HMO-POS - Univera Healthcare

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Univera SeniorChoice® Group HMO-POS Plan
Univera® Medicare Group PPO Plan
2016 Formulary
(List of Covered Drugs)
PLEASE READ:
THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 11/1/2016. For more recent information or other questions, please
contact Univera Healthcare at 1-800-659-1986 or, for TTY users, 1-800-421-1220, Monday – Friday,
8:00 a.m. – 8:00 p.m.; From October 1 to February 14, representatives are available to assist you
seven days a week from 8:00 a.m. – 8:00 p.m., or visit UniveraMedicare.com.
Note to existing members: This formulary has changed since last year. Please review this document
to make sure that it still contains the drugs you take.
Univera Healthcare contracts with the Federal Government and is a HMO plan and PPO plan with a
Medicare contract. Enrollment in Univera Healthcare depends on contract renewal.
H3351, H3335
Formulary ID 16473 Ver 22
M-107C Y16
9710-15 Group
When this drug list (formulary) refers to “we,” “us,” or “our,” it means Univera Healthcare. When it refers
to “plan” or “our plan,” it means Univera Healthcare.
This document includes a list of the drugs (formulary) for our plan which is current as of 11/1/2016. For an
updated formulary, please contact us. Our contact information, along with the date we last updated the
formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to
time during the year.
What is the Univera SeniorChoice® Group HMO-POS and
Univera® Medicare Group PPO Formulary?
A formulary is a list of covered drugs selected by
our plan in consultation with a team of health
care providers, which represents the prescription
therapies believed to be a necessary part of a
quality treatment program. Our plan will generally
cover the drugs listed in our formulary as long as
the drug is medically necessary, the prescription
is filled at a plan network pharmacy, and other
plan rules are followed. For more information on
how to fill your prescriptions, please review your
Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2016
formulary that was covered at the beginning of the
year, we will not discontinue or reduce coverage
of the drug during the 2016 coverage year except
when a new, less expensive generic drug becomes
available or when new adverse information
about the safety or effectiveness of a drug is
released. Other types of formulary changes, such
as removing a drug from our formulary, will not
affect members who are currently taking the drug.
It will remain available at the same cost–sharing
for those members taking it for the remainder of
the coverage year. We feel it is important that you
have continued access for the remainder of the
coverage year to the formulary drugs that were
available when you chose our plan, except for
cases in which you can save additional money or
we can ensure your safety.
becomes effective, or at the time the member
requests a refill of the drug, at which time the
member will receive a 60-day supply of the drug.
If the Food and Drug Administration deems a
drug on our formulary to be unsafe or the drug’s
manufacturer removes the drug from the market,
we will immediately remove the drug from our
formulary and provide notice to members who
take the drug. The enclosed formulary is current
as of 11/1/2016. To get updated information about
the drugs covered by our plan, please contact
us. Our contact information appears on the front
and back cover pages. If we make any mid-year
non-maintenance changes to our formulary,
we will update the formulary with any CMS
approved changes. We will notify you of any nonmaintenance changes to your printed formulary
60 days prior to the effective date of the changes.
The updated formulary will be available on our
Web site. A printed copy of the updated formulary
can be requested by calling us. See the contact
information that appears on the front and back
cover pages.
If we remove drugs from our formulary, add prior
authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher
cost-sharing tier, we must notify affected members
of the change at least 60 days before the change
M-107C Y16
I
How do I use the Formulary?
There are two ways to find your drug within the
formulary:
Alphabetical Listing
If you are not sure what category to look under, you
should look for your drug in the Index that begins on
page 102. The Index provides an alphabetical list of all
of the drugs included in this document. Both brand
name drugs and generic drugs are listed in the Index.
Look in the Index and find your drug. Next to your
drug, you will see the page number where you can
find coverage information. Turn to the page listed in
the Index and find the name of your drug in the first
column of the list.
Medical Condition
The formulary begins on page 1. The drugs in this
formulary are grouped into categories depending
on the type of medical conditions that they are
used to treat. For example, drugs used to treat
a heart condition are listed under the category,
“Cardiovascular Agents.” If you know what your
drug is used for, look for the category name in the
list that begins on page 1. Then look under the
category name for your drug.
What are generic drugs?
Our plan covers both brand name drugs and generic
drugs. A generic drug is approved by the FDA as
having the same active ingredient as the brand
name drug. Generally, generic drugs cost less than
brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional
requirements or limits on coverage. These
requirements and limits may include:
treat your medical condition, our plan may not cover
Drug B unless you try Drug A first. If Drug A does
not work for you, our plan will then cover Drug B.
• Prior Authorization: Our plan requires you
or your physician to get prior authorization for
certain drugs. This means that you will need to
get approval from our plan before you fill your
prescriptions. If you don’t get approval, our plan
may not cover the drug.
You can find out if your drug has any additional
requirements or limits by looking in the formulary that
begins on page 1. You can also get more information
about the restrictions applied to specific covered
drugs by visiting our Web site. We have posted online
documents that explain our prior authorization and
step therapy restrictions. You may also ask us to send
you a copy. Our contact information, along with the
date we last updated the formulary, appears on the
front and back cover pages.
• Quantity Limits: For certain drugs, our plan
limits the amount of the drug that our plan will
cover. For example, our plan provides 30 tablets
per prescription for CRESTOR. This may be
in addition to a standard one–month or
three–month supply.
You can ask our plan to make an exception to these
restrictions or limits or for a list of other, similar drugs
that may treat your health condition. See the section,
“How do I request an exception to the Univera
SeniorChoice® Group HMO-POS and Univera®
Medicare Group PPO Formulary?” on page III for
information about how to request an exception.
• Step Therapy: In some cases, our plan requires
you to first try certain drugs to treat your medical
condition before we will cover another drug for that
condition. For example, if Drug A and Drug B both
II
M-107C Y16
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of
covered drugs), you should first contact Customer
Care and ask if your drug is covered.
receive the list, show it to your doctor and ask him
or her to prescribe a similar drug that is covered by
our plan.
If you learn that our plan does not cover your drug,
you have two options:
• You can ask our plan to make an exception and
cover your drug. See below for information about
how to request an exception.
• You can ask Customer Care for a list of similar
drugs that are covered by our plan. When you
How do I request an exception to the Univera SeniorChoice®
Group HMO-POS and Univera® Medicare Group PPO Formulary?
You can ask our plan to make an exception to our
coverage rules. There are several types of exceptions
that you can ask us to make.
plan’s formulary, the lower cost-sharing drug or
additional utilization restrictions would not be as
effective in treating your condition and/or would cause
you to have adverse medical effects.
• You can ask us to cover a drug even if it is not on
our formulary. If approved, this drug will be covered
at a pre-determined cost-sharing level, and you
would not be able to ask us to provide the drug at
a lower cost-sharing level.
You should contact us to ask us for an initial
coverage decision for a formulary, tier or utilization
restriction exception. When you request a
formulary, tier or utilization restriction
exception you should submit a statement
from your prescriber or physician supporting
your request. Generally, we must make our
decision within 72 hours of getting your prescriber’s
supporting statement. You can request an expedited
(fast) exception if you or your doctor believe that
your health could be seriously harmed by waiting
up to 72 hours for a decision. If your request to
expedite is granted, we must give you a decision
no later than 24 hours after we get a supporting
statement from your doctor or other prescriber.
• You can ask us to cover a formulary drug at a lower
cost-sharing level if this drug is not on the specialty
tier. If approved this would lower the amount you
must pay for your drug.
• You can ask us to waive coverage restrictions or
limits on your drug. For example, for certain drugs,
our plan limits the amount of the drug that we will
cover. If your drug has a quantity limit, you can ask
us to waive the limit and cover a greater amount.
Generally, our plan will only approve your request for
an exception if the alternative drugs included on the
M-107C Y16
III
What do I do before I can talk to my doctor about changing my
drugs or requesting an exception?
As a new or continuing member in our plan you may
be taking drugs that are not on our formulary. Or,
you may be taking a drug that is on our formulary but
your ability to get it is limited. For example, you may
need a prior authorization from us before you can fill
your prescription. You should talk to your doctor to
decide if you should switch to an appropriate drug
that we cover or request a formulary exception so
that we will cover the drug you take. While you talk to
your doctor to determine the right course of action for
you, we may cover your drug in certain cases during
the first 90 days you are a member of our plan.
If you are a resident of a long-term care facility,
we will allow you to refill your prescription until we
have provided you with a 98-day transition supply,
consistent with dispensing increment, (unless you
have a prescription written for fewer days). We will
cover more than one refill of these drugs for the first
90 days you are a member of our plan. If you need
a drug that is not on our formulary or if your ability
to get your drugs is limited, but you are past the first
90 days of membership in our plan, we will cover a
31-day emergency supply of that drug (unless you
have a prescription for fewer days) while you pursue
a formulary exception.
For each of your drugs that is not on our formulary
or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply (unless you
have a prescription written for fewer days) when
you go to a network pharmacy. After your first
30-day supply, we will not pay for these drugs, even
if you have been a member of the plan less
than 90 days.
Any member experiencing a level of care change,
such as a change in their treatment setting, will be
provided a one time, up to 31-day supply of
medication. This includes emergency supplies of
non-formulary drugs and most Part D drugs which
require prior authorization or step therapy.
For more information
For more detailed information about your Univera
Healthcare prescription drug coverage, please review
your Evidence of Coverage and other plan materials.
If you have general questions about Medicare
prescription drug coverage, please call Medicare
at 1-800-MEDICARE (1-800-633-4227) 24 hours a
day/7 days a week. TTY users should call
1-877-486-2048. Or, visit http://www.medicare.gov.
If you have questions about our plan, please contact
us. Our contact information, along with the date we
last updated the formulary, appears on the front and
back cover pages.
IV
M-107C Y16
Univera Healthcare’s Formulary
The formulary that begins on the next page provides
coverage information about the drugs covered by our
plan. If you have trouble finding your drug in the list,
turn to the Index that begins on page 102.
and generic drugs are listed in lower-case italics
(e.g., atorvastatin).
The information in the Requirements/Limits
column tells you if our plan has any
special requirements for coverage of your drug.
The first column of the chart lists the drug name.
Brand-name drugs are capitalized (e.g., CRESTOR)
Explanation of Requirements/Limits
PRIOR
AUTHORIZATION
(PA)
Certain medications require prior authorization. This means that you need to get
approval before you fill your prescription. If you don’t get approval, the drug may not
be covered.
STEP THERAPY
(STEP)
In some cases, we require you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if
Drug A and Drug B both treat your medical condition, we may not cover
Drug B unless you try Drug A first. If Drug A does not work for you, we will
then cover Drug B.
QUANTITY
LIMITS (QL)
For certain drugs, we limit the amount of the drug that we will cover. For example,
we provide 30 tablets per prescription for CRESTOR.
EXCLUDED PART
D DRUGS (*)
VERIFICATION
FOR PART B OR
PART D (BD)
M-107C Y16
This prescription drug is not normally covered in a Medicare Prescription Drug
Plan. The amount you pay when you fill a prescription for this drug does not count
towards your total drug costs (that is, the amount you pay does not help you qualify
for catastrophic coverage). In addition, if you are receiving extra help to pay for
your prescriptions, you will not get any extra help to pay for this drug.
These medications require prior authorization only to determine whether they
qualify for payment under Part B or Part D.
V
Explanation of Tiers
TIER 1
TIER 2
TIER 3
Most generic drugs on our formulary.
Preferred brand-name drugs that have unique, significant clinical advantages and
offer overall greater value over the other products in the same drug class. Certain
generic drugs may appear in Tier 2 due to the high cost of the drug or the potential
safety concerns for our Part D members.
Non-preferred or higher cost specialty brand-name drugs. Certain generic drugs may
appear in Tier 3 due to the high cost of the drug or the potential safety concerns for
our Part D members.
M-107C Y16
VI
Drug Name
Drug Tier
Requirements/Limits
ANALGESICS
ABSTRAL TAB SUBL............................................................3 ................... PA, QL-120 unit(s) per 30 day(s)
acetaminophen-codeine solution...........................................1 ..............................................................
acetaminophen-codeine tablet ..............................................1...............................................................
ACTIQ LOZENGE HD ...........................................................3 ................... PA, QL-120 unit(s) per 30 day(s)
ascomp with codeine capsule................................................1 ..............................................................
aspirin-caffeine-dihydrocodein capsule .................................1 ..............................................................
astramorph-pf vial..................................................................1 ..............................................................
BELBUCA FILM ....................................................................3 .................................. QL-60 per 30 day(s)
BUPRENEX AMPUL .............................................................3 ..............................................................
buprenorphine hcl syringe .....................................................1 ..............................................................
buprenorphine hcl tab subl ....................................................1...............................................................
BUTALB-ACETAMINOPH-CAFF-CODEIN CAPSULE .........3 ..............................................................
BUTALBITAL COMPOUND-CODEINE CAPSULE ...............3 ..............................................................
BUTALBITAL-ACETAMINOPHEN TABLET..........................3 ..............................................................
BUTALBITAL-ACETAMINOPHEN-CAFFE CAPSULE..........3 ..............................................................
BUTALBITAL-ACETAMINOPHEN-CAFFE TABLET.............3...............................................................
BUTALBITAL-ASPIRIN-CAFFEINE CAPSULE.....................3 ..............................................................
BUTORPHANOL TARTRATE VIAL ......................................3 ..............................................................
BUTORPHANOL TARTRATE SPRAY ..................................3...............................................................
BUTRANS PATCH TDWK.....................................................3 ............................ QL-4 unit(s) per 28 day(s)
codeine sulfate tablet ............................................................1 ..............................................................
diskets tablet sol ....................................................................1 ..............................................................
DURAGESIC PATCH TD72 ..................................................3 ................. STEP, QL-15 unit(s) per 30 day(s)
Strength: 100 MCG/HR, 75MCG/HR
DURAGESIC PATCH TD72 ..................................................3 ................. STEP, QL-15 unit(s) per 30 day(s)
Strength: 12 MCG/HR, 25 MCG/HR, 50MCG/HR
duramorph ampul ..................................................................1 ..............................................................
EMBEDA CAP ER PO...........................................................3 .......................... QL-60 unit(s) per 30 day(s)
endocet tablet ........................................................................1 ..............................................................
endodan tablet.......................................................................1 ..............................................................
fentanyl patch td72 ................................................................1 ................. STEP, QL-15 unit(s) per 30 day(s)
Strength: 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50mcg/hr, 75mcg/hr
FENTANYL PATCH TD72.....................................................3 ................. STEP, QL-15 unit(s) per 30 day(s)
Strength: 37.5MCG/HR, 62.5MCG/HR
FENTANYL PATCH TD72.....................................................3 ................. STEP, QL-15 unit(s) per 30 day(s)
Strength: 87.5MCG/HR
1
You can find information on what the symbols and abbreviations on this table mean by
going to page V.
Drug Name
Drug Tier
Requirements/Limits
ANALGESICS (continued)
FENTANYL CITRATE LOZENGE HD................................... 3 ................... PA, QL-120 unit(s) per 30 day(s)
Strength: 1200 MCG, 1600 MCG, 400 MCG, 600 MCG, 800 MCG
FENTANYL CITRATE LOZENGE HD................................... 3 ................... PA, QL-120 unit(s) per 30 day(s)
Strength: 200 MCG
FENTORA TABLET EFF....................................................... 3 ................... PA, QL-120 unit(s) per 30 day(s)
hydrocodone-acetaminophen tablet...................................... 1 ..............................................................
hydrocodone-acetaminophen solution .................................. 1...............................................................
hydrocodone-ibuprofen tablet ............................................... 1 ..............................................................
HYDROMORPHONE ER TAB ER 24H ................................ 2 .......................... QL-30 unit(s) per 30 day(s)
Strength: 12 MG, 16 MG, 8 MG
HYDROMORPHONE ER TAB ER 24H ................................ 2 .......................... QL-60 unit(s) per 30 day(s)
Strength: 32 MG
hydromorphone hcl vial ......................................................... 1 ..............................................................
hydromorphone hcl liquid ...................................................... 1...............................................................
hydromorphone hcl tablet...................................................... 1...............................................................
hydromorphone hcl syringe................................................... 1...............................................................
hydromorphone hcl ampul..................................................... 1...............................................................
HYSINGLA ER TAB ER 24H ................................................ 3 .......................... QL-30 unit(s) per 30 day(s)
HYSINGLA ER TAB ER 24H ................................................ 3 .......................... QL-30 unit(s) per 30 day(s)
Strength: 20 MG, 30 MG, 40 MG, 60 MG
INFUMORPH AMPUL ........................................................... 3 ..............................................................
KADIAN CAP ER PEL........................................................... 3 .......................... QL-60 unit(s) per 30 day(s)
LAZANDA SPRAY/PUMP ..................................................... 3 ............................. PA, QL-30 per 30 day(s)
LEVORPHANOL TARTRATE TABLET................................. 2..............................................................
MARTEN-TAB TABLET ........................................................ 3 ..............................................................
methadone hcl vial ................................................................ 1 ..............................................................
methadone hcl solution ......................................................... 1...............................................................
methadone hcl tablet............................................................. 1...............................................................
methadone intensol oral conc ............................................... 1 ..............................................................
methadose tablet sol ............................................................. 1..............................................................
MORPHINE SULFATE VIAL................................................. 2 ..............................................................
MORPHINE SULFATE CARTRIDGE ................................... 2...............................................................
MORPHINE SULFATE PEN INJCTR ................................... 2...............................................................
MORPHINE SULFATE PCA VIAL ........................................ 2...............................................................
morphine sulfate tablet.......................................................... 1...............................................................
morphine sulfate solution ...................................................... 1...............................................................
2
going to page V.
Drug Name
Drug Tier
Requirements/Limits
MORPHINE SULFATE SYRINGE.........................................2...............................................................
MORPHINE SULFATE SUPP.RECT ....................................2...............................................................
morphine sulfate er tablet er..................................................1 .......................... QL-90 unit(s) per 30 day(s)
MORPHINE SULFATE ER CAP ER PEL..............................2................................... QL-60 unit(s) per 30 day(s)
MORPHINE SULFATE ER CPMP 24HR ..............................2 ........................ QL-120 unit(s) per 30 day(s)
Strength: 120 MG
MORPHINE SULFATE ER CPMP 24HR ..............................2 .......................... QL-30 unit(s) per 30 day(s)
Strength: 30 MG, 45 MG, 60 MG, 75 MG, 90 MG
MORPHINE SULFATE IN DEXTROSE PLAST. BAG...........2 ..............................................................
MORPHINE SULFATE-0.9% NACL PUMP RESVR .............2 ..............................................................
MORPHINE SULFATE-0.9% NACL SYRINGE.....................2...............................................................
MORPHINE SULFATE-0.9% NACL PLAST. BAG ................2...............................................................
MORPHINE SULFATE-0.9% NACL PCA SYRING...............2 ..............................................................
Strength: 125MG/25ML, 25MG/25ML, 55 MG/55ML
MORPHINE SULFATE-0.9% NACL PCA SYRING...............2 ..............................................................
Strength: 150MG/30ML, 275MG/55ML, 50 MG/25ML
MORPHINE SULFATE-D5W PCA SYRING..........................2 ..............................................................
MORPHINE SULFATE-D5W PUMP RESVR ........................2...............................................................
MORPHINE SULFATE-D5W PLAST. BAG...........................2...............................................................
nalbuphine hcl vial .................................................................1 ..............................................................
NUCYNTA TABLET...............................................................3 ........................ QL-180 unit(s) per 30 day(s)
NUCYNTA ER TAB ER 12H..................................................3 .......................... QL-60 unit(s) per 30 day(s)
oxycodone hcl oral conc ........................................................1 ..............................................................
oxycodone hcl tablet..............................................................1...............................................................
oxycodone hcl solution ..........................................................1...............................................................
oxycodone hcl capsule ..........................................................1...............................................................
OXYCODONE HCL ER TAB ER 12H ...................................3 .......................... QL-90 unit(s) per 30 day(s)
Strength: 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG
OXYCODONE HCL ER TAB ER 12H ...................................3 ........................ QL-120 unit(s) per 30 day(s)
Strength: 80 MG
oxycodone hcl-aspirin tablet ..................................................1 ..............................................................
oxycodone hcl-ibuprofen tablet .............................................1 ..............................................................
oxycodone-acetaminophen tablet .........................................1 ..............................................................
oxycodone-acetaminophen solution ......................................1...............................................................
OXYCONTIN TAB ER 12H....................................................3 .......................... QL-90 unit(s) per 30 day(s)
Strength: 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG
3
going to page V.
Drug Name
Drug Tier
Requirements/Limits
OXYCONTIN TAB ER 12H ................................................... 3......................... QL-120 unit(s) per 30 day(s)
Strength: 80 MG
OXYMORPHONE HCL TABLET........................................... 2 ..............................................................
OXYMORPHONE HCL ER TAB ER 12H.............................. 2 .......................... QL-90 unit(s) per 30 day(s)
PENTAZOCINE-NALOXONE HCL TABLET......................... 2..............................................................
roxicet solution ...................................................................... 1 ..............................................................
roxicet tablet.......................................................................... 1...............................................................
SUBSYS SPRAY .................................................................. 3................... PA, QL-120 unit(s) per 30 day(s)
TALWIN VIAL........................................................................ 3 ..............................................................
tencon tablet.......................................................................... 1 ..............................................................
tramadol hcl tablet................................................................. 1 ..............................................................
TRAMADOL HCL ER TAB ER 24H ...................................... 2 .......................... QL-30 unit(s) per 30 day(s)
TRAMADOL HCL ER CPBP 17-83 ....................................... 2 ...................................QL-30 unit(s) per 30 day(s)
TRAMADOL HCL ER CPBP 25-75 ....................................... 2 ...................................QL-60 unit(s) per 30 day(s)
tramadol hcl-acetaminophen tablet ....................................... 1 ..............................................................
vanatol lq solution ................................................................. 1 ..............................................................
XARTEMIS XR TAB IR ERO ................................................ 3 ......................... QL-120 unit(s) per 30 day(s)
XTAMPZA ER CAP SPR 12 ................................................. 3 ................................... QL-90 per 30 day(s)
Strength: 13.5 MG, 18 MG, 27 MG, 9 MG
XTAMPZA ER CAP SPR 12 ................................................. 3................................. QL-240 per 30 day(s)
Strength: 36 MG
zebutal capsule ..................................................................... 1 ..............................................................
ZOHYDRO ER CAP ER 12H ................................................ 3 ..................... PA, QL-60 unit(s) per 30 day(s)
ANESTHETICS
ALCAINE DROPS ................................................................. 3 ..............................................................
EMLA CREAM ..................................................................... 3 .......................................................... PA
lidocaine oint. ....................................................................... 1 .......................................................... PA
LIDOCAINE ADH. PATCH .................................................... 2 ..................... PA, QL-90 unit(s) per 30 day(s)
lidocaine hcl vial .................................................................... 1 .......................................................... PA
lidocaine hcl jel ..................................................................... 1...............................................................
lidocaine hcl ampul................................................................ 1 .......................................................................... PA
lidocaine hcl solution ............................................................. 1...............................................................
lidocaine hcl syringe.............................................................. 1..............................................................
Strength: 100 mg/5ml
lidocaine hcl viscous solution ................................................ 1 ..............................................................
4
going to page V.
Drug Name
Drug Tier
Requirements/Limits
ANESTHETICS (continued)
lidocaine-prilocaine cream ....................................................1 ......................................................... PA
LIDODERM ADH. PATCH.....................................................3 ..................... PA, QL-90 unit(s) per 30 day(s)
PLIAGLIS CREAM ...............................................................3 ......................................................... PA
PONTOCAINE SOLUTION ...................................................3 ......................................................... PA
relador pak kit ........................................................................1 ......................................................... PA
SYNERA M.HT PATCH.........................................................3 ......................................................... PA
XYLOCAINE VIAL .................................................................3 ......................................................... PA
XYLOCAINE-MPF AMPUL....................................................3 ......................................................... PA
XYLOCAINE-MPF VIAL ........................................................3...........................................................................PA
ANTI-ADDICTION, SUBSTANCE ABUSE TREATMENTS
ACAMPROSATE CALCIUM TABLET DR .............................2 ..............................................................
buprenorphine-naloxone tab subl ..........................................1 ..............................................................
buproban tablet er .................................................................1 ..............................................................
bupropion hcl sr tablet er .......................................................1 ..............................................................
Strength: 150 mg
CHANTIX TABLET ................................................................2 ....................... QL-336 unit(s) per 365 day(s)
CHANTIX TAB DS PK ...........................................................2...............................QL-336 unit(s) per 365 day(s)
DISULFIRAM TABLET ..........................................................2 ..............................................................
EVZIO AUTO INJCT..............................................................3 ............................ QL-1 unit(s) per 30 day(s)
naloxone hcl vial ....................................................................1 ..............................................................
naloxone hcl syringe..............................................................1...............................................................
naltrexone hcl tablet ..............................................................1 ..............................................................
NARCAN SPRAY ..................................................................2 .................................... QL-2 per 30 day(s)
NICOTROL CARTRIDGE......................................................3 ..............................................................
NICOTROL NS SPRAY.........................................................3 ..............................................................
SUBOXONE FILM .................................................................3 ..............................................................
VIVITROL SUS ER REC .......................................................3 ..............................................................
ANTIBACTERIALS
ACETIC ACID IRRIG SOLN ..................................................3 ..............................................................
ALTABAX OINT. ...................................................................3 ...................................................... STEP
amikacin sulfate vial ..............................................................1 ..............................................................
amoxicillin capsule.................................................................1 ..............................................................
amoxicillin tab chew...............................................................1...............................................................
5
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Drug Name
Drug Tier
Requirements/Limits
ANTIBACTERIALS (continued)
amoxicillin susp recon ........................................................... 1...............................................................
amoxicillin tablet.................................................................... 1...............................................................
amoxicillin er tbmp 24hr ........................................................ 1 .......................... QL-10 unit(s) per 30 day(s)
amoxicillin-clavulanate pot er tab er 12h............................... 1..............................................................
amoxicillin-clavulanate potass susp recon ............................ 1..............................................................
amoxicillin-clavulanate potass tab chew ............................... 1...............................................................
amoxicillin-clavulanate potass tablet..................................... 1...............................................................
ampicillin sodium vial port ..................................................... 1 ..............................................................
ampicillin sodium vial ............................................................ 1...............................................................
ampicillin trihydrate capsule .................................................. 1 ..............................................................
ampicillin trihydrate susp recon............................................. 1...............................................................
AMPICILLIN-SULBACTAM VIAL .......................................... 3 ..............................................................
AUGMENTIN SUSP RECON................................................ 3 ..............................................................
AVELOX IV PIGGYBACK ..................................................... 3 ..............................................................
AVYCAZ VIAL ....................................................................... 3 ..............................................................
AZACTAM-ISO-OSMOTIC DEXTROSE FROZ.PIGGY........ 3 ..............................................................
AZASITE DROPS ................................................................. 3 ..............................................................
azithromycin tablet ................................................................ 1 ..............................................................
azithromycin vial.................................................................... 1...............................................................
azithromycin packet .............................................................. 1...............................................................
azithromycin susp recon ....................................................... 1...............................................................
aztreonam vial....................................................................... 1 ..............................................................
baciim vial ............................................................................. 1 ..............................................................
bacitracin vial ........................................................................ 1 ..............................................................
bacitracin oint. ...................................................................... 1...............................................................
bacitracin-polymyxin oint. ..................................................... 1 ..............................................................
BESIVANCE DROPS SUSP ................................................. 3 ..............................................................
BETHKIS AMPUL-NEB......................................................... 3 ......................................................... BD
BICILLIN C-R SYRINGE ....................................................... 3 ..............................................................
BICILLIN L-A SYRINGE........................................................ 3 ..............................................................
CAYSTON VIAL-NEB ........................................................... 3 ..............................................................
cefaclor susp recon ............................................................... 1..............................................................
cefaclor capsule .................................................................... 1...............................................................
cefaclor er tab er 12h ............................................................ 1..............................................................
cefadroxil susp recon ............................................................ 1..............................................................
cefadroxil tablet ..................................................................... 1...............................................................
cefadroxil capsule ................................................................. 1...............................................................
6
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Drug Name
Drug Tier
Requirements/Limits
cefazolin sodium vial .............................................................1 ..............................................................
cefazolin sodium-dextrose piggyback....................................1 ..............................................................
cefdinir susp recon ................................................................1 ..............................................................
cefdinir capsule .....................................................................1...............................................................
CEFDITOREN PIVOXIL TABLET..........................................3 ..............................................................
cefepime hcl vial ....................................................................1 ..............................................................
cefixime susp recon...............................................................1 ..............................................................
cefotan vial ............................................................................1 ..............................................................
cefotaxime sodium vial ..........................................................1 ..............................................................
cefotetan vial .........................................................................1 ..............................................................
cefoxitin vial ...........................................................................1 ..............................................................
cefoxitin sodium piggyback....................................................1 ..............................................................
cefpodoxime proxetil tablet....................................................1 ..............................................................
cefpodoxime proxetil susp recon ...........................................1...............................................................
cefprozil tablet .......................................................................1 ..............................................................
cefprozil susp recon ..............................................................1...............................................................
ceftazidime vial ......................................................................1 ..............................................................
ceftazidime piggyback ...........................................................1...............................................................
ceftibuten capsule .................................................................1 ..............................................................
ceftibuten susp recon ............................................................1...............................................................
CEFTIN SUSP RECON.........................................................3 ..............................................................
CEFTRIAXONE FROZ.PIGGY..............................................3 ..............................................................
ceftriaxone vial ......................................................................1...............................................................
cefuroxime tablet ...................................................................1 ..............................................................
cefuroxime sodium vial ..........................................................1 ..............................................................
centany oint. .........................................................................1 ..............................................................
cephalexin capsule ................................................................1 ..............................................................
cephalexin susp recon...........................................................1...............................................................
cephalexin tablet ...................................................................1...............................................................
CETRAXAL DROPERETTE ..................................................3 ..............................................................
chloramphenicol sod succinate vial .......................................1 ..............................................................
CILOXAN OINT. ...................................................................3 ..............................................................
CIPRO SUS MC REC............................................................3 ..............................................................
ciprofloxacin sus mc rec ........................................................1 ..............................................................
ciprofloxacin vial ....................................................................1...............................................................
ciprofloxacin er tbmp 24hr .....................................................1 .......................... QL-30 unit(s) per 30 day(s)
ciprofloxacin hcl tablet ...........................................................1 ..............................................................
ciprofloxacin hcl otic droperette .............................................1...............................................................
7
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Drug Name
Drug Tier
Requirements/Limits
ciprofloxacin hcl opth drops................................................... 1...............................................................
ciprofloxacin-d5w piggyback ................................................. 1 ..............................................................
clarithromycin tablet .............................................................. 1..............................................................
clarithromycin susp recon ..................................................... 1...............................................................
clarithromycin er tab er 24h................................................... 1 ..............................................................
CLEOCIN SUPP.VAG........................................................... 3 ..............................................................
CLINDACIN P MED. SWAB.................................................. 3 ..............................................................
CLINDAGEL GEL ................................................................. 3 ..............................................................
clindamycin hcl capsule ........................................................ 1 ..............................................................
clindamycin palmitate hcl soln recon..................................... 1..............................................................
clindamycin phosphate cream/appl....................................... 1 ..............................................................
clindamycin phosphate foam................................................. 1...............................................................
clindamycin phosphate gel ................................................... 1...............................................................
clindamycin phosphate lotion ................................................ 1...............................................................
clindamycin phosphate solution ............................................ 1...............................................................
clindamycin phosphate med. swab ....................................... 1...............................................................
clindamycin phosphate vial ................................................... 1...............................................................
clindamycin phosphate-d5w piggyback................................. 1..............................................................
CLINDESSE CRM ER .......................................................... 3 ..............................................................
COLISTIMETHATE VIAL ...................................................... 3 ..............................................................
CORTISPORIN CREAM ...................................................... 3 ..............................................................
CUBICIN VIAL....................................................................... 3 ..............................................................
DALVANCE VIAL .................................................................. 3 ..............................................................
demeclocycline hcl tablet ...................................................... 1 ..............................................................
dicloxacillin sodium capsule .................................................. 1 ..............................................................
DIFICID TABLET................................................................... 3.......................... QL-20 unit(s) per 10 day(s)
DORIBAX VIAL ..................................................................... 3 ..............................................................
doxy 100 vial ......................................................................... 1 ..............................................................
doxycycline hyclate vial......................................................... 1 ..............................................................
doxycycline hyclate tablet ..................................................... 1...............................................................
doxycycline hyclate capsule.................................................. 1...............................................................
DOXYCYCLINE HYCLATE TABLET DR .............................. 2...............................................................
DOXYCYCLINE IR-DR CAP IR DR ...................................... 3 ..............................................................
doxycycline monohydrate tablet............................................ 1 ..............................................................
doxycycline monohydrate susp recon ................................... 1...............................................................
doxycycline monohydrate capsule ........................................ 1 ..............................................................
Strength: 100 mg, 50 mg
8
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Drug Name
Drug Tier
Requirements/Limits
DOXYCYCLINE MONOHYDRATE CAPSULE......................3 ..............................................................
Strength: 75 MG
E.E.S. 200 SUSP RECON.....................................................3 ..............................................................
e.e.s. 400 tablet .....................................................................1 ..............................................................
ery med. swab .......................................................................1 ..............................................................
ERYGEL GEL .......................................................................3 ..............................................................
ERYPED 200 SUSP RECON ................................................3 ..............................................................
ERYPED 400 SUSP RECON ................................................3 ..............................................................
ERY-TAB TABLET DR ..........................................................2 ..............................................................
ERYTHROCIN LACTOBIONATE VIAL PORT ......................3 ..............................................................
ERYTHROCIN STEARATE TABLET ....................................3 ..............................................................
ERYTHROMYCIN CAPSULE DR .........................................2 ..............................................................
erythromycin oint. .................................................................1...............................................................
ERYTHROMYCIN TABLET...................................................2...............................................................
erythromycin solution.............................................................1...............................................................
erythromycin med. swab........................................................1...............................................................
erythromycin gel ...................................................................1...............................................................
ERYTHROMYCIN ETHYLSUCCINATE TABLET .................2 ..............................................................
EVOCLIN FOAM ...................................................................3 ..............................................................
FACTIVE TABLET.................................................................3 ..............................................................
FLAGYL ER TABLET ER ......................................................3 ..............................................................
FORTAZ VIAL .......................................................................3 ..............................................................
gatifloxacin drops ..................................................................1 ............................ QL-5 mL(s) per 25 day(s)
gentak oint. ...........................................................................1 ..............................................................
gentamicin sulfate cream ......................................................1 ..............................................................
gentamicin sulfate drops .......................................................1...............................................................
gentamicin sulfate vial ...........................................................1...............................................................
gentamicin sulfate oint. .........................................................1 ..............................................................
Strength: 0.1 %
gentamicin sulfate in ns piggyback........................................1 ..............................................................
imipenem-cilastatin sodium vial.............................................1 ..............................................................
INVANZ VIAL ........................................................................3 ..............................................................
KETEK TABLET ....................................................................3 ..............................................................
LANSOPRAZ-AMOX-CLARITHRO COMBO. PKG...............3 ........................ QL-112 unit(s) per 30 day(s)
levofloxacin tablet ..................................................................1 ..............................................................
9
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Drug Name
Drug Tier
Requirements/Limits
levofloxacin drops ................................................................. 1...............................................................
levofloxacin vial ..................................................................... 1...............................................................
levofloxacin solution .............................................................. 1...............................................................
levofloxacin-d5w piggyback .................................................. 1 ..............................................................
LINCOCIN VIAL .................................................................... 3 ..............................................................
LINCOMYCIN HCL VIAL....................................................... 2 ..............................................................
LINEZOLID IV SOLN ............................................................ 3 .......................................................... PA
LINEZOLID TABLET ............................................................. 3..................... PA, QL-20 unit(s) per 10 day(s)
LINEZOLID SUSP RECON................................................... 3 ........................... PA, QL-600 mL(s) per 10 day(s)
MACROBID CAPSULE ......................................................... 3 ..............................................................
MACRODANTIN CAPSULE.................................................. 3 ..............................................................
MEROPENEM VIAL.............................................................. 2 ..............................................................
MERREM VIAL ..................................................................... 3 ..............................................................
methenamine hippurate tablet............................................... 1 ..............................................................
metronidazole capsule .......................................................... 1 ..............................................................
metronidazole piggyback ...................................................... 1...............................................................
metronidazole lotion .............................................................. 1...............................................................
metronidazole tablet.............................................................. 1...............................................................
metronidazole gel w/appl ...................................................... 1...............................................................
metronidazole gel ................................................................. 1...............................................................
metronidazole cream ............................................................ 1...............................................................
MINOCYCLINE HCL TABLET .............................................. 2 ..............................................................
minocycline hcl capsule ........................................................ 1...............................................................
MINOCYCLINE HCL ER TAB ER 24H ................................. 3..............................................................
MONUROL PACKET ............................................................ 3 ..............................................................
MOXATAG TBMP 24HR ....................................................... 3 ..............................................................
MOXEZA DROPS VISC........................................................ 3 ..............................................................
moxifloxacin hcl tablet ........................................................... 1..............................................................
mupirocin cream ................................................................... 1 ..............................................................
mupirocin oint. ...................................................................... 1...............................................................
NAFCILLIN FROZ.PIGGY..................................................... 3 ..............................................................
NAFCILLIN SODIUM VIAL.................................................... 3 ..............................................................
NAFCILLIN SODIUM VIAL PORT......................................... 3...............................................................
neomycin sulfate tablet ......................................................... 1 ..............................................................
neomycin-bacitracin-poly-hc oint. ......................................... 1 ..............................................................
10
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Drug Name
Drug Tier
Requirements/Limits
neomycin-bacitracin-polymyxin oint. .....................................1 ..............................................................
neomycin-polymyxin b ampul ................................................1 ..............................................................
neomycin-polymyxin-gramicidin drops ..................................1 ..............................................................
neomycin-polymyxin-hc drops susp ......................................1 ..............................................................
Strength: 3.5-10k-10
neo-polycin oint. ...................................................................1 ..............................................................
neo-polycin hc oint. ..............................................................1 ..............................................................
NEO-SYNALAR CREAM ......................................................3 ..............................................................
nitrofurantoin capsule ............................................................1 ..............................................................
NITROFURANTOIN ORAL SUSP.........................................2...............................................................
nitrofurantoin mono-macro capsule .......................................1 ..............................................................
NORITATE CREAM .............................................................3 ..............................................................
NUVESSA GEL W/APPL.......................................................3 ..............................................................
ofloxacin tablet ......................................................................1 ..............................................................
ofloxacin otic drops................................................................1 ..............................................................
Strength: 0.3 %
ofloxacin opth drops ..............................................................1...............................................................
Strength: 0.3 %
ORACEA CAP IR DR ............................................................3 ..............................................................
OXACILLIN FROZ.PIGGY.....................................................3 ..............................................................
OXACILLIN SODIUM VIAL....................................................3 ..............................................................
OXACILLIN SODIUM VIAL PORT.........................................3...............................................................
paromomycin sulfate capsule ................................................1 ..............................................................
PCE TAB PART ....................................................................3 ..............................................................
penicillin g potassium vial ......................................................1 ..............................................................
penicillin g procaine syringe ..................................................1 ..............................................................
penicillin g sodium vial...........................................................1 ..............................................................
PENICILLIN GK-ISO-OSM DEXTROSE FROZ.PIGGY ........3 ..............................................................
penicillin v potassium tablet...................................................1 ..............................................................
penicillin v potassium soln recon ...........................................1...............................................................
PFIZERPEN VIAL .................................................................3 ..............................................................
piperacillin-tazobactam vial ...................................................1 ..............................................................
polymyxin b sulfate vial..........................................................1 ..............................................................
polymyxin b sul-trimethoprim drops.......................................1 ..............................................................
PRIMSOL SOLUTION ...........................................................3 ..............................................................
silver sulfadiazine cream ......................................................1 ..............................................................
SIVEXTRO TABLET..............................................................3 ........................ PA, QL-6 unit(s) per 6 day(s)
11
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Drug Name
Drug Tier
Requirements/Limits
SIVEXTRO VIAL ................................................................... 3 ................................. PA, QL-6 mL(s) per 6 day(s)
SOLODYN TAB ER 24H ....................................................... 3.......................... QL-30 unit(s) per 30 day(s)
Strength: 105 MG, 115MG
SOLODYN TAB ER 24H ....................................................... 3 ..............................................................
SPECTRACEF TABLET ....................................................... 3 ..............................................................
ssd cream ............................................................................. 1 ..............................................................
streptomycin sulfate vial........................................................ 1 ..............................................................
sulfacetamide sodium drops ................................................. 1 ..............................................................
sulfadiazine tablet ................................................................. 1 ..............................................................
sulfamethoxazole-trimethoprim oral susp ............................. 1..............................................................
sulfamethoxazole-trimethoprim vial....................................... 1...............................................................
sulfamethoxazole-trimethoprim tablet ................................... 1...............................................................
SULFAMYLON CREAM ....................................................... 3 ..............................................................
SUPRAX TAB CHEW ........................................................... 3 ..............................................................
SUPRAX CAPSULE.............................................................. 3...............................................................
SUPRAX SUSP RECON....................................................... 3...............................................................
SYNERCID VIAL................................................................... 3 ..............................................................
TARGADOX TABLET ........................................................... 3 ..............................................................
TAZICEF VIAL ...................................................................... 3 ..............................................................
TEFLARO VIAL..................................................................... 3 ..............................................................
tetracycline hcl capsule ......................................................... 1 ..............................................................
thermazene cream ............................................................... 1..............................................................
TIMENTIN FROZ.PIGGY ...................................................... 3 ..............................................................
TIMENTIN VIAL .................................................................... 3...............................................................
TOBI AMPUL-NEB................................................................ 3 ......................................................... BD
TOBI PODHALER CAP W/DEV............................................ 3 ..............................................................
TOBRAMYCIN AMPUL-NEB ................................................ 3 ......................................................... BD
tobramycin drops................................................................... 1...............................................................
tobramycin sulfate vial........................................................... 1..............................................................
tobramycin sulfate in ns piggyback ....................................... 1 ..............................................................
TOBREX OINT. .................................................................... 3 ..............................................................
trimethoprim tablet ................................................................ 1 ..............................................................
TYGACIL VIAL ...................................................................... 3 ..............................................................
VANCOCIN HCL CAPSULE ................................................. 3 ..............................................................
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Drug Name
Drug Tier
Requirements/Limits
VANCOMYCIN HCL FROZ.PIGGY.......................................3 ..............................................................
VANCOMYCIN HCL CAPSULE ............................................2...............................................................
vancomycin hcl vial................................................................1...............................................................
VIBATIV VIAL ........................................................................3 ..............................................................
VIBRAMYCIN SYRUP...........................................................3 ..............................................................
VIGAMOX DROPS ................................................................3 ..............................................................
XIFAXAN TABLET ................................................................3 ..............................................................
Strength: 200 MG
XIFAXAN TABLET ................................................................3 ..............................................................
Strength: 550 MG
ZERBAXA VIAL .....................................................................3 ..............................................................
ZMAX SUS ER REC..............................................................3 ..............................................................
ZOSYN FROZ.PIGGY ...........................................................3 ..............................................................
ZYVOX IV SOLN ...................................................................3 ......................................................... PA
ZYVOX SUSP RECON..........................................................3 .................... PA, QL-600 mL(s) per 10 day(s)
ZYVOX TABLET....................................................................3............................ PA, QL-20 unit(s) per 10 day(s)
ANTICONVULSANTS
APTIOM TABLET ..................................................................3 .......................... QL-30 unit(s) per 30 day(s)
Strength: 200 MG
Strength: 400 MG, 800 MG
Strength: 600 MG
BANZEL ORAL SUSP ...........................................................3 ........................ QL-2400 mL(s) per 30 day(s)
BANZEL TABLET ..................................................................3 ........................ QL-480 unit(s) per 30 day(s)
Strength: 200 MG
BANZEL TABLET ..................................................................3 ........................ QL-240 unit(s) per 30 day(s)
Strength: 400 MG
BRIVIACT VIAL .....................................................................3 ......................................................... PA
BRIVIACT SOLUTION...........................................................3 .................... PA, QL-600 mL(s) per 30 day(s)
BRIVIACT TABLET ...............................................................3............................ PA, QL-60 unit(s) per 30 day(s)
carbamazepine oral susp ......................................................1 ..............................................................
carbamazepine tab chew ......................................................1...............................................................
carbamazepine tablet ............................................................1...............................................................
carbamazepine er tab er 12h ................................................1 ..............................................................
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Drug Name
Drug Tier
Requirements/Limits
ANTICONVULSANTS (continued)
carbamazepine er cpmp 12hr ............................................... 1...............................................................
CELONTIN CAPSULE .......................................................... 3 ..............................................................
clonazepam tablet ................................................................. 1 ..............................................................
clonazepam tab rapdis .......................................................... 1...............................................................
clorazepate dipotassium tablet.............................................. 1 ..............................................................
DEPACON VIAL.................................................................... 3 ..............................................................
DEPAKENE CAPSULE......................................................... 3 ..............................................................
DEPAKENE SOLUTION ....................................................... 3...............................................................
DEPAKOTE TABLET DR...................................................... 3 ..............................................................
DEPAKOTE ER TAB ER 24H ............................................... 3 ..............................................................
DEPAKOTE SPRINKLE CAP SPRINK ................................. 3..............................................................
DILANTIN TAB CHEW.......................................................... 3 ..............................................................
DILANTIN CAPSULE ............................................................ 3...............................................................
DILANTIN-125 ORAL SUSP ................................................. 3 ..............................................................
divalproex sodium cap sprink................................................ 1 ..............................................................
divalproex sodium tablet dr ................................................... 1...............................................................
divalproex sodium er tab er 24h............................................ 1 ..............................................................
epitol tablet............................................................................ 1 ..............................................................
ethosuximide solution............................................................ 1..............................................................
ethosuximide capsule............................................................ 1...............................................................
FELBAMATE ORAL SUSP ................................................... 3 ..............................................................
felbamate tablet..................................................................... 1 ..............................................................
Strength: 400 mg
FELBAMATE TABLET .......................................................... 3 ..............................................................
Strength: 600 MG
FELBATOL ORAL SUSP ...................................................... 3 ..............................................................
FELBATOL TABLET ............................................................. 3...............................................................
fosphenytoin sodium vial....................................................... 1 ..............................................................
FYCOMPA ORAL SUSP....................................................... 3 ..............................................................
FYCOMPA TABLET.............................................................. 3...............................................................
gabapentin solution ............................................................... 1..............................................................
gabapentin tablet................................................................... 1...............................................................
gabapentin capsule ............................................................... 1...............................................................
GABITRIL TABLET ............................................................... 3 ..............................................................
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Drug Name
Drug Tier
Requirements/Limits
GRALISE TAB ER 24H .........................................................3 ..................... PA, QL-60 unit(s) per 30 day(s)
Strength: 300 MG
GRALISE TAB ER 24H .........................................................3 ......................................................... PA
Strength: 300-600 MG
GRALISE TAB ER 24H .........................................................3 ..................... PA, QL-90 unit(s) per 30 day(s)
Strength: 600 MG
HORIZANT TABLET ER........................................................3 ..................... PA, QL-90 unit(s) per 30 day(s)
Strength: 300 MG
HORIZANT TABLET ER........................................................3 ..................... PA, QL-60 unit(s) per 30 day(s)
Strength: 600 MG
KEPPRA VIAL .......................................................................3 ..............................................................
KEPPRA TABLET .................................................................3...............................................................
KEPPRA SOLUTION.............................................................3...............................................................
KEPPRA XR TAB ER 24H ....................................................3 ..............................................................
LAMICTAL ODT (BLUE) TB RD DSPK .................................3 ..............................................................
LAMICTAL ODT (GREEN) TB RD DSPK..............................3 ..............................................................
LAMICTAL ODT (ORANGE) TB RD DSPK...........................3 ..............................................................
LAMOTRIGINE TB CHW DSP ..............................................2 ..............................................................
lamotrigine tab ds pk .............................................................1...............................................................
lamotrigine tablet ...................................................................1...............................................................
LAMOTRIGINE ER TAB ER 24.............................................2 ..............................................................
LAMOTRIGINE ODT TAB RAPDIS.......................................2 ..............................................................
LAMOTRIGINE ODT (BLUE) TB RD DSPK..........................2 ..............................................................
LAMOTRIGINE ODT (GREEN) TB RD DSPK ......................2 ..............................................................
LAMOTRIGINE ODT (ORANGE) TB RD DSPK....................2 ..............................................................
levetiracetam vial...................................................................1 ..............................................................
levetiracetam solution............................................................1...............................................................
levetiracetam tablet ...............................................................1...............................................................
levetiracetam er tab er 24h....................................................1 ........................ QL-180 unit(s) per 30 day(s)
Strength: 500 mg
levetiracetam er tab er 24h....................................................1 ........................ QL-120 unit(s) per 30 day(s)
Strength: 750 mg
LEVETIRACETAM-NACL PIGGYBACK................................3 ..............................................................
LYRICA SOLUTION ..............................................................2 ..............................................................
ONFI ORAL SUSP ................................................................3 ..............................................................
15
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Drug Name
Drug Tier
Requirements/Limits
ONFI TABLET ....................................................................... 3...............................................................
oxcarbazepine oral susp ....................................................... 1 ..............................................................
oxcarbazepine tablet ............................................................. 1...............................................................
OXTELLAR XR TAB ER 24H................................................ 3 ..............................................................
PEGANONE TABLET ........................................................... 3 ..............................................................
phenobarbital elixir ................................................................ 1.......................................................... PA
phenobarbital tablet............................................................... 1 .......................................................................... PA
PHENYTEK CAPSULE ......................................................... 3 ..............................................................
phenytoin tab chew ............................................................... 1..............................................................
phenytoin oral susp ............................................................... 1...............................................................
phenytoin sodium syringe ..................................................... 1 ..............................................................
phenytoin sodium vial............................................................ 1...............................................................
phenytoin sodium extended capsule..................................... 1..............................................................
POTIGA TABLET .................................................................. 3.......................... QL-90 unit(s) per 30 day(s)
primidone tablet..................................................................... 1 ..............................................................
QUDEXY XR CAP SPR 24 ................................................... 3..................... PA, QL-30 unit(s) per 30 day(s)
QUDEXY XR CAP SPR 24 ................................................... 3..................... PA, QL-60 unit(s) per 30 day(s)
QUDEXY XR CAP SPR 24 ................................................... 3 .......................................................... PA
Strength: 25 MG
roweepra tablet ..................................................................... 1 ..............................................................
SABRIL POWD PACK .......................................................... 3 ................... PA, QL-180 unit(s) per 30 day(s)
SABRIL TABLET................................................................... 3 .......................... PA, QL-180 unit(s) per 30 day(s)
SPRITAM TAB SUSP ........................................................... 3..................... PA, QL-60 unit(s) per 30 day(s)
SPRITAM TAB SUSP ........................................................... 3 ................... PA, QL-120 unit(s) per 30 day(s)
Strength: 750 MG
TEGRETOL TABLET ............................................................ 3 ..............................................................
TEGRETOL ORAL SUSP ..................................................... 3...............................................................
TEGRETOL XR TAB ER 12H ............................................... 3 ..............................................................
tiagabine hcl tablet ................................................................ 1 ..............................................................
TOPAMAX TABLET .............................................................. 3 ..............................................................
TOPAMAX CAP SPRINK...................................................... 3...............................................................
topiramate cap sprink............................................................ 1..............................................................
topiramate tablet ................................................................... 1...............................................................
16
going to page V.
Drug Name
Drug Tier
Requirements/Limits
TOPIRAMATE ER CAP SPR 24 ...........................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
TOPIRAMATE ER CAP SPR 24 ...........................................3 ..................... PA, QL-60 unit(s) per 30 day(s)
TRILEPTAL ORAL SUSP......................................................3 ..............................................................
TROKENDI XR CAP ER 24H ................................................3 ..................... PA, QL-90 unit(s) per 30 day(s)
valproate sodium vial.............................................................1 ..............................................................
valproic acid capsule .............................................................1 ..............................................................
valproic acid solution .............................................................1...............................................................
VIMPAT SOLUTION..............................................................3 ..............................................................
VIMPAT VIAL ........................................................................3...............................................................
VIMPAT TABLET ..................................................................3 .......................... QL-60 unit(s) per 30 day(s)
ZARONTIN CAPSULE ..........................................................3 ..............................................................
ZARONTIN SOLUTION.........................................................3...............................................................
zonisamide capsule ...............................................................1 ..............................................................
ANTIDEMENTIA AGENTS
donepezil hcl tablet................................................................1 ..............................................................
DONEPEZIL HCL TABLET ...................................................2 .......................... QL-30 unit(s) per 30 day(s)
Strength: 23 MG
donepezil hcl odt tab rapdis...................................................1 ..............................................................
ERGOLOID MESYLATES TABLET ......................................2 ..............................................................
EXELON PATCH TD24 .........................................................2 ..............................................................
Strength: 13.3MG/24H, 9.5MG/24HR
EXELON PATCH TD24 .........................................................2 .......................... QL-30 unit(s) per 30 day(s)
Strength: 4.6MG/24HR
galantamine hbr cap24h pel ..................................................1 .......................... QL-30 unit(s) per 30 day(s)
galantamine hbr tablet ...........................................................1................................... QL-60 unit(s) per 30 day(s)
galantamine hydrobromide solution.......................................1 ..............................................................
memantine hcl tablet .............................................................1 .......................... QL-60 unit(s) per 30 day(s)
memantine hcl tab ds pk .......................................................1................................... QL-49 unit(s) per 28 day(s)
memantine hcl solution..........................................................1..................................QL-300 mL(s) per 30 day(s)
NAMENDA TAB DS PK.........................................................2 .......................... QL-49 unit(s) per 28 day(s)
NAMENDA SOLUTION .........................................................3..................................QL-360 mL(s) per 30 day(s)
NAMENDA TABLET ..............................................................2................................... QL-60 unit(s) per 30 day(s)
NAMENDA XR CAP24 DSPK ...............................................3 .......................... QL-30 unit(s) per 30 day(s)
17
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Drug Name
Drug Tier
Requirements/Limits
ANTIDEMENTIA AGENTS (continued)
NAMENDA XR CAP SPR 24 ................................................ 3 ...................................QL-30 unit(s) per 30 day(s)
NAMZARIC CAP SPR 24...................................................... 3 ..................... PA, QL-30 unit(s) per 30 day(s)
rivastigmine capsule.............................................................. 1.......................... QL-60 unit(s) per 30 day(s)
rivastigmine patch td24 ......................................................... 1 ..............................................................
Strength: 13.3mg/24h, 9.5mg/24hr
rivastigmine patch td24 ......................................................... 1 .......................... QL-30 unit(s) per 30 day(s)
Strength: 4.6mg/24hr
ANTIDEPRESSANTS
AMITRIPTYLINE HCL TABLET ............................................ 2 ..............................................................
amoxapine tablet................................................................... 1 ..............................................................
APLENZIN TAB ER 24H ....................................................... 3 .................. STEP, QL-30 unit(s) per 30 day(s)
BRINTELLIX TABLET ........................................................... 3 ..................... PA, QL-30 unit(s) per 30 day(s)
bupropion hcl tablet............................................................... 1..............................................................
bupropion hcl sr tablet er....................................................... 1 ..............................................................
bupropion xl tab er 24h ......................................................... 1 ..............................................................
citalopram hbr tablet.............................................................. 1..............................................................
citalopram hbr solution .......................................................... 1...............................................................
clomipramine hcl capsule...................................................... 1 ..............................................................
desipramine hcl tablet ........................................................... 1..............................................................
DESVENLAFAXINE ER (BRAND) TAB 24H ........................ 3 .................. STEP, QL-30 unit(s) per 30 day(s)
desvenlafaxine er (like khedezla) tab 24............................... 1.......................... QL-30 unit(s) per 30 day(s)
DESVENLAFAXINE FUMARATE ER (BRAND) TAB 24 ...... 3 .................. STEP, QL-30 unit(s) per 30 day(s)
doxepin hcl capsule............................................................... 1..............................................................
doxepin hcl oral conc ............................................................ 1...............................................................
duloxetine hcl capsule dr....................................................... 1 .......................... QL-60 unit(s) per 30 day(s)
Strength: 20 mg, 40 mg, 60 mg
duloxetine hcl capsule dr....................................................... 1 .......................... QL-90 unit(s) per 30 day(s)
Strength: 30 mg
EMSAM PATCH TD24 .......................................................... 3 .................. STEP, QL-30 unit(s) per 30 day(s)
ESCITALOPRAM OXALATE SOLUTION ............................. 3..............................................................
escitalopram oxalate tablet ................................................... 1...............................................................
FETZIMA CAP24HDSPK ...................................................... 3.......................... QL-28 unit(s) per 28 day(s)
FETZIMA CAP SA 24H ......................................................... 3 ...................................QL-30 unit(s) per 30 day(s)
FLUOXETINE DR (WEEKLY) CAPSULE DR ....................... 2............................ QL-8 unit(s) per 28 day(s)
fluoxetine hcl capsule............................................................ 1..............................................................
FLUOXETINE HCL TABLET................................................. 2...............................................................
18
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Drug Name
Drug Tier
Requirements/Limits
ANTIDEPRESSANTS (continued)
fluoxetine hcl solution ............................................................1...............................................................
fluvoxamine maleate tablet....................................................1 ..............................................................
fluvoxamine maleate er cap er 24h .......................................1 ..............................................................
IMIPRAMINE HCL TABLET ..................................................2 ..............................................................
IMIPRAMINE PAMOATE CAPSULE.....................................3 ..............................................................
maprotiline hcl tablet .............................................................1 ..............................................................
MARPLAN TABLET...............................................................3 ..............................................................
mirtazapine tab rapdis ...........................................................1 ..............................................................
mirtazapine tablet ..................................................................1...............................................................
nefazodone hcl tablet ............................................................1 ..............................................................
nortriptyline hcl capsule .........................................................1 ..............................................................
nortriptyline hcl solution .........................................................1...............................................................
OLEPTRO ER TAB ER 24H..................................................3 ................. STEP, QL-30 unit(s) per 30 day(s)
PAROXETINE ER TAB ER 24H............................................2 ..............................................................
paroxetine hcl tablet ..............................................................1 ..............................................................
PAXIL ORAL SUSP...............................................................3 ...................................................... STEP
PEXEVA TABLET .................................................................3 ...................................................... STEP
phenelzine sulfate tablet........................................................1 ..............................................................
PRISTIQ ER TAB ER 24H.....................................................3 ................. STEP, QL-30 unit(s) per 30 day(s)
PROTRIPTYLINE HCL TABLET ...........................................2 ..............................................................
SARAFEM TABLET...............................................................3 ...................................................... STEP
sertraline hcl tablet ................................................................1 ..............................................................
sertraline hcl oral conc...........................................................1...............................................................
SURMONTIL CAPSULE........................................................3 ..............................................................
tranylcypromine sulfate tablet................................................1 ..............................................................
trazodone hcl tablet ...............................................................1 ..............................................................
TRIMIPRAMINE MALEATE CAPSULE.................................2 ..............................................................
TRINTELLIX TABLET............................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
venlafaxine hcl tablet .............................................................1 ..............................................................
venlafaxine hcl er cap er 24h ................................................1 .......................... QL-90 unit(s) per 30 day(s)
VIIBRYD TAB DS PK ............................................................3 ................. STEP, QL-30 unit(s) per 30 day(s)
VIIBRYD TABLET .................................................................3........................ STEP, QL-30 unit(s) per 30 day(s)
ANTIEMETICS
AKYNZEO CAPSULE............................................................3 ...................... BD, QL-2 unit(s) per 28 day(s)
19
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Drug Name
Drug Tier
Requirements/Limits
ANTIEMETICS (continued)
ALOXI VIAL........................................................................... 3 ..............................................................
ANZEMET TABLET .............................................................. 3...................... BD, QL-4 unit(s) per 28 day(s)
CESAMET CAPSULE ........................................................... 3......................... QL-120 unit(s) per 30 day(s)
compro supp.rect .................................................................. 1 ..............................................................
DRONABINOL CAPSULE..................................................... 3 .......................................................... PA
Strength: 10 MG
DRONABINOL CAPSULE..................................................... 3 .......................................................... PA
Strength: 2.5 MG, 5 MG
EMEND CAP DS PK ............................................................. 3...................... BD, QL-2 pack(s) per 30 day(s)
EMEND SUSP RECON ........................................................ 3 ...............................BD, QL-6 mL(s) per 30 day(s)
EMEND CAPSULE ............................................................... 3...................... BD, QL-2 unit(s) per 30 day(s)
Strength: 125 MG
EMEND CAPSULE ............................................................... 3...................... BD, QL-4 unit(s) per 30 day(s)
granisetron hcl vial ................................................................ 1........................... QL-60 mL(s) per 30 day(s)
granisetron hcl tablet............................................................. 1 ............................BD, QL-60 unit(s) per 30 day(s)
MARINOL CAPSULE ............................................................ 3 .......................................................... PA
meclizine hcl tablet................................................................ 1 ..............................................................
metoclopramide hcl solution.................................................. 1 ..............................................................
metoclopramide hcl tablet ..................................................... 1...............................................................
metoclopramide hcl vial......................................................... 1...............................................................
metoclopramide hcl odt tab rapdis ........................................ 1 ..............................................................
METOZOLV ODT TAB RAPDIS ........................................... 3 ...................................................... STEP
ONDANSETRON HCL SOLUTION....................................... 2 ......................................................... BD
ondansetron hcl ampul.......................................................... 1...............................................................
ondansetron hcl vial .............................................................. 1...............................................................
ondansetron hcl syringe ........................................................ 1...............................................................
ondansetron hcl tablet........................................................... 1..................... BD, QL-30 unit(s) per 30 day(s)
Strength: 24 mg
ondansetron hcl tablet........................................................... 1..................... BD, QL-90 unit(s) per 30 day(s)
Strength: 4 mg
ondansetron hcl tablet........................................................... 1................... BD, QL-120 unit(s) per 30 day(s)
Strength: 8 mg
ondansetron odt tab rapdis ................................................... 1 ..................... BD, QL-90 unit(s) per 30 day(s)
Strength: 4 mg
ondansetron odt tab rapdis ................................................... 1 ................... BD, QL-120 unit(s) per 30 day(s)
Strength: 8 mg
PHENADOZ SUPP.RECT..................................................... 3 ..............................................................
20
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Drug Name
Drug Tier
Requirements/Limits
ANTIEMETICS (continued)
PHENERGAN SUPP.RECT ..................................................3 ..............................................................
PHENERGAN AMPUL ..........................................................3...............................................................
prochlorperazine supp.rect ....................................................1 ..............................................................
prochlorperazine maleate tablet ............................................1 ..............................................................
PROMETHAZINE HCL SUPP.RECT ....................................3 ..............................................................
PROMETHAZINE HCL VIAL .................................................3...............................................................
PROMETHAZINE HCL SYRUP ............................................3...............................................................
PROMETHAZINE HCL TABLET ...........................................3...............................................................
PROMETHAZINE HCL AMPUL ............................................3...............................................................
PROMETHEGAN SUPP.RECT.............................................3 ..............................................................
SANCUSO PATCH TDWK ....................................................3 ................... STEP, QL-4 unit(s) per 28 day(s)
TRANSDERM-SCOP PATCH TD 3 ......................................3 .................................... QL-4 per 30 day(s)
TRIMETHOBENZAMIDE HCL CAPSULE.............................2 ......................................................... BD
VARUBI TABLET ..................................................................3 ...................... BD, QL-4 unit(s) per 28 day(s)
ZUPLENZ FILM .....................................................................3 ............ BD, STEP, QL-90 unit(s) per 30 day(s)
Strength: 4 MG
ZUPLENZ FILM .....................................................................3 .......... BD, STEP, QL-120 unit(s) per 30 day(s)
Strength: 8 MG
ANTIFUNGALS
ABELCET VIAL .....................................................................3 ......................................................... BD
AMBISOME VIAL ..................................................................3 ......................................................... BD
amphotericin b vial ................................................................1 ......................................................... BD
CANCIDAS VIAL ...................................................................3 ..............................................................
CICLODAN SOLUTION.........................................................3 ...................................................... STEP
CICLODAN CREAM .............................................................3.......................................................................STEP
ciclopirox cream ....................................................................1 ..............................................................
ciclopirox suspension ............................................................1...............................................................
ciclopirox solution ..................................................................1...............................................................
ciclopirox shampoo................................................................1...............................................................
ciclopirox gel .........................................................................1...............................................................
clotrimazole troche ................................................................1 ..............................................................
clotrimazole solution ..............................................................1...............................................................
clotrimazole cream ...............................................................1...............................................................
clotrimazole-betamethasone lotion........................................1 ..............................................................
21
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Drug Name
Drug Tier
Requirements/Limits
ANTIFUNGALS (continued)
clotrimazole-betamethasone cream ..................................... 1...............................................................
CRESEMBA VIAL ................................................................. 3 ..............................................................
CRESEMBA CAPSULE ........................................................ 3.......................... QL-68 unit(s) per 30 day(s)
econazole nitrate cream ....................................................... 1 ..............................................................
ECOZA FOAM ...................................................................... 3 ...................................................... STEP
ERAXIS (WATER DILUENT) VIAL ....................................... 3 ..............................................................
ERTACZO CREAM .............................................................. 3 ...................................................... STEP
EXELDERM CREAM ........................................................... 3 ...................................................... STEP
EXELDERM SOLUTION ....................................................... 3 ...................................................................... STEP
EXTINA FOAM...................................................................... 3 ...................................................... STEP
fluconazole susp recon ......................................................... 1 ..............................................................
fluconazole tablet .................................................................. 1...............................................................
fluconazole-nacl piggyback ................................................... 1 ..............................................................
FLUCYTOSINE CAPSULE ................................................... 3 ..............................................................
GRIFULVIN V TABLET ......................................................... 3 ..............................................................
GRISEOFULVIN ORAL SUSP.............................................. 2 ..............................................................
GRISEOFULVIN TABLET..................................................... 2...............................................................
GRISEOFULVIN ULTRAMICROSIZE TABLET .................... 2 ..............................................................
ITRACONAZOLE CAPSULE ................................................ 2 ..............................................................
JUBLIA SOL W/APPL ........................................................... 3....................... PA, QL-8 mL(s) per 30 day(s)
KERYDIN SOL W/APPL ....................................................... 3 .......................................................... PA
ketoconazole cream ............................................................. 1..............................................................
ketoconazole shampoo ......................................................... 1...............................................................
ketoconazole tablet ............................................................... 1...............................................................
ketoconazole foam ................................................................ 1...............................................................
KETODAN FOAM ................................................................. 3 ...................................................... STEP
LAMISIL GRAN PACK .......................................................... 3 .................. STEP, QL-30 unit(s) per 30 day(s)
LUZU CREAM ...................................................................... 3 ...................................................... STEP
MENTAX CREAM ................................................................ 3 ...................................................... STEP
miconazole 3 supp.vag ......................................................... 1 ..............................................................
MYCAMINE VIAL .................................................................. 3 ..............................................................
NAFTIFINE HCL CREAM .................................................... 3 ..............................................................
NAFTIN GEL ........................................................................ 3 ...................................................... STEP
22
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Drug Name
Drug Tier
Requirements/Limits
ANTIFUNGALS (continued)
NAFTIN CREAM ...................................................................3.......................................................................STEP
NATACYN DROPS SUSP.....................................................3 ..............................................................
NOXAFIL ORAL SUSP..........................................................3 ..............................................................
NOXAFIL TABLET DR ..........................................................3...............................................................
NOXAFIL VIAL ......................................................................3...............................................................
nyamyc powder .....................................................................1 ..............................................................
nystatin oral susp ..................................................................1 ..............................................................
nystatin cream ......................................................................1...............................................................
nystatin oint. .........................................................................1...............................................................
nystatin powder .....................................................................1...............................................................
nystatin tablet ........................................................................1...............................................................
nystatin-triamcinolone cream ................................................1 ..............................................................
nystatin-triamcinolone oint. ...................................................1...............................................................
nystop powder .......................................................................1 ..............................................................
ONMEL TABLET ...................................................................3 ...................................................... STEP
OXICONAZOLE NITRATE CREAM .....................................3 ..............................................................
OXISTAT CREAM ................................................................3 ...................................................... STEP
OXISTAT LOTION.................................................................3.......................................................................STEP
SPORANOX SOLUTION.......................................................3 ...................................................... STEP
SPORANOX CAPSULE ........................................................3 ...................................................... STEP
Strength: 100 MG
SPORANOX PULSEPAK CAPSULE ....................................3 ...................................................... STEP
Strength: 100 MG
terbinafine hcl tablet ..............................................................1 ..............................................................
terconazole cream/appl .........................................................1 ..............................................................
terconazole supp.vag ............................................................1...............................................................
VFEND TABLET....................................................................3 ...................................................... STEP
VFEND SUSP RECON..........................................................3.......................................................................STEP
VFEND IV VIAL .....................................................................3 ...................................................... STEP
VORICONAZOLE VIAL .........................................................3 ..............................................................
VORICONAZOLE TABLET ...................................................3...............................................................
VORICONAZOLE SUSP RECON .........................................3...............................................................
VUSION OINT. .....................................................................3 ..............................................................
XOLEGEL GEL ....................................................................3 ...................................................... STEP
23
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Drug Name
Drug Tier
Requirements/Limits
ANTIGOUT AGENTS
allopurinol tablet .................................................................... 1 ..............................................................
COLCHICINE CAPSULE ...................................................... 3 .......................... QL-60 unit(s) per 30 day(s)
COLCHICINE TABLET ......................................................... 3 .................................QL-120 unit(s) per 30 day(s)
COLCRYS TABLET .............................................................. 2......................... QL-120 unit(s) per 30 day(s)
MITIGARE CAPSULE ........................................................... 3.......................... QL-60 unit(s) per 30 day(s)
probenecid tablet................................................................... 1 ..............................................................
probenecid-colchicine tablet.................................................. 1 ..............................................................
ULORIC TABLET .................................................................. 2 .................. STEP, QL-30 unit(s) per 30 day(s)
ZURAMPIC TABLET............................................................. 3..................... PA, QL-30 unit(s) per 30 day(s)
ANTI-INFLAMMATORY AGENTS
CALDOLOR VIAL.................................................................. 3 ..............................................................
CAMBIA POWD PACK ......................................................... 3 ...................................................... STEP
celecoxib capsule.................................................................. 1.......................... QL-60 unit(s) per 30 day(s)
diclofenac potassium tablet................................................... 1 ..............................................................
diclofenac sodium tablet dr ................................................... 1 ..............................................................
diclofenac sodium gel ........................................................... 1..............................................................
Strength: 1 %
DICLOFENAC SODIUM DROPS.......................................... 2 ..............................................................
Strength: 1.5 %
diclofenac sodium er tab er 24h ............................................ 1 ..............................................................
diclofenac sodium-misoprostol tab ir dr................................. 1..............................................................
diflunisal tablet ...................................................................... 1 ..............................................................
etodolac capsule ................................................................... 1 ..............................................................
etodolac tablet....................................................................... 1...............................................................
etodolac er tab er 24h ........................................................... 1..............................................................
fenoprofen calcium tablet ...................................................... 1 ..............................................................
FLECTOR PATCH TD12 ...................................................... 3..................... PA, QL-60 unit(s) per 30 day(s)
flurbiprofen tablet .................................................................. 1 ..............................................................
ibuprofen tablet ..................................................................... 1 ..............................................................
ibuprofen oral susp................................................................ 1...............................................................
indomethacin capsule ........................................................... 1..............................................................
indomethacin capsule er ....................................................... 1...............................................................
ketoprofen capsule................................................................ 1 ..............................................................
ketoprofen cap24h pel........................................................... 1.......................... QL-30 unit(s) per 30 day(s)
ketorolac tromethamine tablet............................................... 1 .......................... QL-20 unit(s) per 30 day(s)
meclofenamate sodium capsule............................................ 1 ..............................................................
24
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Drug Name
Drug Tier
Requirements/Limits
ANTI-INFLAMMATORY AGENTS (continued)
MELOXICAM ORAL SUSP ...................................................3 ......................... QL-300 mL(s) per 30 day(s)
meloxicam tablet ...................................................................1 .......................... QL-30 unit(s) per 30 day(s)
Strength: 15 mg
meloxicam tablet ...................................................................1 .......................... QL-60 unit(s) per 30 day(s)
Strength: 7.5 mg
nabumetone tablet.................................................................1 ..............................................................
naproxen tablet......................................................................1 ..............................................................
naproxen tablet dr .................................................................1...............................................................
naproxen oral susp ................................................................1...............................................................
naproxen sodium tablet .........................................................1 ..............................................................
oxaprozin tablet .....................................................................1 ..............................................................
piroxicam capsule..................................................................1 ..............................................................
sulindac tablet .......................................................................1 ..............................................................
TIVORBEX CAPSULE...........................................................3 .......................... QL-90 unit(s) per 30 day(s)
tolmetin sodium tablet ...........................................................1 ..............................................................
tolmetin sodium capsule ........................................................1...............................................................
VIMOVO TAB IR DR .............................................................3 .......................... QL-60 unit(s) per 30 day(s)
VOLTAREN GEL ..................................................................3 ..............................................................
ANTIMIGRAINE AGENTS
almotriptan malate tablet .......................................................1 .......................... QL-12 unit(s) per 30 day(s)
ALSUMA PEN INJCTR..........................................................3 .................... STEP, QL-6 mL(s) per 30 day(s)
AXERT TABLET ....................................................................3 ................. STEP, QL-12 unit(s) per 30 day(s)
CAFERGOT TABLET ............................................................2 .......................... QL-40 unit(s) per 30 day(s)
D.H.E.45 AMPUL ..................................................................3 ..............................................................
DIHYDROERGOTAMINE MESYLATE SPRAY/PUMP .........3 ..............................................................
DIHYDROERGOTAMINE MESYLATE AMPUL ....................3...............................................................
ERGOMAR TAB SUBL..........................................................3 .......................... QL-20 unit(s) per 28 day(s)
FROVA TABLET ...................................................................3 ................. STEP, QL-18 unit(s) per 30 day(s)
frovatriptan succinate tablet ..................................................1 .......................... QL-18 unit(s) per 30 day(s)
INNOPRAN XL CAP ER 24H ................................................3 ..............................................................
MIGERGOT SUPP.RECT .....................................................3 .......................... QL-20 unit(s) per 28 day(s)
MIGRANAL SPRAY/PUMP ...................................................3 ............................ QL-8 mL(s) per 28 day(s)
naratriptan hcl tablet ..............................................................1 .......................... QL-18 unit(s) per 30 day(s)
ONZETRA XSAIL AER POW BA ..........................................3 .......................... STEP, QL-16 per 30 day(s)
propranolol hcl er cap sa 24h ................................................1 ..............................................................
25
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Drug Name
Drug Tier
Requirements/Limits
ANTIMIGRAINE AGENTS (continued)
RELPAX TABLET ................................................................. 3 .................. STEP, QL-12 unit(s) per 30 day(s)
rizatriptan tablet..................................................................... 1 .......................... QL-24 unit(s) per 30 day(s)
rizatriptan tab rapdis.............................................................. 1 ...................................QL-24 unit(s) per 30 day(s)
SUMATRIPTAN SPRAY ....................................................... 2.......................... QL-12 unit(s) per 30 day(s)
Strength: 20 MG
SUMATRIPTAN SPRAY ....................................................... 2.......................... QL-18 unit(s) per 30 day(s)
Strength: 5 MG
SUMATRIPTAN SUCCINATE VIAL...................................... 2 ........................... QL-10 mL(s) per 30 day(s)
SUMATRIPTAN SUCCINATE SYRINGE ............................. 2 ....................................QL-10 mL(s) per 30 day(s)
SUMATRIPTAN SUCCINATE CARTRIDGE ........................ 2 ...................................QL-10 unit(s) per 30 day(s)
SUMATRIPTAN SUCCINATE PEN INJCTR ........................ 2 ....................................QL-10 mL(s) per 30 day(s)
sumatriptan succinate tablet ................................................. 1 ............................ QL-9 unit(s) per 30 day(s)
Strength: 100 mg
sumatriptan succinate tablet ................................................. 1 .......................... QL-18 unit(s) per 30 day(s)
SUMAVEL DOSEPRO NDL FR INJ...................................... 3 ................... STEP, QL-5 unit(s) per 30 day(s)
timolol maleate tablet ............................................................ 1..............................................................
TREXIMET TABLET ............................................................. 3 .................. STEP, QL-10 unit(s) per 30 day(s)
ZECUITY PATCH IOPH........................................................ 3............................... PA, QL-4 per 28 day(s)
ZEMBRACE SYMTOUCH PEN INJCTR .............................. 3 .................... STEP, QL-5 mL(s) per 30 day(s)
zolmitriptan tablet .................................................................. 1.......................... QL-12 unit(s) per 30 day(s)
zolmitriptan odt tab rapdis ..................................................... 1 .......................... QL-12 unit(s) per 30 day(s)
ZOMIG SPRAY ..................................................................... 3.................. STEP, QL-12 unit(s) per 30 day(s)
ANTIMYASTHENIC AGENTS
GUANIDINE HCL TABLET ................................................... 3 ..............................................................
MESTINON TABLET ER....................................................... 3 ..............................................................
MESTINON SYRUP.............................................................. 3...............................................................
pyridostigmine bromide tablet ............................................... 1 ..............................................................
pyridostigmine bromide er tablet er....................................... 1 ..............................................................
REGONOL AMPUL............................................................... 3 ..............................................................
ANTIMYCOBACTERIALS
CAPASTAT SULFATE VIAL ................................................. 3 ..............................................................
CYCLOSERINE CAPSULE................................................... 3 ..............................................................
dapsone tablet....................................................................... 1 ..............................................................
26
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Drug Name
Drug Tier
Requirements/Limits
ANTIMYCOBACTERIALS (continued)
ethambutol hcl tablet .............................................................1 ..............................................................
isoniazid vial ..........................................................................1 ..............................................................
isoniazid tablet.......................................................................1...............................................................
isoniazid solution ...................................................................1...............................................................
PASER GRANPKT DR..........................................................3 ..............................................................
PRIFTIN TABLET ..................................................................3 ..............................................................
pyrazinamide tablet ...............................................................1 ..............................................................
RIFABUTIN CAPSULE..........................................................3 ..............................................................
RIFAMATE CAPSULE...........................................................3 ..............................................................
rifampin vial ...........................................................................1 ..............................................................
rifampin capsule ....................................................................1...............................................................
RIFATER TABLET.................................................................3 ..............................................................
SIRTURO TABLET................................................................3 .......................... QL-68 unit(s) per 28 day(s)
TRECATOR TABLET ............................................................3 ..............................................................
ANTINEOPLASTICS
ABRAXANE VIAL ..................................................................3 ..............................................................
ADCETRIS VIAL ...................................................................3 ......................................................... PA
adrucil vial .............................................................................1 ..............................................................
AFINITOR TABLET ...............................................................3 ..................... PA, QL-60 unit(s) per 30 day(s)
Strength: 10 MG, 7.5 MG
AFINITOR TABLET ...............................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
AFINITOR DISPERZ TAB SUSP ..........................................3 ......................................................... PA
AFINITOR DISPERZ TAB SUSP ..........................................3 ................... PA, QL-112 unit(s) per 28 day(s)
Strength: 5 MG
ALECENSA CAPSULE..........................................................3 ................... PA, QL-240 unit(s) per 30 day(s)
ALIMTA VIAL.........................................................................3 ..............................................................
ALKERAN VIAL .....................................................................3 ..............................................................
AMIFOSTINE VIAL................................................................3 ..............................................................
anastrozole tablet ..................................................................1 ..............................................................
ARRANON VIAL....................................................................3 ..............................................................
ARZERRA VIAL ....................................................................3 ......................................................... PA
AVASTIN VIAL ......................................................................3 ......................................................... PA
27
going to page V.
Drug Name
Drug Tier
Requirements/Limits
ANTINEOPLASTICS (continued)
azacitidine vial....................................................................... 1 ..............................................................
BELEODAQ VIAL.................................................................. 3 .......................................................... PA
BENDEKA VIAL .................................................................... 3 .......................................................... PA
BEXAROTENE CAPSULE.................................................... 3 ..............................................................
BICNU VIAL .......................................................................... 3 ..............................................................
bleomycin sulfate vial ............................................................ 1..............................................................
BLINCYTO KIT...................................................................... 3 .......................................................... PA
BOSULIF TABLET ................................................................ 3 ................... PA, QL-120 unit(s) per 30 day(s)
Strength: 100 MG
BOSULIF TABLET ................................................................ 3..................... PA, QL-30 unit(s) per 30 day(s)
Strength: 500 MG
BUSULFEX VIAL .................................................................. 3 ..............................................................
CABOMETYX TABLET ......................................................... 3..................... PA, QL-30 unit(s) per 30 day(s)
CAPRELSA TABLET ............................................................ 3..................... PA, QL-60 unit(s) per 30 day(s)
Strength: 100 MG
CAPRELSA TABLET ............................................................ 3..................... PA, QL-30 unit(s) per 30 day(s)
Strength: 300 MG
carboplatin vial ...................................................................... 1 ..............................................................
cerubidine vial ....................................................................... 1 ..............................................................
cisplatin vial........................................................................... 1 ..............................................................
CLADRIBINE VIAL................................................................ 3 ..............................................................
CLOLAR VIAL ....................................................................... 3 ..............................................................
COMETRIQ CAPSULE ......................................................... 3 .......................................................... PA
COSMEGEN VIAL ................................................................ 3 ..............................................................
COTELLIC TABLET .............................................................. 3..................... PA, QL-63 unit(s) per 28 day(s)
CYCLOPHOSPHAMIDE CAPSULE ..................................... 3 ......................................................... BD
cyclophosphamide vial .......................................................... 1...............................................................
CYRAMZA VIAL.................................................................... 3 .......................................................... PA
cytarabine vial ....................................................................... 1 ..............................................................
dacarbazine vial .................................................................... 1 ..............................................................
DACOGEN VIAL ................................................................... 3 ..............................................................
DARZALEX VIAL .................................................................. 3 .......................................................... PA
daunorubicin hcl vial.............................................................. 1..............................................................
DAUNOXOME VIAL.............................................................. 3 ..............................................................
decitabine vial ....................................................................... 1 ..............................................................
28
going to page V.
Drug Name
Drug Tier
Requirements/Limits
DEXRAZOXANE VIAL...........................................................3 ..............................................................
DOCEFREZ VIAL ..................................................................3 ..............................................................
DOCETAXEL VIAL ................................................................3 ..............................................................
DOXIL VIAL ...........................................................................3 ..............................................................
doxorubicin hcl vial ................................................................1 ..............................................................
doxorubicin hcl liposome vial.................................................1 ..............................................................
DROXIA CAPSULE ...............................................................3 ..............................................................
ELITEK VIAL .........................................................................3 ..............................................................
ELLENCE VIAL .....................................................................3 ..............................................................
ELOXATIN VIAL ....................................................................3 ..............................................................
EMCYT CAPSULE ................................................................3 ..............................................................
EMPLICITI VIAL ....................................................................3 ......................................................... PA
epirubicin hcl vial ...................................................................1 ..............................................................
ERBITUX VIAL ......................................................................3 ......................................................... PA
ERIVEDGE CAPSULE ..........................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
ERWINAZE VIAL...................................................................3 ......................................................... PA
ETOPOPHOS VIAL ...............................................................3 ..............................................................
etoposide vial ........................................................................1 ..............................................................
EVOMELA VIAL ....................................................................3 ..............................................................
EXEMESTANE TABLET .......................................................2 ..............................................................
FARESTON TABLET ............................................................3 ..............................................................
FARYDAK CAPSULE............................................................3 ...................... PA, QL-6 unit(s) per 21 day(s)
FASLODEX SYRINGE ..........................................................3 ..............................................................
FIRMAGON VIAL ..................................................................3 ..............................................................
Strength: 120 MG
FIRMAGON VIAL ..................................................................3 ..............................................................
Strength: 80 MG
fludarabine phosphate vial ....................................................1 ..............................................................
fluorouracil vial ......................................................................1 ......................................................... BD
FOLOTYN VIAL.....................................................................3 ......................................................... PA
FUSILEV VIAL.......................................................................3 ..............................................................
GAZYVA VIAL .......................................................................3 ......................................................... PA
GEMCITABINE HCL VIAL.....................................................3 ..............................................................
29
going to page V.
Drug Name
Drug Tier
Requirements/Limits
GEMZAR VIAL ...................................................................... 3 ..............................................................
GILOTRIF TABLET ............................................................... 3..................... PA, QL-30 unit(s) per 30 day(s)
GLEEVEC TABLET............................................................... 3 ................... PA, QL-120 unit(s) per 30 day(s)
Strength: 100 MG
GLEEVEC TABLET............................................................... 3..................... PA, QL-60 unit(s) per 30 day(s)
Strength: 400 MG
GLEOSTINE CAPSULE........................................................ 3 ..............................................................
HALAVEN VIAL..................................................................... 3 .......................................................... PA
HERCEPTIN VIAL................................................................. 3 ..............................................................
HEXALEN CAPSULE............................................................ 3 ..............................................................
HYCAMTIN VIAL................................................................... 3 ..............................................................
hydroxyurea capsule ............................................................. 1..............................................................
IBRANCE CAPSULE ............................................................ 3..................... PA, QL-21 unit(s) per 28 day(s)
ICLUSIG TABLET ................................................................. 3 .......................................................... PA
IDAMYCIN PFS VIAL............................................................ 3 ..............................................................
IDARUBICIN HCL VIAL ........................................................ 3 ..............................................................
ifosfamide vial ....................................................................... 1 ..............................................................
IFOSFAMIDE-MESNA KIT.................................................... 3 ..............................................................
IMATINIB MESYLATE TABLET............................................ 3 ................... PA, QL-120 unit(s) per 30 day(s)
Strength: 100 MG
IMATINIB MESYLATE TABLET............................................ 3 ..................... PA, QL-60 unit(s) per 30 day(s)
Strength: 400 MG
IMBRUVICA CAPSULE ........................................................ 3 ................... PA, QL-120 unit(s) per 30 day(s)
IMLYGIC VIAL....................................................................... 3....................... PA, QL-8 mL(s) per 28 day(s)
INLYTA TABLET ................................................................... 3 ................... PA, QL-180 unit(s) per 30 day(s)
Strength: 1 MG
INLYTA TABLET ................................................................... 3 ................... PA, QL-120 unit(s) per 30 day(s)
Strength: 5 MG
IRESSA TABLET .................................................................. 3..................... PA, QL-30 unit(s) per 30 day(s)
irinotecan hcl vial................................................................... 1 ..............................................................
ISTODAX VIAL...................................................................... 3 .......................................................... PA
IXEMPRA VIAL ..................................................................... 3 .......................................................... PA
JAKAFI TABLET ................................................................... 3 .......................................................... PA
JEVTANA VIAL ..................................................................... 3 .......................................................... PA
30
going to page V.
Drug Name
Drug Tier
Requirements/Limits
KADCYLA VIAL .....................................................................3 ......................................................... PA
KEYTRUDA VIAL ..................................................................3 ......................................................... PA
KYPROLIS VIAL....................................................................3 ......................................................... PA
LENVIMA CAPSULE .............................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
Strength: 10 MG/DAY
Strength: 14 MG/DAY, 20 MG/DAY, 8 MG/DAY
Strength: 18 MG/DAY, 24 MG/DAY
letrozole tablet .......................................................................1 ..............................................................
leucovorin calcium vial...........................................................1 ..............................................................
leucovorin calcium tablet .......................................................1...............................................................
LEUKERAN TABLET.............................................................2 ..............................................................
LEVOLEUCOVORIN CALCIUM VIAL ...................................3 ..............................................................
Strength: 10 MG/ML
LEVOLEUCOVORIN CALCIUM VIAL ...................................3 ..............................................................
Strength: 50 MG
lipodox vial.............................................................................1 ..............................................................
lipodox 50 vial........................................................................1 ..............................................................
lomustine capsule..................................................................1 ..............................................................
LONSURF TABLET...............................................................3 ................... PA, QL-100 unit(s) per 28 day(s)
Strength: 15-6.14 MG
LONSURF TABLET...............................................................3 ..................... PA, QL-80 unit(s) per 28 day(s)
Strength: 20-8.19 MG
LYNPARZA CAPSULE..........................................................3 ................... PA, QL-480 unit(s) per 30 day(s)
MARQIBO KIT .......................................................................3 ......................................................... PA
MATULANE CAPSULE .........................................................3 ..............................................................
MEKINIST TABLET ...............................................................3 ..................... PA, QL-90 unit(s) per 30 day(s)
Strength: 0.5 MG
MEKINIST TABLET ...............................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
Strength: 2 MG
MELPHALAN HCL VIAL........................................................3 ..............................................................
mercaptopurine tablet............................................................1 ..............................................................
mesna vial .............................................................................1 ..............................................................
MESNEX TABLET.................................................................3 ..............................................................
mitomycin vial ........................................................................1 ..............................................................
mitoxantrone hcl vial..............................................................1 ..............................................................
31
going to page V.
Drug Name
Drug Tier
Requirements/Limits
MUSTARGEN VIAL .............................................................. 3 ..............................................................
NAVELBINE VIAL ................................................................. 3 ..............................................................
NEXAVAR TABLET .............................................................. 3 ................... PA, QL-120 unit(s) per 30 day(s)
NILUTAMIDE TABLET.......................................................... 3 ..............................................................
NINLARO CAPSULE ............................................................ 3....................... PA, QL-3 unit(s) per 28 day(s)
NIPENT VIAL ........................................................................ 3 ..............................................................
ODOMZO CAPSULE ............................................................ 3..................... PA, QL-30 unit(s) per 30 day(s)
ONCASPAR VIAL ................................................................. 3 ..............................................................
OPDIVO VIAL ....................................................................... 3 .......................................................... PA
OXALIPLATIN VIAL .............................................................. 3 ..............................................................
paclitaxel vial......................................................................... 1 ..............................................................
PANRETIN GEL ................................................................... 3 ..............................................................
PERJETA VIAL ..................................................................... 3 .......................................................... PA
PHOTOFRIN VIAL ................................................................ 3 ..............................................................
POMALYST CAPSULE......................................................... 3..................... PA, QL-21 unit(s) per 28 day(s)
PORTRAZZA VIAL................................................................ 3 .......................................................... PA
PROLEUKIN VIAL................................................................. 3 ..............................................................
PURIXAN ORAL SUSP......................................................... 3 ..............................................................
REVLIMID CAPSULE ........................................................... 3.......................... QL-30 unit(s) per 30 day(s)
RITUXAN VIAL...................................................................... 3 .......................................................... PA
SOLTAMOX SOLUTION....................................................... 3 ..............................................................
SPRYCEL TABLET............................................................... 3 ..................... PA, QL-30 unit(s) per 30 day(s)
SPRYCEL TABLET............................................................... 3 ..................... PA, QL-60 unit(s) per 30 day(s)
STIVARGA TABLET ............................................................. 3 .......................................................... PA
SUTENT CAPSULE .............................................................. 3..................... PA, QL-30 unit(s) per 30 day(s)
SYLATRON KIT .................................................................... 3 .......................................................... PA
SYLVANT VIAL ..................................................................... 3 .......................................................... PA
SYNRIBO VIAL ..................................................................... 3 .......................................................... PA
TABLOID TABLET ................................................................ 3 ..............................................................
TAFINLAR CAPSULE ........................................................... 3 ................... PA, QL-120 unit(s) per 30 day(s)
32
going to page V.
Drug Name
Drug Tier
Requirements/Limits
TAGRISSO TABLET .............................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
tamoxifen citrate tablet ..........................................................1 ..............................................................
TARCEVA TABLET ...............................................................3 .......................... QL-30 unit(s) per 30 day(s)
TARGRETIN CAPSULE ........................................................3 ..............................................................
TARGRETIN GEL .................................................................3...............................................................
TASIGNA CAPSULE .............................................................3 ................... PA, QL-120 unit(s) per 30 day(s)
TAXOTERE VIAL ..................................................................3 ..............................................................
TECENTRIQ VIAL .................................................................3 ......................................................... PA
teniposide ampul ...................................................................1 ..............................................................
THALOMID CAPSULE ..........................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
THALOMID CAPSULE ..........................................................3 ..................... PA, QL-60 unit(s) per 30 day(s)
Strength: 200 MG
thiotepa vial ...........................................................................1 ..............................................................
toposar vial ............................................................................1 ..............................................................
TOPOTECAN HCL VIAL .......................................................3 ..............................................................
TORISEL VIAL ......................................................................3 ......................................................... PA
TREANDA VIAL ....................................................................3 ......................................................... PA
TRETINOIN CAPSULE .........................................................3 ..............................................................
TRISENOX AMPUL...............................................................3 ..............................................................
TYKERB TABLET .................................................................3 ................... PA, QL-150 unit(s) per 30 day(s)
UNITUXIN VIAL.....................................................................3 ..............................................................
VALCHLOR GEL ..................................................................3 ..................... PA, QL-60 grams per 30 day(s)
VECTIBIX VIAL .....................................................................3 ..............................................................
VELCADE VIAL .....................................................................3 ......................................................... PA
VENCLEXTA TABLET...........................................................3 ...................... PA, QL-14 unit(s) per 7 day(s)
Strength: 10 MG
VENCLEXTA TABLET...........................................................3 ................... PA, QL-112 unit(s) per 28 day(s)
Strength: 100 MG
VENCLEXTA TABLET...........................................................3 ........................ PA, QL-7 unit(s) per 7 day(s)
Strength: 50 MG
VENCLEXTA STARTING PACK TAB DS PK .......................3 ..................... PA, QL-42 unit(s) per 28 day(s)
VIDAZA VIAL.........................................................................3 ..............................................................
vinblastine sulfate vial ...........................................................1 ..............................................................
33
going to page V.
Drug Name
Drug Tier
Requirements/Limits
vincasar pfs vial..................................................................... 1 ..............................................................
vincristine sulfate vial ............................................................ 1..............................................................
vinorelbine tartrate vial .......................................................... 1 ..............................................................
VOTRIENT TABLET ............................................................. 3 ................... PA, QL-120 unit(s) per 30 day(s)
XALKORI CAPSULE............................................................. 3 .......................................................... PA
YERVOY VIAL ...................................................................... 3 .......................................................... PA
YONDELIS VIAL ................................................................... 3 .......................................................... PA
ZALTRAP VIAL ..................................................................... 3 .......................................................... PA
ZANOSAR VIAL .................................................................... 3 ..............................................................
ZELBORAF TABLET............................................................. 3 .......................................................... PA
ZINECARD VIAL ................................................................... 3 ..............................................................
ZOLINZA CAPSULE ............................................................. 3 ................... PA, QL-120 unit(s) per 30 day(s)
ZYDELIG TABLET ................................................................ 3..................... PA, QL-60 unit(s) per 30 day(s)
ZYKADIA CAPSULE ............................................................. 3 .......................................................... PA
ZYTIGA TABLET................................................................... 3......................... QL-120 unit(s) per 30 day(s)
ANTIPARASITICS
ALBENZA TABLET ............................................................... 3 ..............................................................
ALINIA SUSP RECON .......................................................... 3 ..............................................................
ALINIA TABLET .................................................................... 3...............................................................
ATOVAQUONE ORAL SUSP ............................................... 3 ..............................................................
ATOVAQUONE-PROGUANIL HCL TABLET........................ 3..............................................................
BILTRICIDE TABLET............................................................ 3 ..............................................................
chloroquine phosphate tablet ................................................ 1 ..............................................................
COARTEM TABLET.............................................................. 3 ..............................................................
DARAPRIM TABLET............................................................. 3 ..............................................................
EMVERM TAB CHEW .......................................................... 3 ..............................................................
EURAX LOTION ................................................................... 3 ..............................................................
EURAX CREAM ................................................................... 3...............................................................
hydroxychloroquine sulfate tablet.......................................... 1 ..............................................................
ivermectin tablet .................................................................... 1 ..............................................................
LINDANE SHAMPOO ........................................................... 2 ..............................................................
LINDANE LOTION ................................................................ 2...............................................................
34
going to page V.
Drug Name
Drug Tier
Requirements/Limits
ANTIPARASITICS (continued)
MALATHION LOTION ...........................................................2 ..............................................................
mefloquine hcl tablet .............................................................1 ..............................................................
MEPRON ORAL SUSP .........................................................3 ..............................................................
NATROBA SUSPENSION.....................................................3 ..............................................................
NEBUPENT VIAL-NEB..........................................................3 ......................................................... BD
PENTAM 300 VIAL................................................................3 ..............................................................
PERMETHRIN CREAM ........................................................2 ..............................................................
PRIMAQUINE TABLET .........................................................3 ..............................................................
QUALAQUIN CAPSULE........................................................3 ......................................................... PA
QUININE SULFATE CAPSULE.............................................2 ......................................................... PA
SOOLANTRA CREAM .........................................................3 ...................................................... STEP
spinosad suspension .............................................................1 ..............................................................
STROMECTOL TABLET .......................................................2 ..............................................................
TINDAMAX TABLET .............................................................3 ..............................................................
tinidazole tablet .....................................................................1 ..............................................................
ULESFIA LOTION .................................................................3 ..............................................................
ANTIPARKINSON AGENTS
APOKYN CARTRIDGE .........................................................3 ..............................................................
AZILECT TABLET .................................................................2 .......................... QL-30 unit(s) per 30 day(s)
benztropine mesylate tablet ..................................................1 ..............................................................
benztropine mesylate ampul..................................................1...............................................................
CARBIDOPA TABLET...........................................................3 ..............................................................
carbidopa-levodopa tablet .....................................................1 ..............................................................
CARBIDOPA-LEVODOPA TAB RAPDIS ..............................2...............................................................
carbidopa-levodopa er tablet er.............................................1 ..............................................................
carbidopa-levodopa-entacapone tablet .................................1 ..............................................................
entacapone tablet ..................................................................1 ........................ QL-240 unit(s) per 30 day(s)
LODOSYN TABLET ..............................................................3 ..............................................................
MIRAPEX ER TAB ER 24H...................................................3 ................. STEP, QL-30 unit(s) per 30 day(s)
NEUPRO PATCH TD24 ........................................................3 .......................... QL-30 unit(s) per 30 day(s)
pramipexole dihydrochloride tablet........................................1 ..............................................................
PRAMIPEXOLE ER TAB ER 24H .........................................2 .......................... QL-30 unit(s) per 30 day(s)
Strength: 0.375 MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 MG
35
going to page V.
Drug Name
Drug Tier
Requirements/Limits
ANTIPARKINSON AGENTS (continued)
PRAMIPEXOLE ER TAB ER 24H......................................... 2 .......................... QL-90 unit(s) per 30 day(s)
Strength: 0.75 MG, 1.5 MG
ROPINIROLE ER TAB ER 24H ............................................ 2 .......................... QL-60 unit(s) per 30 day(s)
ropinirole hcl tablet ................................................................ 1 ..............................................................
selegiline hcl capsule ............................................................ 1..............................................................
selegiline hcl tablet................................................................ 1...............................................................
SINEMET 10-100 TABLET ................................................... 3 ..............................................................
SINEMET 25-100 TABLET ................................................... 3 ..............................................................
SINEMET 25-250 TABLET ................................................... 3 ..............................................................
SINEMET CR TABLET ER ................................................... 3 ..............................................................
TASMAR TABLET................................................................. 3 ..............................................................
TOLCAPONE TABLET ......................................................... 3 ..............................................................
trihexyphenidyl hcl tablet....................................................... 1 ..............................................................
trihexyphenidyl hcl elixir ........................................................ 1...............................................................
ZELAPAR TAB RAPDIS ....................................................... 3 ...................................................... STEP
ANTIPSYCHOTICS
ABILIFY VIAL ........................................................................ 3 ..............................................................
ABILIFY SOLUTION ............................................................. 3...............................................................
ABILIFY TABLET .................................................................. 3...............................................................
ABILIFY DISCMELT TAB RAPDIS ....................................... 3 ..............................................................
ABILIFY MAINTENA SUSER VIAL ....................................... 3 ..............................................................
ABILIFY MAINTENA SUSER SYR ....................................... 3...............................................................
ADASUVE AER POW BA ..................................................... 3 ..............................................................
ARIPIPRAZOLE SOLUTION................................................. 2 ..............................................................
aripiprazole tablet.................................................................. 1...............................................................
ARIPIPRAZOLE ODT TAB RAPDIS ..................................... 2 ..............................................................
ARISTADA SUSER SYR ...................................................... 3 ..............................................................
chlorpromazine hcl ampul ..................................................... 1 ..............................................................
chlorpromazine hcl tablet ...................................................... 1...............................................................
clozapine tablet ..................................................................... 1 ..............................................................
clozapine odt tab rapdis ........................................................ 1 ..............................................................
FANAPT TAB DS PK ............................................................ 3 ..................... PA, QL-60 unit(s) per 30 day(s)
FANAPT TABLET ................................................................. 3..................... PA, QL-60 unit(s) per 30 day(s)
36
going to page V.
Drug Name
Drug Tier
Requirements/Limits
ANTIPSYCHOTICS (continued)
FANAPT TABLET..................................................................3 ..................... PA, QL-60 unit(s) per 30 day(s)
FAZACLO TAB RAPDIS........................................................3 ..............................................................
fluphenazine decanoate vial ..................................................1 ..............................................................
fluphenazine hcl elixir ............................................................1 ..............................................................
fluphenazine hcl oral conc .....................................................1...............................................................
fluphenazine hcl vial ..............................................................1...............................................................
fluphenazine hcl tablet...........................................................1...............................................................
GEODON VIAL......................................................................3 ..............................................................
haloperidol tablet ...................................................................1 ..............................................................
haloperidol decanoate ampul ................................................1 ..............................................................
haloperidol decanoate vial.....................................................1...............................................................
haloperidol lactate vial ...........................................................1 ..............................................................
haloperidol lactate oral conc..................................................1...............................................................
INVEGA TAB ER 24 ..............................................................3 ................. STEP, QL-30 unit(s) per 30 day(s)
Strength: 1.5 MG, 3 MG, 9 MG
INVEGA TAB ER 24 ..............................................................3 ................. STEP, QL-60 unit(s) per 30 day(s)
Strength: 6 MG
INVEGA SUSTENNA SYRINGE ...........................................3 ...................................................... STEP
Strength: 117MG/0.75, 156 MG/ML, 234MG/1.5, 78MG/0.5ML
INVEGA SUSTENNA SYRINGE ...........................................3 ...................................................... STEP
Strength: 39MG/0.25
INVEGA TRINZA SYRINGE..................................................3 ...................................................... STEP
LATUDA TABLET..................................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
loxapine capsule....................................................................1 ..............................................................
MOLINDONE HCL TABLET ..................................................3 ..............................................................
NUPLAZID TABLET ..............................................................3 ..................... PA, QL-60 unit(s) per 30 day(s)
olanzapine tablet ...................................................................1 ..............................................................
OLANZAPINE VIAL ...............................................................3...............................................................
OLANZAPINE ODT TAB RAPDIS.........................................2 ..............................................................
OLANZAPINE-FLUOXETINE HCL CAPSULE ......................3 ..............................................................
ORAP TABLET......................................................................3 ..............................................................
PALIPERIDONE ER TAB ER 24 ...........................................2 .......................... QL-30 unit(s) per 30 day(s)
PALIPERIDONE ER TAB ER 24 ...........................................2 .......................... QL-60 unit(s) per 30 day(s)
Strength: 6 MG
perphenazine tablet ...............................................................1 ..............................................................
37
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Drug Name
Drug Tier
Requirements/Limits
ANTIPSYCHOTICS (continued)
PERPHENAZINE-AMITRIPTYLINE TABLET ....................... 2 ..............................................................
PIMOZIDE TABLET .............................................................. 2 ..............................................................
prochlorperazine edisylate vial.............................................. 1 ..............................................................
quetiapine fumarate tablet..................................................... 1 ..............................................................
REXULTI TABLET ................................................................ 3..................... PA, QL-30 unit(s) per 30 day(s)
Strength: 0.25 MG, 2 MG, 3 MG, 4 MG
REXULTI TABLET ................................................................ 3 ................... PA, QL-120 unit(s) per 30 day(s)
RISPERDAL CONSTA SYRINGE......................................... 3 ..............................................................
Strength: 12.5MG/2ML, 25 MG/2 ML
RISPERDAL CONSTA SYRINGE......................................... 3 ..............................................................
Strength: 37.5MG/2ML, 50 MG/2 ML
risperidone solution ............................................................... 1..............................................................
risperidone tablet................................................................... 1...............................................................
RISPERIDONE ODT TAB RAPDIS ...................................... 2 ..............................................................
SAPHRIS TAB SUBL ............................................................ 3..................... PA, QL-60 unit(s) per 30 day(s)
SEROQUEL XR TAB ER 24H............................................... 2 .......................... QL-30 unit(s) per 30 day(s)
SEROQUEL XR TAB ER 24H............................................... 2 .......................... QL-60 unit(s) per 30 day(s)
thioridazine hcl tablet ............................................................ 1..............................................................
thiothixene capsule ............................................................... 1..............................................................
trifluoperazine hcl tablet ........................................................ 1 ..............................................................
VERSACLOZ ORAL SUSP................................................... 3.......................... QL-540 mL(s) per 30 day(s)
VRAYLAR CAP DS PK ......................................................... 3 .......................................................... PA
VRAYLAR CAPSULE............................................................ 3..................... PA, QL-30 unit(s) per 30 day(s)
ziprasidone hcl capsule......................................................... 1 ..............................................................
ZYPREXA RELPREVV VIAL ................................................ 3 ..............................................................
ANTISPASTICITY AGENTS
baclofen tablet....................................................................... 1 ..............................................................
dantrolene sodium capsule ................................................... 1 ..............................................................
GABLOFEN SYRINGE ......................................................... 3 ......................................................... BD
Strength: 40000/20 ML
tizanidine hcl capsule ............................................................ 1..............................................................
tizanidine hcl tablet................................................................ 1...............................................................
38
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Drug Name
Drug Tier
Requirements/Limits
ANTIVIRALS
ABACAVIR TABLET..............................................................3 ..............................................................
ABACAVIR-LAMIVUDINE-ZIDOVUDINE TABLET ...............3 ..............................................................
ACYCLOVIR ORAL SUSP ....................................................3 ..............................................................
acyclovir tablet.......................................................................1...............................................................
acyclovir capsule ...................................................................1...............................................................
ACYCLOVIR OINT. ..............................................................3 ........................ QL-30 gram(s) per 30 day(s)
adefovir dipivoxil tablet ..........................................................1 .......................... QL-30 unit(s) per 30 day(s)
ALFERON N VIAL .................................................................3 ..............................................................
amantadine tablet ..................................................................1 ..............................................................
amantadine solution ..............................................................1...............................................................
amantadine capsule ..............................................................1...............................................................
APTIVUS SOLUTION............................................................3 ..............................................................
APTIVUS CAPSULE .............................................................3...............................................................
ATRIPLA TABLET .................................................................3 .......................... QL-30 unit(s) per 30 day(s)
BARACLUDE TABLET ..........................................................3 .......................... QL-30 unit(s) per 30 day(s)
BARACLUDE SOLUTION .....................................................3..................................QL-600 mL(s) per 30 day(s)
CIDOFOVIR VIAL..................................................................3 ..............................................................
COMBIVIR TABLET ..............................................................3 ..............................................................
COMPLERA TABLET............................................................3 ..............................................................
COPEGUS TABLET ..............................................................3 ......................................................... PA
CRIXIVAN CAPSULE............................................................3 ..............................................................
DAKLINZA TABLET ..............................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
DENAVIR CREAM ................................................................3 .......................... QL-5 gram(s) per 30 day(s)
DESCOVY TABLET ..............................................................3 .......................... QL-30 unit(s) per 30 day(s)
didanosine capsule dr ...........................................................1 ..............................................................
EDURANT TABLET...............................................................3 ..............................................................
EMTRIVA SOLUTION ...........................................................3 ..............................................................
EMTRIVA CAPSULE.............................................................3...............................................................
ENTECAVIR TABLET ...........................................................3 .......................... QL-30 unit(s) per 30 day(s)
EPIVIR SOLUTION ...............................................................3 ..............................................................
EPIVIR HBV SOLUTION .......................................................3 ..............................................................
EPZICOM TABLET................................................................3 ..............................................................
EVOTAZ TABLET .................................................................3 .......................... QL-30 unit(s) per 30 day(s)
39
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Drug Name
Drug Tier
Requirements/Limits
ANTIVIRALS (continued)
famciclovir tablet ................................................................... 1 .......................... QL-90 unit(s) per 30 day(s)
foscarnet sodium infus. btl .................................................... 1 ......................................................... BD
FUZEON VIAL....................................................................... 3 ..............................................................
GANCICLOVIR SODIUM VIAL ............................................. 3 ..............................................................
GENVOYA TABLET.............................................................. 3 .......................... QL-30 unit(s) per 30 day(s)
HARVONI TABLET ............................................................... 3..................... PA, QL-30 unit(s) per 30 day(s)
HEPSERA TABLET .............................................................. 3.......................... QL-30 unit(s) per 30 day(s)
INTELENCE TABLET ........................................................... 3......................... QL-120 unit(s) per 30 day(s)
INTELENCE TABLET ........................................................... 3......................... QL-120 unit(s) per 30 day(s)
Strength: 25 MG
INTRON A VIAL .................................................................... 3 ..............................................................
INVIRASE TABLET............................................................... 3 ..............................................................
INVIRASE CAPSULE............................................................ 3...............................................................
ISENTRESS POWD PACK................................................... 3 ..............................................................
ISENTRESS TABLET ........................................................... 3.......................... QL-60 unit(s) per 30 day(s)
ISENTRESS TAB CHEW...................................................... 3.......................... QL-60 unit(s) per 30 day(s)
Strength: 100 MG
ISENTRESS TAB CHEW...................................................... 2 ..............................................................
Strength: 25 MG
KALETRA SOLUTION .......................................................... 3 ..............................................................
KALETRA TABLET ............................................................... 3 ..............................................................
Strength: 100MG-25MG
KALETRA TABLET ............................................................... 3 ..............................................................
lamivudine tablet ................................................................... 1 ..............................................................
lamivudine solution................................................................ 1...............................................................
lamivudine hbv tablet ............................................................ 1..............................................................
LAMIVUDINE-ZIDOVUDINE TABLET .................................. 3 ..............................................................
LEXIVA ORAL SUSP ............................................................ 3 ..............................................................
LEXIVA TABLET ................................................................... 3...............................................................
MODERIBA TABLET ............................................................ 3 .......................................................... PA
MODERIBA TAB DS PK ....................................................... 3 .......................................................................... PA
nevirapine oral susp .............................................................. 1..............................................................
nevirapine tablet.................................................................... 1...............................................................
40
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Drug Name
Drug Tier
Requirements/Limits
nevirapine er tab er 24h ........................................................1 .......................... QL-30 unit(s) per 30 day(s)
NORVIR SOLUTION .............................................................2 ..............................................................
NORVIR TABLET ..................................................................2...............................................................
NORVIR CAPSULE...............................................................2...............................................................
ODEFSEY TABLET...............................................................3 .......................... QL-30 unit(s) per 30 day(s)
OLYSIO CAPSULE ...............................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
PEGASYS VIAL ....................................................................3 ......................................................... PA
PEGASYS SYRINGE ............................................................3 ....................... PA, QL-2 mL(s) per 28 day(s)
PEGASYS PROCLICK PEN INJCTR....................................3 ......................................................... PA
Strength: 135MCG/0.5
PEGASYS PROCLICK PEN INJCTR....................................3 ....................... PA, QL-2 mL(s) per 28 day(s)
PEGINTRON KIT...................................................................3 ...................... PA, QL-4 unit(s) per 28 day(s)
PEGINTRON REDIPEN PEN IJ KIT .....................................3 ...................... PA, QL-4 unit(s) per 28 day(s)
PREZCOBIX TABLET ...........................................................3 .......................... QL-30 unit(s) per 30 day(s)
PREZISTA ORAL SUSP .......................................................3 ..............................................................
PREZISTA TABLET ..............................................................3...............................................................
REBETOL SOLUTION ..........................................................3 ......................................................... PA
REBETOL CAPSULE ............................................................3...........................................................................PA
RELENZA BLST W/DEV .......................................................3 .......................... QL-56 unit(s) per 30 day(s)
RESCRIPTOR TABLET ........................................................3 ..............................................................
RESCRIPTOR TAB DISPER.................................................3...............................................................
RETROVIR VIAL ...................................................................3 ..............................................................
REYATAZ POWD PACK .......................................................3 ..............................................................
REYATAZ CAPSULE ............................................................3...............................................................
ribasphere capsule ................................................................1 ......................................................... PA
ribasphere tablet....................................................................1 ......................................................... PA
RIBASPHERE TABLET.........................................................3 ......................................................... PA
Strength: 600 MG
RIBASPHERE RIBAPAK TAB DS PK ...................................3 ......................................................... PA
RIBATAB TAB DS PK ...........................................................3 ......................................................... PA
ribavirin capsule ....................................................................1 ......................................................... PA
ribavirin tablet ........................................................................1...........................................................................PA
41
going to page V.
Drug Name
Drug Tier
Requirements/Limits
rimantadine hcl tablet ............................................................ 1..............................................................
SELZENTRY TABLET .......................................................... 3.......................... QL-60 unit(s) per 30 day(s)
Strength: 150 MG
SELZENTRY TABLET .......................................................... 3......................... QL-120 unit(s) per 30 day(s)
Strength: 300 MG
SOVALDI TABLET ................................................................ 3..................... PA, QL-30 unit(s) per 30 day(s)
stavudine soln recon ............................................................. 1..............................................................
stavudine capsule ................................................................. 1...............................................................
STRIBILD TABLET ............................................................... 3 ..............................................................
SUSTIVA TABLET ................................................................ 3 ..............................................................
SUSTIVA CAPSULE ............................................................. 3...............................................................
TAMIFLU SUSP RECON ...................................................... 3 ..............................................................
TAMIFLU CAPSULE ............................................................. 3 ..............................................................
TAMIFLU CAPSULE ............................................................. 3.......................... QL-28 unit(s) per 30 day(s)
Strength: 75 MG
TECHNIVIE TABLET ............................................................ 3..................... PA, QL-60 unit(s) per 30 day(s)
TIVICAY TABLET.................................................................. 3.......................... QL-30 unit(s) per 30 day(s)
TIVICAY TABLET.................................................................. 3 ..............................................................
Strength: 50 MG
trifluridine drops..................................................................... 1 ..............................................................
TRIUMEQ TABLET ............................................................... 3.......................... QL-30 unit(s) per 30 day(s)
TRIZIVIR TABLET................................................................. 3 ..............................................................
TRUVADA TABLET .............................................................. 3 ..............................................................
TYBOST TABLET ................................................................. 2 ..............................................................
TYZEKA TABLET.................................................................. 3.......................... QL-30 unit(s) per 30 day(s)
valacyclovir tablet.................................................................. 1 ..............................................................
VALCYTE SOLN RECON ..................................................... 3 ..............................................................
VALCYTE TABLET ............................................................... 3...............................................................
VALGANCICLOVIR HCL TABLET........................................ 3 ..............................................................
VIDEX SOLN RECON........................................................... 3 ..............................................................
VIEKIRA PAK TAB DS PK .................................................... 3 ................... PA, QL-112 unit(s) per 28 day(s)
VIEKIRA XR TAB BP 24H..................................................... 3 ..................... PA, QL-90 unit(s) per 30 day(s)
42
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Drug Name
Drug Tier
Requirements/Limits
VIRACEPT TABLET ..............................................................3 ..............................................................
VIRAMUNE TABLET .............................................................3 ..............................................................
VIRAMUNE ORAL SUSP ......................................................3...............................................................
VIRAMUNE XR TAB ER 24H ................................................3 .......................... QL-30 unit(s) per 30 day(s)
Strength: 100 MG
VIRAMUNE XR TAB ER 24H ................................................3 .......................... QL-30 unit(s) per 30 day(s)
Strength: 400 MG
VIRAZOLE VIAL-NEB ...........................................................3 ..............................................................
VIREAD TABLET ..................................................................3 ..............................................................
VIREAD POWDER ................................................................3...............................................................
VISTIDE VIAL........................................................................3 ..............................................................
VITEKTA TABLET .................................................................3 .......................... QL-30 unit(s) per 30 day(s)
ZEPATIER TABLET ..............................................................3 ..................... PA, QL-28 unit(s) per 28 day(s)
ZIAGEN SOLUTION..............................................................3 ..............................................................
ZIAGEN TABLET ..................................................................3...............................................................
zidovudine tablet ...................................................................1 ..............................................................
zidovudine syrup ...................................................................1...............................................................
zidovudine capsule ................................................................1...............................................................
ZIRGAN GEL ........................................................................3 ..............................................................
ZOVIRAX CREAM ................................................................3 ........................ QL-15 gram(s) per 30 day(s)
ANXIOLYTICS
alprazolam tablet ...................................................................1 ..............................................................
alprazolam er tab er 24h .......................................................1 ..............................................................
alprazolam odt tab rapdis ......................................................1 ..............................................................
buspirone hcl tablet ...............................................................1 ..............................................................
chlordiazepoxide hcl capsule.................................................1 ..............................................................
CHLORDIAZEPOXIDE-AMITRIPTYLINE TABLET...............3 ..............................................................
diazepam tablet .....................................................................1 ..............................................................
diazepam syringe ..................................................................1...............................................................
diazepam solution .................................................................1...............................................................
DIAZEPAM KIT .....................................................................3...............................................................
diazepam oral conc ...............................................................1...............................................................
HYDROXYZINE PAMOATE CAPSULE ................................2 ..............................................................
lorazepam syringe .................................................................1 ..............................................................
lorazepam tablet ....................................................................1...............................................................
43
going to page V.
Drug Name
Drug Tier
Requirements/Limits
ANXIOLYTICS (continued)
lorazepam vial ....................................................................... 1...............................................................
oxazepam capsule ................................................................ 1 ..............................................................
BIPOLAR AGENTS
EQUETRO CPMP 12HR....................................................... 3 ..............................................................
lithium solution ...................................................................... 1 ..............................................................
LITHIUM CARBONATE TABLET.......................................... 3 ..............................................................
lithium carbonate capsule ..................................................... 1 ..............................................................
LITHIUM CARBONATE CAPSULE....................................... 3 ..............................................................
Strength: 600 MG
lithium carbonate er tablet er................................................. 1 ..............................................................
BLOOD GLUCOSE REGULATORS
acarbose tablet...................................................................... 1 ..............................................................
ACTOPLUS MET XR TBMP 24HR ....................................... 3 .......................... QL-30 unit(s) per 30 day(s)
ALOGLIPTIN TABLET .......................................................... 3.................. STEP, QL-30 unit(s) per 30 day(s)
ALOGLIPTIN-METFORMIN TABLET ................................... 3 .................. STEP, QL-60 unit(s) per 30 day(s)
ALOGLIPTIN-PIOGLITAZONE TABLET............................... 3 .................. STEP, QL-30 unit(s) per 30 day(s)
AVANDAMET TABLET ......................................................... 3.......................... QL-60 unit(s) per 30 day(s)
AVANDARYL TABLET.......................................................... 3.......................... QL-30 unit(s) per 30 day(s)
AVANDIA TABLET................................................................ 3.......................... QL-30 unit(s) per 30 day(s)
BYDUREON VIAL ................................................................. 2 ............................. QL-4 mL(s) per 28 day(s)
BYDUREON PEN PEN INJCTR ........................................... 2............................. QL-4 mL(s) per 28 day(s)
BYETTA PEN INJCTR .......................................................... 2.......................... QL-2.4 mL(s) per 30 day(s)
BYETTA PEN INJCTR .......................................................... 2.......................... QL-1.2 mL(s) per 30 day(s)
Strength: 5MCG/0.02
CHLORPROPAMIDE TABLET ............................................. 2..................... PA, QL-90 unit(s) per 30 day(s)
CYCLOSET TABLET ............................................................ 3 ..............................................................
DIABETA TABLET ................................................................ 3..................... PA, QL-60 unit(s) per 30 day(s)
Strength: 1.25 MG
DIABETA TABLET ................................................................ 3..................... PA, QL-90 unit(s) per 30 day(s)
Strength: 2.5 MG
DIABETA TABLET ................................................................ 3 ................... PA, QL-120 unit(s) per 30 day(s)
Strength: 5 MG
44
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Drug Name
Drug Tier
Requirements/Limits
BLOOD GLUCOSE REGULATORS (continued)
glimepiride tablet ...................................................................1 ........................ QL-180 unit(s) per 30 day(s)
Strength: 1 mg
glimepiride tablet ...................................................................1 .......................... QL-90 unit(s) per 30 day(s)
Strength: 2 mg
glimepiride tablet ...................................................................1 .......................... QL-60 unit(s) per 30 day(s)
Strength: 4 mg
glipizide tablet........................................................................1 ........................ QL-120 unit(s) per 30 day(s)
glipizide er tab er 24 ..............................................................1 .......................... QL-90 unit(s) per 30 day(s)
Strength: 2.5 mg, 5 mg
glipizide xl tab er 24...............................................................1 .......................... QL-60 unit(s) per 30 day(s)
Strength: 10 mg
glipizide-metformin tablet.......................................................1 ........................ QL-240 unit(s) per 30 day(s)
Strength: 2.5-250 mg
glipizide-metformin tablet.......................................................1 ........................ QL-120 unit(s) per 30 day(s)
Strength: 2.5-500 mg, 5 mg-500mg
GLUCAGEN VIAL .................................................................2 ..............................................................
GLUCAGON EMERGENCY KIT KIT.....................................2 ..............................................................
GLUCOVANCE TABLET.......................................................3 ................... PA, QL-120 unit(s) per 30 day(s)
GLUMETZA TABERGR24H ..................................................3 .......................... QL-60 unit(s) per 30 day(s)
Strength: 1000 MG
GLUMETZA TABERGR24H ..................................................3 ........................ QL-120 unit(s) per 30 day(s)
Strength: 500 MG
GLYBURIDE TABLET ...........................................................2 ..................... PA, QL-60 unit(s) per 30 day(s)
Strength: 1.25 MG
GLYBURIDE TABLET ...........................................................2 ..................... PA, QL-90 unit(s) per 30 day(s)
Strength: 2.5 MG
GLYBURIDE TABLET ...........................................................2 ................... PA, QL-120 unit(s) per 30 day(s)
Strength: 5 MG
GLYBURIDE MICRONIZED TABLET ...................................2 ..................... PA, QL-60 unit(s) per 30 day(s)
GLYBURIDE-METFORMIN HCL TABLET ............................2 ..................... PA, QL-60 unit(s) per 30 day(s)
Strength: 1.25-250MG
GLYBURIDE-METFORMIN HCL TABLET ............................2 ................... PA, QL-120 unit(s) per 30 day(s)
Strength: 2.5-500 MG, 5 MG-500MG
GLYNASE TABLET ...............................................................3 ..................... PA, QL-60 unit(s) per 30 day(s)
GLYSET TABLET..................................................................3 ..............................................................
HUMALOG CARTRIDGE ......................................................2 ..............................................................
HUMALOG VIAL ...................................................................2...............................................................
HUMALOG KWIKPEN U-100 INSULN PEN .........................2 ..............................................................
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Drug Name
Drug Tier
Requirements/Limits
HUMALOG KWIKPEN U-200 INSULN PEN ......................... 2 ..............................................................
HUMALOG MIX 50-50 VIAL.................................................. 2 ..............................................................
HUMALOG MIX 50-50 KWIKPEN INSULN PEN .................. 2 ..............................................................
HUMALOG MIX 75-25 VIAL.................................................. 2 ..............................................................
HUMALOG MIX 75-25 KWIKPEN INSULN PEN .................. 2 ..............................................................
HUMULIN 70/30 KWIKPEN INSULN PEN............................ 2 ..............................................................
HUMULIN 70-30 VIAL........................................................... 2 ..............................................................
HUMULIN N VIAL ................................................................. 2 ..............................................................
HUMULIN N KWIKPEN INSULN PEN .................................. 2..............................................................
HUMULIN R VIAL ................................................................. 2 ..............................................................
HUMULIN R U-500 VIAL....................................................... 2 ..............................................................
HUMULIN R U-500 KWIKPEN INSULN PEN ....................... 2 ..............................................................
INVOKAMET TABLET .......................................................... 2.......................... QL-60 unit(s) per 30 day(s)
INVOKAMET XR TAB BP 24H.............................................. 2 .......................... QL-60 unit(s) per 30 day(s)
INVOKANA TABLET ............................................................. 2.......................... QL-60 unit(s) per 30 day(s)
Strength: 100 MG
INVOKANA TABLET ............................................................. 2.......................... QL-30 unit(s) per 30 day(s)
Strength: 300 MG
JANUMET TABLET............................................................... 2.......................... QL-60 unit(s) per 30 day(s)
JANUMET XR TBMP 24HR .................................................. 2 .......................... QL-30 unit(s) per 30 day(s)
Strength: 100-1000MG, 50MG-500MG
JANUMET XR TBMP 24HR .................................................. 2 .......................... QL-60 unit(s) per 30 day(s)
Strength: 50-1000 MG
JANUVIA TABLET ................................................................ 2 .......................... QL-30 unit(s) per 30 day(s)
JARDIANCE TABLET ........................................................... 3.......................... QL-30 unit(s) per 30 day(s)
JENTADUETO TABLET........................................................ 3.......................... QL-60 unit(s) per 30 day(s)
JENTADUETO XR TAB BP 24H........................................... 3 .......................... QL-60 unit(s) per 30 day(s)
JENTADUETO XR TAB BP 24H........................................... 3 .......................... QL-30 unit(s) per 30 day(s)
KAZANO TABLET................................................................. 3 .................. STEP, QL-60 unit(s) per 30 day(s)
KOMBIGLYZE XR TBMP 24HR............................................ 2 .......................... QL-60 unit(s) per 30 day(s)
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Drug Name
Drug Tier
Requirements/Limits
KOMBIGLYZE XR TBMP 24HR ............................................2 .......................... QL-30 unit(s) per 30 day(s)
Strength: 5 MG-500MG, 5MG-1000MG
LANTUS VIAL .......................................................................2 ..............................................................
LANTUS SOLOSTAR INSULN PEN .....................................2 ..............................................................
LEVEMIR VIAL ......................................................................2 ..............................................................
LEVEMIR FLEXTOUCH INSULN PEN .................................2 ..............................................................
metformin hcl tablet ...............................................................1 .......................... QL-60 unit(s) per 30 day(s)
Strength: 1000 mg
metformin hcl tablet ...............................................................1 ........................ QL-150 unit(s) per 30 day(s)
Strength: 500 mg
metformin hcl tablet ...............................................................1 .......................... QL-90 unit(s) per 30 day(s)
Strength: 850 mg
metformin hcl er (like fortamet) tab 24..................................1 .......................... QL-60 unit(s) per 30 day(s)
Strength: 1000 mg
metformin hcl er (like fortamet) tab 24...................................1 ........................ QL-150 unit(s) per 30 day(s)
Strength: 500 mg
metformin hcl er (like glucophage xr) tab 24h .......................1 ........................ QL-120 unit(s) per 30 day(s)
Strength: 500 mg
metformin hcl er (like glucophage xr) tab 24h .......................1 .......................... QL-90 unit(s) per 30 day(s)
Strength: 750 mg
METFORMIN HCL ER (LIKE GLUMETZA) TABGR24H.......3 .......................... QL-60 unit(s) per 30 day(s)
Strength: 1000 MG
METFORMIN HCL ER (LIKE GLUMETZA) TABGR24H.......3 .......................... QL-90 unit(s) per 30 day(s)
Strength: 500 MG
miglitol tablet .........................................................................1 ..............................................................
nateglinide tablet ...................................................................1 ..............................................................
NESINA TABLET ..................................................................3 ................. STEP, QL-30 unit(s) per 30 day(s)
ONGLYZA TABLET...............................................................2 .......................... QL-30 unit(s) per 30 day(s)
OSENI TABLET.....................................................................3 ................. STEP, QL-30 unit(s) per 30 day(s)
pioglitazone hcl tablet ............................................................1 .......................... QL-30 unit(s) per 30 day(s)
pioglitazone-glimepiride tablet ...............................................1 .......................... QL-30 unit(s) per 30 day(s)
pioglitazone-metformin tablet ................................................1 .......................... QL-90 unit(s) per 30 day(s)
PRANDIMET TABLET...........................................................3 ........................ QL-150 unit(s) per 30 day(s)
PROGLYCEM ORAL SUSP ..................................................3 ..............................................................
repaglinide tablet ...................................................................1 ........................ QL-240 unit(s) per 30 day(s)
REPAGLINIDE-METFORMIN HCL TABLET.........................2 ........................ QL-150 unit(s) per 30 day(s)
RIOMET SOLUTION .............................................................3 ......................... QL-765 mL(s) per 30 day(s)
SYMLINPEN 120 PEN INJCTR.............................................2 ........................... QL-12 mL(s) per 28 day(s)
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Drug Name
Drug Tier
Requirements/Limits
SYMLINPEN 60 PEN INJCTR .............................................. 2 ........................... QL-12 mL(s) per 28 day(s)
SYNJARDY TABLET ............................................................ 3.......................... QL-60 unit(s) per 30 day(s)
tolazamide tablet ................................................................... 1 .......................... QL-60 unit(s) per 30 day(s)
tolbutamide tablet.................................................................. 1......................... QL-180 unit(s) per 30 day(s)
TOUJEO SOLOSTAR INSULN PEN .................................... 2..............................................................
TRADJENTA TABLET .......................................................... 3.......................... QL-30 unit(s) per 30 day(s)
VICTOZA 3-PAK PEN INJCTR ............................................. 2 ............................. QL-9 mL(s) per 30 day(s)
BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS
AGGRENOX CPMP 12HR.................................................... 3 .......................... QL-60 unit(s) per 30 day(s)
anagrelide hcl capsule .......................................................... 1 ..............................................................
ARANESP VIAL .................................................................... 3 .......................................................... PA
Strength: 100 MCG/ML, 200 MCG/ML, 300 MCG/ML
ARANESP SYRINGE............................................................ 3 .......................................................... PA
Strength: 100MCG/0.5, 150MCG/0.3, 200MCG/0.4, 300MCG/0.6, 500 MCG/ML
ARANESP SYRINGE............................................................ 3 .......................................................... PA
Strength: 10MCG/0.4, 25MCG/0.42, 40 MCG/0.4, 60MCG/0.3
ARANESP VIAL .................................................................... 3 .......................................................... PA
Strength: 25 MCG/ML, 40 MCG/ML, 60MCG/ML
ARIXTRA SYRINGE ............................................................. 3 ..............................................................
ASPIRIN-DIPYRIDAMOLE ER CPMP 12HR........................ 3 .......................... QL-60 unit(s) per 30 day(s)
BRILINTA TABLET ............................................................... 2.......................... QL-60 unit(s) per 30 day(s)
cilostazol tablet...................................................................... 1 ..............................................................
clopidogrel tablet ................................................................... 1............................ QL-1 unit(s) per 30 day(s)
Strength: 300 mg
clopidogrel tablet ................................................................... 1 .......................... QL-60 unit(s) per 30 day(s)
Strength: 75 mg
COUMADIN TABLET ............................................................ 3 ..............................................................
CYKLOKAPRON AMPUL ..................................................... 3 ..............................................................
dipyridamole tablet ................................................................ 1 ..............................................................
EFFIENT TABLET................................................................. 2.......................... QL-30 unit(s) per 30 day(s)
ELIQUIS TABLET ................................................................. 2.......................... QL-60 unit(s) per 30 day(s)
Strength: 2.5 MG
ELIQUIS TABLET ................................................................. 2.......................... QL-74 unit(s) per 30 day(s)
Strength: 5 MG
ENOXAPARIN SODIUM VIAL .............................................. 2 ..............................................................
48
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Drug Name
Drug Tier
Requirements/Limits
BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS (continued)
ENOXAPARIN SODIUM SYRINGE ......................................2...............................................................
EPOGEN VIAL ......................................................................3 ......................................................... PA
Strength: 10000/ML, 2000/ML, 3000/ML, 4000/ML
EPOGEN VIAL ......................................................................3 ......................................................... PA
Strength: 20000/ML
FONDAPARINUX SODIUM SYRINGE .................................3 ..............................................................
FRAGMIN VIAL .....................................................................3 ..............................................................
FRAGMIN SYRINGE.............................................................3...............................................................
GRANIX SYRINGE................................................................3 ..............................................................
heparin sodium syringe .........................................................1 ......................................................... PA
heparin sodium vial ...............................................................1...........................................................................PA
heparin sodium in 0.45% nacl iv soln ....................................1 ..............................................................
heparin sodium-0.9% nacl iv soln..........................................1 ..............................................................
heparin sodium-d5w iv soln ...................................................1 ..............................................................
jantoven tablet .......................................................................1 ..............................................................
LEUKINE VIAL ......................................................................3 ..............................................................
MIRCERA SYRINGE.............................................................3 ......................................................... PA
Strength: 100MCG/0.3, 50 MCG/0.3, 75 MCG/0.3
MIRCERA SYRINGE.............................................................3 ......................................................... PA
MOZOBIL VIAL .....................................................................3 ......................................................... PA
NEULASTA SYRINGE ..........................................................3 ............................ QL-2 mL(s) per 30 day(s)
NEULASTA SYR W/ INJ .......................................................3............................................... QL-2 per 30 day(s)
NEUMEGA VIAL ...................................................................3 ..............................................................
NEUPOGEN SYRINGE.........................................................3 ..............................................................
NEUPOGEN VIAL .................................................................3...............................................................
PRADAXA CAPSULE............................................................3 .......................... QL-60 unit(s) per 30 day(s)
PROCRIT VIAL .....................................................................3 ......................................................... PA
Strength: 2000/ML, 20000/2ML, 3000/ML, 4000/ML
PROCRIT VIAL .....................................................................3 ......................................................... PA
Strength: 20000/ML, 40000/ML
PROMACTA TABLET............................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
PROMACTA TABLET............................................................3 ..................... PA, QL-90 unit(s) per 30 day(s)
Strength: 25 MG
PROTAMINE SULFATE VIAL ...............................................3 ......................................................... PA
49
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Drug Name
Drug Tier
Requirements/Limits
BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS (continued)
ticlopidine hcl tablet............................................................... 1..............................................................
tranexamic acid vial............................................................... 1..............................................................
tranexamic acid tablet ........................................................... 1...............................................................
warfarin sodium tablet ........................................................... 1..............................................................
XARELTO TAB DS PK.......................................................... 2.......................... QL-51 unit(s) per 30 day(s)
XARELTO TABLET............................................................... 2 .......................... QL-30 unit(s) per 30 day(s)
XARELTO TABLET............................................................... 2 .......................... QL-60 unit(s) per 30 day(s)
Strength: 15 MG
ZARXIO SYRINGE................................................................ 3 ..............................................................
ZONTIVITY TABLET............................................................. 3..................... PA, QL-30 unit(s) per 30 day(s)
CARDIOVASCULAR AGENTS
acebutolol hcl capsule........................................................... 1..............................................................
acetazolamide sodium vial .................................................... 1 ..............................................................
ADVICOR TBMP 24HR......................................................... 3 .................. STEP, QL-30 unit(s) per 30 day(s)
afeditab cr tablet er ............................................................... 1..............................................................
ALDACTAZIDE TABLET....................................................... 3 ..............................................................
ALTOPREV TAB ER 24H ..................................................... 3 .................. STEP, QL-30 unit(s) per 30 day(s)
amiloride hcl tablet ................................................................ 1 ..............................................................
amiloride-hydrochlorothiazide tablet ..................................... 1..............................................................
amiodarone hcl syringe ......................................................... 1 ..............................................................
amiodarone hcl tablet............................................................ 1...............................................................
amiodarone hcl vial ............................................................... 1...............................................................
amlodipine besylate tablet..................................................... 1 ..............................................................
amlodipine besylate-benazepril capsule ............................... 1..............................................................
AMLODIPINE-ATORVASTATIN TABLET............................. 3 .......................... QL-30 unit(s) per 30 day(s)
amlodipine-valsartan tablet ................................................... 1 .......................... QL-30 unit(s) per 30 day(s)
amlodipine-valsartan-hctz tablet ........................................... 1 .......................... QL-30 unit(s) per 30 day(s)
AMTURNIDE TABLET .......................................................... 3.......................... QL-30 unit(s) per 30 day(s)
atenolol tablet........................................................................ 1 ..............................................................
atenolol-chlorthalidone tablet ................................................ 1 ..............................................................
atorvastatin calcium tablet..................................................... 1 ..............................................................
AZOR TABLET...................................................................... 2 .......................... QL-30 unit(s) per 30 day(s)
benazepril hcl tablet .............................................................. 1..............................................................
benazepril-hydrochlorothiazide tablet ................................... 1..............................................................
BENICAR TABLET................................................................ 2 ..............................................................
50
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Drug Name
Drug Tier
Requirements/Limits
CARDIOVASCULAR AGENTS (continued)
BENICAR HCT TABLET........................................................2 ..............................................................
betaxolol hcl tablet.................................................................1 ..............................................................
BIDIL TABLET .......................................................................3 ........................ QL-180 unit(s) per 30 day(s)
bisoprolol fumarate tablet ......................................................1 ..............................................................
bisoprolol-hydrochlorothiazide tablet .....................................1 ..............................................................
bumetanide tablet ..................................................................1 ..............................................................
bumetanide vial .....................................................................1...............................................................
BYSTOLIC TABLET ..............................................................2 .......................... QL-30 unit(s) per 30 day(s)
Strength: 10 MG, 2.5 MG, 5 MG
BYSTOLIC TABLET ..............................................................2 .......................... QL-60 unit(s) per 30 day(s)
Strength: 20 MG
BYVALSON TABLET ............................................................2 ........................ QL-120 unit(s) per 30 day(s)
candesartan cilexetil tablet ....................................................1 .......................... QL-30 unit(s) per 30 day(s)
candesartan-hydrochlorothiazid tablet...................................1 .......................... QL-30 unit(s) per 30 day(s)
captopril tablet .......................................................................1 ..............................................................
captopril-hydrochlorothiazide tablet.......................................1 ..............................................................
CARDENE I.V. PIGGYBACK ................................................3 ..............................................................
CARDENE SR CAPSULE ER ...............................................3 ..............................................................
CARDURA XL TAB ER 24 ....................................................3 ..............................................................
cartia xt cap er 24h ................................................................1 ..............................................................
carvedilol tablet .....................................................................1 ..............................................................
chlorothiazide tablet ..............................................................1 ..............................................................
chlorothiazide sodium vial .....................................................1 ..............................................................
chlorthalidone tablet ..............................................................1 ..............................................................
cholestyramine powd pack ....................................................1 ..............................................................
cholestyramine light powd pack.............................................1 ..............................................................
CLEVIPREX VIAL .................................................................3 ..............................................................
CLONIDINE PATCH TDWK ..................................................2 ............................ QL-8 unit(s) per 28 day(s)
clonidine hcl tablet .................................................................1 ..............................................................
CLORPRES TABLET ............................................................3 ..............................................................
colestipol hcl packet ..............................................................1 ..............................................................
colestipol hcl tablet ................................................................1...............................................................
COREG CR CPMP 24HR......................................................3 ................. STEP, QL-30 unit(s) per 30 day(s)
CORLANOR TABLET............................................................3 .......................... QL-60 unit(s) per 30 day(s)
CRESTOR TABLET ..............................................................2 .......................... QL-45 unit(s) per 30 day(s)
51
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Drug Name
Drug Tier
Requirements/Limits
CRESTOR TABLET .............................................................. 2.......................... QL-30 unit(s) per 30 day(s)
Strength: 40 MG
DEMSER CAPSULE ............................................................. 3 ..............................................................
DIBENZYLINE CAPSULE..................................................... 3 ..............................................................
digitek tablet .......................................................................... 1 ..............................................................
digoxin tablet ......................................................................... 1 ..............................................................
digoxin syringe ...................................................................... 1...............................................................
DIGOXIN SOLUTION............................................................ 3...............................................................
DILATRATE-SR CAPSULE ER ............................................ 3 ..............................................................
diltiazem 12hr er cap er 12h.................................................. 1 ..............................................................
diltiazem 24hr er cap er 24h.................................................. 1 ..............................................................
diltiazem er capsule er .......................................................... 1 ..............................................................
diltiazem er tab er 24h........................................................... 1...............................................................
diltiazem hcl tablet................................................................. 1 ..............................................................
diltiazem hcl vial .................................................................... 1...............................................................
diltiazem hcl vial port............................................................. 1...............................................................
dilt-xr cap er deg ................................................................... 1 ..............................................................
dofetilide capsule .................................................................. 1 ..............................................................
DYRENIUM CAPSULE ......................................................... 3 ..............................................................
EDARBI TABLET .................................................................. 3.................. STEP, QL-30 unit(s) per 30 day(s)
EDARBYCLOR TABLET....................................................... 3 .................. STEP, QL-30 unit(s) per 30 day(s)
EDECRIN TABLET ............................................................... 3 ..............................................................
enalapril maleate tablet ......................................................... 1 ..............................................................
enalapril-hydrochlorothiazide tablet ...................................... 1 ..............................................................
ENTRESTO TABLET ............................................................ 3.......................... QL-60 unit(s) per 30 day(s)
eplerenone tablet .................................................................. 1 ..............................................................
eprosartan mesylate tablet.................................................... 1 .......................... QL-30 unit(s) per 30 day(s)
ETHACRYNATE SODIUM VIAL ........................................... 3 ..............................................................
ETHACRYNIC ACID TABLET............................................... 2 ..............................................................
felodipine er tab er 24h ......................................................... 1 ..............................................................
fenofibrate capsule................................................................ 1.......................... QL-30 unit(s) per 30 day(s)
FENOFIBRATE TABLET ...................................................... 3.......................... QL-30 unit(s) per 30 day(s)
Strength: 120 MG
fenofibrate tablet ................................................................... 1 .......................... QL-30 unit(s) per 30 day(s)
Strength: 145mg, 160 mg, 48 mg, 54 mg
FENOFIBRATE TABLET ...................................................... 3.......................... QL-30 unit(s) per 30 day(s)
Strength: 40 MG
52
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Drug Name
Drug Tier
Requirements/Limits
fenofibric acid tablet ..............................................................1 .......................... QL-30 unit(s) per 30 day(s)
fenofibric acid capsule dr.......................................................1................................... QL-30 unit(s) per 30 day(s)
FENOGLIDE TABLET ...........................................................3 .......................... QL-30 unit(s) per 30 day(s)
flecainide acetate tablet.........................................................1 ..............................................................
fluvastatin er tab er 24h .........................................................1 .......................... QL-30 unit(s) per 30 day(s)
fluvastatin sodium capsule ....................................................1 .......................... QL-30 unit(s) per 30 day(s)
Strength: 20 mg
fluvastatin sodium capsule ....................................................1 .......................... QL-60 unit(s) per 30 day(s)
Strength: 40 mg
fosinopril sodium tablet..........................................................1 ..............................................................
fosinopril-hydrochlorothiazide tablet ......................................1 ..............................................................
furosemide solution ...............................................................1 ..............................................................
furosemide tablet ...................................................................1...............................................................
furosemide syringe ................................................................1...............................................................
furosemide vial ......................................................................1...............................................................
gemfibrozil tablet ...................................................................1 ..............................................................
guanfacine hcl tablet .............................................................1 ......................................................... PA
hydralazine hcl vial ................................................................1 ..............................................................
hydralazine hcl tablet.............................................................1...............................................................
hydrochlorothiazide tablet .....................................................1 ..............................................................
hydrochlorothiazide capsule ..................................................1...............................................................
indapamide tablet ..................................................................1 ..............................................................
irbesartan tablet.....................................................................1 .......................... QL-60 unit(s) per 30 day(s)
irbesartan tablet.....................................................................1 .......................... QL-30 unit(s) per 30 day(s)
Strength: 300 mg
irbesartan-hydrochlorothiazide tablet ....................................1 .......................... QL-30 unit(s) per 30 day(s)
isochron tablet er ...................................................................1 ..............................................................
isosorbide dinitrate tablet ......................................................1 ..............................................................
isosorbide dinitrate tablet er ..................................................1...............................................................
isosorbide mononitrate tablet ................................................1 ..............................................................
isosorbide mononitrate er tab er 24h.....................................1 ..............................................................
isradipine capsule..................................................................1 ..............................................................
JUXTAPID CAPSULE ...........................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
KYNAMRO SYRINGE ...........................................................3 ....................... PA, QL-4 mL(s) per 28 day(s)
labetalol hcl vial .....................................................................1 ..............................................................
labetalol hcl tablet..................................................................1...............................................................
LANOXIN TABLET ................................................................3 ..............................................................
LANOXIN AMPUL .................................................................3...............................................................
53
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Drug Name
Drug Tier
Requirements/Limits
LANOXIN PEDIATRIC AMPUL............................................. 3 ..............................................................
LESCOL XL TAB ER 24H ..................................................... 3 .................. STEP, QL-30 unit(s) per 30 day(s)
LEVATOL TABLET ............................................................... 3 ..............................................................
lidocaine hcl syringe.............................................................. 1..............................................................
Strength: 50 mg/5 ml
LIPTRUZET TABLET ............................................................ 3 .................. STEP, QL-30 unit(s) per 30 day(s)
lisinopril tablet ....................................................................... 1 ..............................................................
lisinopril-hydrochlorothiazide tablet ....................................... 1 ..............................................................
LIVALO TABLET ................................................................... 3 .................. STEP, QL-30 unit(s) per 30 day(s)
LOPRESSOR TABLET ......................................................... 3 ..............................................................
losartan potassium tablet ...................................................... 1 .......................... QL-30 unit(s) per 30 day(s)
Strength: 100 mg
losartan potassium tablet ...................................................... 1 .......................... QL-60 unit(s) per 30 day(s)
losartan-hydrochlorothiazide tablet ....................................... 1 .......................... QL-30 unit(s) per 30 day(s)
lovastatin tablet ..................................................................... 1 ..............................................................
matzim la tab er 24h.............................................................. 1..............................................................
methazolamide tablet ............................................................ 1..............................................................
methyclothiazide tablet.......................................................... 1 ..............................................................
methyldopa tablet.................................................................. 1.......................................................... PA
methyldopa-hydrochlorothiazide tablet ................................. 1.......................................................... PA
methyldopate hcl vial............................................................. 1..............................................................
metolazone tablet.................................................................. 1 ..............................................................
metoprolol succinate tab er 24h ............................................ 1 ..............................................................
metoprolol tartrate tablet ....................................................... 1 ..............................................................
metoprolol tartrate vial........................................................... 1...............................................................
metoprolol-hydrochlorothiazide tablet ................................... 1..............................................................
mexiletine hcl capsule ........................................................... 1..............................................................
midodrine hcl tablet ............................................................... 1..............................................................
minitran patch td24................................................................ 1 ..............................................................
minoxidil tablet ...................................................................... 1 ..............................................................
moexipril hcl tablet ................................................................ 1 ..............................................................
moexipril-hydrochlorothiazide tablet...................................... 1 ..............................................................
MULTAQ TABLET................................................................. 2.......................... QL-60 unit(s) per 30 day(s)
nadolol tablet......................................................................... 1 ..............................................................
nadolol-bendroflumethiazide tablet ....................................... 1 ..............................................................
niacin er tab er 24h ............................................................... 1.......................... QL-60 unit(s) per 30 day(s)
54
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Drug Name
Drug Tier
Requirements/Limits
niacin er tab er 24h................................................................1 .......................... QL-90 unit(s) per 30 day(s)
Strength: 500 mg
niacor tablet ...........................................................................1 ..............................................................
nicardipine hcl vial .................................................................1 ..............................................................
nicardipine hcl capsule ..........................................................1...............................................................
nifedical xl tab er 24 ..............................................................1 ..............................................................
nifedipine er tab er 24............................................................1 ..............................................................
nifedipine er tablet er .............................................................1...............................................................
nimodipine capsule................................................................1 ..............................................................
nisoldipine tab er 24h ............................................................1 ..............................................................
NITRO-BID OINT. .................................................................3 ..............................................................
NITRO-DUR PATCH TD24 ...................................................3 ..............................................................
nitroglycerin patch td24 .........................................................1 ..............................................................
nitroglycerin spray .................................................................1...............................................................
nitroglycerin tab subl .............................................................1...............................................................
nitroglycerin vial.....................................................................1...............................................................
NITROLINGUAL SPRAY.......................................................3 ..............................................................
NITROMIST SPRAY..............................................................3 ..............................................................
NITROSTAT TAB SUBL........................................................2 ..............................................................
NORTHERA CAPSULE.........................................................3 ................... PA, QL-180 unit(s) per 30 day(s)
omega-3 acid ethyl esters capsule ........................................1 ........................ QL-120 unit(s) per 30 day(s)
pacerone tablet......................................................................1 ..............................................................
pentoxifylline tablet er............................................................1 ..............................................................
perindopril erbumine tablet ....................................................1 ..............................................................
PHENOXYBENZAMINE HCL CAPSULE ..............................3 ..............................................................
pindolol tablet ........................................................................1 ..............................................................
PRALUENT PEN PEN INJCTR.............................................3 ....................... PA, QL-2 mL(s) per 28 day(s)
PRALUENT SYRINGE SYRINGE .........................................3 ....................... PA, QL-2 mL(s) per 28 day(s)
pravastatin sodium tablet ......................................................1 ..............................................................
prazosin hcl capsule ..............................................................1 ..............................................................
prevalite powd pack...............................................................1 ..............................................................
procainamide hcl vial .............................................................1 ..............................................................
propafenone hcl tablet ...........................................................1 ..............................................................
propafenone hcl er cap er 12h ..............................................1 ..............................................................
propranolol hcl tablet .............................................................1 ..............................................................
propranolol hcl solution .........................................................1...............................................................
propranolol hcl vial ................................................................1...............................................................
55
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Drug Name
Drug Tier
Requirements/Limits
propranolol-hydrochlorothiazid tablet .................................... 1..............................................................
quinapril hcl tablet ................................................................. 1 ..............................................................
quinapril-hydrochlorothiazide tablet ...................................... 1 ..............................................................
quinidine gluconate vial......................................................... 1 ..............................................................
QUINIDINE GLUCONATE TABLET ER................................ 2...............................................................
quinidine sulfate tablet er ...................................................... 1 ..............................................................
quinidine sulfate tablet .......................................................... 1...............................................................
ramipril capsule ..................................................................... 1 ..............................................................
RANEXA TAB ER 12H.......................................................... 2.......................... QL-60 unit(s) per 30 day(s)
Strength: 1000 MG
RANEXA TAB ER 12H.......................................................... 2......................... QL-120 unit(s) per 30 day(s)
Strength: 500 MG
REPATHA PUSHTRONEX WEAR INJCT ............................ 3 ............................... PA, QL-4 per 30 day(s)
REPATHA SURECLICK PEN INJCTR ................................. 3 ....................... PA, QL-3 mL(s) per 28 day(s)
REPATHA SYRINGE SYRINGE........................................... 3 ....................... PA, QL-3 mL(s) per 28 day(s)
reserpine tablet ..................................................................... 1 ..............................................................
rosuvastatin calcium tablet.................................................... 1 .......................... QL-45 unit(s) per 30 day(s)
rosuvastatin calcium tablet.................................................... 1 .......................... QL-30 unit(s) per 30 day(s)
Strength: 40 mg
SAMSCA TABLET ................................................................ 3 .......................................................... PA
SIMCOR TBMP 24HR........................................................... 3 .................. STEP, QL-60 unit(s) per 30 day(s)
simvastatin tablet .................................................................. 1 ..............................................................
SODIUM EDECRIN VIAL...................................................... 3 ..............................................................
sorine tablet........................................................................... 1 ..............................................................
sotalol tablet .......................................................................... 1 ..............................................................
SOTYLIZE SOLUTION ......................................................... 3 ..............................................................
spironolactone tablet ............................................................. 1..............................................................
spironolactone-hctz tablet ..................................................... 1 ..............................................................
taztia xt capsule er ................................................................ 1 ..............................................................
TEKAMLO TABLET .............................................................. 3.......................... QL-30 unit(s) per 30 day(s)
TEKTURNA TABLET ............................................................ 2.......................... QL-30 unit(s) per 30 day(s)
TEKTURNA HCT TABLET.................................................... 2.......................... QL-30 unit(s) per 30 day(s)
telmisartan tablet................................................................... 1 .......................... QL-30 unit(s) per 30 day(s)
telmisartan-amlodipine tablet ................................................ 1 .......................... QL-30 unit(s) per 30 day(s)
telmisartan-hydrochlorothiazid tablet .................................... 1.......................... QL-30 unit(s) per 30 day(s)
terazosin hcl capsule............................................................. 1..............................................................
56
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Drug Name
Drug Tier
Requirements/Limits
TEVETEN HCT TABLET .......................................................3 ................. STEP, QL-30 unit(s) per 30 day(s)
TIKOSYN CAPSULE .............................................................3 ..............................................................
torsemide vial ........................................................................1 ..............................................................
torsemide tablet .....................................................................1...............................................................
trandolapril tablet ...................................................................1 ..............................................................
trandolapril-verapamil er tab bp 24h......................................1 .......................... QL-30 unit(s) per 30 day(s)
triamterene-hydrochlorothiazid capsule.................................1 ..............................................................
triamterene-hydrochlorothiazid tablet ....................................1...............................................................
TRIBENZOR TABLET ...........................................................2 .......................... QL-30 unit(s) per 30 day(s)
TRIGLIDE TABLET ...............................................................3 .......................... QL-30 unit(s) per 30 day(s)
valsartan tablet ......................................................................1 .......................... QL-60 unit(s) per 30 day(s)
valsartan tablet ......................................................................1 .......................... QL-30 unit(s) per 30 day(s)
Strength: 320 mg
valsartan-hydrochlorothiazide tablet......................................1 .......................... QL-30 unit(s) per 30 day(s)
VASCEPA CAPSULE............................................................2 ........................ QL-120 unit(s) per 30 day(s)
VECAMYL TABLET...............................................................3 ..............................................................
verapamil er cap24h pel ........................................................1 ..............................................................
verapamil er tablet er.............................................................1...............................................................
verapamil er pm cap24h pct ..................................................1 ..............................................................
verapamil hcl vial ...................................................................1 ..............................................................
verapamil hcl cap24h pel.......................................................1...............................................................
verapamil hcl tablet ...............................................................1...............................................................
VYTORIN TABLET ................................................................3 ................. STEP, QL-30 unit(s) per 30 day(s)
WELCHOL POWD PACK......................................................3 ..............................................................
WELCHOL TABLET ..............................................................3...............................................................
ZETIA TABLET......................................................................2 .......................... QL-30 unit(s) per 30 day(s)
CENTRAL NERVOUS SYSTEM AGENTS
AMPYRA TAB ER 12H..........................................................3 ..................... PA, QL-60 unit(s) per 30 day(s)
AUBAGIO TABLET ...............................................................3 .......................... QL-30 unit(s) per 30 day(s)
AVONEX SYRINGEKIT.........................................................3 ............................ QL-4 unit(s) per 30 day(s)
AVONEX KIT .........................................................................3..................................... QL-4 unit(s) per 30 day(s)
AVONEX PEN PEN IJ KIT ....................................................3 ............................ QL-4 unit(s) per 30 day(s)
BETASERON KIT..................................................................3 ..................... PA, QL-14 unit(s) per 28 day(s)
CLONIDINE HCL ER TAB ER 12H .......................................2 ........................ QL-120 unit(s) per 30 day(s)
57
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Drug Name
Drug Tier
Requirements/Limits
CENTRAL NERVOUS SYSTEM AGENTS (continued)
COPAXONE SYRINGE......................................................... 3........................... QL-30 mL(s) per 30 day(s)
Strength: 20 MG/ML
COPAXONE SYRINGE......................................................... 3........................... QL-12 mL(s) per 28 day(s)
Strength: 40 MG/ML
DAYTRANA PATCH TD24.................................................... 3.......................... QL-30 unit(s) per 30 day(s)
DEXEDRINE TABLET........................................................... 3 ..............................................................
DEXMETHYLPHENIDATE HCL TABLET............................. 2..............................................................
DEXMETHYLPHENIDATE HCL ER CPBP 50-50 ................ 2 .......................... QL-60 unit(s) per 30 day(s)
DEXMETHYLPHENIDATE HCL ER CPBP 50-50 ................ 2 .......................... QL-30 unit(s) per 30 day(s)
DEXTROAMPHETAMINE SULFATE SOLUTION ................ 3 ..............................................................
DEXTROAMPHETAMINE SULFATE TABLET ..................... 3...............................................................
DEXTROAMPHETAMINE SULFATE ER CAPSULE ER...... 3 ..............................................................
DEXTROAMPHETAMINE-AMPHET ER CAP ER 24H......... 2 .......................... QL-90 unit(s) per 30 day(s)
Strength: 10 MG, 15 MG, 20 MG, 25 MG, 5 MG
DEXTROAMPHETAMINE-AMPHET ER CAP ER 24H......... 2 .......................... QL-60 unit(s) per 30 day(s)
Strength: 30 MG
DEXTROAMPHETAMINE-AMPHETAMINE TABLET........... 2 ..............................................................
EXTAVIA KIT ........................................................................ 3..................... PA, QL-15 unit(s) per 30 day(s)
GILENYA CAPSULE............................................................. 3.......................... QL-30 unit(s) per 30 day(s)
GUANFACINE HCL ER TAB ER 24H................................... 2 .......................... QL-60 unit(s) per 30 day(s)
GUANFACINE HCL ER TAB ER 24H................................... 2 .......................... QL-30 unit(s) per 30 day(s)
KAPVAY TAB ER 12H .......................................................... 3......................... QL-120 unit(s) per 30 day(s)
LEMTRADA VIAL.................................................................. 3 .......................................................... PA
LYRICA CAPSULE ............................................................... 2......................... QL-180 unit(s) per 30 day(s)
Strength: 100 MG
Strength: 150 MG
LYRICA CAPSULE ............................................................... 2.......................... QL-90 unit(s) per 30 day(s)
Strength: 25 MG
58
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Drug Name
Drug Tier
Requirements/Limits
LYRICA CAPSULE................................................................2 .......................... QL-60 unit(s) per 30 day(s)
Strength: 300 MG
LYRICA CAPSULE................................................................2 ........................ QL-360 unit(s) per 30 day(s)
Strength: 50 MG
LYRICA CAPSULE................................................................2 ........................ QL-240 unit(s) per 30 day(s)
Strength: 75 MG
metadate er tablet er .............................................................1 ..............................................................
methamphetamine hcl tablet .................................................1 ..............................................................
METHYLIN TAB CHEW ........................................................3 ..............................................................
METHYLPHENIDATE ER TABLET ER.................................2 ..............................................................
METHYLPHENIDATE ER TAB ER 24 ..................................2 .......................... QL-90 unit(s) per 30 day(s)
METHYLPHENIDATE ER TAB ER 24 ..................................2 .......................... QL-60 unit(s) per 30 day(s)
METHYLPHENIDATE HCL TABLET.....................................2 ..............................................................
methylphenidate hcl tab chew ...............................................1...............................................................
METHYLPHENIDATE HCL CD CPBP 30-70 ........................2 .......................... QL-90 unit(s) per 30 day(s)
Strength: 30 MG
NUEDEXTA CAPSULE .........................................................3 ..................... PA, QL-60 unit(s) per 30 day(s)
phentermine hcl capsule .......................................................1 *, QL-84 unit(s) per 365 day(s) (capped benefit)
phentermine hcl tablet ...........................................................1.. *, QL-84 unit(s) per 365 day(s) (capped benefit)
PLEGRIDY SYRINGE ...........................................................3 ............................ QL-1 mL(s) per 28 day(s)
PLEGRIDY PEN PEN INJCTR..............................................3 ............................ QL-1 mL(s) per 28 day(s)
REBIF SYRINGE...................................................................3 ........................... QL-12 mL(s) per 28 day(s)
REBIF REBIDOSE PEN INJCTR ..........................................3 ........................... QL-12 mL(s) per 28 day(s)
RILUTEK TABLET.................................................................3 ..............................................................
riluzole tablet .........................................................................1 ..............................................................
RITALIN LA CPBP 50-50 ......................................................3 ........................ QL-180 unit(s) per 30 day(s)
Strength: 10 MG
RITALIN LA CPBP 50-50 ......................................................3 .......................... QL-30 unit(s) per 30 day(s)
Strength: 60 MG
SAVELLA TAB DS PK...........................................................3 ...................................................... STEP
59
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Drug Name
Drug Tier
Requirements/Limits
SAVELLA TABLET................................................................ 3 .................. STEP, QL-60 unit(s) per 30 day(s)
STRATTERA CAPSULE ....................................................... 3.......................... QL-60 unit(s) per 30 day(s)
TECFIDERA CAPSULE DR.................................................. 3.......................... QL-60 unit(s) per 30 day(s)
TETRABENAZINE TABLET.................................................. 3 ................... PA, QL-240 unit(s) per 30 day(s)
Strength: 12.5 MG
TETRABENAZINE TABLET.................................................. 3 ................... PA, QL-120 unit(s) per 30 day(s)
Strength: 25 MG
TYSABRI VIAL ...................................................................... 3 .......................................................... PA
VYVANSE CAPSULE ........................................................... 3.......................... QL-30 unit(s) per 30 day(s)
XENAZINE TABLET.............................................................. 3 ................... PA, QL-240 unit(s) per 30 day(s)
Strength: 12.5 MG
XENAZINE TABLET.............................................................. 3 ................... PA, QL-120 unit(s) per 30 day(s)
Strength: 25 MG
DENTAL AND ORAL AGENTS
CEVIMELINE HCL CAPSULE .............................................. 2 ..............................................................
chlorhexidine gluconate mouthwash ..................................... 1..............................................................
KEPIVANCE VIAL................................................................. 3 ..............................................................
periogard mouthwash............................................................ 1..............................................................
PILOCARPINE HCL TABLET ............................................... 2 ..............................................................
triamcinolone acetonide paste ............................................. 1 ..............................................................
DERMATOLOGICAL AGENTS
8-MOP CAPSULE ................................................................. 3 ..............................................................
ABSORICA CAPSULE.......................................................... 3 ..............................................................
ACANYA GEL W/PUMP ....................................................... 3 ..............................................................
ACITRETIN CAPSULE ......................................................... 3 ..............................................................
ACZONE GEL ...................................................................... 3 .......................................................... PA
ACZONE GEL W/PUMP ....................................................... 3 .......................................................................... PA
ADAPALENE LOTION .......................................................... 3 .......................................................... PA
ADAPALENE CREAM .......................................................... 3 .......................................................................... PA
ADAPALENE GEL ............................................................... 3 .......................................................................... PA
ammonium lactate lotion ....................................................... 1 ..............................................................
ammonium lactate cream ..................................................... 1...............................................................
AMNESTEEM CAPSULE...................................................... 2 ..............................................................
60
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Drug Name
Drug Tier
Requirements/Limits
DERMATOLOGICAL AGENTS (continued)
ANACAINE OINT. .................................................................3 ..............................................................
ATRALIN GEL ......................................................................3 ......................................................... PA
AVITA GEL ...........................................................................3 ......................................................... PA
AVITA CREAM .....................................................................3...........................................................................PA
AZELEX CREAM ..................................................................3 ..............................................................
BENZAMYCIN GEL ..............................................................3 ..............................................................
CALCIPOTRIENE CREAM ...................................................2 ..............................................................
CALCIPOTRIENE OINT. ......................................................2...............................................................
CALCIPOTRIENE SOLUTION ..............................................2...............................................................
CALCIPOTRIENE-BETAMETHASONE DP OINT. ...............3 ..............................................................
calcitrene oint. ......................................................................1 ..............................................................
calcitriol oint. .........................................................................1 ..............................................................
CARAC CREAM ...................................................................3 ..............................................................
CLARAVIS CAPSULE ...........................................................2 ..............................................................
clindamycin phos-benzoyl perox gel .....................................1 ..............................................................
CLINDAMYCIN PHOS-TRETINOIN GEL .............................3 ..............................................................
clindamycin-benzoyl peroxide gel .........................................1 ..............................................................
CONDYLOX SOLUTION .......................................................3 ..............................................................
CONDYLOX GEL .................................................................3...............................................................
DICLOFENAC SODIUM GEL ...............................................3 ..............................................................
Strength: 3 %
DIFFERIN CREAM ...............................................................3 ......................................................... PA
DIFFERIN GEL .....................................................................3...........................................................................PA
DIFFERIN LOTION................................................................3...........................................................................PA
DOXEPIN HCL CREAM .......................................................3 ..............................................................
ELIDEL CREAM ...................................................................3 ....................... QL-100 gram(s) per 30 day(s)
ENSTILAR FOAM..................................................................3 ...................................................... STEP
EPIDUO GEL W/PUMP.........................................................3 ..............................................................
EPIDUO FORTE GEL W/PUMP............................................3 ..............................................................
erythromycin-benzoyl peroxide gel .......................................1 ..............................................................
FABIOR FOAM......................................................................3 ......................................................... PA
FINACEA FOAM....................................................................3 ..............................................................
FINACEA GEL ......................................................................3...............................................................
61
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Drug Name
Drug Tier
Requirements/Limits
FLUOROPLEX CREAM ....................................................... 3 ..............................................................
fluorouracil solution ............................................................... 1..............................................................
FLUOROURACIL CREAM ................................................... 3 ..............................................................
Strength: 0.5 %
fluorouracil cream ................................................................. 1 ..............................................................
Strength: 5 %
IMIQUIMOD CREAM PACK.................................................. 2 ..............................................................
METHOXSALEN CAPSULE ................................................. 3 ..............................................................
MYORISAN CAPSULE ......................................................... 2 ..............................................................
ONEXTON GEL W/PUMP .................................................... 3 ..............................................................
OXSORALEN LOTION ......................................................... 3 ..............................................................
OXSORALEN-ULTRA CAPSULE ......................................... 3 ..............................................................
PICATO GEL ........................................................................ 2 ..............................................................
podofilox solution .................................................................. 1 ..............................................................
PROTOPIC OINT. ................................................................ 3....................... QL-100 gram(s) per 30 day(s)
PRUDOXIN CREAM ............................................................ 3 ..............................................................
REGRANEX GEL ................................................................. 3 ..............................................................
RETIN-A GEL ....................................................................... 3 .......................................................... PA
RETIN-A CREAM ................................................................. 3 .......................................................................... PA
RETIN-A MICRO GEL W/PUMP........................................... 3 .......................................................... PA
RETIN-A MICRO GEL .......................................................... 3 .......................................................................... PA
SANTYL OINT. ..................................................................... 3 ..............................................................
selenium sulfide lotion........................................................... 1..............................................................
SORIATANE CAPSULE........................................................ 3 .......................... QL-60 unit(s) per 30 day(s)
SORILUX FOAM ................................................................... 3 ..............................................................
sulfacetamide sodium suspension ........................................ 1 ..............................................................
TACLONEX SUSPENSION .................................................. 3 ...................................................... STEP
TACLONEX OINT. ............................................................... 3 ...................................................................... STEP
tacrolimus oint. ..................................................................... 1 ....................... QL-100 gram(s) per 30 day(s)
TAZORAC CREAM .............................................................. 3 .......................................................... PA
TAZORAC GEL .................................................................... 3 .......................................................................... PA
TOLAK CREAM ................................................................... 3 ..............................................................
TRETINOIN GEL .................................................................. 2 .......................................................... PA
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Drug Name
Drug Tier
Requirements/Limits
TRETINOIN CREAM ............................................................2...........................................................................PA
TRETINOIN MICROSPHERE GEL ......................................3 ......................................................... PA
TRETIN-X CREAM ...............................................................3 ......................................................... PA
UVADEX VIAL .......................................................................3 ..............................................................
VEREGEN OINT. .................................................................3 ..............................................................
XERESE CREAM .................................................................3 ..............................................................
ZENATANE CAPSULE..........................................................2 ..............................................................
ZONALON CREAM ..............................................................3 ..............................................................
ZYCLARA CRM MD PMP .....................................................3 ..............................................................
ENZYME REPLACEMENTS/ MODIFIERS
ADAGEN VIAL ......................................................................3 ..............................................................
ALDURAZYME VIAL .............................................................3 ......................................................... PA
BUPHENYL POWDER ..........................................................3 ..............................................................
BUPHENYL TABLET.............................................................3...............................................................
CARBAGLU TAB DISPER ....................................................3 ......................................................... PA
CERDELGA CAPSULE .........................................................3 ..................... PA, QL-56 unit(s) per 28 day(s)
CEREZYME VIAL..................................................................3 ......................................................... PA
CREON CAPSULE DR..........................................................2 ..............................................................
CYSTADANE POWDER .......................................................3 ..............................................................
CYSTAGON CAPSULE.........................................................3 ..............................................................
ELAPRASE VIAL...................................................................3 ......................................................... PA
ELELYSO VIAL .....................................................................3 ......................................................... PA
FABRAZYME VIAL................................................................3 ......................................................... PA
KANUMA VIAL ......................................................................3 ......................................................... PA
KRYSTEXXA VIAL ................................................................3 ......................................................... PA
KUVAN TABLET SOL ...........................................................3 ......................................................... PA
KUVAN POWD PACK ...........................................................3...........................................................................PA
LUMIZYME VIAL ...................................................................3 ..............................................................
MYOZYME VIAL ...................................................................3 ......................................................... PA
NAGLAZYME VIAL ...............................................................3 ......................................................... PA
ORFADIN CAPSULE.............................................................3 ......................................................... PA
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Drug Name
Drug Tier
Requirements/Limits
ENZYME REPLACEMENTS/ MODIFIERS (continued)
ORFADIN ORAL SUSP ........................................................ 3 .......................................................................... PA
PANCREAZE CAPSULE DR ................................................ 2 ..............................................................
PROCYSBI CAP DR SPR..................................................... 3 .......................................................... PA
RAVICTI LIQUID ................................................................... 3 .......................................................... PA
SODIUM PHENYLBUTYRATE POWDER ............................ 3 ..............................................................
STRENSIQ VIAL ................................................................... 3................... PA, QL-10.8 mL(s) per 28 day(s)
Strength: 18MG/.45ML
Strength: 28MG/0.7ML
STRENSIQ VIAL ................................................................... 3 ...................... PA, QL-24 mL(s) per 28 day(s)
Strength: 40 MG/ML
SUCRAID SOLUTION........................................................... 3 ..............................................................
VIMIZIM VIAL........................................................................ 3 .......................................................... PA
VPRIV VIAL........................................................................... 3 .......................................................... PA
ZAVESCA CAPSULE............................................................ 3 .......................................................... PA
ZENPEP CAPSULE DR........................................................ 3 ..............................................................
GASTROINTESTINAL AGENTS
ALOSETRON HCL TABLET ................................................. 3.......................... QL-60 unit(s) per 30 day(s)
atropine sulfate syringe ......................................................... 1 ..............................................................
atropine sulfate vial ............................................................... 1...............................................................
BENTYL AMPUL................................................................... 3 ..............................................................
CANTIL TABLET................................................................... 3 ..............................................................
CARAFATE ORAL SUSP ..................................................... 3 ..............................................................
CARAFATE TABLET ............................................................ 3...............................................................
CHOLBAM CAPSULE........................................................... 3 .......................................................... PA
cimetidine tablet .................................................................... 1 ..............................................................
cimetidine solution................................................................. 1...............................................................
constulose solution................................................................ 1 ..............................................................
DEXILANT CAP DR BP ........................................................ 3 ..............................................................
dicyclomine hcl tablet ............................................................ 1..............................................................
DICYCLOMINE HCL SOLUTION.......................................... 2...............................................................
dicyclomine hcl capsule ........................................................ 1...............................................................
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Drug Name
Drug Tier
Requirements/Limits
GASTROINTESTINAL AGENTS (continued)
diphenoxylate-atropine tablet ................................................1 ..............................................................
diphenoxylate-atropine liquid.................................................1...............................................................
enulose solution ....................................................................1 ..............................................................
esomeprazole magnesium capsule dr...................................1 .......................... QL-60 unit(s) per 30 day(s)
esomeprazole sodium vial .....................................................1 ..............................................................
famotidine piggyback.............................................................1 ..............................................................
famotidine tablet ....................................................................1...............................................................
famotidine vial .......................................................................1...............................................................
GASTROCROM ORAL CONC ..............................................3 ..............................................................
GATTEX KIT .........................................................................3 ......................................................... PA
gavilyte-c soln recon..............................................................1 ..............................................................
gavilyte-g soln recon .............................................................1 ..............................................................
gavilyte-h and bisacodyl kit....................................................1 ..............................................................
gavilyte-n soln recon .............................................................1 ..............................................................
generlac solution ...................................................................1 ..............................................................
glycopyrrolate tablet ..............................................................1 ..............................................................
glycopyrrolate vial..................................................................1...............................................................
KRISTALOSE PACKET.........................................................3 ..............................................................
lactulose solution ...................................................................1 ..............................................................
lansoprazole capsule dr ........................................................1 .......................... QL-60 unit(s) per 30 day(s)
LINZESS CAPSULE..............................................................2 .......................... QL-30 unit(s) per 30 day(s)
loperamide capsule ...............................................................1 ..............................................................
LOTRONEX TABLET ............................................................3 .......................... QL-60 unit(s) per 30 day(s)
methscopolamine bromide tablet...........................................1 ..............................................................
misoprostol tablet ..................................................................1 ..............................................................
MOTOFEN TABLET ..............................................................3 ..............................................................
MOVANTIK TABLET .............................................................2 .......................... QL-30 unit(s) per 30 day(s)
MOVIPREP POWD PACK.....................................................3 ..............................................................
NEXIUM SUSPDR PKT.........................................................3 .......................... QL-60 unit(s) per 30 day(s)
NEXIUM I.V. VIAL .................................................................3 ..............................................................
nizatidine solution ..................................................................1 ..............................................................
nizatidine capsule ..................................................................1...............................................................
OCALIVA TABLET ................................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
omeprazole capsule dr ..........................................................1 .......................... QL-60 unit(s) per 30 day(s)
omeprazole capsule dr ..........................................................1 ........................ QL-120 unit(s) per 30 day(s)
Strength: 20 mg
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Drug Name
Drug Tier
Requirements/Limits
GASTROINTESTINAL AGENTS (continued)
OMEPRAZOLE-SODIUM BICARBONATE CAPSULE ......... 3 .......................... QL-60 unit(s) per 30 day(s)
OMEPRAZOLE-SODIUM BICARBONATE PACKET ........... 3 ...................................QL-60 unit(s) per 30 day(s)
OSMOPREP TABLET........................................................... 3 ..............................................................
pantoprazole sodium tablet dr............................................... 1 .......................... QL-60 unit(s) per 30 day(s)
peg 3350-electrolyte soln recon ............................................ 1 ..............................................................
Strength: 420g
peg-3350 and electrolytes soln recon ................................... 1..............................................................
polyethylene glycol 3350 powd pack..................................... 1..............................................................
polyethylene glycol 3350 powder .......................................... 1...............................................................
PRILOSEC SUSPDR PKT .................................................... 3 ..............................................................
PYLERA CAPSULE .............................................................. 2 ..............................................................
rabeprazole sodium tablet dr................................................. 1 .......................... QL-60 unit(s) per 30 day(s)
RANITIDINE HCL VIAL......................................................... 2 ..............................................................
ranitidine hcl tablet ................................................................ 1...............................................................
RANITIDINE HCL CAPSULE................................................ 2...............................................................
RANITIDINE HCL SYRUP .................................................... 2...............................................................
RELISTOR SYRINGE ........................................................... 3...................... PA, QL-30 mL(s) per 30 day(s)
RELISTOR VIAL ................................................................... 3 ............................. PA, QL-30 mL(s) per 30 day(s)
RELISTOR TABLET.............................................................. 3 ............................ PA, QL-90 unit(s) per 30 day(s)
sucralfate tablet..................................................................... 1 ..............................................................
SUPREP SOLN RECON....................................................... 3 ..............................................................
trilyte with flavor packets soln recon ..................................... 1..............................................................
ursodiol capsule .................................................................... 1 ..............................................................
ursodiol tablet........................................................................ 1...............................................................
VIBERZI TABLET.................................................................. 3 .......................... QL-60 unit(s) per 30 day(s)
GENITOURINARY AGENTS
alfuzosin hcl er tab er 24h ..................................................... 1 .......................... QL-60 unit(s) per 30 day(s)
AURYXIA TABLET................................................................ 3 ..............................................................
bethanechol chloride tablet ................................................... 1 ..............................................................
calcium acetate tablet ........................................................... 1..............................................................
calcium acetate capsule........................................................ 1...............................................................
CIALIS TABLET .................................................................... 3 .... *, QL-6 unit(s) per 30 day(s) (capped benefit)
CIALIS TABLET .................................................................... 3..................... PA, QL-30 unit(s) per 30 day(s)
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Drug Name
Drug Tier
Requirements/Limits
GENITOURINARY AGENTS (continued)
darifenacin er tab er 24h .......................................................1 .......................... QL-30 unit(s) per 30 day(s)
doxazosin mesylate tablet .....................................................1 ..............................................................
dutasteride capsule ...............................................................1 .......................... QL-30 unit(s) per 30 day(s)
dutasteride-tamsulosin cpmp 24hr ........................................1 .......................... QL-30 unit(s) per 30 day(s)
eliphos tablet .........................................................................1 ..............................................................
ELMIRON CAPSULE ............................................................3 ..............................................................
ENABLEX TAB ER 24H ........................................................3 ................. STEP, QL-30 unit(s) per 30 day(s)
finasteride tablet ....................................................................1 ..............................................................
Strength: 5 mg
flavoxate hcl tablet.................................................................1 ..............................................................
FOSRENOL TAB CHEW.......................................................3 ..............................................................
FOSRENOL POWD PACK....................................................3...............................................................
GELNIQUE GEL MD PMP ....................................................3 ....................... QL-276 gram(s) per 30 day(s)
GELNIQUE GEL PACKET ....................................................3.................................QL-30 gram(s) per 30 day(s)
LEVITRA TABLET .................................................................3 ... *, QL-6 unit(s) per 30 day(s) (capped benefit)
LITHOSTAT TABLET ............................................................3 ..............................................................
MYRBETRIQ TAB ER 24H....................................................2 .......................... QL-30 unit(s) per 30 day(s)
oxybutynin chloride syrup ......................................................1 ..............................................................
oxybutynin chloride tablet ......................................................1...............................................................
oxybutynin chloride er tab er 24 ............................................1 .......................... QL-60 unit(s) per 30 day(s)
oxybutynin chloride er tab er 24 ............................................1 .......................... QL-30 unit(s) per 30 day(s)
Strength: 5 mg
OXYTROL PATCH TDSW.....................................................3 ................... STEP, QL-8 unit(s) per 28 day(s)
PHOSLYRA SOLUTION........................................................3 ..............................................................
RAPAFLO CAPSULE ............................................................2 ..............................................................
RENVELA POWD PACK.......................................................2 ..............................................................
RENVELA TABLET ...............................................................2 ........................ QL-270 unit(s) per 30 day(s)
STAXYN TAB RAPDIS..........................................................3 ... *, QL-6 unit(s) per 30 day(s) (capped benefit)
STENDRA TABLET...............................................................3 ... *, QL-6 unit(s) per 30 day(s) (capped benefit)
tamsulosin hcl cap er 24h......................................................1 .......................... QL-60 unit(s) per 30 day(s)
THIOLA TABLET ...................................................................3 ..............................................................
tolterodine tartrate tablet .......................................................1 ..............................................................
tolterodine tartrate er cap er 24h ...........................................1 .......................... QL-30 unit(s) per 30 day(s)
TOVIAZ TAB ER 24H ............................................................3 ................. STEP, QL-30 unit(s) per 30 day(s)
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Drug Name
Drug Tier
Requirements/Limits
GENITOURINARY AGENTS (continued)
trospium chloride tablet ......................................................... 1 ..............................................................
trospium chloride er cap er 24h............................................. 1 .......................... QL-30 unit(s) per 30 day(s)
VESICARE TABLET ............................................................. 2.......................... QL-30 unit(s) per 30 day(s)
VIAGRA TABLET .................................................................. 3 .... *, QL-6 unit(s) per 30 day(s) (capped benefit)
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)
a-hydrocort vial...................................................................... 1 ......................................................... BD
ala-cort cream ...................................................................... 1 ..............................................................
ALA-SCALP LOTION ............................................................ 3 ...................................................... STEP
alclometasone dipropionate oint. ......................................... 1 ..............................................................
alclometasone dipropionate cream ...................................... 1...............................................................
AMCINONIDE LOTION......................................................... 2 ..............................................................
AMCINONIDE OINT. ............................................................ 2...............................................................
AMCINONIDE CREAM ........................................................ 2...............................................................
a-methapred vial ................................................................... 1......................................................... BD
APEXICON E CREAM ......................................................... 2 ..............................................................
ARISTOSPAN VIAL .............................................................. 3 ......................................................... BD
betamethasone dipropionate oint. ........................................ 1 ..............................................................
betamethasone dipropionate cream ..................................... 1...............................................................
betamethasone dipropionate lotion ....................................... 1...............................................................
betamethasone dipropionate gel .......................................... 1...............................................................
betamethasone valerate cream ............................................ 1 ..............................................................
BETAMETHASONE VALERATE FOAM............................... 2...............................................................
betamethasone valerate lotion .............................................. 1...............................................................
betamethasone valerate oint. ............................................... 1...............................................................
CAPEX SHAMPOO............................................................... 3 ...................................................... STEP
CELESTONE VIAL................................................................ 3 ..............................................................
clobetasol propionate solution............................................... 1 ..............................................................
clobetasol propionate oint. ................................................... 1...............................................................
clobetasol propionate lotion .................................................. 1...............................................................
clobetasol propionate cream ................................................ 1...............................................................
clobetasol propionate shampoo ............................................ 1...............................................................
clobetasol propionate gel ..................................................... 1...............................................................
clobetasol propionate foam ................................................... 1...............................................................
clobetasol propionate spray .................................................. 1...............................................................
CLOBEX SPRAY .................................................................. 3 ...................................................... STEP
clocortolone pivalate cream ................................................. 1 ..............................................................
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Drug Name
Drug Tier
Requirements/Limits
(continued)
CORDRAN MED. TAPE ........................................................3 ...................................................... STEP
CORDRAN LOTION ..............................................................3.......................................................................STEP
CORDRAN CREAM .............................................................3.......................................................................STEP
CORDRAN OINT. .................................................................3.......................................................................STEP
CORTIFOAM FOAM/APPL ...................................................3 ..............................................................
cortisone acetate tablet .........................................................1 ......................................................... BD
deltasone tablet .....................................................................1 ......................................................... BD
DEPO-MEDROL VIAL ...........................................................3 ......................................................... BD
DESONATE GEL .................................................................3 ...................................................... STEP
DESONIDE CREAM .............................................................2 ..............................................................
DESONIDE LOTION .............................................................2...............................................................
DESONIDE OINT. ................................................................2...............................................................
DESOXIMETASONE CREAM ..............................................2 ..............................................................
DESOXIMETASONE GEL ....................................................2...............................................................
DESOXIMETASONE OINT. .................................................2...............................................................
dexamethasone elixir ............................................................1 ......................................................... BD
dexamethasone tablet ...........................................................1.......................................................................... BD
dexamethasone intensol drops .............................................1 ..............................................................
dexamethasone sodium phosphate vial ................................1 ......................................................... BD
diflorasone diacetate oint. ....................................................1 ..............................................................
diflorasone diacetate cream .................................................1...............................................................
fludrocortisone acetate tablet ................................................1 ..............................................................
fluocinolone acetonide oint. ..................................................1 ..............................................................
fluocinolone acetonide cream ...............................................1...............................................................
fluocinolone acetonide solution .............................................1...............................................................
fluocinolone acetonide oil ......................................................1...............................................................
fluocinonide oint. ..................................................................1 ..............................................................
fluocinonide solution ..............................................................1...............................................................
fluocinonide gel ....................................................................1...............................................................
fluocinonide cream ...............................................................1 ..............................................................
Strength: 0.05 %
FLUOCINONIDE CREAM ....................................................2 ..............................................................
Strength: 0.1 %
FLURANDRENOLIDE CREAM ............................................2 ..............................................................
FLURANDRENOLIDE LOTION.............................................2...............................................................
69
going to page V.
Drug Name
Drug Tier
Requirements/Limits
(continued)
fluticasone propionate cream ............................................... 1 ..............................................................
fluticasone propionate oint. .................................................. 1...............................................................
FLUTICASONE PROPIONATE LOTION .............................. 2...............................................................
H.P. ACTHAR VIAL............................................................... 3 .......................................................... PA
halobetasol propionate oint. ................................................. 1 ..............................................................
halobetasol propionate cream .............................................. 1...............................................................
HALOG OINT. ...................................................................... 3 ...................................................... STEP
HALOG CREAM ................................................................... 3 ...................................................................... STEP
hydrocortisone cream ........................................................... 1..............................................................
hydrocortisone lotion ............................................................. 1...............................................................
hydrocortisone tablet............................................................. 1 .......................................................................... BD
hydrocortisone oint. .............................................................. 1...............................................................
hydrocortisone butyrate solution ........................................... 1 ..............................................................
hydrocortisone butyrate cream ............................................. 1...............................................................
hydrocortisone butyrate oint. ................................................ 1...............................................................
hydrocortisone valerate oint. ................................................ 1 ..............................................................
hydrocortisone valerate cream ............................................. 1...............................................................
KENALOG AEROSOL .......................................................... 3 ...................................................... STEP
KENALOG-10 VIAL............................................................... 3 ......................................................... BD
KENALOG-40 VIAL............................................................... 3 ......................................................... BD
LOCOID SOLUTION ............................................................. 3 ...................................................... STEP
LOCOID LOTION .................................................................. 3 ...................................................................... STEP
LOCOID OINT. ..................................................................... 3 ...................................................................... STEP
LOCOID LIPOCREAM CREAM ........................................... 3 ...................................................... STEP
MEDROL TABLET ................................................................ 3 ......................................................... BD
methylprednisolone tab ds pk ............................................... 1 ......................................................... BD
methylprednisolone tablet ..................................................... 1 ......................................................... BD
methylprednisolone acetate vial............................................ 1 ......................................................... BD
methylprednisolone sod succ vial ......................................... 1 ......................................................... BD
mometasone furoate cream ................................................. 1 ..............................................................
mometasone furoate oint. .................................................... 1...............................................................
mometasone furoate solution................................................ 1...............................................................
NUCORT LOTION ................................................................ 3 ..............................................................
ORAPRED ODT TAB RAPDIS ............................................. 3 ..............................................................
70
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Drug Name
Drug Tier
Requirements/Limits
(continued)
PANDEL CREAM .................................................................3 ...................................................... STEP
PRAMOSONE LOTION.........................................................2 ..............................................................
prednicarbate oint. ................................................................1 ..............................................................
prednicarbate cream ............................................................1...............................................................
prednisolone sodium phos odt tab rapdis..............................1 ..............................................................
prednisolone sodium phosphate solution ..............................1 ......................................................... BD
prednisone solution ...............................................................1 ......................................................... BD
prednisone tab ds pk .............................................................1...............................................................
prednisone tablet ...................................................................1.......................................................................... BD
prednisone intensol oral conc................................................1 ......................................................... BD
PROCTOFOAM-HC FOAM ...................................................3 ..............................................................
procto-med hc cream/appl.....................................................1 ..............................................................
procto-pak cream .................................................................1 ..............................................................
proctosol-hc cream/appl ........................................................1 ..............................................................
proctozone-hc cream/appl .....................................................1 ..............................................................
SERNIVO SPRAY/PUMP......................................................3 ...................................................... STEP
SOLU-CORTEF VIAL ............................................................3 ......................................................... BD
SOLU-MEDROL VIAL ...........................................................3 ......................................................... BD
TOPICORT SPRAY...............................................................3 ...................................................... STEP
TRIAMCINOLONE ACETONIDE AEROSOL ........................2 ..............................................................
triamcinolone acetonide cream .............................................1...............................................................
triamcinolone acetonide lotion ...............................................1...............................................................
triamcinolone acetonide oint. ................................................1...............................................................
triamcinolone acetonide vial ..................................................1.......................................................................... BD
trianex oint. ...........................................................................1 ..............................................................
triderm cream .......................................................................1 ..............................................................
u-cort cream .........................................................................1 ..............................................................
VERDESO FOAM..................................................................3 ...................................................... STEP
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)
CHORIONIC GONADOTROPIN VIAL...................................3 ..............................................................
DDAVP AMPUL.....................................................................3 ..............................................................
desmopressin acetate spray/pump........................................1 ..............................................................
desmopressin acetate tablet .................................................1...............................................................
desmopressin acetate vial .....................................................1...............................................................
desmopressin acetate solution ..............................................1...............................................................
71
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Drug Name
Drug Tier
Requirements/Limits
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)
(continued)
EGRIFTA VIAL...................................................................... 3 .......................................................... PA
GENOTROPIN CARTRIDGE................................................ 3 .......................................................... PA
GENOTROPIN SYRINGE..................................................... 2 .......................................................... PA
Strength: 0.2MG/0.25
GENOTROPIN SYRINGE..................................................... 3 .......................................................... PA
Strength: 0.4MG/0.25, 0.6MG/0.25, 0.8MG/0.25, 1.2MG/0.25, 1.4MG/0.25, 1.6MG/0.25, 1.8MG/
0.25, 1MG/0.25ML, 2MG/0.25ML
HUMATROPE CARTRIDGE ................................................. 3 .......................................................... PA
HUMATROPE VIAL .............................................................. 3 .......................................................................... PA
INCRELEX VIAL ................................................................... 3 .......................................................... PA
NORDITROPIN FLEXPRO PEN INJCTR ............................. 3.......................................................... PA
novarel vial ............................................................................ 1 ..............................................................
NUTROPIN AQ CARTRIDGE ............................................... 3 .......................................................... PA
NUTROPIN AQ NUSPIN PEN INJCTR ................................ 3.......................................................... PA
OMNITROPE VIAL................................................................ 3 .......................................................... PA
OMNITROPE CARTRIDGE .................................................. 3 .......................................................................... PA
pregnyl vial ............................................................................ 1 ..............................................................
SAIZEN CARTRIDGE ........................................................... 3 .......................................................... PA
SAIZEN VIAL ........................................................................ 3 .......................................................................... PA
SEROSTIM VIAL................................................................... 3 .......................................................... PA
STIMATE SPRAY/PUMP ...................................................... 3 ..............................................................
TEV-TROPIN VIAL................................................................ 3 .......................................................... PA
ZOMACTON VIAL................................................................. 3 .......................................................... PA
ZORBTIVE VIAL ................................................................... 3 .......................................................... PA
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/
MODIFIERS)
ALORA PATCH TDSW ......................................................... 3 ............................ QL-8 unit(s) per 28 day(s)
altavera tablet........................................................................ 1 ..............................................................
alyacen tablet ........................................................................ 1 ..............................................................
amabelz tablet....................................................................... 1 ..............................................................
amethia tbdspk 3mo.............................................................. 1..............................................................
amethia lo tbdspk 3mo .......................................................... 1 ..............................................................
amethyst tablet...................................................................... 1 ..............................................................
72
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Drug Name
Drug Tier
Requirements/Limits
MODIFIERS) (continued)
ANADROL-50 TABLET .........................................................3 ..............................................................
ANDRODERM PATCH TD24 ................................................2 ..................... PA, QL-30 unit(s) per 30 day(s)
ANDROGEL GEL MD PMP...................................................2 .................. PA, QL-300 gram(s) per 30 day(s)
Strength: 1.25 G(1%)
ANDROGEL GEL PACKET...................................................2 ................... PA, QL-38 gram(s) per 30 day(s)
Strength: 1.25G-1.62
ANDROGEL GEL PACKET...................................................2 .................. PA, QL-150 gram(s) per 30 day(s)
Strength: 2.5G-1.62%
ANDROGEL GEL MD PMP...................................................2 .................. PA, QL-150 gram(s) per 30 day(s)
Strength: 20.25/1.25
ANDROGEL GEL PACKET...................................................2 ................... PA, QL-75 gram(s) per 30 day(s)
Strength: 25MG(1%)
ANDROGEL GEL PACKET...................................................2 .................. PA, QL-300 gram(s) per 30 day(s)
Strength: 50 MG (1%)
ANDROID CAPSULE ............................................................3 ..............................................................
androxy tablet ........................................................................1 ..............................................................
ANGELIQ TABLET ................................................................3 ..............................................................
apri tablet...............................................................................1 ..............................................................
aranelle tablet ........................................................................1 ..............................................................
ashlyna tbdspk 3mo ..............................................................1 ..............................................................
aubra tablet ...........................................................................1 ..............................................................
aviane tablet ..........................................................................1 ..............................................................
AXIRON SOL MD PMP .........................................................3 .................... PA, QL-180 mL(s) per 30 day(s)
azurette tablet........................................................................1 ..............................................................
balziva tablet .........................................................................1 ..............................................................
bekyree tablet ........................................................................1 ..............................................................
BEYAZ TABLET ....................................................................3 ..............................................................
blisovi 24 fe tablet..................................................................1 ..............................................................
blisovi fe tablet.......................................................................1 ..............................................................
briellyn tablet .........................................................................1 ..............................................................
camila tablet ..........................................................................1 ..............................................................
camrese tbdspk 3mo .............................................................1 ..............................................................
camrese lo tbdspk 3mo .........................................................1 ..............................................................
chateal tablet .........................................................................1 ..............................................................
CLIMARA PATCH TDWK......................................................3 ............................ QL-4 unit(s) per 28 day(s)
CLIMARA PRO PATCH TDWK .............................................3 ............................ QL-4 unit(s) per 28 day(s)
73
going to page V.
Drug Name
Drug Tier
Requirements/Limits
COMBIPATCH PATCH TDSW ............................................. 3 ............................ QL-8 unit(s) per 28 day(s)
cryselle tablet ........................................................................ 1 ..............................................................
cyclafem tablet ...................................................................... 1 ..............................................................
cyred tablet............................................................................ 1 ..............................................................
danazol capsule .................................................................... 1 ..............................................................
dasetta tablet......................................................................... 1 ..............................................................
daysee tbdspk 3mo ............................................................... 1..............................................................
deblitane tablet...................................................................... 1 ..............................................................
DELESTROGEN VIAL .......................................................... 3 ..............................................................
delyla tablet ........................................................................... 1 ..............................................................
DEPO-ESTRADIOL VIAL...................................................... 3 ..............................................................
DEPO-SUBQ PROVERA 104 SYRINGE.............................. 3 ..............................................................
desogestrel-ethinyl estradiol tablet........................................ 1 ..............................................................
desogestr-eth estrad eth estra tablet .................................... 1..............................................................
DIVIGEL GEL PACKET ........................................................ 3 ..............................................................
drospirenone-ethinyl estradiol tablet ..................................... 1..............................................................
DUAVEE TABLET................................................................. 3 ..............................................................
ELESTRIN GEL MD PMP ..................................................... 3 ..............................................................
elinest tablet .......................................................................... 1 ..............................................................
ELLA TABLET....................................................................... 2 ..............................................................
emoquette tablet ................................................................... 1 ..............................................................
ENJUVIA TABLET ................................................................ 3 ..............................................................
enpresse tablet...................................................................... 1 ..............................................................
enskyce tablet ....................................................................... 1 ..............................................................
errin tablet ............................................................................. 1 ..............................................................
estarylla tablet ....................................................................... 1 ..............................................................
ESTRACE CREAM/APPL ..................................................... 3 ..............................................................
estradiol tablet....................................................................... 1 ..............................................................
estradiol patch tdsw .............................................................. 1............................ QL-8 unit(s) per 28 day(s)
estradiol patch tdwk .............................................................. 1 .....................................QL-4 unit(s) per 28 day(s)
estradiol valerate vial ............................................................ 1..............................................................
estradiol-norethindrone acetat tablet..................................... 1..............................................................
ESTRING VAG RING............................................................ 3............................ QL-1 unit(s) per 90 day(s)
ESTROGEL GEL MD PMP ................................................... 3 ..............................................................
estropipate tablet................................................................... 1 ..............................................................
EVAMIST SPRAY ................................................................. 3 ..............................................................
74
going to page V.
Drug Name
Drug Tier
Requirements/Limits
falmina tablet .........................................................................1 ..............................................................
FEMHRT TABLET .................................................................3 ..............................................................
FEMRING VAG RING ...........................................................3 ............................ QL-1 unit(s) per 90 day(s)
FORTESTA GEL MD PMP....................................................3 .................. PA, QL-120 gram(s) per 30 day(s)
fyavolv tablet .........................................................................1 ..............................................................
GENERESS FE TAB CHEW .................................................3 ..............................................................
gianvi tablet ...........................................................................1 ..............................................................
gildagia tablet ........................................................................1 ..............................................................
gildess tablet .........................................................................1 ..............................................................
gildess 24 fe tablet ................................................................1 ..............................................................
gildess fe tablet .....................................................................1 ..............................................................
heather tablet ........................................................................1 ..............................................................
HYDROXYPROGESTERONE CAPROATE VIAL.................3 ..............................................................
introvale tbdspk 3mo .............................................................1 ..............................................................
jencycla tablet........................................................................1 ..............................................................
jinteli tablet ............................................................................1 ..............................................................
jolessa tbdspk 3mo................................................................1 ..............................................................
jolivette tablet ........................................................................1 ..............................................................
juleber tablet ..........................................................................1 ..............................................................
junel tablet .............................................................................1 ..............................................................
junel fe tablet .........................................................................1 ..............................................................
junel fe 24 tablet ....................................................................1 ..............................................................
kaitlib fe tab chew ..................................................................1 ..............................................................
kariva tablet ...........................................................................1 ..............................................................
kelnor 1-35 tablet...................................................................1 ..............................................................
kimidess tablet.......................................................................1 ..............................................................
kurvelo tablet .........................................................................1 ..............................................................
larin tablet ..............................................................................1 ..............................................................
larin 24 fe tablet .....................................................................1 ..............................................................
larin fe tablet ..........................................................................1 ..............................................................
larissia tablet .........................................................................1 ..............................................................
leena tablet ............................................................................1 ..............................................................
lessina tablet .........................................................................1 ..............................................................
levonest tablet .......................................................................1 ..............................................................
levonorgestrel tablet ..............................................................1 ..............................................................
levonorgestrel-eth estradiol tablet .........................................1 ..............................................................
levonorg-eth estrad eth estrad tbdspk 3mo ...........................1 ..............................................................
75
going to page V.
Drug Name
Drug Tier
Requirements/Limits
levora-28 tablet ..................................................................... 1 ..............................................................
LO LOESTRIN FE TABLET .................................................. 3 ..............................................................
lomedia 24 fe tablet............................................................... 1..............................................................
LOPREEZA TABLET ............................................................ 3 ..............................................................
loryna tablet........................................................................... 1 ..............................................................
low-ogestrel tablet ................................................................. 1 ..............................................................
lutera tablet ........................................................................... 1 ..............................................................
marlissa tablet ....................................................................... 1 ..............................................................
medroxyprogesterone acetate tablet..................................... 1..............................................................
medroxyprogesterone acetate vial ........................................ 1...............................................................
medroxyprogesterone acetate syringe.................................. 1...............................................................
MEGACE ES ORAL SUSP ................................................... 3 ..............................................................
megestrol acetate tablet........................................................ 1 ..............................................................
megestrol acetate oral susp .................................................. 1 ..............................................................
Strength: 400mg/10ml
MEGESTROL ACETATE ORAL SUSP ................................ 2..............................................................
Strength: 625MG/5ML
MENEST TABLET................................................................. 3 ..............................................................
METHITEST TABLET ........................................................... 3 ..............................................................
METHYLTESTOSTERONE CAPSULE ................................ 2..............................................................
microgestin tablet .................................................................. 1 ..............................................................
microgestin fe tablet .............................................................. 1..............................................................
mimvey lo tablet .................................................................... 1 ..............................................................
MINASTRIN 24 FE TAB CHEW............................................ 3 ..............................................................
mono-linyah tablet................................................................. 1 ..............................................................
mononessa tablet.................................................................. 1 ..............................................................
myzilra tablet ......................................................................... 1 ..............................................................
NATAZIA TABLET ................................................................ 3 ..............................................................
NATESTO GEL MD PMP...................................................... 3 ................... PA, QL-33 gram(s) per 30 day(s)
necon tablet........................................................................... 1 ..............................................................
nikki tablet ............................................................................. 1 ..............................................................
nora-be tablet ........................................................................ 1 ..............................................................
norethindrone tablet .............................................................. 1..............................................................
norethindrone acetate tablet ................................................. 1 ..............................................................
norethindron-ethinyl estradiol tablet ...................................... 1 ..............................................................
norethin-eth estra-ferrous fum tablet..................................... 1..............................................................
76
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Drug Name
Drug Tier
Requirements/Limits
norethin-eth estra-ferrous fum tab chew................................1...............................................................
norgestimate-ethinyl estradiol tablet......................................1 ..............................................................
NORINYL 1+35 TABLET.......................................................3 ..............................................................
NORINYL 1+50 TABLET.......................................................3 ..............................................................
norlyroc tablet ........................................................................1 ..............................................................
nortrel tablet ..........................................................................1 ..............................................................
NUVARING VAG RING .........................................................3 ..............................................................
ocella tablet ...........................................................................1 ..............................................................
ogestrel tablet ........................................................................1 ..............................................................
orsythia tablet ........................................................................1 ..............................................................
ORTHO TRI-CYCLEN LO TABLET.......................................3 ..............................................................
OXANDRIN TABLET .............................................................3 ..............................................................
OXANDROLONE TABLET ....................................................3 ..............................................................
Strength: 10 MG
OXANDROLONE TABLET ....................................................2 ..............................................................
Strength: 2.5 MG
philith tablet ...........................................................................1 ..............................................................
pimtrea tablet.........................................................................1 ..............................................................
pirmella tablet ........................................................................1 ..............................................................
portia tablet............................................................................1 ..............................................................
PREFEST TABLET ...............................................................3 ..............................................................
PREMARIN CREAM/APPL ...................................................2 ..............................................................
PREMARIN VIAL...................................................................2...............................................................
PREMARIN TABLET .............................................................2...............................................................
PREMPHASE TABLET .........................................................2 ..............................................................
PREMPRO TABLET..............................................................2 ..............................................................
previfem tablet .......................................................................1 ..............................................................
progesterone capsule ............................................................1 ..............................................................
QUARTETTE TBDSPK 3MO.................................................3 ..............................................................
quasense tbdspk 3mo ...........................................................1 ..............................................................
RALOXIFENE HCL TABLET .................................................2 .......................... QL-30 unit(s) per 30 day(s)
reclipsen tablet ......................................................................1 ..............................................................
SAFYRAL TABLET ...............................................................3 ..............................................................
setlakin tbdspk 3mo...............................................................1 ..............................................................
sharobel tablet .......................................................................1 ..............................................................
77
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Drug Name
Drug Tier
Requirements/Limits
sprintec tablet........................................................................ 1 ..............................................................
sronyx tablet.......................................................................... 1 ..............................................................
STRIANT MUC ER 12H ........................................................ 3 ..................... PA, QL-60 unit(s) per 30 day(s)
SYEDA TABLET ................................................................... 3 ..............................................................
tarina fe tablet ....................................................................... 1 ..............................................................
TAYTULLA CAPSULE .......................................................... 3 ..............................................................
TESTIM GEL ........................................................................ 3 .................. PA, QL-300 gram(s) per 30 day(s)
TESTOSTERONE GEL PACKET ......................................... 3 ................... PA, QL-75 gram(s) per 30 day(s)
TESTOSTERONE GEL ........................................................ 3 ........................ PA, QL-300 gram(s) per 30 day(s)
TESTOSTERONE GEL MD PMP ......................................... 3 .................. PA, QL-300 gram(s) per 30 day(s)
Strength: 1.25 G(1%)
TESTOSTERONE GEL MD PMP ......................................... 3 .................. PA, QL-120 gram(s) per 30 day(s)
Strength: 10 MG (2%)
testosterone cypionate vial.................................................... 1 ..............................................................
testosterone enanthate vial ................................................... 1 ..............................................................
TESTRED CAPSULE............................................................ 3 ..............................................................
tilia fe tablet ........................................................................... 1 ..............................................................
tri-estarylla tablet................................................................... 1 ..............................................................
tri-legest fe tablet................................................................... 1 ..............................................................
tri-linyah tablet....................................................................... 1 ..............................................................
tri-lo-estarylla tablet............................................................... 1..............................................................
tri-lo-marzia tablet ................................................................. 1 ..............................................................
tri-lo-sprintec tablet................................................................ 1 ..............................................................
trinessa tablet........................................................................ 1 ..............................................................
tri-previfem tablet .................................................................. 1 ..............................................................
tri-sprintec tablet.................................................................... 1 ..............................................................
trivora-28 tablet ..................................................................... 1 ..............................................................
VAGIFEM TABLET ............................................................... 3 ..............................................................
velivet tablet .......................................................................... 1 ..............................................................
vestura tablet......................................................................... 1 ..............................................................
vienva tablet .......................................................................... 1 ..............................................................
viorele tablet.......................................................................... 1 ..............................................................
VIVELLE-DOT PATCH TDSW .............................................. 3............................ QL-8 unit(s) per 28 day(s)
VOGELXO GEL MD PMP ..................................................... 3 .................. PA, QL-300 gram(s) per 30 day(s)
VOGELXO GEL ................................................................... 3 ........................ PA, QL-300 gram(s) per 30 day(s)
vyfemla tablet ........................................................................ 1 ..............................................................
78
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Drug Name
Drug Tier
Requirements/Limits
wera tablet .............................................................................1 ..............................................................
wymzya fe tab chew ..............................................................1 ..............................................................
zarah tablet............................................................................1 ..............................................................
zenchent tablet ......................................................................1 ..............................................................
zenchent fe tab chew ............................................................1 ..............................................................
zeosa tab chew .....................................................................1 ..............................................................
zovia 1-35e tablet ..................................................................1 ..............................................................
zovia 1-50e tablet ..................................................................1 ..............................................................
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID)
CYTOMEL TABLET...............................................................3 ..............................................................
levothyroxine sodium tablet ...................................................1 ..............................................................
levothyroxine sodium vial ......................................................1...............................................................
levoxyl tablet..........................................................................1 ..............................................................
liothyronine sodium tablet......................................................1 ..............................................................
liothyronine sodium vial .........................................................1...............................................................
SYNTHROID TABLET...........................................................2 ..............................................................
THYROLAR-1 TABLET .........................................................3 ..............................................................
THYROLAR-1/2 TABLET ......................................................3 ..............................................................
THYROLAR-1/4 TABLET ......................................................3 ..............................................................
THYROLAR-2 TABLET .........................................................3 ..............................................................
THYROLAR-3 TABLET .........................................................3 ..............................................................
unithroid tablet .......................................................................1 ..............................................................
HORMONAL AGENTS, SUPPRESSANT (ADRENAL)
LYSODREN TABLET ............................................................2 ..............................................................
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
SENSIPAR TABLET..............................................................2 ..............................................................
Strength: 30 MG
SENSIPAR TABLET..............................................................3 ..............................................................
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
bromocriptine mesylate capsule ............................................1 ..............................................................
bromocriptine mesylate tablet................................................1...............................................................
cabergoline tablet ..................................................................1 ..............................................................
79
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Drug Name
Drug Tier
Requirements/Limits
HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (continued)
ELIGARD SYRINGE ............................................................. 3 .......................................................... PA
leuprolide acetate kit ............................................................. 1.......................................................... PA
LUPRON DEPOT SYRINGEKIT ........................................... 3 .......................................................... PA
LUPRON DEPOT-PED KIT................................................... 3 .......................................................... PA
LUPRON DEPOT-PED SYRINGEKIT .................................. 3 .......................................................................... PA
OCTREOTIDE ACETATE SYRINGE.................................... 2 ..............................................................
OCTREOTIDE ACETATE VIAL ............................................ 2 ..............................................................
Strength: 100 MCG/ML, 200 MCG/ML
OCTREOTIDE ACETATE VIAL ............................................ 3 ..............................................................
Strength: 1000MCG/ML, 500 MCG/ML
SANDOSTATIN VIAL............................................................ 3 ..............................................................
SANDOSTATIN AMPUL ....................................................... 3 ..............................................................
Strength: 100 MCG/ML, 500 MCG/ML
SANDOSTATIN AMPUL ....................................................... 3 ..............................................................
Strength: 50 MCG/ML
SANDOSTATIN LAR KIT ...................................................... 3 ..............................................................
SIGNIFOR LAR VIAL ............................................................ 3 ....................... PA, QL-1 mL(s) per 28 day(s)
SOMATULINE DEPOT SYRINGE ........................................ 3 .......................................................... PA
SOMAVERT VIAL ................................................................. 3 .......................................................... PA
SYNAREL SPRAY ................................................................ 3 ..............................................................
TRELSTAR SYRINGE .......................................................... 3 .......................................................... PA
HORMONAL AGENTS, SUPPRESSANT (SEX HORMONES/ MODIFIERS)
bicalutamide tablet ................................................................ 1 ..............................................................
flutamide capsule .................................................................. 1 ..............................................................
NILANDRON TABLET .......................................................... 3 ..............................................................
XTANDI CAPSULE ............................................................... 3 ................... PA, QL-120 unit(s) per 30 day(s)
xulane patch tdwk ................................................................. 1 ..............................................................
HORMONAL AGENTS, SUPPRESSANT (THYROID)
methimazole tablet ................................................................ 1 ..............................................................
propylthiouracil tablet ............................................................ 1..............................................................
IMMUNOLOGICAL AGENTS
ACTEMRA VIAL.................................................................... 3 .......................................................... PA
ACTEMRA SYRINGE ........................................................... 3 .......................................................................... PA
80
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Drug Name
Drug Tier
Requirements/Limits
IMMUNOLOGICAL AGENTS (continued)
ACTHIB VIAL ........................................................................3 ..............................................................
ACTIMMUNE VIAL ................................................................3 ..............................................................
ADACEL TDAP SYRINGE ....................................................3 ..............................................................
ADACEL TDAP VIAL.............................................................3...............................................................
ARCALYST VIAL...................................................................3 ......................................................... PA
ASTAGRAF XL CAP ER 24H................................................3 ......................................................... BD
ATGAM AMPUL ....................................................................3 ......................................................... PA
AZASAN TABLET .................................................................3 ......................................................... BD
azathioprine tablet .................................................................1 ......................................................... BD
AZATHIOPRINE SODIUM VIAL............................................3 ......................................................... BD
BCG (TICE STRAIN) VIAL ....................................................3 ..............................................................
BCG VACCINE (TICE STRAIN) VIAL ...................................3 ..............................................................
BENLYSTA VIAL ...................................................................3 ......................................................... PA
BERINERT KIT......................................................................3 ......................................................... PA
BEXSERO SYRINGE ............................................................3 ..............................................................
BIOTHRAX VIAL ...................................................................3 ..............................................................
BIVIGAM VIAL.......................................................................3 ......................................................... PA
BOOSTRIX TDAP VIAL.........................................................3 ..............................................................
BOOSTRIX TDAP SYRINGE ................................................3...............................................................
CARIMUNE NF NANOFILTERED VIAL ................................3 ......................................................... PA
CELLCEPT CAPSULE ..........................................................3 ......................................................... BD
CELLCEPT SUSP RECON ...................................................3.......................................................................... BD
CELLCEPT TABLET .............................................................3.......................................................................... BD
CELLCEPT VIAL ...................................................................3.......................................................................... BD
CERVARIX SYRINGE ...........................................................3 ..............................................................
CIMZIA KIT............................................................................3 ...................... PA, QL-6 unit(s) per 28 day(s)
CIMZIA SYRINGEKIT............................................................3.............................. PA, QL-6 unit(s) per 28 day(s)
CINRYZE VIAL ......................................................................3 ......................................................... PA
COMVAX VIAL ......................................................................3 ..............................................................
COSENTYX (2 SYRINGES) SYRINGE.................................3 ...................... PA, QL-10 mL(s) per 28 day(s)
COSENTYX PEN (2 PENS) PEN INJCTR ............................3 ...................... PA, QL-10 mL(s) per 28 day(s)
cyclosporine solution .............................................................1 ......................................................... BD
81
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Drug Name
Drug Tier
Requirements/Limits
cyclosporine ampul ............................................................... 1 .......................................................................... BD
cyclosporine capsule............................................................. 1 .......................................................................... BD
cyclosporine modified capsule .............................................. 1 ......................................................... BD
DAPTACEL DTAP VIAL........................................................ 3 ..............................................................
DIPHTHERIA-TETANUS TOXOIDS-PED VIAL.................... 3 ..............................................................
ENBREL SYRINGE............................................................... 3....................... PA, QL-8 mL(s) per 28 day(s)
Strength: 25 MG
ENBREL VIAL ....................................................................... 3 ............................. PA, QL-16 mL(s) per 28 day(s)
Strength: 25 MG
ENBREL PEN INJCTR.......................................................... 3....................... PA, QL-8 mL(s) per 28 day(s)
Strength: 50 MG
ENGERIX-B ADULT VIAL..................................................... 3 ......................................................... BD
ENGERIX-B ADULT SYRINGE ............................................ 3 .......................................................................... BD
ENGERIX-B PEDIATRIC-ADOLESCENT VIAL.................... 3 ......................................................... BD
ENGERIX-B PEDIATRIC-ADOLESCENT SYRINGE ........... 3 .......................................................................... BD
ENVARSUS XR TAB ER 24H............................................... 3 ......................................................... BD
FIRAZYR SYRINGE.............................................................. 3 .......................................................... PA
FLEBOGAMMA DIF VIAL ..................................................... 3 .......................................................... PA
GAMMAGARD LIQUID VIAL ................................................ 3 .......................................................... PA
GAMMAKED VIAL ................................................................ 3 .......................................................... PA
GAMMAPLEX VIAL............................................................... 3 .......................................................... PA
GAMUNEX-C VIAL ............................................................... 3 .......................................................... PA
GARDASIL VIAL ................................................................... 3 ..............................................................
GARDASIL SYRINGE........................................................... 3...............................................................
GARDASIL 9 VIAL ................................................................ 3 ..............................................................
GARDASIL 9 SYRINGE........................................................ 3...............................................................
gengraf capsule..................................................................... 1 ......................................................... BD
gengraf solution..................................................................... 1 .......................................................................... BD
HAVRIX VIAL ........................................................................ 3 ..............................................................
HAVRIX SYRINGE................................................................ 3...............................................................
HIBERIX VIAL ....................................................................... 3 ..............................................................
HIZENTRA VIAL ................................................................... 3 .......................................................... PA
HUMIRA SYRINGEKIT ......................................................... 3....................... PA, QL-2 unit(s) per 28 day(s)
82
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Drug Name
Drug Tier
Requirements/Limits
HUMIRA SYRINGEKIT..........................................................3 ...................... PA, QL-6 unit(s) per 28 day(s)
Strength: 20MG/0.4ML, 40MG/0.8ML
HUMIRA PEDIATRIC CROHN'S SYRINGEKIT ....................3 ...................... PA, QL-6 unit(s) per 28 day(s)
HUMIRA PEN PEN IJ KIT .....................................................3 ...................... PA, QL-6 unit(s) per 28 day(s)
HUMIRA PEN CROHN-UC-HS STARTER PEN IJ KIT.........3 ...................... PA, QL-6 unit(s) per 28 day(s)
HUMIRA PEN PSORIASIS-UVEITIS PEN IJ KIT..................3 ...................... PA, QL-6 unit(s) per 28 day(s)
HYQVIA VIAL ........................................................................3 ......................................................... PA
ILARIS VIAL ..........................................................................3 ..............................................................
IMOVAX RABIES VACCINE VIAL.........................................3 ......................................................... BD
INFANRIX DTAP VIAL ..........................................................3 ..............................................................
IPOL SYRINGE .....................................................................3 ..............................................................
IPOL VIAL .............................................................................3...............................................................
IXIARO SYRINGE .................................................................3 ..............................................................
KINERET SYRINGE..............................................................3 ......................................................... PA
KINRIX VIAL..........................................................................3 ..............................................................
KINRIX SYRINGE .................................................................3...............................................................
leflunomide tablet ..................................................................1 ..............................................................
MENACTRA VIAL..................................................................3 ..............................................................
MENHIBRIX VIAL..................................................................3 ..............................................................
MENOMUNE-A-C-Y-W-135 VIAL..........................................3 ..............................................................
MENVEO A-C-Y-W-135-DIP KIT...........................................3 ..............................................................
MENVEO MENA COMPONENT VIAL ..................................3 ..............................................................
MENVEO MENCYW-135 COMPONENT VIAL .....................3 ..............................................................
methotrexate vial ...................................................................1 ......................................................... BD
methotrexate tablet................................................................1.......................................................................... BD
M-M-R II VACCINE VIAL.......................................................3 ..............................................................
MYCOPHENOLATE MOFETIL SUSP RECON.....................2 ......................................................... BD
mycophenolate mofetil capsule .............................................1.......................................................................... BD
mycophenolate mofetil tablet.................................................1.......................................................................... BD
MYCOPHENOLIC ACID TABLET DR ...................................2 ......................................................... BD
MYFORTIC TABLET DR .......................................................3 ......................................................... BD
Strength: 180 MG
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Drug Name
Drug Tier
Requirements/Limits
MYFORTIC TABLET DR....................................................... 3 ......................................................... BD
Strength: 360 MG
NEORAL CAPSULE.............................................................. 3 ......................................................... BD
NEORAL SOLUTION ............................................................ 3 .......................................................................... BD
NULOJIX VIAL ...................................................................... 3 .......................................................... PA
OCTAGAM VIAL ................................................................... 3 .......................................................... PA
ORENCIA VIAL ..................................................................... 3 .......................................................... PA
ORENCIA SYRINGE............................................................. 3 .......................................................................... PA
ORENCIA CLICKJECT AUTO INJCT ................................... 3............................... PA, QL-4 per 28 day(s)
OTEZLA TABLET.................................................................. 3..................... PA, QL-60 unit(s) per 30 day(s)
OTEZLA TAB DS PK ............................................................ 3 ............................ PA, QL-60 unit(s) per 30 day(s)
PEDIARIX SYRINGE ............................................................ 3 ..............................................................
PEDVAXHIB VIAL................................................................. 3 ..............................................................
PENTACEL KIT..................................................................... 3 ..............................................................
PRIVIGEN VIAL .................................................................... 3 .......................................................... PA
PROGRAF AMPUL ............................................................... 3 ......................................................... BD
PROGRAF CAPSULE........................................................... 3 .......................................................................... BD
PROLIA SYRINGE................................................................ 3 .......................................................... PA
PROQUAD VIAL ................................................................... 3 ..............................................................
QUADRACEL DTAP-IPV VIAL ............................................. 3 ..............................................................
RABAVERT VIAL .................................................................. 3 ......................................................... BD
RAPAMUNE SOLUTION ...................................................... 3 ......................................................... BD
RAPAMUNE TABLET ........................................................... 3 ......................................................... BD
Strength: 0.5 MG
RAPAMUNE TABLET ........................................................... 3 ......................................................... BD
RECOMBIVAX HB VIAL ....................................................... 3 ......................................................... BD
RECOMBIVAX HB SYRINGE ............................................... 3 .......................................................................... BD
REMICADE VIAL .................................................................. 3 .......................................................... PA
RIDAURA CAPSULE ............................................................ 3 ..............................................................
ROTARIX SUSP RECON ..................................................... 3 ..............................................................
ROTATEQ ORAL SUSP ....................................................... 3 ..............................................................
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Drug Name
Drug Tier
Requirements/Limits
RUCONEST VIAL..................................................................3 ......................................................... PA
SANDIMMUNE AMPUL.........................................................3 ......................................................... BD
SANDIMMUNE CAPSULE ....................................................3.......................................................................... BD
SANDIMMUNE SOLUTION...................................................3.......................................................................... BD
SIMPONI SYRINGE ..............................................................3 ....................... PA, QL-1 mL(s) per 28 day(s)
SIMPONI PEN INJCTR .........................................................3............................... PA, QL-1 mL(s) per 28 day(s)
SIMPONI ARIA VIAL .............................................................3 ......................................................... PA
SIMULECT VIAL ...................................................................3 ..............................................................
sirolimus tablet ......................................................................1 ......................................................... BD
SOLIRIS VIAL .......................................................................3 ......................................................... PA
STELARA SYRINGE .............................................................3 ......................................................... PA
tacrolimus capsule.................................................................1 ......................................................... BD
TALTZ AUTOINJECTOR AUTO INJCT ................................3 ............................... PA, QL-4 per 28 day(s)
TALTZ SYRINGE SYRINGE .................................................3 ....................... PA, QL-4 mL(s) per 28 day(s)
TENIVAC SYRINGE..............................................................3 ..............................................................
TETANUS DIPHTHERIA TOXOIDS VIAL .............................3 ..............................................................
TETANUS TOXOID ADSORBED VIAL .................................2 ......................................................... BD
THERACYS VIAL ..................................................................3 ..............................................................
THYMOGLOBULIN VIAL.......................................................3 ......................................................... PA
TRUMENBA SYRINGE .........................................................3 ..............................................................
TWINRIX VIAL ......................................................................3 ..............................................................
TWINRIX SYRINGE ..............................................................3...............................................................
TYPHIM VI SYRINGE ...........................................................3 ..............................................................
TYPHIM VI VIAL....................................................................3...............................................................
VAQTA VIAL .........................................................................3 ..............................................................
VARIVAX VACCINE VIAL .....................................................3 ..............................................................
VARIZIG VIAL .......................................................................3 ..............................................................
XELJANZ XR TAB ER 24H ...................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
YF-VAX VIAL.........................................................................3 ..............................................................
ZORTRESS TABLET ............................................................3 ......................................................... BD
Strength: 0.25 MG
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Drug Name
Drug Tier
Requirements/Limits
ZORTRESS TABLET ............................................................ 3 ......................................................... BD
ZOSTAVAX VIAL .................................................................. 2 .......................................................... PA
INFLAMMATORY BOWEL DISEASE AGENTS
ASACOL HD TABLET DR..................................................... 2 ..............................................................
balsalazide disodium capsule ............................................... 1 ..............................................................
BUDESONIDE EC CAPDR - ER........................................... 3 ..............................................................
CANASA SUPP.RECT.......................................................... 2 ..............................................................
colocort enema...................................................................... 1 ..............................................................
CORTENEMA ENEMA ......................................................... 3 ..............................................................
DELZICOL CAP .................................................................... 2 ..............................................................
DIPENTUM CAPSULE.......................................................... 3 ..............................................................
ENTOCORT EC CAPDR - ER .............................................. 3 ..............................................................
GIAZO TABLET .................................................................... 3 ..............................................................
hydrocortisone enema........................................................... 1..............................................................
LIALDA TABLET DR ............................................................. 2 ......................... QL-120 unit(s) per 30 day(s)
mesalamine enema............................................................... 1..............................................................
MESALAMINE TABLET DR.................................................. 3...............................................................
methylprednisolone tablet ..................................................... 1 ......................................................... BD
Strength: 4 mg
PENTASA CAPSULE ER...................................................... 2 ..............................................................
SFROWASA ENEMA............................................................ 3 ..............................................................
sulfasalazine tablet................................................................ 1 ..............................................................
sulfasalazine dr tablet dr ....................................................... 1 ..............................................................
UCERIS FOAM/APPL ........................................................... 3 .......................................................... PA
UCERIS TABDR - ER ........................................................... 3............................. PA, QL-30 per 30 day(s)
METABOLIC BONE DISEASE AGENTS
alendronate sodium solution ................................................. 1 .......................... QL-300 mL(s) per 28 day(s)
alendronate sodium tablet..................................................... 1 .......................... QL-30 unit(s) per 30 day(s)
alendronate sodium tablet..................................................... 1 ............................ QL-4 unit(s) per 28 day(s)
BINOSTO TABLET EFF........................................................ 3 ................... STEP, QL-4 unit(s) per 28 day(s)
BONIVA SYRINGE ............................................................... 3 .......................................................... PA
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Drug Name
Drug Tier
Requirements/Limits
METABOLIC BONE DISEASE AGENTS (continued)
calcitonin-salmon spray/pump ...............................................1 ..............................................................
calcitriol ampul.......................................................................1 ......................................................... PA
calcitriol solution ....................................................................1...........................................................................PA
calcitriol capsule ....................................................................1...........................................................................PA
DOXERCALCIFEROL AMPUL..............................................2 ......................................................... PA
DOXERCALCIFEROL CAPSULE .........................................2...........................................................................PA
etidronate disodium tablet .....................................................1 ..............................................................
FORTEO PEN INJCTR .........................................................3 ....................... PA, QL-3 mL(s) per 28 day(s)
fortical spray/pump ................................................................1 ..............................................................
FOSAMAX PLUS D TABLET ................................................3 ................... STEP, QL-4 unit(s) per 28 day(s)
HECTOROL CAPSULE.........................................................3 ......................................................... PA
HECTOROL VIAL..................................................................3...........................................................................PA
ibandronate sodium tablet .....................................................1 ..............................................................
ibandronate sodium vial ........................................................1...........................................................................PA
ibandronate sodium syringe ..................................................1...........................................................................PA
MIACALCIN VIAL ..................................................................3 ......................................................... PA
NATPARA CARTRIDGE .......................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
pamidronate disodium vial.....................................................1 ......................................................... PA
PARICALCITOL VIAL............................................................3 ......................................................... PA
paricalcitol capsule ................................................................1...........................................................................PA
risedronate sodium tablet ......................................................1 ............................ QL-1 unit(s) per 28 day(s)
Strength: 150 mg
risedronate sodium tablet ......................................................1 .......................... QL-30 unit(s) per 30 day(s)
risedronate sodium tablet ......................................................1 ............................ QL-4 unit(s) per 28 day(s)
Strength: 35 mg
risedronate sodium dr tablet dr..............................................1 ............................ QL-4 unit(s) per 28 day(s)
ROCALTROL CAPSULE.......................................................3 ......................................................... PA
ROCALTROL SOLUTION .....................................................3...........................................................................PA
XGEVA VIAL .........................................................................3 ......................................................... PA
ZEMPLAR CAPSULE............................................................3 ......................................................... PA
ZEMPLAR VIAL.....................................................................3...........................................................................PA
ZOLEDRONIC ACID PIGGYBACK .......................................3 ..............................................................
ZOLEDRONIC ACID INFUS. BTL .........................................3...............................................................
ZOLEDRONIC ACID VIAL.....................................................3...............................................................
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Drug Name
Drug Tier
Requirements/Limits
METABOLIC BONE DISEASE AGENTS (continued)
ZOMETA VIAL ...................................................................... 3 ..............................................................
ZOMETA INFUS. BTL........................................................... 3...............................................................
MISCELLANEOUS THERAPEUTIC AGENTS
ALCOHOL PREP PADS MED. PAD ..................................... 3..............................................................
AMINOCAPROIC ACID TABLET.......................................... 3 ..............................................................
BD ULTRA-FINE PEN NEEDLE DIS NEEDLE..................... 3 ..............................................................
BOTOX VIAL......................................................................... 3 .......................................................... PA
CARNITOR VIAL................................................................... 3 .......................................................... PA
CARNITOR TABLET............................................................. 3 .......................................................................... PA
CARNITOR SF SOLUTION .................................................. 3 .......................................................... PA
CHENODAL TABLET............................................................ 3 ..............................................................
CROFAB VIAL ...................................................................... 3 ..............................................................
CUROSURF VIAL ................................................................. 3 ..............................................................
CYTOGAM VIAL ................................................................... 3 ..............................................................
deferoxamine mesylate vial................................................... 1 .......................................................... PA
DESFERAL VIAL .................................................................. 3 .......................................................... PA
DESFERAL MESYLATE VIAL .............................................. 3 .......................................................... PA
dextrose in water iv soln........................................................ 1 ..............................................................
Strength: 5 %
DIGIFAB VIAL ....................................................................... 3 ..............................................................
FOMEPIZOLE VIAL .............................................................. 3 ..............................................................
freamine iii iv soln.................................................................. 1......................................................... BD
FULYZAQ TABLET DR......................................................... 3 .......................................................... PA
GRASTEK TAB SUBL........................................................... 3 .......................................................... PA
INSULIN SYRINGE DISP SYRIN ......................................... 3 ..............................................................
INTRALIPID EMULSION....................................................... 3 ......................................................... BD
ISOPTO ATROPINE DROPS ............................................... 3 ..............................................................
KALBITOR VIAL.................................................................... 3 .......................................................... PA
KEVEYIS TABLET ................................................................ 3 ................... PA, QL-120 unit(s) per 30 day(s)
KORLYM TABLET ................................................................ 3................... PA, QL-120 unit(s) per 30 day(s)
levocarnitine solution............................................................. 1.......................................................... PA
levocarnitine vial.................................................................... 1 .......................................................................... PA
levocarnitine tablet ................................................................ 1 .......................................................................... PA
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Drug Name
Drug Tier
Requirements/Limits
MISCELLANEOUS THERAPEUTIC AGENTS (continued)
METHYLERGONOVINE MALEATE TABLET .......................3 ..............................................................
MIFEPREX TABLET..............................................................3 ..............................................................
MYALEPT VIAL .....................................................................3 ......................................................... PA
NUTRILIPID EMULSION.......................................................3 ......................................................... BD
ORALAIR TAB SUBL ............................................................3 ......................................................... PA
RADIOGARDASE CAPSULE................................................3 ..............................................................
RAGWITEK TAB SUBL .........................................................3 ......................................................... PA
SIGNIFOR AMPUL................................................................3 ......................................................... PA
SMOFLIPID EMULSION .......................................................3 ......................................................... BD
STERILE PADS BANDAGE ..................................................3 ..............................................................
SYNAGIS VIAL......................................................................3 ..............................................................
VELTASSA POWD PACK .....................................................3 .......................... QL-30 unit(s) per 30 day(s)
VGO 40 EACH ......................................................................3 ..............................................................
water irrig soln .......................................................................1 ..............................................................
XELJANZ TABLET ................................................................3 ..................... PA, QL-60 unit(s) per 30 day(s)
OPHTHALMIC AGENTS
acetazolamide capsule er......................................................1 ..............................................................
acetazolamide tablet .............................................................1...............................................................
ACUVAIL DROPERETTE......................................................3 ..............................................................
ALOCRIL DROPS .................................................................3 ..............................................................
ALOMIDE DROPS.................................................................3 ..............................................................
ALPHAGAN P DROPS..........................................................3 ..............................................................
Strength: 0.1%
ALREX DROPS SUSP ..........................................................3 ..............................................................
apraclonidine hcl drops .........................................................1 ..............................................................
atropine care drops ...............................................................1 ..............................................................
atropine sulfate oint. .............................................................1 ..............................................................
atropine sulfate drops ............................................................1...............................................................
azelastine hcl drops...............................................................1 ..............................................................
AZOPT DROPS SUSP ..........................................................3 ........................... QL-15 mL(s) per 25 day(s)
BEPREVE DROPS................................................................3 ..............................................................
betaxolol hcl drops ................................................................1 ..............................................................
BETIMOL DROPS .................................................................3 ..............................................................
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Drug Name
Drug Tier
Requirements/Limits
OPHTHALMIC AGENTS (continued)
BETOPTIC S DROPS SUSP ................................................ 3 ..............................................................
bimatoprost drops ................................................................. 1.......................... QL-7.5 mL(s) per 25 day(s)
BLEPHAMIDE DROPS SUSP .............................................. 3 ..............................................................
BLEPHAMIDE S.O.P. OINT. ................................................ 3 ..............................................................
brimonidine tartrate drops ..................................................... 1 ..............................................................
bromfenac sodium drops....................................................... 1 ..............................................................
carteolol hcl drops ................................................................. 1 ..............................................................
COMBIGAN DROPS............................................................. 3 ..............................................................
CORTISPORIN OINT. .......................................................... 3 ..............................................................
COSOPT PF DROPERETTE................................................ 3 .......................... QL-60 unit(s) per 25 day(s)
cromolyn sodium drops ......................................................... 1 ..............................................................
CYCLOGYL DROPS............................................................. 3 ..............................................................
cyclopentolate hcl drops........................................................ 1 ..............................................................
CYSTARAN DROPS............................................................. 3 ..............................................................
dexamethasone sodium phosphate drops ............................ 1..............................................................
diclofenac sodium drops ....................................................... 1 ..............................................................
Strength: 0.1 %
dorzolamide hcl drops ........................................................... 1........................... QL-10 mL(s) per 25 day(s)
dorzolamide-timolol drops ..................................................... 1 ........................... QL-10 mL(s) per 25 day(s)
DUREZOL DROPS ............................................................... 2 ..............................................................
EMADINE DROPS ................................................................ 3 ..............................................................
epinastine hcl drops .............................................................. 1..............................................................
FLAREX DROPS SUSP........................................................ 3 ..............................................................
fluorometholone drops susp.................................................. 1 ..............................................................
flurbiprofen sodium drops...................................................... 1 ..............................................................
FML FORTE DROPS SUSP ................................................. 3 ..............................................................
FML S.O.P. OINT. ................................................................ 3 ..............................................................
gentamicin sulfate oint. ........................................................ 1 ..............................................................
Strength: 0.3 %
homatropaire drops ............................................................... 1..............................................................
homatropine hydrobromide drops ......................................... 1 ..............................................................
ILEVRO DROPS SUSP ........................................................ 2 ..............................................................
IOPIDINE DROPERETTE..................................................... 3 ..............................................................
ISTALOL DROP DAILY......................................................... 3 ..............................................................
ketorolac tromethamine drops............................................... 1 ........................... QL-15 mL(s) per 25 day(s)
LACRISERT INSERT............................................................ 3 ..............................................................
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Drug Name
Drug Tier
Requirements/Limits
latanoprost drops...................................................................1 .......................... QL-2.5 mL(s) per 25 day(s)
levobunolol hcl drops.............................................................1 ..............................................................
LOTEMAX DROPS GEL .......................................................2 ..............................................................
LOTEMAX DROPS SUSP.....................................................2...............................................................
LOTEMAX OINT. ..................................................................2...............................................................
LUMIGAN DROPS ................................................................2 .......................... QL-7.5 mL(s) per 25 day(s)
MAXIDEX DROPS SUSP......................................................3 ..............................................................
metipranolol drops .................................................................1 ..............................................................
MYDRIACYL DROPS............................................................3 ..............................................................
naphazoline hcl drops ...........................................................1 ..............................................................
neomycin-polymyxin-dexameth oint. ....................................1 ..............................................................
neomycin-polymyxin-dexameth drops susp ..........................1...............................................................
NEVANAC DROPS SUSP.....................................................2 ..............................................................
olopatadine hcl drops ............................................................1 ..............................................................
PATADAY DROPS ................................................................3 ..............................................................
PATANOL DROPS ................................................................3 ..............................................................
PHOSPHOLINE IODIDE DROPS .........................................3 ..............................................................
pilocarpine hcl drops .............................................................1 ..............................................................
PRED MILD DROPS SUSP ..................................................3 ..............................................................
PRED-G DROPS SUSP ........................................................3 ..............................................................
PRED-G OINT. .....................................................................3...............................................................
prednisolone acetate drops susp ..........................................1 ..............................................................
prednisolone sodium phosphate drops..................................1 ..............................................................
proparacaine hcl drops ..........................................................1 ..............................................................
RESCULA DROPS................................................................3 ............................ QL-5 mL(s) per 25 day(s)
RESTASIS DROPERETTE ...................................................2 ..............................................................
SIMBRINZA DROPS SUSP ..................................................3 ..............................................................
sulfacetamide sodium oint. ...................................................1 ..............................................................
sulfacetamide-prednisolone drops.........................................1 ..............................................................
timolol maleate drops ............................................................1 ..............................................................
timolol maleate sol-gel...........................................................1...............................................................
TIMOPTIC DROPS................................................................3 ..............................................................
TIMOPTIC OCUDOSE DROPERETTE.................................3 ..............................................................
TOBRADEX OINT. ...............................................................3 ..............................................................
91
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Drug Name
Drug Tier
Requirements/Limits
TOBRADEX ST DROPS SUSP ............................................ 3 ..............................................................
tobramycin-dexamethasone drops susp ............................... 1..............................................................
TRAVATAN Z DROPS .......................................................... 2............................. QL-5 mL(s) per 25 day(s)
travoprost drops .................................................................... 1............................. QL-5 mL(s) per 25 day(s)
tropicamide drops.................................................................. 1 ..............................................................
VEXOL DROPS SUSP.......................................................... 3 ..............................................................
ZIOPTAN DROPERETTE ..................................................... 3.......................... QL-30 unit(s) per 30 day(s)
ZYLET DROPS SUSP .......................................................... 3 ..............................................................
OTIC AGENTS
acetasol hc drops .................................................................. 1 ..............................................................
acetic acid solution................................................................ 1 ..............................................................
CIPRO HC DROPS SUSP .................................................... 3 ..............................................................
CIPRODEX DROPS SUSP................................................... 3 ..............................................................
COLY-MYCIN S DROPS SUSP............................................ 3 ..............................................................
CORTISPORIN-TC DROPS SUSP....................................... 3 ..............................................................
fluocinolone acetonide oil drops............................................ 1 ..............................................................
HYDROCORTISONE-ACETIC ACID DROPS ...................... 2 ..............................................................
neomycin-polymyxin-hc drops susp ...................................... 1 ..............................................................
Strength: 3.5-10k-1
neomycin-polymyxin-hydrocort solution ................................ 1..............................................................
OTOVEL VIAL....................................................................... 3 .................................... QL-28 per 7 day(s)
RESPIRATORY TRACT AGENTS
acetylcysteine vial ................................................................. 1......................................................... BD
ADCIRCA TABLET ............................................................... 3..................... PA, QL-60 unit(s) per 30 day(s)
ADEMPAS TABLET .............................................................. 3..................... PA, QL-90 unit(s) per 30 day(s)
ADVAIR DISKUS BLST W/DEV............................................ 2 .......................... QL-60 unit(s) per 30 day(s)
ADVAIR HFA HFA AER AD .................................................. 2......................... QL-12 gram(s) per 30 day(s)
ALBUTEROL SULFATE SYRUP .......................................... 3 ..............................................................
ALBUTEROL SULFATE TABLET ......................................... 3...............................................................
albuterol sulfate neb solution ................................................ 1 .......................................................................... BD
albuterol sulfate tab er 12h.................................................... 1...............................................................
albuterol sulfate vial-neb ....................................................... 1 .......................................................................... BD
aminophylline vial.................................................................. 1 ..............................................................
ANORO ELLIPTA BLST W/DEV........................................... 2 .......................... QL-60 unit(s) per 30 day(s)
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Drug Name
Drug Tier
Requirements/Limits
RESPIRATORY TRACT AGENTS (continued)
ARALAST NP VIAL ...............................................................3 ......................................................... PA
arbinoxa liquid .......................................................................1 ..............................................................
arbinoxa tablet .......................................................................1...............................................................
ARNUITY ELLIPTA BLST W/DEV.........................................2 .......................... QL-30 unit(s) per 30 day(s)
ASMANEX AER POW BA .....................................................2 ............................ QL-1 unit(s) per 30 day(s)
ASMANEX HFA HFA AER AD ..............................................2 ........................ QL-13 gram(s) per 30 day(s)
ATROVENT HFA HFA AER AD ............................................3 ...................... QL-25.8 gram(s) per 30 day(s)
azelastine hcl spray/pump .....................................................1 ........................... QL-30 mL(s) per 25 day(s)
BECONASE AQ SPRAY .......................................................3 .......................... STEP, QL-50 per 30 day(s)
benzonatate capsule .............................................................1 ........................................................... *
BREO ELLIPTA BLST W/DEV ..............................................2 .......................... QL-60 unit(s) per 30 day(s)
BROVANA VIAL-NEB............................................................3 .................... BD, QL-120 mL(s) per 30 day(s)
BUDESONIDE AMPUL-NEB.................................................2 .................... BD, QL-120 mL(s) per 30 day(s)
budesonide spray/pump ........................................................1..............................QL-17.2 gram(s) per 30 day(s)
CINQAIR VIAL.......................................................................3 ......................................................... PA
clemastine fumarate syrup ....................................................1 ..............................................................
clemastine fumarate tablet ....................................................1...............................................................
COMBIVENT RESPIMAT MIST INHAL.................................3 .......................... QL-8 gram(s) per 30 day(s)
CROMOLYN SODIUM ORAL CONC ....................................3 ..............................................................
cromolyn sodium ampul-neb .................................................1.......................................................................... BD
cyproheptadine hcl syrup ......................................................1 ..............................................................
cyproheptadine hcl tablet ......................................................1...............................................................
DALIRESP TABLET ..............................................................3 .......................... QL-30 unit(s) per 30 day(s)
desloratadine tablet ...............................................................1 .......................... QL-30 unit(s) per 30 day(s)
desloratadine tab rapdis ........................................................1................................... QL-30 unit(s) per 30 day(s)
diphenhydramine hcl elixir .....................................................1 ..............................................................
diphenhydramine hcl vial .......................................................1...............................................................
diphenhydramine hcl syringe.................................................1...............................................................
DULERA HFA AER AD .........................................................3 ........................ QL-13 gram(s) per 30 day(s)
ELIXOPHYLLIN ELIXIR ........................................................3 ..............................................................
epinephrine syringe ...............................................................1 ..............................................................
EPINEPHRINE AUTO INJCT ................................................3 ..............................................................
Strength: 0.15/0.15
epinephrine auto injct ............................................................1 ..............................................................
Strength: 0.3mg/0.3
EPIPEN 2-PAK AUTO INJCT................................................2 ............................ QL-2 unit(s) per 30 day(s)
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Drug Name
Drug Tier
Requirements/Limits
EPIPEN JR 2-PAK AUTO INJCT .......................................... 2 ............................ QL-2 unit(s) per 30 day(s)
epoprostenol sodium vial ...................................................... 1 .......................................................... PA
ESBRIET CAPSULE ............................................................. 3 ................... PA, QL-270 unit(s) per 30 day(s)
FLOLAN VIAL ....................................................................... 3 .......................................................... PA
FLOVENT DISKUS BLST W/DEV ........................................ 2 .......................... QL-60 unit(s) per 30 day(s)
Strength: 100 MCG, 50 MCG
FLOVENT DISKUS BLST W/DEV ........................................ 2 ......................... QL-240 unit(s) per 30 day(s)
Strength: 250 MCG
FLOVENT HFA AER W/ADAP.............................................. 2 ......................... QL-24 gram(s) per 30 day(s)
flunisolide spray .................................................................... 1 ........................... QL-50 mL(s) per 30 day(s)
fluticasone propionate spray susp......................................... 1 ......................... QL-16 gram(s) per 30 day(s)
FORADIL CAP W/DEV ......................................................... 2.......................... QL-60 unit(s) per 30 day(s)
GLASSIA VIAL ...................................................................... 3 .......................................................... PA
hydrocodone bt-homatropine mbr tablet ............................... 1............................................................ *
hydrocodone-homatropine mbr syrup ................................... 1............................................................ *
hydromet syrup ..................................................................... 1 ............................................................ *
HYDROXYZINE HCL SOLUTION......................................... 2 ..............................................................
HYDROXYZINE HCL TABLET ............................................. 2...............................................................
HYDROXYZINE HCL VIAL ................................................... 2...............................................................
INCRUSE ELLIPTA BLST W/DEV........................................ 3 .......................... QL-30 unit(s) per 30 day(s)
ipratropium bromide neb solution.......................................... 1 ......................................................... BD
ipratropium bromide spray .................................................... 1...............................................................
ipratropium-albuterol ampul-neb ........................................... 1 ......................................................... BD
ISUPREL AMPUL ................................................................. 3 ..............................................................
KALYDECO GRAN PACK .................................................... 3..................... PA, QL-60 unit(s) per 30 day(s)
KALYDECO TABLET ............................................................ 3 ............................ PA, QL-60 unit(s) per 30 day(s)
LETAIRIS TABLET................................................................ 3..................... PA, QL-30 unit(s) per 30 day(s)
LEVALBUTEROL CONCENTRATE VIAL-NEB .................... 2 ......................................................... BD
LEVALBUTEROL HCL VIAL-NEB ........................................ 2......................................................... BD
levocetirizine dihydrochloride solution................................... 1.......................... QL-300 mL(s) per 30 day(s)
levocetirizine dihydrochloride tablet ...................................... 1 ...................................QL-60 unit(s) per 30 day(s)
LUFYLLIN TABLET............................................................... 3 ..............................................................
metaproterenol sulfate tablet................................................. 1 ..............................................................
metaproterenol sulfate syrup................................................. 1...............................................................
mometasone furoate spray/pump ......................................... 1 ......................... QL-34 gram(s) per 30 day(s)
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Drug Name
Drug Tier
Requirements/Limits
montelukast sodium gran pack..............................................1 ..............................................................
montelukast sodium tab chew ...............................................1 .......................... QL-30 unit(s) per 30 day(s)
montelukast sodium tablet.....................................................1................................... QL-30 unit(s) per 30 day(s)
NASONEX SPRAY/PUMP ....................................................2 ........................ QL-34 gram(s) per 30 day(s)
NUCALA VIAL .......................................................................3 ......................................................... PA
OFEV CAPSULE ...................................................................3 ..................... PA, QL-60 unit(s) per 30 day(s)
OLOPATADINE HCL SPRAY/PUMP ....................................2 ........................ QL-31 gram(s) per 30 day(s)
OMNARIS SPRAY/PUMP .....................................................3 ................ STEP, QL-13 gram(s) per 30 day(s)
OPSUMIT TABLET................................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
ORENITRAM ER TABLET ER ..............................................3 ..................... PA, QL-90 unit(s) per 30 day(s)
Strength: 0.125 MG
ORENITRAM ER TABLET ER ..............................................3 ..................... PA, QL-90 unit(s) per 30 day(s)
ORENITRAM ER TABLET ER ..............................................3 ......................................................... PA
Strength: 2.5 MG
ORKAMBI TABLET ...............................................................3 ................... PA, QL-120 unit(s) per 30 day(s)
PATANASE SPRAY/PUMP...................................................3 ........................ QL-31 gram(s) per 30 day(s)
PERFOROMIST VIAL-NEB...................................................3 .................... BD, QL-120 mL(s) per 30 day(s)
PROAIR HFA HFA AER AD ..................................................2 ........................ QL-17 gram(s) per 30 day(s)
PROAIR RESPICLICK AER POW BA...................................2 ............................ QL-2 unit(s) per 30 day(s)
PROLASTIN C VIAL..............................................................3 ......................................................... PA
promethazine vc syrup ..........................................................1 ..............................................................
PROVENTIL HFA HFA AER AD ...........................................3 ...................... QL-13.4 gram(s) per 30 day(s)
PULMICORT AMPUL-NEB ...................................................3 .................... BD, QL-120 mL(s) per 30 day(s)
PULMOZYME SOLUTION ....................................................3 ......................................................... PA
QNASL HFA AER AD............................................................3 ............... STEP, QL-8.7 gram(s) per 30 day(s)
QNASL CHILDREN HFA AER AD ........................................3 ............... STEP, QL-4.9 gram(s) per 30 day(s)
QVAR AER W/ADAP.............................................................2 ...................... QL-21.9 gram(s) per 30 day(s)
REMODULIN VIAL ................................................................3 ......................................................... PA
REVATIO VIAL ......................................................................3 ......................................................... PA
REVATIO SUSP RECON ......................................................3 .................... PA, QL-180 mL(s) per 30 day(s)
REVATIO TABLET ................................................................3............................ PA, QL-90 unit(s) per 30 day(s)
SEMPREX-D CAPSULE .......................................................3 ..............................................................
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Drug Name
Drug Tier
Requirements/Limits
SEREVENT DISKUS BLST W/DEV...................................... 2 .......................... QL-60 unit(s) per 30 day(s)
sildenafil tablet ...................................................................... 1 ..................... PA, QL-90 unit(s) per 30 day(s)
SILDENAFIL CITRATE VIAL ................................................ 3 .......................................................... PA
SPIRIVA CAP W/DEV........................................................... 2.......................... QL-30 unit(s) per 30 day(s)
SPIRIVA RESPIMAT MIST INHAL ....................................... 2 .......................... QL-4 gram(s) per 30 day(s)
STIOLTO RESPIMAT MIST INHAL ...................................... 2 .......................... QL-4 gram(s) per 30 day(s)
STRIVERDI RESPIMAT MIST INHAL .................................. 3 .......................... QL-5 gram(s) per 30 day(s)
SYMBICORT HFA AER AD .................................................. 2......................... QL-11 gram(s) per 30 day(s)
terbutaline sulfate tablet ........................................................ 1 ..............................................................
terbutaline sulfate vial ........................................................... 1...............................................................
THEO-24 CAP ER 24H ......................................................... 3 ..............................................................
theochron tab er 12h ............................................................. 1..............................................................
theophylline tab er 24h.......................................................... 1 ..............................................................
theophylline anhydrous tab er 12h ........................................ 1 ..............................................................
TRACLEER TABLET ............................................................ 3..................... PA, QL-60 unit(s) per 30 day(s)
triamcinolone acetonide spray .............................................. 1 ...................... QL-16.5 gram(s) per 25 day(s)
TYVASO (DRUG ONLY) AMPUL-NEB................................. 3 ...................... PA, QL-87 mL(s) per 30 day(s)
TYVASO STARTER KIT AMPUL-NEB ................................. 3 ...................... PA, QL-87 mL(s) per 30 day(s)
TYZINE DROPS.................................................................... 3 ..............................................................
UPTRAVI TAB DS PK........................................................... 3 ................... PA, QL-200 unit(s) per 30 day(s)
UPTRAVI TABLET ................................................................ 3..................... PA, QL-60 unit(s) per 30 day(s)
Strength: 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 400 MCG, 600 MCG, 800 MCG
UPTRAVI TABLET ................................................................ 3 ................... PA, QL-140 unit(s) per 28 day(s)
Strength: 200 MCG
UTIBRON NEOHALER CAP W/DEV .................................... 3 .......................... QL-60 unit(s) per 30 day(s)
VELETRI VIAL ...................................................................... 3 .......................................................... PA
VENTAVIS AMPUL-NEB ...................................................... 3 .......................................................... PA
VENTOLIN HFA HFA AER AD ............................................. 2 ......................... QL-36 gram(s) per 30 day(s)
VERAMYST SPRAY SUSP .................................................. 3 ................ STEP, QL-10 gram(s) per 30 day(s)
XOLAIR VIAL ........................................................................ 3 .......................................................... PA
XOPENEX VIAL-NEB ........................................................... 3 ......................................................... BD
XOPENEX CONCENTRATE VIAL-NEB ............................... 3......................................................... BD
XOPENEX HFA HFA AER AD .............................................. 3 ......................... QL-30 gram(s) per 30 day(s)
zafirlukast tablet .................................................................... 1 .......................... QL-60 unit(s) per 30 day(s)
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Drug Name
Drug Tier
Requirements/Limits
ZEMAIRA VIAL......................................................................3 ......................................................... PA
ZETONNA HFA AER AD.......................................................3 ............... STEP, QL-6.1 gram(s) per 30 day(s)
ZYFLO TABLET ....................................................................3 ................ STEP, QL-120 unit(s) per 30 day(s)
ZYFLO CR TBMP 12HR........................................................3 ................ STEP, QL-120 unit(s) per 30 day(s)
SKELETAL MUSCLE RELAXANTS
CARISOPRODOL TABLET ...................................................3 ........................ QL-120 unit(s) per 30 day(s)
Strength: 250 MG
CARISOPRODOL TABLET ...................................................2 ........................ QL-120 unit(s) per 30 day(s)
Strength: 350 MG
CARISOPRODOL-ASPIRIN TABLET ...................................3 ..............................................................
CARISOPRODOL-ASPIRIN-CODEINE TABLET..................3 ..............................................................
chlorzoxazone tablet .............................................................1 ..............................................................
cyclobenzaprine hcl tablet .....................................................1 ..............................................................
metaxall tablet .......................................................................1 ..............................................................
metaxalone tablet ..................................................................1 ..............................................................
methocarbamol tablet ............................................................1 ..............................................................
methocarbamol vial ...............................................................1...............................................................
orphenadrine citrate tablet er ................................................1 ..............................................................
orphenadrine citrate ampul....................................................1...............................................................
PARAFON FORTE DSC TABLET.........................................3 ..............................................................
ROBAXIN TABLET................................................................3 ..............................................................
ROBAXIN VIAL .....................................................................3...............................................................
ROBAXIN-750 TABLET.........................................................3 ..............................................................
SKELAXIN TABLET ..............................................................3 ..............................................................
SOMA TABLET .....................................................................3 ........................ QL-120 unit(s) per 30 day(s)
SLEEP DISORDER AGENTS
AMBIEN TABLET ..................................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
AMBIEN CR TAB MPHASE ..................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
ARMODAFINIL TABLET .......................................................2 ..................... PA, QL-30 unit(s) per 30 day(s)
BELSOMRA TABLET ............................................................3 .......................... QL-30 unit(s) per 30 day(s)
EDLUAR TAB SUBL..............................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
eszopiclone tablet..................................................................1 ..................... PA, QL-30 unit(s) per 30 day(s)
HETLIOZ CAPSULE..............................................................3 ..................... PA, QL-30 unit(s) per 30 day(s)
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Drug Name
Drug Tier
Requirements/Limits
SLEEP DISORDER AGENTS (continued)
INTERMEZZO TAB SUBL .................................................... 3 ..................... PA, QL-30 unit(s) per 30 day(s)
LUNESTA TABLET ............................................................... 3..................... PA, QL-30 unit(s) per 30 day(s)
modafinil tablet ...................................................................... 1 ..................... PA, QL-60 unit(s) per 30 day(s)
NUVIGIL TABLET ................................................................. 3..................... PA, QL-30 unit(s) per 30 day(s)
PROVIGIL TABLET............................................................... 3..................... PA, QL-60 unit(s) per 30 day(s)
ROZEREM TABLET.............................................................. 3 ..............................................................
SILENOR TABLET................................................................ 3 ..............................................................
SONATA CAPSULE.............................................................. 3..................... PA, QL-30 unit(s) per 30 day(s)
temazepam capsule .............................................................. 1..............................................................
TEMAZEPAM CAPSULE ...................................................... 2 ..............................................................
XYREM SOLUTION .............................................................. 3 .................... PA, QL-540 mL(s) per 30 day(s)
zaleplon capsule ................................................................... 1 ..................... PA, QL-30 unit(s) per 30 day(s)
ZOLPIDEM TARTRATE TAB SUBL ..................................... 2 ..................... PA, QL-30 unit(s) per 30 day(s)
zolpidem tartrate tablet.......................................................... 1 ............................ PA, QL-30 unit(s) per 30 day(s)
zolpidem tartrate er tab mphase ........................................... 1 ..................... PA, QL-30 unit(s) per 30 day(s)
ZOLPIMIST SPRAY/PUMP................................................... 3....................... PA, QL-8 mL(s) per 30 day(s)
THERAPEUTIC NUTRIENTS/MINERALS/ ELECTROLYTES
acyclovir sodium vial ............................................................. 1......................................................... BD
AMINOSYN IV SOLN............................................................ 3 ......................................................... BD
AMINOSYN II IV SOLN......................................................... 3 ......................................................... BD
AMINOSYN II WITH ELECTROLYTES IV SOLN ................. 3 ......................................................... BD
AMINOSYN M IV SOLN........................................................ 3 ......................................................... BD
AMINOSYN WITH ELECTROLYTES IV SOLN .................... 3 ......................................................... BD
AMINOSYN-HBC IV SOLN ................................................... 3 ......................................................... BD
AMINOSYN-PF IV SOLN ...................................................... 3 ......................................................... BD
AMINOSYN-RF IV SOLN...................................................... 3 ......................................................... BD
ammonium chloride vial ........................................................ 1 ..............................................................
calcium gluconate vial ........................................................... 1.......................................................... PA
CHEMET CAPSULE ............................................................. 3 ..............................................................
CLINIMIX IV SOLN ............................................................... 3 ......................................................... BD
CLINIMIX E IV SOLN ............................................................ 3 ......................................................... BD
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Drug Name
Drug Tier
Requirements/Limits
THERAPEUTIC NUTRIENTS/MINERALS/ ELECTROLYTES (continued)
CLINISOL IV SOLN ...............................................................3 ......................................................... BD
CUPRIMINE CAPSULE.........................................................2 ..............................................................
cyanocobalamin injection vial ................................................1 ........................................................... *
denta 5000 plus cream .........................................................1 ..............................................................
dentagel gel ..........................................................................1 ..............................................................
DEPEN TABLET ...................................................................3 ..............................................................
dextrose 10%-0.2% nacl dehp fr bg ......................................1 ..............................................................
dextrose 10%-0.45% nacl iv soln ..........................................1 ..............................................................
dextrose 2.5%-0.45% nacl iv soln .........................................1 ..............................................................
dextrose 5%-0.2% nacl iv soln ..............................................1 ..............................................................
dextrose 5%-0.2% nacl-kcl iv soln.........................................1 ..............................................................
dextrose 5%-0.225% nacl iv soln ..........................................1 ..............................................................
dextrose 5%-0.225% nacl-kcl iv soln.....................................1 ..............................................................
dextrose 5%-0.3% nacl-kcl iv soln.........................................1 ..............................................................
dextrose 5%-0.33% nacl iv soln ............................................1 ..............................................................
dextrose 5%-0.33% nacl-kcl iv soln.......................................1 ..............................................................
dextrose 5%-0.45% nacl iv soln ............................................1 ..............................................................
dextrose 5%-0.45% nacl-kcl iv soln.......................................1 ..............................................................
dextrose 5%-1/2ns-kcl iv soln................................................1 ..............................................................
dextrose 5%-1/4ns-kcl iv soln................................................1 ..............................................................
dextrose 5%-electrolyte #48 iv soln.......................................1 ..............................................................
dextrose 5%-ns-kcl iv soln.....................................................1 ..............................................................
dextrose 5%-potassium chloride iv soln ................................1 ..............................................................
dextrose in lactated ringers iv soln ........................................1 ..............................................................
dextrose in ringers injection iv soln........................................1 ..............................................................
dextrose in water vial.............................................................1 ..............................................................
dextrose in water syringe.......................................................1...............................................................
dextrose in water ampul ........................................................1...............................................................
dextrose in water iv soln ........................................................1 ..............................................................
Strength: 10 %, 20 %, 30 %, 40 %, 70 %
EXJADE TAB DISPER ..........................................................3 ..............................................................
FERRIPROX TABLET ...........................................................3 ..............................................................
FERRIPROX SOLUTION ......................................................3...............................................................
folic acid tablet.......................................................................1 ........................................................... *
Strength: 1 mg
FREAMINE HBC IV SOLN ....................................................3 ......................................................... BD
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Drug Name
Drug Tier
Requirements/Limits
hepatamine iv soln ................................................................ 1......................................................... BD
IONOSOL B WITH DEXTROSE 5% IV SOLN ...................... 3 ..............................................................
IONOSOL MB-DEXTROSE 5% IV SOLN ............................. 3..............................................................
ISOLYTE M WITH DEXTROSE IV SOLN............................. 3 ..............................................................
ISOLYTE P WITH DEXTROSE IV SOLN ............................. 3..............................................................
ISOLYTE S IV SOLN ............................................................ 3 ..............................................................
JADENU TABLET ................................................................. 3 ..............................................................
KABIVEN EMULSION........................................................... 3 ......................................................... BD
kionex oral susp .................................................................... 1 ..............................................................
klor-con 10 tablet er .............................................................. 1..............................................................
klor-con 8 tablet er ................................................................ 1 ..............................................................
klor-con m10 tab er prt .......................................................... 1 ..............................................................
klor-con sprinkle capsule er .................................................. 1 ..............................................................
lactated ringers irrig soln ....................................................... 1 ..............................................................
lactated ringers iv soln .......................................................... 1...............................................................
MAGNESIUM CHLORIDE VIAL............................................ 3 ..............................................................
MAGNESIUM SULFATE IV SOLN........................................ 3 ..............................................................
magnesium sulfate syringe ................................................... 1...............................................................
magnesium sulfate vial.......................................................... 1...............................................................
MAGNESIUM SULFATE PIGGYBACK................................. 3...............................................................
MAGNESIUM SULFATE-0.45% NACL PLAST. BAG........... 3 ..............................................................
MAGNESIUM SULFATE-D5W PIGGYBACK ....................... 3..............................................................
MEPHYTON TABLET ........................................................... 3 ............................................................ *
multivitamin with fluoride tab chew........................................ 1 ..............................................................
NEPHRAMINE IV SOLN ....................................................... 3 ......................................................... BD
normosol-m and dextrose iv soln .......................................... 1 ..............................................................
normosol-r and dextrose iv soln ............................................ 1 ..............................................................
NORMOSOL-R PH 7.4 IV SOLN .......................................... 3 ..............................................................
PERIKABIVEN EMULSION .................................................. 3 ......................................................... BD
PHOSPHA 250 NEUTRAL TABLET ..................................... 3 ..............................................................
physiolyte irrig soln................................................................ 1 ..............................................................
physiosol irrig soln................................................................. 1 ..............................................................
PLASMA-LYTE 148 IV SOLN ............................................... 3 ..............................................................
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Drug Name
Drug Tier
Requirements/Limits
PLASMA-LYTE 56 IN DEXTROSE IV SOLN ........................3 ..............................................................
PLASMA-LYTE A PH 7.4 IV SOLN .......................................3 ..............................................................
potassium chl-normal saline iv soln.......................................1 ..............................................................
potassium chloride piggyback ...............................................1 ..............................................................
potassium chloride capsule er ...............................................1...............................................................
potassium chloride tab er prt .................................................1...............................................................
potassium chloride tablet er...................................................1...............................................................
potassium chloride vial ..........................................................1...............................................................
potassium chloride liquid .......................................................1...............................................................
POTASSIUM CHLORIDE IN D5LR IV SOLN........................3 ..............................................................
POTASSIUM CHLORIDE-NACL IV SOLN............................3 ..............................................................
potassium citrate er tablet er .................................................1 ..............................................................
PREMASOL IV SOLN ...........................................................3 ......................................................... BD
PRENATAL PLUS TABLET...................................................3 ..............................................................
PREVIDENT PASTE ............................................................3 ..............................................................
PREVIDENT 5000 SENSITIVE PASTE ...............................3 ..............................................................
PROCALAMINE IV SOLN .....................................................3 ......................................................... BD
PROSOL IV SOLN ................................................................3 ......................................................... BD
RENACIDIN IRRIG SOLN .....................................................3 ..............................................................
ringers injection iv soln ..........................................................1 ..............................................................
ringers irrigation irrig soln ......................................................1 ..............................................................
sf 5000 plus cream ...............................................................1 ..............................................................
sodium chloride vial ...............................................................1 ..............................................................
sodium chloride iv soln ..........................................................1...............................................................
sodium chloride irrig soln.......................................................1...............................................................
sodium fluoride solution.........................................................1 ..............................................................
sodium lactate vial .................................................................1 ..............................................................
sodium polystyrene sulfonate oral susp ................................1 ..............................................................
sodium polystyrene sulfonate enema ....................................1...............................................................
sps oral susp .........................................................................1 ..............................................................
SYPRINE CAPSULE .............................................................3 ..............................................................
tpn electrolytes ii vial .............................................................1 ..............................................................
TRAVASOL IV SOLN ............................................................3 ......................................................... BD
TROPHAMINE IV SOLN .......................................................3 ......................................................... BD
vitamin d2 capsule.................................................................1 ........................................................... *
Strength: 50000 units
101
going to page V.
Index of Drugs
8
8-MOP ................................... 60
A
ABACAVIR ............................. 39
ABACAVIRLAMIVUDINEZIDOVUDINE ......................... 39
ABELCET .............................. 21
ABILIFY ................................. 36
ABILIFY DISCMELT .............. 36
ABILIFY MAINTENA .............. 36
ABRAXANE ........................... 27
ABSORICA ............................ 60
ABSTRAL ................................ 1
ACAMPROSATE
CALCIUM ................................. 5
ACANYA ................................ 60
acarbose ................................ 44
acebutolol hcl ......................... 50
acetaminophen-codeine .......... 1
acetasol hc ............................. 92
acetazolamide ........................ 89
acetazolamide sodium ........... 50
ACETIC ACID .................... 5, 92
acetylcysteine ........................ 92
ACITRETIN ............................ 60
ACTEMRA ............................. 80
ACTHIB .................................. 81
ACTIMMUNE ......................... 81
ACTIQ ...................................... 1
ACTOPLUS MET XR ............. 44
ACUVAIL ............................... 89
ACYCLOVIR .......................... 39
acyclovir sodium .................... 98
ACZONE ................................ 60
ADACEL TDAP ...................... 81
ADAGEN ................................ 63
ADAPALENE ......................... 60
ADASUVE .............................. 36
ADCETRIS ............................. 27
ADCIRCA ............................... 92
adefovir dipivoxil .................... 39
ADEMPAS ............................. 92
adrucil .................................... 27
ADVAIR DISKUS ................... 92
ADVAIR HFA ......................... 92
ADVICOR .............................. 50
afeditab cr .............................. 50
AFINITOR .............................. 27
AFINITOR DISPERZ ............. 27
AGGRENOX .......................... 48
a-hydrocort ............................. 68
AKYNZEO .............................. 19
ala-cort ................................... 68
ALA-SCALP ........................... 68
ALBENZA .............................. 34
ALBUTEROL SULFATE ........ 92
ALCAINE ................................. 4
alclometasone
dipropionate ........................... 68
ALCOHOL PREP PADS ........ 88
ALDACTAZIDE ...................... 50
ALDURAZYME ...................... 63
ALECENSA ............................ 27
alendronate sodium ............... 86
ALFERON N .......................... 39
alfuzosin hcl er ....................... 66
ALIMTA .................................. 27
ALINIA ................................... 34
ALKERAN .............................. 27
allopurinol .............................. 24
almotriptan malate ................. 25
ALOCRIL ............................... 89
ALOGLIPTIN .......................... 44
ALOGLIPTINMETFORMIN ......................... 44
ALOGLIPTINPIOGLITAZONE .................... 44
ALOMIDE ............................... 89
ALORA ................................... 72
ALOSETRON HCL ................ 64
ALOXI .................................... 20
ALPHAGAN P ........................ 89
alprazolam ............................. 43
alprazolam er ......................... 43
alprazolam odt ....................... 43
ALREX ................................... 89
ALSUMA ................................ 25
ALTABAX ................................. 5
altavera .................................. 72
102
ALTOPREV ............................ 50
alyacen .................................. 72
amabelz ................................. 72
amantadine ............................ 39
AMBIEN ................................. 97
AMBIEN CR ........................... 97
AMBISOME ........................... 21
AMCINONIDE ........................ 68
a-methapred .......................... 68
amethia .................................. 72
amethia lo .............................. 72
amethyst ................................ 72
AMIFOSTINE ......................... 27
amikacin sulfate ....................... 5
amiloride hcl ........................... 50
amiloridehydrochlorothiazide ................ 50
AMINOCAPROIC ACID ......... 88
aminophylline ......................... 92
AMINOSYN ............................ 98
AMINOSYN II ......................... 98
AMINOSYN II WITH
ELECTROLYTES................... 98
AMINOSYN M ........................ 98
AMINOSYN WITH
ELECTROLYTES................... 98
AMINOSYN-HBC ................... 98
AMINOSYN-PF ...................... 98
AMINOSYN-RF ...................... 98
amiodarone hcl ...................... 50
AMITRIPTYLINE HCL............ 18
amlodipine besylate ............... 50
amlodipine besylatebenazepril .............................. 50
AMLODIPINEATORVASTATIN ................... 50
amlodipine-valsartan .............. 50
amlodipine-valsartanhctz ........................................ 50
ammonium chloride................ 98
ammonium lactate.................. 60
AMNESTEEM ........................ 60
amoxapine ............................. 18
amoxicillin ................................ 5
amoxicillin er ............................ 6
Index of Drugs
amoxicillin-clavulanate
pot er ........................................ 6
amoxicillin-clavulanate
potass ....................................... 6
amphotericin b ........................ 21
ampicillin sodium ...................... 6
ampicillin trihydrate .................. 6
AMPICILLINSULBACTAM ........................... 6
AMPYRA ................................ 57
AMTURNIDE .......................... 50
ANACAINE ............................. 61
ANADROL-50 ......................... 73
anagrelide hcl ......................... 48
anastrozole ............................. 27
ANDRODERM ........................ 73
ANDROGEL ........................... 73
ANDROID ............................... 73
androxy .................................. 73
ANGELIQ ............................... 73
ANORO ELLIPTA ................... 92
ANZEMET .............................. 20
APEXICON E ......................... 68
APLENZIN .............................. 18
APOKYN ................................ 35
apraclonidine hcl .................... 89
apri ......................................... 73
APTIOM ................................. 13
APTIVUS ................................ 39
ARALAST NP ......................... 93
aranelle .................................. 73
ARANESP .............................. 48
arbinoxa ................................. 93
ARCALYST ............................ 81
ARIPIPRAZOLE ..................... 36
ARIPIPRAZOLE ODT ............ 36
ARISTADA ............................. 36
ARISTOSPAN ........................ 68
ARIXTRA ................................ 48
ARMODAFINIL ....................... 97
ARNUITY ELLIPTA ................ 93
ARRANON ............................. 27
ARZERRA .............................. 27
ASACOL HD .......................... 86
ascomp with codeine ................ 1
ashlyna ................................... 73
ASMANEX .............................. 93
ASMANEX HFA ..................... 93
aspirin-caffeinedihydrocodein ........................... 1
ASPIRINDIPYRIDAMOLE ER .............. 48
ASTAGRAF XL ...................... 81
astramorph-pf ........................... 1
atenolol ................................... 50
atenolol-chlorthalidone ........... 50
ATGAM .................................. 81
atorvastatin calcium ............... 50
ATOVAQUONE ...................... 34
ATOVAQUONEPROGUANIL HCL .................. 34
ATRALIN ................................61
ATRIPLA ................................39
atropine care .......................... 89
atropine sulfate ................. 64, 89
ATROVENT HFA ................... 93
AUBAGIO ............................... 57
aubra ...................................... 73
AUGMENTIN ............................ 6
AURYXIA ............................... 66
AVANDAMET ......................... 44
AVANDARYL ......................... 44
AVANDIA ............................... 44
AVASTIN ................................27
AVELOX IV .............................. 6
aviane ..................................... 73
AVITA ..................................... 61
AVONEX ................................57
AVONEX PEN ........................ 57
AVYCAZ ................................... 6
AXERT ................................... 25
AXIRON ................................. 73
azacitidine .............................. 28
AZACTAM-ISOOSMOTIC DEXTROSE ............6
AZASAN ................................. 81
AZASITE ..................................6
azathioprine ............................ 81
AZATHIOPRINE
SODIUM ................................. 81
103
azelastine hcl ...................89, 93
AZELEX .................................61
AZILECT ................................35
azithromycin .............................6
AZOPT ...................................89
AZOR .....................................50
aztreonam ................................6
azurette ..................................73
B
baciim .......................................6
bacitracin ..................................6
bacitracin-polymyxin .................6
baclofen ..................................38
balsalazide disodium ..............86
balziva ....................................73
BANZEL .................................13
BARACLUDE .........................39
BCG (TICE STRAIN) ..............81
BCG VACCINE (TICE
STRAIN) .................................81
BD ULTRA-FINE PEN
NEEDLE .................................88
BECONASE AQ .....................93
bekyree ..................................73
BELBUCA ................................1
BELEODAQ ...........................28
BELSOMRA ...........................97
benazepril hcl .........................50
benazeprilhydrochlorothiazide ................50
BENDEKA ..............................28
BENICAR ...............................50
BENICAR HCT .......................51
BENLYSTA ............................81
BENTYL .................................64
BENZAMYCIN ........................61
benzonatate ...........................93
benztropine mesylate .............35
BEPREVE ..............................89
BERINERT .............................81
BESIVANCE .............................6
betamethasone
dipropionate ...........................68
betamethasone valerate .........68
BETASERON .........................57
Index of Drugs
betaxolol hcl ..................... 51, 89
bethanechol chloride .............. 66
BETHKIS ................................. 6
BETIMOL ............................... 89
BETOPTIC S ......................... 90
BEXAROTENE ...................... 28
BEXSERO ............................. 81
BEYAZ ................................... 73
bicalutamide ........................... 80
BICILLIN C-R ........................... 6
BICILLIN L-A ............................ 6
BICNU .................................... 28
BIDIL ...................................... 51
BILTRICIDE ........................... 34
bimatoprost ............................ 90
BINOSTO ............................... 86
BIOTHRAX ............................ 81
bisoprolol fumarate ................ 51
bisoprololhydrochlorothiazide ................ 51
BIVIGAM ................................ 81
bleomycin sulfate ................... 28
BLEPHAMIDE ........................ 90
BLEPHAMIDE S.O.P. ............ 90
BLINCYTO ............................. 28
blisovi 24 fe ............................ 73
blisovi fe ................................. 73
BONIVA ................................. 86
BOOSTRIX TDAP .................. 81
BOSULIF ............................... 28
BOTOX .................................. 88
BREO ELLIPTA ..................... 93
briellyn ................................... 73
BRILINTA ............................... 48
brimonidine tartrate ................ 90
BRINTELLIX .......................... 18
BRIVIACT .............................. 13
bromfenac sodium ................. 90
bromocriptine mesylate .......... 79
BROVANA ............................. 93
BUDESONIDE ....................... 93
BUDESONIDE EC ................. 86
bumetanide ............................ 51
BUPHENYL ........................... 63
BUPRENEX ............................. 1
buprenorphine hcl .................... 1
buprenorphinenaloxone .................................. 5
buproban .................................. 5
bupropion hcl ......................... 18
bupropion hcl sr ................. 5, 18
bupropion xl ........................... 18
buspirone hcl ......................... 43
BUSULFEX ............................ 28
BUTALBACETAMINOPH-CAFFCODEIN ................................... 1
BUTALBITAL
COMPOUND-CODEINE .......... 1
BUTALBITALACETAMINOPHEN ................. 1
BUTALBITALACETAMINOPHENCAFFE ..................................... 1
BUTALBITAL-ASPIRINCAFFEINE ............................... 1
BUTORPHANOL
TARTRATE .............................. 1
BUTRANS ................................ 1
BYDUREON .......................... 44
BYDUREON PEN .................. 44
BYETTA ................................. 44
BYSTOLIC ............................. 51
BYVALSON ........................... 51
C
cabergoline ............................ 79
CABOMETYX ........................ 28
CAFERGOT ........................... 25
CALCIPOTRIENE .................. 61
CALCIPOTRIENEBETAMETHASONE DP ......... 61
calcitonin-salmon ................... 87
calcitrene ............................... 61
calcitriol ............................ 61, 87
calcium acetate ...................... 66
calcium gluconate .................. 98
CALDOLOR ........................... 24
CAMBIA ................................. 24
camila .................................... 73
camrese ................................. 73
104
camrese lo ............................. 73
CANASA ................................ 86
CANCIDAS ............................ 21
candesartan cilexetil .............. 51
candesartanhydrochlorothiazid .................. 51
CANTIL .................................. 64
CAPASTAT SULFATE ........... 26
CAPEX ................................... 68
CAPRELSA ............................ 28
captopril ................................. 51
captoprilhydrochlorothiazide ................ 51
CARAC .................................. 61
CARAFATE ............................ 64
CARBAGLU ........................... 63
carbamazepine ...................... 13
carbamazepine er .................. 13
CARBIDOPA .......................... 35
carbidopa-levodopa ............... 35
carbidopa-levodopa er ........... 35
carbidopa-levodopaentacapone ............................ 35
carboplatin ............................. 28
CARDENE I.V. ....................... 51
CARDENE SR ....................... 51
CARDURA XL ........................ 51
CARIMUNE NF
NANOFILTERED ................... 81
CARISOPRODOL .................. 97
CARISOPRODOLASPIRIN ................................ 97
CARISOPRODOLASPIRIN-CODEINE ............... 97
CARNITOR ............................ 88
CARNITOR SF....................... 88
carteolol hcl ............................ 90
cartia xt .................................. 51
carvedilol ................................ 51
CAYSTON ............................... 6
cefaclor .................................... 6
cefaclor er ................................ 6
cefadroxil ................................. 6
cefazolin sodium ...................... 7
Index of Drugs
cefazolin sodiumdextrose ................................... 7
cefdinir ...................................... 7
CEFDITOREN PIVOXIL ........... 7
cefepime hcl ............................. 7
cefixime .................................... 7
cefotan ..................................... 7
cefotaxime sodium ................... 7
cefotetan .................................. 7
cefoxitin .................................... 7
cefoxitin sodium ....................... 7
cefpodoxime proxetil ................ 7
cefprozil .................................... 7
ceftazidime ............................... 7
ceftibuten .................................. 7
CEFTIN .................................... 7
CEFTRIAXONE ........................ 7
cefuroxime ................................ 7
cefuroxime sodium ................... 7
celecoxib ................................ 24
CELESTONE ......................... 68
CELLCEPT ............................. 81
CELONTIN ............................. 14
centany ..................................... 7
cephalexin ................................ 7
CERDELGA ........................... 63
CEREZYME ........................... 63
cerubidine ............................... 28
CERVARIX ............................. 81
CESAMET .............................. 20
CETRAXAL .............................. 7
CEVIMELINE HCL ................. 60
CHANTIX ................................. 5
chateal .................................... 73
CHEMET ................................ 98
CHENODAL ........................... 88
chloramphenicol sod
succinate .................................. 7
chlordiazepoxide hcl ............... 43
CHLORDIAZEPOXIDEAMITRIPTYLINE .................... 43
chlorhexidine gluconate ......... 60
chloroquine phosphate ........... 34
chlorothiazide ......................... 51
chlorothiazide sodium ............ 51
chlorpromazine hcl ................. 36
CHLORPROPAMIDE ............. 44
chlorthalidone ......................... 51
chlorzoxazone ........................ 97
CHOLBAM ............................. 64
cholestyramine ....................... 51
cholestyramine light ............... 51
CHORIONIC
GONADOTROPIN .................. 71
CIALIS .................................... 66
CICLODAN ............................. 21
ciclopirox ................................21
CIDOFOVIR ........................... 39
cilostazol ................................48
CILOXAN ................................. 7
cimetidine ............................... 64
CIMZIA ................................... 81
CINQAIR ................................93
CINRYZE ............................... 81
CIPRO ...................................... 7
CIPRO HC .............................. 92
CIPRODEX ............................ 92
ciprofloxacin ............................. 7
ciprofloxacin er ......................... 7
ciprofloxacin hcl ........................ 7
ciprofloxacin-d5w ..................... 8
cisplatin .................................. 28
citalopram hbr ........................ 18
CLADRIBINE .......................... 28
CLARAVIS ............................. 61
clarithromycin ........................... 8
clarithromycin er ....................... 8
clemastine fumarate ............... 93
CLEOCIN ................................. 8
CLEVIPREX ........................... 51
CLIMARA ............................... 73
CLIMARA PRO ...................... 73
CLINDACIN P .......................... 8
CLINDAGEL ............................. 8
clindamycin hcl ......................... 8
clindamycin palmitate
hcl ............................................. 8
clindamycin phosbenzoyl perox ......................... 61
clindamycin phosphate ............. 8
105
clindamycin phosphated5w ...........................................8
CLINDAMYCIN PHOSTRETINOIN ............................61
clindamycin-benzoyl
peroxide .................................61
CLINDESSE .............................8
CLINIMIX ................................98
CLINIMIX E ............................98
CLINISOL ...............................99
clobetasol propionate .............68
CLOBEX .................................68
clocortolone pivalate ..............68
CLOLAR .................................28
clomipramine hcl ....................18
clonazepam ............................14
CLONIDINE ............................51
clonidine hcl ...........................51
CLONIDINE HCL ER .............57
clopidogrel ..............................48
clorazepate dipotassium ........14
CLORPRES ...........................51
clotrimazole ............................21
clotrimazolebetamethasone ......................21
clozapine ................................36
clozapine odt ..........................36
COARTEM .............................34
codeine sulfate .........................1
COLCHICINE .........................24
COLCRYS ..............................24
colestipol hcl ...........................51
COLISTIMETHATE ..................8
colocort ...................................86
COLY-MYCIN S .....................92
COMBIGAN ............................90
COMBIPATCH .......................74
COMBIVENT
RESPIMAT .............................93
COMBIVIR .............................39
COMETRIQ ............................28
COMPLERA ...........................39
compro ...................................20
COMVAX ................................81
CONDYLOX ...........................61
Index of Drugs
constulose .............................. 64
COPAXONE .......................... 58
COPEGUS ............................. 39
CORDRAN ............................. 69
COREG CR ........................... 51
CORLANOR .......................... 51
CORTENEMA ........................ 86
CORTIFOAM ......................... 69
cortisone acetate ................... 69
CORTISPORIN .................. 8, 90
CORTISPORIN-TC ................ 92
COSENTYX (2
SYRINGES) ........................... 81
COSENTYX PEN (2
PENS) .................................... 81
COSMEGEN .......................... 28
COSOPT PF .......................... 90
COTELLIC ............................. 28
COUMADIN ........................... 48
CREON .................................. 63
CRESEMBA ........................... 22
CRESTOR ............................. 51
CRIXIVAN .............................. 39
CROFAB ................................ 88
CROMOLYN SODIUM ..... 90, 93
cryselle ................................... 74
CUBICIN .................................. 8
CUPRIMINE ........................... 99
CUROSURF .......................... 88
cyanocobalamin
injection .................................. 99
cyclafem ................................. 74
cyclobenzaprine hcl ............... 97
CYCLOGYL ........................... 90
cyclopentolate hcl .................. 90
CYCLOPHOSPHAMIDE ........ 28
CYCLOSERINE ..................... 26
CYCLOSET ........................... 44
cyclosporine ........................... 81
cyclosporine modified ............ 82
CYKLOKAPRON ................... 48
cyproheptadine hcl ................. 93
CYRAMZA ............................. 28
cyred ...................................... 74
CYSTADANE ......................... 63
CYSTAGON ........................... 63
CYSTARAN ........................... 90
cytarabine .............................. 28
CYTOGAM ............................. 88
CYTOMEL ............................. 79
D
D.H.E.45 ................................ 25
dacarbazine ........................... 28
DACOGEN ............................. 28
DAKLINZA ............................. 39
DALIRESP ............................. 93
DALVANCE ............................. 8
danazol .................................. 74
dantrolene sodium ................. 38
dapsone ................................. 26
DAPTACEL DTAP ................. 82
DARAPRIM ............................ 34
darifenacin er ......................... 67
DARZALEX ............................ 28
dasetta ................................... 74
daunorubicin hcl ..................... 28
DAUNOXOME ....................... 28
daysee ................................... 74
DAYTRANA ........................... 58
DDAVP .................................. 71
deblitane ................................ 74
decitabine .............................. 28
deferoxamine mesylate .......... 88
DELESTROGEN .................... 74
deltasone ............................... 69
delyla ..................................... 74
DELZICOL ............................. 86
demeclocycline hcl ................... 8
DEMSER ............................... 52
DENAVIR ............................... 39
denta 5000 plus ..................... 99
dentagel ................................. 99
DEPACON ............................. 14
DEPAKENE ........................... 14
DEPAKOTE ........................... 14
DEPAKOTE ER ..................... 14
DEPAKOTE SPRINKLE ........ 14
DEPEN .................................. 99
DEPO-ESTRADIOL ............... 74
106
DEPO-MEDROL .................... 69
DEPO-SUBQ
PROVERA 104 ...................... 74
DESCOVY ............................. 39
DESFERAL ............................ 88
DESFERAL MESYLATE ........ 88
desipramine hcl ...................... 18
desloratadine ......................... 93
desmopressin acetate ............ 71
desogestrel-ethinyl
estradiol ................................. 74
desogestr-eth estrad eth
estra ....................................... 74
DESONATE ........................... 69
DESONIDE ............................ 69
DESOXIMETASONE ............. 69
DESVENLAFAXINE ER
(BRAND) ................................ 18
desvenlafaxine er (like
khedezla) ............................... 18
DESVENLAFAXINE
FUMARATE ER
(BRAND) ................................ 18
dexamethasone ..................... 69
dexamethasone intensol ........ 69
dexamethasone sodium
phosphate ........................ 69, 90
DEXEDRINE .......................... 58
DEXILANT ............................. 64
DEXMETHYLPHENIDA
TE HCL .................................. 58
DEXMETHYLPHENIDA
TE HCL ER ............................ 58
DEXRAZOXANE .................... 29
DEXTROAMPHETAMIN
E SULFATE ........................... 58
DEXTROAMPHETAMIN
E SULFATE ER ..................... 58
DEXTROAMPHETAMIN
E-AMPHET ER ...................... 58
DEXTROAMPHETAMIN
E-AMPHETAMINE ................. 58
dextrose 10%-0.2% nacl ........ 99
dextrose 10%-0.45%
nacl ........................................ 99
dextrose 2.5%-0.45%
nacl ........................................ 99
Index of Drugs
dextrose 5%-0.2% nacl .......... 99
dextrose 5%-0.2% naclkcl ........................................... 99
dextrose 5%-0.225%
nacl ......................................... 99
dextrose 5%-0.225%
nacl-kcl ................................... 99
dextrose 5%-0.3% nacl .......... 99
dextrose 5%-0.3% naclkcl ........................................... 99
dextrose 5%-0.33% nacl ........ 99
dextrose 5%-0.33%
nacl-kcl ................................... 99
dextrose 5%-0.45% nacl ........ 99
dextrose 5%-0.45%
nacl-kcl ................................... 99
dextrose 5%-0.9% nacl .......... 99
dextrose 5%-1/2ns-kcl ............ 99
dextrose 5%-1/4ns-kcl ............ 99
dextrose 5%-electrolyte
#48 ......................................... 99
dextrose 5%-ns-kcl ................. 99
dextrose 5%-potassium
chloride ................................... 99
dextrose in lactated
ringers .................................... 99
dextrose in ringers
injection .................................. 99
dextrose in water .............. 88, 99
DIABETA ................................ 44
diazepam ................................ 43
DIBENZYLINE ........................ 52
diclofenac potassium .............. 24
DICLOFENAC SODIUM .. 24, 61,
90
diclofenac sodium er .............. 24
diclofenac sodiummisoprostol ............................. 24
dicloxacillin sodium .................. 8
dicyclomine hcl ....................... 64
didanosine .............................. 39
DIFFERIN ............................... 61
DIFICID .................................... 8
diflorasone diacetate .............. 69
diflunisal ................................. 24
DIGIFAB ................................. 88
digitek ..................................... 52
digoxin .................................... 52
DIHYDROERGOTAMIN
E MESYLATE ......................... 25
DILANTIN ............................... 14
DILANTIN-125 ........................ 14
DILATRATE-SR ..................... 52
diltiazem 12hr er ..................... 52
diltiazem 24hr er ..................... 52
diltiazem er ............................. 52
diltiazem hcl ........................... 52
dilt-xr ...................................... 52
DIPENTUM ............................ 86
diphenhydramine hcl .............. 93
diphenoxylate-atropine ........... 65
DIPHTHERIATETANUS TOXOIDSPED ........................................ 82
dipyridamole ........................... 48
diskets ...................................... 1
DISULFIRAM ........................... 5
divalproex sodium .................. 14
divalproex sodium er .............. 14
DIVIGEL ................................. 74
DOCEFREZ ........................... 29
DOCETAXEL ......................... 29
dofetilide ................................. 52
donepezil hcl .......................... 17
donepezil hcl odt .................... 17
DORIBAX ................................. 8
dorzolamide hcl ...................... 90
dorzolamide-timolol ................ 90
doxazosin mesylate ................ 67
DOXEPIN HCL ................. 18, 61
DOXERCALCIFEROL ............ 87
DOXIL .................................... 29
doxorubicin hcl ....................... 29
doxorubicin hcl liposome ........ 29
doxy 100 ................................... 8
doxycycline hyclate .................. 8
DOXYCYCLINE IR-DR ............8
doxycycline
monohydrate ............................ 8
DRONABINOL ....................... 20
107
drospirenone-ethinyl
estradiol ..................................74
DROXIA .................................29
DUAVEE ................................74
DULERA .................................93
duloxetine hcl .........................18
DURAGESIC ............................1
duramorph ................................1
DUREZOL ..............................90
dutasteride .............................67
dutasteride-tamsulosin ...........67
DYRENIUM ............................52
E
E.E.S. 200 ................................9
e.e.s. 400 .................................9
econazole nitrate ....................22
ECOZA ...................................22
EDARBI ..................................52
EDARBYCLOR ......................52
EDECRIN ...............................52
EDLUAR .................................97
EDURANT ..............................39
EFFIENT ................................48
EGRIFTA ................................72
ELAPRASE ............................63
ELELYSO ...............................63
ELESTRIN ..............................74
ELIDEL ...................................61
ELIGARD ...............................80
elinest .....................................74
eliphos ....................................67
ELIQUIS .................................48
ELITEK ...................................29
ELIXOPHYLLIN ......................93
ELLA ......................................74
ELLENCE ...............................29
ELMIRON ...............................67
ELOXATIN .............................29
EMADINE ...............................90
EMBEDA ..................................1
EMCYT ...................................29
EMEND ..................................20
EMLA .......................................4
emoquette ..............................74
Index of Drugs
EMPLICITI ............................. 29
EMSAM .................................. 18
EMTRIVA ............................... 39
EMVERM ............................... 34
ENABLEX .............................. 67
enalapril maleate ................... 52
enalaprilhydrochlorothiazide ................ 52
ENBREL ................................ 82
endocet .................................... 1
endodan ................................... 1
ENGERIX-B ADULT .............. 82
ENGERIX-B
PEDIATRICADOLESCENT ...................... 82
ENJUVIA ................................ 74
ENOXAPARIN SODIUM ........ 48
enpresse ................................ 74
enskyce .................................. 74
ENSTILAR ............................. 61
entacapone ............................ 35
ENTECAVIR .......................... 39
ENTOCORT EC ..................... 86
ENTRESTO ........................... 52
enulose .................................. 65
ENVARSUS XR ..................... 82
EPIDUO ................................. 61
EPIDUO FORTE .................... 61
epinastine hcl ......................... 90
epinephrine ............................ 93
EPIPEN 2-PAK ...................... 93
EPIPEN JR 2-PAK ................. 94
epirubicin hcl .......................... 29
epitol ...................................... 14
EPIVIR ................................... 39
EPIVIR HBV ........................... 39
eplerenone ............................. 52
EPOGEN ............................... 49
epoprostenol sodium ............. 94
eprosartan mesylate .............. 52
EPZICOM .............................. 39
EQUETRO ............................. 44
ERAXIS (WATER
DILUENT) .............................. 22
ERBITUX ............................... 29
ERGOLOID
MESYLATES ......................... 17
ERGOMAR ............................ 25
ERIVEDGE ............................ 29
errin ........................................ 74
ERTACZO .............................. 22
ERWINAZE ............................ 29
ery ............................................ 9
ERYGEL .................................. 9
ERYPED 200 ........................... 9
ERYPED 400 ........................... 9
ERY-TAB ................................. 9
ERYTHROCIN
LACTOBIONATE ..................... 9
ERYTHROCIN
STEARATE .............................. 9
ERYTHROMYCIN .................... 9
ERYTHROMYCIN
ETHYLSUCCINATE ................ 9
erythromycin-benzoyl
peroxide ................................. 61
ESBRIET ............................... 94
ESCITALOPRAM
OXALATE .............................. 18
esomeprazole
magnesium ............................ 65
esomeprazole sodium ............ 65
estarylla ................................. 74
ESTRACE .............................. 74
estradiol ................................. 74
estradiol valerate ................... 74
estradiol-norethindrone
acetat ..................................... 74
ESTRING ............................... 74
ESTROGEL ........................... 74
estropipate ............................. 74
eszopiclone ............................ 97
ETHACRYNATE
SODIUM ................................ 52
ETHACRYNIC ACID .............. 52
ethambutol hcl ....................... 27
ethosuximide .......................... 14
etidronate disodium ............... 87
etodolac ................................. 24
etodolac er ............................. 24
ETOPOPHOS ........................ 29
108
etoposide ............................... 29
EURAX .................................. 34
EVAMIST ............................... 74
EVOCLIN ................................. 9
EVOMELA ............................. 29
EVOTAZ ................................ 39
EVZIO ...................................... 5
EXELDERM ........................... 22
EXELON ................................ 17
EXEMESTANE ...................... 29
EXJADE ................................. 99
EXTAVIA ................................ 58
EXTINA .................................. 22
F
FABIOR ................................. 61
FABRAZYME ......................... 63
FACTIVE .................................. 9
falmina ................................... 75
famciclovir .............................. 40
famotidine .............................. 65
FANAPT ................................. 36
FARESTON ........................... 29
FARYDAK .............................. 29
FASLODEX ............................ 29
FAZACLO .............................. 37
FELBAMATE ......................... 14
FELBATOL ............................ 14
felodipine er ........................... 52
FEMHRT ................................ 75
FEMRING .............................. 75
fenofibrate .............................. 52
fenofibric acid ......................... 53
FENOGLIDE .......................... 53
fenoprofen calcium ................ 24
fentanyl .................................... 1
FENTANYL CITRATE .............. 2
FENTORA ................................ 2
FERRIPROX .......................... 99
FETZIMA ............................... 18
FINACEA ............................... 61
finasteride .............................. 67
FIRAZYR ............................... 82
FIRMAGON............................ 29
FLAGYL ER ............................. 9
Index of Drugs
FLAREX ................................. 90
flavoxate hcl ........................... 67
FLEBOGAMMA DIF ............... 82
flecainide acetate ................... 53
FLECTOR .............................. 24
FLOLAN ................................. 94
FLOVENT DISKUS ................ 94
FLOVENT HFA ...................... 94
fluconazole ............................. 22
fluconazole-nacl ..................... 22
FLUCYTOSINE ...................... 22
fludarabine phosphate ............ 29
fludrocortisone acetate ........... 69
flunisolide ............................... 94
fluocinolone acetonide ........... 69
fluocinolone acetonide
oil ............................................ 92
fluocinonide ............................ 69
fluorometholone ..................... 90
FLUOROPLEX ....................... 62
fluorouracil ........................ 29, 62
FLUOXETINE DR
(WEEKLY) .............................. 18
fluoxetine hcl .......................... 18
fluphenazine decanoate ......... 37
fluphenazine hcl ..................... 37
FLURANDRENOLIDE ............ 69
flurbiprofen ............................. 24
flurbiprofen sodium ................. 90
flutamide ................................. 80
fluticasone propionate ...... 70, 94
fluvastatin er ........................... 53
fluvastatin sodium .................. 53
fluvoxamine maleate .............. 19
fluvoxamine maleate er .......... 19
FML FORTE ........................... 90
FML S.O.P. ............................ 90
folic acid ................................. 99
FOLOTYN .............................. 29
FOMEPIZOLE ........................ 88
FONDAPARINUX
SODIUM ................................. 49
FORADIL ................................ 94
FORTAZ ................................... 9
FORTEO ................................ 87
FORTESTA ............................ 75
fortical ..................................... 87
FOSAMAX PLUS D ................ 87
foscarnet sodium .................... 40
fosinopril sodium .................... 53
fosinoprilhydrochlorothiazide ................ 53
fosphenytoin sodium .............. 14
FOSRENOL ........................... 67
FRAGMIN ............................... 49
FREAMINE HBC .................... 99
freamine iii .............................. 88
FROVA ................................... 25
frovatriptan succinate ............. 25
FULYZAQ ............................... 88
furosemide ............................. 53
FUSILEV ................................29
FUZEON ................................40
fyavolv .................................... 75
FYCOMPA ............................. 14
G
gabapentin ............................. 14
GABITRIL ............................... 14
GABLOFEN ............................ 38
galantamine hbr ..................... 17
galantamine
hydrobromide ......................... 17
GAMMAGARD LIQUID ..........82
GAMMAKED .......................... 82
GAMMAPLEX ........................ 82
GAMUNEX-C ......................... 82
GANCICLOVIR
SODIUM ................................. 40
GARDASIL ............................. 82
GARDASIL 9 .......................... 82
GASTROCROM ..................... 65
gatifloxacin ............................... 9
GATTEX ................................. 65
gavilyte-c ................................65
gavilyte-g ................................65
gavilyte-h and bisacodyl ......... 65
gavilyte-n ................................65
GAZYVA ................................. 29
GELNIQUE ............................. 67
GEMCITABINE HCL .............. 29
109
gemfibrozil ..............................53
GEMZAR ................................30
GENERESS FE ......................75
generlac .................................65
gengraf ...................................82
GENOTROPIN .......................72
gentak ......................................9
gentamicin sulfate ..............9, 90
gentamicin sulfate in ns ............9
GENVOYA .............................40
GEODON ...............................37
gianvi ......................................75
GIAZO ....................................86
gildagia ...................................75
gildess ....................................75
gildess 24 fe ...........................75
gildess fe ................................75
GILENYA ................................58
GILOTRIF ...............................30
GLASSIA ................................94
GLEEVEC ..............................30
GLEOSTINE ...........................30
glimepiride ..............................45
glipizide ..................................45
glipizide er ..............................45
glipizide xl ...............................45
glipizide-metformin .................45
GLUCAGEN ...........................45
GLUCAGON
EMERGENCY KIT .................45
GLUCOVANCE ......................45
GLUMETZA ............................45
GLYBURIDE ..........................45
GLYBURIDE
MICRONIZED ........................45
GLYBURIDEMETFORMIN HCL .................45
glycopyrrolate .........................65
GLYNASE ..............................45
GLYSET .................................45
GRALISE ................................15
granisetron hcl ........................20
GRANIX .................................49
GRASTEK ..............................88
GRIFULVIN V .........................22
Index of Drugs
GRISEOFULVIN .................... 22
GRISEOFULVIN
ULTRAMICROSIZE ............... 22
guanfacine hcl ........................ 53
GUANFACINE HCL ER ......... 58
GUANIDINE HCL ................... 26
H
H.P. ACTHAR ........................ 70
HALAVEN .............................. 30
halobetasol propionate .......... 70
HALOG .................................. 70
haloperidol ............................. 37
haloperidol decanoate ........... 37
haloperidol lactate .................. 37
HARVONI .............................. 40
HAVRIX ................................. 82
heather ................................... 75
HECTOROL ........................... 87
heparin sodium ...................... 49
heparin sodium in 0.45%
nacl ........................................ 49
heparin sodium-0.9%
nacl ........................................ 49
heparin sodium-d5w .............. 49
hepatamine .......................... 100
HEPSERA .............................. 40
HERCEPTIN .......................... 30
HETLIOZ ................................ 97
HEXALEN .............................. 30
HIBERIX ................................ 82
HIZENTRA ............................. 82
homatropaire .......................... 90
homatropine
hydrobromide ......................... 90
HORIZANT ............................ 15
HUMALOG ............................. 45
HUMALOG KWIKPEN
U-100 ..................................... 45
HUMALOG KWIKPEN
U-200 ..................................... 46
HUMALOG MIX 50-50 ........... 46
HUMALOG MIX 50-50
KWIKPEN .............................. 46
HUMALOG MIX 75-25 ........... 46
HUMALOG MIX 75-25
KWIKPEN .............................. 46
HUMATROPE ........................ 72
HUMIRA ................................. 82
HUMIRA PEDIATRIC
CROHN'S ............................... 83
HUMIRA PEN ........................ 83
HUMIRA PEN CROHNUC-HS STARTER .................. 83
HUMIRA PEN
PSORIASIS-UVEITIS ............ 83
HUMULIN 70/30
KWIKPEN .............................. 46
HUMULIN 70-30 .................... 46
HUMULIN N ........................... 46
HUMULIN N KWIKPEN ......... 46
HUMULIN R ........................... 46
HUMULIN R U-500 ................ 46
HUMULIN R U-500
KWIKPEN .............................. 46
HYCAMTIN ............................ 30
hydralazine hcl ....................... 53
hydrochlorothiazide ................ 53
hydrocodone bthomatropine mbr .................... 94
hydrocodoneacetaminophen ........................ 2
hydrocodonehomatropine mbr .................... 94
hydrocodone-ibuprofen ............ 2
hydrocortisone ................. 70, 86
hydrocortisone butyrate ......... 70
hydrocortisone valerate ......... 70
HYDROCORTISONEACETIC ACID ........................ 92
hydromet ................................ 94
HYDROMORPHONE
ER ............................................ 2
hydromorphone hcl .................. 2
hydroxychloroquine
sulfate .................................... 34
HYDROXYPROGESTE
RONE CAPROATE ................ 75
hydroxyurea ........................... 30
HYDROXYZINE HCL ............. 94
110
HYDROXYZINE
PAMOATE ............................. 43
HYQVIA ................................. 83
HYSINGLA ER ......................... 2
I
ibandronate sodium ............... 87
IBRANCE ............................... 30
ibuprofen ................................ 24
ICLUSIG ................................ 30
IDAMYCIN PFS ..................... 30
IDARUBICIN HCL .................. 30
ifosfamide .............................. 30
IFOSFAMIDE-MESNA ........... 30
ILARIS ................................... 83
ILEVRO .................................. 90
IMATINIB MESYLATE ........... 30
IMBRUVICA ........................... 30
imipenem-cilastatin
sodium ..................................... 9
IMIPRAMINE HCL ................. 19
IMIPRAMINE
PAMOATE ............................. 19
IMIQUIMOD ........................... 62
IMLYGIC ................................ 30
IMOVAX RABIES
VACCINE ............................... 83
INCRELEX ............................. 72
INCRUSE ELLIPTA ............... 94
indapamide ............................ 53
indomethacin ......................... 24
INFANRIX DTAP.................... 83
INFUMORPH ........................... 2
INLYTA .................................. 30
INNOPRAN XL....................... 25
INSULIN SYRINGE................ 88
INTELENCE ........................... 40
INTERMEZZO........................ 98
INTRALIPID ........................... 88
INTRON A .............................. 40
introvale ................................. 75
INVANZ .................................... 9
INVEGA ................................. 37
INVEGA SUSTENNA ............. 37
INVEGA TRINZA ................... 37
INVIRASE .............................. 40
Index of Drugs
INVOKAMET .......................... 46
INVOKAMET XR .................... 46
INVOKANA ............................. 46
IONOSOL B WITH
DEXTROSE 5% ................... 100
IONOSOL MBDEXTROSE 5% ................... 100
IOPIDINE ............................... 90
IPOL ....................................... 83
ipratropium bromide ............... 94
ipratropium-albuterol .............. 94
irbesartan ............................... 53
irbesartanhydrochlorothiazide ................ 53
IRESSA .................................. 30
irinotecan hcl .......................... 30
ISENTRESS ........................... 40
isochron .................................. 53
ISOLYTE M WITH
DEXTROSE ......................... 100
ISOLYTE P WITH
DEXTROSE ......................... 100
ISOLYTE S ........................... 100
isoniazid ................................. 27
ISOPTO ATROPINE .............. 88
isosorbide dinitrate ................. 53
isosorbide mononitrate ........... 53
isosorbide mononitrate
er ............................................ 53
isradipine ................................ 53
ISTALOL ................................ 90
ISTODAX ............................... 30
ISUPREL ................................ 94
ITRACONAZOLE ................... 22
ivermectin ............................... 34
IXEMPRA ............................... 30
IXIARO ................................... 83
J
JADENU ............................... 100
JAKAFI ................................... 30
jantoven .................................. 49
JANUMET .............................. 46
JANUMET XR ........................ 46
JANUVIA ................................ 46
JARDIANCE ........................... 46
jencycla .................................. 75
JENTADUETO ....................... 46
JENTADUETO XR ................. 46
JEVTANA ............................... 30
jinteli ....................................... 75
jolessa .................................... 75
jolivette ................................... 75
JUBLIA ................................... 22
juleber .................................... 75
junel ........................................ 75
junel fe .................................... 75
junel fe 24 ............................... 75
JUXTAPID .............................. 53
K
KABIVEN ..............................100
KADCYLA .............................. 31
KADIAN .................................... 2
kaitlib fe .................................. 75
KALBITOR ............................. 88
KALETRA ............................... 40
KALYDECO ............................ 94
KANUMA ................................63
KAPVAY ................................. 58
kariva ...................................... 75
KAZANO ................................46
kelnor 1-35 ............................. 75
KENALOG .............................. 70
KENALOG-10 ......................... 70
KENALOG-40 ......................... 70
KEPIVANCE ........................... 60
KEPPRA ................................. 15
KEPPRA XR ........................... 15
KERYDIN ............................... 22
KETEK ..................................... 9
ketoconazole .......................... 22
KETODAN .............................. 22
ketoprofen .............................. 24
ketorolac tromethamine ....24, 90
KEVEYIS ................................88
KEYTRUDA ............................ 31
kimidess ................................. 75
KINERET ................................83
KINRIX ................................... 83
kionex ................................... 100
111
klor-con 10 ...........................100
klor-con 8 .............................100
klor-con m10 ........................100
klor-con m15 ........................100
klor-con m20 ........................100
klor-con sprinkle ...................100
KOMBIGLYZE XR ..................46
KORLYM ................................88
KRISTALOSE .........................65
KRYSTEXXA ..........................63
kurvelo ....................................75
KUVAN ...................................63
KYNAMRO .............................53
KYPROLIS .............................31
L
labetalol hcl ............................53
LACRISERT ...........................90
lactated ringers .....................100
lactulose .................................65
LAMICTAL ODT (BLUE) ........15
LAMICTAL ODT
(GREEN) ................................15
LAMICTAL ODT
(ORANGE) .............................15
LAMISIL .................................22
lamivudine ..............................40
lamivudine hbv .......................40
LAMIVUDINEZIDOVUDINE .........................40
LAMOTRIGINE ......................15
LAMOTRIGINE ER ................15
LAMOTRIGINE ODT ..............15
LAMOTRIGINE ODT
(BLUE) ...................................15
LAMOTRIGINE ODT
(GREEN) ................................15
LAMOTRIGINE ODT
(ORANGE) .............................15
LANOXIN ...............................53
LANOXIN PEDIATRIC ...........54
LANSOPRAZ-AMOXCLARITHRO ............................9
lansoprazole ...........................65
LANTUS .................................47
LANTUS SOLOSTAR ............47
Index of Drugs
larin ........................................ 75
larin 24 fe ............................... 75
larin fe .................................... 75
larissia .................................... 75
latanoprost ............................. 91
LATUDA ................................. 37
LAZANDA ................................ 2
leena ...................................... 75
leflunomide ............................ 83
LEMTRADA ........................... 58
LENVIMA ............................... 31
LESCOL XL ........................... 54
lessina .................................... 75
LETAIRIS ............................... 94
letrozole ................................. 31
leucovorin calcium ................. 31
LEUKERAN ........................... 31
LEUKINE ............................... 49
leuprolide acetate .................. 80
LEVALBUTEROL
CONCENTRATE ................... 94
LEVALBUTEROL HCL .......... 94
LEVATOL ............................... 54
LEVEMIR ............................... 47
LEVEMIR FLEXTOUCH ........ 47
levetiracetam ......................... 15
levetiracetam er ..................... 15
LEVETIRACETAMNACL ..................................... 15
LEVITRA ................................ 67
levobunolol hcl ....................... 91
levocarnitine ........................... 88
levocetirizine
dihydrochloride ...................... 94
levofloxacin .............................. 9
levofloxacin-d5w .................... 10
LEVOLEUCOVORIN
CALCIUM ............................... 31
levonest ................................. 75
levonorgestrel ........................ 75
levonorgestrel-eth
estradiol ................................. 75
levonorg-eth estrad eth
estrad ..................................... 75
levora-28 ................................ 76
LEVORPHANOL
TARTRATE .............................. 2
levothyroxine sodium ............. 79
levoxyl .................................... 79
LEXIVA .................................. 40
LIALDA .................................. 86
lidocaine ................................... 4
lidocaine hcl ....................... 4, 54
lidocaine hcl viscous ................ 4
lidocaine-prilocaine .................. 5
LIDODERM .............................. 5
LINCOCIN .............................. 10
LINCOMYCIN HCL ................ 10
LINDANE ............................... 34
LINEZOLID ............................ 10
LINZESS ................................ 65
liothyronine sodium ................ 79
lipodox ................................... 31
lipodox 50 .............................. 31
LIPTRUZET ........................... 54
lisinopril .................................. 54
lisinoprilhydrochlorothiazide ................ 54
lithium .................................... 44
LITHIUM CARBONATE ......... 44
lithium carbonate er ............... 44
LITHOSTAT ........................... 67
LIVALO .................................. 54
LO LOESTRIN FE ................. 76
LOCOID ................................. 70
LOCOID LIPOCREAM ........... 70
LODOSYN ............................. 35
lomedia 24 fe ......................... 76
lomustine ............................... 31
LONSURF .............................. 31
loperamide ............................. 65
LOPREEZA ............................ 76
LOPRESSOR ........................ 54
lorazepam .............................. 43
loryna ..................................... 76
losartan potassium ................. 54
losartanhydrochlorothiazide ................ 54
LOTEMAX .............................. 91
LOTRONEX ........................... 65
112
lovastatin ................................ 54
low-ogestrel ........................... 76
loxapine ................................. 37
LUFYLLIN .............................. 94
LUMIGAN .............................. 91
LUMIZYME ............................ 63
LUNESTA .............................. 98
LUPRON DEPOT................... 80
LUPRON DEPOT-PED .......... 80
lutera ...................................... 76
LUZU ..................................... 22
LYNPARZA ............................ 31
LYRICA ............................ 15, 58
LYSODREN ........................... 79
M
MACROBID............................ 10
MACRODANTIN .................... 10
MAGNESIUM
CHLORIDE .......................... 100
MAGNESIUM
SULFATE ............................. 100
MAGNESIUM
SULFATE-0.45% NACL ....... 100
MAGNESIUM
SULFATE-D5W.................... 100
MALATHION .......................... 35
maprotiline hcl ........................ 19
MARINOL .............................. 20
marlissa ................................. 76
MARPLAN ............................. 19
MARQIBO .............................. 31
MARTEN-TAB.......................... 2
MATULANE ........................... 31
matzim la ............................... 54
MAXIDEX ............................... 91
meclizine hcl .......................... 20
meclofenamate sodium .......... 24
MEDROL ............................... 70
medroxyprogesterone
acetate ................................... 76
mefloquine hcl ........................ 35
MEGACE ES ......................... 76
megestrol acetate .................. 76
MEKINIST .............................. 31
MELOXICAM ......................... 25
Index of Drugs
MELPHALAN HCL ................. 31
memantine hcl ........................ 17
MENACTRA ........................... 83
MENEST ................................ 76
MENHIBRIX ........................... 83
MENOMUNE-A-C-Y-W135 ......................................... 83
MENTAX ................................ 22
MENVEO A-C-Y-W-135DIP ......................................... 83
MENVEO MENA
COMPONENT ........................ 83
MENVEO MENCYW135 COMPONENT ................. 83
MEPHYTON ......................... 100
MEPRON ............................... 35
mercaptopurine ...................... 31
MEROPENEM ........................ 10
MERREM ............................... 10
mesalamine ............................ 86
mesna .................................... 31
MESNEX ................................ 31
MESTINON ............................ 26
metadate er ............................ 59
metaproterenol sulfate ........... 94
metaxall .................................. 97
metaxalone ............................. 97
metformin hcl .......................... 47
metformin hcl er (like
fortamet) ................................. 47
metformin hcl er (like
glucophage xr) ....................... 47
METFORMIN HCL ER
(LIKE GLUMETZA) ................ 47
methadone hcl .......................... 2
methadone intensol .................. 2
methadose ............................... 2
methamphetamine hcl ............ 59
methazolamide ....................... 54
methenamine hippurate ......... 10
methimazole ........................... 80
METHITEST ........................... 76
methocarbamol ...................... 97
methotrexate .......................... 83
METHOXSALEN .................... 62
methscopolamine
bromide .................................. 65
methyclothiazide .................... 54
methyldopa ............................. 54
methyldopahydrochlorothiazide ................ 54
methyldopate hcl .................... 54
METHYLERGONOVINE
MALEATE .............................. 89
METHYLIN ............................. 59
METHYLPHENIDATE
ER .......................................... 59
METHYLPHENIDATE
HCL ........................................ 59
METHYLPHENIDATE
HCL CD .................................. 59
methylprednisolone .......... 70, 86
methylprednisolone
acetate ................................... 70
methylprednisolone sod
succ ........................................ 70
METHYLTESTOSTERO
NE .......................................... 76
metipranolol ............................ 91
metoclopramide hcl ................ 20
metoclopramide hcl odt ..........20
metolazone ............................. 54
metoprolol succinate .............. 54
metoprolol tartrate .................. 54
metoprololhydrochlorothiazide ................ 54
METOZOLV ODT ................... 20
metronidazole ......................... 10
mexiletine hcl ......................... 54
MIACALCIN ............................ 87
miconazole 3 .......................... 22
microgestin ............................. 76
microgestin fe ......................... 76
midodrine hcl .......................... 54
MIFEPREX ............................. 89
MIGERGOT ............................ 25
miglitol .................................... 47
MIGRANAL ............................ 25
mimvey lo ............................... 76
MINASTRIN 24 FE ................. 76
minitran .................................. 54
113
MINOCYCLINE HCL ..............10
MINOCYCLINE HCL ER ........10
minoxidil .................................54
MIRAPEX ER .........................35
MIRCERA ...............................49
mirtazapine .............................19
misoprostol .............................65
MITIGARE ..............................24
mitomycin ...............................31
mitoxantrone hcl .....................31
M-M-R II VACCINE ................83
modafinil .................................98
MODERIBA ............................40
moexipril hcl ...........................54
moexiprilhydrochlorothiazide ................54
MOLINDONE HCL .................37
mometasone furoate ........70, 94
mono-linyah ............................76
mononessa .............................76
montelukast sodium ...............95
MONUROL .............................10
MORPHINE SULFATE .............2
morphine sulfate er ..................3
MORPHINE SULFATE
IN DEXTROSE .........................3
MORPHINE SULFATE0.9% NACL ..............................3
MORPHINE SULFATED5W .........................................3
MOTOFEN .............................65
MOVANTIK ............................65
MOVIPREP ............................65
MOXATAG .............................10
MOXEZA ................................10
moxifloxacin hcl ......................10
MOZOBIL ...............................49
MULTAQ ................................54
multivitamin with fluoride ......100
mupirocin ................................10
MUSTARGEN ........................32
MYALEPT ..............................89
MYCAMINE ............................22
MYCOPHENOLATE
MOFETIL ................................83
Index of Drugs
MYCOPHENOLIC ACID ........ 83
MYDRIACYL .......................... 91
MYFORTIC ............................ 83
MYORISAN ............................ 62
MYOZYME ............................. 63
MYRBETRIQ ......................... 67
myzilra ................................... 76
N
nabumetone ........................... 25
nadolol ................................... 54
nadololbendroflumethiazide .............. 54
NAFCILLIN ............................ 10
NAFCILLIN SODIUM ............. 10
NAFTIFINE HCL .................... 22
NAFTIN .................................. 22
NAGLAZYME ......................... 63
nalbuphine hcl .......................... 3
naloxone hcl ............................. 5
naltrexone hcl .......................... 5
NAMENDA ............................. 17
NAMENDA XR ....................... 17
NAMZARIC ............................ 18
naphazoline hcl ...................... 91
naproxen ................................ 25
naproxen sodium ................... 25
naratriptan hcl ........................ 25
NARCAN .................................. 5
NASONEX ............................. 95
NATACYN .............................. 23
NATAZIA ................................ 76
nateglinide ............................. 47
NATESTO .............................. 76
NATPARA .............................. 87
NATROBA ............................. 35
NAVELBINE ........................... 32
NEBUPENT ........................... 35
necon ..................................... 76
nefazodone hcl ...................... 19
neomycin sulfate .................... 10
neomycin-bacitracinpoly-hc ................................... 10
neomycin-bacitracinpolymyxin ................................11
neomycin-polymyxin b ............11
neomycin-polymyxindexameth ............................... 91
neomycin-polymyxingramicidin .............................. 11
neomycin-polymyxin-hc ... 11, 92
neomycin-polymyxinhydrocort ................................ 92
neo-polycin ............................ 11
neo-polycin hc ........................ 11
NEORAL ................................ 84
NEO-SYNALAR ..................... 11
NEPHRAMINE ..................... 100
NESINA ................................. 47
NEULASTA ............................ 49
NEUMEGA ............................. 49
NEUPOGEN .......................... 49
NEUPRO ............................... 35
NEVANAC ............................. 91
nevirapine .............................. 40
nevirapine er .......................... 41
NEXAVAR .............................. 32
NEXIUM ................................. 65
NEXIUM I.V. .......................... 65
niacin er ................................. 54
niacor ..................................... 55
nicardipine hcl ........................ 55
NICOTROL .............................. 5
NICOTROL NS ........................ 5
nifedical xl .............................. 55
nifedipine er ........................... 55
nikki ........................................ 76
NILANDRON .......................... 80
NILUTAMIDE ......................... 32
nimodipine ............................. 55
NINLARO ............................... 32
NIPENT .................................. 32
nisoldipine .............................. 55
NITRO-BID ............................ 55
NITRO-DUR ........................... 55
nitrofurantoin .......................... 11
nitrofurantoin monomacro ..................................... 11
nitroglycerin ........................... 55
NITROLINGUAL .................... 55
NITROMIST ........................... 55
114
NITROSTAT........................... 55
nizatidine ................................ 65
nora-be .................................. 76
NORDITROPIN
FLEXPRO .............................. 72
norethindrone ......................... 76
norethindrone acetate ............ 76
norethindron-ethinyl
estradiol ................................. 76
norethin-eth estraferrous fum ............................. 76
norgestimate-ethinyl
estradiol ................................. 77
NORINYL 1+35 ...................... 77
NORINYL 1+50 ...................... 77
NORITATE ............................. 11
norlyroc .................................. 77
normosol-m and
dextrose ............................... 100
normosol-r and dextrose ...... 100
NORMOSOL-R PH 7.4 ........ 100
NORTHERA ........................... 55
nortrel ..................................... 77
nortriptyline hcl ....................... 19
NORVIR ................................. 41
novarel ................................... 72
NOXAFIL ............................... 23
NUCALA ................................ 95
NUCORT................................ 70
NUCYNTA................................ 3
NUCYNTA ER.......................... 3
NUEDEXTA ........................... 59
NULOJIX ................................ 84
NUPLAZID ............................. 37
NUTRILIPID ........................... 89
NUTROPIN AQ ...................... 72
NUTROPIN AQ
NUSPIN ................................. 72
NUVARING ............................ 77
NUVESSA .............................. 11
NUVIGIL ................................ 98
nyamyc .................................. 23
nystatin .................................. 23
nystatin-triamcinolone ............ 23
nystop .................................... 23
Index of Drugs
O
OCALIVA ................................ 65
ocella ...................................... 77
OCTAGAM ............................. 84
OCTREOTIDE
ACETATE ............................... 80
ODEFSEY .............................. 41
ODOMZO ............................... 32
OFEV ..................................... 95
ofloxacin ................................. 11
ogestrel .................................. 77
olanzapine .............................. 37
OLANZAPINE ODT ................ 37
OLANZAPINEFLUOXETINE HCL ................ 37
OLEPTRO ER ........................ 19
OLOPATADINE HCL ....... 91, 95
OLYSIO .................................. 41
omega-3 acid ethyl
esters ..................................... 55
omeprazole ............................ 65
OMEPRAZOLESODIUM
BICARBONATE ..................... 66
OMNARIS .............................. 95
OMNITROPE ......................... 72
ONCASPAR ........................... 32
ONDANSETRON HCL ........... 20
ondansetron odt ..................... 20
ONEXTON ............................. 62
ONFI ....................................... 15
ONGLYZA .............................. 47
ONMEL .................................. 23
ONZETRA XSAIL ................... 25
OPDIVO ................................. 32
OPSUMIT ............................... 95
ORACEA ................................ 11
ORALAIR ............................... 89
ORAP ..................................... 37
ORAPRED ODT ..................... 70
ORENCIA ............................... 84
ORENCIA CLICKJECT .......... 84
ORENITRAM ER .................... 95
ORFADIN ............................... 63
ORKAMBI ............................... 95
orphenadrine citrate ............... 97
orsythia ................................... 77
ORTHO TRI-CYCLEN
LO .......................................... 77
OSENI .................................... 47
OSMOPREP .......................... 66
OTEZLA ................................. 84
OTOVEL ................................. 92
OXACILLIN ............................ 11
OXACILLIN SODIUM ............. 11
OXALIPLATIN ........................ 32
OXANDRIN ............................ 77
OXANDROLONE ................... 77
oxaprozin ................................25
oxazepam ............................... 44
oxcarbazepine ........................ 16
OXICONAZOLE
NITRATE ................................23
OXISTAT ................................23
OXSORALEN ......................... 62
OXSORALEN-ULTRA ............ 62
OXTELLAR XR ...................... 16
oxybutynin chloride ................ 67
oxybutynin chloride er ............ 67
oxycodone hcl .......................... 3
OXYCODONE HCL ER ............3
oxycodone hcl-aspirin .............. 3
oxycodone hcl-ibuprofen .......... 3
oxycodoneacetaminophen ......................... 3
OXYCONTIN ............................ 3
OXYMORPHONE HCL ............4
OXYMORPHONE HCL
ER ............................................ 4
OXYTROL .............................. 67
P
pacerone ................................55
paclitaxel ................................32
PALIPERIDONE ER ............... 37
pamidronate disodium ............ 87
PANCREAZE ......................... 64
PANDEL ................................. 71
PANRETIN ............................. 32
pantoprazole sodium .............. 66
PARAFON FORTE DSC ........ 97
115
PARICALCITOL .....................87
paromomycin sulfate .............. 11
PAROXETINE ER ..................19
paroxetine hcl .........................19
PASER ...................................27
PATADAY ..............................91
PATANASE ............................95
PATANOL ..............................91
PAXIL .....................................19
PCE ........................................ 11
PEDIARIX ..............................84
PEDVAXHIB ...........................84
peg 3350-electrolyte ...............66
peg-3350 and
electrolytes .............................66
PEGANONE ...........................16
PEGASYS ..............................41
PEGASYS PROCLICK ...........41
PEGINTRON ..........................41
PEGINTRON REDIPEN .........41
penicillin g potassium ............. 11
penicillin g procaine ................ 11
penicillin g sodium .................. 11
PENICILLIN GK-ISOOSM DEXTROSE .................. 11
penicillin v potassium ............. 11
PENTACEL ............................84
PENTAM 300 .........................35
PENTASA ..............................86
PENTAZOCINENALOXONE HCL .....................4
pentoxifylline ..........................55
PERFOROMIST .....................95
PERIKABIVEN .....................100
perindopril erbumine ..............55
periogard ................................60
PERJETA ...............................32
PERMETHRIN .......................35
perphenazine .........................37
PERPHENAZINEAMITRIPTYLINE ....................38
PEXEVA .................................19
PFIZERPEN ........................... 11
PHENADOZ ...........................20
phenelzine sulfate ..................19
Index of Drugs
PHENERGAN ........................ 21
phenobarbital ......................... 16
PHENOXYBENZAMINE
HCL ........................................ 55
phentermine hcl ..................... 59
PHENYTEK ........................... 16
phenytoin ............................... 16
phenytoin sodium ................... 16
phenytoin sodium
extended ................................ 16
philith ..................................... 77
PHOSLYRA ........................... 67
PHOSPHA 250
NEUTRAL ............................ 100
PHOSPHOLINE
IODIDE .................................. 91
PHOTOFRIN .......................... 32
physiolyte ............................. 100
physiosol .............................. 100
PICATO ................................. 62
PILOCARPINE HCL ........ 60, 91
PIMOZIDE ............................. 38
pimtrea ................................... 77
pindolol .................................. 55
pioglitazone hcl ...................... 47
pioglitazone-glimepiride ......... 47
pioglitazone-metformin .......... 47
piperacillin-tazobactam ...........11
pirmella .................................. 77
piroxicam ............................... 25
PLASMA-LYTE 148 ............. 100
PLASMA-LYTE 56 IN
DEXTROSE ......................... 101
PLASMA-LYTE A PH
7.4 ........................................ 101
PLEGRIDY ............................. 59
PLEGRIDY PEN .................... 59
PLIAGLIS ................................. 5
podofilox ................................ 62
polyethylene glycol 3350 ........ 66
polymyxin b sulfate .................11
polymyxin b sultrimethoprim ............................11
POMALYST ........................... 32
PONTOCAINE ......................... 5
portia ...................................... 77
PORTRAZZA ......................... 32
potassium chl-normal
saline ................................... 101
potassium chloride ............... 101
POTASSIUM
CHLORIDE IN D5LR ........... 101
POTASSIUM
CHLORIDE-NACL ............... 101
potassium citrate er ............. 101
POTIGA ................................. 16
PRADAXA .............................. 49
PRALUENT PEN ................... 55
PRALUENT SYRINGE .......... 55
pramipexole
dihydrochloride ...................... 35
PRAMIPEXOLE ER ............... 35
PRAMOSONE ....................... 71
PRANDIMET .......................... 47
pravastatin sodium ................. 55
prazosin hcl ............................ 55
PRED MILD ........................... 91
PRED-G ................................. 91
prednicarbate ......................... 71
prednisolone acetate ............. 91
prednisolone sodium
phos odt ................................. 71
prednisolone sodium
phosphate ........................ 71, 91
prednisone ............................. 71
prednisone intensol ................ 71
PREFEST .............................. 77
pregnyl ................................... 72
PREMARIN ............................ 77
PREMASOL ......................... 101
PREMPHASE ........................ 77
PREMPRO ............................. 77
PRENATAL PLUS ............... 101
prevalite ................................. 55
PREVIDENT ........................ 101
PREVIDENT 5000
SENSITIVE .......................... 101
previfem ................................. 77
PREZCOBIX .......................... 41
PREZISTA ............................. 41
116
PRIFTIN ................................. 27
PRILOSEC ............................. 66
PRIMAQUINE ........................ 35
primidone ............................... 16
PRIMSOL ............................... 11
PRISTIQ ER .......................... 19
PRIVIGEN .............................. 84
PROAIR HFA ......................... 95
PROAIR RESPICLICK ........... 95
probenecid ............................. 24
probenecid-colchicine ............ 24
procainamide hcl .................... 55
PROCALAMINE ................... 101
prochlorperazine .................... 21
prochlorperazine
edisylate ................................. 38
prochlorperazine
maleate .................................. 21
PROCRIT ............................... 49
PROCTOFOAM-HC ............... 71
procto-med hc ........................ 71
procto-pak .............................. 71
proctosol-hc ........................... 71
proctozone-hc ........................ 71
PROCYSBI ............................ 64
progesterone .......................... 77
PROGLYCEM ........................ 47
PROGRAF ............................. 84
PROLASTIN C ....................... 95
PROLEUKIN .......................... 32
PROLIA .................................. 84
PROMACTA........................... 49
PROMETHAZINE HCL .......... 21
promethazine vc .................... 95
PROMETHEGAN ................... 21
propafenone hcl ..................... 55
propafenone hcl er ................. 55
proparacaine hcl .................... 91
propranolol hcl ....................... 55
propranolol hcl er ................... 25
propranololhydrochlorothiazid .................. 56
propylthiouracil ....................... 80
PROQUAD ............................. 84
PROSOL .............................. 101
Index of Drugs
PROTAMINE SULFATE ......... 49
PROTOPIC ............................ 62
PROTRIPTYLINE HCL .......... 19
PROVENTIL HFA ................... 95
PROVIGIL .............................. 98
PRUDOXIN ............................ 62
PULMICORT .......................... 95
PULMOZYME ........................ 95
PURIXAN ............................... 32
PYLERA ................................. 66
pyrazinamide .......................... 27
pyridostigmine bromide .......... 26
pyridostigmine bromide
er ............................................ 26
Q
QNASL ................................... 95
QNASL CHILDREN ................ 95
QUADRACEL DTAPIPV ......................................... 84
QUALAQUIN .......................... 35
QUARTETTE ......................... 77
quasense ................................ 77
QUDEXY XR .......................... 16
quetiapine fumarate ............... 38
quinapril hcl ............................ 56
quinaprilhydrochlorothiazide ................ 56
quinidine gluconate ................ 56
quinidine sulfate ..................... 56
QUININE SULFATE ............... 35
QVAR ..................................... 95
R
RABAVERT ............................ 84
rabeprazole sodium ................ 66
RADIOGARDASE .................. 89
RAGWITEK ............................ 89
RALOXIFENE HCL ................ 77
ramipril ................................... 56
RANEXA ................................ 56
RANITIDINE HCL ................... 66
RAPAFLO .............................. 67
RAPAMUNE ........................... 84
RAVICTI ................................. 64
REBETOL .............................. 41
REBIF ..................................... 59
REBIF REBIDOSE ................. 59
reclipsen ................................. 77
RECOMBIVAX HB ................. 84
REGONOL ............................. 26
REGRANEX ........................... 62
relador pak ............................... 5
RELENZA ............................... 41
RELISTOR ............................. 66
RELPAX ................................. 26
REMICADE ............................ 84
REMODULIN .......................... 95
RENACIDIN ......................... 101
RENVELA .............................. 67
repaglinide .............................. 47
REPAGLINIDEMETFORMIN HCL ................. 47
REPATHA
PUSHTRONEX ...................... 56
REPATHA SURECLICK ......... 56
REPATHA SYRINGE ............. 56
RESCRIPTOR ........................ 41
RESCULA .............................. 91
reserpine ................................56
RESTASIS ............................. 91
RETIN-A ................................. 62
RETIN-A MICRO .................... 62
RETROVIR ............................. 41
REVATIO ............................... 95
REVLIMID .............................. 32
REXULTI ................................38
REYATAZ ............................... 41
ribasphere .............................. 41
RIBASPHERE
RIBAPAK ................................41
RIBATAB ................................41
ribavirin ................................... 41
RIDAURA ............................... 84
RIFABUTIN ............................ 27
RIFAMATE ............................. 27
rifampin .................................. 27
RIFATER ................................27
RILUTEK ................................59
riluzole .................................... 59
rimantadine hcl ....................... 42
ringers injection .................... 101
117
ringers irrigation ...................101
RIOMET .................................47
risedronate sodium .................87
risedronate sodium dr ............87
RISPERDAL CONSTA ...........38
risperidone .............................38
RISPERIDONE ODT ..............38
RITALIN LA ............................59
RITUXAN ...............................32
rivastigmine ............................18
rizatriptan ...............................26
ROBAXIN ...............................97
ROBAXIN-750 ........................97
ROCALTROL .........................87
ROPINIROLE ER ...................36
ropinirole hcl ...........................36
rosuvastatin calcium ...............56
ROTARIX ...............................84
ROTATEQ ..............................84
roweepra ................................16
roxicet .......................................4
ROZEREM .............................98
RUCONEST ...........................85
S
SABRIL ..................................16
SAFYRAL ...............................77
SAIZEN ..................................72
SAMSCA ................................56
SANCUSO .............................21
SANDIMMUNE .......................85
SANDOSTATIN ......................80
SANDOSTATIN LAR ..............80
SANTYL .................................62
SAPHRIS ...............................38
SARAFEM ..............................19
SAVELLA ...............................59
selegiline hcl ...........................36
selenium sulfide .....................62
SELZENTRY ..........................42
SEMPREX-D ..........................95
SENSIPAR .............................79
SEREVENT DISKUS .............96
SERNIVO ...............................71
SEROQUEL XR .....................38
Index of Drugs
SEROSTIM ............................ 72
sertraline hcl .......................... 19
setlakin ................................... 77
sf 5000 plus ......................... 101
SFROWASA .......................... 86
sharobel ................................. 77
SIGNIFOR ............................. 89
SIGNIFOR LAR ..................... 80
sildenafil ................................. 96
SILDENAFIL CITRATE .......... 96
SILENOR ............................... 98
silver sulfadiazine ...................11
SIMBRINZA ........................... 91
SIMCOR ................................ 56
SIMPONI ................................ 85
SIMPONI ARIA ...................... 85
SIMULECT ............................. 85
simvastatin ............................. 56
SINEMET 10-100 ................... 36
SINEMET 25-100 ................... 36
SINEMET 25-250 ................... 36
SINEMET CR ......................... 36
sirolimus ................................. 85
SIRTURO ............................... 27
SIVEXTRO ..............................11
SKELAXIN ............................. 97
SMOFLIPID ........................... 89
sodium chloride .................... 101
SODIUM EDECRIN ............... 56
sodium fluoride .................... 101
sodium lactate ...................... 101
SODIUM
PHENYLBUTYRATE ............. 64
sodium polystyrene
sulfonate .............................. 101
SOLIRIS ................................. 85
SOLODYN ............................. 12
SOLTAMOX ........................... 32
SOLU-CORTEF ..................... 71
SOLU-MEDROL .................... 71
SOMA .................................... 97
SOMATULINE DEPOT .......... 80
SOMAVERT ........................... 80
SONATA ................................ 98
SOOLANTRA ......................... 35
SORIATANE .......................... 62
SORILUX ............................... 62
sorine ..................................... 56
sotalol .................................... 56
SOTYLIZE ............................. 56
SOVALDI ............................... 42
SPECTRACEF ....................... 12
spinosad ................................ 35
SPIRIVA ................................. 96
SPIRIVA RESPIMAT ............. 96
spironolactone ....................... 56
spironolactone-hctz ................ 56
SPORANOX .......................... 23
SPORANOX
PULSEPAK ............................ 23
sprintec .................................. 78
SPRITAM ............................... 16
SPRYCEL .............................. 32
sps ....................................... 101
sronyx .................................... 78
ssd ......................................... 12
stavudine ............................... 42
STAXYN ................................ 67
STELARA .............................. 85
STENDRA .............................. 67
STERILE PADS ..................... 89
STIMATE ............................... 72
STIOLTO RESPIMAT ............ 96
STIVARGA ............................. 32
STRATTERA ......................... 60
STRENSIQ ............................ 64
streptomycin sulfate ............... 12
STRIANT ............................... 78
STRIBILD ............................... 42
STRIVERDI RESPIMAT ........ 96
STROMECTOL ...................... 35
SUBOXONE ............................ 5
SUBSYS .................................. 4
SUCRAID ............................... 64
sucralfate ............................... 66
sulfacetamide sodium 12, 62, 91
sulfacetamideprednisolone .......................... 91
sulfadiazine ............................ 12
118
sulfamethoxazoletrimethoprim ........................... 12
SULFAMYLON....................... 12
sulfasalazine .......................... 86
sulfasalazine dr ...................... 86
sulindac .................................. 25
SUMATRIPTAN ..................... 26
SUMATRIPTAN
SUCCINATE .......................... 26
SUMAVEL DOSEPRO ........... 26
SUPRAX ................................ 12
SUPREP ................................ 66
SURMONTIL .......................... 19
SUSTIVA ............................... 42
SUTENT ................................ 32
SYEDA ................................... 78
SYLATRON ........................... 32
SYLVANT .............................. 32
SYMBICORT.......................... 96
SYMLINPEN 120 ................... 47
SYMLINPEN 60 ..................... 48
SYNAGIS ............................... 89
SYNAREL .............................. 80
SYNERA .................................. 5
SYNERCID ............................ 12
SYNJARDY ............................ 48
SYNRIBO ............................... 32
SYNTHROID .......................... 79
SYPRINE ............................. 101
T
TABLOID ............................... 32
TACLONEX ........................... 62
tacrolimus ........................ 62, 85
TAFINLAR ............................. 32
TAGRISSO ............................ 33
TALTZ
AUTOINJECTOR ................... 85
TALTZ SYRINGE ................... 85
TALWIN ................................... 4
TAMIFLU ............................... 42
tamoxifen citrate .................... 33
tamsulosin hcl ........................ 67
TARCEVA .............................. 33
TARGADOX ........................... 12
TARGRETIN .......................... 33
Index of Drugs
tarina fe .................................. 78
TASIGNA ............................... 33
TASMAR ................................ 36
TAXOTERE ............................ 33
TAYTULLA ............................. 78
TAZICEF ................................ 12
TAZORAC .............................. 62
taztia xt ................................... 56
TECENTRIQ .......................... 33
TECFIDERA ........................... 60
TECHNIVIE ............................ 42
TEFLARO ............................... 12
TEGRETOL ............................ 16
TEGRETOL XR ...................... 16
TEKAMLO .............................. 56
TEKTURNA ............................ 56
TEKTURNA HCT ................... 56
telmisartan .............................. 56
telmisartan-amlodipine ........... 56
telmisartanhydrochlorothiazid .................. 56
temazepam ............................ 98
tencon ...................................... 4
teniposide ............................... 33
TENIVAC ................................ 85
terazosin hcl ........................... 56
terbinafine hcl ......................... 23
terbutaline sulfate ................... 96
terconazole ............................. 23
TESTIM .................................. 78
TESTOSTERONE .................. 78
testosterone cypionate ........... 78
testosterone enanthate .......... 78
TESTRED .............................. 78
TETANUS
DIPHTHERIA TOXOIDS ........ 85
TETANUS TOXOID
ADSORBED ........................... 85
TETRABENAZINE ................. 60
tetracycline hcl ....................... 12
TEVETEN HCT ...................... 57
TEV-TROPIN ......................... 72
THALOMID ............................. 33
THEO-24 ................................ 96
theochron ............................... 96
theophylline ............................ 96
theophylline anhydrous ..........96
THERACYS ............................ 85
thermazene ............................ 12
THIOLA .................................. 67
thioridazine hcl ....................... 38
thiotepa .................................. 33
thiothixene .............................. 38
THYMOGLOBULIN ................ 85
THYROLAR-1 ........................ 79
THYROLAR-1/2 ..................... 79
THYROLAR-1/4 ..................... 79
THYROLAR-2 ........................ 79
THYROLAR-3 ........................ 79
tiagabine hcl ........................... 16
ticlopidine hcl .......................... 50
TIKOSYN ............................... 57
tilia fe ...................................... 78
TIMENTIN .............................. 12
timolol maleate ................. 26, 91
TIMOPTIC .............................. 91
TIMOPTIC OCUDOSE ........... 91
TINDAMAX ............................. 35
tinidazole ................................35
TIVICAY ................................. 42
TIVORBEX ............................. 25
tizanidine hcl .......................... 38
TOBI ....................................... 12
TOBI PODHALER .................. 12
TOBRADEX ........................... 91
TOBRADEX ST ...................... 92
TOBRAMYCIN ....................... 12
tobramycin sulfate .................. 12
tobramycin sulfate in ns ......... 12
tobramycindexamethasone ...................... 92
TOBREX ................................12
TOLAK ................................... 62
tolazamide .............................. 48
tolbutamide ............................. 48
TOLCAPONE ......................... 36
tolmetin sodium ...................... 25
tolterodine tartrate .................. 67
tolterodine tartrate er .............. 67
119
TOPAMAX ..............................16
TOPICORT .............................71
topiramate ..............................16
TOPIRAMATE ER ..................17
toposar ...................................33
TOPOTECAN HCL .................33
TORISEL ................................33
torsemide ...............................57
TOUJEO SOLOSTAR ............48
TOVIAZ ..................................67
tpn electrolytes ii ..................101
TRACLEER ............................96
TRADJENTA ..........................48
tramadol hcl ..............................4
TRAMADOL HCL ER ...............4
tramadol hclacetaminophen .........................4
trandolapril .............................57
trandolapril-verapamil er ........57
tranexamic acid ......................50
TRANSDERM-SCOP .............21
tranylcypromine sulfate ..........19
TRAVASOL ..........................101
TRAVATAN Z .........................92
travoprost ...............................92
trazodone hcl ..........................19
TREANDA ..............................33
TRECATOR ...........................27
TRELSTAR ............................80
TRETINOIN ......................33, 62
TRETINOIN
MICROSPHERE ....................63
TRETIN-X ...............................63
TREXIMET .............................26
TRIAMCINOLONE
ACETONIDE ..............60, 71, 96
triamterenehydrochlorothiazid ..................57
trianex ....................................71
TRIBENZOR ..........................57
triderm ....................................71
tri-estarylla ..............................78
trifluoperazine hcl ...................38
trifluridine ................................42
TRIGLIDE ...............................57
Index of Drugs
trihexyphenidyl hcl ................. 36
tri-legest fe ............................. 78
TRILEPTAL ............................ 17
tri-linyah ................................. 78
tri-lo-estarylla ......................... 78
tri-lo-marzia ............................ 78
tri-lo-sprintec .......................... 78
trilyte with flavor packets ........ 66
TRIMETHOBENZAMID
E HCL .................................... 21
trimethoprim ........................... 12
TRIMIPRAMINE
MALEATE .............................. 19
trinessa .................................. 78
TRINTELLIX .......................... 19
tri-previfem ............................. 78
TRISENOX ............................ 33
tri-sprintec .............................. 78
TRIUMEQ .............................. 42
trivora-28 ................................ 78
TRIZIVIR ................................ 42
TROKENDI XR ...................... 17
TROPHAMINE ..................... 101
tropicamide ............................ 92
trospium chloride ................... 68
trospium chloride er ............... 68
TRUMENBA ........................... 85
TRUVADA .............................. 42
TWINRIX ................................ 85
TYBOST ................................ 42
TYGACIL ............................... 12
TYKERB ................................ 33
TYPHIM VI ............................. 85
TYSABRI ............................... 60
TYVASO (DRUG ONLY) ........ 96
TYVASO STARTER KIT ........ 96
TYZEKA ................................. 42
TYZINE .................................. 96
U
UCERIS ................................. 86
u-cort ...................................... 71
ULESFIA ................................ 35
ULORIC ................................. 24
unithroid ................................. 79
UNITUXIN .............................. 33
UPTRAVI ............................... 96
ursodiol .................................. 66
UTIBRON NEOHALER .......... 96
UVADEX ................................ 63
V
VAGIFEM ............................... 78
valacyclovir ............................ 42
VALCHLOR ........................... 33
VALCYTE .............................. 42
VALGANCICLOVIR
HCL ........................................ 42
valproate sodium ................... 17
valproic acid ........................... 17
valsartan ................................ 57
valsartanhydrochlorothiazide ................ 57
vanatol lq ................................. 4
VANCOCIN HCL .................... 12
VANCOMYCIN HCL .............. 13
VAQTA ................................... 85
VARIVAX VACCINE .............. 85
VARIZIG ................................ 85
VARUBI ................................. 21
VASCEPA .............................. 57
VECAMYL .............................. 57
VECTIBIX .............................. 33
VELCADE .............................. 33
VELETRI ................................ 96
velivet ..................................... 78
VELTASSA ............................ 89
VENCLEXTA ......................... 33
VENCLEXTA
STARTING PACK .................. 33
venlafaxine hcl ....................... 19
venlafaxine hcl er ................... 19
VENTAVIS ............................. 96
VENTOLIN HFA ..................... 96
VERAMYST ........................... 96
verapamil er ........................... 57
verapamil er pm ..................... 57
verapamil hcl .......................... 57
VERDESO ............................. 71
VEREGEN ............................. 63
VERSACLOZ ......................... 38
VESICARE ............................. 68
120
vestura ................................... 78
VEXOL ................................... 92
VFEND ................................... 23
VFEND IV .............................. 23
VGO 40 .................................. 89
VIAGRA ................................. 68
VIBATIV ................................. 13
VIBERZI ................................. 66
VIBRAMYCIN......................... 13
VICTOZA 3-PAK .................... 48
VIDAZA .................................. 33
VIDEX .................................... 42
VIEKIRA PAK ........................ 42
VIEKIRA XR ........................... 42
vienva .................................... 78
VIGAMOX .............................. 13
VIIBRYD ................................ 19
VIMIZIM ................................. 64
VIMOVO ................................ 25
VIMPAT ................................. 17
vinblastine sulfate .................. 33
vincasar pfs ............................ 34
vincristine sulfate ................... 34
vinorelbine tartrate ................. 34
viorele .................................... 78
VIRACEPT ............................. 43
VIRAMUNE ............................ 43
VIRAMUNE XR ...................... 43
VIRAZOLE ............................. 43
VIREAD ................................. 43
VISTIDE ................................. 43
vitamin d2 ............................ 101
VITEKTA ................................ 43
VIVELLE-DOT ....................... 78
VIVITROL ................................ 5
VOGELXO ............................. 78
VOLTAREN ........................... 25
VORICONAZOLE .................. 23
VOTRIENT ............................. 34
VPRIV .................................... 64
VRAYLAR .............................. 38
VUSION ................................. 23
vyfemla .................................. 78
VYTORIN ............................... 57
Index of Drugs
VYVANSE .............................. 60
W
warfarin sodium ...................... 50
water ...................................... 89
WELCHOL ............................. 57
wera ....................................... 79
wymzya fe .............................. 79
X
XALKORI ................................ 34
XARELTO .............................. 50
XARTEMIS XR ......................... 4
XELJANZ ............................... 89
XELJANZ XR ......................... 85
XENAZINE ............................. 60
XERESE ................................. 63
XGEVA ................................... 87
XIFAXAN ................................ 13
XOLAIR .................................. 96
XOLEGEL .............................. 23
XOPENEX .............................. 96
XOPENEX
CONCENTRATE .................... 96
XOPENEX HFA ...................... 96
XTAMPZA ER .......................... 4
XTANDI .................................. 80
xulane ..................................... 80
XYLOCAINE ............................. 5
XYLOCAINE-MPF .................... 5
XYREM .................................. 98
Y
YERVOY ................................ 34
YF-VAX .................................. 85
YONDELIS ............................. 34
Z
zafirlukast ............................... 96
zaleplon .................................. 98
ZALTRAP ............................... 34
ZANOSAR .............................. 34
zarah ...................................... 79
ZARONTIN ............................. 17
ZARXIO .................................. 50
ZAVESCA .............................. 64
zebutal ...................................... 4
ZECUITY ................................ 26
ZELAPAR ............................... 36
ZELBORAF ............................ 34
ZEMAIRA ............................... 97
ZEMBRACE
SYMTOUCH ........................... 26
ZEMPLAR .............................. 87
ZENATANE ............................ 63
zenchent ................................. 79
zenchent fe ............................. 79
ZENPEP ................................. 64
zeosa ...................................... 79
ZEPATIER .............................. 43
ZERBAXA .............................. 13
ZETIA ..................................... 57
ZETONNA .............................. 97
ZIAGEN .................................. 43
zidovudine .............................. 43
ZINECARD ............................. 34
ZIOPTAN ................................92
ziprasidone hcl ....................... 38
ZIRGAN .................................. 43
ZMAX ..................................... 13
ZOHYDRO ER ......................... 4
ZOLEDRONIC ACID .............. 87
ZOLINZA ................................34
zolmitriptan ............................. 26
zolmitriptan odt ....................... 26
ZOLPIDEM TARTRATE ......... 98
zolpidem tartrate er ................ 98
ZOLPIMIST ............................ 98
ZOMACTON ........................... 72
ZOMETA ................................88
ZOMIG ................................... 26
ZONALON .............................. 63
zonisamide ............................. 17
ZONTIVITY ............................ 50
ZORBTIVE ............................. 72
ZORTRESS ............................ 85
ZOSTAVAX ............................ 86
ZOSYN ................................... 13
zovia 1-35e ............................. 79
zovia 1-50e ............................. 79
ZOVIRAX ............................... 43
ZUPLENZ ............................... 21
ZURAMPIC ............................ 24
121
ZYCLARA ...............................63
ZYDELIG ................................34
ZYFLO ....................................97
ZYFLO CR .............................97
ZYKADIA ................................34
ZYLET ....................................92
ZYPREXA RELPREVV ..........38
ZYTIGA ..................................34
ZYVOX ...................................13
205 Park Club Lane
Buffalo, NY 14221
Important Plan Information
This formulary was updated on 11/1/2016. For more recent information or other questions, please contact Univera
Healthcare at 1-800-659-1986 or, for TTY users, 1-800-421-1220, Monday – Friday, 8:00 a.m. – 8:00 p.m.; From
October 1 to February 14, representatives are available to assist you seven days a week from 8:00 a.m. – 8:00 p.m.,
or visit UniveraMedicare.com.

HMO-POS - Univera Healthcare

Transcription

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