Cardiovascular Agents - Meridian Health Plan

Transcription

H0480_17003LOCD_Accepted
Meridian Complete (Medicare-Medicaid Plan) | 2015 List of
Covered Drugs (Formulary)
This formulary was updated on August 8, 2014. For more recent information or other questions,
please contact Meridian Complete at 855-323-4578 (TTY 711) 8:00 a.m. to 8:00 p.m., Monday –
Sunday, or visit www.medicaremeridian.com.
This is a list of drugs that members can get in Meridian Complete.
 Meridian Complete is a health plan that contracts with both Medicare and Michigan Medicaid
to provide benefits of both programs to enrollees.
 Benefits, List of Covered Drugs, and pharmacy and provider networks may change from time
to time throughout the year and on January 1 of each year. Please contact the plan for more
details.
 You can always check Meridian Complete’s up-to-date List of Covered Drugs online at
www.medicaremeridian.com.
 Limitations, restrictions, and patient pay amounts may apply. This means that you may have
to pay for some services and that you need to follow certain rules to have Meridian Complete
pay for your services. For more information, call Meridian Complete Member Services or read
the Meridian Complete Member Handbook.
 You can ask for this information in other formats, such as Braille or large print. Call 855-3234578 (TTY 711). The call is free.
 You can speak with someone about getting this information in other languages. Call 855-3234578. The call is free.
 Usted puede obtener document en español, o hablar con alguien acera de esta informacion
en otros idiomas de forma gratuita. Llame 855-323-4578. Esta llamada es gratis.
‫ إن هذا االتصال‬،855-323-4578 ‫ اتصل بالرقم‬.‫يمكنك التحدّث مع أحد األشخاص للحصول على هذه المعلومات بلغات أخرى‬
.‫مجاني‬
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If you have questions, please call Meridian Complete at 855-323-4578 (TTY 711), Monday –
Sunday from 8:00 a.m. to 8:00 p.m. EST. The call is free. For more information, visit
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Frequently Asked Questions (FAQ)
Find answers here to questions you have about this List of Covered Drugs. You can read all of
the FAQ to learn more, or look for a question and answer.
1.
What prescription drugs are on the List of Covered Drugs?
(We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the List of Covered Drugs that starts on page 10 are the drugs covered by Meridian
Complete. These drugs are available at pharmacies within our network. A pharmacy is in our
network if we have an agreement with them to work with us and provide you services. We refer to
these pharmacies as “network pharmacies.”
 Meridian Complete will cover all medically necessary drugs on the Drug List if:

your doctor or other prescriber says you need them to get better or stay healthy, and

you fill the prescription at a Meridian Complete network pharmacy.
 Meridian Complete may have additional steps to access certain drugs (see question #5
below).
You can also see an up-to-date list of drugs that we cover on our website at
www.medicaremeridian.com or call Member Services at 855-323-4578 (TTY 711).
2.
Does the Drug List ever change?
Yes. Meridian Complete may add or remove drugs on the Drug List during the year. Generally,
the Drug List will only change if:

a cheaper drug comes along that works as well as a drug on the Drug List now, or

we learn that a drug is not safe.
We may also change our rules about drugs. For example, we could:
 Decide to require or not require prior approval for a drug. (Prior approval is permission from
Meridian Complete before you can get a drug.)
 Add or change the amount of a drug you can get (called “quantity limits”).
 Add or change step therapy restrictions on a drug. (Step therapy means you must try one
drug before we will cover another drug.)
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(For more information on these drug rules, see page 4.)
We will tell you when a drug you are taking is removed from the Drug List. We will also tell you
when we change our rules for covering a drug. Questions 3, 4, and 7 below have more
information on what happens when the Drug List changes.
 You can always check Meridian Complete’s up to date Drug List online at
www.medicaremeridian.com. You can also call Member Services to check the current Drug
List at 855-323-4578 (TTY 711).
3.
What happens when a cheaper drug comes along that works as
well as a drug on the Drug List now?
If you are taking a drug that is removed because a cheaper drug that works just as well comes
along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or
when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the
Drug List is made. We will inform you when a cheaper drug becomes available by sending a letter
that you will receive at least 60 days before the drug is removed from our Drug List.
4.
What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it
off the Drug List right away. We will also send you a letter telling you that. At that time, you should
immediately contact the provider who prescribed the medication to discuss your next step.
5.
Are there any restrictions or limits on drug coverage? Or are there
any required actions to take in order to get certain drugs?
Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases
you must do something before you can get the drug. For example:

Prior approval (or prior authorization): For some drugs, you or your doctor or other
prescriber must get approval from Meridian Complete before you fill your prescription. If
you don’t get approval, Meridian Complete may not cover the drug.

Quantity limits: Sometimes Meridian Complete limits the amount of a drug you can get.

Step therapy: Sometimes Meridian Complete requires you to do step therapy. This
means you will have to try drugs in a certain order for your medical condition. You might
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have to try one drug before we will cover another drug. If your prescriber thinks the first
drug doesn’t work for you, then we will cover the second.
You can find out if your drug has any additional requirements or limits by looking in the tables on
pages 10-103. You can also get more information by visiting our web site at
www.medicaremeridian.com. We have posted online a document that explains our prior
authorization and step therapy restrictions. You may also ask us to send you a copy.
You can also ask for an “exception” from these limits. Please see question 11 for more
information on exceptions.
 If you are in a nursing home or other long-term care facility and need a drug that is not on the
Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day
emergency supply of the drug you need (unless you have a prescription for fewer days),
whether or not you are a new Meridian Complete member. This will give you time to talk to
your doctor or other prescriber. He or she can help you decide if there is a similar drug on the
Drug List you can take instead or whether to request an exception. Please see question 11 for
more information about exceptions.
6.
How will you know if the drug you want has limitations or if there
are required actions to take to get the drug?
The List of Covered Drugs on page 10 has a column labeled “Necessary actions, restrictions, or
limits on use.”
7.
What happens if we change our rules on how we cover some
drugs? For example, if we add prior authorization (approval),
quantity limits, and/or step therapy restrictions on a drug.
We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug.
We will tell you at least 60 days before the restriction is added or when you next ask for a refill.
Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This
gives you time to talk to your doctor or other prescriber about what to do next.
8.
How can you find a drug on the Drug List?
There are two ways to find a drug:

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You can search alphabetically (if you know how to spell the drug), or
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
You can search by medical condition.
To search alphabetically, go to the Alphabetical Listing section. You can find it starting on page
104. This section provides an alphabetical list of all drugs included in this document, including
both brand name drugs and generic drugs. Next to your drug, you will see the page number
where you can find coverage information. Turn to the page listed and find the name of your drug
in the first column of the list.
To search by medical condition, find the section labeled “List of drugs by medical condition” on
page 10. Then find your medical condition. For example, if you have a heart condition, you should
look in that category. That is where you will find drugs that treat heart conditions.
9.
What if the drug you want to take is not on the Drug List?
If you don’t see your drug on the Drug List, call Member Services at 855-323-4578 (TTY 711) and
ask about it. If you learn that Meridian Complete will not cover the drug, you can do one of these
things:

Ask Member Services for a list of drugs like the one you want to take. Then show the list
to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is
like the one you want to take. Or

You can ask the health plan to make an exception to cover your drug. Please see question
11 for more information about exceptions.
10. What if you are a new Meridian Complete member and can’t find
your drug on the Drug List or have a problem getting your drug?
We can help. We may cover a temporary 31-day supply of your drug during the first 90 days you
are a member of Meridian Complete. This will give you time to talk to your doctor or other
prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take
instead or whether to request an exception.
We will cover a 31-day supply of your drug if:
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
you are taking a drug that is not on our Drug List, or

health plan rules do not let you get the amount ordered by your prescriber, or

the drug requires prior approval by Meridian Complete, or

you are taking a drug that is part of a step therapy restriction.
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If you live in a nursing home or other long-term care facility, you may refill your prescription
for as long as 98 days. You may refill the drug multiple times during the 98 days. This gives your
prescriber time to change your drugs to ones on the Drug List or ask for an exception.
If you transition from one care setting to another (for example, from a long-term care facility back
into the community) and no longer have access to the medications you were taking, you will be
able to refill your prescriptions upon transition to the new care setting.
11. Can you ask for an exception to cover your drug?
Yes. You can ask Meridian Complete to make an exception to cover a drug that is not on the Drug
List.
You can also ask us to change the rules on your drug.

For example, Meridian Complete may limit the amount of a drug we will cover. If your drug
has a limit, you can ask us to change the limit and cover more.

Other examples: You can ask us to drop step therapy restrictions or prior approval
requirements.
12. How long does it take to get an exception?
First, we must receive a statement from your prescriber supporting your request for an exception.
After we receive the statement, we will give you a decision on your exception request within 72
hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a
decision, you can ask for an expedited exception. This is a faster decision. If your prescriber
supports your request, we will give you a decision within 24 hours of receiving your prescriber’s
supporting statement.
13. How can you ask for an exception?
To ask for an exception, call Member Services. A Member Services representative will work with
you and your provider to help you ask for an exception.
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14. What are generic drugs?
Generic drugs are made up of the same active ingredients as brand name drugs. They usually
cost less than the brand name drug and usually don’t have well-known names. Generic drugs are
approved by the Food and Drug Administration (FDA).
Meridian Complete covers both brand name drugs and generic drugs.
15. What are OTC drugs?
OTC stands for “over-the-counter”. Meridian Complete covers some OTC drugs when they are
written as prescriptions by your provider.
16. Does Meridian Complete cover OTC non-drug products?
Meridian Complete covers some OTC non-drug products when they are written as prescriptions
by your provider.
You can read the Meridian Complete Drug List to see what OTC non-drug products are covered.
17. What is your copay?
Meridian Complete members have no copays for prescription and OTC drugs.
18. What are drug tiers?
Tier 1: Generic Drugs
Tier 2: Brand Name Drugs
Tier 3: OTC Drugs
Remember, all drug tiers have no copay.
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List of Covered Drugs
The list of covered drugs that begins below gives you information about the drugs covered by
Meridian Complete. If you have trouble finding your drug in the list, turn to the Index that begins
on page 104.
The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g.,
CELEBREX) and generic drugs are listed in lower-case italics (e.g., diflunisal).
The information in the necessary actions, restrictions, or limits on use column tells you if Meridian
Complete has any rules for covering your drug.
Note: The * next to a drug means the drug is not a “Part D drug.” These drugs may have different
rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to
change it if you think we made a mistake. For example, we might decide that a drug that you want
is not covered or is no longer covered by Medicare or Medicaid. If you or your prescriber
disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call
Member Services at 855-323-4578 (TTY 711). You can also read the Member Handbook to learn
how to appeal a decision.
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Meridian Complete
Legend
Tier
Description
1
Generics ($0.00)
2
Brands ($0.00)
3
Medicaid Covered Drugs
($0.00)
Symbol
Description
QL
Quantity limit, dispense limit for 30 days, unless otherwise noted
PA
You (or your physician) are required to get prior authorization before you fill your
prescription for this drug. Without prior approval, we may not cover this drug.
ST
Step therapy exception required
AL
This prescription drug may only be covered if you meet the minimum or maximum age limit.
LA
Limited access, This prescription may be available only at certain pharmacies
CB
There is a limit on the amount of this drug that is covered.
MDD
There is a limit on the amount of this drug that is covered per day.
MFL
There is a limit on the number of times this drug can be refilled.
MDS
There is a limit on the amount of this drug that is covered.
CD
There is a limit on how long this drug is covered.
BD
Covered under Medicare Part B or D
*
Non-Part D drugs or OTC items that are covered by Medicaid
(g)
Only the generic version of this drug is covered. The brand name version is not covered.
M
The brand name version of this drug is in Tier 2. The generic version is in Tier 1
If you have questions, please call Meridian Complete at 855-323-4578 (TTY 711) , Monday Sunday from 8:00 AM to 8:00 PM EST. The call is free. For more information, visit
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Analgesics
Name of drug
What the drug will cost you
(tier level)
Necessary actions,
restrictions, or limits on use
Nonsteroidal Anti-inflammatory Drugs
CELEBREX (100 MG CAPSULE, 200 MG
CAPSULE, 400 MG CAPSULE, 50 MG
CAPSULE)
$0.00 (Tier 2)
ST
diclofenac potassium 50 mg tablet
$0.00 (Tier 1)
(g)
diclofenac sodium (100 mg tab er 24h,
25 mg tablet dr, 50 mg tablet dr, 75 mg
tablet dr)
$0.00 (Tier 1)
(g)
diflunisal 500 mg tablet
$0.00 (Tier 1)
(g)
etodolac (200 mg capsule, 400 mg tab
er 24h, 400 mg tablet, 500 mg tab er
24h, 500 mg tablet, 600 mg tab er 24h)
$0.00 (Tier 1)
(g)
fenoprofen calcium 600 mg tablet
$0.00 (Tier 1)
(g)
flurbiprofen (100 mg tablet, 50 mg
tablet)
$0.00 (Tier 1)
(g)
ibuprofen (400 mg tablet, 600 mg
tablet, 800 mg tablet)
$0.00 (Tier 1)
(g)
INDOCIN 25 MG/5 ML SUSPENSION
$0.00 (Tier 2)
indomethacin (25 mg capsule, 50 mg
capsule, 75 mg capsule er)
$0.00 (Tier 1)
(g)
ketoprofen (200 mg cap24h pel, 50 mg
capsule, 75 mg capsule)
$0.00 (Tier 1)
(g)
ketorolac tromethamine 10 mg tablet
$0.00 (Tier 1)
(g)
meloxicam (15 mg tablet, 7.5 mg
tablet)
$0.00 (Tier 1)
(g)
nabumetone (500 mg tablet, 750 mg
tablet)
$0.00 (Tier 1)
(g)
oxaprozin 600 mg tablet
$0.00 (Tier 1)
(g)
piroxicam (10 mg capsule, 20 mg
capsule)
$0.00 (Tier 1)
(g)
PONSTEL 250 MG KAPSEALS
$0.00 (Tier 2)
SPRIX 15.75 MG NASAL SPRAY
$0.00 (Tier 2)
sulindac (150 mg tablet, 200 mg tablet)
$0.00 (Tier 1)
(g)
You can find information on what the symbols and abbreviations in this table mean by going
to the Legend on page 9.
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Analgesics
Name of drug
(tier level)
Necessary actions,
Opioid Analgesics, Long-acting
AVINZA 90 MG CAPSULE
$0.00 (Tier 2)
DILAUDID 1 MG/ML AMPUL
$0.00 (Tier 2)
DURAMORPH (0.5 MG/ML AMPUL, 1
MG/ML AMPUL, 10 MG/10 ML AMPUL,
5 MG/10 ML AMPUL)
$0.00 (Tier 2)
fentanyl (100 mcg/hr patch td72, 12
mcg/hr patch td72, 25mcg/hr patch
td72, 50mcg/hr patch td72, 75mcg/hr
patch td72)
$0.00 (Tier 1)
(g)
hydromorphone hcl/pf (10 mg/ml
ampul, 10 mg/ml vial)
$0.00 (Tier 1)
(g)
levorphanol tartrate 2 mg tablet
$0.00 (Tier 1)
(g)
methadone hcl (10 mg tablet, 5 mg
tablet)
$0.00 (Tier 1)
QL (180 PER 30 DAYS), (g)
methadone hcl (10 mg/5 ml solution, 10
mg/ml syringe, 10 mg/ml vial, 5 mg/5
ml solution)
$0.00 (Tier 1)
(g)
morphine sulfate (100 mg cap er pel,
100 mg tablet er, 15 mg tablet, 15 mg
tablet er, 20 mg cap er pel, 200 mg
tablet er, 30 mg cap er pel, 30 mg
tablet er, 50 mg cap er pel, 60 mg cap
er pel, 60 mg tablet er, 80 mg cap er
pel)
$0.00 (Tier 1)
morphine sulfate (2 mg/ml cartridge, 2
mg/ml syringe, 4 mg/ml cartridge, 4
mg/ml syringe)
$0.00 (Tier 1)
(g)
morphine sulfate 30 mg tablet
$0.00 (Tier 1)
oxycodone hcl (10 mg tablet, 20 mg
tablet)
$0.00 (Tier 1)
oxycodone hcl (15 mg tablet, 20 mg/ml
oral conc, 30 mg tablet, 5 mg capsule, 5
mg tablet)
$0.00 (Tier 1)
(g)
tramadol hcl 50 mg tablet
$0.00 (Tier 1)
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Analgesics
(tier level)
Necessary actions,
acetaminophen with codeine phosphate
(120-12mg/5 solution, 240-24/10
solution, 300mg/12.5 solution, 36036/15 solution)
$0.00 (Tier 1)
QL (5000 ML PER 30 DAYS),
(g)
(300mg-15mg tablet, 300mg-30mg
tablet, 300mg-60mg tablet)
$0.00 (Tier 1)
butalbit/acetamin/caff/codeine 50-32530 capsule
$0.00 (Tier 1)
butorphanol tartrate (1 mg/ml disp
syrin, 1 mg/ml vial, 10 mg/ml spray, 2
mg/ml vial)
$0.00 (Tier 1)
(g)
codeine sulfate (15 mg tablet, 30 mg
$0.00 (Tier 1)
(g)
DILAUDID 1 MG/ML LIQUID
$0.00 (Tier 2)
fentanyl citrate (1200 mcg lozenge hd,
1600 mcg lozenge hd, 200 mcg lozenge
hd, 400 mcg lozenge hd, 600 mcg
lozenge hd, 800 mcg lozenge hd)
$0.00 (Tier 1)
PA, (g)
hydrocodone bitartrate/acetaminophen
(10mg-325mg tablet, 5 mg-325mg
tablet, 5mg-300mg tablet, 7.5-300mg
tablet, 7.5-325mg tablet)
$0.00 (Tier 1)
(2.5-108/5 solution, 5-217mg/10
solution, 7.5-325/15 solution)
$0.00 (Tier 1)
(g)
hydrocodone/ibuprofen 7.5-200 mg
tablet
$0.00 (Tier 1)
(g)
hydromorphone hcl (2 mg tablet, 4 mg
$0.00 (Tier 1)
ibuprofen/oxycodone hcl 400mg-5mg
tablet
$0.00 (Tier 1)
(g)
meperidine hcl 50 mg tablet
$0.00 (Tier 1)
meperidine hcl 50 mg/5 ml solution
$0.00 (Tier 1)
(g)
meperidine hcl/pf (100 mg/ml vial, 25
mg/ml vial, 50 mg/ml vial)
$0.00 (Tier 1)
(g)
Name of drug
Opioid Analgesics, Short-acting
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Analgesics
Name of drug
(tier level)
Necessary actions,
MEPERITAB 100 MG TABLET
$0.00 (Tier 1)
morphine sulfate (10 mg/5 ml solution,
100 mg/5ml solution, 10mg/0.5ml
syringe, 20 mg/5 ml solution)
$0.00 (Tier 1)
(g)
nalbuphine hcl (10 mg/ml ampul, 10
mg/ml vial, 20 mg/ml ampul, 20 mg/ml
vial)
$0.00 (Tier 1)
BD, (g)
NUCYNTA (100 MG TABLET, 50 MG
TABLET, 75 MG TABLET)
$0.00 (Tier 2)
NUCYNTA ER (ER 100 MG TABLET, ER
150 MG TABLET, ER 200 MG TABLET, ER
250 MG TABLET, ER 50 MG TABLET)
$0.00 (Tier 2)
oxycodone hcl/acetaminophen (10mg325mg tablet, 2.5-325mg tablet, 5 mg325mg tablet, 7.5-325mg tablet)
$0.00 (Tier 1)
oxycodone hcl/aspirin 4.8355-325
tablet
$0.00 (Tier 1)
(g)
pentazocine hcl/naloxone hcl 50mg0.5mg tablet
$0.00 (Tier 1)
(g)
tramadol hcl/acetaminophen 37.5325mg tablet
$0.00 (Tier 1)
(tier level)
Necessary actions,
lidocaine 5 % oint. (g)
$0.00 (Tier 1)
(g)
lidocaine hcl (2 % jel (ml), 2 % solution,
4 % solution, 40 mg/ml solution)
$0.00 (Tier 1)
(g)
lidocaine/prilocaine (2.5 %-2.5% cream
(g), 2.5 %-2.5% kit)
$0.00 (Tier 1)
(g)
Anesthetics
Name of drug
Local Anesthetics
Anti-Addiction/ Substance Abuse Treatment Agents
Name of drug
(tier level)
Necessary actions,
Alcohol Deterrents/Anti-craving
13
acamprosate calcium 333 mg tablet dr
$0.00 (Tier 2)
(g)
Anti-Addiction/ Substance Abuse Treatment Agents
Name of drug
(tier level)
Necessary actions,
disulfiram (250 mg tablet, 500 mg
tablet)
$0.00 (Tier 1)
(g)
VIVITROL (380 MG VIAL, 380 MG VIAL +
DILUENT)
$0.00 (Tier 2)
Opioid Dependence Treatments
buprenorphine hcl (2 mg tab subl, 8 mg
tab subl)
$0.00 (Tier 1)
(g)
naltrexone hcl 50 mg tablet
$0.00 (Tier 1)
(g)
SUBOXONE (2 MG-0.5 MG SL FILM, 8
MG-2 MG SL FILM)
$0.00 (Tier 2)
Opioid Reversal Agents
naloxone hcl 1 mg/ml syringe
$0.00 (Tier 1)
(g)
Smoking Cessation Agents
BUPROBAN 150 MG TABLET
$0.00 (Tier 2)
CHANTIX (0.5 MG TABLET, 1 MG
TABLET)
$0.00 (Tier 2)
ST, QL (180 PER 90 DAYS)
desipramine hcl 50 mg tablet
$0.00 (Tier 1)
(g)
doxepin hcl 10 mg capsule
$0.00 (Tier 1)
(g)
NICOTROL NS 10 MG/ML SPRAY
$0.00 (Tier 2)
ST, QL (30 ML PER 30 DAYS)
(tier level)
Necessary actions,
Anti-inflammatory Agents
Name of drug
Nonsteroidal anti-inflammatory drugs
meclofenamate sodium (100 mg
$0.00 (Tier 1)
(g)
naproxen (250 mg tablet, 375 mg
tablet, 375 mg tablet dr, 500 mg tablet,
500 mg tablet dr)
$0.00 (Tier 1)
(g)
naproxen sodium (275 mg tablet, 550
mg tablet)
$0.00 (Tier 1)
(g)
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Anti-inflammatory Agents
Name of drug
(tier level)
Necessary actions,
tolmetin sodium (400 mg capsule, 600
mg tablet)
$0.00 (Tier 1)
(g)
(tier level)
Necessary actions,
amikacin sulfate (1000mg/4ml vial, 500
mg/2ml vial)
$0.00 (Tier 1)
BD, (g)
GENTAK (0.3 % EYE OINTMENT, 3
MG/GM EYE OINTMENT)
$0.00 (Tier 2)
gentamicin sulfate (0.1 % cream (g), 0.1
% oint. (g), 0.3 % drops, 40 mg/ml vial)
$0.00 (Tier 1)
(g)
gentamicin sulfate in sodium chloride,
iso-osmotic (gentamic100mg/0.1l
piggyback, gentamic120mg/0.1l
piggyback, gentamic60 mg/50ml
piggyback, gentamic80mg/100ml
piggyback, gentamic90mg/100ml
piggyback)
$0.00 (Tier 1)
(g)
gentamicin sulfate/pf (100mg/10ml vial
port, 20 mg/2 ml vial, 60 mg/6 ml vial
port, 80 mg/8 ml vial port)
$0.00 (Tier 1)
(g)
neomycin sulfate 500 mg tablet
$0.00 (Tier 1)
(g)
neomycin sulfate/polymyxin b sulfate
(ampul, vial)
$0.00 (Tier 1)
(g)
paromomycin sulfate 250 mg capsule
$0.00 (Tier 1)
(g)
PRED-G 1% EYE DROPS
$0.00 (Tier 2)
streptomycin sulfate 1 g vial
$0.00 (Tier 1)
(g)
tobramycin 0.3 % drops
$0.00 (Tier 1)
(g)
tobramycin sulfate (1.2 g vial, 10 mg/ml
vial, 40 mg/ml vial)
$0.00 (Tier 1)
(g)
tobramycin/sodium chloride
80mg/100ml piggyback
$0.00 (Tier 1)
(g)
Antibacterials
Name of drug
Aminoglycosides
15
Antibacterials
Name of drug
(tier level)
Necessary actions,
Antibacterials, Other
ALTABAX 1% OINTMENT
$0.00 (Tier 2)
bacitracin 500 unit/g oint. (g)
$0.00 (Tier 1)
BACTROBAN 2% CREAM
$0.00 (Tier 2)
BACTROBAN NASAL 2% OINTMENT
$0.00 (Tier 2)
chloramphenicol sod succ 1 g vial
$0.00 (Tier 1)
CLEOCIN HCL 75 MG CAPSULE
$0.00 (Tier 2)
clindamycin hcl (150 mg capsule, 300
mg capsule)
$0.00 (Tier 1)
(g)
clindamycin phosphate (150 mg/ml vial,
2 % cream/appl, 300 mg/2ml vial port,
600 mg/4ml vial port, 900mg/6ml vial
port)
$0.00 (Tier 1)
(g)
colistin (colistimethate na) 150 mg vial
$0.00 (Tier 1)
(g)
CUBICIN 500 MG VIAL
$0.00 (Tier 2)
PA
MACRODANTIN 25 MG CAPSULE
$0.00 (Tier 2)
methenamine hippurate 1 g tablet
$0.00 (Tier 1)
(g)
metronidazole (0.75 % cream (g), 0.75
% gel (gram), 0.75 % gel w/appl, 0.75 %
lotion, 250 mg tablet, 500 mg tablet)
$0.00 (Tier 1)
(g)
metronidazole/sodium chloride
500mg/0.1l piggyback
$0.00 (Tier 1)
(g)
mupirocin 2 % oint. (g)
$0.00 (Tier 1)
(g)
neomy sulf/bacitra/polymyxin b 3.5mg400 oint. (g)
$0.00 (Tier 1)
(g)
neomycin/polymyxin b sulf/hc 3.5-10k10 drops susp
$0.00 (Tier 1)
(g)
nitrofurantoin 25 mg/5 ml oral susp
$0.00 (Tier 1)
(g)
nitrofurantoin macrocrystal 50 mg
capsule
$0.00 (Tier 1)
(g)
nitrofurantoin monohyd/m-cryst 100
mg capsule
$0.00 (Tier 1)
(g)
polymyxin b sulf/trimethoprim 100001/ml drops
$0.00 (Tier 1)
(g)
(g)
(g)
16
Antibacterials
Name of drug
(tier level)
Necessary actions,
SYNERCID 500 MG VIAL
$0.00 (Tier 2)
tinidazole (250 mg tablet, 500 mg
tablet)
$0.00 (Tier 1)
(g)
trimethoprim 100 mg tablet
$0.00 (Tier 1)
(g)
TYGACIL 50 MG VIAL
$0.00 (Tier 2)
vancomycin hcl (1 g vial, 1 g vial port,
10 g vial, 125 mg capsule, 250 mg
capsule, 5 g vial, 500 mg vial, 500 mg
vial port, 750 mg vial)
$0.00 (Tier 1)
(g)
XIFAXAN (200 MG TABLET, 550 MG
TABLET)
$0.00 (Tier 2)
PA
ZYVOX (100 MG/5 ML SUSPENSION,
200 MG/100 ML IV SOLN, 600 MG
TABLET, 600 MG/300 ML IV SOLN)
$0.00 (Tier 2)
PA
cefaclor (250 mg capsule, 500 mg
capsule, 500 mg tab er 12h)
$0.00 (Tier 1)
(g)
cefadroxil (1 g tablet, 250 mg/5ml susp
recon, 500 mg capsule, 500 mg/5ml
susp recon)
$0.00 (Tier 1)
(g)
cefazolin sodium (1 g vial, 10 g vial,
100g bulkbaginj, 20 g vial, 300g
bulkbaginj, 500 mg vial)
$0.00 (Tier 1)
(g)
cefazolin sodium/dextrose, iso-osmotic
(1 g/50 ml froz.piggy, 1 g/50 ml
piggyback)
$0.00 (Tier 1)
(g)
cefdinir (125 mg/5ml susp recon, 250
mg/5ml susp recon, 300 mg capsule)
$0.00 (Tier 1)
(g)
cefepime hcl (1 g vial, 2 g vial)
$0.00 (Tier 1)
(g)
cefotaxime sodium 10 g vial
$0.00 (Tier 1)
(g)
cefotetan disodium (1 g vial, 10 g vial, 2
g vial)
$0.00 (Tier 1)
(g)
cefoxitin sodium (1 g vial, 10 g vial, 2 g
vial)
$0.00 (Tier 1)
(g)
cefoxitin sodium/dextrose, iso-osmotic
(1 g/50 ml piggyback, 2 g/50 ml
piggyback)
$0.00 (Tier 1)
(g)
Beta-lactam, Cephalosporins
17
Antibacterials
Name of drug
(tier level)
Necessary actions,
cefpodoxime proxetil (100 mg tablet,
100 mg/5ml susp recon, 200 mg tablet,
50 mg/5 ml susp recon)
$0.00 (Tier 1)
(g)
cefprozil (125 mg/5ml susp recon, 250
mg tablet, 250 mg/5ml susp recon, 500
mg tablet)
$0.00 (Tier 1)
(g)
ceftazidime pentahydrate (1 g vial, 2 g
vial, 6g vial)
$0.00 (Tier 1)
(g)
ceftazidime pentahydrate in dextrose
5%-water (1 g/50 ml piggyback, 2 g/50
ml piggyback)
$0.00 (Tier 1)
(g)
ceftriaxone sodium (1 g vial, 1 g vial
port, 10 g vial, 100g bulkbaginj, 2 g vial,
2 g vial port, 250 mg vial, 500 mg vial)
$0.00 (Tier 1)
(g)
cefuroxime axetil (250 mg tablet, 500
mg tablet)
$0.00 (Tier 1)
(g)
cefuroxime sodium (1.5 g vial, 7.5g vial,
750 mg vial)
$0.00 (Tier 1)
(g)
cephalexin (125 mg/5ml susp recon,
250 mg capsule, 250 mg tablet, 250
mg/5ml susp recon, 500 mg capsule,
500 mg tablet)
$0.00 (Tier 1)
(g)
SUPRAX (100 MG TABLET CHEWABLE,
100 MG/5 ML SUSPENSION, 200 MG
TABLET CHEWABLE, 200 MG/5 ML
SUSPENSION, 400 MG CAPSULE, 400
MG TABLET, 500 MG/5 ML
SUSPENSION)
$0.00 (Tier 2)
TEFLARO (400 MG VIAL, 600 MG VIAL)
$0.00 (Tier 2)
Beta-lactam, Other
AZACTAM-ISO-OSMOTIC DEXTROSE (1
GM/50 ML, 2 GM/50 ML)
$0.00 (Tier 2)
aztreonam (1 g vial, 2 g vial)
$0.00 (Tier 2)
CAYSTON 75 MG INHAL SOLUTION
$0.00 (Tier 2)
DORIBAX 500 MG VIAL
$0.00 (Tier 2)
PA
imipenem/cilastatin sodium (250 mg
vial, 500 mg vial)
$0.00 (Tier 1)
PA, (g)
(g)
18
Antibacterials
Name of drug
(tier level)
Necessary actions,
INVANZ 1 GM VIAL
$0.00 (Tier 2)
meropenem (1 g vial, 500 mg vial)
$0.00 (Tier 1)
(g)
amoxicillin (125 mg tab chew, 125
mg/5ml susp recon, 200 mg/5ml susp
recon, 250 mg capsule, 250 mg tab
chew, 250 mg/5ml susp recon, 400
mg/5ml susp recon, 500 mg capsule,
500 mg tablet, 875 mg tablet, 875mg
tablet)
$0.00 (Tier 1)
(g)
amoxicillin/potassium clavulanate
(1000-62.5 tab er 12h, 200-28.5/5 susp
recon, 200-28.5mg tab chew, 250-125
mg tablet, 250-62.5/5 susp recon, 40057mg tab chew, 400-57mg/5 susp
recon, 500-125 mg tablet, 600-42.9/5
susp recon, 875-125 mg tablet)
$0.00 (Tier 1)
(g)
ampicillin sodium (1 g vial, 1 g vial port,
10 g vial, 125 mg vial, 2 g vial, 250 mg
vial, 500 mg vial)
$0.00 (Tier 1)
(g)
ampicillin sodium/sulbactam sodium
(1.5 g vial, 15 g vial, 3 g vial)
$0.00 (Tier 1)
(g)
ampicillin trihydrate (125 mg/5ml susp
recon, 250 mg capsule, 250 mg/5ml
susp recon, 500 mg capsule)
$0.00 (Tier 1)
(g)
BICILLIN C-R (1.2 MILLION UNIT, 900300 SYRINGE)
$0.00 (Tier 2)
BICILLIN L-A (1,200,000 UNITS,
2,400,000 UNITS, 600,000 UNIT/ML)
$0.00 (Tier 2)
dicloxacillin sodium (250 mg capsule,
500 mg capsule)
$0.00 (Tier 1)
(g)
nafcillin in dextrose, iso-osmotic (1 g/50
ml froz.piggy, 2 g/100 ml froz.piggy)
$0.00 (Tier 1)
(g)
nafcillin sodium (1 g vial, 10 g vial, 2 g
vial)
$0.00 (Tier 1)
(g)
oxacillin sodium (1 g vial, 10 g vial, 2 g
vial, 2 g vial port)
$0.00 (Tier 1)
(g)
oxacillin sodium/dextrose, iso-osmotic
(1 g/50 ml froz.piggy, 2 g/50 ml
froz.piggy)
$0.00 (Tier 1)
(g)
Beta-lactam, Penicillins
19
Antibacterials
Name of drug
(tier level)
Necessary actions,
penicillin g potassium (20mm unit vial,
5mm unit vial)
$0.00 (Tier 1)
(g)
penicillin g potassium/dextrose-water
(2mm/50ml froz.piy, 3mm/50ml
froz.piy)
$0.00 (Tier 1)
(g)
penicillin g procaine 1.2mm/2 ml
syringe
$0.00 (Tier 1)
(g)
penicillin g sodium 5mm unit vial
$0.00 (Tier 1)
(g)
penicillin v potassium (125 mg/5ml soln
recon, 250 mg tablet, 250 mg/5ml soln
recon, 500 mg tablet)
$0.00 (Tier 1)
(g)
piperacillin sodium/tazobactam sodium
(2.25 g vial, 3.375 g vial, 3.375 g vial
port, 4.5 g vial, 4.5 g vial port, 40.5 g
vial)
$0.00 (Tier 1)
PA, (g)
ZOSYN (2.25 GM/50 ML GALAXY BAG,
3.375 GM/50 ML GALAXY, 4.5 GM/100
ML GALAXY BAG)
$0.00 (Tier 2)
PA
azithromycin (100 mg/5ml susp recon,
200 mg/5ml susp recon, 250 mg tablet,
500 mg tablet, 500 mg vial, 500 mg vial
port, 600 mg tablet)
$0.00 (Tier 1)
(g)
clarithromycin (125 mg/5ml susp recon,
250 mg tablet, 250 mg/5ml susp recon,
500 mg tab er 24h, 500 mg tablet)
$0.00 (Tier 1)
(g)
DIFICID 200 MG TABLET
$0.00 (Tier 2)
PA
E.E.S. 200 MG/5 ML GRANULES
$0.00 (Tier 2)
ERYPED 200 MG/5 ML SUSPENSION
$0.00 (Tier 2)
ERYPED 400 MG/5 ML SUSPENSION
$0.00 (Tier 2)
ERYTHROCIN 250 MG FILMTAB
$0.00 (Tier 2)
ERYTHROCIN LACTOBIONATE (500 MG
ADDVNT VL, 500 MG VIAL)
$0.00 (Tier 2)
erythromycin base (250 mg tablet, 5
mg/g oint. (g), 500 mg tablet)
$0.00 (Tier 1)
(g)
erythromycin ethylsuccinate 400 mg
tablet
$0.00 (Tier 1)
(g)
Macrolides
20
Antibacterials
Name of drug
(tier level)
Necessary actions,
KETEK (300 MG TABLET, 400 MG
TABLET)
$0.00 (Tier 2)
PA
Quinolones
AVELOX 400 MG TABLET
$0.00 (Tier 2)
AVELOX IV 400 MG/250 ML
$0.00 (Tier 2)
CILOXAN 0.3% OINTMENT
$0.00 (Tier 2)
CIPRO (10% SUSPENSION, 5%
SUSPENSION)
$0.00 (Tier 2)
CIPRO HC OTIC SUSPENSION
$0.00 (Tier 2)
CIPRO I.V. (200 MG/100 ML D5W, 400
MG/200 ML D5W)
$0.00 (Tier 2)
CIPRODEX OTIC SUSPENSION
$0.00 (Tier 2)
ciprofloxacin hcl (0.3 % drops, 100 mg
tablet, 250 mg tablet, 500 mg tablet,
750 mg tablet)
$0.00 (Tier 1)
(g)
ciprofloxacin lactate (200mg/20ml vial,
400mg/40ml vial)
$0.00 (Tier 1)
(g)
ciprofloxacin/ciprofloxacin hcl (1000 mg
tbmp 24hr, 500 mg tbmp 24hr)
$0.00 (Tier 1)
(g)
levofloxacin (25 mg/ml vial, 250 mg
tablet, 250mg/10ml solution, 500 mg
tablet, 500mg/20ml solution, 750 mg
tablet)
$0.00 (Tier 1)
(g)
levofloxacin/dextrose 5 % in water
(250mg/50ml piggyback, 500mg/0.1l
piggyback, 750mg/.15l piggyback)
$0.00 (Tier 1)
(g)
MOXEZA 0.5% EYE DROPS
$0.00 (Tier 2)
ofloxacin (0.3 % drops, 200 mg tablet,
300 mg tablet, 400 mg tablet)
$0.00 (Tier 1)
VIGAMOX 0.5% EYE DROPS
$0.00 (Tier 2)
ZYMAXID 0.5% EYE DROPS
$0.00 (Tier 2)
(g)
Sulfonamides
sulfacetamide sodium (10 % drops, 10
% oint. (g), 10 % suspension)
$0.00 (Tier 1)
(g)
21
Antibacterials
Name of drug
(tier level)
Necessary actions,
sulfadiazine 500 mg tablet
$0.00 (Tier 1)
(g)
sulfamethoxazole/trimethoprim (20040mg/5 oral susp, 400mg-80mg tablet,
80-16mg/ml vial, 800-160 mg tablet,
800-160/20 oral susp)
$0.00 (Tier 1)
(g)
doxycycline hyclate (100 mg capsule,
100 mg tablet, 100 mg tablet dr, 150
mg tablet dr, 20 mg tablet, 50 mg
capsule, 75 mg tablet dr)
$0.00 (Tier 1)
(g)
doxycycline monohydrate (150 mg
tablet, 50 mg tablet, 75 mg capsule, 75
mg tablet)
$0.00 (Tier 1)
(g)
minocycline hcl (100 mg capsule, 100
mg tablet, 135 mg tab er 24h, 45 mg
tab er 24h, 50 mg capsule, 50 mg
tablet, 75 mg capsule, 75 mg tablet, 90
mg tab er 24h)
$0.00 (Tier 1)
(g)
(tier level)
Necessary actions,
levetiracetam (100 mg/ml solution,
1000 mg tablet, 250 mg tablet, 500 mg
tab er 24h, 500 mg tablet, 500 mg/5ml
solution, 500 mg/5ml vial, 750 mg tab
er 24h, 750 mg tablet)
$0.00 (Tier 1)
(g)
POTIGA (200 MG TABLET, 300 MG
TABLET, 400 MG TABLET, 50 MG
TABLET)
$0.00 (Tier 2)
Tetracyclines
Anticonvulsants
Name of drug
Anticonvulsants, Other
Calcium Channel Modifying Agents
CELONTIN 300 MG KAPSEAL
$0.00 (Tier 2)
ethosuximide (250 mg capsule, 250
mg/5ml solution)
$0.00 (Tier 1)
(g)
22
Anticonvulsants
Name of drug
(tier level)
LYRICA (100 MG CAPSULE, 150 MG
CAPSULE, 20 MG/ML ORAL SOLUTION,
200 MG CAPSULE, 225 MG CAPSULE, 25
MG CAPSULE, 300 MG CAPSULE, 50 MG
CAPSULE, 75 MG CAPSULE)
$0.00 (Tier 2)
zonisamide (100 mg capsule, 25 mg
$0.00 (Tier 1)
Necessary actions,
(g)
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam (0.125 mg tab rapdis, 0.25
mg tab rapdis, 0.5 mg tab rapdis, 0.5
mg tablet, 1 mg tab rapdis, 1 mg tablet,
2 mg tab rapdis, 2 mg tablet)
$0.00 (Tier 1)
(g)
clorazepate dipotassium (15 mg tablet,
3.75 mg tablet, 7.5 mg tablet)
$0.00 (Tier 1)
(g)
diazepam (12.5-15-20 kit, 2.5 mg kit, 57.5-10mg kit)
$0.00 (Tier 1)
PA, (g)
divalproex sodium (125 mg cap sprink,
125 mg tablet dr, 250 mg tab er 24h,
250 mg tablet dr, 500 mg tab er 24h,
500 mg tablet dr)
$0.00 (Tier 1)
(g)
gabapentin (100 mg capsule, 250
mg/5ml solution, 300 mg capsule, 300
mg/6ml solution, 400 mg capsule, 600
mg tablet, 800 mg tablet)
$0.00 (Tier 1)
(g)
GABITRIL (12 MG TABLET, 16 MG
TABLET)
$0.00 (Tier 2)
ONFI (10 MG TABLET, 2.5 MG/ML
SUSPENSION, 20 MG TABLET)
$0.00 (Tier 2)
phenobarbital (100 mg tablet, 15 mg
tablet, 16.2 mg tablet, 20 mg/5 ml
elixir, 30 mg tablet, 32.4 mg tablet, 60
mg tablet, 64.8 mg tablet, 97.2mg
tablet)
$0.00 (Tier 1)
(g)
primidone (250 mg tablet, 50 mg
tablet)
$0.00 (Tier 1)
(g)
SABRIL (500 MG POWDER PACKET, 500
MG TABLET)
$0.00 (Tier 2)
PA
tiagabine hcl (2 mg tablet, 4 mg tablet)
$0.00 (Tier 1)
(g)
23
Anticonvulsants
Name of drug
(tier level)
Necessary actions,
valproic acid (as sodium salt) (valproate
sodium) (250 mg/5ml solution, 250
mg/5ml syringe, 500 mg/5ml vial,
500mg/10ml solution)
$0.00 (Tier 1)
(g)
felbamate (400 mg tablet, 600 mg
tablet, 600 mg/5ml oral susp)
$0.00 (Tier 1)
(g)
FYCOMPA (10 MG TABLET, 12 MG
TABLET, 2 MG TABLET, 4 MG TABLET, 6
MG TABLET, 8 MG TABLET)
$0.00 (Tier 2)
LAMICTAL ODT (ODT 100 MG TABLET,
ODT 200 MG TABLET, ODT 25 MG
TABLET, ODT 50 MG TABLET)
$0.00 (Tier 2)
LAMICTAL TAB START KIT (BLUE)
$0.00 (Tier 2)
LAMICTAL TAB START KIT (GREEN)
$0.00 (Tier 2)
LAMICTAL TB START KIT (ORANGE)
$0.00 (Tier 2)
LAMICTAL XR START KIT (BLUE)
$0.00 (Tier 2)
LAMICTAL XR START KIT (GREEN)
$0.00 (Tier 2)
LAMICTAL XR START KIT (ORANGE)
$0.00 (Tier 2)
lamotrigine (100 mg tab er 24, 100 mg
tablet, 150 mg tablet, 200 mg tab er 24,
200 mg tablet, 25 mg tab er 24, 25 mg
tablet, 25 mg tb chw dsp, 250 mg tab er
24, 300 mg tab er 24, 5 mg tb chw dsp,
50 mg tab er 24)
$0.00 (Tier 1)
(g)
topiramate (100 mg tablet, 15 mg cap
sprink, 200 mg tablet, 25 mg cap sprink,
$0.00 (Tier 1)
(g)
TROKENDI XR (100 MG CAPSULE, 200
MG CAPSULE, 25 MG CAPSULE, 50 MG
CAPSULE)
$0.00 (Tier 2)
Glutamate Reducing Agents
Sodium Channel Agents
APTIOM (200 MG TABLET, 400 MG
TABLET)
$0.00 (Tier 2)
BANZEL (200 MG TABLET, 40 MG/ML
SUSPENSION, 400 MG TABLET)
$0.00 (Tier 2)
24
Anticonvulsants
Name of drug
(tier level)
Necessary actions,
carbamazepine (100 mg cpmp 12hr,
100 mg tab chew, 100 mg/5ml oral
susp, 200 mg cpmp 12hr, 200 mg tab er
12h, 200 mg tablet, 200mg/10ml oral
susp, 300 mg cpmp 12hr, 400 mg tab er
12h)
$0.00 (Tier 1)
(g)
DILANTIN (30 MG CAPSULE, 30 MG
KAPSEAL)
$0.00 (Tier 2)
fosphenytoin sodium (100mg pe/2 vial,
500 pe/10 vial)
$0.00 (Tier 1)
(g)
oxcarbazepine (150 mg tablet, 300 mg
tablet, 300 mg/5ml oral susp, 600 mg
tablet)
$0.00 (Tier 1)
(g)
OXTELLAR XR (150 MG TABLET, 300 MG
$0.00 (Tier 2)
PEGANONE 250 MG TABLET
$0.00 (Tier 2)
phenytoin (100 mg/4ml oral susp, 125
mg/5ml oral susp, 50 mg tab chew)
$0.00 (Tier 1)
(g)
phenytoin sodium (50 mg/ml ampul, 50
mg/ml vial)
$0.00 (Tier 1)
(g)
phenytoin sodium extended (100 mg
capsule, 200 mg capsule, 300 mg
capsule)
$0.00 (Tier 1)
(g)
TEGRETOL XR 100 MG TABLET
$0.00 (Tier 2)
VIMPAT (10 MG/ML SOLUTION, 100
MG TABLET, 150 MG TABLET, 200 MG
$0.00 (Tier 2)
VIMPAT 200 MG/20 ML VIAL
$0.00 (Tier 2)
BD
(tier level)
Necessary actions,
$0.00 (Tier 1)
(g)
Antidementia Agents
Name of drug
Antidementia Agents, Other
ergoloid mesylates 1 mg tablet
25
Antidementia Agents
(tier level)
Necessary actions,
donepezil hcl (10 mg tab rapdis, 10 mg
tablet, 5 mg tab rapdis, 5 mg tablet)
$0.00 (Tier 1)
(g)
EXELON (4.6 MG/24HR PATCH, 9.5
MG/24HR PATCH)
$0.00 (Tier 2)
EXELON 13.3 MG/24HR PATCH
$0.00 (Tier 2)
QL (30 PER 30 DAYS)
galantamine hbr (12 mg tablet, 16 mg
cap24h pel, 24 mg cap24h pel, 4 mg
tablet, 4 mg/ml solution, 8 mg cap24h
pel, 8 mg tablet)
$0.00 (Tier 1)
(g)
rivastigmine tartrate (1.5 mg capsule, 3
mg capsule, 4.5 mg capsule, 6 mg
capsule)
$0.00 (Tier 1)
(g)
Name of drug
Cholinesterase Inhibitors
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA 10 MG/5 ML SOLUTION
$0.00 (Tier 2)
Antidepressants
Name of drug
(tier level)
Necessary actions,
Antidepressants, Other
APLENZIN (ER 174 MG TABLET, ER 348
MG TABLET, ER 522 MG TABLET)
$0.00 (Tier 2)
bupropion hcl (100 mg tablet, 100 mg
tablet er, 150 mg tab er 24h, 150 mg
tablet er, 200 mg tablet er, 300 mg tab
er 24h, 75 mg tablet)
$0.00 (Tier 1)
FORFIVO XL 450 MG TABLET
$0.00 (Tier 2)
mirtazapine (15 mg tab rapdis, 15 mg
tablet, 30 mg tab rapdis, 30 mg tablet,
45 mg tab rapdis, 45 mg tablet, 7.5 mg
tablet)
$0.00 (Tier 1)
(g)
quetiapine fumarate (100 mg tablet,
tablet, 400 mg tablet, 50 mg tablet)
$0.00 (Tier 1)
(g)
SEROQUEL XR (150 MG TABLET, 200
MG TABLET, 300 MG TABLET, 400 MG
$0.00 (Tier 2)
(g)
26
Antidepressants
Name of drug
(tier level)
Necessary actions,
Monoamine Oxidase Inhibitors
EMSAM (12 MG/24 HOURS PATCH, 6
MG/24 HOURS PATCH, 9 MG/24
HOURS PATCH)
$0.00 (Tier 2)
MARPLAN 10 MG TABLET
$0.00 (Tier 2)
phenelzine sulfate 15 mg tablet
$0.00 (Tier 1)
(g)
tranylcypromine sulfate 10 mg tablet
$0.00 (Tier 1)
(g)
SSRIs/SNRIs(Selective Serotonin Reuptake
Inhibitors/SerotoninandNorepinephrineReuptakeInhibitors)
BRINTELLIX (10 MG TABLET, 20 MG
$0.00 (Tier 2)
BRISDELLE 7.5 MG CAPSULE
$0.00 (Tier 2)
citalopram hydrobromide (10 mg
tablet, 10 mg/5 ml solution, 20 mg
tablet, 20 mg/10ml solution, 40 mg
tablet)
$0.00 (Tier 1)
(g)
desvenlafaxine (100 mg tab er 24, 100
mg tab er 24h, 50 mg tab er 24, 50 mg
tab er 24h)
$0.00 (Tier 1)
(g)
duloxetine hcl (20 mg capsule dr, 30 mg
capsule dr, 60 mg capsule dr)
$0.00 (Tier 1)
(g)
escitalopram oxalate (10 mg tablet, 20
mg tablet, 5 mg tablet, 5 mg/5 ml
solution)
$0.00 (Tier 1)
(g)
FETZIMA (20-40 MG TITRATION PAK, ER
120 MG CAPSULE, ER 20 MG CAPSULE,
ER 40 MG CAPSULE, ER 80 MG
CAPSULE)
$0.00 (Tier 2)
fluoxetine hcl (10 mg capsule, 10 mg
tablet, 20 mg capsule, 20 mg tablet, 20
mg/5 ml solution, 40 mg capsule, 60 mg
tablet, 90 mg capsule dr)
$0.00 (Tier 1)
(g)
fluvoxamine maleate (100 mg cap er
24h, 100 mg tablet, 150 mg cap er 24h,
$0.00 (Tier 1)
(g)
KHEDEZLA (ER 100 MG TABLET, ER 50
MG TABLET)
$0.00 (Tier 2)
27
Antidepressants
Name of drug
(tier level)
Necessary actions,
maprotiline hcl (25 mg tablet, 50 mg
$0.00 (Tier 1)
(g)
nefazodone hcl (100 mg tablet, 150 mg
tablet, 200 mg tablet, 250 mg tablet, 50
mg tablet)
$0.00 (Tier 1)
(g)
olanzapine/fluoxetine hcl (12mg-25mg
capsule, 12mg-50mg capsule, 3 mg-25
mg capsule, 6mg-25mg capsule, 6mg50mg capsule)
$0.00 (Tier 1)
PA, (g)
paroxetine hcl (10 mg tablet, 12.5 mg
tab er 24h, 20 mg tablet, 25 mg tab er
24h, 30 mg tablet, 37.5 mg tab er 24h,
40 mg tablet)
$0.00 (Tier 1)
(g)
PAXIL 10 MG/5 ML SUSPENSION
$0.00 (Tier 2)
PRISTIQ ER (ER 100 MG TABLET, ER 50
MG TABLET)
$0.00 (Tier 2)
sertraline hcl (100 mg tablet, 20 mg/ml
oral conc, 25 mg tablet, 50 mg tablet)
$0.00 (Tier 1)
(g)
trazodone hcl (100 mg tablet, 150 mg
$0.00 (Tier 1)
(g)
venlafaxine hcl (100 mg tablet, 150 mg
cap er 24h, 150 mg tab er 24, 225 mg
tab er 24, 25 mg tablet, 37.5 mg cap er
24h, 37.5 mg tab er 24, 37.5 mg tablet,
50 mg tablet, 75 mg cap er 24h, 75 mg
tab er 24, 75 mg tablet)
$0.00 (Tier 1)
(g)
VIIBRYD (10 MG TABLET, 20 MG
TABLET, 40 MG TABLET, TITRATION
PACK)
$0.00 (Tier 2)
Tricyclics
amitriptyline hcl (10 mg tablet, 100 mg
$0.00 (Tier 1)
(g)
amitriptyline hcl/chlordiazepoxide
(12.5mg-5mg tablet, 25 mg-10mg
tablet)
$0.00 (Tier 1)
(g)
amoxapine (100 mg tablet, 150 mg
$0.00 (Tier 1)
(g)
28
Antidepressants
Name of drug
(tier level)
Necessary actions,
clomipramine hcl (25 mg capsule, 50
mg capsule, 75 mg capsule)
$0.00 (Tier 1)
(g)
desipramine hcl (10 mg tablet, 100 mg
mg tablet)
$0.00 (Tier 1)
(g)
doxepin hcl (10 mg/ml oral conc, 100
mg capsule, 150 mg capsule, 25 mg
capsule, 50 mg capsule, 75 mg capsule)
$0.00 (Tier 1)
(g)
imipramine hcl (10 mg tablet, 25 mg
$0.00 (Tier 1)
(g)
imipramine pamoate (100 mg capsule,
125 mg capsule, 150 mg capsule, 75 mg
capsule)
$0.00 (Tier 1)
(g)
nortriptyline hcl (10 mg capsule, 10
mg/5 ml solution, 25 mg capsule, 50 mg
$0.00 (Tier 1)
(g)
perphenazine/amitriptyline hcl (2 mg10 mg tablet, 2 mg-25 mg tablet, 4 mg25 mg tablet, 4mg-10mg tablet, 4mg50mg tablet)
$0.00 (Tier 1)
(g)
protriptyline hcl (10 mg tablet, 5 mg
tablet)
$0.00 (Tier 1)
(g)
SILENOR (3 MG TABLET, 6 MG TABLET)
$0.00 (Tier 2)
SURMONTIL (100 MG CAPSULE, 25 MG
$0.00 (Tier 2)
ZONALON 5% CREAM
$0.00 (Tier 2)
Antiemetics
(tier level)
Necessary actions,
chlorpromazine hcl (10 mg tablet, 100
mg tablet, 200 mg tablet, 25 mg tablet,
25 mg/ml ampul, 50 mg tablet)
$0.00 (Tier 1)
(g)
meclizine hcl (12.5 mg tablet, 25 mg
tablet)
$0.00 (Tier 1)
(g)
Name of drug
Antiemetics, Other
29
Antiemetics
Name of drug
(tier level)
Necessary actions,
perphenazine (16 mg tablet, 2 mg
$0.00 (Tier 1)
(g)
prochlorperazine edisylate (10 mg/2 ml
vial, 5 mg/ml vial)
$0.00 (Tier 1)
(g)
prochlorperazine maleate (10 mg
tablet, 25 mg supp.rect, 5 mg tablet)
$0.00 (Tier 1)
(g)
promethazine hcl (12.5 mg supp.rect,
25 mg supp.rect)
$0.00 (Tier 1)
PA, (g)
TRANSDERM-SCOP 1.5 MG/72HR
$0.00 (Tier 2)
trimethobenzamide hcl 300 mg capsule
$0.00 (Tier 1)
PA, (g)
ALOXI 0.25 MG/5 ML VIAL
$0.00 (Tier 2)
BD
ANZEMET (100 MG TABLET, 20 MG/ML
VIAL, 50 MG TABLET)
$0.00 (Tier 2)
BD
CESAMET 1 MG CAPSULE
$0.00 (Tier 2)
BD
dronabinol (10 mg capsule, 2.5 mg
$0.00 (Tier 1)
BD, (g)
EMEND (125 MG CAPSULE, 40 MG
$0.00 (Tier 2)
BD
granisetron hcl (1 mg tablet, 1 mg/ml
vial, 1 mg/ml(1) vial)
$0.00 (Tier 1)
BD, (g)
granisetron hcl/pf 1 mg/ml(1) vial
$0.00 (Tier 1)
BD, (g)
ondansetron (4 mg tab rapdis, 8 mg tab
rapdis)
$0.00 (Tier 1)
BD, (g)
ondansetron hcl (24 mg tablet, 4 mg
tablet, 4 mg/5 ml solution, 8 mg tablet)
$0.00 (Tier 1)
BD, (g)
ondansetron hcl/pf (4 mg/2 ml ampul, 4
mg/2 ml vial)
$0.00 (Tier 1)
BD, (g)
SANCUSO 3.1 MG/24 HR PATCH
$0.00 (Tier 2)
Emetogenic Therapy Adjuncts
Antifungals
Name of drug
(tier level)
Necessary actions,
Antifungals
30
ABELCET 100 MG/20 ML VIAL
$0.00 (Tier 2)
PA
Name of drug
(tier level)
Necessary actions,
AMBISOME 50 MG VIAL
$0.00 (Tier 2)
PA
amphotericin b 50 mg vial
$0.00 (Tier 1)
(g)
CANCIDAS (50 MG VIAL, 70 MG VIAL)
$0.00 (Tier 2)
PA
ciclopirox (0.77 % gel (gram), 8 %
solution)
$0.00 (Tier 1)
(g)
ciclopirox olamine (0.77 % cream (g),
0.77 % suspension)
$0.00 (Tier 1)
(g)
clotrimazole (1 % cream (g), 1 %
solution, 10 mg troche)
$0.00 (Tier 1)
(g)
econazole nitrate 1 % cream (g)
$0.00 (Tier 1)
(g)
EXELDERM (CREAM, SOLUTION)
$0.00 (Tier 2)
fluconazole (10 mg/ml susp recon, 100
mg tablet, 150 mg tablet, 200 mg
tablet, 40 mg/ml susp recon, 50 mg
tablet)
$0.00 (Tier 1)
(g)
fluconazole in dextrose, iso-osmotic
(200mg/0.1l piggyback, 400mg/0.2l
piggyback)
$0.00 (Tier 1)
PA, (g)
flucytosine (250 mg capsule, 500 mg
capsule)
$0.00 (Tier 1)
(g)
GRIS-PEG (125 MG TABLET, 250 MG
TABLET)
$0.00 (Tier 2)
griseofulvin, microsize 125 mg/5ml oral
susp
$0.00 (Tier 1)
(g)
itraconazole 100 mg capsule
$0.00 (Tier 1)
(g)
ketoconazole (2 % cream (g), 2 %
shampoo, 200 mg tablet)
$0.00 (Tier 1)
(g)
LAMISIL (125 MG GRANULES PACKET,
187.5 MG GRANULES PACK)
$0.00 (Tier 2)
miconazole nitrate 200 mg supp.vag
$0.00 (Tier 1)
NAFTIN (1% CREAM, 1% GEL, PUMP 1%
CREAM)
$0.00 (Tier 2)
NOXAFIL 40 MG/ML SUSPENSION
$0.00 (Tier 2)
Antifungals
(g)
ST
31
Antifungals
Name of drug
(tier level)
Necessary actions,
nystatin (100000/g oint. (g), 100000/g
powder, 100000/ml oral susp, 150mm
unit powder(ea), 500k unit tablet,
500mm unit powder(ea), 50mm unit
powder(ea))
$0.00 (Tier 1)
(g)
OXISTAT (CREAM, LOTION)
$0.00 (Tier 2)
SPORANOX 10 MG/ML SOLUTION
$0.00 (Tier 2)
ST
terbinafine hcl 250 mg tablet
$0.00 (Tier 1)
(g)
terconazole (0.4 % cream/appl, 0.8 %
cream/appl, 80 mg supp.vag)
$0.00 (Tier 1)
(g)
VFEND 40 MG/ML SUSPENSION
$0.00 (Tier 2)
ST
voriconazole (200 mg tablet, 50 mg
tablet)
$0.00 (Tier 1)
(g)
voriconazole 200 mg vial
$0.00 (Tier 1)
PA, (g)
(tier level)
Necessary actions,
allopurinol (100 mg tablet, 300 mg
tablet)
$0.00 (Tier 1)
(g)
colchicine/probenecid 0.5-500mg tablet
$0.00 (Tier 1)
(g)
COLCRYS 0.6 MG TABLET
$0.00 (Tier 2)
probenecid 500 mg tablet
$0.00 (Tier 1)
ULORIC (40 MG TABLET, 80 MG
TABLET)
$0.00 (Tier 2)
Antigout Agents
Name of drug
Antigout Agents
(g)
Antimigraine Agents
Name of drug
(tier level)
Necessary actions,
$0.00 (Tier 1)
(g)
Ergot Alkaloids
dihydroergotamine mesylate (1 mg/ml
32
Antimigraine Agents
Name of drug
(tier level)
Necessary actions,
methylergonovine maleate 0.2 mg
tablet
$0.00 (Tier 1)
(g)
MIGERGOT SUPPOSITORY
$0.00 (Tier 2)
Prophylactic
valproic acid 250 mg capsule
$0.00 (Tier 1)
(g)
Serotonin (5-HT) 1b/1d Receptor Agonists
IMITREX (20 MG NASAL SPRAY, 5 MG
NASAL SPRAY)
$0.00 (Tier 2)
naratriptan hcl (1 mg tablet, 2.5 mg
tablet)
$0.00 (Tier 1)
rizatriptan benzoate (10 mg tab rapdis,
10 mg tablet, 5 mg tab rapdis, 5 mg
tablet)
$0.00 (Tier 1)
(g)
sumatriptan succinate (100 mg tablet,
$0.00 (Tier 1)
sumatriptan succinate (6 mg/0.5ml
cartridge, 6 mg/0.5ml pen injctr, 6
mg/0.5ml syringe, 6 mg/0.5ml vial)
$0.00 (Tier 1)
(g)
TREXIMET 85-500 MG TABLET
$0.00 (Tier 2)
ZOMIG (2.5 MG TABLET, 5 MG TABLET)
$0.00 (Tier 2)
ZOMIG 5 MG NASAL SPRAY
$0.00 (Tier 2)
ZOMIG ZMT (2.5 MG TABLET, 5 MG
TABLET)
$0.00 (Tier 2)
QL (9 PER 30 DAYS)
(tier level)
Necessary actions,
guanidine hcl 125 mg tablet
$0.00 (Tier 1)
(g)
MESTINON (180 MG TIMESPAN, 60
MG/5 ML SYRUP)
$0.00 (Tier 2)
pyridostigmine bromide 60 mg tablet
$0.00 (Tier 1)
QL (9 PER 30 DAYS)
Antimyasthenic Agents
Name of drug
Parasympathomimetics
(g)
33
Antimycobacterials
(tier level)
Necessary actions,
dapsone (100 mg tablet, 25 mg tablet)
$0.00 (Tier 1)
(g)
MYCOBUTIN 150 MG CAPSULE
$0.00 (Tier 2)
Name of drug
Antimycobacterials, Other
Antituberculars
CAPASTAT SULFATE 1 GM VIAL
$0.00 (Tier 2)
ethambutol hcl (100 mg tablet, 400 mg
tablet)
$0.00 (Tier 1)
(g)
isoniazid (100 mg tablet, 100 mg/ml
vial, 300 mg tablet, 50 mg/5 ml
solution)
$0.00 (Tier 1)
(g)
PASER GRANULES 4 GM PACKET
$0.00 (Tier 2)
PRIFTIN 150 MG TABLET
$0.00 (Tier 2)
pyrazinamide 500 mg tablet
$0.00 (Tier 2)
RIFAMATE CAPSULE
$0.00 (Tier 2)
rifampin (150 mg capsule, 300 mg
capsule, 600 mg vial)
$0.00 (Tier 1)
RIFATER TABLET
$0.00 (Tier 2)
TRECATOR 250 MG TABLET
$0.00 (Tier 2)
(g)
(g)
Antineoplastics
(tier level)
Necessary actions,
BICNU 100 MG VIAL
$0.00 (Tier 2)
PA
BUSULFEX (60 MG/10 ML AMPUL, 60
MG/10 ML VIAL)
$0.00 (Tier 2)
PA
cyclophosphamide (25 mg tablet, 50 mg
tablet)
$0.00 (Tier 1)
PA, (g)
dacarbazine (100 mg vial, 200 mg vial)
$0.00 (Tier 1)
PA, (g)
HEXALEN 50 MG CAPSULE
$0.00 (Tier 2)
PA
ifosfamide (1 g vial, 1 g/20 ml vial, 3 g
vial, 3g/60ml vial)
$0.00 (Tier 1)
PA, (g)
Name of drug
Alkylating Agents
34
Antineoplastics
Name of drug
(tier level)
Necessary actions,
LEUKERAN 2 MG TABLET
$0.00 (Tier 2)
lomustine (10 mg capsule, 100 mg
$0.00 (Tier 1)
(g)
MATULANE 50 MG CAPSULE
$0.00 (Tier 2)
PA, LA
melphalan hcl 50 mg vial
$0.00 (Tier 1)
PA, (g)
MUSTARGEN 10 MG VIAL
$0.00 (Tier 2)
PA
TREANDA (100 MG VIAL, 25 MG VIAL)
$0.00 (Tier 2)
PA
bicalutamide 50 mg tablet
$0.00 (Tier 1)
(g)
flutamide 125 mg capsule
$0.00 (Tier 1)
(g)
NILANDRON 150 MG TABLET
$0.00 (Tier 2)
POMALYST (1 MG CAPSULE, 2 MG
CAPSULE)
$0.00 (Tier 2)
PA, LA
REVLIMID (10 MG CAPSULE, 15 MG
CAPSULE, 2.5 MG CAPSULE, 20 MG
CAPSULE)
$0.00 (Tier 2)
PA, LA
THALOMID (100 MG CAPSULE, 150 MG
CAPSULE)
$0.00 (Tier 2)
PA
XTANDI 40 MG CAPSULE
$0.00 (Tier 2)
PA, LA
ZYTIGA 250 MG TABLET
$0.00 (Tier 2)
PA, LA
EMCYT 140 MG CAPSULE
$0.00 (Tier 2)
PA
FARESTON 60 MG TABLET
$0.00 (Tier 2)
PA
SOLTAMOX 10 MG/5 ML SOLN
$0.00 (Tier 2)
PA
tamoxifen citrate (10 mg tablet, 20 mg
tablet)
$0.00 (Tier 1)
(g)
ALIMTA (100 MG VIAL, 500 MG VIAL)
$0.00 (Tier 2)
PA
ARRANON 250 MG VIAL
$0.00 (Tier 2)
PA
Antiangiogenic Agents
Antiestrogens/Modifiers
Antimetabolites
35
Antineoplastics
Name of drug
(tier level)
Necessary actions,
azacitidine 100 mg vial
$0.00 (Tier 1)
PA, (g)
cladribine 10 mg/10ml vial
$0.00 (Tier 1)
PA, (g)
CLOLAR 20 MG/20 ML VIAL
$0.00 (Tier 2)
PA
cytarabine 20 mg/ml vial
$0.00 (Tier 1)
PA, (g)
cytarabine/pf (1 g vial, 100 mg/5ml
vial, 2 g/20 ml vial, 20 mg/ml vial)
$0.00 (Tier 1)
PA, (g)
cytarabine/pf 500 mg vial
$0.00 (Tier 1)
PA, (g)
decitabine 50 mg vial
$0.00 (Tier 1)
PA, (g)
DROXIA (200 MG CAPSULE, 300 MG
$0.00 (Tier 2)
ELITEK (1.5 MG VIAL, 7.5 MG VIAL)
$0.00 (Tier 2)
BD
FOLOTYN (20 MG/ML VIAL, 40 MG/2
ML VIAL)
$0.00 (Tier 2)
PA
gemcitabine hcl (1 g vial, 1 g/26.3ml
vial, 2 g vial, 2 g/52.6ml vial,
200mg/5.26 vial)
$0.00 (Tier 1)
PA, (g)
gemcitabine hcl 200 mg vial
$0.00 (Tier 1)
PA, PA, (g)
hydroxyurea 500 mg capsule
$0.00 (Tier 1)
(g)
mercaptopurine 50 mg tablet
$0.00 (Tier 1)
(g)
methotrexate sodium/pf (1 g vial, 25
mg/ml vial)
$0.00 (Tier 1)
PA, (g)
TABLOID 40 MG TABLET
$0.00 (Tier 2)
PA
ABRAXANE 100 MG VIAL
$0.00 (Tier 2)
PA
amifostine crystalline 500 mg vial
$0.00 (Tier 1)
(g)
bleomycin sulfate (15 unit vial, 30 unit
vial)
$0.00 (Tier 1)
PA, (g)
carboplatin (10 mg/ml vial, 150 mg vial)
$0.00 (Tier 1)
PA, (g)
cisplatin 1 mg/ml vial
$0.00 (Tier 1)
PA, (g)
COSMEGEN 0.5 MG VIAL
$0.00 (Tier 2)
PA
daunorubicin hcl (20 mg vial, 5 mg/ml
vial)
$0.00 (Tier 1)
PA, (g)
Antineoplastics, Other
36
Antineoplastics
Name of drug
(tier level)
Necessary actions,
dexrazoxane hcl (250 mg vial, 500 mg
vial)
$0.00 (Tier 1)
PA, (g)
DOCEFREZ (20 MG VIAL, 80 MG VIAL)
$0.00 (Tier 2)
PA
docetaxel (140 mg/7ml vial,
20mg/ml(1) vial, 80 mg/4 ml vial)
$0.00 (Tier 1)
PA, PA, (g)
docetaxel (160mg/16ml vial, 20 mg/2
ml vial, 80 mg/8 ml vial)
$0.00 (Tier 1)
PA, (g)
DOXIL 2 MG/ML VIAL
$0.00 (Tier 2)
PA
doxorubicin hcl (10 mg vial, 10 mg/5 ml
vial, 2 mg/ml vial, 20 mg/10ml vial, 50
mg vial, 50 mg/25ml vial)
$0.00 (Tier 1)
PA, (g)
epirubicin hcl (200 mg vial, 50 mg vial,
50 mg/25ml vial)
$0.00 (Tier 1)
PA, (g)
epirubicin hcl 200mg/0.1l vial
$0.00 (Tier 1)
PA, PA, (g)
ERWINAZE 10,000 UNITS VIAL
$0.00 (Tier 2)
PA
FASLODEX 250 MG/5 ML SYRINGE
$0.00 (Tier 2)
PA
fludarabine phosphate (50 mg vial, 50
mg/2 ml vial)
$0.00 (Tier 1)
PA, (g)
HALAVEN 1 MG/2 ML VIAL
$0.00 (Tier 2)
PA
idarubicin hcl 1 mg/ml vial
$0.00 (Tier 1)
PA, (g)
INTRON A (10 MILLION UNIT/ML, 10
MILLION UNITS VIL, 6 MILLION
UNIT/ML VL)
$0.00 (Tier 2)
PA
irinotecan hcl (100 mg/5ml vial, 40
mg/2 ml vial, 500mg/25ml vial)
$0.00 (Tier 1)
PA, (g)
ISTODAX 10 MG VIAL
$0.00 (Tier 2)
PA
IXEMPRA (15 MG KIT, 45 MG KIT)
$0.00 (Tier 2)
PA
JEVTANA 60 MG/1.5 ML KIT
$0.00 (Tier 2)
PA
KADCYLA (100 MG VIAL, 160 MG VIAL)
$0.00 (Tier 2)
PA, LA
leucovorin calcium (10 mg tablet, 15
mg tablet, 25 mg tablet, 5 mg tablet)
$0.00 (Tier 1)
(g)
leucovorin calcium (10 mg/ml vial, 100
mg vial, 200 mg vial, 350 mg vial, 50
mg vial, 500 mg vial, 500mg/50ml vial)
$0.00 (Tier 1)
BD, (g)
37
Antineoplastics
Name of drug
(tier level)
Necessary actions,
mesna 100 mg/ml vial
$0.00 (Tier 1)
(g)
MESNEX 400 MG TABLET
$0.00 (Tier 2)
mitomycin (20 mg vial, 40 mg vial, 5 mg
vial)
$0.00 (Tier 1)
PA, (g)
mitoxantrone hcl 2 mg/ml vial
$0.00 (Tier 1)
PA, (g)
ONCASPAR 750 UNIT/ML VIAL
$0.00 (Tier 2)
PA
oxaliplatin (100 mg vial, 100mg/20ml
vial, 50 mg vial, 50 mg/10ml vial)
$0.00 (Tier 1)
PA, (g)
paclitaxel 6 mg/ml vial
$0.00 (Tier 1)
PA, PA, (g)
PROLEUKIN 22 MILLION UNIT VIAL
$0.00 (Tier 2)
PA
SYNAGIS (100 MG/1 ML VIAL, 50
MG/0.5 ML VIAL)
$0.00 (Tier 2)
PA
SYNRIBO 3.5 MG/ML VIAL
$0.00 (Tier 2)
PA
TORISEL 25 MG KIT
$0.00 (Tier 2)
PA
TRISENOX 10 MG/10 ML AMPULE
$0.00 (Tier 2)
PA
VELCADE 3.5 MG VIAL
$0.00 (Tier 2)
PA
vinblastine sulfate (1 mg/ml vial, 10 mg
vial)
$0.00 (Tier 1)
PA, (g)
vincristine sulfate (1 mg/ml vial, 2 mg/2
ml vial)
$0.00 (Tier 1)
PA, (g)
vinorelbine tartrate (10 mg/ml vial, 50
mg/5 ml vial)
$0.00 (Tier 1)
PA, (g)
YERVOY (200 MG/40 ML VIAL, 50
MG/10 ML VIAL)
$0.00 (Tier 2)
PA, LA
ZALTRAP (100 MG/4 ML VIAL, 200
MG/8 ML VIAL)
$0.00 (Tier 2)
PA
ZANOSAR 1 GM POWDER VIAL
$0.00 (Tier 2)
PA
ZOLINZA 100 MG CAPSULE
$0.00 (Tier 2)
PA
Aromatase Inhibitors, 3rd Generation
anastrozole 1 mg tablet
$0.00 (Tier 1)
(g)
exemestane 25 mg tablet
$0.00 (Tier 1)
(g)
letrozole 2.5 mg tablet
$0.00 (Tier 1)
(g)
38
Antineoplastics
(tier level)
Necessary actions,
etoposide 20 mg/ml vial
$0.00 (Tier 1)
(g)
topotecan hcl (4 mg vial, 4 mg/4 ml
vial)
$0.00 (Tier 1)
PA, (g)
AFINITOR (10 MG TABLET, 2.5 MG
TABLET, 5 MG TABLET, 7.5 MG TABLET)
$0.00 (Tier 2)
PA
AFINITOR DISPERZ (2 MG TABLET, 3 MG
$0.00 (Tier 2)
PA
BOSULIF (100 MG TABLET, 500 MG
TABLET)
$0.00 (Tier 2)
PA
CAPRELSA (100 MG TABLET, 300 MG
TABLET)
$0.00 (Tier 2)
PA
COMETRIQ (100 MG DAILY-DOSE PK,
140 MG DAILY-DOSE PK, 60 MG DAILYDOSE PACK)
$0.00 (Tier 2)
PA, LA
ERIVEDGE 150 MG CAPSULE
$0.00 (Tier 2)
PA, LA
GILOTRIF (20 MG TABLET, 30 MG
$0.00 (Tier 2)
PA, LA
GLEEVEC (100 MG TABLET, 400 MG
TABLET)
$0.00 (Tier 2)
PA
IMBRUVICA 140 MG CAPSULE
$0.00 (Tier 2)
PA, LA
INLYTA (1 MG TABLET, 5 MG TABLET)
$0.00 (Tier 2)
PA, LA
JAKAFI (10 MG TABLET, 15 MG TABLET,
20 MG TABLET, 25 MG TABLET, 5 MG
TABLET)
$0.00 (Tier 2)
PA, LA
MEKINIST (0.5 MG TABLET, 2 MG
TABLET)
$0.00 (Tier 2)
PA, LA
NEXAVAR 200 MG TABLET
$0.00 (Tier 2)
PA, LA
SPRYCEL (100 MG TABLET, 140 MG
TABLET, 20 MG TABLET, 50 MG TABLET,
70 MG TABLET, 80 MG TABLET)
$0.00 (Tier 2)
PA
STIVARGA 40 MG TABLET
$0.00 (Tier 2)
PA, LA
SUTENT (12.5 MG CAPSULE, 25 MG
$0.00 (Tier 2)
PA
Name of drug
Enzyme Inhibitors
Molecular Target Inhibitors
39
Antineoplastics
Name of drug
(tier level)
Necessary actions,
TAFINLAR (50 MG CAPSULE, 75 MG
CAPSULE)
$0.00 (Tier 2)
PA, LA
TARCEVA (100 MG TABLET, 150 MG
$0.00 (Tier 2)
PA, LA
TASIGNA (150 MG CAPSULE, 200 MG
CAPSULE)
$0.00 (Tier 2)
PA
TYKERB 250 MG TABLET
$0.00 (Tier 2)
PA, LA
VOTRIENT 200 MG TABLET
$0.00 (Tier 2)
PA, LA
XALKORI (200 MG CAPSULE, 250 MG
CAPSULE)
$0.00 (Tier 2)
PA, LA
ZELBORAF 240 MG TABLET
$0.00 (Tier 2)
PA, LA
ZYKADIA 150 MG CAPSULE
$0.00 (Tier 2)
Monoclonal Antibodies
ARZERRA (1,000 MG/50 ML VIAL, 100
MG/5 ML VIAL)
$0.00 (Tier 2)
PA, LA
AVASTIN (100 MG/4 ML VIAL, 400
MG/16 ML VIAL)
$0.00 (Tier 2)
PA
ERBITUX (100 MG/50 ML VIAL, 200
MG/100 ML VIAL)
$0.00 (Tier 2)
BD
HERCEPTIN 440 MG VIAL
$0.00 (Tier 2)
BD
PERJETA 420 MG/14 ML VIAL
$0.00 (Tier 2)
BD
RITUXAN 10 MG/ML VIAL
$0.00 (Tier 2)
PA, LA
VECTIBIX (100 MG/5 ML VIAL, 400
MG/20 ML VIAL)
$0.00 (Tier 2)
BD
PANRETIN 0.1% GEL
$0.00 (Tier 2)
PA
TARGRETIN (1% GEL, 75 MG CAPSULE,
75 MG SOFTGEL)
$0.00 (Tier 2)
PA
tretinoin 10 mg capsule
$0.00 (Tier 1)
(g)
Retinoids
40
Antiparasitics
Name of drug
(tier level)
Necessary actions,
Anthelmintics
ALBENZA 200 MG TABLET
$0.00 (Tier 2)
BILTRICIDE 600 MG TABLET
$0.00 (Tier 2)
STROMECTOL 3 MG TABLET
$0.00 (Tier 2)
Antiprotozoals
ALINIA (100 MG/5 ML SUSPENSION,
500 MG TABLET)
$0.00 (Tier 2)
atovaquone/proguanil hcl 250-100 mg
tablet
$0.00 (Tier 1)
(g)
chloroquine phosphate (250 mg tablet,
500 mg tablet)
$0.00 (Tier 1)
(g)
COARTEM TABLETS
$0.00 (Tier 2)
DARAPRIM 25 MG TABLET
$0.00 (Tier 2)
hydroxychloroquine sulfate 200 mg
tablet
$0.00 (Tier 1)
(g)
mefloquine hcl 250 mg tablet
$0.00 (Tier 1)
(g)
MEPRON 750 MG/5 ML SUSPENSION
$0.00 (Tier 2)
NEBUPENT 300 MG INHAL POWDER
$0.00 (Tier 2)
PENTAM 300 VIAL
$0.00 (Tier 2)
primaquine phosphate 26.3 mg tablet
$0.00 (Tier 1)
(g)
quinine sulfate 324 mg capsule
$0.00 (Tier 1)
(g)
lindane (1 % lotion, 1 % shampoo)
$0.00 (Tier 1)
(g)
malathion 0.5 % lotion
$0.00 (Tier 1)
(g)
permethrin 5 % cream (g)
$0.00 (Tier 1)
(g)
(tier level)
Necessary actions,
BD
Pediculicides/Scabicides
Antiparkinson Agents
Name of drug
Anticholinergics
41
benztropine mesylate (0.5 mg tablet, 1
$0.00 (Tier 1)
(g)
Name of drug
(tier level)
Necessary actions,
trihexyphenidyl hcl (2 mg tablet, 2 mg/5
ml elixir, 5 mg tablet)
$0.00 (Tier 1)
(g)
Antiparkinson Agents, Other
COMTAN 200 MG TABLET
$0.00 (Tier 2)
TASMAR 100 MG TABLET
$0.00 (Tier 2)
Dopamine Agonists
APOKYN 30 MG/3 ML CARTRIDGE
$0.00 (Tier 2)
bromocriptine mesylate (2.5 mg tablet,
5 mg capsule)
$0.00 (Tier 1)
CYCLOSET 0.8 MG TABLET
$0.00 (Tier 2)
MIRAPEX ER (ER 0.375 MG TABLET, ER
0.75 MG TABLET, ER 1.5 MG TABLET, ER
3 MG TABLET, ER 4.5 MG TABLET)
$0.00 (Tier 2)
NEUPRO (1 MG/24 HR PATCH, 2 MG/24
HR PATCH, 3 MG/24 HR PATCH, 4
MG/24 HR PATCH, 6 MG/24 HR PATCH,
8 MG/24 HR PATCH)
$0.00 (Tier 2)
pramipexole di-hcl (0.125 mg tablet,
0.25 mg tablet, 0.5 mg tablet, 0.75 mg
tablet, 1 mg tablet, 1.5 mg tablet)
$0.00 (Tier 1)
(g)
ropinirole hcl (0.25 mg tablet, 0.5 mg
tablet, 1 mg tablet, 12 mg tab er 24h, 2
mg tab er 24h, 2 mg tablet, 3 mg tablet,
4 mg tab er 24h, 4 mg tablet, 5 mg
tablet, 6 mg tab er 24h, 8 mg tab er
24h)
$0.00 (Tier 1)
(g)
carbidopa/levodopa (10mg-100mg tab
rapdis, 10mg-100mg tablet, 25mg100mg tab rapdis, 25mg-100mg tablet,
25mg-100mg tablet er, 25mg-250mg
tab rapdis, 25mg-250mg tablet, 50mg200mg tablet er)
$0.00 (Tier 1)
(g)
STALEVO 100 TABLET
$0.00 (Tier 2)
(g)
Dopamine Precursors/ L-Amino Acid
42
Name of drug
(tier level)
STALEVO 125 TABLET
$0.00 (Tier 2)
STALEVO 150 TABLET
$0.00 (Tier 2)
STALEVO 200 TABLET
$0.00 (Tier 2)
STALEVO 50 TABLET
$0.00 (Tier 2)
STALEVO 75 TABLET
$0.00 (Tier 2)
Necessary actions,
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT (0.5 MG TABLET, 1 MG TABLET)
$0.00 (Tier 2)
selegiline hcl (5 mg capsule, 5 mg
tablet)
$0.00 (Tier 1)
ZELAPAR 1.25 MG ODT TABLET
$0.00 (Tier 2)
(g)
Antipsychotics
(tier level)
Necessary actions,
fluphenazine decanoate 25 mg/ml vial
$0.00 (Tier 1)
(g)
fluphenazine hcl (1 mg tablet, 10 mg
tablet, 2.5 mg tablet, 2.5 mg/5ml elixir,
2.5 mg/ml vial, 5 mg tablet, 5 mg/ml
oral conc)
$0.00 (Tier 1)
(g)
haloperidol (0.5 mg tablet, 1 mg tablet,
10 mg tablet, 2 mg tablet, 20 mg tablet,
5 mg tablet)
$0.00 (Tier 1)
(g)
haloperidol decanoate (100 mg/ml
ampul, 100 mg/ml vial, 50 mg/ml
$0.00 (Tier 1)
(g)
haloperidol lactate (2 mg/ml oral conc,
5 mg/ml ampul, 5 mg/ml vial)
$0.00 (Tier 1)
(g)
loxapine succinate (10 mg capsule, 25
mg capsule, 5 mg capsule, 50 mg
capsule)
$0.00 (Tier 1)
(g)
ORAP (1 MG TABLET, 2 MG TABLET)
$0.00 (Tier 2)
thioridazine hcl (10 mg tablet, 100 mg
$0.00 (Tier 1)
Name of drug
1st Generation/Typical
PA, (g)
43
Antipsychotics
Name of drug
(tier level)
Necessary actions,
thiothixene (1 mg capsule, 10 mg
$0.00 (Tier 1)
(g)
trifluoperazine hcl (1 mg tablet, 10 mg
$0.00 (Tier 1)
(g)
2nd Generation/Atypical
ABILIFY (1 MG/ML SOLUTION, 10 MG
TABLET, 9.7 MG/1.3 ML VIAL)
$0.00 (Tier 2)
ABILIFY DISCMELT (10 MG TABLET, 15
MG TABLET)
$0.00 (Tier 2)
ABILIFY MAINTENA (ER 300 MG SYR, ER
300 MG VL, ER 400 MG SYR, ER 400 MG
VL)
$0.00 (Tier 2)
FANAPT (1 MG TABLET, 10 MG TABLET,
TITRATION PACK)
$0.00 (Tier 2)
GEODON 20 MG/ML VIAL
$0.00 (Tier 2)
INVEGA (ER 1.5 MG TABLET, ER 3 MG
TABLET, ER 6 MG TABLET, ER 9 MG
TABLET)
$0.00 (Tier 2)
INVEGA SUSTENNA (117 MG PREF SY,
156 MG PREF SY, 234 MG PREF SY, 39
MG PREF SYR, 78 MG PREF SYR)
$0.00 (Tier 2)
LATUDA (120 MG TABLET, 20 MG
80 MG TABLET)
$0.00 (Tier 2)
olanzapine (10 mg tab rapdis, 10 mg
tablet, 10 mg vial, 15 mg tab rapdis, 15
mg tablet, 2.5 mg tablet, 20 mg tab
rapdis, 20 mg tablet, 5 mg tab rapdis, 5
mg tablet, 7.5 mg tablet)
$0.00 (Tier 1)
(g)
RISPERDAL CONSTA (12.5 MG SYR, 25
MG SYR, 37.5 MG SYR, 50 MG SYR)
$0.00 (Tier 2)
PA
PA
44
Antipsychotics
Name of drug
(tier level)
Necessary actions,
risperidone (0.25 mg tab rapdis, 0.25
mg tablet, 0.5 mg tab rapdis, 0.5 mg
tablet, 1 mg tab rapdis, 1 mg tablet, 1
mg/ml solution, 1 mg/ml syringe, 2 mg
tab rapdis, 2 mg tablet, 2 mg/2 ml
syringe, 3 mg tab rapdis, 3 mg tablet, 3
mg/3 ml syringe, 4 mg tab rapdis, 4 mg
tablet)
$0.00 (Tier 1)
(g)
SAPHRIS (10 MG TAB SL BLK CHERY, 10
MG TAB SUBLINGUAL, 5 MG TAB SL BLK
CHERRY, 5 MG TABLET SUBLINGUAL)
$0.00 (Tier 2)
ziprasidone hcl (20 mg capsule, 40 mg
$0.00 (Tier 1)
(g)
clozapine (100 mg tablet, 200 mg
$0.00 (Tier 1)
(g)
FAZACLO (100 MG ODT, 12.5 MG ODT,
150 MG ODT, 200 MG ODT, 25 MG
ODT)
$0.00 (Tier 2)
granisetron hcl/pf 100 mcg/ml vial
$0.00 (Tier 1)
BD, (g)
nystatin 100000/g cream (g)
$0.00 (Tier 1)
(g)
REBETOL 40 MG/ML SOLUTION
$0.00 (Tier 2)
PA
VERSACLOZ 50 MG/ML SUSPENSION
$0.00 (Tier 2)
Treatment-Resistant
Antispasticity Agents
(tier level)
Necessary actions,
baclofen (10 mg tablet, 20 mg tablet)
$0.00 (Tier 1)
(g)
dantrolene sodium (100 mg capsule, 25
mg capsule, 50 mg capsule)
$0.00 (Tier 1)
(g)
tizanidine hcl (2 mg tablet, 4 mg tablet)
$0.00 (Tier 1)
(g)
Name of drug
Antispasticity Agents
45
Antivirals
Name of drug
(tier level)
Necessary actions,
Anti-HIV Agents, Integrase Inhibitors (INSTI)
ISENTRESS (100 MG POWDER PACKET,
100 MG TABLET CHEW, 25 MG TABLET
CHEW, 400 MG TABLET)
$0.00 (Tier 2)
TIVICAY 50 MG TABLET
$0.00 (Tier 2)
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
ATRIPLA TABLET
$0.00 (Tier 2)
COMPLERA TABLET
$0.00 (Tier 2)
EDURANT 25 MG TABLET
$0.00 (Tier 2)
INTELENCE (100 MG TABLET, 200 MG
$0.00 (Tier 2)
nevirapine 200 mg tablet
$0.00 (Tier 1)
RESCRIPTOR (100 MG TABLET, 200 MG
TABLET)
$0.00 (Tier 2)
STRIBILD TABLET
$0.00 (Tier 2)
SUSTIVA (200 MG CAPSULE, 50 MG
CAPSULE, 600 MG TABLET)
$0.00 (Tier 2)
VIRAMUNE 50 MG/5 ML SUSP
$0.00 (Tier 2)
VIRAMUNE XR 100 MG TABLET
$0.00 (Tier 2)
(g)
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
abacavir sulfate 300 mg tablet
$0.00 (Tier 1)
(g)
abacavir/lamivudine/zidovudine 150300mg tablet
$0.00 (Tier 1)
(g)
didanosine (125 mg capsule dr, 200 mg
capsule dr, 250 mg capsule dr, 400 mg
capsule dr)
$0.00 (Tier 1)
(g)
EMTRIVA (10 MG/ML SOLUTION, 200
MG CAPSULE)
$0.00 (Tier 2)
EPZICOM TABLET
$0.00 (Tier 2)
lamivudine/zidovudine 150-300mg
tablet
$0.00 (Tier 1)
RETROVIR 10 MG/ML VIAL
$0.00 (Tier 2)
(g)
46
Antivirals
Name of drug
(tier level)
Necessary actions,
stavudine (1 mg/ml soln recon, 15 mg
capsule, 20 mg capsule, 30 mg capsule,
40 mg capsule)
$0.00 (Tier 1)
(g)
TRUVADA 200 MG-300 MG TABLET
$0.00 (Tier 2)
VIDEX (2 GM PEDIATRIC SOLN, 4 GM
PEDIATRIC SOLN)
$0.00 (Tier 2)
ZIAGEN 20 MG/ML SOLUTION
$0.00 (Tier 2)
zidovudine (10 mg/ml syrup, 100 mg
capsule, 300 mg tablet)
$0.00 (Tier 1)
(g)
Anti-HIV Agents, Other
FUZEON (90 MG VIAL, CONVENIENCE
KIT)
$0.00 (Tier 2)
SELZENTRY (150 MG TABLET, 300 MG
TABLET)
$0.00 (Tier 2)
Anti-HIV Agents, Protease Inhibitors
APTIVUS (100 MG/ML SOLUTION, 250
MG CAPSULE)
$0.00 (Tier 2)
CRIXIVAN (200 MG CAPSULE, 400 MG
CAPSULE)
$0.00 (Tier 2)
INVIRASE (200 MG CAPSULE, 500 MG
TABLET)
$0.00 (Tier 2)
KALETRA (100-25 MG TABLET, 200-50
MG TABLET, 400-100/5 ML ORAL SOLU)
$0.00 (Tier 2)
LEXIVA (50 MG/ML SUSPENSION, 700
MG TABLET)
$0.00 (Tier 2)
NORVIR (100 MG SOFTGEL CAP, 100
MG TABLET, 80 MG/ML SOLUTION)
$0.00 (Tier 2)
PREZISTA (100 MG/ML SUSPENSION,
150 MG TABLET, 600 MG TABLET, 75
MG TABLET, 800 MG TABLET)
$0.00 (Tier 2)
REYATAZ (150 MG CAPSULE, 200 MG
$0.00 (Tier 2)
VIRACEPT (250 MG TABLET, 625 MG
TABLET)
$0.00 (Tier 2)
47
Antivirals
(tier level)
Necessary actions,
amantadine hcl (100 mg capsule, 100
mg tablet, 50 mg/5 ml syrup)
$0.00 (Tier 1)
(g)
RELENZA 5 MG DISKHALER
$0.00 (Tier 2)
rimantadine hcl 100 mg tablet
$0.00 (Tier 1)
TAMIFLU (30 MG CAPSULE, 45 MG
CAPSULE, 6 MG/ML SUSPENSION, 75
MG CAPSULE)
$0.00 (Tier 2)
Name of drug
Anti-Influenza Agents
(g)
Anti-cytomegalovirus (CMV) Agents
cidofovir 75 mg/ml vial
$0.00 (Tier 1)
PA, (g)
foscarnet sodium 24 mg/ml infus. btl
$0.00 (Tier 1)
(g)
ganciclovir sodium 500 mg vial
$0.00 (Tier 1)
PA, (g)
VALCYTE (450 MG TABLET, 50 MG/ML
SOLUTION)
$0.00 (Tier 2)
Anti-hepatitis B (HBV) Agents
BARACLUDE (0.05 MG/ML SOLUTION,
0.5 MG TABLET, 1 MG TABLET)
$0.00 (Tier 2)
EPIVIR 10 MG/ML ORAL SOLN
$0.00 (Tier 2)
EPIVIR HBV (100 MG TABLET, 25 MG/5
ML SOLN)
$0.00 (Tier 2)
HEPSERA 10 MG TABLET
$0.00 (Tier 2)
lamivudine (150 mg tablet, 300 mg
tablet)
$0.00 (Tier 1)
(g)
SYLATRON (200 MCG KIT, 300 MCG KIT,
600 MCG KIT)
$0.00 (Tier 2)
PA
SYLATRON 4-PACK (200 MCG 4-PACK,
300 MCG 4-PACK, 888 MCG 4-PACK)
$0.00 (Tier 2)
PA
TYZEKA 600 MG TABLET
$0.00 (Tier 2)
PA
VIREAD (150 MG TABLET, 200 MG
TABLET, POWDER)
$0.00 (Tier 2)
48
Antivirals
(tier level)
Necessary actions,
INCIVEK 375 MG TABLET
$0.00 (Tier 2)
PA
OLYSIO 150 MG CAPSULE
$0.00 (Tier 2)
PA
PEGASYS (180 MCG/0.5 ML SYRINGE,
180 MCG/ML VIAL)
$0.00 (Tier 2)
PA
PEGASYS PROCLICK 180 MCG/0.5
$0.00 (Tier 2)
PA
PEGINTRON 50 MCG KIT
$0.00 (Tier 2)
PA
PEGINTRON REDIPEN (120 MCG, 120
MCG 4PK, 150 MCG, 150 MCG 4PK, 50
MCG, 50 MCG 4PK, 80 MCG, 80 MCG
4PK)
$0.00 (Tier 2)
PA
RIBASPHERE (400 MG TABLET, 600 MG
TABLET)
$0.00 (Tier 2)
PA
ribavirin (200 mg capsule, 200 mg
tablet)
$0.00 (Tier 1)
PA, (g)
SOVALDI 400 MG TABLET
$0.00 (Tier 2)
PA
VICTRELIS 200 MG CAPSULE
$0.00 (Tier 2)
PA
VIRAZOLE 6 GM VIAL
$0.00 (Tier 2)
BD
acyclovir (200 mg capsule, 200 mg/5ml
oral susp, 400 mg tablet, 800 mg
tablet)
$0.00 (Tier 1)
(g)
acyclovir sodium (1000 mg vial, 50
mg/ml vial, 500 mg vial)
$0.00 (Tier 1)
(g)
famciclovir (125 mg tablet, 250 mg
$0.00 (Tier 1)
(g)
trifluridine 1 % drops
$0.00 (Tier 1)
(g)
valacyclovir hcl (1000 mg tablet, 500
mg tablet)
$0.00 (Tier 1)
(g)
ZOVIRAX 5% OINTMENT
$0.00 (Tier 2)
Name of drug
Anti-hepatitis C (HCV) Agents
Antiherpetic Agents
49
Anxiolytics
(tier level)
Necessary actions,
buspirone hcl (10 mg tablet, 15 mg
tablet, 30 mg tablet, 5 mg tablet, 7.5
mg tablet)
$0.00 (Tier 1)
(g)
hydroxyzine hcl (10 mg tablet, 10 mg/5
ml syrup, 25 mg tablet, 50 mg tablet)
$0.00 (Tier 1)
PA, (g)
hydroxyzine hcl (25 mg/ml vial, 50
mg/ml vial)
$0.00 (Tier 1)
(g)
meprobamate (200 mg tablet, 400 mg
tablet)
$0.00 (Tier 1)
(g)
alprazolam (0.25 mg tablet, 0.5 mg
$0.00 (Tier 1)
(g)
diazepam (10 mg tablet, 2 mg tablet, 5
mg tablet, 5 mg/5 ml solution)
$0.00 (Tier 1)
(g)
lorazepam (0.5 mg tablet, 1 mg tablet,
2 mg tablet)
$0.00 (Tier 1)
(g)
LORAZEPAM INTENSOL 2 MG/ML
$0.00 (Tier 1)
Name of drug
Anxiolytics, Other
Benzodiazepines
Bipolar Agents
(tier level)
Necessary actions,
lithium carbonate (150 mg capsule, 300
mg capsule, 300 mg tablet, 300 mg
tablet er, 450 mg tablet er, 600 mg
capsule)
$0.00 (Tier 1)
(g)
lithium citrate 8 meq/5 ml solution
$0.00 (Tier 1)
(g)
(tier level)
Necessary actions,
$0.00 (Tier 1)
(g)
Name of drug
Mood Stabilizers
Blood Glucose Regulators
Name of drug
Antidiabetic Agents
acarbose (100 mg tablet, 25 mg tablet,
50 mg tablet)
50
Name of drug
(tier level)
Necessary actions,
ACTOPLUS MET XR (15-1,000 MG TB,
30-1,000 MG TB)
$0.00 (Tier 2)
ST
AVANDAMET (2 MG-1,000 MG TAB, 4
MG-1,000 MG TABLET)
$0.00 (Tier 2)
AVANDAMET (2 MG-500 MG TABLET, 4
MG-500 MG TABLET)
$0.00 (Tier 2)
ST
AVANDARYL (4 MG-1 MG TABLET, 4
MG-2 MG TABLET, 4 MG-4 MG TABLET,
8 MG-2 MG TABLET, 8 MG-4 MG
TABLET)
$0.00 (Tier 2)
ST
AVANDIA (2 MG TABLET, 4 MG TABLET,
8 MG TABLET)
$0.00 (Tier 2)
BYETTA (10 MCG DOSE PEN INJ, 5 MCG
DOSE PEN INJ)
$0.00 (Tier 2)
PA
chlorpropamide (100 mg tablet, 250 mg
tablet)
$0.00 (Tier 1)
(g)
glimepiride (1 mg tablet, 2 mg tablet, 4
mg tablet)
$0.00 (Tier 1)
(g)
glipizide (10 mg tab er 24, 10 mg tablet,
2.5 mg tab er 24, 5 mg tab er 24, 5 mg
tablet)
$0.00 (Tier 1)
(g)
glipizide/metformin hcl (2.5-250 mg
tablet, 2.5-500 mg tablet, 5 mg-500mg
tablet)
$0.00 (Tier 1)
(g)
glyburide (1.25 mg tablet, 2.5 mg
$0.00 (Tier 1)
(g)
glyburide,micronized (1.5 mg tablet, 3
$0.00 (Tier 1)
(g)
glyburide/metformin hcl (1.25-250mg
tablet, 2.5-500 mg tablet, 5 mg-500mg
tablet)
$0.00 (Tier 1)
(g)
JANUMET (50-1,000 MG TABLET, 50500 MG TABLET)
$0.00 (Tier 2)
ST
JANUVIA (100 MG TABLET, 25 MG
$0.00 (Tier 2)
KOMBIGLYZE XR (2.5-1,000 MG TAB, 51,000 MG TAB, 5-500 MG TABLET)
$0.00 (Tier 2)
ST
51
Name of drug
(tier level)
Necessary actions,
metformin hcl (1000 mg tablet, 500 mg
tab er 24, 500 mg tab er 24h, 500 mg
tablet, 750 mg tab er 24h, 850 mg
tablet)
$0.00 (Tier 1)
(g)
nateglinide (120 mg tablet, 60 mg
tablet)
$0.00 (Tier 1)
(g)
ONGLYZA (2.5 MG TABLET, 5 MG
TABLET)
$0.00 (Tier 2)
ST
pioglitazone hcl (15 mg tablet, 30 mg
$0.00 (Tier 1)
(g)
pioglitazone hcl/glimepiride (30 mg-2
mg tablet, 30 mg-4 mg tablet)
$0.00 (Tier 1)
(g)
pioglitazone hcl/metformin hcl (15mg500mg tablet, 15mg-850mg tablet)
$0.00 (Tier 1)
(g)
PRANDIMET (1 MG-500 MG TABLET, 2
MG-500 MG TABLET)
$0.00 (Tier 2)
ST
PRANDIN (0.5 MG TABLET, 1 MG
$0.00 (Tier 2)
RIOMET 500 MG/5 ML SOLUTION
$0.00 (Tier 2)
ST
SYMLINPEN 120 PEN INJECTOR
$0.00 (Tier 2)
PA
SYMLINPEN 60 PEN INJECTOR
$0.00 (Tier 2)
PA
tolazamide (250 mg tablet, 500 mg
tablet)
$0.00 (Tier 1)
(g)
tolbutamide 500 mg tablet
$0.00 (Tier 1)
(g)
VICTOZA 2-PAK 18 MG/3 ML PEN
$0.00 (Tier 2)
PA
VICTOZA 3-PAK 18 MG/3 ML PEN
$0.00 (Tier 2)
PA
WELCHOL (3.75G PACKET, 625 MG
TABLET)
$0.00 (Tier 2)
ST
Glycemic Agents
GLUCAGON 1 MG EMERGENCY KIT
$0.00 (Tier 1)
PROGLYCEM 50 MG/ML ORAL SUSP
$0.00 (Tier 2)
Insulins
APIDRA 100 UNITS/ML VIAL
$0.00 (Tier 2)
52
Name of drug
(tier level)
Necessary actions,
APIDRA SOLOSTAR 100 UNITS/ML
$0.00 (Tier 2)
HUMULIN 70-30 (PEN, RELION VIAL,
VIAL)
$0.00 (Tier 2)
HUMULIN 70/30 KWIKPEN
$0.00 (Tier 2)
HUMULIN N (N 100 UNITS/ML PEN, N
100 UNITS/ML VIAL, RELION N 100
UNIT/ML)
$0.00 (Tier 2)
HUMULIN N 100 UNITS/ML KWIKPEN
$0.00 (Tier 2)
HUMULIN R (R 100 UNITS/ML VIAL,
RELION R 100 UNIT/ML)
$0.00 (Tier 2)
HUMULIN R 500 UNITS/ML VIAL
$0.00 (Tier 2)
ST
INCRELEX 40 MG/4 ML VIAL
$0.00 (Tier 2)
PA
LANTUS (100 UNITS/ML CARTRIDGE,
100 UNITS/ML VIAL)
$0.00 (Tier 2)
LANTUS SOLOSTAR 100 UNITS/ML
$0.00 (Tier 2)
LEVEMIR 100 UNITS/ML VIAL
$0.00 (Tier 2)
LEVEMIR FLEXPEN 100 UNITS/ML
$0.00 (Tier 2)
LEVEMIR FLEXTOUCH 100 UNITS/ML
$0.00 (Tier 2)
NOVOLIN 70-30 (100 UNIT/ML VIAL,
RELION VIAL)
$0.00 (Tier 2)
NOVOLIN N (N 100 UNITS/ML VIAL,
RELION N 100 UNIT/ML)
$0.00 (Tier 2)
NOVOLIN R (R 100 UNITS/ML VIAL,
RELION R 100 UNIT/ML)
$0.00 (Tier 2)
NOVOLOG (100 UNIT/ML CARTRIDGE,
100 UNIT/ML VIAL)
$0.00 (Tier 2)
NOVOLOG FLEXPEN SYRINGE
$0.00 (Tier 2)
NOVOLOG MIX 70-30 FLEXPEN SYRN
$0.00 (Tier 2)
NOVOLOG MIX 70-30 VIAL
$0.00 (Tier 2)
53
Blood Products/Modifiers/ Volume Expanders
(tier level)
Necessary actions,
enoxaparin sodium (100 mg/ml syringe,
120mg/.8ml syringe, 150 mg/ml
syringe, 30mg/0.3ml syringe,
40mg/0.4ml syringe, 60mg/0.6ml
syringe, 80mg/0.8ml syringe)
$0.00 (Tier 1)
PA, (g)
fondaparinux sodium (10mg/0.8ml
syringe, 2.5 mg/0.5 syringe, 5mg/0.4ml
syringe, 7.5mg/0.6 syringe)
$0.00 (Tier 1)
(g)
FRAGMIN (10,000 UNITS SYRINGE,
25,000 UNITS/ML VIAL)
$0.00 (Tier 2)
QL (30 ML PER 180 DAYS)
FRAGMIN (12,500 UNITS SYRINGE,
15,000 UNITS SYRINGE, 18,000 UNITS
SYRINGE, 5,000 UNITS SYRINGE, 7,500
UNITS SYRINGE)
$0.00 (Tier 2)
FRAGMIN 2,500 UNITS SYRINGE
$0.00 (Tier 2)
heparin sodium,porcine (1000/ml vial,
10000/ml vial, 20000/ml vial, 5000/ml
vial, 5000/ml(1) cartridge)
$0.00 (Tier 1)
(g)
heparin sodium,porcine in 0.9 % sodium
chloride/pf (1000/500ml iv soln,
2k/1000ml iv soln)
$0.00 (Tier 1)
(g)
heparin sodium,porcine/dextrose 5 % in
water (12500/250 iv soln, 20k/500ml iv
soln, 25000/250 iv soln, 25000/500 iv
soln)
$0.00 (Tier 1)
(g)
PRADAXA (150 MG CAPSULE, 75 MG
CAPSULE)
$0.00 (Tier 2)
warfarin sodium (1 mg tablet, 10 mg
tablet, 2 mg tablet, 2.5 mg tablet, 3 mg
tablet, 4 mg tablet, 5 mg tablet, 6 mg
tablet, 7.5 mg tablet)
$0.00 (Tier 1)
XARELTO (10 MG TABLET, 15 MG
$0.00 (Tier 2)
Name of drug
Anticoagulants
(g)
Blood Formation Modifiers
anagrelide hcl (0.5 mg capsule, 1 mg
capsule)
$0.00 (Tier 1)
(g)
54
Name of drug
(tier level)
Necessary actions,
ARANESP (100 MCG/0.5 ML SYRINGE,
100 MCG/ML VIAL, 150 MCG/0.3 ML
SYRINGE, 150 MCG/0.75 ML VIAL, 200
MCG/0.4 ML SYRINGE, 200 MCG/ML
VIAL, 25 MCG/0.42 ML SYRING, 300
MCG/0.6 ML SYRINGE, 300 MCG/ML
VIAL, 40 MCG/0.4 ML SYRINGE, 500
MCG/1 ML SYRINGE, 60 MCG/0.3 ML
SYRINGE, 60 MCG/ML VIAL)
$0.00 (Tier 2)
PA
ARANESP (25 MCG/ML VIAL, 40
MCG/ML VIAL)
$0.00 (Tier 2)
BD
EPOGEN (10,000 UNITS/ML VIAL, 2,000
UNITS/ML VIAL, 20,000 UNITS/2 ML
VIAL, 20,000 UNITS/ML VIAL, 3,000
UNITS/ML VIAL, 4,000 UNITS/ML VIAL)
$0.00 (Tier 2)
BD
LEUKINE 250 MCG VIAL
$0.00 (Tier 2)
PA
MOZOBIL (20 MG/ML VIAL, 24 MG/1.2
ML VIAL)
$0.00 (Tier 2)
PA
NEULASTA 6 MG/0.6 ML SYRINGE
$0.00 (Tier 2)
PA
NEUMEGA 5 MG VIAL
$0.00 (Tier 2)
PA
NEUPOGEN (300 MCG/0.5 ML SYR, 300
MCG/ML VIAL, 480 MCG/0.8 ML SYR,
480 MCG/1.6 ML VIAL)
$0.00 (Tier 2)
PA
PROCRIT (10,000 UNITS/ML VIAL, 2,000
UNITS/ML VIAL, 20,000 UNITS/ML VIAL,
3,000 UNITS/ML VIAL, 4,000 UNITS/ML
VIAL, 40,000 UNITS/ML VIAL)
$0.00 (Tier 2)
BD
PROMACTA (25 MG TABLET, 50 MG
$0.00 (Tier 2)
PA
tranexamic acid (1000 mg/10 ampul,
1000 mg/10 vial)
$0.00 (Tier 1)
(g)
tranexamic acid 650 mg tablet
$0.00 (Tier 2)
(g)
Coagulants
Platelet Modifying Agents
AGGRENOX 25 MG-200 MG CAPSULE
$0.00 (Tier 2)
BRILINTA 90 MG TABLET
$0.00 (Tier 2)
55
Name of drug
(tier level)
Necessary actions,
cilostazol (100 mg tablet, 50 mg tablet)
$0.00 (Tier 1)
(g)
clopidogrel bisulfate (300 mg tablet, 75
mg tablet)
$0.00 (Tier 1)
(g)
dipyridamole (25 mg tablet, 50 mg
$0.00 (Tier 1)
(g)
EFFIENT (10 MG TABLET, 5 MG TABLET)
$0.00 (Tier 2)
ticlopidine hcl 250 mg tablet
$0.00 (Tier 1)
(g)
(tier level)
Necessary actions,
clonidine (0.1mg/24hr patch tdwk,
0.2mg/24hr patch tdwk, 0.3mg/24hr
patch tdwk)
$0.00 (Tier 1)
(g)
clonidine hcl (0.1 mg tablet, 0.2 mg
$0.00 (Tier 1)
(g)
DEMSER 250 MG CAPSULE
$0.00 (Tier 2)
guanfacine hcl (1 mg tablet, 2 mg
tablet)
$0.00 (Tier 1)
(g)
methyldopa (250 mg tablet, 500 mg
tablet)
$0.00 (Tier 1)
(g)
methyldopa/hydrochlorothiazide
(250mg-15mg tablet, 250mg-25mg
tablet)
$0.00 (Tier 1)
(g)
midodrine hcl (10 mg tablet, 2.5 mg
$0.00 (Tier 1)
(g)
Cardiovascular Agents
Name of drug
Alpha-adrenergic Agonists
Alpha-adrenergic Blocking Agents
DIBENZYLINE 10 MG CAPSULE
$0.00 (Tier 2)
prazosin hcl (1 mg capsule, 2 mg
$0.00 (Tier 1)
(g)
reserpine (0.1 mg tablet, 0.25 mg
tablet)
$0.00 (Tier 1)
(g)
terazosin hcl (1 mg capsule, 10 mg
$0.00 (Tier 1)
(g)
56
Name of drug
(tier level)
Necessary actions,
Angiotensin II Receptor Antagonists
BENICAR (20 MG TABLET, 40 MG
$0.00 (Tier 2)
BENICAR HCT (20-12.5 MG TABLET, 4012.5 MG TABLET, 40-25 MG TABLET)
$0.00 (Tier 2)
DIOVAN (160 MG TABLET, 320 MG
TABLET, 40 MG TABLET, 80 MG TABLET)
$0.00 (Tier 2)
irbesartan (150 mg tablet, 300 mg
$0.00 (Tier 1)
(g)
irbesartan/hydrochlorothiazide (15012.5mg tablet, 300-12.5mg tablet)
$0.00 (Tier 1)
(g)
losartan potassium (100 mg tablet, 25
$0.00 (Tier 1)
(g)
losartan potassium/hydrochlorothiazide
(100-12.5mg tablet, 100mg-25mg
tablet, 50-12.5 mg tablet)
$0.00 (Tier 1)
(g)
MICARDIS (20 MG TABLET, 40 MG
$0.00 (Tier 2)
MICARDIS HCT (40-12.5 MG TABLET,
80-12.5 MG TABLET, 80-25 MG TABLET)
$0.00 (Tier 2)
ST
TRIBENZOR (20-5-12.5 MG TABLET, 4010-12.5 MG TABLET, 40-10-25 MG
TABLET, 40-5-12.5 MG TABLET, 40-5-25
MG TABLET)
$0.00 (Tier 2)
ST
valsartan/hydrochlorothiazide (16012.5mg tablet, 160-25mg tablet, 32012.5mg tablet, 320mg-25mg tablet, 8012.5mg tablet)
$0.00 (Tier 1)
(g)
ST
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl (10 mg tablet, 20 mg
$0.00 (Tier 1)
(g)
benazepril hcl/hydrochlorothiazide (1012.5mg tablet, 20-12.5 mg tablet, 2025mg tablet, 5-6.25mg tablet)
$0.00 (Tier 1)
(g)
captopril (100 mg tablet, 12.5 mg
$0.00 (Tier 1)
(g)
57
Name of drug
(tier level)
Necessary actions,
captopril/hydrochlorothiazide (25 mg15mg tablet, 25 mg-25mg tablet, 50
mg-15mg tablet, 50 mg-25mg tablet)
$0.00 (Tier 1)
(g)
enalapril maleate (10 mg tablet, 2.5 mg
$0.00 (Tier 1)
(g)
enalapril maleate/hydrochlorothiazide
(10 mg-25mg tablet, 5mg-12.5mg
tablet)
$0.00 (Tier 1)
(g)
fosinopril sodium (10 mg tablet, 20 mg
$0.00 (Tier 1)
(g)
fosinopril sodium/hydrochlorothiazide
(10-12.5mg tablet, 20-12.5 mg tablet)
$0.00 (Tier 1)
(g)
lisinopril (10 mg tablet, 2.5 mg tablet,
$0.00 (Tier 1)
(g)
lisinopril/hydrochlorothiazide (1012.5mg tablet, 20-12.5 mg tablet, 2025mg tablet)
$0.00 (Tier 1)
(g)
moexipril hcl 15 mg tablet
$0.00 (Tier 1)
(g)
moexipril hcl/hydrochlorothiazide (1512.5mg tablet, 15-25mg tablet, 7.512.5mg tablet)
$0.00 (Tier 1)
(g)
perindopril erbumine (2 mg tablet, 4 mg
$0.00 (Tier 1)
(g)
quinapril hcl (10 mg tablet, 20 mg
$0.00 (Tier 1)
(g)
quinapril hcl/hydrochlorothiazide (1012.5mg tablet, 20-12.5 mg tablet, 2025mg tablet)
$0.00 (Tier 1)
(g)
ramipril (1.25 mg capsule, 10 mg
capsule, 2.5 mg capsule, 5 mg capsule)
$0.00 (Tier 1)
(g)
TARKA (ER 1-240 MG TABLET, ER 2-180
MG TABLET, ER 2-240 MG TABLET, ER
4-240 MG TABLET)
$0.00 (Tier 2)
ST
trandolapril (1 mg tablet, 2 mg tablet, 4
mg tablet)
$0.00 (Tier 1)
(g)
58
(tier level)
Necessary actions,
amiodarone hcl (200 mg tablet, 400 mg
tablet)
$0.00 (Tier 1)
(g)
disopyramide phosphate (100 mg
$0.00 (Tier 1)
(g)
flecainide acetate (100 mg tablet, 150
$0.00 (Tier 1)
(g)
mexiletine hcl (150 mg capsule, 200 mg
$0.00 (Tier 1)
(g)
MULTAQ 400 MG TABLET
$0.00 (Tier 2)
PA
NORPACE CR (100 MG CAPSULE, 150
MG CAPSULE)
$0.00 (Tier 2)
propafenone hcl (150 mg tablet, 225
mg cap er 12h, 225 mg tablet, 300 mg
tablet, 325 mg cap er 12h, 425 mg cap
er 12h)
$0.00 (Tier 1)
(g)
quinidine gluconate 324 mg tablet er
$0.00 (Tier 1)
(g)
quinidine sulfate (200 mg tablet, 300
mg tablet, 300 mg tablet er)
$0.00 (Tier 1)
(g)
sotalol hcl (120 mg tablet, 160 mg
$0.00 (Tier 1)
(g)
TIKOSYN (125 MCG CAPSULE, 250 MCG
CAPSULE, 500 MCG CAPSULE)
$0.00 (Tier 2)
Name of drug
Antiarrhythmics
Beta-adrenergic Blocking Agents
acebutolol hcl (200 mg capsule, 400 mg
capsule)
$0.00 (Tier 1)
(g)
atenolol (100 mg tablet, 25 mg tablet,
50 mg tablet)
$0.00 (Tier 1)
(g)
atenolol/chlorthalidone (100mg-25mg
tablet, 50 mg-25mg tablet)
$0.00 (Tier 1)
(g)
betaxolol hcl 20 mg tablet
$0.00 (Tier 1)
(g)
bisoprolol fumarate (10 mg tablet, 5 mg
tablet)
$0.00 (Tier 1)
(g)
bisoprolol
fumarate/hydrochlorothiazide (106.25mg tablet, 2.5-6.25mg tablet, 56.25mg tablet)
$0.00 (Tier 1)
(g)
59
Name of drug
(tier level)
Necessary actions,
BYSTOLIC (10 MG TABLET, 2.5 MG
$0.00 (Tier 2)
carvedilol (12.5 mg tablet, 25 mg
tablet, 3.125 mg tablet, 6.25 mg tablet)
$0.00 (Tier 1)
(g)
labetalol hcl (100 mg tablet, 200 mg
$0.00 (Tier 1)
(g)
metoprolol succinate (100 mg tab er
24h, 200 mg tab er 24h, 25 mg tab er
24h, 50 mg tab er 24h)
$0.00 (Tier 1)
(g)
metoprolol tartrate (100 mg tablet, 25
$0.00 (Tier 1)
(g)
metoprolol
tartrate/hydrochlorothiazide (100mg25mg tablet, 100mg-50mg tablet, 50
mg-25mg tablet)
$0.00 (Tier 1)
(g)
nadolol (20 mg tablet, 40 mg tablet, 80
mg tablet)
$0.00 (Tier 1)
(g)
pindolol (10 mg tablet, 5 mg tablet)
$0.00 (Tier 1)
(g)
propranolol hcl (10 mg tablet, 120 mg
cap sa 24h, 160 mg cap sa 24h, 20 mg
tablet, 20 mg/5 ml solution, 40 mg
tablet, 40mg/5ml solution, 60 mg cap
sa 24h, 60 mg tablet, 80 mg cap sa 24h,
80 mg tablet)
$0.00 (Tier 1)
(g)
propranolol hcl/hydrochlorothiazide (40
mg-25mg tablet, 80 mg-25mg tablet)
$0.00 (Tier 1)
(g)
timolol maleate (10 mg tablet, 20 mg
$0.00 (Tier 1)
(g)
amlodipine besylate (10 mg tablet, 2.5
$0.00 (Tier 1)
(g)
amlodipine besylate/benazepril hcl (10
mg-20mg capsule, 10 mg-40mg
capsule, 2.5mg-10mg capsule, 5 mg-10
mg capsule, 5 mg-20 mg capsule, 5 mg40 mg capsule)
$0.00 (Tier 1)
(g)
AZOR (5-20 MG TABLET, 5-40 MG
TABLET)
$0.00 (Tier 2)
ST
Calcium Channel Blocking Agents
60
Name of drug
(tier level)
Necessary actions,
diltiazem hcl (120 mg cap er 12h, 120
mg cap er 24h, 120 mg cap er deg, 120
mg capsule er, 120 mg tablet, 180 mg
cap er 24h, 180 mg cap er deg, 180 mg
capsule er, 240 mg cap er 24h, 240 mg
cap er deg, 240 mg capsule er, 30 mg
tablet, 300 mg cap er 24h, 300 mg
tablet, 90 mg cap er 12h, 90 mg tablet)
$0.00 (Tier 1)
(g)
EXFORGE (10-160 MG TABLET, 10-320
MG TABLET, 5-160 MG TABLET, 5-320
MG TABLET)
$0.00 (Tier 2)
ST
EXFORGE HCT (10-160-12.5 MG TAB,
10-160-25 MG TAB, 10-320-25 MG TAB,
5-160-12.5 MG TAB, 5-160-25 MG TAB)
$0.00 (Tier 2)
ST
felodipine (10 mg tab er 24h, 2.5 mg
tab er 24h, 5 mg tab er 24h)
$0.00 (Tier 1)
(g)
isradipine (2.5 mg capsule, 5 mg
capsule)
$0.00 (Tier 1)
(g)
nicardipine hcl (20 mg capsule, 30 mg
capsule)
$0.00 (Tier 1)
(g)
nifedipine (10 mg capsule, 20 mg
capsule, 30 mg tab er 24, 30 mg tablet
er, 60 mg tab er 24, 60 mg tablet er, 90
mg tab er 24, 90 mg tablet er)
$0.00 (Tier 1)
(g)
nimodipine 30 mg capsule
$0.00 (Tier 1)
(g)
nisoldipine (17 mg tab er 24h, 20 mg
tab er 24h, 25.5 mg tab er 24h, 30 mg
tab er 24h, 34 mg tab er 24h, 40 mg tab
er 24h, 8.5mg tab er 24h)
$0.00 (Tier 1)
(g)
verapamil hcl (100 mg cap24h pct, 120
mg cap24h pel, 120 mg tablet, 120 mg
tablet er, 180 mg cap24h pel, 180 mg
tablet er, 200 mg cap24h pct, 240 mg
cap24h pel, 240 mg tablet er, 300 mg
cap24h pct, 40 mg tablet, 80 mg tablet)
$0.00 (Tier 1)
(g)
VERELAN 360 MG CAP PELLET
$0.00 (Tier 2)
61
(tier level)
Necessary actions,
AMTURNIDE (150-5-12.5 MG TAB, 30010-12.5 MG TAB, 300-10-25 MG TAB,
300-5-12.5 MG TAB, 300-5-25 MG TAB)
$0.00 (Tier 2)
ST
digoxin (125 mcg tablet, 250 mcg
tablet, 50 mcg/ml solution)
$0.00 (Tier 1)
(g)
pentoxifylline 400 mg tablet er
$0.00 (Tier 1)
(g)
RANEXA (ER 1,000 MG TABLET, ER 500
MG TABLET)
$0.00 (Tier 2)
PA
TEKAMLO (150 MG-10 MG TABLET, 150
MG-5 MG TABLET, 300 MG-10 MG
TABLET, 300 MG-5 MG TABLET)
$0.00 (Tier 2)
TEKTURNA (150 MG TABLET, 300 MG
TABLET)
$0.00 (Tier 2)
TEKTURNA HCT (150-12.5 MG TAB, 15025 MG TABLET, 300-12.5 MG TAB, 30025 MG TABLET)
$0.00 (Tier 2)
ST
acetazolamide (125 mg tablet, 250 mg
tablet, 500 mg capsule er)
$0.00 (Tier 1)
(g)
methazolamide (25 mg tablet, 50 mg
tablet)
$0.00 (Tier 1)
(g)
bumetanide (0.5 mg tablet, 1 mg tablet,
2 mg tablet)
$0.00 (Tier 1)
(g)
furosemide (10 mg/ml solution, 10
mg/ml vial, 20 mg tablet, 40 mg tablet,
40 mg/4 ml solution, 40mg/5ml
solution, 80 mg tablet)
$0.00 (Tier 1)
(g)
torsemide (10 mg tablet, 100 mg tablet,
20 mg tablet, 20 mg/2 ml vial, 5 mg
tablet, 50 mg/5 ml vial)
$0.00 (Tier 1)
(g)
amiloride hcl 5 mg tablet
$0.00 (Tier 1)
(g)
amiloride/hydrochlorothiazide 5mg50mg tablet
$0.00 (Tier 1)
(g)
Name of drug
Cardiovascular Agents, Other
Diuretics, Carbonic Anhydrase
Diuretics, Loop
Diuretics, Potassium-sparing
62
Name of drug
(tier level)
Necessary actions,
DYRENIUM (100 MG CAPSULE, 50 MG
CAPSULE)
$0.00 (Tier 2)
eplerenone (25 mg tablet, 50 mg tablet)
$0.00 (Tier 1)
(g)
spironolact/hydrochlorothiazid 25 mg25mg tablet
$0.00 (Tier 1)
(g)
spironolactone (100 mg tablet, 25 mg
$0.00 (Tier 1)
(g)
triamterene/hydrochlorothiazide (37.525 mg capsule, 37.5-25 mg tablet, 75
mg-50mg tablet)
$0.00 (Tier 1)
(g)
chlorothiazide (250 mg tablet, 500 mg
tablet)
$0.00 (Tier 1)
(g)
chlorthalidone (25 mg tablet, 50 mg
tablet)
$0.00 (Tier 1)
(g)
CLORPRES (0.1-15 TABLET, 0.2-15
TABLET, 0.3-15 TABLET)
$0.00 (Tier 2)
hydrochlorothiazide (12.5 mg capsule,
12.5 mg tablet, 25 mg tablet, 50 mg
tablet)
$0.00 (Tier 1)
(g)
indapamide (1.25 mg tablet, 2.5 mg
tablet)
$0.00 (Tier 1)
(g)
methyclothiazide 5 mg tablet
$0.00 (Tier 1)
(g)
metolazone (10 mg tablet, 2.5 mg
$0.00 (Tier 1)
(g)
Diuretics, Thiazide
Dyslipidemics, Fibric Acid Derivatives
fenofibrate (160 mg tablet, 54 mg
tablet)
$0.00 (Tier 1)
(g)
fenofibrate nanocrystallized (145mg
$0.00 (Tier 1)
(g)
fenofibrate,micronized (134mg capsule,
200 mg capsule, 67 mg capsule)
$0.00 (Tier 1)
(g)
gemfibrozil 600 mg tablet
$0.00 (Tier 1)
(g)
TRILIPIX (DR 135 MG CAPSULE, DR 45
MG CAPSULE)
$0.00 (Tier 2)
ST
63
Name of drug
(tier level)
Necessary actions,
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium (10 mg tablet, 20
$0.00 (Tier 1)
(g)
CRESTOR (10 MG TABLET, 20 MG
$0.00 (Tier 2)
ST
fluvastatin sodium (20 mg capsule, 40
mg capsule)
$0.00 (Tier 1)
(g)
lovastatin (10 mg tablet, 20 mg tablet,
40 mg tablet)
$0.00 (Tier 1)
(g)
pravastatin sodium (10 mg tablet, 20
$0.00 (Tier 1)
(g)
simvastatin (10 mg tablet, 20 mg
tablet)
$0.00 (Tier 1)
(g)
cholestyramine/aspartame (4 g powd
pack, 4 g powder)
$0.00 (Tier 1)
(g)
colestipol hcl (1 g tablet, 5 g granules, 5
g packet)
$0.00 (Tier 1)
(g)
LOVAZA 1 GM CAPSULE
$0.00 (Tier 2)
NIACOR 500 MG TABLET
$0.00 (Tier 2)
NIASPAN (ER 1,000 MG TABLET, ER 500
MG TABLET, ER 750 MG TABLET)
$0.00 (Tier 2)
SIMCOR (1,000-40 MG TABLET, 500-20
MG TABLET, 500-40 MG TABLET, 75020 MG TABLET)
$0.00 (Tier 2)
ST
VYTORIN (10-10 MG TABLET, 10-20 MG
TABLET, 10-40 MG TABLET, 10-80 MG
TABLET)
$0.00 (Tier 2)
ST
ZETIA 10 MG TABLET
$0.00 (Tier 2)
Dyslipidemics, Other
Vasodilators, Direct-acting Arterial
hydralazine hcl (10 mg tablet, 100 mg
$0.00 (Tier 1)
(g)
minoxidil (10 mg tablet, 2.5 mg tablet)
$0.00 (Tier 1)
(g)
64
Name of drug
(tier level)
Necessary actions,
Vasodilators, Direct-acting Arterial/Venous
isosorbide dinitrate (10 mg tablet, 20
mg tablet, 30 mg tablet, 40 mg tablet
er, 5 mg tablet)
$0.00 (Tier 1)
(g)
isosorbide mononitrate (10 mg tablet,
120 mg tab er 24h, 20 mg tablet, 30 mg
tab er 24h, 60 mg tab er 24h)
$0.00 (Tier 1)
(g)
NITRO-BID 2% OINTMENT
$0.00 (Tier 2)
nitroglycerin (0.1mg/hr patch td24,
0.2mg/hr patch td24, 0.4mg/hr patch
td24, 0.6mg/hr patch td24)
$0.00 (Tier 1)
NITROMIST 400 MCG SPRAY
$0.00 (Tier 2)
NITROSTAT (0.3 MG TABLET SL, 0.4 MG
TABLET SL, 0.6 MG TABLET SL)
$0.00 (Tier 2)
(g)
Central Nervous System Agents
Name of drug
(tier level)
Necessary actions,
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
ADDERALL XR 25 MG CAPSULE
$0.00 (Tier 2)
dextroamphetamine sulfsaccharate/amphetamine sulfaspartate (10 mg tablet, 12.5 mg
mg tablet, 5 mg tablet, 7.5 mg tablet)
$0.00 (Tier 1)
(g)
dextroamphetamine sulfate (10 mg
capsule er, 10 mg tablet, 15 mg capsule
er, 5 mg capsule er, 5 mg tablet)
$0.00 (Tier 1)
PA, (g)
VYVANSE (20 MG CAPSULE, 30 MG
CAPSULE)
$0.00 (Tier 2)
PA
Attention Deficit Hyperactivity Disorder Agents, Non- amphetamines
CONCERTA (ER 18 MG TABLET, ER 27
MG TABLET, ER 36 MG TABLET, ER 54
MG TABLET)
$0.00 (Tier 2)
PA
65
Name of drug
(tier level)
Necessary actions,
DAYTRANA 15 MG/9 HR PATCH
$0.00 (Tier 2)
PA
dexmethylphenidate hcl (10 mg tablet,
2.5 mg tablet, 5 mg tablet)
$0.00 (Tier 1)
PA, (g)
FOCALIN XR (10 MG CAPSULE, 15 MG
CAPSULE)
$0.00 (Tier 2)
PA
INTUNIV (ER 3 MG TABLET, ER 4 MG
TABLET)
$0.00 (Tier 2)
PA
METADATE CD (30 MG CAPSULE, 40
MG CAPSULE)
$0.00 (Tier 2)
PA
METHYLIN (10 MG CHEWABLE TABLET,
2.5 MG CHEWABLE TAB, 5 MG
CHEWABLE TABLET)
$0.00 (Tier 2)
PA
methylphenidate hcl (10 mg cpbp 3070, 10 mg tablet, 10 mg/5 ml solution,
20 mg tablet, 20 mg tablet er, 5 mg
tablet, 5 mg/5 ml solution, 50 mg cpbp
30-70, 60 mg cpbp 30-70)
$0.00 (Tier 1)
PA, (g)
RITALIN LA (20 MG CAPSULE, 30 MG
$0.00 (Tier 2)
PA
STRATTERA (10 MG CAPSULE, 18 MG
CAPSULE)
$0.00 (Tier 2)
QL (60 PER 30 DAYS)
STRATTERA (100 MG CAPSULE, 60 MG
$0.00 (Tier 2)
QL (30 PER 30 DAYS)
Central Nervous System, Other
HORIZANT ER 600 MG TABLET
$0.00 (Tier 2)
NUEDEXTA 20-10 MG CAPSULE
$0.00 (Tier 2)
RILUTEK 50 MG TABLET
$0.00 (Tier 2)
XENAZINE (12.5 MG TABLET, 25 MG
TABLET)
$0.00 (Tier 2)
PA
PA
Fibromyalgia Agents
SAVELLA (100 MG TABLET, 12.5 MG
$0.00 (Tier 2)
66
(tier level)
Necessary actions,
AMPYRA ER 10 MG TABLET
$0.00 (Tier 2)
PA
AVONEX (30 MCG, 30 MCG KT)
$0.00 (Tier 2)
PA
AVONEX ADMIN PACK 30 MCG VL
$0.00 (Tier 2)
PA
AVONEX PEN 30 MCG/0.5 ML
$0.00 (Tier 2)
PA
BETASERON (0.3 MG KIT, 0.3 MG VIAL)
$0.00 (Tier 2)
PA
COPAXONE 20 MG/ML SYRINGE
$0.00 (Tier 2)
EXTAVIA (0.3 MG KIT, 0.3 MG VIAL)
$0.00 (Tier 2)
PA
GILENYA 0.5 MG CAPSULE
$0.00 (Tier 2)
PA
REBIF (22 MCG/0.5 ML SYRINGE, 44
MCG/0.5 ML SYRINGE)
$0.00 (Tier 2)
PA
REBIF REBIDOSE (22 MCG/0.5 ML, 44
MCG/0.5 ML)
$0.00 (Tier 2)
PA
TYSABRI 300 MG/15 ML VIAL
$0.00 (Tier 2)
PA
(tier level)
Necessary actions,
cevimeline hcl 30 mg capsule
$0.00 (Tier 1)
(g)
chlorhexidine gluconate 0.12 %
mouthwash
$0.00 (Tier 2)
(g)
KEPIVANCE 6.25 MG VIAL
$0.00 (Tier 2)
pilocarpine hcl (5 mg tablet, 7.5 mg
tablet)
$0.00 (Tier 1)
(g)
triamcinolone acetonide 0.1 % paste (g)
$0.00 (Tier 1)
(g)
(tier level)
Necessary actions,
Name of drug
Multiple Sclerosis Agents
Dental and Oral Agents
Name of drug
Dental and Oral Agents
Dermatological Agents
Name of drug
67
adapalene (0.1 % cream (g), 0.1 % gel
(gram))
$0.00 (Tier 1)
(g)
Name of drug
(tier level)
Necessary actions,
ammonium lactate 12 % lotion
$0.00 (Tier 1)
(g)
AMNESTEEM (10 MG CAPSULE, 20 MG
$0.00 (Tier 2)
calcipotriene (0.005 % oint. (g), 0.005 %
solution)
$0.00 (Tier 1)
CARAC (, 0.5%)
$0.00 (Tier 2)
CLARAVIS (10 MG CAPSULE, 20 MG
CAPSULE)
$0.00 (Tier 2)
clindamycin phosphate (1 % gel (gram),
1 % lotion, 1 % med. swab, 1 % solution)
$0.00 (Tier 1)
(g)
clobetasol propionate/emoll 0.05 %
cream (g)
$0.00 (Tier 1)
(g)
CORTISPORIN CREAM
$0.00 (Tier 2)
DENAVIR 1% CREAM
$0.00 (Tier 2)
diclofenac sodium 3 % gel (gram)
$0.00 (Tier 1)
ELIDEL 1% CREAM
$0.00 (Tier 2)
erythromycin base/ethyl alcohol (2 %
gel (gram), 2 % solution)
$0.00 (Tier 1)
(g)
erythromycin/benzoyl peroxide 3 %-5 %
gel (gram)
$0.00 (Tier 1)
(g)
fluocinonide/emollient base 0.05 %
cream (g)
$0.00 (Tier 1)
(g)
fluorouracil (1 g/20 ml vial, 2.5 g/50ml
vial, 5 g/100 ml vial, 500mg/10ml vial)
$0.00 (Tier 1)
BD, (g)
fluorouracil (2 % solution, 5 % cream
(g), 5 % solution)
$0.00 (Tier 1)
(g)
imiquimod 5 % cream pack
$0.00 (Tier 1)
(g)
LIDODERM 5% PATCH
$0.00 (Tier 2)
PA
nystatin/triamcinolone acetonide
(cream (g), oint. (g))
$0.00 (Tier 1)
(g)
OXSORALEN 1% LOTION
$0.00 (Tier 2)
PA
(g)
(g)
68
Name of drug
(tier level)
Necessary actions,
OXSORALEN-ULTRA 10 MG CAP
$0.00 (Tier 2)
PA
PENNSAID 1.5% SOLUTION
$0.00 (Tier 2)
PICATO (0.015% GEL, 0.05% GEL)
$0.00 (Tier 2)
PA
podofilox 0.5 % solution
$0.00 (Tier 1)
(g)
PROTOPIC (0.03% OINTMENT, 0.1%
OINTMENT)
$0.00 (Tier 2)
SANTYL OINTMENT
$0.00 (Tier 2)
silver sulfadiazine 1 % cream (g)
$0.00 (Tier 1)
SOLARAZE 3% GEL
$0.00 (Tier 2)
SORIATANE (10 MG CAPSULE, 17.5 MG
$0.00 (Tier 2)
TACLONEX (0.005%-0.064% SUSPENS,
OINTMENT)
$0.00 (Tier 2)
TAZORAC (0.05% CREAM, 0.05% GEL,
0.1% CREAM, 0.1% GEL)
$0.00 (Tier 2)
tretinoin (0.01 % gel (gram), 0.025 %
cream (g), 0.025 % gel (gram), 0.05 %
cream (g), 0.1 % cream (g))
$0.00 (Tier 1)
UVADEX 20 MCG/ML VIAL
$0.00 (Tier 2)
VOLTAREN 1% GEL
$0.00 (Tier 2)
ZYCLARA (, PUMP)
$0.00 (Tier 2)
(g)
(g)
Enzyme Replacement/ Modifiers
Name of drug
(tier level)
Necessary actions,
ADAGEN 250 UNITS/ML VIAL
$0.00 (Tier 2)
CEREZYME (200 UNITS VIAL, 400 UNITS
VIAL)
$0.00 (Tier 2)
CREON (DR 12,000 UNITS CAPSULE, DR
24,000 UNITS CAPSULE, DR 6,000 UNITS
CAPSULE)
$0.00 (Tier 2)
CYSTADANE POWDER
$0.00 (Tier 2)
BD
69
Name of drug
(tier level)
Necessary actions,
FABRAZYME (35 MG VIAL, 5 MG VIAL)
$0.00 (Tier 2)
KUVAN 100 MG TABLET
$0.00 (Tier 2)
PA
levocarnitine (with sugar) 100 mg/ml
solution
$0.00 (Tier 1)
BD, (g)
levocarnitine 330 mg tablet
$0.00 (Tier 1)
BD, (g)
LUMIZYME 50 MG VIAL
$0.00 (Tier 2)
PA
NAGLAZYME 5 MG/5 ML VIAL
$0.00 (Tier 2)
PANCREAZE (DR 10,500 UNIT CAP, DR
16,800 UNIT CAP, DR 21,000 UNIT CAP,
DR 4,200 UNIT CAP)
$0.00 (Tier 2)
ZAVESCA 100 MG CAPSULE
$0.00 (Tier 2)
ZENPEP (DR 10,000 UNITS CAPSULE, DR
15,000 UNITS CAPSULE, DR 20,000
UNITS CAPSULE, DR 25,000 UNITS
CAPSULE, DR 3,000 UNITS CAPSULE, DR
5,000 UNITS CAPSULE)
$0.00 (Tier 2)
Gastrointestinal Agents
(tier level)
Necessary actions,
dicyclomine hcl (10 mg capsule, 10
mg/5 ml solution, 20 mg tablet)
$0.00 (Tier 1)
PA, (g)
glycopyrrolate (1 mg tablet, 2 mg
tablet)
$0.00 (Tier 1)
(g)
methscopolamine bromide (2.5 mg
$0.00 (Tier 1)
(g)
propantheline bromide 15 mg tablet
$0.00 (Tier 1)
(g)
oxybutynin chloride (10 mg tab er 24,
15 mg tab er 24, 5 mg tab er 24, 5 mg
tablet, 5 mg/5 ml syrup)
$0.00 (Tier 1)
(g)
tolterodine tartrate (1 mg tablet, 2 mg
tablet)
$0.00 (Tier 1)
(g)
Name of drug
Antispasmodics, Gastrointestinal
Antispasmodics, Urinary
70
Name of drug
(tier level)
Necessary actions,
Benign Prostatic Hypertrophy Agents
doxazosin mesylate (1 mg tablet, 2 mg
$0.00 (Tier 1)
(g)
finasteride 5 mg tablet
$0.00 (Tier 1)
(g)
tamsulosin hcl 0.4 mg cap er 24h
$0.00 (Tier 1)
(g)
Gastrointestinal Agents, Other
CHENODAL 250 MG TABLET
$0.00 (Tier 2)
diphenoxylate hcl/atropine sulfate (2.5.025/5 liquid, 2.5-.025mg tablet)
$0.00 (Tier 1)
(g)
loperamide hcl 2 mg capsule
$0.00 (Tier 1)
(g)
metoclopramide hcl (10 mg tablet, 10
mg/10ml solution, 5 mg tablet, 5 mg/5
ml solution)
$0.00 (Tier 1)
(g)
metoclopramide hcl (5 mg/ml ampul, 5
mg/ml vial)
$0.00 (Tier 1)
BD, (g)
RELISTOR (12 MG/0.6 ML KIT, 12
MG/0.6 ML VIAL)
$0.00 (Tier 2)
ursodiol (250 mg tablet, 300 mg
$0.00 (Tier 1)
(g)
Histamine2 (H2) Receptor Antagonists
cimetidine (200 mg tablet, 300 mg
$0.00 (Tier 1)
(g)
cimetidine hcl 300 mg/5ml solution
$0.00 (Tier 1)
(g)
famotidine (20 mg tablet, 40 mg tablet,
40mg/5ml oral susp)
$0.00 (Tier 1)
(g)
famotidine in nacl,iso-osm/pf 20
mg/50ml piggyback
$0.00 (Tier 1)
(g)
famotidine/pf 20 mg/2 ml vial
$0.00 (Tier 1)
(g)
nizatidine (150 mg capsule,
150mg/10ml solution, 300 mg capsule)
$0.00 (Tier 1)
(g)
ranitidine hcl (15 mg/ml syrup, 150 mg
capsule, 150 mg tablet, 25 mg/ml vial,
300 mg capsule, 300 mg tablet, 50
mg/2 ml vial)
$0.00 (Tier 1)
(g)
71
Name of drug
(tier level)
Necessary actions,
Irritable Bowel Syndrome Agents
AMITIZA (24 MCG CAPSULES, 8 MCG
CAPSULE)
$0.00 (Tier 2)
LOTRONEX (0.5 MG TABLET, 1 MG
TABLET)
$0.00 (Tier 2)
Laxatives
lactulose (10 g/15 ml solution, 20 g/30
ml solution)
$0.00 (Tier 1)
(g)
polyethylene glycol 3350 (3350 17g
powd pack, 3350 17g/dose powder)
$0.00 (Tier 1)
(g)
calcium acetate 667 mg capsule
$0.00 (Tier 1)
(g)
RENVELA (0.8 GM POWDER PACKET,
2.4 GM POWDER PACKET, 800 MG
TABLET)
$0.00 (Tier 2)
Phosphate Binders
Protectants
CARAFATE 1 GM/10 ML SUSP
$0.00 (Tier 2)
misoprostol 200 mcg tablet
$0.00 (Tier 1)
(g)
sucralfate 1 g tablet
$0.00 (Tier 1)
(g)
DEXILANT (DR 30 MG CAPSULE, DR 60
MG CAPSULE)
$0.00 (Tier 2)
ST
lansoprazole (15 mg capsule dr, 30 mg
capsule dr)
$0.00 (Tier 1)
(g)
NEXIUM I.V. (20 MG VIAL, 40 MG VIAL)
$0.00 (Tier 2)
ST
omeprazole (10 mg capsule dr, 20 mg
capsule dr, 40 mg capsule dr)
$0.00 (Tier 1)
(g)
pantoprazole sodium (20 mg tablet dr,
40 mg tablet dr, 40 mg vial)
$0.00 (Tier 1)
(g)
ZEGERID (20 MG PACKET, 40 MG
PACKET)
$0.00 (Tier 2)
Proton Pump Inhibitors
72
Genitourinary Agents
(tier level)
Necessary actions,
DETROL LA (2 MG CAPSULE, 4 MG
CAPSULE)
$0.00 (Tier 2)
ST
flavoxate hcl 100 mg tablet
$0.00 (Tier 1)
(g)
OXYTROL 3.9 MG/24HR PATCH
$0.00 (Tier 2)
ST
trospium chloride (20 mg tablet, 60 mg
cap er 24h)
$0.00 (Tier 1)
(g)
VESICARE (10 MG TABLET, 5 MG
TABLET)
$0.00 (Tier 2)
ST
Name of drug
Antispasmodics, Urinary
Benign Prostatic Hypertrophy Agents
alfuzosin hcl 10 mg tab er 24h
$0.00 (Tier 1)
(g)
AVODART 0.5 MG SOFTGEL
$0.00 (Tier 2)
CIALIS (2.5 MG TABLET, 5 MG TABLET)
$0.00 (Tier 2)
PA
JALYN 0.5-0.4 MG CAPSULE
$0.00 (Tier 2)
ST
RAPAFLO (4 MG CAPSULE, 8 MG
CAPSULE)
$0.00 (Tier 2)
ST
bethanechol chloride (10 mg tablet, 25
$0.00 (Tier 1)
(g)
DEPEN 250 MG TITRATAB
$0.00 (Tier 2)
Genitourinary Agents, Other
Phosphate Binders
FOSRENOL (1,000 MG TABLET CHEW,
500 MG TABLET CHEW, 750 MG TABLET
CHEW)
$0.00 (Tier 2)
RENAGEL (400 MG TABLET, 800 MG
TABLET)
$0.00 (Tier 2)
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Name of drug
(tier level)
Necessary actions,
73
ASMANEX (TWISTHALER 110 MCG #30,
TWISTHALER 220 MCG #30,
TWISTHALER 220 MCG #60, TWISTHALR
220 MCG #120)
$0.00 (Tier 2)
Name of drug
(tier level)
Necessary actions,
betamethasone dipropionate (0.05 %
cream (g), 0.05 % lotion, 0.05 % oint.
(g))
$0.00 (Tier 1)
(g)
betamethasone dipropionate/propylene
glycol (0.05 % cream (g), 0.05 % lotion,
0.05 % oint. (g))
$0.00 (Tier 1)
(g)
betamethasone valerate (0.1 % cream
(g), 0.1 % lotion, 0.1 % oint. (g))
$0.00 (Tier 1)
(g)
budesonide (0.25mg/2ml ampul-neb,
0.5 mg/2ml ampul-neb)
$0.00 (Tier 1)
BD, (g)
clobetasol propionate (0.05 % foam,
0.05 % gel (gram), 0.05 % lotion, 0.05 %
oint. (g), 0.05 % shampoo, 0.05 %
solution)
$0.00 (Tier 1)
(g)
desonide (0.05 % cream (g), 0.05 %
lotion, 0.05 % oint. (g))
$0.00 (Tier 1)
(g)
desoximetasone (0.05 % cream (g), 0.05
% gel (gram), 0.25 % cream (g), 0.25 %
oint. (g))
$0.00 (Tier 1)
(g)
dexamethasone (0.5 mg tablet, 0.5
mg/5ml elixir, 0.5 mg/5ml solution,
0.75 mg tablet, 1 mg tablet, 1.5 mg
tablet)
$0.00 (Tier 1)
(g)
DEXAMETHASONE INTENSOL 1MG/1ML
$0.00 (Tier 1)
dexamethasone sod phosphate 4
mg/ml vial
$0.00 (Tier 1)
(g)
diflorasone diacetate (0.05 % cream (g),
0.05 % oint. (g))
$0.00 (Tier 1)
(g)
fludrocortisone acetate 0.1 mg tablet
$0.00 (Tier 1)
(g)
fluocinolone acetonide (0.01 % cream
(g), 0.01 % oil, 0.01 % solution, 0.025 %
cream (g), 0.025 % oint. (g))
$0.00 (Tier 1)
(g)
fluocinonide (0.05 % gel (gram), 0.05 %
oint. (g), 0.05 % solution)
$0.00 (Tier 1)
(g)
74
Name of drug
(tier level)
Necessary actions,
fluticasone propionate (0.005 % oint.
(g), 0.05 % cream (g))
$0.00 (Tier 1)
(g)
fluticasone propionate 50 mcg spray
susp
$0.00 (Tier 1)
QL (120 GM PER 30 DAYS),
(g)
halobetasol propionate (0.05 % cream
(g), 0.05 % oint. (g))
$0.00 (Tier 1)
(g)
HP ACTHAR GEL 80 UNIT/ML VIAL
$0.00 (Tier 2)
hydrocortisone (1 % cream (g), 1 % oint.
(g), 10 mg tablet, 2.5 % cream (g), 2.5
% lotion, 2.5 % oint. (g), 20 mg tablet, 5
mg tablet)
$0.00 (Tier 1)
(g)
hydrocortisone valerate (0.2 % cream
(g), 0.2 % oint. (g))
$0.00 (Tier 1)
(g)
KENALOG AEROSOL SPRAY
$0.00 (Tier 2)
methylprednisolone (16 mg tablet, 32
mg tablet, 4 mg tab ds pk, 4 mg tablet,
8 mg tablet)
$0.00 (Tier 1)
(g)
methylprednisolone acetate (40 mg/ml
vial, 80 mg/ml vial)
$0.00 (Tier 1)
(g)
methylprednisolone sodium succinate
(1000 mg vial, 125 mg vial, 40 mg vial,
500 mg vial)
$0.00 (Tier 1)
(g)
mometasone furoate (0.1 % cream (g),
0.1 % oint. (g))
$0.00 (Tier 1)
(g)
NASONEX 50 MCG NASAL SPRAY
$0.00 (Tier 2)
prednisolone 15 mg/5 ml solution
$0.00 (Tier 1)
(g)
prednisolone sod phosphate (15 mg/5
ml solution, 5 mg/5 ml solution)
$0.00 (Tier 1)
(g)
prednisone (1 mg tablet, 10 mg tab ds
pk, 10 mg tablet, 2.5 mg tablet, 20 mg
tablet, 5 mg tab ds pk, 5 mg tablet, 5
mg/5 ml solution, 50 mg tablet)
$0.00 (Tier 1)
(g)
PREDNISONE 5 MG/ML SOLUTION
$0.00 (Tier 1)
SOLU-CORTEF (1,000 MG VIAL, 250 MG
VIAL, 500 MG VIAL)
$0.00 (Tier 2)
SOLU-MEDROL 2,000 MG VIAL
$0.00 (Tier 2)
75
Name of drug
(tier level)
Necessary actions,
triamcinolone acetonide (0.025 %
cream (g), 0.025 % lotion, 0.025 % oint.
(g), 0.1 % cream (g), 0.1 % lotion, 0.1 %
oint. (g), 0.5 % cream (g), 0.5 % oint.
(g))
$0.00 (Tier 1)
(g)
Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/
Modifiers)
Name of drug
(tier level)
Necessary actions,
$0.00 (Tier 1)
(g)
Anabolic Steroids
oxandrolone 10 mg tablet
Androgens
ANDROGEL (1% GEL PUMP, 1%(2.5G)
GEL PACKET, 1%(5G) GEL PACKET,
1.62% GEL PUMP, 1.62%(1.25G) GEL
PCKT, 1.62%(2.5G) GEL PCKT)
$0.00 (Tier 2)
ANDROID 10 MG CAPSULE
$0.00 (Tier 2)
ANDROXY 10 MG TABLET
$0.00 (Tier 2)
AXIRON 30 MG/ACTUATION SOLN
$0.00 (Tier 2)
danazol (100 mg capsule, 200 mg
$0.00 (Tier 1)
FORTESTA 10 MG GEL PUMP
$0.00 (Tier 2)
TESTIM 1% (50MG) GEL
$0.00 (Tier 2)
testosterone cypionate (100 mg/ml vial,
200 mg/ml vial)
$0.00 (Tier 1)
PA
(g)
(g)
Estrogens
ARANELLE 28 TABLET
$0.00 (Tier 2)
AVIANE-28 TABLET
$0.00 (Tier 2)
BALZIVA 28 TABLET
$0.00 (Tier 2)
CRYSELLE-28 TABLET
$0.00 (Tier 2)
ENPRESSE-28 TABLET
$0.00 (Tier 2)
76
Modifiers)
Name of drug
(tier level)
Necessary actions,
estradiol (0.5 mg tablet, 1 mg tablet, 2
mg tablet)
$0.00 (Tier 1)
(g)
estradiol/norethindrone acet 1 mg0.5mg tablet
$0.00 (Tier 1)
(g)
JINTELI 1 MG-5 MCG TABLET
$0.00 (Tier 2)
JUNEL (1 MG-20 MCG TABLET, 1.5 MG30 MCG TABLET)
$0.00 (Tier 2)
JUNEL FE (1 MG-20 MCG TABLET, 1.5
MG-30 MCG TABLET)
$0.00 (Tier 2)
LESSINA-28 TABLET
$0.00 (Tier 2)
levonorgestrel-ethinyl estradiol (tablet,
tbdspk 3mo)
$0.00 (Tier 1)
LOW-OGESTREL-28 TABLET
$0.00 (Tier 2)
LUTERA-28 TABLET
$0.00 (Tier 2)
MENEST (0.3 MG TABLET, 0.625 MG
TABLET, 1.25 MG TABLET, 2.5 MG
TABLET)
$0.00 (Tier 2)
MENOSTAR 14 MCG/DAY PATCH
$0.00 (Tier 2)
MICROGESTIN (21 1-20 TABLET, 21 1.530 TAB)
$0.00 (Tier 2)
MICROGESTIN FE (1-20 TABLET, 1.5-30
TAB)
$0.00 (Tier 2)
MONONESSA 28 TABLET
$0.00 (Tier 2)
NECON (0.5-35-28 TABLET, 1-35-28
TABLET, 7-7-7-28 TABLET)
$0.00 (Tier 2)
NORTREL 0.5-35 TABLET
$0.00 (Tier 2)
OGESTREL TABLET
$0.00 (Tier 2)
ORTHO EVRA PATCH
$0.00 (Tier 2)
OVCON-35 28 TABLET
$0.00 (Tier 2)
PREMARIN (0.3 MG TABLET, 0.45 MG
TABLET, 0.625 MG TABLET, 0.9 MG
TABLET, 1.25 MG TABLET, 25 MG VIAL,
VAGINAL CREAM-APPL)
$0.00 (Tier 2)
(g)
77
Modifiers)
Name of drug
(tier level)
SPRINTEC 28 DAY TABLET
$0.00 (Tier 2)
TRI-SPRINTEC TABLET
$0.00 (Tier 2)
TRINESSA TABLET
$0.00 (Tier 2)
TRIVORA-28 TABLET
$0.00 (Tier 2)
ZOVIA 1-35E TABLET
$0.00 (Tier 2)
ZOVIA 1-50E TABLET
$0.00 (Tier 2)
Necessary actions,
Progesterone Agonists/Antagonists
ELLA 30 MG TABLET
$0.00 (Tier 2)
Progestins
CAMILA TABLET
$0.00 (Tier 2)
DEPO-PROVERA 400 MG/ML VIAL
$0.00 (Tier 2)
DEPO-SUBQ PROVERA 104 SYRINGE
$0.00 (Tier 2)
medroxyprogesterone acetate (10 mg
tablet, 150 mg/ml syringe, 150 mg/ml
vial, 2.5 mg tablet, 5 mg tablet)
$0.00 (Tier 1)
MEGACE ES 625 MG/5 ML SUSP
$0.00 (Tier 2)
megestrol acetate (20 mg tablet, 40 mg
tablet, 400mg/10ml oral susp,
800mg/20ml oral susp)
$0.00 (Tier 1)
(g)
norethindrone 0.35 mg tablet
$0.00 (Tier 1)
(g)
norethindrone acetate 5 mg tablet
$0.00 (Tier 1)
(g)
progesterone,micronized (100 mg
$0.00 (Tier 1)
(g)
(g)
Selective Estrogen Receptor Modifying Agents
EVISTA 60 MG TABLET
$0.00 (Tier 2)
Hormonal Agents, Suppressant (Adrenal)
Name of drug
(tier level)
Necessary actions,
Hormonal Agents, Suppressant (Adrenal)
LYSODREN 500 MG TABLET
$0.00 (Tier 2)
78
Hormonal Agents, Suppressant (Parathyroid)
Name of drug
(tier level)
Necessary actions,
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR (30 MG TABLET, 60 MG
$0.00 (Tier 2)
Hormonal Agents, Suppressant (Pituitary)
Name of drug
(tier level)
Necessary actions,
cabergoline 0.5 mg tablet
$0.00 (Tier 2)
(g)
ELIGARD (22.5 MG SYRINGE KIT, 30 MG
SYRINGE KIT, 45 MG SYRINGE KIT, 7.5
MG SYRINGE KIT)
$0.00 (Tier 2)
PA
FIRMAGON (2 X 120 MG KIT, 2 X 120
MG VIALS, 80 MG KIT, 80 MG VIAL)
$0.00 (Tier 2)
PA
leuprolide acetate 1 mg/0.2ml kit
$0.00 (Tier 1)
PA, (g)
LUPRON DEPOT (DEPOT 22.5 MG 3MO
KIT, DEPOT 45 MG 6MO KIT, DEPOT 7.5
MG KIT, DEPOT-4 MONTH KIT)
$0.00 (Tier 2)
PA
LUPRON DEPOT 3.75 MG KIT
$0.00 (Tier 2)
LUPRON DEPOT-PED (30 MG 3MO KIT,
7.5 MG KIT)
$0.00 (Tier 2)
LUPRON DEPOT-PED 11.25 MG KIT
$0.00 (Tier 2)
octreotide acetate (100 mcg/ml ampul,
100 mcg/ml vial, 200 mcg/ml vial, 50
mcg/ml ampul, 50 mcg/ml vial)
$0.00 (Tier 1)
BD, (g)
octreotide acetate (1000mcg/ml vial,
500 mcg/ml ampul, 500 mcg/ml vial)
$0.00 (Tier 1)
PA, (g)
SANDOSTATIN LAR (10 MG KIT, 20 MG
KIT, 30 MG KIT)
$0.00 (Tier 2)
BD
SOMATULINE DEPOT (120 MG/0.5 ML,
60 MG/0.2 ML, 90 MG/0.3 ML)
$0.00 (Tier 2)
PA
SOMAVERT (10 MG VIAL, 15 MG VIAL,
20 MG VIAL)
$0.00 (Tier 2)
PA
SYNAREL 2 MG/ML NASAL SPRAY
$0.00 (Tier 2)
PA
79
Name of drug
(tier level)
Necessary actions,
TRELSTAR (11.25 MG SYRINGE, 22.5 MG
SYRINGE, 22.5 MG VIAL, 3.75 MG
SYRINGE)
$0.00 (Tier 2)
PA
TRELSTAR DEPOT 3.75 MG VIAL
$0.00 (Tier 2)
PA
TRELSTAR LA 11.25 MG VIAL
$0.00 (Tier 2)
PA
Hormonal Agents, Suppressant (Thyroid)
(tier level)
Necessary actions,
methimazole (10 mg tablet, 5 mg
tablet)
$0.00 (Tier 1)
(g)
propylthiouracil 50 mg tablet
$0.00 (Tier 1)
(g)
Name of drug
Antithyroid Agents
Hormonal Agents,Stimulant/Replacement/ Modifying (Pituitary)
Name of drug
(tier level)
Necessary actions,
Hormonal Agents,Stimulant/Replacement/ Modifying (Pituitary)
chorionic gonadotropin, human 10000
unit vial
$0.00 (Tier 1)
(g)
desmopressin acetate (0.1 mg tablet,
0.2 mg tablet, 10/spray spray/pump)
$0.00 (Tier 1)
(g)
desmopressin acetate (ampul, vial)
$0.00 (Tier 2)
PA, (g)
GENOTROPIN (12 MG CARTRIDGE, 5
MG CARTRIDGE, MINIQUICK 0.2 MG,
MINIQUICK 0.4 MG, MINIQUICK 0.6
MG, MINIQUICK 0.8 MG, MINIQUICK 1
MG, MINIQUICK 1.2 MG, MINIQUICK
1.4 MG, MINIQUICK 1.6 MG,
MINIQUICK 1.8 MG, MINIQUICK 2 MG)
$0.00 (Tier 2)
PA
OMNITROPE (10 MG/1.5 ML CRTG, 5
MG/1.5 ML CRTG, 5.8 MG VIAL)
$0.00 (Tier 2)
PA
80
Hormonal Agents,Stimulant/Replacement/ Modifying (Thyroid)
Name of drug
(tier level)
Necessary actions,
Hormonal Agents,Stimulant/Replacement/ Modifying (Thyroid)
levothyroxine sodium (100 mcg tablet,
112 mcg tablet, 125 mcg tablet, 137
mcg tablet, 150 mcg tablet, 175mcg
tablet, 200 mcg tablet, 25 mcg tablet,
300 mcg tablet, 50 mcg tablet, 75 mcg
tablet, 88 mcg tablet)
$0.00 (Tier 1)
(g)
liothyronine sodium (25 mcg tablet, 5
mcg tablet, 50 mcg tablet)
$0.00 (Tier 1)
(g)
(tier level)
Necessary actions,
CINRYZE 500 UNIT VIAL
$0.00 (Tier 2)
PA
FIRAZYR 30 MG/3 ML SYRINGE
$0.00 (Tier 2)
PA
ASTAGRAF XL (0.5 MG CAPSULE, 1 MG
$0.00 (Tier 2)
BD
AZASAN (100 MG TABLET, 75 MG
TABLET)
$0.00 (Tier 2)
BD
azathioprine 50 mg tablet
$0.00 (Tier 1)
BD, (g)
CELLCEPT 200 MG/ML ORAL SUSP
$0.00 (Tier 2)
BD
CELLCEPT 500 MG VIAL
$0.00 (Tier 2)
PA
cyclosporine (100 mg capsule, 100
mg/ml solution, 25 mg capsule, 250
mg/5ml ampul, 250 mg/5ml vial)
$0.00 (Tier 1)
BD, (g)
cyclosporine, modified (100 mg capsule,
100 mg/ml solution, 25 mg capsule, 50
mg capsule)
$0.00 (Tier 1)
BD, (g)
ENBREL (25 MG KIT, 25 MG/0.5 ML
SYRINGE, 50 MG/ML SURECLICK SYR, 50
MG/ML SYRINGE)
$0.00 (Tier 2)
PA
FUSILEV I.V. 50 MG VIAL
$0.00 (Tier 2)
Immunological Agents
Name of drug
Angioedema (HAE) Agents
Immune Suppressants
81
Name of drug
(tier level)
Necessary actions,
HUMIRA (20 MG/0.4 ML SYRINGE, 40
MG/0.8 ML PEN, 40 MG/0.8 ML
SYRINGE, CROHN'S STARTER PACK,
PSORIASIS STARTER PACK)
$0.00 (Tier 2)
PA
HUMIRA PED CROHN'S STARTER PK
$0.00 (Tier 2)
PA
KINERET (100 MG/0.67 ML SYR, 100
MG/0.67 ML SYRINGE)
$0.00 (Tier 2)
PA
methotrexate sodium 2.5 mg tablet
$0.00 (Tier 1)
BD, (g)
mycophenolate mofetil (250 mg
$0.00 (Tier 1)
BD, (g)
mycophenolate sodium (180 mg tablet
dr, 360 mg tablet dr)
$0.00 (Tier 1)
BD, (g)
NULOJIX 250 MG VIAL
$0.00 (Tier 2)
PA
PROGRAF 5 MG/ML AMPULE
$0.00 (Tier 2)
BD
RAPAMUNE (1 MG TABLET, 1 MG/ML
ORAL SOLN, 2 MG TABLET)
$0.00 (Tier 2)
BD
REMICADE 100 MG VIAL
$0.00 (Tier 2)
PA
SANDIMMUNE 100 MG/ML SOLN
$0.00 (Tier 2)
BD
SIMPONI (50 MG/0.5 ML PEN INJEC, 50
MG/0.5 ML SYRINGE)
$0.00 (Tier 2)
PA
SIMULECT (10 MG VIAL, 20 MG VIAL)
$0.00 (Tier 2)
PA
sirolimus 0.5 mg tablet
$0.00 (Tier 1)
BD, (g)
tacrolimus (0.5 mg capsule, 1 mg
$0.00 (Tier 1)
BD, (g)
TREXALL (10 MG TABLET, 15 MG
TABLET, 5 MG TABLET, 7.5 MG TABLET)
$0.00 (Tier 2)
BD
ZORTRESS (0.25 MG TABLET, 0.5 MG
TABLET, 0.75 MG TABLET)
$0.00 (Tier 2)
PA
Immunizing Agents, Passive
ATGAM 50 MG/ML AMPUL
$0.00 (Tier 2)
CARIMUNE NF NANOFILTERED (12 GM
VIAL, 3 GM VIAL, 6 GM VIAL)
$0.00 (Tier 2)
PA
GAMMAGARD LIQUID 10% VIAL
$0.00 (Tier 2)
PA
82
Name of drug
(tier level)
Necessary actions,
GAMMAGARD S-D (0.5 GM VL W-ST, 10
G (IGA<1) SOL, 10 GM VL W/ST, 2.5 GM
VL W/ST, 5 G (IGA<1) SOLN, 5 GM VL
W/SET)
$0.00 (Tier 2)
PA
GAMMAPLEX 5% VIAL
$0.00 (Tier 2)
BD
GAMUNEX 10% VIAL
$0.00 (Tier 2)
BD
GAMUNEX-C (1 GRAM/10 ML VIAL, 10
GRAM/100 ML VIAL, 2.5 GRAM/25 ML
VIAL, 20 GRAM/200 ML VIAL, 40
GRAM/400 ML VIAL, 5 GRAM/50 ML
VIAL)
$0.00 (Tier 2)
BD
PRIVIGEN 10% VIAL
$0.00 (Tier 2)
BD
ACTEMRA (200 MG/10 ML VIAL, 400
MG/20 ML VIAL, 80 MG/4 ML VIAL)
$0.00 (Tier 2)
PA
ACTIMMUNE 100 MCG/0.5 ML VIAL
$0.00 (Tier 2)
ARCALYST 220 MG INJECTION
$0.00 (Tier 2)
BENLYSTA (120 MG VIAL, 400 MG VIAL)
$0.00 (Tier 2)
ILARIS 180 MG VIAL
$0.00 (Tier 2)
leflunomide (10 mg tablet, 20 mg
tablet)
$0.00 (Tier 1)
RIDAURA 3 MG CAPSULE
$0.00 (Tier 2)
Immunomodulators
PA
(g)
Vaccines
ACTHIB (VIAL, WITH DILUENT)
$0.00 (Tier 2)
ADACEL TDAP VIAL
$0.00 (Tier 2)
BOOSTRIX TDAP (SYRINGE, VIAL)
$0.00 (Tier 2)
CERVARIX VACCINE SYRINGE
$0.00 (Tier 2)
COMVAX VACCINE VIAL
$0.00 (Tier 2)
DAPTACEL DTAP VACCINE
$0.00 (Tier 2)
ENGERIX-B ADULT (20 MCG/ML SYRN,
20 MCG/ML VIAL)
$0.00 (Tier 2)
BD
ENGERIX-B PEDIATRIC-ADOLESCENT (10
MCG/0.5 ML PED VL, PEDI 10 MCG/0.5
SYRN)
$0.00 (Tier 2)
BD
83
Name of drug
(tier level)
Necessary actions,
GARDASIL VIAL
$0.00 (Tier 2)
HAVRIX (1,440 UNITS/ML VIAL, 720
UNIT/0.5 ML SYRINGE, 720 UNITS/0.5
ML VIAL)
$0.00 (Tier 2)
IMOVAX RABIES VACCINE (VACCINE
VIAL, VACCINE+DILUENT)
$0.00 (Tier 2)
INFANRIX DTAP VIAL
$0.00 (Tier 2)
IPOL (SINGLE DOSE SYRINGE, VIAL)
$0.00 (Tier 2)
IXIARO 6 MCG/0.5 ML SYRINGE
$0.00 (Tier 2)
M-M-R II VACCINE (VIAL, WITH
DILUENT)
$0.00 (Tier 2)
MENACTRA VIAL
$0.00 (Tier 2)
MENOMUNE-A-C-Y-W-135 VIAL
$0.00 (Tier 2)
MENVEO A-C-Y-W-135-DIP VIAL
$0.00 (Tier 2)
PEDVAXHIB VACCINE VIAL
$0.00 (Tier 2)
PENTACEL ACTHIB COMPONENT VIAL
$0.00 (Tier 2)
PROQUAD VIAL
$0.00 (Tier 2)
RABAVERT RABIES VACCINE VIAL
$0.00 (Tier 2)
RECOMBIVAX HB (10 MCG/ML VIAL, 40
MCG/ML VIAL, 5 MCG/0.5 ML VL)
$0.00 (Tier 2)
ROTARIX VACCINE SUSPENSION
$0.00 (Tier 2)
ROTATEQ VACCINE
$0.00 (Tier 2)
tetanus & diphtheria tox,adult 2-2 lf/0.5
vial
$0.00 (Tier 1)
(g)
tetanus toxoid, adsorbed/pf 5 lf/0.5ml
vial
$0.00 (Tier 1)
(g)
tetanus,diphtheria toxd ped/pf 525/0.5ml vial
$0.00 (Tier 1)
(g)
TWINRIX VACCINE VIAL
$0.00 (Tier 2)
TYPHIM VI 25 MCG/0.5 ML VIAL
$0.00 (Tier 2)
VAQTA (25 UNITS/0.5 ML VIAL, 50
UNITS/ML VIAL)
$0.00 (Tier 2)
BD
84
Name of drug
(tier level)
VARIVAX VACCINE (VIAL, WITH
DILUENT)
$0.00 (Tier 2)
YF-VAX (1 DOSE VIAL, 5 DOSE VIAL)
$0.00 (Tier 2)
ZOSTAVAX VIAL
$0.00 (Tier 2)
Necessary actions,
Inflammatory Bowel Disease Agents
Name of drug
(tier level)
Necessary actions,
Aminosalicylates
APRISO ER 0.375 GRAM CAPSULE
$0.00 (Tier 2)
ASACOL HD DR 800 MG TABLET
$0.00 (Tier 2)
balsalazide disodium 750 mg capsule
$0.00 (Tier 1)
CANASA 1,000 MG SUPPOSITORY
$0.00 (Tier 2)
DIPENTUM 250 MG CAPSULE
$0.00 (Tier 2)
LIALDA DR 1.2 GM TABLET
$0.00 (Tier 2)
mesalamine w/cleansing wipes 4 g/60
ml enema kit
$0.00 (Tier 1)
PENTASA (250 MG CAPSULE, 500 MG
CAPSULE)
$0.00 (Tier 2)
(g)
(g)
Glucocorticoids
budesonide 3 mg capdr - er
$0.00 (Tier 1)
(g)
hydrocortisone 100mg/60ml enema
$0.00 (Tier 1)
(g)
sulfasalazine 500 mg tablet
$0.00 (Tier 1)
(g)
SULFAZINE EC 500 MG TAB
$0.00 (Tier 1)
Sulfonamides
Metabolic Bone Disease Agents
Name of drug
(tier level)
Necessary actions,
85
ACTONEL (150 MG TABLET, 30 MG
$0.00 (Tier 2)
ST
Name of drug
(tier level)
Necessary actions,
alendronate sodium (10 mg tablet, 35
mg tablet, 40 mg tablet, 5 mg tablet, 70
mg tablet)
$0.00 (Tier 1)
(g)
BONIVA 3 MG/3 ML SYRINGE
$0.00 (Tier 2)
calcitonin,salmon,synthetic 200/spray
spray/pump
$0.00 (Tier 1)
(g)
calcitriol (0.25 mcg capsule, 0.5 mcg
capsule)
$0.00 (Tier 1)
(g)
calcitriol 1 mcg/ml solution
$0.00 (Tier 1)
BD, (g)
etidronate disodium (200 mg tablet,
400 mg tablet)
$0.00 (Tier 1)
(g)
FORTEO 600 MCG/2.4 ML PEN INJ
$0.00 (Tier 2)
PA
ibandronate sodium 150 mg tablet
$0.00 (Tier 1)
(g)
MIACALCIN 200 UNIT/ML VIAL
$0.00 (Tier 2)
pamidronate disodium (30 mg vial,
30mg/10ml vial, 60 mg/10ml vial, 90
mg vial, 90 mg/10ml vial)
$0.00 (Tier 1)
(g)
PROLIA 60 MG/ML SYRINGE
$0.00 (Tier 2)
PA
RECLAST 5 MG/100 ML SOLUTION
$0.00 (Tier 2)
PA
XGEVA 120 MG/1.7 ML VIAL
$0.00 (Tier 2)
PA
ZEMPLAR (10 MCG/2 ML VIAL, 2
MCG/ML VIAL, 5 MCG/ML VIAL)
$0.00 (Tier 2)
ZOMETA 4 MG/5 ML VIAL
$0.00 (Tier 2)
BD
Miscellaneous Therapeutic Agents
(tier level)
Necessary actions,
alcohol antiseptic pads med. pad
$0.00 (Tier 1)
(g)
BOTOX 100 UNITS VIAL
$0.00 (Tier 2)
PA
gauze bandage (2" x 2", 3" x 3", 4" x 4")
$0.00 (Tier 1)
(g)
Name of drug
86
Name of drug
(tier level)
Necessary actions,
needles, insulin disposable (29 gauge
dis needle, 29gx1/2" dis needle,
29gx5/16" dis needle, 30gx1/3" dis
needle, 30gx5/16" dis needle, 31 gauge
dis needle, 31gx1/4" dis needle,
needle, 32 gx 1/6" dis needle, 32 gx0.2"
dis needle, 32gx 5/32" dis needle,
32gx0.25" dis needle, 32gx3/16" dis
needle, 32gx5/16" dis needle, 33gx
0.25" dis needle, 33gx 3/16" dis needle,
33gx 5/16" dis needle, 33gx 5/32" dis
needle)
$0.00 (Tier 1)
(g)
needles, insulin disposable, safety
(29gx1/2" dis needle, 29gx3/16" dis
needle, 29gx5/16" dis needle, 30gx1/3"
dis needle)
$0.00 (Tier 1)
(g)
pen needle, diabetic, remover &
disposal unit (29gx1/2" dis needle,
needle, 31gx5/16" dis needle, 32gx
5/32" dis needle)
$0.00 (Tier 1)
(g)
pen needle, diabetic, safety 30 gx3/16"
dis needle
$0.00 (Tier 1)
(g)
syr,ndl,ins,safe,disp un,0.3ml 30gx5/16"
disp syrin
$0.00 (Tier 1)
(g)
syring w-ndl,disp,insul,0.3
ml/container,empty (29gx1/2" syringe,
30gx5/16" syringe)
$0.00 (Tier 1)
(g)
ml/container,empty (29gx1/2" syringe,
30gx1/2" syringe, 30gx5/16" syringe,
31gx5/16" syringe)
$0.00 (Tier 1)
(g)
syringe w/needle,insulin disposable 0.3
ml (half unit mark) (0.3 ml half mark
29gx1/2" disp in, 0.3 ml half mark
31gx5/16" disp in)
$0.00 (Tier 1)
(g)
syringe with needle, insulin, safety, 0.3
ml (29gx1/2" disp syrin, 30gx5/16" disp
syrin)
$0.00 (Tier 1)
(g)
87
Name of drug
(tier level)
Necessary actions,
syringe with needle, insulin, safety, 0.5
ml (29gx1/2" disp syrin, 30gx5/16" disp
syrin)
$0.00 (Tier 1)
(g)
syringe with needle, insulin, safety, 1 ml
(29gx1/2" disp syrin, 30gx1/2" disp
syrin, 30gx5/16" disp syrin)
$0.00 (Tier 1)
(g)
syringe with needle, insulin,1 ml and
sharps container (29gx1/2" syringe,
30gx1/2" syringe, 30gx5/16" syringe,
31gx5/16" syringe)
$0.00 (Tier 1)
(g)
syringe with needle,disposable,insulin
(29gx1/2" disp syrin, disp syrin)
$0.00 (Tier 1)
(g)
syringe with needle,disposable,insulin 1
ml (ml disp syrin, ml 25gx1" disp syrin,
ml 25gx5/8" disp syrin, ml 26gx1/2"
disp syrin, ml 27gx1/2" disp syrin, ml
27gx5/8" disp syrin, ml 28 gauge disp
syrin, ml 28gx1/2" disp syrin, ml 29
gauge disp syrin, ml 29gx1/2" disp
syrin, ml 29gx7/16" disp syrin, ml 30
gauge disp syrin, ml 30gx1/2" disp
syrin, ml 30gx3/8" disp syrin, ml
30gx5/16" disp syrin, ml 31gx15/64"
disp syrin, ml 31gx3/8" disp syrin, ml
31gx5/16" disp syrin)
$0.00 (Tier 1)
(g)
88
Name of drug
(tier level)
Necessary actions,
syringe with needle,insulin
disposable,0.3 ml (w-ndl,disp,insul,0.3
ml 28 gauge disp syrin, wndl,disp,insul,0.3 ml 28gx1/2" disp
syrin, w-ndl,disp,insul,0.3 ml 29 gauge
disp syrin, w-ndl,disp,insul,0.3 ml
29gx1/2" disp syrin, w-ndl,disp,insul,0.3
syrin, w-ndl,disp,insul,0.3 ml 30gx3/8"
30gx5/16" disp syrin, wndl,disp,insul,0.3 ml 31gx15/64" disp
31gx5/16" disp syrin, wndl,disp,insul,0.3ml 29 gauge disp syrin,
w-ndl,disp,insul,0.3ml 30 gauge disp
syrin)
$0.00 (Tier 1)
(g)
syringe with needle,insulin
disposable,0.5 ml (w-ndl,disp,insul,0.5
ml 27gx1/2" disp syrin, wndl,disp,insul,0.5 ml 28 gauge disp
disp syrin, w-ndl,disp,insul,0.5 ml 29
gauge disp syrin, w-ndl,disp,insul,0.5 ml
29gx1/2" disp syrin, w-ndl,disp,insul,0.5
30gx5/16" disp syrin, wndl,disp,insul,0.5 ml 31gx15/64" disp
31gx5/16" disp syrin, wndl,disp,insul,0.5ml 28 gauge disp syrin,
w-ndl,disp,insul,0.5ml 29 gauge disp
syrin, w-ndl,disp,insul,0.5ml 30 gauge
disp syrin)
$0.00 (Tier 1)
(g)
syringe,needle,insulin,safety,disposal
unit, 1 ml (1 ml 28gx1/2" disp syrin, 1
ml 29gx1/2" disp syrin)
$0.00 (Tier 1)
(g)
syringe,needle,insulin,safety,disposal
unit,0.5 ml (29gx1/2" disp syrin,
30gx5/16" disp syrin)
$0.00 (Tier 1)
(g)
89
Name of drug
(tier level)
Necessary actions,
water for irrigation,sterile irrig soln
$0.00 (Tier 1)
(g)
(tier level)
Necessary actions,
proparacaine hcl 0.5 % drops
$0.00 (Tier 1)
(g)
RESTASIS 0.05% EYE EMULSION
$0.00 (Tier 2)
Ophthalmic Agents
Name of drug
Ophthalmic Agents, Other
Ophthalmic Anti-allergy Agents
ALOCRIL 2% EYE DROPS
$0.00 (Tier 2)
ALOMIDE 0.1% EYE DROPS
$0.00 (Tier 2)
azelastine hcl 0.05 % drops
$0.00 (Tier 1)
(g)
epinastine hcl 0.05 % drops
$0.00 (Tier 1)
(g)
Ophthalmic Anti-inflammatories
ACUVAIL 0.45% OPHTH SOLUTION
$0.00 (Tier 2)
BLEPHAMIDE EYE DROPS
$0.00 (Tier 2)
BLEPHAMIDE EYE OINTMENT
$0.00 (Tier 2)
bromfenac sodium 0.09% drops
$0.00 (Tier 1)
(g)
dexamethasone sod phosphate 0.1 %
drops
$0.00 (Tier 1)
(g)
DUREZOL 0.05% EYE DROPS
$0.00 (Tier 2)
flurbiprofen sodium 0.03 % drops
$0.00 (Tier 1)
(g)
ketorolac tromethamine (0.4 % drops,
0.5 % drops)
$0.00 (Tier 1)
(g)
neomy sulf/bacitrac zn/poly/hc 3.5-10k1 oint. (g)
$0.00 (Tier 1)
(g)
NEVANAC 0.1% DROPTAINER
$0.00 (Tier 2)
PRED MILD 0.12% EYE DROPS
$0.00 (Tier 2)
prednisolone sod phosphate 1 % drops
$0.00 (Tier 1)
(g)
sulfacetamide/prednisolone sp 10 %0.23% drops
$0.00 (Tier 1)
(g)
90
Ophthalmic Agents
Name of drug
(tier level)
TOBRADEX EYE OINTMENT
$0.00 (Tier 2)
TOBRADEX ST EYE DROPS
$0.00 (Tier 2)
tobramycin/dexamethasone 0.3 %-0.1%
drops susp
$0.00 (Tier 1)
TOBREX 0.3% EYE OINTMENT
$0.00 (Tier 2)
Necessary actions,
(g)
Ophthalmic Antiglaucoma Agents
ALPHAGAN P 0.1% DROPS
$0.00 (Tier 2)
AZOPT 1% EYE DROPS
$0.00 (Tier 2)
betaxolol hcl 0.5 % drops
$0.00 (Tier 1)
BETOPTIC S 0.25% EYE DROPS
$0.00 (Tier 2)
brimonidine tartrate (0.15 % drops, 0.2
% drops)
$0.00 (Tier 1)
(g)
dorzolamide hcl 2 % drops
$0.00 (Tier 1)
(g)
dorzolamide hcl/timolol maleat 2 %-0.5
% drops
$0.00 (Tier 1)
(g)
ISOPTO CARPINE (1% EYE DROPS, 2%
EYE DROPS, 4% EYE DROPS)
$0.00 (Tier 2)
levobunolol hcl 0.5 % drops
$0.00 (Tier 1)
(g)
timolol maleate (0.25 % drops, 0.25 %
sol-gel, 0.5 % drops, 0.5 % sol-gel)
$0.00 (Tier 1)
(g)
(g)
Ophthalmic Prostaglandin and Prostamide Analogs
apraclonidine hcl 0.5 % drops
$0.00 (Tier 1)
(g)
COMBIGAN EYE DROPS
$0.00 (Tier 2)
latanoprost 0.005 % drops
$0.00 (Tier 1)
(g)
LUMIGAN 0.01% EYE DROPS
$0.00 (Tier 2)
QL (2.5 ML PER 30 DAYS)
TRAVATAN Z 0.004% EYE DROP
$0.00 (Tier 2)
Otic Agents
Name of drug
(tier level)
Necessary actions,
$0.00 (Tier 1)
(g)
Otic Agents
acetic acid 2 % solution
91
Otic Agents
Name of drug
(tier level)
Necessary actions,
acetic acid/hydrocortisone 2 %-1 %
drops
$0.00 (Tier 1)
(g)
neomycin sulfate/polymyxin b
sulfate/hydrocortisone (drops susp,
solution)
$0.00 (Tier 1)
(g)
Respiratory Tract/ Pulmonary Agents
Name of drug
(tier level)
Necessary actions,
Anti-inflammatories, Inhaled Corticosteroids
FLOVENT DISKUS (100 MCG DISKUS,
250 MCG DISKUS, 50 MCG DISKUS)
$0.00 (Tier 2)
QL (120 PER 30 DAYS)
FLOVENT HFA (110 MCG INHALER, 220
MCG INHALER, 44 MCG INHALER)
$0.00 (Tier 2)
QL (120 GM PER 30 DAYS)
OMNARIS 50 MCG NASAL SPRAY
$0.00 (Tier 2)
QVAR (40 MCG ORAL INHALER, 80 MCG
ORAL INHALER)
$0.00 (Tier 2)
triamcinolone acetonide 55 mcg spray
$0.00 (Tier 1)
VERAMYST 27.5 MCG NASAL SPRAY
$0.00 (Tier 2)
(g)
Antihistamines
azelastine hcl 137 mcg spray/pump
$0.00 (Tier 1)
(g)
cetirizine hcl 1 mg/ml solution
$0.00 (Tier 1)
(g)
CLARINEX 0.5 MG/ML (2.5 MG/5)
$0.00 (Tier 2)
ST
clemastine fumarate 2.68 mg tablet
$0.00 (Tier 1)
(g)
cyproheptadine hcl (2 mg/5 ml syrup, 4
mg tablet, 4 mg/10 ml syrup)
$0.00 (Tier 1)
(g)
desloratadine (2.5 mg tab rapdis, 5 mg
tab rapdis, 5 mg tablet)
$0.00 (Tier 1)
(g)
diphenhydramine hcl 50 mg/ml vial
$0.00 (Tier 1)
(g)
hydroxyzine pamoate (100 mg capsule,
25 mg capsule, 50 mg capsule)
$0.00 (Tier 1)
PA, (g)
levocetirizine dihydrochloride (2.5
mg/5ml solution, 5 mg tablet)
$0.00 (Tier 1)
(g)
92
Name of drug
(tier level)
Necessary actions,
phenylephrine hcl/prometh hcl 56.25mg/5 syrup
$0.00 (Tier 1)
(g)
promethazine hcl (12.5 mg tablet, 25
mg tablet, 50 mg tablet, 6.25mg/5ml
syrup)
$0.00 (Tier 1)
PA, (g)
promethazine hcl (25 mg/ml ampul, 25
mg/ml syringe, 25 mg/ml vial, 50
mg/ml ampul, 50 mg/ml vial)
$0.00 (Tier 1)
(g)
montelukast sodium (10 mg tablet, 4
mg gran pack, 4 mg tab chew, 5 mg tab
chew)
$0.00 (Tier 1)
zafirlukast (10 mg tablet, 20 mg tablet)
$0.00 (Tier 1)
ZYFLO CR 600 MG TABLET
$0.00 (Tier 2)
Antileukotrienes
Bronchodilators, Anticholinergic
ATROVENT HFA INHALER
$0.00 (Tier 2)
ipratropium bromide (21 mcg spray,
42mcg spray)
$0.00 (Tier 1)
(g)
ipratropium bromide 0.2 mg/ml
solution
$0.00 (Tier 1)
BD, (g)
ipratropium/albuterol sulfate 0.53mg/3 ampul-neb
$0.00 (Tier 1)
BD, (g)
SPIRIVA 18 MCG CP-HANDIHALER
$0.00 (Tier 2)
Bronchodilators, Sympathomimetic
albuterol sulfate (0.63mg/3ml vial-neb,
1.25mg/3ml vial-neb, 2.5 mg/0.5 vialneb, 2.5 mg/3ml vial-neb, 5 mg/ml
solution)
$0.00 (Tier 1)
BD, (g)
albuterol sulfate (2 mg tablet, 2 mg/5
ml syrup, 4 mg tab er 12h, 4 mg tablet,
8 mg tab er 12h)
$0.00 (Tier 1)
(g)
EPIPEN 0.3 MG AUTO-INJECTOR
$0.00 (Tier 2)
EPIPEN 2-PAK 0.3 MG AUTO-INJCT
$0.00 (Tier 2)
EPIPEN JR 0.15 MG AUTO-INJCT
$0.00 (Tier 2)
93
Name of drug
(tier level)
Necessary actions,
EPIPEN JR 2-PAK 0.15 MG INJCTR
$0.00 (Tier 2)
metaproterenol sulfate (10 mg tablet,
10 mg/5 ml syrup, 20 mg tablet)
$0.00 (Tier 1)
(g)
PROAIR HFA 90 MCG INHALER
$0.00 (Tier 2)
PROVENTIL HFA 90 MCG INHALER
$0.00 (Tier 2)
SEREVENT DISKUS 50 MCG
$0.00 (Tier 2)
terbutaline sulfate (1 mg/ml ampul, 1
mg/ml vial, 2.5 mg tablet, 5 mg tablet)
$0.00 (Tier 1)
(g)
VENTOLIN HFA (90 MCG INHALER,
RELION 90 MCG INH)
$0.00 (Tier 2)
KALYDECO 150 MG TABLET
$0.00 (Tier 2)
PA
TOBI 300 MG/5 ML SOLUTION
$0.00 (Tier 2)
PA, LA
cromolyn sodium 20 mg/2 ml ampulneb
$0.00 (Tier 1)
BD, (g)
cromolyn sodium 20 mg/ml solution
$0.00 (Tier 1)
(g)
Cystic Fibrosis Agents
Mast Cell Stabilizers
Phosphodiesterase Inhibitors, Airways Disease
aminophylline (250mg/10ml ampul,
250mg/10ml vial, 500mg/20ml ampul,
500mg/20ml vial)
$0.00 (Tier 1)
(g)
ELIXOPHYLLIN (100 MG/18.75 ML, 80
MG/15 ML ELIX)
$0.00 (Tier 2)
theophylline anhydrous (100 mg tab er
12h, 200 mg tab er 12h, 300 mg tab er
12h, 400 mg tablet er, 450 mg tab er
12h, 600 mg tablet er)
$0.00 (Tier 1)
(g)
ADCIRCA 20 MG TABLET
$0.00 (Tier 2)
PA
LETAIRIS (10 MG TABLET, 5 MG TABLET)
$0.00 (Tier 2)
PA
REMODULIN (1 MG/ML VIAL, 10
MG/ML VIAL, 2.5 MG/ML VIAL, 5
MG/ML VIAL)
$0.00 (Tier 2)
PA
Pulmonary Antihypertensives
94
Name of drug
(tier level)
Necessary actions,
sildenafil citrate 20 mg tablet
$0.00 (Tier 1)
PA, (g)
TRACLEER (125 MG TABLET, 62.5 MG
TABLET)
$0.00 (Tier 2)
PA
acetylcysteine (100 mg/ml vial, 200
mg/ml vial)
$0.00 (Tier 1)
BD, (g)
DALIRESP 500 MCG TABLET
$0.00 (Tier 2)
PA
DULERA (100 MCG/5 MCG INHALER,
200 MCG/5 MCG INHALER)
$0.00 (Tier 2)
ST, QL (60 GM PER 30 DAYS)
PROLASTIN C 1,000 MG VIAL
$0.00 (Tier 2)
PA
PULMOZYME 1 MG/ML AMPUL
$0.00 (Tier 2)
BD
SYMBICORT (160-4.5 MCG INHALER,
80-4.5 MCG INHALER)
$0.00 (Tier 2)
ST
XOLAIR 150 MG VIAL
$0.00 (Tier 2)
PA
ZEMAIRA 1,000 MG VIAL
$0.00 (Tier 2)
PA
(tier level)
Necessary actions,
carisoprodol 350 mg tablet
$0.00 (Tier 1)
PA, (g)
chlorzoxazone 500 mg tablet
$0.00 (Tier 1)
(g)
cyclobenzaprine hcl (10 mg tablet, 5 mg
$0.00 (Tier 1)
PA, (g)
methocarbamol (500 mg tablet, 750 mg
tablet)
$0.00 (Tier 1)
PA, (g)
orphenadrine citrate 100 mg tablet er
$0.00 (Tier 1)
PA, (g)
(tier level)
Necessary actions,
Respiratory Tract Agents, Other
Skeletal Muscle Relaxants
Name of drug
Skeletal Muscle Relaxants
Sleep Disorder Agents
Name of drug
GABA Receptor Modulators
95
EDLUAR (10 MG SL TABLET, 5 MG SL
TABLET)
$0.00 (Tier 2)
Sleep Disorder Agents
Name of drug
(tier level)
Necessary actions,
zaleplon (10 mg capsule, 5 mg capsule)
$0.00 (Tier 1)
(g)
zolpidem tartrate (10 mg tablet, 12.5
mg tab mphase, 5 mg tablet, 6.25 mg
tab mphase)
$0.00 (Tier 1)
(g)
ZOLPIMIST 5 MG ORAL SPRAY
$0.00 (Tier 2)
Sleep Disorders, Other
modafinil (100 mg tablet, 200 mg
tablet)
$0.00 (Tier 1)
ROZEREM 8 MG TABLET
$0.00 (Tier 2)
XYREM 500 MG/ML ORAL SOLUTION
$0.00 (Tier 2)
PA, (g)
Therapeutic Nutrients/ Minerals/ Electrolytes
(tier level)
Necessary actions,
EXJADE (125 MG TABLET, 250 MG
$0.00 (Tier 2)
PA, LA
sodium lactate 5 meq/ml vial
$0.00 (Tier 1)
(g)
sodium polystyrene sulfonate
(15g/60ml oral susp, 30g/120ml
enema, 50g/200ml enema, powder)
$0.00 (Tier 1)
(g)
SYPRINE 250 MG CAPSULE
$0.00 (Tier 2)
Name of drug
Electrolyte/Mineral Modifiers
Electrolyte/Mineral Replacement
0.9 % sodium chloride (0.9 % pggybk
prt, 0.9 % pgy vl prt, 0.9 % 0.9 % iv
soln, 0.9 % 0.9 % syringe, 0.9 % 0.9 %
vial)
$0.00 (Tier 1)
BD, (g)
AMINOSYN 8.5%-ELECTROLYTES SOL
$0.00 (Tier 2)
BD
AMINOSYN II (10% IV SOLUTION, 15%
IV SOLUTION, 7% IV SOLUTION, 8.5% IV
SOLUTION)
$0.00 (Tier 2)
BD
96
Name of drug
(tier level)
Necessary actions,
AMINOSYN II 8.5%-ELECTROLYTES
$0.00 (Tier 2)
BD
AMINOSYN M 3.5% IV SOLUTION
$0.00 (Tier 2)
BD
AMINOSYN-HBC 7% IV SOLUTION
$0.00 (Tier 2)
BD
AMINOSYN-PF (10% IV SOLUTION, 7%
IV SOLUTION)
$0.00 (Tier 2)
BD
CHEMET 100 MG CAPSULE
$0.00 (Tier 2)
CLINIMIX (2.75%-5% SOLUTION, 4.25%10% SOLUTION, 4.25%-20% SOLUTION,
4.25%-25% SOLUTION, 4.25%-5%
SOLUTION, 5%-15% SOLUTION, 5%-20%
SOLUTION, 5%-25% SOLUTION)
$0.00 (Tier 2)
BD
CLINIMIX E (2.75%-10% SOLUTION,
2.75%-5% SOLUTION, 4.25%-25%
SOLUTION, 4.25%-5% SOLUTION, 5%15% SOLUTION, 5%-20% SOLUTION,
5%-25% SOLUTION)
$0.00 (Tier 2)
BD
CLINISOL 15% SOLUTION
$0.00 (Tier 2)
BD
dextrose 10 % and 0.2 % sodium
chloride (10 % and 0.2 % nacl 10 %-0.2
% dehp fr bg, 10 % and 0.2 % nacl 10 %0.2 % iv soln)
$0.00 (Tier 1)
(g)
dextrose 10 % and 0.45 % nacl 10%0.45% iv soln
$0.00 (Tier 1)
(g)
dextrose 10 % in water (10 % in water
10 % dehp fr bg, 10 % in water 10 % iv
soln)
$0.00 (Tier 1)
(g)
dextrose 2.5 % and 0.45 % nacl 2.5%0.45% iv soln
$0.00 (Tier 1)
(g)
dextrose 5 % and 0.3 % nacl 5 %-0.3 %
iv soln
$0.00 (Tier 1)
(g)
dextrose 5 % and 0.9 % nacl 5 %-0.9 %
iv soln
$0.00 (Tier 1)
(g)
dextrose 5 % in water (5 % in water
pggybk prt, 5 % in water pgy vl prt, 5 %
in water 5 % iv soln, 5 % in water 5 %
vial)
$0.00 (Tier 1)
(g)
dextrose 5 %-0.2 % nacl 5 %-0.2 % iv
soln
$0.00 (Tier 1)
(g)
97
Name of drug
(tier level)
Necessary actions,
dextrose 5 %-0.45 % nacl 5 %-0.45 % iv
soln
$0.00 (Tier 1)
(g)
dextrose 5%-lactated ringers 5 % iv soln
$0.00 (Tier 1)
(g)
FLUOR-A-DAY (0.25 MG TAB CHEW, 0.5
MG TAB CHEW, 1 MG TABLET CHEW)
$0.00 (Tier 1)
FLUORITAB (0.5 MG TABLET CHEW, 1
MG TABLET CHEW)
$0.00 (Tier 1)
HEPATAMINE 8% IV SOLUTION
$0.00 (Tier 2)
BD
HEPATASOL 8% IV SOLUTION
$0.00 (Tier 2)
BD
INTRALIPID (20% IV FAT EMUL, 30% IV
FAT EMUL)
$0.00 (Tier 2)
BD
IONOSOL MB-D5W IV SOLUTION
$0.00 (Tier 2)
ISOLYTE S IV SOLUTION-EXCEL
$0.00 (Tier 2)
KLOR-CON M15 TABLET
$0.00 (Tier 2)
LIPOSYN III (10% IV FAT EMULSN, 20%
IV FAT EMULSN)
$0.00 (Tier 2)
LUDENT FLUORIDE (0.25 MG TB CHW,
0.5 MG TB CHEW, 1 MG TAB CHEW)
$0.00 (Tier 1)
NORMOSOL-M AND DEXTROSE 5%
$0.00 (Tier 2)
NORMOSOL-R PH 7.4 IV SOLUTION
$0.00 (Tier 2)
NORMOSOL-R-DEXTROSE 5% IV SOLN
$0.00 (Tier 2)
OSMOPREP TABLET
$0.00 (Tier 2)
PLASMA-LYTE 148 IV SOLUTION
$0.00 (Tier 2)
PLASMA-LYTE 56-DEXTROSE 5%
$0.00 (Tier 2)
PLASMA-LYTE A PH 7.4 SOLN.
$0.00 (Tier 2)
potassium chloride (10 meq capsule er,
10 meq tab er prt, 10 meq tablet er,
10meq/0.1l piggyback, 10meq/50ml
piggyback, 2 meq/ml iv soln, 2 meq/ml
vial, 20 meq tab er prt, 20 meq tablet
er, 20meq/0.1l piggyback, 20meq/50ml
piggyback, 40meq/0.1l piggyback, 8
meq capsule er)
$0.00 (Tier 1)
(g)
potassium chloride in 0.9 % sodium
chloride (20 meq/l iv soln, 40 meq/l iv
soln)
$0.00 (Tier 1)
(g)
BD
98
Name of drug
(tier level)
Necessary actions,
potassium chloride in 5 % dextrose in
water (20 meq/l iv soln, 40 meq/l iv
soln)
$0.00 (Tier 1)
(g)
potassium chloride in dextrose 5 % and
0.9 % sodium chloride (20 meq/l iv soln,
40 meq/l iv soln)
$0.00 (Tier 1)
(g)
potassium chloride in dextrose 5 %-0.45
% sodium chloride (10 meq/l iv soln, 20
meq/l iv soln, 30 meq/l iv soln, 40 meq/l
iv soln)
$0.00 (Tier 1)
(g)
potassium chloride in lr-d5 20 meq/l iv
soln
$0.00 (Tier 1)
(g)
potassium chloride-0.45% nacl 20 meq/l
iv soln
$0.00 (Tier 1)
(g)
potassium chloride/d5-0.2%nacl 20
meq/l iv soln
$0.00 (Tier 1)
(g)
potassium chloride/d5-0.3%nacl 20
meq/l iv soln
$0.00 (Tier 1)
(g)
potassium citrate (10 meq tablet er, 5
meq tablet er)
$0.00 (Tier 1)
(g)
PREMASOL (10% IV SOLUTION, 6% IV
SOLUTION)
$0.00 (Tier 2)
BD
PROCALAMINE IV SOLUTION
$0.00 (Tier 2)
BD
PROSOL 20% INJECTION
$0.00 (Tier 2)
BD
ringers solution iv soln
$0.00 (Tier 1)
(g)
ringers solution,lactated iv soln
$0.00 (Tier 1)
(g)
SAMSCA (15 MG TABLET, 30 MG
TABLET)
$0.00 (Tier 2)
sodium chloride (2.5 meq/ml iv soln, 2.5
meq/ml vial)
$0.00 (Tier 1)
BD, (g)
sodium chloride 0.45 % (0.45 % pggybk
prt, 0.45 % 0.45 % iv soln)
$0.00 (Tier 1)
BD, (g)
sodium chloride 3 % 3 % iv soln
$0.00 (Tier 1)
BD, (g)
sodium chloride 5 % 5 % iv soln
$0.00 (Tier 1)
BD, (g)
sodium chloride irrig solution 0.9 % irrig
soln
$0.00 (Tier 1)
BD, (g)
99
Name of drug
(tier level)
Necessary actions,
sodium fluoride (0.25(0.55) tab chew,
0.5(1.1)mg tab chew, 1mg(2.2mg) tab
chew, 1mg(2.2mg) tablet)
$0.00 (Tier 1)
(g)
TPN ELECTROLYTES VIAL
$0.00 (Tier 1)
TRAVASOL 10% SOLN VIAFLEX
$0.00 (Tier 2)
BD
TROPHAMINE (10% IV SOLUTION, 6% IV
SOLUTION)
$0.00 (Tier 2)
BD
(tier level)
Necessary actions,
8 HOUR ER 650 MG CAPLET
$0.00 (Tier 3)
*
acetaminophen 120 mg supp.rect
$0.00 (Tier 3)
QL (33 PER DAY), (g), *
acetaminophen 650 mg supp.rect
$0.00 (Tier 3)
(g), *
ACID CONTROL 75 MG TABLET
$0.00 (Tier 3)
*
ACID REDUCER (10 MG TABLET, 75 MG
TABLET, SM 10 MG TABLET, SM 75 MG
TABLET)
$0.00 (Tier 3)
*
ALL DAY ALLERGY (10 MG TABLET, HM
10 MG TAB, QC 10 MG TAB, SM 10 MG
TAB)
$0.00 (Tier 3)
*
ALL DAY PAIN RELIEF (PAIN RELIEF 220
MG TAB, PAIN RLF 220 MG CAPLET, SM
RELIEF 220 MG CAPLT)
$0.00 (Tier 3)
*
ALLERGY (10 MG TABLET, SB 10 MG
TABLET)
$0.00 (Tier 3)
*
ALLERGY RELIEF (10 MG ODT, 10 MG
TABLET, HM 10 MG ODT, QC 10 MG
ODT, SM 1.34 MG TAB, SM 10 MG ODT)
$0.00 (Tier 3)
*
ALLERHIST-1 1.34 MG TABLET
$0.00 (Tier 3)
*
ampicillin sodium/sulbactam na 1.5 g
vial port
$0.00 (Tier 1)
(g)
ANTI-DIARRHEAL (2 MG CAPLET, 2 MG
TABLET, QC 2 MG CAPLET, SM 2 MG
CAPLET)
$0.00 (Tier 3)
*
Uncategorized
Name of drug
Unclassified
100
Uncategorized
Name of drug
(tier level)
Necessary actions,
ARTHRITIS PAIN RELIEF (ER 650 MG
CAPLT, HM ER 650 MG, QC ER 650 MG,
SB ER 650 MG, SM ER 650 MG)
$0.00 (Tier 3)
*
ATHLETE'S FOOT (QC, SM)
$0.00 (Tier 3)
*
cetirizine hcl (10 mg tab chew, 5 mg tab
chew, 5 mg tablet)
$0.00 (Tier 3)
(g), *
cetirizine hcl 10 mg tablet
$0.00 (Tier 3)
AL (Up to 65 yrs old), (g), *
CHILD CLEAR-ATADINE 10 MG TAB
$0.00 (Tier 3)
*
chlorpheniramine maleate 12 mg tablet
er
$0.00 (Tier 3)
(g), *
CLEARLAX (, SM)
$0.00 (Tier 3)
*
clotrimazole 1 % cream/appl
$0.00 (Tier 3)
AL (At least 10 yrs old), (g), *
COMPLETE (HM TABLET CHEW, TABLET
CHEW)
$0.00 (Tier 3)
*
cromolyn sodium 5.2 mg spray/pump
$0.00 (Tier 3)
(g), *
DAYHIST ALLERGY 1.34 MG TABLET
$0.00 (Tier 3)
*
famotidine 10 mg tablet
$0.00 (Tier 3)
(g), *
GAVILAX POWDER
$0.00 (Tier 3)
*
HEALTHYLAX POWDER PACKET
$0.00 (Tier 3)
*
HEARTBURN RELIEF 10 MG TABLET
$0.00 (Tier 3)
*
ibuprofen 100 mg tab chew
$0.00 (Tier 3)
ibuprofen 200 mg capsule
$0.00 (Tier 3)
QL (16 PER DAY), AL (Up to
65 yrs old), (g), *
ibuprofen 200 mg tablet
$0.00 (Tier 3)
QL (16 PER DAY), (g), *
ibuprofen 50 mg/1.25 drops susp
$0.00 (Tier 3)
QL (80 ML PER DAY), (g), *
ITCHY EYE 0.025% DROPS
$0.00 (Tier 3)
*
LAMISIL AT 1% CREAM
$0.00 (Tier 3)
*
LICE TREATMENT (CREME RINSE, HM
LOTION)
$0.00 (Tier 3)
*
lidocaine hcl 2 % jel/pf app
$0.00 (Tier 1)
(g)
loperamide hcl (1 mg/5 ml liquid,
1mg/7.5ml liquid)
$0.00 (Tier 3)
(g), *
101
Uncategorized
Name of drug
(tier level)
Necessary actions,
loratadine (10 mg tab rapdis, 10 mg
tablet)
$0.00 (Tier 3)
(g), *
loratadine 5 mg/5 ml solution
$0.00 (Tier 3)
methotrexate sodium 25 mg/ml vial
$0.00 (Tier 1)
PA, (g)
miconazole nitrate (100 mg supp.vag, 2
% cream/appl, 200 mg-2 % kit)
$0.00 (Tier 3)
(g), *
miconazole nitrate 200 mg-2 % cmb pf
crm
$0.00 (Tier 3)
morphine sulfate (30 mg cpmp 24hr, 60
mg cpmp 24hr)
$0.00 (Tier 1)
naproxen sodium 220 mg tablet
$0.00 (Tier 3)
(g), *
nicotine 21 mg/24hr patch td24
$0.00 (Tier 3)
QL (1 PER DAY), AL (At least
17 yrs old), CB (6 / 360
days), MDD (6 per day), MFL
(6 / 360 days), (g), *
nicotine polacrilex (2 mg gum, 4 mg
gum)
$0.00 (Tier 3)
QL (11.2 PER DAY), AL (At
least 17 yrs old), CB (67.2 /
360 days), MDD (67.2 per
day), MFL (6 / 360 days),
MDS (360 days), CD (360
days), (g), *
nicotine polacrilex (2 mg lozenge, 4 mg
lozenge)
$0.00 (Tier 3)
QL (12 PER DAY), AL (At least
17 yrs old), CB (72 / 360
days), MDD (72 per day),
MFL (6 / 360 days), MDS
(360 days), CD (360 days),
(g), *
NON-DROWSY ALLERGY 10 MG TAB
$0.00 (Tier 3)
*
PAIN RELIEF ER 650 MG CAPLET
$0.00 (Tier 3)
*
permethrin 1 % liquid
$0.00 (Tier 3)
(g), *
PLAN B ONE-STEP 1.5 MG TABLET
$0.00 (Tier 3)
*
PRILOSEC OTC 20.6 MG TABLET
$0.00 (Tier 3)
*
QC 3 DAY VAGINAL 4% CREAM
$0.00 (Tier 3)
*
QC ACID CONTROLLER 10 MG TAB
$0.00 (Tier 3)
*
ranitidine hcl 75 mg tablet
$0.00 (Tier 3)
(g), *
SB ANTI-DIARRHEA 2 MG CAPLET
$0.00 (Tier 3)
*
102
Uncategorized
Name of drug
(tier level)
Necessary actions,
SM 8 HOUR PAIN RELIEF 650 MG
$0.00 (Tier 3)
*
terbinafine hcl 1 % cream (g)
$0.00 (Tier 3)
(g), *
TIOCONAZOLE 1 6.5% OINTMENT
$0.00 (Tier 3)
*
ZADITOR 0.025% EYE DROPS
$0.00 (Tier 3)
*
103
Alphabetical Listing
0
0.9 % sodium chloride
96
3
3 DAY VAGINAL
102
8
8 HOUR
8 HOUR PAIN RELIEF
100
103
A
abacavir sulfate
abacavir sulfate/lamivudine/zidovudine
ABELCET
ABILIFY
ABILIFY DISCMELT
ABILIFY MAINTENA
ABRAXANE
acamprosate calcium
acarbose
acebutolol hcl
acetaminophen
acetazolamide
acetic acid
acetic acid/hydrocortisone
acetylcysteine
ACID CONTROL
ACID CONTROLLER
ACID REDUCER
ACTEMRA
ACTHIB
ACTIMMUNE
ACTONEL
ACTOPLUS MET XR
ACUVAIL
acyclovir
acyclovir sodium
ADACEL TDAP
ADAGEN
46
46
31
44
44
44
36
14
50
59
100
12
62
91
92
95
100
102
100
83
83
83
86
51
90
49
49
83
69
adapalene
ADCIRCA
ADDERALL XR
AFINITOR
AFINITOR DISPERZ
AGGRENOX
ALBENZA
albuterol sulfate
alcohol antiseptic pads
alendronate sodium
alfuzosin hcl
ALIMTA
ALINIA
ALL DAY ALLERGY
ALL DAY PAIN RELIEF
ALLERGY
ALLERGY RELIEF
ALLERHIST-1
allopurinol
ALOCRIL
ALOMIDE
ALOXI
ALPHAGAN P
alprazolam
ALTABAX
amantadine hcl
AMBISOME
amifostine crystalline
amikacin sulfate
amiloride hcl
amiloride hcl/hydrochlorothiazide
aminophylline
AMINOSYN II
AMINOSYN II WITH ELECTROLYTES
AMINOSYN M
AMINOSYN WITH ELECTROLYTES
AMINOSYN-HBC
AMINOSYN-PF
amiodarone hcl
AMITIZA
amitriptyline hcl
68
94
65
39
39
55
41
93
86
86
73
35
41
100
100
100
100
100
32
90
90
30
91
50
16
48
31
36
15
62
62
94
96
97
97
96
97
97
59
72
28
104
amitriptyline hcl/chlordiazepoxide
amlodipine besylate
amlodipine besylate/benazepril hcl
ammonium lactate
AMNESTEEM
amoxapine
amoxicillin
amoxicillin/potassium clavulanate
amphotericin b
ampicillin sodium
ampicillin sodium/sulbactam sodium
ampicillin trihydrate
AMPYRA
AMTURNIDE
anagrelide hcl
anastrozole
ANDROGEL
ANDROID
ANDROXY
ANTI-DIARRHEA
ANTI-DIARRHEAL
ANZEMET
APIDRA
APIDRA SOLOSTAR
APLENZIN
APOKYN
apraclonidine hcl
APRISO
APTIOM
APTIVUS
ARANELLE
ARANESP
ARCALYST
ARRANON
ARTHRITIS PAIN RELIEF
ARZERRA
ASACOL HD
ASMANEX
ASTAGRAF XL
atenolol
atenolol/chlorthalidone
28
60
60
68
68
28
19
19
31
19
19,100
19
67
62
54
38
76
76
76
102
100
30
52
53
26
42
91
85
24
47
76
55
83
35
101
40
85
74
81
59
59
ATGAM
82
ATHLETE'S FOOT
101
atorvastatin calcium
64
atovaquone/proguanil hcl
41
ATRIPLA
46
ATROVENT HFA
93
AVANDAMET
51
AVANDARYL
51
AVANDIA
51
AVASTIN
40
AVELOX
21
AVELOX IV
21
AVIANE
76
AVINZA
11
AVODART
73
AVONEX
67
AVONEX ADMINISTRATION PACK
67
AVONEX PEN
67
AXIRON
76
azacitidine
36
AZACTAM-ISO-OSMOTIC DEXTROSE
18
AZASAN
81
azathioprine
81
azelastine hcl
90,92
AZILECT
43
azithromycin
20
AZOPT
91
AZOR
60
aztreonam
18
B
bacitracin
baclofen
BACTROBAN
BACTROBAN NASAL
balsalazide disodium
BALZIVA
BANZEL
BARACLUDE
benazepril hcl
benazepril hcl/hydrochlorothiazide
16
45
16
16
85
76
24
48
57
57
105
BENICAR
57
BENICAR HCT
57
BENLYSTA
83
benztropine mesylate
42
betamethasone dipropionate
74
betamethasone dipropionate/propylene
glycol
74
betamethasone valerate
74
BETASERON
67
betaxolol hcl
59,91
bethanechol chloride
73
BETOPTIC S
91
bicalutamide
35
BICILLIN C-R
19
BICILLIN L-A
19
BICNU
34
BILTRICIDE
41
bisoprolol fumarate
59
bisoprolol fumarate/hydrochlorothiazide
59
bleomycin sulfate
36
BLEPHAMIDE
90
BLEPHAMIDE S.O.P.
90
BONIVA
86
BOOSTRIX TDAP
83
BOSULIF
39
BOTOX
86
BRILINTA
55
brimonidine tartrate
91
BRINTELLIX
27
BRISDELLE
27
bromfenac sodium
90
bromocriptine mesylate
42
budesonide
74,85
bumetanide
62
buprenorphine hcl
14
BUPROBAN
14
bupropion hcl
26
buspirone hcl
50
BUSULFEX
34
butalbital/acetaminophen/caffeine/codeine
phosphate
12
butorphanol tartrate
BYETTA
BYSTOLIC
12
51
60
C
cabergoline
calcipotriene
calcitonin,salmon,synthetic
calcitriol
calcium acetate
CAMILA
CANASA
CANCIDAS
CAPASTAT SULFATE
CAPRELSA
captopril
captopril/hydrochlorothiazide
CARAC
CARAFATE
carbamazepine
carbidopa/levodopa
carboplatin
CARIMUNE NF NANOFILTERED
carisoprodol
carvedilol
CAYSTON
cefaclor
cefadroxil
cefazolin sodium
cefazolin sodium/dextrose, iso-osmotic
cefdinir
cefepime hcl
cefotaxime sodium
cefotetan disodium
cefoxitin sodium
cefoxitin sodium/dextrose, iso-osmotic
cefpodoxime proxetil
cefprozil
ceftazidime pentahydrate
ceftazidime pentahydrate in dextrose 5%water
79
68
86
86
72
78
85
31
34
39
57
58
68
72
25
42
36
82
95
60
18
17
17
17
17
17
17
17
17
17
17
18
18
18
18
106
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
CELEBREX
CELLCEPT
CELONTIN
cephalexin
CEREZYME
CERVARIX
CESAMET
cetirizine hcl
cevimeline hcl
CHANTIX
CHEMET
CHENODAL
CHILDREN'S CLEAR-ATADINE
chloramphenicol sod succ
chlorhexidine gluconate
chloroquine phosphate
chlorothiazide
chlorpheniramine maleate
chlorpromazine hcl
chlorpropamide
chlorthalidone
chlorzoxazone
cholestyramine/aspartame
chorionic gonadotropin, human
CIALIS
ciclopirox
ciclopirox olamine
cidofovir
cilostazol
CILOXAN
cimetidine
cimetidine hcl
CINRYZE
CIPRO
CIPRO HC
CIPRO I.V.
CIPRODEX
ciprofloxacin hcl
18
18
18
10
81
22
18
69
83
30
92,101
67
14
97
71
101
16
67
41
63
101
29
51
63
95
64
80
73
31
31
48
56
21
71
71
81
21
21
21
21
21
ciprofloxacin lactate
ciprofloxacin/ciprofloxacin hcl
cisplatin
citalopram hydrobromide
cladribine
CLARAVIS
CLARINEX
clarithromycin
CLEARLAX
clemastine fumarate
CLEOCIN HCL
clindamycin hcl
clindamycin phosphate
CLINIMIX
CLINIMIX E
CLINISOL
clobetasol propionate
clobetasol propionate/emollient base
CLOLAR
clomipramine hcl
clonazepam
clonidine
clonidine hcl
clopidogrel bisulfate
clorazepate dipotassium
CLORPRES
clotrimazole
clozapine
COARTEM
codeine sulfate
colchicine/probenecid
COLCRYS
colestipol hcl
colistin (as colistimethate sodium)
COMBIGAN
COMETRIQ
COMPLERA
COMPLETE
COMTAN
COMVAX
CONCERTA
21
21
36
27
36
68
92
20
101
92
16
16
16,68
97
97
97
74
68
36
29
23
56
56
56
23
63
31,101
45
41
12
32
32
64
16
91
39
46
101
42
83
65
107
COPAXONE
CORTISPORIN
COSMEGEN
CREON
CRESTOR
CRIXIVAN
cromolyn sodium
CRYSELLE
CUBICIN
cyclobenzaprine hcl
cyclophosphamide
CYCLOSET
cyclosporine
cyclosporine, modified
cyproheptadine hcl
CYSTADANE
cytarabine
cytarabine/pf
67
68
36
69
64
47
94,101
76
16
95
34
42
81
81
92
69
36
36
D
dacarbazine
DALIRESP
danazol
dantrolene sodium
dapsone
DAPTACEL DTAP
DARAPRIM
daunorubicin hcl
DAYHIST ALLERGY
DAYTRANA
decitabine
DEMSER
DENAVIR
DEPEN
DEPO-PROVERA
DEPO-SUBQ PROVERA 104
desipramine hcl
desloratadine
desmopressin acetate
desonide
desoximetasone
34
95
76
45
34
83
41
36
101
66
36
56
68
73
78
78
14,29
92
80
74
74
desvenlafaxine
27
DETROL LA
73
dexamethasone
74
DEXAMETHASONE INTENSOL
74
dexamethasone sod phosphate
74,90
DEXILANT
72
dexmethylphenidate hcl
66
dexrazoxane hcl
37
dextroamphetamine sulfsaccharate/amphetamine sulf-aspartate
65
dextroamphetamine sulfate
65
dextrose 10 % and 0.2 % sodium chloride 97
dextrose 10 % in water
97
dextrose 2.5 % and 0.45 % sodium chloride97
dextrose 5 % in lactated ringers
98
dextrose 5 % in water
97
diazepam
23,50
DIBENZYLINE
56
diclofenac potassium
10
diclofenac sodium
10,68
dicloxacillin sodium
19
dicyclomine hcl
70
didanosine
46
DIFICID
20
diflorasone diacetate
74
diflunisal
10
digoxin
62
dihydroergotamine mesylate
32
DILANTIN
25
DILAUDID
11,12
diltiazem hcl
61
DIOVAN
57
DIPENTUM
85
diphenhydramine hcl
92
diphenoxylate hcl/atropine sulfate
71
dipyridamole
56
108
disopyramide phosphate
disulfiram
divalproex sodium
DOCEFREZ
docetaxel
donepezil hcl
DORIBAX
dorzolamide hcl
dorzolamide hcl/timolol maleate
doxazosin mesylate
doxepin hcl
DOXIL
doxorubicin hcl
doxycycline hyclate
doxycycline monohydrate
dronabinol
DROXIA
DULERA
duloxetine hcl
DURAMORPH
DUREZOL
DYRENIUM
59
14
23
37
37
26
18
91
91
71
14,29
37
37
22
22
30
36
95
27
11
90
63
E
E.E.S. 200
econazole nitrate
EDLUAR
EDURANT
EFFIENT
ELIDEL
ELIGARD
ELITEK
ELIXOPHYLLIN
ELLA
EMCYT
EMEND
EMSAM
EMTRIVA
enalapril maleate
enalapril maleate/hydrochlorothiazide
ENBREL
20
31
96
46
56
68
79
36
94
78
35
30
27
46
58
58
81
ENGERIX-B ADULT
ENGERIX-B PEDIATRIC-ADOLESCENT
enoxaparin sodium
ENPRESSE
epinastine hcl
EPIPEN
EPIPEN 2-PAK
EPIPEN JR
EPIPEN JR 2-PAK
epirubicin hcl
EPIVIR
EPIVIR HBV
eplerenone
EPOGEN
EPZICOM
ERBITUX
ergoloid mesylates
ERIVEDGE
ERWINAZE
ERYPED 200
ERYPED 400
ERYTHROCIN LACTOBIONATE
ERYTHROCIN STEARATE
erythromycin base
erythromycin base/benzoyl peroxide
erythromycin base/ethyl alcohol
erythromycin ethylsuccinate
escitalopram oxalate
estradiol
estradiol/norethindrone acetate
ethambutol hcl
ethosuximide
etidronate disodium
etodolac
etoposide
EVISTA
EXELDERM
EXELON
exemestane
EXFORGE
EXFORGE HCT
83
83
54
76
90
93
93
93
94
37
48
48
63
55
46
40
25
39
37
20
20
20
20
20
68
68
20
27
77
77
34
22
86
10
39
78
31
26
38
61
61
109
EXJADE
EXTAVIA
96
67
F
FABRAZYME
famciclovir
famotidine
famotidine in sodium chloride, isoosmotic/pf
famotidine/pf
FANAPT
FARESTON
FASLODEX
FAZACLO
felbamate
felodipine
fenofibrate
fenofibrate nanocrystallized
fenofibrate,micronized
fenoprofen calcium
fentanyl
fentanyl citrate
FETZIMA
finasteride
FIRAZYR
FIRMAGON
flavoxate hcl
flecainide acetate
FLOVENT DISKUS
FLOVENT HFA
fluconazole
fluconazole in dextrose, iso-osmotic
flucytosine
fludarabine phosphate
fludrocortisone acetate
fluocinolone acetonide
fluocinonide
fluocinonide/emollient base
FLUOR-A-DAY
FLUORITAB
fluorouracil
70
49
71,101
71
71
44
35
37
45
24
61
63
63
63
10
11
12
27
71
81
79
73
59
92
92
31
31
31
37
74
74
74
68
98
98
68
fluoxetine hcl
fluphenazine decanoate
fluphenazine hcl
flurbiprofen
flurbiprofen sodium
flutamide
fluticasone propionate
fluvastatin sodium
fluvoxamine maleate
FOCALIN XR
FOLOTYN
fondaparinux sodium
FORFIVO XL
FORTEO
FORTESTA
foscarnet sodium
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
fosphenytoin sodium
FOSRENOL
FRAGMIN
furosemide
FUSILEV
FUZEON
FYCOMPA
27
43
43
10
90
35
75
64
27
66
36
54
26
86
76
48
58
58
25
73
54
62
81
47
24
G
gabapentin
GABITRIL
galantamine hbr
GAMMAGARD LIQUID
GAMMAGARD S-D
GAMMAPLEX
GAMUNEX
GAMUNEX-C
ganciclovir sodium
GARDASIL
gauze bandage
GAVILAX
gemcitabine hcl
gemfibrozil
23
23
26
82
83
83
83
83
48
84
86
101
36
63
110
GENOTROPIN
80
GENTAK
15
gentamicin sulfate
15
gentamicin sulfate in sodium chloride, isoosmotic
15
gentamicin sulfate/pf
15
GEODON
44
GILENYA
67
GILOTRIF
39
GLEEVEC
39
glimepiride
51
glipizide
51
glipizide/metformin hcl
51
GLUCAGON EMERGENCY KIT
52
glyburide
51
glyburide,micronized
51
glyburide/metformin hcl
51
glycopyrrolate
70
granisetron hcl
30
granisetron hcl/pf
30,45
GRIS-PEG
31
griseofulvin, microsize
31
guanfacine hcl
56
guanidine hcl
33
HEPATASOL
98
HEPSERA
48
HERCEPTIN
40
HEXALEN
34
HORIZANT
66
HUMIRA
82
HUMIRA PEDIATRIC
82
HUMULIN 70-30
53
HUMULIN 70/30 KWIKPEN
53
HUMULIN N
53
HUMULIN N KWIKPEN
53
HUMULIN R
53
hydralazine hcl
64
hydrochlorothiazide
63
12
hydrocodone/ibuprofen
12
hydrocortisone
75,85
hydrocortisone valerate
75
hydromorphone hcl
12
hydromorphone hcl/pf
11
hydroxychloroquine sulfate
41
hydroxyurea
36
hydroxyzine hcl
50
hydroxyzine pamoate
92
H
I
H.P. ACTHAR
75
HALAVEN
37
halobetasol propionate
75
haloperidol
43
haloperidol decanoate
43
haloperidol lactate
43
HAVRIX
84
HEALTHYLAX
101
HEARTBURN RELIEF
101
heparin sodium,porcine
54
heparin sodium,porcine in 0.9 % sodium
chloride/pf
54
heparin sodium,porcine/dextrose 5 % in
water
54
HEPATAMINE
98
ibandronate sodium
ibuprofen
ibuprofen/oxycodone hcl
idarubicin hcl
ifosfamide
ILARIS
IMBRUVICA
imipenem/cilastatin sodium
imipramine hcl
imipramine pamoate
imiquimod
IMITREX
IMOVAX RABIES VACCINE
INCIVEK
INCRELEX
86
10,101
12
37
34
83
39
18
29
29
68
33
84
49
53
111
indapamide
INDOCIN
indomethacin
INFANRIX DTAP
INLYTA
INTELENCE
INTRALIPID
INTRON A
INTUNIV
INVANZ
INVEGA
INVEGA SUSTENNA
INVIRASE
IONOSOL MB-DEXTROSE 5%
IPOL
ipratropium bromide
ipratropium bromide/albuterol sulfate
irbesartan
irbesartan/hydrochlorothiazide
irinotecan hcl
ISENTRESS
ISOLYTE S
isoniazid
ISOPTO CARPINE
isosorbide dinitrate
isosorbide mononitrate
isradipine
ISTODAX
ITCHY EYE
itraconazole
IXEMPRA
IXIARO
63
10
10
84
39
46
98
37
66
19
44
44
47
98
84
93
93
57
57
37
46
98
34
91
65
65
61
37
101
31
37
84
J
JAKAFI
JALYN
JANUMET
JANUVIA
JEVTANA
JINTELI
JUNEL
39
73
51
51
37
77
77
JUNEL FE
77
K
KADCYLA
KALETRA
KALYDECO
KENALOG
KEPIVANCE
KETEK
ketoconazole
ketoprofen
ketorolac tromethamine
KHEDEZLA
KINERET
KLOR-CON M15
KOMBIGLYZE XR
KUVAN
37
47
94
75
67
21
31
10
10,90
27
82
98
51
70
L
labetalol hcl
lactulose
LAMICTAL (BLUE)
LAMICTAL (GREEN)
LAMICTAL (ORANGE)
LAMICTAL ODT
LAMICTAL XR (BLUE)
LAMICTAL XR (GREEN)
LAMICTAL XR (ORANGE)
LAMISIL
LAMISIL AT
lamivudine
lamivudine/zidovudine
lamotrigine
lansoprazole
LANTUS
LANTUS SOLOSTAR
latanoprost
LATUDA
leflunomide
LESSINA
LETAIRIS
60
72
24
24
24
24
24
24
24
31
101
48
46
24
72
53
53
91
44
83
77
94
112
letrozole
38
leucovorin calcium
37
LEUKERAN
35
LEUKINE
55
leuprolide acetate
79
LEVEMIR
53
LEVEMIR FLEXPEN
53
LEVEMIR FLEXTOUCH
53
levetiracetam
22
levobunolol hcl
91
levocarnitine
70
levocarnitine (with sugar)
70
levocetirizine dihydrochloride
92
levofloxacin
21
levofloxacin/dextrose 5 % in water
21
levonorgestrel-ethinyl estradiol
77
levorphanol tartrate
11
levothyroxine sodium
81
LEXIVA
47
LIALDA
85
LICE TREATMENT
101
lidocaine
13
lidocaine hcl
13,101
lidocaine/prilocaine
13
LIDODERM
68
lindane
41
liothyronine sodium
81
LIPOSYN III
98
lisinopril
58
lisinopril/hydrochlorothiazide
58
lithium carbonate
50
lithium citrate
50
lomustine
35
loperamide hcl
71,101
loratadine
102
lorazepam
50
LORAZEPAM INTENSOL
50
losartan potassium
57
losartan potassium/hydrochlorothiazide
57
LOTRONEX
72
lovastatin
64
LOVAZA
LOW-OGESTREL
loxapine succinate
LUDENT FLUORIDE
LUMIGAN
LUMIZYME
LUPRON DEPOT
LUPRON DEPOT-PED
LUTERA
LYRICA
LYSODREN
64
77
43
98
91
70
79
79
77
23
78
M
M-M-R II VACCINE
MACRODANTIN
malathion
maprotiline hcl
MARPLAN
MATULANE
meclizine hcl
meclofenamate sodium
medroxyprogesterone acetate
mefloquine hcl
MEGACE ES
megestrol acetate
MEKINIST
meloxicam
melphalan hcl
MENACTRA
MENEST
MENOMUNE-A-C-Y-W-135
MENOSTAR
MENVEO A-C-Y-W-135-DIP
meperidine hcl
meperidine hcl/pf
MEPERITAB
meprobamate
MEPRON
mercaptopurine
meropenem
mesalamine with cleansing wipes
84
16
41
28
27
35
29
14
78
41
78
78
39
10
35
84
77
84
77
84
12
12
13
50
41
36
19
85
113
mesna
38
MESNEX
38
MESTINON
33
METADATE CD
66
metaproterenol sulfate
94
metformin hcl
52
methadone hcl
11
methazolamide
62
methenamine hippurate
16
methimazole
80
methocarbamol
95
methotrexate sodium
82,102
methotrexate sodium/pf
36
methscopolamine bromide
70
methyclothiazide
63
methyldopa
56
methyldopa/hydrochlorothiazide
56
methylergonovine maleate
33
METHYLIN
66
methylphenidate hcl
66
methylprednisolone
75
methylprednisolone acetate
75
methylprednisolone sodium succinate
75
metoclopramide hcl
71
metolazone
63
metoprolol succinate
60
metoprolol tartrate
60
metoprolol tartrate/hydrochlorothiazide
60
metronidazole
16
metronidazole in sodium chloride
16
mexiletine hcl
59
MIACALCIN
86
MICARDIS
57
MICARDIS HCT
57
miconazole nitrate
31,102
MICROGESTIN
77
MICROGESTIN FE
77
midodrine hcl
56
MIGERGOT
33
minocycline hcl
22
minoxidil
64
MIRAPEX ER
mirtazapine
misoprostol
mitomycin
mitoxantrone hcl
modafinil
moexipril hcl
moexipril hcl/hydrochlorothiazide
mometasone furoate
MONONESSA
montelukast sodium
morphine sulfate
MOXEZA
MOZOBIL
MULTAQ
mupirocin
MUSTARGEN
MYCOBUTIN
mycophenolate mofetil
mycophenolate sodium
42
26
72
38
38
96
58
58
75
77
93
11,13,102
21
55
59
16
35
34
82
82
N
nabumetone
nadolol
nafcillin in dextrose, iso-osmotic
nafcillin sodium
NAFTIN
NAGLAZYME
nalbuphine hcl
naloxone hcl
naltrexone hcl
NAMENDA
naproxen
naproxen sodium
naratriptan hcl
NASONEX
nateglinide
NEBUPENT
NECON
needles, insulin disposable
needles, insulin disposable, safety
10
60
19
19
31
70
13
14
14
26
14
14,102
33
75
52
41
77
87
87
114
nefazodone hcl
28
neomycin sulfate
15
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone
90
neomycin sulfate/bacitracin/polymyxin b
16
neomycin sulfate/polymyxin b sulfate
15
neomycin sulfate/polymyxin b
sulfate/hydrocortisone
16,92
NEULASTA
55
NEUMEGA
55
NEUPOGEN
55
NEUPRO
42
NEVANAC
90
nevirapine
46
NEXAVAR
39
NEXIUM I.V.
72
NIACOR
64
NIASPAN
64
nicardipine hcl
61
nicotine
102
nicotine polacrilex
102
NICOTROL NS
14
nifedipine
61
NILANDRON
35
nimodipine
61
nisoldipine
61
NITRO-BID
65
nitrofurantoin
16
nitrofurantoin macrocrystal
16
nitrofurantoin monohydrate/macrocrystals 16
nitroglycerin
65
NITROMIST
65
NITROSTAT
65
nizatidine
71
NON-DROWSY ALLERGY
102
norethindrone
78
norethindrone acetate
78
NORMOSOL-M AND DEXTROSE
98
NORMOSOL-R AND DEXTROSE
98
NORMOSOL-R PH 7.4
98
NORPACE CR
59
NORTREL
nortriptyline hcl
NORVIR
NOVOLIN 70-30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG MIX 70-30 FLEXPEN
NOXAFIL
NUCYNTA
NUCYNTA ER
NUEDEXTA
NULOJIX
nystatin
nystatin/triamcinolone acetonide
77
29
47
53
53
53
53
53
53
53
31
13
13
66
82
32,45
68
O
octreotide acetate
ofloxacin
OGESTREL
olanzapine
olanzapine/fluoxetine hcl
OLYSIO
omeprazole
OMNARIS
OMNITROPE
ONCASPAR
ondansetron
ondansetron hcl
ondansetron hcl/pf
ONFI
ONGLYZA
ORAP
orphenadrine citrate
ORTHO EVRA
OSMOPREP
OVCON-35
oxacillin sodium
oxacillin sodium/dextrose, iso-osmotic
79
21
77
44
28
49
72
92
80
38
30
30
30
23
52
43
95
77
98
77
19
19
115
oxaliplatin
oxandrolone
oxaprozin
oxcarbazepine
OXISTAT
OXSORALEN
OXSORALEN-ULTRA
OXTELLAR XR
oxybutynin chloride
oxycodone hcl
oxycodone hcl/acetaminophen
oxycodone hcl/aspirin
OXYTROL
38
76
10
25
32
68
69
25
70
11
13
13
73
P
paclitaxel
38
PAIN RELIEF
102
pamidronate disodium
86
PANCREAZE
70
PANRETIN
40
pantoprazole sodium
72
paromomycin sulfate
15
paroxetine hcl
28
PASER
34
PAXIL
28
PEDVAXHIB
84
PEGANONE
25
PEGASYS
49
PEGASYS PROCLICK
49
PEGINTRON
49
PEGINTRON REDIPEN
49
pen needle, diabetic disposable, safety
87
pen needle, diabetic, remover & disposal
unit
87
penicillin g potassium
20
penicillin g potassium/dextrose-water
20
penicillin g procaine
20
penicillin g sodium
20
penicillin v potassium
20
PENNSAID
69
PENTACEL ACTHIB COMPONENT
84
PENTAM 300
41
PENTASA
85
pentazocine hcl/naloxone hcl
13
pentoxifylline
62
perindopril erbumine
58
PERJETA
40
permethrin
41,102
perphenazine
30
perphenazine/amitriptyline hcl
29
phenelzine sulfate
27
phenobarbital
23
phenylephrine hcl/promethazine hcl
93
phenytoin
25
phenytoin sodium
25
phenytoin sodium extended
25
PICATO
69
pilocarpine hcl
67
pindolol
60
pioglitazone hcl
52
pioglitazone hcl/glimepiride
52
pioglitazone hcl/metformin hcl
52
piperacillin sodium/tazobactam sodium
20
piroxicam
10
PLAN B ONE-STEP
102
PLASMA-LYTE 148
98
PLASMA-LYTE 56 IN DEXTROSE
98
PLASMA-LYTE A PH 7.4
98
podofilox
69
polyethylene glycol 3350
72
polymyxin b sulfate/trimethoprim
16
POMALYST
35
PONSTEL
10
potassium chloride
98
chloride
99
chloride
98
potassium chloride in 5 % dextrose in water99
potassium chloride in dextrose 5 % and 0.9 %
sodium chloride
99
116
potassium chloride in dextrose 5 %-0.2 %
sodium chloride
99
potassium chloride in dextrose 5 %-0.45 %
sodium chloride
99
potassium chloride in dextrose 5% and 0.3 %
sodium chloride
99
potassium chloride in lactated ringers and 5
% dextrose
99
potassium citrate
99
POTIGA
22
PRADAXA
54
pramipexole di-hcl
42
PRANDIMET
52
PRANDIN
52
pravastatin sodium
64
prazosin hcl
56
PRED MILD
90
PRED-G
15
prednisolone
75
prednisolone sod phosphate
75,90
prednisone
75
PREDNISONE INTENSOL
75
PREMARIN
77
PREMASOL
99
PREZISTA
47
PRIFTIN
34
PRILOSEC OTC
102
primaquine phosphate
41
primidone
23
PRISTIQ ER
28
PRIVIGEN
83
PROAIR HFA
94
probenecid
32
PROCALAMINE
99
prochlorperazine edisylate
30
prochlorperazine maleate
30
PROCRIT
55
progesterone,micronized
78
PROGLYCEM
52
PROGRAF
82
PROLASTIN C
95
PROLEUKIN
PROLIA
PROMACTA
promethazine hcl
propafenone hcl
propantheline bromide
proparacaine hcl
propranolol hcl
propranolol hcl/hydrochlorothiazide
propylthiouracil
PROQUAD
PROSOL
PROTOPIC
protriptyline hcl
PROVENTIL HFA
PULMOZYME
pyrazinamide
pyridostigmine bromide
38
86
55
30,93
59
70
90
60
60
80
84
99
69
29
94
95
34
33
Q
quetiapine fumarate
quinapril hcl
quinapril hcl/hydrochlorothiazide
quinidine gluconate
quinidine sulfate
quinine sulfate
QVAR
26
58
58
59
59
41
92
R
RABAVERT
ramipril
RANEXA
ranitidine hcl
RAPAFLO
RAPAMUNE
REBETOL
REBIF
REBIF REBIDOSE
RECLAST
RECOMBIVAX HB
RELENZA
84
58
62
71,102
73
82
45
67
67
86
84
48
117
RELISTOR
REMICADE
REMODULIN
RENAGEL
RENVELA
RESCRIPTOR
reserpine
RESTASIS
RETROVIR
REVLIMID
REYATAZ
RIBASPHERE
ribavirin
RIDAURA
RIFAMATE
rifampin
RIFATER
RILUTEK
rimantadine hcl
ringers solution
ringers solution,lactated
RIOMET
RISPERDAL CONSTA
risperidone
RITALIN LA
RITUXAN
rivastigmine tartrate
rizatriptan benzoate
ropinirole hcl
ROTARIX
ROTATEQ
ROZEREM
71
82
94
73
72
46
56
90
46
35
47
49
49
83
34
34
34
66
48
99
99
52
44
45
66
40
26
33
42
84
84
96
S
SABRIL
SAMSCA
SANCUSO
SANDIMMUNE
SANDOSTATIN LAR
SANTYL
SAPHRIS
23
99
30
82
79
69
45
SAVELLA
selegiline hcl
SELZENTRY
SENSIPAR
SEREVENT DISKUS
SEROQUEL XR
sertraline hcl
sildenafil citrate
SILENOR
silver sulfadiazine
SIMCOR
SIMPONI
SIMULECT
simvastatin
sirolimus
sodium chloride
sodium chloride 0.45 %
sodium chloride 3 %
sodium chloride 5 %
sodium chloride irrigating solution
sodium fluoride
sodium lactate
sodium polystyrene sulfonate
SOLARAZE
SOLTAMOX
SOLU-CORTEF
SOLU-MEDROL
SOMATULINE DEPOT
SOMAVERT
SORIATANE
sotalol hcl
SOVALDI
SPIRIVA
spironolactone
spironolactone/hydrochlorothiazide
SPORANOX
SPRINTEC
SPRIX
SPRYCEL
STALEVO 100
STALEVO 125
66
43
47
79
94
26
28
95
29
69
64
82
82
64
82
99
99
99
99
99
100
96
96
69
35
75
75
79
79
69
59
49
93
63
63
32
78
10
39
42
43
118
STALEVO 150
43
STALEVO 200
43
STALEVO 50
43
STALEVO 75
43
stavudine
47
STIVARGA
39
STRATTERA
66
streptomycin sulfate
15
STRIBILD
46
STROMECTOL
41
SUBOXONE
14
sucralfate
72
sulfacetamide sodium
21
sulfacetamide sodium/prednisolone sodium
phosphate
90
sulfadiazine
22
sulfamethoxazole/trimethoprim
22
sulfasalazine
85
SULFAZINE EC
85
sulindac
10
sumatriptan succinate
33
SUPRAX
18
SURMONTIL
29
SUSTIVA
46
SUTENT
39
SYLATRON
48
SYLATRON 4-PACK
48
SYMBICORT
95
SYMLINPEN 120
52
SYMLINPEN 60
52
SYNAGIS
38
SYNAREL
79
SYNERCID
17
SYNRIBO
38
SYPRINE
96
ml/container,empty
87
ml/container,empty
87
syringe w/needle,insulin disposable 0.3 ml
(half unit mark)
87
syringe with needle, insulin, safety, 0.3 ml 87
syringe with needle, insulin, safety, 0.5 ml 88
syringe with needle, insulin, safety, 1 ml
88
syringe with needle, insulin,1 ml and sharps
container
88
syringe with needle,disposable,insulin
88
syringe with needle,disposable,insulin 1 ml 88
syringe with needle,insulin disposable,0.3
ml
89
syringe with needle,insulin disposable,0.5
ml
89
syringe,needle,insulin,safety,disposal unit, 1
ml
89
syringe,needle,insulin,safety,disposal unit,0.3
ml
87
syringe,needle,insulin,safety,disposal unit,0.5
ml
89
T
TABLOID
TACLONEX
tacrolimus
TAFINLAR
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TARCEVA
TARGRETIN
TARKA
TASIGNA
TASMAR
TAZORAC
TEFLARO
TEGRETOL XR
TEKAMLO
TEKTURNA
TEKTURNA HCT
terazosin hcl
terbinafine hcl
terbutaline sulfate
terconazole
36
69
82
40
48
35
71
40
40
58
40
42
69
18
25
62
62
62
56
32,103
94
32
119
TESTIM
testosterone cypionate
tetanus and diphtheria toxoids, adult
tetanus toxoid, adsorbed/pf
tetanus,diphtheria toxoid ped/pf
THALOMID
theophylline anhydrous
thioridazine hcl
thiothixene
tiagabine hcl
ticlopidine hcl
TIKOSYN
timolol maleate
tinidazole
TIOCONAZOLE 1
TIVICAY
tizanidine hcl
TOBI
TOBRADEX
TOBRADEX ST
tobramycin
tobramycin sulfate
tobramycin sulfate/sodium chloride
tobramycin/dexamethasone
TOBREX
tolazamide
tolbutamide
tolmetin sodium
tolterodine tartrate
topiramate
topotecan hcl
TORISEL
torsemide
TPN ELECTROLYTES
TRACLEER
tramadol hcl
tramadol hcl/acetaminophen
trandolapril
tranexamic acid
TRANSDERM-SCOP
tranylcypromine sulfate
76
76
84
84
84
35
94
43
44
23
56
59
60,91
17
103
46
45
94
91
91
15
15
15
91
91
52
52
15
70
24
39
38
62
100
95
11
13
58
55
30
27
TRAVASOL
TRAVATAN Z
trazodone hcl
TREANDA
TRECATOR
TRELSTAR
TRELSTAR DEPOT
TRELSTAR LA
tretinoin
TREXALL
TREXIMET
TRI-SPRINTEC
triamcinolone acetonide
triamterene/hydrochlorothiazide
TRIBENZOR
trifluoperazine hcl
trifluridine
trihexyphenidyl hcl
TRILIPIX
trimethobenzamide hcl
trimethoprim
TRINESSA
TRISENOX
TRIVORA-28
TROKENDI XR
TROPHAMINE
trospium chloride
TRUVADA
TWINRIX
TYGACIL
TYKERB
TYPHIM VI
TYSABRI
TYZEKA
100
91
28
35
34
80
80
80
40,69
82
33
78
67,76,92
63
57
44
49
42
63
30
17
78
38
78
24
100
73
47
84
17
40
84
67
48
U
ULORIC
ursodiol
UVADEX
32
71
69
120
VYVANSE
V
valacyclovir hcl
VALCYTE
valproic acid
valproic acid (as sodium salt) (valproate
sodium)
valsartan/hydrochlorothiazide
vancomycin hcl
VAQTA
VARIVAX VACCINE
VECTIBIX
VELCADE
venlafaxine hcl
VENTOLIN HFA
VERAMYST
verapamil hcl
VERELAN
VERSACLOZ
VESICARE
VFEND
VICTOZA 2-PAK
VICTOZA 3-PAK
VICTRELIS
VIDEX
VIGAMOX
VIIBRYD
VIMPAT
vinblastine sulfate
vincristine sulfate
vinorelbine tartrate
VIRACEPT
VIRAMUNE
VIRAMUNE XR
VIRAZOLE
VIREAD
VIVITROL
VOLTAREN
voriconazole
VOTRIENT
VYTORIN
49
48
33
24
57
17
84
85
40
38
28
94
92
61
61
45
73
32
52
52
49
47
21
28
25
38
38
38
47
46
46
49
48
14
69
32
40
64
65
W
warfarin sodium
water for irrigation,sterile
WELCHOL
54
90
52
X
XALKORI
XARELTO
XENAZINE
XGEVA
XIFAXAN
XOLAIR
XTANDI
XYREM
40
54
66
86
17
95
35
96
Y
YERVOY
YF-VAX
38
85
Z
ZADITOR
zafirlukast
zaleplon
ZALTRAP
ZANOSAR
ZAVESCA
ZEGERID
ZELAPAR
ZELBORAF
ZEMAIRA
ZEMPLAR
ZENPEP
ZETIA
ZIAGEN
zidovudine
ziprasidone hcl
ZOLINZA
zolpidem tartrate
ZOLPIMIST
103
93
96
38
38
70
72
43
40
95
86
70
64
47
47
45
38
96
96
121
ZOMETA
ZOMIG
ZOMIG ZMT
ZONALON
zonisamide
ZORTRESS
ZOSTAVAX
ZOSYN
ZOVIA 1-35E
ZOVIA 1-50E
ZOVIRAX
ZYCLARA
ZYFLO CR
ZYKADIA
ZYMAXID
ZYTIGA
ZYVOX
86
33
33
29
23
82
85
20
78
78
49
69
93
40
21
35
17
122
This formulary was updated on August 8, 2014. For more recent information or other questions,
please contact Meridian Complete at 855-323-4578 (TTY 711) 8:00 a.m. to 8:00 p.m., Monday –
Sunday, or visit www.medicaremeridian.com.
?

Cardiovascular Agents - Meridian Health Plan

Transcription

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