formulary - Physicians Plus

Transcription

FORMULARY
Premier Formulary
Updated July 13, 2015
2016
P+6129-1410
INTRODUCTION
Physicians Plus Insurance Corporation (Physicians Plus) maintains a Drug Formulary as a guide for
prescribers of outpatient drugs and select drugs administered by a healthcare professional (e.g. clinic,
infusion center). The Physicians Plus Pharmacy and Therapeutics (P&T) Committee of physicians and
pharmacists reviews and approves the agents listed based on efficacy, comparative studies, safety,
drug interactions, side effects, pharmacokinetics and cost-effectiveness. Prescribers are notified in the
bi-annual newsletter about formulary updates and changes. All formulary changes are posted to the
website by the 30th of every month after each P&T meeting. Physicians receive a copy of the
formulary upon joining the plan and have the option of receiving it annually thereafter. Physicians
Plus reserves the right to change the formulary and any pharmacy benefit-related program at
any time without notice. The Physicians Plus website maintains a current version of the drug
formulary at:
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
http://www.pplusic.com/documents/upload/him-formulary-2016.pdf (Adobe Acrobat Reader is
necessary to view the document).
A hard copy may be requested and sent via mail by contacting Pharmacy Services via phone at
608-260-7803 or 800-545-5015, or via email at [email protected].
Drug formulary information is also available using RxManager. RxManager is accessible using
MyChart on a desktop or using our iPhone/Android App. The App can be downloaded from:
o iTunes (for iPhone, iPad, or iPod):
http://itunes.apple.com/us/app/rxmanager/id540771801?mt=8
o Google Play (for Android-based smartphones):
https://play.google.com/store/apps/details?id=com.pplus.rxmanager&feature=search_r
esult#?t=W10.
Your comments and suggestions are vital for continued success of this formulary. Please send your
comments or formulary requests to:
Director of Pharmacy Services
Physicians Plus Insurance Corporation
P.O. Box 2078
Madison, WI 53701-2078
Phone: 608-260-7803 or 800-545-5015
Fax: 608-327-0324
www.pplusic.com
DRUG COVERAGE
At a community network pharmacy all members may receive either a 30 day supply of the covered
drug or as defined by quantity limits on the formulary. At select community network pharmacies
some qualified drugs may be available for a three month supply for three copays or the cost of the
drug whichever is less. At a mail order network, pharmacy members may receive a three month
supply for two and a half copays for preferred drugs, three copays for non-preferred drugs, or the
cost of the drug whichever is less. Pharmacy benefits with a coinsurance will continue to have the
same coinsurance percentage regardless if the drug is obtained at a community network pharmacy or
a mail order pharmacy. All specialty drugs must be obtained at an in-network specialty pharmacy.
For information on the specialty pharmacy network, please review www.pplusic.com. Specialty drugs
will only be available for a 30 day supply or as defined by quantity limits on the formulary. Please see
your specific summary of benefits document for more information.
For most drug benefit plans, formulary insulin copays are at a Tier 3 level. There is a limit of 20 mL (2
vials) of insulin per insulin type per 30 day supply. If a member requires a higher quantity per month,
the member, member designee, pharmacy, or provider may call Physicians Plus Pharmacy Services
and request a override deviation from the quantity limits or submit the request using the Prior
Authorization process. Please review the Prior Authorization (PA) procedure for details regarding
prior authorization drugs.
New drugs not reviewed by the Physicians Plus P&T Committee for placement at a formulary Tier level
are not covered. For drugs not listed on the Physicians Plus formulary, the drug is not covered and
the member is responsible for 100% of the cost. There is a Prior Authorization Process for formulary
drugs and an Exception Process for non-formulary drugs. If the Prior Authorization or Exception is
denied or not pursued, the member is responsible for 100% of the cost. Physicians Plus does have a
Discount Drug program that provides members with access to negotiated discounts for nonformulary and in select instances, non-preferred formulary drugs (some restrictions apply), see the
Discount Drug Program for more details. Please review the exception procedure for details regarding
non-formulary drugs.
DEFINITIONS OF DRUGS
Drug coverage is based on the formulary status of the drug. See your specific Summary of Benefits
document for coverage level details.
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
Formulary: a list of covered drugs
Generic drugs: drugs available from one or more manufacturers that are no longer patent
protected
Brand drugs: drugs which are patent protected and usually available from one manufacturer
only
Preferred Formulary Drug: indicates a generic or brand drug that is on the formulary at a
lower tier level and typically results in a lower member cost share than a non-preferred
formulary drug
Non-Preferred Formulary Drug: indicates a generic or brand drug that is on the formulary
that has a higher tier level and typically results in a higher member cost share than a preferred
formulary drug

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Non-Formulary Drug: indicates a generic or brand drug this is not on the formulary list and is
not covered
$0 copay (Tier 0 ACA Preventive Drugs): select generic and brand drugs for $0 member cost
share (See chart below)
First-Tier (Tier 1): preferred, value generic drugs; Lower member cost share (usually $5 to $25
or the cost of the prescription per month) for Tier 1 formulary drugs
Second-Tier (Tier 2): preferred generic drugs; Low member cost share (usually $10 to $30 per
month) for Tier 2 formulary drugs
Third Tier (Tier 3): preferred brand drugs; Higher member cost share (usually $30 to $75 per
month or a 30% coinsurance) for Tier 3 formulary drugs
Fourth Tier (Tier 4): preferred specialty brands and generic drugs; may require filling at an innetwork specialty pharmacy and most require prior authorization (PA). Usual member costs for
copays can range between $50 and $250 per prescription per month. Usual member cost for
coinsurances can range from 10% to 50% of the cost of the drug.
Fifth Tier (Tier 5): non-preferred generics, brand, and specialty drugs; Specialty drugs may
require filling at an in-network specialty pharmacy and require PA. Usual member costs for
non-preferred drugs are at least 50% coinsurance.
Drug/Supplement
Aspirin
$0 Drugs and Requirements
Gender
Males & Females
Age Requirement
Prevention Men 45-79, Females 18-79;
For cardiovascular disease (CVD),
no age requirement
≥65 years of age
≥50 to 75 years of age
6 months to 6 years
6 months to 12 months
No age restriction
No age restriction
No age restriction
≥35 years of age
Vitamin D – 400 unit & 1,000 unit
Males & Females
Polyethylene Glycol Soln (1 day supply per year)
Males & Females
Fluoride Supplements
Males & Females
Iron Supplements
Males & Females
Folic Acid 400mcg & 800 mcg
Females
Prenatal Vitamin (Select)
Females
Contraceptives (Select)
Females
Tamoxifen or Raloxifene for Breast Cancer Primary
Females
Prevention
Immunization Vaccines
Males & Females
Based on Vaccine Recommendations
*This list is subject to change during the policy based upon updated recommendations and/or law requirements.
Nicotine Addiction & Tobacco Cessation Products at $0 Cost Share for Limited Duration
Nicotine Gum
Nicotine Nasal Spray
Buproban
(Brand Zyban not covered)
Nicotine Patches
Nicotine Inhalers
Nicotine Lozenges
Varenicline
GENERIC SUBSTITUTION POLICY
Physicians Plus supports the use of generic drugs. Physicians Plus establishes that when an equivalent
generic becomes available for a brand product, the brand product is removed from the formulary.
Members currently receiving these drugs will be automatically switched to generic at their next fill.
When the drug is removed from formulary, the member is responsible for 100% of the cost of the
prescription. If your prescriber believes it is medically necessary to receive the brand product, a PA
request must be submitted for review with clinical documentation.
In drug classes where there are several drugs available or in disease states with treatment by multiple
drug classes available, only certain products within that class may be on the formulary. By limiting the
products available, drug costs are reduced through use of generic drugs, cost-effective choices, and
manufacturer rebates.
PRIOR AUTHORIZATION (PA) PROCEDURE
Physicians Plus has drugs that require specific criteria to be met before any coverage for the drug will
occur at any Tier level. A standard prior authorization request may be initiated by the member,
member designee, pharmacy, or provider through a fax, by telephone, or electronically. If a prior
authorization is not obtained or denied, the member is responsible for 100% of the cost. For a
listing of drugs and their prior authorization criteria, please see the Physicians Plus website at
http://www.pplusic.com/providers/pharmacy. Specific PA forms are available at the website or by
contacting Physicians Plus Pharmacy Services. A standard prior authorization request will be handled
during business hours of 8am to 5pm Monday through Friday. Standard coverage determination
decisions are typically made within five business days, but Physicians Plus is allowed up to 14 days for
a decision. Physicians Plus Pharmacy Services contact information for prior authorization
requests is the following: telephone number 608-260-7803 or 1-800-545-5015, fax number
608-327-0324, [email protected] or through RxManager in MyChart.
Physicians Plus also has an expedited PA process that can be used in urgent circumstances such as
when the medical condition will seriously jeopardize the individual’s life, health, ability to function, or
the individual is already currently using the drug with no coverage at any tier level. It must include
the information in the standard PA request as well as the following: be labeled or requested as
“Expedited 24-Hour PA Process”, have the reason or description of harm that could reasonably occur
if a decision is not rendered within 24 hours, and a justification supporting that all formulary drugs
(on any tier) would be ineffective, less effective, or have information regarding why or how a switch to
a formulary alternative would cause harm or destabilization of the patient’s condition. After review of
the request, Physicians Plus has the right to change the expedited designation to standard
designation if appropriate. The expedited prior authorization process can be initiated Monday
through Friday before 5pm through the same contact information as the standard prior authorization
request (see above). For expedited reviews on weekends (after 5pm Friday through Sunday) and
holidays, please call 608-381-4723 and state this is a “24-Hour Expedited Review Process” as well as
the member name, date of birth, preferred pharmacy telephone number, required information for the
standard and expedited review as described above, and a preferred call back number. Faxed
expedited prior authorization requests should be submitted to 608-327-0324 or electronic requests
through RxManager or [email protected] and should be submitted with all the required
standard and expedited information.
STANDARD EXCEPTION REQUEST
Physicians Plus has a standard exception request procedure for non-formulary drugs that a member,
member designee, pharmacy, or prescriber may initiate. For a standard exception request sufficient
information must be provided to Physicians Plus to review and supported with justification regarding
the need for the non-formulary drug to treat the member’s condition and include a statement that all
covered formulary drugs on any tier will be or have been ineffective, would not be as effective as the
non-formulary drug, or would have adverse effects. A standard exception coverage determination will
be handled within 72 hours when all the required information is provided. A standard exception
request can be initiated by contacting Physicians Plus Pharmacy Services at the following: telephone
number 608-260-7803 or 1-800-545-5015, fax number 608-327-0324, [email protected] or
through RxManager in MyChart.
EXPEDITED EXCEPTION REQUEST AND EXTERNAL EXCEPTION REQUEST REVIEW
Physicians Plus has an expedited exception request procedure for non-formulary drugs that a
member, member designee, pharmacy, or prescriber may initiate in exigent circumstances. Exigent
circumstances exist when a member is suffering from a health condition that may seriously jeopardize
the member’s life, health, or ability to regain maximum function or when a member is undergoing a
current course of treatment using the non-formulary drug. An expedited exception coverage
determination will be handled within 24 hours when all the required information is provided. An
expedited request should be clearly documented as an “Expedited Non-formulary Exception Request”
and can be initiated by contacting Physicians Plus Pharmacy Services at telephone number 608-2607803 or 1-800-545-5015, telephone number on weekends or holidays 608-381-4723, fax number 608327-0324, [email protected] or through RxManager in MyChart. Physicians Plus also has an
external exception request review that can be initiated if necessary. See the medical certificate for
more information.
DISCOUNT DRUG PROGRAM
The Discount Drug Program allows a Physicians Plus member to obtain the Physicians Plus contracted
rate for a drug that is not on formulary (drugs that are normally not covered). The member is
responsible for 100% of the cost of the drug as well as a minimal fee. Drugs paying through the
discount drug wrap will not be accumulated towards the deductible or maximum out-ofpocket. To use the Discount Drug Program the claim needs to be adjudicated on-line at the
pharmacy at the time of the sale. Discount Drug Program does not apply to excluded drugs, prior
authorization drugs, or other drugs as determined by Physicians Plus. This program is subject to
change without notification.
SPECIAL CODES KEY

PA - Prior Authorization (PA) Drug: Prior Authorization criteria established. The P&T
Committee decided that coverage is available when specific clinical criteria and circumstances
are met. Member, prescriber, or designee must follow the PA procedure to request coverage
of the drug and if applicable the facility where the drug is being administered. PA forms are
available at http://www.pplusic.com/providers/pharmacy or by calling Physicians Plus Pharmacy
Services at 608-260-7803 or 800-545-5015, emailing at [email protected] to request
a form or through RxManager. Refer to the Physicians Plus formulary list to check the PA
status of a drug.

ST – Step Therapy required. Prior to receiving coverage, a trial of prerequisite drug(s) is
necessary. Submission of a prior authorization request may be required. Some drugs may not
require a PA form if the prerequisite drug(s) have been filled within the pharmacy claims
system. If the step therapy requirement has been met, tier level that the drug is covered at is
determined by Physicians Plus and may be at the specified Tier level (e.g. Tier 5ST=if step
therapy is fulfilled the drug is covered at Tier 5). Refer to the Physicians Plus formulary list to
check the ST status of a drug.

$0 - $0 copay. Drugs are available for a $0 monthly copay if a prescription is written and
submitted to the participating pharmacy, and the claim is run through the Physicians Plus
pharmacy claims system.

QL – Quantity limit. The quantity listed is the quantity per month limitation. For Physicians
Plus, the drug benefit allows coverage for a maximum of 30 days supply per prescription claim.
For drugs with a higher strength available, members must use the higher strength with any
dose increases. If a member requires a higher quantity per month, prior authorization is
required. Refer to the Physicians Plus formulary list to check the QL of a drug.
In addition, formulary test strips have a quantity limit of up to 50 test strips per 90 day supply
for members not on blood glucose lowering drug therapy. For members on blood glucose
lowering drug therapy, the quantity limit is up to 150 test strips per 30 day supply.
There is a limit of up to 20 mL (2 vials) of insulin per insulin type per 30 day supply. If a
member requires a higher quantity per month, the member, pharmacy, or provider may call
Physicians Plus Pharmacy Services with the daily dose for immediate authorization or submit a
prior authorization request for review.

AL – Age limit. Drugs are covered without prior authorization for members in the designated
age range. Consideration for coverage for those outside the age range may be made through
the submission of a PA request. For example, budesonide respules require a PA/exception
request for members aged 9 years and older. Refer to the Physicians Plus formulary list to
check for AL drugs.

SP – Specialty Drug. All specialty drugs must be filled at an in-network specialty pharmacy.
Most specialty drugs require prior authorization. If approved, these products are covered at
the Tier 4 or Tier 5 level. Refer to the Physicians Plus formulary list to check for SP drugs.

PF – Partial Fill. During the first three months of treatment with these drugs, members will
have the first 16 days filled, and the member will pay half of their normal monthly cost. For the
next 12-14 days fill (to complete the first month), the member will pay the other half of their
normal montly cost. Each month thereafter a one month supply will be available for the
member’s total monthly cost. Refer to the Physicians Plus formulary list to check for PF drugs.

TS – Voluntary Tablet Splitting Program. Members choosing to tablet split and use #15
tablets per month will receive a HALF-copay or the total coinsurance amount for drugs in this
program. More information about the program may be found at
http://www.pplusic.com/documents/upload/p5347-tablet-splitting-program.pdf. Members
may call Pharmacy Services to obtain a FREE tablet splitter. Physicians Plus reserves the right to
change this list at any time without notice. Refer to the Physicians Plus formulary list to check
for TS drugs.
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OTC – OTC covered. Most over-the-counter (OTC) drugs are excluded from coverage.
However, those designated with ‘OTC’ may be covered with a written prescription, filled by a
participating pharmacy, and if the claim is run through the Physicians Plus pharmacy claims
system. Refer to the Physicians Plus formulary list to check for OTC drugs.

NC – Not covered. Drug is not covered because a formulary equivalent is available, formulary
alternatives are available, the drug has not been reviewed by P&T Committee, or the drug is
excluded from coverage by the medical certificate. For example, Vaniqa cream is not covered
for cosmetic indications.

MB – Medical Benefit. Physicians Plus has select medical benefit drugs that have set prior
authorization criteria. If a prior authorization is approved, medical benefit drugs may be
covered under the medical benefit coverage at an in-network facility. If a prior authorization is
not obtained or not approved for these medical benefit drugs and facility prior to
administration, the member will be responsible for 100% of the cost of the drug and associated
administration fees. In general, drugs covered under the medical benefit are drugs
administered by a healthcare professional to a member. Drugs obtained at an outpatient
pharmacy and administered to a member by themselves or family member are generally
considered underneath the pharmacy benefit. Physicians Plus reserves the right to
determine which drugs are under the medical or pharmacy benefit. In addition,
Physicians Plus also reserves the right to change the Medical Benefit (MB) drugs to the
list of MB drugs requiring prior authorization at any time without notice.

DME – Durable Medical Expense. Under the pharmacy benefit, some products considered
DME include formulary spacers for asthma treatment and formulary diabetic test strips.
Formulary DME benefits are usually 20% coinsurance and typically do not correspond to drug
benefit tiers (e.g. diabetic test strips). Preferred level of coverage may vary between each
pharmacy benefit plan. Please see your Summary of Benefit Sheet. Non-preferred pharmacy
DME benefits are either 50% coinsurance. Non-formulary pharmacy DME are not covered.
EXCLUSIONS
Below are only a few of the common drugs Physicians Plus does not cover. See the medical certificate
for a more complete listing.
1.) Over –the-counter (OTC) drugs unless specified on the Physicians Plus formulary document.
a. A prescription written by a participating provider would need to be filled through the
Physicians Plus pharmacy claims system to allow coverage of these formulary OTC
products.
2.) Weight modification drugs
3.) Growth hormone (PA required)
 Providers MUST complete a drug-specific PA/exception request form (found at
http://www.pplusic.com/providers/pharmacy under ‘Drug PA forms’ for ‘Growth
Hormone’).
 If criteria are not fulfilled, member is responsible for the full cost of the drug.
4.) Anabolic steroids are only covered for replacement
5.) Infertility drugs
6.) Drugs used for sexual dysfunction
7.) Drugs not reviewed by the P&T Committee
LEGEND
TIER
DESCRIPTION
0
$0 ACA Preventive
Medications
1
Tier 1: Preferred, Value
Generics
2
Tier 2: Preferred Generics
3
Tier 3: Preferred Brands
4
Tier 4: Preferred SpecialtyGenerics or Brands
5
Tier 5: Non-Preferred Generics,
Brands, or Specialty
TYPE
DESCRIPTION
Quantity Limit
There is a limit on the amount of this drug that is covered per
prescription, or within a specific time frame.
PA
Prior Authorization
You (or your physician) are required to get prior authorization before
you fill your prescription for this drug. Without prior approval, we may
not cover this drug.
ST
Step Therapy
In some cases, you may be required to first try certain drugs to treat
your medical condition before we will cover another drug for that
condition.
AL
Age Limit
This prescription drug may only be covered if you meet the minimum
or maximum age limit.
C
Custom
This drug has unique restrictions
Specialty Drug
Specialty drugs are high-cost drugs used to treat complex or rare
conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis
C, and hemophilia.
QL
S
PAGE 9
LAST UPDATED 07/2015
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
Analgesics
Nonsteroidal Anti-inflammatory Drugs
celecoxib 100 mg capsule
2
PA
2
PA
2
PA
2
PA
comfort pac-ibuprofen kit
1
COMFORT PAC-MELOXICAM KIT
meloxicam/irritants counter-irritants combination no.2
1
COMFORT PAC-NAPROXEN KIT
naproxen/irritants counter-irritants combination #2
1
diclofenac pot 50 mg tablet
2
diclofenac sod dr 25 mg tab
2
2
2
diclofenac sod ec 25 mg tab
2
2
2
diflunisal 500 mg tablet
2
etodolac 200 mg capsule
2
2
etodolac 400 mg tablet
2
2
fenoprofen 600 mg tablet
5
flurbiprofen 100 mg tablet
1
1
ibuprofen 400 mg tablet
1
1
1
PAGE 10
QL
1 / 1 days
PRODUCT DESCRIPTION
TIER
indomethacin 25 mg capsule
1
1
indomethacin er 75 mg capsule
2
ketoprofen 50 mg capsule
5
PA
5
PA
ketorolac 10 mg tablet
2
QL
meclofenamate 100 mg capsule
5
PA
5
PA
mefenamic acid 250 mg capsule
5
PA
meloxicam 15 mg tablet
1
QL
1 / 1 days
meloxicam 7.5 mg tablet
1
QL
1 / 1 days
nabumetone 750 mg tablet
1
naproxen 125 mg/5 ml suspen
1
naproxen 250 mg tablet
1
1
naproxen 500 mg kit
1
1
naproxen dr 500 mg tablet
1
naproxen ec 500 mg tablet
1
naproxen sodium 275 mg tab
1
1
oxaprozin 600 mg caplet
2
oxaprozin 600 mg tablet
2
piroxicam 10 mg capsule
2
2
sulindac 150 mg tablet
1
1
tolmetin sodium 200 mg tab
2
tolmetin sodium 400 mg cap
2
2
PAGE 11
1 / 1 days
PRODUCT DESCRIPTION
TIER
Opioid Analgesics, Long-acting
BUTRANS 10 MCG/HR PATCH
buprenorphine
5
buprenorphine
5
buprenorphine
5
buprenorphine
5
EXALGO ER 12 MG TABLET
hydromorphone hcl
5
PA
hydromorphone hcl
5
PA
hydromorphone hcl
5
PA
hydromorphone hcl
5
PA
fentanyl 100 mcg/hr patch
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
QL
fentanyl cit otfc 1,200 mcg
1 / 1 days
5
PA
QL
1 / 1 days
5
PA
QL
fentanyl citrate otfc 200 mcg
1 / 1 days
5
PA
QL
1 / 1 days
5
PA
QL
1 / 1 days
5
PA
QL
1 / 1 days
5
PA
PAGE 12
PRODUCT DESCRIPTION
TIER
KADIAN ER 10 MG CAPSULE
morphine sulfate
5
PA
morphine sulfate
5
PA
morphine sulfate
5
PA
levorphanol 2 mg tablet
2
methadone 10 mg/5 ml solution
2
PA
methadone hcl 10 mg tablet
2
PA
2
PA
methadose 40 mg tablet dispr
2
PA
morphine sulf er 100 mg tablet
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
morphine sulfate er 100 mg cap
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
NUCYNTA ER 100 MG TABLET
tapentadol hcl
QL
1 / 1 days
5
tapentadol hcl
5
tapentadol hcl
5
PAGE 13
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
PRODUCT DESCRIPTION
TIER
QL
tapentadol hcl
5
tapentadol hcl
5
oxymorphone hcl er 10 mg tab
2
2
2
2
2
oxymorphone hcl er 5 mg tablet
2
oxymorphone hcl er 7.5 mg tab
2
tramadol er 100 mg tablet
5
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
5
PA
QL
1 / 1 days
5
PA
QL
tramadol hcl er 100 mg tablet
1 / 1 days
5
PA
QL
1 / 1 days
5
PA
QL
1 / 1 days
5
PA
Opioid Analgesics, Short-acting
butorphanol 10 mg/ml spray
5
codeine sulfate 15 mg tablet
2
2
2
2
QL
1 / 1 days
2
QL
1 / 1 days
PAGE 14
PA
PRODUCT DESCRIPTION
TIER
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
QL
1 / 1 days
5
PA
QL
1 / 1 days
5
PA
QL
1 / 1 days
5
PA
QL
1 / 1 days
5
PA
QL
1 / 1 days
5
PA
QL
1 / 1 days
5
PA
hydromorphone 1 mg/ml solution
2
hydromorphone 2 mg tablet
2
hydromorphone 2 mg/ml vial
2
2
hydromorphone 5 mg/5 ml soln
2
2
hydromorphone hcl 2 mg/ml amp
2
meperidine 100 mg tablet
2
PA
meperidine 50 mg tablet
2
PA
meperitab 100 mg tablet
2
PA
methadone 10 mg/5 ml solution
2
PA
2
PA
2
PA
methadose 40 mg tablet dispr
2
PA
PAGE 15
PRODUCT DESCRIPTION
TIER
morphine 10 mg/ml carpuject
2
PA
morphine 10 mg/ml isecure syr
2
PA
morphine 10 mg/ml syringe
2
PA
morphine 15 mg/ml vial
2
PA
morphine 300 mg/20 ml vial
2
PA
morphine sulf 10 mg/5 ml soln
2
QL
1 / 1 days
PA
QL
morphine sulf 20 mg/5 ml soln
1 / 1 days
2
PA
morphine sulfate ir 15 mg tab
2
QL
1 / 1 days
morphine sulfate ir 30 mg tab
2
QL
1 / 1 days
nalbuphine 10 mg/ml ampul
5
PA
nalbuphine 100 mg/10 ml vial
5
PA
nalbuphine 20 mg/ml ampul
5
PA
nalbuphine 200 mg/10 ml vial
5
PA
oxycodone hcl 10 mg tablet
2
2
2
2
2
TALWIN 30 MG/ML AMPUL
pentazocine lactate
5
PA
TALWIN 30 MG/ML VIAL
pentazocine lactate
5
PA
tramadol hcl 50 mg tablet
2
Anesthetics
Local Anesthetics
lidocaine 2% viscous soln
2
lidocaine 5% patch
2
PAGE 16
PA
PRODUCT DESCRIPTION
TIER
lidocaine hcl 2% jelly
2
2
lidocaine hcl 4% solution
2
lidocaine hcl 4% solution
2
lidocaine-prilocaine cream
2
2
proparacaine 0.5% eye drops
2
QL
acamprosate calc dr 333 mg tab
5
PA
disulfiram 250 mg tablet
2
disulfiram 500 mg tablet
2
VIVITROL 380 MG VIAL
naltrexone microspheres
5
VIVITROL 380 MG VIAL + DILUENT
5
1 / 1 days
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
PA
S
Specialty Drug
PA
S
Specialty Drug
Opioid Antagonists
buprenorphine 2 mg tablet sl
4
PA
buprenorphine 8 mg tablet sl
4
PA
naloxone 0.4 mg/ml syringe
4
PA
naloxone 0.4 mg/ml vial
4
PA
naloxone 2 mg/2 ml syringe
4
PA
naloxone 4 mg/10 ml vial
4
PA
VIVITROL 380 MG VIAL
5
VIVITROL 380 MG VIAL + DILUENT
5
PA
S
Specialty Drug
PA
S
Specialty Drug
Smoking Cessation Agents
buproban 150 mg tablet
PAGE 17
0
PRODUCT DESCRIPTION
TIER
CHANTIX 0.5 MG TABLET
varenicline tartrate
0
CHANTIX 1 MG CONT MONTH BOX
0
CHANTIX 1 MG TABLET
QL
1 / 1 days
0
QL
1 / 1 days
CHANTIX STARTING MONTH BOX
0
QL
1 / 1 days
NICOTROL CARTRIDGE INHALER
nicotine
0
QL
14 / 1 days
NICOTROL NS 10 MG/ML SPRAY
nicotine
0
QL
40 / 30 days
Anti-inflammatory Agents
Glucocorticoids
ALA-SCALP 2% LOTION
hydrocortisone
2
alclometasone dipr 0.05% oint
2
alclometasone dipro 0.05% crm
2
amcinonide 0.1% cream
5
amcinonide 0.1% lotion
5
amcinonide 0.1% ointment
5
ANUSOL-HC 2.5% CREAM
hydrocortisone
2
apexicon e 0.05% cream
5
betamethasone dp 0.05% crm
2
betamethasone dp 0.05% lot
2
betamethasone dp 0.05% oint
2
betamethasone dp aug 0.05% crm
2
betamethasone dp aug 0.05% gel
2
betamethasone dp aug 0.05% lot
2
betamethasone dp aug 0.05% oin
2
betamethasone va 0.1% cream
2
betamethasone va 0.1% lotion
2
betamethasone valer 0.1% ointm
2
PAGE 18
PA
PRODUCT DESCRIPTION
TIER
betamethasone valer 0.12% foam
2
CAPEX SHAMPOO
fluocinolone acetonide
5
clobetasol 0.05% cream
2
clobetasol 0.05% gel
2
clobetasol 0.05% ointment
2
clobetasol 0.05% shampoo
2
clobetasol 0.05% solution
2
clobetasol emollient 0.05% crm
2
clobetasol emollnt 0.05% foam
2
clobetasol emulsion 0.05% foam
2
clobetasol prop 0.05% foam
2
CLOBEX 0.05% SPRAY
clobetasol propionate
5
CORDRAN 0.05% LOTION
flurandrenolide
3
cortisone 25 mg tablet
2
desonide 0.05% cream
2
desonide 0.05% lotion
2
desonide 0.05% ointment
2
desoximetasone 0.05% cream
2
desoximetasone 0.05% gel
2
2
desoximetasone 0.25% ointment
2
diflorasone 0.05% cream
2
diflorasone 0.05% ointment
2
fludrocortisone 0.1 mg tablet
2
fluocinolone 0.01% body oil
2
fluocinolone 0.01% cream
2
fluocinolone 0.01% scalp oil
2
fluocinolone 0.01% solution
2
2
fluocinolone 0.025% ointment
2
PAGE 19
PA
PA
PRODUCT DESCRIPTION
TIER
fluocinonide 0.05% cream
2
fluocinonide 0.05% gel
2
fluocinonide 0.05% ointment
2
fluocinonide 0.05% solution
2
fluocinonide-e 0.05% cream
2
fluticasone prop 0.005% oint
2
fluticasone prop 0.05% cream
2
fluticasone prop 0.05% lotion
2
halobetasol prop 0.05% cream
2
halobetasol prop 0.05% ointmnt
2
HALOG 0.1% CREAM
halcinonide
3
HALOG 0.1% OINTMENT
halcinonide
3
hydrocort buty 0.1% lipid crm
2
hydrocort buty 0.1% lipo cream
2
hydrocortisone 1% cream
2
hydrocortisone 2.5% cream
1
hydrocortisone 2.5% lotion
2
hydrocortisone 2.5% ointment
1
hydrocortisone buty 0.1% cream
2
methylprednisolone 16 mg tab
2
2
methylprednisolone 4 mg dosepk
2
methylprednisolone 4 mg tablet
2
2
millipred 5 mg tablet
3
millipred dp 5 mg 12-day pack
3
3
neomycin-polymyxin-hc ear soln
2
QL
1 / 1 days
neomycin-polymyxin-hc ear susp
2
QL
1 / 1 days
nystatin-triamcinolone cream
2
PAGE 20
PA
PRODUCT DESCRIPTION
TIER
nystatin-triamcinolone ointm
2
prednisolone 15 mg/5 ml soln
2
2
prednisolone 15 mg/5 ml syrup
2
2
prednisolone sod ph 25 mg/5 ml
1
prednisone 1 mg tablet
1
prednisone 10 mg tab dose pack
1
1
prednisone 2.5 mg tablet
1
1
1
1
prednisone 5 mg/5 ml solution
2
prednisone 5 mg/ml solution
1
1
procto-pak 1% cream
2
PROCTOCORT 1% CREAM
hydrocortisone
2
scalacort 2% lotion
2
TEXACORT 2.5% SOLUTION
hydrocortisone
3
triamcinolone 0.025% cream
1
triamcinolone 0.025% lotion
1
triamcinolone 0.025% oint
1
1
1
triamcinolone 0.1% ointment
1
triamcinolone 0.1% paste
2
1
1
VERIPRED 20 20 MG/5 ML SOLN
prednisolone sod phosphate
3
PAGE 21
QL
1 / 1 days
PRODUCT DESCRIPTION
TIER
Nonsteroidal Anti-inflammatory Drugs
comfort pac-ibuprofen kit
1
COMFORT PAC-MELOXICAM KIT
meloxicam/irritants counter-irritants combination no.2
1
COMFORT PAC-NAPROXEN KIT
naproxen/irritants counter-irritants combination #2
1
diclofenac pot 50 mg tablet
2
2
2
2
2
2
2
diflunisal 500 mg tablet
2
2
2
2
2
fenoprofen 600 mg tablet
5
1
1
1
1
1
1
1
indomethacin er 75 mg capsule
2
5
PA
5
PA
ketorolac 10 mg tablet
2
QL
5
PA
PAGE 22
QL
1 / 1 days
1 / 1 days
PRODUCT DESCRIPTION
TIER
5
PA
mefenamic acid 250 mg capsule
5
PA
meloxicam 15 mg tablet
1
QL
1 / 1 days
meloxicam 7.5 mg tablet
1
QL
1 / 1 days
nabumetone 750 mg tablet
1
naproxen 125 mg/5 ml suspen
1
1
1
naproxen 500 mg kit
1
1
naproxen dr 500 mg tablet
1
naproxen ec 500 mg tablet
1
1
1
oxaprozin 600 mg caplet
2
oxaprozin 600 mg tablet
2
2
2
1
1
2
tolmetin sodium 400 mg cap
2
2
Antibacterials
Aminoglycosides
gentamicin 0.1% cream
2
gentamicin 0.1% ointment
2
gentamicin 0.3% eye drops
1
QL
1 / 1 days
gentamicin 0.3% eye ointment
1
QL
1 / 1 days
gentamicin 3 mg/ml eye drops
1
QL
1 / 1 days
PAGE 23
PRODUCT DESCRIPTION
TIER
neomycin 500 mg tablet
2
paromomycin 250 mg capsule
2
TOBI 300 MG/5 ML SOLUTION
tobramycin in 0.225 % sodium chloride
4
TOBRADEX EYE OINTMENT
tobramycin/dexamethasone
3
QL
1 / 1 days
tobramycin 0.3% eye drops
1
QL
1 / 1 days
TOBREX 0.3% EYE OINTMENT
tobramycin
3
PA
S
Specialty Drug
Antibacterials, Other
acetasol hc ear drops
5
acetic acid 2% ear solution
2
QL
1 / 1 days
acetic acid-aluminum drops
2
QL
1 / 1 days
bacitracin 500 unit/gm ophth
1
QL
1 / 1 days
BACTROBAN NASAL 2% OINTMENT
mupirocin calcium
3
chlorhexidine 0.12% rinse
1
CLEOCIN 100 MG VAGINAL OVULE
clindamycin phosphate
3
clindacin etz 1% pledget
5
PA
CLINDACIN ETZ KIT
clindamycin phosphate/skin cleanser comb no.19
5
PA
clindacin p 1% pledgets
5
PA
CLINDACIN PAC KIT
5
PA
CLINDAGEL 1% GEL
5
PA
clindamycin 150 mg/ml addvan
3
3
3
clindamycin 2% vaginal cream
2
clindamycin 75 mg/5 ml soln
1
clindamycin hcl 150 mg capsule
2
PAGE 24
PRODUCT DESCRIPTION
TIER
1
1
clindamycin pediatr 75 mg/5 ml
1
clindamycin ph 1% gel
2
clindamycin ph 1% solution
2
clindamycin ph 300 mg/2 ml vl
3
3
clindamycin ph 9 g/60 ml vial
3
3
clindamycin phos 1% pledget
3
clindamycin phosp 1% lotion
2
clindamycin phosphate 1% foam
3
CLINDESSE 2% VAGINAL CREAM
3
CUBICIN 500 MG VIAL
daptomycin
5
cycloserine 250 mg capsule
4
hydrocortison-acetic acid soln
5
LINCOCIN 300 MG/ML VIAL
lincomycin hcl
5
MACRODANTIN 25 MG CAPSULE
nitrofurantoin macrocrystal
3
methenamine hipp 1 gm tablet
5
PA
methenamine md 1 gm tablet
5
PA
METROGEL TOPICAL 1% GEL
metronidazole
5
PA
METROGEL TOPICAL 1% PUMP
metronidazole
5
PA
metronidazole 0.75% cream
2
metronidazole 0.75% lotion
5
metronidazole 250 mg tablet
2
metronidazole 375 mg capsule
2
metronidazole 500 mg tablet
2
PAGE 25
PA
PA
PA
PRODUCT DESCRIPTION
TIER
metronidazole topical 0.75% gl
2
metronidazole vaginal 0.75% gl
2
MONUROL 3 GM SACHET
fosfomycin tromethamine
5
PA
mupirocin 2% cream
2
QL
1 / 1 days
mupirocin 2% ointment
2
QL
1 / 1 days
nitrofurantoin mcr 100 mg cap
2
nitrofurantoin mcr 50 mg cap
2
nitrofurantoin mono-mcr 100 mg
2
paroex 0.12% oral rinse
2
SULFAMYLON 8.5% CREAM
mafenide acetate
3
AL
At least 5 yrs old
trimethoprim 100 mg tablet
5
PA
vancomycin hcl 125 mg capsule
4
vancomycin hcl 250 mg capsule
4
XIFAXAN 200 MG TABLET
rifaximin
5
PA
rifaximin
5
PA
ZYVOX 100 MG/5 ML SUSPENSION
linezolid
4
PA
ZYVOX 600 MG TABLET
linezolid
3
PA
Beta-lactam, Cephalosporins
cefaclor 125 mg/5 ml susp
5
cefaclor 250 mg capsule
5
cefaclor 250 mg/5 ml susp
5
cefaclor 375 mg/5 ml suspen
5
cefaclor 500 mg capsule
5
cefaclor er 500 mg tablet
5
cefadroxil 1 gm tablet
2
cefadroxil 500 mg capsule
2
cefdinir 125 mg/5 ml susp
2
PAGE 26
PRODUCT DESCRIPTION
TIER
cefdinir 250 mg/5 ml susp
2
cefdinir 300 mg capsule
2
cefpodoxime 100 mg tablet
2
cefpodoxime 200 mg tablet
2
cefprozil 125 mg/5 ml susp
3
PA
cefprozil 250 mg tablet
5
PA
cefprozil 250 mg/5 ml susp
5
PA
cefprozil 500 mg tablet
5
PA
ceftriaxone 1 gm vial
5
5
5
ceftriaxone 100 gram bulk bag
5
ceftriaxone 2 gm add vial
5
5
ceftriaxone 250 mg vial
5
ceftriaxone 500 mg vial
5
cefuroxime axetil 250 mg tab
2
cefuroxime axetil 500 mg tab
2
cephalexin 125 mg/5 ml susp
2
cephalexin 250 mg capsule
1
cephalexin 250 mg/5 ml susp
2
cephalexin 500 mg capsule
1
cephalexin 500 mg tablet
2
Beta-lactam, Other
CAYSTON 75 MG INHAL SOLUTION
aztreonam lysine
4
PA
Beta-lactam, Penicillins
amox tr-k clv 200-28.5 tab chw
1
amox tr-k clv 200-28.5/5 susp
1
1
amox tr-k clv 400-57 tab chew
1
PAGE 27
PRODUCT DESCRIPTION
TIER
amox tr-k clv 400-57/5 susp
1
amox tr-k clv 500-125 mg tab
1
1
amox tr-k clv 875-125 mg tab
1
amoxicillin 125 mg tab chew
1
amoxicillin 125 mg/5 ml susp
1
1
amoxicillin 250 mg capsule
1
amoxicillin 250 mg tab chew
1
1
1
amoxicillin 500 mg capsule
1
amoxicillin 500 mg tablet
1
amoxicillin 875 mg tablet
1
amoxicillin er 775 mg tablet
1
ampicillin 125 mg/5 ml susp
1
ampicillin 250 mg capsule
1
ampicillin 250 mg/5 ml susp
1
ampicillin 500 mg capsule
1
AUGMENTIN 125-31.25 MG/5 ML
amoxicillin/potassium clavulanate
3
dicloxacillin 250 mg capsule
2
dicloxacillin 500 mg capsule
2
penicillin vk 125 mg/5 ml soln
1
penicillin vk 250 mg tablet
1
penicillin vk 250 mg/5 ml soln
1
penicillin vk 500 mg tablet
1
Macrolides
AZASITE 1% EYE DROPS
azithromycin
3
QL
azithromycin 1 gm pwd packet
5
PA
azithromycin 100 mg/5 ml susp
1
PAGE 28
1 / 1 days
PRODUCT DESCRIPTION
TIER
azithromycin 200 mg/5 ml susp
1
azithromycin 250 mg tablet
1
1
1
clarithromycin 125 mg/5 ml sus
2
clarithromycin 250 mg tablet
2
clarithromycin 250 mg/5 ml sus
2
2
clarithromycin er 500 mg tab
2
DIFICID 200 MG TABLET
fidaxomicin
3
ery 2% pads
2
ERY-TAB EC 250 MG TABLET
erythromycin base
3
erythromycin base
3
erythromycin base
3
ERYPED 200 MG/5 ML SUSPENSION
erythromycin ethylsuccinate
3
ERYPED 400 MG/5 ML SUSPENSION
erythromycin ethylsuccinate
3
ERYTHROCIN 250 MG FILMTAB
erythromycin stearate
3
erythromycin 0.5% eye ointment
1
erythromycin 2% solution
2
erythromycin 250 mg filmtab
2
erythromycin 500 mg filmtab
5
erythromycin es 400 mg tab
2
KETEK 300 MG TABLET
telithromycin
5
PA
KETEK 400 MG TABLET
telithromycin
5
PA
PCE 333 MG TABLET
erythromycin base
2
PAGE 29
PA
S
QL
Specialty Drug
1 / 1 days
PRODUCT DESCRIPTION
PCE 500 MG TABLET
erythromycin base
TIER
2
Quinolones
AVELOX 400 MG TABLET
moxifloxacin hcl
5
BESIVANCE 0.6% SUSP
besifloxacin hcl
3
CILOXAN 0.3% OINTMENT
ciprofloxacin hcl
2
QL
1 / 1 days
ciprofloxacin 0.3% eye drop
3
QL
1 / 1 days
ciprofloxacin 250 mg/5 ml susp
2
ciprofloxacin 500 mg/5 ml susp
2
ciprofloxacin hcl 100 mg tab
2
QL
1 / 1 days
1
2
QL
1 / 1 days
1
FACTIVE 320 MG TABLET
gemifloxacin mesylate
5
levofloxacin 0.5% eye drops
2
levofloxacin 25 mg/ml solution
2
levofloxacin 250 mg tablet
1
levofloxacin 250 mg/10 ml soln
2
1
levofloxacin 500 mg/20 ml soln
2
1
MOXEZA 0.5% EYE DROPS
moxifloxacin hcl
3
ofloxacin 0.3% ear drops
2
QL
1 / 1 days
ofloxacin 0.3% eye drops
2
QL
1 / 1 days
ofloxacin 400 mg tablet
5
PA
VIGAMOX 0.5% EYE DROPS
moxifloxacin hcl
3
QL
ZYMAXID 0.5% EYE DROPS
gatifloxacin
3
PAGE 30
PA
PA
1 / 1 days
PRODUCT DESCRIPTION
TIER
Sulfonamides
silver sulfadiazine 1% cream
1
sodium sulfacetamide 10% lot
2
sulfacetamide 10% eye drops
2
sulfacetamide sod 10% top susp
2
sulfadiazine 500 mg tablet
2
sulfamethoxazole-tmp ds tablet
1
sulfamethoxazole-tmp ss tablet
1
sulfamethoxazole-tmp susp
1
QL
1 / 1 days
QL
1 / 1 days
Tetracyclines
demeclocycline 150 mg tablet
5
PA
5
PA
doxycycline hyclate 100 mg cap
2
doxycycline hyclate 100 mg tab
2
2
doxycycline mono 100 mg cap
2
doxycycline mono 100 mg tablet
2
doxycycline mono 50 mg cap
2
minocycline 100 mg capsule
2
2
minocycline hcl 100 mg tablet
1
1
tetracycline 250 mg capsule
1
tetracycline 500 mg capsule
1
Anticonvulsants
Anticonvulsants, Other
acetazolamide 125 mg tablet
2
2
acetazolamide sod 500 mg vial
2
FYCOMPA 10 MG TABLET
perampanel
5
PAGE 31
PA
PRODUCT DESCRIPTION
TIER
FYCOMPA 12 MG TABLET
perampanel
5
levetiracetam 1,000 mg tablet
2
levetiracetam 100 mg/ml soln
2
levetiracetam 250 mg tablet
2
2
levetiracetam 500 mg/5 ml soln
2
2
POTIGA 200 MG TABLET
ezogabine
3
ezogabine
3
ezogabine
3
POTIGA 50 MG TABLET
ezogabine
3
primidone 250 mg tablet
2
primidone 50 mg tablet
2
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
Calcium Channel Modifying Agents
CELONTIN 300 MG KAPSEAL
methsuximide
5
ethosuximide 250 mg capsule
2
ethosuximide 250 mg/5 ml soln
2
LYRICA 100 MG CAPSULE
pregabalin
3
pregabalin
3
LYRICA 20 MG/ML ORAL SOLUTION
pregabalin
3
pregabalin
3
PAGE 32
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
PRODUCT DESCRIPTION
TIER
QL
pregabalin
3
pregabalin
3
pregabalin
3
pregabalin
3
pregabalin
3
zonisamide 100 mg capsule
2
2
2
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
Gamma-aminobutyric Acid (GABA) Augmenting Agents
divalproex sod dr 125 mg tab
2
2
2
divalproex sod er 250 mg tab
2
2
divalproex sodium 125 mg cap
2
gabapentin 100 mg capsule
1
C
Tablet Split (TS)
gabapentin 250 mg/5 ml soln
2
C
Tablet Split (TS)
1
C
Tablet Split (TS)
2
C
Tablet Split (TS)
1
C
Tablet Split (TS)
gabapentin 600 mg tablet
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
GABITRIL 12 MG TABLET
tiagabine hcl
5
PA
GABITRIL 16 MG TABLET
tiagabine hcl
5
PA
PAGE 33
PRODUCT DESCRIPTION
TIER
PA
SABRIL 500 MG POWDER PACKET
vigabatrin
3
SABRIL 500 MG TABLET
vigabatrin
3
tiagabine hcl 2 mg tablet
2
tiagabine hcl 4 mg tablet
2
valproic acid 250 mg capsule
2
valproic acid 250 mg/5 ml soln
2
valproic acid 500 mg/10 ml sol
2
S
Specialty Drug
PA
S
Specialty Drug
Glutamate Reducing Agents
felbamate 400 mg tablet
2
felbamate 600 mg tablet
2
LAMICTAL TAB START KIT (GREEN)
lamotrigine
3
LAMICTAL TB START KIT (ORANGE)
lamotrigine
3
lamotrigine 100 mg tablet
1
QL
C
QL
1
C
QL
1
C
QL
lamotrigine 25 mg disper tab
2
C
QL
1
C
QL
lamotrigine 25 mg tb start kit
2
C
QL
lamotrigine 5 mg disper tablet
topiramate 100 mg tablet
PAGE 34
2
1
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
C
Tablet Split (TS)
C
Tablet Split (TS)
PRODUCT DESCRIPTION
TIER
topiramate 15 mg sprinkle cap
2
C
Tablet Split (TS)
1
C
Tablet Split (TS)
2
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
BANZEL 200 MG TABLET
rufinamide
3
PA
BANZEL 400 MG TABLET
rufinamide
3
PA
carbamazepine 100 mg tab chew
2
carbamazepine 100 mg/5 ml susp
2
carbamazepine 200 mg tablet
2
carbamazepine er 100 mg cap
2
2
carbamazepine er 200 mg tablet
2
2
2
carbamazepine xr 200 mg tablet
2
2
DILANTIN 30 MG CAPSULE
phenytoin sodium extended
5
PA
epitol 200 mg tablet
5
PA
oxcarbazepine 150 mg tablet
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
oxcarbazepine 300 mg/5 ml susp
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
PEGANONE 250 MG TABLET
ethotoin
5
PA
phenytoin 100 mg/4 ml susp
2
phenytoin 125 mg/5 ml susp
2
Sodium Channel Agents
PAGE 35
PRODUCT DESCRIPTION
TIER
phenytoin 50 mg infatab
2
phenytoin 50 mg tablet chew
2
phenytoin sod ext 100 mg cap
2
2
2
TEGRETOL XR 100 MG TABLET
carbamazepine
5
VIMPAT 100 MG TABLET
lacosamide
3
lacosamide
3
lacosamide
3
VIMPAT 50 MG TABLET
lacosamide
3
ziprasidone hcl 20 mg capsule
2
2
2
2
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
Antidementia Agents
Antidementia Agents, Other
ergoloid mesylates 1 mg tab
5
PA
Cholinesterase Inhibitors
donepezil hcl 10 mg tablet
2
2
2
donepezil hcl odt 10 mg tablet
2
donepezil hcl odt 5 mg tablet
2
EXELON 13.3 MG/24HR PATCH
rivastigmine
3
rivastigmine
3
PAGE 36
PRODUCT DESCRIPTION
TIER
rivastigmine
3
galantamine 4 mg/ml oral soln
2
galantamine er 16 mg capsule
2
2
2
galantamine hbr 12 mg tablet
2
2
2
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA 10 MG TABLET
memantine hcl
3
NAMENDA 5 MG TABLET
memantine hcl
3
NAMENDA 5-10 MG TITRATION PK
memantine hcl
3
NAMENDA XR 14 MG CAPSULE
memantine hcl
3
memantine hcl
3
memantine hcl
3
memantine hcl
3
NAMENDA XR TITRATION PACK
memantine hcl
3
Antidepressants
Antidepressants, Other
bupropion hcl 100 mg tablet
1
bupropion hcl 75 mg tablet
1
bupropion hcl sr 100 mg tablet
1
bupropion hcl sr 150 mg tablet
1
bupropion hcl sr 200 mg tab
1
bupropion hcl xl 150 mg tablet
1
bupropion hcl xl 300 mg tablet
1
PAGE 37
PRODUCT DESCRIPTION
TIER
maprotiline 25 mg tablet
2
2
2
mirtazapine 15 mg odt
1
mirtazapine 15 mg tablet
1
1
1
1
1
mirtazapine 7.5 mg tablet
2
nefazodone hcl 100 mg tablet
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
SEROQUEL XR 150 MG TABLET
quetiapine fumarate
5
PA
quetiapine fumarate
5
PA
quetiapine fumarate
5
PA
quetiapine fumarate
5
PA
quetiapine fumarate
5
PA
trazodone 100 mg tablet
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
3
PA
Monoamine Oxidase Inhibitors
EMSAM 12 MG/24 HOURS PATCH
selegiline
PAGE 38
PRODUCT DESCRIPTION
TIER
selegiline
3
PA
selegiline
3
PA
phenelzine sulfate 15 mg tab
2
tranylcypromine sulf 10 mg tab
2
Serotonin/Norepinephrine Reuptake Inhibitors
citalopram hbr 10 mg tablet
1
C
Tablet Split (TS)
citalopram hbr 10 mg/5 ml soln
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
duloxetine hcl dr 20 mg cap
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
QL
escitalopram 10 mg tablet
1 / 1 days
1
C
QL
1
C
QL
1
C
fluoxetine hcl 10 mg capsule
1
fluoxetine hcl 10 mg tablet
1
1
fluoxetine hcl 20 mg tablet
1
1
fluvoxamine maleate 100 mg tab
2
QL
C
QL
2
C
QL
2
C
PAGE 39
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
PRODUCT DESCRIPTION
TIER
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
paroxetine hcl 10 mg tablet
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
PRISTIQ ER 100 MG TABLET
desvenlafaxine succinate
5
PA
PRISTIQ ER 50 MG TABLET
desvenlafaxine succinate
5
PA
sertraline 20 mg/ml oral conc
1
PA
C
Tablet Split (TS)
sertraline hcl 100 mg tablet
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
venlafaxine hcl 100 mg tablet
1
QL
1 / 1 days
1
QL
1 / 1 days
venlafaxine hcl 37.5 mg tablet
1
QL
1 / 1 days
1
QL
1 / 1 days
1
QL
1 / 1 days
venlafaxine hcl er 150 mg cap
1
QL
1 / 1 days
VENLAFAXINE HCL ER 225 MG TAB
venlafaxine hcl
QL
1 / 1 days
5
venlafaxine hcl er 37.5 mg cap
1
QL
1 / 1 days
1
QL
1 / 1 days
PAGE 40
PA
PRODUCT DESCRIPTION
TIER
Tricyclics
amitriptyline hcl 10 mg tab
1
1
1
1
1
1
amoxapine 100 mg tablet
2
2
2
2
clomipramine 25 mg capsule
2
2
2
desipramine 10 mg tablet
2
2
2
2
2
2
doxepin 10 mg capsule
2
doxepin 10 mg/ml oral conc
2
2
2
2
2
2
imipramine hcl 10 mg tablet
2
2
2
imipramine pamoate 150 mg cap
2
PAGE 41
PRODUCT DESCRIPTION
TIER
nortriptyline 10 mg/5 ml sol
1
nortriptyline hcl 10 mg cap
1
1
1
1
protriptyline hcl 10 mg tablet
5
PA
protriptyline hcl 5 mg tablet
5
PA
Antiemetics
Antiemetics, Other
chlorpromazine 10 mg tablet
2
2
2
2
2
hydroxyzine hcl 10 mg tablet
2
2
2
hydroxyzine pam 100 mg cap
2
2
2
meclizine 12.5 mg tablet
2
meclizine 25 mg tablet
2
metoclopramide 10 mg tablet
1
metoclopramide 10 mg/10 ml sol
1
1
metoclopramide 5 mg/5 ml soln
1
1
METOZOLV ODT 5 MG TABLET
metoclopramide hcl
5
perphenazine 16 mg tablet
2
2
PAGE 42
PA
PRODUCT DESCRIPTION
TIER
2
2
prochlorperazine 10 mg tab
2
prochlorperazine 10 mg/2 ml vl
2
prochlorperazine 25 mg supp
2
prochlorperazine 5 mg tablet
2
prochlorperazine 5 mg/ml vial
2
promethazine 12.5 mg suppos
2
promethazine 12.5 mg tablet
2
promethazine 25 mg suppository
2
promethazine 25 mg tablet
2
2
promethazine 6.25 mg/5 ml syrp
2
promethegan 50 mg suppository
2
TRANSDERM-SCOP 1.5 MG/72HR
scopolamine
3
QL
1 / 1 days
QL
1 / 1 days
Emetogenic Therapy Adjuncts
ANZEMET 100 MG TABLET
dolasetron mesylate
3
ANZEMET 50 MG TABLET
dolasetron mesylate
3
CESAMET 1 MG CAPSULE
nabilone
3
dronabinol 10 mg capsule
4
dronabinol 2.5 mg capsule
4
4
EMEND 125 MG CAPSULE
aprepitant
3
EMEND 80 MG CAPSULE
aprepitant
3
EMEND TRIFOLD PACK
aprepitant
3
ondansetron 4 mg/5 ml solution
2
PAGE 43
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
PRODUCT DESCRIPTION
TIER
ondansetron hcl 24 mg tablet
2
2
2
ondansetron odt 4 mg tablet
2
ondansetron odt 8 mg tablet
2
Antifungals
ciclopirox 0.77% cream
2
ciclopirox 0.77% gel
2
ciclopirox 0.77% topical susp
2
clotrimazole 10 mg troche
2
econazole nitrate 1% cream
2
ERTACZO 2% CREAM
sertaconazole nitrate
5
EXELDERM 1% CREAM
sulconazole nitrate
3
EXELDERM 1% SOLUTION
sulconazole nitrate
3
fluconazole 10 mg/ml susp
2
fluconazole 100 mg tablet
2
2
2
fluconazole 40 mg/ml susp
2
2
flucytosine 250 mg capsule
2
flucytosine 500 mg capsule
2
griseofulvin 125 mg/5 ml susp
2
griseofulvin micro 500 mg tab
2
griseofulvin ultra 125 mg tab
2
griseofulvin ultra 250 mg tab
2
itraconazole 100 mg capsule
2
ketoconazole 2% cream
2
ketoconazole 2% shampoo
2
PAGE 44
PA
ST
PA
PRODUCT DESCRIPTION
TIER
ketoconazole 200 mg tablet
2
ST
NAFTIN 1% CREAM
naftifine hcl
3
ST
NAFTIN 1% GEL
naftifine hcl
3
ST
NAFTIN 2% CREAM
naftifine hcl
3
ST
NATACYN EYE DROPS
natamycin
3
QL
NOXAFIL 40 MG/ML SUSPENSION
posaconazole
3
PA
nystatin 100,000 unit/gm cream
1
nystatin 100,000 units/gm oint
1
nystatin 100,000 units/ml susp
2
nystatin 150,000,000 units pwd
2
2
nystatin 500,000 unit oral tab
2
nystatin 500,000 units/5 ml
2
2
nystop 100,000 units/gm powder
2
OXISTAT 1% CREAM
oxiconazole nitrate
3
OXISTAT 1% LOTION
oxiconazole nitrate
3
SPORANOX 10 MG/ML SOLUTION
itraconazole
5
terbinafine hcl 250 mg tablet
1
terconazole 0.4% cream
2
terconazole 0.8% cream
2
terconazole 80 mg suppository
2
voriconazole 200 mg tablet
3
PA
voriconazole 200 mg vial
3
PA
voriconazole 50 mg tablet
3
PA
PAGE 45
1 / 1 days
PA
PRODUCT DESCRIPTION
TIER
Antigout Agents
allopurinol 100 mg tablet
1
allopurinol 300 mg tablet
1
colchicine 0.6 mg tablet
2
probenecid 500 mg tablet
2
probenecid-colchicine tabs
2
1
1
ULORIC 40 MG TABLET
febuxostat
5
PA
ULORIC 80 MG TABLET
febuxostat
5
PA
Antimigraine Agents
Ergot Alkaloids
dihydroergotamine 1 mg/ml am
2
dihydroergotamine 1 mg/ml vl
2
dihydroergotamine 4 mg/ml spry
2
ERGOMAR 2 MG TABLET SL
ergotamine tartrate
5
PA
Prophylactic
2
2
2
2
2
2
timolol maleate 10 mg tablet
5
PA
5
PA
5
PA
1
C
Tablet Split (TS)
2
C
Tablet Split (TS)
PAGE 46
PRODUCT DESCRIPTION
TIER
1
C
Tablet Split (TS)
2
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
2
2
2
Serotonin (5-HT) 1b/1d Receptor Agonists
QL
AXERT 12.5 MG TABLET
almotriptan malate
5
1 / 1 days
PA
ST
QL
AXERT 6.25 MG TABLET
almotriptan malate
5
1 / 1 days
PA
ST
FROVA 2.5 MG TABLET
frovatriptan succinate
PA
5
ST
QL
naratriptan 1 mg tablet
5
ST
C
QL
naratriptan 2.5 mg tablet
5
QL
5
QL
5
QL
5
QL-9/18
1 / 1 days
QL-9/18
1 / 1 days
ST
C
RELPAX 20 MG TABLET
eletriptan hbr
1 / 1 days
ST
C
naratriptan hcl 2.5 mg tablet
QL-9/18
ST
C
naratriptan hcl 1 mg tablet
1 / 1 days
QL-9/18
1 / 1 days
PA
ST
PAGE 47
PRODUCT DESCRIPTION
TIER
QL
RELPAX 40 MG TABLET
eletriptan hbr
5
1 / 1 days
PA
ST
rizatriptan 10 mg odt
2
QL
1 / 1 days
rizatriptan 10 mg tablet
2
QL
1 / 1 days
rizatriptan 5 mg odt
2
QL
1 / 1 days
rizatriptan 5 mg tablet
2
QL
1 / 1 days
sumatriptan 20 mg nasal spray
1
QL
1 / 1 days
QL
1 / 1 days
sumatriptan 4 mg/0.5 ml cart
5
ST
C
QL
sumatriptan 4 mg/0.5 ml inject
5
QL
5
QL
5
QL
5
QL
5
QL
1
QL-6/12
1 / 1 days
QL-6/12
1 / 1 days
QL-6/12
1 / 1 days
ST
C
PAGE 48
1 / 1 days
ST
C
sumatriptan succ 100 mg tablet
QL-6/12
ST
C
sumatriptan 6 mg/0.5 ml vial
1 / 1 days
ST
C
sumatriptan 6 mg/0.5 ml syrng
QL-6/12
ST
C
sumatriptan 6 mg/0.5 ml refill
1 / 1 days
ST
C
sumatriptan 6 mg/0.5 ml inject
QL-6/12
QL-6/12
PRODUCT DESCRIPTION
TIER
QL
sumatriptan succ 50 mg tablet
1
1 / 1 days
ST
C
QL-6/12
ST
SUMAVEL DOSEPRO 6 MG/0.5 ML
sumatriptan succinate
5
zolmitriptan 2.5 mg odt
2
C
QL
QL-6/12
1 / 1 days
ST
QL
zolmitriptan 2.5 mg tablet
1 / 1 days
2
ST
QL
zolmitriptan 5 mg odt
1 / 1 days
2
ST
QL
zolmitriptan 5 mg tablet
1 / 1 days
2
ST
ZOMIG 5 MG NASAL SPRAY
zolmitriptan
QL
1 / 1 days
2
ST
Antimyasthenic Agents
Parasympathomimetics
MESTINON 180 MG TIMESPAN
pyridostigmine bromide
5
pyridostigmine br 60 mg tablet
2
PA
Antimycobacterials
Antimycobacterials, Other
dapsone 100 mg tablet
2
2
MYCOBUTIN 150 MG CAPSULE
rifabutin
3
Antituberculars
CAPASTAT SULFATE 1 GM VIAL
capreomycin sulfate
5
cycloserine 250 mg capsule
4
ethambutol hcl 100 mg tablet
2
PAGE 49
PA
PRODUCT DESCRIPTION
TIER
ethambutol hcl 400 mg tablet
2
isoniazid 100 mg tablet
2
isoniazid 300 mg tablet
2
isoniazid 50 mg/5 ml solution
2
PASER GRANULES 4 GM PACKET
aminosalicylic acid
5
pyrazinamide 500 mg tablet
2
rifampin 150 mg capsule
2
rifampin 300 mg capsule
2
RIFATER TABLET
rifampin/isoniazid/pyrazinamide
3
TRECATOR 250 MG TABLET
ethionamide
3
Antineoplastics
Alkylating Agents
LEUKERAN 2 MG TABLET
chlorambucil
4
MATULANE 50 MG CAPSULE
procarbazine hcl
4
PA
PA
S
Specialty Drug
Antiangiogenic Agents
PA
POMALYST 1 MG CAPSULE
pomalidomide
4
pomalidomide
4
pomalidomide
4
pomalidomide
4
REVLIMID 10 MG CAPSULE
lenalidomide
4
lenalidomide
4
PAGE 50
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
REVLIMID 2.5 MG CAPSULE
lenalidomide
4
lenalidomide
4
lenalidomide
4
lenalidomide
4
THALOMID 100 MG CAPSULE
thalidomide
4
thalidomide
4
thalidomide
4
thalidomide
4
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
Antiestrogens/Modifiers
EMCYT 140 MG CAPSULE
estramustine phosphate sodium
4
PA
FARESTON 60 MG TABLET
toremifene citrate
4
PA
tamoxifen 10 mg tablet
0
tamoxifen 20 mg tablet
0
Antimetabolites
adrucil 5 gram/100 ml vial
4
PA
adrucil 50 mg/ml vial
4
PA
adrucil 500 mg/10 ml vial
4
PA
DROXIA 200 MG CAPSULE
hydroxyurea
4
PA
hydroxyurea
4
PA
PAGE 51
PRODUCT DESCRIPTION
TIER
hydroxyurea
4
PA
fluorouracil 1,000 mg/20 ml vl
4
PA
fluorouracil 2,500 mg/50 ml vl
4
PA
fluorouracil 2.5 gm/50 ml vial
4
PA
fluorouracil 5 gm/100 ml vial
4
PA
fluorouracil 5,000 mg/100 ml
4
PA
fluorouracil 500 mg/10 ml vial
4
PA
hydroxyurea 500 mg capsule
2
mercaptopurine 50 mg tablet
2
methotrexate 1 gram/40 ml vial
2
methotrexate 100 mg/4 ml vial
2
methotrexate 2.5 mg tablet
2
2
methotrexate 25 mg/ml vial
2
2
2
2
2
RHEUMATREX 2.5 MG TABLET
methotrexate sodium
3
TABLOID 40 MG TABLET
thioguanine
4
PA
Antineoplastics, Other
calcium folinate 10 mg/ml vial
2
flutamide 125 mg capsule
4
HEXALEN 50 MG CAPSULE
altretamine
4
imiquimod 5% cream packet
4
PA
QL
1 / 1 days
PA
INTRON A 10 MILLION UNIT/ML
interferon alfa-2b,recomb.
PAGE 52
PA
4
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
INTRON A 10 MILLION UNITS VIAL
4
4
4
INTRON A 6 MILLION UNIT/ML VL
4
leucovorin calcium 10 mg tab
2
leucovorin calcium 100 mg vial
2
2
2
2
2
2
leucovorin calcium 500 mg vl
2
ZYCLARA 2.5% CREAM PUMP
imiquimod
5
PA
ZYCLARA 3.75% CREAM
imiquimod
5
PA
imiquimod
5
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
Aromatase Inhibitors, 3rd Generation
anastrozole 1 mg tablet
2
exemestane 25 mg tablet
4
letrozole 2.5 mg tablet
2
PA
Enzyme Inhibitors
GILOTRIF 20 MG TABLET
afatinib dimaleate
4
PA
afatinib dimaleate
4
PA
afatinib dimaleate
4
PA
PAGE 53
PRODUCT DESCRIPTION
TIER
PA
JAKAFI 10 MG TABLET
ruxolitinib phosphate
4
JAKAFI 15 MG TABLET
4
JAKAFI 20 MG TABLET
4
JAKAFI 25 MG TABLET
4
JAKAFI 5 MG TABLET
4
MEKINIST 0.5 MG TABLET
trametinib dimethyl sulfoxide
4
MEKINIST 2 MG TABLET
trametinib dimethyl sulfoxide
4
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
VOTRIENT 200 MG TABLET
pazopanib hcl
ZYTIGA 250 MG TABLET
abiraterone acetate
4
C
Partial Fill (PF)
S
Specialty Drug
PA
4
S
Specialty Drug
Molecular Target Inhibitors
PA
AFINITOR 10 MG TABLET
everolimus
4
C
Partial Fill (PF)
S
Specialty Drug
PA
AFINITOR 2.5 MG TABLET
everolimus
4
C
Partial Fill (PF)
S
Specialty Drug
PA
AFINITOR 5 MG TABLET
everolimus
PAGE 54
4
C
Partial Fill (PF)
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
AFINITOR DISPERZ 2 MG TABLET
everolimus
4
C
Partial Fill (PF)
S
Specialty Drug
PA
everolimus
4
C
Partial Fill (PF)
S
Specialty Drug
PA
everolimus
4
C
Partial Fill (PF)
S
Specialty Drug
CAPRELSA 100 MG TABLET
vandetanib
4
PA
CAPRELSA 300 MG TABLET
vandetanib
4
PA
COMETRIQ 100 MG DAILY-DOSE PK
cabozantinib s-malate
4
PA
COMETRIQ 140 MG DAILY-DOSE PK
4
PA
COMETRIQ 60 MG DAILY-DOSE PACK
4
PA
ERIVEDGE 150 MG CAPSULE
vismodegib
4
GLEEVEC 100 MG TABLET
imatinib mesylate
4
GLEEVEC 400 MG TABLET
imatinib mesylate
4
ICLUSIG 15 MG TABLET
ponatinib hcl
4
ICLUSIG 45 MG TABLET
ponatinib hcl
4
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
NEXAVAR 200 MG TABLET
sorafenib tosylate
PAGE 55
4
C
Partial Fill (PF)
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
SPRYCEL 140 MG TABLET
dasatinib
4
C
Partial Fill (PF)
S
Specialty Drug
PA
dasatinib
4
C
Partial Fill (PF)
S
Specialty Drug
PA
dasatinib
4
C
Partial Fill (PF)
S
Specialty Drug
PA
dasatinib
4
C
Partial Fill (PF)
S
Specialty Drug
PA
dasatinib
STIVARGA 40 MG TABLET
regorafenib
4
C
Partial Fill (PF)
S
Specialty Drug
PA
4
S
Specialty Drug
PA
SUTENT 12.5 MG CAPSULE
sunitinib malate
4
C
Partial Fill (PF)
S
Specialty Drug
PA
SUTENT 25 MG CAPSULE
sunitinib malate
4
C
Partial Fill (PF)
S
Specialty Drug
PA
SUTENT 50 MG CAPSULE
sunitinib malate
4
C
Partial Fill (PF)
S
Specialty Drug
PA
TARCEVA 100 MG TABLET
erlotinib hcl
4
C
Partial Fill (PF)
S
Specialty Drug
PA
erlotinib hcl
PAGE 56
4
C
Partial Fill (PF)
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
erlotinib hcl
TASIGNA 150 MG CAPSULE
nilotinib hcl
4
C
Partial Fill (PF)
S
Specialty Drug
C
Partial Fill (PF)
S
Specialty Drug
4
PA
TASIGNA 200 MG CAPSULE
nilotinib hcl
4
C
Partial Fill (PF)
S
Specialty Drug
PA
TYKERB 250 MG TABLET
lapatinib ditosylate
4
XALKORI 200 MG CAPSULE
crizotinib
4
XALKORI 250 MG CAPSULE
crizotinib
4
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
ZOLINZA 100 MG CAPSULE
vorinostat
4
C
Partial Fill (PF)
S
Specialty Drug
Retinoids
PANRETIN 0.1% GEL
alitretinoin
4
PA
PA
TARGRETIN 1% GEL
bexarotene
4
C
Partial Fill (PF)
S
Specialty Drug
PA
TARGRETIN 75 MG CAPSULE
bexarotene
4
C
Partial Fill (PF)
S
Specialty Drug
PA
tretinoin 10 mg capsule
4
S
PAGE 57
Specialty Drug
PRODUCT DESCRIPTION
TIER
Antiparasitics
Anthelmintics
ALBENZA 200 MG TABLET
albendazole
3
BILTRICIDE 600 MG TABLET
praziquantel
3
STROMECTOL 3 MG TABLET
ivermectin
3
Antiprotozoals
ALINIA 100 MG/5 ML SUSPENSION
nitazoxanide
3
ALINIA 500 MG TABLET
nitazoxanide
3
atovaquone-proguanil 250-100
2
atovaquone-proguanil 62.5-25
2
chloroquine ph 250 mg tablet
2
chloroquine ph 500 mg tablet
2
2
1
hydroxychloroquine 200 mg tab
2
mefloquine hcl 250 mg tablet
2
MEPRON 750 MG/5 ML SUSPENSION
atovaquone
5
PA
NEBUPENT 300 MG INHAL POWDER
pentamidine isethionate
5
PA
PENTAM 300 VIAL
pentamidine isethionate
5
PA
primaquine 26.3 mg tablet
2
Pediculicides/Scabicides
EURAX 10% CREAM
crotamiton
3
EURAX 10% LOTION
crotamiton
3
lindane 1% lotion
2
lindane 1% shampoo
2
PAGE 58
PRODUCT DESCRIPTION
TIER
malathion 0.5% lotion
2
permethrin 5% cream
2
SKLICE 0.5% LOTION
ivermectin
5
PA
ULESFIA 5% LOTION
benzyl alcohol
5
PA
Antiparkinson Agents
Anticholinergics
benztropine mes 0.5 mg tab
2
benztropine mes 1 mg tablet
2
benztropine mes 2 mg tablet
2
trihexyphenidyl 2 mg tablet
2
trihexyphenidyl 2 mg/5 ml elx
2
trihexyphenidyl 5 mg tablet
2
Antiparkinson Agents, Other
amantadine 100 mg capsule
2
amantadine 100 mg/10 ml soln
2
amantadine 50 mg/5 ml solution
2
entacapone 200 mg tablet
2
TASMAR 100 MG TABLET
tolcapone
3
Dopamine Agonists
PA
APOKYN 30 MG/3 ML CARTRIDGE
apomorphine hcl
4
bromocriptine 2.5 mg tablet
2
bromocriptine 5 mg capsule
2
pramipexole 0.125 mg tablet
2
2
2
2
pramipexole 1 mg tablet
2
PAGE 59
C
QL-90
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
2
ropinirole hcl 0.25 mg tablet
2
ropinirole hcl 0.5 mg tablet
2
ropinirole hcl 1 mg tablet
2
2
2
2
2
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors
carbidopa 25 mg tablet
5
carbidopa-levo 10-100 mg odt
2
2
2
carbidopa-levo er 25-100 tab
2
carbidopa-levo er 50-200 tab
2
carbidopa-levodopa 10-100 tab
2
2
2
PA
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT 0.5 MG TABLET
rasagiline mesylate
5
PA
AZILECT 1 MG TABLET
rasagiline mesylate
5
PA
selegiline hcl 5 mg capsule
2
selegiline hcl 5 mg tablet
2
ZELAPAR 1.25 MG ODT TABLET
selegiline hcl
5
PA
Antipsychotics
1st Generation/Typical
2
2
2
PAGE 60
PRODUCT DESCRIPTION
TIER
2
2
fluphenazine 1 mg tablet
2
2
fluphenazine 2.5 mg tablet
2
fluphenazine 2.5 mg/5 ml elix
2
fluphenazine 2.5 mg/ml vial
2
2
fluphenazine 5 mg/ml conc
2
fluphenazine dec 125 mg/5 ml
2
fluphenazine dec 25 mg/ml vial
2
haloperidol 0.5 mg tablet
2
haloperidol 1 mg tablet
2
1
1
2
2
haloperidol lac 2 mg/ml conc
2
loxapine 10 mg capsule
2
2
2
2
ORAP 1 MG TABLET
pimozide
3
ORAP 2 MG TABLET
pimozide
3
2
2
2
2
prochlorperazine 10 mg tab
2
prochlorperazine 10 mg/2 ml vl
2
PAGE 61
PRODUCT DESCRIPTION
TIER
prochlorperazine 5 mg tablet
2
prochlorperazine 5 mg/ml vial
2
thioridazine 10 mg tablet
2
2
2
2
thiothixene 1 mg capsule
2
2
2
2
trifluoperazine 1 mg tablet
2
2
2
2
2nd Generation/Atypical
FANAPT 1 MG TABLET
iloperidone
3
PA
FANAPT 10 MG TABLET
iloperidone
3
PA
FANAPT 12 MG TABLET
iloperidone
3
PA
FANAPT 2 MG TABLET
iloperidone
3
PA
FANAPT 4 MG TABLET
iloperidone
3
PA
FANAPT 6 MG TABLET
iloperidone
3
PA
FANAPT 8 MG TABLET
iloperidone
3
PA
INVEGA ER 1.5 MG TABLET
paliperidone
3
PA
INVEGA ER 3 MG TABLET
paliperidone
3
PA
paliperidone
3
PA
PAGE 62
PRODUCT DESCRIPTION
paliperidone
TIER
3
PA
QL
LATUDA 120 MG TABLET
lurasidone hcl
3
PA
C
QL
LATUDA 20 MG TABLET
lurasidone hcl
3
QL
3
QL
3
1 / 1 days
Tablet Split (TS)
1 / 1 days
PA
C
LATUDA 80 MG TABLET
lurasidone hcl
Tablet Split (TS)
PA
C
LATUDA 40 MG TABLET
lurasidone hcl
1 / 1 days
Tablet Split (TS)
1 / 1 days
PA
C
Tablet Split (TS)
olanzapine 10 mg tablet
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
olanzapine 2.5 mg tablet
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
olanzapine odt 10 mg tablet
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
quetiapine fumarate 100 mg tab
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
PAGE 63
PRODUCT DESCRIPTION
TIER
2
C
Tablet Split (TS)
risperidone 0.25 mg tablet
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
risperidone 1 mg tablet
2
C
Tablet Split (TS)
risperidone 1 mg/ml solution
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
SAPHRIS 10 MG TAB SL BLK CHERY
asenapine maleate
3
PA
SAPHRIS 5 MG TAB SL BLK CHERRY
asenapine maleate
3
PA
quetiapine fumarate
5
PA
quetiapine fumarate
5
PA
quetiapine fumarate
5
PA
quetiapine fumarate
5
PA
quetiapine fumarate
5
PA
2
2
2
2
Treatment-Resistant
clozapine 100 mg tablet
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
PAGE 64
PRODUCT DESCRIPTION
TIER
Antispasticity Agents
baclofen 10 mg tablet
1
baclofen 20 mg tablet
1
COMFORT PAC-TIZANIDINE KIT
tizanidine hcl/irritants counter-irritants combination no.2
2
dantrolene sodium 100 mg cap
2
2
2
MYRBETRIQ ER 25 MG TABLET
mirabegron
5
PA
MYRBETRIQ ER 50 MG TABLET
mirabegron
5
PA
tizanidine hcl 2 mg capsule
2
C
Tablet Split (TS)
tizanidine hcl 2 mg tablet
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
tizanidine hcl 4 mg tablet
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
C
Tablet Split (TS)
Antivirals
Anti-cytomegalovirus (CMV) Agents
PA
VALCYTE 450 MG TABLET
valganciclovir hcl
5
VALCYTE 50 MG/ML SOLUTION
valganciclovir hcl
5
ZIRGAN 0.15% OPHTHALMIC GEL
ganciclovir
3
S
Specialty Drug
PA
S
Specialty Drug
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors
EDURANT 25 MG TABLET
rilpivirine hcl
4
INTELENCE 100 MG TABLET
etravirine
4
etravirine
4
etravirine
4
PAGE 65
PRODUCT DESCRIPTION
TIER
nevirapine 200 mg tablet
4
RESCRIPTOR 100 MG TABLET
delavirdine mesylate
4
RESCRIPTOR 200 MG TABLET
delavirdine mesylate
4
SUSTIVA 200 MG CAPSULE
efavirenz
4
SUSTIVA 50 MG CAPSULE
efavirenz
4
SUSTIVA 600 MG TABLET
efavirenz
4
VIRAMUNE XR 400 MG TABLET
nevirapine
4
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors
abacavir 300 mg tablet
4
abacavir-lamivudine-zidov tab
4
didanosine dr 125 mg capsule
2
2
2
2
EMTRIVA 10 MG/ML SOLUTION
emtricitabine
4
EMTRIVA 200 MG CAPSULE
emtricitabine
4
EPIVIR 10 MG/ML ORAL SOLN
lamivudine
4
EPZICOM TABLET
abacavir sulfate/lamivudine
4
lamivudine 150 mg tablet
S
Specialty Drug
2
S
Specialty Drug
lamivudine 300 mg tablet
2
S
Specialty Drug
lamivudine-zidovudine tablet
4
stavudine 1 mg/ml solution
4
stavudine 15 mg capsule
2
2
2
PAGE 66
PA
PRODUCT DESCRIPTION
TIER
2
TRUVADA 200 MG-300 MG TABLET
emtricitabine/tenofovir disoproxil fumarate
4
VIDEX 2 GM PEDIATRIC SOLN
didanosine
4
VIDEX 4 GM PEDIATRIC SOLN
didanosine
4
VIREAD 150 MG TABLET
tenofovir disoproxil fumarate
4
4
4
4
VIREAD POWDER
4
ZIAGEN 20 MG/ML SOLUTION
abacavir sulfate
4
zidovudine 100 mg capsule
2
zidovudine 300 mg tablet
2
zidovudine 50 mg/5 ml syrup
4
PA
Anti-HIV Agents, Other
FUZEON 90 MG VIAL
enfuvirtide
4
ISENTRESS 100 MG TABLET CHEW
raltegravir potassium
4
ISENTRESS 25 MG TABLET CHEW
4
ISENTRESS 400 MG TABLET
4
SELZENTRY 150 MG TABLET
maraviroc
4
SELZENTRY 300 MG TABLET
maraviroc
4
STRIBILD TABLET
elvitegravir/cobicistat/emtricitabine/tenofovir
4
PAGE 67
PRODUCT DESCRIPTION
TIER
Anti-HIV Agents, Protease Inhibitors
APTIVUS 100 MG/ML SOLUTION
tipranavir/vitamin e tpgs
4
APTIVUS 250 MG CAPSULE
tipranavir
4
CRIXIVAN 200 MG CAPSULE
indinavir sulfate
4
CRIXIVAN 400 MG CAPSULE
indinavir sulfate
4
INVIRASE 200 MG CAPSULE
saquinavir mesylate
4
INVIRASE 500 MG TABLET
saquinavir mesylate
4
KALETRA 100-25 MG TABLET
lopinavir/ritonavir
4
KALETRA 200-50 MG TABLET
lopinavir/ritonavir
4
KALETRA 400-100/5 ML ORAL SOLU
lopinavir/ritonavir
4
LEXIVA 700 MG TABLET
fosamprenavir calcium
4
NORVIR 100 MG SOFTGEL CAP
ritonavir
4
NORVIR 100 MG TABLET
ritonavir
4
PREZISTA 150 MG TABLET
darunavir ethanolate
4
4
4
4
REYATAZ 150 MG CAPSULE
atazanavir sulfate
4
atazanavir sulfate
4
atazanavir sulfate
4
PAGE 68
PRODUCT DESCRIPTION
TIER
VIRACEPT 250 MG TABLET
nelfinavir mesylate
4
VIRACEPT 625 MG TABLET
nelfinavir mesylate
4
Anti-influenza Agents
amantadine 100 mg capsule
2
amantadine 100 mg/10 ml soln
2
amantadine 50 mg/5 ml solution
2
RELENZA 5 MG DISKHALER
zanamivir
3
rimantadine hcl 100 mg tablet
2
TAMIFLU 30 MG CAPSULE
oseltamivir phosphate
QL
1 / 1 days
3
QL
1 / 1 days
3
QL
1 / 1 days
TAMIFLU 6 MG/ML SUSPENSION
3
QL
1 / 1 days
3
QL
1 / 1 days
BARACLUDE 0.05 MG/ML SOLUTION
entecavir
4
PA
entecavir 0.5 mg tablet
4
PA
entecavir 1 mg tablet
4
PA
EPIVIR HBV 100 MG TABLET
lamivudine
4
S
Specialty Drug
EPIVIR HBV 25 MG/5 ML SOLN
lamivudine
4
S
Specialty Drug
HEPSERA 10 MG TABLET
adefovir dipivoxil
5
PA
INTRON A 10 MILLION UNIT/ML
4
4
4
Antihepatitis Agents
PAGE 69
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
4
INTRON A 6 MILLION UNIT/ML VL
4
PEGASYS 180 MCG/0.5 ML SYRINGE
peginterferon alfa-2a
5
PEGINTRON 120 MCG KIT
peginterferon alfa-2b
3
3
3
3
PEGINTRON REDIPEN 120 MCG
3
PEGINTRON REDIPEN 120 MCG 4PK
3
3
PEGINTRON REDIPEN 150 MCG 4PK
3
3
3
ribasphere 400 mg tablet
4
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
ribasphere 600 mg tablet
4
S
PA
RIBASPHERE RIBAPAK 200-400 MG
ribavirin
3
ribavirin
4
ribavirin
3
PAGE 70
Specialty Drug
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
ribavirin
4
RIBATAB 400-400 MG DOSEPACK
ribavirin
4
ribavirin
4
ribavirin
4
ribavirin 200 mg capsule
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
2
S
Specialty Drug
ribavirin 200 mg tablet
2
S
Specialty Drug
TYZEKA 600 MG TABLET
telbivudine
4
4
4
4
4
VIREAD POWDER
4
PA
S
Specialty Drug
Antiherpetic Agents
acyclovir 200 mg capsule
1
acyclovir 200 mg/5 ml susp
2
acyclovir 400 mg tablet
1
acyclovir 800 mg tablet
1
DENAVIR 1% CREAM
penciclovir
5
famciclovir 125 mg tablet
2
2
2
trifluridine 1% eye drops
2
PAGE 71
PA
QL
1 / 1 days
PRODUCT DESCRIPTION
TIER
valacyclovir hcl 1 gram tablet
2
C
Tablet Split (TS)
valacyclovir hcl 500 mg tablet
2
C
Tablet Split (TS)
buspirone hcl 10 mg tablet
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
buspirone hcl 7.5 mg tablet
1
C
Tablet Split (TS)
2
2
2
2
2
2
2
2
2
2
2
2
2
meprobamate 200 mg tablet
2
meprobamate 400 mg tablet
2
Anxiolytics
Anxiolytics, Other
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitors)
2
1
QL
1 / 1 days
QL
1 / 1 days
C
QL
1
C
PAGE 72
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
PRODUCT DESCRIPTION
TIER
QL
1
1 / 1 days
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
sertraline 20 mg/ml oral conc
1
PA
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
QL
1 / 1 days
1
QL
1 / 1 days
venlafaxine hcl 37.5 mg tablet
1
QL
1 / 1 days
1
QL
1 / 1 days
1
QL
1 / 1 days
1
QL
1 / 1 days
VENLAFAXINE HCL ER 225 MG TAB
venlafaxine hcl
QL
1 / 1 days
5
venlafaxine hcl er 37.5 mg cap
1
QL
1 / 1 days
1
QL
1 / 1 days
PA
Bipolar Agents
Bipolar Agents, Other
2
2
2
2
2
PAGE 73
PRODUCT DESCRIPTION
TIER
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
risperidone 1 mg/ml solution
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
SAPHRIS 10 MG TAB SL BLK CHERY
asenapine maleate
3
PA
SAPHRIS 5 MG TAB SL BLK CHERRY
asenapine maleate
3
PA
quetiapine fumarate
5
PA
PAGE 74
PRODUCT DESCRIPTION
TIER
quetiapine fumarate
5
PA
quetiapine fumarate
5
PA
quetiapine fumarate
5
PA
quetiapine fumarate
5
PA
2
2
2
2
Mood Stabilizers
carbamazepine 100 mg tab chew
2
carbamazepine 100 mg/5 ml susp
2
carbamazepine 200 mg tablet
2
2
2
2
2
2
2
2
2
2
2
2
2
2
epitol 200 mg tablet
5
LAMICTAL TAB START KIT (GREEN)
lamotrigine
3
LAMICTAL TB START KIT (ORANGE)
lamotrigine
3
PAGE 75
PA
PRODUCT DESCRIPTION
TIER
QL
1
C
QL
1
C
QL
1
C
QL
lamotrigine 25 mg disper tab
2
C
QL
1
C
QL
lamotrigine 25 mg tb start kit
2
C
QL
lamotrigine 5 mg disper tablet
2
C
lithium carbonate 150 mg cap
2
lithium carbonate 300 mg cap
1
lithium carbonate 300 mg tab
1
lithium carbonate er 300 mg tb
2
lithium carbonate er 450 mg tb
2
TEGRETOL XR 100 MG TABLET
carbamazepine
5
2
2
2
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
PA
Blood Glucose Regulators
Antidiabetic Agents
acarbose 100 mg tablet
2
2
2
AVANDIA 2 MG TABLET
rosiglitazone maleate
3
PAGE 76
PRODUCT DESCRIPTION
TIER
AVANDIA 4 MG TABLET
3
AVANDIA 8 MG TABLET
3
BYDUREON 2 MG VIAL
exenatide microspheres
5
BYETTA 10 MCG DOSE PEN INJ
exenatide
5
BYETTA 5 MCG DOSE PEN INJ
exenatide
5
chlorpropamide 100 mg tablet
2
chlorpropamide 250 mg tablet
2
glimepiride 1 mg tablet
1
1
1
glipizide 10 mg tablet
1
glipizide 5 mg tablet
1
glipizide er 10 mg tablet
1
QL
1 / 1 days
glipizide er 2.5 mg tablet
1
QL
1 / 1 days
glipizide er 5 mg tablet
1
QL
1 / 1 days
glipizide xl 10 mg tablet
1
QL
1 / 1 days
glipizide xl 2.5 mg tablet
1
QL
1 / 1 days
glipizide xl 5 mg tablet
1
QL
1 / 1 days
glyburide 1.25 mg tablet
1
glyburide 2.5 mg tablet
1
glyburide 5 mg tablet
1
glyburide micro 1.5 mg tab
1
glyburide micro 3 mg tablet
1
glyburide micro 6 mg tablet
1
GLYSET 100 MG TABLET
miglitol
3
PAGE 77
PA
ST
PA
ST
PA
ST
PRODUCT DESCRIPTION
TIER
GLYSET 25 MG TABLET
miglitol
3
GLYSET 50 MG TABLET
miglitol
3
INVOKANA 100 MG TABLET
canagliflozin
5
PA
INVOKANA 300 MG TABLET
canagliflozin
5
PA
QL
JANUVIA 100 MG TABLET
sitagliptin phosphate
5
1 / 1 days
PA
ST
QL
5
1 / 1 days
PA
ST
QL
5
1 / 1 days
PA
ST
metformin hcl 1,000 mg tablet
1
metformin hcl 500 mg tablet
1
metformin hcl 850 mg tablet
1
metformin hcl er 500 mg osm-tb
1
metformin hcl er 500 mg tablet
1
metformin hcl er 750 mg tablet
1
nateglinide 120 mg tablet
2
nateglinide 60 mg tablet
2
NESINA 12.5 MG TABLET
alogliptin benzoate
3
NESINA 25 MG TABLET
alogliptin benzoate
3
NESINA 6.25 MG TABLET
alogliptin benzoate
3
ONGLYZA 2.5 MG TABLET
saxagliptin hcl
5
ONGLYZA 5 MG TABLET
saxagliptin hcl
5
PAGE 78
PA
ST
PA
ST
PRODUCT DESCRIPTION
TIER
pioglitazone hcl 15 mg tablet
2
2
2
repaglinide 0.5 mg tablet
5
PA
repaglinide 1 mg tablet
5
PA
tolazamide 250 mg tablet
2
tolazamide 500 mg tablet
2
tolbutamide 500 mg tablet
2
QL
TRADJENTA 5 MG TABLET
linagliptin
5
1 / 1 days
PA
ST
VICTOZA 2-PAK 18 MG/3 ML PEN
liraglutide
3
VICTOZA 3-PAK 18 MG/3 ML PEN
liraglutide
3
WELCHOL 625 MG TABLET
colesevelam hcl
3
Glycemic Agents
GLUCAGON 1 MG EMERGENCY KIT
glucagon,human recombinant
3
PROGLYCEM 50 MG/ML ORAL SUSP
diazoxide
5
PA
Insulins
PA
APIDRA 100 UNITS/ML VIAL
insulin glulisine
5
HUMALOG 100 UNITS/ML VIAL
insulin lispro
3
QL
1 / 1 days
HUMALOG MIX 50-50 KWIKPEN
insulin lispro protamine & insulin lispro
3
QL
1 / 1 days
HUMALOG MIX 50-50 VIAL
3
QL
1 / 1 days
3
QL
1 / 1 days
HUMALOG MIX 75-25 VIAL
3
QL
1 / 1 days
PAGE 79
ST
PRODUCT DESCRIPTION
TIER
HUMULIN R 500 UNITS/ML VIAL
insulin regular, human
3
QL
1 / 1 days
LANTUS 100 UNITS/ML VIAL
insulin glargine,human recombinant analog
3
QL
1 / 1 days
LANTUS SOLOSTAR 100 UNITS/ML
insulin glargine,human recombinant analog
3
QL
1 / 1 days
LEVEMIR 100 UNITS/ML VIAL
insulin detemir
3
QL
1 / 1 days
LEVEMIR FLEXTOUCH 100 UNITS/ML
insulin detemir
3
QL
1 / 1 days
NOVOLOG 100 UNIT/ML VIAL
insulin aspart
QL
1 / 1 days
5
NOVOLOG MIX 70-30 FLEXPEN SYRN
insulin aspart protamine human/insulin aspart
5
NOVOLOG MIX 70-30 VIAL
insulin aspart protamine human/insulin aspart
5
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
Blood Products/Modifiers/ Volume Expanders
Anticoagulants
ELIQUIS 2.5 MG TABLET
apixaban
3
ELIQUIS 5 MG TABLET
apixaban
3
QL
enoxaparin 100 mg/ml syringe
4
PA
S
QL
enoxaparin 120 mg/0.8 ml syr
4
QL
4
QL
4
Specialty Drug
1 / 1 days
Specialty Drug
1 / 1 days
PA
S
PAGE 80
1 / 1 days
PA
S
Specialty Drug
PA
S
enoxaparin 150 mg/ml syringe
1 / 1 days
Specialty Drug
PRODUCT DESCRIPTION
TIER
QL
enoxaparin 300 mg/3 ml vial
4
PA
S
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
Specialty Drug
1 / 1 days
Specialty Drug
1 / 1 days
Specialty Drug
1 / 1 days
Specialty Drug
1 / 1 days
Specialty Drug
1 / 1 days
PA
S
PAGE 81
1 / 1 days
PA
S
FRAGMIN 12,500 UNITS/0.5 ML
dalteparin sodium,porcine
Specialty Drug
PA
S
FRAGMIN 10,000 UNITS/ML SYRING
1 / 1 days
PA
S
fondaparinux 7.5 mg/0.6 ml syr
Specialty Drug
PA
S
fondaparinux 5 mg/0.4 ml syr
1 / 1 days
PA
S
fondaparinux 2.5 mg/0.5 ml syr
Specialty Drug
PA
S
fondaparinux 10 mg/0.8 ml syr
1 / 1 days
PA
S
Specialty Drug
PA
S
1 / 1 days
Specialty Drug
PRODUCT DESCRIPTION
TIER
QL
FRAGMIN 18,000 UNITS/0.72 ML
4
PA
S
QL
FRAGMIN 2,500 UNITS/0.2 ML SYR
4
QL
4
QL
4
Specialty Drug
1 / 1 days
Specialty Drug
1 / 1 days
PA
S
heparin 10,000 unit/10 ml vial
5
PA
5
PA
5
PA
heparin 40,000 units/4 ml vial
5
PA
5
PA
heparin 50,000 units/10 ml vl
5
PA
heparin 50,000 units/5 ml vial
5
PA
heparin sod 1,000 unit/ml vial
5
PA
heparin sod 10,000 unit/ml vl
5
PA
heparin sod 20,000 unit/ml vl
5
PA
heparin sod 5,000 unit/ 0.5 ml
5
PA
heparin sod 5,000 unit/ml syr
5
PA
heparin sod 5,000 unit/ml vial
5
PA
jantoven 1 mg tablet
3
3
3
jantoven 2.5 mg tablet
3
PAGE 82
1 / 1 days
PA
S
Specialty Drug
PA
S
1 / 1 days
Specialty Drug
PRODUCT DESCRIPTION
TIER
3
3
3
3
jantoven 7.5 mg tablet
3
LOVENOX 100 MG/ML SYRINGE
enoxaparin sodium
5
LOVENOX 120 MG/0.8 ML SYRINGE
enoxaparin sodium
5
LOVENOX 150 MG/ML SYRINGE
enoxaparin sodium
5
enoxaparin sodium
5
enoxaparin sodium
5
enoxaparin sodium
5
PA
S
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
QL
PRADAXA 150 MG CAPSULE
dabigatran etexilate mesylate
Specialty Drug
5
Specialty Drug
1 / 1 days
PA
ST
QL
PRADAXA 75 MG CAPSULE
dabigatran etexilate mesylate
5
1 / 1 days
PA
ST
warfarin sodium 1 mg tablet
1
1
1
warfarin sodium 2.5 mg tablet
1
1
1
1
1
PAGE 83
PRODUCT DESCRIPTION
TIER
warfarin sodium 7.5 mg tablet
1
XARELTO 10 MG TABLET
rivaroxaban
3
rivaroxaban
3
rivaroxaban
3
Blood Formation Modifiers
anagrelide hcl 0.5 mg capsule
2
anagrelide hcl 1 mg capsule
2
QL
ARANESP 100 MCG/0.5 ML SYRINGE
darbepoetin alfa in polysorbate 80
PA
4
C
QL-4
S
Specialty Drug
QL
ARANESP 100 MCG/ML VIAL
C
QL-4
S
Specialty Drug
C
QL-4
S
Specialty Drug
C
QL-4
S
Specialty Drug
PAGE 84
1 / 1 days
PA
4
C
QL-4
S
Specialty Drug
QL
1 / 1 days
PA
4
QL
ARANESP 25 MCG/0.42 ML SYRING
1 / 1 days
PA
4
QL
1 / 1 days
PA
4
QL
1 / 1 days
1 / 1 days
PA
4
C
QL-4
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
QL
PA
4
C
QL-4
S
Specialty Drug
QL
C
QL-4
S
Specialty Drug
C
QL-4
S
Specialty Drug
C
QL-4
S
Specialty Drug
C
QL-4
S
Specialty Drug
C
QL-4
S
Specialty Drug
C
QL-4
S
Specialty Drug
4
1 / 1 days
PA
S
PAGE 85
1 / 1 days
PA
4
QL
EPOGEN 10,000 UNITS/ML VIAL
epoetin alfa
1 / 1 days
PA
4
QL
1 / 1 days
PA
4
QL
1 / 1 days
PA
4
QL
ARANESP 500 MCG/1 ML SYRINGE
1 / 1 days
PA
4
QL
1 / 1 days
PA
4
QL
1 / 1 days
Specialty Drug
PRODUCT DESCRIPTION
TIER
QL
EPOGEN 20,000 UNITS/2 ML VIAL
epoetin alfa
4
PA
S
QL
epoetin alfa
4
QL
4
QL
4
5
4
QL
1 / 1 days
Specialty Drug
1 / 1 days
QL-4
S
Specialty Drug
1 / 1 days
PA
4
C
QL-4
S
Specialty Drug
4
1 / 1 days
PA
S
Specialty Drug
PA
PROMACTA 12.5 MG TABLET
eltrombopag olamine
4
PROMACTA 25 MG TABLET
eltrombopag olamine
4
PAGE 86
Specialty Drug
C
QL
PROCRIT 40,000 UNITS/ML VIAL
epoetin alfa
1 / 1 days
PA
4
QL
NEUPOGEN 480 MCG/0.8 ML SYR
filgrastim
Specialty Drug
PA
S
NEUPOGEN 300 MCG/0.5 ML SYR
filgrastim
1 / 1 days
PA
QL
NEULASTA 6 MG/0.6 ML SYRINGE
pegfilgrastim
Specialty Drug
PA
S
LEUKINE 250 MCG VIAL
sargramostim
1 / 1 days
PA
S
epoetin alfa
Specialty Drug
PA
S
epoetin alfa
1 / 1 days
S
Specialty Drug
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
eltrombopag olamine
4
eltrombopag olamine
4
S
Specialty Drug
PA
S
Specialty Drug
Coagulants
CYKLOKAPRON 100 MG/ML AMPUL
tranexamic acid
4
Platelet Modifying Agents
PA
AGGRENOX 25 MG-200 MG CAPSULE
aspirin/dipyridamole
5
anagrelide hcl 0.5 mg capsule
2
anagrelide hcl 1 mg capsule
2
BRILINTA 90 MG TABLET
ticagrelor
5
cilostazol 100 mg tablet
1
cilostazol 50 mg tablet
1
clopidogrel 300 mg tablet
1
clopidogrel 75 mg tablet
1
dipyridamole 25 mg tablet
2
2
2
EFFIENT 10 MG TABLET
prasugrel hcl
3
QL
1 / 1 days
EFFIENT 5 MG TABLET
prasugrel hcl
3
QL
1 / 1 days
ticlopidine 250 mg tablet
2
ST
PA
ST
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine hcl 0.1 mg tablet
1
1
1
guanfacine 1 mg tablet
1
PAGE 87
PRODUCT DESCRIPTION
TIER
guanfacine 2 mg tablet
1
methyldopa 250 mg tablet
1
methyldopa 500 mg tablet
1
midodrine hcl 2.5 mg tablet
2
midodrine hcl 5 mg tablet
2
Alpha-adrenergic Blocking Agents
DIBENZYLINE 10 MG CAPSULE
phenoxybenzamine hcl
4
doxazosin mesylate 1 mg tab
2
2
2
2
prazosin 1 mg capsule
2
2
2
terazosin 1 mg capsule
1
2
1
1
PA
Angiotensin II Receptor Antagonists
PA
BENICAR 20 MG TABLET
olmesartan medoxomil
5
BENICAR 40 MG TABLET
olmesartan medoxomil
5
candesartan cilexetil 16 mg tb
5
ST
PA
ST
PA
ST
PA
candesartan cilexetil 32 mg tb
5
ST
PA
candesartan cilexetil 4 mg tab
5
ST
PA
candesartan cilexetil 8 mg tab
5
ST
PAGE 88
PRODUCT DESCRIPTION
TIER
EDARBI 40 MG TABLET
azilsartan medoxomil
3
EDARBI 80 MG TABLET
azilsartan medoxomil
3
eprosartan mesylate 600 mg tab
5
PA
ST
irbesartan 150 mg tablet
1
1
1
losartan potassium 100 mg tab
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
telmisartan 20 mg tablet
5
PA
ST
PA
5
ST
PA
5
ST
valsartan 160 mg tablet
2
2
2
2
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl 10 mg tablet
1
1
1
1
captopril 100 mg tablet
2
captopril 12.5 mg tablet
2
2
2
PAGE 89
PRODUCT DESCRIPTION
TIER
enalapril maleate 10 mg tab
1
enalapril maleate 2.5 mg tab
1
enalapril maleate 20 mg tab
1
enalapril maleate 5 mg tablet
1
fosinopril sodium 10 mg tab
1
1
1
lisinopril 10 mg tablet
1
lisinopril 2.5 mg tablet
1
1
1
1
1
moexipril hcl 15 mg tablet
5
PA
ST
PA
moexipril hcl 7.5 mg tablet
5
ST
perindopril erbumine 2 mg tab
2
2
2
quinapril 10 mg tablet
1
QL
1 / 1 days
1
QL
1 / 1 days
1
QL
1 / 1 days
1
QL
1 / 1 days
ramipril 1.25 mg capsule
1
ramipril 10 mg capsule
1
ramipril 2.5 mg capsule
1
ramipril 5 mg capsule
1
trandolapril 1 mg tablet
1
1
PAGE 90
PRODUCT DESCRIPTION
TIER
1
Antiarrhythmics
amiodarone hcl 200 mg tablet
1
atropine 0.05 mg/ml syringe
2
atropine 0.1 mg/ml abboject
2
2
disopyramide 100 mg capsule
2
disopyramide 150 mg capsule
2
flecainide acetate 100 mg tab
2
2
2
glycopyrrolate 0.2 mg/ml vial
2
glycopyrrolate 0.4 mg/2 ml vl
2
glycopyrrolate 1 mg/5 ml vial
2
2
mexiletine 150 mg capsule
2
2
2
MULTAQ 400 MG TABLET
dronedarone hcl
3
NORPACE CR 100 MG CAPSULE
disopyramide phosphate
5
PA
NORPACE CR 150 MG CAPSULE
disopyramide phosphate
5
PA
procainamide 100 mg/ml vial
5
PA
procainamide 500 mg/ml vial
5
PA
propafenone hcl 150 mg tablet
2
propafenone hcl 225 mg tab
2
propafenone hcl 300 mg tab
2
quinidine gluc er 324 mg tab
2
quinidine sulf er 300 mg tab
2
quinidine sulfate 200 mg tab
2
PAGE 91
PRODUCT DESCRIPTION
TIER
sotalol 120 mg tablet
1
1
1
1
sotalol af 120 mg tablet
1
1
1
TIKOSYN 125 MCG CAPSULE
dofetilide
4
PA
dofetilide
4
PA
dofetilide
4
PA
verapamil 120 mg tablet
2
2
2
Beta-adrenergic Blocking Agents
acebutolol 200 mg capsule
1
acebutolol 400 mg capsule
1
atenolol 100 mg tablet
1
1
1
betaxolol 10 mg tablet
5
PA
betaxolol 20 mg tablet
5
PA
bisoprolol fumarate 10 mg tab
2
bisoprolol fumarate 5 mg tab
2
BYSTOLIC 10 MG TABLET
nebivolol hcl
3
BYSTOLIC 2.5 MG TABLET
nebivolol hcl
3
nebivolol hcl
3
nebivolol hcl
3
PAGE 92
PRODUCT DESCRIPTION
TIER
carvedilol 12.5 mg tablet
1
carvedilol 25 mg tablet
1
1
1
COREG CR 10 MG CAPSULE
carvedilol phosphate
3
QL
1 / 1 days
3
QL
1 / 1 days
3
QL
1 / 1 days
3
QL
1 / 1 days
INNOPRAN XL 120 MG CAPSULE
propranolol hcl
5
PA
INNOPRAN XL 80 MG CAPSULE
propranolol hcl
5
PA
labetalol hcl 100 mg tablet
2
2
2
metoprolol succ er 100 mg tab
2
2
2
2
metoprolol tartrate 100 mg tab
1
1
1
nadolol 20 mg tablet
5
PA
5
PA
5
PA
pindolol 10 mg tablet
2
pindolol 5 mg tablet
2
propranolol 10 mg tablet
1
1
PAGE 93
PRODUCT DESCRIPTION
TIER
propranolol 20 mg/5 ml soln
2
1
1
1
propranolol er 120 mg capsule
2
2
2
2
5
PA
5
PA
5
PA
Calcium Channel Blocking Agents
amlodipine besylate 10 mg tab
1
amlodipine besylate 2.5 mg tab
1
amlodipine besylate 5 mg tab
1
cartia xt 120 mg capsule
5
PA
5
PA
5
PA
5
PA
dilt xr 120 mg capsule
2
2
2
diltiazem 120 mg tablet
1
diltiazem 12hr er 120 mg cap
2
2
2
diltiazem 24hr cd 120 mg cap
2
2
2
2
PAGE 94
PRODUCT DESCRIPTION
TIER
2
2
2
2
2
1
1
1
diltiazem er 120 mg capsule
2
2
2
2
2
diltiazem hcl er 120 mg cap
2
2
2
2
2
2
felodipine er 10 mg tablet
2
felodipine er 2.5 mg tablet
2
felodipine er 5 mg tablet
2
isradipine 2.5 mg capsule
5
PA
isradipine 5 mg capsule
5
PA
nifedical xl 30 mg tablet
2
nifedical xl 60 mg tablet
2
nifedipine 10 mg capsule
2
nifedipine 20 mg capsule
2
nifedipine er 30 mg tablet
2
2
2
PAGE 95
PRODUCT DESCRIPTION
TIER
2
nimodipine 30 mg capsule
5
PA
nisoldipine er 20 mg tablet
5
PA
taztia xt 120 mg capsule
2
2
2
2
2
2
2
2
verapamil er 120 mg tablet
2
2
2
Cardiovascular Agents, Other
digoxin 0.25 mg tablet
2
digoxin 125 mcg tablet
2
digoxin 250 mcg tablet
2
digoxin 50 mcg/ml solution
2
pentoxifylline er 400 mg tab
1
RANEXA ER 1,000 MG TABLET
ranolazine
3
RANEXA ER 500 MG TABLET
ranolazine
3
TEKTURNA 150 MG TABLET
aliskiren hemifumarate
5
TEKTURNA 300 MG TABLET
aliskiren hemifumarate
5
QL
1 / 1 days
PA
QL
1 / 1 days
PA
Diuretics, Carbonic Anhydrase Inhibitors
2
2
PAGE 96
PRODUCT DESCRIPTION
TIER
acetazolamide er 500 mg cap
2
acetazolamide sod 500 mg vial
2
methazolamide 25 mg tablet
5
PA
5
PA
Diuretics, Loop
bumetanide 0.5 mg tablet
2
bumetanide 1 mg tablet
2
bumetanide 2 mg tablet
2
furosemide 10 mg/ml solution
2
furosemide 20 mg tablet
1
1
furosemide 40 mg/5 ml soln
2
1
SODIUM EDECRIN 50 MG VIAL
ethacrynate sodium
5
torsemide 10 mg tablet
2
2
2
2
PA
Diuretics, Potassium-sparing
amiloride hcl 5 mg tablet
2
DYRENIUM 100 MG CAPSULE
triamterene
3
DYRENIUM 50 MG CAPSULE
triamterene
3
eplerenone 25 mg tablet
5
PA
eplerenone 50 mg tablet
5
PA
spironolactone 100 mg tablet
1
1
1
PAGE 97
PRODUCT DESCRIPTION
TIER
Diuretics, Thiazide
chlorothiazide 250 mg tablet
1
chlorothiazide 500 mg tablet
1
chlorthalidone 25 mg tablet
2
chlorthalidone 50 mg tablet
2
hydrochlorothiazide 12.5 mg cp
1
hydrochlorothiazide 25 mg tab
1
hydrochlorothiazide 50 mg tab
1
indapamide 1.25 mg tablet
2
indapamide 2.5 mg tablet
2
methyclothiazide 5 mg tablet
5
metolazone 10 mg tablet
2
metolazone 2.5 mg tablet
2
metolazone 5 mg tablet
2
PA
Dyslipidemics, Fibric Acid Derivatives
fenofibrate 134 mg capsule
4
fenofibrate 145 mg tablet
5
QL
1 / 1 days
QL
1 / 1 days
PA
2
QL
1 / 1 days
4
QL
1 / 1 days
QL
1 / 1 days
5
PA
2
QL
1 / 1 days
4
QL
1 / 1 days
gemfibrozil 600 mg tablet
1
TRILIPIX DR 135 MG CAPSULE
fenofibric acid (choline)
QL
1 / 1 days
5
TRILIPIX DR 45 MG CAPSULE
fenofibric acid (choline)
5
PAGE 98
PA
QL
1 / 1 days
PA
PRODUCT DESCRIPTION
TIER
Dyslipidemics, HMG CoA Reductase Inhibitors
QL
atorvastatin 10 mg tablet
1
C
QL
1
C
QL
1
C
QL
1
C
QL
CRESTOR 10 MG TABLET
rosuvastatin calcium
3
3
3
CRESTOR 5 MG TABLET
3
fluvastatin sodium 20 mg cap
5
C
QL
C
QL
C
QL
C
QL
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
PA
QL
fluvastatin sodium 40 mg cap
1 / 1 days
5
PA
PA
LIVALO 1 MG TABLET
pitavastatin calcium
5
LIVALO 2 MG TABLET
5
LIVALO 4 MG TABLET
5
lovastatin 10 mg tablet
1
ST
PA
ST
PA
ST
QL
C
QL
1
C
PAGE 99
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
PRODUCT DESCRIPTION
TIER
QL
1
C
QL
pravastatin sodium 10 mg tab
2
C
QL
2
C
QL
2
C
QL
2
C
QL
simvastatin 10 mg tablet
1
C
QL
1
C
QL
1
C
QL
1
C
1
QL
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Dyslipidemics, Other
cholestyramine light packet
2
cholestyramine light powder
2
cholestyramine packet
2
cholestyramine powder
2
colestipol hcl 1 gm tablet
2
colestipol hcl granules
2
colestipol hcl granules packet
2
colestipol micronized 1 gm tab
2
niacin er 1,000 mg tablet
2
ST
niacin er 500 mg tablet
2
ST
PAGE 100
PRODUCT DESCRIPTION
TIER
niacin er 750 mg tablet
2
ST
niacor 500 mg tablet
2
ST
omega-3 ethyl esters 1 gm cap
3
PA
ST
WELCHOL 625 MG TABLET
colesevelam hcl
3
ZETIA 10 MG TABLET
ezetimibe
3
C
Tablet Split (TS)
Vasodilators, Direct-acting Arterial
hydralazine 10 mg tablet
1
1
1
1
minoxidil 10 mg tablet
2
minoxidil 2.5 mg tablet
2
Vasodilators, Direct-acting Arterial/Venous
DILATRATE-SR 40 MG CAPSULE
isosorbide dinitrate
3
isochron 40 mg tablet sa
2
ISORDIL 40 MG TABLET
isosorbide dinitrate
5
isosorbide dn 10 mg tablet
1
1
1
1
isosorbide mn 10 mg tablet
1
isosorbide mn 20 mg tablet
1
isosorbide mn er 120 mg tab
1
isosorbide mn er 30 mg tablet
1
isosorbide mn er 60 mg tablet
1
NITRO-BID 2% OINTMENT
nitroglycerin
3
NITRO-DUR 0.3 MG/HR PATCH
nitroglycerin
3
PAGE 101
PA
PRODUCT DESCRIPTION
TIER
NITRO-DUR 0.8 MG/HR PATCH
nitroglycerin
3
nitroglycerin 0.1 mg/hr patch
2
2
2
2
nitroglycerin 400 mcg spray
5
PA
nitroglycerin lingual 0.4 mg
5
PA
NITROSTAT 0.3 MG TABLET SL
nitroglycerin
3
nitroglycerin
3
nitroglycerin
3
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
ADDERALL XR 10 MG CAPSULE
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate
3
QL
1 / 1 days
3
QL
1 / 1 days
3
QL
1 / 1 days
3
QL
1 / 1 days
3
QL
1 / 1 days
3
QL
1 / 1 days
amphetamine salts 10 mg tablet
2
C
Tablet Split (TS)
amphetamine salts 12.5 mg tab
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
PAGE 102
PRODUCT DESCRIPTION
TIER
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
2
C
Tablet Split (TS)
amphetamine salts 7.5 mg tab
2
C
Tablet Split (TS)
d-amphetamine er 10 mg capsule
2
2
2
dextroamphetamine 10 mg tab
2
dextroamphetamine 5 mg tab
2
methamphetamine 5 mg tablet
2
VYVANSE 20 MG CAPSULE
lisdexamfetamine dimesylate
3
QL
1 / 1 days
3
QL
1 / 1 days
3
QL
1 / 1 days
3
QL
1 / 1 days
3
QL
1 / 1 days
3
QL
1 / 1 days
DAYTRANA 10 MG/9 HR PATCH
methylphenidate
3
QL
1 / 1 days
DAYTRANA 15 MG/9 HR PATCH
methylphenidate
3
QL
1 / 1 days
DAYTRANA 20 MG/9 HOUR PATCH
methylphenidate
3
QL
1 / 1 days
DAYTRANA 30 MG/9 HOUR PATCH
methylphenidate
3
QL
1 / 1 days
dexmethylphenidate 10 mg tab
2
QL
1 / 1 days
dexmethylphenidate 2.5 mg tab
2
QL
1 / 1 days
dexmethylphenidate 5 mg tab
2
QL
1 / 1 days
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
PAGE 103
PRODUCT DESCRIPTION
TIER
dexmethylphenidate er 10 mg cp
2
2
ST
QL
1 / 1 days
ST
QL
1 / 1 days
2
ST
QL
1 / 1 days
2
ST
dexmethylphenidate er 5 mg cap
2
FOCALIN XR 20 MG CAPSULE
dexmethylphenidate hcl
2
2
2
guanfacine hcl er 1 mg tablet
2
2
2
2
METHYLIN 10 MG CHEWABLE TABLET
methylphenidate hcl
3
METHYLIN 2.5 MG CHEWABLE TAB
methylphenidate hcl
3
METHYLIN 5 MG CHEWABLE TABLET
methylphenidate hcl
3
methylphenidate 10 mg tablet
2
methylphenidate 10 mg/5 ml sol
2
2
2
methylphenidate 5 mg/5 ml soln
2
methylphenidate cd 10 mg cap
2
2
2
PAGE 104
ST
QL
1 / 1 days
ST
QL
1 / 1 days
ST
QL
1 / 1 days
ST
PRODUCT DESCRIPTION
TIER
2
2
2
methylphenidate er 10 mg tab
2
2
methylphenidate er 20 mg cap
2
2
2
2
2
2
2
methylphenidate la 20 mg cap
2
2
2
RITALIN LA 10 MG CAPSULE
methylphenidate hcl
3
STRATTERA 10 MG CAPSULE
atomoxetine hcl
3
atomoxetine hcl
3
atomoxetine hcl
3
atomoxetine hcl
3
atomoxetine hcl
3
atomoxetine hcl
3
atomoxetine hcl
3
Central Nervous System Agents, Other
cevimeline hcl 30 mg capsule
2
4
PAGE 105
PRODUCT DESCRIPTION
TIER
dronabinol 2.5 mg capsule
4
4
1
C
Tablet Split (TS)
2
C
Tablet Split (TS)
1
C
Tablet Split (TS)
2
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
1
C
Tablet Split (TS)
tapentadol hcl
5
tapentadol hcl
5
tapentadol hcl
5
tapentadol hcl
5
tapentadol hcl
5
NUEDEXTA 20-10 MG CAPSULE
dextromethorphan hbr/quinidine sulfate
4
PA
RILUTEK 50 MG TABLET
riluzole
5
PA
XENAZINE 12.5 MG TABLET
tetrabenazine
4
PA
XENAZINE 25 MG TABLET
tetrabenazine
4
PA
2
QL
1 / 1 days
pregabalin
QL
1 / 1 days
3
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
Fibromyalgia Agents
PAGE 106
PA
PRODUCT DESCRIPTION
TIER
QL
pregabalin
3
LYRICA 20 MG/ML ORAL SOLUTION
pregabalin
3
pregabalin
3
pregabalin
3
pregabalin
3
pregabalin
3
pregabalin
3
pregabalin
3
SAVELLA 100 MG TABLET
milnacipran hcl
3
SAVELLA 12.5 MG TABLET
milnacipran hcl
3
milnacipran hcl
3
milnacipran hcl
3
SAVELLA TITRATION PACK
milnacipran hcl
3
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
Multiple Sclerosis Agents
PA
AMPYRA ER 10 MG TABLET
dalfampridine
4
AUBAGIO 14 MG TABLET
teriflunomide
5
PAGE 107
S
Specialty Drug
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
AUBAGIO 7 MG TABLET
teriflunomide
5
AVONEX ADMIN PACK 30 MCG VL
interferon beta-1a/albumin human
S
Specialty Drug
4
S
Specialty Drug
AVONEX PREFILLED SYR 30 MCG
interferon beta-1a
4
S
Specialty Drug
AVONEX PREFILLED SYR 30 MCG KT
interferon beta-1a
4
S
Specialty Drug
BETASERON 0.3 MG KIT
interferon beta-1b
5
BETASERON 0.3 MG VIAL
interferon beta-1b
5
COPAXONE 20 MG/ML SYRINGE
glatiramer acetate
4
EXTAVIA 0.3 MG KIT
interferon beta-1b
5
EXTAVIA 0.3 MG VIAL
interferon beta-1b
5
GILENYA 0.5 MG CAPSULE
fingolimod hcl
5
REBIF 22 MCG/0.5 ML SYRINGE
5
5
REBIF TITRATION PACK
5
TECFIDERA DR 120 MG CAPSULE
dimethyl fumarate
5
TECFIDERA DR 240 MG CAPSULE
dimethyl fumarate
5
PAGE 108
PA
S
Specialty Drug
PA
S
Specialty Drug
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
Dental and Oral Agents
cevimeline hcl 30 mg capsule
2
chlorhexidine 0.12% rinse
1
clotrimazole 10 mg troche
2
2
2
2
1
1
paroex 0.12% oral rinse
2
pilocarpine hcl 5 mg tablet
2
pilocarpine hcl 7.5 mg tablet
2
triamcinolone 0.1% paste
2
Dermatological Agents
8-MOP 10 MG CAPSULE
methoxsalen
5
ABSORICA 10 MG CAPSULE
isotretinoin
4
isotretinoin
4
isotretinoin
4
isotretinoin
4
acitretin 10 mg capsule
4
PA
acitretin 17.5 mg capsule
4
PA
acitretin 25 mg capsule
4
PA
adapalene 0.1% cream
2
PA
PA
AL
At least 5 yrs old
PA
adapalene 0.1% gel
2
AL
ALA-SCALP 2% LOTION
hydrocortisone
PAGE 109
At least 5 yrs old
2
PRODUCT DESCRIPTION
TIER
2
2
5
5
5
ammonium lactate 12% cream
2
amnesteem 10 mg capsule
4
4
4
5
AVAGE 0.1% CREAM
tazarotene
3
AZELEX 20% CREAM
azelaic acid
5
BACTROBAN NASAL 2% OINTMENT
mupirocin calcium
3
BENZACLIN GEL 35G PUMP
clindamycin phosphate/benzoyl peroxide
5
PA
BENZACLIN GEL 50G PUMP
clindamycin phosphate/benzoyl peroxide
5
PA
BENZAMYCINPAK GEL
erythromycin base/benzoyl peroxide
3
2
2
2
2
2
2
2
2
2
2
calcipotriene 0.005% cream
4
PAGE 110
PA
PA
AL
At least 5 yrs old
PA
AL
At least 5 yrs old
PRODUCT DESCRIPTION
TIER
calcipotriene 0.005% solution
4
CAPEX SHAMPOO
5
ciclopirox 0.77% cream
2
ciclopirox 0.77% gel
2
ciclopirox 0.77% topical susp
2
claravis 10 mg capsule
4
4
4
4
CLEOCIN 100 MG VAGINAL OVULE
3
clind ph-benzoyl perox 1.2-5%
2
clindacin etz 1% pledget
5
PA
CLINDACIN ETZ KIT
5
PA
clindacin p 1% pledgets
5
PA
CLINDACIN PAC KIT
5
PA
CLINDAGEL 1% GEL
5
PA
clindamycin 2% vaginal cream
2
clindamycin ph 1% gel
2
clindamycin ph 1% solution
2
clindamycin phos 1% pledget
3
clindamycin phosp 1% lotion
2
clindamycin phosphate 1% foam
3
clindamycin-benzoyl perox gel
2
2
2
2
2
2
PAGE 111
PA
PRODUCT DESCRIPTION
TIER
2
2
2
2
CLOBEX 0.05% SPRAY
5
clotrimazole-betamethasone crm
2
clotrimazole-betamethasone lot
2
CONDYLOX 0.5% GEL
podofilox
3
flurandrenolide
3
CORTISPORIN OINTMENT
neomycin/bacitracin/polymyxin b/hydrocortisone
3
cyclosporine 100 mg/ml soln
4
cyclosporine modified 25 mg
4
4
2
2
2
2
2
2
2
2
2
DIFFERIN 0.1% LOTION
adapalene
5
PA
DIFFERIN 0.3% GEL
adapalene
5
PA
DIFFERIN 0.3% GEL PUMP
adapalene
5
PA
2
2
PAGE 112
PA
PA
QL
1 / 1 days
PRODUCT DESCRIPTION
TIER
econazole nitrate 1% cream
2
ELIDEL 1% CREAM
pimecrolimus
3
ERTACZO 2% CREAM
sertaconazole nitrate
5
ery 2% pads
2
erythromycin 2% solution
2
erythromycin-benzoyl gel
2
EURAX 10% CREAM
crotamiton
3
EURAX 10% LOTION
crotamiton
3
FINACEA 15% GEL
azelaic acid
5
2
2
2
2
2
2
2
2
2
2
2
FLUOROPLEX 1% CREAM
fluorouracil
5
PA
fluorouracil 0.5% cream
4
PA
fluorouracil 2% topical soln
4
PA
fluorouracil 5% cream
4
PA
fluorouracil 5% top solution
4
PA
2
PAGE 113
PA
ST
PA
AL
At least 5 yrs old
PRODUCT DESCRIPTION
TIER
2
2
gengraf 100 mg capsule
4
gengraf 100 mg/ml solution
4
4
gentamicin 0.1% cream
2
gentamicin 0.1% ointment
2
2
2
HALOG 0.1% CREAM
halcinonide
3
HALOG 0.1% OINTMENT
halcinonide
3
2
2
2
1
2
1
2
4
PA
QL
1 / 1 days
PA
ketoconazole 2% cream
2
ketoconazole 2% shampoo
2
ketoconazole 200 mg tablet
2
2
2
2
malathion 0.5% lotion
2
2
2
2
PAGE 114
ST
PRODUCT DESCRIPTION
TIER
2
2
2
2
2
2
mometasone furoate 0.1% cream
1
mometasone furoate 0.1% oint
1
mupirocin 2% ointment
2
myorisan 10 mg capsule
4
4
4
NAFTIN 1% CREAM
naftifine hcl
3
ST
NAFTIN 1% GEL
naftifine hcl
3
ST
NAFTIN 2% CREAM
naftifine hcl
3
ST
NEORAL 100 MG GELATIN CAPSULE
cyclosporine, modified
4
NEORAL 100 MG/ML SOLUTION
4
4
nystatin 100,000 unit/gm cream
1
nystatin 100,000 units/gm oint
1
nystatin-triamcinolone cream
2
nystatin-triamcinolone ointm
2
nystop 100,000 units/gm powder
2
OXISTAT 1% CREAM
oxiconazole nitrate
3
OXISTAT 1% LOTION
oxiconazole nitrate
3
OXSORALEN 1% LOTION
methoxsalen
5
PAGE 115
QL
1 / 1 days
PA
PRODUCT DESCRIPTION
TIER
OXSORALEN-ULTRA 10 MG CAP
methoxsalen, rapid
5
PA
PANRETIN 0.1% GEL
alitretinoin
4
PA
podofilox 0.5% topical soln
2
prednicarbate 0.1% cream
2
prednicarbate 0.1% ointment
2
PROTOPIC 0.03% OINTMENT
tacrolimus
5
PA
PRUDOXIN 5% CREAM
doxepin hcl
5
PA
refissa 0.05% cream
2
REGRANEX 0.01% GEL
becaplermin
4
RENOVA 0.02% CREAM
tretinoin/emollient base
3
RENOVA PUMP 0.02% CREAM
tretinoin/emollient base
3
RETIN-A MICRO 0.1% GEL
tretinoin microspheres
5
RETIN-A MICRO PUMP 0.1% GEL
5
methotrexate sodium
3
SANTYL OINTMENT
collagenase clostridium histolyticum
3
scalacort 2% lotion
2
selenium sulfide 2.25% shampoo
2
selenium sulfide 2.5% lotion
2
silver sulfadiazine 1% cream
1
sodium sulfacetamide 10% lot
PA
PA
AL
At least 5 yrs old
PA
AL
At least 5 yrs old
PA
PA
AL
At least 5 yrs old
2
QL
1 / 1 days
SOLARAZE 3% GEL
diclofenac sodium
5
PA
spinosad 0.9% topical susp
5
PA
PAGE 116
PRODUCT DESCRIPTION
TIER
sulfacetamide sod 10% top susp
2
QL
1 / 1 days
TACLONEX OINTMENT
calcipotriene/betamethasone dipropionate
5
PA
tacrolimus 0.03% ointment
4
S
Specialty Drug
tacrolimus 0.1% ointment
2
S
Specialty Drug
PA
TARGRETIN 1% GEL
bexarotene
4
C
Partial Fill (PF)
S
Specialty Drug
TAZORAC 0.05% CREAM
tazarotene
3
TAZORAC 0.05% GEL
tazarotene
3
TAZORAC 0.1% CREAM
tazarotene
3
TAZORAC 0.1% GEL
tazarotene
3
hydrocortisone
3
tretinoin 0.01% gel
2
AL
At least 5 yrs old
tretinoin 0.025% cream
2
AL
At least 5 yrs old
tretinoin 0.025% gel
2
AL
At least 5 yrs old
2
AL
At least 5 yrs old
tretinoin 0.05% emollient crm
2
AL
At least 5 yrs old
2
PA
AL
At least 5 yrs old
PA
tretinoin gel micro 0.04% pump
5
ST
AL
At least 5 yrs old
PA
tretinoin gel micro 0.04% tube
5
ST
AL
PAGE 117
At least 5 yrs old
1
PRODUCT DESCRIPTION
TIER
1
1
1
1
1
1
1
ULESFIA 5% LOTION
benzyl alcohol
5
VEREGEN 15% OINTMENT
sinecatechins
3
zenatane 10 mg capsule
4
4
4
4
imiquimod
5
PA
ZYCLARA 3.75% CREAM
imiquimod
5
PA
imiquimod
5
PA
BUPHENYL 500 MG TABLET
sodium phenylbutyrate
3
S
CREON DR 12,000 UNITS CAPSULE
lipase/protease/amylase
3
QL
1 / 1 days
3
QL
1 / 1 days
3
QL
1 / 1 days
3
QL
1 / 1 days
CYSTADANE POWDER
betaine
4
KUVAN 100 MG POWDER PACKET
sapropterin dihydrochloride
4
PA
Enzyme Replacement/ Modifiers
PAGE 118
Specialty Drug
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
QL
PANCREAZE DR 10,500 UNIT CAP
5
1 / 1 days
PA
ST
QL
5
1 / 1 days
PA
ST
QL
5
1 / 1 days
PA
ST
QL
5
1 / 1 days
PA
ST
QL
pancrelipase dr 5,000 unit cap
5
1 / 1 days
PA
ST
PA
PERTZYE DR 16,000 UNITS CAPS
5
PERTZYE DR 8,000 UNITS CAPSULE
5
ULTRESA DR 13,800 UNIT CAPSULE
5
5
5
ZAVESCA 100 MG CAPSULE
miglustat
4
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
S
QL
ZENPEP DR 25,000 UNITS CAPSULE
3
Specialty Drug
1 / 1 days
PA
ST
PAGE 119
PRODUCT DESCRIPTION
TIER
QL
ZENPEP DR 5,000 UNITS CAPSULE
3
1 / 1 days
PA
ST
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
2
atropine 0.1 mg/ml abboject
2
2
BENTYL 10 MG/ML AMPUL
dicyclomine hcl
2
CANTIL 25 MG TABLET
mepenzolate bromide
3
dicyclomine 10 mg capsule
2
dicyclomine 20 mg tablet
2
2
2
glycopyrrolate 1 mg tablet
2
2
glycopyrrolate 2 mg tablet
2
2
methscopolamine brom 2.5 mg tb
2
methscopolamine brom 5 mg tab
2
Gastrointestinal Agents, Other
APRISO ER 0.375 GRAM CAPSULE
mesalamine
3
ASACOL HD DR 800 MG TABLET
mesalamine
3
CANASA 1,000 MG SUPPOSITORY
mesalamine
3
2
2
DELZICOL DR 400 MG CAPSULE
mesalamine
5
PAGE 120
PRODUCT DESCRIPTION
TIER
diphenoxylat-atrop 2.5-0.025/5
2
diphenoxylate-atrop 2.5-0.025
2
LIALDA DR 1.2 GM TABLET
mesalamine
3
mesalamine 4 gm/60 ml enema
2
mesalamine 4 gm/60 ml kit
2
1
metoclopramide 10 mg/10 ml sol
1
1
1
1
METOZOLV ODT 5 MG TABLET
metoclopramide hcl
5
PA
MOTOFEN TABLET
difenoxin hcl/atropine sulfate
5
PA
PENTASA 250 MG CAPSULE
mesalamine
3
mesalamine
3
sulfasalazine 500 mg tablet
2
sulfasalazine dr 500 mg tab
2
sulfazine ec 500 mg tab
2
ursodiol 250 mg tablet
2
ursodiol 300 mg capsule
2
ursodiol 500 mg tablet
2
rifaximin
5
PA
Histamine2 (H2) Receptor Antagonists
cimetidine 300 mg tablet
2
cimetidine 300 mg/5 ml soln
2
2
2
famotidine 20 mg tablet
1
famotidine 40 mg tablet
1
PAGE 121
PRODUCT DESCRIPTION
TIER
famotidine 40 mg/5 ml susp
1
nizatidine 150 mg capsule
2
nizatidine 300 mg capsule
2
ranitidine 15 mg/ml syrup
1
ranitidine 150 mg/10 ml syrup
1
ranitidine 300 mg tablet
1
Irritable Bowel Syndrome Agents
alosetron hcl 0.5 mg tablet
3
PA
alosetron hcl 1 mg tablet
3
PA
AMITIZA 24 MCG CAPSULES
lubiprostone
3
PA
AMITIZA 8 MCG CAPSULE
lubiprostone
3
PA
LINZESS 145 MCG CAPSULE
linaclotide
3
LINZESS 290 MCG CAPSULE
linaclotide
3
QL
1 / 1 days
PA
QL
1 / 1 days
PA
Laxatives
constulose 10 gm/15 ml soln
3
lactulose 10 gm/15 ml solution
1
lactulose 20 gm/30 ml solution
1
MOVIPREP POWDER PACKET
peg 3350/sodium sulfate/sod chloride/kcl/ascorbate sod/vit c
3
PREPOPIK POWDER PACKET
sodium picosulfate/magnesium oxide/citric acid
5
PA
Protectants
misoprostol 100 mcg tablet
2
2
sucralfate 1 gm tablet
2
Proton Pump Inhibitors
DEXILANT DR 30 MG CAPSULE
dexlansoprazole
PAGE 122
PA
5
ST
PRODUCT DESCRIPTION
TIER
PA
DEXILANT DR 60 MG CAPSULE
dexlansoprazole
5
esomeprazole mag dr 20 mg cap
2
esomeprazole mag dr 40 mg cap
2
lansoprazole dr 30 mg capsule
2
omeprazole dr 10 mg capsule
1
omeprazole dr 20 mg capsule
1
pantoprazole sod dr 20 mg tab
ST
QL
1 / 1 days
1
QL
1 / 1 days
pantoprazole sod dr 40 mg tab
1
QL
1 / 1 days
PREVACID 15 MG SOLUTAB
lansoprazole
3
PREVACID 30 MG SOLUTAB
lansoprazole
3
rabeprazole sod dr 20 mg tab
2
PA
ST
PA
ST
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl 100 mg tablet
2
oxybutynin 5 mg tablet
2
QL
1 / 1 days
oxybutynin 5 mg/5 ml syrup
2
QL
1 / 1 days
oxybutynin cl er 10 mg tablet
2
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
tolterodine tart er 2 mg cap
2
tolterodine tart er 4 mg cap
2
tolterodine tartrate 1 mg tab
2
tolterodine tartrate 2 mg tab
2
TOVIAZ ER 4 MG TABLET
fesoterodine fumarate
3
TOVIAZ ER 8 MG TABLET
fesoterodine fumarate
3
PAGE 123
PRODUCT DESCRIPTION
TIER
VESICARE 10 MG TABLET
solifenacin succinate
3
VESICARE 5 MG TABLET
solifenacin succinate
3
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er 10 mg tablet
2
AVODART 0.5 MG SOFTGEL
dutasteride
3
CIALIS 5 MG TABLET
tadalafil
5
2
2
2
2
finasteride 5 mg tablet
2
2
2
2
RAPAFLO 4 MG CAPSULE
silodosin
5
RAPAFLO 8 MG CAPSULE
silodosin
5
tamsulosin hcl 0.4 mg capsule
2
1
2
1
1
PA
ST
QL
1 / 1 days
PA
QL
1 / 1 days
PA
Genitourinary Agents, Other
bethanechol 10 mg tablet
2
2
2
2
PAGE 124
PRODUCT DESCRIPTION
TIER
PA
CIALIS 5 MG TABLET
tadalafil
5
CUPRIMINE 250 MG CAPSULE
penicillamine
5
CYSTAGON 150 MG CAPSULE
cysteamine bitartrate
5
CYSTAGON 50 MG CAPSULE
cysteamine bitartrate
5
DEPEN 250 MG TITRATAB
penicillamine
5
ELMIRON 100 MG CAPSULE
pentosan polysulfate sodium
3
ST
PA
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
Phosphate Binders
calcium acetate 667 mg capsule
1
calcium acetate 667 mg gelcap
1
calcium acetate 667 mg tablet
1
FOSRENOL 1,000 MG TABLET CHEW
lanthanum carbonate
4
FOSRENOL 500 MG TABLET CHEW
lanthanum carbonate
4
FOSRENOL 750 MG TABLET CHEW
lanthanum carbonate
4
PHOSLYRA 667 MG/5 ML SOLUTION
calcium acetate
3
RENAGEL 400 MG TABLET
sevelamer hcl
3
RENAGEL 800 MG TABLET
sevelamer hcl
3
QL
1 / 1 days
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Glucocorticoids/Mineralocorticoids
ALA-SCALP 2% LOTION
hydrocortisone
2
2
2
5
PAGE 125
PRODUCT DESCRIPTION
TIER
5
5
hydrocortisone
2
5
2
2
2
2
2
2
2
2
2
2
CAPEX SHAMPOO
5
2
2
2
2
2
2
2
2
2
CLOBEX 0.05% SPRAY
5
flurandrenolide
3
cortisone 25 mg tablet
2
2
2
PAGE 126
PA
PA
PA
PRODUCT DESCRIPTION
TIER
2
2
2
2
2
dexamethasone 0.1% eye drop
1
dexamethasone 0.5 mg tablet
1
dexamethasone 0.5 mg/5 ml elx
1
dexamethasone 0.5 mg/5 ml liq
1
1
dexamethasone 1 mg tablet
1
1
1
1
dexamethasone intensol 1mg/1ml
3
DEXPAK 10 DAY 1.5 MG TABLET
dexamethasone
3
diclofenac 0.1% eye drops
1
2
2
DUREZOL 0.05% EYE DROPS
difluprednate
3
FLAREX 0.1% EYE DROPS
fluorometholone acetate
2
FLOVENT 250 MCG DISKUS
fluticasone propionate
5
5
FLOVENT HFA 110 MCG INHALER
5
5
PAGE 127
QL
1 / 1 days
QL
1 / 1 days
PA
ST
PA
ST
PA
ST
PA
ST
PRODUCT DESCRIPTION
TIER
PA
5
fludrocortisone 0.1 mg tablet
2
2
2
2
2
2
2
fluocinolone oil 0.01% ear drp
2
2
2
2
2
2
fluorometholone 0.1% drops
2
2
2
2
PA
fluticasone prop 50 mcg spray
1
QL
1 / 1 days
FML FORTE 0.25% EYE DROPS
fluorometholone
3
QL
1 / 1 days
FML S.O.P. 0.1% OINTMENT
fluorometholone
3
QL
1 / 1 days
2
2
HALOG 0.1% CREAM
halcinonide
3
HALOG 0.1% OINTMENT
halcinonide
3
2
2
PAGE 128
ST
QL
1 / 1 days
QL
1 / 1 days
PRODUCT DESCRIPTION
TIER
hydrocortisone 0.1% soln
2
2
hydrocortisone 10 mg tablet
1
1
2
1
1
1
2
hydrocortisone butyr 0.1% oint
2
hydrocortisone val 0.2% cream
2
hydrocortisone val 0.2% ointmt
2
MAXIDEX 0.1% EYE DROPS
dexamethasone
3
2
2
2
2
2
millipred 5 mg tablet
3
3
3
mometasone furoate 0.1% cream
1
mometasone furoate 0.1% oint
1
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
PANDEL 0.1% CREAM
hydrocortisone probutate
5
PA
2
2
prednisolone 15 mg/5 ml syrup
2
2
PAGE 129
PRODUCT DESCRIPTION
TIER
prednisolone ac 1% eye drop
2
QL
1 / 1 days
prednisolone sod ph 25 mg/5 ml
1
QL
1 / 1 days
1
1
1
1
1
1
1
2
1
1
procto-pak 1% cream
2
scalacort 2% lotion
2
SOLARAZE 3% GEL
diclofenac sodium
5
hydrocortisone
3
1
1
1
1
1
1
1
1
triamcinolone 55 mcg nasal spr
5
PA
PA
ST
VERAMYST 27.5 MCG NASAL SPRAY
fluticasone furoate
3
VERIPRED 20 20 MG/5 ML SOLN
prednisolone sod phosphate
3
PAGE 130
QL
1 / 1 days
PRODUCT DESCRIPTION
TIER
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
5
PA
5
PA
desmopressin 0.01% solution
2
desmopressin 0.01% spray
2
desmopressin 0.1 mg/ml sol
2
desmopressin 10 mcg/0.1 ml spr
2
desmopressin 40 mcg/10 ml vial
2
desmopressin ac 4 mcg/ml ampul
2
desmopressin ac 4 mcg/ml vial
2
desmopressin acetate 0.1 mg tb
2
desmopressin acetate 0.2 mg tb
2
GENOTROPIN 12 MG CARTRIDGE
somatropin
5
GENOTROPIN 5 MG CARTRIDGE
somatropin
5
GENOTROPIN MINIQUICK 0.2 MG
somatropin
5
somatropin
5
somatropin
5
somatropin
5
GENOTROPIN MINIQUICK 1 MG
somatropin
5
somatropin
5
somatropin
5
PAGE 131
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PRODUCT DESCRIPTION
TIER
PA
somatropin
5
somatropin
5
GENOTROPIN MINIQUICK 2 MG
somatropin
5
HUMATROPE 12 MG CARTRIDGE
somatropin
5
somatropin
5
HUMATROPE 5 MG VIAL
somatropin
5
somatropin
5
INCRELEX 40 MG/4 ML VIAL
mecasermin
4
NORDITROPIN FLEXPRO 10 MG/1.5
somatropin
4
somatropin
4
somatropin
4
NORDITROPIN NORDIFLEX 30 MG/3
somatropin
4
NUTROPIN AQ 20 MG/2ML PEN CART
somatropin
5
NUTROPIN AQ NUSPIN 10 PEN CART
somatropin
5
somatropin
5
PAGE 132
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
ST
PA
ST
PA
ST
PRODUCT DESCRIPTION
TIER
PA
somatropin
5
NUTROPIN AQ PEN CARTRIDGE
somatropin
5
OMNITROPE 10 MG/1.5 ML CRTG
somatropin
5
OMNITROPE 5 MG/1.5 ML CRTG
somatropin
5
OMNITROPE 5.8 MG VIAL
somatropin
5
SAIZEN 5 MG VIAL
somatropin
5
SAIZEN 8.8 MG CLICK.EASY CARTG
somatropin
5
SEROSTIM 4 MG VIAL
somatropin
4
SEROSTIM 6 MG VIAL
somatropin
4
ZORBTIVE 8.8 MG VIAL
somatropin
4
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)
2
2
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Anabolic Steroids
ANADROL-50 TABLET
oxymetholone
5
PA
oxandrolone 10 mg tablet
5
PA
oxandrolone 2.5 mg tablet
5
PA
PAGE 133
PRODUCT DESCRIPTION
TIER
Androgens
ANDRODERM 2 MG/24HR PATCH
testosterone
3
PA
ANDRODERM 4 MG/24HR PATCH
testosterone
3
PA
danazol 100 mg capsule
2
2
2
METHITEST 10 MG TABLET
methyltestosterone
4
PA
STRIANT 30 MG MUCOADHESIVE
testosterone
5
PA
testosteron enan 1,000 mg/5 ml
2
PA
testosterone enan 200 mg/ml
2
PA
TESTRED 10 MG CAPSULE
methyltestosterone
4
PA
Estrogens
alyacen 1-35-28 tablet
0
alyacen 7-7-7-28 tablet
0
apri 28 day tablet
0
azurette 28 day tablet
0
balziva 28 tablet
0
briellyn tablet
0
cyclafem 1-35-28 tablet
0
cyclafem 7-7-7-28 tablet
0
dasetta 1-35-28 tablet
0
dasetta 7/7/7-28 tablet
0
desogestrel-ethinyl estrad tab
0
emoquette 28 day tablet
0
enskyce 28 tablet
0
estarylla 0.25-0.035 mg tablet
0
ESTRACE 0.01% CREAM
estradiol
3
PAGE 134
PRODUCT DESCRIPTION
TIER
estradiol 0.025 mg/day patch
2
2
2
2
2
2
estradiol 0.5 mg tablet
1
estradiol 1 mg tablet
1
estradiol 2 mg tablet
1
estradiol tds 0.025 mg/day
2
2
2
2
2
2
ESTRING 2 MG VAGINAL RING
estradiol
3
estropipate 0.625(0.75 mg) tab
1
estropipate 1.25(1.5 mg) tab
1
estropipate 2.5(3 mg) tab
1
FEMRING 0.05 MG VAGINAL RING
estradiol acetate
QL
1 / 1 days
3
QL
1 / 1 days
FEMRING 0.10 MG VAGINAL RING
estradiol acetate
3
QL
1 / 1 days
gildagia 0.4 mg-0.035 mg tab
0
gildess fe 1-20 tablet
0
gildess fe 1.5-30 tablet
0
junel fe 1 mg-20 mcg tablet
0
junel fe 1.5 mg-30 mcg tablet
0
kariva 28 day tablet
0
larin fe 1-20 tablet
0
larin fe 1.5-30 tablet
0
LOESTRIN FE 1.5-30 TABLET
norethindrone acetate-ethinyl estradiol/ferrous fumarate
5
PAGE 135
PA
PRODUCT DESCRIPTION
TIER
lomedia 24 fe 1 mg-20 mcg tab
0
MENEST 0.3 MG TABLET
estrogens,esterified
3
3
3
MENOSTAR 14 MCG/DAY PATCH
estradiol
3
microgestin fe 1-20 tablet
0
microgestin fe 1.5-30 tab
0
MINASTRIN 24 FE CHEWABLE TAB
0
mono-linyah 28 tablet
0
mononessa 28 tablet
0
necon 1-35-28 tablet
0
necon 7-7-7-28 tablet
0
norethin-estrad-ferr 1-0.02 mg
0
norethin-estrad-ferr 1-0.02 mg
0
norg-ethin estra 0.25-0.035 mg
0
norgestimate-eth estradiol tab
0
NORINYL 1+35-28 TABLET
norethindrone-ethinyl estradiol
5
nortrel 1-35 tablet
0
nortrel 7-7-7-28 tablet
0
ORTHO-NOVUM 1-35-28 TABLET
0
ORTHO-NOVUM 7-7-7-28 TABLET
0
OVCON-35 28 TABLET
0
philith 0.4-0.035 mg tablet
0
pimtrea 28 day tablet
0
pirmella 1-35-28 tablet
0
pirmella 7-7-7-28 tablet
0
PAGE 136
QL
1 / 1 days
PRODUCT DESCRIPTION
TIER
PREMARIN 0.3 MG TABLET
estrogens, conjugated
3
3
3
3
3
PREMARIN VAGINAL CREAM-APPL
3
previfem tablet
0
reclipsen 28 day tablet
0
sprintec 28 day tablet
0
tarina fe 1-20 tablet
0
tri-estarylla tablet
0
tri-linyah tablet
0
tri-previfem tablet
0
tri-sprintec tablet
0
trinessa tablet
0
VAGIFEM 10 MCG VAGINAL TAB
estradiol
3
viorele 28 day tablet
0
vyfemla 28 tablet
0
zenchent 0.4 mg-35 mcg tablet
0
Progestins
camila tablet
0
deblitane 0.35 mg tablet
0
DEPO-SUBQ PROVERA 104 SYRINGE
medroxyprogesterone acetate
0
ELLA 30 MG TABLET
ulipristal acetate
0
enskyce 28 tablet
0
errin 0.35 mg tablet
0
PAGE 137
PRODUCT DESCRIPTION
TIER
estarylla 0.25-0.035 mg tablet
0
gildagia 0.4 mg-0.035 mg tab
0
heather tablet
0
jencycla 0.35 mg tablet
0
jolivette tablet
0
larin fe 1-20 tablet
0
larin fe 1.5-30 tablet
0
lyza 0.35 mg tablet
0
medroxyprogesterone 10 mg tab
1
medroxyprogesterone 150 mg/ml
0
medroxyprogesterone 150 mg/ml
0
medroxyprogesterone 2.5 mg tab
1
medroxyprogesterone 5 mg tab
1
MEGACE ES 625 MG/5 ML SUSP
megestrol acetate
4
megestrol 20 mg tablet
2
megestrol 40 mg tablet
2
megestrol acet 40 mg/ml susp
2
megestrol acet 400 mg/10 ml
2
MINASTRIN 24 FE CHEWABLE TAB
0
mono-linyah 28 tablet
0
nora-be tablet
0
norethindrone 0.35 mg tablet
0
norethindrone 5 mg tablet
0
norlyroc 0.35 mg tablet
0
pimtrea 28 day tablet
0
pirmella 1-35-28 tablet
0
pirmella 7-7-7-28 tablet
0
progesterone 100 mg capsule
2
progesterone 200 mg capsule
2
sharobel 0.35 mg tablet
0
PAGE 138
PRODUCT DESCRIPTION
tri-estarylla tablet
TIER
0
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothyroxine 100 mcg tablet
1
1
1
1
1
1
1
1
1
1
1
1
liothyronine sod 25 mcg tab
2
2
2
THYROLAR-1 STRENGTH TABLET
liotrix
3
THYROLAR-1/2 STRENGTH TAB
liotrix
3
THYROLAR-1/4 STRENGTH TAB
liotrix
3
liotrix
3
liotrix
3
Hormonal Agents, Suppressant (Adrenal)
LYSODREN 500 MG TABLET
mitotane
PA
4
S
Specialty Drug
Hormonal Agents, Suppressant (Parathyroid)
calcitriol 0.25 mcg capsule
2
2
PAGE 139
PRODUCT DESCRIPTION
TIER
PA
SENSIPAR 30 MG TABLET
cinacalcet hcl
4
cinacalcet hcl
4
cinacalcet hcl
4
ZEMPLAR 1 MCG CAPSULE
paricalcitol
4
PA
paricalcitol
4
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
Hormonal Agents, Suppressant (Pituitary)
bromocriptine 2.5 mg tablet
2
bromocriptine 5 mg capsule
2
cabergoline 0.5 mg tablet
2
ELIGARD 22.5 MG SYRINGE KIT
leuprolide acetate
4
ELIGARD 30 MG SYRINGE KIT
leuprolide acetate
4
ELIGARD 7.5 MG SYRINGE KIT
leuprolide acetate
4
leuprolide 2wk 1 mg/0.2 ml kit
4
LUPRON DEPOT 11.25 MG 3MO KIT
leuprolide acetate
4
LUPRON DEPOT 22.5 MG 3MO KIT
leuprolide acetate
4
LUPRON DEPOT 3.75 MG KIT
leuprolide acetate
4
LUPRON DEPOT 45 MG 6MO KIT
leuprolide acetate
4
LUPRON DEPOT 7.5 MG KIT
leuprolide acetate
4
PAGE 140
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
LUPRON DEPOT-4 MONTH KIT
leuprolide acetate
4
LUPRON DEPOT-PED 11.25 MG 3MO
leuprolide acetate
4
LUPRON DEPOT-PED 11.25 MG KIT
leuprolide acetate
4
LUPRON DEPOT-PED 15 MG KIT
leuprolide acetate
4
LUPRON DEPOT-PED 30 MG 3MO KIT
leuprolide acetate
4
LUPRON DEPOT-PED 7.5 MG KIT
leuprolide acetate
4
octreotide 1,000 mcg/5 ml vial
4
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
octreotide 1,000 mcg/ml vial
4
S
Specialty Drug
PA
octreotide 5,000 mcg/5 ml vial
4
S
Specialty Drug
PA
octreotide acet 100 mcg/ml amp
4
S
Specialty Drug
PA
octreotide acet 100 mcg/ml vl
4
S
Specialty Drug
PA
4
S
Specialty Drug
PA
4
S
Specialty Drug
PA
octreotide acet 50 mcg/ml vial
4
S
Specialty Drug
PA
4
S
PAGE 141
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
SYNAREL 2 MG/ML NASAL SPRAY
nafarelin acetate
4
4
S
Specialty Drug
S
Specialty Drug
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
Antiandrogens
AVODART 0.5 MG SOFTGEL
dutasteride
3
bicalutamide 50 mg tablet
2
finasteride 5 mg tablet
2
flutamide 125 mg capsule
4
NILANDRON 150 MG TABLET
nilutamide
4
PA
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole 10 mg tablet
2
methimazole 5 mg tablet
2
propylthiouracil 50 mg tablet
2
Immunological Agents
Immune Suppressants
azathioprine 50 mg tablet
4
CIMZIA 200 MG VIAL KIT
certolizumab pegol
4
CIMZIA 200 MG/ML STARTER KIT
certolizumab pegol
4
CIMZIA 200 MG/ML SYRINGE KIT
certolizumab pegol
4
glatiramer acetate
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
4
S
Specialty Drug
penicillamine
5
PA
cyclosporine 100 mg capsule
4
PAGE 142
PRODUCT DESCRIPTION
TIER
cyclosporine 100 mg/ml soln
4
cyclosporine 25 mg capsule
4
4
4
4
penicillamine
5
ELIDEL 1% CREAM
pimecrolimus
3
PA
PA
ENBREL 25 MG KIT
etanercept
5
ST
S
Specialty Drug
PA
ENBREL 25 MG/0.5 ML SYRINGE
etanercept
5
ST
S
Specialty Drug
PA
ENBREL 50 MG/ML SYRINGE
etanercept
5
ST
S
4
gengraf 100 mg/ml solution
4
4
HUMIRA 20 MG/0.4 ML SYRINGE
adalimumab
4
HUMIRA 40 MG/0.8 ML PEN
adalimumab
4
adalimumab
4
HUMIRA CROHN'S STARTER PACK
adalimumab
4
HUMIRA PED CROHN'S STARTER PK
adalimumab
4
HUMIRA PSORIASIS STARTER PACK
adalimumab
4
PAGE 143
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
KINERET 100 MG/0.67 ML SYRINGE
anakinra
4
2
2
2
2
2
2
2
2
2
mycophenolate 200 mg/ml susp
S
Specialty Drug
4
S
Specialty Drug
mycophenolate 250 mg capsule
4
S
Specialty Drug
mycophenolate 500 mg tablet
4
S
Specialty Drug
MYFORTIC 180 MG TABLET
mycophenolate sodium
4
S
Specialty Drug
MYFORTIC 360 MG TABLET
mycophenolate sodium
4
S
Specialty Drug
4
NEORAL 100 MG/ML SOLUTION
4
4
RAPAMUNE 0.5 MG TABLET
sirolimus
4
RAPAMUNE 1 MG TABLET
sirolimus
4
RAPAMUNE 2 MG TABLET
sirolimus
4
RESTASIS 0.05% EYE EMULSION
cyclosporine
3
PAGE 144
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
QL
Specialty Drug
1 / 1 days
PA
PRODUCT DESCRIPTION
TIER
methotrexate sodium
3
SANDIMMUNE 100 MG CAPSULE
cyclosporine
4
SANDIMMUNE 100 MG/ML SOLN
cyclosporine
4
SANDIMMUNE 25 MG CAPSULE
cyclosporine
4
tacrolimus 0.5 mg capsule
4
S
Specialty Drug
tacrolimus 1 mg capsule
4
S
Specialty Drug
tacrolimus 5 mg capsule
4
S
Specialty Drug
ZORTRESS 0.25 MG TABLET
everolimus
4
everolimus
4
everolimus
4
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
Immunizing Agents, Passive
carimune nf 12 gm vial
4
PA
carimune nf 6 gm vial
4
PA
GAMASTAN S-D VIAL
immune globulin,gamma(igg)
4
PA
GAMMAGARD S-D 10 G (IGA<1) SOL
4
PA
GAMMAGARD S-D 10 GM VL W/ST
4
PA
GAMMAGARD S-D 2.5 GM VL W/ST
4
PA
GAMMAGARD S-D 5 G (IGA<1) SOLN
4
PA
GAMMAGARD S-D 5 GM VL W/SET
4
PA
HIZENTRA 1 GRAM/5 ML VIAL
4
PA
PAGE 145
PRODUCT DESCRIPTION
TIER
HIZENTRA 10 GRAM/ 50 ML VIAL
4
PA
4
PA
4
PA
Immunomodulators
PA
ARCALYST 220 MG INJECTION
rilonacept
5
AVONEX ADMIN PACK 30 MCG VL
S
Specialty Drug
4
S
Specialty Drug
AVONEX PREFILLED SYR 30 MCG
interferon beta-1a
4
S
Specialty Drug
AVONEX PREFILLED SYR 30 MCG KT
interferon beta-1a
4
S
Specialty Drug
BETASERON 0.3 MG KIT
interferon beta-1b
5
BETASERON 0.3 MG VIAL
interferon beta-1b
5
EXTAVIA 0.3 MG KIT
interferon beta-1b
5
EXTAVIA 0.3 MG VIAL
interferon beta-1b
5
GILENYA 0.5 MG CAPSULE
fingolimod hcl
5
4
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
QL
Specialty Drug
1 / 1 days
PA
leflunomide 10 mg tablet
2
leflunomide 20 mg tablet
2
pomalidomide
4
pomalidomide
4
PAGE 146
PA
S
Specialty Drug
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
pomalidomide
4
pomalidomide
4
5
5
REBIF TITRATION PACK
5
lenalidomide
4
lenalidomide
4
REVLIMID 2.5 MG CAPSULE
lenalidomide
4
lenalidomide
4
lenalidomide
4
lenalidomide
4
RIDAURA 3 MG CAPSULE
auranofin
4
2
2
2
thalidomide
4
thalidomide
4
PAGE 147
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
PA
S
Specialty Drug
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
thalidomide
4
thalidomide
4
XELJANZ 5 MG TABLET
tofacitinib citrate
5
PA
imiquimod
5
PA
ZYCLARA 3.75% CREAM
imiquimod
5
PA
imiquimod
5
PA
S
Specialty Drug
PA
S
Specialty Drug
Inflammatory Bowel Disease Agents
Aminosalicylates
APRISO ER 0.375 GRAM CAPSULE
mesalamine
3
ASACOL HD DR 800 MG TABLET
mesalamine
3
balsalazide disodium 750 mg cp
1
CANASA 1,000 MG SUPPOSITORY
mesalamine
3
DELZICOL DR 400 MG CAPSULE
mesalamine
5
DIPENTUM 250 MG CAPSULE
olsalazine sodium
3
LIALDA DR 1.2 GM TABLET
mesalamine
3
mesalamine 4 gm/60 ml enema
2
mesalamine 4 gm/60 ml kit
2
mesalamine
3
mesalamine
3
Glucocorticoids
hydrocortisone
PAGE 148
2
PRODUCT DESCRIPTION
TIER
colocort 100 mg enema
2
1
dexamethasone 0.5 mg/5 ml elx
1
dexamethasone 0.5 mg/5 ml liq
1
1
1
1
1
1
dexamethasone intensol 1mg/1ml
3
DEXPAK 10 DAY 1.5 MG TABLET
dexamethasone
3
1
hydrocortisone 100 mg/60 ml
2
1
1
2
2
2
2
2
1
1
1
1
1
1
1
2
1
1
procto-pak 1% cream
2
PAGE 149
PRODUCT DESCRIPTION
TIER
proctosol-hc 2.5% cream
2
proctozone-hc 2.5% cream
2
Sulfonamides
2
2
2
Metabolic Bone Disease Agents
ACTONEL 30 MG TABLET
risedronate sodium
3
ACTONEL 35 MG TABLET
risedronate sodium
3
ACTONEL 5 MG TABLET
risedronate sodium
3
alendronate sodium 10 mg tab
1
1
1
alendronate sodium 5 mg tablet
1
1
calcitonin-salmon 200 units sp
2
2
2
etidronate disodium 200 mg tab
2
etidronate disodium 400 mg tab
2
FORTEO 600 MCG/2.4 ML PEN INJ
teriparatide
4
HECTOROL 0.5 MCG CAPSULE
doxercalciferol
4
PA
HECTOROL 1 MCG CAPSULE
doxercalciferol
4
PA
ibandronate sodium 150 mg tab
5
PA
MIACALCIN 200 UNIT/ML VIAL
calcitonin,salmon,synthetic
3
risedronate sodium 150 mg tab
2
PAGE 150
PA
S
Specialty Drug
ST
PRODUCT DESCRIPTION
TIER
paricalcitol
4
PA
paricalcitol
4
PA
latanoprost 0.005% eye drops
1
QL
1 / 1 days
LUMIGAN 0.01% EYE DROPS
bimatoprost
3
QL
1 / 1 days
TRAVATAN Z 0.004% EYE DROP
travoprost
3
QL
1 / 1 days
AZASITE 1% EYE DROPS
azithromycin
3
QL
1 / 1 days
bacitracin 500 unit/gm ophth
1
QL
1 / 1 days
BESIVANCE 0.6% SUSP
besifloxacin hcl
3
CILOXAN 0.3% OINTMENT
ciprofloxacin hcl
2
QL
1 / 1 days
ciprofloxacin 0.3% eye drop
3
QL
1 / 1 days
erythromycin 0.5% eye ointment
1
QL
1 / 1 days
gentamicin 0.3% eye drops
1
QL
1 / 1 days
gentamicin 0.3% eye ointment
1
QL
1 / 1 days
gentamicin 3 mg/ml eye drops
1
QL
1 / 1 days
levofloxacin 0.5% eye drops
2
MOXEZA 0.5% EYE DROPS
moxifloxacin hcl
3
NATACYN EYE DROPS
natamycin
3
QL
1 / 1 days
ofloxacin 0.3% eye drops
2
QL
1 / 1 days
proparacaine 0.5% eye drops
2
QL
1 / 1 days
RESTASIS 0.05% EYE EMULSION
cyclosporine
QL
1 / 1 days
3
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
Ophthalmic Agents, Other
PAGE 151
PA
PRODUCT DESCRIPTION
TIER
sulfacetamide 10% eye drops
2
TOBRADEX EYE OINTMENT
3
QL
1 / 1 days
tobramycin 0.3% eye drops
1
QL
1 / 1 days
TOBREX 0.3% EYE OINTMENT
tobramycin
3
trifluridine 1% eye drops
2
QL
1 / 1 days
tropicamide 0.5% eye drops
1
tropicamide 1% eye drops
1
VIGAMOX 0.5% EYE DROPS
moxifloxacin hcl
3
QL
1 / 1 days
ZIRGAN 0.15% OPHTHALMIC GEL
ganciclovir
3
ZYMAXID 0.5% EYE DROPS
gatifloxacin
3
Ophthalmic Anti-allergy Agents
ALOCRIL 2% EYE DROPS
nedocromil sodium
5
PA
ALOMIDE 0.1% EYE DROPS
lodoxamide tromethamine
3
QL
1 / 1 days
azelastine hcl 0.05% drops
2
cromolyn 4% eye drops
1
QL
1 / 1 days
EMADINE 0.05% EYE DROPS
emedastine difumarate
QL
1 / 1 days
3
epinastine hcl 0.05% eye drops
2
PATADAY 0.2% EYE DROPS
olopatadine hcl
3
PATANOL 0.1% EYE DROPS
olopatadine hcl
3
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
Ophthalmic Anti-inflammatories
ACUVAIL 0.45% OPHTH SOLUTION
ketorolac tromethamine/pf
5
PA
ALREX 0.2% EYE DROPS
loteprednol etabonate
3
QL
PAGE 152
1 / 1 days
PRODUCT DESCRIPTION
TIER
QL
bromfenac sodium 0.09% eye drp
1 / 1 days
5
PA
dexamethasone 0.1% eye drop
1
QL
1 / 1 days
diclofenac 0.1% eye drops
1
QL
1 / 1 days
DUREZOL 0.05% EYE DROPS
difluprednate
3
FLAREX 0.1% EYE DROPS
fluorometholone acetate
2
fluorometholone 0.1% drops
2
QL
1 / 1 days
flurbiprofen 0.03% eye drop
2
QL
1 / 1 days
FML FORTE 0.25% EYE DROPS
fluorometholone
3
QL
1 / 1 days
FML S.O.P. 0.1% OINTMENT
fluorometholone
3
QL
1 / 1 days
ILEVRO 0.3% OPHTH DROPS
nepafenac
5
PA
ketorolac 0.4% ophth solution
1
QL
1 / 1 days
ketorolac 0.5% ophth solution
1
QL
1 / 1 days
LOTEMAX 0.5% EYE DROPS
3
QL
1 / 1 days
LOTEMAX 0.5% EYE OINTMENT
3
QL
1 / 1 days
LOTEMAX 0.5% OPHTHALMIC GEL
3
QL
1 / 1 days
MAXIDEX 0.1% EYE DROPS
dexamethasone
3
QL
1 / 1 days
NEVANAC 0.1% DROPTAINER
nepafenac
3
QL
1 / 1 days
PRED MILD 0.12% EYE DROPS
prednisolone acetate
3
QL
1 / 1 days
prednisolone ac 1% eye drop
2
QL
1 / 1 days
prednisolone sod 1% eye drop
2
QL
1 / 1 days
VEXOL 1% EYE DROPS
rimexolone
3
QL
1 / 1 days
PAGE 153
PRODUCT DESCRIPTION
TIER
Ophthalmic Antiglaucoma Agents
ALPHAGAN P 0.1% DROPS
brimonidine tartrate
3
apraclonidine hcl 0.5% drops
2
QL
C
1 / 1 days
QL-2
AZOPT 1% EYE DROPS
brinzolamide
3
QL
1 / 1 days
betaxolol hcl 0.5% eye drop
2
QL
1 / 1 days
BETIMOL 0.25% EYE DROPS
timolol
3
QL
1 / 1 days
BETIMOL 0.5% EYE DROPS
timolol
3
QL
1 / 1 days
BETOPTIC S 0.25% EYE DROPS
betaxolol hcl
3
QL
1 / 1 days
brimonidine 0.2% eye drop
2
QL
1 / 1 days
brimonidine tartrate 0.15% drp
2
QL
1 / 1 days
carteolol hcl 1% eye drops
1
QL
1 / 1 days
COMBIGAN EYE DROPS
brimonidine tartrate/timolol maleate
3
QL
1 / 1 days
COSOPT PF EYE DROPS
dorzolamide hcl/timolol maleate/pf
3
dorzolamide hcl 2% eye drops
1
QL
1 / 1 days
dorzolamide-timolol eye drops
1
QL
1 / 1 days
IOPIDINE 1% EYE DROPS
apraclonidine hcl
5
C
ISTALOL 0.5% EYE DROPS
timolol maleate
3
latanoprost 0.005% eye drops
1
QL
1 / 1 days
levobunolol 0.5% eye drops
1
QL
1 / 1 days
LUMIGAN 0.01% EYE DROPS
bimatoprost
3
QL
1 / 1 days
5
PA
5
PA
PAGE 154
QL-2
PRODUCT DESCRIPTION
TIER
metipranolol 0.3% eye drops
1
QL
1 / 1 days
PHOSPHOLINE IODIDE 0.125%
echothiophate iodide
3
QL
1 / 1 days
pilocarpine 1% eye drops
2
2
2
RESCULA 0.15% EYE DROPS
unoprostone isopropyl
3
timolol 0.25% eye drops
2
QL
1 / 1 days
timolol 0.25% gel-solution
2
QL
1 / 1 days
timolol 0.25% gfs gel-solution
2
QL
1 / 1 days
timolol 0.5% eye drops
2
QL
1 / 1 days
timolol 0.5% gel-solution
2
QL
1 / 1 days
timolol 0.5% gfs gel-solution
2
QL
1 / 1 days
ZIOPTAN 0.0015% EYE DROPS
tafluprost/pf
3
Otic Agents
acetasol hc ear drops
5
acetic acid 2% ear solution
2
QL
1 / 1 days
acetic acid-aluminum drops
2
QL
1 / 1 days
CIPRO HC OTIC SUSPENSION
ciprofloxacin hcl/hydrocortisone
5
PA
CIPRODEX OTIC SUSPENSION
ciprofloxacin hcl/dexamethasone
3
fluocinolone oil 0.01% ear drp
2
hydrocortison-acetic acid soln
5
PAGE 155
QL
1 / 1 days
2
QL
1 / 1 days
2
QL
1 / 1 days
PRODUCT DESCRIPTION
TIER
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
PA
ALVESCO 160 MCG INHALER
ciclesonide
5
ALVESCO 80 MCG INHALER
ciclesonide
5
ASMANEX TWISTHALER 110 MCG #30
mometasone furoate
3
mometasone furoate
3
mometasone furoate
3
mometasone furoate
3
mometasone furoate
3
ASMANEX TWISTHALR 220 MCG #120
mometasone furoate
3
budesonide 0.25 mg/2 ml susp
2
ST
PA
ST
PA
AL
At least 5 yrs old
PA
budesonide 0.5 mg/2 ml susp
2
AL
PA
5
5
5
5
5
fluticasone prop 50 mcg spray
1
PAGE 156
At least 5 yrs old
ST
PA
ST
PA
ST
PA
ST
PA
ST
QL
1 / 1 days
PRODUCT DESCRIPTION
NASONEX 50 MCG NASAL SPRAY
mometasone furoate
OMNARIS 50 MCG NASAL SPRAY
ciclesonide
TIER
3
5
QL
1 / 1 days
QL
1 / 1 days
PA
ST
PULMICORT 180 MCG FLEXHALER
budesonide
3
PULMICORT 90 MCG FLEXHALER
budesonide
3
QVAR 40 MCG ORAL INHALER
beclomethasone dipropionate
3
RHINOCORT AQUA NASAL SPRAY
budesonide
3
triamcinolone 55 mcg nasal spr
5
PA
PA
ST
VERAMYST 27.5 MCG NASAL SPRAY
fluticasone furoate
ZETONNA 37 MCG NASAL SPRAY
ciclesonide
3
5
QL
1 / 1 days
QL
1 / 1 days
PA
ST
Antihistamines
ASTEPRO 0.15% NASAL SPRAY
azelastine hcl
3
azelastine 0.1% (137 mcg) spry
2
CLARINEX 0.5 MG/ML (2.5 MG/5)
desloratadine
5
clemastine 0.5 mg/5 ml syrup
5
cyproheptadine 2 mg/5 ml syrup
2
cyproheptadine 4 mg tablet
2
cyproheptadine 4 mg/10 ml syrp
2
desloratadine 2.5 mg odt
5
desloratadine 5 mg odt
5
desloratadine 5 mg tablet
5
2
PAGE 157
QL
1 / 1 days
PA
PRODUCT DESCRIPTION
TIER
2
2
2
2
2
PATANASE 665 MCG NASAL SPRAY
olopatadine hcl
3
promethazine 12.5 mg tablet
2
2
2
promethazine 6.25 mg/5 ml syrp
2
QL
1 / 1 days
Antileukotrienes
montelukast sod 10 mg tablet
1
montelukast sod 4 mg tab chew
1
montelukast sod 5 mg tab chew
1
zafirlukast 10 mg tablet
2
zafirlukast 20 mg tablet
2
ZYFLO CR 600 MG TABLET
zileuton
5
PA
Bronchodilators, Anticholinergic
ATROVENT HFA INHALER
ipratropium bromide
3
ipratropium 0.03% spray
2
ipratropium 0.06% spray
2
ipratropium br 0.02% soln
2
SPIRIVA 18 MCG CP-HANDIHALER
tiotropium bromide
5
TUDORZA PRESSAIR 400 MCG INH
aclidinium bromide
5
PA
ST
ST
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
ELIXOPHYLLIN 80 MG/15 ML ELIX
theophylline anhydrous
3
theochron er 100 mg tablet
2
PAGE 158
PRODUCT DESCRIPTION
TIER
2
2
theophylline 80 mg/15 ml soln
2
theophylline 80 mg/15 ml soln
2
theophylline er 400 mg tablet
2
theophylline er 450 mg tab
2
theophylline er 600 mg tablet
2
Bronchodilators, Sympathomimetic
ADRENALIN 1 MG/ML VIAL
epinephrine
5
ST
albuterol 2.5 mg/0.5 ml sol
2
QL
1 / 1 days
albuterol 5 mg/ml solution
2
QL
1 / 1 days
albuterol sul 2.5 mg/3 ml soln
2
QL
1 / 1 days
albuterol sulf 2 mg/5 ml syrup
2
ARCAPTA NEOHALER 75 MCG CAP
indacaterol maleate
5
PA
BROVANA 15 MCG/2 ML SOLUTION
arformoterol tartrate
5
PA
epinephrine 0.1 mg/ml syringe
5
ST
epinephrine 0.15 mg auto-injct
5
ST
epinephrine 0.3 mg auto-inject
5
ST
epinephrine 1 mg/ml ampul
5
ST
epinephrine 1 mg/ml ampul
5
PA
ST
epinephrine 1 mg/ml vial
5
EPIPEN JR 2-PAK 0.15 MG INJCTR
epinephrine
3
FORADIL AEROLIZER 12 MCG CAP
formoterol fumarate
3
levalbuterol 0.31 mg/3 ml sol
2
ST
QL
1 / 1 days
ST
QL
1 / 1 days
ST
AL
PAGE 159
At least 5 yrs old
PRODUCT DESCRIPTION
TIER
ST
2
AL
At least 5 yrs old
ST
2
AL
At least 5 yrs old
ST
levalbuterol conc 1.25 mg/0.5
2
metaproterenol 10 mg tablet
2
metaproterenol 10 mg/5 ml syr
2
metaproterenol 20 mg tablet
2
PROAIR HFA 90 MCG INHALER
albuterol sulfate
3
PROVENTIL HFA 90 MCG INHALER
albuterol sulfate
3
terbutaline sulfate 2.5 mg tab
2
terbutaline sulfate 5 mg tab
2
VENTOLIN HFA 90 MCG INHALER
albuterol sulfate
3
AL
At least 5 yrs old
QL
1 / 1 days
Mast Cell Stabilizers
cromolyn 100 mg/5 ml oral conc
2
cromolyn 20 mg/2 ml neb soln
2
Pulmonary Antihypertensives
LETAIRIS 10 MG TABLET
ambrisentan
PA
4
C
QL-45
S
Specialty Drug
QL
LETAIRIS 5 MG TABLET
ambrisentan
PA
4
C
QL-45
S
Specialty Drug
REMODULIN 1 MG/ML VIAL
treprostinil sodium
4
PA
treprostinil sodium
4
PA
PAGE 160
1 / 1 days
PRODUCT DESCRIPTION
TIER
REMODULIN 2.5 MG/ML VIAL
treprostinil sodium
4
PA
treprostinil sodium
4
PA
TRACLEER 125 MG TABLET
bosentan
4
TRACLEER 62.5 MG TABLET
bosentan
4
VENTAVIS 10 MCG/1 ML SOLUTION
iloprost tromethamine
4
VENTAVIS 20 MCG/1 ML SOLUTION
iloprost tromethamine
4
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
Respiratory Tract Agents, Other
acetylcysteine 10% vial
5
PA
acetylcysteine 20% vial
5
PA
CAYSTON 75 MG INHAL SOLUTION
aztreonam lysine
4
PA
DALIRESP 500 MCG TABLET
roflumilast
3
2
2
2
2
TYZINE 0.1% NOSE DROPS
tetrahydrozoline hcl
3
TYZINE PEDIATRIC 0.05% DROP
3
Skeletal Muscle Relaxants
carisoprodol 350 mg tablet
2
chlorzoxazone 500 mg tablet
2
COMFORT PAC-CYCLOBENZAPRINE KT
cyclobenzaprine hcl/irritants counter-irritants combo #2
1
cyclobenzaprine 10 mg tablet
1
PAGE 161
PRODUCT DESCRIPTION
TIER
cyclobenzaprine 5 mg tablet
1
LORZONE 375 MG TABLET
chlorzoxazone
5
LORZONE 750 MG TABLET
chlorzoxazone
2
metaxalone 800 mg tablet
2
methocarbamol 500 mg tablet
2
methocarbamol 750 mg tablet
2
orphenadrine er 100 mg tablet
2
Sleep Disorder Agents
GABA Receptor Modulators
eszopiclone 1 mg tablet
1
1
1
zaleplon 10 mg capsule
1
QL
1 / 1 days
zaleplon 5 mg capsule
1
QL
1 / 1 days
zolpidem tartrate 10 mg tablet
1
zolpidem tartrate 5 mg tablet
1
Sleep Disorders, Other
2
2
2
2
2
2
2
modafinil 100 mg tablet
4
QL
1 / 1 days
modafinil 200 mg tablet
4
QL
1 / 1 days
NUVIGIL 150 MG TABLET
armodafinil
3
QL
1 / 1 days
armodafinil
3
QL
1 / 1 days
PAGE 162
PRODUCT DESCRIPTION
TIER
armodafinil
3
QL
ROZEREM 8 MG TABLET
ramelteon
5
PA
1 / 1 days
Therapeutic Nutrients/ Minerals/ Electrolytes
Electrolyte/Mineral Modifiers
CHEMET 100 MG CAPSULE
succimer
5
penicillamine
5
PA
penicillamine
5
PA
EXJADE 125 MG TABLET
deferasirox
3
S
Specialty Drug
deferasirox
3
S
Specialty Drug
deferasirox
3
S
Specialty Drug
kionex 15 gm/60 ml suspension
3
kionex powder
3
QL
SAMSCA 15 MG TABLET
tolvaptan
4
PA
S
QL
SAMSCA 30 MG TABLET
tolvaptan
4
Specialty Drug
1 / 1 days
PA
S
SYPRINE 250 MG CAPSULE
trientine hcl
1 / 1 days
5
PA
bacteriostatic saline vial
5
PA
bd normal saline flush syringe
5
KLOR-CON M15 TABLET
potassium chloride
3
magnesium sulfate 50% syringe
2
magnesium sulfate 50% vial
2
Specialty Drug
Electrolyte/Mineral Replacement
PAGE 163
PRODUCT DESCRIPTION
TIER
monoject 0.9% sodium cl syring
5
monoject prefill 0.9% flush
5
monoject prefill 0.9% na syr
5
normal saline flush syringe
5
potassium citrate er 10 meq tb
2
potassium citrate er 5 meq tab
2
potassium cl er 10 meq capsule
1
potassium cl er 10 meq tablet
1
1
1
1
potassium cl er 8 meq capsule
1
1
saline 0.9% soln-excel cont
5
sodium chloride 0.9% 100 ml
5
5
5
5
5
sodium chloride 0.9% soln
5
sodium chloride 0.9% solution
5
sodium chloride 0.9% solution
5
sodium chloride 0.9% syringe
5
sodium chloride 0.9% vial
5
sodium chloride 0.9% zr syr
5
syrex sodium chl 0.9% syr
5
UROCIT-K ER 15 MEQ TABLET
potassium citrate
5
PA
Uncategorized
Unclassified
PA
4-aminopyridine powder
4
S
PAGE 164
Specialty Drug
PRODUCT DESCRIPTION
TIER
5-aminosalicylic acid powd
3
5-aminosalicylic acid powder
3
6-aminocaproic acid powder
4
isotretinoin
4
isotretinoin
4
acetamin-codein 300-30 mg/12.5
2
acetaminop-codeine 120-12 mg/5
2
acetaminophen-cod #2 tablet
2
2
2
acetaminophn-butalbital 325-50
2
acetic acid 0.25% irrig soln
2
acetyl salicylic acid powder
0
ACZONE 5% GEL
dapsone
5
ADACEL TDAP SYRINGE
diphtheria,pertussis(acell),tetanus vaccine/pf
0
ADACEL TDAP VIAL
diphtheria,pertussis(acell),tetanus vaccine/pf
0
adenovirus type 4 & 7 ec tabs
0
adenovirus type 4 ec tablet
0
adenovirus type 7 ec tablet
0
ADVAIR 100-50 DISKUS
fluticasone propionate/salmeterol xinafoate
5
ST
5
ST
5
ST
ADVAIR HFA 115-21 MCG INHALER
5
ST
5
ST
5
ST
PAGE 165
PA
PRODUCT DESCRIPTION
TIER
PA
ADVICOR 1,000 MG-20 MG TABLET
niacin/lovastatin
5
ADVICOR 1,000 MG-40 MG TABLET
niacin/lovastatin
5
ADVICOR 500 MG-20 MG TABLET
niacin/lovastatin
5
ADVICOR 750 MG-20 MG TABLET
niacin/lovastatin
5
AFLURIA 2015-2016 SYRINGE
influenza virus vaccine trivalnt 2015-2016 (5 yr & older)/pf
0
AFLURIA 2015-2016 VIAL
influenza virus vaccine trivalent 2015-2016 (5 yr & older)
0
ak-poly-bac eye ointment
1
AKTEN 3.5% GEL DROPS
lidocaine hcl/pf
2
ALA-QUIN 3-0.5% CREAM
clioquinol/hydrocortisone
5
alcohol,dehydrated 98% ampule
5
alcohol,dehydrated 98% vial
5
ALDACTAZIDE 50-50 TABLET
spironolactone/hydrochlorothiazide
3
ALFERON N 5 MILLION UNITS VIAL
interferon alfa-n3
4
ALKERAN 2 MG TABLET
melphalan
4
allopurinol powder
1
alprazolam 0.25 mg tablet
1
alprazolam 0.5 mg tablet
1
alprazolam 1 mg tablet
1
alprazolam 2 mg tablet
1
altacaine 0.5% eye drops
1
altavera-28 tablet
0
amethia 0.15-0.03-0.01 mg tab
0
PAGE 166
ST
PA
ST
PA
ST
PA
ST
PA
PA
S
Specialty Drug
PA
PRODUCT DESCRIPTION
TIER
amethia lo tablet
0
amethyst 90-20 mcg tablet
0
aminocaproic acid 5 g/20 ml vl
4
aminocaproic acid powder
4
aminolevulinic acid hcl powd
4
aminosalicylic acid powder
5
amlodipine besilate powder
1
amlodipine besylate powder
1
amoxicillin trihydrate powder
1
ANACAINE OINTMENT
benzocaine
5
ANDROGEL 1% GEL PUMP
testosterone
3
ANDROGEL 1.62% GEL PUMP
testosterone
3
ANDROGEL 1.62%(1.25G) GEL PCKT
testosterone
3
ANDROGEL 1.62%(2.5G) GEL PCKT
testosterone
3
ANORO ELLIPTA 62.5-25 MCG INH
umeclidinium bromide/vilanterol trifenatate
3
antipyrine-benzocaine ear drop
2
antipyrine-benzocaine otic sol
2
PA
QL
1 / 1 days
PA
apomorphine hcl powder
aranelle 28 tablet
4
C
QL-90
S
Specialty Drug
0
PA
4
C
QL-4
S
Specialty Drug
QL
ARANESP 150 MCG/0.75 ML VIAL
PAGE 167
1 / 1 days
PA
4
C
QL-4
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
QL
1 / 1 days
PA
4
C
QL-4
S
Specialty Drug
ARMOUR THYROID 120 MG TABLET
thyroid,pork
3
thyroid,pork
3
thyroid,pork
3
thyroid,pork
3
thyroid,pork
3
ascorbic acid 500 mg/ml vial
5
ASMANEX HFA 100 MCG INHALER
mometasone furoate
3
ASMANEX HFA 200 MCG INHALER
mometasone furoate
3
aspirin powder
0
atenolol-chlorthalidone 100-25
1
atenolol-chlorthalidone 50-25
1
ATRIPLA TABLET
efavirenz/emtricitabine/tenofovir disoproxil fumarate
3
atropine 0.4 mg/ml vial
2
atropine 1 mg/ml vial
2
atropine 1% eye drops
1
QL
1 / 1 days
atropine 1% eye ointment
1
QL
1 / 1 days
atropine 8 mg/20 ml vial
2
aubra-28 tablet
0
auroguard otic solution
2
QL
1 / 1 days
AVANDAMET 2 MG-1,000 MG TAB
rosiglitazone maleate/metformin hcl
3
AVANDAMET 2 MG-500 MG TABLET
rosiglitazone maleate/metformin hcl
3
PAGE 168
PA
PRODUCT DESCRIPTION
TIER
AVAR LS CLEANSER
sulfacetamide sodium/sulfur
5
AVC 15% CREAM
sulfanilamide
3
aviane-28 tablet
0
AVONEX PEN 30 MCG/0.5 ML
interferon beta-1a
4
S
Specialty Drug
AVONEX PEN 30 MCG/0.5 ML KIT
interferon beta-1a
4
S
Specialty Drug
AZOR 10-20 MG TABLET
amlodipine besylate/olmesartan medoxomil
5
AZOR 10-40 MG TABLET
5
AZOR 5-20 MG TABLET
5
AZOR 5-40 MG TABLET
5
bacitracin-polymyxin eye oint
1
BAL IN OIL 100 MG/ML AMPULE
dimercaprol
5
PA
belladonna-opium 16.2-30 supp
5
PA
belladonna-opium 16.2-60 supp
5
PA
BELSOMRA 10 MG TABLET
suvorexant
5
suvorexant
5
suvorexant
5
suvorexant
5
benazepril-hctz 10-12.5 mg tab
2
2
PAGE 169
PA
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PRODUCT DESCRIPTION
TIER
benazepril-hctz 20-25 mg tab
2
2
BENICAR HCT 20-12.5 MG TABLET
olmesartan medoxomil/hydrochlorothiazide
5
BENICAR HCT 40-12.5 MG TABLET
5
BENICAR HCT 40-25 MG TABLET
5
benzepro 6% foaming cloths
2
benzocaine powder
5
benzocaine powder
5
benzonatate 100 mg capsule
1
benzonatate 200 mg capsule
1
benzoyl peroxide 5.3% foam
2
benzoyl peroxide 9.8% foam
2
benzoyl peroxide powder
2
BETADINE 5% EYE SOLUTION
povidone-iodine
2
BEXSERO PREFILLED SYRINGE
meningococcal group b vaccine, 4-component/pf
0
BEYAZ 28 TABLET
drospirenone/ethinyl estradiol/levomefolate calcium
0
BLEPHAMIDE EYE DROPS
sulfacetamide sodium/prednisolone acetate
3
BLEPHAMIDE EYE OINTMENT
sulfacetamide sodium/prednisolone acetate
3
BOOSTRIX TDAP VACCINE SYRINGE
diphtheria,pertussis(acellular),tetanus vaccine
0
BOOSTRIX TDAP VACCINE VIAL
diphtheria,pertussis(acellular),tetanus vaccine
0
BOSULIF 100 MG TABLET
bosutinib
4
BOSULIF 500 MG TABLET
bosutinib
4
PAGE 170
PA
ST
PA
ST
PA
ST
PA
S
Specialty Drug
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
bp folinatal plus b tablet
0
bpo 3% foaming cloths
2
bpo 4% gel
4
5
bpo 8% gel
4
5
BREVICON 28 TABLET
5
budesonide ec 3 mg capsule
2
PA
buprenorphin-naloxon 8-2 mg sl
4
PA
buprenorphn-naloxn 2-0.5 mg sl
4
PA
butalb-acetamin-caff 50-325-40
2
butalb-caff-acetaminoph-codein
2
butalbit-acetaminophen-caff cp
2
butalbital comp-codeine #3 cap
2
butalbital-asa-caffeine cap
2
BUTISOL SODIUM 30 MG TABLET
butabarbital sodium
3
BUTRANS 7.5 MCG/HR PATCH
buprenorphine
5
BYDUREON 2 MG PEN INJECT
exenatide microspheres
5
calcipotriene 0.005% ointment
4
camrese 0.15-0.03-0.01 mg tab
0
camrese lo tablet
0
CAMRESE LO TABLET
levonorgestrel-eth estra/ethinyl estradiol
0
candesartan-hctz 16-12.5 mg tb
5
PA
ST
PA
ST
PA
candesartan-hctz 32-12.5 mg tb
5
ST
PA
candesartan-hctz 32-25 mg tab
5
ST
PAGE 171
PRODUCT DESCRIPTION
TIER
PA
capecitabine 150 mg tablet
4
S
Specialty Drug
PA
capecitabine 500 mg tablet
4
S
CAPITAL WITH CODEINE SUSP
acetaminophen with codeine phosphate
5
carb-o-philic 40% cream
2
carbidopa-levodopa-enta 100 mg
2
2
2
2
2
2
carisoprodl-aspirin 200-325 mg
2
carisoprodol compound tab
2
carisoprodol cpd-codeine tab
2
carisoprodol-aspirin-codein tb
2
CARNITOR SF 100 MG/ML ORAL SOL
levocarnitine
5
caziant 28 day tablet
0
ceftriaxone sodium powder
5
cem-urea 45% pre-filled appl
2
CERVARIX VACCINE SYRINGE
human papillomavirus vaccine, bivalent/pf
0
CERVIDIL 10 MG VAGINAL INSRT
dinoprostone
5
CETROTIDE 0.25 MG KIT
cetrorelix acetate
4
chateal-28 tablet
0
CHENODAL 250 MG TABLET
chenodiol
3
chlorambucil powder
4
chlordiazepo-amitriptyl 5-12.5
2
PAGE 172
Specialty Drug
PA
PA
PA
PA
S
Specialty Drug
PA
PRODUCT DESCRIPTION
TIER
chlordiazepox-amitriptyl 10-25
2
chlordiazepoxide 10 mg capsule
1
1
1
chlordiazepoxide-clidinium cap
2
chlorhexidine gluc 20% soln
5
choline mag trisal liquid
2
2
CITRANATAL B-CALM COMBO PACK
prenatal vit comb no.48/iron, carbonyl & gluconate/fa/b6
0
CLIMARA PRO PATCH
estradiol/levonorgestrel
3
clindamycin phos crystals
3
clindamycin phosphate powder
3
CLINPRO 5000 1.1% TOOTHPASTE
sodium fluoride
0
clonazepam 0.5 mg tablet
1
clonazepam 1 mg tablet
1
clonazepam 2 mg tablet
1
clorazepate 15 mg tablet
2
clorazepate 3.75 mg tablet
2
clorazepate 7.5 mg tablet
2
clotrimazole 1% solution
1
colistimethate 150 mg vial
5
colistimethate sodium powder
5
COMBIPATCH 0.05-0.14 MG PTCH
estradiol/norethindrone acetate
3
COMBIPATCH 0.05-0.25 MG PTCH
estradiol/norethindrone acetate
3
COMPLERA TABLET
emtricitabine/rilpivirine hcl/tenofovir disoproxil fumarate
3
COMVAX VACCINE VIAL
hepatitis b virus vaccine/haemoph b polysac conj-mening/pf
0
glatiramer acetate
4
PAGE 173
PA
AL
6mos to 6 yrs old
S
Specialty Drug
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
CORTIFOAM 10% AEROSOL
hydrocortisone acetate
3
covaryx h.s. tablet
2
covaryx tablet
2
cryselle-28 tablet
0
cyanocobalamin 1,000 mcg/ml
2
CYCLOGYL 0.5% EYE DROPS
cyclopentolate hcl
2
CYCLOMYDRIL EYE DROPS
cyclopentolate hcl/phenylephrine hcl
3
QL
1 / 1 days
cyclopentolate 1% eye drops
1
QL
1 / 1 days
cyclopentolate hcl 2% drops
1
QL
1 / 1 days
DAPTACEL DTAP VACCINE
diphtheria, pertussis(acell), tetanus ped vacc/pf
0
daysee 0.15-0.03-0.01 mg tab
0
deferoxamine 2 gram vial
2
deferoxamine 500 mg vial
2
delyla-28 tablet
0
DEMSER 250 MG CAPSULE
metyrosine
5
PA
denta 5000 plus cream
0
AL
6mos to 6 yrs old
dentagel 1.1% gel
0
AL
6mos to 6 yrs old
diazepam 10 mg rectal gel syst
2
diazepam 10 mg tablet
1
1
diazepam 2.5 mg rectal gel sys
2
diazepam 20 mg rectal gel syst
2
1
diazepam 5 mg/5 ml oral soln
2
diazepam 5 mg/5 ml solution
2
diphtheria-tetanus toxoids-ped
0
dmsa powder
5
doxycycline hyclate 50 mg cap
2
PAGE 174
PRODUCT DESCRIPTION
TIER
doxycycline mono 150 mg tablet
2
DRITHOCREME HP 1% CREAM
anthralin
4
drospirenone-eth estradiol tab
0
DUAVEE 0.45-20 MG TABLET
estrogens, conjugated/bazedoxifene acetate
3
DULERA 100 MCG/5 MCG INHALER
mometasone furoate/formoterol fumarate
3
DULERA 200 MCG/5 MCG INHALER
mometasone furoate/formoterol fumarate
3
DUOPA 4.63 MG-20 MG/ML SUSPENS
carbidopa/levodopa
2
DUTOPROL 100-12.5 MG TABLET
metoprolol succinate/hydrochlorothiazide
3
PA
3
PA
3
PA
ECOZA 1% FOAM
econazole nitrate
5
PA
EDARBYCLOR 40-12.5 MG TABLET
azilsartan medoxomil/chlorthalidone
3
EDARBYCLOR 40-25 MG TABLET
azilsartan medoxomil/chlorthalidone
3
EGRIFTA 1 MG VIAL
tesamorelin acetate
5
EGRIFTA 2 MG VIAL
tesamorelin acetate
5
elinest-28 tablet
0
enalapril-hctz 10-25 mg tablet
1
enalapril-hctz 5-12.5 mg tab
1
PA
ST
PA
ST
PA
ENBREL 50 MG/ML SURECLICK SYR
etanercept
5
ST
S
ENGERIX-B 10 MCG/0.5 ML PED VL
hepatitis b virus vaccine recombinant/pf
PAGE 175
Specialty Drug
0
PRODUCT DESCRIPTION
TIER
ENGERIX-B 20 MCG/ML SYRN
0
ENGERIX-B 20 MCG/ML VIAL
0
ENGERIX-B PEDI 10 MCG/0.5 SYRN
0
enpresse-28 tablet
0
epinephrine powder
5
erythromycin dr 250 mg cap
2
erythromycin ec 250 mg cap
2
erythromycin powder
2
estazolam 1 mg tablet
2
estazolam 2 mg tablet
2
estradiol-noreth 0.5-0.1 mg tb
0
ESTROSTEP FE-28 TABLET
5
PA
etoposide 50 mg capsule
4
PA
EXFORGE 10-160 MG TABLET
amlodipine besylate/valsartan
5
5
5
5
EXFORGE HCT 10-160-12.5 MG TAB
amlodipine besylate/valsartan/hydrochlorothiazide
5
EXFORGE HCT 10-320-25 MG TAB
5
EXFORGE HCT 5-160-12.5 MG TAB
5
falmina-28 tablet
0
PAGE 176
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PA
ST
PRODUCT DESCRIPTION
TIER
FARXIGA 10 MG TABLET
dapagliflozin propanediol
5
PA
FARXIGA 5 MG TABLET
dapagliflozin propanediol
5
PA
FASLODEX 250 MG/5 ML SYRINGE
fulvestrant
4
PA
femcap 22 mm cervical cap
0
0
0
FEMHRT 0.5 MG-2.5 MCG TABLET
norethindrone acetate-ethinyl estradiol
3
ferrogels forte softgel
2
FLUARIX QUAD 2015-2016 SYRINGE
influenza virus vaccine quadrival split 2015-16(36 mos+)/pf
0
FLUBLOK 2015-2016 VIAL
influenza virus vaccine tv 2015-2016(18 yrs & older)rcmb/pf
0
FLUCAINE EYE DROPS
proparacaine hcl/fluorescein sodium
1
FLUCELVAX 2015-2016 SYRINGE
influenza vaccine trivalent 2015-2016(18 yr+)cell derived/pf
0
FLULAVAL QUAD 2015-2016 VIAL
influenza virus vaccine quadrival 2015-2016 (36 mos & older)
0
fluocinolone acetonide powder
5
FLUOR-A-DAY 0.25 MG TAB CHEW
sodium fluoride/xylitol
0
FLUOR-A-DAY 0.5 MG TAB CHEW
0
FLUOR-A-DAY 1 MG TABLET CHEW
0
FLUOR-A-DAY 2.5 MG/ML DROPS
sodium fluoride
0
AL
6mos to 6 yrs old
FLUORABON 0.25 MG/0.6 ML DROPS
sodium fluoride
0
AL
6mos to 6 yrs old
fluoride 0.25 mg tablet chew
0
AL
6mos to 6 yrs old
fluoride 0.5 mg tablet chew
0
AL
6mos to 6 yrs old
fluoride 1 mg tablet chewable
0
AL
6mos to 6 yrs old
PAGE 177
PRODUCT DESCRIPTION
TIER
fluoridex defense 1.1% gel
0
AL
6mos to 6 yrs old
fluoritab 0.125 mg/drp drops
0
AL
6mos to 6 yrs old
fluoritab 0.5 mg tablet chew
0
AL
6mos to 6 yrs old
fluorouracil powder
4
PA
flura-drops 0.25 mg/drop
0
AL
6mos to 6 yrs old
flurazepam 15 mg capsule
2
flurazepam 30 mg capsule
2
FLUVIRIN 2015-2016 SYRINGE
influenza virus vaccine trivalnt 2015-2016 (4 yr & older)/pf
0
FLUVIRIN 2015-2016 VIAL
influenza virus vaccine trivalent 2015-2016 (4 yr & older)
0
FLUZONE 2015-2016 VIAL
influenza virus vaccine trivalent 2015-16 (6 mos and older)
0
FLUZONE HIGH-DOSE 2015-16 SYR
influenza virus vaccine trivalent split 2015-2016(65 yr+)/pf
0
FLUZONE QUAD 2015-2016 SYRINGE
0
FLUZONE QUAD 2015-2016 VIAL
0
FLUZONE QUAD 2015-2016 VIAL
influenza virus vaccine qvalsplit 2015-2016(6 mos and older)
0
FLUZONE QUAD PEDI 2015-16 SYR
influenza virus vaccine quadrival 2015-16 (6 mos-35 mos)/pf
0
folic acid 1 mg tablet
0
folic acid 5 mg/ml vial
2
AL
At least 5 yrs old
GARDASIL 9 SYRINGE
human papillomavirus vaccine, 9-valent/pf
0
GARDASIL 9 VIAL
human papillomavirus vaccine, 9-valent/pf
0
GARDASIL SYRINGE
human papillomavirus vaccine, quadrivalent/pf
0
GARDASIL VIAL
human papillomavirus vaccine, quadrivalent/pf
0
gavilyte-c solution
1
gianvi 3 mg-0.02 mg tablet
0
PAGE 178
PRODUCT DESCRIPTION
TIER
gildess 1 mg-20 mcg tablet
0
gildess 1.5 mg-30 mcg tablet
0
glyburid-metformin 1.25-250 mg
1
glyburide-metformin 2.5-500 mg
1
glyburide-metformin 5-500 mg
1
GORDO-UREA 22% OINTMENT
urea
2
GORDO-UREA 40% OINTMENT
urea
3
GRASTEK 2,800 BAU SL TABLET
grass pollen-timothy, std
4
PA
PA
HARVONI 90-400 MG TABLET
ledipasvir/sofosbuvir
5
ST
S
Specialty Drug
HAVRIX 1,440 UNITS/ML SYRINGE
hepatitis a virus vaccine/pf
0
HAVRIX 1,440 UNITS/ML VIAL
0
HAVRIX 720 UNIT/0.5 ML SYRINGE
0
HAVRIX 720 UNITS/0.5 ML VIAL
0
hematogen fa softgel
2
hematogen forte softgel
2
HETLIOZ 20 MG CAPSULE
tasimelteon
5
PA
homatropaire 5% eye drops
1
QL
1 / 1 days
QL
1 / 1 days
HORIZANT ER 300 MG TABLET
gabapentin enacarbil
5
PA
ST
HUMALOG 100 UNITS/ML CARTRIDGE
insulin lispro
3
QL
1 / 1 days
HUMALOG 100 UNITS/ML KWIKPEN
insulin lispro
3
QL
1 / 1 days
adalimumab
4
PAGE 179
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
HYCAMTIN 0.25 MG CAPSULE
topotecan hcl
4
HYCAMTIN 1 MG CAPSULE
topotecan hcl
4
HYDRO 40 FOAM
urea
2
hydrocod-homatrop 5-1.5 mg tab
2
hydrocodon-acetamin 7.5-325/15
2
hydrocodon-acetaminoph 2.5-325
2
2
2
hydrocodon-acetaminophen 5-300
2
hydrocodon-acetaminophen 5-325
2
hydrocodon-acetaminophn 10-300
2
hydrocodon-acetaminophn 10-325
2
hydrocodone-acetamin 10-325/15
2
hydrocodone-acetamin 2.5-108/5
2
hydrocodone-acetamin 2.5-167/5
2
hydrocodone-acetamin 5-163/7.5
2
hydrocodone-acetamin 5-217/10
2
hydrocodone-chlorphen er susp
2
hydrocort-pram 2.5%-1% crm kit
2
hydrocort-pram 2.5%-1% crm kit
2
hydrocort-pramoxine 1%-1% crm
2
hydrocortisone 1% absorbase
1
hydrocortisone 1% ointment
1
hydrocortisone ac 25 mg supp
2
hydrocortisone powder
2
hydromet syrup
2
hydromorphone 3 mg suppos
2
hydroxocobalamin 1,000 mcg/ml
5
hyoscyamine 0.125 mg odt
2
PAGE 180
S
Specialty Drug
PA
PA
PRODUCT DESCRIPTION
TIER
hyoscyamine 0.125 mg tab sl
2
hyoscyamine 0.125 mg/5 ml elix
2
hyoscyamine 0.125 mg/ml drop
2
hyoscyamine 125 mcg/5 ml elix
2
hyoscyamine er 0.375 mg tab
2
hyoscyamine sr 0.375 mg tab
2
hyoscyamine sulf 0.125 mg tab
2
hyosyne 0.125 mg/ml drop
2
hyosyne 125 mcg/5 ml elixir
2
ILUVIEN 0.19 MG IMPLANT
5
IMBRUVICA 140 MG CAPSULE
ibrutinib
4
PA
imiquimod powder
5
PA
INCRUSE ELLIPTA 62.5 MCG INH
umeclidinium bromide
3
INFANRIX DTAP SYRINGE
0
INFANRIX DTAP VIAL
0
INFED 100 MG/2 ML VIAL
iron dextran complex
3
INLYTA 1 MG TABLET
axitinib
4
INLYTA 5 MG TABLET
axitinib
4
INTEGRILIN 20 MG/10 ML VIAL
eptifibatide
5
PA
eptifibatide
5
PA
eptifibatide
5
PA
introvale 0.15-0.03 mg tablet
0
INVOKAMET 150-1,000 MG TABLET
canagliflozin/metformin hcl
5
PAGE 181
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
PRODUCT DESCRIPTION
TIER
INVOKAMET 150-500 MG TABLET
5
PA
INVOKAMET 50-1,000 MG TABLET
5
PA
INVOKAMET 50-500 MG TABLET
5
PA
IPOL SINGLE DOSE SYRINGE
poliomyelitis vaccine, killed
0
IPOL VIAL
poliomyelitis vaccine, killed
0
iprat-albut 0.5-3(2.5) mg/3 ml
2
irbesartan-hctz 150-12.5 mg tb
1
irbesartan-hctz 300-12.5 mg tb
1
isomethept-caff-acetaminophen
5
isomethept-dichloralp-acetamin
2
isotretinoin powder
4
isoxsuprine 10 mg tablet
2
isoxsuprine 20 mg tablet
2
JALYN 0.5-0.4 MG CAPSULE
dutasteride/tamsulosin hcl
5
JANUMET 50-1,000 MG TABLET
sitagliptin phosphate/metformin hcl
5
JANUMET 50-500 MG TABLET
5
PA
PA
PA
ST
PA
ST
QL
JANUMET XR 100-1,000 MG TABLET
5
1 / 1 days
PA
ST
QL
JANUMET XR 50-1,000 MG TABLET
5
1 / 1 days
PA
ST
QL
JANUMET XR 50-500 MG TABLET
5
1 / 1 days
PA
ST
PAGE 182
PRODUCT DESCRIPTION
TIER
PA
JENTADUETO 2.5 MG-1000 MG TAB
linagliptin/metformin hcl
5
5
5
jinteli 1 mg-5 mcg tablet
2
jolessa 0.15 mg-0.03 mg tablet
0
junel 1 mg-20 mcg tablet
0
junel 1.5 mg-30 mcg tablet
0
K-PHOS #2 TABLET
sodium phosphate,monobasic/potassium phosphate,monobasic
3
K-PHOS NEUTRAL TABLET
phosphorus #1
3
K-PHOS ORIGINAL TABLET
potassium phosphate,monobasic
3
k-sol 10% (20 meq/15 ml) liq
1
k-sol 20% (40 meq/15 ml) liq
1
KAZANO 12.5-1,000 MG TABLET
alogliptin benzoate/metformin hcl
3
KAZANO 12.5-500 MG TABLET
alogliptin benzoate/metformin hcl
3
kelnor 1-35 28 tablet
0
kendall 0.9% nacl syringe-cap
5
KERAFOAM 30% FOAM
urea
2
KERAFOAM 42% FOAM
urea
2
KINEVAC 5 MCG VIAL
sincalide
5
KINRIX TIP-LOK SYRINGE
diphtheria, pertussis(acell),tetanus,polio vaccine/pf
0
KINRIX VIAL
0
klor-con 20 meq packet
3
PAGE 183
ST
PA
ST
PA
ST
PA
PA
PRODUCT DESCRIPTION
TIER
KLOR-CON 25 MEQ PACKET
potassium chloride
3
KOMBIGLYZE XR 2.5-1,000 MG TAB
saxagliptin hcl/metformin hcl
5
KOMBIGLYZE XR 5-1,000 MG TAB
5
KOMBIGLYZE XR 5-500 MG TABLET
5
kurvelo tablet
0
KUVAN 100 MG TABLET
sapropterin dihydrochloride
4
lactic acid 10% e cream
2
lactic acid 10% lotion
2
LANOXIN 187.5 MCG TABLET
digoxin
3
LANOXIN 62.5 MCG TABLET
digoxin
3
lansoprazole dr 15 mg capsule
2
larin 1.5 mg-30 mcg tablet
0
larin 21 1-20 tablet
0
leena 28 tablet
0
lessina-28 tablet
0
levocarnitine 100 mg/ml soln
2
levocarnitine 330 mg tablet
2
levonest-28 tablet
0
levono-e estrad 0.10-0.02-0.01
0
levonor-eth estrad 0.1-0.02 mg
0
levonor-eth estrad 0.15-0.03
0
levonor-eth estrad 0.15-0.03
0
levonorgestrel 1.5 mg tablet
0
levora-28 tablet
0
LEVULAN KERASTICK
aminolevulinic acid hcl
4
PAGE 184
PA
PA
ST
PA
ST
PA
ST
PA
S
QL
Specialty Drug
1 / 1 days
PA
PRODUCT DESCRIPTION
TIER
lidocaine 5% ointment
2
lidocaine powder
2
lidocaine-hc 3-0.5% cream
2
lidocaine-hc 3-0.5% cream
2
lidocaine-hc 3-0.5% cream kit
2
lidocaine-hc 3-0.5% cream kit
2
LIDOVEX 3.75% CREAM
lidocaine
2
LILETTA 52 MG SYSTEM
levonorgestrel
0
lisinopril-hctz 10-12.5 mg tab
1
lisinopril-hctz 20-12.5 mg tab
1
lisinopril-hctz 20-25 mg tab
1
LITHOSTAT 250 MG TABLET
acetohydroxamic acid
2
LO LOESTRIN FE 1-10 TABLET
0
loperamide 2 mg capsule
2
lorazepam 0.5 mg tablet
1
lorazepam 1 mg tablet
1
lorazepam 2 mg tablet
1
lorcet 5-325 mg tablet
2
lorcet hd 10-325 mg tablet
2
lorcet plus 7.5-325 mg tablet
2
lortab 10 mg-300 mg/15 ml elxr
2
lortab 10-325 mg tablet
2
lortab 5-325 mg tablet
2
lortab 7.5-325 mg tablet
2
loryna 3 mg-0.02 mg tablet
0
losartan-hctz 100-12.5 mg tab
1
C
Tablet Split (TS)
losartan-hctz 100-25 mg tab
1
C
Tablet Split (TS)
losartan-hctz 50-12.5 mg tab
1
C
Tablet Split (TS)
PAGE 185
PRODUCT DESCRIPTION
TIER
low-ogestrel-28 tablet
0
ludent fluoride 0.25 mg tb chw
0
AL
6mos to 6 yrs old
ludent fluoride 0.5 mg tb chew
0
AL
6mos to 6 yrs old
ludent fluoride 1 mg tab chew
0
AL
6mos to 6 yrs old
LUPANETA PK 11.25-5 MG 3MO KIT
leuprolide acetate/norethindrone acetate
4
LUPANETA PK 3.75-5 MG 1MO KIT
leuprolide acetate/norethindrone acetate
4
lutera-28 tablet
0
M-M-R II VACCINE VIAL
measles,mumps&rubella vaccine live/pf
0
M-M-R II VACCINE WITH DILUENT
measles,mumps&rubella vaccine live/pf
0
magnesium chl 200 mg/ml vial
2
marlissa-28 tablet
0
MEDROL 2 MG TABLET
methylprednisolone
3
MENACTRA VIAL
meningococcal vaccine a,c,y,w-135,diphtheria toxoid conj/pf
0
MENHIBRIX VACCINE VIAL
meningococcal vaccine c,y/haemophilus b conj-tetanus tox/pf
0
MENOMUNE-A-C-Y-W-135 VIAL
meningococcal vac a,c,y,w-135
0
MENOMUNE-A-C-Y-W-135 VIAL
meningococcal vaccine a,c,y,w-135/pf
0
MENVEO A-C-Y-W-135-DIP VIAL
meningococcal vaccine a,c,y,w-135,diphtheria toxoid conj/pf
0
MEPHYTON 5 MG TABLET
phytonadione
3
mesalamine powder
3
MESNEX 400 MG TABLET
mesna
4
methenamine md 500 mg tablet
5
PA
methylene blue 1% ampul
5
PA
methylene blue 1% vial
5
PA
PAGE 186
PRODUCT DESCRIPTION
TIER
methylergonovine 0.2 mg tablet
2
methylergonovine 0.2 mg/ml amp
5
PA
methylergonovine 0.2 mg/ml vl
5
PA
metoclopramide 10 mg/2 ml syr
1
miconazole 3 200 mg vag supp
2
microgestin 21 1-20 tablet
0
microgestin 21 1.5-30 tab
0
midazolam 10 mg/2 ml syringe
2
PA
midazolam 5 mg/ml carpuject
2
PA
midazolam 5 mg/ml isecure syr
2
PA
midazolam 5 mg/ml syringe
2
PA
midazolam hcl 10 mg/2 ml vial
2
PA
2
PA
midazolam hcl 2 mg/ml syrup
2
PA
2
PA
midazolam hcl 5 mg/ml vial
2
PA
2
PA
2
PA
2
PA
2
PA
migergot suppository
5
migragesic ida capsule
2
mimvey 1-0.5 mg tablet
3
MIRENA SYSTEM
levonorgestrel
0
MITOSOL 0.2 MG KIT
mitomycin
5
MODICON 28 TABLET
0
morphine sulf 20 mg suppos
2
PAGE 187
PA
PA
PRODUCT DESCRIPTION
TIER
morphine sulf 30 mg suppos
2
PA
MYLERAN 2 MG TABLET
busulfan
4
PA
myzilra-28 tablet
0
naltrexone 50 mg tablet
4
NATAZIA 28 TABLET
estradiol valerate/dienogest
0
NATURE-THROID 113.75 MG TABLET
thyroid,pork
3
NATURE-THROID 130 MG TABLET
thyroid,pork
3
thyroid,pork
3
thyroid,pork
3
thyroid,pork
3
thyroid,pork
3
thyroid,pork
3
thyroid,pork
3
thyroid,pork
3
thyroid,pork
3
thyroid,pork
3
thyroid,pork
3
thyroid,pork
3
necon 0.5-35-28 tablet
0
0
0
neo-bacit-poly-hc eye ointment
2
PAGE 188
PA
QL
1 / 1 days
PRODUCT DESCRIPTION
TIER
neomyc-bacit-polymix eye oint
2
neomyc-polym-dexamet eye ointm
2
neomyc-polym-dexameth eye drop
2
neomyc-polym-gramicid eye drop
2
neomycin-poly-hc eye drops
2
NEUMEGA 5 MG VIAL
oprelvekin
4
QL
1 / 1 days
QL
1 / 1 days
PA
S
QL
NEUPOGEN 300 MCG/ML VIAL
filgrastim
C
QL-4
S
Specialty Drug
1 / 1 days
PA
4
C
QL-4
S
Specialty Drug
NEUPRO 1 MG/24 HR PATCH
rotigotine
4
PA
rotigotine
4
PA
rotigotine
4
PA
neutral sodium fluoride
2
AL
NEXPLANON 68 MG IMPLANT
etonogestrel
0
nikki 3 mg-0.02 mg tablet
0
nitro-time er 2.5 mg capsule
2
nitro-time er 6.5 mg capsule
2
nitro-time er 9 mg capsule
2
nitroglycerin er 2.5 mg cap
2
nitroglycerin er 6.5 mg cap
2
nitroglycerin er 9 mg capsule
2
nodolor capsule
5
PAGE 189
1 / 1 days
PA
4
QL
NEUPOGEN 480 MCG/1.6 ML VIAL
filgrastim
Specialty Drug
At least 5 yrs old
PA
PRODUCT DESCRIPTION
TIER
norethin-estra-fe 0.8-0.025 mg
0
norethind-eth estrad 1-0.02 mg
0
NORINYL 1+50-28 TABLET
norethindrone-mestranol
5
nortrel 0.5-35 tablet
0
NOVOLOG 100 UNIT/ML CARTRIDGE
insulin aspart
5
NOVOLOG 100 UNITS/ML FLEXPEN
insulin aspart
5
np thyroid 30 mg tablet
2
2
2
NPLATE 250 MCG VIAL
romiplostim
4
NPLATE 500 MCG VIAL
romiplostim
4
NUCORT LOTION
hydrocortisone acetate/aloe vera
3
NUOX GEL
benzoyl peroxide/sulfur
3
NUVARING VAGINAL RING
etonogestrel/ethinyl estradiol
0
armodafinil
4
ocella 3 mg-0.03 mg tablet
0
ogestrel tablet
0
omeprazole-bicarb 20-1,100 cap
1
omeprazole-bicarb 40-1,100 cap
5
PA
ONCASPAR 750 UNIT/ML VIAL
pegaspargase
4
PA
ONFI 10 MG TABLET
clobazam
3
PA
ONFI 20 MG TABLET
clobazam
3
PA
PAGE 190
PA
QL
1 / 1 days
PA
QL
1 / 1 days
PA
PA
S
Specialty Drug
PA
S
QL
Specialty Drug
1 / 1 days
PRODUCT DESCRIPTION
TIER
opium tincture 10 mg/ml
2
ORALAIR 300 IR STARTER PACK
grass pollen-orchard/sweet vernal/rye/kentucky/timothy, std.
5
PA
ORALAIR 300 IR SUBLINGUAL TAB
grass pollen-orchard/sweet vernal/rye/kentucky/timothy, std.
5
PA
ORENCIA 125 MG/ML SYRINGE
abatacept
5
ORENITRAM ER 0.125 MG TABLET
treprostinil diolamine
4
PA
4
PA
ORENITRAM ER 1 MG TABLET
4
PA
4
PA
orsythia-28 tablet
0
ORTHO TRI-CYCLEN LO TABLET
norgestimate-ethinyl estradiol
0
OSENI 12.5-15 MG TABLET
alogliptin benzoate/pioglitazone hcl
3
3
3
OSENI 25-15 MG TABLET
3
3
3
otic care otic solution
2
QL
OVACE PLUS 10% CREAM
sulfacetamide sodium
5
PA
OVACE PLUS 10% SHAMPOO
5
PA
OVACE PLUS 9.8% LOTION
5
PA
PAGE 191
PA
S
Specialty Drug
1 / 1 days
PRODUCT DESCRIPTION
TIER
oxazepam 10 mg capsule
2
2
2
oxycodon-acetaminophen 7.5-325
2
oxycodone hcl 5 mg capsule
2
oxycodone hcl 5 mg/5 ml soln
2
oxycodone-acetaminophen 10-325
2
oxycodone-acetaminophen 5-325
2
PACNEX HP 7% CLEANSING PADS
benzoyl peroxide
2
PACNEX LP 4.25% CLEANSING PADS
benzoyl peroxide
2
PACNEX MX 4.25% CLEANSER
benzoyl peroxide
2
PARAGARD T 380-A IUD
copper
0
paregoric liquid
2
PAREMYD EYE DROPS
hydroxyamphetamine hbr/tropicamide
3
PEDIARIX 0.5 ML SYRINGE
hep b virus,rcmb/dipth,pertus(acell),tet,polio vaccine/pf
0
PEDVAXHIB VACCINE VIAL
haemophilus b conjugate vaccine (meningococcal prot.conj)/pf
0
peg-3350 and electrolytes soln
1
PEGASYS 180 MCG/ML VIAL
4
PEGASYS PROCLICK 180 MCG/0.5
5
PENNSAID 2% PUMP
diclofenac sodium
5
PENTACEL DTAP-IPV COMPONENT VL
0
PENTACEL VIAL KIT
diphtheria,pertuss(acell),tetanus,polio vacc/hib conj-tet/pf
0
pentazocine-naloxone tablet
2
PAGE 192
QL
1 / 1 days
QL
1 / 1 days
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
PA
PRODUCT DESCRIPTION
TIER
perphen-amitrip 2 mg-10 mg tab
2
perphen-amitrip 2 mg-25 mg tab
2
phenazopyridine 100 mg tab
2
phenazopyridine 200 mg tab
2
phenobarbital 100 mg tablet
2
2
2
phenobarbital 32.4 mg tablet
2
2
phenobarbital 97.2 mg tablet
2
phenylephrine 10 mg/ml vial
5
phenylephrine 10% eye drops
2
phenylephrine 2.5% eye drop
2
phenylephrine hcl powder
5
phenytoin 50 mg/ml syringe
2
phospha 250 neutral tablet
2
PHYSICIANS EZ USE B-12 KIT
cyanocobalamin (vitamin b-12)
2
phytonadione 1 mg/0.5 ml syr
2
pinnacaine 20% otic drops
5
pioglitazone-metformin 15-500
2
pioglitazone-metformin 15-850
2
PNEUMOVAX 23 VIAL
pneumococcal 23-valent polysaccharide vaccine
0
podocon-25 liquid
2
poly-iron 150 forte capsule
2
polymyxin b-tmp eye drops
1
portia-28 tablet
0
POTABA 500 MG CAPSULE
potassium aminobenzoate
2
potass cit-sod cit-citric soln
2
potassium cit-citric acid soln
2
PAGE 193
QL
1 / 1 days
QL
1 / 1 days
PRODUCT DESCRIPTION
TIER
potassium cl 10% (20 meq/15 ml
1
1
1
potassium hydroxide 5% soln
2
pr benzoyl peroxide 7% wash
2
pr benzoyl peroxide 7% wash
2
PRANDIMET 1 MG-500 MG TABLET
repaglinide/metformin hcl
3
PRANDIMET 2 MG-500 MG TABLET
repaglinide/metformin hcl
3
PRED-G 1% EYE DROPS
gentamicin sulfate/prednisolone acetate
3
QL
1 / 1 days
PRED-G S.O.P. EYE OINTMENT
gentamicin sulfate/prednisolone acetate
3
QL
1 / 1 days
PREMPHASE 0.625-5 MG TABLET
estrogens, conjugated/medroxyprogesterone acetate
3
PREMPRO 0.3 MG-1.5 MG TABLET
3
PREMPRO 0.45-1.5 MG TABLET
3
PREMPRO 0.625-2.5 MG TABLET
3
PREMPRO 0.625-5 MG TABLET
3
PREPIDIL 0.5 MG/3 GM GEL
dinoprostone
5
PA
prevident 1.1% gel
3
AL
6mos to 6 yrs old
PREVIDENT 5000 1.1% DRY MOUTH
sodium fluoride
3
AL
6mos to 6 yrs old
PREVIDENT 5000 BOOSTER PLUS
sodium fluoride
3
AL
6mos to 6 yrs old
PREVIDENT 5000 ENAMEL PROTECT
sodium fluoride/potassium nitrate
3
PREVIDENT 5000 PLUS CREAM
sodium fluoride
3
AL
6mos to 6 yrs old
PREVIDENT 5000 SENSITIVE PASTE
sodium fluoride/potassium nitrate
3
PAGE 194
PRODUCT DESCRIPTION
TIER
PREVNAR 13 SYRINGE
pneumococcal 13-valent conjugate vaccine (diphtheria crm)/pf
0
4
prochlorperazine edisylate pow
2
PROCTOFOAM-HC 1%-1% FOAM
hydrocortisone acetate/pramoxine hcl
3
promethazine vc syrup
2
promethazine vc-codeine syrup
2
promethazine-codeine syrup
2
promethazine-dm syrup
2
propantheline 15 mg tablet
2
propranolol-hctz 40-25 mg tab
2
propranolol-hctz 80-25 mg tab
2
PROQUAD VIAL
measles, mumps, rubella, and varicella vaccine live/pf
0
PROSTIN E2 VAGINAL 20 MG SUP
dinoprostone
5
PROTOPAM CHLORIDE 1 GM VIAL
pralidoxime chloride
3
PULMOZYME 1 MG/ML AMPUL
dornase alfa
4
PURIXAN 20 MG/ML ORAL SUSP
mercaptopurine
4
pyridoxine 100 mg/ml vial
2
PYROGALLIC ACID 25% OINTMENT
pyrogallol
3
QUARTETTE TABLET
levonorgestrel-eth estra/ethinyl estradiol
0
quasense 0.15-0.03 mg tablet
0
QVAR 80 MCG ORAL INHALER
beclomethasone dipropionate
3
RAGWITEK SUBLINGUAL TABLET
weed pollen-short ragweed
4
raloxifene hcl 60 mg tablet
0
ranitidine 150 mg tablet
1
PAGE 195
PA
PA
S
Specialty Drug
PA
PA
PRODUCT DESCRIPTION
TIER
rea lo 39 cream
2
rea lo 40 cream
2
rea lo 40 lotion
2
REBIF REBIDOSE 22 MCG/0.5 ML
5
REBIF REBIDOSE 44 MCG/0.5 ML
5
REBIF REBIDOSE TITRATION PACK
5
RECOMBIVAX HB 10 MCG/ML SYR
0
RECOMBIVAX HB 10 MCG/ML VIAL
0
RECOMBIVAX HB 40 MCG/ML VIAL
0
RECOMBIVAX HB 5 MCG/0.5 ML SYR
0
RECOMBIVAX HB 5 MCG/0.5 ML VL
0
RELISTOR 12 MG/0.6 ML SYRINGE
methylnaltrexone bromide
4
PA
RELISTOR 8 MG/0.4 ML SYRINGE
methylnaltrexone bromide
4
PA
remeven 50% cream
2
reserpine 0.1 mg tablet
2
reserpine 0.25 mg tablet
2
RETIN-A MICRO PUMP 0.08% GEL
5
RETISERT IMPLANT
5
ROTARIX VACCINE SUSPENSION
rotavirus vacc, live oral attenuated, 89-12 strain, g1p(8)
0
ROTATEQ VACCINE
rotavirus vaccine, live oral pentavalent
0
RYTARY ER 23.75 MG-95 MG CAP
carbidopa/levodopa
2
PAGE 196
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
AL
At least 5 yrs old
PRODUCT DESCRIPTION
TIER
carbidopa/levodopa
2
carbidopa/levodopa
2
carbidopa/levodopa
2
SAFYRAL TABLET
drospirenone/ethinyl estradiol/levomefolate calcium
0
salicylic acid 26% liquid
2
salicylic acid 6% gel
2
salicylic acid 6% lotion
2
salicylic acid 6% lotion
2
salicylic acid 6% lotion kit
2
salsalate 500 mg tablet
2
salsalate 750 mg tablet
2
scopolamine 0.4 mg/ml vial
2
SECONAL SODIUM 100 MG CAPSULE
secobarbital sodium
5
PA
sf 1.1% gel
1
AL
6mos to 6 yrs old
sf 5000 plus cream
1
AL
6mos to 6 yrs old
silver nitrate 0.5% soln
2
silver nitrate 10% ointment
2
silver nitrate 10% solution
2
silver nitrate 50% solution
2
SIMCOR 1,000-20 MG TABLET
niacin/simvastatin
5
SIMCOR 1,000-40 MG TABLET
niacin/simvastatin
5
SIMCOR 500-20 MG TABLET
niacin/simvastatin
5
SIMCOR 500-40 MG TABLET
niacin/simvastatin
5
PAGE 197
PA
ST
PA
ST
PA
ST
PA
ST
PRODUCT DESCRIPTION
TIER
SITAVIG 50 MG BUCCAL TABLET
acyclovir
3
SKYLA SYSTEM
levonorgestrel
0
sod sulfacet-sulfur 10-5% clsr
2
sod sulfacetamide-sulfur lotn
2
sod sulfacetamide-sulfur lotn
2
sod sulfacetamide-sulfur susp
2
sodium fluoride 0.5 mg(1.1 mg)
0
AL
6mos to 6 yrs old
sodium fluoride 0.5 mg/ml drop
0
AL
6mos to 6 yrs old
sodium fluoride 1 mg (2.2 mg)
0
AL
6mos to 6 yrs old
sodium sulf-sulfur cleanser
2
sodium sulf-sulfur cleanser
2
SOLTAMOX 10 MG/5 ML SOLN
tamoxifen citrate
4
SOVALDI 400 MG TABLET
sofosbuvir
5
SPIRIVA RESPIMAT INHAL SPRAY
tiotropium bromide
5
spironolactone-hctz 25-25 tab
2
sronyx 0.10-0.02 mg tablet
0
sss 10-5 cream
2
sterile water for irrigation
2
STIMATE 1.5 MG/ML NASAL SPRAY
desmopressin acetate
3
S
SUBOXONE 12 MG-3 MG SL FILM
buprenorphine hcl/naloxone hcl
4
PA
SUBOXONE 2 MG-0.5 MG SL FILM
4
PA
4
PA
4
PA
succimer dmsa powder
5
PAGE 198
PA
PA
S
Specialty Drug
ST
Specialty Drug
PRODUCT DESCRIPTION
TIER
sulf-pred 10-0.23% eye drops
1
QL
1 / 1 days
sulf-pred 10-0.25% eye drops
1
QL
1 / 1 days
sulfacetamide 10% eye ointment
2
QL
1 / 1 days
sulfacetamide-sulfur 10-5% crm
2
sumatriptan succinate powder
5
ST
C
QL-6/12
ST
SUMAVEL DOSEPRO 4 MG/0.5 ML
sumatriptan succinate
5
SURVANTA 25 MG/ML VIAL
beractant
5
syeda 28 tablet
0
SYMBICORT 160-4.5 MCG INHALER
budesonide/formoterol fumarate
3
SYMBICORT 80-4.5 MCG INHALER
budesonide/formoterol fumarate
3
TANZEUM 30 MG PEN INJECT
albiglutide
3
TANZEUM 50 MG PEN INJECT
albiglutide
3
telmisartan-amlodipine 40-10
5
C
QL-6/12
PA
PA
ST
PA
telmisartan-amlodipine 40-5 mg
5
ST
PA
telmisartan-amlodipine 80-10
5
ST
PA
telmisartan-amlodipine 80-5 mg
5
ST
temazepam 15 mg capsule
1
temazepam 30 mg capsule
1
temozolomide 100 mg capsule
4
PA
S
Specialty Drug
PA
4
S
PAGE 199
Specialty Drug
PRODUCT DESCRIPTION
TIER
PA
4
S
Specialty Drug
PA
4
S
Specialty Drug
PA
4
S
Specialty Drug
PA
4
S
Specialty Drug
TENIVAC SYRINGE
tetanus and diphtheria toxoids, adsorbed, adult/pf
0
TENIVAC VIAL
tetanus and diphtheria toxoids, adsorbed, adult/pf
0
testosterone 25 mg/2.5 gm pkt
2
testosterone 50 mg/5 gram gel
2
testosterone 50 mg/5 gram pkt
2
tetanus diphtheria toxoids
0
tetracaine 0.5% eye drops
1
QL
1 / 1 days
tetracaine 0.5% eye drops
1
QL
1 / 1 days
TETRAVISC 0.5% EYE DROPS
tetracaine hcl
1
QL
1 / 1 days
TETRAVISC FORTE 0.5% EYE DROPS
tetracaine hcl
1
QL
1 / 1 days
TEVETEN HCT 600-25 MG TAB
eprosartan mesylate/hydrochlorothiazide
5
thiamine 200 mg/2 ml vial
2
THIOLA 100 MG TABLET
tiopronin
4
tilia fe 28 tablet
0
TIROSINT 100 MCG CAPSULE
levothyroxine sodium
3
3
3
PAGE 200
PA
ST
PA
PRODUCT DESCRIPTION
TIER
3
3
3
3
3
3
3
tl gard rx tablet
2
TOBRADEX ST EYE DROPS
3
QL
1 / 1 days
tobramycin-dexameth ophth susp
2
QL
1 / 1 days
topiramate er 100 mg capsule
5
PA
C
Tablet Split (TS)
PA
5
C
Tablet Split (TS)
PA
5
C
Tablet Split (TS)
PA
5
C
Tablet Split (TS)
PA
5
C
tranexamic acid 650 mg tablet
4
TRI-CHLOR 80% SOLUTION
trichloroacetic acid
3
tri-legest fe-28 day tablet
0
TRI-NORINYL 28 TABLET
0
triamterene-hctz 37.5-25 mg cp
1
PAGE 201
Tablet Split (TS)
PRODUCT DESCRIPTION
TIER
triamterene-hctz 37.5-25 mg tb
1
triamterene-hctz 75-50 mg tab
1
triazolam 0.125 mg tablet
2
triazolam 0.25 mg tablet
2
TRIBENZOR 40-10-12.5 MG TABLET
olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide
5
TRIBENZOR 40-10-25 MG TABLET
5
TRIBENZOR 40-5-12.5 MG TABLET
5
TRIBENZOR 40-5-25 MG TABLET
5
tricitrates oral solution
2
tricon capsule
2
TRIUMEQ TABLET
abacavir sulfate/dolutegravir sodium/lamivudine
4
trivora-28 tablet
0
TRUMENBA 120 MCG/0.5 ML VACCIN
neisseria meningitidis group b, lipidated fhbp recombinant
0
TWINRIX VACCINE SYRINGE
hepatitis a virus & hepatitis b virus vaccine/pf
0
TWINRIX VACCINE VIAL
hepatitis a virus & hepatitis b virus vaccine/pf
0
TYVASO 1.74 MG/2.9 ML SOLUTION
treprostinil
4
TYVASO INHALATION REFILL KIT
treprostinil/nebulizer accessories
4
TYVASO INHALATION STARTER KIT
treprostinil/nebulizer/nebulizer accessories
4
TYVASO INSTITUTIONAL START KIT
treprostinil/nebulizer/nebulizer accessories
4
TYZINE 0.1% NOSE SPRAY
3
PAGE 202
PA
ST
PA
ST
PA
ST
PA
ST
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
ULTRAVATE X CREAM COMBO PACK
halobetasol propionate/lactic acid
5
PA
ULTRAVATE X OINTMENT COMBO PAC
halobetasol propionate/lactic acid
5
PA
UMECTA 40% EMULSION
urea
3
umecta 40% mousse
2
UMECTA 40% NAIL FILM PEN
urea
3
UMECTA PD 40% EMULSION
urea
2
UMECTA PD 40% SUSPENSION
urea
2
URAMAXIN 20% FOAM
urea
2
URAMAXIN GT 45% PRE-FILLED APP
urea
2
urea 35% foam
2
urea 39% cream
2
urea 40% cream
2
urea 40% gel
2
urea 40% lotion
2
urea 40% nail film susp
2
urea 45% cream
2
urea 45% lotion
2
urea 45% nail gel
2
urea 47% cream
2
urea 50% cream
2
urea 50% nail stick
2
urea powder
2
UREVAZ 44% CREAM
urea
2
ursodiol powder
2
UTOPIC 41% CREAM
urea
2
PAGE 203
PRODUCT DESCRIPTION
TIER
VAQTA 25 UNITS/0.5 ML SYRINGE
0
VAQTA 25 UNITS/0.5 ML VIAL
0
VAQTA 50 UNITS/ML SYRINGE
0
VAQTA 50 UNITS/ML VIAL
0
VARIVAX VACCINE VIAL
varicella virus vaccine live/pf
0
VARIVAX VACCINE WITH DILUENT
varicella virus vaccine live/pf
0
vasopressin 20 units/ml vial
2
velivet 28 day tablet
0
VENELEX OINTMENT
balsam peru/castor oil
3
verdrocet 2.5-325 mg tablet
2
vestura 3 mg-0.02 mg tablet
0
vicodin 5-300 mg tablet
2
vicodin es 7.5-300 mg tablet
2
vicodin hp 10-300 mg tablet
2
QL
VIOKACE 10,440-39,150 UNITS TB
5
1 / 1 days
PA
ST
QL
VIOKACE 20,880-78,300 UNITS TB
5
1 / 1 days
PA
ST
virt-phos 250 neutral tablet
2
virt-vite forte tablet
2
virt-vite tablet
2
vit d2 1.25 mg (50,000 unit)
2
vitamin k-1 1 mg/0.5 ml ampul
2
vitamin k-1 10 mg/ml ampul
2
VYTORIN 10-10 MG TABLET
ezetimibe/simvastatin
3
PAGE 204
AL
At least 5 yrs old
QL
1 / 1 days
C
Tablet Split (TS)
PRODUCT DESCRIPTION
TIER
QL
3
3
3
wera 0.5/0.035 mg 28 tablet
0
wide seal diaphragm 60mm
0
0
0
0
0
0
0
0
wymzya fe chewable tablet
0
XARELTO STARTER PACK
rivaroxaban
3
XIGDUO XR 10 MG-1,000 MG TAB
dapagliflozin propanediol/metformin hcl
5
XIGDUO XR 10 MG-500 MG TABLET
5
XIGDUO XR 5 MG-1,000 MG TABLET
5
XIGDUO XR 5 MG-500 MG TABLET
5
XTANDI 40 MG CAPSULE
enzalutamide
4
xulane patch
0
YAZ 28 TABLET
ethinyl estradiol/drospirenone
0
PAGE 205
C
QL
C
QL
C
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
1 / 1 days
Tablet Split (TS)
PA
ST
PA
ST
PA
ST
PA
ST
PA
S
Specialty Drug
PRODUCT DESCRIPTION
TIER
ZAMICET 10-325 MG/15 ML SOLN
hydrocodone bitartrate/acetaminophen
2
zarah tablet
0
ZELBORAF 240 MG TABLET
vemurafenib
4
zenchent fe tablet chewable
0
zeosa chewable tablet
0
ZITHRANOL 1% SHAMPOO
anthralin micronized
5
ZOSTAVAX VIAL
zoster vaccine live/pf
0
zovia 1-35e tablet
0
zovia 1-50e tablet
0
ZYDELIG 100 MG TABLET
idelalisib
4
PA
ZYDELIG 150 MG TABLET
idelalisib
4
PA
ZYKADIA 150 MG CAPSULE
ceritinib
4
PA
ZYLET EYE DROPS
tobramycin/loteprednol etabonate
5
PAGE 206
PA
S
Specialty Drug
PA
QL
1 / 1 days
PA
Index of covered drugs
0
0.9 % SODIUM CHLORIDE
163,164,183
8
8-MOP
109
A
ABACAVIR SULFATE
66,67
ABACAVIR SULFATE/DOLUTEGRAVIR
SODIUM/LAMIVUDINE
202
ABACAVIR SULFATE/LAMIVUDINE
66
ADENOVIRUS VACCINE LIVE TYPE-4
165
ADENOVIRUS VACCINE LIVE TYPE-7
165
ADRENALIN
159
ADVAIR DISKUS
165
ADVAIR HFA
165
ADVICOR
166
AFATINIB DIMALEATE
53
AFINITOR
54
AFINITOR DISPERZ
55
AFLURIA 2015-2016
166
AGGRENOX
87
AKTEN
166
ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE 66
ALA-QUIN
166
ABATACEPT
ALA-SCALP
191
ABIRATERONE ACETATE
ABSORICA
54
109,165
18,109,125
ALBENDAZOLE
58
ALBENZA
58
ACAMPROSATE CALCIUM
17
ALBIGLUTIDE
ACARBOSE
76
ALBUTEROL SULFATE
ACEBUTOLOL HCL
92
ALCLOMETASONE DIPROPIONATE
ACETAMINOPHEN WITH CODEINE
199
159,160
18,110,125
ALDACTAZIDE
166
PHOSPHATE
165,172
ALENDRONATE SODIUM
150
ACETAZOLAMIDE
31,96,97
ALFERON N
166
ALFUZOSIN HCL
124
ACETAZOLAMIDE SODIUM
ACETIC ACID
ACETIC ACID/ALUMINUM ACETATE
ACETIC ACID/HYDROCORTISONE
31,97
24,155,165
24,155
24,25,155
ALINIA
58
ALISKIREN HEMIFUMARATE
96
ALITRETINOIN
57,116
ACETOHYDROXAMIC ACID
185
ALKERAN
ACETYLCYSTEINE
161
ALLOPURINOL
ACITRETIN
109
ALMOTRIPTAN MALATE
ACLIDINIUM BROMIDE
158
ALOCRIL
ACTONEL
150
ALOGLIPTIN BENZOATE
ACUVAIL
152
ALOGLIPTIN BENZOATE/METFORMIN HCL
183
ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL
191
ACYCLOVIR
71,198
166
46,166
47
152
78
ACZONE
165
ALOMIDE
152
ADACEL TDAP
165
ALOSETRON HCL
122
ADALIMUMAB
143,179
ALPHAGAN P
154
ADAPALENE
109,112
ALPRAZOLAM
166
ALREX
152
ADDERALL XR
102
ADEFOVIR DIPIVOXIL
69
ALTRETAMINE
ADENOVIRUS VAC LIVE TYPE-4 & ADENOVIRUS
ALVESCO
VAC LIVE TYPE-7
AMANTADINE HCL
PAGE 207
165
52
156
59,69
AMBRISENTAN
AMCINONIDE
160
18,110,125,126
AMILORIDE HCL
97
APREPITANT
43
APRISO
120,148
APTIVUS
68
AMINOCAPROIC ACID
165,167
ARANESP
AMINOLEVULINIC ACID HCL
167,184
ARCALYST
146
ARCAPTA NEOHALER
159
ARFORMOTEROL TARTRATE
159
AMINOSALICYLIC ACID
50,167
AMIODARONE HCL
91
AMITIZA
122
AMITRIPTYLINE HCL
41
ARMODAFINIL
ASACOL HD
AMLODIPINE BESYLATE
ASCORBIC ACID
AMLODIPINE BESYLATE/OLMESARTAN
162,163,190
ARMOUR THYROID
AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE 172,173
94,167
84,85,167,168
168
120,148
168
ASENAPINE MALEATE
64,74
MEDOXOMIL
169
ASMANEX
156
AMLODIPINE BESYLATE/VALSARTAN
176
ASMANEX HFA
168
AMLODIPINE
ASPIRIN
BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE
ASPIRIN/DIPYRIDAMOLE
176
ASTEPRO
AMMONIUM LACTATE
110
AMOXAPINE
41
AMOXICILLIN
28,167
AMOXICILLIN/POTASSIUM CLAVULANATE
AMPICILLIN TRIHYDRATE
27,28
28
165,168
87
157
ATAZANAVIR SULFATE
68
ATENOLOL
92
ATENOLOL/CHLORTHALIDONE
168
ATOMOXETINE HCL
105
ATORVASTATIN CALCIUM
99
AMPYRA
107
ATOVAQUONE
58
ANACAINE
167
ATOVAQUONE/PROGUANIL HCL
58
ANADROL-50
133
ATRIPLA
ANAGRELIDE HCL
ANAKINRA
ANASTROZOLE
84,87
144
53
168
ATROPINE SULFATE
91,120,168
ATROVENT HFA
158
AUBAGIO
107,108
ANDRODERM
134
AUGMENTIN
28
ANDROGEL
167
AURANOFIN
147
ANORO ELLIPTA
167
AVAGE
110
ANTHRALIN
175
AVANDAMET
168
ANTHRALIN MICRONIZED
206
AVANDIA
76,77
167,168,191
AVAR LS
169
AVC
169
ANTIPYRINE/BENZOCAINE
ANUSOL-HC
18,126,148
ANZEMET
43
AVELOX
APIDRA
79
AVODART
124,142
APIXABAN
80
AVONEX
108,146
APOKYN
59
AVONEX ADMINISTRATION PACK
108,146
APOMORPHINE HCL
APRACLONIDINE HCL
PAGE 208
59,167
154
AVONEX PEN
AXERT
30
169
47
AXITINIB
181
AZASITE
28,151
AZATHIOPRINE
142
BENZOYL PEROXIDE/SULFUR
190
BENZTROPINE MESYLATE
59
BENZYL ALCOHOL
59,118
AZELAIC ACID
110,113
BERACTANT
199
AZELASTINE HCL
152,157
BESIFLOXACIN HCL
30,151
BESIVANCE
30,151
AZELEX
110
AZILECT
60
BETADINE
170
AZILSARTAN MEDOXOMIL
89
BETAINE
118
AZILSARTAN MEDOXOMIL/CHLORTHALIDONE 175
BETAMETHASONE DIPROPIONATE
AZITHROMYCIN
BETAMETHASONE DIPROPIONATE/PROPYLENE
28,29,151
AZOPT
154
GLYCOL
AZOR
169
BETAMETHASONE VALERATE
AZTREONAM LYSINE
27,161
18,110,126
18,110,126
18,19,110,126
BETASERON
108,146
BETAXOLOL HCL
B
BACITRACIN
24,151
BACITRACIN/POLYMYXIN B SULFATE
BACLOFEN
166,169
65
BACTERIOSTATIC SODIUM CHLORIDE
BACTROBAN NASAL
163
24,110
92,154
BETHANECHOL CHLORIDE
124
BETIMOL
154
BETOPTIC S
154
BEXAROTENE
57,117
BEXSERO
170
BEYAZ
170
142
BAL IN OIL
169
BICALUTAMIDE
BALSALAZIDE DISODIUM
148
BILTRICIDE
BALSAM PERU/CASTOR OIL
204
BIMATOPROST
58
151,154
BANZEL
35
BISOPROLOL FUMARATE
BARACLUDE
69
BLEPHAMIDE
170
BLEPHAMIDE S.O.P.
170
BOOSTRIX TDAP
170
BOSENTAN
161
BOSULIF
170
BOSUTINIB
170
BREVICON
171
BECAPLERMIN
116
BECLOMETHASONE DIPROPIONATE
BELSOMRA
157,195
169
BENAZEPRIL HCL
89
BENAZEPRIL
HCL/HYDROCHLOROTHIAZIDE
169,170
BENICAR
88
92
BRILINTA
87
BENICAR HCT
170
BRIMONIDINE TARTRATE
BENTYL
120
BRIMONIDINE TARTRATE/TIMOLOL MALEATE 154
BENZACLIN
110
BRINZOLAMIDE
154
BENZAMYCINPAK
110
BROMFENAC SODIUM
153
BENZOCAINE
167,170,193
BROMOCRIPTINE MESYLATE
BENZOCAINE MICRONIZED
170
BROVANA
BENZONATATE
170
BUDESONIDE
BENZOYL PEROXIDE
170,171,192,194
BENZOYL PEROXIDE MICROSPHERES
PAGE 209
194
154
59,140
159
156,157,171
BUDESONIDE/FORMOTEROL FUMARATE
BUMETANIDE
199
97
BUPHENYL
118
BUPRENORPHINE
12,171
BUPRENORPHINE HCL
17
BUPRENORPHINE HCL/NALOXONE HCL
171,198
BUPROPION HCL
17,37
BUSPIRONE HCL
72
CAPITAL W-CODEINE
172
CAPRELSA
55
CAPREOMYCIN SULFATE
49
CAPTOPRIL
89
CARBAMAZEPINE
35,36,75,76
CARBIDOPA
60
BUSULFAN
188
CARBIDOPA/LEVODOPA
BUTABARBITAL SODIUM
171
CARBIDOPA/LEVODOPA/ENTACAPONE
172
BUTALBITAL/ACETAMINOPHEN
165
CARISOPRODOL
161
BUTALBITAL/ACETAMINOPHEN/CAFFEINE
171
CARISOPRODOL/ASPIRIN
172
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEIN
CARNITOR SF
172
E PHOSPHATE
171
CARTEOLOL HCL
154
BUTALBITAL/ASPIRIN/CAFFEINE
171
CARVEDILOL
93
BUTISOL SODIUM
171
CARVEDILOL PHOSPHATE
93
BUTORPHANOL TARTRATE
BUTRANS
BYDUREON
BYDUREON PEN
14
12,171
77
171
60,175,196,197
CAYSTON
27,161
CEFACLOR
26
CEFADROXIL
26
CEFDINIR
26,27
BYETTA
77
CEFPODOXIME PROXETIL
27
BYSTOLIC
92
CEFPROZIL
27
CEFTRIAXONE SODIUM
C
CABERGOLINE
CABOZANTINIB S-MALATE
CALCIPOTRIENE
140
55
110,111,171
CALCIPOTRIENE/BETAMETHASONE
27,172
CEFUROXIME AXETIL
27
CELECOXIB
10
CELONTIN
32
CEPHALEXIN
27
CERITINIB
206
DIPROPIONATE
117
CERTOLIZUMAB PEGOL
142
CALCITONIN,SALMON,SYNTHETIC
150
CERVARIX
172
CERVICAL CAP
177
CALCITRIOL
139,150
CALCIUM ACETATE
125
CERVIDIL
172
CAMRESE LO
171
CESAMET
43
CANAGLIFLOZIN
78
CETRORELIX ACETATE
172
172
CANAGLIFLOZIN/METFORMIN HCL
181,182
CETROTIDE
CANASA
120,148
CEVIMELINE HCL
CANDESARTAN CILEXETIL
88
CANDESARTAN
105,109
CHANTIX
18
CHEMET
163
CILEXETIL/HYDROCHLOROTHIAZIDE
171
CHENODAL
172
CANTIL
120
CHENODIOL
172
CAPASTAT SULFATE
CAPECITABINE
CAPEX SHAMPOO
PAGE 210
49
172
19,111,126
CHLORAMBUCIL
50,172
CHLORDIAZEPOXIDE HCL
173
CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE
173
CHLORHEXIDINE GLUCONATE
24,26,109,173
CLINDAMYCIN PHOSPHATE/BENZOYL
CHLOROQUINE PHOSPHATE
58
PEROXIDE
CHLOROTHIAZIDE
98
CLINDAMYCIN PHOSPHATE/SKIN CLEANSER
CHLORPROMAZINE HCL
42,60,61,73
110,111
COMB NO.19
24,111
CHLORPROPAMIDE
77
CLINDESSE
25
CHLORTHALIDONE
98
CLINPRO 5000
173
CHLORZOXAZONE
161,162
CLIOQUINOL/HYDROCORTISONE
166
190
CHOLESTYRAMINE (WITH SUGAR)
100
CLOBAZAM
CHOLESTYRAMINE/ASPARTAME
100
CLOBETASOL PROPIONATE
CHOLINE SALICYLATE/MAGNESIUM
19,111,112,126
CLOBETASOL PROPIONATE/EMOLLIENT
SALICYLATE
173
BASE
19,112,126
19,112,126
CIALIS
124,125
CLOBEX
CICLESONIDE
156,157
CLOMIPRAMINE HCL
41
CICLOPIROX
44,111
CLONAZEPAM
CICLOPIROX OLAMINE
44,111
CLONIDINE HCL
87
CLOPIDOGREL BISULFATE
87
CILOSTAZOL
87
CILOXAN
30,151
CIMETIDINE
121,173
173
CLORAZEPATE DIPOTASSIUM
CLOTRIMAZOLE
173
44,109,173
CIMETIDINE HCL
121
CLOTRIMAZOLE/BETAMETHASONE
CIMZIA
142
DIPROPIONATE
CINACALCET HCL
140
CLOZAPINE
CIPRO HC
155
CODEINE
CIPRODEX
155
PHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE 171
CIPROFLOXACIN
30
CIPROFLOXACIN HCL
30,151
112
64
CODEINE
PHOSPHATE/CARISOPRODOL/ASPIRIN
172
CIPROFLOXACIN HCL/DEXAMETHASONE
155
CODEINE SULFATE
14
CIPROFLOXACIN HCL/HYDROCORTISONE
155
COLCHICINE
46
COLCHICINE/PROBENECID
46
CITALOPRAM HYDROBROMIDE
39
CITRANATAL B-CALM
173
COLESEVELAM HCL
CLARINEX
157
COLESTIPOL HCL
100
COLISTIN (AS COLISTIMETHATE SODIUM)
173
CLARITHROMYCIN
CLEMASTINE FUMARATE
CLEOCIN
CLIMARA PRO
29,120
157
24,111
173
79,101
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 116
COMBIGAN
154
COMBIPATCH
173
CLINDACIN ETZ
24,111
COMETRIQ
CLINDACIN PAC
24,111
COMFORT PAC-CYCLOBENZAPRINE
CLINDAGEL
24,111
COMFORT PAC-MELOXICAM
10,22
24,25,58
COMFORT PAC-NAPROXEN
10,22
24,25
COMFORT PAC-TIZANIDINE
65
CLINDAMYCIN HCL
CLINDAMYCIN PALMITATE HCL
CLINDAMYCIN PHOSPHATE
PAGE 211
24,25,111,173
55
161
COMPLERA
173
COMVAX
173
CONDYLOX
112
COPAXONE
108,142,173
COPPER
192
CORDRAN
19,112,126
COREG CR
93
CORTIFOAM
174
CORTISONE ACETATE
19,126
DANAZOL
134
DANTROLENE SODIUM
65
DAPAGLIFLOZIN PROPANEDIOL
177
DAPAGLIFLOZIN PROPANEDIOL/METFORMIN
HCL
205
DAPSONE
49,112,165
DAPTACEL DTAP
174
CORTISPORIN
112
DAPTOMYCIN
25
COSOPT PF
154
DARBEPOETIN ALFA IN POLYSORBATE
CREON
118
80
84,85,167,168
CRESTOR
99
DARUNAVIR ETHANOLATE
CRIXIVAN
68
DASATINIB
55,56
CRIZOTINIB
57
DAYTRANA
103
DEFERASIROX
163
DEFEROXAMINE MESYLATE
174
CROMOLYN SODIUM
152,160
CROTAMITON
58,113
CUBICIN
25
CUPRIMINE
125,142,163
CYANOCOBALAMIN (VITAMIN B-12)
174,193
CYANOCOBALAMIN/FOLIC
68,195
DELAVIRDINE MESYLATE
66
DELZICOL
120,148
DEMECLOCYCLINE HCL
31,131
DEMSER
174
71
ACID/PYRIDOXINE
201,204
DENAVIR
CYCLOBENZAPRINE HCL
161,162
DEPEN
125,143,163
CYCLOBENZAPRINE HCL/IRRITANTS COUNTER-
DEPO-SUBQ PROVERA 104
IRRITANTS COMBO #2
161
DESIPRAMINE HCL
CYCLOGYL
174
DESLORATADINE
CYCLOMYDRIL
174
DESMOPRESSIN ACETATE
CYCLOPENTOLATE HCL
174
DESMOPRESSIN ACETATE (NON-
41
157
CYCLOPENTOLATE HCL/PHENYLEPHRINE HCL 174
REFRIGERATED)
CYCLOSERINE
DESOGESTREL-ETHINYL
25,49
137
131,198
131
CYCLOSPORINE
142,143,144,145,151
ESTRADIOL
CYCLOSPORINE, MODIFIED
112,114,115,143,144
DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL
CYKLOKAPRON
134,137,172,204
87
ESTRADIOL
CYPROHEPTADINE HCL
157
DESONIDE
CYSTADANE
118
DESOXIMETASONE
CYSTAGON
125
DESVENLAFAXINE SUCCINATE
CYSTEAMINE BITARTRATE
125
DEXAMETHASONE
D
DABIGATRAN ETEXILATE MESYLATE
DALFAMPRIDINE
DALIRESP
DALTEPARIN SODIUM,PORCINE
PAGE 212
83
107,164
161
134,135,136,137,138
19,112,126,127
19,112,127
40
127,129,149,153
DEXAMETHASONE SOD PHOSPHATE
127,153
DEXILANT
122,123
DEXLANSOPRAZOLE
122,123
DEXMETHYLPHENIDATE HCL
103,104
DEXPAK
127,149
81,82
DEXTROAMPHETAMINE SULF-
DIPHTHERIA,PERTUSSIS(ACELL),TETANUS
SACCHARATE/AMPHETAMINE SULF-
VACCINE/PF
ASPARTATE
102,103
DEXTROAMPHETAMINE SULFATE
103
DEXTROMETHORPHAN HBR/PROMETHAZINE
HCL
195
DEXTROMETHORPHAN HBR/QUINIDINE
165
DIPHTHERIA,PERTUSSIS(ACELLULAR),TETANUS
VACCINE
170
DIPYRIDAMOLE
87
DISOPYRAMIDE PHOSPHATE
91
DISULFIRAM
17
SULFATE
106
DIVALPROEX SODIUM
DIAPHRAGMS, WIDE SEAL
205
DOFETILIDE
92
DIAZEPAM
174
DOLASETRON MESYLATE
43
DIAZOXIDE
79
DONEPEZIL HCL
36
DIBENZYLINE
88
DORNASE ALFA
195
DORZOLAMIDE HCL
154
DORZOLAMIDE HCL/TIMOLOL MALEATE
154
DORZOLAMIDE HCL/TIMOLOL MALEATE/PF
154
DICLOFENAC POTASSIUM
DICLOFENAC SODIUM
10,22
10,22,116,127,130,153,192
DICLOXACILLIN SODIUM
28
DICYCLOMINE HCL
120
DIDANOSINE
66,67
DOXAZOSIN MESYLATE
DOXEPIN HCL
121
DOXERCALCIFEROL
DIFFERIN
112
DOXYCYCLINE HYCLATE
29
DIFLORASONE DIACETATE
19,112,127
DIFLORASONE DIACETATE/EMOLLIENT
BASE
88,124
41,72,116,162
DIFENOXIN HCL/ATROPINE SULFATE
DIFICID
33,46,75
150
DOXYCYCLINE MONOHYDRATE
DRITHOCREME HP
DIFLUNISAL
10,22
DIFLUPREDNATE
127,153
DIGOXIN
31,175
175
DRONABINOL
18,110,126
31,109,174
43,105,106
DRONEDARONE HCL
91
DROSPIRENONE/ETHINYL
ESTRADIOL/LEVOMEFOLATE CALCIUM
170,197
96,184
DROXIA
51,52
DIHYDROERGOTAMINE MESYLATE
46
DUAVEE
175
DILANTIN
35
DULERA
175
DILATRATE-SR
101
DILTIAZEM HCL
94,95,96
DIMERCAPROL
169
DUREZOL
127,153
DIMETHYL FUMARATE
108
DUTASTERIDE
124,142
DINOPROSTONE
172,194,195
DULOXETINE HCL
39,72,106
DUOPA
175
DUTASTERIDE/TAMSULOSIN HCL
182
DIPENTUM
148
DUTOPROL
175
DIPHENOXYLATE HCL/ATROPINE SULFATE
121
DYRENIUM
97
DIPHTHERIA, PERTUSSIS(ACELL), TETANUS PED
VACC/PF
174,181
E
DIPHTHERIA, PERTUSSIS(ACELL),TETANUS,POLIO
ECHOTHIOPHATE IODIDE
VACCINE/PF
ECONAZOLE NITRATE
183,192
155
44,113,175
DIPHTHERIA,PERTUSS(ACELL),TETANUS,POLIO
ECOZA
175
VACC/HIB CONJ-TET/PF
EDARBI
89
PAGE 213
192
EDARBYCLOR
175
EPINEPHRINE HCL/PF
159
159
EDURANT
65
EPIPEN JR 2-PAK
EFAVIRENZ
66
EPIVIR
66
EPIVIR HBV
69
168
EPLERENONE
97
EFFIENT
87
EPOETIN ALFA
85,86
EGRIFTA
175
EPOGEN
85,86
EFAVIRENZ/EMTRICITABINE/TENOFOVIR
DISOPROXIL FUMARATE
ELETRIPTAN HBR
ELIDEL
47,48
113,143
ELIGARD
140
ELIQUIS
80
EPROSARTAN MESYLATE
89
EPROSARTAN
MESYLATE/HYDROCHLOROTHIAZIDE
200
EPTIFIBATIDE
181
ELIXOPHYLLIN
158
EPZICOM
ELLA
137
ERGOCALCIFEROL (VITAMIN D2)
ELMIRON
125
ERGOLOID MESYLATES
36
ERGOMAR
46
ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN
ERGOTAMINE TARTRATE
46
OFOVIR
ERGOTAMINE TARTRATE/CAFFEINE
ELTROMBOPAG OLAMINE
86,87
67
EMADINE
152
EMCYT
51
EMEDASTINE DIFUMARATE
66
204
187
ERIVEDGE
55
ERLOTINIB HCL
56,57
152
ERTACZO
EMEND
43
ERY-TAB
29
EMSAM
38,39
ERYPED 200
29
66
ERYPED 400
29
ERYTHROCIN STEARATE
29
EMTRICITABINE
EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR
DISOPROXIL FUMARATE
173
EMTRICITABINE/TENOFOVIR DISOPROXIL
44,113
ERYTHROMYCIN BASE
29,30,151,176
ERYTHROMYCIN BASE/BENZOYL
FUMARATE
67
PEROXIDE
EMTRIVA
66
ERYTHROMYCIN BASE/ETHYL ALCOHOL
ENALAPRIL MALEATE
90
ERYTHROMYCIN ETHYLSUCCINATE
29
ERYTHROMYCIN STEARATE
29
ENALAPRIL
MALEATE/HYDROCHLOROTHIAZIDE
ENBREL
ENFUVIRTIDE
ENGERIX-B ADULT
175
143,175
67
176
110,113
ESCITALOPRAM OXALATE
29,113
39,72,73
ESOMEPRAZOLE MAGNESIUM
123
ESTAZOLAM
176
ESTRACE
134
ENGERIX-B PEDIATRIC-ADOLESCENT
175,176
ESTRADIOL
134,135,136,137
ENOXAPARIN SODIUM
80,81,83
ESTRADIOL ACETATE
135
ENTACAPONE
59
ESTRADIOL VALERATE/DIENOGEST
188
ENTECAVIR
69
ESTRADIOL/LEVONORGESTREL
173
ENZALUTAMIDE
205
ESTRADIOL/NORETHINDRONE
EPINASTINE HCL
152
ACETATE
EPINEPHRINE
PAGE 214
159,176
173,176,187
ESTRAMUSTINE PHOSPHATE SODIUM
51
ESTRING
135
EXJADE
ESTROGENS, CONJUGATED
137
EXTAVIA
ESTROGENS, CONJUGATED/BAZEDOXIFENE
ACETATE
163
108,146
EZETIMIBE
175
ESTROGENS,
101
EZETIMIBE/SIMVASTATIN
204,205
EZOGABINE
CONJUGATED/MEDROXYPROGESTERONE
32
ACETATE
194
F
ESTROGENS,ESTERIFIED
136
FACTIVE
30
ESTROGENS,ESTERIFIED/METHYLTESTOSTERON
FAMCICLOVIR
71
E
174
FAMOTIDINE
ESTROPIPATE
135
FANAPT
62
ESTROSTEP FE
176
FARESTON
51
ESZOPICLONE
162
FARXIGA
177
FASLODEX
177
ETANERCEPT
ETHACRYNATE SODIUM
143,175
FEBUXOSTAT
46
FELBAMATE
34
ETHINYL
FELODIPINE
95
ESTRADIOL/DROSPIRENONE 175,178,185,189,190,1
FEMHRT
177
99,204,205,206
FEMRING
135
ETHAMBUTOL HCL
97
121,122
49,50
ETHIONAMIDE
50
FENOFIBRATE
98
ETHOSUXIMIDE
32
FENOFIBRATE NANOCRYSTALLIZED
98
ETHOTOIN
35
FENOFIBRATE,MICRONIZED
98
166
FENOFIBRIC ACID (CHOLINE)
98
ETHYL ALCOHOL
ETHYNODIOL DIACETATE-ETHINYL
ESTRADIOL
ETIDRONATE DISODIUM
ETODOLAC
FENOPROFEN CALCIUM
183,206
150
10,22
FENTANYL
12,14,15
FENTANYL CITRATE
12,15
FERROUS FUMARATE/ASCORBIC ACID/B12-
ETONOGESTREL
189
IF/FOLIC ACID
ETONOGESTREL/ETHINYL ESTRADIOL
190
FERROUS FUMARATE/ASCORBIC
ETOPOSIDE
176
ACID/CYANOCOBALAMIN/FOLIC ACID
ETRAVIRINE
65
EURAX
EVEROLIMUS
58,113
54,55,145
10,22
202
FESOTERODINE FUMARATE
FIDAXOMICIN
177,179
123
29
FILGRASTIM
86,189
EXALGO
12
FINACEA
EXELDERM
44
FINASTERIDE
124,142
FINGOLIMOD HCL
108,146
127,153
EXELON
36,37
EXEMESTANE
53
FLAREX
EXENATIDE
77
FLAVOXATE HCL
EXENATIDE MICROSPHERES
77,171
123
FLECAINIDE ACETATE
EXFORGE
176
FLOVENT DISKUS
EXFORGE HCT
176
FLOVENT HFA
PAGE 215
113
91
127,156
127,128,156
FLUARIX QUAD 2015-2016
177
FML FORTE
128,153
FLUBLOK 2015-2016
177
FML S.O.P.
128,153
FLUCAINE
177
FOCALIN XR
104
FLUCELVAX 2015-2016
177
FOLIC ACID
178
FLUCONAZOLE
44
FONDAPARINUX SODIUM
FLUCYTOSINE
44
FORADIL
159
FORMOTEROL FUMARATE
159
FORTEO
150
FLUDROCORTISONE ACETATE
19,128
FLULAVAL QUAD 2015-2016
177
FLUOCINOLONE
ACETONIDE
19,111,113,126,128,177,181,196
FLUOCINOLONE ACETONIDE OIL
128,155
FLUOCINOLONE ACETONIDE/SHOWER
81
FOSAMPRENAVIR CALCIUM
68
FOSFOMYCIN TROMETHAMINE
26
FOSINOPRIL SODIUM
90
FOSRENOL
125
CAP
19,113,128
FRAGMIN
81,82
FLUOCINONIDE
20,113,128
FROVA
47
FLUOCINONIDE/EMOLLIENT BASE
20,113,128
FROVATRIPTAN SUCCINATE
47
FLUOR-A-DAY
177
FULVESTRANT
177
FLUORABON
177
FUROSEMIDE
97
67
FLUOROMETHOLONE
128,153
FUZEON
FLUOROMETHOLONE ACETATE
127,153
FYCOMPA
FLUOROPLEX
113
FLUOROURACIL
51,52,113,178
31,32
G
FLUOXETINE HCL
39
GABAPENTIN
FLUPHENAZINE DECANOATE
61
GABAPENTIN ENACARBIL
FLUPHENAZINE HCL
61
GABITRIL
33
FLURANDRENOLIDE
19,112,126
GALANTAMINE HBR
37
FLURAZEPAM HCL
178
FLURBIPROFEN
10,22
FLURBIPROFEN SODIUM
153
FLUTAMIDE
52,142
FLUTICASONE FUROATE
130,157
FLUTICASONE
PROPIONATE
33,106
179
GAMASTAN S-D
145
GAMMAGARD S-D
145
GANCICLOVIR
65,152
GARDASIL
178
GARDASIL 9
178
GATIFLOXACIN
20,113,114,127,128,156
FLUTICASONE PROPIONATE/SALMETEROL
XINAFOATE
FLUVASTATIN SODIUM
FLUVIRIN 2015-2016
FLUVOXAMINE MALEATE
165
99
178
30,152
GEMFIBROZIL
98
GEMIFLOXACIN MESYLATE
30
GENOTROPIN
131,132
GENTAMICIN SULFATE
23,114,151
GENTAMICIN SULFATE/PREDNISOLONE
39
ACETATE
194
FLUZONE 2015-2016
178
GILENYA
108,146
FLUZONE HIGH-DOSE 2015-2016
178
GILOTRIF
53
FLUZONE QUAD 2015-2016
178
GLATIRAMER ACETATE
FLUZONE QUAD PEDI 2015-2016
178
GLEEVEC
PAGE 216
108,142,173
55
GLIMEPIRIDE
77
HEPATITIS B VIRUS VACCINE/HAEMOPH B
GLIPIZIDE
77
POLYSAC CONJ-MENING/PF
GLUCAGON EMERGENCY KIT
79
HEPSERA
69
GLUCAGON,HUMAN RECOMBINANT
79
HETLIOZ
179
GLYBURIDE
77
HEXALEN
52
GLYBURIDE,MICRONIZED
77
HIZENTRA
GLYBURIDE/METFORMIN HCL
179
GLYCOPYRROLATE
173
145,146
HOMATROPINE HBR
179
91,120,161
HORIZANT
179
77,78
HUMALOG
79,179
GLYSET
GORDO-UREA
179
GRASS POLLEN-ORCHARD/SWEET
HUMALOG KWIKPEN
179
HUMALOG MIX 50-50
79
VERNAL/RYE/KENTUCKY/TIMOTHY, STD.
191
79
GRASS POLLEN-TIMOTHY, STD
179
HUMALOG MIX 75-25
79
GRASTEK
179
79
GRISEOFULVIN ULTRAMICROSIZE
44
HUMAN PAPILLOMAVIRUS VACCINE, 9-
GRISEOFULVIN, MICROSIZE
44
VALENT/PF
GUANFACINE HCL
87,88,104
178
HUMAN PAPILLOMAVIRUS VACCINE,
BIVALENT/PF
H
172
HUMAN PAPILLOMAVIRUS VACCINE,
HAEMOPHILUS B CONJUGATE VACCINE
(MENINGOCOCCAL PROT.CONJ)/PF
192
QUADRIVALENT/PF
178
HUMATROPE
132
HALCINONIDE
20,114,128
HUMIRA
HALOBETASOL PROPIONATE
20,114,128
HUMIRA CROHN'S
143
HUMIRA PEDIATRIC CROHN'S
143
HUMIRA PSORIASIS
143
HALOBETASOL PROPIONATE/LACTIC ACID
HALOG
203
20,114,128
143,179
HALOPERIDOL
61
HUMULIN R U-500
80
HALOPERIDOL LACTATE
61
HYCAMTIN
180
HARVONI
179
HYDRALAZINE HCL
101
HAVRIX
179
HYDRO 40
180
HECTOROL
150
HYDROCHLOROTHIAZIDE
98
HEP B
HYDROCODONE
VIRUS,RCMB/DIPTH,PERTUS(ACELL),TET,POLIO
BITARTRATE/ACETAMINOPHEN
VACCINE/PF
HYDROCODONE BITARTRATE/HOMATROPINE
192
HEPARIN SODIUM,PORCINE
82
METHYLBROMIDE
HEPARIN SODIUM,PORCINE/PF
82
HYDROCODONE
HEPATITIS A VIRUS & HEPATITIS B VIRUS
VACCINE/PF
HEPATITIS A VIRUS VACCINE/PF
PAGE 217
180
POLISTIREX/CHLORPHENIRAMINE POLISTIREX180
202
179,204
HEPATITIS B VIRUS VACCINE
RECOMBINANT/PF
180,185,204,206
HYDROCORTISONE 18,20,21,109,114,116,117,125,1
26,129,130,148,149,150,180
HYDROCORTISONE ACETATE
175,176,196
HYDROCORTISONE ACETATE/ALOE VERA
174,180
190
HYDROCORTISONE ACETATE/PRAMOXINE
HCL
180,195
INCRUSE ELLIPTA
181
INDACATEROL MALEATE
159
HYDROCORTISONE
INDAPAMIDE
98
ACETATE/PRAMOXINE/EMOLLIENT/PRAMOXINE
INDINAVIR SULFATE
68
COMB#1
180
INDOMETHACIN
11,22
20,114,129
INFANRIX DTAP
181
HYDROCORTISONE BUTYRATE/EMOLLIENT
INFED
181
BASE
INFLUENZA VACCINE TRIVALENT 2015-2016(18
HYDROCORTISONE BUTYRATE
20,114,128
HYDROCORTISONE PROBUTATE
129
YR+)CELL DERIVED/PF
HYDROCORTISONE VALERATE
129
INFLUENZA VIRUS VACCINE QUADRIVAL 2015-16
HYDROCORTISONE/MINERAL
(6 MOS-35 MOS)/PF
OIL/PETROLATUM,WHITE
180
HYDROMORPHONE HCL
177
12,15,180
HYDROMORPHONE HCL/PF
15
HYDROXOCOBALAMIN
180
178
INFLUENZA VIRUS VACCINE QUADRIVAL 20152016 (36 MOS & OLDER)
177
INFLUENZA VIRUS VACCINE QUADRIVAL SPLIT
2015-16(36 MOS+)/PF
177,178
HYDROXYAMPHETAMINE HBR/TROPICAMIDE 192
INFLUENZA VIRUS VACCINE QVALSPLIT 2015-
HYDROXYCHLOROQUINE SULFATE
2016(6 MOS AND OLDER)
HYDROXYUREA
58
51,52
HYDROXYZINE HCL
42,72,157,158
HYDROXYZINE PAMOATE
42,72,158
HYOSCYAMINE SULFATE
180,181
178
INFLUENZA VIRUS VACCINE TRIVALENT 2015-16
(6 MOS AND OLDER)
178
(4 YR & OLDER)
178
I
(5 YR & OLDER)
166
IBANDRONATE SODIUM
150
INFLUENZA VIRUS VACCINE TRIVALENT SPLIT
IBRUTINIB
181
2015-2016(65 YR+)/PF
IBUPROFEN
10,22
178
INFLUENZA VIRUS VACCINE TRIVALNT 2015-2016
IBUPROFEN/IRRITANTS COUNTER-IRRITANTS
(4 YR & OLDER)/PF
COMBINATION #2
INFLUENZA VIRUS VACCINE TRIVALNT 2015-2016
10,22
ICLUSIG
55
178
(5 YR & OLDER)/PF
166
IDELALISIB
206
INFLUENZA VIRUS VACCINE TV 2015-2016(18 YRS
ILEVRO
153
& OLDER)RCMB/PF
177
INLYTA
181
ILOPERIDONE
62
ILOPROST TROMETHAMINE
161
INNOPRAN XL
ILUVIEN
181
INSULIN ASPART
IMATINIB MESYLATE
55
IMBRUVICA
181
93
80,190
INSULIN ASPART PROTAMINE HUMAN/INSULIN
ASPART
80
80
IMIPRAMINE HCL
41
INSULIN DETEMIR
IMIPRAMINE PAMOATE
41
INSULIN GLARGINE,HUMAN RECOMBINANT
IMIQUIMOD
52,53,114,118,146,148,181
IMMUNE GLOBULIN,GAMMA(IGG)
INCRELEX
PAGE 218
145,146
132
ANALOG
80
INSULIN GLULISINE
79
INSULIN LISPRO
79,179
INSULIN LISPRO PROTAMINE & INSULIN LISPRO 79
INSULIN REGULAR, HUMAN
80
J
INTEGRILIN
181
JAKAFI
54
INTELENCE
65
JALYN
182
JANUMET
182
JANUMET XR
182
INTERFERON ALFA-2B,RECOMB.
52,53,69,70
INTERFERON ALFA-N3
166
INTERFERON BETA-1A
108,146,169
INTERFERON BETA-1A/ALBUMIN
HUMAN
JANUVIA
78
JENTADUETO
108,146,147,196
INTERFERON BETA-1B
108,146
INTRON A
52,53,69,70
INVEGA
62,63
INVIRASE
68
INVOKAMET
181,182
183
K
K-PHOS NEUTRAL
183
K-PHOS NO.2
183
K-PHOS ORIGINAL
183
KADIAN
13
78
KALETRA
68
IOPIDINE
154
KAZANO
183
IPOL
182
KERAFOAM
183
IPRATROPIUM BROMIDE
158
KETEK
INVOKANA
IPRATROPIUM BROMIDE/ALBUTEROL
29
KETOCONAZOLE
SULFATE
182
IRBESARTAN
89
44,45,114
KETOPROFEN
11,22
KETOROLAC TROMETHAMINE
11,22,153
IRBESARTAN/HYDROCHLOROTHIAZIDE
182
KETOROLAC TROMETHAMINE/PF
152
IRON DEXTRAN COMPLEX
181
KINERET
144
KINEVAC
183
KINRIX
183
KLOR-CON
184
KLOR-CON M15
163
KOMBIGLYZE XR
184
IRON POLYSACCHARIDE
COMPLEX/CYANOCOBALAMIN/FOLIC ACID
ISENTRESS
193
67
ISOMETHEPTENE
MUCATE/CAFFEINE/ACETAMINOPHEN
182
ISOMETHEPTENE
KUVAN
MUCATE/DICHLORALPHENAZONE/ACETAMINOPH
EN
182,187,189
ISONIAZID
50
118,184
L
LABETALOL HCL
93
ISORDIL
101
LACOSAMIDE
36
ISOSORBIDE DINITRATE
101
LACTIC ACID
184
ISOSORBIDE MONONITRATE
101
LACTULOSE
122
ISOTRETINOIN
ISOXSUPRINE HCL
ISRADIPINE
ISTALOL
109,110,111,115,118,165,182
182
95
154
LAMICTAL (GREEN)
34,75
LAMICTAL (ORANGE)
34,75
LAMIVUDINE
66,69
LAMIVUDINE/ZIDOVUDINE
ITRACONAZOLE
44,45
LAMOTRIGINE
IVERMECTIN
58,59
LANOXIN
PAGE 219
66
34,75,76
184
LANSOPRAZOLE
123,184
LANTHANUM CARBONATE
LIDOCAINE/PRILOCAINE
17,114
125
LIDOVEX
185
LANTUS
80
LILETTA
185
LANTUS SOLOSTAR
80
LINACLOTIDE
122
LAPATINIB DITOSYLATE
57
LINAGLIPTIN
79
LATANOPROST
151,154
LATUDA
63
LINAGLIPTIN/METFORMIN HCL
183
LINCOCIN
25
LEDIPASVIR/SOFOSBUVIR
179
LINCOMYCIN HCL
25
LEFLUNOMIDE
146
LINDANE
58
LINEZOLID
26
LENALIDOMIDE
50,51,147
LETAIRIS
160
LETROZOLE
53
LEUCOVORIN CALCIUM
52,53
LINZESS
122
LIOTHYRONINE SODIUM
139
LIOTRIX
139
LEUKERAN
50
LIPASE/PROTEASE/AMYLASE
LEUKINE
86
LIRAGLUTIDE
LEUPROLIDE ACETATE
140,141
LEUPROLIDE ACETATE/NORETHINDRONE
ACETATE
79
LISDEXAMFETAMINE DIMESYLATE
LISINOPRIL
186
LEVALBUTEROL HCL
118,119,120,204
159,160
103
90
LISINOPRIL/HYDROCHLOROTHIAZIDE
LITHIUM CARBONATE
185
76
LEVEMIR
80
LITHOSTAT
LEVEMIR FLEXTOUCH
80
LIVALO
LEVETIRACETAM
32
LO LOESTRIN FE
185
LODOXAMIDE TROMETHAMINE
152
LOESTRIN FE
135
LOPERAMIDE HCL
185
LEVOBUNOLOL HCL
154
LEVOCARNITINE
172,184
LEVOCARNITINE (WITH SUGAR)
184
LEVOFLOXACIN
30,151
LEVONORGESTREL
184,185,187,198
185
99
LOPINAVIR/RITONAVIR
68
LORAZEPAM
185
LEVONORGESTREL-ETH ESTRA/ETHINYL
LORZONE
162
ESTRADIOL
LOSARTAN POTASSIUM
166,167,171,174,184,195
89
LEVONORGESTREL-ETHINYL
LOSARTAN
ESTRADIOL 166,167,168,169,172,174,176,181,183,18
POTASSIUM/HYDROCHLOROTHIAZIDE
185
4,186,188,191,193,195,198,202
LOTEMAX
153
LEVORPHANOL TARTRATE
13
LEVOTHYROXINE SODIUM
139,200,201
LEVULAN
184
LEXIVA
68
LIALDA
121,148
LIDOCAINE
LIDOCAINE HCL
16,185
16,17,114
LOTEPREDNOL ETABONATE
LOVASTATIN
83
LOXAPINE SUCCINATE
61
LUBIPROSTONE
LUMIGAN
LUPANETA PACK
LUPRON DEPOT
LIDOCAINE HCL/PF
LUPRON DEPOT-PED
PAGE 220
99,100
LOVENOX
LIDOCAINE HCL/HYDROCORTISONE ACETATE 185
166
152,153
122
151,154
186
140,141
141
LURASIDONE HCL
LYRICA
63
32,33,106,107
LYSODREN
139
MENINGOCOCCAL VACCINE A,C,Y,W-135/PF
186
MENINGOCOCCAL VACCINE C,Y/HAEMOPHILUS B
CONJ-TETANUS TOX/PF
186
MENOMUNE-A-C-Y-W-135
186
MENOSTAR
136
186
MENVEO A-C-Y-W-135-DIP
186
MACRODANTIN
25
MEPENZOLATE BROMIDE
120
MAFENIDE ACETATE
26
MEPERIDINE HCL
M
M-M-R II VACCINE
15
MAGNESIUM CHLORIDE
186
MEPHYTON
MAGNESIUM SULFATE
163
MEPROBAMATE
72
MEPRON
58
MALATHION
59,114
186
MAPROTILINE HCL
38
MERCAPTOPURINE
MARAVIROC
67
MESALAMINE
MATULANE
50
MESALAMINE WITH CLEANSING WIPES
MAXIDEX
129,153
MEASLES, MUMPS, RUBELLA, AND VARICELLA
VACCINE LIVE/PF
195
52,195
120,121,148,165,186
121,148
MESNA
186
MESNEX
186
MESTINON
49
MEASLES,MUMPS&RUBELLA VACCINE LIVE/PF 186
METAPROTERENOL SULFATE
160
MECASERMIN
METAXALONE
162
132
MECLIZINE HCL
MECLOFENAMATE SODIUM
42
11,22,23
MEDROL
MEDROXYPROGESTERONE ACETATE
186
137,138
MEFENAMIC ACID
11,23
MEFLOQUINE HCL
58
METFORMIN HCL
78
METHADONE HCL
13,15
METHAMPHETAMINE HCL
103
METHAZOLAMIDE
97,154
METHENAMINE HIPPURATE
25
METHENAMINE MANDELATE
25,186
MEGACE ES
138
METHIMAZOLE
142
MEGESTROL ACETATE
138
METHITEST
134
METHOCARBAMOL
162
MEKINIST
MELOXICAM
54
11,23
METHOTREXATE SODIUM
52,114,115,116,144,145
MELOXICAM/IRRITANTS COUNTER-IRRITANTS
METHOTREXATE SODIUM/PF
COMBINATION NO.2
METHOXSALEN
MELPHALAN
MEMANTINE HCL
10,22
166
37
52,114,115,144
109,115
METHOXSALEN, RAPID
116
METHSCOPOLAMINE BROMIDE
120
MENACTRA
186
METHSUXIMIDE
32
MENEST
136
METHYCLOTHIAZIDE
98
MENHIBRIX
186
METHYLDOPA
88
MENINGOCOCCAL GROUP B VACCINE, 4-
METHYLENE BLUE
186
COMPONENT/PF
170
METHYLERGONOVINE MALEATE
187
MENINGOCOCCAL VAC A,C,Y,W-135
186
METHYLIN
104
METHYLNALTREXONE BROMIDE
196
METHYLPHENIDATE
103
MENINGOCOCCAL VACCINE A,C,Y,W135,DIPHTHERIA TOXOID CONJ/PF
PAGE 221
186
METHYLPHENIDATE HCL
104,105
METHYLPREDNISOLONE
20,129,149,186
MOTOFEN
121
METHYLTESTOSTERONE
134
MOVIPREP
122
METIPRANOLOL
155
MOXEZA
METOCLOPRAMIDE HCL
42,121,187
MORPHINE SULFATE
30,151
MOXIFLOXACIN HCL
METOLAZONE
98
MULTAQ
METOPROLOL SUCCINATE
93
MUPIROCIN
METOPROLOL
13,16,187,188
30,151,152
91
26,115
MUPIROCIN CALCIUM
SUCCINATE/HYDROCHLOROTHIAZIDE
METOPROLOL TARTRATE
175
93
METOZOLV ODT
42,121
METROGEL
25
METRONIDAZOLE
25,26
METYROSINE
174
MEXILETINE HCL
91
MYCOBUTIN
144
MYCOPHENOLATE SODIUM
144
MYFORTIC
144
MYLERAN
188
MYRBETRIQ
150
N
MICONAZOLE NITRATE
187
NABILONE
MIDAZOLAM HCL
187
NABUMETONE
MIDAZOLAM HCL/PF
187
NADOLOL
88
MIGLITOL
77,78
49
MYCOPHENOLATE MOFETIL
MIACALCIN
MIDODRINE HCL
24,26,110
65
43
11,23
93
NAFARELIN ACETATE
142
NAFTIFINE HCL
45,115
45,115
MIGLUSTAT
119
NAFTIN
MILNACIPRAN HCL
107
NALBUPHINE HCL
16
NALOXONE HCL
17
MINASTRIN 24 FE
136,138
MINOCYCLINE HCL
31,109
MINOXIDIL
101
MIRABEGRON
65
MIRENA
187
MIRTAZAPINE
38
MISOPROSTOL
122,133
NALTREXONE HCL
188
NALTREXONE MICROSPHERES
17
NAMENDA
37
NAMENDA XR
37
NAPROXEN
11,23
NAPROXEN SODIUM
11,23
MITOMYCIN
187
NAPROXEN/IRRITANTS COUNTER-IRRITANTS
MITOSOL
187
COMBINATION #2
MITOTANE
139
NARATRIPTAN HCL
MODAFINIL
162
NASONEX
157
MODICON
187
NATACYN
45,151
NATAMYCIN
45,151
MOEXIPRIL HCL
MOMETASONE FUROATE
90
115,129,156,157,168
MOMETASONE FUROATE/FORMOTEROL
NATAZIA
NATEGLINIDE
10,22
47
188
78
FUMARATE
175
NATURE-THROID
188
MONTELUKAST SODIUM
158
NEBIVOLOL HCL
92
NEBUPENT
58
MONUROL
PAGE 222
26
NEDOCROMIL SODIUM
152
NEFAZODONE HCL
38,40
NITAZOXANIDE
58
NITRO-BID
101
NEISSERIA MENINGITIDIS GROUP B, LIPIDATED
NITRO-DUR
FHBP RECOMBINANT
NITROFURANTOIN MACROCRYSTAL
202
101,102
NELFINAVIR MESYLATE
69
NITROFURANTOIN
NEOMYCIN SULFATE
24
MONOHYDRATE/MACROCRYSTALS
NEOMYCIN SULFATE/BACITRACIN
NITROGLYCERIN
ZINC/POLYMYXIN B/HYDROCORTISONE
188
NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN
B
189
NEOMYCIN SULFATE/POLYMYXIN B
SULFATE/GRAMICIDIN D
189
NEOMYCIN SULFATE/POLYMYXIN B
SULFATE/HYDROCORTISONE
NEOMYCIN/BACITRACIN/POLYMYXIN
B/HYDROCORTISONE
NEORAL
NEPAFENAC
NITROSTAT
102
NIZATIDINE
122
NORDITROPIN FLEXPRO
132
NORDITROPIN NORDIFLEX
132
NORELGESTROMIN/ETHINYL ESTRADIOL
205
137,138
NORETHINDRONE ACETATE
138
NORETHINDRONE ACETATE-ETHINYL
112
NEOMYCIN/POLYMYXIN B
SULFATE/DEXAMETHASONE
26
101,102,189
NORETHINDRONE
20,129,155,189
25,26
ESTRADIOL
177,179,183,184,187,190
NORETHINDRONE ACETATE-ETHINYL
189
115,144
153
ESTRADIOL/FERROUS
FUMARATE
135,136,137,138,176,185,200,201
NORETHINDRONE-ETHINYL
NESINA
78
ESTRADIOL 134,135,136,137,138,167,171,184,187,18
NEULASTA
86
8,190,201,205
NEUMEGA
189
NEUPOGEN
86,189
NORETHINDRONE-ETHINYL
ESTRADIOL/FERROUS FUMARATE
NEUPRO
189
NORETHINDRONE-MESTRANOL
NEVANAC
153
NORGESTIMATE-ETHINYL
NEVIRAPINE
66
ESTRADIOL
NEXAVAR
55
NORGESTREL-ETHINYL
NEXPLANON
NIACIN
189
190,205,206
188,190
134,136,137,138,139,191
ESTRADIOL
174,175,186,190
100,101
NORINYL 1+35
136
NIACIN/LOVASTATIN
166
NORINYL 1+50
190
NIACIN/SIMVASTATIN
197
NORPACE CR
91
NICOTINE
18
NORTRIPTYLINE HCL
42
NICOTROL
18
NORVIR
68
NICOTROL NS
18
NOVOLOG
80,190
NIFEDIPINE
95,96
NOVOLOG FLEXPEN
190
NILANDRON
142
NOVOLOG MIX 70-30
80
NOVOLOG MIX 70-30 FLEXPEN
80
NILOTINIB HCL
57
NILUTAMIDE
142
NOXAFIL
45
NIMODIPINE
96
NPLATE
190
NISOLDIPINE
96
NUCORT
190
PAGE 223
NUCYNTA ER
13,14,106
OSELTAMIVIR PHOSPHATE
69
NUEDEXTA
106
OSENI
191
NUOX
190
OVACE PLUS
191
NUTROPIN AQ
132,133
OVCON-35
136
NUTROPIN AQ NUSPIN
132,133
OXANDROLONE
133
NUVARING
NUVIGIL
190
162,163,190
NYSTATIN
45,115
NYSTATIN/TRIAMCINOLONE ACETONIDE 20,21,115
O
OCTREOTIDE ACETATE
141,142
OFLOXACIN
30,151
OLANZAPINE
63,74
OLMESARTAN MEDOXOMIL
88
OLMESARTAN MEDOXOMIL/AMLODIPINE
BESYLATE/HYDROCHLOROTHIAZIDE
OLOPATADINE HCL
11,23
OXAZEPAM
192
OXCARBAZEPINE
35
OXICONAZOLE NITRATE
45,115
OXISTAT
45,115
OXSORALEN
115
OXSORALEN-ULTRA
116
OXYBUTYNIN CHLORIDE
123
OXYCODONE HCL
16,192
OXYCODONE HCL/ACETAMINOPHEN
192
OXYMETHOLONE
133
202
OXYMORPHONE HCL
170
P
OLMESARTAN
MEDOXOMIL/HYDROCHLOROTHIAZIDE
OXAPROZIN
14
152,158
PACNEX HP
192
OLSALAZINE SODIUM
148
PACNEX LP
192
OMEGA-3 ACID ETHYL ESTERS
101
PACNEX MX
192
OMEPRAZOLE
123
PALIPERIDONE
OMEPRAZOLE/SODIUM BICARBONATE
190
PANCREAZE
119
OMNARIS
157
PANDEL
129
OMNITROPE
133
PANRETIN
ONCASPAR
190
PANTOPRAZOLE SODIUM
123
PARAGARD T 380-A
192
PAREGORIC
192
PAREMYD
192
ONDANSETRON
ONDANSETRON HCL
ONFI
ONGLYZA
44
43,44
190
78
62,63
57,116
PARICALCITOL
140,151
OPIUM TINCTURE
191
PAROMOMYCIN SULFATE
OPIUM/BELLADONNA ALKALOIDS
169
PAROXETINE HCL
OPRELVEKIN
189
PASER
ORALAIR
191
PATADAY
152
PATANASE
158
152
ORAP
61
24
40,73
50
ORENCIA
191
PATANOL
ORENITRAM ER
191
PAZOPANIB HCL
ORPHENADRINE CITRATE
162
PCE
ORTHO TRI-CYCLEN LO
191
PEDIARIX
192
ORTHO-NOVUM
136
PEDVAXHIB
192
PAGE 224
54
29,30
PEG 3350/SOD SULF/SOD BICARBONATE/SOD
PHOSLYRA
125
CHLORIDE/POTASSIUM CHL
PHOSPHOLINE IODIDE
155
178,192
PEG 3350/SODIUM SULFATE/SOD
PHOSPHORUS #1
CHLORIDE/KCL/ASCORBATE SOD/VIT C
122
PEGANONE
35
PEGASPARGASE
190
PEGASYS
70,192
PEGASYS PROCLICK
PEGFILGRASTIM
183,193,204
PHYSICIANS EZ USE B-12
193
PHYTONADIONE
186,193,204
PILOCARPINE HCL
109,155
PIMECROLIMUS
113,143
192
PIMOZIDE
61
86
PINDOLOL
93
PIOGLITAZONE HCL
79
PEGINTERFERON ALFA-2A
70,192
PEGINTERFERON ALFA-2B
70
PIOGLITAZONE HCL/METFORMIN HCL
PEGINTRON
70
PIROXICAM
PEGINTRON REDIPEN
70
PITAVASTATIN CALCIUM
PENCICLOVIR
71
PNEUMOCOCCAL 13-VALENT CONJUGATE
PENICILLAMINE
125,142,143,163
PENICILLIN V POTASSIUM
28
193
11,23
99
VACCINE (DIPHTHERIA CRM)/PF
195
PNEUMOCOCCAL 23-VALENT POLYSACCHARIDE
PENNSAID
192
VACCINE
193
PENTACEL
192
PNEUMOVAX 23
193
PENTACEL DTAP-IPV COMPONENT
192
PODOFILOX
112,116
PENTAM 300
58
PODOPHYLLUM RESIN
193
PENTAMIDINE ISETHIONATE
58
POLIOMYELITIS VACCINE, KILLED
182
POLYMYXIN B SULFATE/TRIMETHOPRIM
193
PENTASA
121,148
PENTAZOCINE HCL/NALOXONE HCL
192
PENTAZOCINE LACTATE
16
PENTOSAN POLYSULFATE SODIUM
125
PENTOXIFYLLINE
96
PERAMPANEL
31,32
POMALIDOMIDE
50,146,147
POMALYST
50,146,147
PONATINIB HCL
55
POSACONAZOLE
45
POTABA
193
193
PERINDOPRIL ERBUMINE
90
POTASSIUM AMINOBENZOATE
PERMETHRIN
59
POTASSIUM CHLORIDE
PERPHENAZINE
42,43,61
163,164,183,184,194
POTASSIUM CITRATE
164
PERPHENAZINE/AMITRIPTYLINE HCL
193
POTASSIUM CITRATE/CITRIC ACID
193
PERTZYE
119
POTASSIUM HYDROXIDE
194
PHENAZOPYRIDINE HCL
193
POTASSIUM PHOSPHATE,MONOBASIC
183
PHENELZINE SULFATE
PHENOBARBITAL
PHENOXYBENZAMINE HCL
39
193
88
POTIGA
32
POVIDONE-IODINE
170
PRADAXA
83
PHENYLEPHRINE HCL
193
PRALIDOXIME CHLORIDE
PHENYLEPHRINE HCL/PROMETHAZINE HCL
195
PRAMIPEXOLE DI-HCL
PHENYTOIN
PHENYTOIN SODIUM
PHENYTOIN SODIUM EXTENDED
PAGE 225
35,36
193
35,36
PRANDIMET
195
59,60
194
PRASUGREL HCL
87
PRAVASTATIN SODIUM
100
PRAZIQUANTEL
58
PRAZOSIN HCL
88,124
PROMACTA
86,87
PROMETHAZINE HCL
43,158
PRED MILD
153
PROMETHAZINE HCL/CODEINE
PRED-G
194
PROMETHAZINE/PHENYLEPHRINE
PREDNICARBATE
116
HCL/CODEINE
PREDNISOLONE
PREDNISOLONE ACETATE
20,21,129
130,153
195
195
PROPAFENONE HCL
91
PROPANTHELINE BROMIDE
195
PREDNISOLONE SOD PHOSPHATE 21,129,130,153
PROPARACAINE HCL
17,151
PREDNISONE
21,130,149
PROPARACAINE HCL/FLUORESCEIN SODIUM 177
PREGABALIN
32,33,106,107
PROPRANOLOL HCL
93,94
PREMARIN
137
PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE 195
PREMPHASE
194
PROPYLTHIOURACIL
142
PREMPRO
194
PROQUAD
195
PRENATAL VIT COMB NO.48/IRON, CARBONYL &
PROSTIN E2 VAGINAL SUPPOSITORY
195
GLUCONATE/FA/B6
PROTOPAM CHLORIDE
195
PRENATAL WITHOUT IRON/FOLIC ACID/CALCIUM
PROTOPIC
116
CARB/PYRIDOXINE/B12
171
PROTRIPTYLINE HCL
PREPIDIL
194
PROVENTIL HFA
160
PREPOPIK
122
PRUDOXIN
116
PREVACID
123
PULMICORT FLEXHALER
157
PREVIDENT
194
PULMOZYME
195
PREVIDENT 5000
194
PURIXAN
195
PREVIDENT 5000 ENAMEL PROTECT
194
PYRAZINAMIDE
50
PREVIDENT 5000 PLUS
194
PYRIDOSTIGMINE BROMIDE
49
PREVIDENT 5000 SENSITIVE
194
PYRIDOXINE HCL
195
PREVNAR 13
195
PYROGALLIC ACID
195
PYROGALLOL
195
PREZISTA
173
68,195
42
PRIMAQUINE PHOSPHATE
58
PRIMIDONE
32
Q
PRISTIQ ER
40
QUARTETTE
PROAIR HFA
160
PROBENECID
46
QUINAPRIL HCL
90
PROCAINAMIDE HCL
91
QUINIDINE GLUCONATE
91
PROCARBAZINE HCL
50
QUINIDINE SULFATE
91
PROCHLORPERAZINE EDISYLATE
PROCHLORPERAZINE MALEATE
43,61,62,195
43,61,62
195
QUETIAPINE FUMARATE
QVAR
38,63,64,74,75
157,195
PROCRIT
86
R
PROCTOCORT
21
RABEPRAZOLE SODIUM
123
PROCTOFOAM-HC
195
RAGWITEK
195
PROGESTERONE,MICRONIZED
138
RALOXIFENE HCL
195
PROGLYCEM
PAGE 226
79
RALTEGRAVIR POTASSIUM
67
RAMELTEON
163
RIFAXIMIN
RAMIPRIL
90
RILONACEPT
RANEXA
96
RILPIVIRINE HCL
RANITIDINE HCL
RANOLAZINE
122,195
96
26,121
146
65
RILUTEK
106
RILUZOLE
106
RAPAFLO
124
RIMANTADINE HCL
RAPAMUNE
144
RIMEXOLONE
153
RISEDRONATE SODIUM
150
RASAGILINE MESYLATE
REBIF
60
108,147
69
RISPERIDONE
64,74
REBIF REBIDOSE
196
RITALIN LA
105
RECOMBIVAX HB
196
RITONAVIR
68
REGORAFENIB
REGRANEX
56
RIVAROXABAN
84,205
116
RIVASTIGMINE
36,37
RELENZA
69
RELISTOR
196
ROFLUMILAST
161
47,48
ROMIPLOSTIM
190
RELPAX
REMODULIN
160,161
RIZATRIPTAN BENZOATE
48
ROPINIROLE HCL
60
RENAGEL
125
ROSIGLITAZONE MALEATE
RENOVA
116
ROSIGLITAZONE MALEATE/METFORMIN HCL
RENOVA PUMP
116
ROSUVASTATIN CALCIUM
REPAGLINIDE
REPAGLINIDE/METFORMIN HCL
RESCRIPTOR
196
194
ROTATEQ
196
66
ROTAVIRUS VACC, LIVE ORAL ATTENUATED, 8912 STRAIN, G1P(8)
RESERPINE
196
ROTAVIRUS VACCINE, LIVE ORAL
RETIN-A MICRO PUMP
144,151
116
116,196
RETISERT
196
REVLIMID
50,51,147
REYATAZ
68
RHEUMATREX
RHINOCORT AQUA
RIBASPHERE RIBAPAK
RIBATAB
RIBAVIRIN
RIDAURA
99
ROTARIX
155
RETIN-A MICRO
168
79
RESCULA
RESTASIS
76,77
52,116,145
157
70,71
71
70,71
147
196
PENTAVALENT
196
ROTIGOTINE
189
ROZEREM
163
RUFINAMIDE
35
RUXOLITINIB PHOSPHATE
54
RYTARY
196,197
S
SABRIL
34
SAFYRAL
197
SAIZEN
133
SALICYLIC ACID
197
RIFABUTIN
49
SALICYLIC ACID/CERAMIDES 1,3,6-11
197
RIFAMPIN
50
SALSALATE
197
RIFAMPIN/ISONIAZID/PYRAZINAMIDE
50
SAMSCA
163
RIFATER
50
SANDIMMUNE
145
PAGE 227
SANTYL
116
SAPHRIS
64,74
SAPROPTERIN DIHYDROCHLORIDE
118,184
SODIUM PHOSPHATE,MONOBASIC/POTASSIUM
PHOSPHATE,MONOBASIC
183
SODIUM PICOSULFATE/MAGNESIUM
SAQUINAVIR MESYLATE
68
OXIDE/CITRIC ACID
122
SARGRAMOSTIM
86
SODIUM POLYSTYRENE SULFONATE
163
SAVELLA
SAXAGLIPTIN HCL
SAXAGLIPTIN HCL/METFORMIN HCL
107
SODIUM/POTASSIUM/POTASSIUM
78
CITRATE/SODIUM CITRATE/CIT AC
184
SCOPOLAMINE
43
193,202
SOFOSBUVIR
198
SOLARAZE
116,130
SCOPOLAMINE HYDROBROMIDE
197
SOLIFENACIN SUCCINATE
124
SECOBARBITAL SODIUM
197
SOLTAMOX
198
SECONAL SODIUM
197
SOMATROPIN
SELEGILINE
38,39
SELEGILINE HCL
60
SELENIUM SULFIDE
116
SORAFENIB TOSYLATE
55
SOTALOL HCL
92
SOVALDI
198
SPINOSAD
116
SPIRIVA
158
38,64,74,75
SPIRIVA RESPIMAT
198
133
SPIRONOLACTONE
97
SELZENTRY
67
SENSIPAR
140
SEROQUEL XR
131,132,133
SEROSTIM
SERTACONAZOLE NITRATE
44,113
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 166,
SERTRALINE HCL
40,73
SEVELAMER HCL
125
SPORANOX
SILODOSIN
124
SPRYCEL
55,56
SILVER NITRATE
197
STAVUDINE
66,67
SILVER SULFADIAZINE
31,116
198
45
STIMATE
198
SIMCOR
197
STIVARGA
SIMVASTATIN
100
STRATTERA
105
SINCALIDE
183
STRIANT
134
SINECATECHINS
118
STRIBILD
67
SIROLIMUS
144
STROMECTOL
58
SITAGLIPTIN PHOSPHATE
78
SUBOXONE
SITAGLIPTIN PHOSPHATE/METFORMIN HCL
182
SUCCIMER
SITAVIG
198
SUCRALFATE
SKLICE
59
SKYLA
198
SODIUM EDECRIN
97
SODIUM
FLUORIDE
56
198
163,174,198
122
SULCONAZOLE NITRATE
44
SULFACETAMIDE SODIUM 31,116,117,152,191,199
SULFACETAMIDE SODIUM/PREDNISOLONE
ACETATE
173,174,177,178,186,189,194,197,198
170
SULFACETAMIDE SODIUM/PREDNISOLONE
SODIUM FLUORIDE/POTASSIUM NITRATE
194
SODIUM PHOSPHATE
SODIUM FLUORIDE/XYLITOL
177
SULFACETAMIDE SODIUM/SULFUR
SODIUM PHENYLBUTYRATE
118
SULFACETAMIDE SODIUM/SULFUR/UREA
PAGE 228
199
169,198,199
198
SULFADIAZINE
31
TELITHROMYCIN
29
SULFAMETHOXAZOLE/TRIMETHOPRIM
31
TELMISARTAN
89
SULFAMYLON
26
TELMISARTAN/AMLODIPINE BESYLATE
199
TEMAZEPAM
199
SULFANILAMIDE
169
SULFASALAZINE
121,147,150
SULINDAC
SUMATRIPTAN
SUMATRIPTAN SUCCINATE
SUMAVEL DOSEPRO
SUNITINIB MALATE
SURVANTA
11,23,46
48
48,49,199
49,199
56
199
TEMOZOLOMIDE
199,200
TENIVAC
200
TENOFOVIR DISOPROXIL FUMARATE
67,71
TERAZOSIN HCL
88,124
TERBINAFINE HCL
45
TERBUTALINE SULFATE
160
TERCONAZOLE
45
SUSTIVA
66
TERIFLUNOMIDE
107,108
SUTENT
56
TERIPARATIDE
150
175
SUVOREXANT
169
TESAMORELIN ACETATE
SYMBICORT
199
TESTOSTERONE
SYNAREL
142
TESTOSTERONE ENANTHATE
134
SYPRINE
163
TESTRED
134
TETANUS AND DIPHTHERIA TOXOIDS,
T
TABLOID
TACLONEX
TACROLIMUS
TADALAFIL
TAFLUPROST/PF
134,167,200
ADSORBED, ADULT/PF
52
117
116,117,145
124,125
200
TETANUS AND DIPHTHERIA TOXOIDS, ADULT 200
TETANUS,DIPHTHERIA TOXOID PED/PF
174
TETRABENAZINE
106
TETRACAINE HCL
166,200
155
TETRACAINE HCL/PF
200
TALWIN
16
TETRACYCLINE HCL
31
TAMIFLU
69
TETRAHYDROZOLINE HCL
TAMOXIFEN CITRATE
51,198
161,202
TETRAVISC
200
TAMSULOSIN HCL
124
TETRAVISC FORTE
200
TANZEUM
199
TEVETEN HCT
200
TAPENTADOL HCL
TARCEVA
TARGRETIN
TASIGNA
TASIMELTEON
TASMAR
TAZAROTENE
13,14,106
56,57
57,117
57
TEXACORT
21,117,130
THALIDOMIDE
51,147,148
THALOMID
51,147,148
THEOPHYLLINE ANHYDROUS
158,159
179
THIAMINE HCL
200
59
THIOGUANINE
52
110,117
THIOLA
200
TAZORAC
117
THIORIDAZINE HCL
62
TECFIDERA
108
THIOTHIXENE
62
TEGRETOL XR
36,76
THYROID,PORK
168,188,190
TEKTURNA
96
THYROLAR-1
139
TELBIVUDINE
71
THYROLAR-1/2
139
PAGE 229
THYROLAR-1/4
139
TRANDOLAPRIL
THYROLAR-2
139
TRANEXAMIC ACID
87,201
THYROLAR-3
139
TRANSDERM-SCOP
43
TRANYLCYPROMINE SULFATE
39
TIAGABINE HCL
33,34
90,91
TICAGRELOR
87
TRAVATAN Z
151
TICLOPIDINE HCL
87
TRAVOPROST
151
TIKOSYN
92
TRAZODONE HCL
38
TIMOLOL
154
TRECATOR
50
TIMOLOL MALEATE
46,94,154,155
TIOPRONIN
200
TIOTROPIUM BROMIDE
158,198
TREPROSTINIL
202
TREPROSTINIL DIOLAMINE
191
TREPROSTINIL SODIUM
160,161
TIPRANAVIR
68
TREPROSTINIL/NEBULIZER ACCESSORIES
TIPRANAVIR/VITAMIN E TPGS
68
TREPROSTINIL/NEBULIZER/NEBULIZER
TIROSINT
200,201
TIZANIDINE HCL
65
ACCESSORIES
202
202
TRETINOIN
57,117
TIZANIDINE HCL/IRRITANTS COUNTER-IRRITANTS
TRETINOIN MICROSPHERES
COMBINATION NO.2
65
TRETINOIN/EMOLLIENT BASE
TOBI
24
TRI-CHLOR
201
TRI-NORINYL
201
TOBRADEX
24,152
TOBRADEX ST
201
TOBRAMYCIN
24,152
TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE
TOBRAMYCIN/DEXAMETHASONE
24
24,152,201
TOBRAMYCIN/LOTEPREDNOL ETABONATE
TOBREX
TOFACITINIB CITRATE
116,117
TRIAMCINOLONE
ACETONIDE
21,109,117,118,130,157
TRIAMTERENE
97
TRIAMTERENE/HYDROCHLOROTHIAZIDE 201,202
206
TRIAZOLAM
202
24,152
TRIBENZOR
202
TRICHLOROACETIC ACID
201
163
148
TOLAZAMIDE
79
TRIENTINE HCL
TOLBUTAMIDE
79
TRIFLUOPERAZINE HCL
TOLCAPONE
59
TRIFLURIDINE
TOLMETIN SODIUM
116,117,196
11,23
62
71,152
TRIHEXYPHENIDYL HCL
59
TOLTERODINE TARTRATE
123
TRILIPIX
98
TOLVAPTAN
163
TRIMETHOPRIM
26
TOPIRAMATE
34,35,46,47,201
TOPOTECAN HCL
180
TRIUMEQ
202
TROPICAMIDE
152
202
TOREMIFENE CITRATE
51
TRUMENBA
TORSEMIDE
97
TRUVADA
67
TOVIAZ
123
TUDORZA PRESSAIR
158
TRACLEER
161
TWINRIX
202
TRADJENTA
79
TYKERB
57
14,16
TYVASO
202
54
TYZEKA
71
TRAMADOL HCL
TRAMETINIB DIMETHYL SULFOXIDE
PAGE 230
TYZINE
161,202
U
ULESFIA
59,118
ULIPRISTAL ACETATE
137
ULORIC
46
VENLAFAXINE HCL ER
40,73
VENTAVIS
161
VENTOLIN HFA
160
VERAMYST
130,157
VERAPAMIL HCL
92,96
VEREGEN
118
ULTRAVATE X
203
VERIPRED 20
ULTRESA
119
VESICARE
124
UMECLIDINIUM BROMIDE
181
VEXOL
153
UMECLIDINIUM BROMIDE/VILANTEROL
21,130
VICTOZA 2-PAK
79
TRIFENATATE
167
VICTOZA 3-PAK
79
UMECTA
203
VIDEX
67
UMECTA PD
203
VIGABATRIN
34
UNOPROSTONE ISOPROPYL
155
VIGAMOX
URAMAXIN
203
VIMPAT
URAMAXIN GT
203
VIOKACE
204
VIRACEPT
69
66
UREA
172,179,180,183,196,203
UREVAZ
203
VIRAMUNE XR
UROCIT-K
164
VIREAD
URSODIOL
UTOPIC
121,203
203
V
VAGIFEM
137
30,152
36
67,71
VISMODEGIB
55
VIVITROL
17
VORICONAZOLE
45
VORINOSTAT
57
VOTRIENT
54
VALACYCLOVIR HCL
72
VYTORIN
204,205
VALCYTE
65
VYVANSE
103
VALGANCICLOVIR HCL
65
VALPROIC ACID
34,47,76
W
VALPROIC ACID (AS SODIUM SALT) (VALPROATE
WARFARIN SODIUM
SODIUM)
34,47,76
WATER FOR IRRIGATION,STERILE
198
VALSARTAN
89
WEED POLLEN-SHORT RAGWEED
195
VANCOMYCIN HCL
26
WELCHOL
VANDETANIB
55
VAQTA
VARENICLINE TARTRATE
204
82,83,84
79,101
X
18
XALKORI
VARICELLA VIRUS VACCINE LIVE/PF
204
XARELTO
84,205
VARIVAX VACCINE
204
XELJANZ
148
VASOPRESSIN
204
XENAZINE
106
VEMURAFENIB
206
XIFAXAN
VENELEX
204
XIGDUO XR
205
XTANDI
205
VENLAFAXINE HCL
PAGE 231
40,73
57
26,121
Y
YAZ
205
Z
ZAFIRLUKAST
158
ZALEPLON
162
ZAMICET
206
ZANAMIVIR
69
ZAVESCA
119
ZELAPAR
60
ZELBORAF
206
ZEMPLAR
140,151
ZENPEP
119,120
ZETIA
101
ZETONNA
157
ZIAGEN
67
ZIDOVUDINE
67
ZILEUTON
158
ZIOPTAN
155
ZIPRASIDONE HCL
ZIRGAN
ZITHRANOL
36,64,75
65,152
206
ZOLINZA
57
ZOLMITRIPTAN
49
ZOLPIDEM TARTRATE
ZOMIG
ZONISAMIDE
162
49
33,36
ZORBTIVE
133
ZORTRESS
145
ZOSTAVAX
206
ZOSTER VACCINE LIVE/PF
206
ZYCLARA
53,118,148
ZYDELIG
206
ZYFLO CR
158
ZYKADIA
206
ZYLET
206
ZYMAXID
30,152
ZYTIGA
54
ZYVOX
26
PAGE 232

formulary - Physicians Plus

Transcription

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