Formulary - MetroPlus Health Plan

Transcription

MetroPlus Health Plan
2016 List of Covered Drugs
PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN
THIS PLAN.
Members must use network pharmacies to fill their prescription drugs. Your benefits, drug list,
pharmacy network, premium and/or copayments/coinsurance may sometimes change.
I
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers
not affiliated with CVS/caremark. ©2015 CVS/caremark. All rights reserved. CVS/caremark Confidential Information.
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What is the MetroPlus Health Plan Drug List?
A drug list is a list of covered drugs. MetroPlus Health Plan works with a team of health care
providers to choose drugs that provide quality treatment. MetroPlus Health Plan covers drugs on
our drug list, as long as:
• The drug is medically necessary
• The prescription is filled at a MetroPlus Health Plan network pharmacy
• Other plan rules are followed
For more information on how to fill your prescriptions, please review your plan document or other
plan materials.
Can the Drug List change?
The drug list may change from time to time as described in the plan document or other plan
materials. The enclosed drug list is the most current drug list covered by MetroPlus Health
Plan. To get updated information about the drugs covered by MetroPlus Health Plan, please
call Member Services at 1-855-809-4073 (TTY: 711), Monday-Saturday, 8 am – 8 pm.
How do I use the Drug List?
There are two ways to find your drug on the drug list:
1. Medical Condition
The drug list starts on page 1. The drugs on this drug list are grouped by the type of medical
conditions they are used to treat. For example, drugs used to treat a heart condition are listed
under “Cardiovascular Agents”.
• If you know what your drug is used for, look for the category name in the list that starts
on page 1
• Then look under the category name for your drug
2. Alphabetical Listing
If you are not sure what category to look under, look for your drug in the Index that starts on
page 110. The Index is an alphabetical list of all the drugs in this document. Both brand-name
drugs and generic drugs are in the Index.
• Look in the Index and find your drug
• Next to your drug, see the page number where you can find coverage information
• Turn to the page listed in the Index and find the name of your drug in the first column of
the list
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For more information about your MetroPlus Health Plan prescription drug coverage, please look at
your plan document and other plan materials. If you have questions about MetroPlus Health Plan,
or this drug list please call Member Services at 1-855-809-4073 (TTY: 711), Monday-Saturday, 8
am – 8 pm.
MetroPlus Health Plan’s Drug List
The drug list set forth below gives information about the drugs covered by MetroPlus Health Plan.
The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g.,
LIPITOR). Generic drugs are listed in lower-case italics (e.g., atorvastatin).
The information in the Requirements/Limits column tells you if MetroPlus Health Plan has any
special requirements for coverage of your drug. These requirements and limits may include:
• Prior Authorization: MetroPlus Health Plan needs you (or your doctor) to get prior approval
or authorization for certain drugs. This means that you need to get approval from MetroPlus
Health Plan before you fill your prescriptions. If you don’t get approval, MetroPlus Health
Plan may not cover the drug
•
Quantity Limits: For certain drugs, MetroPlus Health Plan limits the amount of the drug that
it will cover. For example, MetroPlus Health Plan provides 90 caps/25 days per prescription
for amphetamine-dextroamphetamine. This may be in addition to a standard one-month or
three-month supply
•
Step Therapy: MetroPlus Health Plan needs you to try certain drugs as the first step to treat
your medical condition before covering another drug for that condition. For example, if Drug
A and Drug B both treat your medical condition, MetroPlus Health Plan may not cover Drug
B unless you try Drug A first. If Drug A does not work for you, MetroPlus Health Plan will
then cover Drug B
Why do my diabetic drugs have a different copayment*?
Some diabetic supplies, insulin, and oral medications are provided as a part of a separate benefit
setup. This means that the amount you pay may differ from the other drugs listed on this formulary.
These drugs have a ‘^’ next to them on the drug list. See your Summary of Benefits to find out
how much you will pay for these drugs.
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What if my drug is not on the Drug List?
If your drug is not on this drug list, call Member Services and make sure that your drug is not
covered. If you learn that MetroPlus Health Plan does not cover your drug, you have two choices:
•
Ask Member Services for a list of similar drugs that are covered by MetroPlus Health Plan.
When you get the list, show it to your doctor and ask him or her to prescribe a similar drug
that is covered by MetroPlus Health Plan. Similar drugs that are preferred and covered by
your plan’s formulary may be easier to obtain and lower cost to you than non-preferred
drugs.
•
Ask MetroPlus Health Plan to make an exception and cover your drug. Exception requests
may include:
o You can ask us to cover your drug, even if it is not on our drug list.
o You can ask us to remove coverage restrictions or limits on your drug. For example,
for certain drugs, MetroPlus Health Plan limits the amount of the drug that we will
cover. If your drug has this quantity limit, you can ask us to remove the limit and
cover more.
Generally, MetroPlus Health Plan will only approve your request for an exception if the preferred
drugs included on the plan’s drug list are not as effective in treating your condition or cause you to
have adverse medical effects.
*Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a
deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan.
not affiliated with CVS/caremark.
Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.
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EXCH_CVSC NY3 3T STND eff 01/01/2016
Drug Name
Drug Tier Requirements/Limits
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
Amphetamines
amphetamine-dextroamphetamine cap sr
24hr 5 mg
24hr 10 mg
24hr 15 mg
24hr 20 mg
24hr 25 mg
24hr 30 mg
amphetamine-dextroamphetamine tab 5
mg
amphetamine-dextroamphetamine tab 7.5
mg
mg
amphetamine-dextroamphetamine tab
12.5 mg
mg
mg
mg
dextroamphetamine sulfate cap sr 24hr 5
mg
mg
mg
dextroamphetamine sulfate oral solution 5
mg/5ml
dextroamphetamine sulfate tab 5 mg
methamphetamine hcl tab 5 mg
VYVANSE CAP 10MG
VYVANSE CAP 20MG
VYVANSE CAP 30MG
VYVANSE CAP 40MG
VYVANSE CAP 50MG
VYVANSE CAP 60MG
VYVANSE CAP 70MG
PA - Prior Authorization QL - Quantity Limits
Counter PA** - PA Applies if Step is Not Met
1
QL (90 caps / 25 days)
1
1
1
1
1
1
QL (90 tabs / 25 days)
1
1
1
1
1
1
1
1
1
1
QL (1,200 mL / 25 days)
1
1
1
2
2
2
2
2
2
2
ST - Step Therapy
OTC - Over the
1
Drug Name
zenzedi tab 2.5mg
zenzedi tab 7.5mg
zenzedi tab 15mg
zenzedi tab 20mg
zenzedi tab 30mg
1
1
1
1
1
Attention-Deficit/Hyperactivity Disorder (ADHD) Agents
guanfacine hcl tab sr 24hr
equiv)
equiv)
equiv)
equiv)
STRATTERA CAP 10MG
STRATTERA CAP 18MG
STRATTERA CAP 25MG
STRATTERA CAP 40MG
STRATTERA CAP 60MG
STRATTERA CAP 80MG
STRATTERA CAP 100MG
1 mg (base
1
ST; PA**
2 mg (base
1
ST; PA**
3 mg (base
1
ST; PA**
4 mg (base
1
ST; PA**
2
2
2
2
2
2
2
Stimulants - Misc.
dexmethylphenidate
dexmethylphenidate
mg
dexmethylphenidate
mg
dexmethylphenidate
mg
dexmethylphenidate
mg
dexmethylphenidate
mg
dexmethylphenidate
dexmethylphenidate
dexmethylphenidate
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
hcl cap sr 24 hr 5 mg 1
hcl cap sr 24 hr 10
1
hcl cap sr 24 hr 15
1
hcl cap sr 24 hr 20
1
hcl cap sr 24 hr 30
1
hcl cap sr 24 hr 40
1
hcl tab 2.5 mg
1
hcl tab 5 mg
1
hcl tab 10 mg
1
cap cr 10 mg
1
cap cr 20 mg
1
cap cr 30 mg
1
cap cr 40 mg
1
cap cr 50 mg
1
cap cr 60 mg
1
cap sr 24hr 20 mg (la)1
soln 5 mg/5ml
1
ST - Step Therapy
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(120 tabs / 25 days)
(60 tabs / 25 days)
(60 caps / 25 days)
(60 caps / 25 days)
(60 caps / 25 days)
(30 caps / 25 days)
(30 caps / 25 days)
(30 caps / 25 days)
(60 caps / 25 days)
(60 caps / 25 days)
(30 caps / 25 days)
(1800 mL / 25 days)
OTC - Over the
2
Drug Name
methylphenidate hcl soln 10 mg/5ml
methylphenidate hcl tab 5 mg
methylphenidate hcl tab cr 10 mg
methylphenidate hcl tab sa osm 18 mg
modafinil tab 100 mg
NUVIGIL TAB 50MG
NUVIGIL TAB 150MG
NUVIGIL TAB 200MG
NUVIGIL TAB 250MG
1
QL (900 mL / 25 days)
1
1
1
1
1
1
1
1
1
1
PA
1
PA
2
PA
2
PA
2
PA
2
PA
AMINOGLYCOSIDES
Aminoglycosides
paromomycin sulfate cap 250 mg
streptomycin sulfate for inj 1 gm
tobramycin nebu soln 300 mg/5ml
1
1
1
PA
ANALGESICS - ANTI-INFLAMMATORY
Anti-TNF-alpha - Monoclonal Antibodies
HUMIRA
HUMIRA
HUMIRA
HUMIRA
INJ 10MG/0.2
KIT 20MG/0.4
KIT 40MG/0.8
PEN INJ CROHNS
3
3
3
3
PA
PA
PA
PA
Interleukin-1 Receptor Antagonist (IL-1Ra)
KINERET INJ
3
PA, ST
3
3
3
3
PA,
PA,
PA,
PA,
Interleukin-6 Receptor Inhibitors
ACTEMRA
ACTEMRA
ACTEMRA
ACTEMRA
INJ
INJ
INJ
INJ
80MG/4ML
162/0.9
200/10ML
400/20ML
ST
ST
ST
ST
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
celecoxib cap 50 mg
celecoxib cap 100 mg
diclofenac potassium tab 50 mg
diclofenac sodium tab delayed release 25
mg
1
1
1
1
1
1
ST - Step Therapy
OTC - Over the
3
Drug Name
mg
mg
diclofenac sodium tab sr 24hr 100 mg
diclofenac w/ misoprostol tab delayed
release 50-0.2 mg
release 75-0.2 mg
etodolac cap 200 mg
etodolac cap 300 mg
etodolac tab 400 mg
etodolac tab 500 mg
fenoprofen calcium cap 400 mg
fenoprofen calcium tab 600 mg
flurbiprofen tab 50 mg
ibuprofen susp 100 mg/5ml
ibuprofen tab 400 mg
INDOCIN SUS 25MG/5ML
indomethacin cap 25 mg
indomethacin cap cr 75 mg
ketoprofen cap 50 mg
ketoprofen cap sr 24hr 200 mg
ketorolac tromethamine im inj 60 mg/2ml
(30 mg/ml)
ketorolac tromethamine inj 15 mg/ml
ketorolac tromethamine inj 60 mg/2ml (30
mg/ml)
ketorolac tromethamine inj 300 mg/10ml
(30 mg/ml)
ketorolac tromethamine tab 10 mg
meclofenamate sodium cap 50 mg
mefenamic acid cap 250 mg
meloxicam susp 7.5 mg/5ml
meloxicam tab 7.5 mg
meloxicam tab 15 mg
nabumetone tab 500 mg
naproxen dr tab 375mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
OTC - Over the
4
Drug Name
naproxen sodium tab 275 mg
naproxen susp 125 mg/5ml
naproxen tab 250 mg
naproxen tab 375 mg
naproxen tab 500 mg
oxaprozin tab 600 mg
piroxicam cap 10 mg
piroxicam cap 20 mg
sulindac tab 150 mg
sulindac tab 200 mg
tolmetin sodium cap 400 mg
tolmetin sodium tab 200 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Pyrimidine Synthesis Inhibitors
leflunomide tab 10 mg
1
1
Selective Costimulation Modulators
ORENCIA INJ 125MG/ML
ORENCIA INJ 250MG
3
3
PA, ST
PA, ST
Soluble Tumor Necrosis Factor Receptor Agents
ENBREL
ENBREL
ENBREL
ENBREL
INJ 25/0.5ML
INJ 25MG
INJ 50MG/ML
SRCLK INJ 50MG/ML
3
3
3
3
PA
PA
PA
PA
1
1
QL (720 mL / 25 days)
1
1
1
1
1
0
QL (100 tabs / 30 days);
OTC; $0 copay for
patients 12 and older
ANALGESICS - NonNarcotic
Analgesics-Sedatives
alagesic lq sol
butalbital-acetaminophen-caffeine cap 50300-40 mg
butalbital-acetaminophen-caffeine tab 50325-40 mg
butalbital-aspirin-caffeine cap 50-325-40
mg
butalbital-aspirin-caffeine tab 50-325-40
mg
margesic cap
Salicylates
aspirin chew tab 81 mg
ST - Step Therapy
OTC - Over the
5
Drug Name
aspirin low tab 81mg ec
0
OTC; $0 copay for
0
OTC; $0 copay for
0
OTC; $0 copay for
0
OTC; $0 copay for
1
aspirin tab 81 mg
aspirin tab 325 mg
aspirin tab delayed release 325 mg
diflunisal tab 500 mg
ANALGESICS - OPIOID
Opioid Agonists
ABSTRAL SUB 100MCG
2
ABSTRAL SUB 200MCG
2
ABSTRAL SUB 300MCG
2
ABSTRAL SUB 400MCG
2
ABSTRAL SUB 600MCG
2
ABSTRAL SUB 800MCG
2
CODEINE SULF SOL 30MG/5ML
codeine sulfate tab 15 mg
EMBEDA CAP 20-0.8MG
EMBEDA CAP 30-1.2MG
EMBEDA CAP 50-2MG
EMBEDA CAP 60-2.4MG
EMBEDA CAP 80-3.2MG
EMBEDA CAP 100-4MG
fentanyl citrate lozenge on a handle
mcg
mcg
mcg
mcg
mcg
mcg
200
2
1
1
1
3
3
3
3
3
3
1
400
1
600
1
800
1
1200
1
1600
1
ST - Step Therapy
QL (120 Units
days), PA
QL (120 Units
days), PA
QL (120 Units
days), PA
QL (120 Units
days), PA
QL (120 Units
days), PA
QL (120 Units
days), PA
per 25
per 25
per 25
per 25
per 25
per 25
QL (120 lozenges / 25
days), PA
days), PA
days), PA
days), PA
days), PA
days), PA
OTC - Over the
6
Drug Name
fentanyl td patch 72hr 12 mcg/hr
1
QL (10 patches / 25
days)
1
QL (10 patches / 25
days)
1
QL (10 patches / 25
days)
1
QL (10 patches / 25
days)
1
QL (10 patches / 25
days)
HYDROMORPHON SUP 3MG
3
QL (120 units / 25 days)
hydromorphone hcl liqd 1 mg/ml
1
QL (600 mL / 25 days)
hydromorphone hcl tab 2 mg
1
1
1
hydromorphone hcl tab er 24hr deter 8 mg 1
QL (30 tablets per 25
days)
hydromorphone hcl tab er 24hr deter 12
1
mg
days)
1
mg
days)
1
mg
days)
levorphanol tartrate tab 2 mg
1
methadone hcl conc 10 mg/ml
1
QL (30mL / 25 days)
methadone hcl soln 5 mg/5ml
1
QL (600 mL / 25 days)
1
QL (300 mL / 25 days)
methadone hcl tab 5 mg
1
1
methadone hcl tab for oral susp 40 mg
1
MORPHINE SUL SUP 30MG
2
QL (180 supp / 25 days)
morphine sulfate beads cap sr 24hr 30 mg 1
morphine sulfate beads cap sr 24hr 120
1
mg
morphine sulfate oral soln 10 mg/5ml
1
QL (900 mL / 25 days)
1
QL (900 mL / 25 days)
morphine sulfate oral soln 100 mg/5ml (20 1
QL (180 mL / 25 days)
mg/ml)
morphine sulfate suppos 5 mg
1
1
1
morphine sulfate tab 15 mg
1
1
ST - Step Therapy
OTC - Over the
7
Drug Name
morphine sulfate tab cr 15 mg
NUCYNTA ER TAB 50MG
NUCYNTA ER TAB 100MG
NUCYNTA TAB 50MG
NUCYNTA TAB 75MG
NUCYNTA TAB 100MG
oxycodone hcl cap 5 mg
oxycodone hcl conc 100 mg/5ml (20
mg/ml)
oxycodone hcl soln 5 mg/5ml
oxycodone hcl tab 5 mg
oxycodone hcl tab er 12hr deter 10 mg
OXYCONTIN TAB 10MG CR
oxymorphone hcl tab 5 mg
oxymorphone hcl tab sr 12hr 5 mg
oxymorphone hcl tab sr 12hr 7.5 mg
tramadol hcl tab 50 mg
tramadol hcl tab sr 24hr 100 mg
1
1
1
1
1
2
2
2
2
2
2
2
2
1
1
QL (180 mL / 25 days)
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(900 mL / 25 days)
(60 tabs / 25 days)
(60 tabs / 25 days)
(60 tabs / 25 days)
(60 tabs / 25 days)
(60 tabs / 25 days)
(30 tabs / 25 days)
OTC - Over the
8
Drug Name
1
1
Opioid Combinations
acetaminophen w/ codeine soln 120-12
1
mg/5ml
acetaminophen w/ codeine tab 300-15 mg 1
CAPITAL/COD SUS 120-12/5
3
endocet tab 5-325mg
1
endocet tab 7.5-325
1
endocet tab 10-325mg
1
hydrocodone-acetaminophen soln 7.5-325 1
mg/15ml
hydrocodone-acetaminophen tab 2.5-325 1
mg
hydrocodone-acetaminophen tab 5-300 mg 1
hydrocodone-acetaminophen tab 5-325 mg 1
mg
mg
hydrocodone-acetaminophen tab 10-300 1
mg
hydrocodone-acetaminophen tab 10-325 1
mg
oxycodone w/ acetaminophen tab 2.5-325 1
mg
oxycodone w/ acetaminophen tab 5-325
1
mg
oxycodone w/ acetaminophen tab 7.5-325 1
mg
oxycodone w/ acetaminophen tab 10-325 1
mg
oxycodone-aspirin tab 4.8355-325 mg
1
oxycodone-ibuprofen tab 5-400 mg
1
PRIMLEV TAB 5-300MG
3
PRIMLEV TAB 7.5-300
3
PRIMLEV TAB 10-300MG
3
ROXICET SOL 5-325/5
3
roxicet tab 5-325mg
1
vicodin es tab 7.5-300
1
vicodin hp tab 10-300mg
1
vicodin tab 5-300mg
1
zamicet sol 10-325mg
1
QL (5000 mL / 25 days)
QL
QL
QL
QL
QL
QL
QL
QL
(400 tabs
(400 tabs
(400 tabs
(5000 mL
(375 tabs
(375 tabs
(375 tabs
(5540 mL
/
/
/
/
/
/
/
/
25
25
25
25
25
25
25
25
days)
days)
days)
days)
days)
days)
days)
days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(28 tabs / 25 days)
(1850 mL / 25 days)
(5540 mL / 25 days)
Opioid Partial Agonists
ST - Step Therapy
OTC - Over the
9
Drug Name
buprenorphine hcl sl tab 2 mg (base equiv) 1
days), PA
buprenorphine hcl sl tab 8 mg (base equiv) 1
days), PA
buprenorphine hcl-naloxone hcl sl tab 21
0.5 mg (base equiv)
days), PA
buprenorphine hcl-naloxone hcl sl tab 8-2 1
mg (base equiv)
days), PA
butorphanol tartrate nasal soln 10 mg/ml 1
QL (2 bottles / 25 days)
nalbuphine hcl inj 10 mg/ml
1
1
SUBOXONE MIS 2-0.5MG
2
QL (120 units per 25
days), PA
SUBOXONE MIS 4-1MG
2
days), PA
SUBOXONE MIS 8-2MG
2
days), PA
SUBOXONE MIS 12-3MG
2
QL (60 films per 25
days), PA
ANDROGENS-ANABOLIC
Anabolic Steroids
ANADROL-50 TAB 50MG
oxandrolone tab 2.5 mg
oxandrolone tab 10 mg
3
1
1
PA
PA
PA
1
3
1
1
1
1
PA
PA
1
PA
1
PA
1
1
1
1
PA
PA
PA
PA
Androgens
android cap 10mg
ANDROXY TAB 10MG
danazol cap 50 mg
danazol cap 100 mg
danazol cap 200 mg
testosterone cypionate im inj in oil 100
mg/ml
mg/ml
testosterone enanthate im inj in oil 200
mg/ml
testosterone td gel 10mg/act (2%)
testosterone td gel 12.5 mg/act (1%)
testosterone td gel 25 mg/2.5gm (1%)
testosterone td gel 50 mg/5gm (1%)
PA
ANORECTAL AGENTS
Intrarectal Steroids
colocort ene 100mg
1
Rectal Steroids
procto-pak cre 1%
proctosol hc cre 2.5%
1
1
ST - Step Therapy
OTC - Over the
10
Drug Name
Vasodilating Agents
RECTIV OIN 0.4%
3
ANTHELMINTICS
Anthelmintics
ALBENZA TAB 200MG
BILTRICIDE TAB 600MG
ivermectin tab 3 mg
2
3
1
ANTI-INFECTIVE AGENTS - MISC.
Anti-infective Agents - Misc.
aztreonam for inj 1 gm
metronidazole cap 375 mg
metronidazole tab 250 mg
NEBUPENT INH 300MG
PENTAM 300 INJ 300MG
PRIMSOL SOL 50MG/5ML
tinidazole tab 250 mg
trimethoprim tab 100 mg
vancomycin hcl cap 125 mg
VIBATIV INJ 250MG
VIBATIV INJ 750MG
XIFAXAN TAB 200MG
XIFAXAN TAB 550MG
1
1
1
1
1
3
3
2
1
1
1
1
1
3
3
2
2
ST; PA**
ST; PA**
PA
Anti-infective Misc. - Combinations
e.s.p. sus 200-600
1
sulfamethoxazole-trimethoprim susp 200- 1
40 mg/5ml
sulfamethoxazole-trimethoprim tab 400-80 1
mg
sulfamethoxazole-trimethoprim tab 800- 1
160 mg
Antiprotozoal Agents
ALINIA SUS 100/5ML
ALINIA TAB 500MG
2
2
Carbapenems
DORIBAX INJ 250MG
DORIBAX INJ 500MG
3
3
Cyclic Lipopeptides
CUBICIN SOL 500MG
3
Ketolides
ST - Step Therapy
OTC - Over the
11
Drug Name
KETEK TAB 300MG
KETEK TAB 400MG
3
3
Leprostatics
dapsone tab 25 mg
dapsone tab 100 mg
1
1
Lincosamides
clindamycin hcl cap 75 mg
1
1
1
Oxazolidinones
linezolid tab 600 mg
ZYVOX SUS 100MG/5M
1
2
ANTIANGINAL AGENTS
Antianginals-Other
RANEXA TAB 500MG
RANEXA TAB 1000MG
2
2
ST; PA**
ST; PA**
Nitrates
isoditrate tab 40mg er
1
ISORDIL TAB 40MG
2
isosorbide dinitrate sl tab 2.5 mg
1
isosorbide dinitrate tab 5 mg
1
1
1
1
isosorbide dinitrate tab cr 40 mg
1
isosorbide mononitrate tab 10 mg
1
1
isosorbide mononitrate tab sr 24hr 30 mg 1
minitran dis 0.1mg/hr
1
1
1
1
NITRO-DUR DIS 0.3MG/HR
2
2
nitroglycerin cap cr 2.5 mg
1
1
nitroglycerin cap cr 9 mg
1
nitroglycerin lingual aerosol 400 mcg/spray 1
nitroglycerin td patch 24hr 0.1 mg/hr
1
1
1
ST - Step Therapy
OTC - Over the
12
Drug Name
NITROSTAT SUB 0.3MG
NITROSTAT SUB 0.4MG
NITROSTAT SUB 0.6MG
1
2
2
2
ANTIANXIETY AGENTS
Antianxiety Agents - Misc.
buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
hydroxyzine hcl syrup 10 mg/5ml
1
1
1
1
1
1
hydroxyzine hcl tab 10 mg
1
1
1
meprobamate tab 200 mg
1
1
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
older
PA; High Risk
older
PA; High Risk
older
Benzodiazepines
ALPRAZOLAM CON 1 MG/ML
2
alprazolam orally disintegrating tab 0.5 mg 1
alprazolam orally disintegrating tab 0.25
1
mg
alprazolam orally disintegrating tab 1 mg 1
alprazolam orally disintegrating tab 2 mg 1
alprazolam tab 0.5 mg
1
1
alprazolam tab 1 mg
1
alprazolam tab 2 mg
1
clorazepate dipotassium tab 3.75 mg
1
1
clorazepate dipotassium tab 15 mg
1
diazepam con 5mg/ml
1
diazepam soln 1 mg/ml
1
diazepam tab 2 mg
1
diazepam tab 5 mg
1
ST - Step Therapy
QL (120 mL / 25 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(90 tabs / 25 days)
(60 tabs / 25 days)
(90 tabs / 25 days)
(90 tabs / 25 days)
(90 tabs / 25 days)
(60 tabs / 25 days)
(240 mL / 25 days)
(1200 mL / 25 days)
OTC - Over the
13
Drug Name
diazepam tab 10 mg
lorazepam conc 2 mg/ml
lorazepam tab 0.5 mg
lorazepam tab 1 mg
lorazepam tab 2 mg
oxazepam cap 10 mg
oxazepam cap 15 mg
oxazepam cap 30 mg
1
1
QL (150 mL / 25 days)
1
1
1
1
1
1
ANTIARRHYTHMICS
Antiarrhythmics Type I-A
disopyramide phosphate cap 100 mg
NORPACE CAP 100MG CR
procainamide hcl inj 100 mg/ml
PROCAINAMIDE INJ 500MG/ML
1
1
2
2
1
3
Antiarrhythmics Type I-B
mexiletine hcl cap 150 mg
1
1
1
Antiarrhythmics Type I-C
flecainide acetate tab 50 mg
propafenone hcl cap sr 12hr 225 mg
propafenone hcl tab 150 mg
1
1
1
1
1
1
1
1
1
Antiarrhythmics Type III
amiodarone hcl tab 200 mg
MULTAQ TAB 400MG
pacerone tab 100mg
pacerone tab 200mg
TIKOSYN CAP 125MCG
TIKOSYN CAP 250MCG
TIKOSYN CAP 500MCG
1
1
3
1
1
3
3
3
PA
PA
PA
PA
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
Anti-Inflammatory Agents
cromolyn sodium soln nebu 20 mg/2ml
1
ST - Step Therapy
QL (2 boxes / 25 days)
OTC - Over the
14
Drug Name
Bronchodilators - Anticholinergics
ipratropium bromide inhal soln 0.02%
SPIRIVA CAP HANDIHLR
SPIRIVA SPR RESPIMAT
1
2
2
Leukotriene Modulators
montelukast sodium chew tab 4 mg (base 1
equiv)
montelukast sodium chew tab 5 mg (base 1
equiv)
montelukast sodium oral granules packet 4 1
mg (base equiv)
montelukast sodium tab 10 mg (base
1
equiv)
zafirlukast tab 10 mg
1
1
ZYFLO CR TAB 600MG
3
Selective Phosphodiesterase 4 (PDE4) Inhibitors
DALIRESP TAB 500MCG
3
PA
ASMANEX 30 AER 110MCG
2
2
2
ASMANEX HFA AER 100 MCG
2
2
budesonide inhalation susp 0.5 mg/2ml
budesonide inhalation susp 0.25 mg/2ml
budesonide inhalation susp 1 mg/2ml
QVAR AER 40MCG
QVAR AER 80MCG
1
1
1
2
2
QL (2
days)
QL (2
days)
QL (1
days)
QL (1
days)
QL (1
days)
QL (2
QL (3
QL (1
Steroid Inhalants
inhalers / 25
inhalers per 25
inhaler per 25
inhaler per 25
inhaler per 25
boxes / 25 days)
boxes / 25 days)
box / 25 days)
Sympathomimetics
ADVAIR DISKU AER 100/50
2
2
2
ADVAIR HFA AER 45/21
2
2
2
albuterol sulfate soln nebu 0.5% (5 mg/ml)1
albuterol sulfate soln nebu 0.5% (5 mg/ml)1
albuterol sulfate soln nebu 0.63 mg/3ml
1
(base equiv)
albuterol sulfate soln nebu 0.083% (2.5
1
mg/3ml)
ST - Step Therapy
OTC - Over the
15
Drug Name
(base equiv)
albuterol sulfate syrup 2 mg/5ml
albuterol sulfate tab 2 mg
albuterol sulfate tab sr 12hr 4 mg
BREO ELLIPTA INH 100-25
1
1
1
1
1
1
3
3
BROVANA NEB 15MCG
COMBIVENT AER RESPIMAT
3
2
epinephrine hcl inj 1 mg/ml
epinephrine hcl soln prefilled syringe 0.1
mg/ml
FORADIL CAP AEROLIZE
ipratropium-albuterol nebu soln 0.5-2.5(3)
mg/3ml
levalbuterol hcl soln nebu 0.31 mg/3ml
(base equiv)
(base equiv)
(base equiv)
levalbuterol hcl soln nebu conc 1.25
mg/0.5ml (base equiv)
metaproterenol sulfate syrup 10 mg/5ml
metaproterenol sulfate tab 10 mg
PERFOROMIST NEB 20MCG
PROAIR HFA AER
1
1
SEREVENT DIS AER 50MCG
terbutaline sulfate tab 2.5 mg
terbutaline sulfate tab 5 mg
3
1
1
QL (1 Package / 25
days), PA
QL (1 Package / 25
days), PA
QL (2 inhalers / 25
days)
2
1
1
1
1
1
1
1
1
2
2
QL (2 inhalers / 25
days)
QL (1 inhaler / 25 days)
Xanthines
theochron tab 100mg cr
theophylline tab sr 12hr 450 mg
1
1
1
1
1
1
ANTICOAGULANTS
Coumarin Anticoagulants
ST - Step Therapy
OTC - Over the
16
Drug Name
jantoven tab 1mg
jantoven tab 2.5mg
jantoven tab 2mg
jantoven tab 3mg
jantoven tab 4mg
jantoven tab 5mg
jantoven tab 6mg
jantoven tab 7.5mg
jantoven tab 10mg
warfarin sodium tab
warfarin sodium tab
warfarin sodium tab
warfarin sodium tab
warfarin sodium tab
warfarin sodium tab
warfarin sodium tab
warfarin sodium tab
warfarin sodium tab
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1 mg
2 mg
2.5 mg
3 mg
4 mg
5 mg
6 mg
7.5 mg
10 mg
Direct Factor Xa Inhibitors
ELIQUIS TAB 2.5MG
ELIQUIS TAB 5MG
XARELTO STAR TAB 15/20MG
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
2
2
2
2
2
2
Heparins And Heparinoid-Like Agents
enoxaparin sodium inj 30 mg/0.3ml
enoxaparin sodium inj 100 mg/ml
enoxaparin sodium inj 300 mg/3ml
fondaparinux sodium subcutaneous inj
mg/0.5ml
mg/0.4ml
mg/0.6ml
mg/0.8ml
FRAGMIN INJ 2500/0.2
1
1
1
1
1
1
1
1
2.5 1
5
1
7.5 1
10 1
3
3
3
ST - Step Therapy
OTC - Over the
17
Drug Name
FRAGMIN INJ 10000/ML
FRAGMIN INJ 12500UNT
heparin sodium (porcine)
unit/0.5ml
3
3
3
3
3
3
inj 1000 unit/ml 1
inj 5000 unit/ml 1
inj 10000 unit/ml 1
inj 20000 unit/ml 1
pf inj 5000
1
Thrombin Inhibitors
ARGATROBAN INJ 125/125
3
argatroban inj 250 mg/2.5ml (concentrate 1
for iv infusion)
3
ANTICONVULSANTS
Anticonvulsants - Benzodiazepines
clonazepam tab 0.5 mg
clonazepam tab 1 mg
clonazepam tab 2 mg
ONFI SUS 2.5MG/ML
ONFI TAB 5MG
ONFI TAB 10MG
ONFI TAB 20MG
1
1
1
3
3
3
3
PA
PA
PA
PA
Anticonvulsants - Misc.
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
carbamazepine chew tab 100 mg
carbamazepine susp 100 mg/5ml
carbamazepine tab 200 mg
carbamazepine tab sr 12hr 200 mg
epitol tab 200mg
gabapentin cap 100 mg
gabapentin tab 600 mg
gabapentin tab 800 mg
LAMICTAL CHW 2MG
lamotrigine orally disintegrating tab 25 mg
lamotrigine orally disintegrating tab 50 mg
3
3
3
1
1
1
1
1
1
1
1
1
1
1
2
1
1
ST - Step Therapy
PA
PA
PA
OTC - Over the
18
Drug Name
lamotrigine orally disintegrating tab 100
1
mg
1
mg
lamotrigine tab 25 mg
1
1
1
1
lamotrigine tab chewable dispersible 5 mg 1
lamotrigine tab chewable dispersible 25 mg1
lamotrigine tab sr 24hr 25 mg
1
1
1
1
1
1
levetiracetam oral soln 100 mg/ml
1
levetiracetam tab 250 mg
1
1
1
1
levetiracetam tab sr 24hr 500 mg
1
1
LYRICA CAP 25MG
3
ST; PA**
LYRICA CAP 50MG
3
ST; PA**
LYRICA CAP 75MG
3
ST; PA**
LYRICA CAP 100MG
3
ST; PA**
LYRICA CAP 150MG
3
ST; PA**
LYRICA CAP 200MG
3
ST; PA**
LYRICA CAP 225MG
3
ST; PA**
LYRICA CAP 300MG
3
ST; PA**
LYRICA SOL 20MG/ML
3
ST; PA**
oxcarbazepine susp 300 mg/5ml (60
1
mg/ml)
oxcarbazepine tab 150 mg
1
1
1
POTIGA TAB 50MG
3
PA
POTIGA TAB 200MG
3
PA
POTIGA TAB 300MG
3
PA
POTIGA TAB 400MG
3
PA
primidone tab 50 mg
1
primidone tab 250 mg
1
TEGRETOL-XR TAB 100MG
2
topiramate sprinkle cap 15 mg
1
ST - Step Therapy
OTC - Over the
19
Drug Name
topiramate tab 25 mg
VIMPAT SOL 10MG/ML
VIMPAT TAB 50MG
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
zonisamide cap 25 mg
1
1
1
1
1
3
PA
3
PA
3
PA
3
PA
3
PA
1
1
1
Carbamates
felbamate susp 600 mg/5ml
felbamate tab 400 mg
1
1
1
GABA Modulators
GABITRIL TAB 12MG
GABITRIL TAB 16MG
SABRIL POW 500MG
SABRIL TAB 500MG
tiagabine hcl tab 2 mg
2
2
3
3
1
1
PA
PA
Hydantoins
PHENYTEK CAP 200MG
PHENYTEK CAP 300MG
phenytoin chew tab 50 mg
phenytoin sodium extended cap 100 mg
phenytoin susp 125 mg/5ml
1
1
1
1
1
Succinimides
ethosuximide cap 250 mg
ethosuximide soln 250 mg/5ml
1
1
Valproic Acid
divalproex sodium cap sprinkle 125 mg
divalproex sodium tab delayed release 125
mg
mg
mg
divalproex sodium tab sr 24 hr 250 mg
divalproex sodium tab sr 24 hr 500 mg
valproate sodium syrup 250 mg/5ml (base
equiv)
1
1
1
1
1
1
1
ST - Step Therapy
OTC - Over the
20
Drug Name
valproic acid cap 250 mg
1
ANTIDEPRESSANTS
Alpha-2 Receptor Antagonists (Tetracyclics)
mirtazapine
mirtazapine
mirtazapine
mirtazapine
mirtazapine
mirtazapine
mirtazapine
orally disintegrating tab 15 mg 1
tab 7.5 mg
1
tab 15 mg
1
tab 30 mg
1
tab 45 mg
1
Antidepressants - Misc.
bupropion hcl tab 75 mg
bupropion hcl tab sr 12hr 100
maprotiline hcl tab 25 mg
mg
mg
mg
mg
mg
1
1
1
1
1
1
1
1
1
1
Modified Cyclics
nefazodone hcl tab 50 mg
trazodone hcl tab 50 mg
VIIBRYD KIT
VIIBRYD TAB 10MG
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG
1
1
1
1
1
1
1
1
1
3
3
3
3
ST;
ST;
ST;
ST;
PA**
PA**
PA**
PA**
Monoamine Oxidase Inhibitors (MAOIs)
EMSAM DIS 6MG/24HR
EMSAM DIS 9MG/24HR
EMSAM DIS 12MG/24H
MARPLAN TAB 10MG
phenelzine sulfate tab 15 mg
tranylcypromine sulfate tab 10 mg
3
3
3
3
1
1
Selective Serotonin Reuptake Inhibitors (SSRIs)
ST - Step Therapy
OTC - Over the
21
Drug Name
citalopram hydrobromide oral soln 10
mg/5ml
citalopram hydrobromide tab 10 mg (base
equiv)
equiv)
equiv)
escitalopram oxalate soln 5 mg/5ml (base
equiv)
escitalopram oxalate tab 5 mg (base
equiv)
equiv)
equiv)
fluoxetine hcl cap 10 mg
fluoxetine hcl solution 20 mg/5ml
fluoxetine hcl tab 10 mg
fluvoxamine maleate cap sr 24hr 100 mg
fluvoxamine maleate cap sr 24hr 150 mg
fluvoxamine maleate tab 25 mg
paroxetine hcl tab 10 mg
paroxetine hcl tab sr 24hr 12.5 mg
paroxetine hcl tab sr 24hr 25 mg
sertraline hcl oral conc 20 mg/ml
sertraline hcl tab 25 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
duloxetine hcl cap 20 mg
venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)
venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)
1
1
1
1
1
ST - Step Therapy
OTC - Over the
22
Drug Name
venlafaxine hcl
equivalent)
venlafaxine hcl
venlafaxine hcl
venlafaxine hcl
venlafaxine hcl
venlafaxine hcl
venlafaxine hcl
equivalent)
venlafaxine hcl
equivalent)
venlafaxine hcl
equivalent)
venlafaxine hcl
equivalent)
cap sr 24hr 150 mg (base
1
tab
tab
tab
tab
tab
tab
1
1
1
1
1
1
25 mg
37.5 mg
50 mg
75 mg
100 mg
sr 24hr 37.5 mg (base
tab sr 24hr 75 mg (base
1
1
1
Tricyclic Agents
amitriptyline hcl tab 10 mg
1
1
1
1
1
1
amoxapine tab 25 mg
1
amoxapine tab 50 mg
1
amoxapine tab 100 mg
1
1
clomipramine hcl cap 25 mg
1
1
ST - Step Therapy
QL applies to members
age 65 and older
age 65 and older
age 65 and older
Members 65 and older
subject to PA
subject to PA
subject to PA
age 65 and older
age 65 and older
age 65 and older
age 65 and older
QL (150 caps / 25
days); QL applies to
members age 65 and
older
QL (150 caps / 25
members age 65 and
older
OTC - Over the
23
Drug Name
desipramine hcl tab 10 mg
doxepin hcl cap 10 mg
doxepin hcl conc 10 mg/ml
imipramine hcl tab 10 mg
imipramine pamoate cap 75 mg
1
QL (90 caps / 25 days);
age 65 and older
1
age 65 and older
1
age 65 and older
1
age 65 and older
1
age 65 and older
1
age 65 and older
1
age 65 and older
1
age 65 and older
1
age 65 and older
1
age 65 and older
1
age 65 and older
1
age 65 and older
1
age 65 and older
1
QL (450 mL / 25 days);
age 65 and older
1
age 65 and older
1
age 65 and older
1
age 65 and older
1
age 65 and older
ST - Step Therapy
OTC - Over the
24
Drug Name
1
age 65 and older
1
subject to PA
1
subject to PA
1
QL (150 caps / 25
members age 65 and
older
1
age 65 and older
1
age 65 and older
1
subject to PA
1
QL (750 mL / 25 days);
age 65 and older
1
age 65 and older
1
age 65 and older
3
age 65 and older
3
age 65 and older
3
age 65 and older
nortriptyline hcl cap 10 mg
nortriptyline hcl soln 10 mg/5ml
protriptyline hcl tab 5 mg
SURMONTIL CAP 25MG
SURMONTIL CAP 50MG
SURMONTIL CAP 100MG
ANTIDIABETICS
Alpha-Glucosidase Inhibitors^
acarbose tab 25 mg
acarbose tab 50 mg
acarbose tab 100 mg
GLYSET TAB 25MG
GLYSET TAB 50MG
GLYSET TAB 100MG
1
1
1
3
3
3
Antidiabetic - Amylin Analogs^
SYMLINPEN 60 INJ 1000MCG
SYMLNPEN 120 INJ 1000MCG
3
3
PA
PA
Antidiabetic Combinations^
glipizide-metformin hcl tab 2.5-250 mg
1
ST - Step Therapy
OTC - Over the
25
Drug Name
glipizide-metformin hcl tab 2.5-500 mg
glipizide-metformin hcl tab 5-500 mg
glyburide-metformin tab 1.25-250 mg
1
1
1
PA; High Risk
older
1
PA; High Risk
older
glyburide-metformin tab 5-500 mg
1
PA; High Risk
older
JANUMET TAB 50-500MG
2
JANUMET TAB 50-1000
2
JANUMET XR TAB 50-500MG
2
JANUMET XR TAB 50-1000
2
2
JENTADUETO TAB 2.5-500
2
2
2
pioglitazone hcl-glimepiride tab 30-2 mg
1
pioglitazone hcl-glimepiride tab 30-4 mg
1
pioglitazone hcl-metformin hcl tab 15-500 1
mg
pioglitazone hcl-metformin hcl tab 15-850 1
mg
Biguanides^
metformin
metformin
metformin
metformin
metformin
metformin
metformin
mg
hcl
hcl
hcl
hcl
hcl
hcl
hcl
tab
tab
tab
tab
tab
tab
tab
500 mg
850 mg
1000 mg
sr 24hr 500 mg
sr 24hr 750 mg
sr 24hr osmotic 500 mg
sr 24hr osmotic 1000
1
1
1
1
1
1
1
Diabetic Other^
GLUCAGON KIT 1MG
INSTA-GLUCOS GEL 77.4%
PROGLYCEM SUS 50MG/ML
2
2
3
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors^
JANUVIA TAB 25MG
JANUVIA TAB 50MG
JANUVIA TAB 100MG
TRADJENTA TAB 5MG
2
2
2
2
Dopamine Receptor Agonists - Antidiabetic^
ST - Step Therapy
OTC - Over the
26
Drug Name
CYCLOSET TAB 0.8MG
3
Incretin Mimetic Agents (GLP-1 Receptor Agonists)^
TRULICITY INJ 0.75/0.5
VICTOZA INJ 18MG/3ML
2
2
2
Insulin Sensitizing Agents^
pioglitazone hcl tab 15 mg (base equiv)
1
1
1
Insulin^
APIDRA INJ SOLOSTAR
APIDRA INJ U-100
HUMALOG INJ 100/ML
HUMALOG KWIK INJ 100/ML
HUMALOG MIX INJ 50/50
HUMALOG MIX INJ 50/50KWP
HUMALOG MIX SUS 75/25
HUMULIN INJ 70/30
HUMULIN INJ 70/30KWP
HUMULIN N INJ U-100
HUMULIN N INJ U-100KWP
HUMULIN R INJ U-100
HUMULIN R INJ U-500
LANTUS INJ 100/ML
LANTUS INJ SOLOSTAR
LEVEMIR INJ
LEVEMIR INJ FLEXTOUC
NOVOLIN INJ 70/30
NOVOLIN N INJ U-100
NOVOLIN R INJ U-100
NOVOLOG INJ 100/ML
NOVOLOG INJ FLEXPEN
NOVOLOG INJ PENFILL
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ FLEXPEN
2
2
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
Meglitinide Analogues^
nateglinide
nateglinide
repaglinide
repaglinide
repaglinide
tab
tab
tab
tab
tab
60 mg
120 mg
0.5 mg
1 mg
2 mg
1
1
1
1
1
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors^
ST - Step Therapy
OTC - Over the
27
Drug Name
FARXIGA TAB 5MG
FARXIGA TAB 10MG
JARDIANCE TAB 10MG
JARDIANCE TAB 25MG
2
2
2
2
Sulfonylureas^
chlorpropamide tab 100 mg
glimepiride tab 1 mg
glipizide tab 5 mg
glipizide tab 10 mg
glipizide tab sr 24hr 2.5 mg
glipizide tab sr 24hr 5 mg
glyburide micronized tab 1.5 mg
1
1
1
1
1
1
1
1
1
1
1
glyburide micronized tab 3 mg
1
1
glyburide tab 1.25 mg
1
1
glyburide tab 5 mg
1
tolbutamide tab 500 mg
1
PA; High Risk
older
PA; High Risk
older
PA; High Risk
older
PA; High Risk
older
PA; High Risk
older
PA; High Risk
older
ANTIDIARRHEALS
Antiperistaltic Agents
anti-diarrhe tab 2mg
diphenoxylate w/ atropine liq 2.5-0.025
mg/5ml
diphenoxylate w/ atropine tab 2.5-0.025
mg
loperamide hcl cap 2 mg
MOTOFEN TAB
1
1
OTC
1
1
3
ST - Step Therapy
OTC - Over the
28
Drug Name
ANTIDOTES
Antidotes - Chelating Agents
CHEMET CAP 100MG
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
FERRIPROX TAB 500MG
3
3
3
3
3
PA
PA
PA
PA
Opioid Antagonists
naltrexone hcl tab 50 mg
1
ANTIEMETICS
5-HT3 Receptor Antagonists
ALOXI INJ 0.25MG/5
3
granisetron hcl tab 1 mg
1
ondansetron hcl oral soln 4 mg/5ml
1
ondansetron hcl tab 4 mg
1
1
1
ondansetron orally disintegrating tab 4 mg 1
ondansetron orally disintegrating tab 8 mg 1
SANCUSO DIS 3.1MG
3
QL
QL
QL
QL
QL
QL
QL
QL
QL
(5 mL / 15 days)
(6 tabs / 15 days)
(2 bottles / 15 days)
(12 tabs / 15 days)
(12 tabs / 15 days)
(1 tab / 15 days)
(12 tabs / 15 days)
(12 tabs / 15 days)
(1 patch / 15 days)
Antiemetics - Anticholinergic
ANTIVERT TAB 50MG
meclizine hcl tab 12.5 mg
meclizine hcl tab 25 mg
TRANSDERM-SC DIS 1MG
trimethobenzamide hcl cap 300 mg
2
1
1
3
1
univert tab 32mg
1
PA; High Risk
older
Antiemetics - Miscellaneous
dronabinol cap 2.5 mg
dronabinol cap 5 mg
dronabinol cap 10 mg
1
1
1
Substance P/Neurokinin 1 (NK1) Receptor Antagonists
EMEND
EMEND
EMEND
EMEND
CAP
CAP
CAP
PAK
40MG
80MG
125MG
80 & 125
3
3
3
3
QL
QL
QL
QL
(3
(2
(1
(3
caps / 180 days)
caps / 15 days)
cap / 15 days)
caps / 15 days)
ANTIFUNGALS
Antifungal - Glucan Synthesis Inhibitors (Echinocandins)
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
3
3
ST - Step Therapy
OTC - Over the
29
Drug Name
ERAXIS INJ 50MG
ERAXIS INJ 100MG
3
3
Antifungals
ABELCET INJ 5MG/ML
AMPHOTEC INJ 50MG
AMPHOTEC INJ 100MG
amphotericin b for inj 50 mg
BIO-STATIN CAP 500000
griseofulvin microsize susp 125 mg/5ml
griseofulvin microsize tab 500 mg
griseofulvin ultramicrosize tab 125 mg
griseofulvin ultramicrosize tab 250 mg
nystatin oral powder
nystatin tab 500000 unit
terbinafine hcl tab 250 mg
3
3
3
1
2
2
1
1
1
1
1
1
1
PA
Imidazole-Related Antifungals
fluconazole for susp 10 mg/ml
fluconazole tab 50 mg
itraconazole cap 100 mg
NOXAFIL SUS 40MG/ML
NOXAFIL TAB 100MG
SPORANOX SOL 10MG/ML
voriconazole for susp 40 mg/ml
voriconazole tab 50 mg
1
1
1
1
1
1
1
2
2
2
1
1
1
PA
PA
PA
PA
PA
ANTIHISTAMINES
Antihistamines - Alkylamines
brompheniramine tannate chew tab 12 mg 1
dexchlorpheniramine maleate syrup 2
1
mg/5ml
Antihistamines - Ethanolamines
arbinoxa sol 4mg/5ml
carbinoxamine maleate tab 4 mg
clemastine fumarate syrup 0.67 mg/5ml
(0.5 mg/5ml base eq)
1
1
1
ST - Step Therapy
PA; High Risk
older
OTC - Over the
30
Drug Name
clemastine fumarate tab 2.68 mg
diphenhydramine
diphenhydramine
diphenhydramine
diphenhydramine
hcl
hcl
hcl
hcl
cap 25 mg
cap 50 mg
elixir 12.5 mg/5ml
inj 50 mg/ml
1
PA; High Risk
older
1
1
1
1
Antihistamines - Non-Sedating
all day allg cap 10mg
all day allg chw 5mg
allergy relf tab 10mg
allergy tab 10mg
cetirizine hcl tab 5 mg
cetirizine sol 1mg/ml
CLARINEX SYP 0.5MG/ML
desloratadine tab 5 mg
desloratadine tab orally disintegrating 2.5
mg
desloratadine tab orally disintegrating 5
mg
fexofenadine hcl tab 60 mg
fexofenadine sus 30mg/5ml
levocetirizine dihydrochloride soln 2.5
mg/5ml (0.5 mg/ml)
levocetirizine dihydrochloride tab 5 mg
loratadine syp 5mg/5ml
1
1
1
1
1
1
1
1
3
1
1
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
ST
ST
ST
1
ST
1
1
1
1
OTC
OTC
OTC
1
1
OTC
Antihistamines - Phenothiazines
promethazine hcl syrup 6.25 mg/5ml
1
promethazine hcl tab 12.5 mg
1
promethazine hcl tab 25 mg
1
1
PA; High Risk
older
PA; High Risk
older
PA; High Risk
older
PA; High Risk
older
Antihistamines - Piperidines
cyproheptadine hcl syrup 2 mg/5ml
1
ST - Step Therapy
OTC - Over the
31
Drug Name
cyproheptadine hcl tab 4 mg
1
ANTIHYPERLIPIDEMICS
Antihyperlipidemics - Combinations
VYTORIN
VYTORIN
VYTORIN
VYTORIN
TAB
TAB
TAB
TAB
10-10MG
10-20MG
10-40MG
10-80MG
2
2
2
2
Antihyperlipidemics - Misc.
omega-3-acid ethyl esters cap 1 gm
1
PA
Bile Acid Sequestrants
cholestyramine light powder 4 gm/dose
cholestyramine light powder packets 4 gm
cholestyramine powder 4 gm/dose
cholestyramine powder packets 4 gm
colestipol hcl granule packets 5 gm
colestipol hcl granules 5 gm
colestipol hcl tab 1 gm
prevalite pow 4gm
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG
1
1
1
1
1
1
1
1
2
2
Fibric Acid Derivatives
fenofibrate cap 50 mg
fenofibrate micronized cap
fenofibrate tab 48 mg
gemfibrozil tab 600 mg
43 mg
67 mg
130 mg
134 mg
200 mg
1
1
1
1
1
1
1
1
1
1
1
1
HMG CoA Reductase Inhibitors
atorvastatin calcium tab
equivalent)
equivalent)
equivalent)
equivalent)
CRESTOR TAB 5MG
CRESTOR TAB 10MG
10 mg (base
1
20 mg (base
1
40 mg (base
1
80 mg (base
1
2
2
ST - Step Therapy
OTC - Over the
32
Drug Name
CRESTOR TAB 20MG
CRESTOR TAB 40MG
fluvastatin sodium cap 20 mg
LIVALO TAB 1MG
LIVALO TAB 2MG
LIVALO TAB 4MG
lovastatin tab 10 mg
pravastatin sodium tab 10 mg
simvastatin tab 5 mg
2
2
1
1
3
PA**
3
PA**
3
PA**
1
1
1
1
1
1
1
1
1
1
1
1
ST
Intestinal Cholesterol Absorption Inhibitors
ZETIA TAB 10MG
2
Nicotinic Acid Derivatives
niacin tab cr 500 mg (antihyperlipidemic) 1
ANTIHYPERTENSIVES
ACE Inhibitors
benazepril hcl tab 5 mg
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
enalapril maleate tab 2.5 mg
enalapril maleate tab 5 mg
fosinopril sodium tab 10 mg
lisinopril tab 2.5 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
OTC - Over the
33
Drug Name
lisinopril tab 5 mg
lisinopril tab 10 mg
moexipril hcl tab 7.5 mg
moexipril hcl tab 15 mg
perindopril erbumine tab 2 mg
quinapril hcl tab 5 mg
ramipril cap 1.25 mg
ramipril cap 2.5 mg
ramipril cap 5 mg
ramipril cap 10 mg
trandolapril tab 1 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Agents for Pheochromocytoma
phenoxybenzamine hcl cap 10 mg
1
Angiotensin II Receptor Antagonists
BENICAR TAB 5MG
BENICAR TAB 20MG
BENICAR TAB 40MG
candesartan cilexetil tab 4 mg
EDARBI TAB 40MG
EDARBI TAB 80MG
eprosartan mesylate tab 600 mg
irbesartan tab 75 mg
losartan potassium tab 25 mg
telmisartan tab 20 mg
valsartan tab 40 mg
3
3
3
1
1
1
1
3
3
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
ST; PA**
ST; PA**
ST; PA**
ST; PA**
ST; PA**
OTC - Over the
34
Drug Name
valsartan tab 80 mg
valsartan tab 160 mg
1
1
1
Antiadrenergic Antihypertensives
clonidine hcl tab 0.1 mg
1
1
1
clonidine hcl td patch weekly 0.1 mg/24hr 1
doxazosin mesylate tab 1 mg
1
1
1
1
guanfacine hcl tab 1 mg
1
1
methyldopa tab 250 mg
1
1
prazosin hcl cap 1 mg
1
1
1
terazosin hcl cap 1 mg
1
1
1
1
Antihypertensive Combinations
amlodipine
10 mg
amlodipine
10 mg
amlodipine
20 mg
amlodipine
40 mg
amlodipine
20 mg
amlodipine
40 mg
amlodipine
mg
amlodipine
mg
amlodipine
mg
amlodipine
mg
besylate-benazepril hcl cap 2.5- 1
besylate-benazepril hcl cap 5-
1
1
1
besylate-benazepril hcl cap 10- 1
besylate-benazepril hcl cap 10- 1
besylate-valsartan tab 5-160
1
besylate-valsartan tab 5-320
1
besylate-valsartan tab 10-160 1
besylate-valsartan tab 10-320 1
ST - Step Therapy
OTC - Over the
35
Drug Name
amlodipine-valsartan-hydrochlorothiazide 1
tab 5-160-12.5 mg
tab 5-160-25 mg
tab 10-160-12.5 mg
tab 10-160-25 mg
tab 10-320-25 mg
atenolol & chlorthalidone tab 50-25 mg
1
atenolol & chlorthalidone tab 100-25 mg
1
benazepril & hydrochlorothiazide tab 51
6.25 mg
benazepril & hydrochlorothiazide tab 10- 1
12.5 mg
benazepril & hydrochlorothiazide tab 20- 1
12.5 mg
benazepril & hydrochlorothiazide tab 20-25 1
mg
bisoprolol & hydrochlorothiazide tab 2.5- 1
6.25 mg
bisoprolol & hydrochlorothiazide tab 5-6.25 1
mg
bisoprolol & hydrochlorothiazide tab 101
6.25 mg
candesartan cilexetil-hydrochlorothiazide 1
tab 16-12.5 mg
tab 32-12.5 mg
tab 32-25 mg
captopril & hydrochlorothiazide tab 25-15 1
mg
mg
mg
mg
enalapril maleate & hydrochlorothiazide tab 1
5-12.5 mg
enalapril maleate & hydrochlorothiazide tab 1
10-25 mg
fosinopril sodium & hydrochlorothiazide tab 1
10-12.5 mg
fosinopril sodium & hydrochlorothiazide tab 1
20-12.5 mg
irbesartan-hydrochlorothiazide tab 1501
12.5 mg
ST - Step Therapy
OTC - Over the
36
Drug Name
irbesartan-hydrochlorothiazide tab 3001
12.5 mg
lisinopril & hydrochlorothiazide tab 10-12.5 1
mg
lisinopril & hydrochlorothiazide tab 20-12.5 1
mg
lisinopril & hydrochlorothiazide tab 20-25 1
mg
losartan potassium & hydrochlorothiazide 1
tab 50-12.5 mg
tab 100-12.5 mg
tab 100-25 mg
metoprolol & hydrochlorothiazide tab 50-251
mg
metoprolol & hydrochlorothiazide tab 100- 1
25 mg
metoprolol & hydrochlorothiazide tab 100- 1
50 mg
moexipril-hydrochlorothiazide tab 7.5-12.5 1
mg
moexipril-hydrochlorothiazide tab 15-12.5 1
mg
moexipril-hydrochlorothiazide tab 15-25
1
mg
nadolol & bendroflumethiazide tab 40-5 mg1
nadolol & bendroflumethiazide tab 80-5 mg1
propranolol & hydrochlorothiazide tab 40- 1
25 mg
propranolol & hydrochlorothiazide tab 80- 1
25 mg
quinapril-hydrochlorothiazide tab 10-12.5 1
mg
quinapril-hydrochlorothiazide tab 20-12.5 1
mg
quinapril-hydrochlorothiazide tab 20-25 mg1
telmisartan-amlodipine tab 40-5 mg
1
1
1
1
telmisartan-hydrochlorothiazide tab 401
12.5 mg
telmisartan-hydrochlorothiazide tab 801
12.5 mg
telmisartan-hydrochlorothiazide tab 80-25 1
mg
trandolapril-verapamil hcl tab cr 1-240 mg 1
trandolapril-verapamil hcl tab cr 2-180 mg 1
ST - Step Therapy
OTC - Over the
37
Drug Name
trandolapril-verapamil hcl tab
trandolapril-verapamil hcl tab
valsartan-hydrochlorothiazide
mg
mg
mg
mg
mg
cr 2-240 mg 1
cr 4-240 mg 1
tab 80-12.5 1
tab 160-12.5 1
tab 160-25
1
tab 320-12.5 1
tab 320-25
1
Direct Renin Inhibitors
TEKTURNA TAB 150MG
TEKTURNA TAB 300MG
3
3
ST; PA**
ST; PA**
Selective Aldosterone Receptor Antagonists (SARAs)
eplerenone tab 25 mg
1
1
Vasodilators
hydralazine hcl tab 10 mg
minoxidil tab 2.5 mg
minoxidil tab 10 mg
1
1
1
1
1
1
ANTIMALARIALS
Antimalarial Combinations
atovaquone-proguanil hcl tab 62.5-25 mg 1
atovaquone-proguanil hcl tab 250-100 mg 1
COARTEM TAB 20-120MG
3
Antimalarials
chloroquine phosphate tab 250 mg
DARAPRIM TAB 25MG
hydroxychloroquine sulfate tab 200 mg
mefloquine hcl tab 250 mg
PRIMAQUINE TAB 26.3MG
quinine sulfate cap 324 mg
quinine sulfate tab 260 mg
1
1
3
1
1
3
1
1
ANTIMYASTHENIC AGENTS
Antimyasthenic Agents
MESTINON SYP 60MG/5ML
pyridostigmine bromide tab 60 mg
pyridostigmine bromide tab cr 180 mg
2
1
1
ST - Step Therapy
OTC - Over the
38
Drug Name
ANTIMYCOBACTERIAL AGENTS
Anti TB Combinations
RIFAMATE CAP
RIFATER TAB
2
2
Antimycobacterial Agents
CAPASTAT SUL INJ 1GM
cycloserine cap 250 mg
ethambutol hcl tab 100 mg
isoniazid syrup 50 mg/5ml
isoniazid tab 100 mg
PRIFTIN TAB 150MG
pyrazinamide tab 500 mg
rifabutin cap 150 mg
rifampin cap 150 mg
rifampin cap 300 mg
TRECATOR TAB 250MG
2
1
1
1
1
1
1
2
1
1
1
1
2
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
Alkylating Agents
ALKERAN TAB 2MG
BICNU INJ 100MG
BUSULFEX INJ 6MG/ML
carboplatin iv for inj 150 mg
carboplatin iv soln 50 mg/5ml
cisplatin inj 50 mg/50ml (1 mg/ml)
CYCLOPHOSPH CAP 25MG
cyclophosphamide for inj 1 gm
cyclophosphamide for inj 500 mg
cyclophosphamide tab 25 mg
ELOXATIN INJ 200MG
GLIADEL WAF 7.7MG
HEXALEN CAP 50MG
ifosfamide for inj 1 gm
ifosfamide iv inj 1 gm/20ml (50 mg/ml)
2
2
2
1
1
1
1
1
1
1
1
2
2
1
1
1
1
1
2
2
2
1
1
ST - Step Therapy
OTC - Over the
39
Drug Name
ifosfamide iv inj 3 gm/60ml (50 mg/ml)
LEUKERAN TAB 2MG
lomustine cap 10 mg
lomustine cap 40 mg
lomustine cap 100 mg
MYLERAN TAB 2MG
oxaliplatin for iv inj 50 mg
oxaliplatin iv soln 50 mg/10ml
TEMODAR INJ 100MG
temozolomide cap 5 mg
ZANOSAR INJ 1GM
1
2
1
1
1
2
1
1
1
1
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
2
Antimetabolites
adrucil inj 2.5g/50m
adrucil inj 500/10ml
ALIMTA INJ 100MG
ALIMTA INJ 500MG
ARRANON INJ 5MG/ML
azacitidine for inj 100 mg
capecitabine tab 150 mg
cladribine inj 1 mg/ml
CLOLAR INJ 1MG/ML
cytarabine for inj 1 gm
cytarabine for inj 100 mg
cytarabine inj 20 mg/ml
cytarabine inj pf 20 mg/ml
decitabine for inj 50 mg
DEPOCYT INJ 50MG/5ML
floxuridine for inj 0.5 gm
fludarabine phosphate for inj 50 mg
fludarabine phosphate inj 25 mg/ml
fluorouracil inj 1 gm/20ml (50 mg/ml)
fluorouracil inj 2.5 gm/50ml (50 mg/ml)
fluorouracil inj 5 gm/100ml (50 mg/ml)
fluorouracil inj 500 mg/10ml (50 mg/ml)
1
1
2
2
2
3
3
3
1
2
1
1
1
1
1
1
3
2
1
1
1
1
1
1
1
ST - Step Therapy
PA
PA
PA
PA
OTC - Over the
40
Drug Name
gemcitabine hcl for inj 1 gm
gemcitabine hcl for inj 200 mg
mercaptopurine tab 50 mg
methotrexate sodium for inj 1 gm
methotrexate sodium inj 25 mg/ml
methotrexate sodium inj pf 25 mg/ml
methotrexate sodium tab 2.5 mg (base
equiv)
TABLOID TAB 40MG
1
1
1
1
1
1
1
1
2
Antineoplastic - Antibodies
ERBITUX INJ 100MG
ERBITUX INJ 200MG
GAZYVA INJ 25MG/ML
KEYTRUDA INJ 100MG/4M
KEYTRUDA SOL 50MG
RITUXAN INJ 100MG
YERVOY INJ 50MG
YERVOY INJ 200MG
3
3
3
3
3
3
3
3
PA
PA
PA
PA
PA
PA
PA
PA
Antineoplastic - Hedgehog Pathway Inhibitors
ERIVEDGE CAP 150MG
3
PA
Antineoplastic - Hormonal and Related Agents
anastrozole tab 1 mg
bicalutamide tab 50 mg
EMCYT CAP 140MG
exemestane tab 25 mg
FARESTON TAB 60MG
FASLODEX INJ 250MG
FIRMAGON INJ 80MG
FIRMAGON INJ 120MG
flutamide cap 125 mg
letrozole tab 2.5 mg
leuprolide acetate inj kit 5 mg/ml
LUPRON DEPOT INJ 3.75MG
LUPRON DEPOT INJ 30MG
LYSODREN TAB 500MG
megestrol acetate susp 40 mg/ml
megestrol acetate tab 20 mg
NILANDRON TAB 150MG
1
1
2
1
2
2
3
3
1
1
3
3
3
3
3
3
3
2
1
1
1
2
ST - Step Therapy
PA
PA
PA
PA
PA
PA
PA
PA
PA
OTC - Over the
41
Drug Name
tamoxifen citrate tab 10 mg (base
equivalent)
1
$0 copay for women >
35 years for the primary
prevention of breast
cancer
1
cancer
3
PA
equivalent)
ZYTIGA TAB 250MG
Antineoplastic Antibiotics
adriamycin inj 10mg
1
ADRIAMYCIN INJ 20MG
2
bleomycin sulfate for inj 15 unit
1
1
dactinomycin for inj 0.5 mg
1
daunorubicin hcl for inj 20 mg
1
daunorubicin hcl inj 5 mg/ml (base equiv) 1
DAUNOXOME INJ 2MG/ML
2
doxorubicin hcl for inj 10 mg
1
1
doxorubicin hcl inj 2 mg/ml
1
epirubicin hcl iv soln 50 mg/25ml (2
1
mg/ml)
1
mg/ml)
EPIRUBICIN INJ 50MG
2
idarubicin hcl iv inj 5 mg/5ml (1 mg/ml)
1
idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 1
lipodox inj 2mg/ml
1
mitomycin for iv soln 5 mg
1
1
1
mitoxantrone hcl inj conc 20 mg/10ml (2 3
mg/ml)
mitoxantrone hcl inj conc 25 mg/12.5ml (2 3
mg/ml)
mitoxantrone hcl inj conc 30 mg/15ml (2 3
mg/ml)
PA
PA
PA
Antineoplastic Combinations
ifosfamide & mesna inj kit 1000-1000 mg
1
Antineoplastic Enzyme Inhibitors
AFINITOR
AFINITOR
AFINITOR
AFINITOR
AFINITOR
DIS TAB 2MG
DIS TAB 3MG
DIS TAB 5MG
TAB 2.5MG
TAB 5MG
3
3
3
3
3
ST - Step Therapy
PA
PA
PA
PA
PA
OTC - Over the
42
Drug Name
AFINITOR TAB 7.5MG
AFINITOR TAB 10MG
BOSULIF TAB 100MG
BOSULIF TAB 500MG
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
COMETRIQ KIT 60MG
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
FARYDAK CAP 10MG
FARYDAK CAP 15MG
FARYDAK CAP 20MG
GLEEVEC TAB 100MG
GLEEVEC TAB 400MG
IBRANCE CAP 75MG
IBRANCE CAP 100MG
IBRANCE CAP 125MG
ICLUSIG TAB 15MG
ICLUSIG TAB 45MG
IMBRUVICA CAP 140MG
INLYTA TAB 1MG
INLYTA TAB 5MG
JAKAFI TAB 5MG
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
KADCYLA INJ 100MG
KADCYLA INJ 160MG
LENVIMA CAP 10MG
LENVIMA CAP 14MG
LENVIMA CAP 20MG
LENVIMA CAP 24MG
LYNPARZA CAP 50MG
MEKINIST TAB 0.5MG
MEKINIST TAB 2MG
NEXAVAR TAB 200MG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 80MG
SPRYCEL TAB 100MG
SPRYCEL TAB 140MG
STIVARGA TAB 40MG
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
ST - Step Therapy
OTC - Over the
43
Drug Name
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 37.5MG
SUTENT CAP 50MG
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
TARCEVA TAB 25MG
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TORISEL SOL 25MG/ML
TYKERB TAB 250MG
VOTRIENT TAB 200MG
XALKORI CAP 200MG
XALKORI CAP 250MG
ZELBORAF TAB 240MG
ZOLINZA CAP 100MG
ZYDELIG TAB 100MG
ZYDELIG TAB 150MG
ZYKADIA CAP 150MG
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
Antineoplastic Enzymes
ONCASPAR INJ 750/ML
3
PA
Antineoplastic Radiopharmaceuticals
QUADRAMET INJ
2
Antineoplastics - Immunomodulators
POMALYST
POMALYST
POMALYST
POMALYST
CAP
CAP
CAP
CAP
1MG
2MG
3MG
4MG
3
3
3
3
PA
PA
PA
PA
3
3
1
1
1
3
3
3
3
2
2
2
2
2
1
PA
PA
Antineoplastics Misc.
ALFERON N INJ 5MU/ML
bexarotene cap 75 mg
dacarbazine for inj 100 mg
hydroxyurea cap 500 mg
INTRON A INJ 10MU
INTRON A INJ 18MU
INTRON A INJ 25MU
INTRON A INJ 50MU
MATULANE CAP 50MG
NIPENT INJ 10MG
PHOTOFRIN INJ 75MG
THERACYS INJ
TICE BCG INJ
tretinoin cap 10 mg
ST - Step Therapy
PA
PA
PA
PA
OTC - Over the
44
Drug Name
TRISENOX SOL 10MG/10M
UVADEX INJ 20MCG/ML
2
2
Chemotherapy Adjuncts
KEPIVANCE INJ 6.25MG
2
Chemotherapy Rescue/Antidote Agents
amifostine crystalline for inj 500 mg
dexrazoxane for inj 250 mg
leucovorin calcium for inj 50 mg
leucovorin calcium tab 5 mg
LEUCOVORIN INJ CALCIUM
mesna inj 100 mg/ml
MESNEX TAB 400MG
1
1
1
1
1
1
1
1
1
1
1
2
1
2
Mitotic Inhibitors
ABRAXANE INJ 100MG
DOCEFREZ INJ 20MG
DOCEFREZ INJ 80MG
docetaxel for inj conc 20 mg/ml
docetaxel for inj conc 80 mg/4ml (20
mg/ml)
DOCETAXEL INJ 20/0.5ML
DOCETAXEL INJ 20MG/2ML
DOCETAXEL INJ 140/7ML
DOCETAXEL INJ 200MG/20
ETOPOPHOS INJ 100MG
etoposide cap 50 mg
etoposide inj 100 mg/5ml (20 mg/ml)
paclitaxel iv conc 30 mg/5ml (6 mg/ml)
paclitaxel iv conc 100 mg/16.7ml (6
mg/ml)
TENIPOSIDE INJ 50MG/5ML
toposar inj 20mg/ml
2
2
2
1
1
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
2
1
ST - Step Therapy
OTC - Over the
45
Drug Name
toposar inj 100/5ml
VINBLASTINE INJ 10MG
vinblastine sulfate inj 1 mg/ml
vincasar pfs inj 1mg/ml
vincristine sulfate iv soln 1 mg/ml
vinorelbine tartrate inj 10 mg/ml (base
equiv)
vinorelbine tartrate inj 50 mg/5ml (10
mg/ml) (base equiv)
1
2
1
1
1
1
1
Topoisomerase I Inhibitors
CAMPTOSAR INJ 300/15ML
2
HYCAMTIN CAP 0.25MG
3
HYCAMTIN CAP 1MG
3
irinotecan hcl inj 40 mg/2ml (20 mg/ml)
1
irinotecan hcl inj 100 mg/5ml (20 mg/ml) 1
irinotecan hcl inj 500 mg/25ml (20 mg/ml) 1
topotecan hcl for inj 4 mg
1
TOPOTECAN INJ 4MG/4ML
2
PA
PA
ANTIPARKINSON AGENTS
Antiparkinson Adjuvants
carbidopa tab 25 mg
1
Antiparkinson Anticholinergics
benztropine mesylate tab 0.5 mg
benztropine mesylate tab 1 mg
trihexyphenidyl hcl elixir 0.4 mg/ml
trihexyphenidyl hcl tab 2 mg
1
1
1
1
1
1
Antiparkinson COMT Inhibitors
entacapone tab 200 mg
tolcapone tab 100 mg
1
1
Antiparkinson Dopaminergics
amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5ml
amantadine hcl tab 100 mg
APOKYN INJ 10MG/ML
bromocriptine mesylate cap 5 mg
bromocriptine mesylate tab 2.5 mg
carbidopa & levodopa orally disintegrating
tab 10-100 mg
tab 25-100 mg
tab 25-250 mg
1
1
1
3
1
1
1
PA
1
1
ST - Step Therapy
OTC - Over the
46
Drug Name
carbidopa & levodopa tab 10-100 mg
1
1
1
carbidopa & levodopa tab cr 25-100 mg
1
carbidopa & levodopa tab cr 50-200 mg
1
carbidopa-levodopa-entacapone tabs 12.5- 1
50-200 mg
carbidopa-levodopa-entacapone tabs
1
18.75-75-200 mg
carbidopa-levodopa-entacapone tabs 25- 1
100-200 mg
1
31.25-125-200 mg
carbidopa-levodopa-entacapone tabs 37.5- 1
150-200 mg
carbidopa-levodopa-entacapone tabs 50- 1
200-200 mg
MIRAPEX ER TAB 2.25MG
2
2
pramipexole dihydrochloride tab 0.5 mg
1
pramipexole dihydrochloride tab 0.25 mg 1
pramipexole dihydrochloride tab 1 mg
1
pramipexole dihydrochloride tab 1.5 mg
1
pramipexole dihydrochloride tab sr 24hr
1
0.75 mg
1
0.375 mg
1
1.5 mg
pramipexole dihydrochloride tab sr 24hr 3 1
mg
1
4.5 mg
ropinirole hydrochloride tab 0.5 mg
1
1
ropinirole hydrochloride tab 1 mg
1
1
1
1
1
Antiparkinson Monoamine Oxidase Inhibitors
AZILECT TAB 0.5MG
AZILECT TAB 1MG
selegiline hcl cap 5 mg
selegiline hcl tab 5 mg
2
2
1
1
ST - Step Therapy
OTC - Over the
47
Drug Name
ANTIPSYCHOTICS/ANTIMANIC AGENTS
Antimanic Agents
lithium carbonate cap 150 mg
lithium carbonate tab 300 mg
lithium carbonate tab cr 300 mg
LITHIUM SOL 8MEQ/5ML
1
1
1
1
1
1
3
Antipsychotics - Misc.
LATUDA TAB 20MG
LATUDA TAB 40MG
LATUDA TAB 60MG
LATUDA TAB 80MG
LATUDA TAB 120MG
ziprasidone hcl cap 20
2
2
2
2
2
1
1
1
1
ST;
ST;
ST;
ST;
ST;
PA**
PA**
PA**
PA**
PA**
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
tab 0.5 mg 1
tab 0.25 1
ST;
ST;
ST;
ST;
ST;
ST;
ST;
ST;
ST;
ST;
ST;
ST;
PA
PA
PA
PA
PA**
PA**
PA**
PA**
PA**
PA**
PA**
PA**
PA**
PA**
PA**
PA**
mg
mg
mg
mg
Benzisoxazoles
FANAPT PAK
FANAPT TAB 1MG
FANAPT TAB 2MG
FANAPT TAB 4MG
FANAPT TAB 6MG
FANAPT TAB 8MG
FANAPT TAB 10MG
FANAPT TAB 12MG
INVEGA TAB 1.5MG
INVEGA TAB 3MG
INVEGA TAB 6MG
INVEGA TAB 9MG
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 50MG
risperidone orally disintegrating
mg
tab
tab
tab
tab
1
2
3
4
mg
mg
mg
mg
1
1
1
1
ST - Step Therapy
OTC - Over the
48
Drug Name
risperidone soln 1 mg/ml
risperidone tab 0.5 mg
risperidone tab 1 mg
1
1
1
1
1
1
1
Butyrophenones
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
decanoate im soln 50 mg/ml
decanoate im soln 100 mg/ml
lactate oral conc 2 mg/ml
tab 0.5 mg
tab 1 mg
tab 2 mg
tab 5 mg
tab 10 mg
tab 20 mg
1
1
1
1
1
1
1
1
1
Dibenzapines
clozapine orally disintegrating tab
clozapine tab 25 mg
clozapine tab 50 mg
clozapine tab 100 mg
loxapine succinate cap 5 mg
olanzapine tab 2.5 mg
olanzapine tab 5 mg
olanzapine tab 10 mg
quetiapine fumarate tab 25 mg
SAPHRIS SUB 2.5MG
12.5 mg
25 mg
100 mg
150 mg
200 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
ST - Step Therapy
ST; PA**
OTC - Over the
49
Drug Name
SAPHRIS SUB 5MG
SAPHRIS SUB 10MG
SEROQUEL XR TAB 50MG
3
ST; PA**
3
ST; PA**
2
ST; PA**
2
ST; PA**
2
ST; PA**
2
ST; PA**
2
ST; PA**
Phenothiazines
chlorpromazine hcl tab 10 mg
compro sup 25mg
fluphenazine hcl elixir 2.5 mg/5ml
fluphenazine hcl oral conc 5 mg/ml
fluphenazine hcl tab 1 mg
fluphenazine hcl tab 2.5 mg
perphenazine tab 2 mg
prochlorperazine maleate tab 5 mg (base
equivalent)
equivalent)
prochlorperazine suppos 25 mg
thioridazine hcl tab 10 mg
trifluoperazine hcl tab 1 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Quinolinone Derivatives
ABILIFY DISC TAB 10MG
aripiprazole oral solution 1 mg/ml
aripiprazole tab 2 mg
2
2
1
1
1
1
ST - Step Therapy
ST; PA**
ST; PA**
OTC - Over the
50
Drug Name
1
1
1
Thioxanthenes
thiothixene
thiothixene
thiothixene
thiothixene
cap
cap
cap
cap
1 mg
2 mg
5 mg
10 mg
1
1
1
1
ANTISEPTICS DISINFECTANTS
Chlorine Antiseptics
PHISOHEX LIQ 3%
3
ANTIVIRALS
Antiretrovirals
abacavir sulfate tab 300 mg (base equiv) 1
abacavir sulfate-lamivudine-zidovudine tab 1
300-150-300 mg
APTIVUS CAP 250MG
2
APTIVUS SOL
2
ATRIPLA TAB
2
COMPLERA TAB
2
CRIXIVAN CAP 200MG
2
CRIXIVAN CAP 400MG
2
didanosine delayed release capsule 125 mg1
EDURANT TAB 25MG
2
EMTRIVA CAP 200MG
2
EMTRIVA SOL 10MG/ML
2
EPZICOM TAB 600-300
2
EVOTAZ TAB 300-150
2
FUZEON INJ 90MG
3
INTELENCE TAB 25MG
2
INTELENCE TAB 100MG
2
INTELENCE TAB 200MG
2
INVIRASE CAP 200MG
2
INVIRASE TAB 500MG
2
ISENTRESS CHW 25MG
2
ISENTRESS CHW 100MG
2
ISENTRESS POW 100MG
2
ISENTRESS TAB 400MG
2
KALETRA SOL
2
KALETRA TAB 100-25MG
2
ST - Step Therapy
PA
OTC - Over the
51
Drug Name
lamivudine oral soln 10 mg/ml
lamivudine tab 150 mg
lamivudine-zidovudine tab 150-300 mg
LEXIVA SUS 50MG/ML
LEXIVA TAB 700MG
nevirapine susp 50 mg/5ml
nevirapine tab 200 mg
nevirapine tab sr 24hr 400 mg
NORVIR CAP 100MG
NORVIR SOL 80MG/ML
NORVIR TAB 100MG
PREZCOBIX TAB 800-150
PREZISTA SUS 100MG/ML
PREZISTA TAB 75MG
PREZISTA TAB 150MG
PREZISTA TAB 400MG
PREZISTA TAB 600MG
PREZISTA TAB 800MG
RESCRIPTOR TAB 100 MG
RESCRIPTOR TAB 200MG
REYATAZ CAP 100MG
REYATAZ CAP 150MG
REYATAZ CAP 200MG
REYATAZ CAP 300MG
REYATAZ POW 50MG
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
stavudine cap 15 mg
stavudine cap 20 mg
stavudine cap 30 mg
stavudine cap 40 mg
stavudine for oral soln 1 mg/ml
STRIBILD TAB
SUSTIVA CAP 50MG
SUSTIVA CAP 200MG
SUSTIVA TAB 600MG
TIVICAY TAB 50MG
TRIUMEQ TAB
TRUVADA TAB 200-300
TYBOST TAB 150MG
VIDEX SOL 2GM
VIDEX SOL 4GM
2
1
1
1
1
2
2
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
ST - Step Therapy
OTC - Over the
52
Drug Name
VIRACEPT TAB 250MG
VIRACEPT TAB 625MG
VIRAMUNE XR TAB 100MG
VIREAD POW 40MG/GM
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
VITEKTA TAB 85MG
VITEKTA TAB 150MG
ZIAGEN SOL 20MG/ML
zidovudine cap 100 mg
zidovudine syrup 10 mg/ml
zidovudine tab 300 mg
2
2
2
2
2
2
2
2
2
2
2
1
1
1
CMV Agents
foscarnet sodium inj 24 mg/ml
VALCYTE SOL 50MG/ML
valganciclovir hcl tab 450 mg (base
equivalent)
1
3
1
Hepatitis Agents
adefovir dipivoxil tab 10 mg
BARACLUDE SOL .05MG/ML
entecavir tab 0.5 mg
entecavir tab 1 mg
EPIVIR HBV SOL 5MG/ML
HARVONI TAB 90-400MG
INFERGEN INJ 9MCG
INFERGEN INJ 15MCG
lamivudine tab 100 mg (hbv)
PEG-INTRON KIT 50MCG RP
PEG-INTRON KIT 80MCG
PEG-INTRON KIT 120 RP
PEGASYS INJ
PEGASYS INJ 180MCG/M
PEGASYS INJ PROCLICK
PEGASYS KIT
REBETOL SOL 40MG/ML
ribasphere cap 200mg
ribasphere tab 200mg
ribavirin cap 200 mg
ribavirin tab 200 mg
1
2
1
1
2
3
3
3
1
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
ST - Step Therapy
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
OTC - Over the
53
Drug Name
SOVALDI TAB 400MG
TYZEKA TAB 600MG
3
PA
3
PA
Herpes Agents
acyclovir cap 200 mg
acyclovir susp 200 mg/5ml
acyclovir tab 400 mg
famciclovir tab 125 mg
valacyclovir hcl tab 1 gm
valacyclovir hcl tab 500 mg
1
1
1
1
1
1
1
1
1
Influenza Agents
RELENZA MIS DISKHALE
2
rimantadine hydrochloride tab 100 mg
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
1
2
2
2
2
QL (2 inhalers / 90
days)
QL
QL
QL
QL
(28 caps / 90 days)
(14 caps / 90 days)
(14 caps / 90 days)
(180 mL / 90 days)
ASSORTED CLASSES
Chelating Agents
DEPEN TITRA TAB 250MG
SYPRINE CAP 250MG
3
3
Immunomodulators
REVLIMID CAP 2.5MG
REVLIMID CAP 5MG
REVLIMID CAP 10MG
REVLIMID CAP 15MG
REVLIMID CAP 20MG
REVLIMID CAP 25MG
THALOMID CAP 50MG
THALOMID CAP 100MG
THALOMID CAP 150MG
THALOMID CAP 200MG
3
3
3
3
3
3
3
3
3
3
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Immunosuppressive Agents
azathioprine tab 50 mg
1
cyclosporine modified cap 25 mg
1
1
1
cyclosporine modified oral soln 100 mg/ml 1
gengraf cap 25mg
1
gengraf cap 100mg
1
ST - Step Therapy
OTC - Over the
54
Drug Name
gengraf sol 100mg/ml
mycophenolate mofetil cap 250 mg
mycophenolate mofetil for oral susp 200
mg/ml
mycophenolate mofetil tab 500 mg
mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)
NULOJIX INJ 250MG
RAPAMUNE SOL 1MG/ML
SIMULECT INJ 10MG
SIMULECT INJ 20MG
sirolimus tab 0.5 mg
sirolimus tab 1 mg
sirolimus tab 2 mg
tacrolimus cap 0.5 mg
tacrolimus cap 1 mg
tacrolimus cap 5 mg
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
1
1
1
1
1
1
3
2
3
3
1
1
1
1
1
1
2
2
2
Potassium Removing Resins
kionex sus 15gm/60
1
sodium polystyrene sulfonate oral susp 15 1
gm/60ml
sodium polystyrene sulfonate rectal susp 1
30 gm/120ml
BETA BLOCKERS
Alpha-Beta Blockers
carvedilol tab 3.125 mg
carvedilol tab 25 mg
labetalol hcl tab 100 mg
1
1
1
1
1
1
1
Beta Blockers Cardio-Selective
acebutolol hcl cap 200 mg
atenolol tab 25 mg
atenolol tab 50 mg
atenolol tab 100 mg
betaxolol hcl tab 10 mg
1
1
1
1
1
1
1
ST - Step Therapy
OTC - Over the
55
Drug Name
bisoprolol fumarate tab 5 mg
BYSTOLIC TAB 2.5MG
BYSTOLIC TAB 5MG
BYSTOLIC TAB 10MG
BYSTOLIC TAB 20MG
metoprolol succinate tab sr 24hr
metoprolol tartrate tab 25 mg
25 mg
50 mg
100 mg
200 mg
1
1
3
3
3
3
1
1
1
1
1
1
1
Beta Blockers Non-Selective
LEVATOL TAB 20MG
nadolol tab 20 mg
nadolol tab 40 mg
nadolol tab 80 mg
pindolol tab 5 mg
pindolol tab 10 mg
propranolol hcl cap sr 24hr 60 mg
propranolol hcl oral soln 20 mg/5ml
propranolol hcl tab 10 mg
sorine tab 80mg
sorine tab 120mg
sorine tab 160mg
sorine tab 240mg
sotalol hcl (afib/afl) tab 80 mg
sotalol hcl tab 80 mg
timolol maleate tab 5 mg
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
OTC - Over the
56
Drug Name
1
CALCIUM CHANNEL BLOCKERS
Calcium Channel Blockers
afeditab tab 30mg cr
1
1
amlodipine besylate tab 2.5 mg
1
amlodipine besylate tab 5 mg
1
1
CARDIZEM LA TAB 120MG
2
cartia xt cap 120/24hr
1
1
1
1
diltiazem hcl cap sr 12hr 60 mg
1
1
1
1
1
1
diltiazem hcl coated beads cap sr 24hr 120 1
mg
mg
mg
mg
mg
diltiazem hcl extended release beads cap sr1
24hr 120 mg
24hr 180 mg
24hr 240 mg
24hr 300 mg
24hr 360 mg
24hr 420 mg
felodipine tab sr 24hr 2.5 mg
1
felodipine tab sr 24hr 5 mg
1
1
isradipine cap 2.5 mg
1
isradipine cap 5 mg
1
ST - Step Therapy
OTC - Over the
57
Drug Name
matzim la tab 180mg/24
nicardipine hcl cap 20 mg
nifedical xl tab 30mg
nifedipine tab sr 24hr 30 mg
nifedipine tab sr 24hr osmotic release 90
mg
nimodipine cap 30 mg
nisoldipine tab sr 24hr 8.5 mg
nisoldipine tab sr 24hr 17 mg
taztia xt cap 120mg/24
verapamil hcl cap sr 24hr 100 mg
verapamil hcl tab cr 120 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
CARDIOTONICS
Cardiac Glycosides
digoxin oral soln 0.05 mg/ml
digoxin tab 125 mcg (0.125 mg)
LANOXIN TAB 0.0625MG
1
1
1
2
ST - Step Therapy
OTC - Over the
58
Drug Name
2
CARDIOVASCULAR AGENTS - MISC.
Cardiovascular Agents Misc. - Combinations
amlodipine besylate-atorvastatin
tab 2.5-10 mg
tab 2.5-20 mg
tab 2.5-40 mg
tab 5-10 mg
tab 5-20 mg
tab 5-40 mg
tab 5-80 mg
tab 10-10 mg
tab 10-20 mg
tab 10-40 mg
tab 10-80 mg
calcium
1
calcium
1
calcium
1
calcium
1
calcium
1
calcium
1
calcium
1
calcium
1
calcium
1
calcium
1
calcium
1
Prostaglandin Vasodilators
epoprostenol sodium for inj 0.5 mg
REMODULIN INJ 1MG/ML
REMODULIN INJ 2.5MG/ML
TYVASO START SOL 0.6MG/ML
3
3
3
3
3
3
3
PA
PA
PA
PA
PA
PA
PA
Pulmonary Hypertension - Endothelin Receptor Antagonists
LETAIRIS TAB 5MG
LETAIRIS TAB 10MG
TRACLEER TAB 62.5MG
TRACLEER TAB 125MG
3
3
3
3
PA
PA
PA
PA
Pulmonary Hypertension - Phosphodiesterase Inhibitors
ADCIRCA TAB 20MG
sildenafil citrate iv soln 10 mg/12.5ml
(base equivalent)
sildenafil citrate tab 20 mg
3
3
PA, ST
PA
3
PA
CEPHALOSPORINS
Cephalosporins - 1st Generation
cefadroxil cap 500 mg
1
ST - Step Therapy
OTC - Over the
59
Drug Name
cefadroxil for susp 250 mg/5ml
cefadroxil tab 1 gm
cephalexin cap 250 mg
cephalexin for susp 125 mg/5ml
cephalexin tab 250 mg
1
1
1
1
1
1
1
1
1
1
Cephalosporins - 2nd Generation
cefaclor cap 250 mg
cefaclor cap 500 mg
CEFACLOR ER TAB 500MG
cefaclor for susp 125 mg/5ml
cefprozil for susp 125 mg/5ml
cefprozil tab 250 mg
CEFTIN SUS 125/5ML
CEFTIN SUS 250/5ML
cefuroxime axetil tab 250 mg
1
1
2
1
1
1
1
1
1
1
2
2
1
1
Cephalosporins - 3rd Generation
cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefixime for susp 100 mg/5ml
cefpodoxime proxetil for susp 50 mg/5ml
cefpodoxime proxetil for susp 100 mg/5ml
cefpodoxime proxetil tab 100 mg
ceftazidime for inj 2 gm
CEFTAZIDIME INJ 100GM
ceftriaxone sodium for inj 1 gm
ceftriaxone sodium for inj 250 mg
ceftriaxone sodium for iv soln 1 gm
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
ST - Step Therapy
OTC - Over the
60
Drug Name
FORTAZ INJ 500MG
SUPRAX CAP 400MG
SUPRAX CHW 100MG
SUPRAX CHW 200MG
SUPRAX SUS 500/5ML
SUPRAX TAB 400MG
tazicef inj 1gm
tazicef inj 2gm
tazicef inj 6gm
3
2
2
2
2
2
1
1
1
Cephalosporins - 4th Generation
cefepime hcl for inj 1 gm
CEFEPIME INJ 1GM
CEFEPIME INJ 2GM
MAXIPIME INJ 1GM
MAXIPIME INJ 2GM
1
1
3
3
3
3
CONTRACEPTIVES
Combination Contraceptives - Oral
altavera tab
alyacen tab 1/35
alyacen tab 7/7/7
amethia tab
amethyst tab 90-20mcg
apri tab
aranelle tab
aviane tab
azurette tab 28 day
BEYAZ TAB
caziant pak
cesia pak
chateal tab 0.15/30
cryselle-28 tab 28 tabs
cyclafem tab 1/35
cyclafem tab 7/7/7
dasetta tab 1/35
dasetta tab 7/7/7
drospirenone-ethinyl estradiol tab 3-0.03
mg
elinest tab
emoquette tab
enpresse-28 tab
falmina tab
gianvi tab 3-0.02mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
ST - Step Therapy
OTC - Over the
61
Drug Name
gildess fe tab 1.5/30
0
gildess fe tab 1/20
0
gildess tab 1.5/30
0
gildess tab 1/20
0
introvale tab
0
jolessa tab
0
junel 1.5/30 tab
0
junel 1/20 tab
0
junel fe tab 1.5/30
0
junel fe tab 1/20
0
kariva tab 28 day
0
kelnor tab 1/35
0
kurvelo tab 0.15/30
0
leena tab
0
lessina tab
0
levonest tab
0
levonorg-eth est tab 0.1-0.02mg(84) & eth 0
est tab 0.01mg(7)
levonorgestrel & ethinyl estradiol (91-day) 0
tab 0.15-0.03 mg
levonorgestrel & ethinyl estradiol tab 0.15 0
mg-30 mcg
levora-28 tab 0.15/30
0
LO LOESTRIN TAB
0
LO MINASTRIN PAK FE
0
lomedia 24 tab fe
0
loryna tab 3-0.02mg
0
low-ogestrel tab
0
lutera tab
0
marlissa tab 0.15/30
0
MINASTRIN 24 CHW FE
0
mono-linyah tab 0.25-35
0
mononessa tab
0
myzilra tab
0
NATAZIA TAB
0
necon tab 0.5/35
0
necon tab 1/35
0
necon tab 1/50-28
0
necon tab 7/7/7
0
NECON TAB 10/11-28
0
norethindrone & ethinyl estradiol-fe chew 0
tab 0.8 mg-25 mcg
norgestimate & ethinyl estradiol tab 0.25 0
mg-35 mcg
ST - Step Therapy
OTC - Over the
62
Drug Name
norgestimate-eth estrad tab 0.1835/0.215-35/0.25-35 mg-mcg
nortrel tab 0.5/35
nortrel tab 1/35
nortrel tab 7/7/7
ocella tab 3-0.03mg
ogestrel tab
orsythia tab
ORTHO TRI- TAB CYCLN LO
portia-28 tab
previfem tab
QUARTETTE TAB
quasense tab
reclipsen tab
SAFYRAL TAB
solia tab
sprintec 28 tab 28 day
sronyx tab
syeda tab 3-0.03mg
tilia fe tab
tri-linyah tab
tri-previfem tab
tri-sprintec tab
trinessa tab
trivora-28 tab
velivet pak
vestura tab 3-0.02mg
viorele tab
wera tab 0.5/35
zarah tab 3-0.03mg
zenchent fe chw 0.4mg-35
zenchent tab
zovia 1/35e tab
zovia 1/50e tab
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Combination Contraceptives - Transdermal
xulane dis 150-35
0
Combination Contraceptives - Vaginal
NUVARING MIS
0
QL (13 / 300 days)
0
QL (1 unit / 300 days)
Copper Contraceptives - IUD
PARAGARD IUD T380A
Emergency Contraceptives
ELLA TAB 30MG
levonorgestrel tab 0.75 mg
0
0
0
ST - Step Therapy
OTC - Over the
63
Drug Name
Progestin Contraceptives - IUD
LILETTA IUD 52MG
MIRENA IUD SYSTEM
SKYLA IUD 13.5MG
0
0
0
QL (1 / 300 days)
QL (1 / 300 days)
QL (1 / 300 days)
0
0
QL (1 / 300 days)
QL (1 / 300 days)
Progestin Contraceptives - Implants
IMPLANON IMP 68MG
NEXPLANON IMP 68MG
Progestin Contraceptives - Injectable
DEPO-SQ PROV INJ 104
0
medroxyprogesterone acetate im susp 150 0
mg/ml
QL (1 inj / 75 days)
QL (1 inj / 75 days)
Progestin Contraceptives - Oral
camila tab 0.35mg
errin tab 0.35mg
heather tab 0.35mg
jolivette tab 0.35mg
nora-be tab 0.35mg
norethindrone tab 0.35 mg
0
0
0
0
0
0
CORTICOSTEROIDS
Glucocorticosteroids
budesonide cap sr 24hr 3 mg
cortisone acetate tab 25 mg
DEXAMETHASON CON 1MG/ML
dexamethasone elixir 0.5 mg/5ml
dexamethasone soln 0.5 mg/5ml
dexamethasone tab 0.5 mg
dexamethasone tab 1 mg
hydrocortisone tab 5 mg
MEDROL TAB 2MG
methylprednisolone tab 4 mg
methylprednisolone tab 4 mg dose pack
prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
ST - Step Therapy
OTC - Over the
64
Drug Name
prednisolone sod phosphate oral soln 15
mg/5ml (base equiv)
prednisolone sodium phosphate oral soln
25 mg/5ml (base eq)
prednisolone syrup 15 mg/5ml (usp
solution equivalent)
PREDNISONE CON 5MG/ML
prednisone oral soln 5 mg/5ml
prednisone tab 1 mg
prednisone tab 2.5 mg
prednisone tab 5 mg
prednisone tab 5 mg dose pack
prednisone tab 10 mg
1
1
1
2
1
1
1
1
1
1
1
1
1
Mineralocorticoids
fludrocortisone acetate tab 0.1 mg
1
COUGH/COLD/ALLERGY
Antitussives
benzonatate cap 100 mg
1
1
hydrocodone w/ homatropine syrup 5-1.5 1
mg/5ml
hydrocodone w/ homatropine tab 5-1.5 mg 1
tussigon tab 5-1.5mg
1
Cough/Cold/Allergy Combinations
ALLFEN CDX LIQ
2
NORTUSS-EX LIQ 200-20/5
2
prometh vc syp plain
1
prometh vc/ syp codeine
1
promethazine w/ codeine syrup 6.25-10
1
mg/5ml
promethazine-dm syrup 6.25-15 mg/5ml 1
pseudoephed-bromphen-dm syrup 30-2-10 1
mg/5ml
tgq 50pse/3 syp brm/30dm
1
Misc. Respiratory Inhalants
sodium
sodium
sodium
sodium
chloride
chloride
chloride
chloride
soln
soln
soln
soln
nebu
nebu
nebu
nebu
0.9%
3%
7%
10%
1
1
1
1
Mucolytics
acetylcysteine inhal soln 10%
1
1
ST - Step Therapy
OTC - Over the
65
Drug Name
DERMATOLOGICALS
Acne Products
ACANYA GEL 1.2-2.5%
acne cleansi bar 10%
acne medicat gel 5%
ACNE MEDICAT LOT 5%
ACNE MEDICAT LOT 10%
adapalene cream 0.1%
3
1
1
1
1
1
adapalene gel 0.1%
1
adapalene gel 0.3%
1
adapalene lotion 0.1%
1
amnesteem cap 10mg
amnesteem cap 20mg
amnesteem cap 40mg
avar cleanse emu 10-5%
avar-e green cre 10-5%
avita cre 0.025%
1
1
1
1
1
1
avita gel 0.025%
1
AZELEX CRE 20%
BENZAMYCIN GEL PAK
benzepro aer 5.3%
BENZIQ GEL 5.25%
BENZIQ LS GEL 2.75%
BENZOYL PER GEL 2.5%
benzoyl per gel 10%
benzoyl per liq 5% wash
benzoyl per lot 6%
benzoyl peroxide foam 5.3%
benzoyl peroxide gel 5%
benzoyl peroxide-erythromycin gel 5-3%
BP CLEANSING LOT 4%
bp gel gel 10%
3
2
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
ST; PA**
OTC
OTC
OTC
OTC
PA; PA applies for
members age 25 and
older
PA; PA applies for
members age 25 and
older
PA; PA applies for
members age 25 and
older
PA; PA applies for
members age 25 and
older
PA
PA
PA
PA; PA applies for
members age 35 and
older
PA; PA applies for
members age 35 and
older
ST; PA**
ST
ST
ST
ST
OTC
OTC
OTC
OTC
ST
OTC
ST
ST
OTC
OTC
OTC
OTC - Over the
66
Drug Name
bp wash liq 2.5%
bp wash liq 5%
bp wash liq 5.25%
bp wash liq 7%
bp wash liq 10%
BPO CLOTHS MIS 3%
bpo cloths mis 6%
BPO CLOTHS MIS 9%
BPO GEL 4%
BPO GEL 8%
bpo-5 wash liq 5%
bpo-10 wash liq 10%
cerisa wash emu 10-1%
claravis cap 10mg
claravis cap 20mg
claravis cap 30mg
claravis cap 40mg
clean&clear cre 10%
CLEAR PORE LIQ 3.5%
clearplex x gel 10%
CLINDACIN KIT PAC 1%
clindacin mis etz 1%
clindamycin phosph-benzoyl peroxide
(refrig) gel 1.2 (1)-5%
clindamycin phosphate foam 1%
clindamycin phosphate gel 1%
clindamycin phosphate lotion 1%
clindamycin phosphate soln 1%
clindamycin phosphate-benzoyl peroxide
gel 1-5%
creamy face liq wash 4%
EPIDUO FORTE GEL 0.3-2.5%
EPIDUO GEL 0.1-2.5%
ery pad 2%
erythromycin gel 2%
erythromycin soln 2%
myorisan cap 10mg
myorisan cap 20mg
myorisan cap 40mg
oscion clnsr lot 6%
persa-gel xs gel 5%
pr benzoyl liq 7% wash
sss 10-5 aer 10-5%
sulfacetamide sodium lotion 10% (acne)
1
ST
1
OTC
1
OTC
1
ST
1
OTC
2
ST
1
ST
2
ST
2
ST
2
ST
1
OTC
1
OTC
1
1
PA
1
PA
1
PA
1
PA
1
OTC
1
OTC
1
ST
3
1
1
1
1
1
1
1
1
3
3
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
OTC
ST
ST
PA
PA
PA
ST
OTC
ST
OTC - Over the
67
Drug Name
sulfacetamide sodium w/
9.8-4.8%
10-2%
cloth 10-5%
pad 10-4%
4.8%
2%
5%
4.8%
5%
4.5%
sulfacleanse sus 8-4%
targetd acne cre 2.5%
tretinoin cream 0.1%
sulfur cleanser
1
sulfur cleanser
1
sulfur cleansing
1
sulfur cleansing
1
sulfur cream 9.8- 1
sulfur cream 10- 1
sulfur cream 10- 1
sulfur lotion 9.8- 1
sulfur lotion 10-
1
sulfur wash 9-4% 1
sulfur wash 91
1
1
1
1
1
tretinoin gel 0.01%
1
tretinoin gel 0.025%
1
VELTIN GEL
3
ZIANA GEL
3
OTC
PA; PA applies for
members age 35 and
older
PA; PA applies for
members age 35 and
older
PA; PA applies for
members age 35 and
older
PA; PA applies for
members age 35 and
older
PA; PA applies for
members age 35 and
older
PA; PA applies for
members age 35 and
older
PA; PA applies for
members age 35 and
older
Agents for External Genital and Perianal Warts
VEREGEN OIN 15%
3
Agents for Facial Wrinkles
AVAGE CRE 0.1%
3
Anti-inflammatory Agents - Topical
VOLTAREN GEL 1%
3
ST - Step Therapy
ST; PA**
OTC - Over the
68
Drug Name
Antibiotics - Topical
ALTABAX OIN 1%
bacitracin oin 500/gm
CENTANY AT KIT 2%
CORTISPORIN CRE 0.5%
CORTISPORIN OIN 1%
gentamicin sulfate cream 0.1%
gentamicin sulfate oint 0.1%
mupirocin oint 2%
triple antib oin
3
1
3
3
3
1
1
1
1
ST
OTC
ST
ST
ST
1
1
1
1
1
1
1
OTC
OTC
OTC
OTC
ST
ST
ST
1
ST
1
1
1
1
3
1
1
1
ST
ST
OTC
ST
OTC
Antifungals - Topical
anti-fungal pow 1%
antifungal cre 1%
antifungal cre 2%
ath foot spr aer 1%
ciclopirox gel 0.77%
ciclopirox kit 8%
ciclopirox olamine cream 0.77% (base
equiv)
ciclopirox olamine susp 0.77% (base
equiv)
ciclopirox shampoo 1%
ciclopirox solution 8%
clotrimazole cre 1%
clotrimazole cream 1%
CLOTRIMAZOLE CRY
clotrimazole soln 1%
clotrimazole w/ betamethasone cream 10.05%
clotrimazole w/ betamethasone lotion 10.05%
cruex aer 2%
desenex spry aer liquid
econazole nitrate cream 1%
ketoconazole cream 2%
ketoconazole shampoo 2%
ketodan aer 2%
LAMISIL ADV GEL 1%
LAMISIL AT SPR 1%
LOTRIMIN ULT CRE 1%
mitrazol pow 2%
naftifine hcl cream 1%
NAFTIN CRE 2%
NAFTIN GEL 1%
OTC
1
1
1
1
1
1
1
1
1
1
1
1
3
3
ST - Step Therapy
OTC
OTC
ST
ST
ST
ST
OTC
OTC
OTC
OTC
ST
ST
ST
OTC - Over the
69
Drug Name
NAFTIN GEL 2%
nyamyc pow 100000
nystatin cream 100000 unit/gm
nystatin oint 100000 unit/gm
nystatin-triamcinolone cream 100000-0.1
unit/gm-%
nystatin-triamcinolone oint 100000-0.1
unit/gm-%
nystop pow 100000
OXISTAT CRE 1%
OXISTAT LOT 1%
terbinafine cre 1%
tolnaftate aerosol pow 1%
tolnaftate soln 1%
triple paste oin af 2%
3
ST
1
ST
1
ST
1
ST
1
1
1
3
3
1
1
1
1
ST
ST
ST
OTC
OTC
OTC
OTC
Antineoplastic or Premalignant Lesion Agents - Topical
FLUOROPLEX CRE 1%
fluorouracil cream 0.5%
fluorouracil cream 5%
fluorouracil soln 2%
PANRETIN GEL 0.1%
PICATO GEL 0.05%
PICATO GEL 0.015%
3
1
1
1
1
3
3
3
Antipruritics - Topical
prudoxin cre 5%
1
Antipsoriatics
acitretin cap 10 mg
acitretin cap 17.5 mg
acitretin cap 25 mg
calcipotriene cream 0.005%
calcipotriene oint 0.005%
calcipotriene soln 0.005% (50 mcg/ml)
calcitriol oint 3 mcg/gm
methoxsalen rapid cap 10 mg
8-MOP CAP 10MG
STELARA INJ 45MG/0.5
STELARA INJ 90MG/ML
TAZORAC CRE 0.1%
TAZORAC CRE 0.05%
TAZORAC GEL 0.1%
TAZORAC GEL 0.05%
1
1
1
1
1
1
1
1
3
3
3
2
2
2
2
PA, ST
PA, ST
PA
PA
PA
PA
Antiseborrheic Products
selenium sulfide lotion 2.5%
1
ST - Step Therapy
OTC - Over the
70
Drug Name
selenium sulfide-pyrithione zinc in urea
shampoo 2.25%
1
Antivirals - Topical
ABREVA CRE 10%
DENAVIR CRE 1%
1
3
OTC
ST
Burn Products
mafenide acetate packet for topical soln
5% (50 gm)
silver sulfadiazine cream 1%
ssd cre 1%
1
1
1
Corticosteroids - Topical
alclometasone dipropionate cream 0.05%
alclometasone dipropionate oint 0.05%
alphatrex gel 0.05%
amcinonide cream 0.1%
amcinonide lotion 0.1%
AMCINONIDE OIN 0.1%
apexicon oin 0.05%
betamethasone dipropionate augmented
cream 0.05%
lotion 0.05%
oint 0.05%
betamethasone dipropionate cream 0.05%
betamethasone dipropionate lotion 0.05%
betamethasone dipropionate oint 0.05%
betamethasone valerate aerosol foam
0.12%
betamethasone valerate cream 0.1%
betamethasone valerate lotion 0.1%
betamethasone valerate oint 0.1%
calcipotriene-betamethasone dipropionate
oint 0.005-0.064%
clobetasol propionate cream 0.05%
clobetasol propionate foam 0.05%
clobetasol propionate gel 0.05%
clobetasol propionate lotion 0.05%
clobetasol propionate oint 0.05%
clobetasol propionate shampoo 0.05%
clobetasol propionate spray 0.05%
clocortolone pivalate cream 0.1%
CORDRAN 24X3 TAP 4MCG/CM
CORDRAN CRE 0.05%
CORDRAN LOT 0.05%
CORDRAN OIN 0.05%
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
ST - Step Therapy
OTC - Over the
71
Drug Name
cormax scalp sol 0.05%
desonide cream 0.05%
desonide lotion 0.05%
desonide oint 0.05%
desoximetasone cream 0.05%
desoximetasone gel 0.05%
desoximetasone oint 0.05%
diflorasone diacetate cream 0.05%
diflorasone diacetate oint 0.05%
fluocin acet oil 0.01% sc
fluocin acet oil body
fluocinolone acetonide cream 0.01%
fluocinolone acetonide oint 0.025%
fluocinolone acetonide soln 0.01%
fluocinonide cream 0.1%
fluocinonide gel 0.05%
fluocinonide oint 0.05%
fluocinonide soln 0.05%
fluticasone propionate cream 0.05%
fluticasone propionate lotion 0.05%
fluticasone propionate oint 0.005%
halobetasol propionate cream 0.05%
halobetasol propionate oint 0.05%
HALOG CRE 0.1%
HALOG OIN 0.1%
hydrocortisone butyrate cream 0.1%
hydrocortisone butyrate hydrophilic lipo
base cream 0.1%
hydrocortisone butyrate oint 0.1%
hydrocortisone butyrate soln 0.1%
hydrocortisone cream 1%
hydrocortisone cream 2.5%
hydrocortisone lotion 2.5%
hydrocortisone oint 1%
hydrocortisone oint 2.5%
hydrocortisone valerate cream 0.2%
hydrocortisone valerate oint 0.2%
lokara lot 0.05%
mometasone furoate cream 0.1%
mometasone furoate oint 0.1%
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
OTC - Over the
72
Drug Name
mometasone furoate solution 0.1% (lotion) 1
scalacort lot 2%
1
TACLONEX SUS
3
triamcinolone acetonide aerosol soln 0.147 1
mg/gm
triamcinolone acetonide cream 0.1%
1
1
1
triamcinolone acetonide lotion 0.1%
1
1
triamcinolone acetonide oint 0.1%
1
1
1
triderm cre 0.1%
1
Emollients
lactic acid (ammonium lactate) cream 12% 1
lactic acid (ammonium lactate) lotion 10% 1
Enzymes - Topical
SANTYL OIN 250/GM
3
Immunomodulating Agents - Topical
imiquimod cream 5%
ZYCLARA CRE 3.75%
ZYCLARA PUMP CRE 2.5%
1
3
3
Immunosuppressive Agents - Topical
ELIDEL CRE 1%
tacrolimus oint 0.1%
2
1
1
ST; PA**
ST; PA**
ST; PA**
Keratolytic/Antimitotic Agents
CONDYLOX GEL 0.5%
podofilox soln 0.5%
3
1
Local Anesthetics - Topical
lidocaine hcl cream 3%
lidocaine hcl gel 2%
lidocaine hcl lotion 3%
lidocaine hcl soln 4%
lidocaine-prilocaine cream 2.5-2.5%
lidocaine-prilocaine kit 2.5-2.5%
pramox gel 1%
SYNERA DIS 70-70MG
1
1
1
1
1
1
1
3
Pigmenting-Depigmenting Agents
OXSORALEN LOT 1%
3
Rosacea Agents
FINACEA GEL 15%
metronidazole cream 0.75%
3
1
ST - Step Therapy
OTC - Over the
73
Drug Name
metronidazole gel 0.75%
metronidazole gel 1%
metronidazole lotion 0.75%
rosadan cre 0.75%
1
1
1
1
Scabicides Pediculicides
acticin cre 5%
EURAX CRE 10%
EURAX LOT 10%
lice trtmnt liq 1%
malathion lotion 0.5%
permethrin cream 5%
permethrin lotion 1%
SKLICE LOT 0.5%
spinosad susp 0.9%
ULESFIA LOT 5%
1
3
3
1
1
1
1
3
1
3
OTC
OTC
ST
ST
Wound Care Products
REGRANEX GEL 0.01%
3
DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS
Dietary Management Products
folbic tab
1
DIGESTIVE AIDS
Digestive Enzymes
CREON CAP 3000UNIT
CREON CAP 6000UNIT
CREON CAP 12000UNT
CREON CAP 24000UNT
CREON CAP 36000UNT
pancrelipase (lip-prot-amyl) dr cap 500017000-27000 unit
SUCRAID SOL 8500/ML
ULTRESA CAP 13800UNT
VIOKACE TAB
VIOKACE TAB 20880
ZENPEP CAP 3000UNIT
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
ZENPEP CAP 20000UNT
ZENPEP CAP 25000UNT
ZENPEP CAP 40000UNT
2
2
2
2
2
1
3
2
2
2
2
2
2
2
2
2
2
2
DIURETICS
ST - Step Therapy
OTC - Over the
74
Drug Name
Carbonic Anhydrase Inhibitors
acetazolamide sodium for inj 500 mg
methazolamide tab 25 mg
1
1
1
Diuretic Combinations
ALDACTAZIDE TAB 50/50
amiloride & hydrochlorothiazide tab 5-50
mg
spironolactone & hydrochlorothiazide tab
25-25 mg
triamterene & hydrochlorothiazide cap
37.5-25 mg
triamterene & hydrochlorothiazide cap 5025 mg
triamterene & hydrochlorothiazide tab
37.5-25 mg
triamterene & hydrochlorothiazide tab 7550 mg
2
1
1
1
1
1
1
Loop Diuretics
bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
EDECRIN TAB 25MG
furosemide oral soln 10 mg/ml
FUROSEMIDE SOL 8MG/ML
furosemide tab 20 mg
SOD EDECRIN INJ 50MG
torsemide tab 5 mg
torsemide tab 10 mg
torsemide tab 20 mg
torsemide tab 100 mg
1
1
1
3
1
2
1
1
1
3
1
1
1
1
Potassium Sparing Diuretics
amiloride hcl tab 5 mg
DYRENIUM CAP 50MG
DYRENIUM CAP 100MG
spironolactone tab 25 mg
1
3
3
1
1
1
Thiazides and Thiazide-Like Diuretics
chlorothiazide tab 250 mg
chlorthalidone tab 25 mg
1
1
1
1
ST - Step Therapy
OTC - Over the
75
Drug Name
DIURIL SUS 250/5ML
hydrochlorothiazide cap 12.5 mg
hydrochlorothiazide tab 12.5 mg
hydrochlorothiazide tab 25 mg
indapamide tab 1.25 mg
metolazone tab 2.5 mg
metolazone tab 5 mg
metolazone tab 10 mg
1
3
1
1
1
1
1
1
1
1
1
ENDOCRINE AND METABOLIC AGENTS - MISC.
Bone Density Regulators
alendronate sodium oral soln 70 mg/75ml
alendronate sodium tab 5 mg
calcitonin (salmon) nasal soln 200 unit/act
FORTEO SOL 600/2.4
ibandronate sodium tab 150 mg (base
equivalent)
pamidronate disodium for inj 30 mg
pamidronate disodium iv soln 3 mg/ml
pamidronate disodium iv soln 9 mg/ml
PAMIDRONATE INJ 6MG/ML
PROLIA SOL 60MG/ML
risedronate sodium tab 5 mg
risedronate sodium tab delayed release 35
mg
zoledronic acid inj conc for iv infusion 4
mg/5ml
zoledronic acid iv soln 5 mg/100ml
ZOLEDRONIC INJ 4MG/100
1
1
1
1
1
1
1
3
1
PA
1
1
1
1
3
3
1
1
1
1
1
PA
3
PA
3
3
PA
PA
3
1
3
3
PA
Fertility Regulators
chorionic gonadotropin for inj 10000 unit
clomiphene citrate tab 50 mg
novarel inj 10000unt
pregnyl inj 10000unt
ST - Step Therapy
PA
PA
OTC - Over the
76
Drug Name
Growth Hormone Receptor Antagonists
SOMAVERT
SOMAVERT
SOMAVERT
SOMAVERT
SOMAVERT
INJ
INJ
INJ
INJ
INJ
10MG
15MG
20MG
25MG
30MG
3
3
3
3
3
PA
PA
PA
PA
PA
3
3
3
3
3
3
3
3
PA
PA
PA
PA
PA
PA
PA
PA
1
cancer
Growth Hormones
HUMATROPE INJ 5MG
HUMATROPE INJ 6MG
HUMATROPE INJ 12MG
HUMATROPE INJ 24MG
NORDITROPIN INJ 5/1.5ML
NORDITROPIN INJ 30/3ML
Hormone Receptor Modulators
raloxifene hcl tab 60 mg
Insulin-Like Growth Factors (Somatomedins)
INCRELEX INJ 40MG/4ML
3
PA
LHRH/GnRH Agonist Analog Pituitary Suppressants
LUPR DEP-PED INJ 7.5MG
LUPR DEP-PED INJ 15MG
SYNAREL SOL 2MG/ML
3
3
3
3
2
PA
PA
PA
PA
Metabolic Modifiers
calcitriol cap 0.5 mcg
calcitriol oral soln 1 mcg/ml
CYSTADANE POW
doxercalciferol cap 0.5 mcg
doxercalciferol cap 1 mcg
FABRAZYME INJ 5MG
FABRAZYME INJ 35MG
MYOZYME INJ 50MG
paricalcitol cap 1 mcg
SENSIPAR TAB 30MG
SENSIPAR TAB 60MG
1
1
1
3
1
1
1
3
3
3
1
1
1
3
3
ST - Step Therapy
PA
PA
PA
PA
PA
OTC - Over the
77
Drug Name
SENSIPAR TAB 90MG
3
PA
Posterior Pituitary Hormones
desmopressin acetate
(refrigerated)
0.01%
0.01% (refrigerated)
nasal soln 0.01%
1
nasal spray soln
1
nasal spray soln
1
tab 0.1 mg
tab 0.2 mg
1
1
Prolactin Inhibitors
cabergoline tab 0.5 mg
1
Somatostatic Agents
octreotide acetate inj 50 mcg/ml (0.05
mg/ml)
mg/ml)
mg/ml)
mg/ml)
octreotide acetate inj 1000 mcg/ml (1
mg/ml)
SOMATULINE INJ 60/0.2ML
SOMATULINE INJ 120/.5ML
3
PA
3
PA
3
PA
3
PA
3
PA
3
3
3
PA
PA
PA
3
3
PA
PA
Vasopressin Receptor Antagonists
SAMSCA TAB 15MG
SAMSCA TAB 30MG
ESTROGENS
Estrogen Combinations
CLIMARA PRO DIS WEEKLY
2
estradiol & norethindrone acetate tab 0.5- 1
0.1 mg
estradiol & norethindrone acetate tab 1-0.5 1
mg
jinteli tab 1mg-5mcg
1
mimvey tab 1-0.5mg
1
norethindrone acetate-ethinyl estradiol tab 1
0.5 mg-2.5 mcg
Estrogens
CENESTIN TAB 0.3MG
3
ST - Step Therapy
PA; High Risk
older
OTC - Over the
78
Drug Name
CENESTIN TAB 0.9MG
CENESTIN TAB 0.45MG
CENESTIN TAB 0.625MG
CENESTIN TAB 1.25MG
ENJUVIA TAB 0.3MG
ENJUVIA TAB 0.9MG
ENJUVIA TAB 0.45MG
ENJUVIA TAB 0.625MG
ENJUVIA TAB 1.25MG
estradiol tab 0.5 mg
estradiol tab 1 mg
estradiol tab 2 mg
estradiol td patch weekly 0.1 mg/24hr
3
PA; High Risk
older
3
PA; High Risk
older
3
PA; High Risk
older
3
PA; High Risk
older
3
PA; High Risk
older
3
PA; High Risk
older
3
PA; High Risk
older
3
PA; High Risk
older
3
PA; High Risk
older
1
PA; High Risk
older
1
PA; High Risk
older
1
PA; High Risk
older
1
PA; High Risk
older
1
PA; High Risk
older
ST - Step Therapy
OTC - Over the
79
Drug Name
estradiol td patch weekly
(37.5 mcg/24hr)
estropipate tab 0.75 mg
estropipate tab 3 mg
MENEST TAB 0.3MG
MENEST TAB 0.625MG
MENEST TAB 1.25MG
MENEST TAB 2.5MG
ortho-est tab 0.625
ortho-est tab 1.25
PREMARIN TAB 0.3MG
1
PA; High Risk
older
0.025 mg/24hr 1
PA; High Risk
older
0.075 mg/24hr 1
PA; High Risk
older
0.0375 mg/24hr 1
PA; High Risk
older
1
PA; High Risk
older
1
PA; High Risk
older
1
PA; High Risk
older
3
PA; High Risk
older
3
PA; High Risk
older
3
PA; High Risk
older
3
PA; High Risk
older
1
PA; High Risk
older
1
PA; High Risk
older
3
PA; High Risk
older
ST - Step Therapy
OTC - Over the
80
Drug Name
PREMARIN TAB 0.9MG
3
PA; High Risk
older
3
PA; High Risk
older
3
PA; High Risk
older
3
PA; High Risk
older
PREMARIN TAB 0.45MG
PREMARIN TAB 0.625MG
PREMARIN TAB 1.25MG
FLUOROQUINOLONES
Fluoroquinolones
ciprofloxacin for oral susp 250 mg/5ml
(5%) (5 gm/100ml)
(10%) (10 gm/100ml)
ciprofloxacin hcl tab 100 mg (base equiv)
ciprofloxacin-ciprofloxacin hcl tab sr 24hr
500 mg (base eq)
1000 mg(base eq)
FACTIVE TAB 320MG
levofloxacin oral soln 25 mg/ml
levofloxacin tab 250 mg
moxifloxacin hcl tab 400 mg (base equiv)
NOROXIN TAB 400MG
1
1
1
1
1
1
1
1
3
1
1
1
1
1
3
GASTROINTESTINAL AGENTS - MISC.
Gallstone Solubilizing Agents
ursodiol cap 300 mg
ursodiol tab 250 mg
ursodiol tab 500 mg
1
1
1
Gastrointestinal Stimulants
metoclopramide hcl soln 5 mg/5ml (10
mg/10ml)
metoclopramide hcl tab 5 mg
1
1
1
ST - Step Therapy
OTC - Over the
81
Drug Name
Inflammatory Bowel Agents
APRISO CAP 0.375GM
balsalazide disodium cap 750 mg
CANASA SUP 1000MG
DIPENTUM CAP 250MG
mesalamine enema 4 gm
mesalamine rectal enema 4 gm & cleanser
wipe kit
sulfasalazine tab 500 mg
sulfasalazine tab delayed release 500 mg
2
1
2
3
1
1
1
1
Irritable Bowel Syndrome (IBS) Agents
alosetron hcl tab 0.5 mg (base equiv)
alosetron hcl tab 1 mg (base equiv)
LINZESS CAP 145MCG
LINZESS CAP 290MCG
1
1
2
2
PA
PA
Peripheral Opioid Receptor Antagonists
MOVANTIK TAB 12.5MG
MOVANTIK TAB 25MG
2
2
Phosphate Binder Agents
calcium acetate (phosphate binder) cap
667 mg (169 mg ca)
calcium acetate (phosphate binder) tab
667 mg
FOSRENOL CHW 500MG
FOSRENOL CHW 750MG
FOSRENOL CHW 1000MG
FOSRENOL POW 750MG
FOSRENOL POW 1000MG
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
1
1
3
3
3
3
3
2
2
2
GENITOURINARY AGENTS - MISCELLANEOUS
Alkalinizers
potassium citrate tab cr 5 meq (540 mg) 1
Cystinosis Agents
CYSTAGON CAP 50MG
CYSTAGON CAP 150MG
3
3
PA
PA
Genitourinary Irrigants
sodium chloride irrigation soln 0.9%
1
Interstitial Cystitis Agents
ELMIRON CAP 100MG
3
Prostatic Hypertrophy Agents
ST - Step Therapy
OTC - Over the
82
Drug Name
alfuzosin hcl tab sr 24hr 10 mg
AVODART CAP 0.5MG
CARDURA XL TAB 4MG
CARDURA XL TAB 8MG
CIALIS TAB 2.5MG
1
3
ST; PA**
3
ST; PA**
3
ST; PA**
3
QL (30 tabs / 25 days),
PA
3
PA
1
3
ST; PA**
3
ST; PA**
3
ST; PA**
1
CIALIS TAB 5MG
finasteride tab 5 mg
JALYN CAP
RAPAFLO CAP 4MG
RAPAFLO CAP 8MG
tamsulosin hcl cap 0.4 mg
Urinary Analgesics
phenazopyridine hcl tab 100 mg
1
1
GOUT AGENTS
Gout Agent Combinations
colchicine w/ probenecid tab 0.5-500 mg
1
Gout Agents
allopurinol tab 100 mg
colchicine tab 0.6 mg
ULORIC TAB 40MG
ULORIC TAB 80MG
1
1
1
3
3
ST; PA**
ST; PA**
Uricosurics
probenecid tab 500 mg
1
HEMATOLOGICAL AGENTS - MISC.
Hematorheologic Agents
pentoxifylline tab cr 400 mg
1
Platelet Aggregation Inhibitors
anagrelide hcl cap 0.5 mg
anagrelide hcl cap 1 mg
aspirin-dipyridamole cap sr 12hr 25-200
mg
BRILINTA TAB 90MG
cilostazol tab 50 mg
clopidogrel bisulfate tab 75 mg (base
equiv)
equiv)
1
1
1
2
1
1
1
1
ST - Step Therapy
OTC - Over the
83
Drug Name
dipyridamole tab 25 mg
EFFIENT TAB 5MG
EFFIENT TAB 10MG
ZONTIVITY TAB 2.08MG
1
PA; High Risk
older
1
PA; High Risk
older
1
PA; High Risk
older
2
2
2
HEMATOPOIETIC AGENTS
Agents for Gaucher Disease
CEREZYME INJ 200UNIT
3
3
PA
PA
Agents for Sickle Cell Anemia
DROXIA CAP 200MG
DROXIA CAP 300MG
DROXIA CAP 400MG
2
2
2
Cobalamins
cyanocobalamin inj 1000 mcg/ml
1
Folic Acid/Folates
folic acid tab 1 mg
folic acid tab 400 mcg
1
0
0
OTC; $0 copay for
women ages 55 and
under
OTC; $0 copay for
women ages 55 and
under
Hematopoietic Growth Factors
ARANESP INJ 10MCG
ARANESP INJ 25MCG
ARANESP INJ 40MCG
ARANESP INJ 60MCG
ARANESP INJ 100MCG
ARANESP INJ 150MCG
ARANESP INJ 200MCG
ARANESP INJ 300MCG
ARANESP INJ 500MCG
LEUKINE INJ 250MCG
LEUKINE INJ 500 MCG
3
3
3
3
3
3
3
3
3
3
3
ST - Step Therapy
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
OTC - Over the
84
Drug Name
NEULASTA INJ 6MG/0.6M
NEUPOGEN INJ 300/0.5
NEUPOGEN INJ 300MCG
NEUPOGEN INJ 480MCG
PROCRIT INJ 2000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 10000/ML
PROMACTA TAB 12.5MG
PROMACTA TAB 25MG
PROMACTA TAB 50MG
PROMACTA TAB 75MG
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
Iron
FER-IN-SOL DRO 15MG/ML
0
FERROUS SUL LIQ 220/5ML
0
FERROUS SULF SYP 300/5ML
0
ferrous sulfate elixir 220 mg/5ml (44
mg/5ml elemental fe)
ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe)
ICAR PEDS SUS GRAPE
0
MYKIDZ IRON SUS 15/1.5ML
0
wee care sus 15/1.25
0
0
0
OTC; $0
months
OTC; $0
months
OTC; $0
months
OTC; $0
months
OTC; $0
months
OTC; $0
months
OTC; $0
months
OTC; $0
months
for ages 6-12
for ages 6-12
for ages 6-12
for ages 6-12
for ages 6-12
for ages 6-12
for ages 6-12
for ages 6-12
Stem Cell Mobilizers
MOZOBIL INJ
3
PA
HEMOSTATICS
Hemostatics - Systemic
tranexamic acid inj 100 mg/ml
tranexamic acid tab 650 mg
1
1
HYPNOTICS
Barbiturate Hypnotics
phenobarbital
phenobarbital
phenobarbital
phenobarbital
phenobarbital
elixir 20 mg/5ml
tab 15 mg
tab 16.2 mg
tab 30 mg
tab 32.4 mg
1
1
1
1
1
ST - Step Therapy
OTC - Over the
85
Drug Name
phenobarbital
phenobarbital
phenobarbital
phenobarbital
tab
tab
tab
tab
1
1
1
1
60 mg
64.8 mg
97.2 mg
100 mg
Non-Barbiturate Hypnotics
eszopiclone tab 1 mg
temazepam cap 7.5 mg
temazepam cap 15 mg
temazepam cap 30 mg
zaleplon cap 5 mg
zaleplon cap 10 mg
zolpidem tartrate tab 5 mg
zolpidem tartrate tab cr 6.25 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(15
(15
(15
(15
(15
(15
(15
(15
(15
(15
(15
(15
(15
tabs / 25 days)
tabs / 25 days)
tabs / 25 days)
caps / 25 days)
caps / 25 days)
caps / 25 days)
caps / 25 days)
caps / 25 days)
caps / 25 days)
tabs / 25 days)
tabs / 25 days)
tabs / 25 days)
tabs / 25 days)
Selective Melatonin Receptor Agonists
ROZEREM TAB 8MG
3
ST; PA**
LAXATIVES
Laxative Combinations
COLYTE/FLAVR SOL PACKS
gavilyte-c sol
gavilyte-g sol
gavilyte-n sol flav pk
GOLYTELY SOL
MOVIPREP SOL
2
1
1
1
2
2
peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm
soln 240 gm
peg 3350-kcl-sod bicarb-nacl for soln 420
gm
PREPOPIK PAK
1
SUPREP BOWEL SOL PREP
3
$0 copay for members
age 50 through 74
1
1
0
PA; $0 copay for
members age 50
through 74
age 50 through 74
Laxatives - Miscellaneous
lactulose solution 10 gm/15ml
polyethylene glycol 3350 oral packet
polyethylene glycol 3350 oral powder
1
1
1
ST - Step Therapy
OTC - Over the
86
Drug Name
Saline Laxatives
OSMOPREP TAB 1.5GM
3
MACROLIDES
Azithromycin
azithromycin
azithromycin
azithromycin
azithromycin
azithromycin
azithromycin
for susp 100 mg/5ml
for susp 200 mg/5ml
powd pack for susp 1 gm
tab 250 mg
tab 500 mg
tab 600 mg
1
1
1
1
1
1
Clarithromycin
clarithromycin
clarithromycin
clarithromycin
clarithromycin
clarithromycin
for susp 125 mg/5ml
for susp 250 mg/5ml
tab 250 mg
tab 500 mg
tab sr 24hr 500 mg
1
1
1
1
1
Erythromycins
e.e.s. 400 tab 400mg
E.E.S. GRAN SUS 200/5ML
ERY-TAB TAB 250MG EC
ERYPED SUS 200/5ML
ERYPED SUS 400/5ML
erythrocin tab 250mg
erythromycin ethylsuccinate tab 400 mg
erythromycin tab 250 mg
erythromycin w/ delayed release particles
cap 250 mg
1
2
2
2
2
2
2
1
1
1
1
1
Fidaxomicin
DIFICID TAB 200MG
2
PA
0
0
0
0
0
0
0
0
0
OTC
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
MEDICAL DEVICES
Contraceptives
FC2 FEMALE MIS CONDOM
FEMCAP MIS 22MM
FEMCAP MIS 26MM
FEMCAP MIS 30MM
OMNIFLEX DPR
ORTHO COIL DPR KIT 50
ORTHO FLAT DPR KIT 55
ST - Step Therapy
/
/
/
/
/
/
/
/
300
300
300
300
300
300
300
300
days)
days)
days)
days)
days)
days)
days)
days)
OTC - Over the
87
Drug Name
ORTHO FLEX DPR 65MM
ORTHO FLEX DPR 70MM
ORTHO FLEX DPR 75MM
ORTHO FLEX DPR 80MM
PRENTIF MIS 22MM
PRENTIF MIS 25MM
PRENTIF MIS 28MM
PRENTIF MIS 31MM
PRENTIF MIS FITTING
WIDE-SEAL DPR KIT 60
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
0
QL (1 / 300 days)
Diabetic Supplies^
ALCOHOL PREP WIPES AND SWABS
2
BLOOD GLUCOSE CALIBRATION SOLUTION 2
FREESTYLE BLOOD GLUCOSE TEST KITS
2
FREESTYLE BLOOD GLUCOSE TEST STRIPS 2
INSULIN INFUSION PUMP KIT
2
2
INSULIN PEN NEEDLES/SYRINGES
2
LANCETS
2
LANCING DEVICE
2
URINE GLUCOSE - KETONE TEST STRIP
2
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
Respiratory Therapy Supplies
ADULT RESPIRATORY MASK
PEDIATRIC RESPIRATORY MASK
2
2
2
OTC
OTC
MIGRAINE PRODUCTS
Migraine Combinations
CAFERGOT TAB 1-100MG
2
ST - Step Therapy
OTC - Over the
88
Drug Name
Migraine Products
dihydroergotamine mesylate nasal spray 4 1
mg/ml
QL (8 kits / 25 days)
Serotonin Agonists
almotriptan malate tab 6.25 mg
1
1
FROVA TAB 2.5MG
3
naratriptan hcl tab 1 mg (base equiv)
naratriptan hcl tab 2.5 mg (base equiv)
RELPAX TAB 20MG
1
1
3
RELPAX TAB 40MG
3
rizatriptan benzoate orally disintegrating
tab 5 mg
tab 10 mg
rizatriptan benzoate tab 5 mg
sumatriptan nasal spray 5 mg/act
1
QL (12 tabs
PA**
QL (12 tabs
PA**
QL (18 tabs
ST; PA**
QL (12 tabs
QL (12 tabs
QL (12 tabs
ST; PA**
QL (12 tabs
ST; PA**
QL (18 tabs
1
1
1
1
1
sumatriptan succinate inj 4 mg/0.5ml
sumatriptan succinate inj 6 mg/0.5ml
sumatriptan succinate solution autoinjector 4 mg/0.5ml
sumatriptan succinate solution cartridge 4
mg/0.5ml
mg/0.5ml
sumatriptan succinate solution prefilled
syringe 6 mg/0.5ml
sumatriptan succinate tab 25 mg
zolmitriptan orally disintegrating tab 2.5
mg
zolmitriptan orally disintegrating tab 5 mg
zolmitriptan tab 2.5 mg
zolmitriptan tab 5 mg
ZOMIG NASAL SPR 5MG
1
1
1
QL (24 sprays / 25
days)
QL (12 sprays / 25
days)
1
1
1
1
1
1
1
1
QL
QL
QL
QL
1
1
1
3
QL (12
QL (12
QL (12
QL (12
days)
ST - Step Therapy
(12
(12
(12
(12
tabs
tabs
tabs
tabs
/ 25 days);
/ 25 days);
/ 25 days),
/ 25 days)
/ 25 days)
/ 25 days),
/ 25 days),
/ 25 days)
/
/
/
/
25
25
25
25
days)
days)
days)
days)
tabs / 25 days)
tabs / 25 days)
tabs / 25 days)
sprays / 25
OTC - Over the
89
Drug Name
ZOMIG SPR 2.5MG
3
QL (12 sprays / 25
days)
MINERALS ELECTROLYTES
Fluoride
fluor-a-day dro 0.125mg
0
FLUORABON DRO
0
fluoritab chw 0.5mg f
0
0
fluoritab chw 2.2mg
flura-drops dro 0.25mg f
1
0
flura-drops dro 0.125mg
0
ludent chw 0.5mg f
0
ludent chw 0.25mg f
0
ludent chw 1mg f
LURIDE CHW 0.5MG F
1
0
LURIDE CHW 0.25MG F
0
LURIDE DRO 0.5MG/ML
0
nafrinse chw 1mg f
sodium fluoride chew tab 0.5 mg f (from
1.1 mg naf)
0.55 mg naf)
sodium fluoride chew tab 1 mg f (from 2.2
mg naf)
sodium fluoride soln 0.5 mg/ml f (from 1.1
mg/ml naf)
sodium fluoride tab 0.5 mg f (from 1.1 mg
naf)
sodium fluoride tab 1 mg f (from 2.2 mg
naf)
1
0
0
$0 applies
and under
$0 applies
and under
$0 applies
and under
$0 applies
and under
for ages 5
$0 applies
and under
$0 applies
and under
$0 applies
and under
$0 applies
and under
for ages 5
for ages 5
for ages 5
for ages 5
for ages 5
for ages 5
for ages 5
$0 applies for ages 5
and under
and under
and under
and under
and under
1
0
0
and under
and under
1
Potassium
klor-con 8 tab 8meq er
KLOR-CON M15 TAB 15MEQ ER
klor-con m20 tab 20meq er
potassium chloride cap cr 8 meq
1
1
2
1
1
1
ST - Step Therapy
OTC - Over the
90
Drug Name
potassium chloride
cr tab 10 meq
potassium chloride
cr tab 20 meq
potassium chloride
meq/15ml)
potassium chloride
meq/15ml)
potassium chloride
potassium chloride
potassium chloride
mg)
microencapsulated crys 1
microencapsulated crys 1
oral soln 10% (20
1
oral soln 20% (40
1
tab cr 8 meq (600 mg) 1
tab cr 10 meq
1
tab cr 20 meq (1500
1
Sodium
sodium
sodium
sodium
sodium
sodium
sodium
sodium
sodium
chloride
chloride
chloride
chloride
chloride
chloride
chloride
chloride
flush iv soln 0.9%
inj 0.9%
inj 0.45%
inj 2.5 meq/ml (14.6%)
inj 3%
inj 4 meq/ml (23.4%)
inj 5%
iv soln 0.9%
1
1
1
1
1
1
1
1
MOUTH/THROAT/DENTAL AGENTS
Anesthetics Topical Oral
lidocaine hcl laryngotracheal soln 4%
lidocaine hcl viscous soln 2%
1
1
Anti-infectives - Throat
clotrimazole troche 10 mg
nystatin susp 100000 unit/ml
1
1
Antiseptics - Mouth/Throat
chlorhexidine gluconate soln 0.12%
periogard sol 0.12%
1
1
Steroids - Mouth/Throat
oralone pst 0.1%
1
triamcinolone acetonide dental paste 0.1% 1
Throat Products - Misc.
cevimeline hcl cap 30 mg
pilocarpine hcl tab 5 mg
pilocarpine hcl tab 7.5 mg
1
1
1
MULTIVITAMINS
Ped MV w/ Fluoride
acd/fluoride dro 0.25mg
multi-vit/fl dro 0.5mg/ml
multi-vit/fl dro 0.25mg
multivit/fl chw 0.5mg
1
1
1
1
ST - Step Therapy
OTC - Over the
91
Drug Name
multivit/fl chw 1mg
mvc-fluoride chw 0.5mg
mvc-fluoride chw 1mg
QUFLORA PED CHW 0.5MG
QUFLORA PED CHW 1MG
quflora ped dro 0.5mg/ml
quflora ped dro 0.25mg
tri-vit/fl dro 0.5mg
1
1
1
1
3
3
3
1
1
1
1
Ped Multi Vitamins w/Fl FE
multi-vit/fe dro /fl 0.25
tri-vit/fe dro /fl 0.25
1
1
Prenatal Vitamins
CITRANATAL
CITRANATAL
CITRANATAL
CITRANATAL
CITRANATAL
CITRANATAL
prenatabs rx
CAP
MIS
MIS
PAK
PAK
TAB
tab
HARMONY
90 DHA
B-CALM
ASSURE
DHA
RX
2
2
2
2
2
2
1
MUSCULOSKELETAL THERAPY AGENTS
Central Muscle Relaxants
baclofen tab 10 mg
baclofen tab 20 mg
carisoprodol tab 250 mg
1
1
1
1
chlorzoxazone tab 500 mg
cyclobenzaprine hcl tab 5 mg
1
1
cyclobenzaprine hcl tab 7.5 mg
1
1
ST - Step Therapy
PA; High Risk
older
PA; High Risk
older
PA; High Risk
older
PA; High Risk
older
PA; High Risk
older
OTC - Over the
92
Drug Name
metaxalone tab 400 mg
methocarbamol tab 500 mg
orphenadrine citrate inj 30 mg/ml
orphenadrine citrate tab sr 12hr 100 mg
tizanidine
tizanidine
tizanidine
tizanidine
tizanidine
hcl
hcl
hcl
hcl
hcl
cap 2 mg (base equivalent)
tab 2 mg (base equivalent)
tab 4 mg (base equivalent)
1
PA; High Risk
older
1
PA; High Risk
older
1
PA; High Risk
older
1
PA; High Risk
older
1
1
PA; High Risk
older
1
1
1
1
1
Direct Muscle Relaxants
dantrolene sodium cap 25 mg
1
1
1
Muscle Relaxant Combinations
orphenadrine w/ aspirin & caffeine tab 25- 1
385-30 mg
PA; High Risk
older
NASAL AGENTS - SYSTEMIC AND TOPICAL
Nasal Antiallergy
azelastine hcl nasal spray 0.1% (137
mcg/spray)
azelastine hcl nasal spray 0.15% (205.5
mcg/spray)
1
1
Nasal Anticholinergics
ipratropium bromide nasal soln 0.03% (21 1
mcg/spray)
ipratropium bromide nasal soln 0.06% (42 1
mcg/spray)
Nasal Steroids
flunisolide nasal soln 25 mcg/act (0.025%) 1
ST - Step Therapy
QL (3 containers / 25
days)
OTC - Over the
93
Drug Name
fluticasone propionate nasal susp 50
mcg/act
triamcinolone acetonide nasal aerosol
suspension 55 mcg/act
1
QL (1 container / 25
days)
1
QL (1 container / 25
days)
Sympathomimetic Decongestants
TYZINE PED DRO 0.05%
TYZINE SOL 0.1%
3
3
NEUROMUSCULAR AGENTS
ALS Agents
riluzole tab 50 mg
1
OPHTHALMIC AGENTS
Artificial Tears and Lubricants
LACRISERT MIS 5MG OP
3
Beta-blockers - Ophthalmic
betaxolol hcl ophth soln 0.5%
1
BETIMOL SOL 0.5%
3
BETIMOL SOL 0.25%
3
BETOPTIC-S SUS 0.25% OP
2
carteolol hcl ophth soln 1%
1
COMBIGAN SOL 0.2/0.5%
2
dorzolamide hcl-timolol maleate ophth soln 1
22.3-6.8 mg/ml
levobunolol hcl ophth soln 0.5%
1
1
metipranolol ophth soln 0.3%
1
timolol maleate ophth gel forming soln
1
0.5%
1
0.25%
timolol maleate ophth soln 0.5%
1
1
TIMOPTIC OCU SOL 0.5% OP
2
2
Cycloplegic Mydriatics
atropine sulfate ophth soln 1%
homatropine hbr ophth soln 5%
ISO HOMATROP SOL 2% OP
tropicamide ophth soln 0.5%
tropicamide ophth soln 1%
1
1
3
1
1
Miotics
PHOSPHOLINE SOL 0.125%OP
PILOPINE HS GEL 4% OP
3
3
Ophthalmic Adrenergic Agents
brimonidine tartrate ophth soln 0.2%
1
ST - Step Therapy
OTC - Over the
94
Drug Name
1
Ophthalmic Anti-infectives
bacitracin ophth oint 500 unit/gm
bacitracin-polymyxin b ophth oint
BESIVANCE SUS 0.6%
CILOXAN OIN 0.3% OP
ciprofloxacin hcl ophth soln 0.3%
erythromycin ophth oint 5 mg/gm
gatifloxacin ophth soln 0.5%
gentamicin sulfate ophth oint 0.3%
gentamicin sulfate ophth soln 0.3%
ilotycin oin op
NATACYN SUS 5% OP
neomycin-polymy-gramicid op sol 1.7510000-0.025mg-unt-mg/ml
ofloxacin ophth soln 0.3%
polycin oin op
polymyxin b-trimethoprim ophth soln
10000 unit/ml-0.1%
romycin oin op
sulfacetamide sodium ophth oint 10%
sulfacetamide sodium ophth soln 10%
tobramycin ophth soln 0.3%
TOBREX OIN 0.3% OP
trifluridine ophth soln 1%
VIGAMOX DRO 0.5%
ZIRGAN GEL 0.15%
1
1
3
2
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
2
1
2
3
Ophthalmic Decongestants
naphazoline hcl ophth soln 0.1%
phenylephrine hcl ophth soln 2.5%
phenylephrine hcl ophth soln 10%
1
1
1
Ophthalmic Immunomodulators
RESTASIS EMU 0.05%
3
Ophthalmic Steroids
ALREX SUS 0.2%
bacitracin-polymyxin-neomycin-hc ophth
oint 1%
BLEPHAMIDE OIN S.O.P.
BLEPHAMIDE SUS OP
dexamethasone sodium phosphate ophth
soln 0.1%
DUREZOL EMU 0.05%
fluorometholone ophth susp 0.1%
LOTEMAX GEL 0.5%
LOTEMAX OIN 0.5%
3
1
2
2
1
3
1
3
3
ST - Step Therapy
OTC - Over the
95
Drug Name
LOTEMAX SUS 0.5%
neomycin-polymyxin-dexamethasone
ophth oint 0.1%
ophth susp 0.1%
neomycin-polymyxin-hc ophth susp
poly-dex oin 0.1% op
PRED MILD SUS 0.12% OP
PRED SOD PHO SOL 1% OP
prednisolone acetate ophth susp 1%
sulfacetamide sodium-prednisolone ophth
soln 10-0.23(0.25)%
TOBRADEX OIN 0.3-0.1%
tobramycin-dexamethasone ophth susp
0.3-0.1%
VEXOL SUS 1% OP
3
1
1
1
1
2
2
1
1
2
1
3
Ophthalmics - Misc.
ALOCRIL SOL 2%
3
ALOMIDE SOL 0.1% OP
3
azelastine hcl ophth soln 0.05%
1
AZOPT SUS 1% OP
3
BEPREVE DRO 1.5%
3
bromfenac sodium ophth soln 0.09% (base 1
equiv) (once-daily)
bromfenac sodium ophth soln 0.09% (base 1
equivalent)
cromolyn sodium ophth soln 4%
1
diclofenac sodium ophth soln 0.1%
1
dorzolamide hcl ophth soln 2%
1
EMADINE SOL 0.05% OP
3
epinastine hcl ophth soln 0.05%
1
flurbiprofen sodium ophth soln 0.03%
1
ketorolac tromethamine ophth soln 0.4% 1
ketorolac tromethamine ophth soln 0.5% 1
ketotif fum dro 0.025%op
1
LASTACAFT SOL 0.25%
3
NEVANAC SUS 0.1%
3
PATADAY SOL 0.2%
3
PATANOL SOL 0.1% OP
3
ST
ST
ST
ST
OTC
ST
ST
ST
Prostaglandins - Ophthalmic
bimatoprost ophth soln 0.03%
latanoprost ophth soln 0.005%
LUMIGAN SOL 0.01%
TRAVATAN Z DRO 0.004%
ZIOPTAN DRO 0.0015%
1
1
3
3
3
ST - Step Therapy
ST; PA**
ST; PA**
ST; PA**
OTC - Over the
96
Drug Name
OTIC AGENTS
Otic Agents - Miscellaneous
acetic acid 2% in aluminum acetate otic
soln
acetic acid otic soln 2%
1
1
Otic Anti-infectives
ofloxacin otic soln 0.3%
1
Otic Combinations
CIPRO HC SUS OTIC
CIPRODEX SUS 0.3-0.1%
CORTISPORIN SUS -TC OTIC
neomycin-polymyxin-hc otic soln 1%
neomycin-polymyxin-hc otic susp 3.5
mg/ml-10000 unit/ml-1%
3
2
3
1
1
Otic Steroids
fluocinolone acetonide (otic) oil 0.01%
hydrocortisone w/ acetic acid otic soln 12%
1
1
PASSIVE IMMUNIZING AGENTS
Immune Serums
GAMASTAN S/D INJ
GAMMAGARD INJ 1GM/10ML
GAMMAGARD INJ 2.5GM/25
GAMMAGARD INJ 10GM/100
GAMMAKED INJ 1GM/10ML
GAMMAKED INJ 2.5GM/25
GAMMAKED INJ 10GM/100
3
3
3
3
3
3
3
3
3
3
3
3
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PENICILLINS
Aminopenicillins
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
mg/5ml
amoxicillin
mg/5ml
amoxicillin
mg/5ml
(trihydrate)
(trihydrate)
(trihydrate)
(trihydrate)
(trihydrate)
cap 250 mg
cap 500 mg
chew tab 125 mg
chew tab 250 mg
for susp 125
1
1
1
1
1
(trihydrate) for susp 200
1
(trihydrate) for susp 250
1
ST - Step Therapy
OTC - Over the
97
Drug Name
amoxicillin (trihydrate) for susp 400
mg/5ml
amoxicillin (trihydrate) tab 500 mg
ampicillin cap 250 mg
ampicillin for susp 125 mg/5ml
1
1
1
1
1
1
1
Natural Penicillins
penicillin
penicillin
penicillin
penicillin
v
v
v
v
potassium
potassium
potassium
potassium
for soln 125 mg/5ml 1
for soln 250 mg/5ml 1
tab 250 mg
1
tab 500 mg
1
Penicillin Combinations
amoxicillin & k clavulanate
28.5 mg
57 mg
28.5 mg/5ml
62.5 mg/5ml
mg/5ml
42.9 mg/5ml
1000-62.5 mg
AUGMENTIN SUS 125/5ML
chew tab 200-
1
chew tab 400-
1
for susp 200-
1
for susp 250-
1
for susp 400-57 1
for susp 600tab
tab
tab
tab
1
250-125 mg1
500-125 mg1
875-125 mg1
sr 12hr
1
2
Penicillinase-Resistant Penicillins
dicloxacillin sodium cap 250 mg
1
1
PROGESTINS
Progestins
medroxyprogesterone acetate tab 2.5 mg
medroxyprogesterone acetate tab 5 mg
medroxyprogesterone acetate tab 10 mg
norethindrone acetate tab 5 mg
progesterone micronized cap 100 mg
1
1
1
1
1
1
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
Agents for Chemical Dependency
ST - Step Therapy
OTC - Over the
98
Drug Name
acamprosate calcium tab delayed release
333 mg
disulfiram tab 250 mg
1
PA
1
1
Anti-Cataplectic Agents
XYREM SOL 500MG/ML
2
PA
Antidementia Agents
donepezil hydrochloride orally
disintegrating tab 5 mg
donepezil hydrochloride tab 5 mg
EXELON SOL 2MG/ML
galantamine hydrobromide cap sr 24hr 8
mg
mg
mg
galantamine hydrobromide oral soln 4
mg/ml
galantamine hydrobromide tab 4 mg
memantine hcl tab 5 mg
1
memantine hcl tab 5 mg (28) & 10 mg
(21) titration pak
1
1
NAMENDA SOL 10MG/5ML
2
NAMENDA XR CAP 7MG
2
NAMENDA XR CAP 14MG
2
NAMENDA XR CAP 21MG
2
NAMENDA XR CAP 28MG
2
1
1
1
1
2
1
PA
1
1
1
1
1
1
1
ST - Step Therapy
PA; PA applies for
members less than
years of age
PA; PA applies for
members less than
years of age
PA; PA applies for
members less than
years of age
PA; PA applies for
members less than
years of age
PA; PA applies for
members less than
years of age
PA; PA applies for
members less than
years of age
PA; PA applies for
members less than
years of age
PA; PA applies for
members less than
years of age
OTC - Over the
30
30
30
30
30
30
30
30
99
Drug Name
NAMENDA XR CAP TITRATIO
rivastigmine
rivastigmine
rivastigmine
rivastigmine
tartrate
tartrate
tartrate
tartrate
cap
cap
cap
cap
2
PA; PA applies for
members less than 30
years of age
1
PA
1
PA
1
PA
1
PA
1.5 mg
3 mg
4.5 mg
6 mg
Fibromyalgia Agents
SAVELLA
SAVELLA
SAVELLA
SAVELLA
SAVELLA
MIS
TAB
TAB
TAB
TAB
TITR PAK
12.5MG
25MG
50MG
100MG
3
3
3
3
3
Multiple Sclerosis Agents
AUBAGIO TAB 7MG
3
AUBAGIO TAB 14MG
3
BETASERON INJ 0.3MG
3
COPAXONE INJ 20MG/ML
3
3
GILENYA CAP 0.5MG
3
glatiramer acetate soln prefilled syringe 20 3
mg/ml
REBIF INJ 22/0.5
3
REBIF INJ 44/0.5
3
REBIF TITRTN INJ PACK
3
TYSABRI INJ 300/15ML
3
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA, ST
Pseudobulbar Affect (PBA) Agents
NUEDEXTA CAP 20-10MG
2
Psychotherapeutic and Neurological Agents - Misc.
ergoloid mesylates tab 1 mg
ORAP TAB 1MG
ORAP TAB 2MG
1
3
3
Smoking Deterrents
buproban tab 150mg
0
CHANTIX PAK 0.5& 1MG
0
CHANTIX PAK 1MG
0
CHANTIX TAB 0.5MG
0
nicotine polacrilex gum 2 mg
0
0
ST - Step Therapy
$0 limited to 2
treatment cycles/year
$0 limited to 2
$0 limited to 2
$0 limited to 2
OTC; $0 limited to 2
OTC - Over the
100
Drug Name
nicotine polacrilex lozenge 2 mg
0
0
0
0
0
0
QL (max 168 days per
year); $0 limited to 2
0
QL (max 168 days per
year); $0 limited to 2
0
0
0
0
nicotine td patch 24hr 7 mg/24hr
NICOTROL INH
NICOTROL NS SPR 10MG/ML
sm nicotine dis 7mg/24hr
sm nicotine dis 14mg/24h
sm nicotine dis 21mg
thrive gum 4mg mint
RESPIRATORY AGENTS - MISC.
Alpha-Proteinase Inhibitor (Human)
ARALAST NP INJ 400MG
GLASSIA INJ
PROLASTIN-C INJ 1000MG
ZEMAIRA INJ 1000MG
3
3
3
3
3
3
3
PA
PA
PA
PA
PA
PA
PA
3
PA
Cystic Fibrosis Agents
ORKAMBI TAB 200-125
SULFONAMIDES
Sulfonamides
SULFADIAZINE TAB 500MG
3
TETRACYCLINES
Tetracyclines
avidoxy tab 100mg
demeclocycline hcl tab 150 mg
doxycycline hyclate cap 50 mg
doxycycline hyclate tab 20 mg
1
1
1
1
1
1
ST - Step Therapy
OTC - Over the
101
Drug Name
doxycycline monohydrate cap 50 mg
doxycycline monohydrate for susp 25
mg/5ml
doxycycline monohydrate tab 50 mg
minocycline hcl cap 50 mg
minocycline hcl tab 50 mg
minocycline hcl tab sr 24hr 45 mg
morgidox cap 1x100mg
tetracycline hcl cap 250 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
THYROID AGENTS
Antithyroid Agents
methimazole tab 5 mg
propylthiouracil tab 50 mg
1
1
1
Thyroid Hormones
levothyroxine sodium
levoxyl tab 25mcg
levoxyl tab 50mcg
levoxyl tab 75mcg
tab
tab
tab
tab
tab
tab
tab
tab
tab
tab
tab
tab
25 mcg
50 mcg
75 mcg
88 mcg
100 mcg
112 mcg
125 mcg
137 mcg
150 mcg
175 mcg
200 mcg
300 mcg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
OTC - Over the
102
Drug Name
levoxyl tab 88mcg
levoxyl tab 100mcg
levoxyl tab 112mcg
levoxyl tab 125mcg
levoxyl tab 137mcg
levoxyl tab 150mcg
levoxyl tab 175mcg
levoxyl tab 200mcg
liothyronine sodium tab 5 mcg
SYNTHROID TAB 25MCG
SYNTHROID TAB 50MCG
SYNTHROID TAB 75MCG
SYNTHROID TAB 88MCG
SYNTHROID TAB 100MCG
unithroid tab 25mcg
unithroid tab 50mcg
unithroid tab 75mcg
unithroid tab 88mcg
unithroid tab 100mcg
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
TOXOIDS
Toxoid Combinations
ADACEL INJ
BOOSTRIX INJ
DAPTACEL INJ
0
0
0
DIP/TET PED INJ 25-5LFU
0
INFANRIX INJ
0
KINRIX INJ
0
ST - Step Therapy
age 18 and younger
age 18 and younger
age 18 and younger
age 18 and younger
OTC - Over the
103
Drug Name
PEDIARIX INJ 0.5ML
0
age 18 and younger
0
age 18 and younger
0
age 19 and older
0
age 19 and older
0
age 18 and younger
PENTACEL INJ
TENIVAC INJ 5-2LF
TET/DIP TOX INJ 2-2 LF
TRIPEDIA SUS P/F
ULCER DRUGS
Antispasmodics
chlordiazepoxide hcl-clidinium bromide cap
5-2.5 mg
CUVPOSA SOL 1MG/5ML
dicyclomine hcl cap 10 mg
dicyclomine hcl oral soln 10 mg/5ml
dicyclomine hcl tab 20 mg
ed-spaz tab 0.125mg
hyomax-sl sub 0.125mg
hyoscyamine sulfate tab 0.125 mg
hyoscyamine sulfate tab disp 0.125 mg
hyoscyamine sulfate tab sl 0.125 mg
hyoscyamine sulfate tab sr 12hr 0.375 mg
methscopolamine bromide tab 2.5 mg
methscopolamine bromide tab 5 mg
nulev tab 0.125mg
oscimin sr tab 0.375mg
oscimin sub 0.125mg
oscimin tab 0.125mg
symax fastab tab 0.125mg
symax-sl sub 0.125mg
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
H-2 Antagonists
cimetidine hcl soln 300 mg/5ml
cimetidine tab 200 mg
famotidine for susp 40 mg/5ml
famotidine tab 20 mg
nizatidine cap 150 mg
nizatidine oral soln 15 mg/ml
ranitidine hcl cap 150 mg
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
OTC - Over the
104
Drug Name
ranitidine hcl
ranitidine hcl
ranitidine hcl
ranitidine hcl
cap 300 mg
1
syrup 15 mg/ml (75 mg/5ml) 1
tab 150 mg
1
tab 300 mg
1
Misc. Anti-Ulcer
CARAFATE SUS 1GM/10ML
sucralfate tab 1 gm
3
1
Proton Pump Inhibitors
DEXILANT CAP 30MG DR
3
3
esomeprazole magnesium cap delayed
release 20 mg (base eq)
lansoprazole cap 15mg dr
1
QL (90 caps / 365
days), ST; PA**
QL (90 caps / 365
days), ST; PA**
1
1
lansoprazole cap delayed release 15 mg
lansoprazole cap delayed release 30 mg
NEXIUM 24HR CAP 20MG
1
1
1
NEXIUM GRA 2.5MG DR
3
NEXIUM GRA 5MG DR
3
NEXIUM GRA 10MG DR
3
NEXIUM GRA 20MG DR
3
NEXIUM GRA 40MG DR
3
omeprazole cap delayed release 10 mg
omeprazole magnesium cap dr 20.6 mg
(20 mg base equiv)
OMEPRAZOLE TAB 20MG
1
1
1
1
pantoprazole sodium ec tab 20 mg (base
equiv)
equiv)
rabeprazole sodium ec tab 20 mg
1
QL (90 caps / 365
days); OTC
QL (90 caps / 365
days); OTC
QL (90 packets / 365
days), ST
days), ST
days), ST
days), ST
days), ST
QL (90 caps / 365
days); OTC
OTC
1
1
1
Ulcer Drugs - Prostaglandins
misoprostol tab 100 mcg
1
1
Ulcer Therapy Combinations
ST - Step Therapy
OTC - Over the
105
Drug Name
omeprazole-sodium bicarbonate cap 201100 mg
1
1
2
PA; High Risk
older; PA applies to
greater than cumulative
90 days of therapy per
year
URINARY ANTI-INFECTIVES
Urinary Anti-infectives
MACRODANTIN CAP 25MG
methenamine hippurate tab 1 gm
1
MONUROL PAK GRANULES
3
nitrofurantoin macrocrystalline cap 50 mg 1
nitrofurantoin macrocrystalline cap 100 mg 1
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
1
PA; High Risk
year
PA; High Risk
year
PA; High Risk
year
URINARY ANTISPASMODICS
Beta-3 Adrenergic Agonists
MYRBETRIQ TAB 25MG
MYRBETRIQ TAB 50MG
3
3
ST; PA**
ST; PA**
Urinary Antispasmodics
bethanechol chloride tab 5 mg
ENABLEX TAB 7.5MG
ENABLEX TAB 15MG
flavoxate hcl tab 100 mg
GELNIQUE GEL 3%
oxybutynin chloride syrup 5 mg/5ml
1
1
1
1
3
3
1
3
1
ST - Step Therapy
ST; PA**
ST; PA**
ST; PA**
OTC - Over the
106
Drug Name
oxybutynin chloride tab 5 mg
oxybutynin chloride tab sr 24hr 5 mg
OXYTROL DIS 3.9MG/24
tolterodine tartrate cap sr 24hr 2 mg
tolterodine tartrate cap sr 24hr 4 mg
tolterodine tartrate tab 1 mg
TOVIAZ TAB 4MG
TOVIAZ TAB 8MG
trospium chloride cap sr 24hr 60 mg
trospium chloride tab 20 mg
VESICARE TAB 5MG
VESICARE TAB 10MG
1
1
1
1
3
ST; PA**
1
1
1
1
3
ST; PA**
3
ST; PA**
1
1
3
ST; PA**
3
ST; PA**
VACCINES
Bacterial Vaccines
ACTHIB INJ
0
BEXSERO INJ
HIBERIX SOL 10MCG
0
0
MENACTRA INJ
MENHIBRIX INJ
0
0
MENOMUNE INJ A/C/Y/W
MENVEO INJ
PEDVAX HIB INJ
0
0
0
PNEUMOVAX 23 INJ 25/0.5
PREVNAR 13 INJ
TRUMENBA INJ
0
0
0
age 18 and younger
age 18 and younger
age 18 and younger
age 18 and younger
Mixed Vaccine Combinations
COMVAX INJ
0
age 18 and younger
Viral Vaccines
AFLURIA INJ 2015-16
AFLURIA INJ PF 15-16
CERVARIX INJ
ENGERIX-B INJ 10/0.5ML
ENGERIX-B INJ 20MCG/ML
FLUBLOK SOL 2015-16
FLUCELVAX INJ 2015-16
FLUMIST QUAD SUS 2014-15
FLUVIRIN INJ 2015-16
0
0
0
0
0
0
0
0
0
ST - Step Therapy
OTC - Over the
107
Drug Name
FLUZONE HD INJ PF 15-16
FLUZONE INJ INTRADRM
FLUZONE QUAD INJ 15-16
FLUZONE SPLT INJ 2015-16
GARDASIL 9 INJ
GARDASIL INJ
HAVRIX INJ 720UNIT
HAVRIX INJ 1440UNIT
INFLUENZA A SPR 09 H1N1
IPOL INJ INACTIVE
0
0
0
0
0
0
0
0
0
0
age 18 and younger
0
0
age 18 and younger
0
0
0
0
age 18 and younger
0
age 18 and younger
0
age 19 and older
0
0
0
0
age 19 and older
M-M-R II INJ
PROQUAD INJ
RECOMBIVA HB INJ 5MCG/0.5
RECOMBIVA HB INJ 10MCG/ML
RECOMBIVA-HB INJ 40MCG/ML
ROTARIX SUS
ROTATEQ SOL
TWINRIX INJ
VAQTA INJ 25/0.5ML
VAQTA INJ 50UNT/ML
VARIVAX INJ
ZOSTAVAX INJ
VAGINAL PRODUCTS
Spermicides
CONCEPTROL GEL 4%
ENCARE SUP 100MG
GYNOL II GEL 3%
SHUR-SEAL GEL 2%
TODAY SPONGE MIS
VCF VAGINAL AER CONTRACP
VCF VAGINAL MIS CONTRACP
0
0
0
0
0
0
0
OTC
OTC
OTC
OTC
OTC
OTC
OTC
Vaginal Anti-infectives
CLEOCIN SUP 100MG
clindamycin phosphate vaginal cream 2%
metronidazole vaginal gel 0.75%
miconazole 3 kit combo pk
miconazole 3 sup 200mg
terconazole vaginal cream 0.4%
terconazole vaginal suppos 80 mg
2
1
1
1
1
1
1
ST - Step Therapy
OTC - Over the
108
Drug Name
vandazole gel 0.75%
zazole cre 0.4%
zazole cre 0.8%
zazole sup 80mg
1
1
1
1
Vaginal Estrogens
ESTRACE VAG CRE 0.1MG/GM
PREMARIN VAG CRE 0.625MG
2
3
Vaginal Progestins
CRINONE GEL 4% VAG
CRINONE GEL 8% VAG
2
2
VASOPRESSORS
Anaphylaxis Therapy Agents
epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)
mg/0.15ml (1:1000)
EPIPEN 2-PAK INJ 0.3MG
EPIPEN-JR INJ 2-PAK
1
1
2
2
Vasopressors
midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg
1
1
1
VITAMINS
Oil Soluble Vitamins
bio-d-mulsio liq 400unit
0
child vit d chw 400unit
0
cholecalciferol cap 400 unit
0
D-VI-SOL LIQ 400UNIT
0
decara cap 50000unt
ergocalciferol cap 50000 unit
MEPHYTON TAB 5MG
pedia d-vite dro 400unit
1
1
2
0
sm vitamin d tab 400unit
0
VITAMIN D2 TAB 400UNIT
0
VITAMIN D3 LIQ 1000UNIT
0
ST - Step Therapy
OTC; $0 applies
65 and older
OTC; $0 applies
65 and older
OTC; $0 applies
65 and older
OTC; $0 applies
65 and older
OTC
for ages
OTC; $0 applies
65 and older
OTC; $0 applies
65 and older
OTC; $0 applies
65 and older
OTC; $0 applies
65 and older
for ages
OTC - Over the
for ages
for ages
for ages
for ages
for ages
for ages
109
Index
8
8-MOP CAP 10MG
70
A
abacavir sulfate tab 300 mg (base
equiv)
51
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg
51
ABELCET INJ 5MG/ML
30
50
50
ABRAXANE INJ 100MG
45
ABREVA CRE 10%
71
ABSTRAL SUB 100MCG
6
ABSTRAL SUB 200MCG
6
ABSTRAL SUB 300MCG
6
ABSTRAL SUB 400MCG
6
ABSTRAL SUB 600MCG
6
ABSTRAL SUB 800MCG
6
acamprosate calcium tab delayed release
333 mg
99
ACANYA GEL 1.2-2.5%
66
acarbose tab 100 mg
25
acarbose tab 25 mg
25
acarbose tab 50 mg
25
acd/fluoride dro 0.25mg
91
55
55
acetaminophen w/ codeine soln 120-12
mg/5ml
9
acetaminophen w/ codeine tab 300-15
mg
9
mg
9
mg
9
acetazolamide sodium for inj 500 mg
75
acetic acid 2% in aluminum acetate otic
soln
97
acetic acid otic soln 2%
97
65
65
acitretin cap 10 mg
70
acitretin cap 17.5 mg
70
acitretin cap 25 mg
70
acne cleansi bar 10%
66
acne medicat gel 5%
66
ACNE MEDICAT LOT 10%
66
ACNE MEDICAT LOT 5%
66
ACTEMRA INJ 162/0.9
3
ACTEMRA INJ 200/10ML
3
ACTEMRA INJ 400/20ML
3
ACTEMRA INJ 80MG/4ML
3
ACTHIB INJ
107
acticin cre 5%
74
acyclovir cap 200 mg
54
acyclovir susp 200 mg/5ml
54
54
54
ADACEL INJ
103
adapalene cream 0.1%
66
adapalene gel 0.1%
66
adapalene gel 0.3%
66
adapalene lotion 0.1%
66
ADCIRCA TAB 20MG
59
adefovir dipivoxil tab 10 mg
53
adriamycin inj 10mg
42
ADRIAMYCIN INJ 20MG
42
adrucil inj 2.5g/50m
40
adrucil inj 500/10ml
40
88
15
15
15
15
15
15
57
57
AFINITOR DIS TAB 2MG
42
42
42
AFINITOR TAB 10MG
43
AFINITOR TAB 2.5MG
42
AFINITOR TAB 5MG
42
AFINITOR TAB 7.5MG
43
AFLURIA INJ 2015-16
107
AFLURIA INJ PF 15-16
107
alagesic lq sol
5
ALBENZA TAB 200MG
11
albuterol sulfate soln nebu 0.083% (2.5
mg/3ml)
15
albuterol sulfate soln nebu 0.5% (5
mg/ml)
15
(base equiv)
15
(base equiv)
16
albuterol sulfate syrup 2 mg/5ml
16
16
16
16
16
alclometasone dipropionate cream
0.05%
71
alclometasone dipropionate oint 0.05% 71
ALCOHOL PREP WIPES AND SWABS
88
ALDACTAZIDE TAB 50/50
75
alendronate sodium oral soln 70
mg/75ml
76
76
76
76
76
76
ALFERON N INJ 5MU/ML
44
alfuzosin hcl tab sr 24hr 10 mg
83
110
ALIMTA INJ 100MG
40
ALIMTA INJ 500MG
40
ALINIA SUS 100/5ML
11
ALINIA TAB 500MG
11
ALKERAN TAB 2MG
39
all day allg cap 10mg
31
31
31
allergy relf tab 10mg
31
allergy tab 10mg
31
ALLFEN CDX LIQ
65
83
83
89
89
ALOCRIL SOL 2%
96
ALOMIDE SOL 0.1% OP
96
alosetron hcl tab 0.5 mg (base equiv) 82
alosetron hcl tab 1 mg (base equiv)
82
ALOXI INJ 0.25MG/5
29
alphatrex gel 0.05%
71
ALPRAZOLAM CON 1 MG/ML
13
mg
13
mg
13
alprazolam orally disintegrating tab 1
mg
13
alprazolam orally disintegrating tab 2
mg
13
13
13
alprazolam tab 1 mg
13
alprazolam tab 2 mg
13
ALREX SUS 0.2%
95
ALTABAX OIN 1%
69
altavera tab
61
alyacen tab 1/35
61
alyacen tab 7/7/7
61
amantadine hcl cap 100 mg
46
amantadine hcl syrup 50 mg/5ml
46
amantadine hcl tab 100 mg
46
amcinonide cream 0.1%
71
amcinonide lotion 0.1%
71
AMCINONIDE OIN 0.1%
71
amethia tab
61
amethyst tab 90-20mcg
61
amifostine crystalline for inj 500 mg
45
amiloride & hydrochlorothiazide tab 5-50
mg
75
amiloride hcl tab 5 mg
75
14
14
23
23
23
23
23
23
57
amlodipine besylate tab 2.5 mg
57
57
amlodipine besylate-atorvastatin calcium
tab 10-10 mg
59
tab 10-20 mg
59
tab 10-40 mg
59
tab 10-80 mg
59
tab 2.5-10 mg
59
tab 2.5-20 mg
59
tab 2.5-40 mg
59
tab 5-10 mg
59
tab 5-20 mg
59
tab 5-40 mg
59
tab 5-80 mg
59
amlodipine besylate-benazepril hcl cap 1020 mg
35
35
amlodipine besylate-benazepril hcl cap
2.5-10 mg
35
35
35
35
amlodipine besylate-valsartan tab 10-160
mg
35
mg
35
mg
35
mg
35
amlodipine-valsartan-hydrochlorothiazide
tab 10-160-12.5 mg
36
tab 10-160-25 mg
36
tab 10-320-25 mg
36
tab 5-160-12.5 mg
36
tab 5-160-25 mg
36
amnesteem cap 10mg
66
amnesteem cap 20mg
66
amnesteem cap 40mg
66
23
23
amoxapine tab 25 mg
23
amoxapine tab 50 mg
23
amoxicillin & k clavulanate chew tab 200-
111
28.5 mg
98
amoxicillin & k clavulanate chew tab 40057 mg
98
amoxicillin & k clavulanate for susp 20028.5 mg/5ml
98
98
amoxicillin & k clavulanate for susp 40057 mg/5ml
98
98
amoxicillin & k clavulanate tab 250-125
mg
98
mg
98
mg
98
amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg
98
amoxicillin (trihydrate) cap 250 mg
97
amoxicillin (trihydrate) cap 500 mg
97
amoxicillin (trihydrate) chew tab 125
mg
97
amoxicillin (trihydrate) chew tab 250
mg
97
mg/5ml
97
mg/5ml
97
mg/5ml
97
mg/5ml
98
98
98
24hr 10 mg
1
24hr 15 mg
1
24hr 20 mg
1
24hr 25 mg
1
24hr 30 mg
1
24hr 5 mg
1
mg
1
amphetamine-dextroamphetamine tab
12.5 mg
1
mg
1
mg
1
mg
1
mg
1
amphetamine-dextroamphetamine tab 7.5
mg
1
AMPHOTEC INJ 100MG
30
AMPHOTEC INJ 50MG
30
amphotericin b for inj 50 mg
30
98
98
98
98
ANADROL-50 TAB 50MG
10
anagrelide hcl cap 0.5 mg
83
anagrelide hcl cap 1 mg
83
anastrozole tab 1 mg
41
android cap 10mg
10
ANDROXY TAB 10MG
10
anti-diarrhe tab 2mg
28
anti-fungal pow 1%
69
antifungal cre 1%
69
antifungal cre 2%
69
ANTIVERT TAB 50MG
29
apexicon oin 0.05%
71
APIDRA INJ SOLOSTAR
27
APIDRA INJ U-100
27
APOKYN INJ 10MG/ML
46
apri tab
61
APRISO CAP 0.375GM
82
APTIVUS CAP 250MG
51
APTIVUS SOL
51
101
101
101
101
aranelle tab
61
ARANESP INJ 100MCG
84
ARANESP INJ 10MCG
84
ARANESP INJ 150MCG
84
ARANESP INJ 200MCG
84
ARANESP INJ 25MCG
84
ARANESP INJ 300MCG
84
ARANESP INJ 40MCG
84
ARANESP INJ 500MCG
84
ARANESP INJ 60MCG
84
arbinoxa sol 4mg/5ml
30
18
argatroban inj 250 mg/2.5ml (concentrate
for iv infusion)
18
18
aripiprazole oral solution 1 mg/ml
50
50
51
50
51
51
50
ARRANON INJ 5MG/ML
40
15
15
15
15
15
aspirin chew tab 81 mg
5
aspirin low tab 81mg ec
6
aspirin tab 325 mg
6
112
aspirin tab 81 mg
6
aspirin tab delayed release 325 mg
6
aspirin-dipyridamole cap sr 12hr 25-200
mg
83
atenolol & chlorthalidone tab 100-25 mg36
atenolol & chlorthalidone tab 50-25 mg 36
atenolol tab 100 mg
55
atenolol tab 25 mg
55
atenolol tab 50 mg
55
ath foot spr aer 1%
69
atorvastatin calcium tab 10 mg (base
equivalent)
32
equivalent)
32
equivalent)
32
equivalent)
32
atovaquone-proguanil hcl tab 250-100
mg
38
atovaquone-proguanil hcl tab 62.5-25
mg
38
ATRIPLA TAB
51
atropine sulfate ophth soln 1%
94
AUBAGIO TAB 14MG
100
AUBAGIO TAB 7MG
100
AUGMENTIN SUS 125/5ML
98
AVAGE CRE 0.1%
68
avar cleanse emu 10-5%
66
avar-e green cre 10-5%
66
aviane tab
61
avidoxy tab 100mg
101
avita cre 0.025%
66
avita gel 0.025%
66
AVODART CAP 0.5MG
83
azacitidine for inj 100 mg
40
azathioprine tab 50 mg
54
azelastine hcl nasal spray 0.1% (137
mcg/spray)
93
azelastine hcl nasal spray 0.15% (205.5
mcg/spray)
93
azelastine hcl ophth soln 0.05%
96
AZELEX CRE 20%
66
AZILECT TAB 0.5MG
47
AZILECT TAB 1MG
47
azithromycin for susp 100 mg/5ml
87
azithromycin for susp 200 mg/5ml
87
azithromycin powd pack for susp 1 gm 87
azithromycin tab 250 mg
87
87
87
AZOPT SUS 1% OP
96
11
11
azurette tab 28 day
61
B
bacitracin oin 500/gm
bacitracin ophth oint 500 unit/gm
bacitracin-polymyxin b ophth oint
69
95
95
bacitracin-polymyxin-neomycin-hc ophth
oint 1%
95
baclofen tab 10 mg
92
baclofen tab 20 mg
92
balsalazide disodium cap 750 mg
82
BANZEL SUS 40MG/ML
18
BANZEL TAB 200MG
18
BANZEL TAB 400MG
18
BARACLUDE SOL .05MG/ML
53
benazepril & hydrochlorothiazide tab 1012.5 mg
36
36
benazepril & hydrochlorothiazide tab 2025 mg
36
36
33
33
33
33
BENICAR TAB 20MG
34
BENICAR TAB 40MG
34
BENICAR TAB 5MG
34
BENZAMYCIN GEL PAK
66
benzepro aer 5.3%
66
BENZIQ GEL 5.25%
66
BENZIQ LS GEL 2.75%
66
65
65
benzoyl per gel 10%
66
BENZOYL PER GEL 2.5%
66
66
66
benzoyl per lot 6%
66
66
66
benzoyl peroxide gel 5%
66
benzoyl peroxide-erythromycin gel 53%
66
benztropine mesylate tab 0.5 mg
46
46
46
BEPREVE DRO 1.5%
96
BESIVANCE SUS 0.6%
95
cream 0.05%
71
lotion 0.05%
71
oint 0.05%
71
betamethasone dipropionate cream
0.05%
71
betamethasone dipropionate lotion
0.05%
71
betamethasone dipropionate oint 0.05% 71
betamethasone valerate aerosol foam
0.12%
71
betamethasone valerate cream 0.1%
71
betamethasone valerate lotion 0.1%
71
betamethasone valerate oint 0.1%
71
113
BETASERON INJ 0.3MG
100
betaxolol hcl ophth soln 0.5%
94
55
55
106
106
106
106
BETIMOL SOL 0.25%
94
BETIMOL SOL 0.5%
94
BETOPTIC-S SUS 0.25% OP
94
bexarotene cap 75 mg
44
BEXSERO INJ
107
BEYAZ TAB
61
bicalutamide tab 50 mg
41
BICNU INJ 100MG
39
BILTRICIDE TAB 600MG
11
bimatoprost ophth soln 0.03%
96
bio-d-mulsio liq 400unit
109
30
30
bisoprolol & hydrochlorothiazide tab 106.25 mg
36
bisoprolol & hydrochlorothiazide tab 2.56.25 mg
36
bisoprolol & hydrochlorothiazide tab 56.25 mg
36
56
56
42
42
BLEPHAMIDE OIN S.O.P.
95
BLEPHAMIDE SUS OP
95
BLOOD GLUCOSE CALIBRATION
SOLUTION
88
BOOSTRIX INJ
103
BOSULIF TAB 100MG
43
BOSULIF TAB 500MG
43
BP CLEANSING LOT 4%
66
bp gel gel 10%
66
bp wash liq 10%
67
bp wash liq 2.5%
67
bp wash liq 5%
67
bp wash liq 5.25%
67
bp wash liq 7%
67
BPO CLOTHS MIS 3%
67
bpo cloths mis 6%
67
BPO CLOTHS MIS 9%
67
BPO GEL 4%
67
BPO GEL 8%
67
bpo-10 wash liq 10%
67
bpo-5 wash liq 5%
67
16
16
BRILINTA TAB 90MG
83
brimonidine tartrate ophth soln 0.15% 95
94
bromfenac sodium ophth soln 0.09%
(base equiv) (once-daily)
96
bromfenac sodium ophth soln 0.09%
(base equivalent)
96
bromocriptine mesylate cap 5 mg
46
bromocriptine mesylate tab 2.5 mg
46
brompheniramine tannate chew tab 12
mg
30
BROVANA NEB 15MCG
16
budesonide cap sr 24hr 3 mg
64
budesonide inhalation susp 0.25
mg/2ml
15
budesonide inhalation susp 0.5 mg/2ml 15
budesonide inhalation susp 1 mg/2ml
15
bumetanide tab 0.5 mg
75
bumetanide tab 1 mg
75
bumetanide tab 2 mg
75
buprenorphine hcl sl tab 2 mg (base
equiv)
10
buprenorphine hcl sl tab 8 mg (base
equiv)
10
buprenorphine hcl-naloxone hcl sl tab 20.5 mg (base equiv)
10
buprenorphine hcl-naloxone hcl sl tab 8-2
mg (base equiv)
10
buproban tab 150mg
100
21
21
bupropion hcl tab sr 12hr 100 mg
21
21
21
21
21
13
13
13
13
buspirone hcl tab 7.5 mg
13
BUSULFEX INJ 6MG/ML
39
5
5
butalbital-acetaminophen-caffeine tab 50325-40 mg
5
butalbital-aspirin-caffeine cap 50-325-40
mg
5
butalbital-aspirin-caffeine tab 50-325-40
mg
5
butorphanol tartrate nasal soln 10
mg/ml
10
BYSTOLIC TAB 10MG
56
BYSTOLIC TAB 2.5MG
56
BYSTOLIC TAB 20MG
56
BYSTOLIC TAB 5MG
56
C
cabergoline tab 0.5 mg
78
CAFERGOT TAB 1-100MG
88
calcipotriene cream 0.005%
70
calcipotriene oint 0.005%
70
calcipotriene soln 0.005% (50 mcg/ml) 70
calcipotriene-betamethasone dipropionate
114
oint 0.005-0.064%
71
calcitonin (salmon) nasal soln 200
unit/act
76
77
77
calcitriol oint 3 mcg/gm
70
calcitriol oral soln 1 mcg/ml
77
calcium acetate (phosphate binder) cap
667 mg (169 mg ca)
82
calcium acetate (phosphate binder) tab
667 mg
82
camila tab 0.35mg
64
CAMPTOSAR INJ 300/15ML
46
CANASA SUP 1000MG
82
CANCIDAS INJ 50MG
29
CANCIDAS INJ 70MG
29
34
34
34
34
candesartan cilexetil-hydrochlorothiazide
tab 16-12.5 mg
36
tab 32-12.5 mg
36
tab 32-25 mg
36
CAPASTAT SUL INJ 1GM
39
40
40
CAPITAL/COD SUS 120-12/5
9
CAPRELSA TAB 100MG
43
CAPRELSA TAB 300MG
43
captopril & hydrochlorothiazide tab 25-15
mg
36
mg
36
mg
36
mg
36
captopril tab 100 mg
33
captopril tab 12.5 mg
33
captopril tab 25 mg
33
captopril tab 50 mg
33
CARAFATE SUS 1GM/10ML
105
carbamazepine chew tab 100 mg
18
carbamazepine susp 100 mg/5ml
18
carbamazepine tab 200 mg
18
18
18
tab 10-100 mg
46
tab 25-100 mg
46
tab 25-250 mg
46
47
47
47
carbidopa & levodopa tab cr 25-100 mg 47
carbidopa & levodopa tab cr 50-200 mg 47
carbidopa tab 25 mg
50-200 mg
18.75-75-200 mg
100-200 mg
31.25-125-200 mg
150-200 mg
200-200 mg
carbinoxamine maleate tab 4 mg
carboplatin iv for inj 150 mg
CARDIZEM LA TAB 120MG
CARDURA XL TAB 4MG
CARDURA XL TAB 8MG
carteolol hcl ophth soln 1%
carvedilol tab 25 mg
caziant pak
cefaclor cap 250 mg
cefaclor cap 500 mg
CEFACLOR ER TAB 500MG
cefadroxil cap 500 mg
cefadroxil tab 1 gm
cefdinir cap 300 mg
CEFEPIME INJ 1GM
CEFEPIME INJ 2GM
cefpodoxime proxetil for susp 100
mg/5ml
cefpodoxime proxetil for susp 50
mg/5ml
46
12.547
47
2547
47
37.547
5047
30
39
39
39
39
39
57
83
83
92
92
94
57
57
57
57
55
55
55
55
61
60
60
60
60
60
60
59
60
60
60
60
60
60
61
61
61
61
60
60
60
60
60
60
60
115
60
60
60
ceftazidime for inj 2 gm
60
CEFTAZIDIME INJ 100GM
60
CEFTIN SUS 125/5ML
60
CEFTIN SUS 250/5ML
60
60
60
60
60
60
60
60
60
60
3
3
3
celecoxib cap 50 mg
3
CENESTIN TAB 0.3MG
78
CENESTIN TAB 0.45MG
79
CENESTIN TAB 0.625MG
79
CENESTIN TAB 0.9MG
79
CENESTIN TAB 1.25MG
79
CENTANY AT KIT 2%
69
60
60
60
60
60
60
60
84
84
cerisa wash emu 10-1%
67
CERVARIX INJ
107
cesia pak
61
31
31
cetirizine sol 1mg/ml
31
cevimeline hcl cap 30 mg
91
CHANTIX PAK 0.5& 1MG
100
CHANTIX PAK 1MG
100
CHANTIX TAB 0.5MG
100
chateal tab 0.15/30
61
CHEMET CAP 100MG
29
child vit d chw 400unit
109
chlordiazepoxide hcl-clidinium bromide cap
5-2.5 mg
104
chlorhexidine gluconate soln 0.12%
91
38
38
75
75
50
50
50
50
50
28
28
76
75
75
chlorzoxazone tab 500 mg
92
cholecalciferol cap 400 unit
109
cholestyramine light powder 4 gm/dose 32
cholestyramine light powder packets 4
gm
32
cholestyramine powder 4 gm/dose
32
cholestyramine powder packets 4 gm
32
chorionic gonadotropin for inj 10000
unit
76
CIALIS TAB 2.5MG
83
CIALIS TAB 5MG
83
ciclopirox gel 0.77%
69
ciclopirox kit 8%
69
ciclopirox olamine cream 0.77% (base
equiv)
69
ciclopirox olamine susp 0.77% (base
equiv)
69
ciclopirox shampoo 1%
69
ciclopirox solution 8%
69
83
83
CILOXAN OIN 0.3% OP
95
cimetidine hcl soln 300 mg/5ml
104
104
104
104
104
CIPRO HC SUS OTIC
97
CIPRODEX SUS 0.3-0.1%
97
(5%) (5 gm/100ml)
81
(10%) (10 gm/100ml)
81
ciprofloxacin hcl ophth soln 0.3%
95
ciprofloxacin hcl tab 100 mg (base
equiv)
81
equiv)
81
equiv)
81
equiv)
81
1000 mg(base eq)
81
500 mg (base eq)
81
cisplatin inj 100 mg/100ml (1 mg/ml) 39
cisplatin inj 200 mg/200ml (1 mg/ml) 39
39
citalopram hydrobromide oral soln 10
mg/5ml
22
equiv)
22
equiv)
22
116
equiv)
22
CITRANATAL CAP HARMONY
92
CITRANATAL MIS 90 DHA
92
CITRANATAL MIS B-CALM
92
CITRANATAL PAK ASSURE
92
CITRANATAL PAK DHA
92
CITRANATAL TAB RX
92
cladribine inj 1 mg/ml
40
claravis cap 10mg
67
claravis cap 20mg
67
claravis cap 30mg
67
claravis cap 40mg
67
CLARINEX SYP 0.5MG/ML
31
clarithromycin for susp 125 mg/5ml
87
clarithromycin for susp 250 mg/5ml
87
clarithromycin tab 250 mg
87
clarithromycin tab 500 mg
87
clarithromycin tab sr 24hr 500 mg
87
clean&clear cre 10%
67
CLEAR PORE LIQ 3.5%
67
clearplex x gel 10%
67
clemastine fumarate syrup 0.67 mg/5ml
(0.5 mg/5ml base eq)
30
clemastine fumarate tab 2.68 mg
31
CLEOCIN SUP 100MG
108
CLIMARA PRO DIS WEEKLY
78
CLINDACIN KIT PAC 1%
67
clindacin mis etz 1%
67
12
12
12
clindamycin phosph-benzoyl peroxide
(refrig) gel 1.2 (1)-5%
67
clindamycin phosphate foam 1%
67
clindamycin phosphate gel 1%
67
clindamycin phosphate lotion 1%
67
clindamycin phosphate soln 1%
67
clindamycin phosphate vaginal cream
2%
108
clindamycin phosphate-benzoyl peroxide
gel 1-5%
67
clobetasol propionate cream 0.05%
71
clobetasol propionate foam 0.05%
71
clobetasol propionate gel 0.05%
71
clobetasol propionate lotion 0.05%
71
clobetasol propionate oint 0.05%
71
clobetasol propionate shampoo 0.05% 71
clobetasol propionate spray 0.05%
71
clocortolone pivalate cream 0.1%
71
CLOLAR INJ 1MG/ML
40
clomiphene citrate tab 50 mg
76
23
23
24
clonazepam tab 0.5 mg
18
clonazepam tab 1 mg
18
clonazepam tab 2 mg
18
35
35
35
clonidine hcl td patch weekly 0.1
mg/24hr
35
mg/24hr
35
mg/24hr
35
equiv)
83
equiv)
83
clorazepate dipotassium tab 15 mg
13
13
13
clotrimazole cre 1%
69
clotrimazole cream 1%
69
CLOTRIMAZOLE CRY
69
69
clotrimazole troche 10 mg
91
clotrimazole w/ betamethasone cream 10.05%
69
clotrimazole w/ betamethasone lotion 10.05%
69
clozapine orally disintegrating tab 100
mg
49
clozapine orally disintegrating tab 12.5
mg
49
mg
49
mg
49
mg
49
49
49
clozapine tab 25 mg
49
clozapine tab 50 mg
49
COARTEM TAB 20-120MG
38
CODEINE SULF SOL 30MG/5ML
6
6
6
6
colchicine tab 0.6 mg
83
colchicine w/ probenecid tab 0.5-500
mg
83
colestipol hcl granule packets 5 gm
32
colestipol hcl granules 5 gm
32
colestipol hcl tab 1 gm
32
colocort ene 100mg
10
COLYTE/FLAVR SOL PACKS
86
COMBIGAN SOL 0.2/0.5%
94
COMBIVENT AER RESPIMAT
16
COMETRIQ KIT 100MG
43
COMETRIQ KIT 140MG
43
COMETRIQ KIT 60MG
43
COMPLERA TAB
51
compro sup 25mg
50
COMVAX INJ
107
CONCEPTROL GEL 4%
108
CONDYLOX GEL 0.5%
73
100
100
117
CORDRAN 24X3 TAP 4MCG/CM
71
CORDRAN CRE 0.05%
71
CORDRAN LOT 0.05%
71
CORDRAN OIN 0.05%
71
cormax scalp sol 0.05%
72
cortisone acetate tab 25 mg
64
CORTISPORIN CRE 0.5%
69
CORTISPORIN OIN 1%
69
CORTISPORIN SUS -TC OTIC
97
creamy face liq wash 4%
67
CREON CAP 12000UNT
74
CREON CAP 24000UNT
74
CREON CAP 3000UNIT
74
CREON CAP 36000UNT
74
CREON CAP 6000UNIT
74
CRESTOR TAB 10MG
32
CRESTOR TAB 20MG
33
CRESTOR TAB 40MG
33
CRESTOR TAB 5MG
32
CRINONE GEL 4% VAG
109
CRINONE GEL 8% VAG
109
CRIXIVAN CAP 200MG
51
CRIXIVAN CAP 400MG
51
cromolyn sodium ophth soln 4%
96
cromolyn sodium soln nebu 20 mg/2ml 14
cruex aer 2%
69
cryselle-28 tab 28 tabs
61
CUBICIN SOL 500MG
11
CUVPOSA SOL 1MG/5ML
104
cyanocobalamin inj 1000 mcg/ml
84
cyclafem tab 1/35
61
cyclafem tab 7/7/7
61
92
92
cyclobenzaprine hcl tab 7.5 mg
92
39
39
39
39
cyclophosphamide for inj 500 mg
39
39
39
cycloserine cap 250 mg
39
CYCLOSET TAB 0.8MG
27
54
54
54
cyclosporine modified oral soln 100
mg/ml
54
cyproheptadine hcl syrup 2 mg/5ml
31
cyproheptadine hcl tab 4 mg
32
CYSTADANE POW
77
CYSTAGON CAP 150MG
82
CYSTAGON CAP 50MG
82
cytarabine for inj 1 gm
40
40
40
cytarabine inj 20 mg/ml
40
40
40
D
D-VI-SOL LIQ 400UNIT
109
44
44
dactinomycin for inj 0.5 mg
42
DALIRESP TAB 500MCG
15
danazol cap 100 mg
10
danazol cap 200 mg
10
danazol cap 50 mg
10
93
93
93
dapsone tab 100 mg
12
dapsone tab 25 mg
12
DAPTACEL INJ
103
DARAPRIM TAB 25MG
38
dasetta tab 1/35
61
dasetta tab 7/7/7
61
daunorubicin hcl for inj 20 mg
42
daunorubicin hcl inj 5 mg/ml (base
equiv)
42
DAUNOXOME INJ 2MG/ML
42
decara cap 50000unt
109
decitabine for inj 50 mg
40
101
101
DENAVIR CRE 1%
71
DEPEN TITRA TAB 250MG
54
DEPO-SQ PROV INJ 104
64
DEPOCYT INJ 50MG/5ML
40
desenex spry aer liquid
69
24
24
24
24
24
24
desloratadine tab 5 mg
31
desloratadine tab orally disintegrating 2.5
mg
31
desloratadine tab orally disintegrating 5
mg
31
desmopressin acetate nasal soln 0.01%
(refrigerated)
78
desmopressin acetate nasal spray soln
0.01%
78
desmopressin acetate nasal spray soln
0.01% (refrigerated)
78
desmopressin acetate tab 0.1 mg
78
desmopressin acetate tab 0.2 mg
78
desonide cream 0.05%
72
desonide lotion 0.05%
72
desonide oint 0.05%
72
72
72
desoximetasone gel 0.05%
72
72
72
DEXAMETHASON CON 1MG/ML
64
dexamethasone elixir 0.5 mg/5ml
64
118
dexamethasone sodium phosphate ophth
soln 0.1%
95
dexamethasone soln 0.5 mg/5ml
64
64
64
64
64
64
64
64
dexchlorpheniramine maleate syrup 2
mg/5ml
30
105
105
dexmethylphenidate hcl cap sr 24 hr 10
mg
2
mg
2
mg
2
mg
2
mg
2
mg
2
dexmethylphenidate hcl tab 10 mg
2
dexmethylphenidate hcl tab 2.5 mg
2
dexmethylphenidate hcl tab 5 mg
2
45
45
mg
1
mg
1
mg
1
dextroamphetamine sulfate oral solution 5
mg/5ml
1
1
1
diazepam con 5mg/ml
13
diazepam soln 1 mg/ml
13
diazepam tab 10 mg
14
diazepam tab 2 mg
13
diazepam tab 5 mg
13
diclofenac potassium tab 50 mg
3
diclofenac sodium ophth soln 0.1%
96
mg
3
mg
4
mg
4
diclofenac sodium tab sr 24hr 100 mg
4
release 50-0.2 mg
4
release 75-0.2 mg
4
98
98
dicyclomine hcl cap 10 mg
104
dicyclomine hcl oral soln 10 mg/5ml
104
dicyclomine hcl tab 20 mg
104
didanosine delayed release capsule 125
mg
51
mg
51
mg
51
mg
51
DIFICID TAB 200MG
87
diflorasone diacetate cream 0.05%
72
diflorasone diacetate oint 0.05%
72
diflunisal tab 500 mg
6
digoxin oral soln 0.05 mg/ml
58
58
58
dihydroergotamine mesylate nasal spray 4
mg/ml
89
57
57
57
57
57
57
diltiazem hcl coated beads cap sr 24hr 120
mg
57
mg
57
mg
57
mg
57
mg
57
diltiazem hcl extended release beads cap
sr 24hr 120 mg
57
sr 24hr 180 mg
57
sr 24hr 240 mg
57
sr 24hr 300 mg
57
sr 24hr 360 mg
57
sr 24hr 420 mg
57
DIP/TET PED INJ 25-5LFU
103
DIPENTUM CAP 250MG
82
diphenhydramine hcl cap 25 mg
31
diphenhydramine hcl cap 50 mg
31
diphenhydramine hcl elixir 12.5 mg/5ml 31
diphenhydramine hcl inj 50 mg/ml
31
diphenoxylate w/ atropine liq 2.5-0.025
mg/5ml
28
diphenoxylate w/ atropine tab 2.5-0.025
mg
28
84
84
84
119
14
14
99
99
DIURIL SUS 250/5ML
76
divalproex sodium cap sprinkle 125 mg 20
mg
20
mg
20
mg
20
divalproex sodium tab sr 24 hr 250 mg 20
divalproex sodium tab sr 24 hr 500 mg 20
DOCEFREZ INJ 20MG
45
DOCEFREZ INJ 80MG
45
docetaxel for inj conc 20 mg/ml
45
docetaxel for inj conc 80 mg/4ml (20
mg/ml)
45
45
45
45
DOCETAXEL INJ 20/0.5ML
45
DOCETAXEL INJ 200MG/20
45
45
45
45
99
99
99
99
99
DORIBAX INJ 250MG
11
DORIBAX INJ 500MG
11
dorzolamide hcl ophth soln 2%
96
dorzolamide hcl-timolol maleate ophth
soln 22.3-6.8 mg/ml
94
35
35
35
35
24
24
24
24
24
24
doxepin hcl conc 10 mg/ml
24
77
doxercalciferol cap 1 mcg
77
77
42
42
doxorubicin hcl inj 2 mg/ml
42
101
101
102
101
doxycycline monohydrate cap 100 mg 102
doxycycline monohydrate for susp 25
mg/5ml
102
doxycycline monohydrate tab 150 mg 102
dronabinol cap 10 mg
29
dronabinol cap 2.5 mg
29
dronabinol cap 5 mg
29
drospirenone-ethinyl estradiol tab 3-0.03
mg
61
DROXIA CAP 200MG
84
DROXIA CAP 300MG
84
DROXIA CAP 400MG
84
22
22
22
DUREZOL EMU 0.05%
95
DYRENIUM CAP 100MG
75
DYRENIUM CAP 50MG
75
E
e.e.s. 400 tab 400mg
E.E.S. GRAN SUS 200/5ML
e.s.p. sus 200-600
econazole nitrate cream 1%
ed-spaz tab 0.125mg
EDARBI TAB 40MG
EDARBI TAB 80MG
EDECRIN TAB 25MG
EDURANT TAB 25MG
EFFIENT TAB 10MG
EFFIENT TAB 5MG
ELIDEL CRE 1%
elinest tab
ELIQUIS TAB 2.5MG
ELIQUIS TAB 5MG
ELLA TAB 30MG
ELMIRON CAP 100MG
ELOXATIN INJ 200MG
EMADINE SOL 0.05% OP
EMBEDA CAP 100-4MG
EMBEDA CAP 20-0.8MG
EMBEDA CAP 30-1.2MG
EMBEDA CAP 50-2MG
EMBEDA CAP 60-2.4MG
EMBEDA CAP 80-3.2MG
EMCYT CAP 140MG
EMEND CAP 125MG
EMEND CAP 40MG
EMEND CAP 80MG
EMEND PAK 80 & 125
emoquette tab
EMSAM DIS 12MG/24H
EMSAM DIS 6MG/24HR
EMSAM DIS 9MG/24HR
EMTRIVA CAP 200MG
87
87
11
69
104
34
34
75
51
84
84
73
61
17
17
63
82
39
96
6
6
6
6
6
6
41
29
29
29
29
61
21
21
21
51
120
EMTRIVA SOL 10MG/ML
51
ENABLEX TAB 15MG
106
ENABLEX TAB 7.5MG
106
enalapril maleate & hydrochlorothiazide
tab 10-25 mg
36
enalapril maleate & hydrochlorothiazide
tab 5-12.5 mg
36
33
enalapril maleate tab 2.5 mg
33
33
33
ENBREL INJ 25/0.5ML
5
ENBREL INJ 25MG
5
ENBREL INJ 50MG/ML
5
ENBREL SRCLK INJ 50MG/ML
5
ENCARE SUP 100MG
108
endocet tab 10-325mg
9
endocet tab 5-325mg
9
endocet tab 7.5-325
9
ENGERIX-B INJ 10/0.5ML
107
ENGERIX-B INJ 20MCG/ML
107
ENJUVIA TAB 0.3MG
79
ENJUVIA TAB 0.45MG
79
ENJUVIA TAB 0.625MG
79
ENJUVIA TAB 0.9MG
79
ENJUVIA TAB 1.25MG
79
17
17
17
17
enoxaparin sodium inj 300 mg/3ml
17
17
17
17
enpresse-28 tab
61
entacapone tab 200 mg
46
entecavir tab 0.5 mg
53
entecavir tab 1 mg
53
EPIDUO FORTE GEL 0.3-2.5%
67
EPIDUO GEL 0.1-2.5%
67
epinastine hcl ophth soln 0.05%
96
epinephrine hcl inj 1 mg/ml
16
epinephrine hcl soln prefilled syringe 0.1
mg/ml
16
mg/0.15ml (1:1000)
109
mg/0.3ml (1:1000)
109
EPIPEN 2-PAK INJ 0.3MG
109
EPIPEN-JR INJ 2-PAK
109
mg/ml)
42
mg/ml)
42
EPIRUBICIN INJ 50MG
42
epitol tab 200mg
18
EPIVIR HBV SOL 5MG/ML
53
38
38
59
59
eprosartan mesylate tab 600 mg
34
EPZICOM TAB 600-300
51
ERAXIS INJ 100MG
30
ERAXIS INJ 50MG
30
ERBITUX INJ 100MG
41
ERBITUX INJ 200MG
41
ergocalciferol cap 50000 unit
109
ergoloid mesylates tab 1 mg
100
ERIVEDGE CAP 150MG
41
errin tab 0.35mg
64
ery pad 2%
67
87
87
87
ERYPED SUS 200/5ML
87
ERYPED SUS 400/5ML
87
erythrocin tab 250mg
87
erythromycin ethylsuccinate tab 400 mg 87
erythromycin gel 2%
67
erythromycin ophth oint 5 mg/gm
95
erythromycin soln 2%
67
87
87
erythromycin w/ delayed release particles
cap 250 mg
87
escitalopram oxalate soln 5 mg/5ml (base
equiv)
22
equiv)
22
equiv)
22
equiv)
22
105
105
ESTRACE VAG CRE 0.1MG/GM
109
estradiol & norethindrone acetate tab 0.50.1 mg
78
estradiol & norethindrone acetate tab 10.5 mg
78
estradiol tab 0.5 mg
79
estradiol tab 1 mg
79
estradiol tab 2 mg
79
estradiol td patch weekly 0.025
mg/24hr
80
(37.5 mcg/24hr)
80
estradiol td patch weekly 0.05 mg/24hr 79
estradiol td patch weekly 0.075
mg/24hr
80
80
80
estropipate tab 3 mg
80
86
86
86
121
ethosuximide cap 250 mg
ethosuximide soln 250 mg/5ml
etodolac cap 200 mg
etodolac cap 300 mg
etodolac tab 400 mg
etodolac tab 500 mg
ETOPOPHOS INJ 100MG
etoposide cap 50 mg
etoposide inj 100 mg/5ml (20 mg/ml)
EURAX CRE 10%
EURAX LOT 10%
EVOTAZ TAB 300-150
EXELON SOL 2MG/ML
exemestane tab 25 mg
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
F
FABRAZYME INJ 35MG
FABRAZYME INJ 5MG
FACTIVE TAB 320MG
falmina tab
famotidine for susp 40 mg/5ml
FANAPT PAK
FANAPT TAB 10MG
FANAPT TAB 12MG
FANAPT TAB 1MG
FANAPT TAB 2MG
FANAPT TAB 4MG
FANAPT TAB 6MG
FANAPT TAB 8MG
FARESTON TAB 60MG
FARXIGA TAB 10MG
FARXIGA TAB 5MG
FARYDAK CAP 10MG
FARYDAK CAP 15MG
FARYDAK CAP 20MG
FASLODEX INJ 250MG
FC2 FEMALE MIS CONDOM
felbamate susp 600 mg/5ml
felodipine tab sr 24hr 2.5 mg
FEMCAP MIS 22MM
FEMCAP MIS 26MM
FEMCAP MIS 30MM
fenofibrate micronized cap 130 mg
39
39
20
20
4
4
4
4
45
45
45
74
74
51
99
41
29
29
29
77
77
81
61
54
54
54
104
104
104
48
48
48
48
48
48
48
48
41
28
28
43
43
43
41
87
20
20
20
57
57
57
87
87
87
32
32
32
32
32
32
32
32
32
32
32
fenoprofen calcium cap 400 mg
4
fenoprofen calcium tab 600 mg
4
fentanyl citrate lozenge on a handle 1200
mcg
6
mcg
6
mcg
6
mcg
6
mcg
6
mcg
6
7
7
7
7
7
FER-IN-SOL DRO 15MG/ML
85
FERRIPROX TAB 500MG
29
FERROUS SUL LIQ 220/5ML
85
FERROUS SULF SYP 300/5ML
85
ferrous sulfate elixir 220 mg/5ml (44
mg/5ml elemental fe)
85
ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe)
85
31
31
fexofenadine sus 30mg/5ml
31
FINACEA GEL 15%
73
finasteride tab 5 mg
83
FIRMAGON INJ 120MG
41
FIRMAGON INJ 80MG
41
flavoxate hcl tab 100 mg
106
14
14
14
floxuridine for inj 0.5 gm
40
FLUBLOK SOL 2015-16
107
FLUCELVAX INJ 2015-16
107
30
30
30
30
30
30
fludarabine phosphate for inj 50 mg
40
fludarabine phosphate inj 25 mg/ml
40
fludrocortisone acetate tab 0.1 mg
65
FLUMIST QUAD SUS 2014-15
107
flunisolide nasal soln 25 mcg/act
122
(0.025%)
93
fluocin acet oil 0.01% sc
72
fluocin acet oil body
72
fluocinolone acetonide (otic) oil 0.01% 97
72
fluocinolone acetonide cream 0.025% 72
fluocinolone acetonide oint 0.025%
72
fluocinolone acetonide soln 0.01%
72
72
72
fluocinonide gel 0.05%
72
fluocinonide oint 0.05%
72
fluocinonide soln 0.05%
72
fluor-a-day dro 0.125mg
90
FLUORABON DRO
90
90
90
fluoritab chw 2.2mg
90
fluorometholone ophth susp 0.1%
95
FLUOROPLEX CRE 1%
70
fluorouracil cream 0.5%
70
fluorouracil cream 5%
70
fluorouracil inj 1 gm/20ml (50 mg/ml) 40
fluorouracil inj 2.5 gm/50ml (50 mg/ml) 40
fluorouracil inj 5 gm/100ml (50 mg/ml) 40
fluorouracil inj 500 mg/10ml (50
mg/ml)
40
70
70
22
22
22
fluoxetine hcl solution 20 mg/5ml
22
22
22
fluphenazine hcl elixir 2.5 mg/5ml
50
fluphenazine hcl oral conc 5 mg/ml
50
50
50
fluphenazine hcl tab 2.5 mg
50
50
flura-drops dro 0.125mg
90
flura-drops dro 0.25mg f
90
flurbiprofen sodium ophth soln 0.03% 96
4
4
flutamide cap 125 mg
41
fluticasone propionate cream 0.05%
72
fluticasone propionate lotion 0.05%
72
fluticasone propionate nasal susp 50
mcg/act
94
fluticasone propionate oint 0.005%
72
33
33
FLUVIRIN INJ 2015-16
107
fluvoxamine maleate cap sr 24hr 100
mg
22
fluvoxamine maleate cap sr 24hr 150
mg
22
22
22
22
FLUZONE HD INJ PF 15-16
108
FLUZONE INJ INTRADRM
108
FLUZONE QUAD INJ 15-16
108
FLUZONE SPLT INJ 2015-16
108
folbic tab
74
folic acid tab 1 mg
84
84
84
fondaparinux sodium subcutaneous inj 10
mg/0.8ml
17
fondaparinux sodium subcutaneous inj 2.5
mg/0.5ml
17
fondaparinux sodium subcutaneous inj 5
mg/0.4ml
17
fondaparinux sodium subcutaneous inj 7.5
mg/0.6ml
17
FORADIL CAP AEROLIZE
16
FORTAZ INJ 500MG
61
FORTEO SOL 600/2.4
76
foscarnet sodium inj 24 mg/ml
53
fosinopril sodium & hydrochlorothiazide
tab 10-12.5 mg
36
fosinopril sodium & hydrochlorothiazide
tab 20-12.5 mg
36
33
33
33
FOSRENOL CHW 1000MG
82
FOSRENOL CHW 500MG
82
FOSRENOL CHW 750MG
82
FOSRENOL POW 1000MG
82
FOSRENOL POW 750MG
82
18
18
18
18
17
18
17
17
18
FREESTYLE BLOOD GLUCOSE TEST KITS88
FREESTYLE BLOOD GLUCOSE TEST
STRIPS
88
FROVA TAB 2.5MG
89
furosemide oral soln 10 mg/ml
75
FUROSEMIDE SOL 8MG/ML
75
75
75
75
FUZEON INJ 90MG
51
G
gabapentin
gabapentin
gabapentin
gabapentin
gabapentin
cap 100 mg
cap 300 mg
cap 400 mg
tab 600 mg
tab 800 mg
18
18
18
18
18
123
GABITRIL TAB 12MG
20
GABITRIL TAB 16MG
20
mg
99
mg
99
mg
99
galantamine hydrobromide oral soln 4
mg/ml
99
galantamine hydrobromide tab 12 mg 99
99
99
GAMASTAN S/D INJ
97
97
97
GAMMAGARD INJ 2.5GM/25
97
97
97
97
97
97
GAMMAKED INJ 2.5GM/25
97
97
97
GARDASIL 9 INJ
108
GARDASIL INJ
108
gatifloxacin ophth soln 0.5%
95
gavilyte-c sol
86
gavilyte-g sol
86
gavilyte-n sol flav pk
86
GAZYVA INJ 25MG/ML
41
GELNIQUE GEL 3%
106
41
41
gemcitabine hcl for inj 200 mg
41
gemfibrozil tab 600 mg
32
gengraf cap 100mg
54
gengraf cap 25mg
54
gengraf sol 100mg/ml
55
gentamicin sulfate cream 0.1%
69
gentamicin sulfate oint 0.1%
69
gentamicin sulfate ophth oint 0.3%
95
gentamicin sulfate ophth soln 0.3%
95
gianvi tab 3-0.02mg
61
gildess fe tab 1.5/30
62
gildess fe tab 1/20
62
gildess tab 1.5/30
62
gildess tab 1/20
62
GILENYA CAP 0.5MG
100
GLASSIA INJ
101
glatiramer acetate soln prefilled syringe 20
mg/ml
100
GLEEVEC TAB 100MG
43
GLEEVEC TAB 400MG
43
GLIADEL WAF 7.7MG
39
28
28
28
glipizide tab 10 mg
28
glipizide tab 5 mg
28
28
glipizide tab sr 24hr 2.5 mg
28
28
glipizide-metformin hcl tab 2.5-250 mg 25
glipizide-metformin hcl tab 2.5-500 mg 26
glipizide-metformin hcl tab 5-500 mg
26
GLUCAGON KIT 1MG
26
glyburide micronized tab 1.5 mg
28
28
28
28
28
glyburide tab 5 mg
28
glyburide-metformin tab 1.25-250 mg 26
26
glyburide-metformin tab 5-500 mg
26
GLYSET TAB 100MG
25
GLYSET TAB 25MG
25
GLYSET TAB 50MG
25
GOLYTELY SOL
86
granisetron hcl tab 1 mg
29
griseofulvin microsize susp 125 mg/5ml 30
griseofulvin microsize tab 500 mg
30
griseofulvin ultramicrosize tab 125 mg 30
griseofulvin ultramicrosize tab 250 mg 30
35
35
guanfacine hcl tab sr 24hr 1 mg (base
equiv)
2
equiv)
2
equiv)
2
equiv)
2
GYNOL II GEL 3%
108
H
halobetasol propionate cream 0.05%
72
halobetasol propionate oint 0.05%
72
HALOG CRE 0.1%
72
HALOG OIN 0.1%
72
haloperidol decanoate im soln 100
mg/ml
49
haloperidol decanoate im soln 50 mg/ml 49
haloperidol lactate oral conc 2 mg/ml
49
haloperidol tab 0.5 mg
49
haloperidol tab 1 mg
49
49
49
49
49
HARVONI TAB 90-400MG
53
HAVRIX INJ 1440UNIT
108
HAVRIX INJ 720UNIT
108
heather tab 0.35mg
64
heparin sodium (porcine) inj 1000
unit/ml
18
124
unit/ml
18
unit/ml
18
unit/ml
18
heparin sodium (porcine) pf inj 5000
unit/0.5ml
18
HEXALEN CAP 50MG
39
HIBERIX SOL 10MCG
107
homatropine hbr ophth soln 5%
94
HUMALOG INJ 100/ML
27
27
27
HUMALOG MIX INJ 50/50
27
27
27
HUMALOG MIX SUS 75/25
27
HUMATROPE INJ 12MG
77
HUMATROPE INJ 24MG
77
HUMATROPE INJ 5MG
77
HUMATROPE INJ 6MG
77
HUMIRA INJ 10MG/0.2
3
HUMIRA KIT 20MG/0.4
3
HUMIRA KIT 40MG/0.8
3
HUMIRA PEN INJ CROHNS
3
HUMULIN INJ 70/30
27
HUMULIN INJ 70/30KWP
27
HUMULIN N INJ U-100
27
HUMULIN N INJ U-100KWP
27
HUMULIN R INJ U-100
27
HUMULIN R INJ U-500
27
HYCAMTIN CAP 0.25MG
46
HYCAMTIN CAP 1MG
46
38
38
38
38
hydrochlorothiazide cap 12.5 mg
76
hydrochlorothiazide tab 12.5 mg
76
76
76
hydrocodone w/ homatropine syrup 5-1.5
mg/5ml
65
hydrocodone w/ homatropine tab 5-1.5
mg
65
hydrocodone-acetaminophen soln 7.5-325
mg/15ml
9
hydrocodone-acetaminophen tab 10-300
mg
9
mg
9
hydrocodone-acetaminophen tab 2.5-325
mg
9
mg
9
mg
9
mg
9
mg
9
hydrocortisone butyrate cream 0.1%
72
hydrocortisone butyrate hydrophilic lipo
base cream 0.1%
72
hydrocortisone butyrate oint 0.1%
72
hydrocortisone butyrate soln 0.1%
72
hydrocortisone cream 1%
72
hydrocortisone cream 2.5%
72
hydrocortisone lotion 2.5%
72
hydrocortisone oint 1%
72
hydrocortisone oint 2.5%
72
64
64
64
hydrocortisone valerate cream 0.2%
72
hydrocortisone valerate oint 0.2%
72
hydrocortisone w/ acetic acid otic soln 12%
97
HYDROMORPHON SUP 3MG
7
hydromorphone hcl liqd 1 mg/ml
7
7
7
7
mg
7
mg
7
mg
7
mg
7
hydroxychloroquine sulfate tab 200 mg 38
hydroxyurea cap 500 mg
44
hydroxyzine hcl syrup 10 mg/5ml
13
13
13
13
hyomax-sl sub 0.125mg
104
hyoscyamine sulfate tab 0.125 mg
104
hyoscyamine sulfate tab disp 0.125 mg104
hyoscyamine sulfate tab sl 0.125 mg 104
hyoscyamine sulfate tab sr 12hr 0.375
mg
104
I
ibandronate sodium tab 150 mg (base
equivalent)
IBRANCE CAP 100MG
IBRANCE CAP 125MG
IBRANCE CAP 75MG
ibuprofen susp 100 mg/5ml
ICAR PEDS SUS GRAPE
ICLUSIG TAB 15MG
ICLUSIG TAB 45MG
idarubicin hcl iv inj 10 mg/10ml (1
mg/ml)
idarubicin hcl iv inj 20 mg/20ml (1
mg/ml)
76
43
43
43
4
4
4
4
85
43
43
42
42
125
ifosfamide & mesna inj kit 1000-1000
mg
42
ifosfamide for inj 1 gm
39
ifosfamide iv inj 1 gm/20ml (50 mg/ml) 39
ifosfamide iv inj 3 gm/60ml (50 mg/ml) 40
ilotycin oin op
95
IMBRUVICA CAP 140MG
43
24
24
24
25
25
25
24
imiquimod cream 5%
73
IMPLANON IMP 68MG
64
INCRELEX INJ 40MG/4ML
77
76
76
INDOCIN SUS 25MG/5ML
4
4
4
indomethacin cap cr 75 mg
4
INFANRIX INJ
103
INFERGEN INJ 15MCG
53
INFERGEN INJ 9MCG
53
INFLUENZA A SPR 09 H1N1
108
INLYTA TAB 1MG
43
INLYTA TAB 5MG
43
INSTA-GLUCOS GEL 77.4%
26
88
INSULIN PEN NEEDLES/SYRINGES
88
INTELENCE TAB 100MG
51
INTELENCE TAB 200MG
51
INTELENCE TAB 25MG
51
INTRON A INJ 10MU
44
INTRON A INJ 18MU
44
INTRON A INJ 25MU
44
INTRON A INJ 50MU
44
introvale tab
62
INVEGA TAB 1.5MG
48
INVEGA TAB 3MG
48
INVEGA TAB 6MG
48
INVEGA TAB 9MG
48
INVIRASE CAP 200MG
51
INVIRASE TAB 500MG
51
IPOL INJ INACTIVE
108
ipratropium bromide inhal soln 0.02% 15
ipratropium bromide nasal soln 0.03% (21
mcg/spray)
93
ipratropium bromide nasal soln 0.06% (42
mcg/spray)
93
ipratropium-albuterol nebu soln 0.5-2.5(3)
mg/3ml
16
34
34
34
irbesartan-hydrochlorothiazide tab 15012.5 mg
36
irbesartan-hydrochlorothiazide tab 30012.5 mg
37
irinotecan hcl inj 100 mg/5ml (20
mg/ml)
46
irinotecan hcl inj 40 mg/2ml (20 mg/ml)46
irinotecan hcl inj 500 mg/25ml (20
mg/ml)
46
ISENTRESS CHW 100MG
51
ISENTRESS CHW 25MG
51
ISENTRESS POW 100MG
51
ISENTRESS TAB 400MG
51
ISO HOMATROP SOL 2% OP
94
isoditrate tab 40mg er
12
isoniazid syrup 50 mg/5ml
39
39
39
ISORDIL TAB 40MG
12
isosorbide dinitrate sl tab 2.5 mg
12
12
12
12
12
isosorbide dinitrate tab cr 40 mg
12
12
12
isosorbide mononitrate tab sr 24hr 120
mg
12
mg
12
mg
12
isradipine cap 2.5 mg
57
isradipine cap 5 mg
57
itraconazole cap 100 mg
30
ivermectin tab 3 mg
11
J
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
JAKAFI TAB 5MG
JALYN CAP
jantoven tab 10mg
jantoven tab 1mg
jantoven tab 2.5mg
jantoven tab 2mg
jantoven tab 3mg
jantoven tab 4mg
jantoven tab 5mg
jantoven tab 6mg
jantoven tab 7.5mg
JANUMET TAB 50-1000
JANUMET TAB 50-500MG
JANUMET XR TAB 50-500MG
JANUVIA TAB 100MG
JANUVIA TAB 25MG
JANUVIA TAB 50MG
43
43
43
43
43
83
17
17
17
17
17
17
17
17
17
26
26
26
26
26
26
26
26
126
JARDIANCE TAB 10MG
JARDIANCE TAB 25MG
jinteli tab 1mg-5mcg
jolessa tab
jolivette tab 0.35mg
junel 1.5/30 tab
junel 1/20 tab
junel fe tab 1.5/30
junel fe tab 1/20
28
28
26
26
26
78
62
64
62
62
62
62
K
KADCYLA INJ 100MG
43
KADCYLA INJ 160MG
43
KALETRA SOL
51
51
52
kariva tab 28 day
62
kelnor tab 1/35
62
KEPIVANCE INJ 6.25MG
45
KETEK TAB 300MG
12
KETEK TAB 400MG
12
ketoconazole cream 2%
69
ketoconazole shampoo 2%
69
ketodan aer 2%
69
4
4
ketoprofen cap sr 24hr 200 mg
4
ketorolac tromethamine im inj 60 mg/2ml
(30 mg/ml)
4
4
4
ketorolac tromethamine inj 300 mg/10ml
(30 mg/ml)
4
ketorolac tromethamine inj 60 mg/2ml (30
mg/ml)
4
ketorolac tromethamine ophth soln
0.4%
96
ketorolac tromethamine ophth soln
0.5%
96
ketorolac tromethamine tab 10 mg
4
ketotif fum dro 0.025%op
96
KEYTRUDA INJ 100MG/4M
41
KEYTRUDA SOL 50MG
41
KINERET INJ
3
KINRIX INJ
103
kionex sus 15gm/60
55
90
90
KLOR-CON M15 TAB 15MEQ ER
90
klor-con m20 tab 20meq er
90
kurvelo tab 0.15/30
62
L
labetalol hcl tab
labetalol hcl tab
labetalol hcl tab
LACRISERT MIS
100 mg
200 mg
300 mg
5MG OP
55
55
55
94
lactic acid (ammonium lactate) cream
12%
73
lactic acid (ammonium lactate) lotion
10%
73
lactulose solution 10 gm/15ml
86
LAMICTAL CHW 2MG
18
LAMISIL ADV GEL 1%
69
LAMISIL AT SPR 1%
69
lamivudine oral soln 10 mg/ml
52
lamivudine tab 100 mg (hbv)
53
52
52
lamivudine-zidovudine tab 150-300 mg 52
mg
19
mg
19
mg
18
mg
18
19
19
19
19
lamotrigine tab chewable dispersible 25
mg
19
lamotrigine tab chewable dispersible 5
mg
19
19
19
19
19
19
19
LANCETS
88
LANCING DEVICE
88
58
59
lansoprazole cap 15mg dr
105
lansoprazole cap delayed release 15
mg
105
lansoprazole cap delayed release 30
mg
105
LANTUS INJ 100/ML
27
LANTUS INJ SOLOSTAR
27
LASTACAFT SOL 0.25%
96
latanoprost ophth soln 0.005%
96
LATUDA TAB 120MG
48
LATUDA TAB 20MG
48
LATUDA TAB 40MG
48
LATUDA TAB 60MG
48
LATUDA TAB 80MG
48
leena tab
62
5
5
LENVIMA CAP 10MG
43
LENVIMA CAP 14MG
43
LENVIMA CAP 20MG
43
LENVIMA CAP 24MG
43
lessina tab
62
127
LETAIRIS TAB 10MG
59
LETAIRIS TAB 5MG
59
letrozole tab 2.5 mg
41
45
45
45
45
45
45
45
45
LEUCOVORIN INJ CALCIUM
45
LEUKERAN TAB 2MG
40
LEUKINE INJ 250MCG
84
LEUKINE INJ 500 MCG
84
leuprolide acetate inj kit 5 mg/ml
41
(base equiv)
16
(base equiv)
16
(base equiv)
16
levalbuterol hcl soln nebu conc 1.25
mg/0.5ml (base equiv)
16
LEVATOL TAB 20MG
56
LEVEMIR INJ
27
LEVEMIR INJ FLEXTOUC
27
levetiracetam oral soln 100 mg/ml
19
19
19
19
19
19
19
94
94
levocetirizine dihydrochloride soln 2.5
mg/5ml (0.5 mg/ml)
31
levocetirizine dihydrochloride tab 5 mg 31
levofloxacin oral soln 25 mg/ml
81
81
81
81
levonest tab
62
levonorg-eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7)
62
levonorgestrel & ethinyl estradiol (91-day)
tab 0.15-0.03 mg
62
levonorgestrel & ethinyl estradiol tab 0.15
mg-30 mcg
62
63
63
levora-28 tab 0.15/30
62
levorphanol tartrate tab 2 mg
7
levothyroxine sodium tab 100 mcg
102
102
102
102
102
102
102
102
102
102
102
102
levoxyl tab 100mcg
103
levoxyl tab 112mcg
103
levoxyl tab 125mcg
103
levoxyl tab 137mcg
103
levoxyl tab 150mcg
103
levoxyl tab 175mcg
103
levoxyl tab 200mcg
103
levoxyl tab 25mcg
102
levoxyl tab 50mcg
102
levoxyl tab 75mcg
102
levoxyl tab 88mcg
103
LEXIVA SUS 50MG/ML
52
LEXIVA TAB 700MG
52
lice trtmnt liq 1%
74
lidocaine hcl cream 3%
73
lidocaine hcl gel 2%
73
lidocaine hcl laryngotracheal soln 4%
91
lidocaine hcl lotion 3%
73
lidocaine hcl soln 4%
73
lidocaine hcl viscous soln 2%
91
lidocaine-prilocaine cream 2.5-2.5%
73
lidocaine-prilocaine kit 2.5-2.5%
73
LILETTA IUD 52MG
64
linezolid tab 600 mg
12
LINZESS CAP 145MCG
82
LINZESS CAP 290MCG
82
103
103
103
lipodox inj 2mg/ml
42
lisinopril & hydrochlorothiazide tab 1012.5 mg
37
lisinopril & hydrochlorothiazide tab 2012.5 mg
37
lisinopril & hydrochlorothiazide tab 20-25
mg
37
34
lisinopril tab 2.5 mg
33
34
34
34
lisinopril tab 5 mg
34
48
48
48
lithium carbonate tab 300 mg
48
48
48
LITHIUM SOL 8MEQ/5ML
48
LIVALO TAB 1MG
33
LIVALO TAB 2MG
33
LIVALO TAB 4MG
33
LO LOESTRIN TAB
62
LO MINASTRIN PAK FE
62
128
lokara lot 0.05%
72
lomedia 24 tab fe
62
lomustine cap 10 mg
40
lomustine cap 100 mg
40
lomustine cap 40 mg
40
loperamide hcl cap 2 mg
28
loratadine syp 5mg/5ml
31
lorazepam conc 2 mg/ml
14
lorazepam tab 0.5 mg
14
lorazepam tab 1 mg
14
lorazepam tab 2 mg
14
loryna tab 3-0.02mg
62
losartan potassium & hydrochlorothiazide
tab 100-12.5 mg
37
tab 100-25 mg
37
tab 50-12.5 mg
37
34
34
34
LOTEMAX GEL 0.5%
95
LOTEMAX OIN 0.5%
95
LOTEMAX SUS 0.5%
96
LOTRIMIN ULT CRE 1%
69
33
33
33
low-ogestrel tab
62
49
49
49
49
ludent chw 0.25mg f
90
ludent chw 0.5mg f
90
ludent chw 1mg f
90
LUMIGAN SOL 0.01%
96
77
77
77
77
41
41
41
41
41
41
LURIDE CHW 0.25MG F
90
LURIDE CHW 0.5MG F
90
LURIDE DRO 0.5MG/ML
90
lutera tab
62
LYNPARZA CAP 50MG
43
LYRICA CAP 100MG
19
LYRICA CAP 150MG
19
LYRICA CAP 200MG
19
LYRICA CAP 225MG
19
LYRICA CAP 25MG
19
LYRICA CAP 300MG
19
LYRICA CAP 50MG
19
LYRICA CAP 75MG
19
LYRICA SOL 20MG/ML
LYSODREN TAB 500MG
19
41
M
M-M-R II INJ
108
MACRODANTIN CAP 25MG
106
mafenide acetate packet for topical soln
5% (50 gm)
71
malathion lotion 0.5%
74
21
21
21
margesic cap
5
marlissa tab 0.15/30
62
MARPLAN TAB 10MG
21
MATULANE CAP 50MG
44
58
58
58
58
58
MAXIPIME INJ 1GM
61
MAXIPIME INJ 2GM
61
meclizine hcl tab 12.5 mg
29
meclizine hcl tab 25 mg
29
4
4
MEDROL TAB 2MG
64
medroxyprogesterone acetate im susp 150
mg/ml
64
medroxyprogesterone acetate tab 10
mg
98
medroxyprogesterone acetate tab 2.5
mg
98
medroxyprogesterone acetate tab 5 mg 98
mefenamic acid cap 250 mg
4
mefloquine hcl tab 250 mg
38
megestrol acetate susp 40 mg/ml
41
41
41
MEKINIST TAB 0.5MG
43
MEKINIST TAB 2MG
43
meloxicam susp 7.5 mg/5ml
4
meloxicam tab 15 mg
4
meloxicam tab 7.5 mg
4
99
99
memantine hcl tab 5 mg (28) & 10 mg
(21) titration pak
99
MENACTRA INJ
107
MENEST TAB 0.3MG
80
MENEST TAB 0.625MG
80
MENEST TAB 1.25MG
80
MENEST TAB 2.5MG
80
MENHIBRIX INJ
107
MENOMUNE INJ A/C/Y/W
107
MENVEO INJ
107
MEPHYTON TAB 5MG
109
13
13
129
mercaptopurine tab 50 mg
41
mesalamine enema 4 gm
82
mesalamine rectal enema 4 gm & cleanser
wipe kit
82
mesna inj 100 mg/ml
45
MESNEX TAB 400MG
45
MESTINON SYP 60MG/5ML
38
metaproterenol sulfate syrup 10
mg/5ml
16
16
16
93
93
metformin hcl tab 1000 mg
26
26
26
metformin hcl tab sr 24hr 500 mg
26
metformin hcl tab sr 24hr 750 mg
26
metformin hcl tab sr 24hr osmotic 1000
mg
26
metformin hcl tab sr 24hr osmotic 500
mg
26
methadone hcl conc 10 mg/ml
7
7
7
7
7
methadone hcl tab for oral susp 40 mg 7
methamphetamine hcl tab 5 mg
1
75
75
methenamine hippurate tab 1 gm
106
102
102
93
93
methotrexate sodium for inj 1 gm
41
methotrexate sodium inj 25 mg/ml
41
methotrexate sodium inj pf 25 mg/ml 41
methotrexate sodium tab 2.5 mg (base
equiv)
41
methoxsalen rapid cap 10 mg
70
methscopolamine bromide tab 2.5 mg 104
methscopolamine bromide tab 5 mg
104
35
35
methylphenidate hcl cap cr 10 mg
2
2
2
2
2
2
methylphenidate hcl cap sr 24hr 20 mg
(la)
2
(la)
2
(la)
2
3
2
3
3
3
3
3
methylphenidate hcl tab sa osm 18 mg 3
64
64
64
methylprednisolone tab 4 mg dose pack 64
64
metipranolol ophth soln 0.3%
94
metoclopramide hcl soln 5 mg/5ml (10
mg/10ml)
81
81
81
metolazone tab 10 mg
76
metolazone tab 2.5 mg
76
metolazone tab 5 mg
76
metoprolol & hydrochlorothiazide tab 10025 mg
37
37
37
metoprolol succinate tab sr 24hr 100
mg
56
metoprolol succinate tab sr 24hr 200
mg
56
metoprolol succinate tab sr 24hr 25 mg 56
metoprolol succinate tab sr 24hr 50 mg 56
56
56
56
metronidazole cap 375 mg
11
metronidazole cream 0.75%
73
metronidazole gel 0.75%
74
metronidazole gel 1%
74
metronidazole lotion 0.75%
74
11
11
metronidazole vaginal gel 0.75%
108
14
14
14
miconazole 3 kit combo pk
108
miconazole 3 sup 200mg
108
109
midodrine hcl tab 2.5 mg
109
109
mimvey tab 1-0.5mg
78
MINASTRIN 24 CHW FE
62
12
12
12
12
102
130
102
102
102
102
102
102
102
102
minoxidil tab 10 mg
38
minoxidil tab 2.5 mg
38
47
47
MIRENA IUD SYSTEM
64
mirtazapine orally disintegrating tab 15
mg
21
mg
21
mg
21
mirtazapine tab 15 mg
21
21
21
mirtazapine tab 7.5 mg
21
105
105
42
42
42
mitoxantrone hcl inj conc 20 mg/10ml (2
mg/ml)
42
mitoxantrone hcl inj conc 25 mg/12.5ml (2
mg/ml)
42
mitoxantrone hcl inj conc 30 mg/15ml (2
mg/ml)
42
mitrazol pow 2%
69
3
3
moexipril hcl tab 15 mg
34
moexipril hcl tab 7.5 mg
34
moexipril-hydrochlorothiazide tab 15-12.5
mg
37
moexipril-hydrochlorothiazide tab 15-25
mg
37
moexipril-hydrochlorothiazide tab 7.5-12.5
mg
37
mometasone furoate cream 0.1%
72
mometasone furoate oint 0.1%
72
mometasone furoate solution 0.1%
(lotion)
73
mono-linyah tab 0.25-35
62
mononessa tab
62
montelukast sodium chew tab 4 mg (base
equiv)
15
montelukast sodium chew tab 5 mg (base
equiv)
15
montelukast sodium oral granules packet
4 mg (base equiv)
15
montelukast sodium tab 10 mg (base
equiv)
15
MONUROL PAK GRANULES
106
morgidox cap 1x100mg
102
MORPHINE SUL SUP 30MG
7
mg
7
mg
7
mg
7
mg
7
mg
7
mg
7
7
(20 mg/ml)
7
7
7
7
7
7
7
8
8
8
8
8
MOTOFEN TAB
28
MOVANTIK TAB 12.5MG
82
MOVANTIK TAB 25MG
82
MOVIPREP SOL
86
moxifloxacin hcl tab 400 mg (base
equiv)
81
MOZOBIL INJ
85
MULTAQ TAB 400MG
14
multi-vit/fe dro /fl 0.25
92
multi-vit/fl dro 0.25mg
91
multi-vit/fl dro 0.5mg/ml
91
92
91
multivit/fl chw 1mg
92
mupirocin oint 2%
69
mvc-fluoride chw 0.5mg
92
mvc-fluoride chw 1mg
92
mycophenolate mofetil cap 250 mg
55
mycophenolate mofetil for oral susp 200
mg/ml
55
mycophenolate mofetil tab 500 mg
55
55
55
MYKIDZ IRON SUS 15/1.5ML
85
MYLERAN TAB 2MG
40
myorisan cap 10mg
67
myorisan cap 20mg
67
myorisan cap 40mg
67
MYOZYME INJ 50MG
77
MYRBETRIQ TAB 25MG
106
MYRBETRIQ TAB 50MG
106
myzilra tab
62
131
N
4
4
nadolol & bendroflumethiazide tab 40-5
mg
37
nadolol & bendroflumethiazide tab 80-5
mg
37
nadolol tab 20 mg
56
nadolol tab 40 mg
56
nadolol tab 80 mg
56
nafrinse chw 1mg f
90
naftifine hcl cream 1%
69
NAFTIN CRE 2%
69
NAFTIN GEL 1%
69
NAFTIN GEL 2%
70
10
10
naltrexone hcl tab 50 mg
29
NAMENDA SOL 10MG/5ML
99
NAMENDA XR CAP 14MG
99
NAMENDA XR CAP 21MG
99
NAMENDA XR CAP 28MG
99
NAMENDA XR CAP 7MG
99
NAMENDA XR CAP TITRATIO
100
naphazoline hcl ophth soln 0.1%
95
4
5
5
5
naproxen susp 125 mg/5ml
5
naproxen tab 250 mg
5
naproxen tab 375 mg
5
naproxen tab 500 mg
5
naratriptan hcl tab 1 mg (base equiv)
89
naratriptan hcl tab 2.5 mg (base equiv) 89
NATACYN SUS 5% OP
95
NATAZIA TAB
62
nateglinide tab 120 mg
27
nateglinide tab 60 mg
27
NEBUPENT INH 300MG
11
necon tab 0.5/35
62
necon tab 1/35
62
necon tab 1/50-28
62
NECON TAB 10/11-28
62
necon tab 7/7/7
62
21
21
21
21
21
neomycin-polymy-gramicid op sol 1.7510000-0.025mg-unt-mg/ml
95
ophth oint 0.1%
96
ophth susp 0.1%
96
neomycin-polymyxin-hc ophth susp
96
neomycin-polymyxin-hc otic soln 1%
97
neomycin-polymyxin-hc otic susp 3.5
mg/ml-10000 unit/ml-1%
97
NEULASTA INJ 6MG/0.6M
85
85
NEUPOGEN INJ 300MCG
85
85
NEUPOGEN INJ 480MCG
85
NEVANAC SUS 0.1%
96
nevirapine susp 50 mg/5ml
52
nevirapine tab 200 mg
52
nevirapine tab sr 24hr 400 mg
52
NEXAVAR TAB 200MG
43
NEXIUM 24HR CAP 20MG
105
NEXIUM GRA 10MG DR
105
NEXIUM GRA 2.5MG DR
105
NEXIUM GRA 20MG DR
105
NEXIUM GRA 40MG DR
105
NEXIUM GRA 5MG DR
105
NEXPLANON IMP 68MG
64
niacin tab cr 1000 mg
(antihyperlipidemic)
33
33
33
58
58
100
100
101
101
101
101
101
NICOTROL INH
101
NICOTROL NS SPR 10MG/ML
101
58
58
58
58
58
nifedipine tab sr 24hr osmotic release 90
mg
58
NILANDRON TAB 150MG
41
nimodipine cap 30 mg
58
NIPENT INJ 10MG
44
58
58
58
58
58
58
58
12
12
nitrofurantoin macrocrystalline cap 100
mg
106
nitrofurantoin macrocrystalline cap 50
mg
106
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
106
12
132
12
nitroglycerin cap cr 9 mg
12
nitroglycerin lingual aerosol 400
mcg/spray
12
12
12
12
13
NITROSTAT SUB 0.3MG
13
NITROSTAT SUB 0.4MG
13
NITROSTAT SUB 0.6MG
13
104
104
nizatidine oral soln 15 mg/ml
104
nora-be tab 0.35mg
64
77
77
NORDITROPIN INJ 30/3ML
77
77
norethindrone & ethinyl estradiol-fe chew
tab 0.8 mg-25 mcg
62
norethindrone acetate tab 5 mg
98
norethindrone acetate-ethinyl estradiol tab
0.5 mg-2.5 mcg
78
norethindrone tab 0.35 mg
64
norgestimate & ethinyl estradiol tab 0.25
mg-35 mcg
62
norgestimate-eth estrad tab 0.1835/0.215-35/0.25-35 mg-mcg
63
NOROXIN TAB 400MG
81
14
14
nortrel tab 0.5/35
63
nortrel tab 1/35
63
nortrel tab 7/7/7
63
25
25
25
25
nortriptyline hcl soln 10 mg/5ml
25
NORTUSS-EX LIQ 200-20/5
65
NORVIR CAP 100MG
52
NORVIR SOL 80MG/ML
52
NORVIR TAB 100MG
52
novarel inj 10000unt
76
NOVOLIN INJ 70/30
27
NOVOLIN N INJ U-100
27
NOVOLIN R INJ U-100
27
NOVOLOG INJ 100/ML
27
NOVOLOG INJ FLEXPEN
27
NOVOLOG INJ PENFILL
27
NOVOLOG MIX INJ 70/30
27
NOVOLOG MIX INJ FLEXPEN
27
NOXAFIL SUS 40MG/ML
30
NOXAFIL TAB 100MG
30
8
8
8
8
NUCYNTA ER TAB 50MG
8
NUCYNTA TAB 100MG
8
NUCYNTA TAB 50MG
8
NUCYNTA TAB 75MG
8
NUEDEXTA CAP 20-10MG
100
nulev tab 0.125mg
104
NULOJIX INJ 250MG
55
NUVARING MIS
63
NUVIGIL TAB 150MG
3
NUVIGIL TAB 200MG
3
NUVIGIL TAB 250MG
3
NUVIGIL TAB 50MG
3
nyamyc pow 100000
70
nystatin cream 100000 unit/gm
70
nystatin oint 100000 unit/gm
70
nystatin oral powder
30
nystatin susp 100000 unit/ml
91
nystatin tab 500000 unit
30
nystatin-triamcinolone cream 100000-0.1
unit/gm-%
70
nystatin-triamcinolone oint 100000-0.1
unit/gm-%
70
nystop pow 100000
70
O
ocella tab 3-0.03mg
63
mg/ml)
78
octreotide acetate inj 1000 mcg/ml (1
mg/ml)
78
mg/ml)
78
mg/ml)
78
mg/ml)
78
ofloxacin ophth soln 0.3%
95
ofloxacin otic soln 0.3%
97
ogestrel tab
63
49
49
49
49
olanzapine tab 5 mg
49
49
omega-3-acid ethyl esters cap 1 gm
32
omeprazole cap delayed release 10 mg 105
omeprazole magnesium cap dr 20.6 mg
(20 mg base equiv)
105
OMEPRAZOLE TAB 20MG
105
106
106
OMNIFLEX DPR
87
ONCASPAR INJ 750/ML
44
ondansetron hcl oral soln 4 mg/5ml
29
29
29
133
29
ondansetron orally disintegrating tab 4
mg
29
ondansetron orally disintegrating tab 8
mg
29
ONFI SUS 2.5MG/ML
18
ONFI TAB 10MG
18
ONFI TAB 20MG
18
ONFI TAB 5MG
18
oralone pst 0.1%
91
ORAP TAB 1MG
100
ORAP TAB 2MG
100
ORENCIA INJ 125MG/ML
5
ORENCIA INJ 250MG
5
ORKAMBI TAB 200-125
101
orphenadrine citrate inj 30 mg/ml
93
orphenadrine citrate tab sr 12hr 100 mg93
orphenadrine w/ aspirin & caffeine tab 25385-30 mg
93
orsythia tab
63
87
87
87
87
88
88
88
88
88
88
88
88
ORTHO FLEX DPR 65MM
88
ORTHO FLEX DPR 70MM
88
ORTHO FLEX DPR 75MM
88
ORTHO FLEX DPR 80MM
88
ORTHO TRI- TAB CYCLN LO
63
ortho-est tab 0.625
80
ortho-est tab 1.25
80
oscimin sr tab 0.375mg
104
oscimin sub 0.125mg
104
oscimin tab 0.125mg
104
oscion clnsr lot 6%
67
OSMOPREP TAB 1.5GM
87
40
40
40
40
oxandrolone tab 10 mg
10
oxandrolone tab 2.5 mg
10
oxaprozin tab 600 mg
5
oxazepam cap 10 mg
14
oxazepam cap 15 mg
14
oxazepam cap 30 mg
14
oxcarbazepine susp 300 mg/5ml (60
mg/ml)
19
19
19
19
OXISTAT CRE 1%
70
OXISTAT LOT 1%
70
OXSORALEN LOT 1%
73
oxybutynin chloride syrup 5 mg/5ml
106
oxybutynin chloride tab 5 mg
107
oxybutynin chloride tab sr 24hr 10 mg 107
oxycodone hcl cap 5 mg
8
oxycodone hcl conc 100 mg/5ml (20
mg/ml)
8
oxycodone hcl soln 5 mg/5ml
8
8
8
8
8
8
oxycodone hcl tab er 12hr deter 10 mg 8
mg
9
oxycodone w/ acetaminophen tab 2.5-325
mg
9
mg
9
oxycodone w/ acetaminophen tab 7.5-325
mg
9
oxycodone-aspirin tab 4.8355-325 mg
9
oxycodone-ibuprofen tab 5-400 mg
9
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
oxymorphone hcl tab sr 12hr 7.5 mg
8
OXYTROL DIS 3.9MG/24
107
P
pacerone tab 100mg
pacerone tab 200mg
paclitaxel iv conc 100 mg/16.7ml (6
mg/ml)
paclitaxel iv conc 150 mg/25ml (6
mg/ml)
paclitaxel iv conc 300 mg/50ml (6
mg/ml)
14
14
45
45
45
45
76
76
134
pamidronate disodium iv soln 3 mg/ml 76
pamidronate disodium iv soln 9 mg/ml 76
PAMIDRONATE INJ 6MG/ML
76
pancrelipase (lip-prot-amyl) dr cap 500017000-27000 unit
74
PANRETIN GEL 0.1%
70
equiv)
105
equiv)
105
PARAGARD IUD T380A
63
77
77
77
paromomycin sulfate cap 250 mg
3
22
22
22
22
22
paroxetine hcl tab sr 24hr 25 mg
22
22
PATADAY SOL 0.2%
96
PATANOL SOL 0.1% OP
96
pedia d-vite dro 400unit
109
PEDIARIX INJ 0.5ML
104
PEDIATRIC RESPIRATORY MASK
88
PEDVAX HIB INJ
107
soln 236 gm
86
soln 240 gm
86
peg 3350-kcl-sod bicarb-nacl for soln 420
gm
86
PEG-INTRON KIT 120 RP
53
53
PEG-INTRON KIT 50MCG RP
53
53
PEGASYS INJ
53
PEGASYS INJ 180MCG/M
53
PEGASYS INJ PROCLICK
53
PEGASYS KIT
53
penicillin v potassium for soln 125
mg/5ml
98
penicillin v potassium for soln 250
mg/5ml
98
penicillin v potassium tab 250 mg
98
penicillin v potassium tab 500 mg
98
PENTACEL INJ
104
PENTAM 300 INJ 300MG
11
pentoxifylline tab cr 400 mg
83
PERFOROMIST NEB 20MCG
16
34
34
34
periogard sol 0.12%
91
permethrin cream 5%
74
permethrin lotion 1%
74
50
50
50
50
persa-gel xs gel 5%
67
83
83
phenelzine sulfate tab 15 mg
21
phenobarbital elixir 20 mg/5ml
85
phenobarbital tab 100 mg
86
85
phenobarbital tab 16.2 mg
85
85
85
86
86
86
phenoxybenzamine hcl cap 10 mg
34
phenylephrine hcl ophth soln 10%
95
phenylephrine hcl ophth soln 2.5%
95
PHENYTEK CAP 200MG
20
PHENYTEK CAP 300MG
20
phenytoin chew tab 50 mg
20
phenytoin sodium extended cap 100 mg 20
phenytoin susp 125 mg/5ml
20
PHISOHEX LIQ 3%
51
PHOSPHOLINE SOL 0.125%OP
94
PHOTOFRIN INJ 75MG
44
PICATO GEL 0.015%
70
PICATO GEL 0.05%
70
pilocarpine hcl tab 5 mg
91
pilocarpine hcl tab 7.5 mg
91
PILOPINE HS GEL 4% OP
94
pindolol tab 10 mg
56
pindolol tab 5 mg
56
pioglitazone hcl tab 15 mg (base equiv) 27
pioglitazone hcl-glimepiride tab 30-2 mg26
pioglitazone hcl-glimepiride tab 30-4 mg26
pioglitazone hcl-metformin hcl tab 15-500
mg
26
pioglitazone hcl-metformin hcl tab 15-850
mg
26
piroxicam cap 10 mg
5
piroxicam cap 20 mg
5
PNEUMOVAX 23 INJ 25/0.5
107
podofilox soln 0.5%
73
poly-dex oin 0.1% op
96
polycin oin op
95
polyethylene glycol 3350 oral packet
86
polyethylene glycol 3350 oral powder
86
polymyxin b-trimethoprim ophth soln
10000 unit/ml-0.1%
95
POMALYST CAP 1MG
44
POMALYST CAP 2MG
44
POMALYST CAP 3MG
44
POMALYST CAP 4MG
44
portia-28 tab
63
90
90
potassium chloride microencapsulated crys
135
cr tab 10 meq
91
potassium chloride microencapsulated crys
cr tab 20 meq
91
potassium chloride oral soln 10% (20
meq/15ml)
91
potassium chloride oral soln 20% (40
meq/15ml)
91
potassium chloride tab cr 10 meq
91
potassium chloride tab cr 20 meq (1500
mg)
91
potassium chloride tab cr 8 meq (600
mg)
91
potassium citrate tab cr 10 meq (1080
mg)
82
mg)
82
mg)
82
POTIGA TAB 200MG
19
POTIGA TAB 300MG
19
POTIGA TAB 400MG
19
POTIGA TAB 50MG
19
pr benzoyl liq 7% wash
67
pramipexole dihydrochloride tab 0.125
mg
47
mg
47
mg
47
pramipexole dihydrochloride tab 1 mg 47
0.375 mg
47
0.75 mg
47
1.5 mg
47
pramipexole dihydrochloride tab sr 24hr 3
mg
47
4.5 mg
47
pramox gel 1%
73
33
33
33
33
35
35
35
PRED MILD SUS 0.12% OP
96
PRED SOD PHO SOL 1% OP
96
prednisolone acetate ophth susp 1%
96
prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)
64
prednisolone sod phosphate oral soln 15
mg/5ml (base equiv)
65
prednisolone sodium phosphate oral soln
25 mg/5ml (base eq)
65
prednisolone syrup 15 mg/5ml (usp
solution equivalent)
65
PREDNISONE CON 5MG/ML
65
prednisone oral soln 5 mg/5ml
65
prednisone tab 1 mg
65
65
65
prednisone tab 2.5 mg
65
65
prednisone tab 5 mg
65
65
65
pregnyl inj 10000unt
76
PREMARIN TAB 0.3MG
80
PREMARIN TAB 0.45MG
81
PREMARIN TAB 0.625MG
81
PREMARIN TAB 0.9MG
81
PREMARIN TAB 1.25MG
81
PREMARIN VAG CRE 0.625MG
109
prenatabs rx tab
92
PRENTIF MIS 22MM
88
PRENTIF MIS 25MM
88
PRENTIF MIS 28MM
88
PRENTIF MIS 31MM
88
PRENTIF MIS FITTING
88
PREPOPIK PAK
86
prevalite pow 4gm
32
previfem tab
63
PREVNAR 13 INJ
107
PREZCOBIX TAB 800-150
52
PREZISTA SUS 100MG/ML
52
PREZISTA TAB 150MG
52
PREZISTA TAB 400MG
52
PREZISTA TAB 600MG
52
PREZISTA TAB 75MG
52
PREZISTA TAB 800MG
52
PRIFTIN TAB 150MG
39
PRIMAQUINE TAB 26.3MG
38
primidone tab 250 mg
19
primidone tab 50 mg
19
PRIMLEV TAB 10-300MG
9
PRIMLEV TAB 5-300MG
9
PRIMLEV TAB 7.5-300
9
PRIMSOL SOL 50MG/5ML
11
PROAIR HFA AER
16
probenecid tab 500 mg
83
procainamide hcl inj 100 mg/ml
14
PROCAINAMIDE INJ 500MG/ML
14
equivalent)
50
equivalent)
50
prochlorperazine suppos 25 mg
50
85
PROCRIT INJ 2000/ML
85
85
PROCRIT INJ 3000/ML
85
PROCRIT INJ 4000/ML
85
85
procto-pak cre 1%
10
proctosol hc cre 2.5%
10
98
136
98
PROGLYCEM SUS 50MG/ML
26
PROLASTIN-C INJ 1000MG
101
PROLIA SOL 60MG/ML
76
PROMACTA TAB 12.5MG
85
PROMACTA TAB 25MG
85
PROMACTA TAB 50MG
85
PROMACTA TAB 75MG
85
prometh vc syp plain
65
prometh vc/ syp codeine
65
promethazine hcl syrup 6.25 mg/5ml
31
promethazine hcl tab 12.5 mg
31
31
31
promethazine w/ codeine syrup 6.25-10
mg/5ml
65
promethazine-dm syrup 6.25-15
mg/5ml
65
14
14
14
14
14
14
propranolol & hydrochlorothiazide tab 4025 mg
37
propranolol & hydrochlorothiazide tab 8025 mg
37
56
56
56
56
56
56
56
56
56
56
56
propylthiouracil tab 50 mg
102
PROQUAD INJ
108
25
25
prudoxin cre 5%
70
pseudoephed-bromphen-dm syrup 30-210 mg/5ml
65
pyrazinamide tab 500 mg
39
pyridostigmine bromide tab 60 mg
38
pyridostigmine bromide tab cr 180 mg 38
Q
QUADRAMET INJ
QUARTETTE TAB
quasense tab
quetiapine fumarate
quetiapine fumarate
quetiapine fumarate
quetiapine fumarate
quetiapine fumarate
quetiapine fumarate
tab
tab
tab
tab
tab
tab
100 mg
200 mg
25 mg
300 mg
400 mg
50 mg
44
63
63
49
49
49
49
49
49
92
92
QUFLORA PED CHW 1MG
92
quflora ped dro 0.25mg
92
quflora ped dro 0.5mg/ml
92
34
34
34
34
quinapril-hydrochlorothiazide tab 10-12.5
mg
37
quinapril-hydrochlorothiazide tab 20-12.5
mg
37
quinapril-hydrochlorothiazide tab 20-25
mg
37
quinine sulfate cap 324 mg
38
quinine sulfate tab 260 mg
38
QVAR AER 40MCG
15
QVAR AER 80MCG
15
R
rabeprazole sodium ec tab 20 mg
raloxifene hcl tab 60 mg
ramipril cap 1.25 mg
ramipril cap 10 mg
ramipril cap 2.5 mg
ramipril cap 5 mg
RANEXA TAB 1000MG
RANEXA TAB 500MG
ranitidine hcl syrup 15 mg/ml (75
mg/5ml)
ranitidine hcl tab 150 mg
ranitidine hcl tab 300 mg
RAPAFLO CAP 4MG
RAPAFLO CAP 8MG
RAPAMUNE SOL 1MG/ML
REBETOL SOL 40MG/ML
REBIF INJ 22/0.5
REBIF INJ 44/0.5
REBIF TITRTN INJ PACK
reclipsen tab
RECOMBIVA HB INJ 10MCG/ML
RECOMBIVA HB INJ 5MCG/0.5
RECOMBIVA-HB INJ 40MCG/ML
RECTIV OIN 0.4%
REGRANEX GEL 0.01%
RELENZA MIS DISKHALE
RELPAX TAB 20MG
RELPAX TAB 40MG
REMODULIN INJ 2.5MG/ML
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
repaglinide tab 0.5 mg
repaglinide tab 1 mg
105
77
34
34
34
34
12
12
104
105
105
105
105
83
83
55
53
100
100
100
63
108
108
108
11
74
54
89
89
59
59
59
59
82
82
82
27
27
137
repaglinide tab 2 mg
27
RESCRIPTOR TAB 100 MG
52
RESCRIPTOR TAB 200MG
52
RESTASIS EMU 0.05%
95
REVLIMID CAP 10MG
54
REVLIMID CAP 15MG
54
REVLIMID CAP 2.5MG
54
REVLIMID CAP 20MG
54
REVLIMID CAP 25MG
54
REVLIMID CAP 5MG
54
REYATAZ CAP 100MG
52
REYATAZ CAP 150MG
52
REYATAZ CAP 200MG
52
REYATAZ CAP 300MG
52
REYATAZ POW 50MG
52
ribasphere cap 200mg
53
53
53
53
ribavirin cap 200 mg
53
ribavirin tab 200 mg
53
rifabutin cap 150 mg
39
RIFAMATE CAP
39
rifampin cap 150 mg
39
rifampin cap 300 mg
39
RIFATER TAB
39
riluzole tab 50 mg
94
rimantadine hydrochloride tab 100 mg 54
76
76
76
76
risedronate sodium tab delayed release 35
mg
76
48
RISPERDAL INJ 25MG
48
48
RISPERDAL INJ 50MG
48
risperidone orally disintegrating tab 0.25
mg
48
risperidone orally disintegrating tab 0.5
mg
48
risperidone orally disintegrating tab 1
mg
48
mg
48
mg
48
mg
48
risperidone soln 1 mg/ml
49
49
49
49
49
49
49
RITUXAN INJ 100MG
41
rivastigmine tartrate cap 1.5 mg
100
rivastigmine tartrate cap 3 mg
100
rivastigmine tartrate cap 4.5 mg
100
rivastigmine tartrate cap 6 mg
100
tab 10 mg
89
tab 5 mg
89
89
89
romycin oin op
95
47
47
47
47
47
47
47
rosadan cre 0.75%
74
ROTARIX SUS
108
ROTATEQ SOL
108
ROXICET SOL 5-325/5
9
roxicet tab 5-325mg
9
ROZEREM TAB 8MG
86
S
SABRIL POW 500MG
20
SABRIL TAB 500MG
20
SAFYRAL TAB
63
SAMSCA TAB 15MG
78
SAMSCA TAB 30MG
78
SANCUSO DIS 3.1MG
29
SANTYL OIN 250/GM
73
SAPHRIS SUB 10MG
50
SAPHRIS SUB 2.5MG
49
SAPHRIS SUB 5MG
50
SAVELLA MIS TITR PAK
100
SAVELLA TAB 100MG
100
SAVELLA TAB 12.5MG
100
SAVELLA TAB 25MG
100
SAVELLA TAB 50MG
100
scalacort lot 2%
73
selegiline hcl cap 5 mg
47
selegiline hcl tab 5 mg
47
selenium sulfide lotion 2.5%
70
selenium sulfide-pyrithione zinc in urea
shampoo 2.25%
71
SELZENTRY TAB 150MG
52
SELZENTRY TAB 300MG
52
SENSIPAR TAB 30MG
77
SENSIPAR TAB 60MG
77
SENSIPAR TAB 90MG
78
SEREVENT DIS AER 50MCG
16
50
50
50
50
50
sertraline hcl oral conc 20 mg/ml
22
22
22
22
138
SHUR-SEAL GEL 2%
108
sildenafil citrate iv soln 10 mg/12.5ml
(base equivalent)
59
sildenafil citrate tab 20 mg
59
silver sulfadiazine cream 1%
71
SIMULECT INJ 10MG
55
SIMULECT INJ 20MG
55
33
33
33
33
33
sirolimus tab 0.5 mg
55
sirolimus tab 1 mg
55
sirolimus tab 2 mg
55
SKLICE LOT 0.5%
74
SKYLA IUD 13.5MG
64
sm nicotine dis 14mg/24h
101
sm nicotine dis 21mg
101
sm nicotine dis 7mg/24hr
101
sm vitamin d tab 400unit
109
SOD EDECRIN INJ 50MG
75
sodium chloride flush iv soln 0.9%
91
sodium chloride inj 0.45%
91
sodium chloride inj 0.9%
91
sodium chloride inj 2.5 meq/ml (14.6%)91
sodium chloride inj 3%
91
sodium chloride inj 4 meq/ml (23.4%) 91
sodium chloride inj 5%
91
sodium chloride irrigation soln 0.9%
82
sodium chloride iv soln 0.9%
91
sodium chloride soln nebu 0.9%
65
sodium chloride soln nebu 10%
65
65
65
0.55 mg naf)
90
1.1 mg naf)
90
sodium fluoride chew tab 1 mg f (from 2.2
mg naf)
90
sodium fluoride soln 0.5 mg/ml f (from 1.1
mg/ml naf)
90
sodium fluoride tab 0.5 mg f (from 1.1 mg
naf)
90
sodium fluoride tab 1 mg f (from 2.2 mg
naf)
90
sodium polystyrene sulfonate oral susp 15
gm/60ml
55
sodium polystyrene sulfonate rectal susp
30 gm/120ml
55
solia tab
63
SOMATULINE INJ 120/.5ML
78
78
78
SOMAVERT INJ 10MG
77
SOMAVERT INJ 15MG
77
SOMAVERT INJ 20MG
77
SOMAVERT INJ 25MG
77
SOMAVERT INJ 30MG
77
sorine tab 120mg
56
sorine tab 160mg
56
sorine tab 240mg
56
sorine tab 80mg
56
56
56
56
56
56
56
56
SOVALDI TAB 400MG
54
spinosad susp 0.9%
74
SPIRIVA CAP HANDIHLR
15
SPIRIVA SPR RESPIMAT
15
spironolactone & hydrochlorothiazide tab
25-25 mg
75
75
75
75
SPORANOX SOL 10MG/ML
30
sprintec 28 tab 28 day
63
SPRYCEL TAB 100MG
43
SPRYCEL TAB 140MG
43
SPRYCEL TAB 20MG
43
SPRYCEL TAB 50MG
43
SPRYCEL TAB 70MG
43
SPRYCEL TAB 80MG
43
sronyx tab
63
ssd cre 1%
71
sss 10-5 aer 10-5%
67
stavudine cap 15 mg
52
stavudine cap 20 mg
52
stavudine cap 30 mg
52
stavudine cap 40 mg
52
stavudine for oral soln 1 mg/ml
52
STELARA INJ 45MG/0.5
70
STELARA INJ 90MG/ML
70
STIVARGA TAB 40MG
43
STRATTERA CAP 100MG
2
STRATTERA CAP 10MG
2
STRATTERA CAP 18MG
2
STRATTERA CAP 25MG
2
STRATTERA CAP 40MG
2
STRATTERA CAP 60MG
2
STRATTERA CAP 80MG
2
streptomycin sulfate for inj 1 gm
3
STRIBILD TAB
52
SUBOXONE MIS 12-3MG
10
SUBOXONE MIS 2-0.5MG
10
SUBOXONE MIS 4-1MG
10
SUBOXONE MIS 8-2MG
10
SUCRAID SOL 8500/ML
74
sucralfate tab 1 gm
105
sulfacetamide sodium lotion 10% (acne)67
sulfacetamide sodium ophth oint 10% 95
sulfacetamide sodium ophth soln 10% 95
sulfacetamide sodium w/ sulfur cleanser
10-2%
68
sulfacetamide sodium w/ sulfur cleanser
139
9.8-4.8%
68
sulfacetamide sodium w/ sulfur cleansing
cloth 10-5%
68
sulfacetamide sodium w/ sulfur cleansing
pad 10-4%
68
sulfacetamide sodium w/ sulfur cream 102%
68
sulfacetamide sodium w/ sulfur cream 105%
68
sulfacetamide sodium w/ sulfur cream 9.84.8%
68
sulfacetamide sodium w/ sulfur lotion 105%
68
sulfacetamide sodium w/ sulfur lotion 9.84.8%
68
sulfacetamide sodium w/ sulfur wash 94%
68
sulfacetamide sodium w/ sulfur wash 94.5%
68
sulfacetamide sodium-prednisolone ophth
soln 10-0.23(0.25)%
96
sulfacleanse sus 8-4%
68
SULFADIAZINE TAB 500MG
101
sulfamethoxazole-trimethoprim susp 20040 mg/5ml
11
sulfamethoxazole-trimethoprim tab 40080 mg
11
sulfamethoxazole-trimethoprim tab 800160 mg
11
sulfasalazine tab 500 mg
82
sulfasalazine tab delayed release 500
mg
82
sulindac tab 150 mg
5
sulindac tab 200 mg
5
89
89
sumatriptan succinate inj 4 mg/0.5ml 89
sumatriptan succinate inj 6 mg/0.5ml 89
89
89
mg/0.5ml
89
mg/0.5ml
89
sumatriptan succinate solution prefilled
syringe 6 mg/0.5ml
89
89
89
89
SUPRAX CAP 400MG
61
SUPRAX CHW 100MG
61
SUPRAX CHW 200MG
61
SUPRAX SUS 500/5ML
61
SUPRAX TAB 400MG
61
SUPREP BOWEL SOL PREP
86
SURMONTIL CAP 100MG
25
SURMONTIL CAP 25MG
25
SURMONTIL CAP 50MG
25
SUSTIVA CAP 200MG
52
SUSTIVA CAP 50MG
SUSTIVA TAB 600MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 37.5MG
SUTENT CAP 50MG
syeda tab 3-0.03mg
symax fastab tab 0.125mg
symax-sl sub 0.125mg
SYMLINPEN 60 INJ 1000MCG
SYMLNPEN 120 INJ 1000MCG
SYNAREL SOL 2MG/ML
SYNERA DIS 70-70MG
SYNTHROID TAB 25MCG
SYNTHROID TAB 50MCG
SYNTHROID TAB 75MCG
SYNTHROID TAB 88MCG
SYPRINE CAP 250MG
T
TABLOID TAB 40MG
TACLONEX SUS
tacrolimus cap 0.5 mg
tacrolimus cap 1 mg
tacrolimus cap 5 mg
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
equivalent)
equivalent)
tamsulosin hcl cap 0.4 mg
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TARCEVA TAB 25MG
targetd acne cre 2.5%
tazicef inj 1gm
tazicef inj 2gm
tazicef inj 6gm
TAZORAC CRE 0.05%
TAZORAC CRE 0.1%
TAZORAC GEL 0.05%
TAZORAC GEL 0.1%
52
52
44
44
44
44
63
104
104
25
25
77
73
103
103
103
103
103
103
103
103
103
103
103
103
54
41
73
55
55
55
73
73
44
44
54
54
54
54
42
42
83
44
44
44
68
61
61
61
70
70
70
70
58
58
58
140
58
58
TEGRETOL-XR TAB 100MG
19
TEKTURNA TAB 150MG
38
TEKTURNA TAB 300MG
38
34
34
34
37
37
37
37
telmisartan-hydrochlorothiazide tab 4012.5 mg
37
telmisartan-hydrochlorothiazide tab 8012.5 mg
37
telmisartan-hydrochlorothiazide tab 80-25
mg
37
temazepam cap 15 mg
86
86
temazepam cap 30 mg
86
86
TEMODAR INJ 100MG
40
40
40
40
40
40
40
TENIPOSIDE INJ 50MG/5ML
45
TENIVAC INJ 5-2LF
104
35
35
35
35
terbinafine cre 1%
70
terbinafine hcl tab 250 mg
30
terbutaline sulfate tab 2.5 mg
16
terbutaline sulfate tab 5 mg
16
terconazole vaginal cream 0.4%
108
terconazole vaginal suppos 80 mg
108
mg/ml
10
mg/ml
10
testosterone enanthate im inj in oil 200
mg/ml
10
testosterone td gel 10mg/act (2%)
10
testosterone td gel 12.5 mg/act (1%) 10
testosterone td gel 25 mg/2.5gm (1%) 10
testosterone td gel 50 mg/5gm (1%)
10
TET/DIP TOX INJ 2-2 LF
104
102
102
tgq 50pse/3 syp brm/30dm
65
THALOMID CAP 100MG
54
THALOMID CAP 150MG
54
THALOMID CAP 200MG
54
THALOMID CAP 50MG
54
16
16
16
16
16
16
THERACYS INJ
44
50
50
50
50
thiothixene cap 1 mg
51
51
51
51
thrive gum 4mg mint
101
20
20
TICE BCG INJ
44
TIKOSYN CAP 125MCG
14
TIKOSYN CAP 250MCG
14
TIKOSYN CAP 500MCG
14
tilia fe tab
63
0.25%
94
0.5%
94
94
94
56
57
56
94
94
11
11
TIVICAY TAB 50MG
52
tizanidine hcl cap 2 mg (base
equivalent)
93
equivalent)
93
equivalent)
93
tizanidine hcl tab 2 mg (base
equivalent)
93
tizanidine hcl tab 4 mg (base
equivalent)
93
TOBRADEX OIN 0.3-0.1%
96
tobramycin nebu soln 300 mg/5ml
3
tobramycin ophth soln 0.3%
95
tobramycin-dexamethasone ophth susp
0.3-0.1%
96
TOBREX OIN 0.3% OP
95
TODAY SPONGE MIS
108
tolbutamide tab 500 mg
28
tolcapone tab 100 mg
46
tolmetin sodium cap 400 mg
5
5
5
tolnaftate aerosol pow 1%
70
tolnaftate soln 1%
70
141
tolterodine tartrate cap sr 24hr 2 mg 107
tolterodine tartrate cap sr 24hr 4 mg 107
107
107
19
20
20
20
20
20
toposar inj 100/5ml
46
toposar inj 20mg/ml
45
topotecan hcl for inj 4 mg
46
TOPOTECAN INJ 4MG/4ML
46
TORISEL SOL 25MG/ML
44
torsemide tab 10 mg
75
torsemide tab 100 mg
75
torsemide tab 20 mg
75
torsemide tab 5 mg
75
TOVIAZ TAB 4MG
107
TOVIAZ TAB 8MG
107
TRACLEER TAB 125MG
59
TRACLEER TAB 62.5MG
59
TRADJENTA TAB 5MG
26
tramadol hcl tab 50 mg
8
8
9
9
34
34
34
trandolapril-verapamil hcl tab cr 1-240
mg
37
mg
37
mg
38
mg
38
tranexamic acid inj 100 mg/ml
85
tranexamic acid tab 650 mg
85
TRANSDERM-SC DIS 1MG
29
tranylcypromine sulfate tab 10 mg
21
TRAVATAN Z DRO 0.004%
96
21
21
21
21
TRECATOR TAB 250MG
39
tretinoin cap 10 mg
44
68
68
68
tretinoin gel 0.01%
68
tretinoin gel 0.025%
68
tri-linyah tab
63
tri-previfem tab
63
tri-sprintec tab
63
tri-vit/fe dro /fl 0.25
92
92
92
triamcinolone acetonide aerosol soln 0.147
mg/gm
73
triamcinolone acetonide cream 0.025% 73
73
73
triamcinolone acetonide dental paste
0.1%
91
triamcinolone acetonide lotion 0.025% 73
73
triamcinolone acetonide nasal aerosol
suspension 55 mcg/act
94
73
73
73
triamterene & hydrochlorothiazide cap
37.5-25 mg
75
triamterene & hydrochlorothiazide cap 5025 mg
75
triamterene & hydrochlorothiazide tab
37.5-25 mg
75
triamterene & hydrochlorothiazide tab 7550 mg
75
triderm cre 0.1%
73
50
50
50
50
trifluridine ophth soln 1%
95
trihexyphenidyl hcl elixir 0.4 mg/ml
46
46
46
trimethobenzamide hcl cap 300 mg
29
trimethoprim tab 100 mg
11
trinessa tab
63
TRIPEDIA SUS P/F
104
triple antib oin
69
triple paste oin af 2%
70
TRISENOX SOL 10MG/10M
45
TRIUMEQ TAB
52
trivora-28 tab
63
tropicamide ophth soln 0.5%
94
tropicamide ophth soln 1%
94
trospium chloride cap sr 24hr 60 mg 107
trospium chloride tab 20 mg
107
27
27
TRUMENBA INJ
107
TRUVADA TAB 200-300
52
tussigon tab 5-1.5mg
65
TWINRIX INJ
108
TYBOST TAB 150MG
52
TYKERB TAB 250MG
44
TYSABRI INJ 300/15ML
100
TYVASO START SOL 0.6MG/ML
59
TYZEKA TAB 600MG
54
TYZINE PED DRO 0.05%
94
TYZINE SOL 0.1%
94
U
142
ULESFIA LOT 5%
74
ULORIC TAB 40MG
83
ULORIC TAB 80MG
83
74
74
74
103
103
103
103
unithroid tab 25mcg
103
103
unithroid tab 50mcg
103
unithroid tab 75mcg
103
unithroid tab 88mcg
103
univert tab 32mg
29
URINE GLUCOSE - KETONE TEST STRIP 88
ursodiol cap 300 mg
81
ursodiol tab 250 mg
81
ursodiol tab 500 mg
81
UVADEX INJ 20MCG/ML
45
V
valacyclovir hcl tab 1 gm
54
valacyclovir hcl tab 500 mg
54
VALCYTE SOL 50MG/ML
53
valganciclovir hcl tab 450 mg (base
equivalent)
53
valproate sodium syrup 250 mg/5ml (base
equiv)
20
valproic acid cap 250 mg
21
35
35
valsartan tab 40 mg
34
valsartan tab 80 mg
35
valsartan-hydrochlorothiazide tab 16012.5 mg
38
valsartan-hydrochlorothiazide tab 160-25
mg
38
valsartan-hydrochlorothiazide tab 32012.5 mg
38
valsartan-hydrochlorothiazide tab 320-25
mg
38
valsartan-hydrochlorothiazide tab 80-12.5
mg
38
11
11
vandazole gel 0.75%
109
VAQTA INJ 25/0.5ML
108
VAQTA INJ 50UNT/ML
108
VARIVAX INJ
108
VCF VAGINAL AER CONTRACP
108
VCF VAGINAL MIS CONTRACP
108
velivet pak
63
VELTIN GEL
68
equivalent)
23
venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)
22
equivalent)
22
venlafaxine hcl tab 100 mg
23
23
venlafaxine hcl tab 37.5 mg
23
23
23
venlafaxine hcl tab sr 24hr 150 mg (base
equivalent)
23
equivalent)
23
venlafaxine hcl tab sr 24hr 37.5 mg (base
equivalent)
23
equivalent)
23
58
58
58
58
58
58
58
58
58
58
VEREGEN OIN 15%
68
VESICARE TAB 10MG
107
VESICARE TAB 5MG
107
vestura tab 3-0.02mg
63
VEXOL SUS 1% OP
96
VIBATIV INJ 250MG
11
VIBATIV INJ 750MG
11
vicodin es tab 7.5-300
9
vicodin hp tab 10-300mg
9
vicodin tab 5-300mg
9
VICTOZA INJ 18MG/3ML
27
VIDEX SOL 2GM
52
VIDEX SOL 4GM
52
VIGAMOX DRO 0.5%
95
VIIBRYD KIT
21
VIIBRYD TAB 10MG
21
VIIBRYD TAB 20MG
21
VIIBRYD TAB 40MG
21
VIMPAT SOL 10MG/ML
20
VIMPAT TAB 100MG
20
VIMPAT TAB 150MG
20
VIMPAT TAB 200MG
20
VIMPAT TAB 50MG
20
VINBLASTINE INJ 10MG
46
vinblastine sulfate inj 1 mg/ml
46
vincasar pfs inj 1mg/ml
46
vincristine sulfate iv soln 1 mg/ml
46
vinorelbine tartrate inj 10 mg/ml (base
equiv)
46
vinorelbine tartrate inj 50 mg/5ml (10
mg/ml) (base equiv)
46
VIOKACE TAB
74
VIOKACE TAB 20880
74
viorele tab
63
VIRACEPT TAB 250MG
53
VIRACEPT TAB 625MG
53
143
VIRAMUNE XR TAB 100MG
VIREAD POW 40MG/GM
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
VITAMIN D2 TAB 400UNIT
VITAMIN D3 LIQ 1000UNIT
VITEKTA TAB 150MG
VITEKTA TAB 85MG
VOLTAREN GEL 1%
voriconazole for susp 40 mg/ml
VOTRIENT TAB 200MG
VYTORIN TAB 10-10MG
VYTORIN TAB 10-20MG
VYTORIN TAB 10-40MG
VYTORIN TAB 10-80MG
VYVANSE CAP 10MG
VYVANSE CAP 20MG
VYVANSE CAP 30MG
VYVANSE CAP 40MG
VYVANSE CAP 50MG
VYVANSE CAP 60MG
VYVANSE CAP 70MG
53
53
53
53
53
53
109
109
53
53
68
30
30
30
44
32
32
32
32
1
1
1
1
1
1
1
W
warfarin sodium tab 1 mg
warfarin sodium tab 2.5 mg
warfarin sodium tab 7.5 mg
wee care sus 15/1.25
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG
wera tab 0.5/35
17
17
17
17
17
17
17
17
17
85
32
32
63
88
88
88
88
88
88
88
88
X
XALKORI CAP 200MG
XALKORI CAP 250MG
XARELTO STAR TAB 15/20MG
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
XIFAXAN TAB 200MG
XIFAXAN TAB 550MG
44
44
17
17
17
17
11
11
xulane dis 150-35
XYREM SOL 500MG/ML
63
99
Y
YERVOY INJ 200MG
YERVOY INJ 50MG
41
41
Z
15
15
zaleplon cap 10 mg
86
zaleplon cap 5 mg
86
zamicet sol 10-325mg
9
ZANOSAR INJ 1GM
40
zarah tab 3-0.03mg
63
zazole cre 0.4%
109
zazole cre 0.8%
109
zazole sup 80mg
109
ZELBORAF TAB 240MG
44
ZEMAIRA INJ 1000MG
101
zenchent fe chw 0.4mg-35
63
zenchent tab
63
ZENPEP CAP 10000UNT
74
ZENPEP CAP 15000UNT
74
ZENPEP CAP 20000UNT
74
ZENPEP CAP 25000UNT
74
ZENPEP CAP 3000UNIT
74
ZENPEP CAP 40000UNT
74
zenzedi tab 15mg
2
zenzedi tab 2.5mg
2
zenzedi tab 20mg
2
zenzedi tab 30mg
2
zenzedi tab 7.5mg
2
ZETIA TAB 10MG
33
ZIAGEN SOL 20MG/ML
53
ZIANA GEL
68
zidovudine cap 100 mg
53
zidovudine syrup 10 mg/ml
53
zidovudine tab 300 mg
53
ZIOPTAN DRO 0.0015%
96
ziprasidone hcl cap 20 mg
48
48
48
48
ZIRGAN GEL 0.15%
95
zoledronic acid inj conc for iv infusion 4
mg/5ml
76
zoledronic acid iv soln 5 mg/100ml
76
ZOLEDRONIC INJ 4MG/100
76
ZOLINZA CAP 100MG
44
zolmitriptan orally disintegrating tab 2.5
mg
89
zolmitriptan orally disintegrating tab 5
mg
89
zolmitriptan tab 2.5 mg
89
zolmitriptan tab 5 mg
89
86
86
86
144
ZOMIG NASAL SPR 5MG
ZOMIG SPR 2.5MG
ZONTIVITY TAB 2.08MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.75MG
ZOSTAVAX INJ
zovia 1/35e tab
zovia 1/50e tab
ZYCLARA CRE 3.75%
ZYCLARA PUMP CRE 2.5%
ZYDELIG TAB 100MG
ZYDELIG TAB 150MG
ZYFLO CR TAB 600MG
ZYKADIA CAP 150MG
ZYTIGA TAB 250MG
ZYVOX SUS 100MG/5M
86
89
90
20
20
20
84
55
55
55
108
63
63
73
73
44
44
15
44
42
12
145

Formulary - MetroPlus Health Plan

Transcription

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