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
?
i
 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.
?
ii
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.
?
iii
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.
?
iv
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.
?
v
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
?
vi
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.
?
vii
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:
?
viii
 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.
?
ix
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?
?
x
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
?
xi
 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)
?
xii
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
Anticance r Agents .................................................................................................................................................. 30
Anticholinergic Agents .......................................................................................................................................... 40
Anticonvulsants ...................................................................................................................................................... 41
Antide mentia Agents ............................................................................................................................................. 45
Antidepressants ...................................................................................................................................................... 46
Antidiabetic Agents ................................................................................................................................................ 50
Antifungals.............................................................................................................................................................. 54
Antihistamines ........................................................................................................................................................ 58
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: 15
An vigè apati: 1 Jiyè 2016
1
Cardiovascular Agents .......................................................................................................................................... 92
Central Nervous System Agents ......................................................................................................................... 107
Contraceptives ...................................................................................................................................................... 109
Cough And Cold Products .................................................................................................................................. 118
Dental And Oral Agents ...................................................................................................................................... 130
Dermatological Agents......................................................................................................................................... 130
Devices................................................................................................................................................................... 140
Disinfectants (For Non-Dermatologic Use)........................................................................................................ 141
Enzyme Replacement/Modifiers ......................................................................................................................... 141
Eye, Ear, Nose, Throat Agents ............................................................................................................................ 142
Gastrointestinal Agents ....................................................................................................................................... 151
Genitourinary Agents .......................................................................................................................................... 164
Heavy Metal Antagonists .................................................................................................................................... 165
Hormonal Agents, Stimulant/Replacement/Modifying .................................................................................... 166
Immunological Agents ......................................................................................................................................... 172
Inflammatory Bowel Disease Agents.................................................................................................................. 182
Irrigating Solutions .............................................................................................................................................. 182
Metabolic Bone Disease Agents .......................................................................................................................... 183
Miscellaneous Therapeutic Agents ..................................................................................................................... 184
Ophthalmic Agents .............................................................................................................................................. 190
Replacement Preparations .................................................................................................................................. 192
Respiratory Tract Agents .................................................................................................................................... 202
Skeletal Muscle Relaxants ................................................................................................................................... 206
Sleep Disorder Agents.......................................................................................................................................... 207
Vasodilating Agents ............................................................................................................................................. 207
Vitamins And Minerals ....................................................................................................................................... 209
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
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$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 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
BELBUCA BUCCAL FILM 150
MCG, 300 MCG, 450 MCG, 600
MCG, 75 MCG, 750 MCG, 900
MCG
(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)
ST; QL (60 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
Tier level
What the
drug will
cost you
1
$0
1
$0
(Fioricet with
Codeine)
1
$0
(Tencon)
1
$0
(Esgic)
1
$0
(Esgic)
1
$0
(Fiorinal)
1
$0
2
$0
Name of Drug
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
(Buprenorphine
HCl)
(Fiorinal with
Codeine #3)
capacet oral capsule 50-325-40 mg
(Esgic)
1
$0
(Acetaminophen)
4
$0
(Infants' Tylenol)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Tylenol Sore
Throat)
4
$0
(Codeine Sulfate)
1
$0
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 *
children's silapap elixir 160 mg/5 ml
*
codeine sulfate oral tablet 15 mg, 30
mg, 60 mg
Necessary Actions,
Restrictions, or
Limits on Use
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
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Tylenol Sore
Throat)
4
$0
(Xolox)
1
$0
(Percodan)
1
$0
(Actiq)
1
$0
Name of Drug
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
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
(Hycet)
1
$0
tablet 10-300 mg, 5-300 mg, 7.5-300 (Norco)
mg
1
$0
tablet 10-325 mg, 2.5-325 mg, 5-325 (Norco)
mg, 7.5-325 mg
1
$0
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
5
Name of Drug
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, 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 liquid 160 mg/5
ml *
mapap 160 mg/5 ml suspension 160
mg/5 ml *
mapap 325 mg tablet 325 mg *
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
(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
(Hydromorphone
HCl)
(Hydromorphone
HCl)
(Dilaudid)
(Acetaminophen)
2
$0
(Norco)
1
$0
(Norco)
(Norco)
1
1
$0
$0
4
$0
(Infants' Tylenol)
4
$0
(Tylenol)
4
$0
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
(Acetaminophen)
(Tylenol)
(Tylenol Sore
Throat)
(Acetaminophen)
4
4
$0
$0
4
$0
4
$0
(Acetaminophen)
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
(Morphine
Sulfate/D5W)
1
$0
Name of Drug
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
morphine in dextrose 5 % injection
pt controlled analgesia syring 100
mg/50 ml (2 mg/ml), 50 mg/25 ml (2
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
Tier level
What the
drug will
cost you
(Morphine Sulfate)
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
(Morphine Sulfate)
1
$0
2
$0
(MS Contin)
1
$0
(MS Contin)
1
$0
(Morphine Sulfate)
1
$0
(Tylenol Sore
Throat)
4
$0
(Acetaminophen)
4
$0
Name of Drug
morphine injection solution 15
mg/ml, 8 mg/ml
morphine injection syringe 10
mg/ml
morphine intramuscular pen
injector 10 mg/0.7 ml
morphine intravenous cartridge 15
mg/ml
morphine intravenous solution 25
mg/ml, 50 mg/ml
morphine intravenous syringe 10
mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml
morphine oral solution 10 mg/5 ml
morphine oral solution 20 mg/5 ml
(4 mg/ml)
MORPHINE ORAL TABLET 15
MG, 30 MG
morphine oral tablet extended
release 100 mg, 30 mg, 60 mg
morphine oral tablet extended
release 15 mg, 200 mg
morphine rectal suppository 10 mg,
20 mg, 30 mg, 5 mg
non-aspirin x-str 167 mg/5 ml 500
mg/15 ml *
nortemp 80 mg/0.8 ml drop 80
mg/0.8 ml *
NUCYNTA ER ORAL TABLET
EXTENDED RELEASE 12 HR 100
MG, 150 MG, 200 MG, 250 MG, 50
MG
NUCYNTA ORAL TABLET 100
MG, 50 MG, 75 MG
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (60 per 30 days)
2
$0
2
$0
8
Tier level
What the
drug will
cost you
(Oxycodone HCl)
1
$0
(Oxycodone HCl)
1
$0
(Roxicodone)
1
$0
(Oxycontin)
1
$0
(Oxycontin)
2
$0
(Xolox)
1
$0
(Xolox)
1
$0
(Xolox)
1
$0
(Percodan)
1
$0
Name of Drug
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
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
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
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (60 per 30 days)
2
$0
(Opana)
2
$0
1
$0
QL (60 per 30 days)
(Opana ER)
1
$0
(Opana ER)
1
$0
9
Tier level
What the
drug will
cost you
(Acetaminophen)
4
$0
(Acetaminophen)
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
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Tylenol)
4
$0
(Tylenol)
4
$0
Name of Drug
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
silapap infant's drops infant's 80
mg/0.8 ml *
sm arthritis pain er 650 mg caplet
650 mg *
sm pain rel jr str tab chew 160 mg *
sm pain reliever 80 mg tab
children's 80 mg *
tactinal 325 mg tablet 325 mg *
tactinal 500 mg tablet extra-strength
500 mg *
(Tylenol Sore
Throat)
(Tylenol)
Necessary Actions,
Restrictions, or
Limits on Use
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)
10
Tier level
What the
drug will
cost you
(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
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
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 *
aspirin 300 mg suppository 300 mg
(Aspirin)
*
aspirin 325 mg tablet 325 mg *
(Ecotrin)
aspirin 600 mg suppository 600 mg
(Aspirin)
*
Necessary Actions,
Restrictions, or
Limits on Use
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
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
(Voltaren)
1
$0
(Arthrotec 50)
1
$0
(Diflunisal)
1
$0
Name of Drug
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
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
(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
(Ecotrin)
4
$0
(Etodolac)
1
$0
(Etodolac)
1
$0
(Etodolac)
1
$0
(Fenoprofen
Calcium)
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 oral capsule 25 mg
(Indomethacin)
1
$0
indomethacin oral capsule 50 mg
(Indomethacin)
1
$0
(Indomethacin)
1
$0
(Indomethacin
Sodium)
1
$0
(Infants' Motrin)
4
$0
Name of Drug
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 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, extended
release 75 mg
indomethacin sodium intravenous
recon soln 1 mg
infant ibuprofen 50 mg/1.25 ml
d/f,a/f,non-staining 50 mg/1.25 ml *
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (60 per
30 days)
PA-HRM
13
Tier level
What the
drug will
cost you
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
4
$0
1
$0
Name of Drug
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
(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)
st. joseph aspirin ec 81 mg tb
(Ecotrin)
enteric coated 81 mg *
sulindac oral tablet 150 mg, 200 mg (Sulindac)
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
1
1
1
$0
$0
$0
4
$0
(Lidocaine HCl)
1
$0
(Xylocaine-MPF)
1
$0
(Xylocaine)
1
$0
(Xylocaine)
1
$0
(Xylocaine)
1
$0
(Lidocaine HCl)
1
$0
(Lidocaine HCl)
1
$0
(Xylocaine)
1
$0
(Lidocaine HCl)
1
$0
(Lidoderm)
1
$0
(Lidocaine)
1
$0
(EMLA)
1
$0
Name of Drug
tolmetin oral capsule 400 mg
(Tolmetin Sodium)
tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium)
VOLTAREN TOPICAL GEL 1 %
wal-profen 200 mg softgel softgel
(Advil)
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 laryngotracheal
solution 4 %
lidocaine hcl mucous membrane gel
2%
lidocaine hcl mucous membrane
jelly in applicator 2 %
lidocaine hcl mucous membrane
solution 2 %, 4 % (40 mg/ml)
lidocaine hcl urethral gel 2 %
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
15
Name of Drug
acamprosate oral tablet,delayed
release (dr/ec) 333 mg
buprenorphine hcl sublingual tablet
2 mg, 8 mg
buprenorphine-naloxone sublingual
tablet 2-0.5 mg, 8-2 mg
bupropion hcl sr 150 mg tablet f/c
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 *
(Acamprosate
Calcium)
(Buprenorphine
HCl)
(Buprenorphine
HCl/Naloxone
HCl)
(Zyban)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (90 per 30
days)
PA; QL (90 per 30
days)
2
$0
2
$0
QL (53 per 28 days)
2
$0
(Antabuse)
1
$0
(Naloxone HCl)
1
$0
(Naloxone HCl)
1
$0
(Revia)
1
$0
2
$0
4
$0
4
$0
4
$0
4
4
$0
$0
(Nicorette)
(Nicorette)
QL (4 per 30 days)
16
Tier level
What the
drug will
cost you
(Nicorette)
4
$0
(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
nicorette 2 mg chewing gum white
ice mint 2 mg *
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
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
(Xanax)
(Chlordiazepoxide
HCl)
(Klonopin)
(Klonopin)
(Clonazepam)
QL (90 per 30 days)
QL (90 per 30 days)
17
Tier level
What the
drug will
cost you
(Clonazepam)
1
$0
(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
Name of Drug
clonazepam oral
tablet,disintegrating 2 mg
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
25's,pedi,latex-free 20 mg/2 ml
PA BvD
(Gentamicin In
Nacl, Iso-Osm)
(Gentamicin
Sulfate)
(Gentamicin
Sulfate/PF)
2
$0
1
$0
1
$0
1
$0
18
Tier level
What the
drug will
cost you
1
$0
1
$0
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
(Cleocin
Phosphate)
1
$0
Name of Drug
gentamicin sulfate (pf) intravenous
solution 80 mg/8 ml
neomycin oral tablet 500 mg
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
(Gentamicin
Sulfate/PF)
(Neomycin Sulfate)
(Streptomycin
Sulfate)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
19
Tier level
What the
drug will
cost you
1
$0
1
$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
(Macrodantin)
1
$0
(Macrobid)
1
$0
(Macrobid)
1
$0
(Polymyxin B
Sulfate)
1
$0
2
$0
(Trimethoprim)
(Vancomycin
HCl/D5W)
1
$0
1
$0
(Vancomycin HCl)
1
$0
Name of Drug
clindamycin phosphate intravenous
solution 600 mg/4 ml
colistin (colistimethate na) injection
recon soln 150 mg
CUBICIN 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
nitrofurantoin monohyd/m-cryst
oral capsule 100 mg
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
(Cleocin
Phosphate)
(Coly-Mycin M
Parenteral)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (120 per
30 days)
20
Tier level
What the
drug will
cost you
(Vancomycin
HCl/D5W)
1
$0
(Vancocin HCl)
1
$0
2
$0
2
$0
2
$0
(Cefaclor)
1
$0
(Cefaclor)
1
$0
(Cefadroxil)
1
$0
(Cefadroxil)
1
$0
(Cefadroxil)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
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
cefadroxil oral suspension for
mg/5 ml
cefadroxil oral tablet 1 gram
CEFAZOLIN IN DEXTROSE
(ISO-OS) INTRAVENOUS
PIGGYBACK 1 GRAM/50 ML
(Cefazolin
cefazolin in dextrose (iso-os)
Sodium/Dextrose,
intravenous piggyback 2 gram/50 ml
Iso)
cefazolin injection recon soln 1
(Cefazolin Sodium)
gram, 10 gram, 500 mg
cefdinir oral capsule 300 mg
(Cefdinir)
cefdinir oral suspension for
(Cefdinir)
mg/5 ml
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (9 per 30 days)
PA
21
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
(Maxipime)
1
$0
(Claforan)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
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
(Spectracef)
(Cefoxitin
cefoxitin in dextrose, iso-osm
Sodium/Dextrose,
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)
cefprozil oral suspension for
(Cefprozil)
mg/5 ml
cefprozil oral tablet 250 mg, 500 mg (Cefprozil)
ceftazidime injection recon soln 2
(Fortaz)
gram, 6 gram
ceftibuten oral capsule 400 mg
(Cedax)
ceftibuten oral suspension for
(Cedax)
ceftriaxone 1 gm piggyback 50ml
(Ceftriaxone
galaxycontainer 1 gram/50 ml
Na/Dextrose, Iso)
ceftriaxone 1 gm vial 10's, fliptop,l/f
(Rocephin)
1 gram
Necessary Actions,
Restrictions, or
Limits on Use
22
Tier level
What the
drug will
cost you
(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
2
$0
2
$0
1
$0
2
$0
(Zithromax)
1
$0
(Zithromax)
1
$0
Name of Drug
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
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
(Fortaz)
Necessary Actions,
Restrictions, or
Limits on Use
23
Tier level
What the
drug will
cost you
(Zithromax)
1
$0
(Zithromax)
1
$0
(Zithromax)
1
$0
(Biaxin)
1
$0
(Biaxin)
1
$0
(Clarithromycin)
1
$0
2
$0
(Erythromycin
Ethylsuccinate)
1
$0
(Eryped 200)
1
$0
(Erythromycin
Base)
1
$0
2
$0
1
$0
2
$0
1
$0
1
$0
1
$0
Name of Drug
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
e.e.s. granules oral suspension for
ery-tab oral tablet,delayed release
(dr/ec) 250 mg, 500 mg
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
(Erythromycin
Stearate)
(Erythromycin
Ethylsuccinate)
(Erythromycin
Base)
(Erythromycin
Base)
Necessary Actions,
Restrictions, or
Limits on Use
QL (20 per 10 days)
24
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
Miscellaneous B-Lactam
Antibiotics
aztreonam injection recon soln 1
(Azactam)
1
$0
gram
CAYSTON INHALATION
LA
SOLUTION FOR
2
$0
NEBULIZATION 75 MG/ML
imipenem-cilastatin intravenous
(Primaxin)
1
$0
recon soln 250 mg, 500 mg
INVANZ INJECTION RECON
2
$0
SOLN 1 GRAM
meropenem intravenous recon soln
(Merrem)
1
$0
500 mg
meropenem iv 1 gm vial outer, latex(Merrem)
1
$0
free 1 gram
Penicillins
amoxicillin oral capsule 250 mg,
(Amoxicillin)
1
$0
500 mg
amoxicillin oral suspension for
(Amoxicillin)
1
$0
mg/5 ml, 250 mg/5 ml, 400 mg/5 ml
amoxicillin oral tablet 500 mg, 875
(Amoxicillin)
1
$0
mg
amoxicillin oral tablet,chewable 125
(Amoxicillin)
1
$0
mg, 250 mg
amoxicillin-pot clavulanate oral
suspension for reconstitution 200(Augmentin)
1
$0
28.5 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,
(Augmentin)
1
$0
875-125 mg
tablet extended release 12 hr 1,000- (Augmentin XR)
1
$0
62.5 mg
25
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(Unasyn)
1
$0
(Unasyn)
1
$0
(Unasyn)
1
$0
2
$0
2
$0
(Dicloxacillin
Sodium)
1
$0
(Nafcillin Sodium)
1
$0
Name of Drug
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
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
(Amoxicillin/Potas
sium Clav)
(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
(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
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
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)
intravenous piggyback 1 gram/50
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
penicillin gk 20 million unit 20
million unit
penicillin v potassium oral recon
soln 125 mg/5 ml, 250 mg/5 ml
penicillin v potassium oral tablet
250 mg, 500 mg
pfizerpen-g injection recon soln 20
million unit
piperacillin-tazobactam intravenous
recon soln 2.25 gram, 3.375 gram,
4.5 gram
(Penicillin G
Potassium)
(Penicillin V
Potassium)
(Penicillin V
Potassium)
(Penicillin G
Potassium)
(Zosyn)
Necessary Actions,
Restrictions, or
Limits on Use
27
Tier level
What the
drug will
cost you
(Zosyn)
1
$0
(Ciprofloxacin
Lactate)
1
$0
(Cipro)
1
$0
(Cipro I.V.)
1
$0
(Ciprofloxacin
Lactate)
1
$0
(Cipro)
1
$0
(Cipro I.V.)
1
$0
(Levaquin)
1
$0
(Levofloxacin)
1
$0
(Levaquin)
1
$0
(Levaquin)
1
$0
(Avelox)
(Ofloxacin)
1
1
$0
$0
(Sulfadiazine)
1
$0
(Sulfamethoxazole/
Trimethoprim)
1
$0
Name of Drug
piperacil-tazobact 40.5 gram p/f,
pharmacy bulk 40.5 gram
Quinolones
ciprofloxacin 200 mg/20 ml vl
sdv,latex-free 200 mg/20 ml
ciprofloxacin hcl oral tablet 100 mg,
250 mg, 500 mg, 750 mg
ciprofloxacin in 5 % dextrose
ml
ciprofloxacin lactate intravenous
ciprofloxacin oral
suspension,microcapsule recon 250
mg/5 ml, 500 mg/5 ml
ciprofloxacn-d5w 400 mg/200 ml
p/f,latex/f, in d5w 400 mg/200 ml
levofloxacin in d5w intravenous
piggyback 500 mg/100 ml, 750
mg/150 ml
levofloxacin intravenous solution 25
mg/ml
levofloxacin oral solution 250
mg/10 ml
levofloxacin oral tablet 250 mg, 500
mg, 750 mg
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
Necessary Actions,
Restrictions, or
Limits on Use
28
Tier level
What the
drug will
cost you
(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
(Adoxa)
1
$0
(Avidoxy)
1
$0
(Avidoxy)
1
$0
(Adoxa)
1
$0
Name of Drug
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 f/c
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
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
Necessary Actions,
Restrictions, or
Limits on Use
29
Tier level
What the
drug will
cost you
(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
(Fluorouracil)
1
$0
Name of Drug
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
adrucil intravenous solution 500
mg/10 ml
AFINITOR DISPERZ ORAL
TABLET FOR SUSPENSION 2
MG, 3 MG, 5 MG
AFINITOR ORAL TABLET 10
MG
2
$0
2
$0
PA NSO; QL (4 per 21
days)
PA BvD
PA BvD
PA BvD
PA BvD
PA NSO; QL (112 per
28 days)
PA NSO; QL (56 per
28 days)
30
Name of Drug
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
2
$0
2
$0
2
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (28 per
28 days)
PA NSO; QL (240 per
30 days)
PA NSO
2
$0
1
$0
2
$0
2
$0
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
BOSULIF ORAL TABLET 500
MG
CABOMETYX ORAL TABLET 20
MG, 60 MG
CABOMETYX ORAL TABLET 40
MG
(Casodex)
(Bleomycin
Sulfate)
(Bleomycin
Sulfate)
1
$0
1
$0
1
$0
2
$0
2
$0
2
$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)
PA NSO; QL (30 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
31
Tier level
What the
drug will
cost you
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
2
$0
2
$0
2
$0
Name of Drug
CAPRELSA ORAL TABLET 100
MG
CAPRELSA ORAL TABLET 300
MG
COMETRIQ ORAL CAPSULE 100
MG/DAY(80 MG[1]-20 MG[1]),
140 MG/DAY(80 MG[1]-20
MG[3]), 60 MG/DAY (20 MG
[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
DROXIA ORAL CAPSULE 200
MG, 300 MG, 400 MG
ELIGARD SUBCUTANEOUS
SYRINGE 22.5 MG (3 MONTH)
SYRINGE 30 MG (4 MONTH)
(Cyclophosphamid
e)
(Cyclophosphamid
e)
Necessary Actions,
Restrictions, or
Limits on Use
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
QL (1 per 84 days)
QL (1 per 112 days)
32
Tier level
What the
drug will
cost you
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
(Flutamide)
1
$0
2
$0
2
$0
2
$0
Name of Drug
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
2.5 gram/50 ml
flutamide oral capsule 125 mg
GAZYVA INTRAVENOUS
SOLUTION 1,000 MG/40 ML
GILOTRIF ORAL TABLET 20
MG, 30 MG, 40 MG
GLEEVEC ORAL TABLET 100
MG
Necessary Actions,
Restrictions, or
Limits on Use
QL (1 per 168 days)
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO
PA BvD
PA BvD
PA BvD
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO; QL (90 per
30 days)
33
Tier level
What the
drug will
cost you
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
2
$0
Name of Drug
GLEEVEC ORAL TABLET 400
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
(Hydrea)
IBRANCE ORAL CAPSULE 100
MG, 125 MG, 75 MG
ifosfamide 1 gm/20 ml vial sd
polymer vial 1 gram/20 ml
ifosfamide intravenous recon soln 1
gram
ifosfamide-mesna intravenous kit 11 gram, 3,000-1,000 mg
IMBRUVICA ORAL CAPSULE
140 MG
IMLYGIC INJECTION
SUSPENSION 10EXP6 (1
MILLION) PFU/ML
IMLYGIC INJECTION
SUSPENSION 10EXP8 (100
MILLION) PFU/ML
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (60 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
$0
PA NSO; QL (4 per
365 days)
2
$0
days)
INLYTA ORAL TABLET 1 MG
2
$0
INLYTA ORAL TABLET 5 MG
2
$0
2
PA NSO; QL (180 per
30 days)
PA NSO; QL (60 per
30 days)
34
Name of Drug
Tier level
What the
drug will
cost you
IRESSA ORAL TABLET 250 MG
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
(Leuprolide
Acetate)
1
$0
(Doxil)
1
$0
(Lomustine)
1
$0
2
$0
2
$0
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 60 MG
LENVIMA ORAL CAPSULE 10
MG/DAY (10 MG X 1/DAY), 14
MG/DAY(10 MG X 1-4 MG X 1),
20 MG/DAY (10 MG X 2), 24
MG/DAY(10 MG X 2-4 MG X 1)
letrozole oral tablet 2.5 mg
LEUKERAN ORAL TABLET 2
MG
leuprolide subcutaneous kit 1
mg/0.2 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
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (60 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO
PA NSO
(Femara)
days)
PA NSO
PA BvD
PA NSO; QL (100 per
28 days)
PA NSO; QL (80 per
28 days)
35
Name of Drug
Tier level
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
What the
drug will
cost you
QL (1 per 84 days)
2
$0
QL (1 per 84 days)
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
MEKINIST ORAL TABLET 0.5
MG
2
$0
MEKINIST ORAL TABLET 2 MG
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
megestrol oral tablet 20 mg, 40 mg
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
Necessary Actions,
Restrictions, or
Limits on Use
QL (1 per 168 days)
(Megestrol
Acetate)
(Mercaptopurine)
(Methotrexate
Sodium)
(Methotrexate
Sodium/PF)
(Methotrexate
Sodium)
(Methotrexate
Sodium)
PA NSO; QL (480 per
30 days)
PA NSO; QL (90 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA BvD; ST
36
Name of Drug
mitoxantrone intravenous
(Mitoxantrone
concentrate 2 mg/ml
HCl)
NEXAVAR ORAL TABLET 200
MG
NILANDRON 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
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
Tier level
What the
drug will
cost you
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; 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)
PA NSO; LA
2
$0
2
$0
2
$0
2
$0
PA NSO
PA NSO; QL (30 per
30 days)
37
Name of Drug
Tier level
What the
drug will
cost you
SPRYCEL ORAL TABLET 20 MG
2
$0
2
$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
1
$0
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
(Tamoxifen
Citrate)
TARCEVA ORAL TABLET 100
MG, 25 MG
TARCEVA ORAL TABLET 150
MG
TARGRETIN ORAL CAPSULE 75
MG
TARGRETIN TOPICAL GEL 1 %
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)
Necessary Actions,
Restrictions, or
Limits on Use
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)
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)
38
Name of Drug
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
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
Tier level
What the
drug will
cost you
1
$0
2
$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
Necessary Actions,
Restrictions, or
Limits on Use
QL (1 per 168 days)
QL (1 per 168 days)
QL (1 per 84 days)
(capsule: 10mg)
PA BvD; ST
PA NSO
PA NSO
PA NSO; LA
PA NSO; LA
39
Name of Drug
vinorelbine intravenous solution 50
mg/5 ml
VOTRIENT ORAL TABLET 200
MG
XALKORI ORAL CAPSULE 200
MG, 250 MG
(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
ZYKADIA ORAL CAPSULE 150
MG
ZYTIGA ORAL TABLET 250 MG
Tier level
What the
drug will
cost you
1
$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
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
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)
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
40
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
(Carbatrol)
1
$0
(Tegretol)
1
$0
(Tegretol)
1
$0
(Tegretol XR)
1
$0
(Carbamazepine)
1
$0
2
$0
Name of Drug
propantheline oral tablet 15 mg
(Propantheline
Bromide)
STIOLTO RESPIMAT
INHALATION MIST 2.5-2.5
MCG/ACTUATION
Necessary Actions,
Restrictions, or
Limits on Use
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,
300 mg
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
ST
ST
ST
PA NSO; QL (80 per
30 days)
PA NSO; QL (600 per
30 days)
PA NSO; QL (60 per
30 days)
41
Tier level
What the
drug will
cost you
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
Name of Drug
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 TABLET 10
MG, 12 MG, 2 MG, 4 MG, 6 MG, 8
MG
gabapentin oral capsule 100 mg,
300 mg, 400 mg
gabapentin oral solution 250 mg/5
ml
gabapentin oral tablet 600 mg, 800
mg
GABITRIL ORAL TABLET 12
MG, 16 MG
LAMICTAL ORAL TABLET,
CHEWABLE DISPERSIBLE 2 MG
Necessary Actions,
Restrictions, or
Limits on Use
ST
2
$0
(Neurontin)
1
$0
(Neurontin)
1
$0
(Neurontin)
1
$0
2
$0
2
$0
42
Tier level
What the
drug will
cost you
(Lamictal)
1
$0
(Lamictal XR)
1
$0
(Lamictal)
1
$0
(Lamictal (Blue))
1
$0
(Keppra)
1
$0
(Keppra)
1
$0
(Keppra)
1
$0
(Keppra XR)
1
$0
Name of Drug
lamotrigine oral tablet 100 mg, 150
mg, 200 mg, 25 mg
lamotrigine oral tablet extended
release 24hr 100 mg, 200 mg, 25
mg, 250 mg, 300 mg, 50 mg
lamotrigine oral tablet, chewable
dispersible 25 mg, 5 mg
lamotrigine oral tablets,dose pack
25 mg (35)
levetiracetam intravenous solution
500 mg/5 ml
levetiracetam oral solution 100
mg/ml
levetiracetam oral tablet 1,000 mg,
250 mg, 500 mg, 750 mg
levetiracetam oral tablet extended
LYRICA ORAL CAPSULE 100
MG, 150 MG, 200 MG, 225 MG, 25
MG, 300 MG, 50 MG, 75 MG
LYRICA ORAL SOLUTION 20
MG/ML
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)
Necessary Actions,
Restrictions, or
Limits on Use
QL (90 per 30 days)
2
$0
2
$0
(Trileptal)
1
$0
(Trileptal)
1
$0
2
$0
2
$0
1
$0
ST
(Phenobarbital)
43
Name of Drug
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
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
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
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
2
$0
2
$0
(Gabitril)
1
$0
(Topamax)
1
$0
(Topamax)
1
$0
(Phenytoin
Sodium)
(Phenytoin
Sodium)
(Mysoline)
QL (2 per 30 days)
QL (90 per 30 days)
ST; QL (60 per 30
days)
ST; QL (120 per 30
days)
44
Tier level
What the
drug will
cost you
(Qudexy XR)
1
$0
(Topamax)
1
$0
Name of Drug
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
2
$0
(Depacon)
1
$0
(Depakene)
1
$0
(Depakene)
1
$0
2
$0
2
$0
2
$0
(Zonegran)
1
$0
(Aricept)
1
$0
(Donepezil HCl)
1
$0
(Razadyne ER)
1
$0
(Galantamine Hbr)
1
$0
(Razadyne)
1
$0
(Namenda)
1
$0
QL (200 per 5 days)
QL (60 per 30 days)
Antidementia Agents
Antidementia Agents
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
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
45
Tier level
What the
drug will
cost you
(Namenda)
1
$0
(Namenda)
1
$0
2
$0
Name of Drug
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 (60 per 30 days)
QL (49 per 28 days)
QL (28 per 28 days)
QL (30 per 30 days)
(Exelon)
2
$0
2
$0
1
$0
QL (60 per 30 days)
QL (30 per 30 days)
(Exelon)
1
$0
(Amitriptyline
HCl)
1
$0
(Amoxapine)
1
$0
2
$0
(Wellbutrin SR)
1
$0
(Wellbutrin)
1
$0
(Wellbutrin SR)
1
$0
(Wellbutrin XL)
1
$0
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
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
PA NSO-HRM
ST
46
Tier level
What the
drug will
cost you
(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
2
$0
Name of Drug
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
FETZIMA ORAL CAPSULE,EXT
REL 24HR DOSE PACK 20 MG
(2)- 40 MG (26)
FETZIMA ORAL
24 HR 120 MG, 20 MG, 40 MG, 80
MG
fluoxetine oral capsule 10 mg, 20
mg, 40 mg
Necessary Actions,
Restrictions, or
Limits on Use
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)
ST
ST
(Prozac)
2
$0
1
$0
47
Tier level
What the
drug will
cost you
(Prozac Weekly)
1
$0
(Fluoxetine HCl)
1
$0
(Fluoxetine HCl)
(Fluvoxamine
Maleate)
(Fluvoxamine
Maleate)
1
$0
1
$0
1
$0
(Tofranil)
1
$0
(Tofranil-Pm)
1
$0
(Maprotiline HCl)
1
$0
2
$0
(Remeron)
1
$0
(Remeron)
1
$0
(Nefazodone HCl)
1
$0
(Pamelor)
1
$0
(Nortriptyline HCl)
1
$0
(Symbyax)
1
$0
(Paxil)
1
$0
Name of Drug
fluoxetine oral capsule,delayed
fluoxetine oral solution 20 mg/5 ml
(4 mg/ml)
fluoxetine oral tablet 10 mg, 20 mg
fluvoxamine oral capsule,extended
release 24hr 100 mg, 150 mg
fluvoxamine oral tablet 100 mg, 25
mg, 50 mg
imipramine hcl oral tablet 10 mg, 25
mg, 50 mg
imipramine pamoate oral capsule
100 mg, 125 mg, 150 mg, 75 mg
maprotiline oral tablet 25 mg, 50
mg, 75 mg
MARPLAN ORAL TABLET 10
MG
mirtazapine oral tablet 15 mg, 30
mg, 45 mg, 7.5 mg
mirtazapine oral
tablet,disintegrating 15 mg, 30 mg,
45 mg
nefazodone oral tablet 100 mg, 150
mg, 200 mg, 250 mg, 50 mg
nortriptyline oral capsule 10 mg, 25
mg, 50 mg, 75 mg
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
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO-HRM
PA NSO-HRM
48
Name of Drug
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
TRINTELLIX ORAL TABLET 10
MG, 20 MG, 5 MG
venlafaxine oral capsule,extended
release 24hr 150 mg, 37.5 mg, 75
mg
venlafaxine oral tablet 100 mg, 25
mg, 37.5 mg, 50 mg, 75 mg
(Paxil CR)
Tier level
What the
drug will
cost you
1
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO-HRM
(Perphenazine/Ami
triptyline HCl)
1
$0
(Nardil)
1
$0
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
2
$0
(Effexor XR)
1
$0
(Venlafaxine HCl)
1
$0
ST; QL (30 per 30
days)
QL (30 per 30 days)
PA NSO-HRM
PA NSO-HRM
ST
49
Name of Drug
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
1
$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
Antidiabetic Agents
Antidiabetic Agents,
Miscellaneous
acarbose oral tablet 100 mg, 25 mg,
(Precose)
50 mg
CYCLOSET ORAL TABLET 0.8
MG
GLYXAMBI ORAL TABLET 10-5
MG, 25-5 MG
INVOKAMET ORAL TABLET
150-1,000 MG, 150-500 MG, 501,000 MG, 50-500 MG
INVOKANA ORAL TABLET 100
MG, 300 MG
JANUMET ORAL TABLET 501,000 MG, 50-500 MG
JANUMET XR ORAL TABLET,
ER MULTIPHASE 24 HR 1001,000 MG, 50-1,000 MG, 50-500
MG
JANUVIA ORAL TABLET 100
MG, 25 MG, 50 MG
JARDIANCE ORAL TABLET 10
MG, 25 MG
QL (90 per 30 days)
ST
ST
ST
ST
50
Tier level
What the
drug will
cost you
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
(Prandin)
1
$0
(Prandimet)
1
$0
Name of Drug
JENTADUETO ORAL TABLET
2.5-1,000 MG, 2.5-500 MG, 2.5-850
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
repaglinide oral tablet 0.5 mg, 1 mg,
2 mg
repaglinide-metformin oral tablet 1500 mg, 2-500 mg
SYMLINPEN 120
SUBCUTANEOUS PEN
INJECTOR 2,700 MCG/2.7 ML
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
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)
PA; QL (10.8 per 28
days)
51
Name of Drug
Tier level
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)
LANTUS SUBCUTANEOUS
NOVOLIN 70/30
SUBCUTANEOUS SUSPENSION
100 UNIT/ML (70-30)
NOVOLIN N SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
2
$0
ST
2
$0
2
$0
2
$0
2
$0
QL (24 per 28 days)
2
$0
QL (40 per 28 days)
2
$0
2
$0
2
$0
QL (40 per 28 days)
2
$0
2
$0
QL (40 per 28 days)
52
Name of Drug
NOVOLIN R INJECTION
NOVOLOG FLEXPEN
100 UNIT/ML
NOVOLOG MIX 70-30 FLEXPEN
100 UNIT/ML (70-30)
NOVOLOG MIX 70-30
SUBCUTANEOUS SOLUTION
100 UNIT/ML (70-30)
NOVOLOG PENFILL
SUBCUTANEOUS CARTRIDGE
100 UNIT/ML
NOVOLOG SUBCUTANEOUS
TOUJEO SOLOSTAR
300 UNIT/ML (1.5 ML)
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg
glimepiride oral tablet 4 mg
glipizide oral tablet 10 mg
glipizide oral tablet 5 mg
glipizide oral tablet extended
release 24hr 10 mg
release 24hr 2.5 mg
release 24hr 5 mg
glipizide-metformin oral tablet 2.5250 mg
glipizide-metformin oral tablet 2.5500 mg, 5-500 mg
Tier level
What the
drug will
cost you
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (40 per 28 days)
QL (30 per 28 days)
QL (30 per 28 days)
2
$0
QL (40 per 28 days)
2
$0
2
$0
2
$0
2
$0
(Amaryl)
(Amaryl)
(Glucotrol)
(Glucotrol)
1
1
1
1
$0
$0
$0
$0
(Glucotrol XL)
1
$0
1
$0
1
$0
1
$0
1
$0
QL (30 per 28 days)
(Glucotrol XL)
(Glipizide/Metform
in HCl)
(Glipizide/Metform
in HCl)
QL (40 per 28 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
53
Name of Drug
glyburide micronized oral tablet 1.5
(Glynase)
mg
glyburide micronized oral tablet 3
(Glynase)
mg
glyburide micronized oral tablet 6
(Glynase)
mg
Tier level
What the
drug will
cost you
1
$0
1
$0
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
1
$0
1
$0
1
1
1
$0
$0
$0
2
$0
4
$0
glyburide-metformin oral tablet
(Glucovance)
1.25-250 mg
glyburide-metformin oral tablet 2.5(Glucovance)
500 mg, 5-500 mg
tolazamide oral tablet 250 mg
(Tolazamide)
tolazamide oral tablet 500 mg
(Tolazamide)
tolbutamide oral tablet 500 mg
(Tolbutamide)
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 % *
(Miconazole
Nitrate)
PA BvD
AMBISOME INTRAVENOUS
PA BvD
SUSPENSION FOR
2
$0
amphotericin b injection recon soln
PA BvD
(Amphotericin B)
1
$0
50 mg
anti-fungal 1% powder 1 % *
(Tolnaftate)
4
$0
baza antifungal 2% cream 12's 2 %
(Nuzole)
4
$0
*
blis-to-sol 1% liquid 1 % *
(Tolnaftate)
4
$0
54
Tier level
What the
drug will
cost you
2
$0
(Ciclodan)
(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
4
$0
$0
$0
4
$0
Name of Drug
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 % *
cvs antifungal 25% liquid 25 % *
cvs miconazole 3 combo pack 3pref
applic w/cream 4 % (200 mg)- 2 %
(9 gram) *
(Clotrimazole/Beta
methasone Dip)
(Miconazole
Nitrate)
(Gyne-Lotrimin)
(Tinactin)
(Undecylenic Acid)
(Miconazole
Nitrate)
Necessary Actions,
Restrictions, or
Limits on Use
(Miconazole
4
$0
Nitrate)
dermafungal 2% ointment 2 % *
55
Tier level
What the
drug will
cost you
(Econazole Nitrate)
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
(Tinactin)
4
$0
(Tolnaftate)
4
$0
Name of Drug
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 %
lamisil af defens 1% spray pwd 1 %
*
lamisil af defense 1% powder 1 % *
(Tinactin)
(Miconazole
Nitrate)
Necessary Actions,
Restrictions, or
Limits on Use
56
Tier level
What the
drug will
cost you
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
(Nystatin)
1
$0
(Nystatin)
1
$0
Name of Drug
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
nystatin oral tablet 500,000 unit
nystatin topical cream 100,000
unit/gram
(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
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 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
Antihistamines
Antihistamines
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
(Children'S Zyrtec)
4
$0
Name of Drug
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 *
cetirizine hcl 1 mg/1 ml soln
children, s/f, grape (otc) 1 mg/ml *
(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)
Necessary Actions,
Restrictions, or
Limits on Use
59
Tier level
What the
drug will
cost you
(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
4
$0
Name of Drug
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 *
CLARITIN 10 MG REDITABS 10
MG *
(Allegra Allergy)
(Children'S Zyrtec)
Necessary Actions,
Restrictions, or
Limits on Use
60
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Zyrtec)
4
$0
(Zyrtec)
4
$0
4
$0
1
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
CLARITIN 10 MG TABLET
(OTC) 10 MG *
CLARITIN 5 MG REDITABS 5
MG *
clemastine fum 1.34 mg tablet (otc)
1.34 mg *
cold-allergy-sinus oral tablet 2.5-60
mg *
compoz 25 mg gelcap 25 mg *
cvs allergy 25 mg tablet 25 mg *
cvs allergy relief 10 mg sftgl 10 mg
*
cvs child allergy 10 mg chw tb 24
hr,indoor/outdoor 10 mg *
(Clemastine
Fumarate)
(Triprolidine/Pseud
oephedrine)
(Diphenhydramine
HCl)
(Diphenhydramine
HCl)
(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 *
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
(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)
(Chlor-Trimeton)
4
4
$0
$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 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 *
wal-finate 4 mg tablet 4 mg *
(Diphenhydramine
HCl)
(Doxylamine
Succinate)
(Chlorpheniramine/
Pseudoephed)
Necessary Actions,
Restrictions, or
Limits on Use
63
Tier level
What the
drug will
cost you
(Chlorpheniramine/
Pseudoephed)
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-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
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
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)
65
Name of Drug
sumatriptan nasal spray,nonaerosol 20 mg/actuation, 5
mg/actuation
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
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
QL (12 per 28 days)
(Imitrex)
1
$0
(Imitrex)
1
$0
(Sumatriptan
Succinate)
1
$0
(Imitrex)
1
$0
(Sumatriptan
Succinate)
1
$0
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)
(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
2
1
$0
$0
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
(Pyrazinamide)
66
Tier level
What the
drug will
cost you
1
$0
1
$0
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
rifabutin oral capsule 150 mg
(Mycobutin)
rifampin intravenous recon soln 600
(Rifadin)
mg
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)
PA BvD
QL (2 per 28 days)
PA BvD
PA BvD
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)
(Antivert)
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
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)
(Qualaquin)
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (90 per 30 days)
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl oral capsule 100 mg (Amantadine HCl)
1
$0
amantadine hcl oral solution 50
(Amantadine HCl)
1
$0
mg/5 ml
amantadine hcl oral tablet 100 mg
(Amantadine HCl)
1
$0
APOKYN SUBCUTANEOUS
QL (60 per 30 days)
2
$0
CARTRIDGE 10 MG/ML
AZILECT ORAL TABLET 0.5
2
$0
MG, 1 MG
benztropine oral tablet 0.5 mg, 1
(Benztropine
PA-HRM
1
$0
mg, 2 mg
Mesylate)
bromocriptine oral capsule 5 mg
(Parlodel)
1
$0
bromocriptine oral tablet 2.5 mg
(Parlodel)
1
$0
cabergoline oral tablet 0.5 mg
(Cabergoline)
1
$0
carbidopa oral tablet 25 mg
(Lodosyn)
1
$0
carbidopa-levodopa oral tablet 10(Sinemet CR)
1
$0
100 mg, 25-100 mg, 25-250 mg
carbidopa-levodopa oral tablet
extended release 25-100 mg, 50-200 (Sinemet CR)
1
$0
mg
carbidopa-levodopa-entacapone
oral tablet 12.5-50-200 mg, 18.7575-200 mg, 25-100-200 mg, 31.25- (Stalevo 50)
1
$0
125-200 mg, 37.5-150-200 mg, 50200-200 mg
entacapone oral tablet 200 mg
(Comtan)
1
$0
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)
(Moban)
(Moban)
(Moban)
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 50 MG
TRIUMEQ ORAL TABLET 60050-300 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
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
(Retrovir)
(Retrovir)
(Zidovudine)
1
1
1
$0
$0
$0
(Foscavir)
1
$0
2
$0
1
$0
2
$0
Name of Drug
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
SYNAGIS 100 MG/1 ML VIAL
100 MG/ML
(Flumadine)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
79
Name of Drug
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
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
INTRON A INJECTION RECON
SOLN 10 MILLION UNIT (1 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
Necessary Actions,
Restrictions, or
Limits on Use
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
PA NSO
80
Name of Drug
INTRON A INJECTION RECON
SOLN 18 MILLION UNIT (1 ML),
50 MILLION UNIT (1 ML)
INTRON A INJECTION
SOLUTION 6 MILLION UNIT/ML
PEGASYS PROCLICK
SUBCUTANEOUS PEN
INJECTOR 135 MCG/0.5 ML, 180
MCG/0.5 ML
PEGASYS SUBCUTANEOUS
SOLUTION 180 MCG/ML
PEGASYS SUBCUTANEOUS
SYRINGE 180 MCG/0.5 ML
PEGINTRON SUBCUTANEOUS
KIT 120 MCG/0.5 ML, 150
MCG/0.5 ML, 50 MCG/0.5 ML, 80
MCG/0.5 ML
SYLATRON SUBCUTANEOUS
KIT 200 MCG, 300 MCG, 600
MCG
Nucleosides And
Nucleotides
acyclovir oral capsule 200 mg
acyclovir oral suspension 200 mg/5
ml
acyclovir oral tablet 400 mg, 800
mg
acyclovir sodium intravenous
solution 50 mg/ml
adefovir oral tablet 10 mg
entecavir oral tablet 0.5 mg, 1 mg
famciclovir oral tablet 125 mg, 250
mg, 500 mg
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO
2
$0
2
$0
PA NSO
PA
2
$0
2
$0
2
$0
PA
PA
PA
2
$0
2
$0
(Zovirax)
1
$0
(Zovirax)
1
$0
(Zovirax)
1
$0
1
$0
1
1
$0
$0
1
$0
(Acyclovir
Sodium)
(Hepsera)
(Baraclude)
(Famvir)
days)
PA BvD
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
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
2
$0
500 UNIT
ELIQUIS ORAL TABLET 2.5 MG,
2
$0
5 MG
enoxaparin subcutaneous solution
(Lovenox)
1
$0
300 mg/3 ml
enoxaparin subcutaneous syringe
100 mg/ml, 120 mg/0.8 ml, 150
(Lovenox)
1
$0
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
QL (24 per 30 days)
(Arixtra)
1
$0
10 mg/0.8 ml
QL (15 per 30 days)
(Arixtra)
1
$0
2.5 mg/0.5 ml
QL (12 per 30 days)
(Arixtra)
1
$0
5 mg/0.4 ml
QL (18 per 30 days)
(Arixtra)
1
$0
7.5 mg/0.6 ml
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
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
Sodium,Porcine/PF
)
(Monoject Prefill
Advanced)
Necessary Actions,
Restrictions, or
Limits on Use
heparin, porcine (pf) injection
1
$0
syringe 5,000 unit/0.5 ml
heparin-0.45% nacl 25,000
(Heparin Sod,Pork
units/250 ml (100 units/ml) bag
1
$0
In 0.45% NaCl)
latex-free, inner 25,000 unit/250 ml
heparin-d5w 25,000 units/250 ml
(Heparin
(100 units/ml) bag excel container
Sodium,Porcine/D5
1
$0
25,000 unit/250 ml(100 unit/ml)
W)
IPRIVASK SUBCUTANEOUS
PA; QL (24 per 28
2
$0
RECON SOLN 15 MG
days)
jantoven oral tablet 1 mg, 10 mg, 2
mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, (Coumadin)
1
$0
7.5 mg
PRADAXA ORAL CAPSULE 110
ST; QL (60 per 30
2
$0
MG, 150 MG, 75 MG
days)
warfarin oral tablet 1 mg, 10 mg, 2
mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, (Coumadin)
1
$0
7.5 mg
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 %
INTRAVENOUS PARENTERAL
SOLUTION 15 %
AMINOSYN 10 %
SOLUTION 10 %
AMINOSYN 3.5 %
SOLUTION 3.5 %
AMINOSYN 7 % INTRAVENOUS
PARENTERAL SOLUTION 7 %
AMINOSYN 7 % WITH
ELECTROLYTES
SOLUTION 7 %
PA BvD
2
$0
2
$0
2
$0
2
$0
PA BvD
PA BvD
PA BvD
PA BvD
2
$0
86
Name of Drug
Tier level
AMINOSYN 8.5 %
SOLUTION 8.5 %
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
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
2
$0
2
$0
PA BvD
PA BvD
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
2
$0
2
$0
PA BvD
PA BvD
87
Name of Drug
Tier level
AMINOSYN-RF 5.2 %
SOLUTION 5.2 %
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
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
2
$0
PA BvD
2
$0
2
$0
PA BvD
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
2
$0
PA BvD
88
Name of Drug
CLINIMIX E 2.75%/D10W SUL
FREE INTRAVENOUS
%
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
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
PA BvD
2
$0
PA BvD
2
$0
2
$0
2
$0
1
$0
PA BvD
PA BvD
(Cysteine HCl)
PA BvD
89
Tier level
What the
drug will
cost you
(Dextrose)
4
$0
(Dextrose 10 % in
Water)
1
$0
Name of Drug
dex4 glucose 4 gm tablet chew
grape flavor 4 gram *
dextrose 10 % in water (d10w)
intravenous parenteral solution 10
%
%
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 %
*
PA BvD
PA BvD
(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
(Dextrose
Ringers)
(Dextrose
Water)
(Dextrose
Water)
(Dextrose
Water)
(Dextrose
Water)
5 % In
5 % in
50 % in
50 % in
70 % in
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
2
$0
(Dextrose)
4
$0
(Dextrose)
4
$0
4
$0
90
Name of Drug
glutose 15 gel 3 pak, outer, u-d 40
%*
HEPATAMINE 8%
SOLUTION 8 %
HEPATASOL 8 %
SOLUTION 8 %
insta-glucose gel 24 gram/31 gram
*
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
KABIVEN INTRAVENOUS
EMULSION 3.31-9.8-3.9 %
LIPOSYN II INTRAVENOUS
EMULSION 20 %
LIPOSYN III INTRAVENOUS
EMULSION 10 %, 20 %, 30 %
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 %
(Dextrose)
Tier level
What the
drug will
cost you
4
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
(Dextrose/Dextrin/
Maltose)
2
$0
4
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
2
$0
91
Name of Drug
PROSOL 20 % INTRAVENOUS
PARENTERAL SOLUTION
TRAVASOL 10 %
SOLUTION 10 %
TROPHAMINE 10 %
SOLUTION 10 %
TROPHAMINE 6%
SOLUTION 6 %
Tier level
What the
drug will
cost you
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
2
$0
PA BvD
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
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
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
2
$0
2
$0
(Atacand)
1
$0
(Atacand HCT)
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
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
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
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (60 per 30
days)
ST
(Diovan)
2
$0
1
$0
93
Tier level
What the
drug will
cost you
(Diovan HCT)
1
$0
(Lotensin)
1
$0
(Lotensin HCT)
1
$0
(Captopril)
1
$0
(Captopril/Hydroch
lorothiazide)
1
$0
(Vasotec)
1
$0
(Enalaprilat
Dihydrate)
1
$0
(Vaseretic)
1
$0
1
$0
1
$0
(Zestril)
1
$0
(Zestoretic)
1
$0
(Moexipril HCl)
1
$0
(Moexipril/Hydroc
hlorothiazide)
1
$0
Name of Drug
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
captopril oral tablet 100 mg, 12.5
mg, 25 mg, 50 mg
captopril-hydrochlorothiazide oral
tablet 25-15 mg, 25-25 mg, 50-15
mg, 50-25 mg
enalapril maleate oral tablet 10 mg,
2.5 mg, 20 mg, 5 mg
enalaprilat intravenous solution
1.25 mg/ml
enalapril-hydrochlorothiazide oral
tablet 10-25 mg, 5-12.5 mg
fosinopril oral tablet 10 mg, 20 mg,
40 mg
fosinopril-hydrochlorothiazide oral
tablet 10-12.5 mg, 20-12.5 mg
lisinopril oral tablet 10 mg, 2.5 mg,
20 mg, 30 mg, 40 mg, 5 mg
lisinopril-hydrochlorothiazide oral
tablet 10-12.5 mg, 20-12.5 mg, 2025 mg
moexipril oral tablet 15 mg, 7.5 mg
moexipril-hydrochlorothiazide oral
tablet 15-12.5 mg, 15-25 mg, 7.512.5 mg
(Fosinopril
Sodium)
(Fosinopril/Hydroc
hlorothiazide)
Necessary Actions,
Restrictions, or
Limits on Use
94
Tier level
What the
drug will
cost you
(Aceon)
1
$0
(Accupril)
1
$0
(Accuretic)
1
$0
(Altace)
1
$0
(Mavik)
1
$0
(Cordarone)
1
$0
(Norpace)
1
$0
(Tambocor)
1
$0
(Lidocaine
HCl/PF)
1
$0
(Lidocaine
HCl/D5w/PF)
1
$0
(Mexiletine HCl)
1
$0
2
$0
(Cordarone)
1
$0
(Procainamide
HCl)
1
$0
(Rythmol SR)
1
$0
Name of Drug
perindopril erbumine oral tablet 2
mg, 4 mg, 8 mg
quinapril oral tablet 10 mg, 20 mg,
40 mg, 5 mg
quinapril-hydrochlorothiazide oral
tablet 10-12.5 mg, 20-12.5 mg, 2025 mg
ramipril oral capsule 1.25 mg, 10
mg, 2.5 mg, 5 mg
trandolapril oral tablet 1 mg, 2 mg,
4 mg
Antiarrhythmic Agents
amiodarone oral tablet 100 mg, 200
mg, 400 mg
disopyramide phosphate oral
capsule 100 mg, 150 mg
flecainide oral tablet 100 mg, 150
mg, 50 mg
lidocaine (pf) intravenous syringe
50 mg/5 ml (1 %)
lidocaine in 5 % dextrose (pf)
mg/ml (0.8 %)
mexiletine oral capsule 150 mg, 200
mg, 250 mg
MULTAQ ORAL TABLET 400
MG
pacerone oral tablet 100 mg, 200
mg, 400 mg
procainamide injection solution 100
mg/ml, 500 mg/ml
propafenone oral capsule,extended
release 12 hr 225 mg, 325 mg, 425
mg
Necessary Actions,
Restrictions, or
Limits on Use
95
Tier level
What the
drug will
cost you
(Rythmol)
1
$0
(Quinidine
Gluconate)
1
$0
(Quinidine Sulfate)
1
$0
(Quinidine Sulfate)
1
$0
2
$0
(Sectral)
1
$0
(Tenormin)
1
$0
(Tenoretic 50)
1
$0
(Kerlone)
1
$0
(Zebeta)
1
$0
(Ziac)
1
$0
2
$0
(Coreg)
1
$0
(Brevibloc)
1
$0
(Labetalol HCl)
1
$0
(Trandate)
1
$0
Name of Drug
propafenone oral tablet 150 mg, 225
mg, 300 mg
quinidine gluconate oral tablet
extended release 324 mg
quinidine sulfate oral tablet 200 mg,
300 mg
quinidine sulfate oral tablet
TIKOSYN ORAL CAPSULE 125
MCG, 250 MCG, 500 MCG
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
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
96
Tier level
What the
drug will
cost you
(Toprol XL)
1
$0
(Lopressor HCT)
1
$0
(Lopressor)
1
$0
(Lopressor)
1
$0
(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
Name of Drug
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
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
Necessary Actions,
Restrictions, or
Limits on Use
97
Tier level
What the
drug will
cost you
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem LA)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Verapamil HCl)
1
$0
Name of Drug
cartia xt oral capsule,extended
mg, 300 mg
diltiazem 24hr er 180 mg cap 180
mg
diltiazem 24hr er 360 mg cap once a
day dosage 360 mg
diltiazem hcl intravenous recon soln
100 mg
diltiazem hcl intravenous solution 5
mg/ml
diltiazem hcl oral capsule, extended
diltiazem hcl oral capsule,extended
release 12 hr 120 mg, 60 mg, 90 mg
diltiazem hcl oral capsule,extended
mg
diltiazem hcl oral tablet 120 mg, 30
mg, 60 mg, 90 mg
diltiazem hcl oral tablet extended
release 24 hr 180 mg, 240 mg, 300
mg, 360 mg, 420 mg
dilt-xr oral capsule,ext release
degradable 120 mg, 180 mg, 240 mg
matzim la oral tablet extended
release 24 hr 180 mg, 240 mg, 300
mg, 360 mg, 420 mg
taztia xt oral capsule, extended
release 120 mg, 180 mg, 240 mg,
300 mg, 360 mg
verapamil intravenous syringe 2.5
mg/ml
Necessary Actions,
Restrictions, or
Limits on Use
98
Tier level
What the
drug will
cost you
(Verelan Pm)
1
$0
(Verelan)
1
$0
(Calan)
1
$0
(Calan SR)
1
$0
2
$0
2
$0
(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
(Lanoxin)
1
$0
(Lanoxin)
1
$0
Name of Drug
verapamil oral capsule, 24 hr er
pellet ct 100 mg, 200 mg, 300 mg
verapamil oral capsule,ext rel.
pellets 24 hr 120 mg, 180 mg, 240
mg, 360 mg
verapamil oral tablet 120 mg, 40
mg, 80 mg
verapamil oral tablet extended
Cardiovascular Agents,
Miscellaneous
CORLANOR ORAL TABLET 5
MG, 7.5 MG
DEMSER ORAL CAPSULE 250
MG
digitek oral tablet 125 mcg
digoxin 0.25 mg/ml syringe 250
mcg/ml
digoxin injection solution 250
mcg/ml
DIGOXIN ORAL SOLUTION 50
MCG/ML
digoxin oral tablet 125 mcg
digoxin oral tablet 250 mcg
Necessary Actions,
Restrictions, or
Limits on Use
ST
QL (30 per 30 days)
PA-HRM; QL (30 per
30 days)
QL (30 per 30 days)
PA-HRM; QL (30 per
30 days)
PA-HRM
PA-HRM
PA-HRM; QL (300 per
30 days)
QL (30 per 30 days)
PA-HRM; QL (30 per
30 days)
99
Name of Drug
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)
epinephrine injection syringe 0.1
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
ethamolin intravenous solution 5 %
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
(Dobutamine
HCl/D5W)
1
$0
(Dobutamine HCl)
1
$0
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
(Epinephrine)
1
$0
2
$0
2
$0
1
$0
(Ethanolamine
Oleate)
FIRAZYR SUBCUTANEOUS
2
$0
SYRINGE 30 MG/3 ML
100
Tier level
What the
drug will
cost you
(Hydralazine HCl)
1
$0
(Hydralazine HCl)
1
$0
2
$0
2
$0
(Milrinone
Lactate/D5W)
1
$0
(Milrinone Lactate)
1
$0
(Levophed
Bitartrate)
1
$0
(Papaverine HCl)
1
$0
(Papaverine HCl)
1
$0
2
$0
(Adalat CC)
1
$0
(Norvasc)
1
$0
(Lotrel)
1
$0
(Exforge)
1
$0
Name of Drug
hydralazine injection solution 20
mg/ml
hydralazine oral tablet 10 mg, 100
mg, 25 mg, 50 mg
LANOXIN ORAL TABLET 187.5
MCG
LANOXIN ORAL TABLET 62.5
MCG
milrinone in 5 % dextrose
ml (200 mcg/ml)
milrinone intravenous solution 1
mg/ml
norepinephrine bitartrate
intravenous solution 1 mg/ml
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
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (30 per
30 days)
QL (30 per 30 days)
PA BvD
PA BvD
PA BvD
PA
PA
101
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
(Felodipine)
1
$0
(Isradipine)
1
$0
(Nicardipine HCl)
1
$0
(Procardia XL)
1
$0
(Adalat CC)
1
$0
(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
Name of Drug
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
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
(Exforge HCT)
Necessary Actions,
Restrictions, or
Limits on Use
ST
102
Tier level
What the
drug will
cost you
2
$0
(Furosemide)
1
$0
(Furosemide)
1
$0
(Furosemide)
1
$0
(Lasix)
1
$0
(Microzide)
1
$0
(Hydrochlorothiazi
de)
1
$0
(Indapamide)
1
$0
(Methyclothiazide)
1
$0
(Zaroxolyn)
1
$0
(Demadex)
1
$0
(Dyazide)
1
$0
(Maxzide)
1
$0
(Caduet)
1
$0
(Lipitor)
1
$0
Name of Drug
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
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
Necessary Actions,
Restrictions, or
Limits on Use
103
Tier level
What the
drug will
cost you
(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
(Lofibra)
1
$0
(Trilipix)
1
$0
(Fibricor)
1
$0
(Lopid)
1
$0
Name of Drug
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
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 *
Necessary Actions,
Restrictions, or
Limits on Use
PA
2
$0
2
$0
(Mevacor)
1
$0
(Slo-Niacin)
(Niacin)
(Slo-Niacin)
4
4
4
$0
$0
$0
104
Tier level
What the
drug will
cost you
(Niaspan)
1
$0
(Slo-Niacin)
4
$0
(Niacinamide)
(Niacin)
4
1
$0
$0
(Lovaza)
1
$0
Name of Drug
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
pravastatin oral tablet 10 mg, 20
mg, 40 mg, 80 mg
prevalite oral powder 4 gram
prevalite packet outer 4 gram
REPATHA SURECLICK
SUBCUTANEOUS PEN
INJECTOR 140 MG/ML
REPATHA SYRINGE
MG/ML
simvastatin oral tablet 10 mg, 20
mg, 40 mg, 5 mg
simvastatin oral tablet 80 mg
VASCEPA ORAL CAPSULE 1
GRAM
WELCHOL ORAL POWDER IN
PACKET 3.75 GRAM
Necessary Actions,
Restrictions, or
Limits on Use
2
$0
2
$0
1
$0
1
$0
1
$0
2
$0
2
$0
(Zocor)
1
$0
(Zocor)
1
$0
2
$0
2
$0
(Pravachol)
(Cholestyramine/A
spartame)
(Cholestyramine/A
spartame)
QL (30 per 30 days)
105
Tier level
What the
drug will
cost you
2
$0
2
$0
(Inspra)
1
$0
(Aldactone)
1
$0
(Aldactazide)
1
$0
2
$0
(Isochron)
1
$0
(Isochron)
1
$0
1
$0
1
$0
(Imdur)
1
$0
(Nitro-Dur)
1
$0
(Nitro-Dur)
1
$0
(Minoxidil)
1
$0
1
$0
Name of Drug
WELCHOL ORAL TABLET 625
MG
ZETIA ORAL TABLET 10 MG
Renin-AngiotensinAldosterone System
Inhibitors
eplerenone oral tablet 25 mg, 50 mg
spironolactone oral tablet 100 mg,
25 mg, 50 mg
spironolacton-hydrochlorothiaz oral
tablet 25-25 mg
Vasodilators
BIDIL ORAL TABLET 20-37.5
MG
isosorbide dinitrate oral tablet 10
mg, 20 mg, 30 mg, 5 mg
isosorbide dinitrate oral tablet
isosorbide dinitrate sublingual
tablet 2.5 mg, 5 mg
isosorbide mononitrate oral tablet
10 mg, 20 mg
isosorbide mononitrate oral tablet
extended release 24 hr 120 mg, 30
mg, 60 mg
minitran transdermal patch 24 hour
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
minitran transdermal patch 24 hour
0.4 mg/hr
minoxidil oral tablet 10 mg, 2.5 mg
NITRO-BID TRANSDERMAL
OINTMENT 2 %
(Isosorbide
Dinitrate)
(Isosorbide
Mononitrate)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (60 per 30 days)
106
Tier level
What the
drug will
cost you
(Nitroglycerin/D5
W)
1
$0
(Nitroglycerin)
1
$0
Name of Drug
nitroglycerin in 5 % dextrose
(400 mcg/ml), 25 mg/250 ml (100
mcg/ml), 50 mg/250 ml (200
mcg/ml)
nitroglycerin intravenous solution
50 mg/10 ml (5 mg/ml)
nitroglycerin transdermal patch 24
hour 0.1 mg/hr, 0.2 mg/hr, 0.6
mg/hr
nitroglycerin transdermal patch 24
hour 0.4 mg/hr
NITROSTAT SUBLINGUAL
TABLET 0.3 MG, 0.4 MG, 0.6 MG
PROGLYCEM ORAL
SUSPENSION 50 MG/ML
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
(Nitro-Dur)
1
$0
(Nitro-Dur)
1
$0
2
$0
2
$0
2
$0
(Cafcit)
1
$0
(Cafcit)
1
$0
(Caffeine/Sodium
Benzoate)
1
$0
(Kapvay)
1
$0
(Focalin)
1
$0
QL (60 per 30 days)
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
PA; QL (60 per 30
days)
QL (60 per 30 days)
107
Name of Drug
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
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
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
(Dexedrine)
1
$0
(Dexedrine)
1
$0
QL (30 per 30 days)
(Adderall XR)
1
$0
QL (60 per 30 days)
(Adderall XR)
1
$0
(Adderall)
1
$0
(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
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
108
Tier level
What the
drug will
cost you
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Methylin)
1
$0
(Ritalin)
1
$0
(Methylphenidate
HCl)
1
$0
(Concerta)
1
$0
(Concerta)
1
$0
2
$0
2
$0
1
$0
2
$0
2
$0
2
$0
1
$0
Name of Drug
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
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
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,
25 mg
Necessary Actions,
Restrictions, or
Limits on Use
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)
(Rilutek)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
(Xenazine)
PA; QL (112 per 28
days)
Contraceptives
Contraceptives
109
Tier level
What the
drug will
cost you
3
$0
(Amethyst)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
(Seasonique)
1
$0
Name of Drug
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
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)
Necessary Actions,
Restrictions, or
Limits on Use
QL (6 per 365 days)
QL (91 per 84 days)
QL (91 per 84 days)
(Seasonique)
1
$0
(Desogen)
1
$0
(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
110
Name of Drug
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
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
(Modicon)
(Nor-Q-D)
Tier level
What the
drug will
cost you
1
1
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
(Seasonique)
1
$0
(Seasonique)
1
$0
(Desogen)
1
$0
(Norgestrel-Ethinyl
Estradiol)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
(Desogen)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
QL (91 per 84 days)
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
111
Name of Drug
Tier level
What the
drug will
cost you
econtra ez 1.5 mg tablet inner 1.5
mg *
(Aftera)
4
$0
elinest oral tablet 0.3-30 mg-mcg
(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
(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
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
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
Necessary Actions,
Restrictions, or
Limits on Use
QL (6 per 365 days)
QL (6 per 365 days)
QL (91 per 84 days)
QL (91 per 84 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
(Mircette)
1
$0
(Demulen 1-50-21)
1
$0
(Mircette)
1
$0
(Amethyst)
1
$0
Name of Drug
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
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
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
113
Tier level
What the
drug will
cost you
(Amethyst)
1
$0
(Amethyst)
1
$0
(Aftera)
4
$0
(Plan B One-Step)
(Plan B One-Step)
1
1
$0
$0
(Amethyst)
1
$0
Name of Drug
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)
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)
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
QL (6 per 365 days)
QL (6 per 365 days)
QL (91 per 84 days)
(Amethyst)
1
$0
QL (91 per 84 days)
(Amethyst)
1
$0
(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
114
Tier level
What the
drug will
cost you
(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
(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
Name of Drug
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
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
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
Necessary Actions,
Restrictions, or
Limits on Use
QL (6 per 365 days)
QL (6 per 365 days)
QL (6 per 365 days)
115
Tier level
What the
drug will
cost you
(Nor-Q-D)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
2
$0
(Yaz)
(Norgestrel-Ethinyl
Estradiol)
1
$0
1
$0
(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
Name of Drug
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
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
(Nor-Q-D)
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (1 per 28 days)
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)
116
Tier level
What the
drug will
cost you
(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
(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
Name of Drug
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)
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
Necessary Actions,
Restrictions, or
Limits on Use
117
Tier level
What the
drug will
cost you
(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
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
Name of Drug
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
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 *
(Chlorpheniramine/
Phenyleph/Dm)
(Chlophedianol
HCl/Guaifenesin)
(Trispec Pse)
(Brompheniramine/
Pseudoephed/Dm)
(Brompheniramine/
Pseudoephed/Dm)
118
Name of Drug
adult wal-tussin dm syrup
a/f,cherry,adult 10-100 mg/5 ml *
(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)
benzonatate 100 mg capsule 100 mg
(Zonatuss)
*
(Zonatuss)
*
(Zonatuss)
*
bio-dtuss dmx liquid 1-30-20 mg/5
(Brompheniramine/
ml *
Pseudoephed/Dm)
bionel pediatric liquid 15-5-50 mg/5
(Trispec Pse)
ml *
biospec dmx liquid 15-25 mg/5 ml * (G-Zyncof)
bp 8 cough oral suspension a/f,
(Guaifenesin/Dm/P
grape (otc) 30-15-175 mg/5 ml *
seudoephedrine)
bpm-pse-dm liquid a/f, cotton candy (Brompheniramine/
(otc) 4-20-20 mg/5 ml *
Pseudoephed/Dm)
bromfed dm cough syrup 2-30-10
(Brompheniramine/
mg/5 ml *
Pseudoephed/Dm)
bromphenex dm syrup (otc) 4-60-30 (Brompheniramine/
mg/5 ml *
Pseudoephed/Dm)
Tier level
What the
drug will
cost you
4
$0
4
$0
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
3
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
119
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
(G-Zyncof)
4
$0
(Tusnel C)
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
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 *
(Brompheniramine/
Pseudoephed/Dm)
(Brompheniramine/
Pseudoephed/Dm)
(Chlorpheniramine/
Phenyleph/Dm)
(Dextromethorphan
/Phenylephrine)
(Cough Formula
Dm)
(Dextromethorphan
child wal-tussin 7.5 mg odt 7.5 mg *
Hbr)
children's mucinex cough liq a/f 5(G-Zyncof)
100 mg/5 ml *
children's silfedrine liq 15 mg/5 ml (Pseudoephedrine
*
HCl)
childs sudafed 15 mg/5 ml liq non- (Pseudoephedrine
drowsy,a/f,s/f 15 mg/5 ml *
HCl)
(Robitussin
chl mucinex chest congest liq a/f
Mucus-Chest
100 mg/5 ml *
Congest)
codituss dm syrup 8.33-5-10 mg/5
(Pyrilamine/Pe/De
ml *
xtromethorphan)
cold multi-symptom day-night
(Dm
pseudoephedrine-free 2-5-10-325
Hb/Pe/Acetaminop
mg *
hen/Chlorph)
(Dm
cold relief multi-symp caplet cplt,12
Hb/Pe/Acetaminop
day,12 night 2-5-10-325 mg *
hen/Chlorph)
Necessary Actions,
Restrictions, or
Limits on Use
120
Name of Drug
cold-flu relief d/n softgel 10-5325mg(d)/ 15-325-6.25mg *
(Vicks DayquilNyquil)
(Dcold-flu relief liquid 12.5-30-1,000
Methorphan/Aceta
mg/30 ml *
min/Doxylamn)
(Guaifenesin/Pseud
congestac tablet 60-400 mg *
oephedrne HCl)
congest-eze 60-400 mg caplet 60(Guaifenesin/Pseud
400 mg *
oephedrne HCl)
(Dcoricidin hbp cold-multi sympt 6.25Methorphan/Aceta
15-325 mg/15 ml *
min/Doxylamn)
(Guaifenesin/Dextr
coricidin hbp softgel 10-200 mg *
omethorphan)
cough & cold tablet 4-30 mg *
(Coricidin Hbp)
cvs chest cong relief pe tab 10-400
(Maxiphen)
mg *
cvs chest congest relief dm tb 20(Allfen Dm)
400 mg *
cvs child cold-cough day liq 2.5-5
(Dextromethorphan
mg/5 ml *
/Phenylephrine)
(Robitussin
cvs child's chest congest liq 100
Mucus-Chest
mg/5 ml *
Congest)
cvs cough & sore throat susp 160-5 (Acetaminophen/D
mg/5 ml *
extromethorphan)
cvs cough relief liquid a/f, grape 15 (Dextromethorphan
mg/5 ml *
Hbr)
cvs daytime-nighttime cold-flu
(Dm/Pe/Acetamino
multi-symp,twin pack 6.25-5-10-325
phen/Doxylamine)
mg/15 ml *
cvs tussin cgh 15 mg liq gels non(Robitussin)
drowsy, liq gels 15 mg *
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
121
Tier level
What the
drug will
cost you
(G-Zyncof)
4
$0
(Dextromethorphan
Hbr)
4
$0
(Triaminic)
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
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 *
(Ddaytime cold & flu liquid a/f, glutenMethorphan/Pe/Ac
free 5-10-325 mg/15 ml *
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 *
(Guaifenesin/Dm/P
despec-dm tablet 30-10-200 mg *
seudoephedrine)
dextromethorphan er 30 mg/5 ml 30
(Delsym)
mg/5 ml *
diabetic tussin dm liquid 10-100
(G-Zyncof)
mg/5 ml *
diabetic tussin dm max-str liq 10(G-Zyncof)
200 mg/5 ml *
ed bron gp liquid 5-100 mg/5 ml *
(Despec)
entre-cough liquid 30-15-175 mg/5
(Trispec Pse)
ml *
(Robitussin
expectorant 100 mg/5 ml syrup 100
Mucus-Chest
mg/5 ml *
Congest)
expectorant dm cough liquid 20-300
(G-Zyncof)
mg/5 ml *
expectorant max cough-cold 30-15 (Dextromethorphan
mg/5 ml *
/Pseudoephed)
Necessary Actions,
Restrictions, or
Limits on Use
122
Tier level
What the
drug will
cost you
(Cough Formula
Dm)
4
$0
(Allfen)
4
$0
(Tusnel C)
4
$0
(Mucinex)
4
$0
4
$0
3
$0
3
$0
3
$0
4
3
$0
$0
4
$0
3
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
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
*
(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 *
(Hydrocodone
hydromet syrup 5-1.5 mg/5 ml *
Bit/Homatrop MeBr)
liquibid d-r tablet 10-400 mg *
(Maxiphen)
lohist-dm syrup 2-5-10 mg/5 ml *
(Ala-Hist Dm)
lortuss ex liquid 30-10-100 mg/5 ml
(Tusnel C)
*
mar-cof bp liquid 2-30-7.5 mg/5 ml (Bromphenira/Pseu
*
doephed/Codein)
mar-cof cg liquid 7.5-225 mg/5 ml * (M-Clear Wc)
mesehist dm oral syrup 2-15-15
(Chlorpheniramin/
mg/5 ml *
Pseudoephed/Dm)
mucus dm 600-30 mg tablet 30-600
(Mucinex Dm)
mg *
mucus dm max tablet 60-1,200 mg * (Mucinex Dm)
mucus relief 400 mg tablet d/f 400
(Allfen)
mg *
(Pseudoephedrine
nasal-sinus decongest tab 30 mg *
HCl)
Necessary Actions,
Restrictions, or
Limits on Use
123
Name of Drug
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 *
(Chlorpheniramine/
Phenyleph/Dm)
(G-Zyncof)
(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)
(Chlorpheniramine/
nohist-dm liquid 4-10-15 mg/5 ml *
Phenyleph/Dm)
pecgen dmx 125-15 mg/5 ml liq 15(G-Zyncof)
125 mg/5 ml *
pedia relief cough-cold liquid a/f,
(Chlorpheniramin/
cherry 1-15-5 mg/5 ml *
Pseudoephed/Dm)
pediacare multi-symt cold liq non
(Dextromethorphan
drowsy, grape 2.5-5 mg/5 ml *
/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)
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
3
$0
Necessary Actions,
Restrictions, or
Limits on Use
124
Name of Drug
promethazine-dm syrup 6.25-15
mg/5 ml *
pseudoephed 30 mg/5 ml soln 30
mg/5 ml *
pseudoephedrine 30 mg tablet 30
mg *
pseudoephedrine 60 mg tablet exstr, non drowsy (otc) 60 mg *
(Promethazine/Dex
tromethorphan)
(Pseudoephedrine
HCl)
(Pseudoephedrine
HCl)
(Pseudoephedrine
HCl)
(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)
(Robitussin
q-tussin 100 mg/5 ml solution a/f,
Mucus-Chest
non-drowsy 100 mg/5 ml *
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 *
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
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
125
Name of Drug
ra multi-symptom cold caplet
nighttime,cplt 2-5-10-325 mg *
ra tussin dm syrup a/f 10-100 mg/5
ml *
refenesen 200 mg tablet 200 mg *
refenesen pe caplet 10-400 mg *
relcof c liquid 6.3-100 mg/5 ml *
REZIRA SOLUTION 60-5 MG/5
ML *
robafen 100 mg/5 ml syrup 100
mg/5 ml *
(Dm
Hb/Pe/Acetaminop
hen/Chlorph)
(Cough Formula
Dm)
(Allfen)
(Maxiphen)
(M-Clear Wc)
(Robitussin
Mucus-Chest
Congest)
robafen cough 15 mg liquidgel non(Robitussin)
drowsy,liquidgel 15 mg *
(Cough Formula
robafen-dm syrup 10-100 mg/5 ml *
Dm)
robitussin cough-chest-cong dm 10- (Guaifenesin/Dextr
200 mg *
omethorphan)
ROBITUSSIN LONG-ACTING
LIQ 1-7.5 MG/5 ML *
robitussin pediatric cough syp
(Dextromethorphan
a/f,long-acting 7.5 mg/5 ml *
Hbr)
(Bromphenira/Pseu
rydex liquid 1.3-10-6.3 mg/5 ml *
doephed/Codein)
rynex dm liquid a/f, prof use only 1- (Brompheniram/Ph
2.5-5 mg/5 ml *
enylephrine/Dm)
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)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
4
3
$0
$0
$0
3
$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
126
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Trispec Pse)
4
$0
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
4
$0
(G-Zyncof)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
siltussin dm cough syrup 10-100
mg/5 ml *
siltussin sa 100 mg/5 ml syr 100
mg/5 ml *
sm adult nasal decongestant lq 15
mg/5 ml *
sm childrens plus cold susp
grape,multi-symptom 1-2.5-5-160
mg/5 ml *
sm cold-cough child elixir 1-15-5
mg/5 ml *
sm cough & runny nose liquid 1-5
mg/5 ml *
sm cough-head congestion lq 20-1066.7 mg/5 ml *
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 *
(Cough Formula
Dm)
(Robitussin
Mucus-Chest
Congest)
(Pseudoephedrine
HCl)
(Dm
Hb/Pe/Acetaminop
hen/Chlorph)
(Brompheniramine/
Pseudoephed/Dm)
(Vicks Children'S
Nyquil)
(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 nite time cold-flu liquid 7.5-6030-1,000 mg/30 ml *
Necessary Actions,
Restrictions, or
Limits on Use
127
Name of Drug
sm tussin cf syrup 30-10-100 mg/5
ml *
sudafed 30 mg tablet nondrowsy,max-str 30 mg *
sudogest 30 mg tablet boxed 30 mg
*
sudogest 60 mg tablet 60 mg *
suphedrin liquid 15 mg/5 ml *
suphedrine pe combo pack cplt 510-325 mg *
THERAFLU COLD AND COUGH
POWDER 10-20-650 MG *
THERAFLU MULTI-SYMP COLD
CPLT 5-10-325 MG *
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 *
(Guaifenesin/Dm/P
seudoephedrine)
(Pseudoephedrine
HCl)
(Pseudoephedrine
HCl)
(Pseudoephedrine
HCl)
(Diphenhydram/Pe/
Dm/Acetamin/Gg)
(Dextromethorphan
/Phenylephrine)
(Chlorpheniramine/
Phenyleph/Dm)
(M-Clear Wc)
(G-Zyncof)
(Tussi-Pres
Pediatric)
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
Necessary Actions,
Restrictions, or
Limits on Use
128
Name of Drug
tussin cold-congestion gelcap liquid
gelcap 30-10-200 mg *
tussin dm syrup 15-100 mg/5 ml *
VANACOF LIQUID 1-30-12.5
MG/5 ML *
vicks dayquil cough liquid a/f,8 hr
rlf 5 mg/5 ml *
vicks dayquil liquicaps cold & flu 510-325 mg *
vicks nature fusion cough liq 5 mg/5
ml *
vicks nyquil severe cold-flu 6.25-510-325 mg/15 ml *
virdec dm drops 1-3.5-3 mg/ml *
virtussin ac liquid 10-100 mg/5 ml *
v-r infant non-asa cold drp 15-5-160
mg/1.6 ml *
v-r non-aspirin flu gelcap gelatin
caplet 30-15-500 mg *
v-r pedia relief inf drops
decongestant + 7.5-2.5 mg/0.8 ml *
vr triacting cold-cough liq 1-15-5
mg/5 ml *
v-r tussin cf syrup 30-10-100 mg/5
ml *
wal-phed 30 mg tablet non-drowsy
30 mg *
wal-phed pe day-night combo pk
gluten-free 5-10-325 mg *
(Guaifenesin/Dm/P
seudoephedrine)
(Cough Formula
Dm)
(Dextromethorphan
Hbr)
(DMethorphan/Pe/Ac
etaminophen)
(Dextromethorphan
Hbr)
(Dm/Pe/Acetamino
phen/Doxylamine)
(Chlorpheniramine/
Phenyleph/Dm)
(M-Clear Wc)
(Dm/Pseudoephed/
Acetaminophen)
(Dm/Pseudoephed/
Acetaminophen)
(Dextromethorphan
/Pseudoephed)
(Chlorpheniramin/
Pseudoephed/Dm)
(Guaifenesin/Dm/P
seudoephedrine)
(Pseudoephedrine
HCl)
(Diphenhydram/Pe/
Dm/Acetamin/Gg)
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
(Tussi-Pres
Pediatric)
4
$0
(Robitussin)
4
$0
4
$0
4
$0
3
$0
(G-Zyncof)
4
$0
(Evoxac)
1
$0
(Peridex)
1
$0
(Triamcinolone
Acetonide)
1
$0
(Peridex)
1
$0
(Salagen)
1
$0
1
$0
(Sodium Fluoride)
1
$0
(Triamcinolone
Acetonide)
1
$0
Name of Drug
wal-tussin cough & cold cf
pseudoephedrine free 5-10-100
mg/5 ml *
wal-tussin cough 15 mg softgel 15
mg *
wal-tussin cough 15 mg/5 ml 15
mg/5 ml *
zephrex-d 30 mg tablet 30 mg *
ZONATUSS 150 MG CAPSULE
150 MG *
zyncof 20-400 mg/5 ml liquid 20400 mg/5 ml *
(Dextromethorphan
Hbr)
(Pseudoephedrine
HCl)
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 %
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 %
Dermatological Agents
Dermatological Agents,
Other
130
Name of Drug
Tier level
What the
drug will
cost you
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
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
(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
amlactin 12% lotion 12 % *
ammonium lactate 12% cream
fragrance free (otc) 12 % *
ammonium lactate 12% lotion (otc)
12 % *
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 %
(Benzoyl Peroxide)
(Zovirax)
(Ammonium
Lactate)
(Ammonium
Lactate)
(Ammonium
Lactate)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
131
Name of Drug
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 %
*
fluorouracil topical cream 0.5 %, 5
%
fluorouracil topical solution 2 %, 5
%
geri-hydrolac 12% lotion 12 % *
geri-hydrolac 5% lotion 5 % *
(Vectical)
Tier level
What the
drug will
cost you
1
$0
4
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
PA
2
$0
2
$0
(Ammonium
Lactate)
4
$0
(Carac)
1
$0
(Fluorouracil)
1
$0
4
$0
4
$0
1
$0
4
4
$0
$0
1
$0
2
$0
(Ammonium
Lactate)
(Ammonium
Lactate)
imiquimod topical cream in packet 5
(Aldara)
%
LACTINOL HX CREAM *
lobana bath oil *
(Mineral Oil)
methoxsalen rapid oral capsule 10
(Oxsoralen-Ultra)
mg
PANRETIN TOPICAL GEL 0.1 %
PA
PA NSO; QL (24 per
30 days)
132
Name of Drug
persa-gel 10% 12's,max-strength 10
(Benzoyl Peroxide)
%*
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
(Podophyllum
podocon topical liquid 25 %
Resin)
podofilox topical solution 0.5 %
(Condylox)
potassium hydroxide topical
(Potassium
solution 5 %
Hydroxide)
pv acne pimple 10% gel 10 % *
(Benzoyl Peroxide)
SANTYL TOPICAL OINTMENT
250 UNIT/GRAM
TALTZ AUTOINJECTOR
SUBCUTANEOUS AUTOINJECTOR 80 MG/ML
TALTZ SYRINGE
MG/ML
TOLAK TOPICAL CREAM 4 %
VALCHLOR TOPICAL GEL 0.016
%
zenatane oral capsule 10 mg, 20 mg,
(Isotretinoin)
30 mg, 40 mg
zinc oxide 20% ointment 20 % *
(Boudreauxs)
ZOVIRAX TOPICAL CREAM 5 %
Dermatological
Antibacterials
bacitracin 500 unit/gm ointmnt 500
(Bacitracin)
unit/gram *
bacitraycin plus 500 unit/gm 500
(Bacitracin)
unit/gram *
clindamycin phosphate topical gel 1
(Cleocin T)
%
Tier level
What the
drug will
cost you
4
$0
2
2
$0
$0
1
$0
1
$0
1
$0
4
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (3 per 56 days)
QL (2 per 56 days)
PA
2
$0
2
$0
2
$0
2
$0
1
$0
4
2
$0
$0
4
$0
4
$0
1
$0
PA
QL (15 per 30 days)
133
Name of Drug
clindamycin phosphate topical
(Cleocin T)
lotion 1 %
clindamycin phosphate topical
(Cleocin T)
solution 1 %
clindamycin phosphate topical swab
(Cleocin T)
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)
(Gentamicin
gentamicin topical ointment 0.1 %
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 %
(Centany)
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)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
134
Tier level
What the
drug will
cost you
(Selenium Sulfide)
1
$0
(Selenium Sulfide)
1
$0
(Silver Nitrate)
1
$0
(Silver Nitrate)
1
$0
(Silvadene)
1
$0
(Silvadene)
1
$0
(Klaron)
1
$0
(Neomycin
Su/Bacitrac
Zn/Poly)
4
$0
1
1
$0
$0
1
$0
1
$0
4
4
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
selenium sulfide topical lotion 2.5 %
selenium sulfide topical shampoo
2.25 %
silver nitrate topical ointment 10 %
silver nitrate topical solution 0.5 %,
10 %, 25 %, 50 %
silver sulfadiazine topical cream 1
%
ssd topical cream 1 %
sulfacetamide sodium (acne) topical
suspension 10 %
triple antibiotic ointment carton
3.5mg-400 unit- 5,000 unit/gram *
Dermatological AntiInflammatory Agents
ala-cort topical cream 1 %
ala-scalp topical lotion 2 %
alclometasone topical cream 0.05 %
(Anusol-HC)
(Scalacort)
(Alclometasone
Dipropionate)
(Alclometasone
Dipropionate)
(Cortizone-10)
(Cortizone-10)
(Betamethasone
Dipropionate)
(Betamethasone
Dipropionate)
(Betamethasone
Dipropionate)
(Betamethasone
Valerate)
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 %
(Luxiq)
foam 0.12 %
Necessary Actions,
Restrictions, or
Limits on Use
135
Tier level
What the
drug will
cost you
1
$0
1
$0
(Diprolene AF)
1
$0
(Betamethasone
Dipropionate)
1
$0
(Diprolene)
1
$0
(Diprolene)
1
$0
(Temovate)
(Clobetasol
Propionate)
(Olux)
(Clobetasol
Propionate)
(Clobex)
(Temovate)
(Clobex)
1
$0
1
$0
1
$0
1
$0
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
4
$0
4
$0
4
4
$0
$0
Name of Drug
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 %
(Betamethasone
Valerate)
(Betamethasone
Valerate)
clobetasol topical lotion 0.05 %
clobetasol topical ointment 0.05 %
clobetasol topical shampoo 0.05 %
clobetasol-emollient topical cream
(Temovate)
0.05 %
clocortolone pivalate topical cream
(Cloderm)
0.1 %
colocort rectal enema 100 mg/60 ml (Cortenema)
(Clobetasol
cormax scalp solution 0.05 %
Propionate)
cortizone-10 1% creme maximum
(Hydrocortisone)
strength 1 % *
CORTIZONE-10 1% LOTION 1 %
*
cortizone-10 1% ointment 1 % *
(Hydrocortisone)
dermarest eczema 1% lotion 1 % * (Cortizone-10)
Necessary Actions,
Restrictions, or
Limits on Use
136
Tier level
What the
drug will
cost you
(Desowen)
(Desonide)
1
1
$0
$0
(Topicort)
1
$0
(Topicort)
1
$0
(Topicort)
1
$0
(Vanos)
(Fluocinonide)
2
1
1
$0
$0
$0
(Fluocinonide)
1
$0
Name of Drug
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
(Fluocinonide)
1
$0
(Vanos)
1
$0
(Cutivate)
1
$0
(Fluticasone
fluticasone topical ointment 0.005 %
1
$0
Propionate)
halobetasol propionate topical
(Ultravate)
1
$0
cream 0.05 %
halobetasol propionate topical
(Ultravate)
1
$0
ointment 0.05 %
hydro skin 1% lotion 1 % *
(Cortizone-10)
4
$0
hydrocortisone 0.5% cream (otc)
(Hydrocortisone)
4
$0
0.5 % *
hydrocortisone 0.5% ointment 0.5 %
(Hydrocortisone)
4
$0
*
hydrocortisone 1% cream maximum
(Hydrocortisone)
4
$0
strength (otc) 1 % *
hydrocortisone 1% cream maximum (Hydrocortisone
4
$0
strength 1 % *
Acetate)
hydrocortisone 1% lotion (otc) 1 %
(Cortizone-10)
3
$0
*
hydrocortisone 1% ointment carton
(Hydrocortisone)
4
$0
(otc) 1 % *
137
Tier level
What the
drug will
cost you
1
$0
4
$0
(Hydrocortisone
Butyrate)
1
$0
(Locoid)
1
$0
(Locoid)
1
$0
(Hydrocortisone
Butyrate)
1
$0
(Cortenema)
1
$0
(Anusol-HC)
1
$0
(Hydrocortisone)
1
$0
(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)
4
1
1
$0
$0
$0
Name of Drug
hydrocortisone acet-aloe vera
topical gel 2 %
hydrocortisone acetate-aloe topical
cream 0.5 % *
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 ointment 1
%, 2.5 %
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 %
(Hydrocortisone
Acetate/Aloe V)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (60 per
30 days)
138
Tier level
What the
drug will
cost you
(Hydrocortisone)
(Hydrocortisone)
(Hydrocortisone)
1
1
4
$0
$0
$0
(Protopic)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
$0
$0
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
(Piperonyl
Butoxide/Pyrethrin
s)
4
$0
Name of Drug
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 %
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 % *
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Hydrocortisone
Acetate/Urea)
(Differin)
(Differin)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
PA
PA
PA
139
Tier level
What the
drug will
cost you
4
1
$0
$0
4
$0
(Elimite)
1
$0
(Nix)
4
$0
(Nix)
4
$0
(Nix)
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
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 % *
(Nix)
(Ovide)
Necessary Actions,
Restrictions, or
Limits on Use
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
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
140
Name of Drug
Tier level
What the
drug will
cost you
4
$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
2
$0
ALDURAZYME INTRAVENOUS
2
$0
SOLUTION 2.9 MG/5 ML
CEREZYME INTRAVENOUS
2
$0
RECON SOLN 400 UNIT
CREON ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000 60,000 UNIT, 24,000-76,000 2
$0
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
2
$0
SOLUTION 6 MG/3 ML
ELITEK INTRAVENOUS RECON
2
$0
SOLN 1.5 MG
FABRAZYME INTRAVENOUS
2
$0
RECON SOLN 35 MG
KANUMA INTRAVENOUS
PA
2
$0
SOLUTION 2 MG/ML
KRYSTEXXA INTRAVENOUS
2
$0
SOLUTION 8 MG/ML
KUVAN ORAL
2
$0
TABLET,SOLUBLE 100 MG
141
Name of Drug
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
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
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
1
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA; LA
2
$0
PA
2
$0
2
$0
2
$0
2
$0
QL (90 per 30 days)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat
Agents, Miscellaneous
142
Tier level
What the
drug will
cost you
2
$0
(Proparacaine HCl)
(Tetravisc)
(Little Remedies)
1
1
4
$0
$0
$0
(Iopidine)
1
$0
4
$0
4
$0
4
$0
4
$0
1
1
1
$0
$0
$0
4
$0
4
$0
1
$0
1
$0
4
$0
1
$0
1
$0
4
$0
Name of Drug
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
%
(Polyvinyl
Alcohol)
(Dextran
artificial tears drops p/f, sterile 0.170/Hypromellose/P
0.3 % *
F)
artificial tears eye drops strl 0.1-0.3
(Tears Naturale)
%*
artificial tears eye ointment 83-15 %
(Genteal Pm)
*
atropine ophthalmic drops 1 %
(Isopto Atropine)
atropine ophthalmic ointment 1 %
(Atropine Sulfate)
atropine-care ophthalmic drops 1 % (Isopto Atropine)
ayr saline 0.65% nose drops 0.65 %
(Sodium Chloride)
*
ayr saline 0.65% nose spray 0.65 %
(Little Remedies)
*
azelastine nasal aerosol,spray 137
(Astepro)
mcg (0.1 %)
azelastine ophthalmic drops 0.05 % (Azelastine HCl)
(Dextran
bion tears eye drops 0.1-0.3 % *
70/Hypromellose/P
F)
carteolol ophthalmic drops 1 %
(Carteolol HCl)
(Cromolyn
cromolyn ophthalmic drops 4 %
Sodium)
cvs artificial tears drops sterile 1(Glycerin/Propylen
0.3 % *
e Glycol)
artificial tears 1.4 % drops 1.4 % *
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 25 days)
143
Name of Drug
Tier level
What the
drug will
cost you
cvs lubricant 0.5% eye drops sterile
0.5 % *
(Refresh Tears)
4
$0
cvs lubricant dry eye rlf 1% 1 % *
(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
1
$0
2
$0
4
$0
4
$0
1
$0
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
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 % *
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 % *
Necessary Actions,
Restrictions, or
Limits on Use
144
Tier level
What the
drug will
cost you
4
$0
4
$0
1
$0
1
$0
(Atrovent)
1
$0
(Atrovent)
1
$0
(Genteal Mild To
Moderate)
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
Name of Drug
GENTEAL SEVERE 0.3% EYE
GEL P/F, STRL, INNER 0.3 % *
genteal tears 0.1%-0.3% drop 0.10.3 % *
homatropaire ophthalmic drops 5 %
homatropine hbr ophthalmic drops
5%
ipratropium bromide nasal
spray,non-aerosol 0.03 %
ipratropium bromide nasal
spray,non-aerosol 0.06 %
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 % *
natural balance tears drops 0.4 % *
nature's tears drops 0.4 % *
(Tears Naturale)
(Isopto
Homatropine)
(Isopto
Homatropine)
(Genteal Mild To
Moderate)
(Genteal Mild To
Moderate)
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
4
1
$0
$0
2
$0
(Mydfrin)
1
$0
(Proparacaine HCl)
1
$0
4
$0
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)
4
$0
Name of Drug
neo-synephrine 12 hour spray 0.05
%*
ocean 0.65% nasal spray 0.65 % *
olopatadine ophthalmic drops 0.1 %
PATADAY OPHTHALMIC
DROPS 0.2 %
phenylephrine hcl ophthalmic drops
10 %, 2.5 %
proparacaine ophthalmic drops 0.5
%
pure & gentle eye drops lubricant
0.3 % *
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 % *
(Oxymetazoline
HCl)
(Little Remedies)
(Patanol)
(Genteal Mild To
Moderate)
(Genteal Mild To
Moderate)
(Polyvinyl
Alcohol)
(Genteal Mild To
Moderate)
Necessary Actions,
Restrictions, or
Limits on Use
ST
146
Name of Drug
sodium chloride 5% eye oint 5 % *
SYSTANE 0.3-0.4% EYE DROPS
0.4-0.3 % *
SYSTANE GEL EYE DROPS 0.40.3 % *
(Sodium Chloride)
(Polyvinyl
Alcohol)
tears again eye ointment 80-20 % * (Genteal Pm)
(Dextran
tears naturale free drops u70/Hypromellose/P
d,36x.9ml,p/f 0.1-0.3 % *
F)
tetracaine hcl (pf) ophthalmic drops (Tetracaine
0.5 %
HCl/PF)
(Lanolin/Min
ultra fresh pm ointment *
Oil/Petrolat, Wht)
(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 %
tears again 1.4 % drops 1.4 % *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
1
$0
2
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
147
Tier level
What the
drug will
cost you
2
$0
(Ilotycin)
1
$0
(Zymaxid)
1
$0
(Garamycin)
1
$0
(Garamycin)
1
$0
(Garamycin)
1
$0
(Levofloxacin)
1
$0
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
Name of Drug
COLY-MYCIN S OTIC
DROPS,SUSPENSION 3.3-3-100.5 MG/ML
erythromycin ophthalmic ointment 5
mg/gram (0.5 %)
gatifloxacin ophthalmic drops 0.5 %
gentak ophthalmic ointment 0.3 %
(3 mg/gram)
gentamicin ophthalmic drops 0.3 %
gentamicin ophthalmic ointment 0.3
% (3 mg/gram)
levofloxacin ophthalmic drops 0.5 %
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
Necessary Actions,
Restrictions, or
Limits on Use
148
Tier level
What the
drug will
cost you
(Neomycin/Polymy
xin B Sulf/HC)
1
$0
(Cortisporin)
1
$0
1
$0
1
$0
1
1
$0
$0
1
$0
4
$0
1
$0
1
$0
1
$0
2
$0
2
$0
(Tobrex)
1
$0
(Tobradex)
1
$0
(Viroptic)
1
$0
Name of Drug
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 %
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 %
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
Su/Bacitra/Polymy
xin)
(Ocuflox)
(Ocuflox)
(Polytrim)
(Sulfacetamide
Sodium)
(Sulfacetamide
Sodium)
(Sulfacetamide/Pre
dnisolone Sp)
Necessary Actions,
Restrictions, or
Limits on Use
149
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
(Bromfenac
Sodium)
1
$0
(Dexasol)
1
$0
(Diclofenac
Sodium)
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
Name of Drug
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 %
dexamethasone sodium phosphate
ophthalmic drops 0.1 %
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
(Acular)
Necessary Actions,
Restrictions, or
Limits on Use
ST
QL (50 per 25 days)
150
Tier level
What the
drug will
cost you
2
$0
2
$0
(Omnipred)
1
$0
(Prednisolone Sod
Phosphate)
1
$0
2
$0
2
$0
(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
Name of Drug
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 %
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
Gastrointestinal Agents
Antiflatulents
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 *
151
Tier level
What the
drug will
cost you
(Phazyme)
4
$0
(Simethicone)
4
$0
(Phazyme)
4
$0
(Pepcid Ac)
4
$0
(Prevpac)
1
$0
2
$0
(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
Name of Drug
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
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 *
Necessary Actions,
Restrictions, or
Limits on Use
(Rx Product Only)
(Rx Product Only)
152
Tier level
What the
drug will
cost you
(Prevacid)
1
$0
(Cytotec)
1
$0
(Omeprazole)
(Omeprazole
Magnesium)
4
$0
4
$0
(Prilosec)
1
$0
(Zegerid)
1
$0
(Protonix)
1
$0
4
$0
(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
Name of Drug
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 *
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
Necessary Actions,
Restrictions, or
Limits on Use
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
153
Tier level
What the
drug will
cost you
(Zantac)
1
$0
(Sucralfate)
1
$0
(Carafate)
(Zantac)
1
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
(Maalox Maximum
Strength)
4
$0
(Tums)
4
$0
(Tums)
4
$0
(Maalox Maximum
Strength)
4
$0
Name of Drug
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
acid gone antacid liquid 95-358
mg/15 ml *
almacone liquid 200-200-20 mg/5
ml *
almacone-2 liquid 400-400-40 mg/5
ml *
aluminum hydroxide gel sugar-free
320 mg/5 ml *
AMITIZA ORAL CAPSULE 24
MCG, 8 MCG
antacid plus x-stren susp 500-45040 mg/5 ml *
antacid ultra tablet chew 400 mg
(1,000 mg) *
antacid xtra strength chew tab
extra-strength 300 mg (750 mg) *
antacid-antigas liquid 200-200-20
mg/5 ml *
(Gaviscon)
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Aluminum
Hydroxide)
Necessary Actions,
Restrictions, or
Limits on Use
(Rx Product Only)
QL (60 per 30 days)
154
Tier level
What the
drug will
cost you
(Imodium A-D)
4
$0
(Pepto-Bismol)
4
$0
2
$0
(Tums)
4
$0
(Tums)
4
$0
(Tums)
4
$0
4
$0
4
$0
2
$0
(Tums)
4
$0
(Tums)
4
$0
4
$0
4
$0
(Lactulose)
1
$0
(Gastrocrom)
1
$0
Name of Drug
anti-diarrheal 2 mg caplet caplet 2
mg *
bismatrol suspension 262 mg/15 ml
*
BUPHENYL ORAL TABLET 500
MG
calci-chew tablet 500 mg calcium
(1,250 mg) *
calcium 500 mg chewable tablet tab
chew,p/f 500 mg calcium (1,250 mg)
*
calcium antacid 500 mg chw tab
assorted fruit 200 mg calcium (500
mg) *
CALCIUM-500 MG TABLET
CHEWABLE SOY FREE, YEAST
FREE 500-100 MG-UNIT *
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)
Necessary Actions,
Restrictions, or
Limits on Use
155
Name of Drug
(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)
digestive relief 262 mg chw tb 262
(Pepto-Bismol Tomg *
Go)
diphenoxylate-atropine oral liquid
(Diphenoxylate
2.5-0.025 mg/5 ml
HCl/Atropine)
diphenoxylate-atropine oral tablet
(Lomotil)
2.5-0.025 mg
enulose oral solution 10 gram/15 ml (Lactulose)
flanax antacid liquid 200-200-20
(Maalox Maximum
mg/5 ml *
Strength)
foaming antacid liquid 95-358
(Gaviscon)
mg/15 ml *
GATTEX 5 MG 30-VIAL KIT 5
MG
GATTEX ONE-VIAL
SUBCUTANEOUS KIT 5 MG
gelusil antacid & antigas liq 400(Maalox Maximum
400-40 mg/5 ml *
Strength)
gelusil tablet chewable cool mint
(Almacone)
200-200-25 mg *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
4
$0
1
$0
1
$0
1
$0
4
$0
4
$0
2
$0
2
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
156
Tier level
What the
drug will
cost you
(Lactulose)
1
$0
(Robinul)
1
$0
(Robinul)
1
$0
(Loperamide HCl)
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
2
$0
(Loperamide HCl)
4
$0
(Loperamide HCl)
1
$0
2
$0
4
$0
4
$0
4
$0
Name of Drug
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
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 *
(Pepto-Bismol)
(Sodium
Polystyrene
Sulfonate)
(Sodium
Polystyrene
Sulfonate)
(Lactulose)
(Maalox Maximum
Strength)
(Uromag)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
157
Tier level
What the
drug will
cost you
(Magox 400)
4
$0
(Magox 400)
4
$0
(Magox 400)
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
(Reglan)
1
$0
(Magox 400)
(Maalox Maximum
Strength)
(Rolaids)
4
$0
4
$0
4
$0
(Maalox Maximum
Strength)
4
$0
(Almacone)
4
$0
(Maalox Maximum
Strength)
4
$0
2
$0
2
$0
4
$0
Name of Drug
magnesium oxide 250 mg tablet 250
mg *
magnesium oxide 400 mg tablet 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
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
phillips 500 mg caplet 500 mg *
(Maalox Maximum
Strength)
(Pepto-Bismol ToGo)
(Methscopolamine
Bromide)
(Metoclopramide
HCl)
(Metoclopramide
HCl)
(Magox 400)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
158
Tier level
What the
drug will
cost you
(Pepto-Bismol ToGo)
4
$0
(Loperamide HCl)
4
$0
(Uromag)
4
$0
2
$0
2
$0
2
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
1
$0
4
$0
4
$0
Name of Drug
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 *
ri-mox suspension 200-200-20 mg/5
ml *
sm foaming antacid tablet chew 8020 mg *
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Gaviscon)
(Bismuth
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 *
sm stomach relief caplet 262 mg *
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
159
Name of Drug
(Sodium
Polystyrene
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)
BLADDER CONTROL PAD XLONG 9'S,X-LONG *
COLACE 100 MG CAPSULE 100
MG *
cvs enema disposable 19-7
(Enema)
gram/118 ml *
cvs fiber therapy 500 mg caplt
(Citrucel)
soluble, caplet 500 mg *
cvs kids 100 mg mini enema 100
(Docusate Sodium)
mg/5 ml *
cvs purelax powder 14 once-daily
(Gavilax)
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
(Senokot)
*
cvs stool softener softgel softgel 240
(Surfak)
mg *
doc-q-lace 100 mg softgel 100 mg * (Colace)
sps 15 gm/60 ml suspension 15
gram/60 ml
Tier level
What the
drug will
cost you
1
$0
1
1
$0
$0
2
$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
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (60 per 30
days)
160
Tier level
What the
drug will
cost you
(Docusate Sodium)
4
$0
(Docusate Sodium)
4
$0
4
$0
4
4
4
4
$0
$0
$0
$0
(Enema)
4
$0
(Enema)
4
$0
(Docusate Sodium)
4
$0
(Docusol Plus)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
1
$0
Name of Drug
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 *
enemeez mini enema 5cc tubes,
outer 283 mg/5 ml *
enemeez plus mini enema outer 28320 mg/5 ml *
(Sennosides/Docus
ate Sodium)
(Docusate Sodium)
(Colace)
(Docusate Sodium)
(Colace)
(Psyllium Seed
(With Sugar))
equalactin 500 mg tab chew 500 mg (Calcium
*
Polycarbophil)
fiber tablet unboxed 625 mg *
(Fibercon)
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
eq fiber therapy powder *
Necessary Actions,
Restrictions, or
Limits on Use
161
Tier level
What the
drug will
cost you
(Nulytely with
Flavor Packs)
1
$0
(Gavilax)
4
$0
(Gavilax)
3
$0
(Miralax)
4
$0
(Psyllium Seed)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
4
$0
4
$0
1
$0
1
$0
4
$0
4
$0
Name of Drug
gavilyte-n oral recon soln 420 gram
gentlelax powder 30 once-daily
glycolax powder 7 doses (otc) 17
gram/dose *
healthylax powder packet 14x17gm,
outer 17 gram *
hydrocil instant packet *
KONSYL 6 GM PACKET S/F,
GLUTEN-F, OUTER 6 GRAM *
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)
natural fiber lax powder *
Necessary Actions,
Restrictions, or
Limits on Use
162
Tier level
What the
drug will
cost you
4
$0
1
$0
1
$0
(Gavilax)
4
$0
(Miralax)
4
$0
(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
4
$0
4
$0
Name of Drug
phosphate oral saline laxative s/f,
ginger lemon 7.2-2.7 gram/15 ml *
polyethylene glycol 3350 oral
powder 17 gram/dose
polyethylene glycol 3350 oral
powder in packet 17 gram
polyethylene glycol 3350 powd 14
once-daily doses (otc) 17 gram/dose
*
polyethylene glycol 3350 powd 17
grams pkts,outer (otc) 17 gram *
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 *
(Na Phos,M-B/Na
Phos,Di-Ba)
(Polyethylene
Glycol 3350)
(Polyethylene
Glycol 3350)
silace 50 mg/5 ml liquid 50 mg/5 ml
(Docusate Sodium)
*
silace 60 mg/15 ml syrup 60 mg/15
(Docusate Sodium)
ml *
Necessary Actions,
Restrictions, or
Limits on Use
163
Tier level
What the
drug will
cost you
(Gavilax)
4
$0
(Citrucel)
4
$0
(Psyllium Seed)
4
$0
(Miralax)
4
$0
(Nulytely with
Flavor Packs)
1
$0
1
1
4
1
$0
$0
$0
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
Name of Drug
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
calphron 667 mg tablet 667 mg *
eliphos oral tablet 667 mg
(Phoslo)
(Calcium Acetate)
(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
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)
164
Tier level
What the
drug will
cost you
(Oxybutynin
Chloride)
1
$0
(Ditropan XL)
1
$0
(Detrol LA)
1
$0
(Detrol)
1
$0
2
$0
1
$0
1
$0
(Uroxatral)
1
$0
(Flomax)
1
$0
(Terazosin HCl)
1
$0
(Desferal)
1
$0
2
$0
2
$0
2
$0
Name of Drug
oxybutynin chloride oral tablet 5 mg
oxybutynin chloride oral tablet
extended release 24hr 10 mg, 15
mg, 5 mg
tolterodine oral capsule,extended
tolterodine oral tablet 1 mg, 2 mg
TOVIAZ ORAL TABLET
MG, 8 MG
trospium oral capsule,extended
release 24hr 60 mg
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
(Trospium
Chloride)
(Trospium
Chloride)
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
PA BvD
165
Name of Drug
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)
Tier level
What the
drug will
cost you
2
$0
1
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
Hormonal Agents,
Stimulant/Replacement/Modif
ying
Androgens
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 %)
2
$0
PA; QL (30 per 30
days)
2
$0
PA; QL (150 per 30
days)
2
$0
(Fluoxymesterone)
1
$0
(Danazol)
1
$0
(Oxandrin)
1
$0
PA; QL (150 per 30
days)
PA
(DepoTestosterone)
1
$0
(Testosterone
Enanthate)
1
$0
(Testim)
1
$0
PA; QL (300 per 30
days)
166
Name of Drug
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
DUAVEE ORAL TABLET 0.45-20
MG
ESTRACE VAGINAL CREAM
0.01 % (0.1 MG/GRAM)
estradiol oral tablet 0.5 mg, 1 mg, 2
mg
estradiol transdermal patch
semiweekly 0.025 mg/24 hr, 0.0375
mg/24 hr, 0.05 mg/24 hr, 0.075
mg/24 hr, 0.1 mg/24 hr
estradiol transdermal patch weekly
0.025 mg/24 hr, 0.0375 mg/24 hr,
0.05 mg/24 hr, 0.06 mg/24 hr, 0.075
mg/24 hr, 0.1 mg/24 hr
estradiol valerate intramuscular oil
10 mg/ml, 20 mg/ml, 40 mg/ml
estradiol-norethindrone acet oral
tablet 0.5-0.1 mg, 1-0.5 mg
estropipate oral tablet 0.75 mg, 1.5
mg, 3 mg
FEMRING VAGINAL RING 0.05
MG/24 HR, 0.1 MG/24 HR
Tier level
What the
drug will
cost you
(Vogelxo)
1
$0
(Androgel)
1
$0
(Testim)
1
$0
2
$0
2
$0
2
$0
1
$0
(Estrace)
(Vivelle-Dot)
1
$0
(Climara)
1
$0
(Delestrogen)
1
$0
(Activella)
1
$0
(Estropipate)
1
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
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)
PA-HRM
PA-HRM
PA-HRM; QL (8 per
28 days)
PA-HRM; QL (4 per
28 days)
PA-HRM
PA-HRM
QL (1 per 84 days)
167
Name of Drug
MENEST ORAL TABLET 0.3 MG,
0.625 MG, 1.25 MG, 2.5 MG
mimvey lo oral tablet 0.5-0.1 mg
mimvey oral tablet 1-0.5 mg
PREMARIN INJECTION RECON
SOLN 25 MG
PREMARIN ORAL TABLET 0.3
MG, 0.45 MG, 0.625 MG, 0.9 MG,
1.25 MG
PREMARIN VAGINAL CREAM
0.625 MG/GRAM
PREMPHASE ORAL TABLET
0.625 MG (14)/ 0.625MG-5MG(14)
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/Mine raloco
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
(Activella)
(Activella)
Tier level
What the
drug will
cost you
2
$0
1
1
$0
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA-HRM
2
$0
1
$0
2
$0
(Hydrocortisone
Sod Succinate)
1
$0
(Celestone)
1
$0
(Cortisone Acetate)
1
$0
(Dexamethasone)
1
$0
(Dexamethasone)
1
$0
(Dexamethasone
Sod Phosphate)
1
$0
(Evista)
QL (18 per 28 days)
PA BvD
PA BvD
PA BvD
168
Tier level
What the
drug will
cost you
(Fludrocortisone
Acetate)
1
$0
(Cortef)
1
$0
(Solu-Medrol)
1
$0
(Depo-Medrol)
1
$0
(Medrol)
1
$0
(Medrol)
1
$0
(Solu-Medrol)
1
$0
(Solu-Medrol)
1
$0
Name of Drug
fludrocortisone oral tablet 0.1 mg
hydrocortisone oral tablet 10 mg, 20
mg, 5 mg
methylprednisolone 125 mg vial 2ml
sdv, 25's,l/f 125 mg
methylprednisolone acetate
injection suspension 40 mg/ml, 80
mg/ml
methylprednisolone oral tablet 16
mg, 32 mg, 4 mg, 8 mg
methylprednisolone oral
tablets,dose pack 4 mg
methylprednisolone sodium succ
injection recon soln 125 mg, 40 mg
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
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
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
PA BvD
PA BvD
PA BvD
PA BvD
169
Tier level
What the
drug will
cost you
(DDAVP)
1
$0
(Desmopressin
Acetate)
1
$0
(DDAVP)
1
$0
Name of Drug
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
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)
Necessary Actions,
Restrictions, or
Limits on Use
QL (15 per 30 days)
QL (15 per 30 days)
PA
2
$0
PA
2
$0
2
$0
QL (1 per 84 days)
2
$0
2
$0
PA
(Octreotide
Acetate)
2
$0
1
$0
170
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
octreotide acetate injection solution
1,000 mcg/ml, 100 mcg/ml, 200
(Sandostatin)
1
$0
mcg/ml, 500 mcg/ml
octreotide acetate injection solution (Octreotide
1
$0
50 mcg/ml
Acetate)
SAIZEN CLICK.EASY
PA
SUBCUTANEOUS CARTRIDGE
2
$0
8.8 MG/1.5 ML (FNL)
SAIZEN SUBCUTANEOUS
PA
2
$0
RECON SOLN 5 MG, 8.8 MG
SANDOSTATIN LAR 10 MG KIT
2
$0
10 MG
2
$0
20 MG
2
$0
30 MG
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR
2
$0
RECON 10 MG, 20 MG, 30 MG
SEROSTIM SUBCUTANEOUS
PA
2
$0
RECON SOLN 4 MG, 5 MG, 6 MG
SOMATULINE DEPOT
QL (1 per 28 days)
2
$0
MG/0.5 ML, 60 MG/0.2 ML, 90
MG/0.3 ML
SOMAVERT SUBCUTANEOUS
RECON SOLN 10 MG, 15 MG, 20
2
$0
MG, 25 MG, 30 MG
SUPPRELIN LA IMPLANT KIT
QL (1 per 360 days)
2
$0
50 MG (65 MCG/DAY)
Progestins
DEPO-PROVERA
QL (10 per 28 days)
INTRAMUSCULAR SOLUTION
2
$0
400 MG/ML
171
Tier level
What the
drug will
cost you
(Depo-Provera)
1
$0
(Depo-Provera)
1
$0
(Provera)
1
$0
2
$0
(Megace Es)
1
$0
(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
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
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
QL (1 per 84 days)
QL (1 per 84 days)
Immunological Agents
Immunological Agents
ARCALYST SUBCUTANEOUS
RECON SOLN 220 MG
172
Name of Drug
ASTAGRAF XL ORAL
24HR 0.5 MG, 1 MG, 5 MG
AUBAGIO ORAL TABLET 14
MG, 7 MG
azathioprine oral tablet 50 mg
azathioprine sodium injection recon
soln 100 mg
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN 6
GRAM
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)
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
(Imuran)
(Azathioprine
Sodium)
2
$0
2
$0
1
$0
1
$0
2
$0
PA; QL (28 per 28
days)
PA BvD
PA BvD
PA BvD
PA BvD
2
$0
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
173
Name of Drug
Tier level
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
GAMMAGARD LIQUID
INJECTION SOLUTION 10 %
GAMMAPLEX INTRAVENOUS
SOLUTION 5 %
gengraf oral capsule 100 mg, 25 mg (Neoral)
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)
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA
2
$0
PA BvD
2
$0
2
$0
2
$0
2
$0
2
$0
1
1
$0
$0
2
$0
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
2
$0
PA
2
$0
2
$0
174
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
HYQVIA SUBCUTANEOUS
PA BvD
SOLUTION 10 GRAM /100 ML
(10 %), 2.5 GRAM /25 ML (10 %),
2
$0
20 GRAM /200 ML (10 %), 30
GRAM /300 ML (10 %), 5 GRAM
/50 ML (10 %)
ILARIS (PF) SUBCUTANEOUS
PA
RECON SOLN 180 MG/1.2 ML
2
$0
(150 MG/ML)
IMOGAM RABIES-HT (PF)
2
$0
150 UNIT/ML
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
175
Name of Drug
PRIVIGEN INTRAVENOUS
SOLUTION 10 %
PROGRAF INTRAVENOUS
SOLUTION 5 MG/ML
RAPAMUNE ORAL SOLUTION 1
MG/ML
RIDAURA ORAL CAPSULE 3
MG
sirolimus oral tablet 0.5 mg, 1 mg, 2
(Rapamune)
mg
tacrolimus oral capsule 0.5 mg, 1
(Hecoria)
mg, 5 mg
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 50
MG
BCG VACCINE, LIVE (PF)
PERCUTANEOUS SUSPENSION
FOR RECONSTITUTION 50 MG
Tier level
What the
drug will
cost you
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
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA; LA; QL (15 per 28
days)
PA BvD; QL (120 per
30 days)
PA BvD
PA BvD
176
Name of Drug
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
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
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
2
$0
PA BvD; QL (3 per
365 days)
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)
2
177
Name of Drug
Tier level
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
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
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
PA BvD
2
$0
2
$0
2
$0
2
$0
2
$0
178
Name of Drug
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
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
Tier level
What the
drug will
cost you
2
$0
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
2
$0
179
Name of Drug
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
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
Tier level
What the
drug will
cost you
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (2 per 365 days)
2
$0
2
$0
PA BvD
2
2
$0
$0
2
$0
2
$0
2
$0
2
$0
PA BvD; QL (3 per
365 days)
PA BvD; QL (3 per
365 days)
180
Name of Drug
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
intramuscular suspension 2-2 lf
unit/0.5 ml
TRUMENBA INTRAMUSCULAR
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
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
(Tetanus,
Diphtheria
Tox,Adult)
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
QL (2 per 365 days)
2
$0
181
Name of Drug
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
Necessary Actions,
Restrictions, or
Limits on Use
QL (1 per 365 days)
2
$0
1
$0
2
$0
2
$0
1
$0
1
$0
2
$0
2
$0
1
$0
2
$0
1
$0
Inflammatory Bowel Disease
Agents
Inflammatory Bowel
Disease Agents
alosetron oral tablet 0.5 mg, 1 mg
(Alosetron HCl)
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 ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 400 MG
DIPENTUM ORAL CAPSULE 250
MG
ST
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation solution 0.25
%
LACTATED RINGERS
IRRIGATION SOLUTION
ringers irrigation solution
(Acetic Acid)
(Tis-U-Sol)
182
Tier level
What the
drug will
cost you
(Sodium Chloride
Irrig Solution)
1
$0
(Sorbitol Solution)
1
$0
1
$0
1
$0
(Alendronate
Sodium)
1
$0
(Fosamax)
1
$0
(Fosamax)
1
$0
Name of Drug
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
(Mannitol/Sorbitol
Solution)
(Water For
Irrigation,Sterile)
Necessary Actions,
Restrictions, or
Limits on Use
Metabolic Bone Disease
Agents
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
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
PA; QL (2.4 per 28
days)
183
Name of Drug
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
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
(Ibandronate
Sodium)
1
$0
(Boniva)
1
$0
(Boniva)
1
$0
2
$0
QL (3 per 84 days)
QL (3 per 84 days)
QL (1 per 28 days)
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
184
Name of Drug
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
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
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA
2
$0
2
$0
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
(Zyloprim)
(Amifostine
Crystalline)
(Citrate Phosphate
Dextros Soln)
PA
ST
ST
ST
PA
ST
PA
185
Tier level
What the
drug will
cost you
1
$0
1
$0
2
$0
2
$0
(Droperidol)
1
$0
(Avodart)
1
$0
(Jalyn)
1
$0
2
$0
1
$0
2
$0
(Proscar)
1
$0
(Fomepizole)
1
$0
2
$0
1
$0
2
$0
2
$0
2
$0
(Guanidine HCl)
1
$0
(Hydroxyzine HCl)
1
$0
Name of Drug
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
dutasteride oral capsule 0.5 mg
dutasteride-tamsulosin oral capsule,
er multiphase 24 hr 0.5-0.4 mg
ELMIRON ORAL CAPSULE 100
MG
ergoloid oral tablet 1 mg
EXTAVIA SUBCUTANEOUS KIT
0.3 MG
finasteride oral tablet 5 mg
fomepizole intravenous solution 1
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
hydroxyzine hcl intramuscular
solution 25 mg/ml, 50 mg/ml
(Colcrys)
(Colchicine/Proben
ecid)
(Ergoloid
Mesylates)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
ST
QL (28 per 28 days)
PA-HRM
186
Tier level
What the
drug will
cost you
(Hydroxyzine HCl)
1
$0
(Hydroxyzine HCl)
1
$0
(Vistaril)
1
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
2
$0
4
$0
1
$0
2
$0
Name of Drug
hydroxyzine hcl oral solution 10
mg/5 ml
hydroxyzine hcl oral tablet 10 mg,
25 mg, 50 mg
hydroxyzine pamoate oral capsule
100 mg, 25 mg, 50 mg
KEVEYIS ORAL TABLET 50 MG
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 %
(Leucovorin
Calcium)
(Leucovorin
Calcium)
(Leucovorin
Calcium)
(Levocarnitine
(With Sugar))
(Carnitor)
(Mesnex)
(Sodium
Morrhuate)
OTEZLA ORAL TABLET 30 MG
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM
PA-HRM
PA NSO; QL (120 per
30 days)
PA
PA; QL (60 per 30
days)
187
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
OTEZLA STARTER ORAL
PA; QL (60 per 30
TABLETS,DOSE PACK 10 MG
days)
2
$0
(4)-20 MG (4)-30 MG (47), 10 MG
(4)-20 MG (4)-30 MG(19)
OTREXUP (PF)
SUBCUTANEOUS AUTOINJECTOR 10 MG/0.4 ML, 15
2
$0
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 *
4
$0
PLEGRIDY SUBCUTANEOUS
ST
PEN INJECTOR 125 MCG/0.5 ML,
2
$0
63 MCG/0.5 ML- 94 MCG/0.5 ML
PLEGRIDY SUBCUTANEOUS
ST
2
$0
MCG/0.5 ML- 94 MCG/0.5 ML
probenecid oral tablet 500 mg
(Probenecid)
1
$0
PROCYSBI ORAL CAPSULE,
DELAYED REL SPRINKLE 25
2
$0
MG, 75 MG
pv extra cleansing douche *
(Acetic Acid)
4
$0
pyridostigmine bromide oral tablet
(Mestinon)
1
$0
60 mg
pyridostigmine bromide oral tablet
(Mestinon)
1
$0
qc mineral oil heavy *
(Mineral Oil)
4
$0
ra feminine care douche *
(Acetic Acid)
4
$0
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,
2
$0
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
188
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
REBIF (WITH ALBUMIN)
2
$0
MCG/0.5 ML, 44 MCG/0.5 ML
REBIF REBIDOSE
SUBCUTANEOUS PEN
INJECTOR 22 MCG/0.5 ML, 44
2
$0
MCG/0.5 ML, 8.8MCG/0.2ML-22
MCG/0.5ML (6)
REBIF TITRATION PACK
SUBCUTANEOUS SYRINGE
2
$0
8.8MCG/0.2ML-22 MCG/0.5ML
(6)
REMICADE INTRAVENOUS
PA
2
$0
RECON SOLN 100 MG
sb disp douche extra clns v&w *
(Acetic Acid)
4
$0
SENSIPAR ORAL TABLET 30
2
$0
MG, 60 MG, 90 MG
SIGNIFOR SUBCUTANEOUS
QL (60 per 30 days)
SOLUTION 0.3 MG/ML (1 ML),
2
$0
0.6 MG/ML (1 ML), 0.9 MG/ML (1
ML)
SIMPONI ARIA INTRAVENOUS
PA
2
$0
SOLUTION 12.5 MG/ML
SIMPONI SUBCUTANEOUS PEN
PA
INJECTOR 100 MG/ML, 50
2
$0
MG/0.5 ML
SIMPONI SUBCUTANEOUS
PA
SYRINGE 100 MG/ML, 50 MG/0.5
2
$0
ML
STELARA SUBCUTANEOUS
PA
SYRINGE 45 MG/0.5 ML, 90
2
$0
MG/ML
STERILE PADS 2" X 2" 2 X 2 "
1
$0
summer's eve dche-xtra clns
(Acetic Acid)
4
$0
12's,extra-cleansing *
189
Name of Drug
summer's eve douche-ultra clns
(Acetic Acid)
12's,2pk,ultra clns *
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
4
$0
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
XELJANZ ORAL TABLET 5 MG
2
$0
XELJANZ XR ORAL TABLET
MG
2
$0
(Diamox Sequels)
1
$0
(Acetazolamide)
1
$0
(Acetazolamide
Sodium)
1
$0
2
$0
2
$0
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)
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 %
190
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%)
191
Tier level
What the
drug will
cost you
(Citracal-Vitamin
D)
4
$0
(Calcium Citrate)
4
$0
(Caltrate 600 + D)
4
$0
(Caltrate 600 + D)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Caltrate 600 + D)
4
$0
(Caltrate 600 + D)
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 softgl 600
mg(1,500mg) -400 unit *
calcium 600 + vit d tablet 600-125
mg-unit *
calcium 600 + vitamin d sftgl rapid
release, sftgl 600 mg(1,500mg) -500
unit *
calcium 600 mg tablet 600 mg
(1,500 mg) *
calcium 600+d softgel 600 mg
calcium- 200 unit *
calcium 600-vit d3 200 tablet 600
mg(1,500mg) -200 unit *
calcium 600-vit d3 400 tablet 600
mg(1,500mg) -400 unit *
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 600 + Vit
D)
(Calcium
Carbonate/Vitamin
D3)
(Caltrate 600 + D)
(Calcium
Carbonate/Vitamin
D3)
(Calcium
Carbonate)
(Calcium
Carbonate/Vitamin
D3)
(Calcium
Carbonate)
(Calcium
Carbonate)
192
Tier level
What the
drug will
cost you
(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
(Caltrate 600 + D)
4
$0
(Caltrate 600 + D)
4
$0
Name of Drug
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 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 *
(Citracal-Vitamin
D)
(Citracal-Vitamin
D)
(Calcium
Gluconate)
(Calcium
Gluconate)
(Calcium
Carbonate/Vitamin
D2)
(Citracal-Vitamin
D)
(Citracal-Vitamin
D)
(Calcium
Carbonate/Vitamin
D3)
Necessary Actions,
Restrictions, or
Limits on Use
193
Tier level
What the
drug will
cost you
(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
(Klor-Con-Ef)
1
$0
1
$0
4
$0
4
$0
Name of Drug
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 %
effer-k oral tablet, effervescent 25
meq
electrolyte-48 in d5w intravenous
parenteral solution
eql calcium 600 mg + d softgel 600
mg(1,500mg) -100 unit *
(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)
(Electrolyte-48
Solution/D5W)
(Calcium
Carbonate/Vitamin
D3)
gnp calcium 500 + vit d3 tab 500mg
(Caltrate 600 + D)
(1,250mg) -600 unit *
Necessary Actions,
Restrictions, or
Limits on Use
194
Name of Drug
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
k-effervescent oral tablet,
effervescent 25 meq
KELP 150 MCG TABLET 150
MCG *
klor-con 10 oral tablet extended
release 10 meq
(Ca/D3/Mag
Ox/Zinc/Cop/Mang
/Bor)
(Ca/D3/Mag
Ox/Zinc/Cop/Mang
/Bor)
(Citracal-Vitamin
D)
(Klor-Con-Ef)
(Potassium
Chloride)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
4
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
195
Name of Drug
(Potassium
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)
magnesium gluc 500 mg tablet 27
(Magonate)
mg (500 mg) *
magnesium sulf in 0.45% nacl
(Magnesium Sulf
intravenous solution 20 gram/500
In 0.45% NaCl)
ml (40 mg/ml)
klor-con m10 tablet 10 meq
Tier level
What the
drug will
cost you
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
4
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
196
Tier level
What the
drug will
cost you
(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
(Caltrate 600 + D)
4
$0
(Caltrate 600 + D)
(Calcium
Carbonate)
4
$0
4
$0
Name of Drug
magnesium sulfate in d5w
intravenous piggyback 1 gram/100
ml, 4 gram/100 ml
magnesium sulfate in water
gram/500 ml (4 %), 40 gram/1,000
ml (4 %)
magnesium sulfate in water
(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+d tablet 500
mg(1,250mg) -200 unit *
oysco d tablet 250-125 mg-unit *
oysco-500 tablet 500 mg calcium
(1,250 mg) *
(Magnesium
Sulfate)
(Magnesium
Sulfate)
(Calcium
Carbonate)
(Slow-Mag)
Necessary Actions,
Restrictions, or
Limits on Use
197
Tier level
What the
drug will
cost you
(Caltrate 600 + D)
4
$0
(Calcium
Carbonate)
4
$0
(Caltrate 600 + D)
4
$0
(Caltrate 600 + D)
4
$0
(Caltrate 600 + D)
4
$0
(Caltrate 600 + D)
4
$0
(Pedialyte)
4
$0
4
$0
1
$0
2
$0
2
$0
2
$0
1
$0
1
$0
1
$0
Name of Drug
oyster shell 250 mg + vit d tb 250125 mg-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 500
mg(1,250mg) -200 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
potassium bicarb and chloride oral
tablet, effervescent 25 meq
potassium bicarb-citric acid oral
tablet, effervescent 25 meq
(K-Phos Neutral)
(Potassium
Acetate)
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
Necessary Actions,
Restrictions, or
Limits on Use
198
Tier level
What the
drug will
cost you
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
1
$0
1
$0
Name of Drug
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-0.45 % nacl
meq/l
(Potassium
Chloride/D50.45nacl)
(Potassium
Chloride In
0.9%NaCl)
(Potassium
Chloride)
(Potassium
Chloride)
(Potassium
Chloride)
(Potassium
Chloride)
(Potassium
Chloride-0.45%
NaCl)
Necessary Actions,
Restrictions, or
Limits on Use
199
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(K-Tab ER)
1
$0
potassium phosphate m-/d-basic
intravenous solution 3 mmol/ml
(Potassium
Phos,M-Basic-DBasic)
1
$0
ra hi-cal plus vitamin d tab 500
mg(1,250mg) -200 unit *
(Caltrate 600 + D)
4
$0
4
$0
4
4
$0
$0
1
$0
4
$0
Name of Drug
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
ra oyster shell-vitamin d tab s/f, p/f
250 (625)-125 mg-unit *
ra pediatric electrolyte soln a/f *
ra pediatric freezer pops *
ringers intravenous parenteral
solution
sm calcium 600-vit d3 800 tab 600
mg(1,500mg) -800 unit *
(Potassium
Chloride/D50.2%NaCl)
(Potassium
(Potassium
(Urocit-K)
(Potassium
Citrate/Citric Acid)
(Potassium
Chloride)
(Potassium
Chloride)
(Calcium
Carbonate/Vitamin
D2)
(Pedialyte)
(Pedialyte)
(Ringers Solution)
Necessary Actions,
Restrictions, or
Limits on Use
200
Tier level
What the
drug will
cost you
(Pedialyte)
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
1
$0
Name of Drug
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
virt-phos 250 neutral oral tablet 250
mg
(Sodium Chloride
0.45 %)
(0.9 % Sodium
Chloride)
(Sodium Chloride
3 %)
(Sodium Chloride
5 %)
(K-Phos Neutral)
Necessary Actions,
Restrictions, or
Limits on Use
201
Name of Drug
v-r calcium 400 + d 133 caplet 400(Caltrate 600 + D)
133.3 mg-unit *
Tier level
What the
drug will
cost you
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
MCG/ACTUATION
QL (60 per 30 days)
2
$0
QL (12 per 28 days)
2
$0
QL (60 per 30 days)
2
$0
QL (13 per 28 days)
2
$0
QL (60 per 30 days)
2
$0
2
$0
QL (12 per 28 days)
2
$0
2
$0
QL (24 per 28 days)
202
Name of Drug
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
Necessary Actions,
Restrictions, or
Limits on Use
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
QL (8 per 30 days)
(Ipratropium
Bromide)
2
$0
1
$0
203
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
(Ipratropium/Albut
erol Sulfate)
(Metaproterenol
Sulfate)
(Metaproterenol
Sulfate)
(Terbutaline
Sulfate)
(Terbutaline
Sulfate)
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
Necessary Actions,
Restrictions, or
Limits on Use
terbutaline subcutaneous solution 1
1
$0
mg/ml
theochron oral tablet extended
(Theophylline
release 12 hr 100 mg, 200 mg, 300
1
$0
Anhydrous)
mg
204
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)
205
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
206
Tier level
What the
drug will
cost you
1
$0
(Zanaflex)
1
$0
(Zanaflex)
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
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
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
QL (30 per 30 days)
PA-HRM; QL (30 per
30 days)
PA
PA
LA
PA-HRM; QL (60 per
30 days)
PA-HRM; QL (30 per
30 days)
PA-HRM; QL (30 per
30 days)
Vasodilating Agents
Vasodilating Agents
ADCIRCA ORAL TABLET 20 MG
PA; QL (60 per 30
days)
PA; QL (90 per 30
days)
PA BvD
ADEMPAS ORAL TABLET 0.5
2
$0
MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG
epoprostenol (glycine) intravenous
(Flolan)
1
$0
recon soln 0.5 mg, 1.5 mg
LETAIRIS ORAL TABLET 10
PA; QL (30 per 30
2
$0
MG, 5 MG
days)
207
Name of Drug
Tier level
What the
drug will
cost you
OPSUMIT ORAL TABLET 10 MG
2
$0
2
$0
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.125 MG,
0.25 MG, 1 MG, 2.5 MG
REMODULIN INJECTION
MG/ML, 2.5 MG/ML, 5 MG/ML
sildenafil intravenous solution 10
(Revatio)
mg/12.5 ml
sildenafil oral tablet 20 mg
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (30 per 30
days)
PA
PA BvD
(Revatio)
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)
2
$0
1
$0
1
$0
2
$0
2
$0
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)
208
Tier level
What the
drug will
cost you
4
$0
4
$0
(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
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Vitamins And Minerals
Vitamins And Minerals
a thru z advanced formula tab
gluten-free 18-400 mg-mcg *
a thru z advanced formula tab new
formula *
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 *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
Minerals/Lut)
(Multivitamin with
Minerals/Lut)
(Mv,Fe,Min/Lutein
)
(Biocel)
(One-A-Day
Vitacraves)
(One-A-Day
Vitacraves)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
209
Name of Drug
(Beta-Carotene(A)
W-C and E/Min)
(Multivitamin with
apatate forte liquid *
Minerals)
(Vitamin B
b complete tablet *
Complex)
(Vitamin B
b complex capsule *
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)
antioxidant softgel softgel *
Tier level
What the
drug will
cost you
4
$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
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
210
Tier level
What the
drug will
cost you
(Vita-Bee with C)
4
$0
(Dialyvite 800)
4
$0
4
$0
4
$0
4
$0
(Ascorbic Acid)
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
4
$0
4
$0
4
$0
Name of Drug
b-complex with c tablet *
b-complex with vit c caplet
s/f,p/f,gluten-free 400 mcg *
biosupp liquid *
biotin 300 mcg tablet 300 mcg *
biovol syrup *
c complex 1,000 mg tablet sa 1,000
mg *
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 *
(Multivitamin with
Minerals)
(Biotin)
(Multivitamin with
Minerals)
centrum silver tablet adults 50 +
(Biocel)
0.4-300-250 mg-mcg-mcg *
century adults 50+ tablet gluten free
(Biocel)
0.4-300-250 mg-mcg-mcg *
(Multivitamin with
century mature tablet *
Minerals/Lut)
Necessary Actions,
Restrictions, or
Limits on Use
211
Name of Drug
century ultimate women's tab 18400 mg-mcg *
cerovite advanced form tab 18-400
mg-mcg *
cerovite liquid 9 mg iron/15 ml *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin/Iron/
Folic Acid)
Gluc)
certavite sr-antioxidant tab 0.4-300(Biocel)
250 mg-mcg-mcg *
(Multivitcertavite-antioxidant liquid 9 mg
Minerals/Ferrous
iron/15 ml *
Gluc)
certavite-antioxidant tablet 18-400 (Multivitamin/Iron/
mg-mcg *
Folic Acid)
(Multivitamin with
child chew + iron tab chew *
Iron)
child chew vitamin tablet *
(Multivitamin)
child ferrous sulfate 15 mg/ml 15
(Fer-In-Sol)
mg iron (75 mg)/ml *
children's chewable vitamin *
(Multivitamin)
childrens multivit tab chew *
(Multivitamin)
complete multi 50+ tablet 500-300(Biocel)
250 mcg *
(Multivit,Th
complete multivitamin tab *
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)
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
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
212
Name of Drug
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)
cvs daily multiple tablet for women
(Multivitamin)
*
cvs daily teen multi-vitamin 18-400 (Multivitamin/Iron/
mg-mcg *
Folic Acid)
cvs gummy swirls chewable *
(Multivitamin)
cvs hair, skin & nails tablet
(Multivitamin with
w/antioxidants *
Minerals)
cvs iron 27 mg tablet 240 mg (27 mg
(Fergon)
iron) *
cvs men's daily gummies p/f, gluten- (One-A-Day
free 200 mcg *
Vitacraves)
cvs men's multi-vit tablet *
(Multivitamin)
(Prenatal Vit
cvs prenatal vitamin tablet *
Calc,Iron,Folic)
cvs spectravite adult 50+ tabs 0.4(Biocel)
300-250 mg-mcg-mcg *
cvs spectravite advanced tab 18-400 (Multivitamin/Iron/
mg-mcg *
Folic Acid)
cvs spectravite liquid *
(Pediavit)
(Multivitamin with
cvs spectravite senior *
Minerals/Lut)
(Multivit with Ironcvs spectravite senior tab *
Minerals)
cvs spectravite senior tablet 500(Biocel)
300-250 mcg *
cvs child vit-mineral tab *
Tier level
What the
drug will
cost you
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
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
213
Name of Drug
cvs spectravite tablet chew *
(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)
cvs vitamin c 1,000 mg tb chw 1,000
(Ascorbic Acid)
mg *
cvs vitamin d3 1,000 unit sfgl softgel
(D3-50)
1,000 unit *
cvs women's daily gummies p/f,
(One-A-Day
gluten-free 200 mcg *
Vitacraves)
cyanocobalamin 1,000 mcg/ml 25's (Cyanocobalamin
1,000 mcg/ml *
(Vitamin B-12))
d3 dots 2,000 unit tablet p/f 2,000
(Vitamin D3)
unit *
(Multivitamin with
daily multi vitamin-iron tab *
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)
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
214
Name of Drug
(Multivitamin with
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)
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)
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)
(Multivitamin with
eql one daily 50 plus tablet *
Minerals)
eql one daily essential tablet *
(Multivitamin)
daily vitamin formula tablet *
Tier level
What the
drug will
cost you
4
$0
4
4
4
$0
$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
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
215
Name of Drug
eql one daily maximum tablet 18-0.4
(Tab A Vite)
mg *
(Multivitamin with
eql one daily men's tablet *
Minerals)
(Beta-Carotene(A)
eql vision formula tablet *
W-C and E/Min)
ergocalciferol 8,000 units/ml 8,000
(Drisdol)
unit/ml *
(Multivitamin/Iron/
essentia tablet 18-400 mg-mcg *
Folic Acid)
(Mv,Fe,Min/Lutein
essential balance tablet *
)
essential daily tablet w/iron &
(Tab A Vite)
calcium 18-0.4 mg *
(Fe Fumarate/Vit
ferocon capsule 110-0.5 mg *
C/B12-If/Fa)
ferretts 325 mg tablet 325 mg (106
(Ferrous Fumarate)
mg iron) *
(Iron
ferrex 150 capsule outer, u-d 150
Polysaccharide
mg iron *
Complex)
(Iron
ferrex 150 plus capsule 150-50-50
Aspgly,Ps/C/Succi
mg *
nic Acid)
ferrocite tablet 324 mg (106 mg
(Ferrous Fumarate)
iron) *
ferrous fumarate 324 mg tab 324 mg
(Ferrous Fumarate)
(106 mg iron) *
ferrous gluconate 240 mg tab
240mg=27mg elemental 240 mg (27 (Fergon)
mg iron) *
ferrous gluconate 324 mg tab 324
mg (36 mg iron), 324 mg (38 mg
(Fergon)
iron) *
Tier level
What the
drug will
cost you
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
Necessary Actions,
Restrictions, or
Limits on Use
216
Tier level
What the
drug will
cost you
(Fergon)
4
$0
(Ferrous Sulfate)
4
$0
(Ferrous Sulfate)
4
$0
(Ferrous Sulfate)
4
$0
(Ferrous Sulfate)
4
$0
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
Name of Drug
ferrous gluconate 325 mg tab
p/f,s/f,gluten-free 325 mg (36 mg
iron) *
ferrous sulf 220 mg/5 ml elix 220 mg
(44 mg iron)/5 ml *
ferrous sulf 300 mg/5 ml liq 300 mg
(60 mg iron)/5 ml *
ferrous sulf ec 324 mg tablet 324 mg
(65 mg iron) *
ferrous sulfate 325 mg tablet red
325 mg (65 mg iron) *
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)
flintstones complete tablet *
Necessary Actions,
Restrictions, or
Limits on Use
217
Tier level
What the
drug will
cost you
(Pnv133/Ferrous
Fumarate/Fa)
4
$0
(Multivitamin)
4
$0
4
$0
4
$0
(Ferrous Fumarate)
4
$0
(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
Name of Drug
gs prenatal vitamins tablet 28-800
mg-mcg *
gummi bear multivit tab chew
multivit & minerals *
hair vitamins *
healthy eyes caplet caplet 1,000
unit-200 mg-60 unit-2 mg *
hemocyte tablet u-u,blister pk 324
mg (106 mg iron) *
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 *
(Multivitamin with
Iron)
(Vit A,C and
E/Lutein/Minerals)
(Multivitamin,Ther
apeutic)
Necessary Actions,
Restrictions, or
Limits on Use
218
Name of Drug
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 *
mega multivitamin-mineral tab *
mega multivit-chelated min tab *
(Multivitamin)
(Multivitamin with
Iron)
(Pediavit)
(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)
milltrium senior multivit tab *
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
4
4
$0
$0
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
219
Name of Drug
multivit-fluor 0.5 mg tab chew
chewable, d/f, s/f 0.5 mg
multivit-iron child tab chew
children's *
multivit-mineral hp cap *
multivit-minerals tablet s/f,p/f *
my favorite multiple liquid *
myvitalife soft-gel capsule *
(Pedi M.Vit No.17
with Fluoride)
(Multivitamin with
Iron)
(Multivitamin,Ther
and Minerals)
(Multivitamin with
Minerals)
(Multivitamin)
(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 *
(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)
Tier level
What the
drug will
cost you
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
3
$0
3
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
220
Tier level
What the
drug will
cost you
(Multivitamin with
Iron)
4
$0
(Quintabs)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
4
$0
4
$0
4
$0
Name of Drug
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 *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin with
one daily tablet *
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)
Necessary Actions,
Restrictions, or
Limits on Use
(All Rx Prenatal
Vitamins Covered)
221
Name of Drug
(Pediatric
Multivitamin
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)
prenatal tablet 28 mg iron- 800 mcg (Prenatal Vit/Iron
*
Fumarate/Fa)
prenatal vitamin plus low iron oral (Pnv with
tablet 27 mg iron- 1 mg
Ca,No.72/Iron/Fa)
prenatal vitamin tablet 28 mg iron- (Prenatal Vit/Iron
800 mcg *
Fumarate/Fa)
prenatal vitamins tablet phosphorus
(Prenatal)
free 28 mg iron- 800 mcg *
prosight tablet 5,000-60-30 unit-mg- (A/C/E/Zinc/Sod
unit *
Selenate/Copper)
(Multivitamin with
pub multivitamin 50 plus tab *
Minerals/Lut)
(Vitamin B
pv b-100 complex *
Complex)
(Vitamin B
pv b-50 complex *
Complex)
pv kid's gummy bear tab chew
(Multivitamin)
chewable *
pv kid's vit + extra c chew tb *
(Multivitamin)
(Multivitamin with
pv kid's vit + iron tab chew *
Iron)
pv kid's vit complete tab chew *
(Multivitamin)
pv kid's vitamins chew tab *
(Multivitamin)
poly-vitamin drops 1,500-35-400
unit-mg-unit/ml *
Tier level
What the
drug will
cost you
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
4
$0
4
4
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
(All Rx Prenatal
Vitamins Covered)
222
Name of Drug
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 *
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 *
(Ped Multivit
#17/Iron Fumarate)
(Multivitamin with
Minerals/Lut)
(Biocel)
(Prenatal Vit
No.131/Iron/Fa)
(Multivitamin,Stres
s Formula/Zn)
(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)
Tier level
What the
drug will
cost you
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
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
223
Tier level
What the
drug will
cost you
4
$0
(Biocel)
4
$0
(Biocel)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Tab A Vite)
4
$0
(Cyanocobalamin
(Vitamin B-12))
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
3
$0
4
$0
(Biocel)
4
$0
(Biocel)
4
$0
Name of Drug
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 *
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 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 *
senior tabs 0.4-300-250 mg-mcgmcg *
sentry senior multivitamin tab
sodium/f,yeast/f 500-300-250 mcg *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
Minerals)
(Multivitamin with
Iron)
(Multivitamin)
(Prenatal Vit/Iron
Fumarate/Fa)
(Vit B Cmplx
3/Fa/Vit C/Biotin)
Necessary Actions,
Restrictions, or
Limits on Use
224
Name of Drug
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)
sm animal shapes tab chew toddlers
(Multivitamin)
*
sm animal shapes w-iron tab
(Multivitamin with
children's *
Iron)
sm antioxidant vitamins tablet 1,000 (Vit A,C and
unit-200 mg-60 unit-2 mg *
E/Lutein/Minerals)
sm b complex with vit c tablet
(Vita-Bee with C)
gluten-free *
sm complete multi-vit-mineral
(Multivitamin/Iron/
advanced formula 18-400 mg-mcg * Folic Acid)
(Multivit with Ironsm complete senior formula tab *
Minerals)
sm complete senior formula tab 0.4(Biocel)
(Multivitamin with
sm multivitamin w-iron tab *
Iron)
(Vit B Complex
sm natural balanced b-100 tab 100
100 Cmb
mg *
#2/Herbs)
sm opti-vitamin tablet 1,000 unit(Vit A,C and
200 mg-60 unit-2 mg *
E/Lutein/Minerals)
sm prenatal vitamins tablet 28 mg
(Prenatal)
iron- 800 mcg *
sm super b complex-c caplet caplet
(Vita-Bee with C)
*
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
225
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
(D3-50)
4
$0
(Sodium Fluoride)
1
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
sm therapeutic m tablet 27-0.4 mg *
sm vitamin b complex tablet glutenfree 0.4 mg *
sm vitamin b-100 complex tab
gluten-free 0.4 mg *
sm vitamin d3 4,000 unit sftgl
softgel, gluten-free 4,000 unit *
sodium fluoride 1 mg (2.2 mg) 1 mg
fluoride (2.2 mg)
sodium fluoride oral tablet 1 mg
fluoride (2.2 mg)
(Multivit,Tx,Iron/C
alcm/Fa/Mins)
(Vitamin B
Complex/Folic
Acid)
(Vitamin B
Complex/Folic
Acid)
(Pedi M.Vit No.17
with Fluoride)
(Vitamin B
stress b tablet *
Complex)
(Multivitamin,Stres
stress b with zinc tablet *
s Formula/Zn)
(Multivitamin,Stres
stress formula tablet *
s Formula)
(Iron/Mv,Stress
stress formula with iron tab *
Form)
(Vit B
stress formula with iron tab 500 mgComp/C/Fa/Iron/Vi
400 mcg- 18 mg iron *
t E)
(Multivitamin,Stres
stress formula with zinc tab *
s Formula/Zn)
(Vit B
stress-c with iron tablet 500 mg-400
Comp/C/Fa/Iron/Vi
mcg- 18 mg iron *
t E)
(Mv-Min/Iron
sunvite tablet 18 mg iron-400 mcgFum/Fa/K/Lyco/Lu
25 mcg *
tn)
super b complex-c caplet caplet * (Vita-Bee with C)
Necessary Actions,
Restrictions, or
Limits on Use
226
Name of Drug
(Vitamin B
super b maxi complex caplet 0.4 mg
Complex/Folic
*
Acid)
(B Complex with
super b with vit c capsule *
Vitamin C)
(Vitamin B
super b-50 complex capsule *
Complex)
(Vitamin B
super b-50 complex plus tab *
Complex)
super b-complex folic-vit c tb p/f
(Dialyvite 800)
400 mcg *
(Multivit with Ironsuper multiple vit-mineral tab *
Minerals)
super multivitamin tablet *
(Multivitamin)
(Vitamin B
super quints b-50 tablet 0.4 mg *
Complex/Folic
Acid)
(Vitamin B
super quints b-50 tablets *
Complex)
(Multivitamin,Ther
super thera vite m tablet *
and Minerals)
(Multivit with Ironsuperior 35 vit-mineral tab sa *
Minerals)
superplex-t tablet *
(Vita-Bee with C)
(Multivitamin with
support liquid *
Minerals)
(B Complex with
support-500 softgel *
Vitamin C)
sv hair, skin & nails caplet 1 mg
(Mv,Ca,Min/Iron
iron-66.7 mcg-1,000 mcg *
Gluc/Fa/Biotin)
tab-a-vite tablet *
(Multivitamin)
(Multivitamin with
tab-a-vite with iron tablet *
Iron)
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
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
227
Name of Drug
(Multivitamin with
Minerals)
thera m plus tablet 9 mg iron-400
(Multivits,Ca,Mine
mcg *
rals/Iron/Fa)
(Multivitamin,Ther
thera tablet *
apeutic)
thera-d 2000 tablet 2,000 unit *
(Vitamin D3)
(Multivit,Tx,Iron/C
theradex m tablet 27-0.4 mg *
alcm/Fa/Mins)
(Multivit,Tx,Iron/C
thera-m caplet caplet 27-0.4 mg *
alcm/Fa/Mins)
thera-m tablet w/beta carotene 9 mg (Multivits,Ca,Mine
iron-400 mcg *
rals/Iron/Fa)
therapeutic-m caplet p/f, s/f, caplet 9 (Multivits,Ca,Mine
mg iron-400 mcg *
rals/Iron/Fa)
(Multivitamin,Ther
thera-tabs tablet *
apeutic)
(Multivitamin with
theratrum compl 50 plus tab *
Minerals/Lut)
theratrum complete 50 plus
(Multivit with Ironp/f,caplet *
Minerals)
thiamine 200 mg/2 ml vial
(Thiamine HCl)
25's,mdv,outer 100 mg/ml *
thiamine 500 mg tablet 500 mg *
(Thiamine HCl)
total b with vit c caplet *
(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)
tab-a-vite-minerals 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
4
$0
4
$0
4
$0
3
$0
4
4
$0
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
228
Name of Drug
(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)
(Beta-Carotene(A)
vision vitamins *
W-C and E/Min)
vision vitamins tablet w/lutein,p/f
(Vit A,C and
1,000 unit-200 mg-60 unit-2 mg *
E/Lutein/Minerals)
vit d2 1.25 mg (50,000 unit) 50,000
(Drisdol)
unit *
vitalets tablet chewable child,
(Multivitamin with
orange,s/f *
Iron)
vitamin a 10,000 units capsule
(Vitamin A)
soluble 10,000 unit *
vitamin a 25,000 units capsule
(Vitamin A)
softgel 25,000 unit *
(Multivitamin,Ther
vitamin and minerals tablet *
and Minerals)
(Vit B
vitamin b complex tablet 500 mgComp/C/Fa/Iron/Vi
400 mcg- 18 mg iron *
t E)
(B Complex with
vitamin b complex-vit c cap *
Vitamin C)
vitamin b complex-vit c tablet *
(Vita-Bee with C)
vitamin b-12 1,000 mcg tablet 1,000
(B-12)
mcg *
Tier level
What the
drug will
cost you
4
$0
4
$0
3
$0
3
$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
Necessary Actions,
Restrictions, or
Limits on Use
229
Tier level
What the
drug will
cost you
(B-12)
4
$0
(B-12)
4
$0
(B-12)
4
$0
(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
Name of Drug
vitamin b-12 100 mcg tablet 100
mcg *
vitamin b-12 250 mcg tablet 250
mcg *
vitamin b12 500 mcg tablet 500 mcg
*
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 *
Necessary Actions,
Restrictions, or
Limits on Use
230
Tier level
What the
drug will
cost you
(Vitamin D3)
4
$0
(Cholecalciferol
(Vitamin D3))
4
$0
(D3-50)
4
$0
(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 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 *
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
231
INDEX
3
3 day vaginal .......................... 55
30pse-150gfn-15dm ............. 112
3-day vaginal.......................... 52
8
8-MOP.................................. 123
A
a thru z advanced formula .... 198
a thru z high potency ............ 198
a thru z select........................ 198
a thru z select 50+ formula... 198
a thru z select women's ........ 198
abacavir .................................. 71
abacavir-lamivudine-zidovudine
............................................ 71
abc plus ................................ 198
ABELCET.............................. 51
ABILIFY MAINTENA ......... 67
ABRAXANE ......................... 28
ABREVA ............................... 61
acamprosate............................ 15
acarbose.................................. 47
acebutolol ............................... 90
acephen..................................... 3
acetaminophen ......................... 3
acetaminophen-codeine............ 3
acetazolamide....................... 180
acetazolamide sodium .......... 180
acetic acid..................... 139, 173
acetylcysteine ....................... 194
acid gone antacid.................. 146
acid reducer (famotidine) ..... 144
acid relief (cimetidine) ......... 145
acitretin................................. 123
acne medication............ 123, 125
ACNE MEDICATION ........ 123
acne-clear ............................. 123
ACTEMRA .......................... 175
ACTHIB (PF)....................... 167
ACTIMMUNE ..................... 175
actinel pediatric .................... 112
acyclovir......................... 77, 123
acyclovir sodium .................... 77
ADACEL(TDAP
ADOLESN/ADULT)(PF) 167
ADAGEN ............................. 133
adapalene.............................. 131
ADCETRIS ............................ 28
ADCIRCA............................ 196
adefovir .................................. 77
ADEMPAS........................... 197
adriamycin.............................. 29
adrucil..................................... 29
adt robitussin peak cld dm max
.......................................... 112
adult multivitamin gummies 198
adult nasal decongestant....... 120
adult one daily gummies ...... 198
adult robitussin lingering cld 112
adult robitussin peak cold dm
.......................................... 112
adult wal-tussin .................... 112
adult wal-tussin dm max ...... 112
adults 50+ ............................. 198
adults 50+ daily formula ...... 198
adults' daily formula............. 199
ADVAIR DISKUS............... 191
ADVAIR HFA ..................... 191
ADVIL ................................... 11
af 52
afeditab cr............................... 95
AFINITOR ............................. 29
AFINITOR DISPERZ............ 29
AFTERA .............................. 103
a-hydrocort ........................... 159
airshield ................................ 213
AKTEN (PF) ........................ 135
AKYNZEO............................. 63
ala-cort.................................. 127
ala-scalp................................ 128
alavert ..................................... 55
alavert d-12 allergy-sinus ....... 55
ALBENZA ............................. 65
albuterol sulfate ............ 192, 193
alcaine................................... 135
alclometasone ....................... 128
ALCOHOL PADS................ 124
ALCOHOL PREP PADS ..... 124
ALDURAZYME .................. 133
ALECENSA ........................... 29
alendronate ........................... 173
alfuzosin ............................... 156
ALIMTA ................................ 29
ALINIA .................................. 65
alka-seltzer plus mucus-conges
.......................................... 112
ALLEGRA ALLERGY.......... 55
aller-chlor ............................... 55
allerclear d-12hr ..................... 56
allerclear d-24hr ..................... 56
allergy (chlorpheniramine) ..... 56
allergy (diphenhydramine) ..... 57
allergy relief (cetirizine) ......... 57
allerhist-1................................ 56
aller-tec d ................................ 56
allopurinol ............................ 175
ALLZITAL............................... 3
almacone............................... 146
almacone-2 ........................... 146
aloe vesta antifungal (micon) . 51
alophen ................................. 151
I-1
alosetron ............................... 172
ALPHAGAN P .................... 180
alprazolam .............................. 16
ALREX ................................ 142
altacaine ............................... 135
altamist ................................. 135
altavera (28) ......................... 103
aluminum hydroxide gel ...... 146
alyacen 1/35 (28).................. 104
alyacen 7/7/7 (28)................. 104
amantadine hcl ....................... 66
ambi 10peh-4cpm-20dm ...... 112
ambi 20dm-4cpm ................. 112
ambi 40pse-400gfn-20dm .... 112
ambi 60pse-4cpm ................... 56
ambi 60pse-4cpm-20dm....... 112
AMBISOME .......................... 51
amethia ................................. 104
amethia lo ............................. 104
amifostine crystalline ........... 175
amiloride ................................ 96
amiloride- hydrochlorothiazide96
AMINO ACIDS 15 %............ 81
aminocaproic acid .................. 80
AMINOSYN 10 %................. 81
AMINOSYN 3.5 %................ 81
AMINOSYN 7 %................... 81
AMINOSYN 7 % WITH
ELECTROLYTES ............. 82
AMINOSYN 8.5 %................ 82
AMINOSYN 8.5 %ELECTROLYTES ............. 82
AMINOSYN II 10 % ............. 82
AMINOSYN II 15 % ............. 82
AMINOSYN II 7 % ............... 82
AMINOSYN II 8.5 % ............ 82
AMINOSYN II 8.5 %ELECTROLYTES ............. 82
AMINOSYN M 3.5 % ........... 82
AMINOSYN-HBC 7% .......... 82
AMINOSYN-PF 10 % ........... 82
AMINOSYN-PF 7 %
(SULFITE-FREE) .............. 83
AMINOSYN-RF 5.2 % ......... 83
amiodarone....................... 89, 90
AMITIZA............................. 146
amitriptyline ..................... 43, 44
amlactin ................................ 124
amlodipine.............................. 96
amlodipine-atorvastatin.... 97, 98
amlodipine-benazepril............ 96
amlodipine-valsartan .............. 96
amlodipine-valsartan-hcthiazid
............................................ 96
ammonium lactate ................ 124
amoxapine .............................. 44
amoxicil-clarithromy- lansopraz
.......................................... 144
amoxicillin ............................. 24
amoxicillin-pot clavulanate.... 24
amphotericin b........................ 51
ampicillin ............................... 24
ampicillin sodium............. 24, 25
ampicillin-sulbactam .............. 25
AMPYRA............................. 101
ANACAINE......................... 124
anagrelide ............................... 80
anastrozole ............................. 29
ANDRODERM .................... 157
ANDROGEL........................ 157
androxy................................. 157
animal chews........................ 199
animal shape vitamins .......... 213
animal shapes plus iron ........ 213
antacid anti- gas .................... 146
antacid anti-gas (ca carb-sim)
.......................................... 147
antacid extra-strength ........... 146
antacid plus extra strength.... 146
anticoag citrate phos dextrose
.......................................... 175
anti-diarrheal ........................ 147
anti-diarrheal (loperamide).. 146,
147
antifungal................................ 52
antifungal (tolnaftate) ....... 51, 55
anti-gas maximum strength .. 143
antioxidant ............................ 199
antioxidant vitamins ............. 213
apatate forte .......................... 199
APOKYN ............................... 66
apraclonidine ........................ 135
apri........................................ 104
APRISO................................ 172
aprodine .................................. 56
APTIOM................................. 38
APTIVUS ............................... 71
aquanil hc ............................. 128
aranelle (28).......................... 104
ARCALYST ......................... 163
aripiprazole ....................... 67, 68
ARISTADA............................ 68
arthritis pain relief (acetam) ... 10
artificial tears ........................ 135
artificial tears (petro/min)..... 135
artificial tears (pf) ................. 135
artificial tears (polyvin alc) .. 135
artificial tears(glycerin-peg) . 136
artificial tears(hypromellose) 138
ASACOL HD ....................... 172
ascomp with codeine ................ 3
ascorbic acid (vitamin c) ..... 203,
218
ashlyna.................................. 104
aspirin ..................................... 11
aspirin, buffered ..................... 11
aspirin-dipyridamole .............. 81
aspir- low ................................. 11
ASSURE ID INSULIN
SAFETY ........................... 132
ASTAGRAF XL .................. 163
atenolol ................................... 91
atenolol-chlorthalidone........... 91
atorvastatin ............................. 98
I-2
atovaquone ............................. 65
atovaquone-proguanil............. 65
ATRIPLA............................... 71
atropine........................... 38, 135
atropine-care......................... 135
ATROVENT HFA ............... 193
AUBAGIO ........................... 163
aubra..................................... 104
AVASTIN .............................. 29
AVC VAGINAL .................... 61
aviane ................................... 104
AVONEX............................. 175
AVONEX (WITH ALBUMIN)
.......................................... 175
ayr saline .............................. 135
azacitidine .............................. 29
azathioprine .......................... 163
azathioprine sodium ............. 163
azelastine .............................. 136
AZILECT ............................... 66
azithromycin........................... 22
AZOPT................................. 180
AZOR..................................... 96
aztreonam ............................... 23
azurette (28) ......................... 104
B
b complete ............................ 199
b complex 1 .......................... 199
b complex 100 ...................... 214
b complex-vitamin b12 ........ 200
b complex-vitamin c-folic acid
.................. 199, 200, 207, 215
b-100 complex...................... 211
b-12 dots............................... 199
b-50 complex........................ 211
bacitracin ................ 18, 126, 139
bacitracin-polymyxin b ........ 139
bacitraycin plus .................... 126
baclofen ................................ 195
bal b-100 .............................. 201
bal b-50 ................................ 201
balance b-100 ....................... 199
balance b-50 ......................... 199
balanced b-100 ............. 199, 212
balanced b-150 ..................... 201
balanced b-50 ....................... 199
balanced b-50 complex ........ 199
balsalazide ............................ 172
balziva (28) .......................... 104
banophen ................................ 56
banophen allergy .................... 56
BANZEL ................................ 39
baza antifungal ....................... 51
BCG VACCINE, LIVE (PF) 167
b-complex............................. 212
b-complex with vitamin c ... 199,
200, 201, 213, 217, 218
BD INSULIN PEN NEEDLE
UF SHORT ...................... 133
BD INSULIN SYRINGE
ULTRA-FINE .......... 132, 133
bekyree (28) ......................... 104
BELBUCA ............................... 3
BELEODAQ .......................... 29
BELSOMRA ........................ 196
benadryl allergy...................... 56
benazepril ............................... 88
benazepril-hydrochlorothiazide
............................................ 88
BENDEKA............................. 29
BENICAR .............................. 87
BENICAR HCT ..................... 87
BENLYSTA......................... 175
benzonatate................... 112, 113
benzoyl peroxide .................. 124
benztropine............................. 66
BETADINE.......................... 124
beta-hc .................................. 128
betamethasone acet,sod phos 159
betamethasone dipropionate. 128
betamethasone valerate ........ 128
betamethasone, augmented .. 128
BETASERON ...................... 175
betaxolol......................... 91, 180
bethanechol chloride ............ 175
BETHKIS ............................... 17
bexarotene .............................. 29
BEXSERO (PF).................... 167
bicalutamide ........................... 29
bicarsim forte........................ 143
BICILLIN C-R ....................... 25
BICILLIN L-A ....................... 25
BIDIL ................................... 100
bimatoprost ........................... 181
bio-dtuss dmx ....................... 113
bion tears (pf) ....................... 136
bionel pediatric ..................... 113
biospec dmx.......................... 113
biosupp ................................. 200
biotin..................................... 200
biovol.................................... 200
bisac-evac ............................. 151
bisacodyl............................... 151
biscolax................................. 151
bismatrol ............................... 146
bisoprolol fumarate ................ 91
bisoprolol-hydrochlorothiazide
............................................ 91
bleomycin ............................... 29
bleph-10................................ 139
BLINCYTO ............................ 30
blisovi 24 fe .......................... 104
blisovi fe 1.5/30 (28) ............ 104
blisovi fe 1/20 (28) ............... 104
blis-to-sol (tolnaftate) ............. 51
BOOSTRIX TDAP .............. 167
BOSULIF ............................... 30
bp 8 cough ............................ 113
BREO ELLIPTA .................. 191
briellyn ................................. 104
BRILINTA ............................. 81
brimonidine .......................... 181
BRINTELLIX ........................ 44
BRIVIACT ............................. 39
bromfed dm .......................... 113
bromfenac ............................. 142
I-3
bromocriptine ......................... 66
bromphenex dm.................... 113
brompheniramine-pseudoephdm............................. 112, 113
budesonide ........................... 172
bufferin................................... 11
bumetanide ............................. 96
BUPHENYL ........................ 146
buprenorphine hcl .............. 3, 15
buprenorphine- naloxone ........ 15
buproban................................. 44
bupropion hcl ................... 15, 44
buspirone .............................. 175
butalbital compound w/codeine 4
butalbital-acetaminop-caf-cod . 4
butalbital-acetaminophen ......... 4
butalbital-acetaminophen-caff . 4
butalbital-aspirin-caffeine ........ 4
BUTRANS ............................... 4
BYSTOLIC ............................ 91
C
c complex ............................. 200
cabergoline ............................. 66
CABOMETYX ...................... 30
ca-d3-mag ox-zinc-cop-mangbor .................................... 184
caffeine citrated.................... 101
caffeine-sodium benzoate .... 101
calci-chew ............................ 146
calcidol ................................. 200
calcipotriene ......................... 124
calcitonin (salmon)............... 173
calcitrate ............................... 182
calcitrate-vitamin d ...... 181, 182
calcitrene .............................. 124
calcitriol ....................... 124, 173
calcium 500 + d.................... 182
calcium 500 + d (d3) ............ 183
calcium 600 .......................... 182
calcium 600 + d(3) ............... 182
calcium 600 with vitamin d3 186
calcium acetate ..................... 155
calcium antacid .................... 146
calcium carbonate ........ 146, 182
calcium carbonate-vitamin d2
.......................................... 183
calcium carbonate-vitamin d3
.................. 182, 183, 184, 190
CALCIUM CARBONATEVITAMIN D3 .................. 147
calcium chloride ................... 182
calcium citrate-vitamin d3 .. 183,
184
calcium gluconate ................ 183
calcium+d............................. 191
CALDOLOR .......................... 11
cal-gest antacid..................... 147
calphron................................ 155
CALTRATE 600 + D........... 183
CALTRATE WITH VITAMIN
D3..................................... 183
camila ................................... 104
camrese................................. 105
camrese lo ............................ 104
CANCIDAS ........................... 51
candesartan............................. 88
candesartan-hydrochlorothiazid
............................................ 88
capacet...................................... 4
CAPASTAT ........................... 62
CAPRELSA ........................... 30
captopril ................................. 89
captopril- hydrochlorothiazide 89
CARAFATE......................... 144
CARBAGLU........................ 147
carbamazepine........................ 39
carbidopa ................................ 66
carbidopa- levodopa ................ 66
carbidopa-levodopa-entacapone
............................................ 66
CARIMUNE NF
NANOFILTERED ........... 164
carisoprodol.......................... 195
carteolol................................ 136
cartia xt ................................... 92
carvedilol ................................ 91
CASTELLANI PAINT
MODIFIED ...................... 124
CAYSTON ............................. 23
caziant (28) ........................... 105
cefaclor ................................... 20
cefadroxil................................ 20
cefazolin ................................. 20
cefazolin in dextrose (iso-os) . 20
CEFAZOLIN IN DEXTROSE
(ISO-OS) ............................ 20
cefdinir ................................... 20
cefditoren pivoxil ................... 20
cefepime ................................. 21
CEFEPIME IN DEXTROSE 5
%......................................... 21
CEFEPIME IN
DEXTROSE,ISO-OSM...... 20
cefotaxime .............................. 21
cefoxitin.................................. 21
cefoxitin in dextrose, iso-osm 21
cefpodoxime ........................... 21
cefprozil.................................. 21
ceftazidime ............................. 21
ceftibuten ................................ 21
ceftriaxone .............................. 21
ceftriaxone in dextrose,iso-os. 21
cefuroxime axetil .................... 22
cefuroxime sodium ................. 22
celecoxib................................. 11
CELLCEPT INTRAVENOUS
.......................................... 164
CELONTIN ............................ 39
centamin ............................... 200
centergy dm .......................... 113
central vite with lutein .......... 212
central- vite............................ 212
central- vite for seniors.......... 200
central- vite select.......... 204, 212
central- vite senior ................. 212
centram-care ......................... 200
I-4
centravites 50 plus................ 200
centrum................................. 200
centrum complete ................. 200
centrum silver....................... 200
century.................................. 206
century adults 50+ ................ 200
century mature...... 200, 204, 206
century ultimate women's .... 201
cephalexin .............................. 22
CEPROTIN (BLUE BAR)..... 77
CERDELGA ........................ 176
CEREZYME ........................ 133
cerovite................................. 201
cerovite advanced formula ... 201
certavite senior-antioxidant.. 201
certavite-antioxid (iron gluc) 201
certavite-antioxidant............. 201
CERVARIX VACCINE (PF)
.......................................... 167
cetirizine ................................. 56
cetirizine-pseudoephedrine .... 56
cevimeline ............................ 123
CHANTIX.............................. 15
CHANTIX CONTINUING
MONTH BOX.................... 15
CHANTIX STARTING
MONTH BOX.................... 15
cheracol d ............................. 113
cheratussin dac ..................... 113
chest congestion relief + dm 114
chest congestion relief pe ..... 114
chewable multi vitamin ........ 204
child allergy relf(cetirizine) ... 58
child complete multivitamin 204
child cough and sore throat .. 115
child mucinex chest congestion
.......................................... 114
child plus cough and runnynose
.......................................... 118
child triaminic cold-allergy .... 56
child triaminic cough-congest
.......................................... 113
child vitamin with minerals . 201
child wal-tap cold-allergy ...... 57
child wal-tussin cough relief 113
CHILDREN'S ADVIL ........... 11
children's allegra allergy .. 56, 57
children's aller-tec .................. 57
children's chest congestion... 115
children's chewable .............. 211
children's chewable complete
.......................................... 202
children's chewable vitamin . 201
children's chewable w/minerals
.......................................... 204
CHILDREN'S CLARITIN56, 57
children's cold-cough daytime
.......................................... 114
children's complete vitamin . 211
children's mapap....................... 4
children's mucinex cough..... 113
children's multivit w/extra c . 204
children's non-aspirin ............... 4
children's pain reliever ........... 10
children's pain- fever relief ....... 4
children's pepto .................... 147
childrens plus multi-symp cold
.......................................... 120
children's silapap ...................... 4
children's silfedrine .............. 113
children's soothe ................... 147
children's sudafed ................. 114
children's sudafed pe cough . 113
children's tactinal ..................... 4
children's wal-dryl allergy...... 57
children's wal- zyr ................... 57
CHILDREN'S ZYRTEC
ALLERGY ......................... 57
childs chew vite.................... 201
child's vitamin with iron....... 202
child's vitamin with vitamin c
.......................................... 202
childs/iron............................. 201
chlophedianol- guaifenesin ... 112
chloramphenicol sod succinate
............................................ 18
chlordiazepoxide hcl .............. 16
chlorhexidine gluconate ....... 123
chloroquine phosphate............ 65
chlorothiazide ......................... 97
chlorothiazide sodium ............ 97
chlorpheniramine-phenyleph-dm
.......................................... 111
chlorpromazine ....................... 68
chlorthalidone ......................... 97
chlorzoxazone....................... 195
cholecalciferol (vitamin d3) 203,
218, 219
cholestyramine (with sugar) ... 98
cholestyramine light ............... 98
choline,magnesium salicylate. 11
ciclopirox.......................... 51, 52
ciclopirox-ure-camph-menth-euc
............................................ 52
cilostazol................................. 81
cimetidine ............................. 144
cimetidine hcl ....................... 144
CIMZIA................................ 164
CIMZIA POWDER FOR
RECONST........................ 164
CINQAIR ............................. 195
CINRYZE............................... 79
CIPRODEX .......................... 139
ciprofloxacin........................... 26
ciprofloxacin hcl..... 26, 139, 140
ciprofloxacin in 5 % dextrose 26,
27
ciprofloxacin lactate ............... 26
citalopram ............................... 44
citracal + d maximum........... 183
citrus calcium ....................... 183
clarithromycin ........................ 23
CLARITIN ............................. 57
CLARITIN LIQUI-GEL ........ 57
CLARITIN REDITABS......... 57
clearlax ................................. 155
I-5
clemastine............................... 57
CLEVIPREX.......................... 96
clindamycin hcl ...................... 18
clindamycin in 5 % dextrose .. 18
clindamycin palmitate hcl ...... 18
clindamycin pediatric ............. 18
clindamycin phosphate.... 18, 19,
61, 126
CLINIMIX 5%/D15W
SULFITE FREE ................. 83
CLINIMIX 5%/D25W
SULFITE-FREE................. 83
CLINIMIX 2.75%/D5W
SULFIT FREE ................... 83
CLINIMIX 4.25%/D10W SULF
FREE .................................. 83
CLINIMIX 4.25%/D5W
SULFIT FREE ................... 83
CLINIMIX 4.25%-D20W
SULF-FREE....................... 83
CLINIMIX 4.25%-D25W
SULF-FREE....................... 83
CLINIMIX 5%D20W(SULFITE-FREE) ... 83
CLINIMIX E 2.75%/D10W
SUL FREE ......................... 84
SULF FREE ....................... 84
SUL FREE ......................... 84
SUL FREE ......................... 84
SULF FREE ....................... 84
CLINIMIX E 5%/D15W
SULFIT FREE ................... 84
CLINIMIX E 5%/D20W
SULFIT FREE ................... 84
CLINIMIX E 5%/D25W
SULFIT FREE ................... 84
CLINISOL SF 15 %............... 84
clobetasol ..................... 128, 129
clobetasol-emollient ............. 129
clocortolone pivalate ............ 129
clomipramine ......................... 44
clonazepam....................... 16, 17
clonidine................................. 87
clonidine hcl ................... 87, 101
clopidogrel ............................. 81
clorazepate dipotassium ......... 17
clorpres................................... 87
clotrimazole............................ 52
clotrimazole-7 ........................ 52
clotrimazole-betamethasone... 52
clozapine ................................ 68
COARTEM ............................ 65
codeine sulfate.......................... 4
codituss dm .......................... 114
COLACE.............................. 151
colchicine ............................. 176
colchicine-probenecid .......... 176
cold and cough (diphenhydr-pe)
............................................ 58
cold multi-symptom day/night
.......................................... 114
cold relief m/s day/night ...... 114
cold-allergy-sinus................... 57
cold-flu relief........................ 114
cold-flu relief, day/night ...... 114
colestipol ................................ 98
colistin (colistimethate na) ..... 19
colocort................................. 129
COLY-MYCIN S ................. 140
COMBIGAN ........................ 181
COMBIPATCH ................... 158
COMBIVENT RESPIMAT . 193
COMETRIQ........................... 30
comfort gel ........................... 147
comfort gel extra strength .... 147
COMPLERA .......................... 72
complete 50+........................ 207
complete multi 50+ .............. 201
complete multivitamin . 201, 204
complete multivitamin- mineral
.................................. 204, 213
complete senior ............ 201, 213
compoz ................................... 57
compro.................................... 63
COMVAX (PF) .................... 167
CONDYLOX ....................... 124
congestac .............................. 114
congest-eze ........................... 114
constulose ............................. 147
COPAXONE ........................ 176
coricidin hbp......................... 114
coricidin hbp cold-multi sympt
.......................................... 114
CORLANOR .......................... 93
cormax .................................. 129
cortisone ............................... 159
cortizone-10.......................... 129
CORTIZONE-10 .................. 129
COSENTYX......................... 125
COSENTYX (2 SYRINGES)
.......................................... 124
COSENTYX PEN ................ 125
COSENTYX PEN (2 PENS) 124
COTELLIC............................. 30
cough and cold ..................... 114
cough and runny nose........... 120
cough relief........................... 115
CREON ................................ 133
CRESTOR .............................. 98
critic-aid clear af..................... 52
CRIXIVAN ............................ 72
cromolyn............... 136, 147, 195
cryselle (28) .......................... 105
CUBICIN ............................... 19
cyanocobalamin (vitamin b-12)
.................. 199, 203, 212, 218
cyclafem 1/35 (28) ............... 105
cyclafem 7/7/7 (28) .............. 105
cyclobenzaprine.................... 195
cyclopentolate....................... 136
cyclophosphamide .................. 30
I-6
CYCLOPHOSPHAMIDE...... 30
CYCLOSET ........................... 47
cyclosporine ......................... 164
cyclosporine modified.......... 164
cyproheptadine ....................... 58
CYRAMZA............................ 30
cyred..................................... 105
CYSTADANE ..................... 176
CYSTARAN ........................ 136
cysteine (l-cysteine) ............... 84
D
.......................................... 183
d2.5 %-0.45 % sodium chloride
.......................................... 184
d3 dots .................................. 203
d5 % and 0.9 % sodium chloride
.......................................... 184
.......................................... 184
dactinomycin .......................... 30
daily gummies ...................... 202
daily multiple ............... 202, 203
daily multivitamin............... 208
daily multivitamin with iron 203
daily multi- vitamins/iron ..... 203
daily teen multivitamin ....... 202
daily value ............................ 203
daily vitamin ........................ 203
daily vitamin formula........... 203
daily vitamin formula + iron 203
daily vitamin formula-minerals
.......................................... 203
daily vitamin with iron ......... 203
daily vites/iron...................... 204
dailyhist-1............................... 58
daily-vite .............................. 203
DAKLINZA ........................... 75
DALIRESP........................... 195
danazol ................................. 157
dantrolene............................. 196
dapsone................................... 62
DAPTACEL (DTAP
PEDIATRIC) (PF) ........... 168
DARAPRIM .......................... 65
DARZALEX .......................... 30
dasetta 1/35 (28)................... 105
dasetta 7/7/7 (28).................. 105
dayhist allergy ........................ 58
daysee................................... 105
daytime cold and cough ....... 115
daytime cold- flu ................... 115
day-time cough..................... 115
daytime-nighttime ................ 118
daytime-nighttime cold-flu .. 115
daytime-nighttime cough ..... 115
deblitane ............................... 105
decitabine ............................... 30
decongestant cough .............. 120
deep sea nasal....................... 136
deferoxamine........................ 156
delsym cough-chest congest dm
.......................................... 115
delyla (28) ............................ 105
DELZICOL .......................... 172
DEMSER ............................... 93
DEPEN TITRATABS.......... 156
DEPO-PROVERA ............... 162
dermafungal ........................... 52
dermarest eczema (hydrocort)
.......................................... 129
DESCOVY............................. 72
desipramine ............................ 44
desmopressin ................ 160, 161
desog-e.estradiol/e.estradiol. 105
desogestrel-ethinyl estradiol 105
desonide ............................... 129
desoximetasone .................... 129
despec-dm (pseudoeph-dmguaif) ................................ 115
dex4 glucose........................... 84
dexamethasone ..................... 159
dexamethasone sodium
phosphate ................. 142, 159
dexmethylphenidate ............. 101
dextroamphetamine .............. 102
dextroamphetamineamphetamine .................... 102
dextromethorphan polistirex 115
dextrose 10 % and 0.2 % nacl
.......................................... 184
............................................ 85
............................................ 85
............................................ 85
............................................ 85
dextrose 5 % in ringers ........... 85
dextrose 5 % in water (d5w) .. 85
dextrose 5 %-lactated ringers184
dextrose 5%-0.2 % sod chloride
.......................................... 184
dextrose 5%-0.3 % sod.chloride
.......................................... 184
............................................ 85
............................................ 85
dextrose with sodium chloride
.......................................... 184
diabetic tussin dm ................. 115
diamode ................................ 147
diazepam................................. 17
diazepam intensol ................... 17
diclofenac potassium .............. 12
diclofenac sodium .......... 12, 142
diclofenac-misoprostol ........... 12
dicloxacillin ............................ 25
dicyclomine .......................... 147
didanosine............................... 72
DIFICID ................................. 23
diflunisal ................................. 12
digestive relief ...................... 147
digitek ..................................... 93
I-7
digox....................................... 94
digoxin ................................... 94
DIGOXIN............................... 94
dihydroergotamine ........... 61, 62
DILANTIN............................. 39
diltiazem hcl ..................... 92, 93
dilt- xr...................................... 93
dimaphen (pe) ........................ 58
dimenhydrinate....................... 63
dimetapp cold-congestion ...... 58
dino- life ................................ 204
dino- life with extra c ............ 204
dino- life with iron- zinc ........ 204
DIPENTUM ......................... 172
diphenhist ............................... 58
diphenhydramine hcl.............. 58
diphenoxylate-atropine......... 148
dipyridamole .......................... 81
disopyramide phosphate......... 90
disulfiram ............................... 15
divalproex............................... 39
dobutamine............................. 94
dobutamine in d5w................. 94
doc-q-lace............................. 152
docu ...................................... 152
docusate sodium ................... 152
docusol ................................. 152
dok........................................ 152
donepezil ................................ 43
dopamine ................................ 94
dopamine in 5 % dextrose ...... 94
dorzolamide.......................... 181
dorzolamide-timolol............. 181
douche vinegar and water extra
.......................................... 179
doxazosin ............................... 87
doxepin................................... 44
doxercalciferol ............. 173, 174
doxorubicin, peg- liposomal ... 31
doxy-100 ................................ 27
doxycycline hyclate.......... 27, 28
doxycycline monohydrate ...... 28
dramamine.............................. 63
dramamine less drowsy .......... 63
driminate ................................ 63
dristan long lasting ............... 136
dronabinol .............................. 63
droperidol ............................. 176
drospirenone-ethinyl estradiol
.......................................... 105
DROXIA ................................ 31
DUAVEE ............................. 158
dulcolax stool softener (dss) 152
DULERA ............................. 191
duloxetine............................... 44
DUREZOL ........................... 142
dutasteride ............................ 176
dutasteride-tamsulosin ......... 176
DYRENIUM .......................... 97
E
e.c. prin................................... 12
e.e.s. 400................................. 23
e.e.s. granules ......................... 23
econazole................................ 52
econtra ez ............................. 105
ed a-hist .................................. 58
ed bron gp............................. 115
ed chlorped jr ......................... 58
EDURANT............................. 72
effer-k................................... 184
EFFIENT................................ 81
ELAPRASE ......................... 134
eldertonic.............................. 204
electrolyte-48 in d5w ........... 184
ELIDEL................................ 129
ELIGARD .............................. 31
elinest ................................... 105
eliphos .................................. 155
ELIQUIS ................................ 77
ELITEK................................ 134
ELLA ................................... 105
ellis tonic .............................. 204
ELMIRON ........................... 176
elon dual defense.................... 52
EMCYT .................................. 31
EMEND.................................. 64
emoquette ............................. 105
EMPLICITI ............................ 31
EMSAM ................................. 44
EMTRIVA.............................. 72
EMVERM .............................. 65
enalapril maleate .................... 89
enalaprilat ............................... 89
enalapril- hydrochlorothiazide 89
ENBREL .............................. 164
ENBREL SURECLICK ....... 164
endocet ..................................... 5
endodan .................................... 5
endur-acin ............................... 98
enema ........................... 152, 154
enema disposable.......... 151, 152
enemeez ................................ 152
enemeez plus ........................ 152
ENGERIX-B (PF) ................ 168
.......................................... 168
enoxaparin ........................ 77, 78
enpresse ................................ 105
enskyce ................................. 106
entacapone .............................. 66
entecavir ................................. 77
entre-cough ........................... 116
ENTRESTO ........................... 88
enulose.................................. 148
ENVARSUS XR .................. 164
ephedrine sulfate .................... 94
epinastine.............................. 136
epinephrine ....................... 94, 95
epinephrine hcl (pf) ................ 94
EPIPEN 2-PAK ...................... 95
EPIPEN JR 2-PAK................. 95
epitol ....................................... 39
EPIVIR HBV.......................... 72
eplerenone ............................ 100
EPOGEN ................................ 79
epoprostenol (glycine) .......... 197
I-8
EPZICOM .............................. 72
eq gentle ............................... 136
equalactin ............................. 152
ergocalciferol (vitamin d2).. 205,
217
ergoloid ................................ 176
ERGOMAR............................ 62
ERIVEDGE............................ 31
errin ...................................... 106
ery pads ................................ 126
ery-tab .................................... 23
ERY-TAB .............................. 23
ERYTHROCIN ...................... 23
erythrocin (as stearate) ........... 23
erythromycin .................. 23, 140
erythromycin ethylsuccinate .. 23
erythromycin with ethanol .. 126,
127
ESBRIET ............................. 195
escitalopram oxalate......... 44, 45
esmolol ................................... 91
esomeprazole sodium ........... 144
essentia ................................. 205
essential balance with lutein 205
essential daily ....................... 205
estarylla ................................ 106
ESTRACE ............................ 158
estradiol ................................ 158
estradiol valerate .................. 158
estradiol-norethindrone acet. 158
estropipate ............................ 158
eszopiclone........................... 196
ethambutol.............................. 63
ethamolin................................ 95
ethosuximide .................... 39, 40
etodolac .................................. 12
ETOPOPHOS ........................ 31
etoposide ................................ 31
EVOTAZ................................ 72
exemestane ............................. 31
EXJADE............................... 157
expectorant ........................... 116
expectorant dm ..................... 116
expectorant max strength ..... 116
EXTAVIA ............................ 176
extra cleansing douche ......... 178
F
FABRAZYME ..................... 134
falmina (28).......................... 106
famciclovir ............................. 77
famotidine .................... 144, 145
famotidine (pf) ..................... 144
famotidine (pf)- nacl (iso-os) 144
FANAPT ................................ 68
FARESTON ........................... 31
FARYDAK ............................ 31
FASLODEX........................... 31
felbamate ................................ 40
felodipine ............................... 96
feminine care douche ........... 178
FEMRING............................ 158
fenofibrate .............................. 98
fenofibrate micronized ........... 98
fenofibrate nanocrystallized ... 98
fenofibric acid ........................ 98
fenofibric acid (choline)......... 98
fenoprofen .............................. 12
fentanyl..................................... 5
fentanyl citrate.......................... 5
ferocon ................................. 205
ferretts .................................. 205
ferrex 150 ............................. 205
ferrex 150 plus ..................... 205
FERRIPROX........................ 157
ferrocite ................................ 205
ferrous fumarate ................... 205
ferrous gluconate.......... 205, 207
ferrous sulfate....... 201, 205, 206
FETZIMA .............................. 45
feverall ..................................... 5
fexofenadine........................... 59
fiber (calcium polycarbophil)
.......................................... 152
fiber laxative (methylcellulo)155
fiber smooth.......................... 155
fiber therapy (m-cell/sugar).. 152
fiber therapy (m-cellulose) ... 151
fiber therapy (psyllium/sugar)
.......................................... 152
fiber- lax ................................ 153
fibertab ................................. 153
finasteride ............................. 176
FIRAZYR ............................... 95
flanax antacid ....................... 148
FLEBOGAMMA DIF .......... 164
flecainide ................................ 90
FLECTOR .............................. 12
FLEET BISACODYL .......... 153
flintstones complete (iron) ... 206
flintstones multivitamin........ 206
flintstones with iron.............. 206
flintstones/extra c ................. 206
FLOVENT DISKUS ............ 192
FLOVENT HFA................... 192
floxuridine .............................. 31
flu formula daytime-nighttime
.......................................... 118
flu relief therapy daytime ..... 118
flu severe cold-congestion.... 120
flucaine ................................. 137
fluconazole ............................. 53
fluconazole in dextrose(iso-o) 53
fluconazole in nacl (iso-osm) . 53
flucytosine .............................. 53
fludrocortisone ..................... 159
flumazenil ............................. 102
flunisolide ............................. 142
fluocinonide.......................... 129
fluocinonide-e....................... 129
fluorometholone ................... 142
fluorouracil ..................... 31, 125
fluoxetine................................ 45
fluphenazine decanoate .......... 68
fluphenazine hcl ............... 68, 69
flurbiprofen............................. 12
flurbiprofen sodium .............. 142
I-9
flutamide ................................ 31
fluticasone .................... 129, 142
fluvoxamine ........................... 45
foaming antacid............ 148, 150
folic acid............................... 206
FOLIC ACID ....................... 206
fomepizole............................ 176
fondaparinux .......................... 78
foot odor control..................... 55
FORTEO .............................. 174
FORTICAL .......................... 174
foscarnet ................................. 75
fosfree................................... 206
fosinopril ................................ 89
fosinopril- hydrochlorothiazide
............................................ 89
fosphenytoin........................... 40
FREAMINE HBC 6.9 %........ 85
FREAMINE III 10 % ............. 85
fungi cure ............................... 53
FUNGI-NAIL......................... 53
fungoid-d ................................ 53
furosemide.............................. 97
FUSILEV ............................. 176
FUZEON ................................ 72
FYCOMPA ............................ 40
G
gabapentin .............................. 40
GABITRIL ............................. 40
galantamine ............................ 43
GAMASTAN S/D................ 165
GAMMAGARD LIQUID.... 165
GAMMAPLEX .................... 165
ganciclovir sodium ................. 77
GARDASIL (PF) ................. 168
GARDASIL 9 (PF) .............. 168
gas relief ............................... 143
gas relief extra strength ........ 143
gas- x ultra-strength .............. 143
gatifloxacin........................... 140
GATTEX 30-VIAL.............. 148
GATTEX ONE-VIAL.......... 148
GAUZE PAD ....................... 176
gavilyte-c.............................. 153
gavilyte-g ............................. 153
gavilyte-n ............................. 153
GAZYVA............................... 32
gelusil antacid and anti-gas .. 148
gemfibrozil ............................. 98
generlac ................................ 148
gengraf ................................. 165
GENOTROPIN .................... 161
GENOTROPIN MINIQUICK
.......................................... 161
gentak ................................... 140
gentamicin .............. 17, 127, 140
gentamicin in nacl (iso-osm).. 17
gentamicin sulfate (ped) (pf).. 18
gentamicin sulfate (pf) ........... 18
GENTEAL MILD TO
MODERATE ................... 137
GENTEAL GEL .................. 137
GENTEAL MILD ................ 137
GENTEAL SEVERE ........... 137
genteal tears.......................... 137
gentlelax ............................... 153
GENVOYA ............................ 72
GEODON ............................... 69
geravim................................. 206
geriaton................................. 206
geri- hydrolac ........................ 125
geri- tussin dm....................... 116
gianvi (28) ............................ 106
gildagia................................. 106
gildess 1.5/30 (21)................ 106
gildess 1/20 (21)................... 106
gildess 24 fe ......................... 106
gildess fe 1.5/30 (28)............ 106
gildess fe 1/20 (28)............... 106
GILENYA ............................ 176
GILOTRIF ............................. 32
GLEEVEC ............................. 32
GLEOSTINE.......................... 32
glimepiride ............................. 50
glipizide .................................. 50
glipizide- metformin................ 50
GLUCAGEN HYPOKIT ..... 176
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 176
gluco burst .............................. 85
glucose.................................... 85
glucose gel .............................. 85
glutose 15 ............................... 85
glyburide................................. 51
glyburide micronized........ 50, 51
glyburide- metformin .............. 51
glycolax ................................ 153
glycopyrrolate....................... 148
glydo ....................................... 14
GLYXAMBI .......................... 47
granisetron (pf) ....................... 64
granisetron hcl ........................ 64
GRANIX ................................ 79
griseofulvin microsize ............ 53
guaifenesin ........................... 116
guaifenesin dac ..................... 116
guanfacine ...................... 87, 102
guanidine .............................. 176
gummi bear multivitamin .... 206,
211
gummy swirls ....................... 202
H
hair vitamins ......................... 206
hair,skin and nails......... 202, 216
halobetasol propionate.. 129, 130
haloperidol.............................. 69
haloperidol decanoate............. 69
haloperidol lactate .................. 69
HARVONI ............................. 75
HAVRIX (PF) ...................... 168
head congestion day-night.... 116
healthy eyes .......................... 206
healthylax ............................. 153
heather .................................. 106
hemocyte .............................. 207
heparin (porcine) .................... 78
I-10
heparin (porcine) in 5 % dex.. 78
heparin (porcine) in nacl (pf) . 78
heparin(porcine) in 0.45% nacl
............................................ 78
heparin, porcine (pf)............... 78
HEPATAMINE 8% ............... 86
HEPATASOL 8 % ................. 86
HERCEPTIN .......................... 32
HETLIOZ............................. 196
HEXALEN ............................. 32
hi-b complex ........................ 207
hi-cal plus vit d..................... 190
homatropaire ........................ 137
homatropine hbr ................... 137
honey bears .......................... 207
honey bears with iron- zinc ... 207
HUMIRA ............................. 165
HUMIRA PEN ..................... 165
HUMIRA PEN CROHN'S-UCHS START ....................... 165
HUMULIN R U-500 (CONC)
KWIKPEN ......................... 49
HUMULIN R U-500
(CONCENTRATED)......... 49
hydralazine ............................. 95
hydrochlorothiazide ............... 97
hydrocil instant..................... 153
hydrocodone-acetaminophen ... 5
hydrocodone-chlorpheniramine
.......................................... 116
hydrocodone-homatropine ... 116
hydrocodone-ibuprofen ............ 5
hydrocortisone.............. 130, 160
hydrocortisone acet-aloe vera
.......................................... 130
hydrocortisone acetate.......... 130
hydrocortisone acetate-aloe.. 130
hydrocortisone butyrate........ 130
hydrocortisone butyr-emollient
.......................................... 130
hydrocortisone valerate 130, 131
hydromet .............................. 116
hydromorphone ........................ 6
hydromorphone (pf) ................. 5
hydroskin.............................. 130
hydroxychloroquine ............... 65
hydroxyurea ........................... 32
hydroxyzine hcl............ 176, 177
hydroxyzine pamoate ........... 177
HYPERLYTE CR ................ 185
HYPERRAB S/D (PF) ......... 165
HYQVIA .............................. 165
HYSINGLA ER ....................... 6
I
ibandronate........................... 174
IBRANCE .............................. 32
ibuprofen .......................... 12, 14
ibuprofen jr strength............... 12
icaps plus.............................. 207
ICLUSIG ................................ 32
iferex 150 ............................. 207
ifosfamide............................... 32
ifosfamide- mesna ................... 32
ILARIS (PF)......................... 165
ILEVRO ............................... 142
IMBRUVICA......................... 32
imipenem-cilastatin ................ 23
imipramine hcl ....................... 45
imipramine pamoate............... 45
imiquimod ............................ 125
IMLYGIC............................... 32
imodium a-d ......................... 148
IMODIUM A-D ................... 148
IMOGAM RABIES-HT (PF)
.......................................... 165
IMOVAX RABIES VACCINE
(PF)................................... 169
INCRELEX .......................... 161
indapamide ............................. 97
indomethacin .......................... 13
indomethacin sodium ............. 13
INFANRIX (DTAP) (PF) .... 169
infant's ibuprofen ................... 13
INFANT'S MOTRIN ............. 13
infants' non-aspirin cold ....... 122
INLYTA ................................. 33
insta- glucose ........................... 86
INSULIN SYRINGE-NEEDLE
U-100................................ 133
INTELENCE .......................... 72
INTRALIPID ......................... 86
INTRON A ............................. 76
introvale................................ 106
INVANZ................................. 24
INVEGA SUSTENNA........... 69
INVEGA TRINZA ................. 69
INVIRASE ............................. 72
INVOKAMET........................ 47
INVOKANA .......................... 47
inzo antifungal ........................ 53
iodine .................................... 133
IONOSOL-B IN D5W ......... 185
IONOSOL-MB IN D5W ...... 185
IPOL ..................................... 169
ipratropium bromide..... 137, 193
ipratropium-albuterol ........... 193
IPRIVASK ............................. 79
irbesartan ................................ 88
irbesartan-hydrochlorothiazide
............................................ 88
IRESSA .................................. 33
iron high potency.................. 202
ISENTRESS ..................... 72, 73
ISOLYTE M IN 5 %
DEXTROSE ..................... 185
ISOLYTE-H IN 5 %
DEXTROSE ..................... 185
ISOLYTE-P IN 5 %
DEXTROSE ..................... 185
ISOLYTE-S.......................... 185
isoniazid ................................. 63
isopto tears............................ 137
isosorbide dinitrate ............... 100
isosorbide mononitrate ......... 100
isradipine ................................ 96
itraconazole ............................ 53
I-11
ivermectin............................... 65
IXEMPRA.............................. 33
IXIARO (PF)........................ 169
J
JAKAFI .................................. 33
jantoven .................................. 79
JANUMET ............................. 47
JANUMET XR ...................... 47
JANUVIA .............................. 48
JARDIANCE ......................... 48
jencycla ................................ 106
JENTADUETO ...................... 48
jolessa................................... 106
jolivette................................. 106
jr. acetaminophen ................... 10
juleber................................... 106
junel 1.5/30 (21) ................... 106
junel 1/20 (21) ...................... 106
junel fe 1.5/30 (28)............... 106
junel fe 1/20 (28).................. 106
junel fe 24............................. 106
junior mapap ............................ 6
JUXTAPID............................. 98
K
KABIVEN.............................. 86
KALETRA ............................. 73
KALYDECO........................ 195
KANUMA............................ 134
kaopectate (bismuth subsalicy)
.......................................... 148
kariva (28) ............................ 107
k-effervescent....................... 185
kelnor 1/35 (28).................... 107
KELP (IODINE) .................. 185
ketoconazole........................... 53
ketoprofen .............................. 13
ketorolac......................... 13, 142
KEVEYIS............................. 177
KEYTRUDA.......................... 33
kids mini enema ................... 152
kid's vitamins ....................... 211
kid's vitamins + extra c ........ 211
kids vitamins + iron ............. 211
kid's vitamins + iron............. 211
kimidess (28)........................ 107
KINERET............................. 165
KINRIX (PF)........................ 169
kionex................................... 148
klor-con 10 ........................... 185
klor-con m10 ........................ 185
klor-con m15 ........................ 185
klor-con m20 ........................ 185
klor-con sprinkle .................. 185
konsyl (sugar)....................... 153
konsyl fiber .......................... 153
KONSYL SUGAR-FREE.... 153
KORLYM .............................. 48
KRYSTEXXA ..................... 134
kurvelo ................................. 107
KUVAN ............................... 134
KYNAMRO ........................... 98
KYPROLIS ............................ 33
L
l norgest/e.estradiol-e.estrad 107
labetalol .................................. 91
LACRISERT ........................ 137
LACTATED RINGERS ...... 173
LACTINOL HX ................... 125
lactulose ............................... 149
LAMICTAL ........................... 40
LAMISIL (AEROSOL) ......... 53
lamisil af................................. 53
LAMISIL AT ......................... 53
lamivudine.............................. 73
lamivudine-zidovudine........... 73
lamotrigine ............................. 40
LANOXIN ............................. 95
lansoprazole ......................... 144
LANTUS ................................ 49
LANTUS SOLOSTAR .......... 49
larin 1.5/30 (21).................... 107
larin 1/20 (21)....................... 107
larin 24 fe ............................. 107
larin fe 1.5/30 (28) ............... 107
larin fe 1/20 (28)................... 107
latanoprost ............................ 181
LATUDA ............................... 69
laxative peg 3350 ................. 154
LAZANDA............................... 6
leena 28 ................................ 107
leflunomide........................... 166
LEMTRADA........................ 177
LENVIMA ............................. 33
lessina ................................... 107
LETAIRIS ............................ 197
letrozole .................................. 33
leucovorin calcium ............... 177
LEUKERAN .......................... 33
LEUKINE............................... 79
leuprolide................................ 33
levetiracetam .................... 40, 41
levobunolol ........................... 181
levocarnitine ......................... 177
levocarnitine (with sugar)..... 177
levocetirizine .......................... 59
levofloxacin .................... 27, 140
levofloxacin in d5w ................ 27
levonest (28) ......................... 107
levonorgestrel ....................... 107
levonorgestrel-ethinyl estrad107,
108
levonorg-eth estrad triphasic 108
levora-28............................... 108
levothyroxine........................ 163
LEXIVA ................................. 73
lice cream rinse..................... 132
lice killing............................. 132
lice treatment ........................ 132
lice treatment (permethrin) ... 132
lidocaine ........................... 14, 15
lidocaine (pf) .................... 14, 90
lidocaine hcl ........................... 14
lidocaine in 5 % dextrose (pf) 90
lidocaine viscous .................... 14
lidocaine-prilocaine ................ 15
life-pack women's................. 207
I-12
linezolid.................................. 19
LINZESS.............................. 149
liothyronine .......................... 163
lipodox ................................... 33
LIPOSYN II ........................... 86
LIPOSYN III.......................... 86
liquibid d-r............................ 116
liquid calcium with vitamin d
.......................................... 186
LIQUI-E ............................... 207
lisinopril ................................. 89
lisinopril- hydrochlorothiazide 89
lithium carbonate.................. 102
lithium citrate ....................... 102
little animals ......................... 207
little animals- iron ................. 207
lobana bath ........................... 125
lohist-dm .............................. 116
lomedia 24 fe........................ 108
lomustine ................................ 33
LONSURF ....................... 33, 34
loperamide............ 147, 149, 150
loratadine................................ 59
loratadine-d ............................ 59
lorazepam ............................... 17
lorcet (hydrocodone) ................ 6
lorcet hd.................................... 6
lorcet plus ................................. 6
lortuss ex .............................. 116
loryna (28)............................ 108
losartan ................................... 88
losartan-hydrochlorothiazide . 88
LOTEMAX .......................... 142
LOTRONEX ........................ 149
lovastatin ................................ 99
low-ogestrel (28) .................. 108
loxapine succinate .................. 69
lubricant dry eye relief ......... 136
lubricant eye ......................... 136
lubricant eye (cmc-glycer)(pf)
.......................................... 137
lubricant eye (cmc-glycerin) 137
lubricant eye (pg-peg 400) ... 139
lubricant eye (polyv alcohol) 138
lubricant eye (propyl glycol) 137
lubricant eye drops ............... 136
lubricant gel.......................... 136
lubricating drops .................. 136
lubrifresh pm ........................ 137
LUMIGAN........................... 181
LUPRON DEPOT.................. 34
............................................ 34
............................................ 34
............................................ 34
LUPRON DEPOT-PED ....... 161
LUPRON DEPOT-PED (3
MONTH).......................... 161
lutera (28) ............................. 108
LYNPARZA .......................... 34
LYRICA................................. 41
lysiplex plus ......................... 207
LYSODREN .......................... 34
lyza ....................................... 108
M
maalox advanced.................. 149
MACUVITE......................... 207
MACUVITE EYE CARE .... 207
mag 64.................................. 186
mag-delay............................. 186
mag-g ................................... 186
MAGNEBIND 300 .............. 149
magnebind 400 ..................... 155
magnesium ................... 183, 186
magnesium (oxide/aa chelate)
.......................................... 186
magnesium chloride ............. 186
magnesium gluconate........... 186
magnesium oxide ......... 149, 150
magnesium sulf in 0.45% nacl
.......................................... 186
magnesium sulfate................ 187
magnesium sulfate in d5w .... 186
magnesium sulfate in water .. 186
malathion .............................. 132
mapap (acetaminophen) ........... 6
mapap arthritis pain .................. 6
mapap extra strength ................ 6
maprotiline ............................. 45
mar-cof bp ............................ 116
mar-cof cg ............................ 116
margesic ................................... 6
marlissa................................. 108
MARPLAN ............................ 45
masanti double strength........ 149
MATULANE ......................... 34
matzim la ................................ 93
maximum daily multivitamin
.......................................... 212
maximum strength flu .......... 118
meclizine ................................ 64
medroxyprogesterone ........... 162
mefenamic acid ...................... 13
mefloquine.............................. 65
MEFOXIN IN DEXTROSE
(ISO-OSM)......................... 22
mega multiple/chelated mineral
.......................................... 208
mega multivitamin with mineral
.......................................... 208
MEGACE ES ....................... 163
megestrol ........................ 34, 163
MEKINIST ............................. 34
meloxicam .............................. 13
memantine .............................. 43
MENACTRA (PF) ............... 169
MENEST .............................. 159
MENHIBRIX (PF) ............... 169
MENOMUNE - A/C/Y/W-135
(PF) ................................... 169
men's daily gummies ............ 202
men's multivitamin.............. 202
men's one daily ..................... 204
I-13
MENVEO A-C-Y-W-135-DIP
(PF)................................... 169
MENVEO MENA
COMPONENT (PF)......... 169
MENVEO MENCYW-135
COMPNT (PF) ................. 170
MEPHYTON ....................... 208
mercaptopurine....................... 34
meropenem............................. 24
mesehist dm.......................... 116
mesna ................................... 177
MESNEX ............................. 177
MESTINON ......................... 177
MESTINON TIMESPAN .... 177
metaproterenol ..................... 193
metaxall ................................ 196
metaxalone ........................... 196
metformin............................... 48
methadone ................................ 7
methadose................................. 7
methazolamide ..................... 181
methenamine hippurate .......... 19
methimazole ......................... 163
methocarbamol..................... 196
methotrexate sodium .............. 34
methotrexate sodium (pf) ....... 34
methoxsalen rapid ................ 125
methscopolamine ................. 149
methyclothiazide .................... 97
methylphenidate ........... 102, 103
methylprednisolone .............. 160
methylprednisolone acetate.. 160
methylprednisolone sodium succ
.......................................... 160
metipranolol ......................... 181
metoclopramide hcl.............. 149
metolazone ............................. 97
metoprolol succinate .............. 91
metoprolol ta-hydrochlorothiaz
............................................ 91
metoprolol tartrate.................. 91
metronidazole........... 19, 61, 127
metronidazole in nacl (iso-os) 19
mexiletine............................... 90
mgo....................................... 149
MIACALCIN ....................... 174
mi-acid ................................. 150
mi-acid gas relief.................. 143
micatin.................................... 53
miconazole 7 .......................... 54
miconazole nitrate ...... 52, 53, 54
miconazole-3 .................... 53, 54
microgestin 1.5/30 (21) ........ 108
microgestin 1/20 (21) ........... 108
microgestin fe 1.5/30 (28) .... 108
microgestin fe 1/20 (28) ....... 108
midodrine ............................... 87
miglitol ................................... 48
milk of magnesia .................. 153
milltrium senior.................... 208
milrinone ................................ 95
milrinone in 5 % dextrose ...... 95
mimvey................................. 159
mimvey lo ............................ 159
mineral oil .................... 178, 180
MINERAL OIL.................... 177
mineral oil laxative............... 153
minitran ................................ 100
minocycline ............................ 28
minoxidil .............................. 100
mintox .................................. 150
mintox maximum strength ... 150
mintox plus........................... 150
MIRCERA ............................. 79
mirtazapine............................. 45
misoprostol........................... 144
mitoxantrone .......................... 35
M-M-R II (PF) ..................... 170
moexipril ................................ 89
moexipril- hydrochlorothiazide
............................................ 89
molindone............................... 69
mometasone ......................... 131
MONISTAT 3 ........................ 54
monistat 7 ............................... 54
mono- linyah ......................... 108
mononessa (28) .................... 108
montelukast .......................... 192
morphine............................... 7, 8
MORPHINE ............................. 8
morphine (pf) in 0.9 % nacl ..... 7
morphine concentrate ............... 7
morphine in dextrose 5 %......... 7
morrhuate sodium................. 177
motion sickness ...................... 63
motion sickness (meclizine) ... 64
MOVANTIK ........................ 150
MOVIPREP.......................... 153
MOXEZA ............................. 140
moxifloxacin........................... 27
MOZOBIL.............................. 79
mucus dm ............................. 117
mucus dm max ..................... 117
mucus relief .................. 117, 119
mucus relief cough ............... 120
MULTAQ ............................... 90
multi complete with iron ...... 208
multi-day with iron ............... 208
multi-delyn with iron............ 208
multiple vitamin- minerals .... 208
multiple vitamins .................. 208
multiple vitamins with iron .. 208
multi-symptom cold night time
.......................................... 119
multivital platinum ............... 211
multivitamin 50 plus............. 211
multivitamin hp/minerals .... 208
multivitamin with fluoride ... 208
multivitamin with iron.. 208, 214
multivitamin with minerals .. 208
multi- vite .............................. 212
multi- vite 50 and over .......... 212
mupirocin ............................. 127
mupirocin calcium ................ 127
muro 128 .............................. 137
my favorite multiple ............. 208
I-14
my way ................................. 108
myco nail a ............................. 54
mycophenolate mofetil......... 166
mycophenolate sodium ........ 166
MYOZYME ......................... 134
MYRBETRIQ .............. 155, 156
mytab gas ............................. 143
mytab gas maximum strength
.......................................... 143
myvitalife ............................ 208
myzilra ................................. 108
N
nabumetone ............................ 13
nadolol.................................... 91
nafcillin .................................. 25
NAGLAZYME .................... 134
naloxone ................................. 15
naltrexone............................... 15
NAMENDA XR..................... 43
NAMZARIC .......................... 43
naphazoline .......................... 137
naproxen................................. 13
naproxen sodium .................... 13
naratriptan .............................. 62
NARCAN............................... 15
nasal and sinus decongestant 117
nasal decongestant (oxymetazl)
.......................................... 138
NASCOBAL ........................ 209
nasohist dm .......................... 117
NATACYN .......................... 140
nateglinide .............................. 48
NATPARA........................... 174
natural b-100 ........................ 219
natural b-100 complex ......... 214
natural balance ..................... 138
natural calcium ..................... 187
natural fiber laxative therapy 153
natural tears (pf) ................... 136
nature's tears (hypromellose) 138
NEBUPENT........................... 66
necon 0.5/35 (28) ................. 108
necon 1/35 (28) .................... 108
necon 1/50 (28) .................... 109
necon 10/11 (28) .................. 109
necon 7/7/7 (28) ................... 109
nefazodone ............................. 45
neomycin ................................ 18
neomycin-bacitracin-poly- hc 140
neomycin-bacitracin-polymyxin
.......................................... 140
neomycin-polymyxin b gu ... 127
neomycin-polymyxin bdexameth .......................... 140
neomycin-polymyxingramicidin ........................ 140
neomycin-polymyxin- hc ..... 140,
141
neo-polycin........................... 141
neo-polycin hc...................... 141
neosporin (neo-bac-polym) .. 127
neosporin anti- itch................ 131
neo-synephrine 12 h spr (oxym)
.......................................... 138
neo-tuss ................................ 117
nephplex rx........................... 209
NEPHRAMINE 5.4 % ........... 86
nephron fa ............................ 209
nephro- vite rx ....................... 209
NEULASTA........................... 80
NEUMEGA............................ 80
NEUPOGEN .......................... 80
NEUPRO................................ 67
NEVANAC .......................... 142
nevirapine............................... 73
NEXAFED ........................... 117
NEXAVAR ............................ 35
next choice one dose ............ 109
niacin ...................................... 99
niacinamide .................... 99, 209
niacor...................................... 99
nicardipine.............................. 96
NICODERM CQ .............. 15, 16
nicorelief ................................ 16
nicorette .................................. 16
nicotine ................................... 16
nicotine (polacrilex) ............... 16
NICOTROL............................ 16
nifedical xl .............................. 96
nifedipine................................ 96
night time.............................. 118
night time cold- flu ................ 120
night time cold- flu relief ...... 120
night time cough-sore throat 117
nighttime cough .................... 117
nikki (28) .............................. 109
NILANDRON ........................ 35
NINLARO .............................. 35
NITE TIME COLD-FLU
RELIEF ............................ 117
nite time-d cold- flu relief ..... 117
NITRO-BID ......................... 100
nitrofurantoin macrocrystal .... 19
............................................ 19
nitroglycerin ......................... 101
nitroglycerin in 5 % dextrose101
NITROSTAT........................ 101
NIX CREME RINSE ........... 132
nohist-dm.............................. 117
non-aspirin cold .................... 120
non-aspirin extra strength ..... 8, 9
non-aspirin flu ...................... 122
non-aspirin jr strength .............. 4
nora-be.................................. 109
NORDITROPIN FLEXPRO 161
norepinephrine bitartrate ........ 95
norethindrone (contraceptive)
.......................................... 109
norethindrone acetate ........... 163
norethindrone ac-eth estradiol
.......................................... 109
norethindrone-e.estradiol- iron
.......................................... 109
norgestimate-ethinyl estradiol
.......................................... 109
I-15
norlyroc ................................ 109
NORMOSOL-M IN 5 %
DEXTROSE..................... 187
NORMOSOL-R PH 7.4 ....... 187
nortemp .................................... 8
NORTHERA .......................... 87
nortrel 0.5/35 (28) ................ 109
nortrel 1/35 (21) ................... 109
nortrel 1/35 (28) ................... 109
nortrel 7/7/7 (28) .................. 109
nortriptyline............................ 46
NORVIR ................................ 73
NOVOLIN 70/30 ................... 49
NOVOLIN N.......................... 49
NOVOLIN R.......................... 50
NOVOLOG ............................ 50
NOVOLOG FLEXPEN ......... 50
NOVOLOG MIX 70-30......... 50
NOVOLOG MIX 70-30
FLEXPEN .......................... 50
NOVOLOG PENFILL ........... 50
NOXAFIL .............................. 54
NUCALA ............................. 195
NUCYNTA .............................. 8
NUCYNTA ER ........................ 8
NUEDEXTA ........................ 103
nu- iron .................................. 209
NULOJIX............................. 166
nu- mag ................................. 187
NUPLAZID............................ 70
NUTRESTORE.................... 150
NUTRILIPID ......................... 86
NUTRILYTE ....................... 187
NUTRILYTE II.................... 187
NUVARING ........................ 109
NUVIGIL ............................. 196
nyamyc ................................... 54
nystatin ................................... 54
nystatin-triamcinolone ........... 54
nystop ..................................... 55
nyt-time sleep ......................... 59
O
ocean nasal ........................... 138
ocella .................................... 109
OCTAGAM ......................... 166
octreotide acetate.................. 161
ocutabs ................................. 209
ODEFSEY.............................. 73
ODOMZO .............................. 35
OFEV ................................... 195
ofloxacin......................... 27, 141
ogestrel (28) ......................... 110
olanzapine .............................. 70
olanzapine- fluoxetine............. 46
olopatadine ........................... 138
OLYSIO ................................. 76
omega-3 acid ethyl esters ....... 99
omeprazole ........................... 144
omeprazole magnesium........ 144
omeprazole-sodium bicarbonate
.......................................... 145
ONCASPAR .......................... 35
oncovite ................................ 209
ondansetron ............................ 64
ondansetron hcl ...................... 64
ondansetron hcl (pf) ............... 64
one daily ....................... 209, 212
one daily 50 plus .................. 204
one daily complete ............... 209
one daily energy ................... 212
one daily essential 204, 206, 209
one daily maximum (with ca)
.......................................... 204
one daily multi-vit w-mineral
.......................................... 209
one daily multivitamin ......... 209
one daily multivit- iron(folic) 209
one daily plus iron 207, 209, 212
one daily plus minerals ........ 210
one daily with iron ............... 209
one-a-day essential ............... 210
one-a-day maximum formula210
one-a-day teen advantage..... 210
ONFI............................... 17, 131
opcicon one-step................... 110
OPDIVO ................................. 35
OPSUMIT ............................ 197
opti-vitamins......................... 214
oral saline laxative................ 153
oralone .................................. 123
ORENCIA ............................ 166
ORENCIA (WITH MALTOSE)
.......................................... 166
ORENITRAM ...................... 197
ORFADIN ............................ 134
ORKAMBI ........................... 195
orsythia ................................. 110
OTEZLA .............................. 177
OTEZLA STARTER............ 178
OTREXUP (PF) ................... 178
oxacillin .................................. 25
oxacillin in dextrose(iso-osm) 25
oxandrolone .......................... 157
oxcarbazepine ......................... 41
OXTELLAR XR .................... 41
oxybutynin chloride.............. 156
oxycodone ................................ 8
oxycodone-acetaminophen ... 8, 9
oxycodone-aspirin .................... 9
OXYCONTIN .......................... 9
oxymorphone............................ 9
oysco 500/d .......................... 187
oysco d.................................. 187
oysco-500 ............................. 187
oyster shell calcium 500 ....... 187
oyster shell calcium with d ... 190
oyster shell calcium- vit d3 ... 187
oystercal-d ............................ 187
P
pacerone ................................. 90
pain relief.................................. 9
pain relief adult......................... 5
pain reliever jr strength .......... 10
paliperidone ............................ 70
pancrelipase 5000 ................. 134
I-16
PANRETIN .......................... 125
PANTILINERS .................... 178
pantoprazole ......................... 145
papaverine .............................. 95
paricalcitol............................ 174
paromomycin ......................... 66
paroxetine hcl ......................... 46
PASER ................................... 63
PATADAY........................... 138
PAXIL .................................... 46
pecgen dmx .......................... 117
pedia relief............................ 120
pedia relief cough-cold......... 117
pedia relief infant ................. 122
pediacare multi-symptom cold
.......................................... 117
PEDIARIX (PF) ................... 170
pediatric electrolyte..... 183, 188,
190
pediatric freezer pops ........... 190
pediatric multivitamin .. 208, 213
PEDVAX HIB (PF) ............. 170
peg 3350-electrolytes ........... 154
PEGANONE .......................... 41
PEGASYS .............................. 76
PEGASYS PROCLICK ......... 76
peg-electrolyte soln .............. 154
PEGINTRON ......................... 76
PEN NEEDLE, DIABETIC . 133
penicillin g pot in dextrose..... 26
penicillin g potassium ............ 26
penicillin g procaine............... 26
penicillin v potassium ............ 26
PENTACEL (PF) ................. 170
PENTACEL ACTHIB
COMPONENT (PF)......... 170
PENTAM ............................... 66
pentoxifylline ......................... 81
pep-t-med ............................. 149
peri-colace ............................ 154
PERIKABIVEN ..................... 86
perindopril erbumine.............. 89
periogard .............................. 123
permethrin ............................ 132
perphenazine .......................... 70
perphenazine-amitriptyline .... 46
persa-gel ............................... 125
pfizerpen- g ............................. 26
pharbetol................................... 9
pharmacist favorite multivit 210
phenadoz ................................ 64
phenelzine .............................. 46
phenobarbital.......................... 41
phenobarbital sodium ............. 41
phenylephrine hcl ........... 87, 138
phenylhistine dh ................... 117
phenytoin................................ 41
phenytoin sodium ................... 41
phenytoin sodium extended ... 41
philith ................................... 110
phillips.................................. 150
phillips liqui- gels ................. 154
PHOSLYRA ........................ 155
PHOS-NAK ......................... 188
phospha 250 neutral ............. 188
phosphate laxative................ 154
PHOSPHOLINE IODIDE ... 181
phytonadione (vitamin k1) ... 219
PICATO ............................... 125
pilocarpine hcl.............. 123, 181
pimozide................................. 70
pimtrea (28).......................... 110
pindolol .................................. 91
pink bismuth......................... 150
pioglitazone ............................ 48
pioglitazone-glimepiride ........ 48
pioglitazone- metformin.......... 48
piperacillin- tazobactam .......... 26
pirmella ................................ 110
piroxicam ............................... 13
PLAN B ONE-STEP............ 110
PLASMA-LYTE 148 ........... 188
PLASMA-LYTE A .............. 188
PLASMA-LYTE-56 IN 5 %
DEXTROSE ..................... 188
PLEGRIDY .......................... 178
podocon ................................ 125
podofilox .............................. 125
polyethylene glycol 3350 ..... 154
poly- iron ............................... 210
polymyxin b sulfate ................ 19
polymyxin b sulf-trimethoprim
.......................................... 141
poly-tussin ............................ 117
poly- vita ............................... 210
poly- vita (iron) ..................... 210
poly- vitamin ......................... 210
poly- vitamin with iron.......... 210
poly- vitamins........................ 210
POMALYST .......................... 35
portia..................................... 110
PORTRAZZA ........................ 35
potassium acetate.................. 188
potassium bicarb and chloride
.......................................... 188
potassium bicarb-citric acid . 188
potassium chlorid-d5-0.45%nacl
.......................................... 188
potassium chloride 188, 189, 190
potassium chloride in 0.9%nacl
.......................................... 188
potassium chloride in 5 % dex
.......................................... 188
potassium chloride in lr-d5... 188
potassium chloride-0.45 % nacl
.......................................... 189
.......................................... 189
.......................................... 189
.......................................... 189
potassium citrate................... 189
potassium citrate-citric acid . 189
potassium hydroxide ............ 125
I-17
potassium phosphate m-/d-basic
.......................................... 190
POTIGA ................................. 42
PRADAXA ............................ 79
PRALUENT PEN .................. 99
PRALUENT SYRINGE ........ 99
pramipexole............................ 67
pravastatin .............................. 99
prazosin .................................. 87
prednicarbate ........................ 131
prednisolone acetate ............. 143
prednisolone sodium phosphate
.................................. 143, 160
prednisone ............................ 160
PREMARIN ......................... 159
PREMASOL 10 % ................. 86
PREMASOL 6 % ................... 86
PREMPHASE ...................... 159
PREMPRO ........................... 159
prenatal................. 206, 211, 214
prenatal formula ................... 211
prenatal plus (calcium carb) . 210
prenatal tablet ....................... 212
prenatal vit#96-ferrous fum-fa
.......................................... 210
prenatal vitamin............ 202, 210
prenatal vitamin plus low iron
.......................................... 210
prenatal vitamin with minerals
.......................................... 211
prenatal vit- iron fumarate- fa 210
preparation h hydrocortisone 131
PREVAIL BLADDER
CONTROL PAD.............. 151
prevalite.................................. 99
PREVIDENT 5000 SENSITIVE
.......................................... 123
previfem ............................... 110
PREZCOBIX ......................... 73
PREZISTA ............................. 73
PRIFTIN................................. 63
PRILOSEC OTC.................. 145
PRIMAQUINE....................... 66
primidone ............................... 42
PRISTIQ................................. 46
PRIVIGEN ........................... 166
PROAIR HFA ...................... 193
PROAIR RESPICLICK ....... 193
probenecid ............................ 178
procainamide .......................... 90
PROCALAMINE 3% ............ 86
prochlorperazine..................... 64
prochlorperazine edisylate ..... 64
prochlorperazine maleate ....... 64
PROCRIT............................... 80
procto- med hc ...................... 131
procto-pak ............................ 131
proctosol hc .......................... 131
proctozone-hc....................... 131
PROCYSBI .......................... 178
progesterone in oil................ 163
progesterone micronized ...... 163
PROGLYCEM ..................... 101
PROGRAF ........................... 166
PROLASTIN-C.................... 195
PROLENSA ......................... 143
PROLEUKIN ......................... 35
PROLIA ............................... 174
PROMACTA ......................... 80
promethazine .................... 59, 65
promethazine vc-codeine ..... 118
promethazine-codeine .......... 118
promethazine-dm ................. 118
promethegan........................... 65
promolaxin ........................... 154
propafenone............................ 90
propantheline.......................... 38
proparacaine ......................... 138
propranolol ....................... 91, 92
propranolol-hydrochlorothiazid
............................................ 92
propylthiouracil .................... 163
PROQUAD (PF) .................. 170
prosight................................. 211
PROSOL 20 % ....................... 86
protamine................................ 81
protriptyline ............................ 46
pseudoephedrine hcl ............. 118
PULMOZYME..................... 134
pure and gentle eye............... 138
purelax .................................. 152
PURIXAN .............................. 35
pyrazinamide .......................... 63
pyridostigmine bromide ....... 178
pyridoxine (vitamin b6)........ 211
Q
q-dryl ...................................... 59
q-pap......................................... 9
q-pap extra strength .................. 9
q-tapp dm.............................. 118
q-tussin ................................. 118
q-tussin dm ........................... 118
QUADRACEL (PF) ............. 170
quasense ............................... 110
quetiapine ............................... 70
QUILLIVANT XR ............... 103
quinapril ................................. 89
quinapril- hydrochlorothiazide 89
quinidine gluconate ................ 90
quinidine sulfate ..................... 90
quinine sulfate ........................ 66
QVAR................................... 192
R
RABAVERT (PF) ................ 170
raloxifene.............................. 159
ramipril ................................... 89
RANEXA ............................... 95
ranitidine hcl......................... 145
RAPAMUNE ....................... 166
RASUVO (PF) ..................... 178
RAVICTI.............................. 150
react ...................................... 110
REBIF (WITH ALBUMIN). 179
REBIF REBIDOSE .............. 179
REBIF TITRATION PACK. 179
reclipsen (28) ........................ 110
I-18
RECOMBIVAX HB (PF) ... 170,
171
recort plus............................. 131
refenesen .............................. 119
refenesen pe.......................... 119
REFRESH CELLUVISC ..... 138
REFRESH CLASSIC (PF) .. 138
REFRESH LACRI-LUBE ... 138
REFRESH OPTIVE ............. 138
REFRESH OPTIVE
ADVANCED ................... 141
reguloid ................................ 154
relcof c.................................. 119
RELENZA DISKHALER...... 75
RELISTOR........................... 150
remedy phytoplex antifungal . 55
REMICADE......................... 179
REMODULIN...................... 197
RENAGEL ........................... 155
rena-vite rx ........................... 213
RENVELA ........................... 155
repaglinide.............................. 48
repaglinide- metformin ........... 48
REPATHA SURECLICK ...... 99
REPATHA SYRINGE ........... 99
reprexain................................. 10
RESCRIPTOR ................. 73, 74
RESTASIS ........................... 143
retaine cmc ........................... 138
RETROVIR............................ 74
revive plus ............................ 136
REVLIMID ............................ 35
revonto ................................. 196
REXULTI............................... 70
REYATAZ ............................. 74
REZIRA ............................... 119
ribasphere ............................... 77
RIDAURA ........................... 166
rifabutin .................................. 63
rifampin .................................. 63
RIFATER ............................... 63
ri-gel ii.................................. 150
riluzole ................................. 103
rimantadine............................. 75
ri- mox................................... 150
ringers........................... 173, 190
risedronate ............................ 174
RISPERDAL CONSTA ......... 70
risperidone.............................. 70
RITUXAN .............................. 35
rivastigmine............................ 43
rivastigmine tartrate ............... 43
rizatriptan ............................... 62
robafen ................................. 119
robafen cough....................... 119
robafen dm ........................... 119
robitussin cough-chest cong dm
.......................................... 119
ROBITUSSIN LONG-ACTING
.......................................... 119
robitussin pediatric ............... 119
ropinirole ................................ 67
rosadan ................................. 127
ROTARIX ............................ 171
ROTATEQ VACCINE ........ 171
roxicet..................................... 10
ROZEREM........................... 196
rydex..................................... 119
rynex dm .............................. 119
S
SABRIL ................................. 42
safe tussin dm....................... 119
SAIZEN ............................... 162
SAIZEN CLICK.EASY ....... 162
saline mist ............................ 138
SANDOSTATIN LAR DEPOT
.......................................... 162
SANTYL .............................. 125
SAPHRIS (BLACK CHERRY)
............................................ 71
SAVELLA ........................... 103
scooby-doo one a day........... 213
scot-tussin dm ...................... 119
scot-tussin expectorant ......... 119
sea soft nasal mist................. 139
selegiline hcl........................... 67
selenium sulfide.................... 127
SELZENTRY ......................... 74
senexon ................................. 154
senior tabs............................. 213
senna ..................................... 154
senna lax ............................... 154
senna laxative ....................... 152
senna with docusate sodium . 152
senokot-s............................... 155
SENSIPAR ........................... 179
sentry .................................... 213
sentry senior ......................... 213
SEREVENT DISKUS .......... 193
SEROSTIM .......................... 162
sertraline ................................. 46
setlakin ................................. 110
sharobel ................................ 110
SIGNIFOR ........................... 179
silace ..................................... 155
siladryl sa................................ 59
silapap..................................... 10
sildenafil ............................... 197
SILENOR ............................... 46
siltussin sa ............................ 120
siltussin-dm .......................... 120
silver nitrate .......................... 127
silver sulfadiazine................. 127
SIMBRINZA ........................ 181
simethicone........................... 143
simply sleep ............................ 59
SIMPONI ............................. 179
SIMPONI ARIA................... 179
simvastatin.............................. 99
sinus and allergy(pseudoephed)
............................................ 59
sirolimus ............................... 166
SIRTURO ............................... 63
skin treatment ....................... 125
sleep aid (diphenhydramine) .. 59
sleep aid (doxylamine) ........... 59
I-19
smoothlax ............................. 155
sodium acetate...................... 190
sodium bicarbonate ...... 151, 190
sodium chloride... 139, 173, 190,
195
sodium chloride 0.45 % ....... 190
sodium chloride 0.9 % ......... 190
sodium chloride 3 % ............ 190
sodium chloride 5 % ............ 190
sodium fluoride ............ 123, 214
sodium lactate ...................... 191
sodium phosphate................. 191
sodium polystyrene (sorb free)
.......................................... 151
sodium polystyrene sulfonate
.......................................... 151
sodium thiosulfate ................ 157
SOLTAMOX ......................... 35
SOLU-CORTEF (PF) .......... 160
SOMATULINE DEPOT...... 162
SOMAVERT........................ 162
soothe (bismuth subsalicylate)
.......................................... 151
soothe regular strength ......... 151
sorbitol ................................. 173
sorbitol- mannitol .................. 173
sorine ...................................... 92
sotalol ..................................... 92
sotalol af ................................. 92
SOVALDI .............................. 76
spectravite ............................ 202
spectravite adult 50+ ............ 202
spectravite advanced formula
.......................................... 202
spectravite senior.................. 202
spectravite senior w-lycopene
.......................................... 202
spectravite ultra women ....... 202
SPIRIVA RESPIMAT ......... 193
SPIRIVA WITH
HANDIHALER ............... 193
spironolactone ...................... 100
spironolacton-hydrochlorothiaz
.......................................... 100
sprintec (28) ......................... 110
SPRITAM .............................. 42
SPRYCEL .............................. 35
sps......................................... 151
sronyx................................... 110
ssd......................................... 127
st joseph aspirin...................... 14
st. joseph aspirin..................... 14
stavudine ................................ 74
STELARA............................ 179
STERILE PADS .................. 179
STIOLTO RESPIMAT .......... 38
STIVARGA ........................... 36
stomach relief ....................... 150
stool softener ........................ 152
STRATTERA....................... 103
STRENSIQ........................... 134
streptomycin........................... 18
stress 500 plus zinc .............. 211
stress b with zinc .................. 214
stress b-biotin ....................... 214
stress formula ....................... 214
stress formula plus iron ........ 214
stress formula with iron 214, 215
stress formula with zinc ....... 215
STRIBILD.............................. 74
STRIVERDI RESPIMAT .... 194
sucralfate .............................. 145
sudafed ................................. 121
sudogest................................ 121
sudogest sinus and allergy ..... 60
sulfacetamide sodium........... 141
sulfacetamide sodium (acne) 127
sulfacetamide-prednisolone . 141
sulfadiazine ............................ 27
sulfamethoxazole-trimethoprim
............................................ 27
sulfasalazine ........................... 27
sulfatrim ................................. 27
sulindac .................................. 14
sumatriptan ............................. 62
sumatriptan succinate ............. 62
summer's eve disposable douche
.......................................... 180
summers eve extra cleansing 179
sunvite .................................. 215
super b complex-vitamin c .. 203,
214, 215
super b maxi complex .......... 215
super b/c ............................... 215
super b-50 complex .............. 215
super b-50 complex plus ...... 215
super multiple ....................... 215
super multivitamin................ 215
super quints .......................... 215
super quints b-50 .................. 215
super thera vite m ................. 215
superior 35 ............................ 215
superplex-t ............................ 215
suphedrin .............................. 121
suphedrine pe day- night ....... 121
suphedrine severe cold max str
.......................................... 120
support .................................. 215
support-500........................... 216
SUPPRELIN LA .................. 162
SUPRAX ................................ 22
SURMONTIL......................... 46
SUSTIVA ............................... 74
SUTENT................................. 36
syeda ..................................... 110
SYLATRON........................... 76
SYLVANT ............................. 36
SYMLINPEN 120 .................. 49
SYMLINPEN 60 .................... 49
SYNAGIS............................... 75
SYNAREL ........................... 180
SYNERCID ............................ 19
SYNJARDY ........................... 49
SYNRIBO .............................. 36
SYPRINE ............................. 157
I-20
SYSTANE (PROPYLENE
GLYCOL) ........................ 139
SYSTANE GEL ................... 139
T
tab-a-vite .............................. 216
tab-a-vite/iron....................... 216
tab-a-vite- minerals ............... 216
TABLOID .............................. 36
tacrolimus ..................... 131, 166
tactinal .................................... 10
tactinal extra strength ............. 10
TAFINLAR ............................ 36
TAGRISSO ............................ 36
TALTZ AUTOINJECTOR .. 126
TALTZ SYRINGE............... 126
TAMIFLU .............................. 75
tamoxifen ............................... 36
tamsulosin ............................ 156
TARCEVA............................. 36
TARGRETIN ......................... 36
tarina fe 1/20 (28)................. 110
TASIGNA .............................. 36
tazicef ..................................... 22
TAZORAC........................... 131
taztia xt ................................... 93
tears again ............................ 139
tears again (pva) ................... 139
tears naturale free (pf) .......... 139
TECENTRIQ ......................... 36
TECFIDERA........................ 180
TECHNIVIE .......................... 76
TEFLARO.............................. 22
telmisartan .............................. 88
telmisartan-hydrochlorothiazid
............................................ 88
TEMODAR ............................ 36
tencon ..................................... 10
TENIVAC (PF) .................... 171
terazosin ............................... 156
terbinafine hcl ........................ 55
terbutaline............................. 194
terconazole ............................. 61
testosterone........................... 158
testosterone cypionate .......... 157
testosterone enanthate .......... 157
TETANUS
TOXOID,ADSORBED (PF)
.......................................... 171
TETANUS,DIPHTHERIA TOX
PED(PF) ........................... 171
tetanus-diphtheria toxoids-td 171
tetrabenazine ........................ 103
tetracaine hcl (pf) ................. 139
tetracycline ............................. 28
THALOMID ........................ 180
the magic bullet .................... 153
theochron.............................. 194
theophylline.......................... 194
theophylline in dextrose 5 % 194
thera m plus (ferrous fumarat)
.......................................... 216
thera vitamin ........................ 216
thera-d .................................. 216
theradex m............................ 216
THERAFLU DAYTIME
COLD-COUGH ............... 121
THERAFLU MULTISYMPTOM COLD .......... 121
thera- m ................................. 216
therapeutic liquid.................. 207
therapeutic m + beta-carotene
.......................................... 212
therapeutic- m ....................... 216
therapeutic- m vitamin/minerals
.......................................... 214
thera-tabs .............................. 216
theratrum complete 50 plus.. 216
theratrum complete 50 plus/lut
.......................................... 216
thiamine hcl (vitamin b1) ..... 216
thioridazine............................. 71
thiotepa................................... 36
thiothixene.............................. 71
tiagabine ................................. 42
TICE BCG ............................ 167
TIKOSYN .............................. 90
tilia fe.................................... 110
timolol maleate ............... 92, 181
TIVICAY ............................... 74
tizanidine .............................. 196
TOBI PODHALER ................ 18
TOBRADEX ........................ 141
TOBRADEX ST .................. 141
tobramycin............................ 141
tobramycin in 0.225 % nacl.... 18
tobramycin in 0.9 % nacl........ 18
tobramycin sulfate .................. 18
tobramycin-dexamethasone.. 141
TOLAK ................................ 126
tolazamide .............................. 51
tolbutamide ............................. 51
tolmetin................................... 14
tolnaftate ................................. 55
tolterodine............................. 156
topiragen ................................. 42
topiramate ............................... 42
toposar .................................... 36
torsemide ................................ 97
total b/c ................................. 216
totalday multiple................... 216
TOUJEO SOLOSTAR ........... 50
TOVIAZ ............................... 156
TPN ELECTROLYTES ....... 191
TPN ELECTROLYTES II ... 191
TRACLEER ......................... 197
TRADJENTA ......................... 49
tramadol.................................. 10
tramadol-acetaminophen ........ 10
trandolapril ............................. 89
tranexamic acid ...................... 81
TRANSDERM-SCOP............ 65
tranylcypromine ..................... 46
TRAVASOL 10 % ................. 86
TRAVATAN Z .................... 181
travel sickness (meclizine) ..... 65
travoprost (benzalkonium) ... 181
I-21
trazodone ................................ 46
TREANDA....................... 36, 37
TRECATOR........................... 63
TRELSTAR ........................... 37
tretinoin ................................ 132
tretinoin (chemotherapy)........ 37
tretinoin microspheres.......... 132
TREXALL ............................. 37
triacting m-sym cold/cough . 122
triamcinolone acetonide ...... 123,
131, 160
triaminic cold and cough (pe)
.......................................... 121
TRIAMINIC COLD AND
COUGHNT(PE)................. 60
TRIAMINIC COUGH-SORE
THROAT ......................... 121
triamterene-hydrochlorothiazid
............................................ 97
trianex................................... 131
TRIBENZOR ......................... 88
tri-buffered aspirin ................. 14
tri-dex pe .............................. 121
tri-estarylla ........................... 110
trifluoperazine ........................ 71
trifluridine ............................ 141
trihexyphenidyl ...................... 67
tri- legest fe ........................... 110
tri- linyah............................... 110
tri- lo-estarylla....................... 111
tri- lo- marzia ......................... 111
tri- lo-sprintec........................ 111
trilyte with flavor packets .... 155
trimethoprim........................... 19
trimipramine........................... 46
trinessa (28).......................... 111
TRINTELLIX ........................ 47
triple antibiotic ............. 126, 127
triple paste af .......................... 55
tri-previfem (28)................... 111
tri-sprintec (28) .................... 111
TRIUMEQ ............................. 74
tri- vi-sol................................ 217
tri- vita................................... 217
tri- vitamin............................. 217
trivora (28) ........................... 111
TROKENDI XR..................... 42
TROPHAMINE 10 % ............ 87
TROPHAMINE 6% ............... 87
trospium ............................... 156
TRULICITY........................... 49
TRUMENBA ....................... 171
TRUVADA ............................ 74
trymine cg ............................ 121
TUDORZA PRESSAIR ....... 194
tusnel diabetic ...................... 121
TUSNEL NEW FORMULA 121
TUSNEL PEDIATRIC ........ 121
TUSSI PRES-B .................... 121
tussin cf ........................ 120, 122
tussin cf cough-cold ............. 121
tussin cold-congestion.......... 121
tussin cough (dm only)......... 115
tussin dm ...................... 119, 121
tussin dm cough and chest ... 115
tussin maximum strength ..... 115
tussin pe................................ 118
TWINRIX (PF) .................... 171
TYBOST .............................. 180
TYGACIL .............................. 28
TYKERB................................ 37
TYPHIM VI ......................... 171
TYSABRI............................. 166
TYVASO ............................. 197
TYVASO REFILL KIT ....... 197
TYVASO STARTER KIT ... 197
TYZEKA................................ 77
U
u-cort .................................... 131
ULORIC............................... 180
ultra b-100 complex ............. 217
ultra fresh pm ....................... 139
ultra strength antacid ............ 146
unisom sleepgels .................... 60
UNITUXIN ............................ 37
UPTRAVI..................... 197, 198
ursodiol ................................. 151
V
VAGIFEM............................ 159
valacyclovir ............................ 77
VALCHLOR ........................ 126
valganciclovir ......................... 77
valproate sodium .................... 42
valproic acid ........................... 42
valproic acid (as sodium salt) . 42
valsartan ................................. 88
valsartan-hydrochlorothiazide 88
VALSTAR ............................. 37
valu-tapp dm......................... 120
VANACOF........................... 122
vancomycin ...................... 19, 20
vancomycin in dextrose 5 % .. 19
VAQTA (PF) ................ 171, 172
VARIVAX (PF) ................... 172
VASCEPA............................ 100
v-c forte ................................ 217
VELCADE ............................. 37
velivet triphasic regimen (28)
.......................................... 111
VENCLEXTA ........................ 37
VENCLEXTA STARTING
PACK ................................. 37
venlafaxine ............................. 47
VENTOLIN HFA................. 194
verapamil ................................ 93
VERSACLOZ ........................ 71
vestura (28)........................... 111
VGO 40 ................................ 133
VIBERZI .............................. 151
vic-forte ................................ 217
vicks dayquil cold- flu relief . 122
vicks dayquil cough.............. 122
vicks nature fusion cough..... 122
vicks nyquil severe cold- flu . 122
vicks qlearquil(oxymetazoline)
.......................................... 139
I-22
vicks sinex 12-hour .............. 139
vicodin.................................... 10
vicodin es ............................... 10
vicodin hp............................... 10
VICTOZA 3-PAK.................. 49
............................................ 74
............................................ 74
VIEKIRA PAK ...................... 76
vienva ................................... 111
VIGAMOX .......................... 141
VIIBRYD ............................... 47
VIMIZIM ............................. 134
VIMPAT .......................... 42, 43
vinorelbine ............................. 37
viorele (28) ........................... 111
VIRACEPT ............................ 74
VIRAMUNE XR ................... 74
VIRAZOLE............................ 77
virdec dm.............................. 122
VIREAD................................. 75
virt-phos 250 neutral ............ 191
virtussin ac ........................... 122
vision .................................... 217
vision formula ...................... 204
vision formula (with lutein) 203,
217
vision plus lutein .................. 217
vit b complex- folic acid ....... 214
vitalets .................................. 217
vitamin a............................... 217
vitamin b complex........ 199, 212
vitamin b-100 complex ........ 203
vitamin b12- folic acid .......... 218
vitamin b-6 ........................... 218
vitamin c....................... 213, 218
vitamin d3 ............ 214, 218, 219
vitamins and minerals .......... 217
vitamins b complex ...... 199, 217
vitamins for hair ................... 219
VITEKTA .............................. 75
vitrum senior ........................ 219
VOLTAREN .......................... 14
voriconazole ........................... 55
VOTRIENT............................ 37
VPRIV.................................. 134
VRAYLAR ............................ 71
vyfemla (28) ......................... 111
W
wal-act d cold and allergy ...... 60
wal-dram ................................ 65
wal-dryl allergy ...................... 60
wal- fex allergy ....................... 60
wal- finate ............................... 60
wal- finate-d ............................ 60
wal- itin ................................... 60
wal- itin d ................................ 60
wal- itin d 12 hour ................... 60
wal-phed......................... 60, 122
wal-phed pe day-night.......... 122
wal-phed pe sinus and allergy 60
wal-profen .............................. 14
wal-sleep z........................ 60, 61
wal-som (diphenhydramine) .. 61
wal-som (doxylamine) ........... 61
wal-tap.................................... 61
wal-tussin cough .................. 122
wal-tussin cough and cold cf 122
wal-tussin dm ....................... 112
wal- zan 75 ............................ 145
wal- zyr (cetirizine) ................. 61
wal- zyr d ................................ 61
warfarin .................................. 79
water for irrigation, sterile ... 173
WELCHOL .......................... 100
wera (28) .............................. 111
womens daily gummies........ 203
women's daily multivitamin . 212
X
XALKORI.............................. 37
XARELTO ............................. 79
XELJANZ ............................ 180
XELJANZ XR...................... 180
XIFAXAN .............................. 20
XOLAIR ............................... 195
XTANDI................................. 37
xulane ................................... 111
xylon 10 .................................. 10
XYREM ............................... 196
Y
yelets..................................... 219
YERVOY ............................... 38
YF-VAX (PF)....................... 172
YONDELIS ............................ 38
Z
zafirlukast ............................. 192
zaleplon ................................ 196
ZANTAC.............................. 145
ZANTAC 75......................... 146
zarah ..................................... 111
ZARXIO ................................. 80
ZAVESCA ........................... 134
zebutal .................................... 11
ZELBORAF ........................... 38
ZEMPLAR ........................... 174
zenatane ................................ 126
zenchent (28) ........................ 111
ZENPEP ............................... 135
ZEPATIER ............................. 76
zephrex-d .............................. 123
ZETIA .................................. 100
ZIAGEN ................................. 75
zidovudine .............................. 75
zinc oxide ............................. 126
ziprasidone hcl........................ 71
ZIRGAN ............................... 142
ZOLADEX ............................. 38
zoledronic acid ..................... 174
.......................................... 174
ZOLINZA............................... 38
zolmitriptan ............................ 62
zolpidem ............................... 196
ZOMETA ............................. 175
ZONATUSS ......................... 123
I-23
zonisamide ............................. 43
zoo chews ............................. 219
ZORTRESS.......................... 167
ZOSTAVAX (PF) ................ 172
zovia 1/35e (28) ................... 111
zovia 1/50e (28) ................... 111
ZOVIRAX............................ 126
z-sleep .................................... 59
ZUBSOLV ............................. 16
ZYDELIG .............................. 38
ZYKADIA ............................. 38
ZYLET ................................. 142
zyncof ................................... 123
ZYPREXA RELPREVV........ 71
ZYRTEC ................................ 61
ZYTIGA ................................. 38
ZYVOX .................................. 20
Nou te fè dènye chanjman nan fòmilè sa a nan dat 29 Jen 2016. Si ou gen kesyon, tanpri rele ICS
Community Care Plus FIDA-MMP nan nimewo 1.877.ICS.2525, lendi jiska vandredi, ant 8 a.m. ak
8 p.m. Koutfil la gratis.
Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
I-24
1.877.ICS.2525
www.icsny.org
Biwo Administratif
Independence Care System
257 Park Ave. South
2nd Floor
New York, NY 10010
Sant pou Manm yo
400 East Fordham Road
10th floor
Bronx, New York 10458
25 Elm Place
5th Floor
Brooklyn, NY 11201

lis medikaman ki kouvri yo

Transcription

Similar documents

LIS MEDIKAMAN KI KOUVRI YO

“Koute aprann mennen” Ki sa ki andedan!

North Shore-LIJ FIDA LiveWell - North Shore