Comprehensive Formulary

Transcription

Comprehensive Formulary - Medicare Part D Plans

SilverScript
2017 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS
INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
Formulary File 17256, Version 6
This formulary was updated on August 1, 2016. For more recent information or other questions, please
contact SilverScript at 1-866-235-5660 or, for TTY users, 711, 24 hours a day, 7 days a week, or visit
www.silverscript.com.
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 SilverScript® Insurance Company. When
it refers to “plan” or “our plan,” it means SilverScript Plus (PDP).
This document includes a list of the drugs (formulary) for our plan which is current as of
January 1, 2017. 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, and/or copayments/coinsurance may change on January 1, 2018, and from time to time
during the year.
Y0080_62001_FORM_COMP_2017 Accepted
0
FRM-CM-PLS-9110-17
What is the SilverScript
Formulary?
A formulary is a list of covered drugs selected by
SilverScript Plus (PDP) in consultation with a
team of health care providers, which represents
the prescription therapies believed to be a
necessary part of a quality treatment program.
Our plan will generally cover the drugs listed in
our formulary as long as the drug is medically
necessary, the prescription is filled at a plan
network pharmacy, and other plan rules are
followed. For more information on how to fill your
prescriptions, please review your Evidence of
Coverage.
Can the Formulary (drug list)
change?
Generally, if you are taking a drug on our 2017
formulary that was covered at the beginning of
the year, we will not discontinue or reduce
coverage of the drug during the 2017 coverage
year except when a new, less expensive generic
drug becomes available or when new adverse
information about the safety or effectiveness of a
drug is released.
Other types of formulary changes, such as
removing a drug from our formulary, will not affect
members who are currently taking the drug. It will
remain available at the same cost-sharing for
those members taking it for the remainder of the
coverage year.
We feel it is important that you have continued
access for the remainder of the coverage year to
the formulary drugs that were available when you
chose our plan, except for cases in which you can
save additional money or we can ensure your
safety.
If the Food and Drug Administration deems a
drug on our formulary to be unsafe or the drug’s
manufacturer removes the drug from the market,
we will immediately remove the drug from our
formulary and provide notice to members who
take the drug.
The enclosed formulary is current as of January
1, 2017. To get updated information about the
drugs covered by SilverScript Plus (PDP), please
contact us. Our contact information appears on
the front and back cover pages.
If we have other types of mid-year
non-maintenance formulary changes unrelated to
the reasons stated above (e.g. remove drugs
from our formulary, add prior authorization
requirements, quantity limits and/or step therapy
restrictions on a drug, or move a drug to a higher
cost-sharing tier), we will notify you by mail. We
will also update our formulary with the new
information. The updated formulary may be
obtained from our website or by calling us. Our
contact information appears on the front and back
cover pages.
How do I use the Formulary?
There are two ways to find your drug within the
formulary:
Medical Condition
The formulary begins on page 7. 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”. If you know what your drug is
used for, look for the category name in the list
that begins on page 7. Then look under the
category name for your drug.
If we remove drugs from our formulary, add prior
authorization, quantity limits and/or step therapy
restrictions on a drug, or move a drug to a higher
cost-sharing tier, we must notify affected
members of the change at least 60 days before
the change becomes effective, or at the time the
member requests a refill of the drug, at which
time the member will receive a 60-day supply of
the drug.
1
Alphabetical Listing
Step Therapy (ST)
If you are not sure what category to look under,
you should look for your drug in the Index that
begins on page 52. 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.
In some cases, SilverScript Plus (PDP) 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.
What are generic drugs?
SilverScript Plus (PDP) 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 (PA)
You can find out if your drug has any additional
requirements or limits by looking in the formulary
that begins on page 7. You can also get more
information about the restrictions applied to
specific covered drugs by visiting our website. We
have posted on line documents that explain our
prior authorization 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 us 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
SilverScript formulary?” on page 3 for information
about how to request an exception.
SilverScript Plus (PDP) 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.
What if my drug is not on the
Formulary?
Quantity Limits (QL)
If you learn that SilverScript Plus (PDP) does not
cover your drug, you have two options:
For certain drugs, SilverScript Plus (PDP) limits
the amount of the drug that we will cover. For
example, our plan provides up to 30 tablets per
prescription for doxazosin. This may be in
addition to a standard one-month or three-month
supply.
If your drug is not included in this formulary (list of
covered drugs), you should first contact Customer
Care and ask if your drug is covered.
 You can ask Customer Care for a list of
similar drugs that are covered by our plan.
When you receive the list, show it to your
doctor and ask him or her to prescribe a
similar drug that is covered by our plan.
 You can ask us to make an exception and
cover your drug. See below for
information about how to request an
exception.
2
How do I request an exception
to the SilverScript Formulary?
You can ask us to make an exception to our
coverage rules. There are several types of
exceptions that you can ask us to make.
 You can ask us to cover a drug even if it is
not on our formulary. If approved, this
drug will be covered at a pre-determined
cost-sharing level, and you would not be
able to ask us to provide the drug at a
lower cost-sharing level.
 You can ask us to cover a formulary drug
at a lower cost-sharing level if this drug is
not on the specialty tier. If approved this
would lower the amount you must pay for
your drug.
 You can ask us to waive coverage
restrictions or limits on your drug. For
example, for certain drugs, our plan limits
the amount of the drug that we will cover.
If your drug has a quantity limit, you can
ask us to waive the limit and cover a
greater amount.
Generally, SilverScript Plus (PDP) will only
approve your request for an exception if the
alternative drugs included on the plan’s formulary,
the lower cost-sharing drug or additional
utilization restrictions would not be as effective in
treating your condition and/or would cause you to
have adverse medical effects.
You should contact us to ask us for an initial
coverage decision for a formulary, tiering or
utilization restriction exception. When you
request a formulary, tiering or utilization
restriction exception 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 prescriber’s supporting
statement. You can request an expedited (fast)
exception if you or your doctor believe that your
health could be seriously harmed by waiting up to
72 hours for a decision.
If your request to expedite is granted, we must
give you a decision no later than 24 hours after
we get a supporting statement from your doctor
or other prescriber.
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 102-day transition
supply, consistent with the dispensing increment,
(unless you have a prescription written for fewer
days). We will cover more than one refill of these
drugs for the first 90 days you are a member of
our plan. If you need a drug that is not on our
formulary or if your ability to get your drugs is
limited, but you are past the first 90 days of
membership in our plan, we will cover a 34-day
emergency supply of that drug (unless you have
a prescription for fewer days) while you pursue a
formulary exception.
3
If you experience a change in your level of care,
such as a move from a home to a long-term care
setting, and need a drug that is not on our
formulary (or if your ability to get your drugs is
limited), we may cover a one-time temporary
supply from a network pharmacy for up to 34 days
unless you have a prescription for fewer days.
You should use the plan's exception process if
you wish to have continued coverage of the drug
after the temporary supply is finished.
For more information
For more detailed information about your
SilverScript Plus (PDP) prescription drug
coverage, please review your Evidence of
Coverage and other plan materials.
If you have questions about our plan, please
contact us. Our contact information, along with
the date we last updated the formulary, appears
on the front and back cover pages.
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
http://www.medicare.gov.
SilverScript Plus (PDP)’s
Formulary
The formulary that begins on page 7 provides
coverage information about the drugs covered by
our plan. If you have trouble finding your drug in
the list, turn to the Index that begins on page 52.
The first column of the chart lists the drug name.
Brand name drugs are capitalized (e.g.,
SYNTHROID) and generic drugs are listed in
lower-case italics (e.g., levothyroxine).
4
The information in the Requirements/Limits column tells you if our plan has any special
requirements for coverage of your drug.
PA – Prior authorization.
QL – Drug has quantity limit.
ST – Step therapy required.
NM – Not available at our mail-order pharmacies.
NDS – Non-extended day supply. Not available for an extended (long-term) supply.
LA – Limited access. This prescription may be
available only at certain pharmacies. For more
information consult your Pharmacy Directory or
call Customer Care at 1-866-235-5660, 24 hours
a day, 7 days a week. TTY users should call 711.
HR – High Risk Drug. According to medical
experts, these drugs may cause more side effects if you are 65 years of age or older. If you are taking one of these drugs, ask your doctor if there are safer options available.
B/D – This drug may be covered under Medicare Part B or Part D depending upon the
circumstances. Information may need to be
submitted describing the use and setting of the
drug to make the determination.
GC – We provide additional coverage of this
prescription drug in the coverage gap. Please
refer to our Evidence of Coverage for more information about this coverage.
The Tier column of the drug list that begins on page 7 tells you which tier your drug is in. The table below
tells you the copayment or coinsurance amount (i.e., the share of the drug's cost that you will pay during the
initial coverage stage) for up to a one-month supply of drugs in each tier.
Initial Coverage Stage Copayment / Coinsurance Levels
Tier
Cost-Sharing Tier 1
(Preferred Generic)
Standard retail
cost-sharing
(in-network)
Preferred retail
cost-sharing
(in-network)
Preferred
Mail-order
cost-sharing
(up to a 30-day supply)
$10.00
$0.00
$0.00
$20.00
$3.00
$3.00
(includes low cost preferred
generic drugs)
Cost-Sharing Tier 2
(Generic)
(includes generic and some
low cost preferred brand
drugs)
Cost-Sharing Tier 3
(Preferred Brand)
(includes preferred brand
and non-preferred generic
drugs)
$47.00
$23.00 - $33.00
$23.00 - $33.00
Please refer to Exhibit 1 Please refer to Exhibit 1
below for the exact
below for the exact
copayment amount in
copayment amount in
your state.
your state.
50%
39% - 45%
39% - 45%
Please refer to Exhibit 1 Please refer to Exhibit 1
below for the exact
below for the exact
coinsurance amount in coinsurance amount in
your state.
your state.
Cost-Sharing Tier 4
(Non-Preferred Drug)
(includes non-preferred
brand and non-preferred
generic drugs)
Cost-Sharing Tier 5
(Specialty Tier)
33%
33%
33%
(includes high cost generic
and brand drugs)
You can find complete cost-sharing information, including costs for long-term supplies and standard mail-order,
long-term care, and out-of-network pharmacy pricing, in your Evidence of Coverage.]
5
Exhibit 1
Your share of the cost when you get a one-month supply of a covered Part D prescription drug
on Tier 3 or Tier 4 by state from a preferred retail or preferred mail-order pharmacy.
State
Alabama
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist. of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
6
Tier 3
(Preferred
Brand)
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$33.00
$23.00
$27.00
$27.00
$33.00
$27.00
$27.00
$33.00
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$33.00
$27.00
Tier 4
(Non-Preferred
Drug)
40%
40%
40%
40%
40%
40%
40%
40%
40%
45%
39%
40%
40%
45%
40%
40%
45%
40%
40%
40%
40%
40%
40%
45%
40%
State
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Tier 3
(Preferred
Brand)
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$33.00
$27.00
$27.00
$33.00
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
$27.00
Tier 4
(Non-Preferred
Drug)
40%
40%
40%
40%
40%
40%
40%
40%
40%
40%
40%
40%
40%
40%
45%
40%
40%
45%
40%
40%
40%
40%
40%
40%
40%
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
ANALGESICS
GOUT
allopurinol tab (generic of
ZYLOPRIM)
colchicine w/ probenecid
COLCRYS
QL (120 tabs / 30 days)
probenecid
ULORIC
2
3
3
GC
QL
3
3
ST
4
QL
NSAIDS
celecoxib (generic of
CELEBREX) CAPS 50mg
QL (240 caps / 30 days)
CELEBREX) CAPS 100mg
diclofenac potassium
diclofenac sodium TB24
diclofenac sodium TBEC
diflunisal
etodolac CAPS; TABS
flurbiprofen TABS
ibuprofen SUSP
ibuprofen TABS 400mg,
600mg, 800mg
ketoprofen CAPS
MELOXICAM SUSP
meloxicam (generic of
MOBIC) TABS
nabumetone TABS
naproxen (generic of
NAPROSYN) SUSP
NAPROSYN) TABS 250mg,
500mg
naproxen TABS 375mg
4
QL
4
QL
4
QL
3
QL
2
2
4
4
3
3
2
GC
GC
3
4
1
GC
GC
2
3
GC
1
GC
1
GC
Drug Name
Drug Requirements/
Tier
Limits
EC-NAPROSYN) TBEC
naproxen sodium TABS
275mg
naproxen sodium (generic of
ANAPROX DS) TABS
550mg
sulindac TABS
2
GC
4
4
2
GC
2
GC QL
2
GC QL
2
GC QL
2
GC QL
OPIOID ANALGESICS
acetaminophen w/ codeine
SOLN
QL (5000 mL / 30 days)
TABS
(generic of
TYLENOL/CODEINE #3)
TABS
(generic of
TYLENOL/CODEINE #4)
TABS
butorphanol tartrate SOLN
1mg/ml, 2mg/ml
BUTRANS 5mcg/hr
QL (16 patches / 28
days)
BUTRANS 10mcg/hr
QL (8 patches / 28 days)
BUTRANS 15mcg/hr,
20mcg/hr
BUTRANS 7.5MCG/HR
nalbuphine hcl (generic of
NUBAIN) SOLN 10mg/ml
nalbuphine hcl SOLN
20mg/ml
tramadol hcl (generic of
ULTRAM) TABS
4
3
QL
3
QL
3
QL
3
QL
4
4
2
GC QL
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
GC - We provide
coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
NDS - Non-Extended Days Supply
HR - High Risk
Medication
7
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
tramadol-acetaminophen
(generic of ULTRACET)
3
QL
4
3
B/D
QL
3
QL
OPIOID ANALGESICS, CII
DURAMORPH
EMBEDA
endocet (generic of
PERCOCET)
fentanyl citrate (generic of
ACTIQ) LPOP
QL (120 lozenges / 30
days)
fentanyl patch 12 mcg/hr
(generic of DURAGESIC)
QL (10 patches / 30
days)
QL (10 patches / 30
days)
QL (10 patches / 30
days)
QL (10 patches / 30
days)
QL (10 patches / 30
days)
FENTORA
hydroco/apap tab 5-325mg
(generic of NORCO)
hydroco/apap tab 7.5-325mg
(generic of NORCO)
(generic of NORCO)
5 NDS QL PA
4
4
QL
QL
4
QL
4
QL
4
QL
5 NDS QL PA
2
2
2
GC QL
GC QL
GC QL
Drug Name
Drug Requirements/
Tier
Limits
hydrocodone-acetaminophen
7.5-325 mg/15ml (generic of
HYCET)
QL (5400 mL / 30 days)
hydrocodone-ibuprofen
7.5-200mg (generic of
VICOPROFEN)
hydromorphone hcl (generic
of DILAUDID) LIQD
of DILAUDID-HP) SOLN
10mg/ml, 50mg/5ml,
500mg/50ml
of DILAUDID) TABS
HYSINGLA ER 20mg, 30mg,
40mg, 60mg
HYSINGLA ER 80mg,
100mg, 120mg
lorcet plus tab 7.5-325
(generic of NORCO)
lorcet tab 5-325mg (generic of
NORCO)
lortab tab 5-325mg (generic of
NORCO)
lortab tab 7.5-325 (generic of
NORCO)
lortab tab 10-325mg (generic
of NORCO)
methadone hcl (generic of
METHADOSE) CONC
QL (120 mL / 30 days)
methadone hcl SOLN
5mg/5ml, 10mg/5ml
QL (600 mL / 30 days)
4
QL
3
QL
3
4
B/D
3
QL
3
QL
3
QL
2
GC QL
2
GC QL
2
GC QL
2
GC QL
2
GC QL
3
QL
3
QL
ST - Step Therapy
mail-order
LA - Limited Access
GC - We provide
HR - High Risk
Medication
8
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
methadone hcl 5mg (generic
of DOLOPHINE)
methadone hcl 10mg (generic
of DOLOPHINE)
morphine ext-rel tab (generic
of MS CONTIN) 15mg,
30mg, 60mg, 100mg
morphine ext-rel tab (generic
of MS CONTIN) 200mg
MORPHINE SUL INJ
1MG/ML
MORPHINE SUL INJ
2MG/ML
MORPHINE SUL INJ
4MG/ML
MORPHINE SUL INJ
10MG/ML
MORPHINE SUL INJ
15MG/ML
morphine sulfate (generic of
MORPHINE SULFATE)
SOLN 4mg/ml, 8mg/ml
MORPHINE SULFATE
SOLN 8mg/ml, 150mg/30ml
morphine sulfate SOLN
.5mg/ml, 1mg/ml
MORPHINE SULFATE
TABS
MORPHINE SULFATE ORAL
SOL
OPANA ER (CRUSH
RESISTANT)
oxycodone hcl CAPS
oxycodone hcl CONC
OXYCODONE HCL SOLN
3
QL
3
QL
4
QL
4
QL
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
3
QL
3
3
QL
4
QL
4
4
Drug Name
Drug Requirements/
Tier
Limits
oxycodone hcl (generic of
ROXICODONE) TABS 5mg,
15mg, 30mg
oxycodone hcl TABS 10mg,
20mg
oxycodone w/ acetaminophen
PERCOCET)
5-325mg (generic of
PERCOCET)
PERCOCET)
10-325mg (generic of
PERCOCET)
soln (generic of ROXICET)
QL (1800 mL / 30 days)
OXYCONTIN
roxicet soln
QL (1800 mL / 30 days)
roxicet tab 5-325mg (generic
of PERCOCET)
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
4
B/D
4
B/D
4
B/D
4
B/D
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl (local anesth.)
(generic of
XYLOCAINE-MPF) 1%
lidocaine hcl (local anesth.)
(generic of XYLOCAINE)
.5%
lidocaine inj 0.5% (generic of
XYLOCAINE-MPF)
lidocaine inj 1% (generic of
XYLOCAINE)
ST - Step Therapy
mail-order
LA - Limited Access
GC - We provide
HR - High Risk
Medication
9
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
lidocaine inj 1.5% (generic of
XYLOCAINE-MPF)
lidocaine inj 2% (generic of
XYLOCAINE)
4
B/D
4
B/D
ANTI-INFECTIVES
ANTI-BACTERIALS - MISCELLANEOUS
amikacin sulfate SOLN
gentamicin in saline
gentamicin sulfate SOLN
gentamicin sulfate/0.9% s
neomycin sulfate TABS
paromomycin sulfate CAPS
streptomycin sulfate SOLR
sulfadiazine TABS
tobramycin (generic of TOBI)
NEBU
tobramycin inj 1.2 gm/30ml
tobramycin inj 1.2gm
tobramycin inj 10mg/ml
tobramycin inj 40mg/ml
tobramycin inj 80mg/2ml
4
4
4
4
3
4
4
4
5 NDS NM PA
4
5
4
4
4
NDS
ANTI-INFECTIVES - MISCELLANEOUS
ALBENZA
ALINIA
atovaquone (generic of
MEPRON) SUSP
AZACTAM IN ISO-OSMOTIC
DE
AZACTAM/DEX INJ 2GM
aztreonam (generic of
AZACTAM)
BILTRICIDE
CAYSTON
clindamycin cap 75mg
(generic of CLEOCIN)
clindamycin cap 300mg
clindamycin hcl cap 150 mg
clindamycin phosphate
(generic of CLEOCIN
PHOSPHATE) SOLN
5
4
5
NDS
NDS
4
4
3
3
5 NDS NM LA
PA
2
GC
2
GC
2
GC
4
Drug Name
Drug Requirements/
Tier
Limits
clindamycin phosphate in d5w
(generic of CLEOCIN IN
D5W)
clindamycin phosphate inj
(generic of CLEOCIN
PHOSPHATE)
clindamycin sol 75mg/5ml
(generic of CLEOCIN
PEDIATRIC GRANULE)
colistimethate sodium
(generic of COLY-MYCIN M)
SOLR
CUBICIN
dapsone TABS
emverm
imipenem-cilastatin (generic
of PRIMAXIN IV)
INVANZ
ivermectin (generic of
STROMECTOL) TABS
linezolid (generic of ZYVOX)
SOLN
LINEZOLID SUSR; TABS
LINEZOLID IN SODIUM
CHLORIDE
meropenem (generic of
MERREM)
methenamine hippurate
(generic of HIPREX)
metronidazole (generic of
FLAGYL) TABS
metronidazole in nacl
NEBUPENT
nitrofurantoin macrocrystal
(generic of MACRODANTIN)
50mg, 100mg
PA applies if 70 years and
older after a 90 day supply
in a calendar year; HR
nitrofurantoin monohyd macro
(generic of MACROBID)
PENTAM 300
4
4
4
4
5
3
4
4
NDS
4
3
5
NDS
5
5
NDS
NDS
4
4
2
GC
4
4
4
B/D
PA
4
PA
4
ST - Step Therapy
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GC - We provide
HR - High Risk
Medication
10
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
SIVEXTRO
sulfamethoxazole-trimethop
ds (generic of BACTRIM DS)
sulfamethoxazole-trimethopri
m inj
m susp
m tab (generic of BACTRIM)
SYNERCID
trimethoprim TABS
TYGACIL
vancomycin hcl (generic of
VANCOCIN HCL) CAPS
vancomycin hcl SOLR
VANCOMYCIN IN NACL
5
2
NDS
GC
4
2
GC
5
2
5
5
NDS
GC
NDS
NDS
4
4
5
4
4
5
3
NDS B/D
B/D
B/D
NDS
2
GC
4
4
4
4
5
Drug Requirements/
Tier
Limits
voriconazole (generic of
VFEND IV) SOLR
voriconazole (generic of
VFEND) SUSR; TABS
4
5
NDS
ANTIMALARIALS
4
ANTIFUNGALS
ABELCET
AMBISOME
amphotericin b SOLR
CANCIDAS
fluconazole (generic of
DIFLUCAN) SUSR
fluconazole (generic of
DIFLUCAN) TABS
fluconazole in dextrose
fluconazole inj nacl 100
flucytosine (generic of
ANCOBON) CAPS
griseofulvin microsize SUSP
griseofulvin microsize TABS
griseofulvin ultramicrosize
(generic of GRIS-PEG)
itraconazole (generic of
SPORANOX) CAPS
ketoconazole TABS
MYCAMINE
NOXAFIL SUSP; TBEC
nystatin TABS
terbinafine hcl (generic of
LAMISIL) TABS
Drug Name
NDS
3
4
4
4
PA
4
5
5
3
2
PA
NDS
NDS
GC
atovaquone-proguanil hcl
(generic of MALARONE)
chloroquine phosphate
TABS 250mg
chloroquine phosphate
(generic of ARALEN) TABS
500mg
COARTEM
mefloquine hcl
PRIMAQUINE PHOSPHATE
quinine sulfate (generic of
QUALAQUIN) CAPS
4
3
3
4
3
3
4
PA
ANTIRETROVIRAL AGENTS
abacavir sulfate (generic of
ZIAGEN)
APTIVUS
CRIXIVAN
didanosine (generic of VIDEX
EC)
EDURANT
EMTRIVA
FUZEON
INTELENCE 25mg
INTELENCE 100mg, 200mg
INVIRASE
ISENTRESS CHEW 25mg
ISENTRESS CHEW 100mg
ISENTRESS PACK
ISENTRESS TABS
lamivudine (generic of
EPIVIR)
LEXIVA SUSP
LEXIVA TABS
NEVIRAPINE SUSP 50
MG/5ML
nevirapine tab 100mg
(generic of VIRAMUNE XR)
nevirapine tab 200mg
(generic of VIRAMUNE)
3
5
4
4
NDS
5
3
5
4
5
5
3
5
5
5
3
NDS
4
5
4
NDS NM
NDS
NDS
NDS
NDS
NDS
NDS
4
3
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HR - High Risk
Medication
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2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
nevirapine tb24 (generic of
VIRAMUNE XR)
NORVIR
PREZISTA SUSP
PREZISTA TABS 75mg,
150mg
PREZISTA TABS 600mg,
800mg
RESCRIPTOR
RETROVIR IV INFUSION
REYATAZ
SELZENTRY
stavudine (generic of ZERIT)
SUSTIVA CAPS 50mg
SUSTIVA CAPS 200mg
SUSTIVA TABS
TIVICAY 10mg
TIVICAY 25mg, 50mg
TYBOST
VIDEX PEDIATRIC
VIRACEPT
VIREAD
VITEKTA
ZIAGEN SOLN
zidovudine (generic of
RETROVIR) CAPS; SYRP
zidovudine TABS
4
3
5
3
NDS
5
NDS
4
4
5
5
4
3
5
5
3
5
3
4
5
5
5
3
4
NDS
NDS
NDS
NDS
NDS
NDS
NDS
NDS
3
ANTIRETROVIRAL COMBINATION
AGENTS
abacavir
sulfate-lamivudine-zidovudine
(generic of TRIZIVIR)
ATRIPLA
COMPLERA
DESCOVY
EPZICOM
EVOTAZ
GENVOYA
KALETRA SOL
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
lamivudine-zidovudine
(generic of COMBIVIR)
5
NDS
5
5
5
5
5
5
5
3
5
4
NDS
NDS
NDS
NDS
NDS
NDS
NDS
NDS
Drug Name
Drug Requirements/
Tier
Limits
ODEFSEY
PREZCOBIX
STRIBILD
TRIUMEQ
TRUVADA TAB 100-150
TRUVADA TAB 133-200
TRUVADA TAB 167-250
TRUVADA TAB 200-300
5
5
5
5
5
NDS
NDS
NDS
NDS
NDS QL
5
NDS QL
5
NDS QL
5
NDS QL
ANTITUBERCULAR AGENTS
CAPASTAT SULFATE
cycloserine CAPS
ethambutol hcl (generic of
MYAMBUTOL) TABS
isoniazid TABS
isoniazid inj 100 mg/ml
isoniazid syp 50mg/5ml
paser d/r
PRIFTIN
pyrazinamide TABS
rifabutin (generic of
MYCOBUTIN)
rifampin (generic of RIFADIN)
CAPS
rifampin (generic of RIFADIN)
SOLR
RIFATER
SIRTURO
TRECATOR
4
5
4
2
4
4
3
4
4
4
NDS
GC
3
4
4
5 NDS LA PA
4
ANTIVIRALS
acyclovir (generic of
ZOVIRAX) CAPS
ZOVIRAX) SUSP
ZOVIRAX) TABS
acyclovir sodium SOLN
acyclovir sodium SOLR
500mg
adefovir dipivoxil (generic of
HEPSERA)
2
GC
4
2
GC
4
4
B/D
B/D
5
NDS
ST - Step Therapy
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Medication
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2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
BARACLUDE SOLN
DAKLINZA
entecavir (generic of
BARACLUDE)
EPIVIR HBV SOLN
famciclovir (generic of
FAMVIR) TABS
ganciclovir inj 500mg (generic
of CYTOVENE)
lamivudine (hbv) (generic of
EPIVIR HBV)
moderiba tab 200mg (generic
of COPEGUS)
PEGASYS
PEGASYS PROCLICK
REBETOL SOL 40MG/ML
RELENZA DISKHALER
ribasphere (generic of
REBETOL) CAPS
ribasphere (generic of
COPEGUS) TABS 200mg
ribasphere TABS 400mg,
600mg
ribavirin cap 200mg (generic
of REBETOL)
ribavirin tab 200mg (generic
of COPEGUS)
rimantadine hydrochloride
(generic of FLUMADINE)
SOVALDI
TAMIFLU
TYZEKA
valacyclovir hcl (generic of
VALTREX) TABS
VALCYTE SOLR
valganciclovir hcl (generic of
VALCYTE)
5
NDS
5 NDS NM PA
5
NDS
4
3
3
B/D
4
4
NM
5 NDS NM PA
5 NDS NM PA
5 NDS NM
3
3
NM
4
NM
5
NDS NM
3
NM
4
NM
4
5 NDS NM PA
3
5
NDS
3
5
5
NDS
NDS
CEPHALOSPORINS
cefaclor CAPS
cefaclor SUSR
cefaclor er tab 500mg
cefadroxil CAPS
cefadroxil SUSR
cefadroxil TABS
3
4
4
2
3
4
GC
Drug Name
Drug Requirements/
Tier
Limits
CEFAZOLIN IN DEXTROSE
2GM/100ML-4%
cefazolin inj
cefazolin sodium 1gm, 20gm
cefazolin sodium 1 gm/50ml
cefdinir CAPS
cefdinir SUSR
cefepime hcl (generic of
MAXIPIME)
cefixime (generic of SUPRAX)
cefotaxime sodium (generic of
CLAFORAN) 1gm, 2gm,
500mg
cefoxitin sodium
cefpodoxime proxetil
cefprozil SUSR
cefprozil TABS
ceftazidime (generic of
FORTAZ)
CEFTAZIDIME/DEXTROSE
ceftriaxone sodium (generic of
ROCEPHIN) SOLR 1gm
ceftriaxone sodium SOLR
1gm, 2gm, 10gm, 250mg,
500mg
cefuroxime axetil (generic of
CEFTIN)
cefuroxime sodium (generic of
ZINACEF) 1.5gm, 7.5gm,
750mg
cephalexin (generic of
KEFLEX) CAPS 250mg,
500mg
cephalexin SUSR
SUPRAX CAPS
suprax CHEW
SUPRAX SUSR 500mg/5ml
tazicef (generic of FORTAZ)
SOLR
tazicef vial (generic of
FORTAZ)
TEFLARO
4
4
4
4
3
4
4
4
4
4
4
4
3
4
4
4
4
3
4
2
GC
3
3
4
3
4
4
5
NDS
ERYTHROMYCINS/MACROLIDES
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2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
AZITHROMYCIN PACK
azithromycin (generic of
ZITHROMAX) SOLR
ZITHROMAX) SUSR
ZITHROMAX) TABS
clarithromycin (generic of
BIAXIN) TABS
clarithromycin er (generic of
BIAXIN XL)
clarithromycin for susp
125mg/5ml
clarithromycin for susp
(generic of BIAXIN)
250mg/5ml
DIFICID
e.e.s. 400mg tab
ery-tab
erythrocin lactobionate
erythrocin stearate
erythromycin base
erythromycin cap 250mg ec
erythromycin ethylsuccinate
3
4
GC
3
4
4
4
5
4
4
4
4
4
4
4
NDS
FLUOROQUINOLONES
ciprofloxacin (generic of
CIPRO) SUSR
ciprofloxacin er (generic of
CIPRO XR)
ciprofloxacin hcl tab 100mg,
750mg
ciprofloxacin hcl tab (generic
of CIPRO) 250mg, 500mg
ciprofloxacin in d5w
ciprofloxacin in d5w (generic
of CIPRO I.V.-IN D5W)
ciprofloxacin inj
levofloxacin (generic of
LEVAQUIN) TABS
levofloxacin in d5w
levofloxacin inj 25mg/ml
levofloxacin oral soln 25
mg/ml
4
4
2
GC
2
GC
4
4
4
2
4
4
4
Drug Requirements/
Tier
Limits
PENICILLINS
3
2
Drug Name
GC
amoxicillin
amoxicillin & pot clavulanate
CHEW
SUSR
(generic of AUGMENTIN)
SUSR
(generic of AUGMENTIN
ES-600) SUSR
TABS
(generic of AUGMENTIN)
TABS
(generic of AUGMENTIN XR)
TB12
ampicillin & sulbactam sodium
(generic of UNASYN)
(generic of UNASYN BULK
PACK)
ampicillin cap
ampicillin inj
ampicillin sodium
ampicillin susp
BICILLIN L-A
dicloxacillin sodium
nafcillin sodium
oxacillin sodium 1gm, 2gm
oxacillin sodium 10gm
PENICILLIN G POT IN
DEXTROSE
penicillin g procaine
penicillin g sodium
penicillin v potassium
penicilln gk inj 5mu
penicilln gk inj 20mu
pfizerpen-g
2
3
GC
3
3
3
2
GC
2
GC
4
4
4
4
2
4
4
3
4
2
4
4
5
4
4
4
2
4
4
4
GC
GC
NDS
GC
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2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
piperacillin
sodium-tazobactam sodium
(generic of ZOSYN)
4
melphalan hcl (generic of
ALKERAN)
MUSTARGEN
TREANDA
TETRACYCLINES
doxy
doxycycline (monohydrate)
CAPS 50mg
(generic of MONODOX)
CAPS 100mg
(generic of ADOXA) TABS
50mg, 75mg, 100mg
(generic of ADOXA PAK
1/150) TABS 150mg
doxycycline hyclate CAPS
50mg
doxycycline hyclate (generic
of VIBRAMYCIN) CAPS
100mg
doxycycline hyclate SOLR
doxycycline hyclate TABS
minocycline hcl (generic of
MINOCIN) CAPS
4
2
GC
2
GC
Drug Requirements/
Tier
Limits
5
NDS B/D
5 NDS B/D
5 NDS B/D NM
ANTHRACYCLINES
3
3
daunorubicin hcl
doxorubicin hcl 50mg
doxorubicin hcl inj 2 mg/ml
doxorubicin hcl liposomal
(generic of DOXIL)
epirubicin hcl (generic of
ELLENCE)
idarubicin hcl (generic of
IDAMYCIN PFS)
4
4
4
5
B/D
B/D
B/D
NDS B/D
4
B/D
5
NDS B/D
4
5
B/D
NDS B/D
ANTIBIOTICS
bleomycin sulfate
mitomycin SOLR
3
ANTIMETABOLITES
3
4
4
2
GC
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
BENDEKA
BICNU
BUSULFEX
CYCLOPHOSPHAMIDE
CAPS
cyclophosphamide SOLR
dacarbazine
EMCYT
GLEOSTINE
HEXALEN
IFEX 3gm
ifosfamide inj 1gm (generic of
IFEX)
ifosfamide inj 1gm/20ml
IFOSFAMIDE INJ 3GM
ifosfamide inj 3gm/60ml
LEUKERAN
Drug Name
5 NDS B/D NM
5 NDS B/D
5 NDS B/D
4
B/D
5
3
4
4
5
4
4
NDS B/D
B/D
4
4
4
4
B/D
B/D
B/D
NDS
B/D
B/D
adrucil
ALIMTA
azacitidine (generic of
VIDAZA)
cladribine
cytarabine 20mg/ml
fludarabine phosphate
SOLN
fludarabine phosphate
(generic of FLUDARA)
SOLR
fluorouracil SOLN
GEMCITABINE HCL SOLN
gemcitabine hcl (generic of
GEMZAR) SOLR 1gm,
200mg
gemcitabine hcl SOLR 2gm
mercaptopurine TABS
METHOTREXATE SODIUM
50mg/2ml
methotrexate sodium
50mg/2ml, 100mg/4ml,
200mg/8ml, 250mg/10ml
methotrexate sodium inj
NIPENT
PURIXAN
4
B/D
5 NDS B/D
5 NDS B/D NM
5
4
4
NDS B/D
B/D
B/D
4
B/D
4
5
5
B/D
NDS B/D
NDS B/D
5
4
4
NDS B/D
4
B/D
4
5
5
B/D
NDS B/D
NDS NM
B/D
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2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
TABLOID
4
NDS B/D
NDS B/D
NDS B/D
VENCLEXTA STARTING
PACK
YERVOY
ZOLINZA
5
NDS B/D
HORMONAL ANTINEOPLASTIC AGENTS
5
5
5
NDS B/D
NDS B/D
NDS B/D
4
B/D
4
4
4
4
B/D
B/D
B/D
B/D
BIOLOGIC RESPONSE MODIFIERS
AVASTIN
BELEODAQ
ERIVEDGE
FARYDAK
HERCEPTIN
IBRANCE
ISTODAX
KADCYLA
KEYTRUDA
LYNPARZA
NINLARO
PROLEUKIN
RITUXAN
TECENTRIQ
VELCADE
VENCLEXTA 10mg, 50mg
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM PA
5
5
5
ANTIMITOTIC, VINCA ALKALOIDS
vinblastine sulfate
vincasar
vincristine sulfate
vinorelbine tartrate (generic of
NAVELBINE)
Drug Requirements/
Tier
Limits
VENCLEXTA 100mg
ANTIMITOTIC, TAXOIDS
ABRAXANE
DOCEFREZ 20mg
DOCETAXEL CONC
20mg/ml
DOCETAXEL CONC
80mg/4ml, 160mg/8ml
docetaxel CONC 140mg/7ml
DOCETAXEL SOLN
DOCETAXEL SOLN
80MG/8ML
paclitaxel
Drug Name
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS B/D NM
5 NDS B/D NM
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS B/D NM
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM PA
4 NM LA PA
anastrozole (generic of
ARIMIDEX) TABS
bicalutamide (generic of
CASODEX)
DEPO-PROVERA INJ 400/ML
exemestane (generic of
AROMASIN)
FARESTON
FASLODEX
flutamide
hydroxyprogesterone
caproate (antineoplastic)
letrozole (generic of
FEMARA) TABS
leuprolide inj 1mg/0.2
LUPRON DEPOT 3.75mg
LUPRON DEPOT INJ
11.25MG (3-MONTH)
LYSODREN
megestrol ac sus 40mg/ml
(generic of MEGACE ORAL)
HR
megestrol ac tab 20mg
HR
megestrol ac tab 40mg
HR
MEGESTROL SUS
625MG/5ML
HR
NILANDRON
nilutamide
SOLTAMOX
tamoxifen citrate TABS
TRELSTAR DEP INJ 3.75MG
TRELSTAR LA INJ 11.25MG
XTANDI
2
GC
3
4
4
B/D
5
5
4
4
NDS
NDS B/D
B/D
3
3
NM PA
5 NDS NM PA
5 NDS NM PA
3
4
4
4
4
PA
5
NDS
5
NDS
4
1
GC
5 NDS NM PA
5 NDS NM PA
5 NDS NM LA
PA
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2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
ZYTIGA
Drug Requirements/
Tier
Limits
5 NDS NM LA
PA
KINASE INHIBITORS
AFINITOR
AFINITOR DISPERZ
ALECENSA
BOSULIF
CABOMETYX
CAPRELSA
COMETRIQ
COTELLIC
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
ICLUSIG
imatinib mesylate (generic of
GLEEVEC) 100mg
imatinib mesylate (generic of
GLEEVEC) 400mg
IMBRUVICA CAP 140MG
5 NDS NM PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS QL NM
PA
5 NDS QL NM
PA
5 NDS NM LA
PA
INLYTA
5 NDS NM LA
PA
IRESSA
5 NDS NM LA
PA
JAKAFI
5 NDS NM LA
PA
LENVIMA 8 MG DAILY DOSE 5 NDS NM LA
PA
LENVIMA 10 MG DAILY
5 NDS NM LA
DOSE
PA
LENVIMA 14 MG DAILY
5 NDS NM LA
DOSE
PA
Drug Name
LENVIMA 18 MG DAILY
DOSE
LENVIMA 20 MG DAILY
DOSE
LENVIMA 24 MG DAILY
DOSE
MEKINIST
NEXAVAR
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
TAGRISSO
TARCEVA
TASIGNA
TYKERB
VOTRIENT
XALKORI
ZELBORAF
ZYDELIG
ZYKADIA
Drug Requirements/
Tier
Limits
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
MISCELLANEOUS
bexarotene (generic of
TARGRETIN)
DROXIA
hydroxyurea (generic of
HYDREA) CAPS
LONSURF
MATULANE
mitoxantrone hcl
ODOMZO
SYLATRON KIT 200MCG
5 NDS NM PA
3
3
5 NDS NM PA
5
NDS LA
3
B/D NM
5 NDS NM LA
PA
5 NDS NM PA
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Drug Name
Drug Requirements/
Tier
Limits
SYLATRON KIT 300MCG
SYLATRON KIT 600MCG
SYNRIBO
tretinoin (chemotherapy)
TRISENOX
5 NDS NM PA
5 NDS NM PA
5 NDS NM PA
5
NDS
5 NDS B/D
PLATINUM-BASED AGENTS
carboplatin
cisplatin
oxaliplatin
4
3
4
B/D
B/D
B/D
5
NDS B/D
5
NDS B/D
PROTECTIVE AGENTS
amifostine crystalline (generic
of ETHYOL)
dexrazoxane (generic of
ZINECARD)
ELITEK
FUSILEV
leucovorin calcium SOLR
leucovorin calcium TABS
leucovorin calcium for inj 500
mg
levoleucovorin calcium
mesna (generic of MESNEX)
MESNEX TABS
5 NDS B/D
5 NDS B/D NM
4
B/D
3
4
B/D
5 NDS B/D NM
4
B/D
5
NDS
TOPOISOMERASE INHIBITORS
etoposide SOLN
irinotecan hcl (generic of
CAMPTOSAR) 40mg/2ml,
100mg/5ml
irinotecan hcl 500mg/25ml
toposar
TOPOTECAN HCL SOLN
topotecan hcl (generic of
HYCAMTIN) SOLR
3
4
4
3
5
5
B/D
B/D
B/D
B/D
NDS B/D
NDS B/D
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine
besylate-benazepril hcl cap
2.5-10 mg
amlodipine
5-10 mg (generic of LOTREL)
amlodipine
5-20 mg (generic of LOTREL)
2
GC
2
GC
2
GC
Drug Name
Drug Requirements/
Tier
Limits
amlodipine
5-40 mg
amlodipine
10-20 mg (generic of
LOTREL)
amlodipine
LOTREL)
benazepril &
hydrochlorothiazide
benazepril &
hydrochlorothiazide (generic
of LOTENSIN HCT)
captopril &
hydrochlorothiazide
enalapril maleate &
hydrochlorothiazide
enalapril maleate &
of VASERETIC)
fosinopril sodium &
hydrochlorothiazide
lisinopril &
of ZESTORETIC)
moexipril-hydrochlorothiazide
quinapril-hydrochlorothiazide
(generic of ACCURETIC)
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
1
GC
2
2
GC
GC
1
1
GC
GC
2
2
GC
GC
2
1
GC
GC
1
GC
2
GC
ACE INHIBITORS
benazepril hcl TABS 5mg
benazepril hcl (generic of
LOTENSIN) TABS 10mg,
20mg, 40mg
captopril TABS
enalapril maleate (generic of
VASOTEC) TABS
fosinopril sodium
lisinopril (generic of ZESTRIL)
TABS 2.5mg, 30mg, 40mg
lisinopril (generic of PRINIVIL)
TABS 5mg, 10mg, 20mg
moexipril hcl
ST - Step Therapy
mail-order
LA - Limited Access
GC - We provide
HR - High Risk
Medication
18
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
perindopril erbumine 2mg
perindopril erbumine (generic
of ACEON) 4mg, 8mg
quinapril hcl (generic of
ACCUPRIL)
ramipril (generic of ALTACE)
trandolapril (generic of
MAVIK)
2
2
GC
GC
2
GC
2
2
GC
GC
ALDOSTERONE RECEPTOR
ANTAGONISTS
eplerenone (generic of
INSPRA)
spironolactone (generic of
ALDACTONE) TABS
4
1
GC
3
QL
ALPHA BLOCKERS
doxazosin mesylate (generic
of CARDURA) 1mg, 2mg,
4mg
doxazosin mesylate (generic
of CARDURA) 8mg
prazosin hcl (generic of
MINIPRESS)
terazosin hcl
3
3
2
GC
ANGIOTENSIN II RECEPTOR
ANTAGONIST COMBINATIONS
amlodipine besylate-valsartan
tab 5-160 mg (generic of
EXFORGE)
EXFORGE)
EXFORGE)
EXFORGE)
amlodipine-valsartan-hctz tab
5-160-12.5 mg (generic of
EXFORGE HCT)
5-160-25 mg (generic of
EXFORGE HCT)
2
2
2
2
2
2
GC
GC
GC
GC
GC
GC
Drug Name
Drug Requirements/
Tier
Limits
10-160-12.5 mg (generic of
EXFORGE HCT)
EXFORGE HCT)
EXFORGE HCT)
BENICAR HCT
ENTRESTO
irbesartan-hydrochlorothiazide
(generic of AVALIDE)
losartan potassium & hctz tab
50-12.5 mg (generic of
HYZAAR)
100-12.5 mg (generic of
HYZAAR)
HYZAAR)
valsartan & hctz tab
80-12.5mg (generic of
DIOVAN HCT)
DIOVAN HCT)
DIOVAN HCT)
DIOVAN HCT)
DIOVAN HCT)
2
GC
2
GC
2
GC
3
4
2
PA
GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
ANGIOTENSIN II RECEPTOR
ANTAGONISTS
BENICAR
3
irbesartan (generic of
2
AVAPRO)
losartan potassium (generic of 1
COZAAR)
GC
GC
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Medication
19
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
valsartan (generic of
DIOVAN)
2
GC
ANTIARRHYTHMICS
amiodarone hcl soln
amiodarone tab 100mg
(generic of CORDARONE)
disopyramide phosphate
(generic of NORPACE)
HR
DOFETILIDE
flecainide acetate
mexiletine hcl
MULTAQ
NORPACE CR
HR
pacerone 100mg, 400mg
pacerone (generic of
CORDARONE) 200mg
propafenone hcl 150mg,
300mg
propafenone hcl (generic of
RYTHMOL) 225mg
propafenone hcl 12hr (generic
of RYTHMOL SR)
quinidine gluconate TBCR
quinidine sulfate TABS
sorine (generic of
BETAPACE) 80mg, 120mg,
160mg
sorine 240mg
sotalol hcl (generic of
BETAPACE) 80mg, 120mg,
160mg
sotalol hcl 240mg
sotalol hcl (afib/afl) (generic of
BETAPACE AF)
4
4
2
GC
4
4
4
3
4
4
4
4
2
NM
Drug Requirements/
Tier
Limits
lovastatin 10mg, 20mg
lovastatin (generic of
MEVACOR) 40mg
pravastatin sodium 10mg
pravastatin sodium (generic of
PRAVACHOL) 20mg, 40mg,
80mg
simvastatin (generic of
ZOCOR) TABS 5mg, 10mg,
20mg, 40mg
simvastatin (generic of
ZOCOR) TABS 80mg
2
2
GC
GC
2
2
GC
GC
1
GC
1
GC QL
ANTILIPEMICS, MISCELLANEOUS
GC
3
3
4
4
2
2
GC
GC
2
2
GC
GC
2
3
GC
ANTILIPEMICS, HMG-CoA REDUCTASE
INHIBITORS
atorvastatin calcium (generic
of LIPITOR) TABS
CRESTOR
Drug Name
1
GC
3
QL
cholestyramine (generic of
QUESTRAN)
cholestyramine light
colestipol hcl (generic of
COLESTID)
fenofibrate (generic of
TRICOR) TABS 48mg,
145mg
fenofibrate (generic of
LOFIBRA) TABS 54mg,
160mg
fenofibrate micronized
(generic of LOFIBRA) 67mg,
134mg, 200mg
gemfibrozil (generic of LOPID)
TABS
JUXTAPID
KYNAMRO
niacin er (antihyperlipidemic)
(generic of NIASPAN)
niacor
omega-3-acid ethyl esters
(generic of LOVAZA)
PRALUENT
prevalite (generic of
QUESTRAN LIGHT)
VASCEPA
WELCHOL
ZETIA
4
4
4
4
4
3
2
GC
5 NDS NM LA
PA
5 NDS NM PA
4
3
4
5 NDS NM PA
4
4
3
4
ST - Step Therapy
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LA - Limited Access
GC - We provide
HR - High Risk
Medication
20
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
BETA-BLOCKER/DIURETIC
COMBINATIONS
atenolol & chlorthalidone
(generic of TENORETIC 50)
atenolol & chlorthalidone
(generic of TENORETIC 100)
bisoprolol &
of ZIAC)
metoprolol &
hydrochlorothiazide
metoprolol &
of LOPRESSOR HCT)
3
3
2
GC
3
3
BETA-BLOCKERS
acebutolol hcl (generic of
SECTRAL) CAPS
atenolol (generic of
TENORMIN) TABS
bisoprolol fumarate (generic
of ZEBETA)
BYSTOLIC
carvedilol (generic of
COREG)
labetalol hcl TABS
metoprolol succinate (generic
of TOPROL XL)
metoprolol tartrate SOLN
metoprolol tartrate TABS
25mg
metoprolol tartrate (generic of
LOPRESSOR) TABS 50mg,
100mg
pindolol
propranolol cap er 60mg,
80mg
propranolol cap er (generic of
INDERAL LA) 120mg,
160mg
propranolol hcl SOLN
propranolol hcl TABS
propranolol oral sol
timolol maleate TABS
2
GC
1
GC
2
GC
4
2
GC
3
1
GC
4
1
GC
1
GC
4
4
4
4
3
3
4
Drug Name
Drug Requirements/
Tier
Limits
afeditab cr (generic of
ADALAT CC)
amlodipine besylate (generic
of NORVASC) TABS
cartia xt (generic of
CARDIZEM CD)
dilt-xr cap
diltiazem cap (generic of
TIAZAC)
diltiazem cap 120mg/24hr
diltiazem cap 240mg/24hr
diltiazem cap er/12hr
diltiazem hcl SOLN
diltiazem hcl (generic of
CARDIZEM) TABS 30mg,
60mg, 120mg
diltiazem hcl TABS 90mg
diltiazem hcl coated beads
(generic of CARDIZEM CD)
CP24
felodipine
isradipine
nicardipine hcl CAPS
nifedical (generic of
PROCARDIA XL)
nifedipine (generic of ADALAT
CC) TB24
nifedipine er (generic of
PROCARDIA XL)
nimodipine CAPS
NYMALIZE
taztia (generic of TIAZAC)
verapamil cap er (generic of
VERELAN PM) 100mg,
200mg, 300mg
verapamil cap er (generic of
VERELAN) 120mg, 180mg,
240mg
VERAPAMIL CAP ER
360mg
verapamil hcl SOLN
verapamil hcl TABS 40mg
3
1
GC
3
3
3
3
3
4
4
2
2
3
GC
GC
3
4
4
3
3
3
5
5
3
4
NDS
NDS
4
4
4
2
GC
CALCIUM CHANNEL BLOCKERS
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21
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
verapamil hcl (generic of
CALAN) TABS 80mg,
120mg
verapamil hcl (generic of
CALAN SR) TBCR
verapamil tab er (generic of
CALAN SR)
2
GC
2
GC
2
GC
3
PA
DIGITALIS GLYCOSIDES
digitek (generic of LANOXIN)
.25mg
PA if 70 years and older;
HR
digitek (generic of LANOXIN)
.125mg
HR (doses > 0.125 mg/day)
digox (generic of LANOXIN)
125mcg
digox (generic of LANOXIN)
250mcg
HR
digoxin (generic of LANOXIN)
TABS 125mcg
digoxin (generic of LANOXIN)
TABS 250mcg
HR
digoxin inj (generic of
LANOXIN)
DIGOXIN SOL 50MCG/ML
HR
3
QL
3
QL
3
PA
3
QL
3
PA
4
3
PA
Drug Requirements/
Tier
Limits
bumetanide SOLN
bumetanide (generic of
BUMEX) TABS
chlorothiazide tabs
chlorthalidone 25mg, 50mg
furosemide SOLN
furosemide (generic of LASIX)
TABS
furosemide inj 10mg/ml
FUROSEMIDE INJ 10mg/ml
of MICROZIDE) CAPS
hydrochlorothiazide TABS
indapamide
methazolamide (generic of
NEPTAZANE) TABS
methyclothiazide
metolazone
spironolactone &
of ALDACTAZIDE)
torsemide tabs (generic of
DEMADEX) 5mg, 10mg,
20mg
torsemide tabs 100mg
triamterene &
of MAXZIDE) TABS
triamterene &
of MAXZIDE-25) TABS
triamterene &
hydrochlorothiazide cap
37.5-25 mg (generic of
DYAZIDE)
4
3
3
3
2
1
GC
GC
4
4
1
GC
1
2
4
GC
GC
3
3
3
2
GC
2
1
GC
GC
1
GC
2
GC
MISCELLANEOUS
DIURETICS
acetazolamide (generic of
DIAMOX) CP12
acetazolamide TABS
amiloride &
hydrochlorothiazide
amiloride hcl TABS
Drug Name
4
3
2
GC
clonidine hcl (generic of
CATAPRES-TTS-1) PTWK
.1mg/24hr
.2mg/24hr
4
4
3
ST - Step Therapy
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22
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
.3mg/24hr
CATAPRES) TABS
DEMSER
hydralazine hcl SOLN
hydralazine hcl TABS
midodrine hcl
minoxidil TABS
NORTHERA
RANEXA
4
2
GC
5
NDS
4
2
GC
4
2
GC
5 NDS NM LA
PA
4
NITRATES
isosorb mononitrate tab
isosorbide dinitrate (generic of
ISORDIL TITRADOSE) 5mg
isosorbide dinitrate 10mg,
20mg, 30mg
isosorbide dinitrate er
isosorbide mononitrate er
minitran (generic of
NITRO-DUR)
nitro-bid
NITRO-DUR DIS 0.3MG/HR
nitroglycerin td patch
NITROSTAT
2
3
GC
3
4
2
3
REMODULIN
REVATIO SUSR
QL (224 mL / 30 days)
Drug Requirements/
Tier
Limits
sildenafil citrate (pulmonary
hypertension) (generic of
REVATIO) TABS
UPTRAVI TABS 200mcg
UPTRAVI TABS 400mcg
UPTRAVI TABS 600mcg
UPTRAVI TABS 800mcg
UPTRAVI TABS 1000mcg
UPTRAVI TABS 1200mcg,
1400mcg, 1600mcg
UPTRAVI TBPK
VENTAVIS
GC
3
4
4
3
3
PULMONARY ARTERIAL
HYPERTENSION
ADCIRCA
ADEMPAS
LETAIRIS
OPSUMIT
Drug Name
5 NDS NM PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS QL NM
PA
3 QL NM PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS NM LA
PA
5 NDS NM PA
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
alprazolam tab 0.5mg
(generic of XANAX)
alprazolam tab 0.25mg
(generic of XANAX)
alprazolam tab 1mg (generic
of XANAX)
alprazolam tab 2 mg (generic
of XANAX)
buspirone hcl TABS
fluvoxamine maleate TABS
25mg, 50mg
fluvoxamine maleate TABS
100mg
lorazepam CONC
QL (150 mL / 30 days)
lorazepam (generic of
ATIVAN) SOLN
2
GC QL
2
GC QL
2
GC QL
2
GC QL
2
3
GC
QL
3
3
QL
4
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HR - High Risk
Medication
23
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
lorazepam (generic of
ATIVAN) TABS
2
GC QL
4
QL
4
QL
4
QL
4
QL
5
5
5
5
4
5
3
4
NDS PA
NDS PA
NDS PA
NDS PA
PA
NDS PA
ANTICONVULSANTS
APTIOM 200mg
APTIOM 400mg
APTIOM 600mg
APTIOM 800mg
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
BRIVIACT SOLN 10mg/ml
BRIVIACT SOLN 50mg/5ml
BRIVIACT TABS
carbamazepine CHEW
carbamazepine (generic of
CARBATROL) CP12
TEGRETOL) SUSP; TABS
TEGRETOL-XR) TB12
CELONTIN
clonazepam (generic of
KLONOPIN) TABS 1mg
KLONOPIN) TABS 2mg
KLONOPIN) TABS .5mg
clonazepam TBDP 1mg
clonazepam TBDP 2mg
clonazepam TBDP .5mg
4
4
4
2
GC QL
2
GC QL
2
GC QL
3
QL
3
QL
3
QL
3
QL
3
QL
Drug Name
Drug Requirements/
Tier
Limits
clorazepate dipotassium
3.75mg
(generic of TRANXENE T)
7.5mg
15mg
diazepam CONC
QL (240 mL / 30 days)
diazepam SOLN 1mg/ml
QL (1200 mL / 30 days)
diazepam SOLN 5mg/ml
diazepam (generic of
VALIUM) TABS
DIAZEPAM GEL
(ANTICONVULSANT)
dilantin
DILANTIN-125 SUS 125/5ML
divalproex sodium (generic of
DEPAKOTE SPRINKLES)
CSDR
DEPAKOTE ER) TB24
DEPAKOTE) TBEC
epitol (generic of TEGRETOL)
ethosuximide (generic of
ZARONTIN) CAPS; SOLN
felbamate (generic of
FELBATOL) SUSP
felbamate (generic of
FELBATOL) TABS
FYCOMPA SUSP
QL (720 mL / 30 days)
FYCOMPA TABS 2mg
FYCOMPA TABS 4mg
FYCOMPA TABS 6mg
3
QL PA
3
QL PA
3
QL PA
3
QL PA
3
QL PA
4
2
GC QL PA
4
4
4
4
4
3
4
4
5
NDS
4
4
QL PA
4
QL PA
4
QL PA
4
QL PA
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24
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
FYCOMPA TABS 8mg,
10mg, 12mg
gabapentin (generic of
NEURONTIN) CAPS; TABS
gabapentin (generic of
NEURONTIN) SOLN
GABITRIL 12mg, 16mg
lamotrigine (generic of
LAMICTAL CHEWABLE
DISPERS) CHEW
LAMICTAL) TABS
LAMICTAL XR) TB24
levetiracetam (generic of
KEPPRA) TABS
levetiracetam (generic of
KEPPRA XR) TB24
levetiracetam inj (generic of
KEPPRA)
LEVETIRACETAM IV
levetiracetam sol 100mg/ml
(generic of KEPPRA)
LYRICA CAPS 25mg, 50mg,
75mg, 100mg, 150mg
LYRICA CAPS 200mg
LYRICA CAPS 225mg,
300mg
LYRICA SOLN
QL (946 mL / 30 days)
ONFI SOLN
ONFI TAB 10mg
ONFI TAB 20mg
oxcarbazepine (generic of
TRILEPTAL) SUSP
oxcarbazepine (generic of
TRILEPTAL) TABS
PEGANONE
phenobarbital ELIX; TABS
HR
4
QL PA
2
GC
4
4
3
2
GC
4
3
3
4
4
3
3
QL
3
QL
3
QL
3
QL
5
4
5
4
NDS PA
PA
NDS PA
3
4
4
PA
Drug Name
Drug Requirements/
Tier
Limits
PHENOBARBITAL SODIUM
SOLN 65mg/ml
HR
phenobarbital sodium SOLN
130mg/ml
HR
phenytek
phenytoin (generic of
DILANTIN INFATABS)
CHEW
phenytoin (generic of
DILANTIN-125) SUSP
phenytoin sodium SOLN
phenytoin sodium extended
(generic of DILANTIN)
100mg
(generic of PHENYTEK)
200mg, 300mg
POTIGA 50mg
POTIGA 200mg
POTIGA 300mg, 400mg
primidone (generic of
MYSOLINE) TABS
roweepra (generic of
KEPPRA)
SABRIL PACK
QL (180 packets / 30
days)
SABRIL TABS
SPRITAM
TEGRETOL
TEGRETOL-XR
tiagabine hcl (generic of
GABITRIL)
topiramate (generic of
TOPAMAX SPRINKLE)
CPSP
topiramate (generic of
TOPAMAX) TABS
4
PA
4
PA
4
3
3
4
3
3
4
4
QL
4
QL
2
GC
3
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
4
4
4
4
4
3
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25
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
valproate sodium (generic of
DEPACON) SOLN
valproate sodium (generic of
DEPAKENE) SYRP
valproic acid (generic of
DEPAKENE)
VIMPAT SOLN 10mg/ml
QL (1200 mL / 30 days)
VIMPAT SOLN 200mg/20ml
VIMPAT TABS 50mg
VIMPAT TABS 100mg,
150mg, 200mg
zonisamide (generic of
ZONEGRAN) CAPS 25mg,
100mg
zonisamide CAPS 50mg
4
2
GC
3
4
QL
4
4
QL
4
QL
3
3
2
2
GC QL
GC
4
3
QL
3
3
4
4
4
Drug Requirements/
Tier
Limits
memantine hcl (generic of
NAMENDA) SOLN
PA if < 30 yrs
memantine hcl (generic of
NAMENDA) TABS 5mg
PA if < 30 yrs
MEMANTINE HCL TABS
10mg
PA if < 30 yrs
NAMENDA XR
PA if < 30 yrs
NAMENDA XR TITRATION
PACK
PA if < 30 yrs
NAMZARIC
rivastigmine tartrate (generic
of EXELON)
3
PA
4
PA
4
PA
4
PA
4
PA
4
4
ANTIDEPRESSANTS
ANTIDEMENTIA
donepezil hydrochloride
(generic of ARICEPT) TABS
5mg
10mg
23mg
TBDP 5mg
TBDP 10mg
EXELON PATCHES
QL (30 patches / 30
days)
galantamine hydrobromide
SOLN
(generic of RAZADYNE)
TABS
galantamine hydrobromide er
(generic of RAZADYNE ER)
Drug Name
QL
amitriptyline hcl TABS 10mg,
50mg, 75mg, 100mg, 150mg
HR
amitriptyline hcl (generic of
ELAVIL) TABS 25mg
HR
amoxapine
bupropion hcl TABS
bupropion hcl (generic of
WELLBUTRIN SR) TB12
bupropion hcl (generic of
WELLBUTRIN XL) TB24
citalopram hydrobromide
SOLN
citalopram hydrobromide
(generic of CELEXA) TABS
clomipramine hcl (generic of
ANAFRANIL) CAPS
HR
desipramine hcl (generic of
NORPRAMIN) TABS 10mg,
25mg
desipramine hcl TABS
50mg, 75mg, 100mg, 150mg
doxepin hcl CAPS; CONC
HR
4
4
3
3
2
GC
3
4
1
GC
4
4
4
4
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GC - We provide
HR - High Risk
Medication
26
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
duloxetine hcl (generic of
CYMBALTA) CPEP 20mg
CYMBALTA) CPEP 30mg
CYMBALTA) CPEP 60mg
EMSAM
QL (30 patches / 30
days)
escitalopram oxalate (generic
of LEXAPRO) SOLN
escitalopram oxalate (generic
of LEXAPRO) TABS
FETZIMA 20mg
FETZIMA 40mg
FETZIMA 80mg, 120mg
FETZIMA TITRATION PACK
fluoxetine cap 10mg (generic
of PROZAC)
of PROZAC)
of PROZAC)
fluoxetine hcl SOLN
fluoxetine hcl TABS 10mg
fluoxetine hcl TABS 20mg
imipramine hcl (generic of
TOFRANIL) TABS
HR
maprotiline hcl
MARPLAN TAB 10MG
mirtazapine TABS 7.5mg
mirtazapine (generic of
REMERON) TABS 15mg
4
QL
4
QL
4
QL
5 NDS QL PA
4
2
GC
4
QL
4
QL
4
QL
4
1
GC
1
GC
1
GC
3
4
QL
4
4
4
4
QL
2
GC QL
2
GC QL
Drug Name
Drug Requirements/
Tier
Limits
REMERON) TABS 30mg,
45mg
REMERON SOLTAB) TBDP
15mg
REMERON SOLTAB) TBDP
30mg, 45mg
nefazodone hcl
nortriptyline hcl (generic of
PAMELOR) CAPS
nortriptyline hcl SOLN
paroxetine hcl (generic of
PAXIL) TABS
PAXIL SUSP
QL (900 mL / 30 days)
phenelzine sulfate (generic of
NARDIL) TABS
PRISTIQ
protriptyline hcl
sertraline hcl (generic of
ZOLOFT) CONC
sertraline hcl (generic of
ZOLOFT) TABS
tranylcypromine sulfate
(generic of PARNATE)
trazodone hcl TABS 50mg,
100mg, 150mg
trimipramine maleate CAPS
25mg
HR
trimipramine maleate CAPS
50mg
HR
trimipramine maleate (generic
of SURMONTIL) CAPS
100mg
HR
2
GC
3
QL
3
4
2
GC
4
1
GC
4
QL
3
3
QL
4
4
1
GC
4
2
GC
4
QL
4
QL
4
QL
ST - Step Therapy
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LA - Limited Access
GC - We provide
HR - High Risk
Medication
27
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
TRINTELLIX 5mg
TRINTELLIX 10mg
TRINTELLIX 20mg
venlafaxine hcl (generic of
EFFEXOR XR) CP24
37.5mg, 75mg
venlafaxine hcl (generic of
EFFEXOR XR) CP24 150mg
venlafaxine hcl TABS
VIIBRYD STARTER PACK
VIIBRYD TAB
4
QL
4
QL
4
QL
2
GC QL
2
3
4
4
GC QL
QL
ANTIPARKINSONIAN AGENTS
amantadine hcl CAPS
amantadine hcl SYRP
amantadine hcl TABS
APOKYN
AZILECT
BENZTROPINE MESYLATE
SOLN
benztropine mesylate TABS
HR
bromocriptine mesylate
(generic of PARLODEL)
CAPS
bromocriptine mesylate
TABS
carbidopa-levodopa (generic
of SINEMET) TABS
carbidopa-levodopa (generic
of SINEMET CR) TBCR
carbidopa-levodopa TBDP
CARBIDOPA/LEVODOPA/EN
TACAPONE
TACAPONE
4
QL
2
GC
4
5 NDS NM LA
PA
3
3
3
PA
4
4
2
3
4
4
4
GC
Drug Name
Drug Requirements/
Tier
Limits
TACAPONE
TACAPONE
TACAPONE
TACAPONE
ENTACAPONE
NEUPRO
pramipexole tab 0.5mg
(generic of MIRAPEX)
pramipexole tab 1mg (generic
of MIRAPEX)
ropinirole tab 0.5mg (generic
of REQUIP)
ropinirole tab 0.25mg (generic
of REQUIP)
ropinirole tab 1mg (generic of
REQUIP)
REQUIP)
REQUIP)
REQUIP)
REQUIP)
selegiline hcl (generic of
ELDEPRYL) CAPS
selegiline hcl TABS
4
4
4
4
4
4
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
4
4
ANTIPSYCHOTICS
ABILIFY MAINTENA 300mg, 4
400mg
QL (1 syringe / 28 days)
QL
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2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
ABILIFY MAINTENA 300mg,
400mg
QL (1 vial / 28 days)
aripiprazole odt
aripiprazole oral solution 1
mg/ml
QL (900 mL / 30 days)
aripiprazole tab (generic of
ABILIFY)
chlorpromazine hcl TABS
chlorpromazine inj
CLOZAPINE ODT 12.5mg
CLOZAPINE ODT 25mg,
100mg, 150mg, 200mg
clozapine tab 25mg (generic
of CLOZARIL)
clozapine tab 50mg
clozapine tab 100mg (generic
of CLOZARIL)
clozapine tab 200mg
FANAPT
FANAPT TITRATION PACK
fluphenazine decanoate
SOLN
fluphenazine hcl CONC;
ELIX; SOLN
fluphenazine hcl TABS
GEODON SOLR
QL (6 mL / 3 days)
haloperidol TABS
haloperidol decanoate
(generic of HALDOL
DECANOATE 50) SOLN
50mg/ml
haloperidol decanoate
(generic of HALDOL
DECANOATE 100) SOLN
100mg/ml
haloperidol lactate conc
haloperidol lactate inj 5mg/ml
(generic of HALDOL)
4
QL
5
NDS QL
5
NDS QL
4
QL
4
4
4
4
PA
PA
3
3
4
4
4
QL
4
4
4
2
4
3
4
4
3
4
GC
QL
Drug Name
Drug Requirements/
Tier
Limits
INVEGA 1.5mg, 3mg, 9mg
INVEGA 6mg
INVEGA SUST INJ
39MG/0.25ML
QL (1 injection / 28
days)
INVEGA SUST INJ
78MG/0.5ML
days)
INVEGA SUST INJ
117MG/0.75ML
days)
INVEGA SUST INJ
156MG/ML
days)
INVEGA SUST INJ
234MG/1.5ML
days)
INVEGA TRINZA
QL (1 syringe / 90 days)
LATUDA 20mg
LATUDA 40mg, 120mg
LATUDA 60mg, 80mg
loxapine succinate
molindone hcl
NUPLAZID
olanzapine (generic of
ZYPREXA) SOLR
QL (3 vials / 1 day)
ZYPREXA) TABS 2.5mg
ZYPREXA) TABS 5mg
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
3
4
5 NDS QL NM
LA PA
4
QL
3
QL
3
QL
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2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
ZYPREXA) TABS 7.5mg
ZYPREXA) TABS 10mg,
15mg, 20mg
ZYPREXA ZYDIS) TBDP
5mg
ZYPREXA ZYDIS) TBDP
10mg, 15mg, 20mg
perphenazine TABS
pimozide (generic of ORAP)
quetiapine fumarate (generic
of SEROQUEL)
REXULTI 1mg
REXULTI 2mg
REXULTI 3mg, 4mg
REXULTI .5mg
REXULTI .25mg
RISPERDAL INJ 12.5MG
QL (2 injections / 28
days)
RISPERDAL INJ 25MG
days)
RISPERDAL INJ 37.5MG
days)
RISPERDAL INJ 50MG
days)
risperidone (generic of
RISPERDAL) SOLN
3
QL
3
QL
4
4
QL
QL
4
4
3
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
Drug Name
Drug Requirements/
Tier
Limits
RISPERDAL) TABS
RISPERDAL M-TAB) TBDP
.5mg, 1mg, 2mg, 3mg, 4mg
risperidone TBDP .25mg
SAPHRIS 2.5mg
SAPHRIS 5mg
SAPHRIS 10mg
SEROQUEL XR 50mg
SEROQUEL XR 150mg,
200mg
SEROQUEL XR 300mg,
400mg
thioridazine hcl TABS
HR
thiothixene
trifluoperazine hcl
VERSACLOZ
QL (600 mL / 30 days)
VRAYLAR 1.5mg
VRAYLAR 3mg
VRAYLAR 4.5mg, 6mg
VRAYLAR THERAPY PACK
ziprasidone hcl (generic of
GEODON)
ZYPREXA RELPREVV
300mg
QL (2 vials / 28 days)
ZYPREXA RELPREVV
405mg
QL (1 vial / 28 days)
ZYPREXA RELPREVV
210MG
3
4
4
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
4
4
5 NDS QL PA
5
NDS QL
5
NDS QL
5
NDS QL
4
4
4
QL PA
4
QL PA
4
QL PA
ST - Step Therapy
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Medication
30
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
ATTENTION DEFICIT HYPERACTIVITY
DISORDER
amphetamine-dextroampheta
mine cap sr 24hr 5 mg
(generic of ADDERALL XR)
mine tab 5 mg (generic of
ADDERALL)
mine tab 7.5 mg (generic of
ADDERALL)
ADDERALL)
mine tab 12.5 mg (generic of
ADDERALL)
ADDERALL)
4
4
4
QL
QL
QL
4
QL
4
QL
4
QL
3
QL
3
QL
3
QL
3
QL
Drug Name
Drug Requirements/
Tier
Limits
ADDERALL)
ADDERALL)
guanfacine er (adhd) (generic
of INTUNIV)
HR
metadate tab 20mg er
methylphenidate hcl (generic
of RITALIN) TABS 5mg,
10mg
methylphenidate hcl (generic
of RITALIN) TABS 20mg
methylphenidate hcl TBCR
methylphenidate hcl oral soln
(generic of METHYLIN)
5mg/5ml
QL (1800 mL / 30 days)
(generic of METHYLIN)
10mg/5ml
QL (900 mL / 30 days)
STRATTERA 10mg, 18mg,
25mg
STRATTERA 40mg
STRATTERA 60mg, 80mg,
100mg
3
QL
3
QL
4
PA
4
QL
3
QL
3
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
HYPNOTICS
HETLIOZ
3
QL
SILENOR 3mg
HR (doses > 6mg/day)
5 NDS NM LA
PA
3
QL
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2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
SILENOR 6mg
HR (doses > 6mg/day)
temazepam (generic of
RESTORIL) 7.5mg
in a calendar year
temazepam (generic of
RESTORIL) 15mg
in a calendar year
zolpidem tartrate (generic of
AMBIEN) TABS
3
QL
2
GC QL PA
2
GC QL PA
Drug Requirements/
Tier
Limits
sumatriptan inj 6mg/0.5ml
SOSY
SUMATRIPTAN NASAL
SPRAY
sumatriptan succinate
(generic of IMITREX) TABS
zolmitriptan (generic of
ZOMIG) TABS
zolmitriptan odt (generic of
ZOMIG ZMT)
4
4
2
GC
4
4
MISCELLANEOUS
3
QL PA
MIGRAINE
cafergot
dihydroergotamine mesylate
(generic of D.H.E. 45)
1mg/ml
migergot
naratriptan hcl (generic of
AMERGE)
rizatriptan benzoate (generic
of MAXALT) TABS
rizatriptan benzoate (generic
of MAXALT-MLT) TBDP
SUMATRIPTAN INJ
4MG/0.5ML
(generic of IMITREX
STATDOSE SYSTEM)
SOAJ
(generic of IMITREX
STATDOSE REFILL) SOCT
(generic of IMITREX) SOLN
Drug Name
4
3
5
3
3
3
4
4
4
4
NDS
GRALISE 300mg
GRALISE 600mg
GRALISE STARTER
lithium carbonate CAPS;
TABS
lithium carbonate er (generic
of LITHOBID) 300mg
lithium carbonate er 450mg
LITHIUM SOLN 8MEQ/5ML
NUEDEXTA
pyridostigmine tab 60mg
(generic of MESTINON)
riluzole (generic of RILUTEK)
TETRABENAZINE 12.5mg
TETRABENAZINE 25mg
3
QL
3
QL
3
2
GC
2
GC
2
3
4
3
GC
PA
3
5 NDS QL NM
PA
5 NDS QL NM
PA
MULTIPLE SCLEROSIS AGENTS
AMPYRA
BETASERON
QL (14 syringes / 28
days)
COPAXONE INJ 40MG/ML
QL (12 syringes / 28
days)
COPAXONE KIT 20MG/ML
QL (30 syringes per 30
days)
GILENYA CAP 0.5MG
5 NDS NM LA
PA
5 NDS QL NM
PA
5 NDS QL NM
PA
5 NDS QL NM
PA
5 NDS QL NM
PA
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2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
TYSABRI
5 NDS NM LA
PA
MUSCULOSKELETAL THERAPY AGENTS
baclofen TABS
cyclobenzaprine hcl TABS
5mg, 10mg
HR
dantrolene sodium (generic of
DANTRIUM) CAPS 25mg,
50mg
dantrolene sodium CAPS
100mg
tizanidine hcl TABS 2mg
tizanidine hcl (generic of
ZANAFLEX) TABS 4mg
2
3
GC
PA
4
4
2
2
GC
GC
NARCOLEPSY/CATAPLEXY
NUVIGIL 50mg
NUVIGIL 150mg
NUVIGIL 200mg, 250mg
XYREM
QL (540 mL / 30 days)
3
QL PA
3
QL PA
3
QL PA
5 NDS QL LA
PA
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium
buprenorphine hcl SUBL
buprenorphine hcl-naloxone
hcl sl
buproban (generic of ZYBAN)
bupropion hcl (smoking
deterrent) (generic of ZYBAN)
CHANTIX CONTINUING
MONTH
CHANTIX PAK 0.5& 1MG
CHANTIX TAB 0.5MG
CHANTIX TAB 1MG
disulfiram (generic of
ANTABUSE) TABS
naloxone inj 0.4mg/ml
naloxone inj 1mg/ml
naltrexone hcl TABS
4
3
3
PA
QL PA
3
3
4
PA
4
4
4
4
PA
PA
PA
3
3
3
Drug Name
NICOTROL INHALER
NICOTROL NS
SUBOXONE MIS 2-0.5MG
QL (120 SL films / 30
days)
SUBOXONE MIS 4-1MG
days)
SUBOXONE MIS 8-2MG
days)
SUBOXONE MIS 12-3MG
days)
Drug Requirements/
Tier
Limits
4
4
4
QL PA
4
QL PA
4
QL PA
4
QL PA
ENDOCRINE AND METABOLIC
ANDROGENS
ANADROL-50
ANDRODERM
QL (30 patches / 30
days)
AXIRON
QL (440 mL / 30 days)
oxandrolone tab 2.5mg
(generic of OXANDRIN)
oxandrolone tab 10mg
(generic of OXANDRIN)
testosterone cypionate
SOLN 100mg/ml
testosterone cypionate
(generic of
DEPO-TESTOSTERONE)
SOLN 200mg/ml
testosterone enanthate
SOLN
5
4
NDS PA
QL PA
3
QL PA
3
PA
3
PA
4
PA
4
PA
4
PA
ANTIDIABETICS, INJECTABLE
ALCOHOL SWABS
BYDUREON INJ
BYDUREON PEN
QL (4 pens / 28 days)
BYETTA
QL (1 pen / 30 days)
GAUZE PADS 2" X 2"
HUMULIN R INJ U-500
3
3
QL
3
QL
4
QL
3
5
NDS B/D
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2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
HUMULIN R U-500 KWIKPEN
INSULIN PEN NEEDLE
INSULIN SYRINGE
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXTOUCH
NOVOLIN 70/30
(brand RELION not
covered)
NOVOLIN N
(brand RELION not
covered)
NOVOLIN R
(brand RELION not
covered)
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30
PREFILL
NOVOLOG PENFILL
SYMLINPEN 60
SYMLINPEN 120
TOUJEO SOLOSTAR
TRESIBA FLEXTOUCH
TRULICITY
VICTOZA
5
3
3
3
3
3
3
3
NDS
3
3
3
3
3
3
3
5 NDS QL PA
5 NDS QL PA
3
3
4
QL
3
QL
ANTIDIABETICS, ORAL
acarbose (generic of
PRECOSE)
FARXIGA 5mg
FARXIGA 10mg
glimepiride (generic of
AMARYL) 1mg
3
3
QL
3
QL
1
GC QL
Drug Name
Drug Requirements/
Tier
Limits
AMARYL) 2mg
AMARYL) 4mg
glip/metform tab 2.5-250mg
glip/metform tab 5-500mg
glipizide (generic of
GLUCOTROL) TABS 5mg
GLUCOTROL) TABS 10mg
GLUCOTROL XL) TB24
2.5mg
GLUCOTROL XL) TB24
5mg
GLUCOTROL XL) TB24
10mg
GLIPIZIDE XL TB24 2.5MG
GLIPIZIDE XL TB24 5MG
INVOKAMET TAB 50-500MG
INVOKAMET TAB
50-1000MG
INVOKAMET TAB
150-500MG
INVOKAMET TAB
150-1000MG
1
GC QL
1
GC QL
2
GC QL
2
GC QL
2
GC QL
1
GC QL
1
GC QL
2
GC QL
2
GC QL
2
GC QL
2
GC QL
2
GC QL
3
QL
3
QL
3
QL
3
QL
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2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
INVOKANA 100mg
INVOKANA 300mg
JANUMET
JANUMET XR TAB
50-500MG
JANUMET XR TAB 50-1000
JANUVIA
metformin hcl (generic of
GLUCOPHAGE) TABS
500mg
GLUCOPHAGE) TABS
850mg
GLUCOPHAGE) TABS
1000mg
GLUCOPHAGE XR) TB24
500mg
GLUCOPHAGE XR) TB24
750mg
nateglinide (generic of
STARLIX)
pioglitazone hcl (generic of
ACTOS)
repaglinide (generic of
PRANDIN) 2mg
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
1
GC QL
1
GC QL
1
1
GC QL
GC QL
1
GC QL
2
GC QL
2
GC QL
2
GC QL
Drug Name
Drug Requirements/
Tier
Limits
repaglinide (generic of
PRANDIN) .5mg, 1mg
XIGDUO XR TAB 5-500MG
2
GC QL
3
QL
3
QL
3
QL
3
QL
1
GC
1
GC
4
4
B/D
B/D NM
4
4
B/D NM
B/D NM
BISPHOSPHONATES
alendronate sodium TABS
5mg, 10mg, 35mg, 40mg
alendronate sodium (generic
of FOSAMAX) TABS 70mg
pamidronate disodium
zoledronic acid (generic of
RECLAST) SOLN
5mg/100ml
zoledronic acid SOLR
zoledronic inj 4mg/5ml
(generic of ZOMETA)
CALCIUM RECEPTOR AGONISTS
SENSIPAR 30mg
SENSIPAR 60mg
SENSIPAR 90mg
3
QL NM
5 NDS QL NM
5 NDS QL NM
CHELATING AGENTS
CHEMET
DEPEN TITRATABS
EXJADE
FERRIPROX
kionex powder (generic of
KAYEXALATE)
kionex susp 15gm/60ml
sodium polystyrene sulfonate
(generic of KAYEXALATE)
POWD
4
5
NDS
5 NDS NM LA
PA
5 NDS NM LA
PA
4
3
4
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2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
SUSP
sps susp 15gm/60ml
SYPRINE
3
3
5
CONTRACEPTIVES
altavera tab
apri 28 day (generic of
DESOGEN)
aranelle 28 (generic of
TRI-NORINYL 28)
aubra 28 day
aviane 28
balziva 28 day (generic of
OVCON-35)
bekyree 28 day (generic of
MIRCETTE)
blisovi 21 fe 1.5/30 28 day
pack (generic of LOESTRIN
FE 1.5/30)
blisovi 21 fe 1/20 28 day pack
(generic of LOESTRIN FE
1/20)
briellyn 28 day (generic of
OVCON-35)
camila 28 day (generic of
NOR-QD)
cryselle 28
cyclafem 1/35 28 day (generic
of NORINYL 1+35)
cyclafem 7/7/7 28 day
(generic of ORTHO-NOVUM
7/7/7)
cyred tab (generic of
DESOGEN)
deblitane 28 day (generic of
NOR-QD)
delyla 28 day
desogestrel-ethinyl estradiol
(biphasic) (generic of
MIRCETTE)
drospirenone-ethinyl estradiol
(generic of YASMIN 28)
drospirenone-ethinyl estradiol
(generic of YAZ)
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
NDS
Drug Name
Drug Requirements/
Tier
Limits
ELLA
emoquette (generic of
DESOGEN)
enpresse 28 day
errin 28 day (generic of
ORTHO MICRONOR)
estarylla tab 0.25-35 (generic
of ORTHO-CYCLEN)
falmina 28 day
GIANVI TAB 3-0.02MG
gildagia (generic of
OVCON-35)
gildess 1.5/30 21 day (generic
of LOESTRIN 1.5/30-21)
heather (generic of NOR-QD)
introvale 91 day
JOLESSA TAB 0.15-0.03 MG
JOLIVETTE
juleber 28 day (generic of
DESOGEN)
junel 1.5/30 21 day (generic of
LOESTRIN 1.5/30-21)
junel 1/20 21 day (generic of
LOESTRIN 1/20-21)
junel fe 1.5/30 28 day (generic
of LOESTRIN FE 1.5/30)
junel fe 1/20 28 day (generic
of LOESTRIN FE 1/20)
kariva 28 day (generic of
MIRCETTE)
kelnor 1/35 28 day
kimidess 28 day (generic of
MIRCETTE)
larin 1.5/30 (generic of
LOESTRIN 1.5/30-21)
larin 1/20 (generic of
LOESTRIN 1/20-21)
larin fe 1.5/30 (generic of
LOESTRIN FE 1.5/30)
larin fe 1/20 (generic of
LOESTRIN FE 1/20)
LEENA TAB
lessina 28 day
levonest 28 day
4
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
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Drug Name
Drug Requirements/
Tier
Limits
levonor/ethi tab
levonorgestrel & eth estradiol
levonorgestrel (emergency
oc) (generic of PLAN B
ONE-STEP)
levonorgestrel-ethinyl
estradiol (91-day)
levora 0.15/30 28 day
loryna 28 day (generic of
YAZ)
low-ogestrel
lutera 28 day
lyza (generic of ORTHO
MICRONOR)
marlissa 28 day
medroxyprogesterone acetate
150 mg/ml (generic of
DEPO-PROVERA
CONTRACEPTIV)
MICROGESTIN 1.5/30
MICROGESTIN 1/20
MICROGESTIN FE 1.5/30
MICROGESTIN FE 1/20
mono-linyah tab 0.25-35
(generic of ORTHO-CYCLEN)
MONONESSA
myzilra
necon 0.5/35 28 day (generic
of BREVICON-28)
necon 1/35 28 day (generic of
NORINYL 1+35)
NECON 1/50-28
NECON 7/7/7
necon 10/11 28 day
nikki 28 day (generic of YAZ)
NORA-BE TAB 0.35MG
norethindrone (contraceptive)
(generic of NOR-QD)
norgest/ethi tab 0.25/35
(generic of ORTHO-CYCLEN)
norgestimate-ethinyl estradiol
(triphasic) (generic of ORTHO
TRI-CYCLEN)
3
3
3
3
3
3
3
3
3
3
4
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Drug Name
Drug Requirements/
Tier
Limits
norgestimate-ethinyl estradiol
(triphasic) (generic of ORTHO
TRI-CYCLEN LO)
norlyroc 28 day (generic of
NOR-QD)
nortrel 0.5/35 28 day (generic
of BREVICON-28)
nortrel 1/35 21 day (generic of
NORINYL 1+35)
nortrel 1/35 28 day (generic of
NORINYL 1+35)
nortrel 7/7/7 28 day (generic
of ORTHO-NOVUM 7/7/7)
NUVARING
OCELLA TAB 3-0.03MG
orsythia 28 day
philith (generic of OVCON-35)
pimtrea pack (generic of
MIRCETTE)
pirmella 1/35 28 day (generic
of NORINYL 1+35)
portia 28 day
previfem 28 day (generic of
ORTHO-CYCLEN)
quasense 91 day
reclipsen 28 day (generic of
DESOGEN)
setlakin tab
sharobel 28 day (generic of
ORTHO MICRONOR)
sprintec 28 day (generic of
ORTHO-CYCLEN)
sronyx 28 day
syeda (generic of YASMIN
28)
tarina fe 1/20 28 day (generic
of LOESTRIN FE 1/20)
tri-legest 28 day (generic of
ESTROSTEP FE)
tri-linyah (generic of ORTHO
TRI-CYCLEN)
tri-lo marzia (generic of
ORTHO TRI-CYCLEN LO)
3
3
3
3
3
3
4
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
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Drug Name
Drug Requirements/
Tier
Limits
tri-lo-estarylla (generic of
ORTHO TRI-CYCLEN LO)
tri-lo-sprintec 28 day (generic
of ORTHO TRI-CYCLEN LO)
tri-previfem 28 day (generic of
ORTHO TRI-CYCLEN)
tri-sprintec 28 day (generic of
ORTHO TRI-CYCLEN)
TRINESSA
TRINESSA LO TAB
trivora 28 day
velivet 28 day (generic of
CYCLESSA)
vestura (generic of YAZ)
vienva 28 day
viorele (generic of
MIRCETTE)
vyfemla 28 day (generic of
OVCON-35)
xulane
zarah (generic of YASMIN 28)
zenchent 28 day (generic of
OVCON-35)
zovia 1/35e 28 day
zovia 1/50e 28 day
3
KUVAN
3
levocarnitine (metabolic
modifiers) (generic of
CARNITOR)
LUMIZYME
3
3
ORFADIN
RAVICTI
sodium phenylbutyrate
(generic of BUPHENYL)
ZAVESCA
3
3
3
4
3
3
3
3
NDS
ENZYME REPLACEMENTS
ADAGEN
ALDURAZYME
BUPHENYL TABS
CARBAGLU
CERDELGA
CEREZYME
CYSTADANE POW
CYSTAGON
FABRAZYME
5 NDS NM LA
PA
4
B/D
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM PA
5 NDS NM LA
PA
ESTROGENS
3
4
5
Drug Requirements/
Tier
Limits
NAGLAZYME
3
3
3
3
ENDOMETRIOSIS
danazol CAPS
SYNAREL
Drug Name
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM LA
4 NM LA PA
5 NDS NM LA
PA
DELESTROGEN 10mg/ml
estrace CREA
estrad val inj 20mg/ml
(generic of DELESTROGEN)
estrad val inj 40mg/ml
(generic of DELESTROGEN)
estradiol (generic of
CLIMARA) PTWK
HR
estradiol (generic of
ESTRACE) TABS
HR
fyavolv tab 1-5mg
HR
jinteli
HR
norethindrone acetate-ethinyl
estradiol
HR
VAGIFEM
4
4
3
3
4
3
4
4
4
4
GLUCOCORTICOIDS
a-hydrocort
cortisone acetate TABS
dexamethasone CONC;
ELIX; SOLN
dexamethasone TABS
4
4
3
2
GC
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Drug Name
Drug Requirements/
Tier
Limits
dexamethasone sodium
phosphate
fludrocortisone acetate
TABS
hydrocortisone (generic of
CORTEF) TABS
methylpr ace inj 40mg/ml
(generic of DEPO-MEDROL)
methylpr ace inj 80mg/ml
(generic of DEPO-MEDROL)
methylpr ss inj 1gm (generic
of SOLU-MEDROL)
methylpr ss inj 40mg (generic
of SOLU-MEDROL)
methylpred pak 4mg (generic
of MEDROL DOSEPAK)
methylpred tab 4mg (generic
of MEDROL)
of MEDROL)
of MEDROL)
of MEDROL)
methylprednisolone sod succ
(generic of SOLU-MEDROL)
pred sod pho sol 5mg/5ml
(generic of PEDIAPRED)
prednisolone sol 15mg/5ml
prednisolone syrup 15 mg/5ml
prednisone con 5mg/ml
prednisone pak 5mg
prednisone pak 10mg
prednisone sol 5mg/5ml
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 5mg
prednisone tab 10mg
prednisone tab 20mg
prednisone tab 50mg
SOLU-CORTEF 250mg
4
2
GC
GLUCAGON EMERGENCY
3
KIT
PROGLYCEM SUS 50MG/ML 4
NORDITROPIN FLEXPRO
4
B/D
4
B/D
4
B/D
4
B/D
2
GC
3
B/D
3
B/D
3
B/D
3
B/D
4
B/D
3
B/D
3
3
2
3
2
2
3
2
2
2
2
2
2
4
B/D
B/D
GC B/D
B/D
GC
GC
B/D
GC B/D
GC B/D
GC B/D
GC B/D
GC B/D
GC B/D
3
Drug Requirements/
Tier
Limits
HUMAN GROWTH HORMONES
3
GLUCOSE ELEVATING AGENTS
GLUCAGEN HYPOKIT
Drug Name
5 NDS NM PA
MISCELLANEOUS
cabergoline
calcitonin (salmon) (generic of
MIACALCIN)
FORTICAL
INCRELEX
KORLYM
LUPRON DEP-PED INJ
7.5MG
LUPRON DEP-PED INJ
11.25MG
LUPRON DEP-PED INJ
11.25MG (3-MONTH)
LUPRON DEP-PED INJ
15MG
LUPRON DEP-PED INJ
30MG (3-MONTH)
methylergonovine maleate
(generic of METHERGINE)
TABS
MIACALCIN 200unit/ml
octreotide acetate (generic of
SANDOSTATIN) 50mcg/ml,
100mcg/ml, 200mcg/ml
octreotide acetate (generic of
SANDOSTATIN)
500mcg/ml, 1000mcg/ml
PROLIA
QL (1 syringe / 180
days)
raloxifene tab 60mg (generic
of EVISTA)
SANDOSTATIN LAR DEPOT
SIGNIFOR
SOMATULINE DEPOT
SOMAVERT
4
3
B/D
3
B/D
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM PA
5 NDS NM PA
5 NDS NM PA
5 NDS NM PA
4
4
4
B/D
NM PA
5 NDS NM PA
4
QL NM
3
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM LA
PA
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Drug Name
Drug Requirements/
Tier
Limits
XGEVA
5 NDS NM PA
PARATHYROID HORMONES
FORTEO
QL (1 pen / 28 days)
NATPARA
5 NDS QL NM
PA
5 NDS NM PA
PHOSPHATE BINDER AGENTS
AURYXIA
calcium acetate (phosphate
binder) (generic of PHOSLO)
CAPS
binder) (generic of ELIPHOS)
TABS
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
4
3
3
3
3
3
PROGESTINS
medroxyprogesterone acetate
tab (generic of PROVERA)
norethindrone acetate
(generic of AYGESTIN)
TABS
2
GC
3
THYROID AGENTS
levothyroxine sodium (generic
of SYNTHROID) TABS
25mcg, 50mcg, 88mcg,
100mcg, 112mcg, 125mcg,
137mcg, 150mcg, 175mcg,
200mcg
LEVOTHYROXINE SODIUM
TABS 75mcg, 300mcg
liothyronine sodium (generic
of CYTOMEL) TABS
methimazole (generic of
TAPAZOLE) TABS
propylthiouracil TABS
SYNTHROID
1
GC
1
GC
3
2
3
4
VASOPRESSINS
desmopressin acetate spray
(generic of DDAVP)
refrigerated
desmopressin acetate tabs
(generic of DDAVP)
4
4
3
GC
Drug Name
Drug Requirements/
Tier
Limits
desmopressin inj 4mcg/ml
4
(generic of DDAVP)
DESMOPRESSIN SOL 0.01% 4
STIMATE
4
NM
GASTROINTESTINAL
ANTIEMETICS
compro
dronabinol (generic of
MARINOL)
EMEND SUSR
EMEND CAP 40MG
EMEND CAP 80MG
EMEND CAP 125MG
EMEND PAK 80 & 125
granisetron hcl SOLN
granisetron hcl TABS
meclizine hcl TABS
metoclopramide hcl SOLN
metoclopramide hcl (generic
of REGLAN) TABS
metoclopramide hcl inj
ondansetron hcl (generic of
ZOFRAN) TABS 4mg, 8mg
ondansetron hcl TABS 24mg
ondansetron hcl inj 4mg/2ml
ondansetron hcl inj (generic of
ZOFRAN) 40mg/20ml
ondansetron hcl oral soln
(generic of ZOFRAN)
ondansetron odt (generic of
ZOFRAN ODT)
phenadoz
HR
phenergan SUPP
HR
prochlorperazine inj
prochlorperazine maleate
TABS
prochlorperazine supp
4
4
4
4
4
4
4
4
4
2
2
2
4
3
B/D QL
B/D
B/D
B/D
B/D
B/D
B/D
GC
GC
GC
B/D
3
4
4
B/D
3
B/D
2
GC B/D
4
PA
4
PA
4
2
GC
4
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Drug Name
Drug Requirements/
Tier
Limits
promethazine hcl (generic of
PHENERGAN) SOLN
HR
promethazine hcl SUPP;
SYRP; TABS
HR
promethegan
HR
TRANSDERM-SCOP
QL (10 patches / 30
days)
HR
4
PA
4
PA
4
4
PA
QL PA
ANTISPASMODICS
dicyclomine hcl (generic of
BENTYL) CAPS
dicyclomine hcl SOLN
10mg/5ml
dicyclomine hcl (generic of
BENTYL) TABS
glycopyrrolate (generic of
ROBINUL) SOLN 4mg/20ml
ROBINUL) TABS 1mg
ROBINUL FORTE) TABS
2mg
2
GC
4
2
GC
4
3
3
H2-RECEPTOR ANTAGONISTS
famotidine SOLN 40mg/4ml,
200mg/20ml
famotidine inj
famotidine tab (generic of
PEPCID)
ranitidine hcl (generic of
ZANTAC) SOLN
ranitidine hcl (generic of
ZANTAC) TABS 150mg,
300mg
ranitidine hcl inj (generic of
ZANTAC)
ranitidine syrup
4
4
2
GC
4
2
GC
4
3
INFLAMMATORY BOWEL DISEASE
Drug Name
Drug Requirements/
Tier
Limits
APRISO
ASACOL HD
balsalazide disodium (generic
of COLAZAL)
budesonide ec (generic of
ENTOCORT EC)
CANASA
colocort (generic of
CORTENEMA)
DELZICOL
DIPENTUM
HYDROCORTISONE
(ENEMA)
mesalamine enema
mesalamine w/ cleanser
(generic of ROWASA)
sulfasalazine (generic of
AZULFIDINE) TABS
sulfasalazine ec (generic of
AZULFIDINE EN-TABS)
3
4
4
5
NDS
4
4
4
5
4
NDS
4
4
3
3
LAXATIVES
constulose
enulose
gavilyte-c (generic of
COLYTE-FLAVOR PACKS)
gavilyte-g (generic of
GOLYTELY)
gavilyte-h
gavilyte-n (generic of
NULYTELY/FLAVOR PACKS)
generlac
GOLYTELY
lactulose
lactulose (encephalopathy)
MOVIPREP
NULYTELY/FLAVOR PACKS
PEG 3350-KCL-SOD
BICARB-SOD
CHLORIDE-SOD SULFATE
peg 3350-potassium
chloride-sod bicarbonate-sod
chloride (generic of
PEG 3350/ELECTROLYTES
2
2
2
GC
GC
GC
2
GC
3
2
GC
2
3
2
2
4
3
2
GC
2
GC
2
GC
GC
GC
GC
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Drug Name
Drug Requirements/
Tier
Limits
polyethylene glycol 3350
2
PACK; POWD
SUPREP BOWEL PREP
4
trilyte (generic of
2
GC
GC
MISCELLANEOUS
alosetron hcl (generic of
LOTRONEX)
AMITIZA
cromolyn sodium
(mastocytosis) (generic of
GASTROCROM)
diphenoxylate w/ atropine
LIQD
diphenoxylate w/ atropine
(generic of LOMOTIL) TABS
GATTEX
LINZESS 145mcg
LINZESS 290mcg
loperamide hcl CAPS
misoprostol (generic of
CYTOTEC) TABS
MOVANTIK 12.5mg
MOVANTIK 25mg
RELISTOR
SUCRAID
sucralfate (generic of
CARAFATE) TABS
ursodiol (generic of
ACTIGALL) CAPS
ursodiol (generic of URSO
250) TABS 250mg
ursodiol (generic of URSO
FORTE) TABS 500mg
XIFAXAN 550mg
5
NDS PA
3
QL
5
NDS
3
3
5 NDS NM LA
PA
3
QL
3
QL
2
3
GC
3
QL
3
QL
5
5
3
NDS PA
NDS LA
4
4
PANCREATIC ENZYMES
CREON
ZENPEP
3
4
Drug Requirements/
Tier
Limits
PROTON PUMP INHIBITORS
DEXILANT CAP 30MG DR
esomeprazole magnesium
(generic of NEXIUM)
esomeprazole sodium inj
20mg
esomeprazole sodium inj
(generic of NEXIUM I.V.)
40mg
NEXIUM GRA 2.5MG DR
NEXIUM GRA 5MG DR
NEXIUM GRA 10MG DR
QL (30 packets / 30
days)
NEXIUM GRA 20MG DR
QL (30 packets / 30
days)
NEXIUM GRA 40MG DR
QL (30 packets / 30
days)
omeprazole cap 10mg
(generic of PRILOSEC)
omeprazole cap 20mg
omeprazole cap 40mg
pantoprazole sodium (generic
of PROTONIX) TBEC
3
3
4
QL
4
4
3
3
3
QL
3
QL
3
QL
1
GC QL
1
GC QL
1
GC QL
2
GC QL
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
4
5
Drug Name
NDS PA
alfuzosin hcl (generic of
UROXATRAL)
dutasteride (generic of
AVODART)
dutasteride-tamsulosin hcl
(generic of JALYN)
2
GC
4
QL
4
QL
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Drug Name
Drug Requirements/
Tier
Limits
finasteride (generic of
PROSCAR) TABS 5mg
tamsulosin hcl (generic of
FLOMAX)
2
GC
2
GC
MISCELLANEOUS
bethanechol chloride (generic
of URECHOLINE) TABS
ELMIRON
POTASSIUM CITRATE
(ALKALINIZER) 540mg
POTASSIUM CITRATE
(ALKALINIZER) 1080mg
3
4
4
4
URINARY ANTISPASMODICS
MYRBETRIQ TAB 25MG
MYRBETRIQ TAB 50MG
oxybutynin chloride SYRP
oxybutynin chloride TABS
oxybutynin chloride (generic
of DITROPAN XL) TB24
tolterodine tartrate cap er
(generic of DETROL LA)
tolterodine tartrate tabs
(generic of DETROL)
TOVIAZ
trospium chloride TABS
VESICARE
4
QL
4
QL
2
3
3
GC
4
QL
4
3
QL
4
4
QL
VAGINAL ANTI-INFECTIVES
vaginal (generic of CLEOCIN)
metronidazole vaginal
(generic of
METROGEL-VAGINAL)
terconazole vaginal (generic
of TERAZOL 7) CREA .4%
terconazole vaginal (generic
of TERAZOL 3) CREA .8%
terconazole vaginal SUPP
VANDAZOLE
ZAZOLE CREAM 0.8%
4
4
3
3
4
4
3
Drug Name
Drug Requirements/
Tier
Limits
HEMATOLOGIC
ANTICOAGULANTS
COUMADIN
enoxaparin sodium (generic of
LOVENOX) 30mg/0.3ml,
40mg/0.4ml, 60mg/0.6ml,
80mg/0.8ml, 100mg/ml,
120mg/0.8ml, 150mg/ml
ENOXAPARIN SODIUM
300mg/3ml
fondaparinux sodium (generic
of ARIXTRA) 2.5mg/0.5ml
fondaparinux sodium (generic
of ARIXTRA) 5mg/0.4ml,
7.5mg/0.6ml, 10mg/0.8ml
heparin sod (porcine) in d5w
HEPARIN SOD (PORCINE)
IN D5W
heparin sod inj 1000/ml
HEPARIN SOD INJ 2000/ML
HEPARIN SODIUM/D5W
HEPARIN SODIUM/NACL
0.45%
jantoven (generic of
COUMADIN)
PRADAXA
warfarin sodium (generic of
COUMADIN)
XARELTO
XARELTO STARTER PACK
4
4
4
4
5
NDS
4
4
4
4
4
4
4
4
4
4
B/D
B/D
B/D
B/D
B/D
B/D
1
GC
3
1
GC
3
3
HEMATOPOIETIC GROWTH FACTORS
GRANIX
LEUKINE
MOZOBIL
NEUPOGEN
PROCRIT 2000unit/ml,
3000unit/ml, 4000unit/ml,
10000unit/ml
PROCRIT 20000unit/ml,
40000unit/ml
5
5
5
5
3
NDS NM PA
NDS NM PA
NDS NM PA
NDS NM PA
NM PA
5 NDS NM PA
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Drug Name
Drug Requirements/
Tier
Limits
MISCELLANEOUS
anagrelide hcl 1mg
anagrelide hcl (generic of
AGRYLIN) .5mg
cilostazol
CINRYZE
FIRAZYR
pentoxifylline TBCR
PROMACTA 12.5mg
PROMACTA 25mg
PROMACTA 50mg
PROMACTA 75mg
tranexamic acid (generic of
CYKLOKAPRON) SOLN
tranexamic acid (generic of
LYSTEDA) TABS
4
4
2
GC
5 NDS NM LA
PA
5 NDS NM PA
3
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
3
4
PLATELET AGGREGATION INHIBITORS
AGGRENOX
BRILINTA
clopidogrel bisulfate (generic
of PLAVIX) 75mg
EFFIENT
ZONTIVITY
3
4
1
GC
4
4
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC
DRUGS (DMARDS)
HUMIRA INJ 10MG/0.2ML
QL (2 boxes / 28 days)
HUMIRA KIT 20MG/0.4ML
HUMIRA KIT 40MG/0.8ML
HUMIRA PEDIATRIC
CROHNS DISEASE
HUMIRA PEN
HUMIRA PEN-CROHNS
DISEASE
5 NDS QL NM
PA
5 NDS QL NM
PA
5 NDS QL NM
PA
5 NDS NM PA
5 NDS QL NM
PA
5 NDS NM PA
Drug Name
Drug Requirements/
Tier
Limits
HUMIRA PEN-PSORIASIS
STAR
hydroxychloroquine sulfate
(generic of PLAQUENIL)
leflunomide (generic of
ARAVA) TABS
methotrexate sodium tabs
REMICADE INJ 100MG
XELJANZ
XELJANZ XR
5 NDS NM PA
4
3
4
5 NDS NM PA
5 NDS QL NM
PA
5 NDS QL NM
PA
IMMUNOGLOBULINS
BIVIGAM
CARIMUNE NANOFILTERED
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAGARD S/D
GAMMAKED
GAMMAPLEX 5gm/100ml,
10gm/200ml
GAMUNEX-C
OCTAGAM 1gm/20ml,
2gm/20ml, 2.5gm/50ml,
5gm/100ml, 10gm/200ml,
25gm/500ml
PRIVIGEN
5
5
5
3
5
5
5
5
NDS NM PA
NDS NM PA
NDS NM PA
B/D NM
NDS NM PA
NDS NM PA
NDS NM PA
NDS NM PA
5 NDS NM PA
5 NDS NM PA
5 NDS NM PA
IMMUNOMODULATORS
ACTIMMUNE
ARCALYST
INTRON-A INJ 10MU
INTRON-A INJ 18MU
INTRON-A INJ 25MU
INTRON-A INJ 50MU
POMALYST CAP 1MG
POMALYST CAP 2MG
POMALYST CAP 3MG
POMALYST CAP 4MG
5 NDS NM LA
PA
5 NDS NM PA
5 NDS B/D NM
5 NDS B/D NM
5 NDS B/D NM
5 NDS B/D NM
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
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Drug Name
Drug Requirements/
Tier
Limits
REVLIMID
THALOMID
5 NDS NM LA
PA
5 NDS NM PA
IMMUNOSUPPRESSANTS
azathioprine SOLR
azathioprine (generic of
IMURAN) TABS
BENLYSTA
cyclosporine (generic of
SANDIMMUNE) CAPS;
SOLN
cyclosporine modified (for
microemulsion) (generic of
NEORAL) CAPS 25mg,
100mg
microemulsion) CAPS 50mg
microemulsion) (generic of
NEORAL) SOLN
gengraf (generic of NEORAL)
mycophenolate mofetil
(generic of CELLCEPT)
CAPS; TABS
mycophenolate mofetil
(generic of CELLCEPT)
SUSR
mycophenolate sodium
(generic of MYFORTIC)
NEORAL
NULOJIX
PROGRAF CAPS 5mg
PROGRAF CAPS .5mg,
1mg
RAPAMUNE SOLN
SANDIMMUNE SOLN
100mg/ml
sirolimus (generic of
RAPAMUNE) TABS 2mg
sirolimus (generic of
RAPAMUNE) TABS .5mg,
1mg
tacrolimus (generic of
PROGRAF) CAPS
ZORTRESS TAB 0.5MG
4
3
B/D
B/D
5 NDS NM PA
4
B/D
4
B/D
4
B/D
4
B/D
4
4
B/D
B/D
5
NDS B/D
4
B/D
3
5
5
4
B/D
NDS B/D
NDS B/D
B/D
5
3
NDS B/D
B/D
5
NDS B/D
4
B/D
4
B/D
5
NDS B/D
Drug Name
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
Drug Requirements/
Tier
Limits
3
5
B/D
NDS B/D
3
3
3
3
3
3
3
3
B/D
VACCINES
ACTHIB
ADACEL
BCG VACCINE
BEXSERO
BOOSTRIX
CERVARIX
DAPTACEL
DIPHTHERIA/TETANUS
TOXOID
ENGERIX-B SUSP
GARDASIL
GARDASIL 9
HAVRIX
HIBERIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
KINRIX
M-M-R II
MENACTRA
MENHIBRIX
MENOMUNE-A/C/Y/W-135
MENVEO
PEDIARIX
PEDVAX HIB
PENTACEL
PROQUAD
QUADRACEL
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
SYNAGIS
TENIVAC
TETANUS/DIPHTHERIA
TOXOID
TRUMENBA
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
B/D
B/D
NDS NM
B/D
B/D
3
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Drug Name
Drug Requirements/
Tier
Limits
TWINRIX INJ
TYPHIM VI
VAQTA
VARIVAX
YF-VAX
ZOSTAVAX
QL (1 vial per lifetime)
3
3
3
3
3
3
2
2
2
2
2
4
3
4
B/D
4
4
B/D
B/D
4
B/D
4
4
B/D
B/D
4
4
4
4
4
4
B/D
B/D
B/D
B/D
B/D
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
IV NUTRITION
QL
GC
GC
GC
GC
GC
3
4
4
4
4
3
4
2
GC
2
GC
2
GC
4
2
Drug Requirements/
Tier
Limits
TPN ELECTROLYTES
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
KLOR-CON 8
KLOR-CON 10
klor-con m10
klor-con m15
klor-con m20
klor-con pow 20 meq
klor-con spr cap 8meq
(generic of MICRO-K)
klor-con spr cap 10meq
(generic of MICRO-K)
magnesium sulfate (generic of
MAGNESIUM SULFATE)
SOLN 2gm/50ml
MAGNESIUM SULFATE
SOLN 2gm/50ml, 4gm/100ml,
4gm/50ml, 20gm/500ml,
40gm/1000ml, 50%
magnesium sulfate SOLN
50%
MAGNESIUM SULFATE IN
D5W
potassium chloride (generic of
MICRO-K) CPCR
POTASSIUM CHLORIDE
SOLN 10%, 20%
potassium chloride TBCR
8meq
POTASSIUM CHLORIDE
TBCR 10meq, 20meq
potassium chloride
microencapsulated crystals cr
SODIUM CHLORIDE SOLN
2.5meq/ml
sodium fluoride chew; tab; 1.1
(0.5 f) mg/ml soln
Drug Name
GC
AMINOSYN
AMINOSYN
7%/ELECTROLYTES
AMINOSYN
8.5%/ELECTROLYTE
AMINOSYN II
AMINOSYN II
8.5%/ELECTROL
AMINOSYN M
AMINOSYN-HBC
AMINOSYN-PF 7%
AMINOSYN-PF 10%
AMINOSYN-RF
CLINIMIX 2.75%/DEXTROSE
5%
5%
25%
CLINIMIX 5%/DEXTROSE
15%
20%
25%
CLINIMIX INJ 4.25/D10
CLINIMIX INJ 4.25/D20
FREAMINE HBC 6.9%
FREAMINE III
HEPATAMINE
INTRALIPID INJ 20%
INTRALIPID INJ 30%
NEPHRAMINE
nutrilipid inj 20%
premasol 6%
premasol 10%
PROCALAMINE
PROSOL
TRAVASOL
TROPHAMINE INJ 10%
IV REPLACEMENT SOLUTIONS
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Drug Name
Drug Requirements/
Tier
Limits
DEXTROSE 2.5%/NACL
0.45%
DEXTROSE 5%
DEXTROSE 5%
/ELECTROLYTE
DEXTROSE 5%/LACTATED
RING
DEXTROSE 5%/NACL 0.2%
DEXTROSE 5%/NACL
0.225%
DEXTROSE 5%/POTASSIUM
CHL
DEXTROSE 10% FLEX
CONTAIN
DEXTROSE 10%/NACL
0.45%
DEXTROSE 50%
DEXTROSE INJ 70%
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE
5%
ISOLYTE P
ISOLYTE S
KCL0.15%/D5W/NACL0.2%
KCL0.15%/D5W/NACL0.225
%
KCL 0.3%/D5W/NACL 0.9%
KCL 0.3%/D5W/NACL 0.45%
KCL 0.15%/D5W/NACL 0.9%
KCL 0.075%/D5W/NACL
0.45%
KCL IN NACL INJ .15-0.45
KCL/D5W INJ 0.3%
KCL/D5W/NACL INJ
0.22%/0.45%
KCL/D5W/NACL INJ .15/.33%
KCL/D5W/NACL INJ .15/.45%
KCL/NACL INJ 0.3-0.9
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Drug Name
Drug Requirements/
Tier
Limits
KCL/NACL INJ 0.15%-0.9%
LACTATED RINGER'S INJ
NORMOSOL-M IN D5W
NORMOSOL-R
NORMOSOL-R IN D5W
PLASMA-LYTE A
PLASMA-LYTE-56/D5W
PLASMA-LYTE-148
pot chloride inj 2meq/ml
POTASSIUM CHLORIDE
SOLN .4meq/ml,
10meq/100ml, 10meq/50ml,
20meq/100ml, 40meq/100ml
potassium chloride in nacl
RINGER'S
SOD CHLORIDE INJ 0.9%
SODIUM CHLORIDE SOLN
3%, 5%
SODIUM CHLORIDE 0.45%
VIA
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
VITAMINS
calcitriol (generic of
ROCALTROL) CAPS
calcitriol inj
calcitriol oral soln 1 mcg/ml
(generic of ROCALTROL)
paricalcitol (generic of
ZEMPLAR) CAPS 1mcg,
2mcg
paricalcitol CAPS 4mcg
prenatal vitamin/folic acid >
0.8 mg (generic)
3
B/D
4
4
B/D
B/D
4
B/D
4
2
B/D
GC
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
bacitracin-poly-neomycin-hc
blephamide OINT
neomycin-polymy-dexameth
(generic of MAXITROL)
neomycin-polymyxin-hc
(ophth)
sulfacetamide
sod-prednisolone
TOBRADEX OINT
3
4
2
GC
4
2
GC
4
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Drug Name
Drug Requirements/
Tier
Limits
TOBRADEX ST
tobramycin-dexamethasone
(generic of TOBRADEX)
ZYLET
4
4
2
4
GC
2
2
2
4
4
3
GC
GC
GC
2
GC
azelastine drop 0.05%
BEPREVE
cromolyn sodium (ophth)
LASTACAFT
PATADAY
PAZEO
2
GC
3
4
2
3
3
2
GC
GC
3
3
3
2
4
4
4
4
ANTI-INFLAMMATORIES
ALREX
bromfenac sodium (ophth)
phosphate (ophth)
diclofenac sodium (ophth)
Drug Requirements/
Tier
Limits
DUREZOL
FLUOROMETHOLONE
flurbiprofen sodium (generic
of OCUFEN)
ILEVRO
ketorolac tromethamine
(ophth) (generic of ACULAR
LS) .4%
(ophth) (generic of ACULAR)
.5%
LOTEMAX
MAXIDEX
PREDNISOLONE ACETATE
(OPHTH)
prednisolone sodium
phosphate (ophth)
ANTI-INFECTIVES
bacitracin (ophthalmic)
bacitracin-polymyxin b (ophth)
BESIVANCE
CILOXAN OINT
ciprofloxacin hcl (ophth)
(generic of CILOXAN)
erythromycin (ophth)
gatifloxacin (ophth) (generic of
ZYMAXID)
gentak
gentamicin sulfate (ophth)
ilotycin
MOXEZA
NATACYN
neomycin-bacitracin
zn-polymyxin
neomycin-polymyxin-gramicidi
n (generic of NEOSPORIN)
ofloxacin (ophth) (generic of
OCUFLOX)
polymyxin b-trimethoprim
(generic of POLYTRIM)
sulfacet sod oin 10% op
sulfacetamide sodium (ophth)
(generic of BLEPH-10)
tobramycin (ophth) (generic of
TOBREX)
TOBREX OINT
trifluridine (generic of
VIROPTIC) SOLN
VIGAMOX
ZIRGAN
Drug Name
3
4
3
3
GC
4
4
2
GC
4
3
3
3
3
3
3
ANTIALLERGICS
3
3
2
4
3
3
GC
ANTIGLAUCOMA
ALPHAGAN P SOL 0.1%
ALPHAGAN P SOL 0.15%
AZOPT
betaxolol hcl (ophth)
BETOPTIC-S
brimonidine sol 0.2%
carteolol hcl (ophth)
COMBIGAN
dorzolamide hcl (generic of
TRUSOPT)
dorzolamide hcl-timolol
maleate (generic of COSOPT)
ISTALOL
latanoprost (generic of
XALATAN) SOLN
levobunolol hcl (generic of
BETAGAN)
LUMIGAN
3
3
4
4
4
2
2
3
3
GC
GC
3
3
2
GC
2
GC
3
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Drug Name
Drug Requirements/
Tier
Limits
metipranolol
PHOSPHOLINE IODIDE
PILOCARPINE HCL SOLN
SIMBRINZA
timolol maleate (ophth) soln
(generic of TIMOPTIC)
TIMOLOL MALEATE GEL
TRAVATAN Z
3
4
4
4
2
GC
4
3
MISCELLANEOUS
CYSTARAN
naphazoline 0.1%
PROLENSA
proparacaine hcl (generic of
ALCAINE) SOLN
RESTASIS
5 NDS NM LA
PA
2
GC
3
2
GC
3
QL
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST
COMBINATIONS
ANORO ELLIPTA
3
QL (60 inhalations / 30
days)
COMBIVENT RESPIMAT
4
QL (2 inhalers / 30 days)
ipratropium-albuterol nebu
3
QL
QL
B/D
ANTICHOLINERGICS
ATROVENT HFA
INCRUSE ELLIPTA
QL (1 inhaler / 30 days)
ipratropium bromide SOLN
ipratropium bromide (nasal)
4
QL
3
QL
2
3
GC B/D
ANTIHISTAMINES
azelastine spr 0.1%
azelastine spr 0.15% (generic
of ASTEPRO)
cetirizine syrup
cyproheptadine hcl SYRP;
TABS
HR
diphenhydramine hcl inj
3
3
3
4
PA
Drug Name
Drug Requirements/
Tier
Limits
hydroxyz hcl inj
HR
hydroxyzine hcl SYRP;
TABS
HR
hydroxyzine pamoate (generic
of VISTARIL) CAPS 25mg,
50mg
HR
hydroxyzine pamoate CAPS
100mg
HR
levocetirizine dihydrochloride
(generic of XYZAL) SOLN
(generic of XYZAL) TABS
4
PA
4
PA
4
PA
4
PA
4
2
GC
2
2
4
3
GC B/D
GC
5
4
3
NDS
3
QL
BETA AGONISTS
albuterol sulfate NEBU
albuterol sulfate SYRP
albuterol sulfate TABS
SEREVENT DISKUS
days)
terbutaline sulfate SOLN
terbutaline sulfate TABS
VENTOLIN HFA
XOPENEX HFA
QL
QL
LEUKOTRIENE MODULATORS
montelukast sodium (generic
of SINGULAIR) CHEW
of SINGULAIR) PACK
of SINGULAIR) TABS
zafirlukast (generic of
ACCOLATE)
3
4
2
GC
4
MAST CELL STABILIZERS
4
cromolyn sod neb 20mg/2ml
3
B/D
MISCELLANEOUS
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Drug Name
Drug Requirements/
Tier
Limits
acetylcysteine SOLN 10%,
20%
ARALAST NP
DALIRESP
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
ESBRIET
KALYDECO
OFEV
ORKAMBI
PROLASTIN-C
PULMOZYME
XOLAIR
ZEMAIRA
3
B/D
5 NDS NM LA
PA
4
3
3
5 NDS NM PA
5 NDS NM PA
5 NDS NM PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM LA
PA
NASAL STEROIDS
flunisolide (nasal)
QL (2 bottles / 30 days)
fluticasone propionate (nasal)
QL (1 bottle / 30 days)
3
QL
2
GC QL
4
QL
4
B/D
4
QL
4
QL
STEROID INHALANTS
ARNUITY ELLIPTA
days)
budesonide (inhalation)
(generic of PULMICORT)
.25mg/2ml, .5mg/2ml
FLOVENT DISKUS
50mcg/blist, 100mcg/blist
days)
FLOVENT DISKUS
250mcg/blist
days)
FLOVENT HFA
PULMICORT FLEXHALER
STEROID/BETA-AGONIST
COMBINATIONS
4
QL
3
QL
Drug Name
Drug Requirements/
Tier
Limits
ADVAIR DISKUS
days)
ADVAIR HFA
BREO ELLIPTA
QL (60 blisters / 30
days)
SYMBICORT
4
QL
4
QL
3
QL
3
QL
XANTHINES
aminophylline inj
elixophyllin
theophylline SOLN
theophylline TB12; TB24
4
4
4
3
TOPICAL
DERMATOLOGY, ACNE
AVITA CREA
AVITA GEL
benzoyl
peroxide-erythromycin
(generic of BENZAMYCIN)
claravis
clindamax (generic of
CLEOCIN-T)
(topical) (generic of
CLEOCIN-T) GEL; LOTN
(topical) (generic of
CLEOCIN-T) SOLN; SWAB
ery pad 2%
erythromycin (acne aid)
(generic of ERYGEL) GEL
erythromycin (acne aid)
SOLN
myorisan
sulfacetamide sodium (acne)
(generic of KLARON)
tretinoin (generic of RETIN-A)
CREA
TRETINOIN GEL .01%
tretinoin (generic of RETIN-A)
GEL .025%
4
4
4
PA
PA
4
4
PA
4
3
4
4
3
4
4
PA
4
PA
4
4
PA
PA
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Drug Name
zenatane
Drug Requirements/
Tier
Limits
4
3
2
ketoconazole shampoo
(generic of NIZORAL)
selenium sulfide LOTN
GC
DERMATOLOGY, CORTICOSTEROIDS
2
GC
2
4
5
GC
NDS
DERMATOLOGY, ANTIFUNGALS
ciclopirox (generic of
LOPROX) CREA
ciclopirox GEL
ciclopirox SUSP
ciclopirox shampoo 1%
(generic of LOPROX
SHAMPOO)
clotrimazole (topical)
ketoconazole cream
nyamyc
nystatin (topical)
nystop
3
4
3
4
3
3
3
3
3
DERMATOLOGY, ANTIPRURITIC
DOXEPIN HCL
(ANTIPRURITIC)
procto-med (generic of
ANUSOL-HC)
procto-pak
proctosol hc cre 2.5%
(generic of ANUSOL-HC)
proctozone hc (generic of
ANUSOL-HC)
4
4
4
4
4
DERMATOLOGY, ANTIPSORIATICS
acitretin (generic of
SORIATANE)
calcipotriene (generic of
DOVONEX) CREA
calcipotriene SOLN
8-MOP
TAZORAC CREA
Drug Requirements/
Tier
Limits
PA
DERMATOLOGY, ANTIBIOTICS
gentamicin sulfate (topical)
mupirocin (generic of
BACTROBAN) OINT
SILVER SULFADIAZINE
CREA
SSD
SULFAMYLON CREA
SULFAMYLON PACK
Drug Name
5
NDS PA
4
4
4
4
PA
DERMATOLOGY, ANTISEBORRHEICS
ala-cort
alclometasone dipropionate
(generic of ACLOVATE)
CREA
OINT
betamethasone dipropionate
(topical) CREA; OINT
(topical) LOTN
augmented (generic of
DIPROLENE AF) CREA
augmented GEL
augmented (generic of
DIPROLENE) LOTN
BETAMETHASONE
DIPROPIONATE
AUGMENTED OINT
betamethasone valerate
CREA; LOTN; OINT
fluocinolone acetonide
(generic of SYNALAR)
SOLN
fluocinonide CREA .05%
fluocinonide GEL
fluocinonide SOLN
fluocinonide emulsified base
fluticasone propionate
(generic of CUTIVATE)
CREA
fluticasone propionate OINT
halobetasol propionate
(generic of ULTRAVATE)
hydrocortisone (topical)
CREA; OINT
hydrocortisone (topical)
LOTN
2
GC
2
GC
2
4
GC
3
4
3
3
4
4
4
3
4
4
4
4
4
2
GC
2
4
GC
2
GC
3
ST - Step Therapy
mail-order
LA - Limited Access
GC - We provide
HR - High Risk
Medication
51
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
hydrocortisone butyrate
(generic of LOCOID)
mometasone furoate (generic
of ELOCON) CREA; OINT;
SOLN
triamcinolone acetonide
(topical) CREA; OINT
(topical) LOTN
triderm
4
VALCHLOR
3
VOLTAREN GEL 1%
2
GC
3
2
GC
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine (generic of
LIDODERM) PTCH
QL (3 patches / 1 day)
lidocaine hcl GEL
lidocaine hcl (generic of
XYLOCAINE) SOLN 4%
lidocaine oint 5%
lidocaine-prilocaine
4
QL PA
3
2
PA
GC PA
4
4
PA
PA
DERMATOLOGY, MISCELLANEOUS SKIN
AND MUCOUS MEMBRANE
ammonium lactate (generic of
LAC-HYDRIN) CREA; LOTN
fluorouracil (topical) (generic
of EFUDEX) CREA 5%
fluorouracil (topical) SOLN
imiquimod (generic of
ALDARA) CREA
metronidazole (topical)
(generic of METROCREAM)
CREA
metronidazole (topical)
(generic of METROLOTION)
LOTN
metronidazole gel 0.75%
PANRETIN
podofilox (generic of
CONDYLOX) SOLN
rosadan cre 0.75% (generic of
METROCREAM)
tacrolimus (topical) (generic of
PROTOPIC)
TARGRETIN GEL
Drug Name
3
4
4
4
4
4
4
5
3
Drug Requirements/
Tier
Limits
5 NDS NM LA
PA
3
DERMATOLOGY, SCABICIDES AND
PEDICULIDES
EURAX
malathion (generic of OVIDE)
permethrin (generic of
ELIMITE)
4
4
3
DERMATOLOGY, WOUND CARE AGENTS
ACETIC ACID .25%
REGRANEX
SANTYL
STERILE WATER
IRRIGATION
2
5
4
2
3
GC
NDS PA
GC
MOUTH/THROAT/DENTAL AGENTS
chlorhexidine gluconate
(mouth-throat) (generic of
PERIDEX)
clotrimazole TROC
lidocaine hcl (mouth-throat)
nystatin (mouth-throat)
paroex sol 0.12% (generic of
PERIDEX)
periogard (generic of
PERIDEX)
PILOCARPINE HCL (ORAL)
5mg
pilocarpine hcl (oral) (generic
of SALAGEN) 7.5mg
(mouth)
2
4
2
3
2
2
GC
GC
GC
GC
4
4
3
OTIC
NDS
4
4
5 NDS NM PA
ACETIC ACID (OTIC)
acetic acid-aluminum acetate
CIPRODEX
fluocinolone acetonide (otic)
(generic of DERMOTIC)
neomycin-polymyxin-hc (otic)
(generic of CORTISPORIN)
SOLN
3
3
4
4
3
ST - Step Therapy
mail-order
LA - Limited Access
GC - We provide
HR - High Risk
Medication
52
2017 SSI Plus 17256 v6 eff 01/01/2017
Drug Name
Drug Requirements/
Tier
Limits
SUSP
ofloxacin (otic) (generic of
FLOXIN OTIC)
3
4
ST - Step Therapy
mail-order
LA - Limited Access
GC - We provide
HR - High Risk
Medication
53
2017 SSI Plus 17256 v6 eff 01/01/2017
Index
8
8-MOP ..............................51
A
abacavir sulfate .................11
abacavir
sulfate-lamivudine-zidovudin
e ........................................12
ABELCET..........................11
ABILIFY
see aripiprazole tab .......29
ABILIFY MAINTENA ...28, 29
ABRAXANE ......................16
acamprosate calcium ........33
acarbose ...........................34
ACCOLATE
see zafirlukast ...............49
ACCUPRIL
see quinapril hcl ............19
ACCURETIC
see
quinapril-hydrochlorothiazi
de ..................................18
acebutolol hcl ....................21
ACEON
see perindopril erbumine
......................................19
acetaminophen w/ codeine .7
acetazolamide ...................22
ACETIC ACID ...................52
ACETIC ACID (OTIC) .......52
acetic acid-aluminum acetate
..........................................52
acetylcysteine ...................50
acitretin .............................51
ACLOVATE
see alclometasone
dipropionate...................51
ACTHIB .............................45
ACTIGALL
see ursodiol ...................42
ACTIMMUNE ....................44
ACTIQ
see fentanyl citrate ..........8
ACTOS
see pioglitazone hcl .......35
ACULAR
see ketorolac
tromethamine (ophth) .... 48
ACULAR LS
see ketorolac
tromethamine (ophth) .... 48
acyclovir ............................ 12
acyclovir sodium ............... 12
ADACEL ........................... 45
ADAGEN........................... 38
ADALAT CC
see afeditab cr ............... 21
see nifedipine ................ 21
ADCIRCA.......................... 23
ADDERALL
see
amphetamine-dextroamph
etamine tab 10 mg......... 31
see
etamine tab 12.5 mg...... 31
see
see
see
see
etamine tab 5 mg .......... 31
see
etamine tab 7.5 mg........ 31
ADDERALL XR
see
etamine cap sr 24hr 10 mg
...................................... 31
see
...................................... 31
see
...................................... 31
see
...................................... 31
see
...................................... 31
see
...................................... 31
adefovir dipivoxil ............... 12
ADEMPAS ........................ 23
ADOXA
see doxycycline
(monohydrate) ............... 15
ADOXA PAK 1/150
see doxycycline
(monohydrate) ............... 15
adrucil ............................... 15
ADVAIR DISKUS .............. 50
ADVAIR HFA .................... 50
afeditab cr ......................... 21
AFINITOR ......................... 17
AFINITOR DISPERZ ........ 17
AGGRENOX ..................... 44
AGRYLIN
see anagrelide hcl ......... 44
a-hydrocort ....................... 38
ala-cort.............................. 51
ALBENZA ......................... 10
albuterol sulfate ................ 49
ALCAINE
see proparacaine hcl ..... 49
.......................................... 51
ALCOHOL SWABS........... 33
ALDACTAZIDE
see spironolactone &
hydrochlorothiazide ....... 22
ALDACTONE
see spironolactone ........ 19
ALDARA
see imiquimod ............... 52
ALDURAZYME ................. 38
ALECENSA ...................... 17
54
2017 SSI Plus 17256 v6 eff 01/01/2017
alendronate sodium ..........35
alfuzosin hcl ......................42
ALIMTA .............................15
ALINIA ..............................10
ALKERAN
see melphalan hcl .........15
allopurinol tab......................7
alosetron hcl......................42
ALPHAGAN P SOL 0.1% ..48
ALPHAGAN P SOL 0.15% 48
alprazolam tab 0.25mg .....23
alprazolam tab 0.5mg .......23
alprazolam tab 1mg ..........23
alprazolam tab 2 mg .........23
ALREX ..............................48
ALTACE
see ramipril ....................19
altavera tab .......................36
amantadine hcl..................28
AMARYL
see glimepiride ..............34
AMBIEN
see zolpidem tartrate .....32
AMBISOME.......................11
AMERGE
see naratriptan hcl .........32
amifostine crystalline .........18
amikacin sulfate ................10
amiloride &
hydrochlorothiazide ...........22
amiloride hcl ......................22
aminophylline inj ...............50
AMINOSYN .......................46
AMINOSYN
7%/ELECTROLYTES .......46
AMINOSYN
8.5%/ELECTROLYTE .......46
AMINOSYN II ....................46
AMINOSYN II
8.5%/ELECTROL ..............46
AMINOSYN M ...................46
AMINOSYN-HBC ..............46
AMINOSYN-PF 10% .........46
AMINOSYN-PF 7% ...........46
AMINOSYN-RF .................46
amiodarone hcl soln ..........20
amiodarone tab 100mg .....20
amiodarone tab 200mg .....20
amiodarone tab 400mg ..... 20
AMITIZA............................ 42
amitriptyline hcl ................. 26
amlodipine besylate .......... 21
amlodipine
10-20 mg........................... 18
amlodipine
10-40 mg........................... 18
amlodipine
2.5-10 mg.......................... 18
amlodipine
5-10 mg............................. 18
amlodipine
5-20 mg............................. 18
amlodipine
5-40 mg............................. 18
amlodipine
besylate-valsartan tab
10-160 mg......................... 19
amlodipine
10-320 mg......................... 19
amlodipine
besylate-valsartan tab 5-160
mg ..................................... 19
amlodipine
besylate-valsartan tab 5-320
mg ..................................... 19
amlodipine-valsartan-hctz
tab 10-160-12.5 mg .......... 19
tab 10-160-25 mg ............. 19
tab 10-320-25 mg ............. 19
tab 5-160-12.5 mg ............ 19
tab 5-160-25 mg ............... 19
ammonium lactate ............ 52
amoxapine ........................ 26
amoxicillin ......................... 14
.......................................... 14
amphetamine-dextroamphet
amine cap sr 24hr 10 mg .. 31
amine cap sr 24hr 5 mg .... 31
amine tab 10 mg ............... 31
amine tab 12.5 mg ............ 31
amine tab 15 mg ............... 31
amine tab 20 mg ............... 31
amine tab 30 mg ............... 31
amine tab 5 mg ................. 31
amine tab 7.5 mg .............. 31
amphotericin b .................. 11
ampicillin & sulbactam
sodium .............................. 14
ampicillin cap .................... 14
ampicillin inj ...................... 14
ampicillin sodium .............. 14
ampicillin susp .................. 14
AMPYRA .......................... 32
ANADROL-50 ................... 33
ANAFRANIL
see clomipramine hcl .... 26
anagrelide hcl ................... 44
ANAPROX DS
see naproxen sodium ...... 7
anastrozole ....................... 16
ANCOBON
see flucytosine .............. 11
ANDRODERM .................. 33
ANORO ELLIPTA ............. 49
ANTABUSE
see disulfiram ................ 33
55
2017 SSI Plus 17256 v6 eff 01/01/2017
ANUSOL-HC
see procto-med .............51
see proctosol hc cre 2.5%
......................................51
see proctozone hc .........51
APOKYN ...........................28
apri 28 day ........................36
APRISO ............................41
APTIOM ............................24
APTIVUS...........................11
ARALAST NP....................50
ARALEN
see chloroquine
phosphate......................11
aranelle 28 ........................36
ARAVA
see leflunomide .............44
ARCALYST .......................44
ARICEPT
see donepezil
hydrochloride .................26
ARIMIDEX
see anastrozole .............16
aripiprazole odt .................29
aripiprazole oral solution 1
mg/ml ................................29
aripiprazole tab .................29
ARIXTRA
see fondaparinux sodium
......................................43
ARNUITY ELLIPTA ...........50
AROMASIN
see exemestane ............16
ASACOL HD .....................41
ASTEPRO
see azelastine spr 0.15%
......................................49
atenolol .............................21
atenolol & chlorthalidone ...21
ATIVAN
see lorazepam .........23, 24
atorvastatin calcium ..........20
atovaquone .......................10
atovaquone-proguanil hcl ..11
ATRIPLA ...........................12
ATROVENT HFA ..............49
aubra 28 day .....................36
AUGMENTIN
see amoxicillin & pot
clavulanate .................... 14
AUGMENTIN ES-600
clavulanate .................... 14
AUGMENTIN XR
clavulanate .................... 14
AURYXIA .......................... 40
AVALIDE
see
irbesartan-hydrochlorothia
zide................................ 19
AVAPRO
see irbesartan ............... 19
AVASTIN .......................... 16
aviane 28 .......................... 36
AVITA ............................... 50
AVODART
see dutasteride .............. 42
AXIRON ............................ 33
AYGESTIN
see norethindrone acetate
...................................... 40
azacitidine ......................... 15
AZACTAM
see aztreonam .............. 10
AZACTAM IN
ISO-OSMOTIC DE ............ 10
AZACTAM/DEX INJ 2GM . 10
azathioprine ...................... 45
azelastine drop 0.05% ...... 48
azelastine spr 0.1% .......... 49
azelastine spr 0.15%......... 49
AZILECT ........................... 28
azithromycin ...................... 14
AZITHROMYCIN .............. 14
AZOPT .............................. 48
aztreonam ......................... 10
AZULFIDINE
see sulfasalazine ........... 41
AZULFIDINE EN-TABS
see sulfasalazine ec ...... 41
B
bacitracin (ophthalmic) ...... 48
bacitracin-polymyxin b
(ophth) .............................. 48
bacitracin-poly-neomycin-hc
.......................................... 47
baclofen ............................ 33
BACTRIM
see
sulfamethoxazole-trimetho
prim tab ......................... 11
BACTRIM DS
see
sulfamethoxazole-trimetho
p ds ............................... 11
BACTROBAN
see mupirocin ................ 51
balsalazide disodium ........ 41
balziva 28 day ................... 36
BANZEL SUS 40MG/ML ... 24
BANZEL TAB 200MG ....... 24
BANZEL TAB 400MG ....... 24
BARACLUDE .................... 13
see entecavir ................. 13
BCG VACCINE ................. 45
bekyree 28 day ................. 36
BELEODAQ ...................... 16
benazepril &
hydrochlorothiazide........... 18
benazepril hcl ................... 18
BENDEKA ........................ 15
BENICAR .......................... 19
BENICAR HCT ................. 19
BENLYSTA ....................... 45
BENTYL
see dicyclomine hcl ....... 41
BENZAMYCIN
see benzoyl
peroxide-erythromycin ... 50
benzoyl
peroxide-erythromycin ...... 50
benztropine mesylate........ 28
BENZTROPINE MESYLATE
.......................................... 28
BEPREVE ......................... 48
BESIVANCE ..................... 48
BETAGAN
see levobunolol hcl........ 48
(topical) ............................. 51
augmented ........................ 51
BETAMETHASONE
56
2017 SSI Plus 17256 v6 eff 01/01/2017
DIPROPIONATE
AUGMENTED ...................51
betamethasone valerate ...51
BETAPACE
see sorine ......................20
see sotalol hcl................20
BETAPACE AF
see sotalol hcl (afib/afl) ..20
BETASERON ....................32
betaxolol hcl (ophth) ..........48
bethanechol chloride .........43
BETOPTIC-S ....................48
bexarotene ........................17
BEXSERO.........................45
BIAXIN
see clarithromycin .........14
see clarithromycin for susp
......................................14
BIAXIN XL
see clarithromycin er .....14
bicalutamide ......................16
BICILLIN L-A .....................14
BICNU ...............................15
BILTRICIDE ......................10
bisoprolol &
bisoprolol fumarate ...........21
BIVIGAM ...........................44
bleomycin sulfate ..............15
BLEPH-10
see sulfacetamide sodium
(ophth) ...........................48
blephamide .......................47
blisovi 21 fe 1.5/30 28 day
pack ..................................36
blisovi 21 fe 1/20 28 day
pack ..................................36
BOOSTRIX .......................45
BOSULIF...........................17
BREO ELLIPTA ................50
BREVICON-28
see necon 0.5/35 28 day
......................................37
see nortrel 0.5/35 28 day
......................................37
briellyn 28 day ...................36
BRILINTA ..........................44
brimonidine sol 0.2% .........48
BRIVIACT ......................... 24
bromfenac sodium (ophth) 48
bromocriptine mesylate ..... 28
budesonide (inhalation)..... 50
budesonide ec .................. 41
bumetanide ....................... 22
BUMEX
see bumetanide ............. 22
BUPHENYL ...................... 38
see sodium phenylbutyrate
...................................... 38
buprenorphine hcl ............. 33
buprenorphine hcl-naloxone
hcl sl.................................. 33
buproban........................... 33
bupropion hcl .................... 26
bupropion hcl (smoking
deterrent) .......................... 33
buspirone hcl .................... 23
BUSULFEX ....................... 15
butorphanol tartrate ............ 7
BUTRANS........................... 7
BUTRANS 7.5MCG/HR ...... 7
BYDUREON INJ ............... 33
BYDUREON PEN ............. 33
BYETTA ............................ 33
BYSTOLIC ........................ 21
C
cabergoline ....................... 39
CABOMETYX ................... 17
cafergot ............................. 32
CALAN
see verapamil hcl .......... 22
CALAN SR
see verapamil hcl .......... 22
see verapamil tab er ...... 22
calcipotriene...................... 51
calcitonin (salmon) ............ 39
calcitriol ............................. 47
calcitriol inj ........................ 47
calcitriol oral soln 1 mcg/ml
.......................................... 47
binder)............................... 40
camila 28 day.................... 36
CAMPTOSAR
see irinotecan hcl .......... 18
CANASA ........................... 41
CANCIDAS ....................... 11
CAPASTAT SULFATE...... 12
CAPRELSA ...................... 17
captopril ............................ 18
captopril &
CARAFATE
see sucralfate ................ 42
CARBAGLU ...................... 38
carbamazepine ................. 24
CARBATROL
see carbamazepine ....... 24
CARBIDOPA/LEVODOPA/E
NTACAPONE ................... 28
carbidopa-levodopa .......... 28
carboplatin ........................ 18
CARDIZEM
see diltiazem hcl............ 21
CARDIZEM CD
see cartia xt ................... 21
see diltiazem hcl coated
beads ............................ 21
CARDURA
see doxazosin mesylate 19
CARIMUNE
NANOFILTERED .............. 44
CARNITOR
see levocarnitine
(metabolic modifiers) ..... 38
carteolol hcl (ophth) .......... 48
cartia xt ............................. 21
carvedilol .......................... 21
CASODEX
see bicalutamide ........... 16
CATAPRES
see clonidine hcl............ 23
CATAPRES-TTS-1
CATAPRES-TTS-2
CATAPRES-TTS-3
CAYSTON ........................ 10
cefaclor ............................. 13
cefaclor er tab 500mg ....... 13
cefadroxil .......................... 13
CEFAZOLIN IN DEXTROSE
2GM/100ML-4%................ 13
57
2017 SSI Plus 17256 v6 eff 01/01/2017
cefazolin inj .......................13
cefazolin sodium ...............13
cefazolin sodium 1 gm/50ml
..........................................13
cefdinir ..............................13
cefepime hcl ......................13
cefixime .............................13
cefotaxime sodium ............13
cefoxitin sodium ................13
cefpodoxime proxetil .........13
cefprozil.............................13
ceftazidime ........................13
CEFTAZIDIME/DEXTROSE
..........................................13
CEFTIN
see cefuroxime axetil .....13
ceftriaxone sodium ............13
cefuroxime axetil ...............13
cefuroxime sodium ............13
CELEBREX
see celecoxib...................7
celecoxib .............................7
CELEXA
see citalopram
hydrobromide ................26
CELLCEPT
see mycophenolate mofetil
......................................45
CELONTIN ........................24
cephalexin .........................13
CERDELGA ......................38
CEREZYME ......................38
CERVARIX........................45
cetirizine syrup ..................49
CHANTIX CONTINUING
MONTH .............................33
CHANTIX PAK 0.5& 1MG .33
CHANTIX TAB 0.5MG ......33
CHANTIX TAB 1MG .........33
CHEMET ...........................35
chlorhexidine gluconate
(mouth-throat) ...................52
chloroquine phosphate ......11
chlorothiazide tabs ............22
chlorpromazine hcl ............29
chlorpromazine inj .............29
chlorthalidone....................22
cholestyramine ..................20
cholestyramine light .......... 20
ciclopirox ........................... 51
ciclopirox shampoo 1% ..... 51
cilostazol ........................... 44
CILOXAN .......................... 48
see ciprofloxacin hcl
(ophth) ........................... 48
CINRYZE .......................... 44
CIPRO
see ciprofloxacin ........... 14
see ciprofloxacin hcl tab 14
CIPRO I.V.-IN D5W
see ciprofloxacin in d5w 14
CIPRO XR
see ciprofloxacin er ....... 14
CIPRODEX ....................... 52
ciprofloxacin ...................... 14
ciprofloxacin er .................. 14
ciprofloxacin hcl (ophth) .... 48
ciprofloxacin hcl tab .......... 14
ciprofloxacin in d5w .......... 14
ciprofloxacin inj ................. 14
cisplatin ............................. 18
citalopram hydrobromide .. 26
cladribine .......................... 15
CLAFORAN
see cefotaxime sodium.. 13
claravis.............................. 50
clarithromycin .................... 14
clarithromycin er ............... 14
clarithromycin for susp ...... 14
CLEOCIN
see clindamycin cap
300mg ........................... 10
see clindamycin cap 75mg
...................................... 10
see clindamycin hcl cap
150 mg .......................... 10
see clindamycin
phosphate vaginal ......... 43
CLEOCIN IN D5W
see clindamycin
phosphate in d5w .......... 10
CLEOCIN PEDIATRIC
GRANULE
see clindamycin sol
75mg/5ml ...................... 10
CLEOCIN PHOSPHATE
see clindamycin
phosphate ..................... 10
see clindamycin
phosphate inj ................. 10
CLEOCIN-T
see clindamax ............... 50
see clindamycin
phosphate (topical)........ 50
CLIMARA
see estradiol .................. 38
clindamax ......................... 50
clindamycin cap 300mg .... 10
clindamycin cap 75mg ...... 10
clindamycin hcl cap 150 mg
.......................................... 10
clindamycin phosphate ..... 10
(topical) ............................. 50
clindamycin phosphate in
d5w ................................... 10
clindamycin phosphate inj . 10
vaginal .............................. 43
clindamycin sol 75mg/5ml . 10
CLINIMIX
2.75%/DEXTROSE 5%..... 46
CLINIMIX
4.25%/DEXTROSE 25%... 46
CLINIMIX
4.25%/DEXTROSE 5%..... 46
15% .................................. 46
20% .................................. 46
25% .................................. 46
CLINIMIX INJ 4.25/D10 .... 46
CLINIMIX INJ 4.25/D20 .... 46
clomipramine hcl ............... 26
clonazepam ...................... 24
clonidine hcl ................ 22, 23
clopidogrel bisulfate .......... 44
clorazepate dipotassium ... 24
clotrimazole ...................... 52
clotrimazole (topical) ......... 51
CLOZAPINE ODT ............. 29
clozapine tab 100mg......... 29
clozapine tab 200mg......... 29
58
2017 SSI Plus 17256 v6 eff 01/01/2017
clozapine tab 25mg ...........29
clozapine tab 50mg ...........29
CLOZARIL
see clozapine tab 100mg
......................................29
see clozapine tab 25mg 29
COARTEM ........................11
COLAZAL
see balsalazide disodium
......................................41
colchicine w/ probenecid .....7
COLCRYS...........................7
COLESTID
see colestipol hcl ...........20
colestipol hcl .....................20
colistimethate sodium .......10
colocort .............................41
COLY-MYCIN M
see colistimethate sodium
......................................10
COLYTE-FLAVOR PACKS
see gavilyte-c ................41
COMBIGAN ......................48
COMBIVENT RESPIMAT .49
COMBIVIR
see lamivudine-zidovudine
......................................12
COMETRIQ.......................17
COMPLERA ......................12
compro ..............................40
CONDYLOX
see podofilox .................52
constulose .........................41
COPAXONE INJ 40MG/ML
..........................................32
COPAXONE KIT 20MG/ML
..........................................32
COPEGUS
see moderiba tab 200mg
......................................13
see ribasphere...............13
see ribavirin tab 200mg .13
CORDARONE
see amiodarone tab
200mg ...........................20
see pacerone.................20
COREG
see carvedilol ................21
CORTEF
see hydrocortisone ........ 39
CORTENEMA
see colocort ................... 41
cortisone acetate .............. 38
CORTISPORIN
see
(otic) .............................. 52
COSOPT
see dorzolamide
hcl-timolol maleate ........ 48
COTELLIC ........................ 17
COUMADIN ...................... 43
see jantoven .................. 43
see warfarin sodium ...... 43
COZAAR
see losartan potassium . 19
CREON ............................. 42
CRESTOR ........................ 20
CRIXIVAN ......................... 11
cromolyn sod neb 20mg/2ml
.......................................... 49
cromolyn sodium
(mastocytosis)................... 42
cromolyn sodium (ophth) .. 48
cryselle 28......................... 36
CUBICIN ........................... 10
CUTIVATE
see fluticasone propionate
...................................... 51
cyclafem 1/35 28 day ........ 36
cyclafem 7/7/7 28 day ....... 36
CYCLESSA
see velivet 28 day ......... 38
cyclobenzaprine hcl .......... 33
cyclophosphamide ............ 15
CYCLOPHOSPHAMIDE ... 15
cycloserine ........................ 12
cyclosporine ...................... 45
microemulsion) ................. 45
CYKLOKAPRON
see tranexamic acid ...... 44
CYMBALTA
see duloxetine hcl ......... 27
cyproheptadine hcl ............ 49
cyred tab ........................... 36
CYSTADANE POW .......... 38
CYSTAGON ..................... 38
CYSTARAN ...................... 49
cytarabine ......................... 15
CYTOMEL
see liothyronine sodium 40
CYTOTEC
see misoprostol ............. 42
CYTOVENE
see ganciclovir inj 500mg
...................................... 13
D
D.H.E. 45
see dihydroergotamine
mesylate ........................ 32
dacarbazine ...................... 15
DAKLINZA ........................ 13
DALIRESP ........................ 50
danazol ............................. 38
DANTRIUM
see dantrolene sodium .. 33
dantrolene sodium ............ 33
dapsone ............................ 10
DAPTACEL ....................... 45
daunorubicin hcl................ 15
DDAVP
see desmopressin acetate
spray ............................. 40
see desmopressin acetate
tabs ............................... 40
see desmopressin inj
4mcg/ml ........................ 40
deblitane 28 day ............... 36
DELESTROGEN............... 38
see estrad val inj 20mg/ml
...................................... 38
see estrad val inj 40mg/ml
...................................... 38
delyla 28 day .................... 36
DELZICOL ........................ 41
DEMADEX
see torsemide tabs ........ 22
DEMSER .......................... 23
DEPACON
see valproate sodium .... 26
DEPAKENE
see valproate sodium .... 26
see valproic acid ........... 26
59
2017 SSI Plus 17256 v6 eff 01/01/2017
DEPAKOTE
see divalproex sodium ...24
DEPAKOTE ER
DEPAKOTE SPRINKLES
DEPEN TITRATABS .........35
DEPO-MEDROL
see methylpr ace inj
40mg/ml.........................39
see methylpr ace inj
80mg/ml.........................39
DEPO-PROVERA
CONTRACEPTIV
see medroxyprogesterone
acetate 150 mg/ml .........37
DEPO-PROVERA INJ
400/ML ..............................16
DEPO-TESTOSTERONE
see testosterone cypionate
......................................33
DERMOTIC
see fluocinolone acetonide
(otic) ..............................52
DESCOVY ........................12
desipramine hcl .................26
..........................................40
refrigerated........................40
desmopressin acetate tabs
..........................................40
desmopressin inj 4mcg/ml.40
DESMOPRESSIN SOL
0.01% ................................40
DESOGEN
see apri 28 day ..............36
see cyred tab .................36
see emoquette...............36
see juleber 28 day .........36
see reclipsen 28 day .....37
desogestrel-ethinyl estradiol
(biphasic) ..........................36
DETROL
see tolterodine tartrate
tabs ...............................43
DETROL LA
see tolterodine tartrate cap
er ................................... 43
dexamethasone ................ 38
phosphate ......................... 39
phosphate (ophth) ............. 48
.......................................... 42
.......................................... 42
dexrazoxane ..................... 18
DEXTROSE 10% FLEX
CONTAIN.......................... 47
DEXTROSE 10%/NACL
0.2%.................................. 47
DEXTROSE 10%/NACL
0.45%................................ 47
DEXTROSE 2.5%/NACL
0.45%................................ 47
DEXTROSE 5% ................ 47
DEXTROSE 5%
/ELECTROLYTE ............... 47
DEXTROSE 5%/LACTATED
RING ................................. 47
.......................................... 47
DEXTROSE 5%/NACL
0.225%.............................. 47
.......................................... 47
DEXTROSE 5%/NACL
0.33%................................ 47
DEXTROSE 5%/NACL
0.45%................................ 47
.......................................... 47
DEXTROSE
5%/POTASSIUM CHL ...... 47
DEXTROSE 50% .............. 47
DEXTROSE INJ 70%........ 47
DIAMOX
see acetazolamide ........ 22
diazepam .......................... 24
DIAZEPAM GEL
(ANTICONVULSANT) ....... 24
diclofenac potassium .......... 7
diclofenac sodium ............... 7
diclofenac sodium (ophth) . 48
dicloxacillin sodium ........... 14
dicyclomine hcl ................. 41
didanosine ........................ 11
DIFICID ............................. 14
DIFLUCAN
see fluconazole ............. 11
diflunisal.............................. 7
digitek ............................... 22
digox ................................. 22
digoxin .............................. 22
digoxin inj.......................... 22
DIGOXIN SOL 50MCG/ML
.......................................... 22
dihydroergotamine mesylate
.......................................... 32
dilantin .............................. 24
DILANTIN
see phenytoin sodium
extended ....................... 25
DILANTIN INFATABS
see phenytoin ................ 25
DILANTIN-125
see phenytoin ................ 25
DILANTIN-125 SUS
125/5ML ............................ 24
DILAUDID
see hydromorphone hcl ... 8
DILAUDID-HP
see hydromorphone hcl ... 8
diltiazem cap ..................... 21
diltiazem cap 120mg/24hr . 21
diltiazem cap 240mg/24hr. 21
diltiazem cap er/12hr ........ 21
diltiazem hcl ...................... 21
diltiazem hcl coated beads 21
dilt-xr cap .......................... 21
DIOVAN
see valsartan ................. 20
DIOVAN HCT
see valsartan & hctz tab
160-12.5mg ................... 19
160-25mg ...................... 19
320-12.5mg ................... 19
320-25mg ...................... 19
60
2017 SSI Plus 17256 v6 eff 01/01/2017
80-12.5mg .....................19
DIPENTUM .......................41
diphenhydramine hcl inj ....49
diphenoxylate w/ atropine .42
DIPHTHERIA/TETANUS
TOXOID ............................45
DIPROLENE
see betamethasone
dipropionate augmented 51
DIPROLENE AF
see betamethasone
dipropionate augmented 51
disopyramide phosphate ...20
disulfiram...........................33
DITROPAN XL
see oxybutynin chloride .43
divalproex sodium .............24
DOCEFREZ ......................16
docetaxel...........................16
DOCETAXEL ....................16
DOCETAXEL SOLN
80MG/8ML ........................16
DOFETILIDE .....................20
DOLOPHINE
see methadone hcl 10mg 9
see methadone hcl 5mg ..9
donepezil hydrochloride ....26
dorzolamide hcl .................48
dorzolamide hcl-timolol
maleate .............................48
DOVONEX
see calcipotriene ...........51
doxazosin mesylate ..........19
doxepin hcl ........................26
DOXEPIN HCL
(ANTIPRURITIC) ..............51
DOXIL
see doxorubicin hcl
liposomal .......................15
doxorubicin hcl ..................15
doxorubicin hcl inj 2 mg/ml 15
doxorubicin hcl liposomal ..15
doxy ..................................15
..........................................15
doxycycline hyclate ...........15
dronabinol .........................40
drospirenone-ethinyl
estradiol ............................ 36
DROXIA ............................ 17
duloxetine hcl .................... 27
DURAGESIC
see fentanyl patch 100
mcg/hr ............................. 8
mcg/hr ............................. 8
mcg/hr ............................. 8
mcg/hr ............................. 8
mcg/hr ............................. 8
DURAMORPH .................... 8
DUREZOL......................... 48
dutasteride ........................ 42
dutasteride-tamsulosin hcl 42
DYAZIDE
see triamterene &
37.5-25 mg .................... 22
E
e.e.s. 400mg tab ............... 14
EC-NAPROSYN
see naproxen .................. 7
EDURANT ........................ 11
EFFEXOR XR
see venlafaxine hcl ........ 28
EFFIENT ........................... 44
EFUDEX
see fluorouracil (topical) 52
ELAVIL
see amitriptyline hcl ....... 26
ELDEPRYL
see selegiline hcl ........... 28
ELIMITE
see permethrin .............. 52
ELIPHOS
see calcium acetate
(phosphate binder) ........ 40
ELITEK ............................. 18
elixophyllin ........................ 50
ELLA ................................. 36
ELLENCE
see epirubicin hcl .......... 15
ELMIRON ......................... 43
ELOCON
see mometasone furoate
...................................... 52
EMBEDA ............................ 8
EMCYT ............................. 15
EMEND ............................. 40
EMEND CAP 125MG........ 40
EMEND CAP 40MG.......... 40
EMEND CAP 80MG.......... 40
EMEND PAK 80 & 125 ..... 40
emoquette ......................... 36
EMSAM ............................ 27
EMTRIVA .......................... 11
emverm ............................. 10
enalapril maleate .............. 18
enalapril maleate &
endocet ............................... 8
ENGERIX-B ...................... 45
enoxaparin sodium ........... 43
ENOXAPARIN SODIUM ... 43
enpresse 28 day ............... 36
ENTACAPONE ................. 28
entecavir ........................... 13
ENTOCORT EC
see budesonide ec ........ 41
ENTRESTO ...................... 19
enulose ............................. 41
EPIPEN 2-PAK ................. 50
EPIPEN-JR 2-PAK............ 50
epirubicin hcl ..................... 15
epitol ................................. 24
EPIVIR
see lamivudine .............. 11
EPIVIR HBV ..................... 13
see lamivudine (hbv) ..... 13
eplerenone ........................ 19
EPZICOM ......................... 12
ERIVEDGE ....................... 16
errin 28 day ....................... 36
ery pad 2% ....................... 50
ERYGEL
see erythromycin (acne
aid) ................................ 50
ery-tab .............................. 14
erythrocin lactobionate...... 14
erythrocin stearate ............ 14
erythromycin (acne aid) .... 50
erythromycin (ophth) ......... 48
61
2017 SSI Plus 17256 v6 eff 01/01/2017
erythromycin base .............14
erythromycin cap 250mg ec
..........................................14
erythromycin ethylsuccinate
..........................................14
ESBRIET...........................50
escitalopram oxalate .........27
esomeprazole magnesium 42
esomeprazole sodium inj ..42
estarylla tab 0.25-35 .........36
estrace ..............................38
ESTRACE
see estradiol ..................38
estrad val inj 20mg/ml .......38
estrad val inj 40mg/ml .......38
estradiol ............................38
ESTROSTEP FE
see tri-legest 28 day ......37
ethambutol hcl...................12
ethosuximide .....................24
ETHYOL
see amifostine crystalline
......................................18
etodolac ..............................7
etoposide ..........................18
EURAX .............................52
EVISTA
see raloxifene tab 60mg 39
EVOTAZ............................12
EXELON
see rivastigmine tartrate 26
EXELON PATCHES .........26
exemestane ......................16
EXFORGE
see amlodipine
10-160 mg .....................19
see amlodipine
10-320 mg .....................19
see amlodipine
5-160 mg .......................19
see amlodipine
5-320 mg .......................19
EXFORGE HCT
see
tab 10-160-12.5 mg ....... 19
see
tab 10-160-25 mg .......... 19
see
tab 10-320-25 mg .......... 19
see
tab 5-160-12.5 mg ......... 19
see
tab 5-160-25 mg ............ 19
EXJADE ............................ 35
F
FABRAZYME .................... 38
falmina 28 day .................. 36
famciclovir ......................... 13
famotidine ......................... 41
famotidine inj..................... 41
famotidine tab ................... 41
FAMVIR
see famciclovir .............. 13
FANAPT............................ 29
FANAPT TITRATION PACK
.......................................... 29
FARESTON ...................... 16
FARXIGA .......................... 34
FARYDAK ......................... 16
FASLODEX....................... 16
felbamate .......................... 24
FELBATOL
see felbamate ................ 24
felodipine .......................... 21
FEMARA
see letrozole .................. 16
fenofibrate ......................... 20
fenofibrate micronized....... 20
fentanyl citrate .................... 8
fentanyl patch 100 mcg/hr... 8
fentanyl patch 12 mcg/hr..... 8
FENTORA........................... 8
FERRIPROX ..................... 35
FETZIMA .......................... 27
FETZIMA TITRATION PACK
.......................................... 27
finasteride ......................... 43
FIRAZYR .......................... 44
FLAGYL
see metronidazole ......... 10
FLEBOGAMMA DIF.......... 44
flecainide acetate .............. 20
FLOMAX
see tamsulosin hcl......... 43
FLOVENT DISKUS ........... 50
FLOVENT HFA ................. 50
FLOXIN OTIC
see ofloxacin (otic) ........ 53
fluconazole ....................... 11
fluconazole in dextrose ..... 11
fluconazole inj nacl 100 .... 11
flucytosine ......................... 11
FLUDARA
see fludarabine phosphate
...................................... 15
fludarabine phosphate ...... 15
fludrocortisone acetate ..... 39
FLUMADINE
see rimantadine
hydrochloride................. 13
flunisolide (nasal) .............. 50
fluocinolone acetonide ...... 51
fluocinolone acetonide (otic)
.......................................... 52
fluocinonide ...................... 51
fluocinonide emulsified base
.......................................... 51
FLUOROMETHOLONE .... 48
fluorouracil ........................ 15
fluorouracil (topical) .......... 52
fluoxetine cap 10mg.......... 27
fluoxetine hcl ..................... 27
fluphenazine decanoate .... 29
fluphenazine hcl ................ 29
flurbiprofen .......................... 7
flurbiprofen sodium ........... 48
flutamide ........................... 16
fluticasone propionate....... 51
62
2017 SSI Plus 17256 v6 eff 01/01/2017
fluticasone propionate
(nasal) ...............................50
fluvoxamine maleate .........23
fondaparinux sodium .........43
FORTAZ
see ceftazidime .............13
see tazicef .....................13
see tazicef vial ...............13
FORTEO ...........................40
FORTICAL ........................39
FOSAMAX
see alendronate sodium 35
fosinopril sodium ...............18
fosinopril sodium &
FREAMINE HBC 6.9% ......46
FREAMINE III ...................46
furosemide ........................22
furosemide inj....................22
FUROSEMIDE INJ ............22
FUSILEV ...........................18
FUZEON ...........................11
fyavolv tab 1-5mg ..............38
FYCOMPA ..................24, 25
G
gabapentin ........................25
GABITRIL..........................25
see tiagabine hcl ...........25
galantamine hydrobromide26
er.......................................26
GAMASTAN S/D ...............44
GAMMAGARD LIQUID .....44
GAMMAGARD S/D ...........44
GAMMAKED .....................44
GAMMAPLEX ...................44
GAMUNEX-C ....................44
ganciclovir inj 500mg ........13
GARDASIL ........................45
GARDASIL 9 .....................45
GASTROCROM
see cromolyn sodium
(mastocytosis) ...............42
gatifloxacin (ophth)............48
GATTEX............................42
GAUZE PADS 2" X 2" .......33
gavilyte-c ...........................41
gavilyte-g...........................41
gavilyte-h .......................... 41
gavilyte-n .......................... 41
gemcitabine hcl ................. 15
GEMCITABINE HCL ......... 15
gemfibrozil ........................ 20
GEMZAR
see gemcitabine hcl....... 15
generlac ............................ 41
gengraf.............................. 45
gentak ............................... 48
gentamicin in saline .......... 10
gentamicin sulfate ............. 10
gentamicin sulfate (ophth). 48
gentamicin sulfate (topical)
.......................................... 51
gentamicin sulfate/0.9% s . 10
GENVOYA ........................ 12
GEODON .......................... 29
see ziprasidone hcl........ 30
GIANVI TAB 3-0.02MG ..... 36
gildagia ............................. 36
gildess 1.5/30 21 day ........ 36
GILENYA CAP 0.5MG ...... 32
GILOTRIF TAB 20MG....... 17
GLEEVEC
see imatinib mesylate .... 17
GLEOSTINE ..................... 15
glimepiride ........................ 34
.......................................... 34
.......................................... 34
glip/metform tab 5-500mg . 34
glipizide ............................. 34
GLIPIZIDE XL TB24 2.5MG
.......................................... 34
GLIPIZIDE XL TB24 5MG . 34
GLUCAGEN HYPOKIT ..... 39
GLUCAGON EMERGENCY
KIT .................................... 39
GLUCOPHAGE
see metformin hcl .......... 35
GLUCOPHAGE XR
see metformin hcl .......... 35
GLUCOTROL
see glipizide .................. 34
GLUCOTROL XL
see glipizide .................. 34
glycopyrrolate ................... 41
GOLYTELY ....................... 41
see gavilyte-g ................ 41
GRALISE .......................... 32
GRALISE STARTER ........ 32
granisetron hcl .................. 40
GRANIX ............................ 43
griseofulvin microsize ....... 11
griseofulvin ultramicrosize 11
GRIS-PEG
see griseofulvin
ultramicrosize ................ 11
guanfacine er (adhd)......... 31
H
HALDOL
see haloperidol lactate inj
5mg/ml .......................... 29
HALDOL DECANOATE 100
see haloperidol decanoate
...................................... 29
HALDOL DECANOATE 50
see haloperidol decanoate
...................................... 29
halobetasol propionate ..... 51
haloperidol ........................ 29
haloperidol decanoate ...... 29
haloperidol lactate conc .... 29
haloperidol lactate inj 5mg/ml
.......................................... 29
HAVRIX ............................ 45
heather ............................. 36
heparin sod (porcine) in d5w
.......................................... 43
HEPARIN SOD (PORCINE)
IN D5W ............................. 43
heparin sod inj 1000/ml..... 43
heparin sod inj 10000/ml ... 43
.......................................... 43
heparin sod inj 20000/ml ... 43
.......................................... 43
heparin sod inj 5000/ml..... 43
HEPARIN SODIUM/D5W . 43
HEPARIN SODIUM/NACL
0.45% ............................... 43
63
2017 SSI Plus 17256 v6 eff 01/01/2017
HEPATAMINE...................46
HEPSERA
see adefovir dipivoxil .....12
HERCEPTIN .....................16
HETLIOZ ...........................31
HEXALEN .........................15
HIBERIX............................45
HIPREX
see methenamine
hippurate .......................10
HUMIRA INJ 10MG/0.2ML 44
HUMIRA KIT 20MG/0.4ML44
HUMIRA KIT 40MG/0.8ML44
HUMIRA PEDIATRIC
CROHNS DISEASE ..........44
HUMIRA PEN ...................44
HUMIRA PEN-CROHNS
DISEASE ..........................44
HUMIRA PEN-PSORIASIS
STAR ................................44
HUMULIN R INJ U-500 .....33
HUMULIN R U-500
KWIKPEN .........................34
HYCAMTIN
see topotecan hcl ..........18
HYCET
see
hydrocodone-acetaminoph
en 7.5-325 mg/15ml ........8
hydralazine hcl ..................23
HYDREA
see hydroxyurea ............17
............................................8
hydroco/apap tab 5-325mg .8
hydroco/apap tab 7.5-325mg
............................................8
hydrocodone-acetaminophen
7.5-325 mg/15ml .................8
7.5-200mg ...........................8
hydrocortisone ..................39
HYDROCORTISONE
(ENEMA) ...........................41
hydrocortisone (topical) .....51
hydrocortisone butyrate ....52
hydromorphone hcl .............8
hydroxychloroquine sulfate
.......................................... 44
hydroxyprogesterone
caproate (antineoplastic)... 16
hydroxyurea ...................... 17
hydroxyz hcl inj ................. 49
hydroxyzine hcl ................. 49
hydroxyzine pamoate ........ 49
HYSINGLA ER .................... 8
HYZAAR
see losartan potassium &
hctz tab 100-12.5 mg..... 19
hctz tab 100-25 mg........ 19
hctz tab 50-12.5 mg....... 19
I
IBRANCE .......................... 16
ibuprofen ............................. 7
ICLUSIG ........................... 17
IDAMYCIN PFS
see idarubicin hcl .......... 15
idarubicin hcl ..................... 15
IFEX .................................. 15
see ifosfamide inj 1gm... 15
ifosfamide inj 1gm ............. 15
ifosfamide inj 1gm/20ml .... 15
IFOSFAMIDE INJ 3GM ..... 15
ifosfamide inj 3gm/60ml .... 15
ILEVRO............................. 48
ilotycin ............................... 48
imatinib mesylate .............. 17
IMBRUVICA CAP 140MG . 17
imipenem-cilastatin ........... 10
imipramine hcl ................... 27
imiquimod ......................... 52
IMITREX
see sumatriptan inj
6mg/0.5ml ..................... 32
see sumatriptan succinate
...................................... 32
IMITREX STATDOSE
REFILL
see sumatriptan inj
6mg/0.5ml ..................... 32
IMITREX STATDOSE
SYSTEM
see sumatriptan inj
6mg/0.5ml ..................... 32
IMOVAX RABIES (H.D.C.V.)
.......................................... 45
IMURAN
see azathioprine ............ 45
INCRELEX ........................ 39
INCRUSE ELLIPTA .......... 49
indapamide ....................... 22
INDERAL LA
see propranolol cap er .. 21
INFANRIX ......................... 45
INLYTA ............................. 17
INSPRA
see eplerenone ............. 19
INSULIN PEN NEEDLE .... 34
INSULIN SYRINGE .......... 34
INTELENCE ..................... 11
INTRALIPID INJ 20% ....... 46
INTRALIPID INJ 30% ....... 46
INTRON-A INJ 10MU ....... 44
introvale 91 day ................ 36
INTUNIV
see guanfacine er (adhd)
...................................... 31
INVANZ ............................ 10
INVEGA ............................ 29
INVEGA SUST INJ
117MG/0.75ML ................. 29
INVEGA SUST INJ
156MG/ML ........................ 29
INVEGA SUST INJ
234MG/1.5ML ................... 29
INVEGA SUST INJ
39MG/0.25ML ................... 29
INVEGA SUST INJ
78MG/0.5ML ..................... 29
INVEGA TRINZA .............. 29
INVIRASE ......................... 11
INVOKAMET TAB
150-1000MG ..................... 34
INVOKAMET TAB
150-500MG ....................... 34
INVOKAMET TAB
50-1000MG ....................... 34
INVOKAMET TAB
64
2017 SSI Plus 17256 v6 eff 01/01/2017
50-500MG .........................34
INVOKANA .......................35
IONOSOL-B/DEXTROSE
5% .....................................47
IONOSOL-MB/DEXTROSE
5% .....................................47
IPOL INACTIVATED IPV ..45
ipratropium bromide ..........49
ipratropium bromide (nasal)
..........................................49
ipratropium-albuterol nebu 49
irbesartan ..........................19
irbesartan-hydrochlorothiazid
e ........................................19
IRESSA .............................17
irinotecan hcl .....................18
ISENTRESS......................11
ISOLYTE P .......................47
ISOLYTE S .......................47
isoniazid ............................12
isoniazid inj 100 mg/ml ......12
isoniazid syp 50mg/5ml .....12
ISORDIL TITRADOSE
see isosorbide dinitrate .23
isosorb mononitrate tab ....23
isosorbide dinitrate ............23
isosorbide dinitrate er ........23
isosorbide mononitrate er .23
isradipine...........................21
ISTALOL ...........................48
ISTODAX ..........................16
itraconazole.......................11
ivermectin..........................10
IXIARO ..............................45
J
JAKAFI ..............................17
JALYN
see dutasteride-tamsulosin
hcl ..................................42
jantoven ............................43
JANUMET .........................35
JANUMET XR TAB
100-1000 ...........................35
..........................................35
JANUMET XR TAB
50-500MG .........................35
JANUVIA ...........................35
jinteli.................................. 38
JOLESSA TAB 0.15-0.03
MG .................................... 36
JOLIVETTE....................... 36
juleber 28 day ................... 36
junel 1.5/30 21 day ........... 36
junel 1/20 21 day .............. 36
junel fe 1.5/30 28 day........ 36
junel fe 1/20 28 day .......... 36
JUXTAPID ........................ 20
K
KADCYLA ......................... 16
KALETRA SOL ................. 12
KALETRA TAB 100-25MG 12
KALETRA TAB 200-50MG 12
KALYDECO ...................... 50
kariva 28 day .................... 36
KAYEXALATE
see kionex powder ........ 35
see sodium polystyrene
sulfonate........................ 35
KCL 0.075%/D5W/NACL
0.45%................................ 47
KCL 0.15%/D5W/NACL
0.9%.................................. 47
KCL 0.3%/D5W/NACL
0.45%................................ 47
KCL 0.3%/D5W/NACL 0.9%
.......................................... 47
KCL IN NACL INJ .15-0.45
.......................................... 47
KCL/D5W INJ 0.3% .......... 47
KCL/D5W/NACL INJ
.15/.33%............................ 47
KCL/D5W/NACL INJ
.15/.45%............................ 47
KCL/D5W/NACL INJ
0.22%/0.45% .................... 47
KCL/NACL INJ 0.15%-0.9%
.......................................... 47
KCL/NACL INJ 0.3-0.9 ...... 47
KCL0.15%/D5W/NACL0.2%
.......................................... 47
KCL0.15%/D5W/NACL0.225
% ...................................... 47
KEFLEX
see cephalexin .............. 13
kelnor 1/35 28 day ............ 36
KEPPRA
see levetiracetam .......... 25
see levetiracetam inj ..... 25
see levetiracetam sol
100mg/ml ...................... 25
see roweepra ................ 25
KEPPRA XR
see levetiracetam .......... 25
ketoconazole .................... 11
ketoconazole cream.......... 51
ketoconazole shampoo ..... 51
ketoprofen ........................... 7
(ophth) .............................. 48
KEYTRUDA ...................... 16
kimidess 28 day ................ 36
KINRIX.............................. 45
kionex powder .................. 35
kionex susp 15gm/60ml .... 35
KLARON
see sulfacetamide sodium
(acne) ............................ 50
KLONOPIN
see clonazepam ............ 24
KLOR-CON 10 .................. 46
KLOR-CON 8 .................... 46
klor-con m10 ..................... 46
klor-con m15 ..................... 46
klor-con m20 ..................... 46
klor-con pow 20 meq ........ 46
klor-con spr cap 10meq .... 46
klor-con spr cap 8meq ...... 46
KORLYM .......................... 39
KUVAN ............................. 38
KYNAMRO ....................... 20
L
labetalol hcl ....................... 21
LAC-HYDRIN
see ammonium lactate .. 52
LACTATED RINGER'S INJ
.......................................... 47
lactulose ........................... 41
lactulose (encephalopathy)
.......................................... 41
LAMICTAL
see lamotrigine .............. 25
LAMICTAL CHEWABLE
DISPERS
65
2017 SSI Plus 17256 v6 eff 01/01/2017
see lamotrigine ..............25
LAMICTAL XR
see lamotrigine ..............25
LAMISIL
see terbinafine hcl .........11
lamivudine .........................11
lamivudine (hbv)................13
lamivudine-zidovudine ......12
lamotrigine ........................25
LANOXIN
see digitek .....................22
see digox .......................22
see digoxin ....................22
see digoxin inj................22
LANTUS ............................34
LANTUS SOLOSTAR .......34
larin 1.5/30 ........................36
larin 1/20 ...........................36
larin fe 1.5/30 ....................36
larin fe 1/20 .......................36
LASIX
see furosemide ..............22
LASTACAFT .....................48
latanoprost ........................48
LATUDA ............................29
LEENA TAB ......................36
leflunomide........................44
LENVIMA 10 MG DAILY
DOSE ................................17
LENVIMA 14 MG DAILY
DOSE ................................17
LENVIMA 18 MG DAILY
DOSE ................................17
LENVIMA 20 MG DAILY
DOSE ................................17
LENVIMA 24 MG DAILY
DOSE ................................17
LENVIMA 8 MG DAILY
DOSE ................................17
lessina 28 day ...................36
LETAIRIS ..........................23
letrozole ............................16
leucovorin calcium ............18
leucovorin calcium for inj 500
mg .....................................18
LEUKERAN.......................15
LEUKINE...........................43
leuprolide inj 1mg/0.2 ........16
LEVAQUIN
see levofloxacin ............. 14
LEVEMIR .......................... 34
LEVEMIR FLEXTOUCH ... 34
levetiracetam .................... 25
levetiracetam inj ................ 25
LEVETIRACETAM IV........ 25
levetiracetam sol 100mg/ml
.......................................... 25
levobunolol hcl .................. 48
levocarnitine (metabolic
modifiers) .......................... 38
.......................................... 49
levofloxacin ....................... 14
levofloxacin in d5w ............ 14
levofloxacin inj 25mg/ml .... 14
levofloxacin oral soln 25
mg/ml ................................ 14
levoleucovorin calcium ...... 18
levonest 28 day................. 36
levonor/ethi tab ................. 37
levonorgestrel & eth estradiol
.......................................... 37
levonorgestrel (emergency
oc) ..................................... 37
levonorgestrel-ethinyl
estradiol (91-day) .............. 37
levora 0.15/30 28 day ....... 37
levothyroxine sodium ........ 40
LEVOTHYROXINE SODIUM
.......................................... 40
LEXAPRO
see escitalopram oxalate
...................................... 27
LEXIVA ............................. 11
lidocaine............................ 52
lidocaine hcl ...................... 52
lidocaine hcl (local anesth.). 9
lidocaine hcl (mouth-throat)
.......................................... 52
lidocaine inj 0.5% ................ 9
lidocaine inj 1% ................... 9
lidocaine inj 1.5% .............. 10
lidocaine inj 2% ................. 10
lidocaine oint 5% ............... 52
lidocaine-prilocaine ........... 52
LIDODERM
see lidocaine ................. 52
linezolid ............................. 10
LINEZOLID ....................... 10
LINEZOLID IN SODIUM
CHLORIDE ....................... 10
LINZESS........................... 42
liothyronine sodium ........... 40
LIPITOR
see atorvastatin calcium 20
lisinopril ............................. 18
lisinopril &
lithium carbonate .............. 32
lithium carbonate er .......... 32
LITHIUM SOLN 8MEQ/5ML
.......................................... 32
LITHOBID
see lithium carbonate er 32
LOCOID
see hydrocortisone
butyrate ......................... 52
LOESTRIN 1.5/30-21
see gildess 1.5/30 21 day
...................................... 36
see junel 1.5/30 21 day . 36
see larin 1.5/30.............. 36
LOESTRIN 1/20-21
see junel 1/20 21 day .... 36
see larin 1/20................. 36
LOESTRIN FE 1.5/30
see blisovi 21 fe 1.5/30 28
day pack ........................ 36
see junel fe 1.5/30 28 day
...................................... 36
see larin fe 1.5/30.......... 36
LOESTRIN FE 1/20
see blisovi 21 fe 1/20 28
day pack ........................ 36
see junel fe 1/20 28 day 36
see larin fe 1/20............. 36
see tarina fe 1/20 28 day
...................................... 37
LOFIBRA
see fenofibrate .............. 20
see fenofibrate micronized
...................................... 20
LOMOTIL
see diphenoxylate w/
66
2017 SSI Plus 17256 v6 eff 01/01/2017
atropine .........................42
LONSURF .........................17
loperamide hcl...................42
LOPID
see gemfibrozil ..............20
LOPRESSOR
see metoprolol tartrate ..21
LOPRESSOR HCT
see metoprolol &
hydrochlorothiazide .......21
LOPROX
see ciclopirox.................51
LOPROX SHAMPOO
see ciclopirox shampoo
1% .................................51
lorazepam ...................23, 24
lorcet plus tab 7.5-325 ........8
lorcet tab 5-325mg ..............8
lortab tab 10-325mg ............8
lortab tab 5-325mg ..............8
lortab tab 7.5-325 ................8
loryna 28 day ....................37
losartan potassium ............19
losartan potassium & hctz
tab 100-12.5 mg ................19
tab 100-25 mg ...................19
tab 50-12.5 mg ..................19
LOTEMAX .........................48
LOTENSIN
see benazepril hcl .........18
LOTENSIN HCT
see benazepril &
LOTREL
see amlodipine
besylate-benazepril hcl
cap 10-20 mg ................18
see amlodipine
cap 10-40 mg ................18
see amlodipine
cap 5-10 mg ..................18
see amlodipine
cap 5-20 mg ..................18
LOTRONEX
see alosetron hcl ........... 42
lovastatin........................... 20
LOVAZA
see omega-3-acid ethyl
esters ............................ 20
LOVENOX
see enoxaparin sodium . 43
low-ogestrel ...................... 37
loxapine succinate ............ 29
LUMIGAN ......................... 48
LUMIZYME ....................... 38
LUPRON DEPOT ............. 16
LUPRON DEPOT INJ
11.25MG (3-MONTH) ....... 16
LUPRON DEP-PED INJ
11.25MG ........................... 39
LUPRON DEP-PED INJ
11.25MG (3-MONTH) ....... 39
LUPRON DEP-PED INJ
15MG ................................ 39
LUPRON DEP-PED INJ
30MG (3-MONTH) ............ 39
LUPRON DEP-PED INJ
7.5MG ............................... 39
lutera 28 day ..................... 37
LYNPARZA ....................... 16
LYRICA ............................. 25
LYSODREN ...................... 16
LYSTEDA
see tranexamic acid ...... 44
lyza ................................... 37
M
MACROBID
see nitrofurantoin
monohyd macro ............ 10
MACRODANTIN
see nitrofurantoin
macrocrystal .................. 10
magnesium sulfate ............ 46
MAGNESIUM SULFATE... 46
see magnesium sulfate . 46
MAGNESIUM SULFATE IN
D5W .................................. 46
MALARONE
see atovaquone-proguanil
hcl.................................. 11
malathion .......................... 52
maprotiline hcl .................. 27
MARINOL
see dronabinol............... 40
marlissa 28 day................. 37
MARPLAN TAB 10MG...... 27
MATULANE ...................... 17
MAVIK
see trandolapril.............. 19
MAXALT
see rizatriptan benzoate 32
MAXALT-MLT
see rizatriptan benzoate 32
MAXIDEX ......................... 48
MAXIPIME
see cefepime hcl ........... 13
MAXITROL
see
neomycin-polymy-dexamet
h .................................... 47
MAXZIDE
see triamterene &
MAXZIDE-25
see triamterene &
meclizine hcl ..................... 40
MEDROL
see methylpred tab 16mg
...................................... 39
see methylpred tab 32mg
...................................... 39
see methylpred tab 4mg 39
see methylpred tab 8mg 39
MEDROL DOSEPAK
see methylpred pak 4mg
...................................... 39
medroxyprogesterone
acetate 150 mg/ml ............ 37
medroxyprogesterone
acetate tab ........................ 40
mefloquine hcl .................. 11
MEGACE ORAL
see megestrol ac sus
40mg/ml ........................ 16
megestrol ac sus 40mg/ml 16
megestrol ac tab 20mg ..... 16
megestrol ac tab 40mg ..... 16
MEGESTROL SUS
67
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625MG/5ML ......................16
MEKINIST .........................17
meloxicam ...........................7
MELOXICAM ......................7
melphalan hcl ....................15
memantine hcl...................26
MEMANTINE HCL ............26
MENACTRA ......................45
MENHIBRIX ......................45
MENOMUNE-A/C/Y/W-135
..........................................45
MENVEO ..........................45
MEPRON
see atovaquone .............10
mercaptopurine .................15
meropenem .......................10
MERREM
see meropenem ............10
mesalamine enema ...........41
mesalamine w/ cleanser ...41
mesna ...............................18
MESNEX ...........................18
see mesna .....................18
MESTINON
see pyridostigmine tab
60mg .............................32
metadate tab 20mg er .......31
metformin hcl ....................35
methadone hcl ....................8
methadone hcl 10mg ..........9
methadone hcl 5mg ............9
METHADOSE
see methadone hcl ..........8
methazolamide ..................22
methenamine hippurate ....10
METHERGINE
see methylergonovine
maleate..........................39
methimazole......................40
methotrexate sodium ........15
METHOTREXATE SODIUM
..........................................15
methotrexate sodium inj ....15
methotrexate sodium tabs .44
methyclothiazide ...............22
methylergonovine maleate 39
METHYLIN
see methylphenidate hcl
oral soln......................... 31
methylphenidate hcl .......... 31
.......................................... 31
methylpr ace inj 40mg/ml .. 39
methylpr ace inj 80mg/ml .. 39
methylpr ss inj 1gm ........... 39
methylpr ss inj 40mg ......... 39
methylpred pak 4mg ......... 39
methylpred tab 16mg ........ 39
methylpred tab 32mg ........ 39
methylpred tab 4mg .......... 39
methylpred tab 8mg .......... 39
methylprednisolone sod succ
.......................................... 39
metipranolol ...................... 49
metoclopramide hcl ........... 40
metoclopramide hcl inj ...... 40
metolazone ....................... 22
metoprolol &
hydrochlorothiazide ........... 21
metoprolol succinate ......... 21
metoprolol tartrate ............. 21
METROCREAM
see metronidazole
(topical) ......................... 52
see rosadan cre 0.75% . 52
METROGEL-VAGINAL
see metronidazole vaginal
...................................... 43
METROLOTION
see metronidazole
(topical) ......................... 52
metronidazole ................... 10
metronidazole (topical)...... 52
metronidazole gel 0.75% .. 52
metronidazole in nacl ........ 10
metronidazole vaginal ....... 43
MEVACOR
see lovastatin ................ 20
mexiletine hcl .................... 20
MIACALCIN ...................... 39
see calcitonin (salmon).. 39
MICROGESTIN 1.5/30...... 37
MICROGESTIN 1/20......... 37
MICROGESTIN FE 1.5/30 37
MICROGESTIN FE 1/20 ... 37
MICRO-K
see klor-con spr cap
10meq ........................... 46
see klor-con spr cap 8meq
...................................... 46
see potassium chloride . 46
MICROZIDE
see hydrochlorothiazide 22
midodrine hcl .................... 23
migergot............................ 32
MINIPRESS
see prazosin hcl ............ 19
minitran ............................. 23
MINOCIN
see minocycline hcl ....... 15
minocycline hcl ................. 15
minoxidil ............................ 23
MIRAPEX
see pramipexole tab
0.125mg ........................ 28
see pramipexole tab
0.25mg .......................... 28
see pramipexole tab
0.5mg ............................ 28
see pramipexole tab
0.75mg .......................... 28
see pramipexole tab
1.5mg ............................ 28
see pramipexole tab 1mg
...................................... 28
MIRCETTE
see bekyree 28 day ....... 36
see desogestrel-ethinyl
estradiol (biphasic) ........ 36
see kariva 28 day .......... 36
see kimidess 28 day...... 36
see pimtrea pack ........... 37
see viorele ..................... 38
mirtazapine ....................... 27
misoprostol ....................... 42
mitomycin ......................... 15
mitoxantrone hcl ............... 17
M-M-R II ............................ 45
MOBIC
see meloxicam ................ 7
moderiba tab 200mg ......... 13
moexipril hcl ...................... 18
moexipril-hydrochlorothiazid
e........................................ 18
68
2017 SSI Plus 17256 v6 eff 01/01/2017
molindone hcl ....................29
mometasone furoate .........52
MONODOX
see doxycycline
(monohydrate) ...............15
mono-linyah tab 0.25-35 ...37
MONONESSA...................37
montelukast sodium ..........49
morphine ext-rel tab ............9
MORPHINE SUL INJ
10MG/ML ............................9
MORPHINE SUL INJ
15MG/ML ............................9
MORPHINE SUL INJ
1MG/ML ..............................9
MORPHINE SUL INJ
2MG/ML ..............................9
MORPHINE SUL INJ
4MG/ML ..............................9
morphine sulfate .................9
MORPHINE SULFATE .......9
see morphine sulfate .......9
MORPHINE SULFATE
ORAL SOL ..........................9
MOVANTIK .......................42
MOVIPREP .......................41
MOXEZA ...........................48
MOZOBIL ..........................43
MS CONTIN
see morphine ext-rel tab ..9
MULTAQ ...........................20
mupirocin ..........................51
MUSTARGEN ...................15
MYAMBUTOL
see ethambutol hcl ........12
MYCAMINE.......................11
MYCOBUTIN
see rifabutin ...................12
mycophenolate mofetil ......45
mycophenolate sodium .....45
MYFORTIC
see mycophenolate
sodium ...........................45
myorisan ...........................50
MYRBETRIQ TAB 25MG ..43
MYRBETRIQ TAB 50MG ..43
MYSOLINE
see primidone ................25
myzilra .............................. 37
N
nabumetone ........................ 7
nafcillin sodium ................. 14
NAGLAZYME .................... 38
nalbuphine hcl..................... 7
naloxone inj 0.4mg/ml ....... 33
naloxone inj 1mg/ml .......... 33
naltrexone hcl ................... 33
NAMENDA
see memantine hcl ........ 26
NAMENDA XR .................. 26
NAMENDA XR TITRATION
PACK ................................ 26
NAMZARIC ....................... 26
naphazoline 0.1% ............. 49
NAPROSYN
see naproxen .................. 7
naproxen ............................. 7
naproxen sodium ................ 7
naratriptan hcl ................... 32
NARDIL
see phenelzine sulfate... 27
NATACYN......................... 48
nateglinide ........................ 35
NATPARA ......................... 40
NAVELBINE
see vinorelbine tartrate .. 16
NEBUPENT ...................... 10
necon 0.5/35 28 day ......... 37
necon 1/35 28 day ............ 37
NECON 1/50-28 ................ 37
necon 10/11 28 day .......... 37
NECON 7/7/7 .................... 37
nefazodone hcl ................. 27
neomycin sulfate ............... 10
neomycin-bacitracin
zn-polymyxin ..................... 48
neomycin-polymy-dexameth
.......................................... 47
neomycin-polymyxin-gramici
din ..................................... 48
(ophth) .............................. 47
.................................... 52, 53
NEORAL ........................... 45
see cyclosporine modified
(for microemulsion) ....... 45
see gengraf ................... 45
NEOSPORIN
see
neomycin-polymyxin-grami
cidin............................... 48
NEPHRAMINE .................. 46
NEPTAZANE
see methazolamide ....... 22
NEUPOGEN ..................... 43
NEUPRO .......................... 28
NEURONTIN
see gabapentin.............. 25
NEVIRAPINE SUSP 50
MG/5ML ............................ 11
nevirapine tab 100mg ....... 11
nevirapine tab 200mg ....... 11
nevirapine tb24 ................. 12
NEXAVAR ........................ 17
NEXIUM
see esomeprazole
magnesium ................... 42
NEXIUM GRA 10MG DR .. 42
NEXIUM GRA 2.5MG DR . 42
NEXIUM GRA 5MG DR .... 42
NEXIUM I.V.
see esomeprazole sodium
inj .................................. 42
niacin er (antihyperlipidemic)
.......................................... 20
niacor ................................ 20
NIASPAN
see niacin er
(antihyperlipidemic) ....... 20
nicardipine hcl ................... 21
NICOTROL INHALER....... 33
NICOTROL NS ................. 33
nifedical ............................ 21
nifedipine .......................... 21
nifedipine er ...................... 21
nikki 28 day ....................... 37
NILANDRON .................... 16
nilutamide ......................... 16
nimodipine ........................ 21
NINLARO .......................... 16
NIPENT ............................ 15
69
2017 SSI Plus 17256 v6 eff 01/01/2017
nitro-bid .............................23
NITRO-DUR
see minitran ...................23
..........................................23
..........................................23
nitrofurantoin macrocrystal 10
nitrofurantoin monohyd
macro ................................10
nitroglycerin td patch .........23
NITROSTAT......................23
NIZORAL
see ketoconazole
shampoo........................51
NORA-BE TAB 0.35MG ....37
NORCO
see hydroco/apap tab
10-325mg ........................8
5-325mg ..........................8
7.5-325mg .......................8
see lorcet plus tab 7.5-325
........................................8
see lorcet tab 5-325mg ....8
see lortab tab 10-325mg..8
see lortab tab 5-325mg ...8
see lortab tab 7.5-325 .....8
NORDITROPIN FLEXPRO
..........................................39
norethindrone
(contraceptive) ..................37
norethindrone acetate .......40
norethindrone acetate-ethinyl
estradiol ............................38
norgest/ethi tab 0.25/35 ....37
norgestimate-ethinyl
estradiol (triphasic) ............37
NORINYL 1+35
see cyclafem 1/35 28 day
......................................36
see necon 1/35 28 day ..37
see nortrel 1/35 21 day ..37
see nortrel 1/35 28 day ..37
see pirmella 1/35 28 day
......................................37
norlyroc 28 day .................37
NORMOSOL-M IN D5W ... 47
NORMOSOL-R ................. 47
NORMOSOL-R IN D5W.... 47
NORPACE
see disopyramide
phosphate ..................... 20
NORPACE CR .................. 20
NORPRAMIN
see desipramine hcl ...... 26
NOR-QD
see camila 28 day ......... 36
see deblitane 28 day ..... 36
see heather ................... 36
see norethindrone
(contraceptive) .............. 37
see norlyroc 28 day ....... 37
NORTHERA...................... 23
nortrel 0.5/35 28 day ......... 37
nortrel 1/35 21 day ............ 37
nortrel 1/35 28 day ............ 37
nortrel 7/7/7 28 day ........... 37
nortriptyline hcl .................. 27
NORVASC
see amlodipine besylate 21
NORVIR ............................ 12
NOVOLIN 70/30 ................ 34
NOVOLIN N ...................... 34
NOVOLIN R ...................... 34
NOVOLOG........................ 34
NOVOLOG FLEXPEN ...... 34
NOVOLOG MIX 70/30 ...... 34
NOVOLOG MIX 70/30
PREFILL ........................... 34
NOVOLOG PENFILL ........ 34
NOXAFIL .......................... 11
NUBAIN
see nalbuphine hcl .......... 7
NUEDEXTA ...................... 32
NULOJIX........................... 45
NULYTELY/FLAVOR
PACKS.............................. 41
see gavilyte-n ................ 41
see peg 3350-potassium
chloride-sod
bicarbonate-sod chloride
...................................... 41
see trilyte ....................... 42
NUPLAZID ........................ 29
nutrilipid inj 20%................ 46
NUVARING ....................... 37
NUVIGIL ........................... 33
nyamyc ............................. 51
NYMALIZE ........................ 21
nystatin ............................. 11
nystatin (mouth-throat)...... 52
nystatin (topical)................ 51
nystop ............................... 51
O
OCELLA TAB 3-0.03MG... 37
OCTAGAM ....................... 44
octreotide acetate ............. 39
OCUFEN
see flurbiprofen sodium . 48
OCUFLOX
see ofloxacin (ophth) ..... 48
ODEFSEY ........................ 12
ODOMZO ......................... 17
OFEV ................................ 50
ofloxacin (ophth) ............... 48
ofloxacin (otic) .................. 53
olanzapine .................. 29, 30
omega-3-acid ethyl esters 20
omeprazole cap 10mg ...... 42
ondansetron hcl ................ 40
ondansetron hcl inj............ 40
ondansetron hcl oral soln .. 40
ondansetron odt ................ 40
ONFI SOLN ...................... 25
ONFI TAB ......................... 25
OPANA ER (CRUSH
RESISTANT) ...................... 9
OPSUMIT ......................... 23
ORAP
see pimozide ................. 30
ORFADIN ......................... 38
ORKAMBI ......................... 50
orsythia 28 day ................. 37
ORTHO MICRONOR
see errin 28 day ............ 36
see lyza ......................... 37
see sharobel 28 day ...... 37
ORTHO TRI-CYCLEN
see norgestimate-ethinyl
estradiol (triphasic) ........ 37
70
2017 SSI Plus 17256 v6 eff 01/01/2017
see tri-linyah ..................37
see tri-previfem 28 day ..38
see tri-sprintec 28 day ...38
ORTHO TRI-CYCLEN LO
see norgestimate-ethinyl
estradiol (triphasic) ........37
see tri-lo marzia .............37
see tri-lo-estarylla ..........38
see tri-lo-sprintec 28 day
......................................38
ORTHO-CYCLEN
see estarylla tab 0.25-35
......................................36
see mono-linyah tab
0.25-35 ..........................37
see norgest/ethi tab
0.25/35 ..........................37
see previfem 28 day ......37
see sprintec 28 day .......37
ORTHO-NOVUM 7/7/7
see cyclafem 7/7/7 28 day
......................................36
see nortrel 7/7/7 28 day .37
OVCON-35
see balziva 28 day .........36
see briellyn 28 day ........36
see gildagia ...................36
see philith ......................37
see vyfemla 28 day .......38
see zenchent 28 day .....38
OVIDE
see malathion ................52
oxacillin sodium.................14
oxaliplatin ..........................18
OXANDRIN
see oxandrolone tab 10mg
......................................33
see oxandrolone tab
2.5mg ............................33
oxandrolone tab 10mg ......33
oxandrolone tab 2.5mg .....33
oxcarbazepine...................25
oxybutynin chloride ...........43
oxycodone hcl .....................9
OXYCODONE HCL ............9
oxycodone w/
acetaminophen 10-325mg ..9
oxycodone w/
acetaminophen 2.5-325mg . 9
oxycodone w/
acetaminophen 5-325mg .... 9
oxycodone w/
acetaminophen 7.5-325mg . 9
oxycodone w/
acetaminophen soln ............ 9
OXYCONTIN ...................... 9
P
pacerone ........................... 20
paclitaxel ........................... 16
PAMELOR
see nortriptyline hcl ....... 27
pamidronate disodium....... 35
PANRETIN........................ 52
pantoprazole sodium......... 42
paricalcitol ......................... 47
PARLODEL
see bromocriptine
mesylate ........................ 28
PARNATE
see tranylcypromine
sulfate............................ 27
paroex sol 0.12% .............. 52
paromomycin sulfate ......... 10
paroxetine hcl ................... 27
paser d/r............................ 12
PATADAY ......................... 48
PAXIL................................ 27
see paroxetine hcl ......... 27
PAZEO.............................. 48
PEDIAPRED
see pred sod pho sol
5mg/5ml ........................ 39
PEDIARIX ......................... 45
PEDVAX HIB .................... 45
PEG 3350/ELECTROLYTES
.......................................... 41
PEG 3350-KCL-SOD
BICARB-SOD
CHLORIDE-SOD SULFATE
.......................................... 41
peg 3350-potassium
chloride-sod bicarbonate-sod
chloride ............................. 41
PEGANONE ..................... 25
PEGASYS......................... 13
PEGASYS PROCLICK ..... 13
PENICILLIN G POT IN
DEXTROSE ...................... 14
penicillin g procaine .......... 14
penicillin g sodium ............ 14
penicillin v potassium ........ 14
penicilln gk inj 20mu ......... 14
penicilln gk inj 5mu ........... 14
PENTACEL ....................... 45
PENTAM 300 .................... 10
pentoxifylline ..................... 44
PEPCID
see famotidine tab ......... 41
PERCOCET
see endocet .................... 8
see oxycodone w/
acetaminophen 10-325mg
........................................ 9
see oxycodone w/
acetaminophen 2.5-325mg
........................................ 9
see oxycodone w/
acetaminophen 5-325mg 9
see oxycodone w/
acetaminophen 7.5-325mg
........................................ 9
see roxicet tab 5-325mg .. 9
PERIDEX
see chlorhexidine
gluconate (mouth-throat)
...................................... 52
see paroex sol 0.12%.... 52
see periogard ................ 52
perindopril erbumine ......... 19
periogard .......................... 52
permethrin ........................ 52
perphenazine .................... 30
pfizerpen-g ........................ 14
phenadoz .......................... 40
phenelzine sulfate ............. 27
phenergan ........................ 40
PHENERGAN
see promethazine hcl .... 41
phenobarbital .................... 25
phenobarbital sodium ....... 25
PHENOBARBITAL SODIUM
.......................................... 25
phenytek ........................... 25
PHENYTEK
71
2017 SSI Plus 17256 v6 eff 01/01/2017
see phenytoin sodium
extended........................25
phenytoin ..........................25
phenytoin sodium ..............25
..........................................25
philith ................................37
PHOSLO
see calcium acetate
(phosphate binder) ........40
PHOSPHOLINE IODIDE ...49
PILOCARPINE HCL ..........49
pilocarpine hcl (oral) ..........52
PILOCARPINE HCL (ORAL)
..........................................52
pimozide............................30
pimtrea pack .....................37
pindolol .............................21
pioglitazone hcl .................35
piperacillin
sodium-tazobactam sodium
..........................................15
pirmella 1/35 28 day ..........37
PLAN B ONE-STEP
see levonorgestrel
(emergency oc) .............37
PLAQUENIL
see hydroxychloroquine
sulfate ............................44
PLASMA-LYTE A ..............47
PLASMA-LYTE-148 ..........47
PLASMA-LYTE-56/D5W ...47
PLAVIX
see clopidogrel bisulfate 44
podofilox............................52
polyethylene glycol 3350 ...42
polymyxin b-trimethoprim ..48
POLYTRIM
see polymyxin
b-trimethoprim ...............48
POMALYST CAP 1MG .....44
portia 28 day .....................37
pot chloride inj 2meq/ml ....47
potassium chloride ............46
POTASSIUM CHLORIDE 46,
47
potassium chloride in nacl. 47
potassium chloride
microencapsulated crystals
cr ....................................... 46
POTASSIUM CITRATE
(ALKALINIZER) ................ 43
POTIGA ............................ 25
PRADAXA......................... 43
PRALUENT ....................... 20
pramipexole tab 0.125mg . 28
pramipexole tab 0.25mg ... 28
pramipexole tab 0.5mg ..... 28
pramipexole tab 0.75mg ... 28
pramipexole tab 1.5mg ..... 28
pramipexole tab 1mg ........ 28
PRANDIN
see repaglinide .............. 35
PRAVACHOL
see pravastatin sodium . 20
pravastatin sodium ............ 20
prazosin hcl ....................... 19
PRECOSE
see acarbose ................. 34
pred sod pho sol 5mg/5ml. 39
PREDNISOLONE ACETATE
(OPHTH) ........................... 48
prednisolone sodium
phosphate (ophth) ............. 48
.......................................... 39
.......................................... 39
prednisolone syrup 15
mg/5ml .............................. 39
prednisone con 5mg/ml..... 39
prednisone pak 10mg ....... 39
prednisone pak 5mg ......... 39
prednisone sol 5mg/5ml .... 39
prednisone tab 10mg ........ 39
prednisone tab 1mg .......... 39
prednisone tab 2.5mg ....... 39
prednisone tab 5mg .......... 39
premasol 10% ................... 46
premasol 6% ..................... 46
prenatal vitamin/folic acid >
0.8 mg (generic)................ 47
prevalite ............................ 20
previfem 28 day ................ 37
PREZCOBIX ..................... 12
PREZISTA ........................ 12
PRIFTIN............................ 12
PRILOSEC
see omeprazole cap 10mg
...................................... 42
...................................... 42
...................................... 42
PRIMAQUINE PHOSPHATE
.......................................... 11
PRIMAXIN IV
see imipenem-cilastatin . 10
primidone .......................... 25
PRINIVIL
see lisinopril .................. 18
PRISTIQ ........................... 27
PRIVIGEN ........................ 44
probenecid .......................... 7
PROCALAMINE................ 46
PROCARDIA XL
see nifedical .................. 21
see nifedipine er ............ 21
prochlorperazine inj .......... 40
prochlorperazine maleate . 40
prochlorperazine supp ...... 40
PROCRIT ......................... 43
procto-med ....................... 51
procto-pak ......................... 51
proctosol hc cre 2.5% ....... 51
proctozone hc ................... 51
PROGLYCEM SUS
50MG/ML .......................... 39
PROGRAF ........................ 45
see tacrolimus ............... 45
PROLASTIN-C.................. 50
PROLENSA ...................... 49
PROLEUKIN ..................... 16
PROLIA ............................ 39
PROMACTA ..................... 44
promethazine hcl .............. 41
promethegan .................... 41
propafenone hcl ................ 20
propafenone hcl 12hr ........ 20
72
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proparacaine hcl ...............49
propranolol cap er .............21
propranolol hcl ..................21
propranolol oral sol ...........21
propylthiouracil ..................40
PROQUAD ........................45
PROSCAR
see finasteride ...............43
PROSOL ...........................46
PROTONIX
see pantoprazole sodium
......................................42
PROTOPIC
see tacrolimus (topical)..52
protriptyline hcl ..................27
PROVERA
see medroxyprogesterone
acetate tab.....................40
PROZAC
see fluoxetine cap 10mg27
PULMICORT
see budesonide
(inhalation).....................50
PULMICORT FLEXHALER
..........................................50
PULMOZYME ...................50
PURIXAN ..........................15
pyrazinamide.....................12
pyridostigmine tab 60mg ...32
Q
QUADRACEL....................45
QUALAQUIN
see quinine sulfate ........11
quasense 91 day...............37
QUESTRAN
see cholestyramine .......20
QUESTRAN LIGHT
see prevalite ..................20
quetiapine fumarate ..........30
quinapril hcl .......................19
quinapril-hydrochlorothiazide
..........................................18
quinidine gluconate ...........20
quinidine sulfate ................20
quinine sulfate ...................11
R
RABAVERT ...................... 45
raloxifene tab 60mg .......... 39
ramipril .............................. 19
RANEXA ........................... 23
ranitidine hcl...................... 41
ranitidine hcl inj ................. 41
ranitidine syrup ................. 41
RAPAMUNE ..................... 45
see sirolimus ................. 45
RAVICTI............................ 38
RAZADYNE
see galantamine
hydrobromide ................ 26
RAZADYNE ER
see galantamine
hydrobromide er ............ 26
REBETOL
see ribasphere .............. 13
see ribavirin cap 200mg 13
REBETOL SOL 40MG/ML 13
RECLAST
see zoledronic acid........ 35
reclipsen 28 day ................ 37
RECOMBIVAX HB ............ 45
REGLAN
see metoclopramide hcl 40
REGRANEX...................... 52
RELENZA DISKHALER .... 13
RELISTOR ........................ 42
REMERON
see mirtazapine ............. 27
REMERON SOLTAB
see mirtazapine ............. 27
REMICADE INJ 100MG .... 44
REMODULIN .................... 23
RENVELA PAK 0.8GM ..... 40
RENVELA PAK 2.4GM ..... 40
RENVELA TAB 800MG .... 40
repaglinide ........................ 35
REQUIP
see ropinirole tab 0.25mg
...................................... 28
see ropinirole tab 0.5mg 28
see ropinirole tab 1mg ... 28
RESCRIPTOR .................. 12
RESTASIS ........................ 49
RESTORIL
see temazepam............. 32
RETIN-A
see tretinoin .................. 50
RETROVIR
see zidovudine .............. 12
RETROVIR IV INFUSION . 12
REVATIO .......................... 23
see sildenafil citrate
(pulmonary hypertension)
...................................... 23
REVLIMID ......................... 45
REXULTI .......................... 30
REYATAZ ......................... 12
ribasphere......................... 13
ribavirin cap 200mg .......... 13
ribavirin tab 200mg ........... 13
rifabutin ............................. 12
RIFADIN
see rifampin .................. 12
rifampin ............................. 12
RIFATER .......................... 12
RILUTEK
see riluzole .................... 32
riluzole .............................. 32
rimantadine hydrochloride 13
RINGER'S......................... 47
RISPERDAL
see risperidone.............. 30
RISPERDAL INJ 12.5MG . 30
RISPERDAL INJ 25MG .... 30
RISPERDAL INJ 37.5MG . 30
RISPERDAL INJ 50MG .... 30
RISPERDAL M-TAB
see risperidone.............. 30
risperidone ........................ 30
RITALIN
see methylphenidate hcl 31
RITUXAN .......................... 16
rivastigmine tartrate .......... 26
rizatriptan benzoate .......... 32
ROBINUL
see glycopyrrolate ......... 41
ROBINUL FORTE
see glycopyrrolate ......... 41
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ROCALTROL
see calcitriol...................47
see calcitriol oral soln 1
mcg/ml ...........................47
ROCEPHIN
see ceftriaxone sodium..13
ropinirole tab 0.25mg ........28
ropinirole tab 0.5mg ..........28
ropinirole tab 1mg .............28
rosadan cre 0.75% ............52
ROTARIX ..........................45
ROTATEQ.........................45
ROWASA
see mesalamine w/
cleanser .........................41
roweepra ...........................25
ROXICET
see oxycodone w/
acetaminophen soln ........9
roxicet soln ..........................9
roxicet tab 5-325mg ............9
ROXICODONE
see oxycodone hcl ...........9
RYTHMOL
see propafenone hcl ......20
RYTHMOL SR
see propafenone hcl 12hr
......................................20
S
SABRIL .............................25
SALAGEN
see pilocarpine hcl (oral)
......................................52
SANDIMMUNE .................45
see cyclosporine............45
SANDOSTATIN
see octreotide acetate ...39
SANDOSTATIN LAR
DEPOT .............................39
SANTYL ............................52
SAPHRIS ..........................30
SECTRAL
see acebutolol hcl ..........21
selegiline hcl .....................28
selenium sulfide ................ 51
SELZENTRY..................... 12
SENSIPAR........................ 35
SEREVENT DISKUS ........ 49
SEROQUEL
see quetiapine fumarate 30
SEROQUEL XR ................ 30
sertraline hcl ..................... 27
setlakin tab........................ 37
sharobel 28 day ................ 37
SIGNIFOR ........................ 39
sildenafil citrate (pulmonary
hypertension) .................... 23
SILENOR .................... 31, 32
SILVER SULFADIAZINE .. 51
SIMBRINZA ...................... 49
simvastatin ........................ 20
SINEMET
see carbidopa-levodopa 28
SINEMET CR
see carbidopa-levodopa 28
SINGULAIR
see montelukast sodium 49
sirolimus............................ 45
SIRTURO.......................... 12
SIVEXTRO........................ 11
SOD CHLORIDE INJ 0.9%
.......................................... 47
SODIUM CHLORIDE .. 46, 47
VIA .................................... 47
.......................................... 52
sodium fluoride chew; tab;
1.1 (0.5 f) mg/ml soln ........ 46
sodium phenylbutyrate ...... 38
.................................... 35, 36
SOLTAMOX ...................... 16
SOLU-CORTEF ................ 39
SOLU-MEDROL
see methylpr ss inj 1gm. 39
see methylpr ss inj 40mg
...................................... 39
see methylprednisolone
sod succ ........................ 39
SOMATULINE DEPOT ..... 39
SOMAVERT ...................... 39
SORIATANE
see acitretin ................... 51
sorine ................................ 20
sotalol hcl .......................... 20
sotalol hcl (afib/afl) ............ 20
SOVALDI .......................... 13
spironolactone .................. 19
spironolactone &
SPORANOX
see itraconazole ............ 11
sprintec 28 day ................. 37
SPRITAM .......................... 25
SPRYCEL ......................... 17
sps susp 15gm/60ml ......... 36
sronyx 28 day ................... 37
SSD .................................. 51
STARLIX
see nateglinide .............. 35
stavudine .......................... 12
STERILE WATER
IRRIGATION ..................... 52
STIMATE .......................... 40
STIVARGA ....................... 17
STRATTERA .................... 31
streptomycin sulfate .......... 10
STRIBILD ......................... 12
STROMECTOL
see ivermectin ............... 10
SUBOXONE MIS 12-3MG 33
SUBOXONE MIS 2-0.5MG
.......................................... 33
SUBOXONE MIS 4-1MG .. 33
SUBOXONE MIS 8-2MG .. 33
SUCRAID ......................... 42
sucralfate .......................... 42
sulfacet sod oin 10% op .... 48
sulfacetamide sodium (acne)
.......................................... 50
sulfacetamide sodium
(ophth) .............................. 48
sulfacetamide
sod-prednisolone .............. 47
sulfadiazine ....................... 10
sulfamethoxazole-trimethop
ds ...................................... 11
m inj .................................. 11
74
2017 SSI Plus 17256 v6 eff 01/01/2017
m susp ..............................11
m tab .................................11
SULFAMYLON..................51
sulfasalazine .....................41
sulfasalazine ec ................41
sulindac ...............................7
SUMATRIPTAN INJ
4MG/0.5ML .......................32
sumatriptan inj 6mg/0.5ml .32
SUMATRIPTAN NASAL
SPRAY ..............................32
sumatriptan succinate .......32
suprax ...............................13
SUPRAX ...........................13
see cefixime ..................13
SUPREP BOWEL PREP...42
SURMONTIL
see trimipramine maleate
......................................27
SUSTIVA...........................12
SUTENT............................17
syeda ................................37
SYLATRON KIT 200MCG .17
SYMBICORT.....................50
SYMLINPEN 120 ..............34
SYMLINPEN 60 ................34
SYNAGIS ..........................45
SYNALAR
see fluocinolone acetonide
......................................51
SYNAREL .........................38
SYNERCID .......................11
SYNRIBO ..........................18
SYNTHROID .....................40
see levothyroxine sodium
......................................40
SYPRINE ..........................36
T
TABLOID...........................16
tacrolimus..........................45
tacrolimus (topical) ............52
TAFINLAR.........................17
TAGRISSO .......................17
TAMIFLU...........................13
tamoxifen citrate ............... 16
tamsulosin hcl ................... 43
TAPAZOLE
see methimazole ........... 40
TARCEVA ......................... 17
TARGRETIN ..................... 52
see bexarotene ............. 17
tarina fe 1/20 28 day ......... 37
TASIGNA .......................... 17
tazicef ............................... 13
tazicef vial ......................... 13
TAZORAC......................... 51
taztia ................................. 21
TECENTRIQ ..................... 16
TEFLARO ......................... 13
TEGRETOL ...................... 25
see epitol ....................... 24
TEGRETOL-XR ................ 25
temazepam ....................... 32
TENIVAC .......................... 45
TENORETIC 100
see atenolol &
chlorthalidone ................ 21
TENORETIC 50
see atenolol &
chlorthalidone ................ 21
TENORMIN
see atenolol ................... 21
TERAZOL 3
see terconazole vaginal. 43
TERAZOL 7
see terconazole vaginal. 43
terazosin hcl ...................... 19
terbinafine hcl ................... 11
terbutaline sulfate ............. 49
terconazole vaginal ........... 43
testosterone cypionate ...... 33
testosterone enanthate ..... 33
TETANUS/DIPHTHERIA
TOXOID ............................ 45
TETRABENAZINE ............ 32
THALOMID ....................... 45
theophylline....................... 50
thioridazine hcl .................. 30
thiothixene ........................ 30
tiagabine hcl...................... 25
TIAZAC
see diltiazem cap .......... 21
see taztia ....................... 21
timolol maleate ................. 21
timolol maleate (ophth) soln
.......................................... 49
TIMOLOL MALEATE GEL 49
TIMOPTIC
see timolol maleate
(ophth) soln ................... 49
TIVICAY............................ 12
tizanidine hcl ..................... 33
TOBI
see tobramycin .............. 10
TOBRADEX ...................... 47
see
tobramycin-dexamethason
e .................................... 48
TOBRADEX ST ................ 48
tobramycin ........................ 10
tobramycin (ophth) ............ 48
tobramycin inj 1.2 gm/30ml
.......................................... 10
tobramycin inj 1.2gm......... 10
tobramycin inj 10mg/ml ..... 10
tobramycin inj 40mg/ml ..... 10
tobramycin inj 80mg/2ml ... 10
tobramycin-dexamethasone
.......................................... 48
TOBREX ........................... 48
see tobramycin (ophth) . 48
TOFRANIL
see imipramine hcl ........ 27
tolterodine tartrate cap er.. 43
tolterodine tartrate tabs ..... 43
TOPAMAX
see topiramate .............. 25
TOPAMAX SPRINKLE
see topiramate .............. 25
topiramate ......................... 25
toposar.............................. 18
topotecan hcl .................... 18
TOPOTECAN HCL ........... 18
TOPROL XL
see metoprolol succinate
...................................... 21
torsemide tabs .................. 22
TOUJEO SOLOSTAR....... 34
75
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TOVIAZ .............................43
TPN ELECTROLYTES .....46
tramadol hcl ........................7
tramadol-acetaminophen ....8
trandolapril ........................19
tranexamic acid .................44
TRANSDERM-SCOP ........41
TRANXENE T
see clorazepate
dipotassium ...................24
tranylcypromine sulfate .....27
TRAVASOL .......................46
TRAVATAN Z....................49
trazodone hcl ....................27
TREANDA .........................15
TRECATOR ......................12
TRELSTAR DEP INJ
3.75MG .............................16
TRELSTAR LA INJ 11.25MG
..........................................16
TRESIBA FLEXTOUCH ....34
tretinoin .............................50
TRETINOIN.......................50
tretinoin (chemotherapy) ...18
(mouth) .............................52
(topical) .............................52
triamterene &
triamterene &
37.5-25 mg ........................22
TRICOR
see fenofibrate...............20
triderm ...............................52
trifluoperazine hcl ..............30
trifluridine ..........................48
tri-legest 28 day ................37
TRILEPTAL
see oxcarbazepine ........25
tri-linyah ............................37
tri-lo marzia .......................37
tri-lo-estarylla ....................38
tri-lo-sprintec 28 day .........38
trilyte .................................42
trimethoprim ......................11
trimipramine maleate ........27
TRINESSA ........................ 38
TRINESSA LO TAB .......... 38
TRI-NORINYL 28
see aranelle 28 .............. 36
TRINTELLIX ..................... 28
tri-previfem 28 day ............ 38
TRISENOX ....................... 18
tri-sprintec 28 day ............. 38
TRIUMEQ ......................... 12
trivora 28 day .................... 38
TRIZIVIR
see abacavir
sulfate-lamivudine-zidovud
ine ................................. 12
TROPHAMINE INJ 10% ... 46
trospium chloride .............. 43
TRULICITY ....................... 34
TRUMENBA...................... 45
TRUSOPT
see dorzolamide hcl ...... 48
TRUVADA TAB 100-150... 12
TWINRIX INJ .................... 46
TYBOST ........................... 12
TYGACIL .......................... 11
TYKERB ........................... 17
TYLENOL/CODEINE #3
see acetaminophen w/
codeine............................ 7
TYLENOL/CODEINE #4
see acetaminophen w/
codeine............................ 7
TYPHIM VI ........................ 46
TYSABRI .......................... 33
TYZEKA ............................ 13
U
ULORIC .............................. 7
ULTRACET
see
tramadol-acetaminophen. 8
ULTRAM
see tramadol hcl .............. 7
ULTRAVATE
see halobetasol
propionate ..................... 51
UNASYN
see ampicillin & sulbactam
sodium .......................... 14
UNASYN BULK PACK
see ampicillin & sulbactam
sodium .......................... 14
UPTRAVI .......................... 23
URECHOLINE
see bethanechol chloride
...................................... 43
UROXATRAL
see alfuzosin hcl............ 42
URSO 250
see ursodiol ................... 42
URSO FORTE
see ursodiol ................... 42
ursodiol ............................. 42
V
VAGIFEM ......................... 38
valacyclovir hcl.................. 13
VALCHLOR ...................... 52
VALCYTE ......................... 13
see valganciclovir hcl .... 13
valganciclovir hcl............... 13
VALIUM
see diazepam ................ 24
valproate sodium .............. 26
valproic acid ...................... 26
valsartan ........................... 20
160-12.5mg ...................... 19
160-25mg ......................... 19
320-12.5mg ...................... 19
320-25mg ......................... 19
80-12.5mg ........................ 19
VALTREX
see valacyclovir hcl ....... 13
VANCOCIN HCL
see vancomycin hcl ....... 11
vancomycin hcl ................. 11
VANCOMYCIN IN NACL .. 11
VANDAZOLE .................... 43
VAQTA ............................. 46
VARIVAX .......................... 46
VASCEPA ......................... 20
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VASERETIC
see enalapril maleate &
VASOTEC
see enalapril maleate ....18
VELCADE .........................16
velivet 28 day ....................38
VENCLEXTA.....................16
VENCLEXTA STARTING
PACK ................................16
venlafaxine hcl ..................28
VENTAVIS ........................23
VENTOLIN HFA ................49
verapamil cap er ...............21
VERAPAMIL CAP ER .......21
verapamil hcl ...............21, 22
verapamil tab er ................22
VERELAN
see verapamil cap er .....21
VERELAN PM
see verapamil cap er .....21
VERSACLOZ ....................30
VESICARE ........................43
vestura ..............................38
VFEND
see voriconazole ...........11
VFEND IV
see voriconazole ...........11
VIBRAMYCIN
see doxycycline hyclate .15
VICOPROFEN
see
7.5-200mg .......................8
VICTOZA ..........................34
VIDAZA
see azacitidine...............15
VIDEX EC
see didanosine ..............11
VIDEX PEDIATRIC ...........12
vienva 28 day ....................38
VIGAMOX .........................48
VIIBRYD STARTER PACK
..........................................28
VIIBRYD TAB....................28
VIMPAT.............................26
vinblastine sulfate .............16
vincasar.............................16
vincristine sulfate .............. 16
vinorelbine tartrate ............ 16
viorele ............................... 38
VIRACEPT ........................ 12
VIRAMUNE
see nevirapine tab 200mg
...................................... 11
VIRAMUNE XR
see nevirapine tab 100mg
...................................... 11
see nevirapine tb24 ....... 12
VIREAD ............................ 12
VIROPTIC
see trifluridine ................ 48
VISTARIL
see hydroxyzine pamoate
...................................... 49
VITEKTA ........................... 12
VOLTAREN GEL 1% ........ 52
voriconazole ...................... 11
VOTRIENT........................ 17
VRAYLAR ......................... 30
VRAYLAR THERAPY PACK
.......................................... 30
vyfemla 28 day.................. 38
W
warfarin sodium ................ 43
WELCHOL ........................ 20
WELLBUTRIN SR
see bupropion hcl .......... 26
WELLBUTRIN XL
see bupropion hcl .......... 26
X
XALATAN
see latanoprost .............. 48
XALKORI .......................... 17
XANAX
see alprazolam tab
0.25mg .......................... 23
see alprazolam tab 0.5mg
...................................... 23
see alprazolam tab 1mg 23
see alprazolam tab 2 mg
...................................... 23
XARELTO ......................... 43
XARELTO STARTER PACK
.......................................... 43
XELJANZ .......................... 44
XELJANZ XR .................... 44
XGEVA ............................. 40
XIFAXAN .......................... 42
XIGDUO XR TAB
10-1000MG ....................... 35
.......................................... 35
.......................................... 35
.......................................... 35
XOLAIR ............................ 50
XOPENEX HFA ................ 49
XTANDI ............................ 16
xulane ............................... 38
XYLOCAINE
see lidocaine hcl............ 52
see lidocaine hcl (local
anesth.) ........................... 9
see lidocaine inj 1% ........ 9
see lidocaine inj 2% ...... 10
XYLOCAINE-MPF
see lidocaine hcl (local
anesth.) ........................... 9
see lidocaine inj 0.5% ..... 9
see lidocaine inj 1.5% ... 10
XYREM ............................. 33
XYZAL
see levocetirizine
dihydrochloride .............. 49
Y
YASMIN 28
see drospirenone-ethinyl
estradiol ........................ 36
see syeda ...................... 37
see zarah ...................... 38
YAZ
see drospirenone-ethinyl
estradiol ........................ 36
see loryna 28 day .......... 37
see nikki 28 day ............ 37
see vestura ................... 38
YERVOY ........................... 16
YF-VAX ............................. 46
Z
zafirlukast ......................... 49
ZANAFLEX
see tizanidine hcl........... 33
77
2017 SSI Plus 17256 v6 eff 01/01/2017
ZANTAC
see ranitidine hcl ...........41
see ranitidine hcl inj .......41
zarah .................................38
ZARONTIN
see ethosuximide ..........24
ZAVESCA .........................38
ZAZOLE CREAM 0.8% .....43
ZEBETA
see bisoprolol fumarate .21
ZELBORAF .......................17
ZEMAIRA ..........................50
ZEMPLAR
see paricalcitol...............47
zenatane ...........................51
zenchent 28 day................38
ZENPEP............................42
ZERIT
see stavudine ................12
ZESTORETIC
see lisinopril &
ZESTRIL
see lisinopril...................18
ZETIA ................................20
ZIAC
see bisoprolol &
ZIAGEN.............................12
see abacavir sulfate ......11
zidovudine .........................12
ZINACEF
see cefuroxime sodium..13
ZINECARD
see dexrazoxane ........... 18
ziprasidone hcl .................. 30
ZIRGAN ............................ 48
ZITHROMAX
see azithromycin ........... 14
ZOCOR
see simvastatin ............. 20
ZOFRAN
see ondansetron hcl ...... 40
see ondansetron hcl inj . 40
see ondansetron hcl oral
soln................................ 40
ZOFRAN ODT
see ondansetron odt...... 40
zoledronic acid .................. 35
zoledronic inj 4mg/5ml ...... 35
ZOLINZA........................... 16
zolmitriptan ....................... 32
zolmitriptan odt ................. 32
ZOLOFT
see sertraline hcl ........... 27
zolpidem tartrate ............... 32
ZOMETA
see zoledronic inj 4mg/5ml
...................................... 35
ZOMIG
see zolmitriptan ............. 32
ZOMIG ZMT
see zolmitriptan odt ....... 32
ZONEGRAN
see zonisamide ............. 26
zonisamide........................ 26
ZONTIVITY ....................... 44
ZORTRESS TAB 0.25MG . 45
ZORTRESS TAB 0.5MG .. 45
ZORTRESS TAB 0.75MG 45
ZOSTAVAX ...................... 46
ZOSYN
see piperacillin
sodium-tazobactam
sodium .......................... 15
zovia 1/35e 28 day............ 38
zovia 1/50e 28 day............ 38
ZOVIRAX
see acyclovir ................. 12
ZYBAN
see buproban ................ 33
see bupropion hcl
(smoking deterrent) ....... 33
ZYDELIG .......................... 17
ZYKADIA .......................... 17
ZYLET .............................. 48
ZYLOPRIM
see allopurinol tab ........... 7
ZYMAXID
see gatifloxacin (ophth) . 48
ZYPREXA
see olanzapine ........ 29, 30
ZYPREXA RELPREVV ..... 30
ZYPREXA RELPREVV
210MG .............................. 30
ZYPREXA ZYDIS
see olanzapine .............. 30
ZYTIGA............................. 17
ZYVOX
see linezolid .................. 10
78
P.O. Box 52424 Phoenix, AZ 85072-2424
This formulary was updated on August 1, 2016. For more recent information or other questions,
please contact SilverScript at 1-866-235-5660 or, for TTY users, 711, 24 hours a day, 7 days a
week, or visit www.silverscript.com.
The Formulary may change at any time. You will receive notice when necessary.
This information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or
copayments/coinsurance may change on January 1 of each year.
This information is available for free in other languages. Please call our Customer Care number
at 1-866-235-5660 (TTY: 711), 24 hours a day, 7 days a week. Esta información está disponible
gratuitamente en otros idiomas. Llame a nuestro Cuidado al Cliente al 1-866-235-5660 (teléfono
de texto (TTY): 711), las 24 horas del día, los 7 días de la semana.
SilverScript is a Prescription Drug Plan with a Medicare contract offered by SilverScript
Insurance Company. Enrollment in SilverScript depends on contract renewal.

Comprehensive Formulary - Medicare Part D Plans

Transcription

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