English - Easy Choice Health Plan

Transcription

2016
COMPREHENSIVE FORMULARY
(LIST OF COVERED DRUGS)
MEDICARE ADVANTAGE PLANS
Please Read: This document contains
information about the drugs we
cover in this plan.
This formulary was updated
on 10/01/2016. For more recent
information or other questions,
please contact WellCare/‘Ohana/
Easy Choice at the telephone number
listed on the inside front and back
covers of this formulary or visit
www.wellcare.com/medicare or
www.ohanahealthplan.com/medicare
or www.easychoicehealthplan.com.
WELLCARE/‘OHANA/EASY CHOICE
WellCare/Easy Choice Access (HMO SNP),
WellCare Choice (HMO/HMO-POS), WellCare
Dividend (HMO/HMO-POS), WellCare Essential
(HMO/HMO-POS), WellCare/‘Ohana Liberty
(HMO SNP), WellCare Reserve (HMO), WellCare
Rx (HMO), WellCare Select (HMO SNP),
WellCare/‘Ohana Value (HMO/HMO-POS)
Y0070_NA029587_WCM_FOR_ENG_FINAL_02 CMS Approved 07202015
©WellCare 2016 NA_10_16
HPMS Approved
Formulary File
Submission ID: 16187
Version Number: 15
NA6V02FOR73846E_1016
We’re always just a phone call away!
If you’re ready to enroll or have enrollment questions, call: In all states except California: 1-866-527-0057 – In California: 1-866-999-3945
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Representatives are available from 8 a.m. to 8 p.m., 7 days a week.
If you’re already a member, call the number for your state/plan listed below.
Arkansas:
All Plans ............................................................................................... 1-800-316-2273
California:
Easy Choice Access Plan (HMO-SNP) ................................... 1-866-999-3945
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Connecticut:
WellCare Access (HMO SNP).................................................... 1-866-635-7047
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WellCare Rx or Value (HMO) .................................................... 1-866-579-8006
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Florida:
WellCare Access, Liberty or Select (HMO SNP) .............. 1-866-637-8041
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WellCare Dividend, Essential, Reserve, Rx or
Value (HMO/HMO-POS) ............................................................ 1-888-888-9355
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Georgia:
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Hawai‘i:
Illinois:
Kentucky:
Louisiana:
Mississippi:
New Jersey:
New York:
South Carolina:
‘Ohana Liberty (HMO SNP)........................................................ 1-877-457-7621
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‘Ohana Value (HMO-POS).......................................................... 1-888-505-1201
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WellCare Choice, Rx or Value (HMO/HMO-POS) .......... 1-866-334-6876
WellCare Access (HMO SNP)................................................... 1-877-560-3206
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WellCare Value (HMO-POS)..................................................... 1-877-560-2766
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WellCare Essential or Value (HMO)........................................ 1-866-804-5926
All Plans ............................................................................................... 1-800-316-2273
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WellCare Liberty (HMO SNP) ................................................... 1-877-706-9509
WellCare Value (HMO)................................................................. 1-866-687-8570
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All Plans ............................................................................................... 1-800-316-2273
Tennessee:
All Plans ............................................................................................... 1-800-316-2273
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Texas:
WellCare Dividend, Essential or
Value (HMO/HMO-POS) ............................................................ 1-866-687-8878
Hours of operation are Monday–Friday, 8 a.m. to 8 p.m. Between October 1 and February 14,
representatives are available Monday–Sunday, 8 a.m. to 8 p.m., or visit us anytime at
www.wellcare.com/medicare, www.ohanahealthplan.com/medicare or
www.easychoicehealthplan.com
Nurse Advice Line..................................................................... 1-800-581-9952 (24 hours, 7 days a week)
TTY for all of the above except California: .......................................................................1-877-247-6272
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TTY for California:..........................................................................................................................1-800-735-2929
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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. When this drug list (formulary)
refers to “we,” “us” or “our,” it means WellCare/‘Ohana/Easy Choice. When it refers to “plan” or
“our plan,” it means 2016 WellCare/‘Ohana/Easy Choice.
This document includes a list of the drugs (formulary) for our plan which is current as of
10/01/2016. For an updated formulary, please contact us. Our contact information along with
the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits,
formulary, pharmacy network, premium and/or co-payments/coinsurance may change on
January 1, 2017, and from time to time during the year.
WHAT IS THE WELLCARE/EASY CHOICE ACCESS (HMO SNP), WELLCARE CHOICE (HMO/
HMO-POS), WELLCARE DIVIDEND (HMO/HMO-POS), WELLCARE ESSENTIAL (HMO/HMO
POS), WELLCARE/‘OHANA LIBERTY (HMO SNP), WELLCARE RESERVE (HMO), WELLCARE
RX (HMO), WELLCARE SELECT (HMO SNP), WELLCARE/‘OHANA VALUE (HMO/HMO-POS)
COMPREHENSIVE FORMULARY?
A formulary is a list of covered drugs. WellCare/‘Ohana/Easy Choice selects the drugs by
working with a team of health care providers. The list contains the prescription medications we
believe are a necessary part of a quality treatment program. WellCare/‘Ohana/Easy Choice will
generally cover the drugs listed in our formulary as long as:
1. the drug is medically necessary,
2. the prescription is filled at a WellCare/‘Ohana/Easy Choice network pharmacy, and
3. other plan rules are followed.
For more information on how to fill your prescriptions, please see your Evidence of Coverage.
CAN THE FORMULARY (DRUG LIST) CHANGE?
In general, if you are taking a drug on our 2016 formulary that was covered at the beginning
of the year, we will not stop or reduce coverage of the drug during the 2016 coverage year.
However, there are some cases when we may stop or reduce coverage. These are:
• when a new, less expensive generic drug becomes available or
• when new negative 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. For those members, it will remain available at
the same cost share for the remainder of the coverage year. We think it’s important that you
can continue to get the formulary drugs that were available when you chose our plan for
the remainder of the coverage year. The only exceptions are for cases in which you can save
additional money or we can ensure your safety.
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When we make certain changes to our formulary, we must notify the members who will be
affected by the changes. This includes if we:
• remove drugs from our formulary;
• add restrictions on a drug such as prior authorization, quantity limits and/or step therapy;
• move a drug to a higher cost-sharing tier.
If we make any of these changes, we must notify affected members at least 60 days before the
change goes into effect. We will also notify the member at the time he or she asks for a refill
of the drug. In that case, the member will receive a 60-day supply of the drug.
If the Food and Drug Administration announces that a drug on our formulary is unsafe, or a
drug manufacturer removes a drug from the market, we will immediately remove the drug from
our formulary and notify members who take the drug.
The enclosed formulary is current as of 10/01/2016. To get updated information about the drugs
covered by WellCare/‘Ohana/Easy Choice, please visit our website at www.wellcare.com/
medicare or www.ohanahealthplan.com/medicare or www.easychoicehealthplan.com or call
Customer Service at the telephone number listed for your state/plan on the inside front and
back cover pages of this formulary.
Every month, our printed comprehensive formulary will be updated. Please contact Customer
Service or visit our website at www.wellcare.com/medicare or www.ohanahealthplan.com/
medicare or www.easychoicehealthplan.com for more information.
HOW DO I USE THE FORMULARY?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. 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 1.
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 85. 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.
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WHAT ARE GENERIC DRUGS?
WellCare/‘Ohana/Easy Choice 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: WellCare/‘Ohana/Easy Choice requires you or your physician to get
prior authorization for certain drugs. This means that you will need to get approval from us
before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
•�Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For
example, WellCare/‘Ohana/Easy Choice provides 18 tablets for 30 days per prescription for
rizatriptan 5mg. This may be in addition to a standard one-month or three-month supply.
•�Step Therapy: In some cases, WellCare/‘Ohana/Easy Choice 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, we may not cover
Drug B unless you try Drug A first. If Drug A does not work for you, we 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 1. You can also get more information about the restrictions
applied to specific covered drugs by visiting our website at www.wellcare.com/medicare or
www.ohanahealthplan.com/medicare or www.easychoicehealthplan.com. We have posted
online documents that explain our prior authorization restriction and step therapy restrictions.
You may also ask us to send you a copy. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
You can ask WellCare/‘Ohana/Easy Choice to make an exception to these restrictions or limits,
or for a list of other, similar drugs that may treat your health condition. See the section, “How
do I request an exception to the WellCare/‘Ohana/Easy Choice formulary?” on page IV 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 (list of covered drugs), you should first contact
Customer Service and ask if your drug is covered. You can contact Customer Service at the
telephone number listed for your state/plan on the inside front and back covers of this
formulary.
If you learn that WellCare/‘Ohana/Easy Choice does not cover your drug, you have two
options:
• You can ask Customer Service for a list of similar drugs that are covered by
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WellCare/‘Ohana/Easy Choice. When you receive the list, show it to your doctor and ask
him or her to prescribe a similar drug that is covered by WellCare/‘Ohana/Easy Choice.
• You can ask WellCare/‘Ohana/Easy Choice to make an exception and cover your drug. See
below for information about how to request an exception.
WHICH VACCINES DO WE COVER?
Your prescription benefit may cover many vaccines. For details, see the Immunological Agents
section. The cost for vaccines varies, depending on the facility where you receive them. For
best coverage, use a network pharmacy.
All commercially available vaccines are covered under Part D, except for those that are covered
under Medicare Part B, such as influenza or pneumococcal vaccines.
HOW DO I REQUEST AN EXCEPTION TO THE WELLCARE/EASY CHOICE ACCESS (HMO SNP),
WELLCARE CHOICE (HMO/HMO-POS), WELLCARE DIVIDEND (HMO/HMO-POS), WELLCARE
ESSENTIAL (HMO/HMO-POS), WELLCARE/‘OHANA LIBERTY (HMO SNP), WELLCARE RESERVE
(HMO), WELLCARE RX (HMO), WELLCARE SELECT (HMO SNP), WELLCARE/‘OHANA VALUE
(HMO/HMO-POS) FORMULARY?
You can ask WellCare/‘Ohana/Easy Choice to make an exception to our coverage rules. There
are several types of formulary exceptions that you can ask us to make.
Initial Coverage Decision Exception
You can ask us to cover your drug even if it is not on our formulary. If your request is approved,
the drug will be covered at a pre-determined cost-sharing level. You would not be able to ask
us to provide the drug at a lower cost-sharing level.
Utilization Restriction Exception
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain
drugs, the amount of the drug that we cover is limited. If your drug has a quantity limit, you can
ask us to waive the limit and cover a greater amount.
Tiering Exception
You can ask us to cover a formulary drug at a lower cost-sharing level if the drug is not on the
preferred generic, preferred brand or specialty tier. If approved, this would lower the amount
you must pay for your drug.
Generally, WellCare/‘Ohana/Easy Choice will only approve your request for an exception if:
• the alternative drugs included on the plan’s formulary would not be as effective in treating
your condition;
• the lower cost-sharing drug would not be as effective in treating your condition;
• the additional utilization restrictions would not be as effective in treating your condition
and/or;
• the alternative drugs would cause you to have adverse medical effects.
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You should contact us to ask us for a formulary exception for an initial coverage decision,
a tiering exception or a utilization restriction exception. When you request any of these
exceptions, you should submit a statement from your prescriber or physician supporting
your request. Generally, we must make our decision within 72 hours of getting your 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 for a fast review 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 30-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 a 93-day transition supply that meets the dispensing instructions
(unless you have a prescription written for fewer days). We will cover more than one refill of
these drugs for the first 93 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 93 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 seek a formulary exception.
If you experience a level of care change (such as being discharged or admitted to a long-term
care facility), your physician or pharmacy can call our Provider Service Center and request a
one-time override. This one-time override will be up to a 31-day supply (unless you have a
prescription written for fewer days).
FOR MORE INFORMATION
For more details about your WellCare/‘Ohana/Easy Choice prescription drug coverage, please
review your Evidence of Coverage and other plan materials.
If you have questions about WellCare/‘Ohana/Easy Choice, please contact us. Our contact
information, along with the date we last updated the formulary, is on the inside front and back
covers of this document. Or visit www.wellcare.com/medicare or www.ohanahealthplan.com/
medicare or www.easychoicehealthplan.com.
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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 users should call
1-877-486-2048. Or visit www.medicare.gov.
WELLCARE/‘OHANA/EASY CHOICE FORMULARY
The comprehensive formulary that begins on page 1 provides coverage information about the
drugs covered by WellCare/‘Ohana/Easy Choice. If you have trouble finding your drug in the
list, turn to the Index that begins on page 85.
The first column of the chart lists the drug name. Brand-name drugs are UPPERCASE (e.g.,
COUMADIN) and generic drugs are listed in lowercase italics (e.g., simvastatin).
The information in the Requirements/Limits column tells you if WellCare/‘Ohana/Easy Choice
has any special requirements for coverage of your drug.
•�NM means the drug is not available via your monthly mail service benefit. This is noted in
the Requirements/Limits column of your formulary. You may be able to receive more than
one month’s supply of most of the drugs on your formulary via mail service at a reduced
cost share. Please see Chapter 5 of your Evidence of Coverage for more information.**
• PA stands for Prior Authorization: Please see page III for details.
• B/D stands for Covered under Medicare B or D: This drug may be eligible for payment
under Medicare Part B or Part D. You (or your physician) are required to get prior
authorization from WellCare/‘Ohana/Easy Choice to determine that this drug is covered
under Medicare Part D before you fill your prescription for this drug. Without prior
approval, WellCare/‘Ohana/Easy Choice may not cover this drug.
• QL stands for Quantity Limits: Please see page III for details.
• LA stands for Limited Access medication. This medication may be available from certain
other pharmacies. For more information, please refer to the Specialty Pharmacy section of
your Pharmacy Directory or contact Customer Service at the telephone number listed for
your state/plan on the inside front and back cover pages of this formulary.
• ST stands for Step Therapy: Please see page III for details.
• ^ = Drug may be available for up to a 30-day supply only.
** You have the choice to sign up for automated mail service delivery. You can get prescription
drugs shipped to your home through our network mail service delivery program. You should
expect to receive your prescription drugs within 7–10 business days from the time that the mail
service pharmacy receives the order. If you do not receive your prescription drugs within this
time, please contact us at the telephone number listed on the inside front and back covers of
this formulary or visit www.wellcare.com/medicare or www.ohanahealthplan.com/medicare
or www.easychoicehealthplan.com.
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DRUG TIER CO-PAYMENT/COINSURANCE AMOUNTS
The WellCare/‘Ohana/Easy Choice formulary is divided into five tiers.
• Tier 1: Preferred Generic Drugs – Drugs that are available at the lowest cost share for this plan.
• Tier 2: Generic Drugs – Drugs that WellCare/‘Ohana/Easy Choice offers at a higher cost to
you than preferred generics.
• Tier 3: Preferred Brand Drugs – Drugs that WellCare/‘Ohana/Easy Choice may be able to
offer at a lower cost to you than non-preferred brand drugs.
• Tier 4: Non-Preferred Brand Drugs – Drugs that WellCare/‘Ohana/Easy Choice offers at a
higher cost to you than preferred brands.
• Tier 5: Specialty Drugs – Some injectables and other high-cost drugs. ^ Indicates specialty
drugs are available for up to a 30-day supply only.
Brand drugs may be available in Tiers 3, 4 and 5. Generic drugs are available in all Tiers.
Consult your Evidence of Coverage or Summary of Benefits for your applicable co-pays/
coinsurance and deductible amounts.
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HOW TO READ FORMULARY LISTINGS:
Drug Name
Drug Tier
CENTRAL NERVOUS SYSTEM
ANTICONVULSANTS
BANZEL TAB 200MG
BANZEL TAB 400MG
carbamazepine cap sr 12hr 100 mg
carbamazepine cap sr 12hr 200 mg
Requirements/Limits
Therapeutic
TherapeuticCategory
Category
Therapeutic Class
Therapeutic
Class
4_
5^
4 ___
4
PA
PA
Tier of Drug
^ = Drug may be available for
up to a 30-day supply only
Name of Drug
UPPERCASE = Brand Drugs
lowercase italics = Generic Drugs
Requirements/Limits Codes:
LA = Limited Access
NM = Not Available by Mail Service
PA = Prior Authorization
B/D = Covered under Medicare B or D
QL = Quantity Limits
ST = Step Therapy
g
u
r
d
r
u
o
y
d
F in
e
qu ickly i n t h
e
I n d e x at t h o k.
bo
ba ck o f t h e
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Drug Name
Drug
Tier
Requirements / Limits
ANALGESICS
GOUT
allopurinol oral tablet 100 mg, 300 mg
1
colchicine-probenecid oral tablet 0.5-500 mg
3
COLCRYS ORAL TABLET 0.6 MG
3
probenecid oral tablet 500 mg
3
ULORIC ORAL TABLET 40 MG, 80 MG
NSAIDS
3
ST
celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg
4
QL (60 EA per 30 days)
diclofenac potassium oral tablet 50 mg
2
diclofenac sodium er oral tablet extended release 24 hr*
100 mg
3
diclofenac sodium oral tablet delayed release 25 mg, 50
mg, 75 mg
2
diflunisal oral tablet 500 mg
3
etodolac er oral tablet extended release 24 hr* 400 mg,
500 mg, 600 mg
2
etodolac oral capsule 200 mg, 300 mg
2
etodolac oral tablet 400 mg, 500 mg
2
flurbiprofen oral tablet 100 mg, 50 mg
2
ibuprofen oral suspension 100 mg/5ml
3
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
1
ketoprofen oral capsule 50 mg, 75 mg
2
meloxicam oral tablet 15 mg, 7.5 mg
1
nabumetone oral tablet 500 mg, 750 mg
2
naproxen dr oral tablet delayed release 375 mg, 500 mg
2
naproxen oral suspension 125 mg/5ml
3
naproxen oral tablet 250 mg, 375 mg, 500 mg
1
naproxen sodium oral tablet 275 mg, 550 mg
1
sulindac oral tablet 150 mg, 200 mg
2
You can find information on what the symbols and abbreviations in this table mean by going to page VIII.
1
Drug Name
Drug
Tier
OPIOID ANALGESICS, CII
DURAMORPH INJECTION SOLUTION 0.5 MG/ML, 1
MG/ML
3
B/D
endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg
3
fentanyl citrate buccal lollipop 1200 mcg, 1600 mcg,
200 mcg, 400 mcg, 600 mcg, 800 mcg
fentanyl transdermal patch 72 hr 100 mcg/hr, 12
mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
5^
4
PA; QL (120 EA per 30 days)
FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400
MCG, 600 MCG, 800 MCG
5^
hydrocodone-acetaminophen oral solution 7.5-325
mg/15ml
4
QL (5400 ML per 30 days)
hydrocodone-acetaminophen oral tablet 10-325 mg,
5-325 mg, 7.5-325 mg
2
hydrocodone-ibuprofen oral tablet 7.5-200 mg
3
hydromorphone hcl oral liquid† 1 mg/ml
4
hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg
3
hydromorphone hcl pf injection solution 500 mg/50ml
4
B/D
lorcet hd oral tablet 10-325 mg
2
lorcet oral tablet 5-325 mg
2
lorcet plus oral tablet 7.5-325 mg
2
lortab oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg
2
methadone hcl intensol oral concentrate 10 mg/ml
3
methadone hcl oral solution 10 mg/5ml, 5 mg/5ml
3
methadone hcl oral tablet 10 mg, 5 mg
2
MORPHINE SULFATE (CONCENTRATE) ORAL SOLUTION
100 MG/5ML
3
morphine sulfate (pf) injection solution 0.5 mg/ml, 1
mg/ml
3
B/D
MORPHINE SULFATE (PF) INTRAVENOUS* SOLUTION 10
MG/ML, 15 MG/ML, 2 MG/ML, 4 MG/ML, 8 MG/ML
3
B/D
morphine sulfate er beads oral capsule extended release
24 hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg
4
2
Drug Name
Drug
Tier
morphine sulfate er oral capsule extended release 24
hour 10 mg, 20 mg, 30 mg, 50 mg, 60 mg
4
morphine sulfate er oral capsule extended release 24
hour 100 mg, 80 mg
5^
morphine sulfate er oral tablet extendedrelease* 100
mg, 15 mg, 30 mg, 60 mg
4
morphine sulfate er oral tablet extendedrelease* 200 mg
4
MORPHINE SULFATE INTRAVENOUS* SOLUTION 1
MG/ML
3
B/D
MORPHINE SULFATE ORAL SOLUTION 10 MG/5ML, 20
MG/5ML
3
MORPHINE SULFATE ORAL TABLET 15 MG, 30 MG
3
OPANA ER ORAL 10 MG, 15 MG, 20 MG, 30 MG, 40 MG,
5 MG, 7.5 MG
3
oxycodone hcl oral capsule 5 mg
4
OXYCODONE HCL ORAL SOLUTION 5 MG/5ML
4
oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg,
5 mg
3
oxycodone-acetaminophen oral solution 5-325 mg/5ml
3
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 5-325 mg, 7.5-325 mg
3
roxicet oral tablet 5-325 mg
OPIOID ANALGESICS
3
acetaminophen-codeine #2 oral tablet 300-15 mg
2
2
2
acetaminophen-codeine oral solution 120-12 mg/5ml
2
nalbuphine hcl injection solution 10 mg/ml, 20 mg/ml
4
tramadol hcl oral tablet 50 mg
ANESTHETICS
2
lidocaine hcl (pf) injection solution 0.5 %, 1 %
2
B/D
lidocaine hcl injection solution 0.5 %, 1 %, 1.5 %, 2 %
2
B/D
LOCAL ANESTHETICS
3
Drug Name
Drug
Tier
ANTI-INFECTIVES
ANTI-BACTERIALS - MISCELLANEOUS
amikacin sulfate injection solution 1 gm/4ml, 500
mg/2ml
3
gentamicin in saline intravenous* solution 0.8-0.9
mg/ml-%, 0.9-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9
mg/ml-%, 1.4-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9
mg/ml-%
2
gentamicin sulfate injection solution 10 mg/ml, 40
mg/ml
2
gentamicin sulfate intravenous* solution 10 mg/ml
2
neomycin sulfate oral tablet 500 mg
3
paromomycin sulfate oral capsule 250 mg
4
streptomycin sulfate intramuscular* solution
reconstituted 1 gm
4
sulfadiazine oral tablet 500 mg
4
tobramycin inhalation nebulization solution 300 mg/5ml
tobramycin sulfate injection solution 1.2 gm/30ml, 10
mg/ml, 2 gm/50ml, 80 mg/2ml
tobramycin sulfate injection solution reconstituted 1.2
gm
ANTIFUNGALS
5^
B/D
3
4
ABELCET INTRAVENOUS* SUSPENSION 5 MG/ML
5^
B/D
AMBISOME INTRAVENOUS* SUSPENSION
RECONSTITUTED 50 MG
5^
B/D
amphotericin b injection solution reconstituted 50 mg
4
B/D
CANCIDAS INTRAVENOUS* SOLUTION RECONSTITUTED
50 MG, 70 MG
5^
fluconazole in dextrose intravenous* solution 200
mg/100ml, 400 mg/200ml
3
fluconazole in sodium chloride intravenous* solution
100-0.9 mg/50ml-%, 200-0.9 mg/100ml-%, 400-0.9
mg/200ml-%
3
4
Drug Name
Drug
Tier
fluconazole oral suspension reconstituted 10 mg/ml, 40
mg/ml
3
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg
2
flucytosine oral capsule 250 mg, 500 mg
5^
griseofulvin microsize oral suspension 125 mg/5ml
3
griseofulvin microsize oral tablet 500 mg
4
griseofulvin ultramicrosize oral tablet 125 mg, 250 mg
4
itraconazole oral capsule 100 mg
4
PA
ketoconazole oral tablet 200 mg
3
PA
MYCAMINE INTRAVENOUS* SOLUTION RECONSTITUTED
100 MG, 50 MG
5^
NOXAFIL ORAL SUSPENSION 40 MG/ML
5^
NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG
5^
nystatin oral tablet 500000 unit
3
terbinafine hcl oral tablet 250 mg
2
voriconazole intravenous* solution reconstituted 200 mg
4
voriconazole oral suspension reconstituted 40 mg/ml
5^
voriconazole oral tablet 200 mg, 50 mg
ANTI-INFECTIVES - MISCELLANEOUS
5^
ALBENZA ORAL TABLET 200 MG
4
ALINIA ORAL SUSPENSION RECONSTITUTED 100
MG/5ML
4
ALINIA ORAL TABLET 500 MG
4
atovaquone oral suspension 750 mg/5ml
5^
aztreonam injection solution reconstituted 1 gm, 2 gm
3
BILTRICIDE ORAL TABLET 600 MG
3
CAYSTON INHALATION SOLUTION RECONSTITUTED 75
MG
5^
clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg
1
clindamycin palmitate hcl oral solution reconstituted 75
mg/5ml
4
PA; LA
clindamycin phosphate in d5w intravenous* solution
3
300 mg/50ml, 600 mg/50ml, 900 mg/50ml
5
Drug Name
Drug
Tier
clindamycin phosphate injection solution 300 mg/2ml,
600 mg/4ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml
2
clindamycin phosphate intravenous* solution 300
mg/2ml, 600 mg/4ml, 900 mg/6ml
2
colistimethate sodium injection solution reconstituted
150 mg
4
CUBICIN INTRAVENOUS* SOLUTION RECONSTITUTED
500 MG
5^
dapsone oral tablet 100 mg, 25 mg
3
DARAPRIM ORAL TABLET 25 MG
4
emverm oral tablet chewable 100 mg
4
imipenem-cilastatin intravenous* solution reconstituted
250 mg, 500 mg
4
INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM
4
INVANZ INTRAVENOUS* SOLUTION RECONSTITUTED 1
GM
4
ivermectin oral tablet 3 mg
3
LINEZOLID IN SODIUM CHLORIDE INTRAVENOUS*
SOLUTION 600-0.9 MG/300ML-%
5^
linezolid intravenous* solution 600 mg/300ml
5^
LINEZOLID ORAL SUSPENSION RECONSTITUTED 100
MG/5ML
5^
LINEZOLID ORAL TABLET 600 MG
5^
meropenem intravenous* solution reconstituted 1 gm,
500 mg
4
methenamine hippurate oral tablet 1 gm
3
metronidazole in nacl intravenous* solution 500-0.79
mg/100ml-%
2
metronidazole oral tablet 250 mg, 500 mg
2
NEBUPENT INHALATION SOLUTION RECONSTITUTED
300 MG
4
B/D
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg
4
PA
nitrofurantoin monohyd macro oral capsule 100 mg
4
PA
nitrofurantoin oral capsule 100 mg
4
PA
6
Drug Name
Drug
Tier
PENTAM INJECTION SOLUTION RECONSTITUTED 300
MG
4
SIVEXTRO INTRAVENOUS* SOLUTION RECONSTITUTED
200 MG
5^
SIVEXTRO ORAL TABLET 200 MG
5^
sulfamethoxazole-trimethoprim intravenous* solution
400-80 mg/5ml
4
sulfamethoxazole-trimethoprim oral suspension 200-40
mg/5ml
3
sulfamethoxazole-trimethoprim oral tablet 400-80 mg,
800-160 mg
1
SYNERCID INTRAVENOUS* SOLUTION RECONSTITUTED
150-350 MG
5^
trimethoprim oral tablet 100 mg
2
TYGACIL INTRAVENOUS* SOLUTION RECONSTITUTED 50
MG
5^
VANCOMYCIN HCL IN NACL INTRAVENOUS* SOLUTION
1-0.9 GM/200ML-%, 500-0.9 MG/100ML-%, 750-0.9
MG/150ML-%
4
vancomycin hcl intravenous* solution reconstituted 10
gm, 1000 mg, 500 mg, 5000 mg, 750 mg
3
vancomycin hcl oral capsule 125 mg, 250 mg
5^
ZYVOX ORAL TABLET 600 MG
ANTIMALARIALS
5^
atovaquone-proguanil hcl oral tablet 250-100 mg,
62.5-25 mg
4
chloroquine phosphate oral tablet 250 mg, 500 mg
3
COARTEM ORAL TABLET 20-120 MG
4
mefloquine hcl oral tablet 250 mg
3
PRIMAQUINE PHOSPHATE ORAL TABLET 26.3 MG
3
quinine sulfate oral capsule 324 mg
ANTIRETROVIRAL AGENTS
4
abacavir sulfate oral tablet 300 mg
3
PA
APTIVUS ORAL CAPSULE 250 MG
5^
7
Drug Name
Drug
Tier
APTIVUS ORAL SOLUTION 100 MG/ML
5^
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
4
didanosine oral capsule delayed release 125 mg, 200
mg, 250 mg, 400 mg
4
EDURANT ORAL TABLET 25 MG
5^
EMTRIVA ORAL CAPSULE 200 MG
3
EMTRIVA ORAL SOLUTION 10 MG/ML
3
FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED
90 MG
5^
INTELENCE ORAL TABLET 100 MG, 200 MG
5^
INTELENCE ORAL TABLET 25 MG
4
INVIRASE ORAL CAPSULE 200 MG
5^
INVIRASE ORAL TABLET 500 MG
5^
ISENTRESS ORAL PACKET 100 MG
3
ISENTRESS ORAL TABLET 400 MG
5^
ISENTRESS ORAL TABLET CHEWABLE 100 MG
5^
ISENTRESS ORAL TABLET CHEWABLE 25 MG
3
lamivudine oral solution 10 mg/ml
3
lamivudine oral tablet 150 mg, 300 mg
3
LEXIVA ORAL SUSPENSION 50 MG/ML
4
LEXIVA ORAL TABLET 700 MG
5^
nevirapine er oral tablet extended release 24 hr* 100
mg, 400 mg
4
NEVIRAPINE ORAL SUSPENSION 50 MG/5ML
4
nevirapine oral tablet 200 mg
3
NORVIR ORAL CAPSULE 100 MG
3
NORVIR ORAL SOLUTION 80 MG/ML
3
NORVIR ORAL TABLET 100 MG
3
PREZISTA ORAL SUSPENSION 100 MG/ML
5^
PREZISTA ORAL TABLET 150 MG, 75 MG
3
PREZISTA ORAL TABLET 600 MG, 800 MG
5^
RESCRIPTOR ORAL TABLET 100 MG, 200 MG
4
8
Drug Name
Drug
Tier
RETROVIR INTRAVENOUS* SOLUTION 10 MG/ML
3
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG
5^
REYATAZ ORAL PACKET 50 MG
5^
SELZENTRY ORAL TABLET 150 MG, 300 MG
5^
stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg
4
stavudine oral solution reconstituted 1 mg/ml
4
SUSTIVA ORAL CAPSULE 200 MG, 50 MG
3
SUSTIVA ORAL TABLET 600 MG
5^
TIVICAY ORAL TABLET 10 MG
3
TIVICAY ORAL TABLET 25 MG, 50 MG
5^
TYBOST ORAL TABLET 150 MG
3
VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM
4
VIRACEPT ORAL TABLET 250 MG, 625 MG
5^
VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24
HR* 100 MG
4
VIREAD ORAL POWDER 40 MG/GM
5^
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300
MG
5^
VITEKTA ORAL TABLET 150 MG, 85 MG
5^
ZIAGEN ORAL SOLUTION 20 MG/ML
3
zidovudine oral capsule 100 mg
3
zidovudine oral syrup 50 mg/5ml
3
zidovudine oral tablet 300 mg
ANTIRETROVIRAL COMBINATION AGENTS
3
abacavir-lamivudine-zidovudine oral tablet
300-150-300 mg
5^
ATRIPLA ORAL TABLET 600-200-300 MG
5^
COMPLERA ORAL TABLET 200-25-300 MG
5^
DESCOVY ORAL TABLET 200-25 MG
5^
EPZICOM ORAL TABLET 600-300 MG
5^
EVOTAZ ORAL TABLET 300-150 MG
5^
GENVOYA ORAL TABLET 150-150-200-10 MG
5^
9
Drug Name
Drug
Tier
KALETRA ORAL SOLUTION 400-100 MG/5ML
5^
KALETRA ORAL TABLET 100-25 MG
3
KALETRA ORAL TABLET 200-50 MG
5^
lamivudine-zidovudine oral tablet 150-300 mg
5^
ODEFSEY ORAL TABLET 200-25-25 MG
5^
PREZCOBIX ORAL TABLET 800-150 MG
5^
STRIBILD ORAL TABLET 150-150-200-300 MG
5^
TRIUMEQ ORAL TABLET 600-50-300 MG
5^
TRUVADA ORAL TABLET 100-150 MG
5^
5^
TRUVADA ORAL TABLET 133-200 MG, 167-250 MG,
200-300 MG
ANTITUBERCULAR AGENTS
CAPASTAT SULFATE INJECTION SOLUTION
RECONSTITUTED 1 GM
4
cycloserine oral capsule 250 mg
5^
ethambutol hcl oral tablet 100 mg, 400 mg
3
isoniazid oral syrup 50 mg/5ml
4
isoniazid oral tablet 100 mg, 300 mg
1
paser oral packet 4 gm
3
PRIFTIN ORAL TABLET 150 MG
4
pyrazinamide oral tablet 500 mg
4
rifabutin oral capsule 150 mg
4
rifampin intravenous* solution reconstituted 600 mg
4
rifampin oral capsule 150 mg, 300 mg
3
RIFATER ORAL TABLET 50-120-300 MG
4
SIRTURO ORAL TABLET 100 MG
5^
TRECATOR ORAL TABLET 250 MG
ANTIVIRALS
4
acyclovir oral capsule 200 mg
2
acyclovir oral suspension 200 mg/5ml
4
acyclovir oral tablet 400 mg, 800 mg
2
acyclovir sodium intravenous* solution 50 mg/ml
4
PA; LA
B/D
10
Drug Name
Drug
Tier
acyclovir sodium intravenous* solution reconstituted
500 mg
adefovir dipivoxil oral tablet 10 mg
4
B/D
5^
BARACLUDE ORAL SOLUTION 0.05 MG/ML
3
DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG
5^
entecavir oral tablet 0.5 mg, 1 mg
5^
PA
EPIVIR HBV ORAL SOLUTION 5 MG/ML
4
famciclovir oral tablet 125 mg, 250 mg, 500 mg
4
ganciclovir sodium intravenous* solution reconstituted
500 mg
3
B/D
5^
PA
HARVONI ORAL TABLET 90-400 MG
lamivudine oral tablet 100 mg
4
moderiba oral tablet 200 mg
3
PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135
MCG/0.5ML, 180 MCG/0.5ML
5^
PA
PEGASYS SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML,
180 MCG/ML
5^
PA
PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 120
MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80
MCG/0.5ML
5^
PA
PEGINTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150
MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML
5^
PA
RELENZA DISKHALER INHALATION AEROSOL POWDER,
BREATH ACTIVATED 5 MG/BLISTER
3
ribasphere oral capsule 200 mg
3
ribasphere oral tablet 200 mg
3
ribavirin oral capsule 200 mg
3
ribavirin oral tablet 200 mg
3
rimantadine hcl oral tablet 100 mg
3
SOVALDI ORAL TABLET 400 MG
5^
TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG
3
TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML
3
TYZEKA ORAL TABLET 600 MG
PA
5^
11
Drug Name
Drug
Tier
valacyclovir hcl oral tablet 1 gm, 500 mg
3
VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML
5^
valganciclovir hcl oral tablet 450 mg
CEPHALOSPORINS
5^
cefaclor oral capsule 250 mg, 500 mg
3
cefadroxil oral capsule 500 mg
1
cefadroxil oral suspension reconstituted 250 mg/5ml,
500 mg/5ml
3
cefadroxil oral tablet 1 gm
4
cefazolin sodium injection solution reconstituted 1 gm,
10 gm, 20 gm, 500 mg
3
cefazolin sodium intravenous* solution 1-5 gm-%
3
cefazolin sodium intravenous* solution reconstituted 1
gm
3
CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS*
SOLUTION 2-4 GM/100ML-%
3
cefdinir oral capsule 300 mg
3
cefdinir oral suspension reconstituted 125 mg/5ml, 250
mg/5ml
4
cefepime hcl injection solution reconstituted 1 gm, 2 gm
4
cefixime oral suspension reconstituted 100 mg/5ml, 200
mg/5ml
3
cefoxitin sodium injection solution reconstituted 10 gm
4
cefoxitin sodium intravenous* solution reconstituted 1
gm, 2 gm
4
cefpodoxime proxetil oral suspension reconstituted 100
mg/5ml, 50 mg/5ml
4
cefpodoxime proxetil oral tablet 100 mg, 200 mg
4
ceftazidime injection solution reconstituted 1 gm, 2 gm,
6 gm
4
ceftriaxone sodium injection solution reconstituted 1
gm, 2 gm, 250 mg, 500 mg
3
ceftriaxone sodium intravenous* solution reconstituted 1
3
gm, 10 gm, 2 gm
12
Drug Name
Drug
Tier
cefuroxime axetil oral tablet 250 mg, 500 mg
3
cefuroxime sodium injection solution reconstituted 1.5
gm, 7.5 gm, 750 mg
3
cefuroxime sodium intravenous* solution reconstituted
1.5 gm
3
cephalexin oral capsule 250 mg, 500 mg
1
cephalexin oral suspension reconstituted 125 mg/5ml,
250 mg/5ml
3
SUPRAX ORAL CAPSULE 400 MG
3
SUPRAX ORAL SUSPENSION RECONSTITUTED 500
MG/5ML
3
suprax oral tablet chewable 100 mg, 200 mg
4
tazicef injection solution reconstituted 1 gm, 2 gm, 6 gm
4
tazicef intravenous* solution reconstituted 1 gm, 2 gm
4
TEFLARO INTRAVENOUS* SOLUTION RECONSTITUTED
400 MG, 600 MG
ERYTHROMYCINS/MACROLIDES
4
azithromycin intravenous* solution reconstituted 500 mg
3
AZITHROMYCIN ORAL PACKET 1 GM
3
azithromycin oral suspension reconstituted 100 mg/5ml,
200 mg/5ml
3
azithromycin oral tablet 250 mg, 250 mg (6 pack), 500
mg, 600 mg
1
clarithromycin er oral tablet extended release 24 hr*
500 mg
3
clarithromycin oral suspension reconstituted 125
mg/5ml, 250 mg/5ml
4
clarithromycin oral tablet 250 mg, 500 mg
4
e.e.s. 400 oral tablet 400 mg
4
ery-tab oral tablet delayed release 250 mg, 333 mg,
500 mg
4
erythrocin lactobionate intravenous* solution
reconstituted 500 mg
4
erythrocin stearate oral tablet 250 mg
4
13
Drug Name
Drug
Tier
erythromycin base oral capsule delayed release
particles 250 mg
4
erythromycin base oral tablet 250 mg, 500 mg
4
erythromycin ethylsuccinate oral tablet 400 mg
FLUOROQUINOLONES
4
ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg,
750 mg
1
ciprofloxacin in d5w intravenous* solution 200
mg/100ml, 400 mg/200ml
4
ciprofloxacin intravenous* solution 200 mg/20ml, 400
mg/40ml
4
levofloxacin in d5w intravenous* solution 250 mg/50ml,
500 mg/100ml, 750 mg/150ml
3
levofloxacin intravenous* solution 25 mg/ml
4
levofloxacin oral solution 25 mg/ml
4
levofloxacin oral tablet 250 mg, 500 mg, 750 mg
PENICILLINS
1
amoxicillin oral capsule 250 mg, 500 mg
1
amoxicillin oral suspension reconstituted 125 mg/5ml,
200 mg/5ml, 250 mg/5ml, 400 mg/5ml
1
amoxicillin oral tablet 500 mg, 875 mg
1
amoxicillin oral tablet chewable 125 mg, 250 mg
2
amoxicillin-pot clavulanate oral suspension
reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml,
400-57 mg/5ml, 600-42.9 mg/5ml
3
amoxicillin-pot clavulanate oral tablet 250-125 mg,
500-125 mg, 875-125 mg
2
amoxicillin-pot clavulanate oral tablet chewable
200-28.5 mg, 400-57 mg
3
ampicillin oral capsule 250 mg, 500 mg
1
ampicillin oral suspension reconstituted 125 mg/5ml,
250 mg/5ml
3
ampicillin sodium injection solution reconstituted 1 gm,
125 mg, 2 gm, 250 mg, 500 mg
4
14
Drug Name
Drug
Tier
ampicillin sodium intravenous* solution reconstituted 1
gm, 10 gm, 2 gm
4
ampicillin-sulbactam sodium injection solution
reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm
4
ampicillin-sulbactam sodium intravenous* solution
reconstituted 15 (10-5) gm, 3 (2-1) gm
4
BICILLIN L-A INTRAMUSCULAR* SUSPENSION 1200000
UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML
4
dicloxacillin sodium oral capsule 250 mg, 500 mg
3
nafcillin sodium injection solution reconstituted 1 gm
4
nafcillin sodium injection solution reconstituted 10 gm,
2 gm
5^
nafcillin sodium intravenous* solution reconstituted 1
gm
4
nafcillin sodium intravenous* solution reconstituted 2
gm
5^
PENICILLIN G POT IN DEXTROSE INTRAVENOUS*
SOLUTION 40000 UNIT/ML, 60000 UNIT/ML
4
penicillin g potassium injection solution reconstituted
20000000 unit, 5000000 unit
4
penicillin g procaine intramuscular* suspension 600000
unit/ml
4
penicillin g sodium injection solution reconstituted
5000000 unit
4
penicillin v potassium oral solution reconstituted 125
mg/5ml, 250 mg/5ml
1
penicillin v potassium oral tablet 250 mg, 500 mg
1
pfizerpen-g injection solution reconstituted 5000000
unit
4
piperacillin sod-tazobactam so intravenous* solution
reconstituted 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5
(4-0.5) gm, 40.5 (36-4.5) gm
TETRACYCLINES
doxy 100 intravenous* solution reconstituted 100 mg
4
4
15
Drug Name
Drug
Tier
doxycycline hyclate intravenous* solution reconstituted
100 mg
4
doxycycline hyclate oral capsule 100 mg, 50 mg
3
doxycycline hyclate oral tablet 100 mg, 20 50, 20 mg
3
doxycycline monohydrate oral capsule 100 mg, 50 mg
2
doxycycline monohydrate oral tablet 100 mg, 50 mg, 75
mg
3
minocycline hcl oral capsule 100 mg, 50 mg, 75 mg
2
morgidox oral capsule 50 mg
ANTINEOPLASTIC AGENTS
3
ALKYLATING AGENTS
CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG
4
B/D
dacarbazine intravenous* solution reconstituted 100 mg,
200 mg
3
B/D
EMCYT ORAL CAPSULE 140 MG
4
GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5
MG
4
HEXALEN ORAL CAPSULE 50 MG
5^
LEUKERAN ORAL TABLET 2 MG
ANTIBIOTICS
4
bleomycin sulfate injection solution reconstituted 15
unit, 30 unit
3
B/D
4
B/D
adrucil intravenous* solution 2.5 gm/50ml, 5 gm/100ml,
500 mg/10ml
3
B/D
ALIMTA INTRAVENOUS* SOLUTION RECONSTITUTED 100
MG, 500 MG
5^
B/D
azacitidine injection suspension reconstituted 100 mg
5^
B/D
fluorouracil intravenous* solution 1 gm/20ml, 2.5
gm/50ml, 5 gm/100ml, 500 mg/10ml
3
B/D
mercaptopurine oral tablet 50 mg
3
mitomycin intravenous* solution reconstituted 20 mg,
40 mg, 5 mg
ANTIMETABOLITES
16
Drug Name
Drug
Tier
methotrexate sodium (pf) injection solution 1 gm/40ml,
100 mg/4ml, 200 mg/8ml, 250 mg/10ml, 50 mg/2ml
2
B/D
methotrexate sodium injection solution 250 mg/10ml
2
B/D
METHOTREXATE SODIUM INJECTION SOLUTION 50
MG/2ML
2
B/D
methotrexate sodium injection solution reconstituted 1
gm
2
B/D
NIPENT INTRAVENOUS* SOLUTION RECONSTITUTED 10
MG
5^
B/D
PURIXAN ORAL SUSPENSION 2000 MG/100ML
5^
TABLOID ORAL TABLET 40 MG
ANTIMITOTIC, TAXOIDS
4
ABRAXANE INTRAVENOUS* SUSPENSION
RECONSTITUTED 100 MG
5^
B/D
docetaxel intravenous* concentrate 140 mg/7ml
5^
B/D
DOCETAXEL INTRAVENOUS* CONCENTRATE 20 MG/ML,
80 MG/4ML
5^
B/D
DOCETAXEL INTRAVENOUS* SOLUTION 160 MG/16ML,
200 MG/20ML, 80 MG/8ML
5^
B/D
4
B/D
DOCETAXEL INTRAVENOUS* SOLUTION 20 MG/2ML
BIOLOGIC RESPONSE MODIFIERS
AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML, 400
MG/16ML
5^
B/D; LA
BELEODAQ INTRAVENOUS* SOLUTION RECONSTITUTED
500 MG
5^
PA
ERIVEDGE ORAL CAPSULE 150 MG
5^
PA; LA
FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG
5^
PA; LA
HERCEPTIN INTRAVENOUS* SOLUTION RECONSTITUTED
440 MG
5^
B/D
IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG
5^
PA; LA
KEYTRUDA INTRAVENOUS* SOLUTION 100 MG/4ML
5^
PA
KEYTRUDA INTRAVENOUS* SOLUTION RECONSTITUTED
50 MG
5^
PA
LYNPARZA ORAL CAPSULE 50 MG
5^
PA; LA
17
Drug Name
Drug
Tier
NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG
5^
PA
RITUXAN INTRAVENOUS* SOLUTION 100 MG/10ML, 500
MG/50ML
5^
PA; LA
TECENTRIQ INTRAVENOUS* SOLUTION 1200 MG/20ML
5^
PA; LA
VELCADE INJECTION SOLUTION RECONSTITUTED 3.5
MG
5^
B/D
VENCLEXTA ORAL TABLET 10 MG, 50 MG
4
PA; LA
VENCLEXTA ORAL TABLET 100 MG
5^
PA; LA
VENCLEXTA STARTING PACK ORAL 10 & 50 & 100 MG
5^
PA; LA
YERVOY INTRAVENOUS* SOLUTION 200 MG/40ML, 50
MG/10ML
5^
PA
5^
PA
ZOLINZA ORAL CAPSULE 100 MG
HORMONAL ANTINEOPLASTIC AGENTS
anastrozole oral tablet 1 mg
2
bicalutamide oral tablet 50 mg
3
exemestane oral tablet 25 mg
4
FARESTON ORAL TABLET 60 MG
5^
FASLODEX INTRAMUSCULAR* SOLUTION 250 MG/5ML
5^
B/D
flutamide oral capsule 125 mg
4
hydroxyprogesterone caproate intramuscular* solution
1.25 gm/5ml
4
letrozole oral tablet 2.5 mg
3
leuprolide acetate injection kit 1 mg/0.2ml
3
PA
5^
PA
LUPRON DEPOT INTRAMUSCULAR* KIT 3.75 MG
B/D
LYSODREN ORAL TABLET 500 MG
3
megestrol acetate oral suspension 40 mg/ml
4
PA
5^
PA
4
PA
MEGESTROL ACETATE ORAL SUSPENSION 625 MG/5ML
megestrol acetate oral tablet 20 mg, 40 mg
NILANDRON ORAL TABLET 150 MG
5^
nilutamide oral tablet 150 mg
5^
SOLTAMOX ORAL SOLUTION 10 MG/5ML
4
tamoxifen citrate oral tablet 10 mg, 20 mg
1
18
Drug Name
Drug
Tier
TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 11.25 MG, 3.75 MG
5^
PA
XTANDI ORAL CAPSULE 40 MG
5^
PA; LA
ZYTIGA ORAL TABLET 250 MG
KINASE INHIBITORS
5^
PA; LA
AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG,
5 MG
5^
PA
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG
5^
PA
ALECENSA ORAL CAPSULE 150 MG
5^
PA; LA
BOSULIF ORAL TABLET 100 MG, 500 MG
5^
PA
CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG
5^
PA; LA
CAPRELSA ORAL TABLET 100 MG, 300 MG
5^
PA; LA
COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X
20 MG
5^
PA; LA
COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X
20 MG
5^
PA; LA
COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG
5^
PA; LA
COTELLIC ORAL TABLET 20 MG
5^
PA; LA
GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG
5^
PA; LA
ICLUSIG ORAL TABLET 15 MG, 45 MG
5^
PA; LA
imatinib mesylate oral tablet 100 mg, 400 mg
5^
PA
IMBRUVICA ORAL CAPSULE 140 MG
5^
PA; LA
INLYTA ORAL TABLET 1 MG, 5 MG
5^
PA; LA
IRESSA ORAL TABLET 250 MG
5^
PA; LA
JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5
MG
5^
PA; LA
LENVIMA 10 MG DAILY DOSE ORAL 10 MG
5^
PA; LA
LENVIMA 14 MG DAILY DOSE ORAL 10 & 4 MG
5^
PA; LA
LENVIMA 18 MG DAILY DOSE ORAL 10 & 4 (2) MG
5^
PA; LA
LENVIMA 20 MG DAILY DOSE ORAL 10 (2) MG
5^
PA; LA
LENVIMA 24 MG DAILY DOSE ORAL 10 (2) & 4 MG
5^
PA; LA
LENVIMA 8 MG DAILY DOSE ORAL 4 (2) MG
5^
PA; LA
19
Drug Name
Drug
Tier
LENVIMA 8MG DAILY DOSE ORAL 4 (2) MG (60 PACK)
5^
PA; LA
MEKINIST ORAL TABLET 0.5 MG, 2 MG
5^
PA; LA
NEXAVAR ORAL TABLET 200 MG
5^
PA; LA
SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50
MG, 70 MG, 80 MG
5^
PA
STIVARGA ORAL TABLET 40 MG
5^
PA; LA
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50
MG
5^
PA
TAFINLAR ORAL CAPSULE 50 MG, 75 MG
5^
PA; LA
TAGRISSO ORAL TABLET 40 MG, 80 MG
5^
PA; LA
TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG
5^
PA; LA
TASIGNA ORAL CAPSULE 150 MG, 200 MG
5^
PA
TYKERB ORAL TABLET 250 MG
5^
PA; LA
VOTRIENT ORAL TABLET 200 MG
5^
PA; LA
XALKORI ORAL CAPSULE 200 MG, 250 MG
5^
PA; LA
ZELBORAF ORAL TABLET 240 MG
5^
PA; LA
ZYDELIG ORAL TABLET 100 MG, 150 MG
5^
PA; LA
ZYKADIA ORAL CAPSULE 150 MG
MISCELLANEOUS
5^
PA; LA
bexarotene oral capsule 75 mg
5^
PA
DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG
3
hydroxyurea oral capsule 500 mg
3
LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG
5^
PA
MATULANE ORAL CAPSULE 50 MG
5^
LA
3
B/D
mitoxantrone hcl intravenous* concentrate 20 mg/10ml,
25 mg/12.5ml, 30 mg/15ml
ODOMZO ORAL CAPSULE 200 MG
5^
PA; LA
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG
5^
PA; LA
SYLATRON SUBCUTANEOUS* KIT 200 MCG, 300 MCG, 4
X 200 MCG, 4 X 300 MCG, 600 MCG
5^
PA
SYNRIBO SUBCUTANEOUS* SOLUTION RECONSTITUTED
3.5 MG
5^
PA
20
Drug Name
Drug
Tier
tretinoin oral capsule 10 mg
5^
TRISENOX INTRAVENOUS* SOLUTION 10 MG/10ML
PROTECTIVE AGENTS
5^
B/D
amifostine intravenous* solution reconstituted 500 mg
5^
B/D
ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED 1.5
MG, 7.5 MG
5^
B/D
FUSILEV INTRAVENOUS* SOLUTION RECONSTITUTED 50
MG
5^
B/D
leucovorin calcium injection solution reconstituted 100
mg, 200 mg, 350 mg, 50 mg, 500 mg
4
B/D
leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5
mg
3
levoleucovorin calcium intravenous* solution 175
mg/17.5ml
5^
B/D
levoleucovorin calcium intravenous* solution
reconstituted 50 mg
5^
B/D
levoleucovorin calcium pf intravenous* solution 250
mg/25ml
5^
B/D
4
B/D
mesna intravenous* solution 100 mg/ml
MESNEX ORAL TABLET 400 MG
TOPOISOMERASE INHIBITORS
5^
etoposide intravenous* solution 500 mg/25ml
3
B/D
toposar intravenous* solution 1 gm/50ml
3
B/D
5^
B/D
topotecan hcl intravenous* solution reconstituted 4 mg
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine besy-benazepril hcl oral capsule 10-20 mg,
2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg
1
amlodipine besy-benazepril hcl oral capsule 10-40 mg
1
benazepril-hydrochlorothiazide oral tablet 10-12.5 mg,
20-12.5 mg, 20-25 mg, 5-6.25 mg
1
captopril-hydrochlorothiazide oral tablet 25-15 mg,
25-25 mg, 50-15 mg, 50-25 mg
1
21
Drug Name
Drug
Tier
enalapril-hydrochlorothiazide oral tablet 10-25 mg,
5-12.5 mg
1
fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5
mg
1
lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg,
20-12.5 mg, 20-25 mg
1
moexipril-hydrochlorothiazide oral tablet 15-12.5 mg,
15-25 mg, 7.5-12.5 mg
1
quinapril-hydrochlorothiazide oral tablet 10-12.5 mg,
20-12.5 mg, 20-25 mg
ACE INHIBITORS
1
benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg
1
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg
1
enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5
mg
1
fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg
1
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40
mg, 5 mg
1
moexipril hcl oral tablet 15 mg, 7.5 mg
1
perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg
1
quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg
1
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg
1
trandolapril oral tablet 1 mg, 2 mg, 4 mg
ALDOSTERONE RECEPTOR ANTAGONISTS
1
eplerenone oral tablet 25 mg, 50 mg
4
spironolactone oral tablet 100 mg, 25 mg, 50 mg
ALPHA BLOCKERS
1
doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg
3
prazosin hcl oral capsule 1 mg, 2 mg, 5 mg
2
terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg
1
22
Drug Name
Drug
Tier
ANGIOTENSIN II RECEPTOR ANTAGONIST
COMBINATIONS
amlodipine besylate-valsartan oral tablet 10-160 mg,
10-320 mg, 5-160 mg, 5-320 mg
1
amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg,
10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg,
5-160-25 mg
1
AZOR ORAL TABLET 10-20 MG, 5-20 MG, 5-40 MG
3
AZOR ORAL TABLET 10-40 MG
3
BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG,
40-25 MG
3
ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103
MG
4
irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg,
300-12.5 mg
1
losartan potassium-hctz oral tablet 100-12.5 mg,
100-25 mg, 50-12.5 mg
1
TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5
MG, 40-5-12.5 MG, 40-5-25 MG
3
TRIBENZOR ORAL TABLET 40-10-25 MG
3
valsartan-hydrochlorothiazide oral tablet 160-12.5 mg,
160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg
ANGIOTENSIN II RECEPTOR ANTAGONISTS
PA
1
BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG
3
irbesartan oral tablet 150 mg, 300 mg, 75 mg
1
losartan potassium oral tablet 100 mg, 25 mg, 50 mg
1
valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg
ANTIARRHYTHMICS
1
amiodarone hcl intravenous* solution 150 mg/3ml, 450
mg/9ml, 900 mg/18ml
2
amiodarone hcl oral tablet 100 mg, 400 mg
4
amiodarone hcl oral tablet 200 mg
1
disopyramide phosphate oral capsule 100 mg, 150 mg
4
PA
dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg
4
23
Drug Name
Drug
Tier
flecainide acetate oral tablet 100 mg, 150 mg, 50 mg
3
mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg
4
MULTAQ ORAL TABLET 400 MG
4
NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12
HOUR 100 MG, 150 MG
4
pacerone oral tablet 100 mg, 400 mg
4
pacerone oral tablet 200 mg
1
propafenone hcl er oral capsule extended release 12
hour 225 mg, 325 mg, 425 mg
4
propafenone hcl oral tablet 150 mg, 225 mg, 300 mg
3
quinidine gluconate er oral tablet extendedrelease* 324
mg
4
quinidine sulfate oral tablet 200 mg, 300 mg
2
sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg
2
sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg
3
sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg
2
TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG
ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS
4
PA
atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg,
80 mg
1
crestor oral tablet 10 mg, 20 mg, 40 mg, 5 mg
1
lovastatin oral tablet 10 mg
1
1
1
pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80
mg
1
rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5
mg
1
1
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80
mg
ANTILIPEMICS, MISCELLANEOUS
cholestyramine light oral packet 4 gm
4
cholestyramine light oral powder 4 gm/dose
4
24
Drug Name
Drug
Tier
cholestyramine oral packet 4 gm
4
cholestyramine oral powder 4 gm/dose
4
colestipol hcl oral granules 5 gm
4
colestipol hcl oral packet 5 gm
4
colestipol hcl oral tablet 1 gm
3
fenofibrate micronized oral capsule 134 mg, 200 mg, 67
mg
3
fenofibrate oral tablet 160 mg, 54 mg
3
gemfibrozil oral tablet 600 mg
2
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40
MG, 5 MG, 60 MG
5^
PA; LA
KYNAMRO SUBCUTANEOUS* 200 MG/ML
5^
PA
niacin er (antihyperlipidemic) oral tablet
extendedrelease* 1000 mg, 750 mg
4
niacin er (antihyperlipidemic) oral tablet
extendedrelease* 500 mg
4
niacor oral tablet 500 mg
3
omega-3-acid ethyl esters oral capsule 1 gm
4
PRALUENT SUBCUTANEOUS* 150 MG/ML, 75 MG/ML
5^
prevalite oral packet 4 gm
4
prevalite oral powder 4 gm/dose
4
VASCEPA ORAL CAPSULE 1 GM
4
WELCHOL ORAL PACKET 3.75 GM
3
WELCHOL ORAL TABLET 625 MG
3
ZETIA ORAL TABLET 10 MG
BETA-BLOCKER/DIURETIC COMBINATIONS
3
atenolol-chlorthalidone oral tablet 100-25 mg, 50-25
mg
3
bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg,
2.5-6.25 mg, 5-6.25 mg
1
metoprolol-hydrochlorothiazide oral tablet 100-25 mg,
100-50 mg, 50-25 mg
3
propranolol-hctz oral tablet 40-25 mg, 80-25 mg
3
PA
25
Drug Name
Drug
Tier
BETA-BLOCKERS
acebutolol hcl oral capsule 200 mg, 400 mg
2
atenolol oral tablet 100 mg, 25 mg, 50 mg
1
bisoprolol fumarate oral tablet 10 mg, 5 mg
2
BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG
4
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25
mg
1
labetalol hcl oral tablet 100 mg, 200 mg, 300 mg
3
metoprolol succinate er oral tablet extended release 24
hr* 100 mg, 200 mg, 25 mg, 50 mg
3
metoprolol tartrate intravenous* solution 1 mg/ml, 5
mg/5ml
3
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
1
nadolol oral tablet 20 mg, 40 mg, 80 mg
2
pindolol oral tablet 10 mg, 5 mg
3
propranolol hcl er oral capsule extended release 24 hour
120 mg, 160 mg, 60 mg, 80 mg
4
propranolol hcl intravenous* solution 1 mg/ml
3
propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml
3
propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg,
80 mg
1
timolol maleate oral tablet 10 mg, 20 mg, 5 mg
CALCIUM CHANNEL BLOCKERS
3
afeditab cr oral tablet extended release 24 hr* 30 mg
2
afeditab cr oral tablet extended release 24 hr* 60 mg
2
amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg
1
cartia xt oral capsule extended release 24 hour 120 mg,
180 mg, 240 mg, 300 mg
3
diltiazem hcl er beads oral capsule extended release 24
hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420
mg
3
26
Drug Name
Drug
Tier
diltiazem hcl er coated beads oral capsule extended
release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360
mg
3
diltiazem hcl er oral capsule extended release 12 hour
120 mg, 60 mg, 90 mg
3
diltiazem hcl er oral capsule extended release 24 hour
120 mg, 240 mg
3
diltiazem hcl intravenous* solution 125 mg/25ml, 25
mg/5ml, 50 mg/10ml
2
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg
2
dilt-xr oral capsule extended release 24 hour 120 mg,
180 mg, 240 mg
3
felodipine er oral tablet extended release 24 hr* 10 mg
2
felodipine er oral tablet extended release 24 hr* 2.5 mg
2
felodipine er oral tablet extended release 24 hr* 5 mg
2
nicardipine hcl oral capsule 20 mg, 30 mg
4
nifedical xl oral tablet extended release 24 hr* 30 mg
2
nifedical xl oral tablet extended release 24 hr* 60 mg
2
nifedipine er oral tablet extended release 24 hr* 30 mg
2
nifedipine er oral tablet extended release 24 hr* 60 mg,
90 mg
2
nifedipine er osmotic release oral tablet extended
release 24 hr* 30 mg
2
nifedipine er osmotic release oral tablet extended
release 24 hr* 60 mg, 90 mg
2
nimodipine oral capsule 30 mg
5^
NYMALIZE ORAL SOLUTION 60 MG/20ML
5^
taztia xt oral capsule extended release 24 hour 120 mg,
180 mg, 240 mg, 300 mg, 360 mg
3
verapamil hcl er oral capsule extended release 24 hour
100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg
3
VERAPAMIL HCL ER ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 360 MG
3
27
Drug Name
Drug
Tier
verapamil hcl er oral tablet extendedrelease* 120 mg,
120 mg (24hr), 180 mg, 240 mg
2
verapamil hcl intravenous* solution 2.5 mg/ml
4
verapamil hcl oral tablet 120 mg, 40 mg, 80 mg
DIGITALIS GLYCOSIDES
1
digitek oral tablet 125 mcg
3
digitek oral tablet 250 mcg
3
PA
digox oral tablet 125 mcg
3
digox oral tablet 250 mcg
3
PA
digoxin injection solution 0.25 mg/ml
3
DIGOXIN ORAL SOLUTION 0.05 MG/ML
3
PA
digoxin oral tablet 125 mcg
3
digoxin oral tablet 250 mcg
DIRECT RENIN INHIBITORS/COMBINATIONS
3
PA
TEKTURNA HCT ORAL TABLET 150-12.5 MG, 300-12.5
MG
3
TEKTURNA HCT ORAL TABLET 150-25 MG
3
TEKTURNA HCT ORAL TABLET 300-25 MG
3
TEKTURNA ORAL TABLET 150 MG
3
TEKTURNA ORAL TABLET 300 MG
DIURETICS
3
acetazolamide er oral capsule extended release 12 hour
500 mg
3
acetazolamide oral tablet 125 mg, 250 mg
3
amiloride hcl oral tablet 5 mg
3
amiloride-hydrochlorothiazide oral tablet 5-50 mg
2
bumetanide injection solution 0.25 mg/ml
3
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg
3
chlorothiazide oral tablet 250 mg, 500 mg
3
chlorthalidone oral tablet 25 mg, 50 mg
3
FUROSEMIDE INJECTION SOLUTION 10 MG/ML
2
furosemide injection solution 10 mg/ml (4ml syringe)
2
28
Drug Name
Drug
Tier
furosemide oral solution 10 mg/ml, 8 mg/ml
2
furosemide oral tablet 20 mg, 40 mg, 80 mg
1
hydrochlorothiazide oral capsule 12.5 mg
1
hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg
1
indapamide oral tablet 1.25 mg, 2.5 mg
2
methazolamide oral tablet 25 mg, 50 mg
4
metolazone oral tablet 10 mg, 2.5 mg, 5 mg
3
spironolactone-hctz oral tablet 25-25 mg
3
torsemide intravenous* solution 50 mg/5ml
2
torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg
2
triamterene-hctz oral capsule 37.5-25 mg
1
triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg
MISCELLANEOUS
1
clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg
1
clonidine hcl transdermal patch weekly 0.1 mg/24hr,
0.2 mg/24hr, 0.3 mg/24hr
2
DEMSER ORAL CAPSULE 250 MG
5^
hydralazine hcl injection solution 20 mg/ml
3
hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50
mg
2
midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg
4
minoxidil oral tablet 10 mg, 2.5 mg
2
RANEXA ORAL TABLET EXTENDED RELEASE 12 HR*
1000 MG, 500 MG
NITRATES
3
isosorbide dinitrate er oral tablet extendedrelease* 40
mg
3
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5
mg
3
isosorbide mononitrate er oral tablet extended release
24 hr* 120 mg, 30 mg, 60 mg
2
isosorbide mononitrate oral tablet 10 mg, 20 mg
2
29
Drug Name
Drug
Tier
minitran transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr,
0.4 mg/hr, 0.6 mg/hr
3
nitro-bid transdermal ointment 2 %
3
nitroglycerin transdermal patch 24 hr 0.1 mg/hr, 0.2
mg/hr, 0.4 mg/hr, 0.6 mg/hr
3
NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG,
0.4 MG, 0.6 MG
PULMONARY ARTERIAL HYPERTENSION
3
ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG,
2.5 MG
5^
PA; LA; QL (90 EA per 30 days)
LETAIRIS ORAL TABLET 10 MG, 5 MG
5^
OPSUMIT ORAL TABLET 10 MG
5^
REMODULIN INJECTION SOLUTION 1 MG/ML, 10
MG/ML, 2.5 MG/ML, 5 MG/ML
5^
B/D; LA
REVATIO ORAL SUSPENSION RECONSTITUTED 10
MG/ML
5^
PA; QL (224 ML per 30 days)
sildenafil citrate oral tablet 20 mg
3
TRACLEER ORAL TABLET 125 MG
5^
TRACLEER ORAL TABLET 62.5 MG
5^
UPTRAVI ORAL 200 & 800 MCG
5^
PA; LA
UPTRAVI ORAL TABLET 1000 MCG
5^
UPTRAVI ORAL TABLET 1200 MCG, 1400 MCG, 1600
MCG
5^
5^
5^
5^
CENTRAL NERVOUS SYSTEM
5^
ANTIANXIETY
alprazolam oral tablet 0.25 mg
1
alprazolam oral tablet 0.5 mg
1
alprazolam oral tablet 1 mg
1
alprazolam oral tablet 2 mg
1
30
Drug Name
Drug
Tier
buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg
3
fluvoxamine maleate oral tablet 100 mg
3
fluvoxamine maleate oral tablet 25 mg, 50 mg
3
lorazepam injection solution 2 mg/ml, 4 mg/ml
2
lorazepam intensol oral concentrate 2 mg/ml
3
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg
ANTICONVULSANTS
1
APTIOM ORAL TABLET 200 MG
4
5^
5^
5^
BANZEL ORAL SUSPENSION 40 MG/ML
5^
PA
BANZEL ORAL TABLET 200 MG
4
PA
BANZEL ORAL TABLET 400 MG
5^
PA
4
PA
BRIVIACT ORAL SOLUTION 10 MG/ML
5^
PA
BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG,
75 MG
5^
PA
BRIVIACT INTRAVENOUS* SOLUTION 50 MG/5ML
carbamazepine er oral capsule extended release 12
hour 100 mg, 200 mg, 300 mg
4
carbamazepine er oral tablet extended release 12 hr*
100 mg, 200 mg, 400 mg
4
carbamazepine oral suspension 100 mg/5ml
4
carbamazepine oral tablet 200 mg
3
carbamazepine oral tablet chewable 100 mg
3
CELONTIN ORAL CAPSULE 300 MG
4
clonazepam oral tablet 0.5 mg
1
clonazepam oral tablet 1 mg
1
clonazepam oral tablet 2 mg
1
clonazepam oral tablet dispersible 0.125 mg
3
3
3
31
Drug Name
Drug
Tier
clonazepam oral tablet dispersible 1 mg
3
clonazepam oral tablet dispersible 2 mg
3
clorazepate dipotassium oral tablet 15 mg
2
clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg
2
DIAZEPAM GEL 10 MG, 2.5 MG, 20 MG
4
diazepam injection solution 5 mg/ml
3
diazepam intensol oral concentrate 5 mg/ml
3
diazepam oral solution 1 mg/ml
3
diazepam oral tablet 10 mg, 2 mg, 5 mg
1
dilantin infatabs oral tablet chewable 50 mg
3
dilantin oral capsule 100 mg, 30 mg
3
DILANTIN ORAL SUSPENSION 125 MG/5ML
3
divalproex sodium er oral tablet extended release 24 hr*
250 mg, 500 mg
4
divalproex sodium oral 125 mg
4
divalproex sodium oral tablet delayed release 125 mg,
250 mg, 500 mg
2
epitol oral tablet 200 mg
3
ethosuximide oral capsule 250 mg
4
ethosuximide oral solution 250 mg/5ml
4
felbamate oral suspension 600 mg/5ml
5^
felbamate oral tablet 400 mg, 600 mg
4
FYCOMPA ORAL SUSPENSION 0.5 MG/ML
4
FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG
4
FYCOMPA ORAL TABLET 2 MG
4
4
4
gabapentin oral capsule 100 mg
2
2
2
gabapentin oral solution 250 mg/5ml
3
gabapentin oral tablet 600 mg
3
32
Drug Name
Drug
Tier
gabapentin oral tablet 800 mg
3
lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg
2
lamotrigine oral tablet chewable 25 mg, 5 mg
3
LEVETIRACETAM IN NACL INTRAVENOUS* SOLUTION
1000 MG/100ML, 1500 MG/100ML, 500 MG/100ML
4
levetiracetam intravenous* solution 500 mg/5ml
4
levetiracetam oral solution 100 mg/ml
3
levetiracetam oral tablet 1000 mg, 250 mg, 500 mg,
750 mg
3
LYRICA ORAL CAPSULE 100 MG, 150 MG, 25 MG, 50
MG, 75 MG
3
LYRICA ORAL CAPSULE 200 MG
3
LYRICA ORAL CAPSULE 225 MG, 300 MG
3
LYRICA ORAL SOLUTION 20 MG/ML
3
ONFI ORAL SUSPENSION 2.5 MG/ML
5^
PA
ONFI ORAL TABLET 10 MG
4
PA
ONFI ORAL TABLET 20 MG
5^
PA
oxcarbazepine oral suspension 300 mg/5ml
4
oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg
3
PEGANONE ORAL TABLET 250 MG
4
phenobarbital oral elixir 20 mg/5ml
4
PA
phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30
mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg
4
PA
phenobarbital sodium injection solution 130 mg/ml
4
PA
PHENOBARBITAL SODIUM INJECTION SOLUTION 65
MG/ML
4
PA
phenytek oral capsule 200 mg, 300 mg
3
phenytoin oral suspension 125 mg/5ml
3
phenytoin oral tablet chewable 50 mg
3
phenytoin sodium extended oral capsule 100 mg, 200
mg, 300 mg
3
phenytoin sodium injection solution 50 mg/ml
3
POTIGA ORAL TABLET 200 MG
5^
33
Drug Name
POTIGA ORAL TABLET 300 MG, 400 MG
Drug
Tier
5^
POTIGA ORAL TABLET 50 MG
4
primidone oral tablet 250 mg, 50 mg
2
roweepra oral tablet 500 mg
3
SABRIL ORAL PACKET 500 MG
5^
SABRIL ORAL TABLET 500 MG
5^
SPRITAM ORAL 1000 MG, 250 MG, 500 MG, 750 MG
4
TEGRETOL ORAL SUSPENSION 100 MG/5ML
4
TEGRETOL ORAL TABLET 200 MG
4
TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12
HR* 100 MG, 200 MG, 400 MG
4
tiagabine hcl oral tablet 2 mg, 4 mg
4
topiramate oral capsule sprinkle 15 mg, 25 mg
4
topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg
2
valproate sodium intravenous* solution 500 mg/5ml
4
valproic acid oral capsule 250 mg
3
valproic acid oral syrup 250 mg/5ml
2
VIMPAT INTRAVENOUS* SOLUTION 200 MG/20ML
4
VIMPAT ORAL SOLUTION 10 MG/ML
4
VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG
5^
VIMPAT ORAL TABLET 50 MG
4
zonisamide oral capsule 100 mg, 25 mg, 50 mg
ANTIDEMENTIA
3
donepezil hcl oral tablet 10 mg
2
donepezil hcl oral tablet 5 mg
2
donepezil hcl oral tablet dispersible 10 mg
4
donepezil hcl oral tablet dispersible 5 mg
4
EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR,
4.6 MG/24HR, 9.5 MG/24HR
2
galantamine hydrobromide er oral capsule extended
release 24 hour 16 mg, 8 mg
4
34
Drug Name
Drug
Tier
galantamine hydrobromide er oral capsule extended
release 24 hour 24 mg
4
galantamine hydrobromide oral solution 4 mg/ml
4
galantamine hydrobromide oral tablet 12 mg
4
4
4
memantine hcl oral solution 2 mg/ml
3
PA
MEMANTINE HCL ORAL TABLET 10 MG
4
PA
memantine hcl oral tablet 5 mg
4
PA
NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24
HOUR 14 MG, 21 MG, 28 MG, 7 MG
4
PA
NAMENDA XR TITRATION PACK ORAL CAPSULE
EXTENDED RELEASE 24 HOUR 7 & 14 & 21
4
PA
NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24
HOUR 14-10 MG, 28-10 MG
ANTIDEPRESSANTS
4
amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
4
amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg
3
BRINTELLIX ORAL TABLET 10 MG
4
4
4
bupropion hcl er (sr) oral tablet extended release 12 hr*
100 mg, 150 mg, 200 mg
2
bupropion hcl er (xl) oral tablet extended release 24 hr*
150 mg
3
bupropion hcl er (xl) oral tablet extended release 24 hr*
300 mg
3
bupropion hcl oral tablet 100 mg, 75 mg
3
citalopram hydrobromide oral solution 10 mg/5ml
3
citalopram hydrobromide oral tablet 10 mg, 20 mg, 40
mg
1
clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg
4
PA
PA
35
Drug Name
Drug
Tier
desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
4
doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
4
PA
doxepin hcl oral concentrate 10 mg/ml
4
PA
duloxetine hcl oral capsule delayed release particles 20
mg, 30 mg, 60 mg
4
EMSAM TRANSDERMAL PATCH 24 HR 12 MG/24HR, 6
MG/24HR, 9 MG/24HR
5^
escitalopram oxalate oral solution 5 mg/5ml
4
escitalopram oxalate oral tablet 10 mg, 5 mg
2
escitalopram oxalate oral tablet 20 mg
2
FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR
120 MG, 80 MG
4
20 MG
4
40 MG
4
FETZIMA TITRATION ORAL 20 & 40 MG
4
fluoxetine hcl oral capsule 10 mg
1
1
1
fluoxetine hcl oral solution 20 mg/5ml
3
fluoxetine hcl oral tablet 10 mg
3
fluoxetine hcl oral tablet 20 mg
3
imipramine hcl oral tablet 10 mg, 25 mg, 50 mg
4
maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg
4
MARPLAN ORAL TABLET 10 MG
4
mirtazapine oral tablet 15 mg, 7.5 mg
2
mirtazapine oral tablet 30 mg, 45 mg
2
mirtazapine oral tablet dispersible 15 mg
3
mirtazapine oral tablet dispersible 30 mg, 45 mg
3
PA
36
Drug Name
Drug
Tier
nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg,
250 mg, 50 mg
4
nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75
mg
1
nortriptyline hcl oral solution 10 mg/5ml
4
paroxetine hcl oral tablet 10 mg, 20 mg, 40 mg
1
paroxetine hcl oral tablet 30 mg
1
PAXIL ORAL SUSPENSION 10 MG/5ML
4
phenelzine sulfate oral tablet 15 mg
3
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100
MG, 25 MG, 50 MG
3
protriptyline hcl oral tablet 10 mg, 5 mg
4
sertraline hcl oral concentrate 20 mg/ml
3
sertraline hcl oral tablet 100 mg
1
sertraline hcl oral tablet 25 mg, 50 mg
1
SURMONTIL ORAL CAPSULE 100 MG
4
4
4
tranylcypromine sulfate oral tablet 10 mg
4
trazodone hcl oral tablet 100 mg, 150 mg, 50 mg
1
trimipramine maleate oral capsule 100 mg
4
4
4
TRINTELLIX ORAL TABLET 10 MG
4
4
4
venlafaxine hcl er oral capsule extended release 24 hour
150 mg, 37.5 mg, 75 mg
2
venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50
mg, 75 mg
3
VIIBRYD ORAL KIT 10 & 20 & 40 MG
4
VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG
4
37
Drug Name
Drug
Tier
VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG
ANTIPARKINSONIAN AGENTS
4
amantadine hcl oral capsule 100 mg
4
amantadine hcl oral syrup 50 mg/5ml
2
amantadine hcl oral tablet 100 mg
4
APOKYN SUBCUTANEOUS* SOLUTION 10 MG/ML
5^
AZILECT ORAL TABLET 0.5 MG, 1 MG
3
benztropine mesylate injection solution 1 mg/ml
3
benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg
4
bromocriptine mesylate oral capsule 5 mg
4
bromocriptine mesylate oral tablet 2.5 mg
4
carbidopa-levodopa er oral tablet extendedrelease*
25-100 mg, 50-200 mg
3
carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg,
25-250 mg
2
carbidopa-levodopa oral tablet dispersible 10-100 mg,
25-100 mg, 25-250 mg
2
ENTACAPONE ORAL TABLET 200 MG
4
NEUPRO TRANSDERMAL PATCH 24 HR 1 MG/24HR, 2
MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8
MG/24HR
4
pramipexole dihydrochloride oral tablet 0.125 mg, 0.25
mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg
2
ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3
mg, 4 mg, 5 mg
2
selegiline hcl oral capsule 5 mg
4
selegiline hcl oral tablet 5 mg
ANTIPSYCHOTICS
4
PA; LA
PA
ABILIFY DISCMELT ORAL TABLET DISPERSIBLE 10 MG
5^
ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 300 MG, 300 MG (1.5ML SYRINGE),
400 MG
5^
aripiprazole oral solution 1 mg/ml
5^
38
Drug Name
Drug
Tier
aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30
mg, 5 mg
5^
aripiprazole oral tablet dispersible 10 mg, 15 mg
5^
chlorpromazine hcl injection solution 25 mg/ml, 50
mg/2ml
4
chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg,
25 mg, 50 mg
4
clozapine oral tablet 100 mg
4
clozapine oral tablet 200 mg
4
clozapine oral tablet 25 mg, 50 mg
3
CLOZAPINE ORAL TABLET DISPERSIBLE 100 MG
4
CLOZAPINE ORAL TABLET DISPERSIBLE 12.5 MG, 25
MG
4
PA
5^
5^
FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4
MG, 6 MG, 8 MG
4
ST; QL (60 EA per 30 days)
FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6
MG
4
ST
FAZACLO ORAL TABLET DISPERSIBLE 150 MG
5^
FAZACLO ORAL TABLET DISPERSIBLE 200 MG
5^
fluphenazine decanoate injection solution 25 mg/ml
4
fluphenazine hcl injection solution 2.5 mg/ml
4
fluphenazine hcl oral concentrate 5 mg/ml
4
fluphenazine hcl oral elixir 2.5 mg/5ml
4
fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg
2
GEODON INTRAMUSCULAR* SOLUTION RECONSTITUTED
20 MG
4
haloperidol decanoate intramuscular* solution 100
mg/ml, 50 mg/ml
3
haloperidol lactate injection solution 5 mg/ml
3
haloperidol lactate oral concentrate 2 mg/ml
3
39
Drug Name
Drug
Tier
haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20
mg, 5 mg
3
INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 1.5
MG, 3 MG, 9 MG
4
INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 6
MG
4
INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 117
MG/0.75ML
5^
QL (0.75 ML per 28 days)
MG/ML
5^
MG/1.5ML
5^
MG/0.25ML
4
MG/0.5ML
5^
INVEGA TRINZA INTRAMUSCULAR* SUSPENSION 273
MG/0.875ML
5^
MG/1.315ML
5^
MG/1.75ML
5^
MG/2.625ML
5^
LATUDA ORAL TABLET 120 MG, 40 MG
4
LATUDA ORAL TABLET 20 MG
4
LATUDA ORAL TABLET 60 MG, 80 MG
4
loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50
mg
3
molindone hcl oral tablet 10 mg, 25 mg, 5 mg
4
NUPLAZID ORAL TABLET 17 MG
5^
olanzapine intramuscular* solution reconstituted 10 mg
4
QL (3 EA per 1 day)
olanzapine oral tablet 10 mg, 15 mg, 20 mg
3
olanzapine oral tablet 2.5 mg, 5 mg, 7.5 mg
3
40
Drug Name
Drug
Tier
olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg
4
olanzapine oral tablet dispersible 5 mg
4
paliperidone er oral tablet extended release 24 hr* 1.5
mg, 3 mg, 9 mg
4
paliperidone er oral tablet extended release 24 hr* 6 mg
4
perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg
4
pimozide oral tablet 1 mg, 2 mg
4
quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg,
300 mg, 400 mg, 50 mg
3
REXULTI ORAL TABLET 0.25 MG
5^
REXULTI ORAL TABLET 0.5 MG
5^
REXULTI ORAL TABLET 1 MG
5^
REXULTI ORAL TABLET 2 MG
5^
REXULTI ORAL TABLET 3 MG, 4 MG
5^
RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 12.5 MG, 25 MG
4
RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 37.5 MG, 50 MG
5^
risperidone oral solution 1 mg/ml
4
risperidone oral tablet 0.25 mg, 0.5 mg
2
risperidone oral tablet 1 mg, 2 mg, 3 mg
2
risperidone oral tablet 4 mg
2
risperidone oral tablet dispersible 0.25 mg, 0.5 mg
4
risperidone oral tablet dispersible 1 mg, 2 mg, 3 mg
4
risperidone oral tablet dispersible 4 mg
4
SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG
4
SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG
4
SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 5 MG
4
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24
HR* 150 MG, 200 MG
4
HR* 300 MG, 400 MG
4
41
Drug Name
Drug
Tier
HR* 50 MG
4
thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50
mg
4
PA
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg
3
trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg
3
VERSACLOZ ORAL SUSPENSION 50 MG/ML
5^
VRAYLAR ORAL 1.5 & 3 MG
4
ST
VRAYLAR ORAL CAPSULE 1.5 MG
5^
VRAYLAR ORAL CAPSULE 3 MG
5^
VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG
5^
ziprasidone hcl oral capsule 20 mg, 40 mg
4
ziprasidone hcl oral capsule 60 mg, 80 mg
4
ZYPREXA RELPREVV INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 210 MG, 300 MG
ZYPREXA RELPREVV INTRAMUSCULAR* SUSPENSION
ATTENTION DEFICIT HYPERACTIVITY DISORDER
5^
5^
amphetamine-dextroamphet er oral capsule extended
release 24 hour 10 mg, 5 mg
4
amphetamine-dextroamphet er oral capsule extended
release 24 hour 15 mg, 20 mg, 25 mg, 30 mg
4
amphetamine-dextroamphetamine oral tablet 10 mg
3
amphetamine-dextroamphetamine oral tablet 12.5 mg
3
3
3
3
3
amphetamine-dextroamphetamine oral tablet 7.5 mg
3
guanfacine hcl er oral tablet extended release 24 hr* 1
mg, 2 mg, 3 mg, 4 mg
4
PA
metadate er oral tablet extendedrelease* 20 mg
4
42
Drug Name
Drug
Tier
methylphenidate hcl er oral tablet extendedrelease* 10
mg, 20 mg
4
methylphenidate hcl oral solution 10 mg/5ml
4
methylphenidate hcl oral solution 5 mg/5ml
4
methylphenidate hcl oral tablet 10 mg, 5 mg
3
methylphenidate hcl oral tablet 20 mg
3
STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG
4
STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG
4
STRATTERA ORAL CAPSULE 40 MG
HYPNOTICS
4
HETLIOZ ORAL CAPSULE 20 MG
5^
PA; LA
ROZEREM ORAL TABLET 8 MG
4
SILENOR ORAL TABLET 3 MG
3
SILENOR ORAL TABLET 6 MG
3
temazepam oral capsule 15 mg
2
temazepam oral capsule 7.5 mg
2
zolpidem tartrate oral tablet 10 mg, 5 mg
MIGRAINE
4
dihydroergotamine mesylate injection solution 1 mg/ml
3
RELPAX ORAL TABLET 20 MG, 40 MG
3
rizatriptan benzoate oral tablet 10 mg, 5 mg
3
SUMATRIPTAN NASAL SOLUTION 20 MG/ACT
4
SUMATRIPTAN NASAL SOLUTION 5 MG/ACT
4
sumatriptan succinate oral tablet 100 mg, 25 mg, 50
mg
2
SUMATRIPTAN SUCCINATE REFILL SUBCUTANEOUS* 4
MG/0.5ML
4
sumatriptan succinate refill subcutaneous* 6 mg/0.5ml
4
sumatriptan succinate subcutaneous* 4 mg/0.5ml, 6
mg/0.5ml, 6 mg/0.5ml (auto-injector)
4
sumatriptan succinate subcutaneous* solution 6
mg/0.5ml
4
43
Drug Name
Drug
Tier
MISCELLANEOUS
lithium carbonate er oral tablet extendedrelease* 300
mg, 450 mg
2
lithium carbonate oral capsule 150 mg, 300 mg, 600
mg
1
lithium carbonate oral tablet 300 mg
2
LITHIUM ORAL SOLUTION 8 MEQ/5ML
3
NUEDEXTA ORAL CAPSULE 20-10 MG
3
pyridostigmine bromide oral tablet 60 mg
3
riluzole oral tablet 50 mg
4
PA
tetrabenazine oral tablet 12.5 mg
5^
tetrabenazine oral tablet 25 mg
MULTIPLE SCLEROSIS AGENTS
5^
AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR* 10
MG
5^
PA; LA
BETASERON SUBCUTANEOUS* KIT 0.3 MG
5^
COPAXONE SUBCUTANEOUS* 20 MG/ML
5^
COPAXONE SUBCUTANEOUS* 40 MG/ML
5^
GILENYA ORAL CAPSULE 0.5 MG
5^
TYSABRI INTRAVENOUS* CONCENTRATE 300 MG/15ML
MUSCULOSKELETAL THERAPY AGENTS
5^
PA; LA
baclofen oral tablet 10 mg, 20 mg
2
dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg
4
tizanidine hcl oral tablet 2 mg, 4 mg
NARCOLEPSY/CATAPLEXY
2
NUVIGIL ORAL TABLET 150 MG
3
NUVIGIL ORAL TABLET 200 MG, 250 MG
3
NUVIGIL ORAL TABLET 50 MG
3
XYREM ORAL SOLUTION 500 MG/ML
PSYCHOTHERAPEUTIC-MISC
5^
acamprosate calcium oral tablet delayed release 333
mg
PA; LA; QL (540 ML per 30 days)
4
44
Drug Name
Drug
Tier
buprenorphine hcl sublingual tablet sublingual 2 mg, 8
mg
4
PA
buprenorphine hcl-naloxone hcl sublingual tablet
sublingual 2-0.5 mg, 8-2 mg
4
buproban oral tablet extended release 12 hr* 150 mg
3
bupropion hcl er (smoking det) oral tablet extended
release 12 hr* 150 mg
3
CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG
4
CHANTIX ORAL TABLET 0.5 MG, 1 MG
4
CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG
X 11 & 1 MG X 42
4
disulfiram oral tablet 250 mg, 500 mg
4
naloxone hcl injection solution 0.4 mg/ml, 1 mg/ml
3
naltrexone hcl oral tablet 50 mg
3
NICOTROL NS NASAL SOLUTION 10 MG/ML
4
SUBOXONE SUBLINGUAL FILM 12-3 MG
4
4
ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR,
4 MG/24HR
4
AXIRON TRANSDERMAL SOLUTION 30 MG/ACT
3
SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2
MG
ENDOCRINE AND METABOLIC
ANDROGENS
oxandrolone oral tablet 10 mg
5^
PA
oxandrolone oral tablet 2.5 mg
3
PA
testosterone cypionate intramuscular* solution 100
mg/ml, 200 mg/ml
3
testosterone enanthate intramuscular* solution 200
mg/ml
ANTIDIABETICS, INJECTABLE
3
ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML
3
BYDUREON SUBCUTANEOUS* 2 MG
3
BYETTA 10 MCG PEN SUBCUTANEOUS* 10 MCG/0.04ML
4
45
Drug Name
Drug
Tier
BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.02ML
4
COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 1 ML
3
CVS GAUZE STERILE PAD 2"X2"
3
EXEL COMFORT POINT PEN NEEDLE 29G X 12MM
3
GLOBAL ALCOHOL PREP EASE PAD 70 %
3
HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS*
SOLUTION 500 UNIT/ML
5^
HUMULIN R U-500 KWIKPEN SUBCUTANEOUS* 500
UNIT/ML
5^
LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML
3
LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML
3
LEVEMIR FLEXTOUCH SUBCUTANEOUS* 100 UNIT/ML
3
LEVEMIR SUBCUTANEOUS* SOLUTION 100 UNIT/ML
3
NOVOLIN 70/30 SUBCUTANEOUS* SUSPENSION (70-30)
100 UNIT/ML
3
NOVOLIN N SUBCUTANEOUS* SUSPENSION 100
UNIT/ML
3
NOVOLIN R INJECTION SOLUTION 100 UNIT/ML
3
NOVOLOG FLEXPEN SUBCUTANEOUS* 100 UNIT/ML
3
NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS*
(70-30) 100 UNIT/ML
3
NOVOLOG MIX 70/30 SUBCUTANEOUS* SUSPENSION
(70-30) 100 UNIT/ML
3
NOVOLOG PENFILL SUBCUTANEOUS* 100 UNIT/ML
3
NOVOLOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML
3
PREFERRED PLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML
3
RELI-ON INSULIN SYRINGE 29G 0.3 ML
3
SYMLINPEN 120 SUBCUTANEOUS* 2700 MCG/2.7ML
5^
SYMLINPEN 60 SUBCUTANEOUS* 1500 MCG/1.5ML
4
TOUJEO SOLOSTAR SUBCUTANEOUS* 300 UNIT/ML
3
TRESIBA FLEXTOUCH SUBCUTANEOUS* 100 UNIT/ML,
200 UNIT/ML
3
B/D
PA; QL (10.8 ML per 30 days)
46
Drug Name
Drug
Tier
4
VICTOZA SUBCUTANEOUS* 18 MG/3ML
ANTIDIABETICS, ORAL
3
acarbose oral tablet 100 mg, 25 mg, 50 mg
3
FARXIGA ORAL TABLET 10 MG
3
FARXIGA ORAL TABLET 5 MG
3
glimepiride oral tablet 1 mg
1
1
1
glipizide er oral tablet extended release 24 hr* 10 mg
1
glipizide er oral tablet extended release 24 hr* 2.5 mg
1
glipizide er oral tablet extended release 24 hr* 5 mg
1
glipizide oral tablet 10 mg
1
glipizide oral tablet 5 mg
1
glipizide xl oral tablet extended release 24 hr* 2.5 mg
1
glipizide xl oral tablet extended release 24 hr* 5 mg
1
glipizide-metformin hcl oral tablet 2.5-250 mg
1
glipizide-metformin hcl oral tablet 2.5-500 mg, 5-500
mg
1
INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG,
50-1000 MG
3
INVOKAMET ORAL TABLET 50-500 MG
3
INVOKANA ORAL TABLET 100 MG
3
INVOKANA ORAL TABLET 300 MG
3
JANUMET ORAL TABLET 50-1000 MG, 50-500 MG
3
JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR*
100-1000 MG
3
JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR*
50-1000 MG, 50-500 MG
3
JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG
3
TRULICITY SUBCUTANEOUS* 0.75 MG/0.5ML, 1.5
MG/0.5ML
JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG,
3
2.5-850 MG
47
Drug Name
Drug
Tier
JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24
HR* 2.5-1000 MG
3
JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24
HR* 5-1000 MG
3
metformin hcl er oral tablet extended release 24 hr* 500
mg
1
metformin hcl er oral tablet extended release 24 hr* 750
mg
1
metformin hcl oral tablet 1000 mg
1
1
1
nateglinide oral tablet 120 mg, 60 mg
1
pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg
1
repaglinide oral tablet 0.5 mg, 1 mg
1
repaglinide oral tablet 2 mg
1
TRADJENTA ORAL TABLET 5 MG
3
XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HR*
10-1000 MG, 10-500 MG
3
3
XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HR*
5-1000 MG, 5-500 MG
ANTIDIABETICS, TESTING SUPPLIES
NDC (53885044801); QL (1 EA per
365 days)
ONETOUCH ULTRA 2 KIT W/DEVICE
Part B
ONETOUCH ULTRA BLUE IN VITRO STRIP
NDC (53885024450, 53885024510,
Part B 53885099425); QL (100 EA per 25
days)
ONETOUCH ULTRA MINI KIT W/DEVICE
NDC (53885042101, 53885042001,
53885020801, 53885091101,
Part B
53885091201, 53885041901); QL
(1 EA per 365 days)
ONETOUCH VERIO IN VITRO STRIP
NDC (53885027210, 53885027150,
Part B 53885027025); QL (100 EA per 25
days)
48
Drug Name
Drug
Tier
ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE
Part B
NDC (53885026701); QL (1 EA per
365 days)
ONETOUCH VERIO KIT W/DEVICE
Part B
NDC (53885065701); QL (1 EA per
365 days)
ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE
Part B
NDC (53885039601); QL (1 EA per
365 days)
BISPHOSPHONATES
alendronate sodium oral tablet 10 mg, 40 mg, 5 mg
1
alendronate sodium oral tablet 35 mg, 70 mg
1
ibandronate sodium oral tablet 150 mg
2
B/D; QL (1 EA per 30 days)
pamidronate disodium intravenous* solution 30
mg/10ml, 6 mg/ml, 90 mg/10ml
3
B/D
zoledronic acid intravenous* concentrate 4 mg/5ml
4
B/D
zoledronic acid intravenous* solution 5 mg/100ml
CALCIUM RECEPTOR AGONISTS
4
B/D
SENSIPAR ORAL TABLET 30 MG
3
5^
CHELATING AGENTS
5^
CHEMET ORAL CAPSULE 100 MG
4
DEPEN TITRATABS ORAL TABLET 250 MG
5^
EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500
MG
5^
PA; LA
FERRIPROX ORAL SOLUTION 100 MG/ML
5^
PA; LA
FERRIPROX ORAL TABLET 500 MG
5^
PA; LA
kionex oral powder
4
kionex oral suspension 15 gm/60ml
3
sodium polystyrene sulfonate oral powder
4
sodium polystyrene sulfonate oral suspension 15
gm/60ml
3
sps oral suspension 15 gm/60ml
3
SYPRINE ORAL CAPSULE 250 MG
5^
49
Drug Name
Drug
Tier
CONTRACEPTIVES
blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg
3
blisovi fe 1/20 oral tablet 1-20 mg-mcg
2
camila oral tablet 0.35 mg
3
cryselle-28 oral tablet 0.3-30 mg-mcg
3
cyclafem 1/35 oral tablet 1-35 mg-mcg
3
deblitane oral tablet 0.35 mg
3
ELLA ORAL TABLET 30 MG
4
enpresse-28 oral tablet
2
errin oral tablet 0.35 mg
3
estarylla oral tablet 0.25-35 mg-mcg
3
heather oral tablet 0.35 mg
3
JOLIVETTE ORAL TABLET 0.35 MG
3
junel fe 1.5/30 oral tablet 1.5-30 mg-mcg
3
junel fe 1/20 oral tablet 1-20 mg-mcg
2
kelnor 1/35 oral tablet 1-35 mg-mcg
3
larin fe 1.5/30 oral tablet 1.5-30 mg-mcg
3
larin fe 1/20 oral tablet 1-20 mg-mcg
2
levonest oral tablet
2
levonorgestrel oral tablet 0.75 mg, 1.5 mg
3
levonorg-eth estrad triphasic oral tablet
2
low-ogestrel oral tablet 0.3-30 mg-mcg
3
lyza oral tablet 0.35 mg
3
medroxyprogesterone acetate intramuscular*
suspension 150 mg/ml
2
MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG
3
MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG
2
mono-linyah oral tablet 0.25-35 mg-mcg
3
MONONESSA ORAL TABLET 0.25-35 MG-MCG
3
myzilra oral tablet
2
necon 1/35 (28) oral tablet 1-35 mg-mcg
3
50
Drug Name
Drug
Tier
NORA-BE ORAL TABLET 0.35 MG
3
norethindrone oral tablet 0.35 mg
3
norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg
3
norgestim-eth estrad triphasic oral tablet
0.18/0.215/0.25 mg-35 mcg
2
norlyroc oral tablet 0.35 mg
3
nortrel 1/35 (21) oral tablet 1-35 mg-mcg
3
nortrel 1/35 (28) oral tablet 1-35 mg-mcg
3
NUVARING VAGINAL RING 0.12-0.015 MG/24HR
4
pirmella 1/35 oral tablet 1-35 mg-mcg
3
previfem oral tablet 0.25-35 mg-mcg
3
sharobel oral tablet 0.35 mg
3
sprintec 28 oral tablet 0.25-35 mg-mcg
3
tarina fe 1/20 oral tablet 1-20 mg-mcg
2
tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg
2
TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35
MCG
2
tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg
2
tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg
2
trivora (28) oral tablet
2
velivet oral tablet 0.1/0.125/0.15 -0.025 mg
3
xulane transdermal patch weekly 150-35 mcg/24hr
4
zovia 1/35e (28) oral tablet 1-35 mg-mcg
3
zovia 1/50e (28) oral tablet 1-50 mg-mcg
ENDOMETRIOSIS
3
danazol oral capsule 100 mg, 200 mg, 50 mg
4
SYNAREL NASAL SOLUTION 2 MG/ML
ENZYME REPLACEMENTS
5^
ADAGEN INTRAMUSCULAR* SOLUTION 250 UNIT/ML
5^
PA; LA
ALDURAZYME INTRAVENOUS* SOLUTION 2.9 MG/5ML
5^
PA; LA
CARBAGLU ORAL TABLET 200 MG
5^
PA; LA
CERDELGA ORAL CAPSULE 84 MG
5^
PA
51
Drug Name
Drug
Tier
CEREZYME INTRAVENOUS* SOLUTION RECONSTITUTED
200 UNIT, 400 UNIT
5^
PA; LA
CYSTADANE ORAL POWDER
5^
LA
CYSTAGON ORAL CAPSULE 150 MG, 50 MG
4
PA; LA
FABRAZYME INTRAVENOUS* SOLUTION
5^
PA; LA
KUVAN ORAL PACKET 100 MG, 500 MG
5^
PA; LA
KUVAN ORAL TABLET SOLUBLE 100 MG
5^
PA; LA
levocarnitine intravenous* solution 200 mg/ml
3
B/D
levocarnitine oral solution 1 gm/10ml
3
B/D
levocarnitine oral tablet 330 mg
3
B/D
LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED
50 MG
5^
PA; LA
MYOZYME INTRAVENOUS* SOLUTION RECONSTITUTED
50 MG
5^
PA; LA
NAGLAZYME INTRAVENOUS* SOLUTION 1 MG/ML
5^
PA; LA
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG
5^
PA; LA
ORFADIN ORAL SUSPENSION 4 MG/ML
5^
PA; LA
RAVICTI ORAL LIQUID† 1.1 GM/ML
5^
PA
ZAVESCA ORAL CAPSULE 100 MG
ESTROGENS
5^
PA; LA
DELESTROGEN INTRAMUSCULAR* OIL 10 MG/ML
4
estrace vaginal cream 0.1 mg/gm
4
estradiol oral tablet 0.5 mg, 1 mg, 2 mg
4
PA
estradiol transdermal patch weekly 0.025 mg/24hr,
0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr
4
PA
estradiol valerate intramuscular* oil 20 mg/ml, 40
mg/ml
3
fyavolv oral tablet 1-5 mg-mcg
4
PA
jinteli oral tablet 1-5 mg-mcg
4
PA
norethindrone-eth estradiol oral tablet 1-5 mg-mcg
4
PA
52
Drug Name
Drug
Tier
GLUCOCORTICOIDS
a-hydrocort injection solution reconstituted 100 mg
2
cortisone acetate oral tablet 25 mg
4
dexamethasone intensol oral concentrate 1 mg/ml
3
dexamethasone oral elixir 0.5 mg/5ml
3
dexamethasone oral solution 0.5 mg/5ml
3
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5
mg, 2 mg, 4 mg, 6 mg
2
dexamethasone sod phosphate pf injection solution 10
mg/ml
2
dexamethasone sodium phosphate injection solution 10
mg/ml, 100 mg/10ml, 120 mg/30ml, 20 mg/5ml, 4
mg/ml
2
fludrocortisone acetate oral tablet 0.1 mg
2
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg
3
methylprednisolone acetate injection suspension 40
mg/ml, 80 mg/ml
2
methylprednisolone oral 4 mg
3
methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8
mg
3
methylprednisolone sodium succ injection solution
reconstituted 1 gm, 125 mg, 40 mg
3
prednisolone oral solution 15 mg/5ml
1
prednisolone sodium phosphate oral solution 15 mg/5ml
2
prednisone intensol oral concentrate 5 mg/ml
3
prednisone oral 10 mg (21), 10 mg (48), 5 mg (21), 5
mg (48)
2
prednisone oral solution 5 mg/5ml
3
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5
mg, 50 mg
1
SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED
250 MG
4
53
Drug Name
Drug
Tier
GLUCOSE ELEVATING AGENTS
GLUCAGEN HYPOKIT INJECTION SOLUTION
RECONSTITUTED 1 MG
3
GLUCAGON EMERGENCY INJECTION KIT 1 MG
3
KORLYM ORAL TABLET 300 MG
5^
PROGLYCEM ORAL SUSPENSION 50 MG/ML
HUMAN GROWTH HORMONES
PA; LA
4
NORDITROPIN FLEXPRO SUBCUTANEOUS* SOLUTION 10
MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML
MISCELLANEOUS
5^
cabergoline oral tablet 0.5 mg
4
calcitonin (salmon) nasal solution 200 unit/act
3
FORTICAL NASAL SOLUTION 200 UNIT/ACT
3
PA
INCRELEX SUBCUTANEOUS* SOLUTION 40 MG/4ML
5^
PA; LA
MIACALCIN INJECTION SOLUTION 200 UNIT/ML
5^
B/D
4
PA
5^
PA
octreotide acetate injection solution 100 mcg/ml, 50
mcg/ml
octreotide acetate injection solution 1000 mcg/ml, 200
mcg/ml, 500 mcg/ml
PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML
4
raloxifene hcl oral tablet 60 mg
3
SIGNIFOR SUBCUTANEOUS* SOLUTION 0.3 MG/ML, 0.6
MG/ML, 0.9 MG/ML
5^
PA; LA
SOMATULINE DEPOT SUBCUTANEOUS* SOLUTION 120
MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML
5^
PA
SOMAVERT SUBCUTANEOUS* SOLUTION
RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG
5^
PA; LA
XGEVA SUBCUTANEOUS* SOLUTION 120 MG/1.7ML
PARATHYROID HORMONES
5^
PA
FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML
5^
PA; QL (2.4 ML per 28 days)
NATPARA SUBCUTANEOUS* 100 MCG, 25 MCG, 50
MCG, 75 MCG
5^
PA
54
Drug Name
Drug
Tier
PHOSPHATE BINDER AGENTS
calcium acetate (phos binder) oral capsule 667 mg
3
calcium acetate (phos binder) oral tablet 667 mg
3
RENVELA ORAL PACKET 0.8 GM, 2.4 GM
5^
RENVELA ORAL TABLET 800 MG
PROGESTINS
5^
medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg,
5 mg
norethindrone acetate oral tablet 5 mg
THYROID AGENTS
1
3
levothyroxine sodium oral tablet 100 mcg, 112 mcg,
125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25
mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg
2
LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG,
137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50
MCG, 75 MCG, 88 MCG
2
liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg
3
methimazole oral tablet 10 mg, 5 mg
2
propylthiouracil oral tablet 50 mg
3
SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125
MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25
MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG
4
UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125
MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300
MCG, 50 MCG, 75 MCG, 88 MCG
VASOPRESSINS
2
DESMOPRESSIN ACE RHINAL TUBE NASAL SOLUTION
0.01 %
4
desmopressin ace spray refrig nasal solution 0.01 %
4
desmopressin acetate injection solution 4 mcg/ml
4
desmopressin acetate oral tablet 0.1 mg, 0.2 mg
3
desmopressin acetate spray nasal solution 0.01 %
4
55
Drug Name
Drug
Tier
GASTROINTESTINAL
ANTIEMETICS
compro suppository 25 mg
4
dronabinol oral capsule 10 mg
5^
dronabinol oral capsule 2.5 mg, 5 mg
4
EMEND ORAL CAPSULE 125 MG, 40 MG, 80 & 125 MG,
80 MG
4
B/D
EMEND ORAL SUSPENSION RECONSTITUTED 125 MG
4
B/D
granisetron hcl intravenous* solution 0.1 mg/ml, 1
mg/ml, 4 mg/4ml
3
granisetron hcl oral tablet 1 mg
4
meclizine hcl oral tablet 12.5 mg, 25 mg
2
metoclopramide hcl injection solution 5 mg/ml
2
metoclopramide hcl oral solution 5 mg/5ml
2
metoclopramide hcl oral tablet 10 mg, 5 mg
1
ondansetron hcl injection solution 4 mg/2ml, 4 mg/2ml
(2ml syringe), 40 mg/20ml
3
ondansetron hcl oral solution 4 mg/5ml
4
ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg
3
ondansetron oral tablet dispersible 4 mg, 8 mg
2
phenadoz suppository 12.5 mg, 25 mg
4
PA
phenergan suppository 12.5 mg, 25 mg, 50 mg
4
PA
prochlorperazine edisylate injection solution 5 mg/ml
3
prochlorperazine maleate oral tablet 10 mg, 5 mg
1
prochlorperazine suppository 25 mg
4
promethazine hcl injection solution 25 mg/ml, 50 mg/ml
4
PA
promethazine hcl oral syrup 6.25 mg/5ml
4
PA
promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg
4
PA
promethazine hcl suppository 12.5 mg, 25 mg, 50 mg
4
PA
promethegan suppository 12.5 mg, 25 mg, 50 mg
4
PA
TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 72
HR 1 MG/3DAYS
4
B/D
56
Drug Name
Drug
Tier
ANTISPASMODICS
dicyclomine hcl oral capsule 10 mg
1
dicyclomine hcl oral solution 10 mg/5ml
3
dicyclomine hcl oral tablet 20 mg
1
glycopyrrolate injection solution 4 mg/20ml
4
glycopyrrolate oral tablet 1 mg, 2 mg
H2-RECEPTOR ANTAGONISTS
3
famotidine intravenous* solution 20 mg/2ml, 200
mg/20ml, 40 mg/4ml
2
famotidine oral tablet 20 mg, 40 mg
1
famotidine premixed intravenous* solution 20-0.9
mg/50ml-%
2
ranitidine hcl injection solution 150 mg/6ml
3
ranitidine hcl injection solution 50 mg/2ml
2
ranitidine hcl oral syrup 15 mg/ml
3
ranitidine hcl oral tablet 150 mg, 300 mg
INFLAMMATORY BOWEL DISEASE
1
APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR
0.375 GM
3
ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG
4
balsalazide disodium oral capsule 750 mg
4
budesonide oral capsule delayed release particles 3 mg
5^
CANASA SUPPOSITORY 1000 MG
5^
colocort enema 100 mg/60ml
4
DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG
4
DIPENTUM ORAL CAPSULE 250 MG
5^
HYDROCORTISONE ENEMA 100 MG/60ML
4
mesalamine enema 4 gm
4
mesalamine-cleanser kit 4 gm
4
sulfasalazine oral tablet 500 mg
3
sulfasalazine oral tablet delayed release 500 mg
3
57
Drug Name
Drug
Tier
UCERIS ORAL TABLET EXTENDED RELEASE 24 HR* 9
MG
LAXATIVES
5^
constulose oral solution 10 gm/15ml
2
enulose oral solution 10 gm/15ml
2
gavilyte-c oral solution reconstituted 240 gm
2
gavilyte-g oral solution reconstituted 236 gm
2
gavilyte-h oral kit 5-210 mg-gm
2
gavilyte-n with flavor pack oral solution reconstituted
420 gm
2
generlac oral solution 10 gm/15ml
2
GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM,
236 GM
3
lactulose encephalopathy oral solution 10 gm/15ml
2
lactulose oral solution 10 gm/15ml
2
MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM
4
NULYTELY WITH FLAVOR PACKS ORAL SOLUTION
RECONSTITUTED 420 GM
3
PEG 3350/ELECTROLYTES ORAL SOLUTION
2
peg 3350-kcl-na bicarb-nacl oral solution reconstituted
420 gm
2
PEG-3350/ELECTROLYTES ORAL SOLUTION
2
polyethylene glycol 3350 oral packet
2
polyethylene glycol 3350 oral powder
2
RELISTOR SUBCUTANEOUS* SOLUTION 12 MG/0.6ML,
12 MG/0.6ML (0.6ML SYRINGE), 8 MG/0.4ML
5^
SUPREP BOWEL PREP ORAL SOLUTION
4
trilyte oral solution reconstituted 420 gm
MISCELLANEOUS
2
alosetron hcl oral tablet 0.5 mg, 1 mg
5^
AMITIZA ORAL CAPSULE 24 MCG, 8 MCG
3
PA
PA
58
Drug Name
Drug
Tier
CARAFATE ORAL SUSPENSION 1 GM/10ML
3
cromolyn sodium oral concentrate 100 mg/5ml
5^
diphenoxylate-atropine oral liquid† 2.5-0.025 mg/5ml
3
diphenoxylate-atropine oral tablet 2.5-0.025 mg
3
GATTEX SUBCUTANEOUS* KIT 5 MG
5^
LINZESS ORAL CAPSULE 145 MCG
3
LINZESS ORAL CAPSULE 290 MCG
3
loperamide hcl oral capsule 2 mg
2
misoprostol oral tablet 100 mcg, 200 mcg
3
MOVANTIK ORAL TABLET 12.5 MG
3
MOVANTIK ORAL TABLET 25 MG
3
sucralfate oral tablet 1 gm
3
ursodiol oral capsule 300 mg
4
ursodiol oral tablet 250 mg, 500 mg
4
XIFAXAN ORAL TABLET 550 MG
PANCREATIC ENZYMES
5^
CREON ORAL CAPSULE DELAYED RELEASE PARTICLES
12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000
UNIT, 6000 UNIT
ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES
10000 UNIT, 15000 UNIT, 20000 UNIT, 25000 UNIT,
3000-10000 UNIT, 40000 UNIT, 5000 UNIT
PROTON PUMP INHIBITORS
PA; LA
PA
3
4
DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG,
60 MG
3
esomeprazole sodium intravenous* solution
reconstituted 20 mg, 40 mg
4
NEXIUM ORAL CAPSULE DELAYED RELEASE 20 MG, 40
MG
2
NEXIUM ORAL PACKET 10 MG, 20 MG, 40 MG
3
NEXIUM ORAL PACKET 2.5 MG, 5 MG
3
omeprazole oral capsule delayed release 10 mg, 20 mg,
40 mg
1
59
Drug Name
Drug
Tier
pantoprazole sodium oral tablet delayed release 20 mg,
40 mg
GENITOURINARY
2
BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl er oral tablet extended release 24 hr* 10
mg
2
dutasteride oral capsule 0.5 mg
4
dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg
4
finasteride oral tablet 5 mg
2
tamsulosin hcl oral capsule 0.4 mg
MISCELLANEOUS
3
bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg,
50 mg
3
ELMIRON ORAL CAPSULE 100 MG
4
POTASSIUM CITRATE ER ORAL TABLET
EXTENDEDRELEASE* 10 MEQ (1080 MG), 5 MEQ (540
MG)
URINARY ANTISPASMODICS
4
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR*
25 MG
4
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR*
50 MG
4
oxybutynin chloride er oral tablet extended release 24
hr* 10 mg, 15 mg
3
oxybutynin chloride er oral tablet extended release 24
hr* 5 mg
3
oxybutynin chloride oral syrup 5 mg/5ml
1
oxybutynin chloride oral tablet 5 mg
3
tolterodine tartrate er oral capsule extended release 24
hour 2 mg, 4 mg
4
tolterodine tartrate oral tablet 1 mg, 2 mg
4
TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR* 4
MG, 8 MG
3
VESICARE ORAL TABLET 10 MG, 5 MG
4
60
Drug Name
Drug
Tier
VAGINAL ANTI-INFECTIVES
clindamycin phosphate vaginal cream 2 %
4
metronidazole vaginal gel 0.75 %
3
terconazole vaginal cream 0.4 %, 0.8 %
3
terconazole vaginal suppository 80 mg
4
VANDAZOLE VAGINAL GEL 0.75 %
3
ZAZOLE VAGINAL CREAM 0.8 %
HEMATOLOGIC
3
ANTICOAGULANTS
COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG,
3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG
4
ELIQUIS ORAL TABLET 2.5 MG, 5 MG
3
enoxaparin sodium injection solution 300 mg/3ml
4
enoxaparin sodium subcutaneous* solution 100 mg/ml,
120 mg/0.8ml, 150 mg/ml
enoxaparin sodium subcutaneous* solution 30
mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml
5^
4
fondaparinux sodium subcutaneous* solution 10
mg/0.8ml, 5 mg/0.4ml, 7.5 mg/0.6ml
5^
fondaparinux sodium subcutaneous* solution 2.5
mg/0.5ml
4
HEPARIN (PORCINE) IN D5W INTRAVENOUS* SOLUTION
40-5 UNIT/ML-%, 50-5 UNIT/ML-%
3
HEPARIN (PORCINE) IN NACL INJECTION SOLUTION
100-0.45 UNIT/ML-%, 50-0.45 UNIT/ML-%
3
HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS*
SOLUTION 100 UNIT/ML
3
heparin sodium (porcine) injection solution 1000 unit/ml,
10000 unit/ml, 20000 unit/ml, 5000 unit/ml
3
B/D
HEPARIN SODIUM (PORCINE) INJECTION SOLUTION
2500 UNIT/ML
3
B/D
HEPARIN SODIUM (PORCINE) INTRAVENOUS* SOLUTION
2000 UNIT/ML
3
B/D
61
Drug Name
Drug
Tier
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4
mg, 5 mg, 6 mg, 7.5 mg
1
PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG
3
warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg,
3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
1
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG
3
XARELTO STARTER PACK ORAL 15 & 20 MG
HEMATOPOIETIC GROWTH FACTORS
3
GRANIX SUBCUTANEOUS* 300 MCG/0.5ML, 480
MCG/0.8ML
5^
PA
LEUKINE INTRAVENOUS* SOLUTION RECONSTITUTED
250 MCG
5^
PA
MOZOBIL SUBCUTANEOUS* SOLUTION 24 MG/1.2ML
5^
PA
NEUMEGA SUBCUTANEOUS* SOLUTION
RECONSTITUTED 5 MG
5^
NEUPOGEN INJECTION 300 MCG/0.5ML, 480
MCG/0.8ML
5^
PA
NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480
MCG/1.6ML
5^
PA
PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000
UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML
3
PA
5^
PA
PROCRIT INJECTION SOLUTION 20000 UNIT/ML, 40000
UNIT/ML
MISCELLANEOUS
anagrelide hcl oral capsule 0.5 mg, 1 mg
4
cilostazol oral tablet 100 mg, 50 mg
2
CINRYZE INTRAVENOUS* SOLUTION RECONSTITUTED
500 UNIT
5^
PA; LA
FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML
5^
PA
pentoxifylline er oral tablet extendedrelease* 400 mg
3
PROMACTA ORAL TABLET 12.5 MG
5^
PROMACTA ORAL TABLET 25 MG
5^
5^
62
Drug Name
Drug
Tier
5^
tranexamic acid intravenous* solution 1000 mg/10ml
3
tranexamic acid oral tablet 650 mg
PLATELET AGGREGATION INHIBITORS
4
AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12
HOUR 25-200 MG
2
BRILINTA ORAL TABLET 60 MG, 90 MG
3
clopidogrel bisulfate oral tablet 75 mg
2
EFFIENT ORAL TABLET 10 MG, 5 MG
4
ZONTIVITY ORAL TABLET 2.08 MG
IMMUNOLOGIC AGENTS
4
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS
(DMARDS)
CIMZIA PREFILLED SUBCUTANEOUS* KIT 2 X 200
MG/ML
5^
PA
CIMZIA STARTER KIT SUBCUTANEOUS* KIT 6 X 200
MG/ML
5^
PA
CIMZIA SUBCUTANEOUS* KIT 2 X 200 MG
5^
PA
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS*
40 MG/0.8ML, 40 MG/0.8ML (6 PACK)
5^
PA
HUMIRA PEN SUBCUTANEOUS* 40 MG/0.8ML
5^
PA
HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 40
MG/0.8ML
5^
PA
HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* 40
MG/0.8ML
5^
PA
HUMIRA SUBCUTANEOUS* 10 MG/0.2ML, 20 MG/0.4ML,
40 MG/0.8ML
5^
PA
hydroxychloroquine sulfate oral tablet 200 mg
4
leflunomide oral tablet 10 mg, 20 mg
3
methotrexate oral tablet 2.5 mg
3
REMICADE INTRAVENOUS* SOLUTION RECONSTITUTED
100 MG
5^
PA
63
Drug Name
Drug
Tier
IMMUNOGLOBULINS
BIVIGAM INTRAVENOUS* SOLUTION 10 GM/100ML, 5
GM/50ML
5^
PA
CARIMUNE NF INTRAVENOUS* SOLUTION
RECONSTITUTED 12 GM, 6 GM
5^
PA
FLEBOGAMMA DIF INTRAVENOUS* SOLUTION 0.5
GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5
GM/50ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML,
5 GM/50ML
5^
PA
FLEBOGAMMA INTRAVENOUS* SOLUTION 0.5 GM/10ML,
10 GM/200ML, 2.5 GM/50ML, 5 GM/100ML
5^
PA
3
B/D
GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10
GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30
GM/300ML, 5 GM/50ML
5^
PA
GAMMAGARD S/D INTRAVENOUS* SOLUTION
RECONSTITUTED 2.5 GM
5^
PA
GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION
RECONSTITUTED 10 GM, 5 GM
5^
PA
GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10
GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML
5^
PA
GAMMAPLEX INTRAVENOUS* SOLUTION 10 GM/200ML,
2.5 GM/50ML, 5 GM/100ML
5^
PA
GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10
GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40
GM/400ML, 5 GM/50ML
5^
PA
OCTAGAM INTRAVENOUS* SOLUTION 1 GM/20ML, 10
GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 25 GM/500ML,
5 GM/100ML
5^
PA
5^
PA
5^
PA; LA
GAMASTAN S/D INTRAMUSCULAR* INJECTABLE
PRIVIGEN INTRAVENOUS* SOLUTION 10 GM/100ML, 20
GM/200ML, 40 GM/400ML, 5 GM/50ML
IMMUNOMODULATORS
ACTIMMUNE SUBCUTANEOUS* SOLUTION 2000000
UNIT/0.5ML
64
Drug Name
Drug
Tier
ARCALYST SUBCUTANEOUS* SOLUTION
5^
PA
INTRON A INJECTION SOLUTION 10000000 UNIT/ML,
6000000 UNIT/ML
5^
B/D
INTRON A INJECTION SOLUTION RECONSTITUTED
10000000 UNIT, 18000000 UNIT, 50000000 UNIT
5^
B/D
REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20
MG, 25 MG, 5 MG
5^
PA; LA
5^
PA
azathioprine oral tablet 50 mg
3
B/D
azathioprine sodium injection solution reconstituted 100
mg
4
B/D
BENLYSTA INTRAVENOUS* SOLUTION RECONSTITUTED
120 MG, 400 MG
5^
PA
cyclosporine modified oral capsule 100 mg, 25 mg, 50
mg
3
B/D
cyclosporine modified oral solution 100 mg/ml
3
B/D
cyclosporine oral capsule 100 mg, 25 mg
4
B/D
gengraf oral capsule 100 mg, 25 mg, 50 mg
3
B/D
gengraf oral solution 100 mg/ml
3
B/D
mycophenolate mofetil oral capsule 250 mg
4
B/D
5^
B/D
mycophenolate mofetil oral tablet 500 mg
4
B/D
mycophenolic acid oral tablet delayed release 180 mg
4
B/D
mycophenolic acid oral tablet delayed release 360 mg
5^
B/D
NEORAL ORAL CAPSULE 100 MG, 25 MG
3
B/D
NEORAL ORAL SOLUTION 100 MG/ML
3
B/D
5^
B/D
4
B/D
THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG,
50 MG
IMMUNOSUPPRESSANTS
mycophenolate mofetil oral suspension reconstituted
200 mg/ml
NULOJIX INTRAVENOUS* SOLUTION RECONSTITUTED
250 MG
PROGRAF ORAL CAPSULE 0.5 MG, 1 MG
65
Drug Name
Drug
Tier
PROGRAF ORAL CAPSULE 5 MG
5^
B/D
RAPAMUNE ORAL SOLUTION 1 MG/ML
5^
B/D
SANDIMMUNE ORAL SOLUTION 100 MG/ML
3
B/D
sirolimus oral tablet 0.5 mg, 1 mg
4
B/D
5^
B/D
4
B/D
5^
B/D
4
B/D
5^
B/D
ACTHIB INTRAMUSCULAR* SOLUTION RECONSTITUTED
3
NM
ADACEL INTRAMUSCULAR* SUSPENSION 5-2-15.5
LF-MCG/0.5
3
NM
BCG VACCINE INJECTION INJECTABLE
3
NM
BEXSERO INTRAMUSCULAR*
3
NM
BOOSTRIX INTRAMUSCULAR* SUSPENSION 5-2.5-18.5 ,
5-2.5-18.5 (0.5ML SYRINGE)
3
NM
CERVARIX INTRAMUSCULAR* SUSPENSION
3
NM
COMVAX INTRAMUSCULAR* SUSPENSION 7.5-5
MCG/0.5ML
3
NM
DAPTACEL INTRAMUSCULAR* SUSPENSION 10-15-5
3
NM
DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR*
SUSPENSION 25-5 LFU/0.5ML
3
B/D; NM
ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 10
MCG/0.5ML (0.5ML SYRINGE), 20 MCG/ML
3
B/D; NM
GARDASIL 9 INTRAMUSCULAR*
3
NM
GARDASIL 9 INTRAMUSCULAR* SUSPENSION
3
NM
GARDASIL INTRAMUSCULAR* SUSPENSION , (0.5ML
SYRINGE)
3
NM
HAVRIX INTRAMUSCULAR* SUSPENSION 1440 EL U/ML,
720 EL U/0.5ML
3
NM
HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG
3
NM
SIROLIMUS ORAL TABLET 2 MG
tacrolimus oral capsule 0.5 mg, 1 mg
tacrolimus oral capsule 5 mg
ZORTRESS ORAL TABLET 0.25 MG
ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG
VACCINES
66
Drug Name
Drug
Tier
IMOVAX RABIES INTRAMUSCULAR* INJECTABLE 2.5
UNIT/ML
3
NM
INFANRIX INTRAMUSCULAR* SUSPENSION 25-58-10
3
NM
IPOL INJECTION INJECTABLE
3
NM
IXIARO INTRAMUSCULAR* SUSPENSION
3
NM
KINRIX INTRAMUSCULAR* SUSPENSION
3
NM
MENACTRA INTRAMUSCULAR* INJECTABLE
3
NM
MENHIBRIX INTRAMUSCULAR* SOLUTION
RECONSTITUTED 5-5-2.5 MCG
3
NM
MENOMUNE SUBCUTANEOUS* INJECTABLE
3
NM
MENVEO INTRAMUSCULAR* SOLUTION RECONSTITUTED
3
NM
M-M-R II SUBCUTANEOUS* INJECTABLE
3
NM
PEDIARIX INTRAMUSCULAR* SUSPENSION
3
NM
PEDVAX HIB INTRAMUSCULAR* SUSPENSION 7.5
MCG/0.5ML
3
NM
PENTACEL INTRAMUSCULAR* SUSPENSION
RECONSTITUTED
3
NM
PROQUAD SUBCUTANEOUS* INJECTABLE
3
NM
QUADRACEL INTRAMUSCULAR* SUSPENSION
3
NM
RABAVERT INTRAMUSCULAR* SUSPENSION
RECONSTITUTED
3
NM
RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML,
10 MCG/ML (1ML SYRINGE), 40 MCG/ML, 5 MCG/0.5ML
3
B/D; NM
ROTARIX ORAL SUSPENSION RECONSTITUTED
3
NM
ROTATEQ ORAL SOLUTION
3
NM
5^
NM
SYNAGIS INTRAMUSCULAR* SOLUTION 100 MG/ML, 50
MG/0.5ML
TENIVAC INTRAMUSCULAR* INJECTABLE 5-2 LFU
3
B/D; NM
TETANUS-DIPHTHERIA TOXOIDS TD INTRAMUSCULAR*
SUSPENSION 2-2 LF/0.5ML
3
B/D; NM
TRUMENBA INTRAMUSCULAR*
3
NM
TWINRIX INTRAMUSCULAR* SUSPENSION 720-20
3
NM
67
Drug Name
Drug
Tier
TYPHIM VI INTRAMUSCULAR* SOLUTION 25 MCG/0.5ML,
25 MCG/0.5ML (0.5ML SYRINGE)
3
NM
VAQTA INTRAMUSCULAR* SUSPENSION 25 UNIT/0.5ML,
50 UNIT/ML
3
NM
VARIVAX SUBCUTANEOUS* INJECTABLE 1350
PFU/0.5ML
3
NM
YF-VAX SUBCUTANEOUS* INJECTABLE
3
NM
3
NM; QL (1 EA per 999 days)
ZOSTAVAX SUBCUTANEOUS* SOLUTION
RECONSTITUTED 19400 UNT/0.65ML
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
KLOR-CON 10 ORAL TABLET EXTENDEDRELEASE* 10
MEQ
3
klor-con m10 oral tablet extendedrelease* 10 meq
2
2
2
klor-con oral packet 20 meq
4
KLOR-CON ORAL TABLET EXTENDEDRELEASE* 8 MEQ
3
klor-con sprinkle oral capsule extended release* 10
meq, 8 meq
3
MAGNESIUM SULFATE IN D5W INTRAVENOUS*
SOLUTION 10-5 MG/ML-%, 20-5 MG/ML-%
3
MAGNESIUM SULFATE INJECTION SOLUTION 50 %
2
magnesium sulfate injection solution 50 % (10ml
syringe)
2
MAGNESIUM SULFATE INTRAVENOUS* SOLUTION 20
GM/500ML, 4 GM/100ML, 4 GM/50ML, 40 GM/1000ML
3
magnesium sulfate solution 2 gm/50ml intravenous* 2
gm/50ml
2
MAGNESIUM SULFATE SOLUTION 2 GM/50ML
INTRAVENOUS* 2 GM/50ML
3
potassium chloride crys er oral tablet extendedrelease*
10 meq, 20 meq
2
68
Drug Name
Drug
Tier
potassium chloride er oral capsule extended release* 10
meq, 8 meq
3
POTASSIUM CHLORIDE ER ORAL TABLET
EXTENDEDRELEASE* 10 MEQ, 20 MEQ
3
potassium chloride er oral tablet extendedrelease* 8
meq
3
potassium chloride oral solution 20 meq/15ml (10%), 40
meq/15ml (20%)
3
SODIUM CHLORIDE INJECTION SOLUTION 2.5 MEQ/ML
2
sodium fluoride oral tablet 2.2 (1 f) mg
2
TPN ELECTROLYTES INTRAVENOUS* SOLUTION
IV NUTRITION
4
B/D
AMINOSYN II INTRAVENOUS* SOLUTION 10 %, 7 %, 8.5
%
4
B/D
AMINOSYN II/ELECTROLYTES INTRAVENOUS* SOLUTION
8.5 %
4
B/D
AMINOSYN INTRAVENOUS* SOLUTION 10 %, 8.5 %
4
B/D
AMINOSYN M INTRAVENOUS* SOLUTION 3.5 %
4
B/D
AMINOSYN/ELECTROLYTES INTRAVENOUS* SOLUTION 7
%, 8.5 %
4
B/D
AMINOSYN-HBC INTRAVENOUS* SOLUTION 7 %
4
B/D
AMINOSYN-PF INTRAVENOUS* SOLUTION 10 %, 7 %
4
B/D
AMINOSYN-RF INTRAVENOUS* SOLUTION 5.2 %
4
B/D
CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS* SOLUTION
2.75 %
4
B/D
CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS*
SOLUTION 4.25 %
4
B/D
SOLUTION 4.25 %
4
B/D
SOLUTION 4.25 %
4
B/D
CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS* SOLUTION
4.25 %
4
B/D
69
Drug Name
Drug
Tier
CLINIMIX/DEXTROSE (5/15) INTRAVENOUS* SOLUTION 5
%
4
B/D
%
4
B/D
%
4
B/D
FREAMINE HBC INTRAVENOUS* SOLUTION 6.9 %
4
B/D
FREAMINE III INTRAVENOUS* SOLUTION 10 %
4
B/D
HEPATAMINE INTRAVENOUS* SOLUTION 8 %
4
B/D
INTRALIPID INTRAVENOUS* EMULSION 20 %, 30 %
4
B/D
NEPHRAMINE INTRAVENOUS* SOLUTION 5.4 %
4
B/D
NUTRILIPID INTRAVENOUS* EMULSION 20 %
4
B/D
premasol intravenous* solution 10 %
4
B/D
premasol intravenous* solution 6 %
2
B/D
PROCALAMINE INTRAVENOUS* SOLUTION 3 %
4
B/D
PROSOL INTRAVENOUS* SOLUTION 20 %
4
B/D
TRAVASOL INTRAVENOUS* SOLUTION 10 %
4
B/D
TROPHAMINE INTRAVENOUS* SOLUTION 10 %
IV REPLACEMENT SOLUTIONS
4
B/D
DEXTROSE 5%/ELECTROLYTE #48 INTRAVENOUS*
SOLUTION
3
DEXTROSE IN LACTATED RINGERS INTRAVENOUS*
SOLUTION 5 %
2
DEXTROSE INTRAVENOUS* SOLUTION 10 %, 5 %, 50 %,
70 %
2
DEXTROSE-NACL INTRAVENOUS* SOLUTION 10-0.2 %
3
DEXTROSE-NACL INTRAVENOUS* SOLUTION 10-0.45 %,
2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.3 %, 5-0.33 %,
5-0.45 %, 5-0.9 %
2
ISOLYTE-P IN D5W INTRAVENOUS* SOLUTION
4
ISOLYTE-S INTRAVENOUS* SOLUTION
4
70
Drug Name
Drug
Tier
KCL IN DEXTROSE-NACL INTRAVENOUS* SOLUTION
10-5-0.45 MEQ/L-%-%, 20-5-0.2 MEQ/L-%-%,
20-5-0.33 MEQ/L-%-%, 20-5-0.45 MEQ/L-%-%,
20-5-0.9 MEQ/L-%-%, 30-5-0.45 MEQ/L-%-%,
40-5-0.45 MEQ/L-%-%, 40-5-0.9 MEQ/L-%-%
2
KCL IN DEXTROSE-NACL INTRAVENOUS* SOLUTION
20-5-0.225 MEQ/L-%-%
3
LACTATED RINGERS INTRAVENOUS* SOLUTION
2
NORMOSOL-M IN D5W INTRAVENOUS* SOLUTION
4
NORMOSOL-R IN D5W INTRAVENOUS* SOLUTION
4
NORMOSOL-R PH 7.4 INTRAVENOUS* SOLUTION
4
PLASMA-LYTE 148 INTRAVENOUS* SOLUTION
4
PLASMA-LYTE A INTRAVENOUS* SOLUTION
4
PLASMA-LYTE-56 IN D5W INTRAVENOUS* SOLUTION
4
POTASSIUM CHLORIDE IN DEXTROSE INTRAVENOUS*
SOLUTION 20-5 MEQ/L-%, 40-5 MEQ/L-%
2
potassium chloride in nacl intravenous* solution 20-0.45
meq/l-%
2
POTASSIUM CHLORIDE IN NACL INTRAVENOUS*
SOLUTION 20-0.9 MEQ/L-%, 40-0.9 MEQ/L-%
2
POTASSIUM CHLORIDE INTRAVENOUS* SOLUTION 0.4
MEQ/ML, 10 MEQ/100ML, 10 MEQ/50ML, 20
MEQ/100ML, 40 MEQ/100ML
2
potassium chloride intravenous* solution 2 meq/ml
2
RINGERS INTRAVENOUS* SOLUTION
2
SODIUM CHLORIDE INTRAVENOUS* SOLUTION 0.45 %,
0.9 %, 3 %, 5 %
VITAMINS
2
calcitriol intravenous* solution 1 mcg/ml
4
B/D
calcitriol oral capsule 0.25 mcg, 0.5 mcg
3
B/D
calcitriol oral solution 1 mcg/ml
4
B/D
paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg
4
B/D
prenatal oral tablet 27-1 mg
2
71
Drug Name
Drug
Tier
OPHTHALMIC
ANTIALLERGICS
azelastine hcl ophthalmic solution 0.05 %
3
BEPREVE OPHTHALMIC SOLUTION 1.5 %
3
cromolyn sodium ophthalmic solution 4 %
2
LASTACAFT OPHTHALMIC SOLUTION 0.25 %
4
PATADAY OPHTHALMIC SOLUTION 0.2 %
3
PAZEO OPHTHALMIC SOLUTION 0.7 %
ANTIGLAUCOMA
3
ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %
3
AZOPT OPHTHALMIC SUSPENSION 1 %
3
betaxolol hcl ophthalmic solution 0.5 %
3
BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %
3
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.15
%
3
brimonidine tartrate ophthalmic solution 0.2 %
2
carteolol hcl ophthalmic solution 1 %
2
COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 %
3
dorzolamide hcl ophthalmic solution 2 %
3
dorzolamide hcl-timolol mal ophthalmic solution
22.3-6.8 mg/ml
3
ISTALOL OPHTHALMIC SOLUTION 0.5 %
3
latanoprost ophthalmic solution 0.005 %
2
levobunolol hcl ophthalmic solution 0.5 %
3
LUMIGAN OPHTHALMIC SOLUTION 0.01 %
3
metipranolol ophthalmic solution 0.3 %
3
PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION
RECONSTITUTED 0.125 %
4
PILOCARPINE HCL OPHTHALMIC SOLUTION 1 %, 2 %, 4
%
3
SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 %
3
72
Drug Name
Drug
Tier
TIMOLOL MALEATE OPHTHALMIC GEL FORMING
SOLUTION 0.25 %, 0.5 %
4
timolol maleate ophthalmic solution 0.25 %, 0.5 %
1
TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %
ANTI-INFECTIVE/ANTI-INFLAMMATORY
3
bacitra-neomycin-polymyxin-hc ophthalmic ointment 1
%
3
blephamide s.o.p. ophthalmic ointment 10-0.2 %
4
neomycin-polymyxin-dexameth ophthalmic ointment
3.5-10000-0.1
2
neomycin-polymyxin-dexameth ophthalmic suspension
3.5-10000-0.1
2
sulfacetamide-prednisolone ophthalmic solution
10-0.23 %
2
TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %
3
TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 %
3
tobramycin-dexamethasone ophthalmic suspension
0.3-0.1 %
4
ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 %
ANTI-INFECTIVES
3
bacitracin ophthalmic ointment 500 unit/gm
3
bacitracin-polymyxin b ophthalmic ointment 500-10000
unit/gm
2
BESIVANCE OPHTHALMIC SUSPENSION 0.6 %
3
CILOXAN OPHTHALMIC OINTMENT 0.3 %
3
ciprofloxacin hcl ophthalmic solution 0.3 %
2
erythromycin ophthalmic ointment 5 mg/gm
2
gatifloxacin ophthalmic solution 0.5 %
2
gentak ophthalmic ointment 0.3 %
2
gentamicin sulfate ophthalmic ointment 0.3 %
2
gentamicin sulfate ophthalmic solution 0.3 %
2
ilotycin ophthalmic ointment 5 mg/gm
2
MOXEZA OPHTHALMIC SOLUTION 0.5 %
3
73
Drug Name
Drug
Tier
NATACYN OPHTHALMIC SUSPENSION 5 %
4
neomycin-bacitracin zn-polymyx ophthalmic ointment
5-400-10000
3
neomycin-polymyxin-gramicidin ophthalmic solution
1.75-10000-.025
3
ofloxacin ophthalmic solution 0.3 %
2
polymyxin b-trimethoprim ophthalmic solution
10000-0.1 unit/ml-%
2
sulfacetamide sodium ophthalmic ointment 10 %
3
sulfacetamide sodium ophthalmic solution 10 %
3
tobramycin ophthalmic solution 0.3 %
2
trifluridine ophthalmic solution 1 %
4
VIGAMOX OPHTHALMIC SOLUTION 0.5 %
3
ZIRGAN OPHTHALMIC GEL 0.15 %
ANTI-INFLAMMATORIES
4
ALREX OPHTHALMIC SUSPENSION 0.2 %
3
BROMFENAC SODIUM (ONCE-DAILY) OPHTHALMIC
SOLUTION 0.09 %
4
bromfenac sodium ophthalmic solution 0.09 %
4
dexamethasone sodium phosphate ophthalmic solution
0.1 %
2
diclofenac sodium ophthalmic solution 0.1 %
2
DUREZOL OPHTHALMIC EMULSION 0.05 %
3
FLUOROMETHOLONE OPHTHALMIC SUSPENSION 0.1 %
3
flurbiprofen sodium ophthalmic solution 0.03 %
2
ILEVRO OPHTHALMIC SUSPENSION 0.3 %
3
ketorolac tromethamine ophthalmic solution 0.4 %, 0.5
%
3
LOTEMAX OPHTHALMIC GEL 0.5 %
3
LOTEMAX OPHTHALMIC OINTMENT 0.5 %
3
LOTEMAX OPHTHALMIC SUSPENSION 0.5 %
3
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1
%
3
74
Drug Name
Drug
Tier
prednisolone sodium phosphate ophthalmic solution 1
%
MISCELLANEOUS
3
naphazoline hcl ophthalmic solution 0.1 %
1
PROLENSA OPHTHALMIC SOLUTION 0.07 %
3
proparacaine hcl ophthalmic solution 0.5 %
2
RESTASIS OPHTHALMIC EMULSION 0.05 %
RESPIRATORY
3
ANORO ELLIPTA INHALATION AEROSOL POWDER,
BREATH ACTIVATED 62.5-25 MCG/INH
3
COMBIVENT RESPIMAT INHALATION AEROSOL,
SOLUTION 20-100 MCG/ACT
4
QL (8 GM per 30 days)
3
B/D
ATROVENT HFA INHALATION AEROSOL, SOLUTION 17
MCG/ACT
4
QL (25.8 GM per 30 days)
INCRUSE ELLIPTA INHALATION AEROSOL POWDER,
BREATH ACTIVATED 62.5 MCG/INH
3
ipratropium bromide inhalation solution 0.02 %
2
B/D
ipratropium bromide nasal solution 0.03 %, 0.06 %
ANTIHISTAMINES
3
ASTEPRO NASAL SOLUTION 0.15 %
3
azelastine hcl nasal solution 0.1 %, 0.15 %
3
cetirizine hcl oral syrup 1 mg/ml
3
diphenhydramine hcl injection solution 50 mg/ml
2
hydroxyzine hcl intramuscular* solution 25 mg/ml, 50
mg/ml
4
levocetirizine dihydrochloride oral solution 2.5 mg/5ml
4
levocetirizine dihydrochloride oral tablet 5 mg
3
olopatadine hcl nasal solution 0.6 %
4
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
ipratropium-albuterol inhalation solution 0.5-2.5 (3)
mg/3ml
ANTICHOLINERGICS
PA
75
Drug Name
Drug
Tier
BETA AGONISTS
albuterol sulfate inhalation nebulization solution (2.5
mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25
mg/3ml
2
albuterol sulfate oral syrup 2 mg/5ml
1
albuterol sulfate oral tablet 2 mg, 4 mg
4
PERFOROMIST INHALATION NEBULIZATION SOLUTION
20 MCG/2ML
4
B/D
SEREVENT DISKUS INHALATION AEROSOL POWDER,
BREATH ACTIVATED 50 MCG/DOSE
3
terbutaline sulfate injection solution 1 mg/ml
B/D
5^
terbutaline sulfate oral tablet 2.5 mg, 5 mg
3
VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108
(90 BASE) MCG/ACT
3
XOPENEX HFA INHALATION AEROSOL† 45 MCG/ACT
LEUKOTRIENE RECEPTOR ANTAGONISTS
3
montelukast sodium oral packet 4 mg
4
montelukast sodium oral tablet 10 mg
3
montelukast sodium oral tablet chewable 4 mg, 5 mg
3
zafirlukast oral tablet 10 mg, 20 mg
MAST CELL STABILIZERS
4
cromolyn sodium inhalation nebulization solution 20
mg/2ml
MISCELLANEOUS
acetylcysteine inhalation solution 10 %, 20 %
ARALAST NP INTRAVENOUS* SOLUTION
3
B/D
3
B/D
5^
DALIRESP ORAL TABLET 500 MCG
4
EPIPEN 2-PAK INJECTION 0.3 MG/0.3ML
3
EPIPEN JR 2-PAK INJECTION 0.15 MG/0.3ML
3
PA; LA
ESBRIET ORAL CAPSULE 267 MG
5^
PA
KALYDECO ORAL PACKET 50 MG, 75 MG
5^
PA
KALYDECO ORAL TABLET 150 MG
5^
PA
76
Drug Name
Drug
Tier
OFEV ORAL CAPSULE 100 MG, 150 MG
5^
PA
ORKAMBI ORAL TABLET 200-125 MG
5^
PA
PROLASTIN-C INTRAVENOUS* SOLUTION
5^
PA; LA
PULMOZYME INHALATION SOLUTION 1 MG/ML
5^
B/D
XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED
150 MG
5^
PA; LA
5^
PA; LA
ZEMAIRA INTRAVENOUS* SOLUTION RECONSTITUTED
1000 MG
NASAL STEROIDS
flunisolide nasal solution 25 mcg/act (0.025%)
3
fluticasone propionate nasal suspension 50 mcg/act
2
NASONEX NASAL SUSPENSION 50 MCG/ACT
STEROID INHALANTS
3
ARNUITY ELLIPTA INHALATION AEROSOL POWDER,
BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT
3
budesonide inhalation suspension 0.25 mg/2ml, 0.5
mg/2ml
4
B/D
FLOVENT DISKUS INHALATION AEROSOL POWDER,
BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST
3
FLOVENT DISKUS INHALATION AEROSOL POWDER,
BREATH ACTIVATED 250 MCG/BLIST
3
FLOVENT HFA INHALATION AEROSOL† 110 MCG/ACT,
220 MCG/ACT
3
FLOVENT HFA INHALATION AEROSOL† 44 MCG/ACT
3
3
ADVAIR DISKUS INHALATION AEROSOL POWDER,
BREATH ACTIVATED 100-50 MCG/DOSE, 250-50
MCG/DOSE, 500-50 MCG/DOSE
3
ADVAIR HFA INHALATION AEROSOL† 115-21 MCG/ACT,
230-21 MCG/ACT, 45-21 MCG/ACT
3
PULMICORT FLEXHALER INHALATION AEROSOL
POWDER, BREATH ACTIVATED 180 MCG/ACT, 90
MCG/ACT
STEROID/BETA-AGONIST COMBINATIONS
77
Drug Name
BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH
ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH
SYMBICORT INHALATION AEROSOL† 160-4.5 MCG/ACT,
80-4.5 MCG/ACT
XANTHINES
Drug
Tier
3
3
aminophylline intravenous* solution 25 mg/ml
3
theophylline er oral tablet extended release 12 hr* 100
mg, 200 mg, 300 mg, 450 mg
3
theophylline er oral tablet extended release 24 hr* 400
mg, 600 mg
TOPICAL
3
DERMATOLOGY, ACNE
amnesteem oral capsule 10 mg, 20 mg, 40 mg
4
AVITA EXTERNAL CREAM 0.025 %
4
AVITA EXTERNAL GEL 0.025 %
4
claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg
4
clindamax external gel 1 %
4
clindamycin phosphate external gel 1 %
4
clindamycin phosphate external lotion 1 %
4
clindamycin phosphate external solution 1 %
3
erythromycin external gel 2 %
3
erythromycin external solution 2 %
3
myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg
4
sulfacetamide sodium external suspension 10 %
3
tretinoin external cream 0.025 %, 0.05 %, 0.1 %
4
tretinoin external gel 0.01 %, 0.025 %
4
zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg
DERMATOLOGY, ANTIBIOTICS
4
gentamicin sulfate external cream 0.1 %
3
gentamicin sulfate external ointment 0.1 %
3
mupirocin calcium external cream 2 %
2
mupirocin external ointment 2 %
2
78
Drug Name
Drug
Tier
SILVER SULFADIAZINE EXTERNAL CREAM 1 %
2
SSD EXTERNAL CREAM 1 %
2
SULFAMYLON EXTERNAL CREAM 85 MG/GM
4
SULFAMYLON EXTERNAL PACKET 5 %
DERMATOLOGY, ANTIFUNGALS
5^
ciclopirox external gel 0.77 %
3
ciclopirox external shampoo 1 %
3
ciclopirox olamine external cream 0.77 %
3
ciclopirox olamine external suspension 0.77 %
3
clotrimazole external cream 1 %
3
clotrimazole external solution 1 %
2
econazole nitrate external cream 1 %
4
ketoconazole external cream 2 %
3
nyamyc external powder 100000 unit/gm
3
nystatin external cream 100000 unit/gm
3
nystatin external ointment 100000 unit/gm
3
nystatin external powder 100000 unit/gm
3
nystop external powder 100000 unit/gm
DERMATOLOGY, ANTIPRURITIC
3
DOXEPIN HCL EXTERNAL CREAM 5 %
4
procto-med hc cream 2.5 %
2
procto-pak cream 1 %
2
proctosol hc cream 2.5 %
2
proctozone-hc cream 2.5 %
2
PRUDOXIN EXTERNAL CREAM 5 %
DERMATOLOGY, ANTIPSORIATICS
4
8-MOP ORAL CAPSULE 10 MG
4
acitretin oral capsule 10 mg, 17.5 mg, 25 mg
5^
calcipotriene external cream 0.005 %
4
calcipotriene external ointment 0.005 %
4
calcipotriene external solution 0.005 %
4
PA
79
Drug Name
Drug
Tier
calcitrene external ointment 0.005 %
4
TAZORAC EXTERNAL CREAM 0.05 %, 0.1 %
DERMATOLOGY, ANTISEBORRHEICS
4
ketoconazole external shampoo 2 %
2
selenium sulfide external lotion 2.5 %
DERMATOLOGY, CORTICOSTEROIDS
2
ala cort external cream 1 %
1
alclometasone dipropionate external cream 0.05 %
3
alclometasone dipropionate external ointment 0.05 %
3
betamethasone dipropionate aug external cream 0.05 %
3
betamethasone dipropionate aug external gel 0.05 %
4
betamethasone dipropionate aug external lotion 0.05 %
4
betamethasone dipropionate aug external ointment 0.05
%
4
betamethasone dipropionate external cream 0.05 %
3
betamethasone dipropionate external lotion 0.05 %
3
betamethasone dipropionate external ointment 0.05 %
4
betamethasone valerate external cream 0.1 %
3
betamethasone valerate external lotion 0.1 %
3
betamethasone valerate external ointment 0.1 %
3
clobetasol propionate e external cream 0.05 %
4
clobetasol propionate emulsion external foam 0.05 %
2
clobetasol propionate external cream 0.05 %
4
clobetasol propionate external foam 0.05 %
2
clobetasol propionate external gel 0.05 %
4
clobetasol propionate external lotion 0.05 %
2
clobetasol propionate external ointment 0.05 %
4
clobetasol propionate external shampoo 0.05 %
2
clobetasol propionate external solution 0.05 %
4
cormax scalp application external solution 0.05 %
4
DESONIDE EXTERNAL CREAM 0.05 %
2
PA
80
Drug Name
Drug
Tier
desonide external ointment 0.05 %
2
fluocinolone acetonide external solution 0.01 %
4
fluocinonide external cream 0.05 %
4
fluocinonide external gel 0.05 %
3
fluocinonide external ointment 0.05 %
4
fluocinonide external solution 0.05 %
4
fluocinonide-e external cream 0.05 %
4
fluticasone propionate external cream 0.05 %
2
fluticasone propionate external ointment 0.005 %
2
hydrocortisone butyrate external cream 0.1 %
4
hydrocortisone butyrate external ointment 0.1 %
4
hydrocortisone butyrate external solution 0.1 %
4
hydrocortisone external cream 1 %, 2.5 %
1
hydrocortisone external lotion 2.5 %
3
hydrocortisone external ointment 1 %, 2.5 %
1
mometasone furoate external cream 0.1 %
3
mometasone furoate external ointment 0.1 %
3
mometasone furoate external solution 0.1 %
3
triamcinolone acetonide external cream 0.025 %, 0.1
%, 0.5 %
2
triamcinolone acetonide external lotion 0.025 %, 0.1 %
3
triamcinolone acetonide external ointment 0.025 %, 0.1
%, 0.5 %
2
triderm external cream 0.1 %
DERMATOLOGY, LOCAL ANESTHETICS
2
lidocaine external ointment 5 %
4
lidocaine external patch 5 %
3
lidocaine hcl external gel 2 %, 2 % (10ml applicator), 2
% (5ml applicator)
2
lidocaine hcl external solution 4 %
1
lidocaine-prilocaine external cream 2.5-2.5 %
3
QL (3 EA per 1 day)
B/D
81
Drug Name
Drug
Tier
DERMATOLOGY, MISCELLANEOUS SKIN AND
MUCOUS MEMBRANE
acyclovir external ointment 5 %
4
ammonium lactate external cream 12 %
3
ammonium lactate external lotion 12 %
2
ELIDEL EXTERNAL CREAM 1 %
4
fluorouracil external cream 5 %
4
fluorouracil external solution 2 %, 5 %
4
imiquimod external cream 5 %
4
metronidazole external cream 0.75 %
4
metronidazole external gel 0.75 %
4
PA
PANRETIN EXTERNAL GEL 0.1 %
5^
podofilox external solution 0.5 %
3
rosadan external cream 0.75 %
4
tacrolimus external ointment 0.03 %, 0.1 %
4
PA
TARGRETIN EXTERNAL GEL 1 %
5^
PA
VALCHLOR EXTERNAL GEL 0.016 %
5^
PA; LA
VOLTAREN TRANSDERMAL GEL 1 %
DERMATOLOGY, SCABICIDES AND PEDICULIDES
3
EURAX EXTERNAL CREAM 10 %
4
EURAX EXTERNAL LOTION 10 %
4
malathion external lotion 0.5 %
4
permethrin external cream 5 %
DERMATOLOGY, WOUND CARE AGENTS
3
acetic acid irrigation solution 0.25 %
2
REGRANEX EXTERNAL GEL 0.01 %
5^
SANTYL EXTERNAL OINTMENT 250 UNIT/GM
4
sodium chloride irrigation solution 0.9 %
1
STERILE WATER FOR IRRIGATION IRRIGATION SOLUTION
MOUTH/THROAT/DENTAL AGENTS
3
chlorhexidine gluconate mouth/throat solution 0.12 %
1
PA
82
Drug Name
Drug
Tier
clotrimazole mouth/throat troche 10 mg
4
lidocaine viscous mouth/throat solution 2 %
1
nystatin mouth/throat suspension 100000 unit/ml
3
paroex mouth/throat solution 0.12 %
1
periogard mouth/throat solution 0.12 %
1
PILOCARPINE HCL ORAL TABLET 5 MG
4
pilocarpine hcl oral tablet 7.5 mg
4
triamcinolone acetonide mouth/throat paste 0.1 %
OTIC
3
acetic acid otic solution 2 %
3
acetic acid-aluminum acetate otic solution 2 %
3
CIPRODEX OTIC SUSPENSION 0.3-0.1 %
3
fluocinolone acetonide otic oil 0.01 %
2
neomycin-polymyxin-hc otic solution 1 %
2
neomycin-polymyxin-hc otic suspension 3.5-10000-1
2
ofloxacin otic solution 0.3 %
2
83
84
Index of Drugs
85
ampicillin-sulbactam sodium
Index
ALIMTA .............................................................................. 16
ALINIA ....................................................................................... 5
allopurinol ......................................................................... 1
alosetron hcl ........................................................... 58
ALPHAGAN P ........................................................... 72
alprazolam .................................................................. 30
ALREX .................................................................................. 74
amantadine hcl .................................................. 38
AMBISOME ...................................................................... 4
amifostine .................................................................... 21
amikacin sulfate ................................................... 4
amiloride hcl ........................................................... 28
amiloride-hydrochlorothiazide
.......................................................................................................... 28
aminophylline ....................................................... 78
AMINOSYN .................................................................. 69
AMINOSYN II ............................................................ 69
AMINOSYN II/ELECTROLYTES
.......................................................................................................... 69
AMINOSYN M ......................................................... 69
AMINOSYN/ELECTROLYTES ....... 69
AMINOSYN-HBC ............................................... 69
AMINOSYN-PF ...................................................... 69
AMINOSYN-RF ..................................................... 69
amiodarone hcl .................................................. 23
AMITIZA ............................................................................ 58
amitriptyline hcl ................................................ 35
amlodipine besy-benazepril hcl
.......................................................................................................... 21
amlodipine besylate .................................. 26
amlodipine besylate-valsartan
.......................................................................................................... 23
amlodipine-valsartan-hctz ........... 23
ammonium lactate ...................................... 82
amnesteem ............................................................... 78
amoxapine .................................................................. 35
amoxicillin ................................................................... 14
amoxicillin-pot clavulanate ......... 14
amphetamine-dextroamphet er
.......................................................................................................... 42
amphetamine-dextroamphetami
ne ................................................................................................. 42
amphotericin b ........................................................ 4
ampicillin ....................................................................... 14
ampicillin sodium ............................ 14, 15
Index
Index
8-MOP ................................................................................ 79
abacavir sulfate ..................................................... 7
abacavir-lamivudine-zidovudine
............................................................................................................... 9
ABELCET ............................................................................. 4
ABILIFY DISCMELT ....................................... 38
ABILIFY MAINTENA ...................................... 38
ABRAXANE .................................................................. 17
acamprosate calcium ............................ 44
acarbose ......................................................................... 47
acebutolol hcl ....................................................... 26
acetaminophen-codeine ....................... 3
acetaminophen-codeine #2 ............ 3
acetazolamide ...................................................... 28
acetazolamide er ............................................ 28
acetic acid ..................................................... 82, 83
acetic acid-aluminum acetate
.......................................................................................................... 83
acetylcysteine ...................................................... 76
acitretin ............................................................................ 79
ACTHIB ............................................................................... 66
ACTIMMUNE ............................................................ 64
acyclovir ............................................................ 10, 82
acyclovir sodium ............................... 10, 11
ADACEL ............................................................................ 66
ADAGEN ........................................................................... 51
adefovir dipivoxil ............................................. 11
ADEMPAS ..................................................................... 30
adrucil ................................................................................. 16
ADVAIR DISKUS ................................................. 77
ADVAIR HFA .............................................................. 77
afeditab cr ................................................................... 26
AFINITOR ........................................................................ 19
AFINITOR DISPERZ ....................................... 19
AGGRENOX ................................................................. 63
a-hydrocort ................................................................ 53
ala cort ............................................................................... 80
ALBENZA ............................................................................. 5
albuterol sulfate ................................................ 76
alclometasone dipropionate ...... 80
ALDURAZYME ....................................................... 51
ALECENSA ................................................................... 19
alendronate sodium .................................. 49
alfuzosin hcl er ................................................... 60
15
AMPYRA ........................................................................... 44
anagrelide hcl ....................................................... 62
anastrozole ................................................................ 18
ANDRODERM ......................................................... 45
ANORO ELLIPTA ................................................ 75
APOKYN ............................................................................ 38
APRISO ............................................................................... 57
APTIOM ............................................................................. 31
APTIVUS ...................................................................... 7, 8
ARALAST NP ............................................................ 76
ARCALYST ................................................................... 65
aripiprazole .................................................. 38, 39
ARNUITY ELLIPTA ........................................... 77
ASACOL HD ............................................................... 57
ASSURE ID INSULIN SAFETY SYR
.......................................................................................................... 45
ASTEPRO ....................................................................... 75
atenolol ............................................................................. 26
atenolol-chlorthalidone ....................... 25
atorvastatin calcium ................................. 24
atovaquone .................................................................... 5
atovaquone-proguanil hcl ................... 7
ATRIPLA ................................................................................ 9
ATROVENT HFA .................................................. 75
AVASTIN .......................................................................... 17
AVITA ..................................................................................... 78
AXIRON .............................................................................. 45
azacitidine ................................................................... 16
azathioprine ............................................................. 65
azathioprine sodium ................................. 65
azelastine hcl .......................................... 72, 75
AZILECT ............................................................................ 38
azithromycin ........................................................... 13
AZITHROMYCIN .................................................. 13
AZOPT ................................................................................. 72
AZOR ...................................................................................... 23
aztreonam ........................................................................ 5
bacitracin ...................................................................... 73
bacitracin-polymyxin b ........................ 73
bacitra-neomycin-polymyxin-hc
.......................................................................................................... 73
baclofen ........................................................................... 44
balsalazide disodium .............................. 57
BANZEL ............................................................................. 31
..........................................................................................................
86
cefoxitin sodium ............................................... 12
cefpodoxime proxetil ............................... 12
ceftazidime ................................................................ 12
ceftriaxone sodium ..................................... 12
cefuroxime axetil ............................................ 13
cefuroxime sodium ..................................... 13
celecoxib ............................................................................ 1
CELONTIN ..................................................................... 31
cephalexin ................................................................... 13
CERDELGA .................................................................. 51
CEREZYME .................................................................. 52
CERVARIX ...................................................................... 66
cetirizine hcl ............................................................ 75
CHANTIX .......................................................................... 45
CHANTIX CONTINUING MONTH
PAK ........................................................................................... 45
CHANTIX STARTING MONTH PAK
.......................................................................................................... 45
CHEMET ........................................................................... 49
chlorhexidine gluconate .................... 82
chloroquine phosphate ............................ 7
chlorothiazide ....................................................... 28
chlorpromazine hcl ..................................... 39
chlorthalidone ....................................................... 28
cholestyramine ................................................... 25
cholestyramine light ................................. 24
ciclopirox ....................................................................... 79
ciclopirox olamine ........................................ 79
cilostazol ........................................................................ 62
CILOXAN .......................................................................... 73
CIMZIA ................................................................................ 63
CIMZIA PREFILLED ....................................... 63
CIMZIA STARTER KIT ............................... 63
CINRYZE .......................................................................... 62
CIPRODEX ..................................................................... 83
ciprofloxacin ............................................................ 14
ciprofloxacin hcl ................................. 14, 73
ciprofloxacin in d5w ................................. 14
citalopram hydrobromide ............... 35
claravis .............................................................................. 78
clarithromycin ...................................................... 13
clarithromycin er ............................................. 13
clindamax ..................................................................... 78
clindamycin hcl ...................................................... 5
clindamycin palmitate hcl .................. 5
clindamycin phosphate
................................................................................... 6, 61, 78
Index
buprenorphine hcl-naloxone hcl
.......................................................................................................... 45
buproban ....................................................................... 45
bupropion hcl ........................................................ 35
bupropion hcl er (smoking det)
.......................................................................................................... 45
bupropion hcl er (sr) ................................. 35
bupropion hcl er (xl) .................................. 35
buspirone hcl ......................................................... 31
BYDUREON ................................................................. 45
BYETTA 10 MCG PEN ............................. 45
BYETTA 5 MCG PEN .................................. 46
BYSTOLIC ...................................................................... 26
cabergoline ................................................................ 54
CABOMETYX ............................................................ 19
calcipotriene ........................................................... 79
calcitonin (salmon) ...................................... 54
calcitrene ...................................................................... 80
calcitriol ........................................................................... 71
calcium acetate (phos binder)
.......................................................................................................... 55
camila .................................................................................. 50
CANASA ........................................................................... 57
CANCIDAS ......................................................................... 4
CAPASTAT SULFATE ................................ 10
CAPRELSA ................................................................... 19
captopril .......................................................................... 22
captopril-hydrochlorothiazide
.......................................................................................................... 21
CARAFATE ................................................................... 59
CARBAGLU .................................................................. 51
carbamazepine .................................................. 31
carbamazepine er ......................................... 31
carbidopa-levodopa .................................. 38
carbidopa-levodopa er ......................... 38
CARIMUNE NF ....................................................... 64
carteolol hcl .............................................................. 72
cartia xt ............................................................................ 26
carvedilol ....................................................................... 26
CAYSTON ........................................................................... 5
cefaclor ............................................................................. 12
cefadroxil ...................................................................... 12
cefazolin sodium ............................................. 12
CEFAZOLIN SODIUM-DEXTROSE
.......................................................................................................... 12
cefdinir ............................................................................... 12
cefepime hcl ........................................................... 12
cefixime ........................................................................... 12
Index
Index
BARACLUDE ............................................................. 11
BCG VACCINE ........................................................ 66
BELEODAQ .................................................................. 17
benazepril hcl ....................................................... 22
benazepril-hydrochlorothiazide
.......................................................................................................... 21
BENICAR ......................................................................... 23
BENICAR HCT ........................................................ 23
BENLYSTA ................................................................... 65
benztropine mesylate ............................. 38
BEPREVE ......................................................................... 72
BESIVANCE ................................................................. 73
betamethasone dipropionate ... 80
betamethasone dipropionate aug
.......................................................................................................... 80
betamethasone valerate ................... 80
BETASERON ............................................................. 44
betaxolol hcl ............................................................ 72
bethanechol chloride .............................. 60
BETOPTIC-S ............................................................. 72
bexarotene ................................................................. 20
BEXSERO ....................................................................... 66
bicalutamide ........................................................... 18
BICILLIN L-A ............................................................ 15
BILTRICIDE ...................................................................... 5
bisoprolol fumarate .................................... 26
bisoprolol-hydrochlorothiazide
.......................................................................................................... 25
BIVIGAM ........................................................................... 64
bleomycin sulfate .......................................... 16
blephamide s.o.p. ......................................... 73
blisovi fe 1.5/30 ............................................... 50
blisovi fe 1/20 ...................................................... 50
BOOSTRIX .................................................................... 66
BOSULIF .......................................................................... 19
BREO ELLIPTA ...................................................... 78
BRILINTA ........................................................................ 63
BRIMONIDINE TARTRATE ................ 72
brimonidine tartrate .................................. 72
BRINTELLIX ................................................................ 35
BRIVIACT ........................................................................ 31
bromfenac sodium ...................................... 74
BROMFENAC SODIUM
(ONCE-DAILY) ........................................................ 74
bromocriptine mesylate ..................... 38
budesonide .................................................. 57, 77
bumetanide ............................................................... 28
buprenorphine hcl ........................................ 45
...............................................................................................................
CLINIMIX/DEXTROSE (2.75/5)
5
69
.......................................................................................................... 69
.......................................................................................................... 69
.......................................................................................................... 69
.......................................................................................................... 69
CLINIMIX/DEXTROSE (5/15) ........ 70
clobetasol propionate ............................. 80
clobetasol propionate e ...................... 80
clobetasol propionate emulsion
.......................................................................................................... 80
clomipramine hcl ........................................... 35
clonazepam ................................................ 31, 32
clonidine hcl ............................................................ 29
clopidogrel bisulfate ................................. 63
clorazepate dipotassium .................. 32
clotrimazole ................................................ 79, 83
clozapine ........................................................................ 39
CLOZAPINE ................................................................. 39
COARTEM .......................................................................... 7
colchicine-probenecid ............................... 1
COLCRYS ............................................................................ 1
colestipol hcl .......................................................... 25
colistimethate sodium ............................... 6
colocort ............................................................................. 57
COMBIGAN .................................................................. 72
COMBIVENT RESPIMAT ....................... 75
COMETRIQ (100 MG DAILY
DOSE) ................................................................................... 19
COMETRIQ (140 MG DAILY
DOSE) ................................................................................... 19
COMETRIQ (60 MG DAILY DOSE)
.......................................................................................................... 19
COMFORT ASSIST INSULIN
SYRINGE .......................................................................... 46
COMPLERA ..................................................................... 9
compro .............................................................................. 56
COMVAX .......................................................................... 66
constulose ................................................................... 58
COPAXONE ................................................................. 44
..........................................................................................................
87
DEXTROSE .................................................................. 70
DEXTROSE 5%/ELECTROLYTE
#48 ........................................................................................... 70
DEXTROSE IN LACTATED
RINGERS ......................................................................... 70
DEXTROSE-NACL ........................................... 70
DIAZEPAM .................................................................... 32
diazepam ....................................................................... 32
diazepam intensol ........................................ 32
diclofenac potassium .................................. 1
diclofenac sodium ............................... 1, 74
diclofenac sodium er ................................... 1
dicloxacillin sodium ................................... 15
dicyclomine hcl .................................................. 57
didanosine ....................................................................... 8
diflunisal .............................................................................. 1
digitek ................................................................................. 28
digox ...................................................................................... 28
digoxin ................................................................................ 28
DIGOXIN ........................................................................... 28
dihydroergotamine mesylate ... 43
dilantin ............................................................................... 32
DILANTIN ....................................................................... 32
dilantin infatabs ................................................ 32
diltiazem hcl ............................................................ 27
diltiazem hcl er .................................................. 27
diltiazem hcl er beads ........................... 26
diltiazem hcl er coated beads
.......................................................................................................... 27
dilt-xr .................................................................................... 27
DIPENTUM ................................................................... 57
diphenhydramine hcl .............................. 75
diphenoxylate-atropine ....................... 59
DIPHTHERIA-TETANUS TOXOIDS
DT ............................................................................................... 66
disopyramide phosphate ................. 23
disulfiram ...................................................................... 45
divalproex sodium ........................................ 32
divalproex sodium er ............................... 32
docetaxel ....................................................................... 17
DOCETAXEL .............................................................. 17
dofetilide ........................................................................ 23
donepezil hcl .......................................................... 34
dorzolamide hcl ................................................ 72
dorzolamide hcl-timolol mal ..... 72
doxazosin mesylate ................................... 22
doxepin hcl ................................................................ 36
DOXEPIN HCL ........................................................ 79
Index
cormax scalp application ................ 80
cortisone acetate ............................................ 53
COTELLIC ...................................................................... 19
COUMADIN ................................................................. 61
CREON ................................................................................ 59
crestor ................................................................................ 24
CRIXIVAN ............................................................................. 8
cromolyn sodium ................ 59, 72, 76
cryselle-28 ................................................................. 50
CUBICIN ................................................................................ 6
CVS GAUZE STERILE ................................ 46
cyclafem 1/35 ...................................................... 50
CYCLOPHOSPHAMIDE ........................... 16
cycloserine ................................................................. 10
cyclosporine ............................................................ 65
cyclosporine modified ........................... 65
CYSTADANE ............................................................. 52
CYSTAGON .................................................................. 52
dacarbazine .............................................................. 16
DAKLINZA ..................................................................... 11
DALIRESP ...................................................................... 76
danazol .............................................................................. 51
dantrolene sodium ....................................... 44
dapsone ................................................................................ 6
DAPTACEL ................................................................... 66
DARAPRIM ....................................................................... 6
deblitane ........................................................................ 50
DELESTROGEN .................................................... 52
DELZICOL ...................................................................... 57
DEMSER .......................................................................... 29
DEPEN TITRATABS ...................................... 49
DESCOVY ............................................................................ 9
desipramine hcl ................................................ 36
DESMOPRESSIN ACE RHINAL
TUBE ...................................................................................... 55
desmopressin ace spray refrig
.......................................................................................................... 55
desmopressin acetate .......................... 55
desmopressin acetate spray .... 55
DESONIDE .................................................................... 80
desonide ......................................................................... 81
dexamethasone ................................................. 53
dexamethasone intensol .................. 53
dexamethasone sod phosphate
pf .................................................................................................. 53
dexamethasone sodium
phosphate ...................................................... 53, 74
DEXILANT ...................................................................... 59
Index
Index
clindamycin phosphate in d5w
88
fluconazole ..................................................................... 5
fluconazole in dextrose ........................... 4
fluconazole in sodium chloride
............................................................................................................... 4
flucytosine ....................................................................... 5
fludrocortisone acetate ....................... 53
flunisolide ..................................................................... 77
fluocinolone acetonide ........... 81, 83
fluocinonide .............................................................. 81
fluocinonide-e ...................................................... 81
FLUOROMETHOLONE .............................. 74
fluorouracil ................................................... 16, 82
fluoxetine hcl ......................................................... 36
fluphenazine decanoate .................... 39
fluphenazine hcl ............................................... 39
flurbiprofen ..................................................................... 1
flurbiprofen sodium ................................... 74
flutamide ........................................................................ 18
fluticasone propionate ............ 77, 81
fluvoxamine maleate ............................... 31
fondaparinux sodium .............................. 61
FORTEO ............................................................................ 54
FORTICAL ...................................................................... 54
fosinopril sodium ............................................ 22
fosinopril sodium-hctz ......................... 22
FREAMINE HBC .................................................. 70
FREAMINE III ............................................................ 70
FUROSEMIDE ......................................................... 28
furosemide ................................................... 28, 29
FUSILEV ............................................................................ 21
FUZEON ................................................................................. 8
fyavolv ................................................................................ 52
FYCOMPA ...................................................................... 32
gabapentin ................................................... 32, 33
galantamine hydrobromide ......... 35
galantamine hydrobromide er
............................................................................................ 34, 35
GAMASTAN S/D ................................................. 64
GAMMAGARD ........................................................ 64
GAMMAGARD S/D ......................................... 64
GAMMAGARD S/D LESS IGA ...... 64
GAMMAKED .............................................................. 64
GAMMAPLEX ........................................................... 64
GAMUNEX-C ............................................................ 64
ganciclovir sodium ...................................... 11
GARDASIL ..................................................................... 66
GARDASIL 9 .............................................................. 66
gatifloxacin ................................................................ 73
Index
erythromycin ethylsuccinate .... 14
ESBRIET ........................................................................... 76
escitalopram oxalate ............................... 36
esomeprazole sodium ........................... 59
estarylla ........................................................................... 50
estrace ............................................................................... 52
estradiol ........................................................................... 52
estradiol valerate ............................................ 52
ethambutol hcl .................................................... 10
ethosuximide ......................................................... 32
etodolac ................................................................................ 1
etodolac er ...................................................................... 1
etoposide ....................................................................... 21
EURAX ................................................................................. 82
EVOTAZ .................................................................................. 9
EXEL COMFORT POINT PEN
NEEDLE ............................................................................. 46
EXELON ............................................................................. 34
exemestane .............................................................. 18
EXJADE ............................................................................. 49
FABRAZYME ............................................................. 52
famciclovir .................................................................. 11
famotidine ................................................................... 57
famotidine premixed ................................ 57
FANAPT ............................................................................. 39
FANAPT TITRATION PACK .............. 39
FARESTON .................................................................. 18
FARXIGA .......................................................................... 47
FARYDAK ........................................................................ 17
FASLODEX ................................................................... 18
FAZACLO ........................................................................ 39
felbamate ...................................................................... 32
felodipine er ............................................................. 27
fenofibrate ................................................................... 25
fenofibrate micronized ......................... 25
fentanyl ................................................................................. 2
fentanyl citrate ........................................................ 2
FENTORA ............................................................................ 2
FERRIPROX ................................................................. 49
FETZIMA .......................................................................... 36
FETZIMA TITRATION ................................. 36
finasteride .................................................................... 60
FIRAZYR ........................................................................... 62
FLEBOGAMMA ..................................................... 64
FLEBOGAMMA DIF ....................................... 64
flecainide acetate .......................................... 24
FLOVENT DISKUS ........................................... 77
FLOVENT HFA ........................................................ 77
Index
Index
doxy 100 ........................................................................ 15
doxycycline hyclate .................................... 16
doxycycline monohydrate .............. 16
dronabinol .................................................................... 56
DROXIA .............................................................................. 20
duloxetine hcl ........................................................ 36
DURAMORPH .............................................................. 2
DUREZOL ....................................................................... 74
dutasteride ................................................................. 60
dutasteride-tamsulosin hcl .......... 60
e.e.s. 400 ..................................................................... 13
econazole nitrate ............................................ 79
EDURANT ........................................................................... 8
EFFIENT ............................................................................ 63
ELIDEL ................................................................................ 82
ELIQUIS ............................................................................. 61
ELITEK ................................................................................. 21
ELLA ....................................................................................... 50
ELMIRON ........................................................................ 60
EMCYT ................................................................................ 16
EMEND ............................................................................... 56
EMSAM ............................................................................. 36
EMTRIVA .............................................................................. 8
emverm ................................................................................. 6
enalapril maleate ........................................... 22
enalapril-hydrochlorothiazide
.......................................................................................................... 22
endocet ................................................................................. 2
ENGERIX-B .................................................................. 66
enoxaparin sodium ..................................... 61
enpresse-28 ............................................................ 50
ENTACAPONE ........................................................ 38
entecavir ........................................................................ 11
ENTRESTO ................................................................... 23
enulose ............................................................................. 58
EPIPEN 2-PAK ....................................................... 76
EPIPEN JR 2-PAK ........................................... 76
epitol ...................................................................................... 32
EPIVIR HBV .................................................................. 11
eplerenone ................................................................. 22
EPZICOM ............................................................................. 9
ERIVEDGE ...................................................................... 17
errin ......................................................................................... 50
ery-tab ............................................................................... 13
erythrocin lactobionate ....................... 13
erythrocin stearate ...................................... 13
erythromycin ............................................ 73, 78
erythromycin base ....................................... 14
89
INVEGA SUSTENNA ..................................... 40
INVEGA TRINZA .................................................. 40
INVIRASE ............................................................................. 8
INVOKAMET .............................................................. 47
INVOKANA .................................................................... 47
IPOL ......................................................................................... 67
ipratropium bromide ................................ 75
ipratropium-albuterol ............................. 75
irbesartan ..................................................................... 23
irbesartan-hydrochlorothiazide
.......................................................................................................... 23
IRESSA ............................................................................... 19
ISENTRESS ..................................................................... 8
ISOLYTE-P IN D5W ...................................... 70
ISOLYTE-S ................................................................... 70
isoniazid .......................................................................... 10
isosorbide dinitrate ..................................... 29
isosorbide dinitrate er ........................... 29
isosorbide mononitrate ....................... 29
isosorbide mononitrate er .............. 29
ISTALOL ........................................................................... 72
itraconazole ................................................................... 5
ivermectin ........................................................................ 6
IXIARO ................................................................................. 67
JAKAFI ................................................................................ 19
jantoven ........................................................................... 62
JANUMET ...................................................................... 47
JANUMET XR .......................................................... 47
JANUVIA ........................................................................... 47
JENTADUETO ......................................................... 47
JENTADUETO XR ............................................. 48
jinteli ...................................................................................... 52
JOLIVETTE ................................................................... 50
junel fe 1.5/30 ..................................................... 50
junel fe 1/20 ............................................................ 50
JUXTAPID ...................................................................... 25
KALETRA ........................................................................ 10
KALYDECO .................................................................. 76
KCL IN DEXTROSE-NACL ................. 71
kelnor 1/35 ................................................................ 50
ketoconazole ................................... 5, 79, 80
ketoprofen ........................................................................ 1
ketorolac tromethamine .................... 74
KEYTRUDA ................................................................... 17
KINRIX ................................................................................. 67
kionex .................................................................................. 49
klor-con ........................................................................... 68
KLOR-CON .................................................................. 68
Index
HIBERIX ............................................................................. 66
HUMIRA ............................................................................ 63
HUMIRA PEDIATRIC CROHNS
START .................................................................................. 63
HUMIRA PEN ........................................................... 63
HUMIRA PEN-CROHNS STARTER
.......................................................................................................... 63
HUMIRA PEN-PSORIASIS
STARTER ........................................................................ 63
HUMULIN R U-500
(CONCENTRATED) ......................................... 46
HUMULIN R U-500 KWIKPEN .... 46
hydralazine hcl ................................................... 29
hydrochlorothiazide ................................... 29
hydrocodone-acetaminophen ..... 2
hydrocodone-ibuprofen .......................... 2
hydrocortisone ...................................... 53, 81
HYDROCORTISONE ...................................... 57
hydrocortisone butyrate .................... 81
hydromorphone hcl ......................................... 2
hydromorphone hcl pf ............................... 2
hydroxychloroquine sulfate ......... 63
hydroxyprogesterone caproate
.......................................................................................................... 18
hydroxyurea ............................................................. 20
hydroxyzine hcl .................................................. 75
ibandronate sodium .................................. 49
IBRANCE ......................................................................... 17
ibuprofen ............................................................................ 1
ICLUSIG ............................................................................. 19
ILEVRO ................................................................................ 74
ilotycin ................................................................................ 73
imatinib mesylate .......................................... 19
IMBRUVICA ................................................................. 19
imipenem-cilastatin ....................................... 6
imipramine hcl .................................................... 36
imiquimod .................................................................... 82
IMOVAX RABIES ................................................ 67
INCRELEX ...................................................................... 54
INCRUSE ELLIPTA .......................................... 75
indapamide ............................................................... 29
INFANRIX ........................................................................ 67
INLYTA ................................................................................ 19
INTELENCE ...................................................................... 8
INTRALIPID ................................................................. 70
INTRON A ...................................................................... 65
INVANZ ................................................................................... 6
INVEGA ............................................................................... 40
Index
Index
GATTEX ............................................................................. 59
gavilyte-c ...................................................................... 58
gavilyte-g ...................................................................... 58
gavilyte-h ...................................................................... 58
gavilyte-n with flavor pack .......... 58
gemfibrozil .................................................................. 25
generlac .......................................................................... 58
gengraf .............................................................................. 65
gentak ................................................................................. 73
gentamicin in saline ...................................... 4
gentamicin sulfate ................ 4, 73, 78
GENVOYA ............................................................................ 9
GEODON .......................................................................... 39
GILENYA ........................................................................... 44
GILOTRIF ......................................................................... 19
GLEOSTINE ................................................................. 16
glimepiride ................................................................. 47
glipizide ............................................................................ 47
glipizide er .................................................................. 47
glipizide xl .................................................................... 47
glipizide-metformin hcl ...................... 47
GLOBAL ALCOHOL PREP EASE
.......................................................................................................... 46
GLUCAGEN HYPOKIT ................................ 54
GLUCAGON EMERGENCY ................. 54
glycopyrrolate ....................................................... 57
GOLYTELY .................................................................... 58
granisetron hcl .................................................... 56
GRANIX .............................................................................. 62
griseofulvin microsize ................................ 5
griseofulvin ultramicrosize ................ 5
guanfacine hcl er ........................................... 42
haloperidol .................................................................. 40
haloperidol decanoate .......................... 39
haloperidol lactate ....................................... 39
HARVONI ......................................................................... 11
HAVRIX ............................................................................... 66
heather .............................................................................. 50
HEPARIN (PORCINE) IN D5W ..... 61
HEPARIN (PORCINE) IN NACL ... 61
HEPARIN SOD (PORCINE) IN D5W
.......................................................................................................... 61
heparin sodium (porcine) ................ 61
HEPARIN SODIUM (PORCINE) ... 61
HEPATAMINE .......................................................... 70
HERCEPTIN ................................................................ 17
HETLIOZ ........................................................................... 43
HEXALEN ........................................................................ 16
75
levofloxacin ............................................................... 14
levofloxacin in d5w .................................... 14
levoleucovorin calcium ....................... 21
levoleucovorin calcium pf .............. 21
levonest ........................................................................... 50
levonorgestrel ....................................................... 50
levonorg-eth estrad triphasic
.......................................................................................................... 50
levothyroxine sodium ............................. 55
LEVOXYL ......................................................................... 55
LEXIVA ..................................................................................... 8
lidocaine ......................................................................... 81
lidocaine hcl ................................................... 3, 81
lidocaine hcl (pf) ................................................... 3
lidocaine viscous ............................................ 83
lidocaine-prilocaine ................................... 81
linezolid ................................................................................. 6
LINEZOLID ........................................................................ 6
LINEZOLID IN SODIUM
CHLORIDE ......................................................................... 6
LINZESS ........................................................................... 59
liothyronine sodium ................................... 55
lisinopril ........................................................................... 22
lisinopril-hydrochlorothiazide
.......................................................................................................... 22
LITHIUM ........................................................................... 44
lithium carbonate ........................................... 44
lithium carbonate er ................................. 44
LONSURF ....................................................................... 20
loperamide hcl .................................................... 59
lorazepam .................................................................... 31
lorazepam intensol ...................................... 31
lorcet .......................................................................................... 2
lorcet hd ............................................................................... 2
lorcet plus ......................................................................... 2
lortab .......................................................................................... 2
losartan potassium ..................................... 23
losartan potassium-hctz ................... 23
LOTEMAX ...................................................................... 74
lovastatin ....................................................................... 24
low-ogestrel ............................................................. 50
loxapine succinate ....................................... 40
LUMIGAN ........................................................................ 72
LUMIZYME ................................................................... 52
LUPRON DEPOT ................................................. 18
LYNPARZA ................................................................... 17
..........................................................................................................
90
LYRICA ................................................................................ 33
LYSODREN .................................................................. 18
lyza ........................................................................................... 50
MAGNESIUM SULFATE ......................... 68
magnesium sulfate ..................................... 68
MAGNESIUM SULFATE IN D5W
.......................................................................................................... 68
malathion ...................................................................... 82
maprotiline hcl .................................................... 36
MARPLAN ..................................................................... 36
MATULANE ................................................................. 20
meclizine hcl .......................................................... 56
medroxyprogesterone acetate
............................................................................................ 50, 55
mefloquine hcl ......................................................... 7
megestrol acetate ......................................... 18
MEGESTROL ACETATE ......................... 18
MEKINIST ...................................................................... 20
meloxicam ....................................................................... 1
memantine hcl .................................................... 35
MEMANTINE HCL ............................................ 35
MENACTRA ................................................................ 67
MENHIBRIX ................................................................. 67
MENOMUNE ............................................................. 67
MENVEO .......................................................................... 67
mercaptopurine ................................................. 16
meropenem ................................................................... 6
mesalamine .............................................................. 57
mesalamine-cleanser ............................ 57
mesna ................................................................................. 21
MESNEX ........................................................................... 21
metadate er .............................................................. 42
metformin hcl ....................................................... 48
metformin hcl er .............................................. 48
methadone hcl ......................................................... 2
methadone hcl intensol .......................... 2
methazolamide .................................................. 29
methenamine hippurate ........................ 6
methimazole ........................................................... 55
methotrexate .......................................................... 63
methotrexate sodium ............................. 17
METHOTREXATE SODIUM .............. 17
methotrexate sodium (pf) ............... 17
methylphenidate hcl ................................. 43
methylphenidate hcl er ....................... 43
methylprednisolone ................................... 53
methylprednisolone acetate ...... 53
Index
levocetirizine dihydrochloride
Index
Index
KLOR-CON 10 ....................................................... 68
klor-con m10 ......................................................... 68
klor-con m15 ......................................................... 68
klor-con m20 ......................................................... 68
klor-con sprinkle ............................................. 68
KORLYM .......................................................................... 54
KUVAN ................................................................................. 52
KYNAMRO .................................................................... 25
labetalol hcl .............................................................. 26
LACTATED RINGERS ................................. 71
lactulose ......................................................................... 58
lactulose encephalopathy .............. 58
lamivudine ......................................................... 8, 11
lamivudine-zidovudine ......................... 10
lamotrigine ................................................................. 33
LANTUS ............................................................................ 46
LANTUS SOLOSTAR ................................... 46
larin fe 1.5/30 ...................................................... 50
larin fe 1/20 ............................................................. 50
LASTACAFT ............................................................... 72
latanoprost ................................................................. 72
LATUDA ............................................................................ 40
leflunomide ............................................................... 63
LENVIMA 10 MG DAILY DOSE
.......................................................................................................... 19
.......................................................................................................... 19
.......................................................................................................... 19
.......................................................................................................... 19
.......................................................................................................... 19
LENVIMA 8 MG DAILY DOSE ...... 19
LENVIMA 8MG DAILY DOSE ........ 20
LETAIRIS ......................................................................... 30
letrozole ........................................................................... 18
leucovorin calcium ...................................... 21
LEUKERAN ................................................................... 16
LEUKINE ........................................................................... 62
leuprolide acetate ......................................... 18
LEVEMIR .......................................................................... 46
LEVEMIR FLEXTOUCH ............................ 46
levetiracetam ......................................................... 33
LEVETIRACETAM IN NACL .............. 33
levobunolol hcl .................................................... 72
levocarnitine ............................................................ 52
91
niacin er (antihyperlipidemic)
Index
MYCAMINE ...................................................................... 5
mycophenolate mofetil ........................ 65
mycophenolic acid ...................................... 65
myorisan ........................................................................ 78
MYOZYME .................................................................... 52
MYRBETRIQ .............................................................. 60
myzilra ............................................................................... 50
nabumetone ................................................................. 1
nadolol ............................................................................... 26
nafcillin sodium ................................................. 15
NAGLAZYME ............................................................ 52
nalbuphine hcl ......................................................... 3
naloxone hcl ............................................................ 45
naltrexone hcl ....................................................... 45
NAMENDA XR ........................................................ 35
NAMENDA XR TITRATION PACK
.......................................................................................................... 35
NAMZARIC ................................................................... 35
naphazoline hcl ................................................. 75
naproxen ............................................................................. 1
naproxen dr ................................................................... 1
naproxen sodium ................................................ 1
NASONEX ...................................................................... 77
NATACYN ....................................................................... 74
nateglinide .................................................................. 48
NATPARA ....................................................................... 54
NEBUPENT ....................................................................... 6
necon 1/35 (28) ................................................ 50
nefazodone hcl ................................................... 37
neomycin sulfate ................................................. 4
neomycin-bacitracin zn-polymyx
.......................................................................................................... 74
neomycin-polymyxin-dexameth
.......................................................................................................... 73
neomycin-polymyxin-gramicidin
.......................................................................................................... 74
neomycin-polymyxin-hc ................... 83
NEORAL ............................................................................ 65
NEPHRAMINE ......................................................... 70
NEUMEGA ..................................................................... 62
NEUPOGEN ................................................................. 62
NEUPRO ........................................................................... 38
NEVIRAPINE ................................................................... 8
nevirapine ......................................................................... 8
nevirapine er ............................................................... 8
NEXAVAR ........................................................................ 20
NEXIUM ............................................................................. 59
Index
Index
methylprednisolone sodium succ
.......................................................................................................... 53
metipranolol ............................................................. 72
metoclopramide hcl .................................. 56
metolazone ................................................................ 29
metoprolol succinate er ..................... 26
metoprolol tartrate ....................................... 26
metoprolol-hydrochlorothiazide
.......................................................................................................... 25
metronidazole ............................... 6, 61, 82
metronidazole in nacl ................................. 6
mexiletine hcl ........................................................ 24
MIACALCIN ................................................................. 54
MICROGESTIN FE 1.5/30 ................. 50
MICROGESTIN FE 1/20 ........................ 50
midodrine hcl ........................................................ 29
minitran ............................................................................ 30
minocycline hcl .................................................. 16
minoxidil ......................................................................... 29
mirtazapine ............................................................... 36
misoprostol ................................................................ 59
mitomycin .................................................................... 16
mitoxantrone hcl ............................................. 20
M-M-R II ......................................................................... 67
moderiba ........................................................................ 11
moexipril hcl ........................................................... 22
moexipril-hydrochlorothiazide
.......................................................................................................... 22
molindone hcl ....................................................... 40
mometasone furoate ............................... 81
mono-linyah ............................................................. 50
MONONESSA .......................................................... 50
montelukast sodium ................................ 76
morgidox ........................................................................ 16
MORPHINE SULFATE .................................... 3
MORPHINE SULFATE
(CONCENTRATE) ................................................... 2
morphine sulfate (pf) .................................... 2
MORPHINE SULFATE (PF) .................... 2
morphine sulfate er ........................................ 3
morphine sulfate er beads ................ 2
MOVANTIK ................................................................... 59
MOVIPREP .................................................................... 58
MOXEZA ........................................................................... 73
MOZOBIL ........................................................................ 62
MULTAQ .......................................................................... 24
mupirocin ...................................................................... 78
mupirocin calcium ....................................... 78
25
niacor ................................................................................... 25
nicardipine hcl ..................................................... 27
NICOTROL NS ........................................................ 45
nifedical xl ................................................................... 27
nifedipine er ............................................................. 27
nifedipine er osmotic release
.......................................................................................................... 27
NILANDRON .............................................................. 18
nilutamide .................................................................... 18
nimodipine .................................................................. 27
NINLARO ......................................................................... 18
NIPENT ............................................................................... 17
nitro-bid ........................................................................... 30
nitrofurantoin .............................................................. 6
nitrofurantoin macrocrystal ............. 6
nitrofurantoin monohyd macro
............................................................................................................... 6
nitroglycerin ............................................................. 30
NITROSTAT ................................................................ 30
NORA-BE ........................................................................ 51
NORDITROPIN FLEXPRO .................... 54
norethindrone ....................................................... 51
norethindrone acetate ........................... 55
norethindrone-eth estradiol ....... 52
norgestimate-eth estradiol .......... 51
norgestim-eth estrad triphasic
.......................................................................................................... 51
norlyroc ............................................................................ 51
NORMOSOL-M IN D5W ....................... 71
NORMOSOL-R IN D5W ......................... 71
NORMOSOL-R PH 7.4 ............................ 71
NORPACE CR .......................................................... 24
nortrel 1/35 (21) ............................................... 51
nortrel 1/35 (28) ............................................... 51
nortriptyline hcl .................................................. 37
NORVIR ................................................................................... 8
NOVOLIN 70/30 ................................................. 46
NOVOLIN N ................................................................. 46
NOVOLIN R .................................................................. 46
NOVOLOG ...................................................................... 46
NOVOLOG FLEXPEN ................................... 46
NOVOLOG MIX 70/30 .............................. 46
NOVOLOG MIX 70/30 FLEXPEN
.......................................................................................................... 46
NOVOLOG PENFILL ...................................... 46
NOXAFIL ............................................................................... 5
..........................................................................................................
92
pimozide ......................................................................... 41
pindolol ............................................................................. 26
pioglitazone hcl ................................................. 48
piperacillin sod-tazobactam so
.......................................................................................................... 15
pirmella 1/35 ......................................................... 51
PLASMA-LYTE 148 ..................................... 71
PLASMA-LYTE A ............................................... 71
PLASMA-LYTE-56 IN D5W ............ 71
podofilox ......................................................................... 82
polyethylene glycol 3350 ................ 58
polymyxin b-trimethoprim ............. 74
POMALYST ................................................................. 20
potassium chloride ....................... 69, 71
POTASSIUM CHLORIDE ....................... 71
potassium chloride crys er ........... 68
potassium chloride er ............................ 69
POTASSIUM CHLORIDE ER ........... 69
POTASSIUM CHLORIDE IN
DEXTROSE .................................................................. 71
potassium chloride in nacl ........... 71
POTASSIUM CHLORIDE IN NACL
.......................................................................................................... 71
POTASSIUM CITRATE ER .................. 60
POTIGA ................................................................. 33, 34
PRADAXA ....................................................................... 62
PRALUENT ................................................................... 25
pramipexole dihydrochloride .... 38
pravastatin sodium ..................................... 24
prazosin hcl .............................................................. 22
prednisolone ........................................................... 53
PREDNISOLONE ACETATE ............. 74
prednisolone sodium phosphate
............................................................................................ 53, 75
prednisone .................................................................. 53
prednisone intensol ................................... 53
PREFERRED PLUS INSULIN
SYRINGE .......................................................................... 46
premasol ........................................................................ 70
prenatal ............................................................................ 71
prevalite ........................................................................... 25
previfem .......................................................................... 51
PREZCOBIX ................................................................ 10
PREZISTA ........................................................................... 8
PRIFTIN ............................................................................. 10
PRIMAQUINE PHOSPHATE .................. 7
primidone ..................................................................... 34
PRISTIQ ............................................................................. 37
Index
pantoprazole sodium .............................. 60
paricalcitol .................................................................. 71
paroex ................................................................................. 83
paromomycin sulfate ................................... 4
paroxetine hcl ....................................................... 37
paser ..................................................................................... 10
PATADAY ........................................................................ 72
PAXIL ..................................................................................... 37
PAZEO ................................................................................. 72
PEDIARIX ........................................................................ 67
PEDVAX HIB .............................................................. 67
PEG 3350/ELECTROLYTES ........... 58
peg 3350-kcl-na bicarb-nacl
.......................................................................................................... 58
PEG-3350/ELECTROLYTES .......... 58
PEGANONE ................................................................. 33
PEGASYS ........................................................................ 11
PEGASYS PROCLICK ................................. 11
PEGINTRON ............................................................... 11
PEG-INTRON REDIPEN .......................... 11
PENICILLIN G POT IN DEXTROSE
.......................................................................................................... 15
penicillin g potassium ........................... 15
penicillin g procaine ................................. 15
penicillin g sodium ...................................... 15
penicillin v potassium ............................ 15
PENTACEL .................................................................... 67
PENTAM ............................................................................... 7
pentoxifylline er ................................................. 62
PERFOROMIST ..................................................... 76
perindopril erbumine ............................... 22
periogard ....................................................................... 83
permethrin .................................................................. 82
perphenazine ......................................................... 41
pfizerpen-g ................................................................ 15
phenadoz ....................................................................... 56
phenelzine sulfate ........................................ 37
phenergan ................................................................... 56
phenobarbital ........................................................ 33
phenobarbital sodium ............................ 33
PHENOBARBITAL SODIUM ............. 33
phenytek ........................................................................ 33
phenytoin ...................................................................... 33
phenytoin sodium .......................................... 33
phenytoin sodium extended ...... 33
PHOSPHOLINE IODIDE ........................... 72
PILOCARPINE HCL ........................... 72, 83
pilocarpine hcl ..................................................... 83
Index
Index
NUEDEXTA .................................................................. 44
NULOJIX .......................................................................... 65
NULYTELY WITH FLAVOR PACKS
.......................................................................................................... 58
NUPLAZID ..................................................................... 40
NUTRILIPID ................................................................. 70
NUVARING .................................................................... 51
NUVIGIL ............................................................................. 44
nyamyc ............................................................................. 79
NYMALIZE .................................................................... 27
nystatin ...................................................... 5, 79, 83
nystop .................................................................................. 79
OCTAGAM ..................................................................... 64
octreotide acetate ......................................... 54
ODEFSEY ........................................................................ 10
ODOMZO ........................................................................ 20
OFEV ....................................................................................... 77
ofloxacin ........................................................... 74, 83
olanzapine ..................................................... 40, 41
olopatadine hcl ................................................... 75
omega-3-acid ethyl esters ........... 25
omeprazole ................................................................ 59
ondansetron ............................................................. 56
ondansetron hcl ................................................ 56
ONETOUCH ULTRA 2 ................................ 48
ONETOUCH ULTRA BLUE ................. 48
ONETOUCH ULTRA MINI .................... 48
ONETOUCH VERIO ........................... 48, 49
ONETOUCH VERIO IQ SYSTEM
.......................................................................................................... 49
ONETOUCH VERIO SYNC
SYSTEM ........................................................................... 49
ONFI ........................................................................................ 33
OPANA ER ......................................................................... 3
OPSUMIT ........................................................................ 30
ORFADIN ......................................................................... 52
ORKAMBI ....................................................................... 77
oxandrolone ............................................................. 45
oxcarbazepine ...................................................... 33
oxybutynin chloride .................................... 60
oxybutynin chloride er .......................... 60
oxycodone hcl ........................................................... 3
OXYCODONE HCL ............................................... 3
oxycodone-acetaminophen ............. 3
pacerone ........................................................................ 24
paliperidone er .................................................... 41
pamidronate disodium ......................... 49
PANRETIN ..................................................................... 82
93
SEROQUEL XR ........................................ 41, 42
sertraline hcl ........................................................... 37
sharobel ........................................................................... 51
SIGNIFOR ....................................................................... 54
sildenafil citrate ................................................ 30
SILENOR .......................................................................... 43
SILVER SULFADIAZINE .......................... 79
SIMBRINZA ................................................................. 72
simvastatin ................................................................ 24
sirolimus ......................................................................... 66
SIROLIMUS ................................................................. 66
SIRTURO ......................................................................... 10
SIVEXTRO ........................................................................... 7
SODIUM CHLORIDE ....................... 69, 71
sodium chloride ................................................ 82
sodium fluoride .................................................. 69
sodium polystyrene sulfonate
.......................................................................................................... 49
SOLTAMOX ................................................................ 18
SOLU-CORTEF ..................................................... 53
SOMATULINE DEPOT ............................... 54
SOMAVERT ................................................................. 54
sorine ................................................................................... 24
sotalol hcl ..................................................................... 24
sotalol hcl (af) ....................................................... 24
SOVALDI .......................................................................... 11
spironolactone ..................................................... 22
spironolactone-hctz .................................. 29
sprintec 28 ................................................................. 51
SPRITAM ......................................................................... 34
SPRYCEL ........................................................................ 20
sps ............................................................................................. 49
SSD .......................................................................................... 79
stavudine ........................................................................... 9
STERILE WATER FOR
IRRIGATION ................................................................ 82
STIVARGA ...................................................................... 20
STRATTERA ............................................................... 43
streptomycin sulfate ..................................... 4
STRIBILD ........................................................................ 10
SUBOXONE ................................................................. 45
sucralfate ...................................................................... 59
sulfacetamide sodium ............ 74, 78
sulfacetamide-prednisolone ..... 73
sulfadiazine ................................................................... 4
sulfamethoxazole-trimethoprim
............................................................................................................... 7
SULFAMYLON ....................................................... 79
Index
RAPAMUNE ................................................................ 66
RAVICTI ............................................................................. 52
RECOMBIVAX HB ............................................. 67
REGRANEX .................................................................. 82
RELENZA DISKHALER ............................. 11
RELI-ON INSULIN SYRINGE .......... 46
RELISTOR ...................................................................... 58
RELPAX ............................................................................. 43
REMICADE ................................................................... 63
REMODULIN ............................................................. 30
RENVELA ........................................................................ 55
repaglinide .................................................................. 48
RESCRIPTOR ................................................................ 8
RESTASIS ...................................................................... 75
RETROVIR .......................................................................... 9
REVATIO ........................................................................... 30
REVLIMID ....................................................................... 65
REXULTI ........................................................................... 41
REYATAZ ............................................................................. 9
ribasphere ................................................................... 11
ribavirin ............................................................................ 11
rifabutin ............................................................................ 10
rifampin ............................................................................ 10
RIFATER ........................................................................... 10
riluzole ................................................................................ 44
rimantadine hcl .................................................. 11
RINGERS ......................................................................... 71
RISPERDAL CONSTA ................................ 41
risperidone ................................................................. 41
RITUXAN .......................................................................... 18
rizatriptan benzoate .................................. 43
ropinirole hcl ........................................................... 38
rosadan ............................................................................. 82
rosuvastatin calcium ............................... 24
ROTARIX .......................................................................... 67
ROTATEQ ....................................................................... 67
roweepra ........................................................................ 34
roxicet ...................................................................................... 3
ROZEREM ...................................................................... 43
SABRIL ............................................................................... 34
SANDIMMUNE ...................................................... 66
SANTYL ............................................................................. 82
SAPHRIS .......................................................................... 41
selegiline hcl ........................................................... 38
selenium sulfide ............................................... 80
SELZENTRY .................................................................... 9
SENSIPAR ..................................................................... 49
SEREVENT DISKUS ...................................... 76
Index
Index
PRIVIGEN ........................................................................ 64
probenecid ...................................................................... 1
PROCALAMINE .................................................... 70
prochlorperazine ............................................. 56
prochlorperazine edisylate ........... 56
prochlorperazine maleate .............. 56
PROCRIT .......................................................................... 62
procto-med hc .................................................... 79
procto-pak .................................................................. 79
proctosol hc ............................................................. 79
proctozone-hc ...................................................... 79
PROGLYCEM ............................................................ 54
PROGRAF ......................................................... 65, 66
PROLASTIN-C ........................................................ 77
PROLENSA .................................................................. 75
PROLIA ............................................................................... 54
PROMACTA .................................................. 62, 63
promethazine hcl ........................................... 56
promethegan .......................................................... 56
propafenone hcl ............................................... 24
propafenone hcl er ...................................... 24
proparacaine hcl ............................................. 75
propranolol hcl .................................................... 26
propranolol hcl er .......................................... 26
propranolol-hctz .............................................. 25
propylthiouracil .................................................. 55
PROQUAD ...................................................................... 67
PROSOL ............................................................................ 70
protriptyline hcl .................................................. 37
PRUDOXIN .................................................................... 79
PULMICORT FLEXHALER .................. 77
PULMOZYME ........................................................... 77
PURIXAN .......................................................................... 17
pyrazinamide ......................................................... 10
pyridostigmine bromide ..................... 44
QUADRACEL ............................................................. 67
quetiapine fumarate ................................. 41
quinapril hcl ............................................................. 22
quinapril-hydrochlorothiazide
.......................................................................................................... 22
quinidine gluconate er .......................... 24
quinidine sulfate .............................................. 24
quinine sulfate ......................................................... 7
RABAVERT ................................................................... 67
raloxifene hcl ......................................................... 54
ramipril .............................................................................. 22
RANEXA ............................................................................ 29
ranitidine hcl ........................................................... 57
94
triderm ............................................................................... 81
trifluoperazine hcl ......................................... 42
trifluridine ..................................................................... 74
tri-linyah ......................................................................... 51
trilyte ..................................................................................... 58
trimethoprim ................................................................ 7
trimipramine maleate ............................ 37
TRINESSA (28) ..................................................... 51
TRINTELLIX ................................................................ 37
tri-previfem ............................................................... 51
TRISENOX ..................................................................... 21
tri-sprintec .................................................................. 51
TRIUMEQ ........................................................................ 10
trivora (28) .................................................................. 51
TROPHAMINE ......................................................... 70
TRULICITY .................................................................... 47
TRUMENBA ................................................................ 67
TRUVADA ....................................................................... 10
TWINRIX ........................................................................... 67
TYBOST ................................................................................. 9
TYGACIL ................................................................................ 7
TYKERB ............................................................................. 20
TYPHIM VI ..................................................................... 68
TYSABRI ........................................................................... 44
TYZEKA .............................................................................. 11
UCERIS ............................................................................... 58
ULORIC ................................................................................... 1
UNITHROID ................................................................. 55
UPTRAVI ........................................................................... 30
ursodiol ............................................................................. 59
valacyclovir hcl .................................................. 12
VALCHLOR ................................................................... 82
VALCYTE ......................................................................... 12
valganciclovir hcl ........................................... 12
valproate sodium ............................................ 34
valproic acid ............................................................ 34
valsartan ......................................................................... 23
valsartan-hydrochlorothiazide
.......................................................................................................... 23
vancomycin hcl ...................................................... 7
VANCOMYCIN HCL IN NACL ............ 7
VANDAZOLE .............................................................. 61
VAQTA ................................................................................. 68
VARIVAX ........................................................................... 68
VASCEPA ........................................................................ 25
VELCADE ........................................................................ 18
velivet .................................................................................. 51
VENCLEXTA ............................................................... 18
Index
terconazole ................................................................ 61
testosterone cypionate ........................ 45
testosterone enanthate ....................... 45
TETANUS-DIPHTHERIA TOXOIDS
TD ............................................................................................... 67
tetrabenazine ......................................................... 44
THALOMID ................................................................... 65
theophylline er .................................................... 78
thioridazine hcl ................................................... 42
thiothixene .................................................................. 42
tiagabine hcl ........................................................... 34
TIKOSYN .......................................................................... 24
timolol maleate .................................... 26, 73
TIMOLOL MALEATE .................................... 73
TIVICAY ................................................................................... 9
tizanidine hcl .......................................................... 44
TOBRADEX .................................................................. 73
TOBRADEX ST ...................................................... 73
tobramycin ........................................................ 4, 74
tobramycin sulfate ........................................... 4
tobramycin-dexamethasone ..... 73
tolterodine tartrate ....................................... 60
tolterodine tartrate er ............................. 60
topiramate ................................................................... 34
toposar ............................................................................... 21
topotecan hcl ......................................................... 21
torsemide ...................................................................... 29
TOUJEO SOLOSTAR ................................... 46
TOVIAZ ................................................................................ 60
TPN ELECTROLYTES ................................ 69
TRACLEER .................................................................... 30
TRADJENTA .............................................................. 48
tramadol hcl ................................................................. 3
trandolapril ................................................................. 22
tranexamic acid ................................................ 63
TRANSDERM-SCOP (1.5 MG)
.......................................................................................................... 56
tranylcypromine sulfate ..................... 37
TRAVASOL ................................................................... 70
TRAVATAN Z ............................................................ 73
trazodone hcl ......................................................... 37
TRECATOR .................................................................. 10
TRELSTAR MIXJECT .................................. 19
TRESIBA FLEXTOUCH ............................. 46
tretinoin .............................................................. 21, 78
triamcinolone acetonide ..... 81, 83
triamterene-hctz ............................................. 29
TRIBENZOR ................................................................ 23
Index
Index
sulfasalazine ........................................................... 57
sulindac ................................................................................ 1
SUMATRIPTAN ..................................................... 43
sumatriptan succinate .......................... 43
SUMATRIPTAN SUCCINATE
REFILL ................................................................................. 43
sumatriptan succinate refill ........ 43
SUPRAX ............................................................................ 13
suprax ................................................................................. 13
SUPREP BOWEL PREP ........................... 58
SURMONTIL .............................................................. 37
SUSTIVA ............................................................................... 9
SUTENT ............................................................................. 20
SYLATRON .................................................................. 20
SYMBICORT .............................................................. 78
SYMLINPEN 120 ............................................... 46
SYMLINPEN 60 ................................................... 46
SYNAGIS .......................................................................... 67
SYNAREL ........................................................................ 51
SYNERCID ......................................................................... 7
SYNRIBO ......................................................................... 20
SYNTHROID ............................................................... 55
SYPRINE .......................................................................... 49
TABLOID .......................................................................... 17
tacrolimus ...................................................... 66, 82
TAFINLAR ...................................................................... 20
TAGRISSO ..................................................................... 20
TAMIFLU ......................................................................... 11
tamoxifen citrate ............................................. 18
tamsulosin hcl ..................................................... 60
TARCEVA ........................................................................ 20
TARGRETIN ................................................................ 82
tarina fe 1/20 ......................................................... 51
TASIGNA .......................................................................... 20
tazicef .................................................................................. 13
TAZORAC ....................................................................... 80
taztia xt ............................................................................. 27
TECENTRIQ ................................................................ 18
TEFLARO ........................................................................ 13
TEGRETOL ................................................................... 34
TEGRETOL-XR ...................................................... 34
TEKTURNA ................................................................... 28
TEKTURNA HCT .................................................. 28
temazepam ............................................................... 43
TENIVAC ........................................................................... 67
terazosin hcl ............................................................ 22
terbinafine hcl ........................................................... 5
terbutaline sulfate ......................................... 76
ziprasidone hcl ................................................... 42
ZIRGAN .............................................................................. 74
zoledronic acid ................................................... 49
ZOLINZA .......................................................................... 18
zolpidem tartrate ............................................ 43
zonisamide ................................................................. 34
ZONTIVITY .................................................................... 63
ZORTRESS ................................................................... 66
ZOSTAVAX ................................................................... 68
zovia 1/35e (28) ............................................... 51
zovia 1/50e (28) ............................................... 51
ZYDELIG ........................................................................... 20
ZYKADIA .......................................................................... 20
ZYLET ................................................................................... 73
ZYPREXA RELPREVV ................................. 42
ZYTIGA ................................................................................ 19
ZYVOX ...................................................................................... 7
Index
Index
VENCLEXTA STARTING PACK ... 18
venlafaxine hcl .................................................... 37
venlafaxine hcl er .......................................... 37
VENTOLIN HFA ..................................................... 76
verapamil hcl ......................................................... 28
verapamil hcl er .................................. 27, 28
VERAPAMIL HCL ER ................................... 27
VERSACLOZ .............................................................. 42
VESICARE ...................................................................... 60
VICTOZA ........................................................................... 47
VIDEX ......................................................................................... 9
VIGAMOX ........................................................................ 74
VIIBRYD ............................................................................. 37
VIIBRYD STARTER PACK ................... 38
VIMPAT .............................................................................. 34
VIRACEPT ........................................................................... 9
VIRAMUNE XR ............................................................ 9
VIREAD .................................................................................... 9
VITEKTA ................................................................................ 9
VOLTAREN ................................................................... 82
voriconazole ................................................................. 5
VOTRIENT ...................................................................... 20
VRAYLAR ........................................................................ 42
warfarin sodium ............................................... 62
WELCHOL ...................................................................... 25
XALKORI .......................................................................... 20
XARELTO ........................................................................ 62
XARELTO STARTER PACK ............... 62
XGEVA .................................................................................. 54
XIFAXAN ........................................................................... 59
XIGDUO XR .................................................................. 48
XOLAIR ............................................................................... 77
XOPENEX HFA ....................................................... 76
XTANDI ............................................................................... 19
xulane .................................................................................. 51
XYREM ................................................................................ 44
YERVOY ............................................................................. 18
YF-VAX ............................................................................... 68
zafirlukast .................................................................... 76
ZAVESCA ........................................................................ 52
ZAZOLE ............................................................................. 61
ZELBORAF ................................................................... 20
ZEMAIRA ......................................................................... 77
zenatane ......................................................................... 78
ZENPEP ............................................................................. 59
ZETIA ..................................................................................... 25
ZIAGEN .................................................................................... 9
zidovudine ........................................................................ 9
95
This information is available for free in other languages. Please call our Customer Service number at
1-877-374-4056, Monday–Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives
are available Monday–Sunday, 8 a.m. to 8 p.m. TTY users should call 1-877-247-6272.
Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de
Servicio al Cliente al 1-877-374-4056, de lunes a viernes, de 8 a.m. a 8 p.m. Entre el 1 de octubre
y el 14 de febrero, los representantes están disponibles de lunes a domingo de 8 a.m. a 8 p.m.
Los usuarios de TTY deben llamar al 1-877-247-6272.
Y0070_NA030731_WCM_INS_MLT_NA_07_15_CCP_14PT_PORTRAIT_FINAL
68921
ENG/SPA/CHI/VIE/KOR
We’re always just a phone call away!
If you’re ready to enroll or have enrollment questions, call: In all states except California: 1-866-527-0057 – In California: 1-866-999-3945
�
Representatives are available from 8 a.m. to 8 p.m., 7 days a week.
If you’re already a member, call the number for your state/plan listed below.
Arkansas:
All Plans ............................................................................................... 1-800-316-2273
California:
Easy Choice Access Plan (HMO-SNP) ................................... 1-866-999-3945
�
Connecticut:
�
WellCare Rx or Value (HMO) .................................................... 1-866-579-8006
�
Florida:
WellCare Access, Liberty or Select (HMO SNP) .............. 1-866-637-8041
�
WellCare Dividend, Essential, Reserve, Rx or
Value (HMO/HMO-POS) ............................................................ 1-888-888-9355
�
Georgia:
�
Hawai‘i:
Illinois:
Kentucky:
Louisiana:
Mississippi:
New Jersey:
New York:
South Carolina:
‘Ohana Liberty (HMO SNP)........................................................ 1-877-457-7621
�
‘Ohana Value (HMO-POS).......................................................... 1-888-505-1201
�
WellCare Access (HMO SNP)................................................... 1-877-560-3206
�
WellCare Value (HMO-POS)..................................................... 1-877-560-2766
�
WellCare Essential or Value (HMO)........................................ 1-866-804-5926
All Plans ............................................................................................... 1-800-316-2273
�
WellCare Value (HMO)................................................................. 1-866-687-8570
�
�
�
All Plans ............................................................................................... 1-800-316-2273
Tennessee:
All Plans ............................................................................................... 1-800-316-2273
�
Texas:
WellCare Dividend, Essential or
Value (HMO/HMO-POS) ............................................................ 1-866-687-8878
Hours of operation are Monday–Friday, 8 a.m. to 8 p.m. Between October 1 and February 14,
representatives are available Monday–Sunday, 8 a.m. to 8 p.m., or visit us anytime at
www.wellcare.com/medicare, www.ohanahealthplan.com/medicare or
www.easychoicehealthplan.com
Nurse Advice Line..................................................................... 1-800-581-9952 (24 hours, 7 days a week)
TTY for all of the above except California: .......................................................................1-877-247-6272
�
TTY for California:..........................................................................................................................1-800-735-2929
�
‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare (HMO) is a Medicare Advantage organization with a Medicare contract. Enrollment in WellCare/‘Ohana/Easy Choice (HMO) depends on contract renewal. WellCare (HMO SNP) is a Medicare Advantage organization with a Medicare contract and a contract with the state Medicaid program. Enrollment in WellCare/‘Ohana (HMO SNP) depends on contract renewal. Easy Choice Health Plan (HMO SNP), a WellCare company, is a Medicare Advantage organization with a Medicare contract and a contract with the California Medicaid program. Enrollment in Easy Choice (HMO SNP) depends on contract renewal. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Some plans are available to those who have medical assistance from both the state and Medicare. Premiums, co-pays, coinsurance and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments and restrictions may apply. Benefits, premiums and/or co-payments/coinsurance may change on January 1 of each year.
�
This formulary was updated on 10/01/2016. For more recent information or other questions, please contact WellCare/‘Ohana/Easy Choice at the telephone number listed on the inside front and back covers of this formulary or visit www.wellcare.com/medicare or www.ohanahealthplan.com/medicare or www.easychoicehealthplan.com.
�
73846
P.O. Box 31389 | Tampa, FL 33631-3389
�

English - Easy Choice Health Plan

Transcription

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