2015 - Ohana Health Plan

Transcription


2015
Comprehensive Formulary
(List of Covered Drugs)
Medicare Advantage Plans
Please Read: This document contains
information about some of the drugs
we cover in this plan.
This formulary was updated on
08/01/2015. For more recent
information or other questions, please
contact WellCare/‘Ohana at the
telephone number listed on the inside
front and back covers of this formulary
or visit www.wellcare.com/medicare or
www.ohanahealthplan.com/medicare.
WellCare/‘Ohana Plans
WellCare Choice (HMO-POS)
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WellCare Dividend (HMO/HMO-POS)
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WellCare Essential (HMO/HMO-POS)
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WellCare Value (HMO/HMO-POS)
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WellCare Emerald Value (HMO)
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WellCare Gold Essential (HMO)
‘Ohana Value (HMO-POS)
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‘Ohana Choice (HMO-POS)
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excluding Connecticut and New York
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Y0070_NA026578_WCM_FOR_ENG_FINAL_03 CMS Approved 08042014
©WellCare 2015 NA_08_15
HPMS Approved
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Formulary File
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Submission ID: 15241
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Version Number: 15
NA5V03FOR59890E 0815
We’re always just a phone call away!
If you’re ready to enroll or have enrollment questions, call 1-877-817-5793,
8 a.m. to 8 p.m., 7 days a week.
If you’re already a member, call the number for your state/plan listed below.
Arkansas:
WellCare Emerald Value (HMO)............................................... 1-800-316-2273
Florida:
WellCare Choice, Dividend, Essential, Value
(HMO/HMO-POS) ......................................................................... 1-888-888-9355
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Georgia:
WellCare Value (HMO)................................................................. 1-866-334-7730
Hawai‘i:
‘Ohana Choice or Value (HMO-POS).................................... 1-888-505-1201
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Illinois:
WellCare Value (HMO-POS)...................................................... 1-866-334-6876
Kentucky:
WellCare Value (HMO-POS)..................................................... 1-877-560-2766
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Louisiana:
Mississippi:
WellCare Value or Gold Essential
(HMO/HMO-POS) ......................................................................... 1-800-316-2273
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New Jersey:
South Carolina:
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Tennessee:
WellCare Dividend or Emerald Value
(HMO/HMO-POS) ......................................................................... 1-800-316-2273
Texas:
WellCare Dividend or Value
(HMO/HMO-POS) ......................................................................... 1-866-687-8878
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Hours of operation are Monday–Friday, 8 a.m. to 8 p.m. Between October 1 and February 14,
representatives are available Monday–Sunday, 8 a.m. to 8 p.m., or visit us anytime at
www.wellcare.com/medicare or www.ohanahealthplan.com/medicare.
Nurse Advice Line .............................................................. 1-800-581-9952 (24 hours, 7 days a week)
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TTY for all of the above .........................................................................................................1-877-247-6272
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Note to existing members: This formulary has changed since last year. Please review this
document to make sure that it still contains the drugs you take. When this drug list (formulary)
refers to “we,” “us” or “our,” it means WellCare/‘Ohana. When it refers to “plan” or “our plan,” it
means WellCare/‘Ohana.
This document includes a list of the drugs (formulary) for our plan which is current as of
08/01/2015. For an updated formulary, please contact us. Our contact information along with
the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits,
formulary, pharmacy network, premium and/or co-payments/coinsurance may change on
January 1, 2016, and from time to time during the year.
What is the WellCare Choice (HMO-POS), WellCare Dividend (HMO/HMOPOS), WellCare Essential (HMO/HMO-POS), WellCare Value (HMO/HMO-POS),
WellCare Emerald Value (HMO), WellCare Gold Essential (HMO), ‘Ohana
Value (HMO-POS), and ‘Ohana Choice (HMO-POS) comprehensive formulary?
A formulary is a list of covered drugs. WellCare/‘Ohana selects the drugs by working with a
team of health care providers. The list contains the prescription medications we believe are a
necessary part of a quality treatment program. WellCare/‘Ohana will generally cover the drugs
listed in our formulary as long as:
1. the drug is medically necessary,
2. the prescription is filled at a/an WellCare/‘Ohana network pharmacy, and
3. other plan rules are followed.
For more information on how to fill your prescriptions, please see your Evidence of Coverage.
Can the formulary (drug list) change?
In general, if you are taking a drug on our 2015 formulary that was covered at the beginning
of the year, we will not stop or reduce coverage of the drug during the 2015 coverage year.
However, there are some cases when we may stop or reduce coverage. These are:
• when a new, less expensive generic drug becomes available or
• when new negative information about the safety or effectiveness of a drug is released.
Other types of formulary changes, such as removing a drug from our formulary, will not affect
members who are currently taking the drug. For those members, it will remain available at
the same cost share for the remainder of the coverage year. We think it’s important that you
can continue to get the formulary drugs that were available when you chose our plan for
the remainder of the coverage year. The only exceptions are for cases in which you can save
additional money or we can ensure your safety.
When we make certain changes to our formulary, we must notify the members who will be
affected by the changes. This includes if we:
• remove drugs from our formulary;
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• add restrictions on a drug such as prior authorization, quantity limits and/or step therapy;
• move a drug to a higher cost-sharing tier.
If we make any of these changes, we must notify affected members at least 60 days before the
change goes into effect. We will also notify the member at the time he or she asks for a refill
of the drug. In that case, the member will receive a 60-day supply of the drug.
If the Food and Drug Administration announces that a drug on our formulary is unsafe, or a
drug manufacturer removes a drug from the market, we will immediately remove the drug from
our formulary and notify members who take the drug.
The enclosed formulary is current as of 08/01/2015. To get updated information about the
drugs covered by WellCare/‘Ohana, please visit our website at www.wellcare.com/medicare or
www.ohanahealthplan.com/medicare or call Customer Service at the telephone number listed
for your state/plan on the inside front and back cover pages of this formulary.
Every month, we update our printed formulary with a monthly addendum. Please contact
Customer Service or visit our website at www.wellcare.com/medicare or
www.ohanahealthplan.com/medicare for more information.
How do I use the formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example, drugs
used to treat a heart condition are listed under the category “Cardiovascular Agents.” If you
know what your drug is used for, look for the category name in the list that begins on page 1.
Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index
that begins on page 87. The Index provides an alphabetical list of all of the drugs included in
this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the
Index and find your drug. Next to your drug, you will see the page number where you can find
coverage information. Turn to the page listed in the Index and find the name of your drug in
the first column of the list.
What are generic drugs?
WellCare/‘Ohana 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:
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•�Prior Authorization: WellCare/‘Ohana requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from us
before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
•�Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For
example, WellCare/‘Ohana provides 9 tablets for 30 days per prescription for sumatriptan
25mg. This may be in addition to a standard one-month or three-month supply.
•�Step Therapy: In some cases, WellCare/‘Ohana requires you to first try certain drugs to
treat your medical condition before we will cover another drug for that condition. For
example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B
unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the
formulary that begins on page 1. You can also get more information about the restrictions
applied to specific covered drugs by visiting our website at www.wellcare.com/medicare or
www.ohanahealthplan.com/medicare. We have posted online documents that explain our
prior authorization restriction and step therapy restrictions. You may also ask us to send you a
copy. Our contact information, along with the date we last updated the formulary, appears on
the front and back cover pages.
You can ask WellCare/‘Ohana to make an exception to these restrictions or limits, or for a list
of other, similar drugs that may treat your health condition. See the section, “How do I request
an exception to the WellCare/‘Ohana formulary?” on page IV for information about how to
request an exception.
What if my drug is not on the formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact
Customer Service and ask if your drug is covered. You can contact Customer Service at the
telephone number listed for your state/plan on the inside front and back covers of this
formulary.
If you learn that WellCare/‘Ohana does not cover your drug, you have two options:
• You can ask Customer Service for a list of similar drugs that are covered by
WellCare/‘Ohana. When you receive the list, show it to your doctor and ask him or her to
prescribe a similar drug that is covered by WellCare/‘Ohana.
• You can ask WellCare/‘Ohana to make an exception and cover your drug. See below for
information about how to request an exception.
Which vaccines do we cover?
Your prescription benefit may cover many vaccines. For details, see the Immunological Agents
section. The cost for vaccines varies, depending on the facility where you receive them. For
best coverage, use a network pharmacy.
All commercially available vaccines are covered under Part D, except for those that are covered
under Medicare Part B, such as influenza or pneumococcal vaccines.
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How do I request an exception to the WellCare Choice (HMO-POS), WellCare
Dividend (HMO/HMO-POS), WellCare Essential (HMO/HMO-POS), WellCare Value
(HMO/HMO-POS), WellCare Emerald Value (HMO), WellCare Gold Essential
(HMO), ‘Ohana Value (HMO-POS), and ‘Ohana Choice (HMO-POS) formulary?
You can ask WellCare/‘Ohana to make an exception to our coverage rules. There are several
types of formulary exceptions that you can ask us to make.
Initial Coverage Decision Exception
You can ask us to cover your drug even if it is not on our formulary. If your request is approved,
the drug will be covered at a pre-determined cost-sharing level. You would not be able to ask
us to provide the drug at a lower cost-sharing level.
Utilization Restriction Exception
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain
drugs, the amount of the drug that we cover is limited. If your drug has a quantity limit, you can
ask us to waive the limit and cover a greater amount.
Tiering Exception
You can ask us to cover a formulary drug at a lower cost-sharing level (if the drug is not on the
specialty tier). If approved, this would lower the amount you must pay for your drug.
Generally, WellCare/‘Ohana will only approve your request for an exception if:
• the alternative drugs included on the plan’s formulary would not be as effective in treating
your condition;
• the lower cost-sharing drug would not be as effective in treating your condition;
• the additional utilization restrictions would not be as effective in treating your condition
and/or;
• the alternative drugs would cause you to have adverse medical effects.
You should contact us to ask us for a formulary exception for an initial coverage decision,
a tiering exception or a utilization restriction exception. When you request any of these
exceptions, you should submit a statement from your prescriber or physician supporting
your request. Generally, we must make our decision within 72 hours of getting your prescribing
physician’s supporting statement. You can request an expedited (fast) exception if you or your
doctor believe that your health could be seriously harmed by waiting up to 72 hours for a
decision. If your request for a fast review is granted, we must give you a decision no later than
24 hours after we get your prescriber’s or prescribing physician’s supporting statement.
What do I do before I can talk to my doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan, you may be taking drugs that are not on our
formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is
limited. For example, you may need a prior authorization from us before you can fill your
prescription. You should talk to your doctor to decide if you should switch to an appropriate
drug that we cover, or request a formulary exception so that we will cover the drug you take.
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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 98-day transition supply that meets the dispensing instructions
(unless you have a prescription written for fewer days). We will cover more than one refill of
these drugs for the first 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 30-day emergency supply of that drug (unless you
have a prescription for fewer days) while you seek a formulary exception.
If you experience a level of care change (such as being discharged or admitted to a long-term
care facility), your physician or pharmacy can call our Provider Service Center and request a
one-time override. This one-time override will be up to a 30-day supply (unless you have a
prescription written for fewer days).
For more information
For more details about your WellCare/‘Ohana prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about WellCare/‘Ohana, please contact us. Our contact information is
on the inside front and back covers of this document. Or visit www.wellcare.com/medicare or
If you have general questions about Medicare prescription drug coverage, please call Medicare
at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call
1-877-486-2048. Or, visit www.medicare.gov.
WellCare/‘Ohana formulary
The comprehensive formulary that begins on page 1 provides coverage information about the
drugs covered by WellCare/‘Ohana. If you have trouble finding your drug in the list, turn to the
Index that begins on page 87.
The first column of the chart lists the drug name. Brand-name drugs are BOLD and UPPERCASE
(e.g., COUMADIN) and generic drugs are listed in lowercase italics (e.g., simvastatin).
The information in the Requirements/Limits column tells you if WellCare/‘Ohana has any
special requirements for coverage of your drug.
• MS means the drug is available by Mail Service (otherwise known as mail-order). Please see
Chapter 5 of your Evidence of Coverage for more information.**
• PA stands for Prior Authorization: Please see page III for details.
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• PA-BvsD stands for Prior Authorization Restriction for Part B vs. Part D Determination: This
drug may be eligible for payment under Medicare Part B or Part D. You (or your physician)
are required to get prior authorization from WellCare/‘Ohana to determine that this drug is
covered under Medicare Part D before you fill your prescription for this drug. Without prior
approval, WellCare/‘Ohana may not cover this drug.
• PA-NS stands for Prior Authorization Restriction for New Starts: This type of prior
authorization restriction will impact new starts to the drug. Members taking this medication
at the time of enrollment will not be required to meet prerequisites for prior authorization.
• QL stands for Quantity Limits: Please see page III for details.
• LA stands for Limited Access medication. This medication may be available from certain
other pharmacies. For more information, please refer to the Specialty Pharmacy section of
your Pharmacy Directory or contact Customer Service at the telephone number listed for
your state/plan on the inside front and back cover pages of this formulary.
• ST stands for Step Therapy: Please see page III for details.
• ST-NS stands for Step Therapy Restriction for New Starts: This type of step therapy
restriction will impact new starts to the drug. Members taking this medication at the time
of enrollment will not be required to meet prerequisites for step therapy.
• * = Drug may be available for up to a 30-day supply only.
** You can get prescription drugs shipped to your home through our network mail-service
delivery program. You should expect to receive your prescription drugs within 7–10 business
days from the time that the mail-service pharmacy receives the order. If you do not receive
your prescription drugs within this time, please contact us at the telephone number listed on
the inside front and back covers of this formulary or visit www.wellcare.com/medicare or
Drug tier co-payment/coinsurance amounts
The WellCare/‘Ohana formulary is divided into five tiers.
• Tier 1: Preferred Generic Drugs – Drugs that are available at the lowest cost share for this plan.
• Tier 2: Non-Preferred Generic Drugs – Drugs that WellCare/‘Ohana offers at a higher cost
to you than preferred generics.
• Tier 3: Preferred Brand Drugs – Drugs that WellCare/‘Ohana may be able to offer at a lower
cost to you than non-preferred brand drugs.
• Tier 4: Non-Preferred Brand Drugs – Drugs that WellCare/‘Ohana offers at a higher cost to
you than preferred brands.
• Tier 5: Specialty Drugs – Some injectables and other high-cost drugs. * Indicates specialty
drugs are available for up to a 30-day supply only.
Brand drugs may be available in Tiers 3, 4 and 5. Generic drugs are available in Tiers 1, 2 and 5.
Consult your Evidence of Coverage or Summary of Benefits for your applicable co-pays/
coinsurance and deductible amounts.
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How to read formulary listings:
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DRUG
TIER
DRUG NAME
REQUIREMENTS/LIMITS
Therapeutic Category
Anticonvulsants
Anticonvulsants, Other
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Therapeutic Class
phenobarbital elixir
2
PA-NS; MS
phenobarbital tablet
2
PA-NS; MS
POTIGA TABLET 50MG, 200MG, 300MG
5*
PA-NS; MS*
POTIGA TABLET 400MG
4
PA-NS; MS
Tier of Drug
* = Drug may be available for
up to a 30-day supply only
Name of Drug
BOLD UPPERCASE = Brand Drugs
lowercase italics = Generic Drugs
g
u
r
d
r
u
o
y
d
F in
e
qu ickly i n t h
e
I n d e x at t h o k.
bo
ba ck o f t h e
Requirements/Limits Codes:
LA = Limited Access
MS = Mail-Service Available
PA = Prior Authorization
PA-BvsD = Prior Authorization Part B vs.
Part D Only
PA-NS = Prior Authorization Restriction
for New Starts
QL = Quantity Limits
ST = Step Therapy
ST-NS = Step Therapy Restriction for
New Starts
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DRUG NAME
DRUG REQUIREMENTS / LIMITS
TIER
Analgesics
Analgesics
acetaminophen-codeine #2 oral tablet 300-15 mg
2
MS; QL (360 EA per 30 days)
2
2
acetaminophen-codeine oral solution 120-12 mg/5ml
2
MS; QL (4500 ML per 30 days)
butalbital-acetaminophen oral tablet 50-325 mg
2
PA; MS; QL (180 EA per 30 days)
butalbital-apap-caff-cod oral capsule 50-300-40-30
mg, 50-325-40-30 mg
2
butalbital-apap-caffeine oral capsule 50-300-40 mg,
50-325-40 mg
2
butalbital-apap-caffeine oral tablet 50-325-40 mg
2
butalbital-aspirin-caffeine oral capsule 50-325-40 mg
2
endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg
2
hydrocodone-acetaminophen oral solution 7.5-325
mg/15ml
2
hydrocodone-acetaminophen oral tablet 10-325 mg,
5-325 mg, 7.5-325 mg
2
hydrocodone-ibuprofen oral tablet 7.5-200 mg
2
lorcet hd oral tablet 10-325 mg
2
lorcet oral tablet 5-325 mg
2
lorcet plus oral tablet 7.5-325 mg
2
lortab oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg
2
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 5-325 mg, 7.5-325 mg
2
roxicet oral tablet 5-325 mg
2
tencon oral tablet 50-325 mg
2
tramadol-acetaminophen oral tablet 37.5-325 mg
Nonsteroidal Anti-Inflammatory Drugs
2
diclofenac potassium oral tablet 50 mg
2
MS
diclofenac sodium er oral tablet extended release 24 hr*
100 mg
2
You can find information on what the symbols and abbreviations in this table mean by going to page VII.
1
DRUG NAME
TIER
diclofenac sodium oral tablet delayed release 25 mg, 50
mg
2
MS
diclofenac sodium oral tablet delayed release 75 mg
2
diflunisal oral tablet 500 mg
2
MS
etodolac er oral tablet extended release 24 hr* 400 mg,
500 mg, 600 mg
2
MS
etodolac oral capsule 200 mg, 300 mg
2
MS
etodolac oral tablet 400 mg, 500 mg
2
MS
fenoprofen calcium oral tablet 600 mg
2
MS
flurbiprofen oral tablet 100 mg, 50 mg
2
MS
ibuprofen oral suspension 100 mg/5ml
2
MS
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
1
MS
indomethacin oral capsule 25 mg, 50 mg
2
ST; MS
ketoprofen er oral capsule extended release 24 hour
200 mg
2
ketoprofen oral capsule 50 mg, 75 mg
2
MS
meloxicam oral suspension 7.5 mg/5ml
2
MS
meloxicam oral tablet 15 mg
1
meloxicam oral tablet 7.5 mg
1
nabumetone oral tablet 500 mg, 750 mg
2
MS
naproxen dr oral tablet delayed release 375 mg, 500 mg
2
MS
naproxen oral suspension 125 mg/5ml
2
MS
naproxen oral tablet 250 mg, 375 mg, 500 mg
2
MS
naproxen sodium oral tablet 275 mg, 550 mg
2
MS
oxaprozin oral tablet 600 mg
2
MS
piroxicam oral capsule 10 mg, 20 mg
2
MS
sulindac oral tablet 150 mg, 200 mg
Opioid Analgesics, Long-Acting
2
MS
duramorph injection solution 0.5 mg/ml, 1 mg/ml
2
MS
fentanyl transdermal patch 72 hr 100 mcg/hr, 12
mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5
mcg/hr, 75 mcg/hr, 87.5 mcg/hr
2
2
DRUG NAME
TIER
methadone hcl injection solution 10 mg/ml
2
MS
methadone hcl oral solution 10 mg/5ml, 5 mg/5ml
2
MS
methadone hcl oral tablet 10 mg, 5 mg
1
morphine sulfate (concentrate) oral solution 20 mg/ml
2
MS
morphine sulfate (pf) injection solution 0.5 mg/ml, 1
mg/ml
2
MS
morphine sulfate (pf) intravenous* solution 8 mg/ml
2
MS
morphine sulfate er oral tablet extendedrelease* 100
mg, 15 mg, 200 mg, 30 mg, 60 mg
2
morphine sulfate injection solution 2 mg/ml
2
MS
morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml
2
MS
morphine sulfate oral tablet 15 mg, 30 mg
2
OPANA ER ORAL 10 MG, 15 MG, 20 MG, 30 MG, 40
MG, 5 MG, 7.5 MG
3
2
codeine sulfate oral tablet 15 mg, 30 mg
2
codeine sulfate oral tablet 60 mg
2
fentanyl citrate buccal lollipop 1200 mcg, 1600 mcg,
200 mcg, 400 mcg, 600 mcg, 800 mcg
5*
hydromorphone hcl oral liquid† 1 mg/ml
2
MS
hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg
2
hydromorphone hcl pf injection solution 1 mg/ml, 4
mg/ml, 500 mg/50ml
2
MS
LAZANDA NASAL SOLUTION 100 MCG/ACT, 400
MCG/ACT
5*
PA; MS
morphine sulfate (pf) intravenous* solution 2 mg/ml, 4
mg/ml
2
MS
oxycodone hcl oral concentrate 20 mg/ml
2
MS
oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg,
5 mg
2
tramadol hcl oral tablet 50 mg
1
oxymorphone hcl er oral tablet extended release 12 hr*
10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg
Opioid Analgesics, Short-Acting
3
DRUG NAME
TIER
Anesthetics
Local Anesthetics
lidocaine external ointment 5 %
2
MS
lidocaine hcl (cardiac) intravenous* solution 20 mg/ml
2
MS
lidocaine hcl (pf) injection solution 0.5 %, 1 %
2
MS
lidocaine hcl external 2 %
2
MS
lidocaine hcl external solution 4 %
1
MS
lidocaine hcl injection solution 2 %
2
MS
lidocaine viscous mouth/throat solution 2 %
1
MS
lidocaine-prilocaine external cream 2.5-2.5 %
2
MS; QL (60 GM per 30 days)
LIDODERM EXTERNAL PATCH 5 %
Anti-Addiction/ Substance Abuse Treatment Agents
3
acamprosate calcium oral tablet delayed release 333
mg
2
MS
disulfiram oral tablet 250 mg, 500 mg
2
MS
naltrexone hcl oral tablet 50 mg
Opioid Dependence Treatments
2
MS
buprenorphine hcl injection solution 0.3 mg/ml
2
PA-BvsD; MS
buprenorphine hcl sublingual tablet sublingual 2 mg, 8
mg
2
PA; MS
4
PA; MS
1
MS
CHANTIX CONTINUING MONTH PAK ORAL TABLET 1
MG
4
CHANTIX ORAL TABLET 0.5 MG, 1 MG
4
CHANTIX STARTING MONTH PAK ORAL TABLET 0.5
MG X 11 & 1 MG X 42
4
NICOTROL NS NASAL SOLUTION 10 MG/ML
3
MS
Alcohol Deterrents/ Anti-Craving
SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG,
4-1 MG, 8-2 MG
Opioid Reversal Agents
naloxone hcl injection solution 1 mg/ml
Smoking Cessation Agents
4
DRUG NAME
TIER
Antibacterials
Aminoglycosides
amikacin sulfate injection solution 500 mg/2ml
2
MS
gentak ophthalmic ointment 0.3 %
2
MS
gentamicin in saline intravenous* solution 0.8-0.9
mg/ml-%, 1-0.9 mg/ml-%, 1.6-0.9 mg/ml-%
2
MS
gentamicin sulfate external cream 0.1 %
1
MS
gentamicin sulfate external ointment 0.1 %
1
MS
gentamicin sulfate injection solution 40 mg/ml
2
MS
gentamicin sulfate intravenous* solution 10 mg/ml
2
MS
gentamicin sulfate ophthalmic ointment 0.3 %
2
MS
gentamicin sulfate ophthalmic solution 0.3 %
2
MS
neomycin sulfate oral tablet 500 mg
2
MS
neomycin-polymyxin b gu irrigation solution 40-200000
2
MS
paromomycin sulfate oral capsule 250 mg
2
MS
streptomycin sulfate intramuscular* solution
reconstituted 1 gm
2
MS
TOBI PODHALER INHALATION CAPSULE 28 MG
5*
tobramycin inhalation nebulization solution 300 mg/5ml
5*
PA; MS
tobramycin ophthalmic solution 0.3 %
2
MS
tobramycin sulfate injection solution 10 mg/ml, 80
mg/2ml
2
MS
2
MS
2
PA-BvsD; MS
5*
PA; MS
acetic acid otic solution 2 %
2
MS
baciim intramuscular* solution reconstituted 50000 unit
2
MS
tobramycin sulfate injection solution reconstituted 1.2
gm
Antibacterials
colistimethate sodium injection solution reconstituted
150 mg
SYNERCID INTRAVENOUS* SOLUTION
RECONSTITUTED 150-350 MG
Antibacterials, Other
5
DRUG NAME
TIER
bacitracin intramuscular* solution reconstituted 50000
unit
2
MS
bacitracin ophthalmic ointment 500 unit/gm
2
MS
chloramphenicol sod succinate intravenous* solution
reconstituted 1 gm
2
MS
clindacin pac external kit 1 %
2
MS
clindamax external 1 %
2
MS
clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg
1
MS
clindamycin phosphate external 1 %
2
MS
clindamycin phosphate external lotion 1 %
2
MS
clindamycin phosphate external solution 1 %
2
MS
clindamycin phosphate external swab 1 %
2
MS
clindamycin phosphate in d5w intravenous* solution
300 mg/50ml, 600 mg/50ml, 900 mg/50ml
2
MS
clindamycin phosphate intravenous* solution 600
mg/4ml
2
MS
clindamycin phosphate vaginal cream 2 %
2
MS
CUBICIN INTRAVENOUS* SOLUTION RECONSTITUTED
500 MG
5*
PA; MS
global alcohol prep ease pad 70 %
1
MS
linezolid intravenous* solution 2 mg/ml
5*
PA; MS
methenamine hippurate oral tablet 1 gm
2
MS
metronidazole external 0.75 %
2
MS
metronidazole external cream 0.75 %
2
MS
metronidazole external lotion 0.75 %
2
MS
metronidazole in nacl intravenous* solution 500-0.79
mg/100ml-%
2
MS
metronidazole oral tablet 250 mg, 500 mg
2
MS
metronidazole vaginal 0.75 %
2
MS
mupirocin calcium external cream 2 %
2
MS
mupirocin external ointment 2 %
2
MS
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg
2
6
DRUG NAME
TIER
nitrofurantoin monohyd macro oral capsule 100 mg
2
sivextro oral tablet 200 mg
5*
PA; MS
trimethoprim oral tablet 100 mg
2
MS
TYGACIL INTRAVENOUS* SOLUTION RECONSTITUTED
50 MG
5*
PA; MS
vancomycin hcl intravenous* solution reconstituted 10
gm, 1000 mg, 500 mg, 5000 mg, 750 mg
2
MS
vancomycin hcl oral capsule 125 mg, 250 mg
5*
PA; MS
vandazole vaginal 0.75 %
2
MS
XIFAXAN ORAL TABLET 200 MG, 550 MG
5*
ST; MS
ZYVOX ORAL SUSPENSION RECONSTITUTED 100
MG/5ML
5*
PA; MS
ZYVOX ORAL TABLET 600 MG
Beta-Lactam, Cephalosporins
5*
cefaclor oral capsule 250 mg, 500 mg
2
MS
cefadroxil oral capsule 500 mg
2
MS
cefadroxil oral suspension reconstituted 250 mg/5ml,
500 mg/5ml
2
MS
cefadroxil oral tablet 1 gm
2
MS
cefazolin sodium injection solution reconstituted 1 gm,
10 gm, 500 mg
2
MS
cefazolin sodium intravenous* solution 1-5 gm-%
2
MS
cefdinir oral capsule 300 mg
2
MS
cefdinir oral suspension reconstituted 125 mg/5ml, 250
mg/5ml
2
MS
cefepime hcl injection solution reconstituted 1 gm, 2 gm
2
MS
cefepime-dextrose intravenous* solution reconstituted 1
gm/50ml, 2 gm/50ml
2
MS
cefixime oral suspension reconstituted 100 mg/5ml, 200
mg/5ml
2
MS
cefotaxime sodium injection solution reconstituted 1
gm, 10 gm, 2 gm, 500 mg
2
MS
cefoxitin sodium injection solution reconstituted 10 gm
2
MS
7
DRUG NAME
TIER
cefoxitin sodium intravenous* solution reconstituted 1
gm, 2 gm
2
MS
cefoxitin sodium-dextrose intravenous* solution
reconstituted 1-4 gm-%, 2-2.2 gm-%
2
MS
cefpodoxime proxetil oral suspension reconstituted 100
mg/5ml, 50 mg/5ml
2
MS
cefpodoxime proxetil oral tablet 100 mg, 200 mg
2
MS
cefprozil oral suspension reconstituted 125 mg/5ml,
250 mg/5ml
2
MS
cefprozil oral tablet 250 mg, 500 mg
2
MS
ceftazidime and dextrose intravenous* solution
reconstituted 1 gm/50ml, 2 gm/50ml
2
MS
ceftazidime injection solution reconstituted 1 gm, 2 gm,
6 gm
2
MS
ceftriaxone sodium injection solution reconstituted 250
mg, 500 mg
2
MS
ceftriaxone sodium intravenous* solution reconstituted 1
gm, 10 gm, 2 gm
2
MS
cefuroxime axetil oral suspension reconstituted 125
mg/5ml
2
MS
cefuroxime axetil oral tablet 250 mg, 500 mg
2
MS
cefuroxime sodium injection solution reconstituted 1.5
gm, 7.5 gm, 750 mg
2
MS
cephalexin oral capsule 250 mg, 500 mg, 750 mg
1
MS
cephalexin oral suspension reconstituted 125 mg/5ml,
250 mg/5ml
2
MS
cephalexin oral tablet 250 mg, 500 mg
2
MS
SUPRAX ORAL CAPSULE 400 MG
4
MS
SUPRAX ORAL SUSPENSION RECONSTITUTED 100
MG/5ML, 200 MG/5ML, 500 MG/5ML
4
MS
SUPRAX ORAL TABLET 400 MG
4
MS
SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG
4
MS
tazicef injection solution reconstituted 1 gm, 2 gm, 6 gm
2
MS
8
DRUG NAME
TIER
TEFLARO INTRAVENOUS* SOLUTION RECONSTITUTED
400 MG, 600 MG
Beta-Lactam, Other
4
PA; MS
aztreonam injection solution reconstituted 1 gm
2
MS
DORIBAX INTRAVENOUS* SOLUTION RECONSTITUTED
500 MG
4
PA; MS
imipenem-cilastatin intravenous* solution reconstituted
250 mg, 500 mg
2
MS
INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM
4
MS
2
MS
amoxicillin oral capsule 250 mg, 500 mg
1
MS
amoxicillin oral suspension reconstituted 125 mg/5ml,
200 mg/5ml, 250 mg/5ml, 400 mg/5ml
2
MS
amoxicillin oral tablet 500 mg, 875 mg
2
MS
amoxicillin oral tablet chewable 125 mg, 250 mg
2
MS
amoxicillin-pot clavulanate oral suspension
reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml,
400-57 mg/5ml, 600-42.9 mg/5ml
2
MS
amoxicillin-pot clavulanate oral tablet 250-125 mg,
500-125 mg, 875-125 mg
2
MS
amoxicillin-pot clavulanate oral tablet chewable
200-28.5 mg, 400-57 mg
2
MS
ampicillin oral capsule 250 mg, 500 mg
1
MS
ampicillin oral suspension reconstituted 125 mg/5ml,
250 mg/5ml
2
MS
ampicillin sodium injection solution reconstituted 1 gm,
125 mg, 2 gm, 250 mg, 500 mg
2
MS
ampicillin-sulbactam sodium injection solution
reconstituted 3 (2-1) gm
2
MS
ampicillin-sulbactam sodium intravenous* solution
reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm
2
MS
bactocill in dextrose intravenous* solution 2 gm/50ml
5*
MS
meropenem intravenous* solution reconstituted 1 gm,
500 mg
Beta-Lactam, Penicillins
9
DRUG NAME
TIER
BICILLIN C-R 900/300 INTRAMUSCULAR*
SUSPENSION 900000-300000 UNIT/2ML
3
MS
BICILLIN C-R INTRAMUSCULAR* SUSPENSION
1200000 UNIT/2ML
3
MS
BICILLIN L-A INTRAMUSCULAR* SUSPENSION
1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000
UNIT/ML
3
MS
dicloxacillin sodium oral capsule 250 mg, 500 mg
2
MS
oxacillin sodium injection solution reconstituted 10 gm
5*
MS
oxacillin sodium injection solution reconstituted 2 gm
2
MS
penicillin g potassium injection solution reconstituted
20000000 unit, 5000000 unit
2
MS
PENICILLIN G PROCAINE INTRAMUSCULAR*
SUSPENSION 600000 UNIT/ML
3
MS
penicillin v potassium oral solution reconstituted 125
mg/5ml, 250 mg/5ml
1
MS
penicillin v potassium oral tablet 250 mg, 500 mg
1
MS
piperacillin sod-tazobactam so intravenous* solution
reconstituted 2-0.25 gm, 3-0.375 gm, 36-4.5 gm, 4-0.5
gm
2
MS
3
MS
azithromycin intravenous* solution reconstituted 500 mg
2
MS
azithromycin oral packet 1 gm
2
MS
azithromycin oral suspension reconstituted 100 mg/5ml,
200 mg/5ml
2
MS
azithromycin oral tablet 250 mg, 500 mg, 600 mg
2
MS
clarithromycin er oral tablet extended release 24 hr*
500 mg
2
MS
clarithromycin oral suspension reconstituted 125
mg/5ml, 250 mg/5ml
2
MS
clarithromycin oral tablet 250 mg, 500 mg
2
MS
DIFICID ORAL TABLET 200 MG
5*
PA; MS
TIMENTIN INTRAVENOUS* SOLUTION
RECONSTITUTED 3.1 GM
Macrolides
10
DRUG NAME
TIER
e.e.s. 400 oral tablet 400 mg
2
MS
E.E.S. GRANULES ORAL SUSPENSION
RECONSTITUTED 200 MG/5ML
4
MS
e.s.p. oral suspension reconstituted 200-600 mg/5ml
2
MS
ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200
MG/5ML
4
MS
ery-tab oral tablet delayed release 250 mg, 333 mg,
500 mg
2
MS
erythrocin lactobionate intravenous* solution
reconstituted 500 mg
2
MS
erythrocin stearate oral tablet 250 mg
2
MS
erythromycin base oral tablet 250 mg, 500 mg
2
MS
erythromycin ethylsuccinate oral tablet 400 mg
2
MS
erythromycin external 2 %
2
MS
erythromycin external solution 2 %
2
MS
erythromycin ophthalmic ointment 5 mg/gm
2
MS
ilotycin ophthalmic ointment 5 mg/gm
Quinolones
2
MS
BESIVANCE OPHTHALMIC SUSPENSION 0.6 %
4
MS
ciprofloxacin hcl ophthalmic solution 0.3 %
2
MS
ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg,
750 mg
1
MS
ciprofloxacin in d5w intravenous* solution 200
mg/100ml
2
MS
ciprofloxacin intravenous* solution 400 mg/40ml
2
MS
gatifloxacin ophthalmic solution 0.5 %
2
MS
levofloxacin in d5w intravenous* solution 250 mg/50ml,
500 mg/100ml, 750 mg/150ml
2
MS
levofloxacin intravenous* solution 25 mg/ml
2
MS
levofloxacin oral solution 25 mg/ml
2
MS
levofloxacin oral tablet 250 mg, 500 mg, 750 mg
2
MS
MOXEZA OPHTHALMIC SOLUTION 0.5 %
4
MS
ofloxacin ophthalmic solution 0.3 %
2
MS
11
DRUG NAME
TIER
ofloxacin oral tablet 200 mg, 300 mg, 400 mg
2
MS
ofloxacin otic solution 0.3 %
2
MS
VIGAMOX OPHTHALMIC SOLUTION 0.5 %
Sulfonamides
4
MS
silver sulfadiazine external cream 1 %
2
MS
ssd external cream 1 %
2
MS
sulfacetamide sodium external suspension 10 %
2
MS
sulfacetamide sodium ophthalmic ointment 10 %
1
MS
sulfacetamide sodium ophthalmic solution 10 %
2
MS
sulfadiazine oral tablet 500 mg
2
MS
sulfamethoxazole-tmp ds oral tablet 800-160 mg
2
MS
sulfamethoxazole-trimethoprim intravenous* solution
400-80 mg/5ml
2
MS
sulfamethoxazole-trimethoprim oral suspension 200-40
mg/5ml
2
MS
sulfamethoxazole-trimethoprim oral tablet 400-80 mg
Tetracyclines
2
MS
demeclocycline hcl oral tablet 150 mg, 300 mg
2
MS
doxycycline hyclate oral capsule 100 mg, 50 mg
2
MS
doxycycline hyclate oral tablet 100 mg, 20 mg
2
MS
doxycycline hyclate oral tablet delayed release 100 mg,
150 mg, 75 mg
2
MS
doxycycline monohydrate oral capsule 100 mg, 50 mg
2
MS
doxycycline monohydrate oral tablet 100 mg, 150 mg,
50 mg, 75 mg
2
MS
minocycline hcl oral capsule 100 mg, 50 mg, 75 mg
2
MS
tetracycline hcl oral capsule 250 mg, 500 mg
Anticonvulsants
1
MS
diazepam 10 mg, 2.5 mg, 20 mg
2
MS
levetiracetam in nacl intravenous* solution 1000
mg/100ml, 1500 mg/100ml, 500 mg/100ml
2
MS
Anticonvulsants, Other
12
DRUG NAME
TIER
levetiracetam intravenous* solution 500 mg/5ml
2
MS
levetiracetam oral solution 100 mg/ml
2
MS
levetiracetam oral tablet 1000 mg, 250 mg, 500 mg,
750 mg
2
MS
POTIGA ORAL TABLET 200 MG, 300 MG, 50 MG
5*
PA-NS; MS
POTIGA ORAL TABLET 400 MG
Calcium Channel Modifying Agents
4
PA-NS; MS
CELONTIN ORAL CAPSULE 300 MG
3
MS
ethosuximide oral capsule 250 mg
2
MS
ethosuximide oral solution 250 mg/5ml
2
MS
LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25
MG, 50 MG, 75 MG
3
LYRICA ORAL CAPSULE 225 MG, 300 MG
3
LYRICA ORAL SOLUTION 20 MG/ML
3
zonisamide oral capsule 100 mg, 25 mg, 50 mg
Gamma-Aminobutyric Acid (Gaba) Augmenting
Agents
2
MS
divalproex sodium er oral tablet extended release 24 hr*
250 mg, 500 mg
2
MS
divalproex sodium oral capsule sprinkle 125 mg
2
MS
divalproex sodium oral tablet delayed release 125 mg,
250 mg, 500 mg
2
MS
gabapentin oral capsule 100 mg, 300 mg
2
gabapentin oral capsule 400 mg
2
gabapentin oral solution 250 mg/5ml
2
MS
gabapentin oral tablet 600 mg
2
gabapentin oral tablet 800 mg
2
GABITRIL ORAL TABLET 12 MG, 16 MG
4
MS
GRALISE ORAL TABLET 300 MG, 600 MG
4
ST-NS; MS
GRALISE STARTER ORAL 300 & 600 MG
4
ST-NS; MS
ONFI ORAL SUSPENSION 2.5 MG/ML
4
MS
ONFI ORAL TABLET 10 MG
4
MS
13
DRUG NAME
TIER
ONFI ORAL TABLET 20 MG
5*
MS
phenobarbital oral elixir 20 mg/5ml
2
PA-NS; MS
phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30
mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg
2
PA-NS; MS
primidone oral tablet 250 mg, 50 mg
2
MS
SABRIL ORAL PACKET 500 MG
5*
PA-NS; LA; QL (180 EA per 30 days)
SABRIL ORAL TABLET 500 MG
5*
tiagabine hcl oral tablet 2 mg, 4 mg
2
MS
valproate sodium intravenous* solution 500 mg/5ml
2
MS
valproic acid oral capsule 250 mg
2
MS
valproic acid oral syrup 250 mg/5ml
Glutamate Reducing Agents
2
MS
felbamate oral suspension 600 mg/5ml
5*
MS
felbamate oral tablet 400 mg
2
MS
felbamate oral tablet 600 mg
5*
MS
FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG,
6 MG, 8 MG
4
PA-NS; MS
lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg
2
MS
lamotrigine oral tablet chewable 25 mg, 5 mg
2
MS
topiramate oral capsule sprinkle 15 mg, 25 mg
2
MS
topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg
1
MS
TROKENDI XR ORAL CAPSULE EXTENDED RELEASE
24 HOUR 100 MG, 25 MG, 50 MG
4
PA-NS; MS; QL (60 EA per 30 days)
5*
APTIOM ORAL TABLET 200 MG
4
APTIOM ORAL TABLET 400 MG, 800 MG
5*
APTIOM ORAL TABLET 600 MG
5*
BANZEL ORAL SUSPENSION 40 MG/ML
5*
PA-NS; MS
BANZEL ORAL TABLET 200 MG
4
BANZEL ORAL TABLET 400 MG
5*
TROKENDI XR ORAL CAPSULE EXTENDED RELEASE
24 HOUR 200 MG
Sodium Channel Agents
14
DRUG NAME
TIER
carbamazepine oral suspension 100 mg/5ml
2
MS
carbamazepine oral tablet 200 mg
2
MS
carbamazepine oral tablet chewable 100 mg
2
MS
DILANTIN INFATABS ORAL TABLET CHEWABLE 50
MG
3
MS
DILANTIN ORAL CAPSULE 30 MG
3
MS
epitol oral tablet 200 mg
2
MS
fosphenytoin sodium injection solution 100 mg pe/2ml
2
MS
oxcarbazepine oral suspension 300 mg/5ml
2
MS
oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg
2
MS
PEGANONE ORAL TABLET 250 MG
4
MS
phenytoin oral suspension 125 mg/5ml
2
MS
phenytoin oral tablet chewable 50 mg
2
MS
phenytoin sodium extended oral capsule 100 mg, 200
mg, 300 mg
2
MS
phenytoin sodium injection solution 50 mg/ml
2
MS
VIMPAT INTRAVENOUS* SOLUTION 200 MG/20ML
3
MS
VIMPAT ORAL SOLUTION 10 MG/ML
3
MS
3
MS
ergoloid mesylates oral tablet 1 mg
Cholinesterase Inhibitors
2
PA; MS
donepezil hcl oral tablet 10 mg, 5 mg
1
MS
donepezil hcl oral tablet dispersible 10 mg, 5 mg
2
MS
EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR,
4.6 MG/24HR, 9.5 MG/24HR
3
galantamine hydrobromide er oral capsule extended
release 24 hour 16 mg, 24 mg, 8 mg
2
galantamine hydrobromide oral solution 4 mg/ml
2
VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50
MG
Antidementia Agents
Antidementia Agents, Other
15
DRUG NAME
TIER
galantamine hydrobromide oral tablet 12 mg, 4 mg, 8
mg
2
2
MS
NAMENDA ORAL SOLUTION 10 MG/5ML
3
PA; MS
NAMENDA ORAL TABLET 10 MG, 5 MG
3
NAMENDA TITRATION PAK ORAL TABLET 5 (28)-10
(21) MG
3
PA; MS
NAMENDA XR ORAL CAPSULE EXTENDED RELEASE
24 HOUR 14 MG, 21 MG, 28 MG, 7 MG
3
3
PA; MS
buproban oral tablet extended release 12 hr* 150 mg
2
bupropion hcl er (sr) oral tablet extended release 12 hr*
100 mg, 150 mg, 200 mg
2
bupropion hcl er (xl) oral tablet extended release 24 hr*
150 mg, 300 mg
2
bupropion hcl oral tablet 100 mg, 75 mg
2
MS
maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg
2
MS
mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg
2
MS
mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg
2
MS
nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg,
250 mg, 50 mg
2
MS
trazodone hcl oral tablet 100 mg, 150 mg, 50 mg
1
MS
trazodone hcl oral tablet 300 mg
2
MS
VIIBRYD ORAL KIT 10 & 20 & 40 MG
Monoamine Oxidase Inhibitors
4
ST-NS; MS; QL (30 EA per 30 days)
EMSAM TRANSDERMAL PATCH 24 HR 12 MG/24HR, 6
MG/24HR, 9 MG/24HR
5*
MARPLAN ORAL TABLET 10 MG
4
MS
rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg,
6 mg
N-Methyl-D-Aspartate (Nmda) Receptor Antagonist
NAMENDA XR TITRATION PACK ORAL CAPSULE
EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 MG
Antidepressants
Antidepressants, Other
16
DRUG NAME
TIER
phenelzine sulfate oral tablet 15 mg
2
MS
tranylcypromine sulfate oral tablet 10 mg
Ssris/ Snris
2
MS
BRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG
4
citalopram hydrobromide oral solution 10 mg/5ml
2
MS
citalopram hydrobromide oral tablet 10 mg, 20 mg
1
citalopram hydrobromide oral tablet 40 mg
1
duloxetine hcl oral capsule delayed release particles 20
mg, 30 mg, 60 mg
2
escitalopram oxalate oral solution 5 mg/5ml
2
MS
escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg
2
FETZIMA ORAL CAPSULE EXTENDED RELEASE 24
HOUR 120 MG, 20 MG, 40 MG, 80 MG
4
FETZIMA TITRATION ORAL 20 & 40 MG
4
fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg
1
MS
fluoxetine hcl oral solution 20 mg/5ml
2
MS
fluoxetine hcl oral tablet 10 mg
1
MS
fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg
2
MS
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg
2
PAXIL ORAL SUSPENSION 10 MG/5ML
4
MS
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR*
100 MG, 25 MG, 50 MG
4
sertraline hcl oral concentrate 20 mg/ml
2
MS
sertraline hcl oral tablet 100 mg, 25 mg, 50 mg
1
MS
venlafaxine hcl er oral capsule extended release 24 hour
150 mg, 37.5 mg, 75 mg
2
venlafaxine hcl er oral tablet extended release 24 hr*
150 mg, 37.5 mg, 75 mg
2
venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50
mg, 75 mg
2
MS
VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG
4
17
DRUG NAME
TIER
Tricyclics
amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
2
PA-NS; MS
amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg
2
MS
clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg
2
PA-NS; MS
desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
2
MS
doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
2
PA-NS; MS
doxepin hcl oral concentrate 10 mg/ml
2
PA-NS; MS
imipramine hcl oral tablet 10 mg, 25 mg, 50 mg
2
PA-NS; MS
imipramine pamoate oral capsule 100 mg, 125 mg, 150
mg, 75 mg
2
PA-NS; MS
nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75
mg
2
MS
nortriptyline hcl oral solution 10 mg/5ml
2
MS
protriptyline hcl oral tablet 10 mg, 5 mg
2
MS
SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG
Antiemetics
4
PA-NS; MS
compro suppository 25 mg
2
MS
hydroxyzine hcl intramuscular* solution 25 mg/ml, 50
mg/ml
2
PA; MS
meclizine hcl oral tablet 12.5 mg, 25 mg
2
MS
phenadoz suppository 12.5 mg, 25 mg
2
PA; MS
phenergan suppository 12.5 mg, 25 mg, 50 mg
2
PA; MS
prochlorperazine suppository 25 mg
2
MS
promethazine hcl injection solution 25 mg/ml, 50 mg/ml
2
PA; MS
promethazine hcl oral syrup 6.25 mg/5ml
2
PA; MS
promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg
2
PA; MS
promethazine hcl suppository 12.5 mg, 25 mg, 50 mg
2
PA; MS
promethegan suppository 25 mg, 50 mg
2
PA; MS
Antiemetics, Other
18
DRUG NAME
TIER
Emetogenic Therapy Adjuncts
dronabinol oral capsule 10 mg
5*
dronabinol oral capsule 2.5 mg, 5 mg
2
EMEND ORAL CAPSULE 125 MG, 40 MG, 80 & 125
MG, 80 MG
4
PA-BvsD; MS
granisetron hcl intravenous* solution 0.1 mg/ml, 1
mg/ml
2
PA; MS; QL (10 ML per 30 days)
granisetron hcl oral tablet 1 mg
2
ondansetron hcl injection solution 4 mg/2ml
2
MS
ondansetron hcl oral solution 4 mg/5ml
2
PA; MS
ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg
1
MS
ondansetron oral tablet dispersible 4 mg, 8 mg
Antifungals
1
MS
ABELCET INTRAVENOUS* SUSPENSION 5 MG/ML
5*
PA; MS
AMBISOME INTRAVENOUS* SUSPENSION
RECONSTITUTED 50 MG
5*
PA; MS
amphotericin b injection solution reconstituted 50 mg
2
PA-BvsD; MS
CANCIDAS INTRAVENOUS* SOLUTION
RECONSTITUTED 50 MG, 70 MG
5*
PA; MS
ciclopirox external 0.77 %
2
MS
ciclopirox external shampoo 1 %
2
MS
ciclopirox external solution 8 %
2
MS
ciclopirox olamine external cream 0.77 %
2
MS
ciclopirox olamine external suspension 0.77 %
2
MS
clotrimazole external cream 1 %
2
MS
clotrimazole external solution 1 %
2
MS
clotrimazole mouth/throat troche 10 mg
2
MS
econazole nitrate external cream 1 %
2
MS
fluconazole in dextrose intravenous* solution 200
mg/100ml, 400 mg/200ml
2
MS
Antifungals
19
DRUG NAME
TIER
fluconazole in sodium chloride intravenous* solution
100-0.9 mg/50ml-%
2
MS
fluconazole oral suspension reconstituted 10 mg/ml, 40
mg/ml
2
MS
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg
1
MS
flucytosine oral capsule 250 mg, 500 mg
5*
MS
griseofulvin microsize oral suspension 125 mg/5ml
2
MS
griseofulvin microsize oral tablet 500 mg
2
MS
griseofulvin ultramicrosize oral tablet 125 mg, 250 mg
2
MS
itraconazole oral capsule 100 mg
2
PA; MS
ketoconazole external cream 2 %
2
MS
ketoconazole external shampoo 2 %
2
MS
ketoconazole oral tablet 200 mg
2
PA; MS
MYCAMINE INTRAVENOUS* SOLUTION
5*
PA; MS
NAFTIN EXTERNAL 1 %, 2 %
3
MS
NAFTIN EXTERNAL CREAM 1 %, 2 %
3
MS
NATACYN OPHTHALMIC SUSPENSION 5 %
3
MS
NOXAFIL ORAL SUSPENSION 40 MG/ML
5*
PA; MS
nyamyc external powder 100000 unit/gm
2
MS
nystatin external cream 100000 unit/gm
2
MS
nystatin external ointment 100000 unit/gm
2
MS
nystatin external powder 100000 unit/gm
2
MS
nystatin mouth/throat suspension 100000 unit/ml
2
MS
nystatin oral tablet 500000 unit
2
MS
nystop external powder 100000 unit/gm
2
MS
pedi-dri external powder 100000 unit/gm
2
MS
terbinafine hcl oral tablet 250 mg
2
MS
terconazole vaginal cream 0.4 %, 0.8 %
2
MS
terconazole vaginal suppository 80 mg
2
MS
voriconazole intravenous* solution reconstituted 200 mg
2
PA; MS
voriconazole oral tablet 200 mg
5*
20
DRUG NAME
TIER
voriconazole oral tablet 50 mg
5*
zazole vaginal cream 0.4 %, 0.8 %
2
MS
ZOLINZA ORAL CAPSULE 100 MG
Antigout Agents
5*
allopurinol oral tablet 100 mg, 300 mg
1
MS
colchicine-probenecid oral tablet 0.5-500 mg
2
MS
COLCRYS ORAL TABLET 0.6 MG
3
MS
probenecid oral tablet 500 mg
2
MS
ULORIC ORAL TABLET 40 MG, 80 MG
Antimigraine Agents
4
ST; MS
dihydroergotamine mesylate injection solution 1 mg/ml
2
MS
MIGERGOT SUPPOSITORY 2-100 MG
4
MS
MIGRANAL NASAL SOLUTION 4 MG/ML
Serotonin (5-Ht) 1B/1D Receptor Agonists
4
MS
naratriptan hcl oral tablet 1 mg, 2.5 mg
2
sumatriptan nasal solution 20 mg/act, 5 mg/act
2
sumatriptan succinate oral tablet 100 mg, 25 mg, 50
mg
2
MS
sumatriptan succinate subcutaneous* 6 mg/0.5ml
2
2
guanidine hcl oral tablet 125 mg
2
MS
MESTINON ORAL SYRUP 60 MG/5ML
3
MS
MESTINON ORAL TABLET EXTENDEDRELEASE* 180
MG
3
MS
pyridostigmine bromide oral tablet 60 mg
2
MS
Antigout Agents
Ergot Alkaloids
sumatriptan succinate subcutaneous* solution 6
mg/0.5ml
Antimyasthenic Agents
Parasympathomimetics
21
DRUG NAME
TIER
Antimycobacterials
Antimycobacterials, Other
DAPSONE ORAL TABLET 100 MG, 25 MG
3
MS
PRIFTIN ORAL TABLET 150 MG
4
MS
rifabutin oral capsule 150 mg
Antituberculars
2
MS
CAPASTAT SULFATE INJECTION SOLUTION
RECONSTITUTED 1 GM
4
MS
ethambutol hcl oral tablet 100 mg, 400 mg
2
MS
isoniazid oral syrup 50 mg/5ml
2
MS
isoniazid oral tablet 100 mg, 300 mg
1
MS
PASER ORAL PACKET 4 GM
4
MS
pyrazinamide oral tablet 500 mg
2
MS
rifampin intravenous* solution reconstituted 600 mg
2
MS
rifampin oral capsule 150 mg, 300 mg
2
MS
TRECATOR ORAL TABLET 250 MG
Antineoplastics
4
MS
cyclophosphamide injection solution reconstituted 1 gm,
2 gm, 500 mg
2
PA-BvsD; MS
cyclophosphamide oral capsule 25 mg, 50 mg
2
PA-BvsD; MS
cyclophosphamide oral tablet 25 mg, 50 mg
2
PA-BvsD; MS
gleostine oral capsule 10 mg, 100 mg, 40 mg
2
MS
HEXALEN ORAL CAPSULE 50 MG
5*
PA-NS; MS
LEUKERAN ORAL TABLET 2 MG
3
MS
lomustine oral capsule 10 mg, 100 mg, 40 mg
2
MS
MATULANE ORAL CAPSULE 50 MG
5*
LA
VALCHLOR EXTERNAL 0.016 %
Antiandrogens
5*
PA-NS; MS
bicalutamide oral tablet 50 mg
2
MS
flutamide oral capsule 125 mg
2
MS
Alkylating Agents
NILANDRON ORAL TABLET 150 MG
5*
MS
22
DRUG NAME
TIER
XTANDI ORAL CAPSULE 40 MG
5*
ZYTIGA ORAL TABLET 250 MG
Antiangiogenic Agents
5*
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG
5*
PA-NS; LA
REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5
MG
5*
PA-NS; LA
5*
PA-NS; MS
EMCYT ORAL CAPSULE 140 MG
4
PA-NS; MS
FARESTON ORAL TABLET 60 MG
5*
SOLTAMOX ORAL SOLUTION 10 MG/5ML
4
MS
tamoxifen citrate oral tablet 10 mg, 20 mg
Antimetabolites
2
MS
DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG
3
MS
hydroxyurea oral capsule 500 mg
2
MS
TABLOID ORAL TABLET 40 MG
Antineoplastics
4
PA-NS; MS
ALIMTA INTRAVENOUS* SOLUTION RECONSTITUTED
100 MG, 500 MG
5*
PA-BvsD; MS
AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML
5*
PA-BvsD; LA
azacitidine injection suspension reconstituted 100 mg
5*
PA-BvsD; MS
bleomycin sulfate injection solution reconstituted 15
unit, 30 unit
2
PA-BvsD; MS
BLINCYTO INTRAVENOUS* SOLUTION
RECONSTITUTED 35 MCG
5*
PA-BvsD; MS
ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED
1.5 MG, 7.5 MG
5*
PA-BvsD; MS
FASLODEX INTRAMUSCULAR* SOLUTION 250
MG/5ML
5*
PA-BvsD; MS; QL (10 ML per 28
days)
ifosfamide intravenous* solution reconstituted 1 gm
2
MS
IXEMPRA KIT INTRAVENOUS* SOLUTION
5*
PA-BvsD; MS
THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG,
50 MG
Antiestrogens/Modifiers
23
DRUG NAME
TIER
LYNPARZA ORAL CAPSULE 50 MG
5*
PA-NS; MS
mesna intravenous* solution 100 mg/ml
2
MS
MESNEX ORAL TABLET 400 MG
5*
MS
PROLEUKIN INTRAVENOUS* SOLUTION
RECONSTITUTED 22000000 UNIT
5*
PA-BvsD; MS
TREANDA INTRAVENOUS* SOLUTION 180 MG/2ML, 45
MG/0.5ML
5*
PA-BvsD; MS
TREANDA INTRAVENOUS* SOLUTION
5*
PA-BvsD; MS
TRISENOX INTRAVENOUS* SOLUTION 10 MG/10ML
5*
PA-BvsD; MS
5*
PA-BvsD; MS
amifostine intravenous* solution reconstituted 500 mg
5*
PA-BvsD; MS
leucovorin calcium injection solution reconstituted 100
mg, 200 mg, 350 mg, 50 mg, 500 mg
2
MS
leucovorin calcium intravenous* solution 10 mg/ml
2
MS
leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5
mg
2
MS
REVLIMID ORAL CAPSULE 2.5 MG, 20 MG
5*
PA-NS; LA
5*
PA-NS; MS
anastrozole oral tablet 1 mg
2
exemestane oral tablet 25 mg
2
MS
letrozole oral tablet 2.5 mg
Enzyme Inhibitors
2
MS
FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG
Molecular Target Inhibitors
5*
PA-NS; MS
AFINITOR ORAL TABLET 10 MG, 5 MG, 7.5 MG
5*
BOSULIF ORAL TABLET 100 MG, 500 MG
5*
PA-NS; MS
CAPRELSA ORAL TABLET 100 MG
5*
CAPRELSA ORAL TABLET 300 MG
5*
VELCADE INJECTION SOLUTION RECONSTITUTED 3.5
MG
Antineoplastics, Other
SYNRIBO SUBCUTANEOUS* SOLUTION
RECONSTITUTED 3.5 MG
Aromatase Inhibitors, 3Rd Generation
24
DRUG NAME
TIER
COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 &
1 X 20 MG
5*
PA-NS; LA
COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 &
3 X 20 MG
5*
PA-NS; LA
COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG
5*
PA-NS; LA
ERIVEDGE ORAL CAPSULE 150 MG
5*
GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG
5*
GLEEVEC ORAL TABLET 100 MG
5*
GLEEVEC ORAL TABLET 400 MG
5*
IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG
5*
ICLUSIG ORAL TABLET 15 MG, 45 MG
5*
PA-NS; MS
IMBRUVICA ORAL CAPSULE 140 MG
5*
PA-NS; LA
INLYTA ORAL TABLET 1 MG, 5 MG
5*
PA-NS; LA
JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG,
5 MG
5*
PA-NS; LA
LENVIMA 10 MG DAILY DOSE ORAL 10 MG
5*
PA-NS; MS
LENVIMA 14 MG DAILY DOSE ORAL 10 & 4 MG
5*
PA-NS; MS
LENVIMA 20 MG DAILY DOSE ORAL 10 (2) MG
5*
PA-NS; MS
LENVIMA 24 MG DAILY DOSE ORAL 10 (2) & 4 MG
5*
PA-NS; MS
MEKINIST ORAL TABLET 0.5 MG, 2 MG
5*
PA-NS; LA
NEXAVAR ORAL TABLET 200 MG
5*
SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50
MG, 70 MG, 80 MG
5*
STIVARGA ORAL TABLET 40 MG
5*
PA-NS; LA
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50
MG
5*
TAFINLAR ORAL CAPSULE 50 MG, 75 MG
5*
PA-NS; LA
TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG
5*
TASIGNA ORAL CAPSULE 150 MG, 200 MG
5*
TYKERB ORAL TABLET 250 MG
5*
VOTRIENT ORAL TABLET 200 MG
5*
XALKORI ORAL CAPSULE 200 MG, 250 MG
5*
25
DRUG NAME
TIER
ZELBORAF ORAL TABLET 240 MG
5*
ZYDELIG ORAL TABLET 100 MG, 150 MG
5*
ZYKADIA ORAL CAPSULE 150 MG
Monoclonal Antibodies
5*
ARZERRA INTRAVENOUS* CONCENTRATE 100
MG/5ML
5*
PA-BvsD; MS
OPDIVO INTRAVENOUS* SOLUTION 100 MG/10ML, 40
MG/4ML
5*
PA-NS; MS
RITUXAN INTRAVENOUS* CONCENTRATE 10 MG/ML
Retinoids
5*
PA-NS; LA
avita external 0.025 %
2
MS
avita external cream 0.025 %
2
MS
PANRETIN EXTERNAL 0.1 %
5*
MS
TARGRETIN EXTERNAL 1 %
5*
PA-NS; MS
TARGRETIN ORAL CAPSULE 75 MG
5*
PA-NS; MS
tretinoin external 0.01 %, 0.025 %
2
MS
tretinoin external cream 0.025 %, 0.05 %, 0.1 %
2
MS
tretinoin oral capsule 10 mg
Antiparasitics
5*
MS
ALBENZA ORAL TABLET 200 MG
4
MS
ivermectin oral tablet 3 mg
Antiprotozoals
2
MS
ALINIA ORAL SUSPENSION RECONSTITUTED 100
MG/5ML
4
MS
ALINIA ORAL TABLET 500 MG
4
MS
atovaquone oral suspension 750 mg/5ml
5*
MS
atovaquone-proguanil hcl oral tablet 250-100 mg
2
MS
chloroquine phosphate oral tablet 250 mg, 500 mg
2
MS
COARTEM ORAL TABLET 20-120 MG
4
MS
DARAPRIM ORAL TABLET 25 MG
3
MS
hydroxychloroquine sulfate oral tablet 200 mg
2
MS
Anthelmintics
26
DRUG NAME
TIER
mefloquine hcl oral tablet 250 mg
2
MS
NEBUPENT INHALATION SOLUTION RECONSTITUTED
300 MG
4
PA-BvsD; MS
PENTAM INJECTION SOLUTION RECONSTITUTED 300
MG
4
PA; MS
primaquine phosphate oral tablet 26.3 mg
2
MS
quinine sulfate oral capsule 324 mg
Pediculicides/ Scabicides
2
malathion external lotion 0.5 %
2
MS
permethrin external cream 5 %
Antiparkinson Agents
2
MS
benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg
2
PA; MS
trihexyphenidyl hcl oral elixir 0.4 mg/ml
2
PA; MS
trihexyphenidyl hcl oral tablet 2 mg, 5 mg
Antiparkinson Agents
2
PA; MS
carbidopa oral tablet 25 mg
Antiparkinson Agents, Other
2
MS
entacapone oral tablet 200 mg
2
MS
TASMAR ORAL TABLET 100 MG
5*
MS
tolcapone oral tablet 100 mg
Dopamine Agonists
5*
MS
APOKYN SUBCUTANEOUS* SOLUTION 10 MG/ML
5*
bromocriptine mesylate oral capsule 5 mg
2
MS
bromocriptine mesylate oral tablet 2.5 mg
2
MS
NEUPRO TRANSDERMAL PATCH 24 HR 1 MG/24HR, 2
MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8
MG/24HR
4
ST; MS; QL (30 EA per 30 days)
pramipexole dihydrochloride oral tablet 0.125 mg, 0.25
mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg
2
MS
ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3
mg, 4 mg, 5 mg
2
MS
Anticholinergics
27
DRUG NAME
TIER
Dopamine Precursors/ L-Amino Acid Decarboxylase
Inhibitors
carbidopa-levodopa er oral tablet extendedrelease*
25-100 mg, 50-200 mg
2
MS
carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg,
25-250 mg
2
MS
2
MS
AZILECT ORAL TABLET 0.5 MG, 1 MG
4
MS
selegiline hcl oral capsule 5 mg
2
MS
selegiline hcl oral tablet 5 mg
2
MS
ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG
Antipsychotics
5*
MS
chlorpromazine hcl injection solution 25 mg/ml
2
MS
chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg,
25 mg, 50 mg
2
MS
fluphenazine decanoate injection solution 25 mg/ml
2
MS
fluphenazine hcl injection solution 2.5 mg/ml
2
MS
fluphenazine hcl oral concentrate 5 mg/ml
2
MS
fluphenazine hcl oral elixir 2.5 mg/5ml
2
MS
fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg
2
MS
HALDOL DECANOATE INTRAMUSCULAR* SOLUTION
100 MG/ML, 50 MG/ML
3
MS
haloperidol decanoate intramuscular* solution 100
mg/ml, 50 mg/ml
2
MS
haloperidol lactate injection solution 5 mg/ml
2
MS
haloperidol lactate oral concentrate 2 mg/ml
2
MS
haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20
mg, 5 mg
2
MS
loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50
mg
2
MS
carbidopa-levodopa oral tablet dispersible 10-100 mg,
25-100 mg, 25-250 mg
Monoamine Oxidase B (Mao-B) Inhibitors
1St Generation/ Typical
28
DRUG NAME
TIER
ORAP ORAL TABLET 1 MG, 2 MG
3
MS
perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg
2
MS
prochlorperazine edisylate injection solution 5 mg/ml
2
MS
prochlorperazine maleate oral tablet 10 mg, 5 mg
2
MS
thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50
mg
2
MS
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg
2
MS
trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg
2Nd Generation/ Atypical
2
MS
ABILIFY DISCMELT ORAL TABLET DISPERSIBLE 10
MG
5*
ABILIFY DISCMELT ORAL TABLET DISPERSIBLE 15
MG
5*
ABILIFY INTRAMUSCULAR* SOLUTION 9.75
MG/1.3ML
4
PA-NS; MS
ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION
5*
ABILIFY ORAL SOLUTION 1 MG/ML
4
ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG,
30 MG, 5 MG
4
aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30
mg, 5 mg
2
FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG, 6 MG
4
FANAPT ORAL TABLET 10 MG, 12 MG, 8 MG
5*
FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 &
6 MG
4
PA-NS; MS
GEODON INTRAMUSCULAR* SOLUTION
RECONSTITUTED 20 MG
4
INVEGA ORAL TABLET EXTENDED RELEASE 24 HR*
1.5 MG, 3 MG, 9 MG
5*
INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 6
MG
5*
29
DRUG NAME
TIER
INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION
117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 78
MG/0.5ML
5*
MS
INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION
39 MG/0.25ML
4
MS
LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60
MG, 80 MG
4
MS
olanzapine intramuscular* solution reconstituted 10 mg
2
MS
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5
mg, 7.5 mg
2
olanzapine oral tablet dispersible 10 mg, 5 mg
2
olanzapine oral tablet dispersible 15 mg, 20 mg
5*
quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg,
300 mg, 400 mg, 50 mg
2
RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 12.5 MG, 25 MG
4
RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 37.5 MG, 50 MG
5*
risperidone oral solution 1 mg/ml
2
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3
mg, 4 mg
2
risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg
2
SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG,
2.5 MG, 5 MG
4
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24
HR* 150 MG, 200 MG
4
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24
HR* 300 MG, 400 MG, 50 MG
4
2
2
MS
ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80
mg
Treatment-Resistant
clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg
30
DRUG NAME
TIER
clozapine oral tablet dispersible 100 mg, 12.5 mg, 25
mg
2
PA-NS; MS
4
PA-NS; MS
baclofen oral tablet 10 mg, 20 mg
1
MS
tizanidine hcl oral tablet 2 mg, 4 mg
Antivirals
2
MS
foscarnet sodium intravenous* solution 24 mg/ml
2
PA; MS
ganciclovir sodium intravenous* solution reconstituted
500 mg
2
PA; MS
VALCYTE ORAL SOLUTION RECONSTITUTED 50
MG/ML
5*
MS
valganciclovir hcl oral tablet 450 mg
5*
MS
ZIRGAN OPHTHALMIC 0.15 %
Anti-Hepatitis B (Hbv) Agents
4
MS
adefovir dipivoxil oral tablet 10 mg
5*
BARACLUDE ORAL SOLUTION 0.05 MG/ML
4
MS
entecavir oral tablet 0.5 mg, 1 mg
5*
EPIVIR HBV ORAL SOLUTION 5 MG/ML
4
MS
INTRON A INJECTION SOLUTION 10000000 UNIT/ML,
6000000 UNIT/ML
5*
PA-NS; MS
INTRON A INJECTION SOLUTION RECONSTITUTED
10000000 UNIT, 18000000 UNIT, 50000000 UNIT
5*
PA-NS; MS
lamivudine oral solution 10 mg/ml
2
MS
lamivudine oral tablet 100 mg
2
MS
TYZEKA ORAL TABLET 600 MG
5*
PA; MS
5*
PA-BvsD; MS
5*
VERSACLOZ ORAL SUSPENSION 50 MG/ML
Antispasticity Agents
Antispasticity Agents
Anti-Cytomegalovirus (Cmv) Agents
VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6
GM
Anti-Hepatitis C (Hcv) Agents
HARVONI ORAL TABLET 90-400 MG
31
DRUG NAME
TIER
moderiba oral tablet 200 mg
2
MS
OLYSIO ORAL CAPSULE 150 MG
5*
PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 120
MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80
MCG/0.5ML
5*
PA; MS
PEGINTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML,
150 MCG/0.5ML, 80 MCG/0.5ML
5*
PA; MS
PEG-INTRON SUBCUTANEOUS* KIT 50 MCG/0.5ML
5*
PA; MS
ribasphere oral tablet 200 mg
2
MS
RIBASPHERE RIBAPAK ORAL TABLET 400 & 600 MG,
400 MG, 600 MG
5*
MS
ribavirin oral tablet 200 mg
2
MS
SOVALDI ORAL TABLET 400 MG
5*
SYLATRON SUBCUTANEOUS* KIT 200 MCG, 300 MCG,
600 MCG
5*
PA-NS; MS
VICTRELIS ORAL CAPSULE 200 MG
Antiherpetic Agents
5*
acyclovir external ointment 5 %
2
MS
acyclovir oral capsule 200 mg
2
MS
acyclovir oral suspension 200 mg/5ml
2
MS
acyclovir oral tablet 400 mg, 800 mg
2
MS
acyclovir sodium intravenous* solution 50 mg/ml
2
PA-BvsD; MS
DENAVIR EXTERNAL CREAM 1 %
3
MS
famciclovir oral tablet 125 mg, 250 mg, 500 mg
2
MS
trifluridine ophthalmic solution 1 %
2
MS
valacyclovir hcl oral tablet 1 gm, 500 mg
2
MS
ZOVIRAX EXTERNAL CREAM 5 %
Anti-Hiv Agents, Integrase Inhibitors (Insti)
4
MS
ISENTRESS ORAL PACKET 100 MG
4
MS
ISENTRESS ORAL TABLET 400 MG
5*
ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG
3
MS
STRIBILD ORAL TABLET 150-150-200-300 MG
5*
32
DRUG NAME
TIER
TIVICAY ORAL TABLET 50 MG
5*
VITEKTA ORAL TABLET 150 MG, 85 MG
Anti-Hiv Agents, Non-Nucleoside Reverse
Transcriptase Inhibitors (Nnrti)
5*
COMPLERA ORAL TABLET 200-25-300 MG
5*
MS
EDURANT ORAL TABLET 25 MG
5*
INTELENCE ORAL TABLET 100 MG
5*
5*
4
nevirapine er oral tablet extended release 24 hr* 400
mg
2
MS
nevirapine oral suspension 50 mg/5ml
2
MS
nevirapine oral tablet 200 mg
2
MS
RESCRIPTOR ORAL TABLET 100 MG, 200 MG
3
MS
SUSTIVA ORAL CAPSULE 200 MG
5*
MS
SUSTIVA ORAL CAPSULE 50 MG
4
MS
SUSTIVA ORAL TABLET 600 MG
5*
MS
4
MS
TRIUMEQ ORAL TABLET 600-50-300 MG
Anti-Hiv Agents, Nucleoside And Nucleotide Reverse
Transcriptase Inhibitors (Nrti)
5*
abacavir sulfate oral tablet 300 mg
2
MS
abacavir-lamivudine-zidovudine oral tablet
300-150-300 mg
5*
ATRIPLA ORAL TABLET 600-200-300 MG
5*
didanosine oral capsule delayed release 125 mg, 200
mg, 250 mg, 400 mg
2
MS
EMTRIVA ORAL CAPSULE 200 MG
3
MS
EMTRIVA ORAL SOLUTION 10 MG/ML
3
MS
EPZICOM ORAL TABLET 600-300 MG
5*
MS
VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24
HR* 100 MG
Anti-Hiv Agents, Nucleoside And Nucleotide Reverse
Transcriptase Inhibitors
33
DRUG NAME
TIER
lamivudine oral tablet 150 mg, 300 mg
2
MS
lamivudine-zidovudine oral tablet 150-300 mg
5*
MS
RETROVIR INTRAVENOUS* SOLUTION 10 MG/ML
4
MS
stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg
2
MS
stavudine oral solution reconstituted 1 mg/ml
2
MS
TRUVADA ORAL TABLET 200-300 MG
5*
VIDEX ORAL SOLUTION RECONSTITUTED 2 GM
4
MS
VIREAD ORAL POWDER 40 MG/GM
5*
MS
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300
MG
5*
MS
ZIAGEN ORAL SOLUTION 20 MG/ML
4
MS
zidovudine oral capsule 100 mg
2
MS
zidovudine oral syrup 50 mg/5ml
2
MS
zidovudine oral tablet 300 mg
Anti-Hiv Agents, Other
2
MS
FUZEON SUBCUTANEOUS* SOLUTION
RECONSTITUTED 90 MG
5*
SELZENTRY ORAL TABLET 150 MG, 300 MG
5*
TYBOST ORAL TABLET 150 MG
Anti-Hiv Agents, Protease Inhibitors
4
APTIVUS ORAL CAPSULE 250 MG
5*
APTIVUS ORAL SOLUTION 100 MG/ML
5*
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
3
MS
EVOTAZ ORAL TABLET 300-150 MG
5*
INVIRASE ORAL CAPSULE 200 MG
5*
MS
INVIRASE ORAL TABLET 500 MG
5*
MS
KALETRA ORAL SOLUTION 400-100 MG/5ML
5*
MS
KALETRA ORAL TABLET 100-25 MG
4
MS
KALETRA ORAL TABLET 200-50 MG
5*
MS
LEXIVA ORAL SUSPENSION 50 MG/ML
4
MS
LEXIVA ORAL TABLET 700 MG
5*
MS
NORVIR ORAL CAPSULE 100 MG
4
MS
34
DRUG NAME
TIER
NORVIR ORAL SOLUTION 80 MG/ML
4
MS
NORVIR ORAL TABLET 100 MG
4
MS
PREZCOBIX ORAL TABLET 800-150 MG
5*
PREZISTA ORAL SUSPENSION 100 MG/ML
5*
PREZISTA ORAL TABLET 150 MG
4
MS
PREZISTA ORAL TABLET 600 MG, 800 MG
5*
PREZISTA ORAL TABLET 75 MG
3
REYATAZ ORAL CAPSULE 150 MG, 200 MG
3
REYATAZ ORAL CAPSULE 300 MG
3
REYATAZ ORAL PACKET 50 MG
3
MS
VIRACEPT ORAL TABLET 250 MG, 625 MG
Anti-Influenza Agents
5*
MS
amantadine hcl oral capsule 100 mg
2
MS
amantadine hcl oral syrup 50 mg/5ml
2
MS
amantadine hcl oral tablet 100 mg
2
MS
RELENZA DISKHALER INHALATION AEROSOL
POWDER, BREATH ACTIVATED 5 MG/BLISTER
3
rimantadine hcl oral tablet 100 mg
2
MS
TAMIFLU ORAL CAPSULE 30 MG
3
TAMIFLU ORAL CAPSULE 45 MG, 75 MG
3
3
buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg,
7.5 mg
2
MS
meprobamate oral tablet 200 mg, 400 mg
2
ST-NS; MS
oxazepam oral capsule 10 mg, 15 mg, 30 mg
2
triazolam oral tablet 0.125 mg
2
triazolam oral tablet 0.25 mg
Benzodiazepines
2
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg
1
MS
TAMIFLU ORAL SUSPENSION RECONSTITUTED 6
MG/ML
Anxiolytics
Anxiolytics, Other
35
DRUG NAME
TIER
clonazepam oral tablet 0.5 mg
1
clonazepam oral tablet 1 mg
1
clonazepam oral tablet 2 mg
1
clonazepam oral tablet dispersible 0.125 mg, 0.25 mg
2
clonazepam oral tablet dispersible 0.5 mg
2
clonazepam oral tablet dispersible 1 mg
2
clonazepam oral tablet dispersible 2 mg
2
clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5
mg
2
MS
diazepam intensol oral concentrate 5 mg/ml
2
MS
diazepam oral solution 1 mg/ml
2
MS
diazepam oral tablet 10 mg, 2 mg, 5 mg
1
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg
Bipolar Agents
1
carbamazepine er oral capsule extended release 12
hour 100 mg, 200 mg, 300 mg
2
MS
lithium carbonate er oral tablet extendedrelease* 300
mg, 450 mg
2
MS
lithium carbonate oral capsule 150 mg, 300 mg, 600
mg
2
MS
lithium carbonate oral tablet 300 mg
2
MS
lithium oral solution 8 meq/5ml
Blood Glucose Regulators
2
MS
acarbose oral tablet 100 mg, 25 mg, 50 mg
2
MS
BYDUREON SUBCUTANEOUS* 2 MG
4
MS
BYDUREON SUBCUTANEOUS* SUSPENSION
RECONSTITUTED 2 MG
4
MS
BYETTA 10 MCG PEN SUBCUTANEOUS* 10
MCG/0.04ML
4
MS
BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.02ML
4
MS
Mood Stabilizers
Antidiabetic Agents
36
DRUG NAME
TIER
CYCLOSET ORAL TABLET 0.8 MG
4
PA; MS
glimepiride oral tablet 1 mg, 2 mg, 4 mg
1
glipizide er oral tablet extended release 24 hr* 10 mg,
2.5 mg, 5 mg
2
glipizide oral tablet 10 mg, 5 mg
1
glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg
2
glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg
2
INVOKAMET ORAL TABLET 150-1000 MG, 150-500
MG, 50-1000 MG, 50-500 MG
4
ST; MS
INVOKANA ORAL TABLET 100 MG, 300 MG
4
ST; MS
JANUVIA ORAL TABLET 100 MG
4
JANUVIA ORAL TABLET 25 MG, 50 MG
4
JARDIANCE ORAL TABLET 10 MG, 25 MG
4
ST; MS
metformin hcl er (osm) oral tablet extended release 24
hr* 500 mg
2
metformin hcl er oral tablet extended release 24 hr* 500
mg
2
metformin hcl er oral tablet extended release 24 hr* 750
mg
2
metformin hcl oral tablet 1000 mg
1
1
1
nateglinide oral tablet 120 mg, 60 mg
2
MS
ONGLYZA ORAL TABLET 2.5 MG, 5 MG
3
MS
pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg
2
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg
2
MS
RIOMET ORAL SOLUTION 500 MG/5ML
3
MS
SYMLINPEN 120 SUBCUTANEOUS* 2700 MCG/2.7ML
5*
PA; MS
SYMLINPEN 60 SUBCUTANEOUS* 1500 MCG/1.5ML
4
PA; MS
tolazamide oral tablet 250 mg, 500 mg
2
tolbutamide oral tablet 500 mg
2
37
DRUG NAME
TIER
Blood Glucose Regulators
glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500
mg, 5-500 mg
2
glyburide-metformin oral tablet 1.25-250 mg, 2.5-500
mg, 5-500 mg
2
JANUMET ORAL TABLET 50-1000 MG, 50-500 MG
4
JANUMET XR ORAL TABLET EXTENDED RELEASE 24
HR* 100-1000 MG
4
JANUMET XR ORAL TABLET EXTENDED RELEASE 24
HR* 50-1000 MG, 50-500 MG
4
KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE
24 HR* 2.5-1000 MG
4
KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE
24 HR* 5-1000 MG, 5-500 MG
4
metformin hcl er (osm) oral tablet extended release 24
hr* 1000 mg
2
pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4
mg
2
pioglitazone hcl-metformin hcl oral tablet 15-500 mg,
15-850 mg
2
4
MS
PRANDIMET ORAL TABLET 1-500 MG, 2-500 MG
Diabetic Testing Supplies
ACCU-CHEK ACTIVE GLUCOSE CONT IN VITRO
LIQUID†
Part B MS; NDC (50924047602)
ACCU-CHEK ACTIVE IN VITRO STRIP
Part B
ACCU-CHEK AVIVA IN VITRO SOLUTION
Part B MS; NDC (65702010710)
ACCU-CHEK AVIVA PLUS IN VITRO STRIP
MS; NDC (65702040710,
Part B 65702040810); QL (100 EA per 25
days)
ACCU-CHEK AVIVA PLUS KIT W/DEVICE
Part B
ACCU-CHEK COMFORT CURVE IN VITRO SOLUTION
Part B MS; NDC (50924041102)
MS; NDC (50924047550); QL (100
EA per 25 days)
MS; NDC (65702010110); QL (1 EA
per 365 days)
38
DRUG NAME
TIER
ACCU-CHEK COMFORT CURVE IN VITRO STRIP
MS; NDC (50924037350,
Part B 50924038110); QL (100 EA per 25
days)
ACCU-CHEK COMPACT BLUE CONTROL IN VITRO
LIQUID†
Part B MS; NDC (65702036910)
ACCU-CHEK COMPACT PLUS CARE KIT
Part B
ACCU-CHEK COMPACT PLUS IN VITRO STRIP
MS; NDC (50924098850,
Part B 50924088401); QL (102 EA per 25
days)
ACCU-CHEK FASTCLIX LANCET KIT
Part B MS; NDC (65702048110)
ACCU-CHEK MULTICLIX LANCET DEV KIT
Part B MS; NDC (50924044601)
ACCU-CHEK MULTICLIX LANCETS
Part B
MS; NDC (50924045001,
50924098101)
ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE
Part B
MS; NDC (65702048310); QL (1 EA
per 365 days)
ACCU-CHEK SAFE-T PRO LANCETS
Part B
MS; NDC (50924095120,
50924007920)
ACCU-CHEK SMARTVIEW CONTROL IN VITRO LIQUID†
MS; NDC (50924001901); QL (1 EA
per 365 days)
Part B MS; NDC (65702048810)
ACCU-CHEK SMARTVIEW IN VITRO STRIP
MS; NDC (65702049210,
Part B 65702049310); QL (100 EA per 25
days)
ACCU-CHEK SOFT TOUCH LANCETS
Part B
ACCU-CHEK SOFTCLIX LANCET DEV
Part B MS; NDC (50924095701)
ACCU-CHEK SOFTCLIX LANCET DEV KIT
Part B MS; NDC (65702040010)
ACCU-CHEK SOFTCLIX LANCETS
Part B
FREESTYLE CONTROL SOLUTION IN VITRO LIQUID†
Part B MS; NDC (99073014002)
FREESTYLE FREEDOM LITE KIT W/DEVICE
Part B
MS; NDC (99073070914); QL (1 EA
per 365 days)
FREESTYLE INSULINX SYSTEM KIT W/DEVICE
Part B
MS; NDC (99073071143); QL (1 EA
per 365 days)
MS; NDC (50924058510,
50924093720)
MS; NDC (50924097110,
65702012410)
39
DRUG NAME
TIER
FREESTYLE INSULINX TEST IN VITRO STRIP
MS; NDC (99073071231,
Part B 99073071227); QL (100 EA per 25
days)
FREESTYLE LITE DEVICE
Part B
FREESTYLE LITE TEST IN VITRO STRIP
MS; NDC (99073070822,
Part B 99073070827); QL (100 EA per 25
days)
FREESTYLE TEST IN VITRO STRIP
MS; NDC (99073012050,
Part B 99073012101); QL (100 EA per 25
days)
MEDISENSE HI/MID/LOW CONTROL IN VITRO LIQUID†
MS; NDC (99073070805); QL (1 EA
per 365 days)
Part B MS; NDC (57599055101)
PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP
MS; NDC (57599972804,
Part B 57599987705); QL (100 EA per 25
days)
PRECISION XTRA DEVICE
Part B
PRECISION XTRA KETONE IN VITRO STRIP
Glycemic Agents
Part B MS; NDC (57599074501)
MS; NDC (57599881401); QL (1 EA
per 365 days)
GLUCAGEN HYPOKIT INJECTION SOLUTION
RECONSTITUTED 1 MG
3
GLUCAGON EMERGENCY INJECTION KIT 1 MG
3
KORLYM ORAL TABLET 300 MG
5*
PROGLYCEM ORAL SUSPENSION 50 MG/ML
Insulins
4
MS
ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML
3
MS
BD INSULIN SYRINGE U-100 1 ML
3
MS
COMFORT ASSIST INSULIN SYRINGE 31G X 5/16" 0.3
ML
3
MS
COMFORT EZ PEN NEEDLES 33G X 5 MM , 33G X 6
MM , 33G X 8 MM
3
MS
CURITY GAUZE PAD 2"X2"
3
MS
EXCEL COMFORT POINT PEN NEEDLE 31G X 8 MM
3
MS
40
DRUG NAME
TIER
HUMALOG KWIKPEN SUBCUTANEOUS* 100 UNIT/ML
3
HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS*
(50-50) 100 UNIT/ML
3
HUMALOG MIX 50/50 SUBCUTANEOUS* SUSPENSION
(50-50) 100 UNIT/ML
3
HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS*
(75-25) 100 UNIT/ML
3
HUMALOG MIX 75/25 SUBCUTANEOUS* SUSPENSION
(75-25) 100 UNIT/ML
3
HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML
3
HUMULIN 70/30 KWIKPEN SUBCUTANEOUS* (70-30)
100 UNIT/ML
3
HUMULIN 70/30 SUBCUTANEOUS* SUSPENSION
(70-30) 100 UNIT/ML
3
HUMULIN N KWIKPEN SUBCUTANEOUS* 100 UNIT/ML
3
HUMULIN N SUBCUTANEOUS* SUSPENSION 100
UNIT/ML
3
HUMULIN R INJECTION SOLUTION 100 UNIT/ML
3
HUMULIN R U-500 (CONCENTRATED)
SUBCUTANEOUS* SOLUTION 500 UNIT/ML
5*
PA-BvsD; MS; QL (40 ML per 30
days)
INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5
ML
3
MS
LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML
3
LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML
3
LEVEMIR FLEXTOUCH SUBCUTANEOUS* 100 UNIT/ML
3
LEVEMIR SUBCUTANEOUS* SOLUTION 100 UNIT/ML
3
ULTICARE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G
X 1/2" 0.5 ML
3
MS
V-GO 20 KIT
4
MS
V-GO 30 KIT
4
MS
V-GO 40 KIT
4
MS
41
DRUG NAME
TIER
Blood Products/ Modifiers/ Volume Expanders
Anticoagulants
COUMADIN INTRAVENOUS* SOLUTION
RECONSTITUTED 5 MG
3
MS
COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5
MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG
3
MS
ELIQUIS ORAL TABLET 2.5 MG, 5 MG
3
MS
enoxaparin sodium injection solution 300 mg/3ml
2
enoxaparin sodium subcutaneous* solution 100 mg/ml,
150 mg/ml
5*
enoxaparin sodium subcutaneous* solution 120
mg/0.8ml
5*
MS; QL (22.4 ML per 30 days)
enoxaparin sodium subcutaneous* solution 30
mg/0.3ml, 40 mg/0.4ml
2
enoxaparin sodium subcutaneous* solution 60 mg/0.6ml
2
enoxaparin sodium subcutaneous* solution 80 mg/0.8ml
2
fondaparinux sodium subcutaneous* solution 10
mg/0.8ml
5*
fondaparinux sodium subcutaneous* solution 2.5
mg/0.5ml
2
fondaparinux sodium subcutaneous* solution 5
mg/0.4ml
5*
fondaparinux sodium subcutaneous* solution 7.5
mg/0.6ml
5*
heparin (porcine) in d5w intravenous* solution 40-5
unit/ml-%, 50-5 unit/ml-%
2
MS
heparin (porcine) in nacl injection solution 2-0.9
unit/ml-%
2
MS
heparin sod (porcine) in d5w intravenous* solution 100
unit/ml
2
MS
heparin sodium (porcine) injection solution 1000 unit/ml,
10000 unit/ml, 20000 unit/ml, 2500 unit/ml, 5000
unit/ml
2
MS
42
DRUG NAME
TIER
heparin sodium (porcine) intravenous* solution 2000
unit/ml
2
MS
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4
mg, 5 mg, 6 mg, 7.5 mg
1
MS
PRADAXA ORAL CAPSULE 150 MG, 75 MG
3
MS
1
MS
anagrelide hcl oral capsule 0.5 mg, 1 mg
2
MS
LEUKINE INTRAVENOUS* SOLUTION RECONSTITUTED
250 MCG
5*
PA; MS
MOZOBIL SUBCUTANEOUS* SOLUTION 24 MG/1.2ML
5*
PA; MS; QL (9.6 ML per 1 day)
NEUMEGA SUBCUTANEOUS* SOLUTION
RECONSTITUTED 5 MG
5*
PA; MS
NEUPOGEN INJECTION SOLUTION 300 MCG/0.5ML,
300 MCG/ML, 480 MCG/0.8ML, 480 MCG/1.6ML
5*
PA; MS
PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000
UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML
3
PA; MS
PROCRIT INJECTION SOLUTION 20000 UNIT/ML,
40000 UNIT/ML
5*
PA; MS
5*
PA; LA; QL (60 EA per 30 days)
tranexamic acid intravenous* solution 100 mg/ml
2
MS
tranexamic acid oral tablet 650 mg
Platelet Modifying Agents
2
MS
AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12
HOUR 25-200 MG
4
MS
BRILINTA ORAL TABLET 90 MG
3
MS
cilostazol oral tablet 100 mg, 50 mg
2
MS
clopidogrel bisulfate oral tablet 300 mg
2
clopidogrel bisulfate oral tablet 75 mg
1
dipyridamole oral tablet 25 mg, 50 mg, 75 mg
2
PA; MS
warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg,
3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
Blood Formation Modifiers
PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG,
75 MG
Coagulants
43
DRUG NAME
TIER
EFFIENT ORAL TABLET 10 MG, 5 MG
3
MS
ticlopidine hcl oral tablet 250 mg
Cardiovascular Agents
2
MS
clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg
1
MS
guanfacine hcl oral tablet 1 mg, 2 mg
2
PA; MS
methyldopa oral tablet 250 mg, 500 mg
2
PA; MS
midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg
Alpha-Adrenergic Blocking Agents
2
MS
prazosin hcl oral capsule 1 mg, 2 mg, 5 mg
2
MS
terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg
Angiotensin Ii Receptor Antagonists
1
MS
DIOVAN ORAL TABLET 160 MG, 40 MG, 80 MG
4
DIOVAN ORAL TABLET 320 MG
4
EDARBI ORAL TABLET 40 MG, 80 MG
4
losartan potassium oral tablet 100 mg
1
losartan potassium oral tablet 25 mg, 50 mg
1
telmisartan oral tablet 20 mg, 40 mg, 80 mg
Angiotensin-Converting Enzyme (Ace) Inhibitors
2
benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg
1
MS
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg
1
MS
enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5
mg
1
MS
fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg
1
MS
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40
mg, 5 mg
1
MS
moexipril hcl oral tablet 15 mg, 7.5 mg
2
MS
perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg
2
MS
quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg
2
MS
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg
2
MS
trandolapril oral tablet 1 mg, 2 mg, 4 mg
1
MS
Alpha-Adrenergic Agonists
44
DRUG NAME
TIER
Antiarrhythmics
amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg
2
MS
disopyramide phosphate oral capsule 100 mg, 150 mg
2
MS
flecainide acetate oral tablet 100 mg, 150 mg, 50 mg
2
MS
mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg
2
MS
MULTAQ ORAL TABLET 400 MG
4
MS
NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12
HOUR 100 MG, 150 MG
4
PA; MS
pacerone oral tablet 100 mg, 200 mg, 400 mg
2
MS
procainamide hcl injection solution 100 mg/ml, 500
mg/ml
1
MS
propafenone hcl oral tablet 150 mg, 225 mg, 300 mg
2
MS
quinidine gluconate er oral tablet extendedrelease* 324
mg
2
MS
quinidine sulfate er oral tablet extendedrelease* 300 mg
2
MS
quinidine sulfate oral tablet 200 mg, 300 mg
2
MS
sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg
2
MS
sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg
2
MS
sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg
2
MS
4
MS
acebutolol hcl oral capsule 200 mg, 400 mg
2
MS
atenolol oral tablet 100 mg, 25 mg, 50 mg
1
MS
betaxolol hcl oral tablet 10 mg, 20 mg
2
MS
bisoprolol fumarate oral tablet 10 mg, 5 mg
2
MS
BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5
MG
4
MS
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25
mg
1
MS
COREG CR ORAL CAPSULE EXTENDED RELEASE 24
HOUR 10 MG, 20 MG, 40 MG, 80 MG
3
labetalol hcl intravenous* solution 5 mg/ml
2
MS
TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500
MCG
Beta-Adrenergic Blocking Agents
45
DRUG NAME
TIER
labetalol hcl oral tablet 100 mg, 200 mg, 300 mg
2
MS
metoprolol succinate er oral tablet extended release 24
hr* 100 mg, 200 mg, 25 mg, 50 mg
2
MS
metoprolol tartrate intravenous* solution 1 mg/ml
2
MS
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
1
MS
nadolol oral tablet 20 mg, 40 mg, 80 mg
2
MS
pindolol oral tablet 10 mg, 5 mg
2
MS
propranolol hcl er oral capsule extended release 24 hour
120 mg, 160 mg, 60 mg, 80 mg
2
MS
propranolol hcl intravenous* solution 1 mg/ml
2
MS
propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml
2
MS
propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg,
80 mg
1
MS
2
MS
afeditab cr oral tablet extended release 24 hr* 30 mg,
60 mg
2
amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg
1
MS
cartia xt oral capsule extended release 24 hour 120 mg,
180 mg, 240 mg, 300 mg
2
MS
diltiazem hcl er beads oral capsule extended release 24
hour 180 mg, 360 mg, 420 mg
2
MS
diltiazem hcl er coated beads oral capsule extended
2
MS
diltiazem hcl er oral capsule extended release 12 hour
120 mg, 60 mg, 90 mg
2
MS
diltiazem hcl intravenous* solution 50 mg/10ml
2
MS
diltiazem hcl intravenous* solution reconstituted 100 mg
2
MS
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg
2
MS
dilt-xr oral capsule extended release 24 hour 120 mg,
180 mg, 240 mg
2
MS
felodipine er oral tablet extended release 24 hr* 10 mg,
2.5 mg, 5 mg
2
timolol maleate oral tablet 10 mg, 20 mg, 5 mg
Calcium Channel Blocking Agents
46
DRUG NAME
TIER
matzim la oral tablet extended release 24 hr* 180 mg,
240 mg, 300 mg, 360 mg, 420 mg
2
MS
nicardipine hcl oral capsule 20 mg, 30 mg
2
MS
nifedical xl oral tablet extended release 24 hr* 30 mg,
60 mg
2
nifedipine er osmotic oral tablet extended release 24 hr*
30 mg, 60 mg, 90 mg
2
nifedipine oral capsule 10 mg, 20 mg
2
PA; MS
nimodipine oral capsule 30 mg
2
MS
taztia xt oral capsule extended release 24 hour 120 mg,
180 mg, 240 mg, 300 mg, 360 mg
2
MS
verapamil hcl er oral capsule extended release 24 hour
100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg,
360 mg
2
MS
verapamil hcl er oral tablet extendedrelease* 120 mg,
180 mg, 240 mg
2
MS
verapamil hcl oral tablet 120 mg, 40 mg, 80 mg
Cardiovascular Agents
1
MS
amiloride-hydrochlorothiazide oral tablet 5-50 mg
2
MS
amlodipine besy-benazepril hcl oral capsule 10-20 mg,
10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg
2
amlodipine besylate-valsartan oral tablet 10-160 mg,
10-320 mg, 5-160 mg, 5-320 mg
2
MS
amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg,
10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg,
5-160-25 mg
2
MS
atenolol-chlorthalidone oral tablet 100-25 mg, 50-25
mg
1
MS
benazepril-hydrochlorothiazide oral tablet 10-12.5 mg,
20-12.5 mg, 20-25 mg, 5-6.25 mg
1
MS
bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg,
2.5-6.25 mg, 5-6.25 mg
1
MS
captopril-hydrochlorothiazide oral tablet 25-15 mg,
25-25 mg, 50-15 mg, 50-25 mg
2
MS
47
DRUG NAME
TIER
clorpres oral tablet 0.1-15 mg, 0.2-15 mg, 0.3-15 mg
2
MS
DEMSER ORAL CAPSULE 250 MG
4
EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG
4
enalapril-hydrochlorothiazide oral tablet 10-25 mg,
5-12.5 mg
2
MS
fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5
mg
2
MS
lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg,
20-12.5 mg, 20-25 mg
1
MS
losartan potassium-hctz oral tablet 100-12.5 mg,
100-25 mg
1
losartan potassium-hctz oral tablet 50-12.5 mg
1
methyldopa-hydrochlorothiazide oral tablet 250-15 mg,
250-25 mg
2
PA; MS
metoprolol-hydrochlorothiazide oral tablet 100-25 mg,
100-50 mg, 50-25 mg
2
MS
moexipril-hydrochlorothiazide oral tablet 15-12.5 mg,
15-25 mg, 7.5-12.5 mg
2
MS
propranolol-hctz oral tablet 40-25 mg, 80-25 mg
2
MS
quinapril-hydrochlorothiazide oral tablet 10-12.5 mg,
20-12.5 mg, 20-25 mg
2
MS
reserpine oral tablet 0.1 mg, 0.25 mg
2
MS
spironolactone-hctz oral tablet 25-25 mg
2
MS
TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25
MG, 300-12.5 MG, 300-25 MG
4
telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg,
80-10 mg, 80-5 mg
2
telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg,
80-25 mg
2
triamterene-hctz oral capsule 37.5-25 mg
2
MS
triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg
2
MS
valsartan-hydrochlorothiazide oral tablet 160-12.5 mg,
80-12.5 mg
2
48
DRUG NAME
TIER
valsartan-hydrochlorothiazide oral tablet 160-25 mg,
320-12.5 mg, 320-25 mg
Cardiovascular Agents, Other
2
digitek oral tablet 125 mcg
1
digitek oral tablet 250 mcg
1
digoxin injection solution 0.25 mg/ml
2
MS
digoxin oral solution 0.05 mg/ml
2
MS
digoxin oral tablet 0.125 mg
1
digoxin oral tablet 250 mcg
1
LANOXIN INJECTION SOLUTION 0.25 MG/ML
3
MS
LANOXIN ORAL TABLET 0.0625 MG
3
MS
LANOXIN ORAL TABLET 0.125 MG
3
LANOXIN ORAL TABLET 0.25 MG, 187.5 MCG
3
LANOXIN PEDIATRIC INJECTION SOLUTION 0.1
MG/ML
3
MS
pentoxifylline er oral tablet extendedrelease* 400 mg
2
MS
RANEXA ORAL TABLET EXTENDED RELEASE 12 HR*
1000 MG, 500 MG
4
4
acetazolamide er oral capsule extended release 12 hour
500 mg
2
MS
acetazolamide oral tablet 125 mg, 250 mg
2
MS
acetazolamide sodium injection solution reconstituted
500 mg
2
MS
methazolamide oral tablet 25 mg, 50 mg
Diuretics, Loop
2
MS
bumetanide injection solution 0.25 mg/ml
2
MS
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg
2
MS
furosemide injection solution 10 mg/ml
2
MS
furosemide oral solution 10 mg/ml, 8 mg/ml
2
MS
furosemide oral tablet 20 mg, 40 mg, 80 mg
1
MS
TEKTURNA ORAL TABLET 150 MG, 300 MG
Diuretics, Carbonic Anhydrase Inhibitors
49
DRUG NAME
TIER
torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg
Diuretics, Potassium-Sparing
2
MS
amiloride hcl oral tablet 5 mg
2
MS
spironolactone oral tablet 100 mg, 25 mg, 50 mg
Diuretics, Thiazide
2
MS
chlorothiazide oral tablet 250 mg, 500 mg
1
MS
chlorothiazide sodium intravenous* solution
reconstituted 500 mg
2
MS
chlorthalidone oral tablet 25 mg, 50 mg
2
MS
hydrochlorothiazide oral capsule 12.5 mg
1
MS
hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg
1
MS
indapamide oral tablet 1.25 mg, 2.5 mg
1
MS
methyclothiazide oral tablet 5 mg
2
MS
metolazone oral tablet 10 mg, 2.5 mg, 5 mg
Dyslipidemics, Fibric Acid Derivatives
2
MS
fenofibrate micronized oral capsule 134 mg, 200 mg, 67
mg
2
MS
fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg
2
MS
gemfibrozil oral tablet 600 mg
Dyslipidemics, Hmg Coa Reductase Inhibitors
2
MS
atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg
1
atorvastatin calcium oral tablet 80 mg
1
CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG
3
LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG
4
MS
lovastatin oral tablet 10 mg, 20 mg, 40 mg
2
MS
pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg
1
pravastatin sodium oral tablet 80 mg
1
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
1
simvastatin oral tablet 80 mg
Dyslipidemics, Other
1
cholestyramine light oral packet 4 gm
2
MS
cholestyramine light oral powder 4 gm/dose
2
MS
50
DRUG NAME
TIER
cholestyramine oral packet 4 gm
2
MS
cholestyramine oral powder 4 gm/dose
2
MS
colestipol hcl oral granules 5 gm
2
MS
colestipol hcl oral tablet 1 gm
2
MS
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG
5*
PA; LA
JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG
5*
PA; MS
niacin er (antihyperlipidemic) oral tablet
extendedrelease* 1000 mg, 500 mg, 750 mg
2
MS
NIACOR ORAL TABLET 500 MG
3
MS
omega-3-acid ethyl esters oral capsule 1 gm
2
MS
prevalite oral powder 4 gm/dose
2
MS
VASCEPA ORAL CAPSULE 1 GM
4
MS
WELCHOL ORAL PACKET 3.75 GM
4
MS
WELCHOL ORAL TABLET 625 MG
4
MS
ZETIA ORAL TABLET 10 MG
Vasodilators, Direct-Acting Arterial
3
MS
hydralazine hcl injection solution 20 mg/ml
2
MS
hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50
mg
2
MS
2
MS
isosorbide dinitrate er oral tablet extendedrelease* 40
mg
2
MS
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5
mg
2
MS
isosorbide mononitrate er oral tablet extended release
24 hr* 120 mg, 30 mg, 60 mg
2
MS
isosorbide mononitrate oral tablet 10 mg, 20 mg
2
MS
minitran transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr,
0.4 mg/hr, 0.6 mg/hr
2
MS
NITRO-BID TRANSDERMAL OINTMENT 2 %
3
MS
nitroglycerin intravenous* solution 5 mg/ml
1
MS
minoxidil oral tablet 10 mg, 2.5 mg
Vasodilators, Direct-Acting Arterial/ Venous
51
DRUG NAME
TIER
nitroglycerin transdermal patch 24 hr 0.1 mg/hr, 0.2
mg/hr, 0.4 mg/hr, 0.6 mg/hr
2
MS
3
MS
amphetamine-dextroamphetamine oral tablet 10 mg,
12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg
2
dexedrine oral tablet 10 mg, 5 mg
2
PA; MS
dextroamphetamine sulfate er oral capsule extended
2
PA; MS
dextroamphetamine sulfate oral tablet 10 mg, 5 mg
2
PA; MS
zenzedi oral tablet 10 mg, 5 mg
Attention Deficit Hyperactivity Disorder Agents,
Non-Amphetamines
2
PA; MS
clonidine hcl er oral tablet extended release 12 hr* 0.1
mg
2
PA; MS
dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg
2
metadate er oral tablet extendedrelease* 20 mg
2
methylphenidate hcl er oral tablet extendedrelease* 20
mg
2
methylphenidate hcl oral solution 5 mg/5ml
2
methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg
2
STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG,
40 MG
4
STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG
Central Nervous System, Other
4
estazolam oral tablet 1 mg, 2 mg
2
MS
NUEDEXTA ORAL CAPSULE 20-10 MG
3
PA; MS
riluzole oral tablet 50 mg
5*
MS
XENAZINE ORAL TABLET 12.5 MG
5*
XENAZINE ORAL TABLET 25 MG
5*
NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3
MG, 0.4 MG, 0.6 MG
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents,
Amphetamines
52
DRUG NAME
TIER
Fibromyalgia Agents
SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50
MG
3
MS
3
MS
AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR*
10 MG
5*
AUBAGIO ORAL TABLET 14 MG, 7 MG
5*
COPAXONE SUBCUTANEOUS* 20 MG/ML
5*
COPAXONE SUBCUTANEOUS* 40 MG/ML
5*
EXTAVIA SUBCUTANEOUS* KIT 0.3 MG
5*
PA; MS
GILENYA ORAL CAPSULE 0.5 MG
5*
mitoxantrone hcl intravenous* concentrate 25
mg/12.5ml
2
MS
REBIF REBIDOSE SUBCUTANEOUS* SOLUTION 22
MCG/0.5ML, 44 MCG/0.5ML
5*
REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS*
SOLUTION 6X8.8 & 6X22 MCG
5*
PA; MS; QL (4.2 ML per 28 days)
REBIF SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML,
44 MCG/0.5ML
5*
REBIF TITRATION PACK SUBCUTANEOUS* SOLUTION
6X8.8 & 6X22 MCG
5*
TECFIDERA ORAL 120 & 240 MG
5*
PA; MS
TECFIDERA ORAL CAPSULE DELAYED RELEASE 120
MG, 240 MG
5*
PA; MS
5*
PA; LA
chlorhexidine gluconate mouth/throat solution 0.12 %
1
MS
periogard mouth/throat solution 0.12 %
1
MS
pilocarpine hcl oral tablet 5 mg, 7.5 mg
2
MS
triamcinolone acetonide mouth/throat paste 0.1 %
2
MS
SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG
Multiple Sclerosis Agents
TYSABRI INTRAVENOUS* CONCENTRATE 300
MG/15ML
Dental And Oral Agents
Dental And Oral Agents
53
DRUG NAME
TIER
Dermatological Agents
Dermatological Agents
8-MOP ORAL CAPSULE 10 MG
5*
MS
acitretin oral capsule 10 mg, 17.5 mg, 25 mg
5*
ammonium lactate external cream 12 %
2
MS
ammonium lactate external lotion 12 %
2
MS
amnesteem oral capsule 10 mg, 20 mg, 40 mg
2
MS
AZELEX EXTERNAL CREAM 20 %
3
MS
benzoyl peroxide-erythromycin external 5-3 %
2
MS
betamethasone dipropionate external lotion 0.05 %
2
MS
calcipotriene external cream 0.005 %
2
MS
calcipotriene external ointment 0.005 %
2
MS
calcipotriene external solution 0.005 %
2
MS
CARAC EXTERNAL CREAM 0.5 %
4
MS
claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg
2
MS
clotrimazole-betamethasone external cream 1-0.05 %
2
MS
clotrimazole-betamethasone external lotion 1-0.05 %
2
MS
CONDYLOX EXTERNAL 0.5 %
4
MS
ELIDEL EXTERNAL CREAM 1 %
4
PA; MS
FINACEA EXTERNAL 15 %
3
MS
FLUOROURACIL EXTERNAL CREAM 0.5 %
4
MS
fluorouracil external cream 5 %
2
MS
fluorouracil external solution 2 %, 5 %
2
MS
imiquimod external cream 5 %
2
PA-NS; MS
methoxsalen rapid oral capsule 10 mg
5*
PA; MS
myorisan oral capsule 10 mg, 20 mg, 40 mg
2
MS
nystatin-triamcinolone external cream 100000-0.1
unit/gm-%
2
MS
nystatin-triamcinolone external ointment 100000-0.1
unit/gm-%
2
MS
podofilox external solution 0.5 %
2
MS
prednicarbate external cream 0.1 %
2
MS
54
DRUG NAME
TIER
REGRANEX EXTERNAL 0.01 %
4
PA; MS
SANTYL EXTERNAL OINTMENT 250 UNIT/GM
4
MS
selenium sulfide external lotion 2.5 %
2
MS
TAZORAC EXTERNAL 0.05 %, 0.1 %
4
MS
TAZORAC EXTERNAL CREAM 0.05 %, 0.1 %
4
MS
VOLTAREN TRANSDERMAL 1 %
3
MS
zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg
Enzyme Replacement/ Modifiers
2
MS
ADAGEN INTRAMUSCULAR* SOLUTION 250 UNIT/ML
5*
PA-BvsD; LA
ALDURAZYME INTRAVENOUS* SOLUTION 2.9 MG/5ML
5*
PA-BvsD; LA
CEREZYME INTRAVENOUS* SOLUTION
5*
PA; LA
CREON ORAL CAPSULE DELAYED RELEASE
PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500
UNIT, 36000 UNIT, 6000 UNIT
4
MS
CYSTADANE ORAL POWDER
5*
LA
CYSTAGON ORAL CAPSULE 150 MG, 50 MG
3
PA; LA
ELAPRASE INTRAVENOUS* SOLUTION 6 MG/3ML
5*
PA-BvsD; LA
FABRAZYME INTRAVENOUS* SOLUTION
5*
PA-BvsD; LA
KUVAN ORAL TABLET SOLUBLE 100 MG
5*
PA; LA
MYOZYME INTRAVENOUS* SOLUTION
RECONSTITUTED 50 MG
5*
PA-BvsD; LA
NAGLAZYME INTRAVENOUS* SOLUTION 1 MG/ML
5*
PA-BvsD; LA
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG
5*
PA; LA
PERTZYE ORAL CAPSULE DELAYED RELEASE
PARTICLES 16000 UNIT, 8000 UNIT
4
MS
SUCRAID ORAL SOLUTION 8500 UNIT/ML
5*
LA
VPRIV INTRAVENOUS* SOLUTION RECONSTITUTED
400 UNIT
5*
PA; MS
ZAVESCA ORAL CAPSULE 100 MG
5*
Enzyme Replacement/ Modifiers
55
DRUG NAME
TIER
ZENPEP ORAL CAPSULE DELAYED RELEASE
PARTICLES 10000 UNIT, 15000 UNIT, 20000 UNIT,
25000 UNIT, 3000-10000 UNIT, 40000 UNIT, 5000
UNIT
Gastrointestinal Agents
4
MS
atropine sulfate injection solution 0.05 mg/ml, 0.1
mg/ml
2
MS
dicyclomine hcl oral capsule 10 mg
2
MS
dicyclomine hcl oral solution 10 mg/5ml
2
MS
dicyclomine hcl oral tablet 20 mg
2
MS
glycopyrrolate injection solution 4 mg/20ml
2
MS
glycopyrrolate oral tablet 1 mg, 2 mg
2
MS
methscopolamine bromide oral tablet 2.5 mg, 5 mg
2
MS
propantheline bromide oral tablet 15 mg
2
MS
4
diphenoxylate-atropine oral liquid† 2.5-0.025 mg/5ml
2
MS
diphenoxylate-atropine oral tablet 2.5-0.025 mg
2
MS
loperamide hcl oral capsule 2 mg
1
MS
metoclopramide hcl injection solution 5 mg/ml
2
MS
metoclopramide hcl oral solution 5 mg/5ml
2
MS
metoclopramide hcl oral tablet 10 mg, 5 mg
1
MS
proctosol hc cream 2.5 %
1
MS
RELISTOR SUBCUTANEOUS* SOLUTION 12 MG/0.6ML,
8 MG/0.4ML
4
PA; MS
ursodiol oral capsule 300 mg
Histamine2 (H2) Receptor Antagonists
2
MS
cimetidine hcl oral solution 300 mg/5ml
2
MS
cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg
2
MS
famotidine intravenous* solution 20 mg/2ml
1
MS
Antispasmodics, Gastrointestinal
TRANSDERM-SCOP TRANSDERMAL PATCH 72 HR 1
MG/3DAYS
Gastrointestinal Agents, Other
56
DRUG NAME
TIER
famotidine oral suspension reconstituted 40 mg/5ml
2
MS
famotidine oral tablet 20 mg, 40 mg
1
MS
famotidine premixed intravenous* solution 20-0.9
mg/50ml-%
1
MS
ranitidine hcl injection solution 150 mg/6ml, 50 mg/2ml
2
MS
ranitidine hcl oral syrup 15 mg/ml
2
MS
ranitidine hcl oral tablet 150 mg, 300 mg
Irritable Bowel Syndrome Agents
1
MS
alosetron hcl oral tablet 0.5 mg, 1 mg
5*
AMITIZA ORAL CAPSULE 24 MCG, 8 MCG
3
MS
budesonide er oral capsule extended release 24 hour 3
mg
5*
MS
LOTRONEX ORAL TABLET 0.5 MG, 1 MG
Laxatives
5*
constulose oral solution 10 gm/15ml
2
MS
enulose oral solution 10 gm/15ml
2
MS
gavilyte-c oral solution reconstituted 240 gm
1
MS
gavilyte-g oral solution reconstituted 236 gm
1
MS
gavilyte-n with flavor pack oral solution reconstituted
420 gm
1
MS
generlac oral solution 10 gm/15ml
2
MS
lactulose oral solution 10 gm/15ml
2
MS
MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM
4
MS
peg 3350/electrolytes oral solution reconstituted 240
gm
1
MS
peg-3350/electrolytes oral solution reconstituted 236
gm
1
MS
polyethylene glycol 3350 oral powder
2
MS
trilyte oral solution reconstituted 420 gm
Protectants
1
MS
CARAFATE ORAL SUSPENSION 1 GM/10ML
4
MS
misoprostol oral tablet 100 mcg, 200 mcg
2
MS
57
DRUG NAME
TIER
sucralfate oral tablet 1 gm
Proton Pump Inhibitors
2
MS
DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG,
60 MG
3
esomeprazole sodium intravenous* solution
reconstituted 20 mg, 40 mg
2
MS
NEXIUM ORAL CAPSULE DELAYED RELEASE 20 MG,
40 MG
3
MS
NEXIUM ORAL PACKET 10 MG, 2.5 MG, 20 MG, 40
MG, 5 MG
3
MS
omeprazole oral capsule delayed release 10 mg, 20 mg,
40 mg
1
MS
pantoprazole sodium intravenous* solution reconstituted
40 mg
2
MS
2
MS
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24
HR* 25 MG, 50 MG
4
MS
oxybutynin chloride er oral tablet extended release 24
hr* 10 mg, 15 mg, 5 mg
2
MS
oxybutynin chloride oral syrup 5 mg/5ml
2
MS
oxybutynin chloride oral tablet 5 mg
2
MS
trospium chloride oral tablet 20 mg
2
MS
VESICARE ORAL TABLET 10 MG, 5 MG
Benign Prostatic Hypertrophy Agents
3
MS
alfuzosin hcl er oral tablet extended release 24 hr* 10
mg
2
MS
AVODART ORAL CAPSULE 0.5 MG
3
CIALIS ORAL TABLET 2.5 MG, 5 MG
4
doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg
1
MS
finasteride oral tablet 5 mg
2
MS
pantoprazole sodium oral tablet delayed release 20 mg,
40 mg
Genitourinary Agents
Antispasmodics, Urinary
58
DRUG NAME
TIER
JALYN ORAL CAPSULE 0.5-0.4 MG
3
RAPAFLO ORAL CAPSULE 4 MG, 8 MG
4
tamsulosin hcl oral capsule 0.4 mg
Genitourinary Agents, Other
2
MS
bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg,
50 mg
2
MS
CUPRIMINE ORAL CAPSULE 250 MG
4
MS
ELMIRON ORAL CAPSULE 100 MG
4
PA; MS
2
MS
calcium acetate oral capsule 667 mg
2
MS
eliphos oral tablet 667 mg
2
MS
FOSRENOL ORAL PACKET 1000 MG, 750 MG
4
MS
FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500
MG, 750 MG
4
MS
RENVELA ORAL PACKET 0.8 GM, 2.4 GM
3
MS
RENVELA ORAL TABLET 800 MG
Hormonal Agents, Stimulant/ Replacement/
Modifying (Adrenal)
3
MS
ala cort external cream 1 %
1
MS
alclometasone dipropionate external cream 0.05 %
2
MS
alclometasone dipropionate external ointment 0.05 %
2
MS
amcinonide external cream 0.1 %
2
MS
amcinonide external lotion 0.1 %
2
MS
amcinonide external ointment 0.1 %
2
MS
betamethasone dipropionate aug external 0.05 %
2
MS
betamethasone dipropionate aug external cream 0.05 %
2
MS
betamethasone dipropionate aug external lotion 0.05 %
2
MS
potassium citrate er oral tablet extendedrelease* 10
meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg)
Phosphate Binders
Modifying (Adrenal)
59
DRUG NAME
TIER
betamethasone dipropionate aug external ointment 0.05
%
2
MS
betamethasone dipropionate external cream 0.05 %
2
MS
betamethasone dipropionate external ointment 0.05 %
2
MS
betamethasone valerate external cream 0.1 %
2
MS
betamethasone valerate external foam 0.12 %
2
MS
betamethasone valerate external lotion 0.1 %
2
MS
betamethasone valerate external ointment 0.1 %
2
MS
clobetasol propionate e external cream 0.05 %
2
MS
clobetasol propionate external 0.05 %
2
MS
clobetasol propionate external cream 0.05 %
2
MS
clobetasol propionate external foam 0.05 %
2
MS
clobetasol propionate external lotion 0.05 %
2
MS
clobetasol propionate external ointment 0.05 %
2
MS
clobetasol propionate external shampoo 0.05 %
2
MS
clobetasol propionate external solution 0.05 %
2
MS
clocortolone pivalate pump external cream 0.1 %
2
MS
clodan external shampoo 0.05 %
2
MS
CLODERM PUMP EXTERNAL CREAM 0.1 %
4
MS
cormax scalp application external solution 0.05 %
2
MS
cortisone acetate oral tablet 25 mg
2
MS
desonide external cream 0.05 %
2
MS
desonide external lotion 0.05 %
2
MS
desonide external ointment 0.05 %
2
MS
desoximetasone external 0.05 %
2
MS
desoximetasone external cream 0.05 %, 0.25 %
2
MS
desoximetasone external ointment 0.05 %, 0.25 %
2
MS
dexamethasone intensol oral concentrate 1 mg/ml
2
MS
dexamethasone oral elixir 0.5 mg/5ml
2
MS
dexamethasone oral solution 0.5 mg/5ml
2
MS
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5
1
MS
mg, 2 mg, 4 mg, 6 mg
60
DRUG NAME
TIER
dexamethasone sod phosphate pf injection solution 10
mg/ml
2
MS
dexamethasone sodium phosphate injection solution 10
mg/ml, 120 mg/30ml
2
MS
fludrocortisone acetate oral tablet 0.1 mg
2
MS
fluocinolone acetonide body external oil 0.01 %
2
MS
fluocinolone acetonide external cream 0.01 %, 0.025 %
2
MS
fluocinolone acetonide external ointment 0.025 %
2
MS
fluocinolone acetonide external solution 0.01 %
2
MS
fluocinolone acetonide otic oil 0.01 %
2
MS
fluocinonide external 0.05 %
2
MS
fluocinonide external cream 0.05 %
2
MS
fluocinonide external ointment 0.05 %
2
MS
fluocinonide external solution 0.05 %
2
MS
fluocinonide-e external cream 0.05 %
2
MS
fluticasone propionate external cream 0.05 %
2
MS
fluticasone propionate external ointment 0.005 %
2
MS
halobetasol propionate external cream 0.05 %
2
MS
halobetasol propionate external ointment 0.05 %
2
MS
hydrocortisone butyrate external ointment 0.1 %
2
MS
hydrocortisone butyrate external solution 0.1 %
2
MS
hydrocortisone external cream 1 %, 2.5 %
1
MS
hydrocortisone external lotion 2.5 %
2
MS
hydrocortisone external ointment 1 %, 2.5 %
1
MS
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg
2
MS
hydrocortisone valerate external cream 0.2 %
2
MS
hydrocortisone valerate external ointment 0.2 %
2
MS
lokara external lotion 0.05 %
2
MS
MEDROL ORAL TABLET 2 MG
4
MS
methylprednisolone (pak) oral tablet 4 mg
2
MS
methylprednisolone acetate injection suspension 40
mg/ml, 80 mg/ml
2
MS
61
DRUG NAME
TIER
methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8
mg
2
MS
methylprednisolone sodium succ injection solution
reconstituted 1000 mg, 125 mg, 40 mg
2
MS
millipred oral tablet 5 mg
2
MS
mometasone furoate external cream 0.1 %
2
MS
mometasone furoate external ointment 0.1 %
2
MS
mometasone furoate external solution 0.1 %
2
MS
prednicarbate external ointment 0.1 %
2
MS
prednisolone oral solution 15 mg/5ml
2
MS
prednisolone sodium phosphate oral solution 15
mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml
2
MS
prednisone intensol oral concentrate 5 mg/ml
2
MS
prednisone oral solution 5 mg/5ml
2
MS
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5
mg, 50 mg
1
MS
proctozone-hc cream 2.5 %
1
MS
triamcinolone acetonide external cream 0.025 %, 0.1
%, 0.5 %
2
MS
triamcinolone acetonide external lotion 0.025 %, 0.1 %
2
MS
triamcinolone acetonide external ointment 0.025 %, 0.1
%, 0.5 %
2
MS
2
MS
chorionic gonadotropin intramuscular* solution
reconstituted 10000 unit
2
PA-BvsD; MS
desmopressin ace rhinal tube nasal solution 0.01 %
2
desmopressin ace spray refrig nasal solution 0.01 %
2
desmopressin acetate injection solution 4 mcg/ml
2
MS
desmopressin acetate oral tablet 0.1 mg, 0.2 mg
2
MS
triderm external cream 0.1 %
Modifying (Pituitary)
Modifying (Pituitary)
62
DRUG NAME
TIER
desmopressin acetate spray nasal solution 0.01 %
2
EGRIFTA SUBCUTANEOUS* SOLUTION
RECONSTITUTED 2 MG
5*
GENOTROPIN MINIQUICK SUBCUTANEOUS* SOLUTION
RECONSTITUTED 0.4 MG, 0.8 MG
5*
PA; LA
GENOTROPIN SUBCUTANEOUS* SOLUTION
RECONSTITUTED 12 MG
5*
PA; LA
HUMATROPE INJECTION SOLUTION RECONSTITUTED
12 MG, 24 MG, 5 MG, 6 MG
5*
PA; LA
INCRELEX SUBCUTANEOUS* SOLUTION 40 MG/4ML
5*
PA; LA
NORDITROPIN FLEXPRO SUBCUTANEOUS* SOLUTION
10 MG/1.5ML
5*
PA
NORDITROPIN FLEXPRO SUBCUTANEOUS* SOLUTION
15 MG/1.5ML, 5 MG/1.5ML
5*
PA; MS
NORDITROPIN NORDIFLEX PEN SUBCUTANEOUS*
SOLUTION 30 MG/3ML
5*
PA; MS
novarel intramuscular* solution reconstituted 10000 unit
2
PA-BvsD; MS
NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS* SOLUTION
5 MG/2ML
5*
PA; LA
NUTROPIN AQ PEN SUBCUTANEOUS* SOLUTION 20
MG/2ML
5*
PA; MS
OMNITROPE SUBCUTANEOUS* SOLUTION 10
MG/1.5ML, 5 MG/1.5ML
5*
PA; LA
OMNITROPE SUBCUTANEOUS* SOLUTION
5*
PA; LA
pregnyl intramuscular* solution reconstituted 10000 unit
2
PA-BvsD; MS
SAIZEN INJECTION SOLUTION RECONSTITUTED 5 MG
Modifying (Sex Hormones/ Modifiers)
5*
PA; LA
ANADROL-50 ORAL TABLET 50 MG
5*
PA; MS
oxandrolone oral tablet 10 mg
5*
oxandrolone oral tablet 2.5 mg
2
Anabolic Steroids
63
DRUG NAME
TIER
Androgens
androxy oral tablet 10 mg
2
MS
danazol oral capsule 100 mg, 200 mg, 50 mg
2
MS
TESTIM TRANSDERMAL 50 MG/5GM (1%)
3
PA; MS
testosterone cypionate intramuscular* solution 100
mg/ml, 200 mg/ml
2
MS
2
MS
DUAVEE ORAL TABLET 0.45-20 MG
3
MS
ESTRACE VAGINAL CREAM 0.1 MG/GM
4
MS
estradiol oral tablet 0.5 mg, 1 mg, 2 mg
2
PA; MS
estradiol transdermal patch biweekly 0.025 mg/24hr,
0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1
mg/24hr
2
MS
estradiol transdermal patch weekly 0.025 mg/24hr,
0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr
2
PA; MS
estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg
2
PA; MS
marlissa oral tablet 0.15-30 mg-mcg
2
MS
MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG,
2.5 MG
4
MS
PREMARIN INJECTION SOLUTION RECONSTITUTED 25
MG
3
MS
PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625
MG, 0.9 MG, 1.25 MG
3
PREMARIN VAGINAL CREAM 0.625 MG/GM
Modifying (Sex Hormones/ Modifiers)
3
MS
amethia oral tablet 0.15-0.03 &0.01 mg
2
MS
amethyst oral tablet 90-20 mcg
2
MS
apri oral tablet 0.15-30 mg-mcg
2
MS
aranelle oral tablet 0.5/1/0.5-35 mg-mcg
2
MS
testosterone enanthate intramuscular* solution 200
mg/ml
Estrogens
64
DRUG NAME
TIER
ashlyna oral tablet 0.15-0.03 &0.01 mg
2
MS
aubra oral tablet 0.1-20 mg-mcg
2
MS
aviane oral tablet 0.1-20 mg-mcg
2
MS
balziva oral tablet 0.4-35 mg-mcg
2
MS
briellyn oral tablet 0.4-35 mg-mcg
2
MS
COMBIPATCH TRANSDERMAL PATCH BIWEEKLY
0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY
4
MS
cryselle-28 oral tablet 0.3-30 mg-mcg
2
MS
cyclafem 1/35 oral tablet 1-35 mg-mcg
2
MS
cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg
2
MS
delyla oral tablet 0.1-20 mg-mcg
2
MS
desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01
mg (21/5)
2
MS
drospirenone-ethinyl estradiol oral tablet 3-0.03 mg
2
MS
emoquette oral tablet 0.15-30 mg-mcg
2
MS
enpresse-28 oral tablet
2
MS
estradiol-norethindrone acet oral tablet 0.5-0.1 mg,
1-0.5 mg
2
PA; MS
falmina oral tablet 0.1-20 mg-mcg
2
MS
gianvi oral tablet 3-0.02 mg
2
MS
gildagia oral tablet 0.4-35 mg-mcg
2
MS
gildess 1.5/30 oral tablet 1.5-30 mg-mcg
2
MS
introvale oral tablet 0.15-0.03 mg
2
MS
jinteli oral tablet 1-5 mg-mcg
2
MS
jolessa oral tablet 0.15-0.03 mg
2
MS
junel 1.5/30 oral tablet 1.5-30 mg-mcg
2
MS
junel 1/20 oral tablet 1-20 mg-mcg
2
MS
junel fe 1.5/30 oral tablet 1.5-30 mg-mcg
2
MS
junel fe 1/20 oral tablet 1-20 mg-mcg
2
MS
kariva oral tablet 0.15-0.02/0.01 mg (21/5)
2
MS
kelnor 1/35 oral tablet 1-35 mg-mcg
2
MS
larin 1.5/30 oral tablet 1.5-30 mg-mcg
2
MS
65
DRUG NAME
TIER
larin 1/20 oral tablet 1-20 mg-mcg
2
MS
larin fe 1.5/30 oral tablet 1.5-30 mg-mcg
2
MS
larin fe 1/20 oral tablet 1-20 mg-mcg
2
MS
leena oral tablet 0.5/1/0.5-35 mg-mcg
2
MS
lessina oral tablet 0.1-20 mg-mcg
2
MS
levonest oral tablet
2
MS
levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg
2
MS
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg,
90-20 mcg
2
MS
levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg
2
MS
lopreeza oral tablet 0.5-0.1 mg, 1-0.5 mg
2
PA; MS
loryna oral tablet 3-0.02 mg
2
MS
low-ogestrel oral tablet 0.3-30 mg-mcg
2
MS
lutera oral tablet 0.1-20 mg-mcg
2
MS
microgestin 1.5/30 oral tablet 1.5-30 mg-mcg
2
MS
microgestin 1/20 oral tablet 1-20 mg-mcg
2
MS
microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg
2
MS
microgestin fe 1/20 oral tablet 1-20 mg-mcg
2
MS
mimvey lo oral tablet 0.5-0.1 mg
2
MS
mimvey oral tablet 1-0.5 mg
2
PA; MS
mononessa oral tablet 0.25-35 mg-mcg
2
MS
necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg
2
MS
necon 1/35 (28) oral tablet 1-35 mg-mcg
2
MS
necon 1/50 (28) oral tablet 1-50 mg-mcg
2
MS
necon 10/11 (28) oral tablet 35 mcg
2
MS
necon 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg
2
MS
nikki oral tablet 3-0.02 mg
2
MS
nora-be oral tablet 0.35 mg
2
MS
norethindrone-eth estradiol oral tablet 1-5 mg-mcg
2
MS
norinyl 1+50 (28) oral tablet 1-50 mg-mcg
2
MS
nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg
2
MS
66
DRUG NAME
TIER
nortrel 1/35 (21) oral tablet 1-35 mg-mcg
2
MS
nortrel 1/35 (28) oral tablet 1-35 mg-mcg
2
MS
nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg
2
MS
ocella oral tablet 3-0.03 mg
2
MS
ogestrel oral tablet 0.5-50 mg-mcg
2
MS
orsythia oral tablet 0.1-20 mg-mcg
2
MS
pimtrea oral tablet 0.15-0.02/0.01 mg (21/5)
2
MS
pirmella 1/35 oral tablet 1-35 mg-mcg
2
MS
portia-28 oral tablet 0.15-30 mg-mcg
2
MS
prefest oral tablet 1/1-0.09 mg (15/15)
2
MS
PREMPHASE ORAL TABLET 0.625-5 MG
3
MS
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG,
0.625-2.5 MG, 0.625-5 MG
3
MS
previfem oral tablet 0.25-35 mg-mcg
2
MS
quasense oral tablet 0.15-0.03 mg
2
MS
reclipsen oral tablet 0.15-30 mg-mcg
2
MS
sprintec 28 oral tablet 0.25-35 mg-mcg
2
MS
sronyx oral tablet 0.1-20 mg-mcg
2
MS
tarina fe 1/20 oral tablet 1-20 mg-mcg
2
MS
tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg
2
MS
trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg
2
MS
tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg
2
MS
tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg
2
MS
trivora (28) oral tablet
2
MS
velivet oral tablet 0.1/0.125/0.15 -0.025 mg
2
MS
vestura oral tablet 3-0.02 mg
2
MS
vyfemla oral tablet 0.4-35 mg-mcg
2
MS
wymzya fe oral tablet chewable 0.4-35 mg-mcg
2
MS
zenchent fe oral tablet chewable 0.4-35 mg-mcg
2
MS
zenchent oral tablet 0.4-35 mg-mcg
2
MS
zovia 1/35e (28) oral tablet 1-35 mg-mcg
2
MS
67
DRUG NAME
TIER
zovia 1/50e (28) oral tablet 1-50 mg-mcg
Progesterone Agonists/ Antagonists
2
MS
ELLA ORAL TABLET 30 MG
Progestins
3
camila oral tablet 0.35 mg
2
MS
deblitane oral tablet 0.35 mg
2
MS
errin oral tablet 0.35 mg
2
MS
jolivette oral tablet 0.35 mg
2
MS
lyza oral tablet 0.35 mg
2
MS
medroxyprogesterone acetate intramuscular*
suspension 150 mg/ml
2
MS
medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg,
5 mg
1
MS
megestrol acetate oral suspension 40 mg/ml
2
MS
megestrol acetate oral tablet 20 mg, 40 mg
2
MS
norethindrone acetate oral tablet 5 mg
2
MS
norethindrone oral tablet 0.35 mg
2
MS
norlyroc oral tablet 0.35 mg
2
MS
progesterone micronized oral capsule 100 mg
1
MS
sharobel oral tablet 0.35 mg
Selective Estrogen Receptor Modifying Agents
2
MS
raloxifene hcl oral tablet 60 mg
Modifying (Thyroid)
2
ARMOUR THYROID ORAL TABLET 120 MG, 15 MG,
180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG
3
MS
levothyroxine sodium intravenous* solution reconstituted
100 mcg
2
MS
levothyroxine sodium intravenous* solution reconstituted
200 mcg, 500 mcg
5*
MS
Modifying (Thyroid)
68
DRUG NAME
TIER
levothyroxine sodium oral tablet 100 mcg, 112 mcg,
125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25
mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg
1
MS
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137
mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg,
75 mcg, 88 mcg
1
MS
liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg
2
MS
NATURE-THROID ORAL TABLET 113.75 MG, 130 MG,
146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG,
32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5
MG
3
MS
np thyroid oral tablet 30 mg, 60 mg, 90 mg
2
MS
SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125
MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25
MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG
3
MS
THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG)
3
MS
THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG)
3
MS
THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG
(MCG)
3
MS
THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG)
3
MS
THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG)
3
MS
1
MS
3
MS
SENSIPAR ORAL TABLET 30 MG
3
5*
5*
unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150
mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg,
75 mcg, 88 mcg
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN ORAL TABLET 500 MG
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Parathyroid)
69
DRUG NAME
TIER
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
cabergoline oral tablet 0.5 mg
2
MS
ELIGARD SUBCUTANEOUS* KIT 22.5 MG, 30 MG, 7.5
MG
4
PA-NS; MS
ELIGARD SUBCUTANEOUS* KIT 45 MG
5*
PA-NS; MS
leuprolide acetate injection kit 1 mg/0.2ml
2
PA-NS; MS
octreotide acetate injection solution 100 mcg/ml, 200
mcg/ml, 50 mcg/ml
2
PA; MS
octreotide acetate injection solution 1000 mcg/ml, 500
mcg/ml
5*
PA; MS
SANDOSTATIN LAR DEPOT INTRAMUSCULAR* KIT 10
MG, 20 MG, 30 MG
5*
PA; MS
SOMATULINE DEPOT SUBCUTANEOUS* SOLUTION 120
MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML
5*
PA; MS
SOMAVERT SUBCUTANEOUS* SOLUTION
RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30
MG
5*
PA; LA
SYNAREL NASAL SOLUTION 2 MG/ML
5*
MS
TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION
5*
PA-BvsD; QL (1 EA per 84 days)
5*
PA-BvsD; MS; QL (1 EA per 168
days)
5*
PA-BvsD; QL (1 EA per 28 days)
methimazole oral tablet 10 mg, 5 mg
2
MS
propylthiouracil oral tablet 50 mg
Immunological Agents
2
MS
5*
PA; MS
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
Angioedema (Hae) Agents
CINRYZE INTRAVENOUS* SOLUTION RECONSTITUTED
500 UNIT
FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML
5*
PA; MS
70
DRUG NAME
TIER
kalbitor subcutaneous* solution 10 mg/ml
Immune Suppressants
5*
PA; MS
AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3
MG, 5 MG
5*
AFINITOR ORAL TABLET 2.5 MG
5*
ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE
24 HOUR 0.5 MG, 1 MG, 5 MG
4
PA-NS; MS
azathioprine oral tablet 50 mg
2
PA-BvsD; MS
cyclosporine intravenous* solution 50 mg/ml
2
PA-BvsD; MS
cyclosporine modified oral capsule 100 mg, 25 mg, 50
mg
2
PA-BvsD; MS
cyclosporine modified oral solution 100 mg/ml
2
PA-BvsD; MS
cyclosporine oral capsule 100 mg, 25 mg
2
PA-BvsD; MS
ENBREL SUBCUTANEOUS* 25 MG/0.5ML, 50 MG/ML
5*
ENBREL SUBCUTANEOUS* KIT 25 MG
5*
gengraf oral capsule 100 mg, 25 mg
2
PA-BvsD; MS
gengraf oral solution 100 mg/ml
2
PA-BvsD; MS
hecoria oral capsule 0.5 mg, 1 mg
2
PA-BvsD; MS
hecoria oral capsule 5 mg
5*
PA-BvsD; MS
HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 40
MG/0.8ML
5*
PA; MS
HUMIRA SUBCUTANEOUS* 10 MG/0.2ML, 20
MG/0.4ML, 40 MG/0.8ML
5*
PA; MS
mercaptopurine oral tablet 50 mg
2
MS
methotrexate oral tablet 2.5 mg
2
MS
methotrexate sodium (pf) injection solution 1 gm/40ml
2
PA-BvsD; MS
methotrexate sodium injection solution reconstituted 1
gm
2
PA-BvsD; MS
mycophenolate mofetil oral capsule 250 mg
2
PA-BvsD; MS
mycophenolate mofetil oral suspension reconstituted
200 mg/ml
5*
PA-BvsD; MS
mycophenolate mofetil oral tablet 500 mg
2
PA-BvsD; MS
71
DRUG NAME
TIER
mycophenolic acid oral tablet delayed release 180 mg,
360 mg
2
PA-BvsD; MS
NULOJIX INTRAVENOUS* SOLUTION RECONSTITUTED
250 MG
5*
PA-BvsD; MS
PROGRAF INTRAVENOUS* SOLUTION 5 MG/ML
3
PA-BvsD; MS
PURIXAN ORAL SUSPENSION 2000 MG/100ML
5*
PA-NS; MS
RAPAMUNE ORAL SOLUTION 1 MG/ML
5*
PA-BvsD; MS
REMICADE INTRAVENOUS* SOLUTION
RECONSTITUTED 100 MG
5*
PA; MS
SANDIMMUNE ORAL SOLUTION 100 MG/ML
4
PA-BvsD; MS
sirolimus oral tablet 0.5 mg, 1 mg
2
PA-BvsD; MS
sirolimus oral tablet 2 mg
5*
PA-BvsD; MS
tacrolimus oral capsule 0.5 mg, 1 mg
2
PA-BvsD; MS
tacrolimus oral capsule 5 mg
5*
PA-BvsD; MS
TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG
4
MS
ZORTRESS ORAL TABLET 0.25 MG
4
PA-BvsD; MS
ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG
Immunizing Agents, Passive
5*
PA-BvsD; MS
CARIMUNE NF INTRAVENOUS* SOLUTION
RECONSTITUTED 12 GM, 6 GM
5*
PA; MS
GAMMAGARD INJECTION SOLUTION 2.5 GM/25ML
5*
PA; MS
SYNAGIS INTRAMUSCULAR* SOLUTION 50 MG/0.5ML
5*
PA; MS
3
PA-NS; MS
ACTIMMUNE SUBCUTANEOUS* SOLUTION 2000000
UNIT/0.5ML
5*
PA-NS; LA
ARCALYST SUBCUTANEOUS* SOLUTION
5*
PA; MS
leflunomide oral tablet 10 mg, 20 mg
2
MS
RIDAURA ORAL CAPSULE 3 MG
5*
MS
THYMOGLOBULIN INTRAVENOUS* SOLUTION
RECONSTITUTED 25 MG
Immunomodulators
72
DRUG NAME
TIER
Vaccines
ACTHIB INTRAMUSCULAR* SOLUTION
RECONSTITUTED
3
ADACEL INTRAMUSCULAR* SUSPENSION 5-2-15.5
LF-MCG/0.5
3
BEXSERO INTRAMUSCULAR*
4
BOOSTRIX INTRAMUSCULAR* SUSPENSION
5-2.5-18.5
3
CERVARIX INTRAMUSCULAR* SUSPENSION
3
COMVAX INTRAMUSCULAR* SUSPENSION 7.5-5
MCG/0.5ML
3
DAPTACEL INTRAMUSCULAR* SUSPENSION 10-15-5
3
DIPHTHERIA-TETANUS TOXOIDS DT
INTRAMUSCULAR* SUSPENSION 25-5 LFU/0.5ML
3
ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML,
20 MCG/ML
3
GARDASIL 9 INTRAMUSCULAR*
3
GARDASIL 9 INTRAMUSCULAR* SUSPENSION
3
GARDASIL INTRAMUSCULAR* SUSPENSION
3
HAVRIX INTRAMUSCULAR* SUSPENSION 1440 EL
U/ML, 720 EL U/0.5ML
3
HIBERIX INJECTION SOLUTION RECONSTITUTED 10
MCG
4
MS
IMOVAX RABIES INTRAMUSCULAR* INJECTABLE 2.5
UNIT/ML
3
PA-BvsD
INFANRIX INTRAMUSCULAR* SUSPENSION 25-58-10
3
IPOL INJECTION INJECTABLE
3
IXIARO INTRAMUSCULAR* SUSPENSION
3
KINRIX INTRAMUSCULAR* SUSPENSION
4
MENACTRA INTRAMUSCULAR* INJECTABLE
4
MENOMUNE SUBCUTANEOUS* INJECTABLE
3
MENVEO INTRAMUSCULAR* SOLUTION
RECONSTITUTED
4
PA-BvsD
73
DRUG NAME
TIER
M-M-R II SUBCUTANEOUS* INJECTABLE
4
PEDIARIX INTRAMUSCULAR* SUSPENSION
3
PEDVAX HIB INTRAMUSCULAR* SUSPENSION 7.5
MCG/0.5ML
3
PENTACEL INTRAMUSCULAR* SUSPENSION
RECONSTITUTED
4
PROQUAD SUBCUTANEOUS* INJECTABLE
3
QUADRACEL INTRAMUSCULAR* SUSPENSION
4
RABAVERT INTRAMUSCULAR* SUSPENSION
RECONSTITUTED
4
PA-BvsD
RECOMBIVAX HB INJECTION SUSPENSION 10
MCG/ML, 40 MCG/ML, 5 MCG/0.5ML
3
PA-BvsD
ROTARIX ORAL SUSPENSION RECONSTITUTED
4
ROTATEQ ORAL SOLUTION
3
TENIVAC INTRAMUSCULAR* INJECTABLE 5-2 LFU
3
MS
TETANUS TOXOID ADSORBED INTRAMUSCULAR*
SOLUTION 5 LFU
3
PA-BvsD
TETANUS-DIPHTHERIA TOXOIDS TD
INTRAMUSCULAR* SUSPENSION 2-2 LF/0.5ML
3
TRUMENBA INTRAMUSCULAR*
4
TWINRIX INTRAMUSCULAR* SUSPENSION 720-20
3
TYPHIM VI INTRAMUSCULAR* SOLUTION 25
MCG/0.5ML
3
VAQTA INTRAMUSCULAR* SUSPENSION 25
UNIT/0.5ML, 50 UNIT/ML
3
VARIVAX SUBCUTANEOUS* INJECTABLE 1350
PFU/0.5ML
3
VARIZIG INTRAMUSCULAR* SOLUTION
4
YF-VAX SUBCUTANEOUS* INJECTABLE
3
ZOSTAVAX SUBCUTANEOUS* SOLUTION
RECONSTITUTED 19400 UNT/0.65ML
4
PA-BvsD
PA-BvsD
PA-BvsD
MS
QL (1 EA per 365 days)
74
DRUG NAME
TIER
Inflammatory Bowel Disease Agents
Aminosalicylates
APRISO ORAL CAPSULE EXTENDED RELEASE 24
HOUR 0.375 GM
4
MS
balsalazide disodium oral capsule 750 mg
2
MS
DIPENTUM ORAL CAPSULE 250 MG
5*
MS
LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM
3
MS
mesalamine-cleanser kit 4 gm
Glucocorticoids
2
MS
colocort enema 100 mg/60ml
2
MS
CORTIFOAM FOAM 90 MG
4
MS
hydrocortisone enema 100 mg/60ml
Sulfonamides
2
MS
sulfasalazine oral tablet 500 mg
2
MS
sulfazine ec oral tablet delayed release 500 mg
Metabolic Bone Disease Agents
2
MS
alendronate sodium oral solution 70 mg/75ml
2
MS
alendronate sodium oral tablet 10 mg, 5 mg
1
MS
alendronate sodium oral tablet 35 mg, 70 mg
1
alendronate sodium oral tablet 40 mg
2
MS
calcitonin (salmon) nasal solution 200 unit/act
2
MS
calcitriol intravenous* solution 1 mcg/ml
2
MS
calcitriol oral capsule 0.25 mcg, 0.5 mcg
2
MS
calcitriol oral solution 1 mcg/ml
2
MS
etidronate disodium oral tablet 200 mg, 400 mg
2
MS
FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML
5*
ibandronate sodium intravenous* solution 3 mg/3ml
2
ibandronate sodium oral tablet 150 mg
2
MIACALCIN INJECTION SOLUTION 200 UNIT/ML
4
PA; MS
Metabolic Bone Disease Agents
pamidronate disodium intravenous* solution 30
2
MS
mg/10ml, 90 mg/10ml
75
DRUG NAME
TIER
paricalcitol intravenous* solution 2 mcg/ml, 5 mcg/ml
2
MS
paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg
2
MS
PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML
4
ST; MS; QL (1 ML per 180 days)
XGEVA SUBCUTANEOUS* SOLUTION 120 MG/1.7ML
5*
PA-NS; MS
zoledronic acid intravenous* concentrate 4 mg/5ml
2
PA; MS
zoledronic acid intravenous* solution 5 mg/100ml
2
PA-BvsD; MS
ZOMETA INTRAVENOUS* SOLUTION 4 MG/100ML
Ophthalmic Agents
5*
PA; MS
bacitracin-polymyxin b ophthalmic ointment 500-10000
unit/gm
2
MS
bacitra-neomycin-polymyxin-hc ophthalmic ointment 1
%
2
MS
neomycin-bacitracin zn-polymyx ophthalmic ointment
5-400-10000
2
MS
neomycin-polymyxin-dexameth ophthalmic ointment
3.5-10000-0.1
2
MS
neomycin-polymyxin-dexameth ophthalmic suspension
3.5-10000-0.1
2
MS
neomycin-polymyxin-gramicidin ophthalmic solution
1.75-10000-0.25
2
MS
neomycin-polymyxin-hc ophthalmic suspension
3.5-10000-1
2
MS
polymyxin b-trimethoprim ophthalmic solution
10000-0.1 unit/ml-%
2
MS
sulfacetamide-prednisolone ophthalmic solution
10-0.23 %
2
MS
tobramycin-dexamethasone ophthalmic suspension
0.3-0.1 %
2
MS
ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 %
Ophthalmic Agents, Other
4
MS
LACRISERT OPHTHALMIC INSERT 5 MG
4
MS
naphazoline hcl ophthalmic solution 0.1 %
1
MS
Ophthalmic Agents
76
DRUG NAME
TIER
RESTASIS OPHTHALMIC EMULSION 0.05 %
3
MS
tropicamide ophthalmic solution 0.5 %, 1 %
Ophthalmic Anti-Allergy Agents
2
MS
ALOCRIL OPHTHALMIC SOLUTION 2 %
3
MS
cromolyn sodium ophthalmic solution 4 %
2
MS
PATADAY OPHTHALMIC SOLUTION 0.2 %
3
MS
PATANOL OPHTHALMIC SOLUTION 0.1 %
Ophthalmic Antiglaucoma Agents
3
MS
ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %, 0.15 %
4
MS
AZOPT OPHTHALMIC SUSPENSION 1 %
3
MS
betaxolol hcl ophthalmic solution 0.5 %
2
MS
brimonidine tartrate ophthalmic solution 0.15 %, 0.2 %
2
MS
carteolol hcl ophthalmic solution 1 %
2
MS
COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 %
3
MS
dorzolamide hcl ophthalmic solution 2 %
2
MS
dorzolamide hcl-timolol mal ophthalmic solution
22.3-6.8 mg/ml
2
MS
levobunolol hcl ophthalmic solution 0.25 %, 0.5 %
2
MS
metipranolol ophthalmic solution 0.3 %
2
MS
pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %
2
MS
SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 %
4
MS
timolol maleate ophthalmic gel forming solution 0.25 %,
0.5 %
2
MS
timolol maleate ophthalmic solution 0.25 %, 0.5 %
Ophthalmic Anti-Inflammatories
2
MS
ALREX OPHTHALMIC SUSPENSION 0.2 %
4
MS
bromfenac sodium ophthalmic solution 0.09 %
2
MS
dexamethasone sodium phosphate ophthalmic solution
0.1 %
2
MS
diclofenac sodium ophthalmic solution 0.1 %
2
MS
DUREZOL OPHTHALMIC EMULSION 0.05 %
4
MS
fluorometholone ophthalmic suspension 0.1 %
2
MS
77
DRUG NAME
TIER
flurbiprofen sodium ophthalmic solution 0.03 %
2
MS
ILEVRO OPHTHALMIC SUSPENSION 0.3 %
4
MS
ketorolac tromethamine ophthalmic solution 0.4 %, 0.5
%
2
MS
LOTEMAX OPHTHALMIC 0.5 %
4
MS
LOTEMAX OPHTHALMIC OINTMENT 0.5 %
4
MS
LOTEMAX OPHTHALMIC SUSPENSION 0.5 %
4
MS
NEVANAC OPHTHALMIC SUSPENSION 0.1 %
4
MS
prednisolone acetate ophthalmic suspension 1 %
2
MS
PROLENSA OPHTHALMIC SOLUTION 0.07 %
Ophthalmic Prostaglandin And Prostamide Analogs
4
MS
latanoprost ophthalmic solution 0.005 %
2
MS
LUMIGAN OPHTHALMIC SOLUTION 0.01 %
3
MS
TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %
Otic Agents
3
MS
acetasol hc otic solution 2-1 %
2
MS
acetic acid-aluminum acetate otic solution 2 %
2
MS
CIPRODEX OTIC SUSPENSION 0.3-0.1 %
4
MS
hydrocortisone-acetic acid otic solution 1-2 %
2
MS
neomycin-polymyxin-hc otic solution 1 %
2
MS
neomycin-polymyxin-hc otic suspension 3.5-10000-1
Respiratory Tract/ Pulmonary Agents
2
MS
arbinoxa oral solution 4 mg/5ml
2
PA; MS
arbinoxa oral tablet 4 mg
2
PA; MS
azelastine hcl nasal solution 0.1 %
2
MS
carbinoxamine maleate oral solution 4 mg/5ml
2
PA; MS
carbinoxamine maleate oral tablet 4 mg
2
PA; MS
clemastine fumarate oral tablet 2.68 mg
2
PA; MS
cyproheptadine hcl oral syrup 2 mg/5ml
2
PA; MS
Otic Agents
Antihistamines
78
DRUG NAME
TIER
cyproheptadine hcl oral tablet 4 mg
2
PA; MS
diphenhydramine hcl injection solution 50 mg/ml
2
MS
hydroxyzine hcl oral solution 10 mg/5ml
2
PA; MS
hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg
2
PA; MS
hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50
mg
2
PA; MS
levocetirizine dihydrochloride oral solution 2.5 mg/5ml
2
MS
levocetirizine dihydrochloride oral tablet 5 mg
2
olopatadine hcl nasal solution 0.6 %
Anti-Inflammatories, Inhaled Corticosteroids
2
MS
ADVAIR DISKUS INHALATION AEROSOL POWDER,
BREATH ACTIVATED 100-50 MCG/DOSE, 250-50
MCG/DOSE, 500-50 MCG/DOSE
3
ADVAIR HFA INHALATION AEROSOL† 115-21
MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT
3
ARNUITY ELLIPTA INHALATION AEROSOL POWDER,
BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT
3
MS
ASMANEX 120 METERED DOSES INHALATION
AEROSOL POWDER, BREATH ACTIVATED 220
MCG/INH
3
MS
MCG/INH, 220 MCG/INH
3
MS
MCG/INH
3
MS
ASMANEX HFA INHALATION AEROSOL† 100
MCG/ACT, 200 MCG/ACT
3
MS
FLOVENT DISKUS INHALATION AEROSOL POWDER,
BREATH ACTIVATED 100 MCG/BLIST, 250
MCG/BLIST, 50 MCG/BLIST
3
FLOVENT HFA INHALATION AEROSOL† 110 MCG/ACT
3
3
3
MS; QL (10.6 GM per 30 days)
79
DRUG NAME
TIER
flunisolide nasal solution 25 mcg/act (0.025%)
2
MS
fluticasone propionate nasal suspension 50 mcg/act
2
MS
NASONEX NASAL SUSPENSION 50 MCG/ACT
4
MS
4
montelukast sodium oral tablet 10 mg
1
montelukast sodium oral tablet chewable 5 mg
1
zafirlukast oral tablet 10 mg, 20 mg
Bronchodilators, Anticholinergic
2
ATROVENT HFA INHALATION AEROSOL, SOLUTION 17
MCG/ACT
3
INCRUSE ELLIPTA INHALATION AEROSOL POWDER,
BREATH ACTIVATED 62.5 MCG/INH
3
MS
ipratropium bromide inhalation solution 0.02 %
2
PA-BvsD; MS
ipratropium bromide nasal solution 0.03 %, 0.06 %
2
MS
3
albuterol sulfate er oral tablet extended release 12 hr* 4
mg, 8 mg
2
MS
albuterol sulfate inhalation nebulization solution (2.5
mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25
mg/3ml
2
PA-BvsD; MS
albuterol sulfate oral syrup 2 mg/5ml
1
MS
albuterol sulfate oral tablet 2 mg, 4 mg
2
MS
ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG
4
MS
AUVI-Q INJECTION 0.15 MG/0.15ML, 0.3 MG/0.3ML
3
MS
BREO ELLIPTA INHALATION AEROSOL POWDER,
BREATH ACTIVATED 100-25 MCG/INH
3
DULERA INHALATION AEROSOL† 100-5 MCG/ACT,
200-5 MCG/ACT
3
PULMICORT FLEXHALER INHALATION AEROSOL
POWDER, BREATH ACTIVATED 180 MCG/ACT, 90
MCG/ACT
Antileukotrienes
TUDORZA PRESSAIR INHALATION AEROSOL POWDER,
BREATH ACTIVATED 400 MCG/ACT
Bronchodilators, Sympathomimetic
80
DRUG NAME
TIER
metaproterenol sulfate oral syrup 10 mg/5ml
2
MS
metaproterenol sulfate oral tablet 10 mg, 20 mg
2
MS
SEREVENT DISKUS INHALATION AEROSOL POWDER,
BREATH ACTIVATED 50 MCG/DOSE
3
terbutaline sulfate injection solution 1 mg/ml
2
MS
terbutaline sulfate oral tablet 2.5 mg, 5 mg
2
MS
3
KALYDECO ORAL PACKET 50 MG, 75 MG
5*
KALYDECO ORAL TABLET 150 MG
Mast Cell Stabilizers
5*
2
PA-BvsD; MS
cromolyn sodium oral concentrate 100 mg/5ml
Phosphodiesterase Inhibitors, Airways Disease
2
MS
aminophylline intravenous* solution 25 mg/ml
2
MS
DALIRESP ORAL TABLET 500 MCG
4
THEO-24 ORAL CAPSULE EXTENDED RELEASE 24
HOUR 100 MG, 200 MG, 300 MG, 400 MG
3
MS
theophylline er oral tablet extended release 12 hr* 100
mg, 200 mg, 300 mg, 450 mg
2
MS
2
MS
ADCIRCA ORAL TABLET 20 MG
5*
LETAIRIS ORAL TABLET 10 MG, 5 MG
5*
REMODULIN INJECTION SOLUTION 1 MG/ML, 10
MG/ML, 2.5 MG/ML, 5 MG/ML
5*
PA; LA
sildenafil citrate oral tablet 20 mg
5*
TRACLEER ORAL TABLET 125 MG, 62.5 MG
Respiratory Tract Agents, Other
5*
PA; LA
acetylcysteine inhalation solution 10 %, 20 %
2
PA-BvsD; MS
VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108
(90 BASE) MCG/ACT
Cystic Fibrosis Agents
cromolyn sodium inhalation nebulization solution 20
mg/2ml
theophylline er oral tablet extended release 24 hr* 400
mg, 600 mg
Pulmonary Antihypertensives
81
DRUG NAME
TIER
ANORO ELLIPTA INHALATION AEROSOL POWDER,
BREATH ACTIVATED 62.5-25 MCG/INH
3
MS
LUMIZYME INTRAVENOUS* SOLUTION
RECONSTITUTED 50 MG
5*
PA-BvsD; LA
5*
PA-BvsD; LA
COMBIVENT RESPIMAT INHALATION AEROSOL,
SOLUTION 20-100 MCG/ACT
3
ipratropium-albuterol inhalation solution 0.5-2.5 (3)
mg/3ml
2
PA-BvsD; MS
promethazine vc plain oral syrup 6.25-5 mg/5ml
2
PA; MS
PULMOZYME INHALATION SOLUTION 1 MG/ML
5*
PA-BvsD; MS
5*
PA; LA
carisoprodol oral tablet 350 mg
2
cyclobenzaprine hcl oral tablet 10 mg, 5 mg
2
methocarbamol oral tablet 500 mg, 750 mg
Sleep Disorder Agents
2
ST; MS
flurazepam hcl oral capsule 15 mg
2
flurazepam hcl oral capsule 30 mg
2
temazepam oral capsule 15 mg, 30 mg
2
zaleplon oral capsule 10 mg, 5 mg
2
zolpidem tartrate oral tablet 10 mg, 5 mg
Sleep Disorders, Other
2
modafinil oral tablet 100 mg
2
modafinil oral tablet 200 mg
5*
XYREM ORAL SOLUTION 500 MG/ML
5*
PA; LA; QL (540 ML per 30 days)
PROLASTIN-C INTRAVENOUS* SOLUTION
Respiratory Tract/ Pulmonary Agents
XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED
150 MG
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
Gaba Receptor Modulators
82
DRUG NAME
TIER
Therapeutic Nutrients/ Minerals/ Electrolytes
Electrolyte/ Mineral Modifiers
EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG,
500 MG
5*
PA; LA
JADENU ORAL TABLET 180 MG, 360 MG, 90 MG
5*
PA; MS
kionex oral powder
2
MS
SAMSCA ORAL TABLET 15 MG, 30 MG
5*
PA; MS
sodium polystyrene sulfonate oral suspension 15
gm/60ml
2
MS
SYPRINE ORAL CAPSULE 250 MG
Electrolyte/ Mineral Replacement
5*
MS
ISOLYTE-S INTRAVENOUS* SOLUTION
4
MS
klor-con 10 oral tablet extendedrelease* 10 meq
2
MS
klor-con m10 oral tablet extendedrelease* 10 meq
2
MS
2
MS
2
MS
klor-con oral tablet extendedrelease* 8 meq
2
MS
magnesium sulfate injection solution 50 %
2
MS
NORMOSOL-R PH 7.4 INTRAVENOUS* SOLUTION
3
MS
PHYSIOLYTE IRRIGATION SOLUTION
4
MS
PHYSIOSOL IRRIGATION IRRIGATION SOLUTION
4
MS
PLASMA-LYTE 148 INTRAVENOUS* SOLUTION
4
MS
PLASMA-LYTE A INTRAVENOUS* SOLUTION
4
MS
potassium chloride crys er oral tablet extendedrelease*
10 meq, 20 meq
2
MS
potassium chloride er oral capsule extended release* 10
meq, 8 meq
2
MS
potassium chloride er oral tablet extendedrelease* 10
meq, 20 meq, 8 meq
2
MS
POTASSIUM CHLORIDE IN NACL INTRAVENOUS*
SOLUTION 20-0.45 MEQ/L-%, 20-0.9 MEQ/L-%,
40-0.9 MEQ/L-%
4
MS
83
DRUG NAME
TIER
potassium chloride intravenous* solution 0.4 meq/ml,
10 meq/50ml, 2 meq/ml
2
MS
POTASSIUM CHLORIDE INTRAVENOUS* SOLUTION 10
MEQ/100ML, 20 MEQ/100ML, 40 MEQ/100ML
4
MS
sodium chloride injection solution 2.5 meq/ml
2
MS
sodium chloride intravenous* solution 0.45 %, 0.9 %, 3
%, 5 %
2
MS
sodium chloride irrigation solution 0.9 %
2
MS
SUPREP BOWEL PREP ORAL SOLUTION
Therapeutic Nutrients/ Minerals/ Electrolytes
3
MS
AMINOSYN II INTRAVENOUS* SOLUTION 10 %, 8.5 %
4
PA-BvsD; MS
AMINOSYN II INTRAVENOUS* SOLUTION 15 %, 7 %
3
PA-BvsD; MS
AMINOSYN II/ELECTROLYTES INTRAVENOUS*
SOLUTION 8.5 %
3
PA-BvsD; MS
AMINOSYN M INTRAVENOUS* SOLUTION 3.5 %
3
PA-BvsD; MS
AMINOSYN/ELECTROLYTES INTRAVENOUS*
SOLUTION 8.5 %
3
PA-BvsD; MS
AMINOSYN-HBC INTRAVENOUS* SOLUTION 7 %
3
PA-BvsD; MS
AMINOSYN-PF INTRAVENOUS* SOLUTION 10 %
4
PA-BvsD; MS
AMINOSYN-PF INTRAVENOUS* SOLUTION 7 %
3
PA-BvsD; MS
CLINIMIX E/DEXTROSE (2.75/10) INTRAVENOUS*
SOLUTION 2.75 %
4
MS
SOLUTION 2.75 %
4
MS
SOLUTION 4.25 %
4
MS
SOLUTION 4.25 %
4
MS
CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS*
SOLUTION 5 %
4
MS
SOLUTION 5 %
4
MS
SOLUTION 5 %
4
MS
84
DRUG NAME
TIER
CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS*
SOLUTION 2.75 %
4
PA-BvsD; MS
SOLUTION 4.25 %
4
PA-BvsD; MS
SOLUTION 4.25 %
4
PA-BvsD; MS
SOLUTION 4.25 %
4
PA-BvsD; MS
SOLUTION 4.25 %
4
PA-BvsD; MS
CLINIMIX/DEXTROSE (5/15) INTRAVENOUS*
SOLUTION 5 %
4
PA-BvsD; MS
SOLUTION 5 %
4
PA-BvsD; MS
SOLUTION 5 %
4
PA-BvsD; MS
CLINISOL SF INTRAVENOUS* SOLUTION 15 %
3
PA-BvsD; MS
DEXTROSE IN LACTATED RINGERS INTRAVENOUS*
SOLUTION 5 %
3
MS
DEXTROSE INTRAVENOUS* SOLUTION 10 %, 5 %
3
MS
DEXTROSE-NACL INTRAVENOUS* SOLUTION 10-0.2
%, 10-0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %,
5-0.33 %, 5-0.45 %, 5-0.9 %
3
MS
fomepizole intravenous* solution 1 gm/ml
5*
MS
HEPATAMINE INTRAVENOUS* SOLUTION 8 %
4
PA-BvsD; MS
HEPATASOL INTRAVENOUS* SOLUTION 8 %
4
PA-BvsD; MS
INTRALIPID INTRAVENOUS* EMULSION 20 %, 30 %
4
PA-BvsD; MS
IONOSOL-B IN D5W INTRAVENOUS* SOLUTION
4
MS
IONOSOL-MB IN D5W INTRAVENOUS* SOLUTION
4
MS
ISOLYTE-P IN D5W INTRAVENOUS* SOLUTION
4
MS
85
DRUG NAME
TIER
KCL IN DEXTROSE-NACL INTRAVENOUS* SOLUTION
10-5-0.45 MEQ/L-%-%, 20-5-0.2 MEQ/L-%-%,
20-5-0.225 MEQ/L-%-%, 20-5-0.33 MEQ/L-%-%,
20-5-0.45 MEQ/L-%-%, 20-5-0.9 MEQ/L-%-%,
30-5-0.45 MEQ/L-%-%, 40-5-0.45 MEQ/L-%-%,
40-5-0.9 MEQ/L-%-%
4
MS
KCL-LACTATED RINGERS-D5W INTRAVENOUS*
SOLUTION 20 MEQ/L
4
MS
LACTATED RINGERS INTRAVENOUS* SOLUTION
3
MS
LACTATED RINGERS IRRIGATION SOLUTION
3
MS
LIPOSYN III INTRAVENOUS* EMULSION 10 %
3
PA-BvsD; MS
LIPOSYN III INTRAVENOUS* EMULSION 20 %
4
PA-BvsD; MS
NEPHRAMINE INTRAVENOUS* SOLUTION 5.4 %
4
PA-BvsD; MS
NORMOSOL-M IN D5W INTRAVENOUS* SOLUTION
4
MS
NORMOSOL-R IN D5W INTRAVENOUS* SOLUTION
3
MS
nutrilipid intravenous* emulsion 20 %
4
PA-BvsD; MS
PLASMA-LYTE-56 IN D5W INTRAVENOUS* SOLUTION
4
MS
POTASSIUM CHLORIDE IN DEXTROSE INTRAVENOUS*
SOLUTION 20-5 MEQ/L-%, 40-5 MEQ/L-%
4
MS
PREMASOL INTRAVENOUS* SOLUTION 10 %, 6 %
4
PA-BvsD; MS
prenatal oral tablet 27-1 mg
1
MS
PROCALAMINE INTRAVENOUS* SOLUTION 3 %
4
PA-BvsD; MS
prosol intravenous* solution 20 %
2
PA-BvsD; MS
RINGERS INTRAVENOUS* SOLUTION
4
MS
RINGERS IRRIGATION IRRIGATION SOLUTION
4
MS
SODIUM LACTATE INTRAVENOUS* SOLUTION 5
MEQ/ML
4
MS
tpn electrolytes intravenous* solution
2
MS
TRAVASOL INTRAVENOUS* SOLUTION 10 %
4
PA-BvsD; MS
TROPHAMINE INTRAVENOUS* SOLUTION 10 %, 6 %
4
PA-BvsD; MS
86
Index of Drugs
87
amikacin sulfate ................................................... 5
amiloride hcl ........................................................... 50
amiloride-hydrochlorothiazide
.......................................................................................................... 47
aminophylline ....................................................... 81
AMINOSYN II ........................................................ 84
AMINOSYN II/ELECTROLYTES
.......................................................................................................... 84
AMINOSYN M ...................................................... 84
AMINOSYN/ELECTROLYTES
.......................................................................................................... 84
AMINOSYN-HBC ............................................ 84
AMINOSYN-PF .................................................. 84
amiodarone hcl .................................................. 45
AMITIZA ......................................................................... 57
amitriptyline hcl ................................................ 18
amlodipine besy-benazepril hcl
.......................................................................................................... 47
amlodipine besylate .................................. 46
amlodipine besylate-valsartan
.......................................................................................................... 47
amlodipine-valsartan-hctz ........... 47
ammonium lactate ...................................... 54
amnesteem ............................................................... 54
amoxapine .................................................................. 18
amoxicillin ........................................................................ 9
amoxicillin-pot clavulanate .............. 9
amphetamine-dextroamphetami
ne ................................................................................................. 52
amphotericin b .................................................... 19
ampicillin ............................................................................ 9
ampicillin sodium ............................................... 9
ampicillin-sulbactam sodium ...... 9
AMPYRA ........................................................................ 53
ANADROL-50 ....................................................... 63
anagrelide hcl ....................................................... 43
anastrozole ................................................................ 24
androxy ............................................................................. 64
ANORO ELLIPTA ............................................. 82
APOKYN .......................................................................... 27
apri ............................................................................................ 64
APRISO ............................................................................. 75
APTIOM ........................................................................... 14
APTIVUS ........................................................................ 34
aranelle ............................................................................. 64
arbinoxa ........................................................................... 78
Index
acetaminophen-codeine #4 ............ 1
acetasol hc ................................................................. 78
acetazolamide ...................................................... 49
acetazolamide er ............................................ 49
acetazolamide sodium ......................... 49
acetic acid ....................................................................... 5
acetic acid-aluminum acetate
.......................................................................................................... 78
acetylcysteine ...................................................... 81
acitretin ............................................................................ 54
ACTHIB ............................................................................. 73
ACTIMMUNE .......................................................... 72
acyclovir .......................................................................... 32
acyclovir sodium ............................................. 32
ADACEL ........................................................................... 73
ADAGEN ......................................................................... 55
ADCIRCA ....................................................................... 81
adefovir dipivoxil ............................................. 31
ADVAIR DISKUS ............................................. 79
ADVAIR HFA .......................................................... 79
afeditab cr ................................................................... 46
AFINITOR ....................................................... 24, 71
AFINITOR DISPERZ .................................. 71
AGGRENOX ............................................................... 43
ala cort ............................................................................... 59
ALBENZA ...................................................................... 26
albuterol sulfate ................................................ 80
albuterol sulfate er ...................................... 80
alclometasone dipropionate ...... 59
ALDURAZYME .................................................... 55
alendronate sodium .................................. 75
alfuzosin hcl er ................................................... 58
ALIMTA ............................................................................ 23
ALINIA ............................................................................... 26
allopurinol .................................................................... 21
ALOCRIL ........................................................................ 77
alosetron hcl ........................................................... 57
ALPHAGAN P ........................................................ 77
alprazolam .................................................................. 35
ALREX ................................................................................ 77
amantadine hcl .................................................. 35
AMBISOME ............................................................... 19
amcinonide ................................................................ 59
amethia ............................................................................ 64
amethyst ........................................................................ 64
amifostine .................................................................... 24
Index
Index
8-MOP ............................................................................... 54
abacavir sulfate ................................................. 33
abacavir-lamivudine-zidovudine
.......................................................................................................... 33
ABELCET ....................................................................... 19
ABILIFY ........................................................................... 29
ABILIFY DISCMELT .................................. 29
ABILIFY MAINTENA ................................ 29
acamprosate calcium ................................. 4
acarbose ......................................................................... 36
ACCU-CHEK ACTIVE .............................. 38
ACCU-CHEK ACTIVE GLUCOSE
CONT .................................................................................... 38
ACCU-CHEK AVIVA .................................. 38
ACCU-CHEK AVIVA PLUS ............ 38
ACCU-CHEK COMFORT CURVE
............................................................................................ 38, 39
ACCU-CHEK COMPACT BLUE
CONTROL ..................................................................... 39
ACCU-CHEK COMPACT PLUS
.......................................................................................................... 39
ACCU-CHEK COMPACT PLUS
CARE ..................................................................................... 39
ACCU-CHEK FASTCLIX LANCET
.......................................................................................................... 39
ACCU-CHEK MULTICLIX
LANCET DEV .......................................................... 39
ACCU-CHEK MULTICLIX
LANCETS ...................................................................... 39
ACCU-CHEK NANO
SMARTVIEW .......................................................... 39
ACCU-CHEK SAFE-T PRO
LANCETS ...................................................................... 39
ACCU-CHEK SMARTVIEW .......... 39
ACCU-CHEK SMARTVIEW
CONTROL ..................................................................... 39
ACCU-CHEK SOFT TOUCH
LANCETS ...................................................................... 39
ACCU-CHEK SOFTCLIX LANCET
DEV .......................................................................................... 39
ACCU-CHEK SOFTCLIX
LANCETS ...................................................................... 39
acebutolol hcl ....................................................... 45
acetaminophen-codeine ....................... 1
88
butalbital-aspirin-caffeine ................. 1
BYDUREON ............................................................... 36
BYETTA 10 MCG PEN .......................... 36
BYETTA 5 MCG PEN ............................... 36
BYSTOLIC .................................................................... 45
cabergoline ................................................................ 70
calcipotriene ........................................................... 54
calcitonin (salmon) ...................................... 75
calcitriol ........................................................................... 75
calcium acetate ................................................ 59
camila .................................................................................. 68
CANCIDAS ................................................................. 19
CAPASTAT SULFATE ............................ 22
CAPRELSA ................................................................. 24
captopril .......................................................................... 44
captopril-hydrochlorothiazide
.......................................................................................................... 47
CARAC ............................................................................... 54
CARAFATE ................................................................. 57
carbamazepine .................................................. 15
carbamazepine er ......................................... 36
carbidopa ...................................................................... 27
carbidopa-levodopa .................................. 28
carbidopa-levodopa er ......................... 28
carbinoxamine maleate ...................... 78
CARIMUNE NF .................................................... 72
carisoprodol ............................................................. 82
carteolol hcl .............................................................. 77
cartia xt ............................................................................ 46
carvedilol ....................................................................... 45
cefaclor ................................................................................. 7
cefadroxil ........................................................................... 7
cefazolin sodium .................................................. 7
cefdinir ................................................................................... 7
cefepime hcl ................................................................ 7
cefepime-dextrose ........................................... 7
cefixime ................................................................................ 7
cefotaxime sodium .......................................... 7
cefoxitin sodium .......................................... 7, 8
cefoxitin sodium-dextrose ................. 8
cefpodoxime proxetil ................................... 8
cefprozil ................................................................................ 8
ceftazidime ..................................................................... 8
ceftazidime and dextrose .................... 8
ceftriaxone sodium .......................................... 8
cefuroxime axetil ................................................. 8
cefuroxime sodium ......................................... 8
CELONTIN ................................................................... 13
Index
balziva ................................................................................. 65
BANZEL ........................................................................... 14
BARACLUDE ........................................................... 31
BD INSULIN SYRINGE ......................... 40
benazepril hcl ....................................................... 44
benazepril-hydrochlorothiazide
.......................................................................................................... 47
benzoyl peroxide-erythromycin
.......................................................................................................... 54
benztropine mesylate ............................. 27
BESIVANCE .............................................................. 11
betamethasone dipropionate
............................................................................................ 54, 60
betamethasone dipropionate aug
............................................................................................ 59, 60
betamethasone valerate ................... 60
betaxolol hcl .............................................. 45, 77
bethanechol chloride .............................. 59
BEXSERO ...................................................................... 73
bicalutamide ........................................................... 22
BICILLIN C-R ........................................................ 10
BICILLIN C-R 900/300 ...................... 10
BICILLIN L-A ......................................................... 10
bisoprolol fumarate .................................... 45
bisoprolol-hydrochlorothiazide
.......................................................................................................... 47
bleomycin sulfate .......................................... 23
BLINCYTO ................................................................... 23
BOOSTRIX .................................................................. 73
BOSULIF ......................................................................... 24
BREO ELLIPTA ................................................... 80
briellyn ............................................................................... 65
BRILINTA ..................................................................... 43
brimonidine tartrate .................................. 77
BRINTELLIX ............................................................ 17
bromfenac sodium ...................................... 77
bromocriptine mesylate ..................... 27
budesonide er ...................................................... 57
bumetanide ............................................................... 49
buprenorphine hcl ............................................. 4
buproban ....................................................................... 16
bupropion hcl ........................................................ 16
bupropion hcl er (sr) ................................. 16
bupropion hcl er (xl) .................................. 16
buspirone hcl ......................................................... 35
butalbital-acetaminophen .................. 1
butalbital-apap-caff-cod ....................... 1
butalbital-apap-caffeine ........................ 1
Index
Index
ARCALYST ................................................................. 72
ARCAPTA NEOHALER ......................... 80
aripiprazole ................................................................ 29
ARMOUR THYROID ................................... 68
ARNUITY ELLIPTA ...................................... 79
ARZERRA ..................................................................... 26
ashlyna .............................................................................. 65
ASMANEX 120 METERED
DOSES ................................................................................ 79
ASMANEX 30 METERED DOSES
.......................................................................................................... 79
ASMANEX 60 METERED DOSES
.......................................................................................................... 79
ASMANEX HFA ................................................. 79
ASSURE ID INSULIN SAFETY
SYR .......................................................................................... 40
ASTAGRAF XL .................................................... 71
atenolol ............................................................................. 45
atenolol-chlorthalidone ....................... 47
atorvastatin calcium ................................. 50
atovaquone ................................................................ 26
atovaquone-proguanil hcl .............. 26
ATRIPLA ........................................................................ 33
atropine sulfate .................................................. 56
ATROVENT HFA ............................................... 80
AUBAGIO ....................................................................... 53
aubra ..................................................................................... 65
AUVI-Q .............................................................................. 80
AVASTIN ........................................................................ 23
aviane .................................................................................. 65
avita ........................................................................................ 26
AVODART .................................................................... 58
azacitidine ................................................................... 23
azathioprine ............................................................. 71
azelastine hcl ........................................................ 78
AZELEX ............................................................................ 54
AZILECT .......................................................................... 28
azithromycin ........................................................... 10
AZOPT ................................................................................ 77
aztreonam ........................................................................ 9
baciim ...................................................................................... 5
bacitracin ........................................................................... 6
bacitracin-polymyxin b ........................ 76
bacitra-neomycin-polymyxin-hc
.......................................................................................................... 76
baclofen ........................................................................... 31
bactocill in dextrose ...................................... 9
balsalazide disodium .............................. 75
89
COMBIPATCH ...................................................... 65
COMBIVENT RESPIMAT ................. 82
COMETRIQ (100 MG DAILY
DOSE) .................................................................................. 25
DOSE) .................................................................................. 25
DOSE) .................................................................................. 25
COMFORT ASSIST INSULIN
SYRINGE ........................................................................ 40
COMFORT EZ PEN NEEDLES
.......................................................................................................... 40
COMPLERA .............................................................. 33
compro .............................................................................. 18
COMVAX ........................................................................ 73
CONDYLOX ............................................................... 54
constulose ................................................................... 57
COPAXONE ............................................................... 53
COREG CR .................................................................. 45
cormax scalp application ................ 60
CORTIFOAM ............................................................ 75
cortisone acetate ............................................ 60
COUMADIN ............................................................... 42
CREON ............................................................................... 55
CRESTOR ...................................................................... 50
CRIXIVAN .................................................................... 34
cromolyn sodium .............................. 77, 81
cryselle-28 ................................................................. 65
CUBICIN .............................................................................. 6
CUPRIMINE .............................................................. 59
CURITY GAUZE .................................................. 40
cyclafem 1/35 ...................................................... 65
cyclafem 7/7/7 ................................................... 65
cyclobenzaprine hcl .................................. 82
cyclophosphamide ...................................... 22
CYCLOSET .................................................................. 37
cyclosporine ............................................................ 71
cyclosporine modified ........................... 71
cyproheptadine hcl ....................... 78, 79
CYSTADANE ........................................................... 55
CYSTAGON ................................................................ 55
DALIRESP ................................................................... 81
danazol .............................................................................. 64
DAPSONE ..................................................................... 22
DAPTACEL ................................................................. 73
DARAPRIM ............................................................... 26
deblitane ........................................................................ 68
delyla .................................................................................... 65
Index
CLINIMIX E/DEXTROSE (4.25/5)
.......................................................................................................... 84
CLINIMIX E/DEXTROSE (5/15)
.......................................................................................................... 84
.......................................................................................................... 84
.......................................................................................................... 84
CLINIMIX/DEXTROSE (2.75/5)
.......................................................................................................... 85
.......................................................................................................... 85
.......................................................................................................... 85
.......................................................................................................... 85
.......................................................................................................... 85
CLINIMIX/DEXTROSE (5/15)
.......................................................................................................... 85
.......................................................................................................... 85
.......................................................................................................... 85
CLINISOL SF .......................................................... 85
clobetasol propionate ............................. 60
clobetasol propionate e ...................... 60
clocortolone pivalate pump ......... 60
clodan .................................................................................. 60
CLODERM PUMP ........................................... 60
clomipramine hcl ........................................... 18
clonazepam .............................................................. 36
clonidine hcl ............................................................ 44
clonidine hcl er ................................................... 52
clopidogrel bisulfate ................................. 43
clorazepate dipotassium .................. 36
clorpres ............................................................................ 48
clotrimazole .............................................................. 19
clotrimazole-betamethasone ... 54
clozapine .......................................................... 30, 31
COARTEM ................................................................... 26
codeine sulfate ....................................................... 3
colchicine-probenecid .......................... 21
COLCRYS ..................................................................... 21
colestipol hcl .......................................................... 51
colistimethate sodium ............................... 5
colocort ............................................................................. 75
COMBIGAN ............................................................... 77
Index
Index
cephalexin ........................................................................ 8
CEREZYME ................................................................ 55
CERVARIX .................................................................. 73
CHANTIX ............................................................................ 4
CHANTIX CONTINUING MONTH
PAK .............................................................................................. 4
CHANTIX STARTING MONTH
PAK .............................................................................................. 4
chloramphenicol sod succinate
............................................................................................................... 6
chlorhexidine gluconate .................... 53
chloroquine phosphate ........................ 26
chlorothiazide ....................................................... 50
chlorothiazide sodium ........................... 50
chlorpromazine hcl ..................................... 28
chlorthalidone ....................................................... 50
cholestyramine ................................................... 51
cholestyramine light ................................. 50
chorionic gonadotropin ....................... 62
CIALIS ................................................................................ 58
ciclopirox ....................................................................... 19
ciclopirox olamine ........................................ 19
cilostazol ........................................................................ 43
cimetidine .................................................................... 56
cimetidine hcl ....................................................... 56
CINRYZE ........................................................................ 70
CIPRODEX .................................................................. 78
ciprofloxacin ............................................................ 11
ciprofloxacin hcl ............................................... 11
ciprofloxacin in d5w ................................. 11
citalopram hydrobromide ............... 17
claravis .............................................................................. 54
clarithromycin ...................................................... 10
clarithromycin er ............................................. 10
clemastine fumarate ................................ 78
clindacin pac ............................................................... 6
clindamax ......................................................................... 6
clindamycin hcl ...................................................... 6
clindamycin phosphate ........................... 6
clindamycin phosphate in d5w
............................................................................................................... 6
CLINIMIX E/DEXTROSE
(2.75/10) ....................................................................... 84
CLINIMIX E/DEXTROSE (2.75/5)
.......................................................................................................... 84
CLINIMIX E/DEXTROSE
(4.25/25) ....................................................................... 84
46
dilt-xr .................................................................................... 46
DIOVAN ............................................................................ 44
DIPENTUM ................................................................. 75
diphenhydramine hcl .............................. 79
diphenoxylate-atropine ....................... 56
DIPHTHERIA-TETANUS
TOXOIDS DT ........................................................... 73
dipyridamole ........................................................... 43
disopyramide phosphate ................. 45
disulfiram .......................................................................... 4
divalproex sodium ........................................ 13
divalproex sodium er ............................... 13
donepezil hcl .......................................................... 15
DORIBAX ........................................................................... 9
dorzolamide hcl ................................................ 77
dorzolamide hcl-timolol mal ..... 77
doxazosin mesylate ................................... 58
doxepin hcl ................................................................ 18
doxycycline hyclate .................................... 12
doxycycline monohydrate .............. 12
dronabinol .................................................................... 19
drospirenone-ethinyl estradiol
.......................................................................................................... 65
DROXIA ............................................................................ 23
DUAVEE ........................................................................... 64
DULERA ........................................................................... 80
duloxetine hcl ........................................................ 17
duramorph ....................................................................... 2
DUREZOL ...................................................................... 77
e.e.s. 400 ..................................................................... 11
E.E.S. GRANULES ........................................ 11
e.s.p. ...................................................................................... 11
econazole nitrate ............................................ 19
EDARBI ............................................................................ 44
EDARBYCLOR ..................................................... 48
EDURANT ..................................................................... 33
EFFIENT .......................................................................... 44
EGRIFTA ......................................................................... 63
ELAPRASE ................................................................. 55
ELIDEL ............................................................................... 54
ELIGARD ........................................................................ 70
eliphos ................................................................................ 59
ELIQUIS ........................................................................... 42
ELITEK ............................................................................... 23
ELLA ...................................................................................... 68
ELMIRON ...................................................................... 59
..........................................................................................................
90
EMCYT ............................................................................... 23
EMEND .............................................................................. 19
emoquette ................................................................... 65
EMSAM ............................................................................ 16
EMTRIVA ...................................................................... 33
enalapril maleate ........................................... 44
enalapril-hydrochlorothiazide
.......................................................................................................... 48
ENBREL ........................................................................... 71
endocet ................................................................................. 1
ENGERIX-B ............................................................... 73
enoxaparin sodium ..................................... 42
enpresse-28 ............................................................ 65
entacapone ................................................................ 27
entecavir ........................................................................ 31
enulose ............................................................................. 57
epitol ...................................................................................... 15
EPIVIR HBV .............................................................. 31
EPZICOM ....................................................................... 33
ergoloid mesylates ...................................... 15
ERIVEDGE ................................................................... 25
errin ......................................................................................... 68
ERYPED 200 ........................................................... 11
ery-tab ............................................................................... 11
erythrocin lactobionate ....................... 11
erythrocin stearate ...................................... 11
erythromycin .......................................................... 11
erythromycin base ....................................... 11
erythromycin ethylsuccinate .... 11
escitalopram oxalate ............................... 17
esomeprazole sodium ........................... 58
estazolam ..................................................................... 52
ESTRACE ...................................................................... 64
estradiol ........................................................................... 64
estradiol-norethindrone acet .... 65
estropipate ................................................................. 64
ethambutol hcl .................................................... 22
ethosuximide ......................................................... 13
etidronate disodium .................................. 75
etodolac ................................................................................ 2
etodolac er ...................................................................... 2
EVOTAZ ........................................................................... 34
EXCEL COMFORT POINT PEN
NEEDLE ............................................................................ 40
EXELON ........................................................................... 15
exemestane .............................................................. 24
EXJADE ........................................................................... 83
EXTAVIA ........................................................................ 53
Index
diltiazem hcl er coated beads
Index
Index
demeclocycline hcl ..................................... 12
DEMSER ......................................................................... 48
DENAVIR ....................................................................... 32
desipramine hcl ................................................ 18
desmopressin ace rhinal tube
.......................................................................................................... 62
desmopressin ace spray refrig
.......................................................................................................... 62
desmopressin acetate .......................... 62
desmopressin acetate spray .... 63
desogestrel-ethinyl estradiol .... 65
desonide ......................................................................... 60
desoximetasone ............................................... 60
dexamethasone ................................................. 60
dexamethasone intensol .................. 60
dexamethasone sod phosphate
pf .................................................................................................. 61
dexamethasone sodium
phosphate ...................................................... 61, 77
dexedrine ...................................................................... 52
DEXILANT ................................................................... 58
dexmethylphenidate hcl .................... 52
dextroamphetamine sulfate ....... 52
dextroamphetamine sulfate er
.......................................................................................................... 52
DEXTROSE ................................................................. 85
DEXTROSE IN LACTATED
RINGERS ....................................................................... 85
DEXTROSE-NACL ........................................ 85
diazepam ......................................................... 12, 36
diazepam intensol ........................................ 36
diclofenac potassium .................................. 1
diclofenac sodium ............................... 2, 77
diclofenac sodium er ................................... 1
dicloxacillin sodium ................................... 10
dicyclomine hcl .................................................. 56
didanosine .................................................................. 33
DIFICID ............................................................................. 10
diflunisal .............................................................................. 2
digitek ................................................................................. 49
digoxin ................................................................................ 49
dihydroergotamine mesylate ... 21
DILANTIN ..................................................................... 15
DILANTIN INFATABS ............................ 15
diltiazem hcl ............................................................ 46
diltiazem hcl er .................................................. 46
diltiazem hcl er beads ........................... 46
91
GILOTRIF ...................................................................... 25
GLEEVEC ....................................................................... 25
gleostine ......................................................................... 22
glimepiride ................................................................. 37
glipizide ............................................................................ 37
glipizide er .................................................................. 37
glipizide-metformin hcl ...................... 38
global alcohol prep ease ....................... 6
GLUCAGEN HYPOKIT ............................ 40
GLUCAGON EMERGENCY ............. 40
glyburide ........................................................................ 37
glyburide micronized .............................. 37
glyburide-metformin ................................ 38
glycopyrrolate ....................................................... 56
GRALISE ........................................................................ 13
GRALISE STARTER ................................... 13
granisetron hcl .................................................... 19
griseofulvin microsize ........................... 20
griseofulvin ultramicrosize ........... 20
guanfacine hcl ..................................................... 44
guanidine hcl ......................................................... 21
HALDOL DECANOATE .......................... 28
halobetasol propionate ........................ 61
haloperidol .................................................................. 28
haloperidol decanoate .......................... 28
haloperidol lactate ....................................... 28
HARVONI ....................................................................... 31
HAVRIX ............................................................................ 73
hecoria ............................................................................... 71
heparin (porcine) in d5w .................. 42
heparin (porcine) in nacl ................... 42
heparin sod (porcine) in d5w ... 42
heparin sodium (porcine)
............................................................................................ 42, 43
HEPATAMINE ....................................................... 85
HEPATASOL ............................................................ 85
HEXALEN ...................................................................... 22
HIBERIX .......................................................................... 73
HUMALOG ................................................................... 41
HUMALOG KWIKPEN ............................. 41
HUMALOG MIX 50/50 ......................... 41
HUMALOG MIX 50/50 KWIKPEN
.......................................................................................................... 41
HUMALOG MIX 75/25 ......................... 41
HUMALOG MIX 75/25 KWIKPEN
.......................................................................................................... 41
HUMATROPE ......................................................... 63
HUMIRA .......................................................................... 71
Index
fomepizole .................................................................. 85
fondaparinux sodium .............................. 42
FORTEO ........................................................................... 75
foscarnet sodium ........................................... 31
fosinopril sodium ............................................ 44
fosinopril sodium-hctz ......................... 48
fosphenytoin sodium ............................... 15
FOSRENOL ................................................................. 59
FREESTYLE CONTROL
SOLUTION ................................................................... 39
FREESTYLE FREEDOM LITE .... 39
FREESTYLE INSULINX SYSTEM
.......................................................................................................... 39
FREESTYLE INSULINX TEST
.......................................................................................................... 40
FREESTYLE LITE ........................................... 40
FREESTYLE LITE TEST ...................... 40
FREESTYLE TEST ......................................... 40
furosemide ................................................................. 49
FUZEON ........................................................................... 34
FYCOMPA .................................................................... 14
gabapentin ................................................................. 13
GABITRIL ...................................................................... 13
galantamine hydrobromide
............................................................................................ 15, 16
galantamine hydrobromide er
.......................................................................................................... 15
GAMMAGARD ..................................................... 72
ganciclovir sodium ...................................... 31
GARDASIL .................................................................. 73
GARDASIL 9 ........................................................... 73
gatifloxacin ................................................................ 11
gavilyte-c ...................................................................... 57
gavilyte-g ...................................................................... 57
gavilyte-n with flavor pack .......... 57
gemfibrozil .................................................................. 50
generlac .......................................................................... 57
gengraf .............................................................................. 71
GENOTROPIN ........................................................ 63
GENOTROPIN MINIQUICK ............ 63
gentak ...................................................................................... 5
gentamicin in saline ...................................... 5
gentamicin sulfate ............................................ 5
GEODON ......................................................................... 29
gianvi .................................................................................... 65
gildagia ............................................................................. 65
gildess 1.5/30 ...................................................... 65
GILENYA ........................................................................ 53
Index
Index
FABRAZYME .......................................................... 55
falmina ............................................................................... 65
famciclovir .................................................................. 32
famotidine ..................................................... 56, 57
famotidine premixed ................................ 57
FANAPT ........................................................................... 29
FANAPT TITRATION PACK ........ 29
FARESTON ................................................................. 23
FARYDAK ..................................................................... 24
FASLODEX ................................................................. 23
felbamate ...................................................................... 14
felodipine er ............................................................. 46
fenofibrate ................................................................... 50
fenofibrate micronized ......................... 50
fenoprofen calcium ......................................... 2
fentanyl ................................................................................. 2
fentanyl citrate ........................................................ 3
FETZIMA ........................................................................ 17
FETZIMA TITRATION ............................. 17
FINACEA ........................................................................ 54
finasteride .................................................................... 58
FIRAZYR ........................................................................ 70
flecainide acetate .......................................... 45
FLOVENT DISKUS ........................................ 79
FLOVENT HFA ..................................................... 79
fluconazole ................................................................. 20
fluconazole in dextrose ....................... 19
fluconazole in sodium chloride
.......................................................................................................... 20
flucytosine ................................................................... 20
fludrocortisone acetate ....................... 61
flunisolide ..................................................................... 80
fluocinolone acetonide ......................... 61
fluocinolone acetonide body ..... 61
fluocinonide .............................................................. 61
fluocinonide-e ...................................................... 61
fluorometholone ............................................... 77
FLUOROURACIL ............................................... 54
fluorouracil ................................................................. 54
fluoxetine hcl ......................................................... 17
fluphenazine decanoate .................... 28
fluphenazine hcl ............................................... 28
flurazepam hcl .................................................... 82
flurbiprofen ..................................................................... 2
flurbiprofen sodium ................................... 78
flutamide ........................................................................ 22
fluticasone propionate ............ 61, 80
fluvoxamine maleate ............................... 17
92
ketoprofen er .............................................................. 2
ketorolac tromethamine .................... 78
KINRIX ............................................................................... 73
kionex .................................................................................. 83
klor-con ........................................................................... 83
klor-con 10 ................................................................ 83
klor-con m10 ......................................................... 83
klor-con m15 ......................................................... 83
klor-con m20 ......................................................... 83
KOMBIGLYZE XR .......................................... 38
KORLYM ......................................................................... 40
KUVAN ............................................................................... 55
labetalol hcl ................................................ 45, 46
LACRISERT ............................................................... 76
LACTATED RINGERS ............................. 86
lactulose ......................................................................... 57
lamivudine .................................................... 31, 34
lamivudine-zidovudine ......................... 34
lamotrigine ................................................................. 14
LANOXIN ....................................................................... 49
LANOXIN PEDIATRIC ............................ 49
LANTUS ........................................................................... 41
LANTUS SOLOSTAR ................................ 41
larin 1.5/30 ................................................................ 65
larin 1/20 ....................................................................... 66
larin fe 1.5/30 ...................................................... 66
larin fe 1/20 ............................................................. 66
latanoprost ................................................................. 78
LATUDA ........................................................................... 30
LAZANDA ......................................................................... 3
leena ...................................................................................... 66
leflunomide ............................................................... 72
LENVIMA 10 MG DAILY DOSE
.......................................................................................................... 25
.......................................................................................................... 25
.......................................................................................................... 25
.......................................................................................................... 25
lessina ................................................................................ 66
LETAIRIS ....................................................................... 81
letrozole ........................................................................... 24
leucovorin calcium ...................................... 24
LEUKERAN ................................................................. 22
LEUKINE ......................................................................... 43
leuprolide acetate ......................................... 70
LEVEMIR ....................................................................... 41
Index
INVEGA ............................................................................. 29
INVEGA SUSTENNA ................................. 30
INVIRASE ..................................................................... 34
INVOKAMET ............................................................ 37
INVOKANA ................................................................. 37
IONOSOL-B IN D5W ................................ 85
IONOSOL-MB IN D5W ......................... 85
IPOL ........................................................................................ 73
ipratropium bromide ................................ 80
ipratropium-albuterol ............................. 82
ISENTRESS ............................................................... 32
ISOLYTE-P IN D5W .................................. 85
ISOLYTE-S ................................................................. 83
isoniazid .......................................................................... 22
isosorbide dinitrate ..................................... 51
isosorbide dinitrate er ........................... 51
isosorbide mononitrate ....................... 51
isosorbide mononitrate er .............. 51
itraconazole .............................................................. 20
ivermectin .................................................................... 26
IXEMPRA KIT ....................................................... 23
IXIARO ............................................................................... 73
JADENU .......................................................................... 83
JAKAFI .............................................................................. 25
JALYN ................................................................................ 59
jantoven ........................................................................... 43
JANUMET .................................................................... 38
JANUMET XR ....................................................... 38
JANUVIA ........................................................................ 37
JARDIANCE ............................................................. 37
jinteli ...................................................................................... 65
jolessa ................................................................................. 65
jolivette ............................................................................. 68
junel 1.5/30 .............................................................. 65
junel 1/20 ..................................................................... 65
junel fe 1.5/30 ..................................................... 65
junel fe 1/20 ............................................................ 65
JUXTAPID ................................................................... 51
kalbitor ............................................................................... 71
KALETRA ...................................................................... 34
KALYDECO ................................................................ 81
kariva .................................................................................... 65
KCL IN DEXTROSE-NACL ............. 86
KCL-LACTATED RINGERS-D5W
.......................................................................................................... 86
kelnor 1/35 ................................................................ 65
ketoconazole .......................................................... 20
ketoprofen ........................................................................ 2
Index
Index
HUMIRA PEN-CROHNS
STARTER ...................................................................... 71
HUMULIN 70/30 ............................................. 41
HUMULIN 70/30 KWIKPEN ....... 41
HUMULIN N .............................................................. 41
HUMULIN N KWIKPEN ........................ 41
HUMULIN R .............................................................. 41
HUMULIN R U-500
(CONCENTRATED) ...................................... 41
hydralazine hcl ................................................... 51
hydrochlorothiazide ................................... 50
hydrocodone-acetaminophen ..... 1
hydrocodone-ibuprofen .......................... 1
hydrocortisone ...................................... 61, 75
hydrocortisone butyrate .................... 61
hydrocortisone valerate ..................... 61
hydrocortisone-acetic acid .......... 78
hydromorphone hcl ......................................... 3
hydromorphone hcl pf ............................... 3
hydroxychloroquine sulfate ......... 26
hydroxyurea ............................................................. 23
hydroxyzine hcl .................................... 18, 79
hydroxyzine pamoate ............................. 79
ibandronate sodium .................................. 75
IBRANCE ....................................................................... 25
ibuprofen ............................................................................ 2
ICLUSIG ........................................................................... 25
ifosfamide .................................................................... 23
ILEVRO .............................................................................. 78
ilotycin ................................................................................ 11
IMBRUVICA ............................................................. 25
imipenem-cilastatin ....................................... 9
imipramine hcl .................................................... 18
imipramine pamoate ............................... 18
imiquimod .................................................................... 54
IMOVAX RABIES ............................................ 73
INCRELEX .................................................................... 63
INCRUSE ELLIPTA ...................................... 80
indapamide ............................................................... 50
indomethacin ............................................................. 2
INFANRIX ..................................................................... 73
INLYTA .............................................................................. 25
INSULIN SYRINGE ...................................... 41
INTELENCE ............................................................... 33
INTRALIPID .............................................................. 85
INTRON A .................................................................... 31
introvale ........................................................................... 65
INVANZ ................................................................................. 9
93
methotrexate .......................................................... 71
methotrexate sodium ............................. 71
methotrexate sodium (pf) ............... 71
methoxsalen rapid ....................................... 54
methscopolamine bromide .......... 56
methyclothiazide ............................................. 50
methyldopa ............................................................... 44
methyldopa-hydrochlorothiazide
.......................................................................................................... 48
methylphenidate hcl ................................. 52
methylphenidate hcl er ....................... 52
methylprednisolone ................................... 62
methylprednisolone (pak) ............... 61
methylprednisolone acetate ...... 61
methylprednisolone sodium succ
.......................................................................................................... 62
metipranolol ............................................................. 77
metoclopramide hcl .................................. 56
metolazone ................................................................ 50
metoprolol succinate er ..................... 46
metoprolol tartrate ....................................... 46
metoprolol-hydrochlorothiazide
.......................................................................................................... 48
metronidazole ........................................................... 6
metronidazole in nacl ................................. 6
mexiletine hcl ........................................................ 45
MIACALCIN .............................................................. 75
microgestin 1.5/30 ..................................... 66
microgestin 1/20 ............................................ 66
microgestin fe 1.5/30 ............................ 66
microgestin fe 1/20 ................................... 66
midodrine hcl ........................................................ 44
MIGERGOT ................................................................. 21
MIGRANAL ................................................................ 21
millipred .......................................................................... 62
mimvey ............................................................................. 66
mimvey lo .................................................................... 66
minitran ............................................................................ 51
minocycline hcl .................................................. 12
minoxidil ......................................................................... 51
mirtazapine ............................................................... 16
misoprostol ................................................................ 57
mitoxantrone hcl ............................................. 53
M-M-R II ....................................................................... 74
modafinil ........................................................................ 82
moderiba ........................................................................ 32
moexipril hcl ........................................................... 44
Index
lovastatin ....................................................................... 50
low-ogestrel ............................................................. 66
loxapine succinate ....................................... 28
LUMIGAN ...................................................................... 78
LUMIZYME ................................................................ 82
lutera ..................................................................................... 66
LYNPARZA ................................................................ 24
LYRICA ............................................................................. 13
LYSODREN ................................................................ 69
lyza ........................................................................................... 68
magnesium sulfate ..................................... 83
malathion ...................................................................... 27
maprotiline hcl .................................................... 16
marlissa ........................................................................... 64
MARPLAN ................................................................... 16
MATULANE ............................................................... 22
matzim la ...................................................................... 47
meclizine hcl .......................................................... 18
MEDISENSE HI/MID/LOW
CONTROL ..................................................................... 40
MEDROL ......................................................................... 61
medroxyprogesterone acetate
.......................................................................................................... 68
mefloquine hcl .................................................... 27
megestrol acetate ......................................... 68
MEKINIST .................................................................... 25
meloxicam ....................................................................... 2
MENACTRA .............................................................. 73
MENEST .......................................................................... 64
MENOMUNE ............................................................ 73
MENVEO ......................................................................... 73
meprobamate ....................................................... 35
mercaptopurine ................................................. 71
meropenem ................................................................... 9
mesalamine-cleanser ............................ 75
mesna ................................................................................. 24
MESNEX ......................................................................... 24
MESTINON ................................................................. 21
metadate er .............................................................. 52
metaproterenol sulfate ........................ 81
metformin hcl ....................................................... 37
metformin hcl er .............................................. 37
metformin hcl er (osm) ......... 37, 38
methadone hcl ......................................................... 3
methazolamide .................................................. 49
methenamine hippurate ........................ 6
methimazole ........................................................... 70
methocarbamol ................................................. 82
Index
Index
LEVEMIR FLEXTOUCH ........................ 41
levetiracetam ......................................................... 13
levetiracetam in nacl ............................... 12
levobunolol hcl .................................................... 77
levocetirizine dihydrochloride
.......................................................................................................... 79
levofloxacin ............................................................... 11
levofloxacin in d5w .................................... 11
levonest ........................................................................... 66
levonorgest-eth estrad 91-day
.......................................................................................................... 66
levonorgestrel-ethinyl estrad ... 66
levora 0.15/30 (28) ..................................... 66
levothyroxine sodium ............... 68, 69
levoxyl ................................................................................. 69
LEXIVA .............................................................................. 34
LIALDA ............................................................................. 75
lidocaine .............................................................................. 4
lidocaine hcl ................................................................. 4
lidocaine hcl (cardiac) ................................ 4
lidocaine hcl (pf) ................................................... 4
lidocaine viscous ................................................. 4
lidocaine-prilocaine ........................................ 4
LIDODERM ..................................................................... 4
linezolid ................................................................................. 6
liothyronine sodium ................................... 69
LIPOSYN III .............................................................. 86
lisinopril ........................................................................... 44
lisinopril-hydrochlorothiazide
.......................................................................................................... 48
lithium ................................................................................. 36
lithium carbonate ........................................... 36
lithium carbonate er ................................. 36
LIVALO .............................................................................. 50
lokara ................................................................................... 61
lomustine ...................................................................... 22
loperamide hcl .................................................... 56
lopreeza ........................................................................... 66
lorazepam .................................................................... 36
lorcet .......................................................................................... 1
lorcet hd ............................................................................... 1
lorcet plus ......................................................................... 1
lortab .......................................................................................... 1
loryna ................................................................................... 66
losartan potassium ..................................... 44
losartan potassium-hctz ................... 48
LOTEMAX .................................................................... 78
LOTRONEX ................................................................ 57
48
mometasone furoate ............................... 62
mononessa ................................................................ 66
montelukast sodium ................................ 80
morphine sulfate .................................................. 3
morphine sulfate (concentrate)
............................................................................................................... 3
morphine sulfate (pf) .................................... 3
morphine sulfate er ........................................ 3
MOVIPREP ................................................................. 57
MOXEZA ......................................................................... 11
MOZOBIL ...................................................................... 43
MULTAQ ......................................................................... 45
mupirocin .......................................................................... 6
mupirocin calcium ............................................ 6
MYCAMINE ............................................................... 20
mycophenolate mofetil ........................ 71
mycophenolic acid ...................................... 72
myorisan ........................................................................ 54
MYOZYME .................................................................. 55
MYRBETRIQ ............................................................ 58
nabumetone ................................................................. 2
nadolol ............................................................................... 46
NAFTIN ............................................................................. 20
NAGLAZYME ......................................................... 55
naloxone hcl ................................................................. 4
naltrexone hcl ........................................................... 4
NAMENDA .................................................................. 16
NAMENDA TITRATION PAK ..... 16
NAMENDA XR ..................................................... 16
NAMENDA XR TITRATION
PACK .................................................................................... 16
naphazoline hcl ................................................. 76
naproxen ............................................................................. 2
naproxen dr ................................................................... 2
naproxen sodium ................................................ 2
naratriptan hcl ..................................................... 21
NASONEX .................................................................... 80
NATACYN .................................................................... 20
nateglinide .................................................................. 37
NATURE-THROID .......................................... 69
NEBUPENT ................................................................ 27
necon 0.5/35 (28) ......................................... 66
necon 1/35 (28) ................................................ 66
necon 1/50 (28) ................................................ 66
necon 10/11 (28) ............................................ 66
necon 7/7/7 .............................................................. 66
..........................................................................................................
94
NORPACE CR ........................................................ 45
nortrel 0.5/35 (28) ........................................ 66
nortrel 1/35 (21) ............................................... 67
nortrel 1/35 (28) ............................................... 67
nortrel 7/7/7 ............................................................ 67
nortriptyline hcl .................................................. 18
NORVIR .............................................................. 34, 35
novarel ............................................................................... 63
NOXAFIL ........................................................................ 20
np thyroid ..................................................................... 69
NUEDEXTA ................................................................ 52
NULOJIX ........................................................................ 72
nutrilipid .......................................................................... 86
NUTROPIN AQ NUSPIN 5 .............. 63
NUTROPIN AQ PEN ................................... 63
nyamyc ............................................................................. 20
nystatin ............................................................................. 20
nystatin-triamcinolone ......................... 54
nystop .................................................................................. 20
ocella .................................................................................... 67
octreotide acetate ......................................... 70
ofloxacin ........................................................... 11, 12
ogestrel ............................................................................. 67
olanzapine ................................................................... 30
olopatadine hcl ................................................... 79
OLYSIO ............................................................................. 32
omega-3-acid ethyl esters ........... 51
omeprazole ................................................................ 58
OMNITROPE ........................................................... 63
ondansetron ............................................................. 19
ondansetron hcl ................................................ 19
ONFI ......................................................................... 13, 14
ONGLYZA ..................................................................... 37
OPANA ER ....................................................................... 3
OPDIVO ............................................................................ 26
ORAP .................................................................................... 29
ORFADIN ....................................................................... 55
orsythia ............................................................................. 67
oxacillin sodium ................................................ 10
oxandrolone ............................................................. 63
oxaprozin ........................................................................... 2
oxazepam ..................................................................... 35
oxcarbazepine ...................................................... 15
oxybutynin chloride .................................... 58
oxybutynin chloride er .......................... 58
oxycodone hcl ........................................................... 3
oxycodone-acetaminophen ............. 1
oxymorphone hcl er ....................................... 3
Index
nefazodone hcl ................................................... 16
neomycin sulfate ................................................. 5
neomycin-bacitracin zn-polymyx
.......................................................................................................... 76
neomycin-polymyxin b gu .................. 5
neomycin-polymyxin-dexameth
.......................................................................................................... 76
neomycin-polymyxin-gramicidin
.......................................................................................................... 76
neomycin-polymyxin-hc ..... 76, 78
NEPHRAMINE ...................................................... 86
NEUMEGA ................................................................... 43
NEUPOGEN ................................................................ 43
NEUPRO .......................................................................... 27
NEVANAC .................................................................... 78
nevirapine .................................................................... 33
nevirapine er ........................................................... 33
NEXAVAR ..................................................................... 25
NEXIUM ........................................................................... 58
niacin er (antihyperlipidemic)
.......................................................................................................... 51
NIACOR ............................................................................ 51
nicardipine hcl ..................................................... 47
NICOTROL NS .......................................................... 4
nifedical xl ................................................................... 47
nifedipine ...................................................................... 47
nifedipine er osmotic .............................. 47
nikki ........................................................................................ 66
NILANDRON ............................................................ 22
nimodipine .................................................................. 47
NITRO-BID ................................................................. 51
nitrofurantoin macrocrystal ............. 6
nitrofurantoin monohyd macro
............................................................................................................... 7
nitroglycerin ............................................... 51, 52
NITROSTAT .............................................................. 52
nora-be ............................................................................. 66
NORDITROPIN FLEXPRO ............... 63
NORDITROPIN NORDIFLEX PEN
.......................................................................................................... 63
norethindrone ....................................................... 68
norethindrone acetate ........................... 68
norethindrone-eth estradiol ....... 66
norinyl 1+50 (28) ........................................... 66
norlyroc ............................................................................ 68
NORMOSOL-M IN D5W .................... 86
NORMOSOL-R IN D5W ...................... 86
NORMOSOL-R PH 7.4 .......................... 83
Index
Index
moexipril-hydrochlorothiazide
95
PREZISTA .................................................................... 35
PRIFTIN ........................................................................... 22
primaquine phosphate ......................... 27
primidone ..................................................................... 14
PRISTIQ ........................................................................... 17
probenecid ................................................................. 21
procainamide hcl ............................................ 45
PROCALAMINE ................................................. 86
prochlorperazine ............................................. 18
prochlorperazine edisylate ........... 29
prochlorperazine maleate .............. 29
PROCRIT ........................................................................ 43
proctosol hc ............................................................. 56
proctozone-hc ...................................................... 62
progesterone micronized ................ 68
PROGLYCEM ......................................................... 40
PROGRAF ..................................................................... 72
PROLASTIN-C ..................................................... 82
PROLENSA ................................................................ 78
PROLEUKIN .............................................................. 24
PROLIA ............................................................................. 76
PROMACTA .............................................................. 43
promethazine hcl ........................................... 18
promethazine vc plain .......................... 82
promethegan .......................................................... 18
propafenone hcl ............................................... 45
propantheline bromide ........................ 56
propranolol hcl .................................................... 46
propranolol hcl er .......................................... 46
propranolol-hctz .............................................. 48
propylthiouracil .................................................. 70
PROQUAD .................................................................... 74
prosol ................................................................................... 86
protriptyline hcl .................................................. 18
PULMICORT FLEXHALER .............. 80
PULMOZYME ........................................................ 82
PURIXAN ....................................................................... 72
pyrazinamide ......................................................... 22
pyridostigmine bromide ..................... 21
QUADRACEL ........................................................... 74
quasense ....................................................................... 67
quetiapine fumarate ................................. 30
quinapril hcl ............................................................. 44
quinapril-hydrochlorothiazide
.......................................................................................................... 48
quinidine gluconate er .......................... 45
quinidine sulfate .............................................. 45
quinidine sulfate er ..................................... 45
Index
piperacillin sod-tazobactam so
.......................................................................................................... 10
pirmella 1/35 ......................................................... 67
piroxicam ........................................................................... 2
PLASMA-LYTE 148 .................................. 83
PLASMA-LYTE A ........................................... 83
PLASMA-LYTE-56 IN D5W ....... 86
podofilox ......................................................................... 54
polyethylene glycol 3350 ................ 57
polymyxin b-trimethoprim ............. 76
POMALYST ............................................................... 23
portia-28 ........................................................................ 67
potassium chloride ..................................... 84
POTASSIUM CHLORIDE ................... 84
potassium chloride crys er ........... 83
potassium chloride er ............................ 83
POTASSIUM CHLORIDE IN
DEXTROSE ................................................................. 86
POTASSIUM CHLORIDE IN
NACL ..................................................................................... 83
potassium citrate er .................................. 59
POTIGA ............................................................................. 13
PRADAXA .................................................................... 43
pramipexole dihydrochloride .... 27
PRANDIMET ........................................................... 38
pravastatin sodium ..................................... 50
prazosin hcl .............................................................. 44
PRECISION XTRA ......................................... 40
PRECISION XTRA BLOOD
GLUCOSE ...................................................................... 40
PRECISION XTRA KETONE ........ 40
prednicarbate .......................................... 54, 62
prednisolone ........................................................... 62
prednisolone acetate ............................... 78
prednisolone sodium phosphate
.......................................................................................................... 62
prednisone .................................................................. 62
prednisone intensol ................................... 62
prefest ................................................................................ 67
pregnyl ............................................................................... 63
PREMARIN ................................................................ 64
PREMASOL ............................................................... 86
PREMPHASE ......................................................... 67
PREMPRO ................................................................... 67
prenatal ............................................................................ 86
prevalite ........................................................................... 51
previfem .......................................................................... 67
PREZCOBIX .............................................................. 35
Index
Index
pacerone ........................................................................ 45
pamidronate disodium ......................... 75
PANRETIN .................................................................. 26
pantoprazole sodium .............................. 58
paricalcitol .................................................................. 76
paromomycin sulfate ................................... 5
paroxetine hcl ....................................................... 17
PASER ................................................................................ 22
PATADAY ..................................................................... 77
PATANOL ..................................................................... 77
PAXIL ................................................................................... 17
PEDIARIX ..................................................................... 74
pedi-dri ............................................................................. 20
PEDVAX HIB ........................................................... 74
peg 3350/electrolytes ........................... 57
peg-3350/electrolytes .......................... 57
PEGANONE ................................................................ 15
PEGINTRON ............................................................. 32
PEG-INTRON ......................................................... 32
PEG-INTRON REDIPEN ...................... 32
penicillin g potassium ........................... 10
PENICILLIN G PROCAINE ............. 10
penicillin v potassium ............................ 10
PENTACEL .................................................................. 74
PENTAM ......................................................................... 27
pentoxifylline er ................................................. 49
perindopril erbumine ............................... 44
periogard ....................................................................... 53
permethrin .................................................................. 27
perphenazine ......................................................... 29
PERTZYE ....................................................................... 55
phenadoz ....................................................................... 18
phenelzine sulfate ........................................ 17
phenergan ................................................................... 18
phenobarbital ........................................................ 14
phenytoin ...................................................................... 15
phenytoin sodium .......................................... 15
phenytoin sodium extended ...... 15
PHYSIOLYTE .......................................................... 83
PHYSIOSOL IRRIGATION ............... 83
pilocarpine hcl ....................................... 53, 77
pimtrea .............................................................................. 67
pindolol ............................................................................. 46
pioglitazone hcl ................................................. 37
pioglitazone hcl-glimepiride ...... 38
pioglitazone hcl-metformin hcl
.......................................................................................................... 38
96
sulfacetamide-prednisolone ..... 76
sulfadiazine ............................................................... 12
sulfamethoxazole-tmp ds .............. 12
sulfamethoxazole-trimethoprim
.......................................................................................................... 12
sulfasalazine ........................................................... 75
sulfazine ec ............................................................... 75
sulindac ................................................................................ 2
sumatriptan .............................................................. 21
sumatriptan succinate .......................... 21
SUPRAX ............................................................................... 8
SUPREP BOWEL PREP ....................... 84
SURMONTIL ............................................................ 18
SUSTIVA ........................................................................ 33
SUTENT ........................................................................... 25
SYLATRON ................................................................ 32
SYMLINPEN 120 ............................................ 37
SYMLINPEN 60 ................................................ 37
SYNAGIS ....................................................................... 72
SYNAREL ...................................................................... 70
SYNERCID ....................................................................... 5
SYNRIBO ....................................................................... 24
SYNTHROID ............................................................. 69
SYPRINE ........................................................................ 83
TABLOID ........................................................................ 23
tacrolimus .................................................................... 72
TAFINLAR ................................................................... 25
TAMIFLU ....................................................................... 35
tamoxifen citrate ............................................. 23
tamsulosin hcl ..................................................... 59
TARCEVA ...................................................................... 25
TARGRETIN .............................................................. 26
tarina fe 1/20 ......................................................... 67
TASIGNA ....................................................................... 25
TASMAR ........................................................................ 27
tazicef ...................................................................................... 8
TAZORAC ..................................................................... 55
taztia xt ............................................................................. 47
TECFIDERA ............................................................... 53
TEFLARO ........................................................................... 9
TEKTURNA ................................................................ 49
TEKTURNA HCT ............................................... 48
telmisartan ................................................................. 44
telmisartan-amlodipine ...................... 48
telmisartan-hctz ............................................... 48
temazepam ............................................................... 82
tencon ...................................................................................... 1
TENIVAC ........................................................................ 74
Index
SAIZEN ............................................................................. 63
SAMSCA ........................................................................ 83
SANDIMMUNE ................................................... 72
SANDOSTATIN LAR DEPOT ..... 70
SANTYL ........................................................................... 55
SAPHRIS ....................................................................... 30
SAVELLA ....................................................................... 53
SAVELLA TITRATION PACK .... 53
selegiline hcl ........................................................... 28
selenium sulfide ............................................... 55
SELZENTRY ............................................................. 34
SENSIPAR ................................................................... 69
SEREVENT DISKUS ................................... 81
SEROQUEL XR .................................................... 30
sertraline hcl ........................................................... 17
sharobel ........................................................................... 68
sildenafil citrate ................................................ 81
silver sulfadiazine ......................................... 12
SIMBRINZA .............................................................. 77
simvastatin ................................................................ 50
sirolimus ......................................................................... 72
sivextro .................................................................................. 7
sodium chloride ................................................ 84
SODIUM LACTATE ...................................... 86
sodium polystyrene sulfonate
.......................................................................................................... 83
SOLTAMOX ............................................................... 23
SOMATULINE DEPOT ........................... 70
SOMAVERT ............................................................... 70
sorine ................................................................................... 45
sotalol hcl ..................................................................... 45
sotalol hcl (af) ....................................................... 45
SOVALDI ........................................................................ 32
spironolactone ..................................................... 50
spironolactone-hctz .................................. 48
sprintec 28 ................................................................. 67
SPRYCEL ...................................................................... 25
sronyx .................................................................................. 67
ssd ............................................................................................. 12
stavudine ....................................................................... 34
STIVARGA .................................................................. 25
STRATTERA ............................................................ 52
streptomycin sulfate ..................................... 5
STRIBILD ...................................................................... 32
SUBOXONE .................................................................... 4
SUCRAID ....................................................................... 55
sucralfate ...................................................................... 58
sulfacetamide sodium .......................... 12
Index
Index
quinine sulfate ..................................................... 27
RABAVERT ................................................................ 74
raloxifene hcl ......................................................... 68
ramipril .............................................................................. 44
RANEXA .......................................................................... 49
ranitidine hcl ........................................................... 57
RAPAFLO ...................................................................... 59
RAPAMUNE ............................................................. 72
REBIF ................................................................................... 53
REBIF REBIDOSE .......................................... 53
REBIF REBIDOSE TITRATION
PACK .................................................................................... 53
REBIF TITRATION PACK ................ 53
reclipsen ......................................................................... 67
RECOMBIVAX HB ......................................... 74
REGRANEX ................................................................ 55
RELENZA DISKHALER ........................ 35
RELISTOR .................................................................... 56
REMICADE ................................................................. 72
REMODULIN ........................................................... 81
RENVELA ...................................................................... 59
repaglinide .................................................................. 37
RESCRIPTOR ......................................................... 33
reserpine ........................................................................ 48
RESTASIS .................................................................... 77
RETROVIR ................................................................... 34
REVLIMID ...................................................... 23, 24
REYATAZ ...................................................................... 35
ribasphere ................................................................... 32
RIBASPHERE RIBAPAK .................... 32
ribavirin ............................................................................ 32
RIDAURA ...................................................................... 72
rifabutin ............................................................................ 22
rifampin ............................................................................ 22
riluzole ................................................................................ 52
rimantadine hcl .................................................. 35
RINGERS ....................................................................... 86
RINGERS IRRIGATION ........................ 86
RIOMET ........................................................................... 37
RISPERDAL CONSTA ............................ 30
risperidone ................................................................. 30
RITUXAN ....................................................................... 26
rivastigmine tartrate ................................. 16
ropinirole hcl ........................................................... 27
ROTARIX ....................................................................... 74
ROTATEQ ...................................................................... 74
roxicet ...................................................................................... 1
SABRIL ............................................................................. 14
97
valsartan-hydrochlorothiazide
............................................................................................ 48, 49
vancomycin hcl ...................................................... 7
vandazole .......................................................................... 7
VAQTA ............................................................................... 74
VARIVAX ....................................................................... 74
VARIZIG .......................................................................... 74
VASCEPA ...................................................................... 51
VELCADE ...................................................................... 24
velivet .................................................................................. 67
venlafaxine hcl .................................................... 17
venlafaxine hcl er .......................................... 17
VENTOLIN HFA .................................................. 81
verapamil hcl ......................................................... 47
verapamil hcl er ................................................ 47
VERSACLOZ ............................................................ 31
VESICARE ................................................................... 58
vestura ............................................................................... 67
V-GO 20 .......................................................................... 41
V-GO 30 .......................................................................... 41
V-GO 40 .......................................................................... 41
VICTRELIS .................................................................. 32
VIDEX .................................................................................. 34
VIGAMOX ..................................................................... 12
VIIBRYD ............................................................ 16, 17
VIMPAT ........................................................................... 15
VIRACEPT ................................................................... 35
VIRAMUNE XR ................................................... 33
VIRAZOLE .................................................................... 31
VIREAD ............................................................................. 34
VITEKTA ......................................................................... 33
VOLTAREN ................................................................. 55
voriconazole ............................................... 20, 21
VOTRIENT ................................................................... 25
VPRIV .................................................................................. 55
vyfemla ............................................................................. 67
warfarin sodium ............................................... 43
WELCHOL .................................................................... 51
wymzya fe ................................................................... 67
XALKORI ........................................................................ 25
XENAZINE ................................................................... 52
XGEVA ................................................................................ 76
XIFAXAN ............................................................................ 7
XOLAIR ............................................................................. 82
XTANDI ............................................................................ 23
XYREM .............................................................................. 82
YF-VAX ............................................................................. 74
zafirlukast .................................................................... 80
Index
TRAVATAN Z ......................................................... 78
trazodone hcl ......................................................... 16
TREANDA ..................................................................... 24
TRECATOR ................................................................ 22
TRELSTAR MIXJECT ............................. 70
tretinoin ............................................................................ 26
TREXALL ....................................................................... 72
triamcinolone acetonide ..... 53, 62
triamterene-hctz ............................................. 48
triazolam ........................................................................ 35
triderm ............................................................................... 62
trifluoperazine hcl ......................................... 29
trifluridine ..................................................................... 32
trihexyphenidyl hcl ...................................... 27
tri-legest fe ................................................................ 67
trilyte ..................................................................................... 57
trimethoprim ................................................................ 7
trinessa (28) ............................................................. 67
tri-previfem ............................................................... 67
TRISENOX ................................................................... 24
tri-sprintec .................................................................. 67
TRIUMEQ ...................................................................... 33
trivora (28) .................................................................. 67
TROKENDI XR ..................................................... 14
TROPHAMINE ...................................................... 86
tropicamide ............................................................... 77
trospium chloride ........................................... 58
TRUMENBA .............................................................. 74
TRUVADA ..................................................................... 34
TUDORZA PRESSAIR ............................ 80
TWINRIX ........................................................................ 74
TYBOST ........................................................................... 34
TYGACIL ............................................................................. 7
TYKERB ........................................................................... 25
TYPHIM VI .................................................................. 74
TYSABRI ........................................................................ 53
TYZEKA ............................................................................ 31
ULORIC ............................................................................. 21
ULTICARE INSULIN SYRINGE
.......................................................................................................... 41
unithroid .......................................................................... 69
ursodiol ............................................................................. 56
valacyclovir hcl .................................................. 32
VALCHLOR ................................................................ 22
VALCYTE ....................................................................... 31
valganciclovir hcl ........................................... 31
valproate sodium ............................................ 14
valproic acid ............................................................ 14
Index
Index
terazosin hcl ............................................................ 44
terbinafine hcl ...................................................... 20
terbutaline sulfate ......................................... 81
terconazole ................................................................ 20
TESTIM ............................................................................. 64
testosterone cypionate ........................ 64
testosterone enanthate ....................... 64
TETANUS TOXOID ADSORBED
.......................................................................................................... 74
TETANUS-DIPHTHERIA
TOXOIDS TD ........................................................... 74
tetracycline hcl ................................................... 12
THALOMID ................................................................. 23
THEO-24 ........................................................................ 81
theophylline er .................................................... 81
thioridazine hcl ................................................... 29
thiothixene .................................................................. 29
THYMOGLOBULIN ....................................... 72
THYROLAR-1 ........................................................ 69
THYROLAR-1/2 ................................................ 69
THYROLAR-1/4 ................................................ 69
THYROLAR-2 ........................................................ 69
THYROLAR-3 ........................................................ 69
tiagabine hcl ........................................................... 14
ticlopidine hcl ........................................................ 44
TIKOSYN ........................................................................ 45
TIMENTIN .................................................................... 10
timolol maleate .................................... 46, 77
TIVICAY ........................................................................... 33
tizanidine hcl .......................................................... 31
TOBI PODHALER ................................................ 5
tobramycin ...................................................................... 5
tobramycin sulfate ........................................... 5
tobramycin-dexamethasone ..... 76
tolazamide .................................................................. 37
tolbutamide ............................................................... 37
tolcapone ...................................................................... 27
topiramate ................................................................... 14
torsemide ...................................................................... 50
tpn electrolytes .................................................. 86
TRACLEER ................................................................. 81
tramadol hcl ................................................................. 3
tramadol-acetaminophen ................... 1
trandolapril ................................................................. 44
tranexamic acid ................................................ 43
TRANSDERM-SCOP ................................ 56
tranylcypromine sulfate ..................... 17
TRAVASOL ................................................................ 86
Index
zaleplon ............................................................................ 82
ZAVESCA ...................................................................... 55
zazole ................................................................................... 21
ZELAPAR ...................................................................... 28
ZELBORAF ................................................................. 26
zenatane ......................................................................... 55
zenchent ......................................................................... 67
zenchent fe ................................................................ 67
ZENPEP ............................................................................ 56
zenzedi .............................................................................. 52
ZETIA ................................................................................... 51
ZIAGEN ............................................................................. 34
zidovudine ................................................................... 34
ziprasidone hcl ................................................... 30
ZIRGAN ............................................................................ 31
zoledronic acid ................................................... 76
ZOLINZA ......................................................................... 21
zolpidem tartrate ............................................ 82
ZOMETA ......................................................................... 76
zonisamide ................................................................. 13
ZORTRESS ................................................................. 72
ZOSTAVAX ................................................................ 74
zovia 1/35e (28) ............................................... 67
zovia 1/50e (28) ............................................... 68
ZOVIRAX ........................................................................ 32
ZYDELIG ......................................................................... 26
ZYKADIA ....................................................................... 26
ZYLET .................................................................................. 76
ZYTIGA .............................................................................. 23
ZYVOX ..................................................................................... 7
98
We’re always just a phone call away!
If you’re ready to enroll or have enrollment questions, call 1-877-817-5793,
8 a.m. to 8 p.m., 7 days a week.
If you’re already a member, call the number for your state/plan listed below.
Arkansas:
Florida:
WellCare Choice, Dividend, Essential, Value
(HMO/HMO-POS) ......................................................................... 1-888-888-9355
�
Georgia:
Hawai‘i:
‘Ohana Choice or Value (HMO-POS) .................................... 1-888-505-1201
�
Illinois:
WellCare Value (HMO-POS) ...................................................... 1-866-334-6876
Kentucky:
WellCare Value (HMO-POS)..................................................... 1-877-560-2766
�
Louisiana:
Mississippi:
WellCare Value or Gold Essential
(HMO/HMO-POS) ......................................................................... 1-800-316-2273
�
New Jersey:
South Carolina:
�
Tennessee:
WellCare Dividend or Emerald Value
(HMO/HMO-POS) ......................................................................... 1-800-316-2273
Texas:
WellCare Dividend or Value
(HMO/HMO-POS) ......................................................................... 1-866-687-8878
�
Hours of operation are Monday–Friday, 8 a.m. to 8 p.m. Between October 1 and February 14,
representatives are available Monday–Sunday, 8 a.m. to 8 p.m., or visit us anytime at
Nurse Advice Line .............................................................. 1-800-581-9952 (24 hours, 7 days a week)
�
TTY for all of the above .........................................................................................................1-877-247-6272
This information is available for free in other languages. Please call our Customer Service number at
1-877-374-4056, Monday–Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives
are available Monday–Sunday, 8 a.m. to 8 p.m. TTY users should call 1-877-247-6272.
Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de
Servicio al Cliente al 1-877-374-4056, de lunes a viernes, de 8 a.m. a 8 p.m. Entre el 1 de octubre
y el 14 de febrero, los representantes están disponibles de lunes a domingo de 8 a.m. a 8 p.m.
Los usuarios de TTY deben llamar al 1-877-247-6272.
‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare (HMO) is a Medicare Advantage organization with a Medicare contract. Enrollment in WellCare/‘Ohana (HMO) depends on contract renewal.
WellCare/‘Ohana uses a formulary. The benefit information provided is a brief summary, not a complete description
of benefits. For more information, contact the plan. Limitations, co-payments and restrictions may apply. Benefits,
formulary, pharmacy network, provider network, premium and/or co-payments/coinsurance may change on
January 1 of each year.
�
This formulary was updated on 08/01/2015. For more recent information or other questions, please contact
WellCare/‘Ohana at the telephone number listed on the inside front and back covers of this formulary or visit
�
64958
P.O. Box 31389 | Tampa, FL 33631-3389

2015 - Ohana Health Plan

Transcription

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