2016 PreferredOne/Clearscript Formulary

Transcription

2016 FORMULARY
(Foundation)
EFFECTIVE 01/01/16
Introduction
This closed formulary is a list of generic and brand medications covered by your prescription drug
benefit. Please note that this formulary is not a complete list of medications and not all listed drugs
may be covered by your plan. It is designed to offer you and your doctor cost-effective choices for safe
and clinically effective prescription drugs.
Coverage for the drugs included on the 2016 PreferredOne Formulary is determined by your
benefit plan design. Please refer to the benefit documents provided by your employer or health
plan for information on your specific benefit coverage. You may also contact the PreferredOne
Customer Service Department at 1-800-997-1750 or visit PreferredOne.com for more
information.
How is the formulary developed?
This formulary was developed based on the recommendations of an independent Pharmacy and
Therapeutics (P&T) Committee comprised of doctors and pharmacists. This committee meets several
times a year to review and select safe, clinically sound, cost-effective drugs for the formulary. Ongoing
review of clinical literature is conducted to evaluate safety, effectiveness and current use in therapy to
determine whether a drug should be included in the formulary.
Does the formulary change throughout the year?
The 2016 PreferredOne Formulary may change throughout the year as new drugs or clinical
information becomes available. Drugs may be added as they are introduced to the marketplace and
other drugs may change tier status as generics become available.
Please contact the PreferredOne Customer Service Department at 1-800-997-1750 or
visit PreferredOne.com for the most current formulary information.
What are formulary tiers?
This formulary is made up of different cost levels or tiers. Your health plan or employer determines your
out-of-pocket costs for each tier. Check your plan’s benefit documents to understand your benefit
structure and out-of-pocket costs. If you are prescribed a drug on a higher tier, discuss the alternative
lower tier options with your doctor to help save money on your out of pocket costs.
Are generic drugs different than brand drugs?
Generic drugs are approved by the U.S. Food and Drug Administration (FDA) to be just as safe and
effective as brand drugs. Although they have the same active ingredients, generic drugs generally cost
significantly less than brand drugs. You can lower your out-of-pocket expenses by asking your doctor if
a generic medication is right for you.
How do I fill my specialty medication?
Specialty medications are typically used to treat rare or chronic conditions and often require special
handling.
To ensure the safest, most clinically appropriate and cost-effective dispensing of these medications,
your plan may require you to fill your prescriptions at a designated specialty pharmacy. Specialty
pharmacies provide personalized care and offer convenient delivery to your home or other approved
location.
Please contact the PreferredOne Customer Service Department at 1-800-997-1750 or visit
PreferredOne.com for the most current formulary information.
Are there any restrictions on my coverage?
Some medications on the formulary may have additional requirements or limits on coverage. These
requirements or limits may include:
Prior Authorization — Your benefit plan may require that the medication you have been prescribed
receive prior authorization. This means that you will need to get approval from your plan before you fill
your prescription. If you don’t get approval, the medication may not be covered by your drug benefit.
Quantity Limits — For some drugs, your plan may limit the amount of the drug that is covered by your
benefit for a certain time period. Quantities that exceed this limit must be reviewed and approved by
your plan before coverage will apply.
Step Therapy — In some cases, your plan may require you to first try certain drugs to treat your
medical condition before another drug for that condition will be covered. For example, if two drugs are
used to treat the same medical condition, you may be required to first try one drug before the second
drug is covered.
Your doctor can request a prior authorization, a quantity limit override, or a step therapy override
approval by submitting the appropriate request form to PreferredOne on your behalf. PreferredOne will
review the request and make a determination of coverage for the drug.
For more information about the 2016 PreferredOne Formulary:
Call the PreferredOne Customer Service Department at 1-800-997-1750
Or, visit PreferredOne.com
TIER
DESCRIPTION
1
$0 Cost Share
2
Preferred Generics (Tier 1
Generics)
3
Generics (Tier 2 Generics)
4
Preferred Brands
5
Specialty/Injectables
6
Medical Service Drugs
TYPE
QL
PA
ST
PAGE 4
DESCRIPTION
Quantity Limit
There is a limit on the amount of this drug that is covered per
prescription, or within a specific time frame.
Prior Authorization
You (or your physician) are required to get prior authorization
before you fill your prescription for this drug. Without prior
approval, we may not cover this drug.
Step Therapy
In some cases, you may be required to first try certain drugs to
treat your medical condition before we will cover another
drug for that condition.
Preferred Drug
Preferred Drug.
LAST UPDATED 04/2016
LIST OF COVERED PRESCRIPTION MEDICATIONS
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
Analgesics
Nonsteroidal Anti-inflammatory Drugs
adult low dose aspirin ec (tablet dr)
1
aspir 81 (tablet dr)
1
aspir-low (tablet dr)
1
aspirin (adult 81 mg chew tab, cvs 81 mg chewable
tab, eq 81 mg chewable tab, eql 81 mg chewable
tab, eql adt 81 mg tab chew, gnp 81 mg chewable
tab, hm 81 mg chewable tab, kro 81 mg chewable
tab, pub 81 mg chewable tab, pv 81 mg chewable
tab, qc 81 mg chewable tab, ra 81 mg chewable tab,
sm 81 mg chewable tab, 81 mg chew tablet, 81 mg
chewable tablet, 81 mg tablet chew)
1
aspirin ec (cvs ec 81 mg tablet, ec 81 mg tablet, eq
ec 81 mg tablet, eql ec 81 mg tablet, gnp ec 81 mg
tablet, hm ec 81 mg tablet, kro ec 81 mg tablet, pv
ec 81 mg tablet, ra ec 81 mg tablet, sb ec 81 mg
tablet, sm ec 81 mg tablet, v-r ec 81 mg tablet)
1
celecoxib 100 mg capsule
3
QL 90 / 30 DAYS
ST
3
QL 120 / 30 DAYS
ST
3
QL 60 / 30 DAYS
ST
3
QL 150 / 30 DAYS
ST
children's aspirin (tab chew)
1
diclofenac potassium (tablet)
2
diclofenac sodium (dr 25 mg tab, dr 50 mg tab, dr 75
mg tab, ec 25 mg tab, ec 50 mg tab, ec 75 mg tab)
2
diclofenac sodium er (tab er 24h)
2
PAGE 5
PRODUCT DESCRIPTION
TIER
diflunisal (tablet)
3
ecotrin ec 81 mg tablet
1
etodolac (200 mg capsule, 300 mg capsule, 400 mg
tablet, 500 mg tablet)
3
etodolac er (tab er 24h)
3
fenoprofen calcium (calcium 400 mg cap, 600 mg
tablet)
2
flurbiprofen (tablet)
2
halfprin (tablet dr)
1
hydrochlorothiazide 25 mg tab
2
ibuprofen (400 mg tablet, 600 mg tablet, 800 mg
tablet)
2
indomethacin (25 mg capsule, 50 mg capsule, er 75
mg capsule)
2
ketoprofen (50 mg capsule, 75 mg capsule)
2
ketorolac 10 mg tablet
2
ketorolac tromethamine (15 mg/ml vial, 30 mg/ml
isecure syr, 30 mg/ml vial, 30 mg/ml syringe, 60
mg/2 ml syringe, 60 mg/2 ml vial, 300 mg/10 ml
vial)
6
lo-dose aspirin ec (tablet dr)
1
low dose aspirin ec (tablet dr)
1
meclofenamate sodium (capsule)
3
mefenamic acid (capsule)
3
meloxicam (7.5 mg tablet, 15 mg tablet)
2
meloxicam 7.5 mg/5 ml susp
3
miniprin (tablet dr)
1
nabumetone (tablet)
2
PAGE 6
QL 20 / 30 DAYS
PRODUCT DESCRIPTION
TIER
naproxen (125 mg/5 ml suspen, 250 mg tablet, dr
375 mg tablet, 375 mg tablet, ec 375 mg tablet, 500
mg kit, 500 mg tablet, dr 500 mg tablet, ec 500 mg
tablet)
2
naproxen sodium (tablet)
2
oxaprozin (tablet)
3
oxycodone hcl-ibuprofen (tablet)
2
piroxicam (capsule)
3
st. joseph aspirin (81 mg chew, ec 81 mg tb)
1
sulindac (tablet)
2
tolmetin sodium (200 mg tab, 400 mg cap, 600 mg
tab)
3
Opioid Analgesics, Long-acting
fentanyl (12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75
mcg/hr, 100 mcg/hr)
3
fentanyl citrate (0.05 mg/ml ampul, 0.05 mg/ml vial,
100 mcg/2 ml vial, 100 mcg/2 ml ampul, 250 mcg/5
ml ampul, 250 mcg/5 ml vial, 1,000 mcg/20 ml
ampul, 1,000 mcg/20 ml vial, 2,500 mcg/50 ml vial)
6
fentanyl citrate (cit 1,200 mcg, cit 1,600 mcg, citrate
200 mcg, citrate 400 mcg, citrate 600 mcg, citrate
800 mcg)
3
levorphanol tartrate (tablet)
2
methadone hcl (hcl 5 mg tablet, 5 mg/5 ml solution,
10 mg/5 ml solution, 10 mg/ml oral conc, hcl 10 mg
tablet, 40 mg tablet dispr)
2
methadone hcl 10 mg/ml vial
6
methadone intensol (oral conc)
2
methadose 40 mg tablet dispr
2
morphine sulfate er (er 15 mg tablet, er 30 mg
tablet, er 60 mg tablet, er 100 mg tablet, er 200 mg
tablet)
3
PAGE 7
QL 10 / 30 DAYS
QL 120 / 30 DAYS
PRODUCT DESCRIPTION
TIER
oxycodone hcl er (er 10 mg tablet, er 20 mg tablet,
er 40 mg tablet, er 80 mg tablet)
3
QL 120 / 30 DAYS
oxycodone hcl er (er 15 mg tablet, er 30 mg tablet,
er 60 mg tablet)
3
QL 120 / 30 days
oxymorphone hcl er (tab er 12h)
3
tramadol hcl er (er 100 mg tablet, er 150 mg
capsule, er 200 mg tablet, er 300 mg tablet)
3
tramadol hcl er (er 100 mg tablet, er 200 mg tablet,
er 300 mg tablet)
3
QL 30 / 30 DAYS
Opioid Analgesics, Short-acting
acetaminophen-codeine (#2 tablet, #3 tablet, #4
tablet)
2
astramorph-pf (0.5 mg/ml amp, 1 mg/ml ampul)
6
buprenorphine hcl (0.3 mg/ml syrn, 0.3 mg/ml vial)
6
butorphanol 10 mg/ml spray
3
butorphanol tartrate (1 mg/ml vial, 2 mg/ml vial)
6
codeine sulfate (15 mg tablet, 30 mg tablet, 60 mg
tablet)
2
hydrocodone-acetaminophen (hydrocodonacetaminoph 7.5-325, hydrocodon-acetaminophen
5-325, hydrocodon-acetaminophn 10-325)
2
hydromorphone hcl (1 mg/ml solution, 5 mg/5 ml
soln)
3
hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mg
tablet)
2
hydromorphone hcl (hcl 1 mg/ml amp, 2 mg/ml vial,
hcl 2 mg/ml amp, hcl 10 mg/ml amp, 10 mg/ml vial,
hcl 10 mg/ml vl, 50 mg/5 ml vial, 500 mg/50 ml via)
6
meperidine hcl (10 mg/ml cartrdge, 25 mg/ml vial,
50 mg/ml vial, 100 mg/ml vial)
6
meperidine hcl (50 mg/5 ml solution, 50 mg tablet,
100 mg tablet)
2
PAGE 8
QL 15 / 90 DAYS
PRODUCT DESCRIPTION
TIER
morphine sulfate (0.5 mg/ml vial, sulfate 1 mg/ml
vial, 1 mg/ml vial p-f, 2 mg/ml syringe, 4 mg/ml
syringe, 5 mg/ml vial, 8 mg/ml syringe, 8 mg/ml vial,
10 mg/ml syringe, 10 mg/ml vial, sulfate 10 mg/ml
vial, 15 mg/ml vial, 100 mg/10 ml vial, 300 mg/20 ml
vial)
6
morphine sulfate (sulf 10 mg/5 ml soln, sulf 20 mg/5
ml soln, sulf 100 mg/5 ml soln, sulfate ir 15 mg tab,
sulfate ir 30 mg tab)
2
nalbuphine hcl (10 mg/ml ampul, 20 mg/ml ampul,
100 mg/10 ml vial, 200 mg/10 ml vial)
6
oxycodone hcl (15 mg tablet, 20 mg tablet, 30 mg
tablet)
3
oxycodone hcl (5 mg tablet, 10 mg tablet)
2
oxycodone-acetaminophen (oxycodonacetaminophen 7.5-325, oxycodone-acetaminophen
10-325)
3
oxycodone-acetaminophen 5-325
2
oxymorphone hcl (tablet)
3
Anesthetics
Local Anesthetics
lidocaine (ointment, patch)
3
lidocaine hcl (2% jelly, 4% solution)
2
lidocaine hcl 2% vial
6
lidocaine hcl in 5% dextrose (iv soln)
6
lidocaine hcl in 7.5% dextrose (ampul)
6
lidocaine hcl viscous (solution)
2
lidocaine-prilocaine (cream , kit)
3
proparacaine hcl (drops)
2
PAGE 9
PRODUCT DESCRIPTION
TIER
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium (tablet dr)
3
CAMPRAL (TABLET DR)
4
disulfiram (tablet)
3
naltrexone hcl (tablet)
3
VIVITROL (SUS ER REC)
6
Opioid Antagonists
buprenorphine hcl (2 mg tablet, 8 mg tablet)
3
naloxone hcl (0.4 mg/ml syringe, 0.4 mg/ml vial, 2
mg/2 ml syringe, 4 mg/10 ml vial)
6
Smoking Cessation Agents
buproban (tablet er)
1
CHANTIX (1 MG CONT MONTH BOX, 1 MG TABLET)
1
QL 90 / 30 DAYS
CHANTIX 0.5 MG TABLET
1
QL 60 / 30 DAYS
CHANTIX STARTING MONTH BOX
1
QL 120 / 30 DAYS
nicoderm cq (7 mg/24hr, 14 mg/24hr)
1
nicorelief (2 mg, 4 mg)
1
nicotine gum (2 mg, cvs 2 mg, cvs 4 mg, eq 2 mg, eq
4 mg, eql 2 mg, eql 4 mg, gnp 2 mg, gnp 4 mg, hm 2
mg, hm 4 mg, ldr 2 mg, ldr 4 mg, pc 2 mg, pv 2 mg,
pv 4 mg, ra 2 mg, ra 4 mg, sm 2 mg, sm 4 mg, sw 2
mg, sw 4 mg, 4 mg)
1
PAGE 10
PRODUCT DESCRIPTION
TIER
nicotine patch (cvs 7 mg/24hr, cvs 14 mg/24hr, cvs
14 mg/24 hr, eq 7 mg/24hr, eq 14 mg/24hr, hm 7
mg/24hr, hm 14 mg/24hr, kro 7 mg/24hr, kro 14
mg/24 hr, kro 14 mg/24hr, pv 7 mg/24 hr, pv 14
mg/24 hr, ra 7 mg/24hr, sm 7 mg/24hr, 7 mg/24hr,
14 mg/24hr, 14 mg/24 hr, ra 14 mg/24hr, sm 14
mg/24hr)
1
NICOTROL (CARTRIDGE)
1
NICOTROL NS (SPRAY)
1
quit 2 mg chewing gum
1
quit 4 mg chewing gum
1
Anti-inflammatory Agents
Glucocorticoids
a-methapred (vial)
5
alclometasone dipropionate (dipr oint, dipro crm)
3
amcinonide (cream, lotion, ointment)
3
apexicon (oint. )
3
apexicon e (cream )
3
betamethasone dipropionate (aug crm, aug gel, aug
lot, aug oin, crm, lot, oint)
3
betamethasone valerate (va cream, va lotion, valer
ointm)
3
clobetasol emollient (emollient crm, emollnt foam)
3
clobetasol emulsion (foam)
3
clobetasol propionate (cream, gel, ointment, prop
foam, shampoo, solution, topical lotn)
3
cormax (solution)
3
cortisone acetate (tablet)
2
desonide (cream, lotion, ointment)
3
PAGE 11
PRODUCT DESCRIPTION
TIER
desoximetasone (0.05% gel, 0.05% ointment, 0.05%
cream, 0.25% cream, 0.25% ointment)
3
dexamethasone sodium phosphate (4 mg/ml vial, 10
mg/ml vial, 20 mg/5 ml vial, 100 mg/10 ml vl, 120
mg/30 ml vl)
5
diflorasone diacetate (cream, ointment)
3
fludrocortisone acetate (tablet)
2
fluocinolone acetonide (0.01% solution, 0.01% body
oil, 0.01% scalp oil, 0.025% cream, 0.025% ointment)
3
fluocinonide (cream, gel, ointment, solution)
3
fluocinonide emollient (cream )
3
fluocinonide-e (cream )
3
fluticasone propionate (0.005% oint, 0.05% cream)
2
halobetasol propionate (cream, ointmnt)
3
hydrocortisone (1% cream, 2.5% cream, 2.5%
ointment, 2.5% lotion)
2
hydrocortisone butyrate (hydrocort lipid crm,
hydrocort lipo cream, hydrocortisone cream)
3
lokara (lotion)
3
methylprednisolone (4 mg dosepk, 8 mg tab, 16 mg
tab, 32 mg tab)
2
methylprednisolone sod succ (40 mg vial, 125 mg
vial)
5
methylprednisolone ss 1 gm vl
6
neomycin-polymyxin-hc ear susp
2
neomycin-polymyxin-hydrocort (solution)
2
nystatin-triamcinolone (cream, ointm)
3
oralone (paste )
3
prednisolone (solution)
2
PAGE 12
PRODUCT DESCRIPTION
TIER
prednisolone sodium phosphate (5 mg/5 ml soln, 15
mg/5 ml soln, sod ph 25 mg/5 ml)
2
prednisone (1 mg tablet, 2.5 mg tablet, 10 mg tab
dose pack, 20 mg tablet, 50 mg tablet)
2
prednisone 5 mg/5 ml solution
3
prednisone intensol (oral conc)
3
procto-pak (cream )
4
proctocream-hc (cream )
4
proctosol-hc (cream/appl)
2
psorcon (cream (g))
3
scalacort (lotion)
3
triamcinolone acetonide (0.025% lotion, 0.1% paste,
0.1% lotion)
3
triamcinolone acetonide (0.025% oint, 0.025%
cream, 0.1% ointment, 0.5% ointment, 0.5% cream)
2
Antibacterials
Aminoglycosides
amikacin sulfate (vial)
6
gentak (oint. )
2
gentamicin sulfate (0.3% drops, 3 mg/ml drops)
2
gentamicin sulfate (10 mg/ml vial, 20 mg/2 ml vial,
ped 20 mg/2 ml vial, 40 mg/ml vial, 80 mg/2 ml vial,
800 mg/20 ml vial)
6
gentamicin sulfate (cream, ointment)
3
gentamicin sulfate in ns (piggyback)
6
neomycin sulfate (tablet)
2
paromomycin sulfate (capsule)
3
streptomycin sulfate (vial)
6
PAGE 13
PRODUCT DESCRIPTION
TIER
tobramycin 0.3% eye drops
2
tobramycin sulfate (1.2 gm vial, 1.2 gram/30 ml vial,
10 mg/ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 1,200
mg/30 ml vial)
6
tobramycin sulfate in ns (piggyback)
6
Antibacterials, Other
acetasol hc (drops)
4
acetic acid 2% ear solution
2
acetic acid-aluminum (drops)
2
baciim (vial)
6
bacitracin 50,000 units vial
6
bacitracin 500 unit/gm ophth
3
chloramphenicol sod succinate (vial)
6
chlorhexidine gluconate (mouthwash)
2
clindacin etz 1% pledget
3
clindacin p (med. swab)
3
clindamax (gel (gram))
3
clindamycin hcl (150 mg capsule, 300 mg capsule)
2
clindamycin hcl 75 mg capsule
3
clindamycin palmitate hcl (soln recon)
3
clindamycin pediatric (soln recon)
3
clindamycin phosphate (ph 1% solution, ph 1% gel,
phos 1% pledget, phosp 1% lotion, phosphate 1%
foam, 2% vaginal cream)
3
clindamycin phosphate (ph 9 g/60 ml vial, 150
mg/ml addvan, ph 300 mg/2 ml vl, 300 mg/2 ml
addvan, 600 mg/4 ml addvan, ph 600 mg/4 ml vl, ph
900 mg/6 ml vl, 900 mg/6 ml addvan)
6
PAGE 14
PRODUCT DESCRIPTION
TIER
clindamycin phosphate-d5w (piggyback)
6
cycloserine (capsule)
3
hydrocortisone-acetic acid (drops)
3
methenamine hippurate (tablet)
3
methenamine md 1 gm tablet
2
metronidazole (0.75% cream, topical 0.75% gl,
0.75% lotion, topical 1% gel)
3
metronidazole (vaginal 0.75% gl, 250 mg tablet, 375
mg capsule, 500 mg tablet)
2
metronidazole 500 mg/100 ml
6
mupirocin 2% cream
3
mupirocin 2% ointment
2
nitrofurantoin (25 mg cap, 50 mg cap, 100 mg cap)
2
nitrofurantoin 25 mg/5 ml susp
3
nitrofurantoin mono-macro (capsule)
2
paroex (mouthwash)
2
periogard (mouthwash)
2
polymyxin b sulfate (vial)
6
SULFAMYLON 8.5% CREAM
4
trimethoprim (tablet)
2
vancomycin (froz.piggy)
6
vancomycin hcl (1 gm vial, hcl 1g/200 ml bag, 1 gm
add-van vial, hcl 5 gm vial, hcl 10 gm vial, 500 mg av vial, 500 mg vial, 750 mg vial, hcl 750 mg vial)
6
vancomycin hcl (125 mg capsule, 250 mg capsule)
5
vancomycin-d5w (froz.piggy)
6
PAGE 15
PRODUCT DESCRIPTION
TIER
Beta-lactam, Cephalosporins
cefaclor (125 mg/5 ml susp, 250 mg/5 ml susp, 250
mg capsule, 375 mg/5 ml suspen, 500 mg capsule)
3
cefaclor er (tab er 12h)
3
cefadroxil (1 gm tablet, 500 mg capsule)
2
cefadroxil (250 mg/5 ml, 500 mg/5 ml)
3
cefazolin (piggyback)
6
cefazolin sodium (1 gm add-van vial, 1 gm vial, 1
gm-d5w bag, 10 gm vial, 20 gm bulk vial, sod 100
gm bulk bag, sod 300 gm bulk bag, 500 mg vial)
6
cefazolin sodium-dextrose (froz.piggy)
6
cefazolin-0.9% nacl (piggyback)
6
cefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, 300
mg capsule)
3
cefditoren pivoxil (tablet)
3
cefepime (froz.piggy)
6
cefepime hcl (vial)
6
cefepime-dextrose (piggyback)
6
cefotaxime sodium (vial)
6
cefotetan & dextrose (piggyback)
6
cefotetan (vial)
6
cefoxitin (vial)
6
cefoxitin sodium (piggyback)
6
cefpodoxime proxetil (50 mg/5 ml susp, 100 mg
tablet, 100 mg/5 ml susp, 200 mg tablet)
3
cefprozil (125 mg/5 ml susp, 250 mg/5 ml susp, 250
mg tablet, 500 mg tablet)
2
ceftazidime (1 gm piggyback, 1 gm vial, 2 gm vial, 2
gm piggyback, 6 gm vial)
6
PAGE 16
PRODUCT DESCRIPTION
TIER
ceftriaxone (1 gm-d5w bag, 1 gm piggyback, 1 gm
vial, 2 gm piggyback, 2 gm-d5w bag, 2 gm add vial,
2 gm vial, 10 gm vial, 250 mg vial, 500 mg vial)
6
cefuroxime (1.5g/50 ml, 750 mg/50 ml)
6
cefuroxime (250 mg tab, 500 mg tab)
3
cefuroxime sodium (1.5 gm vial, 7.5 gm vial, 75 gm
bulk bag, 750 mg vial)
6
cephalexin (125 mg/5 ml susp, 250 mg tablet, 250
mg capsule, 250 mg/5 ml susp, 500 mg tablet, 500
mg capsule)
2
tazicef (1 gram vial, 1 gm add-vantage vial, 2 gram
vial, 2 gm add-vantage, 6 gram vial)
6
Beta-lactam, Other
aztreonam (vial)
6
imipenem-cilastatin sodium (vial)
6
meropenem (vial)
6
Beta-lactam, Penicillins
amoxicillin (125 mg tab chew, 125 mg/5 ml susp,
200 mg/5 ml susp, 250 mg capsule, 250 mg tab
chew, 250 mg/5 ml susp, 400 mg/5 ml susp, 500 mg
tablet, 500 mg capsule, 875 mg tablet)
2
amoxicillin-clavulanate pot er (tab er 12h)
3
amoxicillin-clavulanate potass (200-28.5 mg tab
chew, 200-28.5 mg/5 ml sus, 250-62.5 mg/5 ml sus,
250-125 mg tablet, 400-57 mg/5 ml susp, 400-57 mg
tab chew, 500-125 mg tablet, 600-42.9 mg/5 ml sus,
875-125 mg tablet)
3
ampicillin sodium (1 gm a-v vial, 1 gm vial, 2 gm a-v
vial, 10 gm vial, 125 mg vial, 250 mg vial, 500 mg
vial)
6
ampicillin trihydrate (125 mg/5 ml susp, 250 mg
capsule, 250 mg/5 ml susp, 500 mg capsule)
2
PAGE 17
PRODUCT DESCRIPTION
TIER
ampicillin-sulbactam (ampicillin-sulb 3 gm add vial,
ampicillin-sulbactam 1.5 gm vl, ampicillin-sulbactam
3 gm vial, ampicillin-sulbactam 15 gm vl)
6
dicloxacillin sodium (capsule)
2
nafcillin (froz.piggy)
6
nafcillin sodium (1 gm add-van vial, 2 gm vial, 2 gm
add-vant vial, 10 gm bulk vial, 10 gm vial)
6
oxacillin (froz.piggy)
6
oxacillin sodium (1 gm vial, 1 gm add-vantage vl, 2
gm add-vantage vl, 2 gm vial, 10 gm vial)
6
penicillin g potassium (vial)
6
penicillin g procaine (syringe)
6
penicillin g sodium (vial)
6
penicillin gk-iso-osm dextrose (froz.piggy)
6
penicillin v potassium (125 mg/5 ml soln, 250 mg
tablet, 250 mg/5 ml soln, 500 mg tablet)
2
piperacillin-tazobactam (piperacil-tazo 2.25 gm add
vl, piperacil-tazobact 2.25 gm vl, piperacil-tazobact
3.375 gm vl, piperacil-tazobact 4.5 gm vial, piperaciltazobact 40.5 gram)
6
Macrolides
AZASITE (DROPS)
4
azithromycin (1 gm pwd packet, 100 mg/5 ml susp,
200 mg/5 ml susp, 250 mg tablet, 500 mg tablet,
600 mg tablet)
2
azithromycin i.v. 500 mg vial
6
clarithromycin (125 mg/5 ml sus, 250 mg tablet, 250
mg/5 ml sus, 500 mg tablet)
3
clarithromycin er (tab er 24h)
3
erythromycin (0.5% eye ointment, 2% gel, 2%
solution, 2% pledgets)
2
PAGE 18
PRODUCT DESCRIPTION
TIER
erythromycin (250 mg, 500 mg)
3
erythromycin ethylsuccinate (tablet)
3
KETEK (TABLET)
4
Quinolones
ciprofloxacin (200 mg/20 ml, 400 mg/40 ml)
6
ciprofloxacin er (tbmp 24hr)
2
ciprofloxacin hcl (0.3% eye drop, hcl 100 mg tab, hcl
250 mg tab, hcl 500 mg tab, hcl 750 mg tab)
2
ciprofloxacin-d5w (piggyback)
6
gatifloxacin (drops)
3
levofloxacin (250 mg tablet, 500 mg tablet, 750 mg
tablet)
2
levofloxacin (500 mg/20 ml vial, 750 mg/30 ml vial)
6
levofloxacin 0.5% eye drops
3
levofloxacin-d5w (piggyback)
6
moxifloxacin hcl (tablet)
3
ofloxacin (200 mg tablet, 300 mg tablet, 400 mg
tablet)
3
ofloxacin (ear drops, eye drops)
2
QL 2 / 30 DAYS
Sulfonamides
silver sulfadiazine (cream )
2
sodium sulfacetamide 10% lot
3
sulfacetamide 10% eye drops
2
sulfacetamide sodium (sod top susp, sodium lotn)
3
sulfadiazine (tablet)
3
sulfamethoxazole-tmp inj vial
6
sulfamethoxazole-trimethoprim (ds tablet, ss tablet,
susp)
2
PAGE 19
PRODUCT DESCRIPTION
TIER
Tetracyclines
avidoxy (tablet)
3
demeclocycline hcl (tablet)
2
doxy 100 (vial)
6
doxycycline hyc 100 mg vial
6
doxycycline hyclate (20 mg tab, 50 mg cap, 100 mg
tab, 100 mg cap)
3
doxycycline monohydrate (25 mg/5 ml susp, mono
50 mg cap, mono 50 mg tablet, mono 75 mg tablet,
mono 75 mg capsule, mono 100 mg tablet, mono
100 mg cap, mono 150 mg tablet)
3
minocycline hcl (50 mg capsule, 75 mg capsule, 100
mg capsule)
2
minocycline hcl (50 mg tablet, 75 mg tablet, 100 mg
tablet)
3
mondoxyne nl (capsule)
3
morgidox 100 mg capsule
3
tetracycline hcl (capsule)
3
Anticonvulsants
Anticonvulsants, Other
acetazolamide (125 mg tablet, 250 mg tablet)
3
acetazolamide sodium (vial)
6
levetiracetam (100 mg/ml soln, 250 mg tablet, 500
mg tablet, 500 mg/5 ml soln, 750 mg tablet, 1,000
mg tablet)
2
levetiracetam 500 mg/5 ml vial
6
levetiracetam er 500 mg tablet
2
QL 180 / 30 days
levetiracetam er 750 mg tablet
2
QL 120 / 30 days
levetiracetam-nacl (piggyback)
6
PAGE 20
PRODUCT DESCRIPTION
TIER
primidone (tablet)
2
Calcium Channel Modifying Agents
ethosuximide (250 mg/5 ml soln, 250 mg capsule)
3
zonisamide (capsule)
2
Gamma-aminobutyric Acid (GABA) Augmenting Agents
divalproex sodium (dr 250 mg tab, dr 500 mg tab)
2
divalproex sodium (sod dr 125 mg tab, sodium 125
mg cap)
3
divalproex sodium er (tab er 24h)
3
gabapentin (100 mg capsule, 300 mg capsule, 400
mg capsule, 600 mg tablet, 800 mg tablet)
2
gabapentin (250 mg/5 ml soln, 300 mg/6 ml soln)
3
phenobarbital (20 mg/5 ml soln, 20 mg/5 ml elix)
3
phenobarbital (32.4 mg tablet, 60 mg tablet, 64.8
mg tablet, 97.2 mg tablet, 100 mg tablet)
2
SABRIL 500 MG TABLET
5
tiagabine hcl (tablet)
3
valproate sodium (vial)
6
valproic acid (250 mg capsule, 250 mg/5 ml soln,
500 mg/10 ml sol)
2
QL 180 / 30 DAYS
PA
Glutamate Reducing Agents
felbamate (400 mg tablet, 600 mg tablet, 600 mg/5
ml susp)
5
lamotrigine (5 mg disper tablet, 25 mg tb start kit,
25 mg disper tab, 25 mg tablet, 100 mg tablet, 200
mg tablet)
2
topiramate (15 mg sprinkle cap, 25 mg sprinkle cap,
25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg
tablet)
2
PAGE 21
PRODUCT DESCRIPTION
topiramate er (er 25 mg capsule, er 50 mg capsule,
er 100 mg capsule, er 150 mg capsule)
TIER
3
Sodium Channel Agents
carbamazepine (100 mg tab chew, 100 mg/5 ml
susp, 200 mg tablet)
2
carbamazepine er (er 100 mg cap, er 200 mg tablet,
er 200 mg cap, er 300 mg cap, er 400 mg tablet)
3
epitol (tablet)
2
fosphenytoin sodium (vial)
5
oxcarbazepine (150 mg tablet, 300 mg tablet, 600
mg tablet)
2
oxcarbazepine 300 mg/5 ml susp
3
phenytoin (50 mg infatab, 50 mg tablet chew, 100
mg/4 ml susp, 125 mg/5 ml susp)
2
phenytoin sodium (50 mg/ml vial, 50 mg/ml ampul,
100 mg/2 ml vial, 250 mg/5 ml vial)
6
phenytoin sodium extended (capsule)
2
ziprasidone hcl 20 mg capsule
3
QL 60 / 30 DAYS
Antidementia Agents
Antidementia Agents, Other
ergoloid mesylates (tablet)
3
Cholinesterase Inhibitors
donepezil hcl (5 mg tablet, 10 mg tablet)
2
QL 30 / 30 DAYS
donepezil hcl odt (tab rapdis)
2
QL 30 / 30 DAYS
galantamine hbr (4 mg tablet, 8 mg tablet, 12 mg
tablet)
2
galantamine hbr (er 8 mg capsule, er 16 mg capsule,
er 24 mg capsule)
2
galantamine hydrobromide (solution)
2
PAGE 22
QL 30 / 30 DAYS
PRODUCT DESCRIPTION
rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mg
capsule, 6 mg capsule)
TIER
3
QL 60 / 30 DAYS
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl (hcl 2 mg/ml solution, hcl 5 mg
tablet, 5-10 mg titration pk, hcl 10 mg tablet)
3
NAMENDA (2 MG/ML SOLUTION, 5-10 MG
TITRATION PK, 5 MG TABLET, 10 MG TABLET)
4
NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21
MG CAPSULE, 28 MG CAPSULE, TITRATION PACK)
4
QL 30 / 30 DAYS
ABILIFY (2 MG TABLET, 5 MG TABLET, 10 MG
TABLET, 15 MG TABLET, 20 MG TABLET, 30 MG
TABLET)
4
QL 30 / 30 DAYS
ABILIFY 1 MG/ML SOLUTION
4
ABILIFY 9.7 MG/1.3 ML VIAL
6
ABILIFY DISCMELT (TAB RAPDIS)
4
ABILIFY MAINTENA (ER 300 MG SYR, ER 300 MG VL,
ER 400 MG VL, ER 400 MG SYR)
5
aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet,
15 mg tablet, 20 mg tablet, 30 mg tablet)
3
aripiprazole 1 mg/ml solution
3
aripiprazole odt (tab rapdis)
3
budeprion sr (tablet er)
2
bupropion hcl (tablet)
2
bupropion hcl sr (tablet er)
2
bupropion hcl xl 150 mg tablet
2
QL 90 / 30 DAYS
bupropion hcl xl 300 mg tablet
2
QL 30 / 30 DAYS
maprotiline hcl (tablet)
2
Antidepressants
Antidepressants, Other
PAGE 23
QL 30 / 30 DAYS
QL 30 / 30 DAYS
QL 30 / 30 days
PRODUCT DESCRIPTION
TIER
mirtazapine (7.5 mg tablet, 15 mg tablet, 15 mg odt,
30 mg tablet, 30 mg odt, 45 mg tablet, 45 mg odt)
2
nefazodone hcl (tablet)
3
SEROQUEL XR (300 MG TABLET, 400 MG TABLET)
4
QL 60 / 30 DAYS
SEROQUEL XR (50 MG TABLET, 150 MG TABLET, 200
MG TABLET)
4
QL 30 / 30 DAYS
trazodone hcl (tablet)
2
QL 30 / 30 DAYS
Monoamine Oxidase Inhibitors
phenelzine sulfate (tablet)
3
tranylcypromine sulfate (tablet)
3
Serotonin/Norepinephrine Reuptake Inhibitors
citalopram hbr (10 mg tablet, 10 mg/5 ml soln, 20
2
duloxetine hcl (dr 30 mg cap, dr 60 mg cap)
3
QL 30 / 30 DAYS
duloxetine hcl dr 20 mg cap
3
QL 90 / 30 DAYS
escitalopram oxalate (5 mg tablet, 10 mg tablet, 20
mg tablet)
2
QL 30 / 30 DAYS
escitalopram oxalate 5 mg/5 ml
3
QL 620 / 30 DAYS
fluoxetine dr (capsule dr)
3
fluoxetine hcl (hcl 10 mg tablet, hcl 10 mg capsule,
hcl 20 mg capsule, 20 mg/5 ml solution, hcl 40 mg
capsule)
2
fluvoxamine maleate (tablet)
2
paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg
2
paroxetine hcl (cr 12.5 mg tablet, cr 25 mg tablet, cr
37.5 mg tablet, er 37.5 mg tablet)
3
sertraline hcl (20 mg/ml oral conc, hcl 25 mg tablet,
hcl 50 mg tablet, hcl 100 mg tablet)
2
PAGE 24
QL 60 / 30 DAYS
PRODUCT DESCRIPTION
TIER
venlafaxine hcl (tablet)
2
venlafaxine hcl er (er 37.5 mg cap, er 150 mg cap)
2
QL 60 / 30 DAYS
venlafaxine hcl er (er 37.5 mg tab, er 150 mg tab)
3
QL 60 / 30 DAYS
venlafaxine hcl er 75 mg cap
2
QL 90 / 30 DAYS
venlafaxine hcl er 75 mg tab
3
QL 90 / 30 DAYS
Tricyclics
amitriptyline hcl (tablet)
2
amoxapine (tablet)
2
clomipramine hcl (capsule)
3
desipramine hcl (tablet)
3
doxepin hcl (10 mg/ml oral conc, 10 mg capsule, 25
mg capsule, 50 mg capsule, 75 mg capsule, 100 mg
capsule, 150 mg capsule)
2
imipramine hcl (tablet)
2
imipramine pamoate (capsule)
3
nortriptyline hcl (10 mg/5 ml sol, hcl 10 mg cap, hcl
25 mg cap, hcl 50 mg cap, hcl 75 mg cap)
2
protriptyline hcl (tablet)
3
trimipramine maleate (capsule)
3
Antiemetics
Antiemetics, Other
chlorpromazine 25 mg/ml amp
5
chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50
mg tablet, 100 mg tablet, 200 mg tablet)
3
compro (supp.rect)
4
diphenhydramine 50 mg/ml vial
5
hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial, 100
mg/2 ml vial, 500 mg/10 ml vial)
5
PAGE 25
PA
PRODUCT DESCRIPTION
TIER
hydroxyzine hcl (hcl 10 mg tablet, 10 mg/5 ml syrup,
10 mg/5 ml soln, hcl 25 mg tablet, 50 mg/25 ml
syrup, hcl 50 mg tablet)
2
hydroxyzine pamoate (capsule)
2
meclizine hcl (tablet)
2
metoclopramide hcl (5 mg tablet, 5 mg/5 ml syrup, 5
mg/5 ml soln, 10 mg tablet, 10 mg/10 ml sol)
2
perphenazine (tablet)
3
phenadoz (supp.rect)
3
PHENERGAN (25 MG/ML AMPUL, 25 MG/ML VIAL,
50 MG/ML VIAL, 50 MG/ML AMPUL)
5
prochlorperazine (supp.rect)
3
prochlorperazine edisylate (vial)
5
prochlorperazine maleate (tablet)
2
promethazine hcl (12.5 mg suppos, 25 mg
suppository)
3
promethazine hcl (25 mg/ml syringe, 25 mg/ml vial,
25 mg/ml ampul, 50 mg/ml vial, 50 mg/ml ampul)
5
promethazine hcl (6.25 mg/5 ml syrp, 12.5 mg
2
promethegan (supp.rect)
3
trimethobenzamide 300 mg cap
3
trimethobenzamide hcl (200 mg/2 ml, 2,000 mg/20)
5
Emetogenic Therapy Adjuncts
dronabinol (capsule)
3
granisetron hcl (0.1 mg/ml vial, 1 mg/ml vial, 4 mg/4
ml vial)
6
granisetron hcl 1 mg tablet
3
granisol (solution)
4
PAGE 26
PRODUCT DESCRIPTION
TIER
ondansetron 40 mg/20 ml vial
6
ondansetron hcl (4 mg/5 ml solution, hcl 4 mg tablet,
hcl 8 mg tablet, hcl 24 mg tablet)
3
ondansetron hcl (hcl 4 mg/2 ml vial, hcl 4 mg/2 ml
syr, 4 mg/2 ml isecure, 4 mg/2 ml ampule)
5
ondansetron odt (tab rapdis)
3
Antifungals
fluconazole-nacl 100 mg/50 ml
6
amphotericin b (vial)
6
ciclodan 0.77% cream
3
ciclopirox (0.77% gel, 0.77% cream, 0.77% topical
susp, 1% shampoo)
3
clotrimazole (cream, solution)
2
clotrimazole 10 mg troche
3
econazole nitrate (cream )
3
fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mg
tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet)
2
fluconazole in dextrose (piggyback)
6
fluconazole in saline (pggybk btl, piggyback)
6
fluconazole-nacl (200 mg/100 ml, 400 mg/200 ml)
6
flucytosine (capsule)
3
griseofulvin (125 mg/5 ml susp, micro 500 mg tab)
3
griseofulvin ultramicrosize (tablet)
3
gynazole 1 (crm/pf app)
3
itraconazole (capsule)
3
ketoconazole (2% foam, 2% shampoo, 2% cream,
200 mg tablet)
2
ketodan 2% foam
3
PAGE 27
QL 90 / 1 years
PRODUCT DESCRIPTION
TIER
nyamyc (powder)
3
nystatin (100,000 unit/gm cream, 100,000 units/gm
oint, 100,000 units/ml susp, 100,000 unit/gm powd,
500,000 unit oral tab, 500,000 units/5 ml,
50,000,000 units pwd, 150,000,000 units pwd,
500,000,000 units pwd)
3
nystop (powder)
3
pedi-dri (powder)
3
terbinafine hcl (tablet)
2
QL 90 / 365 DAYS
terconazole (0.4%, 0.8%)
3
QL 45 / 30 DAYS
terconazole 80 mg suppository
3
voriconazole (50 mg tablet, 200 mg tablet)
5
voriconazole 200 mg vial
6
zazole (cream/appl)
3
QL 45 / 30 DAYS
Antigout Agents
allopurinol (tablet)
2
allopurinol sodium (vial)
6
COLCRYS (TABLET)
4
KRYSTEXXA (VIAL)
6
probenecid (tablet)
2
probenecid-colchicine (tablet)
2
ULORIC (TABLET)
4
QL 30 / 30 DAYS
Antimigraine Agents
Ergot Alkaloids
D.H.E.45 (AMPUL)
5
dihydroergotamine mesylate (1 mg/ml vl, 1 mg/ml
am)
5
PAGE 28
PRODUCT DESCRIPTION
TIER
Prophylactic
timolol maleate (5 mg tablet, 10 mg tablet, 20 mg
tablet)
3
Serotonin (5-HT) 1b/1d Receptor Agonists
naratriptan 1 mg tablet
3
QL 54 / 90 DAYS
naratriptan 2.5 mg tablet
3
QL 27 / 90 DAYS
naratriptan hcl 1 mg tablet
3
QL 54 / 90 DAYS
naratriptan hcl 2.5 mg tablet
3
QL 27 / 90 DAYS
rizatriptan (10 mg odt, 10 mg tablet)
2
QL 36 / 90 DAYS
rizatriptan 5 mg tablet
2
QL 72 / 90 DAYS
sumatriptan (spray)
3
QL 36 / 90 DAYS
sumatriptan succ 100 mg tablet
2
QL 27 / 90 DAYS
sumatriptan succinate (25 mg tablet, 50 mg tablet)
2
QL 54 / 90 DAYS
sumatriptan succinate (4 mg/0.5 ml cart, 4 mg/0.5
ml inject, 6 mg/0.5 ml vial, 6 mg/0.5 ml refill, 6
mg/0.5 ml syrng)
5
QL 9 / 90 DAYS
zolmitriptan 2.5 mg odt
3
QL 36 / 90 DAYS
zolmitriptan 2.5 mg tablet
3
QL 36 / 90 DAYS
zolmitriptan 5 mg odt
3
QL 18 / 90 DAYS
zolmitriptan 5 mg tablet
3
QL 18 / 90 DAYS
ZOMIG 5 MG NASAL SPRAY
4
QL 36 / 90 DAYS
Antimyasthenic Agents
Parasympathomimetics
guanidine hcl (tablet)
2
pyridostigmine bromide (tablet)
2
PAGE 29
PRODUCT DESCRIPTION
TIER
Antimycobacterials
Antimycobacterials, Other
dapsone (tablet)
2
MYCOBUTIN (CAPSULE)
4
rifabutin (capsule)
3
Antituberculars
ethambutol hcl (tablet)
3
isoniazid (50 mg/5 ml solution, 100 mg tablet, 300
mg tablet)
2
isoniazid 100 mg/ml vial
6
pyrazinamide (tablet)
3
rifampin (150 mg capsule, 300 mg capsule)
3
rifampin iv 600 mg vial
6
Antineoplastics
Alkylating Agents
BUSULFEX (VIAL)
6
cyclophosphamide (25 mg capsule, 25 mg tab, 50
mg tablet, 50 mg capsule)
5
LEUKERAN (TABLET)
5
LOMUSTINE (CAPSULE)
5
melphalan hcl (vial)
6
temozolomide (capsule)
5
PA
REVLIMID (2.5 MG CAPSULE, 5 MG CAPSULE, 20 MG
CAPSULE, 25 MG CAPSULE)
5
PA
THALOMID 50 MG CAPSULE
5
PA
PA
Antiangiogenic Agents
PAGE 30
PRODUCT DESCRIPTION
TIER
Antiestrogens/Modifiers
EMCYT (CAPSULE)
5
SOLTAMOX (SOLUTION)
1
tamoxifen citrate (tablet)
1
Antimetabolites
adrucil (vial)
6
capecitabine 500 mg tablet
5
fludarabine phosphate (50 mg vial, 50 mg/2 ml vial)
6
fluorouracil (2.5 gm/50 ml vial, 5 gm/100 ml vial,
500 mg/10 ml vial, 1,000 mg/20 ml vl, 2,500 mg/50
ml vl, 5,000 mg/100 ml)
6
hydroxyurea (capsule)
2
mercaptopurine (tablet)
3
methotrexate (1 gm vial, 50 mg/2 ml vial, 250
mg/10 ml vial)
5
methotrexate 2.5 mg tablet
2
PA
Antineoplastics, Other
amifostine (vial)
6
bleomycin sulfate (vial)
5
calcium folinate (vial)
5
flutamide (capsule)
5
imiquimod (cream pack)
3
INTRON A (6 MILLION UNIT/ML VL, 10 MILLION
UNIT/ML, 10 MILLION UNITS VIL, 18 MILLION UNITS
VIL, 50 MILLION UNITS VIL)
6
leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab,
25 mg tab)
2
PAGE 31
PA
PRODUCT DESCRIPTION
TIER
leucovorin calcium (cal 500 mg/50 ml vl, calcium 50
mg vial, calcium 100 mg vial, calcium 350 mg vial,
calcium 500 mg vl)
5
mitoxantrone hcl (vial)
6
Aromatase Inhibitors, 3rd Generation
anastrozole (tablet)
2
exemestane (tablet)
3
letrozole (tablet)
2
QL 30 / 30 DAYS
PA
Enzyme Inhibitors
etoposide (100 mg/5 ml vial, 500 mg/25 ml vial,
1,000 mg/50 ml vial)
6
etoposide 50 mg capsule
5
toposar (vial)
6
topotecan hcl (4 mg/4 ml vial, 4 mg vial)
6
PA
Molecular Target Inhibitors
AFINITOR (TABLET)
5
QL 30 / 30 DAYS
PA
AFINITOR DISPERZ (TAB SUSP)
5
QL 30 / 30 DAYS
PA
GLEEVEC (TABLET)
5
PA
ICLUSIG (TABLET)
5
QL 30 / 30 DAYS
NEXAVAR (TABLET)
5
PA
SPRYCEL (TABLET)
5
PA
STIVARGA (TABLET)
5
QL 252 / 84 DAYS
PA
SUTENT (CAPSULE)
5
PA
TARCEVA (TABLET)
5
PA
PAGE 32
PRODUCT DESCRIPTION
TIER
TASIGNA (CAPSULE)
5
PA
TYKERB (TABLET)
5
PA
XALKORI (CAPSULE)
5
Monoclonal Antibodies
RITUXAN (VIAL)
6
PA
5
PA
Retinoids
tretinoin 10 mg capsule
Antiparasitics
Anthelmintics
ALBENZA (TABLET)
4
BILTRICIDE (TABLET)
4
ivermectin (tablet)
3
spinosad (suspension)
3
STROMECTOL (TABLET)
4
Antiprotozoals
atovaquone-proguanil hcl (tablet)
3
chloroquine phosphate (tablet)
2
hydroxychloroquine sulfate (tablet)
2
mefloquine hcl (tablet)
2
primaquine (tablet)
3
Pediculicides/Scabicides
elimite (cream (g))
3
lindane (lotion, shampoo)
3
malathion (lotion)
3
permethrin (cream (g))
3
PAGE 33
PRODUCT DESCRIPTION
SKLICE (LOTION)
TIER
4
QL 120 / 7 DAYS
Antiparkinson Agents
Anticholinergics
benztropine mesylate (0.5 mg tab, 1 mg tablet, 2 mg
tablet)
2
benztropine mesylate (2 mg/2 ml vial, 2 mg/2 ml
ampule)
5
trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elx, 5 mg
tablet)
2
Antiparkinson Agents, Other
amantadine (100 mg tablet, 100 mg capsule)
3
amantadine (50 mg/5 ml solution, 100 mg/10 ml
soln)
2
entacapone (tablet)
3
Dopamine Agonists
bromocriptine mesylate (2.5 mg tablet, 5 mg
capsule)
3
pramipexole dihydrochloride (tablet)
2
QL 90 / 30 DAYS
pramipexole er (er 0.375 mg tablet, er 0.75 mg
tablet, er 1.5 mg tablet)
3
QL 30 / 30 DAYS
ropinirole er (tab er 24h)
3
QL 30 / 30 DAYS
ropinirole hcl (tablet)
2
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors
carbidopa (tablet)
3
carbidopa-levodopa (10-100 mg odt, 25-250 mg odt,
25-100 mg odt)
3
carbidopa-levodopa (10-100 tab, 25-250 tab, 25-100
tab)
2
carbidopa-levodopa er (tablet er)
2
PAGE 34
PRODUCT DESCRIPTION
LODOSYN (TABLET)
TIER
4
Monoamine Oxidase B (MAO-B) Inhibitors
selegiline hcl (5 mg tablet, 5 mg capsule)
3
Antipsychotics
1st Generation/Typical
fluphenazine 2.5 mg/ml vial
5
fluphenazine decanoate (vial)
5
fluphenazine hcl (1 mg tablet, 2.5 mg/5 ml elix, 2.5
mg tablet, 5 mg/ml conc, 5 mg tablet, 10 mg tablet)
2
haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet,
5 mg tablet, 10 mg tablet, 20 mg tablet)
2
haloperidol 5 mg/ml ampul
5
haloperidol decanoate (dec 50 mg/ml vial, dec 100
mg/ml vial, decan 50 mg/ml amp)
5
haloperidol decanoate 100 (ampul)
5
haloperidol lac 2 mg/ml conc
2
haloperidol lactate (5 mg/ml vial, 50 mg/10 ml vl)
5
loxapine (capsule)
2
ORAP (TABLET)
4
pimozide (tablet)
3
thioridazine hcl (tablet)
2
thiothixene (capsule)
3
trifluoperazine hcl (tablet)
2
2nd Generation/Atypical
olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg
2
olanzapine 10 mg vial
5
PAGE 35
QL 30 / 30 DAYS
PRODUCT DESCRIPTION
TIER
olanzapine odt (tab rapdis)
3
QL 30 / 30 DAYS
quetiapine fumarate (tablet)
2
QL 60 / 30 DAYS
risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg
tablet, 2 mg tablet, 3 mg tablet)
2
QL 60 / 30 DAYS
risperidone 0.25 mg odt
3
risperidone 4 mg odt
3
QL 120 / 30 DAYS
risperidone 4 mg tablet
2
QL 120 / 30 DAYS
risperidone odt (0.5 mg odt, 1 mg odt, 2 mg odt, 3
mg odt)
3
QL 60 / 30 DAYS
ziprasidone hcl (40 mg capsule, 60 mg capsule, 80
mg capsule)
3
QL 60 / 30 DAYS
clozapine (tablet)
3
QL 120 / 30 DAYS
clozapine odt (odt 12.5 mg tablet, odt 25 mg tablet,
odt 100 mg tablet)
3
QL 120 / 30 DAYS
Treatment-Resistant
Antispasticity Agents
baclofen (tablet)
2
dantrolene sodium (capsule)
3
tizanidine hcl (2 mg capsule, 4 mg capsule, 6 mg
capsule)
3
tizanidine hcl (2 mg tablet, 4 mg tablet)
2
Antivirals
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors
EDURANT (TABLET)
4
QL 30 / 30 DAYS
INTELENCE (25 MG TABLET, 100 MG TABLET)
4
QL 120 / 30 DAYS
INTELENCE 200 MG TABLET
4
QL 60 / 30 DAYS
nevirapine (50 mg/5 ml susp, 200 mg tablet)
2
PAGE 36
PRODUCT DESCRIPTION
TIER
nevirapine er (tab er 24h)
3
RESCRIPTOR (100 MG TABLET, 200 MG TABLET)
4
SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600
MG TABLET)
4
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors
abacavir (tablet)
5
abacavir-lamivudine-zidovudine (tablet)
4
didanosine (capsule dr)
5
EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE)
4
EPZICOM (TABLET)
4
lamivudine (10 mg/ml oral soln, 150 mg tablet, 300
mg tablet)
5
lamivudine-zidovudine (tablet)
5
stavudine (1 mg/ml solution, 15 mg capsule, 20 mg
capsule, 30 mg capsule, 40 mg capsule)
5
TRIZIVIR (TABLET)
4
TRUVADA (TABLET)
4
VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG
TABLET, 300 MG TABLET, POWDER)
4
zidovudine (50 mg/5 ml syrup, 100 mg capsule, 300
mg tablet)
5
Anti-HIV Agents, Other
ATRIPLA (TABLET)
4
FUZEON (90 MG VIAL, CONVENIENCE KIT)
5
ISENTRESS (100 MG POWDER PACKET, 400 MG
TABLET)
4
ISENTRESS 100 MG TABLET CHEW
4
QL 180 / 30 DAYS
ISENTRESS 25 MG TABLET CHEW
4
QL 120 / 30 DAYS
PAGE 37
PRODUCT DESCRIPTION
TIER
STRIBILD (TABLET)
4
QL 30 / 30 DAYS
TIVICAY (TABLET)
5
QL 30 / 30 DAYS
TRIUMEQ (TABLET)
5
Anti-HIV Agents, Protease Inhibitors
APTIVUS 250 MG CAPSULE
4
CRIXIVAN (CAPSULE)
4
INVIRASE (200 MG CAPSULE, 500 MG TABLET)
4
KALETRA (100-25 MG TABLET, 200-50 MG TABLET,
400-100/5 ML ORAL SOLU)
4
LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET)
4
NORVIR (80 MG/ML SOLUTION, 100 MG TABLET,
100 MG SOFTGEL CAP)
4
PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION,
150 MG TABLET, 400 MG TABLET, 600 MG TABLET,
800 MG TABLET)
4
REYATAZ (50 MG POWDER PACKET, 100 MG
CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 300
MG CAPSULE)
4
VIRACEPT (TABLET)
4
Anti-cytomegalovirus (CMV) Agents
cidofovir (vial)
6
ZIRGAN (GEL (GRAM))
4
Anti-influenza Agents
RELENZA (BLST W/DEV)
4
rimantadine hcl (tablet)
3
TAMIFLU (45 MG CAPSULE, 75 MG CAPSULE)
4
QL 10 / 180 DAYS
TAMIFLU 30 MG CAPSULE
4
QL 20 / 180 DAYS
TAMIFLU 6 MG/ML SUSPENSION
4
PAGE 38
QL 20 / 180 DAYS
PRODUCT DESCRIPTION
TIER
Antihepatitis Agents
adefovir dipivoxil (tablet)
5
QL 30 / 30 DAYS
PA
BARACLUDE (0.05 MG/ML SOLUTION, 0.5 MG
TABLET, 1 MG TABLET)
5
PA
entecavir (tablet)
5
PA
HARVONI (TABLET)
5
PA
HEPSERA (TABLET)
5
QL 30 / 30 DAYS
PA
INCIVEK (TABLET)
5
PA
INFERGEN 15 MCG/0.5 ML VIAL
6
QL 6 / 30 DAYS
INFERGEN 9 MCG/0.3 ML VIAL
6
QL 4 / 30 DAYS
lamivudine 100 mg tablet
5
QL 30 / 30 DAYS
PA
lamivudine hbv (tablet)
5
QL 30 / 30 DAYS
PA
PEGASYS 180 MCG/0.5 ML SYRINGE
5
PA
PEGASYS PROCLICK (PEN INJCTR)
5
PA
PEGINTRON (KIT)
5
QL 4 / 28 DAYS
PA
PEGINTRON REDIPEN (PEN IJ KIT)
5
QL 4 / 28 DAYS
PA
ribasphere (400 mg tablet, 600 mg tablet)
5
PA
ribavirin 200 mg capsule
5
PA
ribavirin 200 mg tablet
5
PA
TYZEKA (TABLET)
5
PA
VICTRELIS (CAPSULE)
5
PA
PAGE 39
PRODUCT DESCRIPTION
VIRAZOLE (VIAL-NEB)
TIER
6
PA
Antiherpetic Agents
acyclovir (200 mg capsule, 200 mg/5 ml susp, 400
2
valacyclovir (tablet)
2
Anxiolytics
Anxiolytics, Other
alprazolam (tablet)
2
alprazolam er (tab er 24h)
2
alprazolam xr (tab er 24h)
2
buspirone hcl (tablet)
2
clonazepam (0.125 mg dis tab, 0.25 mg odt, 0.5 mg
dis tablet, 0.5 mg tablet, 1 mg tablet, 1 mg dis
tablet, 2 mg odt, 2 mg tablet)
2
diazepam (2 mg tablet, 5 mg/5 ml solution, 5 mg/5
ml oral soln, 5 mg tablet, 5 mg/ml oral conc, 10 mg
tablet)
2
lisinopril (5 mg tablet, 10 mg tablet)
2
lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
2
meprobamate (tablet)
3
Bipolar Agents
Mood Stabilizers
lithium (solution)
2
lithium carbonate (150 mg cap, 300 mg tab, 300 mg
cap, 600 mg cap)
2
lithium carbonate er (tablet er)
2
PAGE 40
PRODUCT DESCRIPTION
TIER
Blood Glucose Regulators
Antidiabetic Agents
acarbose (tablet)
2
BYETTA (PEN INJCTR)
5
chlorpropamide (tablet)
3
glimepiride (tablet)
2
glipizide (tablet)
2
glipizide er (er 5 mg tablet, er 10 mg tablet)
2
glipizide xl (5 mg tablet, 10 mg tablet)
2
glyburide (tablet)
2
glyburide micronized (tablet)
2
metformin hcl (tablet)
2
metformin hcl er (er 1,000 mg osm-tab, hcl er 500
mg osm-tb)
3
metformin hcl er (er 500 mg tablet, er 750 mg
tablet)
2
nateglinide (tablet)
3
QL 90 / 30 DAYS
pioglitazone hcl (tablet)
2
QL 30 / 30 DAYS
repaglinide (tablet)
3
QL 240 / 30 DAYS
tolazamide (tablet)
3
tolbutamide (tablet)
3
QL 2 / 30 DAYS
Glycemic Agents
GLUCAGON EMERGENCY KIT (KIT)
5
Insulins
APIDRA (VIAL)
4
APIDRA SOLOSTAR (INSULN PEN)
4
PAGE 41
PRODUCT DESCRIPTION
TIER
HUMALOG (100 UNITS/ML CARTRIDGE, 100
UNITS/ML VIAL)
4
HUMALOG KWIKPEN U-100 (INSULN PEN)
4
HUMALOG KWIKPEN U-200 (INSULN PEN)
4
HUMULIN 70-30 (PEN, VIAL)
4
HUMULIN 70/30 KWIKPEN (INSULN PEN)
4
HUMULIN N (N 100 UNITS/ML PEN, N 100 UNITS/ML
VIAL)
4
HUMULIN N KWIKPEN (INSULN PEN)
4
HUMULIN R 100 UNITS/ML VIAL
4
HUMULIN R U-500 (VIAL)
4
HUMULIN R U-500 KWIKPEN (INSULN PEN)
4
LANTUS (VIAL)
4
LANTUS SOLOSTAR (INSULN PEN)
4
LEVEMIR (VIAL)
4
LEVEMIR FLEXPEN (INSULN PEN)
4
LEVEMIR FLEXTOUCH (INSULN PEN)
4
NOVOLIN 70-30 100 UNIT/ML VIAL
4
NOVOLIN N 100 UNITS/ML VIAL
4
NOVOLIN R 100 UNITS/ML VIAL
4
NOVOLOG (100 UNIT/ML CARTRIDGE, 100 UNIT/ML
VIAL)
4
NOVOLOG FLEXPEN (INSULN PEN)
4
NOVOLOG MIX 70-30 (VIAL)
4
NOVOLOG MIX 70-30 FLEXPEN (INSULN PEN)
4
PAGE 42
PRODUCT DESCRIPTION
TIER
Blood Products/Modifiers/ Volume Expanders
Anticoagulants
enoxaparin 30 mg/0.3 ml syr
5
QL 18 / 30 DAYS
enoxaparin 300 mg/3 ml vial
5
QL 180 / 30 DAYS
5
QL 24 / 30 DAYS
5
QL 36 / 30 DAYS
enoxaparin sodium (100 mg/ml, 150 mg/ml)
5
QL 60 / 30 DAYS
enoxaparin sodium (80 mg/0.8 ml, 120 mg/0.8 ml)
5
QL 48 / 30 DAYS
fondaparinux sodium (syringe)
5
heparin lock (lock flush 100 unit/ml, 500 unit/5 ml
(100/ml), 1,000 unit/10 (100/ml), 3,000 unit/30
(100/ml))
6
heparin sodium (sod 1,000 unit/ml vial, 2,000 unit/2
ml vial, sod 5,000 unit/ml syr, sod 5,000 unit/0.5 ml,
sod 5,000 unit/ml vial, sod 5,000 unit/ 0.5 ml, 10,000
unit/10 ml vial, sod 10,000 unit/ml vl, sod 20,000
unit/ml vl, 30,000 unit/30 ml vial, 40,000 units/4 ml
vial, 50,000 units/5 ml vial, 50,000 unit/10 ml vial,
50,000 units/10 ml vl)
5
heparin sodium in 0.45% nacl (iv soln)
6
heparin sodium-0.9% nacl (1,000 units/500 ml, 2,000
unit/1,000 ml)
6
heparin sodium-d5w (iv soln)
6
jantoven (tablet)
2
PRADAXA (CAPSULE)
4
SAVAYSA (TABLET)
4
warfarin sodium (tablet)
2
XARELTO (10 MG TABLET, 15 MG TABLET, 20 MG
TABLET)
4
XARELTO STARTER PACK
4
PAGE 43
QL 60 / 30 DAYS
QL 30 / 30 DAYS
PRODUCT DESCRIPTION
TIER
Blood Formation Modifiers
anagrelide hcl (capsule)
3
ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/ML
VIAL, 25 MCG/0.42 ML SYRING, 40 MCG/ML VIAL, 40
MCG/0.4 ML SYRINGE, 60 MCG/0.3 ML SYRINGE, 60
MCG/ML VIAL, 100 MCG/ML VIAL, 100 MCG/0.5 ML
SYRINGE, 150 MCG/0.3 ML SYRINGE, 150 MCG/0.75
ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML
VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL,
500 MCG/1 ML SYRINGE)
5
EPOGEN (VIAL)
5
LEUKINE (250 MCG VIAL, 500 MCG/ML VIAL)
5
MOZOBIL (VIAL)
6
NEULASTA 6 MG/0.6 ML SYRINGE
5
NEULASTA ONPRO 6 MG/0.6 ML KIT
5
NEUPOGEN (300 MCG/ML VIAL, 300 MCG/0.5 ML
SYR, 480 MCG/1.6 ML VIAL, 480 MCG/0.8 ML SYR)
5
NPLATE (VIAL)
6
PROCRIT (VIAL)
5
QL 13 / 30 DAYS
6
PA
QL 13 / 30 DAYS
QL 1 / 30 DAYS
Coagulants
tranexamic acid 1,000 mg/10 ml
Platelet Modifying Agents
cilostazol (tablet)
2
clopidogrel (tablet)
2
dipyridamole (25 mg tablet, 50 mg tablet, 75 mg
tablet)
2
ticlopidine hcl (tablet)
2
PAGE 44
QL 30 / 30 DAYS
PRODUCT DESCRIPTION
TIER
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine (patch tdwk)
3
clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg
tablet)
2
guanfacine hcl (tablet)
2
methyldopa (tablet)
2
methyldopate hcl (vial)
6
midodrine hcl (tablet)
3
Alpha-adrenergic Blocking Agents
DIBENZYLINE (CAPSULE)
5
doxazosin mesylate (tablet)
2
phenoxybenzamine hcl (capsule)
5
prazosin hcl (capsule)
2
terazosin hcl (capsule)
2
Angiotensin II Receptor Antagonists
candesartan cilexetil (tablet)
3
eprosartan mesylate (tablet)
3
irbesartan (tablet)
2
QL 30 / 30 DAYS
losartan potassium (tablet)
2
QL 30 / 30 DAYS
telmisartan (tablet)
3
QL 30 / 30 DAYS
valsartan (tablet)
3
QL 30 / 30 DAYS
QL 30 / 30 DAYS
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl (tablet)
2
captopril (tablet)
3
PAGE 45
PRODUCT DESCRIPTION
TIER
enalapril maleate (tablet)
2
fosinopril sodium (tablet)
2
lisinopril (2.5 mg tablet, 20 mg tablet, 30 mg tablet,
40 mg tablet)
2
moexipril hcl (tablet)
2
perindopril erbumine (tablet)
2
quinapril hcl (tablet)
2
ramipril (capsule)
2
trandolapril (tablet)
2
Antiarrhythmics
amiodarone hcl (100 mg tablet, 200 mg tablet, 400
mg tablet)
2
atropine sulfate (0.05 mg/ml syringe, 0.1 mg/ml
abboject, 0.1 mg/ml syringe)
5
diltiazem hcl (25 mg/5 ml vial, 50 mg/10 ml vial, hcl
100 mg vial, 125 mg/25 ml vial)
6
disopyramide phosphate (capsule)
2
flecainide acetate (tablet)
2
glycopyrrolate (0.2 mg/ml vial, 0.4 mg/2 ml vl, 1
mg/5 ml vial, 4 mg/20 ml vial)
5
mexiletine hcl (capsule)
3
MULTAQ (TABLET)
4
pacerone 200 mg tablet
2
procainamide hcl (vial)
6
propafenone hcl (tablet)
3
propafenone hcl er (cap er 12h)
3
quinidine gluc 80 mg/ml vial
5
quinidine gluc er 324 mg tab
2
PAGE 46
QL 60 / 30 DAYS
PRODUCT DESCRIPTION
TIER
quinidine sulfate (sulf er 300 mg tab, sulfate 200 mg
tab, sulfate 300 mg tab)
2
sotalol (tablet)
2
sotalol af (tablet)
2
sotalol hcl (vial)
6
verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg
tablet)
2
Beta-adrenergic Blocking Agents
acebutolol hcl (capsule)
2
atenolol (tablet)
2
betaxolol hcl (10 mg tablet, 20 mg tablet)
3
bisoprolol fumarate (tablet)
2
carvedilol (tablet)
2
labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg
tablet)
2
labetalol hcl (100 mg/20 ml, 200 mg/40 ml)
6
metoprolol succinate (tab er 24h)
2
metoprolol tartrate (1 mg/ml carpuject, tart 5 mg/5
ml amp, tart 5 mg/5 ml vial)
6
metoprolol tartrate (25 mg tab, 37.5 mg tb, 50 mg
tab, 75 mg tab, 100 mg tab)
2
nadolol (tablet)
3
pindolol (tablet)
3
propranolol 1 mg/ml vial
6
propranolol hcl (10 mg tablet, 20 mg/5 ml soln, 20
mg tablet, 40 mg tablet, 40 mg/5 ml soln, 60 mg
2
propranolol hcl er (cap sa 24h)
3
PAGE 47
PRODUCT DESCRIPTION
TIER
Calcium Channel Blocking Agents
afeditab cr (tablet er)
2
amlodipine besylate (tablet)
2
cartia xt (cap er 24h)
2
dilt-cd (cap er 24h)
2
dilt-xr (cap er deg)
2
diltia xt (cap er deg)
2
diltiazem 12hr er (cap er 12h)
3
diltiazem 24hr cd (120 mg cap, 180 mg cap, 240 mg
cap, 300 mg cap)
2
diltiazem 24hr cd 360 mg cap
3
diltiazem 24hr er (er 120 mg cap, er 180 mg cap, er
240 mg cap, er 300 mg cap)
2
diltiazem 24hr er 360 mg cap
3
diltiazem er (er 120 mg capsule, er 180 mg capsule,
er 240 mg capsule, hcl er 120 mg cap, hcl er 180 mg
cap, hcl er 240 mg cap, hcl er 300 mg cap, hcl er 360
mg cap, hcl er 420 mg cap)
2
diltiazem er (er 180 mg tablet, er 240 mg tablet, er
300 mg tablet, er 360 mg tablet, er 420 mg tablet)
3
diltiazem hcl (30 mg tablet, 60 mg tablet, 90 mg
2
diltzac er (capsule er)
2
felodipine er (tab er 24h)
2
isradipine (capsule)
3
nicardipine hcl (20 mg capsule, 30 mg capsule)
3
nicardipine hcl (25 mg/10 ml ampule, 25 mg/10 ml
vial)
6
nifediac cc (tablet er)
2
PAGE 48
QL 30 / 30 DAYS
PRODUCT DESCRIPTION
TIER
nifedical xl (tab er 24)
2
nifedipine (capsule)
3
nifedipine er (tab er 24, tablet er)
2
nisoldipine (tab er 24h)
3
taztia xt (capsule er)
2
verapamil 360 mg cap pellet
2
verapamil er (er 120 mg capsule, er 120 mg tablet,
er 180 mg tablet, er 180 mg capsule, er 240 mg
capsule, er 240 mg tablet)
2
verapamil er pm (cap24h pct)
3
verapamil hcl (2.5 mg/ml vial, 2.5 mg/ml ampul)
6
verapamil sr (cap24h pel)
2
Cardiovascular Agents, Other
atenolol-chlorthalidone (tablet)
2
digox (tablet)
2
digoxin (0.125 mg tablet, 0.25 mg tablet, 50 mcg/ml
solution, 125 mcg tablet, 250 mcg tablet)
2
digoxin (0.25 mg/ml syringe, 500 mcg/2 ml ampule)
5
lisinopril-hydrochlorothiazide (tablet)
2
losartan-hydrochlorothiazide (tablet)
2
pentoxifylline (tablet er)
2
spironolactone-hctz (tablet)
2
triamterene-hydrochlorothiazid (37.5-25 mg cp,
37.5-25 mg tb, 50-25 mg cap, 75-50 mg tab)
2
valsartan-hydrochlorothiazide (tablet)
2
QL 30 / 30 DAYS
QL 30 / 30 DAYS
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide er 500 mg cap
PAGE 49
3
PRODUCT DESCRIPTION
methazolamide (tablet)
TIER
3
Diuretics, Loop
bumetanide (0.25 mg/ml vial, 1 mg/4 ml vial, 2.5
mg/10 ml vial)
5
bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
2
furosemide (10 mg/ml solution, 20 mg tablet, 40
mg/5 ml soln, 40 mg tablet, 80 mg tablet)
2
furosemide (20 mg/2 ml vial, 40 mg/4 ml vial, 100
mg/10 ml vial)
5
torsemide (20 mg/2 ml vial, 50 mg/5 ml vial)
6
torsemide (5 mg tablet, 10 mg tablet, 20 mg tablet,
100 mg tablet)
2
Diuretics, Potassium-sparing
amiloride hcl (tablet)
2
eplerenone (tablet)
3
spironolactone (tablet)
2
QL 60 / 30 DAYS
Diuretics, Thiazide
chlorothiazide (tablet)
2
chlorthalidone (tablet)
2
hydrochlorothiazide (12.5 mg tb, 12.5 mg cp, 50 mg
tab)
2
indapamide (tablet)
2
methyclothiazide (tablet)
2
metolazone (tablet)
2
Dyslipidemics, Fibric Acid Derivatives
fenofibrate (48 mg tablet, 54 mg tablet, 67 mg
capsule, 130 mg capsule, 134 mg capsule, 145 mg
tablet, 160 mg tablet, 200 mg capsule)
PAGE 50
3
QL 30 / 30 DAYS
PRODUCT DESCRIPTION
TIER
fenofibrate 43 mg capsule
3
QL 60 / 30 DAYS
fenofibric acid (35 mg tablet, 105 mg tablet)
3
QL 30 / 30 DAYS
gemfibrozil (tablet)
2
lofibra (54 mg tablet, 67 mg capsule, 134 mg
capsule, 160 mg tablet, 200 mg capsule)
3
QL 30 / 30 DAYS
atorvastatin calcium (tablet)
2
QL 30 / 30 DAYS
CRESTOR (TABLET)
4
QL 30 / 30 DAYS
lovastatin (tablet)
2
pravastatin sodium (tablet)
2
QL 30 / 30 DAYS
simvastatin (tablet)
2
QL 30 / 30 DAYS
Dyslipidemics, HMG CoA Reductase Inhibitors
Dyslipidemics, Other
cholestyramine (packet, powder)
3
cholestyramine light (packet, powder)
3
colestipol hcl (hcl 1 gm tablet, hcl granules, hcl
granules packet, micronized 1 gm tab)
3
niacor (tablet)
4
VASCEPA (CAPSULE)
4
QL 120 / 30 DAYS
ZETIA (TABLET)
4
QL 30 / 30 DAYS
Vasodilators, Direct-acting Arterial
hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg
2
minoxidil (tablet)
2
Vasodilators, Direct-acting Arterial/Venous
isochron (tablet er)
3
isosorbide dinitrate (2.5 mg tab sl, 5 mg tablet, 5 mg
tablet sl, 10 mg tablet, 20 mg tablet, 30 mg tablet,
er 40 mg tablet)
3
PAGE 51
PRODUCT DESCRIPTION
TIER
isosorbide mononitrate (tablet)
2
isosorbide mononitrate er (tab er 24h)
2
minitran (patch td24)
2
nitroglycerin (lingual 0.4 mg, 400 mcg spray)
3
nitroglycerin 5 mg/ml vial
6
nitroglycerin in d5w (infus. btl)
6
nitroglycerin patch (patch td24)
2
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
dextroamphetamine sulfate (5 mg tab, 10 mg tab)
3
dextroamphetamine sulfate er (er 5 mg capsule, er
15 mg capsule)
3
dextroamphetamine-amphet er (cap er 24h)
3
dextroamphetamine-amphetamine (tablet)
3
methamphetamine hcl (tablet)
3
PA
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
clonidine hcl er (tab er 12h)
3
dexmethylphenidate hcl (tablet)
2
guanfacine hcl er (tab er 24h)
3
metadate er (tablet er)
3
methylphenidate er (er 10 mg tab, er 20 mg tab, er
20 mg cap, er 30 mg cap, er 40 mg cap)
3
methylphenidate er (er 18 mg tab, er 27 mg tab, er
54 mg tab)
3
QL 30 / 30 DAYS
methylphenidate er 36 mg tab
3
QL 60 / 30 DAYS
methylphenidate hcl (5 mg tablet, 10 mg tablet, 20
mg tablet)
2
PAGE 52
QL 60 / 30 DAYS
QL 30 / 30 DAYS
PRODUCT DESCRIPTION
TIER
methylphenidate hcl cd (10 mg cap, 20 mg cap, 30
mg cap, 40 mg cap)
3
QL 60 / 30 DAYS
methylphenidate hcl cd (50 mg cap, 60 mg cap)
3
QL 30 / 30 DAYS
methylphenidate la (cpbp 50-50)
3
methylphenidate sr (tablet er)
3
STRATTERA (CAPSULE)
4
QL 60 / 30 DAYS
Central Nervous System Agents, Other
butalb-acetamin-caff 50-325-40
2
cevimeline hcl (capsule)
3
tetrabenazine (tablet)
5
XENAZINE (TABLET)
5
Multiple Sclerosis Agents
AMPYRA (TAB ER 12H)
5
QL 30 / 30 DAYS
AUBAGIO (TABLET)
5
QL 30 / 30 DAYS
PA
BETASERON (KIT)
5
QL 15 / 30 DAYS
PA
COPAXONE 20 MG/ML SYRINGE
5
QL 30 / 30 DAYS
PA
COPAXONE 40 MG/ML SYRINGE
5
QL 12 / 28 DAYS
PA
glatopa (syringe)
5
QL 30 / 30 DAYS
PA
PLEGRIDY (SYRINGE)
5
QL 1 / 28 DAYS
PA
PLEGRIDY PEN (PEN INJCTR)
5
QL 1 / 28 DAYS
PA
PAGE 53
PRODUCT DESCRIPTION
TIER
REBIF 44 MCG/0.5 ML SYRINGE
5
QL 13 / 30 DAYS
PA
TECFIDERA (CAPSULE DR)
5
QL 60 / 30 DAYS
PA
TYSABRI (VIAL)
6
PA
Dental and Oral Agents
KEPIVANCE (VIAL)
6
pilocarpine hcl (5 mg tablet, 7.5 mg tablet)
3
Dermatological Agents
adapalene (0.1% gel, 0.1% cream, 0.3% gel pump,
0.3% gel)
3
ammonium lactate 12% lotion
2
calcipotriene (cream, ointment, solution)
5
calcitriol 3 mcg/g ointment
3
claravis 30 mg capsule
3
clindamycin phos-benzoyl perox (gel (gram))
3
clindamycin-benzoyl peroxide (gel (gram))
3
clotrimazole-betamethasone (crm, lot)
3
cyclosporine 100 mg/ml soln
5
cyclosporine modified (25 mg, 50 mg)
5
ELIDEL (CREAM )
4
erythromycin-benzoyl peroxide (gel (gram))
2
fluorouracil (2% topical soln, 5% top solution, 5%
cream)
3
gengraf (25 mg capsule, 100 mg/ml solution, 100 mg
capsule)
5
hypercare (solution)
2
PAGE 54
QL 150 / 365 DAYS
PRODUCT DESCRIPTION
TIER
mometasone furoate (cream, oint)
2
myorisan 30 mg capsule
3
podofilox (solution)
3
prednicarbate (cream, ointment)
3
refissa (cream (g))
3
selenium sulfide 2.25% shampoo
3
selenium sulfide 2.5% lotion
2
STELARA (SYRINGE)
5
tretinoin (0.01% gel, 0.025% gel, 0.025% cream,
0.05% emollient crm, 0.05% cream, 0.1% cream)
3
tretinoin microsphere (gel pump, gel tube)
3
trianex (oint. )
3
zenatane (capsule)
3
QL 150 / 365 DAYS
CERDELGA (CAPSULE)
5
PA
CEREZYME (VIAL)
6
ELELYSO (VIAL)
6
KUVAN 100 MG TABLET
5
pancrelipase 5,000 (capsule dr)
3
VPRIV (VIAL)
6
ZENPEP (CAPSULE DR)
4
QL 150 / 365 DAYS
PA
Enzyme Replacement/ Modifiers
PA
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
dicyclomine 10 mg/5 ml soln
3
dicyclomine hcl (10 mg capsule, 20 mg tablet)
2
glycopyrrolate (1 mg tablet, 2 mg tablet)
3
PAGE 55
PRODUCT DESCRIPTION
methscopolamine bromide (tablet)
TIER
3
Gastrointestinal Agents, Other
APRISO (CAP ER 24H)
4
diphenoxylate-atropine (diphenoxylat-atrop 2.50.025/5, diphenoxylate-atrop 2.5-0.025)
2
LIALDA (TABLET DR)
4
loperamide (capsule)
2
mesalamine 4 gm/60 ml enema
5
sulfasalazine (tablet)
2
sulfasalazine dr (tablet dr)
2
ursodiol (250 mg tablet, 300 mg capsule, 500 mg
tablet)
3
QL 120 / 30 DAYS
Histamine2 (H2) Receptor Antagonists
cimetidine (300 mg tablet, 300 mg/5 ml soln, 400
2
famotidine (20 mg piggyback, 20 mg/2 ml vial, 40
mg/4 ml vial, 200 mg/20 ml vial, 500 mg/50 ml vial)
6
famotidine (20 mg tablet, 40 mg tablet)
2
nizatidine (15 mg/ml solution, 150 mg capsule, 300
mg capsule)
2
ranitidine hcl (15 mg/ml syrup, 150 mg/10 ml syrup,
150 mg tablet, 150 mg capsule, 300 mg capsule, 300
mg tablet)
2
ranitidine hcl (hcl 25 mg/ml vial, hcl 50 mg/2 ml vial,
hcl 150 mg/6 ml vl, 1,000 mg/40 ml vial)
5
Irritable Bowel Syndrome Agents
LINZESS (CAPSULE)
4
QL 30 / 30 DAYS
Laxatives
clearlax (eql, gnp)
PAGE 56
1
PRODUCT DESCRIPTION
TIER
constulose (solution)
2
enulose (solution)
2
gavilax (powder)
1
gavilyte-c (soln recon)
1
gavilyte-g (soln recon)
1
gavilyte-n (soln recon)
1
generlac (solution)
2
glycolax (powder)
1
lactulose (solution)
2
laxa clear (powder)
1
laxative peg 3350 (powder)
1
peg 3350-electrolyte (soln recon)
1
peg-3350 and electrolytes (soln recon)
1
peg-3350 with flavor packs (soln recon)
1
peg3350 (powder)
1
polyethylene glycol 3350 (powd pack, powder)
3
purelax (powder)
1
smoothlax (powder)
1
trilyte with flavor packets (soln recon)
1
Protectants
misoprostol (tablet)
2
sucralfate (tablet)
2
Proton Pump Inhibitors
omeprazole (capsule dr)
2
QL 60 / 30 DAYS
pantoprazole sodium (dr 20 mg tab, dr 40 mg tab)
2
QL 30 / 30 DAYS
PAGE 57
PRODUCT DESCRIPTION
pantoprazole sodium 40 mg vial
TIER
6
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl (tablet)
2
oxybutynin chloride (5 mg/5 ml syrup, 5 mg tablet)
2
oxybutynin chloride er (tab er 24)
2
tolterodine tartrate (tablet)
3
QL 60 / 30 DAYS
tolterodine tartrate er (cap er 24h)
3
QL 30 / 30 DAYS
alfuzosin hcl er (tab er 24h)
2
QL 30 / 30 DAYS
CIALIS (2.5 MG TABLET, 5 MG TABLET)
4
QL 18 / 90 DAYS
finasteride 1 mg tablet
2
finasteride 5 mg tablet
2
QL 30 / 30 DAYS
tamsulosin hcl (cap er 24h)
2
QL 60 / 30 DAYS
Benign Prostatic Hypertrophy Agents
Genitourinary Agents, Other
bethanechol chloride (tablet)
2
CUPRIMINE (CAPSULE)
5
PA
DEPEN (TABLET)
5
PA
ELMIRON (CAPSULE)
4
STENDRA (TABLET)
4
QL 6 / 30 days
Phosphate Binders
AURYXIA (TABLET)
4
calcium acetate (667 mg capsule, 667 mg tablet, 667
mg gelcap)
3
eliphos (tablet)
3
PAGE 58
PRODUCT DESCRIPTION
TIER
RENVELA (0.8 GM POWDER PACKET, 2.4 GM
POWDER PACKET, 800 MG TABLET)
4
sevelamer carbonate (tablet)
3
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Glucocorticoids/Mineralocorticoids
a-hydrocort (vial)
5
budesonide ec (capdr - er)
5
dexamethasone (0.5 mg tablet, 0.5 mg/5 ml elx, 0.5
mg/5 ml liq, 0.75 mg tablet, 1 mg tablet, 1.5 mg
2
dexamethasone 0.1% eye drop
2
dexamethasone intensol (drops)
2
diclofenac 0.1% eye drops
2
FLOVENT DISKUS (BLST W/DEV)
4
FLOVENT HFA (AER W/ADAP)
4
fluocinolone 0.01% cream
3
fluocinolone acetonide oil (drops)
3
fluorometholone (drops susp)
3
fluticasone prop 50 mcg spray
2
hydrocortisone (10 mg tablet, 20 mg tablet)
2
hydrocortisone butyrate (butyr oint, soln)
3
hydrocortisone valerate (cream, ointmt)
3
methylprednisolone 4 mg tablet
2
methylprednisolone acetate (vial)
5
mometasone furoate 0.1% soln
2
prednisone (5 mg tab dose pack, 5 mg tablet, 10 mg
tablet)
2
PAGE 59
PRODUCT DESCRIPTION
TIER
triamcinolone 0.1% cream
2
triamcinolone 55 mcg nasal spr
3
u-cort (cream (g))
3
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
chorionic gonadotropin (vial)
5
desmopressin acetate (0.01% spray, 0.01% solution,
0.1 mg/ml spray, acetate 0.1 mg tb, 0.1 mg/ml sol,
acetate 0.2 mg tb, 10 mcg/0.1 ml spr)
3
desmopressin acetate (ac 4 mcg/ml vial, ac 4
mcg/ml ampul, 40 mcg/10 ml vial)
5
QL 3 / 30 DAYS
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)
HEMABATE (AMPUL)
6
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Anabolic Steroids
oxandrolone (tablet)
3
Androgens
androxy (tablet)
3
danazol (capsule)
3
testosterone cypionate (vial)
5
testosterone enanthate (vial)
5
PA
Estrogens
altavera (tablet)
1
alyacen (tablet)
1
amethia (tbdspk 3mo)
1
amethia lo (tbdspk 3mo)
1
amethyst (tablet)
1
PAGE 60
PRODUCT DESCRIPTION
TIER
apri (tablet)
1
aranelle (tablet)
1
ashlyna (tbdspk 3mo)
1
aubra (tablet)
1
aviane (tablet)
1
azurette (tablet)
1
balziva (tablet)
1
bekyree (tablet)
1
BEYAZ (TABLET)
1
blisovi 24 fe (tablet)
1
blisovi fe (tablet)
1
briellyn (tablet)
1
camrese (tbdspk 3mo)
1
camrese lo (tbdspk 3mo)
1
caziant (tablet)
1
chateal (tablet)
1
cryselle (tablet)
1
cyclafem (tablet)
1
cyred (tablet)
1
dasetta (tablet)
1
daysee (tbdspk 3mo)
1
delyla (tablet)
1
desogestr-eth estrad eth estra (tablet)
1
desogestrel-ethinyl estradiol (tablet)
1
drospirenone-ethinyl estradiol (tablet)
1
PAGE 61
PRODUCT DESCRIPTION
TIER
elinest (tablet)
1
emoquette (tablet)
1
enpresse (tablet)
1
enskyce (tablet)
1
estarylla (tablet)
1
estradiol (0.025 mg/day patch, tds 0.025 mg/day,
0.0375 mg/day patch, tds 0.0375 mg/day, tds 0.05
mg/day, 0.05 mg/day patch, 0.06 mg/day patch, tds
0.06 mg/day, tds 0.075 mg/day, 0.075 mg/day
patch, 0.1 mg/day patch, tds 0.1 mg/day)
3
estradiol (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
2
estradiol valerate (vial)
6
estropipate (tablet)
2
falmina (tablet)
1
gianvi (tablet)
1
gildagia (tablet)
1
gildess (tablet)
1
gildess 24 fe (tablet)
1
gildess fe (tablet)
1
introvale (tbdspk 3mo)
1
jolessa (tbdspk 3mo)
1
juleber (tablet)
1
junel (tablet)
1
junel fe (tablet)
1
junel fe 24 (tablet)
1
kaitlib fe (tab chew)
1
kariva (tablet)
1
PAGE 62
QL 4 / 28 DAYS
PRODUCT DESCRIPTION
TIER
kelnor 1-35 (tablet)
1
kimidess (tablet)
1
kurvelo (tablet)
1
larin (tablet)
1
larin 24 fe (tablet)
1
larin fe (tablet)
1
leena (tablet)
1
lessina (tablet)
1
levonest (tablet)
1
levonorg-eth estrad eth estrad (tbdspk 3mo)
1
levonorgestrel-eth estradiol (tablet, tbdspk 3mo)
1
levora-28 (tablet)
1
LO LOESTRIN FE (TABLET)
1
LO MINASTRIN FE (CMBTABCHTB)
1
LOESTRIN 24 FE (TABLET)
1
lomedia 24 fe (tablet)
1
loryna (tablet)
1
low-ogestrel (tablet)
1
lutera (tablet)
1
marlissa (tablet)
1
microgestin (tablet)
1
microgestin fe (tablet)
1
MINASTRIN 24 FE (TAB CHEW)
1
mono-linyah (tablet)
1
mononessa (tablet)
1
PAGE 63
PRODUCT DESCRIPTION
TIER
myzilra (tablet)
1
NATAZIA (TABLET)
1
necon (tablet)
1
nikki (tablet)
1
norethin-eth estra ferrous fum (norethin-estra-fe
0.8-0.025 mg, norethin-estrad-ferr 1-0.02 mg)
1
norethind-eth estrad 1-0.02 mg
1
norgestimate-ethinyl estradiol (tablet)
1
nortrel (tablet)
1
NUVARING (VAG RING)
1
ocella (tablet)
1
ogestrel (tablet)
1
orsythia (tablet)
1
ORTHO TRI-CYCLEN LO (TABLET)
4
philith (tablet)
1
pimtrea (tablet)
1
pirmella (tablet)
1
portia (tablet)
1
previfem (tablet)
1
QUARTETTE (TBDSPK 3MO)
1
quasense (tbdspk 3mo)
1
reclipsen (tablet)
1
SAFYRAL (TABLET)
1
setlakin (tbdspk 3mo)
1
sprintec (tablet)
1
sronyx (tablet)
1
PAGE 64
QL 30 / 30 DAYS
QL 1 / 30 DAYS
QL 91 / 91 DAYS
PRODUCT DESCRIPTION
TIER
syeda (tablet)
1
tarina fe (tablet)
1
tilia fe (tablet)
1
tri-estarylla (tablet)
1
tri-legest fe (tablet)
1
tri-linyah (tablet)
1
tri-lo-estarylla (tablet)
1
tri-lo-marzia (tablet)
1
tri-lo-sprintec (tablet)
1
tri-previfem (tablet)
1
tri-sprintec (tablet)
1
trinessa (tablet)
1
trinessa lo (tablet)
1
trivora-28 (tablet)
1
velivet (tablet)
1
vestura (tablet)
1
vienva (tablet)
1
viorele (tablet)
1
vyfemla (tablet)
1
wera (tablet)
1
wymzya fe (tab chew)
1
xulane (patch tdwk)
1
zarah (tablet)
1
zenchent (tablet)
1
zenchent fe (tab chew)
1
PAGE 65
QL 9 / 84 DAYS
PRODUCT DESCRIPTION
TIER
zeosa (tab chew)
1
zovia 1-35e (tablet)
1
zovia 1-50e (tablet)
1
Progestins
camila (tablet)
1
deblitane (tablet)
1
DEPO-PROVERA 400 MG/ML VIAL
5
DEPO-SUBQ PROVERA 104 (SYRINGE)
1
ELLA (TABLET)
1
errin (tablet)
1
heather (tablet)
1
IMPLANON (IMPLANT)
6
jencycla (tablet)
1
jolivette (tablet)
1
levonorgestrel 0.75 mg tablet
1
QL 2 / 365 DAYS
levonorgestrel 1.5 mg tablet
1
QL 1 / 365 DAYS
LILETTA (IUD)
6
lyza (tablet)
1
medroxyprogesterone 150 mg/ml
1
medroxyprogesterone acetate (2.5 mg tab, 5 mg
tab, 10 mg tab)
2
megestrol acetate (20 mg tablet, acet 40 mg/ml
susp, 40 mg tablet, acet 400 mg/10 ml)
2
MIRENA (IUD)
6
my way (tablet)
1
NEXPLANON (IMPLANT)
6
PAGE 66
QL 1 / 90 DAYS
QL 1 / 90 DAYS
QL 1 / 365 DAYS
PRODUCT DESCRIPTION
TIER
next choice one dose (tablet)
1
nora-be (tablet)
1
norethindrone (tablet)
1
norethindrone acetate (tablet)
2
norlyroc (tablet)
1
progesterone (100 mg capsule, 200 mg capsule)
3
progesterone in oil (vial)
5
progesterone oil 50 mg/ml vl
5
sharobel (tablet)
1
SKYLA (IUD)
6
QL 1 / 365 DAYS
Selective Estrogen Receptor Modifying Agents
EVISTA (TABLET)
1
QL 30 / 30 DAYS
ST
OSPHENA (TABLET)
4
QL 30 / 30 DAYS
raloxifene hcl (tablet)
1
QL 30 / 30 days
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothyroxine sodium (25 mcg tablet, 50 mcg tablet,
75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112
mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg
tablet, 175 mcg tablet, 200 mcg tablet, 300 mcg
tablet)
2
liothyronine sod 10 mcg/ml vl
6
liothyronine sodium (5 mcg tab, 25 mcg tab, 50 mcg
tab)
2
Hormonal Agents, Suppressant (Adrenal)
LYSODREN (TABLET)
PAGE 67
4
PRODUCT DESCRIPTION
TIER
Hormonal Agents, Suppressant (Parathyroid)
calcitriol (0.25 mcg capsule, 0.5 mcg capsule)
2
calcitriol 1 mcg/ml ampul
6
calcitriol 1 mcg/ml solution
3
Hormonal Agents, Suppressant (Pituitary)
cabergoline (tablet)
3
GANIRELIX ACETATE (SYRINGE)
5
leuprolide acetate (kit)
5
octreotide acetate (acet 0.05 mg/ml vl, acet 50
mcg/ml amp, acet 50 mcg/ml vial, acet 100 mcg/ml
vl, acet 100 mcg/ml amp, acet 200 mcg/ml vl, acet
500 mcg/ml vl, acet 500 mcg/ml amp, 1,000 mcg/5
ml vial, 1,000 mcg/ml vial, 5,000 mcg/5 ml vial)
6
PA
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
Antiandrogens
bicalutamide (tablet)
2
NILANDRON (TABLET)
4
XTANDI (CAPSULE)
5
QL 30 / 30 DAYS
QL 120 / 30 DAYS
PA
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole (tablet)
2
propylthiouracil (tablet)
2
Immunological Agents
Immune Suppressants
azathioprine (tablet)
5
azathioprine sodium (vial)
5
PAGE 68
PRODUCT DESCRIPTION
TIER
BENLYSTA (VIAL)
6
cyclosporine (25 mg capsule, 100 mg capsule)
5
cyclosporine (50 mg/ml vial, 50 mg/ml ampul)
6
cyclosporine modified 100 mg
5
hecoria (capsule)
5
HUMIRA (SYRINGEKIT)
5
QL 2 / 28 DAYS
PA
HUMIRA PEDIATRIC CROHN'S (SYRINGEKIT)
5
QL 3 / 28 DAYS
PA
HUMIRA PEN (PEN IJ KIT)
5
QL 2 / 28 DAYS
PA
HUMIRA PEN CROHN'S-UC-HS (PEN IJ KIT)
5
QL 6 / 28 DAYS
PA
HUMIRA PEN PSORIASIS (PEN IJ KIT)
5
QL 4 / 28 DAYS
PA
methotrexate 100 mg/4 ml vial
5
methotrexate sodium (vial)
5
mycophenolate mofetil (250 mg capsule, 500 mg
tablet)
5
ORENCIA 250 MG VIAL
6
PA
REMICADE (VIAL)
6
PA
SIMPONI ARIA (VIAL)
6
PA
sirolimus (tablet)
5
tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg
capsule)
5
PA
Immunizing Agents, Passive
BIVIGAM (VIAL)
6
carimune nf nanofiltered (vial)
6
PAGE 69
PRODUCT DESCRIPTION
TIER
FLEBOGAMMA DIF (5% VIAL, 10% VIAL)
6
gammagard liquid (vial)
6
GAMMAPLEX (VIAL)
6
GAMUNEX (VIAL)
6
privigen (vial)
6
Immunomodulators
ACTEMRA (80 MG/4 ML VIAL, 200 MG/10 ML VIAL,
400 MG/20 ML VIAL)
6
PA
ACTIMMUNE (VIAL)
6
PA
leflunomide (tablet)
2
RIDAURA (CAPSULE)
4
Vaccines
ACTHIB (VIAL)
6
ADACEL TDAP (SYRINGE, VIAL)
6
BEXSERO (SYRINGE)
6
BOOSTRIX TDAP (SYRINGE, VIAL)
6
CERVARIX (SYRINGE)
6
DAPTACEL DTAP (VIAL)
6
diphtheria-tetanus toxoids-ped (vial)
6
ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML
VIAL)
6
ENGERIX-B PEDIATRIC-ADOLESCENT (10 MCG/0.5
ML PED VL, PEDI 10 MCG/0.5 SYRN)
6
FLUARIX QUAD 2015-2016 (SYRINGE)
6
FLUBLOK 2015-2016 (VIAL)
6
FLUCELVAX 2015-2016 (SYRINGE)
6
FLULAVAL QUAD 2015-2016 (VIAL)
6
PAGE 70
PRODUCT DESCRIPTION
TIER
FLUVIRIN 2015-2016 (SYRINGE, VIAL)
6
FLUZONE 2015-2016 (VIAL)
6
FLUZONE HIGH-DOSE 2015-2016 (SYRINGE)
6
FLUZONE QUAD 2015-2016 (SYRINGE, VIAL)
6
FLUZONE QUAD PEDI 2015-2016 (SYRINGE)
6
GARDASIL (SYRINGE, VIAL)
6
GARDASIL 9 (9 VIAL, 9 SYRINGE)
6
HAVRIX (720 UNITS/0.5 ML VIAL, 720 UNIT/0.5 ML
SYRINGE, 1,440 UNITS/ML VIAL, 1,440 UNITS/ML
SYRINGE)
6
INFANRIX DTAP (SYRINGE, VIAL)
6
IPOL (SINGLE DOSE SYRINGE, VIAL)
6
M-M-R II VACCINE (VIAL)
6
MENACTRA (VIAL)
6
MENOMUNE-A-C-Y-W-135 (VIAL)
6
PEDVAXHIB (VIAL)
6
PENTACEL ACTHIB COMPONENT (VIAL)
6
PNEUMOVAX 23 (23 SYRINGE, 23 VIAL)
6
PREVNAR 13 (SYRINGE)
6
RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML
VL, 10 MCG/ML VIAL, 10 MCG/ML SYR, 40 MCG/ML
VIAL)
6
ROTARIX (SUSP RECON)
6
ROTATEQ (ORAL SUSP)
6
TENIVAC (SYRINGE, VIAL)
6
tetanus diphtheria toxoids (vial)
6
TRUMENBA (SYRINGE)
6
PAGE 71
QL 0.5 / 365 DAYS
PRODUCT DESCRIPTION
TIER
VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 ML
VIAL, 50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL)
6
VARIVAX VACCINE (VIAL)
6
ZOSTAVAX (VIAL)
6
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium (capsule)
3
Glucocorticoids
colocort (enema)
4
dexamethasone 4 mg/ml syringe
5
hydrocortisone 100 mg/60 ml
3
proctozone-hc (cream/appl)
2
MISCELLANEOUS THERAPEUTIC AGENTS
accu-chek (kit)
4
accu-chek active (strip)
4
accu-chek aviva (strip)
4
accu-chek aviva connect (each)
4
accu-chek aviva plus (meter, test strp)
4
accu-chek comfort curve (strip)
4
accu-chek compact (strip)
4
accu-chek compact plus (strip)
4
accu-chek nano smartview (each)
4
accu-chek smartview (strip)
4
accu-chek voicemate (kit)
4
aftera (tablet)
1
alophen pills (tablet dr)
1
PAGE 72
PRODUCT DESCRIPTION
TIER
aspir-trin (tablet dr)
1
aspirin (bayer 325 mg caplet, bayer 325 mg tablet,
coated 325 mg tablet, cvs 325 mg tablet, cvs 325 mg
caplet, eq 325 mg tablet, eql 325 mg tablet, gnp 325
mg tablet, hm 325 mg tablet, kro 325 mg tablet, pub
325 mg tablet, pv 325 mg tablet, qc 325 mg tablet,
ra 325 mg tablet, sb 325 mg tablet, sm 325 mg
tablet, soba 325 mg tablet, 325 mg lite-coat tab, 325
mg tablet, 325 mg coated tablet)
1
aspirin ec (cvs ec 325 mg tablet, ec 325 mg tablet, eq
ec 325 mg tablet, gnp ec 325 mg tablet, hm ec 325
mg tablet, kro ec 325 mg tablet, pv ec 325 mg tablet,
qc ec 325 mg tablet, ra ec 325 mg tablet, sb ec 325
mg tablet, sm ec 325 mg tablet, soba ec 325 mg
tablet, v-r ec 325 mg tablet)
1
bisa-lax (tablet dr)
1
bisacodyl (cvs ec 5 mg tablet, ec 5 mg tablet, fleet ec
5 mg tab, ra ec 5 mg tablet, sb ec 5 mg tablet)
1
caya contoured (diaphragm)
1
children's ferrous sulfate (drops)
1
children's iron (drops)
1
children's vitamin d (tab chew)
1
citrate of magnesia (solution)
1
citroma (solution)
1
clearlax (, eq, hm, sm, sw)
1
clomiphene citrate (tablet)
2
CONCEPTROL (GEL/PF APP)
1
d3 dots (tablet)
1
delta d3 (tablet)
1
ducodyl (tablet dr)
1
econtra ez (tablet)
1
PAGE 73
PRODUCT DESCRIPTION
TIER
ecpirin (tablet dr)
1
fa-8 (capsule)
1
fallback solo (tablet)
1
fc2 female condom (each)
1
femcap (each)
1
fer-iron (drops)
1
ferrous sulf 15 mg iron/ml drp
1
folic acid (cvs 0.4 mg tablet, 0.8 mg tablet, eql 400
mcg tab, hm 400 mcg tablet, pv 400 mcg tablet, ra
0.4 mg tablet, 0.4 mg tablet, sm 0.4 mg tablet, 400
mcg tablet, cvs 800 mcg tablet, gnp 400 mcg tablet,
pv 800 mcg tablet, ra 800 mcg tablet, sm 400 mcg
tablet, sv 800 mcg tablet, 800 mcg capsule, 800 mcg
tablet)
1
gentle laxative (cvs ec 5 mg tb, ec 5 mg tablet, eq dr
5 mg tab, qc ec 5 mg tab, 5 mg tablet, sm ec 5 mg
tab)
1
gentlelax (powder)
1
gynol ii (jelly/appl)
1
iron (drops)
1
kids vitamin d3 (tab chew)
1
laxative (pub ec 5 mg tablet, 5 mg tablet, ec 5 mg
tablet, eql ec 5 mg tablet, gnp ec 5 mg tablet, hm ec
5 mg tablet, pv 5 mg tab, pv ec 5 mg tablet, sm
tablet)
1
laxative feminine (tablet)
1
lite coat aspirin (tablet)
1
lo-so liquid prep kit (kit)
1
lo-so prep kit (kit)
1
magnesium citrate (solution)
1
PAGE 74
PRODUCT DESCRIPTION
TIER
nicoderm cq 21 mg/24hr patch
1
nicorelief (2 mg, 4 mg)
1
nicotine gum (2 mg, 4 mg)
1
nicotine lozenge (lozenge)
1
nicotine patch (eq 21 mg/24hr patch, eql 21
mg/24hr patch, pv 21 mg/24 hr patch, ra 21
mg/24hr patch, soba 11 mg/24hr patch, 21 mg/24
hr patch, hm 21 mg/24hr patch, kro 21 mg/24hr
patch, sm 21 mg/24hr patch, 21 mg/24hr patch, 22
mg/24hr patch, transdermal system)
1
nts (patch td24)
1
onetouch ultra system (kit)
4
onetouch ultra test strips (strip)
4
onetouch ultra2 (kit)
4
onetouch ultralink (kit)
4
onetouch ultramini (kit)
4
onetouch verio (meter system, test strip)
4
onetouch verio flex (each)
4
onetouch verio iq (meter, system kit)
4
onetouch verio sync (kit)
4
opcicon one-step (tablet)
1
ortho all-flex (diaphragm 65mm, diaphragm 70mm,
diaphragm 75mm, diaphragm 80mm, fitting set)
1
PARAGARD T 380-A (IUD)
6
powderlax (powder)
1
quit 2 mg lozenge
1
quit 4 mg lozenge
1
stop smoking aid (lozenge)
1
PAGE 75
PRODUCT DESCRIPTION
TIER
thera-d (2000 tablet, rapid repletion tablet, sport
2,000 unit tab)
1
TODAY CONTRACEPTIVE SPONGE (CON.SPONGE)
1
vcf (film, foam, gel)
1
vitamin d (tablet)
1
vitamin d-400 (tablet)
1
vitamin d2 (400 tablet, 2,000 tablet)
1
vitamin d3 (cvs vit 1,000 unit soft chw, cvs vit 1,000
unit gummies, cvs vitamin 400 unit sftgl, gnp vit 400
unit tab chew, gnp vitamin 400 unit tablet, gnp
vitamin 1,000 unit tab, gnp vitamin 2,000 unit tab,
hm vitamin 400 unit tablet, hm vitamin 1,000 unit
tab, pv vit 400 unit tab chew, pv vit 1,000 unit tab
chew, pv vitamin 400 unit tablet, pv vitamin 400 unit
softgel, pv vitamin 1,000 unit tab, pv vitamin 1,000
units sfgl, pv vitamin 2,000 unit tab, pv vitamin
2,000 unit sftgl, ra vitamin 1,000 unit tab, sm
vitamin 400 unit tablet, sm vitamin 1,000 unit tab, sv
vitamin 400 unit softgel, vitamin 400 unit tablet,
vitamin 400 unit softgel, vitamin 400 unit tab chew,
vitamin 400 unit/5 ml liq, vitamin 800 unit gummy,
vitamin 1,000 unit tablet, vitamin 1,000 unit tab
chew, vitamin 1,000 unit gummies, vitamin 2,000
unit softgel, vitamin 2,000 unit tablet)
1
wide seal diaphragm (diaphragm)
1
woman's laxative (ec 5 mg tab, eql 5 mg tab, sm 5
mg tab, tablet)
1
women's gentle laxative (tablet dr)
1
women's laxative (eq women's 5 mg tab, eq
women's ec 5 mg tb, eql women's ec 5 mg, pv
women's 5 mg tab, ra women's tablet, womans
tablet, women's 5 mg tablet, women's ec 5 mb tab,
women's tablet)
1
PAGE 76
PRODUCT DESCRIPTION
TIER
Metabolic Bone Disease Agents
alendronate sodium (5 mg tablet, 10 mg tab, 35 mg
tab, 40 mg tab, 70 mg tab)
2
calcitonin-salmon (spray/pump)
3
etidronate disodium (tablet)
2
ibandronate sodium 150 mg tab
2
pamidronate disodium (30 mg/10 ml vial, disod 30
mg vial, 60 mg/10 ml vial, 90 mg/10 ml vial, disod 90
mg vial)
6
paricalcitol 2 mcg/ml vial
6
PA
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost (drops)
2
QL 15 / 90 DAYS
LUMIGAN (DROPS)
4
QL 15 / 90 DAYS
TRAVATAN Z (DROPS)
4
QL 15 / 90 DAYS
travoprost (drops)
3
Ophthalmic Agents, Other
ak-poly-bac (oint. (g))
3
atropine care (drops)
3
atropine sulfate (drops, ointment)
3
bacitracin-polymyxin (oint. (g))
3
cyclopentolate 1% eye drops
3
gentamicin sulfate (0.3% ointment, 3 mg/gm oint)
2
homatropaire (drops)
3
homatropine hydrobromide (drops)
3
ISOPTO ATROPINE (DROPS)
4
PAGE 77
PRODUCT DESCRIPTION
TIER
naphazoline hcl (drops)
2
neo-polycin (oint. (g))
3
neomycin-bacitracin-poly-hc (oint. (g))
3
neomycin-bacitracin-polymyxin (oint. (g))
3
neomycin-poly-hc eye drops
3
neomycin-polymyxin-dexameth (neomyc-polymdexamet ointm, neomyc-polym-dexameth drop)
3
neomycin-polymyxin-gramicidin (drops)
3
phenylephrine 2.5% eye drop
3
polycin (oint. (g))
3
polymyxin b sul-trimethoprim (drops)
3
sulfacetamide-prednisolone (drops)
3
tobramycin-dexamethasone (drops susp)
3
Ophthalmic Anti-allergy Agents
azelastine hcl 0.05% drops
3
cromolyn 4% eye drops
2
Ophthalmic Anti-inflammatories
bromfenac sodium (drops)
3
flurbiprofen sodium (drops)
2
ILEVRO (DROPS SUSP)
4
ketorolac tromethamine (0.4%, 0.5%)
2
LOTEMAX (EYE DROPS, EYE OINTMENT,
OPHTHALMIC GEL)
4
prednisolone acetate (drops susp)
3
prednisolone sod 1% eye drop
3
PAGE 78
QL 2 / 14 DAYS
PRODUCT DESCRIPTION
TIER
Ophthalmic Antiglaucoma Agents
betaxolol hcl 0.5% eye drop
3
brimonidine tartrate (drops)
3
carteolol hcl (drops)
2
dorzolamide hcl (drops)
2
dorzolamide-timolol (drops)
2
levobunolol hcl (drops)
2
metipranolol (drops)
2
pilocarpine hcl (1% drops, 2% drops, 4% drops)
3
timolol maleate (0.25% drops, 0.5% drops)
2
timolol maleate (0.25% gfs, 0.25%, 0.5% gfs, 0.5%)
3
Otic Agents
antipyrine-benzocaine ear drop
3
CIPRODEX (DROPS SUSP)
4
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
ARNUITY ELLIPTA (BLST W/DEV)
4
budesonide (0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml
inh)
3
budesonide 32 mcg nasal spray
3
flunisolide (spray)
3
mometasone furoate 50 mcg spry
3
NASONEX (SPRAY/PUMP)
4
ST
OMNARIS (SPRAY/PUMP)
4
QL 12.5 / 30 days
ST
QVAR (AER W/ADAP)
4
PAGE 79
QL 140 / 30 DAYS
PRODUCT DESCRIPTION
TIER
Antihistamines
arbinoxa (4 mg tablet, 4 mg/5 ml liquid)
3
azelastine 0.1% (137 mcg) spry
3
carbinoxamine maleate (4 mg/5 ml liquid, maleate 4
mg tab)
2
clemastine 0.5 mg/5 ml syrup
3
clemastine fum 2.68 mg tab
2
cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet, 4
mg/10 ml syrp)
2
desloratadine 2.5 mg odt
3
QL 90 / 30 DAYS
desloratadine 5 mg odt
3
QL 60 / 30 DAYS
desloratadine 5 mg tablet
3
QL 30 / 30 DAYS
levocetirizine 2.5 mg/5 ml sol
3
levocetirizine 5 mg tablet
3
palgic (4 mg/5 ml liquid, 4 mg tablet)
3
promethazine 25 mg tablet
2
QL 30 / 30 DAYS
Antileukotrienes
montelukast sod 4 mg granules
3
QL 30 / 30 DAYS
montelukast sodium (4 mg tab chew, 5 mg tab chew,
10 mg tablet)
2
QL 30 / 30 DAYS
Bronchodilators, Anticholinergic
INCRUSE ELLIPTA (BLST W/DEV)
4
ipratropium bromide (br 0.02% soln, 0.03% spray,
0.06% spray)
2
SPIRIVA (CAP W/DEV)
4
QL 90 / 90 DAYS
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
aminophylline (ampul, vial)
PAGE 80
6
PRODUCT DESCRIPTION
TIER
theochron (tab er 12h)
2
theophylline (80 mg/15 ml soln, er 400 mg tablet, er
600 mg tablet)
2
theophylline anhydrous (tab er 12h)
2
Bronchodilators, Sympathomimetic
albuterol sul 0.63 mg/3 ml sol
2
albuterol sulfate (2 mg tab, er 4 mg tab, er 8 mg tab)
3
albuterol sulfate (sul 1.25 mg/3 ml sol, sul 2.5 mg/3
ml soln, sulf 2 mg/5 ml syrup, 2.5 mg/0.5 ml sol,
sulfate 4 mg tab, 5 mg/ml solution)
2
COMBIVENT RESPIMAT (MIST INHAL)
4
epinephrine (0.1 mg/ml syringe, 0.15 mg auto-injct,
1 mg/ml vial, 1 mg/ml ampul)
5
epinephrine 0.3 mg auto-inject
5
ipratropium-albuterol (ampul-neb)
3
levalbuterol concentrate (vial-neb)
3
levalbuterol hcl (vial-neb)
3
metaproterenol sulfate (10 mg tablet, 10 mg/5 ml
syr, 20 mg tablet)
3
SEREVENT DISKUS (BLST W/DEV)
4
terbutaline sulf 1 mg/ml vial
5
terbutaline sulfate (2.5 mg tab, 5 mg tab)
2
QL 360 / 30 DAYS
QL 6 / 30 DAYS
QL 6 / 90 DAYS
QL 60 / 30 DAYS
Mast Cell Stabilizers
cromolyn 100 mg/5 ml oral conc
5
cromolyn 20 mg/2 ml neb soln
3
Pulmonary Antihypertensives
epoprostenol sodium (vial)
PAGE 81
6
PRODUCT DESCRIPTION
TIER
REMODULIN (VIAL)
6
sildenafil (tablet)
3
TRACLEER (TABLET)
5
VENTAVIS (AMPUL-NEB)
5
QL 90 / 30 DAYS
PA
Respiratory Tract Agents, Other
acetylcysteine (10% vial, 20% vial)
3
benzonatate (100 mg capsule, 200 mg capsule)
2
hydrocodone-chlorpheniramne er (sus er 12h)
3
promethazine vc-codeine (syrup)
3
promethazine-codeine (syrup)
2
promethazine-dm (syrup)
2
promethazine-phenyleph-codeine (syrup)
3
sodium chloride 0.9% inhal vl
2
TYZINE (PEDIATRIC 0.05% DROP, 0.1% NOSE SPRAY,
0.1% NOSE DROPS)
4
Skeletal Muscle Relaxants
carisoprodol 250 mg tablet
3
QL 120 / 30 days
carisoprodol 350 mg tablet
3
QL 120 / 30 DAYS
chlorzoxazone (tablet)
2
cyclobenzaprine hcl (5 mg tablet, 10 mg tablet)
2
metaxall (tablet)
3
metaxalone (tablet)
3
methocarbamol (500 mg tablet, 750 mg tablet)
2
orphenadrine er 100 mg tablet
2
PAGE 82
PRODUCT DESCRIPTION
TIER
Sleep Disorder Agents
GABA Receptor Modulators
eszopiclone (tablet)
3
QL 30 / 30 DAYS
zaleplon (capsule)
2
QL 30 / 30 DAYS
zolpidem tartrate (5 mg tablet, 10 mg tablet)
2
QL 30 / 30 DAYS
zolpidem tartrate er (tab mphase)
3
QL 30 / 30 DAYS
modafinil 100 mg tablet
3
QL 120 / 30 DAYS
modafinil 200 mg tablet
3
QL 60 / 30 DAYS
Sleep Disorders, Other
Therapeutic Nutrients/ Minerals/ Electrolytes
Electrolyte/Mineral Modifiers
CHEMET (CAPSULE)
4
FERRIPROX 500 MG TABLET
5
levocarnitine (100 mg/ml soln, 330 mg tablet)
3
SAMSCA (TABLET)
5
sodium polystyrene sulf powder
3
sodium polystyrene sulfonate (15 gm/60 ml
suspension, 30 gm/120 ml enema, 50 gm/200 ml
enema)
2
PA
QL 60 / 30 DAYS
PA
Electrolyte/Mineral Replacement
ammonium chloride (vial)
6
cyanocobalamin injection (vial)
5
d3-2000 (capsule)
1
ergocalciferol (vitamin d2) (capsule)
2
fluoride (tab chew)
1
PAGE 83
PRODUCT DESCRIPTION
TIER
fluoritab (0.125 mg/drp drops, 0.5 mg tablet chew)
1
flura-drops (drops)
1
folic acid (1 mg tablet, 1,000 mcg tablet)
2
hydroxocobalamin (vial)
5
kendall 0.9% nacl with cap (syringe cp)
6
klor-con m10 (tab er prt)
2
KLOR-CON M15 (TAB ER PRT)
4
2
2
klor-con sprinkle (capsule er)
2
ludent fluoride (tab chew)
1
magnesium sulfate (4% soln, 8% soln)
6
magnesium sulfate (syringe, vial)
5
magnesium sulfate-d5w (piggyback)
6
magnesium-lactated ringers (plast. bag)
6
monoject 0.9% sodium chloride (syringe)
6
monoject prefill 0.9% flush
6
monoject prefill 0.9% na syr
6
normal saline flush (syringe)
6
potassium chl-normal saline (iv soln)
6
potassium chloride (2 meq/ml vial, 2 meq/ml iv sol,
10 meq/100 ml sol, 10 meq/50 ml sol, 10 meq/5 ml
conc, 20 meq/10 ml conc, 20 meq/50 ml sol, 20
meq/100 ml sol, 30 meq/100 ml sol, 30 meq/15 ml
conc, 40 meq/20 ml conc, 40 meq/100 ml sol)
6
potassium chloride (er 8 capsule, er 8 tablet, er 10
tablet, er 10 capsule, er 20 tablet)
2
potassium chloride-nacl (iv soln)
6
PAGE 84
PRODUCT DESCRIPTION
TIER
potassium citrate er (er 5 tab, er 10 tb)
3
sodium chloride (saline 0.45% soln-excel con, saline
0.9% soln-excel cont, sodium chloride 0.45% soln,
sodium chloride 0.45% solution, sodium chloride
0.9% syringe, sodium chloride 0.9% 250 ml, sodium
chloride 0.9% 50 ml, sodium chloride 0.9% solution,
sodium chloride 0.9% soln, sodium chloride 0.9% 500
ml, sodium chloride 0.9% 1,000 ml, sodium chloride
0.9% zr syr, sodium chloride 0.9% 100 ml, sodium
chloride 3% iv soln, sodium chloride 5% iv soln,
sodium cl 2.5 meq/ml vial)
6
sodium chloride 0.9% irrig.
2
sodium chloride 0.9% vial
5
sodium fluoride (0.5 mg/ml drop, 0.5 mg(1.1 mg), 1
mg (2.2 mg))
1
syrex (syringe)
6
vit d2 1.25 mg (50,000 unit)
2
vitamin d3 (cvs 1,000 unit sfgl, 1,000 units capsule,
1,000 units softgel, 1,000 unit softgel, cvs 2,000 unit
sfgl, hm 2,000 unit sftgl, ra 2,000 unit sftgl, ra 2,000
unit sfgl, sm 2,000 unit sftgl, sv 1,000 units sfgl, sv
2,000 unit sftgl)
1
PAGE 85
Index of Covered Drugs
A
a-hydrocort
a-methapred
abacavir
abacavir-lamivudine-zidovudine
ABILIFY
ABILIFY DISCMELT
ABILIFY MAINTENA
acamprosate calcium
acarbose
accu-chek
accu-chek active
accu-chek aviva
accu-chek aviva connect
accu-chek aviva plus
accu-chek comfort curve
accu-chek compact
accu-chek compact plus
accu-chek nano smartview
accu-chek smartview
accu-chek voicemate
acebutolol hcl
acetaminophen-codeine
acetasol hc
acetazolamide
acetazolamide sodium
acetic acid
acetic acid-aluminum
acetylcysteine
ACTEMRA
ACTHIB
ACTIMMUNE
acyclovir
ADACEL TDAP
adapalene
adefovir dipivoxil
adrucil
adult low dose aspirin ec
afeditab cr
AFINITOR
59
11
37
37
23
23
23
10
41
72
72
72
72
72
72
72
72
72
72
72
47
8
14
20,49
20
14
14
82
70
70
70
40
70
54
39
31
5
48
32
AFINITOR DISPERZ
aftera
ak-poly-bac
ALBENZA
albuterol sulfate
alclometasone dipropionate
alendronate sodium
alfuzosin hcl er
allopurinol
allopurinol sodium
alophen pills
alprazolam
alprazolam er
alprazolam xr
altavera
alyacen
amantadine
amcinonide
amethia
amethia lo
amethyst
amifostine
amikacin sulfate
amiloride hcl
aminophylline
amiodarone hcl
amitriptyline hcl
amlodipine besylate
ammonium chloride
ammonium lactate
amoxapine
amoxicillin
amoxicillin-clavulanate pot er
amoxicillin-clavulanate potass
amphotericin b
ampicillin sodium
ampicillin trihydrate
ampicillin-sulbactam
AMPYRA
anagrelide hcl
anastrozole
32
72
77
33
81
11
77
58
28
28
72
40
40
40
60
60
34
11
60
60
60
31
13
50
80
46
25
48
83
54
25
17
17
17
27
17
17
18
53
44
32
androxy
antipyrine-benzocaine
apexicon
apexicon e
APIDRA
APIDRA SOLOSTAR
apri
APRISO
APTIVUS
aranelle
ARANESP
arbinoxa
aripiprazole
aripiprazole odt
ARNUITY ELLIPTA
ashlyna
aspir 81
aspir-low
aspir-trin
aspirin
aspirin ec
astramorph-pf
atenolol
atenolol-chlorthalidone
atorvastatin calcium
atovaquone-proguanil hcl
ATRIPLA
atropine care
atropine sulfate
AUBAGIO
aubra
AURYXIA
aviane
avidoxy
AZASITE
azathioprine
azathioprine sodium
azelastine hcl
azithromycin
aztreonam
azurette
60
79
11
11
41
41
61
56
38
61
44
80
23
23
79
61
5
5
73
5,73
5,73
8
47
49
51
33
37
77
46,77
53
61
58
61
20
18
68
68
78,80
18
17
61
B
baciim
bacitracin
bacitracin-polymyxin
baclofen
balsalazide disodium
balziva
BARACLUDE
bekyree
benazepril hcl
BENLYSTA
benzonatate
benztropine mesylate
betamethasone dipropionate
betamethasone valerate
BETASERON
betaxolol hcl
bethanechol chloride
BEXSERO
BEYAZ
bicalutamide
BILTRICIDE
bisa-lax
bisacodyl
bisoprolol fumarate
BIVIGAM
bleomycin sulfate
blisovi 24 fe
blisovi fe
BOOSTRIX TDAP
briellyn
brimonidine tartrate
bromfenac sodium
bromocriptine mesylate
budeprion sr
budesonide
budesonide ec
bumetanide
buprenorphine hcl
buproban
14
14
77
36
72
61
39
61
45
69
82
34
11
11
53
47,79
58
70
61
68
33
73
73
47
69
31
61
61
70
61
79
78
34
23
79
59
50
8,10
10
bupropion hcl
bupropion hcl sr
bupropion xl
buspirone hcl
BUSULFEX
butalbital-acetaminophen-caffe
butorphanol tartrate
BYETTA
23
23
23
40
30
53
8
41
C
cabergoline
calcipotriene
calcitonin-salmon
calcitriol
calcium acetate
calcium folinate
camila
CAMPRAL
camrese
camrese lo
candesartan cilexetil
capecitabine
captopril
carbamazepine
carbamazepine er
carbidopa
carbidopa-levodopa
carbidopa-levodopa er
carbinoxamine maleate
carimune nf nanofiltered
carisoprodol
carteolol hcl
cartia xt
carvedilol
caya contoured
caziant
cefaclor
cefaclor er
cefadroxil
cefazolin
cefazolin sodium
68
54
77
54,68
58
31
66
10
61
61
45
31
45
22
22
34
34
34
80
69
82
79
48
47
73
61
16
16
16
16
16
cefazolin sodium-dextrose
cefazolin-0.9% nacl
cefdinir
cefditoren pivoxil
cefepime
cefepime hcl
cefepime-dextrose
cefotaxime sodium
cefotetan
cefotetan & dextrose
cefoxitin
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime
ceftriaxone
cefuroxime
cefuroxime sodium
celecoxib
cephalexin
CERDELGA
CEREZYME
CERVARIX
cevimeline hcl
CHANTIX
chateal
CHEMET
children's aspirin
children's ferrous sulfate
children's iron
children's vitamin d
chloramphenicol sod succinate
chlorhexidine gluconate
chloroquine phosphate
chlorothiazide
chlorpromazine hcl
chlorpropamide
chlorthalidone
chlorzoxazone
cholestyramine
cholestyramine light
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
17
17
17
5
17
55
55
70
53
10
61
83
5
73
73
73
14
14
33
50
25
41
50
82
51
51
chorionic gonadotropin
CIALIS
ciclodan
ciclopirox
cidofovir
cilostazol
cimetidine
CIPRODEX
ciprofloxacin
ciprofloxacin er
ciprofloxacin hcl
ciprofloxacin-d5w
citalopram hbr
citrate of magnesia
citroma
claravis
clarithromycin
clarithromycin er
clearlax
clemastine fumarate
clindacin etz
clindacin p
clindamax
clindamycin hcl
clindamycin palmitate hcl
clindamycin pediatric
clindamycin phos-benzoyl perox
clindamycin phosphate
clindamycin phosphate-d5w
clindamycin-benzoyl peroxide
clobetasol emollient
clobetasol emulsion
clobetasol propionate
clomiphene citrate
clomipramine hcl
clonazepam
clonidine
clonidine hcl
clonidine hcl er
clopidogrel
clotrimazole
60
58
27
27
38
44
56
79
19
19
19
19
24
73
73
54
18
18
56,73
80
14
14
14
14
14
14
54
14
15
54
11
11
11
73
25
40
45
45
52
44
27
clotrimazole-betamethasone
clozapine
clozapine odt
codeine sulfate
COLCRYS
colestipol hcl
colocort
COMBIVENT RESPIMAT
compro
CONCEPTROL
constulose
COPAXONE
cormax
cortisone acetate
CRESTOR
CRIXIVAN
cromolyn sodium
cryselle
CUPRIMINE
cyanocobalamin injection
cyclafem
cyclobenzaprine hcl
cyclopentolate hcl
cyclophosphamide
cycloserine
cyclosporine
cyclosporine modified
cyproheptadine hcl
cyred
54
36
36
8
28
51
72
81
25
73
57
53
11
11
51
38
78,81
61
58
83
61
82
77
30
15
54,69
54,69
80
61
D
D.H.E.45
d3 dots
d3-2000
danazol
dantrolene sodium
dapsone
DAPTACEL DTAP
dasetta
daysee
deblitane
28
73
83
60
36
30
70
61
61
66
delta d3
delyla
demeclocycline hcl
DEPEN
DEPO-PROVERA
DEPO-SUBQ PROVERA 104
desipramine hcl
desloratadine
desmopressin acetate
desogestr-eth estrad eth estra
desogestrel-ethinyl estradiol
desonide
desoximetasone
dexamethasone
dexamethasone intensol
dexamethasone sodium phosphate
dexmethylphenidate hcl
dextroamphetamine sulfate
dextroamphetamine sulfate er
dextroamphetamine-amphet er
dextroamphetamine-amphetamine
diazepam
DIBENZYLINE
diclofenac potassium
diclofenac sodium
diclofenac sodium er
dicloxacillin sodium
dicyclomine hcl
didanosine
diflorasone diacetate
diflunisal
digox
digoxin
dihydroergotamine mesylate
dilt-cd
dilt-xr
diltia xt
diltiazem 12hr er
diltiazem 24hr cd
diltiazem 24hr er
diltiazem er
73
61
20
58
66
66
25
80
60
61
61
11
12
59
59
12,59,72
52
52
52
52
52
40
45
5
5,59
5
18
55
37
12
6
49
49
28
48
48
48
48
48
48
48
diltiazem hcl
diltzac er
diphenhydramine hcl
diphenoxylate-atropine
diphtheria-tetanus toxoids-ped
dipyridamole
disopyramide phosphate
disulfiram
divalproex sodium
divalproex sodium er
donepezil hcl
donepezil hcl odt
dorzolamide hcl
dorzolamide-timolol
doxazosin mesylate
doxepin hcl
doxy 100
doxycycline hyclate
doxycycline monohydrate
dronabinol
drospirenone-ethinyl estradiol
ducodyl
duloxetine hcl
46,48
48
25
56
70
44
46
10
21
21
22
22
79
79
45
25
20
20
20
26
61
73
24
E
econazole nitrate
econtra ez
ecotrin
ecpirin
EDURANT
ELELYSO
ELIDEL
elimite
elinest
eliphos
ELLA
ELMIRON
EMCYT
emoquette
EMTRIVA
enalapril maleate
27
73
6
74
36
55
54
33
62
58
66
58
31
62
37
46
ENGERIX-B ADULT
ENGERIX-B PEDIATRIC-ADOLESCENT
enoxaparin sodium
enpresse
enskyce
entacapone
entecavir
enulose
epinephrine
epitol
eplerenone
EPOGEN
epoprostenol sodium
eprosartan mesylate
EPZICOM
ergocalciferol (vitamin d2)
ergoloid mesylates
errin
erythromycin
erythromycin ethylsuccinate
erythromycin-benzoyl peroxide
escitalopram oxalate
estarylla
estradiol
estradiol valerate
estropipate
eszopiclone
ethambutol hcl
ethosuximide
etidronate disodium
etodolac
etodolac er
etoposide
EVISTA
exemestane
70
70
43
62
62
34
39
57
81
22
50
44
81
45
37
83
22
66
18,19
19
54
24
62
62
62
62
83
30
21
77
6
6
32
67
32
F
fa-8
fallback solo
falmina
famotidine
74
74
62
56
fc2 female condom
felbamate
felodipine er
femcap
fenofibrate
fenofibric acid
fenoprofen calcium
fentanyl
fentanyl citrate
fer-iron
FERRIPROX
ferrous sulfate
finasteride
flavoxate hcl
FLEBOGAMMA DIF
flecainide acetate
FLOVENT DISKUS
FLOVENT HFA
FLUARIX QUAD 2015-2016
FLUBLOK 2015-2016
FLUCELVAX 2015-2016
fluconazole
fluconazole in dextrose
fluconazole in saline
fluconazole-nacl
flucytosine
fludarabine phosphate
fludrocortisone acetate
FLULAVAL QUAD 2015-2016
flunisolide
fluocinolone acetonide
fluocinolone acetonide oil
fluocinonide
fluocinonide emollient
fluocinonide-e
fluoride
fluoritab
fluorometholone
fluorouracil
fluoxetine dr
fluoxetine hcl
74
21
48
74
50,51
51
6
7
7
74
83
74
58
58
70
46
59
59
70
70
70
27
27
27
27
27
31
12
70
79
12,59
59
12
12
12
83
84
59
31,54
24
24
fluphenazine decanoate
fluphenazine hcl
flura-drops
flurbiprofen
flurbiprofen sodium
flutamide
fluticasone propionate
FLUVIRIN 2015-2016
fluvoxamine maleate
FLUZONE 2015-2016
FLUZONE HIGH-DOSE 2015-2016
FLUZONE QUAD 2015-2016
FLUZONE QUAD PEDI 2015-2016
folic acid
fondaparinux sodium
fosinopril sodium
fosphenytoin sodium
furosemide
FUZEON
35
35
84
6
78
31
12,59
71
24
71
71
71
71
74,84
43
46
22
50
37
G
gabapentin
galantamine hbr
galantamine hydrobromide
gammagard liquid
GAMMAPLEX
GAMUNEX
GANIRELIX ACETATE
GARDASIL
GARDASIL 9
gatifloxacin
gavilax
gavilyte-c
gavilyte-g
gavilyte-n
gemfibrozil
generlac
gengraf
gentak
gentamicin sulfate
gentamicin sulfate in ns
21
22
22
70
70
70
68
71
71
19
57
57
57
57
51
57
54
13
13,77
13
gentle laxative
gentlelax
gianvi
gildagia
gildess
gildess 24 fe
gildess fe
glatopa
GLEEVEC
glimepiride
glipizide
glipizide er
glipizide xl
GLUCAGON EMERGENCY KIT
glyburide
glyburide micronized
glycolax
glycopyrrolate
granisetron hcl
granisol
griseofulvin
griseofulvin ultramicrosize
guanfacine hcl
guanfacine hcl er
guanidine hcl
gynazole 1
gynol ii
74
74
62
62
62
62
62
53
32
41
41
41
41
41
41
41
57
46,55
26
26
27
27
45
52
29
27
74
H
halfprin
halobetasol propionate
haloperidol
haloperidol decanoate
haloperidol decanoate 100
haloperidol lactate
HARVONI
HAVRIX
heather
hecoria
HEMABATE
heparin lock
6
12
35
35
35
35
39
71
66
69
60
43
heparin sodium
heparin sodium in 0.45% nacl
heparin sodium-0.9% nacl
heparin sodium-d5w
HEPSERA
homatropaire
homatropine hydrobromide
HUMALOG
HUMALOG KWIKPEN U-100
HUMALOG KWIKPEN U-200
HUMIRA
HUMIRA PEDIATRIC CROHN'S
HUMIRA PEN
HUMIRA PEN CROHN'S-UC-HS
HUMIRA PEN PSORIASIS
HUMULIN 70-30
HUMULIN 70/30 KWIKPEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN R
HUMULIN R U-500
HUMULIN R U-500 KWIKPEN
hydralazine hcl
hydrochlorothiazide
hydrocodone-acetaminophen
hydrocodone-chlorpheniramne er
hydrocortisone
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone-acetic acid
hydromorphone hcl
hydroxocobalamin
hydroxychloroquine sulfate
hydroxyurea
hydroxyzine hcl
hydroxyzine pamoate
hypercare
43
43
43
43
39
77
77
42
42
42
69
69
69
69
69
42
42
42
42
42
42
42
51
6,50
8
82
12,59,72
12,59
59
15
8
84
33
31
25,26
26
54
I
ibandronate sodium
ibuprofen
77
6
ICLUSIG
ILEVRO
imipenem-cilastatin sodium
imipramine hcl
imipramine pamoate
imiquimod
IMPLANON
INCIVEK
INCRUSE ELLIPTA
indapamide
indomethacin
INFANRIX DTAP
INFERGEN
INTELENCE
INTRON A
introvale
INVIRASE
IPOL
ipratropium bromide
ipratropium-albuterol
irbesartan
iron
ISENTRESS
isochron
isoniazid
ISOPTO ATROPINE
isosorbide dinitrate
isosorbide mononitrate
isosorbide mononitrate er
isradipine
itraconazole
ivermectin
32
78
17
25
25
31
66
39
80
50
6
71
39
36
31
62
38
71
80
81
45
74
37
51
30
77
51
52
52
48
27
33
J
jantoven
jencycla
jolessa
jolivette
juleber
junel
junel fe
43
66
62
66
62
62
62
junel fe 24
62
K
kaitlib fe
KALETRA
kariva
kelnor 1-35
kendall 0.9% nacl with cap
KEPIVANCE
KETEK
ketoconazole
ketodan
ketoprofen
ketorolac tromethamine
kids vitamin d3
kimidess
klor-con m10
KLOR-CON M15
klor-con m15
klor-con m20
klor-con sprinkle
KRYSTEXXA
kurvelo
KUVAN
62
38
62
63
84
54
19
27
27
6
6,78
74
63
84
84
84
84
84
28
63
55
L
labetalol hcl
lactulose
lamivudine
lamivudine hbv
lamivudine-zidovudine
lamotrigine
LANTUS
LANTUS SOLOSTAR
larin
larin 24 fe
larin fe
latanoprost
laxa clear
laxative
laxative feminine
47
57
37,39
39
37
21
42
42
63
63
63
77
57
74
74
laxative peg 3350
leena
leflunomide
lessina
letrozole
leucovorin calcium
LEUKERAN
LEUKINE
leuprolide acetate
levalbuterol concentrate
levalbuterol hcl
LEVEMIR
LEVEMIR FLEXPEN
LEVEMIR FLEXTOUCH
levetiracetam
levetiracetam er
levetiracetam-nacl
levobunolol hcl
levocarnitine
levocetirizine dihydrochloride
levofloxacin
levofloxacin-d5w
levonest
levonorg-eth estrad eth estrad
levonorgestrel
levonorgestrel-eth estradiol
levora-28
levorphanol tartrate
levothyroxine sodium
LEXIVA
LIALDA
lidocaine
lidocaine hcl
lidocaine hcl in 5% dextrose
lidocaine hcl in 7.5% dextrose
lidocaine hcl viscous
lidocaine-prilocaine
LILETTA
lindane
LINZESS
liothyronine sodium
57
63
70
63
32
31,32
30
44
68
81
81
42
42
42
20
20
20
79
83
80
19
19
63
63
66
63
63
7
67
38
56
9
9
9
9
9
9
66
33
56
67
lisinopril
lisinopril-hydrochlorothiazide
lite coat aspirin
lithium
lithium carbonate
lithium carbonate er
LO LOESTRIN FE
LO MINASTRIN FE
lo-dose aspirin ec
lo-so liquid prep kit
lo-so prep kit
LODOSYN
LOESTRIN 24 FE
lofibra
lokara
lomedia 24 fe
LOMUSTINE
loperamide
lorazepam
loryna
losartan potassium
losartan-hydrochlorothiazide
LOTEMAX
lovastatin
low dose aspirin ec
low-ogestrel
loxapine
ludent fluoride
LUMIGAN
lutera
LYSODREN
lyza
40,46
49
74
40
40
40
63
63
6
74
74
35
63
51
12
63
30
56
40
63
45
49
78
51
6
63
35
84
77
63
67
66
M
M-M-R II VACCINE
magnesium citrate
magnesium sulfate
magnesium sulfate-d5w
magnesium-lactated ringers
malathion
maprotiline hcl
71
74
84
84
84
33
23
marlissa
meclizine hcl
meclofenamate sodium
medroxyprogesterone acetate
mefenamic acid
mefloquine hcl
megestrol acetate
meloxicam
melphalan hcl
memantine hcl
MENACTRA
MENOMUNE-A-C-Y-W-135
meperidine hcl
meprobamate
mercaptopurine
meropenem
mesalamine
metadate er
metaproterenol sulfate
metaxall
metaxalone
metformin hcl
metformin hcl er
methadone hcl
methadone intensol
methadose
methamphetamine hcl
methazolamide
methenamine hippurate
methenamine mandelate
methimazole
methocarbamol
methotrexate
methotrexate sodium
methscopolamine bromide
methyclothiazide
methyldopa
methyldopate hcl
methylphenidate er
methylphenidate hcl
methylphenidate hcl cd
63
26
6
66
6
33
66
6
30
23
71
71
8
40
31
17
56
52
81
82
82
41
41
7
7
7
52
50
15
15
68
82
31,69
69
56
50
45
45
52
52
53
methylphenidate la
methylphenidate sr
methylprednisolone
methylprednisolone acetate
methylprednisolone sod succ
metipranolol
metoclopramide hcl
metolazone
metoprolol succinate
metoprolol tartrate
metronidazole
mexiletine hcl
microgestin
microgestin fe
midodrine hcl
MINASTRIN 24 FE
miniprin
minitran
minocycline hcl
minoxidil
MIRENA
mirtazapine
misoprostol
mitoxantrone hcl
modafinil
moexipril hcl
mometasone furoate
mondoxyne nl
mono-linyah
monoject 0.9% sodium chloride
monoject prefill
monoject prefill advanced
mononessa
montelukast sodium
morgidox
morphine sulfate
morphine sulfate er
moxifloxacin hcl
MOZOBIL
MULTAQ
mupirocin
53
53
12,59
59
12
79
26
50
47
47
15
46
63
63
45
63
6
52
20
51
66
24
57
32
83
46
55,59,79
20
63
84
84
84
63
80
20
9
7
19
44
46
15
my way
MYCOBUTIN
mycophenolate mofetil
myorisan
myzilra
66
30
69
55
64
N
nabumetone
nadolol
nafcillin
nafcillin sodium
nalbuphine hcl
naloxone hcl
naltrexone hcl
NAMENDA
NAMENDA XR
naphazoline hcl
naproxen
naproxen sodium
naratriptan
naratriptan hcl
NASONEX
NATAZIA
nateglinide
necon
nefazodone hcl
neo-polycin
neomycin sulfate
neomycin-bacitracin-poly-hc
neomycin-bacitracin-polymyxin
neomycin-polymyxin-dexameth
neomycin-polymyxin-gramicidin
neomycin-polymyxin-hc
neomycin-polymyxin-hydrocort
NEULASTA
NEUPOGEN
nevirapine
nevirapine er
NEXAVAR
NEXPLANON
next choice one dose
6
47
18
18
9
10
10
23
23
78
7
7
29
29
79
64
41
64
24
78
13
78
78
78
78
12,78
12
44
44
36
37
32
66
67
niacor
nicardipine hcl
nicoderm cq
nicorelief
nicotine gum
nicotine lozenge
nicotine patch
NICOTROL
NICOTROL NS
nifediac cc
nifedical xl
nifedipine
nifedipine er
nikki
NILANDRON
nisoldipine
nitrofurantoin
nitrofurantoin mono-macro
nitroglycerin
nitroglycerin in d5w
nitroglycerin patch
nizatidine
nora-be
norethin-eth estra ferrous fum
norethindron-ethinyl estradiol
norethindrone
norethindrone acetate
norgestimate-ethinyl estradiol
norlyroc
normal saline flush
nortrel
nortriptyline hcl
NORVIR
NOVOLIN 70-30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG MIX 70-30 FLEXPEN
NPLATE
51
48
10,75
10,75
10,75
75
11,75
11
11
48
49
49
49
64
68
49
15
15
52
52
52
56
67
64
64
67
67
64
67
84
64
25
38
42
42
42
42
42
42
42
44
nts
NUVARING
nyamyc
nystatin
nystatin-triamcinolone
nystop
75
64
28
28
12
28
O
ocella
octreotide acetate
ofloxacin
ogestrel
olanzapine
olanzapine odt
omeprazole
OMNARIS
ondansetron hcl
ondansetron odt
onetouch ultra system
onetouch ultra test strips
onetouch ultra2
onetouch ultralink
onetouch ultramini
onetouch verio
onetouch verio flex
onetouch verio iq
onetouch verio sync
opcicon one-step
oralone
ORAP
ORENCIA
orphenadrine citrate
orsythia
ortho all-flex
ORTHO TRI-CYCLEN LO
OSPHENA
oxacillin
oxacillin sodium
oxandrolone
oxaprozin
oxcarbazepine
64
68
19
64
35
36
57
79
27
27
75
75
75
75
75
75
75
75
75
75
12
35
69
82
64
75
64
67
18
18
60
7
22
oxybutynin chloride
oxybutynin chloride er
oxycodone hcl
oxycodone hcl er
oxycodone hcl-ibuprofen
oxycodone-acetaminophen
oxymorphone hcl
oxymorphone hcl er
58
58
9
8
7
9
9
8
P
pacerone
palgic
pamidronate disodium
pancrelipase 5,000
pantoprazole sodium
PARAGARD T 380-A
paricalcitol
paroex
paromomycin sulfate
paroxetine hcl
pedi-dri
PEDVAXHIB
peg 3350-electrolyte
peg-3350 and electrolytes
peg-3350 with flavor packs
peg3350
PEGASYS
PEGASYS PROCLICK
PEGINTRON
PEGINTRON REDIPEN
penicillin g potassium
penicillin g procaine
penicillin g sodium
penicillin gk-iso-osm dextrose
penicillin v potassium
PENTACEL ACTHIB COMPONENT
pentoxifylline
perindopril erbumine
periogard
permethrin
perphenazine
46
80
77
55
57,58
75
77
15
13
24
28
71
57
57
57
57
39
39
39
39
18
18
18
18
18
71
49
46
15
33
26
phenadoz
phenelzine sulfate
PHENERGAN
phenobarbital
phenoxybenzamine hcl
phenylephrine hcl
phenytoin
phenytoin sodium
phenytoin sodium extended
philith
pilocarpine hcl
pimozide
pimtrea
pindolol
pioglitazone hcl
piperacillin-tazobactam
pirmella
piroxicam
PLEGRIDY
PLEGRIDY PEN
PNEUMOVAX 23
podofilox
polycin
polyethylene glycol 3350
polymyxin b sul-trimethoprim
polymyxin b sulfate
portia
potassium chl-normal saline
potassium chloride
potassium chloride-nacl
potassium citrate er
powderlax
PRADAXA
pramipexole dihydrochloride
pramipexole er
pravastatin sodium
prazosin hcl
prednicarbate
prednisolone
prednisolone acetate
prednisolone sodium phosphate
26
24
26
21
45
78
22
22
22
64
54,79
35
64
47
41
18
64
7
53
53
71
55
78
57
78
15
64
84
84
84
85
75
43
34
34
51
45
55
12
78
13,78
prednisone
prednisone intensol
previfem
PREVNAR 13
PREZISTA
primaquine
primidone
privigen
probenecid
probenecid-colchicine
procainamide hcl
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
PROCRIT
procto-pak
proctocream-hc
proctosol-hc
proctozone-hc
progesterone
progesterone in oil
promethazine hcl
promethazine vc-codeine
promethazine-codeine
promethazine-dm
promethazine-phenyleph-codeine
promethegan
propafenone hcl
propafenone hcl er
proparacaine hcl
propranolol hcl
propranolol hcl er
propylthiouracil
protriptyline hcl
psorcon
purelax
pyrazinamide
pyridostigmine bromide
13,59
13
64
71
38
33
21
70
28
28
46
26
26
26
44
13
13
13
72
67
67
26,80
82
82
82
82
26
46
46
9
47
47
68
25
13
57
30
29
Q
QUARTETTE
64
quasense
quetiapine fumarate
quinapril hcl
quinidine gluconate
quinidine sulfate
quit 2
quit 4
QVAR
64
36
46
46
47
11,75
11,75
79
R
raloxifene hcl
ramipril
ranitidine hcl
REBIF
reclipsen
RECOMBIVAX HB
refissa
RELENZA
REMICADE
REMODULIN
RENVELA
repaglinide
RESCRIPTOR
REVLIMID
REYATAZ
ribasphere
ribavirin
RIDAURA
rifabutin
rifampin
rimantadine hcl
risperidone
risperidone odt
RITUXAN
rivastigmine
rizatriptan
ropinirole er
ropinirole hcl
ROTARIX
ROTATEQ
67
46
56
54
64
71
55
38
69
82
59
41
37
30
38
39
39
70
30
30
38
36
36
33
23
29
34
34
71
71
S
SABRIL
SAFYRAL
SAMSCA
SAVAYSA
scalacort
selegiline hcl
selenium sulfide
SEREVENT DISKUS
SEROQUEL XR
sertraline hcl
setlakin
sevelamer carbonate
sharobel
sildenafil
silver sulfadiazine
SIMPONI ARIA
simvastatin
sirolimus
SKLICE
SKYLA
smoothlax
sodium chloride
sodium fluoride
sodium polystyrene sulfonate
sodium sulfacetamide
SOLTAMOX
sotalol
sotalol af
sotalol hcl
spinosad
SPIRIVA
spironolactone
spironolactone-hctz
sprintec
SPRYCEL
sronyx
st. joseph aspirin
stavudine
STELARA
21
64
83
43
13
35
55
81
24
24
64
59
67
82
19
69
51
69
34
67
57
82,85
85
83
19
31
47
47
47
33
80
50
49
64
32
64
7
37
55
STENDRA
STIVARGA
stop smoking aid
STRATTERA
streptomycin sulfate
STRIBILD
STROMECTOL
sucralfate
sulfacetamide sodium
sulfacetamide-prednisolone
sulfadiazine
sulfamethoxazole-trimethoprim
SULFAMYLON
sulfasalazine
sulfasalazine dr
sulindac
sumatriptan
sumatriptan succinate
SUSTIVA
SUTENT
syeda
syrex
58
32
75
53
13
38
33
57
19
78
19
19
15
56
56
7
29
29
37
32
65
85
T
tacrolimus
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TARCEVA
tarina fe
TASIGNA
tazicef
taztia xt
TECFIDERA
telmisartan
temozolomide
TENIVAC
terazosin hcl
terbinafine hcl
terbutaline sulfate
terconazole
69
38
31
58
32
65
33
17
49
54
45
30
71
45
28
81
28
testosterone cypionate
testosterone enanthate
tetanus diphtheria toxoids
tetrabenazine
tetracycline hcl
THALOMID
theochron
theophylline
theophylline anhydrous
thera-d
thioridazine hcl
thiothixene
tiagabine hcl
ticlopidine hcl
tilia fe
timolol maleate
TIVICAY
tizanidine hcl
tobramycin
tobramycin sulfate
tobramycin sulfate in ns
tobramycin-dexamethasone
TODAY CONTRACEPTIVE SPONGE
tolazamide
tolbutamide
tolmetin sodium
tolterodine tartrate
tolterodine tartrate er
topiramate
topiramate er
toposar
topotecan hcl
torsemide
TRACLEER
tramadol hcl er
trandolapril
tranexamic acid
tranylcypromine sulfate
TRAVATAN Z
travoprost
trazodone hcl
60
60
71
53
20
30
81
81
81
76
35
35
21
44
65
29,79
38
36
14
14
14
78
76
41
41
7
58
58
21
22
32
32
50
82
8
46
44
24
77
77
24
tretinoin
tretinoin microsphere
tri-estarylla
tri-legest fe
tri-linyah
tri-lo-estarylla
tri-lo-marzia
tri-lo-sprintec
tri-previfem
tri-sprintec
triamcinolone acetonide
triamterene-hydrochlorothiazid
trianex
trifluoperazine hcl
trihexyphenidyl hcl
trilyte with flavor packets
trimethobenzamide hcl
trimethoprim
trimipramine maleate
trinessa
trinessa lo
TRIUMEQ
trivora-28
TRIZIVIR
TRUMENBA
TRUVADA
TYKERB
TYSABRI
TYZEKA
TYZINE
33,55
55
65
65
65
65
65
65
65
65
13,60
49
55
35
34
57
26
15
25
65
65
38
65
37
71
37
33
54
39
82
U
u-cort
ULORIC
ursodiol
60
28
56
V
valacyclovir
valproate sodium
valproic acid
valsartan
40
21
21
45
valsartan-hydrochlorothiazide
vancomycin
vancomycin hcl
vancomycin-d5w
VAQTA
VARIVAX VACCINE
VASCEPA
vcf
velivet
venlafaxine hcl
venlafaxine hcl er
VENTAVIS
verapamil er
verapamil er pm
verapamil hcl
verapamil sr
vestura
VICTRELIS
vienva
viorele
VIRACEPT
VIRAZOLE
VIREAD
vitamin d
vitamin d-400
vitamin d2
vitamin d3
VIVITROL
voriconazole
VPRIV
vyfemla
49
15
15
15
72
72
51
76
65
25
25
82
49
49
47,49
49
65
39
65
65
38
40
37
76
76
76,85
76,85
10
28
55
65
W
warfarin sodium
wera
wide seal diaphragm
woman's laxative
women's gentle laxative
women's laxative
wymzya fe
43
65
76
76
76
76
65
X
XALKORI
XARELTO
XENAZINE
XTANDI
xulane
33
43
53
68
65
Z
zaleplon
zarah
zazole
zenatane
zenchent
zenchent fe
ZENPEP
zeosa
ZETIA
zidovudine
ziprasidone hcl
ZIRGAN
zolmitriptan
zolmitriptan odt
zolpidem tartrate
zolpidem tartrate er
ZOMIG
zonisamide
ZOSTAVAX
zovia 1-35e
zovia 1-50e
83
65
28
55
65
65
55
66
51
37
22,36
38
29
29
83
83
29
21
72
66
66

2016 PreferredOne/Clearscript Formulary

Transcription

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