2015 Formulary (List of Covered Drugs)When this drug list

Transcription

Blue MedicareRx Premier (PDP)
2015 Formulary (List of Covered Drugs)
Please read: This document contains
information about some of the drugs
we cover in this plan.
This formulary was updated on October 1, 2015. For more recent information or other questions, please
contact Blue MedicareRx Premier (PDP) Customer Service at 1-866-755-2776 or, for TTY users, 711, 8 a.m.
to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14,
and Monday to Friday (except holidays) from February 15 through September 30, or visit
www.partdkansascity.com/shop.
Y0071_15_20444_U_021 CMS Accepted 08/09/2014
45979MUSENMUB_021 S5596_045
Premier_15283_v14_1511_1
Note to existing members:
This formulary has changed since last year. Please review this document
to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us” or “our,” it means
Blue Cross and Blue Shield of Kansas City. When it refers to “plan” or
“our plan,” it means Blue MedicareRx Premier (PDP).
This document includes a list of the drugs (formulary) for our plan which
is current as of October 1, 2015. 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, 2015 and from time to time during
the year.
Effective Date November 1, 2015
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What is the Blue MedicareRx Premier
(PDP) 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 2015 formulary
that was covered at the beginning of the year, we will not
discontinue or reduce coverage of the drug during the
2015 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 forumulary drugs that were available when you chose
our plan, except for cases in which you can save additional
money or we can ensure your safety.
If we remove drugs from our formulary, or add prior
authorization, quantity limits and/or step-therapy
restrictions on a drug 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 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 (FDA) 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 January 1, 2015. 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 any other type of approved
formulary change (nonmaintenance change) is made during
the year, we will notify you by sending you a list of these
changes, or by sending you an updated formulary.
How do I use the formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 8. 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 Medications.” If you
know what your drug is used for, look for the category name
in the list that begins on page 8. Then look under the
category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should
look for your drug in the Index that begins on page 62.
The Index provides an alphabetical list of all of the drugs
included in this document. Both brand-name drugs and
generic drugs are listed in the Index. Look in the Index and
find your drug. Next to your drug, you will see the page
number where you can find coverage information. Turn to
the page listed in the Index and find the name of your drug
in the first column of the list.
What are generic drugs?
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:
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.
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 irbesartan
75mg tablets. This may be in addition to a standard
one-month or three-month supply.
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Step Therapy: In some cases, our plan requires you to first How do I request an exception to the
try certain drugs to treat your medical condition before we
will cover another drug for that condition. For example, if Blue MedicareRx Premier (PDP)'s
Drug A and Drug B both treat your medical condition, our formulary?
plan may not cover Drug B unless you try Drug A first. If You can ask our plan to make an exception to our coverage
rules. There are several types of exceptions that you can ask
Drug A does not work for you, our plan will then cover
us to make:
Drug B.
You can find out if your drug has any additional
requirements or limits by looking in the formulary that
begins on page 8. You can also get more information about
the restrictions applied to specific covered drugs by visiting
our website. 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.
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 Blue MedicareRx Premier
(PDP)'s formulary?” on page 4 for information about how
to request an exception.
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
predetermined cost-sharing level, and you would not be
able to ask us to provide the drug at a lower cost-sharing
level.
You can ask us to 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 plan’s
If your drug is not included in this formulary (list of covered
formulary, the lower cost-sharing drug or additional
drugs), you should first contact Customer Service and ask
utilization restrictions would not be as effective in treating
if your drug is covered.
your condition and/or would cause you to have adverse
medical effects.
If you learn that our plan does not cover your drug, you
have two options:
You should contact us to ask us for an initial coverage
You can ask Customer Service for a list of similar drugs that decision for a formulary, tiering or utilization restriction
are covered by our plan. When you receive the list, show it exception. When you request a formulary, tiering or
to your doctor and ask him or her to prescribe a similar drug utilization restriction exception, you should submit a
statement from your prescriber or physician supporting
that is covered by our plan.
your request. Generally, we must make our decision within
You can ask our plan to make an exception and cover your 72 hours of getting your prescriber’s supporting statement.
You can request an expedited (fast) exception if you or your
drug. See below for information about how to request an
doctor believe that your health could be seriously harmed
exception.
by waiting up to 72 hours for a decision. If your request to
expedite is granted, we must give you a decision no later
than 24 hours after we get a supporting statement from your
doctor or other prescriber.
What if my drug is not on the formulary?
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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.
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.
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 the
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 more information
For more detailed information about our plan prescription
drug coverage, please review your Evidence of Coverage and
other plan materials.
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.
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.
Our plan’s formulary
The formulary on page 8 provides coverage information
about some of the drugs covered by our plan. If you have
trouble finding your drug in the list, turn to the Index that
begins on page 62.
The first column of the chart lists the drug name.
Brand-name drugs are capitalized (e.g., CRESTOR) and
generic drugs are listed in lowercase italics (e.g., atenolol).
The information in the Requirements/Limits column tells
you if our plan has any special requirements for coverage of
your drug.
QLL - Quantity Limits: Restricts the frequency, amount
or dosage of medication for which you can obtain benefits
each time you get a prescription filled (most often set on a
monthly basis).
PAR - Prior Authorization: The process of obtaining
approval for certain prescriptions before benefits will be
approved. You, your doctor or other network provider will
During the time when you are getting a temporary supply need to request prior authorization before you fill the
of a drug, you should talk to your prescriber or prescribing prescription.
physician to decide what to do when your supply runs out.
ST - Step Therapy: The process of first trying a certain
You can call Customer Service to ask for a list of covered
drug or drugs to determine if that drug or those drugs will
drugs that treat the same medical condition. This list can
help your doctor find a covered drug that might work for treat your medical condition before your plan will cover
you while you pursue a formulary exception. Please refer to another drug for that condition.
the Evidence of Coverage for more information about
B/D - Part B vs. Part D: This drug may be covered under
exceptions.
either your Part D prescripton drug benefits or as a Part B
drug under your medical benefits, as determined by
Medicare.
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LA - Limited Access: This prescription may be available
only at certain pharmacies. For more information, consult
your Pharmacy Directory or call Customer Service at
1-866-755-2776, 8 a.m. to 8 p.m., seven days a week (except
Thanksgiving and Christmas) from October 1 through
February 14, and Monday to Friday (except holidays) from
February 15 through September 30. TTY/TDD users should
call 711.
INJ - Injectable: The drug is available in injectable form.
MO - Mail Orders: Prescription drugs available through
mail order.
CG – Coverage Gap: We provide additional coverage of
this prescription drug in the coverage gap. Please refer to
your Evidence of Coverage for more information about this
coverage.
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Cost-sharing for a one-month supply of a covered Part D prescription drug
during the Initial Coverage Stage:
Cost-Sharing Tier 1: Preferred Generics
Network Pharmacy with preferred cost-sharing (30-day supply) or Mail-Order
Pharmacy** (30-day supply)
$1.00
Network Pharmacy with standard cost-sharing (30-day supply) or
Long-Term-Care Pharmacy (34-day supply)
$9.00
Cost-Sharing Tier 2: Nonpreferred Generic
$3.00
$17.00
Cost-Sharing Tier 3: Preferred Brand
$40.00
$45.00
Cost-Sharing Tier 4: Nonpreferred Brand
38%
40%
Cost-Sharing Tier 5: Specialty Tier
33%
33%
Please refer to our Evidence of Coverage for more information for cost sharing.
Network Pharmacy with preferred cost-sharing – A network pharmacy that offers covered drugs to members of our plan
that may have lower cost-sharing levels than other network pharmacies with standard cost-sharing.
** Mail-Order Pharmacy – Mail-order service allows you to order a 30–90-day supply of drugs. The drugs available through
our plan’s mail-order service are marked as “mail-order” drugs in our drug list.
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Covered Medications by Therapeutic Category
Legend
Generic drugs are shown in lower-case italics (e.g. atenolol)
Brand-name drugs are shown in capital letters (e.g. CRESTOR)
QLL - Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits
each time you get a prescription filled (most often set on a monthly basis).
PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved.
You, your doctor or other network provider will need to request prior authorization before you fill the prescription.
ST - Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat
your medical condition before your plan will cover another drug for that condition.
B/D - Part B vs Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B
drug under your medical benefits, as determined by Medicare.
LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your
Pharmacy Directory or call Customer Service 1-866-755-2776, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving
and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through
September 30. TTY/TDD users should call 711.
INJ - Injectable: The drug is available in injectable form.
MO - Mail Order: Prescription drugs available through mail order.
CG – Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your
Evidence of Coverage for more information about this coverage.
Drug Name
Anti - Infectives
abacavir
abacavir-lamivudinezidovudine
ABELCET
acyclovir oral capsule
acyclovir oral suspension 200
mg/5 ml
acyclovir oral tablet
acyclovir sodium intravenous
recon soln 500 mg
acyclovir sodium intravenous
solution
adefovir
ALBENZA
ALINIA ORAL
SUSPENSION FOR
RECONSTITUTION
ALINIA ORAL TABLET
amantadine hcl oral capsule
amantadine hcl oral solution
amantadine hcl oral tablet
AMBISOME
Drug Requirements/
Tier Limits
4
5
MO
MO
5
2
3
B/D PAR; MO
MO; CG
MO
2
4
MO; CG
B/D PAR
4
B/D PAR; MO
5
4
4
MO
MO
MO; QLL (180 per
3 days)
4
2
3
2
5
MO
MO; CG
MO
MO; CG
B/D PAR; MO
Drug Name
amikacin injection solution 1,
000 mg/4 ml, 500 mg/2 ml
amoxicillin oral capsule
amoxicillin oral suspension for
reconstitution 125 mg/5 ml
amoxicillin oral suspension for
reconstitution 200 mg/5 ml,
250 mg/5 ml, 400 mg/5 ml
amoxicillin oral tablet
amoxicillin oral tablet,chewable
125 mg, 250 mg
amoxicillin-pot clavulanate oral
suspension for reconstitution
tablet 250-125 mg
tablet 500-125 mg, 875-125
mg
tablet extended release 12 hr
tablet,chewable 200-28.5 mg
tablet,chewable 400-57 mg
Drug Requirements/
Tier Limits
4
MO
2
1
MO; CG
MO; CG
2
MO; CG
2
2
MO; CG
MO; CG
3
MO
3
MO
2
MO; CG
3
MO
3
MO
2
MO; CG
You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8.
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Drug Name
Drug Requirements/
Tier Limits
amphotericin b
ampicillin oral capsule
ampicillin oral suspension for
ampicillin oral suspension for
ampicillin sodium injection
ampicillin sodium intravenous
ampicillin-sulbactam injection
recon soln 1.5 gram, 3 gram
ampicillin-sulbactam injection
recon soln 15 gram
ampicillin-sulbactam
intravenous recon soln 1.5 gram
ampicillin-sulbactam
intravenous recon soln 3 gram
APTIVUS ORAL CAPSULE
APTIVUS ORAL
SOLUTION
atovaquone
atovaquone-proguanil
ATRIPLA
AVELOX
4
2
3
B/D PAR; MO
MO; CG
MO
2
MO; CG
4
4
4
MO
AVELOX ABC PACK
4
AVELOX IN NACL (ISOOSMOTIC)
AZACTAM IN DEXTROSE
(ISO-OSM)
azithromycin intravenous
azithromycin oral packet
azithromycin oral suspension
for reconstitution
azithromycin oral tablet 250
mg (6 pack)
azithromycin oral tablet 250
mg, 500 mg, 600 mg
aztreonam
baciim
bacitracin intramuscular
BACTRIM
BACTRIM DS
BARACLUDE
BICILLIN C-R
4
MO
4
4
4
MO
5
5
MO
5
3
5
4
PAR; MO
MO
MO
MO; QLL (21 per 1
day)
MO; QLL (5 per 1
day)
MO
4
4
2
2
MO
MO; CG
MO; CG
2
CG
2
MO; CG
4
4
4
4
4
5
4
MO
MO
MO
MO
PAR; MO
MO
Drug Name
BICILLIN L-A
BILTRICIDE
CANCIDAS
CAPASTAT
CAYSTON
CEDAX ORAL CAPSULE
cefaclor oral capsule 250 mg
cefaclor oral capsule 500 mg
cefaclor oral suspension for
250 mg/5 ml, 375 mg/5 ml
cefaclor oral tablet extended
release 12 hr
cefadroxil oral capsule
cefadroxil oral suspension for
500 mg/5 ml
cefadroxil oral tablet
cefazolin in dextrose (iso-os)
intravenous piggyback 1 gram/
50 ml, 2 gram/50 ml
cefazolin injection recon soln 1
gram, 500 mg
cefazolin injection recon soln
10 gram, 100 gram, 20 gram,
300 g
cefazolin intravenous
cefdinir
cefepime
cefepime in dextrose,iso-osm
50 ml
cefepime in dextrose,iso-osm
100 ml
cefixime
cefotaxime injection recon soln
1 gram, 2 gram, 500 mg
cefotetan
cefoxitin in dextrose, iso-osm
cefoxitin intravenous recon soln
1 gram
cefoxitin intravenous recon soln
10 gram, 2 gram
cefpodoxime
Drug Requirements/
Tier Limits
4
4
5
4
5
4
2
3
2
MO
MO
B/D PAR; MO
2
MO; CG
2
2
MO; CG
MO; CG
3
4
MO
MO
4
MO
PAR; MO; LA
MO
MO; CG
MO
MO; CG
4
4
3
4
4
MO
MO
4
MO
4
4
MO
4
4
4
MO
4
4
MO
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9
Drug Name
cefprozil oral suspension for
cefprozil oral suspension for
cefprozil oral tablet 250 mg
cefprozil oral tablet 500 mg
CEFTAZIDIME IN D5W
ceftazidime injection recon soln
1 gram, 2 gram
ceftazidime injection recon soln
6 gram
ceftibuten
CEFTIN ORAL
SUSPENSION FOR
RECONSTITUTION
ceftriaxone in dextrose,iso-os
ceftriaxone injection recon soln
1 gram, 2 gram, 250 mg, 500
mg
ceftriaxone injection recon soln
10 gram
ceftriaxone intravenous recon
soln
cefuroxime axetil oral tablet
cefuroxime sodium injection
recon soln 1.5 gram, 750 mg
cefuroxime sodium intravenous
cephalexin oral capsule 250 mg,
500 mg
cephalexin oral capsule 750 mg
cephalexin oral suspension for
reconstitution
cephalexin oral tablet
chloramphenicol sod succinate
chloroquine phosphate oral
cidofovir
CIPRO IN D5W
INTRAVENOUS
PIGGYBACK 400 MG/200
ML
CIPRO ORAL
SUSPENSION,
MICROCAPSULE RECON
CIPRO ORAL TABLET 250
MG, 500 MG
Drug Requirements/
Tier Limits
4
MO
3
MO
2
3
4
4
MO; CG
MO
MO
4
4
4
MO
MO
4
4
MO
MO
4
4
MO
2
4
MO; CG
MO
4
2
MO; CG
4
2
MO
MO; CG
2
4
2
5
4
MO; CG
MO; CG
B/D PAR; MO
4
MO
4
MO
Drug Name
ciprofloxacin (mixture) oral
tablet, er multiphase 24 hr 1,
000 mg
ciprofloxacin (mixture) oral
tablet, er multiphase 24 hr 500
mg
ciprofloxacin hcl oral tablet
ciprofloxacin in 5 % dextrose
ciprofloxacin lactate
intravenous solution 200 mg/
20 ml
ciprofloxacin lactate
40 ml
ciprofloxacin oral suspension,
microcapsule recon
CLAFORAN INJECTION
RECON SOLN 1 GRAM,
10 GRAM, 2 GRAM
CLAFORAN INJECTION
RECON SOLN 500 MG
CLAFORAN
INTRAVENOUS RECON
SOLN
clarithromycin oral suspension
for reconstitution
clarithromycin oral tablet
clarithromycin oral tablet
extended release 24 hr
CLEOCIN ORAL
clindamycin hcl
clindamycin in 5 % dextrose
clindamycin phosphate injection
clindamycin phosphate
intravenous solution 300 mg/2
ml, 900 mg/6 ml
clindamycin phosphate
ml
clotrimazole mucous membrane
COARTEM
colistin (colistimethate na)
COLY-MYCIN M
PARENTERAL
COMPLERA
Drug Requirements/
Tier Limits
3
MO; QLL (14 per 1
day)
3
MO; QLL (3 per 1
day)
2
4
4
MO; CG
MO
MO
4
4
4
MO
4
4
3
MO
3
3
MO
MO; QLL (28 per 1
day)
MO
MO; CG
MO
MO
4
2
4
4
4
4
MO
2
4
4
4
MO; CG
MO
MO
MO
5
MO
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10
Drug Name
Drug Requirements/
Tier Limits
CRIXIVAN ORAL
CAPSULE 200 MG, 400 MG
CUBICIN
DAKLINZA
3
MO; CG
5
5
DAPSONE
DARAPRIM
demeclocycline oral
dicloxacillin
didanosine
DIFLUCAN
DORIBAX
DOXY-100
doxycycline hyclate intravenous
doxycycline hyclate oral capsule
doxycycline hyclate oral tablet
100 mg, 20 mg
doxycycline hyclate oral tablet
50 mg
doxycycline monohydrate oral
capsule 75 mg
tablet 100 mg, 50 mg, 75 mg
tablet 150 mg
E.E.S. GRANULES
EDURANT
EMTRIVA
entecavir
EPIVIR HBV ORAL
SOLUTION
EPIVIR ORAL SOLUTION
EPZICOM
ery-tab oral tablet,delayed
release (dr/ec) 250 mg, 333 mg
ERY-TAB ORAL TABLET,
DELAYED RELEASE (DR/
EC) 500 MG
ERYPED 200
ERYPED 400
erythrocin (as stearate) oral
tablet 250 mg
3
3
4
2
3
4
4
4
4
2
2
B/D PAR; MO
PAR; MO; QLL (30
per 30 days)
MO
MO; CG
MO
MO; CG
MO
MO
2
4
MO
MO; CG
MO; CG
CG
4
MO; QLL (60 per 1
day)
MO
2
MO; CG
3
MO
4
5
4
5
3
MO
MO
MO
PAR; MO
MO; CG
4
5
3
MO
MO
MO
4
MO
4
4
3
MO
MO
MO
Drug Name
Drug Requirements/
Tier Limits
ERYTHROCIN
INTRAVENOUS RECON
SOLN 500 MG
erythromycin ethylsuccinate oral
tablet
erythromycin oral capsule,
delayed release(dr/ec)
erythromycin oral tablet
ethambutol
EVOTAZ
famciclovir oral tablet 125 mg,
250 mg
famciclovir oral tablet 500 mg
4
FLAGYL ER
FLAGYL ORAL CAPSULE
fluconazole
fluconazole in dextrose(iso-o)
fluconazole in nacl (iso-osm)
intravenous piggyback 200 mg/
100 ml
fluconazole in nacl (iso-osm)
200 ml
flucytosine
foscarnet
FUZEON
SUBCUTANEOUS RECON
SOLN
ganciclovir sodium
gentamicin in nacl (iso-osm)
100 ml, 60 mg/50 ml
GENTAMICIN IN NACL
(ISO-OSM)
INTRAVENOUS
PIGGYBACK 100 MG/50
ML, 120 MG/100 ML
gentamicin in nacl (iso-osm)
50 ml, 80 mg/100 ml, 80 mg/
50 ml, 90 mg/100 ml
gentamicin injection
gentamicin sulfate (ped) (pf)
4
4
2
4
4
3
MO
2
MO; CG
3
2
5
3
MO
MO; CG
MO
MO; QLL (60 per
30 days)
MO; QLL (21 per 7
days)
MO
MO
MO; CG
4
MO
4
5
4
5
MO
B/D PAR; MO
MO; QLL (60 per
30 days)
4
4
MO
MO
4
4
4
4
MO
MO
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
gentamicin sulfate (pf)
10 ml
GENTAMICIN SULFATE
(PF) INTRAVENOUS
SOLUTION 60 MG/6 ML
gentamicin sulfate (pf)
ml
griseofulvin microsize oral
suspension
griseofulvin microsize oral
tablet
griseofulvin ultramicrosize oral
tablet 125 mg
griseofulvin ultramicrosize oral
tablet 250 mg
HARVONI
4
HIPREX
hydroxychloroquine oral
imipenem-cilastatin
INTELENCE ORAL
TABLET 100 MG, 200 MG
INTELENCE ORAL
TABLET 25 MG
INVANZ INJECTION
INVANZ INTRAVENOUS
INVIRASE
ISENTRESS ORAL
POWDER IN PACKET
ISENTRESS ORAL
TABLET
ISENTRESS ORAL
TABLET,CHEWABLE 100
MG
ISENTRESS ORAL
TABLET,CHEWABLE 25
MG
isoniazid injection
isoniazid oral solution
isoniazid oral tablet
itraconazole
ivermectin oral
KALETRA ORAL
SOLUTION
4
2
3
5
MO
4
Drug Name
Drug Requirements/
Tier Limits
KALETRA ORAL TABLET
100-25 MG
KALETRA ORAL TABLET
200-50 MG
KEFLEX ORAL CAPSULE
KETEK
4
MO
5
MO
4
3
ketoconazole oral
LAMISIL ORAL
GRANULES IN PACKET
LAMISIL ORAL TABLET
2
4
MO
MO; CG; QLL (20
per 1 day)
MO; CG
MO
lamivudine oral solution
lamivudine oral tablet 100 mg,
150 mg
lamivudine oral tablet 300 mg
lamivudine-zidovudine
levofloxacin in d5w intravenous
piggyback 250 mg/50 ml
levofloxacin in d5w intravenous
piggyback 500 mg/100 ml, 750
mg/150 ml
levofloxacin oral tablet
4
3
LEXIVA ORAL
SUSPENSION
LEXIVA ORAL TABLET
LINCOCIN
linezolid intravenous
linezolid oral
4
linezolid-0.9% sodium chloride
MALARONE
MALARONE PEDIATRIC
mefloquine
MEPRON
meropenem
methenamine hippurate
methenamine mandelate
metro i.v.
metronidazole in nacl (iso-os)
metronidazole oral
minocycline oral capsule
minocycline oral tablet 100 mg,
75 mg
5
4
4
2
5
4
2
2
4
4
2
2
3
4
2
3
MO; CG
4
MO
4
MO
3
MO
5
PAR; MO; QLL (28
per 28 days)
MO
MO; CG
MO
MO
4
4
4
5
4
MO
5
MO
MO
MO
5
MO
3
MO
4
3
1
4
3
4
MO
MO; CG
PAR; MO
MO
MO
MO; QLL (30 per
30 days)
MO
MO
4
5
4
MO
MO
4
MO
2
MO; CG; QLL (14
per 1 day)
MO
5
4
5
5
MO
MO
PAR; MO; QLL (28
per 1 day)
MO
MO
MO; CG
PAR; MO
MO
MO; CG
MO; CG
MO
MO
MO; CG
MO; CG
MO
Premier_15283_v14_1511_1
12
Drug Name
minocycline oral tablet 50 mg
MONUROL
MOXATAG
moxifloxacin
MYAMBUTOL ORAL
TABLET 400 MG
MYCAMINE
MYCOBUTIN
nafcillin in dextrose iso-osm
50 ml
nafcillin in dextrose iso-osm
100 ml
nafcillin injection recon soln 1
gram
nafcillin injection recon soln 10
gram, 2 gram
nafcillin intravenous
NEBUPENT
neomycin
nevirapine oral suspension
nevirapine oral tablet
nevirapine oral tablet extended
release 24 hr
nitrofurantoin macrocrystal oral
capsule 100 mg, 50 mg
nitrofurantoin monohyd/mcryst
NORVIR
NOXAFIL ORAL
SUSPENSION
nystatin oral suspension
nystatin oral tablet
ofloxacin oral tablet 400 mg
OLYSIO
ORACEA
oxacillin in dextrose(iso-osm)
50 ml
oxacillin in dextrose(iso-osm)
50 ml
oxacillin injection recon soln 1
gram, 2 gram
Drug Requirements/
Tier Limits
2
4
4
2
4
MO; CG
MO
MO
MO; CG; QLL (21
per 1 day)
MO
5
4
4
MO
MO
4
MO
4
MO
5
MO
5
3
2
4
2
4
MO
B/D PAR; MO; CG
MO; CG
MO
MO; CG
MO
4
PAR; MO
4
4
5
2
2
2
5
4
4
PAR; MO
MO
PAR; MO; QLL
(630 per 30 days)
MO; CG
MO; CG
CG
PAR; MO
MO
5
MO
4
MO
Drug Name
Drug Requirements/
Tier Limits
oxacillin injection recon soln 10
gram
oxacillin intravenous recon soln
1 gram
oxacillin intravenous recon soln
2 gram
paromomycin
PASER
PCE
PENICILLIN G POT IN
DEXTROSE
penicillin g potassium
penicillin g procaine
intramuscular syringe 1.2
million unit/2 ml
penicillin g procaine
intramuscular syringe 600,000
unit/ml
penicillin g sodium
penicillin v potassium
PENTAM
pfizerpen-g
piperacillin-tazobactam
polymyxin b sulfate
PREZCOBIX
PREZISTA ORAL
SUSPENSION
PREZISTA ORAL TABLET
150 MG, 75 MG
PREZISTA ORAL TABLET
600 MG, 800 MG
PRIFTIN
PRIMAQUINE
PRIMSOL
pyrazinamide
QUALAQUIN
quinine sulfate
REBETOL ORAL
SOLUTION
RELENZA DISKHALER
5
RESCRIPTOR
RETROVIR
INTRAVENOUS
REYATAZ ORAL CAPSULE
150 MG, 200 MG, 300 MG
MO
5
4
3
4
4
4
MO
MO
MO
4
4
MO
MO
4
4
2
4
4
4
4
5
5
MO
MO; CG
MO
4
MO
5
MO
3
3
4
2
4
3
5
MO; CG
MO; CG
MO
MO; CG
PAR; MO
PAR; MO
PAR; MO
3
4
4
MO; CG; QLL (60
per 180 days)
MO
MO
5
MO
MO
MO
MO
Premier_15283_v14_1511_1
13
Drug Name
REYATAZ ORAL POWDER
IN PACKET
ribasphere oral tablet 200 mg
ribavirin oral capsule
ribavirin oral tablet 200 mg
rifabutin
RIFADIN
RIFAMATE
rifampin intravenous
rifampin oral
RIFATER
rimantadine
SELZENTRY
SOVALDI
stavudine
STREPTOMYCIN
INTRAMUSCULAR
STRIBILD
STROMECTOL
sulfadiazine oral
sulfamethoxazole-trimethoprim
intravenous
oral suspension
oral tablet 400-80 mg
oral tablet 800-160 mg
SUPRAX ORAL
SUSPENSION FOR
RECONSTITUTION 100
MG/5 ML, 200 MG/5 ML
SUPRAX ORAL
SUSPENSION FOR
RECONSTITUTION 500
MG/5 ML
SUSTIVA
SYNAGIS
SYNERCID
TAMIFLU ORAL CAPSULE
30 MG
45 MG
Drug Requirements/
Tier Limits
4
MO
3
4
5
3
3
3
4
4
4
2
3
3
5
5
3
4
PAR; MO
PAR; MO
PAR; MO
PAR; MO
PAR; MO
MO
MO
MO
MO
MO; CG
MO; CG
MO
MO
PAR; MO
MO
MO
5
3
3
4
MO
MO; CG
MO
MO
2
MO; CG
1
MO; CG
2
MO; CG
4
MO
4
3
5
5
3
3
MO; CG
PAR; MO; LA
MO; CG; QLL (84
per 1 day)
MO; CG; QLL (42
per 1 day)
Drug Name
Drug Requirements/
Tier Limits
75 MG
TAMIFLU ORAL
SUSPENSION FOR
RECONSTITUTION
TEFLARO
terbinafine hcl oral
3
tetracycline
tinidazole
TIVICAY
tobramycin in 0.225 % nacl
2
3
5
5
tobramycin in 0.9 % nacl
100 ml
tobramycin sulfate injection
recon soln
tobramycin sulfate injection
solution
TRECATOR
trimethoprim
TRIUMEQ
TRIZIVIR
TRUVADA
TYBOST
TYGACIL
TYZEKA
valacyclovir oral tablet 1 gram
4
valacyclovir oral tablet 500 mg
2
VALCYTE ORAL TABLET
valganciclovir
VANCOMYCIN IN D5W
INTRAVENOUS
PIGGYBACK 1 GRAM/200
ML
VANCOMYCIN IN D5W
INTRAVENOUS
PIGGYBACK 500 MG/100
ML
VANCOMYCIN IN
DEXTROSE ISO-OSM
vancomycin intravenous
3
4
2
MO; CG; QLL (56
per 365 days)
MO; CG; QLL (360
per 180 days)
MO
MO; CG; QLL (30
per 30 days)
MO; CG
MO
MO
B/D PAR; MO;
QLL (280 per 28
days)
MO
4
4
MO
4
2
5
5
5
4
5
5
3
5
5
4
MO
MO; CG
MO
MO
MO
MO
MO
PAR; MO
MO; QLL (30 per 1
day)
MO; CG; QLL (30
per 1 day)
MO
MO
B/D PAR; MO
4
B/D PAR
4
B/D PAR
4
B/D PAR; MO
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
VANCOMYCIN
INTRAVENOUS 750 MG
vancomycin oral capsule 125
mg
vancomycin oral capsule 250
mg
VIBRAMYCIN ORAL
CAPSULE 100 MG
VIBRAMYCIN ORAL
SUSPENSION FOR
RECONSTITUTION
VIBRAMYCIN ORAL
SYRUP
VIDEX 2 GRAM
PEDIATRIC
VIDEX 4 GRAM
PEDIATRIC
VIEKIRA PAK
VIRACEPT ORAL TABLET
VIRAMUNE XR
VIRAZOLE
VIREAD ORAL POWDER
4
B/D PAR; MO
5
PAR; MO; QLL (40
per 1 day)
PAR; MO; QLL (80
per 1 day)
MO
VIREAD ORAL TABLET
150 MG, 300 MG
VIREAD ORAL TABLET
200 MG, 250 MG
VITEKTA
voriconazole intravenous
voriconazole oral suspension for
reconstitution
voriconazole oral tablet 200 mg
voriconazole oral tablet 50 mg
5
XIFAXAN ORAL TABLET
200 MG
ZIAGEN ORAL
SOLUTION
zidovudine oral capsule
zidovudine oral syrup
zidovudine oral tablet
ZITHROMAX
ZITHROMAX TRI-PAK
ZITHROMAX Z-PAK
ZMAX
5
4
4
MO
4
MO
3
MO; CG
3
MO; CG
5
5
4
5
5
5
PAR; MO
MO
MO
PAR; MO
MO; QLL (240 per
30 days)
MO
4
MO
5
4
5
5
MO
MO
PAR; MO; QLL
(300 per 30 days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL
(120 per 30 days)
MO
4
MO
3
3
2
4
4
4
3
MO
MO
MO; CG
MO
MO
MO
MO; CG
5
Drug Name
ZOVIRAX ORAL
ZYVOX INTRAVENOUS
PARENTERAL SOLUTION
200 MG/100 ML
ZYVOX INTRAVENOUS
PARENTERAL SOLUTION
600 MG/300 ML
ZYVOX ORAL
SUSPENSION FOR
RECONSTITUTION
ZYVOX ORAL TABLET
Drug Requirements/
Tier Limits
4
5
MO
5
MO
5
PAR; MO; QLL
(1800 per 1 day)
5
PAR; MO; QLL (28
per 1 day)
Antineoplastic / Immunosuppressant Drugs
ABRAXANE
5 B/D PAR; MO
adrucil intravenous solution 2.5 4 B/D PAR
gram/50 ml
adrucil intravenous solution 5
4 B/D PAR; MO
gram/100 ml, 500 mg/10 ml
AFINITOR
5 PAR; MO
AFINITOR DISPERZ
5 PAR; MO
ALIMTA
5 PAR; MO
ALKERAN
4 B/D PAR
INTRAVENOUS
ALKERAN ORAL
4 B/D PAR; MO
amifostine crystalline
5 PAR; MO
anastrozole
2 MO; CG
ARRANON
4 B/D PAR
ARZERRA
5 B/D PAR; MO
ASTAGRAF XL
4 B/D PAR; MO
AVASTIN INTRAVENOUS 5 PAR; MO
SOLUTION 25 MG/ML
AVASTIN INTRAVENOUS 5 PAR
SOLUTION 25 MG/ML (16
ML)
azacitidine
5 PAR; MO
AZASAN
4 B/D PAR; MO
azathioprine
2 B/D PAR; MO; CG
BELEODAQ
5 PAR; MO
bexarotene
5 PAR; MO
bicalutamide
2 MO; CG
BICNU
4 B/D PAR; MO
bleomycin
4 B/D PAR; MO
BLINCYTO
5 PAR; MO
BOSULIF
5 PAR; MO
BUSULFEX
4 B/D PAR
Premier_15283_v14_1511_1
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Drug Name
CAPRELSA
carboplatin intravenous
solution
CASODEX
CELLCEPT
CELLCEPT
INTRAVENOUS
cisplatin
cladribine
CLOLAR
COMETRIQ
COSMEGEN
cyclophosphamide oral capsule
cyclosporine intravenous
cyclosporine modified
cyclosporine oral capsule 100
mg
cyclosporine oral capsule 25 mg
CYRAMZA
INTRAVENOUS
SOLUTION 10 MG/ML
CYRAMZA
INTRAVENOUS
SOLUTION 10 MG/ML (50
ML)
cytarabine
cytarabine (pf) injection
solution 100 mg/5 ml (20 mg/
ml), 2 gram/20 ml (100 mg/
ml)
cytarabine (pf) injection
solution 20 mg/ml
dacarbazine
DACOGEN
daunorubicin intravenous
solution
DAUNOXOME
decitabine
dexrazoxane hcl intravenous
recon soln 250 mg
dexrazoxane hcl intravenous
recon soln 500 mg
DOCEFREZ
INTRAVENOUS RECON
SOLN 20 MG
Drug Requirements/
Tier Limits
5
4
PAR; MO; LA
B/D PAR; MO
4
5
4
MO
B/D PAR; MO
B/D PAR; MO
4
5
5
5
5
4
4
3
4
B/D PAR; MO
B/D PAR; MO
B/D PAR; MO
PAR; MO
B/D PAR; MO
B/D PAR; MO
B/D PAR
B/D PAR; MO
B/D PAR; MO
3
5
B/D PAR; MO
PAR; MO
5
PAR
4
4
B/D PAR; MO
B/D PAR; MO
4
B/D PAR
4
5
4
B/D PAR; MO
B/D PAR; MO
B/D PAR
5
5
5
B/D PAR; MO
B/D PAR; MO
B/D PAR
5
B/D PAR; MO
5
B/D PAR
Drug Name
docetaxel intravenous solution
10 mg/ml, 140 mg/7 ml (20
mg/ml), 160 mg/16 ml (10 mg/
ml), 20 mg/2 ml (10 mg/ml)
docetaxel intravenous solution
20 mg/ml (1 ml), 80 mg/4 ml
(20 mg/ml), 80 mg/8 ml (10
mg/ml)
DOXIL
doxorubicin intravenous recon
soln
doxorubicin intravenous
solution
DROXIA
ELITEK
ELLENCE
EMCYT
epirubicin intravenous solution
200 mg/100 ml
epirubicin intravenous solution
50 mg/25 ml
ERBITUX
ERIVEDGE
ERWINAZE
ETOPOPHOS
etoposide intravenous
exemestane
FARESTON
FARYDAK ORAL
CAPSULE 10 MG
FARYDAK ORAL
FASLODEX
FIRMAGON KIT W
DILUENT SYRINGE
SUBCUTANEOUS RECON
SOLN 120 MG
FIRMAGON KIT W
DILUENT SYRINGE
SUBCUTANEOUS RECON
SOLN 80 MG
fludarabine intravenous recon
soln
fludarabine intravenous
solution
fluorouracil intravenous
Drug Requirements/
Tier Limits
5
B/D PAR
5
B/D PAR; MO
5
4
B/D PAR; MO
B/D PAR
4
B/D PAR; MO
4
5
4
4
4
MO
PAR; MO
B/D PAR; MO
MO
B/D PAR
4
B/D PAR; MO
5
5
5
4
3
3
5
5
5
5
PAR; MO
PAR; MO
B/D PAR; MO
B/D PAR; MO
B/D PAR; MO
MO
MO
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL (30
per 30 days)
PAR; MO
B/D PAR; MO
4
B/D PAR; MO
4
B/D PAR; MO
4
B/D PAR
4
B/D PAR; MO
5
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
flutamide
FOLOTYN
FUSILEV
GAZYVA
gemcitabine intravenous recon
soln 1 gram, 200 mg
gemcitabine intravenous recon
soln 2 gram
gemcitabine intravenous
solution
gengraf
GILOTRIF
GLEEVEC
GLEOSTINE
HALAVEN
HERCEPTIN
HEXALEN
HYDREA
hydroxyurea
IBRANCE
2
5
5
5
5
MO; CG
B/D PAR; MO
B/D PAR; MO
PAR; MO
B/D PAR; MO
5
B/D PAR
ICLUSIG
idarubicin
ifosfamide intravenous recon
soln 1 gram
ifosfamide intravenous recon
soln 3 gram
ifosfamide intravenous solution
IMBRUVICA
INLYTA
IRESSA
irinotecan intravenous solution
100 mg/5 ml, 40 mg/2 ml
irinotecan intravenous solution
500 mg/25 ml
ISTODAX
IXEMPRA
JAKAFI
JEVTANA
KADCYLA
KEYTRUDA
LENVIMA ORAL
CAPSULE 10 MG/DAY (10
MG [1]/DAY)
5
5
4
5
B/D PAR
3
5
5
4
5
5
5
4
2
5
B/D PAR; MO
PAR; MO
PAR; MO
MO
PAR; MO
PAR; MO
MO
MO
MO; CG
PAR; MO; QLL (30
per 30 days)
PAR; MO
B/D PAR
B/D PAR; MO
4
B/D PAR
4
5
5
5
5
B/D PAR
PAR; MO
PAR; MO
MO
B/D PAR; MO
5
B/D PAR
5
5
5
5
5
5
5
PAR; MO
B/D PAR; MO
PAR; MO
B/D PAR; MO
PAR; MO
PAR; MO
PAR; MO; QLL (30
per 30 days)
Drug Name
Drug Requirements/
Tier Limits
LENVIMA ORAL
CAPSULE 14 MG (10
MG[1] -4 MG[1])/DAY, 20
MG/DAY (10 MG [2]/DAY)
LENVIMA ORAL
CAPSULE 24 MG (10
MG[2] -4 MG[1])/DAY
letrozole
leucovorin calcium injection
recon soln 100 mg, 200 mg,
350 mg, 50 mg
leucovorin calcium injection
recon soln 500 mg
leucovorin calcium oral tablet
10 mg, 5 mg
leucovorin calcium oral tablet
15 mg, 25 mg
LEUKERAN
leuprolide
LOMUSTINE
LUPRON DEPOT
INTRAMUSCULAR
SYRINGE KIT 3.75 MG, 7.5
MG
LUPRON DEPOT-PED
INTRAMUSCULAR KIT
7.5 MG (PED)
LYNPARZA
5
PAR; MO; QLL (60
per 30 days)
5
PAR; MO; QLL (90
per 30 days)
2
4
MO; CG
B/D PAR; MO
4
B/D PAR
2
MO; CG
3
MO
3
4
4
5
MO; CG
PAR; MO
MO
PAR; MO
5
PAR; MO
5
LYSODREN
MATULANE
MEGACE
megestrol oral suspension 400
mg/10 ml (10 ml)
megestrol oral suspension 400
mg/10 ml (40 mg/ml)
megestrol oral tablet
MEKINIST
melphalan hcl
mercaptopurine
mesna
MESNEX ORAL
methotrexate sodium (pf)
injection recon soln
methotrexate sodium (pf)
injection solution
3
5
4
3
PAR; MO; QLL
(480 per 30 days)
MO; CG
MO
PAR; MO
PAR
3
PAR; MO
3
5
4
2
4
5
4
PAR; MO
PAR; MO
B/D PAR
MO; CG
B/D PAR; MO
MO
4
MO
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
methotrexate sodium injection
methotrexate sodium oral
mitomycin
mitoxantrone
MUSTARGEN
mycophenolate mofetil oral
capsule
tablet
mycophenolate sodium
MYFORTIC ORAL
TABLET,DELAYED
RELEASE (DR/EC) 180 MG
MYFORTIC ORAL
TABLET,DELAYED
RELEASE (DR/EC) 360 MG
NEORAL
NEXAVAR
4
2
4
3
4
2
NILANDRON
NIPENT
NULOJIX
octreotide acetate injection
solution 1,000 mcg/ml
solution 100 mcg/ml, 200 mcg/
ml, 50 mcg/ml, 500 mcg/ml
syringe 100 mcg/ml (1 ml), 50
mcg/ml (1 ml)
syringe 500 mcg/ml (1 ml)
ONCASPAR
OPDIVO
oxaliplatin intravenous recon
soln 100 mg
oxaliplatin intravenous recon
soln 50 mg
oxaliplatin intravenous solution
paclitaxel
PERJETA
POMALYST
PROGRAF
INTRAVENOUS
5
5
5
5
5
2
4
4
5
4
5
4
4
5
5
5
5
5
5
4
5
5
4
MO
MO; CG
B/D PAR; MO
MO
B/D PAR; MO
B/D PAR; MO; CG
Drug Name
PURIXAN
RAPAMUNE ORAL
SOLUTION
RAPAMUNE ORAL
TABLET 0.5 MG
RAPAMUNE ORAL
TABLET 1 MG, 2 MG
REVLIMID ORAL
B/D PAR; MO
CAPSULE 10 MG
B/D PAR; MO; CG REVLIMID ORAL
CAPSULE 15 MG, 2.5 MG,
20 MG, 25 MG
B/D PAR; MO
REVLIMID ORAL
B/D PAR; MO
CAPSULE 5 MG
RHEUMATREX ORAL
TABLETS,DOSE PACK 2.5
B/D PAR; MO
MG
RHEUMATREX ORAL
TABLETS,DOSE PACK 2.5
B/D PAR; MO
PAR; MO; LA; QLL MG (DOSE PACK 12), 2.5
MG (DOSE PACK 16), 2.5
(120 per 30 days)
MG (DOSE PACK 20), 2.5
MO
MG (DOSE PACK 8)
B/D PAR; MO
RITUXAN
B/D PAR; MO
SANDIMMUNE
PAR; MO
SANDOSTATIN LAR
DEPOT
PAR; MO
SIMULECT
INTRAVENOUS RECON
SOLN 10 MG
PAR; MO
SIMULECT
INTRAVENOUS RECON
SOLN 20 MG
PAR; MO
sirolimus
SOLTAMOX
B/D PAR; MO
SOMATULINE DEPOT
PAR; MO
SPRYCEL
B/D PAR; MO
STIVARGA
B/D PAR
SUTENT
SYNRIBO
B/D PAR; MO
TABLOID
B/D PAR; MO
tacrolimus oral capsule 0.5 mg,
PAR; MO
1 mg
PAR; MO
tacrolimus oral capsule 5 mg
B/D PAR; MO
TAFINLAR
Drug Requirements/
Tier Limits
5
3
PAR; MO
B/D PAR; MO; CG
3
B/D PAR; MO; CG
5
B/D PAR; MO
5
PAR; MO; LA; QLL
(60 per 30 days)
PAR; MO; LA; QLL
(30 per 30 days)
5
5
4
PAR; MO; LA; QLL
(150 per 30 days)
MO
4
5
4
5
PAR; MO
B/D PAR; MO
PAR; MO
5
B/D PAR
5
B/D PAR; MO
3
4
5
5
5
5
5
4
3
B/D PAR; MO
MO
MO
PAR; MO
PAR; MO; QLL
(120 per 30 days)
PAR; MO
PAR; MO
MO
B/D PAR; MO
5
5
B/D PAR; MO
PAR; MO
Premier_15283_v14_1511_1
18
Drug Name
Drug Requirements/
Tier Limits
tamoxifen
TARCEVA
TARGRETIN
TASIGNA
THALOMID ORAL
THALOMID ORAL
thiotepa
toposar
topotecan
TORISEL
TREANDA
TRELSTAR
TRELSTAR DEPOT
TRELSTAR LA
tretinoin (chemotherapy)
TREXALL
TRISENOX
TYKERB
UNITUXIN
VECTIBIX
VELCADE
vinblastine intravenous solution
vincasar pfs intravenous
solution 1 mg/ml
vincasar pfs intravenous
solution 2 mg/2 ml
vincristine
vinorelbine
VOTRIENT
XALKORI
XGEVA
2
5
5
5
5
XTANDI
YERVOY
ZALTRAP
ZANOSAR
ZELBORAF
ZOLINZA
ZORTRESS ORAL TABLET
0.25 MG
ZORTRESS ORAL TABLET
0.5 MG, 0.75 MG
5
5
5
4
5
5
4
5
4
4
5
5
5
5
5
5
5
4
5
5
5
5
5
4
4
4
4
4
5
5
5
5
MO; CG
PAR; MO
PAR; MO
PAR; MO
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL (60
per 30 days)
B/D PAR; MO
B/D PAR; MO
B/D PAR; MO
B/D PAR; MO
B/D PAR; MO
MO
Drug Name
ZYDELIG
Drug Requirements/
Tier Limits
5
PAR; MO; QLL (60
per 30 days)
ZYKADIA
5 PAR; MO
ZYTIGA
5 PAR; MO
Autonomic / Cns Drugs, Neurology / Psych
ABILIFY MAINTENA
5 MO; QLL (1 per 28
INTRAMUSCULAR
days)
SUSPENSION,EXTENDED
REL RECON
ABILIFY MAINTENA
5 QLL (1 per 28 days)
INTRAMUSCULAR
SUSPENSION,EXTENDED
REL SYRING
ABILIFY ORAL TABLET 10 5 MO; QLL (90 per
MG
30 days)
MG, 20 MG
30 days)
MO
ABILIFY
ORAL
TABLET
2
5
MO; QLL (450 per
MO
MG
30 days)
B/D PAR; MO
PAR; MO; LA
MG
30 days)
MO
ABILIFY ORAL TABLET 5
5 MO; QLL (180 per
PAR; MO
MG
30 days)
PAR; MO
ABSTRAL
5
PAR; MO; QLL
B/D PAR; MO
(120 per 30 days)
B/D PAR
acetaminophen-codeine oral
3 QLL (4500 per 30
solution
120
mg-12
mg
/5
ml
days)
B/D PAR; MO
(5 ml), 240 mg-24 mg /10 ml
(10 ml), 300 mg-30 mg /12.5
B/D PAR; MO
ml
B/D PAR; MO
3 MO; QLL (4500 per
PAR; MO
solution
120-12
mg/5
ml
30 days)
PAR; MO
3 MO; QLL (390 per
PAR; MO; QLL (1.7 acetaminophen-codeine oral
tablet
300-15
mg
30 days)
per 28 days)
3 MO; QLL (360 per
PAR; MO
tablet 300-30 mg
30 days)
PAR; MO
acetaminophen-codeine
oral
3
MO; QLL (180 per
PAR; MO
tablet 300-60 mg
30 days)
B/D PAR; MO
ACTIQ
5 PAR; MO; QLL
PAR; MO
(120 per 30 days)
PAR; MO
ADASUVE
4
B/D PAR; MO
alprazolam oral tablet
3 MO; QLL (90 per
30 days)
B/D PAR; MO
amitriptyline
3 PAR; MO
amoxapine
2 MO; CG
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
amphetamine salt combo oral
tablet 10 mg, 12.5 mg, 15 mg,
20 mg, 5 mg, 7.5 mg
amphetamine salt combo oral
tablet 30 mg
AMPYRA
3
APOKYN
APTIOM
aripiprazole oral solution
5
4
5
aripiprazole oral tablet 10 mg
3
5
5
aripiprazole oral tablet 15 mg,
20 mg
5
5
5
ARTHROTEC 50
ARTHROTEC 75
AZILECT
baclofen oral tablet 10 mg
baclofen oral tablet 20 mg
BANZEL ORAL
SUSPENSION
BANZEL ORAL TABLET
200 MG
BANZEL ORAL TABLET
400 MG
benztropine injection
benztropine oral
BRINTELLIX ORAL
TABLET 10 MG
BRINTELLIX ORAL
TABLET 20 MG
BRINTELLIX ORAL
TABLET 5 MG
bromocriptine
BUPRENEX
buprenorphine hcl injection
solution
buprenorphine hcl injection
syringe
4
4
3
1
2
5
5
4
5
4
3
4
4
4
3
5
4
4
Drug Name
buprenorphine hcl sublingual
tablet 2 mg
buprenorphine hcl sublingual
PAR; MO; QLL (60 tablet 8 mg
per 30 days)
buprenorphine-naloxone
PAR; MO; LA; QLL sublingual tablet 2-0.5 mg
(60 per 30 days)
buprenorphine-naloxone
sublingual tablet 8-2 mg
PAR; MO; LA
bupropion hcl oral tablet 100
ST; MO
MO; QLL (900 per mg
bupropion hcl oral tablet 75 mg
30 days)
MO; QLL (90 per
bupropion hcl oral tablet
30 days)
extended release 100 mg
MO; QLL (60 per
30 days)
MO; QLL (450 per extended release 150 mg, 200
mg
30 days)
MO; QLL (30 per
extended release 24 hr 150 mg
30 days)
MO; QLL (180 per bupropion hcl oral tablet
30 days)
buspirone
MO
butalbital-acetaminop-caf-cod
MO
oral capsule 50-300-40-30 mg
MO
butorphanol tartrate injection
MO; CG
butorphanol tartrate nasal
MO; CG
PAR; MO; QLL
CAPITAL WITH
(2400 per 30 days)
CODEINE
PAR; MO; QLL
carbamazepine oral capsule, er
(480 per 30 days)
multiphase 12 hr
PAR; MO; QLL
carbamazepine oral suspension
(240 per 30 days)
100 mg/5 ml
PAR; MO
carbamazepine oral tablet
PAR; MO
carbamazepine oral tablet
ST; MO; QLL (60
per 30 days)
carbamazepine oral tablet,
ST; MO; QLL (30
chewable
per 30 days)
ST; MO; QLL (120 CARBATROL
carbidopa
per 30 days)
carbidopa-levodopa
MO
carbidopa-levodopa-entacapone
MO
CELEBREX
MO
PAR; MO; QLL (90
per 30 days)
celecoxib
Drug Requirements/
Tier Limits
3
3
4
4
2
2
2
2
2
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL
(360 per 30 days)
PAR; MO; QLL (90
per 30 days)
MO; CG; QLL (135
per 30 days)
MO; CG; QLL (180
per 30 days)
MO; CG; QLL (120
per 30 days)
MO; CG; QLL (60
per 30 days)
3
MO; CG; QLL (90
per 30 days)
MO; CG; QLL (45
per 30 days)
MO; CG
PAR; MO; QLL
(180 per 30 days)
MO
MO; QLL (5 per 28
days)
MO; QLL (2700 per
30 days)
MO
3
MO
3
3
MO
MO
3
MO
4
4
3
3
4
MO
ST; MO
MO
MO
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL (60
per 30 days)
2
2
4
4
3
4
4
Premier_15283_v14_1511_1
20
Drug Name
CELONTIN ORAL
CAPSULE 300 MG
chlorpromazine injection
chlorpromazine oral tablet 10
mg, 25 mg, 50 mg
chlorpromazine oral tablet 100
mg, 200 mg
citalopram oral solution
citalopram oral tablet 10 mg
Drug Requirements/
Tier Limits
4
4
2
3
2
1
1
1
clomipramine
clonazepam oral tablet 0.5 mg
4
3
clonazepam oral tablet 1 mg
3
clonazepam oral tablet 2 mg
3
clonazepam oral tablet,
disintegrating 0.125 mg
disintegrating 1 mg
disintegrating 2 mg
clorazepate dipotassium
4
clozapine oral tablet 100 mg
3
3
4
4
4
4
2
3
3
clozapine oral tablet,
disintegrating 100 mg
4
4
Drug Name
PAR; MO
PAR; MO; CG
PAR; MO
codeine sulfate oral tablet 15
MO; CG; QLL (600 mg, 30 mg
codeine sulfate oral tablet 60
per 30 days)
MO; CG; QLL (120 mg
per 30 days)
COGENTIN
MO; CG; QLL (60 COPAXONE
per 30 days)
SUBCUTANEOUS
MO; CG; QLL (30 SYRINGE 20 MG/ML
per 30 days)
COPAXONE
SUBCUTANEOUS
PAR; MO
SYRINGE 40 MG/ML
PAR; MO; QLL
cyclobenzaprine oral tablet
(1200 per 30 days)
CYMBALTA ORAL
PAR; MO; QLL
CAPSULE,DELAYED
(600 per 30 days)
RELEASE(DR/EC) 20 MG
PAR; MO; QLL
CYMBALTA ORAL
(300 per 30 days)
CAPSULE,DELAYED
PAR; MO; QLL
(4800 per 30 days)
CYMBALTA ORAL
PAR; MO; QLL
CAPSULE,DELAYED
(2400 per 30 days)
PAR; MO; QLL
dantrolene
(1200 per 30 days)
DEPACON
PAR; MO; QLL
DEPAKENE
(600 per 30 days)
desipramine oral tablet 10 mg,
PAR; MO; QLL
100 mg, 25 mg, 50 mg, 75 mg
(300 per 30 days)
MO; CG; QLL (120 desipramine oral tablet 150 mg
per 30 days)
DESVENLAFAXINE
MO; QLL (270 per FUMARATE ORAL
TABLET EXTENDED
30 days)
MO; QLL (135 per RELEASE 24HR 100 MG
DESVENLAFAXINE
30 days)
MO; QLL (1080 per FUMARATE ORAL
TABLET EXTENDED
30 days)
MO; QLL (540 per RELEASE 24HR 50 MG
DESVENLAFAXINE ORAL
30 days)
TABLET EXTENDED
QLL (270 per 30
RELEASE 24 HR 100 MG
days)
QLL (2160 per 30
days)
MO
Drug Requirements/
Tier Limits
4
4
4
3
3
4
5
QLL (180 per 30
days)
QLL (135 per 30
days)
QLL (1080 per 30
days)
MO; CG; QLL (360
per 30 days)
MO; CG; QLL (180
per 30 days)
PAR; MO
PAR; MO; QLL (30
per 30 days)
5
PAR; MO; QLL (12
per 28 days)
2
4
PAR; MO; CG
MO; QLL (180 per
30 days)
4
MO; QLL (120 per
30 days)
4
MO; QLL (60 per
30 days)
3
4
4
2
MO
B/D PAR; MO
MO
MO; CG
3
4
MO
MO; QLL (120 per
30 days)
4
MO; QLL (240 per
30 days)
4
MO; QLL (120 per
30 days)
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
DESVENLAFAXINE ORAL
TABLET EXTENDED
RELEASE 24 HR 50 MG
DESVENLAFAXINE ORAL
TABLET EXTENDED
RELEASE 24HR 100 MG
DESVENLAFAXINE ORAL
TABLET EXTENDED
RELEASE 24HR 50 MG
dextroamphetamine oral tablet
10 mg
dextroamphetamine oral tablet
5 mg
diazepam intensol
4
diazepam oral concentrate
3
diazepam oral solution 5 mg/5
ml
diazepam oral tablet 10 mg
3
3
3
diazepam rectal
4
4
4
3
3
3
3
diclofenac potassium
diclofenac sodium oral
diclofenac-misoprostol
diflunisal
dihydrocodeine-aspirin-caff
2
2
3
2
4
dihydroergotamine injection
dihydroergotamine nasal
4
4
DILANTIN 30 MG
CAPSULE
DILANTIN EXTENDED
DILANTIN INFATABS
DILANTIN-125
diskets
3
divalproex
DOLOPHINE ORAL
TABLET 10 MG
4
3
4
3
2
4
MO; QLL (240 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
DOLOPHINE ORAL
TABLET 5 MG
donepezil oral tablet 10 mg, 5
mg
donepezil oral tablet 23 mg
4
donepezil oral tablet,
disintegrating
doxepin oral
PAR; MO; QLL
duloxetine oral capsule,delayed
(180 per 30 days)
release(dr/ec) 20 mg
PAR; MO; QLL (90 duloxetine oral capsule,delayed
per 30 days)
PAR; MO; QLL
duloxetine oral capsule,delayed
(240 per 30 days)
PAR; QLL (240 per duloxetine oral capsule,delayed
30 days)
MO; QLL (1200 per duramorph (pf) injection
30 days)
solution 0.5 mg/ml
PAR; MO; QLL
duramorph (pf) injection
(120 per 30 days)
solution 1 mg/ml
PAR; MO; QLL
EC-NAPROSYN
(600 per 30 days)
EMSAM
PAR; MO; QLL
(240 per 30 days)
endocet oral tablet 10-325 mg,
MO; QLL (2 per 1 5-325 mg, 7.5-325 mg
day)
endodan
MO; CG
MO; CG
entacapone
MO
epitol
MO; CG
EQUETRO ORAL
QLL (240 per 30
CAPSULE, ER
days)
MULTIPHASE 12 HR 100
MO
MG
MO; QLL (8 per 28 EQUETRO ORAL
days)
CAPSULE, ER
MO
MG
EQUETRO ORAL
MO
CAPSULE, ER
MO
MO
MG
QLL (30 per 30
ergoloid
days)
ERGOMAR
MO; CG
MO; QLL (180 per escitalopram oxalate oral
solution
30 days)
2
QLL (120 per 30
days)
QLL (240 per 30
days)
4
MO; QLL (360 per
30 days)
MO; CG; QLL (30
per 30 days)
ST; MO; QLL (30
per 30 days)
MO; CG; QLL (30
per 30 days)
PAR; MO
MO; QLL (180 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
B/D PAR; MO
4
B/D PAR
4
5
MO
PAR; MO; QLL (30
per 30 days)
MO; QLL (360 per
30 days)
MO; QLL (360 per
30 days)
MO
MO; CG
MO; QLL (480 per
30 days)
2
3
3
3
3
3
3
3
3
3
1
4
4
MO; QLL (240 per
30 days)
4
MO; QLL (180 per
30 days)
3
3
3
PAR; MO
MO
MO; QLL (600 per
30 days)
Premier_15283_v14_1511_1
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Drug Name
escitalopram oxalate oral tablet
10 mg
20 mg
5 mg
ethosuximide
etodolac
FANAPT ORAL TABLET 1
MG
FANAPT ORAL TABLET
10 MG
FANAPT ORAL TABLET
12 MG
MG
MG
MG
MG
FANAPT ORAL TABLETS,
DOSE PACK
FAZACLO ORAL TABLET,
DISINTEGRATING 100
MG
DISINTEGRATING 12.5
MG
DISINTEGRATING 150
MG
DISINTEGRATING 200
MG
DISINTEGRATING 25 MG
felbamate oral suspension
felbamate oral tablet 400 mg
felbamate oral tablet 600 mg
FELDENE
fenoprofen oral tablet
fentanyl citrate
Drug Requirements/
Tier Limits
2
2
2
3
2
4
5
4
4
4
4
4
4
4
4
4
Drug Requirements/
Tier Limits
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (120
per 30 days)
MO
MO; CG
MO; QLL (720 per
30 days)
MO; QLL (72 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (8 per 30
days)
QLL (270 per 30
days)
fentanyl transdermal patch 72
hour 100 mcg/hr, 12 mcg/hr,
25 mcg/hr, 50 mcg/hr, 75 mcg/
hr
FENTORA
4
ST; MO; QLL (15
per 30 days)
5
FETZIMA ORAL
CAPSULE,EXT REL 24HR
DOSE PACK
FETZIMA ORAL
CAPSULE,EXTENDED
RELEASE 24 HR 120 MG,
80 MG
FETZIMA ORAL
CAPSULE,EXTENDED
RELEASE 24 HR 20 MG
FETZIMA ORAL
CAPSULE,EXTENDED
RELEASE 24 HR 40 MG
FIORICET WITH
CODEINE ORAL
CAPSULE 50-300-40-30
MG
fluoxetine oral capsule 10 mg
4
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL (28
per 365 days)
1
QLL (2160 per 30
days)
2
fluoxetine oral capsule,delayed
release(dr/ec)
fluoxetine oral solution
4
fluoxetine oral tablet 10 mg
1
fluoxetine oral tablet 20 mg
2
FLUOXETINE ORAL
TABLET 60 MG
fluphenazine decanoate
fluphenazine hcl injection
fluphenazine hcl oral
flurbiprofen
fluvoxamine oral tablet 100 mg
4
QLL (180 per 30
days)
4
QLL (135 per 30
days)
4
QLL (1080 per 30
days)
MO
MO
MO
MO
MO; CG
PAR; MO; QLL
(120 per 30 days)
5
4
5
4
2
5
Drug Name
4
PAR; MO; QLL (30
per 30 days)
4
PAR; MO; QLL
(180 per 30 days)
4
PAR; MO; QLL (90
per 30 days)
4
PAR; MO; QLL
(180 per 30 days)
1
MO; CG; QLL (240
per 30 days)
MO; CG; QLL (120
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; QLL (4 per 28
days)
MO; CG; QLL (600
per 30 days)
MO; CG; QLL (240
per 30 days)
MO; CG; QLL (120
per 30 days)
MO; QLL (30 per
30 days)
MO
MO
MO; CG
MO; CG
MO; CG; QLL (90
per 30 days)
2
4
4
2
2
2
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
2
2
fosphenytoin
FYCOMPA ORAL TABLET
10 MG, 12 MG
FYCOMPA ORAL TABLET
2 MG
FYCOMPA ORAL TABLET
4 MG
FYCOMPA ORAL TABLET
6 MG
FYCOMPA ORAL TABLET
8 MG
gabapentin oral capsule 100 mg
4
4
2
2
4
4
4
4
2
gabapentin oral solution 250
mg/5 ml
gabapentin oral solution 250
mg/5 ml (5 ml), 300 mg/6 ml
(6 ml)
gabapentin oral tablet 600 mg
3
gabapentin oral tablet 800 mg
2
GABITRIL ORAL TABLET
12 MG, 16 MG
galantamine oral capsule,ext
rel. pellets 24 hr
galantamine oral solution
4
galantamine oral tablet
3
GEODON
INTRAMUSCULAR
GILENYA
4
GLATOPA
5
guanfacine oral tablet extended
release 24 hr
3
2
3
3
5
4
MO; CG; QLL (360
per 30 days)
MO; CG; QLL (180
per 30 days)
B/D PAR; MO
MO; QLL (30 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (45 per
30 days)
MO; CG; QLL
(1080 per 30 days)
MO; CG; QLL (360
per 30 days)
MO; CG; QLL (270
per 30 days)
MO; QLL (2160 per
30 days)
QLL (2160 per 30
days)
MO; CG; QLL (180
per 30 days)
MO; CG; QLL (135
per 30 days)
MO
MO; QLL (30 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (60 per
30 days)
MO
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL (30
per 30 days)
Drug Name
Drug Requirements/
Tier Limits
guanidine
haloperidol
haloperidol decanoate
haloperidol lactate injection
haloperidol lactate oral
HORIZANT ORAL
TABLET EXTENDED
RELEASE 300 MG
HORIZANT ORAL
TABLET EXTENDED
RELEASE 600 MG
HYCET
3
2
4
4
2
4
MO; CG
MO; CG
MO
MO
MO; CG
PAR; MO; QLL
(120 per 30 days)
4
PAR; MO; QLL (60
per 30 days)
4
hydrocodone-acetaminophen
oral solution 2.5-167 mg/5 ml
oral solution 7.5-325 mg/15 ml
oral tablet 10-325 mg, 5-325
mg, 7.5-325 mg
hydrocodone-ibuprofen
3
MO; QLL (2700 per
30 days)
QLL (2700 per 30
days)
MO; QLL (2700 per
30 days)
MO; QLL (360 per
30 days)
hydromorphone (pf) injection
solution 1 mg/ml
hydromorphone (pf) injection
solution 10 mg/ml, 4 mg/ml
hydromorphone injection
solution
syringe 1 mg/ml
syringe 2 mg/ml
syringe 4 mg/ml
hydromorphone oral liquid
4
hydromorphone oral tablet 2
mg, 4 mg
hydromorphone oral tablet 8
mg
ibuprofen oral suspension
ibuprofen oral tablet 400 mg,
600 mg, 800 mg
ibuprofen-oxycodone
3
imipramine hcl
2
3
3
3
MO; QLL (480 per
30 days)
4
MO
4
MO; QLL (180 per
30 days)
4
4
4
4
3
1
1
3
QLL (180 per 30
days)
MO
MO; QLL (720 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
MO; CG
MO; CG
MO; QLL (28 per 1
day)
PAR; MO; CG
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
INTUNIV ER
4
INVEGA ORAL TABLET
EXTENDED RELEASE
24HR 1.5 MG
INVEGA ORAL TABLET
EXTENDED RELEASE
24HR 3 MG
INVEGA ORAL TABLET
EXTENDED RELEASE
24HR 6 MG
INVEGA ORAL TABLET
EXTENDED RELEASE
24HR 9 MG
INVEGA SUSTENNA
INTRAMUSCULAR
SYRINGE 117 MG/0.75
ML, 156 MG/ML, 234 MG/
1.5 ML
INVEGA SUSTENNA
INTRAMUSCULAR
SYRINGE 39 MG/0.25 ML,
78 MG/0.5 ML
INVEGA TRINZA
INTRAMUSCULAR
SYRINGE 273 MG/0.875
ML
INVEGA TRINZA
INTRAMUSCULAR
ML
INVEGA TRINZA
INTRAMUSCULAR
SYRINGE 546 MG/1.75 ML
INVEGA TRINZA
INTRAMUSCULAR
ML
ketoprofen oral capsule
ketoprofen oral capsule,ext rel.
pellets 24 hr 200 mg
KHEDEZLA ORAL
TABLET EXTENDED
RELEASE 24HR 100 MG
4
PAR; MO; QLL (30
per 30 days)
MO; QLL (240 per
30 days)
4
MO; QLL (120 per
30 days)
5
MO; QLL (60 per
30 days)
5
5
4
5
5
5
5
MO; QLL (40 per
30 days)
MO; QLL (2 per 28
days)
MO; QLL (2 per 28
days)
MO; QLL (0.875
per 90 days)
MO; QLL (1.315
per 90 days)
MO; QLL (1.75 per
90 days)
MO; QLL (2.625
per 90 days)
2
4
MO; CG
MO
4
MO; QLL (120 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
KHEDEZLA ORAL
TABLET EXTENDED
RELEASE 24HR 50 MG
LAMICTAL ORAL TABLET
LAMICTAL ORAL
TABLET, CHEWABLE
DISPERSIBLE 25 MG, 5
MG
LAMICTAL STARTER
(BLUE) KIT
LAMICTAL STARTER
(GREEN) KIT
LAMICTAL STARTER
(ORANGE) KIT
lamotrigine oral tablet
lamotrigine oral tablet,
chewable dispersible
LATUDA ORAL TABLET
120 MG
LATUDA ORAL TABLET
20 MG
LATUDA ORAL TABLET
40 MG
LATUDA ORAL TABLET
60 MG
LATUDA ORAL TABLET
80 MG
LAZANDA
4
MO; QLL (240 per
30 days)
4
4
MO
MO
4
MO
4
MO
4
MO
2
3
MO; CG
MO
5
levetiracetam in nacl (iso-os)
intravenous piggyback 1,000
mg/100 ml, 1,500 mg/100 ml
levetiracetam in nacl (iso-os)
100 ml
levetiracetam intravenous
levetiracetam oral solution 100
mg/ml
levetiracetam oral solution 500
mg/5 ml (5 ml)
levetiracetam oral tablet
4
MO; QLL (30 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (75 per
30 days)
MO; QLL (60 per
30 days)
PAR; MO; QLL (30
per 30 days)
B/D PAR
4
B/D PAR; MO
4
3
B/D PAR; MO
MO
4
4
4
4
5
3
2
3
3
MO; CG
MO; QLL (180 per
30 days)
MO; QLL (120 per
30 days)
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
levorphanol tartrate
2
lithium carbonate oral capsule
150 mg, 300 mg
lithium carbonate oral capsule
600 mg
lithium carbonate oral tablet
lithium carbonate oral tablet
extended release
lithium citrate oral solution 8
meq/5 ml
LITHOBID
LODOSYN
lorazepam oral tablet
1
MO; CG; QLL (180
per 30 days)
MO; CG
2
MO; CG
1
2
MO; CG
MO; CG
loxapine succinate
LYRICA ORAL CAPSULE
100 MG
LYRICA ORAL CAPSULE
150 MG
LYRICA ORAL CAPSULE
200 MG
LYRICA ORAL CAPSULE
225 MG, 300 MG
LYRICA ORAL CAPSULE
25 MG
LYRICA ORAL CAPSULE
50 MG
LYRICA ORAL CAPSULE
75 MG
LYRICA ORAL SOLUTION
2
4
2
4
4
3
4
4
4
4
4
4
4
maprotiline oral tablet 25 mg
2
2
MARPLAN
meclofenamate oral
mefenamic acid
meloxicam oral suspension
meloxicam oral tablet
MESTINON ORAL SYRUP
2
4
4
4
3
1
3
MO; CG
MO
ST; MO
MO; QLL (90 per
30 days)
MO; CG
PAR; MO; QLL
(180 per 30 days)
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL (90
per 30 days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL
(720 per 30 days)
PAR; MO; QLL
(360 per 30 days)
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL
(900 per 30 days)
MO; CG; QLL (270
per 30 days)
MO; CG; QLL (135
per 30 days)
MO; CG
MO
MO
MO
MO; QLL (300 per
30 days)
MO; CG; QLL (30
per 30 days)
MO; CG
Drug Name
Drug Requirements/
Tier Limits
MESTINON ORAL
TABLET
MESTINON TIMESPAN
methadone injection
methadone intensol
4
MO
3
4
3
MO; CG
methadone oral concentrate
3
methadone oral solution 10 mg/
5 ml
methadone oral solution 5 mg/
5 ml
methadone oral tablet 10 mg
3
methadone oral tablet 5 mg
3
methadone oral tablet,soluble
3
methadose oral concentrate
3
methadose oral tablet,soluble
3
methylphenidate oral tablet
3
migergot
MIGRANAL
4
5
mirtazapine oral tablet 15 mg
1
1
2
mirtazapine oral tablet 7.5 mg
2
mirtazapine oral tablet,
modafinil oral tablet 100 mg
2
modafinil oral tablet 200 mg
5
3
3
2
2
4
MO; QLL (180 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (900 per
30 days)
MO; QLL (1800 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (360 per
30 days)
QLL (30 per 30
days)
MO; QLL (180 per
30 days)
MO; QLL (30 per
30 days)
PAR; MO; QLL (90
per 30 days)
MO
MO; QLL (8 per 28
days)
MO; CG; QLL (90
per 30 days)
MO; CG; QLL (45
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (180
per 30 days)
MO; CG; QLL (90
per 30 days)
MO; CG; QLL (45
per 30 days)
MO; CG; QLL (30
per 30 days)
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL (60
per 30 days)
Premier_15283_v14_1511_1
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Drug Name
morphine (pf) injection solution
0.5 mg/ml
morphine (pf) injection solution
1 mg/ml
morphine (pf) intravenous
patient control.analgesia soln
150 mg/30 ml
morphine (pf) intravenous
patient control.analgesia soln
30 mg/30 ml
morphine concentrate oral
solution
morphine intravenous cartridge
MORPHINE
INTRAVENOUS
CARTRIDGE
morphine intravenous solution
100 mg/4 ml, 25 mg/ml, 250
mg/10 ml
morphine intravenous solution
50 mg/ml
morphine intravenous syringe
2 mg/ml, 4 mg/ml
morphine oral solution 10 mg/
5 ml
morphine oral solution 20 mg/
5 ml
morphine oral tablet 15 mg
Drug Requirements/
Tier Limits
4
B/D PAR
4
B/D PAR; MO
4
MO
4
3
4
4
4
4
MO
4
3
3
3
morphine oral tablet 30 mg
3
morphine oral tablet extended
release 100 mg, 15 mg, 30 mg,
60 mg
morphine oral tablet extended
release 200 mg
morphine rectal
3
nabumetone
nalbuphine injection
naloxone injection solution
naloxone injection syringe 0.4
mg/ml
naloxone injection syringe 1 mg/
ml
naltrexone oral
MO; CG; QLL (270
per 30 days)
3
3
2
4
4
4
MO; CG; QLL
(2700 per 30 days)
MO; CG; QLL
(1350 per 30 days)
MO; CG; QLL (360
per 30 days)
MO; CG; QLL (180
per 30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (180 per
30 days)
MO; CG
MO
MO
3
MO
2
MO; CG
Drug Name
Drug Requirements/
Tier Limits
NAMENDA ORAL
SOLUTION
3
NAMENDA ORAL
TABLET 10 MG
NAMENDA ORAL
TABLET 5 MG
NAMENDA TITRATION
PAK
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR
DOSE PACK
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER
24HR
NAMZARIC
naproxen oral suspension
naproxen oral tablet 250 mg
naproxen oral tablet 375 mg,
500 mg
naproxen oral tablet,delayed
release (dr/ec)
naproxen sodium oral tablet
275 mg, 550 mg
naratriptan oral tablet 1 mg
3
naratriptan oral tablet 2.5 mg
3
NARDIL
nefazodone oral tablet 100 mg
4
2
2
2
2
2
NEUPRO
4
NEURONTIN ORAL
CAPSULE 100 MG
NEURONTIN ORAL
CAPSULE 300 MG
4
3
3
3
PAR; MO; CG;
QLL (300 per 30
days)
MO; QLL (60 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
PAR; MO; QLL (28
per 365 days)
3
PAR; MO; QLL (30
per 30 days)
3
2
2
1
MO
MO; CG
MO; CG
MO; CG
2
MO; CG
2
MO; CG
2
MO; CG; QLL (9
per 30 days)
MO; QLL (9 per 30
days)
MO
MO; CG; QLL (180
per 30 days)
MO; CG; QLL (120
per 30 days)
MO; CG; QLL (90
per 30 days)
MO; CG; QLL (72
per 30 days)
MO; CG; QLL (360
per 30 days)
MO; QLL (30 per
30 days)
MO; QLL (1080 per
30 days)
MO; QLL (360 per
30 days)
4
Premier_15283_v14_1511_1
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Drug Name
NEURONTIN ORAL
CAPSULE 400 MG
NEURONTIN ORAL
SOLUTION
NEURONTIN ORAL
TABLET 600 MG
NEURONTIN ORAL
TABLET 800 MG
NORPRAMIN
nortriptyline oral capsule 10
mg, 25 mg
nortriptyline oral capsule 50
mg, 75 mg
nortriptyline oral solution
NUEDEXTA
olanzapine intramuscular
Drug Requirements/
Tier Limits
4
4
4
4
4
1
2
MO; CG
2
3
MO; CG
MO; QLL (60 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (40 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (80 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (40 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (120 per
30 days)
PAR; MO; QLL
(480 per 30 days)
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL (60
per 30 days)
MO; CG
MO
4
olanzapine oral tablet 10 mg
3
4
olanzapine oral tablet 2.5 mg
MO; QLL (270 per
30 days)
MO; QLL (2160 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (135 per
30 days)
MO
MO; CG
3
4
3
olanzapine oral tablet 7.5 mg
3
olanzapine oral tablet,
disintegrating 5 mg
ONFI ORAL SUSPENSION
4
ONFI ORAL TABLET 10
MG
ONFI ORAL TABLET 20
MG
ORAP
oxaprozin
4
4
5
3
4
4
3
3
Drug Name
Drug Requirements/
Tier Limits
oxazepam
2
oxcarbazepine
OXTELLAR XR ORAL
TABLET EXTENDED
OXTELLAR XR ORAL
TABLET EXTENDED
OXTELLAR XR ORAL
TABLET EXTENDED
oxycodone oral capsule
3
4
oxycodone oral concentrate
3
oxycodone oral solution
3
oxycodone oral tablet 10 mg, 5
mg
oxycodone oral tablet 15 mg
3
oxycodone oral tablet 20 mg,
30 mg
oxycodone-acetaminophen oral
tablet 10-325 mg, 2.5-325 mg,
5-325 mg, 7.5-325 mg
oxycodone-aspirin
3
OXYCONTIN ORAL
TABLET,ORAL ONLY,
EXT.REL.12 HR 10 MG, 15
MG, 20 MG, 30 MG, 40
MG
OXYCONTIN ORAL
TABLET,ORAL ONLY,
EXT.REL.12 HR 60 MG
paroxetine hcl oral tablet 10 mg
4
2
2
2
PAR; MO; CG;
QLL (120 per 30
days)
MO
MO; QLL (480 per
30 days)
4
MO; QLL (240 per
30 days)
4
MO; QLL (120 per
30 days)
3
MO; QLL (360 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (1800 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (540 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (360 per
30 days)
3
3
3
MO; QLL (360 per
30 days)
ST; MO; QLL (60
per 30 days)
4
ST; MO; QLL (120
per 30 days)
2
MO; CG; QLL (180
per 30 days)
MO; CG; QLL (90
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (45
per 30 days)
Premier_15283_v14_1511_1
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Drug Name
paroxetine hcl oral tablet
extended release 24 hr 12.5 mg
extended release 24 hr 37.5 mg
PAXIL ORAL
SUSPENSION
PAXIL ORAL TABLET 10
MG
MG
MG
MG
PEGANONE
perphenazine
phenelzine
phenobarbital oral elixir
phenobarbital oral tablet 100
mg
phenobarbital oral tablet 15 mg
Drug Requirements/
Tier Limits
4
4
4
4
4
4
4
4
4
2
2
3
3
3
phenobarbital oral tablet 16.2
mg
3
mg
3
mg
mg
PHENYTEK
phenytoin oral suspension 100
mg/4 ml
phenytoin oral suspension 125
mg/5 ml
phenytoin oral tablet,chewable
phenytoin sodium extended
phenytoin sodium intravenous
solution
3
3
3
3
4
3
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (900 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (45 per
30 days)
MO
MO; CG
MO; CG
PAR; MO; QLL
(3000 per 30 days)
PAR; QLL (120 per
30 days)
PAR; MO; QLL
(800 per 30 days)
PAR; MO; QLL
(741 per 30 days)
PAR; MO; QLL
(400 per 30 days)
PAR; MO; QLL
(370 per 30 days)
PAR; MO; QLL
(200 per 30 days)
PAR; MO; QLL
(185 per 30 days)
PAR; MO; QLL
(123 per 30 days)
MO
3
MO
3
3
4
MO
MO
B/D PAR; MO
Drug Name
Drug Requirements/
Tier Limits
phenytoin sodium intravenous
syringe
piroxicam
POTIGA ORAL TABLET
200 MG, 400 MG
POTIGA ORAL TABLET
300 MG
POTIGA ORAL TABLET
50 MG
pramipexole oral tablet
primidone
PRISTIQ ORAL TABLET
EXTENDED RELEASE 24
HR 100 MG
PRISTIQ ORAL TABLET
EXTENDED RELEASE 24
HR 25 MG
PRISTIQ ORAL TABLET
EXTENDED RELEASE 24
HR 50 MG
protriptyline oral tablet 10 mg
protriptyline oral tablet 5 mg
pyridostigmine bromide oral
tablet
pyridostigmine bromide oral
tablet extended release
quetiapine oral tablet 100 mg
4
B/D PAR
2
4
MO; CG
MO; QLL (90 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (270 per
30 days)
MO
MO
MO; QLL (120 per
30 days)
3
3
3
3
3
regonol
REQUIP XL
REXULTI ORAL TABLET
0.25 MG, 0.5 MG, 1 MG, 2
MG
REXULTI ORAL TABLET
3 MG, 4 MG
4
4
5
5
4
3
3
4
4
MO; QLL (480 per
30 days)
4
MO; QLL (240 per
30 days)
3
2
2
MO
MO; CG
MO; CG
3
MO
3
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (960 per
30 days)
MO; QLL (80 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (480 per
30 days)
5
MO
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL (30
per 30 days)
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
RISPERDAL CONSTA
INTRAMUSCULAR
SYRINGE 12.5 MG/2 ML,
25 MG/2 ML
RISPERDAL CONSTA
INTRAMUSCULAR
SYRINGE 37.5 MG/2 ML
RISPERDAL CONSTA
INTRAMUSCULAR
SYRINGE 50 MG/2 ML
risperidone oral solution
4
risperidone oral tablet 0.25 mg
2
5
5
3
risperidone oral tablet 0.5 mg
2
risperidone oral tablet 1 mg
2
2
2
2
risperidone oral tablet,
disintegrating 1 mg
disintegrating 2 mg
disintegrating 3 mg
disintegrating 4 mg
rivastigmine tartrate oral
capsule
ropinirole
ROZEREM
SABRIL ORAL POWDER
IN PACKET
SABRIL ORAL TABLET
3
3
3
3
3
3
3
3
3
4
5
MO; QLL (2 per 28
days)
Drug Name
SAPHRIS (BLACK
CHERRY) SUBLINGUAL
TABLET 10 MG
SAPHRIS (BLACK
MO; QLL (2 per 28 CHERRY) SUBLINGUAL
days)
TABLET 2.5 MG
SAPHRIS (BLACK
MO
CHERRY) SUBLINGUAL
TABLET 5 MG
SARAFEM ORAL TABLET
MO; QLL (480 per 10 MG
30 days)
SARAFEM ORAL TABLET
MO; CG; QLL
20 MG
(1920 per 30 days)
selegiline hcl
MO; CG; QLL (960 SEROQUEL XR ORAL
per 30 days)
TABLET EXTENDED
MO; CG; QLL (480 RELEASE 24 HR 150 MG
per 30 days)
SEROQUEL XR ORAL
MO; CG; QLL (240 TABLET EXTENDED
per 30 days)
MO; CG; QLL (160 SEROQUEL XR ORAL
per 30 days)
TABLET EXTENDED
MO; CG; QLL (120 RELEASE 24 HR 300 MG
per 30 days)
SEROQUEL XR ORAL
MO; QLL (1920 per TABLET EXTENDED
30 days)
MO; QLL (960 per SEROQUEL XR ORAL
TABLET EXTENDED
30 days)
MO; QLL (480 per RELEASE 24 HR 50 MG
sertraline oral concentrate
30 days)
MO; QLL (240 per
sertraline oral tablet 100 mg
30 days)
MO; QLL (160 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
STRATTERA ORAL
30 days)
CAPSULE 10 MG, 18 MG,
MO
25 MG, 40 MG
MO; QLL (30 per
STRATTERA ORAL
30 days)
PAR; MO; LA; QLL CAPSULE 100 MG, 60 MG,
80 MG
(180 per 30 days)
PAR; MO; LA; QLL SUBOXONE
SUBLINGUAL FILM 12-3
(180 per 30 days)
MG
Drug Requirements/
Tier Limits
4
MO; QLL (60 per
30 days)
4
MO; QLL (240 per
30 days)
4
MO; QLL (120 per
30 days)
4
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO
MO; QLL (160 per
30 days)
4
3
4
4
MO; QLL (120 per
30 days)
4
MO; QLL (80 per
30 days)
5
MO; QLL (60 per
30 days)
4
MO; QLL (480 per
30 days)
2
MO; CG; QLL (300
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (240
per 30 days)
MO; CG; QLL (120
per 30 days)
PAR; MO; QLL (60
per 30 days)
2
2
2
4
4
PAR; MO; QLL (30
per 30 days)
4
PAR; MO; QLL (60
per 30 days)
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
3
2
4
3
PAR; MO
MO; CG
MO
MO
4
2
5
2
2
3
4
MO
MO; CG
MO
MO; CG
MO; CG
MO
PAR; MO
4
PAR; MO
5
PAR; MO
3
PAR; MO
2
2
MO; QLL (4 per 30
days)
QLL (4 per 30 days)
3
1
PAR; MO; CG
MO; CG; QLL (240
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (240
per 30 days)
MO
MO; CG
2
2
4
5
4
3
3
MO; CG
MO; CG
MO
MO; LA
B/D PAR; MO
MO
MO
4
sulindac oral
sumatriptan nasal spray,nonaerosol 20 mg/actuation
sumatriptan nasal spray,nonaerosol 5 mg/actuation
sumatriptan succinate oral
2
3
sumatriptan succinate
subcutaneous cartridge
subcutaneous pen injector 4 mg/
0.5 ml, 6 mg/0.5 ml
subcutaneous pen injector 6 mg/
0.5 ml (auto-injector)
subcutaneous solution
subcutaneous syringe 6 mg/0.5
ml
SURMONTIL
SYNALGOS-DC
4
TASMAR ORAL TABLET
100 MG
TECFIDERA
TEGRETOL ORAL
SUSPENSION
TEGRETOL ORAL
TABLET
TEGRETOL XR
tetrabenazine oral tablet 12.5
mg
tetrabenazine oral tablet 25 mg
5
PAR; MO
MO; QLL (240 per
30 days)
MO
5
4
PAR; MO
MO
4
MO
4
5
MO
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL
(120 per 30 days)
4
5
3
2
4
4
4
4
4
4
5
Drug Requirements/
Tier Limits
thioridazine
thiothixene
tiagabine
PAR; MO; QLL
tizanidine oral capsule 2 mg, 4
(180 per 30 days)
mg
tizanidine oral capsule 6 mg
PAR; MO; QLL (90 tizanidine oral tablet
per 30 days)
tolcapone
tolmetin oral capsule
PAR; MO; LA; QLL tolmetin oral tablet 200 mg
(120 per 30 days)
tolmetin oral tablet 600 mg
MO; CG
TOPAMAX ORAL
MO; QLL (8 per 30 CAPSULE, SPRINKLE
days)
TOPAMAX ORAL TABLET
MO; QLL (16 per
100 MG, 25 MG, 50 MG
30 days)
TOPAMAX ORAL TABLET
MO; CG; QLL (9
200 MG
per 30 days)
topiramate oral capsule,
MO; QLL (4 per 30 sprinkle
days)
topiramate oral tablet
MO; QLL (4 per 30 tramadol oral tablet
days)
tramadol oral tablet extended
QLL (4 per 30 days) release 24 hr 100 mg, 200 mg
tramadol-acetaminophen
SUBOXONE
SUBLINGUAL FILM 2-0.5
MG
SUBOXONE
SUBLINGUAL FILM 4-1
MG
SUBOXONE
SUBLINGUAL FILM 8-2
MG
SUBSYS
4
Drug Name
PAR; MO; QLL
(360 per 30 days)
tranylcypromine
trazodone oral tablet 100 mg,
150 mg, 50 mg
trazodone oral tablet 300 mg
trifluoperazine
TRILEPTAL
TYSABRI
valproate sodium
valproic acid
valproic acid (as sodium salt)
oral solution 250 mg/5 ml
valproic acid (as sodium salt)
oral solution 250 mg/5 ml (5
ml), 500 mg/10 ml (10 ml)
venlafaxine oral capsule,
extended release 24hr 150 mg
extended release 24hr 37.5 mg
2
2
3
2
2
2
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (180
per 30 days)
MO; CG; QLL (90
per 30 days)
Premier_15283_v14_1511_1
31
Drug Name
Drug Requirements/
Tier Limits
venlafaxine oral tablet 100 mg
2
2
venlafaxine oral tablet 37.5 mg
2
2
2
venlafaxine oral tablet extended
release 24hr 150 mg
VENLAFAXINE ORAL
TABLET EXTENDED
RELEASE 24HR 225 MG
release 24hr 37.5 mg
release 24hr 75 mg
VERSACLOZ
3
4
3
3
5
VIIBRYD ORAL TABLET
10 MG
VIIBRYD ORAL TABLET
20 MG
VIIBRYD ORAL TABLET
40 MG
VIIBRYD ORAL TABLETS,
DOSE PACK 10 MG (7)- 20
MG (23)
VIIBRYD ORAL TABLETS,
DOSE PACK 10 MG (7)-20
MG (7)-40 MG (16)
VIMPAT INTRAVENOUS
4
VIMPAT ORAL
SOLUTION
VIMPAT ORAL TABLET
100 MG
VIMPAT ORAL TABLET
150 MG
VIMPAT ORAL TABLET
200 MG
VIMPAT ORAL TABLET
50 MG
4
4
4
4
4
4
4
4
4
4
MO; CG; QLL (113
per 30 days)
MO; CG; QLL (450
per 30 days)
MO; CG; QLL (300
per 30 days)
MO; CG; QLL (225
per 30 days)
MO; CG; QLL (150
per 30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
LA; QLL (600 per
30 days)
ST; MO; QLL (120
per 30 days)
ST; MO; QLL (60
per 30 days)
ST; MO; QLL (30
per 30 days)
ST; QLL (30 per 30
days)
Drug Name
Drug Requirements/
Tier Limits
VOLTAREN GEL
TOPICAL GEL 1 %
XENAZINE ORAL TABLET
12.5 MG
XENAZINE ORAL TABLET
25 MG
XYREM
3
zaleplon oral capsule 10 mg
3
zaleplon oral capsule 5 mg
3
ZAMICET
3
ZARONTIN
ZELAPAR
ziprasidone hcl oral capsule 20
mg
mg
mg, 80 mg
zolpidem oral tablet
4
4
3
5
5
5
3
3
3
MO; CG; QLL
(1000 per 30 days)
PAR; MO; LA; QLL
(240 per 30 days)
PAR; MO; LA; QLL
(120 per 30 days)
PAR; MO; LA; QLL
(540 per 30 days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL (30
per 30 days)
QLL (2700 per 30
days)
MO
MO
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
PAR; MO; QLL (30
per 30 days)
MO
LA
zonisamide
3
ZYPREXA RELPREVV
4
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 210
MG, 405 MG
ST; MO; QLL (30
ZYPREXA RELPREVV
4 MO; LA
per 30 days)
INTRAMUSCULAR
SUSPENSION FOR
B/D PAR; QLL
RECONSTITUTION 300
(1200 per 30 days)
MG
MO; QLL (1200 per Cardiovascular, Hypertension / Lipids
30 days)
ACCURETIC
4 MO
MO; QLL (120 per acebutolol
2 MO; CG
30 days)
ADALAT CC
4 MO
MO; QLL (80 per
afeditab cr
2 MO; CG
30 days)
AGGRENOX
3 MO; QLL (60 per
MO; QLL (60 per
30 days)
30 days)
ALDACTAZIDE
4 MO
MO; QLL (240 per ALDACTONE
4 MO
30 days)
ALTOPREV
4 PAR; MO; QLL (30
per 30 days)
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
amiloride oral
amiloride-hydrochlorothiazide
amiodarone intravenous
solution
amiodarone intravenous syringe
amiodarone oral
amlodipine oral tablet 10 mg,
2.5 mg
amlodipine oral tablet 5 mg
2
1
4
MO; CG
MO; CG
B/D PAR; MO
4
2
1
amlodipine-atorvastatin
2
amlodipine-benazepril
amlodipine-valsartan
1
3
amlodipine-valsartan-hcthiazid
3
aspirin-dipyridamole
3
B/D PAR
MO; CG
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (45
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
1
ATACAND HCT ORAL
TABLET 16-12.5 MG
ATACAND HCT ORAL
TABLET 32-12.5 MG, 32-25
MG
ATACAND ORAL TABLET
16 MG, 4 MG, 8 MG
ATACAND ORAL TABLET
32 MG
atenolol
atenolol-chlorthalidone
atorvastatin
4
AZOR
3
benazepril
benazepril-hydrochlorothiazide
BENICAR HCT
1
1
3
BENICAR ORAL TABLET
20 MG, 40 MG
BENICAR ORAL TABLET
5 MG
betaxolol oral
BIDIL
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
3
4
4
4
1
1
1
3
2
3
2
1
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; CG
MO; CG
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG
MO; CG
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; CG
MO
MO; CG
MO; CG
Drug Name
Drug Requirements/
Tier Limits
BRILINTA ORAL TABLET
90 MG
bumetanide injection
bumetanide oral tablet 0.5 mg,
1 mg
bumetanide oral tablet 2 mg
BYSTOLIC
CALAN
CALAN SR
candesartan oral tablet 16 mg,
4 mg, 8 mg
candesartan oral tablet 32 mg
3
candesartan-hydrochlorothiazid
oral tablet 16-12.5 mg
candesartan-hydrochlorothiazid
oral tablet 32-12.5 mg, 32-25
mg
captopril
captopril-hydrochlorothiazide
CARDIZEM LA ORAL
TABLET EXTENDED
CARDURA XL
cartia xt
carvedilol
chlorothiazide
chlorothiazide sodium
chlorthalidone oral tablet 25
mg
chlorthalidone oral tablet 50
mg
cholestyramine (with sugar)
cholestyramine light
cilostazol
clonidine hcl oral tablet
clonidine transdermal patch
weekly 0.1 mg/24 hr
clonidine transdermal patch
weekly 0.2 mg/24 hr, 0.3 mg/
24 hr
clopidogrel oral tablet 300 mg
2
clopidogrel oral tablet 75 mg
2
clorpres
4
4
1
2
3
4
4
2
2
2
MO; QLL (60 per
30 days)
MO
MO; CG
MO; CG
MO; CG
MO
MO
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (30
per 30 days)
1
1
4
MO; CG
MO; CG
MO
4
2
1
1
4
1
MO
MO; CG
MO; CG
MO; CG
MO
MO; CG
2
MO; CG
2
2
2
1
2
MO; CG
MO; CG
MO; CG
MO; CG
MO; CG; QLL (4
per 28 days)
MO; QLL (4 per 28
days)
3
3
MO; QLL (1 per 30
days)
MO; CG; QLL (30
per 30 days)
MO
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
colestipol
COREG CR
COUMADIN ORAL
CRESTOR
2
4
4
3
DEMADEX ORAL TABLET
10 MG, 20 MG, 5 MG
DEMSER
DIBENZYLINE
digitek oral tablet 125 mcg
4
4
4
2
MO; CG
ST; MO
MO
MO; CG; QLL (30
per 30 days)
MO
MO
MO
MO; CG; QLL (30
per 30 days)
PAR; MO
Drug Name
Drug Requirements/
Tier Limits
doxazosin oral tablet 1 mg, 2
mg, 8 mg
doxazosin oral tablet 4 mg
DYAZIDE
DYRENIUM
EDECRIN
EFFIENT
2
MO; CG
1
4
4
4
3
3
MO; CG
MO
MO
MO
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (74 per
30 days)
MO; CG
MO; CG
MO; QLL (84 per
30 days)
MO; QLL (28 per
30 days)
MO; QLL (22.4 per
30 days)
MO; QLL (28 per
30 days)
MO; QLL (8.4 per
30 days)
MO; QLL (11.2 per
30 days)
MO; QLL (16.8 per
30 days)
MO; QLL (22.4 per
30 days)
MO; CG
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG
MO; CG
2
MO; CG
ELIQUIS ORAL TABLET
2.5 MG
ELIQUIS ORAL TABLET 5
MG
enalapril maleate
enalapril-hydrochlorothiazide
enoxaparin subcutaneous
solution
syringe 100 mg/ml
syringe 120 mg/0.8 ml
syringe 150 mg/ml
eplerenone
eprosartan
1
MO; CG
EXFORGE
3
4
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (90 per
30 days)
MO
EXFORGE HCT
3
felodipine
fenofibrate micronized oral
capsule 130 mg, 43 mg
fenofibrate micronized oral
capsule 134 mg, 200 mg, 67
mg
fenofibrate nanocrystallized
fenofibrate oral tablet 160 mg,
54 mg
2
2
DIGITEK ORAL TABLET
250 MCG
digox oral tablet 125 mcg
3
digox oral tablet 250 mcg
digoxin oral solution 50 mcg/ml
digoxin oral tablet 125 mcg
3
2
2
2
digoxin oral tablet 250 mcg
DILATRATE-SR
dilt-xr
diltiazem hcl intravenous
diltiazem hcl oral capsule,
extended release
diltiazem hcl oral capsule,ext
release degradable
extended release 24hr
diltiazem hcl oral tablet 120
mg
diltiazem hcl oral tablet 30 mg,
60 mg, 90 mg
DIOVAN HCT
3
4
2
4
2
DIOVAN ORAL TABLET
160 MG
DIOVAN ORAL TABLET
320 MG
DIOVAN ORAL TABLET
40 MG, 80 MG
DIURIL
DIURIL IV
3
2
MO; CG; QLL (30
per 30 days)
PAR; MO
MO; CG
MO; CG; QLL (30
per 30 days)
PAR; MO
MO
MO; CG
MO; CG
MO; CG
2
MO; CG
2
MO; CG
3
3
4
4
3
1
1
4
4
5
5
4
4
4
4
2
2
2
MO; CG; QLL (30
per 30 days)
2
2
MO; CG
MO; CG; QLL (30
per 30 days)
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
fenofibric acid (choline) dr
capsules
flecainide
fluvastatin oral capsule
2
MO; CG
2
2
fluvastatin oral tablet extended
release 24 hr
fondaparinux subcutaneous
syringe 2.5 mg/0.5 ml
syringe 5 mg/0.4 ml
syringe 7.5 mg/0.6 ml
fosinopril
fosinopril-hydrochlorothiazide
FRAGMIN
SUBCUTANEOUS
SOLUTION
FRAGMIN
SUBCUTANEOUS
SYRINGE 10,000 ANTI-XA
UNIT/ML, 12,500 ANTI-XA
UNIT/0.5 ML, 15,000
ANTI-XA UNIT/0.6 ML, 18,
000 ANTI-XA UNIT/0.72
ML, 7,500 ANTI-XA UNIT/
0.3 ML
FRAGMIN
SUBCUTANEOUS
SYRINGE 2,500 ANTI-XA
UNIT/0.2 ML, 5,000 ANTIXA UNIT/0.2 ML
furosemide injection
furosemide oral solution 10 mg/
ml, 40 mg/5 ml
furosemide oral tablet
gemfibrozil oral
heparin (porcine) in 5 % dex
intravenous parenteral solution
12,500 unit/250 ml, 20,000
unit/500 ml (40 unit/ml)
heparin (porcine) in 5 % dex
25,000 unit/250 ml(100 unit/
4
1
1
5
MO; CG
MO; CG; QLL (60
per 30 days)
MO; QLL (30 per
30 days)
MO; QLL (24 per
30 days)
MO; QLL (15 per
30 days)
MO; QLL (12 per
30 days)
MO; QLL (18 per
30 days)
MO; CG
MO; CG
MO
5
MO
5
4
5
5
4
MO
4
1
MO
MO; CG
1
2
4
MO; CG
MO; CG
B/D PAR
4
B/D PAR; MO
Drug Name
ml), 25,000 unit/500 ml (50
unit/ml)
heparin (porcine) in nacl (pf)
1,000 unit/500 ml, 2,000
unit/1,000 ml
heparin (porcine) injection
cartridge
heparin (porcine) injection
solution
HEPARIN(PORCINE) IN
0.45% NACL
INTRAVENOUS
PARENTERAL SOLUTION
12,500 UNIT/250 ML
heparin(porcine) in 0.45% nacl
25,000 unit/250 ml, 25,000
unit/500 ml
heparin, porcine (pf) injection
hydralazine injection
hydralazine oral
hydrochlorothiazide
indapamide
INNOPRAN XL
irbesartan
irbesartan-hydrochlorothiazide
irbesartan-hydrochlorothiazide
ISORDIL
ISORDIL TITRADOSE
ORAL TABLET 5 MG
isosorbide dinitrate oral
isosorbide mononitrate oral
tablet
tablet extended release 24 hr
120 mg, 60 mg
tablet extended release 24 hr 30
mg
isradipine
jantoven
labetalol intravenous solution
Drug Requirements/
Tier Limits
4
B/D PAR
4
B/D PAR; MO
4
B/D PAR; MO
4
B/D PAR
4
B/D PAR
4
4
2
1
1
4
1
4
4
B/D PAR; MO
MO
MO; CG
MO; CG
MO; CG
MO
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (30
per 30 days)
MO
MO
2
2
MO; CG
MO; CG
2
MO; CG
1
MO; CG
2
1
4
MO; CG
MO; CG
MO
1
1
Premier_15283_v14_1511_1
35
Drug Name
labetalol oral
LANOXIN ORAL TABLET
125 MCG
LANOXIN ORAL TABLET
62.5 MCG
LASIX
LESCOL
Drug Requirements/
Tier Limits
2
3
3
4
4
LESCOL XL
4
lisinopril
lisinopril-hydrochlorothiazide
LIVALO
1
1
4
LOFIBRA ORAL CAPSULE
67 MG
LOPRESSOR
LOPRESSOR HCT ORAL
TABLET 50-25 MG
losartan oral tablet 100 mg
4
losartan oral tablet 25 mg, 50
mg
losartan-hydrochlorothiazide
1
lovastatin oral tablet 10 mg, 20
mg
lovastatin oral tablet 40 mg
1
matzim la
MAXZIDE
MAXZIDE-25MG
methyclothiazide
metolazone
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate intravenous
solution
metoprolol tartrate intravenous
syringe
metoprolol tartrate oral
mexiletine
MICARDIS ORAL TABLET
20 MG, 40 MG
MICARDIS ORAL TABLET
80 MG
4
4
4
2
2
3
2
4
4
4
1
1
1
MO; CG
MO; QLL (30 per
30 days)
MO
MO
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; CG
MO; CG
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO
MO
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (60
per 30 days)
MO
MO
MO
MO; CG
MO; CG
MO
MO; CG
MO
4
1
2
3
3
MO; CG
MO; CG
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
MICROZIDE
MINIPRESS
minoxidil oral
moexipril
moexipril-hydrochlorothiazide
MULTAQ
4
4
2
1
1
3
nadolol
nadolol-bendroflumethiazide
niacin oral tablet extended
release 24 hr 1,000 mg, 750
mg
niacin oral tablet extended
release 24 hr 500 mg
NIACOR
nicardipine intravenous
nicardipine oral
nifedical xl
nifedipine oral tablet extended
release
nifedipine oral tablet extended
release 24hr
nimodipine
nitro-bid
nitroglycerin intravenous
nitroglycerin transdermal patch
24 hour
nitroglycerin translingual
NITROLINGUAL
NITROSTAT
omega-3 acid ethyl esters
pacerone oral tablet 100 mg
pacerone oral tablet 200 mg,
400 mg
pentoxifylline
perindopril erbumine
phenoxybenzamine
pindolol
PLETAL
PRADAXA
2
2
3
pravastatin
1
prazosin oral capsule 1 mg
1
3
MO
MO
MO; CG
MO; CG
MO; CG
MO; QLL (60 per
30 days)
MO; CG
MO; CG
MO; QLL (60 per
30 days)
3
4
2
2
2
MO; QLL (30 per
30 days)
MO
MO
MO; CG
MO; CG
MO; CG
2
MO; CG
4
2
4
2
MO
MO; CG
B/D PAR
MO; CG
4
4
3
3
3
2
MO
MO
MO; CG
PAR; MO
MO
MO; CG
2
1
4
2
4
4
MO; CG
MO; CG
MO
MO; CG
MO
MO; QLL (60 per
30 days)
MO; CG; QLL (30
per 30 days)
MO; CG
Premier_15283_v14_1511_1
36
Drug Name
Drug Requirements/
Tier Limits
prazosin oral capsule 2 mg, 5
mg
prevalite
procainamide injection solution
100 mg/ml
procainamide injection solution
500 mg/ml
PROMACTA ORAL
TABLET 12.5 MG, 25 MG,
75 MG
PROMACTA ORAL
TABLET 50 MG
propafenone oral capsule,
propafenone oral tablet
propranolol intravenous
propranolol oral capsule,
propranolol oral solution 20
mg/5 ml
propranolol oral solution 40
mg/5 ml
propranolol oral tablet 10 mg,
20 mg, 40 mg, 80 mg
propranolol oral tablet 60 mg
propranolol-hydrochlorothiazid
quinapril
quinapril-hydrochlorothiazide
quinidine sulfate oral tablet
200 mg
quinidine sulfate oral tablet
300 mg
ramipril
RANEXA
REMODULIN
reserpine oral tablet 0.1 mg
simvastatin
2
sorine oral tablet 120 mg, 160
mg, 80 mg
sorine oral tablet 240 mg
sotalol af oral tablet 120 mg,
160 mg
sotalol af oral tablet 80 mg
sotalol oral tablet 120 mg, 160
mg, 240 mg
Drug Name
Drug Requirements/
Tier Limits
sotalol oral tablet 80 mg
spironolacton-hydrochlorothiaz
MO; CG
spironolactone oral tablet 100
mg, 50 mg
MO
spironolactone oral tablet 25
mg
TARKA
PAR; MO; LA; QLL taztia xt
(30 per 30 days)
TEKTURNA
1
2
2
MO; CG
MO; CG
MO; CG
1
MO; CG
4
2
4
PAR; MO; LA; QLL TEKTURNA HCT
(60 per 30 days)
MO
telmisartan oral tablet 20 mg,
40 mg
MO; CG
telmisartan oral tablet 80 mg
4
MO; CG
telmisartan-amlodipine
2
2
MO; CG
2
4
MO
telmisartan-hydrochlorothiazid
oral tablet 40-12.5 mg, 80-25
mg
telmisartan-hydrochlorothiazid
TENORETIC 100
TENORETIC 50
TENORMIN
terazosin
TIAZAC
TIKOSYN
timolol maleate oral
TOPROL XL
torsemide oral
trandolapril
trandolapril-verapamil
tranexamic acid intravenous
triamterene-hydrochlorothiazid
oral capsule 37.5-25 mg
triamterene-hydrochlorothiazid
oral tablet
TRIBENZOR
MO
MO; CG
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (30
per 30 days)
valsartan oral tablet 160 mg
3
valsartan oral tablet 320 mg
3
2
4
4
5
5
4
2
4
2
1
MO; CG
MO; CG
2
2
1
1
1
MO; CG
MO; CG
MO; CG
MO; CG
MO; CG
2
MO; CG
1
4
5
3
1
2
MO; CG
MO
PAR; MO; LA
PAR; MO; CG
MO; CG; QLL (30
per 30 days)
MO; CG
2
2
CG
MO; CG
1
2
MO; CG
MO; CG
2
2
2
4
4
4
1
4
4
2
4
2
1
4
3
1
MO; CG; QLL (60
per 30 days)
MO
MO
MO
MO; CG
MO
MO
MO; CG
MO
MO; CG
MO; CG
MO
MO
MO; CG
1
MO; CG
3
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
valsartan oral tablet 40 mg, 80
mg
valsartan-hydrochlorothiazide
3
VECAMYL
verapamil intravenous solution
verapamil intravenous syringe
verapamil oral capsule, 24 hr
er pellet ct
verapamil oral capsule,ext rel.
pellets 24 hr
verapamil oral tablet 120 mg,
80 mg
verapamil oral tablet 40 mg
verapamil oral tablet extended
release
VYTORIN 10-10
4
4
4
2
VYTORIN 10-20
4
VYTORIN 10-40
VYTORIN 10-80
warfarin
WELCHOL
XARELTO ORAL TABLET
10 MG, 20 MG
XARELTO ORAL TABLET
15 MG
XARELTO ORAL
TABLETS,DOSE PACK
ZETIA
2
MO; QLL (90 per
30 days)
MO; CG; QLL (30
per 30 days)
MO
MO; CG
2
MO; CG
1
MO; CG
2
2
MO; CG
MO; CG
4
4
4
1
3
3
3
3
4
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL (30
per 30 days)
MO; CG
MO; CG
MO; QLL (30 per
30 days)
MO; QLL (42 per
30 days)
MO; QLL (51 per
365 days)
MO; QLL (30 per
30 days)
MO
ZIAC
4
Dermatologicals/Topical Therapy
8-MOP
4 PAR; MO
acitretin
5 MO
acyclovir topical
4 MO; QLL (30 per
30 days)
adapalene topical gel 0.1 %
3 MO
ala-cort topical cream
4 MO
ALA-SCALP
4 MO
alclometasone
2 MO; CG
ALTABAX
4 MO
amcinonide
3 MO
Drug Name
Drug Requirements/
Tier Limits
ammonium lactate topical
amnesteem oral capsule 10 mg
amnesteem oral capsule 20 mg,
40 mg
apexicon e
BACTROBAN
betamethasone dipropionate
betamethasone valerate topical
cream
foam
lotion
ointment
betamethasone, augmented
topical cream
topical gel
topical lotion
topical ointment
calcipotriene topical cream
2
3
4
MO; CG
MO
MO
4
4
2
2
MO
MO
MO; CG
MO; CG
4
MO
2
MO; CG
2
MO; CG
2
MO; CG
3
MO
3
MO
3
MO
4
calcipotriene topical ointment
4
calcipotriene topical solution
3
calcipotriene-betamethasone
CAPEX
ciclodan topical cream
ciclodan topical solution
ciclopirox topical cream
ciclopirox topical gel
ciclopirox topical shampoo
ciclopirox topical solution
ciclopirox topical suspension
claravis
CLEOCIN T
CLINDAGEL
clindamycin phosphate topical
foam
gel
4
4
3
3
3
3
3
3
3
4
4
4
4
MO; QLL (120 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO
MO
MO
PAR; MO
MO
MO
MO
PAR; MO
MO
MO
MO
MO
MO
2
MO; CG
Premier_15283_v14_1511_1
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Drug Name
lotion
solution
swab
clindamycin-benzoyl peroxide
clobetasol topical cream
clobetasol topical foam
clobetasol topical gel
clobetasol topical lotion
clobetasol topical ointment
clobetasol topical shampoo
clobetasol topical solution
clobetasol topical spray,nonaerosol
clobetasol-emollient
CLOBEX
CLOCORTOLONE
PIVALATE
CLODERM
clotrimazole topical
clotrimazole-betamethasone
topical cream
clotrimazole-betamethasone
topical lotion
CONDYLOX TOPICAL
GEL
CORDRAN TAPE LARGE
ROLL
CORDRAN TAPE SMALL
ROLL
cormax topical solution
CORTISPORIN TOPICAL
DENAVIR
DERMATOP
desonide topical cream
desonide topical lotion
desonide topical ointment
desoximetasone topical cream
0.05 %
desoximetasone topical cream
0.25 %
desoximetasone topical gel
Drug Requirements/
Tier Limits
2
MO; CG
2
MO; CG
2
MO; CG
3
2
3
2
3
2
3
2
4
MO
MO; CG
MO
MO; CG
MO
MO; CG
MO
MO; CG
MO
2
4
4
MO; CG
MO
MO
4
2
2
MO
MO; CG
MO; CG
3
MO
4
MO
4
MO
4
MO
2
4
3
4
3
3
3
3
MO; CG
MO
MO; CG; QLL (5
per 1 day)
MO
MO; CG
MO
MO
MO
2
MO; CG
3
MO
Drug Name
Drug Requirements/
Tier Limits
desoximetasone topical ointment
0.05 %
desoximetasone topical ointment
0.25 %
diclofenac sodium topical gel
3
MO; CG
4
MO
3
diflorasone
econazole topical
ELIDEL
4
2
4
ELOCON
ery pads
erythromycin with ethanol
erythromycin-benzoyl peroxide
EURAX
EXELDERM
FINACEA TOPICAL GEL
fluocinolone topical cream
fluocinolone topical oil
fluocinolone topical ointment
fluocinolone topical solution
fluocinolone-shower cap
fluocinonide topical cream 0.05
%
fluocinonide topical cream 0.1
%
fluocinonide topical gel
fluocinonide topical ointment
fluocinonide topical solution
fluocinonide-e
fluorouracil topical cream 5 %
fluorouracil topical solution 2
%
fluorouracil topical solution 5
%
fluticasone topical cream
fluticasone topical lotion
fluticasone topical ointment
gentamicin topical
halobetasol propionate
HALOG
hydrocortisone butyr-emollient
hydrocortisone butyrate topical
cream
4
2
2
2
4
4
4
3
3
2
3
4
2
PAR; MO; QLL
(100 per 30 days)
MO
MO; CG
PAR; MO; QLL (60
per 1 day)
MO
MO; CG
MO; CG
MO; CG
MO
MO
MO
MO
MO
MO; CG
MO
MO
MO; CG
4
MO
2
2
2
2
4
2
MO; CG
MO; CG
MO; CG
MO; CG
MO
MO; CG
3
MO
2
4
2
2
3
4
4
2
MO; CG
MO
MO; CG
MO; CG
MO
MO
MO
MO; CG
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
ointment
solution
hydrocortisone topical cream 1
%, 2.5 %
hydrocortisone topical lotion 2.5
%
hydrocortisone topical ointment
1 %, 2.5 %
hydrocortisone valerate topical
cream
hydrocortisone valerate topical
ointment
hydrocortisone-min oil-wht pet
imiquimod
KENALOG TOPICAL
ketoconazole topical cream
ketoconazole topical shampoo
KLARON
lidocaine hcl mucous membrane
solution 2 %
lidocaine topical adhesive patch,
medicated
lidocaine topical ointment
lidocaine viscous
lidocaine-prilocaine
LIDODERM
2
MO; CG
1
MO; CG
2
MO; CG
lindane topical lotion
lindane topical shampoo
LOCOID
LOCOID LIPOCREAM
LOKARA
LOTRISONE TOPICAL
CREAM
malathion
MENTAX
methoxsalen rapid
METROCREAM
METROGEL TOPICAL
GEL 1 %
METROGEL TOPICAL
GEL WITH PUMP
metronidazole topical cream
3
4
4
4
4
4
2
MO; CG
2
MO; CG
2
MO; CG
3
MO
2
4
4
2
2
4
2
MO; CG
MO
MO
MO; CG
MO; CG
MO
CG
3
PAR; MO; QLL (90
per 30 days)
MO
MO; CG
MO
PAR; MO; QLL (90
per 30 days)
MO
MO
MO
MO
3
2
3
4
MO
4
4
5
4
4
MO
MO
PAR; MO
MO
MO
4
MO
3
MO
Drug Name
Drug Requirements/
Tier Limits
metronidazole topical gel 0.75
%
metronidazole topical gel 1 %
metronidazole topical gel with
pump
metronidazole topical lotion
mometasone
mupirocin
mupirocin calcium
myorisan oral capsule 10 mg,
20 mg, 40 mg
naftifine
NAFTIN
NIZORAL TOPICAL
SHAMPOO
nyamyc
nystatin topical
nystatin-triamcinolone
nystop
OXISTAT
PANDEL
PANRETIN
permethrin topical cream
podofilox
prednicarbate
PROTOPIC
2
MO; CG
4
4
MO
MO
3
2
2
3
4
MO
MO; CG
MO; CG
MO
MO
4
4
4
MO
MO
MO
2
2
3
2
4
4
5
4
2
2
4
prudoxin
rosadan topical cream
rosadan topical gel
SANTYL
3
2
2
4
selenium sulfide topical
suspension
SILVADENE
silver sulfadiazine
SOLARAZE
2
MO; CG
MO; CG
MO
MO; CG
MO
MO
MO
MO
MO; CG
MO; CG
PAR; MO; QLL (60
per 1 day)
MO; CG
MO; CG
MO; CG
MO; QLL (30 per
30 days)
MO; CG
ssd
sulfacetamide sodium (acne)
SULFAMYLON TOPICAL
CREAM
TACLONEX TOPICAL
OINTMENT
2
2
4
MO
MO; CG
PAR; MO; QLL
(100 per 30 days)
MO; CG
MO; CG
MO
5
MO
4
2
4
Premier_15283_v14_1511_1
40
Drug Name
Drug Requirements/
Tier Limits
TACLONEX TOPICAL
SUSPENSION
tacrolimus topical
4
MO
4
TAZORAC
TOPICORT TOPICAL
CREAM
TOPICORT TOPICAL GEL
TOPICORT TOPICAL
OINTMENT
tretinoin topical cream
4
4
PAR; MO; QLL (60
per 1 day)
PAR; MO
MO
4
4
MO
MO
3
MO; QLL (45 per
30 days)
MO; QLL (45 per
30 days)
MO
tretinoin topical gel 0.01 %,
3
0.025 %
triamcinolone acetonide topical 4
aerosol
triamcinolone acetonide topical 2 MO; CG
cream
lotion
ointment 0.025 %, 0.1 %, 0.5
%
trianex
2 MO; CG
triderm topical cream
2 MO; CG
U-CORT
4 MO
UVADEX
4
VALCHLOR
5 MO
VANOS
4 MO
VELTIN
4 MO
ZIANA
4 MO
ZONALON
4 MO
ZOVIRAX TOPICAL
3 MO; CG; QLL (5
CREAM
per 1 day)
Diagnostics / Miscellaneous Agents
acamprosate
2 MO; CG
acetic acid irrigation
2 MO; CG
acetylcysteine intravenous
2 B/D PAR; MO; CG
ACTONEL ORAL TABLET 4 ST; MO; QLL (30
30 MG
per 30 days)
ADAGEN
5 MO
alendronate oral tablet 40 mg
2 MO; CG; QLL (30
per 30 days)
anagrelide
2 MO; CG
ARALAST NP
4 PAR; MO; LA
Drug Name
Drug Requirements/
Tier Limits
BUPHENYL ORAL
TABLET
buproban
5
PAR; MO
2
CARBAGLU
cevimeline
CHANTIX
5
4
4
CHANTIX CONTINUING
MONTH BOX
CHANTIX STARTING
MONTH BOX
CHEMET
CLINIMIX 4.25%/D5W
SULFIT FREE
CLINIMIX E 2.75%/D10W
SUL FREE
SULF FREE
d10 % & 0.45 % sodium
chloride
d2.5 %-0.45 % sodium
chloride
d5 % and 0.9 % sodium
chloride
d5 %-0.45 % sodium chloride
dextrose 10 % and 0.2 % nacl
dextrose 10 % in water (d10w)
dextrose 5 %-lactated ringers
dextrose 5%-0.2 % sod chloride
dextrose 5%-0.3 % sod.chloride
intravenous syringe
dextrose with sodium chloride
disulfiram
etidronate disodium
EVOXAC
4
4
4
MO; CG; QLL (60
per 30 days)
PAR; MO; LA
MO
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL (56
per 28 days)
PAR; MO; QLL (53
per 365 days)
MO
B/D PAR
4
B/D PAR
4
B/D PAR
4
B/D PAR
4
B/D PAR
4
B/D PAR; MO
4
4
4
B/D PAR; MO
B/D PAR
B/D PAR; MO
4
4
4
4
4
4
4
4
B/D PAR
B/D PAR
B/D PAR
B/D PAR; MO
B/D PAR; MO
B/D PAR
B/D PAR
B/D PAR; MO
4
B/D PAR
4
4
2
2
4
B/D PAR; MO
B/D PAR
MO; CG
MO; CG
MO
4
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
EXJADE
INCRELEX
KAYEXALATE
kionex
lactated ringers irrigation
levocarnitine (with sugar)
levocarnitine intravenous
levocarnitine oral tablet
midodrine
neomycin-polymyxin b gu
NICOTROL
NICOTROL NS
5
5
4
2
4
2
4
2
2
4
4
3
ORFADIN
PHYSIOLYTE
PHYSIOSOL IRRIGATION
pilocarpine hcl oral tablet 5 mg
pilocarpine hcl oral tablet 7.5
mg
PROLASTIN-C
RENAGEL
RENVELA ORAL
POWDER IN PACKET 0.8
GRAM
RENVELA ORAL
POWDER IN PACKET 2.4
GRAM
RENVELA ORAL TABLET
5
4
4
2
3
riluzole
ringers irrigation
risedronate oral tablet 30 mg
5
4
4
sodium chloride 0.9 %
intravenous
sodium chloride irrigation
sodium phenylbutyrate
sodium polystyrene (sorb free)
sodium polystyrene sulfonate
oral powder
oral suspension
rectal
4
Drug Name
Drug Requirements/
Tier Limits
PAR; MO; LA
PAR; MO; LA
MO
MO; CG
B/D PAR; MO
B/D PAR; MO; CG
B/D PAR; MO
B/D PAR; MO; CG
MO; CG
MO
MO
MO; CG; QLL (120
per 30 days)
LA
B/D PAR
B/D PAR
MO; CG
MO
SODIUM POLYSTYRENE
3
SULFONATE RECTAL
sps oral
3
sps rectal
3
SYPRINE
5
water for irrigation, sterile
4
Ear, Nose / Throat Medications
acetasol hc
3
acetic acid otic
2
acetic acid-aluminum acetate
2
ATROVENT
4
5
4
5
PAR; MO; LA
ST; MO
MO; QLL (180 per
30 days)
5
MO; QLL (90 per
30 days)
3
MO; CG; QLL (270
per 30 days)
MO
B/D PAR; MO
ST; MO; QLL (30
per 30 days)
MO
4
3
4
4
2
2
3
3
2
4
5
3
3
3
3
MO
PAR; MO
MO
azelastine nasal aerosol,spray
2
azelastine nasal spray,nonaerosol
BACTROBAN NASAL
chlorhexidine gluconate mucous
membrane
CIPRO HC
CIPRODEX
COLY-MYCIN S
CORTISPORIN-TC
denta 5000 plus
dentagel
fluocinolone acetonide oil
hydrocortisone-acetic acid
ipratropium bromide nasal
3
neomycin-polymyxin-hc otic
ofloxacin otic
olopatadine
2
2
4
paroex oral rinse
PATANASE
1
4
periogard
sf 5000 plus
triamcinolone acetonide dental
TYZINE NASAL DROPS
0.05 %
Endocrine/Diabetes
a-hydrocort
acarbose oral tablet 100 mg
1
2
3
4
4
1
4
2
MO
MO
B/D PAR; MO
MO
MO; CG
MO; CG
MO; QLL (30 per
30 days)
MO; CG; QLL (30
per 25 days)
MO; QLL (30 per
25 days)
MO
MO; CG
MO
MO; CG
MO
MO
MO; CG
MO; CG
MO
MO
MO; CG; QLL (30
per 30 days)
MO; CG
MO; CG
MO; QLL (31 per
30 days)
MO; CG
MO; QLL (31 per
30 days)
MO; CG
MO; CG
MO
MO
MO
MO; CG; QLL (90
per 30 days)
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
2
2
ACTHAR H.P.
ACTOPLUS MET XR
ORAL TABLET, ER
MULTIPHASE 24 HR 15-1,
000 MG
ACTOPLUS MET XR
ORAL TABLET, ER
000 MG
alcohol pads
ALDURAZYME
AMARYL ORAL TABLET 1
MG
MG
MG
ANDRODERM
5
3
ANDROGEL
TRANSDERMAL GEL IN
METERED-DOSE PUMP
1.25 GRAM/ ACTUATION
(1 %)
ANDROGEL
TRANSDERMAL GEL IN
METERED-DOSE PUMP
20.25 MG/1.25 GRAM (1.62
%)
ANDROGEL
TRANSDERMAL GEL IN
PACKET 1 % (25 MG/
2.5GRAM), 1 % (50 MG/5
GRAM)
ANDROGEL
TRANSDERMAL GEL IN
PACKET 1.62 % (20.25
MG/1.25 GRAM)
ANDROGEL
TRANSDERMAL GEL IN
PACKET 1.62 % (40.5 MG/
2.5 GRAM)
3
3
1
5
4
4
4
4
3
MO; CG; QLL (360
per 30 days)
MO; CG; QLL (180
per 30 days)
PAR; MO
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (45
per 30 days)
MO; CG
PAR; MO
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
PAR; MO; QLL (30
per 30 days)
PAR; MO; CG;
QLL (300 per 30
days)
PAR; MO; CG;
QLL (150 per 30
days)
3
PAR; MO; CG;
QLL (300 per 30
days)
3
PAR; MO; CG;
QLL (30 per 30
days)
3
PAR; MO; CG;
QLL (60 per 30
days)
Drug Name
Drug Requirements/
Tier Limits
androxy
BYDUREON
4
3
BYETTA
SUBCUTANEOUS PEN
INJECTOR 10 MCG/
DOSE(250 MCG/ML) 2.4
ML
BYETTA
SUBCUTANEOUS PEN
INJECTOR 5 MCG/DOSE
(250 MCG/ML) 1.2 ML
cabergoline
calcitonin (salmon)
3
calcitriol intravenous solution
1 mcg/ml
calcitriol oral capsule
calcitriol oral solution
CEREZYME
INTRAVENOUS RECON
SOLN 400 UNIT
CORTEF
cortisone
CYCLOSET
CYTOMEL
danazol oral capsule 100 mg,
50 mg
danazol oral capsule 200 mg
DDAVP INJECTION
desmopressin injection
desmopressin nasal
desmopressin oral
dexamethasone intensol
dexamethasone oral elixir
dexamethasone oral solution
dexamethasone oral tablet 0.5
mg, 1.5 mg
dexamethasone oral tablet 0.75
mg, 1 mg, 2 mg, 4 mg, 6 mg
dexamethasone sodium phos (pf)
dexamethasone sodium
phosphate injection
DEXPAK 10 DAY
DEXPAK 13 DAY
PAR; MO
MO; QLL (4 per 28
days)
MO; CG; QLL (2.4
per 30 days)
3
MO; CG; QLL (1.2
per 30 days)
3
2
4
MO
MO; CG; QLL (4
per 30 days)
B/D PAR; MO
2
3
5
B/D PAR; MO; CG
B/D PAR; MO
PAR; MO
4
2
4
4
2
MO
MO; CG
ST; MO; QLL (180
per 30 days)
MO
MO; CG
3
4
4
3
3
4
2
2
1
MO
MO
MO
MO
MO
MO
MO; CG
MO; CG
MO; CG
2
MO; CG
4
4
MO
MO
4
4
MO
MO
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
DEXPAK 6 DAY
doxercalciferol intravenous
ELAPRASE
FABRAZYME
fludrocortisone
FORTAMET ORAL
TABLET EXTENDED
RELEASE 24HR 1,000 MG
FORTAMET ORAL
TABLET EXTENDED
RELEASE 24HR 500 MG
fortical
4
4
5
5
2
4
gauze pads 2 x 2
1
glimepiride oral tablet 1 mg
1
4
2
1
1
glipizide oral tablet 10 mg
1
glipizide oral tablet 5 mg
1
glipizide oral tablet extended
release 24hr 10 mg
release 24hr 2.5 mg
release 24hr 5 mg
glipizide-metformin oral tablet
2.5-250 mg
glipizide-metformin oral tablet
2.5-500 mg, 5-500 mg
GLUCAGEN HYPOKIT
GLUCAGON
EMERGENCY KIT
(HUMAN)
GLUCOPHAGE ORAL
TABLET 1,000 MG
GLUCOPHAGE ORAL
TABLET 500 MG
GLUCOPHAGE ORAL
TABLET 850 MG
1
1
1
1
1
3
4
4
4
4
MO
B/D PAR
PAR; MO
PAR; MO
MO; CG
MO; QLL (75 per
30 days)
MO; QLL (150 per
30 days)
MO; CG; QLL (4
per 30 days)
MO; CG; QLL (200
per 30 days)
MO; CG; QLL (240
per 30 days)
MO; CG; QLL (120
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (120
per 30 days)
MO; CG; QLL (240
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (240
per 30 days)
MO; CG; QLL (120
per 30 days)
MO; CG; QLL (240
per 30 days)
MO; CG; QLL (120
per 30 days)
MO
MO
MO; QLL (76 per
30 days)
MO; QLL (153 per
30 days)
MO; QLL (90 per
30 days)
Drug Name
GLUCOPHAGE XR ORAL
TABLET EXTENDED
GLUCOPHAGE XR ORAL
TABLET EXTENDED
GLUCOTROL ORAL
TABLET 10 MG
GLUCOTROL ORAL
TABLET 5 MG
GLUCOTROL XL ORAL
TABLET EXTENDED
RELEASE 24HR 10 MG
GLUCOTROL XL ORAL
TABLET EXTENDED
RELEASE 24HR 2.5 MG
GLUCOTROL XL ORAL
TABLET EXTENDED
RELEASE 24HR 5 MG
GLUMETZA ORAL
TABLET,ER
GAST.RETENTION 24 HR
1,000 MG
GLUMETZA ORAL
TABLET,ER
GAST.RETENTION 24 HR
500 MG
GLYSET ORAL TABLET
100 MG
GLYSET ORAL TABLET 25
MG
GLYSET ORAL TABLET 50
MG
HECTOROL
INTRAVENOUS
SOLUTION 2 MCG/ML (1
ML)
HECTOROL
INTRAVENOUS
SOLUTION 4 MCG/2 ML
HUMALOG KWIKPEN
SUBCUTANEOUS
INSULIN PEN 100 UNIT/
ML
HUMALOG KWIKPEN
SUBCUTANEOUS
Drug Requirements/
Tier Limits
4
MO; QLL (120 per
30 days)
4
MO; QLL (80 per
30 days)
4
MO; QLL (120 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (60 per
30 days)
4
4
4
MO; QLL (240 per
30 days)
4
MO; QLL (120 per
30 days)
4
MO; QLL (60 per
30 days)
4
MO; QLL (120 per
30 days)
4
4
MO; QLL (90 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
PAR
4
PAR; MO
3
MO; CG
3
MO
4
4
Premier_15283_v14_1511_1
44
Drug Name
INSULIN PEN 200 UNIT/
ML (3 ML)
HUMALOG MIX 50-50
HUMALOG MIX 50-50
KWIKPEN
HUMALOG MIX 75-25
HUMALOG MIX 75-25
KWIKPEN
HUMALOG
SUBCUTANEOUS
CARTRIDGE
HUMALOG
SUBCUTANEOUS
SOLUTION 100 UNIT/ML
HUMALOG
SUBCUTANEOUS
SOLUTION 100 UNIT/ML
(PREFILLED SYRINGE)
HUMULIN 70/30
HUMULIN 70/30
KWIKPEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN R
HUMULIN R U-500
"CONCENTRATED"
hydrocortisone oral
INSULIN PEN NEEDLE
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
3
3
MO
MO
JANUVIA ORAL TABLET
100 MG
JANUVIA ORAL TABLET
25 MG
JANUVIA ORAL TABLET
50 MG
JARDIANCE
3
MO; CG
JENTADUETO
4
KOMBIGLYZE XR ORAL
TABLET, ER
MULTIPHASE 24 HR 2.51,000 MG
KOMBIGLYZE XR ORAL
TABLET, ER
000 MG, 5-500 MG
KUVAN ORAL TABLET,
SOLUBLE
LANTUS
LANTUS SOLOSTAR
levothyroxine oral
levoxyl oral tablet 100 mcg,
112 mcg, 25 mcg, 50 mcg, 75
mcg, 88 mcg
levoxyl oral tablet 125 mcg,
137 mcg, 150 mcg, 175 mcg,
200 mcg
liothyronine intravenous
liothyronine oral
MEDROL
MEDROL (PAK)
metformin oral tablet 1,000 mg
3
metformin oral tablet 500 mg
1
metformin oral tablet 850 mg
1
metformin oral tablet extended
release 24hr 1,000 mg
1
3
3
MO
MO
3
MO; CG
3
CG
3
3
MO
MO; CG
3
3
3
3
MO
MO
MO
MO
2
3
MO; CG
MO; QLL (200 per
30 days)
MO; QLL (200 per
30 days)
MO; QLL (200 per
30 days)
MO; QLL (200 per
30 days)
MO; CG; QLL (60
per 30 days)
MO; QLL (30 per
30 days)
INSULIN SYRINGE (DISP)
U-100 0.3 ML
U-100 1 ML
U-100 1/2 ML
JANUMET
3
JANUMET XR ORAL
TABLET, ER
MULTIPHASE 24 HR 1001,000 MG
JANUMET XR ORAL
TABLET, ER
000 MG, 50-500 MG
3
3
3
3
3
MO; QLL (60 per
30 days)
3
3
3
4
MO; QLL (30 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
PAR; MO; QLL (30
per 30 days)
MO; QLL (60 per
30 days)
MO; QLL (60 per
30 days)
3
MO; QLL (30 per
30 days)
5
PAR; MO
3
3
1
1
MO
MO
MO; CG
MO; CG
2
MO; CG
5
2
4
4
1
MO
MO; CG
MO
MO
MO; CG; QLL (76
per 30 days)
MO; CG; QLL (153
per 30 days)
MO; CG; QLL (90
per 30 days)
MO; CG; QLL (120
per 30 days)
MO; CG; QLL (80
per 30 days)
MO; CG; QLL (75
per 30 days)
1
1
Premier_15283_v14_1511_1
45
Drug Name
release 24hr 500 mg
methimazole oral tablet 10 mg
methimazole oral tablet 5 mg
methylprednisolone acetate
methylprednisolone oral tablet
16 mg, 4 mg, 8 mg
methylprednisolone oral tablet
32 mg
methylprednisolone oral tablets,
dose pack
methylprednisolone sodium succ
injection recon soln 125 mg, 40
mg
methylprednisolone sodium succ
intravenous
millipred dp
millipred oral tablet
MYOZYME
NAGLAZYME
nateglinide oral tablet 120 mg
Drug Requirements/
Tier Limits
1
2
1
4
2
MO; CG; QLL (150
per 30 days)
MO; CG
MO; CG
MO
MO; CG
3
MO
2
4
MO
4
3
5
5
2
MO
MO
PAR; MO
PAR; MO; LA
MO; CG; QLL (90
per 30 days)
MO; CG; QLL (180
per 30 days)
MO; QLL (200 per
30 days)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (30
per 30 days)
MO
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL
(120 per 30 days)
B/D PAR; MO
B/D PAR; MO
MO; CG; QLL (90
per 30 days)
MO; CG; QLL (45
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; QLL (30 per
30 days)
2
NEEDLES, INSULIN DISP.,
SAFETY
ONGLYZA ORAL TABLET
2.5 MG
ONGLYZA ORAL TABLET
5 MG
ORAPRED ODT
oxandrolone oral tablet 10 mg
3
pamidronate
paricalcitol oral
pioglitazone oral tablet 15 mg
pioglitazone-glimepiride
MO
4
nateglinide oral tablet 60 mg
oxandrolone oral tablet 2.5 mg
MO; CG
3
3
4
5
3
4
4
2
2
2
3
Drug Name
Drug Requirements/
Tier Limits
pioglitazone-metformin
3
PRANDIN ORAL TABLET
0.5 MG
PRANDIN ORAL TABLET
1 MG
PRANDIN ORAL TABLET
2 MG
PRECOSE ORAL TABLET
100 MG
PRECOSE ORAL TABLET
25 MG
PRECOSE ORAL TABLET
50 MG
prednisolone oral solution 15
mg/5 ml
prednisolone sodium phosphate
oral solution 15 mg/5 ml, 5 mg
base/5 ml (6.7 mg/5 ml)
oral tablet,disintegrating
prednisone intensol
prednisone oral solution
prednisone oral tablet
prednisone oral tablets,dose
pack
PROGLYCEM
propylthiouracil
repaglinide oral tablet 0.5 mg
4
repaglinide oral tablet 1 mg
4
repaglinide oral tablet 2 mg
4
RIOMET
4
SAMSCA ORAL TABLET
15 MG
SAMSCA ORAL TABLET
30 MG
SENSIPAR ORAL TABLET
30 MG
60 MG
90 MG
5
2
MO; QLL (90 per
30 days)
MO; QLL (960 per
30 days)
MO; QLL (480 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
MO; CG
2
MO; CG
4
MO
2
2
1
1
MO; CG
MO; CG
MO; CG
MO; CG
4
2
4
MO
MO; CG
MO; QLL (960 per
30 days)
MO; QLL (480 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (765 per
30 days)
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL (60
per 30 days)
MO; QLL (60 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (120 per
30 days)
4
4
4
4
4
5
3
5
5
Premier_15283_v14_1511_1
46
Drug Name
SOMAVERT
STARLIX ORAL TABLET
120 MG
STARLIX ORAL TABLET
60 MG
STIMATE
SYMLINPEN 120
Drug Requirements/
Tier Limits
5
4
4
4
5
SYMLINPEN 60
4
SYNAREL
SYNTHROID
TANZEUM
5
3
4
TAPAZOLE
TESTIM
4
3
testosterone cypionate
testosterone enanthate
testosterone transdermal gel in
packet
tolazamide oral tablet 250 mg
4
4
3
tolazamide oral tablet 500 mg
2
tolbutamide
2
TOUJEO SOLOSTAR
TRADJENTA
3
4
triamcinolone acetonide
injection suspension 10 mg/ml
triamcinolone acetonide
injection suspension 40 mg/ml
TRULICITY
4
unithroid oral tablet 100 mcg,
112 mcg, 125 mcg, 137 mcg,
150 mcg, 175 mcg, 200 mcg,
25 mcg, 50 mcg, 75 mcg, 88
mcg
unithroid oral tablet 300 mcg
veripred 20
VICTOZA 2-PAK
1
2
PAR; MO; LA
MO; QLL (90 per
30 days)
MO; QLL (180 per
30 days)
MO
PAR; MO; QLL (11
per 30 days)
PAR; MO; QLL (6
per 30 days)
PAR; MO
MO
MO; QLL (4 per 28
days)
MO
PAR; MO; CG;
QLL (300 per 30
days)
MO
MO
PAR; MO; QLL
(300 per 30 days)
MO; CG; QLL (120
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (180
per 30 days)
MO
MO; QLL (30 per
30 days)
MO
4
4
2
4
3
MO; QLL (2 per 28
days)
MO; CG
MO; CG
MO
MO; CG; QLL (9
per 30 days)
Drug Name
Drug Requirements/
Tier Limits
VICTOZA 3-PAK
3
ZAVESCA
zoledronic acid intravenous
recon soln
zoledronic acid intravenous
solution
ZOMETA INTRAVENOUS
SOLUTION 4 MG/100 ML
Gastroenterology
alosetron
5
5
MO; CG; QLL (9
per 30 days)
PAR; MO; LA
PAR
5
PAR; MO
5
PAR; MO
5
ALOXI
AMITIZA
ANTIVERT ORAL TABLET
12.5 MG, 25 MG
ANUSOL-HC RECTAL
CREAM
APRISO
ASACOL HD
atropine injection syringe 0.05
mg/ml, 0.1 mg/ml
AZULFIDINE
AZULFIDINE EN-TABS
balsalazide
budesonide oral
CANASA
CANTIL
carafate
CESAMET
CIMZIA
4
3
4
PAR; MO; QLL (60
per 30 days)
MO
MO; CG
MO
4
MO
3
3
4
MO; CG
MO; CG
4
4
3
5
4
4
4
5
5
CIMZIA POWDER FOR
RECONST
CIMZIA STARTER KIT
5
colocort
compro
constulose
CORTIFOAM
CREON ORAL CAPSULE,
DELAYED RELEASE(DR/
EC) 12,000-38,000 -60,000
UNIT, 24,000-76,000 -120,
000 UNIT, 6,000-19,000 30,000 UNIT
3
3
2
4
3
MO
MO
MO
MO
MO
MO
MO
B/D PAR; MO
PAR; MO; QLL (6
per 28 days)
PAR; MO; QLL (6
per 28 days)
PAR; MO; QLL (6
per 28 days)
MO
PAR; MO
MO; CG
MO
MO; CG
5
Premier_15283_v14_1511_1
47
Drug Name
Drug Requirements/
Tier Limits
CREON ORAL CAPSULE,
DELAYED RELEASE(DR/
EC) 3,000-9,500- 15,000
UNIT, 36,000-114,000- 180,
000 UNIT
cromolyn oral
CYSTADANE
CYTOTEC
DELZICOL
DEXILANT
3
MO
4
5
4
3
4
dicyclomine oral capsule
dicyclomine oral solution
dicyclomine oral tablet
DIPENTUM
diphenoxylate-atropine oral
tablet
dronabinol oral capsule 10 mg
2
3
2
5
2
MO
MO
MO
MO
ST; MO; QLL (30
per 30 days)
MO; CG
MO
MO; CG
MO
MO; CG
dronabinol oral capsule 2.5 mg,
5 mg
4
EMEND ORAL CAPSULE
125 MG
EMEND ORAL CAPSULE
40 MG
EMEND ORAL CAPSULE
80 MG
EMEND ORAL CAPSULE,
DOSE PACK
3
enulose
esomeprazole magnesium
2
4
esomeprazole sodium
famotidine (pf)
famotidine (pf)-nacl (iso-os)
famotidine intravenous
famotidine oral suspension
famotidine oral tablet 20 mg,
40 mg
GATTEX 30-VIAL
GATTEX ONE-VIAL
gavilyte-c
gavilyte-g
4
4
4
4
2
2
5
3
3
3
5
5
2
2
B/D PAR; MO;
QLL (120 per 30
days)
B/D PAR; MO;
QLL (120 per 30
days)
B/D PAR; MO; CG;
QLL (4 per 30 days)
B/D PAR; MO; CG;
QLL (1 per 1 day)
B/D PAR; MO; CG;
QLL (8 per 30 days)
B/D PAR; MO; CG;
QLL (12 per 30
days)
MO; CG
ST; MO; QLL (30
per 30 days)
Drug Name
Drug Requirements/
Tier Limits
gavilyte-h and bisacodyl
gavilyte-n
generlac
glycopyrrolate injection
glycopyrrolate oral
GOLYTELY
granisetron (pf)
granisetron hcl intravenous
granisetron hcl oral
3
2
2
4
2
4
4
4
4
hydrocortisone rectal enema
KRISTALOSE
lactulose
lansoprazole oral capsule,
delayed release(dr/ec)
LIALDA
LINZESS
loperamide oral capsule
LOTRONEX
3
4
2
2
meclizine oral tablet 12.5 mg,
25 mg
mesalamine rectal
mesalamine with cleansing wipe
methscopolamine oral
metoclopramide hcl injection
solution
metoclopramide hcl injection
syringe
metoclopramide hcl oral
solution
metoclopramide hcl oral tablet
misoprostol
MOVIPREP
NEXIUM
2
MO
MO; CG
MO; CG
MO
MO; CG
MO
MO
MO
B/D PAR; MO;
QLL (30 per 30
days)
MO; CG
MO
MO; CG
MO; CG; QLL (30
per 30 days)
MO; CG
MO
MO; CG
PAR; MO; QLL (60
per 30 days)
MO; CG
3
4
3
4
MO
MO
MO
MO
NEXIUM IV
INTRAVENOUS RECON
SOLN 40 MG
NEXIUM PACKET
4
nizatidine oral capsule
NULYTELY WITH
FLAVOR PACKS
2
4
3
3
2
5
4
2
MO; CG
1
2
4
4
MO; CG
MO; CG
MO
ST; MO; QLL (30
per 30 days)
MO
MO
MO
MO; CG
MO; CG
MO
MO
MO; CG
MO; CG
4
ST; MO; QLL (30
per 30 days)
MO; CG
MO
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
omeprazole oral capsule,delayed
release(dr/ec)
ondansetron hcl (pf) injection
solution
ondansetron hcl (pf) injection
syringe
ondansetron hcl intravenous
solution
ondansetron hcl oral solution
2
ondansetron hcl oral tablet 24
mg
ondansetron hcl oral tablet 4
mg, 8 mg
4
ondansetron oral tablet,
disintegrating 4 mg
3
ondansetron oral tablet,
disintegrating 8 mg
2
opium tincture oral tincture
OSMOPREP
pantoprazole oral tablet,delayed
release (dr/ec) 20 mg
pantoprazole oral tablet,delayed
release (dr/ec) 40 mg
paregoric
peg 3350-electrolytes oral recon
soln 236-22.74-6.74 -5.86
gram
peg 3350-electrolytes oral recon
soln 240-22.72-6.72 -5.84
gram
peg-3350 with flavor packs
peg-electrolyte soln
PENTASA
polyethylene glycol 3350 oral
prochlorperazine edisylate
injection solution 10 mg/2 ml
(5 mg/ml)
prochlorperazine maleate oral
prochlorperazine maleate rectal
procto-pak
proctosol hc
2
4
1
4
4
4
4
2
2
2
2
2
2
2
3
2
4
2
4
2
2
Drug Name
Drug Requirements/
Tier Limits
proctozone-hc
2 MO; CG
propantheline
2 MO; CG
ranitidine hcl injection
4 MO
ranitidine hcl oral syrup
2 MO; CG
ranitidine hcl oral tablet 150
2 MO; CG
mg
MO
ranitidine hcl oral tablet 300
1 MO; CG
mg
B/D PAR; MO;
RELISTOR
4 PAR; MO
QLL (450 per 30
SUBCUTANEOUS
days)
SOLUTION
B/D PAR; QLL (30 RELISTOR
4 PAR; MO
per 30 days)
SUBCUTANEOUS
B/D PAR; MO; CG; SYRINGE
QLL (90 per 30
REMICADE
5 PAR; MO
days)
SUCRAID
5 MO
B/D PAR; MO;
sucralfate oral tablet
2 MO; CG
QLL (90 per 30
sulfasalazine
2 MO; CG
days)
sulfazine
1 MO; CG
B/D PAR; MO; CG; sulfazine ec
2 MO; CG
QLL (90 per 30
SUPREP BOWEL PREP KIT 3 MO
days)
trilyte with flavor packets
2 MO; CG
MO; CG
UCERIS ORAL
5 MO
MO
ursodiol oral capsule
2 MO; CG
MO; CG; QLL (30 ursodiol oral tablet
3 MO
per 30 days)
ZENPEP
4 MO
MO; CG; QLL (30 ZOFRAN (AS
4 MO
per 30 days)
HYDROCHLORIDE)
MO; CG
INTRAVENOUS
MO; CG
Immunology, Vaccines / Biotechnology
ACTHIB (PF)
3 MO; CG
ACTIMMUNE
5 PAR; MO
CG
ADACEL(TDAP
3 MO; CG
ADOLESN/ADULT)(PF)
INTRAMUSCULAR
CG
SUSPENSION
CG
ADACEL(TDAP
3 MO
MO; CG
ADOLESN/ADULT)(PF)
MO; CG
INTRAMUSCULAR
PAR; MO
SYRINGE
ARANESP (IN
5 PAR; MO
POLYSORBATE)
PAR; MO; CG
INJECTION SOLUTION
PAR; MO
100 MCG/ML, 150 MCG/
MO; CG
0.75 ML, 200 MCG/ML,
MO; CG
300 MCG/ML
MO; CG; QLL (30
per 30 days)
MO
Premier_15283_v14_1511_1
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Drug Name
ARANESP (IN
POLYSORBATE)
INJECTION SOLUTION
25 MCG/ML, 40 MCG/ML,
60 MCG/ML
ARANESP (IN
POLYSORBATE)
INJECTION SYRINGE 10
MCG/0.4 ML, 25 MCG/
0.42 ML, 40 MCG/0.4 ML,
60 MCG/0.3 ML
ARANESP (IN
POLYSORBATE)
INJECTION SYRINGE 100
MCG/0.5 ML, 150 MCG/
0.3 ML, 200 MCG/0.4 ML,
300 MCG/0.6 ML, 500
MCG/ML
ARCALYST
AVONEX (WITH
ALBUMIN)
AVONEX
INTRAMUSCULAR PEN
INJECTOR KIT
AVONEX
INTRAMUSCULAR
SYRINGE
AVONEX
INTRAMUSCULAR
SYRINGE KIT
BCG VACCINE, LIVE (PF)
BETASERON
SUBCUTANEOUS KIT
BEXSERO (PF)
BIVIGAM
BOOSTRIX TDAP
CARIMUNE NF
NANOFILTERED
INTRAVENOUS RECON
SOLN 12 GRAM, 6 GRAM
CERVARIX VACCINE (PF)
COMVAX (PF)
DAPTACEL (DTAP
PEDIATRIC) (PF)
ENGERIX-B (PF)
Drug Requirements/
Tier Limits
4
4
5
5
5
5
PAR; MO
PAR; MO
PAR; MO
PAR; MO
PAR; MO; QLL (4
per 28 days)
PAR; MO; QLL (4
per 28 days)
5
PAR; MO; QLL (4
per 28 days)
5
PAR; MO; QLL (4
per 28 days)
4
5
MO
PAR; MO
3
5
3
5
MO
PAR; MO
MO; CG
PAR; MO
3
3
3
MO; CG
MO; CG
MO; CG
3
B/D PAR; MO; CG
Drug Name
ENGERIX-B PEDIATRIC
(PF) INTRAMUSCULAR
SUSPENSION
ENGERIX-B PEDIATRIC
(PF) INTRAMUSCULAR
SYRINGE
EPOGEN INJECTION
SOLUTION 10,000 UNIT/
ML, 2,000 UNIT/ML, 20,
000 UNIT/2 ML, 3,000
UNIT/ML, 4,000 UNIT/ML
EPOGEN INJECTION
ML
EXTAVIA
SUBCUTANEOUS KIT
EXTAVIA
SUBCUTANEOUS RECON
SOLN
fomepizole
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAGARD S-D (IGA
< 1 MCG/ML)
GAMMAPLEX
GAMUNEX-C
GARDASIL (PF)
INTRAMUSCULAR
SUSPENSION
GARDASIL (PF)
INTRAMUSCULAR
SYRINGE
GARDASIL 9 (PF)
GENOTROPIN
GENOTROPIN
MINIQUICK
SUBCUTANEOUS
SYRINGE 0.2 MG/0.25 ML
GENOTROPIN
MINIQUICK
SUBCUTANEOUS
SYRINGE 0.4 MG/0.25 ML,
0.6 MG/0.25 ML, 0.8 MG/
0.25 ML, 1 MG/0.25 ML,
1.2 MG/0.25 ML, 1.4 MG/
0.25 ML, 1.6 MG/0.25 ML,
Drug Requirements/
Tier Limits
3
B/D PAR; MO; CG
3
B/D PAR; CG
4
PAR; MO; QLL (12
per 28 days)
5
PAR; MO; QLL (12
per 28 days)
5
PAR; MO
5
PAR
5
3
5
5
MO
PAR; MO
PAR; MO
PAR; MO
5
5
3
PAR; MO
PAR; MO
MO; CG
3
MO
3
5
4
MO
PAR; MO
PAR; MO
5
PAR; MO
Premier_15283_v14_1511_1
50
Drug Name
1.8 MG/0.25 ML, 2 MG/
0.25 ML
HAVRIX (PF)
INTRAMUSCULAR
SUSPENSION
HAVRIX (PF)
INTRAMUSCULAR
SYRINGE 1,440 ELISA
UNIT/ML
HAVRIX (PF)
INTRAMUSCULAR
SYRINGE 720 ELISA
UNIT/0.5 ML
ILARIS (PF)
IMOVAX RABIES
VACCINE (PF)
INFANRIX (DTAP) (PF)
INTRAMUSCULAR
SUSPENSION
INFANRIX (DTAP) (PF)
INTRAMUSCULAR
SYRINGE
INTRON A INJECTION
RECON SOLN 10
MILLION UNIT (1 ML)
INTRON A INJECTION
RECON SOLN 18
MILLION UNIT (1 ML), 50
MILLION UNIT (1 ML)
INTRON A INJECTION
SOLUTION 10 MILLION
UNIT/ML
INTRON A INJECTION
SOLUTION 6 MILLION
UNIT/ML
IPOL INJECTION
SUSPENSION
IPOL INJECTION
SYRINGE
IXIARO (PF)
LEUKINE INJECTION
RECON SOLN
M-M-R II (PF)
MENACTRA (PF)
INTRAMUSCULAR
SOLUTION
Drug Requirements/
Tier Limits
3
3
3
MO; CG
MO
CG
5
3
PAR; MO; LA
MO
3
MO; CG
3
MO
4
PAR; MO
5
PAR; MO
4
PAR; MO
5
PAR; MO
3
MO; CG
3
CG
3
5
MO; CG
PAR; MO
3
3
MO; CG
MO; CG
Drug Name
Drug Requirements/
Tier Limits
MENOMUNE - A/C/Y/W135
MENOMUNE - A/C/Y/W135 (PF)
MENVEO A-C-Y-W-135DIP (PF)
MOZOBIL
NEULASTA
SUBCUTANEOUS
SYRINGE
NEUMEGA
3
CG
3
MO; CG
3
MO; CG
5
5
PAR; MO
PAR; MO; QLL (2
per 28 days)
5
NEUPOGEN
NORDITROPIN FLEXPRO
PEDVAX HIB (PF)
PEGASYS
PEGASYS PROCLICK
PEGINTRON
PEGINTRON REDIPEN
PRIVIGEN
PROCRIT INJECTION
ML, 2,000 UNIT/ML, 20,
000 UNIT/2 ML, 3,000
UNIT/ML, 4,000 UNIT/ML
PROCRIT INJECTION
ML, 40,000 UNIT/ML
PROLEUKIN
PROQUAD (PF)
QUADRACEL (PF)
RABAVERT (PF)
REBIF (WITH ALBUMIN)
REBIF REBIDOSE
REBIF TITRATION PACK
RECOMBIVAX HB (PF)
INTRAMUSCULAR
SUSPENSION
RECOMBIVAX HB (PF)
INTRAMUSCULAR
SYRINGE 10 MCG/ML
RECOMBIVAX HB (PF)
INTRAMUSCULAR
SYRINGE 5 MCG/0.5 ML
ROTARIX
ROTATEQ VACCINE
5
5
3
5
5
5
5
5
4
PAR; MO; QLL (21
per 21 days)
PAR; MO
PAR; MO
MO; CG
PAR; MO
PAR; MO
PAR; MO
PAR; MO
PAR; MO
PAR; MO; QLL (12
per 28 days)
5
PAR; MO; QLL (12
per 28 days)
5
3
3
4
5
5
5
3
B/D PAR; MO
CG
3
B/D PAR; MO
3
B/D PAR
3
3
MO; CG
MO
PAR; MO
PAR; MO
PAR; MO
B/D PAR; MO; CG
Premier_15283_v14_1511_1
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Drug Name
Drug Requirements/
Tier Limits
SYLATRON
5
TETANUS,DIPHTHERIA
3
TOX PED(PF)
TETANUS-DIPHTHERIA
3
TOXOIDS-TD
THYMOGLOBULIN
5
TICE BCG
4
TRUMENBA
3
TWINRIX (PF)
3
INTRAMUSCULAR
SUSPENSION
TWINRIX (PF)
3
INTRAMUSCULAR
SYRINGE
TYPHIM VI
3
INTRAMUSCULAR
SOLUTION
TYPHIM VI
3
INTRAMUSCULAR
SYRINGE
VAQTA (PF)
3
INTRAMUSCULAR
SUSPENSION
VAQTA (PF)
3
INTRAMUSCULAR
SYRINGE
VARIVAX (PF)
3
VARIZIG
3
INTRAMUSCULAR
RECON SOLN
VARIZIG
3
INTRAMUSCULAR
SOLUTION
XEOMIN
4
YF-VAX (PF)
3
ZOSTAVAX (PF)
3
Musculoskeletal / Rheumatology
ACTEMRA
5
INTRAVENOUS
ACTONEL ORAL TABLET 4
150 MG
35 MG
5 MG
PAR; MO
MO
MO; CG
B/D PAR
MO
MO; CG
MO
CG
MO
MO; CG
MO; CG
MO
PAR; MO
MO; CG
MO
Drug Name
Drug Requirements/
Tier Limits
1
alendronate oral tablet 35 mg,
70 mg
1
allopurinol
aloprim
BENLYSTA
BONIVA INTRAVENOUS
colchicine-probenecid
COLCRYS
DEPEN TITRATABS
ENBREL
SUBCUTANEOUS RECON
SOLN
ENBREL
SUBCUTANEOUS
SYRINGE 25 MG/0.5ML
(0.51)
ENBREL
SUBCUTANEOUS
SYRINGE 50 MG/ML (0.98
ML)
ENBREL SURECLICK
1
4
5
4
2
3
3
5
EVISTA
3
FORTEO
5
FOSAMAX PLUS D
4
HUMIRA CROHN'S DIS
START PCK
HUMIRA PED CROHN'S
STARTER PK
HUMIRA PEN
5
HUMIRA PSORIASIS
STARTER PACK
HUMIRA
SUBCUTANEOUS
SYRINGE KIT 10 MG/0.2
ML, 20 MG/0.4 ML
HUMIRA
SUBCUTANEOUS
5
2
PAR; MO
B/D PAR; MO
MO; CG
MO
MO
PAR; MO; QLL (8
per 28 days)
5
PAR; MO; QLL
(4.08 per 28 days)
5
PAR; MO; QLL (8
per 28 days)
5
PAR; MO; QLL (8
per 28 days)
MO; QLL (30 per
30 days)
PAR; MO; QLL (3
per 28 days)
ST; MO; QLL (4
per 28 days)
PAR; MO; QLL (4.8
per 365 days)
PAR; MO; QLL (4.8
per 365 days)
PAR; MO; QLL (3.2
per 28 days)
PAR; MO; QLL (3.2
per 28 days)
PAR; MO; QLL (2
per 28 days)
5
5
PAR; MO
ST; MO; QLL (1
per 28 days)
ST; MO; QLL (4
per 28 days)
ST; MO; QLL (30
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (4
per 28 days)
MO; CG; QLL (30
per 30 days)
MO; CG
5
5
PAR; MO; QLL (3.2
per 28 days)
Premier_15283_v14_1511_1
52
Drug Name
SYRINGE KIT 40 MG/0.8
ML
ibandronate intravenous
solution
ibandronate intravenous syringe
ibandronate oral
Drug Requirements/
Tier Limits
4
B/D PAR; MO
4
2
KINERET
5
leflunomide
probenecid
PROLIA
2
2
4
raloxifene
3
RIDAURA
4
3
4
(12 pack)
4
SAVELLA ORAL TABLET
100 MG
SAVELLA ORAL TABLET
12.5 MG
SAVELLA ORAL TABLET
25 MG
SAVELLA ORAL TABLET
50 MG
SAVELLA ORAL TABLETS,
DOSE PACK
SIMPONI
3
ULORIC
ZYLOPRIM
Obstetrics / Gynecology
altavera (28)
alyacen 1/35 (28)
alyacen 7/7/7 (28)
apri
aranelle (28)
aviane
AYGESTIN
4
4
MO
MO; CG; QLL (1
per 28 days)
PAR; MO; QLL (28
per 28 days)
MO; CG
MO; CG
PAR; MO; QLL (2
per 365 days)
MO; QLL (30 per
30 days)
MO
MO; QLL (1 per 28
days)
ST; MO; QLL (4
per 28 days)
ST; QLL (4 per 28
days)
ST; MO; QLL (30
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (480
per 30 days)
MO; CG; QLL (240
per 30 days)
MO; CG; QLL (120
per 30 days)
MO; CG; QLL (1
per 365 days)
PAR; MO; QLL (1
per 28 days)
ST; MO
MO
4
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
4
3
3
3
3
5
Drug Name
Drug Requirements/
Tier Limits
azurette (28)
balziva (28)
briellyn
camila
caziant (28)
CLEOCIN VAGINAL
clindamycin phosphate vaginal
CRINONE
cryselle (28)
cyclafem 1/35 (28)
cyclafem 7/7/7 (28)
dasetta 1/35 (28)
dasetta 7/7/7 (28)
drospirenone-ethinyl estradiol
drospirenone-ethinyl estradiol
elinest
ELLA
emoquette
enpresse
errin
estarylla
ESTRACE VAGINAL
estradiol oral
estradiol transdermal patch
weekly
ESTRING
4
4
4
2
4
4
3
4
4
4
4
4
4
4
MO
MO
MO
MO; CG
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
MO
4
3
4
4
4
4
4
3
3
falmina (28)
FEMRING
4
4
gianvi (28)
gildagia
gildess
gildess fe
heather
introvale
jolessa
jolivette
junel 1.5/30 (21)
junel 1/20 (21)
junel fe 1.5/30 (28)
junel fe 1/20 (28)
kariva (28)
4
4
4
4
4
4
4
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
PAR; MO
PAR; MO; QLL (4
per 28 days)
MO; QLL (1 per 90
days)
MO
MO; QLL (1 per 90
days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
Premier_15283_v14_1511_1
53
Drug Name
kelnor 1/35 (28)
leena 28
lessina
levonest (28)
levonorgestrel-ethinyl estrad oral
tablet 0.1-20 mg-mcg, 0.150.03 mg
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month
levora-28
LOMEDIA 24 FE
loryna (28)
low-ogestrel (28)
lutera (28)
lyza
marlissa
medroxyprogesterone
intramuscular
medroxyprogesterone oral
MENEST
methylergonovine oral
metronidazole vaginal
miconazole-3 vaginal
suppository
microgestin 1.5/30 (21)
microgestin 1/20 (21)
microgestin fe 1.5/30 (28)
microgestin fe 1/20 (28)
mono-linyah
mononessa (28)
myzilra
necon 0.5/35 (28)
necon 1/35 (28)
necon 1/50 (28)
necon 10/11 (28)
necon 7/7/7 (28)
NOR-QD
nora-be
norethindrone (contraceptive)
norethindrone acetate
norgestimate-ethinyl estradiol
nortrel 0.5/35 (28)
nortrel 1/35 (21)
nortrel 1/35 (28)
nortrel 7/7/7 (28)
Drug Requirements/
Tier Limits
4
4
4
4
4
MO
MO
MO
MO
MO
4
MO
4
4
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
1
4
4
2
4
MO; CG
PAR; MO
MO
MO; CG
MO; QLL (6 per 30
days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO; CG
MO
MO
MO
MO
MO
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
4
4
4
4
4
Drug Name
NUVARING
ocella
ogestrel (28)
orsythia
ORTHO EVRA
philith
pirmella oral tablet 1-35 mgmcg
portia
PREMARIN ORAL
PREMARIN VAGINAL
PREMPRO
previfem
progesterone micronized
PROMETRIUM
PROVERA
quasense
reclipsen (28)
sprintec (28)
sronyx
syeda
TERAZOL 3 VAGINAL
CREAM
TERAZOL 7
terconazole vaginal cream 0.4
%
terconazole vaginal cream 0.8
%
terconazole vaginal suppository
tilia fe
tranexamic acid oral
tri-estarylla
tri-legest fe
tri-linyah
tri-previfem (28)
tri-sprintec (28)
trinessa (28)
trivora (28)
VAGIFEM
vandazole
velivet triphasic regimen (28)
vestura (28)
viorele (28)
XULANE
zarah
Drug Requirements/
Tier Limits
4
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
4
3
3
4
4
2
4
4
4
4
4
4
4
4
MO
MO
MO
PAR; MO
MO
ST; MO; CG
ST; MO
MO
MO
MO
MO
MO
MO
MO
4
2
MO
MO; CG
3
MO
4
4
3
4
4
4
4
4
4
4
4
2
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO; CG
MO
MO
MO
MO
MO
Premier_15283_v14_1511_1
54
Drug Name
zazole vaginal cream 0.4 %
zazole vaginal cream 0.8 %
zenchent (28)
zenchent fe
zeosa
zovia 1/35e (28)
zovia 1/50e (28)
Ophthalmology
acetazolamide oral capsule,
extended release
acetazolamide oral tablet
acetazolamide sodium
ACULAR
ACULAR LS
ak-poly-bac
ALCAINE
ALOCRIL
ALOMIDE
ALPHAGAN P
OPHTHALMIC DROPS 0.1
%
ALPHAGAN P
OPHTHALMIC DROPS
0.15 %
ALREX
apraclonidine
atropine ophthalmic drops
AZASITE
azelastine ophthalmic
AZOPT
bacitracin ophthalmic
bacitracin-polymyxin b
ophthalmic
BESIVANCE
BETAGAN OPHTHALMIC
DROPS 0.5 %
betaxolol ophthalmic
BETIMOL
BETOPTIC S
bimatoprost
BLEPH-10
BLEPHAMIDE
BLEPHAMIDE S.O.P.
brimonidine
carteolol
Drug Requirements/
Tier Limits
2
4
4
4
4
4
4
CG
3
MO
2
4
4
4
2
4
4
4
3
MO; CG
MO
MO
MO
MO; CG
MO
MO
MO
MO; CG
4
MO
4
2
2
4
2
4
3
2
MO
MO; CG
MO; CG
MO
MO; CG
MO
MO
MO; CG
4
4
MO
MO
2
4
4
3
4
4
4
2
1
MO; CG
MO
MO
MO
MO
MO
MO
MO; CG
MO; CG
MO
MO
MO
MO
MO
Drug Name
CILOXAN
ciprofloxacin hcl ophthalmic
COMBIGAN
cromolyn ophthalmic
dexamethasone sodium
phosphate ophthalmic
diclofenac sodium ophthalmic
dorzolamide
dorzolamide-timolol
DUREZOL
ELESTAT
EMADINE
epinastine
erythromycin ophthalmic
FLAREX
fluorometholone
flurbiprofen sodium
FML FORTE
FML LIQUIFILM
FML S.O.P.
gentak ophthalmic ointment
gentamicin ophthalmic
ILEVRO
IOPIDINE
ISTALOL
ketorolac ophthalmic
LACRISERT
latanoprost
levobunolol ophthalmic drops
0.5 %
levofloxacin ophthalmic
LOTEMAX OPHTHALMIC
DROPS,SUSPENSION
LOTEMAX OPHTHALMIC
OINTMENT
LUMIGAN OPHTHALMIC
DROPS 0.01 %
MAXIDEX
MAXITROL
methazolamide oral tablet 25
mg
methazolamide oral tablet 50
mg
metipranolol
MOXEZA
Drug Requirements/
Tier Limits
4
2
3
2
2
MO
MO; CG
MO; CG
MO; CG
MO; CG
2
2
2
3
4
4
2
2
4
2
2
4
4
4
2
2
3
4
4
2
3
1
2
MO; CG
MO; CG
MO; CG
MO; CG
MO
MO
MO; CG
MO; CG
MO
MO; CG
MO; CG
MO
MO
MO
MO; CG
MO; CG
MO
MO
MO
MO; CG
MO
MO; CG
MO; CG
2
4
MO; CG
MO
4
MO
3
MO; CG
4
4
2
MO
MO
MO; CG
3
MO
2
3
MO; CG
MO; CG
Premier_15283_v14_1511_1
55
Drug Name
naphazoline
NATACYN
neo-polycin
neo-polycin hc
neomycin-bacitracin-poly-hc
neomycin-bacitracin-polymyxin
neomycin-polymyxin bdexameth
neomycin-polymyxingramicidin
neomycin-polymyxin-hc
ophthalmic
NEOSPORIN (NEOPOLYM-GRAMICID)
NEVANAC
OCUFLOX
ofloxacin ophthalmic
PATADAY
PATANOL
PAZEO
PHOSPHOLINE IODIDE
pilocarpine hcl ophthalmic
drops 1 %, 2 %, 4 %
polycin
polymyxin b sulf-trimethoprim
POLYTRIM
PRED FORTE
PRED MILD
PRED-G
PRED-G S.O.P.
prednisolone acetate
ophthalmic
RESTASIS
SIMBRINZA
sulfacetamide sodium
ophthalmic drops
sulfacetamide sodium
ophthalmic ointment
sulfacetamide-prednisolone
timolol maleate ophthalmic
drops
timolol maleate ophthalmic gel
forming solution
TIMOPTIC
Drug Requirements/
Tier Limits
1
3
2
2
3
2
2
MO; CG
MO; CG
MO; CG
CG
MO
MO; CG
MO; CG
2
MO; CG
3
MO
4
MO
3
4
1
3
3
3
4
2
MO; CG
MO
MO; CG
MO; CG
MO; CG
MO
MO
MO; CG
2
1
4
4
4
4
4
2
2
CG
MO; CG
MO
MO
MO
MO
MO
MO; CG
MO; CG
3
4
2
MO
MO
MO; CG
3
MO
2
1
MO; CG
MO; CG
2
MO; CG
4
MO
Drug Name
Drug Requirements/
Tier Limits
TIMOPTIC OCUDOSE
(PF)
TIMOPTIC-XE
TOBRADEX
OPHTHALMIC DROPS,
SUSPENSION
TOBRADEX
OPHTHALMIC
OINTMENT
TOBRADEX ST
tobramycin
tobramycin-dexamethasone
TOBREX
TRAVATAN Z
travoprost (benzalkonium)
trifluridine
tropicamide ophthalmic
VEXOL
VIGAMOX
VIROPTIC
ZIOPTAN (PF)
ZIRGAN
ZYLET
Respiratory And Allergy
acetylcysteine
ADCIRCA
4
MO
4
4
MO
MO
3
MO; CG
3
2
3
4
3
2
3
2
4
3
4
4
3
4
MO; CG
MO; CG
MO
MO
MO; CG
MO; CG
MO
MO; CG
MO
MO; CG
MO
MO
MO
MO
2
5
ADRENACLICK
4
ADVAIR DISKUS
3
ADVAIR HFA
3
AEROSPAN
4
albuterol sulfate inhalation
solution for nebulization 0.63
mg/3 ml
mg/3 ml, 2.5 mg /3 ml (0.083
%)
mg/0.5 ml, 5 mg/ml
albuterol sulfate oral syrup
3
B/D PAR; MO; CG
PAR; MO; QLL (60
per 30 days)
MO; QLL (2 per 1
day)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (12
per 30 days)
MO; QLL (18 per
30 days)
B/D PAR; MO;
QLL (360 per 30
days)
B/D PAR; MO; CG;
QLL (360 per 30
days)
2
2
2
B/D PAR; MO; CG;
QLL (60 per 30
days)
MO; CG
Premier_15283_v14_1511_1
56
Drug Name
Drug Requirements/
Tier Limits
albuterol sulfate oral tablet
albuterol sulfate oral tablet
aminophylline intravenous
ANORO ELLIPTA
2
3
ARNUITY ELLIPTA
3
ASMANEX HFA
3
ASMANEX TWISTHALER
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 110 MCG (30
DOSES)
ASMANEX TWISTHALER
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 110 MCG (7
DOSES), 220 MCG (14
DOSES)
ASMANEX TWISTHALER
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 220 MCG
(120 DOSES), 220 MCG (30
DOSES), 220 MCG (60
DOSES)
ATROVENT HFA
3
BECONASE AQ
4
BREO ELLIPTA
3
BROVANA
4
cetirizine oral solution 1 mg/ml
2
CINRYZE
clemastine oral tablet 2.68 mg
COMBIVENT RESPIMAT
5
3
4
cromolyn inhalation
4
3
3
3
4
2
MO; CG
MO
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (13 per
30 days)
MO; CG; QLL
(0.14 per 30 days)
Drug Name
Drug Requirements/
Tier Limits
DALIRESP
4
diphenhydramine hcl injection
solution 50 mg/ml
diphenhydramine hcl injection
syringe
DULERA
4
PAR; MO; QLL (30
per 30 days)
PAR; MO
4
PAR; MO
3
ELIXOPHYLLIN ORAL
ELIXIR 80 MG/15 ML
epinephrine injection autoinjector
epinephrine injection solution
1 mg/ml (1:1,000)
epinephrine injection syringe
0.1 mg/ml (1:10,000)
EPIPEN 2-PAK
3
MO; QLL (13 per
30 days)
MO
EPIPEN JR 2-PAK
4
FIRAZYR
MO; CG; QLL
FLOVENT DISKUS
(0.24 per 30 days)
INHALATION BLISTER
WITH DEVICE 100 MCG/
ACTUATION
FLOVENT DISKUS
INHALATION BLISTER
WITH DEVICE 250 MCG/
MO; QLL (26 per
ACTUATION, 50 MCG/
30 days)
ACTUATION
ST; MO; QLL (50
FLOVENT HFA
per 30 days)
INHALATION HFA
MO; QLL (60 per
AEROSOL INHALER 110
30 days)
MCG/ACTUATION
B/D PAR; MO;
FLOVENT HFA
QLL (120 per 30
INHALATION HFA
days)
AEROSOL INHALER 220
MO; CG; QLL (300 MCG/ACTUATION
per 30 days)
FLOVENT HFA
PAR; MO
INHALATION HFA
PAR; MO
AEROSOL INHALER 44
MO; QLL (8 per 30 MCG/ACTUATION
flunisolide nasal spray,nondays)
B/D PAR; MO; CG; aerosol 25 mcg (0.025 %)
fluticasone nasal
QLL (240 per 30
days)
4
4
MO; QLL (2 per 1
day)
MO
4
MO
4
MO; QLL (2 per 1
day)
MO; QLL (2 per 1
day)
PAR; MO
MO; CG; QLL (60
per 30 days)
5
3
3
MO; CG; QLL (240
per 30 days)
3
MO; CG; QLL (12
per 30 days)
3
MO; CG; QLL (24
per 30 days)
3
MO; CG; QLL (11
per 30 days)
2
MO; CG; QLL (75
per 30 days)
MO; CG; QLL (16
per 30 days)
1
Premier_15283_v14_1511_1
57
Drug Name
Drug Requirements/
Tier Limits
FORADIL AEROLIZER
3
ipratropium bromide
inhalation
ipratropium-albuterol
2
2
KALYDECO ORAL
TABLET
LETAIRIS
5
levalbuterol hcl inhalation
mg/3 ml
mg/3 ml
mg/0.5 ml, 1.25 mg/3 ml
levocetirizine oral tablet
2
metaproterenol oral
montelukast oral granules in
packet
montelukast oral tablet
2
3
5
2
4
3
2
montelukast oral tablet,
chewable
NASONEX
2
OMNARIS
4
PERFOROMIST
4
PROAIR HFA
3
PROAIR RESPICLICK
3
promethazine injection solution
PULMOZYME
QVAR INHALATION
AEROSOL 40 MCG/
ACTUATION
3
4
5
3
MO; CG; QLL (60
per 30 days)
B/D PAR; MO; CG
B/D PAR; MO; CG;
QLL (540 per 30
days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; LA; QLL
(30 per 30 days)
B/D PAR; MO; CG;
QLL (270 per 30
days)
B/D PAR; MO; CG;
QLL (540 per 30
days)
B/D PAR; MO;
QLL (270 per 30
days)
MO; QLL (30 per
30 days)
MO; CG
MO; QLL (30 per
30 days)
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (17
per 30 days)
ST; MO; QLL (13
per 30 days)
B/D PAR; MO;
QLL (120 per 30
days)
MO; CG; QLL (18
per 30 days)
MO; QLL (2 per 30
days)
PAR; MO
B/D PAR; MO
MO; CG; QLL (9
per 30 days)
Drug Name
Drug Requirements/
Tier Limits
QVAR INHALATION
AEROSOL 80 MCG/
ACTUATION
REVATIO INTRAVENOUS
3
MO; CG; QLL (18
per 30 days)
5
RHINOCORT AQUA
4
SEREVENT DISKUS
3
sildenafil intravenous
5
sildenafil oral
5
SPIRIVA RESPIMAT
INHALATION MIST 2.5
MCG/ACTUATION
SPIRIVA WITH
HANDIHALER
STIOLTO RESPIMAT
3
PAR; MO; QLL
(1125 per 30 days)
ST; MO; QLL (18
per 30 days)
MO; CG; QLL (60
per 30 days)
PAR; QLL (1125
per 30 days)
PAR; MO; QLL (90
per 30 days)
MO; QLL (4 per 30
days)
terbutaline oral
terbutaline subcutaneous
theophylline oral elixir
theophylline oral solution
theophylline oral tablet
extended release
extended release 12 hr 200 mg,
300 mg, 450 mg
TRACLEER
2
4
2
2
2
MO; QLL (30 per
30 days)
MO; QLL (4 per 30
days)
MO; CG
MO
CG
CG
MO; CG
1
MO; CG
2
MO; CG
5
triamcinolone acetonide nasal
2
TYVASO
TYVASO
INSTITUTIONAL START
KIT
TYVASO REFILL KIT
TYVASO STARTER KIT
VENTAVIS
VERAMYST
5
5
PAR; MO; LA; QLL
(60 per 30 days)
MO; CG; QLL (34
per 30 days)
PAR; MO
PAR
XOLAIR
5
3
3
5
5
5
4
PAR; MO
PAR; MO
PAR; MO
ST; MO; QLL (10
per 30 days)
PAR; MO; LA; QLL
(6 per 28 days)
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Drug Name
Drug Requirements/
Tier Limits
zafirlukast
2
MO; CG; QLL (60
per 30 days)
Urologicals
alfuzosin
AMMONIUM CHLORIDE
AVODART
2
4
3
MO; CG
bethanechol chloride
CIALIS ORAL TABLET 2.5
MG, 5 MG
CYSTAGON
cytra k crystals
cytra-k
ELMIRON
finasteride oral tablet 5 mg
flavoxate
JALYN
2
4
MYRBETRIQ
4
oxybutynin chloride oral syrup
2
3
2
2
4
2
2
3
oxybutynin chloride oral tablet
2
extended release 24hr 10 mg,
15 mg
potassium citrate oral tablet
extended release 10 meq (1,080
mg), 5 meq (540 mg)
RAPAFLO
sodium citrate-citric acid
tamsulosin
tolterodine oral tablet 1 mg
2
tolterodine oral tablet 2 mg
3
TOVIAZ
4
trospium oral tablet
2
VESICARE
4
2
2
4
2
2
2
Vitamins, Hematinics / Electrolytes
MO; QLL (30 per
30 days)
MO; CG
PAR; MO; QLL (30
per 30 days)
MO; CG; LA
MO; CG
MO; CG
MO
MO; CG
MO; CG
MO; CG; QLL (30
per 30 days)
MO; QLL (30 per
30 days)
MO; CG; QLL (600
per 30 days)
MO; CG; QLL (120
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (30
per 30 days)
MO; CG
MO
MO; CG
MO; CG
MO; CG; QLL (60
per 30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; CG; QLL (60
per 30 days)
MO; QLL (30 per
30 days)
Drug Name
AMINOSYN 10 %
AMINOSYN 7 % WITH
ELECTROLYTES
AMINOSYN 8.5 %
AMINOSYN 8.5 %ELECTROLYTES
AMINOSYN II 10 %
AMINOSYN II 15 %
AMINOSYN II 7 %
AMINOSYN II 8.5 %
AMINOSYN II 8.5 %ELECTROLYTES
AMINOSYN M 3.5 %
AMINOSYN-HBC 7%
AMINOSYN-PF 10 %
AMINOSYN-PF 7 %
(SULFITE-FREE)
AMINOSYN-RF 5.2 %
calcium acetate oral capsule
CLINIMIX 5%/D15W
SULFITE FREE
CLINIMIX 5%/D25W
SULFITE-FREE
CLINIMIX 2.75%/D5W
SULFIT FREE
CLINIMIX 4.25%-D20W
SULF-FREE
CLINIMIX 4.25%-D25W
SULF-FREE
CLINIMIX 4.25%/D10W
SULF FREE
CLINIMIX 5%D20W(SULFITE-FREE)
SUL FREE
SUL FREE
SULF FREE
CLINIMIX E 5%/D15W
SULFIT FREE
CLINIMIX E 5%/D20W
SULFIT FREE
CLINIMIX E 5%/D25W
SULFIT FREE
CLINISOL SF 15 %
Drug Requirements/
Tier Limits
4
4
B/D PAR
B/D PAR
4
4
B/D PAR
B/D PAR
4
4
4
4
4
B/D PAR
B/D PAR
B/D PAR
B/D PAR
B/D PAR
4
4
4
4
B/D PAR
B/D PAR
B/D PAR
B/D PAR
4
2
4
B/D PAR
MO; CG
B/D PAR
4
B/D PAR
4
B/D PAR
4
B/D PAR
4
B/D PAR
4
B/D PAR
4
B/D PAR
4
4
B/D PAR
4
B/D PAR
4
B/D PAR
4
B/D PAR
4
B/D PAR
4
B/D PAR; MO
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59
Drug Name
dextrose-kcl-nacl
fluoritab oral tablet,chewable
1 mg fluoride (2.2 mg)
freamine iii 10 %
HEPATAMINE 8%
intralipid intravenous emulsion
20 %
INTRALIPID
INTRAVENOUS
EMULSION 30 %
IONOSOL-B IN D5W
IONOSOL-MB IN D5W
ISOLYTE S PH 7.4
ISOLYTE-P IN 5 %
DEXTROSE
ISOLYTE-S
k-effervescent
k-phos-neutral
K-TAB ORAL TABLET
EXTENDED RELEASE 10
MEQ
k-tab oral tablet extended
release 8 meq
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
klor-con/ef
lactated ringers intravenous
liposyn iii intravenous emulsion
10 %
liposyn iii intravenous emulsion
20 %
ludent fluoride
magnesium sulfate in water
50 ml (4 %), 4 gram/50 ml (8
%)
100 ml (4 %)
magnesium sulfate injection
solution
Drug Requirements/
Tier Limits
4
2
B/D PAR
MO; CG
4
4
4
B/D PAR
B/D PAR
B/D PAR; MO
4
B/D PAR
4
4
4
4
B/D PAR
4
1
4
4
MO; CG
MO
MO
2
CG
2
2
2
2
2
1
4
4
MO; CG
MO; CG
MO; CG
MO; CG
MO; CG
MO; CG
B/D PAR; MO
B/D PAR
4
B/D PAR; MO
2
4
MO; CG
4
4
4
MO
MO
Drug Name
magnesium sulfate injection
syringe
NEPHRAMINE 5.4 %
NORMOSOL-M IN 5 %
DEXTROSE
NORMOSOL-R
NORMOSOL-R IN 5 %
DEXTROSE
NORMOSOL-R PH 7.4
PHOSLO
phospha 250 neutral
PLASMA-LYTE 148
PLASMA-LYTE A
PLASMA-LYTE-56 IN 5 %
DEXTROSE
potassium bicarb and chloride
potassium bicarb-citric acid
potassium chlorid-d50.45%nacl intravenous
parenteral solution 10 meq/l,
30 meq/l, 40 meq/l
potassium chlorid-d50.45%nacl intravenous
parenteral solution 20 meq/l
potassium chloride in 0.9%nacl
20 meq/l, 40 meq/l
potassium chloride in 5 % dex
20 meq/l, 30 meq/l, 40 meq/l
potassium chloride in lr-d5
20 meq/l
potassium chloride in lr-d5
40 meq/l
potassium chloride intravenous
piggyback 10 meq/100 ml, 20
meq/100 ml, 20 meq/50 ml,
30 meq/100 ml, 40 meq/100
ml
piggyback 10 meq/50 ml
solution
Drug Requirements/
Tier Limits
4
4
4
B/D PAR
B/D PAR
4
4
B/D PAR
B/D PAR
4
4
2
4
4
4
B/D PAR
ST; MO
MO; CG
B/D PAR
2
1
4
MO; CG
MO; CG
B/D PAR
4
B/D PAR; MO
4
B/D PAR
4
B/D PAR
4
B/D PAR; MO
4
B/D PAR
4
B/D PAR
4
B/D PAR; MO
4
B/D PAR; MO
B/D PAR
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60
Drug Name
potassium chloride oral capsule,
extended release
potassium chloride oral liquid
potassium chloride oral tablet
extended release
potassium chloride oral tablet,
er particles/crystals
potassium chloride-0.45 % nacl
potassium chloride-d50.2%nacl intravenous
parenteral solution 30 meq/l,
40 meq/l
premasol 10 %
PREMASOL 6 %
prenatal vitamin oral tablet
PROCALAMINE 3%
PROSOL 20 %
ringers intravenous
sodium bicarbonate intravenous
solution
sodium bicarbonate intravenous
syringe
intravenous piggyback
sodium chloride 3 %
sodium chloride 5 %
sodium chloride intravenous
sodium fluoride oral tablet
sodium fluoride oral tablet,
chewable 0.25 mg fluorid (0.55
mg), 0.5 mg fluoride (1.1 mg)
Drug Requirements/
Tier Limits
2
MO; CG
1
2
MO; CG
MO; CG
2
MO; CG
4
4
B/D PAR
B/D PAR; MO
4
B/D PAR
4
B/D PAR
4
B/D PAR; MO
4
B/D PAR
4
4
2
4
4
4
4
B/D PAR; MO
B/D PAR
MO; CG
B/D PAR
B/D PAR; MO
B/D PAR
MO
Drug Name
sodium fluoride oral tablet,
chewable 1 mg fluoride (2.2
mg)
sodium lactate intravenous
solution
TPN ELECTROLYTES
travasol 10 %
TROPHAMINE 10 %
TROPHAMINE 6%
Drug Requirements/
Tier Limits
4
MO
4
4
4
4
4
B/D PAR
B/D PAR; MO
B/D PAR; MO
B/D PAR
4
4
MO
4
4
4
4
4
2
MO
B/D PAR; MO
MO
MO; CG
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61
Index of Drugs:
Legend
Generic drugs are shown in lowercase italics (e.g. atenolol)
Brand-name drugs are shown in capital letters (e.g. CRESTOR)
The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and
generic drugs are listed. 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.
Drug Name
Page
8-MOP....................................................................38
a-hydrocort...............................................................42
abacavir.....................................................................8
abacavir-lamivudine-zidovudine.................................8
ABELCET................................................................8
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED REL RECON.......19
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING......19
ABILIFY ORAL TABLET 10 MG.........................19
ABILIFY ORAL TABLET 15 MG, 20 MG............19
ABILIFY ORAL TABLET 2 MG...........................19
ABILIFY ORAL TABLET 30 MG.........................19
ABILIFY ORAL TABLET 5 MG...........................19
ABRAXANE...........................................................15
ABSTRAL...............................................................19
acamprosate..............................................................41
acarbose oral tablet 100 mg.......................................42
acarbose oral tablet 25 mg.........................................43
acarbose oral tablet 50 mg.........................................43
ACCURETIC.........................................................32
acebutolol.................................................................32
acetaminophen-codeine oral solution 120 mg-12 mg
/5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300
mg-30 mg /12.5 ml...............................................19
acetaminophen-codeine oral solution 120-12 mg/5
ml.........................................................................19
acetaminophen-codeine oral tablet 300-15 mg............19
acetasol hc................................................................42
acetazolamide oral capsule, extended release................55
acetazolamide oral tablet...........................................55
acetazolamide sodium...............................................55
acetic acid irrigation.................................................41
acetic acid otic..........................................................42
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acetic acid-aluminum acetate....................................42
acetylcysteine.............................................................56
acetylcysteine intravenous..........................................41
acitretin...................................................................38
ACTEMRA INTRAVENOUS...............................52
ACTHAR H.P........................................................43
ACTHIB (PF).........................................................49
ACTIMMUNE......................................................49
ACTIQ...................................................................19
ACTONEL ORAL TABLET 150 MG...................52
ACTONEL ORAL TABLET 30 MG.....................41
ACTONEL ORAL TABLET 35 MG.....................52
ACTONEL ORAL TABLET 5 MG.......................52
ACTOPLUS MET XR ORAL TABLET, ER
MULTIPHASE 24 HR 15-1,000 MG.................43
ACTOPLUS MET XR ORAL TABLET, ER
MULTIPHASE 24 HR 30-1,000 MG.................43
ACULAR................................................................55
ACULAR LS...........................................................55
acyclovir oral capsule...................................................8
acyclovir oral suspension 200 mg/5 ml..........................8
acyclovir oral tablet.....................................................8
acyclovir sodium intravenous recon soln 500 mg...........8
acyclovir sodium intravenous solution...........................8
acyclovir topical........................................................38
ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SUSPENSION.................49
ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SYRINGE.........................49
ADAGEN...............................................................41
ADALAT CC.........................................................32
adapalene topical gel 0.1 %.......................................38
ADASUVE.............................................................19
ADCIRCA..............................................................56
adefovir......................................................................8
ADRENACLICK....................................................56
adrucil intravenous solution 2.5 gram/50 ml..............15
62
ALPHAGAN P OPHTHALMIC DROPS 0.15
%.........................................................................55
alprazolam oral tablet...............................................19
ALREX...................................................................55
ALTABAX..............................................................38
altavera (28)............................................................53
ALTOPREV...........................................................32
alyacen 1/35 (28).....................................................53
alyacen 7/7/7 (28)....................................................53
amantadine hcl oral capsule........................................8
amantadine hcl oral solution.......................................8
amantadine hcl oral tablet..........................................8
AMARYL ORAL TABLET 1 MG..........................43
AMBISOME............................................................8
amcinonide..............................................................38
amifostine crystalline.................................................15
amikacin injection solution 1,000 mg/4 ml, 500 mg/
2 ml........................................................................8
amiloride oral...........................................................33
amiloride-hydrochlorothiazide...................................33
aminophylline intravenous........................................57
AMINOSYN 10 %.................................................59
AMINOSYN 7 % WITH ELECTROLYTES........59
AMINOSYN 8.5 %................................................59
AMINOSYN 8.5 %-ELECTROLYTES.................59
AMINOSYN II 10 %.............................................59
AMINOSYN II 15 %.............................................59
AMINOSYN II 7 %...............................................59
AMINOSYN II 8.5 %............................................59
AMINOSYN II 8.5 %-ELECTROLYTES.............59
AMINOSYN M 3.5 %...........................................59
AMINOSYN-HBC 7%..........................................59
AMINOSYN-PF 10 %...........................................59
AMINOSYN-PF 7 % (SULFITE-FREE)...............59
AMINOSYN-RF 5.2 %..........................................59
amiodarone intravenous solution...............................33
amiodarone intravenous syringe.................................33
amiodarone oral.......................................................33
AMITIZA...............................................................47
amitriptyline............................................................19
amlodipine oral tablet 10 mg, 2.5 mg........................33
amlodipine oral tablet 5 mg......................................33
amlodipine-atorvastatin............................................33
amlodipine-benazepril..............................................33
amlodipine-valsartan................................................33
amlodipine-valsartan-hcthiazid.................................33
adrucil intravenous solution 5 gram/100 ml, 500 mg/
10 ml....................................................................15
ADVAIR DISKUS..................................................56
ADVAIR HFA........................................................56
AEROSPAN...........................................................56
afeditab cr................................................................32
AFINITOR.............................................................15
AFINITOR DISPERZ............................................15
AGGRENOX.........................................................32
ak-poly-bac...............................................................55
ala-cort topical cream................................................38
ALA-SCALP...........................................................38
ALBENZA................................................................8
albuterol sulfate inhalation solution for nebulization
0.63 mg/3 ml........................................................56
1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %)..................56
2.5 mg/0.5 ml, 5 mg/ml.........................................56
albuterol sulfate oral syrup.........................................56
albuterol sulfate oral tablet........................................57
albuterol sulfate oral tablet extended release 12 hr.......57
ALCAINE...............................................................55
alclometasone............................................................38
alcohol pads..............................................................43
ALDACTAZIDE....................................................32
ALDACTONE.......................................................32
ALDURAZYME.....................................................43
alendronate oral tablet 10 mg....................................52
alendronate oral tablet 35 mg, 70 mg........................52
alendronate oral tablet 40 mg....................................41
alendronate oral tablet 5 mg......................................52
alfuzosin..................................................................59
ALIMTA.................................................................15
ALINIA ORAL SUSPENSION FOR
RECONSTITUTION...........................................8
ALINIA ORAL TABLET.........................................8
ALKERAN INTRAVENOUS................................15
ALKERAN ORAL..................................................15
allopurinol...............................................................52
ALOCRIL...............................................................55
ALOMIDE.............................................................55
aloprim....................................................................52
alosetron...................................................................47
ALOXI....................................................................47
ALPHAGAN P OPHTHALMIC DROPS 0.1
%.........................................................................55
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AMMONIUM CHLORIDE..................................59
ammonium lactate topical.........................................38
amnesteem oral capsule 10 mg...................................38
amnesteem oral capsule 20 mg, 40 mg........................38
amoxapine...............................................................19
amoxicillin oral capsule...............................................8
amoxicillin oral suspension for reconstitution 125 mg/
5 ml........................................................................8
amoxicillin oral suspension for reconstitution 200 mg/
5 ml, 250 mg/5 ml, 400 mg/5 ml.............................8
amoxicillin oral tablet.................................................8
amoxicillin oral tablet,chewable 125 mg, 250 mg.........8
amoxicillin-pot clavulanate oral suspension for
reconstitution..........................................................8
amoxicillin-pot clavulanate oral tablet 250-125
mg..........................................................................8
amoxicillin-pot clavulanate oral tablet 500-125 mg,
875-125 mg............................................................8
amoxicillin-pot clavulanate oral tablet extended release
12 hr......................................................................8
amoxicillin-pot clavulanate oral tablet,chewable 20028.5 mg..................................................................8
amoxicillin-pot clavulanate oral tablet,chewable 40057 mg.....................................................................8
amphetamine salt combo oral tablet 10 mg, 12.5 mg,
15 mg, 20 mg, 5 mg, 7.5 mg..................................20
amphetamine salt combo oral tablet 30 mg.................20
amphotericin b...........................................................9
ampicillin oral capsule................................................9
ampicillin oral suspension for reconstitution 125 mg/
5 ml........................................................................9
ampicillin oral suspension for reconstitution 250 mg/
5 ml........................................................................9
ampicillin sodium injection.........................................9
ampicillin sodium intravenous.....................................9
ampicillin-sulbactam injection recon soln 1.5 gram, 3
gram.......................................................................9
ampicillin-sulbactam injection recon soln 15 gram........9
ampicillin-sulbactam intravenous recon soln 1.5
gram.......................................................................9
ampicillin-sulbactam intravenous recon soln 3
gram.......................................................................9
AMPYRA................................................................20
anagrelide................................................................41
anastrozole...............................................................15
ANDRODERM.....................................................43
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ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 1.25 GRAM/
ACTUATION (1 %)...........................................43
METERED-DOSE PUMP 20.25 MG/1.25
GRAM (1.62 %)..................................................43
PACKET 1 % (25 MG/2.5GRAM), 1 % (50
MG/5 GRAM).....................................................43
PACKET 1.62 % (20.25 MG/1.25 GRAM)........43
PACKET 1.62 % (40.5 MG/2.5 GRAM)............43
androxy....................................................................43
ANORO ELLIPTA................................................57
ANTIVERT ORAL TABLET 12.5 MG, 25
MG......................................................................47
ANUSOL-HC RECTAL CREAM.........................47
apexicon e................................................................38
APOKYN................................................................20
apraclonidine...........................................................55
apri.........................................................................53
APRISO..................................................................47
APTIOM................................................................20
APTIVUS ORAL CAPSULE....................................9
APTIVUS ORAL SOLUTION................................9
ARALAST NP........................................................41
aranelle (28)............................................................53
ARANESP (IN POLYSORBATE) INJECTION
SOLUTION 100 MCG/ML, 150 MCG/0.75
ML, 200 MCG/ML, 300 MCG/ML...................49
SOLUTION 25 MCG/ML, 40 MCG/ML, 60
MCG/ML............................................................50
SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML,
40 MCG/0.4 ML, 60 MCG/0.3 ML...................50
SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3
ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500
MCG/ML............................................................50
ARCALYST............................................................50
aripiprazole oral solution...........................................20
aripiprazole oral tablet 10 mg...................................20
aripiprazole oral tablet 15 mg, 20 mg........................20
aripiprazole oral tablet 2 mg.....................................20
aripiprazole oral tablet 30 mg...................................20
aripiprazole oral tablet 5 mg.....................................20
64
ARNUITY ELLIPTA..............................................57
ARRANON............................................................15
ARTHROTEC 50..................................................20
ARTHROTEC 75..................................................20
ARZERRA..............................................................15
ASACOL HD.........................................................47
ASMANEX HFA....................................................57
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED
110 MCG (30 DOSES).......................................57
110 MCG (7 DOSES), 220 MCG (14
DOSES)...............................................................57
220 MCG (120 DOSES), 220 MCG (30
DOSES), 220 MCG (60 DOSES).......................57
aspirin-dipyridamole.................................................33
ASTAGRAF XL......................................................15
ATACAND HCT ORAL TABLET 16-12.5
MG......................................................................33
ATACAND HCT ORAL TABLET 32-12.5 MG,
32-25 MG............................................................33
ATACAND ORAL TABLET 16 MG, 4 MG, 8
MG......................................................................33
ATACAND ORAL TABLET 32 MG.....................33
atenolol....................................................................33
atenolol-chlorthalidone..............................................33
atorvastatin..............................................................33
atovaquone.................................................................9
atovaquone-proguanil.................................................9
ATRIPLA..................................................................9
atropine injection syringe 0.05 mg/ml, 0.1 mg/ml.......47
atropine ophthalmic drops.........................................55
ATROVENT..........................................................42
ATROVENT HFA.................................................57
AVASTIN INTRAVENOUS SOLUTION 25 MG/
ML.......................................................................15
AVASTIN INTRAVENOUS SOLUTION 25 MG/
ML (16 ML)........................................................15
AVELOX..................................................................9
AVELOX ABC PACK..............................................9
AVELOX IN NACL (ISO-OSMOTIC)...................9
aviane......................................................................53
AVODART............................................................59
AVONEX (WITH ALBUMIN).............................50
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AVONEX INTRAMUSCULAR PEN INJECTOR
KIT......................................................................50
AVONEX INTRAMUSCULAR SYRINGE...........50
AVONEX INTRAMUSCULAR SYRINGE
KIT......................................................................50
AYGESTIN............................................................53
azacitidine...............................................................15
AZACTAM IN DEXTROSE (ISO-OSM)...............9
AZASAN................................................................15
AZASITE................................................................55
azathioprine.............................................................15
azelastine nasal aerosol,spray.....................................42
azelastine nasal spray,non-aerosol...............................42
azelastine ophthalmic................................................55
AZILECT...............................................................20
azithromycin intravenous............................................9
azithromycin oral packet.............................................9
azithromycin oral suspension for reconstitution.............9
azithromycin oral tablet 250 mg (6 pack)....................9
azithromycin oral tablet 250 mg, 500 mg, 600 mg.......9
AZOPT..................................................................55
AZOR.....................................................................33
aztreonam..................................................................9
AZULFIDINE........................................................47
AZULFIDINE EN-TABS.......................................47
azurette (28)............................................................53
baciim.......................................................................9
bacitracin intramuscular.............................................9
bacitracin ophthalmic...............................................55
bacitracin-polymyxin b ophthalmic............................55
baclofen oral tablet 10 mg.........................................20
baclofen oral tablet 20 mg.........................................20
BACTRIM................................................................9
BACTRIM DS..........................................................9
BACTROBAN.......................................................38
BACTROBAN NASAL..........................................42
balsalazide...............................................................47
balziva (28).............................................................53
BANZEL ORAL SUSPENSION............................20
BANZEL ORAL TABLET 200 MG.......................20
BANZEL ORAL TABLET 400 MG.......................20
BARACLUDE..........................................................9
BCG VACCINE, LIVE (PF)..................................50
BECONASE AQ....................................................57
BELEODAQ..........................................................15
benazepril................................................................33
benazepril-hydrochlorothiazide..................................33
BENICAR HCT.....................................................33
65
BENICAR ORAL TABLET 20 MG, 40 MG.........33
BENICAR ORAL TABLET 5 MG.........................33
BENLYSTA............................................................52
benztropine injection................................................20
benztropine oral.......................................................20
BESIVANCE..........................................................55
BETAGAN OPHTHALMIC DROPS 0.5 %.........55
betamethasone dipropionate.......................................38
betamethasone valerate topical cream.........................38
betamethasone valerate topical foam...........................38
betamethasone valerate topical lotion.........................38
betamethasone valerate topical ointment.....................38
betamethasone, augmented topical cream....................38
betamethasone, augmented topical gel........................38
betamethasone, augmented topical lotion....................38
betamethasone, augmented topical ointment...............38
BETASERON SUBCUTANEOUS KIT................50
betaxolol ophthalmic.................................................55
betaxolol oral............................................................33
bethanechol chloride..................................................59
BETIMOL..............................................................55
BETOPTIC S.........................................................55
bexarotene................................................................15
BEXSERO (PF)......................................................50
bicalutamide............................................................15
BICILLIN C-R.........................................................9
BICILLIN L-A..........................................................9
BICNU...................................................................15
BIDIL.....................................................................33
BILTRICIDE...........................................................9
bimatoprost..............................................................55
bisoprolol fumarate...................................................33
bisoprolol-hydrochlorothiazide...................................33
BIVIGAM...............................................................50
bleomycin.................................................................15
BLEPH-10..............................................................55
BLEPHAMIDE......................................................55
BLEPHAMIDE S.O.P............................................55
BLINCYTO...........................................................15
BONIVA INTRAVENOUS...................................52
BOOSTRIX TDAP................................................50
BOSULIF...............................................................15
BREO ELLIPTA.....................................................57
briellyn....................................................................53
BRILINTA ORAL TABLET 90 MG.....................33
brimonidine.............................................................55
BRINTELLIX ORAL TABLET 10 MG.................20
BRINTELLIX ORAL TABLET 20 MG.................20
Premier_15283_v14_1511_1
BRINTELLIX ORAL TABLET 5 MG...................20
bromocriptine...........................................................20
BROVANA.............................................................57
budesonide oral.........................................................47
bumetanide injection................................................33
bumetanide oral tablet 0.5 mg, 1 mg.........................33
bumetanide oral tablet 2 mg......................................33
BUPHENYL ORAL TABLET...............................41
BUPRENEX...........................................................20
buprenorphine hcl injection solution..........................20
buprenorphine hcl injection syringe............................20
buprenorphine hcl sublingual tablet 2 mg...................20
buprenorphine hcl sublingual tablet 8 mg...................20
buprenorphine-naloxone sublingual tablet 2-0.5
mg........................................................................20
buprenorphine-naloxone sublingual tablet 8-2 mg......20
buproban.................................................................41
bupropion hcl oral tablet 100 mg...............................20
bupropion hcl oral tablet 75 mg.................................20
bupropion hcl oral tablet extended release 100 mg.......20
bupropion hcl oral tablet extended release 150 mg, 200
mg........................................................................20
bupropion hcl oral tablet extended release 24 hr 150
mg........................................................................20
bupropion hcl oral tablet extended release 24 hr 300
mg........................................................................20
buspirone.................................................................20
BUSULFEX............................................................15
butalbital-acetaminop-caf-cod oral capsule 50-30040-30 mg..............................................................20
butorphanol tartrate injection....................................20
butorphanol tartrate nasal.........................................20
BYDUREON.........................................................43
BYETTA SUBCUTANEOUS PEN INJECTOR
10 MCG/DOSE(250 MCG/ML) 2.4 ML...........43
BYETTA SUBCUTANEOUS PEN INJECTOR
5 MCG/DOSE (250 MCG/ML) 1.2 ML............43
BYSTOLIC.............................................................33
cabergoline...............................................................43
CALAN..................................................................33
CALAN SR.............................................................33
calcipotriene topical cream.........................................38
calcipotriene topical ointment....................................38
calcipotriene topical solution......................................38
calcipotriene-betamethasone.......................................38
calcitonin (salmon)...................................................43
calcitriol intravenous solution 1 mcg/ml.....................43
calcitriol oral capsule.................................................43
66
calcitriol oral solution...............................................43
calcium acetate oral capsule.......................................59
camila......................................................................53
CANASA................................................................47
CANCIDAS.............................................................9
candesartan oral tablet 16 mg, 4 mg, 8 mg.................33
candesartan oral tablet 32 mg....................................33
candesartan-hydrochlorothiazid oral tablet 16-12.5
mg........................................................................33
candesartan-hydrochlorothiazid oral tablet 32-12.5
mg, 32-25 mg.......................................................33
CANTIL.................................................................47
CAPASTAT..............................................................9
CAPEX...................................................................38
CAPITAL WITH CODEINE................................20
CAPRELSA............................................................16
captopril...................................................................33
captopril-hydrochlorothiazide....................................33
carafate....................................................................47
CARBAGLU...........................................................41
carbamazepine oral capsule, er multiphase 12 hr........20
carbamazepine oral suspension 100 mg/5 ml..............20
carbamazepine oral tablet.........................................20
carbamazepine oral tablet extended release 12 hr........20
carbamazepine oral tablet,chewable...........................20
CARBATROL........................................................20
carbidopa.................................................................20
carbidopa-levodopa...................................................20
carbidopa-levodopa-entacapone.................................20
carboplatin intravenous solution................................16
CARDIZEM LA ORAL TABLET EXTENDED
RELEASE 24 HR 120 MG..................................33
CARDURA XL.......................................................33
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN 12 GRAM,
6 GRAM..............................................................50
carteolol...................................................................55
cartia xt...................................................................33
carvedilol.................................................................33
CASODEX.............................................................16
CAYSTON...............................................................9
caziant (28).............................................................53
CEDAX ORAL CAPSULE.......................................9
cefaclor oral capsule 250 mg........................................9
cefaclor oral capsule 500 mg........................................9
cefaclor oral suspension for reconstitution 125 mg/5
ml, 250 mg/5 ml, 375 mg/5 ml................................9
cefaclor oral tablet extended release 12 hr.....................9
Premier_15283_v14_1511_1
cefadroxil oral capsule.................................................9
cefadroxil oral suspension for reconstitution 250 mg/5
ml, 500 mg/5 ml.....................................................9
cefadroxil oral tablet...................................................9
cefazolin in dextrose (iso-os) intravenous piggyback 1
gram/50 ml, 2 gram/50 ml.......................................9
cefazolin injection recon soln 1 gram, 500 mg..............9
cefazolin injection recon soln 10 gram, 100 gram, 20
gram, 300 g............................................................9
cefazolin intravenous..................................................9
cefdinir......................................................................9
cefepime.....................................................................9
cefepime in dextrose,iso-osm intravenous piggyback 1
gram/50 ml.............................................................9
cefepime in dextrose,iso-osm intravenous piggyback 2
gram/100 ml...........................................................9
cefixime......................................................................9
cefotaxime injection recon soln 1 gram, 2 gram, 500
mg..........................................................................9
cefotetan.....................................................................9
cefoxitin in dextrose, iso-osm........................................9
cefoxitin intravenous recon soln 1 gram........................9
cefoxitin intravenous recon soln 10 gram, 2 gram.........9
cefpodoxime................................................................9
cefprozil oral suspension for reconstitution 125 mg/5
ml.........................................................................10
cefprozil oral suspension for reconstitution 250 mg/5
ml.........................................................................10
cefprozil oral tablet 250 mg.......................................10
cefprozil oral tablet 500 mg.......................................10
CEFTAZIDIME IN D5W.....................................10
ceftazidime injection recon soln 1 gram, 2 gram.........10
ceftazidime injection recon soln 6 gram......................10
ceftibuten.................................................................10
CEFTIN ORAL SUSPENSION FOR
RECONSTITUTION.........................................10
ceftriaxone in dextrose,iso-os......................................10
ceftriaxone injection recon soln 1 gram, 2 gram, 250
mg, 500 mg...........................................................10
ceftriaxone injection recon soln 10 gram.....................10
ceftriaxone intravenous recon soln..............................10
cefuroxime axetil oral tablet.......................................10
cefuroxime sodium injection recon soln 1.5 gram, 750
mg........................................................................10
cefuroxime sodium intravenous..................................10
CELEBREX............................................................20
celecoxib...................................................................20
CELLCEPT............................................................16
67
CELLCEPT INTRAVENOUS...............................16
CELONTIN ORAL CAPSULE 300 MG...............21
cephalexin oral capsule 250 mg, 500 mg....................10
cephalexin oral capsule 750 mg..................................10
cephalexin oral suspension for reconstitution...............10
cephalexin oral tablet................................................10
CEREZYME INTRAVENOUS RECON SOLN
400 UNIT...........................................................43
CERVARIX VACCINE (PF)..................................50
CESAMET.............................................................47
cetirizine oral solution 1 mg/ml.................................57
cevimeline................................................................41
CHANTIX.............................................................41
CHANTIX CONTINUING MONTH BOX........41
CHANTIX STARTING MONTH BOX...............41
CHEMET...............................................................41
chloramphenicol sod succinate....................................10
chlorhexidine gluconate mucous membrane.................42
chloroquine phosphate oral........................................10
chlorothiazide...........................................................33
chlorothiazide sodium...............................................33
chlorpromazine injection...........................................21
chlorpromazine oral tablet 10 mg, 25 mg, 50 mg.......21
chlorpromazine oral tablet 100 mg, 200 mg...............21
chlorthalidone oral tablet 25 mg................................33
chlorthalidone oral tablet 50 mg................................33
cholestyramine (with sugar).......................................33
cholestyramine light..................................................33
CIALIS ORAL TABLET 2.5 MG, 5 MG...............59
ciclodan topical cream...............................................38
ciclodan topical solution............................................38
ciclopirox topical cream.............................................38
ciclopirox topical gel..................................................38
ciclopirox topical shampoo.........................................38
ciclopirox topical solution..........................................38
ciclopirox topical suspension.......................................38
cidofovir...................................................................10
cilostazol..................................................................33
CILOXAN..............................................................55
CIMZIA.................................................................47
CIMZIA POWDER FOR RECONST...................47
CIMZIA STARTER KIT.......................................47
CINRYZE..............................................................57
CIPRO HC............................................................42
CIPRO IN D5W INTRAVENOUS PIGGYBACK
400 MG/200 ML.................................................10
CIPRO ORAL SUSPENSION,MICROCAPSULE
RECON..............................................................10
Premier_15283_v14_1511_1
CIPRO ORAL TABLET 250 MG, 500 MG..........10
CIPRODEX...........................................................42
ciprofloxacin (mixture) oral tablet, er multiphase 24
hr 1,000 mg..........................................................10
ciprofloxacin (mixture) oral tablet, er multiphase 24
hr 500 mg.............................................................10
ciprofloxacin hcl ophthalmic......................................55
ciprofloxacin hcl oral tablet.......................................10
ciprofloxacin in 5 % dextrose.....................................10
ciprofloxacin lactate intravenous solution 200 mg/20
ml.........................................................................10
ciprofloxacin lactate intravenous solution 400 mg/40
ml.........................................................................10
ciprofloxacin oral suspension,microcapsule recon.........10
cisplatin...................................................................16
citalopram oral solution............................................21
citalopram oral tablet 10 mg.....................................21
cladribine.................................................................16
CLAFORAN INJECTION RECON SOLN 1
GRAM, 10 GRAM, 2 GRAM.............................10
CLAFORAN INJECTION RECON SOLN 500
MG......................................................................10
CLAFORAN INTRAVENOUS RECON
SOLN..................................................................10
claravis....................................................................38
clarithromycin oral suspension for reconstitution.........10
clarithromycin oral tablet..........................................10
clarithromycin oral tablet extended release 24 hr.........10
clemastine oral tablet 2.68 mg...................................57
CLEOCIN ORAL..................................................10
CLEOCIN T..........................................................38
CLEOCIN VAGINAL...........................................53
CLINDAGEL.........................................................38
clindamycin hcl........................................................10
clindamycin in 5 % dextrose.....................................10
clindamycin phosphate injection................................10
clindamycin phosphate intravenous solution 300 mg/
2 ml, 900 mg/6 ml................................................10
clindamycin phosphate intravenous solution 600 mg/
4 ml......................................................................10
clindamycin phosphate topical foam...........................38
clindamycin phosphate topical gel...............................38
clindamycin phosphate topical lotion..........................39
clindamycin phosphate topical solution.......................39
clindamycin phosphate topical swab...........................39
clindamycin phosphate vaginal..................................53
68
clindamycin-benzoyl peroxide....................................39
CLINIMIX 2.75%/D5W SULFIT FREE...............59
CLINIMIX 4.25%-D20W SULF-FREE................59
CLINIMIX 4.25%-D25W SULF-FREE................59
CLINIMIX 4.25%/D10W SULF FREE.................59
CLINIMIX 4.25%/D5W SULFIT FREE...............41
CLINIMIX 5%-D20W(SULFITE-FREE)..............59
CLINIMIX 5%/D15W SULFITE FREE...............59
CLINIMIX 5%/D25W SULFITE-FREE...............59
CLINIMIX E 2.75%/D10W SUL FREE................41
CLINIMIX E 2.75%/D5W SULF FREE...............41
CLINIMIX E 4.25%/D5W SULF FREE...............59
CLINIMIX E 5%/D15W SULFIT FREE..............59
CLINISOL SF 15 %...............................................59
clobetasol topical cream.............................................39
clobetasol topical foam...............................................39
clobetasol topical gel..................................................39
clobetasol topical lotion.............................................39
clobetasol topical ointment.........................................39
clobetasol topical shampoo.........................................39
clobetasol topical solution..........................................39
clobetasol topical spray,non-aerosol.............................39
clobetasol-emollient...................................................39
CLOBEX................................................................39
CLOCORTOLONE PIVALATE...........................39
CLODERM............................................................39
CLOLAR................................................................16
clomipramine...........................................................21
clonazepam oral tablet 0.5 mg...................................21
clonazepam oral tablet 1 mg......................................21
clonazepam oral tablet 2 mg......................................21
clonazepam oral tablet,disintegrating 0.125 mg..........21
clonazepam oral tablet,disintegrating 0.25 mg............21
clonazepam oral tablet,disintegrating 0.5 mg..............21
clonazepam oral tablet,disintegrating 1 mg.................21
clonazepam oral tablet,disintegrating 2 mg.................21
clonidine hcl oral tablet.............................................33
clonidine transdermal patch weekly 0.1 mg/24 hr.......33
clonidine transdermal patch weekly 0.2 mg/24 hr, 0.3
mg/24 hr...............................................................33
clopidogrel oral tablet 300 mg...................................33
clopidogrel oral tablet 75 mg.....................................33
clorazepate dipotassium.............................................21
clorpres.....................................................................33
Premier_15283_v14_1511_1
clotrimazole mucous membrane.................................10
clotrimazole topical...................................................39
clotrimazole-betamethasone topical cream..................39
clotrimazole-betamethasone topical lotion...................39
clozapine oral tablet 100 mg.....................................21
clozapine oral tablet 200 mg.....................................21
clozapine oral tablet 25 mg.......................................21
clozapine oral tablet 50 mg.......................................21
clozapine oral tablet,disintegrating 100 mg................21
clozapine oral tablet,disintegrating 12.5 mg...............21
clozapine oral tablet,disintegrating 25 mg..................21
COARTEM............................................................10
codeine sulfate oral tablet 15 mg, 30 mg....................21
codeine sulfate oral tablet 60 mg................................21
COGENTIN..........................................................21
colchicine-probenecid................................................52
COLCRYS..............................................................52
colestipol..................................................................34
colistin (colistimethate na).........................................10
colocort....................................................................47
COLY-MYCIN M PARENTERAL........................10
COLY-MYCIN S....................................................42
COMBIGAN..........................................................55
COMBIVENT RESPIMAT...................................57
COMETRIQ..........................................................16
COMPLERA..........................................................10
compro.....................................................................47
COMVAX (PF)......................................................50
CONDYLOX TOPICAL GEL...............................39
constulose.................................................................47
COPAXONE SUBCUTANEOUS SYRINGE 20
MG/ML...............................................................21
COPAXONE SUBCUTANEOUS SYRINGE 40
MG/ML...............................................................21
CORDRAN TAPE LARGE ROLL........................39
CORDRAN TAPE SMALL ROLL........................39
COREG CR...........................................................34
cormax topical solution.............................................39
CORTEF................................................................43
CORTIFOAM.......................................................47
cortisone...................................................................43
CORTISPORIN TOPICAL...................................39
CORTISPORIN-TC..............................................42
COSMEGEN.........................................................16
COUMADIN ORAL.............................................34
69
CREON ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000 -60,000
UNIT, 24,000-76,000 -120,000 UNIT, 6,00019,000 -30,000 UNIT.........................................47
CREON ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 3,000-9,500- 15,000 UNIT,
36,000-114,000- 180,000 UNIT.........................48
CRESTOR.............................................................34
CRINONE.............................................................53
CRIXIVAN ORAL CAPSULE 200 MG, 400
MG......................................................................11
cromolyn inhalation..................................................57
cromolyn ophthalmic.................................................55
cromolyn oral...........................................................48
cryselle (28)..............................................................53
CUBICIN...............................................................11
cyclafem 1/35 (28)....................................................53
cyclafem 7/7/7 (28)...................................................53
cyclobenzaprine oral tablet........................................21
cyclophosphamide oral capsule....................................16
CYCLOSET...........................................................43
cyclosporine intravenous............................................16
cyclosporine modified................................................16
cyclosporine oral capsule 100 mg................................16
cyclosporine oral capsule 25 mg..................................16
CYMBALTA ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 20 MG.................................21
RELEASE(DR/EC) 30 MG.................................21
RELEASE(DR/EC) 60 MG.................................21
CYRAMZA INTRAVENOUS SOLUTION 10
MG/ML...............................................................16
CYRAMZA INTRAVENOUS SOLUTION 10
MG/ML (50 ML)................................................16
CYSTADANE........................................................48
CYSTAGON..........................................................59
cytarabine................................................................16
cytarabine (pf) injection solution 100 mg/5 ml (20
mg/ml), 2 gram/20 ml (100 mg/ml).......................16
cytarabine (pf) injection solution 20 mg/ml................16
CYTOMEL............................................................43
CYTOTEC.............................................................48
cytra k crystals..........................................................59
cytra-k.....................................................................59
d10 % & 0.45 % sodium chloride............................41
d2.5 %-0.45 % sodium chloride...............................41
d5 % and 0.9 % sodium chloride..............................41
Premier_15283_v14_1511_1
d5 %-0.45 % sodium chloride..................................41
dacarbazine..............................................................16
DACOGEN...........................................................16
DAKLINZA...........................................................11
DALIRESP.............................................................57
danazol oral capsule 100 mg, 50 mg..........................43
danazol oral capsule 200 mg.....................................43
dantrolene................................................................21
DAPSONE.............................................................11
DAPTACEL (DTAP PEDIATRIC) (PF)...............50
DARAPRIM...........................................................11
dasetta 1/35 (28)......................................................53
dasetta 7/7/7 (28).....................................................53
daunorubicin intravenous solution.............................16
DAUNOXOME.....................................................16
DDAVP INJECTION............................................43
decitabine................................................................16
DELZICOL............................................................48
DEMADEX ORAL TABLET 10 MG, 20 MG, 5
MG......................................................................34
demeclocycline oral....................................................11
DEMSER................................................................34
DENAVIR..............................................................39
denta 5000 plus.......................................................42
dentagel...................................................................42
DEPACON............................................................21
DEPAKENE...........................................................21
DEPEN TITRATABS............................................52
DERMATOP.........................................................39
desipramine oral tablet 10 mg, 100 mg, 25 mg, 50
mg, 75 mg.............................................................21
desipramine oral tablet 150 mg.................................21
desmopressin injection...............................................43
desmopressin nasal....................................................43
desmopressin oral......................................................43
desonide topical cream...............................................39
desonide topical lotion...............................................39
desonide topical ointment..........................................39
desoximetasone topical cream 0.05 %........................39
desoximetasone topical cream 0.25 %........................39
desoximetasone topical gel..........................................39
desoximetasone topical ointment 0.05 %....................39
desoximetasone topical ointment 0.25 %....................39
DESVENLAFAXINE FUMARATE ORAL
TABLET EXTENDED RELEASE 24HR 100
MG......................................................................21
70
DESVENLAFAXINE FUMARATE ORAL
TABLET EXTENDED RELEASE 24HR 50
MG......................................................................21
DESVENLAFAXINE ORAL TABLET
EXTENDED RELEASE 24 HR 100 MG...........21
EXTENDED RELEASE 24 HR 50 MG.............22
EXTENDED RELEASE 24HR 100 MG............22
EXTENDED RELEASE 24HR 50 MG..............22
dexamethasone intensol.............................................43
dexamethasone oral elixir..........................................43
dexamethasone oral solution......................................43
dexamethasone oral tablet 0.5 mg, 1.5 mg..................43
dexamethasone oral tablet 0.75 mg, 1 mg, 2 mg, 4
mg, 6 mg...............................................................43
dexamethasone sodium phos (pf)................................43
dexamethasone sodium phosphate injection.................43
dexamethasone sodium phosphate ophthalmic.............55
DEXILANT............................................................48
DEXPAK 10 DAY..................................................43
DEXPAK 13 DAY..................................................43
DEXPAK 6 DAY....................................................44
dexrazoxane hcl intravenous recon soln 250 mg..........16
dexrazoxane hcl intravenous recon soln 500 mg..........16
dextroamphetamine oral tablet 10 mg........................22
dextroamphetamine oral tablet 5 mg..........................22
dextrose 10 % and 0.2 % nacl..................................41
dextrose 10 % in water (d10w) intravenous parenteral
solution.................................................................41
dextrose 25 % in water (d25w).................................41
dextrose 5 % in water (d5w).....................................41
dextrose 5 %-lactated ringers.....................................41
dextrose 5%-0.2 % sod chloride.................................41
dextrose 5%-0.3 % sod.chloride.................................41
dextrose 50 % in water (d50w) intravenous parenteral
solution.................................................................41
dextrose 50 % in water (d50w) intravenous
syringe...................................................................41
dextrose with sodium chloride....................................41
dextrose-kcl-nacl.......................................................60
diazepam intensol.....................................................22
diazepam oral concentrate.........................................22
diazepam oral solution 5 mg/5 ml..............................22
Premier_15283_v14_1511_1
diazepam oral tablet 10 mg.......................................22
diazepam oral tablet 2 mg.........................................22
diazepam oral tablet 5 mg.........................................22
diazepam rectal........................................................22
DIBENZYLINE.....................................................34
diclofenac potassium..................................................22
diclofenac sodium ophthalmic....................................55
diclofenac sodium oral...............................................22
diclofenac sodium topical gel......................................39
diclofenac-misoprostol...............................................22
dicloxacillin..............................................................11
dicyclomine oral capsule............................................48
dicyclomine oral solution...........................................48
dicyclomine oral tablet..............................................48
didanosine................................................................11
diflorasone................................................................39
DIFLUCAN...........................................................11
diflunisal..................................................................22
digitek oral tablet 125 mcg........................................34
DIGITEK ORAL TABLET 250 MCG..................34
digox oral tablet 125 mcg..........................................34
digox oral tablet 250 mcg..........................................34
digoxin oral solution 50 mcg/ml.................................34
digoxin oral tablet 125 mcg.......................................34
digoxin oral tablet 250 mcg.......................................34
dihydrocodeine-aspirin-caff........................................22
dihydroergotamine injection......................................22
dihydroergotamine nasal...........................................22
DILANTIN 30 MG CAPSULE.............................22
DILANTIN EXTENDED.....................................22
DILANTIN INFATABS........................................22
DILANTIN-125.....................................................22
DILATRATE-SR....................................................34
dilt-xr......................................................................34
diltiazem hcl intravenous..........................................34
diltiazem hcl oral capsule, extended release.................34
diltiazem hcl oral capsule,ext release degradable..........34
diltiazem hcl oral capsule,extended release 12 hr.........34
diltiazem hcl oral capsule,extended release 24hr..........34
diltiazem hcl oral tablet 120 mg................................34
diltiazem hcl oral tablet 30 mg, 60 mg, 90 mg...........34
DIOVAN HCT......................................................34
DIOVAN ORAL TABLET 160 MG......................34
DIOVAN ORAL TABLET 320 MG......................34
DIOVAN ORAL TABLET 40 MG, 80 MG..........34
DIPENTUM..........................................................48
diphenhydramine hcl injection solution 50 mg/ml.......57
diphenhydramine hcl injection syringe........................57
71
diphenoxylate-atropine oral tablet..............................48
diskets......................................................................22
disulfiram................................................................41
DIURIL..................................................................34
DIURIL IV.............................................................34
divalproex................................................................22
DOCEFREZ INTRAVENOUS RECON SOLN
20 MG.................................................................16
docetaxel intravenous solution 10 mg/ml, 140 mg/7
ml (20 mg/ml), 160 mg/16 ml (10 mg/ml), 20 mg/
2 ml (10 mg/ml)....................................................16
docetaxel intravenous solution 20 mg/ml (1 ml), 80
mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml).........16
DOLOPHINE ORAL TABLET 10 MG................22
DOLOPHINE ORAL TABLET 5 MG..................22
donepezil oral tablet 10 mg, 5 mg..............................22
donepezil oral tablet 23 mg.......................................22
donepezil oral tablet,disintegrating.............................22
DORIBAX..............................................................11
dorzolamide.............................................................55
dorzolamide-timolol..................................................55
doxazosin oral tablet 1 mg, 2 mg, 8 mg......................34
doxazosin oral tablet 4 mg.........................................34
doxepin oral.............................................................22
doxercalciferol intravenous........................................44
DOXIL...................................................................16
doxorubicin intravenous recon soln............................16
doxorubicin intravenous solution...............................16
DOXY-100.............................................................11
doxycycline hyclate intravenous..................................11
doxycycline hyclate oral capsule..................................11
doxycycline hyclate oral tablet 100 mg, 20 mg............11
doxycycline hyclate oral tablet 50 mg..........................11
doxycycline monohydrate oral capsule 75 mg...............11
doxycycline monohydrate oral suspension for
reconstitution........................................................11
doxycycline monohydrate oral tablet 100 mg, 50 mg,
75 mg...................................................................11
doxycycline monohydrate oral tablet 150 mg...............11
dronabinol oral capsule 10 mg...................................48
dronabinol oral capsule 2.5 mg, 5 mg........................48
drospirenone-ethinyl estradiol oral tablet 3-0.02
mg........................................................................53
drospirenone-ethinyl estradiol oral tablet 3-0.03
mg........................................................................53
DROXIA................................................................16
DULERA................................................................57
Premier_15283_v14_1511_1
duloxetine oral capsule,delayed release(dr/ec) 20
mg........................................................................22
mg........................................................................22
mg........................................................................22
mg........................................................................22
duramorph (pf) injection solution 0.5 mg/ml..............22
duramorph (pf) injection solution 1 mg/ml.................22
DUREZOL.............................................................55
DYAZIDE..............................................................34
DYRENIUM..........................................................34
E.E.S. GRANULES................................................11
EC-NAPROSYN....................................................22
econazole topical.......................................................39
EDECRIN..............................................................34
EDURANT............................................................11
EFFIENT...............................................................34
ELAPRASE.............................................................44
ELESTAT...............................................................55
ELIDEL..................................................................39
elinest......................................................................53
ELIQUIS ORAL TABLET 2.5 MG.......................34
ELIQUIS ORAL TABLET 5 MG..........................34
ELITEK..................................................................16
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15
ML.......................................................................57
ELLA......................................................................53
ELLENCE..............................................................16
ELMIRON.............................................................59
ELOCON...............................................................39
EMADINE.............................................................55
EMCYT..................................................................16
EMEND ORAL CAPSULE 125 MG.....................48
EMEND ORAL CAPSULE 40 MG.......................48
EMEND ORAL CAPSULE 80 MG.......................48
EMEND ORAL CAPSULE,DOSE PACK.............48
emoquette.................................................................53
EMSAM.................................................................22
EMTRIVA..............................................................11
enalapril maleate......................................................34
enalapril-hydrochlorothiazide....................................34
ENBREL SUBCUTANEOUS RECON
SOLN..................................................................52
ENBREL SUBCUTANEOUS SYRINGE 25 MG/
0.5ML (0.51).......................................................52
72
ENBREL SUBCUTANEOUS SYRINGE 50 MG/
ML (0.98 ML).....................................................52
ENBREL SURECLICK..........................................52
endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325
mg........................................................................22
endodan...................................................................22
ENGERIX-B (PF)...................................................50
ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SUSPENSION.................50
ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SYRINGE.........................50
enoxaparin subcutaneous solution..............................34
enoxaparin subcutaneous syringe 100 mg/ml...............34
enoxaparin subcutaneous syringe 120 mg/0.8 ml.........34
enoxaparin subcutaneous syringe 150 mg/ml...............34
enoxaparin subcutaneous syringe 30 mg/0.3 ml...........34
enoxaparin subcutaneous syringe 40 mg/0.4 ml..........34
enpresse....................................................................53
entacapone...............................................................22
entecavir..................................................................11
enulose.....................................................................48
epinastine.................................................................55
epinephrine injection auto-injector.............................57
epinephrine injection solution 1 mg/ml (1:1,000).......57
epinephrine injection syringe 0.1 mg/ml (1:10,
000).....................................................................57
EPIPEN 2-PAK......................................................57
EPIPEN JR 2-PAK.................................................57
epirubicin intravenous solution 200 mg/100 ml.........16
epirubicin intravenous solution 50 mg/25 ml.............16
epitol.......................................................................22
EPIVIR HBV ORAL SOLUTION.........................11
EPIVIR ORAL SOLUTION..................................11
eplerenone................................................................34
EPOGEN INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2
ML, 3,000 UNIT/ML, 4,000 UNIT/ML............50
EPOGEN INJECTION SOLUTION 20,000
UNIT/ML...........................................................50
eprosartan................................................................34
EPZICOM.............................................................11
EQUETRO ORAL CAPSULE, ER MULTIPHASE
12 HR 100 MG...................................................22
12 HR 200 MG...................................................22
Premier_15283_v14_1511_1
12 HR 300 MG...................................................22
ERBITUX...............................................................16
ergoloid....................................................................22
ERGOMAR............................................................22
ERIVEDGE............................................................16
errin........................................................................53
ERWINAZE...........................................................16
ery pads....................................................................39
ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333
mg........................................................................11
ERY-TAB ORAL TABLET,DELAYED RELEASE
(DR/EC) 500 MG...............................................11
ERYPED 200..........................................................11
ERYPED 400..........................................................11
erythrocin (as stearate) oral tablet 250 mg..................11
ERYTHROCIN INTRAVENOUS RECON
SOLN 500 MG...................................................11
erythromycin ethylsuccinate oral tablet.......................11
erythromycin ophthalmic...........................................55
erythromycin oral capsule,delayed release(dr/ec)...........11
erythromycin oral tablet............................................11
erythromycin with ethanol.........................................39
erythromycin-benzoyl peroxide...................................39
escitalopram oxalate oral solution...............................22
escitalopram oxalate oral tablet 10 mg.......................23
escitalopram oxalate oral tablet 20 mg.......................23
escitalopram oxalate oral tablet 5 mg.........................23
esomeprazole magnesium...........................................48
esomeprazole sodium.................................................48
estarylla....................................................................53
ESTRACE VAGINAL............................................53
estradiol oral............................................................53
estradiol transdermal patch weekly.............................53
ESTRING...............................................................53
ethambutol...............................................................11
ethosuximide............................................................23
etidronate disodium..................................................41
etodolac....................................................................23
ETOPOPHOS.......................................................16
etoposide intravenous................................................16
EURAX...................................................................39
EVISTA..................................................................52
EVOTAZ................................................................11
EVOXAC...............................................................41
EXELDERM..........................................................39
exemestane...............................................................16
EXFORGE.............................................................34
73
EXFORGE HCT....................................................34
EXJADE.................................................................42
EXTAVIA SUBCUTANEOUS KIT......................50
EXTAVIA SUBCUTANEOUS RECON
SOLN..................................................................50
FABRAZYME.........................................................44
falmina (28)............................................................53
famciclovir oral tablet 125 mg, 250 mg.....................11
famciclovir oral tablet 500 mg...................................11
famotidine (pf).........................................................48
famotidine (pf)-nacl (iso-os)......................................48
famotidine intravenous.............................................48
famotidine oral suspension.........................................48
famotidine oral tablet 20 mg, 40 mg..........................48
FANAPT ORAL TABLET 1 MG...........................23
FANAPT ORAL TABLET 10 MG.........................23
FANAPT ORAL TABLET 12 MG.........................23
FANAPT ORAL TABLETS,DOSE PACK............23
FARESTON...........................................................16
FARYDAK ORAL CAPSULE 10 MG....................16
FARYDAK ORAL CAPSULE 15 MG, 20 MG......16
FASLODEX...........................................................16
FAZACLO ORAL TABLET,DISINTEGRATING
100 MG...............................................................23
12.5 MG..............................................................23
150 MG...............................................................23
200 MG...............................................................23
25 MG.................................................................23
felbamate oral suspension..........................................23
felbamate oral tablet 400 mg.....................................23
felbamate oral tablet 600 mg.....................................23
FELDENE..............................................................23
felodipine.................................................................34
FEMRING.............................................................53
fenofibrate micronized oral capsule 130 mg, 43
mg........................................................................34
fenofibrate micronized oral capsule 134 mg, 200 mg,
67 mg...................................................................34
fenofibrate nanocrystallized.......................................34
fenofibrate oral tablet 160 mg, 54 mg........................34
Premier_15283_v14_1511_1
fenofibric acid (choline) dr capsules............................35
fenoprofen oral tablet................................................23
fentanyl citrate.........................................................23
fentanyl transdermal patch 72 hour 100 mcg/hr, 12
mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr...............23
FENTORA.............................................................23
FETZIMA ORAL CAPSULE,EXT REL 24HR
DOSE PACK.......................................................23
FETZIMA ORAL CAPSULE,EXTENDED
RELEASE 24 HR 120 MG, 80 MG....................23
RELEASE 24 HR 20 MG....................................23
RELEASE 24 HR 40 MG....................................23
FINACEA TOPICAL GEL....................................39
finasteride oral tablet 5 mg........................................59
FIORICET WITH CODEINE ORAL CAPSULE
50-300-40-30 MG...............................................23
FIRAZYR...............................................................57
FIRMAGON KIT W DILUENT SYRINGE
SUBCUTANEOUS RECON SOLN 120
MG......................................................................16
FIRMAGON KIT W DILUENT SYRINGE
SUBCUTANEOUS RECON SOLN 80
MG......................................................................16
FLAGYL ER...........................................................11
FLAGYL ORAL CAPSULE....................................11
FLAREX.................................................................55
flavoxate..................................................................59
flecainide.................................................................35
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION.......57
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 250 MCG/ACTUATION, 50
MCG/ACTUATION..........................................57
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 110 MCG/ACTUATION.................57
INHALER 220 MCG/ACTUATION.................57
INHALER 44 MCG/ACTUATION...................57
fluconazole...............................................................11
fluconazole in dextrose(iso-o).....................................11
fluconazole in nacl (iso-osm) intravenous piggyback
200 mg/100 ml.....................................................11
fluconazole in nacl (iso-osm) intravenous piggyback
400 mg/200 ml.....................................................11
flucytosine................................................................11
74
FML LIQUIFILM..................................................55
FML S.O.P.............................................................55
FOLOTYN.............................................................17
fomepizole................................................................50
fondaparinux subcutaneous syringe 10 mg/0.8 ml.......35
fondaparinux subcutaneous syringe 2.5 mg/0.5 ml......35
fondaparinux subcutaneous syringe 5 mg/0.4 ml.........35
fondaparinux subcutaneous syringe 7.5 mg/0.6 ml......35
FORADIL AEROLIZER........................................58
FORTAMET ORAL TABLET EXTENDED
RELEASE 24HR 1,000 MG................................44
FORTAMET ORAL TABLET EXTENDED
RELEASE 24HR 500 MG...................................44
FORTEO...............................................................52
fortical.....................................................................44
FOSAMAX PLUS D...............................................52
foscarnet...................................................................11
fosinopril..................................................................35
fosinopril-hydrochlorothiazide...................................35
fosphenytoin.............................................................24
FRAGMIN SUBCUTANEOUS SOLUTION.......35
FRAGMIN SUBCUTANEOUS SYRINGE 10,000
ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/
0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,
000 ANTI-XA UNIT/0.72 ML, 7,500 ANTI-XA
UNIT/0.3 ML.....................................................35
FRAGMIN SUBCUTANEOUS SYRINGE 2,500
ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA
UNIT/0.2 ML.....................................................35
freamine iii 10 %.....................................................60
furosemide injection..................................................35
furosemide oral solution 10 mg/ml, 40 mg/5 ml..........35
furosemide oral tablet................................................35
FUSILEV................................................................17
FUZEON SUBCUTANEOUS RECON
SOLN..................................................................11
FYCOMPA ORAL TABLET 10 MG, 12 MG.......24
FYCOMPA ORAL TABLET 2 MG.......................24
gabapentin oral capsule 100 mg.................................24
gabapentin oral solution 250 mg/5 ml........................24
gabapentin oral solution 250 mg/5 ml (5 ml), 300
mg/6 ml (6 ml)......................................................24
gabapentin oral tablet 600 mg...................................24
fludarabine intravenous recon soln.............................16
fludarabine intravenous solution................................16
fludrocortisone..........................................................44
flunisolide nasal spray,non-aerosol 25 mcg (0.025
%)........................................................................57
fluocinolone acetonide oil..........................................42
fluocinolone topical cream.........................................39
fluocinolone topical oil..............................................39
fluocinolone topical ointment.....................................39
fluocinolone topical solution......................................39
fluocinolone-shower cap.............................................39
fluocinonide topical cream 0.05 %............................39
fluocinonide topical cream 0.1 %..............................39
fluocinonide topical gel..............................................39
fluocinonide topical ointment....................................39
fluocinonide topical solution......................................39
fluocinonide-e...........................................................39
fluoritab oral tablet,chewable 1 mg fluoride (2.2
mg).......................................................................60
fluorometholone........................................................55
fluorouracil intravenous............................................16
fluorouracil topical cream 5 %..................................39
fluorouracil topical solution 2 %................................39
fluorouracil topical solution 5 %................................39
fluoxetine oral capsule 10 mg.....................................23
fluoxetine oral capsule,delayed release(dr/ec)...............23
fluoxetine oral solution..............................................23
fluoxetine oral tablet 10 mg.......................................23
fluoxetine oral tablet 20 mg.......................................23
FLUOXETINE ORAL TABLET 60 MG...............23
fluphenazine decanoate.............................................23
fluphenazine hcl injection..........................................23
fluphenazine hcl oral.................................................23
flurbiprofen..............................................................23
flurbiprofen sodium..................................................55
flutamide.................................................................17
fluticasone nasal.......................................................57
fluticasone topical cream...........................................39
fluticasone topical lotion............................................39
fluticasone topical ointment.......................................39
fluvastatin oral capsule..............................................35
fluvastatin oral tablet extended release 24 hr..............35
fluvoxamine oral tablet 100 mg.................................23
fluvoxamine oral tablet 25 mg...................................24
fluvoxamine oral tablet 50 mg...................................24
FML FORTE..........................................................55
Premier_15283_v14_1511_1
75
gabapentin oral tablet 800 mg...................................24
GABITRIL ORAL TABLET 12 MG, 16 MG........24
galantamine oral capsule,ext rel. pellets 24 hr.............24
galantamine oral solution..........................................24
galantamine oral tablet.............................................24
GAMASTAN S/D..................................................50
GAMMAGARD LIQUID......................................50
GAMMAGARD S-D (IGA < 1 MCG/ML).......50
GAMMAPLEX.......................................................50
GAMUNEX-C.......................................................50
ganciclovir sodium....................................................11
GARDASIL (PF) INTRAMUSCULAR
SUSPENSION....................................................50
GARDASIL (PF) INTRAMUSCULAR
SYRINGE............................................................50
GARDASIL 9 (PF).................................................50
GATTEX 30-VIAL.................................................48
GATTEX ONE-VIAL............................................48
gauze pads 2 x 2.......................................................44
gavilyte-c..................................................................48
gavilyte-g..................................................................48
gavilyte-h and bisacodyl............................................48
gavilyte-n.................................................................48
GAZYVA................................................................17
gemcitabine intravenous recon soln 1 gram, 200
mg........................................................................17
gemcitabine intravenous recon soln 2 gram.................17
gemcitabine intravenous solution...............................17
gemfibrozil oral........................................................35
generlac....................................................................48
gengraf.....................................................................17
GENOTROPIN.....................................................50
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE 0.2 MG/0.25
ML.......................................................................50
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE 0.4 MG/0.25
ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/
0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML,
1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25
ML.................................................................50–51
gentak ophthalmic ointment......................................55
gentamicin in nacl (iso-osm) intravenous piggyback
100 mg/100 ml, 60 mg/50 ml................................11
GENTAMICIN IN NACL (ISO-OSM)
INTRAVENOUS PIGGYBACK 100 MG/50
ML, 120 MG/100 ML.........................................11
Premier_15283_v14_1511_1
gentamicin in nacl (iso-osm) intravenous piggyback
70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/
100 ml..................................................................11
gentamicin injection.................................................11
gentamicin ophthalmic..............................................55
gentamicin sulfate (ped) (pf)......................................11
gentamicin sulfate (pf) intravenous solution 100 mg/
10 ml....................................................................12
GENTAMICIN SULFATE (PF) INTRAVENOUS
SOLUTION 60 MG/6 ML.................................12
gentamicin sulfate (pf) intravenous solution 80 mg/8
ml.........................................................................12
gentamicin topical....................................................39
GEODON INTRAMUSCULAR...........................24
gianvi (28)...............................................................53
gildagia....................................................................53
gildess.......................................................................53
gildess fe...................................................................53
GILENYA...............................................................24
GILOTRIF.............................................................17
GLATOPA.............................................................24
GLEEVEC..............................................................17
GLEOSTINE.........................................................17
glimepiride oral tablet 1 mg......................................44
glipizide oral tablet 10 mg........................................44
glipizide oral tablet 5 mg..........................................44
glipizide oral tablet extended release 24hr 10 mg........44
glipizide oral tablet extended release 24hr 2.5 mg.......44
glipizide oral tablet extended release 24hr 5 mg..........44
glipizide-metformin oral tablet 2.5-250 mg...............44
glipizide-metformin oral tablet 2.5-500 mg, 5-500
mg........................................................................44
GLUCAGEN HYPOKIT.......................................44
GLUCAGON EMERGENCY KIT
(HUMAN)..........................................................44
GLUCOPHAGE ORAL TABLET 1,000 MG.......44
GLUCOPHAGE ORAL TABLET 500 MG..........44
GLUCOPHAGE ORAL TABLET 850 MG..........44
GLUCOPHAGE XR ORAL TABLET
GLUCOPHAGE XR ORAL TABLET
GLUCOTROL ORAL TABLET 10 MG...............44
GLUCOTROL ORAL TABLET 5 MG.................44
GLUCOTROL XL ORAL TABLET EXTENDED
RELEASE 24HR 10 MG.....................................44
76
RELEASE 24HR 2.5 MG....................................44
RELEASE 24HR 5 MG.......................................44
GLUMETZA ORAL TABLET,ER
GAST.RETENTION 24 HR 1,000 MG.............44
GLUMETZA ORAL TABLET,ER
GAST.RETENTION 24 HR 500 MG................44
glycopyrrolate injection..............................................48
glycopyrrolate oral.....................................................48
GLYSET ORAL TABLET 100 MG.......................44
GLYSET ORAL TABLET 25 MG.........................44
GLYSET ORAL TABLET 50 MG.........................44
GOLYTELY...........................................................48
granisetron (pf).........................................................48
granisetron hcl intravenous........................................48
granisetron hcl oral...................................................48
griseofulvin microsize oral suspension.........................12
griseofulvin microsize oral tablet................................12
griseofulvin ultramicrosize oral tablet 125 mg............12
griseofulvin ultramicrosize oral tablet 250 mg............12
guanfacine oral tablet extended release 24 hr..............24
guanidine.................................................................24
HALAVEN.............................................................17
halobetasol propionate...............................................39
HALOG.................................................................39
haloperidol...............................................................24
haloperidol decanoate................................................24
haloperidol lactate injection.......................................24
haloperidol lactate oral..............................................24
HARVONI.............................................................12
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION....................................................51
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,
440 ELISA UNIT/ML.........................................51
HAVRIX (PF) INTRAMUSCULAR SYRINGE
720 ELISA UNIT/0.5 ML...................................51
heather.....................................................................53
HECTOROL INTRAVENOUS SOLUTION 2
MCG/ML (1 ML)...............................................44
HECTOROL INTRAVENOUS SOLUTION 4
MCG/2 ML.........................................................44
heparin (porcine) in 5 % dex intravenous parenteral
solution 12,500 unit/250 ml, 20,000 unit/500 ml
(40 unit/ml)..........................................................35
heparin (porcine) in 5 % dex intravenous parenteral
solution 25,000 unit/250 ml(100 unit/ml), 25,000
unit/500 ml (50 unit/ml).......................................35
Premier_15283_v14_1511_1
heparin (porcine) in nacl (pf) intravenous parenteral
solution 1,000 unit/500 ml, 2,000 unit/1,000
ml.........................................................................35
heparin (porcine) injection cartridge..........................35
heparin (porcine) injection solution............................35
HEPARIN(PORCINE) IN 0.45% NACL
INTRAVENOUS PARENTERAL SOLUTION
12,500 UNIT/250 ML........................................35
heparin(porcine) in 0.45% nacl intravenous parenteral
solution 25,000 unit/250 ml, 25,000 unit/500
ml.........................................................................35
heparin, porcine (pf) injection...................................35
HEPATAMINE 8%...............................................60
HERCEPTIN.........................................................17
HEXALEN.............................................................17
HIPREX.................................................................12
HORIZANT ORAL TABLET EXTENDED
RELEASE 300 MG..............................................24
HORIZANT ORAL TABLET EXTENDED
RELEASE 600 MG..............................................24
HUMALOG KWIKPEN SUBCUTANEOUS
INSULIN PEN 100 UNIT/ML..........................44
HUMALOG KWIKPEN SUBCUTANEOUS
INSULIN PEN 200 UNIT/ML (3 ML)........44–45
HUMALOG MIX 50-50........................................45
HUMALOG MIX 50-50 KWIKPEN.....................45
HUMALOG MIX 75-25........................................45
HUMALOG MIX 75-25 KWIKPEN.....................45
HUMALOG SUBCUTANEOUS
CARTRIDGE......................................................45
HUMALOG SUBCUTANEOUS SOLUTION
100 UNIT/ML....................................................45
HUMALOG SUBCUTANEOUS SOLUTION
100 UNIT/ML (PREFILLED SYRINGE)...........45
HUMIRA CROHN'S DIS START PCK...............52
HUMIRA PED CROHN'S STARTER PK............52
HUMIRA PEN.......................................................52
HUMIRA PSORIASIS STARTER PACK..............52
HUMIRA SUBCUTANEOUS SYRINGE KIT 10
MG/0.2 ML, 20 MG/0.4 ML..............................52
HUMIRA SUBCUTANEOUS SYRINGE KIT 40
MG/0.8 ML...................................................52–53
HUMULIN 70/30..................................................45
HUMULIN 70/30 KWIKPEN..............................45
HUMULIN N........................................................45
HUMULIN N KWIKPEN.....................................45
HUMULIN R........................................................45
HUMULIN R U-500 "CONCENTRATED"........45
77
HYCET..................................................................24
hydralazine injection................................................35
hydralazine oral.......................................................35
HYDREA...............................................................17
hydrochlorothiazide..................................................35
hydrocodone-acetaminophen oral solution 2.5-167 mg/
5 ml......................................................................24
hydrocodone-acetaminophen oral solution 7.5-325 mg/
15 ml....................................................................24
hydrocodone-acetaminophen oral tablet 10-325 mg,
5-325 mg, 7.5-325 mg..........................................24
hydrocodone-ibuprofen..............................................24
hydrocortisone butyr-emollient...................................39
hydrocortisone butyrate topical cream.........................39
hydrocortisone butyrate topical ointment....................40
hydrocortisone butyrate topical solution......................40
hydrocortisone oral....................................................45
hydrocortisone rectal enema.......................................48
hydrocortisone topical cream 1 %, 2.5 %...................40
hydrocortisone topical lotion 2.5 %............................40
hydrocortisone topical ointment 1 %, 2.5 %...............40
hydrocortisone valerate topical cream..........................40
hydrocortisone valerate topical ointment.....................40
hydrocortisone-acetic acid..........................................42
hydrocortisone-min oil-wht pet..................................40
hydromorphone (pf) injection solution 1 mg/ml...........24
hydromorphone (pf) injection solution 10 mg/ml, 4
mg/ml...................................................................24
hydromorphone injection solution..............................24
hydromorphone injection syringe 1 mg/ml...................24
hydromorphone oral liquid........................................24
hydromorphone oral tablet 2 mg, 4 mg.......................24
hydromorphone oral tablet 8 mg................................24
hydroxychloroquine oral............................................12
hydroxyurea..............................................................17
ibandronate intravenous solution...............................53
ibandronate intravenous syringe.................................53
ibandronate oral.......................................................53
IBRANCE..............................................................17
ibuprofen oral suspension...........................................24
ibuprofen oral tablet 400 mg, 600 mg, 800 mg..........24
ibuprofen-oxycodone.................................................24
ICLUSIG................................................................17
idarubicin................................................................17
ifosfamide intravenous recon soln 1 gram...................17
ifosfamide intravenous recon soln 3 gram...................17
Premier_15283_v14_1511_1
ifosfamide intravenous solution..................................17
ILARIS (PF)............................................................51
ILEVRO.................................................................55
IMBRUVICA.........................................................17
imipenem-cilastatin..................................................12
imipramine hcl.........................................................24
imiquimod...............................................................40
IMOVAX RABIES VACCINE (PF).......................51
INCRELEX............................................................42
indapamide..............................................................35
INFANRIX (DTAP) (PF) INTRAMUSCULAR
SUSPENSION....................................................51
INFANRIX (DTAP) (PF) INTRAMUSCULAR
SYRINGE............................................................51
INLYTA.................................................................17
INNOPRAN XL.....................................................35
INSULIN PEN NEEDLE......................................45
INSULIN SYRINGE (DISP) U-100 0.3 ML.........45
INSULIN SYRINGE (DISP) U-100 1 ML............45
INSULIN SYRINGE (DISP) U-100 1/2 ML.........45
INTELENCE ORAL TABLET 100 MG, 200
MG......................................................................12
INTELENCE ORAL TABLET 25 MG.................12
intralipid intravenous emulsion 20 %........................60
INTRALIPID INTRAVENOUS EMULSION 30
%.........................................................................60
INTRON A INJECTION RECON SOLN 10
MILLION UNIT (1 ML)....................................51
INTRON A INJECTION RECON SOLN 18
MILLION UNIT (1 ML), 50 MILLION UNIT
(1 ML).................................................................51
INTRON A INJECTION SOLUTION 10
MILLION UNIT/ML.........................................51
INTRON A INJECTION SOLUTION 6
MILLION UNIT/ML.........................................51
introvale..................................................................53
INTUNIV ER........................................................25
INVANZ INJECTION..........................................12
INVANZ INTRAVENOUS...................................12
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 1.5 MG....................................25
RELEASE 24HR 3 MG.......................................25
RELEASE 24HR 6 MG.......................................25
RELEASE 24HR 9 MG.......................................25
78
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234
MG/1.5 ML.........................................................25
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 39 MG/0.25 ML, 78 MG/0.5
ML.......................................................................25
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 273 MG/0.875 ML............................25
SYRINGE 410 MG/1.315 ML............................25
SYRINGE 546 MG/1.75 ML..............................25
SYRINGE 819 MG/2.625 ML............................25
INVIRASE..............................................................12
IONOSOL-B IN D5W..........................................60
IONOSOL-MB IN D5W.......................................60
IOPIDINE.............................................................55
IPOL INJECTION SUSPENSION.......................51
IPOL INJECTION SYRINGE...............................51
ipratropium bromide inhalation................................58
ipratropium bromide nasal........................................42
ipratropium-albuterol...............................................58
irbesartan.................................................................35
irbesartan-hydrochlorothiazide oral tablet 150-12.5
mg........................................................................35
irbesartan-hydrochlorothiazide oral tablet 300-12.5
mg........................................................................35
IRESSA...................................................................17
irinotecan intravenous solution 100 mg/5 ml, 40 mg/
2 ml......................................................................17
irinotecan intravenous solution 500 mg/25 ml............17
ISENTRESS ORAL POWDER IN PACKET........12
ISENTRESS ORAL TABLET................................12
ISENTRESS ORAL TABLET,CHEWABLE 100
MG......................................................................12
ISENTRESS ORAL TABLET,CHEWABLE 25
MG......................................................................12
ISOLYTE S PH 7.4................................................60
ISOLYTE-P IN 5 % DEXTROSE.........................60
ISOLYTE-S............................................................60
isoniazid injection....................................................12
isoniazid oral solution...............................................12
isoniazid oral tablet..................................................12
ISORDIL................................................................35
ISORDIL TITRADOSE ORAL TABLET 5
MG......................................................................35
isosorbide dinitrate oral.............................................35
Premier_15283_v14_1511_1
isosorbide mononitrate oral tablet..............................35
isosorbide mononitrate oral tablet extended release 24
hr 120 mg, 60 mg.................................................35
isosorbide mononitrate oral tablet extended release 24
hr 30 mg...............................................................35
isradipine.................................................................35
ISTALOL...............................................................55
ISTODAX..............................................................17
itraconazole..............................................................12
ivermectin oral.........................................................12
IXEMPRA..............................................................17
IXIARO (PF)..........................................................51
JAKAFI...................................................................17
JALYN....................................................................59
jantoven...................................................................35
JANUMET.............................................................45
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 100-1,000 MG...............45
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 50-1,000 MG, 50-500
MG......................................................................45
JANUVIA ORAL TABLET 100 MG.....................45
JANUVIA ORAL TABLET 25 MG.......................45
JANUVIA ORAL TABLET 50 MG.......................45
JARDIANCE..........................................................45
JENTADUETO.....................................................45
JEVTANA..............................................................17
jolessa.......................................................................53
jolivette....................................................................53
junel 1.5/30 (21)......................................................53
junel 1/20 (21).........................................................53
junel fe 1.5/30 (28)..................................................53
junel fe 1/20 (28).....................................................53
k-effervescent............................................................60
k-phos-neutral..........................................................60
K-TAB ORAL TABLET EXTENDED RELEASE
10 MEQ..............................................................60
k-tab oral tablet extended release 8 meq.....................60
KADCYLA.............................................................17
KALETRA ORAL SOLUTION.............................12
KALETRA ORAL TABLET 100-25 MG...............12
KALETRA ORAL TABLET 200-50 MG...............12
KALYDECO ORAL TABLET...............................58
kariva (28)..............................................................53
KAYEXALATE.......................................................42
KEFLEX ORAL CAPSULE....................................12
kelnor 1/35 (28).......................................................54
KENALOG TOPICAL...........................................40
79
KETEK...................................................................12
ketoconazole oral......................................................12
ketoconazole topical cream.........................................40
ketoconazole topical shampoo.....................................40
ketoprofen oral capsule..............................................25
ketoprofen oral capsule,ext rel. pellets 24 hr 200
mg........................................................................25
ketorolac ophthalmic.................................................55
KEYTRUDA..........................................................17
KHEDEZLA ORAL TABLET EXTENDED
RELEASE 24HR 100 MG...................................25
KHEDEZLA ORAL TABLET EXTENDED
RELEASE 24HR 50 MG.....................................25
KINERET..............................................................53
kionex......................................................................42
KLARON...............................................................40
klor-con 10..............................................................60
klor-con 8................................................................60
klor-con m10............................................................60
klor-con m15............................................................60
klor-con m20............................................................60
klor-con/ef................................................................60
KOMBIGLYZE XR ORAL TABLET, ER
MULTIPHASE 24 HR 2.5-1,000 MG................45
KOMBIGLYZE XR ORAL TABLET, ER
MULTIPHASE 24 HR 5-1,000 MG, 5-500
MG......................................................................45
KRISTALOSE........................................................48
KUVAN ORAL TABLET,SOLUBLE....................45
labetalol intravenous solution....................................35
labetalol oral............................................................36
LACRISERT...........................................................55
lactated ringers intravenous.......................................60
lactated ringers irrigation..........................................42
lactulose...................................................................48
LAMICTAL ORAL TABLET................................25
LAMICTAL ORAL TABLET, CHEWABLE
DISPERSIBLE 25 MG, 5 MG............................25
LAMICTAL STARTER (BLUE) KIT....................25
LAMICTAL STARTER (GREEN) KIT.................25
LAMICTAL STARTER (ORANGE) KIT.............25
LAMISIL ORAL GRANULES IN PACKET..........12
LAMISIL ORAL TABLET.....................................12
lamivudine oral solution...........................................12
lamivudine oral tablet 100 mg, 150 mg.....................12
lamivudine oral tablet 300 mg..................................12
lamivudine-zidovudine.............................................12
lamotrigine oral tablet...............................................25
Premier_15283_v14_1511_1
lamotrigine oral tablet, chewable dispersible...............25
LANOXIN ORAL TABLET 125 MCG.................36
LANOXIN ORAL TABLET 62.5 MCG................36
lansoprazole oral capsule,delayed release(dr/ec)............48
LANTUS................................................................45
LANTUS SOLOSTAR...........................................45
LASIX.....................................................................36
latanoprost...............................................................55
LATUDA ORAL TABLET 120 MG......................25
LATUDA ORAL TABLET 20 MG........................25
LAZANDA.............................................................25
leena 28...................................................................54
leflunomide..............................................................53
LENVIMA ORAL CAPSULE 10 MG/DAY (10
MG [1]/DAY)......................................................17
LENVIMA ORAL CAPSULE 14 MG (10 MG[1]
-4 MG[1])/DAY, 20 MG/DAY (10 MG [2]/
DAY)...................................................................17
LENVIMA ORAL CAPSULE 24 MG (10 MG[2]
-4 MG[1])/DAY...................................................17
LESCOL.................................................................36
LESCOL XL...........................................................36
lessina......................................................................54
LETAIRIS...............................................................58
letrozole...................................................................17
leucovorin calcium injection recon soln 100 mg, 200
mg, 350 mg, 50 mg...............................................17
leucovorin calcium injection recon soln 500 mg..........17
leucovorin calcium oral tablet 10 mg, 5 mg................17
leucovorin calcium oral tablet 15 mg, 25 mg..............17
LEUKERAN...........................................................17
LEUKINE INJECTION RECON SOLN..............51
leuprolide.................................................................17
levalbuterol hcl inhalation solution for nebulization
0.31 mg/3 ml........................................................58
0.63 mg/3 ml........................................................58
1.25 mg/0.5 ml, 1.25 mg/3 ml...............................58
levetiracetam in nacl (iso-os) intravenous piggyback 1,
000 mg/100 ml, 1,500 mg/100 ml.........................25
levetiracetam in nacl (iso-os) intravenous piggyback
500 mg/100 ml.....................................................25
levetiracetam intravenous..........................................25
levetiracetam oral solution 100 mg/ml.......................25
80
levetiracetam oral solution 500 mg/5 ml (5 ml)..........25
levetiracetam oral tablet............................................25
levetiracetam oral tablet extended release 24 hr 500
mg........................................................................25
levetiracetam oral tablet extended release 24 hr 750
mg........................................................................25
levobunolol ophthalmic drops 0.5 %..........................55
levocarnitine (with sugar)..........................................42
levocarnitine intravenous..........................................42
levocarnitine oral tablet.............................................42
levocetirizine oral tablet............................................58
levofloxacin in d5w intravenous piggyback 250 mg/50
ml.........................................................................12
levofloxacin in d5w intravenous piggyback 500 mg/
100 ml, 750 mg/150 ml........................................12
levofloxacin ophthalmic.............................................55
levofloxacin oral tablet..............................................12
levonest (28).............................................................54
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg,
0.15-0.03 mg........................................................54
levonorgestrel-ethinyl estrad oral tablets,dose pack,3
month...................................................................54
levora-28.................................................................54
levorphanol tartrate..................................................26
levothyroxine oral.....................................................45
levoxyl oral tablet 100 mcg, 112 mcg, 25 mcg, 50 mcg,
75 mcg, 88 mcg.....................................................45
levoxyl oral tablet 125 mcg, 137 mcg, 150 mcg, 175
mcg, 200 mcg........................................................45
LEXIVA ORAL SUSPENSION.............................12
LEXIVA ORAL TABLET.......................................12
LIALDA..................................................................48
lidocaine hcl mucous membrane solution 2 %.............40
lidocaine topical adhesive patch,medicated.................40
lidocaine topical ointment.........................................40
lidocaine viscous.......................................................40
lidocaine-prilocaine..................................................40
LIDODERM..........................................................40
LINCOCIN............................................................12
lindane topical lotion................................................40
lindane topical shampoo............................................40
linezolid intravenous.................................................12
linezolid oral............................................................12
linezolid-0.9% sodium chloride.................................12
LINZESS................................................................48
liothyronine intravenous............................................45
liothyronine oral.......................................................45
liposyn iii intravenous emulsion 10 %.......................60
Premier_15283_v14_1511_1
liposyn iii intravenous emulsion 20 %.......................60
lisinopril..................................................................36
lisinopril-hydrochlorothiazide....................................36
lithium carbonate oral capsule 150 mg, 300 mg.........26
lithium carbonate oral capsule 600 mg.......................26
lithium carbonate oral tablet.....................................26
lithium carbonate oral tablet extended release.............26
lithium citrate oral solution 8 meq/5 ml.....................26
LITHOBID............................................................26
LIVALO.................................................................36
LOCOID................................................................40
LOCOID LIPOCREAM........................................40
LODOSYN............................................................26
LOFIBRA ORAL CAPSULE 67 MG.....................36
LOKARA................................................................40
LOMEDIA 24 FE...................................................54
LOMUSTINE........................................................17
loperamide oral capsule.............................................48
LOPRESSOR.........................................................36
LOPRESSOR HCT ORAL TABLET 50-25
MG......................................................................36
lorazepam oral tablet................................................26
loryna (28)...............................................................54
losartan oral tablet 100 mg.......................................36
losartan oral tablet 25 mg, 50 mg..............................36
losartan-hydrochlorothiazide.....................................36
LOTEMAX OPHTHALMIC DROPS,
SUSPENSION....................................................55
LOTEMAX OPHTHALMIC OINTMENT.........55
LOTRISONE TOPICAL CREAM........................40
LOTRONEX..........................................................48
lovastatin oral tablet 10 mg, 20 mg...........................36
lovastatin oral tablet 40 mg.......................................36
low-ogestrel (28).......................................................54
loxapine succinate.....................................................26
ludent fluoride..........................................................60
LUMIGAN OPHTHALMIC DROPS 0.01 %......55
LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT 3.75 MG, 7.5 MG......................17
LUPRON DEPOT-PED INTRAMUSCULAR
KIT 7.5 MG (PED).............................................17
lutera (28)...............................................................54
LYNPARZA............................................................17
LYRICA ORAL CAPSULE 100 MG......................26
LYRICA ORAL CAPSULE 225 MG, 300 MG......26
LYRICA ORAL CAPSULE 25 MG........................26
81
LYRICA ORAL SOLUTION.................................26
LYSODREN...........................................................17
lyza..........................................................................54
M-M-R II (PF).......................................................51
magnesium sulfate in water intravenous parenteral
solution.................................................................60
magnesium sulfate in water intravenous piggyback 2
gram/50 ml (4 %), 4 gram/50 ml (8 %)................60
magnesium sulfate in water intravenous piggyback 4
gram/100 ml (4 %)...............................................60
magnesium sulfate injection solution..........................60
magnesium sulfate injection syringe............................60
MALARONE.........................................................12
MALARONE PEDIATRIC....................................12
malathion................................................................40
maprotiline oral tablet 25 mg....................................26
marlissa...................................................................54
MARPLAN.............................................................26
MATULANE..........................................................17
matzim la................................................................36
MAXIDEX.............................................................55
MAXITROL...........................................................55
MAXZIDE.............................................................36
MAXZIDE-25MG..................................................36
meclizine oral tablet 12.5 mg, 25 mg.........................48
meclofenamate oral...................................................26
MEDROL..............................................................45
MEDROL (PAK)...................................................45
medroxyprogesterone intramuscular............................54
medroxyprogesterone oral...........................................54
mefenamic acid........................................................26
mefloquine...............................................................12
MEGACE...............................................................17
megestrol oral suspension 400 mg/10 ml (10 ml)........17
megestrol oral suspension 400 mg/10 ml (40 mg/
ml).......................................................................17
megestrol oral tablet..................................................17
MEKINIST............................................................17
meloxicam oral suspension.........................................26
meloxicam oral tablet................................................26
melphalan hcl...........................................................17
MENACTRA (PF) INTRAMUSCULAR
SOLUTION........................................................51
MENEST...............................................................54
Premier_15283_v14_1511_1
MENOMUNE - A/C/Y/W-135.............................51
MENOMUNE - A/C/Y/W-135 (PF).....................51
MENTAX...............................................................40
MENVEO A-C-Y-W-135-DIP (PF).......................51
MEPRON..............................................................12
mercaptopurine.........................................................17
meropenem...............................................................12
mesalamine rectal.....................................................48
mesalamine with cleansing wipe................................48
mesna......................................................................17
MESNEX ORAL....................................................17
MESTINON ORAL SYRUP..................................26
MESTINON ORAL TABLET...............................26
MESTINON TIMESPAN.....................................26
metaproterenol oral...................................................58
metformin oral tablet 1,000 mg.................................45
metformin oral tablet 500 mg....................................45
metformin oral tablet 850 mg....................................45
metformin oral tablet extended release 24 hr 500
mg........................................................................45
metformin oral tablet extended release 24 hr 750
mg........................................................................45
metformin oral tablet extended release 24hr 1,000
mg........................................................................45
metformin oral tablet extended release 24hr 500
mg........................................................................46
methadone injection..................................................26
methadone intensol...................................................26
methadone oral concentrate.......................................26
methadone oral solution 10 mg/5 ml..........................26
methadone oral solution 5 mg/5 ml............................26
methadone oral tablet 10 mg.....................................26
methadone oral tablet 5 mg.......................................26
methadone oral tablet,soluble.....................................26
methadose oral concentrate........................................26
methadose oral tablet,soluble......................................26
methazolamide oral tablet 25 mg...............................55
methazolamide oral tablet 50 mg...............................55
methenamine hippurate............................................12
methenamine mandelate...........................................12
methimazole oral tablet 10 mg..................................46
methimazole oral tablet 5 mg....................................46
methotrexate sodium (pf) injection recon soln..............17
methotrexate sodium (pf) injection solution................17
methotrexate sodium injection...................................18
methotrexate sodium oral..........................................18
methoxsalen rapid.....................................................40
methscopolamine oral................................................48
82
methyclothiazide.......................................................36
methylergonovine oral...............................................54
methylphenidate oral tablet.......................................26
methylprednisolone acetate.........................................46
methylprednisolone oral tablet 16 mg, 4 mg, 8 mg......46
methylprednisolone oral tablet 32 mg.........................46
methylprednisolone oral tablets,dose pack....................46
methylprednisolone sodium succ injection recon soln
125 mg, 40 mg......................................................46
methylprednisolone sodium succ intravenous...............46
metipranolol.............................................................55
metoclopramide hcl injection solution.........................48
metoclopramide hcl injection syringe..........................48
metoclopramide hcl oral solution................................48
metoclopramide hcl oral tablet...................................48
metolazone...............................................................36
metoprolol succinate..................................................36
metoprolol ta-hydrochlorothiaz..................................36
metoprolol tartrate intravenous solution.....................36
metoprolol tartrate intravenous syringe.......................36
metoprolol tartrate oral.............................................36
metro i.v..................................................................12
METROCREAM...................................................40
METROGEL TOPICAL GEL 1 %........................40
METROGEL TOPICAL GEL WITH PUMP.......40
metronidazole in nacl (iso-os)....................................12
metronidazole oral....................................................12
metronidazole topical cream......................................40
metronidazole topical gel 0.75 %...............................40
metronidazole topical gel 1 %....................................40
metronidazole topical gel with pump..........................40
metronidazole topical lotion......................................40
metronidazole vaginal...............................................54
mexiletine................................................................36
MICARDIS ORAL TABLET 20 MG, 40 MG.......36
MICARDIS ORAL TABLET 80 MG....................36
miconazole-3 vaginal suppository...............................54
microgestin 1.5/30 (21)............................................54
microgestin 1/20 (21)...............................................54
microgestin fe 1.5/30 (28).........................................54
microgestin fe 1/20 (28)............................................54
MICROZIDE.........................................................36
midodrine................................................................42
migergot...................................................................26
MIGRANAL...........................................................26
millipred dp.............................................................46
millipred oral tablet..................................................46
MINIPRESS...........................................................36
Premier_15283_v14_1511_1
minocycline oral capsule............................................12
minocycline oral tablet 100 mg, 75 mg......................12
minocycline oral tablet 50 mg....................................13
minoxidil oral..........................................................36
mirtazapine oral tablet 15 mg...................................26
mirtazapine oral tablet 7.5 mg..................................26
mirtazapine oral tablet,disintegrating 15 mg..............26
misoprostol...............................................................48
mitomycin................................................................18
mitoxantrone............................................................18
modafinil oral tablet 100 mg.....................................26
modafinil oral tablet 200 mg.....................................26
moexipril..................................................................36
moexipril-hydrochlorothiazide...................................36
mometasone..............................................................40
mono-linyah.............................................................54
mononessa (28).........................................................54
montelukast oral granules in packet............................58
montelukast oral tablet..............................................58
montelukast oral tablet,chewable...............................58
MONUROL...........................................................13
morphine (pf) injection solution 0.5 mg/ml................27
morphine (pf) injection solution 1 mg/ml...................27
morphine (pf) intravenous patient control.analgesia
soln 150 mg/30 ml................................................27
morphine (pf) intravenous patient control.analgesia
soln 30 mg/30 ml..................................................27
morphine concentrate oral solution.............................27
morphine intravenous cartridge.................................27
MORPHINE INTRAVENOUS
CARTRIDGE......................................................27
morphine intravenous solution 100 mg/4 ml, 25 mg/
ml, 250 mg/10 ml.................................................27
morphine intravenous solution 50 mg/ml...................27
morphine intravenous syringe 2 mg/ml, 4 mg/ml.........27
morphine oral solution 10 mg/5 ml............................27
morphine oral solution 20 mg/5 ml............................27
morphine oral tablet 15 mg.......................................27
morphine oral tablet 30 mg.......................................27
morphine oral tablet extended release 100 mg, 15 mg,
30 mg, 60 mg........................................................27
morphine oral tablet extended release 200 mg.............27
morphine rectal........................................................27
MOVIPREP...........................................................48
83
MOXATAG...........................................................13
MOXEZA...............................................................55
moxifloxacin.............................................................13
MOZOBIL.............................................................51
MULTAQ..............................................................36
mupirocin................................................................40
mupirocin calcium....................................................40
MUSTARGEN.......................................................18
MYAMBUTOL ORAL TABLET 400 MG............13
MYCAMINE..........................................................13
MYCOBUTIN.......................................................13
mycophenolate mofetil oral capsule.............................18
mycophenolate mofetil oral suspension for
reconstitution........................................................18
mycophenolate mofetil oral tablet...............................18
mycophenolate sodium...............................................18
MYFORTIC ORAL TABLET,DELAYED
RELEASE (DR/EC) 180 MG..............................18
MYFORTIC ORAL TABLET,DELAYED
RELEASE (DR/EC) 360 MG..............................18
myorisan oral capsule 10 mg, 20 mg, 40 mg...............40
MYOZYME............................................................46
MYRBETRIQ........................................................59
myzilra....................................................................54
nabumetone.............................................................27
nadolol.....................................................................36
nadolol-bendroflumethiazide.....................................36
nafcillin in dextrose iso-osm intravenous piggyback 1
gram/50 ml...........................................................13
nafcillin in dextrose iso-osm intravenous piggyback 2
gram/100 ml.........................................................13
nafcillin injection recon soln 1 gram..........................13
nafcillin injection recon soln 10 gram, 2 gram............13
nafcillin intravenous.................................................13
naftifine...................................................................40
NAFTIN.................................................................40
NAGLAZYME.......................................................46
nalbuphine injection.................................................27
naloxone injection solution........................................27
naloxone injection syringe 0.4 mg/ml.........................27
naloxone injection syringe 1 mg/ml............................27
naltrexone oral.........................................................27
NAMENDA ORAL SOLUTION..........................27
NAMENDA ORAL TABLET 10 MG...................27
NAMENDA ORAL TABLET 5 MG.....................27
NAMENDA TITRATION PAK............................27
NAMENDA XR ORAL CAP,SPRINKLE,ER
24HR DOSE PACK............................................27
Premier_15283_v14_1511_1
NAMENDA XR ORAL CAPSULE,SPRINKLE,
ER 24HR.............................................................27
NAMZARIC..........................................................27
naphazoline..............................................................56
naproxen oral suspension...........................................27
naproxen oral tablet 250 mg.....................................27
naproxen oral tablet 375 mg, 500 mg........................27
naproxen oral tablet,delayed release (dr/ec).................27
naproxen sodium oral tablet 275 mg, 550 mg............27
naratriptan oral tablet 1 mg......................................27
naratriptan oral tablet 2.5 mg...................................27
NARDIL.................................................................27
NASONEX.............................................................58
NATACYN.............................................................56
nateglinide oral tablet 120 mg...................................46
nateglinide oral tablet 60 mg.....................................46
NEBUPENT..........................................................13
necon 0.5/35 (28).....................................................54
necon 1/35 (28)........................................................54
necon 1/50 (28)........................................................54
necon 10/11 (28)......................................................54
necon 7/7/7 (28).......................................................54
NEEDLES, INSULIN DISP.,SAFETY..................46
nefazodone oral tablet 100 mg...................................27
nefazodone oral tablet 50 mg.....................................27
neo-polycin...............................................................56
neo-polycin hc...........................................................56
neomycin..................................................................13
neomycin-bacitracin-poly-hc......................................56
neomycin-bacitracin-polymyxin.................................56
neomycin-polymyxin b gu..........................................42
neomycin-polymyxin b-dexameth...............................56
neomycin-polymyxin-gramicidin................................56
neomycin-polymyxin-hc ophthalmic...........................56
neomycin-polymyxin-hc otic.......................................42
NEORAL................................................................18
NEOSPORIN (NEO-POLYM-GRAMICID)........56
NEPHRAMINE 5.4 %...........................................60
NEULASTA SUBCUTANEOUS SYRINGE.........51
NEUMEGA............................................................51
NEUPOGEN.........................................................51
NEUPRO...............................................................27
NEURONTIN ORAL CAPSULE 100 MG...........27
84
NEURONTIN ORAL SOLUTION......................28
NEURONTIN ORAL TABLET 600 MG.............28
NEURONTIN ORAL TABLET 800 MG.............28
NEVANAC............................................................56
nevirapine oral suspension.........................................13
nevirapine oral tablet................................................13
nevirapine oral tablet extended release 24 hr..............13
NEXAVAR.............................................................18
NEXIUM...............................................................48
NEXIUM IV INTRAVENOUS RECON SOLN
40 MG.................................................................48
NEXIUM PACKET...............................................48
niacin oral tablet extended release 24 hr 1,000 mg,
750 mg.................................................................36
niacin oral tablet extended release 24 hr 500 mg........36
NIACOR................................................................36
nicardipine intravenous............................................36
nicardipine oral........................................................36
NICOTROL..........................................................42
NICOTROL NS....................................................42
nifedical xl...............................................................36
nifedipine oral tablet extended release.........................36
nifedipine oral tablet extended release 24hr................36
NILANDRON.......................................................18
nimodipine...............................................................36
NIPENT.................................................................18
nitro-bid..................................................................36
nitrofurantoin macrocrystal oral capsule 100 mg, 50
mg........................................................................13
nitrofurantoin monohyd/m-cryst................................13
nitroglycerin intravenous...........................................36
nitroglycerin transdermal patch 24 hour.....................36
nitroglycerin translingual..........................................36
NITROLINGUAL.................................................36
NITROSTAT.........................................................36
nizatidine oral capsule..............................................48
NIZORAL TOPICAL SHAMPOO.......................40
NOR-QD...............................................................54
nora-be....................................................................54
NORDITROPIN FLEXPRO.................................51
norethindrone (contraceptive)....................................54
norethindrone acetate................................................54
norgestimate-ethinyl estradiol.....................................54
NORMOSOL-M IN 5 % DEXTROSE.................60
NORMOSOL-R.....................................................60
NORMOSOL-R IN 5 % DEXTROSE..................60
NORMOSOL-R PH 7.4........................................60
NORPRAMIN.......................................................28
Premier_15283_v14_1511_1
nortrel 0.5/35 (28)...................................................54
nortrel 1/35 (21)......................................................54
nortrel 1/35 (28)......................................................54
nortrel 7/7/7 (28).....................................................54
nortriptyline oral capsule 10 mg, 25 mg.....................28
nortriptyline oral capsule 50 mg, 75 mg.....................28
nortriptyline oral solution..........................................28
NORVIR................................................................13
NOXAFIL ORAL SUSPENSION..........................13
NUEDEXTA..........................................................28
NULOJIX...............................................................18
NULYTELY WITH FLAVOR PACKS..................48
NUVARING..........................................................54
nyamyc.....................................................................40
nystatin oral suspension.............................................13
nystatin oral tablet....................................................13
nystatin topical.........................................................40
nystatin-triamcinolone..............................................40
nystop......................................................................40
ocella.......................................................................54
octreotide acetate injection solution 1,000 mcg/ml.......18
octreotide acetate injection solution 100 mcg/ml, 200
mcg/ml, 50 mcg/ml, 500 mcg/ml............................18
octreotide acetate injection syringe 100 mcg/ml (1 ml),
50 mcg/ml (1 ml)..................................................18
octreotide acetate injection syringe 500 mcg/ml (1
ml).......................................................................18
OCUFLOX............................................................56
ofloxacin ophthalmic.................................................56
ofloxacin oral tablet 400 mg......................................13
ofloxacin otic............................................................42
ogestrel (28).............................................................54
olanzapine intramuscular..........................................28
olanzapine oral tablet 10 mg.....................................28
olanzapine oral tablet 2.5 mg....................................28
olanzapine oral tablet 5 mg.......................................28
olanzapine oral tablet 7.5 mg....................................28
olanzapine oral tablet,disintegrating 10 mg................28
olanzapine oral tablet,disintegrating 5 mg..................28
olopatadine..............................................................42
OLYSIO.................................................................13
omega-3 acid ethyl esters............................................36
omeprazole oral capsule,delayed release(dr/ec).............49
OMNARIS.............................................................58
85
ONCASPAR...........................................................18
ondansetron hcl (pf) injection solution........................49
ondansetron hcl (pf) injection syringe.........................49
ondansetron hcl intravenous solution..........................49
ondansetron hcl oral solution.....................................49
ondansetron hcl oral tablet 24 mg..............................49
ondansetron hcl oral tablet 4 mg, 8 mg......................49
ondansetron oral tablet,disintegrating 4 mg................49
ondansetron oral tablet,disintegrating 8 mg................49
ONFI ORAL SUSPENSION.................................28
ONFI ORAL TABLET 10 MG..............................28
ONFI ORAL TABLET 20 MG..............................28
ONGLYZA ORAL TABLET 2.5 MG....................46
ONGLYZA ORAL TABLET 5 MG.......................46
OPDIVO................................................................18
opium tincture oral tincture......................................49
ORACEA................................................................13
ORAP.....................................................................28
ORAPRED ODT...................................................46
ORFADIN.............................................................42
orsythia....................................................................54
ORTHO EVRA......................................................54
OSMOPREP..........................................................49
oxacillin in dextrose(iso-osm) intravenous piggyback 1
gram/50 ml...........................................................13
oxacillin in dextrose(iso-osm) intravenous piggyback 2
gram/50 ml...........................................................13
oxacillin injection recon soln 1 gram, 2 gram..............13
oxacillin injection recon soln 10 gram........................13
oxacillin intravenous recon soln 1 gram......................13
oxacillin intravenous recon soln 2 gram......................13
oxaliplatin intravenous recon soln 100 mg..................18
oxaliplatin intravenous recon soln 50 mg....................18
oxaliplatin intravenous solution.................................18
oxandrolone oral tablet 10 mg...................................46
oxandrolone oral tablet 2.5 mg..................................46
oxaprozin.................................................................28
oxazepam.................................................................28
oxcarbazepine...........................................................28
OXISTAT...............................................................40
OXTELLAR XR ORAL TABLET EXTENDED
RELEASE 24 HR 150 MG..................................28
RELEASE 24 HR 300 MG..................................28
RELEASE 24 HR 600 MG..................................28
oxybutynin chloride oral syrup...................................59
oxybutynin chloride oral tablet...................................59
Premier_15283_v14_1511_1
oxybutynin chloride oral tablet extended release 24hr
10 mg, 15 mg........................................................59
oxybutynin chloride oral tablet extended release 24hr
5 mg.....................................................................59
oxycodone oral capsule...............................................28
oxycodone oral concentrate.........................................28
oxycodone oral solution..............................................28
oxycodone oral tablet 10 mg, 5 mg.............................28
oxycodone oral tablet 15 mg......................................28
oxycodone oral tablet 20 mg, 30 mg...........................28
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5325 mg, 5-325 mg, 7.5-325 mg.............................28
oxycodone-aspirin.....................................................28
OXYCONTIN ORAL TABLET,ORAL ONLY,
EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30
MG, 40 MG........................................................28
OXYCONTIN ORAL TABLET,ORAL ONLY,
EXT.REL.12 HR 60 MG....................................28
pacerone oral tablet 100 mg......................................36
pacerone oral tablet 200 mg, 400 mg.........................36
paclitaxel..................................................................18
pamidronate.............................................................46
PANDEL................................................................40
PANRETIN............................................................40
pantoprazole oral tablet,delayed release (dr/ec) 20
mg........................................................................49
pantoprazole oral tablet,delayed release (dr/ec) 40
mg........................................................................49
paregoric..................................................................49
paricalcitol oral........................................................46
paroex oral rinse.......................................................42
paromomycin............................................................13
paroxetine hcl oral tablet 10 mg.................................28
paroxetine hcl oral tablet 40 mg................................28
paroxetine hcl oral tablet extended release 24 hr 12.5
mg........................................................................29
paroxetine hcl oral tablet extended release 24 hr 25
mg........................................................................29
paroxetine hcl oral tablet extended release 24 hr 37.5
mg........................................................................29
PASER....................................................................13
PATADAY..............................................................56
PATANASE............................................................42
PATANOL.............................................................56
PAXIL ORAL SUSPENSION................................29
PAXIL ORAL TABLET 10 MG.............................29
86
PAZEO...................................................................56
PCE........................................................................13
PEDVAX HIB (PF)................................................51
peg 3350-electrolytes oral recon soln 236-22.74-6.74
-5.86 gram............................................................49
peg 3350-electrolytes oral recon soln 240-22.72-6.72
-5.84 gram............................................................49
peg-3350 with flavor packs.......................................49
peg-electrolyte soln.....................................................49
PEGANONE..........................................................29
PEGASYS...............................................................51
PEGASYS PROCLICK..........................................51
PEGINTRON........................................................51
PEGINTRON REDIPEN......................................51
PENICILLIN G POT IN DEXTROSE.................13
penicillin g potassium................................................13
penicillin g procaine intramuscular syringe 1.2 million
unit/2 ml..............................................................13
penicillin g procaine intramuscular syringe 600,000
unit/ml.................................................................13
penicillin g sodium....................................................13
penicillin v potassium................................................13
PENTAM...............................................................13
PENTASA..............................................................49
pentoxifylline............................................................36
PERFOROMIST....................................................58
perindopril erbumine................................................36
periogard..................................................................42
PERJETA................................................................18
permethrin topical cream...........................................40
perphenazine............................................................29
pfizerpen-g...............................................................13
phenelzine................................................................29
phenobarbital oral elixir............................................29
phenobarbital oral tablet 100 mg..............................29
phenobarbital oral tablet 15 mg................................29
phenobarbital oral tablet 16.2 mg.............................29
phenoxybenzamine....................................................36
PHENYTEK...........................................................29
phenytoin oral suspension 100 mg/4 ml......................29
Premier_15283_v14_1511_1
phenytoin oral suspension 125 mg/5 ml......................29
phenytoin oral tablet,chewable...................................29
phenytoin sodium extended........................................29
phenytoin sodium intravenous solution.......................29
phenytoin sodium intravenous syringe........................29
philith......................................................................54
PHOSLO................................................................60
phospha 250 neutral.................................................60
PHOSPHOLINE IODIDE....................................56
PHYSIOLYTE........................................................42
PHYSIOSOL IRRIGATION.................................42
pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 %.......56
pilocarpine hcl oral tablet 5 mg.................................42
pilocarpine hcl oral tablet 7.5 mg..............................42
pindolol...................................................................36
pioglitazone oral tablet 15 mg...................................46
pioglitazone-glimepiride............................................46
pioglitazone-metformin.............................................46
piperacillin-tazobactam............................................13
pirmella oral tablet 1-35 mg-mcg..............................54
piroxicam.................................................................29
PLASMA-LYTE 148...............................................60
PLASMA-LYTE A..................................................60
PLASMA-LYTE-56 IN 5 % DEXTROSE..............60
PLETAL.................................................................36
podofilox..................................................................40
polycin.....................................................................56
polyethylene glycol 3350 oral.....................................49
polymyxin b sulf-trimethoprim...................................56
polymyxin b sulfate...................................................13
POLYTRIM...........................................................56
POMALYST...........................................................18
portia.......................................................................54
potassium bicarb and chloride...................................60
potassium bicarb-citric acid.......................................60
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 10 meq/l, 30 meq/l, 40 meq/
l............................................................................60
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 20 meq/l...................................60
potassium chloride in 0.9%nacl intravenous parenteral
solution 20 meq/l, 40 meq/l....................................60
potassium chloride in 5 % dex intravenous parenteral
solution 20 meq/l, 30 meq/l, 40 meq/l.....................60
potassium chloride in lr-d5 intravenous parenteral
solution 20 meq/l...................................................60
87
potassium chloride in lr-d5 intravenous parenteral
solution 40 meq/l...................................................60
potassium chloride intravenous piggyback 10 meq/100
ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100
ml, 40 meq/100 ml................................................60
potassium chloride intravenous piggyback 10 meq/50
ml.........................................................................60
potassium chloride intravenous solution......................60
potassium chloride oral capsule, extended release.........61
potassium chloride oral liquid....................................61
potassium chloride oral tablet extended release............61
potassium chloride oral tablet,er particles/crystals.........61
potassium chloride-0.45 % nacl.................................61
potassium chloride-d5-0.2%nacl intravenous
parenteral solution 30 meq/l, 40 meq/l....................61
potassium citrate oral tablet extended release 10 meq
(1,080 mg), 5 meq (540 mg).................................59
POTIGA ORAL TABLET 200 MG, 400 MG.......29
POTIGA ORAL TABLET 300 MG.......................29
POTIGA ORAL TABLET 50 MG.........................29
PRADAXA..............................................................36
pramipexole oral tablet..............................................29
PRANDIN ORAL TABLET 0.5 MG.....................46
PRANDIN ORAL TABLET 1 MG........................46
PRANDIN ORAL TABLET 2 MG........................46
pravastatin...............................................................36
prazosin oral capsule 1 mg.........................................36
prazosin oral capsule 2 mg, 5 mg...............................37
PRECOSE ORAL TABLET 100 MG....................46
PRECOSE ORAL TABLET 25 MG......................46
PRECOSE ORAL TABLET 50 MG......................46
PRED FORTE.......................................................56
PRED MILD..........................................................56
PRED-G.................................................................56
PRED-G S.O.P.......................................................56
prednicarbate...........................................................40
prednisolone acetate..................................................56
prednisolone oral solution 15 mg/5 ml........................46
prednisolone sodium phosphate ophthalmic.................56
Premier_15283_v14_1511_1
prednisolone sodium phosphate oral solution 15 mg/5
ml, 5 mg base/5 ml (6.7 mg/5 ml)..........................46
prednisolone sodium phosphate oral tablet,
disintegrating........................................................46
prednisone intensol....................................................46
prednisone oral solution.............................................46
prednisone oral tablet................................................46
prednisone oral tablets,dose pack................................46
PREMARIN ORAL................................................54
PREMARIN VAGINAL.........................................54
premasol 10 %.........................................................61
PREMASOL 6 %....................................................61
PREMPRO.............................................................54
prenatal vitamin oral tablet......................................61
prevalite...................................................................37
previfem...................................................................54
PREZCOBIX..........................................................13
PREZISTA ORAL SUSPENSION.........................13
PREZISTA ORAL TABLET 150 MG, 75 MG......13
PREZISTA ORAL TABLET 600 MG, 800
MG......................................................................13
PRIFTIN................................................................13
PRIMAQUINE......................................................13
primidone................................................................29
PRIMSOL..............................................................13
PRISTIQ ORAL TABLET EXTENDED
RELEASE 24 HR 100 MG..................................29
RELEASE 24 HR 25 MG....................................29
RELEASE 24 HR 50 MG....................................29
PRIVIGEN.............................................................51
PROAIR HFA........................................................58
PROAIR RESPICLICK..........................................58
probenecid................................................................53
procainamide injection solution 100 mg/ml................37
procainamide injection solution 500 mg/ml................37
PROCALAMINE 3%.............................................61
prochlorperazine edisylate injection solution 10 mg/2
ml (5 mg/ml).........................................................49
prochlorperazine maleate oral....................................49
prochlorperazine maleate rectal..................................49
PROCRIT INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2
ML, 3,000 UNIT/ML, 4,000 UNIT/ML............51
PROCRIT INJECTION SOLUTION 20,000
UNIT/ML, 40,000 UNIT/ML............................51
procto-pak................................................................49
88
proctosol hc...............................................................49
proctozone-hc...........................................................49
progesterone micronized............................................54
PROGLYCEM.......................................................46
PROGRAF INTRAVENOUS................................18
PROLASTIN-C......................................................42
PROLEUKIN.........................................................51
PROLIA.................................................................53
PROMACTA ORAL TABLET 12.5 MG, 25 MG,
75 MG.................................................................37
PROMACTA ORAL TABLET 50 MG..................37
promethazine injection solution.................................58
PROMETRIUM....................................................54
propafenone oral capsule,extended release 12 hr..........37
propafenone oral tablet..............................................37
propantheline...........................................................49
propranolol intravenous............................................37
propranolol oral capsule,extended release 24 hr...........37
propranolol oral solution 20 mg/5 ml.........................37
propranolol oral solution 40 mg/5 ml.........................37
propranolol oral tablet 10 mg, 20 mg, 40 mg, 80
mg........................................................................37
propranolol oral tablet 60 mg....................................37
propranolol-hydrochlorothiazid..................................37
propylthiouracil........................................................46
PROQUAD (PF)....................................................51
PROSOL 20 %.......................................................61
PROTOPIC...........................................................40
protriptyline oral tablet 10 mg...................................29
protriptyline oral tablet 5 mg.....................................29
PROVERA.............................................................54
prudoxin..................................................................40
PULMOZYME......................................................58
PURIXAN..............................................................18
pyrazinamide...........................................................13
pyridostigmine bromide oral tablet.............................29
pyridostigmine bromide oral tablet extended
release...................................................................29
QUADRACEL (PF)...............................................51
QUALAQUIN.......................................................13
quasense...................................................................54
quetiapine oral tablet 100 mg...................................29
quetiapine oral tablet 25 mg.....................................29
quetiapine oral tablet 50 mg.....................................29
quinapril..................................................................37
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quinapril-hydrochlorothiazide...................................37
quinidine sulfate oral tablet 200 mg..........................37
quinidine sulfate oral tablet 300 mg..........................37
quinine sulfate..........................................................13
QVAR INHALATION AEROSOL 40 MCG/
ACTUATION.....................................................58
QVAR INHALATION AEROSOL 80 MCG/
ACTUATION.....................................................58
RABAVERT (PF)...................................................51
raloxifene.................................................................53
ramipril...................................................................37
RANEXA................................................................37
ranitidine hcl injection..............................................49
ranitidine hcl oral syrup............................................49
ranitidine hcl oral tablet 150 mg...............................49
ranitidine hcl oral tablet 300 mg...............................49
RAPAFLO..............................................................59
RAPAMUNE ORAL SOLUTION.........................18
RAPAMUNE ORAL TABLET 0.5 MG.................18
RAPAMUNE ORAL TABLET 1 MG, 2 MG........18
REBETOL ORAL SOLUTION.............................13
REBIF (WITH ALBUMIN)...................................51
REBIF REBIDOSE................................................51
REBIF TITRATION PACK..................................51
reclipsen (28)............................................................54
RECOMBIVAX HB (PF) INTRAMUSCULAR
SUSPENSION....................................................51
SYRINGE 10 MCG/ML.....................................51
SYRINGE 5 MCG/0.5 ML.................................51
regonol.....................................................................29
RELENZA DISKHALER.......................................13
RELISTOR SUBCUTANEOUS SOLUTION......49
RELISTOR SUBCUTANEOUS SYRINGE..........49
REMICADE...........................................................49
REMODULIN.......................................................37
RENAGEL.............................................................42
RENVELA ORAL POWDER IN PACKET 0.8
GRAM.................................................................42
RENVELA ORAL POWDER IN PACKET 2.4
GRAM.................................................................42
RENVELA ORAL TABLET...................................42
repaglinide oral tablet 0.5 mg....................................46
repaglinide oral tablet 1 mg.......................................46
repaglinide oral tablet 2 mg.......................................46
REQUIP XL...........................................................29
RESCRIPTOR.......................................................13
89
RISPERDAL CONSTA INTRAMUSCULAR
SYRINGE 50 MG/2 ML.....................................30
risperidone oral solution............................................30
risperidone oral tablet 0.25 mg..................................30
risperidone oral tablet 0.5 mg....................................30
risperidone oral tablet 1 mg.......................................30
risperidone oral tablet,disintegrating 0.25 mg.............30
risperidone oral tablet,disintegrating 0.5 mg...............30
risperidone oral tablet,disintegrating 1 mg..................30
RITUXAN..............................................................18
rivastigmine tartrate oral capsule...............................30
ropinirole.................................................................30
rosadan topical cream...............................................40
rosadan topical gel....................................................40
ROTARIX..............................................................51
ROTATEQ VACCINE..........................................51
ROZEREM............................................................30
SABRIL ORAL POWDER IN PACKET...............30
SABRIL ORAL TABLET.......................................30
SAMSCA ORAL TABLET 15 MG........................46
SAMSCA ORAL TABLET 30 MG........................46
SANDIMMUNE....................................................18
SANDOSTATIN LAR DEPOT.............................18
SANTYL.................................................................40
SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET 10 MG.................................................30
TABLET 2.5 MG................................................30
TABLET 5 MG...................................................30
SARAFEM ORAL TABLET 10 MG......................30
SARAFEM ORAL TABLET 20 MG......................30
SAVELLA ORAL TABLET 100 MG.....................53
SAVELLA ORAL TABLET 12.5 MG....................53
SAVELLA ORAL TABLET 25 MG.......................53
SAVELLA ORAL TABLET 50 MG.......................53
SAVELLA ORAL TABLETS,DOSE PACK...........53
selegiline hcl.............................................................30
selenium sulfide topical suspension.............................40
SELZENTRY.........................................................14
SENSIPAR ORAL TABLET 30 MG......................46
reserpine oral tablet 0.1 mg.......................................37
RESTASIS..............................................................56
RETROVIR INTRAVENOUS..............................13
REVATIO INTRAVENOUS.................................58
REVLIMID ORAL CAPSULE 10 MG..................18
REVLIMID ORAL CAPSULE 15 MG, 2.5 MG,
20 MG, 25 MG...................................................18
REVLIMID ORAL CAPSULE 5 MG....................18
REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1
MG, 2 MG..........................................................29
REXULTI ORAL TABLET 3 MG, 4 MG.............29
REYATAZ ORAL CAPSULE 150 MG, 200 MG,
300 MG...............................................................13
REYATAZ ORAL POWDER IN PACKET...........14
RHEUMATREX ORAL TABLETS,DOSE PACK
2.5 MG................................................................18
RHEUMATREX ORAL TABLETS,DOSE PACK
2.5 MG (DOSE PACK 12), 2.5 MG (DOSE
PACK 16), 2.5 MG (DOSE PACK 20), 2.5 MG
(DOSE PACK 8).................................................18
RHINOCORT AQUA...........................................58
ribasphere oral tablet 200 mg....................................14
ribavirin oral capsule................................................14
ribavirin oral tablet 200 mg......................................14
RIDAURA..............................................................53
rifabutin..................................................................14
RIFADIN...............................................................14
RIFAMATE............................................................14
rifampin intravenous................................................14
rifampin oral............................................................14
RIFATER...............................................................14
riluzole....................................................................42
rimantadine.............................................................14
ringers intravenous....................................................61
ringers irrigation.......................................................42
RIOMET................................................................46
risedronate oral tablet 150 mg...................................53
risedronate oral tablet 30 mg.....................................42
risedronate oral tablet 35 mg.....................................53
risedronate oral tablet 35 mg (12 pack)......................53
risedronate oral tablet 5 mg.......................................53
SYRINGE 12.5 MG/2 ML, 25 MG/2 ML..........30
SYRINGE 37.5 MG/2 ML..................................30
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90
SEREVENT DISKUS............................................58
SEROQUEL XR ORAL TABLET EXTENDED
RELEASE 24 HR 150 MG..................................30
RELEASE 24 HR 200 MG..................................30
RELEASE 24 HR 300 MG..................................30
RELEASE 24 HR 400 MG..................................30
RELEASE 24 HR 50 MG....................................30
sertraline oral concentrate..........................................30
sertraline oral tablet 100 mg.....................................30
sertraline oral tablet 25 mg.......................................30
sertraline oral tablet 50 mg.......................................30
sf 5000 plus..............................................................42
sildenafil intravenous................................................58
sildenafil oral...........................................................58
SILVADENE..........................................................40
silver sulfadiazine.....................................................40
SIMBRINZA..........................................................56
SIMPONI...............................................................53
SIMULECT INTRAVENOUS RECON SOLN
10 MG.................................................................18
SIMULECT INTRAVENOUS RECON SOLN
20 MG.................................................................18
simvastatin...............................................................37
sirolimus..................................................................18
sodium bicarbonate intravenous solution....................61
sodium bicarbonate intravenous syringe......................61
sodium chloride 0.45 % intravenous parenteral
solution.................................................................61
sodium chloride 0.45 % intravenous piggyback..........61
sodium chloride 0.9 % intravenous............................42
sodium chloride 3 %.................................................61
sodium chloride 5 %.................................................61
sodium chloride intravenous......................................61
sodium chloride irrigation.........................................42
sodium citrate-citric acid...........................................59
sodium fluoride oral tablet.........................................61
sodium fluoride oral tablet,chewable 0.25 mg fluorid
(0.55 mg), 0.5 mg fluoride (1.1 mg).......................61
sodium fluoride oral tablet,chewable 1 mg fluoride
(2.2 mg)...............................................................61
sodium lactate intravenous solution............................61
sodium phenylbutyrate..............................................42
sodium polystyrene (sorb free).....................................42
Premier_15283_v14_1511_1
sodium polystyrene sulfonate oral powder....................42
sodium polystyrene sulfonate oral suspension...............42
sodium polystyrene sulfonate rectal.............................42
SODIUM POLYSTYRENE SULFONATE
RECTAL.............................................................42
SOLARAZE............................................................40
SOLTAMOX..........................................................18
SOMATULINE DEPOT.......................................18
SOMAVERT..........................................................47
sorine oral tablet 120 mg, 160 mg, 80 mg..................37
sorine oral tablet 240 mg..........................................37
sotalol af oral tablet 120 mg, 160 mg.........................37
sotalol af oral tablet 80 mg........................................37
sotalol oral tablet 120 mg, 160 mg, 240 mg...............37
sotalol oral tablet 80 mg............................................37
SOVALDI..............................................................14
SPIRIVA RESPIMAT INHALATION MIST 2.5
MCG/ACTUATION..........................................58
SPIRIVA WITH HANDIHALER..........................58
spironolacton-hydrochlorothiaz..................................37
spironolactone oral tablet 100 mg, 50 mg...................37
spironolactone oral tablet 25 mg................................37
sprintec (28).............................................................54
SPRYCEL...............................................................18
sps oral.....................................................................42
sps rectal...................................................................42
sronyx......................................................................54
ssd............................................................................40
STARLIX ORAL TABLET 120 MG......................47
STARLIX ORAL TABLET 60 MG........................47
stavudine.................................................................14
STIMATE..............................................................47
STIOLTO RESPIMAT..........................................58
STIVARGA............................................................18
STRATTERA ORAL CAPSULE 10 MG, 18 MG,
25 MG, 40 MG...................................................30
STRATTERA ORAL CAPSULE 100 MG, 60 MG,
80 MG.................................................................30
STREPTOMYCIN INTRAMUSCULAR..............14
STRIBILD..............................................................14
STROMECTOL....................................................14
SUBOXONE SUBLINGUAL FILM 12-3 MG......30
SUBOXONE SUBLINGUAL FILM 2-0.5
MG......................................................................31
SUBOXONE SUBLINGUAL FILM 4-1 MG........31
SUBOXONE SUBLINGUAL FILM 8-2 MG........31
SUBSYS..................................................................31
SUCRAID..............................................................49
91
SYNTHROID........................................................47
SYPRINE................................................................42
TABLOID..............................................................18
TACLONEX TOPICAL OINTMENT.................40
TACLONEX TOPICAL SUSPENSION...............41
tacrolimus oral capsule 0.5 mg, 1 mg.........................18
tacrolimus oral capsule 5 mg......................................18
tacrolimus topical.....................................................41
TAFINLAR............................................................18
TAMIFLU ORAL CAPSULE 30 MG....................14
TAMIFLU ORAL SUSPENSION FOR
RECONSTITUTION.........................................14
tamoxifen.................................................................19
tamsulosin................................................................59
TANZEUM............................................................47
TAPAZOLE...........................................................47
TARCEVA.............................................................19
TARGRETIN.........................................................19
TARKA...................................................................37
TASIGNA..............................................................19
TASMAR ORAL TABLET 100 MG......................31
TAZORAC.............................................................41
taztia xt...................................................................37
TECFIDERA..........................................................31
TEFLARO..............................................................14
TEGRETOL ORAL SUSPENSION......................31
TEGRETOL ORAL TABLET...............................31
TEGRETOL XR....................................................31
TEKTURNA..........................................................37
TEKTURNA HCT................................................37
telmisartan oral tablet 20 mg, 40 mg.........................37
telmisartan oral tablet 80 mg....................................37
telmisartan-amlodipine.............................................37
telmisartan-hydrochlorothiazid oral tablet 40-12.5
mg, 80-25 mg.......................................................37
telmisartan-hydrochlorothiazid oral tablet 80-12.5
mg........................................................................37
TENORETIC 100..................................................37
TENORETIC 50....................................................37
TENORMIN..........................................................37
TERAZOL 3 VAGINAL CREAM.........................54
TERAZOL 7..........................................................54
terazosin..................................................................37
terbinafine hcl oral...................................................14
terbutaline oral.........................................................58
terbutaline subcutaneous...........................................58
sucralfate oral tablet..................................................49
sulfacetamide sodium (acne)......................................40
sulfacetamide sodium ophthalmic drops......................56
sulfacetamide sodium ophthalmic ointment................56
sulfacetamide-prednisolone........................................56
sulfadiazine oral.......................................................14
sulfamethoxazole-trimethoprim intravenous...............14
sulfamethoxazole-trimethoprim oral suspension...........14
sulfamethoxazole-trimethoprim oral tablet 400-80
mg........................................................................14
sulfamethoxazole-trimethoprim oral tablet 800-160
mg........................................................................14
SULFAMYLON TOPICAL CREAM.....................40
sulfasalazine.............................................................49
sulfazine...................................................................49
sulfazine ec...............................................................49
sulindac oral.............................................................31
sumatriptan nasal spray,non-aerosol 20 mg/
actuation...............................................................31
sumatriptan nasal spray,non-aerosol 5 mg/
actuation...............................................................31
sumatriptan succinate oral.........................................31
sumatriptan succinate subcutaneous cartridge.............31
sumatriptan succinate subcutaneous pen injector 4 mg/
0.5 ml, 6 mg/0.5 ml..............................................31
sumatriptan succinate subcutaneous pen injector 6 mg/
0.5 ml (auto-injector)............................................31
sumatriptan succinate subcutaneous solution...............31
sumatriptan succinate subcutaneous syringe 6 mg/0.5
ml.........................................................................31
SUPRAX ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML, 200 MG/
5 ML....................................................................14
SUPRAX ORAL SUSPENSION FOR
RECONSTITUTION 500 MG/5 ML................14
SUPREP BOWEL PREP KIT................................49
SURMONTIL........................................................31
SUSTIVA...............................................................14
SUTENT................................................................18
syeda........................................................................54
SYLATRON...........................................................52
SYMLINPEN 120..................................................47
SYMLINPEN 60....................................................47
SYNAGIS...............................................................14
SYNALGOS-DC....................................................31
SYNAREL..............................................................47
SYNERCID............................................................14
SYNRIBO...............................................................18
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92
terconazole vaginal cream 0.4 %...............................54
terconazole vaginal cream 0.8 %...............................54
terconazole vaginal suppository..................................54
TESTIM.................................................................47
testosterone cypionate.................................................47
testosterone enanthate................................................47
testosterone transdermal gel in packet.........................47
TETANUS,DIPHTHERIA TOX PED(PF)...........52
TETANUS-DIPHTHERIA TOXOIDS-TD.........52
tetrabenazine oral tablet 12.5 mg..............................31
tetrabenazine oral tablet 25 mg.................................31
tetracycline...............................................................14
THALOMID ORAL CAPSULE 100 MG, 50
MG......................................................................19
THALOMID ORAL CAPSULE 150 MG, 200
MG......................................................................19
theophylline oral elixir..............................................58
theophylline oral solution...........................................58
theophylline oral tablet extended release......................58
theophylline oral tablet extended release 12 hr 100
mg........................................................................58
theophylline oral tablet extended release 12 hr 200 mg,
300 mg, 450 mg....................................................58
thioridazine.............................................................31
thiotepa....................................................................19
thiothixene...............................................................31
THYMOGLOBULIN............................................52
tiagabine..................................................................31
TIAZAC.................................................................37
TICE BCG.............................................................52
TIKOSYN..............................................................37
tilia fe......................................................................54
timolol maleate ophthalmic drops...............................56
timolol maleate ophthalmic gel forming solution.........56
timolol maleate oral..................................................37
TIMOPTIC............................................................56
TIMOPTIC OCUDOSE (PF)...............................56
TIMOPTIC-XE......................................................56
tinidazole.................................................................14
TIVICAY................................................................14
tizanidine oral capsule 2 mg, 4 mg............................31
tizanidine oral capsule 6 mg......................................31
tizanidine oral tablet................................................31
TOBRADEX OPHTHALMIC DROPS,
SUSPENSION....................................................56
TOBRADEX OPHTHALMIC OINTMENT.......56
TOBRADEX ST.....................................................56
tobramycin...............................................................56
Premier_15283_v14_1511_1
tobramycin in 0.225 % nacl.....................................14
tobramycin in 0.9 % nacl intravenous piggyback 80
mg/100 ml............................................................14
tobramycin sulfate injection recon soln.......................14
tobramycin sulfate injection solution..........................14
tobramycin-dexamethasone........................................56
TOBREX................................................................56
tolazamide oral tablet 250 mg...................................47
tolazamide oral tablet 500 mg...................................47
tolbutamide..............................................................47
tolcapone..................................................................31
tolmetin oral capsule.................................................31
tolmetin oral tablet 200 mg.......................................31
tolmetin oral tablet 600 mg.......................................31
tolterodine oral tablet 1 mg.......................................59
tolterodine oral tablet 2 mg.......................................59
TOPAMAX ORAL CAPSULE, SPRINKLE..........31
TOPAMAX ORAL TABLET 100 MG, 25 MG,
50 MG.................................................................31
TOPAMAX ORAL TABLET 200 MG..................31
TOPICORT TOPICAL CREAM..........................41
TOPICORT TOPICAL GEL.................................41
TOPICORT TOPICAL OINTMENT..................41
topiramate oral capsule, sprinkle................................31
topiramate oral tablet...............................................31
toposar.....................................................................19
topotecan..................................................................19
TOPROL XL..........................................................37
TORISEL...............................................................19
torsemide oral...........................................................37
TOUJEO SOLOSTAR...........................................47
TOVIAZ.................................................................59
TPN ELECTROLYTES.........................................61
TRACLEER............................................................58
TRADJENTA.........................................................47
tramadol oral tablet..................................................31
tramadol oral tablet extended release 24 hr 100 mg,
200 mg.................................................................31
tramadol-acetaminophen...........................................31
trandolapril..............................................................37
trandolapril-verapamil..............................................37
tranexamic acid intravenous......................................37
tranexamic acid oral.................................................54
tranylcypromine........................................................31
travasol 10 %...........................................................61
TRAVATAN Z.......................................................56
travoprost (benzalkonium)........................................56
trazodone oral tablet 100 mg, 150 mg, 50 mg............31
93
TRUVADA............................................................14
TWINRIX (PF) INTRAMUSCULAR
SUSPENSION....................................................52
TWINRIX (PF) INTRAMUSCULAR
SYRINGE............................................................52
TYBOST................................................................14
TYGACIL...............................................................14
TYKERB.................................................................19
TYPHIM VI INTRAMUSCULAR
SOLUTION........................................................52
TYPHIM VI INTRAMUSCULAR SYRINGE.......52
TYSABRI................................................................31
TYVASO................................................................58
TYVASO INSTITUTIONAL START KIT...........58
TYVASO REFILL KIT...........................................58
TYVASO STARTER KIT......................................58
TYZEKA................................................................14
TYZINE NASAL DROPS 0.05 %.........................42
U-CORT................................................................41
UCERIS ORAL......................................................49
ULORIC................................................................53
unithroid oral tablet 100 mcg, 112 mcg, 125 mcg,
137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50
mcg, 75 mcg, 88 mcg.............................................47
unithroid oral tablet 300 mcg....................................47
UNITUXIN...........................................................19
ursodiol oral capsule..................................................49
ursodiol oral tablet....................................................49
UVADEX...............................................................41
VAGIFEM..............................................................54
valacyclovir oral tablet 1 gram...................................14
valacyclovir oral tablet 500 mg..................................14
VALCHLOR..........................................................41
VALCYTE ORAL TABLET...................................14
valganciclovir...........................................................14
valproate sodium......................................................31
valproic acid.............................................................31
valproic acid (as sodium salt) oral solution 250 mg/5
ml.........................................................................31
valproic acid (as sodium salt) oral solution 250 mg/5
ml (5 ml), 500 mg/10 ml (10 ml)..........................31
valsartan oral tablet 160 mg.....................................37
valsartan oral tablet 320 mg.....................................37
valsartan oral tablet 40 mg, 80 mg............................38
valsartan-hydrochlorothiazide....................................38
VANCOMYCIN IN D5W INTRAVENOUS
PIGGYBACK 1 GRAM/200 ML........................14
trazodone oral tablet 300 mg.....................................31
TREANDA.............................................................19
TRECATOR..........................................................14
TRELSTAR............................................................19
TRELSTAR DEPOT..............................................19
TRELSTAR LA......................................................19
tretinoin (chemotherapy)...........................................19
tretinoin topical cream..............................................41
tretinoin topical gel 0.01 %, 0.025 %.......................41
TREXALL..............................................................19
tri-estarylla...............................................................54
tri-legest fe................................................................54
tri-linyah.................................................................54
tri-previfem (28)......................................................54
tri-sprintec (28)........................................................54
triamcinolone acetonide dental..................................42
triamcinolone acetonide injection suspension 10 mg/
ml.........................................................................47
triamcinolone acetonide injection suspension 40 mg/
ml.........................................................................47
triamcinolone acetonide nasal....................................58
triamcinolone acetonide topical aerosol.......................41
triamcinolone acetonide topical cream........................41
triamcinolone acetonide topical lotion........................41
triamcinolone acetonide topical ointment 0.025 %,
0.1 %, 0.5 %........................................................41
triamterene-hydrochlorothiazid oral capsule 37.5-25
mg........................................................................37
triamterene-hydrochlorothiazid oral tablet..................37
trianex.....................................................................41
TRIBENZOR.........................................................37
triderm topical cream................................................41
trifluoperazine..........................................................31
trifluridine...............................................................56
TRILEPTAL...........................................................31
trilyte with flavor packets..........................................49
trimethoprim............................................................14
trinessa (28).............................................................54
TRISENOX............................................................19
TRIUMEQ.............................................................14
trivora (28)..............................................................54
TRIZIVIR..............................................................14
TROPHAMINE 10 %...........................................61
TROPHAMINE 6%..............................................61
tropicamide ophthalmic.............................................56
trospium oral tablet..................................................59
TRULICITY...........................................................47
TRUMENBA.........................................................52
Premier_15283_v14_1511_1
94
VANCOMYCIN IN D5W INTRAVENOUS
PIGGYBACK 500 MG/100 ML.........................14
VANCOMYCIN IN DEXTROSE ISO-OSM.......14
vancomycin intravenous............................................14
VANCOMYCIN INTRAVENOUS 750 MG........15
vancomycin oral capsule 125 mg................................15
vancomycin oral capsule 250 mg................................15
vandazole.................................................................54
VANOS..................................................................41
VAQTA (PF) INTRAMUSCULAR
SUSPENSION....................................................52
VAQTA (PF) INTRAMUSCULAR SYRINGE......52
VARIVAX (PF).......................................................52
VARIZIG INTRAMUSCULAR RECON
SOLN..................................................................52
VARIZIG INTRAMUSCULAR SOLUTION.......52
VECAMYL.............................................................38
VECTIBIX.............................................................19
VELCADE..............................................................19
velivet triphasic regimen (28)....................................54
VELTIN.................................................................41
venlafaxine oral capsule,extended release 24hr 150
mg........................................................................31
venlafaxine oral capsule,extended release 24hr 37.5
mg........................................................................31
venlafaxine oral capsule,extended release 24hr 75
mg........................................................................31
venlafaxine oral tablet 100 mg..................................32
venlafaxine oral tablet 25 mg....................................32
venlafaxine oral tablet 37.5 mg.................................32
venlafaxine oral tablet extended release 24hr 150
mg........................................................................32
VENLAFAXINE ORAL TABLET EXTENDED
RELEASE 24HR 225 MG...................................32
venlafaxine oral tablet extended release 24hr 37.5
mg........................................................................32
venlafaxine oral tablet extended release 24hr 75
mg........................................................................32
VENTAVIS............................................................58
VERAMYST...........................................................58
verapamil intravenous solution..................................38
verapamil intravenous syringe....................................38
verapamil oral capsule, 24 hr er pellet ct....................38
verapamil oral capsule,ext rel. pellets 24 hr.................38
verapamil oral tablet 120 mg, 80 mg.........................38
verapamil oral tablet 40 mg......................................38
Premier_15283_v14_1511_1
verapamil oral tablet extended release.........................38
veripred 20...............................................................47
VERSACLOZ.........................................................32
VESICARE.............................................................59
vestura (28)..............................................................54
VEXOL..................................................................56
VIBRAMYCIN ORAL CAPSULE 100 MG...........15
VIBRAMYCIN ORAL SUSPENSION FOR
RECONSTITUTION.........................................15
VIBRAMYCIN ORAL SYRUP..............................15
VICTOZA 2-PAK..................................................47
VICTOZA 3-PAK..................................................47
VIDEX 2 GRAM PEDIATRIC..............................15
VIDEX 4 GRAM PEDIATRIC..............................15
VIEKIRA PAK........................................................15
VIGAMOX.............................................................56
VIIBRYD ORAL TABLET 10 MG........................32
VIIBRYD ORAL TABLETS,DOSE PACK 10 MG
(7)- 20 MG (23)..................................................32
VIIBRYD ORAL TABLETS,DOSE PACK 10 MG
(7)-20 MG (7)-40 MG (16).................................32
VIMPAT INTRAVENOUS...................................32
VIMPAT ORAL SOLUTION...............................32
VIMPAT ORAL TABLET 100 MG.......................32
VIMPAT ORAL TABLET 50 MG.........................32
vinblastine intravenous solution.................................19
vincasar pfs intravenous solution 1 mg/ml..................19
vincasar pfs intravenous solution 2 mg/2 ml...............19
vincristine................................................................19
vinorelbine...............................................................19
viorele (28)..............................................................54
VIRACEPT ORAL TABLET.................................15
VIRAMUNE XR....................................................15
VIRAZOLE............................................................15
VIREAD ORAL POWDER...................................15
VIREAD ORAL TABLET 150 MG, 300 MG.......15
VIREAD ORAL TABLET 200 MG, 250 MG.......15
VIROPTIC.............................................................56
VITEKTA...............................................................15
VOLTAREN GEL TOPICAL GEL 1 %................32
voriconazole intravenous...........................................15
voriconazole oral suspension for reconstitution............15
voriconazole oral tablet 200 mg.................................15
voriconazole oral tablet 50 mg...................................15
95
VOTRIENT...........................................................19
VYTORIN 10-10...................................................38
VYTORIN 10-20...................................................38
VYTORIN 10-40...................................................38
VYTORIN 10-80...................................................38
warfarin..................................................................38
water for irrigation, sterile.........................................42
WELCHOL............................................................38
XALKORI..............................................................19
XARELTO ORAL TABLET 10 MG, 20 MG........38
XARELTO ORAL TABLET 15 MG......................38
XARELTO ORAL TABLETS,DOSE PACK..........38
XENAZINE ORAL TABLET 12.5 MG.................32
XENAZINE ORAL TABLET 25 MG....................32
XEOMIN...............................................................52
XGEVA..................................................................19
XIFAXAN ORAL TABLET 200 MG.....................15
XOLAIR.................................................................58
XTANDI................................................................19
XULANE................................................................54
XYREM..................................................................32
YERVOY................................................................19
YF-VAX (PF)..........................................................52
zafirlukast................................................................59
zaleplon oral capsule 10 mg.......................................32
zaleplon oral capsule 5 mg.........................................32
ZALTRAP..............................................................19
ZAMICET..............................................................32
ZANOSAR.............................................................19
zarah.......................................................................54
ZARONTIN..........................................................32
ZAVESCA..............................................................47
zazole vaginal cream 0.4 %......................................55
zazole vaginal cream 0.8 %......................................55
ZELAPAR...............................................................32
ZELBORAF............................................................19
zenchent (28)...........................................................55
zenchent fe...............................................................55
ZENPEP.................................................................49
zeosa........................................................................55
ZETIA....................................................................38
ZIAC......................................................................38
ZIAGEN ORAL SOLUTION................................15
ZIANA...................................................................41
zidovudine oral capsule.............................................15
zidovudine oral syrup................................................15
Premier_15283_v14_1511_1
zidovudine oral tablet...............................................15
ZIOPTAN (PF)......................................................56
ziprasidone hcl oral capsule 20 mg.............................32
ziprasidone hcl oral capsule 40 mg.............................32
ziprasidone hcl oral capsule 60 mg, 80 mg..................32
ZIRGAN................................................................56
ZITHROMAX.......................................................15
ZITHROMAX TRI-PAK.......................................15
ZITHROMAX Z-PAK...........................................15
ZMAX....................................................................15
ZOFRAN (AS HYDROCHLORIDE)
INTRAVENOUS................................................49
zoledronic acid intravenous recon soln........................47
zoledronic acid intravenous solution...........................47
ZOLINZA..............................................................19
zolpidem oral tablet..................................................32
ZOMETA INTRAVENOUS SOLUTION 4 MG/
100 ML................................................................47
ZONALON............................................................41
zonisamide...............................................................32
ZORTRESS ORAL TABLET 0.25 MG.................19
ZORTRESS ORAL TABLET 0.5 MG, 0.75
MG......................................................................19
ZOSTAVAX (PF)...................................................52
zovia 1/35e (28).......................................................55
zovia 1/50e (28).......................................................55
ZOVIRAX ORAL...................................................15
ZOVIRAX TOPICAL CREAM.............................41
ZYDELIG...............................................................19
ZYKADIA..............................................................19
ZYLET...................................................................56
ZYLOPRIM...........................................................53
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 210
MG, 405 MG......................................................32
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 300
MG......................................................................32
ZYTIGA.................................................................19
ZYVOX INTRAVENOUS PARENTERAL
SOLUTION 200 MG/100 ML...........................15
ZYVOX INTRAVENOUS PARENTERAL
SOLUTION 600 MG/300 ML...........................15
ZYVOX ORAL SUSPENSION FOR
RECONSTITUTION.........................................15
ZYVOX ORAL TABLET.......................................15
96
Blue Cross and Blue Shield of Kansas City is a PDP plan with a Medicare contract. Enrollment in Blue Cross
and Blue Shield of Kansas City depends on contract renewal.
Blue Cross and Blue Shield of Kansas City provides administrative services for Blue MedicareRx Plans.
Anthem Insurance Companies, Inc. is the legal entity that has contracted with the Centers for Medicare &
Medicaid Services (CMS) to offer the Part D plans noted. AICI is the risk-bearing entity licensed under
applicable state law or under a federal waiver program to offer the Part D plans noted. Blue Cross and Blue
Shield of Kansas City's service area covers 30 counties in greater Kansas City and northwest Missouri, plus
Johnson and Wyandotte counties in Kansas. Blue Cross and Blue Shield of Kansas City and Anthem Insurance
®
Companies, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross
and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
This information is available for free in other languages. Please contact our customer service number
at 1-866-755-2776 or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving
and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from
February 15 through September 30.
This formulary was updated on October 1, 2015. For more recent information or other questions, please
contact Blue MedicareRx Premier (PDP) Customer Service at 1-866-755-2776 or, for TTY users, 711, 8 a.m.
to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14,
and Monday to Friday (except holidays) from February 15 through September 30, or visit
www.partdkansascity.com/shop.
45979MUSENMUB_021 S5596_045
KCMO

2015 Formulary (List of Covered Drugs)When this drug list

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