA
ribasphere cap 200mg (ribavirin)
T1
PA, SP
ribasphere tab 200mg (ribavirin)
T1
PA, SP
ribasphere tab 400mg (ribavirin)
T1
PA, SP
ribasphere tab 600mg (ribavirin)
T1
PA, SP
ribatab pak 1000/day (ribavirin)
T1
PA, SP
ribatab tab 1200/day (ribavirin)
T1
PA, SP
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
13
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTI-INFECTIVE AGENTS
ANTIVIRALS (SYSTEMIC)
NUCLEOSIDES AND NUCLEOTIDES
ribatab tab 800/day (ribavirin)
T1
PA, SP
ribavirin cap 200mg
T1
PA, SP
ribavirin tab 200mg
T1
PA, SP
TYZEKA TAB 600MG (telbivudine)
T4
PA, SP
valacyclovir tab 1gm
T1
QL (30 tabs/30 days)
valacyclovir tab 500mg
T1
QL (30 tabs/30 days)
VALCYTE TAB 450MG (valganciclovir)
T3
PA
valganciclov tab 450mg
T1
PA
hyophen tab (methenamine-hyosc-methylene)
T1
QL
methenam hip tab 1gm
T1
MONUROL PAK GRANULES (fosfomycin)
T3
nitrofur mac cap 100mg
T1
nitrofur mac cap 50mg
T1
nitrofurantn cap 100mg
T1
nitrofurantn sus 25mg/5ml
T1
nitrofuranto cap 100mg
T1
trimethoprim tab 100mg
T1
URINARY ANTI-INFECTIVES
PA, QL (3 packs/fill)
ANTINEOPLASTIC AGENTS
AFINITOR TAB 10MG (everolimus)
T4
PA, SP
AFINITOR TAB 2.5MG (everolimus)
T4
PA, SP
AFINITOR TAB 5MG (everolimus)
T4
PA, SP
AFINITOR TAB 7.5MG (everolimus)
T4
PA, SP
ALKERAN TAB 2MG (melphalan)
T4
anastrozole tab 1mg
T1
bexarotene cap 75mg
T4
bicalutamide tab 50mg
T1
BOSULIF TAB 100MG (bosutinib)
T4
PA, SP
BOSULIF TAB 500MG (bosutinib)
T4
PA, SP
capecitabine tab 150mg
T4
PA, SP
capecitabine tab 500mg
T4
PA, SP
PA
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
14
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTINEOPLASTIC AGENTS
CAPRELSA TAB 100MG (vandetanib)
T4
PA
CAPRELSA TAB 300MG (vandetanib)
T4
PA
COMETRIQ KIT 100MG (cabozantinib)
T4
PA
COMETRIQ KIT 140MG (cabozantinib)
T4
PA
COMETRIQ KIT 60MG (cabozantinib)
T4
PA
cyclophosph cap 25mg
T1
cyclophosph tab 25mg
T1
cyclophosph tab 50mg
T1
DROXIA CAP 200MG (hydroxyurea)
T2
DROXIA CAP 300MG (hydroxyurea)
T2
DROXIA CAP 400MG (hydroxyurea)
T2
EMCYT CAP 140MG (estramustine)
T2
ERIVEDGE CAP 150MG (vismodegib)
T4
etoposide cap 50mg
T1
exemestane tab 25mg
T1
FARESTON TAB 60MG (toremifene)
T2
floxuridine inj 0.5gm
T1
flutamide cap 125mg
T1
GILOTRIF TAB 20MG (afatinib)
T4
PA, SP
GILOTRIF TAB 30MG (afatinib)
T4
PA, SP
GILOTRIF TAB 40MG (afatinib)
T4
PA, SP
GLEEVEC TAB 100MG (imatinib)
T4
PA, SP
GLEEVEC TAB 400MG (imatinib)
T4
PA, SP
GLEOSTINE CAP 100MG (lomustine)
T2
GLEOSTINE CAP 10MG (lomustine)
T2
GLEOSTINE CAP 40MG (lomustine)
T2
HEXALEN CAP 50MG (altretamine)
T2
hydroxyurea cap 500mg
T1
IBRANCE CAP 100MG (palbociclib)
T4
PA
IBRANCE CAP 125MG (palbociclib)
T4
PA
IBRANCE CAP 75MG (palbociclib)
T4
PA
ICLUSIG TAB 15MG (ponatinib)
T4
PA
ICLUSIG TAB 45MG (ponatinib)
T4
PA
PA, SP
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
15
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTINEOPLASTIC AGENTS
IMBRUVICA CAP 140MG (ibrutinib)
T4
PA, SP
INLYTA TAB 1MG (axitinib)
T4
PA, SP
INLYTA TAB 5MG (axitinib)
T4
PA, SP
INTRON A INJ 10MU (interferon)
T4
PA
INTRON A INJ 18MU (interferon)
T4
INTRON A INJ 18MU (interferon)
T4
PA
INTRON A INJ 25MU (interferon)
T4
PA
INTRON A INJ 50MU (interferon)
T4
IRESSA TAB 250MG (gefitinib)
T4
PA, SP
JAKAFI TAB 10MG (ruxolitinib)
T4
PA, SP
JAKAFI TAB 15MG (ruxolitinib)
T4
PA, SP
JAKAFI TAB 20MG (ruxolitinib)
T4
PA, SP
JAKAFI TAB 25MG (ruxolitinib)
T4
PA, SP
JAKAFI TAB 5MG (ruxolitinib)
T4
PA, SP
letrozole tab 2.5mg
T1
LEUKERAN TAB 2MG (chlorambucil)
T2
LYSODREN TAB 500MG (mitotane)
T2
MATULANE CAP 50MG (procarbazine)
T2
megestrol ac sus 400mg/10
T1
megestrol ac sus 40mg/ml
T1
megestrol ac sus 800mg/20
T1
megestrol ac tab 20mg
T1
megestrol ac tab 40mg
T1
MEKINIST TAB 0.5MG (trametinib)
T4
PA, SP
MEKINIST TAB 2MG (trametinib)
T4
PA, SP
mercaptopur tab 50mg
T1
methotrexate tab 2.5mg
T1
MYLERAN TAB 2MG (busulfan)
T4
PA
NEXAVAR TAB 200MG (sorafenib)
T4
PA, SP
NILANDRON TAB 150MG (nilutamide)
T4
PA
POMALYST CAP 1MG (pomalidomide)
T4
PA, SP
POMALYST CAP 2MG (pomalidomide)
T4
PA, SP
POMALYST CAP 3MG (pomalidomide)
T4
PA, SP
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
16
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTINEOPLASTIC AGENTS
POMALYST CAP 4MG (pomalidomide)
T4
PA, SP
REVLIMID CAP 10MG (lenalidomide)
T4
PA, SP
REVLIMID CAP 15MG (lenalidomide)
T4
PA, SP
REVLIMID CAP 2.5MG (lenalidomide)
T4
PA, SP
REVLIMID CAP 20MG (lenalidomide)
T4
PA, SP
REVLIMID CAP 25MG (lenalidomide)
T4
PA, SP
REVLIMID CAP 5MG (lenalidomide)
T4
PA, SP
RITUXAN INJ 500MG (rituximab)
MED
PA, SP
SPRYCEL TAB 100MG (dasatinib)
T4
PA, SP
SPRYCEL TAB 140MG (dasatinib)
T4
PA, SP
SPRYCEL TAB 20MG (dasatinib)
T4
PA, SP
SPRYCEL TAB 50MG (dasatinib)
T4
PA, SP
SPRYCEL TAB 70MG (dasatinib)
T4
PA, SP
SPRYCEL TAB 80MG (dasatinib)
T4
PA, SP
STIVARGA TAB 40MG (regorafenib)
T4
PA, SP
SUTENT CAP 12.5MG (sunitinib)
T4
PA, SP
SUTENT CAP 25MG (sunitinib)
T4
PA, SP
SUTENT CAP 37.5MG (sunitinib)
T4
PA, SP
SUTENT CAP 50MG (sunitinib)
T4
PA, SP
SYLATRON KIT 200MCG (peginterferon)
T4
PA, SP
SYLATRON KIT 300MCG (peginterferon)
T4
PA, SP
SYLATRON KIT 600MCG (peginterferon)
T4
PA, SP
SYLATRON 296 MCG 4-PACK (PEGINTERFERON)
T4
PA, SP
SYLATRON 444 MCG 4-PACK (PEGINTERFERON)
T4
PA, SP
SYLATRON 888 MCG 4-PACK (PEGINTERFERON)
T4
PA, SP
TABLOID TAB 40MG (thioguanine)
T2
TAFINLAR CAP 50MG (dabrafenib)
T4
PA, SP
TAFINLAR CAP 75MG (dabrafenib)
T4
PA, SP
tamoxifen citrate tab 10 mg
T0
HCR Rules for Coverage
tamoxifen citrate tab 20 mg
T0
HCR Rules for Coverage
TARCEVA TAB 100MG (erlotinib)
T4
PA, SP
TARCEVA TAB 150MG (erlotinib)
T4
PA, SP
TARCEVA TAB 25MG (erlotinib)
T4
PA, SP
Medical coinsurance
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
17
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ANTINEOPLASTIC AGENTS
TARGRETIN CAP 75MG (bexarotene)
T4
PA, SP
TASIGNA CAP 150MG (nilotinib)
T4
PA, SP
TASIGNA CAP 200MG (nilotinib)
T4
PA, SP
temozolomide cap 100mg
T4
PA, SP
temozolomide cap 140mg
T4
PA, SP
temozolomide cap 180mg
T4
PA, SP
temozolomide cap 20mg
T4
PA, SP
temozolomide cap 250mg
T4
PA, SP
temozolomide cap 5mg
T4
PA, SP
tretinoin cap 10mg
T1
TREXALL TAB 10MG (methotrexate)
T4
PA
TREXALL TAB 15MG (methotrexate)
T4
PA
TREXALL TAB 5MG (methotrexate)
T4
PA
TREXALL TAB 7.5MG (methotrexate)
T4
PA
TYKERB TAB 250MG (lapatinib)
T4
PA, SP
VOTRIENT TAB 200MG (pazopanib)
T4
PA, SP
XALKORI CAP 200MG (crizotinib)
T4
PA, SP
XALKORI CAP 250MG (crizotinib)
T4
PA, SP
XTANDI CAP 40MG (enzalutamide)
T4
PA, SP
ZELBORAF TAB 240MG (vemurafenib)
T4
PA, SP
ZOLINZA CAP 100MG (vorinostat)
T4
PA, SP
ZYDELIG TAB 100MG (idelalisib)
T4
PA, SP
ZYDELIG TAB 150MG (idelalisib)
T4
PA, SP
ZYTIGA TAB 250MG (abiraterone)
T4
PA, SP
AUTONOMIC DRUGS
ANTICHOLINERGIC AGENTS
ANTIMUSCARINICS/ANTISPASMODICS
ANORO ELLIPT AER 62.5-25 (umeclidiniumvilanterol)
T3
atropine sul inj 0.05mg/1
T1
atropine sul inj 0.1mg/ml
T1
atropine sul inj 0.4/0.5
T1
ATROVENT HFA AER 17MCG (ipratropium)
T2
PA, QL
QL (15 inhalers/364 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
18
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
AUTONOMIC DRUGS
ANTICHOLINERGIC AGENTS
ANTIMUSCARINICS/ANTISPASMODICS
chlord/clidi cap 5-2.5mg
T1
QL
clidi/chlord cap 2.5-5mg
T1
QL
dicyclomine cap 10mg
T1
dicyclomine sol 10mg/5ml
T1
dicyclomine tab 20mg
T1
glycopyrrol tab 1mg
T1
glycopyrrol tab 2mg
T1
hyoscyamine sub 0.125mg
T1
QL
hyoscyamine tab 0.125mg
T1
QL
ipratropium sol 0.02%inh
T1
ipratropium spr 0.03%
T1
ipratropium spr 0.06%
T1
methscopolam tab 2.5mg
T1
methscopolam tab 5mg
T1
nulev tab 0.125mg (hyoscyamine)
T1
QL
oscimin sub 0.125mg (hyoscyamine)
T1
QL
oscimin tab 0.125mg (hyoscyamine)
T1
QL
SPIRIVA CAP HANDIHLR (tiotropium)
T2
QL (1 inhaler/30 days)
SPIRIVA SPR RESPIMAT (tiotropium)
T2
QL
symax fastab tab 0.125mg (hyoscyamine)
T1
QL
symax-sl sub 0.125mg (hyoscyamine)
T1
QL
TUDORZA PRES AER 400/ACT (aclidinium)
T2
QL (1 inhaler/30 days)
ANTIPARKINSONIAN AGENTS
benztropine tab 1mg
T1
benztropine tab 2mg
T1
AUTONOMIC DRUGS, MISCELLANEOUS
CHANTIX PAK 0.5& 1MG (varenicline)
T0
QL
HCR Rules for Coverage
CHANTIX PAK 1MG (varenicline)
T0
QL (1 fill/30 days; 6 fills/365
days)
HCR Rules for Coverage
CHANTIX TAB 0.5MG (varenicline)
T0
QL (1 fill/30 days; 6 fills/365
days)
HCR Rules for Coverage
CHANTIX TAB 1MG (varenicline)
T0
QL (1 fill/30 days; 6 fills/365
days)
HCR Rules for Coverage
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
19
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
AUTONOMIC DRUGS
AUTONOMIC DRUGS, MISCELLANEOUS
HCR Rules for Coverage
nicotine kit
T0
nicotine patch 14 mg/24hr
T0
QL (14 Patches/14 days, 12
fills/365 days)
HCR Rules for Coverage
nicotine patch 14 mg/24hr
T0
QL
HCR Rules for Coverage
nicotine patch 21 mg/24hr
T0
QL
HCR Rules for Coverage
nicotine patch 21 mg/24hr
T0
QL (14 Patches/14 days, 12
fills/365 days)
HCR Rules for Coverage
nicotine patch 7 mg/24hr
T0
QL
HCR Rules for Coverage
nicotine patch 7 mg/24hr
T0
QL (14 Patches/14 days, 12
fills/365 days)
HCR Rules for Coverage
nicotine polacrilex gum 2 mg
T0
QL (360 units/30 days, 6 fills/365 HCR Rules for Coverage
days)
nicotine polacrilex gum 2 mg
T0
QL
HCR Rules for Coverage
nicotine polacrilex lozg 2 mg
T0
QL
HCR Rules for Coverage
nicotine polacrilex lozg 2 mg
T0
QL (360 units/30 days, 6 fills/365
days)
HCR Rules for Coverage
nicotine polacrilex lozg 4 mg
T0
QL (360 units/30 days, 6 fills/365
days)
HCR Rules for Coverage
nicotine polacrilex lozg 4 mg
T0
QL
HCR Rules for Coverage
NICOTROL INH (nicotine)
T3
QL (14 Patches/14 days, 12
fills/365 days)
NICOTROL NS SPR 10MG/ML (nicotine)
T3
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
cevimeline cap 30mg
T1
donepezil tab 10mg
T1
donepezil tab 10mg odt
T1
donepezil tab 5mg
T1
donepezil tab 5mg odt
T1
galantamine cap 16mg er
T1
galantamine cap 24mg er
T1
galantamine cap 8mg er
T1
galantamine sol 4mg/ml
T1
galantamine tab 12mg
T1
galantamine tab 4mg
T1
galantamine tab 8mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
20
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
AUTONOMIC DRUGS
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
guanidine tab 125mg
T1
MESTINON SYP 60MG/5ML (pyridostigmine)
T2
pilocarpine tab 5mg
T1
pilocarpine tab 7.5mg
T1
pyridostigm tab 60mg
T1
pyridostigmi tab 180mg
T1
rivastigmine cap 1.5mg
T1
QL (60 caps/30 days)
rivastigmine cap 3mg
T1
QL (60 caps/30 days)
rivastigmine cap 4.5mg
T1
QL (60 caps/30 days)
rivastigmine cap 6mg
T1
QL (60 caps/30 days)
SKELETAL MUSCLE RELAXANTS
methocarbam tab 500mg
T1
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT
carisopr/asa tab 200-325
T1
QL (120 tabs/30 days)
carisoprodol tab 250mg
T1
QL (120 tabs/30 days)
carisoprodol tab 350mg
T1
QL (120 tabs/30 days)
carisoprodol tab asa/cod
T1
QL (120 tabs/30 days)
chlorzoxazon tab 500mg
T1
cyclobenzapr tab 10mg
T1
QL (90 tabs/30 days)
cyclobenzapr tab 5mg
T1
QL (90 tabs/30 days)
LORZONE TAB 750MG (chlorzoxazone)
T3
metaxalone tab 400mg
T1
metaxalone tab 800mg
T1
methocarbam tab 750mg
T1
tizanidine tab 2mg
T1
tizanidine tab 4mg
T1
DIRECT-ACTING SKELETAL MUSCLE RELAXANTS
dantrolene cap 100mg
T1
dantrolene cap 25mg
T1
dantrolene cap 50mg
T1
GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT
baclofen tab 10mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
21
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
AUTONOMIC DRUGS
SKELETAL MUSCLE RELAXANTS
GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT
baclofen tab 20mg
T1
SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS
orphenadrine inj 30mg/ml
T1
orphenadrine tab 100mg cr (orphenadrine)
T1
orphenadrine tab 100mg er
T1
SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS
ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)
alfuzosin tab 10mg
T1
ergoloid mes tab 1mg oral
T1
MIGRANAL SPR 4MG/ML (dihydroergotamine)
T2
QL (6 units/30 days)
RAPAFLO CAP 8MG (silodosin)
T3
PA, QL (30 caps/30 days)
tamsulosin cap 0.4mg
T1
QL (30 caps/30 days)
alfuzosin,
finasteride,
tamsulosin
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ALPHA- AND BETA-ADRENERGIC AGONISTS
epinephrine inj 0.1mg/ml
T1
epinephrine inj 1mg/ml
T1
EPIPEN 2-PAK INJ 0.3MG (epinephrine)
T2
EPIPEN-JR INJ 2-PAK (epinephrine)
T2
ALPHA-ADRENERGIC AGONISTS
midodrine tab 10mg
T1
midodrine tab 2.5mg
T1
midodrine tab 5mg
T1
BETA-ADRENERGIC AGONISTS
ADVAIR DISKU AER 100/50 (fluticasone-salmeterol)
T2
QL (1 inhaler/30 days)
ADVAIR DISKU AER 250/50 (fluticasone-salmeterol)
T2
QL (1 inhaler/30 days)
ADVAIR DISKU AER 500/50 (fluticasone-salmeterol)
T2
QL (1 inhaler/30 days)
ADVAIR HFA AER 115/21 (fluticasone-salmeterol)
T2
QL (1 inhaler/30 days)
ADVAIR HFA AER 230/21 (fluticasone-salmeterol)
T2
QL (1 inhaler/30 days)
ADVAIR HFA AER 45/21 (fluticasone-salmeterol)
T2
QL (1 inhaler/30 days)
albuterol neb 0.083%
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
22
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
AUTONOMIC DRUGS
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
BETA-ADRENERGIC AGONISTS
albuterol neb 0.5%
T1
albuterol neb 0.63mg/3
T1
albuterol neb 1.25mg/3
T1
albuterol syp 2mg/5ml
T1
albuterol tab 2mg
T1
albuterol tab 4mg
T1
albuterol tab 4mg er
T1
ARCAPTA CAP 75MCG (indacaterol)
T3
QL (30 caps/30 days)
BROVANA NEB 15MCG (arformoterol)
T3
PA
COMBIVENT AER RESPIMAT (ipratropiumalbuterol)
T2
QL
FORADIL CAP AEROLIZE (formoterol)
T3
levalbuterol neb 0.31mg
T1
levalbuterol neb 0.63mg
T1
levalbuterol neb 1.25/0.5
T1
levalbuterol neb 1.25mg
T1
MAXAIR AUTOH AER 200MCG (pirbuterol)
T3
metaproteren syp 10mg/5ml
T1
metaproteren tab 10mg
T1
metaproteren tab 20mg
T1
PERFOROMIST NEB 20MCG (formoterol)
T3
QL
PROAIR HFA AER (albuterol)
T2
QL (15 canister/365 days)
PROAIR RESPI AER (albuterol)
T2
QL
PROVENTIL AER HFA (albuterol)
T3
QL (15 canister/365 days)
SEREVENT DIS AER 50MCG (salmeterol)
T2
QL (1 diskus/30 days)
terbutaline tab 2.5mg
T1
terbutaline tab 5mg
T1
VENTOLIN HFA AER (albuterol)
T2
QL (15 canister/365 days)
XOPENEX HFA AER (levalbuterol)
T3
PA
QL (1 canister/month)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
PROAIR HFA,
VENTOLIN HFA
PROAIR HFA,
VENTOLIN HFA
PROAIR HFA,
VENTOLIN HFA
23
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
BLOOD FORMATION,COAGULATION & THROMBOSIS
ANTIANEMIA DRUGS
IRON PREPARATIONS
carbonyl iron chew 15 mg
T0
HCR Rules for Coverage
carbonyl iron suspension 15 mg/1.25ml
T0
HCR Rules for Coverage
fe c plus tab (iron-vitamin)
T1
ferrous aspartate tab 112 mg
T0
HCR Rules for Coverage
ferrous fumarate cap 86 mg
T0
HCR Rules for Coverage
ferrous fumarate tab 18 mg
T0
HCR Rules for Coverage
ferrous fumarate tab 29 mg
T0
HCR Rules for Coverage
ferrous fumarate tab 324 mg
T0
HCR Rules for Coverage
ferrous fumarate tab 325 mg
T0
HCR Rules for Coverage
ferrous fumarate tab 90 mg
T0
HCR Rules for Coverage
ferrous gluconate tab 225 mg
T0
HCR Rules for Coverage
ferrous gluconate tab 240 mg
T0
HCR Rules for Coverage
ferrous gluconate tab 27 mg
T0
HCR Rules for Coverage
ferrous gluconate tab 324 mg
T0
HCR Rules for Coverage
ferrous gluconate tab 325 mg
T0
HCR Rules for Coverage
ferrous sulfate elixir 220 mg/5ml
T0
HCR Rules for Coverage
ferrous sulfate soln 15 mg/ml
T0
HCR Rules for Coverage
ferrous sulfate syrup 300 mg/5ml
T0
HCR Rules for Coverage
ferrous sulfate tab 134 mg
T0
HCR Rules for Coverage
ferrous sulfate tab 140 mg
T0
HCR Rules for Coverage
ferrous sulfate tab 142 mg
T0
HCR Rules for Coverage
ferrous sulfate tab 143 mg
T0
HCR Rules for Coverage
ferrous sulfate tab 160 mg
T0
HCR Rules for Coverage
ferrous sulfate tab 200 mg
T0
HCR Rules for Coverage
ferrous sulfate tab 27 mg
T0
HCR Rules for Coverage
ferrous sulfate tab 28 mg
T0
HCR Rules for Coverage
ferrous sulfate tab 324 mg
T0
HCR Rules for Coverage
ferrous sulfate tab 325 mg
T0
HCR Rules for Coverage
ferrous sulfate tab 45 mg
T0
HCR Rules for Coverage
ferrous sulfate tab 47.5 mg
T0
HCR Rules for Coverage
ferrous sulfate tab 50 mg
T0
HCR Rules for Coverage
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
24
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
BLOOD FORMATION,COAGULATION & THROMBOSIS
ANTIANEMIA DRUGS
IRON PREPARATIONS
ferrous sulfate tab 65 mg
T0
HCR Rules for Coverage
ferrous sulfate tab 90 mg
T0
HCR Rules for Coverage
polysaccharide iron complex cap 150 mg
T0
HCR Rules for Coverage
polysaccharide iron complex cap 200 mg
T0
HCR Rules for Coverage
ANTIHEMORRHAGIC AGENTS
HEMOSTATICS
ADVATE INJ 1000UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
ADVATE INJ 1500UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
ADVATE INJ 2000UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
ADVATE INJ 250UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
ADVATE INJ 3000UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
ADVATE INJ 500UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
ALPHANATE INJ VWF/HUM (antihemophilic)
MED
PA, SP
Medical coinsurance
ALPHANATE 1,000-400 UNIT VIAL
(ANTIHEMOPHILIC)
MED
PA, SP
Medical coinsurance
ALPHANATE 1,500-600 UNIT VIAL
(ANTIHEMOPHILIC)
MED
PA, SP
Medical coinsurance
ALPHANATE 500-200 UNIT VIAL (ANTIHEMOPHILIC)
MED
PA, SP
Medical coinsurance
ALPHANINE SD INJ 1000UNIT (coagulation)
MED
PA, SP
Medical coinsurance
ALPHANINE SD INJ 1500UNIT (coagulation)
MED
PA, SP
Medical coinsurance
BEBULIN INJ 200-1200 (factor)
MED
PA, SP
Medical coinsurance
BEBULIN VH IMMU 200-1,200 UNIT (FACTOR)
MED
PA, SP
Medical coinsurance
BENEFIX INJ 1000UNIT (coagulation)
MED
PA, SP
Medical coinsurance
BENEFIX INJ 2000UNIT (coagulation)
MED
PA, SP
Medical coinsurance
BENEFIX INJ 250UNIT (coagulation)
MED
PA, SP
Medical coinsurance
BENEFIX INJ 500UNIT (coagulation)
MED
PA, SP
Medical coinsurance
CORIFACT KIT (factor)
MED
PA, SP
Medical coinsurance
ELOCTATE INJ 1000UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
ELOCTATE INJ 1500UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
ELOCTATE INJ 2000UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
ELOCTATE INJ 250UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
ELOCTATE INJ 3000UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
25
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
BLOOD FORMATION,COAGULATION & THROMBOSIS
ANTIHEMORRHAGIC AGENTS
HEMOSTATICS
ELOCTATE INJ 500UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
ELOCTATE INJ 750UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
FEIBA VH IMMU 1,750-3,250 UNIT
(ANTIINHIBITOR)
MED
PA, SP
Medical coinsurance
HELIXATE FS INJ 1000UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
HELIXATE FS INJ 2000UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
HELIXATE FS INJ 250UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
HELIXATE FS INJ 500UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
HEMOFIL M INJ 1700UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
HEMOFIL M INJ 220-400 (antihemophilic)
MED
PA, SP
Medical coinsurance
HEMOFIL M INJ 401-800 (antihemophilic)
MED
PA, SP
Medical coinsurance
HEMOFIL M SOL 501-2000 (antihemophilic)
MED
PA, SP
Medical coinsurance
HEMOFIL M SOL 801-1500 (antihemophilic)
MED
PA, SP
Medical coinsurance
HUMATE-P SOL 2400UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
HUMATE-P SOL 250-600 (antihemophilic)
MED
PA, SP
Medical coinsurance
HUMATE-P SOL 500-1200 (antihemophilic)
MED
PA, SP
Medical coinsurance
KCENTRA KIT 1000UNIT (prothrombin)
MED
PA, SP
Medical coinsurance
KCENTRA KIT 500UNIT (prothrombin)
MED
PA, SP
Medical coinsurance
koate-dvi inj 1000unit (antihemophilic)
MED
PA, SP
Medical coinsurance
koate-dvi inj 250unit (antihemophilic)
MED
PA, SP
Medical coinsurance
KOATE-DVI INJ 500UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
KOGENATE FS INJ 1000/BS (antihemophilic)
MED
PA, SP
Medical coinsurance
KOGENATE FS INJ 1000UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
KOGENATE FS INJ 2000/BS (antihemophilic)
MED
PA, SP
Medical coinsurance
KOGENATE FS INJ 2000UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
KOGENATE FS INJ 250/BS (antihemophilic)
MED
PA, SP
Medical coinsurance
KOGENATE FS INJ 250UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
KOGENATE FS INJ 3000/BS (antihemophilic)
MED
PA, SP
Medical coinsurance
KOGENATE FS INJ 3000UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
KOGENATE FS INJ 500/BS (antihemophilic)
MED
PA, SP
Medical coinsurance
KOGENATE FS INJ 500UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
MONOCLATE-P INJ 250UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
26
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
BLOOD FORMATION,COAGULATION & THROMBOSIS
ANTIHEMORRHAGIC AGENTS
HEMOSTATICS
MONOCLATE-P INJ 500UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
MONONINE INJ 500UNIT (coagulation)
MED
PA, SP
Medical coinsurance
NOVOSEVEN INJ 2400MCG (coagulation)
MED
PA, SP
Medical coinsurance
NOVOSEVEN 1,200 MCG VIAL (COAGULATION)
MED
PA, SP
Medical coinsurance
NOVOSEVEN 4,800 MCG VIAL (COAGULATION)
MED
PA, SP
Medical coinsurance
NOVOSEVEN RT INJ 1MG (coagulation)
MED
PA, SP
Medical coinsurance
NOVOSEVEN RT INJ 2MG (coagulation)
MED
PA, SP
Medical coinsurance
NOVOSEVEN RT INJ 5MG (coagulation)
MED
PA, SP
Medical coinsurance
NOVOSEVEN RT INJ 8MG (coagulation)
MED
PA, SP
Medical coinsurance
PROFILNINE SD 500 UNITS VIAL (FACTOR)
MED
PA, SP
Medical coinsurance
RECOMBINATE INJ 220-400 (antihemophilic)
MED
PA, SP
Medical coinsurance
RECOMBINATE INJ 401-800 (antihemophilic)
MED
PA, SP
Medical coinsurance
RECOMBINATE INJ 801-1240 (antihemophilic)
MED
PA, SP
Medical coinsurance
RIASTAP SOL 1GM (fibrinogen)
MED
PA, SP
Medical coinsurance
RIXUBIS INJ 1000UNIT (coagulation)
MED
PA, SP
Medical coinsurance
RIXUBIS INJ 2000UNIT (coagulation)
MED
PA, SP
Medical coinsurance
RIXUBIS INJ 250 UNIT (coagulation)
MED
PA, SP
Medical coinsurance
RIXUBIS INJ 3000UNIT (coagulation)
MED
PA, SP
Medical coinsurance
RIXUBIS INJ 500UNIT (coagulation)
MED
PA, SP
Medical coinsurance
tranex acid tab 650mg
T1
WILATE INJ (antihemophilic)
MED
PA, SP
Medical coinsurance
WILATE 1,000-1,000 UNIT KIT (ANTIHEMOPHILIC)
MED
PA, SP
Medical coinsurance
WILATE 450-450 UNIT KIT (ANTIHEMOPHILIC)
MED
PA, SP
Medical coinsurance
WILATE 900-900 UNIT KIT (ANTIHEMOPHILIC)
MED
PA, SP
Medical coinsurance
XYNTHA INJ 1000UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
XYNTHA INJ 2000UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
XYNTHA INJ 250UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
XYNTHA INJ 500UNIT (antihemophilic)
MED
PA, SP
Medical coinsurance
ANTITHROMBOTIC AGENTS
ANTICOAGULANTS
coumadin tab 10mg (warfarin)
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
27
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
BLOOD FORMATION,COAGULATION & THROMBOSIS
ANTITHROMBOTIC AGENTS
ANTICOAGULANTS
coumadin tab 1mg (warfarin)
T1
coumadin tab 2.5mg (warfarin)
T1
coumadin tab 2mg (warfarin)
T1
coumadin tab 3mg (warfarin)
T1
coumadin tab 4mg (warfarin)
T1
coumadin tab 5mg (warfarin)
T1
coumadin tab 6mg (warfarin)
T1
coumadin tab 7.5mg (warfarin)
T1
ELIQUIS TAB 2.5MG (apixaban)
T2
QL (60 tabs/30 days)
ELIQUIS TAB 5MG (apixaban)
T2
QL (60 tabs/30 days)
enoxaparin inj 100mg/ml
T1
QL
enoxaparin inj 120/0.8
T1
QL
enoxaparin inj 150mg/ml
T1
QL
enoxaparin inj 30/0.3ml
T1
QL
enoxaparin inj 300/3ml
T1
QL
enoxaparin inj 40/0.4ml
T1
QL
enoxaparin inj 60/0.6ml
T1
QL
enoxaparin inj 80/0.8ml
T1
QL
fondaparinux inj 10/0.8ml
T1
QL
fondaparinux inj 2.5/0.5
T1
QL
fondaparinux inj 5/0.4ml
T1
QL
fondaparinux inj 7.5/0.6
T1
QL
FRAGMIN INJ 10000/ML (dalteparin)
T3
PA
FRAGMIN INJ 12500UNT (dalteparin)
T3
FRAGMIN INJ 15000UNT (dalteparin)
T3
FRAGMIN INJ 18000UNT (dalteparin)
T3
FRAGMIN INJ 2500/0.2 (dalteparin)
T3
FRAGMIN INJ 5000/0.2 (dalteparin)
T3
FRAGMIN INJ 7500/0.3 (dalteparin)
T3
FRAGMIN INJ 95000UNT (dalteparin)
T3
PRADAXA CAP 150MG (dabigatran)
T2
QL (60 caps/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
28
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
BLOOD FORMATION,COAGULATION & THROMBOSIS
ANTITHROMBOTIC AGENTS
ANTICOAGULANTS
PRADAXA CAP 75MG (dabigatran)
T2
warfarin tab 10mg
T1
warfarin tab 1mg
T1
warfarin tab 2.5mg
T1
warfarin tab 2mg
T1
warfarin tab 3mg
T1
warfarin tab 4mg
T1
warfarin tab 5mg
T1
warfarin tab 6mg
T1
warfarin tab 7.5mg
T1
warfarin sod tab 10mg
T1
XARELTO TAB 10MG (rivaroxaban)
T2
QL (30 tabs/30 days)
XARELTO TAB 15MG (rivaroxaban)
T2
QL (30 tabs/30 days)
XARELTO TAB 20MG (rivaroxaban)
T2
QL (30 tabs/30 days)
XARELTO STAR TAB 15/20MG (rivaroxaban)
T2
QL (30 tabs/30 days)
QL (60 caps/30 days)
PLATELET-AGGREGATION INHIBITORS
AGGRENOX CAP 25-200MG (aspirin-dipyridamole)
T2
QL (60 caps/30 days)
BRILINTA TAB 60MG (ticagrelor)
T3
QL
clopidogrel
BRILINTA TAB 90MG (ticagrelor)
T3
PA, QL (60 tabs/30 days)
clopidogrel
cilostazol tab 100mg
T1
cilostazol tab 50mg
T1
clopidogrel tab 300mg
T1
clopidogrel tab 75mg
T1
QL (30 tabs/30 days)
EFFIENT TAB 10MG (prasugrel)
T3
PA, QL (30 tabs/30 days)
clopidogrel
EFFIENT TAB 5MG (prasugrel)
T3
PA, QL (30 tabs/30 days)
clopidogrel
ticlopidine tab 250mg
T1
PLATELET-REDUCING AGENTS
anagrelide cap 0.5mg
T1
anagrelide cap 1mg
T1
HEMATOPOIETIC AGENTS
ARANESP INJ 100MCG (darbepoetin)
T4
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
29
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
BLOOD FORMATION,COAGULATION & THROMBOSIS
HEMATOPOIETIC AGENTS
ARANESP INJ 10MCG (darbepoetin)
T4
ARANESP INJ 150MCG (darbepoetin)
T4
ARANESP INJ 200MCG (darbepoetin)
T4
ARANESP INJ 25MCG (darbepoetin)
T4
ARANESP INJ 300MCG (darbepoetin)
T4
ARANESP INJ 40MCG (darbepoetin)
T4
ARANESP INJ 500MCG (darbepoetin)
T4
ARANESP INJ 60MCG (darbepoetin)
T4
EPOGEN INJ 10000/ML (epoetin)
T4
EPOGEN INJ 2000/ML (epoetin)
T4
EPOGEN INJ 20000/ML (epoetin)
T4
EPOGEN INJ 3000/ML (epoetin)
T4
EPOGEN INJ 4000/ML (epoetin)
T4
LEUKINE INJ 250MCG (sargramostim)
T4
LEUKINE INJ 500 MCG (sargramostim)
T4
NEULASTA INJ 6MG/0.6M (pegfilgrastim)
T4
PA
NEULASTA KIT 6MG/0.6M (pegfilgrastim)
T4
PA
NEUPOGEN INJ 300/0.5 (filgrastim)
T4
QL
NEUPOGEN INJ 300MCG (filgrastim)
T4
QL
NEUPOGEN INJ 480/0.8 (filgrastim)
T4
QL
NEUPOGEN INJ 480MCG (filgrastim)
T4
QL
PROCRIT INJ 10000/ML (epoetin)
T4
QL (4 vials/30 days)
PROCRIT INJ 2000/ML (epoetin)
T4
PROCRIT INJ 20000/ML (epoetin)
T4
PROCRIT INJ 3000/ML (epoetin)
T4
PROCRIT INJ 4000/ML (epoetin)
T4
PROCRIT INJ 40000/ML (epoetin)
T4
PROMACTA TAB 12.5MG (eltrombopag)
T4
PA, SP
PROMACTA TAB 25MG (eltrombopag)
T4
PA, SP
PROMACTA TAB 50MG (eltrombopag)
T4
PA, SP
PROMACTA TAB 75MG (eltrombopag)
T4
PA, SP
QL (4 vials/30 days)
QL (4 vials/30 days)
QL (4 vials/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
30
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
BLOOD FORMATION,COAGULATION & THROMBOSIS
HEMORRHEOLOGIC AGENTS
pentoxifylli tab 400mg cr
T1
pentoxifylli tab 400mg er
T1
CARDIOVASCULAR DRUGS
ALPHA-ADRENERGIC BLOCKING AGENTS
CARDURA XL TAB 4MG (doxazosin)
T3
doxazosin tab 1mg
T1
doxazosin tab 2mg
T1
doxazosin tab 4mg
T1
doxazosin tab 8mg
T1
prazosin hcl cap 1mg
T1
prazosin hcl cap 2mg
T1
prazosin hcl cap 5mg
T1
terazosin cap 10mg
T1
terazosin cap 1mg
T1
terazosin cap 2mg
T1
terazosin cap 5mg
T1
QL (30 tabs/30 days)
ANTILIPEMIC AGENTS
ANTILIPEMIC AGENTS, MISCELLANEOUS
niacin tab 500mg er
T1
QL
niacin er tab 1000mg
T1
QL
niacin er tab 500mg
T1
QL
niacin er tab 750mg
T1
QL
omega-3-acid cap 1gm
T1
PA, QL (120 caps/30 days)
BILE ACID SEQUESTRANTS
cholestyram pow 4gm
T1
cholestyram pow 4gm lite
T1
colestipol gra 5gm
T1
colestipol tab 1gm (colestipol)
T1
prevalite pow 4gm (cholestyramine)
T1
prevalite pow 4gm pk (cholestyramine)
T1
WELCHOL PAK 3.75GM (colesevelam)
T3
PA, QL (30 packets/30 days)
cholestyramine
WELCHOL TAB 625MG (colesevelam)
T3
PA, QL (210 tabs/30 days)
cholestyramine
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
31
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
ANTILIPEMIC AGENTS
CHOLESTEROL ABSORPTION INHIBITORS
ZETIA TAB 10MG (ezetimibe)
T2
QL (30 tabs/30 days)
FIBRIC ACID DERIVATIVES
fenofibrate cap 130mg
T1
fenofibrate cap 134mg
T1
fenofibrate cap 200mg
T1
fenofibrate cap 43mg
T1
fenofibrate cap 67mg
T1
fenofibrate tab 120mg
T1
fenofibrate tab 145mg
T1
fenofibrate tab 160mg
T1
fenofibrate tab 40mg
T1
fenofibrate tab 48mg
T1
fenofibrate tab 54mg
T1
fenofibric tab 105mg
T1
fenofibric tab 35mg
T1
gemfibrozil tab 600mg
T1
HMG-COA REDUCTASE INHIBITORS
ADVICOR TAB 1000-20 (niacin-lovastatin)
T3
QL (60 tabs/30 days)
ADVICOR TAB 1000-40 (niacin-lovastatin)
T3
QL (60 tabs/30 days)
ADVICOR TAB 500-20MG (niacin-lovastatin)
T3
QL (60 tabs/30 days)
ADVICOR TAB 750-20MG (niacin-lovastatin)
T3
QL (60 tabs/30 days)
atorvastatin tab 10mg
T1
atorvastatin tab 20mg
T1
atorvastatin tab 40mg
T1
atorvastatin tab 80mg
T1
CRESTOR TAB 10MG (rosuvastatin)
T3
QL (30 tabs/30 days), ST
(atorvastatin 80MG)
atorvastatin,
simvastatin
CRESTOR TAB 20MG (rosuvastatin)
T3
QL (30 tabs/30 days), ST
(atorvastatin 80MG)
atorvastatin,
simvastatin
CRESTOR TAB 40MG (rosuvastatin)
T3
QL (30 tabs/30 days), ST
(atorvastatin 80MG)
atorvastatin,
simvastatin
CRESTOR TAB 5MG (rosuvastatin)
T3
QL (30 tabs/30 days), ST
(atorvastatin 80MG)
atorvastatin,
simvastatin
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
32
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
ANTILIPEMIC AGENTS
HMG-COA REDUCTASE INHIBITORS
fluvastatin cap 20mg
T1
fluvastatin cap 40mg
T1
Fluvastatin TAB 80MG
T1
PA, QL (30 tabs/30 days)
atorvastatin,
pravastatin,
simvastatin
LIVALO TAB 1MG (pitavastatin)
T3
PA, QL (30 tabs/30 days)
atorvastatin,
pravastatin,
simvastatin
LIVALO TAB 2MG (pitavastatin)
T3
PA, QL (30 tabs/30 days)
atorvastatin,
pravastatin,
simvastatin
LIVALO TAB 4MG (pitavastatin)
T3
PA, QL (30 tabs/30 days)
atorvastatin,
pravastatin,
simvastatin
lovastatin tab 10mg
T1
lovastatin tab 20mg
T1
lovastatin tab 40mg
T1
pravastatin tab 10mg
T1
pravastatin tab 20mg
T1
pravastatin tab 40mg
T1
pravastatin tab 80mg
T1
simvastatin tab 10mg
T1
simvastatin tab 20mg
T1
simvastatin tab 40mg
T1
simvastatin tab 5mg
T1
simvastatin tab 80mg
T1
VYTORIN TAB 10-10MG (ezetimibe-simvastatin)
T3
QL (30 tabs/30 days), ST
(simvastatin, atorvastatin 80MG)
atorvastatin,
simvastatin
VYTORIN TAB 10-20MG (ezetimibe-simvastatin)
T3
QL (30 tabs/30 days), ST
(simvastatin, atorvastatin 80MG)
atorvastatin,
simvastatin
VYTORIN TAB 10-40MG (ezetimibe-simvastatin)
T3
QL (30 tabs/30 days), ST
(simvastatin, atorvastatin 80MG)
atorvastatin,
simvastatin
VYTORIN TAB 10-80MG (ezetimibe-simvastatin)
T3
QL (30 tabs/30 days), ST
(simvastatin, atorvastatin 80MG)
atorvastatin,
simvastatin
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol cap 200mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
atenolol
33
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol cap 400mg
T1
atenol/chlor tab 100-25mg
T1
QL (60 tabs/30 days)
atenol/chlor tab 50-25mg
T1
QL (60 tabs/30 days)
atenolol tab 100mg
T1
atenolol tab 25mg
T1
atenolol tab 50mg
T1
betaxolol tab 10mg
T1
betaxolol tab 20mg
T1
bisoprl/hctz tab 10/6.25
T1
QL (60 tabs/30 days)
bisoprl/hctz tab 2.5/6.25
T1
QL (60 tabs/30 days)
bisoprl/hctz tab 5-6.25mg
T1
QL (60 tabs/30 days)
bisoprol fum tab 10mg
T1
bisoprol fum tab 5mg
T1
BYSTOLIC TAB 10MG (nebivolol)
T3
PA, QL (30 tabs/30 days)
BYSTOLIC TAB 2.5MG (nebivolol)
T3
PA, QL (30 tabs/30 days)
BYSTOLIC TAB 20MG (nebivolol)
T3
PA, QL (30 tabs/30 days)
BYSTOLIC TAB 5MG (nebivolol)
T3
PA, QL (30 tabs/30 days)
carvedilol tab 12.5mg
T1
carvedilol tab 25mg
T1
carvedilol tab 3.125mg
T1
carvedilol tab 6.25mg
T1
labetalol tab 100mg
T1
labetalol tab 200mg
T1
labetalol tab 300mg
T1
LEVATOL TAB 20MG (penbutolol)
T2
PA, QL (60 tabs/30 days)
metoprl/hctz tab 100-25mg
T1
QL
metoprl/hctz tab 100-50mg
T1
QL
metoprl/hctz tab 50-25mg
T1
QL
metoprol tar tab 100mg
T1
metoprol tar tab 25mg
T1
metoprol tar tab 50mg
T1
metoprolol tab 100mg er
T1
atenolol
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
atenolol, carvedilol
34
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
BETA-ADRENERGIC BLOCKING AGENTS
metoprolol tab 200mg er
T1
metoprolol tab 25mg er
T1
metoprolol tab 50mg er
T1
nadolol tab 20mg
T1
nadolol tab 40mg
T1
nadolol tab 80mg
T1
pindolol tab 10mg
T1
atenolol
pindolol tab 5mg
T1
atenolol
propranolol cap 120mg er
T1
propranolol cap 160mg er
T1
propranolol cap 60mg er
T1
propranolol cap 80mg er
T1
propranolol sol 20mg/5ml
T1
propranolol sol 40mg/5ml
T1
propranolol tab 10mg
T1
propranolol tab 20mg
T1
propranolol tab 40mg
T1
propranolol tab 60mg
T1
propranolol tab 80mg
T1
sorine tab 120mg (sotalol)
T1
sorine tab 160mg (sotalol)
T1
sorine tab 240mg (sotalol)
T1
sorine tab 80mg (sotalol)
T1
sotalol hcl tab 120mg
T1
sotalol hcl tab 160mg
T1
sotalol hcl tab 240mg
T1
sotalol hcl tab 80mg
T1
timolol mal tab 10mg
T1
timolol mal tab 20mg
T1
timolol mal tab 5mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
35
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
CALCIUM-CHANNEL BLOCKING AGENTS
CALCIUM-CHANNEL BLOCKING AGENTS, MISC.
cartia xt cap 120/24hr (diltiazem)
T1
cartia xt cap 180/24hr (diltiazem)
T1
cartia xt cap 240/24hr (diltiazem)
T1
cartia xt cap 300/24hr (diltiazem)
T1
dilt-cd cap 120mg (diltiazem)
T1
dilt-cd cap 180mg (diltiazem)
T1
dilt-cd cap 240mg (diltiazem)
T1
dilt-cd cap 300mg (diltiazem)
T1
diltiazem cap 120mg cd (diltiazem)
T1
diltiazem cap 120mg er
T1
diltiazem cap 120mg er
T1
diltiazem cap 180mg cd (diltiazem)
T1
diltiazem cap 180mg er
T1
diltiazem cap 180mg er
T1
diltiazem cap 180mg/24
T1
diltiazem cap 240mg cd
T1
diltiazem cap 240mg er
T1
diltiazem cap 240mg er
T1
diltiazem cap 240mg/24
T1
diltiazem cap 300mg cd
T1
diltiazem cap 300mg er
T1
diltiazem cap 300mg/24
T1
diltiazem cap 360mg cd (diltiazem)
T1
diltiazem cap 360mg er
T1
diltiazem cap 360mg/24
T1
diltiazem cap 420mg/24
T1
diltiazem cap 60mg er
T1
diltiazem cap 90mg er
T1
diltiazem tab 120mg
T1
diltiazem tab 30mg
T1
diltiazem tab 60mg
T1
QL
QL
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
36
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
CALCIUM-CHANNEL BLOCKING AGENTS
CALCIUM-CHANNEL BLOCKING AGENTS, MISC.
diltiazem tab 90mg
T1
diltiazem er tab 180mg
T1
QL
diltiazem er tab 240mg
T1
QL
diltiazem er tab 300mg
T1
QL
diltiazem er tab 360mg
T1
QL
diltiazem er tab 420mg
T1
QL
dilt-xr cap 120mg (diltiazem)
T1
QL
dilt-xr cap 180mg (diltiazem)
T1
QL
dilt-xr cap 240mg (diltiazem)
T1
QL
diltzac cap 180mg/24 (diltiazem)
T1
diltzac cap 240mg/24 (diltiazem)
T1
diltzac cap 300mg/24 (diltiazem)
T1
diltzac cap 360mg/24 (diltiazem)
T1
matzim la tab 180mg/24 (diltiazem)
T1
QL
matzim la tab 240mg/24 (diltiazem)
T1
QL
matzim la tab 300mg/24 (diltiazem)
T1
QL
matzim la tab 360mg/24 (diltiazem)
T1
QL
matzim la tab 420mg/24 (diltiazem)
T1
QL
taztia xt cap 180mg/24 (diltiazem)
T1
taztia xt cap 240mg/24 (diltiazem)
T1
taztia xt cap 300mg/24 (diltiazem)
T1
taztia xt cap 360mg/24 (diltiazem)
T1
verapamil cap 100mg er
T1
verapamil cap 120mg er
T1
verapamil cap 120mg sr
T1
verapamil cap 180mg er
T1
verapamil cap 180mg sr
T1
verapamil cap 200mg er
T1
verapamil cap 240mg er
T1
verapamil cap 240mg sr
T1
verapamil cap 300mg er
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
37
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
CALCIUM-CHANNEL BLOCKING AGENTS
CALCIUM-CHANNEL BLOCKING AGENTS, MISC.
verapamil cap 360mg sr
T1
verapamil tab 120mg
T1
verapamil tab 120mg er
T1
verapamil tab 120mg sr
T1
verapamil tab 180mg er
T1
verapamil tab 180mg sa
T1
verapamil tab 180mg sr
T1
verapamil tab 240mg cr
T1
verapamil tab 240mg er
T1
verapamil tab 240mg sa
T1
verapamil tab 240mg sr
T1
verapamil tab 40mg
T1
verapamil tab 80mg
T1
DIHYDROPYRIDINES
afeditab tab 30mg cr (nifedipine)
T1
afeditab tab 60mg cr (nifedipine)
T1
amlod/benazp cap 10-20mg
T1
QL (60 caps/30 days)
amlod/benazp cap 10-40mg
T1
QL (60 caps/30 days)
amlod/benazp cap 2.5-10mg
T1
QL (60 caps/30 days)
amlod/benazp cap 5-10mg
T1
QL (60 caps/30 days)
amlod/benazp cap 5-20mg
T1
QL (60 caps/30 days)
amlod/benazp cap 5-40mg
T1
QL (60 caps/30 days)
amlod/valsar tab /hctz
T1
QL (60 caps/30 days)
amlodipine tab 10mg
T1
amlodipine tab 2.5mg
T1
amlodipine tab 5mg
T1
felodipine tab 10mg er
T1
felodipine tab 2.5mg er
T1
felodipine tab 5mg er
T1
isradipine cap 2.5mg
T1
isradipine cap 5mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
38
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
CALCIUM-CHANNEL BLOCKING AGENTS
DIHYDROPYRIDINES
nicardipine cap 20mg
T1
nicardipine cap 30mg
T1
nifediac cc tab 30mg er (nifedipine)
T1
nifediac cc tab 60mg er (nifedipine)
T1
nifedical xl tab 30mg (nifedipine)
T1
nifedical xl tab 60mg (nifedipine)
T1
nifedipine cap 10mg
T1
nifedipine cap 20mg
T1
nifedipine tab 30mg er
T1
nifedipine tab 60mg er
T1
nifedipine tab 90mg er
T1
nimodipine cap 30mg
T1
nisoldipine tab 17mg er
T1
nisoldipine tab 20mg
T1
nisoldipine tab 25.5mg
T1
nisoldipine tab 30mg
T1
nisoldipine tab 34mg er
T1
nisoldipine tab 40mg
T1
nisoldipine tab 8.5mg er
T1
CARDIAC DRUGS
ANTIARRHYTHMIC AGENTS
amiodarone tab 200mg
T1
amiodarone tab 400mg
T1
disopyramide cap 100mg
T1
disopyramide cap 150mg
T1
flecainide tab 100mg
T1
flecainide tab 150mg
T1
flecainide tab 50mg
T1
mexiletine cap 150mg
T1
QL (90 caps/30 days)
mexiletine cap 200mg
T1
QL (90 caps/30 days)
mexiletine cap 250mg
T1
QL (90 caps/30 days)
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
39
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
CARDIAC DRUGS
ANTIARRHYTHMIC AGENTS
MULTAQ TAB 400MG (dronedarone)
T2
NORPACE CAP 100MG CR (disopyramide)
T3
pacerone tab 200mg (amiodarone)
T1
pacerone tab 400mg (amiodarone)
T1
propafenone cap 225mg er
T1
propafenone cap 325mg er
T1
propafenone cap 425mg sr
T1
propafenone tab 150mg
T1
propafenone tab 225mg
T1
propafenone tab 300mg
T1
quinidine gl tab 324mg cr
T1
quinidine gl tab 324mg er
T1
quinidine su tab 300mg
T1
quinidine su tab 300mg er
T1
TIKOSYN CAP 125MCG (dofetilide)
T2
QL (120 caps/30 days)
TIKOSYN CAP 250MCG (dofetilide)
T2
QL (120 caps/30 days)
TIKOSYN CAP 500MCG (dofetilide)
T2
QL (120 caps/30 days)
PA, QL (60 tabs/30 days)
QL
CARDIAC DRUGS, MISCELLANEOUS
RANEXA TAB 1000MG (ranolazine)
T3
QL (60 tabs/30 days)
RANEXA TAB 500MG (ranolazine)
T3
QL (60 tabs/30 days)
CARDIOTONIC AGENTS
digitek tab 0.125mg (digoxin)
T1
digitek tab 0.25mg (digoxin)
T1
digox tab 0.125mg (digoxin)
T1
digox tab 0.25mg (digoxin)
T1
digoxin inj 0.25mg/1
T1
digoxin sol 50mcg/ml
T1
digoxin tab 0.125mg
T1
digoxin tab 0.25mg
T1
lanoxin tab 0.125mg (digoxin)
T1
lanoxin tab 0.25mg (digoxin)
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
40
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
CARDIAC DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS, MISC
ENTRESTO TAB 24-26MG (sacubitril-valsartan)
T4
ENTRESTO TAB 49-51MG (sacubitril-valsartan)
T4
ENTRESTO TAB 97-103MG (sacubitril-valsartan)
T4
HYPOTENSIVE AGENTS
CENTRAL ALPHA-AGONISTS
clonidine dis 0.1/24hr
T1
clonidine dis 0.2/24hr
T1
clonidine dis 0.3/24hr
T1
clonidine tab 0.1mg
T1
clonidine tab 0.2mg
T1
clonidine tab 0.3mg
T1
guanfacine tab 1mg
T1
guanfacine tab 2mg
T1
methyldopa tab 250mg
T1
methyldopa tab 500mg
T1
DIRECT VASODILATORS
hydralazine inj 20mg/ml
T1
hydralazine tab 100mg
T1
hydralazine tab 10mg
T1
hydralazine tab 25mg
T1
hydralazine tab 50mg
T1
minoxidil tab 10mg
T1
minoxidil tab 2.5mg
T1
DIURETICS (HYPOTENSIVE AGENTS)
acetazolamid tab 250mg
T1
PERIPHERAL ADRENERGIC INHIBITORS
reserpine tab 0.1mg
T1
reserpine tab 0.25mg
T1
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
ANGIOTENSIN II RECEPTOR ANTAGONISTS
candesa/hctz tab 16-12.5
T1
candesa/hctz tab 32-12.5
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
41
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
ANGIOTENSIN II RECEPTOR ANTAGONISTS
candesa/hctz tab 32-25mg
T1
candesartan tab 16mg
T1
PA
candesartan tab 32mg
T1
PA
candesartan tab 4mg
T1
PA
candesartan tab 8mg
T1
PA
EDARBI TAB 40MG (azilsartan)
T3
PA
EDARBI TAB 80MG (azilsartan)
T3
PA
eprosart mes tab 600mg
T1
irbesar/hctz tab 150-12.5
T1
irbesar/hctz tab 300-12.5
T1
irbesartan tab 150mg
T1
irbesartan tab 300mg
T1
irbesartan tab 75mg
T1
losartan pot tab 100mg
T1
losartan pot tab 25mg
T1
losartan pot tab 50mg
T1
losartan/hct tab 100-12.5
T1
losartan/hct tab 100-25
T1
losartan/hct tab 50-12.5
T1
telmisartan tab 20mg
T1
PA
telmisartan tab 40mg
T1
PA
telmisartan tab 80mg
T1
PA
valsart/hctz tab 160-12.5
T1
valsart/hctz tab 160-25mg
T1
valsart/hctz tab 320-12.5
T1
valsart/hctz tab 320-25mg
T1
valsart/hctz tab 80-12.5
T1
valsartan tab 160mg
T1
QL
valsartan tab 320mg
T1
QL
valsartan tab 40mg
T1
QL
valsartan tab 80mg
T1
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
42
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
benazep/hctz tab 10-12.5
T1
benazep/hctz tab 20-12.5
T1
benazep/hctz tab 20-25mg
T1
benazep/hctz tab 5-6.25
T1
benazepril tab 10mg
T1
benazepril tab 20mg
T1
benazepril tab 40mg
T1
benazepril tab 5mg
T1
captopr/hctz tab 25-15mg
T1
captopr/hctz tab 25-25mg
T1
captopr/hctz tab 50-15mg
T1
captopr/hctz tab 50-25mg
T1
captopril tab 100mg
T1
captopril tab 12.5mg
T1
captopril tab 25mg
T1
captopril tab 50mg
T1
enalapr/hctz tab 10-25mg
T1
enalapr/hctz tab 5-12.5mg
T1
enalapril tab 10mg
T1
enalapril tab 2.5mg
T1
enalapril tab 20mg
T1
enalapril tab 5mg
T1
fosinop/hctz tab 10/12.5
T1
fosinop/hctz tab 20/12.5
T1
fosinopril tab 10mg
T1
fosinopril tab 20mg
T1
fosinopril tab 40mg
T1
lisinop/hctz tab 10-12.5
T1
lisinop/hctz tab 20-12.5
T1
lisinop/hctz tab 20-25mg
T1
lisinopril tab 10mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
43
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
lisinopril tab 2.5mg
T1
lisinopril tab 20mg
T1
lisinopril tab 30mg
T1
lisinopril tab 40mg
T1
lisinopril tab 5mg
T1
moexipr/hctz tab 15-12.5
T1
moexipr/hctz tab 15-25mg
T1
moexipr/hctz tab 7.5-12.5
T1
moexipril tab 15mg
T1
moexipril tab 7.5mg
T1
perindopril tab 2mg
T1
QL (60 tabs/30 days)
perindopril tab 4mg
T1
QL (60 tabs/30 days)
perindopril tab 8mg
T1
QL (60 tabs/30 days)
qnapril/hctz tab 10-12.5
T1
qnapril/hctz tab 20-12.5
T1
qnapril/hctz tab 20-25mg
T1
quinapril tab 10mg
T1
quinapril tab 20mg
T1
quinapril tab 40mg
T1
quinapril tab 5mg
T1
ramipril cap 1.25mg
T1
ramipril cap 10mg
T1
ramipril cap 2.5mg
T1
ramipril cap 5mg
T1
trandolapril tab 1mg
T1
trandolapril tab 2mg
T1
trandolapril tab 4mg
T1
MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS
eplerenone tab 25mg
T1
eplerenone tab 50mg
T1
spirono/hctz tab 25/25
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
44
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS
spironolact tab 100mg
T1
spironolact tab 25mg
T1
spironolact tab 50mg
T1
RENIN INHIBITORS
TEKTURNA TAB 150MG (aliskiren)
T3
PA, QL (30 tabs/30 days)
irbesartan,
lisinopril, losartan
TEKTURNA TAB 300MG (aliskiren)
T3
PA, QL (30 tabs/30 days)
irbesartan,
lisinopril, losartan
VASODILATING AGENTS
NITRATES AND NITRITES
isoditrate tab 40mg er (isosorbide)
T1
ISORDIL TAB 40MG (isosorbide)
T3
isosorb din tab 10mg
T1
isosorb din tab 20mg
T1
isosorb din tab 30mg
T1
isosorb din tab 40mg er
T1
isosorb din tab 40mg sa
T1
isosorb din tab 5mg
T1
isosorb mono tab 10mg
T1
isosorb mono tab 120mg er
T1
isosorb mono tab 20mg
T1
isosorb mono tab 30mg er
T1
isosorb mono tab 60mg er
T1
NITRO-BID OIN 2% (nitroglycerin)
T3
NITRO-DUR DIS 0.3MG/HR (nitroglycerin)
T3
nitroglycer aer 400mcg
T1
nitroglycer cap 2.5mg er
T1
nitroglycer cap 2.5mg sr
T1
nitroglycer cap 6.5mg er
T1
nitroglycer cap 6.5mg sr
T1
nitroglycer cap 9mg er
T1
NITRONAL SOL 1MG/ML (nitroglycerin)
T3
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
45
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CARDIOVASCULAR DRUGS
VASODILATING AGENTS
NITRATES AND NITRITES
NITROSTAT SUB 0.3MG (nitroglycerin)
T3
NITROSTAT SUB 0.4MG (nitroglycerin)
T3
NITROSTAT SUB 0.6MG (nitroglycerin)
T3
nitro-time cap 2.5mg cr (nitroglycerin)
T1
nitro-time cap 6.5mg cr (nitroglycerin)
T1
nitro-time cap 9mg cr (nitroglycerin)
T1
PHOSPHODIESTERASE TYPE 5 INHIBITORS
ADCIRCA TAB 20MG (tadalafil)
T4
PA
CIALIS TAB 5MG (tadalafil)
T3
PA, QL (30 tabs/30 days)
sildenafil tab 20mg
T1
QL
for BPH
alfuzosin,
finasteride,
tamsulosin
VASODILATING AGENTS, MISCELLANEOUS
dipyridamole inj 5mg/ml
T1
dipyridamole tab 25mg
T1
dipyridamole tab 50mg
T1
dipyridamole tab 75mg
T1
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
ANALGESICS AND ANTIPYRETICS, MISC.
but/apap/caf cap
T1
QL
but/apap/caf tab
T1
QL (120 tabs/30 days)
zebutal cap (butalbital-acetaminophen-caffeine)
T1
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
aspirin chew 81 mg
T0
QL
HCR Rules for Coverage
aspirin chew 81 mg
T0
QL
HCR Rules for Coverage
aspirin tab 324 mg
T0
HCR Rules for Coverage
aspirin tab 325 mg
T0
HCR Rules for Coverage
aspirin tab 325 mg
T0
HCR Rules for Coverage
aspirin tab 81 mg
T0
QL
HCR Rules for Coverage
aspirin tab 81 mg
T0
QL
HCR Rules for Coverage
BAYER CHILD CHW ASA 81MG (aspirin)
T1
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
46
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
but/asa/caff cap
T1
but/asa/caff tab
T1
celecoxib cap 100mg
T1
QL, ST
celecoxib cap 200mg
T1
QL, ST
celecoxib cap 400mg
T1
QL, ST
celecoxib cap 50mg
T1
QL, ST
cho mag tris liq 500/5ml
T1
cho mag tris tab 1000mg
T1
diclo/misopr tab 50-0.2mg
T1
diclo/misopr tab 75-0.2mg
T1
diclofen pot tab 50mg
T1
diclofenac tab 100mg er
T1
diclofenac tab 100mg xr
T1
diclofenac tab 25mg dr
T1
diclofenac tab 50mg dr
T1
diclofenac tab 75mg dr
T1
diflunisal tab 500mg
T1
etodolac cap 200mg
T1
etodolac cap 300mg
T1
etodolac tab 400mg
T1
etodolac tab 500mg
T1
etodolac er tab 400mg
T1
etodolac er tab 500mg (etodolac)
T1
etodolac er tab 600mg
T1
fenoprofen tab 600mg
T1
flurbiprofen tab 100mg
T1
flurbiprofen tab 50mg
T1
ibuprofen sus 100/5ml (ibuprofen)
T1
ibuprofen tab 400mg
T1
ibuprofen tab 600mg
T1
ibuprofen tab 800mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
47
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
indomethacin cap 25mg
T1
indomethacin cap 50mg
T1
indomethacin cap 75mg cr
T1
indomethacin cap 75mg er
T1
indomethacin cap 75mg sa
T1
indomethacin cap 75mg sr
T1
ketoprofen cap 200mg er
T1
ketoprofen cap 50mg
T1
ketoprofen cap 75mg
T1
ketorolac tab 10mg
T1
meclofen sod cap 100mg
T1
meclofen sod cap 50mg
T1
MEDI-SELTZER TAB (aspirin)
T3
mefenam acid cap 250mg
T1
meloxicam sus 7.5/5ml
T1
meloxicam tab 15mg
T1
meloxicam tab 7.5mg
T1
nabumetone tab 500mg
T1
nabumetone tab 750mg
T1
naproxen sus 125/5ml
T1
naproxen tab 250mg
T1
naproxen tab 375mg
T1
naproxen tab 500mg (naproxen)
T1
naproxen dr tab 375mg (naproxen)
T1
naproxen dr tab 500mg (naproxen)
T1
naproxen ec tab 375mg (naproxen)
T1
naproxen ec tab 500mg (naproxen)
T1
naproxen sod tab 220mg (naproxen)
T1
naproxen sod tab 275mg
T1
naproxen sod tab 550mg
T1
orph/asa/caf tab
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
48
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
oxaprozin tab 600mg
T1
piroxicam cap 10mg
T1
piroxicam cap 20mg
T1
salsalate tab 500mg
T1
salsalate tab 750mg
T1
sulindac tab 150mg
T1
sulindac tab 200mg
T1
tolmetin sod cap 400mg
T1
tolmetin sod tab 200mg
T1
tolmetin sod tab 600mg
T1
OPIATE AGONISTS
apap/caff/di tab hydrocod
T1
QL (240 caps/30 days)
apap/codeine sol 120-12/5
T1
QL (4500ml/30 days)
apap/codeine tab 300-15mg
T1
QL (300 tabs/30 days)
apap/codeine tab 300-30mg
T1
QL
apap/codeine tab 300-60mg
T1
QL
asa/caff/but cap cod 30mg
T1
ascomp/cod cap 30mg (acetaminophen)
T1
but/apap/caf cap codeine
T1
but/asa/caf/ cap cod 30mg
T1
butal cpd/ cap codeine (acetaminophen)
T1
codeine sulf tab 15mg
T1
codeine sulf tab 30mg
T1
codeine sulf tab 60mg
T1
codeine/apap tab 15-300mg
T1
QL
codeine/apap tab 30-300mg
T1
QL
codeine/apap tab 60-300mg
T1
QL
duramorph inj 0.5mg/ml (morphine)
T1
duramorph inj 1mg/ml (morphine)
T1
endocet tab 10-325mg (oxycodone)
T1
QL
endocet tab 10-650mg (oxycodone)
T1
QL (300 tabs/30 days)
QL (240 caps/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
49
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
OPIATE AGONISTS
endocet tab 5-325mg (oxycodone)
T1
QL
endocet tab 7.5-325 (oxycodone)
T1
QL
endocet tab 7.5-500m (oxycodone)
T1
QL (300 tabs/30 days)
fentanyl dis 100mcg/h
T1
QL (10 patches/30 days)
fentanyl dis 12mcg/hr
T1
QL (10 patches/30 days)
fentanyl dis 25mcg/hr
T1
QL (10 patches/30 days)
fentanyl dis 37.5mcg
T1
QL
fentanyl dis 50mcg/hr
T1
QL (10 patches/30 days)
fentanyl dis 62.5mcg
T1
QL
fentanyl dis 75mcg/hr
T1
QL (10 patches/30 days)
fentanyl dis 87.5mcg
T1
QL
fentanyl ot loz 1200mcg
T1
PA
fentanyl ot loz 1600mcg
T1
PA
fentanyl ot loz 200mcg
T1
PA
fentanyl ot loz 400mcg
T1
PA
fentanyl ot loz 600mcg
T1
PA
fentanyl ot loz 800mcg
T1
PA
hydroco/apap sol 5-217/10
T1
QL (3600ml/30 days)
hydroco/apap sol 7.5-325
T1
QL (3600ml/30 days)
hydroco/apap tab 10-325mg
T1
QL (4 patches/28 days)
hydroco/apap tab 5-325mg
T1
QL (28 tabs/28 days)
hydroco/apap tab 7.5-325
T1
QL (28 tabs/28 days)
hydrocod/ibu tab 2.5-200
T1
QL (28 tabs/28 days)
hydrocod/ibu tab 7.5-200
T1
QL (28 tabs/28 days)
hydromorphon liq 1mg/ml
T1
hydromorphon sup 3mg
T1
hydromorphon tab 2mg
T1
hydromorphon tab 4mg
T1
hydromorphon tab 8mg
T1
IBUDONE TAB 10-200MG (hydrocodone-ibuprofen)
T3
levorphanol tab 2mg
T1
PA
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
50
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
OPIATE AGONISTS
lorcet tab 5-325mg (hydrocodoneacetaminophen)
T1
QL (28 tabs/28 days)
lorcet hd tab 10-325mg (hydrocodoneacetaminophen)
T1
QL (150 tabs/30 days)
lorcet plus tab 7.5-325 (hydrocodoneacetaminophen)
T1
QL (150 tabs/30 days)
lortab tab 10-325mg (hydrocodoneacetaminophen)
T1
QL (4 patches/28 days)
lortab tab 5-325mg (hydrocodoneacetaminophen)
T1
QL (28 tabs/28 days)
lortab tab 7.5-325 (hydrocodone-acetaminophen)
T1
QL (28 tabs/28 days)
meperidine inj 100mg/ml
T1
meperidine inj 10mg/ml
T1
meperidine inj 25mg/ml
T1
meperidine inj 50mg/ml
T1
meperidine sol 50mg/5ml
T1
meperidine tab 100mg
T1
meperidine tab 50mg
T1
meperitab tab 100mg (meperidine)
T1
meperitab tab 50mg (meperidine)
T1
methadone sol 10mg/5ml
T1
methadone sol 5mg/5ml
T1
methadone tab 10mg
T1
methadone tab 5mg
T1
morphine sul cap 100mg er
T1
QL (60 caps/30 days)
morphine sul cap 120mg er
T1
PA, QL (30 caps/30 days)
morphine sul cap 20mg er
T1
QL (60 caps/30 days)
morphine sul cap 30mg er
T1
PA, QL (60 caps/30 days)
morphine sul cap 30mg er
T1
QL (60 caps/30 days)
morphine sul cap 45mg er
T1
PA, QL (60 caps/30 days)
morphine sul cap 50mg er
T1
QL (90 caps/30 days)
morphine sul cap 60mg er
T1
PA, QL (30 caps/30 days)
morphine sul cap 60mg er
T1
QL (90 caps/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
51
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
OPIATE AGONISTS
morphine sul cap 75mg er
T1
PA, QL (30 caps/30 days)
morphine sul cap 80mg er
T1
QL (90 caps/30 days)
morphine sul cap 90mg er
T1
PA, QL (30 caps/30 days)
morphine sul inj 0.5mg/ml
T1
morphine sul inj 10mg/ml
T1
morphine sul inj 150/30ml
T1
morphine sul inj 15mg/ml
T1
morphine sul inj 1mg/ml
T1
morphine sul inj 25mg/ml
T1
morphine sul inj 2mg/ml
T1
morphine sul inj 4mg/ml
T1
morphine sul inj 50mg/ml
T1
morphine sul inj 8mg/ml
T1
morphine sul sol 10/0.5ml
T1
morphine sul sol 100/5ml
T1
morphine sul sol 10mg/5ml
T1
morphine sul sol 20mg/5ml
T1
morphine sul sol 20mg/ml
T1
morphine sul sup 20mg
T1
morphine sul sup 5mg
T1
morphine sul tab 100mg cr
T1
QL
morphine sul tab 100mg er
T1
QL (90 tabs/30 days)
morphine sul tab 15mg
T1
QL (120 tabs/30 days)
morphine sul tab 15mg cr
T1
QL
morphine sul tab 15mg er
T1
QL (90 tabs/30 days)
morphine sul tab 200mg er
T1
QL (90 tabs/30 days)
morphine sul tab 30mg
T1
QL (120 tabs/30 days)
morphine sul tab 30mg cr
T1
QL
morphine sul tab 30mg er
T1
QL (90 tabs/30 days)
morphine sul tab 60mg cr
T1
QL
morphine sul tab 60mg er
T1
QL (90 tabs/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
52
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
OPIATE AGONISTS
NUCYNTA TAB 100MG (tapentadol)
T3
PA, QL (180 tabs/30 days)
morphine,
oxycodone
NUCYNTA TAB 75MG (tapentadol)
T3
PA, QL (180 tabs/30 days)
morphine,
oxycodone
NUCYNTA ER TAB 100MG (tapentadol)
T3
PA, QL (60 tabs/30 days)
morphine,
oxycodone
NUCYNTA ER TAB 200MG (tapentadol)
T3
PA, QL (60 tabs/30 days)
morphine,
oxycodone
oxycod/apap tab 10-325mg
T1
QL (180 abs/30 days)
oxycod/apap tab 2.5-325
T1
QL (180 tabs/30 days)
oxycod/apap tab 5-325mg
T1
QL (180 tabs/30 days)
oxycod/apap tab 7.5-325
T1
QL (180 tabs/30 days)
oxycod/apap tab 7.5-500
T1
QL (180 tabs/30 days)
oxycod/ibu tab 5-400mg
T1
QL (240 tabs/30 days)
oxycodone cap 5mg
T1
PA, QL (150 caps/30 days)
oxycodone sol 5mg/5ml
T1
QL (500ml/30 days)
oxycodone tab 10mg
T1
QL (120 tabs/30 days)
oxycodone tab 10mg er
T1
QL
oxycodone tab 15mg
T1
QL (120 tabs/30 days)
oxycodone tab 20mg
T1
QL (120 tabs/30 days)
oxycodone tab 20mg er
T1
QL
oxycodone tab 30mg
T1
QL (120 tabs/30 days)
oxycodone tab 40mg er
T1
QL
oxycodone tab 5mg
T1
QL (120 tabs/30 days)
oxycodone tab 80mg er
T1
QL
oxycontin tab 40mg cr (oxycodone)
T1
QL
oxycontin tab 80mg cr (oxycodone)
T1
QL
oxymorphone tab 10mg er
T1
PA, QL (60 tabs/30 days)
oxymorphone tab 15mg er
T1
PA, QL (60 tabs/30 days)
oxymorphone tab 20mg er
T1
PA, QL (60 tabs/30 days)
oxymorphone tab 30mg er
T1
PA, QL (60 tabs/30 days)
oxymorphone tab 40mg er
T1
PA, QL (60 tabs/30 days)
oxymorphone tab 5mg er
T1
PA, QL (60 tabs/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
53
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
OPIATE AGONISTS
oxymorphone tab 7.5mg er
T1
PA, QL (60 tabs/30 days)
oxymorphone tab hcl 10mg
T1
PA, QL (60 tabs/30 days)
oxymorphone tab hcl 5mg
T1
PA, QL (60 tabs/30 days)
roxicet tab 5-325mg (oxycodone)
T1
QL
tramadl/apap tab 37.5-325
T1
QL (240 tabs/30 days)
tramadol hcl tab 100mg er
T1
tramadol hcl tab 200mg er
T1
tramadol hcl tab 300mg er
T1
tramadol hcl tab 50mg
T1
OPIATE PARTIAL AGONISTS
bupren/nalox sub 2-0.5mg
T1
PA, QL
bupren/nalox sub 8-2mg
T1
PA, QL
buprenorphin inj 0.3mg/ml
T1
buprenorphin sub 2mg
T1
buprenorphin sub 8mg
T1
butorphanol inj 1mg/ml
T1
QL
butorphanol sol 10mg/ml
T1
QL (2.5ml/14 days)
BUTRANS DIS 10MCG/HR (buprenorphine)
T3
PA, QL (4 patches/28 days)
BUTRANS DIS 15MCG/HR (buprenorphine)
T3
PA, QL (4 patches/28 days)
BUTRANS DIS 20MCG/HR (buprenorphine)
T3
PA, QL (4 patches/28 days)
BUTRANS DIS 5MCG/HR (buprenorphine)
T3
PA, QL (4 patches/28 days)
BUTRANS DIS 7.5/HR (buprenorphine)
T3
PA, QL (4 patches/28 days)
penta/apap tab 25-650mg
T1
pentaz/nalox tab 50-0.5mg
T1
ANOREXIGENICS AGENTS AND RESPIRATORY AND CNS STIMULANTS
AMPHETAMINES
amphetamine cap 10mg er
T1
QL (60 caps/30 days)
amphetamine cap 15mg er
T1
QL (60 caps/30 days)
amphetamine cap 20mg er
T1
QL (60 caps/30 days)
amphetamine cap 25mg er
T1
QL (60 caps/30 days)
amphetamine cap 30mg er
T1
QL (60 caps/30 days)
amphetamine cap 5mg er
T1
QL (60 caps/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
54
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANOREXIGENICS AGENTS AND RESPIRATORY AND CNS STIMULANTS
AMPHETAMINES
amphetamine tab 10mg
T1
QL (60 caps/30 days)
amphetamine tab 12.5mg
T1
QL (60 caps/30 days)
amphetamine tab 15mg
T1
QL (60 tabs/30 days)
amphetamine tab 20mg
T1
QL (60 tabs/30 days)
amphetamine tab 30mg
T1
QL (60 tabs/30 days)
amphetamine tab 5mg
T1
QL (60 tabs/30 days)
amphetamine tab 7.5mg
T1
QL
benzphetamin tab 50mg
T1
dexedrine tab 10mg (dextroamphetamine)
T1
QL (120 tabs/30 days)
dexedrine tab 5mg (dextroamphetamine)
T1
QL (180 tabs/30 days)
dextroamphet cap 10mg er
T1
QL (120 tabs/30 days)
dextroamphet cap 15mg er
T1
QL (120 tabs/30 days)
dextroamphet cap 5mg er
T1
QL (120 tabs/30 days)
dextroamphet tab 10mg
T1
QL (120 tabs/30 days)
dextroamphet tab 5mg
T1
QL (28 tabs/28 days)
methamphetam tab 5mg
T1
VYVANSE CAP 10MG (lisdexamfetamine)
T3
PA, QL (30 caps/30 days)
amphetaminedextroamphetamine
VYVANSE CAP 20MG (lisdexamfetamine)
T3
PA, QL (30 caps/30 days)
amphetaminedextroamphetamine
VYVANSE CAP 30MG (lisdexamfetamine)
T3
PA, QL (30 caps/30 days)
amphetaminedextroamphetamine
VYVANSE CAP 40MG (lisdexamfetamine)
T3
PA, QL (30 caps/30 days)
amphetaminedextroamphetamine
VYVANSE CAP 50MG (lisdexamfetamine)
T3
PA, QL (30 caps/30 days)
amphetaminedextroamphetamine
VYVANSE CAP 60MG (lisdexamfetamine)
T3
PA, QL (30 caps/30 days)
amphetaminedextroamphetamine
VYVANSE CAP 70MG (lisdexamfetamine)
T3
PA, QL (30 caps/30 days)
amphetaminedextroamphetamine
BELVIQ TAB 10MG (lorcaserin)
T3
PA
diethylprop tab 75mg er
T1
phentermine tab 37.5mg
T1
ANOREXIGENIC AGENTS
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
55
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANOREXIGENICS AGENTS AND RESPIRATORY AND CNS STIMULANTS
RESPIRATORY AND CNS STIMULANTS
DAYTRANA DIS 10MG/9HR (methylphenidate)
T3
PA, QL (30 patches/30 days)
methylphenidate
DAYTRANA DIS 15MG/9HR (methylphenidate)
T3
PA, QL (30 patches/30 days)
methylphenidate
DAYTRANA DIS 20MG/9HR (methylphenidate)
T3
PA, QL (30 patches/30 days)
methylphenidate
DAYTRANA DIS 30MG/9HR (methylphenidate)
T3
PA, QL (30 patches/30 days)
methylphenidate
dexmethylph cap 15mg er
T1
PA
dexmethylph cap 30mg er
T1
PA
dexmethylph cap 40mg er
T1
PA
dexmethylph tab 10mg
T1
QL (90 tabs/30 days)
dexmethylph tab 2.5mg
T1
QL (90 tabs/30 days)
dexmethylph tab 5mg
T1
QL (90 tabs/30 days)
dexmethylphe cap 10mg er
T1
PA, QL
dexmethylphe cap 20mg er
T1
PA, QL
dexmethylphe cap 5mg er
T1
PA, QL
FOCALIN XR CAP 10MG (dexmethylphenidate)
T3
PA
dexmethylphenidate
, methylphenidate
FOCALIN XR CAP 20MG (dexmethylphenidate)
T3
PA
dexmethylphenidate
, methylphenidate
FOCALIN XR CAP 25MG (dexmethylphenidate)
T3
PA, QL
dexmethylphenidate
, methylphenidate
FOCALIN XR CAP 35MG (dexmethylphenidate)
T3
PA
dexmethylphenidate
, methylphenidate
metadate tab 20mg er (methylphenidate)
T1
QL (60 tabs/30 days)
methylphenid cap 10mg
T1
QL (28 tabs/28 days)
methylphenid cap 20mg
T1
QL (28 tabs/28 days)
methylphenid cap 20mg er
T1
QL (60 tabs/30 days)
methylphenid cap 30mg
T1
QL (28 tabs/28 days)
methylphenid cap 30mg er
T1
QL (60 tabs/30 days)
methylphenid cap 40mg
T1
QL (60 caps/30 days)
methylphenid cap 40mg er
T1
QL (60 tabs/30 days)
methylphenid cap 50mg
T1
QL (60 caps/30 days)
methylphenid cap 60mg
T1
QL (30 caps/30 days)
methylphenid sol 10mg/5ml
T1
methylphenid sol 5mg/5ml
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
56
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANOREXIGENICS AGENTS AND RESPIRATORY AND CNS STIMULANTS
RESPIRATORY AND CNS STIMULANTS
methylphenid tab 10mg
T1
QL (28 tabs/28 days)
methylphenid tab 10mg er
T1
QL (60 tabs/30 days)
methylphenid tab 18mg er
T1
QL
methylphenid tab 18mg er
T1
QL (60 tabs/30 days)
methylphenid tab 20mg
T1
QL (28 tabs/28 days)
methylphenid tab 20mg er
T1
QL (60 tabs/30 days)
methylphenid tab 20mg sr
T1
QL (60 tabs/30 days)
methylphenid tab 27mg er
T1
QL
methylphenid tab 27mg er
T1
QL (60 tabs/30 days)
methylphenid tab 36mg er
T1
QL
methylphenid tab 36mg er
T1
QL (60 tabs/30 days)
methylphenid tab 54mg er
T1
QL
methylphenid tab 54mg er
T1
QL (60 tabs/30 days)
methylphenid tab 5mg
T1
QL (28 tabs/28 days)
WAKEFULNESS-PROMOTING AGENTS
modafinil tab 100mg
T1
PA, QL (60 tabs/30 days)
modafinil tab 200mg
T1
PA, QL (60 tabs/30 days)
NUVIGIL TAB 150MG (armodafinil)
T3
PA, QL (30 tabs/30 days)
modafinil
NUVIGIL TAB 200MG (armodafinil)
T3
PA, QL (30 tabs/30 days)
modafinil
NUVIGIL TAB 250MG (armodafinil)
T3
PA, QL (30 tabs/30 days)
modafinil
ANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
BANZEL TAB 200MG (rufinamide)
T3
QL (240 tabs/30 days)
carbamazepine,
divalproex,
lamotrigine,
levetiracetam,
topiramate,
zonisamide
BANZEL TAB 400MG (rufinamide)
T3
QL (240 tabs/30 days)
carbamazepine,
divalproex,
lamotrigine,
levetiracetam,
topiramate,
zonisamide
carbamazepin cap 100mg er
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
57
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
carbamazepin cap 200mg er
T1
carbamazepin cap 300mg er
T1
carbamazepin chw 100mg
T1
carbamazepin sus 100/5ml
T1
carbamazepin tab 200mg
T1
carbamazepin tab 200mg er
T1
carbamazepin tab 400mg er
T1
divalproex cap 125mg
T1
divalproex tab 125mg dr
T1
divalproex tab 250mg dr
T1
divalproex tab 250mg er
T1
divalproex tab 500mg dr
T1
divalproex tab 500mg er
T1
epitol tab 200mg (carbamazepine)
T1
felbamate sus 600/5ml
T1
felbamate tab 400mg
T1
felbamate tab 600mg
T1
gabapentin cap 100mg
T1
gabapentin cap 300mg
T1
gabapentin cap 400mg
T1
gabapentin sol 250/5ml
T1
gabapentin tab 600mg
T1
gabapentin tab 800mg
T1
HORIZANT TAB 300MG (gabapentin)
T3
PA
HORIZANT TAB 600MG (gabapentin)
T3
PA
LAMICTAL CHW 25MG (lamotrigine)
T1
PA
LAMICTAL CHW 5MG (lamotrigine)
T1
PA
LAMICTAL KIT START 49 (lamotrigine)
T3
PA, QL (1 kit/fill, 1 fill per 365
days)
lamotrigine chw 25mg
T1
PA
lamotrigine chw 5mg
T1
PA
lamotrigine tab 100mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
58
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
lamotrigine tab 100mg er
T1
lamotrigine tab 150mg
T1
lamotrigine tab 200mg
T1
lamotrigine tab 200mg er
T1
QL (30 tabs/30 days)
lamotrigine tab 250mg er
T1
QL (30 tabs/30 days)
lamotrigine tab 25mg
T1
lamotrigine tab 25mg er
T1
QL (30 tabs/30 days)
lamotrigine tab 300mg er
T1
QL (30 tabs/30 days)
lamotrigine tab 50mg er
T1
QL (30 tabs/30 days)
levetiraceta sol 100mg/ml
T1
levetiraceta sol 500/5ml
T1
levetiraceta tab 1000mg
T1
levetiraceta tab 250mg
T1
levetiraceta tab 500mg
T1
levetiraceta tab 500mg er
T1
levetiraceta tab 750mg
T1
levetiraceta tab 750mg er
T1
levetiracetm inj 500/5ml
T1
LYRICA CAP 100MG (pregabalin)
T3
PA, QL (60 caps/30 days)
gabapentin
LYRICA CAP 150MG (pregabalin)
T3
PA, QL (60 caps/30 days)
gabapentin
LYRICA CAP 200MG (pregabalin)
T3
PA, QL (60 caps/30 days)
gabapentin
LYRICA CAP 225MG (pregabalin)
T3
PA, QL (60 caps/30 days)
gabapentin
LYRICA CAP 25MG (pregabalin)
T3
PA, QL (60 caps/30 days)
gabapentin
LYRICA CAP 300MG (pregabalin)
T3
PA, QL (60 caps/30 days)
gabapentin
LYRICA CAP 50MG (pregabalin)
T3
PA, QL (60 caps/30 days)
gabapentin
LYRICA CAP 75MG (pregabalin)
T3
PA, QL (60 caps/30 days)
gabapentin
oxcarbazepin sus 300mg/5m
T1
oxcarbazepin tab 150mg
T1
oxcarbazepin tab 300mg
T1
oxcarbazepin tab 600mg
T1
QL (30 tabs/30 days)
QL
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
59
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
POTIGA TAB 200MG (ezogabine)
T3
QL (180 tabs/30 days)
carbamazepine,
divalproex,
lamotrigine,
levetiracetam,
topiramate,
zonisamide
POTIGA TAB 300MG (ezogabine)
T3
QL (180 tabs/30 days)
carbamazepine,
divalproex,
lamotrigine,
levetiracetam,
topiramate,
zonisamide
POTIGA TAB 400MG (ezogabine)
T3
QL (180 tabs/30 days)
carbamazepine,
divalproex,
lamotrigine,
levetiracetam,
topiramate,
zonisamide
POTIGA TAB 50MG (ezogabine)
T3
QL (180 tabs/30 days)
carbamazepine,
divalproex,
lamotrigine,
levetiracetam,
topiramate,
zonisamide
SABRIL POW 500MG (vigabatrin)
T3
QL (210 packets/30 days)
carbamazepine,
divalproex,
lamotrigine,
levetiracetam,
topiramate,
zonisamide
SABRIL TAB 500MG (vigabatrin)
T3
QL (360 tabs/30 days)
carbamazepine,
divalproex,
lamotrigine,
levetiracetam,
topiramate,
zonisamide
STAVZOR CAP 125MG (valproic)
T3
PA
divalproex,
valproate, valproic
STAVZOR CAP 250MG (valproic)
T3
PA
divalproex,
valproate, valproic
STAVZOR CAP 500MG (valproic)
T3
PA
divalproex,
valproate, valproic
tiagabine tab 2mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
60
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
tiagabine tab 4mg
T1
topiragen tab 100mg (topiramate)
T1
topiragen tab 200mg (topiramate)
T1
topiragen tab 25mg (topiramate)
T1
topiragen tab 50mg (topiramate)
T1
topiramate cap 15mg
T1
topiramate cap 25mg
T1
topiramate tab 100mg
T1
topiramate tab 200mg
T1
topiramate tab 25mg
T1
topiramate tab 50mg
T1
valproate inj 100mg/ml
T1
valproate inj 500/5ml
T1
valproic acd cap 250mg
T1
valproic acd sol 250/5ml
T1
valproic acd syp 250/5ml
T1
VIMPAT INJ 200MG/20 (lacosamide)
T3
VIMPAT SOL 10MG/ML (lacosamide)
T3
QL (1200 ml/30 days)
carbamazepine,
divalproex,
lamotrigine,
levetiracetam,
topiramate,
zonisamide
VIMPAT TAB 100MG (lacosamide)
T3
QL (60 tabs/30 days)
carbamazepine,
divalproex,
lamotrigine,
levetiracetam,
topiramate,
zonisamide
carbamazepine,
divalproex,
lamotrigine,
levetiracetam,
topiramate,
zonisamide
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
61
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
VIMPAT TAB 150MG (lacosamide)
T3
QL (60 tabs/30 days)
carbamazepine,
divalproex,
lamotrigine,
levetiracetam,
topiramate,
zonisamide
VIMPAT TAB 200MG (lacosamide)
T3
QL (60 tabs/30 days)
carbamazepine,
divalproex,
lamotrigine,
levetiracetam,
topiramate,
zonisamide
VIMPAT TAB 50MG (lacosamide)
T3
QL (60 tabs/30 days)
carbamazepine,
divalproex,
lamotrigine,
levetiracetam,
topiramate,
zonisamide
zonisamide cap 100mg
T1
zonisamide cap 25mg
T1
zonisamide cap 50mg
T1
BARBITURATES (ANTICONVULSANTS)
primidone tab 250mg
T1
primidone tab 50mg
T1
BENZODIAZEPINES (ANTICONVULSANTS)
clonazep odt tab 0.125mg
T1
clonazep odt tab 0.25mg
T1
clonazep odt tab 0.5mg
T1
clonazep odt tab 1mg
T1
clonazep odt tab 2mg
T1
clonazepam tab 0.5mg
T1
clonazepam tab 1mg
T1
clonazepam tab 2mg
T1
ONFI TAB 10MG (clobazam)
T3
QL (60 tabs/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
clonazepam,
lamotrigine,
topiramate
62
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
BENZODIAZEPINES (ANTICONVULSANTS)
ONFI TAB 20MG (clobazam)
T3
QL (60 tabs/30 days)
clonazepam,
lamotrigine,
topiramate
ONFI TAB 5MG (clobazam)
T3
QL (60 tabs/30 days)
clonazepam,
lamotrigine,
topiramate
HYDANTOINS
DILANTIN CAP 30MG (phenytoin)
T2
DILANTIN CHW 50MG (phenytoin)
T2
DILANTIN-125 SUS 125/5ML (phenytoin)
T2
PEGANONE TAB 250MG (ethotoin)
T2
PHENYTEK CAP 200MG (phenytoin)
T2
PHENYTEK CAP 300MG (phenytoin)
T2
phenytoin chw 50mg (phenytoin)
T1
phenytoin inj 50mg/ml
T1
phenytoin sus 125/5ml
T1
phenytoin ex cap 100mg
T1
phenytoin ex cap 200mg
T1
phenytoin ex cap 300mg
T1
SUCCINIMIDES
CELONTIN CAP 300MG (methsuximide)
T2
QL (120 caps/30 days)
ethosuximide cap 250mg
T1
QL (210 caps/30 days)
ethosuximide sol 250/5ml
T1
ANTIMANIC AGENTS
lithium sol 8meq/5ml
T1
lithium carb cap 150mg
T1
lithium carb cap 300mg
T1
lithium carb cap 600mg
T1
lithium carb tab 300mg
T1
lithium carb tab 300mg er
T1
lithium carb tab 450mg er
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
63
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMIGRAINE AGENTS
SELECTIVE SEROTONIN AGONISTS
almotrip mal tab 12.5mg
T1
PA
almotrip mal tab 6.25mg
T1
PA
almotriptan tab 12.5mg
T1
PA
almotriptan tab 6.25mg
T1
PA
FROVA TAB 2.5MG (frovatriptan)
T3
PA, QL (12 tabs/30 days)
IMITREX SPR 5MG/ACT (sumatriptan)
T3
QL
naratriptan tab 1mg
T1
QL (12 tabs/30 days)
naratriptan tab 2.5mg
T1
QL (12 tabs/30 days)
RELPAX TAB 20MG (eletriptan)
T3
PA, QL (12 tabs/30 days)
naratriptan,
rizatriptan,
sumatriptan
RELPAX TAB 40MG (eletriptan)
T3
PA, QL (12 tabs/30 days)
naratriptan,
rizatriptan,
sumatriptan
rizatriptan tab 10mg
T1
QL (12 tabs/30 days)
rizatriptan tab 10mg odt
T1
QL (12 tabs/30 days)
rizatriptan tab 5mg
T1
QL (12 tabs/30 days)
rizatriptan tab 5mg odt
T1
QL (12 tabs/30 days)
sumatriptan inj 4mg/0.5
T1
QL (12 units/30 days)
sumatriptan inj 4mg/0.5
T1
QL
sumatriptan inj 6mg/0.5
T1
QL (12 units/30 days)
sumatriptan spr 5mg/act
T1
QL
sumatriptan tab 100mg
T1
QL (18 tabs/30 days)
sumatriptan tab 25mg
T1
QL (18 tabs/30 days)
sumatriptan tab 50mg
T1
QL (18 tabs/30 days)
zolmitriptan tab 2.5mg
T1
PA, QL (12 tabs/30 days)
zolmitriptan tab 5mg
T1
PA, QL (12 tabs/30 days)
naratriptan,
rizatriptan,
sumatriptan
ANTIPARKINSONIAN AGENTS (CNS)
ADAMANTANES (CNS)
amantadine cap 100mg
T1
amantadine syp 50mg/5ml
T1
amantadine tab 100mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
64
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS (CNS)
ANTICHOLINERGIC AGENTS (CNS)
benztropine tab 0.5mg
T1
trihexyphen elx 0.4mg/ml
T1
trihexyphen tab 2mg
T1
trihexyphen tab 5mg
T1
CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.
entacapone tab 200mg
T1
tolcapone tab 100mg
T1
DOPAMINE PRECURSORS
carb/levo tab 10-100mg
T1
carb/levo tab 25-250mg
T1
carb/levo 50 tab /entacap
T1
carb/levo 75 tab /entacap
T1
carb/levo er tab 25-100mg
T1
carb/levo er tab 50-200mg
T1
carb/levo sr tab 50-200mg
T1
carb/levo100 tab /entacap
T1
carb/levo125 tab /entacap
T1
carb/levo150 tab /entacap
T1
carb/levo200 tab /entacap
T1
carbidopa tab 25mg
T1
DOPAMINE RECEPTOR AGONISTS
bromocriptin cap 5mg
T1
bromocriptin tab 2.5mg
T1
cabergoline tab 0.5mg
T1
MIRAPEX ER TAB 2.25MG (pramipexole)
T3
NEUPRO DIS 1MG/24HR (rotigotine)
T3
NEUPRO DIS 2MG/24HR (rotigotine)
T3
NEUPRO DIS 3MG/24HR (rotigotine)
T3
NEUPRO DIS 4MG/24HR (rotigotine)
T3
PA, QL (30 patches/30 days)
NEUPRO DIS 6MG/24HR (rotigotine)
T3
PA, QL (30 patches/30 days)
NEUPRO DIS 8MG/24HR (rotigotine)
T3
PA, QL (30 patches/30 days)
pramipexole tab 0.125mg
T1
QL (30 tabs/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
65
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS (CNS)
DOPAMINE RECEPTOR AGONISTS
pramipexole tab 0.25mg
T1
pramipexole tab 0.375mg
T1
pramipexole tab 0.5mg
T1
pramipexole tab 0.75mg
T1
pramipexole tab 1.5mg
T1
pramipexole tab 1mg
T1
requip tab 1mg (ropinirole)
T1
ropinirole tab 0.25mg
T1
ropinirole tab 0.5mg
T1
ropinirole tab 12mg er
T1
ropinirole tab 1mg
T1
ropinirole tab 2mg
T1
ropinirole tab 2mg er
T1
ropinirole tab 3mg
T1
ropinirole tab 4mg
T1
ropinirole tab 4mg er
T1
ropinirole tab 5mg
T1
ropinirole tab 6mg er
T1
ropinirole tab 8mg er
T1
QL
MONOAMINE OXIDASE B INHIBITORS
AZILECT TAB 0.5MG (rasagiline)
T3
QL (30 tabs/30 days)
AZILECT TAB 1MG (rasagiline)
T3
QL (30 tabs/30 days)
EMSAM DIS 12MG/24H (selegiline)
T3
PA, QL (30 patches/30 days)
amitriptyline,
duloxetine,
paroxetine,
venlafaxine
EMSAM DIS 6MG/24HR (selegiline)
T3
PA, QL (30 patches/30 days)
amitriptyline,
duloxetine,
paroxetine,
venlafaxine
EMSAM DIS 9MG/24HR (selegiline)
T3
PA, QL (30 patches/30 days)
amitriptyline,
duloxetine,
paroxetine,
venlafaxine
selegiline cap 5mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
66
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES AND HYPNOTICS
ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.
buspirone tab 10mg
T1
buspirone tab 15mg
T1
buspirone tab 30mg
T1
buspirone tab 5mg
T1
buspirone tab 7.5mg
T1
eszopiclone tab 1mg
T1
QL (30 tabs/30 days)
zolpidem
eszopiclone tab 2mg
T1
QL (30 tabs/30 days)
zolpidem
eszopiclone tab 3mg
T1
QL (30 tabs/30 days)
zolpidem
hydroxyz hcl sol 10mg/5ml
T1
hydroxyz hcl syp 10mg/5ml
T1
hydroxyz hcl tab 10mg
T1
hydroxyz hcl tab 25mg
T1
hydroxyz hcl tab 50mg
T1
hydroxyz pam cap 100mg
T1
hydroxyz pam cap 25mg
T1
hydroxyz pam cap 50mg
T1
meprobamate tab 200mg
T1
meprobamate tab 400mg
T1
ROZEREM TAB 8MG (ramelteon)
T3
PA, QL (30 tabs/30 days)
zolpidem
zaleplon cap 10mg
T1
zaleplon cap 5mg
T1
zolpidem tab 10mg
T1
QL (30 tabs/30 days)
zolpidem tab 5mg
T1
QL (30 tabs/30 days)
zolpidem er tab 12.5mg
T1
zolpidem er tab 6.25mg
T1
QL (30 tabs/30 days)
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
phenobarb elx 20mg/5ml
T1
phenobarb sol 20mg/5ml
T1
phenobarb tab 100mg
T1
phenobarb tab 15mg
T1
phenobarb tab 16.2mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
67
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES AND HYPNOTICS
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
phenobarb tab 30mg
T1
phenobarb tab 32.4mg
T1
phenobarb tab 60mg
T1
phenobarb tab 64.8mg
T1
phenobarb tab 97.2mg
T1
BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
alprazolam tab 0.25 odt
T1
alprazolam tab 0.25mg
T1
alprazolam tab 0.5mg
T1
alprazolam tab 0.5mg er
T1
alprazolam tab 0.5mg od
T1
alprazolam tab 0.5mg xr (alprazolam)
T1
alprazolam tab 1mg
T1
alprazolam tab 1mg er
T1
alprazolam tab 1mg odt
T1
alprazolam tab 1mg xr (alprazolam)
T1
alprazolam tab 2mg
T1
alprazolam tab 2mg er
T1
alprazolam tab 2mg odt
T1
alprazolam tab 2mg xr (alprazolam)
T1
alprazolam tab 3mg er
T1
alprazolam tab 3mg xr (alprazolam)
T1
chlordiazep cap 10mg
T1
chlordiazep cap 25mg
T1
chlordiazep cap 5mg
T1
cloraz dipot tab 15mg
T1
cloraz dipot tab 3.75mg
T1
cloraz dipot tab 7.5mg
T1
diazepam gel 10mg
T1
diazepam gel 2.5mg
T1
diazepam gel 20mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
68
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES AND HYPNOTICS
BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
diazepam inj 5mg/ml
T1
diazepam sol 1mg/ml
T1
diazepam sol 5mg/5ml
T1
diazepam tab 10mg
T1
diazepam tab 2mg
T1
diazepam tab 5mg
T1
estazolam tab 1mg
T1
estazolam tab 2mg
T1
flurazepam cap 15mg
T1
flurazepam cap 30mg
T1
lorazepam tab 0.5mg
T1
lorazepam tab 1mg
T1
lorazepam tab 2mg
T1
midazolam syp 2mg/ml
T1
oxazepam cap 10mg
T1
oxazepam cap 15mg
T1
oxazepam cap 30mg
T1
temazepam cap 15mg
T1
temazepam cap 22.5mg
T1
temazepam cap 30mg
T1
temazepam cap 7.5mg
T1
triazolam tab 0.125mg
T1
triazolam tab 0.25mg
T1
CENTRAL NERVOUS SYSTEM AGENTS, MISC.
acampro cal tab 333mg
T1
guanfacine tab 1mg er
T1
PA
guanfacine tab 2mg er
T1
PA
guanfacine tab 3mg er
T1
PA
guanfacine tab 4mg er
T1
PA
memantine tab hcl 5mg
T1
memantine hc tab 10mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
69
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS, MISC.
NAMENDA SOL 10MG/5ML (memantine)
T3
ST (donepezil)
NAMENDA TAB 10MG (memantine)
T3
ST (donepezil)
NAMENDA TAB 5MG (memantine)
T3
ST (donepezil)
NUEDEXTA CAP 20-10MG (dextromethorphan)
T3
PA, QL (60 caps/30 days)
riluzole tab 50mg
T1
STRATTERA CAP 100MG (atomoxetine)
T3
PA, QL (30 caps/30 days)
STRATTERA CAP 10MG (atomoxetine)
T3
PA, QL (60 caps/30 days)
STRATTERA CAP 18MG (atomoxetine)
T3
PA, QL (60 caps/30 days)
STRATTERA CAP 25MG (atomoxetine)
T3
PA, QL (60 caps/30 days)
STRATTERA CAP 40MG (atomoxetine)
T3
PA, QL (60 caps/30 days)
STRATTERA CAP 60MG (atomoxetine)
T3
PA, QL (60 caps/30 days)
STRATTERA CAP 80MG (atomoxetine)
T3
PA, QL (30 caps/30 days)
tetrabenazin tab 12.5mg
T4
PA
tetrabenazin tab 25mg
T4
PA
XYREM SOL 500MG/ML (sodium)
T4
PA, QL (540 ml/30 days)
SAVELLA MIS TITR PAK (milnacipran)
T3
PA, QL (60 tabs/30 days)
SAVELLA TAB 100MG (milnacipran)
T3
PA, QL (60 tabs/30 days)
SAVELLA TAB 25MG (milnacipran)
T3
PA, QL (60 tabs/30 days)
SAVELLA TAB 50MG (milnacipran)
T3
PA, QL (60 tabs/30 days)
FIBROMYALGIA AGENTS
OPIATE ANTAGONISTS
naloxone inj 1mg/ml
T1
naltrexone tab 50mg
T1
VIVITROL INJ 380MG (naltrexone)
MED
PA, SP
Medical coinsurance
PSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
amitriptylin tab 100mg
T1
amitriptylin tab 10mg
T1
amitriptylin tab 150mg
T1
amitriptylin tab 25mg
T1
amitriptylin tab 50mg
T1
amitriptylin tab 75mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
70
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
amoxapine tab 100mg
T1
amoxapine tab 150mg
T1
amoxapine tab 25mg
T1
amoxapine tab 50mg
T1
budeprion tab 100mg sr (bupropion)
T1
budeprion tab 150mg sr (bupropion)
T1
bupropion tab 100mg
T1
bupropion tab 100mg er
T1
bupropion tab 100mg sr
T1
bupropion tab 150mg er
T1
bupropion tab 150mg sr
T1
bupropion tab 200mg er
T1
bupropion tab 200mg sr
T1
bupropion tab 75mg
T1
bupropion hcl (smoking deterrent) tab 150 mg
T0
bupropn hcl tab 150mg xl
T1
bupropn hcl tab 300mg xl
T1
citalopram sol 10mg/5ml
T1
citalopram tab 10mg
T1
citalopram tab 20mg
T1
citalopram tab 40mg
T1
clomipramine cap 25mg
T1
clomipramine cap 50mg
T1
clomipramine cap 75mg
T1
desipramine tab 100mg
T1
desipramine tab 10mg
T1
desipramine tab 150mg
T1
desipramine tab 25mg
T1
desipramine tab 50mg
T1
desipramine tab 75mg
T1
desvenlafax tab 100mg er
T1
QL (30 tabs/30 days)
HCR Rules for Coverage
PA
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
71
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
desvenlafax tab 50mg er
T1
doxepin hcl cap 100mg
T1
doxepin hcl cap 10mg
T1
doxepin hcl cap 150mg
T1
doxepin hcl cap 25mg
T1
doxepin hcl cap 50mg
T1
doxepin hcl cap 75mg
T1
doxepin hcl con 10mg/ml
T1
duloxetine cap 20mg
T1
QL (60 caps/30 days)
duloxetine cap 30mg
T1
QL (60 caps/30 days)
duloxetine cap 60mg
T1
QL (60 caps/30 days)
escitalopram sol 5mg/5ml
T1
escitalopram tab 10mg
T1
escitalopram tab 20mg
T1
escitalopram tab 5mg
T1
fluoxetine cap 10mg
T1
fluoxetine cap 20mg
T1
fluoxetine cap 40mg
T1
fluoxetine cap 90mg dr
T1
fluoxetine sol 20mg/5ml
T1
fluoxetine tab 10mg
T1
fluoxetine tab 20mg
T1
fluvoxamine tab 100mg
T1
fluvoxamine tab 25mg
T1
fluvoxamine tab 50mg
T1
imipram hcl tab 10mg
T1
imipram hcl tab 25mg
T1
imipram hcl tab 50mg
T1
imipram pam cap 100mg
T1
imipram pam cap 125mg
T1
imipram pam cap 150mg
T1
PA
PA
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
72
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
imipram pam cap 75mg
T1
maprotiline tab 25mg
T1
PA
maprotiline tab 50mg
T1
PA
maprotiline tab 75mg
T1
PA
MARPLAN TAB 10MG (isocarboxazid)
T3
QL (180 tabs/30 days)
mirtazapine tab 15mg
T1
mirtazapine tab 15mg odt
T1
mirtazapine tab 30mg
T1
mirtazapine tab 30mg odt
T1
mirtazapine tab 45mg
T1
mirtazapine tab 45mg odt
T1
mirtazapine tab 7.5mg
T1
nefazodone tab 100mg
T1
nefazodone tab 150mg
T1
nefazodone tab 200mg
T1
nefazodone tab 250mg
T1
nefazodone tab 50mg
T1
nortriptylin cap 10mg
T1
nortriptylin cap 25mg
T1
nortriptylin cap 50mg
T1
nortriptylin cap 75mg
T1
nortriptylin sol 10mg/5ml
T1
olanza/fluox cap 12-25mg
T1
QL (30 caps/30 days)
olanza/fluox cap 12-50mg
T1
QL (30 caps/30 days)
olanza/fluox cap 6-25mg
T1
QL (30 caps/30 days)
olanza/fluox cap 6-50mg
T1
QL (30 caps/30 days)
paroxetine tab 10mg
T1
QL (30 tabs/30 days)
paroxetine tab 20mg
T1
QL (30 tabs/30 days)
paroxetine tab 30mg
T1
QL (30 tabs/30 days)
paroxetine tab 40mg
T1
QL (30 tabs/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
amitriptyline,
duloxetine,
paroxetine,
venlafaxine
73
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
phenelzine tab 15mg
T1
PRISTIQ TAB 100MG (desvenlafaxine)
T3
PA, QL (30 tabs/30 days)
venlafaxine
PRISTIQ TAB 100MG (desvenlafaxine)
T3
QL (30 tabs/30 days)
venlafaxine
PRISTIQ TAB 25MG (desvenlafaxine)
T3
PRISTIQ TAB 50MG (desvenlafaxine)
T3
PA, QL (30 tabs/30 days)
venlafaxine
PRISTIQ TAB 50MG (desvenlafaxine)
T3
QL (30 tabs/30 days)
venlafaxine
protriptylin tab 10mg
T1
protriptylin tab 5mg
T1
sertraline con 20mg/ml
T1
sertraline tab 100mg
T1
sertraline tab 25mg
T1
sertraline tab 50mg
T1
tranylcyprom tab 10mg
T1
trazodone tab 100mg
T1
trazodone tab 150mg
T1
trazodone tab 300mg
T1
trazodone tab 50mg
T1
venlafaxine cap 150mg er
T1
QL (60 caps/30 days)
venlafaxine cap 37.5 er
T1
QL (60 caps/30 days)
venlafaxine cap 37.5mg
T1
QL (60 caps/30 days)
venlafaxine cap 75mg er
T1
QL (60 caps/30 days)
venlafaxine tab 100mg
T1
QL
venlafaxine tab 150mg er
T1
QL
venlafaxine tab 225mg er
T1
QL
venlafaxine tab 25mg
T1
QL
venlafaxine tab 37.5 er
T1
QL
venlafaxine tab 37.5mg
T1
QL
venlafaxine tab 50mg
T1
QL
venlafaxine tab 75mg
T1
QL
venlafaxine tab 75mg er
T1
QL
venlafaxine
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
74
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
VIIBRYD TAB 10MG (vilazodone)
T3
PA, QL (30 tabs/30 days)
amitriptyline,
duloxetine,
paroxetine,
venlafaxine
VIIBRYD TAB 20MG (vilazodone)
T3
PA, QL (30 tabs/30 days)
amitriptyline,
duloxetine,
paroxetine,
venlafaxine
VIIBRYD TAB 40MG (vilazodone)
T3
PA, QL (30 tabs/30 days)
amitriptyline,
duloxetine,
paroxetine,
venlafaxine
ANTIPSYCHOTIC AGENTS
ABILIFY INJ 9.75MG (aripiprazole)
T3
ABILIFY SOL 1MG/ML (aripiprazole)
T3
QL (700ml/30 days), ST
(risperidone, olanzapine,
quetiapine)
olanzapine,
quetiapine,
risperidone
ABILIFY TAB 10MG (aripiprazole)
T3
QL (60 tabs/30 days), ST
(risperidone, olanzapine,
quetiapine)
olanzapine,
quetiapine,
risperidone
ABILIFY TAB 15MG (aripiprazole)
T3
QL (60 tabs/30 days), ST
(risperidone, olanzapine,
quetiapine)
olanzapine,
quetiapine,
risperidone
ABILIFY TAB 20MG (aripiprazole)
T3
QL (60 tabs/30 days), ST
(risperidone, olanzapine,
quetiapine)
olanzapine,
quetiapine,
risperidone
ABILIFY TAB 2MG (aripiprazole)
T3
QL (60 tabs/30 days), ST
(risperidone, olanzapine,
quetiapine)
olanzapine,
quetiapine,
risperidone
ABILIFY TAB 30MG (aripiprazole)
T3
QL (60 tabs/30 days), ST
(risperidone, olanzapine,
quetiapine)
olanzapine,
quetiapine,
risperidone
ABILIFY TAB 5MG (aripiprazole)
T3
QL (60 tabs/30 days), ST
(risperidone, olanzapine,
quetiapine)
olanzapine,
quetiapine,
risperidone
aripiprazole tab 10mg
T1
QL
olanzapine,
quetiapine,
risperidone
olanzapine,
quetiapine,
risperidone
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
75
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
ANTIPSYCHOTIC AGENTS
aripiprazole tab 15mg
T1
QL
olanzapine,
quetiapine,
risperidone
aripiprazole tab 20mg
T1
QL
olanzapine,
quetiapine,
risperidone
aripiprazole tab 2mg
T1
QL
olanzapine,
quetiapine,
risperidone
aripiprazole tab 30mg
T1
QL
olanzapine,
quetiapine,
risperidone
aripiprazole tab 5mg
T1
QL
olanzapine,
quetiapine,
risperidone
chlorpromaz inj 25mg/ml
T1
chlorpromaz inj 50mg/2ml
T1
chlorpromaz tab 100mg
T1
chlorpromaz tab 10mg
T1
chlorpromaz tab 200mg
T1
chlorpromaz tab 25mg
T1
chlorpromaz tab 50mg
T1
clozapine tab 100mg
T1
QL (150 tabs/30 days)
clozapine tab 200mg
T1
QL (150 tabs/30 days)
clozapine tab 25mg
T1
QL (150 tabs/30 days)
clozapine tab 50mg
T1
QL (150 tabs/30 days)
compazine sup 25mg (prochlorperazine)
T1
compro sup 25mg (prochlorperazine)
T1
FANAPT TAB 10MG (iloperidone)
T3
FANAPT TAB 12MG (iloperidone)
T3
FANAPT TAB 1MG (iloperidone)
T3
FANAPT TAB 2MG (iloperidone)
T3
FANAPT TAB 4MG (iloperidone)
T3
FANAPT TAB 6MG (iloperidone)
T3
FANAPT TAB 8MG (iloperidone)
T3
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
76
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
ANTIPSYCHOTIC AGENTS
fluphenazine tab 10mg
T1
fluphenazine tab 1mg
T1
fluphenazine tab 2.5mg
T1
fluphenazine tab 5mg
T1
haloperidol con 2mg/ml
T1
haloperidol tab 0.5mg
T1
haloperidol tab 10mg
T1
haloperidol tab 1mg
T1
haloperidol tab 20mg
T1
haloperidol tab 2mg
T1
haloperidol tab 5mg
T1
INVEGA TAB 1.5MG (paliperidone)
T3
PA, QL (30 tabs/30 days)
olanzapine,
risperidone
INVEGA TAB 3MG (paliperidone)
T3
PA, QL (30 tabs/30 days)
olanzapine,
risperidone
INVEGA TAB 6MG (paliperidone)
T3
PA, QL (30 tabs/30 days)
olanzapine,
risperidone
INVEGA TAB 9MG (paliperidone)
T3
PA, QL (30 tabs/30 days)
olanzapine,
risperidone
LATUDA TAB 120MG (lurasidone)
T3
PA, QL (30tabs/30days)
LATUDA TAB 20MG (lurasidone)
T3
PA, QL (30 tabs/30 days)
LATUDA TAB 40MG (lurasidone)
T3
PA, QL (30 tabs/30 days)
LATUDA TAB 60MG (lurasidone)
T3
PA, QL (30tabs/30days)
LATUDA TAB 80MG (lurasidone)
T3
PA, QL (30 tabs/30 days)
loxapine cap 10mg
T1
loxapine cap 25mg
T1
loxapine cap 50mg
T1
loxapine cap 5mg
T1
olanzapine tab 10mg
T1
QL (30 tabs/30 days)
olanzapine tab 10mg odt
T1
QL (30 tabs/30 days)
olanzapine tab 15mg
T1
QL (30 tabs/30 days)
olanzapine tab 15mg odt
T1
QL (30 tabs/30 days)
olanzapine tab 2.5mg
T1
QL (30 tabs/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
77
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
ANTIPSYCHOTIC AGENTS
olanzapine tab 20mg
T1
QL (30 tabs/30 days)
olanzapine tab 20mg odt
T1
QL (30 tabs/30 days)
olanzapine tab 5mg
T1
QL (30 tabs/30 days)
olanzapine tab 5mg odt
T1
QL (30 tabs/30 days)
olanzapine tab 7.5mg
T1
QL (30 tabs/30 days)
ORAP TAB 1MG (PIMOZIDE)
T2
ORAP TAB 2MG (PIMOZIDE)
T2
paliperidone tab er 1.5mg
T4
paliperidone tab er 3mg
T4
paliperidone tab er 6mg
T4
paliperidone tab er 9mg
T4
perphenazine tab 16mg
T1
perphenazine tab 2mg
T1
perphenazine tab 4mg
T1
perphenazine tab 8mg
T1
prochlorper sup 25mg
T1
prochlorper tab 10mg
T1
prochlorper tab 5mg
T1
quetiapine tab 100mg
T1
QL (60 tabs/30 days)
quetiapine tab 200mg
T1
QL (60 tabs/30 days)
quetiapine tab 25mg
T1
QL (60 tabs/30 days)
quetiapine tab 300mg
T1
QL (60 tabs/30 days)
quetiapine tab 400mg
T1
QL (60 tabs/30 days)
quetiapine tab 50mg
T1
QL (60 tabs/30 days)
risperidone sol 1mg/ml
T1
risperidone tab 0.25 odt
T1
risperidone tab 0.25mg
T1
QL (280 tabs/30 days)
risperidone tab 0.5mg
T1
QL (280 tabs/30 days)
risperidone tab 0.5mg od (risperidone)
T1
risperidone tab 1 mg
T1
QL (280 tabs/30 days)
risperidone tab 1mg
T1
QL (280 tabs/30 days)
PA
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
78
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
ANTIPSYCHOTIC AGENTS
risperidone tab 1mg odt
T1
QL (280 tabs/30 days)
risperidone tab 2mg
T1
QL (280 tabs/30 days)
risperidone tab 2mg odt
T1
QL (280 tabs/30 days)
risperidone tab 3mg
T1
QL (280 tabs/30 days)
risperidone tab 3mg odt
T1
QL (280 tabs/30 days)
risperidone tab 4mg
T1
QL (280 tabs/30 days)
risperidone tab 4mg odt
T1
QL (280 tabs/30 days)
SAPHRIS SUB 10MG (asenapine)
T3
PA, QL (60 tabs/30 days)
SAPHRIS SUB 2.5MG (asenapine)
T3
PA
SAPHRIS SUB 5MG (asenapine)
T3
PA
SEROQUEL XR TAB 150MG (quetiapine)
T3
PA, QL (30 tabs/30 days)
SEROQUEL XR TAB 200MG (quetiapine)
T3
PA, QL (30 tabs/30 days)
SEROQUEL XR TAB 300MG (quetiapine)
T3
PA, QL (30 tabs/30 days)
SEROQUEL XR TAB 400MG (quetiapine)
T3
PA, QL (30 tabs/30 days)
SEROQUEL XR TAB 50MG (quetiapine)
T3
PA, QL (30 tabs/30 days)
thioridazine tab 100mg
T1
thioridazine tab 10mg
T1
thioridazine tab 25mg
T1
thioridazine tab 50mg
T1
thiothixene cap 10mg
T1
thiothixene cap 1mg
T1
thiothixene cap 2mg
T1
thiothixene cap 5mg
T1
trifluoperaz tab 10mg
T1
trifluoperaz tab 1mg
T1
trifluoperaz tab 2mg
T1
trifluoperaz tab 5mg
T1
ziprasidone cap 20mg
T1
QL (60 caps/30 days)
ziprasidone cap 40mg
T1
QL (120 caps/30 days)
ziprasidone cap 60mg
T1
QL (60 caps/30 days)
ziprasidone cap 80mg
T1
QL (120 caps/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
79
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
HCR Rules for Coverage
encare sup 100mg (nonoxynol-9)
T0
SHUR-SEAL GEL 2% (nonoxynol-9)
T3
vcf vaginal aer contracp (nonoxynol-9)
T0
HCR Rules for Coverage
vcf vaginal gel contrace (nonoxynol-9)
T0
HCR Rules for Coverage
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ALKALINIZING AGENTS
cytra-k sol (potassium)
T1
k citrate sol citr acd
T1
pot citrate tab 1080mg
T1
pot citrate tab 1620mg
T1
pot citrate tab 540mg er
T1
virtrate-k sol (potassium)
T1
virtrate-k sol 1100-334 (potassium)
T1
AMMONIA DETOXICANTS
BUPHENYL TAB 500MG (sodium)
T4
constulose sol 10gm/15 (lactulose)
T1
enulose sol 10gm/15 (lactulose)
T1
generlac sol 10gm/15 (lactulose)
T1
KRISTALOSE PAK 10GM (lactulose)
T2
KRISTALOSE PAK 20GM (lactulose)
T2
lactulose sol 10gm/15
T1
lactulose sol 20gm/30
T1
PA, SP
DIURETICS
LOOP DIURETICS
bumetanide inj 0.25/ml
T1
bumetanide tab 0.5mg
T1
bumetanide tab 1mg
T1
bumetanide tab 2mg
T1
EDECRIN TAB 25MG (ethacrynic)
T3
furosemide inj 100/10ml
T1
furosemide inj 10mg/ml
T1
furosemide inj 20mg/2ml
T1
furosemide inj 40mg/4ml
T1
QL (480 tabs/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
80
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ELECTROLYTIC, CALORIC, AND WATER BALANCE
DIURETICS
LOOP DIURETICS
furosemide sol 10mg/ml
T1
furosemide sol 40mg/4ml
T1
furosemide sol 8mg/ml
T1
furosemide tab 20mg
T1
furosemide tab 40mg
T1
furosemide tab 80mg
T1
torsemide tab 100mg
T1
torsemide tab 10mg
T1
torsemide tab 20mg
T1
torsemide tab 5mg
T1
POTASSIUM-SPARING DIURETICS
amilor/hctz tab 5-50
T1
amiloride tab 5mg
T1
DYRENIUM CAP 100MG (triamterene)
T3
PA, QL (120 caps/30 days)
DYRENIUM CAP 50MG (triamterene)
T3
PA, QL (120 caps/30 days)
triamt/hctz cap 37.5-25
T1
triamt/hctz cap 50-25mg
T1
triamt/hctz tab 37.5-25
T1
triamt/hctz tab 75-50mg
T1
THIAZIDE DIURETICS
chlorothiaz tab 250mg
T1
chlorothiaz tab 500mg
T1
hydrochlorot cap 12.5mg
T1
hydrochlorot tab 12.5mg
T1
hydrochlorot tab 25mg
T1
hydrochlorot tab 50mg
T1
methyclothia tab 5mg
T1
THIAZIDE-LIKE DIURETICS
chlorthalid tab 100mg
T1
chlorthalid tab 25mg
T1
chlorthalid tab 50mg
T1
indapamide tab 1.25mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
81
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ELECTROLYTIC, CALORIC, AND WATER BALANCE
DIURETICS
THIAZIDE-LIKE DIURETICS
indapamide tab 2.5mg
T1
metolazone tab 10mg
T1
metolazone tab 2.5mg
T1
metolazone tab 5mg
T1
VASOPRESSIN ANTAGONISTS
SAMSCA TAB 15MG (tolvaptan)
T4
PA
SAMSCA TAB 30MG (tolvaptan)
T4
PA
FOSRENOL CHW 1000MG (lanthanum)
T3
QL (150 tabs/30 days)
FOSRENOL CHW 500MG (lanthanum)
T3
QL (150 tabs/30 days)
FOSRENOL CHW 750MG (lanthanum)
T3
QL (150 tabs/30 days)
RENAGEL TAB 400MG (sevelamer)
T3
QL (120 tabs/30 days)
RENAGEL TAB 800MG (sevelamer)
T3
QL (120 tabs/30 days)
RENVELA PAK 0.8GM (sevelamer)
T3
RENVELA PAK 2.4GM (sevelamer)
T3
QL (540 packs/30 days)
sevelamer tab 800mg
T1
QL (540 tabs/30 days)
ION-REMOVING AGENTS
PHOSPHATE-REMOVING AGENTS
POTASSIUM-REMOVING AGENTS
kionex sus 15gm/60 (sodium)
T1
sod poly sul sus 15gm/60
T1
sod poly sul sus 30/120ml
T1
sod poly sul sus 50/200ml
T1
sps sus 15gm/60 (sodium)
T1
REPLACEMENT PREPARATIONS
calc acetate cap 667mg
T1
chloromag inj 20% (magnesium)
T1
EFFER-K TAB 10MEQ (potassium)
T2
EFFER-K TAB 20MEQ (potassium)
T2
effer-k tab 25meq ef (potassium)
T1
k-effervesce tab 25meq ef (potassium)
T1
klor-con 10 tab 10meq er (potassium)
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
82
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ELECTROLYTIC, CALORIC, AND WATER BALANCE
REPLACEMENT PREPARATIONS
klor-con 8 tab 8meq er (potassium)
T1
klor-con m10 tab 10meq er (potassium)
T1
KLOR-CON M15 TAB (potassium)
T3
KLOR-CON M15 TAB 15MEQ ER (potassium)
T3
klor-con m20 tab 20meq er (potassium)
T1
klor-con spr cap 10meq (potassium)
T1
klor-con spr cap 8meq (potassium)
T1
klor-con/ef tab 25meq ef (potassium)
T1
klor-con/ef tab 25meq fr (potassium)
T1
k-prime tab 25meq ef (potassium)
T1
k-sol sol 10% (potassium)
T1
k-sol sol 20% (potassium)
T1
k-vescent tab 25meq ef (potassium)
T1
magnesium cl inj 20%
T1
PHOSLYRA SOL (calcium)
T3
phospha 250 tab neutral (potassium)
T1
pot bicarbon tab 25meq ef
T1
pot chloride cap 10meq er
T1
pot chloride cap 8meq er
T1
pot chloride inj 10meq
T1
pot chloride inj 20meq
T1
pot chloride inj 2meq/ml
T1
pot chloride inj 40meq
T1
pot chloride sol 10%
T1
pot chloride sol 10% sf
T1
pot chloride sol 20%
T1
pot chloride sol 20% sf
T1
pot chloride tab 10meq cr
T1
pot chloride tab 10meq er
T1
pot chloride tab 20meq er
T1
pot chloride tab 25meq ef (potassium)
T1
pot chloride tab 8meq cr
T1
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
83
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
ELECTROLYTIC, CALORIC, AND WATER BALANCE
REPLACEMENT PREPARATIONS
pot chloride tab 8meq er
T1
pot chloride tab 8meq sa
T1
pot chloride tab 8meq sr
T1
pot cl micro tab 10meq cr
T1
pot cl micro tab 10meq er
T1
pot cl micro tab 20meq cr
T1
pot cl micro tab 20meq er
T1
pot/chloride tab 25meq ef
T1
potassium tab 25meq ef
T1
virt-phos tab 250 neut (potassium)
T1
zinc sulfate cap 220mg
T1
QL
URICOSURIC AGENTS
proben/colch tab 500-0.5
T1
probenecid tab 500mg
T1
EYE, EAR, NOSE AND THROAT (EENT) PREPS.
ANTIALLERGIC AGENTS
ALOCRIL SOL 2% (nedocromil)
T3
ALOMIDE SOL 0.1% OP (lodoxamide)
T2
azelastine dro 0.05%
T1
azelastine spr 0.1%
T1
azelastine spr 0.15%
T1
BEPREVE DRO 1.5% (bepotastine)
T3
cromolyn sod sol 4% op
T1
EMADINE SOL 0.05% OP (emedastine)
T3
epinastine dro 0.05%
T1
ketotif fum dro 0.025%op
T1
LASTACAFT SOL 0.25% (alcaftadine)
T3
QL (3 ml/fill)
PATADAY SOL 0.2% (olopatadine)
T3
QL (2.5 ml/fill)
Olopatadine SOL 0.1% OP
T1
QL (5 ml/fill)
QL (5 ml/fill)
PA
QL (5 ml/fill)
ANTIGLAUCOMA AGENTS
ALPHA-ADRENERGIC AGONISTS (EENT)
brimonidine sol 0.15%
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
84
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
EYE, EAR, NOSE AND THROAT (EENT) PREPS.
ANTIGLAUCOMA AGENTS
ALPHA-ADRENERGIC AGONISTS (EENT)
brimonidine sol 0.2% op
T1
COMBIGAN SOL 0.2/0.5% (brimonidine)
T3
QL (10 ml/fill)
SIMBRINZA SUS 1-0.2% (brinzolamide-brimonidine)
T3
PA
BETA-ADRENERGIC BLOCKING AGENTS (EENT)
betaxolol sol 0.5% op
T1
BETOPTIC-S SUS 0.25% OP (betaxolol)
T3
carteolol sol 1% op
T1
levobunolol sol 0.25% op
T1
levobunolol sol 0.5% op
T1
metipranolol sol 0.3% oph
T1
timolol gel sol 0.25% op
T1
timolol gel sol 0.5% op
T1
timolol mal sol 0.25% op
T1
timolol mal sol 0.5% op
T1
QL (10 ml/fill)
betaxolol
CARBONIC ANHYDRASE INHIBITORS (EENT)
acetazolamid cap 500mg er
T1
acetazolamid tab 125mg
T1
AZOPT SUS 1% OP (brinzolamide)
T2
dorzol/timol sol 22.3-6.8
T1
dorzolamide sol 2% op
T1
methazolamid tab 25mg
T1
methazolamid tab 50mg
T1
QL (10 ml/fill)
MIOTICS
PHOSPHOLINE SOL 0.125%OP (echothiophate)
T3
pilocarpine sol 1% op
T1
pilocarpine sol 2% op
T1
pilocarpine sol 4% op
T1
PROSTAGLANDIN ANALOGS
latanoprost sol 0.005%
T1
LUMIGAN SOL 0.01% (bimatoprost)
T2
QL (5 ml/fill), ST (latanoprost)
TRAVATAN Z DRO 0.004% (travoprost)
T2
QL (5 ml/fill), ST (latanoprost)
travoprost dro 0.004%
T1
QL, ST (latanoprost)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
85
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
EYE, EAR, NOSE AND THROAT (EENT) PREPS.
ANTIGLAUCOMA AGENTS
PROSTAGLANDIN ANALOGS
ZIOPTAN DRO 0.0015% (tafluprost)
T3
PA, QL (3 pouches/fill)
AZASITE SOL 1% (azithromycin)
T2
QL (2.5 ml/30 days)
bacitracin oin op
T1
BESIVANCE SUS 0.6% (besifloxacin)
T3
CILOXAN OIN 0.3% OP (ciprofloxacin)
T2
ciprofloxacn sol 0.2%
T1
ciprofloxacn sol 0.3% op
T1
erythromycin oin 5mg/gm
T1
erythromycin oin op
T1
garamycin oin 0.3% op (gentamicin)
T1
gatifloxacin sol 0.5%
T1
gentak oin 0.3% op (gentamicin)
T1
gentamicin oin 0.3% op
T1
gentamicin sol 0.3% op
T1
ilotycin oin op (erythromycin)
T1
levofloxacin sol 0.5%
T1
QL (5 ml/30 days)
MOXEZA SOL 0.5% (moxifloxacin)
T3
QL (3 ml (1 bottle)/fill)
ofloxacin dro 0.3% op
T1
ofloxacin dro 0.3%otic
T1
polymyxin b/ sol trimethp
T1
polytrim sol op (polymyxin)
T1
romycin oin op (erythromycin)
T1
sod sulfacet sol 10% op
T1
sulfacet sod sol 10% op
T1
tobramycin sol 0.3% op
T1
TOBREX OIN 0.3% OP (tobramycin)
T3
tobrex sol 0.3% op (tobramycin)
T1
trimethoprim sol polymyxn
T1
VIGAMOX DRO 0.5% (moxifloxacin)
T2
ANTI-INFECTIVES (EENT)
ANTIBACTERIALS (EENT)
QL (5 ml/30 days)
QL
QL (1 tube/fill)
QL (3 ml (1 bottle)/fill)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
86
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
EYE, EAR, NOSE AND THROAT (EENT) PREPS.
ANTI-INFECTIVES (EENT)
ANTIVIRALS (EENT)
trifluridine sol 1% op
T1
ZIRGAN GEL 0.15% (ganciclovir)
T3
QL (5 gram/ fill)
EENT ANTI-INFECTIVES, MISCELLANEOUS
chlorhex glu sol 0.12%
T1
paroex sol 0.12% (chlorhexidine)
T1
periogard sol 0.12% (chlorhexidine)
T1
ANTI-INFLAMMATORY AGENTS (EENT)
CORTICOSTEROIDS (EENT)
acetasol hc sol otic (hydrocortisone)
T1
ALREX SUS 0.2% (loteprednol)
T2
antibiot ear sol 1% otic (neomycin-polymyxin-hc)
T1
BECONASE AQ SUS 0.042% (beclomethasone)
T3
ST (fluticasone nasal spray,
triamcinolone nasal spray)
BLEPHAMIDE SUS LIQUIFLM (sulfacetamide)
T2
QL
BLEPHAMIDE SUS OP (sulfacetamide)
T2
QL
budesonide sus 32mcg
T1
CIPRO HC SUS OTIC (ciprofloxacin-hydrocortisone)
T3
QL (1 bottle/fill)
CIPRODEX SUS 0.3-0.1% (ciprofloxacindexamethasone)
T2
QL (7.5ml/ fill)
COLY-MYCIN S SUS OTIC (neomycin-colistin-hcthonzonium)
T2
CORTISPORIN SUS -TC OTIC (neomycin-colistin-hcthonzonium)
T2
dexameth pho sol 0.1% op
T1
DUREZOL EMU 0.05% (difluprednate)
T2
FLAREX SUS 0.1% OP (fluorometholone)
T2
flunisolide spr 0.025%
T1
fluocin acet oil 0.01%
T1
fluocin acet oil ear0.01%
T1
fluoromethol sus 0.1% op
T1
fluticasone spr 50mcg
T1
hc/acet acid sol otic
T1
LOTEMAX SUS 0.5% (loteprednol)
T3
fluticasone,
triamcinolone
hc = hydrocortisone
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
87
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
EYE, EAR, NOSE AND THROAT (EENT) PREPS.
ANTI-INFLAMMATORY AGENTS (EENT)
CORTICOSTEROIDS (EENT)
MAXIDEX SUS 0.1% OP (dexamethasone)
T2
NASONEX SPR 50MCG/AC (mometasone)
T3
ST (fluticasone nasal spray,
triamcinolone nasal spray)
neo/poly/dex sus 0.1% op
T1
QL
neo/poly/hc sol 1% otic
T1
neo/poly/hc sus 1% otic
T1
PRED MILD SUS 0.12% OP (prednisolone)
T3
pred sod pho sol 1% op
T1
prednisolone sus 1% op
T1
sulf/pred na sol op
T1
tobra/dexame sus 0.3-0.1%
T1
TOBRADEX OIN 0.3-0.1% (tobramycindexamethasone)
T2
triamcinolon aer 55mcg/ac
T1
VERAMYST SPR 27.5MCG (fluticasone)
T3
PA
VEXOL SUS 1% OP (rimexolone)
T3
PA
ZETONNA AER 37MCG (ciclesonide)
T3
ST (fluticasone nasal spray,
triamcinolone nasal spray)
fluticasone,
triamcinolone
QL
fluticasone,
triamcinolone
fluticasone,
triamcinolone
EENT NONSTEROIDAL ANTI-INFLAM. AGENTS
ACUVAIL SOL 0.45% (ketorolac)
T3
bromfenac sol 0.09%
T1
bromfenac sol 0.09% op
T1
diclofenac sol 0.1% op
T1
flurbiprofen sol 0.03% op
T1
ILEVRO DRO 0.3% OP (nepafenac)
T2
ketorolac sol 0.4%
T1
ketorolac sol 0.5%
T1
NEVANAC SUS 0.1% (nepafenac)
T2
QL (1.7 ml/fill)
EENT DRUGS, MISCELLANEOUS
acetic acid sol 2% otic
T1
apraclonidin sol 0.5% op
T1
IOPIDINE SOL 1% OP (apraclonidine)
T2
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
88
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
EYE, EAR, NOSE AND THROAT (EENT) PREPS.
LOCAL ANESTHETICS (EENT)
a/b sol otic (antipyrine-benzocaine)
T1
altacaine sol 0.5% op (tetracaine)
T1
antipy/benzo sol otic
T1
aurodex sol otic (antipyrine-benzocaine)
T1
auroguard sol otic (antipyrine-benzocaine)
T1
lidocaine sol 2% visc
T1
parcaine sol 0.5% op (proparacaine)
T1
proparacaine sol 0.5% op
T1
tetcaine sol 0.5% op (tetracaine)
T1
tetracaine sol 0.5% op
T1
tetravisc sol 0.5% op (tetracaine)
T1
tetravisc sol forte (tetracaine)
T1
MYDRIATICS
atropin-care sol 1% op (atropine)
T1
atropine sul oin 1% op
T1
atropine sul sol 1% op
T1
cyclopentol sol 1% op
T1
cyclopentol sol 2% op
T1
homatropaire sol 5% op (homatropine)
T1
homatropine sol 5% op
T1
mydral sol 0.5% op (tropicamide)
T1
mydral sol 1% op (tropicamide)
T1
tropicamide sol 0.5% op
T1
tropicamide sol 1% op
T1
VASOCONSTRICTORS
altafrin sol 10% op (phenylephrine)
T1
altafrin sol 2.5% op (phenylephrine)
T1
naphazoline sol 0.1% op
T1
neofrin sol 10% op (phenylephrine)
T1
neofrin sol 2.5% op (phenylephrine)
T1
phenylephrin sol 10% op
T1
phenylephrin sol 2.5% op
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
89
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
EYE, EAR, NOSE AND THROAT (EENT) PREPS.
VASOCONSTRICTORS
TYZINE PED DRO 0.05% (tetrahydrozoline)
T3
GASTROINTESTINAL DRUGS
ANTIDIARRHEA AGENTS
diphen/atrop liq 2.5/5
T1
diphen/atrop tab 2.5mg
T1
diphenatol tab 2.5mg (diphenoxylate)
T1
kaopectate tab (bismuth)
T1
lofene tab 2.5mg (diphenoxylate)
T1
lonox tab 2.5mg (diphenoxylate)
T1
loperamide cap 2mg (loperamide)
T1
QL
ANZEMET TAB 100MG (dolasetron)
T3
QL (3 tabs/21 days), ST
(ondansetron, granisetron)
ondansetron
ANZEMET TAB 50MG (dolasetron)
T3
QL (3 tabs/21 days), ST
(ondansetron, granisetron)
ondansetron
granisetron tab 1mg
T1
ondansetron inj 4mg/2ml
T1
ondansetron sol 4mg/5ml
T1
ondansetron tab 24mg
T1
ondansetron tab 4mg
T1
ondansetron tab 4mg odt
T1
ondansetron tab 8mg
T1
ondansetron tab 8mg odt
T1
ANTIEMETICS
5-HT3 RECEPTOR ANTAGONISTS
ANTIEMETICS, MISCELLANEOUS
CESAMET CAP 1MG (nabilone)
T3
PA
DICLEGIS TAB 10-10MG (doxylamine-pyridoxine)
T4
PA, SP, QL (120 tabs/ 30 days)
dronabinol cap 10mg
T1
QL
dronabinol cap 2.5mg
T1
QL
dronabinol cap 5mg
T1
QL
EMEND CAP 125MG (aprepitant)
T3
QL
EMEND CAP 40MG (aprepitant)
T3
QL (1 capsule/fill)
EMEND CAP 80MG (aprepitant)
T3
QL (1 capsule/fill)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
90
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
GASTROINTESTINAL DRUGS
ANTIEMETICS
ANTIEMETICS, MISCELLANEOUS
EMEND PAK 80 & 125 (aprepitant)
T3
QL (1 capsule/fill)
TRANSDERM-SC DIS 1.5MG (scopolamine)
T3
QL (3 patches/fill)
TRANSDERM-SC DIS 1MG (scopolamine)
T3
QL (3 patches/fill)
ANTIHISTAMINES (GI DRUGS)
meclizine tab 12.5mg
T1
meclizine tab 25mg
T1
trimethobenz cap 300mg
T1
ANTI-INFLAMMATORY AGENTS (GI DRUGS)
balsalazide cap 750mg
T1
CANASA SUP 1000MG (mesalamine)
T3
QL (70 supp/30 days)
DELZICOL CAP 400MG (mesalamine)
T2
QL (180 caps/30 days)
DIPENTUM CAP 250MG (olsalazine)
T2
LIALDA TAB 1.2GM (mesalamine)
T3
mesalamine ene 4gm
T1
mesalamine kit 4gm
T1
QL (1 kit/fill)
PENTASA CAP 250MG CR (mesalamine)
T3
QL (360 caps/30 days)
PENTASA CAP 500MG CR (mesalamine)
T3
QL (360 caps/30 days)
QL (180 tabs/30 days)
ANTIULCER AGENTS AND ACID SUPPRESSANTS
HISTAMINE H2-ANTAGONISTS
cimetidine tab 200mg (cimetidine)
T1
cimetidine tab 300mg
T1
cimetidine tab 400mg
T1
cimetidine tab 800mg
T1
famotidine tab 20mg (famotidine)
T1
famotidine tab 40mg
T1
nizatidine cap 150mg
T1
nizatidine cap 300mg
T1
nizatidine sol 15mg/ml
T1
ranitidine syp 150/10ml
T1
ranitidine syp 15mg/ml
T1
ranitidine syp 75mg/5ml
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
91
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
GASTROINTESTINAL DRUGS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
HISTAMINE H2-ANTAGONISTS
ranitidine tab 150mg
T1
ranitidine tab 300mg
T1
PROSTAGLANDINS
misoprostol tab 100mcg
T1
misoprostol tab 200mcg
T1
PROTECTANTS
CARAFATE SUS 1GM/10ML (sucralfate)
T2
sucralfate tab 1gm
T1
PROTON-PUMP INHIBITORS
lansoprazole cap 15mg dr
T1
QL (30 tabs/30 days)
lansoprazole cap 30mg dr
T1
QL (30 tabs/30 days)
LANSOPRAZOLE SUS 3MG/ML (lansoprazole)
T3
QL
omeprazole cap 10mg
T1
QL (60 caps/30 days)
omeprazole cap 20mg
T1
omeprazole cap 40mg
T1
pantoprazole tab 20mg
T1
pantoprazole tab 40mg
T1
rabeprazole tab 20mg
T1
QL (60 caps/30 days)
QL (30 tabs/30 days)
lansoprazole,
omeprazole,
pantoprazole
CATHARTICS AND LAXATIVES
gavilyte-c sol (peg)
T1
gavilyte-g sol (peg)
T1
gavilyte-n sol flav pk (peg)
T1
OSMOPREP TAB 1.5GM (sodium)
T3
peg 3350 sol electrol
T1
peg-3350 sol electrol
T1
peg-3350/kcl sol /sodium
T1
pegylax pow (polyethylene)
T1
polyeth glyc pow 3350 nf (polyethylene)
T1
PREPOPIK PAK (sodium)
T3
SUPREP BOWEL SOL PREP (sodium)
T3
QL
QL
PA
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
92
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
GASTROINTESTINAL DRUGS
CATHARTICS AND LAXATIVES
trilyte sol (peg)
T1
QL
CHOLELITHOLYTIC AGENTS
ursodiol cap 300mg
T1
ursodiol tab 250mg
T1
ursodiol tab 500mg
T1
DIGESTANTS
CREON CAP 12000UNT (pancrelipase)
T3
CREON CAP 24000UNT (pancrelipase)
T3
CREON CAP 3000UNIT (pancrelipase)
T3
CREON CAP 36000UNT (pancrelipase)
T3
CREON CAP 6000UNIT (pancrelipase)
T3
PANCREAZE CAP 10500UNT (pancrelipase)
T3
PANCREAZE CAP 16800UNT (pancrelipase)
T3
PANCREAZE CAP 21000UNT (pancrelipase)
T3
PANCREAZE CAP 4200UNIT (pancrelipase)
T3
pancrelipase cap 5000unit
T1
PERTZYE CAP (pancrelipase)
T3
ZENPEP CAP 10000UNT (pancrelipase)
T3
ZENPEP CAP 15000UNT (pancrelipase)
T3
ZENPEP CAP 20000UNT (pancrelipase)
T3
ZENPEP CAP 25000UNT (pancrelipase)
T3
ZENPEP CAP 3000UNIT (pancrelipase)
T3
ZENPEP CAP 40000UNT (pancrelipase)
T3
ZENPEP CAP 5000UNIT (pancrelipase)
T3
GI DRUGS, MISCELLANEOUS
AMITIZA CAP 24MCG (lubiprostone)
T3
PA, QL (60 caps/30 days)
AMITIZA CAP 8MCG (lubiprostone)
T3
PA, QL (60 caps/30 days)
ENTYVIO INJ 300MG (vedolizumab)
T4
PA
GATTEX KIT 5MG (teduglutide)
T4
PA, SP
LINZESS CAP 145MCG (linaclotide)
T3
PA, QL (30 caps/30 days)
LINZESS CAP 290MCG (linaclotide)
T3
PA, QL (30 caps/30 days)
XENICAL CAP 120MG (orlistat)
T3
PA
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
93
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
GASTROINTESTINAL DRUGS
PROKINETIC AGENTS
metoclopram inj 10mg/2ml
T1
metoclopram inj 5mg/ml
T1
metoclopram sol 10/10ml
T1
metoclopram sol 5mg/5ml
T1
metoclopram tab 10mg
T1
metoclopram tab 5mg
T1
GOLD COMPOUNDS
RIDAURA CAP 3MG (auranofin)
T2
HEAVY METAL ANTAGONISTS
CHEMET CAP 100MG (succimer)
T2
CUPRIMINE CAP 250MG (penicillamine)
T3
DEPEN TITRA TAB 250MG (penicillamine)
T2
EXJADE TAB 125MG (deferasirox)
T4
PA, SP
EXJADE TAB 250MG (deferasirox)
T4
PA, SP
EXJADE TAB 500MG (deferasirox)
T4
PA, SP
SYPRINE CAP 250MG (trientine)
T3
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
ALVESCO AER 160MCG (ciclesonide)
T3
QL (1 inhaler/30 days)
ADVAIR DISKUS,
FLOVENT DISKUS,
QVAR
ALVESCO AER 80MCG (ciclesonide)
T3
QL (1 inhaler/30 days)
ADVAIR DISKUS,
FLOVENT DISKUS,
QVAR
ASMANEX 120 AER 220MCG (mometasone)
T3
QL (1 inhaler/30 days)
ADVAIR DISKUS,
FLOVENT DISKUS,
QVAR
ASMANEX 30 AER 110MCG (mometasone)
T3
QL
ASMANEX 30 AER 220MCG (mometasone)
T3
ASMANEX 60 AER 220MCG (mometasone)
T3
QL (1 inhaler/30 days)
ASMANEX 7 AER 110MCG (mometasone)
T3
QL
ASMANEX HFA AER 100 MCG (mometasone)
T3
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
ADVAIR DISKUS,
FLOVENT DISKUS,
QVAR
94
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
ASMANEX HFA AER 200 MCG (mometasone)
T3
baycadron elx 0.5/5ml (dexamethasone)
T1
QL
budesonide cap 3mg/24hr
T1
PA
budesonide sus 0.25mg/2
T1
budesonide sus 0.5mg/2
T1
budesonide sus 1mg/2ml
T1
cortisone ac tab 25mg
T1
deltasone tab 20mg (prednisone)
T1
DEXAMETHASON CON 1MG/ML (dexamethasone)
T2
QL (30 ml/ fill)
dexamethason elx 0.5/5ml
T1
QL
dexamethason sol 0.5/5ml
T1
dexamethason tab 0.5mg
T1
dexamethason tab 0.75mg
T1
dexamethason tab 1.5mg
T1
dexamethason tab 1mg
T1
dexamethason tab 2mg
T1
dexamethason tab 4mg
T1
dexamethason tab 6mg
T1
DULERA AER 100-5MCG (mometasone)
T3
QL (1 inhaler/30 days)
ADVAIR DISKUS,
FLOVENT DISKUS,
QVAR
DULERA AER 200-5MCG (mometasone)
T3
QL (1 inhaler/30 days)
ADVAIR DISKUS,
FLOVENT DISKUS,
QVAR
FLOVENT DISK AER 100MCG (fluticasone)
T2
FLOVENT DISK AER 250MCG (fluticasone)
T2
FLOVENT DISK AER 50MCG (fluticasone)
T2
FLOVENT HFA AER 110MCG (fluticasone)
T2
FLOVENT HFA AER 220MCG (fluticasone)
T2
FLOVENT HFA AER 44MCG (fluticasone)
T2
fludrocort tab 0.1mg
T1
hydrocort tab 10mg
T1
hydrocort tab 20mg
T1
hydrocort tab 5mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
95
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
methylpred pak 4mg
T1
methylpred tab 16mg
T1
methylpred tab 32mg
T1
methylpred tab 4mg
T1
methylpred tab 8mg
T1
pred sod pho sol 5mg/5ml
T1
prednisolone sol 15mg/5ml
T1
prednisolone sol 15mg/5ml
T1
prednisolone sol 25mg/5ml
T1
prednisolone syp 15mg/5ml
T1
PREDNISONE CON 5MG/ML (prednisone)
T2
prednisone pak 10mg
T1
prednisone pak 5mg
T1
prednisone sol 5mg/5ml
T1
prednisone tab 10mg
T1
prednisone tab 1mg
T1
prednisone tab 2.5mg
T1
prednisone tab 20mg
T1
prednisone tab 50mg
T1
prednisone tab 5mg
T1
PULMICORT INH 180MCG (budesonide)
T2
QL (1 inhaler/30 days)
PULMICORT INH 90MCG (budesonide)
T2
QL (1 inhaler/30 days)
QVAR AER 40MCG (beclomethasone)
T2
QVAR AER 80MCG (beclomethasone)
T2
SYMBICORT AER 160-4.5 (budesonide-formoterol)
T3
QL (1 inhaler/30 days)
ADVAIR DISKUS,
FLOVENT DISKUS,
QVAR
SYMBICORT AER 80-4.5 (budesonide-formoterol)
T3
QL (1 inhaler/30 days)
ADVAIR DISKUS,
FLOVENT DISKUS,
QVAR
VERIPRED 20 SOL 20MG/5ML (prednisolone)
T2
QL (480ml/30 days)
T3
PA, QL (60 packets/30 days)
QL
QL
ANDROGENS
ANDROGEL GEL 1%(25MG) (testosterone)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
96
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
ANDROGENS
ANDROGEL GEL 1.62% (testosterone)
T3
PA
ANDROGEL GEL PUMP 1% (testosterone)
T3
PA, QL (2 bottles/30 days)
danazol cap 100mg
T1
PA
danazol cap 200mg
T1
PA
danazol cap 50mg
T1
PA
NATESTO GEL 5.5MG (testosterone)
T3
oxandrolone tab 10mg
T1
oxandrolone tab 2.5mg
T1
testosterone gel 1%(25mg)
T1
PA, QL
testosterone gel 1%(50mg)
T1
PA, QL
testosterone gel pump 1%
T1
PA, QL
ANTIDIABETIC AGENTS
ALPHA-GLUCOSIDASE INHIBITORS
acarbose tab 100mg
T1
acarbose tab 25mg
T1
acarbose tab 50mg
T1
GLYSET TAB 100MG (miglitol)
T3
acarbose
GLYSET TAB 25MG (miglitol)
T3
acarbose
GLYSET TAB 50MG (miglitol)
T3
acarbose
AMYLINOMIMETICS
SYMLINPEN 60 INJ 1000MCG (pramlintide)
T3
PA
ANTIDIABETIC AGENTS, MISCELLANEOUS
CYCLOSET TAB 0.8MG (bromocriptine)
T3
PA, QL (180 tabs/30 days)
BIGUANIDES
metformin tab 1000mg
T1
metformin tab 500mg
T1
metformin tab 500mg er
T1
metformin tab 750mg er
T1
metformin tab 850mg
T1
DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS
JANUVIA TAB 100MG (sitagliptin)
T2
QL (30 tabs/30 days)
JANUVIA TAB 25MG (sitagliptin)
T2
QL (30 tabs/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
97
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
ANTIDIABETIC AGENTS
DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS
JANUVIA TAB 50MG (sitagliptin)
T2
QL (30 tabs/30 days)
ONGLYZA TAB 2.5MG (saxagliptin)
T3
PA, QL (30 tabs/30 days)
JANUVIA
ONGLYZA TAB 5MG (saxagliptin)
T3
PA, QL (30 tabs/30 days)
JANUVIA
TRADJENTA TAB 5MG (linagliptin)
T3
PA, QL (30 tabs/30 days)
JANUVIA
BYDUREON INJ (exenatide)
T3
PA
BYDUREON INJ (exenatide)
T2
PA
BYETTA INJ 5MCG (exenatide)
T3
PA, QL (1 cartridge/month)
VICTOZA INJ 18MG/3ML (liraglutide)
T3
PA, QL (2 pens/30 days)
APIDRA INJ SOLOSTAR (insulin)
T2
QL (60 ml/30 days)
APIDRA INJ U-100 (insulin)
T2
QL (60 ml/30 days)
HUMALOG INJ 100/ML (insulin)
T3
QL (60ml/30 days)
NOVOLOG
HUMALOG KWIK INJ 100/ML (insulin)
T3
QL (60ml/30 days)
NOVOLOG,
NOVOLOG MIX
70/30
HUMALOG MIX INJ 50/50 (insulin)
T3
QL (60ml/30 days)
NOVOLOG,
NOVOLOG MIX
70/30
HUMALOG MIX INJ 50/50KWP (insulin)
T3
QL (60ml/30 days)
NOVOLOG,
NOVOLOG MIX
70/30
HUMALOG MIX INJ 75/25KWP (insulin)
T3
QL (60ml/30 days)
NOVOLOG,
NOVOLOG MIX
70/30
HUMALOG MIX SUS 75/25 (insulin)
T3
QL (60ml/30 days)
NOVOLOG,
NOVOLOG MIX
70/30
HUMULIN INJ 70/30 (insulin)
T3
QL (60 ml/30 days)
HUMULIN INJ 70/30KWP (insulin)
T3
QL (60 ml/30 days)
HUMULIN N INJ U-100 (insulin)
T3
QL (60 ml/30 days)
HUMULIN N INJ U-100KWP (insulin)
T3
QL (60 ml/30 days)
HUMULIN N PN INJ U-100 (insulin)
T3
QL (60 ml/30 days)
HUMULIN PEN INJ 70/30 (insulin)
T3
QL (60 ml/30 days)
INCRETIN MIMETICS
INSULINS
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
98
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
ANTIDIABETIC AGENTS
INSULINS
HUMULIN R INJ U-100 (insulin)
T3
QL (60 ml/30 days)
HUMULIN R INJ U-500 (insulin)
T3
QL (60ml/30 days)
LANTUS INJ 100/ML (insulin)
T2
QL (60 ml/30 days)
LANTUS INJ SOLOSTAR (insulin)
T2
QL (60 ml/30 days)
LEVEMIR INJ (insulin)
T2
QL (60 ml/30 days)
LEVEMIR INJ FLEXPEN (insulin)
T2
QL (60 ml/30 days)
LEVEMIR INJ FLEXTOUC (insulin)
T2
QL (60 ml/30 days)
NOVOLIN INJ 70/30 (insulin)
T2
QL (60 ml/30 days)
NOVOLIN N INJ U-100 (insulin)
T2
QL (60 ml/30 days)
NOVOLIN R INJ U-100 (insulin)
T2
QL (60 ml/30 days)
NOVOLOG INJ 100/ML (insulin)
T2
QL (60ml/30 days)
NOVOLOG INJ FLEXPEN (insulin)
T2
QL (60ml/30 days)
NOVOLOG INJ PENFILL (insulin)
T2
QL (60ml/30 days)
NOVOLOG MIX INJ 70/30 (insulin)
T2
QL (60ml/30 days)
NOVOLOG MIX INJ FLEXPEN (insulin)
T2
QL (60ml/30 days)
TOUJEO SOLO INJ 300IU/ML (insulin)
T4
QL
NOVOLOG,
NOVOLOG MIX
70/30, quetiapine
LANTUS
MEGLITINIDES
nateglinide tab 120mg
T1
nateglinide tab 60mg
T1
repaglinide tab 0.5mg
T1
QL (240 tabs/30 days)
repaglinide tab 1mg
T1
QL (240 tabs/30 days)
repaglinide tab 2mg
T1
QL (240 tabs/30 days)
SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBITORS
FARXIGA TAB 10MG (dapagliflozin)
T3
PA
FARXIGA TAB 5MG (dapagliflozin)
T3
PA
SULFONYLUREAS
chlorpropam tab 100mg
T1
chlorpropam tab 250mg
T1
glimepiride tab 1mg
T1
glimepiride tab 2mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
99
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
ANTIDIABETIC AGENTS
SULFONYLUREAS
glimepiride tab 4mg
T1
glip/metform tab 2.5-250m
T1
glip/metform tab 2.5-500m
T1
glip/metform tab 5-500mg
T1
glipizide tab 10mg
T1
glipizide tab 5mg
T1
glipizide er tab 10mg
T1
glipizide er tab 2.5mg
T1
glipizide er tab 5mg
T1
glipizide xl tab 10mg (glipizide)
T1
glipizide xl tab 2.5mg (glipizide)
T1
glipizide xl tab 5mg (glipizide)
T1
glyb/metform tab 1.25-250
T1
glyb/metform tab 2.5-500
T1
glyb/metform tab 5-500mg
T1
glyburid mcr tab 1.5mg
T1
glyburid mcr tab 3mg
T1
glyburid mcr tab 6mg
T1
glyburide tab 1.25mg
T1
glyburide tab 2.5mg
T1
glyburide tab 5mg
T1
tolazamide tab 250mg
T1
tolazamide tab 500mg
T1
tolbutamide tab 500mg
T1
THIAZOLIDINEDIONES
AVANDIA TAB 2MG (rosiglitazone)
T2
QL (60 tabs/30 days)
AVANDIA TAB 4MG (rosiglitazone)
T2
QL (60 tabs/30 days)
AVANDIA TAB 8MG (rosiglitazone)
T2
QL (60 tabs/30 days)
pioglita/met tab 15-500mg
T1
QL (120 tabs/30 days)
pioglita/met tab 15-850mg
T1
QL (120 tabs/30 days)
pioglitazone tab 15mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
100
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
ANTIDIABETIC AGENTS
THIAZOLIDINEDIONES
pioglitazone tab 30mg
T1
pioglitazone tab 45mg
T1
ANTIHYPOGLYCEMIC AGENTS
ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS
PROGLYCEM SUS 50MG/ML (diazoxide)
T2
GLYCOGENOLYTIC AGENTS
GLUCAGEN INJ HYPOKIT (glucagon)
T3
GLUCAGON KIT 1MG (glucagon)
T3
CONTRACEPTIVES
aftera tab 1.5mg (levonorgestrel)
T0
QL
HCR Rules for Coverage
altavera tab (levonorgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
alyacen tab 1/35 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
alyacen tab 7/7/7 (norethindrone-eth)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
amethia tab (levonorgestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
amethia lo tab (levonorgestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
amethyst tab 90-20mcg (levonorgestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
apri tab (desogestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
aranelle tab (norethindrone-eth)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
ashlyna tab (levonorgestrel-ethinyl)
T0
QL
HCR Rules for Coverage
aubra tab 0.1-0.02 (levonorgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
aviane tab (levonorgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
azurette tab 28 day (desogestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
balziva tab (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
briellyn tab (norethindrone)
T0
QL (2.5ml/14 days)
HCR Rules for Coverage
camila tab 0.35mg (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
camrese tab (levonorgestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
camrese lo tab (levonorgestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
caziant pak (desogestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
cesia pak (desogestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
chateal tab 0.15/30 (levonorgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
cryselle-28 tab 28 tabs (norgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
101
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
CONTRACEPTIVES
cyclafem tab 1/35 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
cyclafem tab 7/7/7 (norethindrone-eth)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
cyred tab (desogestrel)
T0
QL
HCR Rules for Coverage
dasetta tab 1/35 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
dasetta tab 7/7/7 (norethindrone-eth)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
daysee tab (levonorgestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
deblitane tab 0.35mg (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
delyla tab 0.1-0.02 (levonorgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
deso/ethinyl tab estradio
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
drospir/ethi tab 3-0.03mg
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
drospirenone tab ethy est
T0
QL
HCR Rules for Coverage
econtra ez tab 1.5mg (levonorgestrel)
T0
QL
HCR Rules for Coverage
elinest tab (norgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
ELLA TAB 30MG (ulipristal)
T2
QL (1 pack /fill, 3 fills/365 days)
emoquette tab (desogestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
enpresse-28 tab (levonorgestrel-eth)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
enskyce tab (desogestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
errin tab 0.35mg (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
estarylla tab 0.25-35 (norgestimate-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
fallback tab 1.5mg (levonorgestrel)
T0
QL
HCR Rules for Coverage
falmina tab (levonorgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
gianvi tab 3-0.02mg (drospirenone-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
gildagia tab 0.4-35 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
gildess tab 1.5/30 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
gildess tab 1/20 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
gildess 24 tab fe 1/20 (norethin)
T0
QL
HCR Rules for Coverage
gildess fe tab 1.5/30 (norethin)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
gildess fe tab 1/20 (norethin)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
heather tab 0.35mg (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
introvale tab (levonorgestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
jencycla tab 0.35mg (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
jolessa tab (levonorgestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
102
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
CONTRACEPTIVES
jolivette tab 0.35mg (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
junel 1.5/30 tab (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
junel 1/20 tab (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
junel fe tab 1.5/30 (norethin)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
junel fe tab 1/20 (norethin)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
junel fe 24 tab 1/20 (norethin)
T0
QL
HCR Rules for Coverage
kariva tab 28 day (desogestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
kelnor tab 1/35 (ethynodiol)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
kimidess tab (desogestrel-ethinyl)
T0
QL
HCR Rules for Coverage
kurvelo tab 0.15/30 (levonorgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
larin tab 1.5/30 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
larin tab 1/20 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
larin 24 tab fe 1/20 (norethin)
T0
QL
HCR Rules for Coverage
larin fe tab 1.5/30 (norethin)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
larin fe tab 1/20 (norethin)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
layolis fe chw (norethindrone)
T0
QL
HCR Rules for Coverage
leena tab (norethindrone-eth)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
lessina tab (levonorgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
levo-eth est tab 90-20mcg
T0
QL
HCR Rules for Coverage
levonest tab (levonorgestrel-eth)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
levonor/ethi tab 0.1-0.02
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
levonor/ethi tab estradio
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
levonorgestr tab 0.75mg
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
levonorgestr tab 1.5mg
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
levora-28 tab 0.15/30 (levonorgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
lomedia 24 tab fe (norethin)
T0
QL
HCR Rules for Coverage
loryna tab 3-0.02mg (drospirenone-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
low-ogestrel tab (norgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
lutera tab (levonorgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
lyza tab 0.35mg (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
marlissa tab 0.15/30 (levonorgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
microgestin tab 1.5/30 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
103
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
CONTRACEPTIVES
microgestin tab 1/20 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
microgestin tab fe 1/20 (norethin)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
microgestin tab fe1.5/30 (norethin)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
mono-linyah tab 0.25-35 (norgestimate-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
mononessa tab (norgestimate-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
my way tab 1.5mg (levonorgestrel)
T0
QL (91 tabs/90 days)
HCR Rules for Coverage
myzilra tab (levonorgestrel-eth)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
necon tab 0.5/35 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
necon tab 1/35 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
necon tab 1/50-28 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
necon tab 10/11-28 (norethindrone-eth)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
necon tab 7/7/7 (norethindrone-eth)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
next choice tab 1.5mg (levonorgestrel)
T0
QL (1 tab/fill, 3 fill per 365 days)
HCR Rules for Coverage
nikki tab 3-0.02mg (drospirenone-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
nora-be tab 0.35mg (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
noreth/ethin chw fe
T0
QL
HCR Rules for Coverage
noreth/ethin tab 1/20
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
noreth/ethin tab fe 1/20
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
norethindron tab 0.35mg
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
norgest/ethi tab 0.25/35
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
norgest/ethi tab estradio
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
norlyroc tab 0.35mg (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
nortrel tab 0.5/35 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
nortrel tab 1/35 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
nortrel tab 7/7/7 (norethindrone-eth)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
NUVARING MIS (etonogestrel-ethinyl)
T0
QL (1 per 28 days)
HCR Rules for Coverage
ocella tab 3-0.03mg (drospirenone-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
ogestrel tab (norgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
opcicon tab 1.5mg (levonorgestrel)
T0
QL
HCR Rules for Coverage
orsythia tab (levonorgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
philith tab 0.4-35 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
pimtrea tab (desogestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
104
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
CONTRACEPTIVES
pirmella tab 1/35 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
pirmella tab 7/7/7 (norethindrone-eth)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
portia-28 tab (levonorgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
previfem tab (norgestimate-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
quasense tab (levonorgestrel-ethinyl)
T0
QL (14 patch/14 days, 12
fills/365 days)
HCR Rules for Coverage
reclipsen tab (desogestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
setlakin tab (levonorgestrel-ethinyl)
T0
QL
HCR Rules for Coverage
sharobel tab 0.35mg (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
solia tab (desogestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
sprintec 28 tab 28 day (norgestimate-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
sronyx tab (levonorgestrel)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
syeda tab 3-0.03mg (drospirenone-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
take action tab 1.5mg (levonorgestrel)
T0
QL
HCR Rules for Coverage
tarina fe tab 1/20 (norethin)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
tilia fe tab (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
tri-estaryll tab (norgestimate-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
tri-legest tab fe (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
tri-linyah tab (norgestimate-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
trinessa tab (norgestimate-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
tri-previfem tab (norgestimate-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
tri-sprintec tab (norgestimate-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
trivora-28 tab (levonorgestrel-eth)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
velivet pak (desogestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
vestura tab 3-0.02mg (drospirenone-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
viorele tab (desogestrel-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
vyfemla tab 0.4-35 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
wera tab 0.5/35 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
wymzya fe chw 0.4mg-35 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
xulane dis 150-35 (norelgestromin-ethinyl)
T0
QL (3 patches/28 days)
HCR Rules for Coverage
zarah tab 3-0.03mg (drospirenone-ethinyl)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
zenchent tab (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
zenchent fe chw 0.4mg-35 (norethindrone)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
105
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
CONTRACEPTIVES
zovia 1/35e tab (ethynodiol)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
zovia 1/50e tab (ethynodiol)
T0
QL (28 tabs/28 days)
HCR Rules for Coverage
ESTROGENS AND ANTIESTROGENS
ESTROGEN AGONIST-ANTAGONISTS
clomiphene tab 50mg
T1
EVISTA TAB 60MG (raloxifene)
T3
raloxifene hcl tab 60 mg
T0
serophene tab 50mg (clomiphene)
T1
QL
CENESTIN TAB 0.3MG (estrogens,)
T3
QL (30 tabs/30 days)
CENESTIN TAB 0.45MG (estrogens,)
T3
QL (30 tabs/30 days)
CENESTIN TAB 0.625MG (estrogens,)
T3
QL (30 tabs/30 days)
CENESTIN TAB 0.9MG (estrogens,)
T3
QL (30 tabs/30 days)
CENESTIN TAB 1.25MG (estrogens,)
T3
QL (30 tabs/30 days)
CLIMARA PRO DIS WEEKLY (estradiollevonorgestrel)
T3
QL (4/30 days)
COMBIPATCH DIS .05/.14 (estradiol)
T3
QL (8 patches/28 days)
COMBIPATCH DIS .05/.25 (estradiol)
T3
QL (8 patches/28 days)
DIVIGEL GEL 0.25MG (estradiol)
T3
QL (1 bottle/30 days)
DIVIGEL GEL 0.5MG (estradiol)
T3
QL (1 bottle/30 days)
DIVIGEL GEL 1MG/GM (estradiol)
T3
QL (1 bottle/30 days)
ELESTRIN GEL 0.06% (estradiol)
T3
QL (1 bottle/30 days)
ENJUVIA TAB 0.3MG (estrogens,)
T3
QL (30 tabs/30 days)
ENJUVIA TAB 0.45MG (estrogens,)
T3
QL (30 tabs/30 days)
ENJUVIA TAB 0.625MG (estrogens,)
T3
QL (30 tabs/30 days)
ENJUVIA TAB 0.9MG (estrogens,)
T3
QL (30 tabs/30 days)
ENJUVIA TAB 1.25MG (estrogens,)
T3
QL (30 tabs/30 days)
estra/noreth tab 0.5-0.1
T1
estra/noreth tab 1-0.5mg
T1
ESTRACE VAG CRE 0.1MG/GM (estradiol)
T3
QL (1 tube = 42.5gm/fill)
estradiol dis 0.025mg
T1
QL
estradiol dis 0.0375mg
T1
QL
estradiol dis 0.05mg
T1
QL
QL
HCR Rules for Coverage
ESTROGENS
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
106
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
ESTROGENS AND ANTIESTROGENS
ESTROGENS
estradiol dis 0.06mg
T1
QL
estradiol dis 0.075mg
T1
QL
estradiol dis 0.1mg
T1
QL
estradiol tab 0.5mg
T1
estradiol tab 1mg
T1
estradiol tab 2mg
T1
ESTRASORB EMU (estradiol)
T3
ESTRING MIS 2MG (estradiol)
T3
QL (1 ring/90 days)
ESTROGEL GEL (estradiol)
T3
QL (1 bottle/30 days)
estropipate tab 0.75mg
T1
estropipate tab 1.5mg
T1
estropipate tab 3mg
T1
EVAMIST SPR 1.53MG (estradiol)
T3
QL (1 bottle/30 days)
FEMRING MIS 0.05/24H (estradiol)
T3
PA, QL (1 ring/90 days)
FEMRING MIS 0.1MG/24 (estradiol)
T3
PA, QL (1 ring/90 days)
jinteli tab 1mg-5mcg (norethindrone)
T1
lopreeza tab 0.5-0.1 (estradiol)
T1
lopreeza tab 1-0.5mg (estradiol)
T1
MENEST TAB 0.3MG (esterified)
T2
MENEST TAB 0.625MG (esterified)
T2
MENEST TAB 1.25MG (esterified)
T2
MENEST TAB 2.5MG (esterified)
T2
MENOSTAR DIS 14MCG (estradiol)
T3
mimvey tab 1-0.5mg (estradiol)
T1
mimvey lo tab 0.5-0.1 (estradiol)
T1
noreth/ethin tab 0.5-2.5
T1
noreth/ethin tab 1mg-5mcg
T1
ortho-est tab 0.625 (estropipate)
T1
ortho-est tab 1.25 (estropipate)
T1
PREFEST TAB (estradiol-norgestimate)
T3
PREMARIN TAB 0.3MG (estrogens,)
T2
QL (4 patches/28 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
107
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
ESTROGENS AND ANTIESTROGENS
ESTROGENS
PREMARIN TAB 0.45MG (estrogens,)
T2
PREMARIN TAB 0.625MG (estrogens,)
T2
PREMARIN TAB 0.9MG (estrogens,)
T2
PREMARIN TAB 1.25MG (estrogens,)
T2
PREMARIN VAG CRE 0.625MG (estrogens,)
T2
PREMPHASE TAB (conjugated)
T2
QL (30 tabs/30 days)
PREMPRO TAB .625-2.5 (conjugated)
T2
QL (30 tabs/30 days)
PREMPRO TAB 0.3-1.5 (conjugated)
T2
QL (30 tabs/30 days)
PREMPRO TAB 0.45-1.5 (conjugated)
T2
QL (30 tabs/30 days)
PREMPRO TAB 0.625-5 (conjugated)
T2
QL (30 tabs/30 days)
VAGIFEM TAB 10MCG (estradiol)
T2
GONADOTROPINS
chor gonadot inj 10000unt
T4
PA
GONAL-F RFF INJ 300 (follitropin)
T4
PA, SP
GONAL-F RFF INJ 300/0.5 (follitropin)
T4
PA, SP
GONAL-F RFF INJ 450 (follitropin)
T4
PA, SP
GONAL-F RFF INJ 450/0.75 (follitropin)
T4
PA, SP
GONAL-F RFF INJ 900 (follitropin)
T4
PA, SP
GONAL-F RFF INJ 900/1.5 (follitropin)
T4
PA, SP
MENOPUR INJ 75UNIT (menotropins)
T4
PA, SP
novarel inj 10000unt (chorionic)
T4
PA
OVIDREL INJ (choriogonadotropin)
T3
PA, QL
pregnyl inj 10000unt (chorionic)
T4
PA
SYNAREL SOL 2MG/ML (nafarelin)
T3
PARATHYROID
FORTEO SOL 600/2.4 (teriparatide)
T4
QL (1 pen/28 days), ST
(alendronate, ibandronate,
Prolia (medical benefit))
alendronate,
ibandronate, PROLIA
PITUITARY
desmopressin sol 0.01%
T1
desmopressin tab 0.1mg
T1
desmopressin tab 0.2mg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
108
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
PROGESTINS
CRINONE GEL 4% VAG (progesterone)
T2
CRINONE GEL 8% VAG (progesterone)
T2
DEPO-PROVERA INJ 400/ML
(medroxyprogesterone)
T3
ENDOMETRIN SUP 100MG (progesterone)
T3
medroxypr ac inj 150mg/ml
T0
medroxypr ac tab 10mg
T1
medroxypr ac tab 2.5mg
T1
medroxypr ac tab 5mg
T1
MEGACE ES SUS (megestrol)
T3
megestrol sus 625mg/5m
T1
norethin ace tab 5mg
T1
progesterone cap 100mg
T1
progesterone cap 200mg
T1
progesterone inj 50mg/ml
T1
QL
HCR Rules for Coverage
QL (175ml/30 days)
SOMATOSTATIN AGONISTS AND ANTAGONISTS
SOMATOSTATIN AGONISTS
SIGNIFOR INJ 0.3MG/ML (pasireotide)
T4
PA, SP
SIGNIFOR INJ 0.6MG/ML (pasireotide)
T4
PA, SP
SIGNIFOR INJ 0.9MG/ML (pasireotide)
T4
PA, SP
SOMATULINE INJ 90/0.3ML (lanreotide)
T3
PA, QL
SOMATOTROPIN AGONISTS AND ANTAGONISTS
SOMATOTROPIN AGONISTS
INCRELEX INJ 40MG/4ML (mecasermin)
T4
PA
NUTROPIN INJ 10MG (somatropin)
T4
PA, SP
NUTROPIN AQ INJ 10MG/2ML (somatropin)
T4
PA, SP
NUTROPIN AQ INJ 20MG/2ML (somatropin)
T4
PA
NUTROPIN AQ INJ NUSPIN 5 (somatropin)
T4
PA, SP
ZOMACTON INJ 10MG (somatropin)
T4
PA
SOMAVERT INJ 10MG (pegvisomant)
T3
PA
SOMAVERT INJ 15MG (pegvisomant)
T3
PA
SOMAVERT INJ 20MG (pegvisomant)
T3
PA
SOMATOTROPIN ANTAGONISTS
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
109
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
SOMATOTROPIN AGONISTS AND ANTAGONISTS
SOMATOTROPIN ANTAGONISTS
SOMAVERT INJ 25MG (pegvisomant)
T3
PA
SOMAVERT INJ 30MG (pegvisomant)
T3
PA
THYROID AND ANTITHYROID AGENTS
ANTITHYROID AGENTS
methimazole tab 10mg
T1
methimazole tab 5mg
T1
propylthiour tab 50mg
T1
THYROID AGENTS
armour thyro tab 120mg (thyroid)
T1
QL (30 tab / 30 days)
ARMOUR THYRO TAB 120MG (thyroid)
T2
QL (30 tab / 30 days)
ARMOUR THYRO TAB 15MG (thyroid)
T2
QL (30 tab / 30 days)
ARMOUR THYRO TAB 180MG (thyroid)
T2
QL (30 tab / 30 days)
armour thyro tab 180mg (thyroid)
T1
QL (30 tab / 30 days)
ARMOUR THYRO TAB 240MG (thyroid)
T2
QL (30 tab / 30 days)
ARMOUR THYRO TAB 300MG (thyroid)
T2
QL (30 tab / 30 days)
ARMOUR THYRO TAB 30MG (thyroid)
T2
QL
armour thyro tab 30mg (thyroid)
T1
QL
ARMOUR THYRO TAB 60MG (thyroid)
T2
QL
armour thyro tab 60mg (thyroid)
T1
QL
ARMOUR THYRO TAB 90MG (thyroid)
T2
QL
levothyroxin inj 100mcg
T1
QL
levothyroxin inj 200mcg
T1
QL
levothyroxin inj 500mcg
T1
QL
levothyroxin tab 100mcg
T1
QL
levothyroxin tab 112mcg
T1
QL
levothyroxin tab 125mcg
T1
QL
levothyroxin tab 137mcg
T1
QL
levothyroxin tab 150mcg
T1
QL
levothyroxin tab 175mcg
T1
QL
levothyroxin tab 200mcg
T1
QL
levothyroxin tab 25mcg
T1
QL
levothyroxin tab 300mcg
T1
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
110
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
THYROID AND ANTITHYROID AGENTS
THYROID AGENTS
levothyroxin tab 50mcg
T1
QL
levothyroxin tab 75mcg
T1
QL
levothyroxin tab 88mcg
T1
QL
levothyroxine tab 0.075mg (levothyroxine)
T1
QL
levoxyl tab 100mcg (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
levoxyl tab 112mcg (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
levoxyl tab 125mcg (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
levoxyl tab 137mcg (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
levoxyl tab 150mcg (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
levoxyl tab 175mcg (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
levoxyl tab 200mcg (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
levoxyl tab 25mcg (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
levoxyl tab 50mcg (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
levoxyl tab 75mcg (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
levoxyl tab 88mcg (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
liothyronine tab 25mcg
T1
liothyronine tab 50mcg
T1
liothyronine tab 5mcg
T1
nature-throi tab 130mg (thyroid)
T1
QL
nature-throi tab 16.25mg (thyroid)
T1
QL
nature-throi tab 195mg (thyroid)
T1
QL
nature-throi tab 32.5mg (thyroid)
T1
QL
nature-throi tab 65mg (thyroid)
T1
QL
np thyroid tab 30mg (thyroid)
T1
QL
np thyroid tab 60mg (thyroid)
T1
QL
np thyroid tab 90mg (thyroid)
T1
QL
SYNTHROID TAB 100MCG (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
SYNTHROID TAB 112MCG (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
SYNTHROID TAB 125MCG (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
SYNTHROID TAB 137MCG (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
SYNTHROID TAB 150MCG (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
111
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
THYROID AND ANTITHYROID AGENTS
THYROID AGENTS
SYNTHROID TAB 175MCG (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
SYNTHROID TAB 200MCG (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
SYNTHROID TAB 25MCG (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
SYNTHROID TAB 300MCG (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
SYNTHROID TAB 50MCG (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
SYNTHROID TAB 75MCG (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
SYNTHROID TAB 88MCG (levothyroxine)
T2
QL (30 tabs/30 days)
levothyroxine
THYROLAR-1 TAB 60MG (liotrix)
T2
THYROLAR-1/2 TAB 30MG (liotrix)
T2
THYROLAR-1/4 TAB 15MG (liotrix)
T2
THYROLAR-2 TAB 120MG (liotrix)
T2
THYROLAR-3 TAB 180MG (liotrix)
T2
TIROSINT CAP 100MCG (levothyroxine)
T2
QL
TIROSINT CAP 112MCG (levothyroxine)
T2
QL
TIROSINT CAP 125MCG (levothyroxine)
T2
QL
TIROSINT CAP 137MCG (levothyroxine)
T2
QL
TIROSINT CAP 13MCG (levothyroxine)
T2
QL
TIROSINT CAP 150MCG (levothyroxine)
T2
QL
TIROSINT CAP 25MCG (levothyroxine)
T2
QL
TIROSINT CAP 50MCG (levothyroxine)
T2
QL
TIROSINT CAP 75MCG (levothyroxine)
T2
QL
TIROSINT CAP 88MCG (levothyroxine)
T2
QL
unith direct tab 100mcg (levothyroxine)
T1
QL
unith direct tab 112mcg (levothyroxine)
T1
QL
unith direct tab 125mcg (levothyroxine)
T1
QL
unith direct tab 150mcg (levothyroxine)
T1
QL
unith direct tab 175mcg (levothyroxine)
T1
QL
unith direct tab 200mcg (levothyroxine)
T1
QL
unith direct tab 25mcg (levothyroxine)
T1
QL
unith direct tab 300mcg (levothyroxine)
T2
QL
unith direct tab 50mcg (levothyroxine)
T1
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
112
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
HORMONES AND SYNTHETIC SUBSTITUTES
THYROID AND ANTITHYROID AGENTS
THYROID AGENTS
unith direct tab 75mcg (levothyroxine)
T1
QL
unith direct tab 88mcg (levothyroxine)
T1
QL
unithroid tab 100mcg (levothyroxine)
T2
QL
unithroid tab 112mcg (levothyroxine)
T2
QL
unithroid tab 125mcg (levothyroxine)
T2
QL
unithroid tab 137mcg (levothyroxine)
T2
QL
unithroid tab 150mcg (levothyroxine)
T2
QL
unithroid tab 175mcg (levothyroxine)
T2
QL
unithroid tab 200mcg (levothyroxine)
T2
QL
unithroid tab 25mcg (levothyroxine)
T2
QL
unithroid tab 300mcg (levothyroxine)
T2
QL
unithroid tab 50mcg (levothyroxine)
T2
QL
unithroid tab 75mcg (levothyroxine)
T2
QL
unithroid tab 88mcg (levothyroxine)
T2
QL
westhroid tab 130mg (thyroid)
T2
QL
westhroid tab 32.5mg (thyroid)
T1
QL
westhroid tab 65mg (thyroid)
T1
QL
WP THYROID TAB 130MG (thyroid)
T2
QL
LOCAL ANESTHETICS (PARENTERAL)
chloroproc inj 2%
T1
chloroproc inj 3%
T1
tetracaine inj 1%
T1
MISCELLANEOUS THERAPEUTIC AGENTS
colchicine tab 0.6mg
T1
leucovor ca tab 15mg
T1
leucovor ca tab 25mg
T1
leucovor ca tab 5mg
T1
5-ALPHA-REDUCTASE INHIBITORS
Dutasteride 0.5MG
T1
finasteride tab 5mg
T1
QL (30 caps/30 days), ST
(finasteride)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
113
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
MISCELLANEOUS THERAPEUTIC AGENTS
ALCOHOL DETERRENTS
disulfiram tab 250mg
T1
disulfiram tab 500mg
T1
ANTIDOTES
leucovor ca tab 10mg
T1
ANTIGOUT AGENTS
allopurinol tab 100mg
T1
allopurinol tab 300mg
T1
colchicine cap 0.6mg
T1
BIOLOGIC RESPONSE MODIFIERS
ACTIMMUNE INJ 2MU/0.5 (interferon)
T4
PA, QL (3 vials / 30 days)
AUBAGIO TAB 14MG (teriflunomide)
T4
PA, SP
AUBAGIO TAB 7MG (teriflunomide)
T4
PA, SP
AVONEX KIT 30MCG (interferon)
T4
PA, SP
AVONEX PEN KIT 30MCG (interferon)
T4
PA
AVONEX PREFL KIT 30MCG (interferon)
T4
PA
BETASERON INJ 0.3MG (interferon)
T4
PA
COPAXONE INJ 20MG/ML (glatiramer)
T4
PA
EXTAVIA INJ 0.3MG (interferon)
T4
PA, SP
GILENYA CAP 0.5MG (fingolimod)
T4
PA, SP
glatopa inj 20mg/ml (glatiramer)
T4
PA
REBIF INJ 22/0.5 (interferon)
T4
PA
REBIF INJ 44/0.5 (interferon)
T4
PA
REBIF REBIDO INJ 22/0.5 (interferon)
T4
PA
REBIF REBIDO INJ 44/0.5 (interferon)
T4
PA
REBIF REBIDO INJ TITRATN (interferon)
T4
PA
REBIF TITRTN INJ PACK (interferon)
T4
PA
THALOMID CAP 100MG (thalidomide)
T4
PA, SP
THALOMID CAP 150MG (thalidomide)
T4
PA, SP
THALOMID CAP 200MG (thalidomide)
T4
PA, SP
THALOMID CAP 50MG (thalidomide)
T4
PA, SP
TYSABRI INJ 300/15ML (natalizumab)
MED
PA, SP, QL (15 ml (1 vial) every
23 days)
Medical coinsurance
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
114
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
MISCELLANEOUS THERAPEUTIC AGENTS
BONE RESORPTION INHIBITORS
ACTONEL TAB 35MG (risedronate)
T3
alendronate tab 10mg
T1
alendronate tab 35mg
T1
alendronate tab 40mg
T1
alendronate tab 5mg
T1
alendronate tab 70mg
T1
etidron disd tab 200mg
T1
etidron disd tab 400mg
T1
FOSAMAX + D TAB 70-2800 (alendronate)
T3
QL (4 tabs/28 days), ST
(alendronate, ibandronate)
FOSAMAX + D TAB 70-5600 (alendronate)
T3
QL (4 tabs/28 days), ST
(alendronate, ibandronate)
ibandronate tab 150mg
T1
QL (1 tab/28 days)
PROLIA SOL 60MG/ML (denosumab)
MED
PA, SP
risedronate tab 150mg
T1
QL (1 tab/28 days)
XGEVA INJ (denosumab)
MED
PA, SP
QL (4 tabs/28 days), ST
(alendronate, ibandronate)
alendronate
Medical coinsurance
Medical coinsurance
CARIOSTATIC AGENTS
sodium fluoride chew 0.25 mg
T0
HCR Rules for Coverage
sodium fluoride chew 0.5 mg
T0
HCR Rules for Coverage
sodium fluoride chew 1 mg
T0
HCR Rules for Coverage
sodium fluoride chew 1.1 mg
T0
HCR Rules for Coverage
sodium fluoride chew 2.2 mg
T0
HCR Rules for Coverage
sodium fluoride lozg 1 mg
T0
HCR Rules for Coverage
sodium fluoride soln 0.125 mg/drop
T0
HCR Rules for Coverage
sodium fluoride soln 0.25 mg/drop
T0
HCR Rules for Coverage
sodium fluoride soln 0.5 mg/ml
T0
HCR Rules for Coverage
sodium fluoride tab 0.5 mg
T0
HCR Rules for Coverage
sodium fluoride tab 1 mg
T0
HCR Rules for Coverage
COMPLEMENT INHIBITORS
BERINERT INJ 500UNIT (c1)
MED
PA, SP
Medical coinsurance
CINRYZE SOL 500 UNIT (c1)
MED
PA, SP
Medical coinsurance
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
115
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
MISCELLANEOUS THERAPEUTIC AGENTS
DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
ACTEMRA INJ 162/0.9 (tocilizumab)
T4
PA
ACTEMRA INJ 200/10ML (tocilizumab)
MED
PA, SP
Medical coinsurance
ACTEMRA INJ 400/20ML (tocilizumab)
MED
PA, SP
Medical coinsurance
ACTEMRA INJ 80MG/4ML (tocilizumab)
MED
PA, SP
Medical coinsurance
CIMZIA KIT (certolizumab)
T4
PA, SP
ENBREL, HUMIRA,
methotrexate
CIMZIA KIT STARTER (certolizumab)
T4
PA, SP
ENBREL, HUMIRA,
methotrexate
CIMZIA PREFL KIT 200MG/ML (certolizumab)
T4
PA, SP
ENBREL, HUMIRA,
methotrexate
ENBREL INJ 25/0.5ML (etanercept)
T4
PA, SP
ENBREL INJ 25MG (etanercept)
T4
PA, SP
ENBREL INJ 50MG/ML (etanercept)
T4
PA, SP
ENBREL SRCLK INJ 50MG/ML (etanercept)
T4
PA, SP
HUMIRA INJ 10MG/0.2 (adalimumab)
T4
PA, SP
HUMIRA INJ 40MG/0.8 (adalimumab)
T4
PA
HUMIRA KIT 20MG/0.4 (adalimumab)
T4
PA
HUMIRA PEDIA INJ CROHNS (adalimumab)
T4
PA
HUMIRA PEN INJ 40MG/0.8 (adalimumab)
T4
PA
HUMIRA PEN INJ CROHNS (adalimumab)
T4
PA
HUMIRA PEN INJ PSORIASI (adalimumab)
T4
PA
leflunomide tab 10mg
T1
leflunomide tab 20mg
T1
ORENCIA INJ 125MG/ML (abatacept)
T4
PA
OTEZLA TAB 10/20/30 (apremilast)
T4
PA, SP, QL (1 kit/ 365 days)
OTEZLA TAB 30MG (apremilast)
T4
PA, SP, QL (60 tab / 30 days)
REMICADE INJ 100MG (infliximab)
MED
PA, SP
SIMPONI INJ 100MG/ML (golimumab)
T4
PA
SIMPONI INJ 50/0.5ML (golimumab)
T4
PA, SP
SIMPONI ARIA SOL 50MG/4ML (golimumab)
T4
XELJANZ TAB 5MG (tofacitinib)
T4
Medical coinsurance
PA, SP
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
ENBREL,
leflunomide,
methotrexate
116
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
MISCELLANEOUS THERAPEUTIC AGENTS
GONADOTROPIN-RELEASING HORMONE ANTAGNTS
CETROTIDE KIT 0.25MG (cetrorelix)
T4
PA, SP
ganirelix ac inj
T4
PA
IMMUNOSUPPRESSIVE AGENTS
azathioprine tab 50mg
T1
BENLYSTA INJ 120MG (belimumab)
MED
PA, SP
Medical coinsurance
BENLYSTA INJ 400MG (belimumab)
MED
PA, SP
Medical coinsurance
cyclosporine cap 100mg
T1
cyclosporine cap 100mg md
T1
cyclosporine cap 25mg
T1
cyclosporine cap 25mg mod
T1
cyclosporine cap 50mg mod
T1
gengraf cap 100mg (cyclosporine)
T1
gengraf cap 25mg (cyclosporine)
T1
hecoria cap 0.5mg (tacrolimus)
T1
hecoria cap 1mg (tacrolimus)
T1
hecoria cap 5mg (tacrolimus)
T1
mycophenolat cap 250mg
T1
mycophenolat sus 200mg/ml
T1
mycophenolat tab 500mg
T1
mycophenolic tab 180mg dr
T1
mycophenolic tab 360mg dr
T1
RAPAMUNE SOL 1MG/ML (sirolimus)
T2
SANDIMMUNE SOL 100MG/ML (cyclosporine)
T3
sirolimus tab 0.5mg
T1
sirolimus tab 1mg
T1
sirolimus tab 2mg
T1
tacrolimus cap 0.5mg
T1
tacrolimus cap 1mg
T1
tacrolimus cap 5mg
T1
ZORTRESS TAB 0.25MG (everolimus)
T3
PA
ZORTRESS TAB 0.5MG (everolimus)
T3
PA
ZORTRESS TAB 0.75MG (everolimus)
T3
PA
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
117
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
MISCELLANEOUS THERAPEUTIC AGENTS
OTHER MISCELLANEOUS THERAPEUTIC AGENTS
AMPYRA TAB 10MG (dalfampridine)
T4
PA, SP
ARCALYST INJ 220MG (rilonacept)
T3
PA
CYSTAGON CAP 150MG (cysteamine)
T2
CYSTAGON CAP 50MG (cysteamine)
T2
ELMIRON CAP 100MG (pentosan)
T2
ORFADIN CAP 10MG (nitisinone)
T2
ORFADIN CAP 2MG (nitisinone)
T2
ORFADIN CAP 5MG (nitisinone)
T2
SENSIPAR TAB 30MG (cinacalcet)
T3
QL (360 tabs/30 days)
SENSIPAR TAB 60MG (cinacalcet)
T3
QL (180 tabs/30 days)
SENSIPAR TAB 90MG (cinacalcet)
T3
QL (120 tabs/30 days)
ESBRIET CAP 267MG (pirfenidone)
T4
PA
OFEV CAP 100MG (nintedanib)
T4
PA
OFEV CAP 150MG (nintedanib)
T4
PA
RESPIRATORY TRACT AGENTS
ANTIFIBROTIC AGENTS
ANTI-INFLAMMATORY AGENTS (RESPIRATORY)
LEUKOTRIENE MODIFIERS
montelukast chw 4mg
T1
montelukast chw 5mg
T1
montelukast gra 4mg
T1
montelukast tab 10mg
T1
zafirlukast tab 10mg
T1
zafirlukast tab 20mg
T1
ZYFLO CR TAB 600MG (zileuton)
T3
QL (120 tabs/30 days)
montelukast
MAST-CELL STABILIZERS
cromolyn sod con 100/5ml
T1
ANTITUSSIVES
benzonatate cap 100mg
T1
benzonatate cap 150mg
T1
benzonatate cap 200mg
T1
chlor/phen dro dm
T1
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
118
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
RESPIRATORY TRACT AGENTS
ANTITUSSIVES
dm/cpm/pe dro
T1
hyd pol/cpm liq 10-8/5ml
T1
nohist-dm liq (phenylephrine-chlorphen-dm)
T1
prometh/cod syp 6.25-10
T1
promethazine syp dm
T1
QL
CYSTIC FIBROSIS (CFTR) MODULATORS
CYSTIC FIBROSIS (CFTR) POTENTIATORS
KALYDECO TAB 150MG (ivacaftor)
T4
PA, SP
MUCOLYTIC AGENTS
pulmosal neb 7% (sodium)
T1
PULMOZYME SOL 1MG/ML (dornase)
T3
sodium chlor neb 7%
T1
PA
PHOSPHODIESTERASE TYPE 4 INHIBITORS
DALIRESP TAB 500MCG (roflumilast)
T3
PA, QL (30 tabs/30 days)
RESPIRATORY TRACT AGENTS, MISCELLANEOUS
XOLAIR SOL 150MG (omalizumab)
MED
PA, SP
Medical coinsurance
VASODILATING AGENTS (RESPIRATORY TRACT)
ADEMPAS TAB 0.5MG (riociguat)
T4
PA, QL (90 tabs/30 days)
ADEMPAS TAB 1.5MG (riociguat)
T4
PA, QL (90 tabs/30 days)
ADEMPAS TAB 1MG (riociguat)
T4
PA, QL (90 tabs/30 days)
ADEMPAS TAB 2.5MG (riociguat)
T4
PA, QL (90 tabs/30 days)
ADEMPAS TAB 2MG (riociguat)
T4
PA, QL (90 tabs/30 days)
LETAIRIS TAB 10MG (ambrisentan)
T4
PA, QL (30 tabs/30 days)
LETAIRIS TAB 5MG (ambrisentan)
T4
PA, QL (30 tabs/30 days)
OPSUMIT TAB 10MG (macitentan)
T4
PA, QL (30 tabs/30 days)
TRACLEER TAB 125MG (bosentan)
T4
PA, QL (60 tabs/30 days)
TRACLEER TAB 62.5MG (bosentan)
T4
PA, QL (60 tabs/30 days)
TYVASO SOL 0.6MG/ML (treprostinil)
T4
PA, QL (28 units / 30 days)
TYVASO REFIL SOL 0.6MG/ML (treprostinil)
T4
PA, QL (28 units / 30 days)
TYVASO START SOL 0.6MG/ML (treprostinil)
T4
PA, QL (28 units / 30 days)
VENTAVIS SOL 10MCG/ML (iloprost)
T4
PA, QL (270 ampules/ 30 days)
VENTAVIS SOL 20MCG/ML (iloprost)
T4
PA, QL (270 ampules/ 30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
119
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SERUMS, TOXOIDS, AND VACCINES
SERUMS
BIVIGAM INJ 10% (immune)
MED
PA, SP
Medical coinsurance
carimune nf inj 12gm (immune)
MED
PA, SP
Medical coinsurance
carimune nf inj 3gm (immune)
MED
PA, SP
Medical coinsurance
carimune nf inj 6gm (immune)
MED
PA, SP
Medical coinsurance
FLEBOGAMMA INJ 20/400ML (immune)
MED
PA, SP
Medical coinsurance
flebogamma 5% vial
MED
PA, SP
Medical coinsurance
gamastan s/d inj (immune)
MED
PA, SP
Medical coinsurance
gammagard inj 1gm/10ml (immune)
MED
PA, SP
Medical coinsurance
gammagard inj 2.5gm/25 (immune)
MED
PA, SP
Medical coinsurance
gammagard inj 20gm/200 (immune)
MED
PA, SP
Medical coinsurance
gammagard inj 5gm/50ml (immune)
MED
PA, SP
Medical coinsurance
GAMMAGARD S-D 10 G (IGA<1) SOL
MED
PA, SP
Medical coinsurance
gammagard s-d 2.5 gm vl w/st
MED
PA, SP
Medical coinsurance
GAMMAGARD S-D 5 G (IGA<1) SOLN
MED
PA, SP
Medical coinsurance
GAMMAKED INJ 10GM/100 (immune)
MED
PA, SP
Medical coinsurance
GAMMAKED INJ 1GM/10ML (immune)
MED
PA, SP
Medical coinsurance
GAMMAKED INJ 2.5GM/25 (immune)
MED
PA, SP
Medical coinsurance
GAMMAKED INJ 20GM/200 (immune)
MED
PA, SP
Medical coinsurance
GAMMAKED INJ 5GM/50ML (immune)
MED
PA, SP
Medical coinsurance
GAMMAPLEX INJ 10GM (immune)
MED
PA, SP
Medical coinsurance
GAMMAPLEX INJ 2.5GM (immune)
MED
PA, SP
Medical coinsurance
GAMMAPLEX INJ 5GM (immune)
MED
PA, SP
Medical coinsurance
GAMUNEX 10% VIAL (IMMUNE)
MED
PA, SP
Medical coinsurance
HIZENTRA INJ 1GM/5ML (immune)
MED
PA, SP
Medical coinsurance
HIZENTRA INJ 2GM/10ML (immune)
MED
PA, SP
Medical coinsurance
HIZENTRA INJ 4GM/20ML (immune)
MED
PA, SP
Medical coinsurance
OCTAGAM INJ 10GM (immune)
MED
PA, SP
Medical coinsurance
OCTAGAM INJ 1GM (immune)
MED
PA, SP
Medical coinsurance
OCTAGAM INJ 2.5GM (immune)
MED
PA, SP
Medical coinsurance
OCTAGAM INJ 25GM (immune)
MED
PA, SP
Medical coinsurance
OCTAGAM INJ 5GM (immune)
MED
PA, SP
Medical coinsurance
PRIVIGEN INJ 10GRAMS (immune)
MED
PA, SP
Medical coinsurance
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
120
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SERUMS, TOXOIDS, AND VACCINES
SERUMS
PRIVIGEN INJ 20GRAMS (immune)
MED
PA, SP
Medical coinsurance
PRIVIGEN INJ 5 GRAMS (immune)
MED
PA, SP
Medical coinsurance
VIVAGLOBIN SOL 160MG/ML (immune)
MED
PA, SP
Medical coinsurance
TOXOIDS
T0
HCR Rules for Coverage
AFLURIA INJ 2015-16 (influenza)
T0
HCR Rules for Coverage
AFLURIA INJ PF 12-13 (influenza)
T0
HCR Rules for Coverage
AFLURIA INJ PF 13-14 (influenza)
T0
HCR Rules for Coverage
AFLURIA INJ PF 14-15 (influenza)
T0
HCR Rules for Coverage
AFLURIA INJ PF 15-16 (influenza)
T0
HCR Rules for Coverage
BEXSERO INJ (meningococcal)
T2
EZ FLU SHOT INJ 2015-16 (influenza)
T0
HCR Rules for Coverage
FLUARIX PF INJ 2013-14 (influenza)
T0
HCR Rules for Coverage
FLUARIX PF INJ 2014-15 (influenza)
T0
HCR Rules for Coverage
FLUARIX QUAD INJ 2013-14 (influenza)
T0
HCR Rules for Coverage
FLUARIX QUAD INJ 2014-15 (influenza)
T0
HCR Rules for Coverage
FLUARIX QUAD INJ 2015-16 (influenza)
T0
HCR Rules for Coverage
FLUBLOK SOL 2013-14 (influenza)
T0
HCR Rules for Coverage
FLUBLOK SOL 2014-15 (influenza)
T0
HCR Rules for Coverage
FLUBLOK SOL 2015-16 (influenza)
T0
HCR Rules for Coverage
FLUCELVAX INJ 2013-14 (influenza)
T0
HCR Rules for Coverage
FLUCELVAX INJ 2014-15 (influenza)
T0
HCR Rules for Coverage
FLUCELVAX INJ 2015-16 (influenza)
T0
HCR Rules for Coverage
FLULAVAL INJ 2013-14 (influenza)
T0
HCR Rules for Coverage
FLULAVAL QUA INJ 2013-14 (influenza)
T0
HCR Rules for Coverage
FLULAVAL QUA INJ 2014-15 (influenza)
T0
HCR Rules for Coverage
FLULAVAL QUA INJ 2015-16 (influenza)
T0
HCR Rules for Coverage
FLUMIST QUAD SUS 2013-14 (influenza)
T0
HCR Rules for Coverage
FLUMIST QUAD SUS 2014-15 (influenza)
T0
HCR Rules for Coverage
FLUMIST QUAD SUS 2015-16 (influenza)
T0
HCR Rules for Coverage
FLUVIRIN INJ 2013-14 (influenza)
T0
HCR Rules for Coverage
tetanus-diphtheria toxoids (td) suspension
VACCINES
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
121
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SERUMS, TOXOIDS, AND VACCINES
VACCINES
FLUVIRIN INJ 2015-16 (influenza)
T0
HCR Rules for Coverage
FLUVIRIN INJ PF 13-14 (influenza)
T0
HCR Rules for Coverage
FLUVIRIN PF INJ 2014-15 (influenza)
T0
HCR Rules for Coverage
FLUZONE INJ INTRADRM (influenza)
T0
HCR Rules for Coverage
FLUZONE INJ PF 13-14 (influenza)
T0
HCR Rules for Coverage
FLUZONE INJ PF 14-15 (influenza)
T0
HCR Rules for Coverage
FLUZONE HD INJ PF 13-14 (influenza)
T0
HCR Rules for Coverage
FLUZONE HD INJ PF 14-15 (influenza)
T0
HCR Rules for Coverage
FLUZONE HD INJ PF 15-16 (influenza)
T0
HCR Rules for Coverage
FLUZONE PED/ INJ PF 13-14 (influenza)
T0
HCR Rules for Coverage
FLUZONE QUAD INJ 13-14 (influenza)
T0
HCR Rules for Coverage
FLUZONE QUAD INJ 14-15 (influenza)
T0
HCR Rules for Coverage
FLUZONE QUAD INJ 15-16 (influenza)
T0
HCR Rules for Coverage
FLUZONE QUAD INJ 2015-16 (influenza)
T0
HCR Rules for Coverage
FLUZONE QUAD INJ 9MCG (influenza)
T0
HCR Rules for Coverage
FLUZONE SPLT INJ 2015-16 (influenza)
T0
HCR Rules for Coverage
GARDASIL 9 INJ (human)
T2
INFLUENZA FIRUS VACCINE (INFLUENZA)
T0
MENHIBRIX INJ (meningococcal)
T2
TRUMENBA INJ (meningococcal)
T2
HCR Rules for Coverage
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)
ALTABAX OIN 1% (retapamulin)
T3
BACTROBAN OIN NASAL 2% (mupirocin)
T2
clindacin mis etz 1% (clindamycin)
T1
clindacin-p pad 1% (clindamycin)
T1
clindamax gel 1% (clindamycin)
T1
clindamax lot 10mg/ml (clindamycin)
T1
clindamy/ben gel 1.2-5%
T1
clindamy/ben gel 1-5%
T1
clindamycin cre 2% vag
T1
QL (1 tube/fill)
clindamycin,
erythromycin
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
122
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)
clindamycin gel 1%
T1
clindamycin lot 1%
T1
clindamycin lot 10mg/ml
T1
clindamycin pad 1%
T1
clindamycin sol 1%
T1
ery pad 2% (erythromycin)
T1
erythromycin gel /benzoyl
T1
erythromycin gel 2%
T1
erythromycin pad 2%
T1
erythromycin sol 2%
T1
gentamicin cre 0.1%
T1
gentamicin oin 0.1%
T1
metronidazol cre 0.75%
T1
metronidazol gel 0.75%vag
T1
metronidazol lot 0.75%
T1
mupirocin cre 2%
T1
mupirocin oin 2%
T1
mupirocin ca cre 2%
T1
QL
neuac gel 1.2-5% (clindamycin)
T1
QL
rosadan cre 0.75% (metronidazole)
T1
sulfacetamid lot 10%
T1
sulfacetamid sus 10%
T1
vandazole gel 0.75% (metronidazole)
T1
QL
ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)
ciclodan cre 0.77% (ciclopirox)
T1
ciclodan sol 8% (ciclopirox)
T1
ciclopirox cre 0.77%
T1
ciclopirox gel 0.77%
T1
ciclopirox sha 1%
T1
ciclopirox sol 8%
T1
ciclopirox sus 0.77%
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
123
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)
clotrim/beta cre 1-0.05%
T1
QL (60 gram tube/fill)
clotrim/beta cre diprop
T1
QL (60 gram tube/fill)
clotrim/beta lot diprop
T1
clotrimazole cre 1% (clotrimazole)
T1
clotrimazole loz 10mg
T1
clotrimazole tro 10mg
T1
econazole cre 1%
T1
ERTACZO CRE 2% (sertaconazole)
T3
QL (60 gm/fill)
EXELDERM SOL 1% (sulconazole)
T3
QL (30 gram tube/fill)
ketoconazole aer 2%
T1
ketoconazole cre 2%
T1
ketoconazole sha 2%
T1
ketodan aer 2% (ketoconazole)
T1
MENTAX CRE 1% (butenafine)
T3
nyamyc pow 100000 (nystatin)
T1
nystatin cre 100000
T1
nystatin oin 100000
T1
nystatin pow 100000
T1
nystop pow 100000 (nystatin)
T1
OXISTAT CRE 1% (oxiconazole)
QL
ciclopirox,
econazole,
ketoconazole,
nystatin
QL (30 gram tube/fill)
ciclopirox, nystatin
T3
QL (60 gm/fill)
ciclopirox, nystatin
OXISTAT LOT 1% (oxiconazole)
T3
QL (60 gm/fill)
ciclopirox, nystatin
pedi-dri pow 100000 (nystatin)
T1
terconazole cre 0.4%
T1
QL
terconazole cre 0.8%
T1
QL
terconazole sup 80mg
T1
zazole cre 0.4% (terconazole)
T1
QL
zazole cre 0.8% (terconazole)
T1
QL
zazole sup 80mg (terconazole)
T1
ANTIVIRALS (SKIN & MUCOUS MEMBRANE)
acyclovir oin 5%
T1
QL (60gm/30 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
124
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
ANTIVIRALS (SKIN & MUCOUS MEMBRANE)
DENAVIR CRE 1% (penciclovir)
T3
QL (5gram / fill)
acyclovir
LOCAL ANTI-INFECTIVES, MISCELLANEOUS
acne medicat gel 10% (benzoyl)
T1
QL
acne medicat gel 5% (benzoyl)
T1
QL
acne pimple gel 10% (benzoyl)
T1
QL
acne treatmn gel 10% (benzoyl)
T1
QL
acne-clear gel 10% (benzoyl)
T1
QL
benzepro aer 5.3% (benzoyl)
T1
benzepro liq creamy (benzoyl)
T1
benzepro sc aer 9.8% (benzoyl)
T1
benziq wash liq 5.25% (benzoyl)
T1
benzoyl per aer 5.3%
T1
benzoyl per aer 9.8%
T1
benzoyl per gel 10% (benzoyl)
T1
QL
benzoyl per gel 5% (benzoyl)
T1
QL
benzoyl per liq 10% wash (benzoyl)
T1
benzoyl pero aer 9.8%
T1
benzoyl pero kit acne pck (benzoyl)
T1
bp foam aer 5.3% (benzoyl)
T1
bp foam aer 9.8% (benzoyl)
T1
bp foaming liq wash 10% (benzoyl)
T1
bp gel gel 10% (benzoyl)
T1
QL
bp gel gel 5% (benzoyl)
T1
QL
bp wash liq 2.5% (benzoyl)
T1
bp wash liq 7% (benzoyl)
T1
bpo gel 4% (benzoyl)
T1
bpo gel 8% (benzoyl)
T1
bpo creamy kit 4% wash (benzoyl)
T1
bpo creamy kit 8% wash (benzoyl)
T1
clearplex v gel 5% (benzoyl)
T1
QL
clearplex x gel 10% (benzoyl)
T1
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
125
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
LOCAL ANTI-INFECTIVES, MISCELLANEOUS
persa-gel gel 10% (benzoyl)
T1
QL
persa-gel xs gel 5% (benzoyl)
T1
QL
pr benzoyl liq 7% wash (benzoyl)
T1
ra renewal gel 10% (benzoyl)
T1
se bpo wash liq 7% (benzoyl)
T1
selenium sul lot 2.5%
T1
selenium sul sha 2.25%
T1
selenium sul sha 2.5%
T1
silver sulfa cre 1%
T1
ssd cre 1% (silver)
T1
thermazene cre 1% (silver)
T1
QL
SCABICIDES AND PEDICULICIDES
acticin cre 5% (permethrin)
T1
EURAX CRE 10% (crotamiton)
T2
EURAX LOT 10% (crotamiton)
T2
lindane lot 1%
T1
lindane sha 1%
T1
malathion lot 0.5%
T1
permethrin cre 5%
T1
SKLICE LOT 0.5% (ivermectin)
T3
ULESFIA LOT 5% (benzyl)
T3
QL (454 ml/30 days)
QL (227 ml/30 days)
ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
ala cort cre 1% (hydrocortisone)
T1
alclometason cre 0.05%
T1
alclometason oin 0.05%
T1
alphatrex gel 0.05% (betamethasone)
T1
amcinonide cre 0.1%
T1
amcinonide lot 0.1%
T1
amcinonide oin 0.1%
T1
anucort-hc sup 25mg (hydrocortisone)
T1
QL
APEXICON E CRE 0.05% (diflorasone)
T2
QL (30 gm/fill)
QL (60 gram tube/fill)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
126
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
aug betamet cre 0.05%
T1
QL (60 gram tube/fill)
aug betamet gel 0.05%
T1
QL (60 gram tube/fill)
aug betamet lot 0.05%
T1
QL (60 gram tube/fill)
aug betamet oin 0.05%
T1
QL (60 gram tube/fill)
beta diprop gel 0.05%
T1
betameth dip cre 0.05%
T1
QL (60 gram tube/fill)
betameth dip lot 0.05%
T1
QL (60 gram tube/fill)
betameth dip oin 0.05%
T1
QL (60 gram tube/fill)
betameth val cre 0.1%
T1
QL (60 gram tube/fill)
betameth val lot 0.1%
T1
PA, QL (60 gram tube/fill)
betameth val oin 0.1%
T1
PA, QL (60 gram tube/fill)
CAPEX SHA 0.01% (fluocinolone)
T3
clobetasol aer 0.05%
T1
QL (60gram/30 days)
clobetasol cre 0.05%
T1
QL (60gram/30 days)
clobetasol gel 0.05%
T1
QL (60gram/30 days)
clobetasol lot 0.05%
T1
QL (60gram/30 days)
clobetasol oin 0.05%
T1
QL (60gram/30 days)
clobetasol sha 0.05%
T1
QL (60gram/30 days)
clobetasol sol 0.05%
T1
QL (60gram/30 days)
clobetasol e cre 0.05% (clobetasol)
T1
QL
clodan sha 0.05% (clobetasol)
T1
QL (60gram/30 days)
CLODERM CRE 0.1% (clocortolone)
T3
QL (45gm/fill)
betamethasone
CLODERM CRE 0.1% PMP (clocortolone)
T3
QL
betamethasone
CORDRAN CRE 0.05% (flurandrenolide)
T3
QL (30 grams/fill)
betamethasone
cormax scalp sol 0.05% (clobetasol)
T1
QL (60gram/30 days)
CORTISPORIN CRE 0.5% (neomycin-polymyxin-hc)
T3
PA
DESONATE GEL 0.05% (desonide)
T2
QL (60gm/fill)
desonide cre 0.05%
T1
desonide lot 0.05%
T1
desonide oin 0.05%
T1
diflorasone cre 0.05%
T1
QL (30 gram tube /fill)
diflorasone oin 0.05%
T1
QL (30 gram tube /fill)
JANUVIA
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
desonide
127
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
fluocin acet cre 0.01%
T1
fluocin acet oil 0.01% sc (fluocinolone)
T1
fluocin acet oil body (fluocinolone)
T1
fluocin acet oil scalp (fluocinolone)
T1
fluocin acet sol 0.01%
T1
fluocinonide cre 0.05%
T1
fluocinonide cre 0.1%
T1
fluocinonide gel 0.05%
T1
fluocinonide oin 0.05%
T1
fluocinonide sol 0.05%
T1
fluticasone cre 0.05%
T1
fluticasone lot 0.05%
T1
fluticasone oin 0.005%
T1
grx hicort sup 25mg (hydrocortisone)
T1
halobetasol cre 0.05%
T1
halobetasol oin 0.05%
T1
HALOG CRE 0.1% (halcinonide)
T3
hc butyrate cre 0.1%
T1
hc = hydrocortisone
hc butyrate oin 0.1%
T1
hc = hydrocortisone
hc butyrate sol 0.1%
T1
hc = hydrocortisone
hc pramoxine cre 1-2.5%
T1
QL
hc = hydrocortisone
hc pramoxine cre 2.5-1%
T1
QL
hc = hydrocortisone
hc valerate cre 0.2%
T1
hc = hydrocortisone
hc valerate oin 0.2%
T1
hc = hydrocortisone
hemorrhoidal sup -hc 25mg (hydrocortisone)
T1
hydrocort cre 1% (hydrocortisone)
T1
hydrocort cre 2.5%
T1
hydrocort lot 2.5%
T1
hydrocort oin 1%
T1
hydrocort oin 2.5%
T1
hydrocort ac sup 25mg
T1
hydrocort/ab oin 1%
T1
PA
QL
QL (30 grams/fill)
betamethasone,
clobetasol
QL
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
128
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
hydrocortiso cre 2.5%
T1
KENALOG AER SPRAY (triamcinolone)
T3
locoid cre 0.1% (hydrocortisone)
T1
lokara lot 0.05% (desonide)
T1
mometasone cre 0.1%
T1
mometasone oin 0.1%
T1
mometasone sol 0.1%
T1
nystat/triam cre
T1
nystat/triam oin
T1
oralone pst 0.1% (triamcinolone)
T1
prednicarbat cre 0.1%
T1
proctocare cre -hc 2.5% (hydrocortisone)
T1
QL
procto-pak cre 1% (hydrocortisone)
T1
QL
proctosol hc cre 2.5% (hydrocortisone)
T1
QL
proctozone cre -hc 2.5% (hydrocortisone)
T1
QL
proctozone cre -hc 2.5% (hydrocortisone)
T1
rectacort-hc sup 25mg (hydrocortisone)
T1
scalacort lot 2% (hydrocortisone)
T1
triamcin/ora pst 0.1%
T1
triamcinolon aer spray
T1
triamcinolon cre 0.025%
T1
triamcinolon cre 0.1%
T1
triamcinolon cre 0.5%
T1
triamcinolon lot 0.025%
T1
triamcinolon lot 0.1%
T1
triamcinolon oin 0.025%
T1
triamcinolon oin 0.1%
T1
triamcinolon oin 0.5%
T1
triamcinolon pst 0.1%
T1
triderm cre 0.1% (triamcinolone)
T1
QL
QL
QL
QL
ANTIPRURITICS AND LOCAL ANESTHETICS
anecream cre 4% (lidocaine)
T1
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
129
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SKIN AND MUCOUS MEMBRANE AGENTS
ANTIPRURITICS AND LOCAL ANESTHETICS
aspercreme cre lidocain (lidocaine)
T1
QL
azo dine tab 95mg (phenazopyridine)
T1
QL
azo dine tab max st (phenazopyridine)
T1
QL
azo pain rel tab 95mg (phenazopyridine)
T1
QL
azo tabs tab 95mg (phenazopyridine)
T1
QL
azo urinary tab 97.5mg (phenazopyridine)
T1
QL
azo urinary tab 97.5mg (phenazopyridine)
T1
azo-standard tab 95mg (phenazopyridine)
T1
glydo gel 2% (lidocaine)
T1
lc-4 lidocne cre 4% (lidocaine)
T1
lido/prilocn cre 2.5-2.5%
T1
lido/prilocn kit 2.5-2.5%
T1
lidocaine cre 3%
T1
QL
lidocaine cre 4%
T1
QL
lidocaine gel 2%
T1
lidocaine gel 2% jelly
T1
lidocaine oin 5%
T1
lidocaine sol 4%
T1
lidocream cre 4% (lidocaine)
T1
QL
lidopin cre 3% (lidocaine)
T1
QL
livixil pak kit 2.5-2.5% (lidocaine-prilocaine)
T1
lp lite pak kit 2.5-2.5% (lidocaine-prilocaine)
T1
phenazo tab 200mg (phenazopyridine)
T1
QL
phenazo tab 95mg (phenazopyridine)
T1
QL
phenazopyrid tab 100mg
T1
QL
phenazopyrid tab 200mg
T1
QL
phenazopyrid tab 95mg
T1
QL
phenazoyrid tab 95mg
T1
QL
PROZENA PAD 4% (lidocaine)
T3
qc azo tab 95mg (phenazopyridine)
T1
QL
ra urinary tab 95mg (phenazopyridine)
T1
QL
ra urinary tab pain max (phenazopyridine)
T1
QL
QL
QL
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
130
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SKIN AND MUCOUS MEMBRANE AGENTS
ANTIPRURITICS AND LOCAL ANESTHETICS
relador pak kit 2.5-2.5% (lidocaine-prilocaine)
T1
relador pak kit plus (lidocaine-prilocaine)
T1
sb urinary tab pain max (phenazopyridine)
T1
QL
sm urinary tab pain max (phenazopyridine)
T1
QL
urinary pain tab 95mg (phenazopyridine)
T1
QL
urinary pain tab 97.5mg (phenazopyridine)
T1
QL
uti relief tab 97.2mg (phenazopyridine)
T1
QL
ASTRINGENTS
hypercare sol 20% (aluminum)
T1
CELL STIMULANTS AND PROLIFERANTS
avita cre 0.025% (tretinoin)
T1
QL (45 gm/30 days)
avita gel 0.025% (tretinoin)
T1
QL (45 gm/30 days)
tretinoin cre 0.025%
T1
QL (45 gm/30 days)
tretinoin cre 0.05%
T1
QL (45 gm/30 days)
tretinoin cre 0.1%
T1
QL (45 gm/30 days)
tretinoin gel 0.01%
T1
QL (45 gm/30 days)
tretinoin gel 0.025%
T1
QL (45 gm/30 days)
tretinoin gel 0.05%
T1
DEPIGMENTING AND PIGMENTING AGENTS
PIGMENTING AGENTS
OXSORALEN LOT 1% (methoxsalen)
T2
EMOLLIENTS, DEMULCENTS, AND PROTECTANTS
BASIC LOTIONS AND LINIMENTS
ammonium lac cre 12%
T1
ammonium lac lot 12%
T1
laclotion lot 12% (lactic)
T1
lactic acid lot 10%
T1
KERATOLYTIC AGENTS
avar cleanse emu 10-5% (sulfacetamide)
T1
QL
bp 10-1 emu (sulfacetamide)
T1
QL
cerisa wash emu 10-1% (sulfacetamide)
T1
QL
prascion emu (sulfacetamide)
T1
QL
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
131
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SKIN AND MUCOUS MEMBRANE AGENTS
KERATOLYTIC AGENTS
rosanil emu cleanser (sulfacetamide)
T1
QL
sod sul/sulf emu 10-5%
T1
QL
urea cre 47%
T1
SKIN AND MUCOUS MEMBRANE AGENTS, MISC.
ACZONE GEL 5% (dapsone)
T3
PA, QL (30gram /30 days)
adapalene cre 0.1%
T1
QL (45 gram/ 30 days)
adapalene gel 0.1%
T1
QL (45 gram/ 30 days)
adapalene gel 0.3%
T1
QL
AMEVIVE 15 MG VIAL (ALEFACEPT)
MED
PA, SP
calcipotrien cre 0.005%
T1
QL (60gm tube/ 30 days)
calcipotrien oin 0.005%
T1
QL (60gm/30 days)
calcipotrien sol 0.005%
T1
calcitrene oin 0.005% (calcipotriene)
T1
calcitriol oin 3mcg/gm
T1
claravis cap 10mg (isotretinoin)
T1
PA
claravis cap 20mg (isotretinoin)
T1
PA
claravis cap 30mg (isotretinoin)
T1
PA
claravis cap 40mg (isotretinoin)
T1
PA
ELIDEL CRE 1% (pimecrolimus)
T3
QL (30gm/30 days)
EPIDUO FORTE GEL 0.3-2.5% (adapalene-benzoyl)
T3
fluorouracil cre 0.5%
T1
fluorouracil cre 5%
T1
fluorouracil dro 2%
T1
fluorouracil dro 5%
T1
fluorouracil sol 2%
T1
fluorouracil sol 5%
T1
imiquimod cre 5%
T1
minocycline tab 135mg er
T1
minocycline tab 45mg er
T1
minocycline tab 90mg er
T1
MIRVASO GEL 0.33% (brimonidine)
T3
clindamycin,
erythromycin
Medical coinsurance
QL (60gm/30 days)
PA
PA
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
132
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS, MISC.
PICATO GEL 0.015% (ingenol)
T3
fluorouracil
PICATO GEL 0.05% (ingenol)
T3
fluorouracil
podofilox sol 0.5%
T1
RECTIV OIN 0.4% (nitroglycerin)
T3
REGRANEX GEL 0.01% (becaplermin)
T3
SANTYL OIN 250/GM (collagenase)
T2
STELARA INJ 45MG/0.5 (ustekinumab)
MED
PA, SP
tacrolimus oin 0.03%
T1
PA
tacrolimus oin 0.1%
T1
PA
TAZORAC CRE 0.05% (tazarotene)
T3
PA
calcipotriene
TAZORAC CRE 0.1% (tazarotene)
T3
PA
calcipotriene
TAZORAC GEL 0.05% (tazarotene)
T3
PA
calcipotriene
TAZORAC GEL 0.1% (tazarotene)
T3
PA
calcipotriene
VEREGEN OIN 15% (sinecatechins)
T3
PA, QL (15gm/fill)
VOLTAREN GEL 1% (diclofenac)
T3
QL (400gm/28 days)
PA, QL
Medical coinsurance
SMOOTH MUSCLE RELAXANTS
GENITOURINARY SMOOTH MUSCLE RELAXANTS
ANTIMUSCARINICS
ENABLEX TAB 15MG (darifenacin)
T3
PA
ENABLEX TAB 7.5MG (darifenacin)
T3
PA
flavoxate tab 100mg
T1
oxybutynin syp 5mg/5ml
T1
oxybutynin tab 10mg er
T1
QL
oxybutynin tab 15mg er
T1
QL
oxybutynin tab 5mg
T1
QL (90 tabs/30 days)
oxybutynin tab 5mg er
T1
QL
tolterodine cap 2mg er
T1
QL (30 caps/30 days)
tolterodine cap 4mg er
T1
QL (30 caps/30 days)
tolterodine tab 1mg
T1
tolterodine tab 2mg
T1
TOVIAZ TAB 4MG (fesoterodine)
T3
PA
TOVIAZ TAB 8MG (fesoterodine)
T3
PA
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
133
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
SMOOTH MUSCLE RELAXANTS
GENITOURINARY SMOOTH MUSCLE RELAXANTS
ANTIMUSCARINICS
VESICARE TAB 10MG (solifenacin)
T3
QL (( 30 tabs/ 30 days)), ST
VESICARE TAB 5MG (solifenacin)
T3
QL (( 30 tabs/ 30 days)), ST
MYRBETRIQ TAB 25MG (mirabegron)
T3
QL (30 tabs/30 days), ST
(Oxybutynin ER, tolterodine)
oxybutynin,
tolterodine
MYRBETRIQ TAB 50MG (mirabegron)
T3
QL (30 tabs/30 days), ST
(Oxybutynin ER, tolterodine)
oxybutynin,
tolterodine
BETA-3-ADRENERGIC AGONISTS
RESPIRATORY SMOOTH MUSCLE RELAXANTS
aminophyllin inj 25mg/ml
T1
THEO-24 CAP 100MG CR (theophylline)
T3
THEO-24 CAP 200MG CR (theophylline)
T3
THEO-24 CAP 300MG CR (theophylline)
T3
THEO-24 CAP 400MG ER (theophylline)
T3
theochron tab 100mg cr (theophylline)
T1
theochron tab 200mg cr (theophylline)
T1
theochron tab 300mg cr (theophylline)
T1
theophylline elx 80/15ml
T1
theophylline tab 100mg cr (theophylline)
T1
theophylline tab 100mg er
T1
theophylline tab 200mg cr
T1
theophylline tab 200mg er
T1
theophylline tab 200mg sr
T1
theophylline tab 300mg cr
T1
theophylline tab 300mg er
T1
theophylline tab 300mg sr
T1
theophylline tab 400mg er
T1
theophylline tab 450mg er (theophylline)
T1
theophylline tab 600mg er
T1
VITAMINS
MULTIVITAMIN PREPARATIONS
prenatal multivit-min w/fe-fa tab
T0
HCR Rules for Coverage
prenatal vit w/ ferrous fumarate-folic acid cap
T0
HCR Rules for Coverage
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
134
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
VITAMINS
MULTIVITAMIN PREPARATIONS
prenatal vit w/ ferrous fumarate-folic acid tab
T0
HCR Rules for Coverage
prenatal vit w/ ferrous gluconate-folic acid tab
T0
HCR Rules for Coverage
VITAMIN B COMPLEX
folic acid tab 1mg
T1
folic acid tab 400 mcg
T0
HCR Rules for Coverage
folic acid tab 800 mcg
T0
HCR Rules for Coverage
QL (30 tabs/ 30 days)
VITAMIN D
calcitriol cap 0.25mcg
T1
calcitriol cap 0.5mcg
T1
cholecalciferol cap 1000 unit
T0
HCR Rules for Coverage
cholecalciferol cap 10000 unit
T0
HCR Rules for Coverage
cholecalciferol cap 2000 unit
T0
HCR Rules for Coverage
cholecalciferol cap 400 unit
T0
HCR Rules for Coverage
cholecalciferol cap 5000 unit
T0
HCR Rules for Coverage
cholecalciferol cap 50000 unit
T0
HCR Rules for Coverage
cholecalciferol chew 1000 unit
T0
HCR Rules for Coverage
cholecalciferol chew 2000 unit
T0
HCR Rules for Coverage
cholecalciferol chew 400 unit
T0
HCR Rules for Coverage
cholecalciferol chew 5000 unit
T0
HCR Rules for Coverage
cholecalciferol liqd 1000 unit/spray
T0
HCR Rules for Coverage
cholecalciferol liqd 1200 unit/15ml
T0
HCR Rules for Coverage
cholecalciferol liqd 2000 unt/0.03ml
T0
HCR Rules for Coverage
cholecalciferol liqd 400 unit/ml
T0
HCR Rules for Coverage
cholecalciferol liqd 400 unt/0.03ml
T0
HCR Rules for Coverage
cholecalciferol liqd 5000 unit/ml
T0
HCR Rules for Coverage
cholecalciferol tab 1000 unit
T0
HCR Rules for Coverage
cholecalciferol tab 3000 unit
T0
HCR Rules for Coverage
cholecalciferol tab 400 unit
T0
HCR Rules for Coverage
cholecalciferol tab 5000 unit
T0
HCR Rules for Coverage
doxercalcif cap 0.5mcg
T1
doxercalcif cap 1mcg
T1
doxercalcif cap 2.5mcg
T1
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
135
Drug Name
Tier
Requirements/
Limits
Comments
Alternatives
VITAMINS
VITAMIN D
ergocalcifer cap 50000unt
T1
QL (30 caps/ 30 days)
paricalcitol cap 1 mcg
T1
QL (60 caps/30 days)
paricalcitol cap 2 mcg
T1
paricalcitol cap 4 mcg
T1
vitamin d cap 50000unt
T1
QL (28 tabs/28 days)
Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit
(SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112
HCR = Health Care Reform
136
Index
Drug Name
Page #
Drug Name
a/b sol otic
abacav/lamiv tab /zidovud
abacavir tab 300mg
ABILIFY INJ 9.75MG
ABILIFY SOL 1MG/ML
ABILIFY TAB 10MG
ABILIFY TAB 15MG
ABILIFY TAB 20MG
ABILIFY TAB 2MG
ABILIFY TAB 30MG
ABILIFY TAB 5MG
acampro cal tab 333mg
acarbose tab 100mg
acarbose tab 25mg
acarbose tab 50mg
acebutolol cap 200mg
acebutolol cap 400mg
acetasol hc sol otic
acetazolamid cap 500mg er
acetazolamid tab 125mg
acetazolamid tab 250mg
acetic acid sol 2% otic
acne medicat gel 10%
acne medicat gel 5%
acne pimple gel 10%
acne treatmn gel 10%
acne-clear gel 10%
ACTEMRA INJ 162/0.9
ACTEMRA INJ 200/10ML
ACTEMRA INJ 400/20ML
ACTEMRA INJ 80MG/4ML
acticin cre 5%
ACTIMMUNE INJ 2MU/0.5
ACTONEL TAB 35MG
ACUVAIL SOL 0.45%
acyclovir cap 200mg
acyclovir oin 5%
acyclovir sus 200/5ml
acyclovir tab 400mg
acyclovir tab 800mg
ACZONE GEL 5%
adapalene cre 0.1%
adapalene gel 0.1%
adapalene gel 0.3%
89
9
9
75
75
75
75
75
75
75
75
69
97
97
97
33
34
87
85
85
41
88
125
125
125
125
125
116
116
116
116
126
114
115
88
13
124
13
13
13
132
132
132
132
ADCIRCA TAB 20MG
adefov dipiv tab 10mg
ADEMPAS TAB 0.5MG
ADEMPAS TAB 1.5MG
ADEMPAS TAB 1MG
ADEMPAS TAB 2.5MG
ADEMPAS TAB 2MG
ADVAIR DISKU AER 100/50
ADVAIR DISKU AER 250/50
ADVAIR DISKU AER 500/50
ADVAIR HFA AER 115/21
ADVAIR HFA AER 230/21
ADVAIR HFA AER 45/21
ADVATE INJ 1000UNIT
ADVATE INJ 1500UNIT
ADVATE INJ 2000UNIT
ADVATE INJ 250UNIT
ADVATE INJ 3000UNIT
ADVATE INJ 500UNIT
ADVICOR TAB 1000-20
ADVICOR TAB 1000-40
ADVICOR TAB 500-20MG
ADVICOR TAB 750-20MG
afeditab tab 30mg cr
afeditab tab 60mg cr
AFINITOR TAB 10MG
AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
AFLURIA INJ 2015-16
AFLURIA INJ PF 12-13
AFLURIA INJ PF 13-14
AFLURIA INJ PF 14-15
AFLURIA INJ PF 15-16
aftera tab 1.5mg
AGGRENOX CAP 25-200MG
ala cort cre 1%
ALBENZA TAB 200MG
albuterol neb 0.083%
albuterol neb 0.5%
albuterol neb 0.63mg/3
albuterol neb 1.25mg/3
albuterol syp 2mg/5ml
albuterol tab 2mg
Page #
46
13
119
119
119
119
119
22
22
22
22
22
22
25
25
25
25
25
25
32
32
32
32
38
38
14
14
14
14
121
121
121
121
121
101
29
126
1
22
23
23
23
23
23
Drug Name
Page #
Drug Name
albuterol tab 4mg
albuterol tab 4mg er
alclometason cre 0.05%
alclometason oin 0.05%
alendronate tab 10mg
alendronate tab 35mg
alendronate tab 40mg
alendronate tab 5mg
alendronate tab 70mg
alfuzosin tab 10mg
ALINIA SUS 100/5ML
ALINIA TAB 500MG
ALKERAN TAB 2MG
allopurinol tab 100mg
allopurinol tab 300mg
almotrip mal tab 12.5mg
almotrip mal tab 6.25mg
almotriptan tab 12.5mg
almotriptan tab 6.25mg
ALOCRIL SOL 2%
ALOMIDE SOL 0.1% OP
ALPHANATE 1,000-400 UNIT VIAL
ALPHANATE 1,500-600 UNIT VIAL
ALPHANATE 500-200 UNIT VIAL
ALPHANATE INJ VWF/HUM
ALPHANINE SD INJ 1000UNIT
ALPHANINE SD INJ 1500UNIT
alphatrex gel 0.05%
alprazolam tab 0.25 odt
alprazolam tab 0.25mg
alprazolam tab 0.5mg
alprazolam tab 0.5mg er
alprazolam tab 0.5mg od
alprazolam tab 0.5mg xr
alprazolam tab 1mg
alprazolam tab 1mg er
alprazolam tab 1mg odt
alprazolam tab 1mg xr
alprazolam tab 2mg
alprazolam tab 2mg er
alprazolam tab 2mg odt
alprazolam tab 2mg xr
alprazolam tab 3mg er
alprazolam tab 3mg xr
ALREX SUS 0.2%
ALTABAX OIN 1%
altacaine sol 0.5% op
23
23
126
126
115
115
115
115
115
22
9
9
14
114
114
64
64
64
64
84
84
25
25
25
25
25
25
126
68
68
68
68
68
68
68
68
68
68
68
68
68
68
68
68
87
122
89
altafrin sol 10% op
altafrin sol 2.5% op
altavera tab
ALVESCO AER 160MCG
ALVESCO AER 80MCG
alyacen tab 1/35
alyacen tab 7/7/7
amantadine cap 100mg
amantadine syp 50mg/5ml
amantadine tab 100mg
amcinonide cre 0.1%
amcinonide lot 0.1%
amcinonide oin 0.1%
amethia lo tab
amethia tab
amethyst tab 90-20mcg
AMEVIVE 15 MG VIAL
amilor/hctz tab 5-50
amiloride tab 5mg
aminophyllin inj 25mg/ml
amiodarone tab 200mg
amiodarone tab 400mg
AMITIZA CAP 24MCG
AMITIZA CAP 8MCG
amitriptylin tab 100mg
amitriptylin tab 10mg
amitriptylin tab 150mg
amitriptylin tab 25mg
amitriptylin tab 50mg
amitriptylin tab 75mg
amlod/benazp cap 10-20mg
amlod/benazp cap 10-40mg
amlod/benazp cap 2.5-10mg
amlod/benazp cap 5-10mg
amlod/benazp cap 5-20mg
amlod/benazp cap 5-40mg
amlod/valsar tab /hctz
amlodipine tab 10mg
amlodipine tab 2.5mg
amlodipine tab 5mg
ammonium lac cre 12%
ammonium lac lot 12%
amox/k clav chw 200mg
amox/k clav chw 400mg
amox/k clav sus 200/5ml
amox/k clav sus 250/5ml
amox/k clav sus 400/5ml
Page #
89
89
101
94
94
101
101
64
64
64
126
126
126
101
101
101
132
81
81
134
39
39
93
93
70
70
70
70
70
70
38
38
38
38
38
38
38
38
38
38
131
131
4
4
4
4
4
Drug Name
Page #
Drug Name
amox/k clav sus 600/5ml
amox/k clav tab 250mg
amox/k clav tab 500mg
amox/k clav tab 875mg
amoxapine tab 100mg
amoxapine tab 150mg
amoxapine tab 25mg
amoxapine tab 50mg
amoxicillin cap 250mg
amoxicillin cap 500mg
amoxicillin chw 125mg
amoxicillin chw 250mg
amoxicillin sus 125/5ml
amoxicillin sus 200/5ml
amoxicillin sus 250/5ml
amoxicillin sus 250mg/5m
amoxicillin sus 400/5ml
amoxicillin tab 500mg
amoxicillin tab 875mg
amox-pot cla tab er
amphetamine cap 10mg er
amphetamine cap 15mg er
amphetamine cap 20mg er
amphetamine cap 25mg er
amphetamine cap 30mg er
amphetamine cap 5mg er
amphetamine tab 10mg
amphetamine tab 12.5mg
amphetamine tab 15mg
amphetamine tab 20mg
amphetamine tab 30mg
amphetamine tab 5mg
amphetamine tab 7.5mg
ampicillin cap 250mg
ampicillin cap 500mg
ampicillin sus 125/5ml
ampicillin sus 250/5ml
AMPYRA TAB 10MG
anagrelide cap 0.5mg
anagrelide cap 1mg
anastrozole tab 1mg
ANDROGEL GEL 1%(25MG)
ANDROGEL GEL 1.62%
ANDROGEL GEL PUMP 1%
anecream cre 4%
ANORO ELLIPT AER 62.5-25
antibiot ear sol 1% otic
4
4
4
4
71
71
71
71
4
4
4
4
4
4
5
5
5
5
5
5
54
54
54
54
54
54
55
55
55
55
55
55
55
5
5
5
5
118
29
29
14
96
97
97
129
18
87
antipy/benzo sol otic
anucort-hc sup 25mg
ANZEMET TAB 100MG
ANZEMET TAB 50MG
apap/caff/di tab hydrocod
apap/codeine sol 120-12/5
apap/codeine tab 300-15mg
apap/codeine tab 300-30mg
apap/codeine tab 300-60mg
APEXICON E CRE 0.05%
APIDRA INJ SOLOSTAR
APIDRA INJ U-100
apraclonidin sol 0.5% op
apri tab
APTIVUS CAP 250MG
APTIVUS SOL
aranelle tab
ARANESP INJ 100MCG
ARANESP INJ 10MCG
ARANESP INJ 150MCG
ARANESP INJ 200MCG
ARANESP INJ 25MCG
ARANESP INJ 300MCG
ARANESP INJ 40MCG
ARANESP INJ 500MCG
ARANESP INJ 60MCG
ARCALYST INJ 220MG
ARCAPTA CAP 75MCG
aripiprazole tab 10mg
aripiprazole tab 15mg
aripiprazole tab 20mg
aripiprazole tab 2mg
aripiprazole tab 30mg
aripiprazole tab 5mg
ARMOUR THYRO TAB 120MG
armour thyro tab 120mg
ARMOUR THYRO TAB 15MG
armour thyro tab 180mg
ARMOUR THYRO TAB 180MG
ARMOUR THYRO TAB 240MG
ARMOUR THYRO TAB 300MG
ARMOUR THYRO TAB 30MG
armour thyro tab 30mg
armour thyro tab 60mg
ARMOUR THYRO TAB 60MG
ARMOUR THYRO TAB 90MG
asa/caff/but cap cod 30mg
Page #
89
126
90
90
49
49
49
49
49
126
98
98
88
101
9
9
101
29
30
30
30
30
30
30
30
30
118
23
75
76
76
76
76
76
110
110
110
110
110
110
110
110
110
110
110
110
49
Drug Name
Page #
Drug Name
ascomp/cod cap 30mg
ashlyna tab
ASMANEX 120 AER 220MCG
ASMANEX 30 AER 110MCG
ASMANEX 30 AER 220MCG
ASMANEX 60 AER 220MCG
ASMANEX 7 AER 110MCG
ASMANEX HFA AER 100 MCG
ASMANEX HFA AER 200 MCG
aspercreme cre lidocain
aspirin chew 81 mg
aspirin chew 81 mg
aspirin tab 324 mg
aspirin tab 325 mg
aspirin tab 325 mg
aspirin tab 81 mg
aspirin tab 81 mg
atenol/chlor tab 100-25mg
atenol/chlor tab 50-25mg
atenolol tab 100mg
atenolol tab 25mg
atenolol tab 50mg
atorvastatin tab 10mg
atorvastatin tab 20mg
atorvastatin tab 40mg
atorvastatin tab 80mg
atovaq/progu tab 250-100
atovaq/progu tab 62.5-25
atovaquone sus 750/5ml
ATRIPLA TAB
atropin-care sol 1% op
atropine sul inj 0.05mg/1
atropine sul inj 0.1mg/ml
atropine sul inj 0.4/0.5
atropine sul oin 1% op
atropine sul sol 1% op
ATROVENT HFA AER 17MCG
AUBAGIO TAB 14MG
AUBAGIO TAB 7MG
aubra tab 0.1-0.02
aug betamet cre 0.05%
aug betamet gel 0.05%
aug betamet lot 0.05%
aug betamet oin 0.05%
aurodex sol otic
auroguard sol otic
AVANDIA TAB 2MG
49
101
94
94
94
94
94
94
95
130
46
46
46
46
46
46
46
34
34
34
34
34
32
32
32
32
8
8
9
9
89
18
18
18
89
89
18
114
114
101
127
127
127
127
89
89
100
AVANDIA TAB 4MG
AVANDIA TAB 8MG
avar cleanse emu 10-5%
aviane tab
avita cre 0.025%
avita gel 0.025%
AVONEX KIT 30MCG
AVONEX PEN KIT 30MCG
AVONEX PREFL KIT 30MCG
AZASITE SOL 1%
azathioprine tab 50mg
azelastine dro 0.05%
azelastine spr 0.1%
azelastine spr 0.15%
AZILECT TAB 0.5MG
AZILECT TAB 1MG
azithromycin pow 1gm pak
azithromycin sus 100/5ml
azithromycin sus 200/5ml
azithromycin tab 250mg
azithromycin tab 500mg
azithromycin tab 600mg
azo dine tab 95mg
azo dine tab max st
azo pain rel tab 95mg
azo tabs tab 95mg
azo urinary tab 97.5mg
azo urinary tab 97.5mg
AZOPT SUS 1% OP
azo-standard tab 95mg
azurette tab 28 day
baciim inj 50000unt
bacitracin inj 50000unt
bacitracin oin op
baclofen tab 10mg
baclofen tab 20mg
BACTROBAN OIN NASAL 2%
balsalazide cap 750mg
balziva tab
BANZEL TAB 200MG
BANZEL TAB 400MG
BARACLUDE SOL .05MG/ML
baycadron elx 0.5/5ml
BAYER CHILD CHW ASA 81MG
BEBULIN INJ 200-1200
BEBULIN VH IMMU 200-1,200 UNIT
BECONASE AQ SUS 0.042%
Page #
100
100
131
101
131
131
114
114
114
86
117
84
84
84
66
66
3
3
3
3
3
3
130
130
130
130
130
130
85
130
101
2
2
86
21
22
122
91
101
57
57
13
95
46
25
25
87
Drug Name
Page #
Drug Name
BELVIQ TAB 10MG
benazep/hctz tab 10-12.5
benazep/hctz tab 20-12.5
benazep/hctz tab 20-25mg
benazep/hctz tab 5-6.25
benazepril tab 10mg
benazepril tab 20mg
benazepril tab 40mg
benazepril tab 5mg
BENEFIX INJ 1000UNIT
BENEFIX INJ 2000UNIT
BENEFIX INJ 250UNIT
BENEFIX INJ 500UNIT
BENLYSTA INJ 120MG
BENLYSTA INJ 400MG
benzepro aer 5.3%
benzepro liq creamy
benzepro sc aer 9.8%
benziq wash liq 5.25%
benzonatate cap 100mg
benzonatate cap 150mg
benzonatate cap 200mg
benzoyl per aer 5.3%
benzoyl per aer 9.8%
benzoyl per gel 10%
benzoyl per gel 5%
benzoyl per liq 10% wash
benzoyl pero aer 9.8%
benzoyl pero kit acne pck
benzphetamin tab 50mg
benztropine tab 0.5mg
benztropine tab 1mg
benztropine tab 2mg
BEPREVE DRO 1.5%
BERINERT INJ 500UNIT
BESIVANCE SUS 0.6%
beta diprop gel 0.05%
betameth dip cre 0.05%
betameth dip lot 0.05%
betameth dip oin 0.05%
betameth val cre 0.1%
betameth val lot 0.1%
betameth val oin 0.1%
BETASERON INJ 0.3MG
betaxolol sol 0.5% op
betaxolol tab 10mg
betaxolol tab 20mg
55
43
43
43
43
43
43
43
43
25
25
25
25
117
117
125
125
125
125
118
118
118
125
125
125
125
125
125
125
55
65
19
19
84
115
86
127
127
127
127
127
127
127
114
85
34
34
BETOPTIC-S SUS 0.25% OP
bexarotene cap 75mg
BEXSERO INJ
bicalutamide tab 50mg
bisoprl/hctz tab 10/6.25
bisoprl/hctz tab 2.5/6.25
bisoprl/hctz tab 5-6.25mg
bisoprol fum tab 10mg
bisoprol fum tab 5mg
BIVIGAM INJ 10%
BLEPHAMIDE SUS LIQUIFLM
BLEPHAMIDE SUS OP
BOSULIF TAB 100MG
BOSULIF TAB 500MG
bp 10-1 emu
bp foam aer 5.3%
bp foam aer 9.8%
bp foaming liq wash 10%
bp gel gel 10%
bp gel gel 5%
bp wash liq 2.5%
bp wash liq 7%
bpo gel 4%
bpo gel 8%
bpo creamy kit 4% wash
bpo creamy kit 8% wash
briellyn tab
BRILINTA TAB 60MG
BRILINTA TAB 90MG
brimonidine sol 0.15%
brimonidine sol 0.2% op
bromfenac sol 0.09%
bromfenac sol 0.09% op
bromocriptin cap 5mg
bromocriptin tab 2.5mg
BROVANA NEB 15MCG
budeprion tab 100mg sr
budeprion tab 150mg sr
budesonide cap 3mg/24hr
budesonide sus 0.25mg/2
budesonide sus 0.5mg/2
budesonide sus 1mg/2ml
budesonide sus 32mcg
bumetanide inj 0.25/ml
bumetanide tab 0.5mg
bumetanide tab 1mg
bumetanide tab 2mg
Page #
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14
121
14
34
34
34
34
34
120
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125
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125
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29
29
84
85
88
88
65
65
23
71
71
95
95
95
95
87
80
80
80
80
Drug Name
BUPHENYL TAB 500MG
bupren/nalox sub 2-0.5mg
bupren/nalox sub 8-2mg
buprenorphin inj 0.3mg/ml
buprenorphin sub 2mg
buprenorphin sub 8mg
bupropion hcl (smoking deterrent) tab
150 mg
bupropion tab 100mg
bupropion tab 100mg er
bupropion tab 100mg sr
bupropion tab 150mg er
bupropion tab 150mg sr
bupropion tab 200mg er
bupropion tab 200mg sr
bupropion tab 75mg
bupropn hcl tab 150mg xl
bupropn hcl tab 300mg xl
buspirone tab 10mg
buspirone tab 15mg
buspirone tab 30mg
buspirone tab 5mg
buspirone tab 7.5mg
but/apap/caf cap
but/apap/caf cap codeine
but/apap/caf tab
but/asa/caf/ cap cod 30mg
but/asa/caff cap
but/asa/caff tab
butal cpd/ cap codeine
butorphanol inj 1mg/ml
butorphanol sol 10mg/ml
BUTRANS DIS 10MCG/HR
BUTRANS DIS 15MCG/HR
BUTRANS DIS 20MCG/HR
BUTRANS DIS 5MCG/HR
BUTRANS DIS 7.5/HR
BYDUREON INJ
BYDUREON INJ
BYETTA INJ 5MCG
BYSTOLIC TAB 10MG
BYSTOLIC TAB 2.5MG
BYSTOLIC TAB 20MG
BYSTOLIC TAB 5MG
cabergoline tab 0.5mg
calc acetate cap 667mg
calcipotrien cre 0.005%
Page #
80
54
54
54
54
54
71
71
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71
71
71
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71
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67
46
49
46
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47
47
49
54
54
54
54
54
54
54
98
98
98
34
34
34
34
65
82
132
Drug Name
calcipotrien oin 0.005%
calcipotrien sol 0.005%
calcitrene oin 0.005%
calcitriol cap 0.25mcg
calcitriol cap 0.5mcg
calcitriol oin 3mcg/gm
camila tab 0.35mg
camrese lo tab
camrese tab
CANASA SUP 1000MG
candesa/hctz tab 16-12.5
candesa/hctz tab 32-12.5
candesa/hctz tab 32-25mg
candesartan tab 16mg
candesartan tab 32mg
candesartan tab 4mg
candesartan tab 8mg
capecitabine tab 150mg
capecitabine tab 500mg
CAPEX SHA 0.01%
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
captopr/hctz tab 25-15mg
captopr/hctz tab 25-25mg
captopr/hctz tab 50-15mg
captopr/hctz tab 50-25mg
captopril tab 100mg
captopril tab 12.5mg
captopril tab 25mg
captopril tab 50mg
CARAFATE SUS 1GM/10ML
carb/levo 50 tab /entacap
carb/levo 75 tab /entacap
carb/levo er tab 25-100mg
carb/levo er tab 50-200mg
carb/levo sr tab 50-200mg
carb/levo tab 10-100mg
carb/levo tab 25-250mg
carb/levo100 tab /entacap
carb/levo125 tab /entacap
carb/levo150 tab /entacap
carb/levo200 tab /entacap
carbamazepin cap 100mg er
carbamazepin cap 200mg er
carbamazepin cap 300mg er
carbamazepin chw 100mg
carbamazepin sus 100/5ml
Page #
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135
132
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65
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65
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57
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58
58
58
Drug Name
Page #
Drug Name
carbamazepin tab 200mg
carbamazepin tab 200mg er
carbamazepin tab 400mg er
carbidopa tab 25mg
carbonyl iron chew 15 mg
carbonyl iron suspension 15 mg/1.25ml
CARDURA XL TAB 4MG
carimune nf inj 12gm
carimune nf inj 3gm
carimune nf inj 6gm
carisopr/asa tab 200-325
carisoprodol tab 250mg
carisoprodol tab 350mg
carisoprodol tab asa/cod
carteolol sol 1% op
cartia xt cap 120/24hr
cartia xt cap 180/24hr
cartia xt cap 240/24hr
cartia xt cap 300/24hr
carvedilol tab 12.5mg
carvedilol tab 25mg
carvedilol tab 3.125mg
carvedilol tab 6.25mg
CAYSTON INH 75MG
caziant pak
CEDAX CAP 400MG
cefaclor cap 250mg
cefaclor cap 500mg
cefaclor er tab 500mg
cefadroxil cap 500mg
cefadroxil sus 250/5ml
cefadroxil sus 500/5ml
cefadroxil tab 1gm
cefdinir cap 300mg
cefdinir sus 125/5ml
cefdinir sus 250/5ml
cefditoren tab 200mg
cefditoren tab 400mg
cefixime sus 100/5ml
cefixime sus 200/5ml
cefpodo prox sus 100/5ml
cefpodo prox sus 50mg/5ml
cefpodoxime tab 100mg
cefpodoxime tab 200mg
cefprozil sus 125/5ml
cefprozil sus 250/5ml
cefprozil tab 250mg
58
58
58
65
24
24
31
120
120
120
21
21
21
21
85
36
36
36
36
34
34
34
34
4
101
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
cefprozil tab 500mg
cefuroxime tab 250mg
cefuroxime tab 500mg
celecoxib cap 100mg
celecoxib cap 200mg
celecoxib cap 400mg
celecoxib cap 50mg
CELONTIN CAP 300MG
CENESTIN TAB 0.3MG
CENESTIN TAB 0.45MG
CENESTIN TAB 0.625MG
CENESTIN TAB 0.9MG
CENESTIN TAB 1.25MG
cephalexin cap 250mg
cephalexin cap 500mg
cephalexin cap 750mg
cephalexin sus 125/5ml
cephalexin sus 250/5ml
cerisa wash emu 10-1%
CESAMET CAP 1MG
cesia pak
CETROTIDE KIT 0.25MG
cevimeline cap 30mg
CHANTIX PAK 0.5& 1MG
CHANTIX PAK 1MG
CHANTIX TAB 0.5MG
CHANTIX TAB 1MG
chateal tab 0.15/30
CHEMET CAP 100MG
chlor/phen dro dm
chlord/clidi cap 5-2.5mg
chlordiazep cap 10mg
chlordiazep cap 25mg
chlordiazep cap 5mg
chlorhex glu sol 0.12%
chloromag inj 20%
chloroproc inj 2%
chloroproc inj 3%
chloroquine tab 250mg
chloroquine tab 500mg
chlorothiaz tab 250mg
chlorothiaz tab 500mg
chlorpromaz inj 25mg/ml
chlorpromaz inj 50mg/2ml
chlorpromaz tab 100mg
chlorpromaz tab 10mg
chlorpromaz tab 200mg
Page #
3
3
3
47
47
47
47
63
106
106
106
106
106
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3
3
3
3
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117
20
19
19
19
19
101
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19
68
68
68
87
82
113
113
8
8
81
81
76
76
76
76
76
Drug Name
Page #
Drug Name
chlorpromaz tab 25mg
chlorpromaz tab 50mg
chlorpropam tab 100mg
chlorpropam tab 250mg
chlorthalid tab 100mg
chlorthalid tab 25mg
chlorthalid tab 50mg
chlorzoxazon tab 500mg
cho mag tris liq 500/5ml
cho mag tris tab 1000mg
cholecalciferol cap 1000 unit
cholecalciferol cap 10000 unit
cholecalciferol cap 2000 unit
cholecalciferol cap 400 unit
cholecalciferol cap 5000 unit
cholecalciferol cap 50000 unit
cholecalciferol chew 1000 unit
cholecalciferol chew 2000 unit
cholecalciferol chew 400 unit
cholecalciferol chew 5000 unit
cholecalciferol liqd 1000 unit/spray
cholecalciferol liqd 1200 unit/15ml
cholecalciferol liqd 2000 unt/0.03ml
cholecalciferol liqd 400 unit/ml
cholecalciferol liqd 400 unt/0.03ml
cholecalciferol liqd 5000 unit/ml
cholecalciferol tab 1000 unit
cholecalciferol tab 3000 unit
cholecalciferol tab 400 unit
cholecalciferol tab 5000 unit
cholestyram pow 4gm
cholestyram pow 4gm lite
chor gonadot inj 10000unt
CIALIS TAB 5MG
ciclodan cre 0.77%
ciclodan sol 8%
ciclopirox cre 0.77%
ciclopirox gel 0.77%
ciclopirox sha 1%
ciclopirox sol 8%
ciclopirox sus 0.77%
cilostazol tab 100mg
cilostazol tab 50mg
CILOXAN OIN 0.3% OP
cimetidine tab 200mg
cimetidine tab 300mg
cimetidine tab 400mg
76
76
99
99
81
81
81
21
47
47
135
135
135
135
135
135
135
135
135
135
135
135
135
135
135
135
135
135
135
135
31
31
108
46
123
123
123
123
123
123
123
29
29
86
91
91
91
cimetidine tab 800mg
CIMZIA KIT
CIMZIA KIT STARTER
CIMZIA PREFL KIT 200MG/ML
CINRYZE SOL 500 UNIT
CIPRO HC SUS OTIC
CIPRODEX SUS 0.3-0.1%
ciprofloxacn sol 0.2%
ciprofloxacn sol 0.3% op
ciprofloxacn sus 250mg/5
ciprofloxacn sus 500mg/5
ciprofloxacn tab 1000mg
ciprofloxacn tab 100mg
ciprofloxacn tab 250mg
ciprofloxacn tab 500mg
ciprofloxacn tab 500mg er
ciprofloxacn tab 750mg
citalopram sol 10mg/5ml
citalopram tab 10mg
citalopram tab 20mg
citalopram tab 40mg
claravis cap 10mg
claravis cap 20mg
claravis cap 30mg
claravis cap 40mg
clarithromyc sus 125/5ml
clarithromyc sus 250/5ml
clarithromyc tab 250mg
clarithromyc tab 500mg
clarithromyc tab 500mg er
clearplex v gel 5%
clearplex x gel 10%
clemastine syp 0.5/5ml
clemastine tab 2.68mg
clidi/chlord cap 2.5-5mg
CLIMARA PRO DIS WEEKLY
clindacin mis etz 1%
clindacin-p pad 1%
clindamax gel 1%
clindamax lot 10mg/ml
clindamy/ben gel 1.2-5%
clindamy/ben gel 1-5%
clindamycin cap 150mg
clindamycin cap 300mg
clindamycin cap 75mg
clindamycin cre 2% vag
clindamycin gel 1%
Page #
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116
116
116
115
87
87
86
86
5
5
5
5
5
5
5
5
71
71
71
71
132
132
132
132
3
3
3
4
4
125
125
1
1
19
106
122
122
122
122
122
122
2
2
2
122
123
Drug Name
Page #
Drug Name
clindamycin lot 1%
clindamycin lot 10mg/ml
clindamycin pad 1%
clindamycin sol 1%
clindamycin sol 75mg/5ml
clobetasol aer 0.05%
clobetasol cre 0.05%
clobetasol e cre 0.05%
clobetasol gel 0.05%
clobetasol lot 0.05%
clobetasol oin 0.05%
clobetasol sha 0.05%
clobetasol sol 0.05%
clodan sha 0.05%
CLODERM CRE 0.1%
CLODERM CRE 0.1% PMP
clomiphene tab 50mg
clomipramine cap 25mg
clomipramine cap 50mg
clomipramine cap 75mg
clonazep odt tab 0.125mg
clonazep odt tab 0.25mg
clonazep odt tab 0.5mg
clonazep odt tab 1mg
clonazep odt tab 2mg
clonazepam tab 0.5mg
clonazepam tab 1mg
clonazepam tab 2mg
clonidine dis 0.1/24hr
clonidine dis 0.2/24hr
clonidine dis 0.3/24hr
clonidine tab 0.1mg
clonidine tab 0.2mg
clonidine tab 0.3mg
clopidogrel tab 300mg
clopidogrel tab 75mg
cloraz dipot tab 15mg
cloraz dipot tab 3.75mg
cloraz dipot tab 7.5mg
clotrim/beta cre 1-0.05%
clotrim/beta cre diprop
clotrim/beta lot diprop
clotrimazole cre 1%
clotrimazole loz 10mg
clotrimazole tro 10mg
clozapine tab 100mg
clozapine tab 200mg
123
123
123
123
2
127
127
127
127
127
127
127
127
127
127
127
106
71
71
71
62
62
62
62
62
62
62
62
41
41
41
41
41
41
29
29
68
68
68
124
124
124
124
124
124
76
76
clozapine tab 25mg
clozapine tab 50mg
COARTEM TAB 20-120MG
codeine sulf tab 15mg
codeine sulf tab 30mg
codeine sulf tab 60mg
codeine/apap tab 15-300mg
codeine/apap tab 30-300mg
codeine/apap tab 60-300mg
colchicine cap 0.6mg
colchicine tab 0.6mg
colestipol gra 5gm
colestipol tab 1gm
COLY-MYCIN S SUS OTIC
COMBIGAN SOL 0.2/0.5%
COMBIPATCH DIS .05/.14
COMBIPATCH DIS .05/.25
COMBIVENT AER RESPIMAT
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
COMETRIQ KIT 60MG
compazine sup 25mg
COMPLERA TAB
compro sup 25mg
constulose sol 10gm/15
COPAXONE INJ 20MG/ML
CORDRAN CRE 0.05%
CORIFACT KIT
cormax scalp sol 0.05%
cortisone ac tab 25mg
CORTISPORIN CRE 0.5%
CORTISPORIN SUS -TC OTIC
coumadin tab 10mg
coumadin tab 1mg
coumadin tab 2.5mg
coumadin tab 2mg
coumadin tab 3mg
coumadin tab 4mg
coumadin tab 5mg
coumadin tab 6mg
coumadin tab 7.5mg
CREON CAP 12000UNT
CREON CAP 24000UNT
CREON CAP 3000UNIT
CREON CAP 36000UNT
CREON CAP 6000UNIT
CRESTOR TAB 10MG
Page #
76
76
8
49
49
49
49
49
49
114
113
31
31
87
85
106
106
23
15
15
15
76
9
76
80
114
127
25
127
95
127
87
27
28
28
28
28
28
28
28
28
93
93
93
93
93
32
Drug Name
Page #
Drug Name
CRESTOR TAB 20MG
CRESTOR TAB 40MG
CRESTOR TAB 5MG
CRINONE GEL 4% VAG
CRINONE GEL 8% VAG
CRIXIVAN CAP 200MG
CRIXIVAN CAP 400MG
CRIXIVAN 100 MG CAPSULE
cromolyn sod con 100/5ml
cromolyn sod sol 4% op
cryselle-28 tab 28 tabs
CUPRIMINE CAP 250MG
cyclafem tab 1/35
cyclafem tab 7/7/7
cyclobenzapr tab 10mg
cyclobenzapr tab 5mg
cyclopentol sol 1% op
cyclopentol sol 2% op
cyclophosph cap 25mg
cyclophosph tab 25mg
cyclophosph tab 50mg
cycloserine cap 250mg
CYCLOSET TAB 0.8MG
cyclosporine cap 100mg
cyclosporine cap 100mg md
cyclosporine cap 25mg
cyclosporine cap 25mg mod
cyclosporine cap 50mg mod
cyproheptad syp 2mg/5ml
cyproheptad tab 4mg
cyred tab
CYSTAGON CAP 150MG
CYSTAGON CAP 50MG
cytra-k sol
DALIRESP TAB 500MCG
danazol cap 100mg
danazol cap 200mg
danazol cap 50mg
dantrolene cap 100mg
dantrolene cap 25mg
dantrolene cap 50mg
dapsone tab 100mg
dapsone tab 25mg
DARAPRIM TAB 25MG
dasetta tab 1/35
dasetta tab 7/7/7
daysee tab
32
32
32
109
109
9
9
9
118
84
101
94
102
102
21
21
89
89
15
15
15
8
97
117
117
117
117
117
1
1
102
118
118
80
119
97
97
97
21
21
21
8
8
9
102
102
102
DAYTRANA DIS 10MG/9HR
DAYTRANA DIS 15MG/9HR
DAYTRANA DIS 20MG/9HR
DAYTRANA DIS 30MG/9HR
deblitane tab 0.35mg
deltasone tab 20mg
delyla tab 0.1-0.02
DELZICOL CAP 400MG
demeclocycl tab 150mg
demeclocycl tab 300mg
DENAVIR CRE 1%
DEPEN TITRA TAB 250MG
DEPO-PROVERA INJ 400/ML
desipramine tab 100mg
desipramine tab 10mg
desipramine tab 150mg
desipramine tab 25mg
desipramine tab 50mg
desipramine tab 75mg
desloratadin tab 5mg
desmopressin sol 0.01%
desmopressin tab 0.1mg
desmopressin tab 0.2mg
deso/ethinyl tab estradio
DESONATE GEL 0.05%
desonide cre 0.05%
desonide lot 0.05%
desonide oin 0.05%
desvenlafax tab 100mg er
desvenlafax tab 50mg er
dexameth pho sol 0.1% op
DEXAMETHASON CON 1MG/ML
dexamethason elx 0.5/5ml
dexamethason sol 0.5/5ml
dexamethason tab 0.5mg
dexamethason tab 0.75mg
dexamethason tab 1.5mg
dexamethason tab 1mg
dexamethason tab 2mg
dexamethason tab 4mg
dexamethason tab 6mg
dexchlorphen syp 2mg/5ml
dexedrine tab 10mg
dexedrine tab 5mg
dexmethylph cap 15mg er
dexmethylph cap 30mg er
dexmethylph cap 40mg er
Page #
56
56
56
56
102
95
102
91
6
6
125
94
109
71
71
71
71
71
71
1
108
108
108
102
127
127
127
127
71
72
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95
95
95
95
95
95
95
95
95
95
1
55
55
56
56
56
Drug Name
Page #
Drug Name
dexmethylph tab 10mg
dexmethylph tab 2.5mg
dexmethylph tab 5mg
dexmethylphe cap 10mg er
dexmethylphe cap 20mg er
dexmethylphe cap 5mg er
dextroamphet cap 10mg er
dextroamphet cap 15mg er
dextroamphet cap 5mg er
dextroamphet tab 10mg
dextroamphet tab 5mg
diazepam gel 10mg
diazepam gel 2.5mg
diazepam gel 20mg
diazepam inj 5mg/ml
diazepam sol 1mg/ml
diazepam sol 5mg/5ml
diazepam tab 10mg
diazepam tab 2mg
diazepam tab 5mg
DICLEGIS TAB 10-10MG
diclo/misopr tab 50-0.2mg
diclo/misopr tab 75-0.2mg
diclofen pot tab 50mg
diclofenac sol 0.1% op
diclofenac tab 100mg er
diclofenac tab 100mg xr
diclofenac tab 25mg dr
diclofenac tab 50mg dr
diclofenac tab 75mg dr
dicloxacill cap 250mg
dicloxacill cap 500mg
dicyclomine cap 10mg
dicyclomine sol 10mg/5ml
dicyclomine tab 20mg
didanosine cap 125mg
didanosine cap 200mg
didanosine cap 250mg
didanosine cap 400mg
diethylprop tab 75mg er
DIFICID TAB 200MG
diflorasone cre 0.05%
diflorasone oin 0.05%
diflunisal tab 500mg
digitek tab 0.125mg
digitek tab 0.25mg
digox tab 0.125mg
56
56
56
56
56
56
55
55
55
55
55
68
68
68
69
69
69
69
69
69
90
47
47
47
88
47
47
47
47
47
5
5
19
19
19
9
9
9
9
55
4
127
127
47
40
40
40
digox tab 0.25mg
digoxin inj 0.25mg/1
digoxin sol 50mcg/ml
digoxin tab 0.125mg
digoxin tab 0.25mg
DILANTIN CAP 30MG
DILANTIN CHW 50MG
DILANTIN-125 SUS 125/5ML
dilt-cd cap 120mg
dilt-cd cap 180mg
dilt-cd cap 240mg
dilt-cd cap 300mg
diltiazem cap 120mg cd
diltiazem cap 120mg er
diltiazem cap 120mg er
diltiazem cap 180mg cd
diltiazem cap 180mg er
diltiazem cap 180mg er
diltiazem cap 180mg/24
diltiazem cap 240mg cd
diltiazem cap 240mg er
diltiazem cap 240mg er
diltiazem cap 240mg/24
diltiazem cap 300mg cd
diltiazem cap 300mg er
diltiazem cap 300mg/24
diltiazem cap 360mg cd
diltiazem cap 360mg er
diltiazem cap 360mg/24
diltiazem cap 420mg/24
diltiazem cap 60mg er
diltiazem cap 90mg er
diltiazem er tab 180mg
diltiazem er tab 240mg
diltiazem er tab 300mg
diltiazem er tab 360mg
diltiazem er tab 420mg
diltiazem tab 120mg
diltiazem tab 30mg
diltiazem tab 60mg
diltiazem tab 90mg
dilt-xr cap 120mg
dilt-xr cap 180mg
dilt-xr cap 240mg
diltzac cap 180mg/24
diltzac cap 240mg/24
diltzac cap 300mg/24
Page #
40
40
40
40
40
63
63
63
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
37
37
37
37
37
36
36
36
37
37
37
37
37
37
37
Drug Name
Page #
Drug Name
diltzac cap 360mg/24
DIPENTUM CAP 250MG
diphen/atrop liq 2.5/5
diphen/atrop tab 2.5mg
diphenatol tab 2.5mg
dipyridamole inj 5mg/ml
dipyridamole tab 25mg
dipyridamole tab 50mg
dipyridamole tab 75mg
disopyramide cap 100mg
disopyramide cap 150mg
disulfiram tab 250mg
disulfiram tab 500mg
divalproex cap 125mg
divalproex tab 125mg dr
divalproex tab 250mg dr
divalproex tab 250mg er
divalproex tab 500mg dr
divalproex tab 500mg er
DIVIGEL GEL 0.25MG
DIVIGEL GEL 0.5MG
DIVIGEL GEL 1MG/GM
dm/cpm/pe dro
donepezil tab 10mg
donepezil tab 10mg odt
donepezil tab 5mg
donepezil tab 5mg odt
dorzol/timol sol 22.3-6.8
dorzolamide sol 2% op
doxazosin tab 1mg
doxazosin tab 2mg
doxazosin tab 4mg
doxazosin tab 8mg
doxepin hcl cap 100mg
doxepin hcl cap 10mg
doxepin hcl cap 150mg
doxepin hcl cap 25mg
doxepin hcl cap 50mg
doxepin hcl cap 75mg
doxepin hcl con 10mg/ml
doxercalcif cap 0.5mcg
doxercalcif cap 1mcg
doxercalcif cap 2.5mcg
doxycyc mono cap 100mg
doxycycl hyc cap 100mg
doxycycl hyc cap 50mg
doxycycl hyc tab 100mg
37
91
90
90
90
46
46
46
46
39
39
114
114
58
58
58
58
58
58
106
106
106
119
20
20
20
20
85
85
31
31
31
31
72
72
72
72
72
72
72
135
135
135
6
6
6
6
dronabinol cap 10mg
dronabinol cap 2.5mg
dronabinol cap 5mg
drospir/ethi tab 3-0.03mg
drospirenone tab ethy est
DROXIA CAP 200MG
DROXIA CAP 300MG
DROXIA CAP 400MG
DULERA AER 100-5MCG
DULERA AER 200-5MCG
duloxetine cap 20mg
duloxetine cap 30mg
duloxetine cap 60mg
duramorph inj 0.5mg/ml
duramorph inj 1mg/ml
DUREZOL EMU 0.05%
Dutasteride 0.5MG
DYRENIUM CAP 100MG
DYRENIUM CAP 50MG
e.e.s. 400 tab 400mg
E.E.S. GRAN SUS 200/5ML
econazole cre 1%
econtra ez tab 1.5mg
EDARBI TAB 40MG
EDARBI TAB 80MG
EDECRIN TAB 25MG
EDURANT TAB 25MG
EFFER-K TAB 10MEQ
EFFER-K TAB 20MEQ
effer-k tab 25meq ef
EFFIENT TAB 10MG
EFFIENT TAB 5MG
ELESTRIN GEL 0.06%
ELIDEL CRE 1%
elinest tab
ELIQUIS TAB 2.5MG
ELIQUIS TAB 5MG
ELLA TAB 30MG
ELMIRON CAP 100MG
ELOCTATE INJ 1000UNIT
ELOCTATE INJ 1500UNIT
ELOCTATE INJ 2000UNIT
ELOCTATE INJ 250UNIT
ELOCTATE INJ 3000UNIT
ELOCTATE INJ 500UNIT
ELOCTATE INJ 750UNIT
EMADINE SOL 0.05% OP
Page #
90
90
90
102
102
15
15
15
95
95
72
72
72
49
49
87
113
81
81
4
4
124
102
42
42
80
10
82
82
82
29
29
106
132
102
28
28
102
118
25
25
25
25
25
26
26
84
Drug Name
Page #
Drug Name
EMCYT CAP 140MG
EMEND CAP 125MG
EMEND CAP 40MG
EMEND CAP 80MG
EMEND PAK 80 & 125
emoquette tab
EMSAM DIS 12MG/24H
EMSAM DIS 6MG/24HR
EMSAM DIS 9MG/24HR
EMTRIVA CAP 200MG
EMTRIVA SOL 10MG/ML
ENABLEX TAB 15MG
ENABLEX TAB 7.5MG
enalapr/hctz tab 10-25mg
enalapr/hctz tab 5-12.5mg
enalapril tab 10mg
enalapril tab 2.5mg
enalapril tab 20mg
enalapril tab 5mg
ENBREL INJ 25/0.5ML
ENBREL INJ 25MG
ENBREL INJ 50MG/ML
ENBREL SRCLK INJ 50MG/ML
encare sup 100mg
endocet tab 10-325mg
endocet tab 10-650mg
endocet tab 5-325mg
endocet tab 7.5-325
endocet tab 7.5-500m
ENDOMETRIN SUP 100MG
ENJUVIA TAB 0.3MG
ENJUVIA TAB 0.45MG
ENJUVIA TAB 0.625MG
ENJUVIA TAB 0.9MG
ENJUVIA TAB 1.25MG
enoxaparin inj 100mg/ml
enoxaparin inj 120/0.8
enoxaparin inj 150mg/ml
enoxaparin inj 30/0.3ml
enoxaparin inj 300/3ml
enoxaparin inj 40/0.4ml
enoxaparin inj 60/0.6ml
enoxaparin inj 80/0.8ml
enpresse-28 tab
enskyce tab
entacapone tab 200mg
entecavir tab 0.5mg
15
90
90
90
91
102
66
66
66
10
10
133
133
43
43
43
43
43
43
116
116
116
116
80
49
49
50
50
50
109
106
106
106
106
106
28
28
28
28
28
28
28
28
102
102
65
13
entecavir tab 1mg
ENTRESTO TAB 24-26MG
ENTRESTO TAB 49-51MG
ENTRESTO TAB 97-103MG
ENTYVIO INJ 300MG
enulose sol 10gm/15
EPIDUO FORTE GEL 0.3-2.5%
epinastine dro 0.05%
epinephrine inj 0.1mg/ml
epinephrine inj 1mg/ml
EPIPEN 2-PAK INJ 0.3MG
EPIPEN-JR INJ 2-PAK
epitol tab 200mg
EPIVIR HBV SOL 5MG/ML
eplerenone tab 25mg
eplerenone tab 50mg
EPOGEN INJ 10000/ML
EPOGEN INJ 2000/ML
EPOGEN INJ 20000/ML
EPOGEN INJ 3000/ML
EPOGEN INJ 4000/ML
eprosart mes tab 600mg
EPZICOM TAB
EPZICOM TAB 600-300
ergocalcifer cap 50000unt
ergoloid mes tab 1mg oral
ERIVEDGE CAP 150MG
errin tab 0.35mg
ERTACZO CRE 2%
ery pad 2%
ERYPED SUS 200/5ML
ERYPED SUS 400/5ML
erythrom eth tab 400mg
erythromycin gel /benzoyl
erythromycin gel 2%
erythromycin oin 5mg/gm
erythromycin oin op
erythromycin pad 2%
erythromycin sol 2%
erythromycin tab 250mg bs
erythromycin tab 500mg bs
ESBRIET CAP 267MG
escitalopram sol 5mg/5ml
escitalopram tab 10mg
escitalopram tab 20mg
escitalopram tab 5mg
estarylla tab 0.25-35
Page #
13
41
41
41
93
80
132
84
22
22
22
22
58
10
44
44
30
30
30
30
30
42
10
10
136
22
15
102
124
123
4
4
4
123
123
86
86
123
123
4
4
118
72
72
72
72
102
Drug Name
Page #
Drug Name
estazolam tab 1mg
estazolam tab 2mg
estra/noreth tab 0.5-0.1
estra/noreth tab 1-0.5mg
ESTRACE VAG CRE 0.1MG/GM
estradiol dis 0.025mg
estradiol dis 0.0375mg
estradiol dis 0.05mg
estradiol dis 0.06mg
estradiol dis 0.075mg
estradiol dis 0.1mg
estradiol tab 0.5mg
estradiol tab 1mg
estradiol tab 2mg
ESTRASORB EMU
ESTRING MIS 2MG
ESTROGEL GEL
estropipate tab 0.75mg
estropipate tab 1.5mg
estropipate tab 3mg
eszopiclone tab 1mg
eszopiclone tab 2mg
eszopiclone tab 3mg
ethambutol tab 100mg
ethambutol tab 400mg
ethosuximide cap 250mg
ethosuximide sol 250/5ml
etidron disd tab 200mg
etidron disd tab 400mg
etodolac cap 200mg
etodolac cap 300mg
etodolac tab 400mg
etodolac tab 500mg
etodolac er tab 400mg
etodolac er tab 500mg
etodolac er tab 600mg
etoposide cap 50mg
EURAX CRE 10%
EURAX LOT 10%
EVAMIST SPR 1.53MG
EVISTA TAB 60MG
EXELDERM SOL 1%
exemestane tab 25mg
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
EXTAVIA INJ 0.3MG
69
69
106
106
106
106
106
106
107
107
107
107
107
107
107
107
107
107
107
107
67
67
67
8
8
63
63
115
115
47
47
47
47
47
47
47
15
126
126
107
106
124
15
94
94
94
114
EZ FLU SHOT INJ 2015-16
FACTIVE TAB 320MG
fallback tab 1.5mg
falmina tab
famciclovir tab 125mg
famciclovir tab 250mg
famciclovir tab 500mg
famotidine tab 20mg
famotidine tab 40mg
FANAPT TAB 10MG
FANAPT TAB 12MG
FANAPT TAB 1MG
FANAPT TAB 2MG
FANAPT TAB 4MG
FANAPT TAB 6MG
FANAPT TAB 8MG
FARESTON TAB 60MG
FARXIGA TAB 10MG
FARXIGA TAB 5MG
fe c plus tab
FEIBA VH IMMU 1,750-3,250 UNIT
felbamate sus 600/5ml
felbamate tab 400mg
felbamate tab 600mg
felodipine tab 10mg er
felodipine tab 2.5mg er
felodipine tab 5mg er
FEMRING MIS 0.05/24H
FEMRING MIS 0.1MG/24
fenofibrate cap 130mg
fenofibrate cap 134mg
fenofibrate cap 200mg
fenofibrate cap 43mg
fenofibrate cap 67mg
fenofibrate tab 120mg
fenofibrate tab 145mg
fenofibrate tab 160mg
fenofibrate tab 40mg
fenofibrate tab 48mg
fenofibrate tab 54mg
fenofibric tab 105mg
fenofibric tab 35mg
fenoprofen tab 600mg
fentanyl dis 100mcg/h
fentanyl dis 12mcg/hr
fentanyl dis 25mcg/hr
fentanyl dis 37.5mcg
Page #
121
5
102
102
13
13
13
91
91
76
76
76
76
76
76
76
15
99
99
24
26
58
58
58
38
38
38
107
107
32
32
32
32
32
32
32
32
32
32
32
32
32
47
50
50
50
50
Drug Name
Page #
Drug Name
fentanyl dis 50mcg/hr
fentanyl dis 62.5mcg
fentanyl dis 75mcg/hr
fentanyl dis 87.5mcg
fentanyl ot loz 1200mcg
fentanyl ot loz 1600mcg
fentanyl ot loz 200mcg
fentanyl ot loz 400mcg
fentanyl ot loz 600mcg
fentanyl ot loz 800mcg
ferrous aspartate tab 112 mg
ferrous fumarate cap 86 mg
ferrous fumarate tab 18 mg
ferrous fumarate tab 29 mg
ferrous fumarate tab 324 mg
ferrous fumarate tab 325 mg
ferrous fumarate tab 90 mg
ferrous gluconate tab 225 mg
ferrous gluconate tab 240 mg
ferrous gluconate tab 27 mg
ferrous gluconate tab 324 mg
ferrous gluconate tab 325 mg
ferrous sulfate elixir 220 mg/5ml
ferrous sulfate soln 15 mg/ml
ferrous sulfate syrup 300 mg/5ml
ferrous sulfate tab 134 mg
ferrous sulfate tab 140 mg
ferrous sulfate tab 142 mg
ferrous sulfate tab 143 mg
ferrous sulfate tab 160 mg
ferrous sulfate tab 200 mg
ferrous sulfate tab 27 mg
ferrous sulfate tab 28 mg
ferrous sulfate tab 324 mg
ferrous sulfate tab 325 mg
ferrous sulfate tab 45 mg
ferrous sulfate tab 47.5 mg
ferrous sulfate tab 50 mg
ferrous sulfate tab 65 mg
ferrous sulfate tab 90 mg
finasteride tab 5mg
FLAREX SUS 0.1% OP
flavoxate tab 100mg
flebogamma 5% vial
FLEBOGAMMA INJ 20/400ML
flecainide tab 100mg
flecainide tab 150mg
50
50
50
50
50
50
50
50
50
50
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
25
25
113
87
133
120
120
39
39
flecainide tab 50mg
FLOVENT DISK AER 100MCG
FLOVENT DISK AER 250MCG
FLOVENT DISK AER 50MCG
FLOVENT HFA AER 110MCG
FLOVENT HFA AER 220MCG
FLOVENT HFA AER 44MCG
floxuridine inj 0.5gm
FLUARIX PF INJ 2013-14
FLUARIX PF INJ 2014-15
FLUARIX QUAD INJ 2013-14
FLUARIX QUAD INJ 2014-15
FLUARIX QUAD INJ 2015-16
FLUBLOK SOL 2013-14
FLUBLOK SOL 2014-15
FLUBLOK SOL 2015-16
FLUCELVAX INJ 2013-14
FLUCELVAX INJ 2014-15
FLUCELVAX INJ 2015-16
fluconazole sus 10mg/ml
fluconazole sus 40mg/ml
fluconazole tab 100mg
fluconazole tab 150mg
fluconazole tab 200mg
fluconazole tab 50mg
flucytosine cap 250mg
flucytosine cap 500mg
fludrocort tab 0.1mg
FLULAVAL INJ 2013-14
FLULAVAL QUA INJ 2013-14
FLULAVAL QUA INJ 2014-15
FLULAVAL QUA INJ 2015-16
FLUMIST QUAD SUS 2013-14
FLUMIST QUAD SUS 2014-15
FLUMIST QUAD SUS 2015-16
flunisolide spr 0.025%
fluocin acet cre 0.01%
fluocin acet oil 0.01%
fluocin acet oil 0.01% sc
fluocin acet oil body
fluocin acet oil ear0.01%
fluocin acet oil scalp
fluocin acet sol 0.01%
fluocinonide cre 0.05%
fluocinonide cre 0.1%
fluocinonide gel 0.05%
fluocinonide oin 0.05%
Page #
39
95
95
95
95
95
95
15
121
121
121
121
121
121
121
121
121
121
121
7
7
7
7
7
7
8
8
95
121
121
121
121
121
121
121
87
128
87
128
128
87
128
128
128
128
128
128
Drug Name
Page #
Drug Name
fluocinonide sol 0.05%
fluoromethol sus 0.1% op
fluorouracil cre 0.5%
fluorouracil cre 5%
fluorouracil dro 2%
fluorouracil dro 5%
fluorouracil sol 2%
fluorouracil sol 5%
fluoxetine cap 10mg
fluoxetine cap 20mg
fluoxetine cap 40mg
fluoxetine cap 90mg dr
fluoxetine sol 20mg/5ml
fluoxetine tab 10mg
fluoxetine tab 20mg
fluphenazine tab 10mg
fluphenazine tab 1mg
fluphenazine tab 2.5mg
fluphenazine tab 5mg
flurazepam cap 15mg
flurazepam cap 30mg
flurbiprofen sol 0.03% op
flurbiprofen tab 100mg
flurbiprofen tab 50mg
flutamide cap 125mg
fluticasone cre 0.05%
fluticasone lot 0.05%
fluticasone oin 0.005%
fluticasone spr 50mcg
Fluvastatin TAB 80MG
fluvastatin cap 20mg
fluvastatin cap 40mg
FLUVIRIN INJ 2013-14
FLUVIRIN INJ 2015-16
FLUVIRIN INJ PF 13-14
FLUVIRIN PF INJ 2014-15
fluvoxamine tab 100mg
fluvoxamine tab 25mg
fluvoxamine tab 50mg
FLUZONE HD INJ PF 13-14
FLUZONE HD INJ PF 14-15
FLUZONE HD INJ PF 15-16
FLUZONE INJ INTRADRM
FLUZONE INJ PF 13-14
FLUZONE INJ PF 14-15
FLUZONE PED/ INJ PF 13-14
FLUZONE QUAD INJ 13-14
128
87
132
132
132
132
132
132
72
72
72
72
72
72
72
77
77
77
77
69
69
88
47
47
15
128
128
128
87
33
33
33
121
122
122
122
72
72
72
122
122
122
122
122
122
122
122
FLUZONE QUAD INJ 14-15
FLUZONE QUAD INJ 15-16
FLUZONE QUAD INJ 2015-16
FLUZONE QUAD INJ 9MCG
FLUZONE SPLT INJ 2015-16
FOCALIN XR CAP 10MG
FOCALIN XR CAP 20MG
FOCALIN XR CAP 25MG
FOCALIN XR CAP 35MG
folic acid tab 1mg
folic acid tab 400 mcg
folic acid tab 800 mcg
fondaparinux inj 10/0.8ml
fondaparinux inj 2.5/0.5
fondaparinux inj 5/0.4ml
fondaparinux inj 7.5/0.6
FORADIL CAP AEROLIZE
FORTEO SOL 600/2.4
FOSAMAX + D TAB 70-2800
FOSAMAX + D TAB 70-5600
fosinop/hctz tab 10/12.5
fosinop/hctz tab 20/12.5
fosinopril tab 10mg
fosinopril tab 20mg
fosinopril tab 40mg
FOSRENOL CHW 1000MG
FOSRENOL CHW 500MG
FOSRENOL CHW 750MG
FRAGMIN INJ 10000/ML
FRAGMIN INJ 12500UNT
FRAGMIN INJ 15000UNT
FRAGMIN INJ 18000UNT
FRAGMIN INJ 2500/0.2
FRAGMIN INJ 5000/0.2
FRAGMIN INJ 7500/0.3
FRAGMIN INJ 95000UNT
FROVA TAB 2.5MG
furosemide inj 100/10ml
furosemide inj 10mg/ml
furosemide inj 20mg/2ml
furosemide inj 40mg/4ml
furosemide sol 10mg/ml
furosemide sol 40mg/4ml
furosemide sol 8mg/ml
furosemide tab 20mg
furosemide tab 40mg
furosemide tab 80mg
Page #
122
122
122
122
122
56
56
56
56
135
135
135
28
28
28
28
23
108
115
115
43
43
43
43
43
82
82
82
28
28
28
28
28
28
28
28
64
80
80
80
80
81
81
81
81
81
81
Drug Name
Page #
Drug Name
FUZEON INJ 90MG
FUZEON CONVENIENCE KIT
gabapentin cap 100mg
gabapentin cap 300mg
gabapentin cap 400mg
gabapentin sol 250/5ml
gabapentin tab 600mg
gabapentin tab 800mg
galantamine cap 16mg er
galantamine cap 24mg er
galantamine cap 8mg er
galantamine sol 4mg/ml
galantamine tab 12mg
galantamine tab 4mg
galantamine tab 8mg
gamastan s/d inj
gammagard inj 1gm/10ml
gammagard inj 2.5gm/25
gammagard inj 20gm/200
gammagard inj 5gm/50ml
GAMMAGARD S-D 10 G (IGA<1) SOL
gammagard s-d 2.5 gm vl w/st
GAMMAGARD S-D 5 G (IGA<1) SOLN
GAMMAKED INJ 10GM/100
GAMMAKED INJ 1GM/10ML
GAMMAKED INJ 2.5GM/25
GAMMAKED INJ 20GM/200
GAMMAKED INJ 5GM/50ML
GAMMAPLEX INJ 10GM
GAMMAPLEX INJ 2.5GM
GAMMAPLEX INJ 5GM
GAMUNEX 10% VIAL
ganciclovir cap 250 mg
ganirelix ac inj
garamycin oin 0.3% op
GARDASIL 9 INJ
gatifloxacin sol 0.5%
GATTEX KIT 5MG
gavilyte-c sol
gavilyte-g sol
gavilyte-n sol flav pk
gemfibrozil tab 600mg
generlac sol 10gm/15
gengraf cap 100mg
gengraf cap 25mg
gentak oin 0.3% op
gentamicin cre 0.1%
10
10
58
58
58
58
58
58
20
20
20
20
20
20
20
120
120
120
120
120
120
120
120
120
120
120
120
120
120
120
120
120
13
117
86
122
86
93
92
92
92
32
80
117
117
86
123
gentamicin oin 0.1%
gentamicin oin 0.3% op
gentamicin sol 0.3% op
gianvi tab 3-0.02mg
gildagia tab 0.4-35
gildess 24 tab fe 1/20
gildess fe tab 1.5/30
gildess fe tab 1/20
gildess tab 1.5/30
gildess tab 1/20
GILENYA CAP 0.5MG
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
glatopa inj 20mg/ml
GLEEVEC TAB 100MG
GLEEVEC TAB 400MG
GLEOSTINE CAP 100MG
GLEOSTINE CAP 10MG
GLEOSTINE CAP 40MG
glimepiride tab 1mg
glimepiride tab 2mg
glimepiride tab 4mg
glip/metform tab 2.5-250m
glip/metform tab 2.5-500m
glip/metform tab 5-500mg
glipizide er tab 10mg
glipizide er tab 2.5mg
glipizide er tab 5mg
glipizide tab 10mg
glipizide tab 5mg
glipizide xl tab 10mg
glipizide xl tab 2.5mg
glipizide xl tab 5mg
GLUCAGEN INJ HYPOKIT
GLUCAGON KIT 1MG
glyb/metform tab 1.25-250
glyb/metform tab 2.5-500
glyb/metform tab 5-500mg
glyburid mcr tab 1.5mg
glyburid mcr tab 3mg
glyburid mcr tab 6mg
glyburide tab 1.25mg
glyburide tab 2.5mg
glyburide tab 5mg
glycopyrrol tab 1mg
glycopyrrol tab 2mg
Page #
123
86
86
102
102
102
102
102
102
102
114
15
15
15
114
15
15
15
15
15
99
99
100
100
100
100
100
100
100
100
100
100
100
100
101
101
100
100
100
100
100
100
100
100
100
19
19
Drug Name
Page #
Drug Name
glydo gel 2%
GLYSET TAB 100MG
GLYSET TAB 25MG
GLYSET TAB 50MG
GONAL-F RFF INJ 300
GONAL-F RFF INJ 300/0.5
GONAL-F RFF INJ 450
GONAL-F RFF INJ 450/0.75
GONAL-F RFF INJ 900
GONAL-F RFF INJ 900/1.5
granisetron tab 1mg
griseofulvin sus 125/5ml
griseofulvin tab micr 500
griseofulvin tab ultr 125
griseofulvin tab ultr 250
grx hicort sup 25mg
guanfacine tab 1mg
guanfacine tab 1mg er
guanfacine tab 2mg
guanfacine tab 2mg er
guanfacine tab 3mg er
guanfacine tab 4mg er
guanidine tab 125mg
halobetasol cre 0.05%
halobetasol oin 0.05%
HALOG CRE 0.1%
haloperidol con 2mg/ml
haloperidol tab 0.5mg
haloperidol tab 10mg
haloperidol tab 1mg
haloperidol tab 20mg
haloperidol tab 2mg
haloperidol tab 5mg
HARVONI TAB 90-400MG
hc butyrate cre 0.1%
hc butyrate oin 0.1%
hc butyrate sol 0.1%
hc pramoxine cre 1-2.5%
hc pramoxine cre 2.5-1%
hc valerate cre 0.2%
hc valerate oin 0.2%
hc/acet acid sol otic
heather tab 0.35mg
hecoria cap 0.5mg
hecoria cap 1mg
hecoria cap 5mg
HELIXATE FS INJ 1000UNIT
130
97
97
97
108
108
108
108
108
108
90
7
7
7
7
128
41
69
41
69
69
69
21
128
128
128
77
77
77
77
77
77
77
12
128
128
128
128
128
128
128
87
102
117
117
117
26
HELIXATE FS INJ 2000UNIT
HELIXATE FS INJ 250UNIT
HELIXATE FS INJ 500UNIT
HEMOFIL M INJ 1700UNIT
HEMOFIL M INJ 220-400
HEMOFIL M INJ 401-800
HEMOFIL M SOL 501-2000
HEMOFIL M SOL 801-1500
hemorrhoidal sup -hc 25mg
HEXALEN CAP 50MG
HIZENTRA INJ 1GM/5ML
HIZENTRA INJ 2GM/10ML
HIZENTRA INJ 4GM/20ML
homatropaire sol 5% op
homatropine sol 5% op
HORIZANT TAB 300MG
HORIZANT TAB 600MG
HUMALOG INJ 100/ML
HUMALOG KWIK INJ 100/ML
HUMALOG MIX INJ 50/50
HUMALOG MIX INJ 50/50KWP
HUMALOG MIX INJ 75/25KWP
HUMALOG MIX SUS 75/25
HUMATE-P SOL 2400UNIT
HUMATE-P SOL 250-600
HUMATE-P SOL 500-1200
HUMIRA INJ 10MG/0.2
HUMIRA INJ 40MG/0.8
HUMIRA KIT 20MG/0.4
HUMIRA PEDIA INJ CROHNS
HUMIRA PEN INJ 40MG/0.8
HUMIRA PEN INJ CROHNS
HUMIRA PEN INJ PSORIASI
HUMULIN INJ 70/30
HUMULIN INJ 70/30KWP
HUMULIN N INJ U-100
HUMULIN N INJ U-100KWP
HUMULIN N PN INJ U-100
HUMULIN PEN INJ 70/30
HUMULIN R INJ U-100
HUMULIN R INJ U-500
hyd pol/cpm liq 10-8/5ml
hydralazine inj 20mg/ml
hydralazine tab 100mg
hydralazine tab 10mg
hydralazine tab 25mg
hydralazine tab 50mg
Page #
26
26
26
26
26
26
26
26
128
15
120
120
120
89
89
58
58
98
98
98
98
98
98
26
26
26
116
116
116
116
116
116
116
98
98
98
98
98
98
99
99
119
41
41
41
41
41
Drug Name
Page #
Drug Name
hydrochlorot cap 12.5mg
hydrochlorot tab 12.5mg
hydrochlorot tab 25mg
hydrochlorot tab 50mg
hydroco/apap sol 5-217/10
hydroco/apap sol 7.5-325
hydroco/apap tab 10-325mg
hydroco/apap tab 5-325mg
hydroco/apap tab 7.5-325
hydrocod/ibu tab 2.5-200
hydrocod/ibu tab 7.5-200
hydrocort ac sup 25mg
hydrocort cre 1%
hydrocort cre 2.5%
hydrocort lot 2.5%
hydrocort oin 1%
hydrocort oin 2.5%
hydrocort tab 10mg
hydrocort tab 20mg
hydrocort tab 5mg
hydrocort/ab oin 1%
hydrocortiso cre 2.5%
hydromorphon liq 1mg/ml
hydromorphon sup 3mg
hydromorphon tab 2mg
hydromorphon tab 4mg
hydromorphon tab 8mg
hydroxychlor tab 200mg
hydroxyurea cap 500mg
hydroxyz hcl sol 10mg/5ml
hydroxyz hcl syp 10mg/5ml
hydroxyz hcl tab 10mg
hydroxyz hcl tab 25mg
hydroxyz hcl tab 50mg
hydroxyz pam cap 100mg
hydroxyz pam cap 25mg
hydroxyz pam cap 50mg
hyophen tab
hyoscyamine sub 0.125mg
hyoscyamine tab 0.125mg
hypercare sol 20%
ibandronate tab 150mg
IBRANCE CAP 100MG
IBRANCE CAP 125MG
IBRANCE CAP 75MG
IBUDONE TAB 10-200MG
ibuprofen sus 100/5ml
81
81
81
81
50
50
50
50
50
50
50
128
128
128
128
128
128
95
95
95
128
129
50
50
50
50
50
9
15
67
67
67
67
67
67
67
67
14
19
19
131
115
15
15
15
50
47
ibuprofen tab 400mg
ibuprofen tab 600mg
ibuprofen tab 800mg
ICLUSIG TAB 15MG
ICLUSIG TAB 45MG
ILEVRO DRO 0.3% OP
ilotycin oin op
IMBRUVICA CAP 140MG
imipram hcl tab 10mg
imipram hcl tab 25mg
imipram hcl tab 50mg
imipram pam cap 100mg
imipram pam cap 125mg
imipram pam cap 150mg
imipram pam cap 75mg
imiquimod cre 5%
IMITREX SPR 5MG/ACT
INCIVEK TAB 375MG
INCRELEX INJ 40MG/4ML
indapamide tab 1.25mg
indapamide tab 2.5mg
indomethacin cap 25mg
indomethacin cap 50mg
indomethacin cap 75mg cr
indomethacin cap 75mg er
indomethacin cap 75mg sa
indomethacin cap 75mg sr
INFERGEN INJ 15MCG
INFERGEN INJ 9MCG
INFLUENZA FIRUS VACCINE
INLYTA TAB 1MG
INLYTA TAB 5MG
INTELENCE TAB 100MG
INTELENCE TAB 200MG
INTELENCE TAB 25MG
INTRON A INJ 10MU
INTRON A INJ 18MU
INTRON A INJ 18MU
INTRON A INJ 25MU
INTRON A INJ 50MU
introvale tab
INVEGA TAB 1.5MG
INVEGA TAB 3MG
INVEGA TAB 6MG
INVEGA TAB 9MG
IOPIDINE SOL 1% OP
ipratropium sol 0.02%inh
Page #
47
47
47
15
15
88
86
16
72
72
72
72
72
72
73
132
64
12
109
81
82
48
48
48
48
48
48
12
12
122
16
16
10
10
10
16
16
16
16
16
102
77
77
77
77
88
19
Drug Name
Page #
Drug Name
ipratropium spr 0.03%
ipratropium spr 0.06%
irbesar/hctz tab 150-12.5
irbesar/hctz tab 300-12.5
irbesartan tab 150mg
irbesartan tab 300mg
irbesartan tab 75mg
IRESSA TAB 250MG
ISENTRESS TAB 400MG
isoditrate tab 40mg er
isoniazid syp 50mg/5ml
isoniazid tab 100mg
isoniazid tab 300mg
ISORDIL TAB 40MG
isosorb din tab 10mg
isosorb din tab 20mg
isosorb din tab 30mg
isosorb din tab 40mg er
isosorb din tab 40mg sa
isosorb din tab 5mg
isosorb mono tab 10mg
isosorb mono tab 120mg er
isosorb mono tab 20mg
isosorb mono tab 30mg er
isosorb mono tab 60mg er
isradipine cap 2.5mg
isradipine cap 5mg
itraconazole cap 100mg
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
JAKAFI TAB 5MG
JANUVIA TAB 100MG
JANUVIA TAB 25MG
JANUVIA TAB 50MG
jencycla tab 0.35mg
jinteli tab 1mg-5mcg
jolessa tab
jolivette tab 0.35mg
junel 1.5/30 tab
junel 1/20 tab
junel fe tab 1.5/30
junel fe tab 1/20
junel fe 24 tab 1/20
k citrate sol citr acd
KALETRA SOL
19
19
42
42
42
42
42
16
10
45
8
8
8
45
45
45
45
45
45
45
45
45
45
45
45
38
38
7
16
16
16
16
16
97
97
98
102
107
102
103
103
103
103
103
103
80
10
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
KALYDECO TAB 150MG
kaopectate tab
kariva tab 28 day
KCENTRA KIT 1000UNIT
KCENTRA KIT 500UNIT
k-effervesce tab 25meq ef
kelnor tab 1/35
KENALOG AER SPRAY
KETEK TAB 300MG
KETEK TAB 400MG
ketoconazole aer 2%
ketoconazole cre 2%
ketoconazole sha 2%
ketoconazole tab 200mg
ketodan aer 2%
ketoprofen cap 200mg er
ketoprofen cap 50mg
ketoprofen cap 75mg
ketorolac sol 0.4%
ketorolac sol 0.5%
ketorolac tab 10mg
ketotif fum dro 0.025%op
kimidess tab
kionex sus 15gm/60
klor-con 10 tab 10meq er
klor-con 8 tab 8meq er
klor-con m10 tab 10meq er
KLOR-CON M15 TAB
KLOR-CON M15 TAB 15MEQ ER
klor-con m20 tab 20meq er
klor-con spr cap 10meq
klor-con spr cap 8meq
klor-con/ef tab 25meq ef
klor-con/ef tab 25meq fr
koate-dvi inj 1000unit
koate-dvi inj 250unit
KOATE-DVI INJ 500UNIT
KOGENATE FS INJ 1000/BS
KOGENATE FS INJ 1000UNIT
KOGENATE FS INJ 2000/BS
KOGENATE FS INJ 2000UNIT
KOGENATE FS INJ 250/BS
KOGENATE FS INJ 250UNIT
KOGENATE FS INJ 3000/BS
KOGENATE FS INJ 3000UNIT
Page #
10
10
119
90
103
26
26
82
103
129
4
4
124
124
124
7
124
48
48
48
88
88
48
84
103
82
82
83
83
83
83
83
83
83
83
83
26
26
26
26
26
26
26
26
26
26
26
Drug Name
Page #
Drug Name
KOGENATE FS INJ 500/BS
KOGENATE FS INJ 500UNIT
k-prime tab 25meq ef
KRISTALOSE PAK 10GM
KRISTALOSE PAK 20GM
k-sol sol 10%
k-sol sol 20%
kurvelo tab 0.15/30
k-vescent tab 25meq ef
labetalol tab 100mg
labetalol tab 200mg
labetalol tab 300mg
laclotion lot 12%
lactic acid lot 10%
lactulose sol 10gm/15
lactulose sol 20gm/30
LAMICTAL CHW 25MG
LAMICTAL CHW 5MG
LAMICTAL KIT START 49
lamivud/zido tab 150-300
lamivudine sol 10mg/ml
lamivudine tab 100mg
lamivudine tab 150mg
lamivudine tab 300mg
lamotrigine chw 25mg
lamotrigine chw 5mg
lamotrigine tab 100mg
lamotrigine tab 100mg er
lamotrigine tab 150mg
lamotrigine tab 200mg
lamotrigine tab 200mg er
lamotrigine tab 250mg er
lamotrigine tab 25mg
lamotrigine tab 25mg er
lamotrigine tab 300mg er
lamotrigine tab 50mg er
lanoxin tab 0.125mg
lanoxin tab 0.25mg
lansoprazole cap 15mg dr
lansoprazole cap 30mg dr
LANSOPRAZOLE SUS 3MG/ML
LANTUS INJ 100/ML
LANTUS INJ SOLOSTAR
larin tab 1.5/30
larin tab 1/20
larin 24 tab fe 1/20
larin fe tab 1.5/30
26
26
83
80
80
83
83
103
83
34
34
34
131
131
80
80
58
58
58
10
10
10
10
10
58
58
58
59
59
59
59
59
59
59
59
59
40
40
92
92
92
99
99
103
103
103
103
larin fe tab 1/20
LASTACAFT SOL 0.25%
latanoprost sol 0.005%
LATUDA TAB 120MG
LATUDA TAB 20MG
LATUDA TAB 40MG
LATUDA TAB 60MG
LATUDA TAB 80MG
layolis fe chw
lc-4 lidocne cre 4%
leena tab
leflunomide tab 10mg
leflunomide tab 20mg
lessina tab
LETAIRIS TAB 10MG
LETAIRIS TAB 5MG
letrozole tab 2.5mg
leucovor ca tab 10mg
leucovor ca tab 15mg
leucovor ca tab 25mg
leucovor ca tab 5mg
LEUKERAN TAB 2MG
LEUKINE INJ 250MCG
LEUKINE INJ 500 MCG
levalbuterol neb 0.31mg
levalbuterol neb 0.63mg
levalbuterol neb 1.25/0.5
levalbuterol neb 1.25mg
LEVATOL TAB 20MG
LEVEMIR INJ
LEVEMIR INJ FLEXPEN
LEVEMIR INJ FLEXTOUC
levetiraceta sol 100mg/ml
levetiraceta sol 500/5ml
levetiraceta tab 1000mg
levetiraceta tab 250mg
levetiraceta tab 500mg
levetiraceta tab 500mg er
levetiraceta tab 750mg
levetiraceta tab 750mg er
levetiracetm inj 500/5ml
levobunolol sol 0.25% op
levobunolol sol 0.5% op
levocetirizi sol 2.5/5ml
levocetirizi tab 5mg
levo-eth est tab 90-20mcg
levofloxacin inj 25mg/ml
Page #
103
84
85
77
77
77
77
77
103
130
103
116
116
103
119
119
16
114
113
113
113
16
30
30
23
23
23
23
34
99
99
99
59
59
59
59
59
59
59
59
59
85
85
1
1
103
5
Drug Name
Page #
Drug Name
levofloxacin sol 0.5%
levofloxacin sol 25mg/ml
levofloxacin tab 250mg
levofloxacin tab 500mg
levofloxacin tab 750mg
levonest tab
levonor/ethi tab 0.1-0.02
levonor/ethi tab estradio
levonorgestr tab 0.75mg
levonorgestr tab 1.5mg
levora-28 tab 0.15/30
levorphanol tab 2mg
levothyroxin inj 100mcg
levothyroxin inj 200mcg
levothyroxin inj 500mcg
levothyroxin tab 100mcg
levothyroxin tab 112mcg
levothyroxin tab 125mcg
levothyroxin tab 137mcg
levothyroxin tab 150mcg
levothyroxin tab 175mcg
levothyroxin tab 200mcg
levothyroxin tab 25mcg
levothyroxin tab 300mcg
levothyroxin tab 50mcg
levothyroxin tab 75mcg
levothyroxin tab 88mcg
levothyroxine tab 0.075mg
levoxyl tab 100mcg
levoxyl tab 112mcg
levoxyl tab 125mcg
levoxyl tab 137mcg
levoxyl tab 150mcg
levoxyl tab 175mcg
levoxyl tab 200mcg
levoxyl tab 25mcg
levoxyl tab 50mcg
levoxyl tab 75mcg
levoxyl tab 88mcg
LEXIVA SUS 50MG/ML
LEXIVA TAB 700MG
LIALDA TAB 1.2GM
lido/prilocn cre 2.5-2.5%
lido/prilocn kit 2.5-2.5%
lidocaine cre 3%
lidocaine cre 4%
lidocaine gel 2%
86
5
5
5
5
103
103
103
103
103
103
50
110
110
110
110
110
110
110
110
110
110
110
110
111
111
111
111
111
111
111
111
111
111
111
111
111
111
111
10
10
91
130
130
130
130
130
lidocaine gel 2% jelly
lidocaine oin 5%
lidocaine sol 2% visc
lidocaine sol 4%
lidocream cre 4%
lidopin cre 3%
lindane lot 1%
lindane sha 1%
linezolid tab 600mg
LINZESS CAP 145MCG
LINZESS CAP 290MCG
liothyronine tab 25mcg
liothyronine tab 50mcg
liothyronine tab 5mcg
lisinop/hctz tab 10-12.5
lisinop/hctz tab 20-12.5
lisinop/hctz tab 20-25mg
lisinopril tab 10mg
lisinopril tab 2.5mg
lisinopril tab 20mg
lisinopril tab 30mg
lisinopril tab 40mg
lisinopril tab 5mg
lithium carb cap 150mg
lithium carb cap 300mg
lithium carb cap 600mg
lithium carb tab 300mg
lithium carb tab 300mg er
lithium carb tab 450mg er
lithium sol 8meq/5ml
LIVALO TAB 1MG
LIVALO TAB 2MG
LIVALO TAB 4MG
livixil pak kit 2.5-2.5%
locoid cre 0.1%
lofene tab 2.5mg
lokara lot 0.05%
lomedia 24 tab fe
lonox tab 2.5mg
loperamide cap 2mg
lopreeza tab 0.5-0.1
lopreeza tab 1-0.5mg
lorazepam tab 0.5mg
lorazepam tab 1mg
lorazepam tab 2mg
lorcet tab 5-325mg
lorcet hd tab 10-325mg
Page #
130
130
89
130
130
130
126
126
2
93
93
111
111
111
43
43
43
43
44
44
44
44
44
63
63
63
63
63
63
63
33
33
33
130
129
90
129
103
90
90
107
107
69
69
69
51
51
Drug Name
Page #
Drug Name
lorcet plus tab 7.5-325
lortab tab 10-325mg
lortab tab 5-325mg
lortab tab 7.5-325
loryna tab 3-0.02mg
LORZONE TAB 750MG
losartan pot tab 100mg
losartan pot tab 25mg
losartan pot tab 50mg
losartan/hct tab 100-12.5
losartan/hct tab 100-25
losartan/hct tab 50-12.5
LOTEMAX SUS 0.5%
lovastatin tab 10mg
lovastatin tab 20mg
lovastatin tab 40mg
low-ogestrel tab
loxapine cap 10mg
loxapine cap 25mg
loxapine cap 50mg
loxapine cap 5mg
lp lite pak kit 2.5-2.5%
LUMIGAN SOL 0.01%
lutera tab
LYRICA CAP 100MG
LYRICA CAP 150MG
LYRICA CAP 200MG
LYRICA CAP 225MG
LYRICA CAP 25MG
LYRICA CAP 300MG
LYRICA CAP 50MG
LYRICA CAP 75MG
LYSODREN TAB 500MG
lyza tab 0.35mg
magnesium cl inj 20%
malathion lot 0.5%
maprotiline tab 25mg
maprotiline tab 50mg
maprotiline tab 75mg
marlissa tab 0.15/30
MARPLAN TAB 10MG
MATULANE CAP 50MG
matzim la tab 180mg/24
matzim la tab 240mg/24
matzim la tab 300mg/24
matzim la tab 360mg/24
matzim la tab 420mg/24
51
51
51
51
103
21
42
42
42
42
42
42
87
33
33
33
103
77
77
77
77
130
85
103
59
59
59
59
59
59
59
59
16
103
83
126
73
73
73
103
73
16
37
37
37
37
37
MAXAIR AUTOH AER 200MCG
MAXIDEX SUS 0.1% OP
meclizine tab 12.5mg
meclizine tab 25mg
meclofen sod cap 100mg
meclofen sod cap 50mg
MEDI-SELTZER TAB
medroxypr ac inj 150mg/ml
medroxypr ac tab 10mg
medroxypr ac tab 2.5mg
medroxypr ac tab 5mg
mefenam acid cap 250mg
mefloquine tab 250mg
MEGACE ES SUS
megestrol ac sus 400mg/10
megestrol ac sus 40mg/ml
megestrol ac sus 800mg/20
megestrol ac tab 20mg
megestrol ac tab 40mg
megestrol sus 625mg/5m
MEKINIST TAB 0.5MG
MEKINIST TAB 2MG
meloxicam sus 7.5/5ml
meloxicam tab 15mg
meloxicam tab 7.5mg
memantine hc tab 10mg
memantine tab hcl 5mg
MENEST TAB 0.3MG
MENEST TAB 0.625MG
MENEST TAB 1.25MG
MENEST TAB 2.5MG
MENHIBRIX INJ
MENOPUR INJ 75UNIT
MENOSTAR DIS 14MCG
MENTAX CRE 1%
meperidine inj 100mg/ml
meperidine inj 10mg/ml
meperidine inj 25mg/ml
meperidine inj 50mg/ml
meperidine sol 50mg/5ml
meperidine tab 100mg
meperidine tab 50mg
meperitab tab 100mg
meperitab tab 50mg
meprobamate tab 200mg
meprobamate tab 400mg
mercaptopur tab 50mg
Page #
23
88
91
91
48
48
48
109
109
109
109
48
9
109
16
16
16
16
16
109
16
16
48
48
48
69
69
107
107
107
107
122
108
107
124
51
51
51
51
51
51
51
51
51
67
67
16
Drug Name
Page #
Drug Name
mesalamine ene 4gm
mesalamine kit 4gm
MESTINON SYP 60MG/5ML
metadate tab 20mg er
metaproteren syp 10mg/5ml
metaproteren tab 10mg
metaproteren tab 20mg
metaxalone tab 400mg
metaxalone tab 800mg
metformin tab 1000mg
metformin tab 500mg
metformin tab 500mg er
metformin tab 750mg er
metformin tab 850mg
methadone sol 10mg/5ml
methadone sol 5mg/5ml
methadone tab 10mg
methadone tab 5mg
methamphetam tab 5mg
methazolamid tab 25mg
methazolamid tab 50mg
methenam hip tab 1gm
methimazole tab 10mg
methimazole tab 5mg
methocarbam tab 500mg
methocarbam tab 750mg
methotrexate tab 2.5mg
methscopolam tab 2.5mg
methscopolam tab 5mg
methyclothia tab 5mg
methyldopa tab 250mg
methyldopa tab 500mg
methylphenid cap 10mg
methylphenid cap 20mg
methylphenid cap 20mg er
methylphenid cap 30mg
methylphenid cap 30mg er
methylphenid cap 40mg
methylphenid cap 40mg er
methylphenid cap 50mg
methylphenid cap 60mg
methylphenid sol 10mg/5ml
methylphenid sol 5mg/5ml
methylphenid tab 10mg
methylphenid tab 10mg er
methylphenid tab 18mg er
methylphenid tab 18mg er
91
91
21
56
23
23
23
21
21
97
97
97
97
97
51
51
51
51
55
85
85
14
110
110
21
21
16
19
19
81
41
41
56
56
56
56
56
56
56
56
56
56
56
57
57
57
57
methylphenid tab 20mg
methylphenid tab 20mg er
methylphenid tab 20mg sr
methylphenid tab 27mg er
methylphenid tab 27mg er
methylphenid tab 36mg er
methylphenid tab 36mg er
methylphenid tab 54mg er
methylphenid tab 54mg er
methylphenid tab 5mg
methylpred pak 4mg
methylpred tab 16mg
methylpred tab 32mg
methylpred tab 4mg
methylpred tab 8mg
metipranolol sol 0.3% oph
metoclopram inj 10mg/2ml
metoclopram inj 5mg/ml
metoclopram sol 10/10ml
metoclopram sol 5mg/5ml
metoclopram tab 10mg
metoclopram tab 5mg
metolazone tab 10mg
metolazone tab 2.5mg
metolazone tab 5mg
metoprl/hctz tab 100-25mg
metoprl/hctz tab 100-50mg
metoprl/hctz tab 50-25mg
metoprol tar tab 100mg
metoprol tar tab 25mg
metoprol tar tab 50mg
metoprolol tab 100mg er
metoprolol tab 200mg er
metoprolol tab 25mg er
metoprolol tab 50mg er
metronidazol cap 375mg
metronidazol cre 0.75%
metronidazol gel 0.75%vag
metronidazol lot 0.75%
metronidazol tab 250mg
metronidazol tab 500mg
mexiletine cap 150mg
mexiletine cap 200mg
mexiletine cap 250mg
microgestin tab 1.5/30
microgestin tab 1/20
microgestin tab fe 1/20
Page #
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9
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9
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Drug Name
Page #
Drug Name
microgestin tab fe1.5/30
midazolam syp 2mg/ml
midodrine tab 10mg
midodrine tab 2.5mg
midodrine tab 5mg
MIGRANAL SPR 4MG/ML
mimvey tab 1-0.5mg
mimvey lo tab 0.5-0.1
minocycline cap 100mg
minocycline cap 50mg
minocycline cap 75mg
minocycline tab 100mg
minocycline tab 135mg er
minocycline tab 45mg er
minocycline tab 50mg
minocycline tab 75mg
minocycline tab 90mg er
minoxidil tab 10mg
minoxidil tab 2.5mg
MIRAPEX ER TAB 2.25MG
mirtazapine tab 15mg
mirtazapine tab 15mg odt
mirtazapine tab 30mg
mirtazapine tab 30mg odt
mirtazapine tab 45mg
mirtazapine tab 45mg odt
mirtazapine tab 7.5mg
MIRVASO GEL 0.33%
misoprostol tab 100mcg
misoprostol tab 200mcg
modafinil tab 100mg
modafinil tab 200mg
moderiba tab 200mg
moexipr/hctz tab 15-12.5
moexipr/hctz tab 15-25mg
moexipr/hctz tab 7.5-12.5
moexipril tab 15mg
moexipril tab 7.5mg
mometasone cre 0.1%
mometasone oin 0.1%
mometasone sol 0.1%
MONOCLATE-P INJ 250UNIT
MONOCLATE-P INJ 500UNIT
mono-linyah tab 0.25-35
mononessa tab
MONONINE INJ 500UNIT
montelukast chw 4mg
104
69
22
22
22
22
107
107
6
6
6
6
132
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6
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41
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65
73
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73
132
92
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57
57
13
44
44
44
44
44
129
129
129
26
27
104
104
27
118
montelukast chw 5mg
montelukast gra 4mg
montelukast tab 10mg
MONUROL PAK GRANULES
morphine sul cap 100mg er
morphine sul cap 120mg er
morphine sul cap 20mg er
morphine sul cap 30mg er
morphine sul cap 30mg er
morphine sul cap 45mg er
morphine sul cap 50mg er
morphine sul cap 60mg er
morphine sul cap 60mg er
morphine sul cap 75mg er
morphine sul cap 80mg er
morphine sul cap 90mg er
morphine sul inj 0.5mg/ml
morphine sul inj 10mg/ml
morphine sul inj 150/30ml
morphine sul inj 15mg/ml
morphine sul inj 1mg/ml
morphine sul inj 25mg/ml
morphine sul inj 2mg/ml
morphine sul inj 4mg/ml
morphine sul inj 50mg/ml
morphine sul inj 8mg/ml
morphine sul sol 10/0.5ml
morphine sul sol 100/5ml
morphine sul sol 10mg/5ml
morphine sul sol 20mg/5ml
morphine sul sol 20mg/ml
morphine sul sup 20mg
morphine sul sup 5mg
morphine sul tab 100mg cr
morphine sul tab 100mg er
morphine sul tab 15mg
morphine sul tab 15mg cr
morphine sul tab 15mg er
morphine sul tab 200mg er
morphine sul tab 30mg
morphine sul tab 30mg cr
morphine sul tab 30mg er
morphine sul tab 60mg cr
morphine sul tab 60mg er
MOXEZA SOL 0.5%
moxifloxacin tab 400mg
MULTAQ TAB 400MG
Page #
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51
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40
Drug Name
Page #
Drug Name
mupirocin ca cre 2%
mupirocin cre 2%
mupirocin oin 2%
my way tab 1.5mg
mycophenolat cap 250mg
mycophenolat sus 200mg/ml
mycophenolat tab 500mg
mycophenolic tab 180mg dr
mycophenolic tab 360mg dr
mydral sol 0.5% op
mydral sol 1% op
MYLERAN TAB 2MG
MYRBETRIQ TAB 25MG
MYRBETRIQ TAB 50MG
myzilra tab
nabumetone tab 500mg
nabumetone tab 750mg
nadolol tab 20mg
nadolol tab 40mg
nadolol tab 80mg
naloxone inj 1mg/ml
naltrexone tab 50mg
NAMENDA SOL 10MG/5ML
NAMENDA TAB 10MG
NAMENDA TAB 5MG
naphazoline sol 0.1% op
naproxen sus 125/5ml
naproxen tab 250mg
naproxen tab 375mg
naproxen tab 500mg
naproxen dr tab 375mg
naproxen dr tab 500mg
naproxen ec tab 375mg
naproxen ec tab 500mg
naproxen sod tab 220mg
naproxen sod tab 275mg
naproxen sod tab 550mg
naratriptan tab 1mg
naratriptan tab 2.5mg
NASONEX SPR 50MCG/AC
nateglinide tab 120mg
nateglinide tab 60mg
NATESTO GEL 5.5MG
nature-throi tab 130mg
nature-throi tab 16.25mg
nature-throi tab 195mg
nature-throi tab 32.5mg
123
123
123
104
117
117
117
117
117
89
89
16
134
134
104
48
48
35
35
35
70
70
70
70
70
89
48
48
48
48
48
48
48
48
48
48
48
64
64
88
99
99
97
111
111
111
111
nature-throi tab 65mg
NEBUPENT INH 300MG
necon tab 0.5/35
necon tab 1/35
necon tab 1/50-28
necon tab 10/11-28
necon tab 7/7/7
nefazodone tab 100mg
nefazodone tab 150mg
nefazodone tab 200mg
nefazodone tab 250mg
nefazodone tab 50mg
neo/poly/dex sus 0.1% op
neo/poly/hc sol 1% otic
neo/poly/hc sus 1% otic
neofrin sol 10% op
neofrin sol 2.5% op
neomycin tab 500mg
neuac gel 1.2-5%
NEULASTA INJ 6MG/0.6M
NEULASTA KIT 6MG/0.6M
NEUPOGEN INJ 300/0.5
NEUPOGEN INJ 300MCG
NEUPOGEN INJ 480/0.8
NEUPOGEN INJ 480MCG
NEUPRO DIS 1MG/24HR
NEUPRO DIS 2MG/24HR
NEUPRO DIS 3MG/24HR
NEUPRO DIS 4MG/24HR
NEUPRO DIS 6MG/24HR
NEUPRO DIS 8MG/24HR
NEVANAC SUS 0.1%
nevirapine sus 50mg/5ml
nevirapine tab 200mg
nevirapine tab 400mg er
NEXAVAR TAB 200MG
next choice tab 1.5mg
niacin tab 500mg er
niacin er tab 1000mg
niacin er tab 500mg
niacin er tab 750mg
nicardipine cap 20mg
nicardipine cap 30mg
nicotine kit
nicotine patch 14 mg/24hr
nicotine patch 14 mg/24hr
nicotine patch 21 mg/24hr
Page #
111
9
104
104
104
104
104
73
73
73
73
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88
88
88
89
89
2
123
30
30
30
30
30
30
65
65
65
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65
65
88
10
10
10
16
104
31
31
31
31
39
39
20
20
20
20
Drug Name
Page #
Drug Name
nicotine patch 21 mg/24hr
nicotine patch 7 mg/24hr
nicotine patch 7 mg/24hr
nicotine polacrilex gum 2 mg
nicotine polacrilex gum 2 mg
nicotine polacrilex lozg 2 mg
nicotine polacrilex lozg 2 mg
nicotine polacrilex lozg 4 mg
nicotine polacrilex lozg 4 mg
NICOTROL INH
NICOTROL NS SPR 10MG/ML
nifediac cc tab 30mg er
nifediac cc tab 60mg er
nifedical xl tab 30mg
nifedical xl tab 60mg
nifedipine cap 10mg
nifedipine cap 20mg
nifedipine tab 30mg er
nifedipine tab 60mg er
nifedipine tab 90mg er
nikki tab 3-0.02mg
NILANDRON TAB 150MG
nimodipine cap 30mg
nisoldipine tab 17mg er
nisoldipine tab 20mg
nisoldipine tab 25.5mg
nisoldipine tab 30mg
nisoldipine tab 34mg er
nisoldipine tab 40mg
nisoldipine tab 8.5mg er
NITRO-BID OIN 2%
NITRO-DUR DIS 0.3MG/HR
nitrofur mac cap 100mg
nitrofur mac cap 50mg
nitrofurantn cap 100mg
nitrofurantn sus 25mg/5ml
nitrofuranto cap 100mg
nitroglycer aer 400mcg
nitroglycer cap 2.5mg er
nitroglycer cap 2.5mg sr
nitroglycer cap 6.5mg er
nitroglycer cap 6.5mg sr
nitroglycer cap 9mg er
NITRONAL SOL 1MG/ML
NITROSTAT SUB 0.3MG
NITROSTAT SUB 0.4MG
NITROSTAT SUB 0.6MG
20
20
20
20
20
20
20
20
20
20
20
39
39
39
39
39
39
39
39
39
104
16
39
39
39
39
39
39
39
39
45
45
14
14
14
14
14
45
45
45
45
45
45
45
46
46
46
nitro-time cap 2.5mg cr
nitro-time cap 6.5mg cr
nitro-time cap 9mg cr
nizatidine cap 150mg
nizatidine cap 300mg
nizatidine sol 15mg/ml
nohist-dm liq
nora-be tab 0.35mg
noreth/ethin chw fe
noreth/ethin tab 0.5-2.5
noreth/ethin tab 1/20
noreth/ethin tab 1mg-5mcg
noreth/ethin tab fe 1/20
norethin ace tab 5mg
norethindron tab 0.35mg
norgest/ethi tab 0.25/35
norgest/ethi tab estradio
norlyroc tab 0.35mg
NOROXIN TAB 400MG
NORPACE CAP 100MG CR
nortrel tab 0.5/35
nortrel tab 1/35
nortrel tab 7/7/7
nortriptylin cap 10mg
nortriptylin cap 25mg
nortriptylin cap 50mg
nortriptylin cap 75mg
nortriptylin sol 10mg/5ml
NORVIR CAP 100MG
NORVIR SOL 80MG/ML
NORVIR TAB 100MG
novarel inj 10000unt
NOVOLIN INJ 70/30
NOVOLIN N INJ U-100
NOVOLIN R INJ U-100
NOVOLOG INJ 100/ML
NOVOLOG INJ FLEXPEN
NOVOLOG INJ PENFILL
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ FLEXPEN
NOVOSEVEN 1,200 MCG VIAL
NOVOSEVEN 4,800 MCG VIAL
NOVOSEVEN INJ 2400MCG
NOVOSEVEN RT INJ 1MG
NOVOSEVEN RT INJ 2MG
NOVOSEVEN RT INJ 5MG
NOVOSEVEN RT INJ 8MG
Page #
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46
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6
40
104
104
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73
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73
73
10
10
10
108
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99
99
99
99
99
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27
27
27
27
27
27
27
Drug Name
Page #
Drug Name
NOXAFIL SUS 40MG/ML
np thyroid tab 30mg
np thyroid tab 60mg
np thyroid tab 90mg
NUCYNTA ER TAB 100MG
NUCYNTA ER TAB 200MG
NUCYNTA TAB 100MG
NUCYNTA TAB 75MG
NUEDEXTA CAP 20-10MG
nulev tab 0.125mg
NUTROPIN INJ 10MG
NUTROPIN AQ INJ 10MG/2ML
NUTROPIN AQ INJ 20MG/2ML
NUTROPIN AQ INJ NUSPIN 5
NUVARING MIS
NUVIGIL TAB 150MG
NUVIGIL TAB 200MG
NUVIGIL TAB 250MG
nyamyc pow 100000
nystat/triam cre
nystat/triam oin
nystatin cre 100000
nystatin oin 100000
nystatin pow
nystatin pow 100000
nystatin pow 10bu
nystatin pow 150mu
nystatin pow 1bu
nystatin pow 2bu
nystatin pow 500mu
nystatin pow 50mu
nystatin pow 5bu
nystatin sus 100000
nystatin tab 500000
nystop pow 100000
ocella tab 3-0.03mg
OCTAGAM INJ 10GM
OCTAGAM INJ 1GM
OCTAGAM INJ 2.5GM
OCTAGAM INJ 25GM
OCTAGAM INJ 5GM
OFEV CAP 100MG
OFEV CAP 150MG
ofloxacin dro 0.3% op
ofloxacin dro 0.3%otic
ofloxacin tab 200mg
ofloxacin tab 300mg
7
111
111
111
53
53
53
53
70
19
109
109
109
109
104
57
57
57
124
129
129
124
124
7
124
7
7
7
7
7
7
7
7
8
124
104
120
120
120
120
120
118
118
86
86
6
6
ofloxacin tab 400mg
ogestrel tab
olanza/fluox cap 12-25mg
olanza/fluox cap 12-50mg
olanza/fluox cap 6-25mg
olanza/fluox cap 6-50mg
olanzapine tab 10mg
olanzapine tab 10mg odt
olanzapine tab 15mg
olanzapine tab 15mg odt
olanzapine tab 2.5mg
olanzapine tab 20mg
olanzapine tab 20mg odt
olanzapine tab 5mg
olanzapine tab 5mg odt
olanzapine tab 7.5mg
Olopatadine SOL 0.1% OP
omega-3-acid cap 1gm
omeprazole cap 10mg
omeprazole cap 20mg
omeprazole cap 40mg
ondansetron inj 4mg/2ml
ondansetron sol 4mg/5ml
ondansetron tab 24mg
ondansetron tab 4mg
ondansetron tab 4mg odt
ondansetron tab 8mg
ondansetron tab 8mg odt
ONFI TAB 10MG
ONFI TAB 20MG
ONFI TAB 5MG
ONGLYZA TAB 2.5MG
ONGLYZA TAB 5MG
opcicon tab 1.5mg
OPSUMIT TAB 10MG
oralone pst 0.1%
ORAP TAB 1MG
ORAP TAB 2MG
ORENCIA INJ 125MG/ML
ORFADIN CAP 10MG
ORFADIN CAP 2MG
ORFADIN CAP 5MG
orph/asa/caf tab
orphenadrine inj 30mg/ml
orphenadrine tab 100mg cr
orphenadrine tab 100mg er
orsythia tab
Page #
6
104
73
73
73
73
77
77
77
77
77
78
78
78
78
78
84
31
92
92
92
90
90
90
90
90
90
90
62
63
63
98
98
104
119
129
78
78
116
118
118
118
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22
22
22
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Drug Name
Page #
Drug Name
ortho-est tab 0.625
ortho-est tab 1.25
oscimin sub 0.125mg
oscimin tab 0.125mg
OSMOPREP TAB 1.5GM
OTEZLA TAB 10/20/30
OTEZLA TAB 30MG
OVIDREL INJ
oxandrolone tab 10mg
oxandrolone tab 2.5mg
oxaprozin tab 600mg
oxazepam cap 10mg
oxazepam cap 15mg
oxazepam cap 30mg
oxcarbazepin sus 300mg/5m
oxcarbazepin tab 150mg
oxcarbazepin tab 300mg
oxcarbazepin tab 600mg
OXISTAT CRE 1%
OXISTAT LOT 1%
OXSORALEN LOT 1%
oxybutynin syp 5mg/5ml
oxybutynin tab 10mg er
oxybutynin tab 15mg er
oxybutynin tab 5mg
oxybutynin tab 5mg er
oxycod/apap tab 10-325mg
oxycod/apap tab 2.5-325
oxycod/apap tab 5-325mg
oxycod/apap tab 7.5-325
oxycod/apap tab 7.5-500
oxycod/ibu tab 5-400mg
oxycodone cap 5mg
oxycodone sol 5mg/5ml
oxycodone tab 10mg
oxycodone tab 10mg er
oxycodone tab 15mg
oxycodone tab 20mg
oxycodone tab 20mg er
oxycodone tab 30mg
oxycodone tab 40mg er
oxycodone tab 5mg
oxycodone tab 80mg er
oxycontin tab 40mg cr
oxycontin tab 80mg cr
oxymorphone tab 10mg er
oxymorphone tab 15mg er
107
107
19
19
92
116
116
108
97
97
49
69
69
69
59
59
59
59
124
124
131
133
133
133
133
133
53
53
53
53
53
53
53
53
53
53
53
53
53
53
53
53
53
53
53
53
53
oxymorphone tab 20mg er
oxymorphone tab 30mg er
oxymorphone tab 40mg er
oxymorphone tab 5mg er
oxymorphone tab 7.5mg er
oxymorphone tab hcl 10mg
oxymorphone tab hcl 5mg
pacerone tab 200mg
pacerone tab 400mg
paliperidone tab er 1.5mg
paliperidone tab er 3mg
paliperidone tab er 6mg
paliperidone tab er 9mg
PANCREAZE CAP 10500UNT
PANCREAZE CAP 16800UNT
PANCREAZE CAP 21000UNT
PANCREAZE CAP 4200UNIT
pancrelipase cap 5000unit
pantoprazole tab 20mg
pantoprazole tab 40mg
parcaine sol 0.5% op
paricalcitol cap 1 mcg
paricalcitol cap 2 mcg
paricalcitol cap 4 mcg
paroex sol 0.12%
paromomycin cap 250mg
paroxetine tab 10mg
paroxetine tab 20mg
paroxetine tab 30mg
paroxetine tab 40mg
PATADAY SOL 0.2%
PCE TAB 333MG EC
PCE TAB 500MG EC
pedi-dri pow 100000
peg 3350 sol electrol
peg-3350 sol electrol
peg-3350/kcl sol /sodium
PEGANONE TAB 250MG
PEGASYS 180 MCG/0.5 ML CONV.PK
PEG-INTRON KIT 120 RP
PEGINTRON KIT 120MCG
PEG-INTRON KIT 120MCG
PEG-INTRON KIT 150 RP
PEGINTRON KIT 150MCG
PEG-INTRON KIT 150MCG
PEGINTRON KIT 50MCG
PEG-INTRON KIT 50MCG
Page #
53
53
53
53
54
54
54
40
40
78
78
78
78
93
93
93
93
93
92
92
89
136
136
136
87
8
73
73
73
73
84
4
4
124
92
92
92
63
12
12
12
12
12
12
12
12
12
Drug Name
Page #
Drug Name
PEG-INTRON KIT 50MCG RP
PEGINTRON KIT 80MCG
PEG-INTRON KIT 80MCG
PEG-INTRON KIT 80MCG RP
pegylax pow
penicilln vk sol 125/5ml
penicilln vk sol 250/5ml
penicilln vk tab 250mg
penicilln vk tab 500mg
penta/apap tab 25-650mg
PENTASA CAP 250MG CR
PENTASA CAP 500MG CR
pentaz/nalox tab 50-0.5mg
pentoxifylli tab 400mg cr
pentoxifylli tab 400mg er
PERFOROMIST NEB 20MCG
perindopril tab 2mg
perindopril tab 4mg
perindopril tab 8mg
periogard sol 0.12%
permethrin cre 5%
perphenazine tab 16mg
perphenazine tab 2mg
perphenazine tab 4mg
perphenazine tab 8mg
persa-gel gel 10%
persa-gel xs gel 5%
PERTZYE CAP
phenadoz sup 25mg
phenazo tab 200mg
phenazo tab 95mg
phenazopyrid tab 100mg
phenazopyrid tab 200mg
phenazopyrid tab 95mg
phenazoyrid tab 95mg
phenelzine tab 15mg
phenergan sup 25mg
phenergan sup 50mg
phenobarb elx 20mg/5ml
phenobarb sol 20mg/5ml
phenobarb tab 100mg
phenobarb tab 15mg
phenobarb tab 16.2mg
phenobarb tab 30mg
phenobarb tab 32.4mg
phenobarb tab 60mg
phenobarb tab 64.8mg
12
12
12
12
92
5
5
5
5
54
91
91
54
31
31
23
44
44
44
87
126
78
78
78
78
126
126
93
1
130
130
130
130
130
130
74
1
1
67
67
67
67
67
68
68
68
68
phenobarb tab 97.2mg
phentermine tab 37.5mg
phenylephrin sol 10% op
phenylephrin sol 2.5% op
PHENYTEK CAP 200MG
PHENYTEK CAP 300MG
phenytoin chw 50mg
phenytoin ex cap 100mg
phenytoin ex cap 200mg
phenytoin ex cap 300mg
phenytoin inj 50mg/ml
phenytoin sus 125/5ml
philith tab 0.4-35
PHOSLYRA SOL
phospha 250 tab neutral
PHOSPHOLINE SOL 0.125%OP
PICATO GEL 0.015%
PICATO GEL 0.05%
pilocarpine sol 1% op
pilocarpine sol 2% op
pilocarpine sol 4% op
pilocarpine tab 5mg
pilocarpine tab 7.5mg
pimtrea tab
pindolol tab 10mg
pindolol tab 5mg
pioglita/met tab 15-500mg
pioglita/met tab 15-850mg
pioglitazone tab 15mg
pioglitazone tab 30mg
pioglitazone tab 45mg
pirmella tab 1/35
pirmella tab 7/7/7
piroxicam cap 10mg
piroxicam cap 20mg
podofilox sol 0.5%
polyeth glyc pow 3350 nf
polymyxin b/ sol trimethp
polysaccharide iron complex cap 150 mg
polysaccharide iron complex cap 200 mg
polytrim sol op
POMALYST CAP 1MG
POMALYST CAP 2MG
POMALYST CAP 3MG
POMALYST CAP 4MG
portia-28 tab
pot bicarbon tab 25meq ef
Page #
68
55
89
89
63
63
63
63
63
63
63
63
104
83
83
85
133
133
85
85
85
21
21
104
35
35
100
100
100
101
101
105
105
49
49
133
92
86
25
25
86
16
16
16
17
105
83
Drug Name
Page #
Drug Name
pot chloride cap 10meq er
pot chloride cap 8meq er
pot chloride inj 10meq
pot chloride inj 20meq
pot chloride inj 2meq/ml
pot chloride inj 40meq
pot chloride sol 10%
pot chloride sol 10% sf
pot chloride sol 20%
pot chloride sol 20% sf
pot chloride tab 10meq cr
pot chloride tab 10meq er
pot chloride tab 20meq er
pot chloride tab 25meq ef
pot chloride tab 8meq cr
pot chloride tab 8meq er
pot chloride tab 8meq sa
pot chloride tab 8meq sr
pot citrate tab 1080mg
pot citrate tab 1620mg
pot citrate tab 540mg er
pot cl micro tab 10meq cr
pot cl micro tab 10meq er
pot cl micro tab 20meq cr
pot cl micro tab 20meq er
pot/chloride tab 25meq ef
potassium tab 25meq ef
POTIGA TAB 200MG
POTIGA TAB 300MG
POTIGA TAB 400MG
POTIGA TAB 50MG
pr benzoyl liq 7% wash
PRADAXA CAP 150MG
PRADAXA CAP 75MG
pramipexole tab 0.125mg
pramipexole tab 0.25mg
pramipexole tab 0.375mg
pramipexole tab 0.5mg
pramipexole tab 0.75mg
pramipexole tab 1.5mg
pramipexole tab 1mg
prascion emu
pravastatin tab 10mg
pravastatin tab 20mg
pravastatin tab 40mg
pravastatin tab 80mg
prazosin hcl cap 1mg
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prazosin hcl cap 2mg
prazosin hcl cap 5mg
PRED MILD SUS 0.12% OP
pred sod pho sol 1% op
pred sod pho sol 5mg/5ml
prednicarbat cre 0.1%
prednisolone sol 15mg/5ml
prednisolone sol 15mg/5ml
prednisolone sol 25mg/5ml
prednisolone sus 1% op
prednisolone syp 15mg/5ml
PREDNISONE CON 5MG/ML
prednisone pak 10mg
prednisone pak 5mg
prednisone sol 5mg/5ml
prednisone tab 10mg
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 20mg
prednisone tab 50mg
prednisone tab 5mg
PREFEST TAB
pregnyl inj 10000unt
PREMARIN TAB 0.3MG
PREMARIN TAB 0.45MG
PREMARIN TAB 0.625MG
PREMARIN TAB 0.9MG
PREMARIN TAB 1.25MG
PREMARIN VAG CRE 0.625MG
PREMPHASE TAB
PREMPRO TAB .625-2.5
PREMPRO TAB 0.3-1.5
PREMPRO TAB 0.45-1.5
PREMPRO TAB 0.625-5
prenatal multivit-min w/fe-fa tab
prenatal vit w/ ferrous fumarate-folic acid
cap
prenatal vit w/ ferrous fumarate-folic acid
tab
prenatal vit w/ ferrous gluconate-folic
acid tab
PREPOPIK PAK
prevalite pow 4gm
prevalite pow 4gm pk
previfem tab
PREZISTA TAB 150MG
PREZISTA TAB 400MG
Page #
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Drug Name
Page #
Drug Name
PREZISTA TAB 600MG
PREZISTA TAB 75MG
PREZISTA TAB 800MG
primaquine tab 26.3mg
primidone tab 250mg
primidone tab 50mg
PRISTIQ TAB 100MG
PRISTIQ TAB 100MG
PRISTIQ TAB 25MG
PRISTIQ TAB 50MG
PRISTIQ TAB 50MG
PRIVIGEN INJ 10GRAMS
PRIVIGEN INJ 20GRAMS
PRIVIGEN INJ 5 GRAMS
PROAIR HFA AER
PROAIR RESPI AER
proben/colch tab 500-0.5
probenecid tab 500mg
prochlorper sup 25mg
prochlorper tab 10mg
prochlorper tab 5mg
PROCRIT INJ 10000/ML
PROCRIT INJ 2000/ML
PROCRIT INJ 20000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 40000/ML
proctocare cre -hc 2.5%
procto-pak cre 1%
proctosol hc cre 2.5%
proctozone cre -hc 2.5%
proctozone cre -hc 2.5%
PROFILNINE SD 500 UNITS VIAL
progesterone cap 100mg
progesterone cap 200mg
progesterone inj 50mg/ml
PROGLYCEM SUS 50MG/ML
PROLIA SOL 60MG/ML
PROMACTA TAB 12.5MG
PROMACTA TAB 25MG
PROMACTA TAB 50MG
PROMACTA TAB 75MG
prometh vc syp 6.25-5/5
prometh vc syp plain
prometh/cod syp 6.25-10
prometh/pe syp 6.25-5/5
promethazine sol 6.25/5ml
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promethazine sup 25mg
promethazine sup 50mg
promethazine syp 6.25/5ml
promethazine syp dm
promethazine tab 12.5mg
promethazine tab 25mg
promethazine tab 50mg
promethegan sup 25mg
promethegan sup 50mg
propafenone cap 225mg er
propafenone cap 325mg er
propafenone cap 425mg sr
propafenone tab 150mg
propafenone tab 225mg
propafenone tab 300mg
proparacaine sol 0.5% op
propranolol cap 120mg er
propranolol cap 160mg er
propranolol cap 60mg er
propranolol cap 80mg er
propranolol sol 20mg/5ml
propranolol sol 40mg/5ml
propranolol tab 10mg
propranolol tab 20mg
propranolol tab 40mg
propranolol tab 60mg
propranolol tab 80mg
propylthiour tab 50mg
protriptylin tab 10mg
protriptylin tab 5mg
PROVENTIL AER HFA
PROZENA PAD 4%
PULMICORT INH 180MCG
PULMICORT INH 90MCG
pulmosal neb 7%
PULMOZYME SOL 1MG/ML
pyrazinamide tab 500mg
pyridostigm tab 60mg
pyridostigmi tab 180mg
qc azo tab 95mg
qnapril/hctz tab 10-12.5
qnapril/hctz tab 20-12.5
qnapril/hctz tab 20-25mg
quasense tab
quetiapine tab 100mg
quetiapine tab 200mg
quetiapine tab 25mg
Page #
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1
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78
Drug Name
Page #
Drug Name
quetiapine tab 300mg
quetiapine tab 400mg
quetiapine tab 50mg
quinapril tab 10mg
quinapril tab 20mg
quinapril tab 40mg
quinapril tab 5mg
quinidine gl tab 324mg cr
quinidine gl tab 324mg er
quinidine su tab 300mg
quinidine su tab 300mg er
QVAR AER 40MCG
QVAR AER 80MCG
ra renewal gel 10%
ra urinary tab 95mg
ra urinary tab pain max
rabeprazole tab 20mg
raloxifene hcl tab 60 mg
ramipril cap 1.25mg
ramipril cap 10mg
ramipril cap 2.5mg
ramipril cap 5mg
RANEXA TAB 1000MG
RANEXA TAB 500MG
ranitidine syp 150/10ml
ranitidine syp 15mg/ml
ranitidine syp 75mg/5ml
ranitidine tab 150mg
ranitidine tab 300mg
RAPAFLO CAP 8MG
RAPAMUNE SOL 1MG/ML
REBIF INJ 22/0.5
REBIF INJ 44/0.5
REBIF REBIDO INJ 22/0.5
REBIF REBIDO INJ 44/0.5
REBIF REBIDO INJ TITRATN
REBIF TITRTN INJ PACK
reclipsen tab
RECOMBINATE INJ 220-400
RECOMBINATE INJ 401-800
RECOMBINATE INJ 801-1240
rectacort-hc sup 25mg
RECTIV OIN 0.4%
REGRANEX GEL 0.01%
relador pak kit 2.5-2.5%
relador pak kit plus
RELENZA AER DISKHALE
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40
40
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RELENZA MIS DISKHALE
RELPAX TAB 20MG
RELPAX TAB 40MG
REMICADE INJ 100MG
RENAGEL TAB 400MG
RENAGEL TAB 800MG
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
repaglinide tab 0.5mg
repaglinide tab 1mg
repaglinide tab 2mg
requip tab 1mg
RESCRIPTOR TAB 100 MG
RESCRIPTOR TAB 200MG
reserpine tab 0.1mg
reserpine tab 0.25mg
REVLIMID CAP 10MG
REVLIMID CAP 15MG
REVLIMID CAP 2.5MG
REVLIMID CAP 20MG
REVLIMID CAP 25MG
REVLIMID CAP 5MG
REYATAZ CAP 100MG
REYATAZ CAP 150MG
REYATAZ CAP 200MG
REYATAZ CAP 300MG
RIASTAP SOL 1GM
ribapak pak 1200/day
ribapak pak 800/day
ribasphere cap 200mg
ribasphere tab 200mg
ribasphere tab 400mg
ribasphere tab 600mg
ribatab pak 1000/day
ribatab tab 1200/day
ribatab tab 800/day
ribavirin cap 200mg
ribavirin tab 200mg
RIDAURA CAP 3MG
rifabutin cap 150mg
RIFAMATE CAP
rifampin cap 150mg
rifampin cap 300mg
rifampin inj 600 mg
riluzole tab 50mg
rimantadine tab 100mg
risedronate tab 150mg
Page #
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64
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115
Drug Name
Page #
Drug Name
risperidone sol 1mg/ml
risperidone tab 0.25 odt
risperidone tab 0.25mg
risperidone tab 0.5mg
risperidone tab 0.5mg od
risperidone tab 1 mg
risperidone tab 1mg
risperidone tab 1mg odt
risperidone tab 2mg
risperidone tab 2mg odt
risperidone tab 3mg
risperidone tab 3mg odt
risperidone tab 4mg
risperidone tab 4mg odt
RITUXAN INJ 500MG
rivastigmine cap 1.5mg
rivastigmine cap 3mg
rivastigmine cap 4.5mg
rivastigmine cap 6mg
RIXUBIS INJ 1000UNIT
RIXUBIS INJ 2000UNIT
RIXUBIS INJ 250 UNIT
RIXUBIS INJ 3000UNIT
RIXUBIS INJ 500UNIT
rizatriptan tab 10mg
rizatriptan tab 10mg odt
rizatriptan tab 5mg
rizatriptan tab 5mg odt
romycin oin op
ropinirole tab 0.25mg
ropinirole tab 0.5mg
ropinirole tab 12mg er
ropinirole tab 1mg
ropinirole tab 2mg
ropinirole tab 2mg er
ropinirole tab 3mg
ropinirole tab 4mg
ropinirole tab 4mg er
ropinirole tab 5mg
ropinirole tab 6mg er
ropinirole tab 8mg er
rosadan cre 0.75%
rosanil emu cleanser
roxicet tab 5-325mg
ROZEREM TAB 8MG
SABRIL POW 500MG
SABRIL TAB 500MG
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salsalate tab 500mg
salsalate tab 750mg
SAMSCA TAB 15MG
SAMSCA TAB 30MG
SANDIMMUNE SOL 100MG/ML
SANTYL OIN 250/GM
SAPHRIS SUB 10MG
SAPHRIS SUB 2.5MG
SAPHRIS SUB 5MG
SAVELLA MIS TITR PAK
SAVELLA TAB 100MG
SAVELLA TAB 25MG
SAVELLA TAB 50MG
sb urinary tab pain max
scalacort lot 2%
se bpo wash liq 7%
selegiline cap 5mg
selenium sul lot 2.5%
selenium sul sha 2.25%
selenium sul sha 2.5%
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
SENSIPAR TAB 30MG
SENSIPAR TAB 60MG
SENSIPAR TAB 90MG
SEREVENT DIS AER 50MCG
serophene tab 50mg
SEROQUEL XR TAB 150MG
SEROQUEL XR TAB 200MG
SEROQUEL XR TAB 300MG
SEROQUEL XR TAB 400MG
SEROQUEL XR TAB 50MG
sertraline con 20mg/ml
sertraline tab 100mg
sertraline tab 25mg
sertraline tab 50mg
setlakin tab
sevelamer tab 800mg
sharobel tab 0.35mg
SHUR-SEAL GEL 2%
SIGNIFOR INJ 0.3MG/ML
SIGNIFOR INJ 0.6MG/ML
SIGNIFOR INJ 0.9MG/ML
sildenafil tab 20mg
silver sulfa cre 1%
SIMBRINZA SUS 1-0.2%
SIMPONI ARIA SOL 50MG/4ML
Page #
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Drug Name
Page #
Drug Name
SIMPONI INJ 100MG/ML
SIMPONI INJ 50/0.5ML
simvastatin tab 10mg
simvastatin tab 20mg
simvastatin tab 40mg
simvastatin tab 5mg
simvastatin tab 80mg
sirolimus tab 0.5mg
sirolimus tab 1mg
sirolimus tab 2mg
SIRTURO TAB 100MG
SKLICE LOT 0.5%
sm urinary tab pain max
smz/tmp ds tab 800-160
smz-tmp ds tab 800-160
smz-tmp sus 200-40/5
smz-tmp tab 400-80mg
sod poly sul sus 15gm/60
sod poly sul sus 30/120ml
sod poly sul sus 50/200ml
sod sul/sulf emu 10-5%
sod sulfacet sol 10% op
sodium chlor neb 7%
sodium fluoride chew 0.25 mg
sodium fluoride chew 0.5 mg
sodium fluoride chew 1 mg
sodium fluoride chew 1.1 mg
sodium fluoride chew 2.2 mg
sodium fluoride lozg 1 mg
sodium fluoride soln 0.125 mg/drop
sodium fluoride soln 0.25 mg/drop
sodium fluoride soln 0.5 mg/ml
sodium fluoride tab 0.5 mg
sodium fluoride tab 1 mg
solia tab
SOMATULINE INJ 90/0.3ML
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
SOMAVERT INJ 20MG
SOMAVERT INJ 25MG
SOMAVERT INJ 30MG
sorine tab 120mg
sorine tab 160mg
sorine tab 240mg
sorine tab 80mg
sotalol hcl tab 120mg
sotalol hcl tab 160mg
116
116
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33
33
33
33
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117
117
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126
131
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82
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109
109
109
109
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110
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sotalol hcl tab 240mg
sotalol hcl tab 80mg
SOVALDI TAB 400MG
SPIRIVA CAP HANDIHLR
SPIRIVA SPR RESPIMAT
spirono/hctz tab 25/25
spironolact tab 100mg
spironolact tab 25mg
spironolact tab 50mg
SPORANOX SOL 10MG/ML
sprintec 28 tab 28 day
SPRYCEL TAB 100MG
SPRYCEL TAB 140MG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 80MG
sps sus 15gm/60
sronyx tab
ssd cre 1%
stavudine cap 15mg
stavudine cap 20mg
stavudine cap 30mg
stavudine cap 40mg
stavudine sol 1mg/ml
STAVZOR CAP 125MG
STAVZOR CAP 250MG
STAVZOR CAP 500MG
STELARA INJ 45MG/0.5
STIVARGA TAB 40MG
STRATTERA CAP 100MG
STRATTERA CAP 10MG
STRATTERA CAP 18MG
STRATTERA CAP 25MG
STRATTERA CAP 40MG
STRATTERA CAP 60MG
STRATTERA CAP 80MG
STRIBILD TAB
sucralfate tab 1gm
sulf/pred na sol op
sulfacet sod sol 10% op
sulfacetamid lot 10%
sulfacetamid sus 10%
sulfadiazine tab 500mg
sulfasalazin tab 500mg
sulfasalazin tab 500mg dr
sulfatrim pd sus 200-40/5
Page #
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Drug Name
Page #
Drug Name
sulfazine ec tab 500mg
sulfazine tab 500mg
sulindac tab 150mg
sulindac tab 200mg
sumatriptan inj 4mg/0.5
sumatriptan inj 4mg/0.5
sumatriptan inj 6mg/0.5
sumatriptan spr 5mg/act
sumatriptan tab 100mg
sumatriptan tab 25mg
sumatriptan tab 50mg
SUPRAX SUS 100/5ML
SUPRAX SUS 200/5ML
SUPRAX SUS 500/5ML
SUPRAX TAB 400MG
SUPREP BOWEL SOL PREP
SUSTIVA CAP 200MG
SUSTIVA CAP 50MG
SUSTIVA TAB 600MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 37.5MG
SUTENT CAP 50MG
syeda tab 3-0.03mg
SYLATRON KIT 200MCG
SYLATRON KIT 300MCG
SYLATRON KIT 600MCG
SYLATRON 296 MCG 4-PACK
SYLATRON 444 MCG 4-PACK
SYLATRON 888 MCG 4-PACK
symax fastab tab 0.125mg
symax-sl sub 0.125mg
SYMBICORT AER 160-4.5
SYMBICORT AER 80-4.5
SYMLINPEN 60 INJ 1000MCG
SYNAGIS INJ 50MG
SYNAREL SOL 2MG/ML
SYNTHROID TAB 100MCG
SYNTHROID TAB 112MCG
SYNTHROID TAB 125MCG
SYNTHROID TAB 137MCG
SYNTHROID TAB 150MCG
SYNTHROID TAB 175MCG
SYNTHROID TAB 200MCG
SYNTHROID TAB 25MCG
SYNTHROID TAB 300MCG
SYNTHROID TAB 50MCG
6
6
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49
64
64
64
64
64
64
64
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3
3
3
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11
11
17
17
17
17
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17
17
17
17
17
19
19
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96
97
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108
111
111
111
111
111
112
112
112
112
112
SYNTHROID TAB 75MCG
SYNTHROID TAB 88MCG
SYPRINE CAP 250MG
TABLOID TAB 40MG
tacrolimus cap 0.5mg
tacrolimus cap 1mg
tacrolimus cap 5mg
tacrolimus oin 0.03%
tacrolimus oin 0.1%
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
take action tab 1.5mg
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
tamoxifen citrate tab 10 mg
tamoxifen citrate tab 20 mg
tamsulosin cap 0.4mg
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TARCEVA TAB 25MG
TARGRETIN CAP 75MG
tarina fe tab 1/20
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TAZORAC CRE 0.05%
TAZORAC CRE 0.1%
TAZORAC GEL 0.05%
TAZORAC GEL 0.1%
taztia xt cap 180mg/24
taztia xt cap 240mg/24
taztia xt cap 300mg/24
taztia xt cap 360mg/24
TECHNIVIE TAB
TEKTURNA TAB 150MG
TEKTURNA TAB 300MG
telmisartan tab 20mg
telmisartan tab 40mg
telmisartan tab 80mg
temazepam cap 15mg
temazepam cap 22.5mg
temazepam cap 30mg
temazepam cap 7.5mg
temozolomide cap 100mg
temozolomide cap 140mg
temozolomide cap 180mg
Page #
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133
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18
Drug Name
Page #
Drug Name
temozolomide cap 20mg
temozolomide cap 250mg
temozolomide cap 5mg
terazosin cap 10mg
terazosin cap 1mg
terazosin cap 2mg
terazosin cap 5mg
terbinafine tab 250mg
terbutaline tab 2.5mg
terbutaline tab 5mg
terconazole cre 0.4%
terconazole cre 0.8%
terconazole sup 80mg
testosterone gel 1%(25mg)
testosterone gel 1%(50mg)
testosterone gel pump 1%
tetanus-diphtheria toxoids (td) suspension
tetcaine sol 0.5% op
tetrabenazin tab 12.5mg
tetrabenazin tab 25mg
tetracaine inj 1%
tetracaine sol 0.5% op
tetracycline cap 250mg
tetracycline cap 500mg
tetravisc sol 0.5% op
tetravisc sol forte
THALOMID CAP 100MG
THALOMID CAP 150MG
THALOMID CAP 200MG
THALOMID CAP 50MG
THEO-24 CAP 100MG CR
THEO-24 CAP 200MG CR
THEO-24 CAP 300MG CR
THEO-24 CAP 400MG ER
theochron tab 100mg cr
theochron tab 200mg cr
theochron tab 300mg cr
theophylline elx 80/15ml
theophylline tab 100mg cr
theophylline tab 100mg er
theophylline tab 200mg cr
theophylline tab 200mg er
theophylline tab 200mg sr
theophylline tab 300mg cr
theophylline tab 300mg er
theophylline tab 300mg sr
theophylline tab 400mg er
18
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18
31
31
31
31
7
23
23
124
124
124
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97
97
121
89
70
70
113
89
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7
89
89
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114
114
114
134
134
134
134
134
134
134
134
134
134
134
134
134
134
134
134
134
theophylline tab 450mg er
theophylline tab 600mg er
thermazene cre 1%
thioridazine tab 100mg
thioridazine tab 10mg
thioridazine tab 25mg
thioridazine tab 50mg
thiothixene cap 10mg
thiothixene cap 1mg
thiothixene cap 2mg
thiothixene cap 5mg
THYROLAR-1 TAB 60MG
THYROLAR-1/2 TAB 30MG
THYROLAR-1/4 TAB 15MG
THYROLAR-2 TAB 120MG
THYROLAR-3 TAB 180MG
tiagabine tab 2mg
tiagabine tab 4mg
ticlopidine tab 250mg
TIKOSYN CAP 125MCG
TIKOSYN CAP 250MCG
TIKOSYN CAP 500MCG
tilia fe tab
timolol gel sol 0.25% op
timolol gel sol 0.5% op
timolol mal sol 0.25% op
timolol mal sol 0.5% op
timolol mal tab 10mg
timolol mal tab 20mg
timolol mal tab 5mg
tinidazole tab 250mg
tinidazole tab 500mg
TIROSINT CAP 100MCG
TIROSINT CAP 112MCG
TIROSINT CAP 125MCG
TIROSINT CAP 137MCG
TIROSINT CAP 13MCG
TIROSINT CAP 150MCG
TIROSINT CAP 25MCG
TIROSINT CAP 50MCG
TIROSINT CAP 75MCG
TIROSINT CAP 88MCG
TIVICAY TAB 50MG
tizanidine tab 2mg
tizanidine tab 4mg
tobra/dexame sus 0.3-0.1%
TOBRADEX OIN 0.3-0.1%
Page #
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126
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79
79
79
79
79
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112
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88
Drug Name
Page #
Drug Name
tobramycin neb 300/5ml
tobramycin sol 0.3% op
TOBREX OIN 0.3% OP
tobrex sol 0.3% op
tolazamide tab 250mg
tolazamide tab 500mg
tolbutamide tab 500mg
tolcapone tab 100mg
tolmetin sod cap 400mg
tolmetin sod tab 200mg
tolmetin sod tab 600mg
tolterodine cap 2mg er
tolterodine cap 4mg er
tolterodine tab 1mg
tolterodine tab 2mg
topiragen tab 100mg
topiragen tab 200mg
topiragen tab 25mg
topiragen tab 50mg
topiramate cap 15mg
topiramate cap 25mg
topiramate tab 100mg
topiramate tab 200mg
topiramate tab 25mg
topiramate tab 50mg
torsemide tab 100mg
torsemide tab 10mg
torsemide tab 20mg
torsemide tab 5mg
TOUJEO SOLO INJ 300IU/ML
TOVIAZ TAB 4MG
TOVIAZ TAB 8MG
TRACLEER TAB 125MG
TRACLEER TAB 62.5MG
TRADJENTA TAB 5MG
tramadl/apap tab 37.5-325
tramadol hcl tab 100mg er
tramadol hcl tab 200mg er
tramadol hcl tab 300mg er
tramadol hcl tab 50mg
trandolapril tab 1mg
trandolapril tab 2mg
trandolapril tab 4mg
tranex acid tab 650mg
TRANSDERM-SC DIS 1.5MG
TRANSDERM-SC DIS 1MG
tranylcyprom tab 10mg
2
86
86
86
100
100
100
65
49
49
49
133
133
133
133
61
61
61
61
61
61
61
61
61
61
81
81
81
81
99
133
133
119
119
98
54
54
54
54
54
44
44
44
27
91
91
74
TRAVATAN Z DRO 0.004%
travoprost dro 0.004%
trazodone tab 100mg
trazodone tab 150mg
trazodone tab 300mg
trazodone tab 50mg
tretinoin cap 10mg
tretinoin cre 0.025%
tretinoin cre 0.05%
tretinoin cre 0.1%
tretinoin gel 0.01%
tretinoin gel 0.025%
tretinoin gel 0.05%
TREXALL TAB 10MG
TREXALL TAB 15MG
TREXALL TAB 5MG
TREXALL TAB 7.5MG
triamcin/ora pst 0.1%
triamcinolon aer 55mcg/ac
triamcinolon aer spray
triamcinolon cre 0.025%
triamcinolon cre 0.1%
triamcinolon cre 0.5%
triamcinolon lot 0.025%
triamcinolon lot 0.1%
triamcinolon oin 0.025%
triamcinolon oin 0.1%
triamcinolon oin 0.5%
triamcinolon pst 0.1%
triamt/hctz cap 37.5-25
triamt/hctz cap 50-25mg
triamt/hctz tab 37.5-25
triamt/hctz tab 75-50mg
triazolam tab 0.125mg
triazolam tab 0.25mg
triderm cre 0.1%
tri-estaryll tab
trifluoperaz tab 10mg
trifluoperaz tab 1mg
trifluoperaz tab 2mg
trifluoperaz tab 5mg
trifluridine sol 1% op
trihexyphen elx 0.4mg/ml
trihexyphen tab 2mg
trihexyphen tab 5mg
tri-legest tab fe
tri-linyah tab
Page #
85
85
74
74
74
74
18
131
131
131
131
131
131
18
18
18
18
129
88
129
129
129
129
129
129
129
129
129
129
81
81
81
81
69
69
129
105
79
79
79
79
87
65
65
65
105
105
Drug Name
Page #
Drug Name
trilyte sol
trimethobenz cap 300mg
trimethoprim sol polymyxn
trimethoprim tab 100mg
trinessa tab
tri-previfem tab
tri-sprintec tab
trivora-28 tab
tropicamide sol 0.5% op
tropicamide sol 1% op
TRUMENBA INJ
TRUVADA TAB
TRUVADA TAB 200-300
TUDORZA PRES AER 400/ACT
TYKERB TAB 250MG
TYSABRI INJ 300/15ML
TYVASO SOL 0.6MG/ML
TYVASO REFIL SOL 0.6MG/ML
TYVASO START SOL 0.6MG/ML
TYZEKA TAB 600MG
TYZINE PED DRO 0.05%
ULESFIA LOT 5%
unith direct tab 100mcg
unith direct tab 112mcg
unith direct tab 125mcg
unith direct tab 150mcg
unith direct tab 175mcg
unith direct tab 200mcg
unith direct tab 25mcg
unith direct tab 300mcg
unith direct tab 50mcg
unith direct tab 75mcg
unith direct tab 88mcg
unithroid tab 100mcg
unithroid tab 112mcg
unithroid tab 125mcg
unithroid tab 137mcg
unithroid tab 150mcg
unithroid tab 175mcg
unithroid tab 200mcg
unithroid tab 25mcg
unithroid tab 300mcg
unithroid tab 50mcg
unithroid tab 75mcg
unithroid tab 88mcg
urea cre 47%
urinary pain tab 95mg
93
91
86
14
105
105
105
105
89
89
122
11
11
19
18
114
119
119
119
14
90
126
112
112
112
112
112
112
112
112
112
113
113
113
113
113
113
113
113
113
113
113
113
113
113
132
131
urinary pain tab 97.5mg
ursodiol cap 300mg
ursodiol tab 250mg
ursodiol tab 500mg
uti relief tab 97.2mg
VAGIFEM TAB 10MCG
valacyclovir tab 1gm
valacyclovir tab 500mg
VALCYTE TAB 450MG
valganciclov tab 450mg
valproate inj 100mg/ml
valproate inj 500/5ml
valproic acd cap 250mg
valproic acd sol 250/5ml
valproic acd syp 250/5ml
valsart/hctz tab 160-12.5
valsart/hctz tab 160-25mg
valsart/hctz tab 320-12.5
valsart/hctz tab 320-25mg
valsart/hctz tab 80-12.5
valsartan tab 160mg
valsartan tab 320mg
valsartan tab 40mg
valsartan tab 80mg
vancomycin cap 125mg
vancomycin cap 250mg
VANCOMYCN 25 SOL 25MG/ML
VANCOMYCN 50 SOL 50MG/ML
vandazole gel 0.75%
vcf vaginal aer contracp
vcf vaginal gel contrace
velivet pak
venlafaxine cap 150mg er
venlafaxine cap 37.5 er
venlafaxine cap 37.5mg
venlafaxine cap 75mg er
venlafaxine tab 100mg
venlafaxine tab 150mg er
venlafaxine tab 225mg er
venlafaxine tab 25mg
venlafaxine tab 37.5 er
venlafaxine tab 37.5mg
venlafaxine tab 50mg
venlafaxine tab 75mg
venlafaxine tab 75mg er
VENTAVIS SOL 10MCG/ML
VENTAVIS SOL 20MCG/ML
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93
93
131
108
14
14
14
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61
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42
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42
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42
2
2
2
2
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105
74
74
74
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74
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74
74
74
74
74
119
119
Drug Name
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Drug Name
VENTOLIN HFA AER
VERAMYST SPR 27.5MCG
verapamil cap 100mg er
verapamil cap 120mg er
verapamil cap 120mg sr
verapamil cap 180mg er
verapamil cap 180mg sr
verapamil cap 200mg er
verapamil cap 240mg er
verapamil cap 240mg sr
verapamil cap 300mg er
verapamil cap 360mg sr
verapamil tab 120mg
verapamil tab 120mg er
verapamil tab 120mg sr
verapamil tab 180mg er
verapamil tab 180mg sa
verapamil tab 180mg sr
verapamil tab 240mg cr
verapamil tab 240mg er
verapamil tab 240mg sa
verapamil tab 240mg sr
verapamil tab 40mg
verapamil tab 80mg
VEREGEN OIN 15%
VERIPRED 20 SOL 20MG/5ML
VESICARE TAB 10MG
VESICARE TAB 5MG
vestura tab 3-0.02mg
VEXOL SUS 1% OP
VICTOZA INJ 18MG/3ML
VICTRELIS CAP 200MG
VIDEX SOL 2GM
VIDEX SOL 4GM
VIEKIRA PAK TAB
VIGAMOX DRO 0.5%
VIIBRYD TAB 10MG
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG
VIMPAT INJ 200MG/20
VIMPAT SOL 10MG/ML
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
VIMPAT TAB 50MG
viorele tab
VIRACEPT TAB 250MG
23
88
37
37
37
37
37
37
37
37
37
38
38
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38
38
38
38
38
38
38
38
38
38
133
96
134
134
105
88
98
12
11
11
12
86
75
75
75
61
61
61
62
62
62
105
11
VIRACEPT TAB 625MG
VIRAMUNE SUS 50MG/5ML
VIRAMUNE XR TAB 100MG
VIREAD POW 40MG/GM
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
virt-phos tab 250 neut
virtrate-k sol
virtrate-k sol 1100-334
vitamin d cap 50000unt
VIVAGLOBIN SOL 160MG/ML
VIVITROL INJ 380MG
VOLTAREN GEL 1%
voriconazole tab 200mg
voriconazole tab 50mg
VOTRIENT TAB 200MG
vyfemla tab 0.4-35
VYTORIN TAB 10-10MG
VYTORIN TAB 10-20MG
VYTORIN TAB 10-40MG
VYTORIN TAB 10-80MG
VYVANSE CAP 10MG
VYVANSE CAP 20MG
VYVANSE CAP 30MG
VYVANSE CAP 40MG
VYVANSE CAP 50MG
VYVANSE CAP 60MG
VYVANSE CAP 70MG
warfarin tab 10mg
warfarin tab 1mg
warfarin tab 2.5mg
warfarin tab 2mg
warfarin tab 3mg
warfarin tab 4mg
warfarin tab 5mg
warfarin tab 6mg
warfarin tab 7.5mg
warfarin sod tab 10mg
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG
wera tab 0.5/35
westhroid tab 130mg
westhroid tab 32.5mg
westhroid tab 65mg
WILATE INJ
Page #
11
11
11
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11
11
12
12
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80
80
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70
133
7
7
18
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33
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Drug Name
Page #
Drug Name
WILATE 1,000-1,000 UNIT KIT
WILATE 450-450 UNIT KIT
WILATE 900-900 UNIT KIT
WP THYROID TAB 130MG
wymzya fe chw 0.4mg-35
XALKORI CAP 200MG
XALKORI CAP 250MG
XARELTO STAR TAB 15/20MG
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
XELJANZ TAB 5MG
XENICAL CAP 120MG
XGEVA INJ
XIFAXAN TAB 200MG
XIFAXAN TAB 550MG
XOLAIR SOL 150MG
XOPENEX HFA AER
XTANDI CAP 40MG
xulane dis 150-35
XYNTHA INJ 1000UNIT
XYNTHA INJ 2000UNIT
XYNTHA INJ 250UNIT
XYNTHA INJ 500UNIT
XYREM SOL 500MG/ML
zafirlukast tab 10mg
zafirlukast tab 20mg
zaleplon cap 10mg
zaleplon cap 5mg
zarah tab 3-0.03mg
zazole cre 0.4%
zazole cre 0.8%
zazole sup 80mg
zebutal cap
ZELBORAF TAB 240MG
zenchent tab
zenchent fe chw 0.4mg-35
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
ZENPEP CAP 20000UNT
ZENPEP CAP 25000UNT
ZENPEP CAP 3000UNIT
ZENPEP CAP 40000UNT
ZENPEP CAP 5000UNIT
ZETIA TAB 10MG
ZETONNA AER 37MCG
ZIAGEN SOL 20MG/ML
27
27
27
113
105
18
18
29
29
29
29
116
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115
2
2
119
23
18
105
27
27
27
27
70
118
118
67
67
105
124
124
124
46
18
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105
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93
93
93
93
93
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12
zidovudine cap 100mg
zidovudine syp 50mg/5ml
zidovudine tab 300mg
zinc sulfate cap 220mg
ZIOPTAN DRO 0.0015%
ziprasidone cap 20mg
ziprasidone cap 40mg
ziprasidone cap 60mg
ziprasidone cap 80mg
ZIRGAN GEL 0.15%
ZOLINZA CAP 100MG
zolmitriptan tab 2.5mg
zolmitriptan tab 5mg
zolpidem tab 10mg
zolpidem tab 5mg
zolpidem er tab 12.5mg
zolpidem er tab 6.25mg
ZOMACTON INJ 10MG
zonisamide cap 100mg
zonisamide cap 25mg
zonisamide cap 50mg
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.75MG
zovia 1/35e tab
zovia 1/50e tab
ZYDELIG TAB 100MG
ZYDELIG TAB 150MG
ZYFLO CR TAB 600MG
ZYTIGA TAB 250MG
ZYVOX SUS 100MG/5M
ZYVOX TAB 600MG
Page #
12
12
12
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86
79
79
79
79
87
18
64
64
67
67
67
67
109
62
62
62
117
117
117
106
106
18
18
118
18
2
2