LIS MEDIKAMAN KI KOUVRI YO

Transcription

LIS MEDIKAMAN
KI KOUVRI YO
Community Care Plus
FIDA-MMP 2016
1.877.ICS.2525
1.877.ICS.2525
www.icsny.org
www.icsny.org
H4465_ListofCoveredDrugs_2016_81415_Approved
H4465_ListofCoveredDrugs_2016_81415
ICS Community Care Plus FIDA-MMP | 2015 Lis Medikaman ki
Garanti yo (Lis)
Lis sa a se yon lis medikaman Patisipan yo kapab resevwa nan ICS Community Care
Plus FIDA-MMP.
 ICS Community Care Plus FIDA-MMP se yon plan swen administre ki gen kontra avèk
Medicare ak Depatman Sante Eta New York (Medicaid) pou bay avantaj toulède
pwogram yo pou Patisipan yo avèk Demonstrasyon Doub Avantaj Entegre Nèt (Fully
Integrated Duals Advantage - FIDA).
 Avantaj yo, Lis Medikaman ki Garanti yo, ak rezo famasi ak pwofesyonèl swen sante
gendwa chanje tanzantan pandan tout ane a ak 1ye janvye chak ane.
 Ou kapab toujou tcheke lis Medikaman ki Garanti ICS Community Care Plus FIDAMMP la pou wè si li ajou sou entènèt nan sitwèb www.icsny.org/care-plus/pharmacybenefits/ oswa depi ou rele Sèvis Patisipan Community Care Plus FIDA-MMP nan
nimewo 1.887.ICS.2525.
 Ka gen limit ak restriksyon ki aplikab. Pou jwenn plis enfòmasyon, rele Sèvis Patisipan
Plan ICS Community Care Plus FIDA-MMP oswa li Gid pou Patisipan ICS Community
Care Plus FIDA-MMP.
 Pa gen kopeman pou okenn medikaman ki garanti.
 Ou kapab jwenn enfòmasyon sa yo gratis nan lòt fòma, tankou ekriti Bray oswa gwo
lèt. Rele nimewo 1.877.ICS.2525. Apèl la gratis.
 Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang yo. Rele 1.877.ICS.2525 ak
TTY 711 depi lendi rive vandredi ant 8è a.m. jiska 8è p.m. Apèl la gratis. Ou kapab
jwenn enfòmasyon sa yo gratis nan lòt lang yo.
 Вы можете бесплатно получить всю эту информацию на других языках. Звоните
в ICS по телефону 1.877.ICS.2525 и телетайпу 1.855.ICS.4TTY с понедельника
по пятницу с 8:00 до 20:00. Звонок бесплатный.
 您可免费获得所有这些信息的其他语言版本。请在周一至周五上午 8 点至晚上 8 点致
电 ICS，电话号码为 1.877.ICS.2525，听障专线 (TTY) 为 711。此为免费电话。
Si w gen kesyon , tanpri rele ICS Community Care Plus FIDA-MMP nan 1.877.ICS.2525, TTY:
711, lendi rive vandredi, 8è:00 a.m jiska 8è:00 p.m. Apèl la gratis. Pou jwenn plis enfòmasyon,
ale sou sitwèb www.icsny.org/care-plus
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 Puede obtener toda esta información en otros idiomas de manera gratuita. Llame a
ICS al 1.877.ICS.2525 y a la línea TTY 711, entre las 8 a. m. y las 8 p. m., de lunes a
viernes. La llamada es gratuita.
 Ou kapab jwenn tout enfòmasyon sa a gratis nan lòt lang. Rele ICS nan
1.877.ICS.2525 ak TTY 711, ant 8è:00 a.m. ak 8è:00 p.m., lendi jiska vandredi. Apèl
la gratis.
 Eta Nouyòk kreye yon Pwogram Medyatè pou Patisipan yo èd gratis an sekrè sou
nenpòt sèvis ICS Community Care Plus FIDA-MMP ofri. Ou ka kontakte Medyatè
Patisipan an gratis nan nimewo 1.844.614.8800 oswa sou entènèt nan sitwèb
www.icannys.org.
711, lendi rive vandredi, 8è a.m jiska 8è p.m. Apèl la gratis. Pou jwenn plis enfòmasyon, ale
sou sitwèb www.icsny.org/care-plus.
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Kesyon Moun Poze Souvan
Jwenn repons yo la a pou kesyon ou genyen konsènan Lis Medikaman ki Garanti sa yo.
Ou kapab li Kesyon Moun Poze Souvan pou aprann plis bagay, oswa pou chèche yon
kesyon ak repons.
1.
Ki medikaman sou preskripsyon ki sou Lis Medikaman ki Garanti
yo?
(Nou rele Lis Medikaman ki Garanti yo “Lis Medikaman” pou l pi
kout.)
Medikaman ki sou Lis Medikaman ki Garanti yo ki kòmanse nan paj 17 se medikaman
ICS Community Care Plus FIDA-MMP garanti. Medikaman sa yo disponib nan famasi ki
anndan rezo nou an. Yon famasi nan rezo nou an si nou gen yon akò avèk yo pou travay
avèk nou epi pou ba ou sèvis. Nou rele famasi sa yo “famasi rezo a.”
 ICS Community Care Plus FIDA-MMP ap garanti tout medikaman ki sou Lis
Medikaman an si:
 doktè ou oswa lòt moun ki gen otorizasyon pou preskri medikaman di ou bezwen yo
pou refè oswa pou rete an sante,
 medikaman an nesesè pou rezon medikal pou pwoblèm sante ou, epi
 ou ranpli preskripsyon an nan yon famasi ki nan rezo ICS Community Care Plus
FIDA-MMP.
 ICS Community Care Plus FIDA-MMP ka gen lòt demach anplis anvan ou kapab
jwenn aksè nan sèten medikaman (gade kesyon 5 ki anba la a). Nan kèk ka, ou ka
gen pou fè yon bagay anvan ou kapab jwenn yon medikaman, tankou eseye lòt
medikaman yo anvan.
Ou kapab wè yon lis medikaman ajou nou garanti sou sitwèb nou nan
www.icsny.org/care-plus/pharmacy-benefits oswa rele Sèvis Patisipan nan nimewo
1.877.ICS.2525.
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2.
Èske Lis Medikaman an gendwa chanje?
Wi. ICS Community Care Plus FIDA-MMP ka ajoute oswa retire medikaman sou Lis
Medikaman an pandan ane a. Anjeneral, Lis Medikaman an ap chanje sèlman si:
 gen yon nouvo medikaman ki efikas menm jan avèk yon medikaman ki sou Lis
Medikaman an kounye a, oswa
 nou aprann yon medikaman danjere.
Nou ka chanje règ yo tou konsènan medikaman yo. Pa egzanp, nou kapab:
 deside pou egzije oswa pa egzije otorizasyon alavans pou yon medikaman.
(Otorizasyon alavans se pèmisyon ou jwenn nan men ICS Community Care Plus
FIDA-MMP oswa nan men Ekip Entèdisiplinè (IDT) an anvan ou kapab resevwa yon
medikaman.)
 ajoute oswa chanje kantite yon medikaman ou kapab resevwa (sa rele “limit sou
kantite”).
 ajoute oswa chanje limit terapi pa etap pou yon medikaman. (Terapi pa etap vle di
ou dwe eseye yon medikaman avan pou nou garanti yon lòt medikaman.)
(Pou jwenn plis enfòmasyon sou règ sou medikaman sa yo, gade paj 5.)
N ap fè ou konnen kilè nou retire yon medikaman w ap pran ki sou Lis Medikaman an. N
ap fè ou konnen tou kilè nou chanje règ yo pou garanti yon medikaman. Kesyon 3, 4 ak 7
ki anba la a gen plis enfòmasyon sou sa k ap pase lè Lis Medikaman an chanje.
 Ou kapab toujou tcheke Lis Medikaman ICS Community Care Plus FIDA-MMP sou
entènèt pou wè si l ajou nan sitwèb www.icsny.org/care-plus/pharmacy-benefits/
 Ou kapab rele Sèvis Patisipan tou pou tcheke dènye Lis Medikaman an nan
nimewo 1.877.ICS.2525.
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3.
Kisa k ap pase lè yon medikaman ki pi bon mache fè pwogrè epi li
travay menm jan avèk yon medikaman ki sou Lis Medikaman an
kounye a?
Si yon medikaman ki pi bon mache vin disponib epi li travay menm jan avèk yon
medikaman ki sou Lis Medikaman an kounye a:

Famasyen ou ka ba ou medikaman ki pi bon mache a pwochen fwa w ap pran
medikaman ak preskripsyon an. Si oumenm ak pwofesyonèl swen sante ou
deside medikaman ki pi bon mache pa bon pou ou, pwofesyonèl swen sante ou
kapab di famasyen an pou li kontinye ba ou medikaman w ap pran kounye a.
 ICS Community Care Plus FIDA-MMP ka deside retire medikaman ki pi chè a sou
Lis Medikaman an. Si w ap pran yon medikaman nou retire nan Lis Medikaman an
paske yon medikaman ki pi bon mache ak efikas tou fè pwogrè, n ap fè ou konnen
sa omwen 60 jou anvan nou retire li sou Lis Medikaman an oswa lè ou mande
pou yon renouvèlman. Answit, ou kapab resevwa yon rezèv medikaman an pou
60 jou anvan nou fè chanjman an sou Lis Medikaman an.

4.
ICS Community Care Plus FIDA-MMP ap fè manm yo konnen chanjman sa yo pa
lapòs, epitou n ap mete enfòmasyon sou fason pou fè yon doleyans, yon
kontestasyon, oswa yon demann eksepsyon. ICS Community Care Plus FIDAMMP ap mete enfòmasyon sa a sou sitwèb nou tou. W ap kapab jwenn li sou
sitwèb www.icsny.org/care-plus, epi n ap fè manm yo konnen dènye fòmilè nou an
chak ane. Nou kapab bay enfòmasyon sa yo nan lòt kalite fòma.
Kisa k ap pase lè nou vin konnen yon medikaman danjere?
Si Ajans Etazini pou Kontwòl Manje ak Medikaman (Food and Drug Administration - FDA)
di yon medikaman w ap pran danjere, n ap retire li sou Lis Medikaman an touswit. N ap
voye yon lèt tou e n ap rele w pou di w yo retire medikaman ki danjere a nan Lis
Medikaman an. Yo va di w pou kontakte doktè ki preskri w li a kou sa posib epi yo va ba
w enstriksyon pou w ranplase medikaman yo retire a. Ou kapab kontakte manadjè swen
sante ou pou jwenn èd.
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5.
Èske gen nenpòt restriksyon oswa limit sou garanti medikaman?
Oswa èske gen nenpòt aksyon ki obligatwa pou mwen fè pou mwen
kapab resevwa sèten medikaman?
Wi, kèk medikaman gen règ sou garanti yo oswa y gen limit sou kantite ou kapab
resevwa ladan yo. Nan kèk ka, ou dwe fè yon bagay anvan ou kapab resevwa
medikaman an. Pa egzanp:
 Otorizasyon alavans (oswa otorizasyon alavans): Pou kèk medikaman, oumenm
oswa doktè ou oswa lòt moun ki gen otorizasyon pou preskri medikaman dwe jwenn
apwobasyon ICS Community Care Plus FIDA-MMP oswa Ekip Entèdisiplinè
(Interdisciplinary Team, IDT) ou anvan ou pran medikaman sou preskripsyon ou. Si
w pa resevwa otorizasyon, ICS Community Care Plus FIDA-MMP pa ka garanti
medikaman an.
 Limit sou kantite: Pafwa ICS Community Care Plus FIDA-MMP limite kantite nan
yon medikaman ou kapab resevwa.
 Terapi-pa-etap: Pafwa ICS Community Care Plus FIDA-MMP egzije ou pou fè
terapi-pa-etap. Sa vle di w ap gen pou eseye medikaman yo nan yon sèten lòd pou
pwoblèm medikal ou. Ou ta ka gen pou eseye yon medikaman anvan n ap garanti
yon lòt medikaman. Si doktè ou panse premye medikaman an pa efikas pou ou, lè
sa a n ap garanti dezyèm nan.
Ou kapab chèche konnen si medikaman ou gen nenpòt kondisyon siplemantè oswa limit.
Pou fè sa, gade nan tablo ki kòmanse nan paj 17 lan. Ou kapab jwenn plis enfòmasyon
tou si ou ale sou sitwèb nou ki nan www.icsny.org/care-plus/pharmacy-benefits. Nou
mete dokiman sou entènèt ki eksplike otorizasyon alavans nou ak restriksyon pou terapipa-etap la. Ou ka mande nou pou voye yon kopi ba ou tou.
Ou kapab mande yon “eksepsyon” nan limit sa yo. Tanpri gade kesyon 11 pou jwenn plis
enfòmasyon sou eksepsyon yo.
 Si ou nan yon kay retrèt oswa nan yon sant medikal pou anpil tan epi ou bezwen yon
medikaman ki pa sou Lis Medikaman an, oswa si ou pa kapab jwenn medikaman ou
bezwen an fasil, nou kapab ede ou. N ap garanti yon kantite nan medikaman ou
bezwen annijans pou 31 jou (sof si ou gen yon preskripsyon pou mwens jou), kit ou se
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yon nouvo Patisipan ICS Community Care Plus FIDA-MMP kit ou pa yon nouvo
Patisipan. Sa ap ba ou tan pou pale avèk doktè ou oswa avèk lòt moun ki gen
otorizasyon pou preskri medikaman. Li kapab ede ou deside si gen yon medikaman
sanblab sou Lis Medikaman ou kapab pran pito oswa si pou mande yon eksepsyon.
Tanpri gade kesyon 11 pou jwenn plis enfòmasyon sou eksepsyon yo.
6.
Kijan w ap konnen si medikaman ou vle a gen limit oswa si gen
aksyon ki nesesè pou fè pou resevwa medikaman an?
Lis Medikaman ki Garanti nan paj 17 la gen yon kolòn ki rele “Aksyon ki nesesè,
restriksyon, oswa limit sou itilizasyon.”
7.
Kisa k ap pase si nou chanje règ nou yo sou fason nou garanti kèk
medikaman? Pa egzanp, si nou ajoute otorizasyon alavans
(apwobasyon), limit sou kantite ak/oswa restriksyon pou terapi-paetap sou yon medikaman.
N ap fè ou konnen si nou ajoute otorizasyon alavans, limit sou kantite, ak/oswa
restriksyon pou terapi-pa-etap sou yon medikaman. N ap fè ou konnen omwen 60 jou
anvan nou ajoute restriksyon an oswa lè ou mande yon renouvèlman yon lòt fwa. Epi, ou
kapab resevwa yon apwovizyònman medikaman an pou 60 jou anvan nou fè chanjman
an sou Lis Medikaman an. Sa ba ou tan pou pale avèk doktè ou oswa avèk lòt moun ki
gen otorizasyon pou preskri medikaman sou sa pou fè apre.
8.
Kijan ou kapab jwenn yon medikaman sou Lis Medikaman an?
Gen de (2) fason pou jwenn yon medikaman:
 Ou kapab fè rechèch nan lòd lèt alfabè a (si ou konnen kijan pou eple medikaman
an), oswa
 Ou kapab fè rechèch dapre pwoblèm medikal la.
Pou chèche nan lòd lèt alfabè a, al nan seksyon lis alfabetik la ki nan paj I-1. Answit
chèche non medikaman ou nan lis la.
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Pou chèche selon pwoblèm medikal, jwenn “Lis medikaman yo selon pwoblèm medikal
la” nan paj 17. Answit jwenn pwoblèm medikal la. Pa egzanp, si ou gen yon pwoblèm kè,
ou ta dwe gade nan kategori sa a. Sa vle di kote w ap jwenn medikaman ki trete pwoblèm
kè.
9.
Kisa pou ou fè si medikaman ou vle pran an pa sou Lis Medikaman
an?
Si w pa wè medikaman ou a sou Lis Medikaman an, rele Sèvi Patisipan nan nimewo
1.855.ICS.2525 epi mande enfòmasyon sou sa. Si ou vin konnen ICS Community Care
Plus FIDA-MMP p ap garanti medikaman an, ou kapab fè youn nan bagay sa yo:
 Mande Sèvis Patisipan yon lis medikaman tankou sa ou vle pran an. Answit, montre
lis la ba doktè ou oswa ba lòt moun ki gen otorizasyon pou preskri medikaman. Li
kapab preskri ou yon medikaman ki sou Lis Medikaman an ki tankou sa ou vle pran
an. Oswa
 Ou kapab mande plan an oswa Ekip Entèdisiplinè (IDT) ou pou fè yon eksepsyon
pou garanti medikaman ou. Tanpri gade kesyon 11 pou jwenn plis enfòmasyon sou
eksepsyon yo.
10. Kisa pou ou fè si ou se yon nouvo Patisipan ICS Community Care
Plus FIDA-MMP epi ou pa kapab jwenn medikaman ou sou Lis
Medikaman an oswa ou gen yon pwoblèm pou jwenn medikaman
ou?
Nou kapab ede w. Nou dwe garanti jiska 90 jou kantite medikaman pwovizwa, jan li
nesesè, pandan premye 90 jou ou se yon Patisipan ICS Community Care Plus FIDAMMP. Sa ap ba ou tan pou pale avèk doktè ou oswa avèk lòt moun ki gen otorizasyon
pou preskri medikaman. Li kapab ede ou deside si gen yon medikaman konsa sou Lis
Medikaman ou kapab pran pito oswa si pou mande yon eksepsyon.
N ap garanti jiska 90 jou kantite pwovizwa medikaman ou si:
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 w ap pran yon medikaman ki pa sou Lis Medikaman nou, oswa
 règ plan sante a pa kite ou resevwa kantite moun ki gen otorizasyon pou preskri
medikaman rekòmande pou ou, oswa
 medikaman an egzije pou gen apwobasyon ICS Community Care Plus FIDA-MMP
oswa Ekip Entèdisiplinè (IDT) ou alavans, oswa
 w ap pran yon medikaman ki se pati nan yon restriksyon terapi-pa-etap.
Si w ap viv nan yon kay retrèt oswa nan yon lòt sant medikal pou swen pwolonje ou ka
renouvle medikaman sou preskripsyon pou jiska 98 jou. Ou ka renouvle medikaman an
anpil fwa pandan 98 jou. Sa bay moun ki gen otorizasyon pou preskri w medikaman an
tan pou l chanje medikaman ou yo ak sa ki sou Lis Medikaman an oswa pou li mande yon
eksepsyon.
Si ou se yon patisipan aktyèl ki gen yon chanjman nan nivo swen soti nan yon
anviwònman tretman ale nan yon lòt, ou gendwa kalifye pou yon rezèv pou jiska 90 jou
pou yon medikaman ki pa sou Lis Medikaman an, pou ou ka bay doktè ou a tan pou l
chechè youn ki sou Lis la oswa fè aplikasyon pou yon eksepsyon. Ou ka kalifye pou yon
rezèv tranzisyon nivo swen si ou:

soti lopital oswa yon lòt anviwònman pou antre nan yon sant swen alontèm (LTC)

kite yon sant medikal LTC epi retounen nan kominote a

jwenn egzeyat pou soti lopital pou ale nan yon kay

fini ak yon sejou nan yon mezon retrèt kalifye ki kouvri pa Medicare Pati A (ki enkli
chaj famasi), epi retounen vin jwenn kouvèti anba Pati D

soti de kondisyon ospis pou tounen nan avantaj nan Pati A ak B Medicare oswa

jwenn egzeyat pou soti lopital sikyatrik avèk rejim medikaman ki trè adapte a chak
moun.
11. Èske ou kapab mande yon eksepsyon pou garanti medikaman ou?
Wi. Ou kapab mande ICS Community Care Plus FIDA-MMP oswa Ekip Entèdisiplinè
(IDT) ou pou fè yon eksepsyon pou garanti yon medikaman ki pa sou Lis Medikaman an.
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Ou kapab mande ICS Community Care Plus FIDA-MMP oswa IDT ou tou pou chanje règ
yo sou medikaman ou.
 Pa egzanp, ICS Community Care Plus FIDA-MMP ka limite kantite yon medikaman
n ap garanti. Si medikaman ou gen yon limit, ou kapab mande nou oswa IDT pou
chanje limit lan epi pou garanti plis.
 Kèk lòt egzanp: Ou kapab mande nou oswa IDT ou pou diminye restriksyon pou
terapi-pa-etap oswa kondisyon pou jwenn apwobasyon alavans.
12. Konbyen tan l ap pran pou jwenn yon eksepsyon?
Toudabò, CS Community Care Plus FIDA-MMP oswa Ekip Entèdisiplinè (IDT) ou dwe
resevwa yon deklarasyon moun ki gen otorizasyon pou preskri medikaman an ki sipòte
demann ou pou yon eksepsyon. Apre nou resevwa deklarasyon an, w ap resevwa yon
desizyon sou demann ou pou eksepsyon an nan 72 èdtan.
Si oumenm oswa moun ki gen otorizasyon pou preskri medikaman an panse sante ou ka
domaje si ou gen pou rete tann 72 èdtan pou yon desizyon, ou kapab mande yon
eksepsyon rapid. Sa a se yon desizyon ki pi rapid. Si moun ki gen otorizasyon pou preskri
medikaman an sipòte demann ou, w ap resevwa yon desizyon nan 24 èdtan apre nou
resevwa deklarasyon sipò moun ki gen otorizasyon pou preskri medikaman an.
13.
Kijan ou kapab mande yon eksepsyon?
Pou mande yon eksepsyon, rele Manadjè Swen Sante ou. Manadjè Swen Sante ou ap
travay avèk ou ak moun ki gen otorizasyon pou preskri medikaman an pou ede ou mande
yon eksepsyon.
14. Kisa medikaman jenerik yo?
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Medikaman jenerik yo fèt avèk menm engredyan ak medikaman mak komèsyal yo.
Anjeneral, yo koute mwens lajan pase medikaman mak komèsyal yo, epitou anjeneral, yo
pa gen non tout moun konnen byen. Ajans Etazini pou Kontwòl Manje ak Medikaman
(Food and Drug Administration - FDA) apwouve medikaman jenerik yo.
ICS Community Care Plus FIDA-MMP pwoteje medikaman ki gen non komèsyal ak
medikaman jenerik.
15. Kisa medikaman OTC ye?
OTC vle di “san preskripsyon”. ICS Community Care Plus FIDA-MMP garanti kèk
medikaman OTC lè se pwofesyonèl swen sante ou ki ekri preskripsyon pou yo.
Ou kapab li Lis Medikaman ICS Community Care Plus FIDA-MMP pou wè ki medikaman
OTC ki garanti.
16. Èske ICS Community Care Plus FIDA-MMP garanti pwodui ki pa
medikaman OTC?
ICS Community Care Plus FIDA-MMP garanti kèk pwodui ki pa medikaman OTC lè se
pwofesyonèl swen sante ou ki ba ou preskripsyon pou yo, pa egzanp, tanpon alkòl,
tanpon-a-gaz, ak sereng pou pran ensilin.
Ou kapab li Lis Medikaman ICS Community Care Plus FIDA-MMP pou wè ki pwodui pa
medikaman OTC ki garanti.
17. Kisa kopeman ou ye?
Nou p ap fè ou peye yon kopeman pou medikaman ki sou Lis Medikaman an.
18. Kisa nivo medikaman yo ye?
Ranje yo se gwoup medikaman. Chak medikaman ki sou Lis Medikaman la pou plan an
tonbe nan youn nan 4 nivo yo. Ou pa gen frè pou peye pou medikaman nan nenpòt nivo.
 Nivo 1: Medicare garanti medikaman jenerik yo
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 Nivo 2: Medicare garanti medikaman non komèsyal yo ak medikaman espesyalize
yo
 Nivo 3: Medicaid garanti medikaman jenerik ak medikaman non komèsyal ki pa
nan Pati D
 Nivo 4: Medicaid garanti Medikaman San Preskripsyon (OTC)
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Lis Medikaman ki Kouvri yo
Lis medikaman ki garanti ki nan paj 17 ba w enfòmasyon sou medikaman ICS
Community Care Plus FIDA-MMP garanti. Si ou gen pwoblèm pou jwenn medikaman ou
nan lis la, ale nan Endèks ki kòmanse nan paj I-1.
Premye kolòn tablo a bay lis non medikaman an. Medikaman mak komèsyal yo ekri an
majiskil (pa egzanp, AVONEX), epi medikaman jenerik yo endike an lèt italik miniskil (pa
egzanp, amoxicillin).
Enfòmasyon ki nan aksyon nesesè, restriksyon oswa limit sou kolòn itilizasyon an ap fè
ou konnen si ICS Community Care Plus FIDA-MMP gen nenpòt règ pou garanti
medikaman ou.
Abrevyasyon ak Senbòl
Ou ka jwenn abrevyasyon pou Utilization Management Utilization yo nan dokiman sa a.
ABREVYASYON NOTASYON GARANTI ASIRANS LAN
ABREVYASYON
DESKRIPSYON
EKSPLIKASYON
Restriksyon pou Kontwòl Itilizasyon
PA
PA BvD
Restriksyon
Otorizasyon Alavans
Oumenm (oswa doktè ou) gen
obligasyon pou jwenn otorizasyon
alavans nan ICS Community Care Plus
FIDA-MMP anvan ou prezante
preskripsyon ou pou medikaman sa a.
Si ou pa mande yon otorizasyon
alavans, ICS Community Care Plus
FIDA-MMP ka pa garanti medikaman
sa a.
Restriksyon
Otorizasyon Alavans
pou Pati B konpare ak
Detèminasyon Pati D
Medikaman sa a ka kalifye pou peman
anba Pati B oswa Pati D Medicare.
Oumenm (oswa doktè ou) gen
FIDA-MMP pou detèmine si
?
xiii
ABREVYASYON
DESKRIPSYON
EKSPLIKASYON
medikaman sa a garanti anba Pati D
Medicare anvan ou prezante
preskripsyon ou pou medikaman sa a.
Si ou pa gen yon otorizasyon alavans,
FIDA Care Complete ka pa garanti
medikaman sa a.
PA NSO
QL
ST
Si ou se yon nouvo manm, oswa si ou
pa t pran medikaman sa a anvan,
oumenm (oswa doktè ou) gen
Restriksyon pou
Otorizasyon alavans
FIDA-MMP anvan ou prezante
pou Nouvo Patisipan yo preskripsyon ou pou medikaman sa a.
Si ou pa gen yon otorizasyon alavans,
FIDA Care Complete ka pa garanti
medikaman sa a.
Restriksyon pou Limit
nan Kantite
ICS Community Care Plus FIDA-MMP
limite kantite medikaman ki garanti pou
chak preskripsyon, oswa nan yon
peryòd tan espesyal.
Anvan ICS Community Care Plus
FIDA-MMP ap bay pwoteksyon pou
medikaman sa a, ou dwe eseye yon
(kèk) lòt medikaman pou trete
pwoblèm medikal ou. Nou ka garanti
medikaman sa a sèlman si lòt
medikaman (yo) pa efikas pou ou.
Restriksyon pou
Terapi-pa-Etap
Ou pa ka jwenn abrevyasyon siplemantè pou kouvèti asirans nan dokiman sa a.
LÒT OBLIGAZYON ESPESYAL POU ASIRANS LA KA PEYE
LA
Medikaman ki gen
Aksè Limite
Preskripsyon sa a ka disponib sèlman
nan sèten famasi. Pou plis
enfòmasyon gade Anyè Famasi w la
oswa rele Sèvis pou Manm yo nan
1.877.ICS.2525 depi 8è a.m. rive 8è
?
xiv
ABREVYASYON
DESKRIPSYON
EKSPLIKASYON
p.m., lendi rive vandredi. Itilizatè
TTY/TDD ddwe rele 711.
NM
Medikaman ou pa ka fè
kòmand pou li pa lapòs
*
Pa yon Medikaman
Pati D
Ou kapab ka resevwa apwovizyònman
pou pi plis pase yon mwa pou pifò nan
medikaman ki sou lis medikaman an
pou yon pri ki pi ba pa lapòs lè w
pataje chaj yo (reduced cost share).
Medikaman ki pa disponib atravè
avantaj kòmann pa lapòs ou a gen nòt
"NM" sou yo nan kolòn Kondisyon/
Limit ki nan lis medikaman w nan.
Medikaman sa a se yon medikaman ki
pa nan Pati D, epi se Medicaid ki
garanti li.
Nòt: Asterisk (*) ki toupre yon medikaman vle di medikaman an pa yon “medikaman Pati D.”
Medikaman sa yo gen règ ki diferan pou kontestasyon. Yon kontestasyon se yon fason fòmèl pou
mande yon revizyon epi pou fè chanjman nan yon desizyon sou pwoteksyon si ou panse te gen
yon erè. Pa egzanp, ICS Community Care Plus FIDA-MMP oswa Ekip Entèdisiplinè (IDT) ou ta ka
deside yon medikaman ou vle pa garanti oswa pa garanti ankò anba Medicare oswa Medicaid. Si
oumenm oswa doktè ou oswa lòt moun ki gen otorizasyon pou preskri medikaman pa dakò avèk
desizyon an, ou kapab fè yon kontestasyon. Pou mande enstriksyon sou fason pou fè yon
kontestasyon, rele Sèvis Patisipan nan 1.877.ICS.2525 oswa Medyatè Patisipan FIDA a nan
1.877.ICS.2525. Ou kapab li Tiliv Patiispan an tou pou aprann kijan pou fè apèl kont yon desizy
Men siyifikasyon kòd yo yo itilize nan kolòn "Aksyon nesesè, restriksyon, oswa limit sou
itilizasyon":
(g) = Sèlman vèsyon jenerik medikaman sa a ki garanti. Vèsyon mak komèsyal la pa garanti.
M = Vèsyon mak komèsyal medikaman sa nan Nivo 3. Vèsyon jenerik la nan nivo 1.
PA = Otorizasyon alavans (apwobasyon): Ou dwen gen otorizasyon nan men plan an oswa
Ekip Entèdisiplinè (IDT) ou an avan ou al chèche medikaman sa a.
ST = Terapi-pa-etap: ou dwe eseye yon lòt medikaman anvan pou w jwenn sa a.
?
xv
?
xvi
Table of Contents
Analgesics.................................................................................................................................................................. 3
Anesthetics .............................................................................................................................................................. 15
Anti-Addiction/Substance Abuse Treatment Agents .......................................................................................... 15
Antianxiety Agents ................................................................................................................................................. 17
Antibacterials ......................................................................................................................................................... 18
Anticancer Agents .................................................................................................................................................. 30
Anticholinergic Agents .......................................................................................................................................... 41
Anticonvulsants ...................................................................................................................................................... 41
Antidementia Agents ............................................................................................................................................. 45
Antidepressants ...................................................................................................................................................... 46
Antidiabetic Agents ................................................................................................................................................ 50
Antifungals.............................................................................................................................................................. 54
Antihistamines ........................................................................................................................................................ 59
Anti-Infectives (Skin And Mucous Membrane) .................................................................................................. 65
Antimigraine Agents .............................................................................................................................................. 65
Antimycobacterials ................................................................................................................................................ 66
Antinausea Agents ................................................................................................................................................. 67
Antiparasite Agents ............................................................................................................................................... 69
Antiparkinsonian Agents....................................................................................................................................... 70
Antipsychotic Agents ............................................................................................................................................. 71
Antivirals (Systemic) .............................................................................................................................................. 75
Blood Products/Modifiers/Volume Expanders ................................................................................................... 82
Caloric Agents ........................................................................................................................................................ 86
ICS Community Care Plus 2016 Fòmilè FIDA-MMP
ID Fòmilè: 16508.000, Vèsyon: 17
An vigè apati: Sèptanm 1 2016
1
Cardiovascular Agents .......................................................................................................................................... 92
Central Nervous System Agents ......................................................................................................................... 108
Contraceptives ...................................................................................................................................................... 110
Cough And Cold Products .................................................................................................................................. 118
Dental And Oral Agents ...................................................................................................................................... 130
Dermatological Agents......................................................................................................................................... 131
Devices ................................................................................................................................................................... 140
Disinfectants (For Non-Dermatologic Use) ........................................................................................................ 141
Enzyme Replacement/Modifiers ......................................................................................................................... 141
Eye, Ear, Nose, Throat Agents ............................................................................................................................ 143
Gastrointestinal Agents ....................................................................................................................................... 151
Genitourinary Agents .......................................................................................................................................... 165
Heavy Metal Antagonists .................................................................................................................................... 166
Hormonal Agents, Stimulant/Replacement/Modifying .................................................................................... 166
Immunological Agents ......................................................................................................................................... 173
Inflammatory Bowel Disease Agents .................................................................................................................. 182
Irrigating Solutions .............................................................................................................................................. 183
Metabolic Bone Disease Agents .......................................................................................................................... 183
Miscellaneous Therapeutic Agents ..................................................................................................................... 185
Ophthalmic Agents .............................................................................................................................................. 191
Replacement Preparations .................................................................................................................................. 193
Respiratory Tract Agents .................................................................................................................................... 203
Skeletal Muscle Relaxants ................................................................................................................................... 207
Sleep Disorder Agents.......................................................................................................................................... 208
Vasodilating Agents ............................................................................................................................................. 209
Vitamins And Minerals ....................................................................................................................................... 210
2
Tier level
What the
drug will
cost you
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Analgesics
Analgesics, Miscellaneous
acephen 120 mg suppository outer
120 mg *
325 mg *
650 mg *
acetaminophen 120 mg suppos outer
120 mg *
acetaminophen 160 mg/5 ml elx 160
mg/5 ml *
acetaminophen 325 mg liqui-gel 325
mg *
acetaminophen 650 mg suppos 650
mg *
acetaminophen 80 mg rapid tab
children's 80 mg *
acetaminophen 80 mg/0.8 ml drp
infants 80 mg/0.8 ml *
acetaminophen-codeine 120 mg-12
mg/5 ml solution 120-12 mg/5 ml
acetaminophen-codeine oral
solution 300 mg-30 mg /12.5 ml
acetaminophen-codeine oral tablet
300-15 mg, 300-30 mg
acetaminophen-codeine oral tablet
300-60 mg
ALLZITAL ORAL TABLET 25325 MG
ascomp with codeine oral capsule
30-50-325-40 mg
(Acetaminophen
with Codeine)
(Acetaminophen
with Codeine)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
(Fiorinal with
Codeine #3)
QL (360 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
PA-HRM; QL (180 per
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, silvouple releICS Community Care Plus FIDA-MMP nannan 1.877.ICS.2525 Itilizatè
TTY yo, silvouple rele 711 depi 8è a.m. jiska 8è p.m., lendi jiska vandredi. Apèl la gratis. Pou jwenn plis
enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
3
Name of Drug
BELBUCA BUCCAL FILM 150
MCG, 300 MCG, 450 MCG, 600
MCG, 75 MCG, 750 MCG, 900
MCG
buprenorphine hcl injection syringe
0.3 mg/ml
butalbital compound w/codeine oral
capsule 30-50-325-40 mg
butalbital-acetaminop-caf-cod oral
capsule 50-300-40-30 mg, 50-32540-30 mg
butalbital-acetaminophen oral
tablet 50-325 mg
butalbital-acetaminophen-caff oral
capsule 50-325-40 mg
butalbital-acetaminophen-caff oral
tablet 50-325-40 mg
butalbital-aspirin-caffeine oral
capsule 50-325-40 mg
BUTRANS TRANSDERMAL
PATCH WEEKLY 10
MCG/HOUR, 15 MCG/HOUR, 20
MCG/HOUR, 5 MCG/HOUR, 7.5
MCG/HOUR
capacet oral capsule 50-325-40 mg
child non-aspirin 160 mg/5 ml
children's 160 mg/5 ml *
child pain-fever 160 mg/5 ml
a/f,gluten/f,cherry 160 mg/5 ml *
child tactinal 80 mg tab chw 80 mg
*
children's mapap 80 mg rapid 80
mg *
Tier level
What the
drug will
cost you
2
$0
1
$0
1
$0
(Fioricet with
Codeine)
1
$0
(Tencon)
1
$0
(Esgic)
1
$0
(Esgic)
1
$0
(Fiorinal)
1
$0
2
$0
(Esgic)
1
$0
(Acetaminophen)
4
$0
(Infants' Tylenol)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Buprenorphine
HCl)
(Fiorinal with
Codeine #3)
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (60 per 30
days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
QL (4 per 28 days)
PA-HRM; QL (180 per
30 days)
QL (30 per 30 days)
QL (30 per 30 days)
4
Tier level
What the
drug will
cost you
(Tylenol Sore
Throat)
4
$0
(Codeine Sulfate)
1
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Tylenol Sore
Throat)
4
$0
(Xolox)
1
$0
(Percodan)
1
$0
(Actiq)
1
$0
Name of Drug
children's silapap elixir 160 mg/5 ml
*
codeine sulfate oral tablet 15 mg, 30
mg, 60 mg
cvs child non-asa 80 mg tb chw 80
mg *
cvs non-aspirin jr tab chew 160 mg
*
cvs pain relief adult liquid 500
mg/15 ml *
endocet oral tablet 10-325 mg, 2.5325 mg, 5-325 mg, 7.5-325 mg
endodan oral tablet 4.8355-325 mg
fentanyl citrate buccal lozenge on a
handle 1,200 mcg, 1,600 mcg, 200
mcg, 400 mcg, 600 mcg, 800 mcg
fentanyl transdermal patch 72 hour
100 mcg/hr, 12 mcg/hr, 25 mcg/hr,
37.5 mcg/hour, 50 mcg/hr, 62.5
mcg/hour, 75 mcg/hr, 87.5 mcg/hour
feverall 120 mg suppository
children's, outer 120 mg *
feverall 325 mg suppository junior
str, outer 325 mg *
feverall 650 mg suppository adult,
outer 650 mg *
hydrocodone-acetaminophen oral
solution 10-325 mg/15 ml(15 ml),
2.5-167 mg/5 ml, 7.5-325 mg/15 ml
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (30 per 30 days)
PA; QL (120 per 30
days)
QL (10 per 30 days)
(Duragesic)
1
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Hycet)
1
$0
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
tablet 10-300 mg, 5-300 mg, 7.5-300 (Norco)
mg
1
$0
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
5
Name of Drug
tablet 10-325 mg, 2.5-325 mg, 5-325
mg, 7.5-325 mg
hydrocodone-ibuprofen oral tablet
10-200 mg, 2.5-200 mg, 5-200 mg,
7.5-200 mg
hydromorphone (pf) injection
solution 10 mg/ml
hydromorphone (pf) injection
solution 4 mg/ml
hydromorphone injection solution 2
mg/ml
hydromorphone injection syringe 2
mg/ml
hydromorphone oral liquid 1 mg/ml
hydromorphone oral tablet 2 mg, 4
mg
hydromorphone oral tablet 8 mg
HYSINGLA ER ORAL
TABLET,ORAL
ONLY,EXT.REL.24 HR 100 MG,
120 MG, 20 MG, 30 MG, 40 MG,
60 MG, 80 MG
junior mapap 160 mg rapid tab 160
mg *
LAZANDA NASAL SPRAY,NONAEROSOL 100 MCG/SPRAY, 300
MCG/SPRAY, 400 MCG/SPRAY
lorcet (hydrocodone) oral tablet 5325 mg
lorcet hd oral tablet 10-325 mg
lorcet plus oral tablet 7.5-325 mg
mapap 160 mg/5 ml elixir 160 mg/5
ml *
Tier level
What the
drug will
cost you
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
(Norco)
(Ibudone)
1
$0
(Dilaudid-HP)
1
$0
(Dilaudid)
1
$0
1
$0
1
$0
1
$0
(Dilaudid)
1
$0
(Dilaudid)
1
$0
2
$0
4
$0
2
$0
(Norco)
1
$0
(Norco)
(Norco)
(Tylenol Sore
Throat)
1
1
$0
$0
4
$0
(Hydromorphone
HCl)
(Hydromorphone
HCl)
(Dilaudid)
(Acetaminophen)
QL (30 per 30 days)
QL (30 per 30 days)
PA; QL (30 per 30
days)
6
Tier level
What the
drug will
cost you
(Infants' Tylenol)
4
$0
(Tylenol)
(Acetaminophen)
(Tylenol)
(Tylenol Sore
Throat)
(Acetaminophen)
4
4
4
$0
$0
$0
4
$0
4
$0
(Tylenol Arthritis)
4
$0
(Esgic)
1
$0
(Methadone HCl)
1
$0
(Methadone HCl)
1
$0
(Diskets)
(Diskets)
(Morphine
Sulfate/0.9%
Nacl/PF)
1
1
$0
$0
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
Name of Drug
mapap 160 mg/5 ml suspension 160
mg/5 ml *
mapap 325 mg tablet 325 mg *
mapap 500 mg capsule 500 mg *
mapap 500 mg tablet 500 mg *
mapap 500 mg/15 ml liquid 500
mg/15 ml *
mapap 80 mg tablet chew 80 mg *
mapap arthritis er 650 mg cplt 650
mg *
margesic oral capsule 50-325-40
mg
methadone injection solution 10
mg/ml
methadone oral solution 10 mg/5
ml, 5 mg/5 ml
methadone oral tablet 10 mg, 5 mg
methadose oral tablet,soluble 40 mg
morphine (pf) in 0.9 % nacl
intravenous pt controlled analgesia
syring 50 mg/25 ml (2 mg/ml)
morphine 10 mg/ml carpuject 10
mg/ml
mg/ml
mg/ml
morphine 8 mg/ml syringe 8 mg/ml
morphine concentrate oral solution
100 mg/5 ml (20 mg/ml)
morphine concentrate oral syringe
20 mg/ml
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
PA-HRM; QL (180 per
30 days)
QL (90 per 30 days)
7
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
morphine in dextrose 5 % injection
pt controlled analgesia syring 100
(Morphine
1
$0
mg/50 ml (2 mg/ml), 50 mg/25 ml (2 Sulfate/D5W)
mg/ml)
morphine injection solution 15
(Morphine Sulfate)
1
$0
mg/ml, 8 mg/ml
morphine injection syringe 10
(Morphine Sulfate)
1
$0
mg/ml
morphine intramuscular pen
(Morphine Sulfate)
1
$0
injector 10 mg/0.7 ml
morphine intravenous cartridge 15
(Morphine Sulfate)
1
$0
mg/ml
morphine intravenous solution 25
(Morphine Sulfate)
1
$0
mg/ml, 50 mg/ml
morphine intravenous syringe 10
(Morphine Sulfate)
1
$0
mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml
morphine oral solution 10 mg/5 ml (Morphine Sulfate)
1
$0
morphine oral solution 20 mg/5 ml
(Morphine Sulfate)
1
$0
(4 mg/ml)
MORPHINE ORAL TABLET 15
2
$0
MG, 30 MG
morphine oral tablet extended
(MS Contin)
1
$0
release 100 mg, 30 mg, 60 mg
morphine oral tablet extended
(MS Contin)
1
$0
release 15 mg, 200 mg
morphine rectal suppository 10 mg,
(Morphine Sulfate)
1
$0
20 mg, 30 mg, 5 mg
non-aspirin x-str 167 mg/5 ml 500
(Tylenol Sore
4
$0
mg/15 ml *
Throat)
nortemp 80 mg/0.8 ml drop 80
QL (30 per 30 days)
(Acetaminophen)
4
$0
mg/0.8 ml *
NUCYNTA ER ORAL TABLET
QL (60 per 30 days)
EXTENDED RELEASE 12 HR 100
2
$0
MG, 150 MG, 200 MG, 250 MG, 50
MG
8
Tier level
What the
drug will
cost you
2
$0
(Oxycodone HCl)
1
$0
(Oxycodone HCl)
1
$0
(Roxicodone)
1
$0
Name of Drug
NUCYNTA ORAL TABLET 100
MG, 50 MG, 75 MG
oxycodone oral concentrate 20
mg/ml
oxycodone oral solution 5 mg/5 ml
oxycodone oral tablet 10 mg, 15 mg,
20 mg, 30 mg, 5 mg
oxycodone oral tablet,oral
only,ext.rel.12 hr 10 mg, 15 mg, 20
mg, 30 mg, 40 mg, 60 mg
oxycodone oral tablet,oral
only,ext.rel.12 hr 80 mg
oxycodone-acetaminophen oral
solution 5-325 mg/5 ml
tablet 10-325 mg, 2.5-325 mg, 5-325
mg, 7.5-325 mg
tablet 10-650 mg
tablet 7.5-500 mg
oxycodone-aspirin oral tablet
4.8355-325 mg
OXYCONTIN ORAL
TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG, 15
MG, 20 MG, 30 MG, 40 MG, 60
MG
OXYCONTIN ORAL
TABLET,ORAL
ONLY,EXT.REL.12 HR 80 MG
oxymorphone oral tablet 10 mg, 5
mg
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
(Oxycontin)
1
$0
(Oxycontin)
2
$0
(Oxycodone
HCl/Acetaminophe
n)
1
$0
(Xolox)
1
$0
(Xolox)
1
$0
(Xolox)
1
$0
(Percodan)
1
$0
QL (60 per 30 days)
2
$0
(Opana)
2
$0
1
$0
9
Tier level
What the
drug will
cost you
(Opana ER)
1
$0
(Opana ER)
1
$0
(Acetaminophen)
4
$0
(Tylenol Arthritis)
4
$0
(Tylenol)
4
$0
(Tylenol)
4
$0
(Acetaminophen)
4
$0
4
$0
4
$0
(Acetaminophen)
4
$0
(Tylenol)
4
$0
(Acetaminophen)
4
$0
(Ibudone)
1
$0
(Oxycodone
HCl/Acetaminophe
n)
1
$0
4
$0
4
$0
4
$0
Name of Drug
oxymorphone oral tablet extended
release 12 hr 10 mg, 15 mg, 20 mg,
5 mg, 7.5 mg
oxymorphone oral tablet extended
release 12 hr 30 mg, 40 mg
pain relief 500 mg capsule 500 mg *
pain reliever er 650 mg caplet 8
hour, caplet 650 mg *
pharbetol 325 mg tablet regular
strength 325 mg *
pharbetol 500 mg caplet extra-str,
caplet 500 mg *
pv non-aspirin 500 mg softgel exstr,liq filled 500 mg *
q-pap 160 mg/5 ml solution a/f,
cherry 160 mg/5 ml *
q-pap 325 mg tablet 325 mg *
q-pap 80 mg/0.8 ml drops 80 mg/0.8
ml *
q-pap ex-str 500 mg tablet aspirin
free 500 mg *
ra jr acetaminophen 160 mg tab
rapid melts 160 mg *
reprexain oral tablet 10-200 mg,
2.5-200 mg, 5-200 mg
roxicet oral solution 5-325 mg/5 ml
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
(Tylenol Sore
Throat)
(Tylenol)
silapap infant's drops infant's 80
(Acetaminophen)
mg/0.8 ml *
sm arthritis pain er 650 mg caplet
(Tylenol Arthritis)
650 mg *
sm pain rel jr str tab chew 160 mg * (Acetaminophen)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
10
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
(Tencon)
1
$0
tramadol oral tablet 50 mg
(Ultram)
tramadol-acetaminophen oral tablet
(Ultracet)
37.5-325 mg
1
$0
1
$0
Name of Drug
sm pain reliever 80 mg tab
(Acetaminophen)
children's 80 mg *
tactinal 325 mg tablet 325 mg *
(Tylenol)
tactinal 500 mg tablet extra-strength
(Tylenol)
500 mg *
tencon oral tablet 50-325 mg
vicodin es oral tablet 7.5-300 mg
(Norco)
1
$0
vicodin hp oral tablet 10-300 mg
(Norco)
1
$0
vicodin oral tablet 5-300 mg
(Norco)
1
$0
xylon 10 oral tablet 10-200 mg
(Ibudone)
1
$0
zebutal oral capsule 50-325-40 mg
(Esgic)
1
$0
4
$0
4
$0
4
$0
Nonsteroidal AntiInflammatory Agents
ADVIL 100 MG TABLET JR
STRENGTH,COATED 100 MG *
ADVIL 200 MG TABLET 200 MG
*
ADVIL JR STR 100 MG TAB
CHEW TB CHEW,8
HOUR,GRAPE 100 MG *
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
PA-HRM; QL (180 per
30 days)
(includes Vicodin,
Vicodin ES and
per 30 days)
(includes Vicodin,
Vicodin ES and
per 30 days)
(includes Vicodin,
Vicodin ES and
per 30 days)
PA-HRM; QL (180 per
30 days)
11
Tier level
What the
drug will
cost you
(Aspirin)
4
$0
(Ecotrin)
4
$0
(Aspirin)
4
$0
4
$0
4
$0
4
4
$0
$0
(Ecotrin)
4
$0
(Ecotrin)
(Aspirin/Calcium
Carbonate/Mag)
4
$0
4
$0
2
$0
1
$0
4
$0
(Choline Sal/Mag
Salicylate)
1
$0
(Advil)
4
$0
(Diclofenac
Potassium)
1
$0
(Voltaren-XR)
1
$0
(Diclofenac
Sodium)
1
$0
Name of Drug
aspirin 300 mg suppository 300 mg
*
aspirin 325 mg tablet 325 mg *
aspirin 600 mg suppository 600 mg
*
aspirin 81 mg chewable tablet 81
mg *
aspirin buffered 325 mg tab 325 mg
*
aspirin ec 325 mg tablet 325 mg *
aspirin ec 500 mg tablet 500 mg *
aspirin ec 81 mg tablet low dose 81
mg *
aspir-low ec 81 mg tablet 81 mg *
bufferin 325 mg tablet coated 325
mg *
CALDOLOR INTRAVENOUS
RECON SOLN 400 MG/4 ML (100
MG/ML)
celecoxib oral capsule 100 mg, 200
mg, 400 mg, 50 mg
CHILDREN'S ADVIL 100 MG/5
ML A/F (OTC) 100 MG/5 ML *
choline,magnesium salicylate oral
liquid 500 mg/5 ml
cvs ibuprofen 200 mg softgel liquid
filled,softge 200 mg *
diclofenac potassium oral tablet 50
mg
diclofenac sodium oral tablet
extended release 24 hr 100 mg
diclofenac sodium oral
tablet,delayed release (dr/ec) 25 mg,
50 mg, 75 mg
(Bayer Chewable
Aspirin)
(Aspirin/Calcium
Carbonate/Mag)
(Ecotrin)
(Ecotrin)
(Celebrex)
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
12
Tier level
What the
drug will
cost you
(Voltaren)
1
$0
(Arthrotec 50)
1
$0
(Diflunisal)
(Ecotrin)
1
4
$0
$0
(Etodolac)
1
$0
(Etodolac)
1
$0
(Etodolac)
1
$0
(Nalfon)
(Fenoprofen
Calcium)
1
$0
1
$0
2
$0
(Flurbiprofen)
1
$0
(Advil)
4
$0
(Children'S Advil)
4
$0
(Advil)
4
$0
(Ibuprofen)
1
$0
(Ibuprofen)
1
$0
(Indomethacin)
(Indomethacin)
1
1
$0
$0
(Indomethacin)
1
$0
(Indomethacin
Sodium)
1
$0
Name of Drug
diclofenac sodium topical gel 3 %
diclofenac-misoprostol oral
tablet,ir,delayed rel,biphasic 50-200
mg-mcg, 75-200 mg-mcg
diflunisal oral tablet 500 mg
ecpirin ec 325 mg tablet 325 mg *
etodolac oral capsule 200 mg, 300
mg
etodolac oral tablet 400 mg, 500 mg
etodolac oral tablet extended
release 24 hr 400 mg, 500 mg, 600
mg
fenoprofen oral capsule 200 mg
fenoprofen oral tablet 600 mg
FLECTOR TRANSDERMAL
PATCH 12 HOUR 1.3 %
flurbiprofen oral tablet 100 mg, 50
mg
gnp ibuprofen jr str 100 mg tb 100
mg *
ibuprofen 100 mg/5 ml susp
children's (otc) 100 mg/5 ml *
ibuprofen 200 mg tablet 200 mg *
ibuprofen oral suspension 100 mg/5
ml
ibuprofen oral tablet 400 mg, 600
mg, 800 mg
indomethacin oral capsule 25 mg
indomethacin oral capsule 50 mg
indomethacin oral capsule, extended
release 75 mg
indomethacin sodium intravenous
recon soln 1 mg
Necessary Actions,
Restrictions, or
Limits on Use
PA
QL (60 per 30 days)
13
Tier level
What the
drug will
cost you
4
$0
3
$0
(Ketoprofen)
1
$0
(Ketoprofen)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
4
$0
4
$0
Name of Drug
infant ibuprofen 50 mg/1.25 ml
d/f,a/f,non-staining 50 mg/1.25 ml *
INFANTS' MOTRIN 50 MG/1.25
ML D/F, BERRY FLAVOR 50
MG/1.25 ML *
ketoprofen oral capsule 50 mg, 75
mg
ketoprofen oral capsule,ext rel.
pellets 24 hr 200 mg
(Infants' Motrin)
(Ketorolac
Tromethamine)
mefenamic acid oral capsule 250 mg (Ponstel)
meloxicam oral suspension 7.5 mg/5
(Mobic)
ml
meloxicam oral tablet 15 mg, 7.5 mg (Mobic)
nabumetone oral tablet 500 mg, 750
(Nabumetone)
mg
naproxen oral suspension 125 mg/5
(Naprosyn)
ml
naproxen oral tablet 250 mg, 375
(Naprosyn)
mg, 500 mg
naproxen oral tablet,delayed release
(Ec-Naprosyn)
(dr/ec) 375 mg, 500 mg
naproxen sodium oral tablet 275
(Anaprox)
mg, 550 mg
piroxicam oral capsule 10 mg, 20
(Feldene)
mg
(Aspirin/Calcium
ra aspirin tri-buffered tb 325 mg *
Carbonate/Mag)
sm ibuprofen ib 100 mg tablet junior
(Advil)
strength 100 mg *
st. joseph aspirin 81 mg chew
(Bayer Chewable
orange 81 mg *
Aspirin)
ketorolac oral tablet 10 mg
Necessary Actions,
Restrictions, or
Limits on Use
QL (20 per 30 days)
14
Tier level
What the
drug will
cost you
(Ecotrin)
4
$0
(Sulindac)
(Tolmetin Sodium)
(Tolmetin Sodium)
1
1
1
1
$0
$0
$0
$0
(Advil)
4
$0
(Lidocaine HCl)
1
$0
(Xylocaine-MPF)
1
$0
(Xylocaine)
1
$0
(Xylocaine)
1
$0
(Lidocaine HCl)
1
$0
(Xylocaine)
1
$0
(Lidoderm)
1
$0
(Lidocaine)
1
$0
(EMLA)
1
$0
(Acamprosate
Calcium)
1
$0
Name of Drug
st. joseph aspirin ec 81 mg tb
enteric coated 81 mg *
sulindac oral tablet 150 mg, 200 mg
tolmetin oral capsule 400 mg
tolmetin oral tablet 200 mg, 600 mg
VOLTAREN TOPICAL GEL 1 %
wal-profen 200 mg softgel softgel
200 mg *
Necessary Actions,
Restrictions, or
Limits on Use
Anesthetics
Local Anesthetics
glydo mucous membrane jelly in
applicator 2 %
lidocaine (pf) injection solution 15
mg/ml (1.5 %), 40 mg/ml (4 %), 5
mg/ml (0.5 %)
lidocaine 2% viscous soln 2 %
lidocaine hcl injection solution 10
mg/ml (1 %), 20 mg/ml (2 %)
lidocaine hcl mucous membrane gel
2%
lidocaine hcl mucous membrane
solution 2 %, 4 % (40 mg/ml)
lidocaine topical adhesive
patch,medicated 5 %
lidocaine topical ointment 5 %
lidocaine-prilocaine topical cream
2.5-2.5 %
PA
Anti-Addiction/Substance
Abuse Treatment Agents
Anti-Addiction/Substance
Abuse Treatment Agents
acamprosate oral tablet,delayed
release (dr/ec) 333 mg
15
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
2
$0
2
$0
2
$0
(Antabuse)
1
$0
(Naloxone HCl)
1
$0
(Naloxone HCl)
1
$0
(Revia)
1
$0
2
$0
4
$0
4
$0
4
$0
(Nicorette)
(Nicorette)
4
4
$0
$0
(Nicorette)
4
$0
Name of Drug
buprenorphine hcl sublingual tablet
2 mg, 8 mg
buprenorphine-naloxone sublingual
tablet 2-0.5 mg, 8-2 mg
bupropion hcl (smoking deter) oral
tablet extended release 150 mg
CHANTIX CONTINUING
MONTH BOX ORAL TABLET 1
MG
CHANTIX ORAL TABLET 0.5
MG, 1 MG
CHANTIX STARTING MONTH
BOX ORAL TABLETS,DOSE
PACK 0.5 MG (11)- 1 MG (42)
disulfiram oral tablet 250 mg, 500
mg
naloxone injection solution 0.4
mg/ml
naloxone injection syringe 0.4
mg/ml, 1 mg/ml
naltrexone oral tablet 50 mg
NARCAN NASAL SPRAY,NONAEROSOL 4 MG/ACTUATION
NICODERM CQ 14 MG/24HR
PATCH 14 MG/24 HR *
PATCH 21 MG/24 HR *
PATCH 7 MG/24 HR *
nicorelief 2 mg gum 2 mg *
nicorelief 4 mg gum 4 mg *
nicorette 2 mg chewing gum white
ice mint 2 mg *
(Buprenorphine
HCl)
(Buprenorphine
HCl/Naloxone
HCl)
(Zyban)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (90 per 30
days)
PA; QL (90 per 30
days)
QL (53 per 28 days)
QL (4 per 30 days)
16
Tier level
What the
drug will
cost you
(Nicoderm Cq)
4
$0
(Nicorette)
4
$0
(Nicorette)
4
$0
(Nicoderm Cq)
4
$0
(Nicoderm Cq)
4
$0
(Nicorette)
4
$0
(Nicorette)
4
$0
(Nicoderm Cq)
4
$0
2
$0
Name of Drug
nicotine 14 mg/24hr patch outer
(otc) 14 mg/24 hr *
nicotine 2 mg chewing gum sugar
free 2 mg *
nicotine 2 mg lozenge mint, 3
quittube 2 mg *
nicotine 21 mg/24hr patch step 1
(otc) 21 mg/24 hr *
nicotine 22 mg/24hr patch 1 week
starter kit 22 mg/24 hr *
nicotine 4 mg chewing gum 4 mg *
nicotine 4 mg lozenge mint, 3
quittube 4 mg *
nicotine 7 mg/24hr patch (otc) 7
mg/24 hr *
NICOTROL INHALATION
CARTRIDGE 10 MG
ZUBSOLV SUBLINGUAL
TABLET 1.4-0.36 MG, 11.4-2.9
MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.62.1 MG
2
$0
1
$0
1
$0
1
1
$0
$0
(Clonazepam)
1
$0
(Clonazepam)
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (90 per 30
days)
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet 0.25 mg, 0.5
mg, 1 mg, 2 mg
chlordiazepoxide hcl oral capsule
10 mg, 25 mg, 5 mg
clonazepam oral tablet 0.5 mg, 1 mg
clonazepam oral tablet 2 mg
clonazepam oral
tablet,disintegrating 0.125 mg, 0.25
mg, 0.5 mg, 1 mg
clonazepam oral
tablet,disintegrating 2 mg
(Xanax)
(Chlordiazepoxide
HCl)
(Klonopin)
(Klonopin)
QL (90 per 30 days)
QL (90 per 30 days)
17
Tier level
What the
drug will
cost you
(Tranxene T-Tab)
1
$0
(Tranxene T-Tab)
1
$0
(Diazepam)
1
$0
(Diazepam)
1
$0
(Diazepam)
1
$0
(Valium)
1
$0
(Diastat)
1
$0
(Ativan)
1
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
clorazepate dipotassium oral tablet
15 mg
clorazepate dipotassium oral tablet
3.75 mg, 7.5 mg
diazepam injection syringe 5 mg/ml
diazepam intensol oral concentrate
5 mg/ml
diazepam oral solution 5 mg/5 ml (1
mg/ml)
diazepam oral tablet 10 mg, 2 mg, 5
mg
diazepam rectal kit 12.5-15-17.5-20
mg, 2.5 mg, 5-7.5-10 mg
lorazepam oral tablet 0.5 mg, 1 mg,
2 mg
ONFI ORAL SUSPENSION 2.5
MG/ML
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (10 per 28 days)
QL (90 per 30 days)
PA NSO; QL (480 per
30 days)
Antibacterials
Aminoglycosides
BETHKIS INHALATION
SOLUTION FOR
NEBULIZATION 300 MG/4 ML
gentamicin in nacl (iso-osm)
intravenous piggyback 100 mg/100
ml, 100 mg/50 ml, 60 mg/50 ml, 70
mg/50 ml, 80 mg/100 ml, 80 mg/50
ml, 90 mg/100 ml
gentamicin injection solution 40
mg/ml
gentamicin ped 20 mg/2 ml vial
latex-free, sdv 20 mg/2 ml
gentamicin sulfate (pf) intravenous
solution 80 mg/8 ml
neomycin oral tablet 500 mg
PA BvD
(Gentamicin In
Nacl, Iso-Osm)
(Gentamicin
Sulfate)
(Gentamicin
Sulfate/PF)
(Gentamicin
Sulfate/PF)
(Neomycin Sulfate)
18
Tier level
What the
drug will
cost you
1
$0
2
$0
(Tobi)
1
$0
(Tobramycin/Sodiu
m Chloride)
1
$0
(Tobramycin
Sulfate)
1
$0
(Bacitracin)
1
$0
(Chloramphenicol
Sod Succ)
1
$0
(Cleocin Palmitate)
1
$0
(Cleocin HCl)
1
$0
(Cleocin Phosphate
In D5w)
1
$0
(Cleocin Palmitate)
1
$0
1
$0
1
$0
1
$0
Name of Drug
streptomycin intramuscular recon
soln 1 gram
TOBI PODHALER INHALATION
CAPSULE, W/INHALATION
DEVICE 28 MG
tobramycin in 0.225 % nacl
inhalation solution for nebulization
300 mg/5 ml
tobramycin in 0.9 % nacl
intravenous piggyback 60 mg/50 ml,
80 mg/100 ml
tobramycin sulfate injection solution
10 mg/ml, 40 mg/ml
Antibacterials,
Miscellaneous
bacitracin intramuscular recon soln
50,000 unit
chloramphenicol sod succinate
intravenous recon soln 1 gram
clindamycin 75 mg/5 ml soln 75
mg/5 ml
clindamycin hcl oral capsule 150
mg, 300 mg, 75 mg
clindamycin in 5 % dextrose
ml, 600 mg/50 ml, 900 mg/50 ml
clindamycin pediatric oral recon
soln 75 mg/5 ml
clindamycin phosphate injection
solution 150 mg/ml
clindamycin phosphate intravenous
solution 600 mg/4 ml
colistin (colistimethate na) injection
recon soln 150 mg
(Streptomycin
Sulfate)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
(Cleocin
Phosphate)
(Cleocin
Phosphate)
(Coly-Mycin M
Parenteral)
19
Tier level
What the
drug will
cost you
2
$0
2
$0
(Zyvox)
1
$0
(Zyvox)
1
$0
(Zyvox)
1
$0
(Hiprex)
1
$0
(Metronidazole/So
dium Chloride)
1
$0
(Flagyl)
1
$0
(Flagyl)
1
$0
Name of Drug
CUBICIN INTRAVENOUS
RECON SOLN 500 MG
CUBICIN RF INTRAVENOUS
RECON SOLN 500 MG
linezolid intravenous parenteral
linezolid oral suspension for
reconstitution 100 mg/5 ml
linezolid oral tablet 600 mg
methenamine hippurate oral tablet 1
gram
metronidazole in nacl (iso-os)
ml
metronidazole oral capsule 375 mg
metronidazole oral tablet 250 mg,
500 mg
nitrofurantoin macrocrystal oral
capsule 100 mg, 25 mg, 50 mg
(Macrodantin)
1
$0
nitrofurantoin monohyd/m-cryst
oral capsule 100 mg
(Macrobid)
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs);
PA-HRM; (High Risk
with over 90 days
cumulative use of
20
Name of Drug
oral capsule 100 mg (75/25)
polymyxin b sulfate injection recon
soln 500,000 unit
SYNERCID INTRAVENOUS
RECON SOLN 500 MG
trimethoprim oral tablet 100 mg
vancomycin hcl 1g/200 ml bag 1
gram/200 ml
vancomycin intravenous recon soln
1,000 mg, 10 gram, 750 mg
vancomycin intravenous recon soln
500 mg
vancomycin oral capsule 125 mg,
250 mg
XIFAXAN ORAL TABLET 200
MG
XIFAXAN ORAL TABLET 550
MG
ZYVOX ORAL SUSPENSION
FOR RECONSTITUTION 100
MG/5 ML
Cephalosporins
cefaclor oral capsule 250 mg, 500
mg
cefaclor oral suspension for
reconstitution 125 mg/5 ml, 250
mg/5 ml, 375 mg/5 ml
cefadroxil oral capsule 500 mg
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
with over 90 days
cumulative use of
(Macrobid)
1
$0
(Polymyxin B
Sulfate)
1
$0
2
$0
(Trimethoprim)
(Vancomycin Hcl
In Dextrose 5 %)
1
$0
1
$0
(Vancomycin HCl)
1
$0
(Vancomycin Hcl
In Dextrose 5 %)
1
$0
(Vancocin HCl)
1
$0
2
$0
2
$0
2
$0
(Cefaclor)
1
$0
(Cefaclor)
1
$0
(Cefadroxil)
1
$0
PA; QL (9 per 30 days)
PA
21
Tier level
What the
drug will
cost you
(Cefadroxil)
1
$0
(Cefadroxil)
(Cefazolin
Sodium/Dextrose,
Iso)
1
$0
1
$0
(Cefazolin Sodium)
1
$0
(Cefdinir)
1
$0
(Cefdinir)
1
$0
(Spectracef)
1
$0
2
$0
2
$0
(Maxipime)
1
$0
(Claforan)
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
cefadroxil oral suspension for
mg/5 ml
cefadroxil oral tablet 1 gram
cefazolin in dextrose (iso-os)
intravenous piggyback 1 gram/50
ml, 2 gram/50 ml
cefazolin injection recon soln 1
gram, 10 gram, 500 mg
cefdinir oral capsule 300 mg
cefdinir oral suspension for
mg/5 ml
cefditoren pivoxil oral tablet 200
mg, 400 mg
CEFEPIME 2 GM INJECTION 2
GRAM/100 ML
CEFEPIME IN DEXTROSE 5 %
INTRAVENOUS PIGGYBACK 1
GRAM/50 ML, 2 GRAM/50 ML
cefepime injection recon soln 1
gram, 2 gram
cefotaxime injection recon soln 1
gram, 10 gram, 2 gram, 500 mg
(Cefoxitin
cefoxitin in dextrose, iso-osm
Sodium/Dextrose,
intravenous piggyback 2 gram/50 ml
Iso)
cefoxitin intravenous recon soln 1
(Cefoxitin Sodium)
gram, 10 gram, 2 gram
cefpodoxime oral suspension for
(Cefpodoxime
reconstitution 100 mg/5 ml, 50 mg/5
Proxetil)
ml
cefpodoxime oral tablet 100 mg, 200 (Cefpodoxime
mg
Proxetil)
Necessary Actions,
Restrictions, or
Limits on Use
22
Tier level
What the
drug will
cost you
(Cefprozil)
1
$0
(Cefprozil)
1
$0
(Fortaz)
1
$0
(Cedax)
1
$0
(Cedax)
1
$0
(Ceftriaxone
Na/Dextrose, Iso)
1
$0
(Rocephin)
1
$0
(Ceftriaxone
Na/Dextrose, Iso)
1
$0
(Rocephin)
1
$0
(Ceftriaxone
Na/Dextrose, Iso)
1
$0
(Ceftin)
1
$0
(Zinacef)
1
$0
(Zinacef)
1
$0
(Keflex)
1
$0
(Cephalexin)
1
$0
(Cephalexin)
1
$0
Name of Drug
cefprozil oral suspension for
mg/5 ml
cefprozil oral tablet 250 mg, 500 mg
ceftazidime injection recon soln 2
gram, 6 gram
ceftibuten oral capsule 400 mg
ceftibuten oral suspension for
ceftriaxone 1 gm piggyback 50ml
galaxycontainer 1 gram/50 ml
ceftriaxone 1 gm vial 10's, fliptop,l/f
1 gram
ceftriaxone 2 gm piggyback 50ml
galaxycontainer 2 gram/50 ml
ceftriaxone injection recon soln 10
gram, 250 mg, 500 mg
ceftriaxone intravenous recon soln 1
gram, 2 gram
cefuroxime axetil oral tablet 250
mg, 500 mg
cefuroxime sodium injection recon
soln 1.5 gram, 750 mg
cefuroxime sodium intravenous
recon soln 7.5 gram
cephalexin oral capsule 250 mg,
500 mg, 750 mg
cephalexin oral suspension for
mg/5 ml
cephalexin oral tablet 250 mg, 500
mg
Necessary Actions,
Restrictions, or
Limits on Use
23
Tier level
What the
drug will
cost you
2
$0
2
$0
1
$0
2
$0
(Zithromax)
1
$0
(Zithromax)
1
$0
(Zithromax)
1
$0
(Zithromax)
1
$0
(Zithromax)
1
$0
(Biaxin)
1
$0
(Biaxin)
1
$0
(Clarithromycin)
1
$0
2
$0
1
$0
Name of Drug
MEFOXIN IN DEXTROSE (ISOOSM) INTRAVENOUS
PIGGYBACK 1 GRAM/50 ML, 2
GRAM/50 ML
SUPRAX ORAL
TABLET,CHEWABLE 100 MG,
200 MG
tazicef injection recon soln 2 gram,
6 gram
TEFLARO INTRAVENOUS
RECON SOLN 400 MG, 600 MG
Macrolides
azithromycin intravenous recon soln
500 mg
azithromycin oral packet 1 gram
azithromycin oral suspension for
mg/5 ml
azithromycin oral tablet 250 mg,
250 mg (6 pack), 600 mg
azithromycin oral tablet 500 mg
clarithromycin oral suspension for
mg/5 ml
clarithromycin oral tablet 250 mg,
500 mg
clarithromycin oral tablet extended
release 24 hr 500 mg
DIFICID ORAL TABLET 200 MG
e.e.s. 400 oral tablet 400 mg
(Fortaz)
(Erythromycin
Ethylsuccinate)
Necessary Actions,
Restrictions, or
Limits on Use
QL (20 per 10 days)
e.e.s. granules oral suspension for
(Eryped 200)
1
$0
ery-tab oral tablet,delayed release
(Erythromycin
1
$0
(dr/ec) 250 mg, 500 mg
Base)
24
Tier level
What the
drug will
cost you
2
$0
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
2
$0
1
$0
2
$0
(Merrem)
1
$0
(Merrem)
1
$0
(Amoxicillin)
1
$0
(Amoxicillin)
1
$0
Name of Drug
ERY-TAB ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
erythrocin (as stearate) oral tablet
250 mg
ERYTHROCIN INTRAVENOUS
RECON SOLN 1,000 MG, 500 MG
erythromycin ethylsuccinate oral
tablet 400 mg
erythromycin oral capsule,delayed
release(dr/ec) 250 mg
erythromycin oral tablet 250 mg,
500 mg
Miscellaneous B-Lactam
Antibiotics
aztreonam injection recon soln 1
gram
CAYSTON INHALATION
SOLUTION FOR
NEBULIZATION 75 MG/ML
imipenem-cilastatin intravenous
recon soln 250 mg, 500 mg
INVANZ INJECTION RECON
SOLN 1 GRAM
meropenem intravenous recon soln
500 mg
meropenem iv 1 gm vial outer, latexfree 1 gram
Penicillins
amoxicillin oral capsule 250 mg,
500 mg
amoxicillin oral suspension for
mg/5 ml, 250 mg/5 ml, 400 mg/5 ml
(Erythromycin
Stearate)
(Erythromycin
Ethylsuccinate)
(Erythromycin
Base)
(Erythromycin
Base)
(Azactam)
Necessary Actions,
Restrictions, or
Limits on Use
LA
(Primaxin)
25
Tier level
What the
drug will
cost you
(Amoxicillin)
1
$0
(Amoxicillin)
1
$0
(Augmentin)
1
$0
(Augmentin)
1
$0
(Augmentin XR)
1
$0
(Amoxicillin/Potas
sium Clav)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(Unasyn)
1
$0
(Unasyn)
1
$0
(Unasyn)
1
$0
Name of Drug
amoxicillin oral tablet 500 mg, 875
mg
amoxicillin oral tablet,chewable 125
mg, 250 mg
amoxicillin-pot clavulanate oral
suspension for reconstitution 20028.5 mg/5 ml, 250-62.5 mg/5 ml,
400-57 mg/5 ml, 600-42.9 mg/5 ml
tablet 250-125 mg, 500-125 mg,
875-125 mg
tablet extended release 12 hr 1,00062.5 mg
tablet,chewable 200-28.5 mg, 40057 mg
ampicillin 2 gm vial 10's, latex-free
2 gram
ampicillin oral capsule 250 mg, 500
mg
ampicillin oral suspension for
mg/5 ml
ampicillin sodium injection recon
soln 1 gram, 10 gram, 125 mg
ampicillin sodium intravenous recon
soln 2 gram
ampicillin-sulbactam 1.5 gm vl p/f,
latex-free 1.5 gram
ampicillin-sulbactam injection
recon soln 15 gram, 3 gram
ampicillin-sulbactam intravenous
recon soln 1.5 gram
(Ampicillin
Sodium)
(Ampicillin
Trihydrate)
(Ampicillin
Trihydrate)
(Ampicillin
Sodium)
(Ampicillin
Sodium)
Necessary Actions,
Restrictions, or
Limits on Use
26
Tier level
What the
drug will
cost you
2
$0
2
$0
(Dicloxacillin
Sodium)
1
$0
(Nafcillin Sodium)
1
$0
(Nafcillin Sodium)
1
$0
(Nafcillin Sodium)
1
$0
(Oxacillin Sodium)
1
$0
(Oxacillin
Sodium/Dextrose,
Iso)
1
$0
(Oxacillin Sodium)
1
$0
(Oxacillin Sodium)
1
$0
(Pen G
Pot/DextroseWater)
1
$0
(Penicillin G
Potassium)
1
$0
(Penicillin G
Procaine)
1
$0
Name of Drug
BICILLIN C-R
INTRAMUSCULAR SYRINGE
1,200,000 UNIT/ 2
ML(600K/600K), 1,200,000 UNIT/
2 ML(900K/300K)
BICILLIN L-A
1,200,000 UNIT/2 ML, 2,400,000
UNIT/4 ML, 600,000 UNIT/ML
dicloxacillin oral capsule 250 mg,
500 mg
nafcillin 2 gm vial sterile, latex-free
2 gram
nafcillin injection recon soln 1
gram, 10 gram
nafcillin intravenous recon soln 2
gram
oxacillin 1 gm add-vantage vl addvantage, inner 1 gram
oxacillin in dextrose(iso-osm)
ml, 2 gram/50 ml
oxacillin injection recon soln 10
gram
oxacillin intravenous recon soln 2
gram
penicillin g pot in dextrose
intravenous piggyback 1 million
unit/50 ml, 2 million unit/50 ml, 3
million unit/50 ml
penicillin g potassium injection
recon soln 5 million unit
penicillin g procaine intramuscular
syringe 1.2 million unit/2 ml,
600,000 unit/ml
Necessary Actions,
Restrictions, or
Limits on Use
27
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
penicillin gk 20 million unit 20
(Penicillin G
1
$0
million unit
Potassium)
penicillin v potassium oral recon
(Penicillin V
1
$0
soln 125 mg/5 ml, 250 mg/5 ml
Potassium)
penicillin v potassium oral tablet
(Penicillin V
1
$0
250 mg, 500 mg
Potassium)
pfizerpen-g injection recon soln 20 (Penicillin G
1
$0
million unit
Potassium)
piperacillin-tazobactam intravenous
recon soln 2.25 gram, 3.375 gram,
(Zosyn)
1
$0
4.5 gram
piperacil-tazobact 40.5 gram p/f,
(Zosyn)
1
$0
latex-free 40.5 gram
Quinolones
ciprofloxacin hcl oral tablet 100 mg,
(Cipro)
1
$0
250 mg, 500 mg, 750 mg
ciprofloxacin in 5 % dextrose
intravenous piggyback 200 mg/100 (Cipro I.V.)
1
$0
ml
ciprofloxacin lactate intravenous
(Ciprofloxacin
1
$0
Lactate)
ciprofloxacin oral
suspension,microcapsule recon 250 (Cipro)
1
$0
mg/5 ml, 500 mg/5 ml
ciprofloxacn-d5w 400 mg/200 ml
(Cipro I.V.)
1
$0
p/f,latex/f, in d5w 400 mg/200 ml
levofloxacin in d5w intravenous
piggyback 500 mg/100 ml, 750
(Levaquin)
1
$0
mg/150 ml
levofloxacin intravenous solution 25
(Levofloxacin)
1
$0
mg/ml
levofloxacin oral solution 250
(Levaquin)
1
$0
mg/10 ml
levofloxacin oral tablet 250 mg, 500
(Levaquin)
1
$0
mg, 750 mg
28
Tier level
What the
drug will
cost you
(Avelox)
(Ofloxacin)
1
1
$0
$0
(Sulfadiazine)
1
$0
(Sulfamethoxazole/
Trimethoprim)
1
$0
(Sulfamethoxazole/
Trimethoprim)
1
$0
(Bactrim)
1
$0
(Azulfidine)
1
$0
(Azulfidine)
1
$0
(Sulfamethoxazole/
Trimethoprim)
1
$0
(Doxycycline
Hyclate)
1
$0
(Morgidox)
1
$0
(Doryx)
1
$0
(Doxycycline
Hyclate)
1
$0
(Adoxa)
1
$0
(Morgidox)
1
$0
(Avidoxy)
1
$0
(Doryx)
1
$0
Name of Drug
moxifloxacin oral tablet 400 mg
ofloxacin oral tablet 400 mg
Sulfonamides
sulfadiazine oral tablet 500 mg
sulfamethoxazole-trimethoprim
intravenous solution 400-80 mg/5
ml
sulfamethoxazole-trimethoprim oral
suspension 200-40 mg/5 ml
sulfamethoxazole-trimethoprim oral
tablet 400-80 mg, 800-160 mg
sulfasalazine oral tablet 500 mg
sulfasalazine oral tablet,delayed
release (dr/ec) 500 mg
sulfatrim oral suspension 200-40
mg/5 ml
Tetracyclines
doxy 100 vial 10's, p/f 100 mg
doxycycline hyclate 100 mg cap 100
mg
doxycycline hyclate 100 mg tab 100
mg
doxycycline hyclate intravenous
recon soln 100 mg
doxycycline hyclate oral capsule
100 mg
doxycycline hyclate oral capsule 50
mg
doxycycline hyclate oral tablet 100
mg, 50 mg
doxycycline hyclate oral tablet 20
mg
Necessary Actions,
Restrictions, or
Limits on Use
29
Tier level
What the
drug will
cost you
(Adoxa)
1
$0
(Avidoxy)
1
$0
(Avidoxy)
1
$0
(Adoxa)
1
$0
(Vibramycin)
1
$0
(Avidoxy)
1
$0
(Minocin)
1
$0
(Minocycline HCl)
1
$0
(Tetracycline HCl)
1
$0
2
$0
2
$0
2
$0
(Doxorubicin HCl)
1
$0
(Doxorubicin HCl)
1
$0
(Fluorouracil)
1
$0
Name of Drug
doxycycline mono 100 mg cap 100
mg
doxycycline mono 100 mg tablet f/c
100 mg
doxycycline mono 50 mg tablet 50
mg
doxycycline monohydrate oral
doxycycline monohydrate oral
suspension for reconstitution 25
mg/5 ml
doxycycline monohydrate oral tablet
150 mg, 75 mg
minocycline oral capsule 100 mg,
50 mg, 75 mg
minocycline oral tablet 100 mg, 50
mg, 75 mg
tetracycline oral capsule 250 mg,
500 mg
TYGACIL INTRAVENOUS
RECON SOLN 50 MG
Necessary Actions,
Restrictions, or
Limits on Use
Anticancer Agents
Anticancer Agents
ABRAXANE INTRAVENOUS
SUSPENSION FOR
RECONSTITUTION 100 MG
ADCETRIS INTRAVENOUS
RECON SOLN 50 MG
adriamycin intravenous recon soln
10 mg, 20 mg, 50 mg
adriamycin intravenous solution 10
mg/5 ml
adrucil 2,500 mg/50 ml vial outer,
latex-free 2.5 gram/50 ml
PA NSO; QL (4 per 21
days)
PA BvD
PA BvD
PA BvD
30
Name of Drug
adrucil intravenous solution 500
(Fluorouracil)
mg/10 ml
AFINITOR DISPERZ ORAL
TABLET FOR SUSPENSION 2
MG, 3 MG, 5 MG
AFINITOR ORAL TABLET 10
MG
AFINITOR ORAL TABLET 2.5
MG, 5 MG, 7.5 MG
ALECENSA ORAL CAPSULE 150
MG
ALIMTA INTRAVENOUS
RECON SOLN 500 MG
anastrozole oral tablet 1 mg
(Arimidex)
AVASTIN INTRAVENOUS
SOLUTION 25 MG/ML, 25
MG/ML (16 ML)
azacitidine injection recon soln 100
(Vidaza)
mg
BELEODAQ INTRAVENOUS
RECON SOLN 500 MG
BENDEKA INTRAVENOUS
SOLUTION 25 MG/ML
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
1
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA NSO; QL (112 per
28 days)
PA NSO; QL (56 per
28 days)
PA NSO; QL (28 per
28 days)
PA NSO; QL (240 per
30 days)
PA NSO
bexarotene oral capsule 75 mg
(Targretin)
1
$0
bicalutamide oral tablet 50 mg
bleomycin injection recon soln 30
unit
bleomycin sulfate 15 unit vial latexfree 15 unit
BLINCYTO INTRAVENOUS KIT
35 MCG
BOSULIF ORAL TABLET 100
MG
(Casodex)
(Bleomycin
Sulfate)
(Bleomycin
Sulfate)
1
$0
1
$0
1
$0
2
$0
2
$0
PA NSO
PA NSO
PA NSO; QL (420 per
30 days)
PA BvD
PA BvD
PA NSO; QL (140 per
365 days)
PA NSO; QL (120 per
30 days)
31
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
1
$0
2
$0
1
$0
2
$0
(Dacogen)
1
$0
(Doxil)
1
$0
Name of Drug
BOSULIF ORAL TABLET 500
MG
CABOMETYX ORAL TABLET 20
MG, 60 MG
CABOMETYX ORAL TABLET 40
MG
CAPRELSA ORAL TABLET 100
MG
CAPRELSA ORAL TABLET 300
MG
COMETRIQ ORAL CAPSULE 100
MG/DAY(80 MG X1-20 MG X1),
140 MG/DAY(80 MG X1-20 MG
X3), 60 MG/DAY (20 MG X
3/DAY)
COTELLIC ORAL TABLET 20
MG
cyclophosphamide intravenous
recon soln 1 gram, 2 gram, 500 mg
CYCLOPHOSPHAMIDE ORAL
CAPSULE 25 MG, 50 MG
cyclophosphamide oral tablet 25
mg, 50 mg
CYRAMZA INTRAVENOUS
MG/ML (50 ML)
dactinomycin intravenous recon
soln 0.5 mg
DARZALEX INTRAVENOUS
SOLUTION 20 MG/ML
decitabine intravenous recon soln
50 mg
doxorubicin, peg-liposomal
intravenous suspension 2 mg/ml
(Cyclophosphamid
e)
(Cyclophosphamid
e)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (30 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (112 per
28 days)
PA NSO; LA; QL (63
per 28 days)
PA BvD
PA BvD; ST
PA BvD; ST
PA NSO
(Dactinomycin)
PA NSO; LA
PA BvD
32
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
(Etoposide)
1
$0
(Aromasin)
1
$0
2
$0
2
$0
2
$0
(Floxuridine)
1
$0
(Fluorouracil)
1
$0
(Fluorouracil)
1
$0
Name of Drug
DROXIA ORAL CAPSULE 200
MG, 300 MG, 400 MG
ELIGARD SUBCUTANEOUS
SYRINGE 22.5 MG (3 MONTH)
SYRINGE 30 MG (4 MONTH)
SYRINGE 45 MG (6 MONTH)
SYRINGE 7.5 MG (1 MONTH)
EMCYT ORAL CAPSULE 140
MG
EMPLICITI INTRAVENOUS
ERIVEDGE ORAL CAPSULE 150
MG
ETOPOPHOS INTRAVENOUS
RECON SOLN 100 MG
etoposide intravenous solution 20
mg/ml
exemestane oral tablet 25 mg
FARESTON ORAL TABLET 60
MG
FARYDAK ORAL CAPSULE 10
MG, 15 MG, 20 MG
FASLODEX INTRAMUSCULAR
SYRINGE 250 MG/5 ML
floxuridine injection recon soln 0.5
gram
fluorouracil 5,000 mg/100 ml latexfree 5 gram/100 ml
fluorouracil intravenous solution 1
gram/20 ml, 2.5 gram/50 ml, 500
mg/10 ml
Necessary Actions,
Restrictions, or
Limits on Use
QL (1 per 84 days)
QL (1 per 112 days)
QL (1 per 168 days)
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO
PA BvD
PA BvD
PA BvD
33
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
ICLUSIG ORAL TABLET 15 MG
2
$0
ICLUSIG ORAL TABLET 45 MG
2
$0
(Ifex)
1
$0
(Ifex)
1
$0
(Ifosfamide/Mesna
)
1
$0
imatinib oral tablet 100 mg
(Gleevec)
1
$0
imatinib oral tablet 400 mg
(Gleevec)
1
$0
2
$0
Name of Drug
flutamide oral capsule 125 mg
GAZYVA INTRAVENOUS
SOLUTION 1,000 MG/40 ML
GILOTRIF ORAL TABLET 20
MG, 30 MG, 40 MG
GLEOSTINE ORAL CAPSULE 10
MG, 100 MG, 40 MG
HERCEPTIN INTRAVENOUS
RECON SOLN 440 MG
HEXALEN ORAL CAPSULE 50
MG
hydroxyurea oral capsule 500 mg
IBRANCE ORAL CAPSULE 100
MG, 125 MG, 75 MG
ifosfamide 1 gm/20 ml vial suv 1
gram/20 ml
ifosfamide intravenous recon soln 1
gram
ifosfamide-mesna intravenous kit 11 gram, 3,000-1,000 mg
(Flutamide)
(Hydrea)
IMBRUVICA ORAL CAPSULE
140 MG
IMLYGIC INJECTION
SUSPENSION 10EXP6 (1
MILLION) PFU/ML
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO
PA NSO; QL (21 per
28 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA NSO; QL (90 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO
PA NSO; QL (4 per
365 days)
34
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
IMLYGIC INJECTION
SUSPENSION 10EXP8 (100
MILLION) PFU/ML
2
$0
days)
INLYTA ORAL TABLET 1 MG
2
$0
INLYTA ORAL TABLET 5 MG
2
$0
IRESSA ORAL TABLET 250 MG
2
$0
2
$0
2
$0
2
$0
2
$0
Name of Drug
IXEMPRA 15 MG KIT WITH
DILUENT 15 MG
IXEMPRA INTRAVENOUS
RECON SOLN 45 MG
JAKAFI ORAL TABLET 10 MG,
15 MG, 20 MG, 25 MG, 5 MG
KEYTRUDA INTRAVENOUS
RECON SOLN 50 MG
KEYTRUDA INTRAVENOUS
SOLUTION 100 MG/4 ML (25
MG/ML)
KYPROLIS INTRAVENOUS
RECON SOLN 30 MG
KYPROLIS INTRAVENOUS
RECON SOLN 60 MG
LENVIMA ORAL CAPSULE 10
MG/DAY (10 MG X 1/DAY), 14
MG/DAY(10 MG X 1-4 MG X 1),
18 MG/DAY (10 MG X 1-4 MG
X2), 20 MG/DAY (10 MG X 2), 24
MG/DAY(10 MG X 2-4 MG X 1), 8
MG/DAY (4 MG X 2)
letrozole oral tablet 2.5 mg
(Femara)
LEUKERAN ORAL TABLET 2
MG
PA NSO; QL (180 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO
PA NSO
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
PA NSO; QL (12 per
28 days)
days)
PA NSO
35
Tier level
What the
drug will
cost you
(Leuprolide
Acetate)
1
$0
(Doxil)
1
$0
(Doxil)
1
$0
(Lomustine)
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
Name of Drug
leuprolide subcutaneous kit 1
mg/0.2 ml
lipodox 50 intravenous suspension 2
mg/ml
lipodox intravenous suspension 2
mg/ml
lomustine oral capsule 10 mg, 100
mg, 40 mg
LONSURF ORAL TABLET 156.14 MG
LONSURF ORAL TABLET 208.19 MG
LUPRON DEPOT (3 MONTH)
KIT 11.25 MG, 22.5 MG
KIT 30 MG
KIT 45 MG
LUPRON DEPOT
KIT 3.75 MG, 7.5 MG
LYNPARZA ORAL CAPSULE 50
MG
LYSODREN ORAL TABLET 500
MG
MATULANE ORAL CAPSULE 50
MG
megestrol oral tablet 20 mg, 40 mg
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA NSO; QL (100 per
28 days)
PA NSO; QL (80 per
28 days)
QL (1 per 84 days)
QL (1 per 84 days)
QL (1 per 168 days)
(Megestrol
Acetate)
MEKINIST ORAL TABLET 0.5
MG
PA NSO; QL (480 per
30 days)
PA NSO; QL (90 per
30 days)
36
Name of Drug
Tier level
What the
drug will
cost you
MEKINIST ORAL TABLET 2 MG
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
mercaptopurine oral tablet 50 mg
methotrexate 50 mg/2 ml vial latexfree, 5's, mdv 25 mg/ml
methotrexate sodium (pf) injection
recon soln 1 gram
methotrexate sodium (pf) injection
solution 25 mg/ml
methotrexate sodium oral tablet 2.5
mg
mitoxantrone intravenous
concentrate 2 mg/ml
NEXAVAR ORAL TABLET 200
MG
NILANDRON ORAL TABLET 150
MG
nilutamide oral tablet 150 mg
NINLARO ORAL CAPSULE 2.3
MG, 3 MG, 4 MG
ODOMZO ORAL CAPSULE 200
MG
ONCASPAR INJECTION
SOLUTION 750 UNIT/ML
OPDIVO INTRAVENOUS
SOLUTION 40 MG/4 ML
POMALYST ORAL CAPSULE 1
MG, 2 MG, 3 MG, 4 MG
PORTRAZZA INTRAVENOUS
MG/ML)
PROLEUKIN INTRAVENOUS
RECON SOLN 22 MILLION UNIT
(Mercaptopurine)
(Methotrexate
Sodium)
(Methotrexate
Sodium/PF)
(Methotrexate
Sodium)
(Methotrexate
Sodium)
(Mitoxantrone
HCl)
(Nilandron)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA BvD; ST
PA NSO; QL (120 per
30 days)
days)
PA NSO; LA
PA NSO
PA NSO
PA NSO; QL (21 per
28 days)
PA NSO; QL (100 per
21 days)
37
Name of Drug
PURIXAN ORAL SUSPENSION
20 MG/ML
REVLIMID ORAL CAPSULE 10
MG, 15 MG, 2.5 MG, 20 MG, 25
MG, 5 MG
RITUXAN INTRAVENOUS
CONCENTRATE 10 MG/ML
SOLTAMOX ORAL SOLUTION
10 MG/5 ML
SPRYCEL ORAL TABLET 100
MG, 140 MG, 50 MG, 70 MG, 80
MG
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; LA
SPRYCEL ORAL TABLET 20 MG
STIVARGA ORAL TABLET 40
MG
SUTENT ORAL CAPSULE 12.5
MG, 25 MG, 37.5 MG, 50 MG
SYLVANT INTRAVENOUS
SYNRIBO SUBCUTANEOUS
RECON SOLN 3.5 MG
TABLOID ORAL TABLET 40 MG
TAFINLAR ORAL CAPSULE 50
MG, 75 MG
TAGRISSO ORAL TABLET 40
MG, 80 MG
tamoxifen oral tablet 10 mg, 20 mg
Tier level
(Tamoxifen
Citrate)
TARCEVA ORAL TABLET 100
MG, 25 MG
TARCEVA ORAL TABLET 150
MG
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
2
$0
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (84 per
28 days)
PA NSO; QL (30 per
30 days)
PA NSO
PA NSO; QL (28 per
28 days)
PA NSO; QL (120 per
30 days)
PA NSO; LA; QL (30
per 30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (90 per
30 days)
38
Name of Drug
Tier level
What the
drug will
cost you
TARGRETIN ORAL CAPSULE 75
MG
2
$0
TARGRETIN TOPICAL GEL 1 %
2
$0
2
$0
2
$0
2
$0
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
2
$0
TASIGNA ORAL CAPSULE 150
MG, 200 MG
TECENTRIQ INTRAVENOUS
SOLUTION 1,200 MG/20 ML (60
MG/ML)
TEMODAR INTRAVENOUS
RECON SOLN 100 MG
thiotepa injection recon soln 15 mg (Thiotepa)
toposar intravenous solution 20
(Etoposide)
mg/ml
TREANDA 25 MG VIAL 25 MG
TREANDA INTRAVENOUS
RECON SOLN 100 MG
TREANDA INTRAVENOUS
SOLUTION 180 MG/2 ML, 45
MG/0.5 ML
TRELSTAR 22.5 MG SYRINGE
WITH MIXJECT 22.5 MG/2 ML
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 22.5 MG
SYRINGE 11.25 MG/2 ML
SYRINGE 3.75 MG/2 ML
tretinoin (chemotherapy) oral
(Tretinoin)
capsule 10 mg
TREXALL ORAL TABLET 10
MG, 15 MG, 5 MG, 7.5 MG
TYKERB ORAL TABLET 250 MG
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (420 per
30 days)
PA NSO; QL (60 per
28 days)
PA NSO; QL (112 per
28 days)
PA NSO; QL (20 per
21 days)
PA NSO; (vial only)
QL (1 per 168 days)
QL (1 per 168 days)
QL (1 per 84 days)
(capsule: 10mg)
PA BvD; ST
39
Name of Drug
UNITUXIN INTRAVENOUS
SOLUTION 3.5 MG/ML
VALSTAR INTRAVESICAL
SOLUTION 40 MG/ML
VELCADE INJECTION RECON
SOLN 3.5 MG
VENCLEXTA ORAL TABLET 10
MG, 100 MG, 50 MG
VENCLEXTA STARTING PACK
ORAL TABLETS,DOSE PACK 10
MG-50 MG- 100 MG
vinorelbine intravenous solution 50
mg/5 ml
VOTRIENT ORAL TABLET 200
MG
XALKORI ORAL CAPSULE 200
MG, 250 MG
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO
PA NSO
PA NSO; LA
PA NSO; LA
(Navelbine)
XTANDI ORAL CAPSULE 40 MG
YERVOY INTRAVENOUS
MG/ML)
YONDELIS INTRAVENOUS
RECON SOLN 1 MG
ZELBORAF ORAL TABLET 240
MG
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG
ZOLADEX SUBCUTANEOUS
IMPLANT 3.6 MG
ZOLINZA ORAL CAPSULE 100
MG
ZYDELIG ORAL TABLET 100
MG, 150 MG
PA NSO; QL (120 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (120 per
30 days)
PA NSO
PA NSO
PA NSO; QL (240 per
30 days)
QL (1 per 84 days)
QL (1 per 28 days)
PA NSO; QL (60 per
30 days)
40
Tier level
What the
drug will
cost you
ZYKADIA ORAL CAPSULE 150
MG
2
$0
ZYTIGA ORAL TABLET 250 MG
2
$0
1
$0
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (140 per
28 days)
PA NSO; QL (120 per
30 days)
Anticholinergic Agents
Antimuscarinics/Antispasm
odics
atropine injection solution 0.4
(Atropine Sulfate)
mg/ml
atropine injection syringe 0.05
(Atropine Sulfate)
mg/ml, 0.1 mg/ml
(Propantheline
propantheline oral tablet 15 mg
Bromide)
STIOLTO RESPIMAT
INHALATION MIST 2.5-2.5
MCG/ACTUATION
QL (4 per 28 days)
Anticonvulsants
Anticonvulsants
APTIOM ORAL TABLET 200 MG,
400 MG, 600 MG, 800 MG
BANZEL ORAL SUSPENSION 40
MG/ML
BANZEL ORAL TABLET 200
MG, 400 MG
BRIVIACT INTRAVENOUS
SOLUTION 50 MG/5 ML
BRIVIACT ORAL SOLUTION 10
MG/ML
BRIVIACT ORAL TABLET 10
MG, 100 MG, 25 MG, 50 MG, 75
MG
carbamazepine oral capsule, er
multiphase 12 hr 100 mg, 200 mg,
(Carbatrol)
300 mg
ST
ST
ST
QL (80 per 30 days)
QL (60 per 30 days)
41
Tier level
What the
drug will
cost you
(Tegretol)
1
$0
(Tegretol)
1
$0
(Tegretol XR)
1
$0
(Carbamazepine)
1
$0
2
$0
1
$0
(Depakote
Sprinkle)
1
$0
(Depakote ER)
1
$0
(Depakote)
1
$0
(Tegretol)
(Zarontin)
1
1
$0
$0
(Zarontin)
1
$0
(Felbatol)
1
$0
(Felbatol)
1
$0
(Cerebyx)
1
$0
(Cerebyx)
1
$0
2
$0
Name of Drug
carbamazepine oral suspension 100
mg/5 ml
carbamazepine oral tablet 200 mg
carbamazepine oral tablet extended
release 12 hr 100 mg, 200 mg, 400
mg
carbamazepine oral tablet,chewable
100 mg
CELONTIN ORAL CAPSULE 300
MG
DILANTIN ORAL CAPSULE 30
MG
divalproex oral capsule, sprinkle
125 mg
divalproex oral tablet extended
divalproex oral tablet,delayed
release (dr/ec) 125 mg, 250 mg, 500
mg
epitol oral tablet 200 mg
ethosuximide oral capsule 250 mg
ethosuximide oral solution 250 mg/5
ml
felbamate oral suspension 600 mg/5
ml
felbamate oral tablet 400 mg, 600
mg
fosphenytoin 500 mg pe/10 ml
10's,sdv,latex-free 500 mg pe/10 ml
fosphenytoin injection solution 100
mg pe/2 ml
FYCOMPA ORAL SUSPENSION
0.5 MG/ML
Necessary Actions,
Restrictions, or
Limits on Use
ST
42
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
FYCOMPA ORAL TABLET 10
ST
MG, 12 MG, 2 MG, 4 MG, 6 MG, 8
2
$0
MG
gabapentin oral capsule 100 mg,
(Neurontin)
1
$0
300 mg, 400 mg
gabapentin oral solution 250 mg/5
(Neurontin)
1
$0
ml
gabapentin oral tablet 600 mg, 800
(Neurontin)
1
$0
mg
GABITRIL ORAL TABLET 12
2
$0
MG, 16 MG
LAMICTAL ORAL TABLET,
2
$0
CHEWABLE DISPERSIBLE 2 MG
lamotrigine oral tablet 100 mg, 150
(Lamictal)
1
$0
mg, 200 mg, 25 mg
lamotrigine oral tablet extended
release 24hr 100 mg, 200 mg, 25
(Lamictal XR)
1
$0
mg, 250 mg, 300 mg, 50 mg
lamotrigine oral tablet, chewable
(Lamictal)
1
$0
dispersible 25 mg, 5 mg
lamotrigine oral tablets,dose pack
(Lamictal (Blue))
1
$0
25 mg (35)
levetiracetam intravenous solution
(Keppra)
1
$0
500 mg/5 ml
levetiracetam oral solution 100
(Keppra)
1
$0
mg/ml
levetiracetam oral tablet 1,000 mg,
(Keppra)
1
$0
250 mg, 500 mg, 750 mg
levetiracetam oral tablet extended
(Keppra XR)
1
$0
LYRICA ORAL CAPSULE 100
QL (90 per 30 days)
MG, 150 MG, 200 MG, 225 MG, 25
2
$0
MG, 300 MG, 50 MG, 75 MG
LYRICA ORAL SOLUTION 20
2
$0
MG/ML
43
Tier level
What the
drug will
cost you
(Trileptal)
1
$0
(Trileptal)
1
$0
Name of Drug
oxcarbazepine oral suspension 300
mg/5 ml
oxcarbazepine oral tablet 150 mg,
300 mg, 600 mg
OXTELLAR XR ORAL TABLET
MG, 300 MG, 600 MG
PEGANONE ORAL TABLET 250
MG
phenobarbital oral elixir 20 mg/5 ml
(4 mg/ml)
phenobarbital oral tablet 100 mg,
15 mg, 16.2 mg, 32.4 mg, 60 mg,
64.8 mg, 97.2 mg
phenobarbital oral tablet 30 mg
phenobarbital sodium injection
solution 130 mg/ml, 65 mg/ml
phenytoin oral suspension 125 mg/5
ml
phenytoin oral tablet,chewable 50
mg
phenytoin sodium extended oral
phenytoin sodium intravenous
solution 50 mg/ml
phenytoin sodium intravenous
syringe 50 mg/ml
POTIGA ORAL TABLET 200 MG,
300 MG, 400 MG
POTIGA ORAL TABLET 50 MG
primidone oral tablet 250 mg, 50 mg
SABRIL ORAL POWDER IN
PACKET 500 MG
SABRIL ORAL TABLET 500 MG
Necessary Actions,
Restrictions, or
Limits on Use
ST
(Phenobarbital)
2
$0
2
$0
1
$0
QL (90 per 30 days)
(Phenobarbital)
1
$0
(Phenobarbital)
(Phenobarbital
Sodium)
1
$0
1
$0
(Dilantin-125)
1
$0
(Dilantin)
1
$0
(Dilantin)
1
$0
1
$0
1
$0
2
$0
2
1
$0
$0
2
$0
2
$0
(Phenytoin
Sodium)
(Phenytoin
Sodium)
(Mysoline)
QL (2 per 30 days)
QL (90 per 30 days)
44
Tier level
What the
drug will
cost you
2
$0
2
$0
(Gabitril)
1
$0
(Topamax)
1
$0
(Topamax)
1
$0
(Qudexy XR)
1
$0
(Topamax)
1
$0
Name of Drug
SPRITAM ORAL TABLET FOR
SUSPENSION 1,000 MG
SPRITAM ORAL TABLET FOR
SUSPENSION 250 MG, 500 MG,
750 MG
tiagabine oral tablet 2 mg, 4 mg
topiragen oral tablet 100 mg, 200
mg, 25 mg, 50 mg
topiramate oral capsule, sprinkle 15
mg, 25 mg
topiramate oral capsule,sprinkle,er
24hr 100 mg, 150 mg, 200 mg, 25
mg, 50 mg
topiramate oral tablet 100 mg, 200
mg, 25 mg, 50 mg
TROKENDI XR ORAL
CAPSULE,EXTENDED RELEASE
24HR 100 MG, 200 MG, 25 MG, 50
MG
valproate sodium intravenous
solution 500 mg/5 ml (100 mg/ml)
valproic acid (as sodium salt) oral
valproic acid oral capsule 250 mg
VIMPAT INTRAVENOUS
SOLUTION 200 MG/20 ML
VIMPAT ORAL SOLUTION 10
MG/ML
VIMPAT ORAL TABLET 100 MG,
150 MG, 200 MG, 50 MG
zonisamide oral capsule 100 mg, 25
mg, 50 mg
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (60 per 30
days)
ST; QL (120 per 30
days)
ST
2
$0
(Depacon)
1
$0
(Depakene)
1
$0
(Depakene)
1
$0
2
$0
2
$0
2
$0
1
$0
(Zonegran)
QL (200 per 5 days)
QL (60 per 30 days)
Antidementia Agents
Antidementia Agents
45
Tier level
What the
drug will
cost you
(Aricept)
1
$0
(Donepezil HCl)
1
$0
(Razadyne ER)
1
$0
(Galantamine Hbr)
1
$0
(Razadyne)
1
$0
(Namenda)
(Namenda)
1
1
$0
$0
(Namenda)
1
$0
Name of Drug
donepezil oral tablet 10 mg, 23 mg,
5 mg
donepezil oral tablet,disintegrating
10 mg, 5 mg
galantamine oral capsule,ext rel.
pellets 24 hr 16 mg, 24 mg, 8 mg
galantamine oral solution 4 mg/ml
galantamine oral tablet 12 mg, 4
mg, 8 mg
memantine oral solution 2 mg/ml
memantine oral tablet 10 mg, 5 mg
memantine oral tablets,dose pack 510 mg
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE
PACK 7-14-21-28 MG
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR
14 MG, 21 MG, 28 MG, 7 MG
NAMZARIC ORAL
CAPSULE,SPRINKLE,ER 24HR
14-10 MG, 28-10 MG
rivastigmine tartrate oral capsule
1.5 mg, 3 mg, 4.5 mg, 6 mg
rivastigmine transdermal patch 24
hour 13.3 mg/24 hour, 4.6 mg/24 hr,
9.5 mg/24 hr
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (49 per 28 days)
QL (28 per 28 days)
2
$0
QL (30 per 30 days)
2
$0
2
$0
(Exelon)
1
$0
(Exelon)
1
$0
(Amitriptyline
HCl)
1
$0
(Amoxapine)
1
$0
QL (60 per 30 days)
QL (30 per 30 days)
Antidepressants
Antidepressants
amitriptyline oral tablet 10 mg, 100
mg, 150 mg, 25 mg, 50 mg, 75 mg
amoxapine oral tablet 100 mg, 150
mg, 25 mg, 50 mg
PA NSO-HRM
46
Tier level
What the
drug will
cost you
2
$0
(Wellbutrin SR)
1
$0
(Wellbutrin)
1
$0
(Wellbutrin SR)
1
$0
(Wellbutrin XL)
1
$0
(Citalopram
Hydrobromide)
1
$0
(Celexa)
1
$0
(Anafranil)
1
$0
(Norpramin)
1
$0
(Doxepin HCl)
1
$0
(Doxepin HCl)
1
$0
(Duloxetine)
1
$0
(Duloxetine)
1
$0
(Duloxetine)
1
$0
2
$0
(Lexapro)
1
$0
(Lexapro)
1
$0
Name of Drug
BRINTELLIX ORAL TABLET 10
MG, 20 MG, 5 MG
buproban oral tablet extended
release 150 mg
bupropion hcl oral tablet 100 mg,
75 mg
bupropion hcl oral tablet extended
bupropion hcl oral tablet extended
citalopram oral solution 10 mg/5 ml
citalopram oral tablet 10 mg, 20
mg, 40 mg
clomipramine oral capsule 25 mg,
50 mg, 75 mg
desipramine oral tablet 10 mg, 100
mg, 150 mg, 25 mg, 50 mg, 75 mg
doxepin oral capsule 10 mg, 100
mg, 150 mg, 25 mg, 50 mg, 75 mg
doxepin oral concentrate 10 mg/ml
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
EMSAM TRANSDERMAL
PATCH 24 HOUR 12 MG/24 HR, 6
MG/24 HR, 9 MG/24 HR
escitalopram oxalate oral solution 5
mg/5 ml
escitalopram oxalate oral tablet 10
mg, 20 mg, 5 mg
Necessary Actions,
Restrictions, or
Limits on Use
ST
QL (30 per 30 days)
PA NSO-HRM
PA NSO-HRM
PA NSO-HRM
(Cymbalta); QL (60
per 30 days)
(Cymbalta); QL (30
per 30 days)
(Irenka); QL (30 per 30
days)
QL (30 per 30 days)
47
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
FETZIMA ORAL CAPSULE,EXT
ST
REL 24HR DOSE PACK 20 MG
2
$0
(2)- 40 MG (26)
FETZIMA ORAL
ST
2
$0
24 HR 120 MG, 20 MG, 40 MG, 80
MG
fluoxetine oral capsule 10 mg, 20
(Prozac)
1
$0
mg, 40 mg
fluoxetine oral capsule,delayed
(Prozac Weekly)
1
$0
fluoxetine oral solution 20 mg/5 ml
(Fluoxetine HCl)
1
$0
(4 mg/ml)
fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl)
1
$0
fluvoxamine oral capsule,extended
(Fluvoxamine
1
$0
release 24hr 100 mg, 150 mg
Maleate)
fluvoxamine oral tablet 100 mg, 25 (Fluvoxamine
1
$0
mg, 50 mg
Maleate)
imipramine hcl oral tablet 10 mg, 25
PA NSO-HRM
(Tofranil)
1
$0
mg, 50 mg
imipramine pamoate oral capsule
PA NSO-HRM
(Tofranil-Pm)
1
$0
100 mg, 125 mg, 150 mg, 75 mg
maprotiline oral tablet 25 mg, 50
(Maprotiline HCl)
1
$0
mg, 75 mg
MARPLAN ORAL TABLET 10
2
$0
MG
mirtazapine oral tablet 15 mg, 30
(Remeron)
1
$0
mg, 45 mg, 7.5 mg
mirtazapine oral
tablet,disintegrating 15 mg, 30 mg, (Remeron)
1
$0
45 mg
nefazodone oral tablet 100 mg, 150
(Nefazodone HCl)
1
$0
mg, 200 mg, 250 mg, 50 mg
nortriptyline oral capsule 10 mg, 25
(Pamelor)
1
$0
mg, 50 mg, 75 mg
48
Tier level
What the
drug will
cost you
(Nortriptyline HCl)
1
$0
(Symbyax)
1
$0
(Paxil)
1
$0
(Paxil CR)
1
$0
2
$0
(Perphenazine/Ami
triptyline HCl)
1
$0
(Nardil)
1
$0
Name of Drug
nortriptyline oral solution 10 mg/5
ml
olanzapine-fluoxetine oral capsule
12-25 mg, 12-50 mg, 3-25 mg, 6-25
mg, 6-50 mg
paroxetine hcl oral tablet 10 mg, 20
mg, 30 mg, 40 mg
paroxetine hcl oral tablet extended
release 24 hr 12.5 mg, 25 mg, 37.5
mg
PAXIL ORAL SUSPENSION 10
MG/5 ML
perphenazine-amitriptyline oral
tablet 2-10 mg, 2-25 mg, 4-10 mg,
4-25 mg, 4-50 mg
phenelzine oral tablet 15 mg
PRISTIQ ORAL TABLET
MG, 25 MG, 50 MG
protriptyline oral tablet 10 mg, 5 mg
sertraline oral concentrate 20
mg/ml
sertraline oral tablet 100 mg, 25
mg, 50 mg
SILENOR ORAL TABLET 3 MG,
6 MG
SURMONTIL ORAL CAPSULE
100 MG, 25 MG, 50 MG
tranylcypromine oral tablet 10 mg
trazodone oral tablet 100 mg, 150
mg, 300 mg, 50 mg
trimipramine oral capsule 100 mg,
25 mg, 50 mg
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO-HRM
2
$0
(Protriptyline HCl)
1
$0
(Zoloft)
1
$0
(Zoloft)
1
$0
2
$0
2
$0
(Parnate)
1
$0
(Trazodone HCl)
1
$0
(Trimipramine
Maleate)
1
$0
ST; QL (30 per 30
days)
QL (30 per 30 days)
PA NSO-HRM
PA NSO-HRM
49
Name of Drug
TRINTELLIX ORAL TABLET 10
MG, 20 MG, 5 MG
venlafaxine oral capsule,extended
release 24hr 150 mg, 37.5 mg, 75
(Effexor XR)
mg
venlafaxine oral tablet 100 mg, 25
(Venlafaxine HCl)
mg, 37.5 mg, 50 mg, 75 mg
venlafaxine oral tablet extended
release 24hr 150 mg, 37.5 mg, 75
(Venlafaxine HCl)
mg
VIIBRYD ORAL TABLET 10 MG,
20 MG, 40 MG
VIIBRYD ORAL TABLETS,DOSE
PACK 10 MG (7)- 20 MG (23), 10
MG (7)-20 MG (7)-40 MG (16)
Tier level
What the
drug will
cost you
2
$0
1
$0
1
$0
1
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST
Antidiabetic Agents
Antidiabetic Agents,
Miscellaneous
acarbose oral tablet 100 mg, 25 mg,
QL (90 per 30 days)
(Precose)
1
$0
50 mg
CYCLOSET ORAL TABLET 0.8
2
$0
MG
GLYXAMBI ORAL TABLET 10-5
ST
2
$0
MG, 25-5 MG
INVOKAMET ORAL TABLET
ST
150-1,000 MG, 150-500 MG, 502
$0
1,000 MG, 50-500 MG
INVOKANA ORAL TABLET 100
ST
2
$0
MG, 300 MG
JANUMET ORAL TABLET 502
$0
1,000 MG, 50-500 MG
JANUMET XR ORAL TABLET,
ER MULTIPHASE 24 HR 1002
$0
1,000 MG, 50-1,000 MG, 50-500
MG
50
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
(Glucophage)
(Glucophage)
(Glucophage)
1
1
1
$0
$0
$0
(Glucophage XR)
1
$0
(Glucophage XR)
1
$0
(Fortamet)
1
$0
(Fortamet)
1
$0
(Glyset)
1
$0
(Starlix)
1
$0
(Actos)
1
$0
(Duetact)
1
$0
(Actoplus Met)
1
$0
Name of Drug
JANUVIA ORAL TABLET 100
MG, 25 MG, 50 MG
JARDIANCE ORAL TABLET 10
MG, 25 MG
JENTADUETO ORAL TABLET
2.5-1,000 MG, 2.5-500 MG, 2.5-850
MG
JENTADUETO XR ORAL
TABLET, IR - ER, BIPHASIC
24HR 2.5-1,000 MG, 5-1,000 MG
KORLYM ORAL TABLET 300
MG
metformin oral tablet 1,000 mg
metformin oral tablet 500 mg
metformin oral tablet 850 mg
metformin oral tablet extended
release 24hr 1,000 mg
release 24hr 500 mg
miglitol oral tablet 100 mg, 25 mg,
50 mg
nateglinide oral tablet 120 mg, 60
mg
pioglitazone oral tablet 15 mg, 30
mg, 45 mg
pioglitazone-glimepiride oral tablet
30-2 mg, 30-4 mg
pioglitazone-metformin oral tablet
15-500 mg, 15-850 mg
Necessary Actions,
Restrictions, or
Limits on Use
ST
PA; QL (112 per 28
days)
QL (75 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
51
Name of Drug
repaglinide oral tablet 0.5 mg, 1 mg,
(Prandin)
2 mg
repaglinide-metformin oral tablet 1(Prandimet)
500 mg, 2-500 mg
SYMLINPEN 120
SUBCUTANEOUS PEN
INJECTOR 2,700 MCG/2.7 ML
SYMLINPEN 60
SUBCUTANEOUS PEN
INJECTOR 1,500 MCG/1.5 ML
SYNJARDY ORAL TABLET 12.51,000 MG, 12.5-500 MG, 5-1,000
MG, 5-500 MG
TRADJENTA ORAL TABLET 5
MG
TRULICITY SUBCUTANEOUS
PEN INJECTOR 0.75 MG/0.5 ML,
1.5 MG/0.5 ML
VICTOZA 3-PAK
SUBCUTANEOUS PEN
INJECTOR 0.6 MG/0.1 ML (18
MG/3 ML)
Insulins
HUMULIN R U-500 (CONC)
KWIKPEN SUBCUTANEOUS
INSULIN PEN 500 UNIT/ML (3
ML)
HUMULIN R U-500
(CONCENTRATED)
SUBCUTANEOUS SOLUTION
500 UNIT/ML
LANTUS SOLOSTAR
SUBCUTANEOUS INSULIN PEN
100 UNIT/ML (3 ML)
Tier level
What the
drug will
cost you
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (10.8 per 28
days)
ST
QL (24 per 28 days)
2
$0
QL (40 per 28 days)
2
$0
2
$0
52
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
LANTUS SUBCUTANEOUS
2
$0
NOVOLIN 70/30
QL (40 per 28 days)
SUBCUTANEOUS SUSPENSION
2
$0
100 UNIT/ML (70-30)
NOVOLIN N SUBCUTANEOUS
QL (40 per 28 days)
2
$0
SUSPENSION 100 UNIT/ML
NOVOLIN R INJECTION
QL (40 per 28 days)
2
$0
NOVOLOG FLEXPEN
QL (30 per 28 days)
2
$0
100 UNIT/ML
NOVOLOG MIX 70-30 FLEXPEN
QL (30 per 28 days)
2
$0
100 UNIT/ML (70-30)
NOVOLOG MIX 70-30
QL (40 per 28 days)
2
$0
100 UNIT/ML (70-30)
NOVOLOG PENFILL
QL (30 per 28 days)
SUBCUTANEOUS CARTRIDGE
2
$0
100 UNIT/ML
NOVOLOG SUBCUTANEOUS
QL (40 per 28 days)
2
$0
TOUJEO SOLOSTAR
2
$0
300 UNIT/ML (1.5 ML)
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg
(Amaryl)
1
$0
QL (30 per 30 days)
glimepiride oral tablet 4 mg
(Amaryl)
1
$0
QL (60 per 30 days)
glipizide oral tablet 10 mg
(Glucotrol)
1
$0
glipizide oral tablet 5 mg
(Glucotrol)
1
$0
QL (60 per 30 days)
glipizide oral tablet extended
QL (60 per 30 days)
(Glucotrol XL)
1
$0
release 24hr 10 mg
glipizide oral tablet extended
QL (30 per 30 days)
(Glucotrol XL)
1
$0
release 24hr 2.5 mg, 5 mg
53
Tier level
What the
drug will
cost you
1
$0
1
$0
(Glynase)
1
$0
(Glynase)
1
$0
Name of Drug
glipizide-metformin oral tablet 2.5250 mg
glipizide-metformin oral tablet 2.5500 mg, 5-500 mg
glyburide micronized oral tablet 1.5
mg
glyburide micronized oral tablet 3
mg
glyburide micronized oral tablet 6
mg
(Glipizide/Metform
in HCl)
(Glipizide/Metform
in HCl)
(Glynase)
1
$0
glyburide oral tablet 1.25 mg
(Glyburide)
1
$0
glyburide oral tablet 2.5 mg
(Glyburide)
1
$0
glyburide oral tablet 5 mg
(Glyburide)
1
$0
(Glucovance)
1
$0
(Glucovance)
1
$0
(Tolazamide)
(Tolazamide)
(Tolbutamide)
1
1
1
$0
$0
$0
2
$0
4
$0
2
$0
1
$0
glyburide-metformin oral tablet
1.25-250 mg
glyburide-metformin oral tablet 2.5500 mg, 5-500 mg
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide oral tablet 500 mg
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (400 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (280 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
QL (60 per 30 days)
Antifungals
Antifungals
ABELCET INTRAVENOUS
SUSPENSION 5 MG/ML
aloe vesta 2% antifungal oint 2 % *
AMBISOME INTRAVENOUS
SUSPENSION FOR
amphotericin b injection recon soln
50 mg
(Miconazole
Nitrate)
PA BvD
PA BvD
(Amphotericin B)
PA BvD
54
Tier level
What the
drug will
cost you
(Tolnaftate)
4
$0
(Nuzole)
4
$0
(Tolnaftate)
4
$0
2
$0
(Loprox)
(Loprox)
(Loprox)
(Penlac)
(Ciclopirox
Olamine)
1
1
1
1
$0
$0
$0
$0
1
$0
(Ciclodan)
1
$0
(Gyne-Lotrimin)
(Lotrimin AF)
4
4
$0
$0
(Clotrimazole)
4
$0
(Clotrimazole)
4
$0
(Clotrimazole)
1
$0
(Clotrimazole)
(Clotrimazole)
(Gyne-Lotrimin)
1
1
4
$0
$0
$0
(Lotrisone)
1
$0
1
$0
4
$0
4
4
$0
$0
Name of Drug
anti-fungal 1% powder 1 % *
baza antifungal 2% cream 12's 2 %
*
blis-to-sol 1% liquid 1 % *
CANCIDAS INTRAVENOUS
ciclopirox topical cream 0.77 %
ciclopirox topical gel 0.77 %
ciclopirox topical shampoo 1 %
ciclopirox topical solution 8 %
ciclopirox topical suspension 0.77
%
ciclopirox-ure-camph-menth-euc
topical solution 8 %
clotrim 1% vaginal cream 1 % *
clotrimazole 1% cream (otc) 1 % *
clotrimazole 1% solution (otc) 1 %
*
clotrimazole insert 100 mg *
clotrimazole mucous membrane
troche 10 mg
clotrimazole topical cream 1 %
clotrimazole topical solution 1 %
clotrimazole-7 cream 1 % *
clotrimazole-betamethasone topical
cream 1-0.05 %
clotrimazole-betamethasone topical
lotion 1-0.05 %
critic-aid clear af 2% oint 12's, w/
antifungal 2 % *
cvs 3-day vaginal cream 2 % *
cvs af 1% spray powder 1 % *
(Clotrimazole/Beta
methasone Dip)
(Miconazole
Nitrate)
(Gyne-Lotrimin)
(Tinactin)
Necessary Actions,
Restrictions, or
Limits on Use
55
Tier level
What the
drug will
cost you
4
$0
4
$0
1
$0
(Undecylenic Acid)
4
$0
(Fluconazole In
Nacl,Iso-Osm)
1
$0
(Fluconazole In
Nacl,Iso-Osm)
1
$0
(Diflucan)
1
$0
(Diflucan)
1
$0
(Fluconazole In
Nacl,Iso-Osm)
1
$0
(Ancobon)
1
$0
(Clotrimazole)
4
4
4
$0
$0
$0
4
$0
(Grifulvin V)
1
$0
(Nuzole)
(Sporanox)
(Ketoconazole)
(Ketoconazole)
(Nizoral)
4
1
1
1
1
$0
$0
$0
$0
$0
Name of Drug
cvs miconazole 3 combo pack 3pref
applic w/cream 4 % (200 mg)- 2 %
(9 gram) *
dermafungal 2% ointment 2 % *
econazole topical cream 1 %
elon dual defense 25% solution 25
%*
fluconazole in dextrose(iso-o)
ml
fluconazole in nacl (iso-osm)
ml, 200 mg/100 ml
fluconazole oral suspension for
reconstitution 10 mg/ml, 40 mg/ml
fluconazole oral tablet 100 mg, 150
mg, 200 mg, 50 mg
fluconazole-nacl 400 mg/200 ml
10's,latex-free, p/f 400 mg/200 ml
flucytosine oral capsule 250 mg,
500 mg
fungi cure intensive 1% spray 1 % *
FUNGI-NAIL TINCTURE *
fungoid-d 1% cream 1 % *
gnp miconazole 3 combo pack 4 %
(200 mg)- 2 % (9 gram) *
griseofulvin microsize oral tablet
500 mg
inzo antifungal 2% cream 2 % *
itraconazole oral capsule 100 mg
ketoconazole oral tablet 200 mg
ketoconazole topical cream 2 %
ketoconazole topical shampoo 2 %
(Miconazole
Nitrate)
(Miconazole
Nitrate)
(Econazole Nitrate)
(Tinactin)
(Miconazole
Nitrate)
Necessary Actions,
Restrictions, or
Limits on Use
56
Tier level
What the
drug will
cost you
(Tinactin)
4
$0
(Tolnaftate)
4
$0
4
$0
(Nuzole)
4
4
$0
$0
(Monistat 3)
4
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
2
$0
2
$0
(Nystatin)
1
$0
(Nystatin)
1
$0
Name of Drug
lamisil af defens 1% spray pwd 1 %
*
lamisil af defense 1% powder 1 % *
LAMISIL ANTIFUNGAL 1%
SPRAY FOR ATHLETES FOOT 1
%*
LAMISIL AT 1% GEL 1 % *
micatin 2% antifungal cream 2 % *
miconazole 3 combo pack 3 sup,9gm
crm w/app 200 mg- 2 % (9 gram) *
miconazole 7 100 mg vag supp 100
mg *
miconazole nitrate 2% cream 2 % *
miconazole nitrate 2% cream 2 % *
miconazole-3 vaginal suppository
200 mg
MONISTAT 3 COMBO PACK 3
SUPP, 9 GM CREAM 200 MG- 2
% (9 GRAM) *
MONISTAT 3 COMBO PACK 4 %
(200 MG)- 2 % (9 GRAM) *
monistat 7 cream 7 applicators 2 %
*
myco nail a 25% solution 25 % *
NOXAFIL ORAL SUSPENSION
200 MG/5 ML (40 MG/ML)
NOXAFIL ORAL
(DR/EC) 100 MG
nyamyc topical powder 100,000
unit/gram
nystatin oral suspension 100,000
unit/ml
(Miconazole
Nitrate)
(Nuzole)
(Miconazole
Nitrate)
(Miconazole
Nitrate)
(Miconazole
Nitrate)
(Undecylenic Acid)
Necessary Actions,
Restrictions, or
Limits on Use
57
Tier level
What the
drug will
cost you
(Nystatin)
1
$0
(Nystatin)
1
$0
(Nystatin)
1
$0
(Nystatin)
1
$0
1
$0
1
$0
(Nystatin)
1
$0
(Tinactin)
4
$0
(Miconazole
Nitrate)
4
$0
(Tolnaftate)
4
$0
4
$0
4
1
4
4
$0
$0
$0
$0
4
$0
(Vfend IV)
1
$0
(Vfend)
1
$0
(Vfend)
1
$0
Name of Drug
nystatin oral tablet 500,000 unit
nystatin topical cream 100,000
unit/gram
nystatin topical ointment 100,000
unit/gram
nystatin topical powder 100,000
unit/gram
nystatin-triamcinolone topical
cream 100,000-0.1 unit/g-%
nystatin-triamcinolone topical
ointment 100,000-0.1 unit/gram-%
nystop topical powder 100,000
unit/gram
pv foot odor control 1% powder 1 %
*
qc 3 day vaginal 4% cream 200
mg/5 gram (4 %) *
ra antifungal 1% liquid spray liquid
spray 1 % *
remedy phytplx antifungal oint 2 %
*
terbinafine 1% cream 1 % *
terbinafine hcl oral tablet 250 mg
tolnaftate 1% cream 1 % *
tolnaftate 1% solution 1 % *
triple paste af 2% ointment 2 % *
voriconazole intravenous solution
200 mg
voriconazole oral suspension for
reconstitution 200 mg/5 ml (40
mg/ml)
voriconazole oral tablet 200 mg, 50
mg
(Nystatin/Triamcin
)
(Nystatin/Triamcin
)
(Miconazole
Nitrate)
(Lamisil At)
(Lamisil)
(Tinactin)
(Tolnaftate)
(Miconazole
Nitrate)
Necessary Actions,
Restrictions, or
Limits on Use
58
Tier level
What the
drug will
cost you
(Claritin)
4
$0
(Claritin-D 12
Hour)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Zzzquil)
4
$0
(Diphenhydramine
HCl)
4
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Antihistamines
Antihistamines
alavert 10 mg odt non-drowsy, mint
10 mg *
alavert d-12 allergy-sinus tab 5-120
mg *
ALLEGRA ALLERGY 180 MG
TABLET 180 MG *
ALLEGRA ALLERGY 60 MG
TABLET 60 MG *
aller-chlor 2 mg/5 ml syrup 2 mg/5
ml *
aller-chlor 4 mg tablet 4 mg *
allerclear d-12hr tablet 5-120 mg *
allerclear d-24hr er tablet nondrowsy 10-240 mg *
allergy 4 mg tablet 4 mg *
allerhist-1 1.34 mg tablet 1.34 mg *
aller-tec d 5-120 mg tablet 5-120
mg *
ambi 60pse-4cpm tablet 4-60 mg *
aprodine tablet 2.5-60 mg *
banophen 25 mg capsule 25 mg *
banophen 25 mg tablet 25 mg *
banophen allergy 12.5 mg/5 ml a/f
12.5 mg/5 ml *
benadryl allergy 25 mg ultratb
ultratab 25 mg *
(Chlorpheniramine
Maleate)
(Chlor-Trimeton)
(Claritin-D 12
Hour)
(Claritin-D 24
Hour)
(Chlor-Trimeton)
(Clemastine
Fumarate)
(Zyrtec-D)
(Chlorpheniramine/
Pseudoephed)
(Triprolidine/Pseud
oephedrine)
(Zzzquil)
(Diphenhydramine
HCl)
59
Tier level
What the
drug will
cost you
(Children'S Zyrtec)
4
$0
(Zyrtec)
4
$0
(Zyrtec)
4
$0
(Zyrtec-D)
4
$0
(Fexofenadine
HCl)
4
$0
4
$0
(Dimetapp)
4
$0
(Dimetapp)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Zzzquil)
4
$0
(Zyrtec)
4
$0
4
$0
Name of Drug
cetirizine hcl 1 mg/1 ml soln
children, s/f, grape (otc) 1 mg/ml *
cetirizine hcl 10 mg tablet indoor &
outdoor 10 mg *
cetirizine hcl 5 mg chew tab
children's,outer,u-d 5 mg *
cetirizine-pse er 5-120 mg tab 5-120
mg *
child allegra allergy 30 mg/5 ml
suspension 30 mg/5 ml *
CHILD CLARITIN 5 MG/5 ML
SOLN A/F,D/F,S/F,GRAPE 5
MG/5 ML *
child triaminic cold & allergy 1-2.5
mg/5 ml *
child wal-tap cold-allergy elx 1-2.5
mg/5 ml *
CHILD ZYRTEC 1 MG/ML
SOLUTION D/F,S/F,GRAPE 1
MG/ML *
children's allegra allergy oral tablet
30 mg *
CHILDREN'S ZYRTEC 10 MG
ODT 10 MG *
child's aller-tec 1 mg/ml soln 1
mg/ml *
CHILD'S CLARITIN 5 MG TAB
CHEW 5 MG *
child's wal-dryl 12.5 mg/5 ml
a/f,s/f,d/f,bubb gum 12.5 mg/5 ml *
child's wal-zyr 10 mg chew tab 10
mg *
CLARITIN 10 MG LIQUI-GEL
CAP 10 MG *
(Allegra Allergy)
(Children'S Zyrtec)
Necessary Actions,
Restrictions, or
Limits on Use
60
Name of Drug
CLARITIN 10 MG REDITABS 10
MG *
CLARITIN 10 MG TABLET
(OTC) 10 MG *
CLARITIN 5 MG REDITABS 5
MG *
cold-allergy-sinus oral tablet 2.5-60 (Triprolidine/Pseud
mg *
oephedrine)
(Diphenhydramine
compoz 25 mg gelcap 25 mg *
HCl)
(Diphenhydramine
cvs allergy 25 mg tablet 25 mg *
HCl)
cvs allergy relief 10 mg sftgl 10 mg
(Zyrtec)
*
cvs child allergy 10 mg chw tb 24
(Zyrtec)
hr,indoor/outdoor 10 mg *
(Triaminic
cvs cold & cough nighttime liq 6.25Nighttime Cold2.5 mg/5 ml *
Cough)
cyproheptadine oral syrup 2 mg/5
(Cyproheptadine
ml
HCl)
(Cyproheptadine
cyproheptadine oral tablet 4 mg
HCl)
(Clemastine
dailyhist-1 1.34 mg tablet 1.34 mg *
Fumarate)
dayhist allergy 1.34 mg tablet 12 hr (Clemastine
relief 1.34 mg *
Fumarate)
dimaphen elixir a/f, grape, gluten-f
(Dimetapp)
1-2.5 mg/5 ml *
(Triaminic
dimetapp cold & congest liquid
Nighttime Cold6.25-2.5 mg/5 ml *
Cough)
diphenhist 12.5 mg/5 ml soln 12.5
(Zzzquil)
mg/5 ml *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
61
Tier level
What the
drug will
cost you
(Zzzquil)
(Diphenhydramine
HCl)
4
$0
4
$0
(Zzzquil)
4
$0
(Zzzquil)
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
1
4
$0
$0
4
$0
4
$0
4
$0
1
$0
Name of Drug
diphenhist 25 mg capsule 25 mg *
diphenhist 25 mg captab captab 25
mg *
diphenhydramine 25 mg capsule
(otc) 25 mg *
diphenhydramine 50 mg capsule
(otc) 50 mg *
diphenhydramine 50 mg tablet 50
mg *
diphenhydramine hcl injection
solution 50 mg/ml
(Diphenhydramine
HCl)
(Diphenhydramine
HCl)
(Chlorpheniramine
ed chlorped jr syrup 2 mg/5 ml *
Maleate)
ed-a-hist 4 mg-10 mg tablet 4-10 mg (Chlorpheniramine/
*
Phenylephrine)
fexofenadine hcl 180 mg tablet
(Allegra Allergy)
24hr,original str (otc) 180 mg *
fexofenadine hcl 30 mg/5 ml 30
(Fexofenadine
mg/5 ml *
HCl)
fexofenadine hcl 60 mg tablet
(Allegra Allergy)
indoor/outdoor (otc) 60 mg *
hm z-sleep 25 mg softgel 25 mg *
(Zzzquil)
levocetirizine oral solution 2.5 mg/5
(Xyzal)
ml
levocetirizine oral tablet 5 mg
(Xyzal)
loratadine 10 mg tablet 10 mg *
(Claritin)
loratadine allergy 5 mg/5 ml d/f, a/f, (Children'S
s/f 5 mg/5 ml *
Claritin)
loratadine-d 12 hour tablet non(Claritin-D 12
drowsy 5-120 mg *
Hour)
loratadine-d 24hr tablet 10-240 mg (Claritin-D 24
*
Hour)
promethazine oral syrup 6.25 mg/5 (Promethazine
ml
HCl)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
62
Tier level
What the
drug will
cost you
(Diphenhydramine
HCl)
4
$0
(Zzzquil)
4
$0
(Zzzquil)
4
$0
(Zzzquil)
4
$0
4
$0
4
$0
4
$0
4
$0
(Zzzquil)
4
$0
(Chlorpheniramine/
Pseudoephed)
4
$0
4
$0
(Zzzquil)
4
$0
(Triprolidine/Pseud
oephedrine)
4
$0
(Zzzquil)
4
$0
(Diphenhydramine
HCl)
4
$0
(Allegra Allergy)
4
$0
(Allegra Allergy)
4
$0
Name of Drug
pv nyt-time sleep 25 mg caplet 25
mg *
q-dryl 12.5 mg/5 ml liquid a/f 12.5
mg/5 ml *
ra sleep aid 50 mg/30 ml liq 50
mg/30 ml *
siladryl 12.5 mg/5 ml liquid 12.5
mg/5 ml *
simply sleep 25 mg caplet caplet 25
mg *
sleep aid 25 mg tablet 25 mg *
sm allergy relief 1.34 mg tab 1.34
mg *
sm sinus and allergy tablet
maximum strength 4-60 mg *
sm z-sleep 50 mg/30 ml liquid
berry,gluten-free 50 mg/30 ml *
sudogest sinus & allergy tab 4-60
mg *
TRIAMINIC NIGHTTIME COLDCOUGH CHILDREN'S, GRAPE
6.25-2.5 MG/5 ML *
unisom 50 mg sleepgels softgel 50
mg *
wal-act d cold & allergy tab 2.5-60
mg *
wal-dryl allergy 25 mg capsule 25
mg *
wal-dryl allergy 25 mg minitab
minitab, coated 25 mg *
wal-fex allergy 180 mg tablet 180
mg *
wal-fex allergy 60 mg tablet 60 mg *
(Diphenhydramine
HCl)
(Doxylamine
Succinate)
(Clemastine
Fumarate)
(Chlorpheniramine/
Pseudoephed)
Necessary Actions,
Restrictions, or
Limits on Use
63
Tier level
What the
drug will
cost you
(Chlor-Trimeton)
(Chlorpheniramine/
Pseudoephed)
4
$0
4
$0
(Claritin)
4
$0
(Claritin)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
Name of Drug
wal-finate 4 mg tablet 4 mg *
wal-finate-d tablet 4-60 mg *
wal-itin 10 mg odt non-drowsy 10
mg *
wal-itin 10 mg tablet non-drowsy 10
mg *
wal-itin 5 mg/5 ml syrup children's,
grape 5 mg/5 ml *
(Children'S
Claritin)
(Claritin-D 12
wal-itin d 12 hour tablet 5-120 mg *
Hour)
wal-itin d 24 hour tablet 10-240 mg (Claritin-D 24
*
Hour)
wal-phed pe sinus & allergy tb 4-10 (Chlorpheniramine/
mg *
Phenylephrine)
wal-phed sinus and allergy tab 4-60 (Chlorpheniramine/
mg *
Pseudoephed)
(Unisom
wal-sleep z 25 mg odt 25 mg *
Sleepmelts)
wal-sleep z 25 mg softgel 25 mg *
(Zzzquil)
wal-sleep z 50 mg/30 ml liquid
(Zzzquil)
berry, a/f, d/f, s/f 50 mg/30 ml *
(Doxylamine
wal-som 25 mg tablet 25 mg *
Succinate)
wal-som 50 mg softgel softgel 50 mg
(Zzzquil)
*
wal-tap elixir 1-2.5 mg/5 ml *
(Dimetapp)
wal-zyr 10 mg tablet 10 mg *
(Zyrtec)
wal-zyr d tablet 12 hr 5-120 mg *
(Zyrtec-D)
wal-zyr solution children's, a/f 1
(Children'S Zyrtec)
mg/ml *
ZYRTEC 10 MG LIQUID GELS 10
MG *
ZYRTEC 10 MG ODT 10 MG *
Necessary Actions,
Restrictions, or
Limits on Use
64
Tier level
What the
drug will
cost you
4
$0
4
$0
2
$0
(Cleocin)
1
$0
(Metrogel-Vaginal)
1
$0
(Terazol 7)
1
$0
(Terconazole)
1
$0
(D.H.E.45)
1
$0
(Migranal)
1
$0
2
$0
(Amerge)
(Maxalt)
1
1
$0
$0
(Maxalt Mlt)
1
$0
(Sumatriptan
Succinate)
1
$0
(Imitrex)
1
$0
Name of Drug
ZYRTEC 10 MG TABLET
INDOOR/OUTDOOR 24 HR
(OTC) 10 MG *
Necessary Actions,
Restrictions, or
Limits on Use
Anti-Infectives (Skin And
Mucous Membrane)
Anti-Infectives (Skin And
Mucous Membrane)
ABREVA 10% CREAM 10 % *
AVC VAGINAL VAGINAL
CREAM 15 %
clindamycin phosphate vaginal
cream 2 %
metronidazole vaginal gel 0.75 %
terconazole vaginal cream 0.4 %,
0.8 %
terconazole vaginal suppository 80
mg
Antimigraine Agents
Antimigraine Agents
dihydroergotamine injection
solution 1 mg/ml
dihydroergotamine nasal spray,nonaerosol 0.5 mg/pump act. (4 mg/ml)
ERGOMAR SUBLINGUAL
TABLET 2 MG
naratriptan oral tablet 1 mg, 2.5 mg
rizatriptan oral tablet 10 mg, 5 mg
rizatriptan oral tablet,disintegrating
10 mg, 5 mg
sumatriptan 6 mg/0.5 ml syrng
p/f,dehp/f,pvc/f 6 mg/0.5 ml
sumatriptan nasal spray,nonaerosol 20 mg/actuation, 5
mg/actuation
QL (30 per 28 days)
QL (8 per 28 days)
QL (40 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (4 per 28 days)
QL (12 per 28 days)
65
Tier level
What the
drug will
cost you
(Imitrex)
1
$0
(Sumatriptan
Succinate)
1
$0
(Imitrex)
1
$0
(Sumatriptan
Succinate)
1
$0
(Sumatriptan
Succinate)
1
$0
(Imitrex)
1
$0
(Zomig)
1
$0
(Zomig Zmt)
1
$0
2
$0
(Dapsone)
1
$0
(Myambutol)
1
$0
(Isoniazid)
1
$0
(Isoniazid)
1
$0
2
$0
(Pyrazinamide)
(Mycobutin)
2
1
1
$0
$0
$0
(Rifadin)
1
$0
Name of Drug
sumatriptan succinate oral tablet
100 mg, 25 mg, 50 mg
sumatriptan succinate subcutaneous
cartridge 4 mg/0.5 ml
cartridge 6 mg/0.5 ml
pen injector 4 mg/0.5 ml
pen injector 6 mg/0.5 ml, 6 mg/0.5
ml (auto-injector)
solution 6 mg/0.5 ml
zolmitriptan oral tablet 2.5 mg, 5
mg
zolmitriptan oral
tablet,disintegrating 2.5 mg, 5 mg
Necessary Actions,
Restrictions, or
Limits on Use
QL (18 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (12 per 28 days)
QL (12 per 28 days)
Antimycobacterials
Antimycobacterials
CAPASTAT INJECTION RECON
SOLN 1 GRAM
dapsone oral tablet 100 mg, 25 mg
ethambutol oral tablet 100 mg, 400
mg
isoniazid oral solution 50 mg/5 ml
isoniazid oral tablet 100 mg, 300
mg
PASER ORAL GRANULES DR
FOR SUSP IN PACKET 4 GRAM
PRIFTIN ORAL TABLET 150 MG
pyrazinamide oral tablet 500 mg
rifabutin oral capsule 150 mg
rifampin intravenous recon soln 600
mg
66
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
2
$0
2
$0
(Compazine)
1
$0
(Dimenhydrinate)
4
$0
(Dimenhydrinate)
1
$0
(Dimenhydrinate)
4
$0
(Meclizine HCl)
4
$0
(Dimenhydrinate)
4
$0
(Marinol)
1
$0
2
$0
2
$0
2
$0
2
$0
Name of Drug
rifampin oral capsule 150 mg, 300
(Rifadin)
mg
RIFATER ORAL TABLET 50-120300 MG
SIRTURO ORAL TABLET 100
MG
TRECATOR ORAL TABLET 250
MG
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (188 per 168
days)
Antinausea Agents
Antinausea Agents
AKYNZEO ORAL CAPSULE 3000.5 MG
compro rectal suppository 25 mg
cvs motion sickness 50 mg tab 50
mg *
dimenhydrinate injection solution 50
mg/ml
dramamine 50 mg tablet 50 mg *
dramamine less drowsy 25 mg tb 25
mg *
driminate 50 mg tablet 50 mg *
dronabinol oral capsule 10 mg, 2.5
mg, 5 mg
EMEND INTRAVENOUS RECON
SOLN 115 MG, 150 MG
EMEND ORAL CAPSULE 125
MG, 80 MG
EMEND ORAL CAPSULE 40 MG
EMEND ORAL CAPSULE,DOSE
PACK 125 MG (1)- 80 MG (2)
EMEND ORAL SUSPENSION
FOR RECONSTITUTION 125 MG
(25 MG/ ML FINAL CONC.)
PA BvD
QL (2 per 28 days)
PA BvD
PA BvD
PA BvD
2
$0
67
Tier level
What the
drug will
cost you
(Granisetron
HCl/PF)
1
$0
(Granisetron HCl)
1
$0
(Granisetron HCl)
1
$0
(Meclizine HCl)
4
$0
(Meclizine HCl)
(Meclizine HCl)
4
1
$0
$0
(Meclizine HCl)
4
$0
1
$0
1
$0
(Zofran)
1
$0
(Zofran)
1
$0
(Zofran Odt)
1
$0
(Phenergan)
1
$0
(Prochlorperazine
Edisylate)
1
$0
(Compazine)
1
$0
(Compazine)
1
$0
(Promethazine
HCl)
1
$0
(Phenergan)
1
$0
Name of Drug
granisetron (pf) intravenous
solution 100 mcg/ml
granisetron hcl intravenous solution
1 mg/ml (1 ml)
granisetron hcl oral tablet 1 mg
meclizine 12.5 mg caplet caplet
(otc) 12.5 mg *
meclizine 25 mg tablet (otc) 25 mg *
meclizine oral tablet 12.5 mg, 25 mg
motion sickness 25 mg tablet 25 mg
*
ondansetron hcl (pf) injection
solution 4 mg/2 ml
ondansetron hcl (pf) injection
syringe 4 mg/2 ml
ondansetron hcl oral solution 4
mg/5 ml
ondansetron hcl oral tablet 24 mg, 4
mg, 8 mg
ondansetron oral
tablet,disintegrating 4 mg, 8 mg
phenadoz rectal suppository 12.5
mg, 25 mg
prochlorperazine edisylate injection
prochlorperazine maleate oral
tablet 10 mg, 5 mg
prochlorperazine rectal suppository
25 mg
promethazine oral tablet 12.5 mg,
25 mg, 50 mg
promethazine rectal suppository
12.5 mg, 25 mg, 50 mg
(Ondansetron
HCl/PF)
(Ondansetron
HCl/PF)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA-HRM
PA-HRM
PA-HRM
68
Tier level
What the
drug will
cost you
1
$0
2
$0
(Bonine)
4
$0
(Dimenhydrinate)
4
$0
2
$0
2
$0
2
$0
(Mepron)
1
$0
(Malarone)
1
$0
(Chloroquine
Phosphate)
1
$0
2
$0
2
$0
1
$0
(Plaquenil)
1
$0
(Stromectol)
(Mefloquine HCl)
1
1
$0
$0
2
$0
Name of Drug
promethegan rectal suppository
12.5 mg, 25 mg, 50 mg
TRANSDERM-SCOP
TRANSDERMAL PATCH 3 DAY
1.5 MG (1 MG OVER 3 DAYS)
travel sickness 25 mg tab chew 25
mg *
wal-dram 50 mg tablet 50 mg *
(Phenergan)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
QL (10 per 30 days)
Antiparasite Agents
Antiparasite Agents
ALBENZA ORAL TABLET 200
MG
ALINIA ORAL SUSPENSION
MG/5 ML
ALINIA ORAL TABLET 500 MG
atovaquone oral suspension 750
mg/5 ml
atovaquone-proguanil oral tablet
250-100 mg, 62.5-25 mg
chloroquine phosphate oral tablet
250 mg, 500 mg
COARTEM ORAL TABLET 20120 MG
DARAPRIM ORAL TABLET 25
MG
EMVERM ORAL
TABLET,CHEWABLE 100 MG
hydroxychloroquine oral tablet 200
mg
ivermectin oral tablet 3 mg
mefloquine oral tablet 250 mg
NEBUPENT INHALATION
RECON SOLN 300 MG
QL (6 per 21 days)
PA BvD
69
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
(Qualaquin)
1
$0
(Amantadine HCl)
1
$0
(Amantadine HCl)
1
$0
(Amantadine HCl)
1
$0
2
$0
2
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Sinemet CR)
1
$0
(Sinemet CR)
1
$0
(Stalevo 50)
1
$0
(Comtan)
1
$0
Name of Drug
paromomycin oral capsule 250 mg
PENTAM INJECTION RECON
SOLN 300 MG
PRIMAQUINE ORAL TABLET
26.3 MG
quinine sulfate oral capsule 324 mg
(Paromomycin
Sulfate)
Necessary Actions,
Restrictions, or
Limits on Use
QL (90 per 30 days)
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl oral capsule 100 mg
amantadine hcl oral solution 50
mg/5 ml
amantadine hcl oral tablet 100 mg
APOKYN SUBCUTANEOUS
CARTRIDGE 10 MG/ML
AZILECT ORAL TABLET 0.5
MG, 1 MG
benztropine oral tablet 0.5 mg, 1
mg, 2 mg
bromocriptine oral capsule 5 mg
bromocriptine oral tablet 2.5 mg
cabergoline oral tablet 0.5 mg
carbidopa oral tablet 25 mg
carbidopa-levodopa oral tablet 10100 mg, 25-100 mg, 25-250 mg
carbidopa-levodopa oral tablet
extended release 25-100 mg, 50-200
mg
carbidopa-levodopa-entacapone
oral tablet 12.5-50-200 mg, 18.7575-200 mg, 25-100-200 mg, 31.25125-200 mg, 37.5-150-200 mg, 50200-200 mg
entacapone oral tablet 200 mg
(Benztropine
Mesylate)
(Parlodel)
(Parlodel)
(Cabergoline)
(Lodosyn)
QL (60 per 30 days)
PA-HRM
70
Tier level
What the
drug will
cost you
2
$0
(Mirapex)
1
$0
(Requip)
1
$0
(Requip XL)
1
$0
1
1
$0
$0
1
$0
1
$0
2
$0
Name of Drug
NEUPRO TRANSDERMAL
PATCH 24 HOUR 1 MG/24
HOUR, 2 MG/24 HOUR, 3 MG/24
HOUR, 4 MG/24 HOUR, 6 MG/24
HOUR, 8 MG/24 HOUR
pramipexole oral tablet 0.125 mg,
0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5
mg
ropinirole oral tablet 0.25 mg, 0.5
mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg
ropinirole oral tablet extended
release 24 hr 12 mg, 2 mg, 4 mg, 6
mg, 8 mg
selegiline hcl oral capsule 5 mg
selegiline hcl oral tablet 5 mg
(Eldepryl)
(Selegiline HCl)
(Trihexyphenidyl
trihexyphenidyl oral elixir 0.4 mg/ml
HCl)
trihexyphenidyl oral tablet 2 mg, 5
(Trihexyphenidyl
mg
HCl)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM
Antipsychotic Agents
Antipsychotic Agents
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON 300 MG
ABILIFY MAINTENA
INTRAMUSCULAR
RECON 400 MG
ABILIFY MAINTENA
INTRAMUSCULAR
SYRING 300 MG, 400 MG
aripiprazole oral solution 1 mg/ml
QL (1 per 28 days)
2
$0
QL (1 per 28 days)
(Abilify)
2
$0
1
$0
71
Tier level
What the
drug will
cost you
(Abilify)
1
$0
(Abilify)
1
$0
(Abilify Discmelt)
1
$0
(Abilify Discmelt)
1
$0
Name of Drug
aripiprazole oral tablet 10 mg, 15
mg, 20 mg, 30 mg, 5 mg
aripiprazole oral tablet 2 mg
aripiprazole oral
aripiprazole oral
ARISTADA INTRAMUSCULAR
SYRING 441 MG/1.6 ML
chlorpromazine injection solution
25 mg/ml
chlorpromazine oral tablet 10 mg,
100 mg, 200 mg, 25 mg, 50 mg
clozapine oral tablet 100 mg
clozapine oral tablet 200 mg
clozapine oral tablet 25 mg, 50 mg
clozapine oral tablet,disintegrating
100 mg, 12.5 mg, 150 mg, 200 mg,
25 mg
FANAPT ORAL TABLET 1 MG,
10 MG, 12 MG, 2 MG, 4 MG, 6
MG, 8 MG
FANAPT ORAL TABLETS,DOSE
PACK 1MG(2)-2MG(2)- 4MG(2)6MG(2)
fluphenazine decanoate injection
solution 25 mg/ml
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (1.6 per 28 days)
2
$0
2
$0
2
$0
1
$0
1
$0
1
1
1
$0
$0
$0
1
$0
(Chlorpromazine
HCl)
(Chlorpromazine
HCl)
(Clozaril)
(Clozaril)
(Clozaril)
(Fazaclo)
2
$0
2
$0
1
$0
QL (90 per 30 days)
ST
ST; QL (60 per 30
days)
ST; QL (8 per 28 days)
(Fluphenazine
Decanoate)
72
Name of Drug
fluphenazine hcl injection solution
2.5 mg/ml
fluphenazine hcl oral concentrate 5
mg/ml
fluphenazine hcl oral elixir 2.5 mg/5
ml
fluphenazine hcl oral tablet 1 mg, 10
mg, 2.5 mg, 5 mg
GEODON INTRAMUSCULAR
RECON SOLN 20 MG/ML (FINAL
CONC.)
haloperidol decanoate
intramuscular solution 100 mg/ml
haloperidol decanoate
intramuscular solution 50 mg/ml
haloperidol lactate injection
solution 5 mg/ml
haloperidol lactate oral concentrate
2 mg/ml
haloperidol oral tablet 0.5 mg, 1
mg, 10 mg, 2 mg, 20 mg, 5 mg
INVEGA SUSTENNA
117 MG/0.75 ML, 156 MG/ML,
234 MG/1.5 ML, 39 MG/0.25 ML,
78 MG/0.5 ML
INVEGA TRINZA
273 MG/0.875 ML, 410 MG/1.315
ML, 546 MG/1.75 ML, 819
MG/2.625 ML
LATUDA ORAL TABLET 120
MG, 20 MG, 40 MG, 60 MG, 80
MG
(Fluphenazine
HCl)
(Fluphenazine
HCl)
(Fluphenazine
HCl)
(Fluphenazine
HCl)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (6 per 28 days)
(Haloperidol
Decanoate)
(Haldol Decanoate
50)
(Haloperidol
Lactate)
(Haloperidol
Lactate)
(Haloperidol)
73
Tier level
What the
drug will
cost you
1
$0
1
1
1
$0
$0
$0
2
$0
(Zyprexa)
1
$0
(Zyprexa)
1
$0
(Zyprexa Zydis)
1
$0
(Zyprexa Zydis)
1
$0
(Invega)
1
$0
(Invega)
1
$0
(Perphenazine)
1
$0
(Orap)
1
$0
(Seroquel)
1
$0
2
$0
2
$0
2
$0
Name of Drug
loxapine succinate oral capsule 10
mg, 25 mg, 5 mg, 50 mg
molindone oral tablet 10 mg
NUPLAZID ORAL TABLET 17
MG
olanzapine intramuscular recon soln
10 mg
olanzapine oral tablet 10 mg, 15
mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg
olanzapine oral tablet,disintegrating
10 mg, 15 mg, 5 mg
olanzapine oral tablet,disintegrating
20 mg
paliperidone oral tablet extended
release 24hr 1.5 mg, 3 mg, 9 mg
paliperidone oral tablet extended
release 24hr 6 mg
perphenazine oral tablet 16 mg, 2
mg, 4 mg, 8 mg
pimozide oral tablet 1 mg, 2 mg
quetiapine oral tablet 100 mg, 200
mg, 25 mg, 300 mg, 400 mg, 50 mg
REXULTI ORAL TABLET 0.25
MG
REXULTI ORAL TABLET 0.5 MG
REXULTI ORAL TABLET 1 MG,
2 MG, 3 MG, 4 MG
RISPERDAL CONSTA
12.5 MG/2 ML, 25 MG/2 ML, 37.5
MG/2 ML, 50 MG/2 ML
risperidone oral solution 1 mg/ml
(Loxapine
Succinate)
(Molindone HCl)
(Molindone HCl)
(Molindone HCl)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (60 per
30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (31 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (4 per 28 days)
(Risperdal)
2
$0
1
$0
74
Tier level
What the
drug will
cost you
(Risperdal)
1
$0
(Risperdal M-Tab)
1
$0
(Risperdal M-Tab)
1
$0
2
$0
(Thioridazine HCl)
1
$0
(Thiothixene)
1
$0
(Trifluoperazine
HCl)
1
$0
2
$0
2
$0
2
$0
1
$0
2
$0
2
$0
Name of Drug
risperidone oral tablet 0.25 mg, 0.5
mg, 1 mg, 2 mg, 3 mg, 4 mg
risperidone oral
tablet,disintegrating 0.25 mg, 0.5
mg, 1 mg, 2 mg
risperidone oral
tablet,disintegrating 3 mg, 4 mg
SAPHRIS (BLACK CHERRY)
SUBLINGUAL TABLET 10 MG,
2.5 MG, 5 MG
thioridazine oral tablet 10 mg, 100
mg, 25 mg, 50 mg
thiothixene oral capsule 1 mg, 10
mg, 2 mg, 5 mg
trifluoperazine oral tablet 1 mg, 10
mg, 2 mg, 5 mg
VERSACLOZ ORAL
SUSPENSION 50 MG/ML
VRAYLAR ORAL CAPSULE 1.5
MG, 3 MG, 4.5 MG, 6 MG
VRAYLAR ORAL
CAPSULE,DOSE PACK 1.5 MG
(1)- 3 MG (6)
ziprasidone hcl oral capsule 20 mg,
40 mg, 60 mg, 80 mg
ZYPREXA RELPREVV 405 MG
VL KIT W/ DILUENT, OUTER
405 MG
ZYPREXA RELPREVV
INTRAMUSCULAR
SUSPENSION FOR
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (60 per 30 days)
ST; QL (60 per 30
days)
PA NSO-HRM
ST; QL (540 per 30
days)
QL (30 per 30 days)
QL (7 per 30 days)
(Geodon)
QL (60 per 30 days)
Antivirals (Systemic)
Antiretrovirals
75
Name of Drug
abacavir oral tablet 300 mg
(Ziagen)
abacavir-lamivudine-zidovudine
(Trizivir)
oral tablet 300-150-300 mg
APTIVUS ORAL CAPSULE 250
MG
APTIVUS ORAL SOLUTION 100
MG/ML
ATRIPLA ORAL TABLET 600200-300 MG
COMPLERA ORAL TABLET 20025-300 MG
CRIXIVAN ORAL CAPSULE 200
MG, 400 MG
DESCOVY ORAL TABLET 20025 MG
didanosine oral capsule,delayed
release(dr/ec) 125 mg, 200 mg, 250 (Videx EC)
mg, 400 mg
EDURANT ORAL TABLET 25
MG
EMTRIVA ORAL CAPSULE 200
MG
EMTRIVA ORAL SOLUTION 10
MG/ML
EPIVIR HBV ORAL SOLUTION
25 MG/5 ML (5 MG/ML)
EPZICOM ORAL TABLET 600300 MG
EVOTAZ ORAL TABLET 300-150
MG
FUZEON SUBCUTANEOUS
RECON SOLN 90 MG
GENVOYA ORAL TABLET 150150-200-10 MG
Tier level
What the
drug will
cost you
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
76
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
(Epivir)
1
$0
(Epivir)
1
$0
(Combivir)
1
$0
2
$0
2
$0
(Viramune)
1
$0
(Viramune)
1
$0
(Viramune XR)
1
$0
2
$0
2
$0
Name of Drug
INTELENCE ORAL TABLET 100
MG, 200 MG, 25 MG
INVIRASE ORAL CAPSULE 200
MG
INVIRASE ORAL TABLET 500
MG
ISENTRESS ORAL POWDER IN
PACKET 100 MG
ISENTRESS ORAL TABLET 400
MG
ISENTRESS ORAL
TABLET,CHEWABLE 100 MG, 25
MG
KALETRA ORAL SOLUTION
400-100 MG/5 ML
KALETRA ORAL TABLET 10025 MG, 200-50 MG
lamivudine oral solution 10 mg/ml
lamivudine oral tablet 100 mg, 150
mg, 300 mg
lamivudine-zidovudine oral tablet
150-300 mg
LEXIVA ORAL SUSPENSION 50
MG/ML
LEXIVA ORAL TABLET 700 MG
nevirapine oral suspension 50 mg/5
ml
nevirapine oral tablet 200 mg
nevirapine oral tablet extended
NORVIR ORAL CAPSULE 100
MG
NORVIR ORAL SOLUTION 80
MG/ML
Necessary Actions,
Restrictions, or
Limits on Use
77
Name of Drug
NORVIR ORAL TABLET 100 MG
ODEFSEY ORAL TABLET 20025-25 MG
PREZCOBIX ORAL TABLET 800150 MG-MG
PREZISTA ORAL SUSPENSION
100 MG/ML
PREZISTA ORAL TABLET 150
MG, 400 MG, 600 MG, 75 MG, 800
MG
RESCRIPTOR ORAL TABLET
200 MG
RESCRIPTOR ORAL TABLET,
DISPERSIBLE 100 MG
RETROVIR INTRAVENOUS
SOLUTION 10 MG/ML
REYATAZ ORAL CAPSULE 150
MG, 200 MG, 300 MG
REYATAZ ORAL POWDER IN
PACKET 50 MG
SELZENTRY ORAL TABLET 150
MG, 300 MG
stavudine oral capsule 15 mg, 20
(Zerit)
mg, 30 mg, 40 mg
stavudine oral recon soln 1 mg/ml
(Zerit)
STRIBILD ORAL TABLET 150150-200-300 MG
SUSTIVA ORAL CAPSULE 200
MG, 50 MG
SUSTIVA ORAL TABLET 600
MG
TIVICAY ORAL TABLET 10 MG,
25 MG, 50 MG
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
78
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
(Retrovir)
(Retrovir)
(Zidovudine)
1
1
1
$0
$0
$0
(Foscavir)
1
$0
2
$0
1
$0
Name of Drug
TRIUMEQ ORAL TABLET 60050-300 MG
TRUVADA ORAL TABLET 100150 MG, 133-200 MG, 167-250
MG, 200-300 MG
VIDEX 2 GRAM PEDIATRIC
ORAL RECON SOLN 10 MG/ML
(FINAL)
VIDEX 4 GM PEDIATRIC SOLN
10 MG/ML (FINAL)
VIRACEPT ORAL TABLET 250
MG, 625 MG
VIRAMUNE XR ORAL TABLET
MG
VIREAD ORAL POWDER 40
MG/SCOOP (40 MG/GRAM)
VIREAD ORAL TABLET 150 MG,
200 MG, 250 MG, 300 MG
VITEKTA ORAL TABLET 150
MG, 85 MG
ZIAGEN ORAL SOLUTION 20
MG/ML
zidovudine oral capsule 100 mg
zidovudine oral syrup 10 mg/ml
zidovudine oral tablet 300 mg
Antivirals, Miscellaneous
foscarnet intravenous solution 24
mg/ml
RELENZA DISKHALER
INHALATION BLISTER WITH
DEVICE 5 MG/ACTUATION
rimantadine oral tablet 100 mg
(Flumadine)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
79
Name of Drug
SYNAGIS 100 MG/1 ML VIAL
100 MG/ML
SYNAGIS INTRAMUSCULAR
SOLUTION 50 MG/0.5 ML
TAMIFLU ORAL CAPSULE 30
MG
MG
MG
TAMIFLU ORAL SUSPENSION
MG/ML
Hcv Antivirals
DAKLINZA ORAL TABLET 30
MG, 60 MG, 90 MG
EPCLUSA ORAL TABLET 400100 MG
HARVONI ORAL TABLET 90-400
MG
OLYSIO ORAL CAPSULE 150
MG
SOVALDI ORAL TABLET 400
MG
TECHNIVIE ORAL TABLET 12.575-50 MG
VIEKIRA PAK ORAL
TABLETS,DOSE PACK 12.5 MG75 MG -50 MG/250 MG
ZEPATIER ORAL TABLET 50100 MG
Interferons
INTRON A 25 MILLION UNIT/2.5
ML 10 MILLION UNIT/ML
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
PA; QL (30 per 30
days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
PA; QL (56 per 28
days)
PA; QL (112 per 28
days)
PA; QL (30 per 30
days)
PA NSO
80
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
INTRON A INJECTION RECON
PA NSO
2
$0
SOLN 10 MILLION UNIT (1 ML)
INTRON A INJECTION RECON
PA NSO
SOLN 18 MILLION UNIT (1 ML),
2
$0
50 MILLION UNIT (1 ML)
INTRON A INJECTION
PA NSO
2
$0
SOLUTION 6 MILLION UNIT/ML
PEGASYS PROCLICK
PA
SUBCUTANEOUS PEN
2
$0
INJECTOR 135 MCG/0.5 ML, 180
MCG/0.5 ML
PEGASYS SUBCUTANEOUS
PA
2
$0
SOLUTION 180 MCG/ML
PEGASYS SUBCUTANEOUS
PA
2
$0
SYRINGE 180 MCG/0.5 ML
PEGINTRON SUBCUTANEOUS
PA
KIT 120 MCG/0.5 ML, 150
2
$0
MCG/0.5 ML, 50 MCG/0.5 ML, 80
MCG/0.5 ML
SYLATRON SUBCUTANEOUS
KIT 200 MCG, 300 MCG, 600
2
$0
days)
MCG
Nucleosides And
Nucleotides
acyclovir oral capsule 200 mg
(Zovirax)
1
$0
acyclovir oral suspension 200 mg/5
(Zovirax)
1
$0
ml
acyclovir oral tablet 400 mg, 800
(Zovirax)
1
$0
mg
acyclovir sodium intravenous
(Acyclovir
PA BvD
1
$0
solution 50 mg/ml
Sodium)
adefovir oral tablet 10 mg
(Hepsera)
1
$0
entecavir oral tablet 0.5 mg, 1 mg
(Baraclude)
1
$0
famciclovir oral tablet 125 mg, 250
(Famvir)
1
$0
mg, 500 mg
81
Tier level
What the
drug will
cost you
(Cytovene)
1
$0
(Rebetol)
1
$0
(Copegus)
1
$0
2
$0
(Valtrex)
1
$0
(Valcyte)
1
$0
2
$0
2
$0
2
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
Name of Drug
ganciclovir sodium intravenous
recon soln 500 mg
ribasphere oral capsule 200 mg
ribasphere oral tablet 200 mg, 400
mg, 600 mg
TYZEKA ORAL TABLET 600 MG
valacyclovir oral tablet 1 gram, 500
mg
valganciclovir oral tablet 450 mg
VIRAZOLE INHALATION
RECON SOLN 6 GRAM
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
Blood
Products/Modifiers/Volume
Expanders
Anticoagulants
CEPROTIN (BLUE BAR)
INTRAVENOUS RECON SOLN
500 UNIT
ELIQUIS ORAL TABLET 2.5 MG,
5 MG
enoxaparin subcutaneous solution
300 mg/3 ml
enoxaparin subcutaneous syringe
100 mg/ml, 120 mg/0.8 ml, 150
mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml,
60 mg/0.6 ml, 80 mg/0.8 ml
fondaparinux subcutaneous syringe
10 mg/0.8 ml
2.5 mg/0.5 ml
5 mg/0.4 ml
7.5 mg/0.6 ml
QL (24 per 30 days)
QL (15 per 30 days)
QL (12 per 30 days)
QL (18 per 30 days)
82
Tier level
What the
drug will
cost you
(Heparin
Sodium,Porcine/D5
W)
1
$0
(Heparin Sod,Pork
In 0.45% NaCl)
1
$0
(Heparin
Sodium,Porcine/Ns
/PF)
1
$0
(Heparin
Sodium,Porcine)
1
$0
1
$0
1
$0
(Heparin Sod,Pork
In 0.45% NaCl)
1
$0
(Heparin
Sodium,Porcine/D5
W)
1
$0
2
$0
1
$0
2
$0
1
$0
Name of Drug
heparin (porcine) in 5 % dex
intravenous parenteral solution
12,500 unit/250 ml, 20,000 unit/500
ml (40 unit/ml), 25,000 unit/500 ml
(50 unit/ml)
heparin (porcine) in 5 % dex
25,000 unit/250 ml(100 unit/ml)
heparin (porcine) in nacl (pf)
1,000 unit/500 ml
heparin (porcine) injection solution
1,000 unit/ml, 10,000 unit/ml,
20,000 unit/ml, 5,000 unit/ml
heparin, porcine (pf) injection
solution 5,000 unit/0.5 ml
heparin, porcine (pf) injection
syringe 5,000 unit/0.5 ml
heparin-0.45% nacl 25,000
units/250 ml (100 units/ml) bag
latex-free, inner 25,000 unit/250 ml
heparin-d5w 25,000 units/250 ml
(100 units/ml) bag excel container
25,000 unit/250 ml(100 unit/ml)
IPRIVASK SUBCUTANEOUS
RECON SOLN 15 MG
jantoven oral tablet 1 mg, 10 mg, 2
mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg,
7.5 mg
PRADAXA ORAL CAPSULE 110
MG, 150 MG, 75 MG
warfarin oral tablet 1 mg, 10 mg, 2
mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg,
7.5 mg
(Heparin
Sodium,Porcine/PF
)
(Monoject Prefill
Advanced)
(Coumadin)
(Coumadin)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (24 per 28
days)
ST; QL (60 per 30
days)
83
Name of Drug
XARELTO ORAL TABLET 10
MG, 15 MG, 20 MG
XARELTO ORAL
TABLETS,DOSE PACK 15 MG
(42)- 20 MG (9)
Blood Formation Modifiers
CINRYZE INTRAVENOUS
RECON SOLN 500 UNIT (5 ML)
EPOGEN 10,000 UNITS/ML VIAL
SDV, P/F, OUTER 10,000
UNIT/ML
EPOGEN INJECTION SOLUTION
2,000 UNIT/ML, 20,000 UNIT/2
ML, 20,000 UNIT/ML, 3,000
UNIT/ML, 4,000 UNIT/ML
GRANIX SUBCUTANEOUS
SYRINGE 300 MCG/0.5 ML, 480
MCG/0.8 ML
LEUKINE INJECTION RECON
SOLN 250 MCG
MIRCERA INJECTION SYRINGE
100 MCG/0.3 ML, 200 MCG/0.3
ML, 50 MCG/0.3 ML, 75 MCG/0.3
ML
MOZOBIL SUBCUTANEOUS
SOLUTION 24 MG/1.2 ML (20
MG/ML)
NEULASTA SUBCUTANEOUS
SYRINGE 6 MG/0.6ML
NEULASTA SUBCUTANEOUS
SYRINGE, W/ WEARABLE
INJECTOR 6 MG/0.6 ML
NEUMEGA SUBCUTANEOUS
RECON SOLN 5 MG
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA; QL (12 per 28
days)
PA; QL (12 per 28
days)
PA; QL (0.6 per 28
days)
84
Name of Drug
NEUPOGEN INJECTION
SOLUTION 300 MCG/ML, 480
MCG/1.6 ML
NEUPOGEN INJECTION
MCG/0.8 ML
PROCRIT 10,000 UNITS/ML
VIAL 4'S, MDV, OUTER 20,000
UNIT/2 ML
PROCRIT INJECTION
SOLUTION 10,000 UNIT/ML,
2,000 UNIT/ML, 20,000 UNIT/ML,
3,000 UNIT/ML, 4,000 UNIT/ML
PROCRIT INJECTION
SOLUTION 40,000 UNIT/ML
PROMACTA ORAL TABLET 12.5
MG, 25 MG, 50 MG, 75 MG
ZARXIO INJECTION SYRINGE
300 MCG/0.5 ML, 480 MCG/0.8
ML
Hematologic Agents,
Miscellaneous
aminocaproic acid oral solution 250
mg/ml (25 %)
aminocaproic acid oral tablet 1,000
mg, 500 mg
anagrelide oral capsule 0.5 mg, 1
mg
protamine intravenous solution 10
mg/ml
tranexamic acid intravenous
solution 1,000 mg/10 ml (100
mg/ml)
tranexamic acid oral tablet 650 mg
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
1
$0
(Agrylin)
1
$0
(Protamine Sulfate)
1
$0
(Tranexamic Acid)
1
$0
(Lysteda)
1
$0
(Aminocaproic
Acid)
(Aminocaproic
Acid)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (12 per 28
days)
PA; QL (12 per 28
days)
PA; QL (30 per 30
days)
QL (30 per 30 days)
85
Tier level
What the
drug will
cost you
1
$0
2
$0
(Pletal)
1
$0
(Plavix)
1
$0
(Persantine)
1
$0
2
$0
1
$0
Name of Drug
Platelet-Aggregation
Inhibitors
aspirin-dipyridamole oral capsule,
er multiphase 12 hr 25-200 mg
BRILINTA ORAL TABLET 60
MG, 90 MG
cilostazol oral tablet 100 mg, 50 mg
clopidogrel oral tablet 300 mg, 75
mg
dipyridamole oral tablet 25 mg, 50
mg, 75 mg
EFFIENT ORAL TABLET 10 MG,
5 MG
pentoxifylline oral tablet extended
release 400 mg
(Aggrenox)
(Pentoxifylline)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
Caloric Agents
Caloric Agents
AMINO ACIDS 15 %
PA BvD
INTRAVENOUS PARENTERAL
2
$0
SOLUTION 15 %
AMINOSYN 10 %
PA BvD
2
$0
SOLUTION 10 %
AMINOSYN 3.5 %
PA BvD
2
$0
SOLUTION 3.5 %
AMINOSYN 7 % INTRAVENOUS
PA BvD
2
$0
PARENTERAL SOLUTION 7 %
AMINOSYN 7 % WITH
PA BvD
ELECTROLYTES
2
$0
SOLUTION 7 %
AMINOSYN 8.5 %
PA BvD
2
$0
SOLUTION 8.5 %
86
Name of Drug
Tier level
AMINOSYN 8.5 %ELECTROLYTES
SOLUTION 8.5 %
AMINOSYN II 10 %
SOLUTION 10 %
AMINOSYN II 15 %
SOLUTION 15 %
AMINOSYN II 7 %
SOLUTION 7 %
AMINOSYN II 8.5 %
SOLUTION 8.5 %
AMINOSYN II 8.5 %ELECTROLYTES
SOLUTION 8.5 %
AMINOSYN M 3.5 %
SOLUTION 3.5 %
AMINOSYN-HBC 7%
SOLUTION 7 %
AMINOSYN-PF 10 %
SOLUTION 10 %
AMINOSYN-PF 7 % (SULFITEFREE) INTRAVENOUS
AMINOSYN-RF 5.2 %
SOLUTION 5.2 %
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
2
$0
2
$0
PA BvD
PA BvD
2
$0
PA BvD
2
$0
2
$0
PA BvD
PA BvD
2
$0
2
$0
2
$0
PA BvD
PA BvD
PA BvD
2
$0
2
$0
2
$0
PA BvD
PA BvD
87
Name of Drug
CLINIMIX 5%/D15W SULFITE
FREE INTRAVENOUS
CLINIMIX 5%/D25W SULFITEFREE INTRAVENOUS
CLINIMIX 2.75%/D5W SULFIT
FREE INTRAVENOUS
PARENTERAL SOLUTION 2.75
%
CLINIMIX 4.25%/D10W SULF
FREE INTRAVENOUS
%
CLINIMIX 4.25%/D5W SULFIT
FREE INTRAVENOUS
%
CLINIMIX 4.25%-D20W SULFFREE INTRAVENOUS
%
CLINIMIX 4.25%-D25W SULFFREE INTRAVENOUS
%
CLINIMIX 5%-D20W(SULFITEFREE) INTRAVENOUS
CLINIMIX E 2.75%/D10W SUL
FREE INTRAVENOUS
%
Tier level
What the
drug will
cost you
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
2
$0
PA BvD
PA BvD
2
$0
88
Name of Drug
CLINIMIX E 2.75%/D5W SULF
FREE INTRAVENOUS
%
FREE INTRAVENOUS
%
FREE INTRAVENOUS
%
CLINIMIX E 4.25%/D5W SULF
FREE INTRAVENOUS
%
CLINIMIX E 5%/D15W SULFIT
FREE INTRAVENOUS
FREE INTRAVENOUS
FREE INTRAVENOUS
CLINISOL SF 15 %
SOLUTION 15 %
cysteine (l-cysteine) intravenous
solution 50 mg/ml
dex4 glucose 4 gm tablet chew
grape flavor 4 gram *
dextrose 10 % in water (d10w)
intravenous parenteral solution 10
%
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
2
$0
2
$0
PA BvD
PA BvD
PA BvD
2
$0
(Cysteine HCl)
1
$0
(Dextrose)
4
$0
(Dextrose 10 % in
Water)
1
$0
PA BvD
PA BvD
89
Tier level
What the
drug will
cost you
(Dextrose 10 % in
Water)
1
$0
(Dextrose 20 % in
Water)
1
$0
(Dextrose 25 % in
Water)
1
$0
(Dextrose 40 % in
Water)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
(Dextrose)
4
$0
(Dextrose)
4
$0
(Dextrose)
4
$0
(Dextrose)
4
$0
Name of Drug
intravenous solution
%
intravenous syringe
%
dextrose 5 % in ringers intravenous
parenteral solution 5 %
intravenous syringe
FREAMINE HBC 6.9 %
SOLUTION 6.9 %
FREAMINE III 10 %
SOLUTION 10 %
gluco burst 40% gel 40 % *
glucose 4 gram tablet chew na/f,
caffeine free 4 gram *
glucose 40% gel tropical fruit 40 %
*
glutose 15 gel 3 pak, outer, u-d 40
%*
(Dextrose 5 % In
Ringers)
(Dextrose 5 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 70 % in
Water)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
90
Name of Drug
HEPATAMINE 8%
SOLUTION 8 %
HEPATASOL 8 %
SOLUTION 8 %
insta-glucose gel 24 gram/31 gram (Dextrose/Dextrin/
*
Maltose)
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
KABIVEN INTRAVENOUS
EMULSION 3.31-9.8-3.9 %
NEPHRAMINE 5.4 %
SOLUTION 5.4 %
NUTRILIPID INTRAVENOUS
EMULSION 20 %
PERIKABIVEN INTRAVENOUS
EMULSION 2.36-6.8-3.5 %
PREMASOL 10 %
SOLUTION 10 %
PREMASOL 6 % INTRAVENOUS
PROCALAMINE 3%
SOLUTION 3 %
PROSOL 20 % INTRAVENOUS
PARENTERAL SOLUTION
TRAVASOL 10 %
SOLUTION 10 %
TROPHAMINE 10 %
SOLUTION 10 %
Tier level
What the
drug will
cost you
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
2
$0
4
$0
2
$0
2
$0
2
$0
2
$0
2
$0
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
2
$0
2
$0
PA BvD
PA BvD
2
$0
2
$0
PA BvD
PA BvD
2
$0
2
$0
PA BvD
91
Tier level
What the
drug will
cost you
2
$0
(Catapres)
1
$0
(Catapres-Tts 1)
1
$0
(Catapres-Tts 1)
1
$0
(Clonidine
HCl/Chlorthalidon
e)
1
$0
(Cardura)
1
$0
(Tenex)
1
$0
(Midodrine HCl)
1
$0
2
$0
(Vazculep)
1
$0
(Minipress)
1
$0
2
$0
2
$0
1
$0
Name of Drug
TROPHAMINE 6%
SOLUTION 6 %
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet 0.1 mg, 0.2
mg, 0.3 mg
clonidine transdermal patch weekly
0.1 mg/24 hr, 0.2 mg/24 hr
clonidine transdermal patch weekly
0.3 mg/24 hr
clorpres oral tablet 0.1-15 mg, 0.215 mg, 0.3-15 mg
doxazosin oral tablet 1 mg, 2 mg, 4
mg, 8 mg
guanfacine oral tablet 1 mg, 2 mg
midodrine oral tablet 10 mg, 2.5 mg,
5 mg
NORTHERA ORAL CAPSULE
100 MG, 200 MG, 300 MG
phenylephrine hcl injection solution
10 mg/ml
prazosin oral capsule 1 mg, 2 mg, 5
mg
Angiotensin Ii Receptor
Antagonists
BENICAR HCT ORAL TABLET
20-12.5 MG, 40-12.5 MG, 40-25
MG
BENICAR ORAL TABLET 20
MG, 40 MG, 5 MG
candesartan oral tablet 16 mg, 32
mg, 4 mg, 8 mg
(Atacand)
QL (4 per 28 days)
QL (8 per 28 days)
PA-HRM
PA; QL (180 per 30
days)
92
Tier level
What the
drug will
cost you
1
$0
2
$0
(Avapro)
1
$0
(Avalide)
1
$0
(Cozaar)
1
$0
(Hyzaar)
1
$0
(Micardis)
1
$0
(Micardis HCT)
1
$0
Name of Drug
candesartan-hydrochlorothiazid
oral tablet 16-12.5 mg, 32-12.5 mg,
32-25 mg
ENTRESTO ORAL TABLET 24-26
MG, 49-51 MG, 97-103 MG
irbesartan oral tablet 150 mg, 300
mg, 75 mg
irbesartan-hydrochlorothiazide oral
tablet 150-12.5 mg, 300-12.5 mg
losartan oral tablet 100 mg, 25 mg,
50 mg
losartan-hydrochlorothiazide oral
tablet 100-12.5 mg, 100-25 mg, 5012.5 mg
telmisartan oral tablet 20 mg, 40
mg, 80 mg
telmisartan-hydrochlorothiazid oral
tablet 40-12.5 mg, 80-12.5 mg, 8025 mg
TRIBENZOR ORAL TABLET 205-12.5 MG, 40-10-12.5 MG, 40-1025 MG, 40-5-12.5 MG, 40-5-25 MG
valsartan oral tablet 160 mg, 320
mg, 40 mg, 80 mg
valsartan-hydrochlorothiazide oral
tablet 160-12.5 mg, 160-25 mg, 32012.5 mg, 320-25 mg, 80-12.5 mg
Angiotensin-Converting
Enzyme Inhibitors
benazepril oral tablet 10 mg, 20 mg,
40 mg, 5 mg
benazepril-hydrochlorothiazide oral
tablet 10-12.5 mg, 20-12.5 mg, 2025 mg, 5-6.25 mg
(Atacand HCT)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (60 per 30
days)
ST
2
$0
(Diovan)
1
$0
(Diovan HCT)
1
$0
(Lotensin)
1
$0
(Lotensin HCT)
1
$0
93
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
captopril oral tablet 100 mg, 12.5
(Captopril)
1
$0
mg, 25 mg, 50 mg
captopril-hydrochlorothiazide oral
(Captopril/Hydroch
tablet 25-15 mg, 25-25 mg, 50-15
1
$0
lorothiazide)
mg, 50-25 mg
enalapril maleate oral tablet 10 mg,
(Vasotec)
1
$0
2.5 mg, 20 mg, 5 mg
enalaprilat intravenous solution
(Enalaprilat
1
$0
1.25 mg/ml
Dihydrate)
enalapril-hydrochlorothiazide oral
(Vaseretic)
1
$0
tablet 10-25 mg, 5-12.5 mg
fosinopril oral tablet 10 mg, 20 mg, (Fosinopril
1
$0
40 mg
Sodium)
fosinopril-hydrochlorothiazide oral (Fosinopril/Hydroc
1
$0
tablet 10-12.5 mg, 20-12.5 mg
hlorothiazide)
lisinopril oral tablet 10 mg, 2.5 mg,
(Zestril)
1
$0
20 mg, 30 mg, 40 mg, 5 mg
lisinopril-hydrochlorothiazide oral
tablet 10-12.5 mg, 20-12.5 mg, 20- (Zestoretic)
1
$0
25 mg
moexipril oral tablet 15 mg, 7.5 mg (Moexipril HCl)
1
$0
moexipril-hydrochlorothiazide oral
(Moexipril/Hydroc
tablet 15-12.5 mg, 15-25 mg, 7.51
$0
hlorothiazide)
12.5 mg
perindopril erbumine oral tablet 2
(Aceon)
1
$0
mg, 4 mg, 8 mg
quinapril oral tablet 10 mg, 20 mg,
(Accupril)
1
$0
40 mg, 5 mg
quinapril-hydrochlorothiazide oral
tablet 10-12.5 mg, 20-12.5 mg, 20- (Accuretic)
1
$0
25 mg
ramipril oral capsule 1.25 mg, 10
(Altace)
1
$0
mg, 2.5 mg, 5 mg
trandolapril oral tablet 1 mg, 2 mg,
(Mavik)
1
$0
4 mg
94
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
Antiarrhythmic Agents
amiodarone oral tablet 100 mg, 200
(Cordarone)
1
$0
mg, 400 mg
disopyramide phosphate oral
(Norpace)
1
$0
capsule 100 mg, 150 mg
dofetilide oral capsule 125 mcg, 250
(Tikosyn)
1
$0
mcg, 500 mcg
flecainide oral tablet 100 mg, 150
(Tambocor)
1
$0
mg, 50 mg
lidocaine (pf) intravenous syringe
(Lidocaine
1
$0
50 mg/5 ml (1 %)
HCl/PF)
lidocaine in 5 % dextrose (pf)
(Lidocaine
1
$0
HCl/D5w/PF)
mg/ml (0.8 %)
mexiletine oral capsule 150 mg, 200
(Mexiletine HCl)
1
$0
mg, 250 mg
MULTAQ ORAL TABLET 400
2
$0
MG
pacerone oral tablet 100 mg, 200
(Cordarone)
1
$0
mg, 400 mg
procainamide injection solution 100 (Procainamide
1
$0
mg/ml, 500 mg/ml
HCl)
propafenone oral capsule,extended
release 12 hr 225 mg, 325 mg, 425 (Rythmol SR)
1
$0
mg
propafenone oral tablet 150 mg, 225
(Rythmol)
1
$0
mg, 300 mg
quinidine gluconate oral tablet
(Quinidine
1
$0
extended release 324 mg
Gluconate)
quinidine sulfate oral tablet 200 mg,
(Quinidine Sulfate)
1
$0
300 mg
quinidine sulfate oral tablet
(Quinidine Sulfate)
1
$0
TIKOSYN ORAL CAPSULE 125
2
$0
MCG, 250 MCG, 500 MCG
95
Tier level
What the
drug will
cost you
(Sectral)
1
$0
(Tenormin)
1
$0
(Tenoretic 50)
1
$0
(Betaxolol HCl)
1
$0
(Zebeta)
1
$0
(Ziac)
1
$0
2
$0
(Coreg)
1
$0
(Brevibloc)
1
$0
(Labetalol HCl)
1
$0
(Trandate)
1
$0
(Toprol XL)
1
$0
(Lopressor HCT)
1
$0
(Lopressor)
1
$0
(Lopressor)
1
$0
Name of Drug
Beta-Adrenergic Blocking
Agents
acebutolol oral capsule 200 mg, 400
mg
atenolol oral tablet 100 mg, 25 mg,
50 mg
atenolol-chlorthalidone oral tablet
100-25 mg, 50-25 mg
betaxolol oral tablet 10 mg, 20 mg
bisoprolol fumarate oral tablet 10
mg, 5 mg
bisoprolol-hydrochlorothiazide oral
tablet 10-6.25 mg, 2.5-6.25 mg, 56.25 mg
BYSTOLIC ORAL TABLET 10
MG, 2.5 MG, 20 MG, 5 MG
carvedilol oral tablet 12.5 mg, 25
mg, 3.125 mg, 6.25 mg
esmolol intravenous solution 100
mg/10 ml (10 mg/ml)
labetalol intravenous solution 5
mg/ml
labetalol oral tablet 100 mg, 200
mg, 300 mg
metoprolol succinate oral tablet
extended release 24 hr 100 mg, 200
mg, 25 mg, 50 mg
metoprolol ta-hydrochlorothiaz oral
tablet 100-25 mg, 100-50 mg, 50-25
mg
metoprolol tartrate intravenous
solution 5 mg/5 ml
metoprolol tartrate oral tablet 100
mg, 25 mg, 37.5 mg, 50 mg, 75 mg
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
96
Tier level
What the
drug will
cost you
(Corgard)
1
$0
(Pindolol)
1
$0
(Propranolol HCl)
1
$0
(Inderal LA)
1
$0
(Propranolol HCl)
1
$0
(Propranolol HCl)
1
$0
(Propranolol/Hydro
chlorothiazid)
1
$0
(Betapace)
1
$0
(Betapace)
(Betapace)
1
1
$0
$0
(Betapace)
1
$0
(Timolol Maleate)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
Name of Drug
nadolol oral tablet 20 mg, 40 mg, 80
mg
pindolol oral tablet 10 mg, 5 mg
propranolol intravenous solution 1
mg/ml
propranolol oral capsule,extended
release 24 hr 120 mg, 160 mg, 60
mg, 80 mg
propranolol oral solution 20 mg/5
ml (4 mg/ml), 40 mg/5 ml (8 mg/ml)
propranolol oral tablet 10 mg, 20
mg, 40 mg, 60 mg, 80 mg
propranolol-hydrochlorothiazid
oral tablet 40-25 mg, 80-25 mg
sorine oral tablet 120 mg, 160 mg,
240 mg, 80 mg
sotalol 120 mg tablet 120 mg
sotalol af oral tablet 120 mg
sotalol oral tablet 160 mg, 240 mg,
80 mg
timolol maleate oral tablet 10 mg,
20 mg, 5 mg
Calcium-Channel Blocking
Agents
cartia xt oral capsule,extended
mg, 300 mg
diltiazem 24hr er 180 mg cap 180
mg
diltiazem 24hr er 360 mg cap 360
mg
diltiazem hcl intravenous recon soln
100 mg
Necessary Actions,
Restrictions, or
Limits on Use
97
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
diltiazem hcl intravenous solution 5
(Cardizem CD)
1
$0
mg/ml
diltiazem hcl oral capsule, extended
(Cardizem CD)
1
$0
diltiazem hcl oral capsule,extended
(Cardizem CD)
1
$0
release 12 hr 120 mg, 60 mg, 90 mg
diltiazem hcl oral capsule,extended
(Cardizem CD)
1
$0
mg
diltiazem hcl oral tablet 120 mg, 30
(Cardizem CD)
1
$0
mg, 60 mg, 90 mg
diltiazem hcl oral tablet extended
release 24 hr 180 mg, 240 mg, 300 (Cardizem LA)
1
$0
mg, 360 mg, 420 mg
dilt-xr oral capsule,ext release
(Cardizem CD)
1
$0
degradable 120 mg, 180 mg, 240 mg
matzim la oral tablet extended
release 24 hr 180 mg, 240 mg, 300 (Cardizem CD)
1
$0
mg, 360 mg, 420 mg
taztia xt oral capsule, extended
release 120 mg, 180 mg, 240 mg,
(Cardizem CD)
1
$0
300 mg, 360 mg
verapamil intravenous syringe 2.5
(Verapamil HCl)
1
$0
mg/ml
verapamil oral capsule, 24 hr er
(Verelan Pm)
1
$0
pellet ct 100 mg, 200 mg, 300 mg
verapamil oral capsule,ext rel.
pellets 24 hr 120 mg, 180 mg, 240
(Verelan)
1
$0
mg, 360 mg
verapamil oral tablet 120 mg, 40
(Calan)
1
$0
mg, 80 mg
verapamil oral tablet extended
(Calan SR)
1
$0
Cardiovascular Agents,
Miscellaneous
98
Name of Drug
CORLANOR ORAL TABLET 5
MG, 7.5 MG
DEMSER ORAL CAPSULE 250
MG
Tier level
What the
drug will
cost you
2
$0
2
$0
digitek oral tablet 125 mcg
(Lanoxin)
1
$0
digitek oral tablet 250 mcg
(Lanoxin)
1
$0
digox 125 mcg tablet 125 mcg
(Lanoxin)
1
$0
digox 250 mcg tablet 250 mcg
(Lanoxin)
1
$0
(Digoxin)
1
$0
(Digoxin)
1
$0
2
$0
digoxin 0.25 mg/ml syringe 250
mcg/ml
digoxin injection solution 250
mcg/ml
DIGOXIN ORAL SOLUTION 50
MCG/ML
Necessary Actions,
Restrictions, or
Limits on Use
ST
(High Risk Med for
Ages 65 and Older and
Dose is Greater Than
125mcg Per Day); QL
(30 per 30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per
30 days)
(High Risk Med for
125mcg Per Day); QL
(30 per 30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days)
PA-HRM
PA-HRM
PA-HRM; QL (300 per
30 days)
99
Name of Drug
Tier level
What the
drug will
cost you
digoxin oral tablet 125 mcg
(Lanoxin)
1
$0
digoxin oral tablet 250 mcg
(Lanoxin)
1
$0
(Dobutamine
HCl/D5W)
1
$0
(Dobutamine HCl)
1
$0
dobutamine in d5w intravenous
parenteral solution 1,000 mg/250 ml
(4,000 mcg/ml), 250 mg/250 ml (1
mg/ml), 500 mg/250 ml (2,000
mcg/ml)
dobutamine intravenous solution
250 mg/20 ml (12.5 mg/ml)
dopamine in 5 % dextrose
intravenous solution 200 mg/250 ml
(800 mcg/ml), 400 mg/250 ml (1,600
mcg/ml), 800 mg/250 ml (3,200
mcg/ml)
dopamine intravenous solution 200
mg/5 ml (40 mg/ml), 400 mg/5 ml
(80 mg/ml), 800 mg/10 ml (80
mg/ml), 800 mg/5 ml (160 mg/ml)
ephedrine sulfate injection solution
50 mg/ml
epinephrine hcl (pf) intravenous
solution 1 mg/ml (1 ml)
epinephrine injection auto-injector
0.15 mg/0.15 ml, 0.3 mg/0.3 ml
epinephrine injection solution 1
mg/ml (1 ml)
Necessary Actions,
Restrictions, or
Limits on Use
(High Risk Med for
125mcg Per Day); QL
(30 per 30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days)
PA BvD
PA BvD
PA BvD
(Dopamine
HCl/D5W)
1
$0
PA BvD
(Dopamine HCl)
1
$0
(Ephedrine Sulfate)
1
$0
(Epinephrine
HCl/PF)
1
$0
(Adrenaclick)
1
$0
(Epinephrine)
1
$0
100
Name of Drug
epinephrine injection syringe 0.1
(Epinephrine)
mg/ml
EPIPEN 2-PAK INJECTION
AUTO-INJECTOR 0.3 MG/0.3 ML
EPIPEN JR 2-PAK INJECTION
AUTO-INJECTOR 0.15 MG/0.3
ML
(Ethanolamine
ethamolin intravenous solution 5 %
Oleate)
FIRAZYR SUBCUTANEOUS
SYRINGE 30 MG/3 ML
hydralazine injection solution 20
(Hydralazine HCl)
mg/ml
hydralazine oral tablet 10 mg, 100
(Hydralazine HCl)
mg, 25 mg, 50 mg
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
1
$0
2
$0
1
$0
1
$0
LANOXIN ORAL TABLET 187.5
MCG
2
$0
LANOXIN ORAL TABLET 62.5
MCG
2
$0
(Milrinone
Lactate/D5W)
1
$0
(Milrinone Lactate)
1
$0
(Levophed
Bitartrate)
1
$0
milrinone in 5 % dextrose
ml (200 mcg/ml), 40 mg/200 ml (200
mcg/ml)
milrinone intravenous solution 1
mg/ml
norepinephrine bitartrate
intravenous solution 1 mg/ml
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days)
(High Risk Med for
125mcg Per Day); QL
(30 per 30 days)
PA BvD
PA BvD
PA BvD
101
Tier level
What the
drug will
cost you
(Papaverine HCl)
1
$0
(Papaverine HCl)
1
$0
2
$0
(Adalat CC)
1
$0
(Norvasc)
1
$0
(Lotrel)
1
$0
(Exforge)
1
$0
(Exforge HCT)
1
$0
2
$0
2
$0
(Felodipine)
1
$0
(Isradipine)
1
$0
(Nicardipine HCl)
1
$0
(Procardia XL)
1
$0
(Adalat CC)
1
$0
Name of Drug
papaverine injection solution 30
mg/ml
papaverine oral capsule, extended
release 150 mg
RANEXA ORAL TABLET
EXTENDED RELEASE 12 HR
1,000 MG, 500 MG
Dihydropyridines
afeditab cr oral tablet extended
amlodipine oral tablet 10 mg, 2.5
mg, 5 mg
amlodipine-benazepril oral capsule
10-20 mg, 10-40 mg, 2.5-10 mg, 510 mg, 5-20 mg, 5-40 mg
amlodipine-valsartan oral tablet 10160 mg, 10-320 mg, 5-160 mg, 5320 mg
amlodipine-valsartan-hcthiazid oral
tablet 10-160-12.5 mg, 10-160-25
mg, 10-320-25 mg, 5-160-12.5 mg,
5-160-25 mg
AZOR ORAL TABLET 10-20 MG,
10-40 MG, 5-20 MG, 5-40 MG
CLEVIPREX INTRAVENOUS
EMULSION 50 MG/100 ML
felodipine oral tablet extended
release 24 hr 10 mg, 2.5 mg, 5 mg
isradipine oral capsule 2.5 mg, 5 mg
nicardipine oral capsule 20 mg, 30
mg
nifedical xl oral tablet extended
nifedipine er 30 mg tablet f/c 30 mg
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
ST
102
Tier level
What the
drug will
cost you
(Adalat CC)
1
$0
(Procardia XL)
1
$0
(Amiloride HCl)
(Amiloride/Hydroc
hlorothiazide)
1
$0
1
$0
(Bumetanide)
1
$0
(Bumetanide)
1
$0
(Chlorothiazide)
1
$0
(Sodium Diuril)
1
$0
(Chlorthalidone)
1
$0
2
$0
(Furosemide)
1
$0
(Furosemide)
1
$0
(Furosemide)
1
$0
(Lasix)
1
$0
(Microzide)
1
$0
(Hydrochlorothiazi
de)
1
$0
(Indapamide)
1
$0
Name of Drug
nifedipine oral tablet extended
release 24hr 30 mg
nifedipine oral tablet extended
Diuretics
amiloride oral tablet 5 mg
amiloride-hydrochlorothiazide oral
tablet 5-50 mg
bumetanide injection solution 0.25
mg/ml
bumetanide oral tablet 0.5 mg, 1
mg, 2 mg
chlorothiazide oral tablet 250 mg,
500 mg
chlorothiazide sodium intravenous
recon soln 500 mg
chlorthalidone oral tablet 25 mg, 50
mg
DYRENIUM ORAL CAPSULE
100 MG, 50 MG
furosemide injection solution 10
mg/ml
furosemide injection syringe 10
mg/ml
furosemide oral solution 10 mg/ml,
40 mg/5 ml (8 mg/ml)
furosemide oral tablet 20 mg, 40
mg, 80 mg
hydrochlorothiazide oral capsule
12.5 mg
hydrochlorothiazide oral tablet 12.5
mg, 25 mg, 50 mg
indapamide oral tablet 1.25 mg, 2.5
mg
Necessary Actions,
Restrictions, or
Limits on Use
103
Tier level
What the
drug will
cost you
(Methyclothiazide)
1
$0
(Zaroxolyn)
1
$0
(Demadex)
1
$0
(Dyazide)
1
$0
(Maxzide)
1
$0
(Caduet)
1
$0
(Lipitor)
1
$0
(Questran)
1
$0
(Questran)
1
$0
(Colestid)
1
$0
(Colestid)
(Colestid)
1
1
$0
$0
1
$0
(Slo-Niacin)
4
$0
(Lofibra)
1
$0
(Tricor)
1
$0
Name of Drug
methyclothiazide oral tablet 5 mg
metolazone oral tablet 10 mg, 2.5
mg, 5 mg
torsemide oral tablet 10 mg, 100
mg, 20 mg, 5 mg
triamterene-hydrochlorothiazid oral
capsule 37.5-25 mg, 50-25 mg
triamterene-hydrochlorothiazid oral
tablet 37.5-25 mg, 75-50 mg
Dyslipidemics
amlodipine-atorvastatin oral tablet
10-10 mg, 10-20 mg, 10-40 mg, 1080 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40
mg, 5-10 mg, 5-20 mg, 5-40 mg, 580 mg
atorvastatin oral tablet 10 mg, 20
mg, 40 mg, 80 mg
cholestyramine light oral powder in
packet 4 gram
cholestyramine packet 4 gram
colestipol hcl granules packet 5
gram
colestipol oral granules 5 gram
colestipol oral tablet 1 gram
CRESTOR ORAL TABLET 10
MG, 20 MG, 40 MG, 5 MG
endur-acin sr 500 mg tablet 500 mg
*
fenofibrate micronized oral capsule
130 mg, 134 mg, 200 mg, 43 mg, 67
mg
fenofibrate nanocrystallized oral
tablet 145 mg, 48 mg
Necessary Actions,
Restrictions, or
Limits on Use
104
Tier level
What the
drug will
cost you
(Lofibra)
1
$0
(Trilipix)
1
$0
(Fibricor)
1
$0
(Lopid)
1
$0
2
$0
2
$0
(Mevacor)
1
$0
(Slo-Niacin)
(Niacin)
(Slo-Niacin)
4
4
4
$0
$0
$0
(Niaspan)
1
$0
(Slo-Niacin)
4
$0
(Niacinamide)
(Niacin)
4
1
$0
$0
(Lovaza)
1
$0
Name of Drug
fenofibrate oral tablet 120 mg, 160
mg, 40 mg, 54 mg
fenofibric acid (choline) oral
capsule,delayed release(dr/ec) 135
mg, 45 mg
fenofibric acid oral tablet 105 mg,
35 mg
gemfibrozil oral tablet 600 mg
JUXTAPID ORAL CAPSULE 10
MG, 20 MG, 30 MG, 40 MG, 5
MG, 60 MG
KYNAMRO SUBCUTANEOUS
SYRINGE 200 MG/ML
lovastatin oral tablet 10 mg, 20 mg,
40 mg
niacin 50 mg tablet 50 mg *
niacin 500 mg capsule sa 500 mg *
niacin 500 mg tablet 500 mg *
niacin oral tablet extended release
24 hr 1,000 mg, 500 mg, 750 mg
niacin tr 500 mg caplet caplet 500
mg *
niacinamide 500 mg tablet 500 mg *
niacor oral tablet 500 mg
omega-3 acid ethyl esters oral
capsule 1 gram
PRALUENT PEN
SUBCUTANEOUS PEN
INJECTOR 150 MG/ML, 75
MG/ML
PRALUENT SYRINGE
SUBCUTANEOUS SYRINGE 150
MG/ML, 75 MG/ML
Necessary Actions,
Restrictions, or
Limits on Use
PA
2
$0
2
$0
105
Name of Drug
pravastatin oral tablet 10 mg, 20
mg, 40 mg, 80 mg
prevalite oral powder 4 gram
prevalite packet outer 4 gram
(Pravachol)
(Cholestyramine/A
spartame)
(Cholestyramine/A
spartame)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
REPATHA PUSHTRONEX
PA; QL (3.5 per 28
SUBCUTANEOUS WEARABLE
2
$0
days)
INJECTOR 420 MG/3.5 ML
REPATHA SURECLICK
SUBCUTANEOUS PEN
2
$0
INJECTOR 140 MG/ML
REPATHA SYRINGE
2
$0
MG/ML
rosuvastatin oral tablet 10 mg, 20
(Crestor)
1
$0
mg, 40 mg, 5 mg
simvastatin oral tablet 10 mg, 20
(Zocor)
1
$0
mg, 40 mg, 5 mg
simvastatin oral tablet 80 mg
(Zocor)
1
$0
QL (30 per 30 days)
VASCEPA ORAL CAPSULE 1
2
$0
GRAM
WELCHOL ORAL POWDER IN
2
$0
PACKET 3.75 GRAM
WELCHOL ORAL TABLET 625
2
$0
MG
ZETIA ORAL TABLET 10 MG
2
$0
Renin-AngiotensinAldosterone System
Inhibitors
eplerenone oral tablet 25 mg, 50 mg (Inspra)
1
$0
spironolactone oral tablet 100 mg,
(Aldactone)
1
$0
25 mg, 50 mg
spironolacton-hydrochlorothiaz oral
(Aldactazide)
1
$0
tablet 25-25 mg
106
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
Vasodilators
BIDIL ORAL TABLET 20-37.5
2
$0
MG
isosorbide dinitrate oral tablet 10
(Isochron)
1
$0
mg, 20 mg, 30 mg, 5 mg
isosorbide dinitrate oral tablet
(Isochron)
1
$0
isosorbide dinitrate sublingual
(Isosorbide
1
$0
tablet 2.5 mg, 5 mg
Dinitrate)
isosorbide mononitrate oral tablet
(Isosorbide
1
$0
10 mg, 20 mg
Mononitrate)
isosorbide mononitrate oral tablet
extended release 24 hr 120 mg, 30
(Imdur)
1
$0
mg, 60 mg
minitran transdermal patch 24 hour
QL (30 per 30 days)
(Nitro-Dur)
1
$0
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
minitran transdermal patch 24 hour
QL (60 per 30 days)
(Nitro-Dur)
1
$0
0.4 mg/hr
minoxidil oral tablet 10 mg, 2.5 mg (Minoxidil)
1
$0
NITRO-BID TRANSDERMAL
1
$0
OINTMENT 2 %
nitroglycerin in 5 % dextrose
(Nitroglycerin/D5
(400 mcg/ml), 25 mg/250 ml (100
1
$0
W)
mcg/ml), 50 mg/250 ml (200
mcg/ml)
nitroglycerin intravenous solution
(Nitroglycerin)
1
$0
50 mg/10 ml (5 mg/ml)
nitroglycerin transdermal patch 24
QL (30 per 30 days)
hour 0.1 mg/hr, 0.2 mg/hr, 0.6
(Nitro-Dur)
1
$0
mg/hr
nitroglycerin transdermal patch 24
QL (60 per 30 days)
(Nitro-Dur)
1
$0
hour 0.4 mg/hr
NITROSTAT SUBLINGUAL
2
$0
TABLET 0.3 MG, 0.4 MG, 0.6 MG
107
Tier level
What the
drug will
cost you
2
$0
2
$0
(Cafcit)
1
$0
(Cafcit)
1
$0
(Caffeine/Sodium
Benzoate)
1
$0
(Kapvay)
1
$0
(Focalin)
1
$0
Name of Drug
PROGLYCEM ORAL
SUSPENSION 50 MG/ML
Necessary Actions,
Restrictions, or
Limits on Use
Central Nervous System
Agents
Central Nervous System
Agents
AMPYRA ORAL TABLET
MG
caffeine citrated intravenous
caffeine citrated oral solution 60
mg/3 ml (20 mg/ml)
caffeine-sodium benzoate injection
solution 250 mg/ml (125 mg/ml
caffeine)
clonidine hcl oral tablet extended
release 12 hr 0.1 mg
dexmethylphenidate oral tablet 10
mg, 2.5 mg, 5 mg
dextroamphetamine oral capsule,
extended release 10 mg, 15 mg, 5
mg
dextroamphetamine oral tablet 10
mg, 5 mg
dextroamphetamine-amphetamine
oral capsule,extended release 24hr
10 mg, 15 mg, 5 mg
oral capsule,extended release 24hr
20 mg, 25 mg, 30 mg
oral tablet 10 mg, 12.5 mg, 15 mg,
20 mg, 30 mg, 5 mg, 7.5 mg
PA; QL (60 per 30
days)
QL (60 per 30 days)
(Dexedrine)
1
$0
(Dexedrine)
1
$0
QL (30 per 30 days)
(Adderall XR)
1
$0
(Adderall XR)
1
$0
(Adderall)
1
$0
QL (60 per 30 days)
QL (60 per 30 days)
108
Tier level
What the
drug will
cost you
(Romazicon)
1
$0
(Intuniv)
1
$0
(Lithium
Carbonate)
1
$0
(Lithobid)
1
$0
(Lithobid)
1
$0
(Lithium Citrate)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Methylin)
1
$0
(Ritalin)
1
$0
(Methylphenidate
HCl)
1
$0
(Concerta)
1
$0
(Concerta)
1
$0
Name of Drug
flumazenil intravenous solution 0.1
mg/ml
guanfacine oral tablet extended
release 24 hr 1 mg, 2 mg, 3 mg, 4
mg
lithium carbonate oral capsule 150
mg, 300 mg, 600 mg
lithium carbonate oral tablet 300
mg
lithium carbonate oral tablet
extended release 300 mg, 450 mg
lithium citrate oral solution 8 meq/5
ml
methylphenidate cd 20 mg cap 20
mg
methylphenidate cd 40 mg cap 40
mg
methylphenidate oral capsule, er
biphasic 30-70 10 mg, 50 mg, 60 mg
methylphenidate oral capsule, er
biphasic 30-70 30 mg
methylphenidate oral capsule,er
biphasic 50-50 20 mg, 40 mg
methylphenidate oral solution 10
mg/5 ml, 5 mg/5 ml
methylphenidate oral tablet 10 mg,
20 mg, 5 mg
methylphenidate oral tablet
extended release 10 mg, 20 mg
extended release 24hr 18 mg, 27
mg, 54 mg
extended release 24hr 36 mg
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
109
Name of Drug
NUEDEXTA ORAL CAPSULE 2010 MG
QUILLIVANT XR ORAL
SUSPENSION,EXT REL
24HR,RECON 5 MG/ML (25 MG/5
ML)
riluzole oral tablet 50 mg
(Rilutek)
SAVELLA ORAL TABLET 100
MG, 12.5 MG, 25 MG, 50 MG
SAVELLA ORAL
TABLETS,DOSE PACK 12.5 MG
(5)-25 MG(8)-50 MG(42)
STRATTERA ORAL CAPSULE 10
MG, 100 MG, 18 MG, 25 MG, 40
MG, 60 MG, 80 MG
tetrabenazine oral tablet 12.5 mg,
(Xenazine)
25 mg
Tier level
What the
drug will
cost you
2
$0
2
$0
1
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
2
$0
2
$0
1
$0
3
$0
(Amethyst)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
PA; QL (112 per 28
days)
Contraceptives
Contraceptives
AFTERA 1.5 MG TABLET 1.5 MG
*
altavera (28) oral tablet 0.15-0.03
mg
alyacen 1/35 (28) oral tablet 1-35
mg-mcg
alyacen 7/7/7 (28) oral tablet
0.5/0.75/1 mg- 35 mcg
amethia lo oral tablets,dose pack,3
month 0.10 mg-20 mcg (84)/10 mcg
(7)
amethia oral tablets,dose pack,3
(7)
apri oral tablet 0.15-0.03 mg
QL (6 per 365 days)
QL (91 per 84 days)
(Seasonique)
1
$0
(Seasonique)
1
$0
(Desogen)
1
$0
QL (91 per 84 days)
110
Tier level
What the
drug will
cost you
(Modicon)
1
$0
(Seasonique)
1
$0
(Amethyst)
(Amethyst)
1
1
$0
$0
(Mircette)
1
$0
(Modicon)
1
$0
(Mircette)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Modicon)
(Nor-Q-D)
1
1
$0
$0
(Seasonique)
1
$0
Name of Drug
aranelle (28) oral tablet 0.5/1/0.535 mg-mcg
ashlyna oral tablets,dose pack,3
(7)
aubra oral tablet 0.1-20 mg-mcg
aviane oral tablet 0.1-20 mg-mcg
azurette (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
balziva (28) oral tablet 0.4-35 mgmcg
bekyree (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
blisovi 24 fe oral tablet 1 mg-20
mcg (24)/75 mg (4)
blisovi fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
blisovi fe 1/20 (28) oral tablet 1 mg20 mcg (21)/75 mg (7)
briellyn oral tablet 0.4-35 mg-mcg
camila oral tablet 0.35 mg
camrese lo oral tablets,dose pack,3
(7)
camrese oral tablets,dose pack,3
(7)
caziant (28) oral tablet 0.1/.125/.1525 mg-mcg
cryselle (28) oral tablet 0.3-30 mgmcg
cyclafem 1/35 (28) oral tablet 1-35
mg-mcg
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
QL (91 per 84 days)
(Seasonique)
1
$0
(Desogen)
1
$0
(Norgestrel-Ethinyl
Estradiol)
1
$0
(Modicon)
1
$0
111
Tier level
What the
drug will
cost you
(Modicon)
1
$0
(Desogen)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
Name of Drug
cyclafem 7/7/7 (28) oral tablet
0.5/0.75/1 mg- 35 mcg
cyred oral tablet 0.15-0.03 mg
dasetta 1/35 (28) oral tablet 1-35
mg-mcg
dasetta 7/7/7 (28) oral tablet
0.5/0.75/1 mg- 35 mcg
daysee oral tablets,dose pack,3
(7)
deblitane oral tablet 0.35 mg
delyla (28) oral tablet 0.1-20 mgmcg
desog-e.estradiol/e.estradiol oral
tablet 0.15-0.02 mgx21 /0.01 mg x 5
desogestrel-ethinyl estradiol oral
tablet 0.15-0.03 mg
drospirenone-ethinyl estradiol oral
tablet 3-0.02 mg, 3-0.03 mg
econtra ez 1.5 mg tablet inner 1.5
mg *
elinest oral tablet 0.3-30 mg-mcg
ELLA ORAL TABLET 30 MG
emoquette oral tablet 0.15-0.03 mg
enpresse oral tablet 50-30 (6)/75-40
(5)/125-30(10)
enskyce oral tablet 0.15-0.03 mg
errin oral tablet 0.35 mg
estarylla oral tablet 0.25-35 mg-mcg
falmina (28) oral tablet 0.1-20 mgmcg
gianvi (28) oral tablet 3-0.02 mg
gildagia oral tablet 0.4-35 mg-mcg
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
(Seasonique)
1
$0
(Nor-Q-D)
1
$0
(Amethyst)
1
$0
(Mircette)
1
$0
(Desogen)
1
$0
(Yaz)
1
$0
(Aftera)
4
$0
(Norgestrel-Ethinyl
Estradiol)
1
$0
(Desogen)
2
1
$0
$0
(Amethyst)
1
$0
(Desogen)
(Nor-Q-D)
(Ortho-Cyclen)
1
1
1
$0
$0
$0
(Amethyst)
1
$0
(Yaz)
(Modicon)
1
1
$0
$0
QL (6 per 365 days)
QL (6 per 365 days)
112
Tier level
What the
drug will
cost you
(Loestrin)
1
$0
(Loestrin)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Nor-Q-D)
(LevonorgestrelEthin Estradiol)
(Nor-Q-D)
(Nor-Q-D)
(Desogen)
1
$0
1
$0
1
$0
1
$0
1
1
$0
$0
(Loestrin)
1
$0
(Loestrin)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Mircette)
1
$0
(Demulen 1-50-21)
1
$0
(Mircette)
1
$0
Name of Drug
gildess 1.5/30 (21) oral tablet 1.5-30
mg-mcg
gildess 1/20 (21) oral tablet 1-20
mg-mcg
gildess 24 fe oral tablet 1 mg-20
mcg (24)/75 mg (4)
gildess fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
gildess fe 1/20 (28) oral tablet 1 mg20 mcg (21)/75 mg (7)
heather oral tablet 0.35 mg
introvale oral tablets,dose pack,3
month 0.15-30 mg-mcg
jencycla oral tablet 0.35 mg
jolessa oral tablets,dose pack,3
jolivette oral tablet 0.35 mg
juleber oral tablet 0.15-0.03 mg
junel 1.5/30 (21) oral tablet 1.5-30
mg-mcg
junel 1/20 (21) oral tablet 1-20 mgmcg
junel fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
junel fe 1/20 (28) oral tablet 1 mg20 mcg (21)/75 mg (7)
junel fe 24 oral tablet 1 mg-20 mcg
(24)/75 mg (4)
kariva (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
kelnor 1/35 (28) oral tablet 1-35
mg-mcg
kimidess (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
QL (91 per 84 days)
113
Name of Drug
kurvelo oral tablet 0.15-0.03 mg
l norgest/e.estradiol-e.estrad oral
tablets,dose pack,3 month 0.10 mg20 mcg (84)/10 mcg (7), 0.15 mg-30
mcg (84)/10 mcg (7)
larin 1.5/30 (21) oral tablet 1.5-30
mg-mcg
larin 1/20 (21) oral tablet 1-20 mgmcg
larin 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
larin fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
larin fe 1/20 (28) oral tablet 1 mg20 mcg (21)/75 mg (7)
leena 28 oral tablet 0.5/1/0.5-35
mg-mcg
lessina oral tablet 0.1-20 mg-mcg
levonest (28) oral tablet 50-30
(6)/75-40 (5)/125-30(10)
levonor-eth estrad 0.15-0.03 outer
0.15-0.03 mg
levonorgestrel 1.5 mg tablet (otc)
1.5 mg *
levonorgestrel oral tablet 0.75 mg
levonorgestrel oral tablet 1.5 mg
levonorgestrel-ethinyl estrad oral
tablet 0.1-20 mg-mcg
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month 0.15-30
mg-mcg
levonorg-eth estrad triphasic oral
tablet 50-30 (6)/75-40 (5)/12530(10)
(Amethyst)
Tier level
What the
drug will
cost you
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
(Seasonique)
1
$0
(Loestrin)
1
$0
(Loestrin)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Modicon)
1
$0
(Amethyst)
1
$0
(Amethyst)
1
$0
(Amethyst)
1
$0
(Aftera)
4
$0
(Plan B One-Step)
(Plan B One-Step)
1
1
$0
$0
(Amethyst)
1
$0
(Amethyst)
1
$0
(Amethyst)
1
$0
QL (91 per 84 days)
QL (6 per 365 days)
QL (6 per 365 days)
QL (91 per 84 days)
QL (91 per 84 days)
114
Tier level
What the
drug will
cost you
(Amethyst)
1
$0
(Loestrin Fe)
1
$0
(Yaz)
(Norgestrel-Ethinyl
Estradiol)
1
$0
1
$0
(Amethyst)
1
$0
(Nor-Q-D)
(Amethyst)
1
1
$0
$0
(Loestrin)
1
$0
(Loestrin)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Ortho-Cyclen)
1
$0
(Ortho-Cyclen)
1
$0
(Aftera)
4
$0
(Amethyst)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
(Norinyl 1+50)
1
$0
(Modicon)
1
$0
Name of Drug
levora-28 oral tablet 0.15-0.03 mg
lomedia 24 fe oral tablet 1 mg-20
mcg (24)/75 mg (4)
loryna (28) oral tablet 3-0.02 mg
low-ogestrel (28) oral tablet 0.3-30
mg-mcg
lutera (28) oral tablet 0.1-20 mgmcg
lyza oral tablet 0.35 mg
marlissa oral tablet 0.15-0.03 mg
microgestin 1.5/30 (21) oral tablet
1.5-30 mg-mcg
microgestin 1/20 (21) oral tablet 120 mg-mcg
microgestin fe 1.5/30 (28) oral
tablet 1.5 mg-30 mcg (21)/75 mg (7)
microgestin fe 1/20 (28) oral tablet
1 mg-20 mcg (21)/75 mg (7)
mono-linyah oral tablet 0.25-35 mgmcg
mononessa (28) oral tablet 0.25-35
mg-mcg
my way 1.5 mg tablet (otc) 1.5 mg *
myzilra oral tablet 50-30 (6)/75-40
(5)/125-30(10)
necon 0.5/35 (28) oral tablet 0.5-35
mg-mcg
necon 1/35 (28) oral tablet 1-35 mgmcg
necon 1/50 (28) oral tablet 1-50 mgmcg
necon 10/11 (28) oral tablet 0.535/1-35 mg-mcg/mg-mcg
Necessary Actions,
Restrictions, or
Limits on Use
QL (6 per 365 days)
115
Tier level
What the
drug will
cost you
(Modicon)
1
$0
(Aftera)
4
$0
(Plan B One-Step)
1
$0
(Yaz)
(Nor-Q-D)
1
1
$0
$0
(Nor-Q-D)
1
$0
(Loestrin)
1
$0
(Loestrin Fe)
1
$0
(Ortho-Cyclen)
1
$0
(Ortho-Cyclen)
1
$0
(Nor-Q-D)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
2
$0
1
$0
1
$0
Name of Drug
necon 7/7/7 (28) oral tablet
0.5/0.75/1 mg- 35 mcg
next choice one dose 1.5 mg tb (otc)
1.5 mg *
next choice one dose oral tablet 1.5
mg
nikki (28) oral tablet 3-0.02 mg
nora-be oral tablet 0.35 mg
norethindrone (contraceptive) oral
tablet 0.35 mg
norethindrone ac-eth estradiol oral
tablet 1-20 mg-mcg
norethindrone-e.estradiol-iron oral
tablet 1 mg-20 mcg (24)/75 mg (4)
norg-ee 0.18-0.215-0.25/0.035 3x28
day regimen 0.18/0.215/0.25 mg-35
mcg (28)
norgestimate-ethinyl estradiol oral
tablet 0.18/0.215/0.25 mg-25 mcg,
0.25-35 mg-mcg
norlyroc oral tablet 0.35 mg
nortrel 0.5/35 (28) oral tablet 0.5-35
mg-mcg
nortrel 1/35 (21) oral tablet 1-35
mg-mcg
nortrel 1/35 (28) oral tablet 1-35
mg-mcg
nortrel 7/7/7 (28) oral tablet
0.5/0.75/1 mg- 35 mcg
NUVARING VAGINAL RING
0.12-0.015 MG/24 HR
ocella oral tablet 3-0.03 mg
ogestrel (28) oral tablet 0.5-50 mgmcg
(Yaz)
(Norgestrel-Ethinyl
Estradiol)
Necessary Actions,
Restrictions, or
Limits on Use
QL (6 per 365 days)
QL (6 per 365 days)
ST; QL (1 per 28 days)
116
Tier level
What the
drug will
cost you
(Aftera)
4
$0
(Amethyst)
(Modicon)
1
1
$0
$0
(Mircette)
1
$0
(Modicon)
1
$0
3
$0
(Amethyst)
(Ortho-Cyclen)
(Aftera)
1
1
$0
$0
1
$0
4
$0
(Desogen)
1
$0
1
$0
1
$0
(Ortho-Cyclen)
1
$0
(Amethyst)
(Yaz)
1
1
$0
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Ortho-Cyclen)
1
$0
(Loestrin Fe)
1
$0
(Ortho-Cyclen)
1
$0
Name of Drug
opcicon one-step 1.5 mg tablet 1.5
mg *
orsythia oral tablet 0.1-20 mg-mcg
philith oral tablet 0.4-35 mg-mcg
pimtrea (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
pirmella oral tablet 0.5/0.75/1 mg35 mcg, 1-35 mg-mcg
PLAN B ONE-STEP 1.5 MG
TABLET (OTC) 1.5 MG *
portia oral tablet 0.15-0.03 mg
previfem oral tablet 0.25-35 mg-mcg
quasense oral tablets,dose pack,3
react 1.5 mg tablet 1.5 mg *
reclipsen (28) oral tablet 0.15-0.03
mg
setlakin oral tablets,dose pack,3
sharobel oral tablet 0.35 mg
sprintec (28) oral tablet 0.25-35 mgmcg
sronyx oral tablet 0.1-20 mg-mcg
syeda oral tablet 3-0.03 mg
tarina fe 1/20 (28) oral tablet 1 mg20 mcg (21)/75 mg (7)
tilia fe oral tablet 1-20(5)/1-30(7)
/1mg-35mcg (9)
tri-estarylla oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
tri-legest fe oral tablet 1-20(5)/130(7) /1mg-35mcg (9)
tri-linyah oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
(Nor-Q-D)
Necessary Actions,
Restrictions, or
Limits on Use
QL (6 per 365 days)
QL (6 per 365 days)
QL (91 per 84 days)
QL (6 per 365 days)
QL (91 per 84 days)
117
Tier level
What the
drug will
cost you
(Ortho-Cyclen)
1
$0
(Ortho-Cyclen)
1
$0
(Ortho-Cyclen)
1
$0
(Ortho-Cyclen)
1
$0
(Ortho-Cyclen)
1
$0
(Ortho-Cyclen)
1
$0
(Amethyst)
1
$0
(Desogen)
1
$0
(Yaz)
(Amethyst)
1
1
$0
$0
(Mircette)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
(Ortho Evra)
1
$0
(Yaz)
1
$0
(Modicon)
1
$0
(Demulen 1-50-21)
1
$0
(Demulen 1-50-21)
1
$0
Name of Drug
tri-lo-estarylla oral tablet
0.18/0.215/0.25 mg-25 mcg
tri-lo-marzia oral tablet
0.18/0.215/0.25 mg-25 mcg
tri-lo-sprintec oral tablet
0.18/0.215/0.25 mg-25 mcg
trinessa (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
tri-previfem (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
tri-sprintec (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
trivora (28) oral tablet 50-30 (6)/7540 (5)/125-30(10)
velivet triphasic regimen (28) oral
tablet 0.1/.125/.15-25 mg-mcg
vestura (28) oral tablet 3-0.02 mg
vienva oral tablet 0.1-20 mg-mcg
viorele (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
vyfemla (28) oral tablet 0.4-35 mgmcg
wera (28) oral tablet 0.5-35 mg-mcg
xulane transdermal patch weekly
150-35 mcg/24 hr
zarah oral tablet 3-0.03 mg
zenchent (28) oral tablet 0.4-35 mgmcg
zovia 1/35e (28) oral tablet 1-35
mg-mcg
zovia 1/50e (28) oral tablet 1-50
mg-mcg
Necessary Actions,
Restrictions, or
Limits on Use
QL (3 per 28 days)
Cough And Cold Products
Cough And Cold Products
118
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
(Trispec Pse)
4
$0
(Dextromethorphan
Hbr)
4
$0
(G-Zyncof)
4
$0
(G-Zyncof)
4
$0
(G-Zyncof)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
15dm-5peh-2cpm liquid strawberry
2-5-15 mg/5 ml *
25cpd-200gfn liquid 25-200 mg/5 ml
*
30pse-150gfn-15dm liquid 30-15150 mg/5 ml *
3brm-15dm-30pse liquid 3-30-15
mg/5 ml *
3brm-30dm-50pse liquid (otc) 3-5030 mg/5 ml *
actinel pediatric liquid 15-5-50
mg/5 ml *
adt robitussin linger cold syr 15
mg/5 ml *
adt robitussin peak cld dm max 10200 mg/5 ml *
adult robitussin peak cold liq nondrowsy 10-100 mg/5 ml *
adult wal-tussin dm max liq
a/f,cherry menthol 10-200 mg/5 ml *
adult wal-tussin dm syrup
a/f,cherry,adult 10-100 mg/5 ml *
(Chlorpheniramine/
Phenyleph/Dm)
(Chlophedianol
HCl/Guaifenesin)
(Trispec Pse)
(Brompheniramine/
Pseudoephed/Dm)
(Brompheniramine/
Pseudoephed/Dm)
(Cough Formula
Dm)
(Robitussin
adult wal-tussin liquid 100 mg/5 ml
Mucus-Chest
*
Congest)
alka-seltzer plus mucus-conges 10- (Guaifenesin/Dextr
200 mg *
omethorphan)
ambi 10peh-4cpm-20dm tablet 4-10- (Chlorpheniramine/
20 mg *
Phenyleph/Dm)
ambi 20dm-4cpm tablet 4-20 mg *
(Coricidin Hbp)
ambi 40pse-400gfn-20dm tablet 40- (Guaifenesin/Dm/P
20-400 mg *
seudoephedrine)
ambi 60pse-4cpm-20dm tablet 4-60- (Chlorpheniramin/
20 mg *
Pseudoephed/Dm)
Necessary Actions,
Restrictions, or
Limits on Use
119
Tier level
What the
drug will
cost you
(Zonatuss)
3
$0
(Zonatuss)
3
$0
(Zonatuss)
3
$0
(Brompheniramine/
Pseudoephed/Dm)
4
$0
(Trispec Pse)
4
$0
(G-Zyncof)
(Guaifenesin/Dm/P
seudoephedrine)
(Brompheniramine/
Pseudoephed/Dm)
(Brompheniramine/
Pseudoephed/Dm)
(Brompheniramine/
Pseudoephed/Dm)
(Brompheniramine/
Pseudoephed/Dm)
(Brompheniramine/
Pseudoephed/Dm)
(Chlorpheniramine/
Phenyleph/Dm)
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
(G-Zyncof)
4
$0
(Tusnel C)
4
$0
4
$0
4
$0
Name of Drug
benzonatate 100 mg capsule 100 mg
*
*
*
bio-dtuss dmx liquid 1-30-20 mg/5
ml *
bionel pediatric liquid 15-5-50 mg/5
ml *
biospec dmx liquid 15-25 mg/5 ml *
bp 8 cough oral suspension a/f,
grape (otc) 30-15-175 mg/5 ml *
bpm-pse-dm liquid a/f, cotton candy
(otc) 4-20-20 mg/5 ml *
bromfed dm cough syrup 2-30-10
mg/5 ml *
bromphenex dm syrup (otc) 4-60-30
mg/5 ml *
bromphenir-pseudoephed-dm syr
(rx) 2-30-10 mg/5 ml *
brom-pse-dm cough syrup butter
scotch (otc) 2-30-10 mg/5 ml *
centergy dm pediatric drops 1-2-3
mg/ml *
cheracol d cough formula 10-100
mg/5 ml *
cheratussin dac syrup 30-10-100
mg/5 ml *
child sudafed pe cough-cold lq 2.5-5
mg/5 ml *
child triaminic cgh-congst syr 5-100
mg/5 ml *
(Dextromethorphan
/Phenylephrine)
(Cough Formula
Dm)
Necessary Actions,
Restrictions, or
Limits on Use
120
Tier level
What the
drug will
cost you
(Dextromethorphan
Hbr)
4
$0
(G-Zyncof)
4
$0
Name of Drug
child wal-tussin 7.5 mg odt 7.5 mg *
children's mucinex cough liq a/f 5100 mg/5 ml *
children's silfedrine liq 15 mg/5 ml
*
childs sudafed 15 mg/5 ml liq nondrowsy,a/f,s/f 15 mg/5 ml *
Necessary Actions,
Restrictions, or
Limits on Use
(Pseudoephedrine
4
$0
HCl)
(Pseudoephedrine
4
$0
HCl)
(Robitussin
chl mucinex chest congest liq a/f
Mucus-Chest
4
$0
100 mg/5 ml *
Congest)
chld triaminic cgh-sor thr sus 160-5 (Acetaminophen/D
4
$0
mg/5 ml *
extromethorphan)
codituss dm syrup 8.33-5-10 mg/5
(Pyrilamine/Pe/De
4
$0
ml *
xtromethorphan)
cold multi-symptom day-night
(Dm
pseudoephedrine-free 2-5-10-325
Hb/Pe/Acetaminop
4
$0
mg *
hen/Chlorph)
(Dm
cold relief multi-symp caplet cplt,12
Hb/Pe/Acetaminop
4
$0
day,12 night 2-5-10-325 mg *
hen/Chlorph)
cold-flu relief d/n softgel 10-5(Vicks Dayquil4
$0
325mg(d)/ 15-325-6.25mg *
Nyquil)
(Dcold-flu relief liquid 12.5-30-1,000
Methorphan/Aceta
4
$0
mg/30 ml *
min/Doxylamn)
(Guaifenesin/Pseud
congestac tablet 60-400 mg *
4
$0
oephedrne HCl)
congest-eze 60-400 mg caplet 60(Guaifenesin/Pseud
4
$0
400 mg *
oephedrne HCl)
(Dcoricidin hbp cold-multi sympt 6.25Methorphan/Aceta
4
$0
15-325 mg/15 ml *
min/Doxylamn)
(Guaifenesin/Dextr
coricidin hbp softgel 10-200 mg *
4
$0
omethorphan)
121
Tier level
What the
drug will
cost you
(Coricidin Hbp)
4
$0
(Maxiphen)
4
$0
(Allfen Dm)
4
$0
4
$0
4
$0
4
$0
4
$0
(Dm/Pe/Acetamino
phen/Doxylamine)
4
$0
(Robitussin)
4
$0
(G-Zyncof)
4
$0
(Dextromethorphan
Hbr)
4
$0
(Triaminic)
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
cough & cold tablet 4-30 mg *
cvs chest cong relief pe tab 10-400
mg *
cvs chest congest relief dm tb 20400 mg *
cvs child cold-cough day liq 2.5-5
mg/5 ml *
cvs child's chest congest liq 100
mg/5 ml *
cvs cough & sore throat susp 160-5
mg/5 ml *
cvs cough relief liquid a/f, grape 15
mg/5 ml *
cvs daytime-nighttime cold-flu
multi-symp,twin pack 6.25-5-10-325
mg/15 ml *
cvs tussin cgh 15 mg liq gels nondrowsy, liq gels 15 mg *
cvs tussin dm cough-chest liq 10200 mg/5 ml *
cvs tussin max-str syrup 15 mg/5 ml
*
daytime cold & cough liquid 1,00030 mg/30 ml *
(Dextromethorphan
/Phenylephrine)
(Robitussin
Mucus-Chest
Congest)
(Acetaminophen/D
extromethorphan)
(Dextromethorphan
Hbr)
(DMethorphan/Pe/Ac
etaminophen)
daytime cough liquid a/f, gluten-free (Dextromethorphan
5 mg/5 ml *
Hbr)
daytime-nighttime cough liquid
(Dextromethorphan
15mg/15ml(d)/ 12.5-30mg/30ml *
Hb/Doxylamine)
delsym cough+chest cngst dm lq 5(G-Zyncof)
100 mg/5 ml *
daytime cold-flu liquid a/f, glutenfree 5-10-325 mg/15 ml *
Necessary Actions,
Restrictions, or
Limits on Use
122
Tier level
What the
drug will
cost you
(Guaifenesin/Dm/P
seudoephedrine)
4
$0
(Delsym)
4
$0
(G-Zyncof)
4
$0
(G-Zyncof)
4
$0
(Despec)
4
$0
(Trispec Pse)
4
$0
(Robitussin
Mucus-Chest
Congest)
4
$0
(G-Zyncof)
4
$0
4
$0
4
$0
(Allfen)
4
$0
(Tusnel C)
4
$0
(Mucinex)
4
$0
4
$0
3
$0
3
$0
Name of Drug
despec-dm tablet 30-10-200 mg *
dextromethorphan er 30 mg/5 ml 30
mg/5 ml *
diabetic tussin dm liquid 10-100
mg/5 ml *
diabetic tussin dm max-str liq 10200 mg/5 ml *
ed bron gp liquid 5-100 mg/5 ml *
entre-cough liquid 30-15-175 mg/5
ml *
expectorant 100 mg/5 ml syrup 100
mg/5 ml *
expectorant dm cough liquid 20-300
mg/5 ml *
expectorant max cough-cold 30-15
mg/5 ml *
geri-tussin dm syrup 10-100 mg/5
ml *
guaifenesin 200 mg tablet (otc) 200
mg *
guaifenesin dac oral solution 30-10100 mg/5 ml *
guaifenesin er 600 mg tablet 600 mg
*
(Dextromethorphan
/Pseudoephed)
(Cough Formula
Dm)
(Dm
head congestion day-night pack 2-5Hb/Pe/Acetaminop
10-325 mg *
hen/Chlorph)
hydrocodone-chlorphen er susp 10(Tussionex)
8 mg/5 ml *
hydrocodone-homatropine 5-1.5 mg
(Tussigon)
tablet 5-1.5 mg *
Necessary Actions,
Restrictions, or
Limits on Use
123
Tier level
What the
drug will
cost you
3
$0
4
3
$0
$0
4
$0
3
$0
3
$0
4
$0
(Mucinex Dm)
4
$0
(Mucinex Dm)
4
$0
(Allfen)
4
$0
(Sudafed 12-Hour)
(Chlorpheniramine/
Phenyleph/Dm)
(G-Zyncof)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
hydromet syrup 5-1.5 mg/5 ml *
liquibid d-r tablet 10-400 mg *
lohist-dm syrup 2-5-10 mg/5 ml *
lortuss ex liquid 30-10-100 mg/5 ml
*
mar-cof bp liquid 2-30-7.5 mg/5 ml
*
mar-cof cg liquid 7.5-225 mg/5 ml *
mesehist dm oral syrup 2-15-15
mg/5 ml *
mucus dm 600-30 mg tablet 30-600
mg *
mucus dm max tablet 60-1,200 mg *
mucus relief 400 mg tablet d/f 400
mg *
nasal-sinus decongest tab 30 mg *
nasohist dm pediatric drops 1-2-3
mg/ml *
neo-tuss liquid 30-200 mg/5 ml *
NEXAFED 30 MG TABLET 30
MG *
NIGHT TIME COLD-FLU RLF
SFTGL SFTGL, MULTISYMPTOM 6.25-15-325 MG *
(Hydrocodone
Bit/Homatrop MeBr)
(Maxiphen)
(Ala-Hist Dm)
(Tusnel C)
(Bromphenira/Pseu
doephed/Codein)
(M-Clear Wc)
(Chlorpheniramin/
Pseudoephed/Dm)
(Dnight time cough & sore throat 12.5Methorphan/Aceta
30-1,000 mg/30 ml *
min/Doxylamn)
nighttime cough liquid gluten-free, (Dextromethorphan
cherry 6.25-15 mg/15 ml *
Hb/Doxylamine)
nighttime d cold-flu rlf liq multi(Dm/Psymptom,cherry 6.25-30-15-500
Ephed/Acetaminop
mg/15 ml *
h/Doxylam)
Necessary Actions,
Restrictions, or
Limits on Use
124
Tier level
What the
drug will
cost you
(Chlorpheniramine/
Phenyleph/Dm)
4
$0
(G-Zyncof)
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
3
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
nohist-dm liquid 4-10-15 mg/5 ml *
pecgen dmx 125-15 mg/5 ml liq 15125 mg/5 ml *
pedia relief cough-cold liquid a/f,
cherry 1-15-5 mg/5 ml *
pediacare multi-symt cold liq non
drowsy, grape 2.5-5 mg/5 ml *
(Chlorpheniramin/
Pseudoephed/Dm)
(Dextromethorphan
/Phenylephrine)
(P-Ephed
phenylhistine dh liquid (otc) 2-30-10
HCl/Cod/Chlorphe
mg/5 ml *
nir)
poly-tussin liquid 9.375-10 mg/5 ml (Chlorcyclizine/Co
*
deine)
promethazine vc-codeine syrup
(Promethazine/Phe
6.25-5-10 mg/5 ml *
nyleph/Codeine)
promethazine-codeine syrup 6.25-10 (Promethazine
mg/5 ml *
HCl/Codeine)
promethazine-dm syrup 6.25-15
(Promethazine/Dex
mg/5 ml *
tromethorphan)
pseudoephed 30 mg/5 ml soln 30
(Pseudoephedrine
mg/5 ml *
HCl)
pseudoephedrine 30 mg tablet 30
(Sudafed 12-Hour)
mg *
pseudoephedrine 60 mg tablet ex(Sudafed 12-Hour)
str, non drowsy (otc) 60 mg *
(Dpv flu relief therapy liquid daytime
Methorphan/Pe/Ac
5-10-325 mg/15 ml *
etaminophen)
(Dm/Ppv night-time softgel multiEphed/Acetaminop
sympt.,softgel 6.25-30-15-325 mg *
h/Doxylam)
pv tussin pe liquid 5-100 mg/5 ml * (Despec)
(Brompheniramine/
q-tapp dm elixir 1-15-5 mg/5 ml *
Pseudoephed/Dm)
Necessary Actions,
Restrictions, or
Limits on Use
125
Name of Drug
(Robitussin
Mucus-Chest
Congest)
(Cough Formula
q-tussin dm syrup 10-100 mg/5 ml *
Dm)
ra child plus cough-runny nose
(Dextromethorphn/
pseudoephedrine free 1-5-160 mg/5
Acetaminoph/Cp)
ml *
ra daytime-nighttime softgel cold-flu
(Vicks Dayquilrelief 10-5-325mg(d)/ 15-325Nyquil)
6.25mg *
ra flu formula gelcap 12.5-5-10-325 (Dm/Pe/Acetamino
mg *
ph/Diphenhydram)
ra maximum strength flu tablet 2(Coricidin Hbp)
15-500 mg *
ra mucus relief 400 mg tablet 400
(Allfen)
mg *
(Dm
ra multi-symptom cold caplet
Hb/Pe/Acetaminop
nighttime,cplt 2-5-10-325 mg *
hen/Chlorph)
ra tussin dm syrup a/f 10-100 mg/5 (Cough Formula
ml *
Dm)
refenesen 200 mg tablet 200 mg *
(Allfen)
refenesen pe caplet 10-400 mg *
(Maxiphen)
relcof c liquid 6.3-100 mg/5 ml *
(M-Clear Wc)
REZIRA SOLUTION 60-5 MG/5
ML *
(Robitussin
robafen 100 mg/5 ml syrup 100
Mucus-Chest
mg/5 ml *
Congest)
robafen cough 15 mg liquidgel non(Robitussin)
drowsy,liquidgel 15 mg *
(Cough Formula
robafen-dm syrup 10-100 mg/5 ml *
Dm)
q-tussin 100 mg/5 ml solution a/f,
non-drowsy 100 mg/5 ml *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
3
$0
$0
$0
3
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
126
Name of Drug
robitussin cough-chest-cong dm 10200 mg *
ROBITUSSIN LONG-ACTING
LIQ 1-7.5 MG/5 ML *
robitussin pediatric cough syp
a/f,long-acting 7.5 mg/5 ml *
rydex liquid 1.3-10-6.3 mg/5 ml *
(Guaifenesin/Dextr
omethorphan)
(Dextromethorphan
Hbr)
(Bromphenira/Pseu
doephed/Codein)
(Brompheniram/Ph
enylephrine/Dm)
rynex dm liquid a/f, prof use only 12.5-5 mg/5 ml *
safetussin dm liquid 10-100 mg/5 ml
(G-Zyncof)
*
(Robitussin
scot-tussin 100 mg/5 ml liq 100
Mucus-Chest
mg/5 ml *
Congest)
scot-tussin dm s-f liquid 2-15 mg/5
(Vicks Children'S
ml *
Nyquil)
siltussin dm cough syrup 10-100
(Cough Formula
mg/5 ml *
Dm)
(Robitussin
siltussin sa 100 mg/5 ml syr 100
Mucus-Chest
mg/5 ml *
Congest)
sm adult nasal decongestant lq 15
(Pseudoephedrine
mg/5 ml *
HCl)
sm childrens plus cold susp
(Dm
grape,multi-symptom 1-2.5-5-160
Hb/Pe/Acetaminop
mg/5 ml *
hen/Chlorph)
sm cold-cough child elixir 1-15-5
(Brompheniramine/
mg/5 ml *
Pseudoephed/Dm)
sm cough & runny nose liquid 1-5
(Vicks Children'S
mg/5 ml *
Nyquil)
sm cough-head congestion lq 20-10(Trispec Pse)
66.7 mg/5 ml *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
127
Tier level
What the
drug will
cost you
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
4
$0
(G-Zyncof)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
sm flu severe cold-congestion
maximum strength 4-60-30-1,000
mg *
sm mucus relief cough liquid
childrens, a/f 5-100 mg/5 ml *
(Dm/PEphed/Acetaminop
h/Doxylam)
(Dm/Psm nite time cold-flu rel sfgl softgel
Ephed/Acetaminop
6.25-30-15-325 mg *
h/Doxylam)
(Dm
sm pain reliever cold caplet 2-30Hb/Pseudoephed/A
15-325 mg *
cetamin/Cp)
sm pedia relief liquid 1-15-5 mg/5
(Chlorpheniramin/
ml *
Pseudoephed/Dm)
sm severe cold m-s caplet 30-15-500 (Dm/Pseudoephed/
mg *
Acetaminophen)
sm tussin cf syrup 30-10-100 mg/5
(Guaifenesin/Dm/P
ml *
seudoephedrine)
sudafed 30 mg tablet non(Sudafed 12-Hour)
drowsy,max-str 30 mg *
sudogest 30 mg tablet boxed 30 mg
(Sudafed 12-Hour)
*
sudogest 60 mg tablet 60 mg *
(Sudafed 12-Hour)
(Pseudoephedrine
suphedrin liquid 15 mg/5 ml *
HCl)
suphedrine pe combo pack cplt 5(Diphenhydram/Pe/
10-325 mg *
Dm/Acetamin/Gg)
THERAFLU COLD AND COUGH
POWDER 10-20-650 MG *
THERAFLU MULTI-SYMP COLD
CPLT 5-10-325 MG *
sm nite time cold-flu liquid 7.5-6030-1,000 mg/30 ml *
Necessary Actions,
Restrictions, or
Limits on Use
128
Name of Drug
TRIAMINIC COUGH-SORE
THROAT LQ A/F,CHILDREN'S
160-5 MG/5 ML *
triaminic daytime cold-cough
children's, cherry 2.5-5 mg/5 ml *
tri-dex pe oral syrup 2-10-15 mg/5
ml *
trymine cg liquid 7.5-225 mg/5 ml *
tusnel diabetic liquid (otc) 10-100
mg/5 ml *
TUSNEL LIQUID A/F,A/F,D/F 3015-200 MG/5 ML *
TUSNEL PEDIATRIC LIQUID
(RX) 15-5-50 MG/5 ML *
TUSSI PRES-B LIQUID 4-10-30
MG/5 ML *
tussin cf cough & cold syrup a/f 510-100 mg/5 ml *
tussin cold-congestion gelcap liquid
gelcap 30-10-200 mg *
tussin dm syrup 15-100 mg/5 ml *
(Dextromethorphan
/Phenylephrine)
(Chlorpheniramine/
Phenyleph/Dm)
(M-Clear Wc)
(G-Zyncof)
(Tussi-Pres
Pediatric)
(Guaifenesin/Dm/P
seudoephedrine)
(Cough Formula
Dm)
VANACOF LIQUID 1-30-12.5
MG/5 ML *
vicks dayquil cough liquid a/f,8 hr
rlf 5 mg/5 ml *
(Dextromethorphan
Hbr)
(Dvicks dayquil liquicaps cold & flu 5Methorphan/Pe/Ac
10-325 mg *
etaminophen)
vicks nature fusion cough liq 5 mg/5 (Dextromethorphan
ml *
Hbr)
vicks nyquil severe cold-flu 6.25-5- (Dm/Pe/Acetamino
10-325 mg/15 ml *
phen/Doxylamine)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
129
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
(Evoxac)
1
$0
(Peridex)
1
$0
Name of Drug
(Chlorpheniramine/
Phenyleph/Dm)
virtussin ac liquid 10-100 mg/5 ml * (M-Clear Wc)
v-r infant non-asa cold drp 15-5-160 (Dm/Pseudoephed/
mg/1.6 ml *
Acetaminophen)
v-r non-aspirin flu gelcap gelatin
(Dm/Pseudoephed/
caplet 30-15-500 mg *
Acetaminophen)
v-r pedia relief inf drops
(Dextromethorphan
decongestant + 7.5-2.5 mg/0.8 ml * /Pseudoephed)
vr triacting cold-cough liq 1-15-5
(Chlorpheniramin/
mg/5 ml *
Pseudoephed/Dm)
v-r tussin cf syrup 30-10-100 mg/5
(Guaifenesin/Dm/P
ml *
seudoephedrine)
wal-phed 30 mg tablet non-drowsy
(Sudafed 12-Hour)
30 mg *
wal-phed pe day-night combo pk
(Diphenhydram/Pe/
gluten-free 5-10-325 mg *
Dm/Acetamin/Gg)
wal-tussin cough & cold cf
(Tussi-Pres
pseudoephedrine free 5-10-100
Pediatric)
mg/5 ml *
wal-tussin cough 15 mg softgel 15
(Robitussin)
mg *
wal-tussin cough 15 mg/5 ml 15
(Dextromethorphan
mg/5 ml *
Hbr)
zephrex-d 30 mg tablet 30 mg *
(Sudafed 12-Hour)
ZONATUSS 150 MG CAPSULE
150 MG *
zyncof 20-400 mg/5 ml liquid 20(G-Zyncof)
400 mg/5 ml *
virdec dm drops 1-3.5-3 mg/ml *
Necessary Actions,
Restrictions, or
Limits on Use
Dental And Oral Agents
Dental And Oral Agents
cevimeline oral capsule 30 mg
chlorhexidine gluconate mucous
membrane mouthwash 0.12 %
130
Tier level
What the
drug will
cost you
(Triamcinolone
Acetonide)
1
$0
(Peridex)
1
$0
(Salagen)
1
$0
1
$0
(Sodium Fluoride)
1
$0
(Triamcinolone
Acetonide)
1
$0
2
$0
(Soriatane)
1
$0
(Benzoyl Peroxide)
4
$0
4
$0
4
1
$0
$0
1
$0
1
$0
4
$0
4
$0
4
$0
Name of Drug
oralone dental paste 0.1 %
periogard mucous membrane
mouthwash 0.12 %
pilocarpine hcl oral tablet 5 mg, 7.5
mg
PREVIDENT 5000 SENSITIVE
DENTAL PASTE 1.1-5 %
sodium fluoride oral
tablet,chewable 0.25 mg fluorid
(0.55 mg)
triamcinolone acetonide dental
paste 0.1 %
Necessary Actions,
Restrictions, or
Limits on Use
Dermatological Agents
Dermatological Agents,
Other
8-MOP ORAL CAPSULE 10 MG
acitretin oral capsule 10 mg, 17.5
mg, 25 mg
acne medication 10% lotion 10 % *
ACNE MEDICATION 5%
LOTION 5 % *
acneclear gel 10 % *
acyclovir topical ointment 5 %
ALCOHOL PADS TOPICAL
PADS, MEDICATED
ALCOHOL PREP PADS
amlactin 12% lotion 12 % *
ammonium lactate 12% cream
fragrance free (otc) 12 % *
ammonium lactate 12% lotion (otc)
12 % *
(Benzoyl Peroxide)
(Zovirax)
(Ammonium
Lactate)
(Ammonium
Lactate)
(Ammonium
Lactate)
QL (30 per 30 days)
131
Tier level
What the
drug will
cost you
(Lac-Hydrin)
1
$0
(Lac-Hydrin)
1
$0
2
$0
(Benzoyl Peroxide)
4
$0
(Benzoyl Peroxide)
4
$0
(Calcipotriene)
(Dovonex)
4
1
1
$0
$0
$0
(Calcipotriene)
1
$0
(Calcipotriene)
1
$0
(Vectical)
1
$0
4
$0
2
$0
2
$0
2
$0
Name of Drug
ammonium lactate topical cream 12
%
ammonium lactate topical lotion 12
%
ANACAINE TOPICAL
OINTMENT 10 %
benzoyl peroxide 10% gel aqueous
(otc) 10 % *
benzoyl peroxide 5% gel aqueous
(otc) 5 % *
BETADINE 5% SPRAY 5 % *
calcipotriene scalp solution 0.005 %
calcipotriene topical cream 0.005 %
calcipotriene topical ointment 0.005
%
calcitrene topical ointment 0.005 %
calcitriol topical ointment 3
mcg/gram
CASTELLANI PAINT MODIFIED
1.5 % *
CONDYLOX TOPICAL GEL 0.5
%
COSENTYX (150 MG/ML) 300
MG DOSE-2 PENS 150 MG/ML
COSENTYX (150 MG/ML) 300
MG DOSE-2 SYRINGES 150
MG/ML
COSENTYX PEN
SUBCUTANEOUS PEN
INJECTOR 150 MG/ML
COSENTYX SUBCUTANEOUS
SYRINGE 150 MG/ML
cvs skin treatment body lotion 12 %
*
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
PA
(Ammonium
Lactate)
2
$0
2
$0
4
$0
PA
132
Tier level
What the
drug will
cost you
(Carac)
1
$0
(Fluorouracil)
1
$0
4
$0
4
$0
(Aldara)
1
$0
(Mineral Oil)
4
4
$0
$0
(Oxsoralen-Ultra)
1
$0
2
$0
4
$0
2
2
$0
$0
1
$0
1
$0
1
$0
4
$0
2
$0
Name of Drug
fluorouracil topical cream 0.5 %, 5
%
fluorouracil topical solution 2 %, 5
%
geri-hydrolac 12% lotion 12 % *
geri-hydrolac 5% lotion 5 % *
imiquimod topical cream in packet 5
%
LACTINOL HX CREAM *
lobana bath oil *
methoxsalen rapid oral capsule 10
mg
PANRETIN TOPICAL GEL 0.1 %
persa-gel 10% 12's,max-strength 10
%*
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
podocon topical liquid 25 %
podofilox topical solution 0.5 %
potassium hydroxide topical
solution 5 %
pv acne pimple 10% gel 10 % *
SANTYL TOPICAL OINTMENT
250 UNIT/GRAM
TALTZ AUTOINJECTOR
SUBCUTANEOUS AUTOINJECTOR 80 MG/ML
TALTZ SYRINGE
MG/ML
TOLAK TOPICAL CREAM 4 %
(Ammonium
Lactate)
(Ammonium
Lactate)
(Benzoyl Peroxide)
(Podophyllum
Resin)
(Condylox)
(Potassium
Hydroxide)
(Benzoyl Peroxide)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (24 per
30 days)
QL (3 per 56 days)
QL (2 per 56 days)
PA
2
$0
2
$0
2
$0
PA
133
Tier level
What the
drug will
cost you
2
$0
(Isotretinoin)
1
$0
(Boudreauxs)
4
2
$0
$0
(Bacitracin)
4
$0
(Bacitracin)
4
$0
(Cleocin T)
1
$0
(Cleocin T)
1
$0
(Cleocin T)
1
$0
(Cleocin T)
1
$0
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
VALCHLOR TOPICAL GEL 0.016
%
zenatane oral capsule 10 mg, 20 mg,
30 mg, 40 mg
zinc oxide 20% ointment 20 % *
ZOVIRAX TOPICAL CREAM 5 %
Dermatological
Antibacterials
bacitracin 500 unit/gm ointmnt 500
unit/gram *
bacitraycin plus 500 unit/gm 500
unit/gram *
clindamycin phosphate topical gel 1
%
clindamycin phosphate topical
lotion 1 %
clindamycin phosphate topical
solution 1 %
clindamycin phosphate topical swab
1%
(Neomycin
cvs triple antibiotic ointment 3.5mgSu/Bacitrac
400 unit- 5,000 unit/gram *
Zn/Poly)
(Erythromycin
ery pads topical swab 2 %
Base/Ethanol)
erythromycin with ethanol topical
(Emgel)
gel 2 %
(Erythromycin
solution 2 %
Base/Ethanol)
(Erythromycin
swab 2 %
Base/Ethanol)
(Gentamicin
gentamicin topical cream 0.1 %
Sulfate)
Necessary Actions,
Restrictions, or
Limits on Use
QL (15 per 30 days)
134
Name of Drug
(Gentamicin
Sulfate)
metronidazole topical cream 0.75 % (Metrocream)
metronidazole topical gel 0.75 %, 1
(Rosadan)
%
metronidazole topical lotion 0.75 % (Metrolotion)
mupirocin calcium topical cream 2
(Bactroban)
%
mupirocin topical ointment 2 %
neomycin-polymyxin b gu irrigation (Neosporin G.U.
solution 40 mg-200,000 unit/ml
Irrigant)
(Neomycin
neosporin ointment 3.5mg-400 unitSu/Bacitrac
5,000 unit/gram *
Zn/Poly)
rosadan topical cream 0.75 %
(Metrocream)
selenium sulfide topical lotion 2.5 % (Selenium Sulfide)
selenium sulfide topical shampoo
(Selenium Sulfide)
2.25 %
silver nitrate topical ointment 10 % (Silver Nitrate)
silver nitrate topical solution 0.5 %,
(Silver Nitrate)
10 %, 25 %, 50 %
silver sulfadiazine topical cream 1
(Silvadene)
%
ssd topical cream 1 %
(Silvadene)
sulfacetamide sodium (acne) topical
(Klaron)
suspension 10 %
(Neomycin
triple antibiotic ointment carton
Su/Bacitrac
3.5mg-400 unit- 5,000 unit/gram *
Zn/Poly)
Dermatological AntiInflammatory Agents
ala-cort topical cream 1 %
(Anusol-HC)
ala-scalp topical lotion 2 %
(Scalacort)
gentamicin topical ointment 0.1 %
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
1
1
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
135
Tier level
What the
drug will
cost you
1
$0
1
$0
4
4
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(Diprolene AF)
1
$0
(Betamethasone
Dipropionate)
1
$0
(Diprolene)
1
$0
(Diprolene)
1
$0
(Temovate)
(Clobetasol
Propionate)
(Olux)
(Clobetasol
Propionate)
1
$0
1
$0
1
$0
1
$0
Name of Drug
alclometasone topical cream 0.05 %
alclometasone topical ointment 0.05
%
aquanil hc 1% lotion 1 % *
beta hc 1% lotion 1 % *
betamethasone dipropionate topical
cream 0.05 %
lotion 0.05 %
ointment 0.05 %
betamethasone valerate topical
cream 0.1 %
foam 0.12 %
lotion 0.1 %
ointment 0.1 %
betamethasone, augmented topical
cream 0.05 %
gel 0.05 %
lotion 0.05 %
ointment 0.05 %
clobetasol 0.05% cream 0.05 %
clobetasol scalp solution 0.05 %
clobetasol topical foam 0.05 %
clobetasol topical gel 0.05 %
(Alclometasone
Dipropionate)
(Alclometasone
Dipropionate)
(Cortizone-10)
(Cortizone-10)
(Betamethasone
Dipropionate)
(Betamethasone
Dipropionate)
(Betamethasone
Dipropionate)
(Betamethasone
Valerate)
(Luxiq)
(Betamethasone
Valerate)
(Betamethasone
Valerate)
Necessary Actions,
Restrictions, or
Limits on Use
136
Tier level
What the
drug will
cost you
(Clobex)
(Temovate)
(Clobex)
1
1
1
$0
$0
$0
(Temovate)
1
$0
(Cloderm)
1
$0
(Cortenema)
(Clobetasol
Propionate)
1
$0
1
$0
(Hydrocortisone)
4
$0
4
$0
(Hydrocortisone)
(Cortizone-10)
(Desowen)
(Desonide)
4
4
1
1
$0
$0
$0
$0
(Topicort)
1
$0
(Topicort)
1
$0
(Topicort)
1
$0
(Vanos)
(Fluocinonide)
2
1
1
$0
$0
$0
(Fluocinonide)
1
$0
(Fluocinonide)
(Vanos)
(Cutivate)
(Fluticasone
fluticasone topical ointment 0.005 %
Propionate)
1
1
1
$0
$0
$0
1
$0
Name of Drug
clobetasol topical lotion 0.05 %
clobetasol topical ointment 0.05 %
clobetasol topical shampoo 0.05 %
clobetasol-emollient topical cream
0.05 %
clocortolone pivalate topical cream
0.1 %
colocort rectal enema 100 mg/60 ml
cormax scalp solution 0.05 %
cortizone-10 1% creme maximum
strength 1 % *
CORTIZONE-10 1% LOTION 1 %
*
cortizone-10 1% ointment 1 % *
dermarest eczema 1% lotion 1 % *
desonide topical cream 0.05 %
desonide topical ointment 0.05 %
desoximetasone topical cream 0.05
%, 0.25 %
desoximetasone topical gel 0.05 %
desoximetasone topical ointment
0.05 %, 0.25 %
ELIDEL TOPICAL CREAM 1 %
fluocinonide 0.05% cream 0.05 %
fluocinonide topical gel 0.05 %
fluocinonide topical ointment 0.05
%
fluocinonide topical solution 0.05 %
fluocinonide-e topical cream 0.05 %
fluticasone topical cream 0.05 %
Necessary Actions,
Restrictions, or
Limits on Use
137
Tier level
What the
drug will
cost you
(Ultravate)
1
$0
(Ultravate)
1
$0
(Cortizone-10)
4
$0
(Hydrocortisone)
4
$0
(Hydrocortisone)
4
$0
(Hydrocortisone)
4
$0
(Hydrocortisone
Acetate)
4
$0
(Cortizone-10)
3
$0
(Hydrocortisone)
4
$0
1
$0
1
$0
(Locoid)
1
$0
(Locoid)
1
$0
(Hydrocortisone
Butyrate)
1
$0
(Cortenema)
1
$0
(Anusol-HC)
1
$0
(Scalacort)
1
$0
(Hydrocortisone)
1
$0
Name of Drug
halobetasol propionate topical
cream 0.05 %
halobetasol propionate topical
ointment 0.05 %
hydro skin 1% lotion 1 % *
hydrocortisone 0.5% cream (otc)
0.5 % *
hydrocortisone 0.5% ointment 0.5 %
*
hydrocortisone 1% cream maximum
strength (otc) 1 % *
hydrocortisone 1% cream maximum
strength 1 % *
hydrocortisone 1% lotion (otc) 1 %
*
hydrocortisone 1% ointment carton
(otc) 1 % *
hydrocortisone acet-aloe vera
topical gel 2 %
hydrocortisone buty 0.1% cream 0.1
%
hydrocortisone butyrate topical
ointment 0.1 %
hydrocortisone butyrate topical
solution 0.1 %
hydrocortisone butyr-emollient
topical cream 0.1 %
hydrocortisone rectal enema 100
mg/60 ml
hydrocortisone topical cream 1 %,
2.5 %
hydrocortisone topical lotion 2.5 %
hydrocortisone topical ointment 1
%, 2.5 %
(Hydrocortisone
Acetate/Aloe V)
(Hydrocortisone
Butyrate)
Necessary Actions,
Restrictions, or
Limits on Use
138
Tier level
What the
drug will
cost you
(Hydrocortisone
Valerate)
1
$0
(Westcort)
1
$0
(Elocon)
(Elocon)
(Elocon)
(Hydrocortisone)
1
1
1
4
$0
$0
$0
$0
2
$0
(Dermatop)
1
$0
(Dermatop)
1
$0
(Hydrocortisone)
(Hydrocortisone)
(Anusol-HC)
(Hydrocortisone)
(Hydrocortisone)
(Hydrocortisone)
4
1
1
1
1
4
$0
$0
$0
$0
$0
$0
(Protopic)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
$0
$0
Name of Drug
hydrocortisone valerate topical
cream 0.2 %
hydrocortisone valerate topical
ointment 0.2 %
mometasone topical cream 0.1 %
mometasone topical ointment 0.1 %
mometasone topical solution 0.1 %
neosporin 1% anti-itch cream 1 % *
ONFI ORAL TABLET 10 MG, 20
MG
prednicarbate topical cream 0.1 %
prednicarbate topical ointment 0.1
%
preparation h hc 1% cream 1 % *
procto-med hc rectal cream 2.5 %
procto-pak rectal cream 1 %
proctosol hc rectal cream 2.5 %
proctozone-hc rectal cream 2.5 %
recort plus 1% cream 1 % *
tacrolimus topical ointment 0.03 %,
0.1 %
triamcinolone acetonide topical
cream 0.025 %, 0.1 %, 0.5 %
lotion 0.025 %, 0.1 %
ointment 0.025 %, 0.1 %, 0.5 %
trianex topical ointment 0.05 %
u-cort topical cream 1-10 %
Dermatological Retinoids
adapalene topical cream 0.1 %
adapalene topical gel 0.1 %
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Hydrocortisone
Acetate/Urea)
(Differin)
(Differin)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (60 per
30 days)
139
Tier level
What the
drug will
cost you
2
$0
(Retin-A Micro)
1
$0
(Retin-A Micro)
1
$0
(Retin-A Micro)
1
$0
(Retin-A)
1
$0
(Retin-A)
1
$0
4
$0
4
1
$0
$0
4
$0
(Elimite)
1
$0
(Nix)
4
$0
(Nix)
4
$0
(Nix)
4
$0
1
$0
1
$0
Name of Drug
TAZORAC TOPICAL CREAM
0.05 %, 0.1 %
tretinoin gel micro 0.04% tube 0.04
%
tretinoin gel micro 0.1% tube 0.1 %
tretinoin microspheres topical gel
with pump 0.04 %, 0.1 %
tretinoin topical cream 0.025 %,
0.05 %, 0.1 %
tretinoin topical gel 0.01 %, 0.025
%, 0.05 %
Scabicides And
Pediculicides
cvs lice killing shampoo maximum
strength 0.33-4 % *
cvs permethrin 1% lotion 1 % *
malathion topical lotion 0.5 %
NIX 1% CREME RINSE LIQUID
W/ NIT COMB 1 % *
permethrin topical cream 5 %
ra lice treatment 1% crm rinse
2x59ml, 2 combs 1 % *
sm lice treatment permethrin 2's 1
%*
v-r lice cream rinse 1 % *
(Piperonyl
Butoxide/Pyrethrin
s)
(Nix)
(Ovide)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
PA
PA
PA
Devices
Devices
ASSURE ID INSULIN SAFETY
SYRINGE 1 ML 29 GAUGE X 1/2"
BD INSULIN SYR 0.3 ML
31GX5/16 0.3 ML 31 GAUGE X
5/16
140
Name of Drug
BD INSULIN SYR 0.5 ML
31GX5/16" 0.5 ML 31 GAUGE X
5/16
BD INSULIN SYR 1 ML
31GX5/16" 1 ML 31 GAUGE X
5/16
BD ULTRA-FINE PEN NDL
8MMX31G SHORT 31 GAUGE X
5/16"
INSULIN SYRINGE-NEEDLE U100 SYRINGE 0.3 ML 29, 1 ML 29
GAUGE X 1/2", 1/2 ML 28
GAUGE
PEN NEEDLE, DIABETIC
NEEDLE 29 GAUGE X 1/2"
VGO 40 DISPOSABLE DEVICE
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
Disinfectants (For NonDermatologic Use)
Disinfectants (For NonDermatologic Use)
sm iodine tincture *
(Iodine)
Enzyme
Replacement/Modifiers
Enzyme
Replacement/Modifiers
ADAGEN INTRAMUSCULAR
ALDURAZYME INTRAVENOUS
SOLUTION 2.9 MG/5 ML
CEREZYME INTRAVENOUS
RECON SOLN 400 UNIT
141
Name of Drug
CREON ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000 60,000 UNIT, 24,000-76,000 120,000 UNIT, 3,000-9,500- 15,000
UNIT, 36,000-114,000- 180,000
UNIT, 6,000-19,000 -30,000 UNIT
ELAPRASE INTRAVENOUS
SOLUTION 6 MG/3 ML
ELITEK INTRAVENOUS RECON
SOLN 1.5 MG, 7.5 MG
FABRAZYME INTRAVENOUS
RECON SOLN 35 MG
KANUMA INTRAVENOUS
SOLUTION 2 MG/ML
KRYSTEXXA INTRAVENOUS
SOLUTION 8 MG/ML
KUVAN ORAL
TABLET,SOLUBLE 100 MG
MYOZYME INTRAVENOUS
RECON SOLN 50 MG
NAGLAZYME INTRAVENOUS
SOLUTION 5 MG/5 ML
ORFADIN ORAL CAPSULE 10
MG, 2 MG, 5 MG
pancrelipase 5000 oral
(Lipase/Protease/A
capsule,delayed release(dr/ec)
mylase)
5,000-17,000 -27,000 unit
PULMOZYME INHALATION
SOLUTION 1 MG/ML
STRENSIQ SUBCUTANEOUS
MG/ML
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA BvD
PA; LA
142
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
(Proparacaine HCl)
(Tetravisc)
(Little Remedies)
1
1
4
$0
$0
$0
(Iopidine)
1
$0
4
$0
4
$0
4
$0
Name of Drug
VIMIZIM INTRAVENOUS
MG/ML)
VPRIV INTRAVENOUS RECON
SOLN 400 UNIT
ZAVESCA ORAL CAPSULE 100
MG
ZENPEP ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-34,000 55,000 UNIT, 15,000-51,000 82,000 UNIT, 20,000-68,000 109,000 UNIT, 25,000-85,000136,000 UNIT, 3,000-10,00016,000 UNIT, 40,000-136,000218,000 UNIT, 5,000-17,000 27,000 UNIT
Necessary Actions,
Restrictions, or
Limits on Use
PA
QL (90 per 30 days)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat
Agents, Miscellaneous
AKTEN (PF) OPHTHALMIC GEL
3.5 %
alcaine ophthalmic drops 0.5 %
altacaine ophthalmic drops 0.5 %
altamist 0.65% nose spray 0.65 % *
apraclonidine ophthalmic drops 0.5
%
artificial tears 1.4 % drops 1.4 % *
artificial tears drops p/f, sterile 0.10.3 % *
(Polyvinyl
Alcohol)
(Dextran
70/Hypromellose/P
F)
artificial tears eye drops strl 0.1-0.3
(Tears Naturale)
%*
143
Tier level
What the
drug will
cost you
(Genteal Pm)
4
$0
(Isopto Atropine)
(Atropine Sulfate)
(Isopto Atropine)
1
1
1
$0
$0
$0
(Sodium Chloride)
4
$0
(Little Remedies)
4
$0
(Astepro)
1
$0
(Azelastine HCl)
(Dextran
70/Hypromellose/P
F)
(Carteolol HCl)
(Cromolyn
Sodium)
(Glycerin/Propylen
e Glycol)
1
$0
4
$0
1
$0
1
$0
4
$0
(Refresh Tears)
4
$0
(Carboxymethylcel
lulose Sodium)
4
$0
(Genteal Pm)
4
$0
(Carboxymethylcel
l/Hypromellose)
4
$0
(Refresh Optive)
4
$0
(Dextran
70/Hypromellose/P
F)
4
$0
Name of Drug
artificial tears eye ointment 83-15 %
*
atropine ophthalmic drops 1 %
atropine ophthalmic ointment 1 %
atropine-care ophthalmic drops 1 %
ayr saline 0.65% nose drops 0.65 %
*
ayr saline 0.65% nose spray 0.65 %
*
azelastine nasal aerosol,spray 137
mcg (0.1 %)
azelastine ophthalmic drops 0.05 %
bion tears eye drops 0.1-0.3 % *
carteolol ophthalmic drops 1 %
cromolyn ophthalmic drops 4 %
cvs artificial tears drops sterile 10.3 % *
cvs lubricant 0.5% eye drops sterile
0.5 % *
cvs lubricant dry eye rlf 1% 1 % *
cvs lubricant eye ointment p/f 57.342.5 % *
cvs lubricant gel eye drops 0.25-0.3
%*
cvs lubricating eye drops dry eye
soln 0.5-0.9 % *
cvs natural tears drops 0.1-0.3 % *
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 25 days)
144
Name of Drug
cyclopentolate ophthalmic drops 0.5
(Cyclogyl)
%, 1 %, 2 %
CYSTARAN OPHTHALMIC
DROPS 0.44 %
deep sea 0.65% nose spray 0.65 % * (Little Remedies)
(Oxymetazoline
dristan long lasting mist 0.05 % *
HCl)
epinastine ophthalmic drops 0.05 % (Elestat)
(Genteal Mild To
eq gentle 0.3% eye drops 0.3 % *
Moderate)
eq revive plus 0.5% eye drops 0.5 % (Carboxymethylcel
*
lulose Sodium)
flucaine ophthalmic drops 0.25-0.5 (Proparacaine/Fluo
%
rescein Sod)
GENTEAL GEL DROPS 0.25-0.3
%*
GENTEAL MILD 0.2% EYE
DROPS 0.2 % *
GENTEAL MILD-MODERATE
EYE DROP P/F, DRY EYE
RELIEF 0.3 % *
GENTEAL SEVERE 0.3% EYE
GEL P/F, STRL, INNER 0.3 % *
genteal tears 0.1%-0.3% drop 0.1(Tears Naturale)
0.3 % *
(Isopto
homatropaire ophthalmic drops 5 %
Homatropine)
homatropine hbr ophthalmic drops (Isopto
5%
Homatropine)
ipratropium bromide nasal
(Atrovent)
spray,non-aerosol 0.03 %
ipratropium bromide nasal
(Atrovent)
spray,non-aerosol 0.06 %
Tier level
What the
drug will
cost you
1
$0
2
$0
4
$0
4
$0
1
$0
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 28 days)
QL (15 per 10 days)
145
Tier level
What the
drug will
cost you
4
$0
2
$0
(Carboxymethylcel
l/Glycerin/PF)
4
$0
(Refresh Optive)
4
$0
(Propylene Glycol)
4
$0
(Genteal Pm)
4
$0
(Sodium Chloride)
(Sodium Chloride)
(Sodium Chloride)
(Naphazoline HCl)
4
4
4
1
$0
$0
$0
$0
(Afrin)
4
$0
4
$0
4
$0
4
$0
4
1
$0
$0
2
$0
1
$0
1
$0
4
$0
Name of Drug
isopto tears 0.5% eye drops 0.5 % *
LACRISERT OPHTHALMIC
INSERT 5 MG
lubricant 0.5-0.9% eye drops 0.50.9 % *
lubricant 0.5-0.9% eye drops 0.50.9 % *
lubricant 0.6% eye drops 0.6 % *
lubrifresh pm eye ointment 83-15 %
*
muro-128 2% eye drops 2 % *
muro-128 5% eye drops 5 % *
muro-128 5% eye ointment 5 % *
naphazoline ophthalmic drops 0.1 %
nasal decongestant 0.05% spray
0.05 % *
(Genteal Mild To
Moderate)
(Genteal Mild To
Moderate)
(Genteal Mild To
nature's tears drops 0.4 % *
Moderate)
neo-synephrine 12 hour spray 0.05 (Oxymetazoline
%*
HCl)
ocean 0.65% nasal spray 0.65 % * (Little Remedies)
olopatadine ophthalmic drops 0.1 % (Patanol)
PATADAY OPHTHALMIC
DROPS 0.2 %
phenylephrine hcl ophthalmic drops
(Mydfrin)
10 %, 2.5 %
proparacaine ophthalmic drops 0.5
(Proparacaine HCl)
%
pure & gentle eye drops lubricant
(Genteal Mild To
0.3 % *
Moderate)
natural balance tears drops 0.4 % *
Necessary Actions,
Restrictions, or
Limits on Use
ST
146
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Carboxymethylcel
lulose Sodium)
4
$0
(Little Remedies)
4
$0
(Little Remedies)
4
$0
(Systane)
4
$0
(Sodium Chloride)
(Sodium Chloride)
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
pv artificial tears 0.4 % *
pv lubricant 1.4 % eye drops 1.4 %
*
pv pure-gentle eye drops sterile 0.3
%*
REFRESH CELLUVISC 1% EYE
DROPS 1 % *
REFRESH CLASSIC EYE DROPS
U-D,P/F,30X.4ML 1.4-0.6 % *
REFRESH LACRI-LUBE
OINTMENT 56.8-42.5 % *
REFRESH OPTIVE EYE DROPS
0.5-0.9 % *
retaine cmc 0.5% eye drops 0.5 % *
saline mist 0.65% nose spry 0.65 %
*
sea soft 0.65% nasal mist 0.65 % *
sm lubricant eye drops strl 0.4-0.3
%*
sodium chloride 5% eye drop 5 % *
sodium chloride 5% eye oint 5 % *
SYSTANE 0.3-0.4% EYE DROPS
0.4-0.3 % *
SYSTANE GEL EYE DROPS 0.40.3 % *
tears again 1.4 % drops 1.4 % *
tears again eye ointment 80-20 % *
tears naturale free drops ud,36x.9ml,p/f 0.1-0.3 % *
(Genteal Mild To
Moderate)
(Polyvinyl
Alcohol)
(Genteal Mild To
Moderate)
(Polyvinyl
Alcohol)
(Genteal Pm)
(Dextran
70/Hypromellose/P
F)
Necessary Actions,
Restrictions, or
Limits on Use
147
Name of Drug
tetracaine hcl (pf) ophthalmic drops (Tetracaine
0.5 %
HCl/PF)
(Lanolin/Mineral
ultra fresh pm ointment *
Oil/Petrolatum)
(Oxymetazoline
vicks qlearquil 0.05% mist 0.05 % *
HCl)
vicks sinex 12 hour spray 0.05 % * (Afrin)
Anti-Infectives Agents
acetic acid otic solution 2 %
(Acetic Acid)
bacitracin ophthalmic ointment 500
(Bacitracin)
unit/gram
bacitracin-polymyxin b ophthalmic (Bacitracin/Polymy
ointment 500-10,000 unit/gram
xin B Sulfate)
(Sulfacetamide
bleph-10 ophthalmic drops 10 %
Sodium)
CIPRODEX OTIC
DROPS,SUSPENSION 0.3-0.1 %
ciprofloxacin hcl ophthalmic drops
(Ciloxan)
0.3 %
ciprofloxacin hcl otic dropperette
(Cetraxal)
0.2 %
COLY-MYCIN S OTIC
DROPS,SUSPENSION 3.3-3-100.5 MG/ML
erythromycin ophthalmic ointment 5
(Ilotycin)
mg/gram (0.5 %)
gatifloxacin ophthalmic drops 0.5 % (Zymaxid)
gentak ophthalmic ointment 0.3 %
(Garamycin)
(3 mg/gram)
gentamicin ophthalmic drops 0.3 % (Garamycin)
gentamicin ophthalmic ointment 0.3
(Garamycin)
% (3 mg/gram)
levofloxacin ophthalmic drops 0.5 % (Levofloxacin)
Tier level
What the
drug will
cost you
1
$0
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
1
$0
2
$0
1
$0
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
148
Tier level
What the
drug will
cost you
2
$0
2
$0
(Neomycin Su/Baci
Zn/Poly/HC)
1
$0
(Neomycin
Su/Bacitra/Polymy
xin)
1
$0
(Maxitrol)
1
$0
(Maxitrol)
1
$0
(Neosporin)
1
$0
(Neomycin/Polymy
xin B Sulf/HC)
1
$0
(Neomycin/Polymy
xin B Sulf/HC)
1
$0
(Cortisporin)
1
$0
1
$0
1
$0
1
1
$0
$0
Name of Drug
MOXEZA OPHTHALMIC
DROPS, VISCOUS 0.5 %
NATACYN OPHTHALMIC
DROPS,SUSPENSION 5 %
neomycin-bacitracin-poly-hc
ophthalmic ointment 3.5-400-10,000
mg-unit/g-1%
neomycin-bacitracin-polymyxin
ophthalmic ointment 3.5-400-10,000
mg-unit-unit/g
neomycin-polymyxin b-dexameth
ophthalmic drops,suspension
3.5mg/ml-10,000 unit/ml-0.1 %
neomycin-polymyxin b-dexameth
ophthalmic ointment 3.5 mg/g10,000 unit/g-0.1 %
neomycin-polymyxin-gramicidin
ophthalmic drops 1.75 mg-10,000
unit-0.025mg/ml
neomycin-polymyxin-hc ophthalmic
drops,suspension 3.5-10,000-10 mgunit-mg/ml
neomycin-polymyxin-hc otic
drops,suspension 3.5-10,000-1
mg/ml-unit/ml-%
neomycin-polymyxin-hc otic
solution 3.5-10,000-1 mg/mlunit/ml-%
neo-polycin hc ophthalmic ointment
3.5-400-10,000 mg-unit/g-1%
neo-polycin ophthalmic ointment
3.5-400-10,000 mg-unit-unit/g
ofloxacin ophthalmic drops 0.3 %
ofloxacin otic drops 0.3 %
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
Su/Bacitra/Polymy
xin)
(Ocuflox)
(Ocuflox)
Necessary Actions,
Restrictions, or
Limits on Use
149
Tier level
What the
drug will
cost you
1
$0
4
$0
1
$0
1
$0
1
$0
2
$0
2
$0
(Tobrex)
1
$0
(Tobradex)
1
$0
(Viroptic)
1
$0
2
$0
2
$0
2
$0
2
$0
1
$0
Name of Drug
polymyxin b sulf-trimethoprim
ophthalmic drops 10,000 unit- 1
mg/ml
REFRESH OPTIVE ADVANCED
DROPS 0.5-1-0.5 % *
sulfacetamide sodium ophthalmic
drops 10 %
sulfacetamide sodium ophthalmic
ointment 10 %
sulfacetamide-prednisolone
ophthalmic drops 10 %-0.23 %
(0.25 %)
TOBRADEX OPHTHALMIC
OINTMENT 0.3-0.1 %
TOBRADEX ST OPHTHALMIC
tobramycin ophthalmic drops 0.3 %
tobramycin-dexamethasone
ophthalmic drops,suspension 0.3-0.1
%
trifluridine ophthalmic drops 1 %
VIGAMOX OPHTHALMIC
DROPS 0.5 %
ZIRGAN OPHTHALMIC GEL
0.15 %
ZYLET OPHTHALMIC
Anti-Inflammatory Agents
ALREX OPHTHALMIC
DROPS,SUSPENSION 0.2 %
bromfenac ophthalmic drops 0.09 %
(Polytrim)
(Sulfacetamide
Sodium)
(Sulfacetamide
Sodium)
(Sulfacetamide/Pre
dnisolone Sp)
(Bromfenac
Sodium)
Necessary Actions,
Restrictions, or
Limits on Use
ST
dexamethasone sodium phosphate
(Dexasol)
1
$0
ophthalmic drops 0.1 %
150
Tier level
What the
drug will
cost you
1
$0
2
$0
(Flunisolide)
1
$0
(FML)
1
$0
(Ocufen)
1
$0
(Fluticasone
Propionate)
1
$0
2
$0
1
$0
2
$0
2
$0
2
$0
2
$0
(Omnipred)
1
$0
(Prednisolone Sod
Phosphate)
1
$0
2
$0
2
$0
Name of Drug
diclofenac sodium ophthalmic drops
0.1 %
DUREZOL OPHTHALMIC
DROPS 0.05 %
flunisolide nasal spray,non-aerosol
25 mcg (0.025 %)
fluorometholone ophthalmic
drops,suspension 0.1 %
flurbiprofen sodium ophthalmic
drops 0.03 %
fluticasone nasal spray,suspension
50 mcg/actuation
ILEVRO OPHTHALMIC
ketorolac ophthalmic drops 0.4 %,
0.5 %
LOTEMAX OPHTHALMIC
DROPS,GEL 0.5 %
LOTEMAX OPHTHALMIC
LOTEMAX OPHTHALMIC
OINTMENT 0.5 %
NEVANAC OPHTHALMIC
prednisolone acetate ophthalmic
drops,suspension 1 %
prednisolone sodium phosphate
ophthalmic drops 1 %
PROLENSA OPHTHALMIC
DROPS 0.07 %
RESTASIS OPHTHALMIC
DROPPERETTE 0.05 %
(Diclofenac
Sodium)
(Acular)
Necessary Actions,
Restrictions, or
Limits on Use
QL (50 per 25 days)
QL (60 per 30 days)
Gastrointestinal Agents
Antiflatulents
151
Tier level
What the
drug will
cost you
(Simethicone)
4
$0
(Gas-X)
4
$0
(Phazyme)
4
$0
(Gas-X)
4
$0
(Gas-X)
4
$0
(Gas-X)
4
$0
(Phazyme)
4
$0
(Gas-X)
4
$0
(Gas-X)
4
$0
(Gas-X)
4
$0
(Phazyme)
4
$0
(Simethicone)
4
$0
(Phazyme)
4
$0
(Pepcid Ac)
4
$0
(Prevpac)
1
$0
2
$0
Name of Drug
bicarsim forte 125 mg tablet 125 mg
*
cvs gas relief 125 mg chew tab extra
strength 125 mg *
cvs gas relief 125 mg softgel softgel
125 mg *
cvs gas relief 80 mg tab chew 80 mg
*
gas relief 125 mg chew tablet max
str,lactose-free 125 mg *
gas relief 80 mg tablet chew lactosefree 80 mg *
gas-x ultra strength softgel 180 mg
*
mi-acid gas 80 mg tab chew 80 mg *
mytab gas 80 mg tablet chew 80 mg
*
mytab gas max str 125 mg tab 125
mg *
simethicone 180 mg softgel 180 mg
*
simethicone 40 mg/0.6 ml drop 40
mg/0.6 ml *
v-r anti-gas 166 mg softgel 166 mg
*
Antiulcer Agents And Acid
Suppressants
acid reducer 20 mg tablet maximum
strength 20 mg *
amoxicil-clarithromy-lansopraz oral
combo pack 500-500-30 mg
CARAFATE ORAL SUSPENSION
100 MG/ML
Necessary Actions,
Restrictions, or
Limits on Use
152
Tier level
What the
drug will
cost you
(Cimetidine HCl)
1
$0
(Cimetidine)
1
$0
(Tagamet Hb)
4
$0
(Nexium I.V.)
1
$0
(Famotidine)
1
$0
(Famotidine In
Nacl,Iso-Osm/PF)
1
$0
(Famotidine)
1
$0
(Pepcid)
1
$0
(Pepcid Ac)
4
$0
(Prevacid 24hr)
4
$0
(Prevacid)
1
$0
(Cytotec)
1
$0
(Omeprazole)
(Omeprazole
Magnesium)
4
$0
4
$0
(Prilosec)
1
$0
(Zegerid)
1
$0
(Protonix)
1
$0
4
$0
Name of Drug
cimetidine hcl oral solution 300
mg/5 ml
cimetidine oral tablet 200 mg, 300
mg, 400 mg, 800 mg
cvs cimetidine 200 mg tablet (otc)
200 mg *
esomeprazole sodium intravenous
recon soln 20 mg, 40 mg
famotidine (pf) intravenous solution
20 mg/2 ml
famotidine (pf)-nacl (iso-os)
intravenous piggyback 20 mg/50 ml
famotidine 40 mg/4 ml vial
25's,outer 10 mg/ml
famotidine oral tablet 20 mg, 40 mg
gnp acid reducer 10 mg tablet 10
mg *
lansoprazole dr 15 mg capsule na/f
(otc) 15 mg *
lansoprazole oral capsule,delayed
release(dr/ec) 15 mg, 30 mg
misoprostol oral tablet 100 mcg,
200 mcg
omeprazole dr 20 mg tablet 20 mg *
omeprazole mag dr 20.6 mg cap two
14-days course 20 mg *
omeprazole oral capsule,delayed
release(dr/ec) 10 mg, 20 mg, 40 mg
omeprazole-sodium bicarbonate
oral capsule 20-1.1 mg-gram
pantoprazole oral tablet,delayed
release (dr/ec) 20 mg, 40 mg
PRILOSEC OTC 20.6 MG
TABLET OTC 20 MG *
Necessary Actions,
Restrictions, or
Limits on Use
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
153
Tier level
What the
drug will
cost you
(Pepcid Ac)
4
$0
(Tagamet Hb)
4
$0
(Zegerid Otc)
4
$0
(Zantac)
4
$0
(Zantac)
4
$0
(Zantac)
1
$0
(Zantac)
1
$0
(Ranitidine HCl)
1
$0
(Ranitidine HCl)
1
$0
(Zantac)
1
$0
(Sucralfate)
1
$0
(Carafate)
(Zantac)
1
4
$0
$0
4
$0
4
$0
4
$0
Name of Drug
pub famotidine 20 mg tablet max
strength (otc) 20 mg *
pv acid relief 200 mg tablet 200 mg
*
ra omeprazole-bicarb 20-1,100
3x14 day course (otc) 20-1.1 mggram *
ranitidine 150 mg tablet maximum
strength (otc) 150 mg *
ranitidine 75 mg tablet s/f, sodiumfree 75 mg *
ranitidine hcl 50 mg/2 ml vial sdv 50
mg/2 ml (25 mg/ml)
ranitidine hcl injection solution 25
mg/ml
ranitidine hcl oral capsule 150 mg,
300 mg
ranitidine hcl oral syrup 15 mg/ml
ranitidine hcl oral tablet 150 mg,
300 mg
sucralfate oral suspension 100
mg/ml
sucralfate oral tablet 1 gram
wal-zan 75 mg tablet 75 mg *
ZANTAC 150 MG TABLET TWIN
PACK(2X45TABS) (OTC) 150 MG
*
ZANTAC 150 MG TABLET TWIN
PK, MAX STRGTH (OTC) 150
MG *
ZANTAC 75 MG TABLET 75 MG
*
Gastrointestinal Agents,
Other
Necessary Actions,
Restrictions, or
Limits on Use
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
154
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
acid gone antacid liquid 95-358
(Gaviscon)
4
$0
mg/15 ml *
almacone liquid 200-200-20 mg/5
(Maalox Maximum
4
$0
ml *
Strength)
almacone-2 liquid 400-400-40 mg/5 (Maalox Maximum
4
$0
ml *
Strength)
aluminum hydroxide gel sugar-free (Aluminum
4
$0
320 mg/5 ml *
Hydroxide)
AMITIZA ORAL CAPSULE 24
QL (60 per 30 days)
2
$0
MCG, 8 MCG
antacid plus x-stren susp 500-450(Maalox Maximum
4
$0
40 mg/5 ml *
Strength)
antacid ultra tablet chew 400 mg
(Tums)
4
$0
(1,000 mg) *
antacid xtra strength chew tab
(Tums)
4
$0
extra-strength 300 mg (750 mg) *
antacid-antigas liquid 200-200-20
(Maalox Maximum
4
$0
mg/5 ml *
Strength)
anti-diarrheal 2 mg caplet caplet 2
(Imodium A-D)
4
$0
mg *
bismatrol suspension 262 mg/15 ml
(Pepto-Bismol)
4
$0
*
BUPHENYL ORAL TABLET 500
2
$0
MG
calci-chew tablet 500 mg calcium
(Tums)
4
$0
(1,250 mg) *
calcium 500 mg chewable tablet tab
chew,p/f 500 mg calcium (1,250 mg) (Tums)
4
$0
*
calcium antacid 500 mg chw tab
assorted fruit 200 mg calcium (500 (Tums)
4
$0
mg) *
CALCIUM-500 MG TABLET
CHEWABLE SOY FREE, YEAST
4
$0
FREE 500-100 MG-UNIT *
155
Tier level
What the
drug will
cost you
4
$0
2
$0
(Tums)
4
$0
(Tums)
4
$0
4
$0
4
$0
(Lactulose)
1
$0
(Gastrocrom)
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
cal-gest 500 mg tablet chew 200 mg
calcium (500 mg) *
CARBAGLU ORAL TABLET,
DISPERSIBLE 200 MG
child soothe 400 mg tab chew 400
mg *
children pepto 400 mg tab chew
bubble gum, na/f 400 mg *
comfort gel max str susp max-str
400-400-40 mg/5 ml *
comfort gel suspension regular str,
cherry 200-200-20 mg/5 ml *
constulose oral solution 10 gram/15
ml
cromolyn oral concentrate 100 mg/5
ml
(Tums)
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Calcium
cvs antacid-antigas tab chew 1,000Carbonate/Simethi
60 mg *
cone)
cvs anti-diarrheal 2 mg sftgel softgel
(Loperamide HCl)
2 mg *
cvs anti-diarrheal suspension 262
(Pepto-Bismol)
mg/15 ml *
cvs loperamide 1 mg/7.5 ml liq mint
(Loperamide HCl)
1 mg/7.5 ml *
diamode 2 mg tablet outer, f/c 2 mg
(Imodium A-D)
*
dicyclomine oral capsule 10 mg
(Bentyl)
dicyclomine oral solution 10 mg/5
(Dicyclomine HCl)
ml
dicyclomine oral tablet 20 mg
(Bentyl)
diphenoxylate-atropine oral liquid
(Diphenoxylate
2.5-0.025 mg/5 ml
HCl/Atropine)
Necessary Actions,
Restrictions, or
Limits on Use
156
Tier level
What the
drug will
cost you
(Lomotil)
1
$0
(Lactulose)
(Maalox Maximum
Strength)
1
$0
4
$0
(Gaviscon)
4
$0
2
$0
2
$0
(Maalox Maximum
Strength)
4
$0
(Almacone)
4
$0
(Lactulose)
1
$0
(Robinul)
1
$0
(Robinul)
1
$0
(Loperamide HCl)
4
$0
4
$0
4
$0
1
$0
1
$0
Name of Drug
diphenoxylate-atropine oral tablet
2.5-0.025 mg
enulose oral solution 10 gram/15 ml
flanax antacid liquid 200-200-20
mg/5 ml *
foaming antacid liquid 95-358
mg/15 ml *
GATTEX 5 MG 30-VIAL KIT 5
MG
GATTEX ONE-VIAL
SUBCUTANEOUS KIT 5 MG
gelusil antacid & antigas liq 400400-40 mg/5 ml *
gelusil tablet chewable cool mint
200-200-25 mg *
generlac oral solution 10 gram/15
ml
glycopyrrolate injection solution 0.2
mg/ml
glycopyrrolate oral tablet 1 mg, 2
mg
imodium a-d 1 mg/7.5 ml liquid mint
1 mg/7.5 ml *
IMODIUM A-D 2 MG CAPLET
CAPLET 2 MG *
kaopectate 262 mg/15 ml susp
vanilla flavor 262 mg/15 ml *
kionex 15 gm/60 ml suspension 15
gram/60 ml
kionex oral powder
(Pepto-Bismol)
(Sodium
Polystyrene
Sulfonate)
(Sodium
Polystyrene
Sulfonate)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
157
Tier level
What the
drug will
cost you
1
$0
2
$0
(Loperamide HCl)
4
$0
(Loperamide HCl)
1
$0
2
$0
4
$0
4
$0
(Uromag)
4
$0
(Magox 400)
4
$0
(Magox 400)
4
$0
(Magox 400)
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
lactulose oral solution 10 gram/15
ml
LINZESS ORAL CAPSULE 145
MCG, 290 MCG
loperamide 1 mg/5 ml liquid 1 mg/5
ml *
loperamide oral capsule 2 mg
LOTRONEX ORAL TABLET 0.5
MG, 1 MG
maalox advanced suspension
regular strength 200-200-20 mg/5
ml *
MAGNEBIND 300 TABLET 250300 MG *
magnesium 500 mg capsule s/f,na/f
500 mg *
magnesium oxide 250 mg tablet 250
mg *
magnesium oxide 400 mg tablet
s/f,p/f,gluten-free 400 mg *
magnesium oxide 500 mg tablet
p/f,s/f,lactose-free 500 mg *
masanti liquid 400-400-40 mg/5 ml
*
medi-first pep-t-med tab chew 262
mg *
methscopolamine oral tablet 2.5 mg,
5 mg
metoclopramide hcl injection
solution 5 mg/ml
metoclopramide hcl oral solution 5
mg/5 ml
metoclopramide hcl oral tablet 10
mg, 5 mg
(Lactulose)
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Pepto-Bismol ToGo)
(Methscopolamine
Bromide)
(Metoclopramide
HCl)
(Metoclopramide
HCl)
(Reglan)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
158
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
(Maalox Maximum
Strength)
4
$0
(Almacone)
4
$0
(Maalox Maximum
Strength)
4
$0
2
$0
2
$0
2
$0
(Magox 400)
(Pepto-Bismol ToGo)
4
$0
4
$0
(Loperamide HCl)
4
$0
(Uromag)
4
$0
2
$0
2
$0
2
$0
4
$0
Name of Drug
mgo 400 mg tablet 400 mg *
mi acid suspension 200-200-20
mg/5 ml, 400-400-40 mg/5 ml *
mi-acid ds tablet 700-300 mg *
mintox maximum strength susp max
str, lemon creme 400-400-40 mg/5
ml *
mintox plus tablet chewable 200200-25 mg *
mintox suspension mint creme 200200-20 mg/5 ml *
MOVANTIK ORAL TABLET 12.5
MG, 25 MG
NUTRESTORE ORAL POWDER
IN PACKET 5 GRAM
OCALIVA ORAL TABLET 10
MG, 5 MG
phillips 500 mg caplet 500 mg *
pink bismuth tablet chew 262 mg *
ra loperamide 1 mg/7.5 ml susp mint
1 mg/7.5 ml *
ra magnesium 500 mg capsule 500
mg *
RAVICTI ORAL LIQUID 1.1
GRAM/ML
RELISTOR SUBCUTANEOUS
RELISTOR SUBCUTANEOUS
SYRINGE 12 MG/0.6 ML, 8
MG/0.4 ML
ri-gel ii suspension 400-400-40
mg/5 ml *
(Magox 400)
(Maalox Maximum
Strength)
(Rolaids)
(Maalox Maximum
Strength)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
PA; QL (30 per 30
days)
PA
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
159
Name of Drug
ri-mox suspension 200-200-20 mg/5 (Maalox Maximum
ml *
Strength)
sm foaming antacid tablet chew 80(Gaviscon)
20 mg *
(Bismuth
sm stomach relief caplet 262 mg *
Subsalicylate)
sodium bicarb 650 mg tablet 10 gr
(Sodium
650 mg *
Bicarbonate)
(Sodium
sodium polystyrene (sorb free) oral
Polystyrene
suspension 15 gram/60 ml
Sulfonate)
(Sodium
sodium polystyrene sulfonate rectal
Polystyrene
enema 30 gram/120 ml
Sulfonate)
soothe 262 mg caplet caplet 262 mg (Bismuth
*
Subsalicylate)
soothe 262 mg/15 ml suspension
(Pepto-Bismol)
s/f,cherry 262 mg/15 ml *
(Sodium
sps 15 gm/60 ml suspension 15
Polystyrene
gram/60 ml
Sulfonate)
ursodiol oral capsule 300 mg
(Actigall)
ursodiol oral tablet 250 mg, 500 mg (Urso)
VIBERZI ORAL TABLET 100
MG, 75 MG
Laxatives
alophen pills 5 mg *
(Dulcolax)
bisac-evac 10 mg suppository 10 mg
(Dulcolax)
*
bisacodyl 10 mg suppository 10 mg
(Dulcolax)
*
bisacodyl ec 5 mg tablet 5 mg *
(Dulcolax)
biscolax 10 mg suppository 10 mg * (Dulcolax)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
1
$0
1
$0
4
$0
4
$0
1
$0
1
1
$0
$0
2
$0
4
$0
4
$0
4
$0
4
4
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (60 per 30
days)
160
Tier level
What the
drug will
cost you
4
$0
4
$0
(Enema)
4
$0
(Citrucel)
4
$0
(Docusate Sodium)
4
$0
(Gavilax)
4
$0
(Miralax)
4
$0
(Senokot)
4
$0
(Surfak)
4
$0
(Colace)
4
$0
(Docusate Sodium)
4
$0
(Docusate Sodium)
4
$0
4
$0
4
4
4
4
$0
$0
$0
$0
(Enema)
4
$0
(Enema)
4
$0
Name of Drug
BLADDER CONTROL PAD XLONG 9'S,X-LONG *
COLACE 100 MG CAPSULE 100
MG *
cvs enema disposable 19-7
gram/118 ml *
cvs fiber therapy 500 mg caplt
soluble, caplet 500 mg *
cvs kids 100 mg mini enema 100
mg/5 ml *
cvs purelax powder 14 once-daily
doses 17 gram/dose *
cvs purelax powder packet s/f, 10
daily doses 17 gram *
cvs senna laxative 8.6 mg tab 8.6 mg
*
cvs stool softener softgel softgel 240
mg *
doc-q-lace 100 mg softgel 100 mg *
docu liquid 50 mg/5 ml 50 mg/5 ml
*
docusate sodium 100 mg tablet
crushable 100 mg *
docusate sodium-senna tablet 8.6-50
mg *
docusol mini-enema outer 283 mg *
dok 100 mg softgel softgel 100 mg *
dok 100 mg tablet 100 mg *
dulcolax ss 100 mg softgel 100 mg *
enema disposable 19-7 gram/118 ml
*
enema ready to use latex-free 19-7
gram/118 ml *
(Sennosides/Docus
ate Sodium)
(Docusate Sodium)
(Colace)
(Docusate Sodium)
(Colace)
Necessary Actions,
Restrictions, or
Limits on Use
161
Name of Drug
enemeez mini enema 5cc tubes,
(Docusate Sodium)
outer 283 mg/5 ml *
enemeez plus mini enema outer 283(Docusol Plus)
20 mg/5 ml *
(Psyllium Seed
eq fiber therapy powder *
(With Sugar))
equalactin 500 mg tab chew 500 mg (Calcium
*
Polycarbophil)
fiber tablet unboxed 625 mg *
(Fibercon)
fiber therapy (psyllium) oral powder
(Psyllium Seed)
*
fiber therapy powder 2 gram/19
(Citrucel)
gram *
fiber-lax captabs 500mg
(Fibercon)
polycarbophil 625 mg *
fibertab oral tablet 625 mg *
(Fibercon)
FLEET BISACODYL 10 MG
ENEMA 10 MG/30 ML *
gavilyte-c oral recon soln 240(Golytely)
22.72-6.72 -5.84 gram
gavilyte-g oral recon soln 236(Golytely)
22.74-6.74 -5.86 gram
(Nulytely with
gavilyte-n oral recon soln 420 gram
Flavor Packs)
gentlelax powder 30 once-daily
(Gavilax)
glycolax powder 7 doses (otc) 17
(Gavilax)
gram/dose *
healthylax powder packet 14x17gm,
(Miralax)
outer 17 gram *
hydrocil instant packet *
(Psyllium Seed)
KONSYL 6 GM PACKET S/F,
GLUTEN-F, OUTER 6 GRAM *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
4
$0
3
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
162
Name of Drug
konsyl fiber 625 mg caplet caplet, s/f
625 mg *
konsyl psyllium fiber packet orange,
gluten free 3.4 gram *
magic bullet 10 mg suppos 10 mg *
milk of magnesia suspension 400
mg/5 ml *
mineral oil laxative *
MOVIPREP ORAL POWDER IN
PACKET 100-7.5-2.691 GRAM
(Fibercon)
(Psyllium Husk
(With Sugar))
(Dulcolax)
(Milk Of
Magnesia)
(Mineral Oil)
(Psyllium Seed
(With Sugar))
oral saline laxative liquid s/f, ginger (Na Phos,M-B/Na
lemon 7.2-2.7 gram/15 ml *
Phos,Di-Ba)
peg 3350-electrolytes oral recon
soln 236-22.74-6.74 -5.86 gram,
(Golytely)
240-22.72-6.72 -5.84 gram
peg-electrolyte soln oral recon soln (Nulytely with
420 gram
Flavor Packs)
(Sennosides/Docus
peri-colace tablet 8.6-50 mg *
ate Sodium)
phillips' lax liqui-gels 100 mg *
(Colace)
phosphate oral saline laxative s/f,
(Na Phos,M-B/Na
ginger lemon 7.2-2.7 gram/15 ml * Phos,Di-Ba)
polyethylene glycol 3350 oral
(Polyethylene
powder 17 gram/dose
Glycol 3350)
polyethylene glycol 3350 oral
(Polyethylene
powder in packet 17 gram
Glycol 3350)
polyethylene glycol 3350 powd 14
once-daily doses (otc) 17 gram/dose (Gavilax)
*
polyethylene glycol 3350 powd 17
(Miralax)
grams pkts,outer (otc) 17 gram *
natural fiber lax powder *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
4
$0
4
$0
1
$0
1
$0
4
$0
4
$0
4
$0
1
$0
1
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
163
Tier level
What the
drug will
cost you
(Miralax)
4
$0
(Docusate Sodium)
(Sennosides)
4
4
$0
$0
(Enema)
4
$0
(Gavilax)
4
$0
(Psyllium Seed
(With Sugar))
4
$0
(Sennosides)
4
$0
(Senokot)
4
$0
(Sennosides)
4
$0
(Senokot)
(Sennosides/Docus
ate Sodium)
4
$0
4
$0
(Docusate Sodium)
4
$0
(Docusate Sodium)
4
$0
(Gavilax)
4
$0
(Citrucel)
4
$0
(Psyllium Seed)
4
$0
(Miralax)
4
$0
(Nulytely with
Flavor Packs)
1
$0
(Phoslo)
(Calcium Acetate)
1
1
$0
$0
Name of Drug
polyethylene glycol 3350 powd
outer,s/f (otc) 17 gram *
promolaxin 100 mg tablet 100 mg *
pv senna 8.6 mg softgel 8.6 mg *
ra enema twin pack 2 x 4.5oz, rtu
19-7 gram/118 ml *
ra laxative peg 3350 powder 14
once-daily doses 17 gram/dose *
reguloid powder orange *
senexon 8.8 mg/5 ml liquid 8.8 mg/5
ml *
senexon tablet 8.6 mg *
senna 8.8 mg/5 ml syrup a/f,
chocolate 8.8 mg/5 ml *
senna-lax 8.6 mg tablet 8.6 mg *
senokot-s tablet 8.6-50 mg *
silace 50 mg/5 ml liquid 50 mg/5 ml
*
silace 60 mg/15 ml syrup 60 mg/15
ml *
sm clearlax powder 14 once-daily
sm fiber laxative 500 mg cplt 500
mg *
sm fiber smooth powder *
smoothlax powder packet 10 oncedaily doses 17 gram *
trilyte with flavor packets oral recon
soln 420 gram
Phosphate Binders
calcium acetate oral capsule 667 mg
calcium acetate oral tablet 667 mg
Necessary Actions,
Restrictions, or
Limits on Use
164
Name of Drug
calphron 667 mg tablet 667 mg *
eliphos oral tablet 667 mg
(Calcium Acetate)
(Calcium Acetate)
(Calcium
magnebind 400 oral tablet 400-200Carbonate/Mag
1 mg
Carb/Fa)
PHOSLYRA ORAL SOLUTION
667 MG (169 MG CALCIUM)/5
ML
RENAGEL ORAL TABLET 400
MG, 800 MG
RENVELA ORAL POWDER IN
PACKET 0.8 GRAM, 2.4 GRAM
RENVELA ORAL TABLET 800
MG
Tier level
What the
drug will
cost you
4
1
$0
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
Genitourinary Agents
Antispasmodics, Urinary
MYRBETRIQ ORAL TABLET
MG, 50 MG
oxybutynin chloride oral syrup 5
mg/5 ml
(Oxybutynin
Chloride)
(Oxybutynin
oxybutynin chloride oral tablet 5 mg
Chloride)
oxybutynin chloride oral tablet
extended release 24hr 10 mg, 15
(Ditropan XL)
mg, 5 mg
tolterodine oral capsule,extended
(Detrol LA)
tolterodine oral tablet 1 mg, 2 mg
(Detrol)
TOVIAZ ORAL TABLET
MG, 8 MG
trospium oral capsule,extended
(Trospium
release 24hr 60 mg
Chloride)
165
Tier level
What the
drug will
cost you
(Trospium
Chloride)
1
$0
(Uroxatral)
1
$0
(Flomax)
1
$0
(Terazosin HCl)
1
$0
(Desferal)
1
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
Name of Drug
trospium oral tablet 20 mg
Genitourinary Agents,
Miscellaneous
alfuzosin oral tablet extended
release 24 hr 10 mg
tamsulosin oral capsule,extended
release 24hr 0.4 mg
terazosin oral capsule 1 mg, 10 mg,
2 mg, 5 mg
Necessary Actions,
Restrictions, or
Limits on Use
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine injection recon soln 2
gram, 500 mg
DEPEN TITRATABS ORAL
TABLET 250 MG
EXJADE ORAL TABLET,
DISPERSIBLE 125 MG, 250 MG,
500 MG
FERRIPROX ORAL SOLUTION
100 MG/ML
FERRIPROX ORAL TABLET 500
MG
sodium thiosulfate intravenous
solution 1 gram/10 ml (100 mg/ml),
12.5 gram/50 ml (250 mg/ml)
SYPRINE ORAL CAPSULE 250
MG
(Sodium
Thiosulfate)
PA BvD
Hormonal Agents,
Stimulant/Replacement/Modif
ying
Androgens
166
Name of Drug
ANDRODERM TRANSDERMAL
PATCH 24 HOUR 2 MG/24
HOUR, 4 MG/24 HR
ANDROGEL TRANSDERMAL
GEL IN METERED-DOSE PUMP
20.25 MG/1.25 GRAM (1.62 %)
ANDROGEL TRANSDERMAL
GEL IN PACKET 1.62 % (20.25
MG/1.25 GRAM), 1.62 % (40.5
MG/2.5 GRAM)
androxy oral tablet 10 mg
danazol oral capsule 100 mg, 200
mg, 50 mg
oxandrolone oral tablet 10 mg, 2.5
mg
testosterone cypionate
intramuscular oil 100 mg/ml, 200
mg/ml
testosterone enanthate
intramuscular oil 200 mg/ml
testosterone transdermal gel 50
mg/5 gram (1 %)
testosterone transdermal gel in
metered-dose pump 1.25 gram/
actuation (1 %)
packet 1 % (25 mg/2.5gram)
packet 1 % (50 mg/5 gram)
Estrogens And
Antiestrogens
COMBIPATCH TRANSDERMAL
PATCH SEMIWEEKLY 0.05-0.14
MG/24 HR, 0.05-0.25 MG/24 HR
Tier level
What the
drug will
cost you
2
$0
PA; QL (30 per 30
days)
$0
PA; QL (150 per 30
days)
2
2
$0
(Fluoxymesterone)
1
$0
(Danazol)
1
$0
(Oxandrin)
1
$0
(DepoTestosterone)
1
$0
(Testosterone
Enanthate)
1
$0
(Testim)
1
$0
(Vogelxo)
1
$0
(Androgel)
1
$0
(Testim)
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (150 per 30
days)
PA
2
$0
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
PA-HRM; QL (8 per
28 days)
167
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
DUAVEE ORAL TABLET 0.45-20
PA-HRM
2
$0
MG
ESTRACE VAGINAL CREAM
2
$0
0.01 % (0.1 MG/GRAM)
estradiol oral tablet 0.5 mg, 1 mg, 2
PA-HRM
(Estrace)
1
$0
mg
estradiol transdermal patch
PA-HRM; QL (8 per
semiweekly 0.025 mg/24 hr, 0.0375
28 days)
(Vivelle-Dot)
1
$0
mg/24 hr, 0.05 mg/24 hr, 0.075
mg/24 hr, 0.1 mg/24 hr
estradiol transdermal patch weekly
PA-HRM; QL (4 per
0.025 mg/24 hr, 0.0375 mg/24 hr,
28 days)
(Climara)
1
$0
0.05 mg/24 hr, 0.06 mg/24 hr, 0.075
mg/24 hr, 0.1 mg/24 hr
estradiol valerate intramuscular oil
(Delestrogen)
1
$0
10 mg/ml, 20 mg/ml, 40 mg/ml
estradiol-norethindrone acet oral
PA-HRM
(Activella)
1
$0
tablet 0.5-0.1 mg, 1-0.5 mg
estropipate oral tablet 0.75 mg, 1.5
PA-HRM
(Estropipate)
1
$0
mg, 3 mg
FEMRING VAGINAL RING 0.05
QL (1 per 84 days)
2
$0
MG/24 HR, 0.1 MG/24 HR
MENEST ORAL TABLET 0.3 MG,
PA-HRM
2
$0
0.625 MG, 1.25 MG, 2.5 MG
mimvey lo oral tablet 0.5-0.1 mg
(Activella)
1
$0
PA-HRM
mimvey oral tablet 1-0.5 mg
(Activella)
1
$0
PA-HRM
PREMARIN INJECTION RECON
2
$0
SOLN 25 MG
PREMARIN ORAL TABLET 0.3
PA-HRM
MG, 0.45 MG, 0.625 MG, 0.9 MG,
2
$0
1.25 MG
PREMARIN VAGINAL CREAM
2
$0
0.625 MG/GRAM
PREMPHASE ORAL TABLET
PA-HRM
2
$0
0.625 MG (14)/ 0.625MG-5MG(14)
168
Tier level
What the
drug will
cost you
2
$0
1
$0
2
$0
(Hydrocortisone
Sod Succinate)
1
$0
(Celestone)
1
$0
(Cortisone Acetate)
1
$0
(Dexamethasone)
1
$0
Name of Drug
PREMPRO ORAL TABLET 0.31.5 MG, 0.45-1.5 MG, 0.625-2.5
MG, 0.625-5 MG
raloxifene oral tablet 60 mg
VAGIFEM VAGINAL TABLET 10
MCG
Glucocorticoids/Mineraloco
rticoids
a-hydrocort injection recon soln 100
mg
betamethasone acet,sod phos
injection suspension 6 mg/ml
cortisone oral tablet 25 mg
dexamethasone oral elixir 0.5 mg/5
ml
dexamethasone oral tablet 0.5 mg,
0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg,
6 mg
dexamethasone sodium phosphate
injection solution 10 mg/ml, 4 mg/ml
fludrocortisone oral tablet 0.1 mg
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
(Evista)
QL (18 per 28 days)
PA BvD
PA BvD
PA BvD
(Dexamethasone)
(Dexamethasone
Sod Phosphate)
(Fludrocortisone
Acetate)
1
$0
1
$0
1
$0
hydrocortisone oral tablet 10 mg, 20
PA BvD
(Cortef)
1
$0
mg, 5 mg
methylprednisolone 125 mg vial 2ml
(Solu-Medrol)
1
$0
sdv, 25's,l/f 125 mg
methylprednisolone acetate
injection suspension 40 mg/ml, 80
(Depo-Medrol)
1
$0
mg/ml
methylprednisolone oral tablet 16
PA BvD
(Medrol)
1
$0
mg, 32 mg, 4 mg, 8 mg
methylprednisolone oral
PA BvD
(Medrol)
1
$0
tablets,dose pack 4 mg
methylprednisolone sodium succ
(Solu-Medrol)
1
$0
injection recon soln 125 mg, 40 mg
169
Name of Drug
methylprednisolone ss 1 gm vl
mdv,latex-free 1,000 mg
prednisolone sodium phosphate oral
solution 15 mg/5 ml (3 mg/ml), 25
mg/5 ml (5 mg/ml), 5 mg base/5 ml
(6.7 mg/5 ml)
prednisone oral solution 5 mg/5 ml
prednisone oral tablet 1 mg, 2.5 mg,
20 mg, 5 mg, 50 mg
prednisone oral tablet 10 mg
prednisone oral tablets,dose pack 10
mg, 5 mg
SOLU-CORTEF (PF) INJECTION
RECON SOLN 100 MG/2 ML
triamcinolone acetonide injection
suspension 10 mg/ml, 40 mg/ml
Pituitary
desmopressin injection solution 4
mcg/ml
desmopressin nasal solution 0.1
mg/ml (refrigerate)
desmopressin nasal spray,nonaerosol 10 mcg/spray (0.1 ml)
desmopressin oral tablet 0.1 mg, 0.2
mg
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE 0.2
MG/0.25 ML, 0.4 MG/0.25 ML, 0.6
MG/0.25 ML, 0.8 MG/0.25 ML, 1
MG/0.25 ML, 1.2 MG/0.25 ML, 1.4
MG/0.25 ML, 1.6 MG/0.25 ML, 1.8
MG/0.25 ML, 2 MG/0.25 ML
(Solu-Medrol)
Tier level
What the
drug will
cost you
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
(Pediapred)
1
$0
(Prednisone)
1
$0
(Prednisone)
1
$0
(Prednisone)
1
$0
(Prednisone)
1
$0
2
$0
(Triamcinolone
Acetonide)
1
$0
(Desmopressin
Acetate)
1
$0
(DDAVP)
1
$0
(Desmopressin
Acetate)
1
$0
(DDAVP)
1
$0
PA BvD
PA BvD
PA BvD
PA BvD
QL (15 per 30 days)
QL (15 per 30 days)
PA
2
$0
170
Name of Drug
GENOTROPIN SUBCUTANEOUS
CARTRIDGE 12 MG/ML (36
UNIT/ML), 5 MG/ML (15
UNIT/ML)
INCRELEX SUBCUTANEOUS
SOLUTION 10 MG/ML
LUPRON DEPOT-PED (3
MONTH) INTRAMUSCULAR
SYRINGE KIT 30 MG
LUPRON DEPOT-PED
INTRAMUSCULAR KIT 11.25
MG, 15 MG, 7.5 MG (PED)
NORDITROPIN FLEXPRO
SUBCUTANEOUS PEN
INJECTOR 10 MG/1.5 ML (6.7
MG/ML), 15 MG/1.5 ML (10
MG/ML), 30 MG/3 ML (10
MG/ML), 5 MG/1.5 ML (3.3
MG/ML)
octreotide acet 50 mcg/ml syr
outer,single-dose,10 50 mcg/ml (1
ml)
octreotide acetate injection solution
1,000 mcg/ml, 100 mcg/ml, 200
mcg/ml, 500 mcg/ml
octreotide acetate injection solution
50 mcg/ml
SAIZEN CLICK.EASY
SUBCUTANEOUS CARTRIDGE
8.8 MG/1.5 ML (FNL)
SAIZEN SUBCUTANEOUS
RECON SOLN 5 MG, 8.8 MG
SANDOSTATIN LAR 10 MG KIT
10 MG
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA
2
$0
2
$0
2
$0
2
$0
QL (1 per 84 days)
PA
2
$0
(Octreotide
Acetate)
1
$0
(Sandostatin)
1
$0
(Octreotide
Acetate)
1
$0
2
$0
2
$0
2
$0
PA
PA
171
Name of Drug
20 MG
30 MG
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR
RECON 10 MG, 20 MG, 30 MG
SEROSTIM SUBCUTANEOUS
RECON SOLN 4 MG, 5 MG, 6 MG
SOMATULINE DEPOT
MG/0.5 ML, 60 MG/0.2 ML, 90
MG/0.3 ML
SOMAVERT SUBCUTANEOUS
RECON SOLN 10 MG, 15 MG, 20
MG, 25 MG, 30 MG
SUPPRELIN LA IMPLANT KIT
50 MG (65 MCG/DAY)
Progestins
DEPO-PROVERA
INTRAMUSCULAR SOLUTION
400 MG/ML
hydroxyprogesterone caproate
intramuscular oil 250 mg/ml
medroxyprogesterone intramuscular
suspension 150 mg/ml
medroxyprogesterone intramuscular
syringe 150 mg/ml
medroxyprogesterone oral tablet 10
mg, 2.5 mg, 5 mg
MEGACE ES ORAL
SUSPENSION 625 MG/5 ML
megestrol oral suspension 400
mg/10 ml (40 mg/ml), 625 mg/5 ml
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
QL (1 per 28 days)
2
$0
2
$0
2
$0
QL (1 per 360 days)
QL (10 per 28 days)
2
$0
(Hydroxyprogester
one Caproate)
1
$0
(Depo-Provera)
1
$0
(Medroxyprogester
one Acetate)
1
$0
(Provera)
1
$0
2
$0
1
$0
(Megace Es)
PA NSO
QL (1 per 84 days)
QL (1 per 84 days)
172
Tier level
What the
drug will
cost you
(Aygestin)
1
$0
(Progesterone)
1
$0
(Prometrium)
1
$0
(Levothyroxine
Sodium)
1
$0
(Levoxyl)
1
$0
(Cytomel)
1
$0
(Tapazole)
(Propylthiouracil)
1
1
$0
$0
2
$0
Name of Drug
norethindrone acetate oral tablet 5
mg
progesterone in oil intramuscular
oil 50 mg/ml
progesterone micronized oral
capsule 100 mg, 200 mg
Thyroid And Antithyroid
Agents
levothyroxine intravenous recon
soln 100 mcg, 200 mcg, 500 mcg
levothyroxine oral tablet 100 mcg,
112 mcg, 125 mcg, 137 mcg, 150
mcg, 175 mcg, 200 mcg, 25 mcg,
300 mcg, 50 mcg, 75 mcg, 88 mcg
liothyronine oral tablet 25 mcg, 5
mcg, 50 mcg
methimazole oral tablet 10 mg, 5 mg
propylthiouracil oral tablet 50 mg
Necessary Actions,
Restrictions, or
Limits on Use
Immunological Agents
Immunological Agents
ARCALYST SUBCUTANEOUS
RECON SOLN 220 MG
ASTAGRAF XL ORAL
24HR 0.5 MG, 1 MG, 5 MG
AUBAGIO ORAL TABLET 14
MG, 7 MG
azathioprine oral tablet 50 mg
(Imuran)
azathioprine sodium injection recon (Azathioprine
soln 100 mg
Sodium)
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN 6
GRAM
PA BvD
2
$0
2
$0
1
$0
1
$0
PA; QL (28 per 28
days)
PA BvD
PA BvD
PA BvD
2
$0
173
Name of Drug
CELLCEPT INTRAVENOUS
500 MG
CIMZIA POWDER FOR
RECONST SUBCUTANEOUS KIT
400 MG (200 MG X 2 VIALS)
CIMZIA SUBCUTANEOUS
SYRINGE KIT 400 MG/2 ML (200
MG/ML X 2)
cyclosporine intravenous solution
250 mg/5 ml
cyclosporine modified oral capsule
100 mg, 25 mg, 50 mg
cyclosporine modified oral solution
100 mg/ml
cyclosporine oral capsule 100 mg,
25 mg
ENBREL SUBCUTANEOUS
RECON SOLN 25 MG (1 ML)
ENBREL SUBCUTANEOUS
SYRINGE 25 MG/0.5ML (0.51), 50
MG/ML (0.98 ML)
ENBREL SURECLICK
SUBCUTANEOUS PEN
INJECTOR 50 MG/ML (0.98 ML)
ENVARSUS XR ORAL TABLET
EXTENDED RELEASE 24 HR
0.75 MG, 1 MG, 4 MG
FLEBOGAMMA DIF
INTRAVENOUS SOLUTION 10
%, 5 %
GAMASTAN S/D
15-18 % RANGE
Tier level
What the
drug will
cost you
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA
2
$0
2
$0
(Sandimmune)
1
$0
(Neoral)
1
$0
(Neoral)
1
$0
(Sandimmune)
1
$0
2
$0
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
2
$0
2
$0
2
$0
PA
PA BvD
PA BvD
2
$0
2
$0
PA BvD
174
Name of Drug
GAMMAGARD LIQUID
INJECTION SOLUTION 10 %
GAMMAPLEX INTRAVENOUS
SOLUTION 5 %
gengraf oral capsule 100 mg, 25
(Neoral)
mg, 50 mg
gengraf oral solution 100 mg/ml
(Neoral)
HUMIRA PEN CROHN'S-UC-HS
START SUBCUTANEOUS PEN
INJECTOR KIT 40 MG/0.8 ML
HUMIRA PEN SUBCUTANEOUS
PEN INJECTOR KIT 40 MG/0.8
ML
HUMIRA SUBCUTANEOUS
SYRINGE KIT 10 MG/0.2 ML, 20
MG/0.4 ML, 40 MG/0.8 ML
HYPERRAB S/D (PF)
150 UNIT/ML, 150 UNIT/ML (10
ML)
HYQVIA IG COMPONENT
2.5 GRAM/25 ML (10 %)
HYQVIA SUBCUTANEOUS
SOLUTION 10 GRAM /100 ML
(10 %), 2.5 GRAM /25 ML (10 %),
20 GRAM /200 ML (10 %), 30
GRAM /300 ML (10 %), 5 GRAM
/50 ML (10 %)
ILARIS (PF) SUBCUTANEOUS
RECON SOLN 180 MG/1.2 ML
(150 MG/ML)
IMOGAM RABIES-HT (PF)
150 UNIT/ML
Tier level
What the
drug will
cost you
2
$0
2
$0
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
PA
PA BvD
PA BvD
2
$0
PA
2
$0
2
$0
175
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
KINERET SUBCUTANEOUS
PA; QL (18.76 per 28
2
$0
SYRINGE 100 MG/0.67 ML
days)
leflunomide oral tablet 10 mg, 20
(Arava)
1
$0
mg
mycophenolate mofetil oral capsule
PA BvD
(Cellcept)
1
$0
250 mg
mycophenolate mofetil oral
PA BvD
suspension for reconstitution 200
(Cellcept)
1
$0
mg/ml
mycophenolate mofetil oral tablet
PA BvD
(Cellcept)
1
$0
500 mg
mycophenolate sodium oral
PA BvD
tablet,delayed release (dr/ec) 180
(Myfortic)
1
$0
mg, 360 mg
NULOJIX INTRAVENOUS
PA BvD
2
$0
RECON SOLN 250 MG
OCTAGAM INTRAVENOUS
PA BvD
2
$0
SOLUTION 10 %, 5 %
ORENCIA (WITH MALTOSE)
PA
2
$0
250 MG
ORENCIA SUBCUTANEOUS
PA
2
$0
SYRINGE 125 MG/ML
PRIVIGEN INTRAVENOUS
PA BvD
2
$0
SOLUTION 10 %
PROGRAF INTRAVENOUS
PA BvD
2
$0
SOLUTION 5 MG/ML
RAPAMUNE ORAL SOLUTION 1
PA BvD
2
$0
MG/ML
RIDAURA ORAL CAPSULE 3
2
$0
MG
sirolimus oral tablet 0.5 mg, 1 mg, 2
PA BvD
(Rapamune)
1
$0
mg
tacrolimus oral capsule 0.5 mg, 1
PA BvD
(Hecoria)
1
$0
mg, 5 mg
176
Name of Drug
TYSABRI INTRAVENOUS
ZORTRESS ORAL TABLET 0.25
MG, 0.5 MG, 0.75 MG
Vaccines
ACTHIB (PF) INTRAMUSCULAR
RECON SOLN 10 MCG/0.5 ML
ADACEL(TDAP
ADOLESN/ADULT)(PF)
INTRAMUSCULAR
SUSPENSION 2 LF-(2.5-5-3-5
MCG)-5LF/0.5 ML
ADACEL(TDAP
ADOLESN/ADULT)(PF)
INTRAMUSCULAR SYRINGE 2
LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
BCG (TICE STRAIN) VIAL
LATEX-FREE, OUTER 50 MG
BCG VACCINE, LIVE (PF)
PERCUTANEOUS SUSPENSION
FOR RECONSTITUTION 50 MG
BEXSERO (PF)
50-50-50-25 MCG/0.5 ML
BOOSTRIX TDAP
INTRAMUSCULAR
SUSPENSION 2.5-8-5 LF-MCGLF/0.5ML
BOOSTRIX TDAP
2.5-8-5 LF-MCG-LF/0.5ML
CERVARIX VACCINE (PF)
20-20 MCG/0.5 ML
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; LA; QL (15 per 28
days)
PA BvD; QL (120 per
30 days)
PA BvD
PA BvD
2
$0
2
$0
2
$0
2
$0
2
$0
177
Name of Drug
COMVAX (PF)
INTRAMUSCULAR
SUSPENSION 5-7.5-125 MCG/0.5
ML
DAPTACEL (DTAP PEDIATRIC)
(PF) INTRAMUSCULAR
SUSPENSION 15-10-5 LF-MCGLF/0.5ML
ENGERIX-B (PF)
MCG/ML
ENGERIX-B 20 MCG/ML VIAL
10'S,ADULT,P/F,OUTER 20
MCG/ML
ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR
SUSPENSION 10 MCG/0.5 ML
MCG/0.5 ML
GARDASIL (PF)
INTRAMUSCULAR
SUSPENSION 20-40-40-20
MCG/0.5 ML
GARDASIL (PF)
20-40-40-20 MCG/0.5 ML
GARDASIL 9 (PF)
INTRAMUSCULAR
SUSPENSION 0.5 ML
GARDASIL 9 (PF)
INTRAMUSCULAR SYRINGE 0.5
ML
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
PA BvD; QL (3 per
365 days)
2
$0
PA BvD; QL (3 per
365 days)
$0
PA BvD; QL (3 per
365 days)
$0
PA BvD; QL (3 per
365 days)
2
2
Necessary Actions,
Restrictions, or
Limits on Use
2
$0
2
$0
2
$0
2
$0
178
Name of Drug
HAVRIX (PF)
INTRAMUSCULAR
SUSPENSION 1,440 ELISA
UNIT/ML
HAVRIX (PF)
1,440 ELISA UNIT/ML, 720
ELISA UNIT/0.5 ML
IMOVAX RABIES VACCINE (PF)
INTRAMUSCULAR RECON
SOLN 2.5 UNIT
INFANRIX (DTAP) (PF)
INTRAMUSCULAR
SUSPENSION 25-58-10 LF-MCGLF/0.5ML
IPOL INJECTION SUSPENSION
40-8-32 UNIT/0.5 ML
IPOL INJECTION SYRINGE 40-832 UNIT/0.5 ML
IXIARO (PF) INTRAMUSCULAR
KINRIX (PF) INTRAMUSCULAR
SUSPENSION 25 LF-58 MCG-10
LF/0.5 ML
KINRIX (PF) INTRAMUSCULAR
SYRINGE 25 LF-58 MCG-10
LF/0.5 ML
MENACTRA (PF)
INTRAMUSCULAR SOLUTION 4
MCG/0.5 ML
MENHIBRIX (PF)
INTRAMUSCULAR RECON
SOLN 5-2.5 MCG/0.5 ML
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
179
Name of Drug
MENOMUNE - A/C/Y/W-135 (PF)
SUBCUTANEOUS RECON SOLN
50 MCG
MENVEO A-C-Y-W-135-DIP (PF)
INTRAMUSCULAR KIT 10-5
MCG/0.5 ML
MENVEO MENA COMPONENT
(PF) INTRAMUSCULAR RECON
SOLN 10 MCG /0.5 ML (FINAL)
MENVEO MENCYW-135
COMPNT (PF)
INTRAMUSCULAR RECON
SOLN 5 MCG X 3/ 0.5 ML
(FINAL)
M-M-R II (PF) SUBCUTANEOUS
RECON SOLN 1,000-12,500
TCID50/0.5 ML
PEDIARIX (PF)
MCG-25LF-25 MCG-10LF/0.5 ML
PEDVAX HIB (PF)
7.5 MCG/0.5 ML
PENTACEL (PF)
INTRAMUSCULAR KIT 15 LF
UNIT-20 MCG-5 LF/0.5 ML
PENTACEL ACTHIB
COMPONENT (PF)
INTRAMUSCULAR RECON
SOLN 10 MCG/0.5 ML
PROQUAD (PF)
FOR RECONSTITUTION
10EXP3-4.3-3- 3.99 TCID50/0.5
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (2 per 365 days)
2
$0
2
$0
2
$0
2
$0
2
$0
QL (2 per 365 days)
2
$0
180
Name of Drug
QUADRACEL (PF)
INTRAMUSCULAR
SUSPENSION 15 LF-48 MCG- 5
LF UNIT/0.5ML
RABAVERT (PF)
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 2.5 UNIT
RECOMBIVAX HB (PF)
INTRAMUSCULAR
SUSPENSION 10 MCG/ML, 40
MCG/ML
RECOMBIVAX HB (PF)
MCG/ML, 5 MCG/0.5 ML
ROTARIX ORAL SUSPENSION
FOR RECONSTITUTION 10EXP6
CCID50/ML
ROTATEQ VACCINE ORAL
SUSPENSION 2 ML
TENIVAC (PF)
INTRAMUSCULAR SYRINGE 52 LF UNIT/0.5 ML
TETANUS TOXOID,ADSORBED
(PF) INTRAMUSCULAR
SUSPENSION 5 LF UNIT/0.5 ML
TETANUS,DIPHTHERIA TOX
PED(PF) INTRAMUSCULAR
SUSPENSION 5-25 LF UNIT/0.5
ML
tetanus-diphtheria toxoids-td
(Tetanus,
intramuscular suspension 2-2 lf
Diphtheria
unit/0.5 ml
Tox,Adult)
TRUMENBA INTRAMUSCULAR
Tier level
What the
drug will
cost you
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
2
2
$0
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
PA BvD; QL (3 per
365 days)
PA BvD; QL (3 per
365 days)
PA BvD
181
Name of Drug
TWINRIX (PF)
INTRAMUSCULAR
SUSPENSION 720 ELISA UNIT 20 MCG/ML
TWINRIX (PF)
720 ELISA UNIT -20 MCG/ML
TYPHIM VI INTRAMUSCULAR
SOLUTION 25 MCG/0.5 ML
TYPHIM VI INTRAMUSCULAR
VAQTA (PF) INTRAMUSCULAR
SUSPENSION 50 UNIT/ML
VAQTA (PF) INTRAMUSCULAR
SYRINGE 25 UNIT/0.5 ML, 50
UNIT/ML
VAQTA 25 UNITS/0.5 ML VIAL
SDV, OUTER 25 UNIT/0.5 ML
VARIVAX (PF)
FOR RECONSTITUTION 1,350
UNIT/0.5 ML
YF-VAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 10 EXP4.74
UNIT/0.5 ML
ZOSTAVAX (PF)
FOR RECONSTITUTION 19,400
UNIT/0.65 ML
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (2 per 365 days)
2
$0
2
$0
QL (1 per 365 days)
2
$0
Inflammatory Bowel Disease
Agents
Inflammatory Bowel
Disease Agents
alosetron oral tablet 0.5 mg, 1 mg
(Alosetron HCl)
1
$0
182
Tier level
What the
drug will
cost you
2
$0
2
$0
1
$0
1
$0
2
$0
2
$0
2
$0
1
$0
2
$0
(Ringers Solution)
(Sodium Chloride
Irrig Solution)
1
$0
1
$0
(Sorbitol Solution)
1
$0
1
$0
1
$0
Name of Drug
APRISO ORAL
24HR 0.375 GRAM
ASACOL HD ORAL
(DR/EC) 800 MG
balsalazide oral capsule 750 mg
(Colazal)
budesonide oral
(Entocort EC)
capsule,delayed,extend.release 3 mg
DELZICOL DR 400 MG
CAPSULE 400 MG
DELZICOL ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 400 MG
DIPENTUM ORAL CAPSULE 250
MG
Necessary Actions,
Restrictions, or
Limits on Use
ST
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation solution 0.25
%
LACTATED RINGERS
IRRIGATION SOLUTION
ringers irrigation solution
sodium chloride irrigation solution
0.9 %
sorbitol irrigation solution 3 %, 3.3
%
sorbitol-mannitol urethral solution
2.7-0.54 g/100 ml
water for irrigation, sterile
irrigation solution
(Acetic Acid)
(Mannitol/Sorbitol
Solution)
(Water For
Irrigation,Sterile)
Metabolic Bone Disease
Agents
183
Tier level
What the
drug will
cost you
(Alendronate
Sodium)
1
$0
(Fosamax)
1
$0
(Fosamax)
1
$0
Name of Drug
Metabolic Bone Disease
Agents
alendronate oral solution 70 mg/75
ml
alendronate oral tablet 10 mg, 40
mg, 5 mg
alendronate oral tablet 35 mg, 70
mg
calcitonin (salmon) nasal
spray,non-aerosol 200
unit/actuation
calcitriol intravenous solution 1
mcg/ml
calcitriol oral capsule 0.25 mcg, 0.5
mcg
calcitriol oral solution 1 mcg/ml
doxercalciferol intravenous solution
4 mcg/2 ml
doxercalciferol oral capsule 0.5
mcg, 1 mcg, 2.5 mcg
FORTEO SUBCUTANEOUS PEN
INJECTOR 20 MCG/DOSE - 600
MCG/2.4 ML
FORTICAL NASAL SPRAY,NONAEROSOL 200
UNIT/ACTUATION
ibandronate intravenous solution 3
mg/3 ml
ibandronate intravenous syringe 3
mg/3 ml
ibandronate oral tablet 150 mg
MIACALCIN INJECTION
Necessary Actions,
Restrictions, or
Limits on Use
QL (4 per 28 days)
(Miacalcin)
1
$0
(Calcitriol)
1
$0
(Rocaltrol)
1
$0
(Rocaltrol)
1
$0
(Doxercalciferol)
1
$0
(Hectorol)
1
$0
2
$0
2
$0
(Ibandronate
Sodium)
1
$0
(Boniva)
1
$0
(Boniva)
1
$0
2
$0
PA; QL (2.4 per 28
days)
QL (3 per 84 days)
QL (3 per 84 days)
QL (1 per 28 days)
184
Name of Drug
NATPARA SUBCUTANEOUS
CARTRIDGE 100 MCG/DOSE, 25
MCG/DOSE, 50 MCG/DOSE, 75
MCG/DOSE
paricalcitol oral capsule 1 mcg, 2
mcg, 4 mcg
PROLIA SUBCUTANEOUS
SYRINGE 60 MG/ML
risedronate oral tablet 150 mg
risedronate oral tablet 30 mg, 5 mg
ZEMPLAR INTRAVENOUS
SOLUTION 2 MCG/ML, 5
MCG/ML
zoledronic acid intravenous solution
4 mg/5 ml
zoledronic acid-mannitol-water
intravenous piggyback 4 mg/100 ml
ZOMETA INTRAVENOUS
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
2
$0
1
$0
2
$0
1
1
$0
$0
2
$0
(Zometa)
1
$0
(Zoledronic
Acid/Mannitol and
Water)
1
$0
(Reclast)
1
$0
2
$0
(Zemplar)
(Actonel)
(Actonel)
QL (1 per 180 days)
QL (1 per 28 days)
QL (30 per 28 days)
Miscellaneous Therapeutic
Agents
Miscellaneous Therapeutic
Agents
ACTEMRA INTRAVENOUS
MG/ML), 400 MG/20 ML (20
MG/ML), 80 MG/4 ML (20
MG/ML)
ACTEMRA SUBCUTANEOUS
SYRINGE 162 MG/0.9 ML
PA
2
$0
2
$0
PA
185
Tier level
What the
drug will
cost you
2
$0
1
$0
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
(Urecholine)
1
$0
(Buspirone HCl)
1
$0
2
$0
1
$0
1
$0
2
$0
2
$0
1
$0
Name of Drug
ACTIMMUNE SUBCUTANEOUS
SOLUTION 100 MCG/0.5 ML
allopurinol oral tablet 100 mg, 300
mg
amifostine crystalline intravenous
recon soln 500 mg
anticoag citrate phos dextrose
solution 2.63-222 gram-mg/100ml
AVONEX (WITH ALBUMIN)
INTRAMUSCULAR KIT 30 MCG
AVONEX INTRAMUSCULAR
PEN INJECTOR KIT 30 MCG/0.5
ML
AVONEX INTRAMUSCULAR
SYRINGE KIT 30 MCG/0.5 ML
BENLYSTA INTRAVENOUS
BETASERON SUBCUTANEOUS
KIT 0.3 MG
bethanechol chloride oral tablet 10
mg, 25 mg, 5 mg, 50 mg
buspirone oral tablet 10 mg, 15 mg,
30 mg, 5 mg, 7.5 mg
CERDELGA ORAL CAPSULE 84
MG
colchicine oral tablet 0.6 mg
colchicine-probenecid oral tablet
0.5-500 mg
COPAXONE SUBCUTANEOUS
SYRINGE 20 MG/ML, 40 MG/ML
CYSTADANE ORAL POWDER 1
GRAM/1.7 ML
droperidol injection solution 2.5
mg/ml
(Zyloprim)
(Amifostine
Crystalline)
(Citrate Phosphate
Dextros Soln)
Necessary Actions,
Restrictions, or
Limits on Use
ST
ST
(Colcrys)
(Colchicine/Proben
ecid)
(Droperidol)
ST
PA
ST
PA
186
Tier level
What the
drug will
cost you
dutasteride oral capsule 0.5 mg
(Avodart)
dutasteride-tamsulosin oral capsule,
(Jalyn)
er multiphase 24 hr 0.5-0.4 mg
ELMIRON ORAL CAPSULE 100
MG
(Ergoloid
ergoloid oral tablet 1 mg
Mesylates)
EXTAVIA SUBCUTANEOUS KIT
0.3 MG
finasteride oral tablet 5 mg
(Proscar)
fomepizole intravenous solution 1
(Fomepizole)
gram/ml
FUSILEV INTRAVENOUS
RECON SOLN 50 MG
GAUZE PAD TOPICAL
BANDAGE 2 X 2 "
GILENYA ORAL CAPSULE 0.5
MG
GLUCAGEN HYPOKIT
INJECTION RECON SOLN 1 MG
GLUCAGON EMERGENCY KIT
(HUMAN) INJECTION KIT 1 MG
guanidine oral tablet 125 mg
(Guanidine HCl)
hydroxyzine hcl intramuscular
(Hydroxyzine HCl)
solution 25 mg/ml, 50 mg/ml
hydroxyzine hcl oral solution 10
(Hydroxyzine HCl)
mg/5 ml
hydroxyzine hcl oral tablet 10 mg,
(Hydroxyzine HCl)
25 mg, 50 mg
hydroxyzine pamoate oral capsule
(Vistaril)
100 mg, 25 mg, 50 mg
1
$0
1
$0
2
$0
1
$0
2
$0
1
$0
1
$0
2
$0
1
$0
2
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
KEVEYIS ORAL TABLET 50 MG
2
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
ST
QL (28 per 28 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA NSO; QL (120 per
30 days)
187
Name of Drug
LEMTRADA INTRAVENOUS
leucovorin calcium 200 mg vial sdv,
p/f, latex-free 200 mg
leucovorin calcium injection recon
soln 100 mg, 350 mg
leucovorin calcium oral tablet 10
mg, 15 mg, 25 mg, 5 mg
levocarnitine (with sugar) oral
solution 100 mg/ml
levocarnitine oral tablet 330 mg
mesna intravenous solution 100
mg/ml
MESNEX ORAL TABLET 400
MG
MESTINON ORAL SYRUP 60
MG/5 ML
MESTINON TIMESPAN ORAL
TABLET EXTENDED RELEASE
180 MG
MINERAL OIL HEAVY *
morrhuate sodium intravenous
solution 5 %
ORENCIA CLICKJECT
SUBCUTANEOUS AUTOINJECTOR 125 MG/ML
ORFADIN ORAL SUSPENSION 4
MG/ML
(Leucovorin
Calcium)
(Leucovorin
Calcium)
(Leucovorin
Calcium)
(Levocarnitine
(With Sugar))
(Carnitor)
(Mesnex)
(Sodium
Morrhuate)
Tier level
What the
drug will
cost you
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
2
$0
4
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
2
$0
2
$0
OTEZLA ORAL TABLET 30 MG
2
$0
OTEZLA STARTER ORAL
TABLETS,DOSE PACK 10 MG
(4)-20 MG (4)-30 MG (47), 10 MG
(4)-20 MG (4)-30 MG(19)
2
$0
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
188
Tier level
What the
drug will
cost you
2
$0
4
$0
2
$0
2
$0
1
$0
2
$0
(Acetic Acid)
4
$0
(Mestinon)
1
$0
(Mestinon)
1
$0
(Mineral Oil)
(Acetic Acid)
4
4
$0
$0
2
$0
2
$0
Name of Drug
OTREXUP (PF)
SUBCUTANEOUS AUTOINJECTOR 10 MG/0.4 ML, 12.5
MG/0.4 ML, 15 MG/0.4 ML, 17.5
MG/0.4 ML, 20 MG/0.4 ML, 22.5
MG/0.4 ML, 25 MG/0.4 ML, 7.5
MG/0.4 ML
PANTILINERS PAD *
PLEGRIDY SUBCUTANEOUS
PEN INJECTOR 125 MCG/0.5 ML,
63 MCG/0.5 ML- 94 MCG/0.5 ML
PLEGRIDY SUBCUTANEOUS
MCG/0.5 ML- 94 MCG/0.5 ML
probenecid oral tablet 500 mg
PROCYSBI ORAL CAPSULE,
DELAYED REL SPRINKLE 25
MG, 75 MG
pv extra cleansing douche *
pyridostigmine bromide oral tablet
60 mg
pyridostigmine bromide oral tablet
qc mineral oil heavy *
ra feminine care douche *
RASUVO (PF) SUBCUTANEOUS
AUTO-INJECTOR 10 MG/0.2 ML,
12.5 MG/0.25 ML, 15 MG/0.3 ML,
17.5 MG/0.35 ML, 20 MG/0.4 ML,
22.5 MG/0.45 ML, 25 MG/0.5 ML,
27.5 MG/0.55 ML, 30 MG/0.6 ML,
7.5 MG/0.15 ML
REBIF (WITH ALBUMIN)
MCG/0.5 ML, 44 MCG/0.5 ML
Necessary Actions,
Restrictions, or
Limits on Use
ST
ST
(Probenecid)
189
Name of Drug
REBIF REBIDOSE
SUBCUTANEOUS PEN
INJECTOR 22 MCG/0.5 ML, 44
MCG/0.5 ML, 8.8MCG/0.2ML-22
MCG/0.5ML (6)
REBIF TITRATION PACK
SUBCUTANEOUS SYRINGE
8.8MCG/0.2ML-22 MCG/0.5ML
(6)
REMICADE INTRAVENOUS
RECON SOLN 100 MG
sb disp douche extra clns v&w *
(Acetic Acid)
SENSIPAR ORAL TABLET 30
MG, 60 MG, 90 MG
SIGNIFOR SUBCUTANEOUS
SOLUTION 0.3 MG/ML (1 ML),
0.6 MG/ML (1 ML), 0.9 MG/ML (1
ML)
SIMPONI ARIA INTRAVENOUS
SOLUTION 12.5 MG/ML
SIMPONI SUBCUTANEOUS PEN
INJECTOR 100 MG/ML, 50
MG/0.5 ML
SIMPONI SUBCUTANEOUS
SYRINGE 100 MG/ML, 50 MG/0.5
ML
STELARA SUBCUTANEOUS
SYRINGE 45 MG/0.5 ML, 90
MG/ML
STERILE PADS 2" X 2" 2 X 2 "
summer's eve dche-xtra clns
(Acetic Acid)
12's,extra-cleansing *
summer's eve douche-ultra clns
(Acetic Acid)
12's,2pk,ultra clns *
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
4
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
QL (60 per 30 days)
2
$0
2
$0
PA
PA
2
$0
2
$0
2
$0
1
$0
4
$0
4
$0
PA
PA
190
Name of Drug
SYNAREL NASAL SPRAY,NONAEROSOL 2 MG/ML
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)240 MG (46), 240 MG
THALOMID ORAL CAPSULE 100
MG, 150 MG, 200 MG, 50 MG
topical light mineral oil *
(Mineral Oil)
TYBOST ORAL TABLET 150 MG
ULORIC ORAL TABLET 40 MG,
80 MG
Tier level
What the
drug will
cost you
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (14 per 30 days)
QL (60 per 30 days)
2
$0
2
$0
4
2
$0
$0
2
$0
2
$0
2
$0
2
$0
(Diamox Sequels)
1
$0
(Acetazolamide)
1
$0
(Acetazolamide
Sodium)
1
$0
2
$0
2
$0
XELJANZ ORAL TABLET 5 MG
XELJANZ XR ORAL TABLET
MG
ZINBRYTA SUBCUTANEOUS
SYRINGE 150 MG/ML
PA NSO; QL (60 per
30 days)
QL (30 per 30 days)
QL (30 per 30 days)
PA; QL (60 per 30
days)
PA; QL (30 per 30
days)
ST
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule,
acetazolamide oral tablet 125 mg,
250 mg
acetazolamide sodium injection
recon soln 500 mg
ALPHAGAN P OPHTHALMIC
DROPS 0.1 %
AZOPT OPHTHALMIC
DROPS,SUSPENSION 1 %
191
Tier level
What the
drug will
cost you
(Betaxolol HCl)
1
$0
(Bimatoprost)
1
$0
(Alphagan P)
1
$0
2
$0
(Trusopt)
1
$0
(Cosopt)
1
$0
(Xalatan)
1
$0
(Betagan)
1
$0
2
$0
(Neptazane)
1
$0
(Metipranolol)
1
$0
2
$0
1
$0
2
$0
(Timoptic)
1
$0
(Timoptic-Xe)
1
$0
2
$0
1
$0
Name of Drug
betaxolol ophthalmic drops 0.5 %
bimatoprost ophthalmic drops 0.03
%
brimonidine ophthalmic drops 0.15
%, 0.2 %
COMBIGAN OPHTHALMIC
DROPS 0.2-0.5 %
dorzolamide ophthalmic drops 2 %
dorzolamide-timolol ophthalmic
drops 22.3-6.8 mg/ml
latanoprost ophthalmic drops 0.005
%
levobunolol ophthalmic drops 0.25
%, 0.5 %
LUMIGAN OPHTHALMIC
DROPS 0.01 %
methazolamide oral tablet 25 mg, 50
mg
metipranolol ophthalmic drops 0.3
%
PHOSPHOLINE IODIDE
OPHTHALMIC DROPS 0.125 %
pilocarpine hcl ophthalmic drops 1
%, 2 %, 4 %
SIMBRINZA OPHTHALMIC
DROPS,SUSPENSION 1-0.2 %
timolol maleate ophthalmic drops
0.25 %, 0.5 %
timolol maleate ophthalmic gel
forming solution 0.25 %, 0.5 %
TRAVATAN Z OPHTHALMIC
DROPS 0.004 %
travoprost (benzalkonium)
ophthalmic drops 0.004 %
(Isopto Carpine)
(Travoprost
(Benzalkonium))
Necessary Actions,
Restrictions, or
Limits on Use
(drops: 0.15%, 0.20%)
192
Tier level
What the
drug will
cost you
(Citracal-Vitamin
D)
4
$0
(Calcium Citrate)
4
$0
(Caltrate 600 Plus
D3)
4
$0
(Caltrate 600 Plus
D3)
4
$0
(Calcium 600 + Vit
D)
4
$0
(Caltrate 600 Plus
D3)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Replacement Preparations
Replacement Preparations
calcitrate + vit d caplet 315-250
mg-unit *
calcitrate 200 mg (950 mg) tab 200
mg (950 mg) *
calcium 1,000 + d3 caplet 1,000
mg(2,500 mg)-800 unit *
calcium 500 + d tablet p/f,na/f,no
lactose 500 mg(1,250mg) -400 unit
*
calcium 500+d tablet chew 500
mg(1,250mg) -400 unit *
calcium 600 + vit d 400 caplet s/f,
p/f, caplet 600 mg(1,500mg) -400
unit *
(Calcium
Carbonate/Vitamin
D3)
calcium 600 + vit d tablet 600-125 (Caltrate 600 Plus
mg-unit *
D3)
calcium 600 + vitamin d sftgl rapid (Calcium
release, sftgl 600 mg(1,500mg) -500 Carbonate/Vitamin
unit *
D3)
calcium 600 mg tablet 600 mg
(Calcium
(1,500 mg) *
Carbonate)
(Calcium
calcium 600+d softgel 600 mg
Carbonate/Vitamin
calcium- 200 unit *
D3)
calcium 600-vit d3 200 tablet 600
(Caltrate 600 Plus
mg(1,500mg) -200 unit *
D3)
calcium 600-vit d3 400 tablet 600
(Caltrate 600 Plus
mg(1,500mg) -400 unit *
D3)
calcium 600 + vit d 400 softgl 600
mg(1,500mg) -400 unit *
193
Tier level
What the
drug will
cost you
4
$0
4
$0
(Calcium Chloride)
1
$0
(Calcium Chloride)
1
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
calcium carb 1,250 mg/5 ml sus 500
mg/5 ml (1,250 mg/5 ml) *
calcium carbonate 648 mg tab 260
mg calcium (648 mg) *
calcium chloride intravenous
solution 100 mg/ml (10 %)
calcium chloride intravenous
syringe 100 mg/ml (10 %)
calcium citrate - vit d caplet caplet,
coated 315-200 mg-unit *
calcium citrate-vit d3 caplet s/f, p/f
315-250 mg-unit *
calcium gluconate 500 mg tab 45
mg (500 mg) *
calcium gluconate intravenous
solution 100 mg/ml (10%)
calcium with vit d tablet 600-125
mg-unit *
CALTRATE 600 + D SOFT CHEW
TAB VANILLA CREME 600 MG
(1,500 MG)-800 UNIT *
CALTRATE 600 PLUS D3
TABLET 600 MG(1,500MG) -800
UNIT *
citracal + d maximum caplet 315250 mg-unit *
citrus calcium + d tablet 315-250
mg-unit *
cvs calcium + vitamin d3 sftgl
absorbable 600 mg(1,500mg) -500
unit *
cvs calcium 500 + vit d 200 tb 500
mg(1,250mg) -200 unit *
(Calcium
Carbonate)
(Calcium
Carbonate)
(Citracal-Vitamin
D)
(Citracal-Vitamin
D)
(Calcium
Gluconate)
(Calcium
Gluconate)
(Calcium
Carbonate/Vitamin
D2)
(Citracal-Vitamin
D)
(Citracal-Vitamin
D)
(Calcium
Carbonate/Vitamin
D3)
(Caltrate 600 Plus
D3)
Necessary Actions,
Restrictions, or
Limits on Use
194
Tier level
What the
drug will
cost you
(Caltrate 600 Plus
D3)
4
$0
(Caltrate 600 Plus
D3)
4
$0
(Magnesium)
4
$0
(Pedialyte)
4
$0
(Pedialyte)
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(Dextrose 5 %-0.2
% NaCl)
1
$0
dextrose-kcl-nacl intravenous
solution 5-0.224-0.225 %
(Potassium
Chloride/D50.2%NaCl)
1
$0
effer-k oral tablet, effervescent 25
meq
(Klor-Con-Ef)
1
$0
Name of Drug
cvs calcium 500 + vit d tablet oyster
shell 500 mg(1,250mg) -125 unit *
cvs calcium 600-vit d3 800 tab p/f,
s/f,gluten-free 600 mg(1,500mg) 800 unit *
cvs magnesium 250 mg tablet 250
mg *
cvs pediatric electrolyte soln *
cvs pediatric electrolyte soln a/f, p/f
*
d10 %-0.45 % sodium chloride
d2.5 %-0.45 % sodium chloride
d5 % and 0.9 % sodium chloride
dextrose 10 % and 0.2 % nacl
dextrose 5 %-lactated ringers
dextrose 5%-0.2 % sod chloride
dextrose 5%-0.3 % sod.chloride
dextrose with sodium chloride
intravenous parenteral solution 50.2 %
(Dextrose 10 %
and 0.45 % NaCl)
(Dextrose 2.5 %
and 0.45 % NaCl)
(Dextrose 5 % and
0.9 % NaCl)
(Dextrose 5 %-0.45
% NaCl)
(Dextrose 10 %
and 0.2 % NaCl)
(Dextrose 5%Lactated Ringers)
(Dextrose 5 %-0.2
% NaCl)
(Dextrose 5 % and
0.3 % NaCl)
Necessary Actions,
Restrictions, or
Limits on Use
195
Name of Drug
electrolyte-48 in d5w intravenous
parenteral solution
eql calcium 600 mg + d softgel 600
mg(1,500mg) -100 unit *
gnp calcium 500-vit d3 600 tab
500mg (1,250mg) -600 unit *
gnp calcium 600+d3+min chew tb
p/f,gluten/f,yeast/f 600 mg calcium800 unit-40 mg *
hm calcium 600+d plus tab chew
gluten-free 600 mg calcium- 800
unit-40 mg *
hm calcium citrate-vit d cplt caplet,
gluten-free 315-250 mg-unit *
HYPERLYTE CR
INTRAVENOUS SOLUTION 2520-5-5-30-30 MEQ/20 ML
IONOSOL-B IN D5W
SOLUTION 5 %
IONOSOL-MB IN D5W
SOLUTION 5 %
ISOLYTE M IN 5 % DEXTROSE
SOLUTION
ISOLYTE-H IN 5 % DEXTROSE
SOLUTION 5 %
ISOLYTE-P IN 5 % DEXTROSE
SOLUTION 5 %
ISOLYTE-S INTRAVENOUS
PARENTERAL SOLUTION
(Electrolyte-48
Solution/D5W)
(Calcium
Carbonate/Vitamin
D3)
(Caltrate 600 Plus
D3)
(Ca/D3/Mag
Ox/Zinc/Cop/Mang
/Bor)
(Ca/D3/Mag
Ox/Zinc/Cop/Mang
/Bor)
(Citracal-Vitamin
D)
Tier level
What the
drug will
cost you
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
196
Name of Drug
k-effervescent oral tablet,
effervescent 25 meq
KELP 150 MCG TABLET 150
MCG *
klor-con 10 oral tablet extended
release 10 meq
(Klor-Con-Ef)
(Potassium
Chloride)
(Potassium
klor-con m10 tablet 10 meq
Chloride)
klor-con m15 oral tablet,er
(Potassium
particles/crystals 15 meq
Chloride)
klor-con m20 oral tablet,er
(Potassium
Chloride)
klor-con sprinkle oral capsule,
(Potassium
extended release 10 meq, 8 meq
Chloride)
(Calcium
liquid calcium 600-vit d3 sfgl 600
Carbonate/Vitamin
mg(1,500mg) -400 unit *
D3)
liquid calcium 600-vit d3 sfgl
(Calcium
softgel,p/f,gluten-f 600 mg(1,500mg) Carbonate/Vitamin
-500 unit *
D3)
liquid calcium with vitamin d
(Calcium
softgel, s/f, p/f 600 mg calcium- 200 Carbonate/Vitamin
unit *
D3)
mag delay dr 64 mg tablet 64 mg * (Slow-Mag)
mag64 dr 64 mg tablet 64 mg *
(Slow-Mag)
mag-g 500 mg tablet 27 mg (500
(Magonate)
mg) *
magnesium 250 mg tablet 250 mg * (Magnesium)
(Magnesium
magnesium 300 mg capsule 300 mg
Oxide/Mag Aa
*
Chelate)
magnesium chloride injection
(Magnesium
solution 200 mg/ml (20 %)
Chloride)
Tier level
What the
drug will
cost you
1
$0
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
197
Tier level
What the
drug will
cost you
(Magonate)
4
$0
(Magnesium Sulf
In 0.45% NaCl)
1
$0
(Magnesium
Sulfate/D5W)
1
$0
(Magnesium
Sulfate in Water)
1
$0
(Magnesium
Sulfate in Water)
1
$0
1
$0
1
$0
4
$0
2
$0
2
$0
4
$0
2
$0
2
$0
4
$0
Name of Drug
magnesium gluc 500 mg tablet 27
mg (500 mg) *
magnesium sulf in 0.45% nacl
intravenous solution 20 gram/500
ml (40 mg/ml)
magnesium sulfate in d5w
ml, 4 gram/100 ml
magnesium sulfate in water
gram/500 ml (4 %), 40 gram/1,000
ml (4 %)
magnesium sulfate in water
intravenous piggyback 2 gram/50 ml
(4 %), 4 gram/100 ml (4 %), 4
gram/50 ml (8 %)
magnesium sulfate injection solution
4 meq/ml (50 %)
magnesium sulfate injection syringe
4 meq/ml
natural calcium 500 mg tablet 500
mg calcium (1,250 mg) *
NORMOSOL-M IN 5 %
DEXTROSE INTRAVENOUS
PARENTERAL SOLUTION
NORMOSOL-R PH 7.4
SOLUTION
nu-mag 71.5 mg tablet 71.5 mg *
NUTRILYTE II INTRAVENOUS
SOLUTION 35-20-5 MEQ/20 ML
NUTRILYTE INTRAVENOUS
SOLUTION 25-40.6-5 MEQ/20 ML
oysco 500-vit d3 200 tablet 500
mg(1,250mg) -200 unit *
(Magnesium
Sulfate)
(Magnesium
Sulfate)
(Calcium
Carbonate)
(Slow-Mag)
(Caltrate 600 Plus
D3)
Necessary Actions,
Restrictions, or
Limits on Use
198
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
(Calcium
Carbonate)
4
$0
(Caltrate 600 Plus
D3)
4
$0
(Caltrate 600 Plus
D3)
4
$0
4
$0
4
$0
4
$0
1
$0
2
$0
2
$0
2
$0
1
$0
Name of Drug
oysco d tablet 250-125 mg-unit *
oysco-500 tablet 500 mg calcium
(1,250 mg) *
oyster shell 250 mg + vit d tb 250125 mg-unit *
oyster shell 500-vit d3 200 tb 500
mg(1,250mg) -200 unit *
oyster shell calcium 500 mg tb
500mg elemental ca 500 mg calcium
(1,250 mg) *
oyster shell calcium tablet 500
mg(1,250mg) -400 unit *
oyster shell calcium-vit d tab
p/f,s/f,gluten-free 500 mg(1,250mg)
-400 unit *
oystercal-d 500 mg-400 unit tb 500
mg(1,250mg) -400 unit *
pediatric electrolyte solution *
PHOS-NAK PACKET 280-160-250
MG *
phospha 250 neutral oral tablet 250
mg
PLASMA-LYTE 148
SOLUTION
PLASMA-LYTE A
SOLUTION
PLASMA-LYTE-56 IN 5 %
DEXTROSE INTRAVENOUS
potassium acetate intravenous
solution 2 meq/ml, 4 meq/ml
(Caltrate 600 Plus
D3)
(Calcium
Carbonate)
(Caltrate 600 Plus
D3)
(Caltrate 600 Plus
D3)
(Caltrate 600 Plus
D3)
(Pedialyte)
(K-Phos Neutral)
(Potassium
Acetate)
Necessary Actions,
Restrictions, or
Limits on Use
199
Tier level
What the
drug will
cost you
(Pot Chloride/Pot
Bicarb/Cit Ac)
1
$0
(Klor-Con-Ef)
1
$0
1
$0
1
$0
(Potassium
Chloride In D5w)
1
$0
(Potassium
Chloride In Lr-D5)
1
$0
(Potassium
Chloride)
1
$0
1
$0
1
$0
1
$0
(Klor-Con)
1
$0
(K-Tab ER)
1
$0
(K-Tab ER)
1
$0
(Potassium
Chloride)
1
$0
Name of Drug
potassium bicarb and chloride oral
tablet, effervescent 25 meq
potassium bicarb-citric acid oral
tablet, effervescent 25 meq
potassium chlorid-d5-0.45%nacl
meq/l, 20 meq/l, 30 meq/l, 40 meq/l
potassium chloride in 0.9%nacl
meq/l, 40 meq/l
potassium chloride in 5 % dex
meq/l, 30 meq/l, 40 meq/l
potassium chloride in lr-d5
meq/l
potassium chloride intravenous
piggyback 10 meq/100 ml, 20
meq/100 ml, 30 meq/100 ml, 40
meq/100 ml
potassium chloride intravenous
solution 2 meq/ml
potassium chloride oral capsule,
extended release 10 meq, 8 meq
potassium chloride oral liquid 20
meq/15 ml, 40 meq/15 ml
potassium chloride oral packet 20
meq
potassium chloride oral tablet
extended release 8 meq
potassium chloride oral tablet,er
potassium chloride oral tablet,er
(Potassium
Chloride/D50.45nacl)
(Potassium
Chloride In
0.9%NaCl)
(Potassium
Chloride)
(Potassium
Chloride)
(Potassium
Chloride)
Necessary Actions,
Restrictions, or
Limits on Use
200
Name of Drug
potassium chloride-0.45 % nacl
meq/l
potassium chloride-d5-0.2%nacl
meq/l, 20 meq/l, 30 meq/l, 40 meq/l
meq/l
meq/l, 40 meq/l
potassium citrate oral tablet
extended release 10 meq (1,080 mg),
15 meq, 5 meq (540 mg)
potassium citrate-citric acid oral
packet 3,300-1,002 mg
potassium cl 10 meq/50 ml sol 10
meq/50 ml
potassium cl 20 meq/50 ml sol 20
meq/50 ml
potassium cl er 10 meq tablet f/c 10
meq
potassium phosphate m-/d-basic
intravenous solution 3 mmol/ml
ra hi-cal plus vitamin d tab 500
mg(1,250mg) -200 unit *
ra oyster shell-vitamin d tab s/f, p/f
250 (625)-125 mg-unit *
(Potassium
Chloride-0.45%
NaCl)
(Potassium
(Potassium
(Potassium
(Urocit-K)
(Potassium
Citrate/Citric Acid)
(Potassium
Chloride)
(Potassium
Chloride)
(K-Tab ER)
(Potassium
Phos,M-Basic-DBasic)
(Caltrate 600 Plus
D3)
(Calcium
Carbonate/Vitamin
D2)
(Pedialyte)
(Pedialyte)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
ra pediatric electrolyte soln a/f *
4
$0
ra pediatric freezer pops *
4
$0
ringers intravenous parenteral
(Ringers Solution)
1
$0
solution
201
Tier level
What the
drug will
cost you
4
$0
4
$0
(Sodium Acetate)
1
$0
(Sodium
Bicarbonate)
1
$0
(Sodium
Bicarbonate)
1
$0
1
$0
1
$0
1
$0
1
$0
(Sodium Chloride)
1
$0
(Sodium Lactate)
1
$0
(Sodium Lactate)
1
$0
(Sodium Phos,MBasic-D-Basic)
1
$0
2
$0
2
$0
Name of Drug
sm calcium 600-vit d3 800 tab 600
mg(1,500mg) -800 unit *
sm pediatric electrolyte soln *
sodium acetate intravenous solution
2 meq/ml, 4 meq/ml
sodium bicarbonate intravenous
solution 1 meq/ml (8.4 %)
sodium bicarbonate intravenous
syringe 10 meq/10 ml (8.4 %), 4.2 %
(0.5 meq/ml), 7.5 % (0.9 meq/ml),
8.4 % (1 meq/ml)
sodium chloride 0.45 % intravenous
parenteral solution 0.45 %
sodium chloride 0.9 % intravenous
parenteral solution 0.9 %
sodium chloride 3 % intravenous
sodium chloride 5 % intravenous
sodium chloride intravenous
parenteral solution 2.5 meq/ml, 4
meq/ml
sodium lactate intravenous
parenteral solution 167 meq/l
sodium lactate intravenous solution
5 meq/ml
sodium phosphate intravenous
solution 3 mmol/ml
TPN ELECTROLYTES II IV
SOLN 25'S,20ML/50ML FTV 1818-5-4.5-35 MEQ/20 ML
TPN ELECTROLYTES
INTRAVENOUS SOLUTION 3520-5 MEQ/20 ML
(Caltrate 600 Plus
D3)
(Pedialyte)
(Sodium Chloride
0.45 %)
(0.9 % Sodium
Chloride)
(Sodium Chloride
3 %)
(Sodium Chloride
5 %)
Necessary Actions,
Restrictions, or
Limits on Use
202
Name of Drug
virt-phos 250 neutral oral tablet 250
(K-Phos Neutral)
mg
v-r calcium 400 + d 133 caplet 400- (Caltrate 600 Plus
133.3 mg-unit *
D3)
Tier level
What the
drug will
cost you
1
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
Respiratory Tract Agents
Anti-Inflammatories,
Inhaled Corticosteroids
ADVAIR DISKUS INHALATION
BLISTER WITH DEVICE 100-50
MCG/DOSE, 250-50 MCG/DOSE,
500-50 MCG/DOSE
ADVAIR HFA INHALATION
HFA AEROSOL INHALER 115-21
MCG/ACTUATION, 230-21
MCG/ACTUATION
BREO ELLIPTA INHALATION
BLISTER WITH DEVICE 100-25
MCG/DOSE, 200-25 MCG/DOSE
DULERA INHALATION HFA
AEROSOL INHALER 100-5
MCG/ACTUATION
FLOVENT DISKUS
DEVICE 100 MCG/ACTUATION,
50 MCG/ACTUATION
FLOVENT DISKUS
DEVICE 250 MCG/ACTUATION
FLOVENT HFA INHALATION
HFA AEROSOL INHALER 110
MCG/ACTUATION
QL (60 per 30 days)
2
$0
QL (12 per 28 days)
2
$0
2
$0
QL (60 per 30 days)
QL (13 per 28 days)
2
$0
QL (60 per 30 days)
2
$0
2
$0
QL (12 per 28 days)
2
$0
203
Name of Drug
MCG/ACTUATION
MCG/ACTUATION
QVAR INHALATION AEROSOL
40 MCG/ACTUATION, 80
MCG/ACTUATION
Antileukotrienes
montelukast oral granules in packet
4 mg
montelukast oral tablet 10 mg
montelukast oral tablet,chewable 4
mg, 5 mg
zafirlukast oral tablet 10 mg, 20 mg
Bronchodilators
albuterol sulfate inhalation solution
for nebulization 0.63 mg/3 ml, 1.25
mg/3 ml, 2.5 mg /3 ml (0.083 %), 5
mg/ml
albuterol sulfate oral syrup 2 mg/5
ml
albuterol sulfate oral tablet 2 mg, 4
mg
albuterol sulfate oral tablet
extended release 12 hr 4 mg, 8 mg
ATROVENT HFA INHALATION
MCG/ACTUATION
COMBIVENT RESPIMAT
INHALATION MIST 20-100
MCG/ACTUATION
ipratropium bromide inhalation
solution 0.02 %
Tier level
What the
drug will
cost you
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (24 per 28 days)
2
$0
2
$0
(Singulair)
1
$0
(Singulair)
1
$0
(Singulair)
1
$0
(Accolate)
1
$0
PA BvD
(Albuterol Sulfate)
1
$0
(Albuterol Sulfate)
1
$0
(Albuterol Sulfate)
1
$0
(Vospire ER)
1
$0
2
$0
2
$0
1
$0
QL (8 per 30 days)
(Ipratropium
Bromide)
PA BvD
204
Name of Drug
ipratropium-albuterol inhalation
solution for nebulization 0.5 mg-3
mg(2.5 mg base)/3 ml
metaproterenol oral syrup 10 mg/5
ml
metaproterenol oral tablet 10 mg,
20 mg
PROAIR HFA INHALATION HFA
AEROSOL INHALER 90
MCG/ACTUATION
PROAIR RESPICLICK
INHALATION AEROSOL
POWDR BREATH ACTIVATED
90 MCG/ACTUATION
SEREVENT DISKUS
DEVICE 50 MCG/DOSE
SPIRIVA RESPIMAT
INHALATION MIST 1.25
MCG/ACTUATION, 2.5
MCG/ACTUATION
SPIRIVA WITH HANDIHALER
INHALATION CAPSULE,
W/INHALATION DEVICE 18
MCG
STRIVERDI RESPIMAT
INHALATION MIST 2.5
MCG/ACTUATION
terbutaline oral tablet 2.5 mg, 5 mg
terbutaline subcutaneous solution 1
mg/ml
theochron oral tablet extended
release 12 hr 100 mg, 200 mg, 300
mg
(Ipratropium/Albut
erol Sulfate)
(Metaproterenol
Sulfate)
(Metaproterenol
Sulfate)
(Terbutaline
Sulfate)
(Terbutaline
Sulfate)
(Theophylline
Anhydrous)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
205
Tier level
What the
drug will
cost you
(Theophylline/D5
W)
1
$0
(Theophylline
Anhydrous)
1
$0
(Theophylline
Anhydrous)
1
$0
(Theophylline
Anhydrous)
1
$0
Name of Drug
theophylline in dextrose 5 %
mg/100 ml, 200 mg/50 ml, 400
mg/250 ml, 400 mg/500 ml, 800
mg/250 ml
theophylline oral solution 80 mg/15
ml
theophylline oral tablet extended
release 12 hr 100 mg, 200 mg, 300
mg, 450 mg
theophylline oral tablet extended
TUDORZA PRESSAIR
INHALATION AEROSOL
POWDR BREATH ACTIVATED
400 MCG/ACTUATION, 400
MCG/ACTUATION (30 ACTUAT)
VENTOLIN HFA INHALATION
MCG/ACTUATION
Respiratory Tract Agents,
Other
acetylcysteine intravenous solution
200 mg/ml (20 %)
acetylcysteine solution 100 mg/ml
(10 %), 200 mg/ml (20 %)
CINQAIR INTRAVENOUS
SOLUTION 10 MG/ML
cromolyn inhalation solution for
nebulization 20 mg/2 ml
cromolyn sodium nasal spray 5.2
mg/spray (4 %) *
DALIRESP ORAL TABLET 500
MCG
Necessary Actions,
Restrictions, or
Limits on Use
QL (2 per 28 days)
2
$0
2
$0
(Acetadote)
1
$0
(Acetadote)
1
$0
2
$0
(Cromolyn
Sodium)
1
$0
(Nasalcrom)
4
$0
2
$0
PA BvD
PA BvD
PA
PA BvD
QL (30 per 30 days)
206
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
3
$0
2
$0
(Baclofen)
1
$0
(Soma)
1
$0
(Parafon Forte
DSC)
1
$0
(Fexmid)
1
$0
(Dantrium)
1
$0
(Skelaxin)
1
$0
(Skelaxin)
1
$0
(Robaxin)
1
$0
Name of Drug
ESBRIET ORAL CAPSULE 267
MG
KALYDECO ORAL GRANULES
IN PACKET 50 MG, 75 MG
KALYDECO ORAL TABLET 150
MG
NUCALA SUBCUTANEOUS
RECON SOLN 100 MG
OFEV ORAL CAPSULE 100 MG,
150 MG
ORKAMBI ORAL TABLET 200125 MG
PROLASTIN-C INTRAVENOUS
RECON SOLN 1,000 MG
sodium chloride 0.9% inhal vl u-d,
suv, p/f (rx) 0.9 % *
XOLAIR SUBCUTANEOUS
RECON SOLN 150 MG
(Pulmosal)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (270 per 30
days)
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
days)
PA
PA; QL (120 per 30
days)
PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen oral tablet 10 mg, 20 mg
carisoprodol oral tablet 250 mg,
350 mg
chlorzoxazone oral tablet 500 mg
cyclobenzaprine oral tablet 10 mg, 5
mg
dantrolene oral capsule 100 mg, 25
mg, 50 mg
metaxall oral tablet 800 mg
metaxalone oral tablet 400 mg, 800
mg
methocarbamol oral tablet 500 mg,
750 mg
PA-HRM; QL (120 per
30 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA-HRM
207
Tier level
What the
drug will
cost you
(Dantrium)
1
$0
(Zanaflex)
1
$0
(Zanaflex)
1
$0
1
$0
2
$0
1
$0
2
$0
2
$0
2
$0
2
$0
Name of Drug
revonto intravenous recon soln 20
mg
tizanidine oral capsule 2 mg, 4 mg,
6 mg
tizanidine oral tablet 2 mg, 4 mg
Necessary Actions,
Restrictions, or
Limits on Use
Sleep Disorder Agents
Sleep Disorder Agents
armodafinil oral tablet 150 mg, 200
(Nuvigil)
mg, 250 mg, 50 mg
BELSOMRA ORAL TABLET 10
MG, 15 MG, 20 MG, 5 MG
eszopiclone oral tablet 1 mg, 2 mg,
(Lunesta)
3 mg
HETLIOZ ORAL CAPSULE 20
MG
NUVIGIL ORAL TABLET 150
MG, 200 MG, 250 MG, 50 MG
ROZEREM ORAL TABLET 8 MG
XYREM ORAL SOLUTION 500
MG/ML
zaleplon oral capsule 10 mg, 5 mg
(Sonata)
1
$0
PA
QL (30 per 30 days)
PA-HRM; QL (30 per
30 days)
PA
PA
LA
PA-HRM; (High Risk
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (60
per 30 days)
208
Name of Drug
Tier level
What the
drug will
cost you
zolpidem oral tablet 10 mg, 5 mg
(Ambien)
1
$0
zolpidem oral tablet,ext release
multiphase 12.5 mg, 6.25 mg
(Ambien CR)
1
$0
2
$0
2
$0
1
$0
2
$0
OPSUMIT ORAL TABLET 10 MG
2
$0
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.125 MG,
0.25 MG, 1 MG, 2.5 MG
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
Vasodilating Agents
Vasodilating Agents
ADCIRCA ORAL TABLET 20 MG
ADEMPAS ORAL TABLET 0.5
MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG
epoprostenol (glycine) intravenous
(Flolan)
recon soln 0.5 mg, 1.5 mg
LETAIRIS ORAL TABLET 10
MG, 5 MG
PA; QL (60 per 30
days)
PA; QL (90 per 30
days)
PA BvD
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
PA
209
Tier level
What the
drug will
cost you
2
$0
(Revatio)
1
$0
(Revatio)
1
$0
2
$0
2
$0
Name of Drug
REMODULIN INJECTION
MG/ML, 2.5 MG/ML, 5 MG/ML
sildenafil intravenous solution 10
mg/12.5 ml
sildenafil oral tablet 20 mg
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
TRACLEER ORAL TABLET 125
MG, 62.5 MG
TYVASO INHALATION
SOLUTION FOR
NEBULIZATION 1.74 MG/2.9 ML
(0.6 MG/ML)
TYVASO REFILL KIT
INHALATION SOLUTION FOR
(0.6 MG/ML)
TYVASO STARTER KIT
INHALATION SOLUTION FOR
UPTRAVI ORAL TABLET 1,000
MCG, 1,200 MCG, 1,400 MCG,
1,600 MCG, 400 MCG, 600 MCG,
800 MCG
UPTRAVI ORAL TABLET 200
MCG
UPTRAVI ORAL
TABLETS,DOSE PACK 200 MCG
(140)- 800 MCG (60)
PA; QL (37.5 per 1
day)
PA; QL (90 per 30
days)
days)
PA BvD
PA BvD
2
$0
PA BvD
2
$0
2
$0
2
$0
2
$0
PA; QL (60 per 30
days)
PA; QL (240 per 30
days)
PA; QL (200 per 365
days)
Vitamins And Minerals
Vitamins And Minerals
a thru z advanced formula tab
(Multivitamin/Iron/
4
$0
gluten-free 18-400 mg-mcg *
Folic Acid)
a thru z advanced formula tab new (Multivitamin with
4
$0
formula *
Minerals/Lut)
210
Tier level
What the
drug will
cost you
(Biocel)
4
$0
(Biocel)
4
$0
(Biocel)
4
$0
(Biocel)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Biocel)
4
$0
(Biocel)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
a thru z select 50+ formula tb
advanced formula 0.4-300-250 mgmcg-mcg *
a thru z select men 50+ tablet 300600-300 mcg *
a thru z select multivit tab 500-300250 mcg *
a thru z select tablet adults
50+,iron-free 0.4-300-250 mg-mcgmcg *
a thru z select tablet new
formulation *
a thru z select women's tablet *
abc plus tablet 0.4-300-250 mgmcg-mcg *
adult multi gummies 200 mcg *
adult one daily gummies 200 mcg *
adults' 50+ daily formula tab 0.4300-250 mg-mcg-mcg *
adults 50+ multivitamin tablet 0.4300-250 mg-mcg-mcg *
adults' daily formula tablet 18-400
mg-mcg *
animal chews tablet *
antioxidant softgel softgel *
apatate forte liquid *
b complete tablet *
(Multivitamin with
Minerals/Lut)
(Mv,Fe,Min/Lutein
)
(Biocel)
(One-A-Day
Vitacraves)
(One-A-Day
Vitacraves)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Beta-Carotene(A)
W-C and E/Min)
(Multivitamin with
Minerals)
(Vitamin B
Complex)
Necessary Actions,
Restrictions, or
Limits on Use
211
Name of Drug
(Vitamin B
Complex)
(Vitamin B
b complex formula #1 tablet *
Complex)
(Vitamin B
b complex tablet *
Complex)
b-12 500 mcg tablet 500 mcg *
(B-12)
b-12 dots 500 mcg tablet 500 mcg * (B-12)
(Vitamin B
balance b-100 tablet *
Complex)
(Vitamin B
balance b-50 tablet *
Complex)
balance b-50 tablet inner,p/f,gluten/f (Vitamin B
*
Complex)
(Vitamin B
balanced b-100 tablet *
Complex)
(Vit B Complex
balanced b-100 tablet 100 mg *
100 No.3/Herbal)
(Vitamin B
Complex)
(Vitamin B
Complex)
balanced b-complex caplet p/f,no(Dialyvite 800)
lactose 400 mcg *
b-complex plus vitamin c cplt caplet
(Vita-Bee with C)
*
(Vitamin B
b-complex with b12 tablet *
Complex)
b-complex with c tablet *
(Vita-Bee with C)
b-complex with vit c caplet
(Dialyvite 800)
s/f,p/f,gluten-free 400 mcg *
(Multivitamin with
biosupp liquid *
Minerals)
biotin 300 mcg tablet 300 mcg *
(Biotin)
b complex capsule *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
212
Tier level
What the
drug will
cost you
(Multivitamin with
Minerals)
4
$0
(Ascorbic Acid)
4
$0
(Drisdol)
(MultivitMinerals/Ferrous
Gluc)
(Multivit with IronMinerals)
Gluc)
(Multivitamin/Iron/
Folic Acid)
Gluc)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
biovol syrup *
c complex 500 mg tablet sa 500 mg
*
calcidol drops 8,000 unit/ml *
centamin liquid 9 mg iron/15 ml *
central-vite seniors tablet *
centram-care multivit-min liq 9 mg
iron/15 ml *
centravites 50 plus tablet *
centrum complete multivit tab 18400 mg-mcg *
centrum multivit-mineral liq 9 mg
iron/15 ml *
Necessary Actions,
Restrictions, or
Limits on Use
centrum silver tablet adults 50 +
(Biocel)
4
$0
0.4-300-250 mg-mcg-mcg *
century adults 50+ tablet gluten free
(Biocel)
4
$0
0.4-300-250 mg-mcg-mcg *
(Multivitamin with
century mature tablet *
4
$0
Minerals/Lut)
century ultimate women's tab 18(Multivitamin/Iron/
4
$0
400 mg-mcg *
Folic Acid)
cerovite advanced form tab 18-400 (Multivitamin/Iron/
4
$0
mg-mcg *
Folic Acid)
(Multivitcerovite liquid 9 mg iron/15 ml *
Minerals/Ferrous
4
$0
Gluc)
certavite sr-antioxidant tab 0.4-300(Biocel)
4
$0
250 mg-mcg-mcg *
213
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
(Fer-In-Sol)
4
$0
(Multivitamin)
(Multivitamin)
4
4
$0
$0
(Biocel)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
Name of Drug
certavite-antioxidant liquid 9 mg
iron/15 ml *
certavite-antioxidant tablet 18-400
mg-mcg *
child chew + iron tab chew *
child chew vitamin tablet *
child ferrous sulfate 15 mg/ml 15
mg iron (75 mg)/ml *
children's chewable vitamin *
childrens multivit tab chew *
complete multi 50+ tablet 500-300250 mcg *
Gluc)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
Iron)
(Multivitamin)
(Multivit,Th
Iron,Other Min)
(Multivit with Ironcomplete senior tablet *
Minerals)
(Vitamin B
cvs bal b-100 tablet *
Complex)
(Vitamin B
cvs bal b-50 tablet *
Complex)
(Vitamin B
cvs balanced b-150 tablet *
Complex)
cvs b-complex-vit c caplet caplet * (Vita-Bee with C)
(Multivit with Ironcvs child vit-mineral tab *
Minerals)
cvs children's chewable vit *
(Multivitamin)
cvs childs vit with c tab chew *
(Multivitamin)
(Multivitamin with
cvs child's vitamin-iron tb *
Iron)
cvs daily gummies complete adult vit (One-A-Day
200 mcg *
Vitacraves)
cvs daily multiple tablet *
(Multivitamin)
complete multivitamin tab *
Necessary Actions,
Restrictions, or
Limits on Use
214
Name of Drug
cvs daily multiple tablet for women
*
cvs daily teen multi-vitamin 18-400
mg-mcg *
cvs gummy swirls chewable *
cvs iron 27 mg tablet 240 mg (27 mg
iron) *
cvs men's daily gummies p/f, glutenfree 200 mcg *
cvs men's multi-vit tablet *
cvs prenatal vitamin tablet *
cvs spectravite adult 50+ tabs 0.4300-250 mg-mcg-mcg *
cvs spectravite advanced tab 18-400
mg-mcg *
cvs spectravite liquid *
cvs spectravite senior *
cvs spectravite senior tab *
cvs spectravite senior tablet 500300-250 mcg *
cvs spectravite tablet chew *
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Fergon)
(One-A-Day
Vitacraves)
(Multivitamin)
(Prenatal Vit
Calc,Iron,Folic)
(Biocel)
(Multivitamin/Iron/
Folic Acid)
(Pediavit)
(Multivitamin with
Minerals/Lut)
(Biocel)
(Multivitamin with
Iron)
(Multivitamin/Iron/
Folic Acid)
cvs spectravite ultra women tb 18400 mg-mcg *
cvs super b complx & c cplt caplet,
(Vita-Bee with C)
p/f *
cvs vision formula tablet 1,000 unit- (Vit A,C and
200 mg-60 unit-2 mg *
E/Lutein/Minerals)
(Vitamin B
cvs vitamin b-100 complx tb *
Complex)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
215
Tier level
What the
drug will
cost you
(Ascorbic Acid)
4
$0
(D3-50)
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
Name of Drug
cvs vitamin c 1,000 mg tb chw 1,000
mg *
cvs vitamin d3 1,000 unit sfgl softgel
1,000 unit *
cvs women's daily gummies p/f,
gluten-free 200 mcg *
cyanocobalamin 1,000 mcg/ml 25's
1,000 mcg/ml *
d3 dots 2,000 unit tablet p/f 2,000
unit *
(One-A-Day
Vitacraves)
(Cyanocobalamin
(Vitamin B-12))
(Vitamin D3)
(Multivitamin with
Iron)
daily multiple tablet 18-400 mg-mcg (Multivitamin/Iron/
*
Folic Acid)
daily multiple vitamin tab sugar
(Multivitamin)
coated *
daily multivitamin-iron tablet 18(Multivitamin/Iron/
400 mg-mcg *
Folic Acid)
daily value multivitamin tab s/f *
(Multivitamin)
daily vit formula + iron tab 18-400 (Multivitamin/Iron/
mg-mcg *
Folic Acid)
(Multivitamin with
daily vitamin + iron tablet *
Iron)
daily vitamin formula tablet *
(Multivitamin)
(Multivitamin with
daily vitamin formula tablet *
Minerals)
daily vitamin tablet p/f,na/f *
(Multivitamin)
daily vite tablet s/f, p/f *
(Multivitamin)
daily vite tablet s/f,p/f *
(Multivitamin)
(Multivitamin with
daily vite with iron tablet *
Iron)
dino-life extra c tab chew *
(Multivitamin)
(Multivit with Irondino-life iron-zinc tb chew *
Minerals)
daily multi vitamin-iron tab *
Necessary Actions,
Restrictions, or
Limits on Use
216
Name of Drug
dino-life tablet chewable *
(Multivitamin)
(B1,B2,B3,B6,B12
eldertonic elixir 0.5-0.6-7-0.7 mg *
/Dexpan/Zn/Mang)
(Multivitamin with
ellis tonic *
Minerals)
(Pedi Mv
eq child complete chew tablet 18 mg
No.58/Ferrous
iron *
Fumarate)
eq complete multivitamin tab 0.4(Biocel)
300-250 mg-mcg-mcg *
eq complete multivitamin tab gluten- (Multivitamin/Iron/
free 18-400 mg-mcg *
Folic Acid)
(Multivitamin with
eql central-vite select tablet *
Minerals/Lut)
eql century mature tablet 500-300(Biocel)
250 mcg *
eql chewable multi vitamin tab *
(Multivitamin)
eql child's multivit tab chew with
(Multivitamin)
vitamin c *
(Multivit with Ironeql childs multivit-mineral tb *
Minerals)
eql eye health plus lutein tab 1,000 (Beta-Carotene(A)
unit-200 mg-60 unit-2 mg *
W-C and E/Min)
(Multivitamin with
eql one daily 50 plus tablet *
Minerals)
eql one daily essential tablet *
(Multivitamin)
eql one daily maximum tablet 18-0.4
(Tab A Vite)
mg *
(Multivitamin with
eql one daily men's tablet *
Minerals)
ergocalciferol 8,000 units/ml 8,000
(Drisdol)
unit/ml *
(Multivitamin/Iron/
essentia tablet 18-400 mg-mcg *
Folic Acid)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
217
Name of Drug
Tier level
What the
drug will
cost you
essential balance tablet *
(Mv,Fe,Min/Lutein
)
4
$0
essential daily tablet w/iron &
calcium 18-0.4 mg *
(Tab A Vite)
4
$0
ferocon capsule 110-0.5 mg *
(Fe Fumarate/Vit
C/B12-If/Fa)
3
$0
ferretts 325 mg tablet 325 mg (106
mg iron) *
(Ferrous Fumarate)
4
$0
4
$0
4
$0
ferrex 150 capsule outer, u-d 150
mg iron *
ferrex 150 plus capsule 150-50-50
mg *
(Iron
Polysaccharide
Complex)
(Iron
Aspgly,Ps/C/Succi
nic Acid)
Necessary Actions,
Restrictions, or
Limits on Use
ferrocite tablet 324 mg (106 mg
(Ferrous Fumarate)
4
$0
iron) *
ferrous fumarate 324 mg tab 324 mg
(Ferrous Fumarate)
4
$0
(106 mg iron) *
ferrous gluconate 240 mg tab
240mg=27mg elemental 240 mg (27 (Fergon)
4
$0
mg iron) *
ferrous gluconate 324 mg tab 324
mg (36 mg iron), 324 mg (38 mg
(Fergon)
4
$0
iron) *
ferrous gluconate 325 mg tab
p/f,s/f,gluten-free 325 mg (36 mg
(Fergon)
4
$0
iron) *
ferrous sulf 220 mg/5 ml elix 220 mg
(Ferrous Sulfate)
4
$0
(44 mg iron)/5 ml *
ferrous sulf 300 mg/5 ml liq 300 mg
(Ferrous Sulfate)
4
$0
(60 mg iron)/5 ml *
ferrous sulf ec 324 mg tablet 324 mg
(Ferrous Sulfate)
4
$0
(65 mg iron) *
ferrous sulfate 325 mg tablet red
(Ferrous Sulfate)
4
$0
325 mg (65 mg iron) *
218
Name of Drug
flintstones extra c tab chew *
(Multivitamin)
flintstones tablet chewable *
(Multivitamin)
(Pedi Mv
flintstones with iron tab chew 18 mg
No.79/Ferrous
iron *
Fumarate)
folic acid 1 mg tablet (rx) 1 mg *
(Folic Acid)
folic acid 1,000 mcg tablet p/f,s/f
(Folic Acid)
(otc) 1 mg *
FOLIC ACID 20 MG CAPSULE 20
MG *
folic acid 400 mcg tablet
(Folic Acid)
s/f,p/f,lactose-free 400 mcg *
(Calcium/Multivita
fosfree tablet 175.5-14.5 mg *
min with Iron)
geravim liquid *
(Pediavit)
geriaton liquid *
(Pediavit)
gnp century mature tablet gluten(Biocel)
free 0.4-300-250 mg-mcg-mcg *
gnp century tablet gluten-free 18(Multivitamin/Iron/
400 mg-mcg *
Folic Acid)
gnp one daily essential tablet *
(Multivitamin)
gs prenatal vitamins tablet 28-800
(Pnv133/Ferrous
mg-mcg *
Fumarate/Fa)
gummi bear multivit tab chew
(Multivitamin)
multivit & minerals *
(Multivitamin with
hair vitamins *
Iron)
healthy eyes caplet caplet 1,000
(Vit A,C and
E/Lutein/Minerals)
hemocyte tablet u-u,blister pk 324
(Ferrous Fumarate)
mg (106 mg iron) *
flintstones complete tablet *
Tier level
What the
drug will
cost you
4
$0
4
4
$0
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
219
Tier level
What the
drug will
cost you
(Vitamin B
Complex)
4
$0
(Biocel)
4
$0
(Multivitamin/Iron/
Folic Acid)
4
$0
(Dialyvite 800)
4
$0
(Multivitamin)
(Multivitamin with
Minerals)
(Iron
Polysaccharide
Complex)
4
$0
4
$0
4
$0
4
$0
(Fergon)
4
$0
(Fergon)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
hi-b complex tablet *
hm complete 50+ tablet 0.4-300-250
mg-mcg-mcg *
hm one daily with iron tablet glutenfree 18-400 mg-mcg *
hm super vitamin b complex glutenfree 400 mcg *
honey bears chew tab *
honey bears-iron-zinc tab chew *
icaps plus tablet lactose free *
iferex 150 capsule 150 mg iron *
iron 27 mg tablet 236 mg (27 mg
iron) *
iron 28 mg tablet 256 mg (28 mg
iron) *
kenwood therapeutic liquid *
life-pack women's p/f,s/f 0.8 mg *
LIQUI-E LIQUID 400 UNIT/15
ML *
little animals child tb chw *
little animals-iron tab chew *
lysiplex plus liquid *
MACUVITE EYE CARE TABLET
7,160 UNIT-113 MG-100 UNIT *
MACUVITE TABLET 5,000-60-30
UNIT-MG-UNIT *
(Multivitamin,Ther
apeutic)
(Multivitamin)
(Multivitamin with
Iron)
(Pediavit)
Necessary Actions,
Restrictions, or
Limits on Use
220
Name of Drug
mega multivitamin-mineral tab *
mega multivit-chelated min tab *
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
MEPHYTON 5 MG TABLET 5
MG *
(Multivitamin with
Minerals/Lut)
multi complete-iron tablet 18-400
(Multivitamin/Iron/
mg-mcg *
Folic Acid)
multi-day plus iron tablet 18-400
(Multivitamin/Iron/
mg-mcg *
Folic Acid)
multi-delyn with iron liquid 10 mg
(Multivitamin/Ferr
iron/5 ml *
ous Gluconate)
(Multivitamin with
multiple vitamin with iron tab *
Iron)
(Multivitamin with
multiple vitamin w-minerals tb *
Minerals)
multiple vitamins tablet one daily * (Multivitamin)
multivitamin child tab chew *
(Multivitamin)
multi-vitamin daily tablet *
(Multivitamin)
(Multivitmultivitamin-mineral liquid 9 mg
Minerals/Ferrous
iron/15 ml *
Gluc)
multivit-fluor 0.5 mg tab chew
(Pedi M.Vit No.17
chewable, d/f, s/f 0.5 mg
with Fluoride)
multivit-iron child tab chew
(Multivitamin with
children's *
Iron)
(Multivitamin,Ther
multivit-mineral hp cap *
and Minerals)
(Multivitamin with
multivit-minerals tablet s/f,p/f *
Minerals)
my favorite multiple liquid *
(Multivitamin)
milltrium senior multivit tab *
Tier level
What the
drug will
cost you
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
221
Name of Drug
myvitalife soft-gel capsule *
(Multivitamin with
Minerals)
NASCOBAL 500 MCG NASAL
SPRAY 500 MCG/SPRAY *
nephplex rx tablet 1-60-300-12.5
mg-mg-mcg-mg *
nephron fa tablet 66.6-75-1 mg *
nephro-vite rx tablet 1-60-300 mgmg-mcg *
niacinamide er 500 mg tablet 500
mg *
nu-iron 150 capsule 150 mg iron *
ocutabs tablet s/f, w/lutein *
oncovite tablet *
one daily complete tablet *
one daily essential tablet *
one daily multivitamin tab *
one daily multivitamin tablet *
one daily multivitamin tablet 400
mcg *
one daily multivitamin-iron tb 18400 mg-mcg *
one daily plus iron tablet 18-400
mg-mcg *
one daily tablet *
(Vit B Cmplx
No3/Fa/C/Biot/Zin
c)
(Fe
Fumarate/Doss/Fa/
Bcomp,C)
(Vit B Cmplx
3/Fa/Vit C/Biotin)
(Niacinamide)
(Iron
Polysaccharide
Complex)
(Beta-Carotene(A)
W-C and E/Min)
(Multivitamin,Ther
apeutic)
(Multivitamin with
Minerals)
(Multivitamin)
(Multivitamin)
(Multivitamin with
Iron)
(Quintabs)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
Tier level
What the
drug will
cost you
4
$0
3
$0
3
$0
3
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
222
Name of Drug
(Multivitamin with
Iron)
one daily tablet men's formula *
(Multivitamin)
(Multivitamin with
one daily with minerals tablet *
Minerals)
one-a-day essential tablet *
(Multivitamin)
(Multivitamin with
one-a-day max formula tab *
Minerals)
one-a-day teen advantage tab 18(Multivitamin/Iron/
400 mg-mcg *
Folic Acid)
one-a-day teen advantage tab 9 mg (Multivits,Ca,Mine
iron-400 mcg *
rals/Iron/Fa)
pharmacist multi-vite tab *
(Multivitamin)
pnv prenatal plus multivit tab s/f,
(Pnv with
gluten-free 27 mg iron- 1 mg
Ca,No.72/Iron/Fa)
(Iron
poly-iron 150 mg capsule 150 mg
Polysaccharide
iron *
Complex)
(Pediatric
poly-vita drops 1,500-35-400 unitMultivitamin
mg-unit/ml *
No.20)
poly-vita with iron drops 1,500 unit- (Ped Multivit
400 unit-10 mg/ml *
#46/Iron Sulfate)
(Pediatric
poly-vitamin drops 1,500-35-400
Multivitamin
unit-mg-unit/ml *
No.20)
poly-vitamin tab chew *
(Multivitamin)
polyvitamin w-iron drops 1,500
(Ped Multivit
unit-400 unit-10 mg/ml *
#46/Iron Sulfate)
(Prenatal Vit
prenatal tablet (otc) 27-0.8 mg *
No.130/Iron/Fa)
(Prenatal
prenatal tablet 27 mg iron- 800 mcg
Vit#96/Ferrous
*
Fum/Fa)
one daily tablet *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
(All Rx Prenatal
Vitamins Covered)
223
Tier level
What the
drug will
cost you
4
$0
2
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Multivitamin)
4
$0
(Multivitamin)
(Multivitamin with
Iron)
(Multivitamin)
(Multivitamin)
(Ped Multivit
#17/Iron Fumarate)
(Multivitamin with
Minerals/Lut)
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
(Biocel)
4
$0
4
$0
4
$0
Name of Drug
prenatal tablet 28 mg iron- 800 mcg
*
prenatal vitamin plus low iron oral
tablet 27 mg iron- 1 mg
prenatal vitamin tablet 28 mg iron800 mcg *
prenatal vitamins tablet phosphorus
free 28 mg iron- 800 mcg *
prosight tablet 5,000-60-30 unit-mgunit *
pub multivitamin 50 plus tab *
pv b-100 complex *
pv b-50 complex *
pv kid's gummy bear tab chew
chewable *
pv kid's vit + extra c chew tb *
pv kid's vit + iron tab chew *
pv kid's vit complete tab chew *
pv kid's vitamins chew tab *
pv kids vitamins+iron tab chew 15
mg iron *
pv multivital platinum tablet *
pv multivital platinum tablet
w/lutein & lycopene 500-300-250
mcg *
pv prenatal formula tablet 28 mg
iron- 800 mcg *
pv stress 500 plus zinc tab *
(Prenatal Vit/Iron
Fumarate/Fa)
(Pnv with
Ca,No.72/Iron/Fa)
(Prenatal Vit/Iron
Fumarate/Fa)
(Prenatal)
(A/C/E/Zinc/Sod
Selenate/Copper)
(Multivitamin with
Minerals/Lut)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Prenatal Vit
No.131/Iron/Fa)
(Multivitamin,Stres
s Formula/Zn)
Necessary Actions,
Restrictions, or
Limits on Use
(All Rx Prenatal
Vitamins Covered)
224
Tier level
What the
drug will
cost you
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Biocel)
4
$0
(Biocel)
4
$0
4
$0
4
$0
Name of Drug
pyridoxine 100 mg/ml vial 100
mg/ml *
qc child complete vit chew tab 18
mg iron *
qc children's chewable tablet *
qc maximum daily multivit tab 180.4 mg *
qc multi-vite 50 & over tablet
w/lycopene *
qc multi-vite tablet 18-400 mg-mcg
*
qc women's daily multivit tab 18-0.4
mg *
ra balanced b-100 tablet 0.4 mg *
ra b-complex tablet p/f *
ra b-complex tablet p/f *
ra central vite select tab p/f *
ra central-vite select tab p/f *
ra central-vite senior tablet 0.4-300250 mg-mcg-mcg *
ra central-vite tablet 0.4-300-250
mg-mcg-mcg *
ra central-vite tablet 18-400 mgmcg *
ra one daily energy tablet *
(Pyridoxine HCl)
(Pedi Mv
No.67/Ferrous
Fumarate)
(Multivitamin)
(Tab A Vite)
(Multivitamin with
Minerals/Lut)
(Multivitamin/Iron/
Folic Acid)
(Tab A Vite)
(Vitamin B
Complex/Folic
Acid)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Multivitamin with
Minerals/Lut)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
Minerals)
Necessary Actions,
Restrictions, or
Limits on Use
225
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
(Tab A Vite)
4
$0
(Cyanocobalamin
(Vitamin B-12))
4
$0
(B-12)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
ra one daily plus iron tablet *
ra one daily tablet p/f *
ra prenatal tablet 28 mg iron- 800
mcg *
ra therapeutic m multivit tab 18-0.4
mg *
ra vit b-12 1,000 mcg/ml liq 1,000
mcg/ml *
ra vitamin b-12 1,000 mcg tab
timed-release 1,000 mcg *
ra vitamin c 1,000 mg tab sa
w/bioflavonoids 1,000 mg *
ra vitamin c 500 mg tab chew p/f
500 mg *
ra vitamin c tr 500 mg caplet
caplet,p/f,s/f 500 mg *
rena-vite rx tablet 1-60-300 mg-mgmcg *
scooby-doo one a day tablet *
(Multivitamin with
Iron)
(Multivitamin)
(Prenatal Vit/Iron
Fumarate/Fa)
(Vit B Cmplx
3/Fa/Vit C/Biotin)
senior tabs 0.4-300-250 mg-mcg(Biocel)
mcg *
sentry senior multivitamin tab
(Biocel)
sodium/f,yeast/f 500-300-250 mcg *
sentry senior tablet 0.4-300-250 mg(Biocel)
mcg-mcg *
(Multivitamin/Iron/
sentry tablet 18-400 mg-mcg *
Folic Acid)
(Vit A,C, and
sm airshield effervescent tab 5,000E/Dietary Supp
1000-30 unit-mg-unit *
No.12)
sm animal shapes tab chew *
(Multivitamin)
Necessary Actions,
Restrictions, or
Limits on Use
226
Name of Drug
sm animal shapes tab chew toddlers
*
sm animal shapes w-iron tab
children's *
sm antioxidant vitamins tablet 1,000
sm b complex with vit c tablet
gluten-free *
sm complete multi-vit-mineral
advanced formula 18-400 mg-mcg *
sm complete senior formula tab *
(Multivitamin)
(Multivitamin with
Iron)
(Vit A,C and
E/Lutein/Minerals)
(Vita-Bee with C)
(Multivitamin/Iron/
Folic Acid)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
sm complete senior formula tab 0.4(Biocel)
4
$0
300-250 mg-mcg-mcg *
sm hair, skin and nails caplet caplet, (Multivitamin with
4
$0
gluten-free *
Minerals)
(Multivitamin with
sm multivitamin w-iron tab *
4
$0
Iron)
(Vit B Complex
sm natural balanced b-100 tab 100
100 Cmb
4
$0
mg *
#2/Herbs)
sm opti-vitamin tablet 1,000 unit(Vit A,C and
4
$0
200 mg-60 unit-2 mg *
E/Lutein/Minerals)
sm prenatal vitamins tablet 28 mg
(Prenatal)
4
$0
iron- 800 mcg *
sm super b complex-c caplet caplet
(Vita-Bee with C)
4
$0
*
(Multivit,Tx,Iron/C
sm therapeutic m tablet 27-0.4 mg *
4
$0
alcm/Fa/Mins)
(Vitamin B
sm vitamin b complex tablet glutenComplex/Folic
4
$0
free 0.4 mg *
Acid)
(Vitamin B
sm vitamin b-100 complex tab
Complex/Folic
4
$0
gluten-free 0.4 mg *
Acid)
227
Name of Drug
sm vitamin d3 4,000 unit sftgl
softgel, gluten-free 4,000 unit *
sodium fluoride oral tablet 1 mg
fluoride (2.2 mg)
(D3-50)
Tier level
What the
drug will
cost you
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
(Pedi M.Vit No.17
1
$0
with Fluoride)
(Vitamin B
stress b tablet *
4
$0
Complex)
(Multivitamin,Stres
stress b with zinc tablet *
4
$0
s Formula/Zn)
(Multivitamin,Stres
stress formula tablet *
4
$0
s Formula)
(Iron/Mv,Stress
stress formula with iron tab *
4
$0
Form)
(Vit B
stress formula with iron tab 500 mgComp/C/Fa/Iron/Vi
4
$0
400 mcg- 18 mg iron *
t E)
(Multivitamin,Stres
stress formula with zinc tab *
4
$0
s Formula/Zn)
(Vit B
stress-c with iron tablet 500 mg-400
Comp/C/Fa/Iron/Vi
4
$0
mcg- 18 mg iron *
t E)
(Mv-Min/Iron
sunvite tablet 18 mg iron-400 mcgFum/Fa/K/Lyco/Lu
4
$0
25 mcg *
tn)
super b complex-c caplet caplet * (Vita-Bee with C)
4
$0
(Vitamin B
super b maxi complex caplet 0.4 mg
Complex/Folic
4
$0
*
Acid)
(B Complex with
super b with vit c capsule *
4
$0
Vitamin C)
(Vitamin B
super b-50 complex capsule *
4
$0
Complex)
(Vitamin B
super b-50 complex plus tab *
4
$0
Complex)
super b-complex folic-vit c tb p/f
(Dialyvite 800)
4
$0
400 mcg *
228
Name of Drug
super multiple vit-mineral tab *
super multivitamin tablet *
super quints b-50 tablet 0.4 mg *
super quints b-50 tablets *
super thera vite m tablet *
superior 35 vit-mineral tab sa *
superplex-t tablet *
support liquid *
support-500 softgel *
sv hair, skin and nails caplet 1 mg
iron-66.7 mcg-1,000 mcg *
tab-a-vite tablet *
tab-a-vite with iron tablet *
tab-a-vite-minerals tablet *
thera m plus tablet 9 mg iron-400
mcg *
thera tablet *
thera-d 2000 tablet 2,000 unit *
theradex m tablet 27-0.4 mg *
thera-m caplet caplet 27-0.4 mg *
(Multivitamin)
(Vitamin B
Complex/Folic
Acid)
(Vitamin B
Complex)
(Multivitamin,Ther
and Minerals)
(Vita-Bee with C)
(Multivitamin with
Minerals)
(B Complex with
Vitamin C)
(Mv,Ca,Min/Iron
Gluc/Fa/Biotin)
(Multivitamin)
(Multivitamin with
Iron)
(Multivitamin with
Minerals)
(Multivits,Ca,Mine
rals/Iron/Fa)
(Multivitamin,Ther
apeutic)
(Vitamin D3)
(Multivit,Tx,Iron/C
alcm/Fa/Mins)
(Multivit,Tx,Iron/C
alcm/Fa/Mins)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
229
Name of Drug
thera-m tablet w/beta carotene 9 mg
iron-400 mcg *
therapeutic-m caplet p/f, s/f, caplet 9
mg iron-400 mcg *
thera-tabs tablet *
theratrum compl 50 plus tab *
theratrum complete 50 plus
p/f,caplet *
thiamine 200 mg/2 ml vial
25's,mdv,outer 100 mg/ml *
thiamine 500 mg tablet 500 mg *
total b with vit c caplet *
(Multivits,Ca,Mine
rals/Iron/Fa)
(Multivits,Ca,Mine
rals/Iron/Fa)
(Multivitamin,Ther
apeutic)
(Multivitamin with
Minerals/Lut)
(Thiamine HCl)
(Thiamine HCl)
(Vita-Bee with C)
(Multivitamin with
totalday multiple tablet sa *
Minerals)
(Vit A
tri-vi-sol drops 750 unit-35 mg -400
Palmitate/Vit C/Vit
unit/ml *
D3)
(Pedi Multivits
tri-vita drops 1,500-35-400 unit-mgA,C, and D3
unit/ml *
No.21)
(Pedi Multivits
tri-vitamin drops 1,500-35-400 unitA,C, and D3
mg-unit/ml *
No.21)
(Vitamin B
ultra b-100 complex tablet *
Complex)
(Multivitaminv-c forte capsule 1 mg *
Minerals No.7/Fa)
(Multivitaminvic-forte capsule 1 mg *
Minerals No.7/Fa)
(Multivitamin with
vision plus lutein vitamin tab *
Minerals/Lut)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
3
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
230
Tier level
What the
drug will
cost you
4
$0
4
$0
3
$0
2
$0
(Multivitamin with
Iron)
4
$0
(Vitamin A)
4
$0
(Vitamin A)
4
$0
4
$0
4
$0
4
$0
4
$0
(B-12)
4
$0
(B-12)
4
$0
(B-12)
4
$0
(B-12)
4
$0
(Cyanocobalamin
(Vitamin B-12))
4
$0
Name of Drug
vision vitamins *
vision vitamins tablet w/lutein,p/f
1,000 unit-200 mg-60 unit-2 mg *
vit d2 1.25 mg (50,000 unit) 50,000
unit *
VITAFOL FE+ (WITH
DOCUSATE) ORAL CAPSULE 90
MG IRON-1 MG -50 MG-200 MG
vitalets tablet chewable child,
orange,s/f *
vitamin a 10,000 units capsule
soluble 10,000 unit *
vitamin a 25,000 units capsule
softgel 25,000 unit *
vitamin and minerals tablet *
vitamin b complex tablet 500 mg400 mcg- 18 mg iron *
vitamin b complex-vit c cap *
vitamin b complex-vit c tablet *
vitamin b-12 1,000 mcg tablet 1,000
mcg *
vitamin b-12 100 mcg tablet 100
mcg *
vitamin b-12 250 mcg tablet 250
mcg *
vitamin b12 500 mcg tablet 500 mcg
*
vitamin b-12 tr 1,000 mcg tab
lactose free 1,000 mcg *
(Beta-Carotene(A)
W-C and E/Min)
(Vit A,C and
E/Lutein/Minerals)
(Drisdol)
(Multivitamin,Ther
and Minerals)
(Vit B
Comp/C/Fa/Iron/Vi
t E)
(B Complex with
Vitamin C)
(Vita-Bee with C)
Necessary Actions,
Restrictions, or
Limits on Use
231
Tier level
What the
drug will
cost you
(Cyanocobalamin/
Folic Acid)
4
$0
(Pyridoxine HCl)
4
$0
(Pyridoxine HCl)
(Fa/Vit B Complex
and C/Rice Bran)
4
$0
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Vitamin D3)
4
$0
(Vitamin D3)
4
$0
(D3-50)
4
$0
(D3-50)
4
$0
(Vitamin D3)
4
$0
(Vitamin D3)
4
$0
(Vitamin D3)
4
$0
(Cholecalciferol
(Vitamin D3))
4
$0
(D3-50)
4
$0
Name of Drug
vitamin b12-folic acid tablet 500400 mcg *
vitamin b-6 250 mg tablet p/f 250
mg *
vitamin b-6 50 mg tablet 50 mg *
vitamin b-complex & c caplet p/f,no
lactose,cplt 400-500 mcg-mg *
vitamin c 1,000 mg tablet 1,000 mg
*
vitamin c 1,500 mg tablet sa
na/f,s/f,starch/free 1,500 mg *
vitamin c 250 mg tablet 250 mg *
vitamin c 250 mg tablet chew 250
mg *
vitamin c 500 mg/5 ml liquid 500
mg/5 ml *
vitamin d 1,000 unit tablet 1,000
unit *
vitamin d3 1,000 unit tablet s/f,p/f
1,000 unit *
vitamin d3 1,000 units softgel
softgel, p/f, s/f 1,000 unit *
vitamin d3 10,000 unit softgel
softgel 10,000 unit *
vitamin d3 2,000 unit tablet s/f,p/f
2,000 unit *
vitamin d3 400 unit tab chew
orange, p/f 400 unit *
vitamin d3 400 unit tablet s/f,p/f 400
unit *
vitamin d3 400 unit/5 ml liq 400
unit/5 ml *
vitamin d3 5,000 unit capsule s/f, p/f
5,000 unit *
Necessary Actions,
Restrictions, or
Limits on Use
232
Tier level
What the
drug will
cost you
(Just D)
4
$0
(Phytonadione)
4
$0
(Multivitamin)
4
$0
(Biocel)
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
vitamin d3 5,000 unit/ml drops a/f,
p/f,gluten-free 5,000 unit/ml *
vitamin k 100 mcg tablet p/f, glutenfree 100 mcg *
vitamins for hair tablet *
vitrum 50+ senior tablet 500-300250 mcg *
vitrum senior tablet f/f,p/f *
v-r natural b-100 tablet *
yelets tablet 18-400 mg-mcg *
zoo chews gummie tablet *
(Multivitamin with
Minerals/Lut)
(Vitamin B
Complex)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
Necessary Actions,
Restrictions, or
Limits on Use
233
INDEX
3
3 day vaginal .......................... 58
30pse-150gfn-15dm ............. 119
3-day vaginal .......................... 55
8
8-MOP.................................. 131
A
a thru z advanced formula .... 210
a thru z high potency ............ 210
a thru z select ....................... 211
a thru z select 50+ formula... 211
a thru z select women's ........ 211
abacavir ............................ 75, 76
abacavir-lamivudine-zidovudine
............................................ 76
abc plus ................................ 211
ABELCET.............................. 54
ABILIFY MAINTENA ......... 71
ABRAXANE ......................... 30
ABREVA ............................... 65
acamprosate............................ 15
acarbose.................................. 50
acebutolol ............................... 96
acephen .................................... 3
acetaminophen ......................... 3
acetaminophen-codeine............ 3
acetazolamide ....................... 191
acetazolamide sodium .......... 191
acetic acid..................... 148, 183
acetylcysteine ....................... 206
acid gone antacid.......... 154, 155
acid reducer (famotidine) .... 152,
153
acid relief (cimetidine) ......... 154
acitretin ................................ 131
acne medication ........... 131, 133
ACNE MEDICATION ........ 131
acne-clear ............................. 131
ACTEMRA .......................... 185
ACTHIB (PF) ....................... 177
ACTIMMUNE ..................... 186
actinel pediatric .................... 119
acyclovir ......................... 81, 131
acyclovir sodium .................... 81
ADACEL(TDAP
ADOLESN/ADULT)(PF) 177
ADAGEN ............................. 141
adapalene .............................. 139
ADCETRIS ............................ 30
ADCIRCA ............................ 209
adefovir .................................. 81
ADEMPAS........................... 209
adriamycin .............................. 30
adrucil............................... 30, 31
adt robitussin peak cld dm max
.......................................... 119
adult multivitamin gummies 211
adult nasal decongestant....... 127
adult one daily gummies ...... 211
adult robitussin lingering cld 119
adult robitussin peak cold dm
.......................................... 119
adult wal-tussin .................... 119
adult wal-tussin dm max ...... 119
adults 50 plus ....................... 211
adults 50+ daily formula ...... 211
adults' daily formula ............. 211
ADVAIR DISKUS ............... 203
ADVAIR HFA ..................... 203
ADVIL ................................... 11
af 55
afeditab cr ............................. 102
AFINITOR ............................. 31
AFINITOR DISPERZ ............ 31
AFTERA .............................. 110
a-hydrocort ........................... 169
airshield ................................ 226
AKTEN (PF) ........................ 143
AKYNZEO ............................ 67
ala-cort.................................. 135
ala-scalp................................ 135
alavert ..................................... 59
alavert d-12 allergy-sinus ....... 59
ALBENZA ............................. 69
albuterol sulfate .................... 204
alcaine .................................. 143
alclometasone ....................... 136
ALCOHOL PADS ............... 131
ALCOHOL PREP PADS ..... 131
ALDURAZYME .................. 141
ALECENSA ........................... 31
alendronate ................... 183, 184
alfuzosin ............................... 166
ALIMTA ................................ 31
ALINIA .................................. 69
alka-seltzer plus mucus-conges
.......................................... 119
ALLEGRA ALLERGY ......... 59
aller-chlor ............................... 59
allerclear d-12hr ..................... 59
allerclear d-24hr ..................... 59
allergy (chlorpheniramine) ..... 59
allergy (diphenhydramine) ..... 61
allergy relief (cetirizine) ......... 61
allergy relief (clemastine) ...... 63
allerhist-1................................ 59
aller-tec d ................................ 59
allopurinol ............................ 186
ALLZITAL .............................. 3
almacone .............................. 155
almacone-2 ........................... 155
I-1
aloe vesta antifungal (micon) . 54
alophen ................................. 160
alosetron ............................... 182
ALPHAGAN P .................... 191
alprazolam .............................. 17
ALREX ................................ 150
altacaine ............................... 143
altamist ................................. 143
altavera (28) ......................... 110
aluminum hydroxide gel ...... 155
alyacen 1/35 (28).................. 110
alyacen 7/7/7 (28) ................ 110
amantadine hcl ....................... 70
ambi 10peh-4cpm-20dm ...... 119
ambi 20dm-4cpm ................. 119
ambi 40pse-400gfn-20dm .... 119
ambi 60pse-4cpm ................... 59
ambi 60pse-4cpm-20dm....... 119
AMBISOME .......................... 54
amethia ................................. 110
amethia lo ............................. 110
amifostine crystalline ........... 186
amiloride .............................. 103
amiloride-hydrochlorothiazide
.......................................... 103
AMINO ACIDS 15 % ............ 86
aminocaproic acid .................. 85
AMINOSYN 10 % ................. 86
AMINOSYN 3.5 % ................ 86
AMINOSYN 7 % ................... 86
AMINOSYN 7 % WITH
ELECTROLYTES ............. 86
AMINOSYN 8.5 % ................ 86
AMINOSYN 8.5 %ELECTROLYTES ............. 87
AMINOSYN II 10 % ............. 87
AMINOSYN II 15 % ............. 87
AMINOSYN II 7 % ............... 87
AMINOSYN II 8.5 % ............ 87
AMINOSYN II 8.5 %ELECTROLYTES ............. 87
AMINOSYN M 3.5 % ........... 87
AMINOSYN-HBC 7% .......... 87
AMINOSYN-PF 10 % ........... 87
AMINOSYN-PF 7 %
(SULFITE-FREE) .............. 87
AMINOSYN-RF 5.2 %.......... 87
amiodarone ............................. 95
AMITIZA ............................. 155
amitriptyline ........................... 46
amlactin ................................ 131
amlodipine............................ 102
amlodipine-atorvastatin ........ 104
amlodipine-benazepril .......... 102
amlodipine-valsartan ............ 102
amlodipine-valsartan-hcthiazid
.......................................... 102
ammonium lactate ........ 131, 132
amoxapine .............................. 46
amoxicil-clarithromy-lansopraz
.......................................... 152
amoxicillin ....................... 25, 26
amoxicillin-pot clavulanate .... 26
amphotericin b........................ 54
ampicillin ............................... 26
ampicillin sodium................... 26
ampicillin-sulbactam .............. 26
AMPYRA............................. 108
ANACAINE ......................... 132
anagrelide ............................... 85
anastrozole ............................. 31
ANDRODERM ............ 166, 167
ANDROGEL ........................ 167
androxy................................. 167
animal chews ........................ 211
animal shape vitamins .......... 227
animal shapes plus iron ........ 227
antacid anti-gas .................... 155
antacid anti-gas (ca carb-sim)
.......................................... 156
antacid extra-strength ........... 155
antacid plus extra strength.... 155
anticoag citrate phos dextrose
.......................................... 186
anti-diarrheal ........................ 156
anti-diarrheal (loperamide).. 155,
156
antifungal (tolnaftate) ....... 55, 58
anti-gas maximum strength .. 152
antioxidant ............................ 211
antioxidant vitamins ............. 227
apatate forte .......................... 211
APOKYN ............................... 70
apraclonidine ........................ 143
apri........................................ 110
APRISO................................ 183
aprodine .................................. 59
APTIOM ................................ 41
APTIVUS ............................... 76
aquanil hc ............................. 136
aranelle (28) ......................... 111
ARCALYST ......................... 173
aripiprazole ....................... 71, 72
ARISTADA............................ 72
armodafinil ........................... 208
arthritis pain relief (acetam) ... 10
artificial tears (petro/min) .... 144
artificial tears (pf) ................. 143
artificial tears (polyvin alc) .. 143
artificial tears(dext70-hypro) 143
artificial tears(glycerin-peg) . 144
artificial tears(hypromellose) 147
ASACOL HD ....................... 183
ascomp with codeine ................ 3
ascorbic acid (vitamin c) ..... 216,
232
ashlyna.................................. 111
aspirin ..................................... 12
aspirin, buffered ..................... 12
aspirin-dipyridamole .............. 86
aspir-low ................................. 12
ASSURE ID INSULIN
SAFETY ........................... 140
ASTAGRAF XL .................. 173
atenolol ................................... 96
atenolol-chlorthalidone .......... 96
I-2
atorvastatin ........................... 104
atovaquone ............................. 69
atovaquone-proguanil ............ 69
ATRIPLA ............................... 76
atropine .......................... 41, 144
atropine-care ........................ 144
ATROVENT HFA ............... 204
AUBAGIO ........................... 173
aubra ..................................... 111
AVASTIN .............................. 31
AVC VAGINAL .................... 65
aviane ................................... 111
AVONEX ............................. 186
AVONEX (WITH ALBUMIN)
.......................................... 186
ayr saline .............................. 144
azacitidine .............................. 31
azathioprine .......................... 173
azathioprine sodium ............. 173
azelastine .............................. 144
AZILECT ............................... 70
azithromycin .......................... 24
AZOPT ................................. 191
AZOR ................................... 102
aztreonam ............................... 25
azurette (28) ......................... 111
B
b complete ............................ 211
b complex 1 .......................... 212
b complex 100 ...................... 227
b complex-vitamin b12 ........ 212
b complex-vitamin c-folic acid
.......................... 212, 220, 228
b-100 complex ..................... 224
b-12 dots............................... 212
b-50 complex ....................... 224
bacitracin ................ 19, 134, 148
bacitracin-polymyxin b ........ 148
bacitraycin plus .................... 134
baclofen ................................ 207
bal b-100 .............................. 214
bal b-50 ................................ 214
balance b-100 ....................... 212
balance b-50 ......................... 212
balanced b-100 ............. 212, 225
balanced b-150 ..................... 214
balanced b-50 ....................... 212
balanced b-50 complex ........ 212
balsalazide ............................ 183
balziva (28) .......................... 111
banophen ................................ 59
banophen allergy .................... 59
BANZEL ................................ 41
baza antifungal ....................... 55
BCG VACCINE, LIVE (PF) 177
b-complex............................. 225
b-complex with vitamin c ... 212,
214, 227, 231, 232
BD INSULIN PEN NEEDLE
UF SHORT ...................... 141
BD INSULIN SYRINGE
ULTRA-FINE .......... 140, 141
bekyree (28) ......................... 111
BELBUCA ............................... 4
BELEODAQ .......................... 31
BELSOMRA ........................ 208
benadryl allergy...................... 59
benazepril ............................... 93
benazepril-hydrochlorothiazide
............................................ 93
BENDEKA............................. 31
BENICAR .............................. 92
BENICAR HCT ..................... 92
BENLYSTA ......................... 186
benzonatate........................... 120
benzoyl peroxide .................. 132
benztropine ............................. 70
BETADINE .......................... 132
beta-hc .................................. 136
betamethasone acet,sod phos 169
betamethasone dipropionate . 136
betamethasone valerate ........ 136
betamethasone, augmented .. 136
BETASERON ...................... 186
betaxolol ......................... 96, 192
bethanechol chloride ............ 186
BETHKIS ............................... 18
bexarotene .............................. 31
BEXSERO (PF) ................... 177
bicalutamide ........................... 31
bicarsim forte ............... 151, 152
BICILLIN C-R ....................... 27
BICILLIN L-A ....................... 27
BIDIL ................................... 107
bimatoprost ........................... 192
bio-dtuss dmx ....................... 120
bion tears (pf) ....................... 144
bionel pediatric ..................... 120
biospec dmx ......................... 120
biosupp ................................. 212
biotin .................................... 212
biovol.................................... 213
bisac-evac ............................. 160
bisacodyl .............................. 160
biscolax ................................ 160
bismatrol ............................... 155
bisoprolol fumarate ................ 96
bisoprolol-hydrochlorothiazide
............................................ 96
bleomycin ............................... 31
bleph-10................................ 148
BLINCYTO............................ 31
blisovi 24 fe .......................... 111
blisovi fe 1.5/30 (28) ............ 111
blisovi fe 1/20 (28) ............... 111
blis-to-sol (tolnaftate) ............. 55
BOOSTRIX TDAP .............. 177
BOSULIF ......................... 31, 32
bp 8 cough ............................ 120
BREO ELLIPTA .................. 203
briellyn ................................. 111
BRILINTA ............................. 86
brimonidine .......................... 192
BRINTELLIX ........................ 47
BRIVIACT ............................. 41
bromfed dm .......................... 120
I-3
bromfenac ............................ 150
bromocriptine ......................... 70
bromphenex dm ................... 120
brompheniramine-pseudoephdm ............................ 119, 120
budesonide ........................... 183
bufferin ................................... 12
bumetanide ........................... 103
BUPHENYL ........................ 155
buprenorphine hcl .............. 4, 16
buprenorphine-naloxone ........ 16
buproban ................................ 47
bupropion hcl ......................... 47
bupropion hcl (smoking deter)16
buspirone .............................. 186
butalbital compound w/codeine 4
butalbital-acetaminop-caf-cod . 4
butalbital-acetaminophen ......... 4
butalbital-acetaminophen-caff . 4
butalbital-aspirin-caffeine ........ 4
BUTRANS ............................... 4
BYSTOLIC ............................ 96
C
c complex ............................. 213
cabergoline ............................. 70
CABOMETYX ...................... 32
ca-d3-mag ox-zinc-cop-mangbor .................................... 196
caffeine citrated .................... 108
caffeine-sodium benzoate .... 108
calci-chew ............................ 155
calcidol ................................. 213
calcipotriene ......................... 132
calcitonin (salmon)............... 184
calcitrate ............................... 193
calcitrate-vitamin d .............. 193
calcitrene .............................. 132
calcitriol ....................... 132, 184
calcium 500 + d............ 193, 194
calcium 500 + d (d3) ............ 195
calcium 600 .......................... 193
calcium 600 + d(3) ............... 193
calcium 600 with vitamin d3 197
calcium acetate ..................... 164
calcium antacid .................... 155
calcium carbonate ........ 155, 194
calcium carbonate-vitamin d2
.......................................... 194
calcium carbonate-vitamin d3
.......... 193, 194, 195, 196, 202
CALCIUM CARBONATEVITAMIN D3 .................. 155
calcium chloride ................... 194
calcium citrate-vitamin d3 .. 194,
196
calcium gluconate ................ 194
calcium+d ............................. 203
CALDOLOR .......................... 12
cal-gest antacid ..................... 156
calphron ................................ 165
CALTRATE 600 + D ........... 194
CALTRATE WITH VITAMIN
D3 ..................................... 194
camila ................................... 111
camrese................................. 111
camrese lo ............................ 111
CANCIDAS ........................... 55
candesartan ............................. 92
candesartan-hydrochlorothiazid
............................................ 93
capacet ...................................... 4
CAPASTAT ........................... 66
CAPRELSA ........................... 32
captopril ................................. 94
captopril-hydrochlorothiazide 94
CARAFATE......................... 152
CARBAGLU ........................ 156
carbamazepine .................. 41, 42
carbidopa ................................ 70
carbidopa-levodopa ................ 70
carbidopa-levodopa-entacapone
............................................ 70
CARIMUNE NF
NANOFILTERED ........... 173
carisoprodol .......................... 207
carteolol ................................ 144
cartia xt ................................... 97
carvedilol ................................ 96
CASTELLANI PAINT
MODIFIED ...................... 132
CAYSTON ............................. 25
caziant (28) ........................... 111
cefaclor ................................... 21
cefadroxil.......................... 21, 22
cefazolin ................................. 22
cefazolin in dextrose (iso-os) . 22
cefdinir ................................... 22
cefditoren pivoxil ................... 22
cefepime ................................. 22
CEFEPIME IN DEXTROSE 5
% ........................................ 22
CEFEPIME IN
DEXTROSE,ISO-OSM ..... 22
cefotaxime .............................. 22
cefoxitin.................................. 22
cefoxitin in dextrose, iso-osm 22
cefpodoxime ........................... 22
cefprozil.................................. 23
ceftazidime ............................. 23
ceftibuten ................................ 23
ceftriaxone .............................. 23
ceftriaxone in dextrose,iso-os. 23
cefuroxime axetil .................... 23
cefuroxime sodium ................. 23
celecoxib ................................ 12
CELLCEPT INTRAVENOUS
.......................................... 174
CELONTIN ............................ 42
centamin ............................... 213
centergy dm .......................... 120
central vite with lutein .......... 225
central-vite............................ 225
central-vite for seniors.......... 213
central-vite select ......... 217, 225
central-vite senior ................. 225
centram-care ......................... 213
I-4
centravites 50 plus................ 213
centrum ................................ 213
centrum complete ................. 213
centrum silver....................... 213
century.................................. 219
century adults 50+ ................ 213
century mature ..... 213, 217, 219
century ultimate women's .... 213
cephalexin .............................. 23
CEPROTIN (BLUE BAR) ..... 82
CERDELGA ........................ 186
CEREZYME ........................ 141
cerovite ................................. 213
cerovite advanced formula ... 213
certavite senior-antioxidant .. 213
certavite-antioxid (iron gluc) 214
certavite-antioxidant ............ 214
CERVARIX VACCINE (PF)
.......................................... 177
cetirizine ................................. 60
cetirizine-pseudoephedrine .... 60
cevimeline ............................ 130
CHANTIX.............................. 16
CHANTIX CONTINUING
MONTH BOX ................... 16
CHANTIX STARTING
MONTH BOX ................... 16
cheracol d ............................. 120
cheratussin dac ..................... 120
chest congestion relief + dm 122
chest congestion relief pe ..... 122
chewable multi vitamin ........ 217
child allergy relf(cetirizine) ... 61
child complete multivitamin 217
child cough and sore throat .. 122
child mucinex chest congestion
.......................................... 121
child plus cough and runnynose
.......................................... 126
child triaminic cold-allergy .... 60
child triaminic cough-congest
.......................................... 120
child triaminic cough-sore thr
.......................................... 121
child vitamin with minerals.. 214
child wal-tap cold-allergy ...... 60
child wal-tussin cough relief 121
CHILDREN'S ADVIL ........... 12
children's allegra allergy ........ 60
children's aller-tec .................. 60
children's chest congestion ... 122
children's chewable .............. 225
children's chewable complete
.......................................... 214
children's chewable vitamin . 214
children's chewable w/minerals
.......................................... 217
CHILDREN'S CLARITIN ..... 60
children's cold-cough daytime
.......................................... 122
children's complete vitamin . 225
children's mapap ....................... 4
children's mucinex cough ..... 121
children's multivit w/extra c . 217
children's non-aspirin ........... 4, 5
children's pain reliever ........... 11
children's pain-fever relief ....... 4
children's pepto .................... 156
childrens plus multi-symp cold
.......................................... 127
children's silapap ...................... 5
children's silfedrine .............. 121
children's soothe ................... 156
children's sudafed ................. 121
children's sudafed pe cough . 120
children's tactinal ..................... 4
children's wal-dryl allergy...... 60
children's wal-zyr ................... 60
CHILDREN'S ZYRTEC
ALLERGY ......................... 60
childs chew vite .................... 214
child's vitamin with iron....... 214
child's vitamin with vitamin c
.......................................... 214
childs/iron ............................. 214
chlophedianol-guaifenesin ... 119
chloramphenicol sod succinate
............................................ 19
chlordiazepoxide hcl .............. 17
chlorhexidine gluconate ....... 130
chloroquine phosphate ........... 69
chlorothiazide ....................... 103
chlorothiazide sodium .......... 103
chlorpheniramine-phenyleph-dm
.................................. 118, 119
chlorpromazine ....................... 72
chlorthalidone ....................... 103
chlorzoxazone ...................... 207
cholecalciferol (vitamin d3) 216,
232, 233
cholestyramine (with sugar) . 104
cholestyramine light ............. 104
choline,magnesium salicylate 12
ciclopirox................................ 55
ciclopirox-ure-camph-menth-euc
............................................ 55
cilostazol ................................ 86
cimetidine ............................. 153
cimetidine hcl ....................... 153
CIMZIA................................ 174
CIMZIA POWDER FOR
RECONST........................ 174
CINQAIR ............................. 206
CINRYZE .............................. 84
CIPRODEX .......................... 148
ciprofloxacin .......................... 28
ciprofloxacin hcl............. 28, 148
ciprofloxacin in 5 % dextrose 28
ciprofloxacin lactate ............... 28
citalopram ............................... 47
citracal + d maximum........... 194
citrus calcium ....................... 194
clarithromycin ........................ 24
CLARITIN ............................. 61
CLARITIN LIQUI-GEL ........ 60
CLARITIN REDITABS......... 61
I-5
clearlax ................................. 164
CLEVIPREX........................ 102
clindamycin hcl ...................... 19
clindamycin in 5 % dextrose .. 19
clindamycin palmitate hcl ...... 19
clindamycin pediatric ............. 19
clindamycin phosphate.... 19, 65,
134
CLINIMIX 5%/D15W
SULFITE FREE ................. 88
CLINIMIX 5%/D25W
SULFITE-FREE ................ 88
CLINIMIX 2.75%/D5W
SULFIT FREE ................... 88
CLINIMIX 4.25%/D10W SULF
FREE .................................. 88
CLINIMIX 4.25%/D5W
SULFIT FREE ................... 88
CLINIMIX 4.25%-D20W
SULF-FREE ....................... 88
CLINIMIX 4.25%-D25W
SULF-FREE ....................... 88
CLINIMIX 5%D20W(SULFITE-FREE) ... 88
CLINIMIX E 2.75%/D10W
SUL FREE ......................... 88
SULF FREE ....................... 89
SUL FREE ......................... 89
SUL FREE ......................... 89
SULF FREE ....................... 89
CLINIMIX E 5%/D15W
SULFIT FREE ................... 89
CLINIMIX E 5%/D20W
SULFIT FREE ................... 89
CLINIMIX E 5%/D25W
SULFIT FREE ................... 89
CLINISOL SF 15 %............... 89
clobetasol ..................... 136, 137
clobetasol-emollient ............. 137
clocortolone pivalate ............ 137
clomipramine ......................... 47
clonazepam............................. 17
clonidine ................................. 92
clonidine hcl ................... 92, 108
clopidogrel ............................. 86
clorazepate dipotassium ......... 18
clorpres ................................... 92
clotrimazole ............................ 55
clotrimazole-7 ........................ 55
clotrimazole-betamethasone... 55
clozapine ................................ 72
COARTEM ............................ 69
codeine sulfate.......................... 5
codituss dm .......................... 121
COLACE .............................. 161
colchicine ............................. 186
colchicine-probenecid .......... 186
cold and cough (diphenhydr-pe)
............................................ 61
cold multi-symptom day/night
.......................................... 121
cold relief m/s day/night ...... 121
cold-allergy-sinus ................... 61
cold-flu relief........................ 121
cold-flu relief, day/night ...... 121
colestipol .............................. 104
colistin (colistimethate na) ..... 19
colocort................................. 137
COLY-MYCIN S ................. 148
COMBIGAN ........................ 192
COMBIPATCH ................... 167
COMBIVENT RESPIMAT . 204
COMETRIQ ........................... 32
comfort gel ........................... 156
comfort gel extra strength .... 156
COMPLERA .......................... 76
complete 50+ ........................ 220
complete multi 50+ .............. 214
complete multivitamin . 214, 217
complete multivitamin-mineral
.................................. 217, 227
complete senior ............ 214, 227
compoz ................................... 61
compro.................................... 67
COMVAX (PF) .................... 178
CONDYLOX ....................... 132
congestac .............................. 121
congest-eze ........................... 121
constulose ............................. 156
COPAXONE ........................ 186
coricidin hbp......................... 121
coricidin hbp cold-multi sympt
.......................................... 121
CORLANOR .................... 98, 99
cormax .................................. 137
cortisone ............................... 169
cortizone-10.......................... 137
CORTIZONE-10 .................. 137
COSENTYX ........................ 132
COSENTYX (2 SYRINGES)
.......................................... 132
COSENTYX PEN ................ 132
COSENTYX PEN (2 PENS) 132
COTELLIC ............................ 32
cough and cold ..................... 122
cough and runny nose........... 127
cough relief........................... 122
CREON ................................ 142
CRESTOR ............................ 104
critic-aid clear af .................... 55
CRIXIVAN ............................ 76
cromolyn .............. 144, 156, 206
cryselle (28) .......................... 111
CUBICIN ............................... 20
CUBICIN RF ......................... 20
cyanocobalamin (vitamin b-12)
.................. 212, 216, 226, 231
cyclafem 1/35 (28) ............... 111
cyclafem 7/7/7 (28) .............. 112
cyclobenzaprine.................... 207
cyclopentolate ...................... 145
I-6
cyclophosphamide.................. 32
CYCLOPHOSPHAMIDE...... 32
CYCLOSET ........................... 50
cyclosporine ......................... 174
cyclosporine modified .......... 174
cyproheptadine ....................... 61
CYRAMZA............................ 32
cyred ..................................... 112
CYSTADANE ..................... 186
CYSTARAN ........................ 145
cysteine (l-cysteine) ............... 89
D
.......................................... 195
d2.5 %-0.45 % sodium chloride
.......................................... 195
d3 dots .................................. 216
d5 % and 0.9 % sodium chloride
.......................................... 195
.......................................... 195
dactinomycin .......................... 32
daily gummies ...................... 214
daily multiple ....... 214, 215, 216
daily multi-vitamin............... 221
daily multivitamin with iron 216
daily multi-vitamins/iron ..... 216
daily teen multi-vitamin ....... 215
daily value ............................ 216
daily vitamin ........................ 216
daily vitamin formula ........... 216
daily vitamin formula + iron 216
daily vitamin formula-minerals
.......................................... 216
daily vitamin with iron ......... 216
daily vites/iron ..................... 216
dailyhist-1 .............................. 61
daily-vite .............................. 216
DAKLINZA ........................... 80
DALIRESP .......................... 206
danazol ................................. 167
dantrolene ............................. 207
dapsone................................... 66
DAPTACEL (DTAP
PEDIATRIC) (PF) ........... 178
DARAPRIM........................... 69
DARZALEX .......................... 32
dasetta 1/35 (28) ................... 112
dasetta 7/7/7 (28) .................. 112
dayhist allergy ........................ 61
daysee ................................... 112
daytime cold and cough ....... 122
daytime cold-flu ................... 122
day-time cough ..................... 122
daytime-nighttime ................ 126
daytime-nighttime cold-flu .. 122
daytime-nighttime cough ..... 122
deblitane ............................... 112
decitabine ............................... 32
decongestant cough .............. 127
deep sea nasal ....................... 145
deferoxamine ........................ 166
delsym cough-chest congest dm
.......................................... 122
delyla (28) ............................ 112
DELZICOL .......................... 183
DEMSER ............................... 99
DEPEN TITRATABS .......... 166
DEPO-PROVERA ............... 172
dermafungal ........................... 56
dermarest eczema (hydrocort)
.......................................... 137
DESCOVY ............................. 76
desipramine ............................ 47
desmopressin ........................ 170
desog-e.estradiol/e.estradiol . 112
desogestrel-ethinyl estradiol 112
desonide ............................... 137
desoximetasone .................... 137
despec-dm (pseudoeph-dmguaif) ................................ 123
dex4 glucose ........................... 89
dexamethasone ..................... 169
dexamethasone sodium
phosphate.................. 150, 169
dexmethylphenidate ............. 108
dextroamphetamine .............. 108
dextroamphetamineamphetamine .................... 108
dextromethorphan polistirex 123
dextrose 10 % and 0.2 % nacl
.......................................... 195
...................................... 89, 90
............................................ 90
............................................ 90
............................................ 90
dextrose 5 % in ringers ........... 90
dextrose 5 % in water (d5w) .. 90
dextrose 5 %-lactated ringers195
dextrose 5%-0.2 % sod chloride
.......................................... 195
dextrose 5%-0.3 % sod.chloride
.......................................... 195
............................................ 90
............................................ 90
dextrose with sodium chloride
.......................................... 195
dextrose-kcl-nacl .................. 195
diabetic tussin dm ................. 123
diamode ................................ 156
diazepam ................................ 18
diazepam intensol ................... 18
diclofenac potassium .............. 12
diclofenac sodium .... 12, 13, 151
diclofenac-misoprostol ........... 13
dicloxacillin ............................ 27
dicyclomine .......................... 156
didanosine .............................. 76
DIFICID ................................. 24
I-7
diflunisal ................................ 13
digitek .................................... 99
digox ...................................... 99
digoxin ........................... 99, 100
DIGOXIN .............................. 99
dihydroergotamine ................. 65
DILANTIN ............................ 42
diltiazem hcl ..................... 97, 98
dilt-xr...................................... 98
dimaphen (pe) ........................ 61
dimenhydrinate ...................... 67
dimetapp cold-congestion ...... 61
dino-life ................................ 217
dino-life with extra c ............ 216
dino-life with iron-zinc ........ 216
DIPENTUM ......................... 183
diphenhist ......................... 61, 62
diphenhydramine hcl .............. 62
diphenoxylate-atropine 156, 157
dipyridamole .......................... 86
disopyramide phosphate......... 95
disulfiram ............................... 16
divalproex .............................. 42
dobutamine........................... 100
dobutamine in d5w............... 100
doc-q-lace ............................. 161
docu ...................................... 161
docusate sodium ................... 161
docusol ................................. 161
dofetilide ................................ 95
dok........................................ 161
donepezil .......................... 45, 46
dopamine .............................. 100
dopamine in 5 % dextrose .... 100
dorzolamide.......................... 192
dorzolamide-timolol............. 192
douche vinegar and water extra
.......................................... 190
doxazosin ............................... 92
doxepin................................... 47
doxercalciferol ..................... 184
doxorubicin, peg-liposomal ... 32
doxy-100 ................................ 29
doxycycline hyclate................ 29
doxycycline monohydrate ...... 30
dramamine .............................. 67
dramamine less drowsy .......... 67
driminate ................................ 67
dristan long lasting ............... 145
dronabinol .............................. 67
droperidol ............................. 186
drospirenone-ethinyl estradiol
.......................................... 112
DROXIA ................................ 33
DUAVEE ............................. 168
dulcolax stool softener (dss) 161
DULERA ............................. 203
duloxetine ............................... 47
DUREZOL ........................... 151
dutasteride ............................ 187
dutasteride-tamsulosin ......... 187
DYRENIUM ........................ 103
E
e.c. prin ................................... 13
e.e.s. 400................................. 24
e.e.s. granules ......................... 24
econazole ................................ 56
econtra ez ............................. 112
ed a-hist .................................. 62
ed bron gp............................. 123
ed chlorped jr ......................... 62
EDURANT............................. 76
effer-k ................................... 195
EFFIENT ................................ 86
ELAPRASE ......................... 142
eldertonic .............................. 217
electrolyte-48 in d5w ........... 196
ELIDEL ................................ 137
ELIGARD .............................. 33
elinest ................................... 112
eliphos .................................. 165
ELIQUIS ................................ 82
ELITEK ................................ 142
ELLA ................................... 112
ellis tonic .............................. 217
ELMIRON............................ 187
elon dual defense .................... 56
EMCYT .................................. 33
EMEND.................................. 67
emoquette ............................. 112
EMPLICITI ............................ 33
EMSAM ................................. 47
EMTRIVA.............................. 76
EMVERM .............................. 69
enalapril maleate .................... 94
enalaprilat ............................... 94
enalapril-hydrochlorothiazide 94
ENBREL .............................. 174
ENBREL SURECLICK ....... 174
endocet ..................................... 5
endodan .................................... 5
endur-acin ............................. 104
enema ........................... 161, 164
enema disposable ................. 161
enemeez ................................ 162
enemeez plus ........................ 162
ENGERIX-B (PF) ................ 178
.......................................... 178
enoxaparin .............................. 82
enpresse ................................ 112
enskyce ................................. 112
entacapone .............................. 70
entecavir ................................. 81
entre-cough ........................... 123
ENTRESTO ........................... 93
enulose.................................. 157
ENVARSUS XR .................. 174
EPCLUSA .............................. 80
ephedrine sulfate .................. 100
epinastine.............................. 145
epinephrine ................... 100, 101
epinephrine hcl (pf) .............. 100
EPIPEN 2-PAK .................... 101
EPIPEN JR 2-PAK............... 101
epitol ....................................... 42
I-8
EPIVIR HBV ......................... 76
eplerenone ............................ 106
EPOGEN ................................ 84
epoprostenol (glycine) ......... 209
EPZICOM .............................. 76
eq gentle ............................... 145
equalactin ............................. 162
ergocalciferol (vitamin d2) . 217,
231
ergoloid ................................ 187
ERGOMAR............................ 65
ERIVEDGE............................ 33
errin ...................................... 112
ery pads ................................ 134
ery-tab .................................... 24
ERY-TAB .............................. 25
ERYTHROCIN ...................... 25
erythrocin (as stearate) ........... 25
erythromycin .................. 25, 148
erythromycin ethylsuccinate .. 25
erythromycin with ethanol ... 134
ESBRIET ............................. 207
escitalopram oxalate............... 47
esmolol ................................... 96
esomeprazole sodium ........... 153
essentia ................................. 217
essential balance with lutein 218
essential daily ....................... 218
estarylla ................................ 112
ESTRACE ............................ 168
estradiol ................................ 168
estradiol valerate .................. 168
estradiol-norethindrone acet. 168
estropipate ............................ 168
eszopiclone........................... 208
ethambutol.............................. 66
ethamolin.............................. 101
ethosuximide .......................... 42
etodolac .................................. 13
ETOPOPHOS ........................ 33
etoposide ................................ 33
EVOTAZ................................ 76
exemestane ............................. 33
EXJADE............................... 166
expectorant ........................... 123
expectorant dm ..................... 123
expectorant max strength ..... 123
EXTAVIA ............................ 187
extra cleansing douche ......... 189
eye health plus lutein............ 217
F
FABRAZYME ..................... 142
falmina (28) .......................... 112
famciclovir ............................. 81
famotidine .................... 153, 154
famotidine (pf) ..................... 153
famotidine (pf)-nacl (iso-os) 153
FANAPT ................................ 72
FARESTON ........................... 33
FARYDAK ............................ 33
FASLODEX ........................... 33
felbamate ................................ 42
felodipine ............................. 102
feminine care douche ........... 189
FEMRING ............................ 168
fenofibrate ............................ 105
fenofibrate micronized ......... 104
fenofibrate nanocrystallized . 104
fenofibric acid ...................... 105
fenofibric acid (choline) ....... 105
fenoprofen .............................. 13
fentanyl..................................... 5
fentanyl citrate.......................... 5
ferocon ................................. 218
ferretts .................................. 218
ferrex 150 ............................. 218
ferrex 150 plus ..................... 218
FERRIPROX ........................ 166
ferrocite ................................ 218
ferrous fumarate ................... 218
ferrous gluconate .......... 218, 220
ferrous sulfate ............... 214, 218
FETZIMA .............................. 48
feverall ..................................... 5
fexofenadine ........................... 62
fiber (calcium polycarbophil)
.......................................... 162
fiber laxative (methylcellulo)164
fiber smooth ......................... 164
fiber therapy (m-cell/sugar).. 162
fiber therapy (m-cellulose) ... 161
fiber therapy (psyllium)........ 162
fiber therapy (psyllium/sugar)
.......................................... 162
fiber-lax ................................ 162
fibertab ................................. 162
finasteride ............................. 187
FIRAZYR ............................. 101
flanax antacid ....................... 157
FLEBOGAMMA DIF .......... 174
flecainide ................................ 95
FLECTOR .............................. 13
FLEET BISACODYL .......... 162
flintstones complete (iron) ... 219
flintstones multivitamin ....... 219
flintstones with iron.............. 219
flintstones/extra c ................. 219
FLOVENT DISKUS ............ 203
FLOVENT HFA........... 203, 204
floxuridine .............................. 33
flu formula daytime-nighttime
.......................................... 126
flu relief therapy daytime ..... 125
flu severe cold-congestion.... 128
flucaine ................................. 145
fluconazole ............................. 56
fluconazole in dextrose(iso-o) 56
fluconazole in nacl (iso-osm) . 56
flucytosine .............................. 56
fludrocortisone ..................... 169
flumazenil ............................. 109
flunisolide ............................. 151
fluocinonide.......................... 137
fluocinonide-e ...................... 137
fluorometholone ................... 151
fluorouracil ..................... 33, 133
I-9
fluoxetine ............................... 48
fluphenazine decanoate .......... 72
fluphenazine hcl ..................... 73
flurbiprofen ............................ 13
flurbiprofen sodium ............. 151
flutamide ................................ 34
fluticasone .................... 137, 151
fluvoxamine ........................... 48
foaming antacid ............ 157, 160
folic acid............................... 219
FOLIC ACID ....................... 219
fomepizole............................ 187
fondaparinux .......................... 82
foot odor control .................... 58
FORTEO .............................. 184
FORTICAL .......................... 184
foscarnet ................................. 79
fosfree .................................. 219
fosinopril ................................ 94
fosinopril-hydrochlorothiazide
............................................ 94
fosphenytoin ........................... 42
FREAMINE HBC 6.9 %........ 90
FREAMINE III 10 % ............. 90
fungi cure ............................... 56
FUNGI-NAIL ........................ 56
fungoid-d ................................ 56
furosemide............................ 103
FUSILEV ............................. 187
FUZEON ................................ 76
FYCOMPA ...................... 42, 43
G
gabapentin .............................. 43
GABITRIL ............................. 43
galantamine ............................ 46
GAMASTAN S/D ................ 174
GAMMAGARD LIQUID .... 175
GAMMAPLEX .................... 175
ganciclovir sodium ................. 82
GARDASIL (PF) ................. 178
GARDASIL 9 (PF) .............. 178
gas relief ............................... 152
gas relief extra strength ........ 152
gas-x ultra-strength .............. 152
gatifloxacin........................... 148
GATTEX 30-VIAL .............. 157
GATTEX ONE-VIAL.......... 157
GAUZE PAD ....................... 187
gavilyte-c .............................. 162
gavilyte-g ............................. 162
gavilyte-n ............................. 162
GAZYVA ............................... 34
gelusil antacid and anti-gas .. 157
gemfibrozil ........................... 105
generlac ................................ 157
gengraf ................................. 175
GENOTROPIN .................... 171
GENOTROPIN MINIQUICK
.......................................... 170
gentak ................................... 148
gentamicin ...... 18, 134, 135, 148
gentamicin in nacl (iso-osm) .. 18
gentamicin sulfate (ped) (pf) .. 18
gentamicin sulfate (pf) ........... 18
GENTEAL MILD TO
MODERATE ................... 145
GENTEAL GEL .................. 145
GENTEAL MILD ................ 145
GENTEAL SEVERE ........... 145
genteal tears.......................... 145
gentlelax ............................... 162
GENVOYA ............................ 76
GEODON ............................... 73
geravim................................. 219
geriaton................................. 219
geri-hydrolac ........................ 133
geri-tussin dm ....................... 123
gianvi (28) ............................ 112
gildagia ................................. 112
gildess 1.5/30 (21) ................ 113
gildess 1/20 (21) ................... 113
gildess 24 fe ......................... 113
gildess fe 1.5/30 (28) ............ 113
gildess fe 1/20 (28) ............... 113
GILENYA ............................ 187
GILOTRIF.............................. 34
GLEOSTINE .......................... 34
glimepiride ............................. 53
glipizide .................................. 53
glipizide-metformin................ 54
GLUCAGEN HYPOKIT ..... 187
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 187
gluco burst .............................. 90
glucose.................................... 90
glucose gel .............................. 90
glutose 15 ............................... 90
glyburide ................................ 54
glyburide micronized ............. 54
glyburide-metformin .............. 54
glycolax ................................ 162
glycopyrrolate ...................... 157
glydo ....................................... 15
GLYXAMBI .......................... 50
granisetron (pf) ....................... 68
granisetron hcl ........................ 68
GRANIX ................................ 84
griseofulvin microsize ............ 56
guaifenesin ........................... 123
guaifenesin dac ..................... 123
guanfacine ...................... 92, 109
guanidine .............................. 187
gummi bear multivitamin .... 219,
224
gummy swirls ....................... 215
H
hair vitamins ......................... 219
hair,skin and nails......... 227, 229
halobetasol propionate ......... 138
haloperidol.............................. 73
haloperidol decanoate............. 73
haloperidol lactate .................. 73
HARVONI ............................. 80
HAVRIX (PF) ...................... 179
head congestion day-night.... 123
healthy eyes .......................... 219
I-10
healthylax ............................. 162
heather .................................. 113
hemocyte .............................. 219
heparin (porcine) .................... 83
heparin (porcine) in 5 % dex .. 83
heparin (porcine) in nacl (pf) . 83
heparin(porcine) in 0.45% nacl
............................................ 83
heparin, porcine (pf)............... 83
HEPATAMINE 8% ............... 91
HEPATASOL 8 % ................. 91
HERCEPTIN.......................... 34
HETLIOZ ............................. 208
HEXALEN ............................. 34
hi-b complex ........................ 220
hi-cal plus vit d..................... 201
homatropaire ........................ 145
homatropine hbr ................... 145
honey bears .......................... 220
honey bears with iron-zinc ... 220
HUMIRA ............................. 175
HUMIRA PEN ..................... 175
HUMIRA PEN CROHN'S-UCHS START ....................... 175
HUMULIN R U-500 (CONC)
KWIKPEN ......................... 52
HUMULIN R U-500
(CONCENTRATED) ......... 52
hydralazine ........................... 101
hydrochlorothiazide ............. 103
hydrocil instant..................... 162
hydrocodone-acetaminophen 5, 6
hydrocodone-chlorpheniramine
.......................................... 123
hydrocodone-homatropine ... 123
hydrocodone-ibuprofen ............ 6
hydrocortisone.............. 138, 169
hydrocortisone acet-aloe vera
.......................................... 138
hydrocortisone acetate ......... 138
hydrocortisone butyrate ....... 138
hydrocortisone butyr-emollient
.......................................... 138
hydrocortisone valerate ........ 139
hydromet .............................. 124
hydromorphone ........................ 6
hydromorphone (pf) ................. 6
hydroskin .............................. 138
hydroxychloroquine ............... 69
hydroxyprogesterone caproate
.......................................... 172
hydroxyurea ........................... 34
hydroxyzine hcl .................... 187
hydroxyzine pamoate ........... 187
HYPERLYTE CR ................ 196
HYPERRAB S/D (PF) ......... 175
HYQVIA .............................. 175
HYQVIA IG COMPONENT
.......................................... 175
HYSINGLA ER ....................... 6
I
ibandronate ........................... 184
IBRANCE .............................. 34
ibuprofen .................... 12, 13, 14
ibuprofen jr strength ............... 13
icaps plus .............................. 220
ICLUSIG ................................ 34
iferex 150 ............................. 220
ifosfamide............................... 34
ifosfamide-mesna ................... 34
ILARIS (PF) ......................... 175
ILEVRO ............................... 151
imatinib .................................. 34
IMBRUVICA ......................... 34
imipenem-cilastatin ................ 25
imipramine hcl ....................... 48
imipramine pamoate ............... 48
imiquimod ............................ 133
IMLYGIC......................... 34, 35
imodium a-d ......................... 157
IMODIUM A-D ................... 157
IMOGAM RABIES-HT (PF)
.......................................... 175
IMOVAX RABIES VACCINE
(PF) ................................... 179
INCRELEX .......................... 171
indapamide ........................... 103
indomethacin .......................... 13
indomethacin sodium ............. 13
INFANRIX (DTAP) (PF) .... 179
infant's ibuprofen .................... 14
INFANT'S MOTRIN ............. 14
infants' non-aspirin cold ....... 130
INLYTA ................................. 35
insta-glucose ........................... 91
INSULIN SYRINGE-NEEDLE
U-100................................ 141
INTELENCE .......................... 77
INTRALIPID ......................... 91
INTRON A ....................... 80, 81
introvale................................ 113
INVANZ ................................ 25
INVEGA SUSTENNA........... 73
INVEGA TRINZA ................. 73
INVIRASE ............................. 77
INVOKAMET........................ 50
INVOKANA .......................... 50
inzo antifungal ........................ 56
iodine .................................... 141
IONOSOL-B IN D5W ......... 196
IONOSOL-MB IN D5W ...... 196
IPOL ..................................... 179
ipratropium bromide..... 145, 204
ipratropium-albuterol ........... 205
IPRIVASK ............................. 83
irbesartan ................................ 93
irbesartan-hydrochlorothiazide
............................................ 93
IRESSA .................................. 35
iron high potency.................. 215
ISENTRESS ........................... 77
ISOLYTE M IN 5 %
DEXTROSE ..................... 196
ISOLYTE-H IN 5 %
DEXTROSE ..................... 196
I-11
ISOLYTE-P IN 5 %
DEXTROSE ..................... 196
ISOLYTE-S ......................... 196
isoniazid ................................. 66
isopto tears ........................... 146
isosorbide dinitrate ............... 107
isosorbide mononitrate ......... 107
isradipine .............................. 102
itraconazole ............................ 56
ivermectin .............................. 69
IXEMPRA.............................. 35
IXIARO (PF) ....................... 179
J
JAKAFI .................................. 35
jantoven .................................. 83
JANUMET ............................. 50
JANUMET XR ...................... 50
JANUVIA .............................. 51
JARDIANCE ......................... 51
jencycla ................................ 113
JENTADUETO ...................... 51
JENTADUETO XR ............... 51
jolessa ................................... 113
jolivette ................................ 113
jr. acetaminophen ................... 10
juleber .................................. 113
junel 1.5/30 (21) ................... 113
junel 1/20 (21) ...................... 113
junel fe 1.5/30 (28) ............... 113
junel fe 1/20 (28) .................. 113
junel fe 24 ............................ 113
junior mapap ............................ 6
JUXTAPID .......................... 105
K
KABIVEN.............................. 91
KALETRA ............................. 77
KALYDECO........................ 207
KANUMA............................ 142
kaopectate (bismuth subsalicy)
.......................................... 157
kariva (28) ............................ 113
k-effervescent ....................... 197
kelnor 1/35 (28) .................... 113
KELP (IODINE) .................. 197
ketoconazole........................... 56
ketoprofen .............................. 14
ketorolac ......................... 14, 151
KEVEYIS............................. 187
KEYTRUDA .......................... 35
kids mini enema ................... 161
kid's vitamins ....................... 224
kid's vitamins + extra c ........ 224
kids vitamins + iron ............. 224
kid's vitamins + iron ............. 224
kimidess (28) ........................ 113
KINERET............................. 176
KINRIX (PF)........................ 179
kionex ................................... 157
klor-con 10 ........................... 197
klor-con m10 ........................ 197
klor-con m15 ........................ 197
klor-con m20 ........................ 197
klor-con sprinkle .................. 197
konsyl (sugar) ....................... 163
konsyl fiber .......................... 163
KONSYL SUGAR-FREE .... 162
KORLYM .............................. 51
KRYSTEXXA ..................... 142
kurvelo ................................. 114
KUVAN ............................... 142
KYNAMRO ......................... 105
KYPROLIS ............................ 35
L
l norgest/e.estradiol-e.estrad 114
labetalol .................................. 96
LACRISERT ........................ 146
LACTATED RINGERS ...... 183
LACTINOL HX ................... 133
lactulose ............................... 158
LAMICTAL ........................... 43
LAMISIL (AEROSOL) ......... 57
lamisil af................................. 57
LAMISIL AT ......................... 57
lamivudine.............................. 77
lamivudine-zidovudine........... 77
lamotrigine ............................. 43
LANOXIN............................ 101
lansoprazole.......................... 153
LANTUS ................................ 53
LANTUS SOLOSTAR .......... 52
larin 1.5/30 (21) .................... 114
larin 1/20 (21) ....................... 114
larin 24 fe ............................. 114
larin fe 1.5/30 (28)................ 114
larin fe 1/20 (28)................... 114
latanoprost ............................ 192
LATUDA ............................... 73
laxative peg 3350 ................. 164
LAZANDA .............................. 6
leena 28 ................................ 114
leflunomide .......................... 176
LEMTRADA........................ 188
LENVIMA ............................. 35
lessina ................................... 114
LETAIRIS ............................ 209
letrozole .................................. 35
leucovorin calcium ............... 188
LEUKERAN .......................... 35
LEUKINE .............................. 84
leuprolide................................ 36
levetiracetam .......................... 43
levobunolol ........................... 192
levocarnitine ......................... 188
levocarnitine (with sugar) .... 188
levocetirizine .......................... 62
levofloxacin .................... 28, 148
levofloxacin in d5w ................ 28
levonest (28) ......................... 114
levonorgestrel ....................... 114
levonorgestrel-ethinyl estrad 114
levonorg-eth estrad triphasic 114
levora-28 .............................. 115
levothyroxine........................ 173
LEXIVA ................................. 77
lice cream rinse .................... 140
lice killing............................. 140
I-12
lice treatment ........................ 140
lice treatment (permethrin) .. 140
lidocaine ................................. 15
lidocaine (pf) .................... 15, 95
lidocaine hcl ........................... 15
lidocaine in 5 % dextrose (pf) 95
lidocaine viscous .................... 15
lidocaine-prilocaine................ 15
life-pack women's ................ 220
linezolid.................................. 20
LINZESS.............................. 158
liothyronine .......................... 173
lipodox ................................... 36
lipodox 50 .............................. 36
liquibid d-r ........................... 124
liquid calcium with vitamin d
.......................................... 197
LIQUI-E ............................... 220
lisinopril ................................. 94
lisinopril-hydrochlorothiazide 94
lithium carbonate ................. 109
lithium citrate ....................... 109
little animals ......................... 220
little animals-iron ................. 220
lobana bath ........................... 133
lohist-dm .............................. 124
lomedia 24 fe........................ 115
lomustine ................................ 36
LONSURF ............................. 36
loperamide............ 156, 158, 159
loratadine................................ 62
loratadine-d ............................ 62
lorazepam ............................... 18
lorcet (hydrocodone) ................ 6
lorcet hd ................................... 6
lorcet plus ................................. 6
lortuss ex .............................. 124
loryna (28) ............................ 115
losartan ................................... 93
losartan-hydrochlorothiazide . 93
LOTEMAX .......................... 151
LOTRONEX ........................ 158
lovastatin .............................. 105
low-ogestrel (28) .................. 115
loxapine succinate .................. 74
lubricant dry eye relief ......... 144
lubricant eye ......................... 144
lubricant eye (cmc-glycer)(pf)
.......................................... 146
lubricant eye (cmc-glycerin) 146
lubricant eye (pg-peg 400) ... 147
lubricant eye (polyv alcohol) 147
lubricant eye (propyl glycol) 146
lubricant eye drops ............... 144
lubricant gel.......................... 144
lubricating drops .................. 144
lubrifresh pm ........................ 146
LUMIGAN ........................... 192
LUPRON DEPOT .................. 36
............................................ 36
............................................ 36
............................................ 36
LUPRON DEPOT-PED ....... 171
LUPRON DEPOT-PED (3
MONTH) .......................... 171
lutera (28) ............................. 115
LYNPARZA .......................... 36
LYRICA ................................. 43
lysiplex plus ......................... 220
LYSODREN .......................... 36
lyza ....................................... 115
M
maalox advanced .................. 158
MACUVITE......................... 220
MACUVITE EYE CARE .... 220
mag 64 .................................. 197
mag-delay ............................. 197
mag-g ................................... 197
MAGNEBIND 300 .............. 158
magnebind 400 ..................... 165
magnesium ................... 195, 197
magnesium (oxide/aa chelate)
.......................................... 197
magnesium chloride ............. 197
magnesium gluconate ........... 198
magnesium oxide ......... 158, 159
magnesium sulf in 0.45% nacl
.......................................... 198
magnesium sulfate ................ 198
magnesium sulfate in d5w .... 198
magnesium sulfate in water .. 198
malathion .............................. 140
mapap (acetaminophen) ....... 6, 7
mapap arthritis pain .................. 7
mapap extra strength ................ 7
maprotiline ............................. 48
mar-cof bp ............................ 124
mar-cof cg ............................ 124
margesic ................................... 7
marlissa ................................ 115
MARPLAN ............................ 48
masanti double strength........ 158
MATULANE ......................... 36
matzim la ................................ 98
maximum daily multivitamin
.......................................... 225
maximum strength flu .......... 126
meclizine ................................ 68
medroxyprogesterone ........... 172
mefenamic acid ...................... 14
mefloquine.............................. 69
MEFOXIN IN DEXTROSE
(ISO-OSM) ......................... 24
mega multiple/chelated mineral
.......................................... 221
mega multivitamin with mineral
.......................................... 221
MEGACE ES ....................... 172
megestrol ........................ 36, 172
MEKINIST ....................... 36, 37
meloxicam .............................. 14
memantine .............................. 46
MENACTRA (PF) ............... 179
I-13
MENEST.............................. 168
MENHIBRIX (PF) ............... 179
MENOMUNE - A/C/Y/W-135
(PF) .................................. 180
men's daily gummies ............ 215
men's multi-vitamin ............. 215
men's one daily..................... 217
MENVEO A-C-Y-W-135-DIP
(PF) .................................. 180
MENVEO MENA
COMPONENT (PF)......... 180
MENVEO MENCYW-135
COMPNT (PF) ................. 180
MEPHYTON ....................... 221
mercaptopurine ...................... 37
meropenem ............................. 25
mesehist dm ......................... 124
mesna ................................... 188
MESNEX ............................. 188
MESTINON ......................... 188
MESTINON TIMESPAN .... 188
metaproterenol ..................... 205
metaxall ................................ 207
metaxalone ........................... 207
metformin ............................... 51
methadone ................................ 7
methadose ................................ 7
methazolamide ..................... 192
methenamine hippurate .......... 20
methimazole ......................... 173
methocarbamol ..................... 207
methotrexate sodium .............. 37
methotrexate sodium (pf) ....... 37
methoxsalen rapid ................ 133
methscopolamine ................. 158
methyclothiazide .................. 104
methylphenidate ................... 109
methylprednisolone .............. 169
methylprednisolone acetate .. 169
methylprednisolone sodium succ
.................................. 169, 170
metipranolol ......................... 192
metoclopramide hcl .............. 158
metolazone ........................... 104
metoprolol succinate .............. 96
metoprolol ta-hydrochlorothiaz
............................................ 96
metoprolol tartrate .................. 96
metronidazole ........... 20, 65, 135
metronidazole in nacl (iso-os) 20
mexiletine ............................... 95
mgo....................................... 159
MIACALCIN ....................... 184
mi-acid ................................. 159
mi-acid gas relief .................. 152
micatin .................................... 57
miconazole 7 .......................... 57
miconazole nitrate ............ 56, 57
miconazole-3 .......................... 57
microgestin 1.5/30 (21) ........ 115
microgestin 1/20 (21) ........... 115
microgestin fe 1.5/30 (28) .... 115
microgestin fe 1/20 (28) ....... 115
midodrine ............................... 92
miglitol ................................... 51
milk of magnesia .................. 163
milltrium senior .................... 221
milrinone .............................. 101
milrinone in 5 % dextrose .... 101
mimvey................................. 168
mimvey lo ............................ 168
mineral oil .................... 189, 191
MINERAL OIL .................... 188
mineral oil laxative............... 163
minitran ................................ 107
minocycline ............................ 30
minoxidil .............................. 107
mintox .................................. 159
mintox maximum strength ... 159
mintox plus........................... 159
MIRCERA ............................. 84
mirtazapine ............................. 48
misoprostol ........................... 153
mitoxantrone .......................... 37
M-M-R II (PF)...................... 180
moexipril ................................ 94
moexipril-hydrochlorothiazide
............................................ 94
molindone ............................... 74
mometasone.......................... 139
MONISTAT 3 ........................ 57
monistat 7 ............................... 57
mono-linyah ......................... 115
mononessa (28) .................... 115
montelukast .......................... 204
morphine .............................. 7, 8
MORPHINE ............................. 8
morphine (pf) in 0.9 % nacl ..... 7
morphine concentrate ............... 7
morphine in dextrose 5 % ........ 8
morrhuate sodium................. 188
motion sickness ...................... 67
motion sickness (meclizine) ... 68
MOVANTIK ........................ 159
MOVIPREP.......................... 163
MOXEZA ............................. 149
moxifloxacin .......................... 29
MOZOBIL.............................. 84
mucus dm ............................. 124
mucus dm max ..................... 124
mucus relief .................. 124, 126
mucus relief cough ............... 128
MULTAQ ............................... 95
multi complete with iron ...... 221
multi-day with iron ............... 221
multi-delyn with iron............ 221
multiple vitamin-minerals .... 221
multiple vitamins.................. 221
multiple vitamins with iron .. 221
multi-symptom cold night time
.......................................... 126
multivital platinum ............... 224
multivitamin 50 plus ............ 224
multi-vitamin hp/minerals .... 221
multivitamin with fluoride ... 221
multivitamin with iron.. 221, 227
I-14
multivitamin with minerals .. 221
multi-vite .............................. 225
multi-vite 50 and over .......... 225
mupirocin ............................. 135
mupirocin calcium ............... 135
muro 128 .............................. 146
my favorite multiple ............. 221
my way ................................. 115
myco nail a ............................. 57
mycophenolate mofetil......... 176
mycophenolate sodium ........ 176
MYOZYME ......................... 142
MYRBETRIQ ...................... 165
mytab gas ............................. 152
mytab gas maximum strength
.......................................... 152
my-vitalife ............................ 222
myzilra ................................. 115
N
nabumetone ............................ 14
nadolol.................................... 97
nafcillin .................................. 27
NAGLAZYME .................... 142
naloxone ................................. 16
naltrexone............................... 16
NAMENDA XR..................... 46
NAMZARIC .......................... 46
naphazoline .......................... 146
naproxen ................................. 14
naproxen sodium .................... 14
naratriptan .............................. 65
NARCAN............................... 16
nasal and sinus decongestant 124
nasal decongestant (oxymetazl)
.......................................... 146
NASCOBAL ........................ 222
nasohist dm .......................... 124
NATACYN .......................... 149
nateglinide .............................. 51
NATPARA ........................... 185
natural b-100 ........................ 233
natural b-100 complex ......... 227
natural balance ..................... 146
natural calcium ..................... 198
natural fiber laxative therapy 163
natural tears (pf) ................... 144
nature's tears (hypromellose) 146
NEBUPENT ........................... 69
necon 0.5/35 (28) ................. 115
necon 1/35 (28) .................... 115
necon 1/50 (28) .................... 115
necon 10/11 (28) .................. 115
necon 7/7/7 (28) ................... 116
nefazodone ............................. 48
neomycin ................................ 18
neomycin-bacitracin-poly-hc 149
neomycin-bacitracin-polymyxin
.......................................... 149
neomycin-polymyxin b gu ... 135
neomycin-polymyxin bdexameth .......................... 149
neomycin-polymyxingramicidin ........................ 149
neomycin-polymyxin-hc ...... 149
neo-polycin........................... 149
neo-polycin hc ...................... 149
neosporin (neo-bac-polym) .. 135
neosporin anti-itch................ 139
neo-synephrine 12 h spr (oxym)
.......................................... 146
neo-tuss ................................ 124
nephplex rx........................... 222
NEPHRAMINE 5.4 % ........... 91
nephron fa ............................ 222
nephro-vite rx ....................... 222
NEULASTA........................... 84
NEUMEGA ............................ 84
NEUPOGEN .......................... 85
NEUPRO................................ 71
NEVANAC .......................... 151
nevirapine ............................... 77
NEXAFED ........................... 124
NEXAVAR ............................ 37
next choice one dose ............ 116
niacin .................................... 105
niacinamide .................. 105, 222
niacor .................................... 105
nicardipine ............................ 102
NICODERM CQ .................... 16
nicorelief ................................ 16
nicorette .................................. 16
nicotine ................................... 17
nicotine (polacrilex) ............... 17
NICOTROL............................ 17
nifedical xl ............................ 102
nifedipine...................... 102, 103
night time ............................. 125
night time cold-flu ................ 128
night time cold-flu relief ...... 128
night time cough-sore throat 124
nighttime cough .................... 124
nikki (28) .............................. 116
NILANDRON ........................ 37
nilutamide ............................... 37
NINLARO .............................. 37
NITE TIME COLD-FLU
RELIEF ............................ 124
nite time-d cold-flu relief ..... 124
NITRO-BID ......................... 107
nitrofurantoin macrocrystal .... 20
...................................... 20, 21
nitroglycerin ......................... 107
nitroglycerin in 5 % dextrose107
NITROSTAT........................ 107
NIX CREME RINSE ........... 140
nohist-dm.............................. 125
non-aspirin cold .................... 128
non-aspirin extra strength ... 8, 10
non-aspirin flu ...................... 130
non-aspirin jr strength .............. 5
nora-be.................................. 116
NORDITROPIN FLEXPRO 171
norepinephrine bitartrate ...... 101
norethindrone (contraceptive)
.......................................... 116
I-15
norethindrone acetate ........... 173
norethindrone ac-eth estradiol
.......................................... 116
norethindrone-e.estradiol-iron
.......................................... 116
norgestimate-ethinyl estradiol
.......................................... 116
norlyroc ................................ 116
NORMOSOL-M IN 5 %
DEXTROSE ..................... 198
NORMOSOL-R PH 7.4 ....... 198
nortemp .................................... 8
NORTHERA .......................... 92
nortrel 0.5/35 (28) ................ 116
nortrel 1/35 (21) ................... 116
nortrel 1/35 (28) ................... 116
nortrel 7/7/7 (28) .................. 116
nortriptyline...................... 48, 49
NORVIR .......................... 77, 78
NOVOLIN 70/30 ................... 53
NOVOLIN N ......................... 53
NOVOLIN R .......................... 53
NOVOLOG ............................ 53
NOVOLOG FLEXPEN ......... 53
NOVOLOG MIX 70-30 ......... 53
NOVOLOG MIX 70-30
FLEXPEN .......................... 53
NOVOLOG PENFILL ........... 53
NOXAFIL .............................. 57
NUCALA ............................. 207
NUCYNTA .............................. 9
NUCYNTA ER ........................ 8
NUEDEXTA ........................ 110
nu-iron .................................. 222
NULOJIX ............................. 176
nu-mag ................................. 198
NUPLAZID............................ 74
NUTRESTORE.................... 159
NUTRILIPID ......................... 91
NUTRILYTE ....................... 198
NUTRILYTE II ................... 198
NUVARING ........................ 116
NUVIGIL ............................. 208
nyamyc ................................... 57
nystatin ............................. 57, 58
nystatin-triamcinolone ........... 58
nystop ..................................... 58
nyt-time sleep ......................... 63
O
OCALIVA ............................ 159
ocean nasal ........................... 146
ocella .................................... 116
OCTAGAM ......................... 176
octreotide acetate.................. 171
ocutabs ................................. 222
ODEFSEY .............................. 78
ODOMZO .............................. 37
OFEV ................................... 207
ofloxacin......................... 29, 149
ogestrel (28) ......................... 116
olanzapine .............................. 74
olanzapine-fluoxetine ............. 49
olopatadine ........................... 146
OLYSIO ................................. 80
omega-3 acid ethyl esters ..... 105
omeprazole ........................... 153
omeprazole magnesium........ 153
omeprazole-sodium bicarbonate
.................................. 153, 154
ONCASPAR .......................... 37
oncovite ................................ 222
ondansetron ............................ 68
ondansetron hcl ...................... 68
ondansetron hcl (pf) ............... 68
one daily ............... 222, 223, 226
one daily 50 plus .................. 217
one daily complete ............... 222
one daily energy ................... 225
one daily essential 217, 219, 222
one daily maximum (with ca)
.......................................... 217
one daily multi-vit w-mineral
.......................................... 222
one daily multivitamin ......... 222
one daily multivit-iron(folic) 222
one daily plus iron 220, 222, 226
one daily plus minerals......... 223
one daily with iron ............... 223
one-a-day essential ............... 223
one-a-day maximum formula223
one-a-day teen advantage ..... 223
ONFI .............................. 18, 139
opcicon one-step................... 117
OPDIVO ................................. 37
OPSUMIT ............................ 209
opti-vitamins ........................ 227
oral saline laxative................ 163
oralone .................................. 131
ORENCIA ............................ 176
ORENCIA (WITH MALTOSE)
.......................................... 176
ORENCIA CLICKJECT ...... 188
ORENITRAM ...................... 209
ORFADIN .................... 142, 188
ORKAMBI ........................... 207
orsythia ................................. 117
OTEZLA .............................. 188
OTEZLA STARTER ........... 188
OTREXUP (PF) ................... 189
oxacillin .................................. 27
oxacillin in dextrose(iso-osm) 27
oxandrolone .......................... 167
oxcarbazepine ......................... 44
OXTELLAR XR .................... 44
oxybutynin chloride ............. 165
oxycodone ................................ 9
oxycodone-acetaminophen ....... 9
oxycodone-aspirin .................... 9
OXYCONTIN .......................... 9
oxymorphone...................... 9, 10
oysco 500/d .......................... 198
oysco d ................................. 199
oysco-500 ............................. 199
oyster shell calcium 500 ....... 199
oyster shell calcium with d ... 201
oyster shell calcium-vit d3 ... 199
I-16
oystercal-d ............................ 199
P
pacerone ................................. 95
pain relief ............................... 10
pain relief adult ........................ 5
pain reliever jr strength .......... 10
paliperidone............................ 74
pancrelipase 5000................. 142
PANRETIN .......................... 133
PANTILINERS .................... 189
pantoprazole ......................... 153
papaverine ............................ 102
paricalcitol............................ 185
paromomycin ......................... 70
paroxetine hcl ......................... 49
PASER ................................... 66
PATADAY .......................... 146
PAXIL .................................... 49
pecgen dmx .......................... 125
pedia relief ........................... 128
pedia relief cough-cold ........ 125
pedia relief infant ................. 130
pediacare multi-symptom cold
.......................................... 125
PEDIARIX (PF) ................... 180
pediatric electrolyte ..... 195, 199,
201, 202
pediatric freezer pops ........... 201
pediatric multivitamin .. 221, 226
PEDVAX HIB (PF) ............. 180
peg 3350-electrolytes ........... 163
PEGANONE .......................... 44
PEGASYS .............................. 81
PEGASYS PROCLICK ......... 81
peg-electrolyte soln .............. 163
PEGINTRON ......................... 81
PEN NEEDLE, DIABETIC . 141
penicillin g pot in dextrose ..... 27
penicillin g potassium ...... 27, 28
penicillin g procaine ............... 27
penicillin v potassium ............ 28
PENTACEL (PF) ................. 180
PENTACEL ACTHIB
COMPONENT (PF) ......... 180
PENTAM ............................... 70
pentoxifylline ......................... 86
pep-t-med ............................. 158
peri-colace ............................ 163
PERIKABIVEN ..................... 91
perindopril erbumine .............. 94
periogard .............................. 131
permethrin ............................ 140
perphenazine .......................... 74
perphenazine-amitriptyline .... 49
persa-gel ............................... 133
pfizerpen-g ............................. 28
pharbetol................................. 10
pharmacist favorite multi-vit 223
phenadoz ................................ 68
phenelzine .............................. 49
phenobarbital .......................... 44
phenobarbital sodium ............. 44
phenylephrine hcl ........... 92, 146
phenylhistine dh ................... 125
phenytoin ................................ 44
phenytoin sodium ................... 44
phenytoin sodium extended ... 44
philith ................................... 117
phillips.................................. 159
phillips liqui-gels.................. 163
PHOSLYRA......................... 165
PHOS-NAK ......................... 199
phospha 250 neutral ............. 199
phosphate laxative ................ 163
PHOSPHOLINE IODIDE.... 192
phytonadione (vitamin k1) ... 233
PICATO ............................... 133
pilocarpine hcl .............. 131, 192
pimozide ................................. 74
pimtrea (28) .......................... 117
pindolol .................................. 97
pink bismuth......................... 159
pioglitazone ............................ 51
pioglitazone-glimepiride ........ 51
pioglitazone-metformin .......... 51
piperacillin-tazobactam .......... 28
pirmella ................................ 117
piroxicam................................ 14
PLAN B ONE-STEP ............ 117
PLASMA-LYTE 148 ........... 199
PLASMA-LYTE A .............. 199
PLASMA-LYTE-56 IN 5 %
DEXTROSE ..................... 199
PLEGRIDY .......................... 189
podocon ................................ 133
podofilox .............................. 133
polyethylene glycol 3350 .... 163,
164
poly-iron ............................... 223
polymyxin b sulfate ................ 21
polymyxin b sulf-trimethoprim
.......................................... 150
poly-tussin ............................ 125
poly-vita ............................... 223
poly-vita (iron) ..................... 223
poly-vitamin ......................... 223
poly-vitamin with iron.......... 223
poly-vitamins........................ 223
POMALYST .......................... 37
portia .................................... 117
PORTRAZZA ........................ 37
potassium acetate ................. 199
potassium bicarb and chloride
.......................................... 200
potassium bicarb-citric acid . 200
potassium chlorid-d5-0.45%nacl
.......................................... 200
potassium chloride ....... 200, 201
potassium chloride in 0.9%nacl
.......................................... 200
potassium chloride in 5 % dex
.......................................... 200
potassium chloride in lr-d5... 200
potassium chloride-0.45 % nacl
.......................................... 201
I-17
.......................................... 201
.......................................... 201
.......................................... 201
potassium citrate .................. 201
potassium citrate-citric acid . 201
potassium hydroxide ............ 133
potassium phosphate m-/d-basic
.......................................... 201
POTIGA ................................. 44
PRADAXA ............................ 83
PRALUENT PEN ................ 105
PRALUENT SYRINGE ...... 105
pramipexole............................ 71
pravastatin ............................ 106
prazosin .................................. 92
prednicarbate ........................ 139
prednisolone acetate ............. 151
prednisolone sodium phosphate
.................................. 151, 170
prednisone ............................ 170
PREMARIN ......................... 168
PREMASOL 10 % ................. 91
PREMASOL 6 % ................... 91
PREMPHASE ...................... 168
PREMPRO ........................... 169
prenatal ................. 219, 224, 227
prenatal formula ................... 224
prenatal plus (calcium carb) . 223
prenatal tablet ....................... 226
prenatal vit#96-ferrous fum-fa
.......................................... 223
prenatal vitamin ........... 215, 223
prenatal vitamin plus low iron
.......................................... 224
prenatal vitamin with minerals
.......................................... 224
prenatal vit-iron fumarate-fa 224
preparation h hydrocortisone 139
PREVAIL BLADDER
CONTROL PAD .............. 161
prevalite ................................ 106
PREVIDENT 5000 SENSITIVE
.......................................... 131
previfem ............................... 117
PREZCOBIX ......................... 78
PREZISTA ............................. 78
PRIFTIN................................. 66
PRILOSEC OTC .................. 153
PRIMAQUINE....................... 70
primidone ............................... 44
PRISTIQ................................. 49
PRIVIGEN ........................... 176
PROAIR HFA ...................... 205
PROAIR RESPICLICK ....... 205
probenecid ............................ 189
procainamide .......................... 95
PROCALAMINE 3% ............ 91
prochlorperazine..................... 68
prochlorperazine edisylate ..... 68
prochlorperazine maleate ....... 68
PROCRIT ............................... 85
procto-med hc ...................... 139
procto-pak ............................ 139
proctosol hc .......................... 139
proctozone-hc ....................... 139
PROCYSBI .......................... 189
progesterone in oil ................ 173
progesterone micronized ...... 173
PROGLYCEM ..................... 108
PROGRAF ........................... 176
PROLASTIN-C .................... 207
PROLENSA ......................... 151
PROLEUKIN ......................... 37
PROLIA ............................... 185
PROMACTA ......................... 85
promethazine .................... 62, 68
promethazine vc-codeine ..... 125
promethazine-codeine .......... 125
promethazine-dm ................. 125
promethegan ........................... 69
promolaxin ........................... 164
propafenone ............................ 95
propantheline .......................... 41
proparacaine ......................... 146
propranolol ............................. 97
propranolol-hydrochlorothiazid
............................................ 97
propylthiouracil .................... 173
PROQUAD (PF) .................. 180
prosight ................................. 224
PROSOL 20 % ....................... 91
protamine................................ 85
protriptyline ............................ 49
pseudoephedrine hcl ............. 125
PULMOZYME .................... 142
pure and gentle eye....... 146, 147
purelax .................................. 161
PURIXAN .............................. 38
pyrazinamide .......................... 66
pyridostigmine bromide ....... 189
pyridoxine (vitamin b6)........ 225
Q
q-dryl ...................................... 63
q-pap ....................................... 10
q-pap extra strength ................ 10
q-tapp dm ............................. 125
q-tussin ................................. 126
q-tussin dm ........................... 126
QUADRACEL (PF) ............. 181
quasense ............................... 117
quetiapine ............................... 74
QUILLIVANT XR ............... 110
quinapril ................................. 94
quinapril-hydrochlorothiazide 94
quinidine gluconate ................ 95
quinidine sulfate ..................... 95
quinine sulfate ........................ 70
QVAR .................................. 204
R
RABAVERT (PF) ................ 181
raloxifene.............................. 169
ramipril ................................... 94
I-18
RANEXA ............................. 102
ranitidine hcl ........................ 154
RAPAMUNE ....................... 176
RASUVO (PF) ..................... 189
RAVICTI ............................. 159
react ...................................... 117
REBIF (WITH ALBUMIN) 189
REBIF REBIDOSE .............. 190
REBIF TITRATION PACK 190
reclipsen (28) ....................... 117
RECOMBIVAX HB (PF) .... 181
recort plus............................. 139
refenesen .............................. 126
refenesen pe ......................... 126
REFRESH CELLUVISC ..... 147
REFRESH CLASSIC (PF) .. 147
REFRESH LACRI-LUBE ... 147
REFRESH OPTIVE ............. 147
REFRESH OPTIVE
ADVANCED ................... 150
reguloid ................................ 164
relcof c ................................. 126
RELENZA DISKHALER ...... 79
RELISTOR .......................... 159
remedy phytoplex antifungal . 58
REMICADE ......................... 190
REMODULIN...................... 210
RENAGEL ........................... 165
rena-vite rx ........................... 226
RENVELA ........................... 165
repaglinide.............................. 52
repaglinide-metformin ........... 52
REPATHA PUSHTRONEX 106
REPATHA SURECLICK .... 106
REPATHA SYRINGE ......... 106
reprexain ................................ 10
RESCRIPTOR ....................... 78
RESTASIS ........................... 151
retaine cmc ........................... 147
RETROVIR............................ 78
revive plus ............................ 145
REVLIMID ............................ 38
revonto ................................. 208
REXULTI............................... 74
REYATAZ ............................. 78
REZIRA ............................... 126
ribasphere ............................... 82
RIDAURA ........................... 176
rifabutin .................................. 66
rifampin ............................ 66, 67
RIFATER ............................... 67
ri-gel ii .................................. 159
riluzole ................................. 110
rimantadine............................. 79
ri-mox ................................... 160
ringers........................... 183, 201
risedronate ............................ 185
RISPERDAL CONSTA ......... 74
risperidone ........................ 74, 75
RITUXAN .............................. 38
rivastigmine ............................ 46
rivastigmine tartrate ............... 46
rizatriptan ............................... 65
robafen ................................. 126
robafen cough ....................... 126
robafen dm ........................... 126
robitussin cough-chest cong dm
.......................................... 127
ROBITUSSIN LONG-ACTING
.......................................... 127
robitussin pediatric ............... 127
ropinirole ................................ 71
rosadan ................................. 135
rosuvastatin .......................... 106
ROTARIX ............................ 181
ROTATEQ VACCINE ........ 181
roxicet..................................... 10
ROZEREM........................... 208
rydex..................................... 127
rynex dm .............................. 127
S
SABRIL ................................. 44
safe tussin dm ....................... 127
SAIZEN ............................... 171
SAIZEN CLICK.EASY ....... 171
saline mist............................. 147
SANDOSTATIN LAR DEPOT
.................................. 171, 172
SANTYL .............................. 133
SAPHRIS (BLACK CHERRY)
............................................ 75
SAVELLA............................ 110
scooby-doo one a day ........... 226
scot-tussin dm....................... 127
scot-tussin expectorant ......... 127
sea soft nasal mist................. 147
selegiline hcl........................... 71
selenium sulfide ................... 135
SELZENTRY ......................... 78
senexon ................................. 164
senior tabs............................. 226
senna ..................................... 164
senna lax ............................... 164
senna laxative ....................... 161
senna with docusate sodium . 161
senokot-s .............................. 164
SENSIPAR ........................... 190
sentry .................................... 226
sentry senior ......................... 226
SEREVENT DISKUS .......... 205
SEROSTIM .......................... 172
sertraline ................................. 49
setlakin ................................. 117
sharobel ................................ 117
SIGNIFOR ........................... 190
silace ..................................... 164
siladryl sa ............................... 63
silapap .................................... 10
sildenafil ............................... 210
SILENOR ............................... 49
siltussin sa ............................ 127
siltussin-dm .......................... 127
silver nitrate .......................... 135
silver sulfadiazine................. 135
SIMBRINZA ........................ 192
simethicone .......................... 152
I-19
simply sleep ........................... 63
SIMPONI ............................. 190
SIMPONI ARIA .................. 190
simvastatin ........................... 106
sinus and allergy(pseudoephed)
............................................ 63
sirolimus............................... 176
SIRTURO .............................. 67
skin treatment ....................... 132
sleep aid (diphenhydramine) .. 63
sleep aid (doxylamine) ........... 63
smoothlax ............................. 164
sodium acetate ...................... 202
sodium bicarbonate ...... 160, 202
sodium chloride ... 147, 183, 202,
207
sodium chloride 0.45 % ....... 202
sodium chloride 0.9 % ......... 202
sodium chloride 3 % ............ 202
sodium chloride 5 % ............ 202
sodium fluoride ............ 131, 228
sodium lactate ...................... 202
sodium phosphate................. 202
sodium polystyrene (sorb free)
.......................................... 160
sodium polystyrene sulfonate
.......................................... 160
sodium thiosulfate ................ 166
SOLTAMOX ......................... 38
SOLU-CORTEF (PF) .......... 170
SOMATULINE DEPOT ...... 172
SOMAVERT........................ 172
soothe (bismuth subsalicylate)
.......................................... 160
soothe regular strength ......... 160
sorbitol ................................. 183
sorbitol-mannitol .................. 183
sorine ...................................... 97
sotalol ..................................... 97
sotalol af ................................. 97
SOVALDI .............................. 80
spectravite ............................ 215
spectravite adult 50+ ............ 215
spectravite advanced formula
.......................................... 215
spectravite senior.................. 215
spectravite senior w-lycopene
.......................................... 215
spectravite ultra women ....... 215
SPIRIVA RESPIMAT ......... 205
SPIRIVA WITH
HANDIHALER ............... 205
spironolactone ...................... 106
spironolacton-hydrochlorothiaz
.......................................... 106
sprintec (28) ......................... 117
SPRITAM .............................. 45
SPRYCEL .............................. 38
sps......................................... 160
sronyx ................................... 117
ssd......................................... 135
st joseph aspirin ...................... 14
st. joseph aspirin ..................... 15
stavudine ................................ 78
STELARA ............................ 190
STERILE PADS .................. 190
STIOLTO RESPIMAT .......... 41
STIVARGA ........................... 38
stomach relief ....................... 160
stool softener ........................ 161
STRATTERA....................... 110
STRENSIQ........................... 142
streptomycin ........................... 19
stress 500 plus zinc .............. 224
stress b with zinc .................. 228
stress b-biotin ....................... 228
stress formula ....................... 228
stress formula plus iron ........ 228
stress formula with iron........ 228
stress formula with zinc ....... 228
STRIBILD .............................. 78
STRIVERDI RESPIMAT .... 205
sucralfate .............................. 154
sudafed ................................. 128
sudogest ................................ 128
sudogest sinus and allergy ...... 63
sulfacetamide sodium ........... 150
sulfacetamide sodium (acne) 135
sulfacetamide-prednisolone.. 150
sulfadiazine ............................ 29
sulfamethoxazole-trimethoprim
............................................ 29
sulfasalazine ........................... 29
sulfatrim ................................. 29
sulindac .................................. 15
sumatriptan ............................. 65
sumatriptan succinate ....... 65, 66
summer's eve disposable douche
.......................................... 190
summers eve extra cleansing 190
sunvite .................................. 228
super b complex-vitamin c .. 215,
227, 228
super b maxi complex .......... 228
super b/c ............................... 228
super b-50 complex .............. 228
super b-50 complex plus ...... 228
super multiple ....................... 229
super multivitamin ............... 229
super quints .......................... 229
super quints b-50 .................. 229
super thera vite m ................. 229
superior 35 ............................ 229
superplex-t ............................ 229
suphedrin .............................. 128
suphedrine pe day-night ....... 128
suphedrine severe cold max str
.......................................... 128
support .................................. 229
support-500 .......................... 229
SUPPRELIN LA .................. 172
SUPRAX ................................ 24
SURMONTIL ........................ 49
SUSTIVA ............................... 78
SUTENT ................................ 38
syeda ..................................... 117
I-20
SYLATRON .......................... 81
SYLVANT ............................. 38
SYMLINPEN 120 .................. 52
SYMLINPEN 60 .................... 52
SYNAGIS .............................. 80
SYNAREL ........................... 191
SYNERCID............................ 21
SYNJARDY........................... 52
SYNRIBO .............................. 38
SYPRINE ............................. 166
SYSTANE (PROPYLENE
GLYCOL) ........................ 147
SYSTANE GEL ................... 147
T
tab-a-vite .............................. 229
tab-a-vite/iron ....................... 229
tab-a-vite-minerals ............... 229
TABLOID .............................. 38
tacrolimus ..................... 139, 176
tactinal .................................... 11
tactinal extra strength ............. 11
TAFINLAR ............................ 38
TAGRISSO ............................ 38
TALTZ AUTOINJECTOR .. 133
TALTZ SYRINGE............... 133
TAMIFLU .............................. 80
tamoxifen ............................... 38
tamsulosin ............................ 166
TARCEVA ............................. 38
TARGRETIN ......................... 39
tarina fe 1/20 (28)................. 117
TASIGNA .............................. 39
tazicef ..................................... 24
TAZORAC ........................... 140
taztia xt ................................... 98
tears again ............................ 147
tears again (pva) ................... 147
tears naturale free (pf) .......... 147
TECENTRIQ ......................... 39
TECFIDERA........................ 191
TECHNIVIE .......................... 80
TEFLARO.............................. 24
telmisartan .............................. 93
telmisartan-hydrochlorothiazid
............................................ 93
TEMODAR ............................ 39
tencon ..................................... 11
TENIVAC (PF) .................... 181
terazosin ............................... 166
terbinafine hcl ........................ 58
terbutaline............................. 205
terconazole ............................. 65
testosterone........................... 167
testosterone cypionate .......... 167
testosterone enanthate .......... 167
TETANUS
TOXOID,ADSORBED (PF)
.......................................... 181
TETANUS,DIPHTHERIA TOX
PED(PF) ........................... 181
tetanus-diphtheria toxoids-td 181
tetrabenazine ........................ 110
tetracaine hcl (pf) ................. 148
tetracycline ............................. 30
THALOMID ........................ 191
the magic bullet .................... 163
theochron .............................. 205
theophylline .......................... 206
theophylline in dextrose 5 % 206
thera m plus (ferrous fumarat)
.......................................... 229
thera vitamin ........................ 229
thera-d .................................. 229
theradex m ............................ 229
THERAFLU DAYTIME
COLD-COUGH ............... 128
THERAFLU MULTISYMPTOM COLD .......... 128
thera-m ......................... 229, 230
therapeutic liquid.................. 220
therapeutic m + beta-carotene
.......................................... 226
therapeutic-m ....................... 230
therapeutic-m vitamin/minerals
.......................................... 227
thera-tabs .............................. 230
theratrum complete 50 plus .. 230
theratrum complete 50 plus/lut
.......................................... 230
thiamine hcl (vitamin b1) ..... 230
thioridazine ............................. 75
thiotepa ................................... 39
thiothixene .............................. 75
tiagabine ................................. 45
TICE BCG ............................ 177
TIKOSYN .............................. 95
tilia fe ................................... 117
timolol maleate ............... 97, 192
TIVICAY ............................... 78
tizanidine .............................. 208
TOBI PODHALER ................ 19
TOBRADEX ........................ 150
TOBRADEX ST .................. 150
tobramycin............................ 150
tobramycin in 0.225 % nacl ... 19
tobramycin in 0.9 % nacl ....... 19
tobramycin sulfate .................. 19
tobramycin-dexamethasone.. 150
TOLAK ................................ 133
tolazamide .............................. 54
tolbutamide ............................. 54
tolmetin .................................. 15
tolnaftate ................................. 58
tolterodine ............................ 165
topiragen ................................. 45
topiramate ............................... 45
toposar .................................... 39
torsemide .............................. 104
total b/c ................................. 230
totalday multiple................... 230
TOUJEO SOLOSTAR ........... 53
TOVIAZ ............................... 165
TPN ELECTROLYTES ....... 202
TPN ELECTROLYTES II ... 202
TRACLEER ......................... 210
I-21
TRADJENTA ........................ 52
tramadol ................................. 11
tramadol-acetaminophen ........ 11
trandolapril ............................. 94
tranexamic acid ...................... 85
TRANSDERM-SCOP............ 69
tranylcypromine ..................... 49
TRAVASOL 10 % ................. 91
TRAVATAN Z .................... 192
travel sickness (meclizine) ..... 69
travoprost (benzalkonium) ... 192
trazodone ................................ 49
TREANDA ............................ 39
TRECATOR .......................... 67
TRELSTAR ........................... 39
tretinoin ................................ 140
tretinoin (chemotherapy) ........ 39
tretinoin microspheres .......... 140
TREXALL ............................. 39
triacting m-sym cold/cough . 130
triamcinolone acetonide ...... 131,
139, 170
triaminic cold and cough (pe)
.......................................... 129
TRIAMINIC COLD AND
COUGHNT(PE) ................. 63
TRIAMINIC COUGH-SORE
THROAT ......................... 129
triamterene-hydrochlorothiazid
.......................................... 104
trianex .................................. 139
TRIBENZOR ......................... 93
tri-buffered aspirin ................. 14
tri-dex pe .............................. 129
tri-estarylla ........................... 117
trifluoperazine ........................ 75
trifluridine ............................ 150
trihexyphenidyl ...................... 71
tri-legest fe ........................... 117
tri-linyah ............................... 117
tri-lo-estarylla ....................... 118
tri-lo-marzia ......................... 118
tri-lo-sprintec ........................ 118
trilyte with flavor packets .... 164
trimethoprim........................... 21
trimipramine ........................... 49
trinessa (28) .......................... 118
TRINTELLIX ........................ 50
triple antibiotic ............. 134, 135
triple paste af .......................... 58
tri-previfem (28) ................... 118
tri-sprintec (28) .................... 118
TRIUMEQ ............................. 79
tri-vi-sol ................................ 230
tri-vita ................................... 230
tri-vitamin............................. 230
trivora (28) ........................... 118
TROKENDI XR ..................... 45
TROPHAMINE 10 % ............ 91
TROPHAMINE 6% ............... 92
trospium ....................... 165, 166
TRULICITY........................... 52
TRUMENBA ....................... 181
TRUVADA ............................ 79
trymine cg ............................ 129
TUDORZA PRESSAIR ....... 206
tusnel diabetic ...................... 129
TUSNEL NEW FORMULA 129
TUSNEL PEDIATRIC ........ 129
TUSSI PRES-B .................... 129
tussin cf ........................ 128, 130
tussin cf cough-cold ............. 129
tussin cold-congestion .......... 129
tussin cough (dm only) ......... 122
tussin dm ...................... 126, 129
tussin dm cough and chest ... 122
tussin maximum strength ..... 122
tussin pe................................ 125
TWINRIX (PF) .................... 182
TYBOST .............................. 191
TYGACIL .............................. 30
TYKERB ................................ 39
TYPHIM VI ......................... 182
TYSABRI............................. 177
TYVASO.............................. 210
TYVASO REFILL KIT ....... 210
TYVASO STARTER KIT ... 210
TYZEKA ................................ 82
U
u-cort .................................... 139
ULORIC ............................... 191
ultra b-100 complex ............. 230
ultra fresh pm ....................... 148
ultra strength antacid ............ 155
unisom sleepgels .................... 63
UNITUXIN ............................ 40
UPTRAVI ............................ 210
ursodiol ................................. 160
V
VAGIFEM............................ 169
valacyclovir ............................ 82
VALCHLOR ........................ 134
valganciclovir ......................... 82
valproate sodium .................... 45
valproic acid ........................... 45
valproic acid (as sodium salt) . 45
valsartan ................................. 93
valsartan-hydrochlorothiazide 93
VALSTAR ............................. 40
valu-tapp dm......................... 127
VANACOF .......................... 129
vancomycin ............................ 21
vancomycin in dextrose 5 % .. 21
VAQTA (PF) ........................ 182
VARIVAX (PF) ................... 182
VASCEPA............................ 106
v-c forte ................................ 230
VELCADE ............................. 40
velivet triphasic regimen (28)
.......................................... 118
VENCLEXTA ........................ 40
VENCLEXTA STARTING
PACK ................................. 40
venlafaxine ............................. 50
VENTOLIN HFA................. 206
verapamil ................................ 98
I-22
VERSACLOZ ........................ 75
vestura (28) .......................... 118
VGO 40 ................................ 141
VIBERZI .............................. 160
vic-forte ................................ 230
vicks dayquil cold-flu relief . 129
vicks dayquil cough ............. 129
vicks nature fusion cough .... 129
vicks nyquil severe cold-flu . 129
vicks qlearquil(oxymetazoline)
.......................................... 148
vicks sinex 12-hour .............. 148
vicodin.................................... 11
vicodin es ............................... 11
vicodin hp............................... 11
VICTOZA .............................. 52
............................................ 79
............................................ 79
VIEKIRA PAK ...................... 80
vienva ................................... 118
VIGAMOX .......................... 150
VIIBRYD ............................... 50
VIMIZIM ............................. 143
VIMPAT ................................ 45
vinorelbine ............................. 40
viorele (28) ........................... 118
VIRACEPT ............................ 79
VIRAMUNE XR ................... 79
VIRAZOLE............................ 82
virdec dm ............................. 130
VIREAD ................................ 79
virt-phos 250 neutral ............ 203
virtussin ac ........................... 130
vision .................................... 231
vision formula (with lutein) 215,
231
vision plus lutein .................. 230
vit b complex-folic acid ....... 227
VITAFOL FE+ (WITH
DOCUSATE) ................... 231
vitalets .................................. 231
vitamin a............................... 231
vitamin b complex ........ 212, 225
vitamin b-100 complex ........ 215
vitamin b12-folic acid .......... 232
vitamin b-6 ........................... 232
vitamin c....................... 226, 232
vitamin d3 .................... 228, 232
vitamins and minerals .......... 231
vitamins b complex ...... 212, 231
vitamins for hair ................... 233
VITEKTA .............................. 79
vitrum senior ........................ 233
VOLTAREN .......................... 15
voriconazole ........................... 58
VOTRIENT ............................ 40
VPRIV .................................. 143
VRAYLAR ............................ 75
vyfemla (28) ......................... 118
W
wal-act d cold and allergy ...... 63
wal-dram ................................ 69
wal-dryl allergy ...................... 63
wal-fex allergy ....................... 63
wal-finate ............................... 64
wal-finate-d ............................ 64
wal-itin ................................... 64
wal-itin d ................................ 64
wal-itin d 12 hour ................... 64
wal-phed ......................... 64, 130
wal-phed pe day-night .......... 130
wal-phed pe sinus and allergy 64
wal-profen .............................. 15
wal-sleep z.............................. 64
wal-som (diphenhydramine) .. 64
wal-som (doxylamine) ........... 64
wal-tap .................................... 64
wal-tussin cough .................. 130
wal-tussin cough and cold cf 130
wal-tussin dm ....................... 119
wal-zan 75 ............................ 154
wal-zyr (cetirizine) ................. 64
wal-zyr d................................. 64
warfarin .................................. 83
water for irrigation, sterile.... 183
WELCHOL .......................... 106
wera (28) .............................. 118
womens daily gummies ........ 216
women's daily multivitamin . 225
X
XALKORI .............................. 40
XARELTO ............................. 84
XELJANZ ............................ 191
XELJANZ XR ...................... 191
XIFAXAN .............................. 21
XOLAIR ............................... 207
XTANDI ................................ 40
xulane ................................... 118
xylon 10 .................................. 11
XYREM ............................... 208
Y
yelets .................................... 233
YERVOY ............................... 40
YF-VAX (PF)....................... 182
YONDELIS ............................ 40
Z
zafirlukast ............................. 204
zaleplon ................................ 208
ZANTAC.............................. 154
ZANTAC 75......................... 154
zarah ..................................... 118
ZARXIO ................................. 85
ZAVESCA ........................... 143
zebutal .................................... 11
ZELBORAF ........................... 40
ZEMPLAR ........................... 185
zenatane ................................ 134
zenchent (28) ........................ 118
ZENPEP ............................... 143
ZEPATIER ............................. 80
zephrex-d .............................. 130
ZETIA .................................. 106
ZIAGEN ................................. 79
zidovudine .............................. 79
I-23
ZINBRYTA ......................... 191
zinc oxide ............................. 134
ziprasidone hcl ....................... 75
ZIRGAN .............................. 150
ZOLADEX ............................. 40
zoledronic acid ..................... 185
.......................................... 185
ZOLINZA .............................. 40
zolmitriptan ............................ 66
zolpidem ............................... 209
ZOMETA ............................. 185
ZONATUSS ......................... 130
zonisamide ............................. 45
zoo chews ............................. 233
ZORTRESS .......................... 177
ZOSTAVAX (PF) ................ 182
zovia 1/35e (28) ................... 118
zovia 1/50e (28) ................... 118
ZOVIRAX ............................ 134
z-sleep .............................. 62, 63
ZUBSOLV ............................. 17
ZYDELIG .............................. 40
ZYKADIA.............................. 41
ZYLET ................................. 150
zyncof ................................... 130
ZYPREXA RELPREVV ........ 75
ZYRTEC .......................... 64, 65
ZYTIGA ................................. 41
ZYVOX .................................. 21
Nou te fè dènye chanjman nan fòmilè sa a nan dat Out 31 2016. Si ou gen kesyon, tanpri rele ICS Community
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I-24
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