2016 Kaiser Permanente Hawaii Marketplace Drug Formulary

Transcription

Kaiser Permanente Hawaii Marketplace Drug Formulary
Effective October 1, 2016
Kaiser Permanente Hawaii uses a drug formulary to ensure that the most appropriate and effective
prescription drugs are available to you. The formulary is a list of drugs that have been approved by our
Pharmacy and Therapeutics (P&T) Committee. Committee members include pharmacists, physicians,
nurses, and other allied health care professionals.
Our drug formulary allows us to select drugs that are safe, effective, and a good value for you. We review
our formulary regularly so that we can add new drugs and remove drugs that can be replaced by newer,
more effective drugs. The formulary also helps us restrict drugs that can be toxic or otherwise dangerous if
misused.
Our drug formulary is considered a closed formulary, which means that drugs on the list are usually
covered under the prescription drug benefit, if you have one. However, drugs on our formulary may not be
automatically covered under your prescription benefit because these benefits vary depending on your
plan. Please check with your Kaiser Permanente pharmacist when you have questions about whether a
drug is on our formulary or if there are any restrictions or limitations to obtaining a drug.
For information on our Medicare Part D formulary, please refer to our Senior Advantage section on the
kp.org website.
NON-FORMULARY DRUGS
Non-formulary drugs are those that are not included on our drug formulary. These include new drugs that
haven’t been reviewed yet; drugs that our clinicians and pharmacists have decided to leave off the
formulary, or a different strength or dosage of a formulary drug that we don’t stock in our Kaiser
Permanente pharmacies.
Even though non-formulary drugs are generally not covered under our prescription drug benefit options,
your Kaiser Permanente doctor can request a non-formulary drug for you when formulary alternatives
have failed and the non-formulary drug is medically necessary, provided the drug is not excluded under
the prescription drug benefit.
If the request is accepted, you may purchase your prescription at your usual supplemental charge. Nonformulary drugs are not usually stocked in our pharmacies, so it may take a little longer to have your
prescription filled for one of these drugs.
SHARE INFORMATION WITH YOUR DOCTOR
If you’re taking multiple drugs–including prescription or over-the-counter drugs, herbs, natural
supplements, and even nutraceuticals (foods or parts of a food that provide health benefits)–be sure to
share this information with your physician or pharmacist. Because some drugs interact with others, we
want to be sure that you get the maximum benefit and the least risk from everything you consume. Bring
all your drugs to each physician appointment or call one of our pharmacies and make an appointment with
a pharmacist to review everything you’re taking.
Kaiser Permanente Hawaii Drug Formulary
USING THE KAISER PERMANENTE HAWAII FORMULARY
Prescription drugs are listed in alphabetical order for easy reference.
Generic drugs are listed in lower case. BRAND names are CAPITALIZED.
This list is subject to change and drugs may be added or removed without notice.
4 Tier definitions:
Tier 1 covers Generic Formulary medications for chronic conditions
Tier 2 covers Generic Formulary medications not covered in Tier 1
Tier 3 covers Brand name Formulary medications
Tier 4 covers Specialty Drugs
3 Tier definitions:
Tier 1 covers Generic Formulary medications for chronic conditions
Tier 2 covers Generic Formulary medications not covered in Tier 1
Tier 3 covers Brand name Formulary medications and Specialty Drugs
Certain drugs may price at a different tier level and members may be responsible for a higher cost share if
prescriptions are filled at an affiliated network pharmacy not owned and operated by Kaiser Permanente.
For a complete list of Kaiser Permanente and affiliate pharmacies, visit kp.org/facilities.
For information about your drug benefits or prescription cost share, please review your Summary of
Benefits or call our Customer Service Center at 808-432-5955 (Oahu) or
1-800-966-5955 (neighbor islands).
Abbreviations/Definitions used in list:
Abbreviation
Definition
ACA
Under the Affordable Care Act certain over-the-counter and
prescription drugs are covered at no charge when prescribed by a
physician for preventative purposes.
HCR
FDA approved contraceptive drugs and devices that are available at
no charge.
TC
Tobacco Cessation list of approved products at no charge.
PAH
Pulmonary Arterial Hypertension
2
GENERIC
Abacavir 300mg Tablet
Abacavir/Dolutegravir/Lamivudine 600mg/50mg/300mg
Tablet
Abacavir/Lamivudine 600mg/300mg Tablet
Abacavir/Lamivudine/Zidovudine 300mg/150mg/300 mg
Tablet
Abatacept 125mg/ml Subcutaneous Solution
Abiraterone Acetate 250mg Tablet
Acamprosate 333mg Delayed Release Enteric Coated Tablet
Acarbose 25mg Tablet
Acebutolol 200mg Capsule
Acetaminophen/Caffeine/Dihydrocodeine
320.5mg/30mg/16mg Capsule
Acetaminophen/Codeine 300mg/30mg Tablet
Acetaminophen/Codeine 300mg/60mg Tablet
Acetaminophen/Codeine 120mg-12 mg/5 mL Solution
Acetazolamide 125mg Tablet
Acetazolamide 25mg/ml Suspension
Acetazolamide 500mg Extended Release Capsule
Acetic Acid 2% Otic Solution
Acetohydroxamic Acid 250mg Tablet
Acetylcysteine 20% Inhalation/Oral Solution
Acetylcysteine 10% Ophthalmic Solution
Acitretin 10mg Capsule
Acitretin 17.5mg Capsule
Acitretin 25mg Capsule
Acyclovir 200mg Capsule
Acyclovir 400mg Tablet
Acyclovir 800mg Tablet
Acyclovir 200mg/5ml Suspension
Acyclovir 5% Topical Ointment
Adalimumab 20mg/0.4ml Subcutaneous Injection Kit
Adalimumab 40mg/0.8ml Subcutaneous Injection Kit
Adapalene 0.1% Topical Cream
Adapalene 0.1% Topical Gel
Adapalene 0.3% Topical Gel
Adapalene/Benzoyl Peroxide 0.1%/2.5% Topical Gel
Adefovir 10mg Tablet
Albendazole 200mg Tablet
3
COMMON BRAND
ZIAGEN
TRIUMEQ
3-Tier
2
3
4-Tier
2
3
EPZICOM
TRIZIVIR
3
2
3
2
ORENCIA
ZYTIGA
CAMPRAL
PRECOSE
PRECOSE
PRECOSE
SECTRAL
--
3
3
2
2
2
2
2
2
4
4
2
2
2
2
2
2
TYLENOL WITH CODEINE NO. 3
TYLENOL WITH CODEINE NO. 4
TYLENOL WITH CODEINE
DIAMOX
DIAMOX
DIAMOX
VOSOL
LITHOSTAT
MUCOMYST
-SORIATANE
SORIATANE
SORIATANE
ZOVIRAX
ZOVIRAX
ZOVIRAX
ZOVIRAX
ZOVIRAX
HUMIRA
HUMIRA
DIFFERIN
DIFFERIN
DIFFERIN
EPIDUO
HEPSERA
ALBENZA
2
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
2
2
3
3
2
2
2
3
2
3
2
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
2
2
4
4
2
2
2
3
2
3
GENERIC
Albuterol 2mg Tablet
Albuterol 4mg Tablet
Albuterol 2mg/5ml Syrup
Albuterol 0.083% Inhalation Solution
Albuterol 0.5% Inhalation Solution
Albuterol 1.25mg/3ml Inhalation Solution
Albuterol 108mcg/Actuation Inhaler
Albuterol 108mcg/Actuation Inhaler
Alcaftadine 0.25% Ophthalmic Solution
Alclometasone Dipropionate 0.05% Topical Ointment
Alendronate 10mg Tablet
Alfuzosin 10mg Extended Release Tablet
Aliskiren Fumarate 150mg Tablet
Alitretinoin 0.1% Topical Gel
Allopurinol 100mg Tablet
Allopurinol 20mg/ml Suspension
Almotriptan 6.25mg Tablet
Alosetron 0.5mg Tablet
Alprazolam 0.25mg Tablet
Alprazolam 0.5mg Tablet
Altretamine 50mg Capsule
Aluminum acetate/Acetic acid 10%/2% Otic Solution
Aluminum Chloride Hexahydrate 20% Topical Solution
Alvimopan 12mg Capsule
Amantadine 100mg Capsule
Amantadine 50mg/5ml Syrup
Ambrisentan 5mg Tablet
Ambrisentan 10mg Tablet
Amcinonide 0.1% Topical Cream
Amcinonide 0.1% Topical Ointment
Amiloride 5mg Tablet
Aminocaproic Acid 500mg Tablet
Aminophylline 100mg Tablet
Aminosalicylic Acid 4gm Granule
Amiodarone 200mg Tablet
Amitriptyline 10mg Tablet
COMMON BRAND
---ACCUNEB
ACCUNEB
ACCUNEB
PROAIR
VENTOLIN
LASTACAFT
ACLOVATE
FOSAMAX
FOSAMAX
FOSAMAX
UROXATRAL
TEKTURNA
PANRETIN
ZYLOPRIM
ZYLOPRIM
AXERT
LOTRONEX
XANAX
XANAX
HEXALEN
DOMEBORO
DRYSOL
ENTEREG
SYMMETREL
SYMMETREL
LETAIRIS
LETAIRIS
---AMICAR
-PASER
CORDARONE
ELAVIL
ELAVIL
ELAVIL
4
3-Tier
2
2
1
1
1
2
2
2
3
2
2
2
2
2
3
3
2
2
3
2
2
2
3
2
3
3
2
2
3
3
2
2
2
3
2
2
2
2
2
2
4-Tier
2
2
1
1
1
2
2
2
3
2
2
2
2
2
3
4
2
2
3
2
2
2
4
2
3
3
2
2
4
4
2
2
2
3
2
2
2
2
2
2
GENERIC
Amlexanox 5% Oral Paste
Amlodipine 2.5mg Tablet
Amlodipine 5mg Tablet
Amlodipine 1mg/ml Suspension
Amlodipine 10mg Tablet
Amoxapine 100mg Tablet
Amoxicillin /Clavulanate 500mg/125mg Tablet
Amoxicillin /Clavulanate 875mg/125mg Tablet
Amoxicillin /Clavulanate 400mg/57mg Chewable Tablet
Amoxicillin /Clavulanate 400mg-57mg /5ml Suspension
Amoxicillin 400mg/5ml Suspension
Amoxicillin /Clavulanate 600mg-42.9mg /5ml Suspension
Amoxicillin 250mg Capsule
Amoxicillin 500mg Capsule
Amphetamine/Dextroamphetamine 5mg Tablet
Amphetamine/Dextroamphetamine 15 mg Tablet
Amphetamine/Dextroamphetamine 5mg Extended Release
Capsule
Capsule
Capsule
Capsule
Capsule
Capsule
Ampicillin 125mg/5ml Oral Suspension
Anagrelide 0.5mg Capsule
Anakinra 100mg/0.67ml Subcutaneous Injection
Anastrozole 1mg Tablet
Antipyrine/Benzocaine 5.4%/1.4% Otic Solution
Apomorphine 10mg/ml Subcutaneous Injection
Apraclonidine 0.5% Ophthalmic Solution
Apremilast 30mg Tablet
Aprepitant 80mg Capsule
Arformoterol Tartrate 15mcg/2ml Inhalation Solution
5
COMMON BRAND
ELAVIL
APHTHASOL
NORVASC
NORVASC
NORVASC
NORVASC
-AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
-AUGMENTIN
--ADDERALL
ADDERALL
ADDERALL
ADDERALL
ADDERALL
ADDERALL
3-Tier
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4-Tier
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
ADDERALL
2
2
ADDERALL
2
2
ADDERALL
2
2
ADDERALL
2
2
ADDERALL
2
2
AMPICILLIN
AGRYLIN
KINERET
ARIMIDEX
AURODEX
APOKYN
IOPIDINE
OTEZLA
EMEND
BROVANA
2
2
3
2
2
3
2
3
3
3
2
2
4
2
2
4
2
4
3
3
GENERIC
Aripiprazole 2mg Tablet
Aripiprazole 1mg/ml Solution
Armodafinil 50mg Tablet
Artemether/Lumefantrine 20mg/120mg Tablet
Artificial Tear 5mg Ophthalmic Insert
Asenapine 5mg Sublingual Tablet
Aspirin 325mg Tablet
Aspirin 81mg Chewable Tablet
Aspirin 81mg Enteric Coated Tablet
Aspirin 325mg Enteric Coated Tablet
Aspirin Buffered (aluminum hydroxide, calcium carbonate,
magnesium hydroxide) 325mg Tablet
Aspirin Buffered 81mg Tablet
Aspirin Buffered (calcium carbonate, magnesium carbonate,
magnesium oxide) 325mg Tablet
Aspirin/Extended Release Dipyridamole 25mg/200mg
Capsule
Atazanavir 150mg Capsule
Atenolol 25mg Tablet
Atenolol 2mg/ml Suspension
Atenolol 50mg Tablet
Atomoxetine 10mg Capsule
Atorvastatin 10mg Tablet
Atovaquone 750mg/5ml Suspension
Atovaquone/Proguanil 62.5mg/25mg Tablet
6
COMMON BRAND
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ABILIFY
NUVIGIL
COARTEM
LACRISERT
SAPHRIS
BUFFERIN
-ECOTRIN LOW STRENGTH
ASCRIPTIN
ASCRIPTIN
3-Tier
2
2
2
2
2
2
2
2
3
3
3
ACA
ACA
ACA
ACA
ACA
4-Tier
2
2
2
2
2
2
2
2
3
3
3
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
AGGRENOX
2
2
REYATAZ
REYATAZ
REYATAZ
TENORMIN
TENORMIN
TENORMIN
STRATTERA
STRATTERA
STRATTERA
STRATTERA
STRATTERA
STRATTERA
STRATTERA
LIPITOR
LIPITOR
LIPITOR
LIPITOR
MEPRON
MALARONE
3
3
3
1
2
1
3
3
3
3
3
3
3
2
2
2
2
2
2
3
3
3
1
2
1
3
3
3
3
3
3
3
2
2
2
2
2
2
-BUFFERIN
GENERIC
Atovaquone/Proguanil 250mg/100mg Tablet
Atropine 1% Ophthalmic Solution
Axitinib 1mg Tablet
Axitinib 5mg Tablet
Azathioprine 50mg Tablet
Azelaic Acid 20% Topical Cream
Azelaic Acid 15% Topical Gel
Azelastine 137mcg/spray Nasal Solution
Azelastine 0.05% Ophthalmic Solution
Azelastine/Fluticasone 137mcg/50mcg Nasal Spray
Azilsartan 40mg Tablet
Azithromycin 250mg Tablet
Azithromycin 100mg/5ml Suspension
Azithromycin 200mg/5ml Suspension
Aztreonam 75mg Inhalation Solution
Bacitracin 500unit/gm Ophthalmic Ointment
Bacitracin/Neomycin/Polymyxin B
400units/3.5mg/10,000units per gm Ophthalmic Ointment
Baclofen 10mg Tablet
Baclofen 5mg/ml Suspension
Balsalazide 750mg Capsule
Becaplermin 0.01% Topical Gel
Beclomethasone 40mcg/actuation Inhaler
Beclomethasone 80mcg/actuation Inhaler
Belladonna/Opium 16.2mg/30mg Suppository
Benazepril 10mg Tablet
Benzonatate 100mg Capsule
Benzoyl Peroxide 5%-Erythromycin 3% Topical Gel
Benztropine 0.5mg Tablet
Benztropine 1mg Tablet
Benztropine 2mg Tablet
Benzyl Alcohol 5% Topical Lotion
Bepotastine 1.5% Ophthalmic Solution
Besifloxacin 0.6% Ophthalmic Suspension
Betamethasone Dipropionate 0.05% Topical Cream
Betamethasone Dipropionate 0.05% Topical Ointment
Betamethasone Valerate 0.1% Topical Lotion
Betaxolol 10mg Tablet
Betaxolol 0.5% Ophthalmic Solution
7
COMMON BRAND
MALARONE
-INLYTA
INLYTA
-AZELEX
FINACEA
ASTELIN
OPTIVAR
DYMISTA
EDARBI
ZITHROMAX
ZITHROMAX
ZITHROMAX
ZITHROMAX
ZITHROMAX
CAYSTON
-CORTISPORIN
LIORESAL
LIORESAL
COLAZAL
REGRANEX
QVAR
QVAR
B&O
LOTENSIN
TESSALON
BENZAMYCIN
COGENTIN
COGENTIN
COGENTIN
ULESFIA
BEPREVE
BESIVANCE
DIPROLENE
DIPROLENE
-KERLONE
BETOPTIC
3-Tier
2
2
3
3
2
3
3
2
2
3
3
2
2
2
2
2
3
2
3
4-Tier
2
2
4
4
2
3
3
2
2
3
3
2
2
2
2
2
4
2
3
2
2
2
3
3
3
3
1
2
2
2
2
1
3
3
3
2
2
2
2
2
2
2
2
4
3
3
3
1
2
2
2
2
1
3
3
3
2
2
2
2
2
GENERIC
Bethanechol Chloride 25mg Tablet
Bexarotene 75mg Capsule
Bexarotene 1% Topical Gel
Bicalutamide 50mg Tablet
Bimatoprost 0.01% Ophthalmic Solution
Bisoprolol Fumarate 5mg Tablet
Bisoprolol Fumarate 10mg Tablet
Bisoprolol/Hydrochlorothiazide 2.5mg/6.25mg Tablet
Bisoprolol/Hydrochlorothiazide 5mg/6.25mg Tablet
Bisoprolol/Hydrochlorothiazide 10mg/6.25mg Tablet
Boceprevir 200mg Capsule
Bosentan 62.5mg Tablet
Bosentan 125mg Tablet
Bosutinib 100mg Tablet
Bosutinib 500mg Tablet
Brimonidine Tartrate 0.2% Ophthalmic Solution
Brimonidine Tartrate 0.33% Topical Gel
Brimonidine/Timolol 0.2%/0.5% Ophthalmic Solution
Brinzolamide 1% Ophthalmic Suspension
Bromfenac 0.09% Ophthalmic Solution
Bromocriptine 0.8mg Tablet
Bromocriptine 2.5mg Tablet
Budesonide 3mg Enteric Coated Capsule
Budesonide 9mg Tablet
Budesonide 0.25mg/2ml Inhalation Suspension
Budesonide 0.5mg/2ml Inhalation Suspension
Bumetanide 0.5mg Tablet
Buprenorphine 5mcg/hr Patch
Buprenorphine 2mg Sublingual Tablet
Buprenorphine 8mg Sublingual Tablet
Buprenorphine/Naloxone 2mg/0.5mg Sublingual Tablet
Buprenorphine/Naloxone 8mg/2mg Sublingual Tablet
Bupropion 100mg Sustained Release Tablet
Bupropion 150mg Extended Release Tablet
Bupropion 300mg Extended Release Tablet
Buspirone 5mg Tablet
COMMON BRAND
URECHOLINE
TARGRETIN
TARGRETIN
CASODEX
LUMIGAN
ZEBETA
ZEBETA
ZIAC
ZIAC
ZIAC
VICTRELIS
TRACLEER
TRACLEER
BOSULIF
BOSULIF
ALPHAGAN
MIRVASO
COMBIGAN
AZOPT
-CYCLOSET
PARLODEL
ENTOCORT
UCERIS
PULMICORT
PULMICORT
BUMEX
BUTRANS
--SUBOXONE
SUBOXONE
WELLBUTRIN
WELLBUTRIN
WELLBUTRIN
WELLBUTRIN
WELLBUTRIN
BUSPAR
BUSPAR
BUSPAR
8
3-Tier
2
3
3
2
3
2
2
1
1
1
3
3
3
3
3
2
3
3
3
2
3
2
3
3
2
2
2
3
2
2
2
2
2
TC
2
2
2
1
1
2
4-Tier
2
3
3
2
3
2
2
1
1
1
4
4
4
4
4
2
3
3
3
2
3
2
3
4
2
2
2
3
2
2
2
2
2
TC
2
2
2
1
1
2
GENERIC
Butalbital/Acetaminophen/Caffeine 50mg/325mg/40mg
Tablet
Butalbital/Aspirin/Caffeine 50mg/325mg/40mg Capsule
Butamben/Tetracaine/Benzocaine 2%/2%/14% Topical Spray
C1 Esterase Inhibitor (Human) 500unit Intravenous Solution
Cabozantinib 60mg Injection Kit
Caffeine Citrate 20mg/ml Solution
Calcipotriene 0.005% Topical Solution
Calcipotriene 0.005% Topical Cream
Calcipotriene/Betamethasone 0.005%/0.064% Topical
Ointment
Calcitonin 200iu/ml Injection
Calcitonin 200unit/actuation Nasal Spray
Calcitriol 0.25mcg Capsule
Calcitriol 0.5mcg Capsule
Calcitriol 3mcg/gm Topical Ointment
Calcium Acetate 667mg Capsule
Calcium Acetate 667mg Tablet
Canagliflozin 100mg Tablet
Canakinumab 180mg Injection
Candesartan 4mg Tablet
Capecitabine 150mg Tablet
Capecitabine 500mg Tablet
Captopril 25mg Tablet
Captopril 50mg Tablet
Captopril 1mg/ml Suspension
Carbamazepine 200mg Tablet
Carbamazepine 100mg Chewable Tablet
Carbamazepine 100mg/5ml Suspension
Carbamazepine 300mg Extended Release Capsule
Carbamazepine 100mg Extended Release Tablet
Carbidopa 25mg Tablet
Carbidopa/Levodopa/Entacapone 25/100/200mg Tablets
Carbidopa/Levodopa/Entacapone 37.5/150/200mg Tablets
Carbidopa/Levodopa/Entacapone 50/200/200mg Tablets
Carbidopa/Levodopa 10mg/100mg Tablet
9
COMMON BRAND
ESGIC
3-Tier
2
4-Tier
2
FIORINAL
CETACAINE
CINRYZE
COMETRIQ
COMETRIQ
COMETRIQ
CAFCIT
DOVONEX
DOVONEX
TACLONEX
2
3
3
3
3
3
2
2
2
2
2
3
4
4
4
4
2
2
2
2
MIACALCIN
MIACALCIN
ROCALTROL
ROCALTROL
VECTICAL
PHOSLO
ELIPHOS
INVOKANA
ILARIS
ATACAND
XELODA
XELODA
CAPOTEN
CAPOTEN
CAPOTEN
TEGRETOL
TEGRETOL
TEGRETOL
CARBATROL
TEGRETOL
TEGRETOL
TEGRETOL
LODOSYN
STALEVO
STALEVO
STALEVO
SINEMET
SINEMET
3
2
2
2
2
2
2
3
3
2
2
2
2
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
3
2
2
2
2
2
2
3
4
2
2
2
2
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
GENERIC
Carbidopa/Levodopa 50mg/200mg Extended Release Tablet
Carbinoxamine 4mg/5ml Solution
Carisoprodol 350mg Tablet
Carteolol 1% Ophthalmic Solution
Carvedilol 0.1mg/ml Suspension
Carvedilol 6.25mg Tablet
Carvedilol 12.5mg Tablet
Carvedilol 25mg Tablet
Carvedilol 1.67mg/ml Suspension
Cefaclor 250mg Capsule
Cefadroxil 500mg/5ml Oral Suspension
Cefazolin 50mg/ml Ophthalmic Solution
Cefdinir 125mg/5ml Suspension
Cefditoren Pivoxil 200mg Tablet
Cefixime 100mg/5ml Oral Suspension
Cefpodoxime 100mg Tablet
Cefpodoxime 200mg Tablet
Cefprozil 250mg Tablet
Ceftibuten 400mg Capsule
Cefuroxime 125mg/5ml Oral Suspension
Celecoxib 50mg Capsule
Celecoxib 100mg Capsule
Cephalexin 250mg Capsule
Cephalexin 500mg Capsule
Cephalexin 250mg/5ml Suspension
Certolizumab 200mg/ml Injection Kit
Cevimeline 30mg Capsule
Chlorambucil 2mg Tablet
Chlordiazepoxide 5mg Capsule
Chlordiazepoxide/Clidinium 5mg/2.5mg Capsule
Chlorhexidine Gluconate 0.12% Mouth/Throat Solution
Chloroquine Phosphate 250mg Tablet
Chloroquine Phosphate 500mg Tablet
Chlorothiazide 250mg Tablet
Chlorpromazine 10mg Tablet
10
COMMON BRAND
SINEMET
SINEMET
PALGIC
SOMA
-COREG
COREG
COREG
COREG
COREG
CECLOR
-KEFZOL
OMNICEF
SPECTRACEF
-VANTIN
VANTIN
--CEFTIN
CELEBREX
CELEBREX
KEFLEX
KEFLEX
KEFLEX
CIMZIA
EVOXAC
LEUKERAN
LIBRIUM
LIBRIUM
LIBRIUM
LIBRAX
PERIDEX
ARALEN
ARALEN
-THORAZINE
THORAZINE
THORAZINE
3-Tier
2
2
2
2
2
2
1
1
1
2
2
2
2
2
3
2
2
2
2
2
3
2
2
2
2
2
3
2
3
2
2
2
2
2
2
2
2
2
2
2
4-Tier
2
2
2
2
2
2
1
1
1
2
2
2
2
2
3
2
2
2
2
2
3
2
2
2
2
2
4
2
3
2
2
2
2
2
2
2
2
2
2
2
GENERIC
Chlorpropamide 100mg Tablet
Chlorpropamide 250mg Tablet
Chlorthalidone 25mg Tablet
Chlorthalidone 50mg Tablet
Chlorzoxazone 500mg Tablet
Cholecalciferol 400unit Capsule
Cholecalciferol 400unit Tablet
Cholecalciferol 400unit Chewable Tablet
Cholecalciferol 1000unit Chewable Tablet
Cholecalciferol 400unit/ml Drop
Cholecalciferol 5000units/ml Drop
Cholecalciferol 400unit/0.03ml Drop
Cholecalciferol 1000unit Spray
Cholestyramine Light 4gm/dose Powder
Choriogonadotropin Alfa 250mcg/0.5ml Subcutaneous
Injection
Ciclesonide 160mcg/actuation Inhaler
Ciclopirox 8% Topical Solution
Ciclopirox 0.77% Topical Cream
Cilostazol 50mg Tablet
Cilostazol 100mg Tablet
Cimetidine 300mg Tablet
Cinacalcet 30mg Tablet
Ciprofloxacin 250mg Tablet
COMMON BRAND
THORAZINE
DIABINESE
DIABINESE
HYGROTON
HYGROTON
---------------------PREVALITE
OVIDREL
ALVESCO
CICLODAN
CICLODAN
PLETAL
PLETAL
TAGAMET
SENSIPAR
SENSIPAR
SENSIPAR
CIPRO
CIPRO
CIPRO
11
3-Tier
2
2
2
2
2
2
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
2
3
4-Tier
2
2
2
2
2
2
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
ACA
2
3
3
2
2
2
2
2
3
3
3
2
2
2
3
2
2
2
2
2
3
4
4
2
2
2
GENERIC
Ciprofloxacin 0.3% Ophthalmic Solution
Ciprofloxacin/Dexamethasone 0.3%/0.1% Otic Suspension
Ciprofloxacin/Hydrocortisone 0.2%/1% Otic Suspension
Citalopram 10mg Tablet
Citric Acid Bladder Mixture Irrigation
Clarithromycin 250mg Tablet
Clarithromycin 500mg Tablet
Clarithromycin 125mg/5ml Suspension
Clemastine Fumarate 2.68mg Tablet
Clindamycin 150mg Capsule
Clindamycin 300mg Capsule
Clindamycin 75mg/5ml Solution
Clindamycin Phosphate 2% Vaginal Cream
Clindamycin Phosphate 1% Topical Solution
Clindamycin Phosphate 1% Topical Gel
Clindamycin/Benzoyl Peroxide 1%/5% Topical Gel
Clindamycin/Benzoyl Peroxide 1.2%/5% Topical Gel
Clindamycin/Tretinoin 1.2%/0.025% Topical Gel
Clobetasol 0.05% Topical Solution
Clobetasol 0.05% Topical Cream
Clobetasol 0.05% Topical Ointment
Clocortolone 0.1% Topical Cream
Clomipramine 25mg Capsule
Clonazepam 0.5mg Tablet
Clonazepam 2mg Tablet
Clonidine 0.1mg Tablet
Clonidine 0.1mg/ml Suspension
Clopidogrel 75mg Tablet
Clopidogrel 5mg/ml Suspension
Clopidogrel 300mg Tablet
Clorazepate 3.75mg Tablet
Clorazepate 7.5mg Tablet
Clorazepate 15mg Tablet
Clotrimazole 10mg Lozenge
Clotrimazole/Betamethasone 1%/0.05% Topical Cream
Clozapine 100mg Tablet
Codeine 30mg Tablet
Codeine 60mg Tablet
12
COMMON BRAND
CILOXAN
CIPRODEX
CIPRO HC
CELEXA
CELEXA
CELEXA
RENACIDIN
BIAXIN
BIAXIN
BIAXIN
TAVIST
CLEOCIN
CLEOCIN
CLEOCIN
CLEOCIN
CLEOCIN-T
CLEOCIN-T
BENZACLIN
DUAC
VELTIN
TEMOVATE
TEMOVATE
TEMOVATE
CLODERM
ANAFRANIL
KLONOPIN
KLONOPIN
CATAPRES
CATAPRES
PLAVIX
PLAVIX
PLAVIX
TRANXENE
TRANXENE
TRANXENE
MYCELEX
LOTRISONE
CLOZARIL
---
3-Tier
2
3
3
2
1
1
3
2
2
2
2
2
2
2
2
2
2
2
2
3
2
2
2
3
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
4-Tier
2
3
3
2
1
1
3
2
2
2
2
2
2
2
2
2
2
2
2
3
2
2
2
3
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
GENERIC
Colchicine 0.6mg Capsule
Colchicine/Probenecid 0.5mg/500mg Tablet
Colesevelam 625mg Tablet
Colestipol 1gm Tablet
Collagenase 250unit/gm Topical Ointment
Condoms - Female
Contraceptive Sponge
Corticotropin 80unit/ml Injection
Cortisone Acetate 25mg Tablet
Crizotinib 200mg Capsule
Crizotinib 250mg Capsule
Cromolyn 20mg/2ml Inhalation Solution
Cromolyn 4% Ophthalmic Solution
Crotamiton 10% Topical Cream
Cyclobenzaprine 10mg Tablet
Cyclophosphamide 50mg Capsule
Cyclophosphamide 50mg Tablet
Cycloserine 250mg Capsule
Cyclosporine 0.05% Ophthalmic Emulsion
Cyclosporine 25mg Capsule
Cyclosporine 100mg Capsule
Cyclosporine 100mg/ml Solution
Cyproheptadine 4mg Tablet
Cyproheptadine 2mg/5ml Syrup
Cysteamine 0.44 % Ophthalmic Solution
Dabigatran 75mg Capsule
Dabigatran 150mg Capsule
Dalfampridine 10mg Tablet
Danazol 200mg Capsule
Dantrolene 25mg Capsule
Dapagliflozin Propanediol 10mg Tablet
Dapsone 100mg Tablet
Darifenacin 7.5mg Tablet
Darunavir 150mg Tablet
Dasatinib 20mg Tablet
COMMON BRAND
MITIGARE
-WELCHOL
COLESTID
SANTYL
--ACTHAR
-XALKORI
XALKORI
INTAL
OPTICROM
EURAX
FLEXERIL
CYTOXAN
CYTOXAN
SEROMYCIN
RESTASIS
GENGRAF
GENGRAF
NEORAL
PERIACTIN
PERIACTIN
CYSTARAN
PRADAXA
PRADAXA
AMPYRA
DANOCRINE
-FARXIGA
-ENABLEX
PREZISTA
PREZISTA
PREZISTA
SPRYCEL
SPRYCEL
SPRYCEL
SPRYCEL
13
3-Tier
2
2
3
2
3
ACA
ACA
3
2
3
3
2
2
3
2
2
2
2
3
2
2
3
2
2
3
3
3
3
2
2
3
2
2
3
3
3
3
3
3
3
4-Tier
2
2
3
2
3
ACA
ACA
4
2
4
4
2
2
3
2
2
2
2
3
2
2
3
2
2
3
3
3
4
2
2
3
2
2
3
3
3
4
4
4
4
GENERIC
Deferasirox 250mg Soluble Tablet
Deferasirox 500mg Soluble Tablet
Deferiprone 500mg Tablet
Delavirdine 200mg Tablet
Demeclocycline 150mg Tablet
Denosumab 60mg/ml Injection
Denosumab 120mg/1.7ml Injection
Desipramine 10mg Tablet
Desloratadine 5mg Tablet
Desmopressin Acetate 0.01% Nasal Solution
Desonide 0.05% Topical Cream
Desoximetasone 0.05% Topical Gel
Desvenlafaxine 100mg Extended Release Tablet
Desvenlafaxine 100mg Tablet
Dexamethasone 0.5mg Tablet
Dexamethasone 4mg Tablet
Dexamethasone 0.5mg/5ml Solution
Dexamethasone 0.1% Ophthalmic Solution
Dexlansoprazole 30mg Delayed Release Capsule
Dexmethylphenidate 2.5mg Tablet
Dextroamphetamine 5mg Tablet
Dextroamphetamine 5mg Sustained Release Capsule
Dextromethorphan/Quinidine 20mg/10mg Capsule
Diaphragm Flex-Spring 65mm
Diazepam 2mg Tablet
Diazepam 5mg Tablet
Diazepam 10mg Tablet
Diazepam 1mg/ml Solution
Diazepam 2.5mg Rectal Gel
COMMON BRAND
SPRYCEL
SPRYCEL
EXJADE
EXJADE
FERRIPROX
RESCRIPTOR
DECLOMYCIN
PROLIA
XGEVA
NORPRAMIN
NORPRAMIN
NORPRAMIN
CLARINEX
DDAVP
DESOWEN
TOPICORT
PRISTIQ
PRISTIQ
DECADRON
DECADRON
DECADRON
DECADRON
DECADRON
DECADRON
DEXILANT
FOCALIN
DEXEDRINE
DEXEDRINE
DEXEDRINE
DEXEDRINE
NUEDEXTA
----VALIUM
VALIUM
VALIUM
VALIUM
DIASTAT
14
3-Tier
3
3
3
3
3
3
2
3
3
2
2
2
2
2
2
2
2
3
2
2
2
2
2
2
3
2
2
2
2
2
3
HCR
HCR
HCR
HCR
2
2
2
2
2
4-Tier
4
4
4
4
4
3
2
3
4
2
2
2
2
2
2
2
2
3
2
2
2
2
2
2
3
2
2
2
2
2
3
HCR
HCR
HCR
HCR
2
2
2
2
2
GENERIC
Diazepam 10mg Rectal Gel
Diazepam 20mg Rectal Gel
Diazoxide 50mg/ml Suspension
Diclofenac 50mg Enteric Coated Tablet
Diclofenac 75mg Enteric Coated Tablet
Diclofenac 0.1% Ophthalmic Solution
Diclofenac 1% Gel
Dicloxacillin 250mg Capsule
Dicloxacillin 500mg Capsule
Dicyclomine 10mg Capsule
Dicyclomine 20mg Tablet
Dicyclomine 10mg/5ml Solution
Didanosine 400mg Delayed Release Capsule
Diethylpropion 25mg Tablet
Diethylpropion 75mg Extended ReleaseTablet
Difenoxin/Atropine 1mg/0.025 mg Tablet
Diflorasone 0.05% Topical Ointment
Diflunisal 500mg Tablet
Difluprednate 0.05% Ophthalmic Emulsion
Digoxin 0.125mg Tablet
Digoxin 0.25mg Tablet
Digoxin 0.05mg/ml Solution
Dihydroergotamine 1mg/ml Injection
Diltiazem 30mg Tablet
Diltiazem 12mg/ml Suspension
Diltiazem 120mg Extended Release Capsule
Dimethyl Fumarate 120mg Capsule
Dimethyl Fumarate 240mg Capsule
Diphenhydramine/Lidocaine/Aluminum
Hydroxide/Magnesium Hydroxide/Simethicone Mouthwash
Diphenoxylate/Atropine 2.5mg/0.025mg Tablet
Diphenoxylate/Atropine 2.5mg-0.025mg/5ml Liquid
Dipyridamole 25mg Tablet
Dipyridamole 75mg Tablet
Disopyramide Phosphate 100mg Capsule
Disopyramide Phosphate 150mg Capsule
15
COMMON BRAND
DIASTAT
DIASTAT
PROGLYCEM
VOLTAREN
VOLTAREN
VOLTAREN
VOLTAREN
--BENTYL
BENTYL
BENTYL
VIDEX
TENUATE
TENUATE
MOTOFEN
APEXICON
DOLOBID
DUREZOL
LANOXIN
LANOXIN
LANOXIN
D.H.E.
CARDIZEM
CARDIZEM
CARDIZEM
CARDIZEM
CARDIZEM
DILT-XR
DILT-XR
DILT-XR
TECFIDERA
TECFIDERA
MAGIC MOUTHWASH
LOMOTIL
LOMOTIL
PERSANTINE
PERSANTINE
NORPACE
NORPACE
3-Tier
2
2
3
2
2
2
3
2
2
2
2
2
2
2
2
3
2
2
3
2
2
3
2
2
2
2
2
2
2
2
2
3
3
2
4-Tier
2
2
3
2
2
2
3
2
2
2
2
2
2
2
2
3
2
2
3
2
2
3
2
2
2
2
2
2
2
2
2
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
GENERIC
Disopyramide Phosphate 100mg Controlled Release Capsule
Disopyramide Phosphate 150mg Controlled Release Capsule
Disulfiram 250mg Tablet
Divalproex 125mg Delayed Release Tablet
Divalproex 125mg Sprinkle Capsule
Divalproex 250mg Extended Release Tablet
Divalproex 500mg Extended Release Tablet
Dofetilide 125mcg Capsule
Dolasetron 50mg Tablet
Dolutegravir 50mg Tablet
Donepezil 10mg Tablet
Dornase 1mg/ml Inhalation Solution
Dorzolamide 2% Ophthalmic Solution
Dorzolamide/Timolol 2%/0.5% Ophthalmic Solution
Doxazosin 1mg Tablet
Doxepin 10mg Capsule
Doxepin 5% Topical Cream
Doxercalciferol 0.5mcg Capsule
Doxycycline 50mg Tablet
Doxycycline 25mg/5ml Suspension
Dronabinol 10mg Capsule
Dronedarone 400mg Tablet
Duloxetine 20mg Delayed Release Capsule
Dutasteride 0.5mg Capsule
Dyphylline 200mg Tablet
Echothiophate Iodide 0.125% Ophthalmic Solution
Econazole 1% Topical Cream
16
COMMON BRAND
NORPACE
NORPACE
ANTABUSE
DEPAKOTE
DEPAKOTE
DEPAKOTE
DEPAKOTE
DEPAKOTE
DEPAKOTE
TIKOSYN
TIKOSYN
TIKOSYN
ANZEMET
TIVICAY
ARICEPT
PULMOZYME
TRUSOPT
COSOPT
CARDURA
CARDURA
CARDURA
CARDURA
SINEQUAN
SINEQUAN
SINEQUAN
PRUDOXIN
HECTOROL
ADOXA
ADOXA
VIBRAMYCIN
-MARINOL
MULTAQ
CYMBALTA
CYMBALTA
CYMBALTA
AVODART
LUFYLLIN
PHOSPHOLINE
SPECTAZOLE
3-Tier
3
3
2
2
2
2
2
2
2
2
2
2
3
3
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
3
2
2
3
2
2
2
2
2
3
2
4-Tier
3
3
2
2
2
2
2
2
2
2
2
2
3
3
2
4
2
2
2
2
2
2
2
2
2
2
2
2
2
3
2
2
3
2
2
2
2
2
3
2
GENERIC
Efavirenz 200mg Capsule
Efavirenz 600mg Tablet
Efavirenz/Emtricitabine/Tenofovir 600mg/200mg/300mg
Tablet
Eletriptan 20mg Tablet
Eltrombopag 12.5mg Tablet
Eltrombopag 25mg Tablet
Elvitegravir/Cobicistat/Emtricitabine/Tenofovir
150mg/150mg/200mg/300mg Tablet
Emedastine 0.05% Ophthalmic Solution
Empagliflozin 10mg Tablet
Emtricitabine 200mg Capsule
Emtricitabine 10mg/ml Solution
Emtricitabine/Rilpivirine/Tenofovir 200mg/25mg/300mg
Tablet
Emtricitabine/Tenofovir 200mg/300mg Tablet
Enalapril 2.5mg Tablet
Enalapril 20mg Tablet
Enalapril Maleate 1mg/ml Oral Solution
Enfuvirtide 90mg Injection
Enoxaparin 30mg/0.3ml Injection
Enoxaparin 100mg/ml Injection
Enoxaparin 150mg/ml Injection
Entacapone 200mg Tablet
Entecavir 0.5mg Tablet
Entecavir 1mg Tablet
Entecavir 0.05mg/ml Solution
Enzalutamide 40mg Capsule
Epinastine 0.05% Ophthalmic Solution
Epinephrine 0.15mg/0.15ml Injection
Epinephrine 0.3mg/0.3ml Injection
Epinephrine 0.1% Nasal Solution
Eplerenone 25mg Tablet
Epoetin 10000unit/ml Injection
COMMON BRAND
SUSTIVA
SUSTIVA
ATRIPLA
17
3-Tier
3
3
3
4-Tier
3
3
3
RELPAX
PROMACTA
PROMACTA
PROMACTA
PROMACTA
STRIBILD
3
3
3
3
3
3
3
4
4
4
4
3
EMADINE
JARDIANCE
EMTRIVA
EMTRIVA
COMPLERA
3
3
3
3
3
3
3
3
3
3
TRUVADA
VASOTEC
VASOTEC
EPANED
FUZEON
LOVENOX
LOVENOX
LOVENOX
LOVENOX
LOVENOX
LOVENOX
LOVENOX
COMTAN
BARACLUDE
BARACLUDE
BARACLUDE
XTANDI
ELESTAT
EPIPEN-JR
EPIPEN
ADRENALIN
INSPRA
PROCRIT
PROCRIT
3
2
2
3
3
2
2
2
2
2
2
2
2
2
2
3
3
2
3
2
3
2
3
3
3
2
2
3
3
2
2
2
2
2
2
2
2
2
2
3
4
2
3
2
3
2
3
3
GENERIC
Eprosartan 600mg Tablet
Ergocalciferol 50000unit Capsule
Ergocalciferol 400unit Tablet
Ergocalciferol 2000unit Tablet
Ergocalciferol 8000unit/ml Solution
Ergoloid Mesylates 1mg Tablet
Ergotamine Tartrate 2mg Sublingual Tablet
Ergotamine/Caffeine 2mg/100mg Rectal Suppository
Erlotinib 25mg Tablet
Erythromycin 250mg Enteric Coated Tablet
Erythromycin 333mg Enteric Coated Tablet
Erythromycin 400mg Tablet
Erythromycin 200mg/5ml Suspension
Erythromycin 400mg/5ml Suspension
Erythromycin 5mg/gm Ophthalmic Ointment
Erythromycin 2% Topical Solution
Escitalopram 5mg Tablet
Esomeprazole 20mg Capsule
Esterified Estrogens 0.3mg Tablet
Esterified Estrogens/Methyltestosterone 0.625mg/1.25mg
Tablet
Esterified Estrogens/Methyltestosterone 1.2mg/2.5mg
Tablet
Estradiol 0.5mg Tablet
Estradiol 1mg Tablet
Estradiol 2mg Tablet
Estradiol 0.05mg/24hr Patch
Estradiol 0.1mg/24hr Patch
Estradiol 10mcg Vaginal Tablet
Estradiol 2mg Vaginal Ring
Estramustine Phosphate 140mg Capsule
Estrogens, Conjugated 0.3mg Tablet
Estrogens, Conjugated 0.625mg/gm Vaginal Cream
Estropipate 0.75mg Tablet
Estropipate 1.5mg Tablet
Estropipate 3mg Tablet
18
COMMON BRAND
PROCRIT
TEVETAN
----HYDERGINE
ERGOMAR
MIGERGOT
TARCEVA
TARCEVA
TARCEVA
ERY-TAB
ERY-TAB
E.E.S.
ERYPED
ERYPED
ILOTYCIN
T-STAT
LEXAPRO
LEXAPRO
LEXAPRO
NEXIUM
MENEST
EEMT HS
3-Tier
3
2
2
ACA
ACA
ACA
2
2
2
3
3
3
2
2
2
3
3
2
2
2
2
2
3
2
2
4-Tier
3
2
2
ACA
ACA
ACA
2
2
2
4
4
4
2
2
2
3
3
2
2
2
2
2
3
2
2
EEMT DS
2
2
ESTRACE
ESTRACE
ESTRACE
CLIMARA
CLIMARA
VAGIFEM
ESTRING
EMCYT
PREMARIN
PREMARIN
OGEN
OGEN
OGEN
2
2
2
2
2
3
3
3
3
3
2
2
2
2
2
2
2
2
3
3
3
3
3
2
2
2
GENERIC
Eszopiclone 1mg Tablet
Etanercept 25mg Injection
Etanercept 50mg/ml Injection
Ethacrynic Acid 25mg Tablet
Ethambutol 400mg Tablet
Ethinyl Estradiol/Drospirenone 0.03mg/3mg Tablet
Ethinyl estradiol/ethynodiol diacetate 0.035 mg /1 mg
Tablet
Ethionamide 250mg Tablet
Ethosuximide 250mg Capsule
Ethotoin 250mg Tablet
Etidronate 200mg Tablet
Etodolac 200mg Capsule
Etodolac 300mg Capsule
Etodolac 400mg Tablet
Etodolac 500mg Tablet
Etoposide 50mg Capsule
Etravirine 100mg Tablet
Etravirine 200mg Tablet
Everolimus 2.5mg Tablet
Everolimus 5mg Tablet
Everolimus 10mg Tablet
Exemestane 25mg Tablet
Exenatide 2mg Injection
Exenatide 5mcg/0.02ml Injection
Ezetimibe 10mg Tablet
Ezogabine 200mg Tablet
Famciclovir 500mg Tablet
Famotidine 40mg/5ml Oral Suspension
Febuxostat 40mg Tablet
Febuxostat 80mg Tablet
Felbamate 400mg Tablet
Felbamate 600mg Tablet
Felbamate 600mg/5ml Suspension
Felodipine 2.5mg Extended Release Tablet
Felodipine 5mg Extended Release Tablet
Felodipine 10mg Extended Release Tablet
Fenofibrate 54mg Tablet
COMMON BRAND
LUNESTA
ENBREL
ENBREL
EDECRIN
MYAMBUTOL
OCELLA
KELNOR
TRECATOR
ZARONTIN
PEGANONE
DIDRONEL
LODINE
LODINE
LODINE
LODINE
VEPESID
INTELENCE
INTELENCE
AFINITOR
AFINITOR
AFINITOR
AFINITOR
ZORTRESS
ZORTRESS
AROMASIN
BYDUREON
BYETTA
ZETIA
POTIGA
FAMVIR
-ULORIC
ULORIC
FELBATOL
FELBATOL
FELBATOL
PLENDIL
PLENDIL
PLENDIL
LOFIBRA
19
3-Tier
2
3
3
2
2
HCR
HCR
4-Tier
2
3
4
2
2
HCR
HCR
3
2
3
2
2
2
2
2
2
3
3
3
3
3
3
3
3
2
3
3
3
3
2
2
3
3
2
2
2
2
2
2
2
3
2
3
2
2
2
2
2
2
3
3
4
4
4
4
4
4
2
3
3
3
3
2
2
3
3
2
2
2
2
2
2
2
GENERIC
Fenofibrate 160mg Tablet
Fenoprofen 600mg Tablet
Fentanyl 12mcg/hr Patch
Ferrous Sulfate 15mg/ml Drop
Fesoterodine Fumarate 4mg Tablet
Fidaxomicin 200mg Tablet
Filgrastim 300mcg/0.5ml Injection
Filgrastim 480mcg/0.8ml Injection
Filgrastim 300mcg/0.5ml Solution Prefilled Syringe
Filgrastim 480mcg/0.8ml Solution Prefilled Syringe
Finasteride 5mg Tablet
Fingolimod 0.5mg Capsule
Flavoxate 100mg Tablet
Flecainide Acetate 100mg Tablet
Flecainide Acetate 20mg/ml Suspension
Fluconazole 100mg Tablet
Flucytosine 250mg Capsule
Flucytosine 500mg Capsule
Fludrocortisone Acetate 0.1mg Tablet
Fluocinolone Acetonide 0.01% Otic Drop
Fluocinolone Acetonide 0.01% Topical Oil
Fluocinolone Acetonide 0.01% Topical Solution
Fluocinolone Acetonide 0.01% Topical Cream
Fluocinonide 0.05% Topical Solution
Fluocinonide 0.05% Topical Gel
Fluocinonide 0.05% Topical Ointment
Fluocinonide 0.05% Topical Cream
Fluorometholone 0.1% Ophthalmic Suspension
Fluorometholone 0.1% Ophthalmic Ointment
Fluorouracil 2% Topical Solution
Fluorouracil 0.5% Topical Cream
Fluorouracil 1% Aqueous Topical Cream
Fluorouracil 5% Topical Cream
Fluorouracil/Diclofenac Sodium5%/1 % Topical Cream
COMMON BRAND
LOFIBRA
--DURAGESIC
DURAGESIC
DURAGESIC
DURAGESIC
FER-IN-SOL
TOVIAZ
DIFICID
NEUPOGEN
NEUPOGEN
ZARXIO
ZARXIO
PROSCAR
GILENYA
-TAMBOCOR
TAMBOCOR
DIFLUCAN
DIFLUCAN
DIFLUCAN
ANCOBON
ANCOBON
FLORINEF
DERMOTIC
DERMA-SMOOTHE/FS
SYNALAR
SYNALAR
LIDEX
LIDEX
LIDEX
LIDEX
FML
FML
EFUDEX
CARAC
FLUOROPLEX
EFUDEX
FLUORAC
20
3-Tier
2
2
2
2
2
2
2
ACA
3
3
3
3
3
3
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
2
2
3
2
3
4-Tier
2
2
2
2
2
2
2
ACA
3
4
3
3
4
4
2
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
2
2
3
2
3
GENERIC
Fluoxetine 10mg Capsule
Fluoxetine 20mg Capsule
Fluoxymesterone 10mg Tablet
Fluphenazine 2.5mg Tablet
Flurandrenolide 4mcg/sqcm Topical Tape
Flurbiprofen 50mg Tablet
Flurbiprofen 0.03% Ophthalmic Solution
Flutamide 125mg Capsule
Fluticasone 50mcg/actuation Nasal Spray
Fluticasone Furoate/Vilanterol Aerosol Inhalation
100mcg/25 mcg per inhalation
Fluticasone 0.005% Topical Ointment
Fluticasone/Salmeterol 100/50 Powder Inhalation
Fluvastatin 20mg Capsule
Fluvoxamine 25mg Tablet
Folic Acid 400mcg Tablet
Folic Acid 800mcg Tablet
Folic Acid 1mg/ml Solution
Formoterol Fumarate 20mcg/2ml Inhaler
Fosamprenavir 700mg Tablet
Fosamprenavir 50mg/ml Suspension
Fosfomycin Tromethamine Powder 3gm
Fosinopril 20mg Tablet
Frovatriptan Succinate 2.5mg Tablet
Furosemide 20mg Tablet
Furosemide 40mg Tablet
Furosemide 10mg/ml Solution
Gabapentin Enacarbil 600mg Tablet
Gabapentin 100mg Capsule
Gabapentin 600mg Tablet
Gabapentin 800mg Tablet
Galantamine 4mg Tablet
Galantamine 8mg Extended Release Capsule
COMMON BRAND
PROZAC
PROZAC
ANDROXY
PROLIXIN
CORDRAN
-OCUFEN
EULEXIN
FLONASE
BREO ELLIPTA
CUTIVATE
ADVAIR
ADVAIR
ADVAIR
LESCOL
LUVOX
---PERFOROMIST
LEXIVA
LEXIVA
MONUROL
MONOPRIL
FROVA
LASIX
LASIX
LASIX
HORIZANT
NEURONTIN
NEURONTIN
NEURONTIN
NEURONTIN
NEURONTIN
RAZADYNE
RAZADYNE
RAZADYNE
RAZADYNE
RAZADYNE
RAZADYNE
21
3-Tier
1
1
2
2
3
2
2
2
2
3
4-Tier
1
1
2
2
3
2
2
2
2
3
2
3
3
3
2
2
ACA
ACA
2
3
3
3
3
2
2
1
1
2
3
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
2
2
ACA
ACA
2
3
3
3
3
2
2
1
1
2
3
2
2
2
2
2
2
2
2
2
2
2
GENERIC
Ganciclovir 0.15% Ophthalmic Gel
Gatifloxacin 0.5% Ophthalmic Solution
Gemfibrozil 600mg Tablet
Gemifloxacin 320mg Tablet
Gentamicin 0.3% Nasal Solution
Gentamicin 0.85mg/ml Irrigation Solution
Gentamicin 13.6mg/ml Ophthalmic Solution
Gentamicin 0.3% Ophthalmic Ointment
Gentamicin 0.1% Topical Cream
Gentamicin 0.1% Topical Ointment
Gentamicin/Prednisolone 0.3%/1% Ophthalmic Suspension
Glatiramer Acetate 20mg/ml Injection
Glimepiride 1mg Tablet
Glipizide 5mg Tablet
Glipizide 10mg Tablet
Glipizide 2.5mg Extended Release Tablet
Glipizide 5mg Extended Release Tablet
Glipizide 10mg Extended Release Tablet
Glipizide/Metformin 5mg/500mg Tablet
Glucagon 1mg Injection
Glyburide 2.5mg Tablet
Glyburide 5mg Tablet
Glyburide/Metformin 5mg/500mg Tablet
Glycerol Phenylbutyrate 1.1gm/ml Liquid
Glycopyrrolate 1mg Tablet
Golimumab 50mg/0.5ml Injection
Granisetron 1mg Tablet
Griseofulvin 250mg Ultramicrosize Tablet
Guaifenesin/Codeine 100mg-10mg/5ml Syrup
Guanfacine 1mg Tablet
Guanfacine 2mg Tablet
Guanfacine 1mg Sustained Release Tablet
Guanidine 125mg Tablet
Halcinonide 0.1% Topical Ointment
Halobetasol 0.05% Topical Ointment
22
COMMON BRAND
ZIRGAN
ZYMAXID
LOPID
FACTIVE
--GARAMYCIN
GENTAK
GARAMYCIN
GARAMYCIN
PRED-G
GLATOPA
AMARYL
AMARYL
AMARYL
GLUCOTROL
GLUCOTROL
GLUCOTROL
GLUCOTROL
GLUCOTROL
METAGLIP
-DIABETA
DIABETA
GLUCOVANCE
RAVICTI
ROBINUL
SIMPONI
KYTRIL
GRIS-PEG
CHERATUSSIN
TENEX
TENEX
INTUNIV
INTUNIV
INTUNIV
INTUNIV
-HALOG
ULTRAVATE
3-Tier
3
2
2
3
2
2
2
2
2
2
3
2
1
1
1
1
1
2
2
2
2
3
2
2
2
3
2
3
2
2
2
1
2
2
2
2
2
3
3
2
4-Tier
3
2
2
3
2
2
2
2
2
2
3
2
1
1
1
1
1
2
2
2
2
3
2
2
2
4
2
4
2
2
2
1
2
2
2
2
2
3
3
2
GENERIC
Haloperidol 0.5mg Tablet
Haloperidol 2mg Tablet
Haloperidol 5mg Tablet
Haloperidol 2mg/ml Liquid
Heparin 1000unit/ml Injection Solution
Heparin 5000u/ml Injection
Hexachlorophene 3% Topical Liquid
Hydralazine 10mg Tablet
Hydralazine 1 mg/mL Solution
Hydrochlorothiazide 25mg Tablet
Hydrochlorothiazide 50mg Tablet
Hydrochlorothiazide 10mg/ml Suspension
Hydrocodone/Acetaminophen 10mg/325mg Tablet
Hydrocodone/Acetaminophen 5mg/325mg Tablet
Hydrocodone/Acetaminophen 7.5mg/325mg Tablet
Hydrocodone/Acetaminophen 7.5mg-325mg/15ml Solution
Hydrocodone/Chlorpheniramine 10mg-8mg/5ml Liquid
Hydrocodone/Homatropine 5mg-1.5mg/5ml Syrup
Hydrocortisone 5mg Tablet
Hydrocortisone 2mg/ml Suspension
Hydrocortisone Acetate 25mg Rectal Suppository
Hydrocortisone 100mg/60ml Rectal Enema
Hydrocortisone Acetate/Pramoxine 2.5%/1% Rectal Cream
Hydrocortisone Acetate/Pramoxine 1%/1% Rectal Foam
Hydrocortisone 2.5% Topical Cream
Hydrocortisone 2.5% Topical Lotion
Hydrocortisone 2.5% Topical Ointment
Hydrocortisone Valerate 0.2% Topical Cream
Hydrocortisone Valerate 0.2% Topical Ointment
Hydrocortisone Butyrate 0.1% Topical Solution
Hydrocortisone Butyrate 0.1% Topical Cream
Hydrocortisone Butyrate 0.1% Topical Ointment
Hydrocortisone/Acetic Acid/Propylene Glycol 1%/2%/3%
Otic Solution
Hydromorphone 2mg Tablet
Hydromorphone 8mg Extended ReleaseTablet
Hydroxychloroquine 200mg Tablet
23
COMMON BRAND
HALDOL
HALDOL
HALDOL
HALDOL
--PHISOHEX
APRESOLINE
APRESOLINE
APRESOLINE
----VICODIN
VICODIN
VICODIN
HYCET
TUSSIONEX
HYDROMET
CORTEF
-CORTEF
CORTEF
ANUCORT
COLOCORT
ANALPRAM-HC
PROCTOFOAM-HC
-LOCOID
LOCOID
-WESTCORT
---ACETASOL HC
DILAUDID
EXALGO
PLAQUENIL
3-Tier
2
2
2
2
2
2
3
1
1
2
2
1
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4-Tier
2
2
2
2
2
2
3
1
1
2
2
1
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
GENERIC
Hydroxyurea 500mg Capsule
Hydroxyzine 10mg Tablet
Hydroxyzine 10mg/5ml Syrup
Hydroxyzine Pamoate 25mg Capsule
Ibandronate 150mg Tablet
Ibuprofen 400mg Tablet
Icatibant Acetate 30mg/3ml Subcutaneous Injection
Icosapent 1gm Capsule
Idelalisib 100mg Tablet
Idelalisib 150mg Tablet
Iloperidone 1mg Tablet
Iloprost 10mcg/ml Inhalation Solution
Imatinib 100mg Tablet
Imatinib 400mg Tablet
Imipramine 25mg Tablet
Imipramine 50mg Tablet
Imiquimod 5% Topical Cream
Indacaterol 75mcg Inhalation Capsule
Indapamide 1.25mg Tablet
Indinavir 400mg Capsule
Indomethacin 50mg Capsule
Indomethacin 25mg Capsule
Indomethacin 50mg Rectal Suppository
Ingenol 0.015% Topical Gel
Insulin Aspart 100u/ml Injection
Insulin Glargine 100u/ml Injection
Insulin Glulisine 100unit/ml Injection
Insulin Lispro 100unit/ml Injection
Insulin Detemir 100unit/ml Injection
Insulin Regular 100unit/ml Injection
Insulin Regular 500u/ml Injection
Insulin Isophane 100unit/ml Injection
Insulin Aspart Subcutaneous Suspension
Insulin Lispro Subcutaneous Suspension
COMMON BRAND
HYDREA
ATARAX
ATARAX
ATARAX
ATARAX
VISTARIL
VISTARIL
VISTARIL
BONIVA
MOTRIN
MOTRIN
MOTRIN
FIRAZYR
VASCEPA
ZYDELIG
ZYDELIG
FANAPT
VENTAVIS
GLEEVEC
GLEEVEC
TOFRANIL
TOFRANIL
ALDARA
ARCAPTA
LOZOL
CRIXIVAN
INDOCIN
INDOCIN
INDOCIN
PICATO
NOVOLOG
LANTUS
APIDRA
HUMALOG
LEVEMIR
HUMULIN R
HUMULIN R
HUMULIN N
NOVOLOG
HUMALOG
24
3-Tier
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
2
2
2
2
2
3
1
3
2
2
2
3
3
3
3
3
3
2
3
2
3
3
4-Tier
2
2
2
2
2
2
2
2
2
2
2
2
4
3
4
4
3
4
2
2
2
2
2
3
1
3
2
2
2
3
3
3
3
3
3
2
3
2
3
3
GENERIC
Insulin Isophane/Insulin Regular 70/30 100unit/ml Injection
Interferon Alfa-2b 6000000u/ml Injection
Interferon Alfa-2b 10mu/ml Injection
Interferon Alfa-2b 18mu Injection
Interferon Alfa-2b 50mu Injection
Interferon Gamma-1b 2000000unit/0.5ml Injection
Interferon Beta-1a 22mcg/0.5ml Injection
Interferon Beta-1a 44mcg/0.5ml Injection
Interferon Beta-1b 0.3mg Injection
Interferon Beta-1b 0.3mg Injection
Iodoquinol/Hydrocortisone 1%/1% Topical Cream
Ipratropium 0.03% Nasal Solution
Ipratropium 0.02% Inhalation Solution
Ipratropium 17mcg/actuation Inhaler
Ipratropium/Albuterol 20mcg/100mcg/actuation Inhaler
Irbesartan 75mg Tablet
Isavuconazonium 186mg Capsule
Isocarboxazid 10mg Tablet
Isoniazid 100mg Tablet
Isoniazid 300mg Tablet
Isoniazid 50mg/5ml Syrup
Isoniazid/Rifampin 150mg/300mg Capsule
Isosorbide Dinitrate 10mg Tablet
Isosorbide Dinitrate 20mg Tablet
Isosorbide Monohydrate 10mg Tablet
Isosorbide Mononitrate 30mg Extended Release Tablet
Isotretinoin 10mg Capsule
Isradipine 5mg Capsule
Itraconazole Capsule
Itraconazole 10mg/ml Solution
Ivacaftor 150mg Tablet
Ivermectin 3mg Tablet
Ketoconazole 20mg/ml Suspension
Ketoconazole 200mg Tablet
Ketoconazole 2% Topical Cream
Ketoconazole 2% Shampoo
25
COMMON BRAND
HUMULIN 70/30
INTRON-A
INTRON-A
INTRON-A
INTRON-A
ACTIMMUNE
REBIF
REBIF
EXTAVIA
BETASERON
DERMAZENE
ATROVENT
ATROVENT
ATROVENT
COMBIVENT
AVAPRO
CRESEMBA
MARPLAN
---RIFAMATE
ISORDIL
ISORDIL
-IMDUR
IMDUR
IMDUR
CLARAVIS
CLARAVIS
CLARAVIS
DYNACIRC
SPORANOX
SPORANOX
KALYDECO
STROMECTOL
NIZORAL
NIZORAL
NIZORAL
NIZORAL
3-Tier
2
3
3
3
3
3
3
3
2
2
2
2
1
3
3
2
3
3
2
2
2
2
2
2
2
1
1
2
2
2
2
2
2
3
3
2
2
2
2
2
4-Tier
2
4
4
4
4
4
3
3
2
2
2
2
1
3
3
2
4
3
2
2
2
2
2
2
2
1
1
2
2
2
2
2
2
3
4
2
2
2
2
2
GENERIC
Ketoprofen 50mg Capsule
Ketorolac 10mg Tablet
Ketorolac Tromethamine 0.4 % Ophthalmic Solution
Labetalol 200mg Tablet
Labetalol 10mg/ml Suspension
Labetalol 300mg Tablet
Labetalol 40mg/ml Suspension
Lacosamide 50mg Tablet
Lactic Acid /Ammonium Hydroxide 12% Topical Cream
Lactulose 10gm/15ml Solution
Lamivudine 150mg Tablet
Lamivudine 300mg Tablet
Lamivudine/Zidovudine 150mg/300mg Tablet
Lamotrigine 25mg Tablet
Lamotrigine 25mg Chewable Tablet
Lansoprazole 30mg Capsule
Lanthanum Carbonate 500mg Chewable Tablet
Lapatinib 250mg Tablet
Latanoprost 0.005% Ophthalmic Solution
Ledipasvir/Sofosbuvir 90mg/400mg Tablet
Leflunomide 20mg Tablet
Lenalidomide 2.5mg Capsule
Lenalidomide 5mg Capsule
Letrozole 2.5mg Tablet
Leucovorin 5mg Tablet
Levalbuterol 1.25mg/3ml Inhalation
Levetiracetam 250mg Tablet
COMMON BRAND
--ACULAR LS
TRANDATE
TRANDATE
TRANDATE
TRANDATE
VIMPAT
VIMPAT
VIMPAT
VIMPAT
LAC-HYDRIN
ENULOSE
EPIVIR
EPIVIR
COMBIVIR
LAMICTAL
LAMICTAL
LAMICTAL
LAMICTAL
LAMICTAL
PREVACID
FOSRENOL
FOSRENOL
FOSRENOL
TYKERB
XALATAN
HARVONI
ARAVA
REVLIMID
REVLIMID
REVLIMID
REVLIMID
REVLIMID
FEMARA
-XOPENEX
KEPPRA
KEPPRA
KEPPRA
26
3-Tier
2
2
2
2
2
2
2
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
2
3
2
3
3
3
3
3
2
2
2
2
2
2
4-Tier
2
2
2
2
2
2
2
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
2
4
2
4
4
4
4
4
2
2
2
2
2
2
GENERIC
Levobunolol 0.5% Ophthalmic Solution
Levocarnitine 1gm/10ml Solution
Levocetirizine 2.5mg/5ml Solution
Levofloxacin 250mg Tablet
Levofloxacin 25mg/ml Solution
Levofloxacin 0.5% Ophthalmic Solution
Levonorgestrel 1.5mg Tablet
Levonorgestrel/Ethinyl Estradiol 0.10mg/0.02mg Tablet
Levonorgestrel/Ethinyl Estradiol 0.15mg/30mg Tablet
Levonorgestrel/Ethinyl Estradiol Tablet
Levorphanol Tartrate 2mg Tablet
Levothyroxine 25mcg Tablet
Levothyroxine 25mcg/ml Liquid
Lidocaine 5% Topical Patch
Lidocaine 4% Topical Solution
Lidocaine 2% Topical Gel
Lidocaine/Aluminum Hydroxide/Magnesium
Hydroxide/Simethicone 3:1 Susp
Lidocaine/Prilocaine Topical Cream
Lidocaine/Prilocaine Topical Kit
Lidocaine/Tetracaine Topical Patch
Linaclotide 145mcg Capsule
Linaclotide 290mcg Capsule
Linagliptin 5mg Tablet
Lindane 1% Topical Shampoo
Linezolid 600mg Tablet
Linezolid 100mg/5ml Suspension
COMMON BRAND
KEPPRA
BETAGAN
CARNITOR
XYZA
LEVAQUIN
LEVAQUIN
LEVAQUIN
LEVAQUIN
-PLAN-B
AVIANE
LEVORA
TRIVORA
LEVO-DROMORAN
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
LIDODERM
XYLOCAINE
XYLOCAINE
GI COCKTAIL
EMLA
EMLA
SYNERA
LINZESS
LINZESS
TRADJENTA
KWELL
ZYVOX
ZYVOX
27
3-Tier
2
2
2
2
2
2
2
2
2
HCR
HCR
HCR
HCR
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4-Tier
2
2
2
2
2
2
2
2
2
HCR
HCR
HCR
HCR
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
2
2
2
2
2
3
3
3
3
2
2
2
GENERIC
Liothyronine 25mcg Tablet
Liotrix 120mg Tablet
Liraglutide 18mg/3ml Subcutaneous Solution
Lisdexamfetamine 20mg Capsule
Lisinopril 2.5mg Tablet
Lisinopril 5mg Tablet
Lisinopril 2mg/ml Suspension
Lisinopril/Hydrochlorothiazide 10mg/12.5mg Tablet
Lisinopril/Hydrochlorothiazide 20mg/12.5mg Tablet
Lisinopril/Hydrochlorothiazide 20mg/25mg Tablet
Lithium Citrate 8meq/5ml Solution
Lithium Carbonate 300mg Capsule
Lithium Carbonate 300mg Extended ReleaseTablet
Lithium Carbonate 450mg Extended ReleaseTablet
Lodoxamide 0.1% Ophthalmic Solution
Lomitapide 5mg Capsule
Lomustine 10mg Capsule
Lopinavir/Ritonavir 200mg/50mg Tablet
Lopinavir/Ritonavir 80mg-20mg/ml Solution
Lorazepam 0.5mg Tablet
Lorazepam 1mg Tablet
Lorazepam 2mg Tablet
Lorazepam 2mg/ml Concentrate Solution
Losartan 25mg Tablet
Losartan/Hydrochlorothiazide 50mg/12.5mg Tablet
Losartan/Hydrochlorothiazide 100mg/12.5mg Tablet
Losartan/Hydrochlorothiazide 100mg/25mg Tablet
Loteprednol 0.5% Ophthalmic Gel
Lovastatin 10mg Tablet
Loxapine Succinate 10mg Capsule
Lubiprostone 8mcg Capsule
Lurasidone 20mg Tablet
COMMON BRAND
CYTOMEL
THYROLAR-2
VICTOZA
VYVANSE
PRINIVIL
PRINIVIL
PRINIVIL
PRINIVIL
PRINIVIL
PRINIVIL
PRINIVIL
PRINIZIDE
PRINIZIDE
PRINIZIDE
LITHOBID
LITHOBID
ESKALITH-CR
ESKALITH-CR
ALOMIDE
JUXTAPID
JUXTAPID
JUXTAPID
GLEOSTINE
KALETRA
KALETRA
ATIVAN
ATIVAN
ATIVAN
ATIVAN
COZAAR
COZAAR
COZAAR
HYZAAR
HYZAAR
HYZAAR
LOTEMAX
MEVACOR
LOXITANE
AMITIZA
LATUDA
28
3-Tier
2
3
3
3
1
1
2
1
1
2
1
1
1
1
3
2
2
2
3
3
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
3
1
2
3
3
4-Tier
2
3
3
3
1
1
2
1
1
2
1
1
1
1
3
2
2
2
3
4
4
4
3
3
3
2
2
2
2
2
2
2
2
2
2
3
1
2
3
4
GENERIC
Mafenide 5 % Topical Solution
Malathion 0.5% Topical Lotion
Maprotiline 50mg Tablet
Maraviroc 150mg Tablet
Maraviroc 300mg Tablet
Mecasermin 40mg/4ml Subcutaneous Solution
Meclofenamate 50mg Capsule
Medroxyprogesterone 2.5mg Tablet
Medroxyprogesterone 5mg Tablet
Medroxyprogesterone 10mg Tablet
Mefenamic Acid 250mg Capsule
Mefloquine 250mg Tablet
Megestrol Acetate 40mg Tablet
Megestrol Acetate 40mg/ml Suspension
Meloxicam 7.5mg Tablet
Meloxicam 15mg Tablet
Melphalan 2mg Tablet
Memantine 5mg Tablet
Memantine 10mg Tablet
Memantine Titration Pack Tablet
Mepenzolate Bromide 25mg Tablet
Meprobamate 200mg Tablet
Mercaptopurine 50mg Tablet
Mesalamine 1.2gm Enteric Coated Tablet
Mesalamine 4gm Rectal Enema
Metaproterenol 10mg Tablet
Metaxalone 800mg Tablet
Metformin 500mg Tablet
Metformin 500mg Sustained Release Tablet
Metformin 750mg Sustained Release Tablet
Methadone 5mg Tablet
Methadone 10mg Tablet
Methamphetamine 5mg Tablet
Methazolamide 50mg Tablet
Methenamine Hippurate 1gm Tablet
Methimazole 5mg Tablet
Methimazole 10mg Tablet
Methocarbamol 500mg Tablet
COMMON BRAND
SULFAMYLON
OVIDE
LUDIOMIL
SELZENTRY
SELZENTRY
INCRELEX
MECLOMEN
PROVERA
PROVERA
PROVERA
PONSTEL
LARIAM
MEGACE
MEGACE
MOBIC
MOBIC
ALKERAN
NAMENDA
NAMENDA
NAMENDA
CANTIL
EQUANIL
PURINETHOL
LIALDA
ROWASA
METAPREL
SKELAXIN
GLUCOPHAGE
GLUCOPHAGE
GLUCOPHAGE
GLUCOPHAGE XR
GLUCOPHAGE XR
DOLOPHINE
DOLOPHINE
DESOXYN
NEPTAZANE
HIPREX
TAPAZOLE
TAPAZOLE
ROBAXIN
29
3-Tier
3
2
2
3
3
3
2
2
2
2
2
2
2
2
2
2
3
2
2
2
3
2
2
3
2
2
2
1
1
1
1
2
2
2
2
2
2
2
2
2
4-Tier
3
2
2
3
3
4
2
2
2
2
2
2
2
2
2
2
3
2
2
2
3
2
2
3
2
2
2
1
1
1
1
2
2
2
2
2
2
2
2
2
GENERIC
Methocarbamol 750mg Tablet
Methotrexate 2.5mg Tablet
Methscopolamine 2.5mg Tablet
Methsuximide 300mg Capsule
Methyclothiazide 5mg Tablet
Methyldopa 250mg Tablet
Methyldopa 500mg Tablet
Methylergonovine 0.2mg Tablet
Methylnaltrexone 12mg/0.6ml Subcutaneous Kit
Methylphenidate 10mg Controlled Delivery Capsule
Methylphenidate 5mg Tablet
Methylphenidate 10mg Tablet
Methylphenidate 20mg Extended Release Tablet
Methylprednisolone 4mg Tablet
Methylprednisolone 16mg Tablet
Methyltestosterone 10mg Tablet
Metipranolol 0.3% Ophthalmic Solution
Metoclopramide 10mg Tablet
Metoclopramide 5mg/5ml Solution
Metolazone 2.5mg Tablet
Metolazone 5mg Tablet
Metoprolol Succinate 25mg Extended Release Tablet
Metoprolol Tartrate 25mg Tablet
Metoprolol Tartrate 10mg/ml Suspension
Metronidazole 250mg Tablet
Metronidazole 500mg Tablet
Metronidazole 50mg/ml Suspension
COMMON BRAND
ROBAXIN
RHEUMATREX
PAMINE
CELONTIN
ENDURON
ALDOMET
ALDOMET
METHERGINE
RELISTOR
METADATE
METADATE
METADATE
METADATE
METADATE
METADATE
RITALIN
RITALIN
METADATE
CONCERTA
CONCERTA
CONCERTA
CONCERTA
MEDROL
MEDROL
METHITEST
OPTIPRANOLOL
REGLAN
REGLAN
ZAROXOLYN
ZAROXOLYN
TOPROL
TOPROL
TOPROL
LOPRESSOR
LOPRESSOR
LOPRESSOR
LOPRESSOR
FLAGYL
FLAGYL
FLAGYL
30
3-Tier
2
2
2
3
2
1
2
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
1
1
2
2
2
4-Tier
2
2
2
3
2
1
2
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
1
1
2
2
2
GENERIC
Metronidazole 0.75% Topical Cream
Metronidazole 0.75% Topical Gel
Mexiletine 150mg Capsule
Midazolam 2mg/ml Syrup
Midodrine 2.5mg Tablet
Midodrine 5mg Tablet
Midodrine 10mg Tablet
Mifepristone 300mg Tablet
Miglitol 25mg Tablet
Miglustat 100mg Capsule
Milnacipran 12.5mg Tablet
Minocycline 50mg Capsule
Minoxidil 2.5mg Tablet
Minoxidil 10mg Tablet
Mipomersen 200mg/ml Subcutaneous Solution
Mirabegron 25mg Sustained Release Tablet
Mirabegron 50mg Sustained Release Tablet
Mirtazapine 15mg Tablet
Mirtazapine 30mg Tablet
Misoprostol 100mcg Tablet
Misoprostol 200mcg Tablet
Mitotane 500mg Tablet
Modafinil 100mg Tablet
Modafinil 200mg Tablet
Moexipril 7.5mg Tablet
Mometasone 110mcg/inh Inhalation Inhaler
Mometasone 220mcg/inh Inhalation Inhaler
Mometasone 0.1% Topical Cream
Mometasone 0.1% Topical Ointment
Mometasone/Formoterol 100mcg-5mcg/inh Inhalation
Inhaler
Mometasone/Formoterol 200mcg-5mcg/inh Inhalation
Inhaler
Montelukast 10mg Tablet
Montelukast 4mg Chewable Tablet
Montelukast 5mg Chewable Tablet
Morphine 15mg Tablet
Morphine 30mg Tablet
Morphine 15mg Extended Release Tablet
Morphine 30mg Extended ReleaseTablet
COMMON BRAND
METROCREAM
METROGEL
MEXITIL
VERSED
PROAMATINE
PROAMATINE
PROAMATINE
KORLYM
GLYSET
ZAVESCA
SAVELLA
MINOCIN
--KYNAMRO
MYRBETRIQ SR
MYRBETRIQ SR
REMERON
REMERON
CYTOTEC
CYTOTEC
LYSODREN
PROVIGIL
PROVIGIL
UNIVASC
ASMANEX
ASMANEX
ELOCON
ELOCON
DULERA
31
3-Tier
2
2
2
2
2
2
2
3
3
3
3
2
2
2
3
3
3
2
2
2
2
3
2
2
2
3
3
2
2
3
4-Tier
2
2
2
2
2
2
2
4
3
4
3
2
2
2
4
3
3
2
2
2
2
3
2
2
2
3
3
2
2
3
DULERA
3
3
SINGULAIR
SINGULAIR
SINGULAIR
--ORAMORPH
ORAMORPH
ORAMORPH
2
2
2
3
3
2
2
2
2
2
2
3
3
2
2
2
GENERIC
Morphine 10mg/5ml Solution
Morphine 20mg/ml Solution
Morphine 10mg Rectal Suppository
Morphine/Naltrexone 30mg/1.2mg Capsule
Moxifloxacin 400mg Tablet
Moxifloxacin 0.5% Ophthalmic Solution
Multivitamin/Fluoride 0.25mg Chewable Tablets
Multivitamin/Fluoride 0.5mg Chewable Tablets
Multivitamin/Fluoride 1mg Chewable Tablets
Multivitamin/Fluoride 0.25mg/ml Drops Solution
Multivitamin/Fluoride 0.5mg/ml Drops Solution
Multivitamin/Iron/Fluoride 0.25mg-10mg/ml Drops Solution
Mupirocin 2% Nasal Ointment
Mupirocin 2% Topical Ointment
Mycophenolate 250mg Capsule
Mycophenolate 500mg Tablet
Nabilone 1mg Capsule
Nabumetone 500mg Tablet
Nabumetone 750mg Tablet
Nadolol 40mg Tablet
Nadolol 80mg Tablet
Nafarelin Acetate 2mg/ml Nasal Solution
Naftifine 1% Topical Cream
Naltrexone 50mg Tablet
Naphazoline 0.1% Ophthalmic Solution
Naproxen 250mg Tablet
Naratriptan 1mg Tablet
Naratriptan 2.5mg Tablet
Natamycin 5% Ophthalmic Suspension
Nateglinide 60mg Tablet
Nebivolol 10mg Tablet
Nedocromil 2% Ophthalmic Solution
Nefazodone 50mg Tablet
32
COMMON BRAND
ORAMORPH
ROXANOL
ROXANOL
RMS
EMBEDA
AVELOX
VIGAMOX
POLY-VI-FLOR
POLY-VI-FLOR
POLY-VI-FLOR
POLY-VI-FLOR
POLY-VI-FLOR
POLY-VI-FLOR WITH IRON
BACTROBAN
BACTROBAN
CELLCEPT
CELLCEPT
CESAMET
RELAFEN
RELAFEN
CORGARD
CORGARD
SYNAREL
NAFTIN
REVIA
AK-CON
NAPROSYN
NAPROSYN
ANAPROX
AMERGE
AMERGE
NATACYN
STARLIX
BYSTOLIC
ALOCRIL
SERZONE
SERZONE
SERZONE
SERZONE
SERZONE
3-Tier
2
2
2
3
3
2
3
2
2
2
2
2
2
3
2
2
2
3
2
2
2
2
3
3
2
2
2
2
2
2
2
3
2
3
3
2
2
2
2
2
4-Tier
2
2
2
3
3
2
3
2
2
2
2
2
2
3
2
2
2
3
2
2
2
2
3
3
2
2
2
2
2
2
2
3
2
3
3
2
2
2
2
2
GENERIC
Nelfinavir 250mg Tablet
Nelfinavir 625mg Tablet
Neomycin 500mg Tablet
Neomycin/Fluocinolone 0.35%0.025 % Topical Cream
Neomycin/Bacitracin/Polymyxin B Ophthalmic Ointment
Neomycin/Colistin/Hydrocortisone/Thonzonium Otic
Suspension
Neomycin/Polymyxin B/Hydrocortisone Topical Cream
Neomycin/Polymyxin B/Gramicidin Ophthalmic Solution
Neomycin/Polymyxin B/Dexamethasone Ophthalmic
Suspension
Neomycin/Polymyxin B/Dexamethasone Ophthalmic
Ointment
Neomycin/Polymyxin B/Hydrocortisone Otic Suspension
Nepafenac 0.1% Ophthalmic Suspension
Nevirapine 200mg Tablet
Nevirapine 400mg Extended Release Tablet
Nicardipine 20mg Capsule
Nicotine 10mg Inhalation Inhaler
Nicotine 7mg/24hr Patch
Nicotine 2mg Dental Gum
Nicotine 4mg Dental Gum
Nifedipine 10mg Capsule
Nifedipine 30mg Extended Release Tablet
Nilotinib 150mg Capsule
Nilotinib 200mg Capsule
Nilutamide 150mg Tablet
Nimodipine 30mg Capsule
Nimodipine 60mg/20ml Solution
Nisoldipine 8.5mg Extended Release Tablet
Nitazoxanide 500mg Tablet
Nitisinone 2mg Capsule
Nitrofurantoin 25mg/5ml Suspension
Nitrofurantoin 25mg Capsule
COMMON BRAND
VIRACEPT
VIRACEPT
-NEO-SYNALAR
NEO-POLYCIN
CORTISPORIN-TC
33
3-Tier
3
3
2
2
2
3
4-Tier
3
3
2
2
2
3
CORTISPORIN
NEOSPORIN
POLY-DEX
2
2
2
2
2
2
MAXITROL
2
2
CORTOMYCIN
NEVANAC
VIRAMUNE
VIRAMUNE
-NICOTROL
HABITROL
HABITROL
HABITROL
NICORETTE
NICORETTE
PROCARDIA
ADALAT
ADALAT
ADALAT
TASIGNA
TASIGNA
NILANDRON
NIMOTOP
NYMALIZE
SULAR
ALINIA
ORFADIN
ORFADIN
ORFADIN
FURADANTIN
MACRODANTIN
MACRODANTIN
2
3
2
2
2
TC
TC
TC
TC
TC
TC
2
2
2
2
3
3
3
2
3
2
3
3
3
3
2
3
2
2
3
2
2
2
3
TC
TC
TC
TC
TC
2
2
2
2
4
4
3
2
3
2
3
4
4
4
2
3
2
GENERIC
Nitroglycerin 2.5mg Extended Release Capsule
Nitroglycerin 0.3mg Sublingual Tablet
Nitroglycerin 0.3% Topical Ointment
Nitroglycerin 0.1mg/hr Patch
Nitroglycerin 0.4% Rectal Ointment
Nizatidine 150mg Capsule
Nonoxynol-9 12.5% Vaginal Foam
Nonoxynol-9 3% Vaginal Gel
Nonoxynol-9 4% Vaginal Gel
Nonoxynol-9 28% Vaginal Film
Norethindrone 0.35mg Tablet
Norethindrone Acetate 5mg Tablet
Norethindrone/Estradiol/Ferrous Fumarate 1mg/20mcg
Tablet
Norethindrone/Ethinyl Estradiol 0.5mg/35mcg Tablet
Norethindrone/Ethinyl Estradiol 1mg/35mcg Tablet
Norethindrone/Ethinyl Estradiol Tablet
Norfloxacin 400mg Tablet
Norgestimate/Ethinyl Estradiol 0.25mg/0.035mg Tablet
Norgestimate/Ethinyl Estradiol Tablet
Nortriptyline 10mg Capsule
Nystatin 500000unit Tablet
Nystatin 100000u/gm Topical Powder
Nystatin/Triamcinolone Topical Cream
Nystatin/Triamcinolone Topical Ointment
Octreotide Acetate 100mcg/ml Injection Solution
Octreotide Acetate 500mcg/ml Injection Solution
Ofloxacin 0.3% Ophthalmic Solution
Ofloxacin 0.3% Otic Solution
Olanzapine 2.5mg Tablet
Olanzapine 5mg Tablet
Olanzapine 7.5mg Tablet
COMMON BRAND
MACROBID
NITRO-TIME
NITROSTAT
NITROSTAT
NITROSTAT
NITROBID
NITRO-DUR
NITRO-DUR
NITRO-DUR
NITRO-DUR
RECTIV
AXID
VCF
GYNOL
CONCEPTROL
VCF
NORA-BE
AYGESTIN
MICROGESTIN FE
NECON
NECON
LEENA
NOROXIN
SPRINTEC
TRI-SPRINTEC
AVENTYL
AVENTYL
AVENTYL
AVENTYL
BIO-STATIN
NYSTOP
--SANDOSTATIN
SANDOSTATIN
OCUFLOX
-ZYPREXA
ZYPREXA
ZYPREXA
34
3-Tier
2
2
3
3
3
2
2
2
3
2
3
2
ACA
ACA
ACA
ACA
HCR
2
HCR
4-Tier
2
2
3
3
3
2
2
2
3
2
3
2
ACA
ACA
ACA
ACA
HCR
2
HCR
HCR
HCR
HCR
3
HCR
HCR
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
HCR
HCR
HCR
3
HCR
HCR
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
GENERIC
Olmesartan 5mg Tablet
Olodaterol Inhalation Solution 2.5mcg/actuation
Olopatadine 0.6% Nasal Solution
Olopatadine 0.1% Ophthalmic Solution
Olsalazine 250mg Capsule
Omacetaxine 3.5mg Subcutaneous Solution
Omega-3-Acid 1gm Capsule
Omeprazole 10mg Capsule
Omeprazole 2mg/ml Solution
Omeprazole/Sodium Bicarbonate 20mg Powder
Omeprazole/Sodium Bicarbonate 40mg Powder
Ondansetron 4mg Disintegrating Tablet
Ondansetron 8mg Disintegrating Tablet
Ondansetron 4mg Tablet
Ondansetron 8mg Tablet
Ondansetron 4mg/5ml Solution
Oprelvekin 5mg Subcutaneous Solution
Orphenadrine Citrate 100mg Extended Release Tablet
Oseltamivir Phosphate 75mg Capsule
Oseltamivir Phosphate 6mg/ml Suspension
Oxandrolone 2.5mg Tablet
Oxaprozin 600mg Tablet
Oxazepam 10mg Capsule
Oxcarbazepine 150mg Tablet
Oxiconazole 1% Topical Cream
Oxybutynin Chloride 5mg Tablet
Oxybutynin Chloride 5mg/5ml Syrup
Oxybutynin Chloride 5mg Extended Release Tablet
Oxycodone 5mg Tablet
Oxycodone 5mg/5ml Solution
Oxycodone 10mg Controlled Release Tablet
COMMON BRAND
ZYPREXA
ZYPREXA
ZYPREXA
BENICAR
STRIVERDI RESPIMAT
PATANASE
PATANOL
DIPENTUM
SYNRIBO
LOVAZA
PRILOSEC
PRILOSEC
ZEGERID
ZEGERID
ZOFRAN
ZOFRAN
ZOFRAN
ZOFRAN
ZOFRAN
NEUMEGA
NORFLEX
TAMIFLU
TAMIFLU
OXANDRIN
DAYPRO
SERAX
SERAX
SERAX
TRILEPTAL
TRILEPTAL
TRILEPTAL
OXISTAT
DITROPAN
DITROPAN
DITROPAN XL
DITROPAN XL
DITROPAN XL
ROXICODONE
ROXICODONE
OXYCONTIN
35
3-Tier
2
2
2
3
3
2
2
3
3
2
2
2
3
3
2
2
2
2
2
3
2
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
4-Tier
2
2
2
3
3
2
2
4
4
2
2
2
3
3
2
2
2
2
2
4
2
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
GENERIC
Oxycodone/Acetaminophen 5mg/325mg Tablet
Oxycodone/Aspirin 4.8355mg/325mg Tablet
Oxycodone/Ibuprofen 5mg/400mg Tablet
Oxymetholone 50mg Tablet
Oxymorphone 5mg Extended Release Crush Resist Tablet
Pancrelipase Enteric Coated 5,000units Capsule
Pantoprazole 40mg Enteric Coated Tablet
Paricalcitol 1mcg Capsule
Paroxetine 10mg Tablet
Pasireotide 0.3mg/ml Subcutaneous Solution
Pazopanib 200mg Tablet
Pegfilgrastim 6mg/0.6ml Subcutaneous Solution
Peginterferon Alfa-2a 180mcg/ml Subcutaneous Solution
Peginterferon Alfa-2a 180mcg/0.5ml Subcutaneous Solution
Peginterferon Alfa-2b 50mcg/0.5ml Subcutaneous Kit
Peginterferon Alfa-2b 296mcg Subcutaneous Kit
Pegvisomant 10mg Subcutaneous Solution
Penbutolol 20mg Tablet
Penciclovir 1% Topical Cream
Penicillamine 250mg Tablet
Penicillin V Potassium 250mg Tablet
Penicillin V Potassium 500mg Tablet
Penicillin V Potassium 125mg/5ml Solution
36
COMMON BRAND
PERCOCET
ENDODAN
-ANADROL
OPANA
OPANA
OPANA
CREON
CREON
CREON
CREON
PROTONIX
-PAXIL
PAXIL
PAXIL
PAXIL
SIGNIFOR
SIGNIFOR
SIGNIFOR
VOTRIENT
NEULASTA
PEGASYS
PEGASYS
PEG-INTRON
PEG-INTRON
PEG-INTRON
PEG-INTRON
SYLATRON
SYLATRON
SYLATRON
SOMAVERT
SOMAVERT
SOMAVERT
LEVATOL
DENAVIR
DEPEN
PEN VK
PEN VK
PEN VK
3-Tier
2
2
2
3
3
3
3
2
3
3
3
2
2
1
1
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
4-Tier
2
2
2
3
3
3
3
2
3
3
3
2
2
1
1
2
2
4
4
4
4
3
4
4
4
4
4
4
3
3
3
4
4
4
3
3
3
2
2
2
GENERIC
Penicillin V Potassium 250mg/5ml Solution
Pentafluoropropane/Tetrafluoroethane 95%/5% Topical
Spray
Pentamidine 300mg Inhalation Mist
Pentosan 100mg Capsule
Pentoxifylline 400mg Extended Release Tablet
Perindopril 2mg Tablet
Permethrin 5% Topical Cream
Perphenazine 2mg Tablet
Perphenazine 4mg Tablet
Phenazopyridine 100mg Tablet
Phenelzine 15mg Tablet
Phenobarbital 16.2mg Tablet
Phenobarbital 20mg/5ml Elixir
Phenoxybenzamine 10mg Capsule
Phentermine 15mg Capsule
Phentermine 30mg Capsule
Phenylepherine/Promethazine/Codeine Syrup
Phenylephrine 2.5% Ophthalmic Solution
Phenylephrine 10% Ophthalmic Solution
Phenytoin 125mg/5ml Suspension
Phenytoin 50mg ChewableTablet
Phenytoin 30mg Capsule
Phenytoin 100mg Capsule
Phytonadione 5mg Tablet
Pilocarpine 1% Ophthalmic Solution
Pilocarpine 5mg Tablet
Pimecrolimus 1% Topical Cream
Pimozide 1mg Tablet
Pindolol 5mg Tablet
Pioglitazone 15mg Tablet
Piroxicam 10mg Capsule
Piroxicam 20mg Capsule
Pitavastatin 1mg Tablet
COMMON BRAND
PEN VK
GEBAUERS
NEBUPENT
ELMIRON
TRENTAL
ACEON
ELIMITE
TRILAFON
TRILAFON
-NARDIL
-----DIBENZYLINE
FASTIN
FASTIN
PHENERGAN VC WITH CODEINE
NEO-SYNEPHRINE
NEO-SYNEPHRINE
DILANTIN
DILANTIN
DILANTIN
DILANTIN
MEPHYTON
ISOPTO-CARPINE
ISOPTO-CARPINE
ISOPTO-CARPINE
SALAGEN
ELIDEL
ORAP
VISKEN
ACTOS
ACTOS
ACTOS
FELDENE
FELDENE
LIVALO
37
3-Tier
2
3
4-Tier
2
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
2
3
2
2
2
2
3
3
2
2
2
2
2
2
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
2
3
2
2
2
2
3
3
2
2
2
2
2
2
3
GENERIC
Podofilox 0.5% Topical Solution
Polyethylene Glycol/Electrolyte Solution
Polyethylene Glycol/Electrolyte Solution
Polymyxin B/Trimethoprim Ophthalmic Solution
Pomalidomide 1mg Capsule
Posaconazole 100mg Delayed Release Tablet
Posaconazole 40mg/ml Suspension
Potassium Citrate 540mg Tablet
Potassium Citrate 1080mg Tablet
Potassium Aminobenzoate 500mg Capsule
Potassium Iodide 1gm/ml Solution
Potassium Bicarbonate 25meq Effervescent Tablet
Potassium Chloride 10meq Controlled Release Tablet
Potassium Chloride 10% Liquid
Potassium Chloride 20meq Powder
Potassium/Citric Acid Solution
Povidone/Iodine 5% Ophthalmic Solution
Pramipexole 0.125mg Tablet
Pramipexole 1mg Tablet
Pramlintide Acetate 1500mcg/1.5ml Subcutaneous Solution
Pramlintide Acetate 2700mcg/2.7ml Subcutaneous Solution
Pramoxine/Hydrocortisone 1% Topical Lotion
Pramoxine/Hydrocortisone 2.5% Topical Lotion
Prasugrel 5mg Tablet
Prasugrel 10mg Tablet
Pravastatin 10mg Tablet
Praziquantel 600mg Tablet
Prazosin 1mg Capsule
Prednisolone 15mg/5ml Solution
Prednisolone 6.7mg/5ml Liquid
38
COMMON BRAND
CONDYLOX
GAVILYTE-C
MOVIPREP
POLYTRIM
POMALYST
POMALYST
POMALYST
POMALYST
NOXAFIL
NOXAFIL
UROCIT-K
UROCIT-K
POTABA
SSKI
KLOR-CON/EF
K-TAB
-KLOR-CON
CYTRA-K
BETADINE
MIRAPEX
MIRAPEX
MIRAPEX
MIRAPEX
SYMLINPEN
SYMLINPEN
PRAMOSONE
PRAMOSONE
EFFIENT
EFFIENT
PRAVACHOL
PRAVACHOL
PRAVACHOL
PRAVACHOL
BILTRICIDE
MINIPRESS
MINIPRESS
MINIPRESS
ORAPRED
ORAPRED
3-Tier
2
2
3
2
3
3
3
3
3
3
2
2
3
3
2
2
2
2
2
3
2
2
2
2
3
3
2
2
3
3
2
2
2
2
3
2
2
2
2
2
4-Tier
2
2
3
2
4
4
4
4
4
4
2
2
3
3
2
2
2
2
2
3
2
2
2
2
3
3
2
2
3
3
2
2
2
2
3
2
2
2
2
2
GENERIC
Prednisolone Acetate 0.12% Ophthalmic Suspension
Prednisolone Acetate 1% Ophthalmic Suspension
Prednisone 1mg Tablet
Prednisone 5mg/5ml Solution
Prednisone 5mg Dose Pack Tablet
Pregabalin 25mg Capsule
Primaquine Phosphate 26.3mg Tablet
Primidone 50mg Tablet
Primidone 250mg Tablet
Probenecid 500mg Tablet
Procarbazine 50mg Capsule
Prochlorperazine 25mg Rectal Suppository
Prochlorperazine 5mg Tablet
Prochlorperazine 10mg Tablet
Progesterone Micronized 100mg Capsule
Progesterone Micronized 200mg Capsule
Promethazine 12.5mg Tablet
Promethazine 25mg Tablet
Promethazine 6.25mg/5ml Syrup
Promethazine 25mg Rectal Suppository
Promethazine/Codeine 6.25mg-10mg/5ml Syrup
Promethazine/Phenylephrine Syrup
Propafenone 150mg Tablet
Propranolol 10mg Tablet
Propranolol 20mg/5ml Solution
Propylthiouracil 50mg Tablet
COMMON BRAND
PRED-MILD
PRED
-------LYRICA
LYRICA
LYRICA
LYRICA
LYRICA
LYRICA
LYRICA
LYRICA
-MYSOLINE
MYSOLINE
BENEMID
MATULANE
COMPRO
COMPAZINE
COMPAZINE
PROMETRIUM
PROMETRIUM
PHENERGAN
PHENERGAN
PHENERGAN
PROMETHEGAN
PHENERGAN-FORTIS
PHENERGAN VC
RYTHMOL
INDERAL
INDERAL
INDERAL
INDERAL
INDERAL
PTU
39
3-Tier
3
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
2
2
2
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4-Tier
3
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
2
2
2
2
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
GENERIC
Protriptyline 10mg Tablet
Pyrazinamide 500mg Tablet
Pyridostigmine 60mg Tablet
Pyridostigmine Timespan 180mg Tablet
Pyrimethamine 25mg Tablet
Quetiapine Fumarate 25mg Tablet
Quetiapine Fumarate 50mg Extended Release Tablet
Quinapril 5mg Tablet
Quinidine Gluconate 324mg Controlled Release Tablet
Quinidine 300mg Extended Release Tablet
Quinine 324mg Capsule
Rabeprazole 20mg Enteric Coated Tablet
Raloxifene 60mg Tablet
Raltegravir 400mg Tablet
Raltegravir 25mg Chewable Tablet
Ramelteon 8mg Tablet
Ramipril 1.25mg Capsule
Ranitidine 15mg/ml Syrup
Ranolazine 500mg Tablet
Rasagiline 0.5mg Tablet
Regorafenib 40mg Tablet
Repaglinide 1mg Tablet
Ribavirin 200mg Capsule
Rifabutin 150mg Capsule
Rifampin 10mg/ml Suspension
Rifampin 300mg Capsule
Rifampin 50mg/ml Suspension
Rifapentine 150mg Tablet
Rifaximin 550mg Tablet
Rilonacept 220mg Subcutaneous Solution
Rilpivirine 25mg Tablet
Riluzole 50mg Tablet
Rimantadine 100mg Tablet
Rimexolone 1% Ophthalmic Suspension
Risedronate 5mg Tablet
COMMON BRAND
VIVACTIL
-MESTINON
MESTINON
DARAPRIM
SEROQUEL
SEROQUEL
SEROQUEL
SEROQUEL
SEROQUEL
SEROQUEL
SEROQUEL XR
ACCUPRIL
QUINAGLUTE
QUINIDEX
QUALAQUIN
ACIPHEX
EVISTA
ISENTRESS
ISENTRESS
ROZEREM
ALTACE
ZANTAC
RANEXA
AZILECT
STIVARGA
PRANDIN
REBETOL
MYCOBUTIN
RIFADIN
RIDADIN
RIFADIN
PRIFTIN
XIFAXAN
ARCALYST
EDURANT
RILUTEK
FLUMADINE
VEXOL
ACTONEL
40
3-Tier
2
2
2
2
3
2
2
2
2
2
2
3
2
2
2
2
2
2, ACA
3
3
3
2
2
3
3
3
2
2
2
2
2
2
3
3
3
3
2
2
3
3
4-Tier
2
2
2
2
3
2
2
2
2
2
2
3
2
2
2
2
2
2, ACA
3
3
3
2
2
3
3
4
2
2
2
2
2
2
3
3
4
3
2
2
3
3
GENERIC
Risedronate 35mg Tablet
Risperidone 0.25mg Tablet
Risperidone 0.5mg Tablet
Risperidone 1mg Tablet
Risperidone 1mg/ml Solution
Ritonavir 100mg Tablet
Ritonavir 80mg/ml Solution
Rivastigmine Tartrate 3mg Capsule
Rizatriptan 5mg Tablet
Rizatriptan 10mg Tablet
Rizatriptan 5mg Disintegrating Tablet
Rizatriptan 10mg Disintegrating Tablet
Roflumilast 500mcg Tablet
Ropinirole 0.25mg Tablet
Ropinirole 0.5mg Tablet
Ropinirole 1mg Tablet
Ropinirole 2mg Tablet
Rosiglitazone 2mg Tablet
Rosuvastatin 5mg Tablet
Rufinamide 200mg Tablet
Ruxolitinib Phosphate 5mg Tablet
Salsalate 750mg Tablet
Sapropterin 100mg Soluble Tablet
Saquinavir 200mg Capsule
Saquinavir 500mg Tablet
Saxagliptin 2.5mg Tablet
Scopolamine 1.5mg Patch
Secukinumab 150mg/ml Subcutaneous Solution
Selegiline 6mg/24hr Patch
Selegiline 5mg Capsule
Selenium 2.5% Topical Shampoo
Sertaconazole 2% Topical Cream
Sertraline 25mg Tablet
COMMON BRAND
ACTONEL
RISPERDAL
RISPERDAL
RISPERDAL
RISPERDAL
RISPERDAL
RISPERDAL
RISPERDAL
NORVIR
NORVIR
EXELON
MAXALT
MAXALT
MAXALT-MLT
MAXALT-MLT
DALIRESP
REQUIP
REQUIP
REQUIP
REQUIP
AVANDIA
CRESTOR
BANZEL
JAKAFI
JAKAFI
JAKAFI
JAKAFI
JAKAFI
DISALCID
KUVAN
INVIRASE
INVIRASE
ONGLYZA
TRANSDERM-SCOP
COSENTYX
EMSAM
ELDEPRYL
SELSUN
ERTACZO
ZOLOFT
41
3-Tier
2
2
2
2
2
2
2
2
3
3
2
2
2
2
2
3
2
2
2
2
3
2
3
3
3
3
3
3
2
3
3
3
3
2
3
3
2
2
3
2
4-Tier
2
2
2
2
2
2
2
2
3
3
2
2
2
2
2
3
2
2
2
2
3
2
3
4
4
4
4
4
2
4
3
3
3
2
4
3
2
2
3
2
GENERIC
Sevelamer Carbonate 800mg Tablet
Sevelamer Carbonate 2.4gm Powder
Sildenafil Citrate 2.5mg/ml Suspension (for PAH only)
Sildenafil Citrate 20 mg Tablet (for PAH only)
Silodosin 4mg Capsule
Silver Sulfadiazine 1% Topical Cream
Silver Nitrate/Potassium Topical Applicators
Simvastatin 5mg Tablet
Sinecatechins 15% Topical Ointment
Sirolimus 1mg Tablet
Sirolimus 2mg Tablet
Sirolimus 1mg/ml Solution
Sitagliptin 25mg Tablet
Sodium Phenylbutyrate 500mg Tablet
Sodium Phenylbutyrate 3gm/tsp Powder
Sodium Phosphate Tablet
Sodium Picosulfate/Magnesium Powder
Sodium Citrate/Citric Acid 334mg/5ml Solution
Sodium Chloride 0.9% Bladder Irrigation Solution
Sodium Oxybate 500mg/ml Solution
Sodium Fluoride 0.25mg Chewable Tablet
Sodium Fluoride 0.5mg Chewable Tablet
Sodium Fluoride 1mg Chewable Tablet
Sodium Fluoride 0.55mg/drop Solution
Sodium Fluoride 0.25mg/drop Solution
Sodium Fluoride 1.1mg/ml Solution
Sodium Polystyrene Sulfate 15gm/60ml Suspension
Sofosbuvir 400mg Tablet
Solifenacin Succinate 5mg Tablet
Somatropin 5mg/2ml Subcutaneous Solution
Somatropin 5mg/1.5ml Subcutaneous Solution
Somatropin 30mg/3ml Subcutaneous Solution
COMMON BRAND
ZOLOFT
ZOLOFT
RENVELA
RENVELA
REVATIO
REVATIO
RAPAFLO
THERMAZENE
ARZOL
ZOCOR
ZOCOR
ZOCOR
ZOCOR
ZOCOR
VEREGEN
RAPAMUNE
RAPAMUNE
RAPAMUNE
JANUVIA
BUPHENYL
BUPHENYL
OSMOPREP
PREPOPIK
--XYREM
FLUORIDE
FLUORIDE
FLUORABON
FLUORABON
FLURA-DROPS
FLUORIDE
KAYEXALATE
SOVALDI
VESICARE
NUTROPIN
OMNITROPE
OMNITROPE
NORDITROPIN
NORDITROPIN
42
3-Tier
2
2
3
3
2
2
3
2
2
2
2
2
2
2
3
3
3
3
3
3
2
3
3
2
2
3
2, ACA
2, ACA
2, ACA
2, ACA
3, ACA
2, ACA
2
3
3
3
2
2
3
3
4-Tier
2
2
3
3
2
2
3
2
2
2
2
2
2
2
3
3
3
3
3
4
2
3
3
2
2
4
2, ACA
2, ACA
2, ACA
2, ACA
3, ACA
2, ACA
2
4
3
4
2
2
4
4
GENERIC
Somatropin 5mg Subcutaneous Solution
Somatropin 12mg Injection Solution
Somatropin 24mg Injection Solution
Somatropin 8.8mg Injection Solution
Somatropin 8.8mg Subcutaneous Solution
Sorafenib 200mg Tablet
Sotalol 80mg Tablet
Sotalol 5mg/ml Suspension
Sotalol 160mg Tablet
Spinosad 0.9% Topical Suspension
Spironolactone 2mg/ml Suspension
Spironolactone 5mg/ml Suspension
Spironolactone 25mg Tablet
Spironolactone/Hydrochlorothiazide 5mg-5mg/ml
Suspension
Spironolactone/Hydrochlorothiazide 25mg/25mg Tablet
Stavudine 20mg Capsule
Sterile Water for Irrigation Solution
Succimer 100mg Capsule
Sucralfate 100mg/ml Suspension
Sulconazole 1% Topical Cream
Sulfacetamide 10% Ophthalmic Solution
Sulfacetamide Sodium/Prednisolone Ophthalmic Solution
Sulfacetamide Sodium/Prednisolone Ophthalmic Ointment
Sulfadiazine 500mg Tablet
Sulfamethoxazole/Trimethoprim 800mg/160mg Tablet
Sulfamethoxazole/Trimethoprim 400mg/80mg Tablet
Sulfamethoxazole/Trimethoprim 200mg-40mg/5ml
Suspension
Sulfasalazine 500mg Delayed Release Enteric Coated Tablet
Sulindac 150mg Tablet
Sulindac 200mg Tablet
Sumatriptan 5mg/act Nasal Spray
Sumatriptan 20mg/act Nasal Spray
43
COMMON BRAND
GENOTROPIN
HUMATROPE
GENOTROPIN
HUMATROPE
GENOTROPIN
SEROSTIM
SAIZEN
ZORBTIVE
NEXAVAR
BETAPACE
BETAPACE
BETAPACE
NATROBA
ALDACTONE
ALDACTONE
ALDACTONE
ALDACTONE
ALDACTONE
ALDACTAZIDE
3-Tier
3
3
3
3
3
3
3
3
3
1
2
2
2
2
2
1
2
2
2
4-Tier
4
4
3
4
3
4
4
4
4
1
2
2
2
2
2
1
2
2
2
ALDACTAZIDE
ZERIT
ZERIT
ZERIT
-CHEMET
CARAFATE
EXELDERM
BLEPHAMIDE
SULFACET
BLEPHAMIDE-S.O.P.
-BACTIM-DS
BACTRIM
BACTRIM
2
2
2
2
2
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
2
2
2
2
2
2
2
AZULFIDINE
CLINORIL
CLINORIL
IMITREX
IMITREX
2
2
2
2
2
2
2
2
2
2
GENERIC
Sumatriptan Succinate 25mg Tablet
Sumatriptan Succinate 6mg/0.5ml Subcutaneous Solution
Sunitinib 12.5mg Capsule
Sunitinib 25mg Capsule
Sunitinib 50mg Capsule
Tacrolimus 0.03% Topical Ointment
Tacrolimus 0.1% Topical Ointment
Tacrolimus 0.5mg Capsule
Tacrolimus 1mg Capsule
Tacrolimus 5mg Capsule
Tacrolimus 0.5mg/ml Suspension
Tafluprost 0.015mg/ml Ophthalmic Solution
Tamoxifen Citrate 10mg Tablet
Tamoxifen Citrate 20mg Tablet
Tamoxifen Citrate 10mg/5ml Solution
Tamsulosin 0.4mg Capsule
Tapentadol 75mg Tablet
Tapentadol 50mg Extended Release Tablet
Tazarotene 0.05% Topical Cream
Tazarotene 0.1% Topical Cream
Tazarotene 0.05% Topical Gel
Tazarotene 0.1% Topical Gel
Tedizolid 200mg Tablet
Teduglutide 5mg Subcutaneous Kit
Telaprevir 375mg Tablet
Telithromycin 300mg Tablet
Telmisartan 20mg Tablet
Temazepam 15mg Capsule
Temazepam 30mg Capsule
Temozolomide 5mg Capsule
Tenofovir 150mg Tablet
Tenofovir 40mg/gm Powder
COMMON BRAND
IMITREX
IMITREX
IMITREX
IMITREX
SUTENT
SUTENT
SUTENT
PROTOPIC
PROTOPIC
PROGRAF
PROGRAF
PROGRAF
PROGRAF
ZIOPTAN
NOLVADEX
NOLVADEX
SOLTAMOX
FLOMAX
NUCYNTA
NUCYNTA
TAZORAC
TAZORAC
TAZORAC
TAZORAC
SIVEXTRO
GATTEX
INCIVEK
KETEK
MICARDIS
RESTORIL
RESTORIL
TEMODAR
TEMODAR
TEMODAR
TEMODAR
VIREAD
VIREAD
VIREAD
VIREAD
VIREAD
44
3-Tier
2
2
2
2
3
3
3
2
2
2
2
2
2
3
2, ACA
ACA
ACA
2
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
3
3
3
3
3
4-Tier
2
2
2
2
4
4
4
2
2
2
2
2
2
3
2, ACA
ACA
ACA
2
3
3
3
3
3
3
4
4
4
3
2
2
2
2
2
2
2
3
3
3
3
3
GENERIC
Terazosin 1mg Capsule
Terbinafine 250mg Tablet
Terbutaline 5mg Tablet
Terconazole 0.4% Vaginal Cream
Terconazole 80mg Vaginal Suppository
Teriflunomide 7mg Tablet
Teriflunomide 14mg Tablet
Teriparatide 600mcg/2.4ml Subcutaneous Solution
Tesamorelin Acetate 2mg Subcutaneous Solution
Testosterone Transdermal Gel 50mg/5gm (1 %)
Tetrabenazine 12.5mg Tablet
Tetrabenazine 25mg Tablet
Tetracycline 250mg Capsule
Thalidomide 50mg Capsule
Theophylline 100mg Controlled Release Tablet
Theophylline 200mg Controlled Release Tablet
Theophylline 300mg Extended Release Tablet
Theophylline 450mg Extended Release Tablet
Thioguanine 40mg Tablet
Thioridazine 10mg Tablet
Thiothixene 5mg Capsule
Thyroid 15mg Tablet
Thyroid 30mg Tablet
Thyroid 60mg Tablet
Thyroid 120mg Tablet
Tiagabine 2mg Tablet
Ticagrelor 90mg Tablet
Ticlopidine 250mg Tablet
Timolol 10mg Tablet
COMMON BRAND
HYTRIN
HYTRIN
HYTRIN
HYTRIN
LAMISIL
BRETHINE
TERAZOL
TERAZOL
AUBAGIO
AUBAGIO
FORTEO
EGRIFTA
TESTIM
XENAZINE
XENAZINE
-THALOMID
THALOMID
THALOMID
THALOMID
THEO-DUR
THEO-DUR
THEO-DUR
THEO-DUR
TABLOID
MELLARIL
MELLARIL
MELLARIL
MELLARIL
NAVANE
ARMOUR THYROID
ARMOUR THYROID
ARMOUR THYROID
ARMOUR THYROID
ARMOUR THYROID
ARMOUR THYROID
GABITRIL
BRILINTA
TICLID
BLOCADREN
45
3-Tier
1
1
1
1
2
2
2
2
3
3
3
3
2
2
2
2
3
3
3
3
2
2
2
2
3
2
2
2
2
2
3
3
3
3
3
3
2
3
2
2
4-Tier
1
1
1
1
2
2
2
2
4
4
4
4
2
2
2
2
4
4
4
4
2
2
2
2
3
2
2
2
2
2
3
3
3
3
3
3
2
3
2
2
GENERIC
Timolol 0.25% Ophthalmic Solution
Timolol 0.5% Ophthalmic Solution
Tinidazole 500mg Tablet
Tiotropium Inhalation Aerosol 2.5mcg/actuation
Tiotropium Bromide/Olodaterol 2.5/2.5 mcg/inhalation
Aerosol Solution
Tipranavir 250mg Capsule
Tipranavir 100mg/ml Solution
Tizanidine 2mg Tablet
Tizanidine 4mg Tablet
Tobramycin 300mg/5ml Inhalation Mist
Tobramycin 13.6mg/ml Ophthalmic Solution
Tobramycin 0.3% Ophthalmic Ointment
Tobramycin/Dexamethasone 0.3%/0.1% Ophthalmic
Ointment
Tofacitinib Citrate 5mg Tablet
Tolazamide 250mg Tablet
Tolbutamide 500mg Tablet
Tolcapone 100mg Tablet
Tolmetin 200mg Tablet
Tolterodine 1mg Tablet
Tolvaptan 15mg Tablet
Topiramate 25mg Tablet
Topiramate 15mg Sprinkle Capsule
Topiramate 25mg Sprinkle Capsule
Toremifene Citrate 60mg Tablet
Torsemide 5mg Tablet
Tramadol 50mg Tablet
Tramadol 100mg Extended Release Tablet
Trandolapril 1mg Tablet
Tranylcypromine 10mg Tablet
Travoprost 0.004% Ophthalmic Solution
Trazodone 50mg Tablet
Tretinoin 10mg Capsule
Tretinoin 0.025% Topical Cream
Tretinoin 0.01% Topical Gel
COMMON BRAND
TIMOPTIC
TIMOPTIC
TINDAMAX
SPIRIVA RESPIMAT
STIOLTO RESPIMAT
46
3-Tier
2
2
3
3
3
4-Tier
2
2
3
3
3
APTIVUS
APTIVUS
ZANAFLEX
ZANAFLEX
TOBI
TOBREX
TOBREX
TOBRADEX
3
3
2
2
2
2
3
3
3
3
2
2
2
2
3
3
XELJANZ
--TASMAR
TOLECTIN
DETROL
SAMSCA
TOPAMAX
TOPAMAX
TOPAMAX
TOPAMAX
TOPAMAX
TOPAMAX
FARESTON
DEMADEX
ULTRAM
ULTRAM
MAVIK
PARNATE
TRAVATAN
DESYREL
VESANOID
RETIN-A
RETIN-A
RETIN-A
RETIN-A
3
2
2
2
2
2
3
2
2
2
2
2
2
3
2
2
2
2
2
3
1
2
2
2
2
2
4
2
2
2
2
2
3
2
2
2
2
2
2
3
2
2
2
2
2
3
1
2
2
2
2
2
GENERIC
Triamcinolone Acetonide 0.1% Dental Paste
Triamcinolone Acetonide Topical Spray
Triamcinolone Acetonide 0.025% Topical Cream
Triamcinolone Acetonide 0.025% Topical Ointment
Triamcinolone Acetonide/LCD 0.1%/10% Topical Ointment
Triamterene 50mg Capsule
Triamterene/Hydrochlorothiazide 75mg/25mg Tablet
Triazolam 0.125mg Tablet
Triazolam 0.25mg Tablet
Trientine 250mg Capsule
Trifluoperazine 2mg Tablet
Trifluridine 1% Ophthalmic Solution
Trihexyphenidyl 2mg Tablet
Trimethobenzamide 300mg Capsule
Trimethoprim 100mg Tablet
Trimipramine 100mg Capsule
Trivitamin/Fluoride 0.25mg/ml Drops Solution
Trospium Chloride 20mg Tablet
Trospium Chloride 60mg Extended Release Capsule
Ulipristal Acetate 30mg Tablet
Urea 40% Topical Cream
Ursodiol 60mg/ml Suspension
Ursodiol 300mg Capsule
Ursodiol 250mg Tablet
Ursodiol 500mg Tablet
Ustekinumab 45mg/0.5ml Subcutaneous Solution
Ustekinumab 90mg/ml Subcutaneous Solution
Valacyclovir 500mg Tablet
Valganciclovir 450mg Tablet
Valganciclovir 50mg/ml Solution
Valproate 250mg/5ml Syrup
Valproic Acid 250mg Capsule
Valsartan 40mg Tablet
Vancomycin 125mg Capsule
47
COMMON BRAND
RETIN-A
RETIN-A
KENALOG
KENALOG
KENALOG
KENALOG
KENALOG
KENALOG
KENALOG
DYRENIUM
MAXZIDE
HALCION
HALCION
SYPRINE
STELAZINE
STELAZINE
STELAZINE
VIROPTIC
ARTANE
TIGAN
-SURMONTIL
TRI-VI-FLOR
SANCTURA
SANCTURA XR
ELLA
CARMOL
ACTIGALL
ACTIGALL
URSO
URSO
STELARA
STELARA
VALTREX
VALCYTE
VALCYTE
VALPROIC
DEPAKENE
DIOVAN
VANCOCIN
3-Tier
2
2
2
2
2
2
2
2
2
3
1
2
2
3
2
2
2
2
2
2
2
3
2
2
2
3
2
2
2
2
2
3
3
2
2
3
2
2
2
2
4-Tier
2
2
2
2
2
2
2
2
2
3
1
2
2
3
2
2
2
2
2
2
2
3
2
2
2
3
2
2
2
2
2
4
4
2
2
3
2
2
2
2
GENERIC
Vancomycin 250mg Capsule
Vancomycin 25mg/ml Ophthalmic Solution
Vancomycin 50mg/ml Ophthalmic Solution
Vancomycin 25mg/ml Solution
Varenicline Tartrate 0.5mg Tablet
Varenicline Tartrate 1mg Tablet
Varenicline Tartrate Tablet
COMMON BRAND
VANCOCIN
--VANCOCIN
CHANTIX
CHANTIX
CHANTIX STARTER MONTH
PACK
ZELBORAF
EFFEXOR
EFFEXOR
EFFEXOR
EFFEXOR
EFFEXOR
EFFEXOR
EFFEXOR
CALAN
CALAN
CALAN
CALAN-SR
SABRIL
SABRIL
VIIBRYD
ERIVEDGE
VFEND
VFEND
VFEND
ZOLINZA
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
ACCOLATE
SONATA
SONATA
RELENZA
Vemurafenib 240mg Tablet
Venlafaxine 25mg Tablet
Venlafaxine 37.5mg Tablet
Venlafaxine 37.5mg Extended Release Capsule
Venlafaxine 75mg Extended Release Capsule
Venlafaxine 150mg Extended Release Capsule
Verapamil 50mg/ml Suspension
Verapamil 80mg Tablet
Verapamil 120mg Tablet
Verapamil 240mg Sustained Release Tablet
Vigabatrin 500mg Tablet
Vigabatrin 500mg Powder
Vilazodone 10mg Tablet
Vismodegib 150mg Capsule
Voriconazole 50mg Tablet
Voriconazole 200mg Tablet
Voriconazole 40mg/ml Suspension
Vorinostat 100mg Capsule
Warfarin 1mg Tablet
Warfarin 2mg Tablet
Warfarin 2.5mg Tablet
Warfarin 3mg Tablet
Warfarin 4mg Tablet
Warfarin 5mg Tablet
Warfarin 6mg Tablet
Warfarin 7.5mg Tablet
Warfarin 10mg Tablet
Zafirlukast 10mg Tablet
Zaleplon 5mg Capsule
Zaleplon 10mg Capsule
Zanamivir 5mg/blister Inhalation Inhaler
48
3-Tier
2
2
2
2
TC
TC
TC
4-Tier
2
2
2
2
TC
TC
TC
3
2
2
2
2
2
2
2
2
1
1
2
3
3
3
3
2
2
2
3
1
1
1
1
1
1
1
1
1
2
2
2
3
4
2
2
2
2
2
2
2
2
1
1
2
4
4
3
4
2
2
2
4
1
1
1
1
1
1
1
1
1
2
2
2
3
GENERIC
Zidovudine 100mg Capsule
Zidovudine 300mg Tablet
Zileuton 600mg Controlled Release Tablet
Ziprasidone 20mg Capsule
Zolmitriptan 2.5mg Disintegrating Tablet
Zolpidem Tartrate 5mg Tablet
Zolpidem Tartrate 10mg Tablet
Zonisamide 100mg Capsule
COMMON BRAND
RETROVIR
RETROVIR
ZYFLO
GEODON
GEODON
GEODON
GEODON
ZOMIG
AMBIEN
AMBIEN
ZONEGRAN
49
3-Tier
2
2
3
2
2
2
2
2
2
2
2
4-Tier
2
2
4
2
2
2
2
2
2
2
2
Kaiser Foundation Health Plan, Inc. (Kaiser Health Plan) complies with applicable Federal civil rights laws
and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health
Plan does not exclude people or treat them differently because of race, color, national origin, age,
disability, or sex. We also:
• Provide free aids and services to people with disabilities to communicate effectively with us, such
as:
• Qualified sign language interpreters
• Written information in other formats, such as large print, audio, and accessible electronic
formats
• Provide free language services to people whose primary language is not English, such as:
• Qualified interpreters
• Information written in other languages
If you need these services, call the number provided below to talk to an interpreter.
Hawaii 1-800-966-5955
TTY 711
If you believe that Kaiser Foundation Health Plan has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with
the Kaiser Civil Rights Coordinator, 711 Kapiolani Blvd, Honolulu, HI 96813, telephone number:
1- 800-966-5955. You can file a grievance by mail or phone. If you need help filing a grievance, the Kaiser
Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for Civil Rights electronically through the Office for
Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone
at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH
Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available
at http://www.hhs.gov/ocr/office/file/index.html.
50
Help in your Language
English: You have the right to get help in your language at no cost. If you have questions about
your application or coverage through Kaiser Permanente, or if this is a notice that requires you to take
action by a specific date, call the number provided for your state or region to talk to an interpreter.
Kaiser Foundation Health Plan, Inc., in Northern and Southern California and Hawaii • Kaiser Foundation Health Plan of Colorado • Kaiser Foundation Health Plan of
Georgia, Inc., Nine Piedmont Center, 3495 Piedmont Road NE, Atlanta, GA 30305, 404-364-7000 • Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., in
Maryland, Virginia, and Washington, D.C., 2101 E. Jefferson St., Rockville, MD 20852 • Kaiser Foundation Health Plan of the Northwest, 500 NE Multnomah St., Suite
100, Portland, OR 97232
51
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2016 Kaiser Permanente Hawaii Marketplace Drug Formulary

Transcription

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