Medicare Plans | AARP

Transcription

2013
Comprehensive
Formulary
(Complete list of covered drugs)
AARP® MedicareRx Saver Plus (PDP)
Inside
•Drug tiers and drug payment stages
•Requirements and limits
• Complete list of drugs by category
• Index of covered drugs
Please read: This document contains information about the drugs covered by
this plan.
Note to existing members: This complete formulary has changed since last year.
Please review this document to make sure it still contains the drugs you take.
00013621, 8
Y0066_3398318_000_Final_P04 CMS Approved
About this complete drug list
This is a complete list of prescription drugs that are covered by the AARP® MedicareRx Saver Plus (PDP)
plan, insured through UnitedHealthcare,® for the 2013 plan year. It is called the Comprehensive
Formulary (drug list) and includes all of the drugs covered by the plan.
For your drug to be covered by the plan, it must be included in the complete drug list. In most cases, your
prescription must also be filled at one of our more than 65,000 network pharmacies. To find out if your
drug is covered:
1. See if your drug is included in this complete drug list.
2. Visit the plan website at www.AARPMedicareRx.com. You can use online tools to look up your
drugs. The information is updated on a regular basis.
3. Call UnitedHealthcare Customer Service at 1-888-867-5575, TTY 711, 8 a.m. to 8 p.m. local time,
7 days a week. UnitedHealthcare Customer Service can look up your drugs and let you know if they
are covered.
For more information
Please take the time to review your Evidence of Coverage and any other 2013 plan materials you have
received. These materials give more detailed information about your drug coverage in the plan.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1‑800‑MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users should call
1‑877‑486‑2048. Or visit www.medicare.gov.
Questions?
Online tools
If you have questions, we’re here to help.
Call UnitedHealthcare Customer Service at
Visit www.AARPMedicareRx.com to
-888-867-5575, TTY 711
1
8 a.m. to 8 p.m. local time,
7 days a week
Or visit www.AARPMedicareRx.com
• Look up your drugs and see what you could
save with lower-cost drugs
• View your cost and benefits summary
• Track your payment status and
claims history
• Find network pharmacies
• Print plan forms and materials
If you are a member of a group sponsored plan (your coverage is provided through a former employer,
union group or trust), please call the UnitedHealthcare Customer Service number on the back of your
member ID card.
2013 Complete drug list
The AARP MedicareRx Saver Plus plan is designed to help you manage your prescription drug costs.
An important part of this is giving you choices so you and your doctor can choose the best course of
treatment for you.
A formulary is a list of the drugs covered by a Part D plan in consultation with a team of health
care providers, which represents the prescription therapies believed to be a necessary part of a
quality treatment program. The plan will generally cover the drugs listed in the formulary as long
as the drug is medically necessary, the prescription is filled at a plan network pharmacy and other
plan rules are followed. For more information on how to fill your prescriptions, please review your
Evidence of Coverage.
With your doctor’s help, you can use this drug list as a tool to choose the drugs that work best for you
and to find lower-cost drugs, if needed.
Using the drug list
There are two ways to find your prescription drugs in this complete drug list:
1.Alphabetical list (index): Turn to the “Index of covered drugs” section, which begins on page 46,
to see the list of drug names in alphabetical order.
2.Medical condition: Turn to the “Covered drugs by category” section, which begins on page 8,
to look for drug names based on your medical conditions. For example, if you want to find
drugs used to treat high cholesterol, go to the “Cardiovascular Drugs” category and look under
“Cholesterol Control Drugs.”
Is it a generic or brand name drug?
The drug list shows brand name drugs in bold type (for example, Crestor) and generic drugs in plain
type (for example, Simvastatin).
More information about your drug
Some drugs have requirements or limits. Please see the “Requirements and limits” section on page 4 for
more information on drugs you may use.
This document is a complete list of covered drugs. If your drug is not included in this drug
list, you should contact UnitedHealthcare Customer Service to ask if it’s covered, or go to
www.AARPMedicareRx.com to look it up online. If you learn that the plan does not cover your drug,
you have two options:
1. Y
ou can ask UnitedHealthcare Customer Service for a list of similar drugs that are covered by the
plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug
that is covered by the plan.
2. Y
ou can ask the plan to make an exception and cover your drug. See the “Coverage decisions”
section on page 5 for information about how to request an exception.
1
Drug tiers and drug payment stages
The amount you pay for a covered drug will depend on:
• Your drug payment stage. The plan has different stages of drug coverage. When you fill a
prescription, the amount you pay depends on the stage you’re in.
• The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier has a different
copay or coinsurance amount. The chart below shows the differences between the tiers.
For more information about drug payment stages and copay or coinsurance amounts for each tier,
please refer to the plan’s Evidence of Coverage (EOC).
If you qualify for extra help
If you qualify for extra help for your prescription drugs, your copays and coinsurance may be lower.
Members who qualify for extra help will receive the “Evidence of Coverage Rider for People Who Get
Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to find out what your costs are.
You can also contact UnitedHealthcare Customer Service.
Drug Tier
Copay or Coinsurance
Includes
Helpful Tips
Tier 1:
Preferred generic
Lowest copay
Lower-cost, commonly used
generic drugs.
Use Tier 1 drugs for the lowest
out‑of-pocket costs.
Tier 2:
Non-preferred generic
Low copay
Most generic drugs.
Use Tier 2 drugs, instead of
Tier 3 or 4, to help reduce your
out-of-pocket costs.
Tier 3:
Preferred brand
Medium copay
Many common brand
name drugs, called
preferred brands, and some
higher‑cost generic drugs.
Many Tier 3 drugs have lower‑cost
options in Tier 1 or 2. Ask your
doctor if they could work for you.
Tier 4:
Non-preferred brand
Highest copay
Non‑preferred generic
and non-preferred
brand name drugs.
Many Tier 4 drugs have lower-cost
options in Tier 1, 2 or 3. Ask your
doctor if you can switch to one of
these drugs to help reduce your
out‑of-pocket costs.
Tier 5:
Specialty tier
Coinsurance
Unique and/or very
high‑cost drugs.
You pay a percentage of the total
drug cost, called coinsurance.
2
Generic drugs
The plan covers both brand name and generic drugs. The Food and Drug Administration (FDA)
requires a generic drug to have the same active ingredient as the brand name drug. Using generic drugs,
whether preferred or non-preferred, may save you money on your copays or coinsurance and may help
you stay out of the coverage gap if you have one.
• To pay less out‑of‑pocket, talk with your doctor to see if any of the brand name drugs you take
have generic versions. While most generics are in Tier 2 of the drug list, some generics can be found
in Tier 1.
• W hile generic drugs usually cost less than brand name drugs, newly available generic drugs can be
expensive so they may be in Tier 2, 3 or 4 of the drug list.
Vaccines
The plan covers a number of Part D vaccines. Our coverage may include the cost of both the vaccine
medication and the administration of the vaccine shot. Some vaccines, like those for the flu and
pneumonia, may be covered by Medicare Part B (doctor and outpatient health care).
For the best coverage, the plan recommends that you get vaccines at a network pharmacy if your state
allows it. The administration fee likely will be lower at a network pharmacy than at your doctor’s office.
You also won’t have to fill out a form to get paid back (reimbursed). If the administration fee is less
than $20, you will pay only your copay or coinsurance amount. If it is more than $20, you will pay the
extra amount.
If you get your vaccines at your doctor’s office, you will pay the entire cost of the vaccine and
administration fee to your doctor. You will have to submit a form to the plan to get reimbursed. You
will pay your copay or coinsurance amount, plus the difference between $20 and the administration fee
charged by your doctor.
Please see your Evidence of Coverage for more information about vaccines and their costs.
To make sure a recommended vaccine is covered or to request a reimbursement form, call UnitedHealthcare
Customer Service at 1-888-867-5575, TTY 711. Or visit www.AARPMedicareRx.com to download a
reimbursement form.
3
Requirements and limits
Some of the plan’s drugs have requirements or limits to help ensure safe, effective and affordable
use. If your drug has any requirements or limits, there will be a code(s) in the “Requirements &
Limits” column of the drug list starting on page 8. The codes and what they mean are shown below.
Visit www.AARPMedicareRx.com for more information.
You and your doctor may ask the plan for an exception to the requirement and/or limit for your drug.
See the “Coverage decisions” section on the next page or see your Evidence of Coverage to learn more.
If you do not get prior approval from the plan for a drug with a requirement or limit, you may be
responsible for paying the full cost of the drug.
B/D
Medicare Part B or Part D
LA
Limited access
PA
Prior authorization
ST
Step therapy
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor
and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need
to provide the plan with more information about how this drug will be used to make sure
it’s correctly covered by Medicare.
Drugs are considered “limited access” if the FDA says the drug can be given out only by
certain facilities or doctors. These drugs may require extra handling, provider coordination or
patient education that can’t be done at a network pharmacy.
The plan requires you or your doctor to get prior authorization for certain drugs. This
means the plan needs more information from your doctor to make sure the drug is being
used correctly for a medical condition covered by Medicare. If you don’t get approval, the
plan may not cover the drug.
There are effective, lower-cost drugs that treat the same medical condition as this drug.
You may be required to try one or more of these other drugs before the plan will cover
your drug. If you have already tried other drugs or your doctor thinks they are not right for
you, you or your doctor can ask the plan to cover this drug.
For more information about requirements and limits, call UnitedHealthcare Customer Service at
1-888-867-5575, TTY 711.
4
Coverage decisions
At times you may need to ask for drug coverage that’s not normally provided by the plan. When you do,
the plan will consider your request and respond with a coverage decision (coverage determination).
Examples of coverage decisions you may ask for include:
•Asking the plan to pay you back for the cost of a drug you bought at an out‑of‑network pharmacy.
• Asking for an exception to the plan’s coverage rules.
How to request an exception
You can ask the plan to make an exception to the coverage rules. There are several types of exceptions
that you can ask the plan to make.
•You can ask the plan to cover your
drug even if it is not on the formulary
(formulary exception).
•You can ask the plan to waive coverage
restrictions or limits on your drug (utilization
exception). For example, for certain drugs,
the plan limits the amount of the drug that it
will cover.
•You can ask the plan to provide a higher level
of coverage for your drug (tier exception). If
your drug is in the non-preferred tier, you can
ask the plan to cover it at the cost-sharing
amount that applies to drugs in the preferred
tier instead. This would lower the amount
you must pay for your drug. Please note, if we
grant your request to cover a drug that is not
in the plan’s formulary, you may not ask us to
provide a higher level of coverage for the drug.
Tier exceptions are not available for drugs in
the specialty tier.
Generally, the plan will only approve your request for an exception if the alternative drugs included in
the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective
in treating your condition and/or would cause you to have adverse medical effects.
Asking for a coverage decision
You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling
UnitedHealthcare Customer Service at 1-888-867-5575, TTY 711.
When you are requesting a formulary, tiering or utilization restriction exception, your prescriber or
physician should submit a statement supporting your request.
See your Evidence of Coverage for more information.
Receiving a coverage decision
Generally, the plan will make a coverage decision within 72 hours after receiving your prescribing
physician’s statement. You can request an expedited, or fast, decision if you or your doctor believe your
health requires it. If the plan agrees to a fast decision, you will receive a decision within 24 hours after the
plan receives your prescriber’s or prescribing physician’s supporting statement.
5
Drug list changes
The plan recognizes that drug list stability is very important to you. That is why the plan tries to make
as few changes to the drug list as possible during the plan year. From time to time, drug list changes
may be necessary for safety or other reasons.
The drug list may change throughout the year when the plan:
• Adds a new drug.
• Removes a drug.
• Changes the requirements or limits for a drug.
• Moves a drug to a lower-cost tier.
• Moves a drug to a higher-cost tier.
I f the FDA declares a drug to be unsafe or the drug’s manufacturer removes the drug from the market,
the plan will immediately remove the drug from the drug list and inform affected members. If a drug
moves to a higher‑cost tier or undergoes some other change, the plan will inform affected members at
least 60 days before the change or at the time the member requests a refill of the drug, at which time the
member will receive a 60-day supply of the drug.
Generally, if you are taking a drug on the 2013 drug list that was covered at the beginning of the year,
the plan will not remove the drug from the drug list or move a drug to a higher tier during the 2013
coverage year except when a new, less expensive generic equivalent drug becomes available (for example,
the brand name drug moves to a higher tier and the less expensive drug is on the lower tier), or when
new information about the safety or effectiveness of a drug is released.
Other types of changes, such as removing a drug from the drug list, will not affect members who are
currently taking the drug. It will remain available at the same cost-sharing for those members taking it
for the remainder of the coverage year. It is important that you have continued access for the remainder
of the coverage year to the list of drugs that were available when you chose the plan, except for cases in
which you can save additional money or your safety is a concern.
If there are changes to the drug list such as regular or necessary updates, members may see information
in the Explanation of Benefits statement, member newsletters or other member mailings. If there are
changes to the drug list outside of regular or necessary updates, members may receive a special mailing.
The plan website also has updated information.
6
Transition supply process
New or continuing members
As a new or continuing member in the plan, you may be taking drugs that are not on the formulary.
Or you may be taking a drug that is on the formulary but your ability to get it is limited. For example,
you may need prior authorization before you can fill your prescription. You should talk to your doctor to
decide if you should switch to an appropriate drug that the plan covers, or request a formulary exception
so that the plan will cover the drug you take. While you talk to your doctor to determine the right
course of action for you, the plan may cover your drug in certain cases during the first 90 days you are a
member of the plan.
For each of your drugs that is not on the formulary, or if your ability to get your drugs is limited, the
plan will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when
you go to a network pharmacy. After your first 31-day supply, the plan will not pay for these drugs, even
if you have been a member of the plan less than 90 days.
Long-term care facility residents
If you’re a resident of a long-term care facility, the plan will allow you to refill your prescription until we
have provided you with a 91- and up to a 98-day transition supply of the drug consistent with dispensing
increment (unless your prescription is for fewer days). The plan will also cover one or more refills for the
first 90 days of your membership. If you need a drug that’s not on the drug list or if you have limited
ability to get your drugs but you are past the first 90 days of your plan membership, the plan will cover
a 31-day emergency supply of the drug (unless your prescription is for fewer days) while you request a
formulary exception.
Other transitions
You may have an unplanned transition, like a hospital discharge or a change in your level of care, after
the first 90 days of your plan membership. If this happens and your doctor prescribes a drug that’s
not on the drug list, or if it’s difficult for you to get your drugs, you are required to use the plan’s
exception process. You may ask for a one-time emergency supply of up to 31 days to give you time to talk
to your doctor about other treatment options or to try to get a formulary exception.
For more information
For more detailed information about AARP MedicareRx Saver Plus prescription
drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions, please call UnitedHealthcare Customer Service at
-888-867-5575, TTY 711
1
8 a.m. to 8 p.m. local time, 7 days a week
If you have general questions about Medicare prescription drug coverage, please call
Medicare at 1‑800‑MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.
TTY/TDD users should call 1‑877‑486‑2048. Or visit www.medicare.gov.
7
Covered drugs by category
The comprehensive formulary (drug list) below provides coverage information about all of the drugs
covered by the plan. It is current as of January 1, 2013.
The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for
example, Crestor) and generic drugs are listed in plain type (for example, Simvastatin). The information
in the Requirements & Limits column tells you if the plan has any special requirements for coverage of
your drug.
If you have trouble finding your drug in the list, turn to the “Index of covered drugs” section
that begins on page 46. If your prescription is not in this complete formulary, please visit
www.AARPMedicareRx.com or call UnitedHealthcare Customer Service at 1-888-867-5575,
TTY 711, for additional help.
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Drug Requirements
Tier & Limits
Ketorolac Tromethamine
(15mg/ml Injection,
3
PA
30mg/ml Injection)
Mefenamic Acid
3
Meloxicam (Tablet)
1
Meloxicam (Suspension)
2
Naproxen
2
Naproxen DR
2
Naproxen Sodium (275mg
2
Tablet, 550mg Tablet)
Oxycodone/Ibuprofen
3
Sulindac
2
Opioid Analgesics, Long-Acting — Opioid
Pain Relievers
Astramorph
3
Duramorph
3
Exalgo
3
Fentanyl (Patch)
3
Levorphanol Tartrate
3
Analgesics — Drugs to Treat Pain,
Inflammation, and Muscle and Joint
Conditions
Nonsteroidal Anti-Inflammatory Drugs —
Pain/Anti-Inflammatory Drugs
Diclofenac Potassium
2
Diclofenac Sodium DR
2
Diclofenac Sodium ER
2
Diflunisal
2
Etodolac
2
(200mg Capsule, Tablet)
Flurbiprofen
2
Ibuprofen (Suspension,
400mg Tablet, 600mg
2
Indomethacin (Capsule)
3
Ketoprofen
3
3
(Tablet)
Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug
PA = Prior authorization
ST = Step therapy
8
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Methadone HCl
(Concentrate,
3
Oral Solution, Tablet)
Methadone HCl
4
(Injection)
Methadose (Tablet)
3
Morphine Sulfate
3
(Oral Solution, Tablet)
Morphine Sulfate ER
3
Nucynta ER
3
Opioid Analgesics, Short-Acting — Opioid
Pain Relievers
Acetaminophen/Codeine
2
Butorphanol Tartrate
3
Co-Gesic
3
Codeine Sulfate (Tablet)
2
Fentanyl Citrate Oral
5
PA
Transmucosal
Hydrocodone/
Acetaminophen
(Oral Solution, 300mg;
10mg Tablet, 300mg;
5mg Tablet, 300mg;
7.5mg Tablet, 325mg;
10mg Tablet, 325mg;
5mg Tablet, 325mg;
3
10mg Tablet, 500mg;
5mg Tablet, 500mg;
10mg Tablet, 650mg;
10mg Tablet, 750mg;
10mg Tablet, 750mg;
7.5mg Tablet)
Hydrocodone/Ibuprofen
3
Hydromorphone HCl
3
(Tablet)
Nalbuphine HCl
3
Onsolis
5
PA
Oxycodone HCl (Capsule,
Concentrate, 15mg Tablet,
30mg Tablet, 5mg Tablet)
Oxycodone/
Acetaminophen
Oxycodone/Aspirin
Roxicet
(500mg; 5mg Tablet)
Stagesic
Tramadol HCl
Tramadol HCl/
Acetaminophen
Drug Requirements
Tier & Limits
3
3
3
3
3
2
2
Anesthetics — Drugs for Numbing
Local Anesthetics
Lidocaine (Ointment)
Lidocaine HCl
(External Solution)
Lidocaine HCl (0.5%
Injection, 1% Injection)
Lidocaine HCl (Gel)
Lidocaine Viscous
Lidocaine/Prilocaine
(Cream)
Lidoderm
3
3
3
B/D
3
3
3
3
Antibacterials — Drugs to Treat
Bacterial Infections
Aminoglycosides — Antibiotics
Amikacin Sulfate
(500mg/2ml Injection,
3
50mg/ml Injection)
Gentak (Ointment)
2
Gentamicin Sulfate (Cream,
Injection, 0.1% Ointment,
2
Ophthalmic Solution)
Gentamicin Sulfate/NaCl
(1.2mg/ml; 0.9% Injection,
2
1.6mg/ml; 0.9% Injection,
1mg/ml; 0.9% Injection)
9
B/D
B/D
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Gentamicin Sulfate/
NaCl (0.9mg/ml; 0.9%
3
Injection, 1.4mg/ml;
0.9% Injection)
Isotonic Gentamicin
2
(0.8mg/ml; 0.9% Injection)
Kanamycin Sulfate
3
Neomycin Sulfate
2
Neomycin/Polymyxin B
3
Sulfates
Paromomycin Sulfate
3
Streptomycin Sulfate
4
Tobi
5
B/D
Tobramycin Sulfate
2
(Ophthalmic Solution)
Tobramycin Sulfate
(10mg/ml Injection,
3
80mg/2ml Injection)
Tobramycin Sulfate/
3
Sodium Chloride
Tobrex (Ointment)
3
Antibacterials, Other — Antibiotics
Baciim
2
Bacitracin (Injection,
2
Ophthalmic Ointment)
Bacitracin/Polymyxin B
2
Chloramphenicol
3
Sodium Succinate
Cleocin (75mg Capsule)
4
Cleocin Galaxy
4
Cleocin in D5W
4
Cleocin Phosphate
4
(900mg/6ml Injection)
Clindamycin HCl (150mg
Capsule, 300mg Capsule)
Clindamycin Phosphate
(Cream)
Add-Vantage
Colistimethate Sodium
Cubicin
Flagyl ER
Lincocin
Methenamine Hippurate
Metronidazole
Metronidazole in NaCl
0.79%
Metronidazole Vaginal
Mupirocin
Neomycin/Bacitracin/
Polymyxin
Neomycin/Polymyxin/
Gramicidin
Nitrofurantoin
Nitrofurantoin
Macrocrystalline
(50mg Capsule)
Nitrofurantoin Monohydrate
Polymyxin B Sulfate
Primsol
Silver Sulfadiazine
SSD
Synercid
Thermazene
Trimethoprim
Drug Requirements
Tier & Limits
2
2
3
4
5
4
4
3
3
B/D
3
2
2
2
2
3
3
3
3
4
2
2
5
2
2
ST = Step therapy
10
Drug Name
Drug Requirements
Tier & Limits
Trimethoprim Sulfate/
2
Polymyxin B Sulfate
Tygacil
4
Vancocin HCl
5
PA
Vancomycin HCl (1000mg
Injection, 10gm Injection,
3
B/D
500mg Injection)
Vancomycin HCl (Capsule)
5
PA
Vandazole
2
Vibativ (250mg Injection) 4
Xifaxan (200mg Tablet)
4
Xifaxan (550mg Tablet)
5
Zyvox
5
PA
Beta-Lactam, Cephalosporins — Antibiotics
Cedax (Capsule)
4
Cefaclor
2
Cefaclor ER
2
Cefadroxil
2
Cefazolin Sodium (10gm
3
1gm; 5% Injection,
500mg Injection)
Cefdinir
3
Cefepime (1gm Injection,
3
2gm Injection)
Cefotaxime Sodium (10gm
3
2gm Injection)
Cefoxitin Sodium
3
Cefoxitin Sodium/
4
Dextrose
Cefpodoxime Proxetil
3
Cefprozil
3
Ceftazidime (1gm Injection,
2gm Injection,
3
6gm Injection)
Ceftazidime/Dextrose
3
Ceftriaxone Sodium
3
Cefuroxime Axetil (Tablet)
2
Drug Name
Drug Requirements
Tier & Limits
Cefuroxime Sodium (1.5gm
Injection, 7.5gm Injection,
2
750mg Injection)
Cephalexin
2
Claforan (1gm Injection)
4
Fortaz (1gm/50ml; 5%
4
2gm/50ml; 5% Injection,
6gm Injection)
Suprax
3
Zinacef
4
(750mg Injection)
Zinacef in Iso-Osmotic
4
Dextrose
4
Diluent
Beta-Lactam, Other — Antibiotics
Azactam in Iso-Osmotic
4
Dextrose
Aztreonam (1gm Injection)
3
Cayston
5
PA
Cefotetan
4
Doribax
4
(500mg Injection)
Imipenem/Cilastatin
3
Invanz
4
Meropenem
3
(500mg Injection)
Primaxin
4
Beta-Lactam, Penicillins — Antibiotics
Amoxicillin
2
Amoxicillin/Potassium
2
Clavulanate
Amoxicillin/Potassium
2
Clavulanate ER
Ampicillin
3
Ampicillin Sodium
(10gm Injection, 125mg
3
Injection, 1gm Injection)
11
Drug Name
Ampicillin-Sulbactam
(10gm; 5gm Injection,
2gm; 1gm Injection)
Bactocill in Dextrose
(1gm/50ml Injection)
Bactocill in Dextrose
Bicillin C-R
Bicillin L-A
Dicloxacillin Sodium
Nafcillin Sodium (10gm
Nallpen/Dextrose
Oxacillin Sodium (10gm
Penicillin G Potassium
(5mu Injection)
Penicillin G Potassium in
Iso-Osmotic Dextrose
Penicillin G Procaine
Penicillin G Sodium
Penicillin V Potassium
Pfizerpen-G
(20mu Injection)
Piperacillin Sodium/
Tazobactam Sodium
(3gm; 0.375gm Injection,
4gm; 0.5gm Injection)
Timentin
(0.1gm; 3gm Injection)
Drug Requirements
Tier & Limits
Drug Name
Zosyn
(3gm; 0.375gm Injection,
5%; 2gm/50ml;
0.25gm/50ml Injection,
5%; 3gm/50ml;
0.375gm/50ml Injection)
Macrolides — Antibiotics
Azithromycin (500mg
Injection, Suspension
Reconstituted, Tablet)
Clarithromycin
Clarithromycin ER
Dificid
E.E.S. 400
E.E.S. Granules
Ery
Ery-Tab
Eryped
Erythrocin Lactobionate
(500mg Injection)
Erythrocin Stearate
Erythromycin (External
Solution, Gel, Ointment)
Erythromycin Base
Erythromycin
Ethylsuccinate
Ketek
PCE
Zmax
Quinolones — Antibiotics
Avelox (Tablet)
Avelox (Injection)
Avelox ABC Pack
3
4
5
4
4
2
3
4
4
4
3
4
4
2
4
3
4
Drug Requirements
Tier & Limits
4
2
3
3
5
2
3
2
3
3
PA
4
4
2
2
2
4
4
4
PA
3
4
3
ST = Step therapy
12
Drug Name
Drug Requirements
Tier & Limits
Cipro (Suspension
4
Reconstituted)
Cipro IV (200mg/100ml;
4
5% Injection)
Ciprofloxacin
2
Ciprofloxacin ER
3
Ciprofloxacin HCl
2
Factive
4
Levofloxacin
3
Levofloxacin in D5W (5%;
3
500mg/100ml Injection)
Moxeza
3
Noroxin
4
Ofloxacin
3
Sulfonamides — Antibiotics
Sodium Sulfacetamide
2
Sulfacetamide Sodium
2
(Ointment)
Sulfadiazine
3
Sulfamethoxazole/
2
Trimethoprim
Sulfamethoxazole/
2
Trimethoprim DS
Tetracyclines — Antibiotics
Demeclocycline HCl
4
Doxycycline
3
(75mg Capsule)
Doxycycline Hyclate
(Capsule, Injection, Tablet,
100mg Tablet Delayed
3
Release, 75mg Tablet
Delayed Release)
Doxycycline Hyclate
(150mg Tablet Delayed
4
Release)
Doxycycline Monohydrate
(150mg Tablet, 50mg
3
Drug Name
Minocycline HCl (Capsule)
Minocycline HCl ER
Tetracycline HCl
Vibramycin (Syrup)
Drug Requirements
Tier & Limits
2
4
2
4
Anticonvulsants — Drugs to Treat
Seizures
Anticonvulsants, Other — Seizure Control
Drugs
Levetiracetam
2
Levetiracetam ER
3
Phenobarbital (Elixir,
16.2mg Tablet, 30mg
Tablet, 32.4mg Tablet,
2
PA
64.8mg Tablet,
97.2mg Tablet)
Potiga
4
Calcium Channel Modifying Agents —
Seizure Control Drugs
Celontin
4
Ethosuximide
3
Lyrica
3
Zonisamide
2
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents — Seizure Control
Drugs
Clonazepam
2
PA
Clonazepam ODT
4
Clorazepate Dipotassium
2
PA
Diazepam (Gel)
4
PA
Divalproex Sodium
2
Divalproex Sodium DR
2
Divalproex Sodium ER
2
Gabapentin
2
Gabitril
4
Onfi
4
PA
Primidone
2
13
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Sabril
5
PA
Valproate Sodium
3
(100mg/ml injection)
Valproic Acid
2
Glutamate Reducing Agents — Seizure
Control Drugs
Felbamate (Tablet)
4
Felbamate (Suspension)
5
Felbatol (Tablet)
4
Felbatol (Suspension)
5
Lamictal ODT
4
(Tablet Dispersible)
Lamictal Starter Kit
4
Lamotrigine (Tablet)
2
Lamotrigine
3
(Tablet Chewable)
Topiramate
2
Sodium Channel Agents — Seizure Control
Drugs
Banzel
4
Carbamazepine
3
Carbamazepine ER
(Capsule Extended
3
Release 12 Hour)
Dilantin
3
Dilantin Infatabs
3
Epitol
3
Equetro
4
Fosphenytoin Sodium
3
(100mg pe/2ml Injection)
Oxcarbazepine
3
Peganone
4
Phenytek
2
Phenytoin
Phenytoin Sodium
Phenytoin Sodium
Extended
Tegretol
Tegretol-XR
Trileptal (Suspension)
Vimpat
Vimpat (Injection)
Drug Requirements
Tier & Limits
2
2
2
3
3
4
4
4
PA
Antidementia Agents — Drugs to Treat
Alzheimer’s Disease and Dementia
Cholinesterase Inhibitors — Alzheimer’s
Disease and Dementia Drugs
Donepezil HCl
2
Exelon (Oral Solution)
4
Exelon (Patch 24 Hour)
4
ST
Rivastigmine Tartrate
3
N-methyl-D-aspartate (NMDA) Receptor
Antagonists — Alzheimer’s Disease and
Dementia Drugs
Namenda
3
Namenda Titration Pak
3
Antidepressants — Drugs to Treat
Depression
Antidepressants, Other — Antidepressants
Budeprion SR
2
Bupropion HCl
2
Bupropion HCl SR
2
Bupropion XL
2
Maprotiline HCl
2
ST = Step therapy
14
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Drug Requirements
Tier & Limits
Tricyclics — Antidepressants
Amitriptyline HCl
2
Amoxapine
2
Clomipramine HCl
2
Desipramine HCl
3
Doxepin HCl
2
Imipramine HCl
2
Imipramine Pamoate
3
Nortriptyline HCl
2
Perphenazine/Amitriptyline 2
Protriptyline HCl
3
Trimipramine Maleate
3
Mirtazapine
2
Mirtazapine ODT
(30mg Tablet Dispersible,
2
45mg Tablet Dispersible)
Nefazodone HCl
2
Trazodone HCl
2
Monoamine Oxidase Inhibitors —
Antidepressants
Emsam
4
ST
Marplan
4
Nardil
3
Phenelzine Sulfate
2
Selegiline HCl
3
Tranylcypromine Sulfate
3
Serotonin/Norepinephrine Reuptake
Inhibitors — Antidepressants
Citalopram Hydrobromide
1
(Tablet)
Citalopram Hydrobromide
3
(Oral Solution)
Cymbalta
4
PA
Escitalopram Oxalate
2
Fluoxetine DR
4
Fluoxetine HCl
(Capsule, Oral Solution,
2
Fluvoxamine Maleate
2
Paroxetine HCl
2
Paroxetine HCl ER
4
Paxil (Suspension)
4
Pristiq
4
PA
Sertraline HCl (Tablet)
1
Sertraline HCl
3
(Concentrate)
Venlafaxine HCl
3
ST
Venlafaxine HCl ER
(Capsule Extended
2
Release 24 Hour)
Viibryd
4
ST
Antidotes, Deterrents and Toxicologic
Agents — Drugs for Overdose or
Deterrents
Alcohol Deterrents/Anti-Craving —
Antidotes/Deterrents/Protectants
Antabuse
3
Disulfiram
3
Naltrexone HCl
3
Vivitrol
5
Opioid Antagonists — Antidotes/
Deterrents/Protectants
Buprenorphine HCl
3
Naloxone HCl
3
(1mg/ml Injection)
Suboxone
4
Smoking Cessation Agents — Deterrents
Buproban
2
Chantix
4
Chantix Pak
4
Nicotrol Inhaler
4
Nicotrol NS
3
15
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Amphotec
(50mg Injection)
Amphotericin B
Ancobon
Cancidas
Ciclopirox
Ciclopirox Nail Lacquer
Ciclopirox Olamine
Clotrimazole
(External Cream,
External Solution, Troche)
Clotrimazole/
Betamethasone
Dipropionate
Econazole Nitrate
Eraxis (100mg Injection)
Fluconazole
Fluconazole in Dextrose
(56mg/ml; 400mg/200ml
Injection)
Flucytosine
Gris-Peg
Griseofulvin Microsize
Itraconazole
Ketoconazole
(Cream, Shampoo, Tablet)
Ketoconazole (Foam)
Lamisil (Packet)
Miconazole 3
Mycamine
Natacyn
Noxafil
Nyamyc
Antiemetics — Drugs to Treat Nausea
and Vomiting
Antiemetics, Other — Nausea and Vomiting
Drugs
Meclizine HCl
2
Emetogenic Therapy Adjuncts —
Nausea and Vomiting Drugs
Aloxi
4
Anzemet (50mg Tablet)
4
B/D
Anzemet (100mg Tablet)
5
B/D
Cesamet
5
B/D, PA
Dronabinol (2.5mg
3
B/D, PA
Dronabinol (10mg Capsule) 5
B/D, PA
Emend (Capsule)
3
B/D, PA
Granisetron HCl (0.1mg/ml
3
Injection, 1mg/ml Injection)
Granisetron HCl (Tablet)
3
B/D
Granisol
3
B/D
Ondansetron HCl (Tablet)
2
B/D
Ondansetron HCl
3
(4mg/2ml Injection)
Ondansetron HCl
3
B/D
(Oral Solution)
Ondansetron ODT
2
B/D
Sancuso
5
Antifungals — Drugs to Treat Fungal
Infections
Antifungals — Fungal Infection Drugs
Abelcet
5
B/D
AmBisome
5
B/D
Drug Requirements
Tier & Limits
4
B/D
3
5
5
3
3
3
B/D
2
2
2
5
2
2
5
4
3
3
PA
2
4
4
2
5
3
5
2
ST = Step therapy
16
Drug Name
Nystatin (Cream, Ointment,
100000unit/gm Powder,
Suspension, Tablet)
Nystatin/Triamcinolone
Nystop
Pedi-Dri
Sporanox (Oral Solution)
Terbinafine HCl (Tablet)
Terconazole
(0.4% Cream, Suppository)
Vfend (Suspension
Reconstituted)
Vfend (Tablet)
Vfend IV
Voriconazole (Tablet)
Zazole (Cream)
Drug Requirements
Tier & Limits
Naratriptan HCl
Sumatriptan Succinate
(Tablet)
Sumatriptan Succinate
(6mg/0.5ml Injection)
2
2
2
2
4
2
2
2
3
Parasympathomimetics — Myasthenia
Gravis Drugs
Mestinon (Syrup)
4
Mestinon Timespan
4
Mytelase
4
Pyridostigmine Bromide
2
Regonol
2
5
ST
Antimycobacterials — Drugs to Treat
Infections
Antigout Agents — Drugs to Treat Gout
Antigout Agents — Gout Drugs
Allopurinol (Tablet)
2
Allopurinol Sodium
2
(Injection)
Colcrys
3
Probenecid
2
Probenecid/Colchicine
2
Uloric
3
Drug Requirements
Tier & Limits
Antimyasthenic Agents — Drugs to Treat
Myasthenia Gravis
PA
2
5
4
5
2
Drug Name
Antimycobacterials, Other — Miscellaneous
Anti-Infectives
Dapsone
3
Mycobutin
4
Antituberculars — Tuberculosis Drugs
Capastat Sulfate
4
Ethambutol HCl
3
Isoniazid
3
Paser
4
Priftin
4
Rifampin (Capsule)
3
Rifampin (Injection)
4
Rifater
4
Seromycin
4
Trecator
4
ST
Antimigraine Agents — Drugs to Treat
Migraines
Ergot Alkaloids — Migraine Drugs
Dihydroergotamine
3
Mesylate
Ergotamine Tartrate/
3
Caffeine
Migergot
3
Serotonin (5-HT) 1b/1d Receptor
Agonists — Migraine Drugs
Maxalt
3
Maxalt-MLT
3
Antineoplastics — Drugs to Treat
Cancer
Alkylating Agents — Chemotherapy Agents
BiCNU
4
Busulfex
5
17
Drug Name
Drug Requirements
Tier & Limits
Drug Name
CeeNU
4
Cyclophosphamide (Tablet) 3
B/D
Dacarbazine
3
(200mg Injection)
Hexalen
5
PA
Ifosfamide (1gm Injection)
3
Leukeran
3
Matulane
5
Melphalan HCl
5
Mustargen
5
Thiotepa
4
Treanda
5
PA
(100mg Injection)
Zanosar
5
Antiangiogenic Agents — Chemotherapy
Agents
Caprelsa
5
PA
Revlimid (10mg Capsule,
15mg Capsule, 25mg
5
PA, LA
Thalomid
5
PA
Antiestrogens/Modifiers — Chemotherapy
Agents
Emcyt
4
PA
Fareston
4
Faslodex
5
Tamoxifen Citrate
2
Antimetabolites — Chemotherapy Agents
Cladribine
5
B/D
Clolar
5
Cytarabine
3
B/D
(500mg Injection)
Drug Requirements
Tier & Limits
Cytarabine Aqueous
2
B/D
(20mg/ml Injection)
Cytarabine Aqueous
3
B/D
(100mg/ml Injection)
Droxia
4
Elitek (1.5mg Injection)
5
Fluorouracil
3
B/D
Folotyn
5
PA
Gemcitabine HCl
5
(1gm Injection)
Gemzar (1gm Injection)
5
Hydroxyurea
2
Mercaptopurine
3
Pentostatin
5
Tabloid
4
PA
Antineoplastics, Other — Chemotherapy
Agents
Abraxane
5
PA
Adriamycin
3
B/D
(2mg/ml Injection)
Alimta (500mg Injection) 5
PA
Amifostine
5
Arranon
5
Bleomycin Sulfate
3
B/D
(30unit Injection)
Carboplatin
3
Cerubidine
4
Cisplatin
3
Cosmegen
4
ST = Step therapy
18
Drug Name
Dacogen
Daunorubicin HCl
(5mg/ml Injection)
Dexrazoxane
(500mg Injection)
Docefrez
Docetaxel
80mg/8ml Injection)
Doxil
Doxorubicin HCl
(2mg/ml Injection)
Elspar
Epirubicin HCl
Erivedge
Fludarabine Phosphate
(50mg Injection)
Fusilev
Halaven
Idarubicin HCl
Irinotecan
Istodax
Ixempra Kit
(45mg Injection)
Jakafi
Jevtana
Leucovorin Calcium
(100mg Injection,
350mg Injection, Tablet)
Menest
Mesna
Mesnex (Tablet)
Mitomycin (20mg Injection)
Mitoxantrone HCl
Ontak
Oxaliplatin
Drug Requirements
Tier & Limits
5
PA
5
5
5
B/D
3
B/D
4
3
5
PA
5
5
5
PA
5
3
5
PA
5
5
5
PA
PA
3
3
3
4
3
3
5
Drug Requirements
Tier & Limits
Paclitaxel
3
Picato
4
Proleukin
5
PA
Sylatron
5
PA
Taxotere
5
Trisenox
4
PA
Velcade
5
PA
Vidaza
5
PA
Vinblastine Sulfate
3
B/D
(10mg Injection)
Vincasar PFS
3
B/D
Vincristine Sulfate
3
B/D
Vinorelbine Tartrate
3
Zolinza
5
PA
Zytiga
5
PA
Aromatase Inhibitors, 3rd Generation —
Chemotherapy Agents
Anastrozole
2
Aromasin
4
Exemestane
3
Letrozole
2
Enzyme Inhibitors — Chemotherapy Agents
Etopophos
5
Etoposide (Injection)
3
Hycamtin (Injection)
5
Toposar
3
Topotecan HCl
5
(4mg Injection)
Molecular Target Inhibitors —
Chemotherapy Agents
Afinitor
5
PA
Gleevec
5
PA
Inlyta
5
PA
Nexavar
5
PA
Sprycel
5
PA
2
5
Drug Name
PA
PA
5
19
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Sutent
5
PA
Tarceva
5
PA
Tasigna
5
PA
Tykerb
5
PA
Votrient
5
PA
Xalkori
5
PA
Zelboraf
5
PA
Monoclonal Antibodies — Chemotherapy
Agents
Arzerra
5
PA
Avastin
5
PA
Campath
5
PA
Erbitux
5
PA
Herceptin
5
PA
Rituxan
5
PA
Vectibix
5
PA
Yervoy
5
PA
Retinoids — Chemotherapy Agents
Panretin
5
PA
Targretin
5
PA
Tretinoin (Capsule)
5
Drug Requirements
Tier & Limits
Antiprotozoals — Protozoal Infection Drugs
Alinia
4
Atovaquone/Proguanil HCl
3
(250mg; 100mg Tablet)
Chloroquine Phosphate
3
Daraprim
3
Hydroxychloroquine Sulfate 2
Malarone
4
Mefloquine HCl
2
Mepron
5
Nebupent
4
B/D
Pentam 300
4
Primaquine Phosphate
4
Qualaquin
4
PA
Pediculicides/Scabicides — Scabies and
Lice Drugs
Lindane
3
Malathion
3
Permethrin (Cream)
2
Antiparkinson Agents — Drugs to Treat
Parkinson’s Disease
Anticholinergics — Parkinson’s Disease
Drugs
Benztropine Mesylate
2
Cogentin
4
Trihexyphenidyl HCl
2
Antiparkinson Agents — Parkinson’s
Disease Drugs
Comtan
3
Tasmar
5
Antiparasitics — Drugs to Treat Parasitic
Infections
Anthelmintics — Worm Infection Drugs
Albenza
3
Biltricide
3
Stromectol
3
ST = Step therapy
20
Drug Name
Drug Requirements
Tier & Limits
Dopamine Agonists — Parkinson’s Disease
Drugs
Apokyn
5
Bromocriptine Mesylate
3
Pramipexole
3
Dihydrochloride
Ropinirole HCl
2
Dopamine Precursors/L-Amino Acid
Decarboxylase Inhibitors — Parkinson’s
Disease Drugs
Carbidopa/Levodopa
2
Carbidopa/Levodopa ER
2
Carbidopa/Levodopa ODT
3
Stalevo
3
Drug Name
Drug Requirements
Tier & Limits
2nd Generation/Atypical — Mood Disorder
Drugs
Abilify
4
ST
Abilify Discmelt
4
ST
Fanapt
4
ST
Fanapt Titration Pack
4
ST
Geodon (Injection)
4
Invega
4
ST
Invega Sustenna
(39mg/0.25ml Injection,
4
78mg/0.5ml Injection)
Invega Sustenna
5
156mg/ml Injection,
Latuda
4
PA
Olanzapine
3
Olanzapine ODT
3
Quetiapine Fumarate
2
Risperdal Consta
(12.5mg Injection,
4
25mg Injection)
Risperdal Consta
(37.5mg Injection,
5
50mg Injection)
Risperidone (Tablet)
2
Risperidone (Oral Solution)
3
Risperidone ODT
3
Saphris
3
Seroquel XR
3
Ziprasidone HCl (Capsule)
4
Zyprexa (Injection)
4
Treatment-Resistant — Mood Disorder
Drugs
Clozapine
3
Fazaclo
3
Antipsychotics — Drugs to Treat Mood
Disorders
1st Generation/Typical — Mood Disorder
Drugs
Chlorpromazine HCl
2
Compro
2
Fluphenazine Decanoate
3
Fluphenazine HCl
2
Haloperidol
2
Haloperidol Decanoate
2
Haloperidol Lactate
2
Loxapine Succinate
2
Orap
3
Perphenazine
2
Prochlorperazine
2
Prochlorperazine Edisylate
3
Prochlorperazine Maleate
2
Thioridazine HCl
3
Thiothixene
2
Trifluoperazine HCl
2
21
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Drug Requirements
Tier & Limits
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors — HIV Drugs
Atripla
5
Complera
5
Edurant
5
Intelence (100mg Tablet,
5
200mg Tablet)
Nevirapine (Tablet)
3
Rescriptor
4
Sustiva
4
Viramune (Tablet)
3
Viramune (Suspension)
4
Viramune XR
3
Anti-HIV Agents, Nucleoside and
Nucleotide Reverse Transcriptase
Inhibitors — HIV Drugs
Combivir
5
Didanosine
3
Emtriva
4
Epivir (Oral Solution)
3
Epivir (Tablet)
4
Epivir HBV
3
Epzicom
5
Lamivudine
3
Lamivudine/Zidovudine
5
Retrovir IV Infusion
4
Stavudine (Capsule)
3
Trizivir
5
Truvada
5
Videx Pediatric
4
(2gm Oral Solution)
Viread
5
Antispasticity Agents — Drugs to Treat
Spasms
Antispasticity Agents — Muscle Spasm
Drugs
Baclofen
2
Dantrolene Sodium
3
(Capsule)
Gablofen
(10000mcg/20ml
3
B/D, PA
Injection, 50mcg/ml
Injection)
Gablofen
(40000mcg/20ml
5
B/D, PA
Injection)
Lioresal Intrathecal
(0.05mg/ml Injection,
3
B/D, PA
Lioresal Intrathecal
5
B/D, PA
Tizanidine HCl (Tablet)
2
Antivirals — Drugs to Treat Viral
Infections
Anti-Cytomegalovirus (CMV) Agents —
Miscellaneous Antiviral Drugs
Cytovene
4
B/D
Foscarnet Sodium
3
B/D
Ganciclovir (Capsule)
4
Ganciclovir (Injection)
4
B/D
Valcyte
5
Vistide
5
ST = Step therapy
22
Drug Name
Drug Requirements
Tier & Limits
Zerit (Oral Solution)
4
Ziagen
4
Zidovudine
3
Anti-HIV Agents, Other — HIV Drugs
Fuzeon
5
Isentress
5
Selzentry
5
Anti-HIV Agents, Protease Inhibitors — HIV
Drugs
Aptivus
5
Crixivan
3
Invirase (Capsule)
4
Invirase (Tablet)
5
Kaletra
4
(100mg; 25mg Tablet)
Kaletra (Oral Solution,
5
200mg; 50mg Tablet)
Lexiva (Suspension)
4
Lexiva (Tablet)
5
Norvir
4
Prezista (150mg Tablet,
4
75mg Tablet)
Prezista (400mg Tablet,
5
600mg Tablet)
Reyataz
3
(100mg Capsule)
Reyataz
(150mg Capsule,
5
200mg Capsule,
300mg Capsule)
Viracept
5
Anti-Influenza Agents — Flu Drugs
Amantadine HCl
2
Relenza Diskhaler
4
Rimantadine HCl
2
Tamiflu
3
Drug Name
Drug Requirements
Tier & Limits
Antihepatitis Agents — Hepatitis Drugs
Baraclude
4
(Oral Solution)
Baraclude (Tablet)
5
Hepsera
5
Incivek
5
PA
Infergen
5
PA
(15mcg/0.5ml Injection)
Intron-A (10mu/0.2ml
Injection, 3mu/0.2ml
4
PA
Injection, 6000000unit/
ml Injection)
Intron-A
5
PA
(5mu/0.2ml Injection)
Intron-A W/Diluent
5
PA
(10mu Injection)
Peg-Intron
5
PA
Peg-Intron Redipen
5
PA
Pegasys
5
PA
Pegasys Proclick
5
PA
Rebetol (Oral Solution)
4
PA
Ribapak (Tablet)
5
PA
Ribasphere
3
PA
(Capsule, 200mg Tablet)
Ribasphere (400mg Tablet,
5
PA
600mg Tablet)
Ribavirin
3
PA
Tyzeka
5
Victrelis
5
PA
Antiherpetic Agents — Herpes Drugs
Acyclovir
2
Acyclovir Sodium
2
B/D
(500mg Injection)
Famciclovir
3
Trifluridine
3
Valacyclovir HCl
3
23
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Byetta
3
Duetact
3
Glimepiride
2
Glipizide
1
Glipizide ER
2
Glipizide/Metformin HCl
2
Glyburide
1
Glyburide Micronized
1
Glyburide/Metformin HCl
2
Kombiglyze XR
3
Metformin HCl
1
Metformin HCl ER
(500mg Tablet Extended
Release 24 Hour,
2
750mg Tablet Extended
Release 24 Hour)
Nateglinide
3
Onglyza
3
Prandimet
4
Prandin
4
Riomet
4
Symlinpen 120
4
Symlinpen 60
4
Tolbutamide
2
Tradjenta
3
Victoza
3
Glycemic Agents — Diabetic Drugs
Clinimix 4.25%/
4
Dextrose 20%
Clinimix 5%/
4
Dextrose 15%
Clinimix 5%/
4
Dextrose 20%
Anxiolytics — Drugs to Treat Anxiety
Anxiolytics, Other — Anxiety Drugs
Alprazolam (0.25mg Tablet,
0.5mg Tablet, 1mg Tablet,
2
2mg Tablet)
Buspirone HCl
2
Chlordiazepoxide HCl
2
Chlordiazepoxide/
2
Amitriptyline
Diazepam
2
Diazepam Intensol
2
Lorazepam (Tablet)
2
Lorazepam Intensol
2
Drug Requirements
Tier & Limits
PA
PA
PA
PA
PA
PA
Bipolar Agents — Drugs to Treat Mood
Disorders
Mood Stabilizers — Mood Disorder Drugs
Lithium Carbonate
2
Lithium Carbonate ER
2
Lithium Citrate
2
Lithobid
3
Blood Glucose Regulators — Drugs to
Regulate Blood Sugar
Antidiabetic Agents — Diabetic Drugs
Acarbose
2
Actoplus Met (15-500mg
3
Tablet, 15-850mg Tablet)
Actos
3
Avandamet
4
PA
Avandaryl
4
PA
Avandia
4
PA
PA
PA
B/D
B/D
B/D
ST = Step therapy
24
Drug Name
Clinimix E 2.75%/
Dextrose 10%
Clinimix E 2.75%/
Dextrose 5%
Clinimix E 4.25%/
Dextrose 25%
Clinimix E 4.25%/
Dextrose 5%
Clinimix E 5%/
Dextrose 15%
Clinimix E 5%/
Dextrose 25%
Dextrose 10%/
NaCl 0.45%
Dextrose 10% Flex
Container
Dextrose 10%/NaCl 0.2%
Dextrose 2.5%/
Sodium Chloride 0.45%
Dextrose 5%
Dextrose 5%/
NaCl 0.225%
Glucagen Hypokit
Glucagon Emergency
Kit
Ionosol-B/Dextrose 5%
Ionosol-MB/
Dextrose 5%
KCl 0.075%/D5W/
NaCl 0.45%
KCl 0.15%/D5W/LR
KCl 0.15%/D5W/
NaCl 0.2%
KCl 0.15%/D5W/
NaCl 0.225%
Drug Requirements
Tier & Limits
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
Drug Name
KCl 0.15%/D5W/
NaCl 0.9%
KCl 0.3%/D5W/
NaCl 0.45%
KCl 0.3%/D5W/
NaCl 0.9%
Normosol-R in D5W
Potassium Chloride
0.15%/D5W/
NaCl 0.45% Viaflex
Potassium Chloride
0.15%/D5W/NaCl 0.33%
Potassium Chloride
0.22%/D5W/NaCl 0.45%
Proglycem
Insulins — Diabetic Drugs
Levemir (Vial)
Novolin (Vial)
Novolog (Vial)
3
3
3
3
3
3
Drug Requirements
Tier & Limits
3
3
3
3
3
3
3
4
3
3
3
Blood Products/Modifiers/Volume
Expanders — Drugs to Treat Blood
Disorders
3
Anticoagulants — Blood Thinners
Argatroban
5
Argatroban (125mg/125ml;
5
0.9% Injection)
Arixtra
4
(2.5mg/0.5ml Injection)
Arixtra
5
5mg/0.4ml Injection,
7.5mg/0.6ml Injection)
Coumadin (Tablet)
3
Enoxaparin Sodium
4
3
3
3
4
3
4
4
3
3
3
3
25
Drug Name
Enoxaparin Sodium
(100mg/ml Injection,
150mg/ml Injection)
Fondaparinux Sodium
(2.5mg/0.5ml Injection)
Fondaparinux Sodium
7.5mg/0.6ml Injection)
Fragmin
(25000unit/ml Injection,
2500unit/0.2ml
Injection,
5000unit/0.2ml
Injection)
Fragmin
12500unit/0.5ml
Injection,
15000unit/0.6ml
Injection,
18000unit/0.72ml
Injection, 7500unit/0.3ml
Injection)
Heparin Sodium
1000unit/ml Injection,
5000unit/ml Injection)
Heparin Sodium/D5W
(5%; 40unit/ml Injection)
Heparin Sodium/NaCl
(100unit/ml; 0.45%
Injection, 50unit/ml; 0.45%
Injection)
Drug Requirements
Tier & Limits
Drug Name
Drug Requirements
Tier & Limits
Heparin Sodium/
3
NaCl 0.9% Premix
Jantoven
2
Lovenox
4
Pradaxa
3
PA
Warfarin Sodium
2
Xarelto
3
PA
Blood Formation Modifiers — Blood
Formation Drugs
Anagrelide HCl
2
Aranesp Albumin Free
(100mcg/0.5ml Injection,
100mcg/ml Injection,
25mcg/0.42ml Injection,
25mcg/ml Injection,
4
B/D, PA
40mcg/ml Injection,
60mcg/ml Injection)
Aranesp Albumin Free
(150mcg/0.3ml Injection,
5
B/D, PA
500mcg/ml Injection)
Epogen
4
B/D, PA
Leukine
5
PA
Mozobil
5
PA
Neulasta
5
PA
Neumega
3
PA
5
4
5
4
5
3
3
3
ST = Step therapy
26
Drug Name
Drug Requirements
Tier & Limits
Neupogen
(300mcg/0.5ml
Injection, 480mcg/0.8ml
5
PA
Injection, 480mcg/1.6ml
Injection)
Procrit
4
B/D, PA
Procrit
5
B/D, PA
Promacta
5
PA
Blood Products/Modifiers/Volume
Expanders
Cinryze
5
PA
Coagulants — Blood Clotting Drugs
Cyklokapron
3
Tranexamic Acid
3
Platelet Modifying Agents — Platelet
Modifying Drugs
Aggrenox
3
Brilinta
4
PA
Cilostazol
2
Clopidogrel
2
Dipyridamole (Tablet)
2
PA
Effient
4
PA
Ticlopidine HCl
3
Drug Name
Drug Requirements
Tier & Limits
Methyldopa/
2
Hydrochlorothiazide
Methyldopate HCl
2
Midodrine HCl
3
Alpha-Adrenergic Blocking Agents —
Blood Pressure Drugs
Dibenzyline
4
Prazosin HCl
2
Reserpine
2
Angiotensin II Receptor Antagonists —
Benicar
3
Benicar HCT
3
Edarbi
4
Edarbyclor
4
Losartan Potassium
1
Losartan Potassium/
1
Hydrochlorothiazide
Micardis
3
Micardis HCT
3
Angiotensin-Converting Enzyme (ACE)
Inhibitors — Blood Pressure Drugs
Benazepril HCl
1
Benazepril HCl/
1
Hydrochlorothiazide
Captopril
2
Captopril/
2
Hydrochlorothiazide
Enalapril Maleate
2
Enalapril Maleate/
2
Hydrochlorothiazide
Lisinopril
1
Lisinopril/
1
Hydrochlorothiazide
Antiarrhythmics — Heart Regulation Drugs
Amiodarone HCl
2
(50mg/ml Injection, Tablet)
Disopyramide Phosphate
2
Cardiovascular Agents — Drugs to Treat
Heart and Circulation Conditions
Alpha-Adrenergic Agonists — Blood
Pressure Drugs
Clonidine HCl (Tablet)
2
Clonidine HCl
3
(Patch Weekly)
Guanfacine HCl
2
Methyldopa
2
27
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Flecainide Acetate
2
Mexiletine HCl
2
Multaq
3
Pacerone (200mg Tablet)
2
Pacerone
4
(100mg Tablet)
Procainamide HCl
3
Propafenone HCl
2
Propafenone HCl ER
3
Quinidine Gluconate
4
Quinidine Gluconate ER
2
Quinidine Sulfate
2
Quinidine Sulfate ER
2
Sorine
2
Sotalol HCl (Tablet)
2
Sotalol HCl (Injection)
3
Tikosyn
4
Beta-Adrenergic Blocking Agents —
Atenolol
1
Atenolol/Chlorthalidone
1
Bisoprolol Fumarate/
2
Hydrochlorothiazide
Bystolic
3
Carvedilol
1
Labetalol HCl
2
Metoprolol Succinate ER
3
Metoprolol Tartrate (Tablet) 1
Metoprolol Tartrate
3
(Injection)
Metoprolol/
3
Hydrochlorothiazide
Drug Requirements
Tier & Limits
Nadolol
3
Pindolol
2
Propranolol HCl
2
Propranolol HCl ER
2
Propranolol/
2
Hydrochlorothiazide
Timolol Maleate (Tablet)
2
Calcium Channel Blocking Agents —
Amlodipine Besylate
1
Cartia XT
2
Dilt-CD (120mg Capsule
Extended Release
24 Hour, 300mg Capsule
2
Extended Release
24 Hour)
Dilt-XR (180mg Capsule
Extended Release
2
Extended Release
24 Hour)
Diltiazem CD (120mg
Capsule Extended Release
Extended Release
2
Extended Release
24 Hour)
Diltiazem HCl (100mg
Injection, 50mg/10ml
2
Injection, Tablet)
Nicardipine HCl
2
Nimodipine
4
ST = Step therapy
28
Drug Name
Drug Requirements
Tier & Limits
Nisoldipine (17mg Tablet
Extended Release
24 Hour, 34mg Tablet
Extended Release
3
24 Hour, 8.5mg Tablet
Extended Release
24 Hour)
Nisoldipine ER
3
Verapamil HCl (Tablet)
2
Verapamil HCl (Injection)
3
Verapamil HCl ER
2
(Tablet Extended Release)
Cardiovascular Agents, Other —
Miscellaneous Cardiac Drugs
Demser
5
Digoxin
2
Lanoxin (Tablet)
3
Pentoxifylline ER
2
Ranexa
3
ST
Tekturna
4
ST
Tekturna HCT
4
ST
Diuretics, Carbonic Anhydrase Inhibitors —
Cardiac Drugs
Acetazolamide Sodium
3
Diuretics, Loop — Cardiac Drugs
Bumetanide
2
Furosemide
2
Torsemide (20mg/2ml
2
Injection, Tablet)
Diuretics, Potassium-Sparing — Cardiac
Drugs
Amiloride HCl
2
Amiloride/
2
Hydrochlorothiazide
Eplerenone
3
Spironolactone
2
Spironolactone/
2
Hydrochlorothiazide
Drug Name
Drug Requirements
Tier & Limits
Triamterene/
2
Hydrochlorothiazide
Diuretics, Thiazide — Cardiac Drugs
Chlorothiazide
2
Chlorothiazide Sodium
2
Chlorthalidone (25mg
2
Diuril
4
Hydrochlorothiazide
2
Indapamide
2
Methyclothiazide
2
Metolazone
2
Dyslipidemics, Fibric Acid Derivatives —
Cholesterol Control Drugs
Antara
3
Fenofibrate
2
Fenofibrate Micronized
2
Gemfibrozil
2
Dyslipidemics, HMG CoA Reductase
Inhibitors — Cholesterol Control Drugs
Atorvastatin Calcium
2
Crestor
3
Lovastatin
2
Pravastatin Sodium
1
Simvastatin
1
Dyslipidemics, Other — Miscellaneous
Cholesterol Control Drugs
Cholestyramine Light
2
(Packet)
Colestipol HCl (Tablet)
2
Colestipol HCl (Granules)
3
Lovaza
4
Niaspan
3
Prevalite (Powder)
2
Welchol
3
Zetia
3
29
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Drug Requirements
Tier & Limits
Vasodilators, Direct-Acting Arterial —
Chest Pain Drugs
Hydralazine HCl
2
Minoxidil (Tablet)
2
Vasodilators, Direct-Acting Arterial/
Venous — Chest Pain Drugs
Isosorbide Dinitrate
2
Isosorbide Dinitrate ER
2
Isosorbide Mononitrate
2
(20mg Tablet)
Isosorbide Mononitrate ER
2
Minitran
2
Nitro-Bid
4
Nitroglycerin
2
(Injection, Patch)
Nitrolingual Pumpspray
4
Nitromist
4
Nitrostat
3
Methylphenidate HCl ER
2
Release)
Methylphenidate HCl
ER (Capsule Extended
3
Release 24 Hour)
Strattera
4
ST
Central Nervous System, Other —
Miscellaneous Central Nervous System
Drugs
Butalbital/Acetaminophen/
3
Caffeine/Codeine
Rilutek
3
Xenazine
5
PA
Multiple Sclerosis Agents — Multiple
Sclerosis Drugs
Ampyra
5
PA
Copaxone
5
PA
Gilenya
5
PA
Central Nervous System Agents —
Drugs to Treat Nerve Conditions
Dental and Oral Agents — Drugs to
Treat Mouth and Throat Conditions
Attention Deficit Hyperactivity Disorder
Agents, Amphetamines — ADHD Drugs
Amphetamine/
Dextroamphetamine
3
(Tablet)
Dextroamphetamine
3
Sulfate
Attention Deficit Hyperactivity Disorder
Agents, Non-amphetamines —
ADHD Drugs
Dexmethylphenidate HCl
3
Intuniv
4
Methylphenidate HCl
2
Dental and Oral Agents
Chlorhexidine Gluconate
Oral Rinse
Kepivance
Periogard
Pilocarpine HCl (Tablet)
Triamcinolone in Orabase
2
5
2
3
2
Dermatological Agents — Drugs to Treat
Skin Conditions
Dermatological Agents — Skin Agents
8-MOP
5
Adapalene
3
ST = Step therapy
30
Drug Name
Amevive
Ammonium Lactate
Amnesteem
Avita
Calcipotriene
Carac
Claravis
(External Solution, Foam,
Gel, Lotion, Swab)
Clindamycin/Benzoyl
Peroxide (5%; 1% Gel)
Dovonex
Elidel
Erythromycin/Benzoyl
Peroxide
Finacea
Fluorouracil (Cream)
Imiquimod
Laclotion
Oxsoralen
Oxsoralen Ultra
Podofilox
Protopic
Regranex
Santyl
Selenium Sulfide (Lotion)
Solaraze
Soriatane
Stelara
Sulfacetamide Sodium
(Suspension)
Tazorac
Tretin-X (Kit)
Tretinoin (Cream, Gel)
Uvadex
Vectical
Zyclara
Drug Requirements
Tier & Limits
5
2
3
3
3
4
3
PA
Enzyme Replacements/Modifiers —
Enzyme Replacement/Modifying Drugs
Adagen
5
Aldurazyme
5
Buphenyl
5
Carbaglu
5
Cerezyme
5
PA
(200unit Injection)
Creon
3
Cystadane
5
Cystagon
4
Elaprase
5
Fabrazyme
5
(35mg Injection)
Kuvan
5
Lumizyme
5
Myozyme
5
Naglazyme
5
Orfadin
5
Sucraid
5
Vpriv
5
PA
Zavesca
5
Zenpep
3
PA
3
ST
2
3
3
4
2
4
5
3
4
5
4
2
4
5
5
PA
PA
ST
PA
Gastrointestinal Agents — Drugs to
Treat Bowel, Intestine and Stomach
Conditions
PA
Antispasmodics, Gastrointestinal —
Bowel Treatment Drugs
Atropine Sulfate
(0.05mg/ml Injection,
2
PA
0.1mg/ml Injection)
Cuvposa
4
Dicyclomine HCl (Capsule,
2
PA
Glycopyrrolate
3
PA
3
4
4
3
4
4
3
Drug Requirements
Tier & Limits
Enzyme Replacements/Modifiers —
Drugs to Treat Enzyme Deficiency
3
4
4
Drug Name
PA
PA
PA
31
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Methscopolamine Bromide
3
Propantheline Bromide
2
Gastrointestinal Agents, Other —
Miscellaneous Gastrointestinal Drugs
Cromolyn Sodium
3
(Concentrate)
Diphenoxylate/Atropine
2
PA
Halflytely Bowel Prep/
3
Flavor Packs
Loperamide HCl (Capsule)
2
Metoclopramide HCl
2
Relistor
4
PA
Ursodiol
3
Histamine2 (H2) Blocking Agents —
Ulcer and Stomach Acid Drugs
Cimetidine
2
Cimetidine HCl
2
Famotidine (Injection,
2
Famotidine Premixed
3
Nizatidine
2
Ranitidine HCl (Capsule,
150mg/6ml Injection,
2
Tablet)
Irritable Bowel Syndrome Agents — Bowel
Treatment Drugs
Amitiza
3
ST
Lotronex
5
PA
Laxatives — Bowel Treatment Drugs
Enulose
2
Gavilyte-C
2
Gavilyte-G
2
Drug Requirements
Tier & Limits
Gavilyte-N/Flavor Pack
2
Lactulose
2
Nulytely/Flavor Packs
3
Polyethylene Glycol 3350
2
(Powder)
Suprep Bowel Prep
4
Trilyte
2
Protectants — Ulcer and Stomach Acid
Drugs
Carafate (Suspension)
4
Misoprostol
2
(200mcg Tablet)
Sucralfate
2
Proton Pump Inhibitors — Ulcer and
Stomach Acid Drugs
Dexilant
4
Lansoprazole
4
Nexium
3
Nexium I.V.
4
Omeprazole (Capsule
2
Delayed Release)
Pantoprazole Sodium
2
Vimovo
3
Genitourinary Agents — Drugs to Treat
Bladder, Genital and Kidney Conditions
Antispasmodics, Urinary — Bladder Control
Drugs
Flavoxate HCl
3
Oxybutynin Chloride
2
Oxybutynin Chloride ER
3
Toviaz
3
Vesicare
3
ST = Step therapy
32
Drug Name
Drug Requirements
Tier & Limits
Benign Prostatic Hypertrophy Agents —
Prostate Enlargement Drugs
Alfuzosin HCl ER
2
Doxazosin Mesylate
2
Finasteride (Tablet)
2
Rapaflo
3
Tamsulosin HCl
2
Terazosin HCl
2
Genitourinary Agents, Other —
Miscellaneous Bladder, Genital and Kidney
Conditions Drugs
Bethanechol Chloride
2
Elmiron
4
Phosphate Binders — Phosphate-Removing
Agents
Fosrenol
5
Renagel
3
ST
Renvela
3
Drug Name
Clobetasol Propionate
(Foam)
Clobetasol Propionate E
Cortisone Acetate
Depo-Medrol
(20mg/ml Injection)
Desonide
Desowen
(Cream, Lotion)
Desoximetasone (Cream,
Gel, 0.25% Ointment)
Dexamethasone
(Elixir, Tablet)
Dexamethasone Intensol
Dexamethasone Sodium
Phosphate
(4mg/ml Injection)
Diflorasone Diacetate
Fludrocortisone Acetate
Fluocinolone Acetonide
(Cream, External Solution,
Ointment)
Fluocinonide (External
Solution, Gel, Ointment)
Fluocinonide-E
Fluticasone Propionate
(Cream, Lotion, Ointment)
Halobetasol Propionate
Hydrocortisone
(1% Cream, 2.5% Cream,
2.5% Lotion, 1% Ointment,
2.5% Ointment, Tablet)
Hydrocortisone Valerate
Lokara
Methylprednisolone
(Tablet)
Methylprednisolone
Acetate (Injection)
Methylprednisolone Dose
Pack
Hormonal Agents, Stimulant/
Replacement/Modifying (Adrenal) —
Drugs to Regulate Hormones
Glucocorticoids/Mineralocorticoids —
Anti-Inflammatory Drugs
A-Hydrocort
3
Ala-Cort
3
Alclometasone
2
Dipropionate
Amcinonide
2
Augmented
Betamethasone
2
Dipropionate (Lotion)
Betamethasone
2
Dipropionate
Betamethasone Valerate
2
Clobetasol Propionate
(External Solution,
2
Gel, Lotion, Ointment,
Shampoo)
33
Drug Requirements
Tier & Limits
3
2
2
4
2
4
3
2
2
2
2
2
2
2
2
2
3
3
3
2
2
3
2
Drug Name
Methylprednisolone
Sodium Succinate
(Injection)
Mometasone Furoate
Prednicarbate
Prednisolone Sodium
Phosphate (Oral Solution)
Prednisone
Prednisone Intensol
Proctocream HC
Solu-Cortef
(100mg Injection,
250mg Injection)
Solu-Medrol
(2gm Injection)
Triamcinolone Acetonide
(Cream, Lotion, Ointment)
Triderm
U-Cort
Drug Requirements
Tier & Limits
Drug Name
Genotropin Miniquick
(0.4mg Injection,
0.6mg Injection,
0.8mg Injection,
1.2mg Injection,
1.4mg Injection,
1.6mg Injection,
1.8mg Injection,
1mg Injection,
2mg Injection)
Humatrope
Increlex
Norditropin Flexpro
Norditropin Nordiflex
Pen
Nutropin
Nutropin AQ
Omnitrope
Omnitrope
(5.8mg Injection,
Pregnyl W/Diluent Benzyl
Alcohol/NaCl
Saizen
Serostim
Stimate
Tev-Tropin
Zorbtive
3
2
2
2
2
2
3
4
4
2
2
2
Replacement/Modifying (Pituitary) —
Drugs to Regulate Hormones
Hormonal Agents, Stimulant/Replacement/
Modifying (Pituitary) — Hormone
Replacement/Modifying Drugs
Chorionic Gonadotropin
3
PA
Desmopressin Acetate
3
Egrifta
5
PA
Genotropin
5
PA
Genotropin Miniquick
4
PA
(0.2mg Injection)
Drug Requirements
Tier & Limits
5
PA
5
5
5
PA
PA
PA
5
PA
5
5
PA
PA
4
PA
5
PA
3
PA
5
5
4
4
5
PA
PA
PA
PA
ST = Step therapy
34
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Estradiol/Norethindrone
Acetate
(1mg; 0.5mg Tablet)
Estropipate
Gianvi
Introvale
Jinteli
Junel
Junel Fe
Kariva
Kelnor
Leena
Lessina
Levora
Low-Ogestrel
Lutera
Marlissa
Microgestin
Microgestin Fe
Mononessa
Necon
Nortrel
Nuvaring
Ocella
Ogestrel
Orsythia
Portia
Premarin (Cream, Tablet)
Premphase
Prempro
Previfem
Quasense
Reclipsen
Sprintec
Sronyx
Tri-Legest Fe
Tri-Previfem
Replacement/Modifying
(Sex Hormones/Modifiers) — Drugs to
Regulate Hormones
Anabolic Steroids — Hormone
Replacement/Modifying Drugs
Oxandrolone
3
PA
(2.5mg Tablet)
Oxandrolone (10mg Tablet) 5
PA
Androgens — Hormone Replacement/
Modifying Drugs
Androgel
3
(50mg/5gm Gel)
Androgel Pump
3
(1.62% Gel)
Androxy
3
Danazol
3
Testosterone Cypionate
3
Testosterone Enanthate
3
Estrogens — Hormone Replacement/
Modifying Drugs
Amethia
2
Amethyst
2
Apri
2
Aranelle
2
Aviane
2
Balziva
2
Briellyn
2
Cryselle
2
Cyclafem 1/35
2
Cyclafem 7/7/7
2
Divigel (1mg/gm Gel)
4
Emoquette
2
Enjuvia
3
Enpresse
2
Estradiol
2
Estradiol Valerate
3
35
Drug Requirements
Tier & Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
2
2
2
2
3
3
3
2
2
2
2
2
2
2
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Tri-Sprintec
2
Trinessa
2
Trivora
2
Velivet
2
Vestura
2
Zeosa
2
Zovia
2
Progesterone — Hormone Replacement/
Modifying Drugs
Ella
4
Progestins — Hormone Replacement/
Modifying Drugs
Camila
2
Crinone
4
Depo-Provera
4
Errin
2
Jolivette
2
Medroxyprogesterone
2
Acetate
Megace ES
4
Megestrol Acetate
2
Next Choice
2
Nora-BE
2
Norethindrone Acetate
2
Selective Estrogen Receptor Modifying
Agents — Hormone Replacement/
Modifying Drugs
Evista
3
Drug Requirements
Tier & Limits
Replacement/Modifying (Thyroid) —
Drugs to Replace Thyroid Hormones
Hormonal Agents, Stimulant/Replacement/
Modifying (Thyroid) — Thyroid Replacement
Drugs
Levothroid
3
Levothyroxine Sodium
2
(Tablet)
Levoxyl
3
Liothyronine Sodium
2
Synthroid
3
Unithroid (100mcg
Tablet, 112mcg Tablet,
125mcg Tablet, 150mcg
2
200mcg Tablet, 25mcg
50mcg Tablet, 75mcg
Tablet, 88mcg Tablet)
Hormonal Agents, Suppressant
(Adrenal) — Drugs to Regulate
Hormones
Hormonal Agents, Suppressant (Adrenal) —
Hormone Suppressants
Lysodren
3
(Parathyroid) — Drugs to Regulate
Hormones
(Parathyroid) — Hormone Suppressants
Sensipar (30mg Tablet)
3
Sensipar (60mg Tablet,
5
90mg Tablet)
ST = Step therapy
36
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Drug Requirements
Tier & Limits
(Pituitary) — Drugs to Regulate
Hormones
(Sex Hormones/Modifiers) — Drugs to
Regulate Hormones
(Pituitary) — Hormone Suppressants
Cabergoline
3
Firmagon
4
PA
(80mg Injection)
Firmagon
5
PA
(120mg Injection)
Leuprolide Acetate
3
Lupron Depot
4
(3.75mg Injection)
Lupron Depot
(22.5mg Injection,
30mg Injection,
5
45mg Injection,
7.5mg Injection)
Lupron Depot-PED
(11.25mg Injection –
4
3 Month)
Lupron Depot-PED
(11.25mg Injection –
5
1 Month, 15mg Injection –
1 Month)
Octreotide Acetate
(100mcg/ml Injection,
4
PA
50mcg/ml Injection)
Octreotide Acetate
5
PA
500mcg/ml Injection)
Sandostatin LAR Depot
5
PA
Somatuline Depot
5
PA
Somavert
5
PA
Synarel
5
PA
Trelstar Depot
5
Trelstar LA
5
Trelstar Mixject
5
Antiandrogens — Hormone Suppressants
Bicalutamide
2
Flutamide
3
Nilandron
4
(Thyroid) — Drugs to Suppress Thyroid
Hormones
Antithyroid Agents — Thyroid Suppressing
Drugs
Methimazole
2
Propylthiouracil
2
Immunological Agents — Drugs that
Stimulate or Suppress the Immune
System
Immune Suppressants — Immune System
Drugs
Azasan
4
Azathioprine
2
Azathioprine Sodium
3
Benlysta
5
PA
(120mg Injection)
Cellcept (Suspension
5
B/D, PA
Reconstituted)
Cellcept Intravenous
4
B/D, PA
Cimzia
5
PA
Cyclosporine
3
B/D
Cyclosporine Modified
(100mg Capsule, 50mg
3
B/D
Capsule, Oral Solution)
Enbrel
5
PA
Gengraf
3
B/D
Humira
5
PA
Humira Starter Kit
5
PA
Kineret
5
PA
37
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Drug Requirements
Tier & Limits
Gammagard Liquid
5
B/D, PA
Gammaplex
5
B/D, PA
Gamunex-C
5
B/D, PA
Hizentra
5
B/D, PA
(1gm/5ml Injection)
Privigen
5
B/D, PA
Thymoglobulin
5
B/D
Immunomodulators — Immune System
Drugs
Actemra
5
PA
Actimmune
5
Arcalyst
5
PA
Avonex
5
PA
Extavia
5
PA
Ilaris
5
PA
Leflunomide
2
Simulect
5
B/D
(20mg Injection)
Synagis
5
Tysabri
5
PA, LA
Vaccines
ActHIB
3
Adacel
3
Boostrix
3
Cervarix
4
Comvax
3
Daptacel
3
Decavac
3
Methotrexate (Tablet)
2
Methotrexate Sodium
2
(25mg/ml Injection)
Methotrexate Sodium
3
(1gm Injection)
Mycophenolate Mofetil
3
B/D, PA
Myfortic (180mg Tablet
4
B/D
Delayed Release)
Myfortic (360mg Tablet
5
B/D
Delayed Release)
Nulojix
5
B/D, PA
Orencia
5
PA
Prograf (Injection)
4
B/D, PA
Rapamune
4
B/D
(0.5mg Tablet)
Rapamune
(Oral Solution,
5
B/D
Remicade
5
PA
Sandimmune (Capsule)
4
B/D
Simponi
5
PA
Tacrolimus (0.5mg
3
B/D, PA
Tacrolimus (5mg Capsule)
5
B/D, PA
Torisel
5
Zortress (0.25mg Tablet) 4
B/D, PA
Zortress (0.5mg Tablet,
5
B/D, PA
0.75mg Tablet)
Immunizing Agents, Passive — Immune
System Drugs
Atgam
5
B/D
Carimune Nanofiltered
5
B/D, PA
(3gm Injection)
ST = Step therapy
38
Drug Name
Engerix-B
Gardasil
Havrix
Infanrix
IPOL
Ixiaro
M-M-R II
Menactra
MenomuneA/C/Y/W-135
Menveo
Pedvax HIB
ProQuad
Rabavert
Recombivax HB
40mcg/ml Injection)
RotaTeq
Tetanus/Diphtheria
Toxoids-Adsorbed Adult
Twinrix
Typhim Vi
Vaqta
(25unit/0.5ml Injection)
Varivax
YF-Vax
Zostavax
Drug Requirements
Tier & Limits
3
3
3
3
3
3
3
3
Drug Requirements
Tier & Limits
Glucocorticoids — Inflammatory Bowel
Disease Drugs
Budesonide
(Capsule Extended
3
Release 24 Hour)
Colocort
3
Hydrocortisone (Enema)
3
Millipred (Tablet)
4
Sulfonamides — Inflammatory Bowel
Disease Drugs
Sulfasalazine (Tablet)
2
Sulfazine EC
2
B/D
3
3
3
3
3
3
Drug Name
Metabolic Bone Disease Agents —
Drugs to Treat Bone Conditions
Metabolic Bone Disease Agents —
Osteoporosis (Bone Loss) Drugs
Alendronate Sodium
2
Calcitonin-Salmon
3
Calcitriol (Capsule,
2
B/D
Injection, Oral Solution)
Etidronate Disodium
3
Forteo
4
B/D, PA
Fortical
3
Hectorol
3
B/D
Miacalcin (Injection)
4
B/D, PA
Pamidronate Disodium
3
B/D
Pamidronate Disodium
4
B/D
(6mg/ml Injection)
Prolia
4
PA
Reclast
4
PA
Xgeva
5
PA
Zemplar
3
B/D
Zometa
5
B/D
3
3
3
3
3
3
3
4
Inflammatory Bowel Disease Agents —
Drugs to Treat Inflammatory Bowel
Disease
Aminosalicylates — Inflammatory Bowel
Disease Drugs
Apriso
3
Asacol
4
Balsalazide Disodium
3
Mesalamine (Kit)
3
39
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Alcohol Preps (Pad)
2
Botox (100unit Injection)
4
Ferriprox
5
Firazyr
5
Fomepizole
5
Gauze Pads
3
Insulin Syringes,
3
Needles
Intralipid
4
(1.7%; 30% Injection)
Intralipid
4
(2.25%; 20% Injection)
Lactated Ringers Irrigation
3
Levocarnitine
3
Liposyn III (1.2%; 2.5%;
10% Injection, 1.2%;
4
2.5%; 20% Injection)
Methergine
3
Methylergonovine Maleate
2
(Tablet)
Physiolyte
4
Physiosol Irrigation
4
Ringers Irrigation
3
2
(Irrigation Solution)
Sterile Water Irrigation
3
Drug Requirements
Tier & Limits
Ophthalmic Agents — Drugs to Treat
Eye Conditions
Ophthalmic Agents, Other — Miscellaneous
Eye Drugs
AK-Con
2
Proparacaine HCl
2
Restasis
3
Tropicamide
2
Ophthalmic Anti-Allergy Agents — Allergy,
Infection and Inflammation Drugs
Azelastine HCl
3
Bepreve
4
Cromolyn Sodium
2
Epinastine HCl
3
Lastacaft
3
Ophthalmic Anti-Inflammatories — Allergy,
Infection and Inflammation Drugs
Alrex
3
Blephamide
3
Blephamide S.O.P.
3
Bromday
4
Bromfenac
3
Dexamethasone Sodium
Phosphate
2
Diclofenac Sodium
2
Durezol
3
Flurbiprofen Sodium
2
3
PA
PA
PA
B/D
B/D
B/D
B/D
ST = Step therapy
40
Drug Name
Drug Requirements
Tier & Limits
Lotemax
3
Neomycin/Polymyxin/
2
Bacitracin/Hydrocortisone
Neomycin/Polymyxin/
2
Dexamethasone
Neomycin/Polymyxin/
Hydrocortisone
2
(Ophthalmic Suspension)
Nevanac
3
Prednisolone Acetate
2
Prednisolone Sodium
Phosphate
2
Sulfacetamide Sodium/
Prednisolone Sodium
2
Phosphate
Tobradex (Ointment)
3
Tobramycin/
3
Dexamethasone
Zylet
3
Ophthalmic Antiglaucoma Agents —
Glaucoma Drugs
Acetazolamide
2
Acetazolamide ER
3
Alphagan P (0.1%
3
Apraclonidine
3
Betaxolol HCl
2
Brimonidine Tartrate
2
Carteolol HCl
2
Combigan
3
Dorzolamide HCl
2
Dorzolamide HCl/
2
Timolol Maleate
Iopidine (1% Ophthalmic
4
Solution)
Levobunolol HCl
2
(0.5% Ophthalmic Solution)
Drug Name
Drug Requirements
Tier & Limits
Methazolamide
2
Metipranolol
2
Phospholine Iodide
3
Pilopine HS
3
Timolol Maleate
(Gel Forming Solution,
2
Ophthalmic Prostaglandin and Prostamide
Analogs — Glaucoma Drugs
Latanoprost
2
Lumigan
3
Travatan Z
3
Otic Agents — Drugs to Treat Ear
Conditions
Otic Agents — Ear Drugs
Acetasol HC
Acetic Acid
Dermotic
Fluocinolone Acetonide
(Otic Oil)
Hydrocortisone/Acetic
Acid
Neomycin/Polymyxin/
Hydrocortisone
(Solution, Suspension)
3
2
3
2
3
2
Respiratory Tract Agents — Drugs to
Treat Allergies, Cough, Cold and Lung
Conditions
Anti-Inflammatories, Inhaled
Corticosteroids — Asthma/Lung Drugs
Asmanex
4
Budesonide (Suspension)
3
B/D
Dulera
4
Flunisolide
2
(0.025% Nasal Solution)
Fluticasone Propionate
2
(Nasal Suspension)
Nasonex
3
41
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Pulmicort
4
B/D
Pulmicort Flexhaler
3
QVAR
3
Symbicort
3
Triamcinolone Acetonide
3
(Inhaler)
Antihistamines — Allergy Drugs
Astepro
3
Azelastine HCl
3
(Nasal Spray)
Carbinoxamine Maleate
2
Cetirizine HCl (Syrup)
2
Clemastine Fumarate
3
(Syrup, 2.68mg Tablet)
Hydroxyzine HCl
2
Hydroxyzine Pamoate
2
Levocetirizine
4
Dihydrochloride (Tablet)
Phenadoz
3
Promethazine HCl
3
Promethazine VC
3
Promethegan
(25mg Suppository,
3
50mg Suppository)
Antileukotrienes — Asthma/Lung Drugs
Singulair
3
Zafirlukast
2
Bronchodilators, Anticholinergic —
Asthma/Lung Drugs
Atrovent HFA
4
Combivent
3
Ipratropium Bromide
2
(Nasal Solution)
Drug Requirements
Tier & Limits
Ipratropium Bromide
2
B/D
(Inhalation Solution)
Ipratropium Bromide/
2
B/D
Albuterol Sulfate
Spiriva Handihaler
3
Bronchodilators, Phosphodiesterase
Inhibitors (Xanthines) — Asthma/Lung
Drugs
Aminophylline
2
Elixophyllin
3
Theophylline ER
Release 12 Hour,
Release 12 Hour,
2
Release 12 Hour,
Release 12 Hour,
Tablet Extended Release
24 Hour)
Bronchodilators, Sympathomimetic —
Asthma/Lung Drugs
Albuterol Sulfate
2
(Syrup, Tablet)
Albuterol Sulfate
2
B/D
(Nebulization Solution)
Albuterol Sulfate ER
2
Brovana
4
B/D
Epinephrine HCl
3
(0.1mg/ml Injection)
Epipen
3
Foradil Aerolizer
3
Levalbuterol
4
B/D, ST
ST = Step therapy
42
Drug Name
Drug Requirements
Tier & Limits
Metaproterenol Sulfate
2
Perforomist
4
B/D
Proair HFA
3
Serevent Diskus
4
ST
Terbutaline Sulfate (Tablet)
2
Terbutaline Sulfate
4
(Injection)
Twinject
4
Mast Cell Stabilizers — Asthma/Lung
Drugs
Cromolyn Sodium
3
B/D
(Nebulization Solution)
Pulmonary Antihypertensives —
Asthma/Lung Drugs
Adcirca
5
PA
Letairis
5
Remodulin
5
B/D, PA
Revatio
5
PA
Tracleer
5
LA
Ventavis (10mcg/ml
5
B/D, PA
Inhalation Solution)
Respiratory Tract Agents, Other —
Asthma/Lung Drugs
Acetylcysteine
2
B/D
Aralast NP
5
PA
(400mg Injection)
Glassia
5
PA
Kalydeco
5
PA
Prolastin-C
5
PA
Pulmozyme
5
B/D
Tyzine
3
Xolair
5
PA
Zemaira
5
PA
Drug Name
Drug Requirements
Tier & Limits
Sedatives/Hypnotics — Drugs for
Sedation and Sleep
GABA Receptor Modulators — Sedation
and Sleep Drugs
Temazepam (15mg
2
PA
Zaleplon
2
Zolpidem Tartrate
2
(5mg Tablet, 10mg Tablet)
Sleep Disorders, Other — Miscellaneous
Sedation and Sleep Drugs
Provigil
4
PA
Xyrem
3
PA, LA
Skeletal Muscle Relaxants — Drugs to
Treat Pain, Inflammation, and Muscle
and Joint Conditions
Skeletal Muscle Relaxants — Pain/Swelling
Management Drugs
Carisoprodol
3
(350mg Tablet)
Chlorzoxazone
3
Cyclobenzaprine HCl
4
(10mg Tablet, 5mg Tablet)
Methocarbamol
3
Orphenadrine Citrate ER
3
Orphenadrine Compound
3
DS
Orphenadrine/Aspirin/
3
Caffeine
Therapeutic Nutrients/Minerals/
Electrolytes — Drugs to Treat Vitamin,
Mineral and Body Fluid Deficiencies
Electrolyte/Mineral Modifiers — Vitamin,
Mineral and Body Fluid Deficiency Drugs
Chemet
4
Exjade
4
(125mg Tablet Soluble)
43
Drug Name
Drug Requirements
Tier & Limits
Drug Name
Exjade
(250mg Tablet Soluble,
5
500mg Tablet Soluble)
Kionex (Powder)
3
Samsca
5
PA
Sodium Lactate
2
Sodium Polystyrene
3
Sulfonate (Suspension)
Syprine
4
Electrolyte/Mineral Replacement —
Vitamin, Mineral and Body Fluid Deficiency
Drugs
Aminosyn 8.5%/
3
B/D
Electrolytes
Aminosyn II
4
B/D
Aminosyn II 8.5%/
3
B/D
Electrolytes
Aminosyn M
4
B/D
Aminosyn-HBC
4
B/D
Aminosyn-PF
4
B/D
Calcium Acetate (Capsule)
3
Clinimix 2.75%/
4
B/D
Dextrose 5%
Clinimix 4.25%/
4
B/D
Dextrose 10%
Clinimix 4.25%/
4
B/D
Dextrose 25%
Clinimix 4.25%/
4
B/D
Dextrose 5%
Clinimix 5%/
4
B/D
Dextrose 25%
Clinimix E 5%/
4
B/D
Dextrose 20%
Clinisol SF 15%
3
B/D
Dextrose 5%/
Lactated Ringers
Dextrose 5%/Potassium
Chloride 0.15%
Freamine III
(8.5% Injection)
Freamine III 3%
Hepatamine
Hepatasol
Isolyte-H/Dextrose 5%
Isolyte-M/Dextrose 5%
Isolyte-P/Dextrose 5%
Isolyte-S
Isolyte-S/Dextrose 5%
Klor-Con 10
Klor-Con 8
Klor-Con M15
Klor-Con M20
Lactated Ringers
Magnesium Sulfate
(50% Injection)
Nephramine
Normosol-M in D5W
Normosol-R
Phoslo
Phoslyra
Plasma-Lyte
Plasma-Lyte/D5W
(16meq/L; 40meq/L;
5%; 3meq/L; 13meq/L;
40meq/L Injection)
Drug Requirements
Tier & Limits
3
3
4
B/D
4
3
4
4
3
4
4
4
2
2
3
2
3
B/D
B/D
B/D
3
4
3
4
3
4
4
B/D
ST
4
ST = Step therapy
44
Drug Name
Potassium Chloride
(0.4meq/ml Injection,
10meq/100ml Injection,
2meq/ml Injection,
30meq/100ml Injection)
Potassium Chloride
(10meq/50ml Injection)
Potassium Chloride
0.15%/NaCl 0.45% Viaflex
Potassium Chloride
0.15%/NaCl 0.9%
Potassium Chloride
0.224%/Dextrose 5%
Viaflex
Potassium Chloride 0.3%/
D5W/Viaflex
Potassium Chloride
0.3%/NaCl 0.9%
Potassium Chloride
ER (Capsule Extended
Release, 10meq Tablet
Extended Release, 20meq
Tablet Extended Release)
Premasol (10% Injection)
Premasol (6% Injection)
Procalamine
Prosol
Ringers Injection
Sodium Chloride
(0.9% Injection, 2.5meq/ml
Injection, 3% Injection,
5% Injection)
Viaflex (Injection)
Sodium Fluoride (Tablet)
TPN Electrolytes
Travasol
Trophamine
Drug Requirements
Tier & Limits
3
3
3
3
3
3
2
B/D
B/D
B/D
B/D
2
2
2
3
4
4
Drug Requirements
Tier & Limits
Vitamins — Vitamin, Mineral and Body Fluid
Deficiency Drugs
Niacor
2
Prenatal Vitamins
2
3
4
4
4
4
3
Drug Name
B/D
B/D
45
Index of covered drugs
8-MOP.................................... 30
Albuterol Sulfate..................... 42 Aminosyn-PF.......................... 44
A
Albuterol Sulfate ER............... 42 Amiodarone HCl.................... 27
Abelcet.................................... 16
Alclometasone Dipropionate.... 33 Amitiza................................... 32
Abilify..................................... 21
Alcohol Preps.......................... 40
Amitriptyline HCl.................. 15
Abilify Discmelt...................... 21
Aldurazyme............................. 31
Amlodipine Besylate............... 28
Abraxane................................. 18
Alendronate Sodium............... 39 Ammonium Lactate................ 31
Acarbose.................................. 24
Alfuzosin HCl ER.................. 33 Amnesteem............................. 31
Acetaminophen/Codeine........... 9
Alimta..................................... 18 Amoxapine.............................. 15
Acetasol HC............................ 41
Alinia...................................... 20 Amoxicillin.............................. 11
Acetazolamide......................... 41
Allopurinol.............................. 17 Amoxicillin/Potassium
Clavulanate........................... 11
Allopurinol Sodium................. 17
Acetazolamide ER................... 41
Aloxi........................................ 16 Amoxicillin/Potassium
Clavulanate ER.................... 11
Alphagan
P.
.
............................
41
Acetic Acid.............................. 41
Amphetamine/
Alprazolam.
.
............................
24
Dextroamphetamine............. 30
Acetylcysteine.......................... 43
Actemra................................... 38 Alrex........................................ 40 Amphotec................................ 16
ActHIB................................... 38 Amantadine HCl..................... 23 Amphotericin B....................... 16
Acetazolamide Sodium............ 29
Actimmune............................. 38
Actoplus Met........................... 24
Actos....................................... 24
Acyclovir................................. 23
Acyclovir Sodium.................... 23
Adacel...................................... 38
Adagen.................................... 31
Adapalene................................ 30
Adcirca.................................... 43
Adriamycin.............................. 18
Afinitor.................................... 19
Aggrenox................................. 27
A-Hydrocort............................ 33
AK-Con.................................. 40
Ala-Cort.................................. 33
Albenza................................... 20
AmBisome............................... 16 Ampicillin............................... 11
Amcinonide............................. 33 Ampicillin Sodium.................. 11
Amethia.................................. 35 Ampicillin-Sulbactam............. 12
Amethyst................................. 35 Ampyra................................... 30
Amevive.................................. 31 Anagrelide HCl....................... 26
Amifostine............................... 18 Anastrozole............................. 19
Amikacin Sulfate....................... 9 Ancobon.................................. 16
Amiloride HCl........................ 29 Androgel................................. 35
Amiloride/
Androgel Pump....................... 35
Hydrochlorothiazide............. 29
Androxy................................... 35
Aminophylline......................... 42
Antabuse.................................. 15
Aminosyn 8.5%/Electrolytes....44
Antara..................................... 29
Aminosyn-HBC...................... 44
Anzemet.................................. 16
Aminosyn II............................ 44
Apokyn.................................... 21
Aminosyn II 8.5%/
Electrolytes........................... 44 Apraclonidine.......................... 41
Aminosyn M........................... 44 Apri......................................... 35
46
Apriso...................................... 39
Azactam in Iso-Osmotic
Dextrose............................... 11
Bisoprolol Fumarate/
Azasan..................................... 37
Bleomycin Sulfate.................... 18
Azathioprine............................ 37
Blephamide.............................. 40
Azathioprine Sodium.............. 37
Blephamide S.O.P................... 40
Azelastine HCl.................. 40, 42
Boostrix................................... 38
Azithromycin.......................... 12
Botox....................................... 40
Aztreonam............................... 11
Briellyn.................................... 35
Aromasin................................. 19
B
Brilinta.................................... 27
Arranon................................... 18
Baciim..................................... 10
Brimonidine Tartrate............... 41
Arzerra.................................... 20
Bacitracin................................ 10
Bromday.................................. 40
Asacol...................................... 39 Bacitracin/Polymyxin B.......... 10
Asmanex.................................. 41 Baclofen................................... 22
Bromfenac............................... 40
Aptivus.................................... 23
Aralast NP.............................. 43
Aranelle................................... 35
Aranesp Albumin Free............ 26
Arcalyst................................... 38
Argatroban.............................. 25
Arixtra..................................... 25
Bromocriptine Mesylate.......... 21
Astepro.................................... 42
Bactocill in Dextrose............... 12
Brovana................................... 42
Astramorph............................... 8
Balsalazide Disodium.............. 39
Budeprion SR.......................... 14
Atenolol................................... 28 Balziva..................................... 35
Atenolol/Chlorthalidone......... 28 Banzel...................................... 14
Budesonide.........................39, 41
Bumetanide............................. 29
Baraclude................................. 23
Buphenyl.................................. 31
Atorvastatin Calcium.............. 29 Benazepril HCl....................... 27
Atovaquone/Proguanil HCl.... 20 Benazepril HCl/
Atripla..................................... 22
Benicar.................................... 27
Atropine Sulfate...................... 31
Benicar HCT.......................... 27
Atrovent HFA......................... 42
Benlysta................................... 37
Augmented Betamethasone
Dipropionate......................... 33 Benztropine Mesylate.............. 20
Buprenorphine HCl................. 15
Avandamet.............................. 24 Bepreve.................................... 40
Avandaryl................................ 24 Betamethasone Dipropionate....33
Butalbital/Acetaminophen/
Caffeine/Codeine................. 30
Avandia................................... 24 Betamethasone Valerate........... 33
Avastin.................................... 20 Betaxolol HCl.......................... 41
Byetta...................................... 24
Avelox...................................... 12 Bethanechol Chloride.............. 33
Avelox ABC Pack.................... 12 Bicalutamide............................ 37
C
Atgam..................................... 38
Buproban................................. 15
Bupropion HCl........................ 14
Bupropion HCl SR.................. 14
Bupropion XL......................... 14
Buspirone HCl........................ 24
Busulfex................................... 17
Butorphanol Tartrate................. 9
Bystolic.................................... 28
Aviane..................................... 35
Bicillin C-R............................. 12 Cabergoline............................. 37
Avita........................................ 31
Bicillin L-A............................. 12 Calcipotriene........................... 31
Avonex..................................... 38
BiCNU.................................... 17 Calcitonin-Salmon.................. 39
Biltricide.................................. 20 Calcitriol.................................. 39
47
Calcium Acetate...................... 44
Cefoxitin Sodium.................... 11
Chorionic Gonadotropin......... 34
Camila..................................... 36
Cefoxitin Sodium/Dextrose.... 11
Ciclopirox................................ 16
Campath.................................. 20
Cefpodoxime Proxetil.............. 11
Ciclopirox Nail Lacquer.......... 16
Cancidas.................................. 16
Cefprozil................................. 11
Ciclopirox Olamine................. 16
Capastat Sulfate....................... 17
Ceftazidime............................. 11
Cilostazol................................. 27
Caprelsa................................... 18
Ceftazidime/Dextrose............. 11
Cimetidine............................... 32
Captopril................................. 27
Ceftriaxone Sodium................ 11
Cimetidine HCl...................... 32
Captopril/
Cefuroxime Axetil................... 11
Cimzia..................................... 37
Cefuroxime Sodium................ 11
Cinryze.................................... 27
Cellcept................................... 37
Cipro....................................... 13
Cellcept Intravenous................ 37
Ciprofloxacin........................... 13
Celontin................................... 13
Ciprofloxacin ER..................... 13
Cephalexin.............................. 11
Ciprofloxacin HCl................... 13
Cerezyme................................ 31
Cipro IV.................................. 13
Cerubidine............................... 18
Cisplatin.................................. 18
Cervarix................................... 38
Citalopram Hydrobromide...... 15
Cesamet................................... 16
Cladribine................................ 18
Cetirizine HCl........................ 42
Claforan................................... 11
Chantix.................................... 15
Claravis.................................... 31
Chantix Pak............................. 15
Clarithromycin........................ 12
Chemet.................................... 43
Clarithromycin ER.................. 12
Chloramphenicol Sodium
Succinate.............................. 10
Clemastine Fumarate.............. 42
Carac....................................... 31
Carafate................................... 32
Carbaglu.................................. 31
Carbamazepine........................ 14
Carbamazepine ER................. 14
Carbidopa/Levodopa............... 21
Carbidopa/Levodopa ER........ 21
Carbidopa/Levodopa ODT..... 21
Carbinoxamine Maleate.......... 42
Carboplatin.............................. 18
Carimune Nanofiltered............ 38
Carisoprodol............................ 43
Carteolol HCl.......................... 41
Cartia XT................................ 28
Carvedilol................................ 28 Chlordiazepoxide/
Amitriptyline........................ 24
Cayston.................................... 11
Cedax...................................... 11 Chlordiazepoxide HCl............ 24
CeeNU.................................... 18 Chlorhexidine Gluconate
Oral Rinse............................ 30
Cefaclor................................... 11
Chloroquine Phosphate........... 20
Cefaclor ER............................. 11
Chlorothiazide......................... 29
Cefadroxil................................ 11
Chlorothiazide Sodium........... 29
Cefazolin Sodium.................... 11
Chlorpromazine HCl.............. 21
Cefdinir................................... 11
Chlorthalidone........................ 29
Cefepime................................. 11
Chlorzoxazone......................... 43
Cefotaxime Sodium................. 11
Cholestyramine Light............. 29
Cefotetan................................. 11
48
Cleocin.................................... 10
Cleocin Galaxy........................ 10
Cleocin in D5W...................... 10
Cleocin Phosphate................... 10
Clindamycin/
Benzoyl Peroxide.................. 31
Clindamycin HCl.................... 10
Clindamycin Phosphate..... 10, 31
Add-Vantage......................... 10
Clinimix 2.75%/
Dextrose 5%......................... 44
Clinimix 4.25%/
Dextrose 5%......................... 44
Clinimix 4.25%/
Dextrose 10%....................... 44
Clinimix 4.25%/
Dextrose 20%....................... 24
Clinimix 4.25%/
Dextrose 25%....................... 44
Clinimix 5%/Dextrose 15%..... 24
Clinimix 5%/Dextrose 20%.... 24
Clinimix 5%/Dextrose 25%.... 44
Clinimix E 2.75%/
Dextrose 5%......................... 25
Clinimix E 2.75%/
Dextrose 10%....................... 25
Cogentin.................................. 20 Cystagon.................................. 31
Co-Gesic................................... 9 Cytarabine............................... 18
Colcrys.................................... 17 Cytarabine Aqueous................ 18
Colestipol HCl........................ 29
Cytovene.................................. 22
Colistimethate Sodium............ 10
D
Colocort................................... 39 Dacarbazine............................. 18
Combigan................................ 41 Dacogen.................................. 19
Combivent............................... 42 Danazol................................... 35
Combivir................................. 22 Dantrolene Sodium................. 22
Complera................................. 22 Dapsone................................... 17
Compro................................... 21 Daptacel.................................. 38
Clinimix E 4.25%/
Dextrose 5%......................... 25
Comtan................................... 20 Daraprim................................. 20
Comvax................................... 38 Daunorubicin HCl.................. 19
Clinimix E 4.25%/
Dextrose 25%....................... 25
Copaxone................................ 30 Decavac................................... 38
Cortisone Acetate.................... 33 Demeclocycline HCl............... 13
Clinimix E 5%/
Dextrose 15%....................... 25
Clinimix E 5%/
Dextrose 20%....................... 44
Clinimix E 5%/
Dextrose 25%....................... 25
Clinisol SF 15%....................... 44
Clobetasol Propionate.............. 33
Clobetasol Propionate E.......... 33
Clolar....................................... 18
Clomipramine HCl................. 15
Clonazepam............................. 13
Clonazepam ODT.................. 13
Clonidine HCl........................ 27
Cosmegen................................ 18 Demser.................................... 29
Coumadin............................... 25 Depo-Medrol.......................... 33
Creon....................................... 31 Depo-Provera.......................... 36
Crestor..................................... 29 Dermotic................................. 41
Crinone................................... 36 Desipramine HCl.................... 15
Crixivan................................... 23 Desmopressin Acetate............. 34
Cromolyn Sodium....... 32, 40, 43 Desonide................................. 33
Cryselle.................................... 35 Desowen.................................. 33
Cubicin.................................... 10 Desoximetasone....................... 33
Cuvposa................................... 31 Dexamethasone....................... 33
Cyclafem 1/35......................... 35 Dexamethasone Intensol......... 33
Cyclafem 7/7/7........................ 35 Dexamethasone Sodium
Phosphate....................... 33, 40
Cyclobenzaprine HCl.............. 43
Cyclophosphamide.................. 18 Dexilant................................... 32
Clorazepate Dipotassium......... 13 Cyclosporine............................ 37 Dexmethylphenidate HCl....... 30
Clotrimazole............................ 16 Cyclosporine Modified............ 37 Dexrazoxane............................ 19
Clopidogrel.............................. 27
Cyklokapron............................ 27 Dextroamphetamine Sulfate.... 30
Clotrimazole/Betamethasone
Dipropionate......................... 16 Cymbalta................................. 15 Dextrose 2.5%/
Sodium Chloride 0.45%....... 25
Clozapine................................ 21 Cystadane................................ 31
Dextrose 5%............................ 25
Codeine Sulfate......................... 9
49
Dextrose 5%/
Lactated Ringers.................. 44
Dipyridamole........................... 27 E.E.S. 400............................... 12
Disopyramide Phosphate......... 27 E.E.S. Granules...................... 12
Dextrose 5%/NaCl 0.2%......... 25 Disulfiram............................... 15 Effient..................................... 27
Dextrose 5%/NaCl 0.9%......... 25 Diuril....................................... 29 Egrifta..................................... 34
Dextrose 5%/NaCl 0.33%....... 25 Divalproex Sodium.................. 13 Elaprase................................... 31
Dextrose 5%/NaCl 0.45%....... 25 Divalproex Sodium DR........... 13 Elidel....................................... 31
Dextrose 5%/NaCl 0.225%..... 25 Divalproex Sodium ER........... 13 Elitek....................................... 18
Dextrose 5%/Potassium
Divigel..................................... 35 Elixophyllin............................. 42
Chloride 0.15%..................... 44
Docefrez.................................. 19 Ella.......................................... 36
Dextrose 10%
Flex Container...................... 25 Docetaxel................................. 19 Elmiron................................... 33
Dextrose 10%/NaCl 0.2%....... 25 Donepezil HCl........................ 14 Elspar...................................... 19
Dextrose 10%/NaCl 0.45%.... 25 Doribax................................... 11 Emcyt...................................... 18
Diazepam.......................... 13, 24 Dorzolamide HCl................... 41
Diazepam Intensol.................. 24 Dorzolamide HCl/
Timolol Maleate................... 41
Dibenzyline............................. 27
Dovonex.................................. 31
Diclofenac Potassium................ 8
Doxazosin Mesylate................ 33
Diclofenac Sodium.................. 40
Doxepin HCl........................... 15
Diclofenac Sodium DR............. 8
Doxil....................................... 19
Diclofenac Sodium ER.............. 8
Doxorubicin HCl.................... 19
Dicloxacillin Sodium............... 12
Doxycycline............................. 13
Dicyclomine HCl.................... 31
Doxycycline Hyclate................ 13
Didanosine.............................. 22
Doxycycline Monohydrate...... 13
Dificid..................................... 12
Dronabinol.............................. 16
Diflorasone Diacetate.............. 33
Droxia...................................... 18
Diflunisal................................... 8
Duetact.................................... 24
Digoxin................................... 29
Dulera...................................... 41
Dihydroergotamine Mesylate....17
Duramorph................................ 8
Dilantin................................... 14
Durezol................................... 40
Dilantin Infatabs..................... 14
Dilt-CD................................... 28
E
Diltiazem CD......................... 28 Econazole Nitrate.................... 16
Diltiazem HCl........................ 28 Edarbi...................................... 27
Dilt-XR................................... 28 Edarbyclor............................... 27
Diphenoxylate/Atropine.......... 32 Edurant................................... 22
50
Emend..................................... 16
Emoquette............................... 35
Emsam.................................... 15
Emtriva.................................... 22
Enalapril Maleate.................... 27
Enalapril Maleate/
Enbrel...................................... 37
Engerix-B................................ 39
Enjuvia.................................... 35
Enoxaparin Sodium........... 25, 26
Enpresse.................................. 35
Enulose.................................... 32
Epinastine HCl....................... 40
Epinephrine HCl..................... 42
Epipen..................................... 42
Epirubicin HCl....................... 19
Epitol....................................... 14
Epivir....................................... 22
Epivir HBV............................. 22
Eplerenone............................... 29
Epogen.................................... 26
Epzicom.................................. 22
Equetro.................................... 14
F
Fluocinonide-E........................ 33
Eraxis...................................... 16
Fabrazyme............................... 31
Fluorouracil....................... 18, 31
Erbitux.................................... 20
Factive..................................... 13
Fluoxetine DR......................... 15
Ergotamine Tartrate/
Caffeine................................ 17
Famciclovir.............................. 23
Fluoxetine HCl........................ 15
Famotidine.............................. 32
Fluphenazine Decanoate......... 21
Famotidine Premixed.............. 32
Fluphenazine HCl................... 21
Fanapt...................................... 21
Flurbiprofen............................... 8
Fanapt Titration Pack.............. 21
Flurbiprofen Sodium............... 40
Fareston................................... 18
Flutamide................................ 37
Faslodex................................... 18
Fluticasone Propionate...... 33, 41
Fazaclo..................................... 21
Fluvoxamine Maleate.............. 15
Felbamate................................ 14
Folotyn.................................... 18
Felbatol.................................... 14
Fomepizole.............................. 40
Fenofibrate............................... 29
Fondaparinux Sodium............. 26
Fenofibrate Micronized........... 29
Foradil Aerolizer..................... 42
Erythromycin Ethylsuccinate....12
Fentanyl..................................... 8
Fortaz...................................... 11
Escitalopram Oxalate.............. 15
Fentanyl Citrate Oral
Transmucosal.......................... 9
Forteo...................................... 39
Fortical.................................... 39
Ferriprox.................................. 40
Foscarnet Sodium.................... 22
Finacea.................................... 31
Fosphenytoin Sodium.............. 14
Estradiol Valerate.................... 35
Finasteride............................... 33
Fosrenol................................... 33
Estropipate.............................. 35
Firazyr..................................... 40
Fragmin................................... 26
Ethambutol HCl..................... 17
Firmagon................................. 37
Freamine III............................ 44
Ethosuximide.......................... 13
Flagyl ER................................ 10
Freamine III 3%...................... 44
Etidronate Disodium............... 39 Flavoxate HCl......................... 32
Etodolac.................................... 8 Flecainide Acetate................... 28
Furosemide.............................. 29
Etopophos............................... 19
Fluconazole............................. 16
Fuzeon..................................... 23
Etoposide................................. 19
Fluconazole in Dextrose.......... 16
G
Evista....................................... 36
Flucytosine.............................. 16
Exalgo....................................... 8
Fludarabine Phosphate............ 19
Exelon..................................... 14
Fludrocortisone Acetate ......... 33
Exemestane............................. 19
Flunisolide............................... 41
Exjade................................ 43, 44
Fluocinolone Acetonide..... 33, 41
Extavia.................................... 38
Fluocinonide............................ 33
Erivedge.................................. 19
Errin........................................ 36
Ery........................................... 12
Eryped..................................... 12
Ery-Tab................................... 12
Erythrocin Lactobionate......... 12
Erythrocin Stearate................. 12
Erythromycin.......................... 12
Erythromycin Base.................. 12
Erythromycin/
Benzoyl Peroxide.................. 31
Estradiol.................................. 35
Estradiol/Norethindrone
Acetate.................................. 35
51
Fusilev..................................... 19
Gabapentin.............................. 13
Gabitril.................................... 13
Gablofen.................................. 22
Gammagard Liquid................. 38
Gammaplex............................. 38
Gamunex-C............................. 38
Ganciclovir.............................. 22
H
Hydroxyzine HCl.................... 42
Gardasil................................... 39 Halaven................................... 19
Gauze Pads.............................. 40 Halflytely Bowel Prep/
Flavor Packs......................... 32
Gavilyte-C.............................. 32
Hydroxyzine Pamoate............. 42
I
Ibuprofen................................... 8
Halobetasol
Propionate.
.
..........
33
Gavilyte-G.............................. 32
Idarubicin HCl........................ 19
Haloperidol.............................
21
Gavilyte-N/Flavor Pack.......... 32
Ifosfamide................................ 18
Haloperidol
Decanoate.
.
..........
21
Gemcitabine HCl.................... 18
Ilaris........................................ 38
Haloperidol
Lactate.
.
...............
21
Gemfibrozil............................. 29
Imipenem/Cilastatin............... 11
Havrix.....................................
39
Gemzar.................................... 18
Imipramine HCl...................... 15
Hectorol.
.
.................................
39
Gengraf................................... 37
Imipramine Pamoate............... 15
Heparin
Sodium.
.
....................
26
Genotropin.............................. 34
Imiquimod............................... 31
Heparin
Sodium/D5W.
.
.........
26
Genotropin Miniquick............ 34
Incivek..................................... 23
Heparin
Sodium/NaCl...........
26
Gentak....................................... 9
Increlex.................................... 34
Heparin
Sodium/
Gentamicin Sulfate.................... 9
Indapamide.............................. 29
NaCl 0.9% Premix................ 26
Gentamicin Sulfate/NaCl.... 9, 10
Indomethacin............................ 8
Hepatamine............................. 44
Geodon.................................... 21
Infanrix................................... 39
Hepatasol................................. 44
Gianvi...................................... 35
Infergen................................... 23
Hepsera................................... 23
Gilenya.................................... 30
Inlyta....................................... 19
Herceptin................................. 20
Glassia..................................... 43
Insulin Syringes, Needles ....... 40
Hexalen................................... 18
Gleevec.................................... 19
Intelence.................................. 22
Hizentra.................................. 38
Glimepiride............................. 24
Intralipid................................. 40
Humatrope.............................. 34
Glipizide.................................. 24
Intron-A.................................. 23
Humira.................................... 37
Glipizide ER........................... 24
Intron-A W/Diluent................ 23
Humira Starter Kit.................. 37
Glipizide/Metformin HCl...... 24
Introvale.................................. 35
Hycamtin................................. 19
Glucagen Hypokit................... 25
Intuniv..................................... 30
Hydralazine HCl..................... 30
Glucagon Emergency Kit........ 25
Invanz...................................... 11
Hydrochlorothiazide................ 29
Glyburide................................ 24
Invega...................................... 21
Hydrocodone/Acetaminophen....9
Glyburide/Metformin HCl..... 24
Invega Sustenna....................... 21
Hydrocodone/Ibuprofen............ 9
Glyburide Micronized............. 24
Invirase.................................... 23
Hydrocortisone.................. 33, 39
Glycopyrrolate......................... 31
Ionosol-B/Dextrose 5%........... 25
Hydrocortisone/Acetic Acid.... 41
Granisetron HCl..................... 16
Ionosol-MB/Dextrose 5%....... 25
Hydrocortisone Valerate.......... 33
Granisol................................... 16
Iopidine................................... 41
Hydromorphone HCl................ 9
Griseofulvin Microsize............ 16
IPOL....................................... 39
Hydroxychloroquine Sulfate.... 20
Gris-Peg.................................. 16
Ipratropium Bromide............... 42
Hydroxyurea............................ 18
Guanfacine HCl...................... 27
52
Ipratropium Bromide/
Albuterol Sulfate................... 42
Irinotecan................................ 19
Isentress................................... 23
Isolyte-H/Dextrose 5%........... 44
Isolyte-M/Dextrose 5%........... 44
Isolyte-P/Dextrose 5%............. 44
Isolyte-S.................................. 44
Isolyte-S/Dextrose 5%............. 44
Isoniazid.................................. 17
Isosorbide Dinitrate................. 30
Isosorbide Dinitrate ER.......... 30
Isosorbide Mononitrate............ 30
Isosorbide Mononitrate ER..... 30
Isotonic Gentamicin................ 10
Istodax..................................... 19
Itraconazole............................. 16
Ixempra Kit............................. 19
Ixiaro....................................... 39
KCl 0.15%/D5W/LR.............. 25 Lanoxin................................... 29
KCl 0.15%/D5W/
Lansoprazole........................... 32
NaCl 0.2%............................ 25
Lastacaft.................................. 40
KCl 0.15%/D5W/
Latanoprost............................. 41
NaCl 0.9%............................ 25
Latuda..................................... 21
KCl 0.15%/D5W/
NaCl 0.225%........................ 25 Leena....................................... 35
Leflunomide............................ 38
KCl 0.075%/D5W/
NaCl 0.45%.......................... 25 Lessina..................................... 35
Kelnor...................................... 35 Letairis.................................... 43
Kepivance................................ 30 Letrozole................................. 19
Ketek....................................... 12 Leucovorin Calcium................ 19
Ketoconazole........................... 16 Leukeran................................. 18
Ketoprofen................................. 8 Leukine................................... 26
Ketorolac Tromethamine..... 8, 40 Leuprolide Acetate.................. 37
Kineret..................................... 37 Levalbuterol............................. 42
Kionex..................................... 44 Levemir................................... 25
Klor-Con 8.............................. 44 Levetiracetam.......................... 13
Klor-Con 10............................ 44 Levetiracetam ER.................... 13
Klor-Con M15........................ 44 Levobunolol HCl..................... 41
J
Klor-Con M20........................ 44
Levocarnitine.......................... 40
Jakafi........................................ 19
Kombiglyze XR....................... 24
Jantoven................................... 26
Kuvan...................................... 31
Levocetirizine
Dihydrochloride................... 42
Jevtana..................................... 19
L
Levofloxacin............................ 13
Jolivette.................................... 36
Labetalol HCl......................... 28 Levofloxacin in D5W.............. 13
Laclotion................................. 31 Levora...................................... 35
Junel......................................... 35
Lactated Ringers..................... 44
Levorphanol Tartrate................. 8
Junel Fe.................................... 35
Lactated Ringers Irrigation..... 40
K
Lactulose................................. 32
Kaletra..................................... 23
Lamictal ODT........................ 14
Kalydeco.................................. 43
Lamictal Starter Kit................ 14
Jinteli....................................... 35
Kanamycin Sulfate.................. 10 Lamisil.................................... 16
Kariva...................................... 35
Lamivudine............................. 22
KCl 0.3%/D5W/NaCl 0.9%.... 25 Lamivudine/Zidovudine......... 22
KCl 0.3%/D5W/NaCl 0.45%....25 Lamotrigine............................. 14
53
Levothroid............................... 36
Levothyroxine Sodium............ 36
Levoxyl.................................... 36
Lexiva...................................... 23
Lidocaine................................... 9
Lidocaine HCl........................... 9
Lidocaine/Prilocaine................. 9
Lidocaine Viscous...................... 9
Lidoderm................................... 9
Lincocin.................................. 10
M
Lindane................................... 20
Magnesium Sulfate.................. 44 Methadose................................. 9
Malarone................................. 20 Methazolamide........................ 41
Lioresal Intrathecal.................. 22
Liothyronine Sodium.............. 36
Liposyn III.............................. 40
Lisinopril................................. 27
Lisinopril/
Lithium Carbonate.................. 24
Lithium Carbonate ER........... 24
Lithium Citrate....................... 24
Lithobid................................... 24
Methadone HCl........................ 9
Malathion................................ 20 Methenamine Hippurate......... 10
Maprotiline HCl..................... 14 Methergine.............................. 40
Marlissa................................... 35 Methimazole........................... 37
Marplan................................... 15 Methocarbamol....................... 43
Matulane................................. 18 Methotrexate........................... 38
Maxalt..................................... 17 Methotrexate Sodium.............. 38
Maxalt-MLT........................... 17 Methscopolamine Bromide..... 32
Meclizine HCl........................ 16 Methyclothiazide..................... 29
Methyldopa............................. 27
Medroxyprogesterone
Acetate.................................. 36 Methyldopa/
Loperamide HCl..................... 32 Mefenamic Acid........................ 8
Lokara..................................... 33
Lorazepam.............................. 24
Lorazepam Intensol................. 24
Losartan Potassium................. 27
Losartan Potassium/
Mefloquine HCl...................... 20 Methyldopate HCl.................. 27
Megace ES.............................. 36 Methylergonovine Maleate...... 40
Megestrol Acetate.................... 36 Methylphenidate HCl............. 30
Meloxicam................................. 8 Methylphenidate HCl ER....... 30
Melphalan HCl....................... 18 Methylprednisolone................. 33
Lotemax.................................. 41
Menactra................................. 39 Methylprednisolone Acetate.... 33
Lotronex.................................. 32
Menest..................................... 19 Methylprednisolone
Lovastatin................................ 29
Dose Pack............................. 33
Menomune-A/C/Y/W-135..... 39
Lovaza..................................... 29
Methylprednisolone Sodium
Menveo.................................... 39
Succinate.............................. 34
Lovenox................................... 26
Mepron.................................... 20 Metipranolol............................ 41
Low-Ogestrel.......................... 35
Mercaptopurine....................... 18 Metoclopramide HCl.............. 32
Loxapine Succinate.................. 21
Meropenem............................. 11 Metolazone.............................. 29
Lumigan.................................. 41
Mesalamine............................. 39 Metoprolol/
Lumizyme............................... 31
Mesna...................................... 19
Lupron Depot.......................... 37
Mesnex.................................... 19 Metoprolol Succinate ER........ 28
Lupron Depot-PED................ 37
Mestinon................................. 17 Metoprolol Tartrate................. 28
Lutera...................................... 35
Mestinon Timespan................ 17 Metronidazole......................... 10
Lyrica...................................... 13
Metaproterenol Sulfate............ 43 Metronidazole in
Lysodren.................................. 36
NaCl 0.79%.......................... 10
Metformin HCl....................... 24
Metronidazole Vaginal............ 10
Metformin HCl ER................ 24
Mexiletine HCl....................... 28
54
Miacalcin................................. 39
N
Neumega................................. 26
Micardis.................................. 27 Nadolol.................................... 28 Neupogen................................ 27
Micardis HCT........................ 27 Nafcillin Sodium..................... 12 Nevanac................................... 41
Miconazole 3........................... 16 Naglazyme............................... 31 Nevirapine............................... 22
Microgestin............................. 35 Nalbuphine HCl........................ 9 Nexavar................................... 19
Microgestin Fe........................ 35 Nallpen/Dextrose.................... 12 Nexium.................................... 32
Midodrine HCl....................... 27 Naloxone HCl......................... 15 Nexium I.V.............................. 32
Migergot.................................. 17 Naltrexone HCl....................... 15 Next Choice............................ 36
Millipred................................. 39 Namenda................................. 14 Niacor...................................... 45
Minitran.................................. 30 Namenda Titration Pak........... 14 Niaspan................................... 29
Minocycline HCl.................... 13 Naproxen................................... 8 Nicardipine HCl...................... 28
Minocycline HCl ER.............. 13 Naproxen DR............................ 8 Nicotrol Inhaler....................... 15
Minoxidil................................ 30 Naproxen Sodium...................... 8 Nicotrol NS............................. 15
Mirtazapine............................. 15 Naratriptan HCl...................... 17 Nilandron................................ 37
Mirtazapine ODT................... 15 Nardil...................................... 15 Nimodipine............................. 28
Misoprostol.............................. 32 Nasonex................................... 41 Nisoldipine.............................. 29
Mitomycin............................... 19 Natacyn................................... 16 Nisoldipine ER........................ 29
Mitoxantrone HCl................... 19 Nateglinide.............................. 24 Nitro-Bid................................. 30
M-M-R II............................... 39 Nebupent................................. 20 Nitrofurantoin......................... 10
Mometasone Furoate............... 34 Necon...................................... 35 Nitrofurantoin
Macrocrystalline................... 10
Mononessa............................... 35 Nefazodone HCl..................... 15
Nitrofurantoin Monohydrate....10
Morphine Sulfate...................... 9 Neomycin/Bacitracin/
Polymyxin............................. 10 Nitroglycerin........................... 30
Morphine Sulfate ER................ 9
Nitrolingual Pumpspray.......... 30
Moxeza.................................... 13 Neomycin/Polymyxin/
Bacitracin/Hydrocortisone....41 Nitromist................................. 30
Mozobil................................... 26
Neomycin/Polymyxin B
Nitrostat.................................. 30
Multaq..................................... 28
Sulfates................................. 10
Nizatidine................................ 32
Mupirocin................................ 10 Neomycin/Polymyxin/
Dexamethasone.................... 41 Nora-BE.................................. 36
Mustargen............................... 18
Norditropin Flexpro................ 34
Mycamine................................ 16 Neomycin/Polymyxin/
Gramicidin........................... 10 Norditropin Nordiflex Pen...... 34
Mycobutin............................... 17
Neomycin/Polymyxin/
Norethindrone Acetate............ 36
Mycophenolate Mofetil........... 38
Hydrocortisone..................... 41
Normosol-M in D5W............. 44
Myfortic.................................. 38
Neomycin Sulfate.................... 10
Normosol-R............................. 44
Myozyme................................. 31
Nephramine............................. 44
Normosol-R in D5W.............. 25
Mytelase.................................. 17
Neulasta................................... 26
Noroxin................................... 13
55
Nortrel..................................... 35
Nortriptyline HCl................... 15
Norvir...................................... 23
Novolin.................................... 25
Novolog................................... 25
Noxafil..................................... 16
Nucynta ER............................... 9
Nulojix..................................... 38
Nulytely/Flavor Packs............. 32
Nutropin.................................. 34
Nutropin AQ........................... 34
Nuvaring................................. 35
Nyamyc.................................... 16
Nystatin................................... 17
Nystatin/Triamcinolone.......... 17
Nystop..................................... 17
O
Ocella...................................... 35
Octreotide Acetate.................. 37
Ofloxacin................................. 13
Ogestrel................................... 35
Olanzapine.............................. 21
Olanzapine ODT.................... 21
Omeprazole............................. 32
Omnitrope............................... 34
Ondansetron HCl................... 16
Ondansetron ODT.................. 16
Onfi......................................... 13
Onglyza................................... 24
Onsolis...................................... 9
Ontak...................................... 19
Orap........................................ 21
Orencia.................................... 38
Orfadin.................................... 31
Orphenadrine/Aspirin/
Caffeine................................ 43
Orphenadrine Citrate ER........ 43
Orphenadrine
Compound DS..................... 43
Orsythia.................................. 35
Oxacillin Sodium.................... 12
Oxaliplatin.............................. 19
Oxandrolone............................ 35
Oxcarbazepine......................... 14
Oxsoralen................................ 31
Oxsoralen Ultra....................... 31
Oxybutynin Chloride.............. 32
Oxybutynin Chloride ER........ 32
Oxycodone/Acetaminophen...... 9
Oxycodone/Aspirin................... 9
Oxycodone HCl........................ 9
Oxycodone/Ibuprofen............... 8
Peg-Intron............................... 23
Peg-Intron Redipen................. 23
Penicillin G Potassium............ 12
Penicillin G Potassium in
Iso-Osmotic Dextrose.......... 12
Penicillin G Procaine.............. 12
Penicillin G Sodium................ 12
Penicillin V Potassium............. 12
Pentam 300............................. 20
Pentostatin............................... 18
Pentoxifylline ER.................... 29
Perforomist.............................. 43
Periogard................................. 30
Permethrin.............................. 20
Perphenazine........................... 21
Perphenazine/Amitriptyline.... 15
Pfizerpen-G............................ 12
Phenadoz................................. 42
P
Phenelzine Sulfate................... 15
Pacerone.................................. 28
Phenobarbital.......................... 13
Paclitaxel................................. 19
Phenytek.................................. 14
Pamidronate Disodium........... 39
Phenytoin................................ 14
Panretin................................... 20
Phenytoin Sodium................... 14
Pantoprazole Sodium............... 32 Phenytoin Sodium Extended....14
Paromomycin Sulfate............... 10 Phoslo...................................... 44
Paroxetine HCl........................ 15
Phoslyra................................... 44
Paroxetine HCl ER................. 15
Phospholine Iodide.................. 41
Paser........................................ 17
Physiolyte................................ 40
Paxil........................................ 15
Physiosol Irrigation................. 40
PCE......................................... 12
Picato....................................... 19
Pedi-Dri.................................. 17
Pilocarpine HCl...................... 30
Pedvax HIB............................. 39 Pilopine HS............................. 41
Peganone................................. 14
Pindolol................................... 28
Pegasys.................................... 23
Piperacillin Sodium/
Tazobactam Sodium............. 12
Pegasys Proclick...................... 23
56
Plasma-Lyte............................. 44 Pregnyl W/Diluent Benzyl
Alcohol/NaCl....................... 34
Plasma-Lyte/D5W.................. 44
Podofilox................................. 31 Premarin.................................. 35
Polyethylene Glycol 3350......... 32 Premasol.................................. 45
Polymyxin B Sulfate................ 10 Premphase............................... 35
Portia....................................... 35 Prempro................................... 35
Potassium Chloride................. 45 Prenatal Vitamins.................... 45
Prevalite................................... 29
D5W/Viaflex........................ 45 Previfem.................................. 35
Prezista.................................... 23
NaCl 0.9%............................ 45
Priftin...................................... 17
Primaquine Phosphate............. 20
D5W/NaCl 0.33%............... 25
Primaxin.................................. 11
D5W/NaCl 0.45% Viaflex....25 Primidone................................ 13
Promethegan........................... 42
Propafenone HCl.................... 28
Propafenone HCl ER.............. 28
Propantheline Bromide............ 32
Proparacaine HCl.................... 40
Propranolol HCl...................... 28
Propranolol HCl ER............... 28
Propranolol/
Propylthiouracil....................... 37
ProQuad.................................. 39
Prosol....................................... 45
Protopic................................... 31
Protriptyline HCl.................... 15
Primsol.................................... 10
NaCl 0.9%............................ 45 Pristiq...................................... 15
Privigen................................... 38
NaCl 0.45% Viaflex.............. 45
Proair HFA............................. 43
D5W/NaCl 0.45%................ 25 Probenecid............................... 17
Probenecid/Colchicine............ 17
Q
Potiga...................................... 13 Prochlorperazine..................... 21
Quetiapine Fumarate............... 21
Provigil.................................... 43
Pulmicort................................. 42
Pulmicort Flexhaler................. 42
Pulmozyme............................. 43
Pyridostigmine Bromide......... 17
Dextrose 5% Viaflex............. 45 Procainamide HCl.................. 28 Qualaquin................................ 20
Potassium Chloride ER........... 45 Procalamine............................. 45 Quasense................................. 35
Pradaxa.................................... 26 Prochlorperazine Edisylate...... 21
Pramipexole Dihydrochloride....21 Prochlorperazine Maleate........ 21
Quinidine Gluconate............... 28
Prandimet................................ 24 Procrit...................................... 27
Prandin.................................... 24 Proctocream HC..................... 34
Quinidine Sulfate.................... 28
Pravastatin Sodium................. 29 Proglycem................................ 25
Prazosin HCl........................... 27 Prograf..................................... 38
Prednicarbate........................... 34 Prolastin-C.............................. 43
Prednisolone Acetate............... 41 Proleukin................................. 19
Quinidine Gluconate ER........ 28
Quinidine Sulfate ER.............. 28
QVAR..................................... 42
R
Rabavert.................................. 39
Ranexa..................................... 29
Prednisolone Sodium
Prolia....................................... 39
Ranitidine HCl....................... 32
Phosphate....................... 34, 41
Promacta.................................. 27
Rapaflo.................................... 33
Prednisone............................... 34
Promethazine HCl.................. 42
Rapamune............................... 38
Prednisone Intensol................. 34
Promethazine VC.................... 42
57
Rebetol.................................... 23
Ropinirole HCl........................ 21 Sodium Sulfacetamide............. 13
Reclast..................................... 39 RotaTeq................................... 39 Solaraze................................... 31
Reclipsen................................. 35
Roxicet....................................... 9
Solu-Cortef.............................. 34
Recombivax HB...................... 39
S
Solu-Medrol............................ 34
Regonol................................... 17
Sabril....................................... 14
Somatuline Depot................... 37
Regranex.................................. 31
Saizen...................................... 34
Somavert.................................. 37
Relenza Diskhaler................... 23 Samsca..................................... 44
Relistor.................................... 32 Sancuso.................................... 16
Soriatane.................................. 31
Sorine...................................... 28
Remicade................................. 38 Sandimmune........................... 38
Remodulin............................... 43 Sandostatin LAR Depot......... 37
Sotalol HCl............................. 28
Renagel.................................... 33 Santyl...................................... 31
Renvela.................................... 33 Saphris..................................... 21
Spironolactone......................... 29
Rescriptor................................ 22 Selegiline HCl......................... 15
Reserpine................................. 27 Selenium Sulfide...................... 31
Spiriva Handihaler.................. 42
Spironolactone/
Sporanox.................................. 17
Sprintec................................... 35
Restasis.................................... 40 Selzentry.................................. 23
Retrovir IV Infusion................ 22 Sensipar................................... 36
Sprycel..................................... 19
Revatio.................................... 43 Serevent Diskus....................... 43
Revlimid.................................. 18 Seromycin................................ 17
SSD......................................... 10
Sronyx..................................... 35
Stagesic...................................... 9
Reyataz.................................... 23 Seroquel XR............................ 21
Ribapak................................... 23 Serostim.................................. 34
Stalevo..................................... 21
Ribasphere............................... 23 Sertraline HCl......................... 15
Ribavirin.................................. 23 Silver Sulfadiazine................... 10
Stelara...................................... 31
Rifampin................................. 17 Simponi................................... 38
Rifater..................................... 17 Simulect................................... 38
Rilutek..................................... 30 Simvastatin.............................. 29
Rimantadine HCl.................... 23 Singulair.................................. 42
Ringers Injection..................... 45 Sodium Chloride..................... 45
Ringers Irrigation.................... 40 Sodium Chloride 0.9%............ 40
Stavudine................................. 22
Sterile Water Irrigation........... 40
Stimate.................................... 34
Strattera................................... 30
Streptomycin Sulfate............... 10
Stromectol............................... 20
Suboxone................................. 15
Sucraid..................................... 31
Riomet..................................... 24 Sodium Chloride 0.45%
Viaflex.................................. 45
Risperdal Consta..................... 21
Risperidone............................. 21 Sodium Fluoride...................... 45
Sulfacetamide Sodium....... 13, 31
Risperidone ODT................... 21 Sodium Lactate....................... 44
Rituxan.................................... 20 Sodium Polystyrene
Sulfonate............................... 44
Rivastigmine Tartrate.............. 14
Sulfadiazine............................. 13
58
Sucralfate................................. 32
Sulfacetamide Sodium/
Prednisolone Sodium
Phosphate............................. 41
Sulfamethoxazole/
Trimethoprim....................... 13
Sulfamethoxazole/
Trimethoprim DS................. 13
Sulfasalazine............................ 39
Sulfazine EC........................... 39
Sulindac..................................... 8
Sumatriptan Succinate............. 17
Suprax...................................... 11
Suprep Bowel Prep.................. 32
Sustiva..................................... 22
Sutent...................................... 20
Sylatron................................... 19
Symbicort................................ 42
Symlinpen 60.......................... 24
Symlinpen 120........................ 24
Synagis.................................... 38
Synarel..................................... 37
Synercid................................... 10
Synthroid................................. 36
Syprine.................................... 44
T
Tekturna.................................. 29
Topotecan HCl........................ 19
Tekturna HCT........................ 29
Torisel...................................... 38
Temazepam............................. 43
Torsemide................................ 29
Terazosin HCl......................... 33
Toviaz...................................... 32
Terbinafine HCl...................... 17
TPN Electrolytes.................... 45
Terbutaline Sulfate.................. 43
Tracleer.................................... 43
Terconazole.............................. 17
Tradjenta................................. 24
Testosterone Cypionate............ 35 Tramadol HCl........................... 9
Testosterone Enanthate........... 35 Tramadol HCl/
Acetaminophen...................... 9
Tetanus/Diphtheria
Toxoids-Adsorbed Adult...... 39 Tranexamic Acid..................... 27
Tetracycline HCl..................... 13 Tranylcypromine Sulfate......... 15
Tev-Tropin............................... 34 Travasol................................... 45
Thalomid................................. 18 Travatan Z............................... 41
Theophylline ER..................... 42 Trazodone HCl....................... 15
Thermazene............................. 10 Treanda................................... 18
Thioridazine HCl.................... 21 Trecator................................... 17
Thiotepa.................................. 18 Trelstar Depot......................... 37
Thiothixene............................. 21 Trelstar LA.............................. 37
Thymoglobulin........................ 38 Trelstar Mixject....................... 37
Ticlopidine HCl...................... 27 Tretinoin............................ 20, 31
Tikosyn................................... 28 Tretin-X................................... 31
Tabloid..................................... 18
Timentin................................. 12 Triamcinolone Acetonide....34, 42
Tacrolimus............................... 38
Timolol Maleate................ 28, 41 Triamcinolone in Orabase....... 30
Tamiflu.................................... 23
Tarceva.................................... 20
Tizanidine HCl....................... 22 Triamterene/
Tobi......................................... 10
Triderm................................... 34
Tobradex.................................. 41
Tobramycin/Dexamethasone....41 Trifluoperazine HCl................ 21
Targretin.................................. 20
Tobramycin Sulfate.................. 10
Trifluridine.............................. 23
Tasigna.................................... 20
Trihexyphenidyl HCl.............. 20
Tasmar..................................... 20
Tobramycin Sulfate/
Sodium Chloride.................. 10
Tri-Legest Fe........................... 35
Taxotere................................... 19
Tobrex...................................... 10
Trileptal................................... 14
Tazorac.................................... 31
Tolbutamide............................ 24
Trilyte...................................... 32
Tegretol................................... 14
Topiramate.............................. 14
Trimethoprim.......................... 10
Tegretol-XR............................. 14
Toposar.................................... 19
Tamoxifen Citrate................... 18
Tamsulosin HCl...................... 33
59
Trimethoprim Sulfate/
Vaqta....................................... 39 Voriconazole............................ 17
Polymyxin B Sulfate............. 11 Varivax..................................... 39
Votrient.................................... 20
Trimipramine Maleate............ 15 Vectibix.................................... 20
Vpriv........................................ 31
Trinessa................................... 36 Vectical.................................... 31
Tri-Previfem............................ 35 Velcade.................................... 19
Trisenox................................... 19 Velivet...................................... 36
Tri-Sprintec............................. 36 Venlafaxine HCl...................... 15
Trivora..................................... 36 Venlafaxine HCl ER............... 15
W
Warfarin Sodium.................... 26
Welchol................................... 29
X
Xalkori.................................... 20
Trizivir..................................... 22 Ventavis................................... 43
Xarelto..................................... 26
Trophamine............................. 45 Verapamil HCl........................ 29
Xenazine.................................. 30
Tropicamide............................. 40 Verapamil HCl ER.................. 29
Xgeva....................................... 39
Truvada................................... 22 Vesicare.................................... 32
Xifaxan.................................... 11
Twinject................................... 43 Vestura..................................... 36
Xolair....................................... 43
Twinrix.................................... 39 Vfend....................................... 17
Xyrem...................................... 43
Tygacil..................................... 11 Vfend IV.................................. 17
Tykerb...................................... 20 Vibativ..................................... 11 Y
Typhim Vi............................... 39 Vibramycin.............................. 13 Yervoy...................................... 20
Tysabri..................................... 38 Victoza.................................... 24 YF-Vax.................................... 39
Tyzeka..................................... 23 Victrelis................................... 23 Z
Tyzine...................................... 43 Vidaza..................................... 19 Zafirlukast............................... 42
U
Videx Pediatric........................ 22 Zaleplon.................................. 43
U-Cort.................................... 34
Uloric....................................... 17
Viibryd.................................... 15 Zanosar.................................... 18
Vimovo.................................... 32 Zavesca.................................... 31
Vimpat..................................... 14 Zazole...................................... 17
Ursodiol................................... 32 Vinblastine Sulfate.................. 19 Zelboraf................................... 20
Uvadex..................................... 31 Vincasar PFS........................... 19 Zemaira................................... 43
Unithroid................................. 36
V
Valacyclovir HCl..................... 23
Valcyte..................................... 22
Valproate Sodium.................... 14
Valproic Acid........................... 14
Vancocin HCl.......................... 11
Vancomycin HCl..................... 11
Vandazole................................ 11
Vincristine Sulfate................... 19 Zemplar................................... 39
Vinorelbine Tartrate................ 19 Zenpep.................................... 31
Viracept................................... 23 Zeosa....................................... 36
Viramune................................. 22 Zerit........................................ 23
Viramune XR.......................... 22 Zetia........................................ 29
Viread...................................... 22 Ziagen..................................... 23
Vistide..................................... 22 Zidovudine.............................. 23
Vivitrol.................................... 15 Zinacef.................................... 11
60
Dextrose............................... 11
Diluent................................. 11
Ziprasidone HCl...................... 21
Zmax....................................... 12
Zolinza.................................... 19
Zolpidem Tartrate................... 43
Zometa.................................... 39
Zonisamide.............................. 13
Zorbtive................................... 34
Zortress................................... 38
Zostavax.................................. 39
Zosyn...................................... 12
Zovia....................................... 36
Zyclara..................................... 31
Zylet........................................ 41
Zyprexa.................................... 21
Zytiga...................................... 19
Zyvox....................................... 11
61
This complete formulary (drug list) is effective January 1, 2013.
It was updated August 2012. Changes may have been made to this list after it was printed.
Call UnitedHealthcare Customer Service for complete,
updated information.
1-888-867-5575, TTY 711
8 a.m. to 8 p.m. local time, 7 days a week
If you are a member of a group sponsored plan (your coverage is provided through a former employer,
union group or trust), please call the UnitedHealthcare Customer Service number on the back of your
member ID card.
This information is available for free in other languages. Please contact our UnitedHealthcare Customer
Service number at 1-888-867-5575, TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week.
Esta información está disponible sin costo en otros idiomas. Comuníquese con el nuestro Servicio al
Cliente de UnitedHealthcare al número 1-888-867-5575, TTY 711, de 8 a.m. a 8 p.m. hora local, los
7 días de la semana.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary,
pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2014.
Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a
Medicare-approved Part D sponsor. AARP® MedicareRx Plans® carry the AARP name, and
UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property.
These fees are used for the general purposes of AARP.
FLXAKEN000_PD3403667

Medicare Plans | AARP

Transcription

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