CHIP Cover.indd - Geisinger Health Plan

Transcription

LIST OF COVERED DRUGS
Member
Formulary
This formulary was designed to be a useful tool if you have prescription drug coverage. It lists
the drugs covered by your benefit. Medications are listed in this formulary in easy-tounderstand groupings, but we encourage you to call our Pharmacy Service Team at (800) 9884861 if you have any questions about this information.
You can also view the formulary online by logging onto thehealthplan.com.
Pharmacy Customer Service Team Contact Information
Telephone: (800) 988-4861 or (570)-271-5673; TDD/TTY 711
Fax: 570-271-5610
Mailing address:
Geisinger Health Plan
Pharmacy Department
Internal Mail Code 32-46
100 North Academy Avenue
Danville, PA 17822
CHIP Pharmacy Benefit
The CHIP Pharmacy benefit assigns each prescription medication to one of two different tiers,
each representing a set copayment amount. The copay amount will depend on your
prescription medication rider. Additional medications, other than those included in this
formulary, may be covered under the CHIP Pharmacy benefit. The definitions of the copay
levels are listed below:
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Tier 1–Includes most generic medications and has the lowest copayment. Prior
authorization is usually not necessary for medications in this tier.
Tier 2–Includes certain formulary brand name medications with no generic equivalent. Prior
authorization may be necessary for medications in this tier.
The Plan maintains sole discretion of assigning medications to tiers and moving medications
from one tier to another. Several factors are considered when assigning medications to tiers.
These factors include but are not limited to:
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Availability of a generic equivalent
Absolute cost of a medication
Cost of the medication relative to other medications in the same therapeutic class
Availability of over-the-counter alternatives
Clinical and economic factors
Please note: A medication may change in tier status without notice due to immediate generic
availability or changes in medication availability in the marketplace
Specialty Vendor Drug Program
Certain medications require the use of a contracted specialty pharmacy vendor for purchase.
Please contact the Pharmacy Service Team at (800) 988-4861 for additional information on the
program and a complete list of the medications included.
A few things you should remember when using this formulary and your prescription
benefit:
All prescriptions must be filled at a participating pharmacy.

You will pay the applicable copay, coinsurance or deductible when you receive the
prescription.

Coverage is for generic drugs when they have equivalent rating in the drug products
list (Orange Book–U.S. Department of Health and Human Services).

Some medications on the formulary require prior authorization which your provider
may request through our Pharmacy Service Team at (800) 988-4861.
If you require medications not listed on this formulary, your provider may request an
exception through our Pharmacy Customer Service Team, except for those items
listed as specific exclusions. Non-formulary medications not requiring prior
authorization will be available at the highest copay level.
Some medications and diabetic supplies may be restricted to a specific manufacturer,
vendor or supplier and may be subject to quantity limits.
Quantity limits may apply to certain medications.
Insulin syringes, lancets, and inhaler spacers are covered at Tier 2.
Non-prescription (over-the-counter) medications are not covered unless required by
healthcare reform legislation.
Note that if certain conditions are met some medications may be covered with no
copay/coinsurance due to healthcare reform legislation. Please contact the pharmacy
customer service team for more information.
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Using this formulary
 The medication Tier is listed in the Drug Tier Column.
 Medication names with QL in the Requirements/Limits column have quantity limits
 Medication names followed by PA in the Requirements/Limits column require prior
authorization.
 Medication names followed by ST in the Requirements/Limits column have step
therapy requirements. (Please see Step Therapy List below).
 This formulary is accurate as of November 30th, 2011, and is subject to change. Any
additions or deletions to the formulary throughout the year may be found in the
following quarterly publications: “Member Update” for members and “Briefly” for
providers. The most up-to-date source for formulary information is the online formulary
search available at www.thehealthplan.com.
 Restrictions in medication availability may result from use of a formulary.
Please be aware that if you choose to obtain a non-formulary drug, you may be required to pay
the full price of that drug. For information about your specific prescription drug
benefits, please contact the Pharmacy Service Team at (800) 988-4861 or (570) 271-5673.
Quantity Limits
 Quantity limits are listed in the Requirements/Limits Column
 Note that non-formulary medications in the same class/category as formulary drugs
with quantity limits will have the same quantity limits applied.
 If not listed above the maximum days supply for specialty vendor medications is 34
days or as otherwise defined in the prescription medication benefit documents.
Step Therapy List
Medication
Name
Byetta
Januvia
Step Therapy Requirement
Formulary oral antidiabetic agent or insulin
Metformin, Actos, or Avandia
What is a medication formulary?
A medication formulary is a continually updated list of prescription medications. It
represents the medications currently covered based upon the clinical judgment of the
Pharmacy and Therapeutics Committee, which is made up of pharmacists and
physicians. (The formulary is continually updated due to the high number of medications
currently on the market, as well as the continuous introduction of new medications.)
This committee thoroughly reviews medical literature to first determine which
medications are likely to produce the best results for patients. Then, if two or more
medications produce the same clinical results, elements like cost and ease of use are
considered.
A well-developed formulary enhances quality of patient care by encouraging physicians
to prescribe medications that are safe, effective, and likely to achieve the best possible
outcome for the patient. When you use a formulary medication, it is considered a
“covered” medication and you pay your particular co-pay or coinsurance for that
medication.
The Plan recognizes that, in some situations, you may not respond well to a given
formulary medication, or may have an allergy or other condition that warrants the use of
a non-formulary medication. An exception process exists for these special instances.
Your physician may initiate a request for a formulary exception by contacting our
Pharmacy Service Team. Your request will be reviewed, including review of pertinent
medical records, treatment and laboratory data. We respond to such requests within 48
hours of receiving all necessary information. If an exception is approved under the
Triple Choice benefit, you will be charged at the highest applicable copay level. If your
request is denied, the medication will be excluded from coverage under your
prescription medication benefits.
Formulary exclusions
There are certain medications that your plan will not cover under any circumstance.
These are called exclusions. Examples of exclusions include, but are not limited to,
over-the-counter medications, medications used for experimental, investigational or
unproven medication therapies, medications used for weight loss and weight
management, life-style medications, medications used for cosmetic purposes, and
medications for erectile dysfunction. Exclusions are subject to change so you should
contact the Pharmacy Service Team when you are unsure whether a medication is
covered.
Formulary development
When deciding whether or not a medication should be included in the formulary, the
Pharmacy and Therapeutics Committee carefully considers each medication for
coverage or non-coverage in order to ensure safety and effectiveness in the
medications being prescribed. This information is then shared with participating
providers for review and feedback. Based upon the gathered information and provider
feedback, the Pharmacy and Therapeutics Committee will determine a medication’s
inclusion or exclusion in the formulary. For the specific criteria used to determine a
medication’s inclusion or exclusion in this formulary, please contact the Pharmacy
Customer Service Team.
What are generics?
When a company develops a new medication, it receives a patent that protects the
medication company’s right to be the only manufacturer of that medication for a certain
period of time, which means that no generic can be manufactured. After that patent
expires, other companies can then make the same medication and sell it in its generic
form. The generic form of a medication has the same active ingredients, the same
strength, and the same dosage as the brand name medication. The inactive ingredients
(which provide texture, shape and color) may be different, which is why a generic
typically looks different than its brand name counterpart. Generic medications are
usually less expensive than brand name medications, but are just as safe and effective.
This is because generic manufacturers have lower advertising costs and greater
competition from other generic manufacturers. Additionally, the U.S. Food and Drug
Administration regulates all pharmaceuticals, including generics, to assure quality,
strength, purity and potency.
Your prescription medication coverage is a generic-based plan and, whenever
possible, you should use a cost-effective generic medication.
Notes for Providers
Formulary review process: Medications selected for inclusion in the formulary are
chosen in consideration of effectiveness, safety and overall value. Evaluation for
formulary inclusion is based on formalized selection criteria to determine the most
optimal benefit to members. These criteria include but are not limited to:
 Medication name/dosage form
 Medication class/pharmacology
 FDA-approved indications
 Adverse reactions
 Clinical evidence of safety and efficacy
 Recommendations of national agencies and organizations
 Therapeutic equivalence
 Cost analysis
The criteria are reviewed by the Health Plan Pharmacy and Therapeutics Committee,
which is comprised of pharmacists and participating physicians in active clinical practice
from various specialties. The medication is then reviewed and evaluated by clinicians in
particular specialties for additional feedback. The feedback is discussed by the
Pharmacy and Therapeutics Committee prior to finalizing a decision on formulary
status. To be included, the medication must offer a distinct advantage over existing
formulary medications in the same therapeutic class. Specifically, the medication must
demonstrate such attributes as:
 A distinct or unique therapeutic feature
 Greater efficacy, proven in clinical trials, over other medications in the same
therapeutic category
 An improved dosing schedule, safety profile or cost-effectiveness over existing
formulary medications
If there are comparable therapeutic agents, additional analysis may be considered.
These factors include:
 Member satisfaction
 Cost analysis
 Contract terms and conditions
 Market share analysis
 Patent life assessment
 Utilization management
 Consumer advertising
 Per member per month costs
Generic substitution policy: The Health Plan prescription benefits are generically
based. Generic substitution will occur for those medications included in the “Approved
Medication Products with Therapeutic Equivalence Evaluations,” also known as “The
Orange Book,” published by the U.S. Department of Health and Human Services.
Generic medications, which have an equivalent rating by these standards, are generally
provided under the member’s prescription medication benefit. The Health Plan may also
elect to include only one brand-name medication in the formulary even if the medication
is marketed by more than one company, or if the brand name medication does not
significantly differ from the generic medication.
Prior authorization: To promote the most appropriate utilization, select medications
may require prior authorization by the Health Plan to be eligible for coverage under the
member’s prescription benefit. The Pharmacy and Therapeutics Committee determines
prior authorization criteria. In order for a member to receive coverage for a medication
requiring prior authorization, the prescribing physician must obtain prior authorization by
contacting the Health Plan Pharmacy Department at the address, telephone, or fax
number above. Submission of medical documentation is required.
Step Therapy: Some medications may require that other medications be tried prior to
or concomitantly with the requested medication. The pharmacy claims system looks for
a record of the required medications and if they are not found, medical documentation
must be submitted showing use of these medications or rationale for skipping the step
therapy medications.
Non-formulary medications: The formulary is designed to meet most therapeutic
needs of the population served by the Health Plan. Occasionally, because of allergy,
therapeutic failure, or a specific diagnostic-related need, formulary medications may not
meet the special needs of an individual member. In these special instances, the
prescribing physician may make requests to the Health Plan Pharmacy Department for
non-formulary or restricted medications. The prescribing physician will receive written
documentation and/or a verbal response from the Health Plan Pharmacy Department
regarding the request.
Formulary addition requests: Requests for changes or additions, comments, and
suggestions for the formulary are welcome and can be made by written request to the
Health Plan Pharmacy Department.
Sources:
Academy of Managed Care Pharmacy (AMCP), “Formulary Management,”
“Formularies,” www.amcp.org., November 2001.
Health Insurance Association of America (HIAA), “Guide to Managed Care: Choosing
and Using a Health Plan.” www.hiaa.org., November 2001.
National Consumers League (NCL), “Consumer Guide to Generic Medications,”
www.nclnet.org., November 2001.
“From the Pharmacist,” www.cvs.com., November 2001.
Drug
Tier
Drug Name
Requirements/Limits
Acidifying and Alkalinizing Agents
Acidifying and Alkalinizing Agents
citric acid/sodium citrate (Bicitra)
(K-phos Neutral)
phosphorus #1
(Urocit-K)
potassium citrate
(Polycitra-k)
potassium citrate/citric
acid
(Polycitra-lc)
sod/pot/k cit/sod cit/cit
acid
K-PHOS ORIGINAL
ORACIT
1
1
1
1
1
2
2
Adrenals
Adrenals
budesonide
cortisone acetate
dexamethasone
fludrocortisone acetate
hydrocortisone
methylprednisolone
prednisolone sod
phosphate
prednisolone
prednisone
VERIPRED 20
ADVAIR DISKUS
ADVAIR HFA
ASMANEX
DULERA
FLOVENT DISKUS
FLOVENT HFA
PULMICORT
FLEXHALER
QVAR
SYMBICORT
(Pulmicort)
(Cortisone Acetate)
(Dexamethasone)
(Florinef Acetate)
(Cortef)
(Medrol)
(Orapred)
1
1
1
1
1
1
1
(Prednisolone)
(Prednisone)
1
1
1
2
2
2
2
2
2
2
2
2
Alpha-Adrenergic Blocking Agents
(Cardura)
doxazosin mesylate
(Minipress)
prazosin hcl
(Hytrin)
terazosin hcl
1
1
1
1
Geisinger 2012 CHIP Formulary
Formulary ID: 80104.000, Version: 2012-1
Effective: January 01, 2012
Drug
Tier
Drug Name
Requirements/Limits
Ammonia Detoxicants
Ammonia Detoxicants
(Lactulose)
lactulose
KRISTALOSE
LITHOSTAT
1
2
2
Analgesics and Antipyretics
Analgesics And Antipyretics, Miscellaneous
(Acetaminophen/caffeine/butalb)
acetaminophen/caffeine/
butalb
acetaminophen/phenyltolx (Staflex)
cit
(Esgic)
butalb/acetaminophen/
caffeine
butalbital/acetaminophen (Tencon)
(Midrin)
isomethept/acetaminop/
dichlphn
(Durabac Forte)
mg sal/acetaminophn/ptlox/caf
sal-amide/acetamin/p-tlox/ (Durabac)
caff
sal-amide/acetaminophn/ (Asp)
p-tlox
PHRENILIN FORTE
Nonsteroidal Anti-inflammatory Agents
butalbital/aspirin/caffeine (Fiorinal)
choline sal/mag salicylate (Choline Sal/mag Salicylate)
(Cataflam)
diclofenac potassium
(Voltaren)
diclofenac sodium
(Diflunisal)
diflunisal
(Etodolac)
etodolac
(Fenoprofen Calcium)
fenoprofen calcium
(Ansaid)
flurbiprofen
(Motrin)
ibuprofen
(Indomethacin)
indomethacin
(Ketoprofen)
ketoprofen
(Toradol)
ketorolac tromethamine
magnesium salicylate
meclofenamate sodium
mefenamic acid
meloxicam
methyl salicylate
(Novasal)
(Meclofenamate Sodium)
(Ponstel)
(Mobic)
(Methyl Salicylate)
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
QL: 20
per fill
tablet
1
1
1
1
1
2
Drug
Tier
Drug Name
nabumetone
naproxen sodium
naproxen
oxaprozin
phenylbutazone
piroxicam
salsalate
sulindac
tolmetin sodium
ARTHROTEC 50
ARTHROTEC 75
CELEBREX
FLECTOR
INDOCIN
NALFON
VIMOVO
VOLTAREN
Opiate Agonists
acetaminophen with
codeine
codeine phos/
acetaminophen
codeine sulf
codeine/butalbit/acetamin/
caff
codeine/butalbital/asa/
caffein
dhcodeine bt/
acetaminophn/caff
fentanyl citrate
(Relafen)
(Anaprox)
(Naprosyn)
(Daypro)
(Phenylbutazone)
(Feldene)
(Salflex)
(Clinoril)
(Tolmetin Sodium)
fentanyl
hydrocodone bit/
acetaminophen
hydrocodone/ibuprofen
hydromorphone hcl
ibuprofen/oxycodone hcl
levorphanol tartrate
meperidine hcl
methadone hcl
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
(Tylenol-codeine No.3)
1
(Codeine Phos/acetaminophen)
1
(Codeine Sulf)
(Fioricet with Codeine)
1
1
(Fiorinal with Codeine #3)
1
(Panlor SS)
1
(Actiq)
1
(Duragesic)
(Vicodin)
1
1
(Vicoprofen)
(Dilaudid)
(Combunox)
(Levo-dromoran)
(Demerol)
(Methadose)
1
1
1
1
1
1
Requirements/Limits
PA
oral susp
PA
PA
PA, QL:
136 in 34
days
tablet
solution, tablet
oral conc, solution,
tablet, tablet sol
3
Drug
Tier
Drug Name
morphine sulfate
(MS Contin)
1
opium/belladonna
alkaloids
oxycodone hcl
oxycodone hcl/
acetaminophen
oxycodone hcl/aspirin
oxycodone hcl/oxycodon
ter/asa
oxymorphone hcl
ROXICODONE
tramadol hcl
tramadol hcl/
acetaminophen
ABSTRAL
(B & O Supprettes No.15-a)
1
(Roxicodone)
(Percocet)
1
1
(Percodan)
(Oxycodone HCl/oxycodon Ter/
asa)
(Opana)
1
1
(Ultram)
(Ultracet)
Requirements/Limits
cap er pel, solution,
supp.rect, tablet,
tablet er
1
1
1
1
2
AVINZA
FENTORA
NUCYNTA ER
NUCYNTA
ONSOLIS
2
2
2
2
2
ORAMORPH SR
OXYCONTIN
Opiate Partial Agonists
(Butorphanol Tartrate)
butorphanol tartrate
(Talacen)
pentazocine hcl/
acetaminophen
pentazocine hcl/naloxone (Talwin NX)
hcl
2
2
1
1
tablet
tablet: 5mg
PA, QL:
136 in 34
days
PA
PA
PA
PA, QL:
136 in 34
days
PA
spray
1
Androgens
Androgens
danazol
estrogen,ester/metestosterone
fluoxymesterone
oxandrolone
testosterone cypionate
(Danocrine)
(Estratest)
1
1
(Fluoxymesterone)
(Oxandrin)
(Depo-testosterone)
1
1
1
4
Drug
Tier
Drug Name
testosterone enanthate
ANDRODERM
ANDROGEL
DELATESTRYL
FORTESTA
STRIANT
(Delatestryl)
1
2
2
2
2
2
Requirements/Limits
PA
PA
Anorexigenics, Respiratory, Cerebral Stimulants
Amphetamines
(Adderall)
1
amphet asp/amphet/damphet
(Didrex)
1
benzphetamine hcl
(Dextrostat)
1
dextroamphetamine
sulfate
(Desoxyn)
1
methamphetamine hcl
VYVANSE
2
PA
Anorexigenics, Respiratory, Cerebral Stimulants, Miscellaneous
(Cafcit)
1
caffeine citrated
(Focalin)
1
dexmethylphenidate hcl
(Diethylpropion HCl)
1
diethylpropion hcl
(Ritalin)
1
methylphenidate hcl
1
phendimetrazine tartrate (Bontril Slow-release)
DAYTRANA
2
PA
FOCALIN XR
2
PA
METADATE CD
NUVIGIL
PROVIGIL
RITALIN LA
2
2
2
2
solution
cpmp 50-50: 5mg,
10mg, 15mg, 20mg,
30mg, 35mg, 40mg
PA
PA
PA
Anthelmintics
Anthelmintics
mebendazole
STROMECTOL
(Mebendazole)
1
2
Antiallergic Agents
Antiallergic Agents
(Astelin)
azelastine hcl
(Elestat)
epinastine hcl
ALOMIDE
ASTEPRO
EMADINE
LASTACAFT
1
1
2
2
2
2
PA
PA
PA
PA
5
Drug
Tier
Drug Name
PATADAY
PATANASE
PATANOL
Requirements/Limits
2
2
2
PA
PA
1
2
PA
1
1
2
2
2
PA
PA
Antibacterials
Aminoglycosides
neomycin sulfate
TOBI
(Neomycin Sulfate)
Antibacterials, Miscellaneous
(Cleocin HCl)
clindamycin hcl
clindamycin palmitate hcl (Cleocin Palmitate)
VANCOCIN HCL
XIFAXAN
ZYVOX
Cephalosporins
(Ceclor)
cefaclor
(Cefadroxil Hydrate)
cefadroxil hydrate
(Omnicef)
cefdinir
(Spectracef)
cefditoren pivoxil
(Vantin)
cefpodoxime proxetil
(Cefzil)
cefprozil
(Ceftin)
cefuroxime axetil
(Keflex)
cephalexin monohydrate
CEFTIN
SUPRAX
Macrolides
(Zithromax)
azithromycin
clarithromycin
ery e-succ/sulfisoxazole
ERY-TAB
erythromycin base
erythromycin
ethylsuccinate
erythromycin stearate
E.E.S. 200
ERYPED 200
ERYPED 400
Penicillins
amoxicillin
amoxicillin/potassium clav
ampicillin trihydrate
1
1
1
1
1
1
1
1
2
2
1
(Biaxin)
(Pediazole)
(Erythromycin Base)
(Erythromycin Ethylsuccinate)
(QL: 34 days supply
per fill)
capsule: 250mg
susp recon
packet, susp recon,
tablet
1
1
1
1
1
(Erythromycin Stearate)
1
2
2
2
(Amoxil)
(Augmentin)
(Ampicillin Trihydrate)
1
1
1
6
Drug
Tier
Drug Name
dicloxacillin sodium
penicillin v potassium
AUGMENTIN
(Dicloxacillin Sodium)
(Veetids 500)
BACTOCILL
Quinolones
(Cipro)
ciprofloxacin hcl
(Cipro XR)
ciprofloxacin/ciprofloxa
hcl
(Levaquin)
levofloxacin
(Nalidixic Acid)
nalidixic acid
(Floxin)
ofloxacin
AVELOX
CIPRO
Sulfonamides (Systemic)
(Sulfadiazine)
sulfadiazine
(Bactrim DS)
sulfamethoxazole/
trimethoprim
(Azulfidine)
sulfasalazine
Tetracyclines
(Declomycin)
demeclocycline hcl
(Morgidox)
doxycycline hyclate
doxycycline monohydrate
minocycline hcl
tetracycline hcl
1
1
2
Requirements/Limits
susp recon: 12531.25/
2
1
1
1
1
1
2
2
1
1
solution, tablet
sus mc rec
oral susp, tablet
1
1
1
(Adoxa)
(Dynacin)
(Ala-tet)
capsule, capsule dr,
tablet, tablet dr
1
1
1
Anticholinergic Agents
Antimuscarinics/Antispasmodics
(Atropine Sulfate)
atropine sulfate
(Librax)
chlordiazepoxide/
clidinium br
(Bentyl)
dicyclomine hcl
(Robinul)
glycopyrrolate
(Levsin-sl)
hyoscyamine sulfate
(Ipratropium Bromide)
ipratropium bromide
(Isopropamide/prochlorperazine)
isopropamide/
prochlorperazine
methscopolamine bromide (Pamine)
(Donnatal)
phenobarb/hyoscy/
atropine/scop
(Propantheline Bromide)
propantheline bromide
1
1
1
1
1
1
1
tablet
tablet
1
1
1
7
Drug
Tier
Drug Name
propantheline/
phenobarbital
ATROVENT HFA
SPIRIVA
(Propantheline/phenobarbital)
Requirements/Limits
1
2
2
Anticonvulsants
Anticonvulsants, Miscellaneous
(Tegretol)
carbamazepine
(Depakote ER)
divalproex sodium
(Felbatol)
felbamate
(Neurontin)
gabapentin
(Lamictal)
lamotrigine
(Keppra)
levetiracetam
1
1
1
1
1
1
(Trileptal)
oxcarbazepine
(Mysoline)
primidone
(Topamax)
topiramate
(Depakene)
valproate sodium
(Depakene)
valproic acid
(Zonegran)
zonisamide
BANZEL
FELBATOL
GABITRIL
LYRICA
SABRIL
VIMPAT
Benzodiazepines (anticonvulsants)
(Klonopin)
clonazepam
Hydantoins
(Dilantin)
phenytoin sodium
extended
(Dilantin-125)
phenytoin
DILANTIN
DILANTIN
PHENYTEK
Succinimides
(Zarontin)
ethosuximide
1
1
1
1
1
1
2
2
2
2
2
2
solution, tab er 24h,
tablet
syrup
PA
oral susp
PA
PA
solution, tablet
1
1
1
2
2
2
capsule: 30mg
tab chew
1
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
(Precose)
acarbose
(Glucophage)
metformin hcl
(Starlix)
nateglinide
1
1
1
8
Drug
Tier
Drug Name
BYETTA
GLYSET
JANUMET
JANUVIA
KOMBIGLYZE XR
ONGLYZA
PRANDIN
SYMLIN
SYMLINPEN 120
SYMLINPEN 60
VICTOZA 3-PAK
Insulins
APIDRA SOLOSTAR
APIDRA
HUMALOG MIX 50-50
HUMALOG MIX 75-25
HUMALOG
HUMULIN 70-30
HUMULIN N
HUMULIN R
LANTUS SOLOSTAR
LANTUS
LEVEMIR
NOVOLIN 70-30
INNOLET
NOVOLIN 70-30
NOVOLIN N INNOLET
NOVOLIN N
NOVOLIN R
NOVOLOG MIX 70-30
NOVOLOG
Sulfonylureas
chlorpropamide
glimepiride
glipizide
glipizide/metformin hcl
glyburide
glyburide,micronized
glyburide/metformin hcl
tolazamide
tolbutamide
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Requirements/Limits
ST
ST
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
2
2
2
2
2
2
(Diabinese)
(Amaryl)
(Glucotrol)
(Metaglip)
(Micronase)
(Glynase)
(Glucovance)
(Tolazamide)
(Tolbutamide)
1
1
1
1
1
1
1
1
1
9
Drug
Tier
Drug Name
Thiazolidinediones
ACTOS
Requirements/Limits
2
Antidiarrhea Agents
Antidiarrhea Agents
diphenoxylate hcl/atropine (Lomotil)
(Loperamide HCl)
loperamide hcl
(Opium)
opium
(Paregoric)
paregoric
1
1
1
1
Antiemetics
5-ht3 Receptor Antagonists
(Kytril)
granisetron hcl
1
(Zofran)
ondansetron hcl
(Zofran Odt)
ondansetron
SANCUSO
Antiemetics, Miscellaneous
(Marinol)
dronabinol
(Scopolamine Hydrobromide)
scopolamine
hydrobromide
EMEND
TRANSDERM-SCOP
Antihistamines (GI Drugs)
(Antivert)
meclizine hcl
prochlorperazine maleate (Compazine)
(Tigan)
trimethobenzamide hcl
COMPAZINE
1
1
2
solution, tablet,
(QL: 2 tablets per 1
fill)
solution, tablet
PA
1
1
2
2
PA
1
1
1
2
cap ds pk, capsule
capsule
syrup
Antifungal (Systemic)
Antifungals, Miscellaneous
(Ancobon)
flucytosine
(Grifulvin V)
griseofulvin,microsize
(Nystatin)
nystatin
ANCOBON
FULVICIN U/F
GRIFULVIN V
GRIS-PEG
Azoles
fluconazole
itraconazole
ketoconazole
1
1
1
2
(QL: 34 days supply
per fill)
2
2
2
(Diflucan)
(Sporanox)
(Nizoral)
1
1
1
PA
10
Drug
Tier
Drug Name
1
PA
NOXAFIL
2
PA
SPORANOX
VFEND
2
2
PA
PA
voriconazole
(Vfend)
Requirements/Limits
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
solution
(QL: 34 days supply
per fill)
Antiglaucoma Agents
Antiglaucoma Agents
(Acetazolamide)
acetazolamide
(Betaxolol HCl)
betaxolol hcl
(Alphagan P)
brimonidine tartrate
(Trusopt)
dorzolamide hcl
(Cosopt)
dorzolamide hcl/timolol
maleat
(Xalatan)
latanoprost
(Betagan)
levobunolol hcl
(Neptazane)
methazolamide
(Optipranolol)
metipranolol
(Isopto Carpine)
pilocarpine hcl
(Timoptic)
timolol maleate
ALPHAGAN P
AZOPT
BETOPTIC S
ISOPTO CARPINE
LUMIGAN
PHOSPHOLINE IODIDE
PILOPINE HS
TRAVATAN Z
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
drops: 0.1%
drops: 8%
PA
Anti-infectives (EENT)
Anti-infectives (EENT)
(Vosol)
acetic acid
(Domeboro)
acetic acid/aluminum
acetate
acetic acid/hydrocortisone (Vosol HC)
(Bacitracin)
bacitracin
(Polycin-b)
bacitracin/polymyxin b
sulfate
(Peridex)
chlorhexidine gluconate
(Ciloxan)
ciprofloxacin hcl
(Cresyl Ace/ben Alc/butanol/ipa)
cresyl ace/ben alc/
butanol/ipa
1
1
1
1
1
1
1
1
11
Drug
Tier
Drug Name
doxycycline hyclate
erythromycin base
gentamicin sulfate
levofloxacin
neo/polymyx b sulf/
dexameth
neomy sulf/bacitra/
polymyxin b
neomy sulf/bacitrac zn/
poly/hc
neomy sulf/polymyx b sulf/
hc
neomycin sulfate/dex na
ph
neomycin/polymyxn b/
gramicidin
ofloxacin
polymyxin b sulfate/tmp
sulfacetamide sodium
sulfacetm na/prednis sp
tobramycin sulf/
dexamethasone
tobramycin sulfate
trifluridine
AZASITE
BACTROBAN NASAL
BESIVANCE
BLEPHAMIDE S.O.P.
BLEPHAMIDE
CILOXAN
CIPRO HC
CIPRODEX
NATACYN
PRED-G
TOBRADEX
VIGAMOX
(Periostat)
(Ilotycin)
(Garamycin)
(Quixin)
(Maxitrol)
1
1
1
1
1
(Neo-polycin)
1
(Triple Antibiotic HC)
1
(Oticin HC)
1
(Neomycin Sulfate/dex Na Ph)
1
(Neosporin)
1
(Ocuflox)
(Polytrim)
(Sulfac)
(Sulfacetm Na/prednis Sp)
(Tobradex)
1
1
1
1
1
(Tobrex)
(Viroptic)
1
1
2
2
2
2
2
2
2
2
2
2
2
2
Requirements/Limits
oint. (g)
drops susp
oint. (g)
Anti-infectives (Skin and Mucous Membrane)
Antibacterials (Skin and Mucous Membrane)
clindamycin phos/benzoyl (Clindamycin Phos/benzoyl
Perox)
perox
(Cleocin T)
clindamycin phosphate
1
1
12
Drug
Tier
Drug Name
(Benzamycin)
erythromycin base/benz
per
erythromycin base/ethanol (Emgel)
(Gentamicin Sulfate)
gentamicin sulfate
(Metrocream)
metronidazole
(Bactroban)
mupirocin
ALTABAX
BACTROBAN
CLEOCIN
CLINDESSE
DUAC CS
METROGEL
Antifungals (Skin and Mucous Membrane)
(Loprox)
ciclopirox olamine
(Loprox)
ciclopirox
Requirements/Limits
1
1
1
1
1
2
2
2
2
2
2
PA
cream (g)
supp.vag
PA
1
1
gel (gram),
shampoo
(Mycelex)
clotrimazole
(Lotrisone)
clotrimazole/betamet
diprop
(Spectazole)
econazole nitrate
(Kuric)
ketoconazole
(Monistat 3)
miconazole nitrate
(Mycostatin)
nystatin
(Mycogen II)
nystatin/triamcin
sodium thiosulfate/sal acid (Sodium Thiosulfate/sal Acid)
(Terazol 7)
terconazole
FIRST-BXN
NAFTIN
Antivirals (Skin and Mucous Membrane)
DENAVIR
1
1
2
PA
VEREGEN
ZOVIRAX
2
2
PA
PA
Local Anti-infectives, Miscellaneous
hydrocortisone/iodoquinol (Vytone)
(Iodine/potassium Iodide)
iodine/potassium iodide
(Selenium Sulfide)
selenium sulfide
(Silver Nitrate)
silver nitrate
(Thermazene)
silver sulfadiazine
1
1
1
1
1
1
1
1
1
1
1
1
2
2
(QL: 1 copay/
coinsurance per
tube)
(QL: 1 copay/
coinsurance per
tube)
13
Drug
Tier
Drug Name
(Sulfacetamd/sulfr/sknclnsr10)
sulfacetamd/sulfr/
sknclnsr10
sulfacetamide sod/sulfur/ (Claris)
urea
(Klaron)
sulfacetamide sodium
sulfacetm na/avobenzone/ (Rosac)
sulfur
(Alcohol Antiseptic Pads)
alcohol antiseptic pads
AVC
Scabicides and Pediculicides
(Lindane)
lindane
(Ovide)
malathion
(Elimite)
permethrin
Requirements/Limits
1
1
1
1
2
2
1
1
1
Anti-inflammatory Agents (EENT)
Anti-inflammatory Agents (EENT)
(Bromfenac Sodium)
bromfenac sodium
(Ak-dex)
dexamethasone sod
phosphate
(Voltaren)
diclofenac sodium
(Nasarel)
flunisolide
fluocinolone acetonide oil (Dermotic)
(Fluorometholone)
fluorometholone
(Ocufen)
flurbiprofen sodium
(Flonase)
fluticasone propionate
hc/pramox hcl/cl-xylenol/ (HC/pramox HCl/cl-xylenol/
water)
water
(Otozone)
hc/pramoxine hcl/
chloroxylenol
(Acular LS)
ketorolac tromethamine
(Pred Forte)
prednisolone acetate
(Prednisol)
prednisolone sod
phosphate
(Nasacort Aq)
triamcinolone acetonide
BECONASE AQ
BROMDAY
DECADRON
FML S.O.P.
FML
MAXIDEX
NASONEX
OMNARIS
RESTASIS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
PA
PA
PA
14
Drug
Tier
Drug Name
RHINOCORT AQUA
VERAMYST
2
2
Requirements/Limits
PA
Anti-inflammatory Agents (GI Drugs)
Anti-inflammatory Agents (GI Drugs)
(Colazal)
balsalazide disodium
(Rowasa)
mesalamine
APRISO
ASACOL
CANASA
DIPENTUM
LIALDA
PENTASA
1
1
2
2
2
2
2
2
PA
Anti-inflammatory Agents (Respiratory)
Anti-inflammatory Agents (Respiratory)
(Cromolyn Sodium)
cromolyn sodium
(Accolate)
zafirlukast
SINGULAIR
1
1
2
Anti-inflammatory Agents (Skin and Mucous)
Anti-inflammatory Agents (Skin and Mucous)
(Aclovate)
alclometasone
dipropionate
(Amcinonide)
amcinonide
(Diprolene AF)
betamet diprop/prop gly
(Del-beta)
betamethasone
dipropionate
(Betamethasone Valerate)
betamethasone valerate
(Temovate)
clobetasol propionate
(Desowen)
desonide
(Topicort)
desoximetasone
(Psorcon)
diflorasone diacetate
(Synalar)
fluocinolone acetonide
(Derma-smoothe-fs)
fluocinolone/shower cap
(Lidex)
fluocinonide
(Cutivate)
fluticasone propionate
(Ultravate Pac)
halobetasol prop/
ammonium lac
(Ultravate)
halobetasol propionate
hydrocort/pramoxin/emol/ (Analpram E)
pram#1
(Hydrocort/pramoxn/skn
hydrocort/pramoxn/skn
Clnsr#16)
clnsr#16
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
15
Drug
Tier
Drug Name
hydrocortisone ac/
lidocaine
hydrocortisone acetate
hydrocortisone acetate/alo
ver
hydrocortisone acetate/
urea
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone
hydrocortisone/pramoxine
mometasone furoate
prednicarbate
triamcinolone acetonide
CORDRAN SP
CORDRAN
CUTIVATE
KENALOG
VERDESO
(Lidamantle HC)
1
(Hydrocortisone Acetate)
(Nucort)
1
1
(Carmol HC)
1
(Locoid)
(Westcort)
(Anusol-HC)
(Pramcort)
(Elocon)
(Dermatop)
(Triamcinolone Acetonide)
1
1
1
1
1
1
1
2
2
2
2
2
Requirements/Limits
lotion
aerosol
PA
Antilipemic Agents
Antilipemic Agents, Miscellaneous
LOVAZA
NIASPAN
VYTORIN
ZETIA
Bile Acid Sequestrants
(Questran)
cholestyramine (with
sugar)
cholestyramine/aspartame (Questran Light)
(Colestid)
colestipol hcl
WELCHOL
Fibric Acid Derivatives
(Lofibra)
fenofibrate
(Lofibra)
fenofibrate,micronized
(Fibricor)
fenofibric acid
(Lopid)
gemfibrozil
ANTARA
TRICOR
TRILIPIX
HMG-CoA Reductase Inhibitors
(Caduet)
amlodipine/atorvastatin
LIPITOR
2
2
2
2
PA
1
1
1
2
1
1
1
1
2
2
2
PA
1
1
16
Drug
Tier
Drug Name
lovastatin
pravastatin sodium
simvastatin
CRESTOR
LESCOL XL
LESCOL
LIVALO
(Mevacor)
(Pravachol)
(Zocor)
1
1
1
2
2
2
2
Requirements/Limits
PA
PA
PA
Antimigraine Agents
Selective Serotonin Agonists
(Amerge)
naratriptan hcl
1
sumatriptan succinate
(Imitrex)
1
sumatriptan
(Imitrex)
1
AXERT
2
FROVA
2
MAXALT MLT
2
MAXALT
2
RELPAX
2
TREXIMET
2
ZOMIG ZMT
2
ZOMIG
2
PA
PA
(QL: 1 copay/
coinsurance per 9
tablets)
(QL: 1 copay/
coinsurance per 9
tablets)
(QL: 1 copay/
coinsurance per 6
units)
(QL: 1 copay/
coinsurance per 6
tablets)
(QL: 1 copay/
coinsurance per 9
tablets)
(QL: 1 copay/
coinsurance per 12
tablets)
(QL: 1 copay/
coinsurance per 12
tablets)
(QL: 1 copay/
coinsurance per 6
tablets)
(QL: 1 copay/
coinsurance per 9
tablets)
(QL: 1 copay/
coinsurance per 6
tablets)
(QL: 1 copay/
coinsurance per 6
units)
17
Drug
Tier
Drug Name
Requirements/Limits
Antimycobacterials
Antimycobacterials
(Dapsone)
dapsone
(Myambutol)
ethambutol hcl
(Isoniazid)
isoniazid
(Pyrazinamide)
pyrazinamide
(Rifadin)
rifampin
(Rifamate)
rifampin/isoniazid
MYCOBUTIN
RIFATER
1
1
1
1
1
1
2
2
syrup, tablet
capsule
Antineoplastic Agents
Antineoplastic Agents
(Arimidex)
anastrozole
(Casodex)
bicalutamide
(Cytoxan)
cyclophosphamide
(Vepesid)
etoposide
(Aromasin)
exemestane
(Flutamide)
flutamide
(Hydrea)
hydroxyurea
(Femara)
letrozole
1
1
1
1
1
1
1
1
PA
1
1
1
1
1
2
PA
ALKERAN
CAPRELSA
2
2
PA
CEENU
EMCYT
GLEEVEC
HEXALEN
HYCAMTIN
IRESSA
LEUKERAN
LYSODREN
MATULANE
2
2
2
2
2
2
2
2
2
megestrol acetate
mercaptopurine
methotrexate sodium
tamoxifen citrate
tretinoin
AFINITOR
(Megace)
(Purinethol)
(Methotrexate Sodium)
(Nolvadex)
(Tretinoin)
tablet
capsule
(QL: 1 copay/
coinsurance per 15
days supply)
tablet
(QL: 34 days
supply per fill)
capsule
PA
18
Drug
Tier
Drug Name
Requirements/Limits
MYLERAN
NEXAVAR
2
2
PA
(QL: 1 copay/
coinsurance per 15
days supply)
NILANDRON
SPRYCEL
2
2
PA
SUTENT
2
PA
(QL: 1 copay/
coinsurance per 15
days supply)
(QL: 1 copay/
coinsurance per 15
days supply)
TARCEVA
TARGRETIN
TASIGNA
2
2
2
PA
PA
TEMODAR
TYKERB
2
2
PA
VANDETANIB
2
PA
VOTRIENT
2
PA
XELODA
ZOLINZA
2
2
PA
(QL: 1 copay/
coinsurance per 15
days supply)
capsule
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 1 copay/
coinsurance per 15
days supply)
(QL: 34 days supply
per fill)
Antiparkinsonian Agents
Antiparkinsonian Agents
(Amantadine HCl)
amantadine hcl
(Benztropine Mesylate)
benztropine mesylate
(Parlodel)
bromocriptine mesylate
(Cabergoline)
cabergoline
(Sinemet 25-100)
carbidopa/levodopa
(Mirapex)
pramipexole di-hcl
(Requip)
ropinirole hcl
(Eldepryl)
selegiline hcl
(Trihexyphenidyl HCl)
trihexyphenidyl hcl
APOKYN
AZILECT
COMTAN
STALEVO 100
1
1
1
1
1
1
1
1
1
2
2
2
2
tablet
19
Drug
Tier
Drug Name
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
TASMAR
Requirements/Limits
2
2
2
2
2
2
Antiprotozoal Agents
Antiprotozoal Agents
atovaquone/proguanil hcl (Malarone)
(Aralen Phosphate)
chloroquine phosphate
(Plaquenil)
hydroxychloroquine
sulfate
(Lariam)
mefloquine hcl
(Flagyl)
metronidazole
(Humatin)
paromomycin sulfate
ALINIA
DARAPRIM
MEPRON
NEBUPENT
QUALAQUIN
YODOXIN
1
1
1
1
1
1
2
2
2
2
2
2
PA
Antipruritics and Local Anesthetics
Antipruritics and Local Anesthetics
(Anamantle Hc Forte)
hydrocortisone ac/
lidocaine
hydrocortisone/lidocaine/ (Peranex HC)
aloe
(Lidamantle)
lidocaine hcl
(EMLA)
lidocaine/prilocaine
(Urodol)
phenazopyridine hcl
LIDODERM
1
1
1
1
1
2
cream (g), lotion
PA
Antitussives
Antitussives
benzonatate
bromphen mal/pe/
carbetapen cit
bromphenira/
pseudoephed/codein
brompheniram/pe/
dihydrocodeine
(Tessalon)
(Trexbrom)
1
1
(Bromphenira/pseudoephed/
codein)
(Brompheniram/pe/
dihydrocodeine)
1
1
20
Drug
Tier
Drug Name
brompheniramin/pe/
codeine phos
brompheniramin/pe/
dextromethor
bromphenrm/pseudoeph/
dihydrocd
car-b-pen ta/chlor-tan
car-b-pen ta/
phenylephrine/pyr
chlorpheniramine/codeine
phos
codeine/promethazine hcl
dihydrocodeine/
guaifenesin
diphenhydramin/pe/
codeine phos
dm/phenyleph/
chlorpheniramine
d-methorp tan/p-epd tan/
d-cp
d-methorp tan/p-ephed
tan/cp
d-methorphan hb/pe/
chlorphenir
d-methorphan hb/p-epd
hcl/bpm
d-methorphan hb/p-ephed
hcl/cp
d-methorphan hb/prometh
hcl
guaifen/d-methorp tan/pephed
guaifenesin/codeine phos
guaifenesin/dm/
pseudoephedrine
guaifenesin/d-methorphan
hb
guaifenesin/p-ephed hcl/
cod
hydrocodone bit/
homatropine
(Brompheniramin/pe/codeine
Phos)
(Lortuss Dm)
1
(Bromphenrm/pseudoeph/
dihydrocd)
(Tussi-12 S)
(Tussi-12d)
1
1
1
(Notuss Ac)
1
(Codeine/promethazine HCl)
(Dihydrocodeine/guaifenesin)
1
1
(Endal Cd)
1
(Rondec-dm)
1
(Tandur Dm)
1
(Allres Ds)
1
(D-methorphan Hb/pe/
chlorphenir)
(Dallergy Dm)
1
Requirements/Limits
1
1
(D-methorphan Hb/p-ephed HCl/
cp)
(D-methorphan Hb/prometh
HCl)
(Guaifen/d-methorp Tan/pephed)
(Myci-gc)
(Donatussin Dm)
1
1
1
(Trispec Dmx)
1
(Guaifenesin/p-ephed HCl/cod)
1
(Hycodan)
1
1
1
21
Drug
Tier
Drug Name
hydrocodone/chlorphen
polis
p-ephed hcl/codeine/
guaifen
p-ephed hcl/dhcodeine bt/
cp
p-ephed hcl/hydrocodone
bit
phenylephrine hcl/cod/
prometh
phenylephrine/dhcodeine
bt/cp
pseudoephedrine hcl/
codeine
pyrilamine/pe/
dextromethorphan
(Tussionex)
1
(Suttar-2)
1
(P-ephed HCl/dhcodeine Bt/cp)
1
(P-ephed HCl/hydrocodone Bit)
1
(Phenylephrine HCl/cod/
prometh)
(Despec-pd)
1
1
(Notuss Dc)
1
(Poly Hist Dm)
1
(Cimetidine HCl)
(Tagamet)
(Pepcid)
(Prevacid)
(Cytotec)
(Axid)
(Prilosec)
(Zegerid)
1
1
1
1
1
1
1
1
(Protonix)
(Zantac)
1
1
(Carafate)
1
2
2
Requirements/Limits
Antiulcer Agents
Antiulcer Agents
cimetidine hcl
cimetidine
famotidine
lansoprazole
misoprostol
nizatidine
omeprazole
omeprazole/sodium
bicarbonate
pantoprazole sodium
ranitidine hcl
sucralfate
ACIPHEX
DEXILANT
NEXIUM
ZEGERID
2
2
solution
oral susp, tablet
PA
capsule, syrup,
tablet
PA
PA, QL:
34 in 34
days
PA
PA
packet
Antivirals (Systemic)
Antiretrovirals
didanosine
lamivudine
stavudine
(Videx EC)
(Lamivudine)
(Zerit)
1
1
1
22
Drug
Tier
Drug Name
(Retrovir)
zidovudine
ATRIPLA
COMBIVIR
CRIXIVAN
EMTRIVA
EPIVIR HBV
EPIVIR
EPZICOM
FUZEON
INTELENCE
INVIRASE
ISENTRESS
KALETRA
LEXIVA
NORVIR
PREZISTA
RESCRIPTOR
REYATAZ
SELZENTRY
SUSTIVA
TRIZIVIR
TRUVADA
VIDEX
VIRACEPT
VIRAMUNE XR
VIRAMUNE
VIREAD
ZIAGEN
Antivirals, Miscellaneous
(Flumadine)
rimantadine hcl
INCIVEK
RELENZA
1
2
2
TAMIFLU
2
Interferons
INFERGEN
2
INTRON A
2
Requirements/Limits
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
solution
PA
(QL: 1 fill of
Tamiflu or Relenza
per season)
(QL: 1 fill of
Tamiflu or Relenza
per season)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
23
Drug
Tier
Drug Name
PEGASYS PROCLICK
2
PEGASYS
2
PEGINTRON REDIPEN
2
PEGINTRON
2
Nucleosides and Nucleotides
(Zovirax)
acyclovir
(Famvir)
famciclovir
(Cytovene)
ganciclovir
RIBATAB
1
1
1
1
ribavirin
valacyclovir hcl
BARACLUDE
HEPSERA
TYZEKA
VALCYTE
(Rebetol)
(Valtrex)
Requirements/Limits
(QL: 34 days
supply per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
tab ds pk: 600600mg
1
1
2
2
2
2
VIRAZOLE
(QL: 34 days supply
per fill)
2
Anxiolytics, Sedatives and Hypnotics
Anxiolytics, Sedatives and Hypnotics, Miscellaneous
(Buspar)
buspirone hcl
(Chloral Hydrate)
chloral hydrate
(Glutethimide)
glutethimide
(Hydroxyzine HCl)
hydroxyzine hcl
(Vistaril)
hydroxyzine pamoate
(Miltown)
meprobamate
(Sonata)
zaleplon
zolpidem tartrate
(Ambien)
1
1
1
1
1
1
1
syrup, tablet
1
LUNESTA
2
PA
ROZEREM
2
PA
(QL: 1 copay/
coinsurance per 15
capsules)
(QL: 1 copay/
coinsurance per 15
tablets)
(QL: 1 copay/
coinsurance per 15
capsules)
(QL: 1 copay/
coinsurance per 15
tablets)
24
Drug
Tier
Drug Name
Barbiturates (anxiolytic, Sedative/hypnotic)
(Phenobarbital)
phenobarbital
Benzodiazepines (anxiolytic, Sedative/hypnotic)
(Xanax)
alprazolam
(Librium)
chlordiazepoxide hcl
(Tranxene T-tab)
clorazepate dipotassium
(Valium)
diazepam
estazolam
flurazepam hcl
LORAZEPAM
INTENSOL
lorazepam
midazolam hcl
oxazepam
temazepam
triazolam
ALPRAZOLAM
INTENSOL
DIASTAT ACUDIAL
Requirements/Limits
1
1
1
1
1
(Prosom)
(Dalmane)
1
1
1
(Ativan)
(Midazolam HCl)
(Oxazepam)
(Restoril)
(Halcion)
1
1
1
1
1
2
kit, oral conc,
solution, tablet
oral conc, tablet
syrup
2
Astringents
Astringents
aluminum chloride
(Drysol)
1
Beta-Adrenergic Blocking Agents
Beta-Adrenergic Blocking Agents
(Sectral)
acebutolol hcl
(Tenormin)
atenolol
(Tenoretic 100)
atenolol/chlorthalidone
(Kerlone)
betaxolol hcl
(Zebeta)
bisoprolol fumarate
(Ziac)
bisoprolol fumarate/hctz
(Coreg)
carvedilol
(Trandate)
labetalol hcl
(Toprol XL)
metoprolol succinate
(Lopressor)
metoprolol tartrate
(Lopressor HCT)
metoprolol/
hydrochlorothiazide
(Corgard)
nadolol
(Corzide)
nadolol/
bendroflumethiazide
(Pindolol)
pindolol
1
1
1
1
1
1
1
1
1
1
1
tablet
tablet
1
1
1
25
Drug
Tier
Drug Name
propranolol hcl
(Inderal)
1
propranolol/
hydrochlorothiazid
sotalol hcl
timolol maleate
BYSTOLIC
COREG CR
INNOPRAN XL
(Inderide-40/25)
1
(Betapace)
(Timolol Maleate)
1
1
2
2
2
Requirements/Limits
cap sa 24h, solution,
tablet
tablet: 5mg, 10mg
PA
PA
Calcium-Channel Blocking Agents
Calcium-Channel Blocking Agents, Miscellaneous
(Cardizem CD)
diltiazem hcl
verapamil hcl
Dihydropyridines
amlodipine besylate
amlodipine besylate/
benazepril
felodipine
isradipine
nicardipine hcl
nifedipine
nimodipine
nisoldipine
AZOR
DYNACIRC CR
EXFORGE HCT
EXFORGE
1
(Calan)
1
(Norvasc)
(Lotrel)
1
1
(Plendil)
(Dynacirc)
(Nicardipine HCl)
(Procardia XL)
(Nimotop)
(Sular)
1
1
1
1
1
1
2
2
2
2
cap er 12h, cap er
24h, cap er deg,
capsule er, tab er
24h, tablet
cap24h pct, cap24h
pel, tablet, tablet er
capsule
PA
PA
PA
Cardiac Drugs
Antiarrhythmic Agents
(Cordarone)
amiodarone hcl
(Norpace)
disopyramide phosphate
(Tambocor)
flecainide acetate
(Mexitil)
mexiletine hcl
(Procainamide HCl)
procainamide hcl
propafenone hcl
quinidine gluconate
quinidine sulfate
1
1
1
1
1
(Rythmol)
(Quinidine Gluconate)
(Quinidine Sulfate)
1
1
1
tablet
capsule, tablet er,
tablet sa
tablet er
26
Drug
Tier
Drug Name
MULTAQ
NORPACE CR
PRONESTYL
TIKOSYN
Cardiac Drugs, Miscellaneous
(Lanoxin)
digoxin
DIGOXIN
RANEXA
Requirements/Limits
2
2
2
2
1
1
2
tablet
PA
Cathartics and Laxatives
Cathartics and Laxatives
OCL
peg 3350/na sulf,bicarb,cl/ (Colyte with Flavor Packets)
kcl
polyethylene glycol 3350 (Polyethylene Glycol 3350)
sod chloride/nahco3/kcl/ (Nulytely with Flavor Packs)
pegs
AMITIZA
GOLYTELY
MOVIPREP
VISICOL
1
1
1
1
2
QL: 68 in
34 days
2
2
2
PA
powd pack
1
PA
1
PA
2
PA
Cell Stimulants and Proliferants
Cell Stimulants and Proliferants
(Retin-A)
tretinoin
tretinoin/emollient
(Tretinoin/emollient)
RETIN-A MICRO
Central Nervous System Agents, Miscellaneous
Central Nervous System Agents, Miscellaneous
(Eskalith)
lithium carbonate
(Lithium Citrate)
lithium citrate
INTUNIV
NAMENDA
RILUTEK
SAVELLA
STRATTERA
XENAZINE
1
1
2
2
2
2
2
2
PA
solution, tablet
PA
PA
27
Drug
Tier
Drug Name
XYREM
2
Requirements/Limits
PA
(QL: 34 days supply
per fill)
Contraceptives
Contraceptives
desogestrel-ethinyl
estradiol
desog-et estra/ethin estra
ethinyl estradiol/
drospirenone
ethynodiol d-ethinyl
estradiol
levonorgestrel
levonorgestrel-eth estra
l-norgest-eth estr/ethin
estra
noreth a-et estra/fe
fumarate
noreth-ethinyl estradiol/
iron
norethindrone a-e
estradiol
norethindrone
norethindrone-ethinyl
estrad
norethindrone-mestranol
norgestimate-ethinyl
estradiol
norgestrel-ethinyl
estradiol
LOESTRIN 24 FE
NUVARING
ORTHO EVRA
ORTHO TRI-CYCLEN
LO
OVCON-50
(Desogen)
1
(Mircette)
(Yaz)
1
1
(Demulen 1-50-21)
1
(Plan B)
(Lybrel)
(Seasonique)
1
1
1
(Loestrin Fe)
1
(Femcon Fe)
1
(Loestrin)
1
(Nor-Q-D)
(Ortho-novum)
1
1
(Ortho-novum)
(Ortho-cyclen)
1
1
(Lo-ovral-28)
1
2
2
2
2
2
Devices
Devices
emollient combination
no.10
hyaluronate sodium
1ST CHOICE LANCETS
(Biafine)
1
(Hyaluronate Sodium)
1
2
28
Drug
Tier
Drug Name
1ST TIER UNILET
COMFORTOUCH
ACCU-CHEK
ACTI-LANCE LITE
ACTI-LANCE SPECIAL
ACTI-LANCE
ADVANCED TRAVEL
LANCETS
ADVOCATE LANCET
ADVOCATE LANCETS
ALTERNATE SITE
LANCET
ASSURE LANCE
AT-LAST LANCETS
AURORA
HEALTHCARE
LANCETS
BD GENIE LANCET
CAREONE
CLEVER CHEK
LANCETS
CLEVER CHEK ULTRA
THIN LANCETS
COAGUCHEK
COLOR LANCETS
COMFORT LANCETS
DROPLET LANCETS
EASY COMFORT
EQUATE
E-Z JECT BLOOD
LANCET
E-Z JECT LANCETS
EZ SMART
E-ZJECT LANCETS
EZ-LETS
FINGERSTIX
FORA LANCETS
FREESTYLE LANCETS
FREESTYLE UNISTIK 2
GLUCOCOM LANCETS
GLUCOSOURCE
HAEMOLANCE PLUS
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
29
Drug
Tier
Drug Name
HAEMOLANCE,
RETRACTABLE
HAEMOLANCE
LADY LITE
LANCETS
MICROTAINER
LANCETS
LIFESCAN
LITE TOUCH
MEDI-LANCE
MEDLANCE PLUS
MICRO THIN LANCET
MICRO THIN LANCETS
MICROLET
MINILET
MONOLET LANCETS
MONOLET THIN
LANCETS
MYGLUCOHEALTH
LANCETS
needles, insulin disposable (Needles, Insulin Disposable)
NOVA SUREFLEX
ONE TOUCH DELICA
ONE TOUCH LANCETS
ONE TOUCH
SURESOFT
PRODIGY LANCETS
PRODIGY TWIST TOP
LANCET
PUBLIX LANCET
RELIEF PLUS
RENEW ADVANCED
MICRO-LANCETS
RIGHTEST GL300
LANCETS
SAFETY LANCETS
SAFETY-LET
SINGLE-LET
SMARTDIABETES
VANTAGE
SMARTEST LANCET
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
30
Drug
Tier
Drug Name
SOFT TOUCH SAFE-TPRO
SOFT TOUCH
SOFTCLIX
SOLO V2 LANCETS
STAT-LET
SUPER THIN LANCET
SUPER THIN LANCETS
SURE COMFORT
LANCETS
SURE-LANCE
SURGILANCE
LANCETS
(Syring W-ndl,disp,insul,0.3ml)
syring wndl,disp,insul,0.3ml
(Syring W-ndl,disp,insul,0.5ml)
syring wndl,disp,insul,0.5ml
(Syringe W-ndl, Disp,insul,1ml)
syringe w-ndl,
disp,insul,1ml
TECHLITE BLOOD
LANCET
TECHLITE
THIN LANCETS
TOPCARE
UNIVERSAL1 THIN
LANCET
ULTICARE
ULTILET BASIC
ULTILET CLASSIC
ULTILET LANCETS
ULTILET
ULTRA THIN II
LANCETS
ULTRA THIN LANCETS
ULTRA THIN PLUS
LANCETS
ULTRA THIN PLUS
ULTRALANCE
ULTRA-THIN II
LANCETS
ULTRATLC LANCETS
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
31
Drug
Tier
Drug Name
UNILET
COMFORTOUCH
UNILET EXCELITE II
UNILET EXCELITE
UNILET GP LANCET
UNILET LANCET
UNISTIK 3 EXTRA
UNISTIK 3
UNISTIK CZT
VALUE PLUS
LANCETS
VITALET PRO PLUS
VITALET PRO
VITALET
WAVESENSE LANCETS
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
Diabetes Mellitus
Diabetes Mellitus
FAST TAKE
2
ONE TOUCH TEST
STRIPS
ONE TOUCH ULTRA
TEST STRIPS
SURESTEP PRO
2
SURESTEP
2
2
2
(QL: 1 copay per
100 strips)
(QL: 1 copay per
100 strips)
(QL: 1 copay per
100 strips)
(QL: 1 copay per
100 strips)
(QL: 1 copay per
100 strips)
Diuretics
Diuretics, Miscellaneous
(Chlorthalidone)
chlorthalidone
(Lozol)
indapamide
(Zaroxolyn)
metolazone
Loop Diuretics
(Bumex)
bumetanide
(Lasix)
furosemide
(Demadex)
torsemide
Potassium-sparing Diuretics
(Midamor)
amiloride hcl
(Amiloride/hydrochlorothiazide)
amiloride/
hydrochlorothiazide
(Maxzide-25mg)
triamterene/
hydrochlorothiazid
1
1
1
1
1
1
tablet
solution, tablet
tablet
1
1
1
32
Drug
Tier
Drug Name
Thiazide Diuretics
(Chlorothiazide)
chlorothiazide
(Hydrochlorothiazide)
hydrochlorothiazide
(Methyclothiazide)
methyclothiazide
DIURIL
Requirements/Limits
1
1
1
2
EENT Drugs, Miscellaneous
EENT Drugs, Miscellaneous
(Iopidine)
apraclonidine hcl
(Bss)
balanced salt irrig soln
comb2
(Carteolol HCl)
carteolol hcl
(Atrovent)
ipratropium bromide
(Albalon)
naphazoline hcl
naphazoline hcl/antazoline (Naphazoline HCl/antazoline)
(Mydfrin)
phenylephrine hcl
1
1
1
1
1
1
1
Enzymes
Enzymes
PULMOZYME
2
PA
SUCRAID
2
PA
(QL: 34 days supply
per fill)
Estrogens and Antiestrogens
Estrogens and Antiestrogens
(Clomid)
clomiphene citrate
(Estrace)
estradiol
(Activella)
estradiol/noreth ac
(Ogen)
estropipate
(Femhrt)
norethind ac/ethinyl
estradiol
COMBIPATCH
DIVIGEL
ELESTRIN
ESTRADERM
ESTRING
EVISTA
FEMHRT
PREMARIN
PREMPHASE
PREMPRO
VAGIFEM
VIVELLE-DOT
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
tablet: 0.5mg-2.5
cream/appl, tablet
33
Drug
Tier
Drug Name
Requirements/Limits
Expectorants
Expectorants
guaifen/dm hb/pephedrine/bpm
guaifen/d-methorphan hb/
pe/cp
guaifen/p-ephed hcl/dihycod
guaifen/phenylephr/
chlorphenir
guaifenesin
guaifenesin/
carbetapentane cit
guaifenesin/d-methorphan
hb/pe
guaifenesin/p-ephed hcl
guaifenesin/phenylephrine
hcl
phenylephrine/
carbetapentan/gg
pot guaiaco/car-bpentane/pe
(Guaifen/dm Hb/p-ephedrine/
bpm)
(Guaifen/d-methorphan Hb/pe/
cp)
(Despec-exp)
1
1
1
(Guaifen/phenylephr/
chlorphenir)
(Organidin Nr)
(Betavent)
1
1
1
(Zotex)
1
(Maxifed-g)
(Entex)
1
1
(Albatussin-nn)
1
(Pot Guaiaco/car-b-pentane/pe)
1
First Generation Antihistamines
First Generation Antihistamines
brompheniramine maleate (Brompheniramine Maleate)
(Palgic)
carbinoxamine maleate
(Ryneze)
chlor-mal/
methscopolamine nit
(Dallergy)
chlor-mal/phenyleph/
methscop
chlorpheniramine maleate (Chlorpheniramine Maleate)
(Clemastine Fumarate)
clemastine fumarate
(Cyproheptadine HCl)
cyproheptadine hcl
(Dexchlorpheniramine Maleate)
dexchlorpheniramine
maleate
(Diphenhydramine HCl)
diphenhydramine hcl
doxylamine succinate
p-epd tan/chlor-tan
p-ephed hcl/chlor-mal/bell
alk
(Doxylamine Succinate)
(P-epd Tan/chlor-tan)
(P-ephed HCl/chlor-mal/bell
Alk)
1
1
1
1
1
1
1
1
1
capsule: 50mg;
elixir
1
1
1
34
Drug
Tier
Drug Name
p-ephed hcl/triprolidine
hcl
phenylephrine hcl/chlormal
phenylephrine hcl/prometh
hcl
phenylephrine/
brompheniramin
phenylephrine/
brompheniramine
phenylephrine/chlor-tan
phenylephrine/
diphenhydramine
phenylephrine/dp-hydram
tan
phenylephrine/p-tlox ci/cp
phenylephrine/pyril tan/cp
phenylephrine/pyrilamine
ma/cp
phenylephrine/pyrilamine
tan
promethazine hcl
(Zymine-d)
1
(Rondec)
1
(Phenylephrine HCl/prometh
HCl)
(Vazobid)
1
1
(Vazol-d)
1
(Rynatan)
(Phenylephrine/
diphenhydramine)
(Phenylephrine/dp-hydram Tan)
1
1
(Phenylephrine/p-tlox Ci/cp)
(Allertan)
(Poly Hist Forte)
1
1
1
(Phenylephrine/pyrilamine Tan)
1
(Promethazine HCl)
1
pseudoephedrine hcl/
chlor-mal
pseudoephedrine/
brompheniramin
pseudoephedrine/cpm/
methscopol
tripelennamine hcl
(Accuhist)
1
(Pseudoephedrine/
brompheniramin)
(Durahist)
1
1
(Tripelennamine HCl)
1
Requirements/Limits
1
supp.rect, syrup,
tablet
Genitourinary Smooth Muscle Relaxants
Genitourinary Smooth Muscle Relaxants
(Urispas)
flavoxate hcl
(Ditropan)
oxybutynin chloride
(Sanctura)
trospium chloride
DETROL LA
DETROL
ENABLEX
OXYTROL
SANCTURA XR
TOVIAZ
VESICARE
1
1
1
2
2
2
2
2
2
2
PA
PA
PA
PA
PA
35
Drug
Tier
Drug Name
Requirements/Limits
GI Drugs, Miscellaneous
GI Drugs, Miscellaneous
(Zenpep)
lipase/protease/amylase
(Reglan)
metoclopramide hcl
(Actigall)
ursodiol
CIMZIA
1
1
1
2
PA
(QL: 34 days supply
per fill)
CREON
LOTRONEX
RELISTOR
2
2
2
PA
ZENPEP
2
(QL: 14 days supply
per fill)
capsule dr: 3k-10k16k, 10-34-55k, 1551-82k, 20-68-109k,
25-85-136k
solution, tablet
Heavy Metal Antagonists
Heavy Metal Antagonists
DEPEN
EXJADE
2
2
(QL: 1 copay/
coinsurance per 15
days supply; 34
days per fill)
Hematologic Agents
Anticoagulants
enoxaparin sodium
(Lovenox)
1
fondaparinux sodium
(Arixtra)
1
heparin sodium,porcine
warfarin sodium
ARIXTRA
(Hep-lock)
(Coumadin)
1
1
2
LOVENOX
2
PRADAXA
XARELTO
2
2
Hematologic Agents, Miscellaneous
(Amicar)
aminocaproic acid
(Agrylin)
anagrelide hcl
(Trental)
pentoxifylline
1
1
1
(QL: 14 days supply
per fill)
(QL: 14 days
supply per fill)
PA
(QL: 14 days supply
per fill)
(QL: 14 days supply
per fill)
QL: 34
per fill
tablet: 10mg
solution, tablet
36
Drug
Tier
Drug Name
Requirements/Limits
ADVATE H
2
PA
ADVATE L
2
PA
ADVATE M
2
PA
ADVATE SH
2
PA
ADVATE UH
2
PA
ADVATE
2
PA
ALPHANATE
2
PA
AMICAR
BIOCLATE
2
2
PA
FEIBA NF
2
PA
FEIBA VH IMMUNO
2
PA
HELIXATE FS
2
PA
HEMOFIL M
2
PA
HUMATE-P
2
PA
KOATE-DVI
2
PA
KOGENATE FS
2
PA
MONOCLATE-P
2
PA
RECOMBINATE
2
PA
REFACTO
2
PA
WILATE
2
PA
XYNTHA
2
PA
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
tablet: 1000mg
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days
supply per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days
supply per fill)
(QL: 34 days supply
per fill)
37
Drug
Tier
Drug Name
Platelet-aggregation Inhibitors
(Pletal)
cilostazol
(Ticlid)
ticlopidine hcl
EFFIENT
PLAVIX
1
1
2
2
Requirements/Limits
PA
Hematopoietic Agents
Hematopoietic Agents
ARANESP
2
PA
EPOGEN
2
PA
LEUKINE
2
PA
NEULASTA
2
PA
NEUMEGA
2
PA
NEUPOGEN
2
PA
PROCRIT
2
PA
PROMACTA
2
PA
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 7 days supply
per fill)
(QL: 7 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 7 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
Hypotensive Agents
Hypotensive Agents, Miscellaneous
(Catapres)
clonidine hcl
(Clonidine HCl/chlorthalidone)
clonidine hcl/
chlorthalidone
(Catapres-TTS 3)
clonidine
(Guanabenz Acetate)
guanabenz acetate
(Tenex)
guanfacine hcl
(Apresoline)
hydralazine hcl
(Hydralazine/
hydralazine/
hydrochlorothiazid)
hydrochlorothiazid
hydralazine/reserpin/hctz (Hydralazine/reserpin/hctz)
(Aldomet)
methyldopa
(Methyldopa/
methyldopa/
hydrochlorothiazide)
hydrochlorothiazide
(Minoxidil)
minoxidil
(Reserpine)
reserpine
(Reserpine/hydrochlorothiazide)
reserpine/
hydrochlorothiazide
1
1
1
1
1
1
1
tablet
1
1
1
1
1
1
38
Drug
Tier
Drug Name
NEXICLON XR
2
Requirements/Limits
PA
Ion-Removing Agents
Ion-Removing Agents
(Phoslo)
calcium acetate
(Sodium Polystyrene Sulfonate)
sodium polystyrene
sulfonate
FOSRENOL
RENAGEL
RENVELA
1
1
2
2
2
PA
Keratolytic Agents
Keratolytic Agents
benzoyl peroxide
microspheres
benzoyl peroxide
benzoyl peroxide/aloe
vera
benzoyl peroxide/skin
clnsr7
potassium hydroxide
salicylic acid
salicylic acid/ammon lact/
aloe
salicylic acid/ceramide
cmb #1
silver nitrate applicator
sulfacet sod/sulfur/witch
haz
sulfacetamide sodium/
sulfur
urea
urea/hyaluronate sodium
urea/lactic ac/zn
undecylenate
urea/lactic acid/salicyl
acid
BENZASHAVE
(Benzoyl Peroxide
Microspheres)
(Delos)
(Benzoyl Peroxide/aloe Vera)
1
1
1
(Benzoyl Peroxide/skin Clnsr7)
1
(Potassium Hydroxide)
(Salex)
(Salkera)
1
1
1
(Salex)
1
(Silver Nitrate Applicator)
(Plexion Sct)
1
1
(Avar)
1
(Uramaxin)
(Umecta)
(Kerol)
1
1
1
(Kerol)
1
2
Keratoplastic Agents
Keratoplastic Agents
sulfacetamide sodium/urea (Rosula Ns)
DRITHOCREME HP
DRITHO-SCALP
1
2
2
39
Drug
Tier
Drug Name
Requirements/Limits
Local Anesthetics
Local Anesthetics
aa/antipyrn/bcaine/
polico#1/al
antipyrine/benzocaine/
glycerin
chloroxylenol/pramoxine
hcl
lidocaine hcl
(Auralgan)
1
(Otra Nr)
1
(Oticin)
1
(Xylocaine)
1
jel (ml), jel/pf app,
solution
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
(Fosamax)
alendronate sodium
(Zyloprim)
allopurinol
(Imuran)
azathioprine
(Colchicine/probenecid)
colchicine/probenecid
(Sandimmune)
cyclosporine
(Neoral)
cyclosporine, modified
(Antabuse)
disulfiram
(Ergoloid Mesylates)
ergoloid mesylates
(Didronel)
etidronate disodium
(Proscar)
finasteride
FLUORITAB
(Leflunomide)
leflunomide
(Leucovorin Calcium)
leucovorin calcium
methylergonovine maleate (Methergine)
(Cellcept)
mycophenolate mofetil
(Sandostatin)
octreotide acetate
(Probenecid)
probenecid
(Prevident 5000 Plus)
sodium fluoride
(Gel-kam)
stannous fluoride
(Prograf)
tacrolimus
ACTIMMUNE
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
PA
(QL: 34 days supply
per fill))
ACTONEL
AMPYRA
2
2
PA
(QL: 34 days supply
per fill)
ARAVA
ARCALYST
2
2
PA
(QL: 34 days supply
per fill)
AVODART
2
capsule, solution
tablet
tablet
40
Drug
Tier
Drug Name
Requirements/Limits
AVONEX
ADMINISTRATION
PACK
AVONEX
2
PA
(QL: 34 days supply
per fill)
2
PA
BETASERON
2
BONIVA
CELLCEPT
CETROTIDE
COLCRYS
COPAXONE
2
2
2
2
2
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
tablet
susp recon
CYSTAGON
ELMIRON
ENBREL
2
2
2
EXTAVIA
FLUOR-A-DAY
FLUOR-A-DAY
FLURA-DROPS
FOSAMAX PLUS D
FOSAMAX
GANIRELIX ACETATE
GILENYA
2
2
2
2
2
2
2
2
GLUCAGEN
2
GLUCAGON
EMERGENCY KIT
HUMIRA
2
2
PA
KINERET
2
PA
KUVAN
2
PA
MESNEX
MYFORTIC
RAPAMUNE
REBIF
2
2
2
2
PA
PA
PA
(QL: 34 days supply
per fill)
PA
PA
(QL: 34 days supply
per fill)
PA
drops
tab chew
solution
PA
(QL: 34 days supply
per fill)
(QL: 2 kits per 1
fill)
(QL: 2 kits per 1
fill)
(QL: 1 copay/
coinsurance per
injection)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
tablet
(QL: 34 days supply
per fill)
41
Drug
Tier
Drug Name
Requirements/Limits
REVLIMID
2
PA
RIDAURA
SANDOSTATIN
SENSIPAR
SIMPONI
2
2
2
2
PA
PA
SOMATULINE DEPOT
SYNAREL
THALOMID
ULORIC
ZAVESCA
2
2
2
2
2
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
PA
PA
PA
(QL: 34 days supply
per fill)
Mydriatics
Mydriatics
atropine sulfate
cyclopentolate hcl
homatropine hbr
tropicamide
ISOPTO
HOMATROPINE
ISOPTO HYOSCINE
(Isopto Atropine)
(Cyclogyl)
(Isopto Homatropine)
(Mydriacyl)
1
1
1
1
2
drops: 2%
2
Ocular Disorders
Ocular Disorders
(Fluorescein Sodium)
fluorescein sodium
1
drops
Opiate Antagonists
Opiate Antagonists
(Revia)
naltrexone hcl
1
Parasympathomimetics (Cholinergic Agents)
Parasympathomimetics (Cholinergic Agents)
(Urecholine)
bethanechol chloride
(Aricept)
donepezil hcl
(Razadyne ER)
galantamine hbr
(Guanidine HCl)
guanidine hcl
(Salagen)
pilocarpine hcl
(Mestinon)
pyridostigmine bromide
(Exelon)
rivastigmine tartrate
CHANTIX
1
1
1
1
1
1
1
2
EXELON
2
(QL: 6 months per
member per
lifetime)
solution
42
Drug
Tier
Drug Name
MESTINON
PROSTIGMIN
Requirements/Limits
2
2
syrup
Parathyroid
Parathyroid
calcitonin,salmon,syntheti (Miacalcin)
c
FORTEO
1
2
FORTICAL
MIACALCIN
PA
2
2
(QL: 34 days supply
per fill)
vial
Pituitary
Pituitary
desmopressin acetate
(DDAVP)
1
solution, spray/
pump, tablet
BRAVELLE
CHORIONIC
GONADOTROPIN
FOLLISTIM AQ
2
2
PA
GENOTROPIN
2
PA
GONAL-F RFF
2
PA
GONAL-F
2
PA
LUVERIS
2
PA
MENOPUR
2
NORDITROPIN
NORDIFLEX
NORDITROPIN
2
PA
2
PA
NOVAREL
2
OVIDREL
2
PREGNYL
2
REPRONEX
2
STIMATE
2
2
PA
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
43
Drug
Tier
Drug Name
Requirements/Limits
Progestins
Progestins
medroxyprogesterone acet (Provera)
(Aygestin)
norethindrone acetate
(Progesterone In Oil)
progesterone
CRINONE
DEPO-PROVERA
DEPO-SUBQ PROVERA
104
PROMETRIUM
1
1
1
2
2
2
vial: 400mg/ml
2
Psychotherapeutic Agents
Antidepressants
amitrip hcl/
chlordiazepoxide
amitriptyline hcl
amoxapine
bupropion hcl
citalopram hydrobromide
clomipramine hcl
desipramine hcl
doxepin hcl
fluoxetine hcl
fluvoxamine maleate
imipramine hcl
imipramine pamoate
maprotiline hcl
mirtazapine
nefazodone hcl
nortriptyline hcl
paroxetine hcl
perphenazine/
amitriptyline hcl
phenelzine sulfate
protriptyline hcl
sertraline hcl
tranylcypromine sulfate
trazodone hcl
trimipramine maleate
VENLAFAXINE HCL
ER
venlafaxine hcl
APLENZIN
(Limbitrol)
1
(Amitriptyline HCl)
(Amoxapine)
(Wellbutrin XL)
(Celexa)
(Anafranil)
(Norpramin)
(Doxepin HCl)
(Prozac)
(Fluvoxamine Maleate)
(Tofranil)
(Tofranil-PM)
(Maprotiline HCl)
(Remeron)
(Serzone)
(Pamelor)
(Paxil)
(Perphenazine/amitriptyline
HCl)
(Nardil)
(Vivactil)
(Zoloft)
(Parnate)
(Desyrel)
(Surmontil)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Effexor XR)
1
2
1
1
1
1
1
1
1
PA
44
Drug
Tier
Drug Name
CYMBALTA
LEXAPRO
OLEPTRO ER
PAXIL
PRISTIQ ER
SYMBYAX
VIIBRYD
Antipsychotic Agents
(Chlorpromazine HCl)
chlorpromazine hcl
(Clozaril)
clozapine
(Fluphenazine Decanoate)
fluphenazine decanoate
(Fluphenazine HCl)
fluphenazine hcl
haloperidol decanoate
haloperidol lactate
haloperidol
loxapine succinate
olanzapine
perphenazine
risperidone
thioridazine hcl
thiothixene
trifluoperazine hcl
ABILIFY DISCMELT
ABILIFY
FANAPT
GEODON
INVEGA
ORAP
RISPERDAL CONSTA
SAPHRIS
SEROQUEL XR
SEROQUEL
(Haloperidol Decanoate)
(Haloperidol Lactate)
(Haloperidol)
(Loxitane)
(Zyprexa Zydis)
(Perphenazine)
(Risperdal)
(Thioridazine HCl)
(Navane)
(Trifluoperazine HCl)
2
2
2
2
2
2
2
Requirements/Limits
PA
oral susp
PA
PA
PA
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
oral conc., tablet
elixir, oral conc,
tablet
solution, tablet
PA
capsule
PA
PA
Renin-Angiotensin-Aldosterone System Inhibitors
Angiotensin II Receptor Antagonists
(Cozaar)
losartan potassium
(Hyzaar)
losartan/
hydrochlorothiazide
ATACAND HCT
ATACAND
AVALIDE
AVAPRO
1
1
2
2
2
2
PA
PA
PA
PA
45
Drug
Tier
Drug Name
BENICAR HCT
BENICAR
DIOVAN HCT
DIOVAN
MICARDIS HCT
MICARDIS
TEVETEN HCT
TEVETEN
Angiotensin-Converting Enzyme Inhibitors
(Lotensin)
benazepril hcl
(Lotensin HCT)
benazepril/
hydrochlorothiazide
(Capoten)
captopril
(Capozide)
captopril/
hydrochlorothiazide
(Vasotec)
enalapril maleate
(Vaseretic)
enalapril/
hydrochlorothiazide
(Monopril)
fosinopril sodium
(Monopril HCT)
fosinopril/
hydrochlorothiazide
(Zestril)
lisinopril
(Prinzide)
lisinopril/
hydrochlorothiazide
(Univasc)
moexipril hcl
(Uniretic)
moexipril/
hydrochlorothiazide
(Aceon)
perindopril erbumine
(Accupril)
quinapril hcl
(Accuretic)
quinapril/
hydrochlorothiazide
(Altace)
ramipril
(Mavik)
trandolapril
trandolapril/verapamil hcl (Trandolapril/verapamil HCl)
Renin-Angiotensin-Aldosterone System Inhibitors
(Inspra)
eplerenone
(Aldactazide)
spironolact/
hydrochlorothiazid
(Aldactone)
spironolactone
AMTURNIDE
TEKTURNA HCT
TEKTURNA
2
2
2
2
2
2
2
2
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
PA
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
PA
PA
PA
46
Drug
Tier
Drug Name
VALTURNA
2
Requirements/Limits
PA
Replacement Preparations
Replacement Preparations
cal carb/mgox/d3/b12/fa/ (Cal Carb/mgox/d3/b12/fa/b6/
bor)
b6/bor
pot chloride/pot bicarb/cit (K-lyte-cl)
ac
potassium bicarbonate/cit (K-lyte)
ac
(K-dur)
potassium chloride
potassium gluconate
zinc sulfate
(Potassium Gluconate)
(Zinc Sulfate)
1
wafer: 500-300-1
1
1
1
1
1
capsule er, liquid,
packet, tab er prt,
tablet er, tablet sa
capsule
Respiratory Tract Agents, Miscellaneous
Respiratory Tract Agents, Miscellaneous
(Acetylcysteine)
acetylcysteine
(Aminophylline)
aminophylline
(Guaifen/theop Anhyd/p-ephed)
guaifen/theop anhyd/pephed
(Difil-g)
guaifenesin/dyphylline
(Theochron)
theophylline anhydrous
THEO-24
1
1
1
liquid, tablet
1
1
2
Second Generation Antihistamines
Second Generation Antihistamines
CLARINEX
2
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
(Baclofen)
baclofen
(Soma)
carisoprodol
(Soma Compound)
carisoprodol/aspirin
(Parafon Forte DSC)
chlorzoxazone
(Chlorzoxazone/acetaminophen)
chlorzoxazone/
acetaminophen
(Soma Compound with Codeine)
codeine phos/
carisoprodol/asa
(Flexeril)
cyclobenzaprine hcl
(Dantrium)
dantrolene sodium
(Skelaxin)
metaxalone
(Robaxin-750)
methocarbamol
(Norflex)
orphenadrine citrate
1
1
1
1
1
1
1
1
1
1
1
capsule
tablet er
47
Drug
Tier
Drug Name
orphenadrine/aspirin/
caffeine
tizanidine hcl
(Norgesic Forte)
1
(Zanaflex)
1
Requirements/Limits
Skin and Mucous Membrane Agents, Miscellaneous
Skin and Mucous Membrane Agents, Miscellaneous
(Differin)
adapalene
(Lac-hydrin)
ammonium lactate
(Dovonex)
calcipotriene
(Efudex)
fluorouracil
(Aldara)
imiquimod
(Accutane)
isotretinoin
(Lactinol)
lactic acid
(Gladase)
papain/urea
(Condylox)
podofilox
trypsin/balsam peru/castor (Xenaderm)
oil
CONDYLOX
DIFFERIN
1
1
1
1
1
1
1
1
1
1
PA
2
2
gel (gram)
gel (gram): 0.3%;
lotion, med. swab
ELIDEL
FINACEA
OXSORALEN
2
2
2
PA
PA
PA
OXSORALEN-ULTRA
2
PA
PROTOPIC
SANTYL
SORIATANE
TARGRETIN
TAZORAC
2
2
2
2
2
PA
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
PA
PA
Somatotropin Agonists and Antagonists
Somatotropin Agonists and Antagonists
SOMAVERT
2
PA
Sympatholytic Adrenergic Blocking Agents
(Uroxatral)
alfuzosin hcl
(D.H.E. 45)
dihydroergotamine
mesylate
(Ergotamine Tartrate/caffeine)
ergotamine tartrate/
caffeine
(Flomax)
tamsulosin hcl
1
1
1
1
48
Drug
Tier
Drug Name
CAFERGOT
DIBENZYLINE
MIGRANAL
RAPAFLO
2
2
2
2
Requirements/Limits
PA
Sympathomimetic (Adrenergic) Agents
Sympathomimetic (Adrenergic) Agents
(Accuneb)
albuterol sulfate
(Albuterol)
albuterol
(Adrenaclick)
epinephrine
ipratropium/albuterol
sulfate
levalbuterol hcl
metaproterenol sulfate
midodrine hcl
p-ephed hcl/
methscopolamn
terbutaline sulfate
VENTOLIN HFA
BROVANA
COMBIVENT
EPIPEN JR
1
1
1
(Duoneb)
1
(Xopenex Concentrate)
(Metaproterenol Sulfate)
(Proamatine)
(P-ephed HCl/methscopolamn)
1
1
1
1
(Brethine)
1
1
2
2
2
pen injctr, (QL: 2
kits per 1 fill)
tablet
PA
(QL: 2 kits per 1
fill)
(QL: 2 kits per 1
fill)
EPIPEN
2
FORADIL
MAXAIR AUTOHALER
PERFOROMIST
SEREVENT DISKUS
TWINJECT
2
2
2
2
2
PA
XOPENEX HFA
XOPENEX
2
2
PA
PA
(QL: 1 package [2
injections] per fill)
Thyroid and Antithyroid Agents
Thyroid and Antithyroid Agents
(Synthroid)
levothyroxine sodium
(Cytomel)
liothyronine sodium
(Tapazole)
methimazole
(Potassium Iodide)
potassium iodide
(Potassium Iodide/iodine)
potassium iodide/iodine
(Propylthiouracil)
propylthiouracil
(Armour Thyroid)
thyroid,pork
1
1
1
1
1
1
1
tablet
tablet
49
Drug
Tier
Drug Name
ARMOUR THYROID
Requirements/Limits
2
tablet: 15mg,
120mg, 180mg,
240mg, 300mg
Urinary Anti-infectives
Urinary Anti-infectives
(Uta)
methen/m-blue/sal/na
phos/hyos
(Methenam/me Blue/ba/salicy/
methenam/me blue/ba/
hyo)
salicy/hyo
(Hiprex)
methenamine hippurate
(Mandelamine)
methenamine mandelate
(Mth/me Blue/sod Phos/phen/
mth/me blue/sod phos/
hyos)
phen/hyos
(Macrodantin)
nitrofurantoin
macrocrystal
(Furadantin)
nitrofurantoin
(Trimethoprim)
trimethoprim
PHOSPHASAL
URETRON D-S
URIN D.S.
1
1
1
1
1
1
1
1
2
2
2
Vasodilating Agents
Vasodilating Agents
(Persantine)
dipyridamole
(Isordil)
isosorbide dinitrate
(Imdur)
isosorbide mononitrate
(Isoxsuprine HCl)
isoxsuprine hcl
(Nitro-dur)
nitroglycerin
1
1
1
1
1
capsule er, patch
td24, spray
1
1
2
PA
AGGRENOX
LETAIRIS
2
2
PA
NITRO-BID
NITRO-DUR
2
2
NITROSTAT
2
nylidrin hcl
papaverine hcl
ADCIRCA
(Nylidrin HCl)
(Papaverine HCl)
tablet
capsule er, tablet
(QL: 1 copay/
coinsurance per 15
days supply)
(QL: 1 copay/
coinsurance per 17
days supply; 34
days per fill)
patch td24: 0.3mg/
hr, 0.8mg/hr
50
Drug
Tier
Drug Name
Requirements/Limits
REMODULIN
2
PA
REVATIO
2
PA
TRACLEER
2
TYVASO
2
PA
VENTAVIS
2
PA
(QL: 1 copay/
coinsurance per 17
days supply; 34
days per fill)
tablet, (QL: 1
copay/coinsurance
per 17 days supply;
34 days per fill)
(QL: 1 copay/
coinsurance per 17
days supply; 34
days per fill)
(QL: 34 days supply
per fill)
(QL: 34 days supply
per fill)
Vitamins and Minerals
Vitamins and Minerals
(Rocaltrol)
calcitriol
(Drisdol)
ergocalciferol (vitamin
d2)
FLURA
(Folic Acid)
folic acid
LOZI-FLUR
(Pedi Mvi No.17 with Fluoride)
pedi mvi no.17 with
fluoride
pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/iron/fa)
DHT
FLUOR-A-DAY
HECTOROL
MEPHYTON
ZEMPLAR
1
1
1
1
1
1
1
2
2
2
2
2
capsule, solution
tablet
capsule
capsule
51
INDEX
1ST CHOICE LANCETS .. 28
1ST TIER UNILET
COMFORTOUCH......... 29
aa/antipyrn/bcaine/polico#1/
al .................................... 40
ABILIFY............................ 45
ABILIFY DISCMELT....... 45
ABSTRAL ........................... 4
acarbose............................... 8
ACCU-CHEK .................... 29
acebutolol hcl..................... 25
acetaminophen with codeine 3
acetaminophen/caffeine/
butalb ............................... 2
acetaminophen/phenyltolx cit
.......................................... 2
acetazolamide .................... 11
acetic acid .......................... 11
acetic acid/aluminum acetate
........................................ 11
acetic acid/hydrocortisone. 11
acetylcysteine ..................... 47
ACIPHEX .......................... 22
ACTI-LANCE.................... 29
ACTI-LANCE LITE.......... 29
ACTI-LANCE SPECIAL .. 29
ACTIMMUNE................... 40
ACTONEL......................... 40
ACTOS .............................. 10
acyclovir............................. 24
adapalene........................... 48
ADCIRCA.......................... 50
ADVAIR DISKUS............... 1
ADVAIR HFA ..................... 1
ADVANCED TRAVEL
LANCETS...................... 29
ADVATE ........................... 37
ADVATE H ....................... 37
ADVATE L........................ 37
ADVATE M....................... 37
ADVATE SH ..................... 37
ADVATE UH.....................37
ADVOCATE LANCET .....29
ADVOCATE LANCETS...29
AFINITOR .........................18
AGGRENOX .....................50
albuterol .............................49
albuterol sulfate..................49
alclometasone dipropionate
........................................15
alcohol antiseptic pads.......14
alendronate sodium ............40
alfuzosin hcl........................48
ALINIA ..............................20
ALKERAN.........................18
allopurinol..........................40
ALOMIDE ...........................5
ALPHAGAN P...................11
ALPHANATE....................37
alprazolam..........................25
ALPRAZOLAM INTENSOL
........................................25
ALTABAX.........................13
ALTERNATE SITE
LANCET ........................29
aluminum chloride..............25
amantadine hcl ...................19
amcinonide .........................15
AMICAR............................37
amiloride hcl ......................32
amiloride/
hydrochlorothiazide .......32
aminocaproic acid..............36
aminophylline .....................47
amiodarone hcl...................26
AMITIZA ...........................27
amitrip hcl/chlordiazepoxide
........................................44
amitriptyline hcl .................44
amlodipine besylate............26
amlodipine besylate/
benazepril .......................26
amlodipine/atorvastatin..... 16
ammonium lactate.............. 48
amoxapine.......................... 44
amoxicillin ........................... 6
amoxicillin/potassium clav .. 6
amphet asp/amphet/d-amphet
......................................... 5
ampicillin trihydrate ............ 6
AMPYRA .......................... 40
AMTURNIDE ................... 46
anagrelide hcl .................... 36
anastrozole......................... 18
ANCOBON ....................... 10
ANDRODERM ................... 5
ANDROGEL ....................... 5
ANTARA........................... 16
antipyrine/benzocaine/
glycerin .......................... 40
APIDRA .............................. 9
APIDRA SOLOSTAR......... 9
APLENZIN........................ 44
APOKYN........................... 19
apraclonidine hcl............... 33
APRISO ............................. 15
ARANESP ......................... 38
ARAVA ............................. 40
ARCALYST ...................... 40
ARIXTRA ......................... 36
ARMOUR THYROID....... 50
ARTHROTEC 50 ................ 3
ARTHROTEC 75 ................ 3
ASACOL ........................... 15
ASMANEX ......................... 1
ASSURE LANCE.............. 29
ASTEPRO ........................... 5
ATACAND........................ 45
ATACAND HCT............... 45
atenolol .............................. 25
atenolol/chlorthalidone ..... 25
AT-LAST LANCETS........ 29
atovaquone/proguanil hcl.. 20
I-1
ATRIPLA........................... 23
atropine sulfate .............. 7, 42
ATROVENT HFA ............... 8
AUGMENTIN ..................... 7
AURORA HEALTHCARE
LANCETS...................... 29
AVALIDE.......................... 45
AVAPRO ........................... 45
AVC ................................... 14
AVELOX ............................. 7
AVINZA .............................. 4
AVODART ........................ 40
AVONEX........................... 41
AVONEX
ADMINISTRATION
PACK............................. 41
AXERT .............................. 17
AZASITE........................... 12
azathioprine ....................... 40
azelastine hcl........................ 5
AZILECT........................... 19
azithromycin......................... 6
AZOPT............................... 11
AZOR................................. 26
bacitracin ........................... 11
bacitracin/polymyxin b sulfate
........................................ 11
baclofen.............................. 47
BACTOCILL ....................... 7
BACTROBAN................... 13
BACTROBAN NASAL .... 12
balanced salt irrig soln
comb2............................. 33
balsalazide disodium.......... 15
BANZEL.............................. 8
BARACLUDE ................... 24
BD GENIE LANCET ........ 29
BECONASE AQ................ 14
benazepril hcl..................... 46
benazepril/
hydrochlorothiazide ....... 46
BENICAR .......................... 46
BENICAR HCT ................. 46
BENZASHAVE................. 39
benzonatate.........................20
benzoyl peroxide.................39
benzoyl peroxide
microspheres ..................39
benzoyl peroxide/aloe vera.39
benzoyl peroxide/skin clnsr7
........................................39
benzphetamine hcl ................5
benztropine mesylate ..........19
BESIVANCE .....................12
betamet diprop/prop gly .....15
betamethasone dipropionate
........................................15
betamethasone valerate......15
BETASERON ....................41
betaxolol hcl .................11, 25
bethanechol chloride ..........42
BETOPTIC S......................11
bicalutamide .......................18
BIOCLATE ........................37
bisoprolol fumarate ............25
bisoprolol fumarate/hctz ....25
BLEPHAMIDE ..................12
BLEPHAMIDE S.O.P........12
BONIVA ............................41
BRAVELLE .......................43
brimonidine tartrate ...........11
BROMDAY .......................14
bromfenac sodium ..............14
bromocriptine mesylate ......19
bromphen mal/pe/carbetapen
cit....................................20
bromphenira/pseudoephed/
codein .............................20
brompheniram/pe/
dihydrocodeine ...............20
brompheniramin/pe/codeine
phos ................................21
brompheniramin/pe/
dextromethor ..................21
brompheniramine maleate..34
bromphenrm/pseudoeph/
dihydrocd........................21
BROVANA ........................49
budesonide ........................... 1
bumetanide......................... 32
bupropion hcl..................... 44
buspirone hcl ..................... 24
butalb/acetaminophen/
caffeine............................. 2
butalbital/acetaminophen .... 2
butalbital/aspirin/caffeine ... 2
butorphanol tartrate ............ 4
BYETTA ............................. 9
BYSTOLIC........................ 26
cabergoline ........................ 19
CAFERGOT ...................... 49
caffeine citrated ................... 5
cal carb/mgox/d3/b12/fa/b6/
bor.................................. 47
calcipotriene ...................... 48
calcitonin,salmon,synthetic 43
calcitriol............................. 51
calcium acetate .................. 39
CANASA........................... 15
CAPRELSA....................... 18
captopril............................. 46
captopril/hydrochlorothiazide
....................................... 46
carbamazepine..................... 8
carbidopa/levodopa ........... 19
carbinoxamine maleate...... 34
car-b-pen ta/chlor-tan ....... 21
car-b-pen ta/phenylephrine/
pyr.................................. 21
CAREONE ........................ 29
carisoprodol ...................... 47
carisoprodol/aspirin .......... 47
carteolol hcl....................... 33
carvedilol ........................... 25
CEENU.............................. 18
cefaclor ................................ 6
cefadroxil hydrate................ 6
cefdinir................................. 6
cefditoren pivoxil ................. 6
cefpodoxime proxetil............ 6
cefprozil ............................... 6
CEFTIN ............................... 6
I-2
cefuroxime axetil.................. 6
CELEBREX......................... 3
CELLCEPT........................ 41
cephalexin monohydrate ...... 6
CETROTIDE ..................... 41
CHANTIX.......................... 42
chloral hydrate................... 24
chlordiazepoxide hcl .......... 25
chlordiazepoxide/clidinium br
.......................................... 7
chlorhexidine gluconate..... 11
chlor-mal/methscopolamine
nit ................................... 34
chlor-mal/phenyleph/
methscop ........................ 34
chloroquine phosphate....... 20
chlorothiazide .................... 33
chloroxylenol/pramoxine hcl
........................................ 40
chlorpheniramine maleate . 34
chlorpheniramine/codeine
phos ................................ 21
chlorpromazine hcl ............ 45
chlorpropamide.................... 9
chlorthalidone .................... 32
chlorzoxazone .................... 47
chlorzoxazone/acetaminophen
........................................ 47
cholestyramine (with sugar)
........................................ 16
cholestyramine/aspartame . 16
choline sal/mag salicylate.... 2
CHORIONIC
GONADOTROPIN........ 43
ciclopirox ........................... 13
ciclopirox olamine ............. 13
cilostazol ............................ 38
CILOXAN.......................... 12
cimetidine........................... 22
cimetidine hcl ..................... 22
CIMZIA ............................. 36
CIPRO.................................. 7
CIPRO HC ......................... 12
CIPRODEX........................ 12
ciprofloxacin hcl.............7, 11
ciprofloxacin/ciprofloxa hcl .7
citalopram hydrobromide...44
citric acid/sodium citrate .....1
CLARINEX........................47
clarithromycin ......................6
clemastine fumarate ...........34
CLEOCIN...........................13
CLEVER CHEK LANCETS
........................................29
CLEVER CHEK ULTRA
THIN LANCETS ...........29
clindamycin hcl ....................6
clindamycin palmitate hcl ....6
clindamycin phos/benzoyl
perox...............................12
clindamycin phosphate.......12
CLINDESSE ......................13
clobetasol propionate.........15
clomiphene citrate ..............33
clomipramine hcl................44
clonazepam...........................8
clonidine .............................38
clonidine hcl .......................38
clonidine hcl/chlorthalidone
........................................38
clorazepate dipotassium.....25
clotrimazole........................13
clotrimazole/betamet diprop
........................................13
clozapine.............................45
COAGUCHEK...................29
codeine phos/acetaminophen3
codeine phos/carisoprodol/
asa ..................................47
codeine sulf...........................3
codeine/butalbit/acetamin/
caff....................................3
codeine/butalbital/asa/caffein
..........................................3
codeine/promethazine hcl...21
colchicine/probenecid ........40
COLCRYS .........................41
colestipol hcl ......................16
COLOR LANCETS........... 29
COMBIPATCH ................. 33
COMBIVENT ................... 49
COMBIVIR ....................... 23
COMFORT LANCETS..... 29
COMPAZINE.................... 10
COMTAN.......................... 19
CONDYLOX..................... 48
COPAXONE ..................... 41
CORDRAN........................ 16
CORDRAN SP .................. 16
COREG CR ....................... 26
cortisone acetate.................. 1
CREON.............................. 36
CRESTOR ......................... 17
cresyl ace/ben alc/butanol/ipa
....................................... 11
CRINONE ......................... 44
CRIXIVAN........................ 23
cromolyn sodium................ 15
CUTIVATE ....................... 16
cyclobenzaprine hcl ........... 47
cyclopentolate hcl .............. 42
cyclophosphamide ............. 18
cyclosporine....................... 40
cyclosporine, modified....... 40
CYMBALTA..................... 45
cyproheptadine hcl ............ 34
CYSTAGON ..................... 41
danazol................................. 4
dantrolene sodium ............. 47
dapsone.............................. 18
DARAPRIM ...................... 20
DAYTRANA....................... 5
DECADRON ..................... 14
DELATESTRYL ................. 5
demeclocycline hcl............... 7
DENAVIR ......................... 13
DEPEN .............................. 36
DEPO-PROVERA............. 44
DEPO-SUBQ PROVERA
104 ................................. 44
desipramine hcl.................. 44
desmopressin acetate......... 43
I-3
desogestrel-ethinyl estradiol
........................................ 28
desog-et estra/ethin estra... 28
desonide ............................. 15
desoximetasone .................. 15
DETROL............................ 35
DETROL LA ..................... 35
dexamethasone..................... 1
dexamethasone sod phosphate
........................................ 14
dexchlorpheniramine maleate
........................................ 34
DEXILANT ....................... 22
dexmethylphenidate hcl........ 5
dextroamphetamine sulfate .. 5
dhcodeine bt/acetaminophn/
caff.................................... 3
DHT ................................... 51
DIASTAT ACUDIAL ....... 25
diazepam ............................ 25
DIBENZYLINE................. 49
diclofenac potassium............ 2
diclofenac sodium .......... 2, 14
dicloxacillin sodium ............. 7
dicyclomine hcl .................... 7
didanosine .......................... 22
diethylpropion hcl ................ 5
DIFFERIN.......................... 48
diflorasone diacetate.......... 15
diflunisal .............................. 2
digoxin................................ 27
DIGOXIN .......................... 27
dihydrocodeine/guaifenesin21
dihydroergotamine mesylate
........................................ 48
DILANTIN .......................... 8
diltiazem hcl ....................... 26
DIOVAN............................ 46
DIOVAN HCT................... 46
DIPENTUM....................... 15
diphenhydramin/pe/codeine
phos ................................ 21
diphenhydramine hcl.......... 34
diphenoxylate hcl/atropine. 10
dipyridamole.......................50
disopyramide phosphate.....26
disulfiram ...........................40
DIURIL ..............................33
divalproex sodium ................8
DIVIGEL............................33
dm/phenyleph/
chlorpheniramine ...........21
d-methorp tan/p-epd tan/d-cp
........................................21
d-methorp tan/p-ephed tan/cp
........................................21
d-methorphan hb/pe/
chlorphenir .....................21
d-methorphan hb/p-epd hcl/
bpm .................................21
d-methorphan hb/p-ephed hcl/
cp ....................................21
d-methorphan hb/prometh hcl
........................................21
donepezil hcl.......................42
dorzolamide hcl ..................11
dorzolamide hcl/timolol
maleat .............................11
doxazosin mesylate...............1
doxepin hcl .........................44
doxycycline hyclate ........7, 12
doxycycline monohydrate.....7
doxylamine succinate .........34
DRITHOCREME HP.........39
DRITHO-SCALP ...............39
dronabinol ..........................10
DROPLET LANCETS.......29
DUAC CS...........................13
DULERA..............................1
DYNACIRC CR.................26
E.E.S. 200.............................6
EASY COMFORT .............29
econazole nitrate ................13
EFFIENT............................38
ELESTRIN .........................33
ELIDEL..............................48
ELMIRON..........................41
EMADINE ...........................5
EMCYT ............................. 18
EMEND ............................. 10
emollient combination no.10
....................................... 28
EMTRIVA ......................... 23
ENABLEX......................... 35
enalapril maleate............... 46
enalapril/hydrochlorothiazide
....................................... 46
ENBREL............................ 41
enoxaparin sodium ............ 36
epinastine hcl....................... 5
epinephrine ........................ 49
EPIPEN.............................. 49
EPIPEN JR ........................ 49
EPIVIR .............................. 23
EPIVIR HBV..................... 23
eplerenone ......................... 46
EPOGEN ........................... 38
EPZICOM.......................... 23
EQUATE ........................... 29
ergocalciferol (vitamin d2) 51
ergoloid mesylates ............. 40
ergotamine tartrate/caffeine
....................................... 48
ery e-succ/sulfisoxazole ....... 6
ERYPED 200....................... 6
ERYPED 400....................... 6
ERY-TAB............................ 6
erythromycin base.......... 6, 12
erythromycin base/benz per13
erythromycin base/ethanol 13
erythromycin ethylsuccinate 6
erythromycin stearate .......... 6
estazolam ........................... 25
ESTRADERM ................... 33
estradiol ............................. 33
estradiol/noreth ac............. 33
ESTRING .......................... 33
estrogen,ester/metestosterone...................... 4
estropipate ......................... 33
ethambutol hcl ................... 18
I-4
ethinyl estradiol/drospirenone
........................................ 28
ethosuximide ........................ 8
ethynodiol d-ethinyl estradiol
........................................ 28
etidronate disodium ........... 40
etodolac................................ 2
etoposide ............................ 18
EVISTA ............................. 33
EXELON............................ 42
exemestane ......................... 18
EXFORGE ......................... 26
EXFORGE HCT ................ 26
EXJADE ............................ 36
EXTAVIA.......................... 41
E-Z JECT BLOOD LANCET
........................................ 29
E-Z JECT LANCETS ........ 29
EZ SMART........................ 29
E-ZJECT LANCETS ......... 29
EZ-LETS............................ 29
famciclovir ......................... 24
famotidine .......................... 22
FANAPT ............................ 45
FAST TAKE ...................... 32
FEIBA NF.......................... 37
FEIBA VH IMMUNO ....... 37
felbamate.............................. 8
FELBATOL ......................... 8
felodipine............................ 26
FEMHRT ........................... 33
fenofibrate .......................... 16
fenofibrate,micronized ....... 16
fenofibric acid .................... 16
fenoprofen calcium............... 2
fentanyl................................. 3
fentanyl citrate ..................... 3
FENTORA ........................... 4
FINACEA .......................... 48
finasteride .......................... 40
FINGERSTIX .................... 29
FIRST-BXN....................... 13
flavoxate hcl ....................... 35
flecainide acetate ............... 26
FLECTOR ............................3
FLOVENT DISKUS ............1
FLOVENT HFA...................1
fluconazole .........................10
flucytosine...........................10
fludrocortisone acetate.........1
flunisolide ...........................14
fluocinolone acetonide .......15
fluocinolone acetonide oil ..14
fluocinolone/shower cap ....15
fluocinonide........................15
FLUOR-A-DAY...........41, 51
fluorescein sodium..............42
FLUORITAB .....................40
fluorometholone .................14
fluorouracil.........................48
fluoxetine hcl ......................44
fluoxymesterone....................4
fluphenazine decanoate ......45
fluphenazine hcl..................45
FLURA...............................51
FLURA-DROPS.................41
flurazepam hcl ....................25
flurbiprofen...........................2
flurbiprofen sodium ............14
flutamide.............................18
fluticasone propionate..14, 15
fluvoxamine maleate...........44
FML....................................14
FML S.O.P. ........................14
FOCALIN XR ......................5
folic acid.............................51
FOLLISTIM AQ ................43
fondaparinux sodium..........36
FORA LANCETS ..............29
FORADIL...........................49
FORTEO ............................43
FORTESTA..........................5
FORTICAL ........................43
FOSAMAX ........................41
FOSAMAX PLUS D..........41
fosinopril sodium................46
fosinopril/
hydrochlorothiazide .......46
FOSRENOL....................... 39
FREESTYLE LANCETS .. 29
FREESTYLE UNISTIK 2 . 29
FROVA.............................. 17
FULVICIN U/F ................. 10
furosemide ......................... 32
FUZEON ........................... 23
gabapentin ........................... 8
GABITRIL........................... 8
galantamine hbr................. 42
ganciclovir ......................... 24
GANIRELIX ACETATE .. 41
gemfibrozil ......................... 16
GENOTROPIN.................. 43
gentamicin sulfate........ 12, 13
GEODON .......................... 45
GILENYA ......................... 41
GLEEVEC ......................... 18
glimepiride........................... 9
glipizide ............................... 9
glipizide/metformin hcl ........ 9
GLUCAGEN ..................... 41
GLUCAGON EMERGENCY
KIT................................. 41
GLUCOCOM LANCETS . 29
GLUCOSOURCE.............. 29
glutethimide ....................... 24
glyburide.............................. 9
glyburide,micronized ........... 9
glyburide/metformin hcl ...... 9
glycopyrrolate...................... 7
GLYSET.............................. 9
GOLYTELY...................... 27
GONAL-F.......................... 43
GONAL-F RFF ................. 43
granisetron hcl................... 10
GRIFULVIN V.................. 10
griseofulvin,microsize........ 10
GRIS-PEG ......................... 10
guaifen/dm hb/p-ephedrine/
bpm ................................ 34
guaifen/d-methorp tan/pephed.............................. 21
I-5
guaifen/d-methorphan hb/pe/
cp.................................... 34
guaifen/p-ephed hcl/dihy-cod
........................................ 34
guaifen/phenylephr/
chlorphenir..................... 34
guaifen/theop anhyd/p-ephed
........................................ 47
guaifenesin ......................... 34
guaifenesin/carbetapentane
cit.................................... 34
guaifenesin/codeine phos ... 21
guaifenesin/dm/
pseudoephedrine ............ 21
guaifenesin/d-methorphan hb
........................................ 21
guaifenesin/d-methorphan hb/
pe.................................... 34
guaifenesin/dyphylline ....... 47
guaifenesin/p-ephed hcl ..... 34
guaifenesin/p-ephed hcl/cod
........................................ 21
guaifenesin/phenylephrine hcl
........................................ 34
guanabenz acetate.............. 38
guanfacine hcl.................... 38
guanidine hcl...................... 42
HAEMOLANCE................ 30
HAEMOLANCE PLUS..... 29
HAEMOLANCE,
RETRACTABLE........... 30
halobetasol prop/ammonium
lac................................... 15
halobetasol propionate ...... 15
haloperidol......................... 45
haloperidol decanoate ....... 45
haloperidol lactate ............. 45
hc/pramox hcl/cl-xylenol/
water .............................. 14
hc/pramoxine hcl/
chloroxylenol.................. 14
HECTOROL ...................... 51
HELIXATE FS .................. 37
HEMOFIL M ..................... 37
heparin sodium,porcine......36
HEPSERA ..........................24
HEXALEN .........................18
homatropine hbr.................42
HUMALOG .........................9
HUMALOG MIX 50-50 ......9
HUMALOG MIX 75-25 ......9
HUMATE-P .......................37
HUMIRA............................41
HUMULIN 70-30.................9
HUMULIN N .......................9
HUMULIN R .......................9
hyaluronate sodium ............28
HYCAMTIN ......................18
hydralazine hcl ...................38
hydralazine/
hydrochlorothiazid .........38
hydralazine/reserpin/hctz ...38
hydrochlorothiazide ...........33
hydrocodone bit/
acetaminophen .................3
hydrocodone bit/homatropine
........................................21
hydrocodone/chlorphen polis
........................................22
hydrocodone/ibuprofen ........3
hydrocort/pramoxin/emol/
pram#1 ...........................15
hydrocort/pramoxn/skn
clnsr#16..........................15
hydrocortisone................1, 16
hydrocortisone ac/lidocaine
..................................16, 20
hydrocortisone acetate .......16
hydrocortisone acetate/alo
ver...................................16
hydrocortisone acetate/urea
........................................16
hydrocortisone butyrate .....16
hydrocortisone valerate......16
hydrocortisone/iodoquinol .13
hydrocortisone/lidocaine/aloe
........................................20
hydrocortisone/pramoxine .16
hydromorphone hcl.............. 3
hydroxychloroquine sulfate 20
hydroxyurea ....................... 18
hydroxyzine hcl .................. 24
hydroxyzine pamoate ......... 24
hyoscyamine sulfate............. 7
ibuprofen.............................. 2
ibuprofen/oxycodone hcl...... 3
imipramine hcl................... 44
imipramine pamoate .......... 44
imiquimod .......................... 48
INCIVEK........................... 23
indapamide ........................ 32
INDOCIN ............................ 3
indomethacin ....................... 2
INFERGEN ....................... 23
INNOPRAN XL ................ 26
INTELENCE ..................... 23
INTRON A ........................ 23
INTUNIV........................... 27
INVEGA............................ 45
INVIRASE......................... 23
iodine/potassium iodide..... 13
ipratropium bromide ..... 7, 33
ipratropium/albuterol sulfate
....................................... 49
IRESSA ............................. 18
ISENTRESS ...................... 23
isomethept/acetaminop/
dichlphn ........................... 2
isoniazid............................. 18
isopropamide/
prochlorperazine ............. 7
ISOPTO CARPINE ........... 11
ISOPTO HOMATROPINE42
ISOPTO HYOSCINE ........ 42
isosorbide dinitrate............ 50
isosorbide mononitrate ...... 50
isotretinoin......................... 48
isoxsuprine hcl................... 50
isradipine ........................... 26
itraconazole ....................... 10
JANUMET........................... 9
JANUVIA............................ 9
I-6
KALETRA......................... 23
KENALOG ........................ 16
ketoconazole................. 10, 13
ketoprofen ............................ 2
ketorolac tromethamine . 2, 14
KINERET .......................... 41
KOATE-DVI...................... 37
KOGENATE FS ................ 37
KOMBIGLYZE XR............. 9
K-PHOS ORIGINAL........... 1
KRISTALOSE ..................... 2
KUVAN ............................. 41
labetalol hcl ....................... 25
lactic acid........................... 48
lactulose ............................... 2
LADY LITE....................... 30
lamivudine.......................... 22
lamotrigine........................... 8
LANCETS.......................... 30
LANCETS MICROTAINER
........................................ 30
lansoprazole....................... 22
LANTUS.............................. 9
LANTUS SOLOSTAR ........ 9
LASTACAFT ...................... 5
latanoprost ......................... 11
leflunomide......................... 40
LESCOL ............................ 17
LESCOL XL ...................... 17
LETAIRIS.......................... 50
letrozole.............................. 18
leucovorin calcium............. 40
LEUKERAN ...................... 18
LEUKINE .......................... 38
levalbuterol hcl .................. 49
LEVEMIR............................ 9
levetiracetam........................ 8
levobunolol hcl................... 11
levofloxacin .................... 7, 12
levonorgestrel .................... 28
levonorgestrel-eth estra ..... 28
levorphanol tartrate ............. 3
levothyroxine sodium ......... 49
LEXAPRO ......................... 45
LEXIVA .............................23
LIALDA .............................15
lidocaine hcl .................20, 40
lidocaine/prilocaine ...........20
LIDODERM.......................20
LIFESCAN.........................30
lindane................................14
liothyronine sodium............49
lipase/protease/amylase .....36
LIPITOR.............................16
lisinopril .............................46
lisinopril/hydrochlorothiazide
........................................46
LITE TOUCH ....................30
lithium carbonate ...............27
lithium citrate .....................27
LITHOSTAT........................2
LIVALO .............................17
l-norgest-eth estr/ethin estra
........................................28
LOESTRIN 24 FE..............28
loperamide hcl....................10
lorazepam ...........................25
LORAZEPAM INTENSOL
........................................25
losartan potassium .............45
losartan/hydrochlorothiazide
........................................45
LOTRONEX ......................36
lovastatin ............................17
LOVAZA ...........................16
LOVENOX.........................36
loxapine succinate ..............45
LOZI-FLUR .......................51
LUMIGAN .........................11
LUNESTA..........................24
LUVERIS ...........................43
LYRICA ...............................8
LYSODREN.......................18
magnesium salicylate ...........2
malathion............................14
maprotiline hcl ...................44
MATULANE .....................18
MAXAIR AUTOHALER ..49
MAXALT .......................... 17
MAXALT MLT................. 17
MAXIDEX ........................ 14
mebendazole ........................ 5
meclizine hcl ...................... 10
meclofenamate sodium ........ 2
MEDI-LANCE .................. 30
MEDLANCE PLUS .......... 30
medroxyprogesterone acet. 44
mefenamic acid .................... 2
mefloquine hcl.................... 20
megestrol acetate............... 18
meloxicam............................ 2
MENOPUR........................ 43
meperidine hcl ..................... 3
MEPHYTON ..................... 51
meprobamate ..................... 24
MEPRON........................... 20
mercaptopurine.................. 18
mesalamine ........................ 15
MESNEX........................... 41
MESTINON....................... 43
METADATE CD................. 5
metaproterenol sulfate....... 49
metaxalone......................... 47
metformin hcl....................... 8
methadone hcl...................... 3
methamphetamine hcl .......... 5
methazolamide ................... 11
methen/m-blue/sal/na phos/
hyos................................ 50
methenam/me blue/ba/salicy/
hyo ................................. 50
methenamine hippurate ..... 50
methenamine mandelate .... 50
methimazole ....................... 49
methocarbamol .................. 47
methotrexate sodium.......... 18
methscopolamine bromide... 7
methyclothiazide ................ 33
methyl salicylate .................. 2
methyldopa......................... 38
methyldopa/
hydrochlorothiazide....... 38
I-7
methylergonovine maleate . 40
methylphenidate hcl ............. 5
methylprednisolone .............. 1
metipranolol....................... 11
metoclopramide hcl............ 36
metolazone ......................... 32
metoprolol succinate.......... 25
metoprolol tartrate............. 25
metoprolol/
METROGEL...................... 13
metronidazole............... 13, 20
mexiletine hcl ..................... 26
mg sal/acetaminophn/p-tlox/
caf..................................... 2
MIACALCIN..................... 43
MICARDIS ........................ 46
MICARDIS HCT ............... 46
miconazole nitrate.............. 13
MICRO THIN LANCET ... 30
MICRO THIN LANCETS. 30
MICROLET ....................... 30
midazolam hcl .................... 25
midodrine hcl ..................... 49
MIGRANAL ...................... 49
MINILET ........................... 30
minocycline hcl .................... 7
minoxidil ............................ 38
mirtazapine ........................ 44
misoprostol......................... 22
moexipril hcl ...................... 46
moexipril/
mometasone furoate ........... 16
MONOCLATE-P............... 37
MONOLET LANCETS ..... 30
MONOLET THIN
LANCETS...................... 30
morphine sulfate................... 4
MOVIPREP ....................... 27
mth/me blue/sod phos/phen/
hyos ................................ 50
MULTAQ .......................... 27
mupirocin ........................... 13
MYCOBUTIN....................18
mycophenolate mofetil........40
MYFORTIC .......................41
MYGLUCOHEALTH
LANCETS......................30
MYLERAN ........................19
nabumetone ..........................3
nadolol................................25
nadolol/bendroflumethiazide
........................................25
NAFTIN .............................13
NALFON..............................3
nalidixic acid ........................7
naltrexone hcl.....................42
NAMENDA .......................27
naphazoline hcl ..................33
naphazoline hcl/antazoline.33
naproxen...............................3
naproxen sodium ..................3
naratriptan hcl....................17
NASONEX.........................14
NATACYN ........................12
nateglinide............................8
NEBUPENT .......................20
needles, insulin disposable.30
nefazodone hcl....................44
neo/polymyx b sulf/dexameth
........................................12
neomy sulf/bacitra/polymyxin
b......................................12
neomy sulf/bacitrac zn/poly/
hc ....................................12
neomy sulf/polymyx b sulf/hc
........................................12
neomycin sulfate...................6
neomycin sulfate/dex na ph 12
neomycin/polymyxn b/
gramicidin ......................12
NEULASTA.......................38
NEUMEGA........................38
NEUPOGEN ......................38
NEXAVAR ........................19
NEXICLON XR.................39
NEXIUM............................22
NIASPAN.......................... 16
nicardipine hcl................... 26
nifedipine ........................... 26
NILANDRON ................... 19
nimodipine ......................... 26
nisoldipine ......................... 26
NITRO-BID....................... 50
NITRO-DUR ..................... 50
nitrofurantoin .................... 50
nitrofurantoin macrocrystal
....................................... 50
nitroglycerin ...................... 50
NITROSTAT ..................... 50
nizatidine ........................... 22
NORDITROPIN ................ 43
NORDITROPIN
NORDIFLEX................. 43
noreth a-et estra/fe fumarate
....................................... 28
noreth-ethinyl estradiol/iron
....................................... 28
norethind ac/ethinyl estradiol
....................................... 33
norethindrone .................... 28
norethindrone acetate........ 44
norethindrone a-e estradiol28
norethindrone-ethinyl estrad
....................................... 28
norethindrone-mestranol ... 28
norgestimate-ethinyl estradiol
....................................... 28
norgestrel-ethinyl estradiol 28
NORPACE CR .................. 27
nortriptyline hcl ................. 44
NORVIR............................ 23
NOVA SUREFLEX .......... 30
NOVAREL ........................ 43
NOVOLIN 70-30................. 9
NOVOLIN 70-30 INNOLET
......................................... 9
NOVOLIN N ....................... 9
NOVOLIN N INNOLET..... 9
NOVOLIN R ....................... 9
NOVOLOG ......................... 9
I-8
NOVOLOG MIX 70-30....... 9
NOXAFIL .......................... 11
NUCYNTA .......................... 4
NUCYNTA ER.................... 4
NUVARING ...................... 28
NUVIGIL............................. 5
nylidrin hcl ......................... 50
nystatin......................... 10, 13
nystatin/triamcin ................ 13
OCL.................................... 27
octreotide acetate............... 40
ofloxacin......................... 7, 12
olanzapine .......................... 45
OLEPTRO ER ................... 45
omeprazole......................... 22
omeprazole/sodium
bicarbonate .................... 22
OMNARIS ......................... 14
ondansetron........................ 10
ondansetron hcl.................. 10
ONE TOUCH DELICA..... 30
ONE TOUCH LANCETS.. 30
ONE TOUCH SURESOFT 30
ONE TOUCH TEST STRIPS
........................................ 32
ONE TOUCH ULTRA TEST
STRIPS .......................... 32
ONGLYZA .......................... 9
ONSOLIS............................. 4
opium.................................. 10
opium/belladonna alkaloids. 4
ORACIT............................... 1
ORAMORPH SR ................. 4
ORAP................................. 45
orphenadrine citrate .......... 47
orphenadrine/aspirin/caffeine
........................................ 48
ORTHO EVRA.................. 28
ORTHO TRI-CYCLEN LO
........................................ 28
OVCON-50 ........................ 28
OVIDREL .......................... 43
oxandrolone ......................... 4
oxaprozin.............................. 3
oxazepam............................25
oxcarbazepine.......................8
OXSORALEN....................48
OXSORALEN-ULTRA .....48
oxybutynin chloride ............35
oxycodone hcl.......................4
oxycodone hcl/acetaminophen
..........................................4
oxycodone hcl/aspirin ..........4
oxycodone hcl/oxycodon ter/
asa ....................................4
OXYCONTIN ......................4
oxymorphone hcl ..................4
OXYTROL.........................35
pantoprazole sodium ..........22
papain/urea ........................48
papaverine hcl ....................50
paregoric ............................10
paromomycin sulfate ..........20
paroxetine hcl.....................44
PATADAY...........................6
PATANASE .........................6
PATANOL ...........................6
PAXIL ................................45
pedi mvi no.17 with fluoride
........................................51
peg 3350/na sulf,bicarb,cl/kcl
........................................27
PEGASYS ..........................24
PEGASYS PROCLICK .....24
PEGINTRON .....................24
PEGINTRON REDIPEN ...24
penicillin v potassium...........7
PENTASA..........................15
pentazocine hcl/
acetaminophen .................4
pentazocine hcl/naloxone hcl4
pentoxifylline ......................36
p-epd tan/chlor-tan.............34
p-ephed hcl/chlor-mal/bell alk
........................................34
p-ephed hcl/codeine/guaifen
........................................22
p-ephed hcl/dhcodeine bt/cp
....................................... 22
p-ephed hcl/hydrocodone bit
....................................... 22
p-ephed hcl/methscopolamn
....................................... 49
p-ephed hcl/triprolidine hcl35
PERFOROMIST................ 49
perindopril erbumine......... 46
permethrin ......................... 14
perphenazine...................... 45
perphenazine/amitriptyline
hcl .................................. 44
phenazopyridine hcl........... 20
phendimetrazine tartrate ..... 5
phenelzine sulfate .............. 44
phenobarb/hyoscy/atropine/
scop.................................. 7
phenobarbital .................... 25
phenylbutazone .................... 3
phenylephrine hcl .............. 33
phenylephrine hcl/chlor-mal
....................................... 35
phenylephrine hcl/cod/
prometh.......................... 22
phenylephrine hcl/prometh
hcl .................................. 35
phenylephrine/
brompheniramin ............ 35
phenylephrine/
brompheniramine........... 35
phenylephrine/carbetapentan/
gg ................................... 34
phenylephrine/chlor-tan .... 35
phenylephrine/dhcodeine bt/
cp ................................... 22
phenylephrine/
diphenhydramine ........... 35
phenylephrine/dp-hydram tan
....................................... 35
phenylephrine/p-tlox ci/cp . 35
phenylephrine/pyril tan/cp. 35
phenylephrine/pyrilamine ma/
cp ................................... 35
I-9
phenylephrine/pyrilamine tan
........................................ 35
PHENYTEK ........................ 8
phenytoin.............................. 8
phenytoin sodium extended .. 8
PHOSPHASAL.................. 50
PHOSPHOLINE IODIDE . 11
phosphorus #1...................... 1
PHRENILIN FORTE........... 2
pilocarpine hcl ............. 11, 42
PILOPINE HS.................... 11
pindolol .............................. 25
piroxicam ............................. 3
PLAVIX............................. 38
pnv with ca,no.72/iron/fa ... 51
podofilox ............................ 48
polyethylene glycol 3350.... 27
polymyxin b sulfate/tmp ..... 12
pot chloride/pot bicarb/cit ac
........................................ 47
pot guaiaco/car-b-pentane/pe
........................................ 34
potassium bicarbonate/cit ac
........................................ 47
potassium chloride ............. 47
potassium citrate.................. 1
potassium citrate/citric acid 1
potassium gluconate........... 47
potassium hydroxide .......... 39
potassium iodide ................ 49
potassium iodide/iodine ..... 49
PRADAXA ........................ 36
pramipexole di-hcl ............. 19
PRANDIN............................ 9
pravastatin sodium............. 17
prazosin hcl.......................... 1
PRED-G ............................. 12
prednicarbate..................... 16
prednisolone......................... 1
prednisolone acetate .......... 14
prednisolone sod phosphate 1,
14
prednisone............................ 1
PREGNYL ......................... 43
PREMARIN .......................33
PREMPHASE ....................33
PREMPRO .........................33
PREZISTA .........................23
primidone .............................8
PRISTIQ ER.......................45
probenecid..........................40
procainamide hcl................26
prochlorperazine maleate ..10
PROCRIT ...........................38
PRODIGY LANCETS .......30
PRODIGY TWIST TOP
LANCET ........................30
progesterone.......................44
PROMACTA......................38
promethazine hcl ................35
PROMETRIUM .................44
PRONESTYL.....................27
propafenone hcl..................26
propantheline bromide .........7
propantheline/phenobarbital8
propranolol hcl...................26
propranolol/
propylthiouracil..................49
PROSTIGMIN ...................43
PROTOPIC.........................48
protriptyline hcl..................44
PROVIGIL ...........................5
pseudoephedrine hcl/chlormal..................................35
pseudoephedrine hcl/codeine
........................................22
pseudoephedrine/
brompheniramin .............35
pseudoephedrine/cpm/
methscopol......................35
PUBLIX LANCET.............30
PULMICORT FLEXHALER
..........................................1
PULMOZYME...................33
pyrazinamide ......................18
pyridostigmine bromide......42
pyrilamine/pe/
dextromethorphan.......... 22
QUALAQUIN ................... 20
quinapril hcl ...................... 46
quinapril/hydrochlorothiazide
....................................... 46
quinidine gluconate ........... 26
quinidine sulfate ................ 26
QVAR.................................. 1
ramipril.............................. 46
RANEXA........................... 27
ranitidine hcl...................... 22
RAPAFLO ......................... 49
RAPAMUNE..................... 41
REBIF................................ 41
RECOMBINATE .............. 37
REFACTO ......................... 37
RELENZA ......................... 23
RELIEF PLUS................... 30
RELISTOR ........................ 36
RELPAX............................ 17
REMODULIN ................... 51
RENAGEL......................... 39
RENEW ADVANCED
MICRO-LANCETS....... 30
RENVELA......................... 39
REPRONEX ...................... 43
RESCRIPTOR ................... 23
reserpine ............................ 38
reserpine/hydrochlorothiazide
....................................... 38
RESTASIS......................... 14
RETIN-A MICRO ............. 27
REVATIO.......................... 51
REVLIMID........................ 42
REYATAZ......................... 23
RHINOCORT AQUA ....... 15
RIBATAB.......................... 24
ribavirin ............................. 24
RIDAURA ......................... 42
rifampin ............................. 18
rifampin/isoniazid.............. 18
RIFATER........................... 18
I-10
RIGHTEST GL300
LANCETS...................... 30
RILUTEK .......................... 27
rimantadine hcl .................. 23
RISPERDAL CONSTA..... 45
risperidone ......................... 45
RITALIN LA ....................... 5
rivastigmine tartrate .......... 42
ropinirole hcl ..................... 19
ROXICODONE ................... 4
ROZEREM ........................ 24
SABRIL ............................... 8
SAFETY LANCETS ......... 30
SAFETY-LET.................... 30
sal-amide/acetamin/p-tlox/
caff.................................... 2
sal-amide/acetaminophn/ptlox.................................... 2
salicylic acid ...................... 39
salicylic acid/ammon lact/
aloe................................. 39
salicylic acid/ceramide cmb
#1.................................... 39
salsalate ............................... 3
SANCTURA XR ............... 35
SANCUSO......................... 10
SANDOSTATIN................ 42
SANTYL............................ 48
SAPHRIS ........................... 45
SAVELLA ......................... 27
scopolamine hydrobromide 10
selegiline hcl ...................... 19
selenium sulfide.................. 13
SELZENTRY..................... 23
SENSIPAR......................... 42
SEREVENT DISKUS........ 49
SEROQUEL....................... 45
SEROQUEL XR ................ 45
sertraline hcl ...................... 44
silver nitrate ....................... 13
silver nitrate applicator ..... 39
silver sulfadiazine .............. 13
SIMPONI ........................... 42
simvastatin ......................... 17
SINGLE-LET .....................30
SINGULAIR ......................15
SMARTDIABETES
VANTAGE.....................30
SMARTEST LANCET ......30
sod chloride/nahco3/kcl/pegs
........................................27
sod/pot/k cit/sod cit/cit acid..1
sodium fluoride...................40
sodium polystyrene sulfonate
........................................39
sodium thiosulfate/sal acid.13
SOFT TOUCH ...................31
SOFT TOUCH SAFE-T-PRO
........................................31
SOFTCLIX.........................31
SOLO V2 LANCETS.........31
SOMATULINE DEPOT ....42
SOMAVERT......................48
SORIATANE .....................48
sotalol hcl ...........................26
SPIRIVA ..............................8
spironolact/
spironolactone....................46
SPORANOX ......................11
SPRYCEL ..........................19
STALEVO 100...................19
STALEVO 125...................20
STALEVO 150...................20
STALEVO 200...................20
STALEVO 50.....................20
STALEVO 75.....................20
stannous fluoride ................40
STAT-LET .........................31
stavudine.............................22
STIMATE...........................43
STRATTERA.....................27
STRIANT .............................5
STROMECTOL ...................5
SUCRAID ..........................33
sucralfate............................22
sulfacet sod/sulfur/witch haz
........................................39
sulfacetamd/sulfr/sknclnsr10
....................................... 14
sulfacetamide sod/sulfur/urea
....................................... 14
sulfacetamide sodium .. 12, 14
sulfacetamide sodium/sulfur
....................................... 39
sulfacetamide sodium/urea 39
sulfacetm na/avobenzone/
sulfur.............................. 14
sulfacetm na/prednis sp ..... 12
sulfadiazine.......................... 7
sulfamethoxazole/
trimethoprim .................... 7
sulfasalazine ........................ 7
sulindac................................ 3
sumatriptan........................ 17
sumatriptan succinate........ 17
SUPER THIN LANCET ... 31
SUPER THIN LANCETS . 31
SUPRAX ............................. 6
SURE COMFORT
LANCETS ..................... 31
SURE-LANCE .................. 31
SURESTEP........................ 32
SURESTEP PRO............... 32
SURGILANCE LANCETS31
SUSTIVA .......................... 23
SUTENT............................ 19
SYMBICORT...................... 1
SYMBYAX ....................... 45
SYMLIN.............................. 9
SYMLINPEN 120 ............... 9
SYMLINPEN 60 ................. 9
SYNAREL......................... 42
syring w-ndl,disp,insul,0.3ml
....................................... 31
syring w-ndl,disp,insul,0.5ml
....................................... 31
syringe w-ndl, disp,insul,1ml
....................................... 31
tacrolimus .......................... 40
TAMIFLU ......................... 23
tamoxifen citrate ................ 18
I-11
tamsulosin hcl .................... 48
TARCEVA......................... 19
TARGRETIN............... 19, 48
TASIGNA .......................... 19
TASMAR........................... 20
TAZORAC......................... 48
TECHLITE ........................ 31
TECHLITE BLOOD
LANCET........................ 31
TEKTURNA ...................... 46
TEKTURNA HCT ............. 46
temazepam.......................... 25
TEMODAR........................ 19
terazosin hcl ......................... 1
terbutaline sulfate .............. 49
terconazole......................... 13
testosterone cypionate.......... 4
testosterone enanthate ......... 5
tetracycline hcl..................... 7
TEVETEN.......................... 46
TEVETEN HCT................. 46
THALOMID ...................... 42
THEO-24............................ 47
theophylline anhydrous...... 47
THIN LANCETS ............... 31
thioridazine hcl .................. 45
thiothixene.......................... 45
thyroid,pork........................ 49
ticlopidine hcl..................... 38
TIKOSYN .......................... 27
timolol maleate............. 11, 26
tizanidine hcl...................... 48
TOBI .................................... 6
TOBRADEX...................... 12
tobramycin sulf/
dexamethasone............... 12
tobramycin sulfate.............. 12
tolazamide ............................ 9
tolbutamide .......................... 9
tolmetin sodium.................... 3
TOPCARE UNIVERSAL1
THIN LANCET ............. 31
topiramate ............................ 8
torsemide............................ 32
TOVIAZ .............................35
TRACLEER .......................51
tramadol hcl .........................4
tramadol hcl/acetaminophen4
trandolapril ........................46
trandolapril/verapamil hcl .46
TRANSDERM-SCOP........10
tranylcypromine sulfate......44
TRAVATAN Z ..................11
trazodone hcl ......................44
tretinoin ........................18, 27
tretinoin/emollient ..............27
TREXIMET........................17
triamcinolone acetonide....14,
16
triamterene/
triazolam.............................25
TRICOR .............................16
trifluoperazine hcl ..............45
trifluridine ..........................12
trihexyphenidyl hcl .............19
TRILIPIX ...........................16
trimethobenzamide hcl .......10
trimethoprim.......................50
trimipramine maleate .........44
tripelennamine hcl..............35
TRIZIVIR...........................23
tropicamide.........................42
trospium chloride ...............35
TRUVADA ........................23
trypsin/balsam peru/castor oil
........................................48
TWINJECT ........................49
TYKERB............................19
TYVASO............................51
TYZEKA............................24
ULORIC .............................42
ULTICARE ........................31
ULTILET ...........................31
ULTILET BASIC...............31
ULTILET CLASSIC ..........31
ULTILET LANCETS ........31
ULTRA THIN II LANCETS
....................................... 31
ULTRA THIN LANCETS 31
ULTRA THIN PLUS......... 31
ULTRA THIN PLUS
LANCETS ..................... 31
ULTRALANCE................. 31
ULTRA-THIN II LANCETS
....................................... 31
ULTRATLC LANCETS ... 31
UNILET COMFORTOUCH
....................................... 32
UNILET EXCELITE......... 32
UNILET EXCELITE II ..... 32
UNILET GP LANCET...... 32
UNILET LANCET ............ 32
UNISTIK 3 ........................ 32
UNISTIK 3 EXTRA.......... 32
UNISTIK CZT................... 32
urea.................................... 39
urea/hyaluronate sodium... 39
urea/lactic ac/zn
undecylenate .................. 39
urea/lactic acid/salicyl acid39
URETRON D-S................. 50
URIN D.S. ......................... 50
ursodiol.............................. 36
VAGIFEM ......................... 33
valacyclovir hcl.................. 24
VALCYTE......................... 24
valproate sodium ................. 8
valproic acid ........................ 8
VALTURNA ..................... 47
VALUE PLUS LANCETS 32
VANCOCIN HCL ............... 6
VANDETANIB ................. 19
venlafaxine hcl................... 44
VENLAFAXINE HCL ER 44
VENTAVIS ....................... 51
VENTOLIN HFA .............. 49
VERAMYST ..................... 15
verapamil hcl ..................... 26
VERDESO......................... 16
VEREGEN......................... 13
I-12
VERIPRED 20 ..................... 1
VESICARE ........................ 35
VFEND .............................. 11
VICTOZA 3-PAK................ 9
VIDEX ............................... 23
VIGAMOX ........................ 12
VIIBRYD........................... 45
VIMOVO ............................. 3
VIMPAT .............................. 8
VIRACEPT ........................ 23
VIRAMUNE ...................... 23
VIRAMUNE XR ............... 23
VIRAZOLE........................ 24
VIREAD ............................ 23
VISICOL............................ 27
VITALET........................... 32
VITALET PRO.................. 32
VITALET PRO PLUS ....... 32
VIVELLE-DOT .................33
VOLTAREN ........................3
voriconazole .......................11
VOTRIENT........................19
VYTORIN..........................16
VYVANSE...........................5
warfarin sodium .................36
WAVESENSE LANCETS.32
WELCHOL ........................16
WILATE.............................37
XARELTO .........................36
XELODA ...........................19
XENAZINE........................27
XIFAXAN............................6
XOPENEX .........................49
XOPENEX HFA ................49
XYNTHA ...........................37
XYREM .............................28
YODOXIN......................... 20
zafirlukast .......................... 15
zaleplon.............................. 24
ZAVESCA......................... 42
ZEGERID .......................... 22
ZEMPLAR......................... 51
ZENPEP............................. 36
ZETIA................................ 16
ZIAGEN ............................ 23
zidovudine.......................... 23
zinc sulfate ......................... 47
ZOLINZA.......................... 19
zolpidem tartrate ............... 24
ZOMIG .............................. 17
ZOMIG ZMT..................... 17
zonisamide ........................... 8
ZOVIRAX ......................... 13
ZYVOX ............................... 6
I-13
CHIP Member Formulary 1/1/12

CHIP Cover.indd - Geisinger Health Plan

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2013 Formulary (List of covered drugs)

REVISED March 5 TIER Formulary doc

SUPPORT - Aero Precision