medicare part d drug formulary

Transcription

55 Water Street, New York, New York 10041-8190 | www.emblemhealth.com
MEDICARE PART D
DRUG FORMULARY
2012 EmblemHealth PPO Medicare, HMO Medicare,
Prescription Drug Plan (PDP)
Comprehensive Medication List
Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance
Company of New York and EmblemHealth Services Company, LLC are EmblemHealth
companies. EmblemHealth Services Company, LLC provides administrative services
to the EmblemHealth companies.
86-9018 8/11
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EmblemHealth Medicare PPO
EmblemHealth Medicare HMO
EmblemHealth Medicare PDP
2012 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE
DRUGS WE COVER IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this
document to make sure that it still contains the drugs you take.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits,
formulary, pharmacy network, premium and/or copayments/coinsurance may change on January
1, 2013.
HIP Health Plan of New York (HIP) is a Medicare Advantage organization with a Medicare
contract. Group Health Incorporated (GHI) is a Medicare Advantage organization and a
standalone prescription drug plan with a Medicare contract. HIP and GHI are EmblemHealth
companies
For alternative formats or language, please call Customer Service toll free at:
Plan
EmblemHealth
Medicare PPO
EmblemHealth
Medicare HMO
EmblemHealth
Medicare PDP
Customer Service
1-877-444-7097
TTY Users
1-888-447-4833
1-800-447-8255
1-888-447-4833
1-877-444-7241
1-888-447-4833
Hours of Operation
8 am to 8 pm Monday
through Sunday
8 am to 8 pm Monday
through Sunday
8 am to 8 pm Monday
through Sunday
Y0026_122616r File and Use 10/29/2011
[12309,Version Number 8]
Page 1 of 103
What is the EmblemHealth plan Formulary?
A formulary is a list of covered drugs selected by your EmblemHealth Plan in consultation with
a team of health care providers, which represents the prescription therapies believed to be a
necessary part of a quality treatment program. Your EmblemHealth Plan will generally cover the
drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled
at an EmblemHealth Plan network pharmacy, and other plan rules are followed. For more
information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary change?
Generally, if you are taking a drug on our 2012 formulary that was covered at the beginning
of the year, we will not discontinue or reduce coverage of the drug during the 2012
coverage year except when a new, less expensive generic drug becomes available or when
new adverse information about the safety or effectiveness of a drug is released. Other types
of formulary changes, such as removing a drug from our formulary, will not affect members
who are currently taking the drug. It will remain available at the same cost-sharing for those
members taking it for the remainder of the coverage year. We feel it is important that you
have continued access for the remainder of the coverage year to the formulary drugs that
were available when you chose our plan, except for cases in which you can save additional
money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or
step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must
notify affected members of the change at least 60 days before the change becomes effective,
or at the time the member requests a refill of the drug, at which time the member will
receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on
our formulary to be unsafe or the drug’s manufacturer removes the drug from the market,
we will immediately remove the drug from our formulary and provide notice to members
who take the drug. The enclosed formulary is current as of January 1, 2012. To get updated
information about the drugs covered by your EmblemHealth Plan, please visit our Web site
at www.emblemhealth.com or call Customer Service at:
Plan
EmblemHealth
Medicare PPO
EmblemHealth
Medicare HMO
EmblemHealth
Medicare PDP
Customer Service
1-877-444-7097
TTY Users
1-888-447-4833
1-800-447-8255
1-888-447-4833
1-877-444-7241
1-888-447-4833
Hours of Operation
8 am to 8 pm Monday
through Sunday
8 am to 8 pm Monday
through Sunday
8 am to 8 pm Monday
through Sunday
We will update the formulary booklet by inserting errata sheets in the event of a mid-year
formulary change.
Page 2 of 103
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 10. The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example, drugs
used to treat a heart condition are listed under the category, Cardiovascular Agents. If you
know what your drug is used for, look for the category name in the list that begins on page
10, then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index
that begins on page 73. The Index provides an alphabetical list of all of the drugs included in
this document. Both brand name drugs and generic drugs are listed in the Index. Look in the
Index and find your drug. Next to your drug, you will 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.
What are generic drugs?
Your EmblemHealth Plan covers both brand name drugs and generic drugs. A generic drug is
approved by the FDA as having the same active ingredient as the brand name drug.
Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These
requirements and limits may include:
Prior Authorization: Your EmblemHealth Plan requires you or your physician to get
prior authorization for certain drugs. This means that you will need to get approval from
your EmblemHealth Plan before you fill your prescriptions. If you don’t get approval,
your EmblemHealth Plan may not cover the drug.
Quantity Limits: For certain drugs, your EmblemHealth Plan limits the amount of the
drug your EmblemHealth Plan will cover. For example, we provide 12 per prescription
for Maxalt 5mg tablets. This may be in addition to a standard one month or three month
supply.
Step Therapy: In some cases, your EmblemHealth Plan requires you to first try certain
drugs to treat your medical condition before we will cover another drug for that
condition. For example, if Drug A and Drug B both treat your medical condition, your
Page 3 of 103
EmblemHealth Plan may not cover Drug B unless you try Drug A first. If Drug A does
not work for you, your EmblemHealth Plan will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the
formulary that begins on page 10. You can also get more information about the restrictions
applied to specific covered drugs by visiting our Web site at www.emblemhealth.com.
You can ask your EmblemHealth Plan to make an exception to these restrictions or limits. See
the section, “How do I request an exception to the plan formulary?” on page 4 for information
about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Member Services and
confirm that your drug is not covered. If you learn that your EmblemHealth Plan does not cover
your drug, you have two options:
You can ask Customer Service for a list of similar drugs that are covered by us. When
you receive the list, show it to your doctor and ask him or her to prescribe a similar drug
that is covered by your EmblemHealth Plan .
You can ask your EmblemHealth Plan to make an exception and cover your drug. See
below for information about how to request an exception.
How do I request an exception to the EmblemHealth Medicare PPO/Medicare
HMO/Medicare Prescription Drug Plan (PDP) Formulary?
You can ask your EmblemHealth Plan to make an exception to our coverage rules. There are
several types of exceptions that you can ask us to make.
You can ask us to cover your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug. For example, for
certain drugs, your EmblemHealth Plan limits the amount of the drug that we will cover.
If your drug has a quantity limit, you can ask us to waive the limit and cover more.
You can ask us to provide a higher level of coverage for your drug. If your drug is
contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount
that applies to drugs in the preferred tier instead. This would lower the amount you must
pay for your drug. Please note, if we grant your request to cover a drug that is not on our
formulary, you may not ask us to provide a higher level of coverage for the drug. Also,
you may not ask us to provide a higher level of coverage for drugs that are in the
Specialty tier (tier 4).
Page 4 of 103
Generally, your EmblemHealth Plan will only approve your request for an exception if the
alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization
restrictions would not be as effective in treating your condition and/or would cause you to have
adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or
utilization restriction exception. When you are requesting a formulary, tiering or utilization
restriction exception you should submit a statement from your physician supporting your
request. Generally, we must make our decision within 72 hours of getting your prescriber’s or
prescribing physician’s supporting statement. You can request an expedited (fast) exception if
you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours
for a decision. If your request to expedite is granted, we must give you a decision no later than
24 hours after we get your prescriber’s or prescribing physician’s supporting statement.
What do I do before I can talk to my doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our
formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is
limited. For example, you may need a prior authorization from us before you can fill your
prescription. You should talk to your doctor to decide if you should switch to an appropriate drug
that we cover or request a formulary exception so that we will cover the drug you take. While
you talk to your doctor to determine the right course of action for you, we may cover your drug
in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited,
we will cover a temporary 30 day supply (unless you have a prescription written for fewer days)
when you go to a network pharmacy. After your first 90-day supply, we will not pay for these
drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription
until we have provided you with up to a 98 day transition supply, consistent with the dispensing
increment, (unless you have a prescription written for fewer days). We will cover more than one
refill of these drugs for the first 31 days you are a member of our plan. If you need a drug that is
not on our formulary, or if your ability to get your drugs is limited; but you are past the first 90
days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless
you have a prescription for fewer days) while you pursue a formulary exception.
If you are a current member in EmblemHealth Plan and you experience a change in the level of
care, such as an admission or discharge from the Long Term Care facility, you will be allowed
an “early” refill of your medications, as needed, to assist with your transition to your new level
of care.
Page 5 of 103
For more information
For more detailed information about your EmblemHealth Plan prescription drug coverage, please
review your Evidence of Coverage and other plan materials.
If you have questions about your EmblemHealth Plan, please call Customer Service toll-free at:
Plan
Customer Service
EmblemHealth
1-877-444-7097
Medicare PPO
EmblemHealth
1-800-447-8255
Medicare HMO
EmblemHealth
1-877-444-7241
Medicare PDP
Or visit www.emblemhealth.com.
TTY Users
1-888-447-4833
1-888-447-4833
1-888-447-4833
Hours of Operation
8 am to 8 pm Monday
through Sunday
8 am to 8 pm Monday
through Sunday
8 am to 8 pm Monday
through Sunday
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should
call 1-877-486-2048. Or, visit www.medicare.gov.
EmblemHealth Medicare PPO/EmblemHealth
Medicare HMO/EmblemHealth Medicare PDP Formulary
The formulary below provides coverage information about some of the drugs covered by your
EmblemHealth Plan. If you have trouble finding your drug in the list, turn to the Index that
begins on page 73.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,
LANOXIN) and generic drugs are listed in lower-case italics (e.g., digoxin).
The information in the Requirements/Limits column tells you if your EmblemHealth Plan has
any special requirements for coverage of your drug.
Page 6 of 103
Note: The following symbols or abbreviations are used to identify drugs that require prior
approval, quantity limits, subject to a protocol or covered with the generic copayment.
The symbol [INJ] next to a drug name indicates that the drug is available in injectable form.
The symbol [E] next to a drug name indicates that this prescription drug is not normally
covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a
prescription for this drug does not count towards your total drug costs (that is, the amount
you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving
extra help to pay for prescriptions, you will not get any extra help to pay for this drug.
The symbol [MNT] in the Restrictions column indicates that the drug is a maintenance
medication available at mail order and select retail pharmacies.
The symbol [G] next to a drug name indicates that the drug may be available in a generic
form.
The symbol [MOE] in the Restrictions column indicates that the drug may not be available
through mail order service.
The symbol [LA] next to a drug name indicates that the drug has been noted as being
restricted to certain pharmacies by the Food and Drug Administration. These drugs can only
be obtained at specialty designated pharmacies able to appropriately handle the drugs.
The symbol [OTC] next to a drug name indicates that the drug is available Over-the-Counter.
The symbol [PA] in the Requirements/Limits column indicates that prior authorization may
apply.
The symbol [PAN] in the Requirements/Limits column indicates that prior authorization may
apply to individuals who are starting the medication for the first time or for the first time in a
long time.
The symbol [PAB] in the Requirements/Limits column indicates that prior authorization may
apply to ensure drug is paid under Medicare Part B if required by Medicare.
The symbol [QLL] next to a drug name indicates that the drug has a quantity level limit.
The symbol [SP] next to the drug name indicates that the drug may be considered a specialty
product under this plan.
The symbol [ST] in the Restrictions column indicates that step therapy may apply.
Please refer to the tables below for information about how the plan cost-sharing relates to the
different tier levels listed in this formulary. If you are eligible for “Extra Help or “Low Income
Subsidy” (LIS), some of the information in these tables about the cost of Part D prescription
drugs may not apply to you. We will send you a separate insert, called the “Evidence of
Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider),
which tells you about your drug coverage. If you don't have this insert, please call Customer
Service at numbers listed above and ask for the “Evidence of Coverage Rider for People Who
Get Extra Help Paying for Prescription Drugs” (LIS Rider).
Page 7 of 103
VIP (HMO), VIP Essential (HMO) and VIP High Option (HMO)
Tier
Tier Name
Initial
Coverage Gap Stage
Number
Coverage
Stage
Tier 1 – Preferred
$5 copay
86% coinsurance of the price for
generic drugs.
Generic Drugs
$35 copay
50% of the price (plus the dispensing
Brand Drugs
fee)
Tier 3 – Non-Preferred 50%
Generic/Brand coinsurance fee) for brand name drugs and 86%
of the price for generic drugs.
Drugs
Tier 4 –
5% of drug
cost*
5% of drug
cost*
5% of drug
cost*
50% of the price (plus the dispensing 5% of drug
fee) for brand name drugs and 86%
cost*
* after you have paid $4,700 out-of-pocket, you will pay the greater of $2.60 or 5% for a
generic drug or drug treated like a generic and the greater of $6.50 or 5% for all other drugs.
PPO II
Tier
Number
Tier 1 –
Tier 2 –
Tier 3 –
Tier 4 –
Specialty
drugs
Catastrophic
Stage
Tier Name
Preferred
Generic Drugs
Preferred
Brand Drugs
Non-Preferred
Generic/Brand
Drugs
Specialty
drugs
25%
coinsurance
Initial
Coverage
Stage
$5 copay
$35 copay
50%
coinsurance
Coverage Gap Stage
generic drugs.
fee)
Catastrophic
Stage
5% of drug
cost*
5% of drug
cost*
5% of drug
cost*
25%
coinsurance
cost*
Page 8 of 103
PPO III and PPO High Option
Tier
Number
Tier Name
Tier 1 –
Preferred
Generic Drugs
Preferred
Brand Drugs
Non-Preferred
Generic/Brand
Drugs
Specialty
drugs
Tier 2 –
Tier 3 –
Tier 4 –
Initial
Coverage
Stage
$5 copay
$35 copay
50%
coinsurance
Coverage Gap Stage
$5 copay
fee)
Catastrophic
Stage
5% of drug
cost*
5% of drug
cost*
5% of drug
cost*
25%
coinsurance
cost*
Dual Eligible (HMO SNP), Dual Eligible (PPO SNP) and Medicare Prescription Drug Plan
(PDP)
Tier
Tier Name
Initial
Coverage Gap Stage
Catastrophic
Number
Coverage
Stage
Stage
$4 copay
5% of drug
generic drugs.
Generic Drugs
cost*
25%
Brand Drugs
coinsurance fee)
cost*
Tier 3 – Non-Preferred 50%
Generic/Brand coinsurance fee) for brand name drugs and 86%
cost*
Drugs
Tier 4 –
Specialty drugs 25%
coinsurance fee) for brand name drugs and 86%
cost*
Page 9 of 103
General Drug Table
Drug
Generic
Tier Requirements/Limits
ANALGESICS
GOUT
allopurinol sodium
allopurinol tablet
COLCRYS
colchicine
probenecid
probenecid-colchicine
ULORIC
febuxostat
1
1
2
1
1
2
[MOE]
[MNT]
[MNT][QLL, 60/30]
[MNT]
[MOE]
[MNT][ST]
1
1
1
[MOE]
[MOE]
[MOE]
1
[MOE]
1
1
1
[MOE]
[MOE]
[MOE]
NARCOTIC ANALGESICS
acetaminophen-codeine
ascomp with codeine
butalb-caff-acetaminophcodein
butorphanol tartrate aerosol
spray, -1 mg/ml vial, -2 mg/ml
vial
co-gesic
hydrocodone bit-ibuprofen
hydrocodone-acetaminophen
capsule, -solution, hydrocodon-acetaminoph 2.5500, -hydrocodonacetaminophen 5-325, hydrocodon-acetaminoph 7.5325, -hydrocodon-acetaminoph
7.5-750, -hydrocodonacetaminophn 10-650, hydrocodon-acetaminophn 10325, -hydrocodon-acetaminoph
7.5-500, -hydrocodonacetaminophn 10-500, hydrocodon-acetaminoph 7.5650, -hydrocodonacetaminophn 10-660, hydrocodon-acetaminophn 10750
Page 10 of 103
Drug
margesic h
reprexain
stagesic
vicodin hp [G]
zamicet
Generic
Tier
1
1
1
1
1
Requirements/Limits
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
1
[MOE]
1
[MOE][PAB]
endocet
endodan
fentanyl
1
2
1
1
1
1
fentanyl 0.05 mg/ml syringe
fentanyl citrate otfc 200 mcg
1
2
fentanyl citrate otfc 400 mcg, otfc 600 mcg, -otfc 800 mcg, cit otfc 1,200 mcg, -cit otfc
1,600 mcg
hydromorphone hcl 10 mg/ml
amp
hydromorphone hcl tablet
4
[MOE]
[MOE]
[MOE][PAB]
[MOE]
[MOE]
[MOE][PA][QLL,
10/30]
[MOE][PAB]
[MOE][PA][QLL,
120/30]
[MOE][PA][QLL,
120/30]
NARCOTIC ANALGESICS, CII
acetaminoph-caffdihydrocodein
astramorph-pf 5 mg/10 ml vial,
-10 mg/10 ml vial [G]
codeine sulfate
DILAUDID-5
duramorph [G]
KADIAN
levorphanol tartrate tablet
meperidine 10 mg/ml syringe,
-25 mg/ml vial, -50 mg/ml vial,
-100 mg/ml vial
methadone hcl injection, solution
methadone hcl tablet
methadose tablet
morphine 0.5 mg/ml vial, -1
mg/ml vial p-f
hydromorphone
morphine
1
[MOE][PAB]
1
2
1
1
[MOE]
[MOE][QLL, 60/30]
[MOE]
[MOE]
1
[MOE]
1
1
1
[MOE][QLL, 240/30]
[MOE][QLL, 240/30]
[MOE][PAB]
Page 11 of 103
Drug
MORPHINE SULF 10 MG/5 ML
SOLN, -SULF 20 MG/5 ML
SOLN
morphine
Generic
morphine sulf 100 mg/5 ml
soln, -tablet
morphine sulf er 15 mg tablet,
-sulf er 30 mg tablet, -sulf er
60 mg tablet, -sulf er 100 mg
tab
morphine sulf er 200 mg tab
oxycodone hcl 5 mg tablet, -15
mg tablet, -30 mg tablet
oxycodone hcl-acetaminophen
oxycodone hcl-ibuprofen
oxycodone w/apap 5/325 tab
oxycodone-acetaminophen
capsule, -oxycodonacetaminophen 2.5-325, oxycodon-acetaminophen 7.5325
oxycodone-aspirin
OXYCONTIN
oxycodone
oxymorphone hcl
ROXICET SOLUTION
oxycodone/acetaminophen
roxicet tablet
2
[MOE]
1
[MOE]
1
[MOE][QLL, 90/30]
1
1
[MOE][QLL, 60/30]
[MOE]
1
1
1
1
[MOE]
[MOE]
[MOE]
[MOE]
1
3
1
2
1
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
1
1
[MOE]
[MOE]
1
1
[MOE][QLL, 240/30]
[MOE]
1
[MOE][QLL, 240/30]
3
3
2
[MNT]
[MNT]
[MNT]
NON-NARCOTIC ANALGESICS
buprenorphine 0.3 mg/ml syrn
nalbuphine 100 mg/10 ml vial,
-200 mg/10 ml vial
tramadol hcl tablet
tramadol hcl tablet sustained
release 24hr
tramadol hcl-acetaminophen
NSAIDS
ARTHROTEC 50
ARTHROTEC 75
CELEBREX
diclofenac sodium/misoprostol
diclofenac sodium/misoprostol
celecoxib
Page 12 of 103
Drug
diclofenac potassium
diclofenac sodium tablet
enteric coated, -tablet
sustained release 24hr
diflunisal
etodolac
fenoprofen calcium
flurbiprofen tablet
ibuprofen 100 mg/5 ml sus
ibuprofen 100 mg/5 ml susp, 400 mg tablet, -600 mg tablet,
-800 mg tablet
INDOCIN
Generic
indomethacin
indomethacin capsule, -capsule
sustained action
ketoprofen capsule, -capsule
24hr sustained release pellets
ketorolac 15 mg/ml vial, -30
mg/ml vial, -tablet
meclofenamate sodium capsule
mefenamic acid capsule
meloxicam suspension oral, tablet
nabumetone
NAPRELAN
naproxen
naproxen sodium 275 mg tab,
-550 mg tab
naproxen suspension oral, -250
mg tablet, -375 mg tablet, tablet enteric coated
oxaprozin
piroxicam capsule
sulindac tablet
tolmetin sodium
VIMOVO
naproxen/esomeprazole mag
1
[MOE]
1
[MNT]
1
1
1
1
1
1
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
2
1
[MOE]
[MOE]
1
[MNT]
1
[MOE]
1
1
1
[MNT]
[MOE]
[MNT]
1
3
1
[MNT]
[MNT]
[MNT]
1
[MNT]
1
1
1
1
2
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
1
[MOE]
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl 0.5% vial, -1%
vial
Page 13 of 103
Drug
Generic
ANTIINFECTIVES
ANTIBACTERIALS
gentamicin 90 mg/ns 100 ml
pb, -70 mg/ns 50 ml pb
kanamycin sulfate injection
tobramycin sulfate in ns
1
[MOE]
1
1
[MOE]
[MOE]
1
[MOE]
1
1
1
1
[MOE]
[MOE]
[MOE]
[MOE]
1
1
[MOE]
[MOE]
moxifloxacin
moxifloxacin
moxifloxacin
2
2
2
1
[MOE]
[MOE]
[MOE]
[MOE]
pen g procaine/pen g benz
penicillin g benzathine
2
2
1
2
1
2
1
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
1
1
1
[MOE]
[MOE]
[MOE]
1
[MOE]
ANTI-INFECTIVES
ANTIBACTERIALS
amikacin sulfate 100 mg/2 ml,
-500 mg/2 ml
amox tr-potassium clavulanate
amoxicillin
amoxicillin-clavulanate er
ampicillin 125 mg vial, -1 gm
vial, -10 gm vial
ampicillin trihydrate
ampicillin-sulbactam 3 gm vial,
-15 gm vl
AVELOX
AVELOX ABC PACK
AVELOX IV
azithromycin injection, suspension, -tablet
BICILLIN C-R
BICILLIN L-A
cefaclor
CEFACLOR ER
cefaclor
cefadroxil
CEFAZOLIN 1 GM-D5W BAG
cefazolin 20 gm bulk vial, -500
mg vial, -1 gm vial
cefdinir
cefepime hcl
cefotaxime sodium 500 mg
vial, -10 gm vial, -1 gm vial, -2
gm vial
cefotetan
cefazolin
Page 14 of 103
Drug
cefoxitin
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime 1 gm vial, -2 gm
vial, -6 gm vial
ceftriaxone 250 mg vial, -500
mg vial, -1 gm vial, -2 gm add
vial, -10 gm vial
cefuroxime axetil
cefuroxime sod 750 mg vial, sod 1.5 gm vial, -sod 7.5 gm
vial
cefuroxime tablet
cephalexin
chloramphenicol sod succinate
CIPRO
Generic
ciprofloxacin
ciprofloxacin 400 mg/40 ml vl
ciprofloxacin er
ciprofloxacin hcl tablet
clarithromycin er
clarithromycin suspension, tablet
demeclocycline hcl
dicloxacillin sodium
doxycycline
doxycycline hyclate capsule, capsule enteric coated, injection, -tablet, -tablet
enteric coated
doxycycline mono 50 mg
tablet, -mono 75 mg tablet
e.e.s. 400
ERYPED 200
ERYTHROCIN LACTOBIONATE
erythrocin stearate
erythromycin tablet
gentamicin 10 mg/ml vial, -40
mg/ml vial
erythromycin ethylsuccinate
erythromycin lactobionate
Tier
1
1
1
1
1
Requirements/Limits
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
1
[MOE]
1
1
[MOE]
[MOE]
1
1
1
2
1
1
1
1
1
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
1
1
1
1
[MOE]
[MOE]
[MOE]
[MOE]
1
[MOE]
1
2
2
1
1
1
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
Page 15 of 103
Drug
isoton gentamicin 60 mg/100
ml, -80 mg/ns 100 ml pb, -100
mg/ns 100 ml, -60 mg/ns 50
ml pb, -80 mg/ns 50 ml pb
isoton gentamicin 80 mg/100
ml, -iso gentamicin 100
mg/100 ml, -isoton gentamicin
60 mg/50 ml, -isoton
gentamicin 80 mg/50 ml [G]
minocycline hcl capsule, tablet, -tablet sustained
release 24hr
nafcillin
nafcillin 1 gm vial, -10 gm bulk
vial, -10 gm vial
neomycin sulfate tablet
ofloxacin tablet
oxacillin 1 gm vial
oxacillin 1 gm/ 50 ml inj
oxacillin 10 gm vial
oxacillin 2 gm/ 50 ml inj
paromomycin sulfate
penicillin g k 5 million unit
PENICILLIN G PROCAINE
Generic
penicillin g procaine
penicillin g sodium
penicillin v potassium
piperacillin 3 gm vial, -40 gm
bulk vial
piperacil-tazobact 3.375 gm vl
streptomycin sulfate injection
SULFADIAZINE
SUPRAX
sulfadiazine
cefixime
tetracycline hcl capsule
tobramycin 10 mg/ml vial, -40
mg/ml vial
1
[MOE]
1
[MOE]
1
[MOE]
4
1
[MOE]
[MOE]
1
1
1
1
4
4
1
1
2
1
1
1
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
1
1
2
3
1
1
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
1
2
4
[MOE][PAB]
[MOE]
[MOE]
ANTIFUNGALS
amphotericin b injection
ANCOBON
CANCIDAS
flucytosine
caspofungin acetate
Page 16 of 103
Drug
clotrimazole troche
fluconazole suspension, -tablet
fluconazole-dext 400 mg/200
ml
griseofulvin suspension oral
GRIS-PEG
Generic
griseofulvin ultramicrosize
itraconazole capsule
ketoconazole tablet
NOXAFIL
posaconazole
nystatin 500,000 unit oral tab
terbinafine hcl
VFEND IV
VFEND SUSPENSION
VFEND TABLET [G]
voriconazole
voriconazole
voriconazole
voriconazole
Tier
1
1
1
Requirements/Limits
[MOE]
[MOE]
[MOE]
1
2
1
1
4
1
1
2
4
4
1
[MOE]
[MOE]
[MOE][PA]
[MOE]
[MOE]
[MOE]
[MOE][QLL, 90/365]
[MOE]
[MOE]
[MOE]
[MOE][QLL, 29/30]
1
3
2
2
1
[MNT]
[MOE]
[MOE]
[MOE]
[MNT]
2
4
2
2
1
2
2
2
4
2
2
4
2
2
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
ANTIMALARIALS
chloroquine phosphate tablet
COARTEM
DARAPRIM
MALARONE
artemether/lumefantrine
pyrimethamine
atovaquone/proguanil hcl
mefloquine hcl
ANTIRETROVIRAL AGENTS
APTIVUS
ATRIPLA
COMBIVIR
CRIXIVAN
tipranavir
emtricitabine/tenofovir/efavir
lamivudine/zidovudine
indinavir
didanosine
EMTRIVA
EPIVIR
EPZICOM
FUZEON
INTELENCE
INVIRASE
ISENTRESS
KALETRA
LEXIVA
emtricitabine
lamivudine
abacavir sulfate/lamivudine
enfuvirtide
etravirine
saquinavir mesylate
raltegravir potassium
ritonavir/lopinavir
fosamprenavir calcium
Page 17 of 103
Drug
NORVIR
PREZISTA 400 MG TABLET, 600 MG TABLET
PREZISTA 75 MG TABLET, -150
MG TABLET
RESCRIPTOR
RETROVIR
REYATAZ
SELZENTRY
Generic
ritonavir
darunavir ethanolate
2
[MNT]
4
[MNT]
darunavir ethanolate
2
[MNT]
delavirdine mesylate
zidovudine
atazanavir sulfate
maraviroc
2
2
2
4
1
2
2
2
2
2
2
2
2
1
[MNT]
[MOE]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
3
1
1
1
1
2
3
3
1
1
3
3
[MOE]
[MNT]
[MOE]
[MOE]
[MNT]
[MOE]
[MNT]
[MOE]
[MNT]
[MOE]
[MOE]
[MOE]
1
[MNT]
1
[MOE]
stavudine
SUSTIVA
TRIZIVIR
TRUVADA
VIDEX
VIRACEPT
VIRAMUNE
VIREAD
ZIAGEN
efavirenz
zidovudine/lamivudine/abacavir
emtricitabine/tenofovir
didanosine
nelfinavir mesylate
nevirapine
tenofovir disproxil fumarate
abacavir sulfate
zidovudine
ANTITUBERCULAR AGENTS
CAPASTAT SULFATE
capreomycin
ethambutol hcl
isonarif
isoniazid injection
isoniazid syrup, -tablet
MYCOBUTIN
PASER
PRIFTIN
rifabutin
aminosalicylic acid
rifapentine
pyrazinamide
rifampin capsule, -injection
SEROMYCIN
TRECATOR
cycloserine
ethionamide
ANTIVIRALS
acyclovir capsule, -suspension
oral, -tablet
acyclovir sodium 500 mg vial
Page 18 of 103
Drug
BARACLUDE SOLUTION
BARACLUDE TABLET
EPIVIR HBV
entecavir
entecavir
lamivudine
Generic
famciclovir
foscarnet sodium
ganciclovir 250 mg capsule
ganciclovir 500 mg capsule
ganciclovir sodium
HEPSERA
REBETOL
RELENZA
adefovir dipivoxil
ribavirin
zanamivir
ribapak
ribasphere 400 mg tablet, -600
mg tablet
ribasphere capsule, -200 mg
tablet
ribavirin capsule, -tablet
rimantadine hcl
Tier
2
4
2
1
1
1
4
1
4
4
2
4
4
Requirements/Limits
[MNT]
[MNT]
[MNT]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE][PAB]
[MOE][PA]
[MOE][PA]
[MOE][QLL, 60
inhalations/180]
[MOE][PA]
[MOE][PA]
1
[MOE][PA]
[MOE][PA]
[MOE]
[MOE][QLL, 84/180]
[MOE][QLL, 42/180]
TAMIFLU 30 MG GELCAP
TAMIFLU 45 MG GELCAP, -75
MG GELCAP
TAMIFLU SUSPENSION
oseltamivir phosphate
1
1
2
2
2
TYZEKA
telbivudine
valganciclovir
4
1
4
[MOE][QLL, 262.5
ml/180]
[MNT][PA]
[MNT]
[MNT]
albendazole
nitazoxanide
2
2
[MOE]
[MOE][QLL, 180/30]
nitazoxanide
2
1
1
1
2
2
1
1
[MOE][QLL, 12/30]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
valacyclovir
VALCYTE
MISCELLANEOUS
ALBENZA
ALINIA SUSPENSION
RECONSTITUTED ORAL
ALINIA TABLET
aztreonam 1 gm vial
baciim
bacitracin injection
CLEOCIN HCL
CLEOCIN PALMITATE [G]
clindamycin 150 mg/ml addvan
clindamycin hcl capsule
clindamycin hcl
clindamycin palmitate
Page 19 of 103
Drug
colistimethate 150 mg vial
CUBICIN
Generic
Tier
1
4
1
1
2
2
1
4
1
1
1
Requirements/Limits
[MOE][PAB]
[MOE][PAB]
[MNT]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
1
1
1
2
2
1
1
3
4
1
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE][PAB]
vancomycin
2
[MOE][PAB]
linezolid
4
[MOE]
carmustine
busulfan
lomustine
2
2
2
1
1
[MOE][PAB]
[MOE][PAB]
[MOE]
[MOE][PAB]
[MOE][PAB]
estramustine phosphate sodium
altretamine
ifosfamide
2
4
2
2
[MOE]
[MOE]
[MOE][PAB]
[MOE][PAB]
daptomycin
dapsone tablet
erythromycin-sulfisoxazole
INVANZ
MACRODANTIN
ertapenem sodium
nitrofurantoin macrocrystal
mebendazole tablet chewable
MEPRON
atovaquone
meropenem iv 500 mg vial
methenamine hippurate
metronidazole capsule, injection, -tablet
nitrofurantoin mcr 50 mg cap
nitrofurantoin mono-macro
polymyxin b sulfate injection
PRIMAXIN
PRIMAXIN I.M.
imipenem/cilastatin sodium
imipenem/cilastatin sodium
sulfamethoxazole-trimethoprim
trimethoprim tablet
TYGACIL
VANCOCIN HCL
vancomycin 1 gm vial, -10 gm
vial
VANCOMYCIN 500 MG A/V
VIAL
ZYVOX
tigecycline
vancomycin
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
BICNU [PartB]
BUSULFEX [PartB]
CEENU
cyclophosphamide tablet
dacarbazine 200 mg vial
[PartB]
EMCYT
HEXALEN
IFEX [PartB][G]
ifosfamide [PartB]
Page 20 of 103
Drug
Tier
2
1
2
4
Requirements/Limits
[MOE]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
adriamycin 2 mg/ml vial
1
[MOE][PAB]
daunorubicin 20 mg vial
1
[MOE][PAB]
4
1
[MOE][PAB]
[MOE][PAB]
4
1
[MOE][PAB]
[MOE][PAB]
1
[MOE][PAB]
dactinomycin
2
1
[MOE][PAB]
[MOE][PAB]
pemetrexed disodium
4
1
[MOE][PAB]
[MOE][PAB]
1
[MOE][PAB]
4
1
1
[MOE][PAB]
[MOE]
[MOE][PAB]
1
2
4
[MOE][PAB]
[MOE]
[MOE][PAB]
LEUKERAN
Generic
chlorambucil
melphalan hcl [PartB]
MUSTARGEN
TREANDA [PartB]
mechlorethamine
bendamustine hcl
ANTHRACYCLINES
[PartB]
[PartB]
DOXIL [PartB]
doxorubicin hcl liposome
doxorubicin 200 mg/100 ml
vial [PartB]
epirubicin hcl [PartB]
idarubicin hcl 10 mg/10 ml vl
[PartB]
ANTIBIOTICS
bleomycin sulfate 30 unit vial
[PartB]
COSMEGEN [PartB][G]
mitomycin 20 mg vial [PartB]
ANTIMETABOLITES
ALIMTA
cytarabine 20 mg/ml vial, -500
mg vial [PartB]
fluorouracil 500 mg/10 ml vial
[PartB]
GEMZAR [PartB][G]
gemcitabine
mercaptopurine tablet
methotrexate 25 mg/ml vial, -1
gm vial
pentostatin [PartB]
TABLOID
VIDAZA
thioguanine
azacitidine
Page 21 of 103
Drug
Generic
ANTIMITOTIC, TAXOIDS
paclitaxel [PartB]
TAXOTERE [PartB]
docetaxel
2
4
[MOE][PAB]
[MOE][PAB]
2
1
1
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
4
2
4
4
2
4
4
4
4
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PA]
[MOE][PAB]
[MOE]
1
2
1
2
1
2
4
2
1
1
1
2
[MNT]
[MNT]
[MNT]
[MNT][PAB]
[MNT]
[MNT]
[MNT][PAB]
[MNT]
[MNT]
[MNT]
[MOE][PA]
[MOE][PA]
ANTIMITOTIC, VINCA ALKALOIDS
VINBLASTINE SULFATE [PartB]
vincristine 1 mg/ml vial [PartB]
vinblastine
vinorelbine 50 mg/5 ml vial
[PartB]
BIOLOGIC RESPONSE MODIFIERS
AVASTIN
CAMPATH
HERCEPTIN [PartB]
ISTODAX [PartB]
ONTAK [PartB]
PROLEUKIN
RITUXAN
VELCADE
ZOLINZA
bevacizumab
alemtuzumab
trastuzumab
romidepsin
denileukin diftitox
aldesleukin
rituximab
bortezomib
vorinostat
HORMONAL ANTINEOPLASTIC AGENTS
anastrozole tablet
AROMASIN [G]
exemestane
bicalutamide
DEPO-PROVERA
medroxyprogesterone
exemestane
FARESTON
FASLODEX
FEMARA [G]
toremifene
fulvestrant
letrozole
flutamide
letrozole
leuprolide acetate injection
LUPRON DEPOT 3.75 MG KIT,
-11.25 MG 3MO KIT
leuprolide
Page 22 of 103
Drug
LUPRON DEPOT 7.5 MG KIT, 22.5 MG 3MO KIT, --4 MONTH
KIT
LUPRON DEPOT-PED
MEGACE ES
leuprolide
Generic
leuprolide
megestrol
4
2
1
[MOE][PA]
[MNT]
[MNT]
triptorelin pamoate
1
2
1
2
[MOE]
[MNT]
[MNT]
[MOE][PAB]
everolimus
imatinib mesylate
sorafenib tosylate
dasatinib
sunitinib malate
erlotinib hcl
nilotinib hydrochloride
lapatinib ditosylate
pazopanib
4
4
4
4
4
4
4
4
4
[MNT][PAN]
[MNT][PAN]
[MOE][PAN]
[MNT][PAN]
[MOE][PAN]
[MNT][PAN]
[MNT][PAN]
[MNT][PAN]
[MOE][PAN]
hydroxyurea
asparaginase
2
2
1
4
4
4
1
2
4
4
2
[MNT]
[MOE][PAB]
[MNT]
[MOE][PAB]
[MOE]
[MOE]
[MNT][PAB]
[MOE][PAB]
[MNT][PAN]
[MOE]
[MOE][PAB]
megestrol acetate suspension
oral
megestrol acetate tablet
NILANDRON
nilutamide
tamoxifen citrate tablet
TRELSTAR
4
[MOE][PA]
KINASE INHIBITORS
AFINITOR
GLEEVEC
NEXAVAR
SPRYCEL
SUTENT
TARCEVA
TASIGNA
TYKERB
VOTRIENT
MISCELLANEOUS
DROXIA
ELSPAR [PartB]
hydroxyurea capsule
irinotecan hcl [PartB]
LYSODREN
MATULANE
mitotane
procarbazine
mitoxantrone 25 mg/12.5 ml vl
PHOTOFRIN [PartB]
TARGRETIN CAPSULE
porfimer sodium
bexarotene
tretinoin capsule
TRISENOX [PartB]
arsenic trioxide
Page 23 of 103
Drug
Generic
NUCLEOSIDE ANALOGS
cladribine [PartB]
fludarabine phosphate [PartB]
1
4
[MOE][PAB]
[MOE][PAB]
carboplatin 150 mg/15 ml vial
1
[MOE][PAB]
cisplatin [PartB]
oxaliplatin [PartB]
1
4
[MOE][PAB]
[MOE][PAB]
4
1
[MOE][PAB]
[MOE][PAB]
4
1
2
[MOE][PAB]
[MOE][PAB]
[MOE]
1
[MOE][PAB]
1
[MOE]
1
4
[MOE][PAB]
[MOE]
1
1
4
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
1
[MNT][QLL, 30/30]
PLATINUM COORDINATION COMPLEX
[PartB]
PROTECTIVE AGENTS
amifostine
dexrazoxane 500 mg vial
[PartB]
ELITEK
rasburicase
ifosfamide-mesna [PartB]
LEUCOVORIN CALCIUM 10 MG
TAB, -15 MG TAB
leucovorin
leucovorin calcium 100 mg vl, 350 mg vl
leucovorin calcium 5 mg tab, 25 mg tab
mesna
MESNEX
mesna
TOPOISOMERASE INHIBITORS
etoposide injection [PartB]
toposar [PartB]
topotecan hcl [PartB]
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine-benazepril 2.5-10, -benazepril 5-10 mg
Page 24 of 103
Drug
amlodipine-benazepril 5-40
mg, --benazepril 10-20 mg, -benazepril 5-20 mg, -benazepril 10-40 mg
benazepril-hydrochlorothiazide
captopril-hydrochlorothiazide
enalapril-hydrochlorothiazide
fosinopril-hydrochlorothiazide
lisinopril-hydrochlorothiazide
moexipril-hydrochlorothiazide
quinapril-hydrochlorothiazide
Generic
1
[MNT]
1
1
1
1
1
1
1
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
1
1
1
1
1
1
1
1
1
1
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
1
1
1
1
[MNT]
[MNT]
[MNT]
[MNT]
1
1
[MNT][PA]
[MNT]
1
[MNT]
ACE INHIBITORS
benazepril hcl
captopril tablet
enalapril maleate tablet
fosinopril sodium
lisinopril tablet
moexipril hcl
perindopril erbumine
quinapril hcl
ramipril
trandolapril
ADRENOLYTICS, CENTRAL
clonidine
clonidine hcl tablet
guanabenz acetate 4 mg tab
guanfacine hcl
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone
spironolactone tablet
ALPHA BLOCKERS
doxazosin mesylate
Page 25 of 103
prazosin hcl
terazosin hcl
Drug
Generic
1
[MNT]
1
[MNT]
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS
AVALIDE
AZOR
BENICAR HCT 20-12.5 MG
TABLET
BENICAR HCT 40-25 MG
TABLET, -40-12.5 MG TABLET
DIOVAN HCT 160-25 MG
TABLET, -320-12.5 MG TAB, 320-25 MG TABLET
DIOVAN HCT 80-12.5 MG
TABLET, -160-12.5 MG TAB
EXFORGE 5-160 MG TABLET
EXFORGE 5-320 MG TABLET, 10-160 MG TABLET, -10-320
MG TABLET
EXFORGE HCT 5-160-12.5 MG
TAB
EXFORGE HCT 5-160-25 MG
TAB, -10-160-12.5 MG TAB, 10-160-25 MG TAB, -10-320-25
MG TAB
irbesartan/hctz
amlodipine bes/olmesartan med
olmesartan medoxomil/hctz
2
2
2
[MNT]
[MNT]
[MNT][QLL, 30/30]
olmesartan medoxomil/hctz
2
[MNT]
hctz/valsartan
2
[MNT]
hctz/valsartan
2
[MNT][QLL, 30/30]
amlodipine/valsartan
amlodipine/valsartan
2
2
[MNT][QLL, 30/30]
[MNT]
amlodipine/valsartan/hctz
2
[MNT][QLL, 30/30]
amlodipine/valsartan/hctz
2
[MNT]
olmesartan med/amlodipine/hct
1
2
[MNT]
[MNT]
2
2
2
1
[MNT]
[MNT]
[MNT]
[MNT]
1
1
[MOE][PAB]
[MNT]
losartan-hydrochlorothiazide
TRIBENZOR
ANGIOTENSIN II RECEPTOR ANTAGONISTS
AVAPRO
BENICAR
DIOVAN
losartan potassium
irbesartan
olmesartan medoxomil
valsartan
ANTIARRHYTHMICS
amiodarone 150 mg/3 ml amp
amiodarone hcl tablet
Page 26 of 103
Drug
atropine 0.1 mg/ml abboject, 0.1 mg/ml syringe, -0.05
mg/ml syringe
disopyramide phosphate
flecainide acetate
mexiletine hcl capsule
MULTAQ
NORPACE CR
PACERONE 100 MG TABLET
Generic
1
1
1
2
2
2
1
1
1
1
1
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MOE]
[MNT]
[MOE]
[MNT]
1
[MNT]
1
1
2
[MNT]
[MNT]
[MNT]
rosuvastatin calcium
rosuvastatin calcium
2
2
[MNT]
[MNT][QLL, 30/30]
atorvastatin calcium
2
[MNT][QLL, 30/30]
atorvastatin calcium
2
1
3
1
[MNT]
[MNT]
[MNT]
[MNT][QLL, 30/30]
1
3
1
[MNT]
[MNT]
[MNT][QLL, 30/30]
1
2
2
[MNT]
[MNT]
[MNT]
dronedarone
disopyramide
amiodarone
pacerone 200 mg tablet
procainamide hcl injection
propafenone hcl
quinidine gluconate injection
quinidine gluconate tablet
sustained action
quinidine sulfate tablet, -tablet
sustained action
sorine
sotalol
TIKOSYN
1
[MOE]
dofetilide
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS
CRESTOR 40 MG TABLET
CRESTOR 5 MG TABLET, -10
MG TABLET, -20 MG TABLET
LIPITOR 10 MG TABLET, -20
LIPITOR 80 MG TABLET
lovastatin
LOVAZA
omega-3 acid ethyl esters
pravastatin sodium 10 mg tab,
-20 mg tab, -40 mg tab
pravastatin sodium 80 mg tab
SIMCOR
niacin/simvastatin
simvastatin 5 mg tablet, -10
mg tablet, -20 mg tablet, -40
mg tablet
simvastatin 80 mg tablet
VYTORIN
ZETIA
ezetimibe/simvastatin
ezetimibe
Page 27 of 103
Drug
Generic
ANTILIPEMICS, MISCELLANEOUS
ANTARA
fenofibrate
cholestyramine light packet
colestipol hcl granules;powderlikenon-efervescent, -tablet
fenofibrate
gemfibrozil tablet
NIASPAN
niacin
prevalite powder
TRICOR
TRILIPIX
WELCHOL
fenofibrate
fenofibric acid
colesevelam
2
1
1
[MNT]
[MNT]
[MNT]
1
1
2
1
2
2
2
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
1
1
1
1
1
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
1
1
1
1
3
1
3
1
1
1
1
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MOE]
[MNT]
[MNT]
[MOE]
1
1
1
[MNT]
[MNT]
[MNT]
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol-chlorthalidone
bisoprolol-hydrochlorothiazide
metoprolol-hydrochlorothiazide
nadolol-bendroflumethiazide
propranolol-hydrochlorothiazid
BETA-BLOCKERS
acebutolol hcl capsule
atenolol tablet
betaxolol hcl tablet
bisoprolol fumarate
BYSTOLIC
nebivolol hcl
carvedilol
COREG CR
labetalol hcl 5 mg/ml vial
labetalol hcl tablet
metoprolol succinate
metoprolol tart 5 mg/5 ml vial,
-tart 1 mg/ml vial
metoprolol tartrate tablet
nadolol tablet
pindolol
carvedilol
Page 28 of 103
Drug
propranolol hcl capsule
sustained action, -solution, tablet
propranolol hcl injection
timolol maleate tablet
Generic
1
[MNT]
1
1
[MOE]
[MNT]
1
1
2
1
1
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
1
[MNT]
1
[MNT]
1
[MOE]
1
[MNT]
1
1
[MNT]
[MNT]
1
1
1
1
1
1
1
1
[MNT]
[MNT]
[MNT]
[MOE]
[MNT]
[MNT]
[MNT]
[MNT]
2
1
1
1
[MOE]
[MNT]
[MNT]
[MOE]
CALCIUM CHANNEL BLOCKERS
afeditab cr
amlodipine besylate tablet
CARDIZEM CD
cartia xt
dilt xr 180 mg capsule, -dilt xr
240 mg capsule
dilt-cd 120 mg capsule, -er 300
mg capsule
diltiazem 24hr cd 120 mg cap,
-24hr cd 240 mg cap, -24hr cd
300 mg cap
diltiazem 25 mg/5 ml vial, -100
mg vial
diltiazem hcl er 360 mg cap, hcl er 420 mg cap, -capsule
sustained release 12 hr
diltiazem hcl tablet
diltzac er 120 mg capsule, -180
mg capsule, -240 mg capsule,
-300 mg capsule
felodipine er
isradipine
matzim la
nicardipine 25 mg/10 ml vial
nicardipine hcl capsule
nifediac cc
nifedical xl
nifedipine er tablet sustained
action
nimodipine
nisoldipine
taztia xt
verapamil 2.5 mg/ml ampul
diltiazem
Page 29 of 103
Drug
verapamil er
verapamil er pm
verapamil hcl tablet, -tablet
sustained action
Generic
Tier
1
1
1
Requirements/Limits
[MNT]
[MNT]
[MNT]
1
1
2
[MOE]
[MNT]
[MNT]
aliskiren/amlodipine/hctz
aliskiren/amlodipine
aliskiren hemifumarate
aliskiren hemifumarate
aliskiren/hydrochlorothiazid
aliskiren/valsartan
2
2
2
2
2
2
[MNT]
[MNT]
[MNT][QLL, 30/30]
[MNT]
[MNT]
[MNT][QLL, 30/30]
aliskiren/valsartan
2
[MNT]
1
[MNT]
1
1
1
1
1
4
1
1
1
1
[MNT]
[MNT]
[MOE]
[MNT]
[MNT]
[MOE]
[MNT]
[MOE]
[MNT]
[MNT]
1
1
[MNT]
[MNT]
DIGITALIS GLYCOSIDES
digoxin 0.25 mg/ml ampul
digoxin solution, -tablet
LANOXIN [G]
digoxin
DIRECT RENIN INHIBITORS/COMBINATIONS
AMTURNIDE
TEKAMLO
TEKTURNA 150 MG TABLET
TEKTURNA 300 MG TABLET
TEKTURNA HCT
VALTURNA 150-160 MG
TABLET
VALTURNA 300-320 MG
TABLET
DIURETICS
acetazolamide capsule
sustained action, -tablet
amiloride hcl tablet
amiloride-hydrochlorothiazide
bumetanide injection
bumetanide tablet
chlorothiazide
chlorothiazide sodium
chlorthalidone
furosemide 10 mg/ml vial
furosemide solution, -tablet
hydrochlorothiazide capsule, tablet
indapamide
methazolamide tablet
Page 30 of 103
Drug
methyclothiazide
metolazone
spironolactone-hctz
TORSEMIDE INJECTION
Generic
torsemide
torsemide tablet
triamterene-hctz
triamterene-hydrochlorothiazid
Tier
1
1
1
2
1
1
1
Requirements/Limits
[MNT]
[MNT]
[MNT]
[MOE]
[MNT]
[MNT]
[MNT]
2
1
1
1
1
[MNT]
[MOE]
[MNT]
[MNT]
[MNT]
1
1
1
2
1
[MOE]
[MOE]
[MNT]
[MNT][PA]
[MNT]
1
2
1
1
1
1
2
1
1
2
2
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MOE]
[MNT]
[MNT]
[MNT]
4
4
[MNT][PAN]
[MNT][PAN]
MISCELLANEOUS
BIDIL
isosorb dinit/hydralazine hcl
hydralazine hcl injection
hydralazine hcl tablet
methyldopa
methyldopahydrochlorothiazide
methyldopate hcl
midodrine hcl
minoxidil tablet
RANEXA
ranolazine
reserpine tablet
NITRATES
isochron [G]
ISORDIL
isosorbide dinitrate
isosorbide dinitrate
isosorbide mononitrate
minitran [G]
nitro-bid
NITRO-DUR
nitroglycerin
nitroglycerin injection
nitroglycerin patch
NITROLINGUAL
NITROSTAT
nitroglycerin
nitroglycerin
PULMONARY ARTERIAL HYPERTENSION
ADCIRCA
LETAIRIS
adcirca (tadalafil)
ambrisentan
Page 31 of 103
Drug
REMODULIN
REVATIO
TRACLEER [LA]
Generic
treprostinil sodium
revatio (sildenafil citrate)
bosentan
Tier
4
4
4
Requirements/Limits
[MOE][PAB]
[MOE][PAN]
[MOE][MNT][PAN]
1
1
[MNT]
[MNT]
1
[MNT][QLL, 45/30]
3
1
[MNT][PAN]
[MNT]
carbamazepine
methsuximide
phenytoin sodium
1
2
2
2
[MNT]
[MNT]
[MNT]
[MNT]
phenytoin
2
[MNT]
phenytoin sodium
2
1
1
1
1
3
1
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MOE]
1
[MNT][QLL,
1080/30]
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT]
[MNT]
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
buspirone hcl tablet
fluvoxamine maleate 100 mg
tab
fluvoxamine maleate 25 mg
tab, -50 mg tab
ANTICONVULSANTS
BANZEL
rufinamide
carbamazepine suspension
oral, -tablet, -tablet chewable
carbamazepine xr
CARBATROL [G]
CELONTIN
DILANTIN 100 MG CAPSULE
[G]
DILANTIN 30 MG CAPSULE, TABLET CHEWABLE
DILANTIN-125 [G]
divalproex sodium
divalproex sodium er
epitol
ethosuximide capsule, -syrup
FELBATOL
felbamate
fosphenytoin 100 mg pe/2 ml
vl
gabapentin 100 mg capsule
gabapentin 600 mg tablet
gabapentin 800 mg tablet
gabapentin solution
GABITRIL
tiagabine
1
1
1
1
1
3
360/30]
270/30]
180/30]
120/30]
Page 32 of 103
Drug
lamotrigine tablet, -tablet
dispersible
levetiracetam injection
levetiracetam solution, -tablet
LYRICA 25 MG CAPSULE, -50
MG CAPSULE, -75 MG
CAPSULE, -100 MG CAPSULE, 150 MG CAPSULE, -200 MG
CAPSULE, -225 MG CAPSULE
LYRICA 300 MG CAPSULE
NEURONTIN [G]
Generic
pregabalin
1
1
2
[MOE]
[MNT]
[MNT][QLL, 120/30]
pregabalin
gabapentin
2
2
1
2
1
1
1
1
4
2
1
[MNT][QLL, 60/30]
[MNT][QLL,
2350/30]
[MNT]
[MNT]
[MOE]
[MNT]
[MNT]
[MNT]
[MOE][PAN]
[MNT]
[MNT]
1
1
2
2
1
[MOE]
[MNT]
[MOE][PAN]
[MNT][PAN]
[MNT]
1
[MNT]
1
[MNT][QLL, 30/30]
rivastigmine tartrate
2
[MNT][QLL, 30/30]
rivastigmine tartrate
2
1
[MNT][QLL, 240/30]
[MNT]
1
1
[MNT][QLL, 30/30]
[MNT]
oxcarbazepine
PEGANONE
ethotoin
phenytoin 50 mg/ml ampul
phenytoin sodium extended
phenytoin suspension oral
primidone tablet
SABRIL
TEGRETOL XR
vigabatrin
carbamazepine
topiramate capsule sprinkle, tablet
valproate sodium injection
valproic acid capsule, -syrup
VIMPAT INJECTION
VIMPAT SOLUTION, -TABLET
1
[MNT]
lacosamide
lacosamide
zonisamide
ANTIDEMENTIA
donepezil hcl 10 mg tablet, odt 10 mg tablet
donepezil hcl 5 mg tablet, -odt
5 mg tablet
EXELON PATCH
TRANSDERMAL 24 HOURS
EXELON SOLUTION
galantamine er 16 mg capsule,
-er 24 mg capsule, -tablet
galantamine er 8 mg capsule
galantamine hydrobromide
Page 33 of 103
Drug
NAMENDA SOLUTION, TABLET
NAMENDA TABLET DOSE PACK
Generic
memantine hcl
2
[MNT]
memantine hcl
2
1
1
1
[MOE]
[MNT][QLL, 240/30]
[MNT][QLL, 120/30]
[MNT][QLL, 60/30]
1
2
1
1
1
1
1
1
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT][QLL, 45/30]
1
1
2
[MNT]
[MNT]
[MNT][QLL, 30/30]
2
1
1
2
1
1
[MNT]
[MNT]
[MNT]
[MNT][PAN][QLL,
30/30]
[MNT]
[MNT][QLL, 30/30]
1
1
[MNT][QLL, 45/30]
[MNT]
escitalopram oxalate
1
1
3
[MNT]
[MNT]
[MNT][QLL, 45/30]
escitalopram oxalate
3
[MNT]
1
[MNT]
rivastigmine 1.5 mg cap
rivastigmine 3 mg capsule
rivastigmine 4.5 mg capsule, -6
mg capsule
ANTIDEPRESSANTS
amitriptyline hcl tablet
AMOXAPINE
amoxapine
budeprion sr
budeprion xl
bupropion hcl sr
bupropion hcl tablet
citalopram
citalopram hbr 10 mg tablet, 20 mg tablet
citalopram hbr 40 mg tablet
clomipramine hcl capsule
CYMBALTA 20 MG CAPSULE, 30 MG CAPSULE
CYMBALTA 60 MG CAPSULE
duloxetine
duloxetine
desipramine hcl tablet
doxepin hcl capsule, -solution
EMSAM
selegiline
fluoxetine dr
fluoxetine hcl 10 mg capsule, 20 mg capsule
fluoxetine hcl 10 mg tablet
fluoxetine hcl 40 mg capsule, solution, -20 mg tablet
imipramine hcl tablet
imipramine pamoate
LEXAPRO 5 MG TABLET, -10
MG TABLET
LEXAPRO SOLUTION, -20 MG
TABLET
maprotiline hcl
Page 34 of 103
Drug
MARPLAN
mirtazapine 30 mg tablet, -45
mg tablet, -30 mg odt, -45 mg
odt
mirtazapine 7.5 mg tablet, -15
mg tablet, -15 mg odt
NARDIL [G]
nefazodone hcl
nortriptyline hcl capsule, solution
paroxetine cr 12.5 mg tablet, cr 37.5 mg tablet, -er 37.5 mg
tablet
paroxetine hcl 10 mg tablet, 20 mg tablet
paroxetine hcl suspension oral,
-30 mg tablet, -40 mg tablet, cr 25 mg tablet
PRISTIQ 100 MG TABLET
PRISTIQ 50 MG TABLET
protriptyline hcl
selfemra
sertraline hcl 25 mg tablet, -50
mg tablet
sertraline hcl solution, -100 mg
tablet
SURMONTIL
Generic
isocarboxazid
phenelzine
desvenlafaxine succinate
desvenlafaxine succinate
trimipramine
tranylcypromine sulfate
trazodone hcl tablet
venlafaxine hcl
venlafaxine hcl er 150 mg cap
venlafaxine hcl er 37.5 mg cap,
-75 mg cap
2
[MNT]
1
[MNT]
1
[MNT][QLL, 45/30]
2
1
1
[MNT]
[MNT]
[MNT]
1
[MNT][QLL, 30/30]
1
[MNT][QLL, 45/30]
1
[MNT]
3
3
1
1
1
[MNT][ST]
[MNT][QLL,
30/30][ST]
[MNT]
[MNT]
[MNT][QLL, 45/30]
1
[MNT]
2
1
1
1
1
1
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT][QLL, 30/30]
1
4
2
1
[MNT]
[MNT]
[MNT]
[MOE]
ANTIPARKINSONIAN AGENTS
amantadine
APOKYN
AZILECT
benztropine 2 mg/2 ml vial
apomorphine hcl
rasagiline mesylate
Page 35 of 103
Drug
benztropine mesylate tablet
bromocriptine mesylate
capsule, -tablet
carbidopa-levodopa
Generic
1
2
1
1
1
2
2
2
2
2
2
1
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
aripiprazole
3
aripiprazole
aripiprazole
aripiprazole
3
3
3
[MNT][QLL,
30/30][ST]
[MNT][ST]
[MOE]
[MNT][ST]
chlorpromazine
2
[MOE]
1
1
3
3
3
1
1
1
[MNT]
[MNT]
[MNT][ST]
[MOE][ST]
[MNT][PAN]
[MOE]
[MNT]
[MOE]
ziprasidone
ziprasidone
ziprasidone
3
3
3
[MNT][QLL, 240/30]
[MNT][QLL, 120/30]
[MNT][QLL, 60/30]
ziprasidone
3
[MOE]
entacapone
COMTAN
pramipexole dihydrochloride
ropinirole hcl
selegiline hcl capsule, -tablet
STALEVO
STALEVO
STALEVO
STALEVO
STALEVO
STALEVO
100
125
150
200
50
75
1
[MNT]
1
[MNT]
carbidopa/levodopa/entacap
trihexyphenidyl hcl
ANTIPSYCHOTICS
ABILIFY 5 MG TABLET, -10 MG
TABLET, -15 MG TABLET
ABILIFY DISCMELT
ABILIFY INJECTION
ABILIFY SOLUTION, -2 MG
TABLET, -20 MG TABLET, -30
MG TABLET
CHLORPROMAZINE HCL
INJECTION
chlorpromazine hcl tablet
clozapine
FANAPT TABLET
FANAPT TABLET DOSE PACK
FAZACLO
fluphenazine decanoate
fluphenazine hcl elixir, -tablet
fluphenazine hcl injection, solution
GEODON 20 MG CAPSULE
GEODON 40 MG CAPSULE
GEODON 60 MG CAPSULE, -80
MG CAPSULE
GEODON INJECTION
iloperidone
iloperidone
clozapine
Page 36 of 103
Drug
haloperidol decanoate
haloperidol lactate injection
haloperidol lactate solution
haloperidol tablet
INVEGA ER 1.5 MG TABLET, ER 3 MG TABLET
INVEGA ER 6 MG TABLET, -ER
9 MG TABLET
INVEGA SUSTENNA 117 MG
PREF SY, -156 MG PREF SY, 234 MG PREF SY
INVEGA SUSTENNA 39 MG
PREF SYR, -78 MG PREF SYR
LATUDA
Generic
paliperidone
Tier
1
1
1
1
3
paliperidone
3
Requirements/Limits
[MNT]
[MOE]
[MNT]
[MNT]
[MNT][QLL,
30/30][ST]
[MNT][ST]
paliperidone
4
[MNT][PAN]
paliperidone
3
[MNT][PAN]
lurasidone hcl
risperidone
3
1
2
1
2
risperidone
4
1
[MNT][ST]
[MNT]
[MNT]
[MNT]
[MNT][PAN][QLL,
2/30]
[MNT][PAN][QLL,
2/30]
[MNT][QLL, 90/30]
1
[MNT][QLL, 90/30]
1
[MNT][QLL, 60/30]
1
[MNT][QLL, 60/30]
1
1
[MNT]
[MNT]
asenapine
quetiapine fumarate
quetiapine fumarate
quetiapine fumarate
quetiapine fumarate
3
2
2
2
2
[MNT][ST]
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
quetiapine fumarate
quetiapine fumarate
2
2
1
[MNT][QLL, 480/30]
[MNT]
[MNT][PAN]
loxapine
ORAP
pimozide
perphenazine
RISPERDAL CONSTA 12.5 MG
SYR, -25 MG SYR
RISPERDAL CONSTA 37.5 MG
SYR, -50 MG SYR
risperidone 0.25 mg odt, -0.5
mg odt
risperidone 0.25 mg tablet, 0.5 mg tablet
risperidone 1 mg odt, -2 mg
odt, -3 mg odt
risperidone 1 mg tablet, -2 mg
tablet, -3 mg tablet
risperidone 4 mg odt
risperidone solution, -4 mg
tablet
SAPHRIS
SEROQUEL 100 MG TABLET
SEROQUEL 300 MG TABLET, 400 MG TABLET
SEROQUEL XR
thioridazine hcl
240/30]
120/30]
960/30]
60/30]
Page 37 of 103
Drug
thiothixene
trifluoperazine hcl
ZYPREXA 10 MG TABLET, -15
ZYPREXA 2.5 MG TABLET, -7.5
MG TABLET
ZYPREXA INJECTION
ZYPREXA ZYDIS 10 MG
TABLET, -15 MG TABLET, -20
MG TABLET
ZYPREXA ZYDIS 5 MG TABLET
Generic
olanzapine
Tier
1
1
3
Requirements/Limits
[MNT]
[MNT]
[MNT]
olanzapine
3
[MNT][QLL, 30/30]
olanzapine
olanzapine
3
3
[MOE]
[MNT]
olanzapine
3
[MNT][QLL, 30/30]
1
1
1
1
1
1
1
1
1
2
[MNT][PA]
[MNT]
[MNT][PA]
[MNT][PA]
[MOE]
[MNT]
[MNT][PA]
[MNT][PA]
[MNT][PA]
[MNT][PA]
3
1
1
1
[MOE]
[MOE][QLL, 30/30]
[MOE][QLL, 30/30]
[MOE]
1
[MOE]
1
1
2
2
[MNT]
[MOE]
[MOE][QLL, 12/30]
[MOE][QLL, 12/30]
ATTENTION DEFICIT HYPERACTIVITY DISORDER
amphetamine salt combo
dexmethylphenidate hcl
dextroamphetamine sulfate
metadate er
methamphetamine hcl
methylin er
methylin tablet
methylphenidate hcl tablet
methylphenidate sr
STRATTERA
atomoxetine
HYPNOTICS
LUNESTA
eszopiclone
zaleplon
zolpidem tartrate tablet
zolpidem tartrate tablet
multiphasic release
MIGRAINE
dihydroergotamine 1 mg/ml
am
ergoloid mesylates tablet
ergotamine-caffeine
MAXALT
MAXALT MLT
rizatriptan benzoate
rizatriptan benzoate
Page 38 of 103
Drug
naratriptan hcl
sumatriptan 4 mg/0.5 ml vial
sumatriptan 6 mg/0.5 ml vial
Tier
2
1
1
1
sumatriptan succinate tablet
1
Requirements/Limits
[MOE]
[MOE]
[MOE][QLL, 10/30]
[MOE][QLL, 10
ml/30]
[MOE][QLL, 9/30]
guanidine
lithium citrate
2
2
1
[MOE]
[MNT]
[MNT]
pyridostigmine
dextromethorphan/quinidine
2
3
1
2
4
4
[MNT]
[MOE][PA]
[MNT]
[MOE]
[MNT]
[MNT][PA]
[MNT][PA]
[MNT][PAN][QLL,
kits/28]
[MNT][PAN][QLL,
kits/28]
[MNT][PAN][QLL,
ml/30]
[MNT][PAN][QLL,
trays/28]
[MNT][PAN]
[MNT][PAN][QLL,
ml/28]
MIGERGOT
Generic
ergotamine tartrate/caffeine
MISCELLANEOUS
GUANIDINE HCL
LITHIUM
lithium carbonate capsule, tablet, -tablet sustained action
MESTINON
NUEDEXTA
pyridostigmine bromide
REGONOL
RILUTEK
XENAZINE
pyridostigmine
riluzole
tetrabenazine
MULTIPLE SCLEROSIS AGENTS
AMPYRA
AVONEX
dalfampridine
interferon beta-1a
4
4
AVONEX ADMINISTRATION
PACK
COPAXONE
interferon beta-1a
4
glatiramer acetate
4
EXTAVIA
interferon beta-1b
4
GILENYA
REBIF 22 MCG/0.5 ML
SYRINGE, -44 MCG/0.5 ML
SYRINGE
REBIF TITRATION PACK
fingolimod hydrochloride
interferon beta-1a/albumin
4
4
interferon beta-1a/albumin
4
[MNT][PAN][QLL, 6
syringes/28]
1
[MNT]
MUSCULOSKELETAL THERAPY AGENTS
baclofen tablet
Page 39 of 103
2
2
30
14
6
Drug
carisoprodol 350 mg tablet
Generic
chlorzoxazone
cyclobenzaprine hcl tablet
dantrolene sodium capsule
metaxalone
methocarbamol tablet
orphenadrine 30 mg/ml vial, 60 mg/2 ml vial
orphenadrine citrate tablet
sustained action
orphenadrine compound
orphenadrine compound forte
ROBAXIN
methocarbamol
tizanidine hcl tablet
1
[MOE][PA][QLL,
120/30]
1
[MOE][PA]
1
[MOE][PA]
1
[MNT]
1
[MOE][PA]
1
[MOE][PA]
1
[MOE]
1
[MOE][PA]
1
1
2
1
[MOE][PA]
[MOE][PA]
[MOE]
[MNT]
2
3
4
[MNT][PA]
[MNT]
[MOE][PA]
2
1
[MNT]
[MOE][PA]
1
2
3
1
1
[MOE]
[MOE][PA]
[MOE][PA]
[MOE]
[MOE]
1
3
3
1
2
[MOE]
[MOE][PA]
[MOE][PA]
[MNT]
[MOE][PA]
NARCOLEPSY/CATAPLEXY
NUVIGIL
PROVIGIL
XYREM [LA]
armodafinil
modafinil
sodium oxybate
PSYCHOTHERAPEUTIC-MISCELLANEOUS
ANTABUSE [G]
disulfiram
buprenorphine hcl tablet
sublingual
buproban
CAMPRAL
CHANTIX
acamprosate calcium
varenicline tartrate
depade
naloxone 0.4 mg/ml syringe, -1
mg/ml syringe
naltrexone hcl tablet
NICOTROL
NICOTROL NS
nicotine inhaler
nicotine ns
perphenazine-amitriptyline
SUBOXONE
buprenorphine/naloxone
Page 40 of 103
Drug
Generic
ENDOCRINE AND METABOLIC
ANDROGENS
ANADROL-50
ANDRODERM
oxymetholone
testosterone
4
2
ANDROGEL
ANDROXY
testosterone
fluoxymesterone
3
2
4
1
3
oxandrolone 10 mg tablet
oxandrolone 2.5 mg tablet
TESTIM
testosterone
testosterone cyp 100 mg/ml
testosterone enanthate
1
1
[MOE][PA]
[MNT][PA][QLL,
30/30]
[MNT]
[MNT][PA]
[MNT][PA]
[MNT][PA]
[MNT][PA][QLL,
300/30]
[MOE]
[MOE]
ANTIDIABETICS, INJECTABLE
ALCOHOL SWABS
APIDRA
APIDRA SOLOSTAR
BYETTA 10 MCG DOSE PEN
INJ
BYETTA 5 MCG DOSE PEN INJ
CURAD GAUZE PADS
HUMALOG
HUMALOG MIX 50-50
HUMALOG MIX 75-25
HUMULIN 70-30
HUMULIN N
HUMULIN R
INSULIN SYRINGE
LANTUS
LANTUS SOLOSTAR
LEVEMIR
NOVOLIN 70-30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG MIX 70-30
exenatide
2
2
2
2
exenatide
2
misc supp (dress,tape,gauze)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
[MOE]
[MNT]
[MNT]
[MNT][PA][QLL, 2.4
ml/30]
[MNT][PA][QLL, 1.2
ml/30]
[MOE]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
Page 41 of 103
Drug
PEN NEEDLE
SYMLIN
SYMLINPEN 120
SYMLINPEN 60
VICTOZA 3-PAK
Generic
Tier
2
2
2
2
2
Requirements/Limits
[MNT]
[MNT][PA]
[MNT][PA]
[MNT][PA]
[MNT]
sitagliptin phos/metformin hcl
sitagliptin phosphate
sitagliptin phosphate
1
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
[MNT]
[MNT][QLL,
[MNT]
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT]
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT][QLL,
[MNT]
[MNT][QLL,
[MNT][QLL,
[MNT]
[MNT][QLL,
[MNT]
[MNT]
[MNT][QLL,
saxagliptin hcl/metformin hcl
2
[MNT]
pramlintide acetate
pramlintide acetate
pramlintide acetate
liraglutide
ANTIDIABETICS, ORAL
acarbose
ACTOPLUS MET
ACTOPLUS MET XR
ACTOS 15 MG TABLET
ACTOS 30 MG TABLET
ACTOS 45 MG TABLET
DUETACT
pioglitazone hcl/metformin hc
pioglitazone hcl/metformin hc
pioglitazone hcl
pioglitazone hcl
pioglitazone hcl
pioglitazone/glimepiride
glimepiride 1 mg tablet
glipizide 10 mg tablet
glipizide 5 mg tablet
glipizide er 10 mg tablet
glipizide er 2.5 mg tablet
glipizide er 5 mg tablet
glipizide-metformin
glyburide 1.25 mg tablet
glyburide 2.5 mg tablet
glyburide 5 mg tablet
glyburide micro 1.5 mg tab
glyburide micro 3 mg tablet
glyburide micro 6 mg tablet
glyburide-metformin hcl
glycron 1.5 mg tablet
glycron 3 mg tablet
glycron 4.5 mg tablet
glycron 6 mg tablet
JANUMET
JANUVIA 100 MG TABLET
JANUVIA 25 MG TABLET, -50
MG TABLET
KOMBIGLYZE XR
90/30]
90/30]
45/30]
30/30]
30/30]
240/30]
120/30]
60/30]
120/30]
240/30]
60/30]
240/30]
120/30]
480/30]
240/30]
120/30]
240/30]
120/30]
60/30]
240/30]
120/30]
60/30]
30/30]
Page 42 of 103
Drug
metformin hcl 500 mg tablet
metformin hcl 850 mg tablet, 1,000 mg tablet
metformin hcl er 500 mg tab
metformin hcl er 750 mg tablet
nateglinide
ONGLYZA 2.5 MG TABLET
ONGLYZA 5 MG TABLET
PRANDIN
Generic
1
[MNT][QLL, 150/30]
1
[MNT][QLL, 90/30]
1
1
1
2
2
2
1
1
[MNT][QLL, 120/30]
[MNT][QLL, 90/30]
[MNT]
[MNT][QLL, 30/30]
[MNT]
[MNT]
[MNT]
[MNT]
2
2
[MOE]
[MNT]
1
[MNT][QLL, 4/30]
1
[MNT]
1
1
[MNT]
[MOE]
denosumab
zoledronic acid
zoledronic acid
3
3
4
[MNT]
[MNT]
[MOE][PAB]
calcitonin
1
1
2
[MNT]
[MNT]
[MOE][PAB]
2
4
[MNT]
[MNT]
saxagliptin hydrochloride
saxagliptin hydrochloride
repaglinide
tolazamide
tolbutamide
BISPHOSPHONATES
ACTONEL 30 MG TABLET
ACTONEL 5 MG TABLET, -35
alendronate sodium 35 mg tab,
-70 mg tab
alendronate sodium 5 mg
tablet, -10 mg tab, -40 mg tab
etidronate disodium
pamidronate 30 mg/10 ml vial,
-60 mg/10 ml vial, -90 mg/10
ml vial
PROLIA
RECLAST
ZOMETA
risedronate
risedronate
CALCITONINS
calcitonin-salmon
fortical
MIACALCIN
CALCIUM RECEPTOR ANTAGONISTS
SENSIPAR 30 MG TABLET
SENSIPAR 60 MG TABLET, -90
MG TABLET
cinacalcet hcl
cinacalcet hcl
Page 43 of 103
Drug
Generic
CHELATING AGENTS
EXJADE 125 MG TABLET
EXJADE 250 MG TABLET, -500
MG TABLET
kionex powder [G]
deferasirox
deferasirox
2
4
[MNT][PA]
[MNT][PA]
trientine
1
1
2
[MOE]
[MOE]
[MOE]
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT][QLL, 1/90]
1
1
1
1
[MNT]
[MNT]
[MNT]
[MNT]
sodium polystyrene sulfonate
SYPRINE
CONTRACEPTIVES
apri
aranelle
aviane
balziva
camila
cesia
cryselle
cyclafem
enpresse
errin
gianvi
jinteli
jolivette
junel
junel fe
kariva
kelnor 1-35
leena
lessina
levora-28
low-ogestrel
lutera
medroxyprogesterone acetate
injection
microgestin
microgestin fe
mononessa
necon 0.5-35-28 tablet, -1/3528 tablet, -7-7-7-28 tablet
Page 44 of 103
Drug
NECON 10-11-28 TABLET
Generic
norethindrone-ethin estradiol
Tier
2
1
1
1
2
1
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Requirements/Limits
[MNT]
[MOE]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
nafarelin
1
2
[MOE]
[MOE]
pegademase bovine
laronidase
sodium phenylbutyrate
imiglucerase
betaine hcl
cysteamine
idursulfase
4
4
4
4
4
2
4
[MOE][PA]
[MOE][PA]
[MOE]
[MNT][PA]
[MOE]
[MNT]
[MNT][PA]
next choice
nora-be
nortrel
NUVARING
etonogestrel/ethin estradiol
ocella
ogestrel
ORTHO EVRA
ORTHO TRI-CYCLEN LO
ethinyl estradiol/norelgest
norgestimate-ethinyl estradiol
portia
previfem
quasense
reclipsen
solia
sprintec
sronyx
tri-legest fe
trinessa
tri-previfem
tri-sprintec
trivora-28
velivet
zeosa
zovia 1-35e
zovia 1-50e
ENDOMETRIOSIS
danazol capsule
SYNAREL
ENZYME REPLACEMENTS
ADAGEN
ALDURAZYME
BUPHENYL
CEREZYME
CYSTADANE
CYSTAGON
ELAPRASE
Page 45 of 103
eliphos
Drug
FABRAZYME
KUVAN
Generic
Tier
1
4
4
1
1
4
4
4
4
4
Requirements/Limits
[MNT]
[MOE][PA]
[MNT][PA]
[MOE]
[MNT][PAB]
[MNT][PA]
[MNT][PA]
[MNT][PA]
[MNT][PA]
[MNT][PA]
3
2
1
[MNT]
[MNT]
[MNT]
estrogens,conjugated
1
1
1
1
3
[MOE]
[MNT]
[MNT][PA]
[MNT][PA]
[MNT]
estrogen/medroxyprogesterone
estradiol
estradiol
3
2
3
3
2
[MOE]
[MNT]
[MNT]
[MNT]
[MNT]
1
1
[MOE]
[MOE]
1
1
[MOE]
[MOE]
1
2
[MOE]
[MOE]
agalsidase
sapropterin dihydrochloride
levocarnitine injection
levocarnitine solution, -tablet
MYOZYME
NAGLAZYME
ORFADIN
VPRIV
ZAVESCA
alglucosidase alfa
galsulfase
nitisinone
velaglucerase alfa
miglustat
ESTROGENS
ESTRACE
ESTRADERM
estradiol
estradiol
estradiol patch transdermal
weekly, -tablet
estradiol valerate injection
estradiol-noreth 1-0.5 mg tab
estropipate
ortho-est
PREMARIN CREAM WITH
APPLICATOR
PREMARIN INJECTION
PREMARIN TABLET
PREMPRO
VAGIFEM
VIVELLE-DOT
GLUCOCORTICOIDS
a-hydrocort
a-methapred 40 mg univial, 125 mg vial
cortisone acetate tablet
dexamethasone 120 mg/30 ml
vl, -20 mg/5 ml vial, -4 mg/ml
vial
dexamethasone elixir, -tablet
DEXAMETHASONE INTENSOL
dexamethasone
Page 46 of 103
Drug
fludrocortisone acetate tablet
hydrocortisone tablet
methylprednisolone 40 mg vial,
-125 mg vial, -ss 1 gm vl
methylprednisolone acetate
injection
methylprednisolone tablet, tablet dose pack
prednisolone
prednisolone sodium
phosphate solution
PREDNISONE INTENSOL
Generic
Tier
1
1
1
Requirements/Limits
[MNT]
[MNT]
[MOE]
1
[MOE]
1
[MOE]
1
1
[MOE]
[MOE]
2
1
2
1
[MOE]
[MOE]
[MOE]
[MOE]
glucagon, human recombinant
glucagon, human recombinant
diazoxide
2
2
2
[MOE]
[MOE]
[MNT]
somatropin
somatropin
4
4
[MNT][PA]
[MNT][PA]
mecasermin
1
1
4
1
2
[MNT]
[MOE][PA]
[MOE][PA]
[MOE][PA]
[MNT][PA]
4
[MNT][PA]
1
4
4
[MOE][PA]
[MNT][PA]
[MNT][PA]
prednisone
prednisone solution, -tablet
SOLU-CORTEF (PF)
hydrocortisone sod succinate
veripred 20
GLUCOSE ELEVATING AGENTS
GLUCAGEN
GLUCAGON EMERGENCY KIT
PROGLYCEM
HUMAN GROWTH HORMONES
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX
MISCELLANEOUS
cabergoline
chorionic gonadotropin
INCRELEX
novarel
octreotide acet 50 mcg/ml
amp, -acet 100 mcg/ml amp, acet 200 mcg/ml vl
octreotide acet 500 mcg/ml
amp, -1,000 mcg/ml vial
pregnyl [G]
SANDOSTATIN LAR
SOMATULINE DEPOT
octreotide
lanreotide acetate
Page 47 of 103
Drug
SOMAVERT
Generic
pegvisomant
4
[MNT][PA]
teriparatide
4
[MNT][PA]
lanthanum carbonate
calcium acetate
sevelamer
sevelamer carbonate
1
2
2
2
2
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
1
[MNT]
1
3
[MNT]
[MNT]
2
[MNT]
1
1
1
1
1
1
1
2
1
[MNT]
[MNT]
[MNT]
[MOE]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
1
[MOE]
PARATHYROID HORMONES
FORTEO
PHOSPHATE BINDER AGENTS
calcium acetate
FOSRENOL
PHOSLO [G]
RENAGEL
RENVELA
PROGESTINS
tablet
norethindrone acetate tablet
PROMETRIUM
progesterone
SELECTIVE ESTROGEN RECEPTOR MODULATORS
EVISTA
raloxifene
THYROID AGENTS
levothroid
levothyroxine sodium tablet
levoxyl
liothyronine sodium injection
liothyronine sodium tablet
methimazole tablet
propylthiouracil
SYNTHROID [G]
unithroid
levothyroxine
VASOPRESSINS
desmopressin ac 4 mcg/ml vl
Page 48 of 103
Drug
desmopressin acetate aerosol
spray w/pump, -solution, tablet
Generic
1
[MNT]
GASTROINTESTINAL
ANTIEMETICS
compro
dronabinol 10 mg capsule
1
4
dronabinol 2.5 mg capsule
2
1
[MOE]
[MOE][PA][QLL,
60/30]
[MOE][PA][QLL,
60/30]
[MOE][PAB][QLL,
2/30]
[MOE]
[MOE][PAB][QLL,
4/30]
[MOE][PAB]
1
1
1
[MOE]
[MOE]
[MOE]
1
[MOE][PAB]
1
1
1
1
[MOE][PAB]
[MOE][PA]
[MOE]
[MOE]
1
[MOE]
1
[MOE][PA]
1
[MOE][PA]
[MOE][PA][QLL,
2/15]
[MOE][PA][QLL,
24/365]
[MOE][PA]
EMEND 125 MG CAPSULE
aprepitant
2
EMEND 40 MG CAPSULE
EMEND TRIFOLD PACK, -80
MG CAPSULE
aprepitant
aprepitant
2
2
granisetron hcl 0.1 mg/ml vial,
-tablet
granisol
meclizine hcl tablet
metoclopramide 5 mg/ml vial, solution oral, -tablet
ondansetron hcl 4 mg/2 ml
vial, -solution, -tablet
ondansetron odt
phenadoz
prochlorperazine edisylate
prochlorperazine maleate
suppository rectal, -tablet
promethazine 25 mg/ml
syringe, -50 mg/ml vial
promethazine hcl suppository
rectal, -syrup, -tablet
promethegan 25 mg supp, -50
mg suppository
SANCUSO
granisetron
2
TRANSDERM-SCOP
scopolamine
2
trimethobenzamide hcl
capsule, -injection
1
Page 49 of 103
Drug
Generic
ANTISPASMODICS
dicyclomine hcl capsule, syrup, -tablet
dicyclomine hcl injection
glycopyrrolate injection, -tablet
methscopolamine bromide
tablet
1
[MOE][PA]
1
1
1
[MOE]
[MOE]
[MOE]
1
1
1
[MOE]
[MNT]
[MOE]
1
[MNT]
1
1
1
[MNT]
[MOE]
[MNT]
2
3
3
1
2
4
1
4
1
2
1
2
1
1
[MNT]
[MNT]
[MNT]
[MOE]
[MNT]
[MNT][PA]
[MOE]
[MOE]
[MOE]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
H2-RECEPTOR ANTAGONISTS
cimetidine injection
cimetidine solution, -tablet
famotidine 20 mg/2 ml vial, 20 mg piggyback
famotidine suspension oral, -20
mg tablet, -40 mg tablet
nizatidine
ranitidine hcl 25 mg/ml vial
ranitidine hcl capsule, -syrup, 150 mg tablet, -300 mg tablet
INFLAMMATORY BOWEL DISEASE
APRISO
ASACOL
ASACOL HD
mesalamine
mesalamine
mesalamine
balsalazide disodium
CANASA
CIMZIA
mesalamine
certolizumab pegol
colocort [G]
ENTOCORT EC [G]
budesonide
hydrocortisone enema
LIALDA
mesalamine
mesalamine enema
PENTASA
sulfasalazine tablet
sulfazine ec
mesalamine
Page 50 of 103
LAXATIVES
Drug
constulose
enulose
gavilyte-c
gavilyte-g
gavilyte-n
lactulose
polyethylene glycol 3350
polyethylene glycol 3350
packet
Generic
1
1
1
1
1
1
1
1
[MNT]
[MNT]
[MOE]
[MOE]
[MOE]
[MNT]
[MOE]
[MOE]
methylnaltrexone bromide
2
1
[MOE][PA]
[MOE]
AMITIZA
lubiprostone
2
CARAFATE
sucralfate
rifaximin
2
1
4
1
2
1
1
1
4
[MNT][QLL,
60/30][ST]
[MNT]
[MOE][PA]
[MOE]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT][PA]
amylase/lipase/protease
3
2
2
[MNT][ST]
[MNT]
[MNT]
RELISTOR
trilyte with flavor packets
MISCELLANEOUS
diphenoxylate-atropine
GASTROCROM
cromolyn
loperamide capsule
LOTRONEX
alosetron
misoprostol
sucralfate tablet
ursodiol capsule, -tablet
XIFAXAN
PANCREATIC ENZYMES
CREON
PANCREAZE
ZENPEP
PROTON PUMP INHIBITOR/ANTI-INFECTIVE COMBINATIONS
PREVPAC
lansoprazole/amox tr/clarith
2
[MOE][QLL, 14/365]
Page 51 of 103
Drug
Generic
PROTON PUMP INHIBITORS
DEXILANT
lansoprazole capsule enteric
coated, -tablet
NEXIUM
NEXIUM I.V.
dexlansoprazole
2
1
[MNT]
[MNT]
esomeprazole mag trihyd
esomeprazole mag trihyd
2
2
1
[MNT]
[MOE]
[MNT]
1
[MNT]
1
[MNT]
1
1
2
[MNT]
[MNT]
[MNT][ST]
1
3
1
[MOE]
[MOE]
[MOE]
1
[MNT]
2
2
2
2
2
2
1
2
1
[MNT]
[MNT]
[MNT][QLL, 30/30]
[MNT]
[MNT]
[MNT][QLL, 30/30]
[MNT]
[MNT]
[MNT]
omeprazole capsule enteric
coated
omeprazole-sodium
bicarbonate
pantoprazole sodium
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
finasteride
tamsulosin hcl
UROXATRAL [G]
alfuzosin hcl
MISCELLANEOUS
bethanechol chloride tablet
ELMIRON
pentosan polysulfate sodium
neomy-polymyxin b 40 mg/ml
amp
potassium citrate tablet
sustained action
URINARY ANTISPASMODICS
AVODART
DETROL
DETROL LA 2 MG CAPSULE
DETROL LA 4 MG CAPSULE
ENABLEX 15 MG TABLET
ENABLEX 7.5 MG TABLET
dutasteride
tolterodine tartrate
darifenacin hydrobromide
darifenacin hydrobromide
flavoxate hcl
GELNIQUE
oxybutynin chloride er
oxybutynin
Page 52 of 103
Drug
oxybutynin chloride syrup, tablet
trospium chloride
VESICARE 10 MG TABLET
VESICARE 5 MG TABLET
Generic
1
[MNT]
1
2
2
[MNT]
[MNT]
[MNT][QLL, 30/30]
2
1
[MOE]
[MOE]
1
[MOE]
1
[MOE]
1
1
1
1
[MOE]
[MOE]
[MOE]
[MOE]
fondaparinux sodium
fondaparinux sodium
2
4
[MOE][QLL, 30/180]
[MOE][QLL, 30/180]
warfarin sodium
dalteparin (porcine)
2
1
2
[MNT]
[MOE][QLL, 60/180]
[MOE][QLL, 30/180]
dalteparin (porcine)
4
[MOE][QLL, 30/180]
solifenacin succinate
solifenacin succinate
VAGINAL ANTI-INFECTIVES
CLEOCIN
clindamycin phosphate
clindamycin phosphate cream
with applicator
metronidazole gel with
applicator
miconazole 3 suppository
vaginal
terconazole
vandazole
zazole 0.8% vaginal cream
zazole vaginal 0.4% cream [G]
HEMATOLOGIC
ANTICOAGULANTS
ARIXTRA 2.5 MG SYRINGE [G]
ARIXTRA 5 MG SYRINGE, -7.5
MG SYRINGE, -10 MG
SYRINGE [G]
COUMADIN [G]
enoxaparin sodium
FRAGMIN 2,500 UNITS
SYRINGE, -5,000 UNITS
SYRINGE, -25,000 UNITS/ML
VIAL
FRAGMIN 7,500 UNITS
SYRINGE
Page 53 of 103
Drug
heparin sod 1,000 unit/ml vial,
-sod 5,000 unit/ml vial, -sod
10,000 unit/ml vl, -sod 20,000
unit/ml vl
HEPARIN SOD 2,000 UNIT/ML
VIAL
Generic
heparin sodium
2
[MOE][PAB]
heparin sodium(porcine)/nacl
1
2
[MOE][PAB]
[MOE][PAB]
1
[MOE][PAB]
1
1
2
1
[MOE][PAB]
[MNT]
[MNT]
[MNT]
sargramostim
plerixafor
oprelvekin
filgrastim
epoetin alfa
4
4
3
4
2
[MOE][PA]
[MOE][PA]
[MOE][PAB]
[MOE][PA]
[MNT][PA][QLL,
12/30]
epoetin alfa
4
epoetin alfa
4
[MNT][PA][QLL,
12/30]
[MNT][PA][QLL,
6/30]
tranexamic acid
1
1
2
1
1
[MNT][PA]
[MNT]
[MOE]
[MNT]
[MNT]
eltrombopag olamine
4
[MNT][PA]
heparin-1/2ns 25,000 unit/250
HEPARIN-1/2NS 25,000
UNIT/500
heparin-d5w 20,000 unit/500
ml
heparin-ns 2,000 unit/1,000 ml
jantoven
PRADAXA
1
[MOE][PAB]
dabigatran etexilate mesylate
warfarin sodium tablet
HEMATOPOIETIC GROWTH FACTORS
LEUKINE
MOZOBIL
NEUMEGA
NEUPOGEN
PROCRIT 2,000 UNITS/ML
VIAL, -3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL, -10,000
UNITS/ML VIAL
VIAL
VIAL
MISCELLANEOUS
anagrelide hcl
cilostazol
CYKLOKAPRON
pentopak
pentoxifylline tablet sustained
action
PROMACTA
Page 54 of 103
Drug
PLATELET AGGREGATION INHIBITORS
AGGRENOX
Generic
aspirin/dipyridamole
2
1
2
2
2
1
[MNT]
[MNT][PA]
[MNT]
[MOE][QLL, 1/30]
[MNT]
[MNT]
4
4
4
1
[MNT][PA]
[MNT]
[MNT][PA]
[MNT]
infliximab
methotrexate
1
1
4
2
[MNT]
[MNT]
[MNT][PA]
[MNT]
immune globulin - im
immune globulin - iv
immune globulin - iv
2
4
4
[MOE][PAB]
[MOE][PA]
[MOE][PA]
interferon gamma-1b,recomb.
rilonacept
interferon alfacon-1
interferon alfa-2b , recomb.
4
4
4
4
[MOE][PAN]
[MNT][PA]
[MOE][PA]
[MNT][PAB]
interferon alfa-2b , recomb.
4
[MOE][PAB]
peginterferon alfa-2a
peginterferon alfa-2b
4
4
[MOE][PA]
[MOE][PA]
dipyridamole tablet
EFFIENT
PLAVIX 300 MG TABLET
PLAVIX 75 MG TABLET
prasugrel
clopidogrel
clopidogrel
ticlopidine hcl
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)
ACTEMRA
ENBREL
HUMIRA
tocilizumab
etanercept
adalimumab
hydroxychloroquine sulfate
tablet
leflunomide
methotrexate tablet
REMICADE
RHEUMATREX
IMMUNOGLOBULINS
GAMASTAN S-D
GAMMAGARD LIQUID
GAMUNEX
IMMUNOMODULATORS
ACTIMMUNE
ARCALYST
INFERGEN
INTRON A 3 MILLION UNIT/ML
PEN, -5 MILLION UNIT/ML
PEN, -10 MILLION UNIT PEN
INTRON A 6 MILLION UNIT/ML
VL, -10 MILLION UNITS VIAL
PEGASYS
PEGINTRON
Page 55 of 103
Drug
PEGINTRON REDIPEN
REVLIMID [LA]
THALOMID
Generic
peginterferon alfa-2b
lenalidomide
thalidomide
Tier
4
4
4
Requirements/Limits
[MOE][PA]
[MOE][MNT][PAN]
[MNT][PAN]
azathioprine
mycophenolate mofetil
2
1
1
2
[MNT][PAB]
[MOE][PAB]
[MNT][PAB]
[MNT][PAB]
3
2
[MOE]
[MNT][PAB]
1
[MNT][PAB]
1
[MOE][PAB]
1
1
1
2
2
2
[MNT][PAB]
[MNT][PAB]
[MNT][PAB]
[MNT][PAB]
[MNT][PAB]
[MNT][PAB]
4
2
2
1
[MNT][PAB]
[MNT][PAB]
[MNT][PAB]
[MNT][PAB]
everolimus
4
2
[MNT][PAB]
[MNT][PAB]
everolimus
4
[MNT][PAB]
haemophilus b-tet toxoid
diphther,pertuss,tetanus vac
human papillomav vacc bival/pf
2
2
2
2
[MOE]
[MOE]
[MOE]
[MOE]
IMMUNOSUPPRESSANTS
AZASAN
azathioprine sodium
azathioprine tablet
CELLCEPT CAPSULE, -TABLET
[G]
CELLCEPT INJECTION
CELLCEPT SUSPENSION
RECONSTITUTED ORAL
cyclosporine 25 mg capsule, 100 mg capsule, -solution
cyclosporine 50 mg/ml amp, unknown
cyclosporine modif 100 mg cap
gengraf
MYFORTIC
NEORAL [G]
PROGRAF 0.5 MG CAPSULE, -1
MG CAPSULE [G]
PROGRAF 5 MG CAPSULE [G]
RAPAMUNE
SANDIMMUNE [G]
mycophenolate sodium
cyclosporine
tacrolimus
tacrolimus
sirolimus
cyclosporine
tacrolimus 0.5 mg capsule, -1
mg capsule
tacrolimus 5 mg capsule
ZORTRESS 0.25 MG TABLET, 0.5 MG TABLET
ZORTRESS 0.75 MG TABLET
VACCINES
ACTHIB
ADACEL
BOOSTRIX
CERVARIX
Page 56 of 103
Drug
COMVAX
DAPTACEL
DIPHTHERIA-TETANUS
TOXOID
ENGERIX-B
GARDASIL
HAVRIX
IMOVAX RABIES VACCINE
INFANRIX
IPOL
IXIARO
JE-VAX
MENACTRA
MENOMUNE-A-C-Y-W-135
MENVEO A-C-Y-W-135-DIP
M-M-R II VACCINE
PEDVAXHIB
PROQUAD
RABAVERT
RECOMBIVAX HB
ROTATEQ
TETANUS DIPHTHERIA
TOXOIDS
TETANUS TOXOID ADSORBED
TETANUS-DIPHTERIADECAVAC
TRIPEDIA
TWINRIX
TYPHIM VI
VAQTA
VARIVAX VACCINE
YF-VAX
ZOSTAVAX
Generic
hepatitis b/haemophilus b vacc
tetanus,diphtheria toxoid
Tier
2
2
2
Requirements/Limits
[MOE]
[MOE]
[MOE][PAB]
hepatitis b virus vaccine
human papillomavirus vacc
hepatatis a virus vaccine
rabies vaccine,human diploid
poliomyelitis vac,killed
japanese encephalitis vaccine
japanese encephalitis vaccine
meningococcal vac a,c,y,w-135
meningococcal vac a,c,y,w-135
mening vac a,c,y,w-135 dip
measles,mumps&rubella vaccine
haemophilus b vaccine
measles,mumps,rub,varicella
rabies vac,pf chick-emb cell
hepatitis b virus vaccine
rotavirus vac, live pentav
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
[MOE][PAB]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE][PAB]
[MOE]
[MOE][PAB]
tetanus toxoid,adsorbed
2
2
[MOE][PAB]
[MOE][PAB]
hep b vir recomb/hep a vir
typhoid vaccine
hepatatis a virus vaccine
varicella virus vaccine live
yellow fever vaccine
varicella vacc/pf
2
2
2
2
2
2
2
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE][QLL, 1/999]
1
1
1
[MNT]
[MNT]
[MNT]
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
ed k+10
klor-con 10
klor-con 8
Page 57 of 103
Drug
KLOR-CON M15
Generic
potassium chloride
Tier
2
1
1
Requirements/Limits
[MNT]
[MNT]
[MOE]
1
[MNT]
1
1
[MOE]
[MOE]
1
1
1
[MOE]
[MNT]
[MOE][PAB]
2
[MOE][PAB]
amino acids
1
2
[MOE][PAB]
[MOE][PAB]
amino acids
2
[MOE][PAB]
amino acids
2
[MOE][PAB]
amino acids
2
[MOE][PAB]
amino acids
2
[MOE][PAB]
amino acids
2
[MOE][PAB]
amino acids
2
[MOE][PAB]
amino acids
1
2
[MOE][PAB]
[MOE][PAB]
amino acids
2
[MOE][PAB]
klor-con m20
magnesium sulf 4% iv soln, sulf 8% iv soln, -50% syringe
potassium chloride capsule
sustained action, -tablet
sust.releaseparticles/crystals
potassium cl 2 meq/ml vial
sodium bicarb 7.5% abboject,
-7.5% syring, -bicarb 8.4%
abboject, -bicarb 8.4% syringe
sodium cl 2.5 meq/ml vial
sodium fluoride tablet
tpn electrolytes [G]
IV NUTRITION
AMINOSYN 3.5% IV
amino acids
SOLUTION, -7% IV SOLUTION,
-10% IV SOLUTION
aminosyn 8.5% iv solution
AMINOSYN 8.5% IV
SOLUTION
AMINOSYN II 3.5% MDEXTROSE 5%
AMINOSYN II 3.5%-DEXTROSE
25%
AMINOSYN II 3.5%-DEXTROSE
5%
AMINOSYN II 4.25%DEXTROSE 25%
AMINOSYN II 5% IN 25%
DEXTROSE
AMINOSYN II 7% IV
SOLUTION, -10% IV
SOLUTION, -15% IV
SOLUTION
aminosyn ii 8.5% electrolyt
AMINOSYN II 8.5%
ELECTROLYT
AMINOSYN II IN DEXTROSE
Page 58 of 103
Drug
Generic
AMINOSYN II WITH LYTES-CA- amino acids
DW
AMINOSYN M
amino acids
AMINOSYN-HBC
amino acids
2
2
1
2
2
2
1
1
2
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
fat emulsions
1
2
1
2
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
fat emulsions
fat emulsions
2
2
[MOE][PAB]
[MOE][PAB]
1
2
2
1
2
2
2
2
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
[MOE][PAB]
1
[MOE]
1
1
[MOE]
[MOE]
aminosyn-hf
AMINOSYN-PF
CLINIMIX
CLINIMIX E
amino acids
amino acids
amino acids
clinisol
freamine iii 8.5% iv soln.
FREAMINE III WITH
ELECTROLYTES
aa 3%/electrolyte-tpn/glycerin
hepatamine
HEPATASOL
amino acids
intralipid 20% iv fat emul [G]
INTRALIPID 30% IV FAT EMUL
[G]
LIPOSYN II
LIPOSYN III 10% IV FAT
EMULSN, -20% IV FAT
EMULSN
liposyn iii 30% iv fat emulsn
NEPHRAMINE
PREMASOL 10% IV SOLUTION
amino acids
amino acids
premasol 6% iv solution
PROCALAMINE
PROSOL
TRAVASOL
TROPHAMINE
2
[MOE][PAB]
aa 3%/electrolyte-tpn/glycerin
amino acids
amino acids
amino acids
IV REPLACEMENT SOLUTIONS
d5%-1/2ns-kcl 10 meq/l iv sol,
-kcl 10 meq in d5w-1/2 ns, -kcl
20 meq in d5w-1/2 ns, -d5%1/2ns-kcl 30 meq/l iv sol, d5%-1/2ns-kcl 40 meq/l iv sol
d5%-1/2ns-kcl 20 meq/l iv sol
d5%-1/3ns-kcl 20 meq/l iv sol
Page 59 of 103
Drug
d5%-1/4ns-kcl 10 meq/l iv sol,
-d5%-1/4ns-kcl 40 meq/l iv
sol, -kcl 10 meq in d5w-1/4 ns,
-kcl 5 meq in d5w-1/4 ns
D5W-KCL 10 MEQ/L IV
SOLUTION, -D5W/KCL 10
MEQ/L IV SOLUTION
Generic
potassium chloride/d5w
2
[MOE]
1
[MOE]
1
2
1
[MOE]
[MOE]
[MOE]
1
[MOE]
2
[MOE]
1
[MOE]
electrolyte solutions
2
[MOE]
dextrose/electrolytes
2
2
2
1
2
2
2
1
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
dextrose/nacl/kcl
2
[MOE]
dextrose/nacl/kcl
2
[MOE]
d5w-kcl 20 meq/l iv solution, kcl 20 meq in d5w solution, d5w-kcl 30 meq/l iv solution, d5w-kcl 40 meq/l iv solution, kcl 40 meq in d5w solution
dextrose 10%-1/4ns
DEXTROSE 10%-1/4NS-KCL
dextrose 5%-1/4ns iv soln., 5%-1/3ns iv soln., -5%-1/2ns
iv soln.
dextrose 5%-1/4ns iv solution,
-5%-1/3ns iv solution, -d10%1/2ns soln/excel cont, -5%1/2ns iv solution, -2.5%-1/2ns
iv soln, -5%-ns iv solution
DEXTROSE 5%-ELECTROLYTE
#48
dextrose 5%-water iv soln, 10%-water iv solution
IONOSOL B WITH DEXTROSE
5%
IONOSOL MB-DEXTROSE 5%
IONOSOL T-DEXTROSE 5%
ISOLYTE H WITH DEXTROSE
potassium chloride/d10-0.25ns
isolyte m with dextrose
ISOLYTE P WITH DEXTROSE
ISOLYTE S
ISOLYTE S WITH DEXTROSE
kcl 10 meq in d5w-1/3 ns, -kcl
20 meq in d5w-1/3 ns, -d51/3ns/kcl 30 meq/l iv sol
KCL 10 MEQ IN D5W-1/4 NS, D5%-1/4NS-KCL 20 MEQ/L IV
SOL
KCL 20 MEQ IN D5W-1/4 NS
1
[MOE]
Page 60 of 103
Drug
KCL 20 MEQ IN D5W-LACT
RINGER
Generic
potassium chloride/d5w
kcl 20 meq in d5w-ns
kcl 20 meq-ns 1,000 ml iv soln,
-kcl 20 meq-ns 500 ml iv soln
kcl 40 meq in d5w-lact ringer
KCL 40 MEQ IN D5W-NACL
0.9%
KCL 40 MEQ-NS 1,000 ML IV
SOLN
1
1
[MOE]
[MOE]
dextrose/nacl/kcl
1
2
[MOE]
[MOE]
pot chloride/na chlor
2
[MOE]
1
2
1
1
2
2
2
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
d5w/electrolyte-56 solution
2
2
[MOE]
[MOE]
2
1
2
1
[MOE]
[MOE]
[MOE]
[MOE]
1
1
[MOE]
[MOE]
1
1
[MOE]
[MOE]
1
1
1
[MOE][PAB]
[MNT][PAB]
[MOE]
lactated ringers injection
MAGNESIUM SULFATE-D5W
magnesium sulfate/d5w
normosol-m and dextrose
normosol-r and dextrose
NORMOSOL-R PH 7.4
PLASMA-LYTE 148
PLASMA-LYTE 148 IN
DEXTROSE
PLASMA-LYTE 56
PLASMA-LYTE 56 IN
DEXTROSE
PLASMA-LYTE A PH 7.4
plasma-lyte r
POTASSIUM CHLORIDE-NACL
potassium cl 10 meq/100 ml
sol, -cl 30 meq/100 ml sol, -cl
10 meq/50 ml sol, -cl 20
meq/50 ml sol
ringers injection
saline 0.45% soln-excel con, saline 0.9% soln-excel cont, 0.9% solution, -3% iv soln, 5% iv soln
sodium chloride 0.9% soln
sodium lactate injection
2
[MOE]
pot chloride/na chlor
VITAMINS
calcitriol 1 mcg/ml ampul
calcitriol capsule, -solution
prenatabs obn
Page 61 of 103
Drug
ZEMPLAR CAPSULE
ZEMPLAR INJECTION
paricalcitol
paricalcitol
Generic
2
[MNT][PAB]
2
[MOE][PAB]
OPHTHALMIC
ANTIALLERGICS
ALREX
loteprednol etabonate
azelastine hcl drops
cromolyn sodium drops
epinastine hcl
parcaine
PATADAY
PATANOL
olopatadine hcl
olopatadine hcl
2
1
1
1
1
2
2
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
1
2
1
2
1
3
2
1
1
2
1
1
1
1
2
1
2
2
1
[MOE]
[MNT]
[MOE]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT]
[MNT][QLL, 2.5/30]
[MNT]
[MNT]
[MNT]
[MNT]
2
[MNT][QLL, 2.5/30]
ANTIGLAUCOMA
acetazolamide sodium
ALPHAGAN P
brimonidine tartrate
apraclonidine hcl
AZOPT
brinzolamide
betaxolol hcl drops
BETIMOL
BETOPTIC S
timolol
betaxolol
brimonidine 0.2% eye drop
carteolol hcl
COMBIGAN
brimonidine tartrate/timolol
dorzolamide hcl
dorzolamide-timolol
latanoprost
levobunolol hcl
LUMIGAN
bimatoprost
metipranolol
PHOSPHOLINE IODIDE
PILOPINE HS
timolol maleate drops, -gelforming solution
TRAVATAN Z
echothiophate iodide
pilocarpine hcl
travoprost
Page 62 of 103
Drug
ANTI-INFECTIVE/ANTI-INFLAMMATORY
BLEPHAMIDE S.O.P.
Generic
sulfacetamide/prednisolone ac
neomycin-bacitracin-poly-hc
neomycin-poly-hc eye drops
neomycin-polymyxin-dexameth
poly-dex
sulfacetamide-prednisolone
tobramycin-dexamethasone
2
1
1
1
1
1
1
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
1
2
1
1
2
1
1
1
1
1
1
2
1
1
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE][QLL, 68/30]
[MOE]
[MOE]
[MOE]
1
1
1
1
1
1
2
1
1
2
2
2
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MNT]
[MOE]
[MOE]
[MOE]
ANTI-INFECTIVES
aktob
AZASITE
azithromycin
bacitracin 500 unit/gm ointmnt
bacitracin-polymyxin eye oint
CILOXAN
ciprofloxacin
ciprofloxacin hcl drops
erythromycin ointment
gentak
gentamicin sulfate drops
gentasol
levofloxacin drops
NATACYN
natamycin
neomycin-bacitracin-polymyxin
neomycin-polymyxingramicidin
ofloxacin 0.3% eye drops
polymyxin b sul-trimethoprim
romycin
sulfacetamide sodium drops
tobramycin sulfate drops
tobrasol
TOBREX
tobramycin
trifluridine
tropicamide drops
VIGAMOX
ZYMAR
ZYMAXID
moxifloxacin
gatifloxacin
gatifloxacin
Page 63 of 103
Drug
Generic
ANTI-INFLAMMATORIES
dexamethasone sodium
phosphate drops
diclofenac sodium drops
fluorometholone suspension
drops
flurbiprofen sodium
FML S.O.P.
ketorolac tromethamine drops
prednisolone acetate
suspension drops
PREDNISOLONE SODIUM
PHOSPHATE DROPS
fluorometholone
prednisolone sod phosphate
1
[MOE]
1
1
[MOE]
[MOE]
1
2
1
1
[MOE]
[MOE]
[MOE]
[MOE]
2
[MOE]
1
2
1
2
[MOE]
[MOE]
[MOE]
[MNT]
2
[MNT][QLL, 30
gm/30]
[MNT][PAB][QLL,
540/30]
MISCELLANEOUS
ak-con
LACRISERT
hydroxypropylmethylcellulose
proparacaine hcl drops
RESTASIS
cyclosporine
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
COMBIVENT
albuterol sulfate/ipratropium
ipratropium-albuterol [PartB]
1
ANTICHOLINERGICS
ATROVENT HFA
ipratropium bromide aerosol
spray
ipratropium bromide solution
non-oral [PartB]
SPIRIVA
ipratropium
2
1
1
tiotropium bromide
2
[MNT][QLL, 26
gm/30]
[MNT]
[MNT][PAB][QLL,
315/30]
[MNT][QLL, 30
capsules/30]
Page 64 of 103
Drug
ANTIHISTAMINES
ASTEPRO
Generic
azelastine hcl
azelastine hcl aerosol spray
w/pump
carbinoxamine maleate
cetirizine hcl 1 mg/1 ml soln, 1 mg/ml soln, -5 mg/5 ml
syrup
cetirizine hcl 1 mg/ml syrup
CLARINEX
2
1
1
[MNT][QLL, 60
ml/30]
[MNT][QLL, 60
ml/30]
[MOE]
[MNT]
1
3
1
[MNT]
[MNT]
[MOE]
1
[MNT][PA]
1
[MOE]
1
[MOE]
1
1
1
1
1
1
[MNT]
[MOE]
[MOE][PA]
[MOE][PA]
[MNT]
[MOE]
1
[MNT][PAB][QLL,
60/30]
[MNT]
1
desloratadine
clemastine fumarate syrup, fum 2.68 mg tab
cyproheptadine hcl syrup, tablet
dexchlorpheniramine maleate
syrup
diphenhydramine 50 mg
capsule, -elixir, -50 mg/ml vial
fexofenadine hcl
hydroxyzine hcl injection
hydroxyzine hcl syrup, -tablet
hydroxyzine pamoate capsule
levocetirizine dihydrochloride
palgic
BETA AGONISTS
albuterol sulfate nebs, solution non-oral [PartB]
albuterol sulfate syrup, -tablet,
-tablet sustained release 12hr
albuterol sulfate vial nebulizer
[PartB]
FORADIL
levalbuterol concentrate
[PartB]
metaproterenol sulfate syrup, tablet
1
1
formoterol fumarate
2
1
1
[MNT][PAB][QLL,
300/30]
[MNT][QLL, 60/30]
[MNT][PAB][QLL,
90/30]
[MNT]
Page 65 of 103
Drug
PERFOROMIST [PartB]
Generic
formoterol fumarate
PROAIR HFA
albuterol
PROVENTIL HFA
SEREVENT DISKUS
albuterol
salmeterol
terbutaline sulfate injection
terbutaline sulfate tablet
VENTOLIN HFA
albuterol
3
[MNT][PAB][QLL,
120/30]
2
[MNT][QLL, 18
gm/30]
2
[MNT]
2
[MNT]
1
[MOE]
1
[MNT]
2
[MNT]
LEUKOTRIENE RECEPTOR ANTAGONISTS
SINGULAIR
montelukast sodium
2
1
[MNT][ST]
[MNT]
1
[MNT][PAB][QLL,
240/30]
1
4
4
1
2
2
1
4
4
4
[MOE][PAB]
[MNT][PA]
[MOE][PA]
[MOE]
[MOE]
[MOE]
[MOE][PA]
[MNT][PAB]
[MOE][PAB]
[MNT][PA]
flunisolide 0.025% spray
1
fluticasone propionate nasal
inhaled steroids
1
[MNT][QLL, 50
ml/30]
[MNT][QLL, 16
gm/30]
[MNT][QLL, 17/30]
zafirlukast
MAST CELL STABILIZERS
cromolyn sodium ampul for
nebulization [PartB]
MISCELLANEOUS
acetylcysteine vial [PartB]
ARALAST NP
CAYSTON
alpha-1-proteinase inhibitor
aztreonam lysine
epinephrine 0.1 mg/ml syringe
EPIPEN
EPIPEN JR
epinephrine hcl
epinephrine hcl
promethazine vc
PULMOZYME [PartB]
TOBI [PartB]
XOLAIR
deoxyribonuclease
tobramycin/sodium chloride
omalizumab
NASAL STEROIDS
NASACORT AQ [G]
triamcinolone acetonide
2
Page 66 of 103
Drug
NASONEX
VERAMYST
Generic
mometasone
fluticasone furoate
2
[MNT]
2
[MNT]
mometasone
2
STEROID INHALANTS
ASMANEX
budesonide ampul for
nebulization [PartB]
FLOVENT DISKUS
FLOVENT HFA
QVAR
1
fluticasone propionate
fluticasone propionate
beclomethasone
2
2
2
[MNT][QLL, 2
doses/30]
[MNT][PAB][QLL,
120/30]
[MNT]
[MNT]
[MNT][QLL, 24/30]
STEROID/BETA-AGONIST COMBINATIONS
ADVAIR DISKUS
ADVAIR HFA
DULERA
salmeterol/fluticasone
salmeterol/fluticasone
mometasone/formoterol
2
2
2
SYMBICORT
budesonide/formoterol fum
2
[MNT]
[MNT]
[MNT][QLL, 13
gm/30]
[MNT][QLL, 11
gm/30]
XANTHINES
aminophylline 250 mg/10 ml vl
aminophylline tablet
ELIXOPHYLLIN
THEO-24
theochron er 100 mg tablet, er 300 mg tablet
theophylline anhydrous tablet
sustained release 12hr
theophylline tablet sustained
action
theophylline
theophylline
1
1
2
2
1
[MOE]
[MNT]
[MNT]
[MNT]
[MNT]
1
[MNT]
1
[MNT]
1
1
1
[MOE]
[MOE]
[MOE]
TOPICAL
DERMATOLOGY, ACNE
adapalene
amnesteem
avita cream [G]
Page 67 of 103
Drug
avita gel
claravis
clindamycin phosphate foam, gel, -lotion, -solution non-oral,
-swab medicated
clindamycin-benzoyl peroxide
ery
erythromycin gel, -solution
non-oral
erythromycin-benzoyl peroxide
sotret
sulfacetamide sodium
suspension topical
tretinoin 0.025% cream, 0.05% cream, -0.1% cream, gel
Generic
Tier
1
1
1
Requirements/Limits
[MOE]
[MOE]
[MOE]
1
1
1
[MOE]
[MOE]
[MOE]
1
1
1
[MOE]
[MOE]
[MOE]
1
[MOE]
fluorouracil
2
1
[MOE]
[MOE]
diclofenac sodium
2
[MOE]
mupirocin calcium
2
1
1
[MOE]
[MOE]
[MOE]
1
1
1
1
1
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
1
[MOE]
DERMATOLOGY, ACTINIC KERATOSIS
CARAC
fluorouracil cream, -solution
non-oral
SOLARAZE
DERMATOLOGY, ANTIBIOTICS
BACTROBAN
clotrimazole-betamethasone
gentamicin sulfate cream, 0.1% ointment
mupirocin ointment
nystatin-triamcinolone
silver sulfadiazine cream
ssd
thermazene
DERMATOLOGY, ANTIFUNGALS
ciclopirox cream, -gel, shampoo, -solution non-oral, suspension topical
Page 68 of 103
Drug
clotrimazole 1% cream, solution non-oral
clotrimazole af 1% cream
econazole nitrate cream
ketoconazole cream
nyamyc
nystatin cream, -ointment, 100,000 unit/gm powd
nystop
pedi-dri
Generic
1
[MOE]
1
1
1
1
1
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
1
1
[MOE]
[MOE]
1
1
1
2
[MOE]
[MOE]
[MOE]
[MOE]
1
2
4
3
[MOE]
[MOE]
[MOE][PA]
[MOE][PA]
1
1
[MOE]
[MOE]
2
2
[MOE]
[MOE]
1
1
1
[MOE]
[MOE]
[MOE]
DERMATOLOGY, ANTIPRURITIC
proctocream-hc [G]
proctosol-hc
proctozone-hc
ZONALON
doxepin
DERMATOLOGY, ANTIPSORIATICS
calcipotriene
DOVONEX
OXSORALEN-ULTRA
TAZORAC
calcipotriene
methoxsalen
tazarotene
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole shampoo
selenium sulfide 2.5% lotion
DERMATOLOGY, ANTIVIRALS
DENAVIR
ZOVIRAX
penciclovir
acyclovir
DERMATOLOGY, CORTICOSTEROIDS
ala-cort cream [G]
ala-cort lotion
alclometasone dipropionate
Page 69 of 103
Drug
amcinonide
betamethasone dipropionate
cream, -lotion, -ointment
betamethasone valerate
cream, -lotion, -ointment
clobetasol emollient
clobetasol propionate gel, ointment, -solution non-oral
DERMA-SMOOTHE-FS
desonide cream, -lotion, ointment
desoximetasone cream, -gel, ointment
diflorasone diacetate
fluocinolone acetonide cream, ointment, -solution non-oral
fluocinonide emollient
fluocinonide gel, -ointment, solution non-oral
fluticasone propionate cream, ointment
halobetasol propionate
hydrocortisone 1% cream, 2.5% cream, -2.5% lotion, 1% absorbase, -1% ointment,
-2.5% ointment
hydrocortisone acetate
hydrocortisone butyrate
hydrocortisone plus 1% cream,
--aloe 1% cream, -1% oint
hydrocortisone valerate
lokara [G]
mometasone furoate cream, ointment, -solution non-oral
prednicarbate
procto-pak
triamcinolone acetonide cream,
-lotion, -ointment
triderm
Generic
fluocinolone acetonide
1
[MOE]
1
[MOE]
1
[MOE]
1
1
[MOE]
[MOE]
2
1
[MOE]
[MOE]
1
[MOE]
1
1
[MOE]
[MOE]
1
1
[MOE]
[MOE]
1
[MOE]
1
1
[MOE]
[MOE]
1
1
1
[MOE]
[MOE]
[MOE]
1
1
1
[MOE]
[MOE]
[MOE]
1
1
1
[MOE]
[MOE]
[MOE]
1
[MOE]
Page 70 of 103
Drug
DERMATOLOGY, IMMUNOMODULATORS
ELIDEL
PROTOPIC
Generic
pimecrolimus
tacrolimus
2
2
[MOE][PA]
[MOE][PA]
1
[MOE]
1
2
[MOE]
[MOE][PA][QLL,
90/30]
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine hcl jel, -ointment, solution non-oral
lidocaine-prilocaine cream
LIDODERM
lidocaine
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
ammonium lactate cream, lotion
imiquimod cream
laclotion [G]
PANRETIN
1
[MOE]
1
1
4
1
4
2
2
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MNT]
[MOE]
metronidazole
2
1
[MOE]
[MOE]
doxycycline monohydrate
2
[MOE]
1
1
1
[MOE]
[MOE]
[MOE]
alitretinoin
podofilox
TARGRETIN GEL
VOLTAREN
ZYCLARA
bexarotene
diclofenac sodium
imiquimod
DERMATOLOGY, ROSACEA
METROGEL
metronidazole cream, -gel, lotion
ORACEA
DERMATOLOGY, SCABICIDES AND PEDICULIDES
acticin
malathion
permethrin cream
Page 71 of 103
Drug
DERMATOLOGY, WOUND CARE AGENTS
REGRANEX
SANTYL
Generic
becaplermin
collagenase
sodium chloride solution
4
2
1
[MOE][PA]
[MOE]
[MOE]
1
[MOE]
2
1
1
1
1
1
[MNT]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
1
1
1
1
2
1
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
[MOE]
1
1
[MOE]
[MOE]
MOUTH/THROAT/DENTAL AGENTS
chlorhexidine gluconate
mouthwash
EVOXAC
cevimeline
lidocaine hcl viscous
nystatin suspension oral
periogard
pilocarpine hcl tablet
triamcinolone acetonide paste
OTIC
acetasol hc
acetic acid solution non-oral
acetic acid-hydrocortisone
cortomycin
DERMOTIC
neomycin-polymixin-hc ear
susp
neomycin-polymyxin-hydrocort
ofloxacin 0.3% ear drops
fluocinolone acetonide
Page 72 of 103
Index:
aa 3%/electrolyte-tpn/glycerin, 59
abacavir sulfate, 18
abacavir sulfate/lamivudine, 17
ABILIFY 5 MG TABLET, -10 MG
TABLET, -15 MG TABLET, 36
ABILIFY DISCMELT, 36
ABILIFY INJECTION, 36
ABILIFY SOLUTION, -2 MG TABLET, 20 MG TABLET, -30 MG TABLET, 36
acamprosate calcium, 40
acarbose, 42
ACE INHIBITOR COMBINATIONS, 24
ACE INHIBITORS, 25
acebutolol hcl capsule, 28
acetaminoph-caff-dihydrocodein, 11
acetaminophen-codeine, 10
acetasol hc, 72
acetazolamide capsule sustained
action, -tablet, 30
acetazolamide sodium, 62
acetic acid solution non-oral, 72
acetic acid-hydrocortisone, 72
acetylcysteine vial, 66
ACTEMRA, 55
ACTHIB, 56
acticin, 71
ACTIMMUNE, 55
ACTONEL 30 MG TABLET, 43
ACTONEL 5 MG TABLET, -35 MG
ACTOPLUS MET, 42
ACTOPLUS MET XR, 42
ACTOS 15 MG TABLET, 42
acyclovir, 69
acyclovir capsule, -suspension oral, tablet, 18
acyclovir sodium 500 mg vial, 18
ADACEL, 56
ADAGEN, 45
adalimumab, 55
adapalene, 67
ADCIRCA, 31
adcirca (tadalafil), 31
adefovir dipivoxil, 19
ADRENOLYTICS, CENTRAL, 25
adriamycin 2 mg/ml vial, 21
ADVAIR DISKUS, 67
ADVAIR HFA, 67
afeditab cr, 29
AFINITOR, 23
agalsidase, 46
AGGRENOX, 55
a-hydrocort, 46
ak-con, 64
aktob, 63
ala-cort cream, 69
ala-cort lotion, 69
albendazole, 19
ALBENZA, 19
albuterol, 66
albuterol sulfate nebs, -solution nonoral, 65
albuterol sulfate syrup, -tablet, -tablet
sustained release 12hr, 65
albuterol sulfate vial nebulizer, 65
albuterol sulfate/ipratropium, 64
alclometasone dipropionate, 69
ALCOHOL SWABS, 41
aldesleukin, 22
ALDOSTERONE RECEPTOR
ANTAGONISTS, 25
ALDURAZYME, 45
alemtuzumab, 22
alendronate sodium 35 mg tab, -70
mg tab, 43
alendronate sodium 5 mg tablet, -10
mg tab, -40 mg tab, 43
alfuzosin hcl, 52
alglucosidase alfa, 46
ALIMTA, 21
Page 73 of 103
ALINIA SUSPENSION
RECONSTITUTED ORAL, 19
ALINIA TABLET, 19
aliskiren hemifumarate, 30
aliskiren/amlodipine, 30
aliskiren/amlodipine/hctz, 30
aliskiren/hydrochlorothiazid, 30
aliskiren/valsartan, 30
alitretinoin, 71
ALKYLATING AGENTS, 20
allopurinol sodium, 10
allopurinol tablet, 10
alosetron, 51
ALPHA BLOCKERS, 25
alpha-1-proteinase inhibitor, 66
ALPHAGAN P, 62
ALREX, 62
altretamine, 20
amantadine, 35
ambrisentan, 31
amcinonide, 70
a-methapred 40 mg univial, -125 mg
vial, 46
amifostine, 24
amikacin sulfate 100 mg/2 ml, -500
mg/2 ml, 14
amiloride hcl tablet, 30
amiloride-hydrochlorothiazide, 30
amino acids, 58, 59
aminophylline 250 mg/10 ml vl, 67
aminophylline tablet, 67
aminosalicylic acid, 18
AMINOSYN 3.5% IV SOLUTION, -7%
IV SOLUTION, -10% IV SOLUTION,
58
aminosyn 8.5% iv solution, 58
AMINOSYN 8.5% IV SOLUTION, 58
AMINOSYN II 3.5% M-DEXTROSE 5%,
58
AMINOSYN II 3.5%-DEXTROSE 25%,
58
58
58
AMINOSYN II 5% IN 25% DEXTROSE,
58
AMINOSYN II 7% IV SOLUTION, -10%
IV SOLUTION, -15% IV SOLUTION,
58
aminosyn ii 8.5% electrolyt, 58
AMINOSYN II 8.5% ELECTROLYT, 58
AMINOSYN II IN DEXTROSE, 58
AMINOSYN II WITH LYTES-CA-DW, 59
AMINOSYN M, 59
AMINOSYN-HBC, 59
aminosyn-hf, 59
AMINOSYN-PF, 59
amiodarone, 27
amiodarone 150 mg/3 ml amp, 26
amiodarone hcl tablet, 26
AMITIZA, 51
amitriptyline hcl tablet, 34
amlodipine bes/olmesartan med, 26
amlodipine besylate tablet, 29
amlodipine/valsartan, 26
amlodipine/valsartan/hctz, 26
amlodipine-benazepril 2.5-10, -benazepril 5-10 mg, 24
amlodipine-benazepril 5-40 mg, -benazepril 10-20 mg, --benazepril 520 mg, --benazepril 10-40 mg, 25
ammonium lactate cream, -lotion, 71
amnesteem, 67
amox tr-potassium clavulanate, 14
amoxapine, 34
AMOXAPINE, 34
amoxicillin, 14
amoxicillin-clavulanate er, 14
amphetamine salt combo, 38
amphotericin b injection, 16
ampicillin 125 mg vial, -1 gm vial, -10
gm vial, 14
Page 74 of 103
ampicillin trihydrate, 14
ampicillin-sulbactam 3 gm vial, -15 gm
vl, 14
AMPYRA, 39
AMTURNIDE, 30
amylase/lipase/protease, 51
ANADROL-50, 41
anagrelide hcl, 54
ANALGESICS, 10
anastrozole tablet, 22
ANCOBON, 16
ANDRODERM, 41
ANDROGEL, 41
ANDROGENS, 41
ANDROXY, 41
ANESTHETICS, 13
ANGIOTENSIN II RECEPTOR
ANTAGONIST COMBINATIONS, 26
ANGIOTENSIN II RECEPTOR
ANTAGONISTS, 26
ANTABUSE, 40
ANTARA, 28
ANTHRACYCLINES, 21
ANTIALLERGICS, 62
ANTIANXIETY, 32
ANTIARRHYTHMICS, 26
ANTIBACTERIALS, 14
ANTIBIOTICS, 21
ANTICHOLINERGIC/BETA AGONIST
COMBINATIONS, 64
ANTICHOLINERGICS, 64
ANTICOAGULANTS, 53
ANTICONVULSANTS, 32
ANTIDEMENTIA, 33
ANTIDEPRESSANTS, 34
ANTIDIABETICS, INJECTABLE, 41
ANTIDIABETICS, ORAL, 42
ANTIEMETICS, 49
ANTIFUNGALS, 16
ANTIGLAUCOMA, 62
ANTIHISTAMINES, 65
ANTI-INFECTIVE/ANTIINFLAMMATORY, 63
ANTIINFECTIVES, 14
ANTI-INFECTIVES, 14
ANTI-INFECTIVES, 63
ANTI-INFLAMMATORIES, 64
ANTILIPEMICS, HMG-CoA REDUCTASE
INHIBITORS, 27
ANTILIPEMICS, MISCELLANEOUS, 28
ANTIMALARIALS, 17
ANTIMETABOLITES, 21
ANTIMITOTIC, TAXOIDS, 22
ANTIMITOTIC, VINCA ALKALOIDS, 22
ANTINEOPLASTIC AGENTS, 20
ANTIPARKINSONIAN AGENTS, 35
ANTIPSYCHOTICS, 36
ANTIRETROVIRAL AGENTS, 17
ANTISPASMODICS, 50
ANTITUBERCULAR AGENTS, 18
ANTIVIRALS, 18
APIDRA, 41
APIDRA SOLOSTAR, 41
APOKYN, 35
apomorphine hcl, 35
apraclonidine hcl, 62
aprepitant, 49
apri, 44
APRISO, 50
APTIVUS, 17
ARALAST NP, 66
aranelle, 44
ARCALYST, 55
aripiprazole, 36
ARIXTRA 2.5 MG SYRINGE, 53
ARIXTRA 5 MG SYRINGE, -7.5 MG
SYRINGE, -10 MG SYRINGE, 53
armodafinil, 40
AROMASIN, 22
arsenic trioxide, 23
artemether/lumefantrine, 17
ARTHROTEC 50, 12
ARTHROTEC 75, 12
Page 75 of 103
ASACOL, 50
ASACOL HD, 50
ascomp with codeine, 10
asenapine, 37
ASMANEX, 67
asparaginase, 23
aspirin/dipyridamole, 55
ASTEPRO, 65
astramorph-pf 5 mg/10 ml vial, -10
mg/10 ml vial, 11
atazanavir sulfate, 18
atenolol tablet, 28
atenolol-chlorthalidone, 28
atomoxetine, 38
atorvastatin calcium, 27
atovaquone, 20
atovaquone/proguanil hcl, 17
ATRIPLA, 17
atropine 0.1 mg/ml abboject, -0.1
mg/ml syringe, -0.05 mg/ml syringe,
27
ATROVENT HFA, 64
ATTENTION DEFICIT HYPERACTIVITY
DISORDER, 38
AVALIDE, 26
AVAPRO, 26
AVASTIN, 22
AVELOX, 14
AVELOX ABC PACK, 14
AVELOX IV, 14
aviane, 44
avita cream, 67
avita gel, 68
AVODART, 52
AVONEX, 39
AVONEX ADMINISTRATION PACK, 39
azacitidine, 21
AZASAN, 56
AZASITE, 63
azathioprine, 56
azathioprine sodium, 56
azathioprine tablet, 56
azelastine hcl, 65
azelastine hcl aerosol spray w/pump,
65
azelastine hcl drops, 62
AZILECT, 35
azithromycin, 63
azithromycin injection, -suspension, tablet, 14
AZOPT, 62
AZOR, 26
aztreonam 1 gm vial, 19
aztreonam lysine, 66
baciim, 19
bacitracin 500 unit/gm ointmnt, 63
bacitracin injection, 19
bacitracin-polymyxin eye oint, 63
baclofen tablet, 39
BACTROBAN, 68
balsalazide disodium, 50
balziva, 44
BANZEL, 32
BARACLUDE SOLUTION, 19
BARACLUDE TABLET, 19
becaplermin, 72
beclomethasone, 67
benazepril hcl, 25
benazepril-hydrochlorothiazide, 25
bendamustine hcl, 21
BENICAR, 26
BENICAR HCT 20-12.5 MG TABLET, 26
BENICAR HCT 40-25 MG TABLET, -4012.5 MG TABLET, 26
BENIGN PROSTATIC HYPERPLASIA, 52
benztropine 2 mg/2 ml vial, 35
benztropine mesylate tablet, 36
BETA AGONISTS, 65
BETA-BLOCKER/DIURETIC
COMBINATIONS, 28
BETA-BLOCKERS, 28
betaine hcl, 45
betamethasone dipropionate cream, lotion, -ointment, 70
Page 76 of 103
betamethasone valerate cream, lotion, -ointment, 70
betaxolol, 62
betaxolol hcl drops, 62
betaxolol hcl tablet, 28
bethanechol chloride tablet, 52
BETIMOL, 62
BETOPTIC S, 62
bevacizumab, 22
bexarotene, 23, 71
bicalutamide, 22
BICILLIN C-R, 14
BICILLIN L-A, 14
BICNU, 20
BIDIL, 31
bimatoprost, 62
BIOLOGIC RESPONSE MODIFIERS, 22
bisoprolol fumarate, 28
bisoprolol-hydrochlorothiazide, 28
BISPHOSPHONATES, 43
bleomycin sulfate 30 unit vial, 21
BLEPHAMIDE S.O.P., 63
BOOSTRIX, 56
bortezomib, 22
bosentan, 32
brimonidine 0.2% eye drop, 62
brimonidine tartrate, 62
brimonidine tartrate/timolol, 62
brinzolamide, 62
bromocriptine mesylate capsule, tablet, 36
budeprion sr, 34
budeprion xl, 34
budesonide, 50
budesonide ampul for nebulization, 67
budesonide/formoterol fum, 67
bumetanide injection, 30
bumetanide tablet, 30
BUPHENYL, 45
buprenorphine 0.3 mg/ml syrn, 12
buprenorphine hcl tablet sublingual, 40
buprenorphine/naloxone, 40
buproban, 40
bupropion hcl sr, 34
bupropion hcl tablet, 34
buspirone hcl tablet, 32
busulfan, 20
BUSULFEX, 20
butalb-caff-acetaminoph-codein, 10
butorphanol tartrate aerosol spray, -1
mg/ml vial, -2 mg/ml vial, 10
BYETTA 10 MCG DOSE PEN INJ, 41
BYETTA 5 MCG DOSE PEN INJ, 41
BYSTOLIC, 28
cabergoline, 47
calcipotriene, 69
calcitonin, 43
CALCITONINS, 43
calcitonin-salmon, 43
calcitriol 1 mcg/ml ampul, 61
calcitriol capsule, -solution, 61
calcium acetate, 48
CALCIUM CHANNEL BLOCKERS, 29
CALCIUM RECEPTOR ANTAGONISTS,
43
camila, 44
CAMPATH, 22
CAMPRAL, 40
CANASA, 50
CANCIDAS, 16
CAPASTAT SULFATE, 18
capreomycin, 18
captopril tablet, 25
captopril-hydrochlorothiazide, 25
CARAC, 68
CARAFATE, 51
carbamazepine, 32, 33
carbamazepine suspension oral, tablet, -tablet chewable, 32
carbamazepine xr, 32
CARBATROL, 32
carbidopa/levodopa/entacap, 36
carbidopa-levodopa, 36
carbinoxamine maleate, 65
Page 77 of 103
carboplatin 150 mg/15 ml vial, 24
CARDIOVASCULAR, 24
CARDIZEM CD, 29
carisoprodol 350 mg tablet, 40
carmustine, 20
carteolol hcl, 62
cartia xt, 29
carvedilol, 28
caspofungin acetate, 16
CAYSTON, 66
CEENU, 20
cefaclor, 14
CEFACLOR ER, 14
cefadroxil, 14
cefazolin, 14
CEFAZOLIN 1 GM-D5W BAG, 14
cefazolin 20 gm bulk vial, -500 mg
vial, -1 gm vial, 14
cefdinir, 14
cefepime hcl, 14
cefixime, 16
cefotaxime sodium 500 mg vial, -10
gm vial, -1 gm vial, -2 gm vial, 14
cefotetan, 14
cefoxitin, 15
cefoxitin sodium, 15
cefpodoxime proxetil, 15
cefprozil, 15
ceftazidime 1 gm vial, -2 gm vial, -6
gm vial, 15
ceftriaxone 250 mg vial, -500 mg vial,
-1 gm vial, -2 gm add vial, -10 gm
vial, 15
cefuroxime axetil, 15
cefuroxime sod 750 mg vial, -sod 1.5
gm vial, -sod 7.5 gm vial, 15
cefuroxime tablet, 15
CELEBREX, 12
celecoxib, 12
CELLCEPT CAPSULE, -TABLET, 56
CELLCEPT INJECTION, 56
CELLCEPT SUSPENSION
RECONSTITUTED ORAL, 56
CELONTIN, 32
CENTRAL NERVOUS SYSTEM, 32
cephalexin, 15
CEREZYME, 45
certolizumab pegol, 50
CERVARIX, 56
cesia, 44
cetirizine hcl 1 mg/1 ml soln, -1 mg/ml
soln, -5 mg/5 ml syrup, 65
cetirizine hcl 1 mg/ml syrup, 65
cevimeline, 72
CHANTIX, 40
CHELATING AGENTS, 44
chlorambucil, 21
chloramphenicol sod succinate, 15
chlorhexidine gluconate mouthwash,
72
chloroquine phosphate tablet, 17
chlorothiazide, 30
chlorothiazide sodium, 30
chlorpromazine, 36
CHLORPROMAZINE HCL INJECTION,
36
chlorpromazine hcl tablet, 36
chlorthalidone, 30
chlorzoxazone, 40
cholestyramine light packet, 28
chorionic gonadotropin, 47
ciclopirox cream, -gel, -shampoo, solution non-oral, -suspension
topical, 68
cilostazol, 54
CILOXAN, 63
cimetidine injection, 50
cimetidine solution, -tablet, 50
CIMZIA, 50
cinacalcet hcl, 43
CIPRO, 15
ciprofloxacin, 15, 63
ciprofloxacin 400 mg/40 ml vl, 15
Page 78 of 103
ciprofloxacin er, 15
ciprofloxacin hcl drops, 63
ciprofloxacin hcl tablet, 15
cisplatin, 24
citalopram, 34
citalopram hbr 10 mg tablet, -20 mg
tablet, 34
citalopram hbr 40 mg tablet, 34
cladribine, 24
claravis, 68
CLARINEX, 65
clarithromycin er, 15
clarithromycin suspension, -tablet, 15
clemastine fumarate syrup, -fum 2.68
mg tab, 65
CLEOCIN, 53
CLEOCIN HCL, 19
CLEOCIN PALMITATE, 19
clindamycin 150 mg/ml addvan, 19
clindamycin hcl, 19
clindamycin hcl capsule, 19
clindamycin palmitate, 19
clindamycin phosphate, 53
clindamycin phosphate cream with
applicator, 53
clindamycin phosphate foam, -gel, lotion, -solution non-oral, -swab
medicated, 68
clindamycin-benzoyl peroxide, 68
CLINIMIX, 59
CLINIMIX E, 59
clinisol, 59
clobetasol emollient, 70
clobetasol propionate gel, -ointment, solution non-oral, 70
clomipramine hcl capsule, 34
clonidine, 25
clonidine hcl tablet, 25
clopidogrel, 55
clotrimazole 1% cream, -solution nonoral, 69
clotrimazole af 1% cream, 69
clotrimazole troche, 17
clotrimazole-betamethasone, 68
clozapine, 36
COARTEM, 17
codeine sulfate, 11
co-gesic, 10
colchicine, 10
COLCRYS, 10
colesevelam, 28
colistimethate 150 mg vial, 20
collagenase, 72
colocort, 50
COMBIGAN, 62
COMBIVENT, 64
COMBIVIR, 17
compro, 49
COMTAN, 36
COMVAX, 57
constulose, 51
CONTRACEPTIVES, 44
COPAXONE, 39
COREG CR, 28
cortisone acetate tablet, 46
cortomycin, 72
COSMEGEN, 21
COUMADIN, 53
CREON, 51
CRESTOR 40 MG TABLET, 27
CRESTOR 5 MG TABLET, -10 MG
CRIXIVAN, 17
cromolyn, 51
cromolyn sodium ampul for
nebulization, 66
cromolyn sodium drops, 62
cryselle, 44
CUBICIN, 20
CURAD GAUZE PADS, 41
cyclafem, 44
cyclobenzaprine hcl tablet, 40
cyclophosphamide tablet, 20
cycloserine, 18
Page 79 of 103
cyclosporine, 56, 64
cyclosporine 25 mg capsule, -100 mg
capsule, -solution, 56
cyclosporine 50 mg/ml amp, unknown, 56
cyclosporine modif 100 mg cap, 56
CYKLOKAPRON, 54
CYMBALTA 20 MG CAPSULE, -30 MG
CAPSULE, 34
CYMBALTA 60 MG CAPSULE, 34
cyproheptadine hcl syrup, -tablet, 65
CYSTADANE, 45
CYSTAGON, 45
cysteamine, 45
cytarabine 20 mg/ml vial, -500 mg
vial, 21
d5%-1/2ns-kcl 10 meq/l iv sol, -kcl 10
meq in d5w-1/2 ns, -kcl 20 meq in
d5w-1/2 ns, -d5%-1/2ns-kcl 30
meq/l iv sol, -d5%-1/2ns-kcl 40
meq/l iv sol, 59
d5%-1/2ns-kcl 20 meq/l iv sol, 59
d5%-1/3ns-kcl 20 meq/l iv sol, 59
d5%-1/4ns-kcl 10 meq/l iv sol, -d5%1/4ns-kcl 40 meq/l iv sol, -kcl 10
meq in d5w-1/4 ns, -kcl 5 meq in
d5w-1/4 ns, 60
d5w/electrolyte-56 solution, 61
D5W-KCL 10 MEQ/L IV SOLUTION, D5W/KCL 10 MEQ/L IV SOLUTION,
60
d5w-kcl 20 meq/l iv solution, -kcl 20
meq in d5w solution, -d5w-kcl 30
meq/l iv solution, -d5w-kcl 40 meq/l
iv solution, -kcl 40 meq in d5w
solution, 60
dabigatran etexilate mesylate, 54
dacarbazine 200 mg vial, 20
dactinomycin, 21
dalfampridine, 39
dalteparin (porcine), 53
danazol capsule, 45
dantrolene sodium capsule, 40
dapsone tablet, 20
DAPTACEL, 57
daptomycin, 20
DARAPRIM, 17
darifenacin hydrobromide, 52
darunavir ethanolate, 18
dasatinib, 23
daunorubicin 20 mg vial, 21
deferasirox, 44
delavirdine mesylate, 18
demeclocycline hcl, 15
DENAVIR, 69
denileukin diftitox, 22
denosumab, 43
deoxyribonuclease, 66
depade, 40
DEPO-PROVERA, 22
DERMA-SMOOTHE-FS, 70
DERMATOLOGY, ACNE, 67
DERMATOLOGY, ACTINIC KERATOSIS,
68
DERMATOLOGY, ANTIBIOTICS, 68
DERMATOLOGY, ANTIFUNGALS, 68
DERMATOLOGY, ANTIPRURITIC, 69
DERMATOLOGY, ANTIPSORIATICS, 69
DERMATOLOGY, ANTISEBORRHEICS,
69
DERMATOLOGY, ANTIVIRALS, 69
DERMATOLOGY, CORTICOSTEROIDS,
69
DERMATOLOGY,
IMMUNOMODULATORS, 71
DERMATOLOGY, LOCAL
ANESTHETICS, 71
DERMATOLOGY, MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE, 71
DERMATOLOGY, ROSACEA, 71
DERMATOLOGY, SCABICIDES AND
PEDICULIDES, 71
DERMATOLOGY, WOUND CARE
AGENTS, 72
Page 80 of 103
DERMOTIC, 72
desipramine hcl tablet, 34
desloratadine, 65
desmopressin ac 4 mcg/ml vl, 48
desmopressin acetate aerosol spray
w/pump, -solution, -tablet, 49
desonide cream, -lotion, -ointment, 70
desoximetasone cream, -gel, ointment, 70
desvenlafaxine succinate, 35
DETROL, 52
DETROL LA 2 MG CAPSULE, 52
DETROL LA 4 MG CAPSULE, 52
dexamethasone, 46
dexamethasone 120 mg/30 ml vl, -20
mg/5 ml vial, -4 mg/ml vial, 46
dexamethasone elixir, -tablet, 46
DEXAMETHASONE INTENSOL, 46
dexamethasone sodium phosphate
drops, 64
dexchlorpheniramine maleate syrup,
65
DEXILANT, 52
dexlansoprazole, 52
dexmethylphenidate hcl, 38
dexrazoxane 500 mg vial, 24
dextroamphetamine sulfate, 38
dextromethorphan/quinidine, 39
dextrose 10%-1/4ns, 60
DEXTROSE 10%-1/4NS-KCL, 60
dextrose 5%-1/4ns iv soln., -5%-1/3ns
iv soln., -5%-1/2ns iv soln., 60
dextrose 5%-1/4ns iv solution, -5%1/3ns iv solution, -d10%-1/2ns
soln/excel cont, -5%-1/2ns iv
solution, -2.5%-1/2ns iv soln, -5%ns iv solution, 60
DEXTROSE 5%-ELECTROLYTE #48, 60
dextrose 5%-water iv soln, -10%water iv solution, 60
dextrose/electrolytes, 60
dextrose/nacl/kcl, 60, 61
diazoxide, 47
diclofenac potassium, 13
diclofenac sodium, 68, 71
diclofenac sodium drops, 64
diclofenac sodium tablet enteric
coated, -tablet sustained release
24hr, 13
diclofenac sodium/misoprostol, 12
dicloxacillin sodium, 15
dicyclomine hcl capsule, -syrup, tablet, 50
dicyclomine hcl injection, 50
didanosine, 17, 18
diflorasone diacetate, 70
diflunisal, 13
DIGITALIS GLYCOSIDES, 30
digoxin, 30
digoxin 0.25 mg/ml ampul, 30
digoxin solution, -tablet, 30
dihydroergotamine 1 mg/ml am, 38
DILANTIN 100 MG CAPSULE, 32
DILANTIN 30 MG CAPSULE, -TABLET
CHEWABLE, 32
DILANTIN-125, 32
DILAUDID-5, 11
dilt xr 180 mg capsule, -dilt xr 240 mg
capsule, 29
dilt-cd 120 mg capsule, -er 300 mg
capsule, 29
diltiazem, 29
diltiazem 24hr cd 120 mg cap, -24hr
cd 240 mg cap, -24hr cd 300 mg
cap, 29
diltiazem 25 mg/5 ml vial, -100 mg
vial, 29
diltiazem hcl er 360 mg cap, -hcl er
420 mg cap, -capsule sustained
release 12 hr, 29
diltiazem hcl tablet, 29
diltzac er 120 mg capsule, -180 mg
capsule, -240 mg capsule, -300 mg
capsule, 29
Page 81 of 103
DIOVAN, 26
DIOVAN HCT 160-25 MG TABLET, 320-12.5 MG TAB, -320-25 MG
TABLET, 26
DIOVAN HCT 80-12.5 MG TABLET, 160-12.5 MG TAB, 26
diphenhydramine 50 mg capsule, elixir, -50 mg/ml vial, 65
diphenoxylate-atropine, 51
diphther,pertuss,tetanus vac, 56, 57
DIPHTHERIA-TETANUS TOXOID, 57
dipyridamole tablet, 55
DIRECT RENIN
INHIBITORS/COMBINATIONS, 30
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS), 55
disopyramide, 27
disopyramide phosphate, 27
disulfiram, 40
DIURETICS, 30
divalproex sodium, 32
divalproex sodium er, 32
docetaxel, 22
dofetilide, 27
donepezil hcl 10 mg tablet, -odt 10 mg
tablet, 33
donepezil hcl 5 mg tablet, -odt 5 mg
tablet, 33
dorzolamide hcl, 62
dorzolamide-timolol, 62
DOVONEX, 69
doxazosin mesylate, 25
doxepin, 69
doxepin hcl capsule, -solution, 34
DOXIL, 21
doxorubicin 200 mg/100 ml vial, 21
doxorubicin hcl liposome, 21
doxycycline, 15
doxycycline hyclate capsule, -capsule
enteric coated, -injection, -tablet, tablet enteric coated, 15
doxycycline mono 50 mg tablet, -mono
75 mg tablet, 15
doxycycline monohydrate, 71
dronabinol 10 mg capsule, 49
dronabinol 2.5 mg capsule, 49
dronedarone, 27
DROXIA, 23
DUETACT, 42
DULERA, 67
duloxetine, 34
duramorph, 11
dutasteride, 52
e.e.s. 400, 15
echothiophate iodide, 62
econazole nitrate cream, 69
ed k+10, 57
efavirenz, 18
EFFIENT, 55
ELAPRASE, 45
electrolyte solutions, 60, 61
ELECTROLYTES, 57
ELIDEL, 71
eliphos, 46
ELITEK, 24
ELIXOPHYLLIN, 67
ELMIRON, 52
ELSPAR, 23
eltrombopag olamine, 54
EMCYT, 20
EMEND 125 MG CAPSULE, 49
EMEND 40 MG CAPSULE, 49
EMEND TRIFOLD PACK, -80 MG
CAPSULE, 49
EMSAM, 34
emtricitabine, 17
emtricitabine/tenofovir, 18
emtricitabine/tenofovir/efavir, 17
EMTRIVA, 17
ENABLEX 15 MG TABLET, 52
ENABLEX 7.5 MG TABLET, 52
enalapril maleate tablet, 25
enalapril-hydrochlorothiazide, 25
Page 82 of 103
ENBREL, 55
endocet, 11
ENDOCRINE AND METABOLIC, 41
endodan, 11
ENDOMETRIOSIS, 45
enfuvirtide, 17
ENGERIX-B, 57
enoxaparin sodium, 53
enpresse, 44
entacapone, 36
entecavir, 19
ENTOCORT EC, 50
enulose, 51
ENZYME REPLACEMENTS, 45
epinastine hcl, 62
epinephrine 0.1 mg/ml syringe, 66
epinephrine hcl, 66
EPIPEN, 66
EPIPEN JR, 66
epirubicin hcl, 21
epitol, 32
EPIVIR, 17
EPIVIR HBV, 19
eplerenone, 25
epoetin alfa, 54
EPZICOM, 17
ergoloid mesylates tablet, 38
ergotamine tartrate/caffeine, 39
ergotamine-caffeine, 38
erlotinib hcl, 23
errin, 44
ertapenem sodium, 20
ery, 68
ERYPED 200, 15
ERYTHROCIN LACTOBIONATE, 15
erythrocin stearate, 15
erythromycin ethylsuccinate, 15
erythromycin gel, -solution non-oral,
68
erythromycin lactobionate, 15
erythromycin ointment, 63
erythromycin tablet, 15
erythromycin-benzoyl peroxide, 68
erythromycin-sulfisoxazole, 20
escitalopram oxalate, 34
esomeprazole mag trihyd, 52
ESTRACE, 46
ESTRADERM, 46
estradiol, 46
estradiol patch transdermal weekly, tablet, 46
estradiol valerate injection, 46
estradiol-noreth 1-0.5 mg tab, 46
estramustine phosphate sodium, 20
estrogen/medroxyprogesterone, 46
ESTROGENS, 46
estrogens,conjugated, 46
estropipate, 46
eszopiclone, 38
etanercept, 55
ethambutol hcl, 18
ethinyl estradiol/norelgest, 45
ethionamide, 18
ethosuximide capsule, -syrup, 32
ethotoin, 33
etidronate disodium, 43
etodolac, 13
etonogestrel/ethin estradiol, 45
etoposide injection, 24
etravirine, 17
everolimus, 23, 56
EVISTA, 48
EVOXAC, 72
EXELON PATCH TRANSDERMAL 24
HOURS, 33
EXELON SOLUTION, 33
exemestane, 22
exenatide, 41
EXFORGE 5-160 MG TABLET, 26
EXFORGE 5-320 MG TABLET, -10-160
MG TABLET, -10-320 MG TABLET,
26
EXFORGE HCT 5-160-12.5 MG TAB, 26
Page 83 of 103
EXFORGE HCT 5-160-25 MG TAB, -10160-12.5 MG TAB, -10-160-25 MG
TAB, -10-320-25 MG TAB, 26
EXJADE 125 MG TABLET, 44
EXJADE 250 MG TABLET, -500 MG
TABLET, 44
EXTAVIA, 39
ezetimibe, 27
ezetimibe/simvastatin, 27
FABRAZYME, 46
famciclovir, 19
famotidine 20 mg/2 ml vial, -20 mg
piggyback, 50
famotidine suspension oral, -20 mg
tablet, -40 mg tablet, 50
FANAPT TABLET, 36
FANAPT TABLET DOSE PACK, 36
FARESTON, 22
FASLODEX, 22
fat emulsions, 59
FAZACLO, 36
febuxostat, 10
felbamate, 32
FELBATOL, 32
felodipine er, 29
FEMARA, 22
fenofibrate, 28
fenofibric acid, 28
fenoprofen calcium, 13
fentanyl, 11
fentanyl 0.05 mg/ml syringe, 11
fentanyl citrate otfc 200 mcg, 11
fentanyl citrate otfc 400 mcg, -otfc
600 mcg, -otfc 800 mcg, -cit otfc
1,200 mcg, -cit otfc 1,600 mcg, 11
fexofenadine hcl, 65
filgrastim, 54
finasteride, 52
fingolimod hydrochloride, 39
flavoxate hcl, 52
flecainide acetate, 27
FLOVENT DISKUS, 67
FLOVENT HFA, 67
fluconazole suspension, -tablet, 17
fluconazole-dext 400 mg/200 ml, 17
flucytosine, 16
fludarabine phosphate, 24
fludrocortisone acetate tablet, 47
flunisolide 0.025% spray, 66
fluocinolone acetonide, 70, 72
fluocinolone acetonide cream, ointment, -solution non-oral, 70
fluocinonide emollient, 70
fluocinonide gel, -ointment, -solution
non-oral, 70
fluorometholone, 64
fluorometholone suspension drops, 64
fluorouracil, 68
fluorouracil 500 mg/10 ml vial, 21
fluorouracil cream, -solution non-oral,
68
fluoxetine dr, 34
fluoxetine hcl 10 mg capsule, -20 mg
capsule, 34
fluoxetine hcl 10 mg tablet, 34
fluoxetine hcl 40 mg capsule, solution, -20 mg tablet, 34
fluoxymesterone, 41
fluphenazine decanoate, 36
fluphenazine hcl elixir, -tablet, 36
fluphenazine hcl injection, -solution,
36
flurbiprofen sodium, 64
flurbiprofen tablet, 13
flutamide, 22
fluticasone furoate, 67
fluticasone propionate, 67
fluticasone propionate cream, ointment, 70
fluticasone propionate nasal inhaled
steroids, 66
fluvoxamine maleate 100 mg tab, 32
fluvoxamine maleate 25 mg tab, -50
mg tab, 32
Page 84 of 103
FML S.O.P., 64
fondaparinux sodium, 53
FORADIL, 65
formoterol fumarate, 65, 66
FORTEO, 48
fortical, 43
fosamprenavir calcium, 17
foscarnet sodium, 19
fosinopril sodium, 25
fosinopril-hydrochlorothiazide, 25
fosphenytoin 100 mg pe/2 ml vl, 32
FOSRENOL, 48
FRAGMIN 2,500 UNITS SYRINGE, 5,000 UNITS SYRINGE, -25,000
UNITS/ML VIAL, 53
FRAGMIN 7,500 UNITS SYRINGE, 10,000 UNITS SYRINGE, -12,500
UNITS SYRINGE, -15,000 UNITS
SYRINGE, -18,000 UNITS SYRINGE,
53
freamine iii 8.5% iv soln., 59
FREAMINE III WITH ELECTROLYTES,
59
fulvestrant, 22
furosemide 10 mg/ml vial, 30
furosemide solution, -tablet, 30
FUZEON, 17
gabapentin, 33
gabapentin 100 mg capsule, 32
gabapentin 600 mg tablet, 32
gabapentin 800 mg tablet, 32
gabapentin solution, 32
GABITRIL, 32
galantamine er 16 mg capsule, -er 24
mg capsule, -tablet, 33
galantamine er 8 mg capsule, 33
galantamine hydrobromide, 33
galsulfase, 46
GAMASTAN S-D, 55
GAMMAGARD LIQUID, 55
GAMUNEX, 55
ganciclovir 250 mg capsule, 19
ganciclovir 500 mg capsule, 19
ganciclovir sodium, 19
GARDASIL, 57
GASTROCROM, 51
GASTROINTESTINAL, 49
gatifloxacin, 63
gavilyte-c, 51
gavilyte-g, 51
gavilyte-n, 51
GELNIQUE, 52
gemcitabine, 21
gemfibrozil tablet, 28
GEMZAR, 21
gengraf, 56
GENITOURINARY, 52
gentak, 63
gentamicin 10 mg/ml vial, -40 mg/ml
vial, 15
gentamicin 90 mg/ns 100 ml pb, -70
mg/ns 50 ml pb, 14
gentamicin sulfate cream, -0.1%
ointment, 68
gentamicin sulfate drops, 63
gentasol, 63
GEODON 20 MG CAPSULE, 36
GEODON 40 MG CAPSULE, 36
GEODON 60 MG CAPSULE, -80 MG
CAPSULE, 36
GEODON INJECTION, 36
gianvi, 44
GILENYA, 39
glatiramer acetate, 39
GLEEVEC, 23
glimepiride 1 mg tablet, 42
glipizide 10 mg tablet, 42
glipizide 5 mg tablet, 42
glipizide er 10 mg tablet, 42
glipizide er 2.5 mg tablet, 42
Page 85 of 103
glipizide er 5 mg tablet, 42
glipizide-metformin, 42
GLUCAGEN, 47
GLUCAGON EMERGENCY KIT, 47
glucagon, human recombinant, 47
GLUCOCORTICOIDS, 46
GLUCOSE ELEVATING AGENTS, 47
glyburide 1.25 mg tablet, 42
glyburide 2.5 mg tablet, 42
glyburide 5 mg tablet, 42
glyburide micro 1.5 mg tab, 42
glyburide micro 3 mg tablet, 42
glyburide micro 6 mg tablet, 42
glyburide-metformin hcl, 42
glycopyrrolate injection, -tablet, 50
glycron 1.5 mg tablet, 42
glycron 3 mg tablet, 42
glycron 4.5 mg tablet, 42
glycron 6 mg tablet, 42
GOUT, 10
granisetron, 49
granisetron hcl 0.1 mg/ml vial, -tablet,
49
granisol, 49
griseofulvin suspension oral, 17
griseofulvin ultramicrosize, 17
GRIS-PEG, 17
guanabenz acetate 4 mg tab, 25
guanfacine hcl, 25
guanidine, 39
GUANIDINE HCL, 39
H2-RECEPTOR ANTAGONISTS, 50
haemophilus b vaccine, 57
haemophilus b-tet toxoid, 56
halobetasol propionate, 70
haloperidol decanoate, 37
haloperidol lactate injection, 37
haloperidol lactate solution, 37
haloperidol tablet, 37
HAVRIX, 57
hctz/valsartan, 26
HEMATOLOGIC, 53
HEMATOPOIETIC GROWTH FACTORS,
54
hep b vir recomb/hep a vir, 57
heparin sod 1,000 unit/ml vial, -sod
5,000 unit/ml vial, -sod 10,000
unit/ml vl, -sod 20,000 unit/ml vl, 54
HEPARIN SOD 2,000 UNIT/ML VIAL,
54
heparin sodium, 54
heparin sodium(porcine)/nacl, 54
heparin-1/2ns 25,000 unit/250, 54
HEPARIN-1/2NS 25,000 UNIT/500, 54
heparin-d5w 20,000 unit/500 ml, 54
heparin-ns 2,000 unit/1,000 ml, 54
hepatamine, 59
HEPATASOL, 59
hepatatis a virus vaccine, 57
hepatitis b virus vaccine, 57
hepatitis b/haemophilus b vacc, 57
HEPSERA, 19
HERCEPTIN, 22
HEXALEN, 20
HORMONAL ANTINEOPLASTIC
AGENTS, 22
HUMALOG, 41
HUMALOG MIX 50-50, 41
HUMALOG MIX 75-25, 41
HUMAN GROWTH HORMONES, 47
human papillomav vacc bival/pf, 56
human papillomavirus vacc, 57
HUMIRA, 55
HUMULIN 70-30, 41
HUMULIN N, 41
HUMULIN R, 41
hydralazine hcl injection, 31
hydralazine hcl tablet, 31
hydrochlorothiazide capsule, -tablet,
30
hydrocodone bit-ibuprofen, 10
hydrocodone-acetaminophen capsule,
-solution, -hydrocodon-acetaminoph
2.5-500, -hydrocodonPage 86 of 103
acetaminophen 5-325, -hydrocodonacetaminoph 7.5-325, -hydrocodonacetaminoph 7.5-750, -hydrocodonacetaminophn 10-650, -hydrocodonacetaminophn 10-325, -hydrocodonacetaminoph 7.5-500, -hydrocodonacetaminophn 10-500, -hydrocodonacetaminoph 7.5-650, -hydrocodonacetaminophn 10-660, -hydrocodonacetaminophn 10-750, 10
hydrocortisone 1% cream, -2.5%
cream, -2.5% lotion, -1%
absorbase, -1% ointment, -2.5%
ointment, 70
hydrocortisone acetate, 70
hydrocortisone butyrate, 70
hydrocortisone enema, 50
hydrocortisone plus 1% cream, --aloe
1% cream, -1% oint, 70
hydrocortisone sod succinate, 47
hydrocortisone tablet, 47
hydrocortisone valerate, 70
hydromorphone, 11
hydromorphone hcl 10 mg/ml amp, 11
hydromorphone hcl tablet, 11
hydroxychloroquine sulfate tablet, 55
hydroxypropylmethylcellulose, 64
hydroxyurea, 23
hydroxyurea capsule, 23
hydroxyzine hcl injection, 65
hydroxyzine hcl syrup, -tablet, 65
hydroxyzine pamoate capsule, 65
HYPNOTICS, 38
ibuprofen 100 mg/5 ml sus, 13
ibuprofen 100 mg/5 ml susp, -400 mg
tablet, -600 mg tablet, -800 mg
tablet, 13
idarubicin hcl 10 mg/10 ml vl, 21
idursulfase, 45
IFEX, 20
ifosfamide, 20
ifosfamide-mesna, 24
iloperidone, 36
imatinib mesylate, 23
imiglucerase, 45
imipenem/cilastatin sodium, 20
imipramine hcl tablet, 34
imipramine pamoate, 34
imiquimod, 71
imiquimod cream, 71
immune globulin - im, 55
immune globulin - iv, 55
IMMUNOGLOBULINS, 55
IMMUNOLOGIC AGENTS, 55
IMMUNOMODULATORS, 55
IMMUNOSUPPRESSANTS, 56
IMOVAX RABIES VACCINE, 57
INCRELEX, 47
indapamide, 30
indinavir, 17
INDOCIN, 13
indomethacin, 13
indomethacin capsule, -capsule
sustained action, 13
INFANRIX, 57
INFERGEN, 55
INFLAMMATORY BOWEL DISEASE, 50
infliximab, 55
INSULIN SYRINGE, 41
INTELENCE, 17
interferon alfa-2b , recomb., 55
interferon alfacon-1, 55
interferon beta-1a, 39
interferon beta-1a/albumin, 39
interferon beta-1b, 39
interferon gamma-1b,recomb., 55
intralipid 20% iv fat emul, 59
INTRALIPID 30% IV FAT EMUL, 59
INTRON A 3 MILLION UNIT/ML PEN, 5 MILLION UNIT/ML PEN, -10
MILLION UNIT PEN, 55
INTRON A 6 MILLION UNIT/ML VL, 10 MILLION UNITS VIAL, 55
INVANZ, 20
Page 87 of 103
INVEGA ER 1.5 MG TABLET, -ER 3 MG
TABLET, 37
INVEGA ER 6 MG TABLET, -ER 9 MG
TABLET, 37
INVEGA SUSTENNA 117 MG PREF SY,
-156 MG PREF SY, -234 MG PREF
SY, 37
INVEGA SUSTENNA 39 MG PREF SYR,
-78 MG PREF SYR, 37
INVIRASE, 17
IONOSOL B WITH DEXTROSE 5%, 60
IONOSOL MB-DEXTROSE 5%, 60
IONOSOL T-DEXTROSE 5%, 60
IPOL, 57
ipratropium, 64
ipratropium bromide aerosol spray, 64
ipratropium bromide solution non-oral,
64
ipratropium-albuterol, 64
irbesartan, 26
irbesartan/hctz, 26
irinotecan hcl, 23
ISENTRESS, 17
isocarboxazid, 35
isochron, 31
ISOLYTE H WITH DEXTROSE, 60
isolyte m with dextrose, 60
ISOLYTE P WITH DEXTROSE, 60
ISOLYTE S, 60
ISOLYTE S WITH DEXTROSE, 60
isonarif, 18
isoniazid injection, 18
isoniazid syrup, -tablet, 18
ISORDIL, 31
isosorb dinit/hydralazine hcl, 31
isosorbide dinitrate, 31
isosorbide mononitrate, 31
isoton gentamicin 60 mg/100 ml, -80
mg/ns 100 ml pb, -100 mg/ns 100
ml, -60 mg/ns 50 ml pb, -80 mg/ns
50 ml pb, 16
isoton gentamicin 80 mg/100 ml, -iso
gentamicin 100 mg/100 ml, -isoton
gentamicin 60 mg/50 ml, -isoton
gentamicin 80 mg/50 ml, 16
isradipine, 29
ISTODAX, 22
itraconazole capsule, 17
IV NUTRITION, 58
IV REPLACEMENT SOLUTIONS, 59
IXIARO, 57
jantoven, 54
JANUMET, 42
JANUVIA 100 MG TABLET, 42
JANUVIA 25 MG TABLET, -50 MG
TABLET, 42
japanese encephalitis vaccine, 57
JE-VAX, 57
jinteli, 44
jolivette, 44
junel, 44
junel fe, 44
KADIAN, 11
KALETRA, 17
kanamycin sulfate injection, 14
kariva, 44
kcl 10 meq in d5w-1/3 ns, -kcl 20 meq
in d5w-1/3 ns, -d5-1/3ns/kcl 30
meq/l iv sol, 60
KCL 10 MEQ IN D5W-1/4 NS, -D5%1/4NS-KCL 20 MEQ/L IV SOL, 60
KCL 20 MEQ IN D5W-1/4 NS, 60
KCL 20 MEQ IN D5W-LACT RINGER,
61
kcl 20 meq in d5w-ns, 61
kcl 20 meq-ns 1,000 ml iv soln, -kcl 20
meq-ns 500 ml iv soln, 61
kcl 40 meq in d5w-lact ringer, 61
KCL 40 MEQ IN D5W-NACL 0.9%, 61
KCL 40 MEQ-NS 1,000 ML IV SOLN, 61
kelnor 1-35, 44
ketoconazole cream, 69
ketoconazole shampoo, 69
Page 88 of 103
ketoconazole tablet, 17
ketoprofen capsule, -capsule 24hr
sustained release pellets, 13
ketorolac 15 mg/ml vial, -30 mg/ml
vial, -tablet, 13
ketorolac tromethamine drops, 64
KINASE INHIBITORS, 23
kionex powder, 44
klor-con 10, 57
klor-con 8, 57
KLOR-CON M15, 58
klor-con m20, 58
KOMBIGLYZE XR, 42
KUVAN, 46
labetalol hcl 5 mg/ml vial, 28
labetalol hcl tablet, 28
laclotion, 71
lacosamide, 33
LACRISERT, 64
lactated ringers injection, 61
lactulose, 51
lamivudine, 17, 19
lamivudine/zidovudine, 17
lamotrigine tablet, -tablet dispersible,
33
LANOXIN, 30
lanreotide acetate, 47
lansoprazole capsule enteric coated, tablet, 52
lansoprazole/amox tr/clarith, 51
lanthanum carbonate, 48
LANTUS, 41
LANTUS SOLOSTAR, 41
lapatinib ditosylate, 23
laronidase, 45
latanoprost, 62
LATUDA, 37
LAXATIVES, 51
leena, 44
leflunomide, 55
lenalidomide, 56
lessina, 44
LETAIRIS, 31
letrozole, 22
leucovorin, 24
LEUCOVORIN CALCIUM 10 MG TAB, 15 MG TAB, 24
leucovorin calcium 100 mg vl, -350 mg
vl, 24
leucovorin calcium 5 mg tab, -25 mg
tab, 24
LEUKERAN, 21
LEUKINE, 54
LEUKOTRIENE RECEPTOR
ANTAGONISTS, 66
leuprolide, 22, 23
leuprolide acetate injection, 22
levalbuterol concentrate, 65
LEVEMIR, 41
levetiracetam injection, 33
levetiracetam solution, -tablet, 33
levobunolol hcl, 62
levocarnitine injection, 46
levocarnitine solution, -tablet, 46
levocetirizine dihydrochloride, 65
levofloxacin drops, 63
levora-28, 44
levorphanol tartrate tablet, 11
levothroid, 48
levothyroxine, 48
levothyroxine sodium tablet, 48
levoxyl, 48
LEXAPRO 5 MG TABLET, -10 MG
TABLET, 34
LEXAPRO SOLUTION, -20 MG TABLET,
34
LEXIVA, 17
LIALDA, 50
lidocaine, 71
lidocaine hcl 0.5% vial, -1% vial, 13
lidocaine hcl jel, -ointment, -solution
non-oral, 71
lidocaine hcl viscous, 72
lidocaine-prilocaine cream, 71
Page 89 of 103
LIDODERM, 71
linezolid, 20
liothyronine sodium injection, 48
liothyronine sodium tablet, 48
LIPITOR 10 MG TABLET, -20 MG
LIPITOR 80 MG TABLET, 27
LIPOSYN II, 59
LIPOSYN III 10% IV FAT EMULSN, 20% IV FAT EMULSN, 59
liposyn iii 30% iv fat emulsn, 59
liraglutide, 42
lisinopril tablet, 25
lisinopril-hydrochlorothiazide, 25
LITHIUM, 39
lithium carbonate capsule, -tablet, tablet sustained action, 39
lithium citrate, 39
LOCAL ANESTHETICS, 13
lokara, 70
lomustine, 20
loperamide capsule, 51
losartan potassium, 26
losartan-hydrochlorothiazide, 26
loteprednol etabonate, 62
LOTRONEX, 51
lovastatin, 27
LOVAZA, 27
low-ogestrel, 44
loxapine, 37
lubiprostone, 51
LUMIGAN, 62
LUNESTA, 38
LUPRON DEPOT 3.75 MG KIT, -11.25
MG 3MO KIT, 22
LUPRON DEPOT 7.5 MG KIT, -22.5 MG
3MO KIT, --4 MONTH KIT, 23
LUPRON DEPOT-PED, 23
lurasidone hcl, 37
lutera, 44
LYRICA 25 MG CAPSULE, -50 MG
CAPSULE, -75 MG CAPSULE, -100
MG CAPSULE, -150 MG CAPSULE, 200 MG CAPSULE, -225 MG
CAPSULE, 33
LYRICA 300 MG CAPSULE, 33
LYSODREN, 23
MACRODANTIN, 20
magnesium sulf 4% iv soln, -sulf 8%
iv soln, -50% syringe, 58
magnesium sulfate/d5w, 61
MAGNESIUM SULFATE-D5W, 61
MALARONE, 17
malathion, 71
maprotiline hcl, 34
maraviroc, 18
margesic h, 11
MARPLAN, 35
MAST CELL STABILIZERS, 66
MATULANE, 23
matzim la, 29
MAXALT, 38
MAXALT MLT, 38
measles,mumps&rubella vaccine, 57
measles,mumps,rub,varicella, 57
mebendazole tablet chewable, 20
mecasermin, 47
mechlorethamine, 21
meclizine hcl tablet, 49
meclofenamate sodium capsule, 13
medroxyprogesterone, 22
injection, 44
medroxyprogesterone acetate tablet,
48
mefenamic acid capsule, 13
mefloquine hcl, 17
MEGACE ES, 23
megestrol, 23
megestrol acetate suspension oral, 23
megestrol acetate tablet, 23
meloxicam suspension oral, -tablet, 13
melphalan hcl, 21
memantine hcl, 34
Page 90 of 103
MENACTRA, 57
mening vac a,c,y,w-135 dip, 57
meningococcal vac a,c,y,w-135, 57
MENOMUNE-A-C-Y-W-135, 57
MENVEO A-C-Y-W-135-DIP, 57
meperidine 10 mg/ml syringe, -25
mg/ml vial, -50 mg/ml vial, -100
mg/ml vial, 11
MEPRON, 20
mercaptopurine tablet, 21
meropenem iv 500 mg vial, 20
mesalamine, 50
mesalamine enema, 50
mesna, 24
MESNEX, 24
MESTINON, 39
metadate er, 38
metaproterenol sulfate syrup, -tablet,
65
metaxalone, 40
metformin hcl 500 mg tablet, 43
metformin hcl 850 mg tablet, -1,000
mg tablet, 43
metformin hcl er 500 mg tab, 43
metformin hcl er 750 mg tablet, 43
methadone hcl injection, -solution, 11
methadone hcl tablet, 11
methadose tablet, 11
methamphetamine hcl, 38
methazolamide tablet, 30
methenamine hippurate, 20
methimazole tablet, 48
methocarbamol, 40
methocarbamol tablet, 40
methotrexate, 55
methotrexate 25 mg/ml vial, -1 gm
vial, 21
methotrexate tablet, 55
methoxsalen, 69
methscopolamine bromide tablet, 50
methsuximide, 32
methyclothiazide, 31
methyldopa, 31
methyldopa-hydrochlorothiazide, 31
methyldopate hcl, 31
methylin er, 38
methylin tablet, 38
methylnaltrexone bromide, 51
methylphenidate hcl tablet, 38
methylphenidate sr, 38
methylprednisolone 40 mg vial, -125
mg vial, -ss 1 gm vl, 47
methylprednisolone acetate injection,
47
methylprednisolone tablet, -tablet
dose pack, 47
metipranolol, 62
metoclopramide 5 mg/ml vial, solution oral, -tablet, 49
metolazone, 31
metoprolol succinate, 28
metoprolol tart 5 mg/5 ml vial, -tart 1
mg/ml vial, 28
metoprolol tartrate tablet, 28
metoprolol-hydrochlorothiazide, 28
METROGEL, 71
metronidazole, 71
metronidazole capsule, -injection, tablet, 20
metronidazole cream, -gel, -lotion, 71
metronidazole gel with applicator, 53
mexiletine hcl capsule, 27
MIACALCIN, 43
miconazole 3 suppository vaginal, 53
microgestin, 44
microgestin fe, 44
midodrine hcl, 31
MIGERGOT, 39
miglustat, 46
MIGRAINE, 38
minitran, 31
minocycline hcl capsule, -tablet, -tablet
minoxidil tablet, 31
Page 91 of 103
mirtazapine 30 mg tablet, -45 mg
tablet, -30 mg odt, -45 mg odt, 35
mirtazapine 7.5 mg tablet, -15 mg
tablet, -15 mg odt, 35
misc supp (dress,tape,gauze), 41
MISCELLANEOUS, 19, 23, 31, 39, 47,
51, 52, 54, 64, 66
misoprostol, 51
mitomycin 20 mg vial, 21
mitotane, 23
mitoxantrone 25 mg/12.5 ml vl, 23
M-M-R II VACCINE, 57
modafinil, 40
moexipril hcl, 25
moexipril-hydrochlorothiazide, 25
mometasone, 67
mometasone furoate cream, ointment, -solution non-oral, 70
mometasone/formoterol, 67
mononessa, 44
montelukast sodium, 66
morphine, 11, 12
morphine 0.5 mg/ml vial, -1 mg/ml
vial p-f, 11
MORPHINE SULF 10 MG/5 ML SOLN, SULF 20 MG/5 ML SOLN, 12
morphine sulf 100 mg/5 ml soln, tablet, 12
morphine sulf er 15 mg tablet, -sulf er
30 mg tablet, -sulf er 60 mg tablet, sulf er 100 mg tab, 12
morphine sulf er 200 mg tab, 12
MOUTH/THROAT/DENTAL AGENTS, 72
moxifloxacin, 14, 63
MOZOBIL, 54
MULTAQ, 27
MULTIPLE SCLEROSIS AGENTS, 39
mupirocin calcium, 68
mupirocin ointment, 68
MUSCULOSKELETAL THERAPY
AGENTS, 39
MUSTARGEN, 21
MYCOBUTIN, 18
mycophenolate mofetil, 56
mycophenolate sodium, 56
MYFORTIC, 56
MYOZYME, 46
nabumetone, 13
nadolol tablet, 28
nadolol-bendroflumethiazide, 28
nafarelin, 45
nafcillin, 16
nafcillin 1 gm vial, -10 gm bulk vial, 10 gm vial, 16
NAGLAZYME, 46
nalbuphine 100 mg/10 ml vial, -200
mg/10 ml vial, 12
naloxone 0.4 mg/ml syringe, -1 mg/ml
syringe, 40
naltrexone hcl tablet, 40
NAMENDA SOLUTION, -TABLET, 34
NAMENDA TABLET DOSE PACK, 34
NAPRELAN, 13
naproxen, 13
naproxen sodium 275 mg tab, -550
mg tab, 13
naproxen suspension oral, -250 mg
tablet, -375 mg tablet, -tablet
enteric coated, 13
naproxen/esomeprazole mag, 13
naratriptan hcl, 39
NARCOLEPSY/CATAPLEXY, 40
NARCOTIC ANALGESICS, 10
NARCOTIC ANALGESICS, CII, 11
NARDIL, 35
NASACORT AQ, 66
NASAL STEROIDS, 66
NASONEX, 67
NATACYN, 63
natamycin, 63
nateglinide, 43
nebivolol hcl, 28
necon 0.5-35-28 tablet, -1/35-28
tablet, -7-7-7-28 tablet, 44
Page 92 of 103
NECON 10-11-28 TABLET, 45
nefazodone hcl, 35
nelfinavir mesylate, 18
neomycin sulfate tablet, 16
neomycin-bacitracin-poly-hc, 63
neomycin-bacitracin-polymyxin, 63
neomycin-poly-hc eye drops, 63
neomycin-polymixin-hc ear susp, 72
neomycin-polymyxin-dexameth, 63
neomycin-polymyxin-gramicidin, 63
neomycin-polymyxin-hydrocort, 72
neomy-polymyxin b 40 mg/ml amp, 52
NEORAL, 56
NEPHRAMINE, 59
NEUMEGA, 54
NEUPOGEN, 54
NEURONTIN, 33
nevirapine, 18
NEXAVAR, 23
NEXIUM, 52
NEXIUM I.V., 52
next choice, 45
niacin, 28
niacin/simvastatin, 27
NIASPAN, 28
nicardipine 25 mg/10 ml vial, 29
nicardipine hcl capsule, 29
nicotine inhaler, 40
nicotine ns, 40
NICOTROL, 40
NICOTROL NS, 40
nifediac cc, 29
nifedical xl, 29
nifedipine er tablet sustained action,
29
NILANDRON, 23
nilotinib hydrochloride, 23
nilutamide, 23
nimodipine, 29
nisoldipine, 29
nitazoxanide, 19
nitisinone, 46
NITRATES, 31
nitro-bid, 31
NITRO-DUR, 31
nitrofurantoin macrocrystal, 20
nitrofurantoin mcr 50 mg cap, 20
nitrofurantoin mono-macro, 20
nitroglycerin, 31
nitroglycerin injection, 31
nitroglycerin patch, 31
NITROLINGUAL, 31
NITROSTAT, 31
nizatidine, 50
NON-NARCOTIC ANALGESICS, 12
nora-be, 45
NORDITROPIN FLEXPRO, 47
NORDITROPIN NORDIFLEX, 47
norethindrone acetate tablet, 48
norethindrone-ethin estradiol, 45
norgestimate-ethinyl estradiol, 45
normosol-m and dextrose, 61
normosol-r and dextrose, 61
NORMOSOL-R PH 7.4, 61
NORPACE CR, 27
nortrel, 45
nortriptyline hcl capsule, -solution, 35
NORVIR, 18
novarel, 47
NOVOLIN 70-30, 41
NOVOLIN N, 41
NOVOLIN R, 41
NOVOLOG, 41
NOVOLOG MIX 70-30, 41
NOXAFIL, 17
NSAIDS, 12
NUCLEOSIDE ANALOGS, 24
NUEDEXTA, 39
NUTRITIONAL/SUPPLEMENTS, 57
NUVARING, 45
NUVIGIL, 40
nyamyc, 69
nystatin 500,000 unit oral tab, 17
Page 93 of 103
nystatin cream, -ointment, -100,000
unit/gm powd, 69
nystatin suspension oral, 72
nystatin-triamcinolone, 68
nystop, 69
ocella, 45
octreotide, 47
octreotide acet 50 mcg/ml amp, -acet
100 mcg/ml amp, -acet 200 mcg/ml
vl, 47
octreotide acet 500 mcg/ml amp, 1,000 mcg/ml vial, 47
ofloxacin 0.3% ear drops, 72
ofloxacin 0.3% eye drops, 63
ofloxacin tablet, 16
ogestrel, 45
olanzapine, 38
olmesartan med/amlodipine/hct, 26
olmesartan medoxomil, 26
olmesartan medoxomil/hctz, 26
olopatadine hcl, 62
omalizumab, 66
omega-3 acid ethyl esters, 27
omeprazole capsule enteric coated, 52
omeprazole-sodium bicarbonate, 52
ondansetron hcl 4 mg/2 ml vial, solution, -tablet, 49
ondansetron odt, 49
ONGLYZA 2.5 MG TABLET, 43
ONGLYZA 5 MG TABLET, 43
ONTAK, 22
OPHTHALMIC, 62
oprelvekin, 54
ORACEA, 71
ORAP, 37
ORFADIN, 46
orphenadrine 30 mg/ml vial, -60 mg/2
ml vial, 40
orphenadrine citrate tablet sustained
action, 40
orphenadrine compound, 40
orphenadrine compound forte, 40
ORTHO EVRA, 45
ORTHO TRI-CYCLEN LO, 45
ortho-est, 46
oseltamivir phosphate, 19
OTIC, 72
oxacillin 1 gm vial, 16
oxacillin 1 gm/ 50 ml inj, 16
oxacillin 10 gm vial, 16
oxacillin 2 gm/ 50 ml inj, 16
oxaliplatin, 24
oxandrolone 10 mg tablet, 41
oxandrolone 2.5 mg tablet, 41
oxaprozin, 13
oxcarbazepine, 33
OXSORALEN-ULTRA, 69
oxybutynin, 52
oxybutynin chloride er, 52
oxybutynin chloride syrup, -tablet, 53
oxycodone, 12
oxycodone hcl 5 mg tablet, -15 mg
oxycodone hcl-acetaminophen, 12
oxycodone hcl-ibuprofen, 12
oxycodone w/apap 5/325 tab, 12
oxycodone/acetaminophen, 12
oxycodone-acetaminophen capsule, oxycodon-acetaminophen 2.5-325, oxycodon-acetaminophen 7.5-325,
12
oxycodone-aspirin, 12
OXYCONTIN, 12
oxymetholone, 41
oxymorphone hcl, 12
PACERONE 100 MG TABLET, 27
pacerone 200 mg tablet, 27
paclitaxel, 22
palgic, 65
paliperidone, 37
pamidronate 30 mg/10 ml vial, -60
mg/10 ml vial, -90 mg/10 ml vial, 43
PANCREATIC ENZYMES, 51
PANCREAZE, 51
Page 94 of 103
PANRETIN, 71
pantoprazole sodium, 52
PARATHYROID HORMONES, 48
parcaine, 62
paricalcitol, 62
paromomycin sulfate, 16
paroxetine cr 12.5 mg tablet, -cr 37.5
mg tablet, -er 37.5 mg tablet, 35
paroxetine hcl 10 mg tablet, -20 mg
tablet, 35
paroxetine hcl suspension oral, -30 mg
tablet, -40 mg tablet, -cr 25 mg
tablet, 35
PASER, 18
PATADAY, 62
PATANOL, 62
pazopanib, 23
pedi-dri, 69
PEDVAXHIB, 57
pegademase bovine, 45
PEGANONE, 33
PEGASYS, 55
peginterferon alfa-2a, 55
peginterferon alfa-2b, 55, 56
PEGINTRON, 55
PEGINTRON REDIPEN, 56
pegvisomant, 48
pemetrexed disodium, 21
pen g procaine/pen g benz, 14
PEN NEEDLE, 42
penciclovir, 69
penicillin g benzathine, 14
penicillin g k 5 million unit, 16
penicillin g procaine, 16
PENICILLIN G PROCAINE, 16
penicillin g sodium, 16
penicillin v potassium, 16
PENTASA, 50
pentopak, 54
pentosan polysulfate sodium, 52
pentostatin, 21
pentoxifylline tablet sustained action,
54
PERFOROMIST, 66
perindopril erbumine, 25
periogard, 72
permethrin cream, 71
perphenazine, 37
perphenazine-amitriptyline, 40
phenadoz, 49
phenelzine, 35
phenytoin, 32
phenytoin 50 mg/ml ampul, 33
phenytoin sodium, 32
phenytoin sodium extended, 33
phenytoin suspension oral, 33
PHOSLO, 48
PHOSPHATE BINDER AGENTS, 48
PHOSPHOLINE IODIDE, 62
PHOTOFRIN, 23
pilocarpine hcl, 62
pilocarpine hcl tablet, 72
PILOPINE HS, 62
pimecrolimus, 71
pimozide, 37
pindolol, 28
pioglitazone hcl, 42
pioglitazone hcl/metformin hc, 42
pioglitazone/glimepiride, 42
piperacillin 3 gm vial, -40 gm bulk vial,
16
piperacil-tazobact 3.375 gm vl, 16
piroxicam capsule, 13
PLASMA-LYTE 148, 61
PLASMA-LYTE 148 IN DEXTROSE, 61
PLASMA-LYTE 56, 61
PLASMA-LYTE 56 IN DEXTROSE, 61
PLASMA-LYTE A PH 7.4, 61
plasma-lyte r, 61
PLATELET AGGREGATION
INHIBITORS, 55
PLATINUM COORDINATION COMPLEX,
24
Page 95 of 103
PLAVIX 300 MG TABLET, 55
PLAVIX 75 MG TABLET, 55
plerixafor, 54
podofilox, 71
poliomyelitis vac,killed, 57
poly-dex, 63
polyethylene glycol 3350, 51
polyethylene glycol 3350 packet, 51
polymyxin b sulfate injection, 20
polymyxin b sul-trimethoprim, 63
porfimer sodium, 23
portia, 45
posaconazole, 17
pot chloride/na chlor, 61
potassium chloride, 58
potassium chloride capsule sustained
action, -tablet
sust.releaseparticles/crystals, 58
potassium chloride/d10-0.25ns, 60
potassium chloride/d5w, 60, 61
POTASSIUM CHLORIDE-NACL, 61
potassium citrate tablet sustained
action, 52
potassium cl 10 meq/100 ml sol, -cl 30
meq/100 ml sol, -cl 10 meq/50 ml
sol, -cl 20 meq/50 ml sol, 61
potassium cl 2 meq/ml vial, 58
colestipol hcl granules, 28
PRADAXA, 54
pramipexole dihydrochloride, 36
pramlintide acetate, 42
PRANDIN, 43
prasugrel, 55
pravastatin sodium 10 mg tab, -20 mg
tab, -40 mg tab, 27
pravastatin sodium 80 mg tab, 27
prazosin hcl, 26
prednicarbate, 70
prednisolone, 47
prednisolone acetate suspension
drops, 64
prednisolone sod phosphate, 64
PREDNISOLONE SODIUM PHOSPHATE
DROPS, 64
prednisolone sodium phosphate
solution, 47
prednisone, 47
PREDNISONE INTENSOL, 47
prednisone solution, -tablet, 47
pregabalin, 33
pregnyl, 47
PREMARIN CREAM WITH
APPLICATOR, 46
PREMARIN INJECTION, 46
PREMARIN TABLET, 46
PREMASOL 10% IV SOLUTION, 59
premasol 6% iv solution, 59
PREMPRO, 46
prenatabs obn, 61
prevalite powder, 28
previfem, 45
PREVPAC, 51
PREZISTA 400 MG TABLET, -600 MG
TABLET, 18
PREZISTA 75 MG TABLET, -150 MG
TABLET, 18
PRIFTIN, 18
PRIMAXIN, 20
PRIMAXIN I.M., 20
primidone tablet, 33
PRISTIQ 100 MG TABLET, 35
PRISTIQ 50 MG TABLET, 35
PROAIR HFA, 66
probenecid, 10
probenecid-colchicine, 10
procainamide hcl injection, 27
PROCALAMINE, 59
procarbazine, 23
prochlorperazine edisylate, 49
prochlorperazine maleate suppository
rectal, -tablet, 49
PROCRIT 2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, -4,000
Page 96 of 103
UNITS/ML VIAL, -10,000 UNITS/ML
VIAL, 54
PROCRIT 20,000 UNITS/ML VIAL, 54
PROCRIT 40,000 UNITS/ML VIAL, 54
proctocream-hc, 69
procto-pak, 70
proctosol-hc, 69
proctozone-hc, 69
progesterone, 48
PROGESTINS, 48
PROGLYCEM, 47
PROGRAF 0.5 MG CAPSULE, -1 MG
CAPSULE, 56
PROGRAF 5 MG CAPSULE, 56
PROLEUKIN, 22
PROLIA, 43
PROMACTA, 54
promethazine 25 mg/ml syringe, -50
mg/ml vial, 49
promethazine hcl suppository rectal, syrup, -tablet, 49
promethazine vc, 66
promethegan 25 mg supp, -50 mg
suppository, 49
PROMETRIUM, 48
propafenone hcl, 27
proparacaine hcl drops, 64
propranolol hcl capsule sustained
action, -solution, -tablet, 29
propranolol hcl injection, 29
propranolol-hydrochlorothiazid, 28
propylthiouracil, 48
PROQUAD, 57
PROSOL, 59
PROTECTIVE AGENTS, 24
PROTON PUMP INHIBITOR/ANTIINFECTIVE COMBINATIONS, 51
PROTON PUMP INHIBITORS, 52
PROTOPIC, 71
protriptyline hcl, 35
PROVENTIL HFA, 66
PROVIGIL, 40
PSYCHOTHERAPEUTICMISCELLANEOUS, 40
PULMONARY ARTERIAL
HYPERTENSION, 31
PULMOZYME, 66
pyrazinamide, 18
pyridostigmine, 39
pyridostigmine bromide, 39
pyrimethamine, 17
quasense, 45
quetiapine fumarate, 37
quinapril hcl, 25
quinapril-hydrochlorothiazide, 25
quinidine gluconate injection, 27
quinidine gluconate tablet sustained
action, 27
quinidine sulfate tablet, -tablet
sustained action, 27
QVAR, 67
RABAVERT, 57
rabies vac,pf chick-emb cell, 57
rabies vaccine,human diploid, 57
raloxifene, 48
raltegravir potassium, 17
ramipril, 25
RANEXA, 31
ranitidine hcl 25 mg/ml vial, 50
ranitidine hcl capsule, -syrup, -150 mg
ranolazine, 31
RAPAMUNE, 56
rasagiline mesylate, 35
rasburicase, 24
REBETOL, 19
REBIF 22 MCG/0.5 ML SYRINGE, -44
MCG/0.5 ML SYRINGE, 39
REBIF TITRATION PACK, 39
RECLAST, 43
reclipsen, 45
RECOMBIVAX HB, 57
REGONOL, 39
REGRANEX, 72
Page 97 of 103
RELENZA, 19
RELISTOR, 51
REMICADE, 55
REMODULIN, 32
RENAGEL, 48
RENVELA, 48
repaglinide, 43
reprexain, 11
RESCRIPTOR, 18
reserpine tablet, 31
RESPIRATORY, 64
RESTASIS, 64
RETROVIR, 18
REVATIO, 32
revatio (sildenafil citrate), 32
REVLIMID, 56
REYATAZ, 18
RHEUMATREX, 55
ribapak, 19
ribasphere 400 mg tablet, -600 mg
tablet, 19
ribasphere capsule, -200 mg tablet, 19
ribavirin, 19
ribavirin capsule, -tablet, 19
rifabutin, 18
rifampin capsule, -injection, 18
rifapentine, 18
rifaximin, 51
rilonacept, 55
RILUTEK, 39
riluzole, 39
rimantadine hcl, 19
ringers injection, 61
risedronate, 43
RISPERDAL CONSTA 12.5 MG SYR, -25
MG SYR, 37
RISPERDAL CONSTA 37.5 MG SYR, -50
MG SYR, 37
risperidone, 37
risperidone 0.25 mg odt, -0.5 mg odt,
37
risperidone 0.25 mg tablet, -0.5 mg
tablet, 37
risperidone 1 mg odt, -2 mg odt, -3
mg odt, 37
risperidone 1 mg tablet, -2 mg tablet,
-3 mg tablet, 37
risperidone 4 mg odt, 37
risperidone solution, -4 mg tablet, 37
ritonavir, 18
ritonavir/lopinavir, 17
RITUXAN, 22
rituximab, 22
rivastigmine 1.5 mg cap, 34
rivastigmine 3 mg capsule, 34
rivastigmine 4.5 mg capsule, -6 mg
capsule, 34
rivastigmine tartrate, 33
rizatriptan benzoate, 38
ROBAXIN, 40
romidepsin, 22
romycin, 63
ropinirole hcl, 36
rosuvastatin calcium, 27
ROTATEQ, 57
rotavirus vac, live pentav, 57
ROXICET SOLUTION, 12
roxicet tablet, 12
rufinamide, 32
SABRIL, 33
saline 0.45% soln-excel con, -saline
0.9% soln-excel cont, -0.9%
solution, -3% iv soln, -5% iv soln,
61
salmeterol, 66
salmeterol/fluticasone, 67
SANCUSO, 49
SANDIMMUNE, 56
SANDOSTATIN LAR, 47
SANTYL, 72
SAPHRIS, 37
sapropterin dihydrochloride, 46
saquinavir mesylate, 17
Page 98 of 103
sargramostim, 54
saxagliptin hcl/metformin hcl, 42
saxagliptin hydrochloride, 43
scopolamine, 49
SELECTIVE ESTROGEN RECEPTOR
MODULATORS, 48
selegiline, 34
selegiline hcl capsule, -tablet, 36
selenium sulfide 2.5% lotion, 69
selfemra, 35
SELZENTRY, 18
SENSIPAR 30 MG TABLET, 43
SENSIPAR 60 MG TABLET, -90 MG
TABLET, 43
SEREVENT DISKUS, 66
SEROMYCIN, 18
SEROQUEL 100 MG TABLET, 37
SEROQUEL 300 MG TABLET, -400 MG
TABLET, 37
SEROQUEL XR, 37
sertraline hcl 25 mg tablet, -50 mg
tablet, 35
sertraline hcl solution, -100 mg tablet,
35
sevelamer, 48
sevelamer carbonate, 48
silver sulfadiazine cream, 68
SIMCOR, 27
simvastatin 5 mg tablet, -10 mg tablet,
-20 mg tablet, -40 mg tablet, 27
simvastatin 80 mg tablet, 27
SINGULAIR, 66
sirolimus, 56
sitagliptin phos/metformin hcl, 42
sitagliptin phosphate, 42
sodium bicarb 7.5% abboject, -7.5%
syring, -bicarb 8.4% abboject, bicarb 8.4% syringe, 58
sodium chloride 0.9% soln, 61
sodium chloride solution, 72
sodium cl 2.5 meq/ml vial, 58
sodium fluoride tablet, 58
sodium lactate injection, 61
sodium oxybate, 40
sodium phenylbutyrate, 45
sodium polystyrene sulfonate, 44
SOLARAZE, 68
solia, 45
solifenacin succinate, 53
SOLU-CORTEF (PF), 47
somatropin, 47
SOMATULINE DEPOT, 47
SOMAVERT, 48
sorafenib tosylate, 23
sorine, 27
sotalol, 27
sotret, 68
SPIRIVA, 64
spironolactone tablet, 25
spironolactone-hctz, 31
sprintec, 45
SPRYCEL, 23
sronyx, 45
ssd, 68
stagesic, 11
STALEVO 100, 36
STALEVO 125, 36
STALEVO 150, 36
STALEVO 200, 36
STALEVO 50, 36
STALEVO 75, 36
stavudine, 18
STEROID INHALANTS, 67
STEROID/BETA-AGONIST
COMBINATIONS, 67
STRATTERA, 38
streptomycin sulfate injection, 16
SUBOXONE, 40
sucralfate, 51
sucralfate tablet, 51
sulfacetamide sodium drops, 63
Page 99 of 103
sulfacetamide sodium suspension
topical, 68
sulfacetamide/prednisolone ac, 63
sulfacetamide-prednisolone, 63
sulfadiazine, 16
SULFADIAZINE, 16
sulfamethoxazole-trimethoprim, 20
sulfasalazine tablet, 50
sulfazine ec, 50
sulindac tablet, 13
sumatriptan 4 mg/0.5 ml vial, 39
sumatriptan 6 mg/0.5 ml vial, 39
sumatriptan succinate tablet, 39
sunitinib malate, 23
SUPRAX, 16
SURMONTIL, 35
SUSTIVA, 18
SUTENT, 23
SYMBICORT, 67
SYMLIN, 42
SYMLINPEN 120, 42
SYMLINPEN 60, 42
SYNAREL, 45
SYNTHROID, 48
SYPRINE, 44
TABLOID, 21
tacrolimus, 56, 71
tacrolimus 0.5 mg capsule, -1 mg
capsule, 56
tacrolimus 5 mg capsule, 56
TAMIFLU 30 MG GELCAP, 19
TAMIFLU 45 MG GELCAP, -75 MG
GELCAP, 19
TAMIFLU SUSPENSION, 19
tamoxifen citrate tablet, 23
tamsulosin hcl, 52
TARCEVA, 23
TARGRETIN CAPSULE, 23
TARGRETIN GEL, 71
TASIGNA, 23
TAXOTERE, 22
tazarotene, 69
TAZORAC, 69
taztia xt, 29
TEGRETOL XR, 33
TEKAMLO, 30
TEKTURNA 150 MG TABLET, 30
TEKTURNA 300 MG TABLET, 30
TEKTURNA HCT, 30
telbivudine, 19
tenofovir disproxil fumarate, 18
terazosin hcl, 26
terbinafine hcl, 17
terbutaline sulfate injection, 66
terbutaline sulfate tablet, 66
terconazole, 53
teriparatide, 48
TESTIM, 41
testosterone, 41
testosterone cyp 100 mg/ml, 41
testosterone enanthate, 41
TETANUS DIPHTHERIA TOXOIDS, 57
TETANUS TOXOID ADSORBED, 57
tetanus toxoid,adsorbed, 57
tetanus,diphtheria toxoid, 57
TETANUS-DIPHTERIA-DECAVAC, 57
tetrabenazine, 39
tetracycline hcl capsule, 16
thalidomide, 56
THALOMID, 56
THEO-24, 67
theochron er 100 mg tablet, -er 300
mg tablet, 67
theophylline, 67
theophylline anhydrous tablet
theophylline tablet sustained action,
67
thermazene, 68
thioguanine, 21
thioridazine hcl, 37
thiothixene, 38
THYROID AGENTS, 48
tiagabine, 32
Page 100 of 103
ticlopidine hcl, 55
tigecycline, 20
TIKOSYN, 27
timolol, 62
timolol maleate drops, -gel-forming
solution, 62
timolol maleate tablet, 29
tiotropium bromide, 64
tipranavir, 17
tizanidine hcl tablet, 40
TOBI, 66
tobramycin, 63
tobramycin 10 mg/ml vial, -40 mg/ml
vial, 16
tobramycin sulfate drops, 63
tobramycin sulfate in ns, 14
tobramycin/sodium chloride, 66
tobramycin-dexamethasone, 63
tobrasol, 63
TOBREX, 63
tocilizumab, 55
tolazamide, 43
tolbutamide, 43
tolmetin sodium, 13
tolterodine tartrate, 52
TOPICAL, 67
topiramate capsule sprinkle, -tablet, 33
TOPOISOMERASE INHIBITORS, 24
toposar, 24
topotecan hcl, 24
toremifene, 22
torsemide, 31
TORSEMIDE INJECTION, 31
torsemide tablet, 31
tpn electrolytes, 58
TRACLEER, 32
tramadol hcl tablet, 12
tramadol hcl tablet sustained release
24hr, 12
tramadol hcl-acetaminophen, 12
trandolapril, 25
tranexamic acid, 54
TRANSDERM-SCOP, 49
tranylcypromine sulfate, 35
trastuzumab, 22
TRAVASOL, 59
TRAVATAN Z, 62
travoprost, 62
trazodone hcl tablet, 35
TREANDA, 21
TRECATOR, 18
TRELSTAR, 23
treprostinil sodium, 32
tretinoin 0.025% cream, -0.05%
cream, -0.1% cream, -gel, 68
tretinoin capsule, 23
triamcinolone acetonide, 66
triamcinolone acetonide cream, -lotion,
-ointment, 70
triamcinolone acetonide paste, 72
triamterene-hctz, 31
triamterene-hydrochlorothiazid, 31
TRIBENZOR, 26
TRICOR, 28
triderm, 70
trientine, 44
trifluoperazine hcl, 38
trifluridine, 63
trihexyphenidyl hcl, 36
tri-legest fe, 45
TRILIPIX, 28
trilyte with flavor packets, 51
trimethobenzamide hcl capsule, injection, 49
trimethoprim tablet, 20
trimipramine, 35
trinessa, 45
TRIPEDIA, 57
tri-previfem, 45
triptorelin pamoate, 23
TRISENOX, 23
tri-sprintec, 45
trivora-28, 45
TRIZIVIR, 18
Page 101 of 103
TROPHAMINE, 59
tropicamide drops, 63
trospium chloride, 53
TRUVADA, 18
TWINRIX, 57
TYGACIL, 20
TYKERB, 23
TYPHIM VI, 57
typhoid vaccine, 57
TYZEKA, 19
ULORIC, 10
unithroid, 48
URINARY ANTISPASMODICS, 52
UROXATRAL, 52
ursodiol capsule, -tablet, 51
VACCINES, 56
VAGIFEM, 46
VAGINAL ANTI-INFECTIVES, 53
valacyclovir, 19
VALCYTE, 19
valganciclovir, 19
valproate sodium injection, 33
valproic acid capsule, -syrup, 33
valsartan, 26
VALTURNA 150-160 MG TABLET, 30
VALTURNA 300-320 MG TABLET, 30
VANCOCIN HCL, 20
vancomycin, 20
vancomycin 1 gm vial, -10 gm vial, 20
VANCOMYCIN 500 MG A/V VIAL, 20
vandazole, 53
VAQTA, 57
varenicline tartrate, 40
varicella vacc/pf, 57
varicella virus vaccine live, 57
VARIVAX VACCINE, 57
VASOPRESSINS, 48
velaglucerase alfa, 46
VELCADE, 22
velivet, 45
venlafaxine hcl, 35
venlafaxine hcl er 150 mg cap, 35
venlafaxine hcl er 37.5 mg cap, -75
mg cap, 35
VENTOLIN HFA, 66
VERAMYST, 67
verapamil 2.5 mg/ml ampul, 29
verapamil er, 30
verapamil er pm, 30
verapamil hcl tablet, -tablet sustained
action, 30
veripred 20, 47
VESICARE 10 MG TABLET, 53
VESICARE 5 MG TABLET, 53
VFEND IV, 17
VFEND SUSPENSION, 17
VFEND TABLET, 17
vicodin hp, 11
VICTOZA 3-PAK, 42
VIDAZA, 21
VIDEX, 18
vigabatrin, 33
VIGAMOX, 63
VIMOVO, 13
VIMPAT INJECTION, 33
VIMPAT SOLUTION, -TABLET, 33
vinblastine, 22
VINBLASTINE SULFATE, 22
vincristine 1 mg/ml vial, 22
vinorelbine 50 mg/5 ml vial, 22
VIRACEPT, 18
VIRAMUNE, 18
VIREAD, 18
VITAMINS, 61
VIVELLE-DOT, 46
VOLTAREN, 71
voriconazole, 17
vorinostat, 22
VOTRIENT, 23
VPRIV, 46
VYTORIN, 27
warfarin sodium, 53
warfarin sodium tablet, 54
WELCHOL, 28
Page 102 of 103
XANTHINES, 67
XENAZINE, 39
XIFAXAN, 51
XOLAIR, 66
XYREM, 40
yellow fever vaccine, 57
YF-VAX, 57
zafirlukast, 66
zaleplon, 38
zamicet, 11
zanamivir, 19
ZAVESCA, 46
zazole 0.8% vaginal cream, 53
zazole vaginal 0.4% cream, 53
ZEMPLAR CAPSULE, 62
ZEMPLAR INJECTION, 62
ZENPEP, 51
zeosa, 45
ZETIA, 27
ZIAGEN, 18
zidovudine, 18
zidovudine/lamivudine/abacavir, 18
ziprasidone, 36
zoledronic acid, 43
ZOLINZA, 22
zolpidem tartrate tablet, 38
zolpidem tartrate tablet multiphasic
release, 38
ZOMETA, 43
ZONALON, 69
zonisamide, 33
ZORTRESS 0.25 MG TABLET, -0.5 MG
TABLET, 56
ZORTRESS 0.75 MG TABLET, 56
ZOSTAVAX, 57
zovia 1-35e, 45
zovia 1-50e, 45
ZOVIRAX, 69
ZYCLARA, 71
ZYMAR, 63
ZYMAXID, 63
ZYPREXA 10 MG TABLET, -15 MG
ZYPREXA 2.5 MG TABLET, -7.5 MG
TABLET, 38
ZYPREXA INJECTION, 38
ZYPREXA ZYDIS 10 MG TABLET, -15
MG TABLET, -20 MG TABLET, 38
ZYPREXA ZYDIS 5 MG TABLET, 38
ZYVOX, 20
Page 103 of 103
55 Water Street, New York, New York 10041-8190 | www.emblemhealth.com
MEDICARE PART D
DRUG FORMULARY
2012 EmblemHealth PPO Medicare, HMO Medicare,
Prescription Drug Plan (PDP)
Comprehensive Medication List
Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance
Company of New York and EmblemHealth Services Company, LLC are EmblemHealth
companies. EmblemHealth Services Company, LLC provides administrative services
to the EmblemHealth companies.
86-9018 8/11
359583_Cover_v1.indd 1
8/16/11 6:28 PM

medicare part d drug formulary

Transcription

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