Printable Formulary for 2016 (effective 9/1/16)

Transcription

Geisinger Gold $0 Deductible Rx
2016 Comprehensive Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 8/25/16. For more recent information or other questions, please contact
Geisinger Gold Member Services at (800) 988-4861 or, for TTY users, 711, 8 a.m. to 8 p.m. (7 days a
week, Oct. – Feb.) or 8 a.m. to 8 p.m. (Mon. – Fri., March – Sept.), or visit
www.thehealthplan.com/Gold/Landing_Pages/Formulary/
Y0032_15209_1_FINAL_8 Populated Template 8/25/16
Y0032_15209_1_FINAL_3 Populated Template 1/29/16
HPMS Approved Formulary File Submission ID 16270, Version Number 21
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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 Geisinger Gold. When it refers to
“plan” or “our plan,” it means Geisinger Gold $0 Deductible Rx.
This document includes a list of the drugs (formulary) for our plan which is current as of February 01, 2016.
For an updated formulary, please contact us. Our contact information, along with the date we last updated the
formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time
during the year.
Geisinger Gold Medicare Advantage HMO, PPO, and HMO SNP plans are offered by Geisinger Health
Plan/Geisinger Indemnity Insurance Company/Geisinger Quality Options, Inc., health plans with a Medicare
contract. Continued enrollment in Geisinger Gold depends on annual contract renewal.
What is the Geisinger Gold $0 Deductible Rx Formulary?
A formulary is a list of covered drugs selected by Geisinger Gold $0 Deductible Rx in consultation with a
team of health care providers, which represents the prescription therapies believed to be a necessary part of a
quality treatment program. Geisinger Gold $0 Deductible Rx will generally cover the drugs listed in our
formulary as long as the drug is medically necessary, the prescription is filled at a Geisinger Gold $0
Deductible Rx network pharmacy, and other plan rules are followed. For more information on how to fill
your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we
will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or effectiveness
of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will
not affect members who are currently taking the drug. It will remain available at the same cost-sharing for
those members taking it for the remainder of the coverage year. We feel it is important that you have
continued access for the remainder of the coverage year to the formulary drugs that were available when you
chose our plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the
change at least 60 days before the change becomes effective, or at the time the member requests a refill of
the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug
Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug
from the market, we will immediately remove the drug from our formulary and provide notice to members
who take the drug. The enclosed formulary is current as of Aug. 25, 2016. To get updated information
about the drugs covered by Geisinger Gold $0 Deductible Rx, please contact us. Our contact information
appears on the front and back cover pages. If non-maintenance changes are made to the formulary during
the plan year, Geisinger Gold $0 Deductible Rx communicates these changes in the member newsletter and
within the monthly explanation of benefits (EOB).
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How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page ten (10). The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a
heart condition are listed under the category, “Cardiovascular Agents”. If you know what your drug is
used for, look for the category name in the list that begins on page ten (10). Then look under the
category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on
page I-1. 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?
Geisinger Gold $0 Deductible Rx covers both brand name drugs and generic drugs. A generic drug is
approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs
cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:
 Prior Authorization: Geisinger Gold $0 Deductible Rx requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from Geisinger Gold
$0 Deductible Rx before you fill your prescriptions. If you don’t get approval, Geisinger Gold $0
Deductible Rx may not cover the drug.

Quantity Limits: For certain drugs, Geisinger Gold $0 Deductible Rx limits the amount of the drug
that Geisinger Gold $0 Deductible Rx will cover. For example, Geisinger Gold $0 Deductible Rx
provides 16 tablets per prescription for sumatriptan. This may be in addition to a standard one-month
or three-month supply.

Step Therapy: In some cases, Geisinger Gold $0 Deductible Rx 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, Geisinger Gold $0 Deductible Rx may not
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cover Drug B unless you try Drug A first. If Drug A does not work for you, Geisinger Gold $0
Deductible Rx 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 ten (10). You can also get more information about the restrictions applied to specific covered
drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and
step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the
date we last updated the formulary, appears on the front and back cover pages.
You can ask Geisinger Gold $0 Deductible Rx 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 Geisinger Gold $0 Deductible Rx formulary?” on page four (4) for information about how to request
an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Member
Services and ask if your drug is covered.
If you learn that Geisinger Gold $0 Deductible Rx does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by Geisinger Gold $0
Deductible Rx. When you receive the list, show it to your doctor and ask him or her to prescribe a
similar drug that is covered by Geisinger Gold $0 Deductible Rx.

You can ask Geisinger Gold $0 Deductible Rx to make an exception and cover your drug. See below
for information about how to request an exception.
How do I request an exception to the Geisinger Gold $0 Deductible Rx Formulary?
You can ask Geisinger Gold $0 Deductible Rx to make an exception to our coverage rules. There are several
types of exceptions that you can ask us to make.

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be
covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the
drug at a lower cost-sharing level.

You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the
specialty tier. If approved this would lower the amount you must pay for your drug.
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
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
Geisinger Gold $0 Deductible Rx limits the amount of the drug that we will cover. If your drug has a
quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, Geisinger Gold $0 Deductible Rx will only approve your request for an exception if the
alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization
restrictions would not be as effective in treating your condition and/or would cause you to have adverse
medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you request a formulary, tiering or utilization restriction exception you
should submit a statement from your prescriber or physician supporting your request. Generally, we
must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request
an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by
waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no
later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need
a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide
if you should switch to an appropriate drug that we cover or request a formulary exception so that we will
cover the drug you take. While you talk to your doctor to determine the right course of action for you, we
may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a
network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a
member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with a 93-day transition supply, consistent with dispensing increment, (unless you have a
prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days
you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your
drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary
exception.
For members who experience a level of care change such as changing from one treatment setting to another
(e.g. hospital to long-term care facility), being admitted to or discharged from a long-term care facility, or
reverting from hospice status back to standard Medicare Part A and B benefits, an exception for a one-time
temporary fill will be granted even if the member is past the first 90 days of membership in our plan. Early
refill edits will not be applied when a level of care change exists.
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For more information
For more detailed information about your Geisinger Gold $0 Deductible Rx prescription drug coverage,
please review your Evidence of Coverage and other plan materials.
If you have questions about Geisinger Gold $0 Deductible Rx, please contact us. Our contact information,
along with the date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or,
visit http://www.medicare.gov.
Geisinger Gold $0 Deductible Rx Formulary
The formulary that begins on page ten (10) provides coverage information about the drugs covered by
Geisinger Gold $0 Deductible Rx. If you have trouble finding your drug in the list, turn to the Index that
begins on page I-1.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ADVAIR DISKUS)
and generic drugs are listed in lower-case italics (e.g., simvastatin).
The information in the Requirements/Limits column tells you if Geisinger Gold $0 Deductible Rx has any
special requirements for coverage of your drug.
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The following Utilization Management abbreviations may be found within the body of this document
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION
DESCRIPTION
EXPLANATION
General
Generic
(BRAND)
The reference brand name in parenthesis is provided for
information only to assist in identifying the generic medication
and does NOT indicate formulary status or coverage.
Utilization Management Restrictions
You (or your physician) are required to get prior authorization
from Geisinger Gold $0 Deductible Rx before you fill your
prescription for this drug. Without prior approval, Geisinger
Gold $0 Deductible Rx may not cover this drug.
PA
Prior
Authorization
Restriction
PA BvD
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 Geisinger Gold $0 Deductible Rx to determine
that this drug is covered under Medicare Part D before you fill
your prescription for this drug. Without prior approval, Geisinger
Gold $0 Deductible Rx may not cover this drug.
PA-HRM
Prior
Authorization
Restriction for
High Risk
Medications
This drug has been deemed by CMS to be potentially harmful and
therefore, a High Risk Medication for Medicare beneficiaries 65
years or older. Members age 65 yrs or older are required to get
prior authorization from Geisinger Gold $0 Deductible Rx before
you fill your prescription for this drug. Without prior approval,
Geisinger Gold $0 Deductible Rx may not cover this drug
PA NSO
Prior
Authorization
Restriction for
New Starts Only
If you are a new member or if you have not taken this drug
before, you (or your physician) are required to get prior
authorization from Geisinger Gold $0 Deductible Rx before you
fill your prescription for this drug. Without prior approval,
Geisinger Gold $0 Deductible Rx may not cover this drug.
QL
Quantity Limit
Restriction
Geisinger Gold $0 Deductible Rx limits the amount of this drug
that is covered per prescription, or within a specific time frame.
ST
Step Therapy
Restriction
Before Geisinger Gold $0 Deductible Rx will provide coverage
for this drug, you must first try another drug(s) to treat your
medical condition. This drug may only be covered if the other
drug(s) does not work for you.
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The following additional coverage note abbreviations may be found within the body of this document
OTHER SPECIAL REQUIREMENTS FOR COVERAGE
ABBREVIATION
LA
NM
GC
DESCRIPTION
EXPLANATION
Limited Access Drug
This prescription may be available only at certain
pharmacies. For more information consult your
Pharmacy Directory or call Member Services at
(800) 988-4861, 8 a.m. to 8 p.m. (7 days a week,
Oct. – Feb.) or 8 a.m. to 8 p.m. (Mon. – Fri.,
March- Sept.). TTY/TDD users should call 711.
Non-Mail Order Drug
Drugs not available via your mail order benefit
are noted with “NM” in the Requirements/Limits
column of your formulary.
Gap Coverage
We may provide coverage of this prescription
drug in the coverage gap. Please refer to your
Evidence of Coverage for more information about
this coverage.
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Every medication on the Geisinger Gold $0 Deductible Rx formulary is in one of five (5) cost-sharing tiers.
In general, the higher the cost-sharing tier number, the higher your cost for the medication: As shown in the
table below, the amount of the copayment or coinsurance depends on which cost-sharing tier your
medication is in. Please note: what you pay for your medication depends on which “drug payment stage”
you are in when you get the medication, where you get the medication filled, and if you qualify for any
additional payment assistance.
Your share of the cost when you get a 30-day supply of a covered Part D prescription drug prior to
entering the coverage gap:
Tier 1 (preferred generic)
Tier 2 (generic)
Tier 3 (preferred brand)
Tier 4 (non-preferred brand)
Tier 5 (specialty tier)
$3
$20
$47
$100
33% coinsurance
If you are a member of an employer group, these prices may not apply to you. Please refer to your
benefit documents for appropriate cost sharing amounts.
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Table of Contents
Contents
of
Table
Analgesics ........................................................................................................................................................................................................................................................................................................ 3
Anesthetics ................................................................................................................................................................................................................................................................................................. 10
Anti-Addiction/Substance Abuse Treatment Agents ................................................................................................................................................................... 10
Antianxiety Agents ........................................................................................................................................................................................................................................................................ 12
Antibacterials ......................................................................................................................................................................................................................................................................................... 13
Anticancer Agents ........................................................................................................................................................................................................................................................................... 24
Anticholinergic Agents ............................................................................................................................................................................................................................................................. 36
Anticonvulsants .................................................................................................................................................................................................................................................................................. 36
Antidementia Agents .................................................................................................................................................................................................................................................................. 41
Antidepressants ................................................................................................................................................................................................................................................................................... 42
Antidiabetic Agents ...................................................................................................................................................................................................................................................................... 47
Antifungals ................................................................................................................................................................................................................................................................................................ 51
Antihistamines ...................................................................................................................................................................................................................................................................................... 53
Anti-Infectives (Skin And Mucous Membrane) .................................................................................................................................................................................. 54
Antimigraine Agents ................................................................................................................................................................................................................................................................... 54
Antimycobacterials ........................................................................................................................................................................................................................................................................ 55
Antinausea Agents ......................................................................................................................................................................................................................................................................... 56
Antiparasite Agents ...................................................................................................................................................................................................................................................................... 57
Antiparkinsonian Agents ...................................................................................................................................................................................................................................................... 58
Antipsychotic Agents ................................................................................................................................................................................................................................................................. 60
Antivirals (Systemic) ................................................................................................................................................................................................................................................................... 64
Blood Products/Modifiers/Volume Expanders ..................................................................................................................................................................................... 70
Caloric Agents ...................................................................................................................................................................................................................................................................................... 75
Cardiovascular Agents ............................................................................................................................................................................................................................................................. 78
Central Nervous System Agents ................................................................................................................................................................................................................................. 91
Contraceptives ...................................................................................................................................................................................................................................................................................... 93
Dental And Oral Agents .................................................................................................................................................................................................................................................... 100
Dermatological Agents ........................................................................................................................................................................................................................................................ 101
Devices ......................................................................................................................................................................................................................................................................................................... 108
Enzyme Replacement/Modifiers ............................................................................................................................................................................................................................ 109
Eye, Ear, Nose, Throat Agents ................................................................................................................................................................................................................................. 110
Gastrointestinal Agents ....................................................................................................................................................................................................................................................... 115
Genitourinary Agents ............................................................................................................................................................................................................................................................. 120
Heavy Metal Antagonists ................................................................................................................................................................................................................................................. 120
Hormonal Agents, Stimulant/Replacement/Modifying ....................................................................................................................................................... 121
Immunological Agents .......................................................................................................................................................................................................................................................... 128
Inflammatory Bowel Disease Agents ............................................................................................................................................................................................................... 137
Irrigating Solutions .................................................................................................................................................................................................................................................................... 138
Metabolic Bone Disease Agents .............................................................................................................................................................................................................................. 138
Miscellaneous Therapeutic Agents ..................................................................................................................................................................................................................... 140
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Geisinger Gold $0 Deductible Rx 2016 Part D Formulary
Formulary ID: 16270.000 Version: 21
Effective: September 01, 2016
Contents
of
Table
Ophthalmic Agents .................................................................................................................................................................................................................................................................... 145
Replacement Preparations .............................................................................................................................................................................................................................................. 146
Respiratory Tract Agents ................................................................................................................................................................................................................................................. 150
Skeletal Muscle Relaxants ............................................................................................................................................................................................................................................... 155
Sleep Disorder Agents ........................................................................................................................................................................................................................................................... 156
Vasodilating Agents .................................................................................................................................................................................................................................................................. 156
Vitamins And Minerals ....................................................................................................................................................................................................................................................... 158
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Drug Name
Drug Tier
Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen-codeine 120 mg-12 mg/5
ml solution 120-12 mg/5 ml
acetaminophen-codeine oral solution 300
mg-30 mg /12.5 ml
acetaminophen-codeine oral tablet 300-15
mg
mg
mg
astramorph-pf injection solution 1 mg/ml
buprenorphine hcl injection syringe 0.3
mg/ml
butalbital-acetaminophen oral tablet
50-325 mg
butalbital-acetaminophen-caff oral
capsule 50-300-40 mg, 50-325-40 mg
butalbital-acetaminophen-caff oral tablet
50-325-40 mg
butalbital-aspirin-caffeine oral capsule
50-325-40 mg
butorphanol tartrate injection solution 1
mg/ml
butorphanol tartrate injection solution 2
mg/ml
butorphanol tartrate nasal
spray,non-aerosol 10 mg/ml
BUTRANS TRANSDERMAL
PATCH WEEKLY 10 MCG/HOUR,
15 MCG/HOUR, 20 MCG/HOUR, 5
MCG/HOUR, 7.5 MCG/HOUR
capacet oral capsule 50-325-40 mg
codeine sulfate oral tablet 15 mg, 30 mg,
60 mg
(Acetaminophen with
Codeine)
(Acetaminophen with
Codeine)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
(Morphine Sulfate/PF)
(Buprenorphine HCl)
2
2
2
NM; QL (5000 per 30
days)
NM; QL (5000 per 30
days)
NM; QL (390 per 30
days)
NM; QL (360 per 30
days)
NM; QL (180 per 30
days)
NM
NM
(Tencon)
2
QL (180 per 30 days)
(Esgic)
2
(Esgic)
2
(Fiorinal)
2
(Butorphanol Tartrate)
2
NM
2
2
NM
4
PA; NM; QL (4 per 28
days)
2
2
NM; QL (180 per 30
days)
(Esgic)
(Codeine Sulfate)
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
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Drug Name
Drug Tier
dihydrocodeine-aspirin-caff oral capsule
16-356.4-30 mg
DURAMORPH (PF) INJECTION
SOLUTION 0.5 MG/ML, 1 MG/ML
endocet oral tablet 10-325 mg, 2.5-325
mg, 5-325 mg, 7.5-325 mg
endodan oral tablet 4.8355-325 mg
(Synalgos-Dc)
fentanyl citrate buccal lozenge on a
handle 1,200 mcg, 1,600 mcg, 200 mcg,
400 mcg, 600 mcg, 800 mcg
fentanyl transdermal patch 72 hour 100
mcg/hr, 75 mcg/hr
fentanyl transdermal patch 72 hour 12
mcg/hr, 25 mcg/hr, 50 mcg/hr
hydrocodone-acetaminophen oral solution
10-325 mg/15 ml(15 ml), 2.5-167 mg/5
ml, 7.5-325 mg/15 ml
hydrocodone-acetaminophen oral tablet
10-300 mg, 5-300 mg, 7.5-300 mg
hydrocodone-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg,
7.5-325 mg
hydrocodone-ibuprofen oral tablet 10-200
mg, 2.5-200 mg, 5-200 mg, 7.5-200 mg
hydromorphone (pf) injection solution 10
mg/ml
hydromorphone (pf) injection solution 4
mg/ml
hydromorphone 2 mg/ml vial latex-free,
suv 2 mg/ml
hydromorphone hcl 10 mg/ml vial p/f, sdv
10 mg/ml
hydromorphone injection solution 2
mg/ml
hydromorphone injection syringe 2 mg/ml
2
4
Requirements/Limits
NM; QL (360 per 30
days)
NM
(Xolox)
2
NM; QL (360 per 30
days)
NM; QL (360 per 30
days)
PA; NM; QL (120 per
30 days)
(Percodan)
2
(Actiq)
5
(Duragesic)
2
(Duragesic)
2
(Hycet)
2
(Norco)
2
(Norco)
2
(Ibudone)
2
(Dilaudid-HP)
2
NM; QL (150 per 30
days)
NM
(Dilaudid)
2
NM
(Hydromorphone HCl)
2
(Dilaudid-HP)
2
(Hydromorphone HCl)
2
NM
(Hydromorphone HCl)
2
NM
NM; QL (20 per 30
days)
NM; QL (10 per 30
days)
NM; QL (2700 per 30
days)
NM; QL (390 per 30
days)
NM; QL (360 per 30
days)
4
Drug Name
Drug Tier
Requirements/Limits
hydromorphone oral tablet 2 mg, 4 mg
(Dilaudid)
2
hydromorphone oral tablet 8 mg
(Dilaudid)
2
ibuprofen-oxycodone oral tablet 400-5
mg
LAZANDA NASAL
SPRAY,NON-AEROSOL 100
MCG/SPRAY, 300 MCG/SPRAY, 400
MCG/SPRAY
levorphanol tartrate oral tablet 2 mg
(Ibuprofen/Oxycodone
HCl)
2
(Levorphanol Tartrate)
2
margesic oral capsule 50-325-40 mg
marten-tab oral tablet 50-325 mg
methadone injection solution 10 mg/ml
methadone intensol oral concentrate 10
mg/ml
methadone oral solution 10 mg/5 ml, 5
mg/5 ml
methadone oral tablet 10 mg, 5 mg
(Esgic)
(Tencon)
(Methadone HCl)
(Methadose)
2
2
2
2
(Methadone HCl)
2
(Diskets)
2
methadose oral tablet,soluble 40 mg
(Diskets)
2
morphine (pf) in dextrose 5 %
intravenous solution 100 mg/100 ml (1
mg/ml)
morphine (pf) injection solution 0.5
mg/ml
morphine (pf) injection solution 1 mg/ml
morphine (pf) intravenous patient
control.analgesia soln 150 mg/30 ml
morphine (pf) intravenous patient
control.analgesia soln 30 mg/30 ml
morphine 10 mg/ml carpuject 10 mg/ml
(Morphine
Sulfate/D5w/PF)
2
2
2
2
2
NM
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
2
2
2
NM
NM
NM
5
NM; QL (180 per 30
days)
NM; QL (240 per 30
days)
NM; QL (28 per 30
days)
PA; NM
NM; QL (180 per 30
days)
NM
NM; QL (1800 per 30
days)
NM; QL (1800 per 30
days)
NM; QL (360 per 30
days)
NM; QL (90 per 30
days)
NM
5
Drug Name
Drug Tier
Requirements/Limits
morphine 8 mg/ml syringe 8 mg/ml
morphine concentrate oral solution 100
mg/5 ml (20 mg/ml)
morphine in 0.9 % nacl intravenous
solution 1 mg/ml
morphine injection solution 15 mg/ml, 8
mg/ml
morphine injection syringe 10 mg/ml, 5
mg/ml
morphine intramuscular pen injector 10
mg/0.7 ml
morphine intravenous cartridge 15 mg/ml
morphine intravenous solution 25 mg/ml,
50 mg/ml
morphine intravenous syringe 10 mg/ml, 2
mg/ml, 4 mg/ml, 8 mg/ml
morphine oral capsule, er multiphase 24
hr 120 mg, 75 mg, 90 mg
morphine oral capsule, er multiphase 24
hr 30 mg, 45 mg, 60 mg
morphine oral capsule,extend.release
pellets 10 mg, 20 mg, 60 mg, 80 mg
morphine oral capsule,extend.release
pellets 100 mg, 30 mg, 50 mg
morphine oral solution 10 mg/5 ml
(Morphine Sulfate)
(Morphine Sulfate)
2
2
NM
(Morphine Sulfate In
0.9 % NaCl)
(Morphine Sulfate)
2
(Morphine Sulfate)
2
(Morphine Sulfate)
2
NM
(Morphine Sulfate)
(Morphine Sulfate)
2
2
NM
NM
(Morphine Sulfate)
2
NM
(Avinza)
2
(Avinza)
2
(Kadian)
2
(Kadian)
2
(Morphine Sulfate)
2
morphine oral solution 20 mg/5 ml (4
mg/ml)
MORPHINE ORAL TABLET 15 MG,
30 MG
morphine oral tablet extended release 100
mg, 15 mg, 30 mg
morphine oral tablet extended release 200
mg, 60 mg
morphine rectal suppository 10 mg, 20
mg, 30 mg, 5 mg
(Morphine Sulfate)
2
NM; QL (60 per 30
days)
NM; QL (30 per 30
days)
NM; QL (120 per 30
days)
NM; QL (90 per 30
days)
NM; QL (700 per 30
days)
NM; QL (300 per 30
days)
NM; QL (180 per 30
days)
NM; QL (90 per 30
days)
NM; QL (120 per 30
days)
NM
2
2
(MS Contin)
2
(MS Contin)
2
(Morphine Sulfate)
2
6
Drug Name
Drug Tier
Requirements/Limits
nalbuphine injection solution 10 mg/ml,
20 mg/ml
oxycodone oral capsule 5 mg
(Nalbuphine HCl)
2
NM
(Oxycodone HCl)
2
oxycodone oral concentrate 20 mg/ml
(Oxycodone HCl)
2
oxycodone oral solution 5 mg/5 ml
(Oxycodone HCl)
2
oxycodone oral tablet 10 mg, 15 mg, 20
mg, 30 mg, 5 mg
oxycodone oral tablet,oral only,ext.rel.12
hr 10 mg, 20 mg, 40 mg
hr 15 mg, 30 mg
hr 60 mg
hr 80 mg
oxycodone-acetaminophen oral solution
5-325 mg/5 ml
oxycodone-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg,
7.5-325 mg
oxycodone-aspirin oral tablet 4.8355-325
mg
OXYCONTIN ORAL
TABLET,ORAL ONLY,EXT.REL.12
HR 10 MG, 15 MG, 20 MG, 30 MG, 40
MG
OXYCONTIN ORAL
TABLET,ORAL ONLY,EXT.REL.12
HR 60 MG, 80 MG
oxymorphone oral tablet 10 mg, 5 mg
(Roxicodone)
2
(Oxycontin)
2
(Oxycontin)
2
NM; QL (180 per 30
days)
NM; QL (180 per 30
days)
NM; QL (1300 per 30
days)
NM; QL (180 per 30
days)
ST; NM; QL (90 per 30
days)
ST; QL (90 per 30 days)
(Oxycontin)
2
(Oxycontin)
2
(Oxycodone
HCl/Acetaminophen)
(Xolox)
2
2
NM; QL (360 per 30
days)
(Percodan)
2
NM; QL (360 per 30
days)
ST; NM; QL (90 per 30
days)
reprexain oral tablet 10-200 mg, 2.5-200
mg, 5-200 mg
4
ST; QL (120 per 30
days)
ST; NM; QL (120 per
30 days)
4
ST; NM; QL (120 per
30 days)
(Opana)
2
(Ibudone)
2
NM; QL (180 per 30
days)
NM; QL (150 per 30
days)
7
Drug Name
Drug Tier
2
roxicet oral tablet 5-325 mg
(Oxycodone
HCl/Acetaminophen)
(Xolox)
tencon oral tablet 50-325 mg
tramadol hcl er 300 mg tablet 300 mg
(Tencon)
(Ultram ER)
2
2
tramadol oral capsule,er biphase 24 hr
17-83 300 mg
tramadol oral capsule,er biphase 24 hr
25-75 100 mg, 150 mg, 200 mg
tramadol oral tablet 50 mg
(Conzip)
2
(Conzip)
2
(Ultram)
2
tramadol oral tablet extended release 24
hr 100 mg
tramadol oral tablet extended release 24
hr 200 mg
tramadol oral tablet, er multiphase 24 hr
300 mg
tramadol-acetaminophen oral tablet
37.5-325 mg
xylon 10 oral tablet 10-200 mg
(Ultram ER)
2
(Ultram ER)
2
(Ultram ER)
2
(Ultracet)
2
(Ibudone)
2
zebutal oral capsule 50-325-40 mg
Nonsteroidal Anti-Inflammatory
Agents
celecoxib oral capsule 100 mg, 200 mg,
400 mg, 50 mg
choline,magnesium salicylate oral liquid
500 mg/5 ml
diclofenac potassium oral tablet 50 mg
diclofenac sodium oral tablet extended
release 24 hr 100 mg
diclofenac sodium oral tablet,delayed
release (dr/ec) 25 mg, 50 mg, 75 mg
diclofenac sodium topical gel 1 %
(Esgic)
2
(Celebrex)
2
(Choline Sal/Mag
Salicylate)
(Diclofenac Potassium)
(Voltaren-XR)
2
(Diclofenac Sodium)
2
(Voltaren)
2
roxicet oral solution 5-325 mg/5 ml
2
Requirements/Limits
NM; QL (1830 per 30
days)
NM; QL (360 per 30
days)
NM; QL (30 per 30
days)
NM; QL (30 per 30
days)
NM; QL (60 per 30
days)
NM; QL (240 per 30
days)
NM; QL (90 per 30
days)
NM; QL (30 per 30
days)
NM; QL (30 per 30
days)
NM; QL (240 per 30
days)
NM; QL (150 per 30
days)
2
2
8
Drug Name
diclofenac sodium topical gel 3 %
diclofenac-misoprostol oral
tablet,ir,delayed rel,biphasic 50-200
mg-mcg, 75-200 mg-mcg
diflunisal oral tablet 500 mg
etodolac oral capsule 200 mg, 300 mg
etodolac oral tablet 400 mg, 500 mg
etodolac oral tablet extended release 24
hr 400 mg, 500 mg, 600 mg
fenoprofen oral capsule 200 mg
fenoprofen oral tablet 600 mg
FLECTOR TRANSDERMAL
PATCH 12 HOUR 1.3 %
flurbiprofen oral tablet 100 mg, 50 mg
ibuprofen oral suspension 100 mg/5 ml
ibuprofen oral tablet 400 mg, 600 mg,
800 mg
ketoprofen oral capsule 50 mg, 75 mg
ketoprofen oral capsule,ext rel. pellets 24
hr 200 mg
meclofenamate oral capsule 100 mg, 50
mg
mefenamic acid oral capsule 250 mg
meloxicam oral suspension 7.5 mg/5 ml
meloxicam oral tablet 15 mg, 7.5 mg
nabumetone oral tablet 500 mg, 750 mg
naproxen oral suspension 125 mg/5 ml
naproxen oral tablet 250 mg, 375 mg, 500
mg
naproxen oral tablet,delayed release
(dr/ec) 375 mg, 500 mg
naproxen sodium oral tablet 275 mg, 550
mg
oxaprozin oral tablet 600 mg
piroxicam oral capsule 10 mg, 20 mg
sulindac oral tablet 150 mg, 200 mg
Drug Tier
(Voltaren)
(Arthrotec 50)
5
2
(Diflunisal)
(Etodolac)
(Etodolac)
(Etodolac)
2
2
2
2
(Nalfon)
(Fenoprofen Calcium)
2
2
4
(Flurbiprofen)
(Ibuprofen)
(Ibuprofen)
2
2
2
(Ketoprofen)
(Ketoprofen)
2
2
(Meclofenamate
Sodium)
(Ponstel)
(Mobic)
(Mobic)
(Nabumetone)
(Naprosyn)
(Naprosyn)
2
(Ec-Naprosyn)
2
(Anaprox)
2
(Daypro)
(Feldene)
(Sulindac)
2
2
2
Requirements/Limits
NM
days)
2
2
2
2
2
2
9
Drug Name
tolmetin oral capsule 400 mg
tolmetin oral tablet 200 mg, 600 mg
Drug Tier
Requirements/Limits
(Tolmetin Sodium)
(Tolmetin Sodium)
2
2
(Cocaine HCl)
(Lidocaine HCl)
2
2
NM
(Xylocaine-MPF)
2
(Xylocaine-MPF)
2
PA BvD; NM; (PA for
ESRD only)
PA BvD
(Lidocaine HCl/PF)
2
NM
(Xylocaine)
(Xylocaine)
2
2
(Lidocaine HCl)
(Xylocaine)
2
2
(Lidoderm)
2
PA
(Lidocaine)
2
PA BvD; (PA for
ESRD only)
PA BvD; (PA for
ESRD only)
Anesthetics
Local Anesthetics
cocaine topical solution 4 %
glydo mucous membrane jelly in
applicator 2 %
lidocaine (pf) injection solution 15 mg/ml
(1.5 %), 40 mg/ml (4 %)
lidocaine (pf) injection solution 5 mg/ml
(0.5 %)
lidocaine (pf) intravenous syringe 100
mg/5 ml (2 %)
lidocaine 2% viscous soln 2 %
lidocaine hcl injection solution 10 mg/ml
(1 %), 20 mg/ml (2 %)
lidocaine hcl mucous membrane gel 2 %
lidocaine hcl mucous membrane solution
2 %, 4 % (40 mg/ml)
lidocaine topical adhesive
patch,medicated 5 %
lidocaine topical ointment 5 %
lidocaine-prilocaine topical cream 2.5-2.5 (EMLA)
%
2
PA BvD; NM; (PA for
ESRD only)
Anti-Addiction/Substance Abuse
Treatment Agents
Anti-Addiction/Substance Abuse
Treatment Agents
acamprosate oral tablet,delayed release
(dr/ec) 333 mg
buprenorphine hcl sublingual tablet 2 mg,
8 mg
buprenorphine-naloxone sublingual tablet
2-0.5 mg
(Acamprosate
Calcium)
(Buprenorphine HCl)
2
NM
2
(Buprenorphine
HCl/Naloxone HCl)
2
days)
PA; NM; QL (360 per
30 days)
10
Drug Name
buprenorphine-naloxone sublingual tablet
8-2 mg
bupropion hcl (smoking deter) oral tablet
extended release 150 mg
CHANTIX CONTINUING MONTH
BOX ORAL TABLET 1 MG
CHANTIX ORAL TABLET 0.5 MG, 1
MG
CHANTIX STARTING MONTH
BOX ORAL TABLETS,DOSE PACK
0.5 MG (11)- 1 MG (42)
disulfiram oral tablet 250 mg
disulfiram oral tablet 500 mg
naloxone injection solution 0.4 mg/ml
naloxone injection syringe 0.4 mg/ml, 1
mg/ml
naltrexone oral tablet 50 mg
NARCAN NASAL
SPRAY,NON-AEROSOL 4
MG/ACTUATION
NICOTROL NS NASAL
SPRAY,NON-AEROSOL 10 MG/ML
SUBOXONE SUBLINGUAL FILM
12-3 MG
2-0.5 MG
4-1 MG
8-2 MG
VIVITROL INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON 380 MG
(Buprenorphine
HCl/Naloxone HCl)
(Zyban)
Drug Tier
Requirements/Limits
2
2
days)
QL (60 per 30 days)
4
QL (60 per 30 days)
4
NM; QL (60 per 30
days)
NM
4
(Antabuse)
(Antabuse)
(Naloxone HCl)
(Naloxone HCl)
2
2
2
2
NM
(Revia)
2
3
NM
QL (4 per 28 days)
4
NM
4
days)
PA; NM; QL (360 per
30 days)
PA; NM; QL (180 per
30 days)
days)
NM
4
4
4
5
NM
NM
11
Drug Name
Drug Tier
Requirements/Limits
Antianxiety Agents
Benzodiazepines
ALPRAZOLAM INTENSOL ORAL
CONCENTRATE 1 MG/ML
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 (Xanax)
mg
alprazolam oral tablet 2 mg
(Xanax)
3
2
2
alprazolam oral tablet extended release
24 hr 0.5 mg, 1 mg
24 hr 2 mg
24 hr 3 mg
alprazolam oral tablet,disintegrating 0.25
mg, 0.5 mg, 1 mg
alprazolam oral tablet,disintegrating 2
mg
clonazepam oral tablet 0.5 mg, 1 mg
(Xanax XR)
2
(Xanax XR)
2
(Xanax XR)
2
(Alprazolam)
2
(Alprazolam)
2
(Klonopin)
2
clonazepam oral tablet 2 mg
(Klonopin)
2
clonazepam oral tablet,disintegrating
(Clonazepam)
0.125 mg, 0.25 mg, 0.5 mg, 1 mg
clonazepam oral tablet,disintegrating 2
(Clonazepam)
mg
clorazepate dipotassium oral tablet 15 mg (Tranxene T-Tab)
2
(Tranxene T-Tab)
2
(Diazepam)
2
(Diazepam)
2
(Valium)
2
clorazepate dipotassium oral tablet 3.75
mg, 7.5 mg
diazepam intensol oral concentrate 5
mg/ml
diazepam oral solution 5 mg/5 ml (1
mg/ml)
diazepam oral tablet 10 mg, 2 mg, 5 mg
2
2
NM; QL (300 per 30
days)
NM; QL (120 per 30
days)
NM; QL (150 per 30
days)
NM; QL (30 per 30
days)
NM; QL (150 per 30
days)
NM; QL (90 per 30
days)
NM; QL (120 per 30
days)
NM; QL (150 per 30
days)
NM; QL (90 per 30
days)
NM; QL (300 per 30
days)
NM; QL (90 per 30
days)
NM; QL (300 per 30
days)
NM; QL (180 per 30
days)
NM; QL (120 per 30
days)
NM; QL (240 per 30
days)
NM; QL (1200 per 30
days)
NM; QL (120 per 30
days)
12
Drug Name
Drug Tier
Requirements/Limits
diazepam rectal kit 12.5-15-17.5-20 mg,
2.5 mg, 5-7.5-10 mg
estazolam oral tablet 1 mg, 2 mg
(Diastat)
2
NM
(Estazolam)
2
lorazepam injection solution 2 mg/ml
(Ativan)
2
lorazepam injection syringe 2 mg/ml
(Lorazepam)
2
lorazepam injection syringe 4 mg/ml
(Lorazepam)
2
NM; QL (30 per 30
days)
NM; QL (120 per 30
days)
NM; QL (120 per 30
days)
NM; QL (90 per 30
days)
NM; QL (150 per 30
days)
NM; QL (120 per 30
days)
PA NSO
lorazepam intensol oral concentrate 2
(Ativan)
mg/ml
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg (Ativan)
2
ONFI ORAL SUSPENSION 2.5
MG/ML
oxazepam oral capsule 10 mg, 15 mg, 30
mg
temazepam oral capsule 15 mg, 22.5 mg,
30 mg, 7.5 mg
4
2
(Oxazepam)
2
NM; QL (120 per 30
days)
NM; QL (30 per 30
days)
(Restoril)
2
(Amikacin Sulfate)
(Amikacin Sulfate)
2
2
NM
NM
5
PA; NM
Antibacterials
Aminoglycosides
amikacin injection solution 500 mg/2 ml
amikacin sulf 1 gram/4 ml vial outer, sdv
1,000 mg/4 ml
BETHKIS INHALATION
SOLUTION FOR NEBULIZATION
300 MG/4 ML
gentamicin in nacl (iso-osm) intravenous
piggyback 100 mg/100 ml, 60 mg/50 ml
gentamicin in nacl (iso-osm) intravenous
piggyback 100 mg/50 ml, 70 mg/50 ml, 80
mg/100 ml, 80 mg/50 ml, 90 mg/100 ml
gentamicin injection solution 40 mg/ml
gentamicin ped 20 mg/2 ml vial
latex-free, sdv 20 mg/2 ml
(Gentamicin In Nacl,
Iso-Osm)
(Gentamicin In Nacl,
Iso-Osm)
2
2
NM
(Gentamicin Sulfate)
(Gentamicin
Sulfate/PF)
2
2
NM
NM
13
Drug Name
gentamicin sulfate (pf) intravenous
solution 80 mg/8 ml
neomycin oral tablet 500 mg
streptomycin intramuscular recon soln 1
gram
TOBI PODHALER INHALATION
CAPSULE, W/INHALATION
DEVICE 28 MG
tobramycin in 0.225 % nacl inhalation
solution for nebulization 300 mg/5 ml
tobramycin in 0.9 % nacl intravenous
piggyback 60 mg/50 ml, 80 mg/100 ml
tobramycin sulfate injection solution 10
mg/ml, 40 mg/ml
Antibacterials, Miscellaneous
baciim intramuscular recon soln 50,000
unit
bacitracin intramuscular recon soln
50,000 unit
chloramphenicol sod succinate
intravenous recon soln 1 gram
clindamycin 75 mg/5 ml soln 75 mg/5 ml
clindamycin hcl oral capsule 150 mg, 300
mg, 75 mg
clindamycin in 5 % dextrose intravenous
piggyback 300 mg/50 ml, 600 mg/50 ml,
900 mg/50 ml
clindamycin pediatric oral recon soln 75
mg/5 ml
clindamycin phosphate injection solution
150 mg/ml
clindamycin phosphate intravenous
solution 600 mg/4 ml
colistin (colistimethate na) injection
recon soln 150 mg
CUBICIN INTRAVENOUS RECON
SOLN 500 MG
Drug Tier
(Gentamicin
Sulfate/PF)
(Neomycin Sulfate)
(Streptomycin Sulfate)
Requirements/Limits
2
NM
2
2
NM
5
PA; NM; QL (224 per
28 days)
(Tobi)
5
PA; NM
(Tobramycin/Sodium
Chloride)
(Tobramycin Sulfate)
2
NM
2
NM
(Bacitracin)
2
NM
(Bacitracin)
2
NM
(Chloramphenicol Sod
Succ)
(Cleocin Palmitate)
(Cleocin HCl)
2
NM
(Cleocin Phosphate In
D5w)
2
(Cleocin Palmitate)
2
(Cleocin Phosphate)
2
(Cleocin Phosphate)
2
(Coly-Mycin M
Parenteral)
2
NM
5
NM
2
2
NM
14
Drug Name
Drug Tier
CUBICIN RF INTRAVENOUS
RECON SOLN 500 MG
LINCOCIN INJECTION SOLUTION
300 MG/ML
lincomycin injection solution 300 mg/ml
linezolid intravenous parenteral solution
600 mg/300 ml
linezolid oral suspension for
reconstitution 100 mg/5 ml
linezolid oral tablet 600 mg
methenamine hippurate oral tablet 1
gram
metronidazole in nacl (iso-os)
intravenous piggyback 500 mg/100 ml
metronidazole oral capsule 375 mg
metronidazole oral tablet 250 mg, 500 mg
moxifloxacin-sod.ace,sul-water
nitrofurantoin macrocrystal oral capsule
100 mg, 50 mg
nitrofurantoin macrocrystal oral capsule
25 mg
nitrofurantoin monohyd/m-cryst oral
capsule 100 mg
nitrofurantoin monohyd/m-cryst oral
capsule 100 mg (75/25)
polymyxin b sulfate injection recon soln
500,000 unit
SIVEXTRO INTRAVENOUS
RECON SOLN 200 MG
SIVEXTRO ORAL TABLET 200 MG
5
NM
4
NM
(Lincocin)
(Zyvox)
2
5
PA; NM
(Zyvox)
5
PA; NM
(Zyvox)
(Hiprex)
2
2
PA
(Metronidazole/Sodiu
m Chloride)
(Flagyl)
(Flagyl)
(Moxifloxacin/Sod.Ace
,Sul/Water)
(Macrodantin)
2
NM
(Macrodantin)
2
(Macrobid)
2
NM
(Macrobid)
2
NM
(Polymyxin B Sulfate)
2
NM
5
5
days)
days)
PA; NM
1
GC
SYNERCID INTRAVENOUS
RECON SOLN 500 MG
trimethoprim oral tablet 100 mg
2
2
2
2
5
(Trimethoprim)
Requirements/Limits
NM
15
Drug Name
vancomycin hcl 1g/200 ml bag 1
gram/200 ml
vancomycin intravenous recon soln 1,000
mg, 10 gram, 750 mg
vancomycin intravenous recon soln 500
mg
vancomycin oral capsule 125 mg, 250 mg
ZYVOX ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML
Cephalosporins
cefaclor oral capsule 250 mg, 500 mg
cefaclor oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
cefaclor oral tablet extended release 12
hr 500 mg
cefadroxil oral capsule 500 mg
cefadroxil oral suspension for
reconstitution 250 mg/5 ml, 500 mg/5 ml
cefadroxil oral tablet 1 gram
cefazolin in dextrose (iso-os) intravenous
piggyback 1 gram/50 ml
cefazolin injection recon soln 1 gram
cefazolin injection recon soln 10 gram,
500 mg
cefdinir oral capsule 300 mg
cefdinir oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml
cefditoren pivoxil oral tablet 200 mg, 400
mg
cefepime injection recon soln 1 gram, 2
gram
CEFOTAN INJECTION RECON
SOLN 2 GRAM
cefotaxime injection recon soln 1 gram
cefotaxime injection recon soln 10 gram,
2 gram, 500 mg
Drug Tier
Requirements/Limits
(Vancomycin Hcl In
Dextrose 5 %)
(Vancomycin HCl)
2
NM
2
NM
(Vancomycin Hcl In
Dextrose 5 %)
(Vancocin HCl)
2
NM
2
5
PA; NM
(Cefaclor)
(Cefaclor)
2
2
(Cefaclor)
2
(Cefadroxil)
(Cefadroxil)
2
2
(Cefadroxil)
(Cefazolin
Sodium/Dextrose, Iso)
(Cefazolin Sodium)
(Cefazolin Sodium)
2
2
(Cefdinir)
(Cefdinir)
2
2
(Spectracef)
2
(Maxipime)
2
2
2
NM
NM
2
(Claforan)
(Claforan)
2
2
NM
16
Drug Name
cefotetan injection recon soln 1 gram, 2
gram
cefotetan intravenous recon soln 10 gram
cefoxitin in dextrose, iso-osm intravenous
cefoxitin intravenous recon soln 1 gram,
10 gram, 2 gram
cefpodoxime oral suspension for
cefpodoxime oral tablet 100 mg, 200 mg
cefprozil oral suspension for
cefprozil oral tablet 250 mg, 500 mg
CEFTAZIDIME IN D5W
INTRAVENOUS PIGGYBACK 1
GRAM/50 ML, 2 GRAM/50 ML
ceftazidime injection recon soln 2 gram, 6
gram
ceftibuten oral capsule 400 mg
ceftibuten oral suspension for
reconstitution 180 mg/5 ml
ceftriaxone 1 gm piggyback 50ml
galaxycontainer 1 gram/50 ml
ceftriaxone 1 gm vial 10's, fliptop,l/f 1
gram
ceftriaxone 500 mg vial
suv,10's,latex-free 500 mg
ceftriaxone injection recon soln 10 gram,
250 mg, 500 mg
ceftriaxone intravenous recon soln 1
gram
cefuroxime axetil oral tablet 250 mg, 500
mg
cefuroxime sodium injection recon soln
1.5 gram, 750 mg
Drug Tier
Requirements/Limits
(Cefotan)
2
NM
(Cefotan)
(Cefoxitin
(Cefoxitin Sodium)
2
2
NM
NM
2
NM
(Cefpodoxime Proxetil)
2
(Cefpodoxime Proxetil)
(Cefprozil)
2
2
(Cefprozil)
2
2
NM
(Fortaz)
2
NM
(Cedax)
(Cedax)
2
2
(Ceftriaxone
Na/Dextrose, Iso)
(Ceftriaxone Sodium)
2
NM
2
NM
2
2
NM
(Ceftriaxone
Na/Dextrose, Iso)
(Ceftin)
2
NM
(Zinacef)
2
2
NM
17
Drug Name
Drug Tier
Requirements/Limits
cefuroxime sodium intravenous recon soln
7.5 gram
cephalexin oral capsule 250 mg, 500 mg,
750 mg
cephalexin oral suspension for
cephalexin oral tablet 250 mg, 500 mg
SUPRAX ORAL CAPSULE 400 MG
tazicef injection recon soln 1 gram, 6
gram
TEFLARO INTRAVENOUS RECON
SOLN 400 MG, 600 MG
ZERBAXA INTRAVENOUS RECON
SOLN 1.5 GRAM
Macrolides
azithromycin intravenous recon soln 500
mg
azithromycin oral packet 1 gram
(Zinacef)
2
(Keflex)
2
(Cephalexin)
2
(Cephalexin)
2
4
2
NM
4
NM
5
NM
(Fortaz)
(Zithromax)
2
(Zithromax)
2
azithromycin oral suspension for
azithromycin oral tablet 250 mg, 250 mg
(6 pack), 600 mg
azithromycin oral tablet 500 mg
(Zithromax)
2
(Zithromax)
2
(Zithromax)
2
clarithromycin oral suspension for
clarithromycin oral tablet 250 mg, 500
mg
clarithromycin oral tablet extended
release 24 hr 500 mg
e.e.s. 400 oral tablet 400 mg
(Biaxin)
2
(Biaxin)
2
(Clarithromycin)
2
(Erythromycin
Ethylsuccinate)
(Erythromycin Base)
2
ery-tab oral tablet,delayed release
(dr/ec) 250 mg, 500 mg
2
NM
PA; (PA only w/
digoxin)
PA; (PA only w/
digoxin)
PA; (PA only w/
digoxin)
PA; (PA only w/
digoxin)
PA; (PA only w/
digoxin)
PA; (PA only w/
digoxin)
PA; (PA only w/
digoxin)
PA; (PA only w/
digoxin)
PA; (PA only w/
digoxin)
18
Drug Name
Drug Tier
ERY-TAB ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
erythrocin (as stearate) oral tablet 250
mg
ERYTHROCIN INTRAVENOUS
RECON SOLN 500 MG
erythromycin ethylsuccinate oral tablet
400 mg
erythromycin oral capsule,delayed
release(dr/ec) 250 mg
erythromycin oral tablet 250 mg, 500 mg
2
PA; (PA only w/
digoxin)
2
PA; (PA only w/
digoxin)
NM
KETEK ORAL TABLET 300 MG, 400
MG
PCE ORAL TABLET,
PARTICLES/CRYSTALS 333 MG,
500 MG
Miscellaneous B-Lactam
Antibiotics
aztreonam injection recon soln 1 gram
CAYSTON INHALATION
75 MG/ML
imipenem-cilastatin intravenous recon
soln 250 mg, 500 mg
INVANZ INJECTION RECON SOLN
1 GRAM
meropenem intravenous recon soln 500
mg
meropenem iv 1 gm vial outer, latex-free
1 gram
Penicillins
amoxicillin oral capsule 250 mg, 500 mg
amoxicillin oral suspension for
reconstitution 125 mg/5 ml, 200 mg/5 ml,
250 mg/5 ml, 400 mg/5 ml
(Erythromycin
Stearate)
3
(Erythromycin
Ethylsuccinate)
(Erythromycin Base)
2
(Erythromycin Base)
2
2
4
Requirements/Limits
PA; (PA only w/
digoxin)
PA; (PA only w/
digoxin)
PA; (PA only w/
digoxin)
PA
4
PA; (PA only w/
digoxin)
(Azactam)
2
5
NM
days)
(Primaxin)
2
NM
4
NM
(Merrem)
2
NM
(Merrem)
2
NM
(Amoxicillin)
(Amoxicillin)
2
2
19
Drug Name
amoxicillin oral tablet 500 mg, 875 mg
amoxicillin oral tablet, er multiphase 24
hr 775 mg
amoxicillin oral tablet,chewable 125 mg,
250 mg
amoxicillin-pot clavulanate oral
suspension for reconstitution 200-28.5
mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5
ml, 600-42.9 mg/5 ml
amoxicillin-pot clavulanate oral tablet
250-125 mg, 500-125 mg, 875-125 mg
amoxicillin-pot clavulanate oral tablet
extended release 12 hr 1,000-62.5 mg
amoxicillin-pot clavulanate oral
tablet,chewable 200-28.5 mg, 400-57 mg
ampicillin 2 gm vial 10's, latex-free 2
gram
ampicillin oral capsule 250 mg, 500 mg
ampicillin oral suspension for
ampicillin sodium injection recon soln 1
gram, 10 gram, 125 mg
ampicillin sodium intravenous recon soln
2 gram
ampicillin-sulbactam 1.5 gm vl p/f,
latex-free 1.5 gram
ampicillin-sulbactam injection recon soln
15 gram
ampicillin-sulbactam injection recon soln
3 gram
ampicillin-sulbactam intravenous recon
soln 1.5 gram
BICILLIN L-A INTRAMUSCULAR
SYRINGE 1,200,000 UNIT/2 ML,
2,400,000 UNIT/4 ML, 600,000
UNIT/ML
dicloxacillin oral capsule 250 mg, 500 mg
Drug Tier
Requirements/Limits
(Amoxicillin)
(Moxatag)
2
2
(Amoxicillin)
2
(Augmentin)
2
(Augmentin)
2
(Augmentin XR)
2
(Amoxicillin/Potassium
Clav)
(Ampicillin Sodium)
2
(Ampicillin Trihydrate)
(Ampicillin Trihydrate)
2
2
(Ampicillin Sodium)
2
NM
(Ampicillin Sodium)
2
NM
(Unasyn)
2
(Unasyn)
2
(Unasyn)
2
(Unasyn)
2
2
4
(Dicloxacillin Sodium)
NM
NM
NM
2
20
Drug Name
nafcillin 2 gm vial sterile, latex-free 2
gram
nafcillin injection recon soln 1 gram, 10
gram
nafcillin intravenous recon soln 2 gram
oxacillin 1 gm add-vantage vl
add-vantage, inner 1 gram
oxacillin in dextrose(iso-osm)
intravenous piggyback 1 gram/50 ml, 2
gram/50 ml
oxacillin injection recon soln 10 gram
oxacillin intravenous recon soln 2 gram
penicillin g pot in dextrose intravenous
piggyback 1 million unit/50 ml, 2 million
unit/50 ml, 3 million unit/50 ml
penicillin g potassium injection recon soln
5 million unit
penicillin g procaine intramuscular
syringe 1.2 million unit/2 ml, 600,000
unit/ml
penicillin gk 20 million unit 20 million
unit
penicillin v potassium oral recon soln 125
mg/5 ml, 250 mg/5 ml
penicillin v potassium oral tablet 250 mg,
500 mg
pfizerpen-g injection recon soln 20 million
unit
piperacillin-tazobactam intravenous
recon soln 2.25 gram
piperacillin-tazobactam intravenous
recon soln 3.375 gram, 4.5 gram
piperacil-tazobact 3.375 gm vl suv, p/f,
latex-free 3.375 gram
piperacil-tazobact 4.5 gm vial 10's, p/f,
sdv 4.5 gram
Drug Tier
Requirements/Limits
(Nafcillin Sodium)
2
NM
(Nafcillin Sodium)
2
NM
(Nafcillin Sodium)
(Oxacillin Sodium)
2
2
NM
NM
(Oxacillin
2
NM
(Oxacillin Sodium)
(Oxacillin Sodium)
(Pen G
Pot/Dextrose-Water)
2
2
2
NM
NM
NM
(Penicillin G
Potassium)
(Penicillin G Procaine)
2
NM
2
NM
(Penicillin G
Potassium)
(Penicillin V
Potassium)
(Penicillin V
Potassium)
(Penicillin G
Potassium)
(Zosyn)
2
NM
(Zosyn)
2
(Zosyn)
2
(Zosyn)
2
2
2
2
NM
2
NM
21
Drug Name
piperacil-tazobact 40.5 gram p/f,
latex-free 40.5 gram
TIMENTIN INTRAVENOUS
PIGGYBACK 3.1 GRAM/100 ML
RECON SOLN 3.1 GRAM
RECON SOLN 31 GRAM
Quinolones
ciprofloxacin (mixture) oral tablet, er
multiphase 24 hr 1,000 mg, 500 mg
ciprofloxacin hcl oral tablet 100 mg, 250
mg, 500 mg, 750 mg
ciprofloxacin in 5 % dextrose intravenous
piggyback 200 mg/100 ml
ciprofloxacin oral
suspension,microcapsule recon 250 mg/5
ml, 500 mg/5 ml
ciprofloxacn-d5w 400 mg/200 ml
p/f,latex/f, in d5w 400 mg/200 ml
levofloxacin in d5w intravenous
levofloxacin in d5w intravenous
levofloxacin intravenous solution 25
mg/ml
levofloxacin oral solution 250 mg/10 ml
levofloxacin oral tablet 250 mg, 500 mg,
750 mg
moxifloxacin oral tablet 400 mg
ofloxacin oral tablet 400 mg
Sulfonamides
sulfadiazine oral tablet 500 mg
sulfamethoxazole-trimethoprim
intravenous solution 400-80 mg/5 ml
Drug Tier
(Zosyn)
2
Requirements/Limits
NM
3
3
3
NM
(Cipro XR)
2
NM; QL (30 per 30
days)
(Cipro)
2
(Cipro I.V.)
2
(Cipro)
2
(Cipro I.V.)
2
(Levaquin)
2
(Levaquin)
2
(Levofloxacin)
2
(Levaquin)
(Levaquin)
2
2
(Avelox)
(Ofloxacin)
2
2
(Sulfadiazine)
(Sulfamethoxazole/Tri
methoprim)
2
2
NM
NM
NM
NM
22
Drug Name
sulfamethoxazole-trimethoprim oral
suspension 200-40 mg/5 ml
sulfamethoxazole-trimethoprim oral
tablet 400-80 mg, 800-160 mg
sulfasalazine oral tablet 500 mg
sulfasalazine oral tablet,delayed release
(dr/ec) 500 mg
sulfatrim oral suspension 200-40 mg/5 ml
Tetracyclines
demeclocycline oral tablet 150 mg, 300
mg
doxy 100 vial 10's, p/f 100 mg
doxycycline hyclate 100 mg cap 100 mg
doxycycline hyclate 100 mg tab 100 mg
doxycycline hyclate intravenous recon
soln 100 mg
doxycycline hyclate oral capsule 100 mg
doxycycline hyclate oral capsule 50 mg
doxycycline hyclate oral tablet 100 mg,
50 mg
doxycycline hyclate oral tablet 20 mg
doxycycline hyclate oral tablet,delayed
release (dr/ec) 100 mg, 150 mg, 200 mg,
50 mg, 75 mg
doxycycline mono 100 mg cap 100 mg
doxycycline mono 100 mg tablet f/c 100
mg
doxycycline mono 50 mg tablet 50 mg
doxycycline monohydrate oral capsule
150 mg, 50 mg, 75 mg
doxycycline monohydrate oral suspension
for reconstitution 25 mg/5 ml
doxycycline monohydrate oral tablet 150
mg, 75 mg
Drug Tier
methoprim)
(Bactrim)
2
(Azulfidine)
(Azulfidine)
2
2
methoprim)
2
(Demeclocycline HCl)
2
(Doxycycline Hyclate)
(Morgidox)
(Doryx)
(Doxycycline Hyclate)
2
2
2
2
(Adoxa)
(Morgidox)
(Avidoxy)
2
2
2
(Doryx)
(Doryx)
2
2
(Adoxa)
(Avidoxy)
2
2
(Avidoxy)
(Adoxa)
2
2
(Vibramycin)
2
(Avidoxy)
2
1
Requirements/Limits
GC
NM
NM
23
Drug Name
minocycline oral capsule 100 mg, 50 mg,
75 mg
minocycline oral tablet 100 mg, 50 mg,
75 mg
minocycline oral tablet extended release
24 hr 135 mg, 45 mg, 90 mg
tetracycline oral capsule 250 mg, 500 mg
TYGACIL INTRAVENOUS RECON
SOLN 50 MG
Drug Tier
Requirements/Limits
(Minocin)
2
(Minocycline HCl)
2
(Minocycline HCl)
2
(Tetracycline HCl)
2
4
NM
5
PA NSO; NM
5
PA NSO; NM
(Fluorouracil)
2
PA BvD; NM
(Fluorouracil)
2
PA BvD
(Fluorouracil)
2
5
PA BvD; NM
PA NSO; NM
5
PA NSO; NM
5
5
PA NSO; NM; QL (240
per 30 days)
NM
2
5
NM
PA NSO; NM
5
PA NSO; NM
NM; QL (30 per 30
days)
Anticancer Agents
Anticancer Agents
ABRAXANE INTRAVENOUS
SUSPENSION FOR
RECONSTITUTION 100 MG
ADCETRIS INTRAVENOUS
RECON SOLN 50 MG
adrucil 2,500 mg/50 ml vial outer,
latex-free 2.5 gram/50 ml
adrucil 500 mg/10 ml vial
sdv,latex-free,inner 500 mg/10 ml
adrucil intravenous solution 500 mg/10 ml
AFINITOR DISPERZ ORAL
TABLET FOR SUSPENSION 2 MG, 3
MG, 5 MG
AFINITOR ORAL TABLET 10 MG,
2.5 MG, 5 MG, 7.5 MG
ALECENSA ORAL CAPSULE 150
MG
ALIMTA INTRAVENOUS RECON
SOLN 500 MG
anastrozole oral tablet 1 mg
ARRANON INTRAVENOUS
SOLUTION 250 MG/50 ML
ARZERRA INTRAVENOUS
SOLUTION 1,000 MG/50 ML, 100
MG/5 ML
(Arimidex)
24
Drug Name
Drug Tier
AVASTIN INTRAVENOUS
SOLUTION 25 MG/ML, 25 MG/ML
(16 ML)
azacitidine injection recon soln 100 mg
BELEODAQ INTRAVENOUS
RECON SOLN 500 MG
BENDEKA INTRAVENOUS
SOLUTION 25 MG/ML
bexarotene oral capsule 75 mg
bicalutamide oral tablet 50 mg
BICNU INTRAVENOUS RECON
SOLN 100 MG
bleomycin injection recon soln 30 unit
bleomycin sulfate 15 unit vial latex-free
15 unit
BLINCYTO INTRAVENOUS KIT 35
MCG
BOSULIF ORAL TABLET 100 MG
BOSULIF ORAL TABLET 500 MG
5
NM
5
5
NM
PA NSO; NM
5
NM
(Targretin)
(Casodex)
5
2
4
NM
NM
NM
(Bleomycin Sulfate)
(Bleomycin Sulfate)
2
2
PA BvD; NM
PA BvD; NM
5
PA NSO; NM
5
5
PA NSO; NM
PA NSO; NM; QL (30
per 30 days)
(Vidaza)
BUSULFEX INTRAVENOUS
CABOMETYX ORAL TABLET 20
MG, 60 MG
CABOMETYX ORAL TABLET 40
MG
CAPRELSA ORAL TABLET 100 MG,
300 MG
carboplatin intravenous solution 10
(Carboplatin)
mg/ml
CERUBIDINE INTRAVENOUS
RECON SOLN 20 MG
cisplatin intravenous solution 1 mg/ml
(Cisplatin)
cladribine intravenous solution 10 mg/10 (Cladribine)
ml
Requirements/Limits
4
5
5
PA NSO; NM; QL (30
per 30 days)
PA NSO; NM; QL (60
per 30 days)
PA NSO; NM; LA
2
NM
5
2
2
2
NM
PA BvD; NM
25
Drug Name
Drug Tier
CLOLAR INTRAVENOUS
COMETRIQ ORAL CAPSULE 100
MG/DAY(80 MG X1-20 MG X1), 140
MG/DAY(80 MG X1-20 MG X3), 60
MG/DAY (20 MG X 3/DAY)
COSMEGEN INTRAVENOUS
RECON SOLN 0.5 MG
COTELLIC ORAL TABLET 20 MG
5
PA NSO; NM
5
PA NSO; NM
4
NM
5
PA NSO; NM; LA; QL
(90 per 30 days)
cyclophosphamide intravenous recon soln
1 gram, 500 mg
cyclophosphamide intravenous recon soln
2 gram
CYCLOPHOSPHAMIDE ORAL
CAPSULE 25 MG, 50 MG
CYRAMZA INTRAVENOUS
(50 ML)
cytarabine (pf) injection solution 2
gram/20 ml (100 mg/ml)
cytarabine injection solution 20 mg/ml
dacarbazine intravenous recon soln 200
mg
DARZALEX 400 MG/20 ML VIAL 20
MG/ML
DARZALEX INTRAVENOUS
SOLUTION 20 MG/ML
daunorubicin intravenous solution 5
mg/ml
DAUNOXOME INTRAVENOUS
SOLUTION 2 MG/ML
decitabine intravenous recon soln 50 mg
DEPOCYT (PF) INTRATHECAL
SUSPENSION 50 MG/5 ML (10
MG/ML)
Requirements/Limits
(Cyclophosphamide)
2
(Cyclophosphamide)
2
NM
4
PA BvD; NM
5
PA NSO; NM
(Cytarabine/PF)
2
PA BvD; NM
(Cytarabine)
(Dacarbazine)
2
2
PA BvD; NM
NM
5
PA NSO; NM
5
PA NSO; NM; LA
2
NM
4
NM
5
4
PA NSO; NM
PA BvD; NM
(Cerubidine)
(Dacogen)
26
Drug Name
Drug Tier
DOCEFREZ INTRAVENOUS
RECON SOLN 20 MG, 80 MG
docetaxel 160 mg/16 ml vial mdv 160
mg/16 ml (10 mg/ml)
docetaxel intravenous solution 20 mg/2
ml (final), 80 mg/4 ml (20 mg/ml), 80
mg/8 ml (10 mg/ml)
doxorubicin 200 mg/100 ml vial mdv, p/f
2 mg/ml
doxorubicin hcl liposome 50 mg/25 ml
vial 2 mg/ml
doxorubicin intravenous recon soln 10
mg, 50 mg
doxorubicin intravenous solution 50
mg/25 ml
doxorubicin, peg-liposomal intravenous
suspension 2 mg/ml
DROXIA ORAL CAPSULE 200 MG,
300 MG, 400 MG
ELIGARD SUBCUTANEOUS
SYRINGE 22.5 MG (3 MONTH), 30
MG (4 MONTH), 45 MG (6 MONTH),
7.5 MG (1 MONTH)
EMCYT ORAL CAPSULE 140 MG
EMPLICITI INTRAVENOUS
epirubicin intravenous solution 50 mg/25
ml
ERBITUX INTRAVENOUS
ERIVEDGE ORAL CAPSULE 150
MG
ERWINAZE INJECTION RECON
SOLN 10,000 UNIT
ETOPOPHOS INTRAVENOUS
RECON SOLN 100 MG
etoposide intravenous solution 20 mg/ml
5
NM
(Taxotere)
5
NM
(Taxotere)
5
NM
(Doxorubicin HCl)
2
PA BvD; NM
(Doxil)
2
PA BvD; NM
(Doxorubicin HCl)
2
PA BvD
(Doxorubicin HCl)
2
PA BvD; NM
(Doxil)
2
PA BvD
4
NM
4
NM
3
5
NM
PA NSO; NM
2
NM
5
NM
5
5
PA NSO; NM; LA; QL
(30 per 30 days)
PA NSO; NM
4
NM
2
NM
(Ellence)
(Etoposide)
Requirements/Limits
27
Drug Name
exemestane oral tablet 25 mg
FARESTON ORAL TABLET 60 MG
FARYDAK ORAL CAPSULE 10
MG, 15 MG, 20 MG
FASLODEX INTRAMUSCULAR
SYRINGE 250 MG/5 ML
FIRMAGON KIT W DILUENT
SYRINGE SUBCUTANEOUS
RECON SOLN 120 MG
FIRMAGON KIT W DILUENT
SYRINGE SUBCUTANEOUS
RECON SOLN 80 MG
floxuridine injection recon soln 0.5 gram
fludarabine 50 mg/2 ml vial sdv, p/f 50
mg/2 ml
fludarabine intravenous recon soln 50 mg
Drug Tier
(Aromasin)
(Floxuridine)
(Fludarabine
Phosphate)
(Fludarabine
Phosphate)
fluorouracil 5,000 mg/100 ml latex-free 5 (Fluorouracil)
gram/100 ml
fluorouracil intravenous solution 1
(Fluorouracil)
gram/20 ml, 500 mg/10 ml
fluorouracil intravenous solution 2.5
(Fluorouracil)
gram/50 ml
flutamide oral capsule 125 mg
(Flutamide)
FOLOTYN 20 MG/ML VIAL 20
MG/ML (1 ML)
FOLOTYN INTRAVENOUS
SOLUTION 40 MG/2 ML (20
MG/ML)
GAZYVA INTRAVENOUS
SOLUTION 1,000 MG/40 ML
gemcitabine intravenous recon soln 1
(Gemzar)
gram
GILOTRIF ORAL TABLET 20 MG,
30 MG, 40 MG
GLEEVEC ORAL TABLET 100 MG,
400 MG
2
4
5
Requirements/Limits
5
NM
NM
PA NSO; NM; QL (6
per 21 days)
NM
5
NM
4
NM
2
2
PA BvD; NM
NM
2
NM
2
PA BvD; NM
2
PA BvD
2
PA BvD; NM
2
5
NM
NM
5
NM
5
PA NSO; NM
5
NM
5
PA NSO; NM; QL (30
per 30 days)
NM
5
28
Drug Name
Drug Tier
GLEOSTINE ORAL CAPSULE 5 MG
HALAVEN INTRAVENOUS
SOLUTION 1 MG/2 ML (0.5 MG/ML)
HERCEPTIN INTRAVENOUS
RECON SOLN 440 MG
HEXALEN ORAL CAPSULE 50 MG
hydroxyurea oral capsule 500 mg
IBRANCE ORAL CAPSULE 100 MG,
125 MG, 75 MG
ICLUSIG ORAL TABLET 15 MG, 45
MG
idarubicin intravenous solution 1 mg/ml
ifosfamide 1 gm/20 ml vial suv 1 gram/20
ml
ifosfamide intravenous recon soln 1 gram
ifosfamide-mesna intravenous kit 1-1
gram, 3,000-1,000 mg
imatinib oral tablet 100 mg, 400 mg
IMBRUVICA ORAL CAPSULE 140
MG
IMLYGIC INJECTION
SUSPENSION 10EXP6 (1 MILLION)
PFU/ML
IMLYGIC INJECTION
SUSPENSION 10EXP8 (100
MILLION) PFU/ML
INLYTA ORAL TABLET 1 MG, 5
MG
IRESSA ORAL TABLET 250 MG
4
5
PA NSO; NM
5
PA BvD; NM
5
2
5
5
NM
NM
PA NSO; NM; QL (21
per 28 days)
PA NSO; NM
(Idamycin Pfs)
(Ifex)
2
2
PA BvD; NM
(Ifex)
(Ifosfamide/Mesna)
2
2
PA BvD; NM
PA BvD; NM
(Gleevec)
2
5
(Hydrea)
irinotecan intravenous solution 100 mg/5 (Camptosar)
ml
irinotecan intravenous solution 500 mg/25 (Camptosar)
ml
ISTODAX INTRAVENOUS RECON
SOLN 10 MG/2 ML
5
Requirements/Limits
PA NSO; NM; QL (120
per 30 days)
PA NSO; NM; QL (4
per 180 days)
5
PA NSO; NM; QL (8
per 28 days)
5
PA NSO; NM; LA
5
PA NSO; NM; QL (30
per 30 days)
NM
2
2
5
PA NSO; NM
29
Drug Name
Drug Tier
IXEMPRA 15 MG KIT WITH
DILUENT 15 MG
IXEMPRA INTRAVENOUS RECON
SOLN 45 MG
JAKAFI ORAL TABLET 10 MG, 15
MG, 20 MG, 25 MG, 5 MG
JEVTANA INTRAVENOUS
SOLUTION 10 MG/ML (FIRST
DILUTION)
KADCYLA 160 MG VIAL 160 MG
KADCYLA INTRAVENOUS
RECON SOLN 100 MG
KEYTRUDA INTRAVENOUS
RECON SOLN 50 MG
KEYTRUDA INTRAVENOUS
MG/ML)
KYPROLIS INTRAVENOUS
LENVIMA ORAL CAPSULE 10
MG/DAY (10 MG X 1/DAY), 14
MG/DAY(10 MG X 1-4 MG X 1), 20
MG/DAY (10 MG X 2), 24
MG/DAY(10 MG X 2-4 MG X 1)
LENVIMA ORAL CAPSULE 18
MG/DAY (10 MG X 1-4 MG X2), 8
MG/DAY (4 MG X 2)
letrozole oral tablet 2.5 mg
LEUKERAN ORAL TABLET 2 MG
leuprolide subcutaneous kit 1 mg/0.2 ml
lipodox 50 intravenous suspension 2
mg/ml
lipodox intravenous suspension 2 mg/ml
lomustine oral capsule 10 mg, 100 mg, 40
mg
LONSURF ORAL TABLET 15-6.14
MG, 20-8.19 MG
5
PA NSO; NM
5
PA NSO; NM
5
5
PA NSO; NM; LA; QL
(60 per 30 days)
PA NSO; NM
5
5
PA NSO; NM
PA NSO; NM
5
PA NSO; NM
5
PA NSO; NM
5
PA NSO; NM
5
PA NSO; NM; QL (90
per 30 days)
5
PA NSO; NM; QL (30
per 30 days)
(Leuprolide Acetate)
(Doxil)
2
3
2
2
NM
NM
NM
PA BvD
(Doxil)
(Lomustine)
2
2
PA BvD; NM
NM
5
PA NSO; NM
(Femara)
Requirements/Limits
30
Drug Name
Drug Tier
Requirements/Limits
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT
11.25 MG, 22.5 MG
30 MG
45 MG
LUPRON DEPOT
3.75 MG, 7.5 MG
LYNPARZA ORAL CAPSULE 50
MG
LYSODREN ORAL TABLET 500 MG
MARQIBO INTRAVENOUS KIT 5
MG/31 ML(0.16 MG/ML) FINAL
MATULANE ORAL CAPSULE 50
MG
megestrol oral tablet 20 mg, 40 mg
(Megestrol Acetate)
MEKINIST ORAL TABLET 0.5 MG
5
NM
5
NM
5
NM
5
NM
5
3
5
PA NSO; NM; QL (448
per 28 days)
NM
PA NSO; NM
5
NM; LA
MEKINIST ORAL TABLET 2 MG
5
melphalan hcl intravenous recon soln 50
mg
mercaptopurine oral tablet 50 mg
methotrexate 50 mg/2 ml vial latex-free,
5's, mdv 25 mg/ml
methotrexate sodium (pf) injection recon
soln 1 gram
methotrexate sodium (pf) injection
solution 25 mg/ml
methotrexate sodium oral tablet 2.5 mg
mitomycin intravenous recon soln 20 mg
mitoxantrone intravenous concentrate 2
mg/ml
2
5
PA NSO; NM; LA; QL
(90 per 30 days)
PA NSO; NM; LA; QL
(30 per 30 days)
NM
(Alkeran)
2
(Mercaptopurine)
(Methotrexate Sodium)
2
2
NM
(Methotrexate
Sodium/PF)
2
PA BvD; NM
(Mitomycin)
(Mitoxantrone HCl)
2
2
2
2
NM
PA BvD; NM
NM
31
Drug Name
Drug Tier
MUSTARGEN INJECTION RECON
SOLN 10 MG
NEXAVAR ORAL TABLET 200 MG
4
NM
5
NILANDRON ORAL TABLET 150
MG
nilutamide oral tablet 150 mg
(Nilandron)
NINLARO ORAL CAPSULE 2.3 MG,
3 MG, 4 MG
NIPENT INTRAVENOUS RECON
SOLN 10 MG
ODOMZO ORAL CAPSULE 200 MG
3
PA NSO; NM; LA; QL
(120 per 30 days)
NM
ONCASPAR INJECTION
SOLUTION 750 UNIT/ML
onxol intravenous concentrate 6 mg/ml
(Paclitaxel)
OPDIVO INTRAVENOUS
SOLUTION 40 MG/4 ML
oxaliplatin intravenous solution 100
(Eloxatin)
mg/20 ml
paclitaxel intravenous concentrate 6
(Paclitaxel)
mg/ml
PERJETA INTRAVENOUS
MG/ML)
PHOTOFRIN INTRAVENOUS
RECON SOLN 75 MG
POMALYST ORAL CAPSULE 1 MG,
2 MG, 3 MG, 4 MG
PORTRAZZA INTRAVENOUS
MG/ML)
PROLEUKIN INTRAVENOUS
RECON SOLN 22 MILLION UNIT
PURIXAN ORAL SUSPENSION 20
MG/ML
5
PA NSO; NM; LA; QL
(30 per 30 days)
NM
2
5
NM
PA NSO; NM
5
NM
2
NM
5
NM
4
NM
5
PA NSO; NM; LA; QL
(21 per 28 days)
PA NSO; NM; LA; QL
(100 per 21 days)
2
5
4
5
5
Requirements/Limits
QL (60 per 30 days)
PA NSO; NM; QL (3
per 28 days)
NM
5
NM
4
NM
32
Drug Name
Drug Tier
REVLIMID ORAL CAPSULE 10
MG, 15 MG, 2.5 MG, 20 MG, 25 MG,
5 MG
RITUXAN INTRAVENOUS
CONCENTRATE 10 MG/ML
SOLTAMOX ORAL SOLUTION 10
MG/5 ML
SPRYCEL ORAL TABLET 100 MG,
140 MG, 20 MG, 50 MG, 70 MG, 80
MG
STIVARGA ORAL TABLET 40 MG
5
PA NSO; NM; LA
5
PA NSO; NM
4
NM
5
PA NSO; NM
5
SUTENT ORAL CAPSULE 12.5 MG,
25 MG, 37.5 MG, 50 MG
SYLVANT INTRAVENOUS RECON
SOLN 100 MG, 400 MG
SYNRIBO SUBCUTANEOUS
RECON SOLN 3.5 MG
TABLOID ORAL TABLET 40 MG
TAFINLAR ORAL CAPSULE 50
MG, 75 MG
TAGRISSO ORAL TABLET 40 MG,
80 MG
tamoxifen oral tablet 10 mg, 20 mg
(Tamoxifen Citrate)
TARCEVA ORAL TABLET 100 MG,
150 MG
TARCEVA ORAL TABLET 25 MG
5
PA NSO; NM; QL (120
per 30 days)
PA NSO; NM
5
PA NSO; NM
5
PA NSO; NM
3
5
TARGRETIN ORAL CAPSULE 75
MG
TARGRETIN TOPICAL GEL 1 %
TASIGNA ORAL CAPSULE 150 MG,
200 MG
TECENTRIQ INTRAVENOUS
SOLUTION 1,200 MG/20 ML (60
MG/ML)
5
NM
PA NSO; NM; LA; QL
(120 per 30 days)
PA NSO; NM; LA; QL
(30 per 30 days)
NM
PA NSO; NM; LA; QL
(30 per 30 days)
PA NSO; NM; LA; QL
(90 per 30 days)
NM
5
2
5
5
5
5
5
Requirements/Limits
NM
PA NSO; NM; QL (120
per 30 days)
PA NSO; NM
33
Drug Name
Drug Tier
TEMODAR INTRAVENOUS
RECON SOLN 100 MG
teniposide intravenous solution 50 mg/5
ml
thiotepa injection recon soln 15 mg
toposar intravenous solution 20 mg/ml
topotecan hcl 4 mg/4 ml vial
suv,latex-free 4 mg/4 ml (1 mg/ml)
topotecan intravenous recon soln 4 mg
TORISEL INTRAVENOUS RECON
SOLN 30 MG/3 ML (10 MG/ML)
(FIRST)
TREANDA 25 MG VIAL 25 MG
TREANDA INTRAVENOUS
RECON SOLN 100 MG
TREANDA INTRAVENOUS
SOLUTION 180 MG/2 ML, 45 MG/0.5
ML
TRELSTAR 22.5 MG SYRINGE
WITH MIXJECT 22.5 MG/2 ML
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 22.5 MG
TRELSTAR INTRAMUSCULAR
SYRINGE 11.25 MG/2 ML, 3.75 MG/2
ML
tretinoin (chemotherapy) oral capsule 10
mg
TRISENOX INTRAVENOUS
TYKERB ORAL TABLET 250 MG
UNITUXIN INTRAVENOUS
SOLUTION 3.5 MG/ML
VALSTAR INTRAVESICAL
SOLUTION 40 MG/ML
4
NM
(Teniposide)
2
NM
(Thiotepa)
(Etoposide)
(Hycamtin)
2
2
2
NM
NM
(Hycamtin)
2
5
PA NSO; NM
5
5
NM
NM
5
NM
5
NM
5
NM
5
NM
5
NM
3
NM
5
5
PA NSO; NM; LA
PA NSO; NM; QL (40
per 30 days)
NM
(Tretinoin)
4
Requirements/Limits
34
Drug Name
Drug Tier
VECTIBIX INTRAVENOUS
MG/ML)
VELCADE INJECTION RECON
SOLN 3.5 MG
VENCLEXTA ORAL TABLET 10
MG
MG
MG
VENCLEXTA STARTING PACK
ORAL TABLETS,DOSE PACK 10
MG-50 MG- 100 MG
vinblastine intravenous solution 1 mg/ml
vincasar pfs 2 mg/2 ml vial 2 mg/2 ml
vincasar pfs intravenous solution 1 mg/ml
vincristine 2 mg/2 ml vial p/f, sdv 2 mg/2
ml
vincristine intravenous solution 1 mg/ml
vinorelbine intravenous solution 50 mg/5
ml
VOTRIENT ORAL TABLET 200 MG
5
PA NSO; NM
5
PA NSO; NM
4
PA NSO; QL (60 per 30
days)
PA NSO; NM; QL (120
per 30 days)
days)
PA NSO; NM; QL (42
per 180 days)
5
4
5
Requirements/Limits
(Vinblastine Sulfate)
(Vincristine Sulfate)
2
2
2
2
PA BvD; NM
PA BvD; NM
PA BvD; NM
PA BvD; NM
(Navelbine)
2
2
PA BvD; NM
NM
5
XALKORI ORAL CAPSULE 200
MG, 250 MG
XTANDI ORAL CAPSULE 40 MG
5
YERVOY INTRAVENOUS
MG/ML)
YONDELIS INTRAVENOUS
RECON SOLN 1 MG
ZALTRAP INTRAVENOUS
MG/ML)
5
PA NSO; NM; QL (120
per 30 days)
PA NSO; NM; LA; QL
(60 per 30 days)
PA NSO; NM; LA; QL
(120 per 30 days)
PA NSO; NM
5
PA NSO; NM
5
PA NSO; NM
5
35
Drug Name
Drug Tier
ZANOSAR INTRAVENOUS RECON
SOLN 1 GRAM
ZELBORAF ORAL TABLET 240 MG
4
NM
5
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG, 3.6 MG
ZOLINZA ORAL CAPSULE 100 MG
ZYDELIG ORAL TABLET 100 MG,
150 MG
ZYKADIA ORAL CAPSULE 150 MG
4
PA NSO; NM; LA; QL
(240 per 30 days)
NM
ZYTIGA ORAL TABLET 250 MG
5
5
5
5
Requirements/Limits
NM
PA NSO; NM; QL (60
per 30 days)
PA NSO; NM; QL (150
per 30 days)
PA NSO; NM; LA; QL
(120 per 30 days)
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine injection solution 0.4 mg/ml, 1
(Atropine Sulfate)
mg/ml
atropine injection syringe 0.05 mg/ml, 0.1 (Atropine Sulfate)
mg/ml
propantheline oral tablet 15 mg
(Propantheline
Bromide)
2
NM
2
NM
2
Anticonvulsants
Anticonvulsants
APTIOM ORAL TABLET 200 MG,
400 MG, 800 MG
APTIOM ORAL TABLET 600 MG
BANZEL ORAL SUSPENSION 40
MG/ML
BANZEL ORAL TABLET 200 MG,
400 MG
BRIVIACT INTRAVENOUS
SOLUTION 50 MG/5 ML
BRIVIACT ORAL SOLUTION 10
MG/ML
4
4
days)
days)
PA NSO
4
PA NSO
4
PA NSO
4
PA NSO; QL (600 per
30 days)
4
36
Drug Name
Drug Tier
Requirements/Limits
BRIVIACT ORAL TABLET 10 MG,
100 MG, 25 MG, 50 MG, 75 MG
carbamazepine oral capsule, er
multiphase 12 hr 100 mg, 200 mg, 300 mg
carbamazepine oral suspension 100 mg/5
ml
carbamazepine oral tablet 200 mg
carbamazepine oral tablet extended
release 12 hr 100 mg, 200 mg, 400 mg
carbamazepine oral tablet,chewable 100
mg
CELONTIN ORAL CAPSULE 300
MG
DILANTIN EXTENDED ORAL
CAPSULE 100 MG
DILANTIN INFATABS ORAL
TABLET,CHEWABLE 50 MG
DILANTIN ORAL CAPSULE 30 MG
divalproex oral capsule, sprinkle 125 mg
divalproex oral tablet extended release 24
hr 250 mg, 500 mg
divalproex oral tablet,delayed release
(dr/ec) 125 mg, 250 mg, 500 mg
epitol oral tablet 200 mg
ethosuximide oral capsule 250 mg
ethosuximide oral solution 250 mg/5 ml
felbamate oral suspension 600 mg/5 ml
felbamate oral tablet 400 mg
felbamate oral tablet 600 mg
fosphenytoin 500 mg pe/10 ml
10's,sdv,latex-free 500 mg pe/10 ml
fosphenytoin injection solution 100 mg
pe/2 ml
FYCOMPA ORAL SUSPENSION 0.5
MG/ML
4
days)
(Carbatrol)
2
(Tegretol)
2
(Tegretol)
(Tegretol XR)
2
2
(Carbamazepine)
2
4
4
3
(Depakote Sprinkle)
(Depakote ER)
4
2
2
(Depakote)
2
(Tegretol)
(Zarontin)
(Zarontin)
(Felbatol)
(Felbatol)
(Felbatol)
(Cerebyx)
2
2
2
2
2
5
2
NM
NM
(Cerebyx)
2
NM
4
PA NSO; QL (720 per
30 days)
37
Drug Name
FYCOMPA ORAL TABLET 10 MG,
12 MG, 2 MG, 4 MG, 6 MG, 8 MG
gabapentin oral capsule 100 mg, 300 mg, (Neurontin)
400 mg
gabapentin oral solution 250 mg/5 ml
(Neurontin)
gabapentin oral tablet 600 mg, 800 mg
(Neurontin)
GABITRIL ORAL TABLET 12 MG,
16 MG
LAMICTAL ODT STARTER (BLUE)
ORAL TABLET DISINTEGRATING,
DOSE PK 25 MG (21) -50 MG (7)
LAMICTAL ODT STARTER
(GREEN) ORAL TABLET
DISINTEGRATING, DOSE PK 50
MG (42) -100 MG (14)
(ORANGE) ORAL TABLET
DISINTEGRATING, DOSE PK 25
MG(14)-50 MG (14)-100 MG (7)
LAMICTAL ORAL TABLET,
CHEWABLE DISPERSIBLE 2 MG
LAMICTAL STARTER (GREEN)
KIT ORAL TABLETS,DOSE PACK
25 MG (84) -100 MG (14)
LAMICTAL STARTER (ORANGE)
KIT ORAL TABLETS,DOSE PACK
25 MG (42) -100 MG (7)
LAMICTAL XR STARTER (BLUE)
ORAL TABLET EXTENDED
REL,DOSE PACK 25 MG (21) -50 MG
(7)
LAMICTAL XR STARTER (GREEN)
REL,DOSE PACK 50 MG(14)-100MG
(14)-200 MG (7)
Drug Tier
Requirements/Limits
4
days)
2
2
2
3
4
4
4
4
4
4
4
4
38
Drug Name
Drug Tier
LAMICTAL XR STARTER
(ORANGE) ORAL TABLET
EXTENDED REL,DOSE PACK
25MG (14)-50 MG (14)-100MG (7)
lamotrigine oral tablet 100 mg, 150 mg,
200 mg, 25 mg
lamotrigine oral tablet disintegrating,
dose pk 25 mg (21) -50 mg (7), 25
mg(14)-50 mg (14)-100 mg (7), 50 mg
(42) -100 mg (14)
lamotrigine oral tablet extended release
24hr 100 mg, 200 mg, 25 mg, 250 mg,
300 mg, 50 mg
lamotrigine oral tablet, chewable
dispersible 25 mg, 5 mg
lamotrigine oral tablet,disintegrating 100
mg, 200 mg, 25 mg, 50 mg
lamotrigine oral tablets,dose pack 25 mg
(35)
levetiracetam in nacl (iso-os) intravenous
piggyback 1,000 mg/100 ml, 1,500
mg/100 ml, 500 mg/100 ml
levetiracetam intravenous solution 500
mg/5 ml
levetiracetam oral solution 100 mg/ml
levetiracetam oral tablet 1,000 mg, 250
mg, 500 mg, 750 mg
levetiracetam oral tablet extended release
24 hr 500 mg, 750 mg
LYRICA ORAL CAPSULE 100 MG,
150 MG, 200 MG, 225 MG, 25 MG,
300 MG, 50 MG, 75 MG
LYRICA ORAL SOLUTION 20
MG/ML
oxcarbazepine oral suspension 300 mg/5
ml
4
Requirements/Limits
(Lamictal)
2
(Lamictal Odt (Blue))
2
(Lamictal XR)
2
(Lamictal)
2
(Lamictal Odt)
2
(Lamictal (Blue))
2
(Levetiracetam In Nacl
(Iso-Os))
2
NM
(Keppra)
2
NM
(Keppra)
(Keppra)
2
2
(Keppra XR)
2
3
3
(Trileptal)
2
39
Drug Name
oxcarbazepine oral tablet 150 mg, 300
mg, 600 mg
OXTELLAR XR ORAL TABLET
EXTENDED RELEASE 24 HR 150
MG, 300 MG, 600 MG
PEGANONE ORAL TABLET 250
MG
phenobarbital oral elixir 20 mg/5 ml (4
mg/ml)
phenobarbital oral tablet 100 mg, 15 mg,
16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8
mg, 97.2 mg
phenobarbital sodium injection solution
130 mg/ml, 65 mg/ml
PHENYTEK ORAL CAPSULE 200
MG, 300 MG
phenytoin 50 mg/ml vial 25's,inner 50
mg/ml
phenytoin oral suspension 125 mg/5 ml
phenytoin oral tablet,chewable 50 mg
phenytoin sodium extended oral capsule
100 mg, 200 mg, 300 mg
phenytoin sodium intravenous solution 50
mg/ml
phenytoin sodium intravenous syringe 50
mg/ml
POTIGA ORAL TABLET 200 MG,
300 MG, 400 MG, 50 MG
primidone oral tablet 250 mg, 50 mg
SABRIL ORAL POWDER IN
PACKET 500 MG
SABRIL ORAL TABLET 500 MG
SPRITAM ORAL TABLET FOR
SUSPENSION 1,000 MG, 250 MG, 500
MG, 750 MG
Drug Tier
(Trileptal)
Requirements/Limits
2
4
3
(Phenobarbital)
2
(Phenobarbital)
2
(Phenobarbital
Sodium)
2
NM
4
(Phenytoin Sodium)
2
(Dilantin-125)
(Dilantin)
(Dilantin)
2
2
2
(Phenytoin Sodium)
2
NM
(Phenytoin Sodium)
2
NM
4
PA NSO
2
5
PA NSO; NM; LA
5
4
PA NSO; NM; LA
ST
(Mysoline)
40
Drug Name
Drug Tier
TEGRETOL XR ORAL TABLET
MG
tiagabine oral tablet 2 mg, 4 mg
topiramate oral capsule, sprinkle 15 mg,
25 mg
topiramate oral capsule,sprinkle,er 24hr
100 mg, 150 mg, 200 mg, 25 mg, 50 mg
topiramate oral tablet 100 mg, 200 mg,
25 mg, 50 mg
TROKENDI XR ORAL
CAPSULE,EXTENDED RELEASE
24HR 100 MG, 200 MG, 25 MG, 50
MG
valproate sodium intravenous solution
500 mg/5 ml (100 mg/ml)
valproic acid (as sodium salt) oral
solution 250 mg/5 ml
valproic acid oral capsule 250 mg
VIMPAT INTRAVENOUS
VIMPAT ORAL SOLUTION 10
MG/ML
VIMPAT ORAL TABLET 100 MG,
150 MG, 200 MG, 50 MG
zonisamide oral capsule 100 mg, 25 mg,
50 mg
3
(Gabitril)
(Topamax)
2
2
(Qudexy XR)
2
(Topamax)
2
Requirements/Limits
PA NSO
4
PA NSO
(Depacon)
2
NM
(Depakene)
2
(Depakene)
2
4
PA NSO; NM
4
PA NSO
4
PA NSO
(Zonegran)
2
(Aricept)
(Donepezil HCl)
2
2
QL (30 per 30 days)
QL (30 per 30 days)
(Razadyne ER)
2
QL (30 per 30 days)
(Galantamine Hbr)
2
Antidementia Agents
Antidementia Agents
donepezil oral tablet 10 mg, 23 mg, 5 mg
donepezil oral tablet,disintegrating 10
mg, 5 mg
galantamine oral capsule,ext rel. pellets
24 hr 16 mg, 24 mg, 8 mg
galantamine oral solution 4 mg/ml
41
Drug Name
galantamine oral tablet 12 mg, 4 mg, 8
mg
memantine oral solution 2 mg/ml
memantine oral tablet 10 mg, 5 mg
memantine oral tablets,dose pack 5-10
mg
NAMENDA ORAL SOLUTION 2
MG/ML
NAMENDA ORAL TABLET 10 MG,
5 MG
NAMENDA TITRATION PAK
ORAL TABLETS,DOSE PACK 5-10
MG
rivastigmine tartrate oral capsule 1.5 mg,
3 mg, 4.5 mg, 6 mg
rivastigmine transdermal patch 24 hour
13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24
hr
Drug Tier
(Razadyne)
2
(Namenda)
(Namenda)
(Namenda)
2
2
2
Requirements/Limits
3
3
3
(Exelon)
2
(Exelon)
2
QL (30 per 30 days)
(Amitriptyline HCl)
2
PA NSO; (PA Req for
Ages 65 and Older;
High Risk Med)
Antidepressants
Antidepressants
amitriptyline oral tablet 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75 mg
amitriptyline-chlordiazepoxide oral tablet (Amitriptyline/Chlordi
12.5-5 mg, 25-10 mg
azepoxide)
amoxapine oral tablet 100 mg, 150 mg,
(Amoxapine)
25 mg, 50 mg
2
APLENZIN ORAL TABLET
MG, 348 MG, 522 MG
BRINTELLIX ORAL TABLET 10
MG, 20 MG, 5 MG
buproban oral tablet extended release 150 (Wellbutrin SR)
mg
bupropion hcl oral tablet 100 mg, 75 mg (Wellbutrin)
4
2
4
PA NSO; (PA Req for
Ages 65 and Older;
High Risk Med)
QL (30 per 30 days)
2
days)
QL (60 per 30 days)
2
42
Drug Name
Drug Tier
bupropion hcl oral tablet extended release (Wellbutrin SR)
100 mg, 150 mg, 200 mg
bupropion hcl oral tablet extended release (Wellbutrin XL)
24 hr 150 mg, 300 mg
citalopram oral solution 10 mg/5 ml
(Citalopram
Hydrobromide)
citalopram oral tablet 10 mg, 20 mg
(Celexa)
Requirements/Limits
2
QL (60 per 30 days)
2
QL (30 per 30 days)
2
1
GC; QL (45 per 30
days)
GC; QL (30 per 30
days)
PA NSO; (PA Req for
Ages 65 and Older;
High Risk Med)
citalopram oral tablet 40 mg
(Celexa)
1
clomipramine oral capsule 25 mg, 50 mg,
75 mg
(Anafranil)
2
desipramine oral tablet 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75 mg
DESVENLAFAXINE FUMARATE
RELEASE 24HR 100 MG, 50 MG
DESVENLAFAXINE ORAL
TABLET EXTENDED RELEASE 24
HR 100 MG, 50 MG
desvenlafaxine oral tablet extended
release 24hr 100 mg, 50 mg
doxepin oral capsule 10 mg, 100 mg, 150
mg, 25 mg, 50 mg, 75 mg
doxepin oral concentrate 10 mg/ml
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 30 mg, 60 mg
duloxetine oral capsule,delayed
EMSAM TRANSDERMAL PATCH
24 HOUR 12 MG/24 HR, 6 MG/24
HR, 9 MG/24 HR
escitalopram oxalate oral solution 5 mg/5
ml
escitalopram oxalate oral tablet 10 mg, 5
mg
(Norpramin)
2
4
4
(Khedezla)
2
(Doxepin HCl)
2
(Doxepin HCl)
(Duloxetine)
2
2
(Duloxetine)
2
5
(Cymbalta); QL (60 per
30 days)
(Irenka); QL (60 per 30
days)
NM; QL (30 per 30
days)
(Lexapro)
2
(Lexapro)
2
QL (45 per 30 days)
43
Drug Name
escitalopram oxalate oral tablet 20 mg
FETZIMA ORAL CAPSULE,EXT
REL 24HR DOSE PACK 20 MG (2)40 MG (26)
FETZIMA ORAL
CAPSULE,EXTENDED RELEASE 24
HR 120 MG, 20 MG, 40 MG, 80 MG
fluoxetine oral capsule 10 mg
fluoxetine oral capsule,delayed
fluoxetine oral solution 20 mg/5 ml (4
mg/ml)
fluoxetine oral tablet 10 mg
fluoxetine oral tablet 20 mg
FLUOXETINE ORAL TABLET 60
MG
fluvoxamine oral capsule,extended
release 24hr 100 mg, 150 mg
fluvoxamine oral tablet 100 mg
FORFIVO XL ORAL TABLET
MG
imipramine hcl oral tablet 10 mg, 25 mg,
50 mg
Drug Tier
Requirements/Limits
2
4
QL (30 per 30 days)
days)
4
days)
(Prozac)
(Prozac)
(Prozac)
(Prozac Weekly)
2
2
2
2
QL (90 per 30 days)
QL (60 per 30 days)
QL (4 per 28 days)
(Fluoxetine HCl)
2
(Fluoxetine HCl)
(Fluoxetine HCl)
2
2
2
QL (90 per 30 days)
QL (30 per 30 days)
(Fluvoxamine Maleate)
2
QL (60 per 30 days)
2
2
2
4
QL (90 per 30 days)
QL (30 per 30 days)
QL (45 per 30 days)
QL (30 per 30 days)
(Tofranil)
2
PA NSO; (PA Req for
Ages 65 and Older;
High Risk Med)
PA NSO; (PA Req for
Ages 65 and Older;
High Risk Med)
(Lexapro)
imipramine pamoate oral capsule 100 mg, (Tofranil-Pm)
125 mg, 150 mg, 75 mg
maprotiline oral tablet 25 mg, 50 mg, 75
mg
MARPLAN ORAL TABLET 10 MG
(Maprotiline HCl)
2
2
3
44
Drug Name
Drug Tier
Requirements/Limits
mirtazapine oral tablet 15 mg, 30 mg, 45
mg, 7.5 mg
mirtazapine oral tablet,disintegrating 15
mg, 30 mg, 45 mg
nefazodone oral tablet 100 mg, 150 mg,
250 mg, 50 mg
nefazodone oral tablet 200 mg
nortriptyline oral capsule 10 mg, 25 mg,
50 mg, 75 mg
nortriptyline oral solution 10 mg/5 ml
olanzapine-fluoxetine oral capsule 12-25
mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50
mg
OLEPTRO ER ORAL TABLET
MG, 300 MG
paroxetine hcl oral tablet 10 mg, 40 mg
(Remeron)
2
QL (30 per 30 days)
(Remeron)
2
QL (30 per 30 days)
(Nefazodone HCl)
2
QL (60 per 30 days)
(Nefazodone HCl)
(Pamelor)
2
1
QL (90 per 30 days)
GC
(Nortriptyline HCl)
(Symbyax)
2
2
QL (30 per 30 days)
4
days)
(Paxil)
1
paroxetine hcl oral tablet 20 mg
(Paxil)
1
paroxetine hcl oral tablet 30 mg
(Paxil)
1
paroxetine hcl oral tablet extended
release 24 hr 12.5 mg
paroxetine hcl oral tablet extended
release 24 hr 25 mg, 37.5 mg
PAXIL ORAL SUSPENSION 10
MG/5 ML
perphenazine-amitriptyline oral tablet
2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg,
4-50 mg
PEXEVA ORAL TABLET 10 MG, 40
MG
PEXEVA ORAL TABLET 20 MG
PEXEVA ORAL TABLET 30 MG
phenelzine oral tablet 15 mg
(Paxil CR)
2
GC; QL (45 per 30
days)
GC; QL (30 per 30
days)
GC; QL (60 per 30
days)
QL (30 per 30 days)
(Paxil CR)
2
QL (60 per 30 days)
4
(Perphenazine/Amitript
yline HCl)
(Nardil)
2
4
QL (45 per 30 days)
4
4
2
QL (30 per 30 days)
QL (60 per 30 days)
45
Drug Name
Drug Tier
Requirements/Limits
4
PRISTIQ ORAL TABLET
MG, 25 MG, 50 MG
protriptyline oral tablet 10 mg, 5 mg
sertraline oral concentrate 20 mg/ml
sertraline oral tablet 100 mg
(Protriptyline HCl)
(Zoloft)
(Zoloft)
2
2
1
sertraline oral tablet 25 mg, 50 mg
(Zoloft)
1
SILENOR ORAL TABLET 3 MG, 6
MG
SURMONTIL ORAL CAPSULE 100
MG, 25 MG, 50 MG
tranylcypromine oral tablet 10 mg
trazodone oral tablet 100 mg, 150 mg, 50
mg
trimipramine oral capsule 100 mg, 25 mg,
50 mg
TRINTELLIX ORAL TABLET 10
MG, 20 MG, 5 MG
venlafaxine oral capsule,extended release
24hr 150 mg, 37.5 mg, 75 mg
venlafaxine oral tablet 100 mg, 25 mg,
37.5 mg, 50 mg, 75 mg
venlafaxine oral tablet extended release
24hr 150 mg, 225 mg, 37.5 mg, 75 mg
VIIBRYD ORAL TABLET 10 MG, 20
MG, 40 MG
VIIBRYD ORAL TABLETS,DOSE
PACK 10 MG (7)- 20 MG (23)
VIIBRYD ORAL TABLETS,DOSE
PACK 10 MG (7)-20 MG (7)-40 MG
(16)
4
4
GC; QL (60 per 30
days)
GC; QL (45 per 30
days)
QL (30 per 30 days)
PA NSO; (PA Req for
Ages 65 and Older;
High Risk Med)
(Parnate)
(Trazodone HCl)
2
1
GC
(Trimipramine
Maleate)
2
PA NSO
4
(Effexor XR)
2
days)
QL (30 per 30 days)
(Venlafaxine HCl)
2
QL (90 per 30 days)
(Venlafaxine HCl)
2
QL (30 per 30 days)
4
days)
PA NSO; QL (30 per
180 days)
days)
4
4
46
Drug Name
Drug Tier
Requirements/Limits
Antidiabetic Agents
Antidiabetic Agents,
Miscellaneous
acarbose oral tablet 100 mg, 25 mg, 50
mg
ACTOPLUS MET XR ORAL
TABLET, ER MULTIPHASE 24 HR
15-1,000 MG
ACTOPLUS MET XR ORAL
TABLET, ER MULTIPHASE 24 HR
30-1,000 MG
BYDUREON SUBCUTANEOUS
PEN INJECTOR 2 MG/0.65 ML
BYDUREON SUBCUTANEOUS
RECON 2 MG
CYCLOSET ORAL TABLET 0.8 MG
(Precose)
GLYSET ORAL TABLET 100 MG, 25
MG, 50 MG
GLYXAMBI ORAL TABLET 10-5
MG, 25-5 MG
INVOKAMET ORAL TABLET
150-1,000 MG, 150-500 MG, 50-1,000
MG, 50-500 MG
INVOKANA ORAL TABLET 100
MG, 300 MG
JANUMET ORAL TABLET 50-1,000
MG, 50-500 MG
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 100-1,000 MG
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 50-1,000 MG,
50-500 MG
JANUVIA ORAL TABLET 100 MG,
25 MG, 50 MG
2
QL (90 per 30 days)
3
QL (60 per 30 days)
3
QL (30 per 30 days)
4
4
4
PA; QL (180 per 30
days)
QL (90 per 30 days)
4
4
4
4
PA; QL (30 per 30
days)
PA; QL (60 per 30
days)
3
PA; QL (30 per 30
days)
QL (60 per 30 days)
3
QL (30 per 30 days)
3
QL (60 per 30 days)
3
47
Drug Name
Drug Tier
JARDIANCE ORAL TABLET 10
MG, 25 MG
KORLYM ORAL TABLET 300 MG
Requirements/Limits
3
ST
5
metformin oral tablet 1,000 mg
(Glucophage)
1
metformin oral tablet 500 mg
(Glucophage)
1
metformin oral tablet 850 mg
(Glucophage)
1
metformin oral tablet extended release 24
hr 500 mg
metformin oral tablet extended release 24
hr 750 mg
metformin oral tablet extended release
24hr 1,000 mg
metformin oral tablet extended release
24hr 500 mg
miglitol oral tablet 100 mg, 25 mg, 50 mg
nateglinide oral tablet 120 mg, 60 mg
pioglitazone oral tablet 15 mg
pioglitazone oral tablet 30 mg, 45 mg
pioglitazone-metformin oral tablet
15-500 mg, 15-850 mg
repaglinide oral tablet 0.5 mg, 1 mg
repaglinide oral tablet 2 mg
SYMLINPEN 120 SUBCUTANEOUS
PEN INJECTOR 2,700 MCG/2.7 ML
SYMLINPEN 60 SUBCUTANEOUS
PEN INJECTOR 1,500 MCG/1.5 ML
SYNJARDY ORAL TABLET
12.5-1,000 MG, 12.5-500 MG, 5-1,000
MG, 5-500 MG
TANZEUM SUBCUTANEOUS PEN
INJECTOR 30 MG/0.5 ML, 50 MG/0.5
ML
(Glucophage XR)
2
PA; NM; LA; QL (120
per 30 days)
GC; QL (75 per 30
days)
GC; QL (150 per 30
days)
GC; QL (90 per 30
days)
(Glucophage XR)
2
QL (60 per 30 days)
(Fortamet)
2
QL (60 per 30 days)
(Fortamet)
2
(Glyset)
(Starlix)
(Actos)
(Actos)
(Actoplus Met)
2
2
2
2
2
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
(Prandin)
(Prandin)
2
2
3
3
PA; QL (10.8 per 28
days)
PA; QL (6 per 28 days)
3
3
ST
48
Drug Name
Drug Tier
Requirements/Limits
TRULICITY SUBCUTANEOUS PEN
INJECTOR 0.75 MG/0.5 ML, 1.5
MG/0.5 ML
VICTOZA 3-PAK SUBCUTANEOUS
PEN INJECTOR 0.6 MG/0.1 ML (18
MG/3 ML)
Insulins
LANTUS SOLOSTAR
SUBCUTANEOUS INSULIN PEN
100 UNIT/ML (3 ML)
LANTUS SUBCUTANEOUS
LEVEMIR FLEXTOUCH
100 UNIT/ML (3 ML)
LEVEMIR SUBCUTANEOUS
NOVOLIN 70/30 SUBCUTANEOUS
SUSPENSION 100 UNIT/ML (70-30)
NOVOLIN N SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
NOVOLIN R INJECTION
NOVOLOG FLEXPEN
100 UNIT/ML
NOVOLOG MIX 70-30 FLEXPEN
100 UNIT/ML (70-30)
NOVOLOG MIX 70-30
SUBCUTANEOUS SOLUTION 100
UNIT/ML (70-30)
NOVOLOG PENFILL
SUBCUTANEOUS CARTRIDGE 100
UNIT/ML
NOVOLOG SUBCUTANEOUS
4
PA
3
ST
3
3
3
3
3
3
3
3
3
3
3
3
49
Drug Name
Drug Tier
Requirements/Limits
TOUJEO SOLOSTAR
300 UNIT/ML (1.5 ML)
Sulfonylureas
chlorpropamide oral tablet 100 mg
3
(Chlorpropamide)
2
chlorpropamide oral tablet 250 mg
(Chlorpropamide)
2
glimepiride oral tablet 1 mg
(Amaryl)
1
(Amaryl)
1
(Amaryl)
1
glipizide oral tablet 10 mg
(Glucotrol)
1
glipizide oral tablet 5 mg
(Glucotrol)
1
glipizide oral tablet extended release 24hr
10 mg
2.5 mg
5 mg
glipizide-metformin oral tablet 2.5-250
mg
glipizide-metformin oral tablet 2.5-500
mg, 5-500 mg
glyburide micronized oral tablet 1.5 mg
(Glucotrol XL)
2
PA; QL (225 per 30
days); AGE (Max 64
Years)
PA; QL (90 per 30
days); AGE (Max 64
Years)
GC; QL (240 per 30
days)
GC; QL (120 per 30
days)
GC; QL (60 per 30
days)
GC; QL (120 per 30
days)
GC; QL (240 per 30
days)
QL (60 per 30 days)
(Glucotrol XL)
2
(Glucotrol XL)
2
(Glipizide/Metformin
HCl)
(Glipizide/Metformin
HCl)
(Glynase)
2
2
2
glyburide micronized oral tablet 3 mg
(Glynase)
2
PA; QL (240 per 30
days); AGE (Max 64
Years)
PA; QL (120 per 30
days); AGE (Max 64
Years)
50
Drug Name
Drug Tier
glyburide micronized oral tablet 6 mg
(Glynase)
2
glyburide oral tablet 1.25 mg
(Glyburide)
2
glyburide oral tablet 2.5 mg
(Glyburide)
2
glyburide oral tablet 5 mg
(Glyburide)
2
glyburide-metformin oral tablet 1.25-250
mg
(Glucovance)
2
glyburide-metformin oral tablet 2.5-500
mg, 5-500 mg
(Glucovance)
2
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide oral tablet 500 mg
(Tolazamide)
(Tolazamide)
(Tolbutamide)
2
2
1
Requirements/Limits
PA; QL (60 per 30
days); AGE (Max 64
Years)
PA; QL (480 per 30
days); AGE (Max 64
Years)
PA; QL (240 per 30
days); AGE (Max 64
Years)
PA; QL (120 per 30
days); AGE (Max 64
Years)
PA; QL (240 per 30
days); AGE (Max 64
Years)
PA; QL (120 per 30
days); AGE (Max 64
Years)
QL (60 per 30 days)
GC; QL (180 per 30
days)
Antifungals
Antifungals
ABELCET INTRAVENOUS
SUSPENSION 5 MG/ML
AMBISOME INTRAVENOUS
SUSPENSION FOR
amphotericin b injection recon soln 50 mg
CANCIDAS INTRAVENOUS
ciclopirox topical cream 0.77 %
ciclopirox topical gel 0.77 %
ciclopirox topical shampoo 1 %
ciclopirox topical solution 8 %
5
PA BvD; NM
5
PA BvD; NM
(Amphotericin B)
2
5
PA BvD; NM
NM
(Loprox)
(Ciclopirox)
(Loprox)
(Penlac)
2
2
2
2
51
Drug Name
ciclopirox topical suspension 0.77 %
clotrimazole mucous membrane troche 10
mg
clotrimazole topical cream 1 %
clotrimazole topical solution 1 %
clotrimazole-betamethasone topical
cream 1-0.05 %
clotrimazole-betamethasone topical
lotion 1-0.05 %
econazole topical cream 1 %
ERAXIS(WATER DILUENT)
INTRAVENOUS RECON SOLN 100
MG
fluconazole in dextrose(iso-o)
fluconazole in nacl (iso-osm) intravenous
fluconazole in nacl (iso-osm) intravenous
fluconazole oral suspension for
reconstitution 10 mg/ml, 40 mg/ml
fluconazole oral tablet 100 mg, 150 mg,
200 mg, 50 mg
fluconazole-nacl 400 mg/200 ml
10's,latex-free, p/f 400 mg/200 ml
flucytosine oral capsule 250 mg, 500 mg
griseofulvin microsize oral suspension 125
mg/5 ml
griseofulvin microsize oral tablet 500 mg
griseofulvin ultramicrosize oral tablet 125
mg, 250 mg
itraconazole oral capsule 100 mg
ketoconazole oral tablet 200 mg
ketoconazole topical cream 2 %
ketoconazole topical foam 2 %
ketoconazole topical shampoo 2 %
Drug Tier
(Ciclopirox Olamine)
(Clotrimazole)
2
2
(Clotrimazole)
(Clotrimazole)
(Lotrisone)
2
2
2
(Clotrimazole/Betamet
hasone Dip)
(Econazole Nitrate)
2
Requirements/Limits
2
5
PA; NM
(Fluconazole In
Nacl,Iso-Osm)
(Fluconazole In
Nacl,Iso-Osm)
(Fluconazole In
Nacl,Iso-Osm)
(Diflucan)
2
NM
(Diflucan)
2
(Fluconazole In
Nacl,Iso-Osm)
(Ancobon)
(Griseofulvin,
Microsize)
(Grifulvin V)
(Gris-Peg)
2
NM
5
2
NM
(Sporanox)
(Ketoconazole)
(Ketoconazole)
(Ketoconazole)
(Nizoral)
2
2
2
2
2
2
2
NM
2
2
2
PA
52
Drug Name
miconazole-3 vaginal suppository 200 mg
naftifine topical cream 1 %, 2 %
NAFTIN TOPICAL CREAM 2 %
NAFTIN TOPICAL GEL 1 %, 2 %
NOXAFIL INTRAVENOUS
SOLUTION 300 MG/16.7 ML
NOXAFIL ORAL SUSPENSION 200
MG/5 ML (40 MG/ML)
NOXAFIL ORAL
(DR/EC) 100 MG
nyamyc topical powder 100,000
unit/gram
nystatin oral suspension 100,000 unit/ml
nystatin oral tablet 500,000 unit
nystatin topical cream 100,000 unit/gram
nystatin topical ointment 100,000
unit/gram
nystatin topical powder 100,000
unit/gram
nystatin-triamcinolone topical cream
100,000-0.1 unit/g-%
nystatin-triamcinolone topical ointment
100,000-0.1 unit/gram-%
nystop topical powder 100,000 unit/gram
terbinafine hcl oral tablet 250 mg
voriconazole intravenous solution 200 mg
voriconazole oral suspension for
reconstitution 200 mg/5 ml (40 mg/ml)
voriconazole oral tablet 200 mg, 50 mg
Drug Tier
(Miconazole Nitrate)
(Naftin)
Requirements/Limits
2
2
3
3
5
PA; NM
5
PA; NM
5
PA; NM
(Nystatin)
2
(Nystatin)
(Nystatin)
(Nystatin)
(Nystatin)
2
2
2
2
(Nystatin)
2
(Nystatin/Triamcin)
2
(Nystatin/Triamcin)
2
(Nystatin)
(Lamisil)
(Vfend IV)
(Vfend)
2
2
2
5
NM
NM
(Vfend)
5
NM
(Cetirizine HCl)
(Cyproheptadine HCl)
2
2
(Rx product only)
PA; AGE (Max 64
Years)
Antihistamines
Antihistamines
cetirizine oral solution 1 mg/ml
cyproheptadine oral syrup 2 mg/5 ml
53
Drug Name
Drug Tier
cyproheptadine oral tablet 4 mg
(Cyproheptadine HCl)
2
desloratadine oral tablet 5 mg
diphenhydramine hcl injection solution 50
mg/ml
levocetirizine oral solution 2.5 mg/5 ml
levocetirizine oral tablet 5 mg
promethazine oral syrup 6.25 mg/5 ml
(Clarinex)
(Diphenhydramine
HCl)
(Xyzal)
(Xyzal)
(Promethazine HCl)
2
2
promethazine vc oral syrup 6.25-5 mg/5
ml
(Phenylephrine
HCl/Prometh HCl)
2
(Cleocin)
2
3
(Metrogel-Vaginal)
(Terazol 7)
(Terconazole)
2
2
2
(Axert)
2
2
2
2
Requirements/Limits
PA; AGE (Max 64
Years)
QL (30 per 30 days)
NM
PA; AGE (Max 64
Years)
PA; AGE (Max 64
Years)
Anti-Infectives (Skin And Mucous
Membrane)
Anti-Infectives (Skin And Mucous
Membrane)
clindamycin phosphate vaginal cream 2 %
CLINDESSE VAGINAL
CREAM,EXTENDED RELEASE 2 %
metronidazole vaginal gel 0.75 %
terconazole vaginal cream 0.4 %, 0.8 %
terconazole vaginal suppository 80 mg
Antimigraine Agents
Antimigraine Agents
almotriptan malate oral tablet 12.5 mg,
6.25 mg
AXERT ORAL TABLET 12.5 MG,
6.25 MG
CAFERGOT ORAL TABLET 1-100
MG
dihydroergotamine injection solution 1
mg/ml
dihydroergotamine nasal
spray,non-aerosol 0.5 mg/pump act. (4
mg/ml)
MIGERGOT RECTAL
SUPPOSITORY 2-100 MG
3
NM; QL (16 per 28
days)
NM; QL (16 per 28
days)
3
(D.H.E.45)
2
(Migranal)
2
NM
2
54
Drug Name
Drug Tier
naratriptan oral tablet 1 mg, 2.5 mg
(Amerge)
2
rizatriptan oral tablet 10 mg, 5 mg
(Maxalt)
2
rizatriptan oral tablet,disintegrating 10
mg, 5 mg
sumatriptan 4 mg/0.5 ml inject latex-free
4 mg/0.5 ml
sumatriptan 6 mg/0.5 ml syrng
p/f,dehp/f,pvc/f 6 mg/0.5 ml
sumatriptan nasal spray,non-aerosol 20
mg/actuation, 5 mg/actuation
sumatriptan succinate oral tablet 100 mg,
25 mg, 50 mg
sumatriptan succinate subcutaneous
cartridge 4 mg/0.5 ml
cartridge 6 mg/0.5 ml
sumatriptan succinate subcutaneous pen
injector 6 mg/0.5 ml, 6 mg/0.5 ml
(auto-injector)
solution 6 mg/0.5 ml
zolmitriptan oral tablet 2.5 mg, 5 mg
(Maxalt Mlt)
2
(Sumatriptan
Succinate)
(Sumatriptan
Succinate)
(Imitrex)
2
(Imitrex)
2
(Sumatriptan
Succinate)
(Imitrex)
2
(Sumatriptan
Succinate)
2
(Imitrex)
2
(Zomig)
2
zolmitriptan oral tablet,disintegrating 2.5 (Zomig Zmt)
mg, 5 mg
2
2
2
2
Requirements/Limits
NM; QL (16 per 28
days)
NM; QL (16 per 28
days)
NM; QL (16 per 28
days)
NM; QL (8 per 28
days)
QL (8 per 28 days)
NM; QL (16 per 28
days)
NM; QL (16 per 28
days)
NM; QL (8 per 28
days)
NM; QL (8 per 28
days)
QL (8 per 28 days)
NM; QL (8 per 28
days)
NM; QL (16 per 28
days)
NM; QL (16 per 28
days)
Antimycobacterials
Antimycobacterials
CAPASTAT INJECTION RECON
SOLN 1 GRAM
cycloserine oral capsule 250 mg
dapsone oral tablet 100 mg, 25 mg
ethambutol oral tablet 100 mg, 400 mg
isoniazid injection solution 100 mg/ml
isoniazid oral solution 50 mg/5 ml
4
(Cycloserine)
(Dapsone)
(Myambutol)
(Isoniazid)
(Isoniazid)
2
2
2
2
2
NM
NM
55
Drug Name
isoniazid oral tablet 100 mg, 300 mg
PASER ORAL GRANULES DR FOR
SUSP IN PACKET 4 GRAM
PRIFTIN ORAL TABLET 150 MG
pyrazinamide oral tablet 500 mg
rifabutin oral capsule 150 mg
rifampin intravenous recon soln 600 mg
rifampin oral capsule 150 mg, 300 mg
RIFATER ORAL TABLET 50-120-300
MG
SIRTURO ORAL TABLET 100 MG
TRECATOR ORAL TABLET 250 MG
Drug Tier
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifadin)
Requirements/Limits
2
4
3
2
2
2
2
4
NM
5
4
PA; NM
4
4
PA BvD
Antinausea Agents
Antinausea Agents
AKYNZEO ORAL CAPSULE 300-0.5
MG
ANZEMET ORAL TABLET 100 MG,
50 MG
compro rectal suppository 25 mg
(Compazine)
DICLEGIS ORAL
(DR/EC) 10-10 MG
dimenhydrinate injection solution 50
(Dimenhydrinate)
mg/ml
dronabinol oral capsule 10 mg
(Marinol)
dronabinol oral capsule 2.5 mg, 5 mg
EMEND ORAL CAPSULE 125 MG,
40 MG, 80 MG
EMEND ORAL CAPSULE,DOSE
PACK 125 MG (1)- 80 MG (2)
granisetron (pf) intravenous solution 100
mcg/ml
granisetron hcl intravenous solution 1
mg/ml (1 ml)
granisetron hcl oral tablet 1 mg
2
4
PA; QL (112 per 28
days)
2
NM
5
2
4
NM; QL (60 per 30
days)
QL (60 per 30 days)
PA
4
PA
(Granisetron HCl/PF)
2
NM
(Granisetron HCl)
2
NM
(Granisetron HCl)
2
PA BvD
(Marinol)
56
Drug Name
meclizine oral tablet 12.5 mg, 25 mg
ondansetron 4 mg/2 ml ampule single
dose, 5's 4 mg/2 ml
ondansetron hcl (pf) injection solution 4
mg/2 ml
ondansetron hcl (pf) injection syringe 4
mg/2 ml
ondansetron hcl oral solution 4 mg/5 ml
ondansetron hcl oral tablet 24 mg, 4 mg,
8 mg
ondansetron oral tablet,disintegrating 4
mg, 8 mg
phenadoz rectal suppository 12.5 mg, 25
mg
prochlorperazine edisylate injection
solution 10 mg/2 ml (5 mg/ml)
prochlorperazine maleate oral tablet 10
mg, 5 mg
prochlorperazine rectal suppository 25
mg
promethazine injection solution 25 mg/ml
promethazine injection solution 50 mg/ml
promethazine oral tablet 12.5 mg, 25 mg,
50 mg
promethazine rectal suppository 12.5 mg,
25 mg, 50 mg
promethegan rectal suppository 12.5 mg,
25 mg, 50 mg
TRANSDERM-SCOP
TRANSDERMAL PATCH 3 DAY 1.5
MG (1 MG OVER 3 DAYS)
VARUBI ORAL TABLET 90 MG
Drug Tier
Requirements/Limits
(Meclizine HCl)
(Ondansetron HCl/PF)
2
2
2
2
(Zofran)
(Zofran)
2
2
PA BvD
PA BvD
(Zofran Odt)
2
PA BvD
(Phenergan)
2
(Prochlorperazine
Edisylate)
(Compazine)
2
(Compazine)
2
(Promethazine HCl)
(Phenergan)
(Promethazine HCl)
2
2
2
(Phenergan)
2
(Phenergan)
2
NM
NM
2
NM
NM
4
4
Antiparasite Agents
Antiparasite Agents
ALBENZA ORAL TABLET 200 MG
3
57
Drug Name
Drug Tier
ALINIA ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML
ALINIA ORAL TABLET 500 MG
atovaquone oral suspension 750 mg/5 ml
atovaquone-proguanil oral tablet 250-100
mg, 62.5-25 mg
BILTRICIDE ORAL TABLET 600
MG
chloroquine phosphate oral tablet 250
mg, 500 mg
COARTEM ORAL TABLET 20-120
MG
DARAPRIM ORAL TABLET 25 MG
hydroxychloroquine oral tablet 200 mg
ivermectin oral tablet 3 mg
mefloquine oral tablet 250 mg
NEBUPENT INHALATION RECON
SOLN 300 MG
paromomycin oral capsule 250 mg
PENTAM INJECTION RECON
SOLN 300 MG
PRIMAQUINE ORAL TABLET 26.3
MG
quinine sulfate oral capsule 324 mg
tinidazole oral tablet 250 mg, 500 mg
4
PA
4
5
2
PA
NM
(Mepron)
(Malarone)
Requirements/Limits
3
(Chloroquine
Phosphate)
2
4
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Paromomycin Sulfate)
3
2
2
2
4
PA BvD
2
4
NM
2
(Qualaquin)
(Tindamax)
2
2
PA
(Amantadine HCl)
(Amantadine HCl)
(Amantadine HCl)
2
2
2
5
NM; LA
4
QL (30 per 30 days)
2
NM
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl oral capsule 100 mg
amantadine hcl oral solution 50 mg/5 ml
amantadine hcl oral tablet 100 mg
APOKYN SUBCUTANEOUS
CARTRIDGE 10 MG/ML
AZILECT ORAL TABLET 0.5 MG, 1
MG
benztropine injection solution 2 mg/2 ml
(Cogentin)
58
Drug Name
Drug Tier
benztropine oral tablet 0.5 mg, 1 mg, 2
mg
bromocriptine oral capsule 5 mg
bromocriptine oral tablet 2.5 mg
cabergoline oral tablet 0.5 mg
carbidopa oral tablet 25 mg
carbidopa-levodopa oral tablet 10-100
mg, 25-100 mg, 25-250 mg
carbidopa-levodopa oral tablet extended
release 25-100 mg, 50-200 mg
carbidopa-levodopa oral
tablet,disintegrating 10-100 mg, 25-100
mg, 25-250 mg
carbidopa-levodopa-entacapone oral
tablet 12.5-50-200 mg, 18.75-75-200 mg,
25-100-200 mg, 31.25-125-200 mg,
37.5-150-200 mg, 50-200-200 mg
entacapone oral tablet 200 mg
NEUPRO TRANSDERMAL PATCH
24 HOUR 1 MG/24 HOUR, 2 MG/24
HOUR, 3 MG/24 HOUR, 4 MG/24
HOUR, 6 MG/24 HOUR, 8 MG/24
HOUR
pramipexole oral tablet 0.125 mg, 0.25
mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg
ropinirole oral tablet 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg, 5 mg
ropinirole oral tablet extended release 24
hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg
selegiline hcl oral capsule 5 mg
selegiline hcl oral tablet 5 mg
tolcapone oral tablet 100 mg
trihexyphenidyl oral elixir 0.4 mg/ml
(Benztropine Mesylate)
2
(Parlodel)
(Parlodel)
(Cabergoline)
(Lodosyn)
(Sinemet CR)
2
2
2
2
2
(Sinemet CR)
2
(Carbidopa/Levodopa)
2
(Stalevo 50)
2
(Comtan)
2
4
trihexyphenidyl oral tablet 2 mg, 5 mg
(Mirapex)
2
(Requip)
2
(Requip XL)
2
(Eldepryl)
(Selegiline HCl)
(Tasmar)
(Trihexyphenidyl HCl)
2
2
2
2
(Trihexyphenidyl HCl)
2
Requirements/Limits
PA
PA; AGE (Max 64
Years)
PA; AGE (Max 64
Years)
59
Drug Name
Drug Tier
Requirements/Limits
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 10
MG, 15 MG
ABILIFY INTRAMUSCULAR
SOLUTION 9.75 MG/1.3 ML
ABILIFY MAINTENA
INTRAMUSCULAR
RECON 300 MG, 400 MG
ABILIFY MAINTENA
INTRAMUSCULAR
SYRING 300 MG, 400 MG
ABILIFY ORAL SOLUTION 1
MG/ML
ADASUVE INHALATION
AEROSOL POWDR BREATH
ACTIVATED 10 MG
aripiprazole oral solution 1 mg/ml
aripiprazole oral tablet 10 mg, 15 mg, 2
mg, 20 mg, 30 mg, 5 mg
aripiprazole oral tablet,disintegrating 10
mg, 15 mg
ARISTADA INTRAMUSCULAR
SYRING 441 MG/1.6 ML
chlorpromazine injection solution 25
mg/ml
5
NM; QL (60 per 30
days)
4
NM
5
PA NSO; NM
5
PA NSO; NM; QL (1
per 30 days)
5
NM
4
PA NSO; QL (1 per 7
days)
(Abilify)
(Abilify)
2
2
QL (30 per 30 days)
(Abilify Discmelt)
5
NM
5
PA NSO; NM; QL (1.6
per 28 days)
5
PA NSO; NM; QL (2.4
per 28 days)
5
PA NSO; NM; QL (3.2
per 28 days)
2
NM
(Chlorpromazine HCl)
60
Drug Name
chlorpromazine oral tablet 10 mg, 100
mg, 200 mg, 25 mg, 50 mg
clozapine oral tablet 100 mg, 200 mg, 25
mg, 50 mg
clozapine oral tablet,disintegrating 100
mg, 12.5 mg, 150 mg, 200 mg, 25 mg
FANAPT ORAL TABLET 1 MG, 10
MG, 12 MG, 2 MG, 4 MG, 6 MG, 8
MG
FANAPT ORAL TABLETS,DOSE
PACK 1MG(2)-2MG(2)4MG(2)-6MG(2)
fluphenazine decanoate injection solution
25 mg/ml
fluphenazine hcl injection solution 2.5
mg/ml
fluphenazine hcl oral concentrate 5 mg/ml
fluphenazine hcl oral elixir 2.5 mg/5 ml
fluphenazine hcl oral tablet 1 mg, 10 mg,
2.5 mg, 5 mg
GEODON INTRAMUSCULAR
RECON SOLN 20 MG/ML (FINAL
CONC.)
haloperidol decanoate intramuscular
solution 100 mg/ml
haloperidol decanoate intramuscular
solution 50 mg/ml
haloperidol lactate injection solution 5
mg/ml
haloperidol lactate oral concentrate 2
mg/ml
haloperidol oral tablet 0.5 mg, 1 mg, 10
mg, 2 mg, 20 mg, 5 mg
INVEGA ORAL TABLET
EXTENDED RELEASE 24HR 1.5
MG, 3 MG, 9 MG
Drug Tier
(Chlorpromazine HCl)
2
(Clozaril)
2
(Fazaclo)
2
Requirements/Limits
4
QL (60 per 30 days)
4
QL (8 per 28 days)
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
2
NM
2
NM
(Fluphenazine HCl)
(Fluphenazine HCl)
(Fluphenazine HCl)
2
2
2
3
NM; QL (60 per 30
days)
(Haloperidol
Decanoate)
(Haldol Decanoate 50)
2
NM
2
NM
(Haloperidol Lactate)
2
NM
(Haloperidol Lactate)
2
(Haloperidol)
2
5
NM; QL (30 per 30
days)
61
Drug Name
Drug Tier
INVEGA ORAL TABLET
EXTENDED RELEASE 24HR 6 MG
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 117
MG/0.75 ML
INVEGA SUSTENNA
MG/ML
INVEGA SUSTENNA
MG/1.5 ML
INVEGA SUSTENNA
MG/0.25 ML
INVEGA SUSTENNA
MG/0.5 ML
INVEGA TRINZA
MG/0.875 ML
INVEGA TRINZA
MG/1.315 ML
INVEGA TRINZA
MG/1.75 ML
INVEGA TRINZA
MG/2.625 ML
LATUDA ORAL TABLET 120 MG,
20 MG, 40 MG, 60 MG
LATUDA ORAL TABLET 80 MG
5
loxapine succinate oral capsule 10 mg, 25 (Loxapine Succinate)
mg, 5 mg, 50 mg
molindone oral tablet 10 mg, 25 mg, 5 mg (Molindone HCl)
2
5
Requirements/Limits
NM; QL (60 per 30
days)
PA NSO; NM; QL
(0.75 per 28 days)
5
PA NSO; NM; QL (1
per 28 days)
5
PA NSO; NM; QL (1.5
per 28 days)
4
PA NSO; NM; QL
(0.25 per 28 days)
5
PA NSO; NM; QL (0.5
per 28 days)
5
PA NSO; NM; QL
(0.88 per 84 days)
5
PA NSO; NM; QL
(1.32 per 84 days)
5
PA NSO; NM; QL
(1.75 per 84 days)
5
PA NSO; NM; QL
(2.63 per 84 days)
4
days)
days)
4
2
62
Drug Name
Drug Tier
NUPLAZID ORAL TABLET 17 MG
olanzapine intramuscular recon soln 10
mg
olanzapine oral tablet 10 mg, 15 mg, 2.5
mg, 20 mg, 5 mg, 7.5 mg
olanzapine oral tablet,disintegrating 10
mg, 15 mg, 20 mg, 5 mg
ORAP ORAL TABLET 1 MG, 2 MG
paliperidone oral tablet extended release
24hr 1.5 mg, 3 mg, 6 mg, 9 mg
perphenazine oral tablet 16 mg, 2 mg, 4
mg, 8 mg
pimozide oral tablet 1 mg, 2 mg
quetiapine oral tablet 100 mg, 200 mg, 25
mg, 50 mg
quetiapine oral tablet 300 mg, 400 mg
REXULTI ORAL TABLET 0.25 MG,
0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG
RISPERDAL CONSTA
INTRAMUSCULAR SYRINGE 12.5
MG/2 ML, 25 MG/2 ML, 37.5 MG/2
ML, 50 MG/2 ML
risperidone oral solution 1 mg/ml
risperidone oral tablet 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg
risperidone oral tablet 4 mg
risperidone oral tablet,disintegrating 0.25
mg, 0.5 mg, 1 mg, 2 mg, 3 mg
risperidone oral tablet,disintegrating 4
mg
SAPHRIS (BLACK CHERRY)
SUBLINGUAL TABLET 10 MG, 2.5
MG, 5 MG
5
Requirements/Limits
(Zyprexa)
2
(Zyprexa)
2
PA NSO; NM; QL (60
per 30 days)
NM; QL (120 per 30
days)
QL (30 per 30 days)
(Zyprexa Zydis)
2
QL (30 per 30 days)
(Invega)
3
5
NM
(Perphenazine)
2
(Orap)
(Seroquel)
2
2
(Seroquel)
2
5
3
QL (90 per 30 days)
QL (60 per 30 days)
PA NSO; NM; QL (30
per 30 days)
PA NSO; NM; QL (2
per 28 days)
(Risperdal)
(Risperdal)
2
2
QL (60 per 30 days)
(Risperdal)
(Risperdal M-Tab)
2
2
QL (60 per 30 days)
(Risperdal M-Tab)
2
3
days)
63
Drug Name
SEROQUEL XR ORAL TABLET
MG, 200 MG, 300 MG, 400 MG, 50
MG
thioridazine oral tablet 10 mg, 100 mg,
25 mg, 50 mg
Drug Tier
Requirements/Limits
3
(Thioridazine HCl)
thiothixene oral capsule 1 mg, 10 mg, 2
(Thiothixene)
mg, 5 mg
trifluoperazine oral tablet 1 mg, 10 mg, 2 (Trifluoperazine HCl)
mg, 5 mg
VERSACLOZ ORAL SUSPENSION
50 MG/ML
VRAYLAR ORAL CAPSULE 1.5
MG, 3 MG, 4.5 MG, 6 MG
VRAYLAR ORAL CAPSULE,DOSE
PACK 1.5 MG (1)- 3 MG (6)
ziprasidone hcl oral capsule 20 mg, 40
(Geodon)
mg, 60 mg, 80 mg
ZYPREXA RELPREVV 405 MG VL
KIT W/ DILUENT, OUTER 405 MG
ZYPREXA RELPREVV
INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 210 MG
2
PA NSO; (PA Req for
Ages 65 and Older;
High Risk Med)
2
2
4
5
2
PA NSO; NM; QL (30
per 30 days)
days)
QL (60 per 30 days)
4
PA NSO; NM
4
PA NSO; NM
2
5
NM
4
Antivirals (Systemic)
Antiretrovirals
abacavir oral tablet 300 mg
abacavir-lamivudine-zidovudine oral
tablet 300-150-300 mg
APTIVUS ORAL CAPSULE 250 MG
APTIVUS ORAL SOLUTION 100
MG/ML
ATRIPLA ORAL TABLET
600-200-300 MG
COMPLERA ORAL TABLET
200-25-300 MG
(Ziagen)
(Trizivir)
4
4
5
NM
5
NM
64
Drug Name
Drug Tier
CRIXIVAN ORAL CAPSULE 200
MG, 400 MG
DESCOVY ORAL TABLET 200-25
MG
didanosine oral capsule,delayed
release(dr/ec) 125 mg, 200 mg, 250 mg,
400 mg
EDURANT ORAL TABLET 25 MG
3
5
(Videx EC)
EMTRIVA ORAL CAPSULE 200 MG
EMTRIVA ORAL SOLUTION 10
MG/ML
EPZICOM ORAL TABLET 600-300
MG
EVOTAZ ORAL TABLET 300-150
MG
FUZEON SUBCUTANEOUS
RECON SOLN 90 MG
GENVOYA ORAL TABLET
150-150-200-10 MG
INTELENCE ORAL TABLET 100
MG
INTELENCE ORAL TABLET 200
MG, 25 MG
INVIRASE ORAL CAPSULE 200 MG
INVIRASE ORAL TABLET 500 MG
ISENTRESS ORAL POWDER IN
PACKET 100 MG
ISENTRESS ORAL TABLET 400 MG
ISENTRESS ORAL
ISENTRESS ORAL
KALETRA ORAL SOLUTION
400-100 MG/5 ML
Requirements/Limits
NM
2
5
NM; QL (30 per 30
days)
3
3
5
NM
5
NM
5
NM
5
NM
5
NM
4
5
5
4
NM
NM
5
5
NM
NM
3
5
NM
65
Drug Name
Drug Tier
KALETRA ORAL TABLET 100-25
MG
KALETRA ORAL TABLET 200-50
MG
lamivudine oral solution 10 mg/ml
lamivudine oral tablet 100 mg, 150 mg,
300 mg
lamivudine-zidovudine oral tablet
150-300 mg
LEXIVA ORAL SUSPENSION 50
MG/ML
LEXIVA ORAL TABLET 700 MG
nevirapine oral suspension 50 mg/5 ml
nevirapine oral tablet 200 mg
nevirapine oral tablet extended release 24
hr 100 mg, 400 mg
NORVIR ORAL CAPSULE 100 MG
NORVIR ORAL SOLUTION 80
MG/ML
NORVIR ORAL TABLET 100 MG
ODEFSEY ORAL TABLET 200-25-25
MG
PREZCOBIX ORAL TABLET 800-150
MG-MG
PREZISTA ORAL SUSPENSION 100
MG/ML
PREZISTA ORAL TABLET 150 MG,
400 MG, 600 MG, 75 MG, 800 MG
RESCRIPTOR ORAL TABLET 200
MG
RESCRIPTOR ORAL TABLET,
DISPERSIBLE 100 MG
RETROVIR INTRAVENOUS
SOLUTION 10 MG/ML
REYATAZ ORAL CAPSULE 150
MG, 300 MG
4
5
(Epivir)
(Epivir)
2
2
(Combivir)
5
Requirements/Limits
NM
NM
4
(Viramune)
(Viramune)
(Viramune XR)
4
2
2
2
3
3
3
5
5
NM; QL (30 per 30
days)
NM
5
NM
5
NM
3
3
4
NM
4
QL (30 per 30 days)
66
Drug Name
Drug Tier
Requirements/Limits
REYATAZ ORAL CAPSULE 200 MG
REYATAZ ORAL POWDER IN
PACKET 50 MG
SELZENTRY ORAL TABLET 150
MG
SELZENTRY ORAL TABLET 300
MG
stavudine oral capsule 15 mg, 20 mg, 30
(Zerit)
mg, 40 mg
stavudine oral recon soln 1 mg/ml
(Zerit)
STRIBILD ORAL TABLET
150-150-200-300 MG
SUSTIVA ORAL CAPSULE 200 MG,
50 MG
SUSTIVA ORAL TABLET 600 MG
TIVICAY ORAL TABLET 10 MG
4
4
QL (60 per 30 days)
5
NM; QL (60 per 30
days)
NM
TRIUMEQ ORAL TABLET
600-50-300 MG
TRUVADA ORAL TABLET 100-150
MG, 133-200 MG, 167-250 MG,
200-300 MG
VIDEX 2 GRAM PEDIATRIC ORAL
RECON SOLN 10 MG/ML (FINAL)
VIDEX 4 GM PEDIATRIC SOLN 10
MG/ML (FINAL)
VIRACEPT ORAL TABLET 250 MG,
625 MG
VIRAMUNE XR ORAL TABLET
MG
VIREAD ORAL POWDER 40
MG/SCOOP (40 MG/GRAM)
5
5
QL (30 per 30 days)
NM; QL (30 per 30
days)
NM
NM
5
NM
5
2
2
5
NM
4
4
4
5
3
3
5
NM
4
4
67
Drug Name
Drug Tier
VIREAD ORAL TABLET 150 MG,
200 MG, 250 MG, 300 MG
VITEKTA ORAL TABLET 150 MG,
85 MG
ZIAGEN ORAL SOLUTION 20
MG/ML
zidovudine oral capsule 100 mg
zidovudine oral syrup 10 mg/ml
zidovudine oral tablet 300 mg
Antivirals, Miscellaneous
foscarnet intravenous solution 24 mg/ml
RELENZA DISKHALER
INHALATION BLISTER WITH
DEVICE 5 MG/ACTUATION
rimantadine oral tablet 100 mg
SYNAGIS 100 MG/1 ML VIAL 100
MG/ML
SYNAGIS INTRAMUSCULAR
TAMIFLU ORAL CAPSULE 30 MG,
45 MG, 75 MG
TAMIFLU ORAL SUSPENSION
FOR RECONSTITUTION 6 MG/ML
Hcv Antivirals
HARVONI ORAL TABLET 90-400
MG
SOVALDI ORAL TABLET 400 MG
3
5
Requirements/Limits
NM; QL (30 per 30
days)
3
(Retrovir)
(Retrovir)
(Zidovudine)
2
2
2
(Foscavir)
2
3
(Flumadine)
2
5
PA; NM
5
PA; NM
3
NM
VIEKIRA PAK ORAL
TABLETS,DOSE PACK 12.5 MG-75
MG -50 MG/250 MG
ZEPATIER ORAL TABLET 50-100
MG
Interferons
INTRON A 10 MILLION UNITS
VIAL LATEX-FREE,SUV 10
MILLION UNIT (1 ML)
PA BvD; NM
3
5
5
5
5
days)
days)
PA; NM; QL (112 per
28 days)
days)
4
68
Drug Name
Drug Tier
Requirements/Limits
INTRON A 25 MILLION UNIT/2.5
ML 10 MILLION UNIT/ML
INTRON A INJECTION RECON
SOLN 10 MILLION UNIT (1 ML), 18
MILLION UNIT (1 ML), 50
MILLION UNIT (1 ML)
INTRON A INJECTION SOLUTION
6 MILLION UNIT/ML
PEGASYS PROCLICK
SUBCUTANEOUS PEN INJECTOR
135 MCG/0.5 ML, 180 MCG/0.5 ML
PEGASYS SUBCUTANEOUS
SOLUTION 180 MCG/ML
PEGASYS SUBCUTANEOUS
SYRINGE 180 MCG/0.5 ML
PEGINTRON REDIPEN
KIT 120 MCG/0.5 ML, 150 MCG/0.5
ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML
PEGINTRON SUBCUTANEOUS
KIT 120 MCG/0.5 ML, 50 MCG/0.5
ML, 80 MCG/0.5 ML
SYLATRON SUBCUTANEOUS KIT
200 MCG, 300 MCG, 600 MCG
Nucleosides And Nucleotides
acyclovir oral capsule 200 mg
acyclovir oral suspension 200 mg/5 ml
acyclovir oral tablet 400 mg, 800 mg
acyclovir sodium intravenous solution 50
mg/ml
adefovir oral tablet 10 mg
BARACLUDE ORAL SOLUTION
0.05 MG/ML
cidofovir intravenous solution 75 mg/ml
entecavir oral tablet 0.5 mg, 1 mg
4
NM
4
NM
4
NM
5
NM
5
NM
5
NM
5
NM
5
NM
5
PA NSO; NM
(Zovirax)
(Zovirax)
(Zovirax)
(Acyclovir Sodium)
2
2
2
2
PA BvD; NM
(Hepsera)
5
5
NM
NM
(Vistide)
(Baraclude)
2
5
NM
NM; QL (30 per 30
days)
69
Drug Name
famciclovir oral tablet 125 mg, 250 mg,
500 mg
ganciclovir sodium intravenous recon soln
500 mg
REBETOL ORAL SOLUTION 40
MG/ML
ribasphere oral capsule 200 mg
ribasphere oral tablet 200 mg, 400 mg,
600 mg
ribasphere ribapak oral tablets,dose pack
200 mg (7)- 400 mg (7), 400-400 mg
(28)-mg (28), 600-400 mg (28)-mg
(28)
ribavirin oral capsule 200 mg
ribavirin oral tablet 200 mg
TYZEKA ORAL TABLET 600 MG
valacyclovir oral tablet 1 gram, 500 mg
valganciclovir oral tablet 450 mg
VIRAZOLE INHALATION RECON
SOLN 6 GRAM
Drug Tier
(Famvir)
2
(Cytovene)
2
Requirements/Limits
PA BvD; NM
4
(Rebetol)
(Copegus)
2
2
(Ribatab)
2
(Rebetol)
(Copegus)
2
2
4
2
5
5
(Valtrex)
(Valcyte)
NM
PA; NM
Blood Products/Modifiers/Volume
Expanders
Anticoagulants
COUMADIN ORAL TABLET 1 MG,
10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5
MG, 6 MG, 7.5 MG
ELIQUIS ORAL TABLET 2.5 MG, 5
MG
enoxaparin subcutaneous solution 300
mg/3 ml
enoxaparin subcutaneous syringe 100
mg/ml
mg/0.8 ml
mg/ml
4
3
(Lovenox)
5
(Lovenox)
5
(Lovenox)
5
(Lovenox)
5
NM; QL (28 per 14
days)
NM; QL (28 per 14
days)
NM; (28 syringes); QL
(22.4 per 14 days)
(28 per 14 days)
70
Drug Name
mg/0.3 ml
mg/0.4 ml
mg/0.6 ml
mg/0.8 ml
fondaparinux subcutaneous syringe 10
mg/0.8 ml
fondaparinux subcutaneous syringe 2.5
mg/0.5 ml
fondaparinux subcutaneous syringe 5
mg/0.4 ml
fondaparinux subcutaneous syringe 7.5
mg/0.6 ml
heparin (porcine) in 5 % dex intravenous
parenteral solution 12,500 unit/250 ml,
20,000 unit/500 ml (40 unit/ml)
heparin (porcine) in 5 % dex intravenous
parenteral solution 25,000 unit/250
ml(100 unit/ml)
HEPARIN (PORCINE) IN 5 % DEX
INTRAVENOUS PARENTERAL
SOLUTION 25,000 UNIT/500 ML (50
UNIT/ML)
heparin (porcine) in nacl (pf)
intravenous parenteral solution 1,000
unit/500 ml
heparin (porcine) injection solution 1,000
unit/ml, 10,000 unit/ml, 20,000 unit/ml,
5,000 unit/ml
heparin, porcine (pf) injection solution
5,000 unit/0.5 ml
heparin, porcine (pf) injection syringe
5,000 unit/0.5 ml
Drug Tier
Requirements/Limits
(Lovenox)
2
(Lovenox)
2
(Lovenox)
2
(Lovenox)
2
(Arixtra)
5
(Arixtra)
2
(Arixtra)
5
(Arixtra)
5
(Heparin
Sodium,Porcine/D5W)
2
(8.4 per 14 days)
(11.2 per 14 days)
(16.8 per 14 days)
(22.4 per 14 days)
NM; QL (11.2 per 14
days)
NM; QL (7 per 14
days)
NM; QL (5.6 per 14
days)
NM; QL (8.4 per 14
days)
NM
(Heparin Sod,Pork In
0.45% NaCl)
2
NM
2
NM
(Heparin
Sodium,Porcine/Ns/PF
)
(Heparin
Sodium,Porcine)
2
2
PA BvD; NM; (PA for
ESRD only)
(Heparin
Sodium,Porcine/PF)
(Heparin
Sodium,Porcine/PF)
2
PA BvD
2
PA BvD; NM; (PA for
ESRD only)
71
Drug Name
heparin-0.45% nacl 25,000 units/250 ml
(100 units/ml) bag latex-free, inner
25,000 unit/250 ml
HEPARIN-0.45% NACL 25,000
UNITS/500 ML (50 UNITS/ML) BAG
LATEX-FREE, OUTER 25,000
UNIT/500 ML
heparin-0.9% nacl 1,000 units/500 ml (2
units/ml) bag excel container 1,000
unit/500 ml
heparin-d5w 25,000 units/250 ml (100
unit/250 ml(100 unit/ml)
heparin-d5w 25,000 units/500 ml (50
unit/500 ml (50 unit/ml)
jantoven oral tablet 1 mg, 10 mg, 2 mg,
2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
PRADAXA ORAL CAPSULE 110
MG, 150 MG, 75 MG
warfarin oral tablet 1 mg, 10 mg, 2 mg,
2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
XARELTO ORAL TABLET 10 MG
XARELTO ORAL TABLET 15 MG,
20 MG
XARELTO ORAL TABLETS,DOSE
PACK 15 MG (42)- 20 MG (9)
Blood Formation Modifiers
ARANESP (IN POLYSORBATE)
INJECTION SOLUTION 100
MCG/ML, 200 MCG/ML, 25
MCG/ML, 300 MCG/ML, 40
MCG/ML, 60 MCG/ML
Drug Tier
(Heparin Sod,Pork In
0.45% NaCl)
Requirements/Limits
2
NM
2
NM
(Heparin
Sodium,Porcine/Ns/PF
)
(Heparin
Sodium,Porcine/D5W)
2
NM
2
NM
(Heparin
Sodium,Porcine/D5W)
2
NM
(Coumadin)
1
GC
4
PA NSO
1
GC
3
3
QL (30 per 30 days)
(Coumadin)
3
4
PA; NM
72
Drug Name
Drug Tier
Requirements/Limits
INJECTION SYRINGE 10 MCG/0.4
ML, 100 MCG/0.5 ML, 150 MCG/0.3
ML, 25 MCG/0.42 ML, 40 MCG/0.4
ML, 60 MCG/0.3 ML
INJECTION SYRINGE 200 MCG/0.4
ML, 300 MCG/0.6 ML, 500 MCG/ML
CINRYZE INTRAVENOUS RECON
SOLN 500 UNIT (5 ML)
EPOGEN 10,000 UNITS/ML VIAL
SDV, P/F, OUTER 10,000 UNIT/ML
EPOGEN INJECTION SOLUTION
2,000 UNIT/ML, 20,000 UNIT/2 ML,
20,000 UNIT/ML, 3,000 UNIT/ML,
4,000 UNIT/ML
GRANIX SUBCUTANEOUS
SYRINGE 300 MCG/0.5 ML, 480
MCG/0.8 ML
LEUKINE INJECTION RECON
SOLN 250 MCG
MOZOBIL SUBCUTANEOUS
SOLUTION 24 MG/1.2 ML (20
MG/ML)
NEULASTA SUBCUTANEOUS
SYRINGE 6 MG/0.6ML
NEULASTA SUBCUTANEOUS
SYRINGE, W/ WEARABLE
INJECTOR 6 MG/0.6 ML
NEUMEGA SUBCUTANEOUS
RECON SOLN 5 MG
NEUPOGEN INJECTION
SOLUTION 300 MCG/ML, 480
MCG/1.6 ML
NEUPOGEN INJECTION SYRINGE
300 MCG/0.5 ML, 480 MCG/0.8 ML
4
PA; NM
5
PA; NM
5
PA; NM; LA
4
PA; NM
4
PA; NM
5
PA; NM
5
PA; NM
5
NM
5
PA; NM
5
PA; NM
5
PA; NM
5
PA; NM
5
PA; NM
73
Drug Name
Drug Tier
PROCRIT 10,000 UNITS/ML VIAL
4'S, MDV, OUTER 20,000 UNIT/2 ML
PROCRIT INJECTION SOLUTION
10,000 UNIT/ML
2,000 UNIT/ML, 20,000 UNIT/ML,
3,000 UNIT/ML, 4,000 UNIT/ML
40,000 UNIT/ML
PROMACTA ORAL TABLET 12.5
MG, 25 MG, 50 MG, 75 MG
Hematologic Agents,
Miscellaneous
aminocaproic acid intravenous solution
250 mg/ml
aminocaproic acid oral solution 250
mg/ml (25 %)
aminocaproic acid oral tablet 1,000 mg,
500 mg
anagrelide oral capsule 0.5 mg, 1 mg
protamine intravenous solution 10 mg/ml
3
PA
3
PA
3
PA; NM
5
PA; NM
5
PA; NM
(Aminocaproic Acid)
2
NM
(Aminocaproic Acid)
2
(Aminocaproic Acid)
2
(Agrylin)
(Protamine Sulfate)
2
2
(Tranexamic Acid)
2
(Lysteda)
2
tranexamic acid intravenous solution
1,000 mg/10 ml (100 mg/ml)
tranexamic acid oral tablet 650 mg
Platelet-Aggregation Inhibitors
AGGRENOX ORAL CAPSULE, ER
MULTIPHASE 12 HR 25-200 MG
aspirin-dipyridamole oral capsule, er
multiphase 12 hr 25-200 mg
BRILINTA ORAL TABLET 60 MG,
90 MG
cilostazol oral tablet 100 mg, 50 mg
clopidogrel oral tablet 75 mg
dipyridamole oral tablet 25 mg, 50 mg,
75 mg
Requirements/Limits
PA BvD; NM; (PA for
ESRD only)
NM
3
(Aggrenox)
2
3
(Pletal)
(Plavix)
(Persantine)
2
2
2
74
Drug Name
EFFIENT ORAL TABLET 10 MG, 5
MG
pentoxifylline oral tablet extended
(Pentoxifylline)
release 400 mg
ticlopidine oral tablet 250 mg
(Ticlopidine HCl)
ZONTIVITY ORAL TABLET 2.08
MG
Volume Expanders
ALBUMIN, HUMAN 20 %
SOLUTION 20 %
ALBUMIN, HUMAN 25 %
SOLUTION 25 %
ALBUMIN, HUMAN 5 %
SOLUTION 5 %
ALBUMINAR 25 % INTRAVENOUS
PARENTERAL SOLUTION 25 %
ALBUMINAR 5 % INTRAVENOUS
ALBURX (HUMAN) 5 %
SOLUTION 5 %
ALBUTEIN 25 % INTRAVENOUS
ALBUTEIN 5 % INTRAVENOUS
Drug Tier
4
Requirements/Limits
QL (30 per 30 days)
2
2
4
PA
4
4
NM
4
NM
4
NM
4
NM
4
NM
4
NM
4
NM
4
PA BvD; NM
4
PA BvD; NM
4
PA BvD; NM
Caloric Agents
Caloric Agents
AMINOSYN 10 % INTRAVENOUS
AMINOSYN 3.5 % INTRAVENOUS
PARENTERAL SOLUTION 3.5 %
AMINOSYN 7 % INTRAVENOUS
75
Drug Name
AMINOSYN 7 % WITH
ELECTROLYTES INTRAVENOUS
AMINOSYN 8.5 % INTRAVENOUS
PARENTERAL SOLUTION 8.5 %
AMINOSYN II 10 %
SOLUTION 10 %
AMINOSYN II 15 %
SOLUTION 15 %
AMINOSYN II 7 % INTRAVENOUS
AMINOSYN II 8.5
%-ELECTROLYTES
SOLUTION 8.5 %
AMINOSYN M 3.5 %
SOLUTION 3.5 %
AMINOSYN-HBC 7%
SOLUTION 7 %
AMINOSYN-PF 10 %
SOLUTION 10 %
AMINOSYN-PF 7 %
(SULFITE-FREE) INTRAVENOUS
AMINOSYN-RF 5.2 %
SOLUTION 5.2 %
CLINISOL SF 15 % INTRAVENOUS
cysteine (l-cysteine) intravenous solution (Cysteine HCl)
50 mg/ml
Drug Tier
Requirements/Limits
4
PA BvD; NM
4
PA BvD; NM
4
PA BvD; NM
4
PA BvD; NM
4
PA BvD; NM
4
PA BvD; NM
4
PA BvD; NM
4
PA BvD; NM
4
PA BvD; NM
4
PA BvD; NM
4
PA BvD; NM
4
PA BvD; NM
2
PA BvD; NM
76
Drug Name
dextrose 10 % in water (d10w)
intravenous parenteral solution 10 %
intravenous solution
intravenous syringe
dextrose 5 % in ringers intravenous
parenteral solution 5 %
dextrose 5 % in water (d5w) intravenous
parenteral solution
intravenous parenteral solution
intravenous syringe
INTRALIPID INTRAVENOUS
EMULSION 20 %
INTRALIPID INTRAVENOUS
EMULSION 30 %
l-cysteine 50 mg/ml vial 25's 50 mg/ml
NUTRILIPID INTRAVENOUS
EMULSION 20 %
PREMASOL 10 % INTRAVENOUS
PREMASOL 6 % INTRAVENOUS
PROSOL 20 % INTRAVENOUS
PARENTERAL SOLUTION
TRAVASOL 10 % INTRAVENOUS
Drug Tier
(Dextrose 10 % in
Water)
(Dextrose 10 % in
Water)
(Dextrose 20 % in
Water)
(Dextrose 25 % in
Water)
(Dextrose 40 % in
Water)
(Dextrose 5 % In
Ringers)
(Dextrose 5 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 70 % in
Water)
(Cysteine HCl)
Requirements/Limits
2
PA BvD
2
PA BvD
2
PA BvD
2
PA BvD; NM
2
PA BvD; NM
2
NM
2
NM
2
PA BvD; NM
2
PA BvD; NM
2
PA BvD; NM
3
PA BvD; NM
4
PA BvD; NM
2
4
PA BvD
PA BvD; NM
4
PA BvD; NM
4
PA BvD; NM
4
PA BvD; NM
4
PA BvD; NM
77
Drug Name
Drug Tier
TROPHAMINE 10 %
SOLUTION 10 %
Requirements/Limits
3
PA BvD; NM
(Catapres)
1
GC
(Catapres-Tts 1)
2
(Clonidine
HCl/Chlorthalidone)
(Cardura)
2
(Midodrine HCl)
2
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet 0.1 mg, 0.2 mg,
0.3 mg
clonidine transdermal patch weekly 0.1
mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr
clorpres oral tablet 0.1-15 mg, 0.2-15 mg,
0.3-15 mg
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8
mg
midodrine oral tablet 10 mg, 2.5 mg, 5
mg
NORTHERA ORAL CAPSULE 100
MG
NORTHERA ORAL CAPSULE 200
MG, 300 MG
phenylephrine hcl injection solution 10
mg/ml
prazosin oral capsule 1 mg, 2 mg, 5 mg
Angiotensin Ii Receptor
Antagonists
BENICAR HCT ORAL TABLET
20-12.5 MG, 40-12.5 MG, 40-25 MG
BENICAR ORAL TABLET 20 MG, 40
MG
BENICAR ORAL TABLET 5 MG
candesartan oral tablet 16 mg, 4 mg, 8
mg
candesartan oral tablet 32 mg
candesartan-hydrochlorothiazid oral
tablet 16-12.5 mg
candesartan-hydrochlorothiazid oral
tablet 32-12.5 mg, 32-25 mg
2
5
5
(Vazculep)
2
(Minipress)
2
days)
PA; NM; QL (180 per
30 days)
NM
4
QL (30 per 30 days)
4
QL (30 per 30 days)
(Atacand)
4
2
QL (60 per 30 days)
QL (60 per 30 days)
(Atacand)
(Atacand HCT)
2
2
QL (30 per 30 days)
QL (60 per 30 days)
(Atacand HCT)
2
QL (30 per 30 days)
78
Drug Name
Drug Tier
Requirements/Limits
EDARBI ORAL TABLET 40 MG, 80
MG
EDARBYCLOR ORAL TABLET
40-12.5 MG, 40-25 MG
ENTRESTO ORAL TABLET 24-26
MG, 49-51 MG, 97-103 MG
eprosartan oral tablet 600 mg
irbesartan oral tablet 150 mg, 300 mg, 75
mg
irbesartan-hydrochlorothiazide oral
tablet 150-12.5 mg, 300-12.5 mg
losartan oral tablet 100 mg
4
QL (30 per 30 days)
4
QL (30 per 30 days)
4
(Teveten)
(Avapro)
2
2
PA; QL (60 per 30
days)
QL (45 per 30 days)
QL (30 per 30 days)
(Avalide)
2
QL (30 per 30 days)
(Cozaar)
1
losartan oral tablet 25 mg, 50 mg
(Cozaar)
1
losartan-hydrochlorothiazide oral tablet
100-12.5 mg, 100-25 mg, 50-12.5 mg
telmisartan oral tablet 20 mg, 40 mg, 80
mg
telmisartan-amlodipine oral tablet 40-10
mg, 40-5 mg, 80-10 mg, 80-5 mg
telmisartan-hydrochlorothiazid oral
tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg
valsartan oral tablet 160 mg, 40 mg, 80
mg
valsartan oral tablet 320 mg
valsartan-hydrochlorothiazide oral tablet
160-12.5 mg, 80-12.5 mg
valsartan-hydrochlorothiazide oral tablet
160-25 mg, 320-12.5 mg, 320-25 mg
Angiotensin-Converting Enzyme
Inhibitors
benazepril oral tablet 10 mg, 20 mg, 40
mg, 5 mg
benazepril-hydrochlorothiazide oral
tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg,
5-6.25 mg
(Hyzaar)
1
(Micardis)
2
GC; QL (45 per 30
days)
GC; QL (60 per 30
days)
GC; QL (30 per 30
days)
QL (30 per 30 days)
(Twynsta)
2
QL (30 per 30 days)
(Micardis HCT)
2
QL (30 per 30 days)
(Diovan)
2
QL (60 per 30 days)
(Diovan)
(Diovan HCT)
2
2
QL (30 per 30 days)
QL (60 per 30 days)
(Diovan HCT)
2
QL (30 per 30 days)
(Lotensin)
1
(Lotensin HCT)
2
GC; QL (60 per 30
days)
QL (60 per 30 days)
79
Drug Name
captopril oral tablet 100 mg, 12.5 mg
captopril oral tablet 25 mg, 50 mg
captopril-hydrochlorothiazide oral tablet
25-15 mg, 50-15 mg
captopril-hydrochlorothiazide oral tablet
25-25 mg, 50-25 mg
enalapril maleate oral tablet 10 mg, 2.5
mg, 20 mg, 5 mg
enalaprilat intravenous solution 1.25
mg/ml
enalapril-hydrochlorothiazide oral tablet
10-25 mg, 5-12.5 mg
fosinopril oral tablet 10 mg, 20 mg, 40
mg
fosinopril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg
lisinopril oral tablet 10 mg, 2.5 mg, 20
mg, 30 mg, 40 mg, 5 mg
lisinopril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg
moexipril oral tablet 15 mg
moexipril oral tablet 7.5 mg
moexipril-hydrochlorothiazide oral tablet
15-12.5 mg, 15-25 mg, 7.5-12.5 mg
perindopril erbumine oral tablet 2 mg, 4
mg, 8 mg
quinapril oral tablet 10 mg, 20 mg, 40
mg, 5 mg
quinapril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg
ramipril oral capsule 1.25 mg, 10 mg, 2.5
mg, 5 mg
trandolapril oral tablet 1 mg, 2 mg, 4 mg
Drug Tier
Requirements/Limits
(Captopril)
(Captopril)
(Captopril/Hydrochlor
othiazide)
(Captopril/Hydrochlor
othiazide)
(Vasotec)
2
2
2
QL (90 per 30 days)
QL (90 per 30 days)
2
QL (60 per 30 days)
1
(Enalaprilat Dihydrate)
2
(Vaseretic)
1
(Fosinopril Sodium)
1
(Fosinopril/Hydrochlor
othiazide)
(Zestril)
2
GC; QL (60 per 30
days)
NM; QL (120 per 30
days)
GC; QL (60 per 30
days)
GC; QL (60 per 30
days)
(Zestoretic)
1
(Moexipril HCl)
(Moexipril HCl)
(Moexipril/Hydrochlor
othiazide)
(Aceon)
2
2
2
GC; QL (60 per 30
days)
GC; QL (60 per 30
days)
QL (60 per 30 days)
QL (60 per 30 days)
2
QL (60 per 30 days)
(Accupril)
1
(Accuretic)
2
GC; QL (60 per 30
days)
QL (60 per 30 days)
(Altace)
1
(Mavik)
1
1
GC; QL (60 per 30
days)
GC; QL (60 per 30
days)
80
Drug Name
Antiarrhythmic Agents
amiodarone 150 mg/3 ml vial
sdv,latex-free,inner 50 mg/ml
amiodarone intravenous solution 50
mg/ml
amiodarone intravenous syringe 150 mg/3
ml
amiodarone oral tablet 100 mg, 200 mg,
400 mg
disopyramide phosphate oral capsule 100
mg, 150 mg
dofetilide oral capsule 125 mcg, 250 mcg,
500 mcg
flecainide oral tablet 100 mg, 150 mg, 50
mg
lidocaine (pf) in d7.5w intrathecal
solution 50 mg/ml (5 %)
lidocaine (pf) intravenous syringe 50
mg/5 ml (1 %)
lidocaine in 5 % dextrose (pf)
intravenous parenteral solution 8 mg/ml
(0.8 %)
mexiletine oral capsule 150 mg, 200 mg,
250 mg
MULTAQ ORAL TABLET 400 MG
pacerone oral tablet 100 mg, 200 mg, 400
mg
procainamide injection solution 100
mg/ml, 500 mg/ml
propafenone oral capsule,extended
propafenone oral tablet 150 mg, 225 mg,
300 mg
quinidine gluconate injection solution 80
mg/ml
quinidine gluconate oral tablet extended
release 324 mg
Drug Tier
Requirements/Limits
(Amiodarone HCl)
2
(Amiodarone HCl)
2
NM
(Amiodarone HCl)
2
NM
(Cordarone)
2
(Norpace)
2
(Tikosyn)
2
(Tambocor)
2
(Lidocaine
HCl/D7.5w/PF)
(Lidocaine HCl/PF)
2
NM
2
NM
(Lidocaine
HCl/D5w/PF)
2
NM
(Mexiletine HCl)
2
(Cordarone)
3
2
(Procainamide HCl)
2
(Rythmol SR)
2
(Rythmol)
2
(Quinidine Gluconate)
2
(Quinidine Gluconate)
2
NM
NM
81
Drug Name
quinidine sulfate oral tablet 200 mg, 300
mg
quinidine sulfate oral tablet extended
release 300 mg
TIKOSYN ORAL CAPSULE 125
MCG, 250 MCG, 500 MCG
Beta-Adrenergic Blocking Agents
acebutolol oral capsule 200 mg, 400 mg
atenolol oral tablet 100 mg, 25 mg, 50 mg
atenolol-chlorthalidone oral tablet 100-25
mg, 50-25 mg
betaxolol oral tablet 10 mg, 20 mg
bisoprolol fumarate oral tablet 10 mg, 5
mg
bisoprolol-hydrochlorothiazide oral tablet
10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg
carvedilol oral tablet 12.5 mg, 25 mg,
3.125 mg, 6.25 mg
esmolol intravenous solution 100 mg/10
ml (10 mg/ml)
INNOPRAN XL ORAL
24HR 120 MG, 80 MG
labetalol intravenous solution 5 mg/ml
labetalol oral tablet 100 mg, 200 mg, 300
mg
metoprolol succinate oral tablet extended
release 24 hr 100 mg, 200 mg, 25 mg, 50
mg
metoprolol ta-hydrochlorothiaz oral
tablet 100-25 mg, 100-50 mg, 50-25 mg
metoprolol tartrate intravenous solution 5
mg/5 ml
metoprolol tartrate oral tablet 100 mg, 25
mg, 50 mg
nadolol oral tablet 20 mg, 40 mg, 80 mg
Drug Tier
(Quinidine Sulfate)
2
(Quinidine Sulfate)
2
Requirements/Limits
3
(Sectral)
(Tenormin)
(Tenoretic 50)
1
1
2
GC
GC
(Betaxolol HCl)
(Zebeta)
2
2
(Ziac)
1
GC
(Coreg)
1
GC
(Brevibloc)
2
PA BvD; NM
3
(Labetalol HCl)
(Trandate)
2
2
NM
(Toprol XL)
2
(Lopressor HCT)
2
(Lopressor)
1
NM; GC
(Lopressor)
1
GC
(Corgard)
2
82
Drug Name
nadolol-bendroflumethiazide oral tablet
40-5 mg, 80-5 mg
pindolol oral tablet 10 mg, 5 mg
propranolol intravenous solution 1 mg/ml
propranolol oral capsule,extended release
24 hr 120 mg, 160 mg, 60 mg, 80 mg
propranolol oral solution 20 mg/5 ml (4
mg/ml), 40 mg/5 ml (8 mg/ml)
propranolol oral tablet 10 mg, 20 mg, 40
mg, 60 mg, 80 mg
propranolol-hydrochlorothiazid oral
tablet 40-25 mg, 80-25 mg
sorine oral tablet 120 mg, 160 mg, 240
mg, 80 mg
sotalol 120 mg tablet 120 mg
sotalol af oral tablet 120 mg
sotalol oral tablet 160 mg, 240 mg, 80 mg
timolol maleate oral tablet 10 mg, 20 mg,
5 mg
Calcium-Channel Blocking Agents
cartia xt oral capsule,extended release
24hr 120 mg, 180 mg, 240 mg, 300 mg
diltiazem 24hr er 180 mg cap 180 mg
diltiazem 24hr er 360 mg cap 360 mg
diltiazem hcl intravenous recon soln 100
mg
diltiazem hcl intravenous solution 5
mg/ml
diltiazem hcl oral capsule, extended
release 180 mg, 360 mg
diltiazem hcl oral capsule, extended
release 420 mg
diltiazem hcl oral capsule,extended
diltiazem hcl oral capsule,extended
release 24hr 120 mg, 240 mg, 300 mg
Drug Tier
Requirements/Limits
(Corzide)
2
(Pindolol)
(Propranolol HCl)
(Inderal LA)
2
2
2
(Propranolol HCl)
2
(Propranolol HCl)
2
(Propranolol/Hydrochl
orothiazid)
(Betapace)
2
(Betapace)
(Betapace)
(Betapace)
(Timolol Maleate)
2
2
2
2
(Cardizem CD)
2
(Cardizem CD)
(Cardizem CD)
(Diltiazem HCl)
2
2
2
NM
(Diltiazem HCl)
2
NM
(Cardizem CD)
2
(Tiazac)
2
(Diltiazem HCl)
2
(Cardizem CD)
2
NM
2
83
Drug Name
diltiazem hcl oral tablet 120 mg, 30 mg,
60 mg, 90 mg
diltiazem hcl oral tablet extended release
24 hr 180 mg, 240 mg, 300 mg, 360 mg,
420 mg
dilt-xr oral capsule,ext release
degradable 120 mg, 180 mg, 240 mg
matzim la oral tablet extended release 24
hr 180 mg, 240 mg, 300 mg, 360 mg, 420
mg
taztia xt oral capsule, extended release
120 mg, 180 mg, 240 mg, 300 mg, 360 mg
verapamil intravenous solution 2.5 mg/ml
verapamil intravenous syringe 2.5 mg/ml
verapamil oral capsule, 24 hr er pellet ct
100 mg, 200 mg, 300 mg
verapamil oral capsule,ext rel. pellets 24
hr 120 mg, 180 mg, 240 mg, 360 mg
verapamil oral tablet 120 mg, 40 mg, 80
mg
verapamil oral tablet extended release
120 mg, 180 mg, 240 mg
Cardiovascular Agents,
Miscellaneous
AUVI-Q INJECTION
AUTO-INJECTOR 0.15 MG/0.15 ML,
0.3 MG/0.3 ML
CORLANOR ORAL TABLET 5 MG,
7.5 MG
DEMSER ORAL CAPSULE 250 MG
digitek oral tablet 125 mcg, 250 mcg
digox 125 mcg tablet 125 mcg
digox 250 mcg tablet 250 mcg
digoxin 0.25 mg/ml syringe 250 mcg/ml
digoxin injection solution 250 mcg/ml
Drug Tier
(Cardizem)
2
(Cardizem LA)
2
(Diltiazem HCl)
2
(Cardizem LA)
2
(Tiazac)
2
(Verapamil HCl)
(Verapamil HCl)
(Verelan Pm)
2
2
2
(Verelan)
2
(Calan)
2
(Calan SR)
2
(Lanoxin)
(Lanoxin)
(Lanoxin)
(Digoxin)
(Digoxin)
Requirements/Limits
NM
3
NM; QL (2 per 30
days)
4
PA; QL (60 per 30
days)
PA; NM
5
2
2
2
2
2
NM
NM
84
Drug Name
Drug Tier
DIGOXIN ORAL SOLUTION 50
MCG/ML
digoxin oral tablet 125 mcg, 250 mcg
dobutamine in d5w intravenous
parenteral solution 1,000 mg/250 ml
(4,000 mcg/ml), 250 mg/250 ml (1
mg/ml), 500 mg/250 ml (2,000 mcg/ml)
dobutamine intravenous solution 250
mg/20 ml (12.5 mg/ml)
dopamine 400 mg-d5w 250 ml 400
mg/250 ml (1,600 mcg/ml)
dopamine in 5 % dextrose intravenous
solution 200 mg/250 ml (800 mcg/ml),
800 mg/250 ml (3,200 mcg/ml)
dopamine in 5 % dextrose intravenous
solution 400 mg/250 ml (1,600 mcg/ml)
dopamine intravenous solution 200 mg/5
ml (40 mg/ml), 800 mg/10 ml (80
mg/ml), 800 mg/5 ml (160 mg/ml)
dopamine intravenous solution 400 mg/5
ml (80 mg/ml)
ephedrine sulfate injection solution 50
mg/ml
epinephrine hcl (pf) intravenous solution
1 mg/ml (1 ml)
epinephrine injection auto-injector 0.3
mg/0.3 ml
epinephrine injection solution 1 mg/ml (1
ml)
epinephrine injection syringe 0.1 mg/ml
EPIPEN 2-PAK INJECTION
AUTO-INJECTOR 0.3 MG/0.3 ML
EPIPEN JR 2-PAK INJECTION
AUTO-INJECTOR 0.15 MG/0.3 ML
ethamolin intravenous solution 5 %
FIRAZYR SUBCUTANEOUS
SYRINGE 30 MG/3 ML
2
Requirements/Limits
(Lanoxin)
(Dobutamine
HCl/D5W)
2
2
PA BvD; NM
(Dobutamine HCl)
2
PA BvD; NM
(Dopamine HCl/D5W)
2
PA BvD; NM
(Dopamine HCl/D5W)
2
PA BvD; NM
(Dopamine HCl/D5W)
2
PA BvD
(Dopamine HCl)
2
PA BvD; NM
(Dopamine HCl)
2
PA BvD
(Ephedrine Sulfate)
2
NM
(Epinephrine HCl/PF)
2
(Adrenaclick)
2
NM
(Epinephrine)
2
NM
(Epinephrine)
2
3
NM
NM; QL (2 per 30
days)
QL (2 per 30 days)
3
(Ethanolamine Oleate)
2
5
NM
PA; NM; LA; QL (9
per 30 days)
85
Drug Name
hydralazine injection solution 20 mg/ml
hydralazine oral tablet 10 mg, 100 mg, 25
mg, 50 mg
LANOXIN ORAL TABLET 125
MCG, 187.5 MCG, 250 MCG, 62.5
MCG
milrinone in 5 % dextrose intravenous
piggyback 20 mg/100 ml (200 mcg/ml)
milrinone in 5 % dextrose intravenous
piggyback 40 mg/200 ml (200 mcg/ml)
milrinone intravenous solution 1 mg/ml
milrinone lact 50 mg/50 ml vl sdv,p/f 1
mg/ml
norepinephrine bitartrate intravenous
solution 1 mg/ml
papaverine injection solution 30 mg/ml
RANEXA ORAL TABLET
EXTENDED RELEASE 12 HR 1,000
MG, 500 MG
Dihydropyridines
afeditab cr oral tablet extended release
30 mg, 60 mg
amlodipine oral tablet 10 mg, 2.5 mg, 5
mg
amlodipine-benazepril oral capsule 10-20
mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20
mg, 5-40 mg
amlodipine-valsartan oral tablet 10-160
mg, 10-320 mg, 5-160 mg, 5-320 mg
amlodipine-valsartan-hcthiazid oral
tablet 10-160-12.5 mg, 10-160-25 mg,
10-320-25 mg, 5-160-12.5 mg, 5-160-25
mg
felodipine oral tablet extended release 24
hr 10 mg, 2.5 mg, 5 mg
isradipine oral capsule 2.5 mg, 5 mg
Drug Tier
(Hydralazine HCl)
(Hydralazine HCl)
2
2
Requirements/Limits
NM
4
(Milrinone
Lactate/D5W)
(Milrinone
Lactate/D5W)
(Milrinone Lactate)
(Milrinone Lactate)
2
PA BvD
2
PA BvD; NM
2
2
PA BvD
PA BvD; NM
(Levophed Bitartrate)
2
PA BvD; NM
(Papaverine HCl)
2
4
NM
(Adalat CC)
2
(Norvasc)
1
(Lotrel)
2
(Exforge)
2
(Exforge HCT)
2
(Felodipine)
2
(Isradipine)
2
GC
86
Drug Name
nicardipine intravenous solution 25 mg/10
ml
nicardipine oral capsule 20 mg, 30 mg
nifedical xl oral tablet extended release
24hr 30 mg, 60 mg
nifedipine er 30 mg tablet f/c 30 mg
nifedipine oral tablet extended release
24hr 30 mg
nifedipine oral tablet extended release
24hr 60 mg, 90 mg
nimodipine oral capsule 30 mg
nisoldipine oral tablet extended release 24
hr 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg,
40 mg, 8.5 mg
Diuretics
amiloride oral tablet 5 mg
amiloride-hydrochlorothiazide oral tablet
5-50 mg
bumetanide injection solution 0.25 mg/ml
bumetanide oral tablet 0.5 mg, 1 mg, 2
mg
chlorothiazide oral tablet 250 mg, 500 mg
chlorothiazide sodium intravenous recon
soln 500 mg
chlorthalidone oral tablet 25 mg, 50 mg
furosemide injection solution 10 mg/ml
furosemide injection syringe 10 mg/ml
furosemide oral solution 10 mg/ml, 40
mg/5 ml (8 mg/ml)
furosemide oral tablet 20 mg, 40 mg, 80
mg
hydrochlorothiazide oral capsule 12.5 mg
hydrochlorothiazide oral tablet 12.5 mg,
25 mg, 50 mg
indapamide oral tablet 1.25 mg, 2.5 mg
methyclothiazide oral tablet 5 mg
Drug Tier
Requirements/Limits
(Nicardipine HCl)
2
NM
(Nicardipine HCl)
(Procardia XL)
2
2
(Adalat CC)
(Adalat CC)
2
2
(Procardia XL)
2
(Nimodipine)
(Sular)
2
2
(Amiloride HCl)
(Amiloride/Hydrochlor
othiazide)
(Bumetanide)
(Bumetanide)
2
2
(Chlorothiazide)
(Sodium Diuril)
2
2
(Chlorthalidone)
(Furosemide)
(Furosemide)
(Furosemide)
2
2
2
2
NM
NM
(Lasix)
1
GC
(Microzide)
(Hydrochlorothiazide)
1
1
GC
GC
(Indapamide)
(Methyclothiazide)
1
2
GC
2
2
NM
87
Drug Name
Drug Tier
Requirements/Limits
metolazone oral tablet 10 mg, 2.5 mg, 5
mg
torsemide intravenous solution 20 mg/2
ml (10 mg/ml)
torsemide intravenous solution 50 mg/5
ml (10 mg/ml)
torsemide oral tablet 10 mg, 100 mg, 20
mg, 5 mg
triamterene-hydrochlorothiazid oral
capsule 37.5-25 mg
capsule 50-25 mg
tablet 37.5-25 mg, 75-50 mg
Dyslipidemics
amlodipine-atorvastatin oral tablet 10-10
mg, 10-20 mg, 10-40 mg, 10-80 mg,
2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10
mg, 5-20 mg, 5-40 mg, 5-80 mg
atorvastatin oral tablet 10 mg, 20 mg, 40
mg
atorvastatin oral tablet 80 mg
(Zaroxolyn)
2
(Torsemide)
2
(Torsemide)
2
(Demadex)
2
(Dyazide)
1
(Dyazide)
2
(Maxzide)
1
GC
(Caduet)
2
QL (30 per 30 days)
(Lipitor)
1
(Lipitor)
1
GC; QL (45 per 30
days)
GC; QL (30 per 30
days)
cholestyramine light oral powder in
packet 4 gram
cholestyramine packet 4 gram
colestipol hcl granules packet 5 gram
colestipol oral granules 5 gram
colestipol oral tablet 1 gram
CRESTOR ORAL TABLET 10 MG,
20 MG, 40 MG, 5 MG
fenofibrate micronized oral capsule 130
mg, 134 mg, 200 mg, 43 mg, 67 mg
fenofibrate nanocrystallized oral tablet
145 mg, 48 mg
fenofibrate oral capsule 150 mg, 50 mg
(Questran)
2
(Questran)
(Colestid)
(Colestid)
(Colestid)
2
2
2
2
3
(Lofibra)
2
(Tricor)
2
(Lipofen)
2
NM
GC
88
Drug Name
Drug Tier
fenofibrate oral tablet 160 mg, 54 mg
fenofibric acid (choline) oral
capsule,delayed release(dr/ec) 135 mg,
45 mg
fenofibric acid oral tablet 105 mg, 35 mg
fluvastatin oral capsule 20 mg, 40 mg
gemfibrozil oral tablet 600 mg
JUXTAPID ORAL CAPSULE 10 MG,
20 MG, 30 MG, 40 MG, 5 MG, 60 MG
KYNAMRO SUBCUTANEOUS
SYRINGE 200 MG/ML
lovastatin oral tablet 10 mg, 20 mg
(Lofibra)
(Trilipix)
2
2
(Fibricor)
(Lescol)
(Lopid)
2
2
2
5
(Lovastatin)
1
lovastatin oral tablet 40 mg
(Lovastatin)
1
niacin oral tablet extended release 24 hr
1,000 mg, 500 mg, 750 mg
niacor oral tablet 500 mg
omega-3 acid ethyl esters oral capsule 1
gram
PRALUENT PEN SUBCUTANEOUS
PEN INJECTOR 150 MG/ML, 75
MG/ML
PRALUENT SYRINGE
SUBCUTANEOUS SYRINGE 150
MG/ML, 75 MG/ML
pravastatin oral tablet 10 mg, 20 mg, 40
mg
pravastatin oral tablet 80 mg
prevalite oral powder 4 gram
(Niaspan)
2
(Niacin)
(Lovaza)
2
2
prevalite packet outer 4 gram
5
Requirements/Limits
QL (60 per 30 days)
days)
PA; NM; LA; QL (4
per 28 days)
GC; QL (45 per 30
days)
GC; QL (60 per 30
days)
3
3
(Pravachol)
2
QL (45 per 30 days)
(Pravachol)
(Cholestyramine/Aspar
tame)
(Cholestyramine/Aspar
tame)
2
2
QL (30 per 30 days)
REPATHA SURECLICK
140 MG/ML
2
3
89
Drug Name
REPATHA SYRINGE
MG/ML
rosuvastatin oral tablet 10 mg, 20 mg, 5
mg
rosuvastatin oral tablet 40 mg
simvastatin oral tablet 10 mg, 20 mg, 5
mg
simvastatin oral tablet 40 mg
simvastatin oral tablet 80 mg
VASCEPA ORAL CAPSULE 1
GRAM
WELCHOL ORAL POWDER IN
PACKET 3.75 GRAM
WELCHOL ORAL TABLET 625 MG
ZETIA ORAL TABLET 10 MG
Renin-Angiotensin-Aldosterone
System Inhibitors
ALDACTAZIDE ORAL TABLET
50-50 MG
eplerenone oral tablet 25 mg, 50 mg
spironolactone oral tablet 100 mg, 25 mg,
50 mg
spironolacton-hydrochlorothiaz oral
tablet 25-25 mg
TEKTURNA HCT ORAL TABLET
150-12.5 MG, 150-25 MG, 300-12.5
MG, 300-25 MG
TEKTURNA ORAL TABLET 150
MG, 300 MG
Vasodilators
isosorbide dinitrate oral tablet 10 mg, 20
mg, 30 mg, 5 mg
Drug Tier
Requirements/Limits
3
(Crestor)
2
QL (45 per 30 days)
(Crestor)
(Zocor)
2
1
(Zocor)
1
(Zocor)
1
QL (30 per 30 days)
GC; QL (45 per 30
days)
PA; GC; (PA only w/
amiodarone); QL (45
per 30 days)
PA; GC; (PA only w/
amiodarone); QL (30
per 30 days)
4
4
4
3
4
(Inspra)
(Aldactone)
2
2
(Aldactazide)
2
QL (60 per 30 days)
4
4
(Isochron)
QL (30 per 30 days)
2
90
Drug Name
isosorbide dinitrate oral tablet extended
release 40 mg
isosorbide mononitrate oral tablet 10 mg,
20 mg
isosorbide mononitrate oral tablet
extended release 24 hr 120 mg, 30 mg, 60
mg
minitran transdermal patch 24 hour 0.1
mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr
minoxidil oral tablet 10 mg, 2.5 mg
NITRO-DUR TRANSDERMAL
PATCH 24 HOUR 0.3 MG/HR, 0.8
MG/HR
nitroglycerin in 5 % dextrose intravenous
solution 100 mg/250 ml (400 mcg/ml), 25
mg/250 ml (100 mcg/ml), 50 mg/250 ml
(200 mcg/ml)
nitroglycerin intravenous solution 50
mg/10 ml (5 mg/ml)
nitroglycerin transdermal patch 24 hour
0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6
mg/hr
nitroglycerin translingual
spray,non-aerosol 400 mcg/spray
NITROSTAT SUBLINGUAL
TABLET 0.3 MG, 0.4 MG, 0.6 MG
PROGLYCEM ORAL SUSPENSION
50 MG/ML
Drug Tier
Requirements/Limits
(Isochron)
2
(Isosorbide
Mononitrate)
(Imdur)
2
(Nitro-Dur)
2
(Minoxidil)
2
3
(Nitroglycerin/D5W)
2
NM
(Nitroglycerin)
2
NM
(Nitro-Dur)
2
(Nitromist)
2
2
3
3
Central Nervous System Agents
Central Nervous System Agents
AMPYRA ORAL TABLET
MG
caffeine citrated intravenous solution 60 (Cafcit)
mg/3 ml (20 mg/ml)
caffeine citrated oral solution 60 mg/3 ml (Cafcit)
(20 mg/ml)
5
PA; NM; LA; QL (60
per 30 days)
2
NM
2
NM
91
Drug Name
caffeine-sodium benzoate injection
solution 250 mg/ml (125 mg/ml caffeine)
dexmethylphenidate oral capsule,er
biphasic 50-50 10 mg, 15 mg, 20 mg, 30
mg, 40 mg, 5 mg
dexmethylphenidate oral tablet 10 mg,
2.5 mg, 5 mg
dextroamphetamine oral capsule,
extended release 10 mg, 15 mg, 5 mg
dextroamphetamine oral solution 5 mg/5
ml
dextroamphetamine oral tablet 10 mg, 5
mg
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 10 mg, 15
mg, 20 mg, 25 mg, 30 mg, 5 mg
dextroamphetamine-amphetamine oral
tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30
mg, 5 mg, 7.5 mg
flumazenil intravenous solution 0.1 mg/ml
guanfacine oral tablet extended release
24 hr 1 mg, 2 mg, 3 mg, 4 mg
lithium carbonate oral capsule 150 mg,
300 mg, 600 mg
lithium carbonate oral tablet 300 mg
lithium carbonate oral tablet extended
release 300 mg
lithium carbonate oral tablet extended
release 450 mg
lithium citrate oral solution 8 meq/5 ml
methamphetamine oral tablet 5 mg
methylphenidate cd 20 mg cap 20 mg
methylphenidate cd 40 mg cap 40 mg
methylphenidate oral capsule, er biphasic
30-70 10 mg, 30 mg, 50 mg, 60 mg
Drug Tier
Requirements/Limits
(Caffeine/Sodium
Benzoate)
(Focalin XR)
2
NM
2
NM
(Focalin)
2
NM
(Dexedrine)
2
NM
(Procentra)
2
NM
(Dexedrine)
2
NM
(Adderall XR)
2
NM
(Adderall)
2
NM
(Romazicon)
(Intuniv)
2
2
NM
PA
(Lithium Carbonate)
2
(Lithobid)
(Lithobid)
2
2
(Lithobid)
2
(Lithium Citrate)
(Desoxyn)
(Metadate Cd)
(Metadate Cd)
(Metadate Cd)
2
2
2
2
2
NM
NM
NM
NM
NM
92
Drug Name
methylphenidate oral capsule,er biphasic
50-50 20 mg, 40 mg
methylphenidate oral solution 10 mg/5
ml, 5 mg/5 ml
methylphenidate oral tablet 10 mg, 20
mg, 5 mg
methylphenidate oral tablet extended
release 10 mg, 20 mg
methylphenidate oral tablet extended
release 24hr 18 mg, 27 mg, 36 mg, 54 mg
methylphenidate oral tablet,chewable 10
mg, 2.5 mg, 5 mg
NUEDEXTA ORAL CAPSULE 20-10
MG
riluzole oral tablet 50 mg
Drug Tier
Requirements/Limits
(Metadate Cd)
2
NM
(Methylin)
2
NM
(Ritalin)
2
NM
(Methylphenidate HCl)
2
NM
(Concerta)
2
NM
(Methylin)
2
NM
4
PA; NM
2
NM; QL (60 per 30
days)
(Rilutek)
SAVELLA ORAL TABLET 100 MG,
12.5 MG, 25 MG, 50 MG
SAVELLA ORAL TABLETS,DOSE
PACK 12.5 MG (5)-25 MG(8)-50
MG(42)
STRATTERA ORAL CAPSULE 10
MG, 100 MG, 18 MG, 25 MG, 40 MG,
60 MG, 80 MG
tetrabenazine oral tablet 12.5 mg, 25 mg (Xenazine)
XENAZINE ORAL TABLET 12.5
MG, 25 MG
3
3
4
PA
5
5
NM
NM; LA
Contraceptives
Contraceptives
altavera (28) oral tablet 0.15-0.03 mg
alyacen 1/35 (28) oral tablet 1-35
mg-mcg
alyacen 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
amethia lo oral tablets,dose pack,3 month
0.10 mg-20 mcg (84)/10 mcg (7)
(Amethyst)
(Modicon)
2
2
(Modicon)
2
(Seasonique)
2
93
Drug Name
amethia oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
AMETHYST ORAL TABLET 90-20
MCG
apri oral tablet 0.15-0.03 mg
aranelle (28) oral tablet 0.5/1/0.5-35
mg-mcg
ashlyna oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
aubra oral tablet 0.1-20 mg-mcg
aviane oral tablet 0.1-20 mg-mcg
azurette (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
balziva (28) oral tablet 0.4-35 mg-mcg
bekyree (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
blisovi 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
blisovi fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
blisovi fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
briellyn oral tablet 0.4-35 mg-mcg
camila oral tablet 0.35 mg
camrese lo oral tablets,dose pack,3 month
0.10 mg-20 mcg (84)/10 mcg (7)
camrese oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
caziant (28) oral tablet 0.1/.125/.15-25
mg-mcg
cryselle (28) oral tablet 0.3-30 mg-mcg
Drug Tier
(Seasonique)
Requirements/Limits
2
2
(Desogen)
(Modicon)
2
2
(Seasonique)
2
(Amethyst)
(Amethyst)
(Mircette)
2
2
2
(Modicon)
(Mircette)
2
2
(Loestrin Fe)
2
(Loestrin Fe)
2
(Loestrin Fe)
2
(Modicon)
(Nor-Q-D)
(Seasonique)
2
2
2
(Seasonique)
2
(Desogen)
2
(Norgestrel-Ethinyl
Estradiol)
(Modicon)
2
cyclafem 1/35 (28) oral tablet 1-35
mg-mcg
cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 (Modicon)
mg- 35 mcg
2
2
94
Drug Name
cyred oral tablet 0.15-0.03 mg
dasetta 1/35 (28) oral tablet 1-35
mg-mcg
dasetta 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
daysee oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
deblitane oral tablet 0.35 mg
delyla (28) oral tablet 0.1-20 mg-mcg
desog-e.estradiol/e.estradiol oral tablet
0.15-0.02 mgx21 /0.01 mg x 5
desogestrel-ethinyl estradiol oral tablet
0.15-0.03 mg
drospirenone-ethinyl estradiol oral tablet
3-0.02 mg, 3-0.03 mg
elinest oral tablet 0.3-30 mg-mcg
ELLA ORAL TABLET 30 MG
emoquette oral tablet 0.15-0.03 mg
enpresse oral tablet 50-30 (6)/75-40
(5)/125-30(10)
enskyce oral tablet 0.15-0.03 mg
errin oral tablet 0.35 mg
estarylla oral tablet 0.25-35 mg-mcg
falmina (28) oral tablet 0.1-20 mg-mcg
gianvi (28) oral tablet 3-0.02 mg
gildagia oral tablet 0.4-35 mg-mcg
gildess 1.5/30 (21) oral tablet 1.5-30
mg-mcg
gildess 1/20 (21) oral tablet 1-20 mg-mcg
gildess 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
gildess fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
gildess fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
Drug Tier
(Desogen)
(Modicon)
2
2
(Modicon)
2
(Seasonique)
2
(Nor-Q-D)
(Amethyst)
(Mircette)
2
2
2
(Desogen)
2
(Yaz)
2
(Norgestrel-Ethinyl
Estradiol)
2
(Desogen)
(Amethyst)
3
2
2
(Desogen)
(Nor-Q-D)
(Ortho-Cyclen)
(Amethyst)
(Yaz)
(Modicon)
(Loestrin)
2
2
2
2
2
2
2
(Loestrin)
(Loestrin Fe)
2
2
(Loestrin Fe)
2
(Loestrin Fe)
2
Requirements/Limits
95
Drug Name
heather oral tablet 0.35 mg
introvale oral tablets,dose pack,3 month
0.15-30 mg-mcg
jencycla oral tablet 0.35 mg
jolessa oral tablets,dose pack,3 month
0.15-30 mg-mcg
jolivette oral tablet 0.35 mg
juleber oral tablet 0.15-0.03 mg
junel 1.5/30 (21) oral tablet 1.5-30
mg-mcg
junel 1/20 (21) oral tablet 1-20 mg-mcg
junel fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
junel fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
junel fe 24 oral tablet 1 mg-20 mcg
(24)/75 mg (4)
kaitlib fe oral tablet,chewable
0.8mg-25mcg(24) and 75 mg (4)
kariva (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
kelnor 1/35 (28) oral tablet 1-35 mg-mcg
kimidess (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
kurvelo oral tablet 0.15-0.03 mg
l norgest/e.estradiol-e.estrad oral
tablets,dose pack,3 month 0.10 mg-20
mcg (84)/10 mcg (7), 0.15 mg-30 mcg
(84)/10 mcg (7)
larin 1.5/30 (21) oral tablet 1.5-30
mg-mcg
larin 1/20 (21) oral tablet 1-20 mg-mcg
larin 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
larin fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
Drug Tier
(Nor-Q-D)
(Levonorgestrel-Ethin
Estradiol)
(Nor-Q-D)
Estradiol)
(Nor-Q-D)
(Desogen)
(Loestrin)
2
2
(Loestrin)
(Loestrin Fe)
2
2
(Loestrin Fe)
2
(Loestrin Fe)
2
(Femcon Fe)
2
(Mircette)
2
(Demulen 1-50-21)
(Mircette)
2
2
(Amethyst)
(Seasonique)
2
2
(Loestrin)
2
(Loestrin)
(Loestrin Fe)
2
2
(Loestrin Fe)
2
Requirements/Limits
2
2
2
2
2
96
Drug Name
larin fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
layolis fe oral tablet,chewable
0.8mg-25mcg(24) and 75 mg (4)
leena 28 oral tablet 0.5/1/0.5-35 mg-mcg
lessina oral tablet 0.1-20 mg-mcg
levonest (28) oral tablet 50-30 (6)/75-40
(5)/125-30(10)
levonor-eth estrad 0.15-0.03 outer
0.15-0.03 mg
levonorgestrel oral tablet 0.75 mg
levonorgestrel-ethinyl estrad oral tablet
0.1-20 mg-mcg, 90-20 mcg
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month 0.15-30
mg-mcg
levonorg-eth estrad triphasic oral tablet
50-30 (6)/75-40 (5)/125-30(10)
levora-28 oral tablet 0.15-0.03 mg
lomedia 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
loryna (28) oral tablet 3-0.02 mg
low-ogestrel (28) oral tablet 0.3-30
mg-mcg
lutera (28) oral tablet 0.1-20 mg-mcg
lyza oral tablet 0.35 mg
marlissa oral tablet 0.15-0.03 mg
microgestin 1.5/30 (21) oral tablet 1.5-30
mg-mcg
microgestin 1/20 (21) oral tablet 1-20
mg-mcg
microgestin fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
microgestin fe 1/20 (28) oral tablet 1
mg-20 mcg (21)/75 mg (7)
mono-linyah oral tablet 0.25-35 mg-mcg
Drug Tier
(Loestrin Fe)
2
(Femcon Fe)
2
(Modicon)
(Amethyst)
(Amethyst)
2
2
2
(Amethyst)
2
(Plan B One-Step)
(Amethyst)
2
2
(Amethyst)
2
(Amethyst)
2
(Amethyst)
(Loestrin Fe)
2
2
(Yaz)
(Norgestrel-Ethinyl
Estradiol)
(Amethyst)
(Nor-Q-D)
(Amethyst)
(Loestrin)
2
2
(Loestrin)
2
(Loestrin Fe)
2
(Loestrin Fe)
2
(Ortho-Cyclen)
2
Requirements/Limits
2
2
2
2
97
Drug Name
mononessa (28) oral tablet 0.25-35
mg-mcg
myzilra oral tablet 50-30 (6)/75-40
(5)/125-30(10)
necon 0.5/35 (28) oral tablet 0.5-35
mg-mcg
necon 1/35 (28) oral tablet 1-35 mg-mcg
necon 1/50 (28) oral tablet 1-50 mg-mcg
necon 10/11 (28) oral tablet 0.5-35/1-35
mg-mcg/mg-mcg
necon 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
nikki (28) oral tablet 3-0.02 mg
nora-be oral tablet 0.35 mg
norethindrone (contraceptive) oral tablet
0.35 mg
norethindrone ac-eth estradiol oral tablet
1-20 mg-mcg
norethindrone-e.estradiol-iron oral tablet
1 mg-20 mcg (24)/75 mg (4)
norg-ee 0.18-0.215-0.25/0.035 3x28 day
regimen 0.18/0.215/0.25 mg-35 mcg (28)
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-25 mcg, 0.25-35
mg-mcg
norlyroc oral tablet 0.35 mg
nortrel 0.5/35 (28) oral tablet 0.5-35
mg-mcg
nortrel 1/35 (21) oral tablet 1-35
mg-mcg
nortrel 1/35 (28) oral tablet 1-35
mg-mcg
nortrel 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
NUVARING VAGINAL RING
0.12-0.015 MG/24 HR
Drug Tier
(Ortho-Cyclen)
2
(Amethyst)
2
(Modicon)
2
(Modicon)
(Norinyl 1+50)
(Modicon)
2
2
2
(Modicon)
2
(Yaz)
(Nor-Q-D)
(Nor-Q-D)
2
2
2
(Loestrin)
2
(Loestrin Fe)
2
(Ortho-Cyclen)
2
(Ortho-Cyclen)
2
(Nor-Q-D)
(Modicon)
2
2
(Modicon)
2
(Modicon)
2
(Modicon)
2
Requirements/Limits
3
98
Drug Name
(Yaz)
(Norgestrel-Ethinyl
Estradiol)
orsythia oral tablet 0.1-20 mg-mcg
(Amethyst)
philith oral tablet 0.4-35 mg-mcg
(Modicon)
pimtrea (28) oral tablet 0.15-0.02 mgx21 (Mircette)
/0.01 mg x 5
pirmella oral tablet 0.5/0.75/1 mg- 35
(Modicon)
mcg, 1-35 mg-mcg
portia oral tablet 0.15-0.03 mg
(Amethyst)
previfem oral tablet 0.25-35 mg-mcg
(Ortho-Cyclen)
quasense oral tablets,dose pack,3 month (Levonorgestrel-Ethin
0.15-30 mg-mcg
Estradiol)
reclipsen (28) oral tablet 0.15-0.03 mg
(Desogen)
setlakin oral tablets,dose pack,3 month
0.15-30 mg-mcg
Estradiol)
sharobel oral tablet 0.35 mg
(Nor-Q-D)
sprintec (28) oral tablet 0.25-35 mg-mcg (Ortho-Cyclen)
sronyx oral tablet 0.1-20 mg-mcg
(Amethyst)
syeda oral tablet 3-0.03 mg
(Yaz)
tarina fe 1/20 (28) oral tablet 1 mg-20
(Loestrin Fe)
mcg (21)/75 mg (7)
tilia fe oral tablet 1-20(5)/1-30(7)
(Loestrin Fe)
/1mg-35mcg (9)
tri-estarylla oral tablet 0.18/0.215/0.25
(Ortho-Cyclen)
mg-35 mcg (28)
tri-legest fe oral tablet 1-20(5)/1-30(7) (Loestrin Fe)
/1mg-35mcg (9)
tri-linyah oral tablet 0.18/0.215/0.25
(Ortho-Cyclen)
mg-35 mcg (28)
tri-lo-estarylla oral tablet 0.18/0.215/0.25 (Ortho-Cyclen)
mg-25 mcg
tri-lo-marzia oral tablet 0.18/0.215/0.25 (Ortho-Cyclen)
mg-25 mcg
tri-lo-sprintec oral tablet 0.18/0.215/0.25 (Ortho-Cyclen)
mg-25 mcg
ocella oral tablet 3-0.03 mg
ogestrel (28) oral tablet 0.5-50 mg-mcg
Drug Tier
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
99
Drug Name
trinessa (28) oral tablet 0.18/0.215/0.25
mg-35 mcg (28)
trinessa lo oral tablet 0.18/0.215/0.25
mg-25 mcg
tri-previfem (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
tri-sprintec (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
trivora (28) oral tablet 50-30 (6)/75-40
(5)/125-30(10)
velivet triphasic regimen (28) oral tablet
0.1/.125/.15-25 mg-mcg
vestura (28) oral tablet 3-0.02 mg
vienva oral tablet 0.1-20 mg-mcg
viorele (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
vyfemla (28) oral tablet 0.4-35 mg-mcg
wera (28) oral tablet 0.5-35 mg-mcg
wymzya fe oral tablet,chewable
0.4mg-35mcg(21) and 75 mg (7)
xulane transdermal patch weekly 150-35
mcg/24 hr
zarah oral tablet 3-0.03 mg
zenchent (28) oral tablet 0.4-35 mg-mcg
zenchent fe oral tablet,chewable
0.4mg-35mcg(21) and 75 mg (7)
zeosa oral tablet,chewable
0.4mg-35mcg(21) and 75 mg (7)
zovia 1/35e (28) oral tablet 1-35 mg-mcg
zovia 1/50e (28) oral tablet 1-50 mg-mcg
Drug Tier
(Ortho-Cyclen)
2
(Ortho-Cyclen)
2
(Ortho-Cyclen)
2
(Ortho-Cyclen)
2
(Amethyst)
2
(Desogen)
2
(Yaz)
(Amethyst)
(Mircette)
2
2
2
(Modicon)
(Modicon)
(Femcon Fe)
2
2
2
(Ortho Evra)
2
(Yaz)
(Modicon)
(Femcon Fe)
2
2
2
(Femcon Fe)
2
(Demulen 1-50-21)
(Demulen 1-50-21)
2
2
(Evoxac)
(Peridex)
2
2
(Sodium Fluoride)
2
Requirements/Limits
Dental And Oral Agents
Dental And Oral Agents
cevimeline oral capsule 30 mg
chlorhexidine gluconate mucous
membrane mouthwash 0.12 %
denta 5000 plus dental cream 1.1 %
100
Drug Name
dentagel dental gel 1.1 %
fluoridex daily defense dental gel 1.1 %
oralone dental paste 0.1 %
periogard mucous membrane mouthwash
0.12 %
pilocarpine hcl oral tablet 5 mg, 7.5 mg
sf 5000 plus dental cream 1.1 %
sodium fluoride dental solution 0.2 %
sodium fluoride oral tablet,chewable 0.25
mg fluorid (0.55 mg)
stannous fluoride dental solution 0.63 %
triamcinolone acetonide dental paste 0.1
%
Drug Tier
(Phos-Flur)
(Phos-Flur)
(Triamcinolone
Acetonide)
(Peridex)
2
2
2
(Salagen)
(Sodium Fluoride)
(Prevident)
(Sodium Fluoride)
2
2
2
2
(Stannous Fluoride)
(Triamcinolone
Acetonide)
2
2
Requirements/Limits
2
Dermatological Agents
Dermatological Agents, Other
8-MOP ORAL CAPSULE 10 MG
ABSORICA ORAL CAPSULE 10
MG, 20 MG, 25 MG, 30 MG, 35 MG,
40 MG
acitretin oral capsule 10 mg, 17.5 mg, 25
mg
acyclovir topical ointment 5 %
ALCOHOL PADS TOPICAL PADS,
MEDICATED
ALCOHOL PREP PADS
ammonium lactate topical cream 12 %
ammonium lactate topical lotion 12 %
amnesteem oral capsule 10 mg, 20 mg, 40
mg
calcipotriene scalp solution 0.005 %
calcipotriene topical cream 0.005 %
calcipotriene topical ointment 0.005 %
calcipotriene-betamethasone topical
ointment 0.005-0.064 %
calcitrene topical ointment 0.005 %
4
3
(Soriatane)
5
(Zovirax)
2
3
(Ammonium Lactate)
(Ammonium Lactate)
(Isotretinoin)
3
2
2
2
(Calcipotriene)
(Dovonex)
(Calcipotriene)
(Taclonex)
2
2
2
2
(Calcipotriene)
2
days)
101
Drug Name
calcitriol topical ointment 3 mcg/gram
claravis oral capsule 10 mg, 20 mg, 30
mg, 40 mg
CONDYLOX TOPICAL GEL 0.5 %
DENAVIR TOPICAL CREAM 1 %
FLUOROPLEX TOPICAL CREAM 1
%
fluorouracil topical cream 0.5 %, 5 %
fluorouracil topical solution 2 %, 5 %
hypercare topical solution 20 %
imiquimod topical cream in packet 5 %
LEVULAN TOPICAL SOLUTION 20
%
methoxsalen rapid oral capsule 10 mg
myorisan oral capsule 10 mg, 20 mg, 30
mg, 40 mg
OXSORALEN TOPICAL LOTION 1
%
PANRETIN TOPICAL GEL 0.1 %
PICATO TOPICAL GEL 0.015 %
Drug Tier
(Vectical)
(Isotretinoin)
2
2
3
4
3
(Carac)
(Fluorouracil)
(Aluminum Chloride)
(Aldara)
2
2
2
2
4
(Oxsoralen-Ultra)
(Isotretinoin)
2
2
QL (5 per 30 days)
4
5
4
PICATO TOPICAL GEL 0.05 %
podocon topical liquid 25 %
podofilox topical solution 0.5 %
potassium hydroxide topical solution 5 %
REGRANEX TOPICAL GEL 0.01 %
SANTYL TOPICAL OINTMENT 250
UNIT/GRAM
TOLAK TOPICAL CREAM 4 %
UVADEX INJECTION SOLUTION
20 MCG/ML
VALCHLOR TOPICAL GEL 0.016 %
XERESE TOPICAL CREAM 5-1 %
zenatane oral capsule 10 mg, 20 mg, 30
mg, 40 mg
Requirements/Limits
4
(Podophyllum Resin)
(Condylox)
(Potassium Hydroxide)
2
2
2
5
3
4
4
(Isotretinoin)
5
4
2
NM
days)
days)
NM
NM
PA NSO; NM
102
Drug Name
Drug Tier
ZONALON TOPICAL CREAM 5 %
ZOVIRAX TOPICAL CREAM 5 %
ZYCLARA 3.75% CREAM PUMP
3.75 %
ZYCLARA TOPICAL CREAM IN
METERED-DOSE PUMP 2.5 %
ZYCLARA TOPICAL CREAM IN
PACKET 3.75 %
Dermatological Antibacterials
clindamycin phosphate topical foam 1 %
clindamycin phosphate topical gel 1 %
clindamycin phosphate topical lotion 1 %
clindamycin phosphate topical solution 1
%
clindamycin phosphate topical swab 1 %
clindamycin-benzoyl peroxide topical gel
1-5 %, 1.2 %(1 % base) -5 %
ery pads topical swab 2 %
3
4
4
Requirements/Limits
QL (5 per 30 days)
4
4
(Evoclin)
(Cleocin T)
(Cleocin T)
(Cleocin T)
2
2
2
2
(Cleocin T)
(Duac)
2
2
(Erythromycin
Base/Ethanol)
erythromycin with ethanol topical gel 2 % (Emgel)
erythromycin with ethanol topical
(Erythromycin
solution 2 %
Base/Ethanol)
erythromycin with ethanol topical swab 2 (Erythromycin
%
Base/Ethanol)
erythromycin-benzoyl peroxide topical
(Benzamycin)
gel 3-5 %
gentamicin topical cream 0.1 %
gentamicin topical ointment 0.1 %
metronidazole topical cream 0.75 %
(Metrocream)
metronidazole topical gel 0.75 %, 1 %
(Rosadan)
metronidazole topical lotion 0.75 %
(Metrolotion)
mupirocin calcium topical cream 2 %
(Bactroban)
mupirocin topical ointment 2 %
neomycin-polymyxin b gu irrigation
(Neosporin G.U.
solution 40 mg-200,000 unit/ml
Irrigant)
rosadan topical cream 0.75 %
(Metrocream)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
103
Drug Name
selenium sulfide topical lotion 2.5 %
selenium sulfide topical shampoo 2.25 %
silver nitrate applicators topical stick
75-25 %
silver nitrate topical ointment 10 %
silver nitrate topical solution 0.5 %, 10 %,
25 %, 50 %
silver sulfadiazine topical cream 1 %
ssd topical cream 1 %
sulfacetamide sodium (acne) topical
suspension 10 %
Dermatological
Anti-Inflammatory Agents
ala-cort topical cream 1 %
ala-scalp topical lotion 2 %
alclometasone topical cream 0.05 %
Drug Tier
(Selenium Sulfide)
(Selenium Sulfide)
(Silver Nitrate
Applicator)
(Silver Nitrate)
(Silver Nitrate)
2
2
2
(Silvadene)
(Silvadene)
(Klaron)
2
2
2
(Anusol-HC)
(Scalacort)
(Alclometasone
Dipropionate)
alclometasone topical ointment 0.05 %
(Alclometasone
Dipropionate)
amcinonide topical cream 0.1 %
(Amcinonide)
amcinonide topical lotion 0.1 %
(Amcinonide)
amcinonide topical ointment 0.1 %
(Amcinonide)
betamethasone dipropionate topical
(Betamethasone
cream 0.05 %
Dipropionate)
(Betamethasone
lotion 0.05 %
Dipropionate)
(Betamethasone
ointment 0.05 %
Dipropionate)
betamethasone valerate topical cream 0.1 (Betamethasone
%
Valerate)
betamethasone valerate topical foam 0.12 (Luxiq)
%
betamethasone valerate topical lotion 0.1 (Betamethasone
%
Valerate)
betamethasone valerate topical ointment (Betamethasone
0.1 %
Valerate)
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
104
Drug Name
betamethasone, augmented topical cream
0.05 %
betamethasone, augmented topical gel
0.05 %
betamethasone, augmented topical lotion
0.05 %
betamethasone, augmented topical
ointment 0.05 %
clobetasol 0.05% cream 0.05 %
clobetasol scalp solution 0.05 %
clobetasol topical foam 0.05 %
clobetasol topical gel 0.05 %
clobetasol topical lotion 0.05 %
clobetasol topical ointment 0.05 %
clobetasol topical shampoo 0.05 %
clobetasol topical spray,non-aerosol 0.05
%
clobetasol-emollient topical cream 0.05 %
clocortolone pivalate topical cream 0.1 %
colocort rectal enema 100 mg/60 ml
cormax scalp solution 0.05 %
desonide topical cream 0.05 %
desonide topical lotion 0.05 %
desonide topical ointment 0.05 %
desoximetasone topical cream 0.05 %,
0.25 %
desoximetasone topical gel 0.05 %
desoximetasone topical ointment 0.05 %,
0.25 %
diflorasone topical cream 0.05 %
diflorasone topical ointment 0.05 %
ELIDEL TOPICAL CREAM 1 %
Drug Tier
(Diprolene AF)
2
(Betamethasone
Dipropionate)
(Diprolene)
2
(Diprolene)
2
(Temovate)
(Clobetasol
Propionate)
(Olux)
(Clobetasol
Propionate)
(Clobex)
(Temovate)
(Clobex)
(Clobex)
2
2
(Temovate)
(Cloderm)
(Cortenema)
(Clobetasol
Propionate)
(Desowen)
(Desowen)
(Desonide)
(Topicort)
2
2
2
2
(Topicort)
(Topicort)
2
2
(Psorcon)
(Diflorasone Diacetate)
2
2
4
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
PA
105
Drug Name
fluocinolone topical cream 0.01 %, 0.025
%
fluocinolone topical oil 0.01 %
Drug Tier
(Synalar)
(Fluocinolone
Acetonide)
fluocinolone topical ointment 0.025 %
(Synalar)
fluocinolone topical solution 0.01 %
(Synalar)
fluocinonide 0.05% cream 0.05 %
(Vanos)
fluocinonide topical gel 0.05 %
(Fluocinonide)
fluocinonide topical ointment 0.05 %
(Fluocinonide)
fluocinonide topical solution 0.05 %
(Fluocinonide)
fluocinonide-e topical cream 0.05 %
(Vanos)
fluticasone topical cream 0.05 %
(Cutivate)
fluticasone topical lotion 0.05 %
(Cutivate)
fluticasone topical ointment 0.005 %
(Fluticasone
Propionate)
halobetasol propionate topical cream 0.05 (Ultravate)
%
halobetasol propionate topical ointment
(Ultravate)
0.05 %
hydrocortisone buty 0.1% cream 0.1 %
(Hydrocortisone
Butyrate)
hydrocortisone butyrate topical ointment (Locoid)
0.1 %
hydrocortisone butyrate topical solution (Locoid)
0.1 %
hydrocortisone butyr-emollient topical
(Hydrocortisone
cream 0.1 %
Butyrate)
hydrocortisone rectal enema 100 mg/60
(Cortenema)
ml
hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC)
hydrocortisone topical lotion 2.5 %
(Scalacort)
hydrocortisone topical ointment 1 %, 2.5 (Hydrocortisone)
%
hydrocortisone valerate topical cream 0.2 (Hydrocortisone
%
Valerate)
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
106
Drug Name
hydrocortisone valerate topical ointment
0.2 %
mometasone topical cream 0.1 %
mometasone topical ointment 0.1 %
mometasone topical solution 0.1 %
ONFI ORAL TABLET 10 MG, 20 MG
prednicarbate topical cream 0.1 %
prednicarbate topical ointment 0.1 %
PROCTOFOAM HC RECTAL
FOAM 1-1 %
procto-med hc rectal cream 2.5 %
procto-pak rectal cream 1 %
proctosol hc rectal cream 2.5 %
proctozone-hc rectal cream 2.5 %
tacrolimus topical ointment 0.03 %, 0.1
%
triamcinolone acetonide topical cream
0.025 %, 0.1 %, 0.5 %
triamcinolone acetonide topical lotion
0.025 %, 0.1 %
triamcinolone acetonide topical ointment
0.025 %, 0.1 %, 0.5 %
trianex topical ointment 0.05 %
triderm topical cream 0.1 %
u-cort topical cream 1-10 %
Dermatological Retinoids
adapalene topical cream 0.1 %
adapalene topical gel 0.1 %, 0.3 %
avita topical cream 0.025 %
avita topical gel 0.025 %
FABIOR TOPICAL FOAM 0.1 %
TAZORAC TOPICAL CREAM 0.05
%, 0.1 %
Drug Tier
(Hydrocortisone
Valerate)
(Elocon)
(Elocon)
(Elocon)
(Dermatop)
(Dermatop)
Requirements/Limits
2
2
2
2
4
2
2
4
(Hydrocortisone)
(Anusol-HC)
(Hydrocortisone)
(Hydrocortisone)
(Protopic)
2
2
2
2
2
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Hydrocortisone
Acetate/Urea)
2
(Differin)
(Differin)
(Retin-A)
(Retin-A)
2
2
2
2
4
4
PA NSO
PA
2
2
2
2
2
PA
PA
PA
PA
107
Drug Name
Drug Tier
Requirements/Limits
TAZORAC TOPICAL GEL 0.05 %,
0.1 %
tretinoin gel micro 0.04% tube 0.04 %
tretinoin gel micro 0.1% tube 0.1 %
tretinoin microspheres topical gel with
pump 0.04 %, 0.1 %
tretinoin topical cream 0.025 %, 0.05 %,
0.1 %
tretinoin topical gel 0.01 %, 0.025 %,
0.05 %
Scabicides And Pediculicides
lindane topical lotion 1 %
lindane topical shampoo 1 %
malathion topical lotion 0.5 %
permethrin topical cream 5 %
spinosad topical suspension 0.9 %
4
PA
(Retin-A Micro)
(Retin-A Micro)
(Retin-A Micro)
2
2
2
PA
PA
PA
(Retin-A)
2
PA
(Retin-A)
2
PA
(Lindane)
(Lindane)
(Ovide)
(Elimite)
(Natroba)
2
2
2
2
2
Devices
Devices
ASSURE ID INSULIN SAFETY
SYRINGE 1 ML 29 GAUGE X 1/2"
BD INSULIN SYR 0.3 ML 31GX5/16
0.3 ML 31 GAUGE X 5/16
BD INSULIN SYR 0.5 ML 31GX5/16"
0.5 ML 31 GAUGE X 5/16
BD INSULIN SYR 1 ML 31GX5/16" 1
ML 31 GAUGE X 5/16
BD ULTRA-FINE PEN NDL
8MMX31G SHORT 31 GAUGE X
5/16"
INSULIN SYRINGE-NEEDLE U-100
SYRINGE 0.3 ML 29, 1 ML 29
GAUGE X 1/2", 1/2 ML 28 GAUGE
PEN NEEDLE, DIABETIC NEEDLE
29 GAUGE X 1/2"
VGO 40 DISPOSABLE DEVICE
3
3
3
3
3
3
3
3
108
Drug Name
Drug Tier
Requirements/Limits
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN INTRAMUSCULAR
ALDURAZYME INTRAVENOUS
SOLUTION 2.9 MG/5 ML
CEREZYME INTRAVENOUS
RECON SOLN 400 UNIT
CREON ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000
-60,000 UNIT, 24,000-76,000 -120,000
UNIT, 3,000-9,500- 15,000 UNIT,
36,000-114,000- 180,000 UNIT,
6,000-19,000 -30,000 UNIT
CYSTAGON ORAL CAPSULE 150
MG, 50 MG
ELAPRASE INTRAVENOUS
SOLUTION 6 MG/3 ML
ELELYSO INTRAVENOUS RECON
SOLN 200 UNIT
ELITEK INTRAVENOUS RECON
SOLN 1.5 MG, 7.5 MG
FABRAZYME INTRAVENOUS
RECON SOLN 35 MG
KUVAN ORAL POWDER IN
PACKET 100 MG
KUVAN ORAL POWDER IN
PACKET 500 MG
KUVAN ORAL TABLET,SOLUBLE
100 MG
MYOZYME INTRAVENOUS
RECON SOLN 50 MG
NAGLAZYME INTRAVENOUS
SOLUTION 5 MG/5 ML
ORFADIN ORAL CAPSULE 10 MG,
2 MG, 5 MG
5
NM
5
PA; NM
5
PA; NM
3
4
NM; LA
5
PA; NM
5
PA; NM; LA
5
PA; NM
5
PA; NM
5
PA; NM; LA
5
PA; NM
5
PA; NM; LA
5
PA; NM
5
PA; NM
5
NM
109
Drug Name
Drug Tier
pancrelipase 5000 oral capsule,delayed
(Lipase/Protease/Amyl
release(dr/ec) 5,000-17,000 -27,000 unit ase)
PULMOZYME INHALATION
SOLUTION 1 MG/ML
STRENSIQ SUBCUTANEOUS
VPRIV INTRAVENOUS RECON
SOLN 400 UNIT
ZAVESCA ORAL CAPSULE 100 MG
ZENPEP ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-34,000
-55,000 UNIT, 15,000-51,000 -82,000
UNIT, 20,000-68,000 -109,000 UNIT,
25,000-85,000- 136,000 UNIT,
3,000-10,000- 16,000 UNIT,
40,000-136,000- 218,000 UNIT
Requirements/Limits
2
5
PA; NM
5
PA; NM; LA
5
PA; NM
5
3
PA; NM; LA
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents,
Miscellaneous
AKTEN (PF) OPHTHALMIC GEL
3.5 %
alcaine ophthalmic drops 0.5 %
ALOMIDE OPHTHALMIC DROPS
0.1 %
altacaine ophthalmic drops 0.5 %
apraclonidine ophthalmic drops 0.5 %
atropine ophthalmic drops 1 %
atropine ophthalmic ointment 1 %
atropine-care ophthalmic drops 1 %
azelastine nasal aerosol,spray 137 mcg
(0.1 %)
azelastine nasal spray,non-aerosol 0.15 %
(205.5 mcg)
azelastine ophthalmic drops 0.05 %
carteolol ophthalmic drops 1 %
4
(Proparacaine HCl)
2
4
(Tetravisc)
(Iopidine)
(Isopto Atropine)
(Atropine Sulfate)
(Isopto Atropine)
(Astepro)
2
2
2
2
2
2
(Astepro)
2
(Azelastine HCl)
(Carteolol HCl)
2
1
GC
110
Drug Name
cromolyn ophthalmic drops 4 %
cyclopentolate ophthalmic drops 0.5 %, 1
%, 2 %
epinastine ophthalmic drops 0.05 %
flucaine ophthalmic drops 0.25-0.5 %
homatropaire ophthalmic drops 5 %
homatropine hbr ophthalmic drops 5 %
ipratropium bromide nasal
spray,non-aerosol 0.03 %, 0.06 %
naphazoline ophthalmic drops 0.1 %
olopatadine nasal spray,non-aerosol 0.6
%
olopatadine ophthalmic drops 0.1 %
PATADAY OPHTHALMIC DROPS
0.2 %
phenylephrine hcl ophthalmic drops 10 %,
2.5 %
proparacaine ophthalmic drops 0.5 %
tetracaine hcl (pf) ophthalmic drops 0.5
%
tropicamide ophthalmic drops 0.5 %, 1 %
TYZINE NASAL DROPS 0.1 %
TYZINE NASAL
SPRAY,NON-AEROSOL 0.1 %
Eye, Ear, Nose, Throat
Anti-Infectives Agents
acetasol hc otic drops 1-2 %
acetic acid otic solution 2 %
AZASITE OPHTHALMIC DROPS 1
%
bacitracin ophthalmic ointment 500
unit/gram
bacitracin-polymyxin b ophthalmic
ointment 500-10,000 unit/gram
Drug Tier
(Cromolyn Sodium)
(Cyclogyl)
2
2
(Elestat)
(Proparacaine/Fluoresc
ein Sod)
(Isopto Homatropine)
(Isopto Homatropine)
(Atrovent)
2
2
(Naphazoline HCl)
(Patanase)
2
2
(Patanol)
2
3
(Mydfrin)
2
(Proparacaine HCl)
(Tetracaine HCl/PF)
2
2
(Mydriacyl)
2
3
4
(Vosol HC)
(Acetic Acid)
2
2
4
(Bacitracin)
2
(Bacitracin/Polymyxin
B Sulfate)
2
Requirements/Limits
2
2
2
111
Drug Name
BESIVANCE OPHTHALMIC
DROPS,SUSPENSION 0.6 %
bleph-10 ophthalmic drops 10 %
BLEPHAMIDE OPHTHALMIC
DROPS,SUSPENSION 10-0.2 %
BLEPHAMIDE S.O.P.
OPHTHALMIC OINTMENT 10-0.2 %
CILOXAN OPHTHALMIC
OINTMENT 0.3 %
CIPRODEX OTIC
DROPS,SUSPENSION 0.3-0.1 %
ciprofloxacin hcl ophthalmic drops 0.3 %
ciprofloxacin hcl otic dropperette 0.2 %
erythromycin ophthalmic ointment 5
mg/gram (0.5 %)
gatifloxacin ophthalmic drops 0.5 %
gentak ophthalmic ointment 0.3 % (3
mg/gram)
gentamicin ophthalmic drops 0.3 %
gentamicin ophthalmic ointment 0.3 % (3
mg/gram)
hydrocortisone-acetic acid otic drops 1-2
%
levofloxacin ophthalmic drops 0.5 %
neomycin-bacitracin-poly-hc ophthalmic
ointment 3.5-400-10,000 mg-unit/g-1%
neomycin-bacitracin-polymyxin
ophthalmic ointment 3.5-400-10,000
mg-unit-unit/g
neomycin-polymyxin b-dexameth
ophthalmic drops,suspension
3.5mg/ml-10,000 unit/ml-0.1 %
ophthalmic ointment 3.5 mg/g-10,000
unit/g-0.1 %
Drug Tier
Requirements/Limits
4
(Sulfacetamide
Sodium)
2
4
3
3
3
(Ciloxan)
(Cetraxal)
(Ilotycin)
2
2
2
(Zymaxid)
(Garamycin)
2
2
(Garamycin)
(Garamycin)
2
2
(Vosol HC)
2
(Levofloxacin)
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
Su/Bacitra/Polymyxin)
2
2
(Maxitrol)
2
(Maxitrol)
2
2
112
Drug Name
neomycin-polymyxin-gramicidin
ophthalmic drops 1.75 mg-10,000
unit-0.025mg/ml
neomycin-polymyxin-hc ophthalmic
drops,suspension 3.5-10,000-10
mg-unit-mg/ml
neomycin-polymyxin-hc otic
drops,suspension 3.5-10,000-1
mg/ml-unit/ml-%
neomycin-polymyxin-hc otic solution
3.5-10,000-1 mg/ml-unit/ml-%
neo-polycin hc ophthalmic ointment
3.5-400-10,000 mg-unit/g-1%
ofloxacin ophthalmic drops 0.3 %
ofloxacin otic drops 0.3 %
polymyxin b sulf-trimethoprim
ophthalmic drops 10,000 unit- 1 mg/ml
PRED-G OPHTHALMIC
DROPS,SUSPENSION 0.3-1 %
sulfacetamide sodium ophthalmic drops
10 %
sulfacetamide sodium ophthalmic
ointment 10 %
sulfacetamide-prednisolone ophthalmic
drops 10 %-0.23 % (0.25 %)
TOBRADEX OPHTHALMIC
OINTMENT 0.3-0.1 %
TOBRADEX ST OPHTHALMIC
DROPS,SUSPENSION 0.3-0.05 %
tobramycin ophthalmic drops 0.3 %
tobramycin-dexamethasone ophthalmic
drops,suspension 0.3-0.1 %
trifluridine ophthalmic drops 1 %
VIGAMOX OPHTHALMIC DROPS
0.5 %
ZIRGAN OPHTHALMIC GEL 0.15 %
Drug Tier
(Neosporin)
2
(Neomycin/Polymyxin
B Sulf/HC)
2
(Neomycin/Polymyxin
B Sulf/HC)
2
(Neomycin/Polymyxin
B Sulf/HC)
(Neomycin Su/Baci
Zn/Poly/HC)
(Ocuflox)
(Ocuflox)
(Polytrim)
2
Requirements/Limits
2
2
2
2
4
(Sulfacetamide
Sodium)
(Sulfacetamide
Sodium)
(Sulfacetamide/Prednis
olone Sp)
2
2
2
3
4
(Tobrex)
(Tobradex)
2
2
(Viroptic)
2
4
4
113
Drug Name
Eye, Ear, Nose, Throat
Anti-Inflammatory Agents
ALOCRIL OPHTHALMIC DROPS 2
%
ALREX OPHTHALMIC
bromfenac ophthalmic drops 0.09 %
budesonide nasal spray,non-aerosol 32
mcg/actuation
dexamethasone sodium phosphate
ophthalmic drops 0.1 %
diclofenac sodium ophthalmic drops 0.1
%
DUREZOL OPHTHALMIC DROPS
0.05 %
FLAREX OPHTHALMIC
flunisolide nasal spray,non-aerosol 25
mcg (0.025 %)
fluocinolone acetonide oil otic drops 0.01
%
fluorometholone ophthalmic
drops,suspension 0.1 %
flurbiprofen sodium ophthalmic drops
0.03 %
fluticasone nasal spray,suspension 50
mcg/actuation
FML FORTE OPHTHALMIC
FML S.O.P. OPHTHALMIC
OINTMENT 0.1 %
ketorolac ophthalmic drops 0.4 %, 0.5 %
LOTEMAX OPHTHALMIC
MAXIDEX OPHTHALMIC
Drug Tier
Requirements/Limits
4
4
(Bromfenac Sodium)
(Rhinocort Aqua)
2
2
(Dexasol)
1
(Diclofenac Sodium)
2
GC
4
4
(Flunisolide)
2
(Dermotic)
2
(FML)
2
(Ocufen)
1
(Fluticasone
Propionate)
2
GC
4
4
(Acular)
2
4
4
114
Drug Name
mometasone nasal spray,non-aerosol 50
mcg/actuation
NASONEX NASAL
MCG/ACTUATION
prednisolone acetate ophthalmic
drops,suspension 1 %
prednisolone sodium phosphate
ophthalmic drops 1 %
RESTASIS OPHTHALMIC
DROPPERETTE 0.05 %
triamcinolone acetonide nasal
aerosol,spray 55 mcg
Drug Tier
(Nasonex)
Requirements/Limits
2
3
(Omnipred)
2
(Prednisolone Sod
Phosphate)
2
4
(Triamcinolone
Acetonide)
2
(Prevpac)
2
Gastrointestinal Agents
Antiulcer Agents And Acid
Suppressants
amoxicil-clarithromy-lansopraz oral
combo pack 500-500-30 mg
CARAFATE ORAL SUSPENSION
100 MG/ML
cimetidine hcl oral solution 300 mg/5 ml
cimetidine oral tablet 200 mg, 300 mg,
400 mg, 800 mg
esomeprazole magnesium oral
capsule,delayed release(dr/ec) 20 mg, 40
mg
esomeprazole sodium intravenous recon
soln 20 mg, 40 mg
famotidine (pf) intravenous solution 20
mg/2 ml
famotidine (pf)-nacl (iso-os)
famotidine 40 mg/4 ml vial 25's,outer 10
mg/ml
famotidine oral suspension 40 mg/5 ml (8
mg/ml)
4
(Cimetidine HCl)
(Cimetidine)
2
2
(Nexium)
2
ST
(Nexium I.V.)
2
PA; NM
(Famotidine)
2
NM
(Famotidine In
Nacl,Iso-Osm/PF)
(Famotidine)
2
NM
2
NM
(Pepcid)
2
115
Drug Name
famotidine oral tablet 20 mg, 40 mg
lansoprazole oral capsule,delayed
release(dr/ec) 15 mg, 30 mg
misoprostol oral tablet 100 mcg, 200 mcg
NEXIUM PACKET ORAL
GRANULES DR FOR SUSP IN
PACKET 20 MG, 40 MG
nizatidine oral capsule 150 mg, 300 mg
nizatidine oral solution 150 mg/10 ml
omeprazole oral capsule,delayed
release(dr/ec) 10 mg, 20 mg, 40 mg
omeprazole-sodium bicarbonate oral
capsule 20-1.1 mg-gram, 40-1.1 mg-gram
pantoprazole intravenous recon soln 40
mg
pantoprazole oral tablet,delayed release
(dr/ec) 20 mg, 40 mg
PROTONIX INTRAVENOUS
RECON SOLN 40 MG
rabeprazole oral tablet,delayed release
(dr/ec) 20 mg
ranitidine hcl oral syrup 15 mg/ml
ranitidine hcl oral tablet 150 mg, 300 mg
sucralfate oral tablet 1 gram
Gastrointestinal Agents, Other
AMITIZA ORAL CAPSULE 24 MCG,
8 MCG
BUPHENYL ORAL TABLET 500 MG
CARBAGLU ORAL TABLET,
DISPERSIBLE 200 MG
CHOLBAM ORAL CAPSULE 250
MG, 50 MG
constulose oral solution 10 gram/15 ml
cromolyn oral concentrate 100 mg/5 ml
dicyclomine oral capsule 10 mg
dicyclomine oral solution 10 mg/5 ml
Drug Tier
Requirements/Limits
(Pepcid)
(Prevacid)
1
2
GC
(Cytotec)
2
4
ST
(Nizatidine)
(Nizatidine)
(Prilosec)
2
2
1
GC
(Zegerid)
2
(Protonix IV)
2
NM
(Protonix)
1
GC
4
(Aciphex)
2
(Ranitidine HCl)
(Zantac)
(Carafate)
2
1
2
GC
4
QL (60 per 30 days)
5
5
NM
PA; NM
5
PA; NM
(Lactulose)
(Gastrocrom)
(Bentyl)
(Dicyclomine HCl)
2
2
2
2
116
Drug Name
dicyclomine oral tablet 20 mg
diphenoxylate-atropine oral liquid
2.5-0.025 mg/5 ml
diphenoxylate-atropine oral tablet
2.5-0.025 mg
enulose oral solution 10 gram/15 ml
GATTEX 5 MG 30-VIAL KIT 5 MG
GATTEX ONE-VIAL
SUBCUTANEOUS KIT 5 MG
generlac oral solution 10 gram/15 ml
glycopyrrolate injection solution 0.2
mg/ml
glycopyrrolate oral tablet 1 mg, 2 mg
KAYEXALATE ORAL POWDER
kionex 15 gm/60 ml suspension 15
gram/60 ml
kionex oral powder
KRISTALOSE ORAL PACKET 10
GRAM, 20 GRAM
lactulose oral solution 10 gram/15 ml
LINZESS ORAL CAPSULE 145
MCG, 290 MCG
Drug Tier
(Bentyl)
(Diphenoxylate
HCl/Atropine)
(Lomotil)
2
2
(Lactulose)
2
5
2
5
(Lactulose)
(Robinul)
2
2
(Robinul)
2
3
2
(Sodium Polystyrene
Sulfonate)
(Sodium Polystyrene
Sulfonate)
Requirements/Limits
PA; NM; LA; QL (30
per 30 days)
PA; NM; LA; QL (30
per 30 days)
NM
2
3
(Lactulose)
loperamide oral capsule 2 mg
(Loperamide HCl)
LOTRONEX ORAL TABLET 0.5
MG, 1 MG
methscopolamine oral tablet 2.5 mg, 5 mg (Methscopolamine
Bromide)
metoclopramide hcl injection solution 5
(Metoclopramide HCl)
mg/ml
metoclopramide hcl oral tablet 10 mg, 5 (Reglan)
mg
MOVANTIK ORAL TABLET 12.5
MG, 25 MG
2
3
2
3
PA; QL (30 per 30
days); AGE (Min 17
Years)
QL (60 per 30 days)
2
2
NM
1
GC
3
QL (30 per 30 days)
117
Drug Name
Drug Tier
Requirements/Limits
RAVICTI ORAL LIQUID 1.1
GRAM/ML
RELISTOR SUBCUTANEOUS
SYRINGE 12 MG/0.6 ML
SYRINGE 8 MG/0.4 ML
sodium phenylbutyrate oral powder 0.94
gram/gram
sodium polystyrene (sorb free) oral
suspension 15 gram/60 ml
sodium polystyrene sulfonate rectal
enema 30 gram/120 ml
sps 15 gm/60 ml suspension 15 gram/60
ml
ursodiol oral capsule 300 mg
ursodiol oral tablet 250 mg, 500 mg
VELPHORO ORAL
VELTASSA ORAL POWDER IN
PACKET 16.8 GRAM, 25.2 GRAM,
8.4 GRAM
Laxatives
gavilyte-c oral recon soln 240-22.72-6.72
-5.84 gram
gavilyte-g oral recon soln 236-22.74-6.74
-5.86 gram
gavilyte-h and bisacodyl oral kit 5-210
mg-gram
gavilyte-n oral recon soln 420 gram
5
PA; NM; QL (525 per
30 days)
days)
PA; (1 per day); QL (18
per 30 days)
PA; NM; (1 per day);
QL (12 per 30 days)
NM
4
4
4
(Buphenyl)
5
(Sodium Polystyrene
Sulfonate)
(Sodium Polystyrene
Sulfonate)
(Sodium Polystyrene
Sulfonate)
(Actigall)
(Urso)
2
2
2
2
2
5
4
(Golytely)
2
(Golytely)
2
(Peg-Prep)
2
(Nulytely with Flavor
Packs)
2
GOLYTELY ORAL POWDER IN
PACKET 227.1-21.5-6.36 GRAM
MOVIPREP ORAL POWDER IN
PACKET 100-7.5-2.691 GRAM
NM
PA; QL (30 per 30
days)
4
4
118
Drug Name
Drug Tier
OSMOPREP ORAL TABLET 1.5
GRAM
peg 3350-electrolytes oral recon soln
236-22.74-6.74 -5.86 gram,
240-22.72-6.72 -5.84 gram
peg-electrolyte soln oral recon soln 420
gram
PEG-PREP ORAL KIT 5-210
MG-GRAM
polyethylene glycol 3350 oral powder 17
gram/dose
polyethylene glycol 3350 oral powder in
packet 17 gram
PREPOPIK ORAL POWDER IN
PACKET 10 MG-3.5 GRAM-12
GRAM
SUCLEAR ORAL SOLN AND SOLN
RECON,SEQUENTIAL 210-17.5-3.13
GRAM
SUPREP BOWEL PREP KIT ORAL
RECON SOLN 17.5-3.13-1.6 GRAM
trilyte with flavor packets oral recon soln
420 gram
Phosphate Binders
calcium acetate oral capsule 667 mg
calcium acetate oral tablet 667 mg
eliphos oral tablet 667 mg
FOSRENOL ORAL POWDER IN
PACKET 1,000 MG, 750 MG
FOSRENOL ORAL
TABLET,CHEWABLE 1,000 MG, 500
MG, 750 MG
magnebind 400 oral tablet 400-200-1 mg
4
(Golytely)
2
Packs)
2
Requirements/Limits
4
(Polyethylene Glycol
3350)
(Polyethylene Glycol
3350)
2
2
4
4
4
Packs)
2
(Phoslo)
(Calcium Acetate)
(Calcium Acetate)
2
2
2
3
4
(Calcium
Carbonate/Mag
Carb/Fa)
RENAGEL ORAL TABLET 400 MG,
800 MG
2
3
119
Drug Name
Drug Tier
RENVELA ORAL POWDER IN
PACKET 0.8 GRAM, 2.4 GRAM
RENVELA ORAL TABLET 800 MG
4
Requirements/Limits
4
Genitourinary Agents
Antispasmodics, Urinary
flavoxate oral tablet 100 mg
MYRBETRIQ ORAL TABLET
MG, 50 MG
oxybutynin chloride oral syrup 5 mg/5 ml
oxybutynin chloride oral tablet 5 mg
oxybutynin chloride oral tablet extended
release 24hr 10 mg, 15 mg, 5 mg
tolterodine oral capsule,extended release
24hr 2 mg, 4 mg
tolterodine oral tablet 1 mg, 2 mg
trospium oral capsule,extended release
24hr 60 mg
trospium oral tablet 20 mg
VESICARE ORAL TABLET 10 MG, 5
MG
Genitourinary Agents,
Miscellaneous
alfuzosin oral tablet extended release 24
hr 10 mg
tamsulosin oral capsule,extended release
24hr 0.4 mg
terazosin oral capsule 1 mg, 10 mg, 2 mg,
5 mg
(Flavoxate HCl)
2
3
(Oxybutynin Chloride)
(Oxybutynin Chloride)
(Ditropan XL)
2
2
2
(oral products only)
(Detrol LA)
2
QL (30 per 30 days)
(Detrol)
(Trospium Chloride)
2
2
(Trospium Chloride)
2
3
(Uroxatral)
1
GC
(Flomax)
1
GC
(Terazosin HCl)
1
GC
2
PA BvD; NM; (PA for
ESRD only)
PA BvD
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine injection recon soln 2 gram (Desferal)
deferoxamine injection recon soln 500 mg (Desferal)
DEPEN TITRATABS ORAL
TABLET 250 MG
2
4
120
Drug Name
Drug Tier
EXJADE ORAL TABLET,
DISPERSIBLE 125 MG, 250 MG, 500
MG
FERRIPROX ORAL TABLET 500
MG
sodium thiosulfate intravenous solution 1
gram/10 ml (100 mg/ml), 12.5 gram/50
ml (250 mg/ml)
SYPRINE ORAL CAPSULE 250 MG
5
PA; NM; LA
5
PA; NM; LA
2
NM
5
PA; NM
(Sodium Thiosulfate)
Requirements/Limits
Hormonal Agents,
Stimulant/Replacement/Modifying
Androgens
ANADROL-50 ORAL TABLET 50
MG
ANDRODERM TRANSDERMAL
PATCH 24 HOUR 2 MG/24 HOUR, 4
MG/24 HR
ANDROGEL TRANSDERMAL GEL
IN METERED-DOSE PUMP 1.25
GRAM/ ACTUATION (1 %), 20.25
MG/1.25 GRAM (1.62 %)
ANDROGEL TRANSDERMAL GEL
IN PACKET 1 % (25 MG/2.5GRAM),
1 % (50 MG/5 GRAM), 1.62 % (20.25
MG/1.25 GRAM), 1.62 % (40.5 MG/2.5
GRAM)
androxy oral tablet 10 mg
danazol oral capsule 100 mg, 200 mg, 50
mg
METHITEST ORAL TABLET 10 MG
oxandrolone oral tablet 10 mg, 2.5 mg
testosterone 50 mg/5 gram gel outer 50
mg/5 gram (1 %)
testosterone cypionate intramuscular oil
100 mg/ml, 200 mg/ml
testosterone enanthate intramuscular oil
200 mg/ml
3
3
3
3
(Fluoxymesterone)
(Danazol)
2
2
(Oxandrin)
(Testim)
4
2
2
(Depo-Testosterone)
2
NM
(Testosterone
Enanthate)
2
NM
121
Drug Name
testosterone transdermal gel in
metered-dose pump 1.25 gram/ actuation
(1 %), 10 mg/0.5 gram /actuation
testosterone transdermal gel in packet 1
% (25 mg/2.5gram)
testosterone transdermal gel in packet 1
% (50 mg/5 gram)
Estrogens And Antiestrogens
DUAVEE ORAL TABLET 0.45-20
MG
ESTRACE VAGINAL CREAM 0.01
% (0.1 MG/GRAM)
estradiol oral tablet 0.5 mg, 1 mg, 2 mg
estradiol transdermal patch semiweekly
0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05
mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr
estradiol transdermal patch weekly 0.025
mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24
hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1
mg/24 hr
estradiol valerate intramuscular oil 20
mg/ml, 40 mg/ml
estradiol-norethindrone acet oral tablet
0.5-0.1 mg, 1-0.5 mg
ESTRING VAGINAL RING 2 MG
estropipate oral tablet 0.75 mg, 1.5 mg, 3
mg
FEMRING VAGINAL RING 0.05
MG/24 HR, 0.1 MG/24 HR
fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5
mg-mcg
jinteli oral tablet 1-5 mg-mcg
lopreeza oral tablet 0.5-0.1 mg, 1-0.5 mg
MENEST ORAL TABLET 0.3 MG,
0.625 MG, 1.25 MG, 2.5 MG
mimvey lo oral tablet 0.5-0.1 mg
mimvey oral tablet 1-0.5 mg
Drug Tier
(Vogelxo)
2
(Androgel)
2
(Testim)
2
4
Requirements/Limits
PA
4
(Estrace)
(Vivelle-Dot)
2
2
(Climara)
2
(Delestrogen)
2
(Activella)
2
(Estropipate)
4
2
4
(Femhrt)
2
(Femhrt)
(Activella)
2
2
4
(Activella)
(Activella)
2
2
NM
QL (1 per 90 days)
122
Drug Name
norethindrone ac-eth estradiol oral tablet (Femhrt)
0.5-2.5 mg-mcg, 1-5 mg-mcg
PREMARIN INJECTION RECON
SOLN 25 MG
PREMARIN ORAL TABLET 0.3 MG,
0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG
PREMARIN VAGINAL CREAM
0.625 MG/GRAM
PREMPHASE ORAL TABLET 0.625
MG (14)/ 0.625MG-5MG(14)
PREMPRO ORAL TABLET 0.3-1.5
MG, 0.45-1.5 MG, 0.625-2.5 MG,
0.625-5 MG
raloxifene oral tablet 60 mg
(Evista)
VAGIFEM VAGINAL TABLET 10
MCG
Glucocorticoids/Mineralocorticoid
s
a-hydrocort injection recon soln 100 mg
(Hydrocortisone Sod
Succinate)
betamethasone acet,sod phos injection
(Celestone)
suspension 6 mg/ml
cortisone oral tablet 25 mg
(Cortisone Acetate)
deltasone oral tablet 20 mg
(Prednisone)
DEXAMETHASONE INTENSOL
ORAL DROPS 1 MG/ML
dexamethasone oral elixir 0.5 mg/5 ml
(Dexamethasone)
dexamethasone oral tablet 0.5 mg, 0.75
(Dexamethasone)
mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg
(Dexamethasone Sod
injection solution 10 mg/ml
Phosphate)
(Dexamethasone Sod
injection solution 4 mg/ml
Phosphate)
fludrocortisone oral tablet 0.1 mg
(Fludrocortisone
Acetate)
hydrocortisone oral tablet 10 mg, 20 mg, (Cortef)
5 mg
Drug Tier
Requirements/Limits
2
3
NM
3
3
3
3
2
4
2
PA BvD; NM
2
PA BvD; NM
2
2
4
PA BvD
2
2
PA BvD
PA BvD
2
PA BvD
2
PA BvD; NM
2
2
PA BvD
123
Drug Name
Drug Tier
KENALOG INJECTION
SUSPENSION 10 MG/ML, 40
MG/ML
methylprednisolone acetate injection
suspension 40 mg/ml, 80 mg/ml
methylprednisolone oral tablet 16 mg, 32
mg, 4 mg, 8 mg
methylprednisolone oral tablets,dose pack
4 mg
methylprednisolone sodium succ injection
recon soln 125 mg, 40 mg
methylprednisolone ss 1 gm vl
mdv,latex-free 1,000 mg
prednisolone sodium phosphate oral
solution 15 mg/5 ml (3 mg/ml), 25 mg/5
ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5
ml)
prednisolone sodium phosphate oral
tablet,disintegrating 10 mg, 15 mg, 30 mg
prednisone oral solution 5 mg/5 ml
prednisone oral tablet 1 mg, 2.5 mg, 20
mg, 5 mg, 50 mg
prednisone oral tablet 10 mg
prednisone oral tablets,dose pack 10 mg,
5 mg
SOLU-MEDROL (PF) INJECTION
RECON SOLN 40 MG/ML
triamcinolone acetonide injection
suspension 10 mg/ml, 40 mg/ml
VERIPRED 20 ORAL SOLUTION 20
MG/5 ML (4 MG/ML)
Pituitary
CHORIONIC GONADOTROPIN,
HUMAN INTRAMUSCULAR
RECON SOLN 10,000 UNIT
desmopressin injection solution 4 mcg/ml
4
NM
(Depo-Medrol)
2
PA BvD; NM
(Medrol)
2
PA BvD
(Medrol)
2
PA BvD
(Solu-Medrol)
2
PA BvD; NM
(Solu-Medrol)
2
PA BvD; NM
(Pediapred)
2
PA BvD
(Orapred Odt)
2
PA BvD
(Prednisone)
(Prednisone)
2
2
PA BvD
PA BvD
(Prednisone)
(Prednisone)
2
2
PA BvD
4
PA BvD; NM
2
NM
2
PA BvD
2
NM
2
NM
(Triamcinolone
Acetonide)
(Desmopressin
Acetate)
Requirements/Limits
124
Drug Name
desmopressin nasal solution 0.1 mg/ml
(refrigerate)
desmopressin nasal spray,non-aerosol 10
mcg/spray (0.1 ml)
desmopressin oral tablet 0.1 mg, 0.2 mg
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE 0.2
MG/0.25 ML, 0.4 MG/0.25 ML, 0.6
MG/0.25 ML, 0.8 MG/0.25 ML, 1
MG/0.25 ML, 1.2 MG/0.25 ML, 1.4
MG/0.25 ML, 1.6 MG/0.25 ML, 1.8
MG/0.25 ML, 2 MG/0.25 ML
GENOTROPIN SUBCUTANEOUS
CARTRIDGE 12 MG/ML (36
UNIT/ML), 5 MG/ML (15 UNIT/ML)
HUMATROPE INJECTION
CARTRIDGE 12 MG (36 UNIT), 24
MG (72 UNIT), 6 MG (18 UNIT)
HUMATROPE INJECTION RECON
SOLN 5 (15 UNIT) MG
INCRELEX SUBCUTANEOUS
SOLUTION 10 MG/ML
LUPRON DEPOT-PED (3 MONTH)
30 MG
LUPRON DEPOT-PED
INTRAMUSCULAR KIT 11.25 MG,
15 MG, 7.5 MG (PED)
NORDITROPIN FLEXPRO
10 MG/1.5 ML (6.7 MG/ML), 15
MG/1.5 ML (10 MG/ML), 5 MG/1.5
ML (3.3 MG/ML)
NORDITROPIN FLEXPRO
30 MG/3 ML (10 MG/ML)
Drug Tier
(DDAVP)
2
(Desmopressin
Acetate)
(DDAVP)
2
Requirements/Limits
2
4
PA; NM
5
PA; NM
5
PA; NM
5
PA; NM
5
NM
5
NM
5
NM
4
PA; NM
4
PA
125
Drug Name
Drug Tier
Requirements/Limits
NUTROPIN AQ NUSPIN
10 MG/2 ML (5 MG/ML), 20 MG/2
ML (10 MG/ML), 5 MG/2 ML (2.5
MG/ML)
NUTROPIN AQ SUBCUTANEOUS
CARTRIDGE 10 MG/2 ML (5
MG/ML), 20 MG/2 ML (10 MG/ML)
octreotide acet 50 mcg/ml syr
outer,single-dose,10 50 mcg/ml (1 ml)
octreotide acetate injection solution 1,000
mcg/ml, 500 mcg/ml
octreotide acetate injection solution 100
mcg/ml, 200 mcg/ml
octreotide acetate injection solution 50
mcg/ml
OMNITROPE SUBCUTANEOUS
CARTRIDGE 10 MG/1.5 ML (6.7
MG/ML), 5 MG/1.5 ML (3.3 MG/ML)
OMNITROPE SUBCUTANEOUS
RECON SOLN 5.8 MG
SAIZEN CLICK.EASY
SUBCUTANEOUS CARTRIDGE 8.8
MG/1.5 ML (FNL)
SAIZEN SUBCUTANEOUS RECON
SOLN 5 MG, 8.8 MG
SEROSTIM SUBCUTANEOUS
RECON SOLN 4 MG, 5 MG, 6 MG
SOMATULINE DEPOT
MG/0.5 ML, 60 MG/0.2 ML, 90
MG/0.3 ML
SOMAVERT SUBCUTANEOUS
RECON SOLN 10 MG, 15 MG, 20
MG, 25 MG, 30 MG
SUPPRELIN LA IMPLANT KIT 50
MG (65 MCG/DAY)
5
PA; NM
5
PA; NM
(Octreotide Acetate)
2
NM
(Sandostatin)
5
NM
(Sandostatin)
2
NM
(Octreotide Acetate)
2
NM
5
PA; NM
5
PA; NM
5
PA; NM
5
PA; NM
5
PA; NM
5
NM
5
NM; LA
4
PA; NM
126
Drug Name
Drug Tier
VANTAS IMPLANT KIT 50 MG (50
MCG/DAY)
vasopressin injection solution 20 unit/ml
VASOSTRICT INTRAVENOUS
SOLUTION 20 UNIT/ML
ZOMACTON SUBCUTANEOUS
ZORBTIVE SUBCUTANEOUS
RECON SOLN 8.8 MG
Progestins
CRINONE VAGINAL GEL 4 %
DEPO-PROVERA
INTRAMUSCULAR SOLUTION 400
MG/ML
hydroxyprogesterone caproate
intramuscular oil 250 mg/ml
medroxyprogesterone intramuscular
suspension 150 mg/ml
medroxyprogesterone intramuscular
syringe 150 mg/ml
medroxyprogesterone oral tablet 10 mg,
2.5 mg, 5 mg
MEGACE ES ORAL SUSPENSION
625 MG/5 ML
megestrol oral suspension 400 mg/10 ml
(40 mg/ml), 625 mg/5 ml
norethindrone acetate oral tablet 5 mg
progesterone in oil intramuscular oil 50
mg/ml
progesterone micronized oral capsule 100
mg, 200 mg
Thyroid And Antithyroid Agents
levothyroxine 200 mcg vial latex-free, p/f,
sdv 200 mcg
levothyroxine 500 mcg vial latex-free, p/f,
sdv 500 mcg
4
NM
2
2
NM
NM
5
PA; NM
5
PA; NM
4
4
NM
(Hydroxyprogesterone
Caproate)
(Depo-Provera)
5
NM
2
NM
(Medroxyprogesterone
Acetate)
(Provera)
2
NM
(Pitressin)
Requirements/Limits
2
4
(Megace Es)
2
(Aygestin)
(Progesterone)
2
2
(Prometrium)
2
(Levothyroxine
Sodium)
(Levothyroxine
Sodium)
2
NM
2
127
Drug Name
levothyroxine intravenous recon soln 100
mcg, 200 mcg, 500 mcg
levothyroxine 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
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
liothyronine intravenous solution 10
mcg/ml
liothyronine oral tablet 25 mcg, 5 mcg, 50
mcg
methimazole oral tablet 10 mg, 5 mg
propylthiouracil oral tablet 50 mg
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
UNITHROID 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
Drug Tier
(Levothyroxine
Sodium)
(Synthroid)
2
Requirements/Limits
NM
2
4
(Triostat)
2
(Cytomel)
2
(Tapazole)
(Propylthiouracil)
2
2
4
NM
4
Immunological Agents
Immunological Agents
ANTIVENIN LATRODECTUS
MACTANS INJECTION RECON
SOLN 6,000 UNIT
ANTIVENIN MICRURUS FULVIUS
INJECTION COMBO PACK
ARCALYST SUBCUTANEOUS
RECON SOLN 220 MG
4
NM
4
NM
5
NM; LA
128
Drug Name
Drug Tier
Requirements/Limits
ASTAGRAF XL ORAL
24HR 0.5 MG, 1 MG, 5 MG
ATGAM INTRAVENOUS
SOLUTION 50 MG/ML
AUBAGIO ORAL TABLET 14 MG
4
PA BvD
3
NM
5
AZASAN ORAL TABLET 100 MG,
75 MG
azathioprine oral tablet 50 mg
azathioprine sodium injection recon soln
100 mg
BIVIGAM INTRAVENOUS
SOLUTION 10 %
CARIMUNE NF NANOFILTERED
GRAM
CELLCEPT INTRAVENOUS
MG
CELLCEPT ORAL SUSPENSION
FOR RECONSTITUTION 200
MG/ML
CIMZIA POWDER FOR RECONST
SUBCUTANEOUS KIT 400 MG (200
MG X 2 VIALS)
CIMZIA SUBCUTANEOUS
SYRINGE KIT 400 MG/2 ML (200
MG/ML X 2)
cyclosporine intravenous solution 250
mg/5 ml
cyclosporine modified oral capsule 100
mg, 25 mg, 50 mg
cyclosporine modified oral solution 100
mg/ml
cyclosporine oral capsule 100 mg, 25 mg
4
days)
PA BvD
2
2
PA BvD
PA BvD; NM
5
PA; NM
5
PA; NM
4
PA BvD; NM
4
PA BvD
5
(Imuran)
(Azathioprine Sodium)
(Sandimmune)
2
PA; NM; (3
vials/syringes); QL (6
per 28 days)
PA; NM; (3
vials/syringes); QL (6
per 28 days)
PA BvD; NM
(Neoral)
2
PA BvD
(Neoral)
2
PA BvD
(Sandimmune)
2
PA BvD
5
129
Drug Name
ENBREL SUBCUTANEOUS RECON
SOLN 25 MG (1 ML)
ENBREL SUBCUTANEOUS
SYRINGE 25 MG/0.5ML (0.51)
ENBREL SUBCUTANEOUS
SYRINGE 50 MG/ML (0.98 ML)
ENBREL SURECLICK
50 MG/ML (0.98 ML)
ENVARSUS XR ORAL TABLET
EXTENDED RELEASE 24 HR 0.75
MG, 1 MG, 4 MG
FLEBOGAMMA DIF
INTRAVENOUS SOLUTION 10 %, 5
%
GAMASTAN S/D
INTRAMUSCULAR SOLUTION
15-18 % RANGE
GAMMAGARD LIQUID
INJECTION SOLUTION 10 %
GAMUNEX-C 20 GRAM/200 ML
VIAL P/F,LTX-FR,SUV,OUTER 20
GRAM/200 ML (10 %)
GAMUNEX-C INJECTION
SOLUTION 1 GRAM/10 ML (10 %)
gengraf oral capsule 100 mg, 25 mg, 50
(Neoral)
mg
gengraf oral solution 100 mg/ml
(Neoral)
HIZENTRA SUBCUTANEOUS
SOLUTION 4 GRAM/20 ML (20 %)
HUMIRA PEN CROHN'S-UC-HS
START SUBCUTANEOUS PEN
INJECTOR KIT 40 MG/0.8 ML
HUMIRA PEN SUBCUTANEOUS
PEN INJECTOR KIT 40 MG/0.8 ML
Drug Tier
5
5
5
5
Requirements/Limits
PA; NM; (8 vials); QL
(8 per 14 days)
PA; NM; (8 syringes);
QL (4 per 14 days)
QL (4 per 14 days)
QL (4 per 14 days)
4
PA BvD
5
PA; NM
3
PA; NM
5
PA; NM
5
PA; NM
5
PA; NM
2
PA BvD
2
5
PA BvD
PA; NM
5
PA; NM; (Starter Kit);
QL (6 per 28 days)
5
days)
130
Drug Name
Drug Tier
Requirements/Limits
HUMIRA SUBCUTANEOUS
SYRINGE KIT 10 MG/0.2 ML, 20
MG/0.4 ML
HUMIRA SUBCUTANEOUS
SYRINGE KIT 40 MG/0.8 ML
HYQVIA IG COMPONENT
SUBCUTANEOUS SOLUTION 2.5
GRAM/25 ML (10 %)
HYQVIA SUBCUTANEOUS
SOLUTION 10 GRAM /100 ML (10
%), 2.5 GRAM /25 ML (10 %), 20
GRAM /200 ML (10 %), 30 GRAM
/300 ML (10 %), 5 GRAM /50 ML (10
%)
ILARIS (PF) SUBCUTANEOUS
RECON SOLN 180 MG/1.2 ML (150
MG/ML)
KINERET SUBCUTANEOUS
leflunomide oral tablet 10 mg, 20 mg
mycophenolate mofetil oral capsule 250
mg
mycophenolate mofetil oral suspension
for reconstitution 200 mg/ml
mycophenolate mofetil oral tablet 500 mg
mycophenolate sodium oral
tablet,delayed release (dr/ec) 180 mg,
360 mg
NULOJIX INTRAVENOUS RECON
SOLN 250 MG
ORENCIA SUBCUTANEOUS
SYRINGE 125 MG/ML
PRIVIGEN INTRAVENOUS
SOLUTION 10 %
PROGRAF INTRAVENOUS
SOLUTION 5 MG/ML
5
days)
5
5
days)
PA; NM
5
PA; NM
5
PA; NM; LA
5
PA; NM
(Arava)
(Cellcept)
2
2
PA BvD
(Cellcept)
2
PA BvD
(Cellcept)
(Myfortic)
2
2
PA BvD
PA BvD
5
PA NSO; NM
5
5
days)
PA; NM
4
PA BvD; NM
131
Drug Name
RAPAMUNE ORAL SOLUTION 1
MG/ML
RIDAURA ORAL CAPSULE 3 MG
sirolimus oral tablet 0.5 mg, 1 mg, 2 mg (Rapamune)
tacrolimus oral capsule 0.5 mg, 1 mg, 5
(Hecoria)
mg
THYMOGLOBULIN
MG
TYSABRI INTRAVENOUS
VARIZIG 125 UNIT VIAL SDV,
OUTER 125 UNIT
VARIZIG INTRAMUSCULAR
SOLUTION 125 UNIT/1.2 ML
ZORTRESS ORAL TABLET 0.25 MG
ZORTRESS ORAL TABLET 0.5 MG,
0.75 MG
Vaccines
ACTHIB (PF) INTRAMUSCULAR
RECON SOLN 10 MCG/0.5 ML
ADACEL(TDAP
ADOLESN/ADULT)(PF)
INTRAMUSCULAR SUSPENSION 2
LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
ADACEL(TDAP
ADOLESN/ADULT)(PF)
LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
BCG (TICE STRAIN) VIAL
LATEX-FREE, OUTER 50 MG
BCG VACCINE (TICE STRAIN)
VIAL P/F,LATEX-FREE,OUTER 50
MG
BCG VACCINE, LIVE (PF)
PERCUTANEOUS SUSPENSION
FOR RECONSTITUTION 50 MG
Drug Tier
Requirements/Limits
4
PA BvD
3
2
2
PA BvD
PA BvD
5
NM
5
PA; NM; LA
4
NM
4
NM
4
5
PA NSO
PA NSO; NM
3
NM
3
NM
3
NM
4
PA BvD; NM
4
PA BvD
4
PA BvD; NM
132
Drug Name
Drug Tier
Requirements/Limits
BEXSERO (PF) INTRAMUSCULAR
SYRINGE 50-50-50-25 MCG/0.5 ML
BOOSTRIX TDAP
2.5-8-5 LF-MCG-LF/0.5ML
BOOSTRIX TDAP
INTRAMUSCULAR SYRINGE
2.5-8-5 LF-MCG-LF/0.5ML
CERVARIX VACCINE (PF)
INTRAMUSCULAR SYRINGE 20-20
MCG/0.5 ML
COMVAX (PF) INTRAMUSCULAR
SUSPENSION 5-7.5-125 MCG/0.5 ML
DAPTACEL (DTAP PEDIATRIC)
(PF) INTRAMUSCULAR
SUSPENSION 15-10-5
LF-MCG-LF/0.5ML
ENGERIX-B (PF)
MCG/ML
ENGERIX-B 10 MCG/0.5 ML PED
VL L/F, P/F, OUTER, SDV 10
MCG/0.5 ML
ENGERIX-B 20 MCG/ML VIAL
10'S,ADULT,P/F,OUTER 20
MCG/ML
ENGERIX-B PEDIATRIC (PF)
10 MCG/0.5 ML
MCG/0.5 ML
GARDASIL (PF)
20-40-40-20 MCG/0.5 ML
4
NM
3
NM
3
NM
3
NM
3
NM
3
NM
3
PA BvD; NM
3
PA BvD
3
PA BvD; NM
3
PA BvD; NM
3
PA BvD; NM
3
NM
133
Drug Name
Drug Tier
Requirements/Limits
GARDASIL (PF)
INTRAMUSCULAR SYRINGE
20-40-40-20 MCG/0.5 ML
GARDASIL 9 (PF)
0.5 ML
GARDASIL 9 (PF)
INTRAMUSCULAR SYRINGE 0.5
ML
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA
UNIT/ML
HAVRIX (PF) INTRAMUSCULAR
SYRINGE 1,440 ELISA UNIT/ML,
720 ELISA UNIT/0.5 ML
HIBERIX (PF) INTRAMUSCULAR
RECON SOLN 10 MCG/0.5 ML
IMOVAX RABIES VACCINE (PF)
INTRAMUSCULAR RECON SOLN
2.5 UNIT
INFANRIX (DTAP) (PF)
25-58-10 LF-MCG-LF/0.5ML
IPOL INJECTION SUSPENSION
40-8-32 UNIT/0.5 ML
IPOL INJECTION SYRINGE 40-8-32
UNIT/0.5 ML
IXIARO (PF) INTRAMUSCULAR
MENACTRA (PF)
INTRAMUSCULAR SOLUTION 4
MCG/0.5 ML
MENHIBRIX (PF)
INTRAMUSCULAR RECON SOLN
5-2.5 MCG/0.5 ML
3
NM
4
NM
4
NM
3
NM
3
NM
3
3
PA BvD; NM
3
NM
3
NM
3
NM
3
NM
3
NM
4
134
Drug Name
Drug Tier
Requirements/Limits
MENOMUNE - A/C/Y/W-135 (PF)
SUBCUTANEOUS RECON SOLN 50
MCG
MENVEO A-C-Y-W-135-DIP (PF)
INTRAMUSCULAR KIT 10-5
MCG/0.5 ML
MENVEO MENA COMPONENT
(PF) INTRAMUSCULAR RECON
SOLN 10 MCG /0.5 ML (FINAL)
MENVEO MENCYW-135 COMPNT
SOLN 5 MCG X 3/ 0.5 ML (FINAL)
M-M-R II (PF) SUBCUTANEOUS
RECON SOLN 1,000-12,500
TCID50/0.5 ML
PEDVAX HIB (PF)
INTRAMUSCULAR SOLUTION 7.5
MCG/0.5 ML
PENTACEL ACTHIB COMPONENT
SOLN 10 MCG/0.5 ML
PROQUAD (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 10EXP3-4.3-33.99 TCID50/0.5
QUADRACEL (PF)
15 LF-48 MCG- 5 LF UNIT/0.5ML
RABAVERT (PF)
FOR RECONSTITUTION 2.5 UNIT
RECOMBIVAX HB (PF)
10 MCG/ML, 40 MCG/ML
RECOMBIVAX HB (PF)
MCG/ML
3
NM
3
NM
4
NM
4
NM
3
NM
3
NM
3
NM
3
NM
4
3
PA BvD; NM
3
PA BvD; NM
3
PA BvD
135
Drug Name
Drug Tier
RECOMBIVAX HB (PF)
MCG/0.5 ML
ROTARIX ORAL SUSPENSION
FOR RECONSTITUTION 10EXP6
CCID50/ML
ROTATEQ VACCINE ORAL
SUSPENSION 2 ML
TENIVAC (PF) INTRAMUSCULAR
SYRINGE 5-2 LF UNIT/0.5 ML
TETANUS TOXOID,ADSORBED
(PF) INTRAMUSCULAR
SUSPENSION 5 LF UNIT/0.5 ML
TETANUS,DIPHTHERIA TOX
PED(PF) INTRAMUSCULAR
SUSPENSION 5-25 LF UNIT/0.5 ML
tetanus-diphtheria toxoids-td
intramuscular suspension 2-2 lf unit/0.5
ml
THERACYS INTRAVESICAL
SUSPENSION FOR
TRUMENBA INTRAMUSCULAR
TWINRIX (PF) INTRAMUSCULAR
SUSPENSION 720 ELISA UNIT -20
MCG/ML
TYPHIM VI INTRAMUSCULAR
SOLUTION 25 MCG/0.5 ML
TYPHIM VI INTRAMUSCULAR
VAQTA (PF) INTRAMUSCULAR
SUSPENSION 50 UNIT/ML
VAQTA (PF) INTRAMUSCULAR
SYRINGE 25 UNIT/0.5 ML, 50
UNIT/ML
3
Requirements/Limits
PA BvD; NM
3
3
4
(Tetanus, Diphtheria
Tox,Adult)
2
PA BvD; NM
3
NM
2
NM
4
PA BvD; NM
4
NM
3
NM
3
NM
3
4
NM
4
NM
136
Drug Name
Drug Tier
Requirements/Limits
VAQTA 25 UNITS/0.5 ML VIAL
SDV, OUTER 25 UNIT/0.5 ML
VARIVAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 1,350 UNIT/0.5
ML
YF-VAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 10 EXP4.74
UNIT/0.5 ML
ZOSTAVAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 19,400
UNIT/0.65 ML
4
NM
3
NM
3
NM
3
NM
(Alosetron HCl)
2
4
QL (60 per 30 days)
(Colazal)
(Entocort EC)
2
5
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease
Agents
alosetron oral tablet 0.5 mg, 1 mg
ASACOL HD ORAL
(DR/EC) 800 MG
balsalazide oral capsule 750 mg
budesonide oral
capsule,delayed,extend.release 3 mg
CANASA RECTAL SUPPOSITORY
1,000 MG
DELZICOL DR 400 MG CAPSULE
400 MG
DELZICOL ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 400 MG
DIPENTUM ORAL CAPSULE 250
MG
mesalamine 4 gm/60 ml enema
u-d,7x60ml, outer 4 gram/60 ml
mesalamine with cleansing wipe rectal
enema kit 4 gram/60 ml
NM
4
3
3
4
(Sfrowasa)
2
(Sfrowasa)
2
137
Drug Name
Drug Tier
PENTASA ORAL CAPSULE,
EXTENDED RELEASE 250 MG, 500
MG
4
Requirements/Limits
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation solution 0.25 %
LACTATED RINGERS
IRRIGATION SOLUTION
ringers irrigation solution
sodium chloride irrigation solution 0.9 %
(Acetic Acid)
2
2
(Ringers Solution)
(Sodium Chloride Irrig
Solution)
(Sorbitol Solution)
(Mannitol/Sorbitol
Solution)
(Water For
Irrigation,Sterile)
2
2
(Alendronate Sodium)
(Fosamax)
2
2
(Miacalcin)
2
(Calcitriol)
2
calcitriol oral capsule 0.25 mcg, 0.5 mcg
(Rocaltrol)
2
calcitriol oral solution 1 mcg/ml
(Rocaltrol)
2
doxercalciferol intravenous solution 4
mcg/2 ml
doxercalciferol oral capsule 0.5 mcg, 1
mcg, 2.5 mcg
etidronate disodium oral tablet 200 mg,
400 mg
(Doxercalciferol)
2
(Hectorol)
2
(Etidronate Disodium)
2
sorbitol irrigation solution 3 %, 3.3 %
sorbitol-mannitol urethral solution
2.7-0.54 g/100 ml
water for irrigation, sterile irrigation
solution
2
2
2
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate oral solution 70 mg/75 ml
alendronate oral tablet 10 mg, 35 mg, 40
mg, 5 mg, 70 mg
calcitonin (salmon) nasal
spray,non-aerosol 200 unit/actuation
calcitriol intravenous solution 1 mcg/ml
PA BvD; NM; (PA for
ESRD only)
PA BvD; (PA for
ESRD only)
PA BvD; (PA for
ESRD only)
PA BvD; NM; (PA for
ESRD only)
PA BvD; (PA for
ESRD only)
138
Drug Name
Drug Tier
FORTEO SUBCUTANEOUS PEN
INJECTOR 20 MCG/DOSE - 600
MCG/2.4 ML
FORTICAL NASAL
UNIT/ACTUATION
FOSAMAX PLUS D ORAL TABLET
70 MG- 2,800 UNIT, 70 MG- 5,600
UNIT
HECTOROL INTRAVENOUS
SOLUTION 2 MCG/ML (1 ML)
HECTOROL INTRAVENOUS
SOLUTION 4 MCG/2 ML
ibandronate intravenous solution 3 mg/3
ml
ibandronate intravenous syringe 3 mg/3
ml
ibandronate oral tablet 150 mg
MIACALCIN INJECTION
NATPARA SUBCUTANEOUS
CARTRIDGE 100 MCG/DOSE, 25
MCG/DOSE, 50 MCG/DOSE, 75
MCG/DOSE
pamidronate intravenous solution 30
mg/10 ml (3 mg/ml), 60 mg/10 ml (6
mg/ml), 90 mg/10 ml (9 mg/ml)
PARICALCITOL HEMODIALYSIS
PORT INJECTION SOLUTION 2
MCG/ML
PARICALCITOL HEMODIALYSIS
PORT INJECTION SOLUTION 5
MCG/ML
paricalcitol oral capsule 1 mcg, 2 mcg, 4
mcg
PROLIA SUBCUTANEOUS
SYRINGE 60 MG/ML
5
Requirements/Limits
PA; NM
2
3
3
PA BvD
3
(Ibandronate Sodium)
2
PA BvD; NM; (PA for
ESRD only)
PA; NM
(Boniva)
2
PA
(Boniva)
2
3
5
(Pamidronate
Disodium)
(Zemplar)
PA BvD; NM; (PA for
ESRD only)
days)
2
PA BvD; NM; (PA for
ESRD only)
3
PA BvD
3
PA BvD; NM; (PA for
ESRD only)
2
PA BvD; (PA for
ESRD only)
PA; NM
4
139
Drug Name
risedronate oral tablet 150 mg, 30 mg, 35
mg (12 pack), 35 mg (4 pack), 5 mg
risedronate oral tablet 35 mg
risedronate oral tablet,delayed release
(dr/ec) 35 mg
XGEVA SUBCUTANEOUS
SOLUTION 120 MG/1.7 ML (70
MG/ML)
ZEMPLAR INTRAVENOUS
SOLUTION 2 MCG/ML, 5 MCG/ML
zoledronic acid intravenous solution 4
mg/5 ml
zoledronic acid-mannitol-water
intravenous solution 5 mg/100 ml
Drug Tier
Requirements/Limits
(Actonel)
2
(Actonel)
(Atelvia)
2
2
QL (4 per 28 days)
5
PA NSO; NM
3
(Zometa)
2
PA BvD; NM; (PA for
ESRD only)
NM
(Reclast)
2
NM
5
days)
5
5
PA; NM; QL (3.6 per
28 days)
NM; LA
(Zyloprim)
(Amifostine
Crystalline)
(Ammonium Chloride)
1
2
GC
NM
2
NM
(Citrate Phosphate
Dextros Soln)
2
NM
3
5
ST; NM
5
ST; NM
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA INTRAVENOUS
MG/ML), 400 MG/20 ML (20
MG/ML), 80 MG/4 ML (20 MG/ML)
ACTEMRA SUBCUTANEOUS
ACTIMMUNE SUBCUTANEOUS
SOLUTION 100 MCG/0.5 ML
allopurinol oral tablet 100 mg, 300 mg
amifostine crystalline intravenous recon
soln 500 mg
ammonium chloride intravenous solution
5 meq/ml
anticoag citrate phos dextrose solution
2.63-222 gram-mg/100ml
AVODART ORAL CAPSULE 0.5 MG
AVONEX (WITH ALBUMIN)
INTRAMUSCULAR KIT 30 MCG
AVONEX INTRAMUSCULAR PEN
INJECTOR KIT 30 MCG/0.5 ML
140
Drug Name
Drug Tier
Requirements/Limits
AVONEX INTRAMUSCULAR
SYRINGE KIT 30 MCG/0.5 ML
BENLYSTA INTRAVENOUS
BETASERON SUBCUTANEOUS
KIT 0.3 MG
bethanechol chloride oral tablet 10 mg,
25 mg, 5 mg, 50 mg
buspirone oral tablet 10 mg, 15 mg, 30
mg, 5 mg, 7.5 mg
colchicine oral tablet 0.6 mg
colchicine-probenecid oral tablet 0.5-500
mg
COPAXONE SUBCUTANEOUS
SYRINGE 20 MG/ML, 40 MG/ML
dexrazoxane hcl intravenous recon soln
250 mg
droperidol injection solution 2.5 mg/ml
dutasteride oral capsule 0.5 mg
ELMIRON ORAL CAPSULE 100 MG
ergoloid oral tablet 1 mg
finasteride oral tablet 5 mg
fomepizole intravenous solution 1
gram/ml
FUSILEV INTRAVENOUS RECON
SOLN 50 MG
GAUZE PAD TOPICAL BANDAGE
2X2"
GILENYA ORAL CAPSULE 0.5 MG
GLUCAGEN HYPOKIT INJECTION
RECON SOLN 1 MG
GLUCAGON EMERGENCY KIT
(HUMAN) INJECTION KIT 1 MG
guanidine oral tablet 125 mg
hydroxyzine hcl intramuscular solution
25 mg/ml, 50 mg/ml
5
ST; NM
5
PA; NM
5
NM
(Urecholine)
2
(Buspirone HCl)
2
(Colcrys)
(Colchicine/Probenecid
)
2
2
QL (60 per 30 days)
5
NM
(Totect)
2
NM
(Droperidol)
(Avodart)
2
2
3
2
1
5
NM
4
NM
(Ergoloid Mesylates)
(Proscar)
(Fomepizole)
QL (90 per 30 days)
GC
NM
3
(Guanidine HCl)
(Hydroxyzine HCl)
5
3
NM
NM
3
NM
2
2
NM
141
Drug Name
hydroxyzine hcl oral solution 10 mg/5 ml
hydroxyzine hcl oral tablet 10 mg, 25 mg,
50 mg
hydroxyzine pamoate oral capsule 100
mg, 25 mg, 50 mg
KEPIVANCE INTRAVENOUS
RECON SOLN 6.25 MG
leucovorin calcium 200 mg vial sdv, p/f,
latex-free 200 mg
leucovorin calcium injection recon soln
100 mg, 350 mg
leucovorin calcium oral tablet 10 mg, 15
mg, 25 mg, 5 mg
levocarnitine (with sugar) oral solution
100 mg/ml
levocarnitine intravenous solution 200
mg/ml
levocarnitine oral tablet 330 mg
Drug Tier
(Hydroxyzine HCl)
(Hydroxyzine HCl)
2
2
(Vistaril)
2
5
PA BvD; NM
(Leucovorin Calcium)
2
NM
2
NM
2
(Levocarnitine (With
Sugar))
(Carnitor)
2
(Carnitor)
2
levoleucovorin calcium intravenous
(Levoleucovorin
solution 10 mg/ml
Calcium)
meprobamate oral tablet 200 mg, 400 mg (Meprobamate)
mesna intravenous solution 100 mg/ml
MESNEX ORAL TABLET 400 MG
methylene blue (antidote) intravenous
solution 1 % (10 mg/ml)
methylergonovine injection solution 0.2
mg/ml (1 ml)
methylergonovine oral tablet 0.2 mg
morrhuate sodium intravenous solution 5
%
NEOSTIGMINE METHYLSULFATE
INTRAVENOUS SOLUTION 0.5
MG/ML, 1 MG/ML
Requirements/Limits
(Mesnex)
(Methylene Blue)
(Methylergonovine
Maleate)
(Methergine)
(Sodium Morrhuate)
2
5
2
PA BvD; (PA for
ESRD only)
PA BvD; NM; (PA for
ESRD only)
PA BvD; (PA for
ESRD only)
NM
2
4
2
PA; AGE (Max 64
Years)
NM
NM
NM
2
NM
2
2
NM
2
142
Drug Name
Drug Tier
NPLATE SUBCUTANEOUS RECON
SOLN 250 MCG, 500 MCG
ORENCIA CLICKJECT
SUBCUTANEOUS
AUTO-INJECTOR 125 MG/ML
OTEZLA ORAL TABLET 30 MG
5
PA; NM; LA
5
days)
5
OTEZLA STARTER ORAL
TABLETS,DOSE PACK 10 MG (4)-20
MG (4)-30 MG (47)
OTEZLA STARTER ORAL
TABLETS,DOSE PACK 10 MG (4)-20
MG (4)-30 MG(19)
physostigmine salicylate injection
solution 1 mg/ml
probenecid oral tablet 500 mg
PROCYSBI ORAL CAPSULE,
DELAYED REL SPRINKLE 25 MG,
75 MG
pyridostigmine bromide oral tablet 60 mg
REMICADE INTRAVENOUS
RECON SOLN 100 MG
SCLEROSOL INTRAPLEURAL
INTRAPLEURAL AEROSOL
POWDER 4 GRAM
SENSIPAR ORAL TABLET 30 MG
SENSIPAR ORAL TABLET 60 MG,
90 MG
SIGNIFOR LAR
FOR RECONSTITUTION 20 MG, 40
MG, 60 MG
SIGNIFOR SUBCUTANEOUS
SOLUTION 0.3 MG/ML (1 ML), 0.6
MG/ML (1 ML), 0.9 MG/ML (1 ML)
SIMPONI ARIA INTRAVENOUS
SOLUTION 12.5 MG/ML
5
PA; NM; LA; QL (60
per 30 days)
days)
(Physostigmine
Salicylate)
(Probenecid)
(Mestinon)
Requirements/Limits
5
PA; NM; LA; QL (60
per 30 days)
2
NM
2
4
LA
2
5
PA; NM
4
NM
3
5
QL (60 per 30 days)
NM
5
days)
5
days)
5
PA; NM
143
Drug Name
Drug Tier
SIMPONI SUBCUTANEOUS PEN
INJECTOR 100 MG/ML
SIMPONI SUBCUTANEOUS PEN
INJECTOR 50 MG/0.5 ML
SIMPONI SUBCUTANEOUS
SYRINGE 100 MG/ML
SIMPONI SUBCUTANEOUS
SIMULECT INTRAVENOUS
RECON SOLN 20 MG
sotradecol intravenous solution 3 % (30
(Sodium Tetradecyl
mg/ml)
Sulfate)
STELARA SUBCUTANEOUS
SYRINGE 45 MG/0.5 ML, 90 MG/ML
STERILE PADS 2" X 2" 2 X 2 "
sterile talc intrapleural suspension for
(Talc)
reconstitution 5 gram
SYNAREL NASAL
SPRAY,NON-AEROSOL 2 MG/ML
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG, 120 MG
(14)- 240 MG (46), 240 MG
THALOMID ORAL CAPSULE 100
MG, 150 MG, 200 MG, 50 MG
TYBOST ORAL TABLET 150 MG
ULORIC ORAL TABLET 40 MG, 80
MG
VORAXAZE INTRAVENOUS
RECON SOLN 1,000 UNIT
XELJANZ ORAL TABLET 5 MG
5
XELJANZ XR ORAL TABLET
MG
5
Requirements/Limits
5
days)
PA; NM; (1 syringe);
QL (0.5 per 28 days)
days)
PA; NM; QL (0.5 per
28 days)
PA BvD; NM
2
NM
5
PA; NM
3
2
NM
5
NM
5
NM; LA
5
NM
3
4
5
5
5
5
5
PA NSO; NM; QL (6
per 30 days)
days)
days)
144
Drug Name
Drug Tier
Requirements/Limits
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule, extended
release 500 mg
acetazolamide oral tablet 125 mg, 250 mg
acetazolamide sodium injection recon
soln 500 mg
ALPHAGAN P OPHTHALMIC
DROPS 0.1 %
AZOPT OPHTHALMIC
DROPS,SUSPENSION 1 %
betaxolol ophthalmic drops 0.5 %
BETOPTIC S OPHTHALMIC
bimatoprost ophthalmic drops 0.03 %
brimonidine ophthalmic drops 0.15 %, 0.2
%
dorzolamide ophthalmic drops 2 %
dorzolamide-timolol ophthalmic drops
22.3-6.8 mg/ml
latanoprost ophthalmic drops 0.005 %
levobunolol ophthalmic drops 0.5 %
LUMIGAN OPHTHALMIC DROPS
0.01 %
methazolamide oral tablet 25 mg, 50 mg
metipranolol ophthalmic drops 0.3 %
PHOSPHOLINE IODIDE
OPHTHALMIC DROPS 0.125 %
pilocarpine hcl ophthalmic drops 1 %, 2
%, 4 %
SIMBRINZA OPHTHALMIC
DROPS,SUSPENSION 1-0.2 %
timolol maleate ophthalmic drops 0.25 %,
0.5 %
timolol maleate ophthalmic gel forming
solution 0.25 %, 0.5 %
(Diamox Sequels)
2
(Acetazolamide)
(Acetazolamide
Sodium)
2
2
NM
3
3
(Betaxolol HCl)
2
4
(Bimatoprost)
(Alphagan P)
2
2
(Trusopt)
(Cosopt)
2
2
(Xalatan)
(Betagan)
2
2
4
(Neptazane)
(Metipranolol)
2
2
4
(Isopto Carpine)
2
ST
3
(Timoptic)
1
(Timoptic-Xe)
2
GC
145
Drug Name
TRAVATAN Z OPHTHALMIC
DROPS 0.004 %
travoprost (benzalkonium) ophthalmic
drops 0.004 %
Drug Tier
Requirements/Limits
3
(Travoprost
(Benzalkonium))
2
(Calcium Chloride)
2
NM
(Calcium Chloride)
2
NM
(Calcium Gluconate)
2
PA BvD; NM; (PA for
ESRD only)
Replacement Preparations
Replacement Preparations
calcium chloride intravenous solution 100
mg/ml (10 %)
calcium chloride intravenous syringe 100
mg/ml (10 %)
calcium gluconate intravenous solution
100 mg/ml (10%)
cytra-2 oral solution 500-334 mg/5 ml
(Citric Acid/Sodium
Citrate)
d10 %-0.45 % sodium chloride
(Dextrose 10 % and
0.45 % NaCl)
d2.5 %-0.45 % sodium chloride
(Dextrose 2.5 % and
0.45 % NaCl)
d5 % and 0.9 % sodium chloride
(Dextrose 5 % and 0.9
% NaCl)
d5 %-0.45 % sodium chloride intravenous (Dextrose 5 %-0.45 %
parenteral solution
NaCl)
dextrose 10 % and 0.2 % nacl intravenous (Dextrose 10 % and 0.2
parenteral solution
% NaCl)
dextrose 5 %-lactated ringers intravenous (Dextrose 5%-Lactated
parenteral solution
Ringers)
dextrose 5%-0.2 % sod chloride
(Dextrose 5 %-0.2 %
NaCl)
dextrose 5%-0.3 % sod.chloride
(Dextrose 5 % and 0.3
% NaCl)
dextrose with sodium chloride
(Dextrose 5 %-0.2 %
intravenous parenteral solution 5-0.2 %
NaCl)
dextrose-kcl-nacl intravenous solution
(Potassium
5-0.224-0.225 %
Chloride/D5-0.2%NaC
l)
effer-k oral tablet, effervescent 25 meq
(Klor-Con-Ef)
2
2
NM
2
NM
2
2
2
NM
2
NM
2
2
NM
2
2
2
146
Drug Name
electrolyte-48 in d5w intravenous
parenteral solution
k-effervescent oral tablet, effervescent 25
meq
klor-con 10 oral tablet extended release
10 meq
KLOR-CON 8 ORAL TABLET
EXTENDED RELEASE 8 MEQ
klor-con m10 tablet 10 meq
klor-con m15 oral tablet,er
particles/crystals 15 meq
klor-con m20 oral tablet,er
KLOR-CON ORAL PACKET 20
MEQ
klor-con sprinkle oral capsule, extended
release 10 meq, 8 meq
KLOR-CON/EF ORAL TABLET,
EFFERVESCENT 25 MEQ
magnesium chloride injection solution 200
mg/ml (20 %)
magnesium sulf in 0.45% nacl intravenous
solution 20 gram/500 ml (40 mg/ml)
magnesium sulfate in d5w intravenous
magnesium sulfate in d5w intravenous
magnesium sulfate in water intravenous
parenteral solution 20 gram/500 ml (4
%)
parenteral solution 40 gram/1,000 ml (4
%)
piggyback 2 gram/50 ml (4 %), 4
gram/100 ml (4 %)
Drug Tier
(Electrolyte-48
Solution/D5W)
(Klor-Con-Ef)
2
(Potassium Chloride)
2
Requirements/Limits
NM
2
2
2
2
2
2
2
2
(Magnesium Chloride)
2
(Magnesium Sulf In
0.45% NaCl)
(Magnesium
Sulfate/D5W)
(Magnesium
Sulfate/D5W)
(Magnesium Sulfate in
Water)
2
Water)
2
Water)
2
2
NM
NM
2
2
NM
147
Drug Name
piggyback 4 gram/50 ml (8 %)
magnesium sulfate injection solution 4
meq/ml (50 %)
magnesium sulfate injection syringe 4
meq/ml
phospha 250 neutral oral tablet 250 mg
potassium acetate intravenous solution 2
meq/ml, 4 meq/ml
potassium bicarb and chloride oral tablet,
effervescent 25 meq
potassium bicarb-citric acid oral tablet,
effervescent 25 meq
potassium chlorid-d5-0.45%nacl
intravenous parenteral solution 10 meq/l,
20 meq/l, 30 meq/l, 40 meq/l
potassium chloride in 0.9%nacl
40 meq/l
potassium chloride in 5 % dex
30 meq/l, 40 meq/l
potassium chloride in lr-d5 intravenous
parenteral solution 20 meq/l
potassium chloride intravenous piggyback
10 meq/100 ml, 20 meq/100 ml, 30
meq/100 ml, 40 meq/100 ml
potassium chloride intravenous solution 2
meq/ml
potassium chloride oral capsule, extended
release 10 meq, 8 meq
potassium chloride oral liquid 20 meq/15
ml, 40 meq/15 ml
potassium chloride oral packet 20 meq
potassium chloride oral tablet extended
release 8 meq
Drug Tier
Requirements/Limits
Water)
(Magnesium Sulfate)
2
NM
(Magnesium Sulfate)
2
NM
(K-Phos Neutral)
(Potassium Acetate)
2
2
NM
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
2
(Potassium
Chloride/D5-0.45nacl)
2
NM
(Potassium Chloride In
0.9%NaCl)
2
NM
D5w)
2
NM
Lr-D5)
2
NM
2
NM
2
NM
2
2
(Klor-Con)
(Klor-Con 8)
2
2
2
2
148
Drug Name
potassium chloride oral tablet,er
potassium chloride oral tablet,er
potassium chloride-0.45 % nacl
intravenous parenteral solution 20 meq/l
potassium chloride-d5-0.2%nacl
20 meq/l, 30 meq/l, 40 meq/l
intravenous parenteral solution 20 meq/l
40 meq/l
potassium citrate oral tablet extended
release 10 meq (1,080 mg), 15 meq, 5
meq (540 mg)
potassium citrate-citric acid oral packet
3,300-1,002 mg
potassium cl 10 meq/50 ml sol 10 meq/50
ml
potassium cl 20 meq/50 ml sol 20 meq/50
ml
potassium cl er 10 meq tablet f/c 10 meq
potassium phosphate m-/d-basic
intravenous solution 3 mmol/ml
ringers intravenous parenteral solution
SHOHL'S MODIFIED ORAL
SOLUTION 500-300 MG/5 ML
sodium acetate intravenous solution 2
meq/ml, 4 meq/ml
sodium bicarbonate intravenous solution
1 meq/ml (8.4 %)
Drug Tier
Requirements/Limits
(Klor-Con 8)
2
2
(Potassium
Chloride-0.45% NaCl)
(Potassium
Chloride/D5-0.2%NaC
l)
(Potassium
Chloride/D5-0.3%NaC
l)
(Potassium
Chloride/D5-0.9%NaC
l)
(Urocit-K)
2
NM
2
NM
2
NM
2
NM
(Potassium
Citrate/Citric Acid)
2
2
NM
2
NM
(Klor-Con 8)
(Potassium
Phos,M-Basic-D-Basic)
(Ringers Solution)
2
2
NM
2
2
NM
(Sodium Acetate)
2
NM
(Sodium Bicarbonate)
2
NM
2
149
Drug Name
sodium bicarbonate intravenous syringe
10 meq/10 ml (8.4 %), 4.2 % (0.5
meq/ml), 7.5 % (0.9 meq/ml), 8.4 % (1
meq/ml)
sodium chloride 0.45 % intravenous
parenteral solution 0.45 %
sodium chloride 0.9 % intravenous
parenteral solution 0.9 %
sodium chloride 3 % intravenous
sodium chloride 5 % intravenous
sodium chloride intravenous parenteral
solution 2.5 meq/ml, 4 meq/ml
sodium citrate-citric acid oral solution
500-334 mg/5 ml
sodium lactate intravenous solution 5
meq/ml
sodium phosphate intravenous solution 3
mmol/ml
TPN ELECTROLYTES II IV SOLN
25'S,20ML/50ML FTV 18-18-5-4.5-35
MEQ/20 ML
TPN ELECTROLYTES
INTRAVENOUS SOLUTION 35-20-5
MEQ/20 ML
virt-phos 250 neutral oral tablet 250 mg
Drug Tier
Requirements/Limits
(Sodium Bicarbonate)
2
NM
(Sodium Chloride 0.45
%)
(0.9 % Sodium
Chloride)
(Sodium Chloride 3 %)
2
NM
2
NM
2
NM
(Sodium Chloride 5 %)
2
NM
(Sodium Chloride)
2
NM
(Citric Acid/Sodium
Citrate)
(Sodium Lactate)
2
2
NM
(Sodium
Phos,M-Basic-D-Basic)
2
NM
2
NM
2
NM
(K-Phos Neutral)
2
Respiratory Tract Agents
Anti-Inflammatories, Inhaled
Corticosteroids
ADVAIR DISKUS INHALATION
BLISTER WITH DEVICE 100-50
MCG/DOSE, 250-50 MCG/DOSE,
500-50 MCG/DOSE
3
150
Drug Name
ADVAIR HFA INHALATION HFA
AEROSOL INHALER 115-21
MCG/ACTUATION, 230-21
MCG/ACTUATION
ARNUITY ELLIPTA INHALATION
BLISTER WITH DEVICE 100
MCG/ACTUATION, 200
MCG/ACTUATION
ASMANEX HFA INHALATION
HFA AEROSOL INHALER 100
MCG/ACTUATION, 200
MCG/ACTUATION
ASMANEX TWISTHALER
INHALATION AEROSOL POWDR
BREATH ACTIVATED 110 MCG (30
DOSES), 110 MCG (7 DOSES), 220
MCG (120 DOSES), 220 MCG (14
DOSES), 220 MCG (30 DOSES), 220
MCG (60 DOSES)
BREO ELLIPTA INHALATION
BLISTER WITH DEVICE 100-25
MCG/DOSE, 200-25 MCG/DOSE
budesonide inhalation suspension for
(Pulmicort)
nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1
mg/2 ml
DULERA INHALATION HFA
AEROSOL INHALER 100-5
MCG/ACTUATION
FLOVENT DISKUS INHALATION
MCG/ACTUATION, 250
MCG/ACTUATION, 50
MCG/ACTUATION
Drug Tier
Requirements/Limits
3
3
4
4
3
2
PA BvD
3
3
151
Drug Name
Drug Tier
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 110
MCG/ACTUATION, 220
MCG/ACTUATION, 44
MCG/ACTUATION
PULMICORT FLEXHALER
BREATH ACTIVATED 180
MCG/ACTUATION, 90
MCG/ACTUATION
PULMICORT INHALATION
SUSPENSION FOR
NEBULIZATION 1 MG/2 ML
QVAR INHALATION AEROSOL 40
MCG/ACTUATION, 80
MCG/ACTUATION
SYMBICORT INHALATION HFA
AEROSOL INHALER 160-4.5
MCG/ACTUATION, 80-4.5
MCG/ACTUATION
Antileukotrienes
montelukast oral granules in packet 4 mg
montelukast oral tablet 10 mg
montelukast oral tablet,chewable 4 mg, 5
mg
zafirlukast oral tablet 10 mg, 20 mg
ZYFLO CR ORAL TABLET, ER
MULTIPHASE 12 HR 600 MG
Bronchodilators
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml,
2.5 mg /3 ml (0.083 %), 5 mg/ml
albuterol sulfate oral syrup 2 mg/5 ml
albuterol sulfate oral tablet 2 mg, 4 mg
albuterol sulfate oral tablet extended
release 12 hr 4 mg, 8 mg
3
Requirements/Limits
3
4
PA BvD
3
4
(Singulair)
(Singulair)
(Singulair)
2
2
2
(Accolate)
2
4
(Albuterol Sulfate)
2
(Albuterol Sulfate)
(Albuterol Sulfate)
(Vospire ER)
2
2
2
ST
PA BvD
152
Drug Name
aminophylline intravenous solution 250
mg/10 ml
ANORO ELLIPTA INHALATION
BLISTER WITH DEVICE 62.5-25
MCG/ACTUATION
ATROVENT HFA INHALATION
MCG/ACTUATION
BROVANA INHALATION
15 MCG/2 ML
COMBIVENT RESPIMAT
INHALATION MIST 20-100
MCG/ACTUATION
elixophyllin oral elixir 80 mg/15 ml
FORADIL AEROLIZER
INHALATION CAPSULE,
W/INHALATION DEVICE 12 MCG
ipratropium bromide inhalation solution
0.02 %
ipratropium-albuterol inhalation solution
for nebulization 0.5 mg-3 mg(2.5 mg
base)/3 ml
levalbuterol hcl inhalation solution for
nebulization 0.31 mg/3 ml, 0.63 mg/3 ml,
1.25 mg/0.5 ml, 1.25 mg/3 ml
metaproterenol oral syrup 10 mg/5 ml
metaproterenol oral tablet 10 mg, 20 mg
Drug Tier
(Aminophylline)
2
Requirements/Limits
NM
3
3
4
PA
4
(Theophylline
Anhydrous)
2
3
(Ipratropium Bromide)
2
PA BvD
(Ipratropium/Albuterol
Sulfate)
2
PA BvD
(Xopenex)
2
PA
(Metaproterenol
Sulfate)
(Metaproterenol
Sulfate)
2
PERFOROMIST INHALATION
20 MCG/2 ML
SEREVENT DISKUS INHALATION
MCG/DOSE
2
4
PA
3
153
Drug Name
Drug Tier
SPIRIVA RESPIMAT INHALATION
MIST 1.25 MCG/ACTUATION, 2.5
MCG/ACTUATION
SPIRIVA WITH HANDIHALER
INHALATION CAPSULE,
W/INHALATION DEVICE 18 MCG
terbutaline oral tablet 2.5 mg, 5 mg
terbutaline subcutaneous solution 1
mg/ml
theochron oral tablet extended release 12
hr 100 mg, 200 mg, 300 mg
theophylline in dextrose 5 % intravenous
parenteral solution 200 mg/100 ml, 200
mg/50 ml, 400 mg/250 ml, 400 mg/500
ml, 800 mg/250 ml
theophylline oral solution 80 mg/15 ml
3
theophylline oral tablet extended release
12 hr 100 mg, 200 mg, 300 mg, 450 mg
theophylline oral tablet extended release
400 mg, 600 mg
TUDORZA PRESSAIR
BREATH ACTIVATED 400
MCG/ACTUATION, 400
MCG/ACTUATION (30 ACTUAT)
VENTOLIN HFA INHALATION
MCG/ACTUATION
Respiratory Tract Agents, Other
acetylcysteine intravenous solution 200
mg/ml (20 %)
acetylcysteine solution 100 mg/ml (10
%), 200 mg/ml (20 %)
ARALAST NP 1,000 MG VIAL
L/F,P/F,PRICE PER MG 1,000 MG
Requirements/Limits
3
(Terbutaline Sulfate)
(Terbutaline Sulfate)
2
2
(Theophylline
Anhydrous)
(Theophylline/D5W)
2
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
2
2
NM
NM
2
2
4
ST
2
(Acetadote)
2
NM
(Acetadote)
2
PA BvD
5
PA; NM
154
Drug Name
ARALAST NP INTRAVENOUS
RECON SOLN 500 MG
cromolyn inhalation solution for
nebulization 20 mg/2 ml
DALIRESP ORAL TABLET 500
MCG
ESBRIET ORAL CAPSULE 267 MG
Drug Tier
(Cromolyn Sodium)
KALYDECO ORAL GRANULES IN
PACKET 50 MG, 75 MG
KALYDECO ORAL TABLET 150
MG
NUCALA SUBCUTANEOUS
RECON SOLN 100 MG
OFEV ORAL CAPSULE 100 MG, 150
MG
ORKAMBI ORAL TABLET 200-125
MG
PROLASTIN-C INTRAVENOUS
RECON SOLN 1,000 MG
XOLAIR SUBCUTANEOUS RECON
SOLN 150 MG
Requirements/Limits
5
PA; NM
2
PA BvD
4
PA
5
5
PA; NM; QL (270 per
30 days)
days)
days)
PA; NM; LA; QL (1
per 28 days)
days)
PA; NM; QL (120 per
30 days)
PA; NM; LA
5
PA; NM
5
5
5
5
5
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen oral tablet 10 mg, 20 mg
carisoprodol oral tablet 250 mg, 350 mg
carisoprodol-asa-codeine oral tablet
200-325-16 mg
carisoprodol-aspirin oral tablet 200-325
mg
chlorzoxazone oral tablet 500 mg
cyclobenzaprine oral tablet 10 mg, 5 mg
dantrolene oral capsule 100 mg, 25 mg,
50 mg
metaxalone oral tablet 400 mg, 800 mg
(Baclofen)
(Soma)
(Codeine/Carisoprodol
/Aspirin)
(Carisoprodol/Aspirin)
2
2
2
(Parafon Forte DSC)
(Fexmid)
(Dantrium)
2
2
2
(Skelaxin)
2
2
155
Drug Name
methocarbamol injection solution 100
mg/ml
methocarbamol oral tablet 500 mg, 750
mg
orphenadrine citrate injection solution 30
mg/ml
orphenadrine citrate oral tablet extended
release 100 mg
revonto intravenous recon soln 20 mg
tizanidine oral capsule 2 mg, 4 mg, 6 mg
tizanidine oral tablet 2 mg, 4 mg
Drug Tier
Requirements/Limits
(Robaxin)
2
NM
(Robaxin)
2
(Orphenadrine Citrate)
2
(Orphenadrine Citrate)
2
(Dantrium)
(Zanaflex)
(Zanaflex)
2
2
2
(Nuvigil)
2
PA
5
2
4
days)
PA
PA
4
5
QL (30 per 30 days)
NM; LA
PA; QL (90 per 365
days); AGE (Max 64
Years)
PA; QL (90 per 365
days); AGE (Max 64
Years)
PA; QL (90 per 365
days); AGE (Max 64
Years)
NM
Sleep Disorder Agents
Sleep Disorder Agents
armodafinil oral tablet 150 mg, 200 mg,
250 mg, 50 mg
HETLIOZ ORAL CAPSULE 20 MG
modafinil oral tablet 100 mg, 200 mg
NUVIGIL ORAL TABLET 150 MG,
200 MG, 250 MG, 50 MG
ROZEREM ORAL TABLET 8 MG
XYREM ORAL SOLUTION 500
MG/ML
zaleplon oral capsule 10 mg, 5 mg
(Provigil)
(Sonata)
2
zolpidem oral tablet 10 mg, 5 mg
(Ambien)
2
zolpidem oral tablet,ext release
multiphase 12.5 mg, 6.25 mg
(Ambien CR)
2
Vasodilating Agents
Vasodilating Agents
ADCIRCA ORAL TABLET 20 MG
5
PA; NM
156
Drug Name
Drug Tier
Requirements/Limits
ADEMPAS ORAL TABLET 0.5 MG,
1 MG, 1.5 MG, 2 MG, 2.5 MG
alprostadil injection solution 500 mcg/ml
CIALIS ORAL TABLET 2.5 MG, 5
MG
epoprostenol (glycine) intravenous recon
soln 0.5 mg, 1.5 mg
LETAIRIS ORAL TABLET 10 MG, 5
MG
OPSUMIT ORAL TABLET 10 MG
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.125 MG
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.25 MG, 1
MG, 2.5 MG
REVATIO ORAL SUSPENSION FOR
RECONSTITUTION 10 MG/ML
sildenafil intravenous solution 10 mg/12.5
ml
sildenafil oral tablet 20 mg
TRACLEER ORAL TABLET 125
MG, 62.5 MG
TYVASO INHALATION SOLUTION
FOR NEBULIZATION 1.74 MG/2.9
ML (0.6 MG/ML)
TYVASO REFILL KIT
INHALATION SOLUTION FOR
NEBULIZATION 1.74 MG/2.9 ML
(0.6 MG/ML)
TYVASO STARTER KIT
INHALATION SOLUTION FOR
NEBULIZATION 1.74 MG/2.9 ML
UPTRAVI ORAL TABLET 1,000
MCG, 1,200 MCG, 1,400 MCG, 1,600
MCG, 200 MCG, 400 MCG, 600 MCG,
800 MCG
5
days)
NM
days)
PA BvD; NM
(Alprostadil)
2
4
(Flolan)
2
5
5
4
PA; NM; LA; QL (30
per 30 days)
PA; NM
PA
5
PA; NM
5
PA; NM
(Revatio)
2
PA; NM
(Revatio)
2
5
5
PA
PA; NM; LA; QL (60
per 30 days)
PA; NM; LA
5
PA; NM; LA
5
PA; NM; LA
5
PA; NM
157
Drug Name
Drug Tier
Requirements/Limits
UPTRAVI ORAL TABLETS,DOSE
PACK 200 MCG (140)- 800 MCG (60)
VENTAVIS INHALATION
10 MCG/ML, 20 MCG/ML
5
PA; NM
5
PA; NM; LA
Vitamins And Minerals
Vitamins And Minerals
multivit-fluor 0.5 mg tab chew chewable,
d/f, s/f 0.5 mg
pnv prenatal plus multivit tab s/f,
gluten-free 27 mg iron- 1 mg
prenatal vitamin plus low iron oral tablet
27 mg iron- 1 mg
sodium fluoride oral tablet 1 mg fluoride
(2.2 mg)
(Pedi M.Vit No.17 with
Fluoride)
(Pnv with
Ca,No.72/Iron/Fa)
(Pnv with
Ca,No.72/Iron/Fa)
(Pedi M.Vit No.17 with
Fluoride)
2
2
2
2
158
INDEX
I-1
AMBISOME ................................................... 51
amcinonide ........................................................ 104
amethia ..................................................................... 94
amethia lo .............................................................. 93
AMETHYST .................................................. 94
amifostine crystalline ......................... 140
amikacin .................................................................. 13
amiloride ................................................................. 87
amiloride-hydrochlorothiazide
............................................................................................... 87
aminocaproic acid ...................................... 74
aminophylline ............................................... 153
AMINOSYN 10 % ................................. 75
AMINOSYN 3.5 % ............................... 75
AMINOSYN 7 % ..................................... 75
AMINOSYN 7 % WITH
ELECTROLYTES ................................. 76
AMINOSYN 8.5 % ............................... 76
AMINOSYN II 10 % .......................... 76
AMINOSYN II 15 % .......................... 76
AMINOSYN II 7 % ............................. 76
AMINOSYN II 8.5
%-ELECTROLYTES ........................ 76
AMINOSYN M 3.5 % ...................... 76
AMINOSYN-HBC 7% .................... 76
AMINOSYN-PF 10 % ..................... 76
AMINOSYN-PF 7 %
(SULFITE-FREE) ................................. 76
AMINOSYN-RF 5.2 % .................. 76
amiodarone .......................................................... 81
AMITIZA ........................................................ 116
amitriptyline ...................................................... 42
amitriptyline-chlordiazepoxide
............................................................................................... 42
amlodipine ............................................................. 86
amlodipine-atorvastatin ..................... 88
amlodipine-benazepril ........................... 86
amlodipine-valsartan .............................. 86
amlodipine-valsartan-hcthiazid
............................................................................................... 86
ammonium chloride .............................. 140
ammonium lactate .................................. 101
Index
a-hydrocort ...................................................... 123
AKTEN (PF) .............................................. 110
AKYNZEO ....................................................... 56
ala-cort .................................................................. 104
ala-scalp ............................................................... 104
ALBENZA ......................................................... 57
ALBUMIN, HUMAN 20 % .... 75
ALBUMIN, HUMAN 25 % .... 75
ALBUMIN, HUMAN 5 % ........ 75
ALBUMINAR 25 % ............................ 75
ALBUMINAR 5 % ............................... 75
ALBURX (HUMAN) 5 % ......... 75
ALBUTEIN 25 % .................................... 75
ALBUTEIN 5 % ........................................ 75
albuterol sulfate ......................................... 152
alcaine ..................................................................... 110
alclometasone ............................................... 104
ALCOHOL PADS .............................. 101
ALCOHOL PREP PADS ........ 101
ALDACTAZIDE ..................................... 90
ALDURAZYME ................................. 109
ALECENSA .................................................... 24
alendronate ...................................................... 138
alfuzosin ............................................................... 120
ALIMTA ............................................................... 24
ALINIA .................................................................. 58
allopurinol ......................................................... 140
almotriptan malate ................................... 54
ALOCRIL ....................................................... 114
ALOMIDE ..................................................... 110
alosetron .............................................................. 137
ALPHAGAN P ....................................... 145
alprazolam ............................................................ 12
ALPRAZOLAM INTENSOL
............................................................................................... 12
alprostadil .......................................................... 157
ALREX ............................................................... 114
altacaine ............................................................... 110
altavera (28) .................................................... 93
alyacen 1/35 (28) ....................................... 93
alyacen 7/7/7 (28) ..................................... 93
amantadine hcl ................................................ 58
Index
Index
8-MOP ................................................................... 101
abacavir .................................................................... 64
abacavir-lamivudine-zidovudine
............................................................................................... 64
ABELCET .......................................................... 51
ABILIFY .............................................................. 60
ABILIFY DISCMELT .................... 60
ABILIFY MAINTENA ................. 60
ABRAXANE .................................................. 24
ABSORICA .................................................. 101
acamprosate ....................................................... 10
acarbose ................................................................... 47
acebutolol ............................................................... 82
acetaminophen-codeine ........................... 3
acetasol hc ......................................................... 111
acetazolamide ............................................... 145
acetazolamide sodium ....................... 145
acetic acid ........................................... 111, 138
acetylcysteine ................................................ 154
acitretin ................................................................. 101
ACTEMRA ................................................... 140
ACTHIB (PF) ............................................ 132
ACTIMMUNE ........................................ 140
ACTOPLUS MET XR ..................... 47
acyclovir ................................................... 69, 101
acyclovir sodium ........................................... 69
ADACEL(TDAP
ADOLESN/ADULT)(PF) ...... 132
ADAGEN ........................................................ 109
adapalene ............................................................ 107
ADASUVE ........................................................ 60
ADCETRIS ...................................................... 24
ADCIRCA ...................................................... 156
adefovir ..................................................................... 69
ADEMPAS .................................................... 157
adrucil ......................................................................... 24
ADVAIR DISKUS ............................ 150
ADVAIR HFA ........................................ 151
afeditab cr ............................................................. 86
AFINITOR ....................................................... 24
AFINITOR DISPERZ .................... 24
AGGRENOX ................................................ 74
I-2
balziva (28) ........................................................ 94
BANZEL .............................................................. 36
BARACLUDE ............................................. 69
BCG VACCINE, LIVE (PF)
........................................................................................... 132
BD INSULIN PEN NEEDLE
UF SHORT ................................................... 108
BD INSULIN SYRINGE
ULTRA-FINE .......................................... 108
bekyree (28) ..................................................... 94
BELEODAQ ................................................... 25
benazepril ............................................................... 79
benazepril-hydrochlorothiazide
............................................................................................... 79
BENDEKA ....................................................... 25
BENICAR .......................................................... 78
BENICAR HCT ........................................ 78
BENLYSTA ................................................. 141
benztropine ............................................... 58, 59
BESIVANCE .............................................. 112
betamethasone acet,sod phos
........................................................................................... 123
betamethasone dipropionate ..... 104
betamethasone valerate ................... 104
betamethasone, augmented ........ 105
BETASERON ........................................... 141
betaxolol .................................................. 82, 145
bethanechol chloride ............................ 141
BETHKIS ............................................................ 13
BETOPTIC S .............................................. 145
bexarotene ............................................................ 25
BEXSERO (PF) ...................................... 133
bicalutamide ....................................................... 25
BICILLIN L-A ............................................ 20
BICNU ..................................................................... 25
BILTRICIDE ................................................. 58
bimatoprost ..................................................... 145
bisoprolol fumarate .................................. 82
bisoprolol-hydrochlorothiazide
............................................................................................... 82
BIVIGAM ....................................................... 129
bleomycin ............................................................... 25
bleph-10 ................................................................ 112
BLEPHAMIDE ...................................... 112
BLEPHAMIDE S.O.P. ................ 112
Index
ASMANEX HFA ................................ 151
ASMANEX TWISTHALER
........................................................................................... 151
aspirin-dipyridamole ............................... 74
ASSURE ID INSULIN
SAFETY ............................................................ 108
ASTAGRAF XL ................................... 129
astramorph-pf ...................................................... 3
atenolol ..................................................................... 82
atenolol-chlorthalidone ....................... 82
ATGAM ............................................................. 129
atorvastatin ......................................................... 88
atovaquone ........................................................... 58
atovaquone-proguanil ............................ 58
ATRIPLA ............................................................ 64
atropine ...................................................... 36, 110
atropine-care ................................................. 110
ATROVENT HFA ............................ 153
AUBAGIO ..................................................... 129
aubra ............................................................................ 94
AUVI-Q .................................................................. 84
AVASTIN ........................................................... 25
aviane .......................................................................... 94
avita ........................................................................... 107
AVODART ................................................... 140
AVONEX .......................................... 140, 141
AVONEX (WITH ALBUMIN)
........................................................................................... 140
AXERT ................................................................... 54
azacitidine ............................................................. 25
AZASAN .......................................................... 129
AZASITE ......................................................... 111
azathioprine .................................................... 129
azathioprine sodium ............................. 129
azelastine ............................................................ 110
AZILECT ............................................................ 58
azithromycin ...................................................... 18
AZOPT ................................................................. 145
aztreonam .............................................................. 19
azurette (28) .................................................... 94
baciim .......................................................................... 14
bacitracin ................................................ 14, 111
bacitracin-polymyxin b ................... 111
baclofen ................................................................. 155
balsalazide ........................................................ 137
Index
Index
amnesteem ........................................................ 101
amoxapine ............................................................ 42
amoxicil-clarithromy-lansopraz
........................................................................................... 115
amoxicillin ................................................. 19, 20
amoxicillin-pot clavulanate ........... 20
amphotericin b ................................................ 51
ampicillin ................................................................ 20
ampicillin sodium ........................................ 20
ampicillin-sulbactam .............................. 20
AMPYRA ........................................................... 91
ANADROL-50 ......................................... 121
anagrelide .............................................................. 74
anastrozole ........................................................... 24
ANDRODERM ..................................... 121
ANDROGEL ............................................. 121
androxy ................................................................. 121
ANORO ELLIPTA ........................... 153
anticoag citrate phos dextrose
........................................................................................... 140
ANTIVENIN
LATRODECTUS MACTANS
........................................................................................... 128
ANTIVENIN MICRURUS
FULVIUS ........................................................ 128
ANZEMET ....................................................... 56
APLENZIN ...................................................... 42
APOKYN ............................................................ 58
apraclonidine ................................................. 110
apri .................................................................................. 94
APTIOM ............................................................... 36
APTIVUS ............................................................. 64
ARALAST NP .......................... 154, 155
aranelle (28) ..................................................... 94
ARANESP (IN
POLYSORBATE) ........................ 72, 73
ARCALYST ................................................ 128
aripiprazole ......................................................... 60
ARISTADA ..................................................... 60
armodafinil ....................................................... 156
ARNUITY ELLIPTA ................... 151
ARRANON ..................................................... 24
ARZERRA ........................................................ 24
ASACOL HD ............................................. 137
ashlyna ....................................................................... 94
I-3
ceftazidime ........................................................... 17
CEFTAZIDIME IN D5W .......... 17
ceftibuten ................................................................ 17
ceftriaxone ........................................................... 17
ceftriaxone in dextrose,iso-os .... 17
cefuroxime axetil ........................................ 17
cefuroxime sodium ......................... 17, 18
celecoxib ..................................................................... 8
CELLCEPT ................................................... 129
CELLCEPT INTRAVENOUS
........................................................................................... 129
CELONTIN ..................................................... 37
cephalexin ............................................................. 18
CEREZYME ............................................... 109
CERUBIDINE ............................................ 25
CERVARIX VACCINE (PF)
........................................................................................... 133
cetirizine .................................................................. 53
cevimeline ........................................................... 100
CHANTIX ......................................................... 11
CHANTIX CONTINUING
MONTH BOX .............................................. 11
CHANTIX STARTING
MONTH BOX .............................................. 11
chloramphenicol sod succinate
............................................................................................... 14
chlorhexidine gluconate .................. 100
chloroquine phosphate .......................... 58
chlorothiazide ................................................... 87
chlorothiazide sodium ........................... 87
chlorpromazine ................................... 60, 61
chlorpropamide .............................................. 50
chlorthalidone .................................................. 87
chlorzoxazone .............................................. 155
CHOLBAM .................................................. 116
cholestyramine (with sugar) ....... 88
cholestyramine light ................................ 88
choline,magnesium salicylate ......... 8
CHORIONIC
GONADOTROPIN, HUMAN
........................................................................................... 124
CIALIS ................................................................. 157
ciclopirox .................................................... 51, 52
cidofovir ................................................................... 69
cilostazol ................................................................. 74
Index
camila .......................................................................... 94
camrese ..................................................................... 94
camrese lo .............................................................. 94
CANASA .......................................................... 137
CANCIDAS ..................................................... 51
candesartan ......................................................... 78
candesartan-hydrochlorothiazid
............................................................................................... 78
capacet .......................................................................... 3
CAPASTAT ..................................................... 55
CAPRELSA ..................................................... 25
captopril ................................................................... 80
captopril-hydrochlorothiazide ... 80
CARAFATE ............................................... 115
CARBAGLU .............................................. 116
carbamazepine ................................................ 37
carbidopa ................................................................ 59
carbidopa-levodopa .................................. 59
carbidopa-levodopa-entacapone
............................................................................................... 59
carboplatin ........................................................... 25
CARIMUNE NF
NANOFILTERED ........................... 129
carisoprodol .................................................... 155
carisoprodol-asa-codeine .............. 155
carisoprodol-aspirin ............................. 155
carteolol ............................................................... 110
cartia xt .................................................................... 83
carvedilol ................................................................ 82
CAYSTON ........................................................ 19
caziant (28) ....................................................... 94
cefaclor ...................................................................... 16
cefadroxil ............................................................... 16
cefazolin ................................................................... 16
cefazolin in dextrose (iso-os) .... 16
cefdinir ....................................................................... 16
cefditoren pivoxil ......................................... 16
cefepime ................................................................... 16
CEFOTAN ........................................................ 16
cefotaxime ............................................................ 16
cefotetan .................................................................. 17
cefoxitin ................................................................... 17
cefoxitin in dextrose, iso-osm ..... 17
cefpodoxime ....................................................... 17
cefprozil .................................................................... 17
Index
Index
BLINCYTO ...................................................... 25
blisovi 24 fe .......................................................... 94
blisovi fe 1.5/30 (28) .............................. 94
blisovi fe 1/20 (28) ................................... 94
BOOSTRIX TDAP ............................ 133
BOSULIF ............................................................ 25
BREO ELLIPTA .................................. 151
briellyn ....................................................................... 94
BRILINTA ........................................................ 74
brimonidine ...................................................... 145
BRINTELLIX .............................................. 42
BRIVIACT ............................................. 36, 37
bromfenac .......................................................... 114
bromocriptine ................................................... 59
BROVANA ................................................... 153
budesonide ........................... 114, 137, 151
bumetanide ........................................................... 87
BUPHENYL ............................................... 116
buprenorphine hcl ................................ 3, 10
buprenorphine-naloxone ......... 10, 11
buproban ................................................................. 42
bupropion hcl ......................................... 42, 43
bupropion hcl (smoking deter)
............................................................................................... 11
buspirone ............................................................. 141
BUSULFEX .................................................... 25
butalbital-acetaminophen .................... 3
butalbital-acetaminophen-caff ...... 3
butalbital-aspirin-caffeine ................... 3
butorphanol tartrate ................................... 3
BUTRANS ............................................................ 3
BYDUREON ................................................. 47
cabergoline ........................................................... 59
CABOMETYX ............................................ 25
CAFERGOT ................................................... 54
caffeine citrated ............................................ 91
caffeine-sodium benzoate ................. 92
calcipotriene ................................................... 101
calcipotriene-betamethasone ... 101
calcitonin (salmon) .............................. 138
calcitrene ............................................................. 101
calcitriol ................................................ 102, 138
calcium acetate ........................................... 119
calcium chloride ........................................ 146
calcium gluconate ................................... 146
I-4
Index
colchicine-probenecid ......................... 141
colestipol ................................................................. 88
colistin (colistimethate na) ........... 14
colocort ................................................................. 105
COMBIVENT RESPIMAT
........................................................................................... 153
COMETRIQ .................................................... 26
COMPLERA .................................................. 64
compro ....................................................................... 56
COMVAX (PF) ....................................... 133
CONDYLOX ............................................. 102
constulose ........................................................... 116
COPAXONE ............................................... 141
CORLANOR ................................................. 84
cormax ................................................................... 105
cortisone ............................................................... 123
COSMEGEN .................................................. 26
COTELLIC ....................................................... 26
COUMADIN ................................................. 70
CREON ............................................................... 109
CRESTOR .......................................................... 88
CRINONE ...................................................... 127
CRIXIVAN ...................................................... 65
cromolyn ................................ 111, 116, 155
cryselle (28) ...................................................... 94
CUBICIN ............................................................. 14
CUBICIN RF ................................................ 15
cyclafem 1/35 (28) ................................... 94
cyclafem 7/7/7 (28) ................................. 94
cyclobenzaprine ......................................... 155
cyclopentolate .............................................. 111
cyclophosphamide ...................................... 26
CYCLOPHOSPHAMIDE ......... 26
cycloserine ............................................................ 55
CYCLOSET ..................................................... 47
cyclosporine .................................................... 129
cyclosporine modified ........................ 129
cyproheptadine .................................... 53, 54
CYRAMZA ...................................................... 26
cyred ............................................................................. 95
CYSTAGON ............................................... 109
cysteine (l-cysteine) .................... 76, 77
cytarabine .............................................................. 26
cytarabine (pf) .............................................. 26
cytra-2 .................................................................... 146
Index
Index
CILOXAN ...................................................... 112
cimetidine ........................................................... 115
cimetidine hcl ................................................ 115
CIMZIA ............................................................. 129
CIMZIA POWDER FOR
RECONST ...................................................... 129
CINRYZE .......................................................... 73
CIPRODEX .................................................. 112
ciprofloxacin ...................................................... 22
ciprofloxacin (mixture) .................... 22
ciprofloxacin hcl ............................ 22, 112
ciprofloxacin in 5 % dextrose ..... 22
cisplatin .................................................................... 25
citalopram ............................................................. 43
cladribine ................................................................ 25
claravis ................................................................... 102
clarithromycin ................................................. 18
clindamycin hcl ............................................... 14
clindamycin in 5 % dextrose ........ 14
clindamycin palmitate hcl ................ 14
clindamycin pediatric ............................. 14
clindamycin phosphate
..................................................................... 14, 54, 103
clindamycin-benzoyl peroxide
........................................................................................... 103
CLINDESSE ................................................... 54
CLINISOL SF 15 % ............................. 76
clobetasol ............................................................ 105
clobetasol-emollient ............................. 105
clocortolone pivalate ........................... 105
CLOLAR .............................................................. 26
clomipramine .................................................... 43
clonazepam .......................................................... 12
clonidine ................................................................... 78
clonidine hcl ........................................................ 78
clopidogrel ............................................................ 74
clorazepate dipotassium ..................... 12
clorpres ...................................................................... 78
clotrimazole ........................................................ 52
clotrimazole-betamethasone ........ 52
clozapine ................................................................. 61
COARTEM ...................................................... 58
cocaine ....................................................................... 10
codeine sulfate ..................................................... 3
colchicine ............................................................ 141
146
d2.5 %-0.45 % sodium chloride
........................................................................................... 146
d5 % and 0.9 % sodium chloride
........................................................................................... 146
........................................................................................... 146
dacarbazine ......................................................... 26
DALIRESP .................................................... 155
danazol ................................................................... 121
dantrolene .......................................................... 155
dapsone ..................................................................... 55
DAPTACEL (DTAP
PEDIATRIC) (PF) ............................. 133
DARAPRIM .................................................. 58
DARZALEX .................................................. 26
dasetta 1/35 (28) ........................................ 95
dasetta 7/7/7 (28) ...................................... 95
daunorubicin ...................................................... 26
DAUNOXOME ......................................... 26
daysee .......................................................................... 95
deblitane .................................................................. 95
decitabine ............................................................... 26
deferoxamine ................................................. 120
deltasone .............................................................. 123
delyla (28) ........................................................... 95
DELZICOL ................................................... 137
demeclocycline ................................................ 23
DEMSER ............................................................. 84
DENAVIR ...................................................... 102
denta 5000 plus ........................................... 100
dentagel ................................................................. 101
DEPEN TITRATABS .................. 120
DEPOCYT (PF) ......................................... 26
DEPO-PROVERA ............................. 127
DESCOVY ......................................................... 65
desipramine ......................................................... 43
desloratadine ..................................................... 54
desmopressin ................................... 124, 125
desog-e.estradiol/e.estradiol ......... 95
desogestrel-ethinyl estradiol ......... 95
desonide ................................................................ 105
desoximetasone .......................................... 105
DESVENLAFAXINE ...................... 43
...........................................................................................
I-5
DUAVEE ......................................................... 122
DULERA ......................................................... 151
duloxetine .............................................................. 43
DURAMORPH (PF) ............................. 4
DUREZOL .................................................... 114
dutasteride ........................................................ 141
e.e.s. 400 .................................................................. 18
econazole ................................................................ 52
EDARBI ................................................................ 79
EDARBYCLOR ....................................... 79
EDURANT ...................................................... 65
effer-k ...................................................................... 146
EFFIENT ............................................................ 75
ELAPRASE .................................................. 109
electrolyte-48 in d5w ........................... 147
ELELYSO ....................................................... 109
ELIDEL .............................................................. 105
ELIGARD .......................................................... 27
elinest .......................................................................... 95
eliphos ..................................................................... 119
ELIQUIS ............................................................... 70
ELITEK .............................................................. 109
elixophyllin ...................................................... 153
ELLA ......................................................................... 95
ELMIRON ..................................................... 141
EMCYT .................................................................. 27
EMEND ................................................................. 56
emoquette ............................................................... 95
EMPLICITI ...................................................... 27
EMSAM ................................................................. 43
EMTRIVA ......................................................... 65
enalapril maleate ......................................... 80
enalaprilat ............................................................. 80
enalapril-hydrochlorothiazide .... 80
ENBREL ........................................................... 130
ENBREL SURECLICK ............ 130
endocet .......................................................................... 4
endodan ........................................................................ 4
ENGERIX-B (PF) .............................. 133
........................................................................................... 133
enoxaparin ................................................ 70, 71
enpresse .................................................................... 95
enskyce ...................................................................... 95
entacapone ............................................................ 59
Index
dicyclomine ....................................... 116, 117
didanosine .............................................................. 65
diflorasone ........................................................ 105
diflunisal ...................................................................... 9
digitek ......................................................................... 84
digox ............................................................................. 84
digoxin ............................................................ 84, 85
DIGOXIN ........................................................... 85
dihydrocodeine-aspirin-caff .............. 4
dihydroergotamine .................................... 54
DILANTIN ...................................................... 37
DILANTIN EXTENDED ......... 37
DILANTIN INFATABS ............. 37
diltiazem hcl ............................................ 83, 84
dilt-xr .......................................................................... 84
dimenhydrinate ............................................... 56
DIPENTUM ................................................ 137
diphenhydramine hcl ............................... 54
diphenoxylate-atropine .................... 117
dipyridamole ...................................................... 74
disopyramide phosphate ..................... 81
disulfiram ............................................................... 11
divalproex .............................................................. 37
dobutamine .......................................................... 85
dobutamine in d5w ..................................... 85
DOCEFREZ ................................................... 27
docetaxel ................................................................. 27
dofetilide ................................................................. 81
donepezil ................................................................. 41
dopamine ................................................................. 85
dopamine in 5 % dextrose ................ 85
dorzolamide ..................................................... 145
dorzolamide-timolol ............................. 145
doxazosin ............................................................... 78
doxepin ...................................................................... 43
doxercalciferol ............................................ 138
doxorubicin .......................................................... 27
doxorubicin, peg-liposomal ........... 27
doxy-100 ................................................................. 23
doxycycline hyclate .................................. 23
doxycycline monohydrate ................ 23
dronabinol ............................................................. 56
droperidol ........................................................... 141
drospirenone-ethinyl estradiol ... 95
DROXIA .............................................................. 27
Index
Index
desvenlafaxine ................................................. 43
DESVENLAFAXINE
FUMARATE ................................................. 43
dexamethasone ........................................... 123
DEXAMETHASONE
INTENSOL ................................................... 123
............................................................................ 114, 123
dexmethylphenidate ................................. 92
dexrazoxane hcl ........................................ 141
dextroamphetamine ................................. 92
dextroamphetamine-amphetamine
............................................................................................... 92
dextrose 10 % and 0.2 % nacl
........................................................................................... 146
............................................................................................... 77
............................................................................................... 77
............................................................................................... 77
............................................................................................... 77
dextrose 5 % in ringers ........................ 77
dextrose 5 % in water (d5w) ...... 77
dextrose 5 %-lactated ringers
........................................................................................... 146
dextrose 5%-0.2 % sod chloride
........................................................................................... 146
dextrose 5%-0.3 % sod.chloride
........................................................................................... 146
............................................................................................... 77
............................................................................................... 77
dextrose with sodium chloride
........................................................................................... 146
dextrose-kcl-nacl ..................................... 146
diazepam ...................................................... 12, 13
diazepam intensol ........................................ 12
DICLEGIS ......................................................... 56
diclofenac potassium .................................. 8
diclofenac sodium ..................... 8, 9, 114
diclofenac-misoprostol ............................. 9
dicloxacillin ......................................................... 20
I-6
FLECTOR ............................................................. 9
FLOVENT DISKUS ...................... 151
FLOVENT HFA ................................... 152
floxuridine ............................................................. 28
flucaine .................................................................. 111
fluconazole ........................................................... 52
fluconazole in dextrose(iso-o)
............................................................................................... 52
fluconazole in nacl (iso-osm) ..... 52
flucytosine ............................................................. 52
fludarabine ........................................................... 28
fludrocortisone ............................................ 123
flumazenil .............................................................. 92
flunisolide ........................................................... 114
fluocinolone ..................................................... 106
fluocinolone acetonide oil ............. 114
fluocinonide ..................................................... 106
fluocinonide-e ............................................... 106
fluoridex daily defense ..................... 101
fluorometholone ........................................ 114
FLUOROPLEX ..................................... 102
fluorouracil ........................................... 28, 102
fluoxetine ............................................................... 44
FLUOXETINE ........................................... 44
fluphenazine decanoate ....................... 61
fluphenazine hcl ............................................. 61
flurbiprofen ............................................................. 9
flurbiprofen sodium .............................. 114
flutamide ................................................................. 28
fluticasone .......................................... 106, 114
fluvastatin .............................................................. 89
fluvoxamine ........................................................ 44
FML FORTE ............................................. 114
FML S.O.P. ................................................... 114
FOLOTYN ........................................................ 28
fomepizole ......................................................... 141
fondaparinux ..................................................... 71
FORADIL AEROLIZER ....... 153
FORFIVO XL .............................................. 44
FORTEO .......................................................... 139
FORTICAL .................................................. 139
FOSAMAX PLUS D ...................... 139
foscarnet .................................................................. 68
fosinopril ................................................................. 80
Index
ESTRING ........................................................ 122
estropipate ........................................................ 122
ethambutol ............................................................ 55
ethamolin ................................................................ 85
ethosuximide ...................................................... 37
etidronate disodium .............................. 138
etodolac ........................................................................ 9
ETOPOPHOS ................................................ 27
etoposide ................................................................. 27
EVOTAZ .............................................................. 65
exemestane ........................................................... 28
EXJADE ............................................................ 121
FABIOR ............................................................ 107
FABRAZYME ........................................ 109
falmina (28) ...................................................... 95
famciclovir ............................................................ 70
famotidine ........................................... 115, 116
famotidine (pf) .......................................... 115
famotidine (pf)-nacl (iso-os)
........................................................................................... 115
FANAPT .............................................................. 61
FARESTON .................................................... 28
FARYDAK ...................................................... 28
FASLODEX .................................................... 28
felbamate ................................................................ 37
felodipine ................................................................ 86
FEMRING .................................................... 122
fenofibrate ................................................. 88, 89
fenofibrate micronized ......................... 88
fenofibrate nanocrystallized ......... 88
fenofibric acid .................................................. 89
fenofibric acid (choline) ................... 89
fenoprofen ................................................................. 9
fentanyl ......................................................................... 4
fentanyl citrate ................................................... 4
FERRIPROX ............................................. 121
FETZIMA .......................................................... 44
finasteride .......................................................... 141
FIRAZYR .......................................................... 85
FIRMAGON KIT W
DILUENT SYRINGE ..................... 28
FLAREX .......................................................... 114
flavoxate .............................................................. 120
FLEBOGAMMA DIF ................. 130
flecainide ................................................................. 81
Index
Index
entecavir .................................................................. 69
ENTRESTO ..................................................... 79
enulose .................................................................... 117
ENVARSUS XR ................................... 130
ephedrine sulfate .......................................... 85
epinastine ............................................................ 111
epinephrine ........................................................... 85
epinephrine hcl (pf) ................................. 85
EPIPEN 2-PAK .......................................... 85
EPIPEN JR 2-PAK ............................... 85
epirubicin ................................................................ 27
epitol ............................................................................. 37
eplerenone ............................................................. 90
EPOGEN .............................................................. 73
epoprostenol (glycine) ..................... 157
eprosartan ............................................................. 79
EPZICOM .......................................................... 65
ERAXIS(WATER DILUENT)
............................................................................................... 52
ERBITUX ........................................................... 27
ergoloid ................................................................. 141
ERIVEDGE ..................................................... 27
errin ............................................................................... 95
ERWINAZE .................................................... 27
ery pads ................................................................. 103
ery-tab ........................................................................ 18
ERY-TAB ............................................................ 19
ERYTHROCIN ......................................... 19
erythrocin (as stearate) .................... 19
erythromycin ...................................... 19, 112
erythromycin ethylsuccinate ........ 19
erythromycin with ethanol .......... 103
erythromycin-benzoyl peroxide
........................................................................................... 103
ESBRIET .......................................................... 155
escitalopram oxalate ................... 43, 44
esmolol ....................................................................... 82
esomeprazole magnesium ............. 115
esomeprazole sodium .......................... 115
estarylla ................................................................... 95
estazolam ............................................................... 13
ESTRACE ....................................................... 122
estradiol ................................................................ 122
estradiol valerate ...................................... 122
estradiol-norethindrone acet .... 122
80
fosphenytoin ....................................................... 37
FOSRENOL ................................................ 119
furosemide ............................................................. 87
FUSILEV ......................................................... 141
FUZEON ............................................................. 65
fyavolv .................................................................... 122
FYCOMPA ............................................ 37, 38
gabapentin ............................................................ 38
GABITRIL ........................................................ 38
galantamine ............................................. 41, 42
GAMASTAN S/D ............................... 130
GAMMAGARD LIQUID .... 130
GAMUNEX-C ......................................... 130
ganciclovir sodium ..................................... 70
GARDASIL (PF) .................. 133, 134
GARDASIL 9 (PF) ........................... 134
gatifloxacin ...................................................... 112
GATTEX 30-VIAL ............................ 117
GATTEX ONE-VIAL .................. 117
GAUZE PAD ............................................ 141
gavilyte-c ............................................................. 118
gavilyte-g ............................................................ 118
gavilyte-h and bisacodyl ................. 118
gavilyte-n ............................................................ 118
GAZYVA ............................................................. 28
gemcitabine ......................................................... 28
gemfibrozil ........................................................... 89
generlac ................................................................. 117
gengraf ................................................................... 130
GENOTROPIN ...................................... 125
GENOTROPIN MINIQUICK
........................................................................................... 125
gentak ...................................................................... 112
gentamicin ............................... 13, 103, 112
gentamicin in nacl (iso-osm) ...... 13
gentamicin sulfate (ped) (pf) ... 13
gentamicin sulfate (pf) ....................... 14
GENVOYA ...................................................... 65
GEODON ........................................................... 61
gianvi (28) ........................................................... 95
gildagia ..................................................................... 95
gildess 1.5/30 (21) .................................... 95
gildess 1/20 (21) .......................................... 95
...............................................................................................
I-7
heparin(porcine) in 0.45% nacl
Index
gildess 24 fe ......................................................... 95
gildess fe 1.5/30 (28) ............................. 95
gildess fe 1/20 (28) .................................. 95
GILENYA ...................................................... 141
GILOTRIF ........................................................ 28
GLEEVEC .......................................................... 28
GLEOSTINE ................................................. 29
glimepiride ............................................................ 50
glipizide .................................................................... 50
glipizide-metformin .................................. 50
GLUCAGEN HYPOKIT ....... 141
GLUCAGON EMERGENCY
KIT (HUMAN) ...................................... 141
glyburide ................................................................. 51
glyburide micronized ................... 50, 51
glyburide-metformin ............................... 51
glycopyrrolate .............................................. 117
glydo ............................................................................. 10
GLYSET ............................................................... 47
GLYXAMBI ................................................... 47
GOLYTELY ............................................... 118
granisetron (pf) ............................................ 56
granisetron hcl ................................................ 56
GRANIX .............................................................. 73
griseofulvin microsize ............................ 52
griseofulvin ultramicrosize ............. 52
guanfacine ............................................................. 92
guanidine ............................................................. 141
HALAVEN ....................................................... 29
halobetasol propionate ..................... 106
haloperidol ............................................................ 61
haloperidol decanoate ........................... 61
haloperidol lactate ..................................... 61
HARVONI ......................................................... 68
HAVRIX (PF) ........................................... 134
heather ....................................................................... 96
HECTOROL ............................................... 139
heparin (porcine) ....................................... 71
heparin (porcine) in 5 % dex
.................................................................................... 71, 72
HEPARIN (PORCINE) IN 5 %
DEX ............................................................................. 71
heparin (porcine) in nacl (pf)
.................................................................................... 71, 72
Index
Index
fosinopril-hydrochlorothiazide
72
HEPARIN(PORCINE) IN
0.45% NACL ................................................... 72
heparin, porcine (pf) ............................. 71
HERCEPTIN ................................................. 29
HETLIOZ ........................................................ 156
HEXALEN ........................................................ 29
HIBERIX (PF) ......................................... 134
HIZENTRA ................................................. 130
homatropaire ................................................. 111
homatropine hbr ........................................ 111
HUMATROPE ....................................... 125
HUMIRA ......................................................... 131
HUMIRA PEN ....................................... 130
HUMIRA PEN
CROHN'S-UC-HS START
........................................................................................... 130
hydralazine .......................................................... 86
hydrochlorothiazide ................................. 87
hydrocodone-acetaminophen ........... 4
hydrocodone-ibuprofen ........................... 4
hydrocortisone .............................. 106, 123
hydrocortisone butyrate ................. 106
hydrocortisone butyr-emollient
........................................................................................... 106
hydrocortisone valerate .... 106, 107
hydrocortisone-acetic acid .......... 112
hydromorphone .......................................... 4, 5
hydromorphone (pf) .................................. 4
hydroxychloroquine ................................. 58
hydroxyprogesterone caproate
........................................................................................... 127
hydroxyurea ....................................................... 29
hydroxyzine hcl ........................... 141, 142
hydroxyzine pamoate ......................... 142
hypercare ............................................................ 102
HYQVIA ........................................................... 131
HYQVIA IG COMPONENT
........................................................................................... 131
ibandronate ...................................................... 139
IBRANCE .......................................................... 29
ibuprofen ..................................................................... 9
ibuprofen-oxycodone ................................. 5
ICLUSIG .............................................................. 29
...............................................................................................
I-8
klor-con m20 .................................................. 147
klor-con sprinkle ....................................... 147
KLOR-CON/EF .................................... 147
KORLYM ........................................................... 48
KRISTALOSE ......................................... 117
kurvelo ....................................................................... 96
KUVAN ............................................................. 109
KYNAMRO .................................................... 89
KYPROLIS ...................................................... 30
l norgest/e.estradiol-e.estrad ....... 96
labetalol ................................................................... 82
LACTATED RINGERS ........... 138
lactulose ............................................................... 117
LAMICTAL .................................................... 38
(BLUE) .................................................................... 38
(GREEN) ............................................................. 38
(ORANGE) ....................................................... 38
LAMICTAL STARTER
(GREEN) KIT .............................................. 38
LAMICTAL STARTER
(ORANGE) KIT ....................................... 38
LAMICTAL XR STARTER
(BLUE) .................................................................... 38
LAMICTAL XR STARTER
(GREEN) ............................................................. 38
LAMICTAL XR STARTER
(ORANGE) ....................................................... 39
lamivudine ............................................................. 66
lamivudine-zidovudine .......................... 66
lamotrigine ........................................................... 39
LANOXIN ......................................................... 86
lansoprazole .................................................... 116
LANTUS .............................................................. 49
LANTUS SOLOSTAR .................... 49
larin 1.5/30 (21) .......................................... 96
larin 1/20 (21) ................................................ 96
larin 24 fe ............................................................... 96
larin fe 1.5/30 (28) ................................... 96
larin fe 1/20 (28) ......................................... 97
latanoprost ....................................................... 145
LATUDA ............................................................. 62
layolis fe .................................................................. 97
Index
itraconazole ........................................................ 52
ivermectin .............................................................. 58
IXEMPRA ......................................................... 30
IXIARO (PF) .............................................. 134
JAKAFI ................................................................. 30
jantoven .................................................................... 72
JANUMET ........................................................ 47
JANUMET XR .......................................... 47
JANUVIA ........................................................... 47
JARDIANCE ................................................ 48
jencycla ..................................................................... 96
JEVTANA .......................................................... 30
jinteli ......................................................................... 122
jolessa .......................................................................... 96
jolivette ...................................................................... 96
juleber ......................................................................... 96
junel 1.5/30 (21) .......................................... 96
junel 1/20 (21) ................................................ 96
junel fe 1.5/30 (28) .................................. 96
junel fe 1/20 (28) ........................................ 96
junel fe 24 ............................................................... 96
JUXTAPID ....................................................... 89
KADCYLA ...................................................... 30
kaitlib fe ................................................................... 96
KALETRA ............................................. 65, 66
KALYDECO .............................................. 155
kariva (28) .......................................................... 96
KAYEXALATE .................................... 117
k-effervescent ................................................ 147
kelnor 1/35 (28) ........................................... 96
KENALOG ................................................... 124
KEPIVANCE ............................................. 142
KETEK ................................................................... 19
ketoconazole ...................................................... 52
ketoprofen ................................................................. 9
ketorolac ............................................................. 114
KEYTRUDA ................................................. 30
kimidess (28) ................................................... 96
KINERET ....................................................... 131
kionex ...................................................................... 117
KLOR-CON ................................................ 147
klor-con 10 ....................................................... 147
KLOR-CON 8 ........................................... 147
klor-con m10 .................................................. 147
klor-con m15 .................................................. 147
Index
Index
idarubicin ............................................................... 29
ifosfamide .............................................................. 29
ifosfamide-mesna ......................................... 29
ILARIS (PF) ................................................ 131
imatinib ..................................................................... 29
IMBRUVICA ................................................ 29
imipenem-cilastatin .................................. 19
imipramine hcl ................................................. 44
imipramine pamoate ............................... 44
imiquimod .......................................................... 102
IMLYGIC ........................................................... 29
IMOVAX RABIES VACCINE
(PF) ............................................................................ 134
INCRELEX .................................................. 125
indapamide ........................................................... 87
INFANRIX (DTAP) (PF) ...... 134
INLYTA ................................................................ 29
INNOPRAN XL ....................................... 82
INSULIN SYRINGE-NEEDLE
U-100 ....................................................................... 108
INTELENCE ................................................. 65
INTRALIPID ................................................ 77
INTRON A ............................................ 68, 69
introvale ................................................................... 96
INVANZ ............................................................... 19
INVEGA .................................................... 61, 62
INVEGA SUSTENNA ................... 62
INVEGA TRINZA ............................... 62
INVIRASE ........................................................ 65
INVOKAMET ............................................. 47
INVOKANA .................................................. 47
IPOL ........................................................................ 134
ipratropium bromide ............ 111, 153
ipratropium-albuterol ........................ 153
irbesartan ............................................................... 79
irbesartan-hydrochlorothiazide
............................................................................................... 79
IRESSA ................................................................... 29
irinotecan ............................................................... 29
ISENTRESS .................................................... 65
isoniazid ........................................................ 55, 56
isosorbide dinitrate ........................ 90, 91
isosorbide mononitrate ........................ 91
isradipine ................................................................ 86
ISTODAX ........................................................... 29
I-9
magnesium sulfate in water
............................................................................ 147, 148
malathion ............................................................ 108
maprotiline ........................................................... 44
margesic ...................................................................... 5
marlissa .................................................................... 97
MARPLAN ...................................................... 44
MARQIBO ........................................................ 31
marten-tab ................................................................ 5
MATULANE ................................................ 31
matzim la ................................................................ 84
MAXIDEX .................................................... 114
meclizine .................................................................. 57
meclofenamate .................................................... 9
medroxyprogesterone ........................ 127
mefenamic acid .................................................. 9
mefloquine ............................................................. 58
MEGACE ES ............................................. 127
megestrol ................................................. 31, 127
MEKINIST ....................................................... 31
meloxicam ................................................................ 9
melphalan hcl .................................................... 31
memantine ............................................................. 42
MENACTRA (PF) ............................ 134
MENEST .......................................................... 122
MENHIBRIX (PF) ............................ 134
MENOMUNE - A/C/Y/W-135
(PF) ............................................................................ 135
MENVEO A-C-Y-W-135-DIP
(PF) ............................................................................ 135
MENVEO MENA
COMPONENT (PF) ........................ 135
MENVEO MENCYW-135
COMPNT (PF) ........................................ 135
meprobamate ................................................. 142
mercaptopurine .............................................. 31
meropenem ........................................................... 19
mesalamine ...................................................... 137
mesalamine with cleansing wipe
........................................................................................... 137
mesna ....................................................................... 142
MESNEX ......................................................... 142
metaproterenol ............................................ 153
metaxalone ....................................................... 155
metformin .............................................................. 48
Index
LINZESS .......................................................... 117
liothyronine ...................................................... 128
lipodox ....................................................................... 30
lipodox 50 .............................................................. 30
lisinopril ................................................................... 80
lisinopril-hydrochlorothiazide .... 80
lithium carbonate ........................................ 92
lithium citrate ................................................... 92
lomedia 24 fe ..................................................... 97
lomustine ................................................................. 30
LONSURF ........................................................ 30
loperamide ........................................................ 117
lopreeza ................................................................. 122
lorazepam .............................................................. 13
lorazepam intensol ..................................... 13
loryna (28) .......................................................... 97
losartan ..................................................................... 79
losartan-hydrochlorothiazide ...... 79
LOTEMAX ................................................... 114
LOTRONEX ............................................... 117
lovastatin ................................................................ 89
low-ogestrel (28) ........................................ 97
loxapine succinate ...................................... 62
LUMIGAN ................................................... 145
LUPRON DEPOT ................................. 31
............................................................................................... 31
............................................................................................... 31
............................................................................................... 31
LUPRON DEPOT-PED ........... 125
LUPRON DEPOT-PED (3
MONTH) .......................................................... 125
lutera (28) ........................................................... 97
LYNPARZA ................................................... 31
LYRICA ................................................................ 39
LYSODREN ................................................... 31
lyza ................................................................................. 97
magnebind 400 ............................................ 119
magnesium chloride .............................. 147
magnesium sulf in 0.45% nacl
........................................................................................... 147
magnesium sulfate .................................. 148
magnesium sulfate in d5w ............ 147
Index
Index
LAZANDA ........................................................... 5
leena 28 ..................................................................... 97
leflunomide ....................................................... 131
LENVIMA ......................................................... 30
lessina .......................................................................... 97
LETAIRIS ...................................................... 157
letrozole .................................................................... 30
leucovorin calcium .................................. 142
LEUKERAN .................................................. 30
LEUKINE .......................................................... 73
leuprolide ................................................................ 30
levalbuterol hcl ............................................ 153
LEVEMIR .......................................................... 49
LEVEMIR FLEXTOUCH ........ 49
levetiracetam ..................................................... 39
levetiracetam in nacl (iso-os) .... 39
levobunolol ........................................................ 145
levocarnitine ................................................... 142
levocarnitine (with sugar) .......... 142
levocetirizine ...................................................... 54
levofloxacin .......................................... 22, 112
levofloxacin in d5w ................................... 22
levoleucovorin calcium ..................... 142
levonest (28) ..................................................... 97
levonorgestrel ................................................... 97
levonorgestrel-ethinyl estrad ....... 97
levonorg-eth estrad triphasic ....... 97
levora-28 ................................................................. 97
levorphanol tartrate ..................................... 5
levothyroxine .................................. 127, 128
LEVOXYL ..................................................... 128
LEVULAN .................................................... 102
LEXIVA ................................................................. 66
lidocaine ................................................................... 10
lidocaine (pf) in d7.5w ...................... 81
lidocaine (pf) ........................................ 10, 81
lidocaine hcl ........................................................ 10
lidocaine in 5 % dextrose (pf)
............................................................................................... 81
lidocaine viscous ........................................... 10
lidocaine-prilocaine .................................. 10
LINCOCIN ....................................................... 15
lincomycin ............................................................. 15
lindane .................................................................... 108
linezolid .................................................................... 15
I-10
naftifine .................................................................... 53
NAFTIN ............................................................... 53
NAGLAZYME ....................................... 109
nalbuphine ................................................................. 7
naloxone .................................................................. 11
naltrexone ............................................................. 11
NAMENDA .................................................... 42
NAMENDA TITRATION
PAK .............................................................................. 42
naphazoline ...................................................... 111
naproxen ..................................................................... 9
naproxen sodium .............................................. 9
naratriptan ........................................................... 55
NARCAN ........................................................... 11
NASONEX .................................................... 115
nateglinide ............................................................. 48
NATPARA .................................................... 139
NEBUPENT .................................................... 58
necon 0.5/35 (28) ....................................... 98
necon 1/35 (28) ............................................. 98
necon 1/50 (28) ............................................. 98
necon 10/11 (28) ......................................... 98
necon 7/7/7 (28) ........................................... 98
nefazodone ............................................................ 45
neomycin ................................................................. 14
neomycin-bacitracin-poly-hc ... 112
neomycin-bacitracin-polymyxin
........................................................................................... 112
neomycin-polymyxin b gu ............ 103
........................................................................................... 112
neomycin-polymyxin-gramicidin
........................................................................................... 113
neomycin-polymyxin-hc ................. 113
neo-polycin hc .............................................. 113
NEOSTIGMINE
METHYLSULFATE ..................... 142
NEULASTA .................................................... 73
NEUMEGA ..................................................... 73
NEUPOGEN .................................................. 73
NEUPRO ............................................................. 59
nevirapine ............................................................... 66
NEXAVAR ....................................................... 32
NEXIUM PACKET ........................ 116
niacin ............................................................................ 89
Index
minitran .................................................................... 91
minocycline .......................................................... 24
minoxidil ................................................................. 91
mirtazapine .......................................................... 45
misoprostol ....................................................... 116
mitomycin .............................................................. 31
mitoxantrone ..................................................... 31
M-M-R II (PF) ......................................... 135
modafinil ............................................................. 156
moexipril ................................................................. 80
moexipril-hydrochlorothiazide
............................................................................................... 80
molindone ............................................................... 62
mometasone ..................................... 107, 115
mono-linyah ........................................................ 97
mononessa (28) ............................................ 98
montelukast ..................................................... 152
morphine .............................................................. 5, 6
MORPHINE ....................................................... 6
morphine (pf) ...................................................... 5
morphine (pf) in dextrose 5 % ..... 5
morphine concentrate ................................ 6
morphine in 0.9 % nacl ............................ 6
morrhuate sodium ................................... 142
MOVANTIK .............................................. 117
MOVIPREP .................................................. 118
moxifloxacin ...................................................... 22
moxifloxacin-sod.ace,sul-water
............................................................................................... 15
MOZOBIL .......................................................... 73
MULTAQ ........................................................... 81
multivitamin with fluoride ........... 158
mupirocin ............................................................ 103
mupirocin calcium .................................. 103
MUSTARGEN ........................................... 32
mycophenolate mofetil ..................... 131
mycophenolate sodium ..................... 131
myorisan .............................................................. 102
MYOZYME ................................................. 109
MYRBETRIQ ........................................... 120
myzilra ....................................................................... 98
nabumetone ............................................................. 9
nadolol ....................................................................... 82
nadolol-bendroflumethiazide ....... 83
nafcillin ..................................................................... 21
Index
Index
methadone ................................................................. 5
methadone intensol ....................................... 5
methadose ................................................................. 5
methamphetamine ...................................... 92
methazolamide ............................................ 145
methenamine hippurate ....................... 15
methimazole .................................................... 128
METHITEST ............................................. 121
methocarbamol ........................................... 156
methotrexate sodium .............................. 31
methotrexate sodium (pf) .............. 31
methoxsalen rapid .................................. 102
methscopolamine ...................................... 117
methyclothiazide .......................................... 87
methylene blue (antidote) ........... 142
methylergonovine .................................... 142
methylphenidate ................................. 92, 93
methylprednisolone ............................... 124
methylprednisolone acetate ....... 124
methylprednisolone sodium succ
........................................................................................... 124
metipranolol .................................................... 145
metoclopramide hcl ............................... 117
metolazone ........................................................... 88
metoprolol succinate ............................... 82
metoprolol ta-hydrochlorothiaz
............................................................................................... 82
metoprolol tartrate ................................... 82
metronidazole ......................... 15, 54, 103
metronidazole in nacl (iso-os)
............................................................................................... 15
mexiletine .............................................................. 81
MIACALCIN ............................................ 139
miconazole-3 ...................................................... 53
microgestin 1.5/30 (21) ..................... 97
microgestin 1/20 (21) ........................... 97
microgestin fe 1.5/30 (28) .............. 97
microgestin fe 1/20 (28) ................... 97
midodrine ............................................................... 78
MIGERGOT .................................................. 54
miglitol ...................................................................... 48
milrinone ................................................................. 86
milrinone in 5 % dextrose ................ 86
mimvey ................................................................... 122
mimvey lo ........................................................... 122
I-11
ORENCIA CLICKJECT ......... 143
ORENITRAM ......................................... 157
ORFADIN ..................................................... 109
ORKAMBI .................................................... 155
orphenadrine citrate ............................ 156
orsythia ..................................................................... 99
OSMOPREP ................................................ 119
OTEZLA ........................................................... 143
OTEZLA STARTER ..................... 143
oxacillin .................................................................... 21
oxacillin in dextrose(iso-osm)
............................................................................................... 21
oxaliplatin ............................................................. 32
oxandrolone .................................................... 121
oxaprozin ................................................................... 9
oxazepam ............................................................... 13
oxcarbazepine ....................................... 39, 40
OXSORALEN .......................................... 102
OXTELLAR XR ...................................... 40
oxybutynin chloride .............................. 120
oxycodone ................................................................. 7
oxycodone-acetaminophen ................. 7
oxycodone-aspirin .......................................... 7
OXYCONTIN .................................................. 7
oxymorphone ........................................................ 7
pacerone ................................................................... 81
paclitaxel ................................................................ 32
paliperidone ........................................................ 63
pamidronate .................................................... 139
pancrelipase 5000 .................................... 110
PANRETIN .................................................. 102
pantoprazole ................................................... 116
papaverine ............................................................. 86
PARICALCITOL ................................ 139
paricalcitol ........................................................ 139
paromomycin .................................................... 58
paroxetine hcl ................................................... 45
PASER ..................................................................... 56
PATADAY .................................................... 111
PAXIL ...................................................................... 45
PCE ............................................................................... 19
PEDVAX HIB (PF) .......................... 135
peg 3350-electrolytes .......................... 119
PEGANONE .................................................. 40
PEGASYS ........................................................... 69
Index
NOVOLOG MIX 70-30
FLEXPEN .......................................................... 49
NOVOLOG PENFILL .................... 49
NOXAFIL .......................................................... 53
NPLATE ........................................................... 143
NUCALA ........................................................ 155
NUEDEXTA .................................................. 93
NULOJIX ........................................................ 131
NUPLAZID ..................................................... 63
NUTRILIPID ............................................... 77
NUTROPIN AQ ................................... 126
NUTROPIN AQ NUSPIN .... 126
NUVARING .................................................. 98
NUVIGIL ........................................................ 156
nyamyc ...................................................................... 53
nystatin ..................................................................... 53
nystatin-triamcinolone ......................... 53
nystop .......................................................................... 53
ocella ............................................................................ 99
octreotide acetate .................................... 126
ODEFSEY .......................................................... 66
ODOMZO ........................................................... 32
OFEV ..................................................................... 155
ofloxacin .................................................. 22, 113
ogestrel (28) ..................................................... 99
olanzapine ............................................................. 63
olanzapine-fluoxetine ............................ 45
OLEPTRO ER ............................................. 45
olopatadine ....................................................... 111
omega-3 acid ethyl esters ................. 89
omeprazole ....................................................... 116
omeprazole-sodium bicarbonate
........................................................................................... 116
OMNITROPE ........................................... 126
ONCASPAR ................................................... 32
ondansetron ......................................................... 57
ondansetron hcl .............................................. 57
ondansetron hcl (pf) ............................... 57
ONFI ........................................................... 13, 107
onxol ............................................................................. 32
OPDIVO ................................................................ 32
OPSUMIT ....................................................... 157
oralone ................................................................... 101
ORAP ........................................................................ 63
ORENCIA ...................................................... 131
Index
Index
niacor ........................................................................... 89
nicardipine ............................................................ 87
NICOTROL NS ......................................... 11
nifedical xl ............................................................ 87
nifedipine ................................................................ 87
nikki (28) .............................................................. 98
NILANDRON ............................................. 32
nilutamide .............................................................. 32
nimodipine ............................................................. 87
NINLARO ......................................................... 32
NIPENT ................................................................. 32
nisoldipine ............................................................. 87
NITRO-DUR ................................................ 91
nitrofurantoin macrocrystal ......... 15
nitrofurantoin monohyd/m-cryst
............................................................................................... 15
nitroglycerin ....................................................... 91
nitroglycerin in 5 % dextrose ...... 91
NITROSTAT ................................................. 91
nizatidine ............................................................. 116
nora-be ....................................................................... 98
NORDITROPIN FLEXPRO
........................................................................................... 125
norepinephrine bitartrate ................. 86
norethindrone (contraceptive)
............................................................................................... 98
norethindrone acetate ........................ 127
norethindrone ac-eth estradiol
................................................................................ 98, 123
norethindrone-e.estradiol-iron ... 98
norgestimate-ethinyl estradiol ... 98
norlyroc .................................................................... 98
NORTHERA ................................................. 78
nortrel 0.5/35 (28) .................................... 98
nortrel 1/35 (21) .......................................... 98
nortrel 1/35 (28) .......................................... 98
nortrel 7/7/7 (28) ....................................... 98
nortriptyline ........................................................ 45
NORVIR ............................................................... 66
NOVOLIN 70/30 ....................................... 49
NOVOLIN N ................................................. 49
NOVOLIN R .................................................. 49
NOVOLOG ...................................................... 49
NOVOLOG FLEXPEN ................. 49
NOVOLOG MIX 70-30 .................. 49
I-12
PRED-G ............................................................. 113
prednicarbate ................................................ 107
prednisolone acetate ............................ 115
prednisolone sodium phosphate
............................................................................ 115, 124
prednisone .......................................................... 124
PREMARIN ................................................ 123
PREMASOL 10 % .................................. 77
PREMASOL 6 % ...................................... 77
PREMPHASE ........................................... 123
PREMPRO .................................................... 123
prenatal plus (calcium carb) ... 158
prenatal vitamin plus low iron
........................................................................................... 158
PREPOPIK .................................................... 119
prevalite .................................................................... 89
previfem .................................................................... 99
PREZCOBIX ................................................. 66
PREZISTA ........................................................ 66
PRIFTIN .............................................................. 56
PRIMAQUINE .......................................... 58
primidone ............................................................... 40
PRISTIQ ............................................................... 46
PRIVIGEN .................................................... 131
probenecid ......................................................... 143
procainamide ..................................................... 81
prochlorperazine ........................................... 57
prochlorperazine edisylate .............. 57
prochlorperazine maleate ................. 57
PROCRIT ........................................................... 74
PROCTOFOAM HC ...................... 107
procto-med hc ............................................... 107
procto-pak ......................................................... 107
proctosol hc ..................................................... 107
proctozone-hc ............................................... 107
PROCYSBI .................................................... 143
progesterone in oil .................................. 127
progesterone micronized ................ 127
PROGLYCEM ............................................ 91
PROGRAF .................................................... 131
PROLASTIN-C ...................................... 155
PROLEUKIN ............................................... 32
PROLIA ............................................................. 139
PROMACTA ................................................. 74
promethazine .......................................... 54, 57
Index
pioglitazone-metformin ....................... 48
piperacillin-tazobactam ........... 21, 22
pirmella ..................................................................... 99
piroxicam ................................................................... 9
podocon ................................................................. 102
podofilox ............................................................. 102
polyethylene glycol 3350 ............... 119
polymyxin b sulfate .................................. 15
polymyxin b sulf-trimethoprim
........................................................................................... 113
POMALYST ................................................... 32
portia ............................................................................ 99
PORTRAZZA .............................................. 32
potassium acetate .................................... 148
potassium bicarb and chloride
........................................................................................... 148
potassium bicarb-citric acid ...... 148
potassium chlorid-d5-0.45%nacl
........................................................................................... 148
potassium chloride .................. 148, 149
potassium chloride in 0.9%nacl
........................................................................................... 148
potassium chloride in 5 % dex
........................................................................................... 148
potassium chloride in lr-d5 ......... 148
potassium chloride-0.45 % nacl
........................................................................................... 149
........................................................................................... 149
........................................................................................... 149
........................................................................................... 149
potassium citrate ...................................... 149
potassium citrate-citric acid ..... 149
potassium hydroxide ........................... 102
potassium phosphate m-/d-basic
........................................................................................... 149
POTIGA ................................................................ 40
PRADAXA ....................................................... 72
PRALUENT PEN .................................. 89
PRALUENT SYRINGE .............. 89
pramipexole ........................................................ 59
pravastatin ............................................................ 89
prazosin .................................................................... 78
Index
Index
PEGASYS PROCLICK ................. 69
peg-electrolyte soln ............................... 119
PEGINTRON ............................................... 69
PEGINTRON REDIPEN .......... 69
PEG-PREP ..................................................... 119
PEN NEEDLE, DIABETIC
........................................................................................... 108
penicillin g pot in dextrose .............. 21
penicillin g potassium ............................ 21
penicillin g procaine ................................. 21
penicillin v potassium ............................. 21
PENTACEL ACTHIB
COMPONENT (PF) ........................ 135
PENTAM ............................................................. 58
PENTASA ...................................................... 138
pentoxifylline .................................................... 75
PERFOROMIST .................................. 153
perindopril erbumine ............................... 80
periogard ............................................................. 101
PERJETA ............................................................ 32
permethrin ......................................................... 108
perphenazine ...................................................... 63
perphenazine-amitriptyline ............ 45
PEXEVA ............................................................... 45
pfizerpen-g ............................................................ 21
phenadoz ................................................................. 57
phenelzine .............................................................. 45
phenobarbital .................................................... 40
phenobarbital sodium ............................ 40
phenylephrine hcl .......................... 78, 111
PHENYTEK ................................................... 40
phenytoin ................................................................ 40
phenytoin sodium ......................................... 40
phenytoin sodium extended ........... 40
philith .......................................................................... 99
phospha 250 neutral ............................. 148
PHOSPHOLINE IODIDE ..... 145
PHOTOFRIN ................................................ 32
physostigmine salicylate ................ 143
PICATO ............................................................. 102
pilocarpine hcl ............................... 101, 145
pimozide ................................................................... 63
pimtrea (28) ...................................................... 99
pindolol ..................................................................... 83
pioglitazone ......................................................... 48
I-13
SAVELLA .......................................................... 93
SCLEROSOL
INTRAPLEURAL ............................ 143
selegiline hcl ....................................................... 59
selenium sulfide .......................................... 104
SELZENTRY ................................................ 67
SENSIPAR .................................................... 143
SEREVENT DISKUS .................. 153
SEROQUEL XR ....................................... 64
SEROSTIM ................................................... 126
sertraline ................................................................. 46
setlakin ...................................................................... 99
sf 5000 plus ...................................................... 101
sharobel .................................................................... 99
SHOHL'S MODIFIED ............... 149
SIGNIFOR .................................................... 143
SIGNIFOR LAR .................................. 143
sildenafil ............................................................... 157
SILENOR ............................................................ 46
silver nitrate .................................................... 104
silver nitrate applicators ................ 104
silver sulfadiazine .................................... 104
SIMBRINZA .............................................. 145
SIMPONI ......................................................... 144
SIMPONI ARIA ................................... 143
SIMULECT .................................................. 144
simvastatin ........................................................... 90
sirolimus ............................................................... 132
SIRTURO ........................................................... 56
SIVEXTRO ....................................................... 15
sodium acetate ............................................. 149
sodium bicarbonate ................ 149, 150
sodium chloride ........................... 138, 150
sodium chloride 0.45 % .................... 150
sodium chloride 0.9 % ....................... 150
sodium chloride 3 % ............................. 150
sodium chloride 5 % ............................. 150
sodium citrate-citric acid .............. 150
sodium fluoride ............................ 101, 158
sodium lactate .............................................. 150
sodium phenylbutyrate ..................... 118
sodium phosphate .................................... 150
sodium polystyrene (sorb free)
........................................................................................... 118
Index
REMICADE ............................................... 143
RENAGEL .................................................... 119
RENVELA ..................................................... 120
repaglinide ............................................................ 48
REPATHA SURECLICK ......... 89
REPATHA SYRINGE ................... 90
reprexain .................................................................... 7
RESCRIPTOR ............................................. 66
RESTASIS ...................................................... 115
RETROVIR ..................................................... 66
REVATIO ....................................................... 157
REVLIMID ...................................................... 33
revonto ................................................................... 156
REXULTI ........................................................... 63
REYATAZ ............................................. 66, 67
ribasphere .............................................................. 70
ribasphere ribapak ..................................... 70
ribavirin .................................................................... 70
RIDAURA .................................................... 132
rifabutin ................................................................... 56
rifampin .................................................................... 56
RIFATER ........................................................... 56
riluzole ....................................................................... 93
rimantadine ......................................................... 68
ringers ...................................................... 138, 149
risedronate ........................................................ 140
RISPERDAL CONSTA ................ 63
risperidone ............................................................ 63
RITUXAN ......................................................... 33
rivastigmine ......................................................... 42
rivastigmine tartrate ............................... 42
rizatriptan ............................................................. 55
ropinirole ................................................................ 59
rosadan .................................................................. 103
rosuvastatin ......................................................... 90
ROTARIX ...................................................... 136
ROTATEQ VACCINE ............... 136
roxicet ............................................................................ 8
ROZEREM ................................................... 156
SABRIL .................................................................. 40
SAIZEN .............................................................. 126
SAIZEN CLICK.EASY ............. 126
SANTYL ........................................................... 102
SAPHRIS (BLACK CHERRY)
............................................................................................... 63
Index
Index
promethazine vc ............................................ 54
promethegan ...................................................... 57
propafenone ........................................................ 81
propantheline .................................................... 36
proparacaine .................................................. 111
propranolol .......................................................... 83
propranolol-hydrochlorothiazid
............................................................................................... 83
propylthiouracil ......................................... 128
PROQUAD (PF) ................................... 135
PROSOL 20 % .............................................. 77
protamine ............................................................... 74
PROTONIX ................................................. 116
protriptyline ........................................................ 46
PULMICORT ........................................... 152
PULMICORT FLEXHALER
........................................................................................... 152
PULMOZYME ....................................... 110
PURIXAN ......................................................... 32
pyrazinamide ..................................................... 56
pyridostigmine bromide .................. 143
QUADRACEL (PF) ........................ 135
quasense ................................................................... 99
quetiapine ............................................................... 63
quinapril ................................................................... 80
quinapril-hydrochlorothiazide ... 80
quinidine gluconate ................................... 81
quinidine sulfate ............................................ 82
quinine sulfate .................................................. 58
QVAR .................................................................... 152
RABAVERT (PF) ............................... 135
rabeprazole ...................................................... 116
raloxifene ........................................................... 123
ramipril ..................................................................... 80
RANEXA ............................................................ 86
ranitidine hcl .................................................. 116
RAPAMUNE ............................................ 132
RAVICTI .......................................................... 118
REBETOL .......................................................... 70
reclipsen (28) ................................................... 99
RECOMBIVAX HB (PF)
............................................................................ 135, 136
REGRANEX ............................................. 102
RELENZA DISKHALER ......... 68
RELISTOR ................................................... 118
118
sodium thiosulfate ................................... 121
SOLTAMOX .................................................. 33
SOLU-MEDROL (PF) ................ 124
SOMATULINE DEPOT .......... 126
SOMAVERT ............................................... 126
sorbitol ................................................................... 138
sorbitol-mannitol ...................................... 138
sorine ............................................................................ 83
sotalol .......................................................................... 83
sotalol af .................................................................. 83
sotradecol ........................................................... 144
SOVALDI ........................................................... 68
spinosad ................................................................ 108
SPIRIVA RESPIMAT .................. 154
SPIRIVA WITH
HANDIHALER .................................... 154
spironolactone ................................................. 90
spironolacton-hydrochlorothiaz
............................................................................................... 90
sprintec (28) ..................................................... 99
SPRITAM ........................................................... 40
SPRYCEL ........................................................... 33
sps ................................................................................. 118
sronyx ......................................................................... 99
ssd ................................................................................. 104
stannous fluoride ...................................... 101
stavudine ................................................................. 67
STELARA ...................................................... 144
STERILE PADS .................................... 144
sterile talc .......................................................... 144
STIVARGA ...................................................... 33
STRATTERA ............................................... 93
STRENSIQ .................................................... 110
streptomycin ...................................................... 14
STRIBILD .......................................................... 67
SUBOXONE ................................................... 11
SUCLEAR ...................................................... 119
sucralfate ............................................................ 116
sulfacetamide sodium ......................... 113
sulfacetamide sodium (acne)
........................................................................................... 104
sulfacetamide-prednisolone ........ 113
sulfadiazine .......................................................... 22
...........................................................................................
I-14
TEGRETOL XR ....................................... 41
TEKTURNA .................................................. 90
TEKTURNA HCT ............................... 90
telmisartan ........................................................... 79
telmisartan-amlodipine ....................... 79
telmisartan-hydrochlorothiazid
............................................................................................... 79
temazepam ........................................................... 13
TEMODAR ...................................................... 34
tencon .............................................................................. 8
teniposide ............................................................... 34
TENIVAC (PF) ....................................... 136
terazosin ............................................................... 120
terbinafine hcl .................................................. 53
terbutaline ......................................................... 154
terconazole ........................................................... 54
testosterone ....................................... 121, 122
testosterone cypionate ...................... 121
testosterone enanthate ...................... 121
TETANUS
TOXOID,ADSORBED (PF)
........................................................................................... 136
TETANUS,DIPHTHERIA
TOX PED(PF) .......................................... 136
tetanus-diphtheria toxoids-td
........................................................................................... 136
tetrabenazine ..................................................... 93
tetracaine hcl (pf) .................................. 111
tetracycline .......................................................... 24
THALOMID ............................................... 144
theochron ............................................................ 154
theophylline ..................................................... 154
theophylline in dextrose 5 % .... 154
THERACYS ................................................ 136
thioridazine .......................................................... 64
thiotepa ..................................................................... 34
thiothixene ............................................................ 64
THYMOGLOBULIN ................... 132
tiagabine .................................................................. 41
TICE BCG ...................................................... 132
ticlopidine .............................................................. 75
TIKOSYN ........................................................... 82
tilia fe .......................................................................... 99
TIMENTIN ...................................................... 22
timolol maleate ................................ 83, 145
Index
sulfamethoxazole-trimethoprim
.................................................................................... 22, 23
sulfasalazine ....................................................... 23
sulfatrim .................................................................. 23
sulindac ......................................................................... 9
sumatriptan ......................................................... 55
sumatriptan succinate ........................... 55
SUPPRELIN LA .................................. 126
SUPRAX .............................................................. 18
SUPREP BOWEL PREP KIT
........................................................................................... 119
SURMONTIL .............................................. 46
SUSTIVA ............................................................. 67
SUTENT ............................................................... 33
syeda ............................................................................. 99
SYLATRON ................................................... 69
SYLVANT ......................................................... 33
SYMBICORT ............................................ 152
SYMLINPEN 120 ................................... 48
SYMLINPEN 60 ...................................... 48
SYNAGIS ........................................................... 68
SYNAREL ..................................................... 144
SYNERCID ..................................................... 15
SYNJARDY .................................................... 48
SYNRIBO ........................................................... 33
SYNTHROID ........................................... 128
SYPRINE ........................................................ 121
TABLOID ........................................................... 33
tacrolimus ........................................... 107, 132
TAFINLAR ..................................................... 33
TAGRISSO ....................................................... 33
TAMIFLU ......................................................... 68
tamoxifen ............................................................... 33
tamsulosin .......................................................... 120
TANZEUM ...................................................... 48
TARCEVA ........................................................ 33
TARGRETIN ............................................... 33
tarina fe 1/20 (28) .................................... 99
TASIGNA ........................................................... 33
tazicef .......................................................................... 18
TAZORAC ..................................... 107, 108
taztia xt .................................................................... 84
TECENTRIQ ................................................. 33
TECFIDERA ............................................. 144
TEFLARO ......................................................... 18
Index
Index
sodium polystyrene sulfonate
88
trianex .................................................................... 107
triderm ................................................................... 107
tri-estarylla .......................................................... 99
trifluoperazine ................................................. 64
trifluridine ......................................................... 113
trihexyphenidyl .............................................. 59
tri-legest fe ........................................................... 99
tri-linyah ................................................................. 99
tri-lo-estarylla .................................................. 99
tri-lo-marzia ....................................................... 99
tri-lo-sprintec .................................................... 99
trilyte with flavor packets ............ 119
trimethoprim ...................................................... 15
trimipramine ...................................................... 46
trinessa (28) .................................................. 100
trinessa lo ........................................................... 100
TRINTELLIX .............................................. 46
tri-previfem (28) ..................................... 100
TRISENOX ...................................................... 34
tri-sprintec (28) ........................................ 100
TRIUMEQ ........................................................ 67
trivora (28) ..................................................... 100
TROKENDI XR ...................................... 41
TROPHAMINE 10 % ....................... 78
tropicamide ...................................................... 111
trospium ............................................................... 120
TRULICITY ................................................... 49
TRUMENBA ............................................. 136
TRUVADA ...................................................... 67
TUDORZA PRESSAIR ............ 154
TWINRIX (PF) ....................................... 136
TYBOST ............................................................ 144
TYGACIL .......................................................... 24
TYKERB .............................................................. 34
TYPHIM VI ................................................. 136
TYSABRI ........................................................ 132
TYVASO ........................................................... 157
TYVASO REFILL KIT ............. 157
TYVASO STARTER KIT ..... 157
TYZEKA .............................................................. 70
TYZINE ............................................................. 111
u-cort ........................................................................ 107
ULORIC ............................................................ 144
...............................................................................................
I-15
UNITHROID ............................................ 128
UNITUXIN ..................................................... 34
UPTRAVI ........................................ 157, 158
ursodiol .................................................................. 118
UVADEX ........................................................ 102
VAGIFEM ..................................................... 123
valacyclovir ......................................................... 70
VALCHLOR ............................................... 102
valganciclovir .................................................... 70
valproate sodium .......................................... 41
valproic acid ....................................................... 41
valproic acid (as sodium salt) ... 41
valsartan .................................................................. 79
valsartan-hydrochlorothiazide ... 79
VALSTAR .......................................................... 34
vancomycin .......................................................... 16
vancomycin in dextrose 5 % ......... 16
VANTAS .......................................................... 127
VAQTA (PF) ................................ 136, 137
VARIVAX (PF) ...................................... 137
VARIZIG ......................................................... 132
VARUBI ............................................................... 57
VASCEPA .......................................................... 90
vasopressin ........................................................ 127
VASOSTRICT .......................................... 127
VECTIBIX ......................................................... 35
VELCADE ......................................................... 35
velivet triphasic regimen (28)
........................................................................................... 100
VELPHORO ............................................... 118
VELTASSA ................................................... 118
VENCLEXTA .............................................. 35
VENCLEXTA STARTING
PACK ........................................................................ 35
venlafaxine ........................................................... 46
VENTAVIS ................................................... 158
VENTOLIN HFA ............................... 154
verapamil ................................................................ 84
VERIPRED 20 ......................................... 124
VERSACLOZ ............................................... 64
VESICARE ................................................... 120
vestura (28) .................................................... 100
VGO 40 ................................................................ 108
VICTOZA ........................................................... 49
Index
triamterene-hydrochlorothiazid
Index
Index
tinidazole ................................................................ 58
TIVICAY ............................................................. 67
tizanidine ............................................................. 156
TOBI PODHALER .............................. 14
TOBRADEX ............................................... 113
TOBRADEX ST .................................... 113
tobramycin ........................................................ 113
tobramycin in 0.225 % nacl ........... 14
tobramycin in 0.9 % nacl .................. 14
tobramycin sulfate ..................................... 14
tobramycin-dexamethasone ...... 113
TOLAK ............................................................... 102
tolazamide ............................................................. 51
tolbutamide .......................................................... 51
tolcapone ................................................................. 59
tolmetin ..................................................................... 10
tolterodine ......................................................... 120
topiramate ............................................................ 41
toposar ....................................................................... 34
topotecan ................................................................ 34
TORISEL ............................................................. 34
torsemide ................................................................ 88
TOUJEO SOLOSTAR ..................... 50
TPN ELECTROLYTES ............ 150
TPN ELECTROLYTES II .... 150
TRACLEER ................................................ 157
tramadol ...................................................................... 8
tramadol-acetaminophen ...................... 8
trandolapril .......................................................... 80
tranexamic acid ............................................. 74
TRANSDERM-SCOP ..................... 57
tranylcypromine ............................................ 46
TRAVASOL 10 % ................................... 77
TRAVATAN Z ....................................... 146
travoprost (benzalkonium) ....... 146
trazodone ................................................................ 46
TREANDA ....................................................... 34
TRECATOR ................................................... 56
TRELSTAR ..................................................... 34
tretinoin ................................................................ 108
tretinoin (chemotherapy) ................ 34
tretinoin microspheres ...................... 108
triamcinolone acetonide
.............................................. 101, 107, 115, 124
I-16
ZYTIGA ................................................................ 36
ZYVOX ................................................................... 16
Index
YF-VAX (PF) ............................................ 137
YONDELIS ...................................................... 35
zafirlukast ......................................................... 152
zaleplon ................................................................. 156
ZALTRAP .......................................................... 35
ZANOSAR ........................................................ 36
zarah ......................................................................... 100
ZAVESCA ...................................................... 110
zebutal ............................................................................ 8
ZELBORAF .................................................... 36
ZEMPLAR .................................................... 140
zenatane ............................................................... 102
zenchent (28) ............................................... 100
zenchent fe ........................................................ 100
ZENPEP ............................................................ 110
zeosa .......................................................................... 100
ZEPATIER ........................................................ 68
ZERBAXA ........................................................ 18
ZETIA ....................................................................... 90
ZIAGEN ............................................................... 68
zidovudine .............................................................. 68
ziprasidone hcl ................................................. 64
ZIRGAN ........................................................... 113
ZOLADEX ........................................................ 36
zoledronic acid ............................................ 140
zoledronic acid-mannitol-water
........................................................................................... 140
ZOLINZA ........................................................... 36
zolmitriptan ........................................................ 55
zolpidem ............................................................... 156
ZOMACTON ............................................. 127
ZONALON ................................................... 103
zonisamide ............................................................ 41
ZONTIVITY ................................................... 75
ZORBTIVE ................................................... 127
ZORTRESS .................................................. 132
ZOSTAVAX (PF) ................................ 137
zovia 1/35e (28) ........................................ 100
zovia 1/50e (28) ........................................ 100
ZOVIRAX ...................................................... 103
ZYCLARA .................................................... 103
ZYDELIG .......................................................... 36
ZYFLO CR ................................................... 152
ZYKADIA ......................................................... 36
ZYPREXA RELPREVV .............. 64
Index
Index
VIDEX 2 GRAM PEDIATRIC
............................................................................................... 67
VIDEX 4 GRAM PEDIATRIC
............................................................................................... 67
VIEKIRA PAK .......................................... 68
vienva ....................................................................... 100
VIGAMOX .................................................... 113
VIIBRYD ............................................................. 46
VIMPAT ............................................................... 41
vinblastine ............................................................. 35
vincasar pfs .......................................................... 35
vincristine ............................................................... 35
vinorelbine ............................................................. 35
viorele (28) ..................................................... 100
VIRACEPT ....................................................... 67
VIRAMUNE XR ..................................... 67
VIRAZOLE ...................................................... 70
VIREAD .................................................... 67, 68
virt-phos 250 neutral ........................... 150
VITEKTA ........................................................... 68
VIVITROL ........................................................ 11
VORAXAZE ............................................... 144
voriconazole ........................................................ 53
VOTRIENT ...................................................... 35
VPRIV ................................................................... 110
VRAYLAR ....................................................... 64
vyfemla (28) .................................................. 100
warfarin .................................................................... 72
water for irrigation, sterile ......... 138
WELCHOL ....................................................... 90
wera (28) ........................................................... 100
wymzya fe .......................................................... 100
XALKORI ......................................................... 35
XARELTO ........................................................ 72
XELJANZ ....................................................... 144
XELJANZ XR .......................................... 144
XENAZINE ..................................................... 93
XERESE ............................................................ 102
XGEVA ............................................................... 140
XOLAIR ............................................................ 155
XTANDI ............................................................... 35
xulane ...................................................................... 100
xylon 10 ....................................................................... 8
XYREM ............................................................. 156
YERVOY ............................................................. 35

Printable Formulary for 2016 (effective 9/1/16)

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