docMPI 3275 1 2/1 4 - Arkansas Blue Cross and Blue Shield
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MPI 3275 1 2/1 4 - Arkansas Blue Cross and Blue Shield
DRUG LIST MPI 3275 12/14 2015 Metallic 2015 Metallic Drug List Index 8-MOP45 ACTIVE FE 57 AHIST20 ALPHAGAN P ABACAVIR SULFATE ACTIVELLA52 AHIST21 ALPRAZOLAM10 ACTONEL 5MG, 30MG, 35MG 50 AKNE-MYCIN43 ALPRAZOLAM INTENSOL ACTONEL 150MG (QL) (60 TABS / 30 DAYS) 50 AKTEN74 ALREX74 ABILIFY DISCMELT (QL) (30 EA / 30 DAYS); AGE30 ACTOPLUS MET 17 ALAGESIC LQ 5 ALTABAX44 17 41 ALTACE23 ABSORICA43 ACTOPLUS MET XR ALAHIST AC ACTOS18 ALA-HIST D 41 ALTOPREV22 ALAHIST DHC 41 ALUMINUM CHLORIDE 31 ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE31 ABILIFY30 ACARBOSE17 ACCOLATE11 ACCUNEB12 ACCUPRIL23 ACCURETIC24 ACEBUTOLOL HCL 34 ACEON23 ACETAMINOPHEN-ISOMETHEPTENE-DICHLORALPHENAZONE63 ACETAMINOPHEN-SALICYLAMIDE-PHENYLTOLOXAMINE3 ACUFLEX5 73 10 65 ALBATUSSIN41 ALVESCO12 ALBENZA (PA) 19 AMANTADINE29 ACUVAIL75 ALBUTEROL INHAL AEROSOL 90 MCG/ACT 12 AMARYL18 ACYCLOVIR32 ALBUTEROL SULFATE 12 ACYCLOVIR TOPICAL ALCLOMETASONE DIPROPIONATE 46 AMBIFED CD 41 ACZONE43 ALCORTIN A 44 AMBIFED CDX 41 ADALAT CC 35 ALDACTAZIDE49 AMBIFED-G CD 41 ADAPALENE43 ALDACTONE49 AMBIFED-G CDX 41 ADCIRCA (PA) ALDARA47 ACULAR75 ACULAR LS 75 45 36 AMBIEN59 AMCINONIDE46 AMERGE63 ADDERALL1 ALENDRONATE SODIUM SOLN 35 ACETAZOLAMIDE49 ADDERALL XR ALENDRONATE SODIUM TABS 50 ACETAZOLAMIDE SODIUM 49 ADEFOVIR DIPIVOXIL 59 ALFUZOSIN HCL 55 ACETIC ACID-ALUMINUM ACETATE 77 ADEMPAS (PA) 82 ALINIA9 ACETIC ACID (OTIC) 77 ADOXA83 ALKERAN26 ACETIC ACID-OXYQUINOLINE VAGINAL 65 ADOXA PAK 1/100 83 ALLERX DF 21 ACETYLCYSTEINE42 ADOXA PAK 2/100 83 ALLERX DF 30 21 ACETYLCYSTEINE (NUTRIENT) ADVAIR DISKUS 12 ALLFEN CD 41 ACITRETIN45 ADVAIR HFA 12 ALLFEN CDX LIQD 41 ACLOVATE46 ADVANCED AM/PM 66 ALLFEN CDX TABS 41 ACTEMRA (PA) 60 ADVICOR22 ALLOPURINOL55 ACTHAR HP (PA) 50 AFINITOR DISPERZ (PA) 27 ALOCRIL75 ACTIGALL53 AFINITOR (QL) (30 TABS / 30 DAYS), (PA) 27 ALOMIDE75 AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM36 ACTIQ (PA) AGGRENOX56 ALPAIN5 AMLODIPINE BESYLATE-BENAZEPRIL HCL ACETAMINOPHEN W/ CODEINE 6 80 6 1 AMICAR58 AMIKACIN SULFATE AMILORIDE HCL 3 49 AMILORIDE & HYDROCHLOROTHIAZIDE 49 AMINOCAPROIC ACID 58 AMIODARONE HCL 100MG (PA) 11 AMIODARONE HCL 200MG, 400MG 11 AMITIZA53 AMITRIPTYLINE HCL 16 AMLODIPINE BESYLATE 2.5MG, 5MG 35 AMLODIPINE BESYLATE 10MG 35 index ii 2015 Metallic Drug List Index 24 ANUSOL-HC8 ASTEPRO71 AZASAN33 AMOXAPINE16 ANZEMET19 ATABEX EC 67 AZASITE74 AMOXICILLIN78 APEXICON E ATABEX PRENATAL 67 AZATHIOPRINE33 AMOXICILLIN & POT CLAVULANATE 78 APHTHASOL65 ATACAND24 AMPHETAMINE-DEXTROAMPHETAMINE1 APIDRA18 ATACAND HCT AZATHIOPRINE SODIUM FOR INJ 100 MG 33 AMPHOTERICIN B APIDRA SOLOSTAR ATENOLOL34 20 46 18 24 AMPICILLIN78 APOKYN29 ATENOLOL & CHLORTHALIDONE AMPICILLIN SODIUM 78 APRACLONIDINE HCL ATIVAN10 AMPICILLIN & SULBACTAM SODIUM 78 APRISO53 ATORVASTATIN CALCIUM 22 AMPYRA (PA) 81 APTIVUS31 ATOVAQUONE-PROGUANIL HCL 25 AMTURNIDE24 ARALEN25 ATRIPLA31 ANACAINE47 ARANESP ALBUMIN FREE (PA) ATROPINE SULFATE 84 ANADROL-50 (PA) ARAVA (PA) ATROPINE SULFATE (OPHTHALMIC) 73 3 73 57 5 24 ANAFRANIL16 ARCAPTA NEOHALER 12 ATROVENT71 ANAGRELIDE HCL ARICEPT ODT (PA) 81 ATROVENT HFA 11 ANALPRAM-HC7 ARICEPT (PA) 81 ATUSS DS 41 ANALPRAM-HC SINGLES 7 ARIMIDEX27 AUBAGIO (PA) 81 ANAPROX DS 4 ARIXTRA13 AUGMENTIN78 ANASPAZ84 ARMOUR THYROID AUGMENTIN ES-600 78 ANASTROZOLE27 AROMASIN27 AUGMENTIN XR 78 ANCOBON20 ARTHROTEC 50 4 AURALGAN77 ANDRODERM7 ARTHROTEC 75 4 AVALIDE24 ANDROGEL7 ASACOL53 AVANDAMET17 ANDROGEL PUMP 1.62% ASACOL HD 53 AVANDARYL17 ANDROGEL PUMP 1.62% (QL) (600 GM / 25 DAYS)7 ASMANEX 7 METERED DOSES (QL) (30 / 30 DAYS)12 AVANDIA18 ANDROXY7 ASMANEX 14 METERED DOSES (QL) (60 / 30 DAYS) 12 AVC87 56 7 ANGELIQ52 ANIMI-3/VITAMIN D 57 ANTABUSE80 ANTARA22 ANTIPYRINE-BENZOCAINE78 ANTIPYRINE-BENZOCAINE-POLYCOSANOL 78 ANTIVERT19 84 ASMANEX 30 METERED DOSES 110MCG/ INH (QL) (30 / 30 DAYS) 12 AVAPRO24 AVELOX53 AVINZA6 ASMANEX 30 METERED DOSES 220MCG/ INH (QL) (60 / 30 DAYS) 12 AVODART55 ASMANEX 60 METERED DOSES (QL) (60 / 30 DAYS) 12 AVONEX PEN ASMANEX 120 METERED DOSES (QL) (60 / 30 DAYS) 12 ASTELIN71 AVONEX81 81 AXERT63 AXID85 AYGESTIN80 AZELASTINE HCL 71 AZELASTINE HCL (OPHTH) 75 AZELEX43 AZILECT29 AZITHROMYCIN61 AZOPT75 AZOR24 AZTREONAM8 AZULFIDINE53 AZULFIDINE EN-TABS 53 BACITRACIN (OPHTHALMIC) 74 BACITRACIN-POLYMYXIN B (OPHTH) 74 BACITRACIN-POLY-NEOMYCIN-HC74 BACLOFEN71 BACMIN67 BACTOCILL IN DEXTROSE BACTRIM DS 78 8 BACTROBAN44 BACTROBAN NASAL 71 BAL-CARE DHA ESSENTIAL 67 BALSALAZIDE DISODIUM 53 BANZEL14 BARACLUDE32 B-COMPLEX W/ C & FOLIC ACID 33 BECONASE AQ 71 BELLADONNA ALKALOIDS & OP 84 BELLADONNA & OPIUM 84 BENAZEPRIL HCL 23 BENAZEPRIL & HYDROCHLOROTHIAZIDE 23 index iii 2015 Metallic Drug List Index BENICAR24 BETIMOL73 BROVEX CT BENICAR HCT 24 BETOPTIC-S73 BUDESONIDE39 CANASA (QL) (60 SUPP / 30 DAYS) 53 BENSAL HP 47 BIAXIN62 BUDESONIDE (INHALATION) CANDESARTAN CILEXETIL 24 BENTYL84 BIAXIN XL 62 BUMETANIDE49 BENZAC AC 43 BIAXIN XL PAC 62 BUPHENYL51 BENZAC AC WASH 43 BICALUTAMIDE27 BUPRENORPHINE HCL 7 CANTIL84 BENZACLIN43 BIDIL36 CAPEX46 BENZAC W WASH 43 BIFERARX57 BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE (PA) 77 CAPITAL/CODEINE6 BENZAMYCIN43 BILTRICIDE19 CAPRELSA (PA) 27 BENZAMYCINPAK43 BISOPROLOL FUMARATE BUPROPION HCL (SMOKING DETERRENT) 82 23 BISOPROLOL & HYDROCHLOROTHIAZIDE 24 16 CAPTOPRIL 12.5MG, 25MG, 50MG BENZIQ43 BUPROPION HCL TABS BUPROPION HCL TB12; TB24 16 CAPTOPRIL (100MG), QUINAPRIL HCL BUSPIRONE HCL 10 BENZOCAINE (DENTAL) 7 BENZONATATE40 BENZOYL PEROXIDE 43 BENZOYL PEROXIDE-ERYTHROMYCIN 43 BENZOYL PEROXIDE LOTION 9% 43 BENZOYL PEROXIDE PAD 3% 43 BENZOYL PEROXIDE W/ CLEANSER 43 BENZTROPINE MESYLATE 28 BESIVANCE74 BETAGAN73 BLEOMYCIN SULFATE 34 27 BLEPH-1074 BLEPHAMIDE74 BLEPHAMIDE S.O.P. 74 B-NEXA67 BONIVA50 BOSULIF (PA) BP CLEANSING LOTION 27 1 BPO43 BETAMETHASONE DIPROPIONATE AUGMENTED46 BPO 3% FOAMING CLOTHS 43 BPO 6% FOAMING CLOTHS 43 BETAMETHASONE DIPROPIONATE (TOPICAL) CREA; OINT 46 BPO 9% FOAMING CLOTHS 43 BETAMETHASONE DIPROPIONATE (TOPICAL) LOTN 40 BPO CREAMY WASH COMPLETE 43 BRILINTA (QL) (60 TABS / 30 DAYS) 56 BRIMONIDINE TARTRATE 73 BROMFENAC SODIUM (OPHTH) 75 BROMOCRIPTINE MESYLATE 29 BETAMETHASONE VALERATE CREA; LOTN; OINT46 BETAMETHASONE VALERATE FOAM 40 BETAPACE35 BRONCOMAR-111 BETASERON81 BRONCOPECTOL41 BETAXOLOL HCL 34 BROVANA12 BETAXOLOL HCL (OPHTH) 73 BROVEX CB 41 86 BROVEX CBX 41 BROVEX CT 20 BETHANECHOL CHLORIDE BETHKIS (PA) 3 21 12 BUTALBITAL-ACETAMINOPHEN3 BUTALBITAL-ACETAMINOPHEN-CAFFEINE3 BUTALBITAL-ACETAMINOPHEN-CAFFEINE5 BUTALBITAL-ASPIRIN-CAFFEINE3 BUTALBITAL-ASPIRIN-CAFFEINE W/COD 76 BUTISOL SODIUM 59 BUTORPHANOL TARTRATE 7 BYETTA18 BYSTOLIC34 CABERGOLINE51 CADUET36 CAFCIT2 CAFERGOT63 CAFFEINE CITRATE 3 CALAN35 CALAN SR 35 CALCIPOTRIENE45 CALCIPOTRIENE-BETAMETHASONE DIPROPIONATE (QL) (400 GM / 56 DAYS) 40 CALCITONIN (SALMON) 50 CALCITRIOL51 CALCITRIOL (TOPICAL) 45 CALCIUM ACETATE (PHOSPHATE BINDER) 54 CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE23 1 CAPTOPRIL & HYDROCHLOROTHIAZIDE 24 CARAC44 CARAFATE85 CARBAMAZEPINE14 CARBAPHEN 12 41 CARBAPHEN 12 PED 41 CARBATROL14 CARBIDOPA-LEVODOPA29 CARBIDOPA-LEVODOPA-ENTACAPONE29 CARBINOXAMINE MALEATE 21 CARDENE SR 35 CARDIZEM CD 35 CARDIZEM LA 35 CARDURA24 CARISOPRODOL71 CARISOPRODOL W/ ASPIRIN 70 CARISOPRODOL W/ ASPIRIN & CODEINE70 CARMOL-HC46 CARNITOR51 CARTEOLOL HCL (OPHTH) 73 CARVEDILOL34 CASODEX27 CATAFLAM4 CATAPRES24 index iv 2015 Metallic Drug List Index CATAPRES-TTS-124 CEVIMELINE HCL 66 CIPRO53 CATAPRES-TTS-224 CGU WC 41 CIPRODEX77 CATAPRES-TTS-324 CHANTIX82 CIPROFLOXACIN-CIPROFLOXACIN HCL 53 CAVAN-ALPHA KIT 67 CHANTIX CONTINUING MONTH 82 CIPROFLOXACIN HCL 53 CAVAN-EC SOD DHA 67 CHANTIX STARTING MONTH PA 82 CIPROFLOXACIN HCL (OPHTH) 74 CAYSTON8 CHLORAL HYDRATE CAP 500 MG 59 CIPRO HC 77 CEDAX37 CHLORDIAZEPOXIDE-AMITRIPTYLINE37 CIPRO XR 53 CEENU26 CHLORDIAZEPOXIDE HCL 34 CITALOPRAM HYDROBROMIDE 16 CEFACLOR37 CHLORHEXIDINE GLUCONATE 37 CITRANATAL B-CALM 67 CEFACLOR ER CHLORHEXIDINE GLUCONATE (MOUTHTHROAT)65 CITRANATAL HARMONY 67 37 CEFADROXIL37 CEFAZOLIN SODIUM 37 CEFDINIR37 CHLOROQUINE PHOSPHATE 25 CHLOROTHIAZIDE49 CHLORPHENIRAMINE & PHENYLEPHRINE TAB CR 8-20 MG 41 CLARITHROMYCIN62 CLEMASTINE FUMARATE CLEOCIN CAPS 9 CLOBEX46 CLODERM PUMP 46 CLOMID50 CLOMIPHENE CITRATE 50 CLOMIPRAMINE HCL 16 CLONAZEPAM TABS 13 CLONAZEPAM TBDP 15 CLONIDINE & CHLORTHALIDONE 23 CLONIDINE HCL 24 CLONIDINE HCL (ADHD) 33 CLOPIDOGREL BISULFATE 56 CLORAZEPATE DIPOTASSIUM 10 37 CEFEPIME HCL 37 CEFOTAXIME SODIUM 37 CHLORPHEN-PSE & METHSCOPOLAMINE TAB SR 12HR 8-120-2.5 MG 41 CEFOXITIN SODIUM 37 CHLORPROMAZINE HCL CEFPODOXIME PROXETIL 37 CHLORPROPAMIDE18 CLIMARA52 CEFPROZIL37 CHLORTHALIDONE49 CLIMARA PRO 52 CEFTAZIDIME37 CHLORZOXAZONE37 CLINAC BPO 43 CEFTIBUTEN37 CHOICE-OB+DHA67 CLINDAGEL43 CEFTIN37 CHOLESTYRAMINE22 CLINDAMYCIN HCL 75MG CEFUROXIME AXETIL 37 CHOLESTYRAMINE LIGHT 22 CLINDAMYCIN HCL 150MG, 300MG CEFUROXIME SODIUM 37 CHOLINE FENOFIBRATE 22 COCET PLUS 6 CELEBREX4 CHOLINE & MAG SALICYLATE 82 CLINDAMYCIN PALMITATE HYDROCHLORIDE9 CODEINE SULFATE SOLN 6 CELEXA16 CICLOPIROX GEL 44 CLINDAMYCIN PHOSPHATE CODEINE SULFATE TABS 6 CELLCEPT33 CICLOPIROX KIT; SHAM 20 CELONTIN15 CICLOPIROX OLAMINE 44 CENESTIN52 CICLOPIROX & VITAMIN E 20 CENFOL57 CILOSTAZOL56 CLINDAMYCIN PHOSPHATE (TOPICAL) 43 CENTANY44 CILOXAN74 CLINDAMYCIN PHOSPHATE VAGINAL 87 CENTANY AT CIMETIDINE85 CLINDAREACH43 CEPHALEXIN37 CIMETIDINE HCL 85 CLINDESSE87 CESAMET19 CIMZIA (PA), (ST) 53 CLINORIL4 CETACAINE47 CIMZIA STARTER KIT (PA), (ST) 53 CLOBETASOL PROPIONATE 44 CLEOCIN PEDIATRIC GRANULE 87 CLOBETASOL PROPIONATE EMULSION 40 CEFDITOREN PIVOXIL 30 CLEOCIN CREA; SUPP 21 CLOBETASOL PROPIONATE EMOLLIENT BASE40 9 CLEOCIN-T43 CLIDINIUM & CHLORDIAZEPOXIDE 84 61 9 9 CLOTRIMAZOLE65 CLOTRIMAZOLE (TOPICAL) 44 CLOTRIMAZOLE W/ BETAMETHASONE 44 CLOZAPINE TABS 30 CLOZAPINE TBDP 48 C-NATE DHA 67 COARTEM25 COCET6 CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE43 COLAZAL53 CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE (REFRIGERATE) 1 COLCRYS55 46 COLCHICINE W/ PROBENECID 55 COLESTID22 COLESTIPOL HCL 22 COLY-MYCIN S 77 COMBIGAN73 COMBIPATCH52 COMBIVENT12 index v 2015 Metallic Drug List Index COMBIVENT RESPIMAT (QL) (11.25 / 30 DAYS)12 COTAB AX 41 CYTOTEC85 COMBIVIR31 COTABFLU41 DALIRESP (QL) (30 TABS / 30 DAYS), (PA) 11 COUMADIN13 DANAZOL7 COVERA-HS35 DANTROLENE SODIUM COZAAR24 DAPSONE9 CPB WC 41 DARAPRIM25 CREON48 DAYTRANA2 CRESTOR22 DDAVP51 CRINONE 4% 87 DECON-A41 CONCERTA2 CRINONE 8% (QL) (45 GM / 30 DAYS), (PA) 87 DECON-G41 CONDYLOX47 CRIXIVAN31 COPAXONE KIT 81 CROMOLYN SODIUM 11 DEMADEX49 COPAXONE SOSY 66 CROMOLYN SODIUM 11 COMETRIQ (PA) 27 COMPLERA31 COMPLETENATE67 COMPLETE-RF PRENATAL 67 COMTAN28 CONCEPT DHA 67 CONCEPT OB 67 CORDARONE11 CROMOLYN SODIUM (MASTOCYTOSIS) 53 CORDRAN46 CROMOLYN SODIUM (OPHTH) CORDRAN SP 46 CUPRIMINE32 CORDRAN TAPE 46 CUTIVATE46 COREG34 CUVPOSA84 COREG CR CYANOCOBALAMIN56 75 71 DELZICOL59 DEMECLOCYCLINE HCL 83 DEMEROL6 DEMSER23 DENAVIR45 DEPAKENE15 DEPAKOTE15 DEPAKOTE ER 15 DESOGESTREL-ETHINYL ESTRADIOL (BIPHASIC)38 DESOGESTREL-ETHINYL ESTRADIOL (TRIPHASIC)38 DESONATE46 DESONIDE CREA 40 DESONIDE LOTN; OINT 46 DESOWEN46 DESOWEN LOTION/CETAPHIL C 46 DESOXIMETASONE CREA .05% 46 DESOXIMETASONE CREA .25% 40 DESOXIMETASONE GEL 46 DESOXIMETASONE OINT 46 DESOXYN1 DESPEC-EXP41 DESPEC-PDC41 DEXAMETHASONE39 DEXAMETHASONE SODIUM PHOSPHATE 39 DEPAKOTE SPRINKLES 15 DEXAMETHASONE SODIUM PHOSPHATE (OPHTH)74 DEPEN TITRATABS 32 DEXCHLORPHENIRAMINE MALEATE 20 DEPO-PROVERA CONTRACEPTIV (QL) (1 INJ / 75 DAYS) 39 DEXCHLORPHENIRAMINE MALEATE 21 CYCLOMYDRIL73 CORTANE-B-OTIC77 CYCLOPENTOLATE HCL DERMA-SMOOTHE/FS BODY 46 DEXILANT85 CORTEF39 CYCLOPHOSPHAMIDE26 DERMA-SMOOTHE/FS SCALP OI 46 DEXMETHYLPHENIDATE HCL CORTENEMA7 CYCLOSERINE26 DERMATOP46 DEXPAK 6 DAY 39 CORTIFOAM7 CYCLOSET17 DERMOTIC78 DEXPAK 10 DAY 39 CORTISONE ACETATE 39 CYCLOSPORINE33 DESIPRAMINE HCL DEXPAK 13 DAY 39 CORTISPORIN44 CYCLOSPORINE MODIFIED (FOR MICROEMULSION)33 DESLORATADINE21 CYMBALTA16 34 CORGARD35 CYCLOBENZAPRINE HCL CORTANE-B46 CYCLOGYL73 CORTANE-B AQUEOUS 77 CORTISPORIN-TC77 CORVITE67 CORVITE 150 57 CORZIDE24 COSOPT73 COTAB A 41 71 43 DESMOPRESSIN ACETATE 16 51 DEXEDRINE1 2 DEXTROAMPHETAMINE SULFATE CP24; TABS1 21 DESMOPRESSIN ACETATE REFRIGERATED 51 DEXTROAMPHETAMINE SULFATE SOLN 3 CYPROHEPTADINE HCL CYSTAGON (PA) 54 DESMOPRESSIN ACETATE SPRAY D.H.E. 45 CYTARABINE26 CYTOMEL84 51 DESMOPRESSIN ACETATE SPRAY REFRIGERATED51 DESOGESTREL & ETHINYL ESTRADIOL 38 DEX-TUSS41 63 DIABETA18 DIALYVITE 5000 66 index vi 2015 Metallic Drug List Index DIALYVITE SUPREME D 67 DILTIAZEM HCL 35 DOVONEX SCALP 45 DURAFLU41 DIAMOX49 DILTIAZEM HCL COATED BEADS 35 DOXAZOSIN MESYLATE 24 DURAGESIC6 DIASTAT ACUDIAL 13 DOXEPIN HCL 16 DUREZOL74 DIASTAT PEDIATRIC 13 DILTIAZEM HCL EXTENDED RELEASE BEADS35 DIMENHYDRINATE19 DOXEPIN HCL (ANTIPRURITIC) 44 DYAZIDE49 DIOVAN24 DOXYCYCLINE HYCLATE CAPS; TABS; TBEC 83 DYLIX12 DIOVAN HCT DOXYCYCLINE HYCLATE CPEP DYNACIRC CR DIAZEPAM10 DIAZEPAM (ANTICONVULSANT) 15 DIAZEPAM INTENSOL 10 DIBENZYLINE23 DICLEGIS19 DICLOFENAC POTASSIUM 4 DICLOFENAC SODIUM 4 24 DIPENTUM53 DIPHENHYDRAMINE HCL CAPS 25MG 21 DIPHENHYDRAMINE HCL CAPS 50MG 21 DIPHENHYDRAMINE HCL ELIX 21 83 DOXYCYCLINE (MONOHYDRATE) CAPS 50MG, 75MG, 150MG 83 DOXYCYCLINE (MONOHYDRATE) CAPS 100MG83 35 DYPHYLLINE-GUAIFENESIN33 DYRENIUM49 EC-NAPROSYN4 DOXYCYCLINE (MONOHYDRATE) SUSR 83 ECONAZOLE NITRATE DOXYCYCLINE (MONOHYDRATE) TABS 50MG, 75MG 83 EDARBI24 19 DOXYCYCLINE (MONOHYDRATE) TABS 100MG, 150MG 83 ED-BRON G 11 ED CHLORPED 20 ED CHLORPED 21 DICLOFENAC SODIUM (ACTINIC KERATOSES)26 DIPHENHYDRAMINE HCL (SLEEP) CAPS21 DICLOFENAC SODIUM (OPHTH) 75 DIPHENHYDRAMINE HCL SOLN 21 DICLOFENAC W/ MISOPROSTOL 4 DIPHENOXYLATE W/ ATROPINE DIPHENHYDRAMINE HCL (SLEEP) TABS 20 DICLOXACILLIN SODIUM 79 DIPROLENE46 DOXYTEX21 DICYCLOMINE HCL 84 DIPROLENE AF DRISDOL88 46 DIDANOSINE31 DIPYRIDAMOLE56 DRITHO-CREME HP DIDRONEL50 DISOPYRAMIDE PHOSPHATE 10 DRITHO-SCALP45 DIFFERIN43 DISULFIRAM80 DRONABINOL19 DIFICID62 DIURIL49 DROSPIRENONE-ETHINYL ESTRADIOL DIFLORASONE DIACETATE DIVALPROEX SODIUM CPSP; TBEC 15 DROXIA56 DIFLUCAN20 DIVALPROEX SODIUM TB24 87 DRYSOL47 DIFLUNISAL5 DIVIGEL52 DUAC43 DIGEX48 DIVISTA57 DUETACT17 DIGEX NF 84 DOLGIC PLUS 5 DUET DHA 400 68 DIGOXIN SOLN .05MG/ML 36 DONATUSS DC 41 DUET DHA 400EC 68 DIGOXIN SOLN .25MG/ML 36 DONEPEZIL HYDROCHLORIDE (PA) 81 DUET DHA 430 68 DIGOXIN TABS 36 DONNATAL84 DUET DHA BALANCED 68 DIHYDROERGOTAMINE MESYLATE 63 DONNATAL EXTENTABS DUET DHA EC 68 DILACOR XR 35 DORAL59 DULERA12 DILANTIN15 DORYX83 DULOXETINE HCL DILANTIN INFATABS 15 DORZOLAMIDE HCL 75 DUONEB12 DILATRATE SR 10 DORZOLAMIDE HCL-TIMOLOL MALEATE73 DURABAC5 DILAUDID6 DOVONEX45 DURABAC FORTE 46 DYNACIN83 84 45 38 16 5 44 EDARBYCLOR24 ED-CHLOR-TAN20 ED-CHLOR-TAN21 ED CYTE F 57 EDECRIN49 EDURANT31 EFFER-K64 EFFEXOR XR 16 EFFIENT56 EFUDEX44 ELESTAT75 ELESTRIN52 ELIDEL47 ELIMITE48 ELIPHOS54 ELIQUIS13 ELIXOPHYLLIN12 ELMIRON54 ELOCON46 EMADINE75 index vii 2015 Metallic Drug List Index EMCYT27 ERTACZO44 ETIDRONATE DISODIUM EMEND19 ERYPED 400 62 ETODOLAC CAPS 200MG 4 EMLA47 ERYSIDORON #2 33 ETODOLAC CAPS 300MG 72 EMSAM16 ERY-TAB62 ETODOLAC TABS EMTRIVA31 ERYTHROMYCIN (ACNE AID) GEL ETODOLAC TB24 ENABLEX86 ERYTHROMYCIN (ACNE AID) PADS; SOLN 43 ETOPOSIDE28 FEMRING87 62 FEMTRACE52 ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE24 ERYTHROMYCIN BASE CPEP EURAX48 ERYTHROMYCIN BASE TABS 250MG 62 EVAMIST52 FENOFIBRATE22 ENBREL (PA) 5 ERYTHROMYCIN BASE TABS 500MG 52 EVISTA51 FENOFIBRATE MICRONIZED 22 ENBREL SURECLICK (PA) 5 ERYTHROMYCIN ETHYLSUCCINATE 52 EVOCLIN43 FENOFIBRIC ACID 22 ENDOMETRIN87 ERYTHROMYCIN (OPHTH) 74 EVOXAC66 FENOGLIDE22 ENJUVIA52 ERYTHROMYCIN STEARATE 52 EXACTUSS41 FENOPROFEN CALCIUM ENOXAPARIN SODIUM 13 ERYTHROMYCIN-SULFISOXAZOLE8 EXELDERM44 FENTANYL6 ENTACAPONE28 ESCAVITE67 EXELON (PA) FENTANYL CITRATE 200MCG, 400MCG, 600MCG, 1200MCG, 1600MCG 76 ENTOCORT EC ESCITALOPRAM OXALATE ENALAPRIL MALEATE 23 39 1 16 EPIDUO43 ESGIC5 EPIFOAM46 ESGIC-PLUS5 EPINASTINE HCL (OPHTH) 75 ESTAZOLAM72 EPINEPHRINE HCL 12 EPIPEN 2-PAK 87 ESTERIFIED ESTROGENS & METHYLTESTOSTERONE52 EPIPEN-JR 2-PAK 87 EPIVIR31 EPIVIR HBV 31 EPLERENONE25 EPOGEN (PA) 57 EPROSARTAN MESYLATE 24 EPZICOM31 EQUAGESIC5 EQUETRO29 ERGOCALCIFEROL72 ERGOLOID MESYLATES 81 ERGOMAR63 ERGOTAMINE W/ CAFFEINE 63 ERIVEDGE (PA) 26 ESTRACE CREA 87 ESTRACE TABS 52 ESTRADIOL52 ESTRADIOL & NORETHINDRONE ACETATE 52 ESTRADIOL VALERATE 52 35 FEMARA (PA) 27 FEMCAP (QL) (1 / 300 DAYS) 62 FEMHRT 1/5 52 4 FEMHRT LOW DOSE 52 4 FEM PH 87 81 EXEMESTANE27 EXFORGE24 EXFORGE HCT 24 EXJADE 125MG, 250MG (PA) 19 EXJADE 500MG 19 EXTAVIA81 FACTIVE53 FAMCICLOVIR32 FAMOTIDINE85 FAMVIR32 FANAPT29 FANAPT TITRATION PACK 29 ESTRASORB52 FARESTON27 ESTRING87 FE 90 PLUS ESTROGEL52 FE FUMARATE-VITAMIN C-VITAMIN B12-FOLIC ACID 58 ESTROPIPATE52 ETHAMBUTOL HCL 100MG 25 ETHAMBUTOL HCL 400MG 26 ETHOSUXIMIDE15 ETHYL CHLORIDE 61 ETHYNODIOL DIACET & ETH ESTRAD 38 57 FELBAMATE15 FELBATOL15 FELBATOL15 FELDENE4 FELODIPINE 35 FENTANYL CITRATE 800MCG (PA) 4 76 FENTORA6 FERIVA57 FERRALET 90 57 FERRAPLUS 90 57 FERRIPROX (PA) 19 FERRO-PLEX HEMATINIC 57 FERROTRIN57 FERROUS FUMARATE-FOLIC ACID 58 FERROUS FUMARATE W/ B12-VIT C-FA-IFC 58 FETRIN57 FEXMID71 FIBRICOR22 FINACEA48 FINASTERIDE55 FINASTERIDE (ALOPECIA) 56 FIORICET5 FIORICET/CODEINE6 FIORINAL5 index viii 2015 Metallic Drug List Index FIRST-DUKES MOUTHWASH 65 FLUOCINOLONE ACETONIDE 46 FOLIC ACID-VITAMIN B6-VITAMIN B12 FIRST-MARYS MOUTHWASH 65 FLUOCINOLONE ACETONIDE (OTIC) 78 FOLIVANE-F57 58 GASTROCROM53 GATIFLOXACIN (OPHTH) FIRST-MOUTHWASH BLM 65 FLUOCINONIDE CREA; GEL; OINT 46 FOLIVANE-OB68 GELCLAIR66 FIRST-PROGESTERONE VGS 10 87 FLUOCINONIDE EMULSIFIED BASE 40 FOLIVANE-PRX DHA NF 68 GEMFIBROZIL22 FIRST-PROGESTERONE VGS 20 87 FLUOCINONIDE SOLN 40 FOLLISTIM AQ (PA) 50 GENTAMICIN SULFATE FIRST-PROGESTERONE VGS 25 87 FLUORABON64 FOLPACE RX 57 GENTAMICIN SULFATE (OPHTH) 74 FIRST-PROGESTERONE VGS 40 87 FLUOR-A-DAY64 FOLTRATE57 GENTAMICIN SULFATE (TOPICAL) 44 FIRST-PROGESTERONE VGS 50 87 FLUORESCEIN W/ PROPARACAINE 76 FONDAPARINUX SODIUM 13 GENTEX ADE 68 74 FORADIL AEROLIZER 12 GEODON29 74 3 FIRST-TESTOSTERONE MC COM 7 FLUOROMETHOLONE (OPHTH) FIRST-VANCOMYCIN 25 8 FLUOROPLEX44 FORTAMET17 GILENYA (PA) 81 FIRST-VANCOMYCIN 50 8 FLUOROURACIL (TOPICAL) 44 FORTEO (PA) GILOTRIF (PA) 27 FLAGYL8 FLUOXETINE HCL 16 FORTICAL50 GILPHEX TR 41 FLAGYL ER FLUPHENAZINE DECANOATE 30 FOSAMAX50 GILTUSS41 FLAREX74 FLUPHENAZINE HCL 30 FOSAMAX PLUS D 50 GILTUSS TR 41 FLAVOXATE HCL FLURAZEPAM HCL 72 FOSINOPRIL SODIUM 23 GLEEVEC (PA) 27 8 86 FLAXSEED OIL-EVENING PRIMROSE OIL-BILBERRY EXTRACT 48 FLECAINIDE ACETATE 50MG, 100 MG, 150MG 10 FLECTOR44 FLEXERIL71 FLEXTRA5 FLEXTRA-6505 FLEXTRA DS 5 FLOMAX55 FLONASE71 FLO-PRED39 FLOVENT DISKUS 12 FLOVENT HFA 12 FLOXURIDINE (PA) 26 FLUCONAZOLE20 FLUCYTOSINE20 FLUDROCORTISONE ACETATE 40 FLUNISOLIDE (NASAL) 71 FLUNISOLIDE NASAL SOLN 29 MCG/ACT (0.025%)71 FLURBIPROFEN4 50 FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE23 GLIMEPIRIDE18 FLUTAMIDE27 FOSPHENYTOIN SODIUM GLIPIZIDE-METFORMIN HCL 17 FLUTICASONE PROPIONATE CREA; LOTN 46 FOSRENOL54 FRAGMIN13 GLUCAGEN HYPOKIT 17 FLUTICASONE PROPIONATE (NASAL) 71 FRENADOL5 GLUCAGON EMERGENCY KIT 17 FLUTICASONE PROPIONATE OINT 40 FROVA63 FLUVASTATIN SODIUM 22 FUMATINIC57 FLUVOXAMINE MALEATE 16 FURADANTIN86 FML74 FUROSEMIDE49 FML FORTE 74 FUSION PLUS 57 FML LIQUIFILM 74 FUZEON KIT 31 FOCALGIN-B68 FUZEON SOLR (PA) 31 FOCALIN2 GABAPENTIN14 FOCALIN XR 5MG, 10MG, 15MG, 20MG, 30MG, 40MG, FOCALIN XR 25MG, 35MG; QL (30 EA / 30 DAYS) 2 GABITRIL15 FLURBIPROFEN SODIUM 75 FOLGARD RX 57 FOLIC ACID 57 FOLIC ACID-PYRIDOXINE-CYANCOBALAMIN 48 GALANTAMINE HYDROBROMIDE (PA) 15 81 GALZIN64 GANIRELIX ACETATE (PA) 50 GARAMYCIN74 GASTRINEX NF 84 GLIPIZIDE18 GLUCOPHAGE17 GLUCOPHAGE XR 17 GLUCOTROL18 GLUCOTROL XL 18 GLUCOVANCE17 GLUMETZA17 GLYBURIDE18 GLYBURIDE-METFORMIN17 GLYBURIDE MICRONIZED 18 GLYCOPYRROLATE84 GLYNASE18 GLYSET17 GOLYTELY60 GRANISETRON HCL 19 GRANISOL19 index ix 2015 Metallic Drug List Index GRIFULVIN V 20 HYALURONATE SODIUM (EMOLLIENT) 50 HYOSCYAMINE SULFATE TB12 .375MG 84 INVIRASE31 GRISEOFULVIN MICROSIZE 20 HYCAMTIN28 HYOSCYAMINE SULFATE TBDP INVOKANA83 GRISEOFULVIN ULTRAMICROSIZE 20 HYCET6 HYPER-SAL42 IODINE STRONG (LUGOL’S) GRIS-PEG20 HYDRALAZINE HCL 25 HYPERSAL42 IODOFLEX30 GUANFACINE HCL 24 HYDREA28 HYZAAR24 IODOQUINOL-HC20 GUANIDINE HCL 25 HYDRO 40 FOAM 60 IBANDRONATE SODIUM 50 IOPIDINE73 GYNAZOLE-187 HYDROCHLOROTHIAZIDE49 IBUPROFEN SUSP 72 IPRATROPIUM-ALBUTEROL12 HALCION59 HYDROCODONE-ACETAMINOPHEN6 IBUPROFEN TABS 4 HALFLYTELY BOWEL PREP/FLA 60 HYDROCODONE/ACETAMINOPHEN6 ICLUSIG (PA) HALOBETASOL PROPIONATE CREA 46 HYDROCODONE-IBUPROFEN76 IMBRUVICA (PA) HALOBETASOL PROPIONATE OINT 40 HALOG46 HALOPERIDOL29 HALOPERIDOL DECANOATE 29 HALOPERIDOL LACTATE 29 HECTOROL51 HELIDAC85 HEMATOGEN FA 57 HEMATRON-AF57 HEMETAB57 HEMOCYTE-F57 HEPARIN SODIUM (PORCINE) 13 HEPSERA32 HEXALEN26 HOMATROPINE HBR 73 HPR PLUS 47 HUMALOG18 HUMALOG MIX 50/50 18 HUMALOG MIX 50/50 KWIKPEN 18 HUMALOG MIX 75/25 18 HUMALOG MIX 75/25 KWIKPEN 18 HUMIRA (PA) 4 HUMIRA PEN-CROHNS DISEASE (PA) 4 HUMIRA PEN-PSORIASIS STAR (PA) 4 HUMULIN R U-500 (CONCENTR 18 46 84 IPRATROPIUM BROMIDE 11 27 IPRATROPIUM BROMIDE (NASAL) 71 26 IRBESARTAN24 HYDROCODONE POLISTIREX-CHLORPHENIRAMINE POLISTIREX 42 IMDUR10 IRBESARTAN-HYDROCHLOROTHIAZIDE23 HYDROCODONE W/ HOMATROPINE IMIPRAMINE HCL 16 IMIPRAMINE PAMOATE 16 IRON POLYSACCHARIDE COMPLEX-VIT B12-FOLIC ACID 40 HYDROCORTISONE39 HYDROCORTISONE ACETATE-ALOE VERA40 HYDROCORTISONE ACETATE (RECTAL) 8 HYDROCORTISONE BUTYRATE HYDROPHILIC LIPO BASE 40 HYDROCORTISONE (INTRARECTAL) 7 HYDROCORTISONE (RECTAL) 8 HYDROCORTISONE VALERATE 40 HYDROCORTISONE W/ACETIC ACID 78 HYDROMORPHONE HCL 6 HYDROQUINONE79 HYDROQUINONE MICROSPHERES 79 HYDROXYCHLOROQUINE SULFATE 25 HYDROXYUREA28 HYDROXYZINE HCL 10 HYDROXYZINE PAMOATE 10 HYLIRA47 HYOSCYAMINE SULFATE ELIX 30 HYOSCYAMINE SULFATE SOLN 30 HYOSCYAMINE SULFATE SUBL 84 HYOSCYAMINE SULFATE TABS 84 HYOSCYAMINE SULFATE TB12 .375MG 84 IMIQUIMOD47 IMITREX63 IMITREX STATDOSE REFILL 63 58 IRON-VITAMIN C-VITAMIN B12-FOLIC ACID 57 IROSPAN 24/6 57 IMURAN33 IRRIGATION SOLUTIONS, PHYSIOLOGICAL 33 INCIVEK (PA) 32 ISENTRESS31 INCRELEX (PA) 51 ISONIAZID26 INDAPAMIDE49 ISONIAZID & RIFAMPIN 26 INDERAL LA 35 ISOPTIN SR 35 INDOCIN4 ISOPTO CARBACHOL 73 INDOMETHACIN4 ISOPTO CARPINE 73 INFERGEN (PA) 32 ISOPTO HOMATROPINE 73 INLYTA (PA) 27 ISOPTO HYOSCINE 73 INNOPRAN XL 35 ISORDIL TITRADOSE 10 INSPRA25 ISOSORBIDE DINITRATE 10 INTEGRA F 57 ISOSORBIDE DINITRATE SL TAB 2.5 MG 10 INTEGRA PLUS 57 ISOSORBIDE DINITRATE SL TAB 5 MG 10 INTELENCE31 ISOSORBIDE MONONITRATE 10 INTRON-A 10MU/ML 28 ISOTRETINOIN43 INTRON-A 6000000UNIT/ML (PA) 28 ISOXSUPRINE HCL INTRON-A W/DILUENT 28 ISRADIPINE35 INTUNIV2 ISTALOL73 INVEGA29 ITRACONAZOLE20 79 index x 2015 Metallic Drug List Index JAKAFI (PA) KLOR-CON M15 64 LAMIVUDINE-ZIDOVUDINE31 LEVOMEFOLATE DHA 68 JALYN55 27 KOMBIGLYZE XR 17 LAMOTRIGINE14 LEVONORGESTREL (EMERGENCY OC) 39 JANUMET17 KORLYM (PA) 17 LANOXIN36 LEVONORGESTREL & ETH ESTRADIOL 38 JANUMET XR K-PHOS64 LANSOPRAZOLE85 JANUVIA17 K-PHOS MF 54 LANTUS18 LEVONORGESTREL-ETH ESTRADIOL (TRIPHASIC)38 J-COF DHC K-PHOS NO 2 54 LANTUS SOLOSTAR 17 41 18 LEVONORGESTREL-ETHINYL ESTRADIOL (91-DAY)38 JENTADUETO17 KRISTALOSE60 LASIX49 J-MAX DHC K-TAB64 LASTACAFT75 LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS)38 JUVISYNC17 KUVAN (PA) 51 LATANOPROST75 LEVORPHANOL TARTRATE 6 JUXTAPID (PA) LABETALOL HCL 34 LATUDA29 LEVOTHYROXINE SODIUM 84 LEVSIN84 41 22 KADIAN6 LAC-HYDRIN47 LAVOCLEN-4 CREAMY WASH KALETRA31 LACRISERT73 LEFLUNOMIDE (PA) KALYDECO (PA) LACTIC ACID (AMMONIUM LACTATE) 47 LEMOHIST PLUS KAPVAY2 LACTIC ACID W/ VITAMIN E 50 LESCOL22 LEXIVA31 KAPVAY DOSE PACK 2 LACTOCAL-F68 LESCOL XL 22 LIALDA53 21 LACTULOSE60 LETAIRIS (PA) 36 LIDOCAINE47 KAYEXALATE33 LACTULOSE (ENCEPHALOPATHY) LETROZOLE (PA) 27 LIDOCAINE HCL CREA; GEL; SOLN KEFLEX37 LAMICTAL14 LEUCOVORIN CALCIUM 28 LIDOCAINE HCL-HYDROCORTIS KENALOG46 LAMICTAL CHEWABLE DISPERS 14 LEUKERAN26 LIDOCAINE HCL (LOCAL ANESTH.) 61 KEPPRA14 LAMICTAL ODT KIT 14 LEUPROLIDE ACETATE LIDOCAINE HCL LOTN 61 KEPPRA XR 500MG (QL) (180 EA / 30 DAYS) 14 LAMICTAL ODT TBDP 25MG (QL) (90 EA / 30 DAYS) 14 LEVACET5 LIDOCAINE HCL (MOUTH-THROAT) 65 KEPPRA XR 750MG (QL) (120 EA / 30 DAYS) 14 LAMICTAL ODT TBDP 50MG, 100MG (QL) (30 EA / 30 DAYS) 14 LEVALBUTEROL HCL LEVAQUIN53 LIDOCAINE-HYDROCORTISONE ACETATE (RECTAL)82 KERALYT47 LAMICTAL ODT TBDP 200MG (QL) (60 EA / 30 DAYS) 14 LEVATOL35 LIDOCAINE-PRILOCAINE47 LEVBID84 LIDODERM47 KARBINAL ER 82 KERLONE34 KETEK9 KETOCONAZOLE20 KETOCONAZOLE (TOPICAL) 44 KETOPROFEN4 KETOROLAC TROMETHAMINE 4 KETOROLAC TROMETHAMINE (OPHTH) 75 KETOTIFEN FUMARATE (OPHTH) 75 KLARON43 KLONOPIN13 54 43 5 LEXAPRO SOLN 16 41 LEXAPRO TABS 16 27 12 47 7 LAMICTAL STARTER/NOT TAKI 14 LEVEMIR18 LIDORX47 LAMICTAL STARTER/TAKING C 14 LEVEMIR FLEXTOUCH 18 LIDOVIR45 LAMICTAL STARTER/TAKING V 14 LEVETIRACETAM SOLN; TB24 14 LINZESS54 LAMICTAL XR KIT 14 LEVETIRACETAM TABS 15 LIOTHYRONINE SODIUM LEVOBUNOLOL HCL 73 LIPITOR22 LEVOCARNITINE (METABOLIC MODIFIERS) 62 LIPOFEN22 LEVOCETIRIZINE DIHYDROCHLORIDE LISINOPRIL & HYDROCHLOROTHIAZIDE 24 LAMICTAL XR TB24 25MG (QL) (90 EA / 30 DAYS)14 LAMICTAL XR TB24 50MG, 100MG, 250MG, 300MG (QL) (30 EA / 30 DAYS) 14 LAMICTAL XR TB24 200MG (QL) (60 EA / 30 DAYS)14 LAMIVUDINE31 21 84 LISINOPRIL23 LEVOFLOXACIN53 LITHIUM CARBONATE LEVOFLOXACIN (OPHTH) LITHOBID29 74 29 index xi 2015 Metallic Drug List Index LITHOSTAT55 LUVOX CR LIVALO22 LUXIQ46 MEDROX-RX47 LOCOID46 LYRICA14 MEDROXYPROGESTERONE ACETATE LOCOID LIPOCREAM 46 LYSODREN27 METHIMAZOLE84 LODOSYN28 LYSTEDA58 MEDROXYPROGESTERONE ACETATE (CONTRACEPTIVE) (QL) (1 INJ / 75 DAYS) 39 LODRANE 24 20 MACRODANTIN86 MEFENAMIC ACID 4 METHOCARBAMOL71 LODRANE 24 21 MAFENIDE ACETATE 45 MEFLOQUINE HCL 25 METHOTREXATE SODIUM 26 LOFIBRA22 MAGNEBIND 400 64 MEGACE ES 80 METHSCOPOLAMINE BROMIDE 84 LOMOTIL19 MAGNESIUM SULFATE 64 MEGESTROL ACETATE 27 METHYCLOTHIAZIDE49 LOMUSTINE26 MALARONE25 MEKINIST (PA) 27 METHYLDOPA24 LOPERAMIDE HCL MALATHION48 MELOXICAM4 METHYLDOPA & HYDROCHLOROTHIAZIDE 23 19 16 LOPRESSOR34 MAPROTILINE HCL LOPRESSOR HCT 24 MARINOL19 LOPROX44 MARNATAL-F68 LOPROX SHAMPOO 44 MARPLAN16 LORAZEPAM10 MATULANE28 LORZONE71 MAVIK23 LOSARTAN POTASSIUM MAXAIR AUTOHALER 24 LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE24 LOTEMAX74 LOTENSIN23 LOTENSIN HCT 24 LOTREL24 LOTRISONE44 LOTRONEX54 LOVASTATIN22 LOVAZA (QL) (120 CAPS / 30 DAYS) 22 LOVENOX13 LOXAPINE SUCCINATE 30 LUFYLLIN12 LUMIGAN75 LUNESTA59 LURIDE64 LUSONAL72 16 12 MAXALT63 MAXALT-MLT63 MAXARON FORTE 57 MAXIFED CD 41 MAXIFED CDX 41 MAXIFED-G CD 41 MAXIFED-G CDX 41 MAXIFLU CD 41 MAXIFLU CDX 41 MAXINATE68 MAXIPHEN CD 41 MAXIPHEN CDX 41 MAXZIDE49 MAXZIDE-2549 MECLIZINE HCL MECLOFENAMATE SODIUM 19 4 MEDROL39 MEDROL DOSEPAK 39 80 MENEST52 MENOPUR (PA) 50 MENOSTAR52 MENTAX44 MEPERIDINE HCL 76 METHENAMINE-HYOSC-METHYLENE BLUESOD PHOS-PHENYL SAL 85 METHENAMINE MANDELATE 86 METHITEST7 METHYLERGONOVINE MALEATE 78 METHYLIN2 METHYLPHENIDATE HCL CP24; SOLN; TABS; TBCR 2 METHYLPHENIDATE HCL CPCR 83 METHYLPREDNISOLONE 4MG 55 MERCAPTOPURINE26 METHYLPREDNISOLONE 4MG, 8MG, 16MG, 32MG 39 MESALAMINE53 METHYLPREDNISOLONE SOD SUCC 39 MESNEX28 METHYLTESTOSTERONE7 MESTINON25 METIPRANOLOL35 MESTINON TIMESPAN METOCLOPRAMIDE HCL MEPHYTON88 MEPROBAMATE10 METADATE CD, METADATE ER 25 53 2 METOLAZONE49 METAGLIP17 METOPROLOL & HYDROCHLOROTHIAZIDE 24 METAPROTERENOL SULFATE 12 METAXALONE71 METOPROLOL SUCCINATE 34 METFORMIN HCL 17 METOPROLOL TARTRATE 34 METHADONE HCL 6 METOZOLV ODT 53 METHAMPHETAMINE HCL 1 METROCREAM48 METHAZOLAMIDE49 METROGEL48 METHENAMINE HIPPURATE 86 METROGEL-VAGINAL87 METHENAMINE-HYOSCAMINE-METHYLENE BLUE-SODIUM PHOSPHATE 85 METHENAMINE-HYOSC-METHYLENE BLUE-BENZOIC ACID-PHENYL SAL 85 METROLOTION48 METRONIDAZOLE8 METRONIDAZOLE (TOPICAL) 48 index xii 2015 Metallic Drug List Index METRONIDAZOLE VAGINAL 87 MEVACOR22 MEXILETINE HCL 10 MIACALCIN50 MICARDIS24 MICARDIS HCT 24 MICRO-K64 MICROZIDE49 MIDAZOLAM HCL 72 MIDODRINE HCL 88 MIGRAL63 MIGRANAL63 MILLIPRED39 MILLIPRED DP 39 MINASTRIN 24 FE 38 MINOCIN83 MINOCYCLINE HCL 83 MINOXIDIL25 MIRAPEX29 MIRTAZAPINE15 MISOPROSTOL85 MOBIC4 MODAFINIL (PA) 2 MODERIBA (PA) 32 MOEXIPRIL HCL 23 MOEXIPRIL-HYDROCHLOROTHIAZIDE23 MOMETASONE FUROATE 46 MONODOX83 MONTELUKAST SODIUM 11 MONUROL86 MORPHINE SULFATE CP24 6 MORPHINE SULFATE SOLN 10MG/5ML, 20MG/5ML6 MORPHINE SULFATE SOLN 20MG/ML MORPHINE SULFATE SUPP 76 6 MORPHINE SULFATE TABS 6 NAFTIN CREA 2% 44 NEEVO68 MORPHINE SULFATE TBCR 15MG, 30MG, 60MG, 100MG (QL) (90 EA / 30 DAYS) 6 NAFTIN GEL 1% 44 NEEVO DHA 68 MORPHINE SULFATE TBCR 200MG (PA) 6 NAFTIN GEL 2% 44 NEFAZODONE HCL 65 NALBUPHINE HCL MOTOFEN19 MOVIPREP60 MOXEZA74 MS CONTIN 15MG, 30MG, 60MG, 100MG (QL) (90 EA / 30 DAYS) 6 MS CONTIN 200MG (PA) 6 MST 600 5 MULTAQ11 MULTICHEW67 MULTIGEN57 MULTIGEN FOLIC 57 MULTIGEN PLUS 58 MUPIROCIN44 MYCELEX65 MYCOBUTIN26 MYCOPHENOLATE MOFETIL 33 MYDRIACYL73 MYFORTIC33 MYKIDZ IRON FL 67 MYLERAN26 MYNATAL-Z68 MYOXIN77 MYRBETRIQ86 MYSOLINE14 MYTELASE25 NABUMETONE4 NADOLOL35 NADOLOL & BENDROFLUMETHIAZIDE 24 NAFCILLIN SODIUM 79 NAFRINSE DAILY/NEUTRAL 66 NAFTIN CREA 1% 44 7 NEOMYCIN-BACITRACIN-POLYMYXIN13 NALFON4 NEOMYCIN-BACITRACIN ZN-POLYMYXIN 75 NALOXONE HCL 19 NEOMYCIN-POLYMY-DEXAMETH74 NALTREXONE HCL 19 NEOMYCIN-POLYMY-GRAMICID74 NAMENDA (PA) 81 NEOMYCIN/POLYMYXIN B GU 55 NAMENDA TITRATION PAK (PA) 81 NEOMYCIN-POLYMYXIN-HC (OPHTH) 74 NAPHAZOLINE HCL 74 NEOMYCIN-POLYMYXIN-HC (OTIC) 77 NAPRELAN 375MG, 750MG; QL (30 EA / 30 DAYS)4 NEOMYCIN SULFATE NAPRELAN 500MG; QL (60 EA / 30 DAYS) 4 NEOTIC77 NAPROSYN4 NAPROXEN4 NAPROXEN SODIUM NARATRIPTAN HCL 4 63 NARDIL16 NASACORT AQ 71 NASCOBAL56 NASONEX71 NATACHEW68 NATACYN74 NATAFORT68 NATA KOMPLETE 68 NATALVIT68 NATAZIA38 NATEGLINIDE18 NATELLE-EZ68 NATELLE ONE 68 NATROBA48 NATURE-THROID84 NATURE-THROID NT-2.5 84 NEBUPENT8 NEBUSAL42 3 NEORAL33 NEOTUSS PLUS 41 NEPHPLEX RX 66 NEPHROCAPS66 NEPHROCAPS QT 66 NEPHRON FA 58 NESTABS68 NESTABS ABC 68 NESTABS DHA 68 NEULASTA (PA) 57 NEUPOGEN (PA) 57 NEUPRO29 NEURONTIN14 NEVANAC75 NEVIRAPINE31 NEXA SELECT 68 NEXAVAR (PA) 27 NEXICLON XR 24 NIACIN22 NIACIN (ANTIHYPERLIPIDEMIC) 72 NIACIN TR 22 NIASPAN22 NICARDIPINE HCL 35 index xiii 2015 Metallic Drug List Index NICAZEL67 NORETHINDRONE ACET & ETH ESTRA 38 NYSTATIN20 OPHTHALMIC IRRIGATION SOLUTION NICOMIDE70 NORETHINDRONE (CONTRACEPTIVE) 39 NYSTATIN (MOUTH-THROAT) 65 NICOTINE83 NORETHINDRONE & ETH ESTRADIOL 38 NYSTATIN (TOPICAL) 44 OPHTHALMIC IRRIGATION SOLUTION INTRAOCULAR76 NICOTROL INHALER 82 NYSTATIN-TRIAMCINOLONE44 NICOTROL NS 82 NORETHINDRONE & ETHINYL ESTRADIOL-FE38 35 38 87 NIFEDIPINE CAPS NORETHINDRONE & MESTRANOL NYSTATIN VAGINAL NORGESTIMATE-ETHINYL ESTRADIOL 38 OB COMPLETE 68 OB COMPLETE 400 68 OB COMPLETE/DHA 68 OB COMPLETE ONE 68 OB COMPLETE PETITE 68 OB COMPLETE PREMIER 68 OB-NATAL ONE 68 OBSTETRIX DHA 68 O-CAL PRENATAL 68 OCTREOTIDE ACETATE (PA) 51 NIFEDIPINE TB24 30MG, 60MG, 90MG 35 NIFEDIPINE TB24 90MG 35 NILANDRON27 NIMODIPINE35 NIRON KOMPLETE 58 NISOLDIPINE35 NITRO-BID10 NITRO-DUR10 NITROFURANTOIN86 NITROFURANTOIN MACROCRYSTAL 86 NITROFURANTOIN MONOHYD MACRO 86 NITROGLYCERIN AERS; CPCR 72 NITROGLYCERIN PT24; SOLN 10 NITROLINGUAL PUMPSPRAY 10 NITROMIST10 NITROSTAT10 NIZATIDINE CAPS 56 NIZATIDINE SOLN 85 NIZORAL44 NORCO6 NORDITROPIN FLEXPRO (PA) 50 NORDITROPIN NORDIFLEX PEN (PA) 50 NOREL SR 41 NORETHIN ACET & ESTRAD-FE 38 NORETHINDRONE ACETATE 80 NORETHINDRONE ACETATE-ETHINYL ESTRADIOL52 NORETHINDRONE ACETATE-ETHINYL ESTRADIOL-FE NORETHINDRONE-ETH ESTRADIOL (TRIPHASIC) 38 NORGESTIMATE-ETHINYL ESTRADIOL (TRIPHASIC)38 NORGESTREL & ETHINYL ESTRADIOL 38 NORITATE48 NOROXIN53 NORPACE10 NORPACE CR 10 NORPRAMIN16 NORTRIPTYLINE HCL 16 NORVASC35 NORVIR31 NOVAFERRUM58 NOVOLIN 70/30 59 NOVOLIN N 59 NOVOLIN R 59 NOVOLOG 18 NOVOLOG FLEXPEN 18 NOVOLOG MIX 70/30 18 NOVOLOG MIX 70/30 FLEXPEN 18 NOVOLOG PENFILL 18 NOXAFIL20 NUCORT46 NUCYNTA6 NUEDEXTA81 NULYTELY/FLAVOR PACKS 60 NUMOISYN66 NUOX43 NUZON46 OCUFLOX74 OFLOXACIN53 OFLOXACIN (OPHTH) 74 OFLOXACIN (OTIC) 77 OFLOXACIN TAB 200 MG 53 OLANZAPINE30 OLANZAPINE-FLUOXETINE HCL 38 OLUX46 OMEPRAZOLE85 OMEPRAZOLE-SODIUM BICARBONATE 85 OMNARIS71 OMNIFLEX DIAPHRAGM (QL) (1 / 300 DAYS) 62 OMNIPRED74 OMNITROPE (PA) 56 ONDANSETRON1 ONDANSETRON HCL 19 ONFI13 ONGLYZA17 ONSOLIS6 OPSUMIT (PA) 76 82 OPTIPRANOLOL73 OPTIVAR75 ORAP81 ORAPRED39 ORAPRED ODT ORENCIA (PA) (ST) 39 5 ORFADIN51 ORPHENADRINE CITRATE 71 ORPHENADRINE W/ ASPIRIN & CAFF 71 ORPHENADRINE W/ ASPIRIN & CAFFEINE TAB 50-770-60 MG 71 ORPHENADRINE W/ ASPIRIN & CAFFEINE TAB 50-770-60 MG 71 ORTHO DIAPHRAGM ALL-FLEX (QL) (1 / 300 DAYS)62 ORTHO DIAPHRAGM COIL SPRI (QL) (1 / 300 DAYS) 62 ORTHO DIAPHRAGM FLAT SPRI (QL) (1 / 300 DAYS) 62 ORTHO EVRA 39 ORTHO TRI-CYCLEN LO 38 OSMOPREP60 OTICIN HC NR 77 OTOZIN77 OVACE PLUS 45 OVACE PLUS WASH 45 OVIDE48 OVIDREL (PA) 50 OXACILLIN SODIUM 79 OXANDROLONE 2.5MG 7 OXANDROLONE 10MG 3 OXAPROZIN4 OXAZEPAM34 index xiv 2015 Metallic Drug List Index OXCARBAZEPINE14 PATANASE71 PERTZYE48 PLAN B ONE-STEP OXISTAT44 PATANOL75 PEXEVA16 PLAQUENIL25 OXSORALEN ULTRA 45 PAXIL16 PHENAZOPYRIDINE HCL 55 PLAVIX56 OXTELLAR XR 14 PAXIL CR PHENELZINE SULFATE 16 PLETAL56 OXYBUTYNIN CHLORIDE 86 PCE62 PHENFLU CD 41 PLEXION CLEANSER 43 OXYCODONE-ASPIRIN76 PEDIATEX TD 41 PHENFLU CDX 41 PLEXION CLEANSING CLOTH 43 OXYCODONE HCL CAPS PEDIATEX TDM 41 PHENOBARBITAL ELIX 34 PLEXION SCT 44 PEDIATRIC MULTIVITAMINS W/FL 67 PHENOBARBITAL ELIX 34 PNV-DHA+DOCUSATE68 PEDIATRIC VITAMINS ACD FLUORIDE & IRON67 PHENOBARBITAL TABS 15MG, 16.2MG, 30MG, 32.4MG, 60MG, 64.8MG, 97.2MG 59 PNV-TOTAL68 PEDIATRIC VITAMINS ACD W/ FLUORIDE 67 PHENOBARBITAL TABS 100MG 34 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE 60 PHENOBARBITAL TABS 100MG 34 PODOFILOX47 PEG 3350-POTASSIUM CHLORIDE-SOD BICARBONATE-SOD CHLORIDE PHENYLEPH-PROMETHAZINE W/ COD 43 PHENYLEPHRINE-CHLORPHEN-DM42 OXYCODONE HCL CONC; SOLN; TABS 76 6 OXYCODONE-IBUPROFEN6 OXYCODONE W/ ACETAMINOPHEN 6 OXYCODONE W/ ACETAMINOPHEN CAP 5-500 MG 6 OXYCODONE W/ ACETAMINOPHEN TAB 7.5500 MG 6 OXYCODONE W/ ACETAMINOPHEN TAB 10650 MG 6 OXYMORPHONE HCL PAIRE OB 6 68 16 60 PEGANONE15 PEGASYS (PA) 32 PEGASYS PROCLICK (PA) 32 PALGIC21 PEG-INTRON (PA) 59 PAMINE84 PEG-INTRON REDIPEN (PA) 59 PAMINE FORTE PENICILLIN G POTASSIUM 78 84 PANCREAZE48 PENICILLIN G SODIUM 78 PANCRELIPASE (LIPASE-PROTEASE-AMYLASE)48 PENICILLIN V POTASSIUM 78 PANDEL46 PANTOPRAZOLE SODIUM 85 PARAFON FORTE DSC 71 PARAGARD INTRAUTERINE COP (QL) (1 / 300 DAYS) 62 PARCOPA29 PARICALCITOL51 PARLODEL29 PARNATE16 PAROMOMYCIN SULFATE PAROXETINE HCL 3 16 PATADAY75 PENTASA53 PENTAZOCINE W/ NALOXONE 77 PENTOXIFYLLINE56 PEPCID85 PERCOCET6 PERCODAN6 PERFOROMIST12 PERIDEX65 PERINDOPRIL ERBUMINE 23 PERIOSTAT83 PERMETHRIN48 PERPHENAZINE30 PERPHENAZINE-AMITRIPTYLINE38 PHENYLEPHRINE-GUAIFENESIN42 PHENYLEPHRINE HCL (OPHTH) 74 PHENYLEPHRINE W/ DM-GG 41 PHENYTEK15 PHENYTOIN15 PHENYTOIN SODIUM 15 PHENYTOIN SODIUM EXTENDED 15 PHISOHEX30 PHOSLO54 PHOSLYRA54 PHRENILIN FORTE 5 PILOCARPINE HCL 64 PILOCARPINE HCL (ORAL) 5MG 66 PILOCARPINE HCL (ORAL) 7.5MG 84 PILOPINE HS 73 PINDOLOL35 PINNACAINE OTIC 77 PIOGLITAZONE HCL 18 PIOGLITAZONE HCL-GLIMEPIRIDE 17 PIOGLITAZONE HCL-METFORMIN HCL 17 PIROXICAM4 PODOCON 25 IN BENZOIN TIN 39 47 POLYCITRA-K CRYSTALS 54 POLYETHYLENE GLYCOL 3350 PACK 61 POLYETHYLENE GLYCOL 3350 POWD 60 POLY HIST DHC 41 POLY HIST NC 41 POLYMYXIN B SULFATE 9 POLYMYXIN B-TRIMETHOPRIM 74 POLY-TUSSIN DHC 41 POLY-TUSSIN EX 41 POLY-VENT DM 11 POLY-VI-FLOR CHEW 67 POLY-VI-FLOR/IRON67 POLY-VI-FLOR SUSP 67 POMALYST (PA) 27 PONSTEL4 POTABA88 POTASSIUM BICARB & CHLORIDE 79 POTASSIUM BICARBONATE 79 POTASSIUM CHLORIDE CPCR; LIQD; SOLN; TBCR 64 POTASSIUM CHLORIDE MICROENCAPSULATED CRYSTALS CR 64 POTASSIUM CHLORIDE PACK 64 POTASSIUM CITRATE (ALKALINIZER) 54 index xv 2015 Metallic Drug List Index POTASSIUM CITRATE-CITRIC ACID 2 PREMPRO52 PR NATAL 400 68 PROPYLTHIOURACIL84 POTIGA14 PRENA1 PLUS/QUATREFOLIC 69 PR NATAL 400 EC 68 PROSCAR55 POT PHOSPHATE MONOBASIC W/ SOD PHOSPHATE DIBASIC & MONOBASIC 79 PRENAFIRST69 PR NATAL 430 EC 68 PROSED/DS86 POT & SOD CITRATES W/CITRIC AC PRENAISSANCE 90 DHA 69 PROAIR HFA 12 PROSOM59 PRENAISSANCE BALANCE 69 PROBENECID55 PROSTIGMIN25 PRENAISSANCE DHA 69 PROCAINAMIDE HCL 10 PROTECTBONE67 PRENAISSANCE PROMISE 69 PROCARDIA XL 35 PROTECTNATAL69 2 PRADAXA13 PRAMIPEXOLE DIHYDROCHLORIDE 29 PRAMOSONE46 PRAMOSONE E 46 PRAMOTIC77 PRAMOXINE-CHLOROXYLENOL78 PRENATA69 PROCENTRA1 PROTECT PLUS NR PRENATAL MV & MIN/FE-FA-D 69 PROCHLORPERAZINE30 PROTID41 PRENATAL PLUS IRON 69 PROCHLORPERAZINE MALEATE PROTOPIC47 30 67 PRENATAL-U69 PROCORT7 PROTRIPTYLINE HCL 16 47 PRENATAL VIT W/ DOCUSATE-IRON CARBONYL-FOLIC ACID 80 PROCRIT (PA) PROVENTIL HFA 12 PRANDIN18 PRENATE69 PROCTOCORT8 PROVERA80 PRAVACHOL22 PRENATE AM 69 PROCTOFOAM HC PROVIDA OB 69 PRAVASTATIN SODIUM 22 PRENATE DHA 69 PRODRIN63 PROVIGIL (PA) 2 PRAZOSIN HCL 24 PRENATE ELITE 69 PROFERRIN-FORTE57 PROZAC16 PRECOSE17 PRENATE ENHANCE 69 PROGESTERONE MICRONIZED 80 PRYFLEX2 PRED FORTE PRENATE ESSENTIAL 69 PROGLYCEM17 PSEUDOEPHED-BROMPHEN-DM42 PRED-G75 PRENATE MINI 69 PROGRAF33 PSEUDOEPHEDRINE-GUAIFENESIN41 PRED-G S.O.P. 75 PRENATE RESTORE 69 PROHIST CD 41 PULMICORT12 PRED MILD 75 PRENTIF CAVITY-RIM CERVIC (QL) (1 / 300 DAYS)62 PROHIST CF 41 PULMICORT FLEXHALER 12 PROHIST LQ 41 PULMOZYME (PA) 82 PROLEX DMX 41 PURINETHOL26 PROMACTA (PA) 57 PYLERA85 PROMETHAZINE-DM41 PYRAZINAMIDE26 PROMETHAZINE HCL 21 PYRIDIUM55 PROMETHAZINE & PHENYLEPHRINE 42 PYRIDOSTIGMINE BROMIDE 25 PROMETHAZINE W/CODEINE 41 QL (13 / 300 DAYS) 39 PRAMOXINE-HC-CHLOROXYLENOL78 PRAMOXINE HCL 74 PREDNICARBATE46 PREDNISOLONE39 PREDNISOLONE ACETATE (OPHTH) 74 PREDNISOLONE SODIUM PHOSPHATE 39 PREDNISONE39 PREFERA OB + DHA 68 PREFERAOB ONE 68 PREFEST52 PREFOL-DHA69 PRE-FOLIC58 PREMARIN CREA 87 PREMARIN TABS 52 PREMPHASE52 PRENTIF FITTING SET (QL) (1 / 300 DAYS) 62 PREPOPIK60 PREQUE 10 69 PREVACID SOLUTAB (QL) (60 EA / 30 DAYS); AGE85 PREVIDENT 5000 DRY MOUTH 66 57 7 PREZISTA31 PROMETRIUM80 QNASL71 PRIFTIN26 PROPAFENONE HCL 10 QUALAQUIN25 PRIMAQUINE PHOSPHATE PROPANTHELINE BROMIDE 30 QUAZEPAM72 PRIMIDONE14 PROPARACAINE HCL 74 QUESTRAN22 PRINIVIL23 PROPRANOLOL HCL 35 QUETIAPINE FUMARATE PRINZIDE24 PROPRANOLOL & HYDROCHLOROTHIAZIDE24 25 30 QUINAPRIL-HYDROCHLOROTHIAZIDE23 QUINIDINE GLUCONATE 10 index xvi 2015 Metallic Drug List Index QUINIDINE SULFATE 10 REQUIP29 2MG, 3MG 34 SAVELLA TITRATION PACK 81 QUININE SULFATE 29 SE-CARE69 25 RESCON42 RISPERIDONE TBDP QVAR12 RESCON-JR42 RITALIN2 SE-CARE CONCEIVE RAMIPRIL23 RESCON-MX42 RITALIN LA 2 SECONAL59 RANEXA9 RESCRIPTOR31 RIVASTIGMINE TARTRATE (PA) 81 SECTRAL34 RANITIDINE HCL 69 85 RESERPINE9 RIZATRIPTAN BENZOATE 63 SELECT-OB69 RAPAFLO55 RESPA-BR20 R-NATAL OB 69 SELEGILINE HCL CAPS 29 RAPAMUNE33 RESPA-BR21 ROBAXIN71 SELEGILINE HCL TABS 29 RAZADYNE ER (PA) 81 RESTASIS74 ROBAXIN-75071 SELENIUM SULFIDE LOTN 45 RAZADYNE (PA) 81 RESTORIL59 ROBINUL84 SELENIUM SULFIDE SHAM 45 REAPHIRM69 RETIN-A44 ROBINUL FORTE SELSUN SHAMPOO 45 REBIF81 RETIN-A MICRO 44 ROCALTROL51 SELZENTRY31 REBIF REBIDOSE 81 RETIN-A MICRO PUMP 44 ROPINIROLE HYDROCHLORIDE SEMPREX-D41 REBIF REBIDOSE TITRATION 81 RETROVIR31 ROSANIL1 SE-NATAL 19 69 REBIF TITRATION PACK 81 84 29 REVATIO (PA) 36 ROXICETTYLENOL/CODEINE #3 SE-NATAL 90 69 RECTIV8 REVLIMID 2.5MG, 20MG (PA) 32 ROXICODONE6 SE-NATAL ONE 69 REGENECARE61 REVLIMID 5MG, 10MG, 15MG, 25MG 32 ROZEREM59 SENSIPAR (PA) 51 REGLAN53 REYATAZ31 RYTHMOL10 SE-PLETE DHA 69 REGRANEX (PA) REZIRA42 RYTHMOL SR SEPTRA DS RELAGESIC5 REZYST SB 18 SABRIL15 SERADEX42 RELCOF PE 41 RHINOCORT AQUA 71 SALAGEN66 SEREVENT DISKUS RELENZA DISKHALER 32 RIBASPHERE RIBAPAK (PA) 32 SALEX47 SEROMYCIN26 RELHIST41 RIBAVIRIN (HEPATITIS C) (PA) 59 SALICEPT66 SEROQUEL30 RELISTOR (PA) 54 RIFAMPIN26 SALICYLIC ACID SEROQUEL XR RELPAX63 RIFATER26 16 RILUTEK72 SALICYLIC ACID IN AMMONIUM LACTATE VEHICLE60 SERTRALINE HCL CONC REMERON15 83 REMERON SOLTAB RILUZOLE72 SALICYLIC ACID W/ CLEANSER SERTRALINE HCL TABS 25MG, 100MG SERTRALINE HCL TABS 50MG 16 SE-TAN DHA 69 48 15 RENAGEL54 RIMANTADINE HYDROCHLORIDE 32 RENATABS66 RINGER’S IRRIGATION 33 RENATABS WITH IRON 66 RIOMET17 RENAX67 RISPERDAL29 RENVELA54 RISPERDAL M-TAB 29 REPAGLINIDE18 RISPERIDONE SOLN 29 REPREXAIN6 RISPERIDONE TABS 4MG 29 REPRONEX (PA) RISPERIDONE TABS .25MG, .5MG, 1MG, 50 6 10 60 60 SALSALATE82 SAMSCA (PA) 51 SANCUSO19 SANDIMMUNE33 SANTYL47 8 12 30 SETONET69 SFROWASA53 SIGNIFOR (PA) 51 SAPHRIS30 SILDENAFIL CITRATE (PULMONARY HYPERTENSION) (PA) 36 SARAFEM81 SILVADENE45 SAVELLA81 SILVER NITRATE 45 index xvii 2015 Metallic Drug List Index SILVER NITRATE-POTASSIUM NITRATE 36 SONATA59 SUBUTEX (PA) SILVER SULFADIAZINE 45 7 SYNAGEX67 SORIATANE45 SUCRALFATE SUSP 85 SYNALAR OINTMENT KIT SIMBRINZA73 SOTALOL HCL SUCRALFATE TABS 85 SYNALGOS-DC6 SIMCOR22 SOTALOL HCL (AFIB/AFL) 80MG, 120MG35 SULAR35 SYNTHROID84 SIMPONI (PA, ST) SOTALOL HCL (AFIB/AFL) 160MG SULFACETAMIDE SODIUM (ACNE) 43 TABLOID26 SULFACETAMIDE SODIUM (OPHTH) OINT 75 TACLONEX OINT (QL) (400 GM / 56 DAYS)46 SULFACETAMIDE SODIUM (OPHTH) SOLN 74 TACROLIMUS33 4 35 35 SIMVASTATIN22 SPECTRACEF37 SINEMET CR SPINOSAD48 29 SINGULAIR11 SPIRIVA HANDIHALER SKELAXIN71 SPIRONOLACTONE49 SKELID50 SPIRONOLACTONE & HYDROCHLOROTHIAZIDE49 SKLICE48 SODIUM CHLORIDE 64 SODIUM CHLORIDE (GU IRRIGANT) 54 SODIUM CHLORIDE (INHALANT) 65 SODIUM CITRATE & CITRIC ACID 54 11 SPORANOX (PA) 20 SPORANOX PULSEPAK (PA) 20 SPRYCEL (PA) 27 SSKI64 SODIUM FLUORIDE CHEW 1MG, 2.2MG 64 STALEVO 50 29 SODIUM FLUORIDE CHEW .25MG, .5MG, .55MG, 1.1MG 64 STALEVO 75 29 STALEVO 100 29 SODIUM FLUORIDE (DENTAL) 43 STALEVO 125 29 SODIUM FLUORIDE-POTASSIUM NITRATE 43 STALEVO 150 29 SODIUM FLUORIDE SOLN STALEVO 200 29 STANNOUS FLUORIDE 43 64 SODIUM FLUORIDE SOLN 0.25 MG/DROP F (FROM 0.55 MG/DROP NAF) 64 SODIUM FLUORIDE TABS 1MG 64 SODIUM FLUORIDE TABS .5MG 64 SODIUM PHENYLBUTYRATE 63 SODIUM POLYSTYRENE SULFONATE POWD80 STARLIX18 STAVUDINE31 STIMATE (PA) 51 STIVARGA (PA) 27 STRATTERA2 STREPTOMYCIN SULFATE 3 SODIUM POLYSTYRENE SULFONATE SUSP 15GM/60ML33 STRIANT7 SODIUM POLYSTYRENE SULFONATE SUSP 30GM/120ML80 STROMECTOL8 SODIUM SULFACETAMIDE/SULF 44 SODIUM THIOSULFATE-SALICYLIC ACID 20 SOMA71 STRIBILD31 STROVITE FORTE 67 SUBOXONE FILM 77 SUBOXONE FILM (PA) 7 SUBOXONE SUBL (PA) 7 SULFACETAMIDE SODIUM-SULFUR IN UREA VEHICLE TACLONEX SUSP TAFINLAR (PA) 46 46 27 1 TAMBOCOR10 SULFACETAMIDE SODIUM-SULFUR W/ SUNSCREENS1 TAMIFLU32 TAMOXIFEN CITRATE 27 SULFACETAMIDE SODIUM W/ SULFUR CREA; LOTN; PADS 44 TAMSULOSIN HCL 55 SULFACETAMIDE SODIUM W/ SULFUR EMUL; FOAM; LIQD; SUSP TANDEM F 58 1 TANDEM OB 69 TANDEM PLUS 58 SULFACETAMIDE SOD-PREDNISOLONE 74 SULFADIAZINE83 SULFAMETHOXAZOLE-TRIMETHOPRIM8 SULFAMYLON45 SULFASALAZINE53 SULINDAC4 SUMATRIPTAN63 SUMATRIPTAN SUCCINATE 63 SUPRAX37 SUPREP BOWEL PREP 60 SURMONTIL16 SUSTIVA31 SUTENT27 SYLATRON (PA) 28 SYMBICORT12 SYMBYAX81 SYMLIN17 SYMLINPEN 60 17 SYMLINPEN 120 17 TAPAZOLE84 TARCEVA (PA) 27 TARGRETIN CAPS 28 TARGRETIN GEL 44 TARKA24 TARON-BC69 TARON-PREX69 TASIGNA (QL) (120 CAPS / 30 DAYS), (PA) 27 TASMAR28 TAZORAC45 TECFIDERA (PA) 81 TECFIDERA STARTER PACK (PA) 81 TEGRETOL14 TEGRETOL-XR14 TEKAMLO24 TEKTURNA25 TEKTURNA HCT 24 TEMAZEPAM59 TEMODAR (PA) 26 index xviii 2015 Metallic Drug List Index TEMOVATE46 THYROLAR-1/284 TOPAMAX SPRINKLE TEMOZOLOMIDE (PA) 14 TRIFLUOPERAZINE HCL 30 26 THYROLAR-1/484 TOPICORT46 TRIFLURIDINE74 TENEX24 THYROLAR-284 TOPIRAMATE14 TRIGLIDE22 TENORETIC 50 24 THYROLAR-384 TOPROL XL TRIHEXYPHENIDYL HCL TENORETIC 100 24 TIAGABINE HCL TORSEMIDE49 TRILEPTAL14 TRILIPIX22 15 34 36 28 TENORMIN34 TIAZAC35 TRACLEER (PA) TERAZOL 3 87 TICLOPIDINE HCL 79 TRADJENTA17 TRIMESIS RX 69 TERAZOL 7 87 TIGAN19 TRAMADOL-ACETAMINOPHEN77 TRIMETHOBENZAMIDE HCL 19 TERAZOSIN HCL 24 TIKOSYN11 TRAMADOL HCL TRIMETHOPRIM8 TERBUTALINE SULFATE 12 TIMOLOL MALEATE 35 TRANDATE34 TRIMIPRAMINE MALEATE TERCONAZOLE VAGINAL 87 TIMOLOL MALEATE (OPHTH) 73 TRANDOLAPRIL23 TRIOXIN77 TERSI FOAM 45 TIMOPTIC73 TRANEXAMIC ACID TRI RX TESSALON PERLES 40 TIMOPTIC-XE73 TRANSDERM-SCOP19 TRIVEEN-ONE70 TESTRED7 TINDAMAX8 TRANYLCYPROMINE SULFATE 16 TRI-VI-FLOR67 TETRACAINE HCL (OPHTH) 76 TINIDAZOLE8 TRAVATAN Z 75 TRI-VI-FLORO67 TETRACYCLINE HCL 83 TIROSINT84 TRAVOPROST80 TRI-ZEL67 TEVETEN24 TIVICAY31 TRAZODONE HCL 16 TRIZIVIR31 TEVETEN HCT 24 TIZANIDINE HCL 71 TREAGAN OTIC 77 TROPICAMIDE73 TGQ 15DM/5PEH/2CPM 42 TL G-FOL OS 67 TRECATOR26 TROSPIUM CHLORIDE TGQ 30PSE/3BRM/15DM 42 TL-SELECT69 TRETINOIN44 TRUSOPT75 TGQ 30PSE/150GFN/15DM 42 TL-SELECT DHA 69 TRETINOIN (CHEMOTHERAPY) 28 TRUST NATAL DHA 3 TRETINOIN (FACIAL WRINKLES) 2 TRUVADA31 TRYPSIN W/ CASTOR OIL & PERUVIAN BALSAM51 6 58 16 69 86 70 THALITONE49 TOBI PODHALER (PA) THALOMID 50MG, 100MG (QL) (30 CAPS / 30 DAYS), (PA) 32 TOBRADEX75 TREXALL26 THALOMID 150MG (QL) (60 CAPS / 30 DAYS), (PA) TOBRADEX ST 75 TRIAMCINOLONE ACETONIDE (MOUTH) 66 32 TOBRAMYCIN-DEXAMETHASONE74 TRIAMCINOLONE ACETONIDE (NASAL) 71 THALOMID 200MG (PA) 32 TOBRAMYCIN SULFATE 3 TRIAMCINOLONE ACETONIDE (TOPICAL)46 TUSNEL PED-C 74 TRIAMTERENE & HYDROCHLOROTHIAZIDE 49 TUSSICAPS42 TUSSIONEX PENNKINETIC EXT 42 TRIANEX46 TYKERB (PA) 27 TRIAZOLAM72 TYLENOL/CODEINE #4 TRIBENZOR24 TYLOX6 TRICARE DHA 301 69 TYVASO STARTER (PA) 36 TRICARE PRENATAL COMPLEAT 69 TYZEKA (PA) 32 TRICARE PRENATAL DHA ONE 69 TYZINE72 THEO-2412 THEOPHYLLINE ELIX 12 THEOPHYLLINE SOLN; TB12; TB24 12 THIOLA55 THIORIDAZINE HCL 30 THIOTHIXENE30 THYROID84 THYROLAR-184 TOBRAMYCIN SULFATE (OPHTH) TOBREX74 TOFRANIL16 TOFRANIL-PM16 TOLAZAMIDE18 TOLBUTAMIDE18 TOLMETIN SODIUM TOLTERODINE TARTRATE 4 86 TOPAMAX14 TRICOR22 TUSNEL41 TYZINE PEDIATRIC NASAL DR 41 6 72 index xix 2015 Metallic Drug List Index UDAMIN67 VALSARTAN-HYDROCHLOROTHIAZIDE24 VINATE AZ 70 VP-ERA OB PLUS 70 ULESFIA48 VALTREX32 VINATE CALCIUM 70 VP-HEME OB 70 ULORIC55 VALTURNA24 VINATE II 70 VP-PNV-DHA70 ULTIMATECARE COMBO 70 VANCOCIN HCL 8 VINATE M 70 VP-ZEL67 ULTIMATECARE ONE NF 70 VANCOMYCIN HCL 8 VINATE PN CARE 70 VUSION44 ULTRACET6 VANDETANIB (PA) 27 VIOKACE48 VYTORIN21 ULTRAM6 VANOXIDE-HC44 VIRACEPT31 VYVANSE1 ULTRAVATE46 VASERETIC24 VIRAMUNE31 WARFARIN SODIUM UNIRETIC24 VASOTEC23 VIRAMUNE XR 31 WELCHOL22 UNIVASC23 VAZOL20 VIREAD31 WELLBUTRIN16 UREA49 VAZOL21 VIROPTIC74 WELLBUTRIN SR UREA IN LACTIC ACID-SALICYLIC ACID VEHICLE49 VECAMYL25 VIRT-BAL DHA UREA IN LACTIC ACID VEHICLE 49 VECTICAL45 VIRT-PN70 WELLBUTRIN XL 150MG (QL) (30 EA / 30 DAYS)16 UREA IN ZINC UNDECYLENATE-LACTIC ACID VEHICLE VEMAVITE-PRX 2 70 VIRT-PN DHA 49 VENATAL COMPLETE DHA 70 VIRT-SELECT70 VENLAFAXINE HCL 16 VISTARIL10 VENTAVIS (PA) 36 VITAFOL-OB+DHA70 VERAMYST71 VITAFOL-ONE70 VERAPAMIL HCL VITAFOL-PLUS70 URELLE86 URETRON D/S 86 URIBEL86 URI-CONTROL RX 32 UROCIT-K 5 54 UROCIT-K 10 54 UROCIT-K 15 54 UROGESIC-BLUE86 UROQID #2 86 UROXATRAL55 URSO 250 53 URSODIOL53 URSO FORTE 53 VAGIFEM87 VALACYCLOVIR HCL 32 VALCYTE31 VALIUM10 VALPROATE SODIUM 15 VALPROIC ACID 15 35 70 70 WELLBUTRIN XL 300MG 13 16 16 WESTHROID84 WESTHROID-P84 WIDE-SEAL SILICONE DIAPHR (QL) (1 / 300 DAYS)62 WP THYROID 84 XALATAN75 VERDESO46 VITAFOL ULTRA 70 VERELAN35 VITAMEDMD ONE RX/QUATREFO 70 VERELAN PM 35 VITAMEDMD REDICHEW RX/QUA 70 VERIPRED 20 39 VITA-PREN70 XARELTO 10MG, 20MG (QL) (30 TABS / 30 DAYS)13 VESICARE86 VITASPIRE70 XARELTO 15MG (QL0 (60 TABS / 30 DAYS)13 VEXOL75 VITUZ42 XCLAIR47 VFEND (PA) VIVACTIL16 XELODA (PA) VIBRAMYCIN83 VIVA CT PRENATAL 70 XENADERM47 VICODIN6 VOLTAREN GEL 44 XENAZINE (PA) 81 VICOPROFEN6 VOLTAREN SOLN 75 XERAC AC 47 VICTOZA (QL) (3 / 30 DAYS) 18 VOLTAREN-XR4 XERESE45 VICTRELIS (PA) 32 VORICONAZOLE (PA) 20 XIFAXAN 200MG (QL) (60 TABS / 30 DAYS) 8 VIDEX EC 31 VOSOL HC 78 VIDEX PEDIATRIC 31 VOSPIRE ER 12 XIFAXAN 550MG (QL) (60 TABS / 30 DAYS), (PA)8 VIGAMOX74 VOTRIENT (PA) 27 XODOL6 VIMPAT14 VP-CH PLUS 70 XOLEGEL44 20 XALKORI (PA) 27 XANAX10 26 index xx 2015 Metallic Drug List Index XOPENEX12 ZITHROMAX61 ZYPREXA30 XOPENEX HFA 12 ZITHROMAX TRI-PAK 61 ZYPREXA ZYDIS 30 XTANDI (PA) 27 ZITHROMAX Z-PAK 61 ZYTIGA (QL) (120 TABS / 30 DAYS), (PA) 27 XYREM (PA) 80 ZMAX61 YODOXIN3 ZOCOR22 ZACLIR CLEANSING ZOFRAN19 44 ZAFIRLUKAST61 ZOFRAN ODT 19 ZALEPLON59 ZOLINZA (PA) 27 ZAMICET6 ZOLMITRIPTAN63 ZANAFLEX71 ZOLOFT16 ZANTAC85 ZOLPIDEM TARTRATE ZARONTIN15 ZOLVIT6 ZAROXOLYN49 ZOMIG63 ZATEAN-CH70 ZOMIG NASAL SPRAY 63 ZATEAN-PN PLUS ZOMIG ZMT 63 70 59 ZAVESCA56 ZONALON44 Z-COF I 42 ZONATUSS40 ZEBETA34 ZONEGRAN14 ZELAPAR29 ZONISAMIDE15 ZELBORAF (PA) ZORTRESS .5MG (QL) (120 TABS / 30 DAYS), (PA)33 27 ZEMPLAR51 ZENPEP48 ZERIT31 ZESTORETIC24 ZESTRIL23 ZETIA22 ZIAC24 ZIAGEN31 ZIDOVUDINE31 ZINOTIC77 ZINOTIC ES 77 ZIOPTAN75 ZIPRASIDONE HCL 29 ZIRGAN74 ZITHRANOL45 ZYVOX9 ZORTRESS .25MG, .75MG 33 ZOVIRAX CAPS; TABS 32 ZOVIRAX CREA; OINT 45 Z-PRAM7 ZUTRIPRO42 ZYBAN82 ZYCLARA47 ZYDONE6 ZYFLO11 ZYFLO CR 11 ZYLET75 ZYLOPRIM55 ZYMAXID74 ZYPRAM7 index xxi 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 5-HT3 RECEPTOR ANTAGONISTS 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON ACE INHIBITORS ACE INHIBITORS CAPTOPRIL (100MG), QUINAPRIL HCL ACNE PRODUCTS ACNE ANTIBIOTICS ERYTHROMYCIN (ACNE AID) GEL ACNE COMBINATIONS CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE (REFRIGERATE) ROSANIL SULFACETAMIDE SODIUM W/ SULFUR EMUL; FOAM; LIQD; SUSP SULFACETAMIDE SODIUM-SULFUR IN UREA VEHICLE SULFACETAMIDE SODIUM-SULFUR W/ SUNSCREENS ACNE PRODUCTS BP CLEANSING LOTION ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS AMPHETAMINES AMPHETAMINE-DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULFATE CP24; TABS METHAMPHETAMINE HCL PA - Prior Authorization QL - Quantity Limits VYVANSE ADDERALL ADDERALL XR DESOXYN DEXEDRINE PROCENTRA ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 1 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS (CONT.) ANALEPTICS CAFCIT ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS INTUNIV STRATTERA KAPVAY KAPVAY DOSE PACK STIMULANTS - MISC. DEXMETHYLPHENIDATE HCL METHYLPHENIDATE HCL CP24; SOLN; TABS; TBCR MODAFINIL (PA) CONCERTA DAYTRANA FOCALIN FOCALIN XR 5MG, 10MG, 15MG, 20MG, 30MG, 40MG, FOCALIN XR 25MG, 35MG; QL (30 EA / 30 DAYS) METADATE CD, METADATE ER METHYLIN PROVIGIL (PA) RITALIN RITALIN LA AGENTS FOR FACIAL WRINKLES AGENTS FOR FACIAL WRINKLES - RETINOIDS TRETINOIN (FACIAL WRINKLES) ALKALINIZERS CITRATES POT & SOD CITRATES W/CITRIC AC POTASSIUM CITRATE-CITRIC ACID ALTERNATIVE MEDICINES ALTERNATIVE MEDICINE COMBINATIONS PRYFLEX PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 2 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 AMBECIDES AMEBICIDES YODOXIN AMINOGLYCOSIDES AMINOGLYCOSIDES NEOMYCIN SULFATE PAROMOMYCIN SULFATE AMIKACIN SULFATE GENTAMICIN SULFATE STREPTOMYCIN SULFATE TOBRAMYCIN SULFATE BETHKIS (PA) TOBI PODHALER (PA) AMPHETAMINES AMPHETAMINES DEXTROAMPHETAMINE SULFATE SOLN ANABOLIC STEROIDS ANABOLIC STEROIDS OXANDROLONE 10MG ANADROL-50 (PA) ANALEPTICS ANALEPTICS CAFFEINE CITRATE ANALGESIC COMBINATIONS ANALGESIC COMBINATIONS ACETAMINOPHEN-SALICYLAMIDE-PHENYLTOLOXAMINE ANALGESICS-SEDATIVES BUTALBITAL-ACETAMINOPHEN BUTALBITAL-ACETAMINOPHEN-CAFFEINE BUTALBITAL-ASPIRIN-CAFFEINE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 3 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONOAL ANTIBODIES HUMIRA (PA) HUMIRA PEN-CROHNS DISEASE (PA) HUMIRA PEN-PSORIASIS STAR (PA) SIMPONI (PA, ST) ANTIRHEUMATIC - ENZYME INHIBITORS XELJANZ (PA) GOLD COMPOUNDS RIDAURA INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA) KINERET (PA) NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) DICLOFENAC POTASSIUM DICLOFENAC SODIUM DICLOFENAC W/ MISOPROSTOL ETODOLAC CAPS 200MG ETODOLAC TABS ETODOLAC TB24 FENOPROFEN CALCIUM FLURBIPROFEN IBUPROFEN TABS INDOMETHACIN KETOPROFEN KETOROLAC TROMETHAMINE MECLOFENAMATE SODIUM MEFENAMIC ACID MELOXICAM NABUMETONE NAPROXEN NAPROXEN SODIUM OXAPROZIN PIROXICAM SULINDAC TOLMETIN SODIUM PA - Prior Authorization QL - Quantity Limits ANAPROX DS ARTHROTEC 50 ARTHROTEC 75 CATAFLAM CELEBREX CLINORIL EC-NAPROSYN FELDENE INDOCIN MOBIC NALFON NAPRELAN 375MG, 750MG; QL (30 EA / 30 DAYS) NAPRELAN 500MG; QL (60 EA / 30 DAYS) NAPROSYN PONSTEL VOLTAREN-XR ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 4 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANALGESICS - ANTI-INFLAMMATORY (CONT.) PYRIMIDINE SYNTHESIS INHIBITORS LEFLUNOMIDE (PA) ARAVA (PA) SELECTIVE COSTIMULATION MODULATORS ORENCIA (PA) (ST) SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL (PA) ENBREL SURECLICK (PA) ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS FLEXTRA LEVACET RELAGESIC ACUFLEX ALAGESIC LQ ALPAIN BUTALBITAL-ACETAMINOPHEN-CAFFEINE DOLGIC PLUS DURABAC DURABAC FORTE EQUAGESIC ESGIC ESGIC-PLUS FIORICET FIORINAL FLEXTRA DS FLEXTRA-650 FRENADOL PHRENILIN FORTE SALICYLATES DIFLUNISAL PA - Prior Authorization QL - Quantity Limits MST 600 ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 5 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANALGESICS - OPIOID OPIOID AGONISTS CODEINE SULFATE TABS FENTANYL HYDROMORPHONE HCL LEVORPHANOL TARTRATE METHADONE HCL MORPHINE SULFATE CP24 MORPHINE SULFATE SOLN 10MG/5ML, 20MG/5ML MORPHINE SULFATE SUPP MORPHINE SULFATE TABS MORPHINE SULFATE TBCR 15MG, 30MG, 60MG, 100MG (QL) (90 EA / 30 DAYS) MORPHINE SULFATE TBCR 200MG (PA) OXYCODONE HCL CONC; SOLN; TABS OXYMORPHONE HCL TRAMADOL HCL ACTIQ (PA) AVINZA CODEINE SULFATE SOLN DEMEROL DILAUDID DURAGESIC FENTORA KADIAN MS CONTIN 15MG, 30MG, 60MG, 100MG (QL) (90 EA / 30 DAYS) MS CONTIN 200MG (PA) NUCYNTA ONSOLIS ROXICODONE ULTRAM OPIOID COMBINATIONS ACETAMINOPHEN W/ CODEINE CAPITAL/CODEINE HYDROCODONE-ACETAMINOPHEN SYNALGOS-DC OXYCODONE W/ ACETAMINOPHEN OXYCODONE W/ ACETAMINOPHEN CAP 5-500 MG OXYCODONE W/ ACETAMINOPHEN TAB 7.5-500 MG OXYCODONE W/ ACETAMINOPHEN TAB 10-650 MG OXYCODONE-IBUPROFEN PA - Prior Authorization QL - Quantity Limits COCET COCET PLUS FIORICET/CODEINE HYCET HYDROCODONE/ACETAMINOPHEN NORCO PERCOCET PERCODAN REPREXAIN ROXICETTYLENOL/CODEINE #3 TYLENOL/CODEINE #4 TYLOX ULTRACET VICODIN VICOPROFEN XODOL ZAMICET ZOLVIT ZYDONE ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 6 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANALGESICS - OPIOID (CONT.) OPIOID PARTIAL AGONISTS BUPRENORPHINE HCL BUTORPHANOL TARTRATE NALBUPHINE HCL SUBOXONE FILM (PA) SUBOXONE SUBL (PA) SUBUTEX (PA) ANDROGENS-ANABOLIC ANABOLIC STEROIDS OXANDROLONE 2.5MG ANDROGENS DANAZOL METHYLTESTOSTERONE ANDROGEL ANDROGEL PUMP 1.62% ANDROGEL PUMP 1.62% (QL) (600 GM / 25 DAYS) ANDRODERM ANDROXY FIRST-TESTOSTERONE MC COM METHITEST STRIANT TESTRED ANESTHETICS TOPICAL ORAL ANESTHETICS TOPICAL ORAL BENZOCAINE (DENTAL) ANORECTAL AGENTS INTRARECTAL STEROIDS HYDROCORTISONE (INTRARECTAL) CORTIFOAM CORTENEMA RECTAL COMBINATIONS PROCTOFOAM HC PA - Prior Authorization QL - Quantity Limits ANALPRAM-HC ANALPRAM-HC SINGLES LIDOCAINE HCL-HYDROCORTIS PROCORT Z-PRAM ZYPRAM ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 7 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANORECTAL AGENTS (CONT.) RECTAL STEROIDS HYDROCORTISONE (RECTAL) HYDROCORTISONE ACETATE (RECTAL) ANUSOL-HC PROCTOCORT VASODILATING AGENTS RECTIV ANTHELMINTICS ANTHELMINTICS STROMECTOL ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC. AZTREONAM METRONIDAZOLE TINIDAZOLE TRIMETHOPRIM VANCOMYCIN HCL FIRST-VANCOMYCIN 25 FIRST-VANCOMYCIN 50 CAYSTON FLAGYL FLAGYL ER NEBUPENT TINDAMAX VANCOCIN HCL XIFAXAN 200MG (QL) (60 TABS / 30 DAYS) XIFAXAN 550MG (QL) (60 TABS / 30 DAYS), (PA) ANTI-INFECTIVE MISC. - COMBINATIONS ERYTHROMYCIN-SULFISOXAZOLE SULFAMETHOXAZOLE-TRIMETHOPRIM PA - Prior Authorization QL - Quantity Limits BACTRIM DS SEPTRA DS ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 8 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTI-INFECTIVE AGENTS - MISC. (CONT.) ANTIPROTOZOAL AGENTS ALINIA KETOLIDES KETEK LEPROSTATICS DAPSONE LINCOSAMIDES CLINDAMYCIN HCL 150MG, 300MG CLINDAMYCIN PALMITATE HYDROCHLORIDE CLINDAMYCIN PHOSPHATE CLEOCIN CAPS CLEOCIN PEDIATRIC GRANULE OXAZOLIDINONES ZYVOX POLYMYXINS POLYMYXIN B SULFATE ANTIADRENERGIC ANTIHYPERTENSIVES RESERPINE RESERPINE ANTIANGINAL AGENTS ANTIANGINALS-OTHER RANEXA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 9 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIANGINAL AGENTS (MISC.) NITRATES ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE SL TAB 2.5 MG ISOSORBIDE DINITRATE SL TAB 5 MG ISOSORBIDE MONONITRATE NITROGLYCERIN PT24; SOLN NITRO-BID DILATRATE SR IMDUR ISORDIL TITRADOSE NITRO-DUR NITROLINGUAL PUMPSPRAY NITROMIST NITROSTAT ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC. BUSPIRONE HCL HYDROXYZINE HCL HYDROXYZINE PAMOATE MEPROBAMATE VISTARIL ALPRAZOLAM CLORAZEPATE DIPOTASSIUM DIAZEPAM LORAZEPAM ALPRAZOLAM INTENSOL ATIVAN DIAZEPAM INTENSOL VALIUM XANAX BENZODIAZEPINES ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A DISOPYRAMIDE PHOSPHATE PROCAINAMIDE HCL QUINIDINE GLUCONATE QUINIDINE SULFATE NORPACE CR NORPACE ANTIARRHYTHMICS TYPE I-B MEXILETINE HCL ANTIARRHYTHMICS TYPE I-C FLECAINIDE ACETATE 50MG, 100 MG, 150MG PROPAFENONE HCL PA - Prior Authorization QL - Quantity Limits RYTHMOL RYTHMOL SR TAMBOCOR ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 10 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIARRHYTHMICS (MISC.) ANTIARRHYTHMICS TYPE III AMIODARONE HCL 200MG, 400MG CORDARONE MULTAQ AMIODARONE HCL 100MG (PA) TIKOSYN ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTI-INFLAMMATORY AGENTS CROMOLYN SODIUM ASTHMA AND BRONCHODILATOR AGENT COMBINATIONS CROMOLYN SODIUM POLY-VENT DM BRONCOMAR-1 ED-BRON G BRONCHODILATORS - ANTICHOLINERGICS IPRATROPIUM BROMIDE ATROVENT HFA SPIRIVA HANDIHALER LEUKOTRIENE MODULATORS MONTELUKAST SODIUM ZYFLO ACCOLATE SINGULAIR ZYFLO CR SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP (QL) (30 TABS / 30 DAYS), (PA) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 11 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIASTHMATIC AND BRONCHODILATOR AGENTS (CONT.) STEROID INHALANTS BUDESONIDE (INHALATION) FLOVENT DISKUS FLOVENT HFA ALVESCO ASMANEX 7 METERED DOSES (QL) (30 / 30 DAYS) ASMANEX 14 METERED DOSES (QL) (60 / 30 DAYS) ASMANEX 30 METERED DOSES 110MCG/INH (QL) (30 / 30 DAYS) ASMANEX 30 METERED DOSES 220MCG/INH (QL) (60 / 30 DAYS) ASMANEX 60 METERED DOSES (QL) (60 / 30 DAYS) ASMANEX 120 METERED DOSES (QL) (60 / 30 DAYS) PULMICORT PULMICORT FLEXHALER QVAR ALBUTEROL SULFATE EPINEPHRINE HCL IPRATROPIUM-ALBUTEROL LEVALBUTEROL HCL METAPROTERENOL SULFATE TERBUTALINE SULFATE ADVAIR DISKUS ADVAIR HFA COMBIVENT FORADIL AEROLIZER PROAIR HFA ACCUNEB ALBUTEROL INHAL AEROSOL 90 MCG/ACT ARCAPTA NEOHALER BROVANA COMBIVENT RESPIMAT (QL) (11.25 / 30 DAYS) DULERA DUONEB MAXAIR AUTOHALER PERFOROMIST PROVENTIL HFA SEREVENT DISKUS SYMBICORT VOSPIRE ER XOPENEX XOPENEX HFA THEOPHYLLINE SOLN; TB12; TB24 THEO-24 DYLIX ELIXOPHYLLIN LUFYLLIN THEOPHYLLINE ELIX XANTHINES SYMPATHOMIMETICS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 12 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIBIOTICS - TOPICAL ANTIBIOTIC MIXTURES TOPICAL NEOMYCIN-BACITRACIN-POLYMYXIN ANTICOAGULANTS COUMARIN ANTICOAGULANTS WARFARIN SODIUM COUMADIN DIRECT FACTOR XA INHIBITORS ELIQUIS XARELTO 10MG, 20MG (QL) (30 TABS / 30 DAYS) XARELTO 15MG (QL0 (60 TABS / 30 DAYS) HEPARINS AND HEPARINOID-LIKE AGENTS ENOXAPARIN SODIUM FONDAPARINUX SODIUM HEPARIN SODIUM (PORCINE) ARIXTRA FRAGMIN LOVENOX THROMBIN INHIBITORS PRADAXA ANTICONVULSANTS ANTICONVULSANTS - BENZODIAZEPINES CLONAZEPAM TABS PA - Prior Authorization QL - Quantity Limits DIASTAT ACUDIAL DIASTAT PEDIATRIC KLONOPIN ONFI ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 13 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTICONVULSANTS (CONT.) DIRECT FACTOR XA INHIBITORS CARBAMAZEPINE GABAPENTIN LAMOTRIGINE LEVETIRACETAM SOLN; TB24 OXCARBAZEPINE PRIMIDONE TOPIRAMATE PA - Prior Authorization QL - Quantity Limits BANZEL CARBATROL KEPPRA KEPPRA XR 500MG (QL) (180 EA / 30 DAYS) KEPPRA XR 750MG (QL) (120 EA / 30 DAYS) LAMICTAL LAMICTAL CHEWABLE DISPERS LAMICTAL ODT KIT LAMICTAL ODT TBDP 25MG (QL) (90 EA / 30 DAYS) LAMICTAL ODT TBDP 50MG, 100MG (QL) (30 EA / 30 DAYS) LAMICTAL ODT TBDP 200MG (QL) (60 EA / 30 DAYS) LAMICTAL STARTER/NOT TAKI LAMICTAL STARTER/TAKING C LAMICTAL STARTER/TAKING V LAMICTAL XR KIT LAMICTAL XR TB24 25MG (QL) (90 EA / 30 DAYS) LAMICTAL XR TB24 50MG, 100MG, 250MG, 300MG (QL) (30 EA / 30 DAYS) LAMICTAL XR TB24 200MG (QL) (60 EA / 30 DAYS) LYRICA MYSOLINE NEURONTIN OXTELLAR XR POTIGA TEGRETOL TEGRETOL-XR TOPAMAX TOPAMAX SPRINKLE TRILEPTAL VIMPAT ZONEGRAN ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 14 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTICONVULSANTS (CONT.) CARBAMATES FELBAMATE FELBATOL TIAGABINE HCL GABITRIL FOSPHENYTOIN SODIUM PHENYTOIN PHENYTOIN SODIUM PHENYTOIN SODIUM EXTENDED DILANTIN DILANTIN INFATABS PEGANONE PHENYTEK ETHOSUXIMIDE CELONTIN ZARONTIN DIVALPROEX SODIUM CPSP; TBEC VALPROATE SODIUM VALPROIC ACID DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES GABA MODULATORS SABRIL HYDANTOINS SUCCINIMIDES VALPROIC ACID ANTICONVULSANTS - BENZODIAZEPINES ANTICONVULSANTS - BENZODIAZEPINES CLONAZEPAM TBDP DIAZEPAM (ANTICONVULSANT) ANTICONVULSANTS - MISC. ANTICONVULSANTS - MISC. LEVETIRACETAM TABS ZONISAMIDE FELBATOL ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS) MIRTAZAPINE PA - Prior Authorization QL - Quantity Limits REMERON REMERON SOLTAB ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 15 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIDEPRESSANTS (CONT.) ANTIDEPRESSANTS - MISC. BUPROPION HCL TABS BUPROPION HCL TB12; TB24 MAPROTILINE HCL WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL 150MG (QL) (30 EA / 30 DAYS) WELLBUTRIN XL 300MG MODIFIED CYCLICS TRAZODONE HCL MONOAMINE OXIDASE INHIBITORS (MAOIS) PHENELZINE SULFATE TRANYLCYPROMINE SULFATE EMSAM MARPLAN NARDIL PARNATE SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) CITALOPRAM HYDROBROMIDE ESCITALOPRAM OXALATE FLUOXETINE HCL FLUVOXAMINE MALEATE PAROXETINE HCL SERTRALINE HCL CONC SERTRALINE HCL TABS 50MG LEXAPRO SOLN CELEXA LEXAPRO TABS LUVOX CR PAXIL PAXIL CR PEXEVA PROZAC ZOLOFT SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) DULOXETINE HCL VENLAFAXINE HCL CYMBALTA EFFEXOR XR AMITRIPTYLINE HCL CLOMIPRAMINE HCL DESIPRAMINE HCL DOXEPIN HCL IMIPRAMINE HCL IMIPRAMINE PAMOATE NORTRIPTYLINE HCL PROTRIPTYLINE HCL TRIMIPRAMINE MALEATE AMOXAPINE ANAFRANIL NORPRAMIN SURMONTIL TOFRANIL TOFRANIL-PM VIVACTIL TRICYCLIC AGENTS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 16 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS ACARBOSE GLYSET PRECOSE ANTIDIABETIC - AMYLIN ANALOGS SYMLIN SYMLINPEN 60 SYMLINPEN 120 ANTIDIABETIC COMBINATIONS GLIPIZIDE-METFORMIN HCL GLYBURIDE-METFORMIN PIOGLITAZONE HCL-GLIMEPIRIDE PIOGLITAZONE HCL-METFORMIN HCL JANUMET JANUMET XR JUVISYNC ACTOPLUS MET ACTOPLUS MET XR AVANDAMET AVANDARYL DUETACT GLUCOVANCE JENTADUETO KOMBIGLYZE XR METAGLIP BIGUANIDES METFORMIN HCL FORTAMET GLUCOPHAGE GLUCOPHAGE XR GLUMETZA RIOMET DIABETIC OTHER GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT KORLYM (PA) PROGLYCEM DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA ONGLYZA TRADJENTA DOPAMINE RECEPTOR AGONISTS - ANTIDIABETIC CYCLOSET PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 17 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIDIABETICS (CONT.) INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) BYETTA VICTOZA (QL) (3 / 30 DAYS) INSULIN HUMALOG HUMALOG MIX 50/50 HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX 75/25 HUMALOG MIX 75/25 KWIKPEN HUMULIN R U-500 (CONCENTR LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXTOUCH NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/30 NOVOLOG MIX 70/30 FLEXPEN NOVOLOG PENFILL APIDRA APIDRA SOLOSTAR PIOGLITAZONE HCL ACTOS AVANDIA INSULIN SENSITIZING AGENTS MEGLITINIDE ANALOGUES NATEGLINIDE REPAGLINIDE PRANDIN STARLIX CHLORPROPAMIDE GLIMEPIRIDE GLIPIZIDE GLYBURIDE GLYBURIDE MICRONIZED TOLAZAMIDE TOLBUTAMIDE AMARYL DIABETA GLUCOTROL GLUCOTROL XL GLYNASE SULFONYLUREAS ANTIDIARRHEALS ANTIDIARRHEAL AGENTS - MISC. REZYST SB PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 18 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIDIARRHEALS (CONT.) ANTIPERISTALTIC AGENTS DIPHENOXYLATE W/ ATROPINE LOPERAMIDE HCL LOMOTIL MOTOFEN ANTIDOTES ANTIDOTES - CHELATING AGENTS FERRIPROX (PA) EXJADE 125MG, 250MG (PA) EXJADE 500MG OPIOID ANTAGONISTS NALOXONE HCL NALTREXONE HCL ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS GRANISETRON HCL ONDANSETRON HCL ANZEMET GRANISOL SANCUSO ZOFRAN ZOFRAN ODT ANTIEMETICS - ANTICHOLINERGIC DIMENHYDRINATE MECLIZINE HCL TRIMETHOBENZAMIDE HCL TRANSDERM-SCOP ANTIVERT TIGAN ANTIEMETICS - MISCELLANEOUS DRONABINOL CESAMET DICLEGIS MARINOL SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS EMEND ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS) ANTHELMINTICS BILTRICIDE PA - Prior Authorization QL - Quantity Limits ALBENZA (PA) ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 19 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIFUNGALS ANTIFUNGALS AMPHOTERICIN B FLUCYTOSINE GRISEOFULVIN MICROSIZE GRISEOFULVIN ULTRAMICROSIZE NYSTATIN ANCOBON GRIFULVIN V GRIS-PEG IMIDAZOLE-RELATED ANTIFUNGALS FLUCONAZOLE ITRACONAZOLE KETOCONAZOLE VORICONAZOLE (PA) DIFLUCAN NOXAFIL SPORANOX (PA) SPORANOX PULSEPAK (PA) VFEND (PA) ANTIFUNGALS - TOPICAL ANTIFUNGALS - TOPICAL CICLOPIROX KIT; SHAM CICLOPIROX & VITAMIN E ANTIFUNGALS - TOPICAL COMBINATIONS IODOQUINOL-HC SODIUM THIOSULFATE-SALICYLIC ACID ANTIHISTAMINE HYPNOTICS ANTIHISTAMINE HYPNOTICS DIPHENHYDRAMINE HCL (SLEEP) TABS ANTIHISTAMINES ANTIHISTAMINES - ALKYLAMINES DEXCHLORPHENIRAMINE MALEATE PA - Prior Authorization QL - Quantity Limits LODRANE 24 RESPA-BR AHIST BROVEX CT ED CHLORPED ED-CHLOR-TAN VAZOL ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 20 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIHISTAMINES ANTIHISTAMINES - ALKYLAMINES DEXCHLORPHENIRAMINE MALEATE LODRANE 24 RESPA-BR AHIST BROVEX CT ED CHLORPED ED-CHLOR-TAN VAZOL ANTIHISTAMINES - COMBINATIONS ALLERX DF ALLERX DF 30 ANTIHISTAMINES - ETHANOLAMINES CARBINOXAMINE MALEATE CLEMASTINE FUMARATE DIPHENHYDRAMINE HCL CAPS 25MG DIPHENHYDRAMINE HCL CAPS 50MG DIPHENHYDRAMINE HCL ELIX DIPHENHYDRAMINE HCL SOLN DIPHENHYDRAMINE HCL (SLEEP) CAPS DOXYTEX KARBINAL ER PALGIC ANTIHISTAMINES - PHENOTHIAZINES PROMETHAZINE HCL ANTIHISTAMINES - PIPERIDINES CYPROHEPTADINE HCL ANTIHISTAMINES - NON-SEDATING ANTIHISTAMINES - NON-SEDATING DESLORATADINE LEVOCETIRIZINE DIHYDROCHLORIDE ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - COMBINATIONS VYTORIN PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 21 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIHYPERLIPIDEMICS (CONT.) ANTIHYPERLIPIDEMICS - MISC. LOVAZA (QL) (120 CAPS / 30 DAYS) BILE ACID SEQUESTRANTS CHOLESTYRAMINE CHOLESTYRAMINE LIGHT COLESTIPOL HCL COLESTID QUESTRAN WELCHOL FIBRIC ACID DERIVATIVES CHOLINE FENOFIBRATE FENOFIBRATE FENOFIBRATE MICRONIZED FENOFIBRIC ACID GEMFIBROZIL ANTARA FENOGLIDE FIBRICOR LIPOFEN LOFIBRA TRICOR TRIGLIDE TRILIPIX HMG COA REDUCTASE INHIBITORS ATORVASTATIN CALCIUM FLUVASTATIN SODIUM LOVASTATIN PRAVASTATIN SODIUM SIMVASTATIN SIMCOR ADVICOR ALTOPREV CRESTOR LESCOL LESCOL XL LIPITOR LIVALO MEVACOR PRAVACHOL ZOCOR INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ZETIA MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORS JUXTAPID (PA) NICOTINIC ACID DERIVATIVES NIACIN NIACIN TR PA - Prior Authorization QL - Quantity Limits NIASPAN ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 22 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIHYPERTENSIVE COMBINATIONS ACE INHIBITORS THIAZIDE/THIAZIDE-LIKE BENAZEPRIL & HYDROCHLOROTHIAZIDE FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE MOEXIPRIL-HYDROCHLOROTHIAZIDE QUINAPRIL-HYDROCHLOROTHIAZIDE ADRENOLYTICS-CENTRAL THIAZIDE/THIAZIDE-LIKE COMB CLONIDINE & CHLORTHALIDONE METHYLDOPA & HYDROCHLOROTHIAZIDE ANGIOTENSIN II RECEPTOR ANTAG THIAZIDE/THIAZIDE-LIKE CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE IRBESARTAN-HYDROCHLOROTHIAZIDE ANTIHYPERTENSIVES ACE INHIBITORS BENAZEPRIL HCL CAPTOPRIL 12.5MG, 25MG, 50MG ENALAPRIL MALEATE FOSINOPRIL SODIUM LISINOPRIL MOEXIPRIL HCL PERINDOPRIL ERBUMINE RAMIPRIL TRANDOLAPRIL ACCUPRIL ACEON ALTACE LOTENSIN MAVIK PRINIVIL UNIVASC VASOTEC ZESTRIL AGENTS FOR PHEOCHROMOCYTOMA DEMSER DIBENZYLINE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 23 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIHYPERTENSIVES (CONT.) ANGIOTENSIN II RECEPTOR ANTAGONISTS CANDESARTAN CILEXETIL EPROSARTAN MESYLATE IRBESARTAN LOSARTAN POTASSIUM BENICAR ATACAND AVAPRO COZAAR DIOVAN EDARBI MICARDIS TEVETEN ANTIADRENERGIC ANTIHYPERTENSIVES CLONIDINE HCL DOXAZOSIN MESYLATE GUANFACINE HCL METHYLDOPA PRAZOSIN HCL TERAZOSIN HCL CARDURA CATAPRES CATAPRES-TTS-1 CATAPRES-TTS-2 CATAPRES-TTS-3 NEXICLON XR TENEX ANTIHYPERTENSIVE COMBINATIONS AMLODIPINE BESYLATE-BENAZEPRIL HCL ATENOLOL & CHLORTHALIDONE BISOPROLOL & HYDROCHLOROTHIAZIDE CAPTOPRIL & HYDROCHLOROTHIAZIDE ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE LISINOPRIL & HYDROCHLOROTHIAZIDE LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE METOPROLOL & HYDROCHLOROTHIAZIDE NADOLOL & BENDROFLUMETHIAZIDE PROPRANOLOL & HYDROCHLOROTHIAZIDE VALSARTAN-HYDROCHLOROTHIAZIDE PA - Prior Authorization QL - Quantity Limits AZOR BENICAR HCT TRIBENZOR ACCURETIC AMTURNIDE ATACAND HCT AVALIDE CORZIDE DIOVAN HCT EDARBYCLOR EXFORGE EXFORGE HCT HYZAAR LOPRESSOR HCT LOTENSIN HCT LOTREL MICARDIS HCT PRINZIDE TARKA TEKAMLO TEKTURNA HCT TENORETIC 50 TENORETIC 100 TEVETEN HCT UNIRETIC VALTURNA VASERETIC ZESTORETIC ZIAC ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 24 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIHYPERTENSIVES (CONT.) ANTIHYPERTENSIVES - MISC. VECAMYL DIRECT RENIN INHIBITORS TEKTURNA SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) EPLERENONE INSPRA VASODILATORS HYDRALAZINE HCL MINOXIDIL ANTIMALARIALS ANTIMALARIAL COMBINATIONS ATOVAQUONE-PROGUANIL HCL COARTEM MALARONE CHLOROQUINE PHOSPHATE HYDROXYCHLOROQUINE SULFATE MEFLOQUINE HCL QUININE SULFATE ARALEN DARAPRIM PLAQUENIL PRIMAQUINE PHOSPHATE QUALAQUIN ANTIMALARIALS ANTIMYASTHENIC AGENTS ANTIMYASTHENIC AGENTS PYRIDOSTIGMINE BROMIDE GUANIDINE HCL MESTINON MESTINON TIMESPAN MYTELASE PROSTIGMIN ANTIMYCOBACTERIAL AGENTS ANTIMYCOBACTERIAL AGENTS ETHAMBUTOL HCL 100MG PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 25 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIMYCOBACTERIAL AGENTS (CONT.) ANTI TB COMBINATIONS ISONIAZID & RIFAMPIN RIFATER ANTIMYCOBACTERIAL AGENTS CYCLOSERINE ETHAMBUTOL HCL 400MG ISONIAZID PYRAZINAMIDE RIFAMPIN MYCOBUTIN PRIFTIN SEROMYCIN TRECATOR ANTINEOPLASTIC ENZYME INHIBITORS ANTINEOPLASTIC - TYROSINE KINASE INHIBITORS IMBRUVICA (PA) ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL ANTINEOPLASTIC OR PREMALIGNANT LESIONS - TOPICAL NSAID’S DICLOFENAC SODIUM (ACTINIC KERATOSES) ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC OR PREMALIGNANT LESIONS - TOPICAL NSAID’S CYCLOPHOSPHAMIDE LOMUSTINE ALKERAN LEUKERAN CEENU HEXALEN MYLERAN TEMODAR (PA) TEMOZOLOMIDE (PA) PURINETHOL TABLOID TREXALL XELODA (PA) ANTIMETABOLITES CYTARABINE FLOXURIDINE (PA) MERCAPTOPURINE METHOTREXATE SODIUM ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS ERIVEDGE (PA) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 26 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES (CONT.) ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS ANASTROZOLE BICALUTAMIDE EXEMESTANE FLUTAMIDE LETROZOLE (PA) MEGESTROL ACETATE TAMOXIFEN CITRATE ARIMIDEX AROMASIN CASODEX EMCYT FARESTON FEMARA (PA) LYSODREN NILANDRON LEUPROLIDE ACETATE XTANDI (PA) ZYTIGA (QL) (120 TABS / 30 DAYS), (PA) ANTINEOPLASTIC - IMMUNOMODULATORS POMALYST (PA) ANTINEOPLASTIC ANTIBIOTICS BLEOMYCIN SULFATE ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR (QL) (30 TABS / 30 DAYS), (PA) AFINITOR DISPERZ (PA) BOSULIF (PA) CAPRELSA (PA) COMETRIQ (PA) GILOTRIF (PA) GLEEVEC (PA) ICLUSIG (PA) INLYTA (PA) JAKAFI (PA) MEKINIST (PA) NEXAVAR (PA) SPRYCEL (PA) STIVARGA (PA) SUTENT TAFINLAR (PA) TARCEVA (PA) TASIGNA (QL) (120 CAPS / 30 DAYS), (PA) TYKERB (PA) VANDETANIB (PA) VOTRIENT (PA) XALKORI (PA) ZELBORAF (PA) ZOLINZA (PA) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 27 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES (CONT.) ANTINEOPLASTICS MISC. HYDROXYUREA TRETINOIN (CHEMOTHERAPY) HYDREA MATULANE INTRON-A 10MU/ML INTRON-A 6000000UNIT/ML (PA) INTRON-A W/DILUENT SYLATRON (PA) TARGRETIN CAPS ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS LEUCOVORIN CALCIUM MESNEX MITOTIC INHIBITORS ETOPOSIDE TOPOISOMERASE I INHIBITORS HYCAMTIN ANTIPARKINSON AGENTS ANTIPARKINSON ADJUVANTS LODOSYN ANTIPARKINSON ANTICHOLINERGICS BENZTROPINE MESYLATE TRIHEXYPHENIDYL HCL ANTIPARKINSON COMT INHIBITORS ENTACAPONE PA - Prior Authorization QL - Quantity Limits COMTAN TASMAR ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 28 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIPARKINSON AGENTS ANTIPARKINSON DOPAMINERGICS AMANTADINE BROMOCRIPTINE MESYLATE CARBIDOPA-LEVODOPA CARBIDOPA-LEVODOPA-ENTACAPONE PRAMIPEXOLE DIHYDROCHLORIDE ROPINIROLE HYDROCHLORIDE MIRAPEX NEUPRO PARCOPA PARLODEL REQUIP SINEMET CR STALEVO 50 STALEVO 75 STALEVO 100 STALEVO 125 STALEVO 150 STALEVO 200 APOKYN ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS SELEGILINE HCL CAPS SELEGILINE HCL TABS AZILECT ZELAPAR ANTIPSYCHOTICS/ANTIMANIC AGENTS ANTIMANIC AGENTS LITHIUM CARBONATE LITHOBID ANTIPSYCHOTICS - MISC. ZIPRASIDONE HCL EQUETRO GEODON LATUDA RISPERIDONE SOLN RISPERIDONE TABS 4MG RISPERIDONE TBDP FANAPT FANAPT TITRATION PACK INVEGA RISPERDAL RISPERDAL M-TAB BENZISOXAZOLES BUTYROPHENONES HALOPERIDOL HALOPERIDOL DECANOATE HALOPERIDOL LACTATE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 29 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIPSYCHOTICS/ANTIMANIC AGENTS (CONT.) DIBENZAPINES CLOZAPINE TABS LOXAPINE SUCCINATE OLANZAPINE QUETIAPINE FUMARATE SAPHRIS SEROQUEL SEROQUEL XR ZYPREXA ZYPREXA ZYDIS PHENOTHIAZINES CHLORPROMAZINE HCL FLUPHENAZINE DECANOATE FLUPHENAZINE HCL PERPHENAZINE PROCHLORPERAZINE PROCHLORPERAZINE MALEATE THIORIDAZINE HCL TRIFLUOPERAZINE HCL QUINOLINONE DERIVATIVES ABILIFY ABILIFY DISCMELT (QL) (30 EA / 30 DAYS); AGE THIOXANTHENES THIOTHIXENE ANTISEPTICS DISINFECTANTS CHLORINE ANTISEPTICS PHISOHEX IODINE ANTISEPTICS IODOFLEX ANTISPASMODICS BELLADONNA ALKALOIDS HYOSCYAMINE SULFATE ELIX HYOSCYAMINE SULFATE SOLN QUATERNARY ANTICHOLINERGICS PROPANTHELINE BROMIDE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 30 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIVIRALS ANTIRETROVIRALS ABACAVIR SULFATE ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE DIDANOSINE LAMIVUDINE LAMIVUDINE-ZIDOVUDINE NEVIRAPINE STAVUDINE ZIDOVUDINE APTIVUS ATRIPLA COMBIVIR COMPLERA CRIXIVAN EDURANT EMTRIVA EPIVIR EPIVIR HBV EPZICOM INTELENCE INVIRASE ISENTRESS KALETRA LEXIVA NORVIR PREZISTA RESCRIPTOR RETROVIR REYATAZ SELZENTRY STRIBILD SUSTIVA TIVICAY TRIZIVIR TRUVADA VIDEX EC VIDEX PEDIATRIC VIRACEPT VIRAMUNE VIRAMUNE XR VIREAD ZERIT ZIAGEN FUZEON KIT FUZEON SOLR (PA) CMV AGENTS VALCYTE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 31 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ANTIVIRALS (CONT.) HEPATITIS AGENTS INCIVEK (PA) BARACLUDE HEPSERA TYZEKA (PA) INFERGEN (PA) MODERIBA (PA) PEGASYS (PA) PEGASYS PROCLICK (PA) RIBASPHERE RIBAPAK (PA) VICTRELIS (PA) HERPES AGENTS ACYCLOVIR FAMCICLOVIR VALACYCLOVIR HCL FAMVIR VALTREX ZOVIRAX CAPS; TABS RIMANTADINE HYDROCHLORIDE RELENZA DISKHALER TAMIFLU INFLUENZA AGENTS ASSORTED CLASSES CHELATING AGENTS CUPRIMINE DEPEN TITRATABS HOMEOPATHIC PRODUCTS URI-CONTROL RX IMMUNOMODULATORS REVLIMID 2.5MG, 20MG (PA) REVLIMID 5MG, 10MG, 15MG, 25MG THALOMID 50MG, 100MG (QL) (30 CAPS / 30 DAYS), (PA) THALOMID 150MG (QL) (60 CAPS / 30 DAYS), (PA) THALOMID 200MG (PA) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 32 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ASSORTED CLASSES (CONT.) IMMUNOSUPPRESSIVE AGENTS AZATHIOPRINE AZATHIOPRINE SODIUM FOR INJ 100 MG CYCLOSPORINE CYCLOSPORINE MODIFIED (FOR MICROEMULSION) MYCOPHENOLATE MOFETIL TACROLIMUS AZASAN CELLCEPT IMURAN MYFORTIC NEORAL PROGRAF RAPAMUNE SANDIMMUNE ZORTRESS .5MG (QL) (120 TABS / 30 DAYS), (PA) ZORTRESS .25MG, .75MG IRRIGATION SOLUTIONS IRRIGATION SOLUTIONS, PHYSIOLOGICAL RINGER’S IRRIGATION MISC NATURAL PRODUCTS ERYSIDORON #2 POTASSIUM REMOVING RESINS SODIUM POLYSTYRENE SULFONATE SUSP 15GM/60ML KAYEXALATE ASTHMA AND BRONCHODILATOR AGENT COMBINATIONS XANTHINE-EXPECTORANTS DYPHYLLINE-GUAIFENESIN ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS CLONIDINE HCL (ADHD) B-COMPLEX W/ FOLIC ACID B-COMPLEX W/ FOLIC ACID B-COMPLEX W/ C & FOLIC ACID PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 33 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 B-COMPLEX W/ FOLIC ACID B-COMPLEX W/ C FOLIC ACID PHENOBARBITAL ELIX PHENOBARBITAL TABS 100MG BARBITURATE HYPNOTICS BARBITURATE HYPNOTICS PHENOBARBITAL ELIX PHENOBARBITAL TABS 100MG BENZISOXAZOLES BENZISOXAZOLES RISPERIDONE TABS .25MG, .5MG, 1MG, 2MG, 3MG BENZODIAZEPINES BENZODIAZEPINES CHLORDIAZEPOXIDE HCL OXAZEPAM BETA BLOCKERS ALPHA-BETA BLOCKERS CARVEDILOL LABETALOL HCL COREG COREG CR TRANDATE BETA BLOCKERS CARDIO-SELECTIVE ACEBUTOLOL HCL ATENOLOL BETAXOLOL HCL BISOPROLOL FUMARATE METOPROLOL SUCCINATE METOPROLOL TARTRATE PA - Prior Authorization QL - Quantity Limits BYSTOLIC KERLONE LOPRESSOR SECTRAL TENORMIN TOPROL XL ZEBETA ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 34 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 BETA BLOCKERS (CONT.) BETA BLOCKERS NON-SELECTIVE NADOLOL PINDOLOL PROPRANOLOL HCL SOTALOL HCL SOTALOL HCL (AFIB/AFL) 80MG, 120MG SOTALOL HCL (AFIB/AFL) 160MG TIMOLOL MALEATE BETAPACE CORGARD INDERAL LA INNOPRAN XL LEVATOL BETA-BLOCKERS - OPHTHALMIC BETA-BLOCKERS - OPHTHALMIC METIPRANOLOL BONE DENSITY REGULATORS BISPHOSPHONATES ALENDRONATE SODIUM SOLN ETIDRONATE DISODIUM CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS AMLODIPINE BESYLATE 2.5MG, 5MG AMLODIPINE BESYLATE 10MG DILTIAZEM HCL DILTIAZEM HCL COATED BEADS DILTIAZEM HCL EXTENDED RELEASE BEADS FELODIPINE NIFEDIPINE CAPS NIFEDIPINE TB24 90MG ISRADIPINE NICARDIPINE HCL NIFEDIPINE TB24 30MG, 60MG, 90MG NIMODIPINE NISOLDIPINE VERAPAMIL HCL PA - Prior Authorization QL - Quantity Limits ADALAT CC CALAN CALAN SR CARDENE SR CARDIZEM CD CARDIZEM LA COVERA-HS DILACOR XR DYNACIRC CR ISOPTIN SR NORVASC PROCARDIA XL SULAR TIAZAC VERELAN VERELAN PM ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 35 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 CARDIAC GLYCOSIDES CARDIAC GLYCOSIDES DIGOXIN SOLN .05MG/ML CARDIOTONICS CARDIAC GLYCOSIDES DIGOXIN SOLN .25MG/ML DIGOXIN TABS LANOXIN CARDIOVASCULAR AGENTS - MISC. CARDIOVASCULAR AGENTS MISC. - COMBINATIONS BIDIL CADUET PROSTAGLANDIN VASODILATORS TYVASO STARTER (PA) VENTAVIS (PA) PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS (PA) TRACLEER (PA) PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS ADCIRCA (PA) REVATIO (PA) SILDENAFIL CITRATE (PULMONARY HYPERTENSION) (PA) CARDIOVASCULAR AGENTS MISC. - COMBINATIONS CALCIUM CHANNEL BLOCKER HMG COA REDUCTASE INHIBIT COMB AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM CAUTERIZING AGENTS CAUTERIZING AGENT COMBINATIONS SILVER NITRATE-POTASSIUM NITRATE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 36 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 CENTRAL MUSCLE RELAXANTS CENTRAL MUSCLE RELAXANTS CHLORZOXAZONE CEPHALOSPORINS CEPHALOSPORINS - 1ST GENERATION CEFADROXIL CEFAZOLIN SODIUM CEPHALEXIN KEFLEX CEPHALOSPORINS - 2ND GENERATION CEFACLOR CEFOXITIN SODIUM CEFPROZIL CEFUROXIME AXETIL CEFUROXIME SODIUM CEFACLOR ER CEFTIN CEPHALOSPORINS - 3RD GENERATION CEFDINIR CEFDITOREN PIVOXIL CEFOTAXIME SODIUM CEFPODOXIME PROXETIL CEFTAZIDIME CEFTIBUTEN CEDAX SPECTRACEF SUPRAX CEPHALOSPORINS - 4TH GENERATION CEFEPIME HCL CHEMICALS LIQUIDS CHLORHEXIDINE GLUCONATE COMBINATION PSYCHOTHERAPEUTICS BENZODIAZEPINES TRICYCLIC AGENTS CHLORDIAZEPOXIDE-AMITRIPTYLINE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 37 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 COMBINATION PSYCHOTHERAPEUTICS (CONT.) PHENOTHIAZINES TRICYCLIC AGENTS PERPHENAZINE-AMITRIPTYLINE THIENBENZODIAZEPINES SSRIS OLANZAPINE-FLUOXETINE HCL CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL DESOGESTREL & ETHINYL ESTRADIOL DESOGESTREL-ETHINYL ESTRADIOL (BIPHASIC) DESOGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) DROSPIRENONE-ETHINYL ESTRADIOL ETHYNODIOL DIACET & ETH ESTRAD LEVONORGESTREL & ETH ESTRADIOL LEVONORGESTREL-ETH ESTRADIOL (TRIPHASIC) LEVONORGESTREL-ETHINYL ESTRADIOL (91-DAY) LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) MINASTRIN 24 FE NATAZIA NORETHIN ACET & ESTRAD-FE NORETHINDRONE & ETH ESTRADIOL NORETHINDRONE & ETHINYL ESTRADIOL-FE NORETHINDRONE & MESTRANOL NORETHINDRONE ACET & ETH ESTRA NORETHINDRONE ACETATE-ETHINYL ESTRADIOL-FE NORETHINDRONE-ETH ESTRADIOL (TRIPHASIC) NORGESTIMATE-ETHINYL ESTRADIOL NORGESTIMATE-ETHINYL ESTRADIOL (TRIPHASIC) NORGESTREL & ETHINYL ESTRADIOL PA - Prior Authorization QL - Quantity Limits ORTHO TRI-CYCLEN LO ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 38 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 CONTRACEPTIVES (CONT.) COMBINATION CONTRACEPTIVES - TRANSDERMAL ORTHO EVRA COMBINATION CONTRACEPTIVES - VAGINAL QL (13 / 300 DAYS) EMERGENCY CONTRACEPTIVES LEVONORGESTREL (EMERGENCY OC) PLAN B ONE-STEP PROGESTIN CONTRACEPTIVES - INJECTABLE DEPO-PROVERA CONTRACEPTIV (QL) (1 INJ / 75 DAYS) MEDROXYPROGESTERONE ACETATE (CONTRACEPTIVE) (QL) (1 INJ / 75 DAYS) PROGESTIN CONTRACEPTIVES - ORAL NORETHINDRONE (CONTRACEPTIVE) CORTICOSTEROIDS GLUCOCORTICOSTEROIDS BUDESONIDE ORAPRED ODT CORTISONE ACETATE DEXAMETHASONE DEXAMETHASONE SODIUM PHOSPHATE HYDROCORTISONE METHYLPREDNISOLONE 4MG, 8MG, 16MG, 32MG METHYLPREDNISOLONE SOD SUCC PREDNISOLONE PREDNISOLONE SODIUM PHOSPHATE PREDNISONE PA - Prior Authorization QL - Quantity Limits CORTEF DEXPAK 6 DAY DEXPAK 10 DAY DEXPAK 13 DAY ENTOCORT EC FLO-PRED MEDROL MEDROL DOSEPAK MILLIPRED MILLIPRED DP ORAPRED VERIPRED 20 ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 39 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 CORTICOSTEROIDS (CONT.) MINERALOCORTICOIDS FLUDROCORTISONE ACETATE CORTICOSTEROIDS - TOPICAL CORTICOSTEROIDS - TOPICAL BETAMETHASONE DIPROPIONATE (TOPICAL) LOTN BETAMETHASONE VALERATE FOAM CLOBETASOL PROPIONATE EMOLLIENT BASE CLOBETASOL PROPIONATE EMULSION DESONIDE CREA DESOXIMETASONE CREA .25% FLUOCINONIDE SOLN FLUOCINONIDE EMULSIFIED BASE FLUTICASONE PROPIONATE OINT HALOBETASOL PROPIONATE OINT HYDROCORTISONE BUTYRATE HYDROPHILIC LIPO BASE HYDROCORTISONE VALERATE TOPICAL STEROID COMBINATIONS CALCIPOTRIENE-BETAMETHASONE DIPROPIONATE (QL) (400 GM / 56 DAYS) HYDROCORTISONE ACETATE-ALOE VERA COUGH/COLD/ALLERGY ANTITUSSIVES BENZONATATE HYDROCODONE W/ HOMATROPINE PA - Prior Authorization QL - Quantity Limits TESSALON PERLES ZONATUSS ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 40 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 COUGH/COLD/ALLERGY (CONT.) COUGH/COLD/ALLERGY COMBINATIONS DEX-TUSS PROMETHAZINE W/CODEINE PROMETHAZINE-DM PA - Prior Authorization QL - Quantity Limits ALA-HIST D ALAHIST AC ALAHIST DHC ALLFEN CD ALLFEN CDX TABS BRONCOPECTOL CHLORPHEN-PSE & METHSCOPOLAMINE TAB SR 12HR 8-1202.5 MG DECON-A GILPHEX TR J-COF DHC J-MAX DHC MAXIFED CD MAXIFED CDX MAXIFED-G CD MAXIFED-G CDX MAXIFLU CD MAXIFLU CDX MAXIPHEN CD MAXIPHEN CDX NEOTUSS PLUS PHENFLU CD PHENFLU CDX PSEUDOEPHEDRINE-GUAIFENESIN RELCOF PE SEMPREX-D TUSNEL TUSNEL PED-C ALBATUSSIN ALLFEN CDX LIQD AMBIFED CD AMBIFED CDX AMBIFED-G CD AMBIFED-G CDX ATUSS DS BROVEX CB BROVEX CBX CARBAPHEN 12 CARBAPHEN 12 PED CGU WC CHLORPHENIRAMINE & PHENYLEPHRINE TAB CR 8-20 MG COTAB A COTAB AX COTABFLU CPB WC DECON-G DESPEC-EXP DESPEC-PDC DONATUSS DC DURAFLU EXACTUSS GILTUSS GILTUSS TR LEMOHIST PLUS NOREL SR PEDIATEX TD PEDIATEX TDM PHENYLEPHRINE W/ DM-GG POLY HIST DHC POLY HIST NC POLY-TUSSIN DHC POLY-TUSSIN EX PROHIST CD PROHIST CF PROHIST LQ PROLEX DMX PROTID RELHIST ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 41 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 COUGH/COLD/ALLERGY (CONT.) COUGH/COLD/ALLERGY COMBINATIONS (CONT.) RESCON RESCON-JR RESCON-MX REZIRA SERADEX TGQ 15DM/5PEH/2CPM TGQ 30PSE/3BRM/15DM TGQ 30PSE/150GFN/15DM TUSSICAPS TUSSIONEX PENNKINETIC EXT VITUZ Z-COF I ZUTRIPRO MISC. RESPIRATORY INHALANTS HYPER-SAL HYPERSAL NEBUSAL MUCOLYTICS ACETYLCYSTEINE COUGH/COLD/ALLERGY COMBINATIONS DECONGESTANT ANTIHISTAMINE PROMETHAZINE & PHENYLEPHRINE DECONGESTANT W/ EXPECTORANT PHENYLEPHRINE-GUAIFENESIN NON-NARC ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE PHENYLEPHRINE-CHLORPHEN-DM PSEUDOEPHED-BROMPHEN-DM OPIOID ANTITUSSIVE-ANTIHISTAMINE HYDROCODONE POLISTIREX-CHLORPHENIRAMINE POLISTIREX PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 42 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 COUGH/COLD/ALLERGY COMBINATIONS (CONT.) OPIOID ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE PHENYLEPH-PROMETHAZINE W/ COD CYCLOPLEGIC MYDRIATICS CYCLOPLEGIC MYDRIATICS CYCLOPENTOLATE HCL DENTAL PRODUCTS DENTAL PRODUCTS - COMBINATIONS SODIUM FLUORIDE-POTASSIUM NITRATE FLUORIDE DENTAL PRODUCTS SODIUM FLUORIDE (DENTAL) STANNOUS FLUORIDE DERMATOLOGICALS ACNE PRODUCTS ADAPALENE BENZOYL PEROXIDE BENZOYL PEROXIDE LOTION 9% BENZOYL PEROXIDE PAD 3% BENZOYL PEROXIDE W/ CLEANSER BENZOYL PEROXIDE-ERYTHROMYCIN BPO 3% FOAMING CLOTHS BPO 6% FOAMING CLOTHS BPO 9% FOAMING CLOTHS BPO CREAMY WASH COMPLETE CLINDAMYCIN PHOSPHATE (TOPICAL) CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE ERYTHROMYCIN (ACNE AID) PADS; SOLN ISOTRETINOIN LAVOCLEN-4 CREAMY WASH SULFACETAMIDE SODIUM (ACNE) PA - Prior Authorization QL - Quantity Limits AKNE-MYCIN AZELEX BENZAMYCINPAK CLINAC BPO ABSORICA ACZONE BENZAC AC BENZAC AC WASH BENZAC W WASH BENZACLIN BENZAMYCIN BENZIQ BPO CLEOCIN-T CLINDAGEL CLINDAREACH DIFFERIN DUAC EPIDUO EVOCLIN KLARON NUOX PLEXION CLEANSER PLEXION CLEANSING CLOTH ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 43 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 DERMATOLOGICALS (CONT.) ( ACNE PRODUCTS (CONT.) SULFACETAMIDE SODIUM W/ SULFUR CREA; LOTN; PADS TRETINOIN PLEXION SCT RETIN-A RETIN-A MICRO RETIN-A MICRO PUMP SODIUM SULFACETAMIDE/SULF VANOXIDE-HC ZACLIR CLEANSING ANTI-INFLAMMATORY AGENTS - TOPICAL FLECTOR VOLTAREN GEL ANTIBIOTICS - TOPICAL GENTAMICIN SULFATE (TOPICAL) MUPIROCIN CORTISPORIN ALTABAX BACTROBAN CENTANY CENTANY AT EXELDERM MENTAX NAFTIN CREA 1% NAFTIN GEL 1% OXISTAT VUSION XOLEGEL ALCORTIN A ERTACZO LOPROX LOPROX SHAMPOO LOTRISONE NAFTIN CREA 2% NAFTIN GEL 2% NIZORAL ANTIFUNGALS - TOPICAL CICLOPIROX GEL CICLOPIROX OLAMINE CLOTRIMAZOLE (TOPICAL) CLOTRIMAZOLE W/ BETAMETHASONE ECONAZOLE NITRATE KETOCONAZOLE (TOPICAL) NYSTATIN (TOPICAL) NYSTATIN-TRIAMCINOLONE ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL FLUOROURACIL (TOPICAL) FLUOROPLEX CARAC EFUDEX TARGRETIN GEL ANTIPRURITICS - TOPICAL DOXEPIN HCL (ANTIPRURITIC) PA - Prior Authorization QL - Quantity Limits ZONALON ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 44 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 DERMATOLOGICALS (CONT.) ANTIPSORIATICS ACITRETIN CALCIPOTRIENE CALCITRIOL (TOPICAL) DRITHO-SCALP DOVONEX DOVONEX SCALP DRITHO-CREME HP 8-MOP OXSORALEN ULTRA SORIATANE TAZORAC VECTICAL ZITHRANOL ANTISEBORRHEIC PRODUCTS SELENIUM SULFIDE LOTN OVACE PLUS OVACE PLUS WASH SELENIUM SULFIDE SHAM SELSUN SHAMPOO TERSI FOAM ANTIVIRALS - TOPICAL ACYCLOVIR TOPICAL DENAVIR LIDOVIR XERESE ZOVIRAX CREA; OINT MAFENIDE ACETATE SILVER SULFADIAZINE SILVADENE SULFAMYLON BURN PRODUCTS CAUTERIZING AGENTS SILVER NITRATE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 45 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 DERMATOLOGICALS (CONT.) CORTICOSTEROIDS - TOPICAL ALCLOMETASONE DIPROPIONATE AMCINONIDE BETAMETHASONE DIPROPIONATE (TOPICAL) CREA; OINT BETAMETHASONE DIPROPIONATE AUGMENTED BETAMETHASONE VALERATE CREA; LOTN; OINT CLOBETASOL PROPIONATE DESONIDE LOTN; OINT DESOXIMETASONE CREA .05% DESOXIMETASONE GEL DESOXIMETASONE OINT DIFLORASONE DIACETATE FLUOCINOLONE ACETONIDE FLUOCINONIDE CREA; GEL; OINT FLUTICASONE PROPIONATE CREA; LOTN HALOBETASOL PROPIONATE CREA MOMETASONE FUROATE PREDNICARBATE TRIAMCINOLONE ACETONIDE (TOPICAL) CAPEX CLODERM PUMP CORDRAN TAPE KENALOG PANDEL ACLOVATE APEXICON E CARMOL-HC CLOBEX CORDRAN CORDRAN SP CORTANE-B CUTIVATE DERMA-SMOOTHE/FS BODY DERMA-SMOOTHE/FS SCALP OI DERMATOP DESONATE DESOWEN DESOWEN LOTION/CETAPHIL C DIPROLENE DIPROLENE AF ELOCON EPIFOAM HALOG LOCOID LOCOID LIPOCREAM LUXIQ NUCORT NUZON OLUX PRAMOSONE PRAMOSONE E SYNALAR OINTMENT KIT TACLONEX OINT (QL) (400 GM / 56 DAYS) TACLONEX SUSP TEMOVATE TOPICORT TRIANEX ULTRAVATE VERDESO EMOLLIENT/KERATOLYTIC AGENTS HYDRO 40 FOAM PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 46 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 DERMATOLOGICALS (CONT.) EMOLLIENTS LACTIC ACID (AMMONIUM LACTATE) HPR PLUS HYLIRA LAC-HYDRIN ENZYMES - TOPICAL SANTYL XENADERM IMMUNOMODULATING AGENTS - TOPICAL IMIQUIMOD ALDARA ZYCLARA IMMUNOSUPPRESSIVE AGENTS - TOPICAL ELIDEL PROTOPIC KERATOLYTIC/ANTIMITOTIC AGENTS PODOFILOX PODOCON 25 IN BENZOIN TIN BENSAL HP CONDYLOX KERALYT SALEX LINIMENTS MEDROX-RX LOCAL ANESTHETICS - TOPICAL LIDOCAINE LIDOCAINE HCL CREA; GEL; SOLN LIDOCAINE-PRILOCAINE PRAMOXINE HCL ANACAINE CETACAINE EMLA LIDODERM LIDORX MISC. DERMATOLOGICAL PRODUCTS XCLAIR MISC. TOPICAL XERAC AC PA - Prior Authorization QL - Quantity Limits DRYSOL ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 47 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 DERMATOLOGICALS (CONT.) ROSACEA AGENTS METRONIDAZOLE (TOPICAL) FINACEA METROCREAM METROGEL METROLOTION NORITATE SCABICIDES PEDICULICIDES MALATHION PERMETHRIN SPINOSAD EURAX ULESFIA ELIMITE NATROBA OVIDE SKLICE WOUND CARE PRODUCTS REGRANEX (PA) DIBENZAPINES DIBENZODIAZEPINES CLOZAPINE TBDP DIETARY MANAGEMENT PRODUCTS (NEW) DIETARY MANAGEMENT PRODUCT COMBINATIONS (NEW) FLAXSEED OIL-EVENING PRIMROSE OIL-BILBERRY EXTRACT FOLIC ACID-PYRIDOXINE-CYANCOBALAMIN DIGESTIVE AIDS DIGESTIVE ENZYMES PANCRELIPASE (LIPASE-PROTEASE-AMYLASE) PA - Prior Authorization QL - Quantity Limits CREON DIGEX PANCREAZE PERTZYE VIOKACE ZENPEP ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 48 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 DIURETICS CARBONIC ANHYDRASE INHIBITORS ACETAZOLAMIDE ACETAZOLAMIDE SODIUM METHAZOLAMIDE DIAMOX DIURETIC COMBINATIONS AMILORIDE & HYDROCHLOROTHIAZIDE SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TRIAMTERENE & HYDROCHLOROTHIAZIDE ALDACTAZIDE DYAZIDE MAXZIDE MAXZIDE-25 LOOP DIURETICS BUMETANIDE FUROSEMIDE TORSEMIDE EDECRIN DEMADEX LASIX DYRENIUM ALDACTONE DIURIL THALITONE MICROZIDE ZAROXOLYN POTASSIUM SPARING DIURETICS AMILORIDE HCL SPIRONOLACTONE THIAZIDES AND THIAZIDE-LIKE DIURETICS CHLOROTHIAZIDE CHLORTHALIDONE HYDROCHLOROTHIAZIDE INDAPAMIDE METHYCLOTHIAZIDE METOLAZONE EMOLLIENT/KERATOLYTIC AGENTS EMOLLIENT/KERATOLYTIC AGENTS UREA EMOLLIENT/KERATOLYTIC COMBINATIONS UREA IN LACTIC ACID VEHICLE UREA IN LACTIC ACID-SALICYLIC ACID VEHICLE UREA IN ZINC UNDECYLENATE-LACTIC ACID VEHICLE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 49 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 EMOLLIENTS EMOLLIENT COMBINATIONS LACTIC ACID W/ VITAMIN E EMOLLIENTS HYALURONATE SODIUM (EMOLLIENT) ENDOCRINE AND METABOLIC AGENTS - MISC. BONE DENSITY REGULATORS ALENDRONATE SODIUM TABS CALCITONIN (SALMON) IBANDRONATE SODIUM ACTONEL 5MG, 30MG, 35MG ACTONEL 150MG (QL) (60 TABS / 30 DAYS) BONIVA DIDRONEL FORTICAL FOSAMAX FOSAMAX PLUS D MIACALCIN SKELID FORTEO (PA) CORTICOTROPIN ACTHAR HP (PA) FERTILITY REGULATORS CLOMIPHENE CITRATE CLOMID FOLLISTIM AQ (PA) MENOPUR (PA) OVIDREL (PA) REPRONEX (PA) GNRH/LHRH ANTAGONISTS GANIRELIX ACETATE (PA) GROWTH HORMONES NORDITROPIN FLEXPRO (PA) NORDITROPIN NORDIFLEX PEN (PA) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 50 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ENDOCRINE AND METABOLIC AGENTS - MISC. (CONT.) HORMONE RECEPTOR MODULATORS EVISTA INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS) INCRELEX (PA) METABOLIC MODIFIERS CALCITRIOL PARICALCITOL BUPHENYL CARNITOR HECTOROL ORFADIN ROCALTROL ZEMPLAR KUVAN (PA) SENSIPAR (PA) DDAVP STIMATE (PA) POSTERIOR PITUITARY HORMONES DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE REFRIGERATED DESMOPRESSIN ACETATE SPRAY DESMOPRESSIN ACETATE SPRAY REFRIGERATED PROLACTIN INHIBITORS CABERGOLINE SOMATOSTATIC AGENTS OCTREOTIDE ACETATE (PA) SIGNIFOR (PA) VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA (PA) ENZYMES - TOPICAL ENZYMES - TOPICAL TRYPSIN W/ CASTOR OIL & PERUVIAN BALSAM PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 51 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ERYTHROMYCINS ERYTHROMYCINS ERYTHROMYCIN BASE TABS 500MG ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN STEARATE ESTROGEN COMBINATIONS ESTROGEN ANDROGEN ESTERIFIED ESTROGENS & METHYLTESTOSTERONE ESTROGENS ESTROGEN COMBINATIONS ESTRADIOL & NORETHINDRONE ACETATE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL COMBIPATCH ACTIVELLA ANGELIQ CLIMARA PRO FEMHRT 1/5 FEMHRT LOW DOSE PREFEST PREMPHASE PREMPRO ESTRADIOL ESTRADIOL VALERATE ESTROPIPATE CENESTIN ENJUVIA EVAMIST MENOSTAR CLIMARA DIVIGEL ELESTRIN ESTRACE TABS ESTRASORB ESTROGEL FEMTRACE MENEST PREMARIN TABS ESTROGENS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 52 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 FLUOROQUINOLONES FLUOROQUINOLONES CIPROFLOXACIN HCL CIPROFLOXACIN-CIPROFLOXACIN HCL LEVOFLOXACIN OFLOXACIN TAB 200 MG OFLOXACIN AVELOX CIPRO CIPRO XR FACTIVE LEVAQUIN NOROXIN GASTROINTESTINAL AGENTS - MISC. GALLSTONE SOLUBILIZING AGENTS URSODIOL ACTIGALL URSO 250 URSO FORTE GASTROINTESTINAL ANTIALLERGY AGENTS CROMOLYN SODIUM (MASTOCYTOSIS) GASTROCROM GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS AMITIZA GASTROINTESTINAL STIMULANTS METOCLOPRAMIDE HCL METOZOLV ODT REGLAN INFLAMMATORY BOWEL AGENTS BALSALAZIDE DISODIUM MESALAMINE SULFASALAZINE PA - Prior Authorization QL - Quantity Limits APRISO ASACOL ASACOL HD AZULFIDINE AZULFIDINE EN-TABS CANASA (QL) (60 SUPP / 30 DAYS) COLAZAL DIPENTUM LIALDA PENTASA SFROWASA CIMZIA (PA), (ST) CIMZIA STARTER KIT (PA), (ST) ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 53 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 GASTROINTESTINAL AGENTS - MISC. (CONT.) INTESTINAL ACIDIFIERS LACTULOSE (ENCEPHALOPATHY) IRRITABLE BOWEL SYNDROME (IBS) AGENTS LINZESS LOTRONEX PERIPHERAL OPIOID RECEPTOR ANTAGONISTS RELISTOR (PA) PHOSPHATE BINDER AGENTS CALCIUM ACETATE (PHOSPHATE BINDER) ELIPHOS FOSRENOL PHOSLO PHOSLYRA RENAGEL RENVELA GENITOURINARY AGENTS - MISCELLANEOUS ACIDIFIERS K-PHOS MF K-PHOS NO 2 ALKALINIZERS POTASSIUM CITRATE (ALKALINIZER) POLYCITRA-K CRYSTALS SODIUM CITRATE & CITRIC ACID UROCIT-K 5 UROCIT-K 10 UROCIT-K 15 CYSTINOSIS AGENTS CYSTAGON (PA) GENITOURINARY IRRIGANTS SODIUM CHLORIDE (GU IRRIGANT) INTERSTITIAL CYSTITIS AGENTS ELMIRON PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 54 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 GENITOURINARY AGENTS - MISCELLANEOUS (CONT.) PROSTATIC HYPERTROPHY AGENTS ALFUZOSIN HCL FINASTERIDE TAMSULOSIN HCL AVODART FLOMAX JALYN PROSCAR RAPAFLO UROXATRAL URINARY ANALGESICS PHENAZOPYRIDINE HCL PYRIDIUM URINARY STONE AGENTS LITHOSTAT THIOLA ULORIC COLCRYS ZYLOPRIM GENITOURINARY IRRIGANTS ANTI-INFECTIVE GENITOURINARY IRRIGANTS NEOMYCIN/POLYMYXIN B GU GLUCOCORTICOSTEROIDS GLUCOCORTICOSTEROIDS METHYLPREDNISOLONE 4MG GOUT AGENTS GOUT AGENT COMBINATIONS COLCHICINE W/ PROBENECID GOUT AGENTS ALLOPURINOL URICOSURICS PROBENECID PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 55 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 GROWTH HORMONE RECEPTOR ANTAGONISTS GROWTH HORMONE RECEPTOR ANTAGONISTS OMNITROPE (PA) H-2 ANTAGONISTS H-2 ANTAGONISTS NIZATIDINE CAPS HAIR GROWTH AGENTS TYPE II 5-ALPHA REDUCTASE INHIBITORS FINASTERIDE (ALOPECIA) HEMATOLOGICAL AGENTS - MISC. HEMATORHEOLOGIC AGENTS PENTOXIFYLLINE PLATELET AGGREGATION INHIBITORS ANAGRELIDE HCL CILOSTAZOL CLOPIDOGREL BISULFATE DIPYRIDAMOLE AGGRENOX BRILINTA (QL) (60 TABS / 30 DAYS) EFFIENT PLAVIX PLETAL HEMATOPOIETIC AGENTS AGENTS FOR GAUCHER DISEASE ZAVESCA AGENTS FOR SICKLE CELL ANEMIA DROXIA COBALAMINS CYANOCOBALAMIN PA - Prior Authorization QL - Quantity Limits NASCOBAL ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 56 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 HEMATOPOIETIC AGENTS (CONT.) FOLIC ACID/FOLATES FOLIC ACID HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE (PA) EPOGEN (PA) NEULASTA (PA) NEUPOGEN (PA) PROCRIT (PA) PROMACTA (PA) HEMATOPOIETIC MIXTURES FETRIN FUMATINIC PROFERRIN-FORTE PA - Prior Authorization QL - Quantity Limits ACTIVE FE ANIMI-3/VITAMIN D BIFERARX CENFOL CORVITE 150 DIVISTA ED CYTE F FE 90 PLUS FERIVA FERRALET 90 FERRAPLUS 90 FERRO-PLEX HEMATINIC FERROTRIN FOLGARD RX FOLIVANE-F FOLPACE RX FOLTRATE FUSION PLUS HEMATOGEN FA HEMATRON-AF HEMETAB HEMOCYTE-F INTEGRA F INTEGRA PLUS IRON-VITAMIN C-VITAMIN B12-FOLIC ACID IROSPAN 24/6 MAXARON FORTE MULTIGEN MULTIGEN FOLIC ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 57 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 HEMATOPOIETIC AGENTS (CONT.) HEMATOPOIETIC MIXTURES (CONT.) MULTIGEN PLUS NEPHRON FA NIRON KOMPLETE NOVAFERRUM PRE-FOLIC TANDEM F TANDEM PLUS HEMATOPOIETIC MIXTURES FOLIC ACID/FOLATE COMBINATIONS FOLIC ACID-VITAMIN B6-VITAMIN B12 IRON COMBINATIONS FE FUMARATE-VITAMIN C-VITAMIN B12-FOLIC ACID FERROUS FUMARATE W/ B12-VIT C-FA-IFC IRON POLYSACCHARIDE COMPLEX-VIT B12-FOLIC ACID IRON W/ FOLIC ACID FERROUS FUMARATE-FOLIC ACID HEMOSTATICS HEMOSTATICS - SYSTEMIC AMICAR LYSTEDA HEMOSTATICS - SYSTEMIC HEMOSTATICS - SYSTEMIC AMINOCAPROIC ACID TRANEXAMIC ACID PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 58 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 HEPATITIS AGENTS HEPATITIS B AGENTS ADEFOVIR DIPIVOXIL HEPATITIS C AGENTS PEG-INTRON (PA) PEG-INTRON REDIPEN (PA) RIBAVIRIN (HEPATITIS C) (PA) HYPNOTICS BARBITURATE HYPNOTICS PHENOBARBITAL TABS 15MG, 16.2MG, 30MG, 32.4MG, 60MG, 64.8MG, 97.2MG BUTISOL SODIUM SECONAL NON-BARBITURATE HYPNOTICS TEMAZEPAM ZALEPLON ZOLPIDEM TARTRATE AMBIEN CHLORAL HYDRATE CAP 500 MG DORAL HALCION LUNESTA PROSOM RESTORIL SONATA SELECTIVE MELATONIN RECEPTOR AGONISTS ROZEREM INFLAMMATORY BOWEL AGENTS INFLAMMATORY BOWEL AGENTS DELZICOL INSULIN HUMAN INSULIN NOVOLIN 70/30 NOVOLIN N NOVOLIN R PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 59 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 INTERLEUKIN-6 RECEPTOR INHIBITORS INTERLEUKIN-6 RECEPTOR INHIBITORS ACTEMRA (PA) IODINE PRODUCTS IODINE PRODUCTS IODINE STRONG (LUGOL’S) KERATOLYTIC/ANTIMITOTIC AGENTS KERATOLYTIC AND/OR ANTIMITOTIC COMBINATIONS SALICYLIC ACID IN AMMONIUM LACTATE VEHICLE KERATOLYTIC/ANTIMITOTIC AGENTS SALICYLIC ACID SALICYLIC ACID W/ CLEANSER LAXATIVES LAXATIVE COMBINATIONS GOLYTELY HALFLYTELY BOWEL PREP/FLA MOVIPREP NULYTELY/FLAVOR PACKS PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE PEG 3350-POTASSIUM CHLORIDE-SOD BICARBONATE-SOD CHLORIDE PREPOPIK SUPREP BOWEL PREP LAXATIVES - MISCELLANEOUS LACTULOSE POLYETHYLENE GLYCOL 3350 POWD KRISTALOSE SALINE LAXATIVES OSMOPREP PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 60 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 LAXATIVES - MISCELLANEOUS LAXATIVES - MISCELLANEOUS POLYETHYLENE GLYCOL 3350 PACK LEUKOTRIENE MODULATORS LEUKOTRIENE RECEPTOR ANTAGONISTS ZAFIRLUKAST LINCOSAMIDES LINCOSAMIDES CLINDAMYCIN HCL 75MG LOCAL ANESTHETICS - TOPICAL LOCAL ANESTHETICS - TOPICAL LIDOCAINE HCL LOTN REGENECARE TOPICAL ANESTHETIC GASSES ETHYL CHLORIDE LOCAL ANESTHETICS-PARENTERAL LOCAL ANESTHETICS - AMIDES LIDOCAINE HCL (LOCAL ANESTH.) MACROLIDES AZITHROMYCIN AZITHROMYCIN PA - Prior Authorization QL - Quantity Limits ZITHROMAX ZITHROMAX TRI-PAK ZITHROMAX Z-PAK ZMAX ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 61 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 MACROLIDES (CONT.) CLARITHROMYCIN CLARITHROMYCIN BIAXIN BIAXIN XL BIAXIN XL PAC ERYTHROMYCINS ERYTHROMYCIN BASE CPEP ERYTHROMYCIN BASE TABS 250MG ERYPED 400 ERY-TAB PCE FIDAXOMICIN DIFICID MEDICAL DEVICES CONTRACEPTIVES FEMCAP (QL) (1 / 300 DAYS) OMNIFLEX DIAPHRAGM (QL) (1 / 300 DAYS) ORTHO DIAPHRAGM ALL-FLEX (QL) (1 / 300 DAYS) ORTHO DIAPHRAGM COIL SPRI (QL) (1 / 300 DAYS) ORTHO DIAPHRAGM FLAT SPRI (QL) (1 / 300 DAYS) PARAGARD INTRAUTERINE COP (QL) (1 / 300 DAYS) PRENTIF CAVITY-RIM CERVIC (QL) (1 / 300 DAYS) PRENTIF FITTING SET (QL) (1 / 300 DAYS) WIDE-SEAL SILICONE DIAPHR (QL) (1 / 300 DAYS) METABOLIC MODIFIERS CARNITINE REPLENISHER - AGENTS LEVOCARNITINE (METABOLIC MODIFIERS) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 62 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 METABOLIC MODIFIERS (CONT.) UREA CYCLE DISORDER - AGENTS SODIUM PHENYLBUTYRATE MIGRAINE COMBINATIONS MIGRAINE COMBINATIONS ACETAMINOPHEN-ISOMETHEPTENE-DICHLORALPHENAZONE MIGRAINE PRODUCTS MIGRAINE COMBINATIONS CAFERGOT ERGOTAMINE W/ CAFFEINE PRODRIN MIGRAINE PRODUCTS DIHYDROERGOTAMINE MESYLATE D.H.E. 45 ERGOMAR MIGRAL MIGRANAL SEROTONIN AGONISTS NARATRIPTAN HCL RIZATRIPTAN BENZOATE SUMATRIPTAN SUMATRIPTAN SUCCINATE ZOLMITRIPTAN PA - Prior Authorization QL - Quantity Limits RELPAX AMERGE AXERT FROVA IMITREX IMITREX STATDOSE REFILL MAXALT MAXALT-MLT ZOMIG ZOMIG NASAL SPRAY ZOMIG ZMT ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 63 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 MINERALS ELECTROLYTES FLUORIDE FLUORABON SODIUM FLUORIDE CHEW 1MG, LURIDE 2.2MG SODIUM FLUORIDE CHEW .25MG, SODIUM FLUORIDE TABS 1MG .5MG, .55MG, 1.1MG SODIUM FLUORIDE SOLN SODIUM FLUORIDE TABS .5MG SODIUM FLUORIDE SOLN 0.25 MG/DROP F (FROM 0.55 MG/ DROP NAF) FLUOR-A-DAY IODINE PRODUCTS SSKI MAGNESIUM MAGNESIUM SULFATE MAGNEBIND 400 PHOSPHATE K-PHOS POTASSIUM POTASSIUM CHLORIDE CPCR; LIQD; SOLN; TBCR POTASSIUM CHLORIDE MICROENCAPSULATED CRYSTALS CR EFFER-K K-TAB KLOR-CON M15 MICRO-K POTASSIUM CHLORIDE PACK SODIUM SODIUM CHLORIDE ZINC GALZIN MIOTICS MIOTICS - DIRECT ACTING PILOCARPINE HCL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 64 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 MISC. RESPIRATORY INHALANTS MISC. RESPIRATORY INHALANTS SODIUM CHLORIDE (INHALANT) MISC. TOPICAL MISC. TOPICAL ALUMINUM CHLORIDE MISCELLANEOUS VAGINAL PRODUCTS MISCELLANEOUS VAGINAL COMBINATIONS ACETIC ACID-OXYQUINOLINE VAGINAL MODIFIED CYCLICS MODIFIED CYCLICS NEFAZODONE HCL MOUTH/THROAT/DENTAL AGENTS ANESTHETICS TOPICAL ORAL LIDOCAINE HCL (MOUTH-THROAT) FIRST-MOUTHWASH BLM ANTI-INFECTIVES - THROAT CLOTRIMAZOLE NYSTATIN (MOUTH-THROAT) FIRST-DUKES MOUTHWASH FIRST-MARYS MOUTHWASH MYCELEX ANTIALLERGY AGENTS - MOUTH/THROAT APHTHASOL ANTISEPTICS - MOUTH/THROAT CHLORHEXIDINE GLUCONATE (MOUTH-THROAT) PA - Prior Authorization QL - Quantity Limits PERIDEX ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 65 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 MOUTH/THROAT/DENTAL AGENTS (CONT.) DENTAL PRODUCTS NAFRINSE DAILY/NEUTRAL PREVIDENT 5000 DRY MOUTH STEROIDS - MOUTH/THROAT TRIAMCINOLONE ACETONIDE (MOUTH) THROAT PRODUCTS - MISC CEVIMELINE HCL PILOCARPINE HCL (ORAL) 5MG EVOXAC GELCLAIR NUMOISYN SALAGEN SALICEPT MULTIPLE SCLEROSIS AGENTS MULTIPLE SCLEROSIS AGENTS COPAXONE SOSY MULTIVITAMINS B-COMPLEX W/ FOLIC ACID DIALYVITE 5000 NEPHPLEX RX NEPHROCAPS NEPHROCAPS QT RENATABS RENATABS WITH IRON MULTIPLE VITAMINS W/ CALCIUM ADVANCED AM/PM PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 66 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 MULTIVITAMINS (CONT.) MULTIPLE VITAMINS W/ MINERALS BACMIN CORVITE DIALYVITE SUPREME D MULTICHEW NICAZEL PROTECT PLUS NR RENAX STROVITE FORTE SYNAGEX TRI-ZEL UDAMIN VP-ZEL MULTIPLE VITAMINS W/ MINERALS CALCIUM-FOLIC ACID TL G-FOL OS PROTECTBONE PED MV W/ FLUORIDE PEDIATRIC MULTIVITAMINS W/FL PEDIATRIC VITAMINS ACD W/ FLUORIDE POLY-VI-FLOR CHEW POLY-VI-FLOR SUSP TRI-VI-FLOR TRI-VI-FLORO PED MULTI VITAMINS W/FL FE PEDIATRIC VITAMINS ACD FLUORIDE & IRON MYKIDZ IRON FL ESCAVITE POLY-VI-FLOR/IRON PRENATAL VITAMINS ATABEX EC ATABEX PRENATAL B-NEXA BAL-CARE DHA ESSENTIAL C-NATE DHA CAVAN-ALPHA KIT CAVAN-EC SOD DHA CHOICE-OB+DHA CITRANATAL B-CALM CITRANATAL HARMONY COMPLETE-RF PRENATAL COMPLETENATE CONCEPT DHA CONCEPT OB PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 67 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 MULTIVITAMINS (CONT.) PRENATAL VITAMINS (CONT.) DUET DHA 400 DUET DHA 400EC DUET DHA 430 DUET DHA BALANCED DUET DHA EC FOCALGIN-B FOLIVANE-OB FOLIVANE-PRX DHA NF GENTEX ADE LACTOCAL-F LEVOMEFOLATE DHA MARNATAL-F MAXINATE MYNATAL-Z NATA KOMPLETE NATACHEW NATAFORT NATALVIT NATELLE ONE NATELLE-EZ NEEVO NEEVO DHA NESTABS NESTABS ABC NESTABS DHA NEXA SELECT O-CAL PRENATAL OB COMPLETE OB COMPLETE 400 OB COMPLETE ONE OB COMPLETE PETITE OB COMPLETE PREMIER OB COMPLETE/DHA OB-NATAL ONE OBSTETRIX DHA PAIRE OB PNV-DHA+DOCUSATE PNV-TOTAL PR NATAL 400 PR NATAL 400 EC PR NATAL 430 EC PREFERA OB + DHA PREFERAOB ONE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 68 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 MULTIVITAMINS (CONT.) PRENATAL VITAMINS (CONT.) PREFOL-DHA PRENA1 PLUS/QUATREFOLIC PRENAFIRST PRENAISSANCE 90 DHA PRENAISSANCE BALANCE PRENAISSANCE DHA PRENAISSANCE PROMISE PRENATA PRENATAL MV & MIN/FE-FA-D PRENATAL PLUS IRON PRENATAL-U PRENATE PRENATE AM PRENATE DHA PRENATE ELITE PRENATE ENHANCE PRENATE ESSENTIAL PRENATE MINI PRENATE RESTORE PREQUE 10 PROTECTNATAL PROVIDA OB R-NATAL OB REAPHIRM SE-CARE SE-CARE CONCEIVE SE-NATAL 19 SE-NATAL 90 SE-NATAL ONE SE-PLETE DHA SE-TAN DHA SELECT-OB SETONET TANDEM OB TARON-BC TARON-PREX TL-SELECT TL-SELECT DHA TRI RX TRICARE DHA 301 TRICARE PRENATAL COMPLEAT TRICARE PRENATAL DHA ONE TRIMESIS RX PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 69 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 MULTIVITAMINS (CONT.) PRENATAL VITAMINS (CONT.) TRIVEEN-ONE TRUST NATAL DHA ULTIMATECARE COMBO ULTIMATECARE ONE NF VEMAVITE-PRX 2 VENATAL COMPLETE DHA VINATE AZ VINATE CALCIUM VINATE II VINATE M VINATE PN CARE VIRT-BAL DHA VIRT-PN VIRT-PN DHA VIRT-SELECT VITA-PREN VITAFOL ULTRA VITAFOL-OB+DHA VITAFOL-ONE VITAFOL-PLUS VITAMEDMD ONE RX/QUATREFO VITAMEDMD REDICHEW RX/QUA VITASPIRE VIVA CT PRENATAL VP-CH PLUS VP-ERA OB PLUS VP-HEME OB VP-PNV-DHA ZATEAN-CH ZATEAN-PN PLUS VITAMIN MIXTURES NICOMIDE MUSCLE RELAXANT COMBINATIONS MUSCLE RELAXANT COMBINATIONS CARISOPRODOL W/ ASPIRIN CARISOPRODOL W/ ASPIRIN & CODEINE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 70 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 MUSCULOSKELETAL THERAPY AGENTS CENTRAL MUSCLE RELAXANTS BACLOFEN CARISOPRODOL CYCLOBENZAPRINE HCL METAXALONE METHOCARBAMOL ORPHENADRINE CITRATE TIZANIDINE HCL FEXMID FLEXERIL LORZONE PARAFON FORTE DSC ROBAXIN ROBAXIN-750 SKELAXIN SOMA ZANAFLEX DIRECT MUSCLE RELAXANTS DANTROLENE SODIUM MUSCLE RELAXANT COMBINATIONS ORPHENADRINE W/ ASPIRIN & CAFF ORPHENADRINE W/ ASPIRIN & CAFFEINE TAB 50-770-60 MG ORPHENADRINE W/ ASPIRIN & CAFFEINE TAB 50-770-60 MG NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL ANTI-INFECTIVES BACTROBAN NASAL NASAL ANTIALLERGY AZELASTINE HCL ASTELIN ASTEPRO PATANASE NASAL ANTICHOLINERGICS IPRATROPIUM BROMIDE (NASAL) ATROVENT NASAL STEROIDS FLUNISOLIDE (NASAL) FLUNISOLIDE NASAL SOLN 29 MCG/ACT (0.025%) FLUTICASONE PROPIONATE (NASAL) TRIAMCINOLONE ACETONIDE (NASAL) PA - Prior Authorization QL - Quantity Limits NASONEX BECONASE AQ FLONASE NASACORT AQ OMNARIS QNASL RHINOCORT AQUA VERAMYST ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 71 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 NASAL AGENTS - SYSTEMIC AND TOPICAL (CONT.) SYMPATHOMIMETIC DECONGESTANTS LUSONAL TYZINE TYZINE PEDIATRIC NASAL DR NEUROMUSCULAR AGENTS ALS AGENTS RILUZOLE RILUTEK NICOTINIC ACID DERIVATIVES NICOTINIC ACID DERIVATIVES NIACIN (ANTIHYPERLIPIDEMIC) NITRATES NITRATES NITROGLYCERIN AERS; CPCR NON-BARBITURATE HYPNOTICS BENZODIAZEPINE HYPNOTICS ESTAZOLAM FLURAZEPAM HCL MIDAZOLAM HCL QUAZEPAM TRIAZOLAM NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) ETODOLAC CAPS 300MG IBUPROFEN SUSP OIL SOLUBLE VITAMINS VITAMIN D ERGOCALCIFEROL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 72 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 OPHTHALMIC ADRENERGIC AGENTS OPHTHALMIC SELECTIVE ALPHA ADRENERGIC AGONISTS APRACLONIDINE HCL OPHTHALMIC AGENTS ARTIFICIAL TEARS AND LUBRICANTS LACRISERT BETA-BLOCKERS - OPHTHALMIC BETAXOLOL HCL (OPHTH) CARTEOLOL HCL (OPHTH) DORZOLAMIDE HCL-TIMOLOL MALEATE LEVOBUNOLOL HCL TIMOLOL MALEATE (OPHTH) BETAGAN BETIMOL BETOPTIC-S COMBIGAN COSOPT ISTALOL OPTIPRANOLOL TIMOPTIC TIMOPTIC-XE CYCLOPLEGIC MYDRIATICS ATROPINE SULFATE (OPHTHALMIC) ISOPTO HYOSCINE HOMATROPINE HBR TROPICAMIDE CYCLOGYL CYCLOMYDRIL ISOPTO HOMATROPINE MYDRIACYL MIOTICS PILOPINE HS ISOPTO CARBACHOL ISOPTO CARPINE IOPIDINE ALPHAGAN P SIMBRINZA OPHTHALMIC ADRENERGIC AGENTS BRIMONIDINE TARTRATE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 73 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 OPHTHALMIC AGENTS (CONT.) OPHTHALMIC ANTI-INFECTIVES BACITRACIN (OPHTHALMIC) VIGAMOX BACITRACIN-POLYMYXIN B (OPHTH) CIPROFLOXACIN HCL (OPHTH) ERYTHROMYCIN (OPHTH) GATIFLOXACIN (OPHTH) GENTAMICIN SULFATE (OPHTH) LEVOFLOXACIN (OPHTH) NEOMYCIN-POLYMY-GRAMICID OFLOXACIN (OPHTH) POLYMYXIN B-TRIMETHOPRIM SULFACETAMIDE SODIUM (OPHTH) SOLN TOBRAMYCIN SULFATE (OPHTH) TRIFLURIDINE AZASITE BESIVANCE BLEPH-10 CILOXAN GARAMYCIN MOXEZA NATACYN OCUFLOX TOBREX VIROPTIC ZIRGAN ZYMAXID OPHTHALMIC DECONGESTANTS NAPHAZOLINE HCL PHENYLEPHRINE HCL (OPHTH) OPHTHALMIC IMMUNOMODULATORS RESTASIS OPHTHALMIC LOCAL ANESTHETICS PROPARACAINE HCL AKTEN OPHTHALMIC STEROIDS BACITRACIN-POLY-NEOMYCIN-HC DEXAMETHASONE SODIUM PHOSPHATE (OPHTH) FLUOROMETHOLONE (OPHTH) NEOMYCIN-POLYMY-DEXAMETH NEOMYCIN-POLYMYXIN-HC (OPHTH) PREDNISOLONE ACETATE (OPHTH) SULFACETAMIDE SOD-PREDNISOLONE TOBRAMYCIN-DEXAMETHASONE PA - Prior Authorization QL - Quantity Limits ALREX BLEPHAMIDE BLEPHAMIDE S.O.P. DUREZOL FLAREX FML FML FORTE FML LIQUIFILM LOTEMAX OMNIPRED PRED FORTE ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 74 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 OPHTHALMIC AGENTS (CONT.) OPHTHALMIC STEROIDS (CONT.) PRED MILD PRED-G PRED-G S.O.P. TOBRADEX TOBRADEX ST VEXOL ZYLET OPHTHALMIC SURGICAL AIDS VISIONBLUE OPHTHALMICS - MISC. AZELASTINE HCL (OPHTH) BROMFENAC SODIUM (OPHTH) CROMOLYN SODIUM (OPHTH) DICLOFENAC SODIUM (OPHTH) DORZOLAMIDE HCL EPINASTINE HCL (OPHTH) FLURBIPROFEN SODIUM KETOROLAC TROMETHAMINE (OPHTH) KETOTIFEN FUMARATE (OPHTH) ALOCRIL ALOMIDE NEVANAC PATADAY PATANOL ACULAR ACULAR LS ACUVAIL AZOPT ELESTAT EMADINE LASTACAFT OPTIVAR TRUSOPT VOLTAREN SOLN TRAVATAN Z LUMIGAN XALATAN ZIOPTAN PROSTAGLANDINS - OPHTHALMIC LATANOPROST OPHTHALMIC ANTI-INFECTIVES OPHTHALMIC ANTI-INFECTIVE COMBINATIONS NEOMYCIN-BACITRACIN ZN-POLYMYXIN OPHTHALMIC SULFONAMIDES SULFACETAMIDE SODIUM (OPHTH) OINT PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 75 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 OPHTHALMIC LOCAL ANESTHETICS OPHTHALMIC LOCAL ANESTHETICS TETRACAINE HCL (OPHTH) OPHTHALMICS - MISC. OPHTHALMIC DIAGNOSTIC PRODUCTS FLUORESCEIN W/ PROPARACAINE OPHTHALMIC IRRIGATION SOLUTIONS OPHTHALMIC IRRIGATION SOLUTION OPHTHALMIC IRRIGATION SOLUTION - INTRAOCULAR OPIOID AGONISTS OPIOID AGONISTS FENTANYL CITRATE 200MCG, 400MCG, 600MCG, 1200MCG, 1600MCG FENTANYL CITRATE 800MCG (PA) MEPERIDINE HCL MORPHINE SULFATE SOLN 20MG/ ML OXYCODONE HCL CAPS OPIOID COMBINATIONS OPIOID COMBINATIONS BUTALBITAL-ASPIRIN-CAFFEINE W/ COD HYDROCODONE COMBINATIONS HYDROCODONE-IBUPROFEN OPIOID COMBINATIONS OXYCODONE-ASPIRIN PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 76 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 OPIOID COMBINATIONS (CONT.) TRAMADOL COMBINATIONS TRAMADOL-ACETAMINOPHEN OPIOID PARTIAL AGONISTS OPIOID PARTIAL AGONISTS BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE (PA) PENTAZOCINE W/ NALOXONE SUBOXONE FILM OTIC AGENTS OTIC AGENTS - MISCELLANEOUS ACETIC ACID (OTIC) ACETIC ACID-ALUMINUM ACETATE OTIC ANALGESICS PINNACAINE OTIC OTIC ANTI-INFECTIVES OFLOXACIN (OTIC) OTIC COMBINATIONS NEOMYCIN-POLYMYXIN-HC (OTIC) PA - Prior Authorization QL - Quantity Limits CIPRODEX COLY-MYCIN S CORTISPORIN-TC AURALGAN CIPRO HC CORTANE-B AQUEOUS CORTANE-B-OTIC MYOXIN NEOTIC OTICIN HC NR OTOZIN PRAMOTIC TREAGAN OTIC TRIOXIN ZINOTIC ZINOTIC ES ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 77 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 OTIC AGENTS (CONT.) OTIC STEROIDS FLUOCINOLONE ACETONIDE (OTIC) HYDROCORTISONE W/ACETIC ACID DERMOTIC VOSOL HC OTIC COMBINATIONS OTIC ANALGESIC COMBINATIONS ANTIPYRINE-BENZOCAINE ANTIPYRINE-BENZOCAINE-POLYCOSANOL PRAMOXINE-CHLOROXYLENOL PRAMOXINE-HC-CHLOROXYLENOL OXYTOCICS OXYTOCICS METHYLERGONOVINE MALEATE PENICILLINASE-RESISTANT PENICILLINS PENICILLINASE-RESISTANT PENICILLINS BACTOCILL IN DEXTROSE PENICILLINS AMINOPENICILLINS AMOXICILLIN AMPICILLIN AMPICILLIN SODIUM NATURAL PENICILLINS PENICILLIN G POTASSIUM PENICILLIN G SODIUM PENICILLIN V POTASSIUM PENICILLIN COMBINATIONS AMOXICILLIN & POT CLAVULANATE AMPICILLIN & SULBACTAM SODIUM PA - Prior Authorization QL - Quantity Limits AUGMENTIN AUGMENTIN ES-600 AUGMENTIN XR ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 78 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 PENICILLINS (CONT.) PENICILLINASE-RESISTANT PENICILLINS DICLOXACILLIN SODIUM NAFCILLIN SODIUM OXACILLIN SODIUM PERIPHERAL VASODILATORS PERIPHERAL VASODILATORS ISOXSUPRINE HCL PHOSPHATE PHOSPHATE POT PHOSPHATE MONOBASIC W/ SOD PHOSPHATE DIBASIC & MONOBASIC PIGMENTING-DEPIGMENTING AGENTS DEPIGMENTING AGENTS HYDROQUINONE HYDROQUINONE MICROSPHERES PLATELET AGGREGATION INHIBITORS THIENOPYRIDINE DERIVATIVES TICLOPIDINE HCL POTASSIUM POTASSIUM POTASSIUM BICARBONATE POTASSIUM COMBINATIONS POTASSIUM BICARB & CHLORIDE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 79 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 POTASSIUM REMOVING RESINS POTASSIUM REMOVING RESINS SODIUM POLYSTYRENE SULFONATE POWD SODIUM POLYSTYRENE SULFONATE SUSP 30GM/120ML PRENATAL VITAMINS PRENATAL MV MIN W/FE-FA PRENATAL VIT W/ DOCUSATE-IRON CARBONYL-FOLIC ACID PROGESTINS PROGESTINS MEDROXYPROGESTERONE ACETATE NORETHINDRONE ACETATE PROGESTERONE MICRONIZED AYGESTIN MEGACE ES PROMETRIUM PROVERA PROSTAGLANDINS - OPHTHALMIC PROSTAGLANDINS - OPHTHALMIC TRAVOPROST PROTEINS AMINO ACIDS-SINGLE ACETYLCYSTEINE (NUTRIENT) PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. AGENTS FOR CHEMICAL DEPENDENCY DISULFIRAM ANTABUSE ANTI-CATAPLECTIC AGENTS XYREM (PA) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 80 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. (CONT.) ANTIDEMENTIA AGENTS DONEPEZIL HYDROCHLORIDE (PA) GALANTAMINE HYDROBROMIDE (PA) RIVASTIGMINE TARTRATE (PA) ARICEPT (PA) ARICEPT ODT (PA) EXELON (PA) NAMENDA (PA) NAMENDA TITRATION PAK (PA) RAZADYNE (PA) RAZADYNE ER (PA) COMBINATION PSYCHOTHERAPEUTICS SYMBYAX FIBROMYALGIA AGENTS SAVELLA SAVELLA TITRATION PACK MOVEMENT DISORDER DRUG THERAPY AVONEX AVONEX PEN COPAXONE KIT XENAZINE (PA) AMPYRA (PA) AUBAGIO (PA) BETASERON EXTAVIA GILENYA (PA) REBIF REBIF REBIDOSE REBIF REBIDOSE TITRATION REBIF TITRATION PACK TECFIDERA (PA) TECFIDERA STARTER PACK (PA) PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS SARAFEM PSEUDOBULBAR AFFECT (PBA) AGENTS NUEDEXTA PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. ERGOLOID MESYLATES PA - Prior Authorization QL - Quantity Limits ORAP ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 81 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. (CONT.) SMOKING DETERRENTS BUPROPION HCL (SMOKING DETERRENT) NICOTROL INHALER NICOTROL NS ZYBAN CHANTIX CHANTIX CONTINUING MONTH CHANTIX STARTING MONTH PA PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS OPSUMIT (PA) PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR PULM HYPERTEN-SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC) ADEMPAS (PA) RECTAL COMBINATIONS RECTAL ANESTHETIC/STEROIDS LIDOCAINE-HYDROCORTISONE ACETATE (RECTAL) RESPIRATORY AGENTS - MISC. CYSTIC FIBROSIS AGENTS KALYDECO (PA) PULMOZYME (PA) SALICYLATES SALICYLATE COMBINATIONS CHOLINE & MAG SALICYLATE SALICYLATES SALSALATE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 82 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) SERTRALINE HCL TABS 25MG, 100MG SMOKING DETERRENTS SMOKING DETERRENTS NICOTINE SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS INVOKANA STIMULANTS - MISC. STIMULANTS - MISC. METHYLPHENIDATE HCL CPCR SULFONAMIDES SULFONAMIDES SULFADIAZINE TETRACYCLINES TETRACYCLINES DEMECLOCYCLINE HCL DOXYCYCLINE (MONOHYDRATE) CAPS 50MG, 75MG, 150MG DOXYCYCLINE (MONOHYDRATE) SUSR DOXYCYCLINE (MONOHYDRATE) TABS 100MG, 150MG DOXYCYCLINE HYCLATE CAPS; TABS; TBEC DOXYCYCLINE (MONOHYDRATE) CAPS 100MG DOXYCYCLINE (MONOHYDRATE) TABS 50MG, 75MG MINOCYCLINE HCL TETRACYCLINE HCL PA - Prior Authorization QL - Quantity Limits ADOXA ADOXA PAK 1/100 ADOXA PAK 2/100 DORYX DOXYCYCLINE HYCLATE CPEP DYNACIN MINOCIN MONODOX PERIOSTAT VIBRAMYCIN ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 83 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 THROAT PRODUCTS - MISC. SALIVA STIMULANTS PILOCARPINE HCL (ORAL) 7.5MG THYROID AGENTS ANTITHYROID AGENTS METHIMAZOLE PROPYLTHIOURACIL TAPAZOLE THYROID HORMONES LEVOTHYROXINE SODIUM LIOTHYRONINE SODIUM THYROID THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3 ARMOUR THYROID CYTOMEL NATURE-THROID NATURE-THROID NT-2.5 SYNTHROID TIROSINT WESTHROID WESTHROID-P WP THYROID ULCER DRUGS ANTISPASMODICS ATROPINE SULFATE CLIDINIUM & CHLORDIAZEPOXIDE DICYCLOMINE HCL GLYCOPYRROLATE HYOSCYAMINE SULFATE SUBL HYOSCYAMINE SULFATE TABS HYOSCYAMINE SULFATE TB12 .375MG HYOSCYAMINE SULFATE TBDP METHSCOPOLAMINE BROMIDE PA - Prior Authorization QL - Quantity Limits ANASPAZ BELLADONNA & OPIUM BELLADONNA ALKALOIDS & OP BENTYL CANTIL CUVPOSA DIGEX NF DONNATAL DONNATAL EXTENTABS GASTRINEX NF HYOSCYAMINE SULFATE TB12 .375MG LEVBID LEVSIN PAMINE PAMINE FORTE ROBINUL ROBINUL FORTE ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 84 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 ULCER DRUGS (CONT.) H-2 ANTAGONISTS CIMETIDINE CIMETIDINE HCL FAMOTIDINE NIZATIDINE SOLN RANITIDINE HCL AXID PEPCID ZANTAC SUCRALFATE TABS CARAFATE SUCRALFATE SUSP MISC. ANTI-ULCER PROTON PUMP INHIBITORS LANSOPRAZOLE OMEPRAZOLE PANTOPRAZOLE SODIUM DEXILANT PREVACID SOLUTAB (QL) (60 EA / 30 DAYS); AGE ULCER DRUGS - PROSTAGLANDINS CYTOTEC ULCER THERAPY COMBINATIONS OMEPRAZOLE-SODIUM BICARBONATE HELIDAC PYLERA ULCER DRUGS - PROSTAGLANDINS ULCER DRUGS - PROSTAGLANDINS MISOPROSTOL URINARY ANTI-INFECTIVE COMBINATIONS URINARY ANTISEPTIC-ANTISPASMODIC /OR ANALGESICS METHENAMINE-HYOSC-METHYLENE BLUE-BENZOIC ACID-PHENYL SAL METHENAMINE-HYOSC-METHYLENE BLUE-SOD PHOS-PHENYL SAL METHENAMINE-HYOSCAMINE-METHYLENE BLUE-SODIUM PHOSPHATE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 85 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 URINARY ANTI-INFECTIVES URINARY ANTI-INFECTIVES METHENAMINE MANDELATE URINARY ANTI-INFECTIVE COMBINATIONS PROSED/DS URELLE URETRON D/S URIBEL UROGESIC-BLUE UROQID #2 URINARY ANTI-INFECTIVES METHENAMINE HIPPURATE NITROFURANTOIN NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN MONOHYD MACRO MONUROL FURADANTIN MACRODANTIN URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) VESICARE ENABLEX URINARY ANTISPASMODICS BETA-3 ADRENERGIC AGONISTS MYRBETRIQ URINARY ANTISPASMODICS BETHANECHOL CHLORIDE OXYBUTYNIN CHLORIDE TOLTERODINE TARTRATE TROSPIUM CHLORIDE URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS FLAVOXATE HCL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 86 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 VAGINAL PRODUCTS MISCELLANEOUS VAGINAL PRODUCTS FEM PH VAGINAL ANTI-INFECTIVES CLINDAMYCIN PHOSPHATE VAGINAL METRONIDAZOLE VAGINAL TERCONAZOLE VAGINAL AVC CLINDESSE GYNAZOLE-1 CLEOCIN CREA; SUPP METROGEL-VAGINAL NYSTATIN VAGINAL TERAZOL 3 TERAZOL 7 VAGINAL ESTROGENS ESTRACE CREA ESTRING FEMRING PREMARIN CREA VAGIFEM VAGINAL PROGESTINS CRINONE 4% CRINONE 8% (QL) (45 GM / 30 DAYS), (PA) ENDOMETRIN FIRST-PROGESTERONE VGS 10 FIRST-PROGESTERONE VGS 20 FIRST-PROGESTERONE VGS 25 FIRST-PROGESTERONE VGS 40 FIRST-PROGESTERONE VGS 50 VALPROIC ACID VALPROIC ACID DIVALPROEX SODIUM TB24 VASOPRESSORS ANAPHYLAXIS THERAPY AGENTS EPIPEN 2-PAK EPIPEN-JR 2-PAK PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 87 2015 Metallic Drug List TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 VASOPRESSORS (CONT.) VASOPRESSORS MIDODRINE HCL VITAMINS OIL SOLUBLE VITAMINS MEPHYTON DRISDOL WATER SOLUBLE VITAMINS POTABA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Specialty Medications) 88
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