Affinity Health Plan Managed Medicaid Formulary

Transcription

Affinity Health Plan Managed Medicaid
Formulary
(Effective 1/1/2017)
INTRODUCTION
We are pleased to provide the 2017 Affinity Health Plan Managed
Medicaid Formulary as a useful reference and informational tool. This
document can assist medical providers in selecting clinically-appropriate
and cost-effective products for their patients.
The drugs represented have been reviewed by a Pharmacy and
Therapeutics (P&T) Committee and are approved for inclusion. The
document is reflective of current medical practice as of the date of review.
The information contained in this document and its appendices is provided
solely for the convenience of medical providers. We do not warrant or
assure accuracy of such information nor is it intended to be
comprehensive in nature. This document is not intended to be a substitute
for the knowledge, expertise, skill and judgment of the medical provider in
his or her choice of prescription drugs. All the information in the document
is provided as a reference for drug therapy selection. Specific drug
selection for an individual patient rests solely with the prescriber.
The document is subject to state-specific regulations and rules, including,
but not limited to, those regarding generic substitution, controlled
substance schedules, preference for brands and mandatory generics
whenever applicable.
We assume no responsibility for the actions or omissions of any medical
provider based upon reliance, in whole or in part, on the information
contained herein. The medical provider should consult the drug
manufacturer's product literature or standard references for more
detailed information.
National guidelines can be found on the National Guideline Clearinghouse
site at http://www.guideline.gov
PREFACE
The document is organized by sections. Each section is divided by therapeutic
drug class primarily defined by mechanism of action. Products are listed by
generic name with brand name for reference only. Unless the cited drug is
available only as an injectable or an exception is specifically noted, most
applicable dosage forms and strengths of the drug cited are included in the
document.
Drugs represented in this document may have varying cost to the plan member
based on the plan's benefit structure. Generic medications typically are available
at the lower cost, brand-name medications on the document will generally cost
more than generics. Generics should be considered the first line of prescribing
subject to applicable rules.
PHARMACY AND THERAPEUTICS (P&T) COMMITTEE
The services of an independent Pharmacy and Therapeutics Committee ("P&T
Committee") are utilized to approve safe and clinically effective drug therapies.
The P&T Committee is an external advisory body of experts from across the
region.
GENERIC SUBSTITUTION
Generic substitution is a pharmacy action whereby a generic version is dispensed
rather than a prescribed brand-name product. Italicize type indicates generic
availability. However, not all strengths or dosage forms of the generic name in
italicize type may be generically available. In most instances, a brand-name drug
for which a generic product becomes available will become non-formulary, with
the generic product covered in its place, upon release of the generic product onto
the market. However, the document is subject to state specific regulations and
rules regarding generic substitution and mandatory generic rules apply where
appropriate.
Generic drugs are usually priced lower than their brand-name equivalents.
Prescription generic drugs are:
•
•
•
Approved by the U.S. Food and Drug Administration for safety and
effectiveness, and are manufactured under the same strict standards that
apply to brand-name drugs.
Tested in humans to assure the generic is absorbed into the bloodstream
in a similar rate and extent compared to the brand-name drug
(bioequivalence). Generics may be different from the brand in size, color,
and inactive ingredients, but this does not alter their effectiveness or
ability to be absorbed just like the brand-name drug.
Manufactured in the same strength and dosage form as the brand-name
drugs.
When a generic drug is substituted for a brand-name drug, you can expect the
generic to produce the same clinical effect and safety profile as the brand-name
drug (therapeutic equivalence).
PLAN DESIGN
The document represents a closed formulary plan design. The medications listed
on the document are covered by the plan as represented. Certain medications
on the list are covered if utilization management criteria are met (i.e. Step
Therapy, Prior Authorization, Quantity Limits, etc); requests for use of such
medications outside of their listed criteria will be reviewed for medical
necessity. If a medication is not listed on the document, a formulary exception
may be requested for coverage. Medical necessity or formulary exception
requests will be reviewed based on drug-specific prior authorization criteria or
standard non-formulary prescription request criteria.
Note: regarding Medicaid nursing home members- Over the counter drugs, Physician
administered drugs (J-code drugs), medical supplies, nutritional supplements, sickroom
supplies, adult diapers and durable medical equipment will continue to be the
responsibility of a nursing home and will be reimbursed within the nursing home
benchmark rate; and Immunization services inclusive of vaccines and their
administration will remain in the nursing home benchmark rate.
MEDICAL SUPPLIES
Some medical supplies may be covered with a prescription. Please refer to the
Medical Supplies List for included products.
LEGEND
PA
Prior Authorization
QL
Quantity Limit
SP
Specialty Drug with network requirement
ST
Step Therapy
CAPITALIZED Indicates brand name drug
Italicize
HRM
Generic drug
High Risk Medication
AGE
Age Limit
OTC Only
Over the Counter Only
Rx Only
Prescription only
DS
Day Supply Limits
NOTICE
The information contained in this document is proprietary. The information may
not be copied in whole or in part without written permission. ©2016. All rights
reserved.
Affinity Health Plan does not operate the websites/organizations listed here, nor
is it responsible for the availability or reliability of the websites' content. This
document contains references to brand-name prescription drugs that are
trademarks or registered trademarks of pharmaceutical manufacturers.
To receive updated information about the drugs covered by please visit
www.affinityplan.org or call CVS Customer Service at 1-855-465-0031, 24
hours/7 days a week. TTY/TDD users, please call 1-800-863-5488.
Drug Name
Requirements/Limits
ANALGESICS
ANALGESICS, OTHER
acetaminophen CHEW
acetaminophen ELIX
acetaminophen LIQD
acetaminophen SUSP 80mg/0.8ml
acetaminophen SUSP 160mg/5ml
acetaminophen TABS
acetaminophen suppositories
acetaminophen suspension 80mg/0.8ml
acetaminophen suspension 160mg/5ml
acetaminophen tabs
COX-II INHIBITORS
celecoxib
QL (200 tabs per 30 days);
OTC ONLY
QL (240 ml per 30 days);
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
QL (100 units per 30 days);
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
PA
GOUT
allopurinol
colchicine
KRYSTEXXA
probenecid
NON-OPIOID ANALGESICS
butalbital-acetaminophen-caffeine
butalbital-acetaminophen-caffeine
butalbital-aspirin-caffeine CAPS
butalbital-aspirin-caffeine TABS
NSAIDS
aspirin
SUPP 300mg
aspirin
SUPP 600mg
diclofenac potassium
diclofenac sodium TB24; TBEC
diflunisal
etodolac
flurbiprofen
QL (30 tabs per 30 days), PA
PA; SP
CAPS
TABS
QL
QL
QL
QL
(60
(60
(60
(60
caps per 30 days)
tabs per 30 days)
caps per 30 days)
tabs per 30 days)
OTC ONLY
OTC ONLY
PA - Prior Authorization
QL - Quantity Limits
DS- Day Supply Limits
ST - Step
Therapy
AGE – Age Restriction HRM – High Risk Medication SP – Specialty
Pharmacy
OTC – Over the Counter
1
Drug Name
ibuprofen CAPS
ibuprofen CHEW
ibuprofen TABS 100mg, 200mg
ibuprofen TABS 400mg, 600mg, 800mg
ibuprofen drop 50mg/1.25ml
ibuprofen suspension 100 mg/5ml
ketoprofen
ketorolac tromethamine TABS
meloxicam
nabumetone
naproxen
naproxen sodium CAPS
naproxen sodium
TABS 220mg
naproxen sodium
oxaprozin
sulindac
TABS 275mg, 550mg
Requirements/Limits
QL (200 caps per 30 days);
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
QL (20 tabs per 5 days)
OTC ONLY
OTC ONLY
NSAIDS, TOPICAL
VOLTAREN GEL
OPIOID ANALGESICS
acetaminophen w/ codeine
acetaminophen w/ codeine solution
QL (5000 ml per 30 days)
fentanyl
QL (15 patches per 30 days)
hydrocodone-acetaminophen
hydromorphone hcl
methadone hcl 5mg
methadone hcl 10mg
morphine sulfate controlled-release 15mg, 30mg, QL (90 tabs per 30 days)
100mg
morphine sulfate controlled-release 60mg, 200mgQL (60 tabs per 30 days)
morphine sulfate sol 100/5ml
morphine sulfate solution
morphine sulfate suppositories
QL (180 units per 30 days)
morphine sulfate tab
oxycodone hcl CAPS
QL (180 caps per 30 days)
oxycodone hcl CONC
oxycodone hcl SOLN
oxycodone hcl TABS
oxycodone w/ acetaminophen SOLN
QL (900 mL / 30 days)
oxycodone w/ acetaminophen TABS
ST - Step
2
Therapy
Pharmacy
Drug Name
Requirements/Limits
oxycodone-aspirin
tramadol hcl
tramadol hcl ext-rel CP24 100mg, 200mg, 300mg QL (30 caps per 30 days)
TRAMADOL HCL EXT-REL CP24 150mg
tramadol hcl ext-rel TB24
tramadol-acetaminophen
ANTI-INFECTIVES
AMINOGLYCOSIDES
amikacin sulfate
gentamicin sulfate inj
neomycin sulfate
streptomycin sulfate
tobramycin inj
ANTIBACTERIALS, CARBAPENEMS
DORIBAX
imipenem-cilastatin
INVANZ
meropenem
ANTIBACTERIALS, CEPHALOSPORIN COMBINATIONS
ZERBAXA
PA; SP
ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN
cefadroxil
cefazolin sodium
cephalexin
ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN
CEFOTETAN DISODIUM
CEFOTETAN/DEXTROSE
cefoxitin sodium SOLN
CEFOXITIN SODIUM SOLR
cefoxitin sodium SOLR 1gm, 2gm, 10gm
cefprozil
cefuroxime axetil
cefuroxime sodium
ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN
cefdinir
cefotaxime sodium
ceftazidime
ceftriaxone
ceftriaxone sodium
ANTIBACTERIALS, CEPHALOSPORINS, 4TH GEN
cefepime
cefepime/dextrose
ANTIBACTERIALS, CEPHALOSPORINS, 5TH GEN
TEFLARO
PA
ST - Step
Therapy
Pharmacy
3
Drug Name
Requirements/Limits
ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES
azithromycin
azithromycin inj 2.5gm
clarithromycin
clarithromycin ext-rel
DIFICID
ERYTHROCIN LACTOBIONATE
erythromycin base
erythromycin base ext-rel
erythromycin stearate
PA
ANTIBACTERIALS, FLUOROQUINOLONES
AVELOX INJ
ciprofloxacin
ciprofloxacin ext-rel
ciprofloxacin hcl tab
ciprofloxacin in d5w
levofloxacin SOLN 25mg/ml
levofloxacin TABS
levofloxacin in d5w
ANTIBACTERIALS, PENICILLINS
amoxicillin
amoxicillin & potassium clavulanate
amoxicillin/potassium clavulanate
ampicillin
ampicillin & sulbactam sodium
ampicillin sodium inj
BICILLIN C-R
BICILLIN L-A
dicloxacillin sodium
nafcillin sodium inj
oxacillin sodium inj
penicillin g potassium
penicillin g procaine
penicillin v potassium
piperacillin sodium-tazobactam sodium
ZOSYN
ANTIBACTERIALS, SULFONAMIDES
sulfamethoxazole-trimethoprim
sulfamethoxazole-trimethoprim ds
ANTIBACTERIALS, TETRACYCLINES
doxycycline (monohydrate) susp
doxycycline hyclate cap 50 mg,
100 mg
AGE: NOT COVERED LESS
THAN 8 YEARS OF AGE
THAN 8 YEARS OF AGE
doxycycline hyclate for inj 100 mg
ST - Step
Therapy
Pharmacy
4
Drug Name
doxycycline hyclate tab 20 mg,
100 mg
tetracycline hcl
Requirements/Limits
THAN 8 YEARS OF AGE
THAN 8 YEARS OF AGE
ANTIFUNGALS
clotrimazole troche 10 mg
fluconazole
griseofulvin microsize susp 125 mg/5ml
griseofulvin ultramicrosize
itraconazole cap
nystatin POWD; TABS
nystatin (mouth-throat)
SPORANOX
terbinafine hcl tab
voriconazole
ANTIMALARIALS
atovaquone-proguanil hcl
chloroquine phosphate
COARTEM
mefloquine hcl
QL (120 caps per 30 days),
PA
PA
PA
QL
QL
QL
QL
(23 tabs per 180 days)
ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS
TYBOST
ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS
abacavir sulfate-lamivudine-zidovudine
ATRIPLA
COMPLERA
EPZICOM
EVOTAZ
lamivudine-zidovudine
PREZCOBIX
STRIBILD
TRIUMEQ
TRUVADA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(60
(30
(30
(30
(30
(60
(30
(30
(30
(30
tabs
tabs
tabs
tabs
tabs
tabs
tabs
tabs
tabs
tabs
per
per
per
per
per
per
per
per
per
per
30
30
30
30
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
ANTIRETROVIRALS, INTEGRASE INHIBITORS
ISENTRESS 25mg
ISENTRESS 100mg
ISENTRESS POW 100MG
ISENTRESS TAB 400MG
TIVICAY
VITEKTA
QL
QL
QL
QL
(60 packets per 30 days)
ST - Step
Therapy
Pharmacy
5
Drug Name
ANTIRETROVIRALS, PROTEASE INHIBITORS
APTIVUS CAP 250MG
APTIVUS SOL
CRIXIVAN 200mg
CRIXIVAN 400mg
INVIRASE CAP 200MG
INVIRASE TAB 500MG
KALETRA SOL
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
LEXIVA SUS 50MG/ML
LEXIVA TAB 700MG
NORVIR CAP 100MG
NORVIR SOL 80MG/ML
NORVIR TAB 100MG
PREZISTA SUSP
PREZISTA TABS 75mg
PREZISTA TABS 150mg
PREZISTA TABS 600mg
PREZISTA TABS 800mg
REYATAZ 150mg, 300mg
REYATAZ 200mg
VIRACEPT 250mg
VIRACEPT 625mg
Requirements/Limits
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(120 caps per 30 days)
(285 ml per 22 days)
ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS NON-NUCLEOSIDE
EDURANT
INTELENCE 25mg, 100mg
INTELENCE 200mg
nevirapine SUSP
nevirapine TABS
nevirapine tab 100 mg ext-rel
nevirapine tab 400mg ext-rel
RESCRIPTOR 100mg
RESCRIPTOR 200mg
SUSTIVA CAPS
SUSTIVA TABS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS NUCLEOSIDE
abacavir sulfate tab
didanosine 125mg, 200mg
didanosine 250mg, 400mg
EMTRIVA CAP 200MG
EMTRIVA SOLN
QL
QL
QL
QL
QL
ST - Step
Therapy
Pharmacy
6
Drug Name
lamivudine 150mg
lamivudine 300mg
stavudine cap
stavudine soln
VIDEX PEDIATRIC SOLN 2gm
VIDEX PEDIATRIC SOLN 4gm
ZIAGEN SOL 20MG/ML
zidovudine cap 100 mg
zidovudine syrup 10 mg/ml
zidovudine tab 300 mg
Requirements/Limits
ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS NUCLEOTIDE
VIREAD
VIREAD
POWD
TABS
QL (240 gm per 30 days)
ANTITUBERCULAR AGENTS
ethambutol hcl
isoniazid
pyrazinamide
rifampin
ANTIVIRALS, CMV AGENTS
cidofovir
CYTOVENE
foscarnet sodium
valganciclovir hcl
valganciclovir hcl tab 450 mg
ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B
adefovir dipivoxil
BARACLUDE SOL .05MG/ML
entecavir
lamivudine (hbv)
TYZEKA
ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C
HARVONI
rebetol sol 40mg/ml
ribavirin
SOVALDI
ZEPATIER
PA;
PA;
PA;
PA;
PA;
SP
SP; DS
SP; DS
SP
SP
ANTIVIRALS, HERPES AGENTS
acyclovir cap 200 mg
acyclovir suspension 200 mg/5ml
acyclovir tab 400 mg
acyclovir tab 800mg
famciclovir
valacyclovir hcl
ST - Step
Therapy
Pharmacy
7
Drug Name
ANTIVIRALS, INFLUENZA AGENTS
TAMIFLU 30mg
TAMIFLU 45mg, 75mg
TAMIFLU SUS 6MG/ML
Requirements/Limits
MISCELLANEOUS
ALBENZA
ST
atovaquone
aztreonam
AZTREONAM IN DEXTROSE INJ
bacitracin SOLR
chloramphenicol sodium succinate
clindamycin hcl
clindamycin palmitate hydrochloride
clindamycin phosphate inj
colistimethate sodium inj
CUBICIN
dapsone
erythromycin-sulfisoxazole
ivermectin
linezolid
PA
metronidazole CAPS
metronidazole TABS
metronidazole in nacl 0.79% iv soln 500 mg/100ml
metronidazole inj
NEUTREXIN
nitrofurantoin
QL (90 ml per 365 days), PA
nitrofurantoin macrocrystal
PA
nitrofurantoin monohydrate macrocrystalline cap QL (90 caps per 365 days),
100 mg
PA
PENTAM 300
polymyxin b sulfate
pyrantel pamoate
QL (60 ml per 30 days); OTC
ONLY
rifabutin cap 150 mg
SYNERCID
trimethoprim
TYGACIL
vancomycin hcl
ST
vancomycin hcl in dextrose inj
vancomycin inj
VIBATIV
ZYVOX SUS 100MG/5M
PA
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
ST - Step
Therapy
Pharmacy
8
Drug Name
ALKERAN
BICNU
BUSULFEX
carboplatin
cisplatin
cyclophosphamide
CYCLOPHOSPHAMIDE CAP 25 MG
CYCLOPHOSPHAMIDE CAP 50 MG
dacarbazine
EMCYT
GLEOSTINE
GLIADEL WAFER
HEXALEN
IFEX
ifosfamide
LEUKERAN
LOMUSTINE CAP 5 MG
melphalan hcl
MUSTARGEN
MYLERAN
oxaliplatin
temozolomide
TREANDA
ZANOSAR
Requirements/Limits
PA; SP
PA; SP
ANTIMETABOLITES
ALIMTA
capecitabine
cladribine
CLOLAR
cytarabine
floxuridine
fludarabine phosphate
fluorouracil
FOLOTYN
gemcitabine hcl
mercaptopurine
methotrexate sodium
TABLOID
TREXALL
PA; SP
PA; SP
HORMONAL ANTINEOPLASTICS, ANTIANDROGENS
bicalutamide
flutamide
nilutamide
ZYTIGA
PA; SP
HORMONAL ANTINEOPLASTICS, ANTIESTROGENS
ST - Step
Therapy
Pharmacy
9
Drug Name
FARESTON
FASLODEX
SOLTAMOX
tamoxifen citrate
Requirements/Limits
HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS
anastrozole
exemestane
letrozole
HORMONAL ANTINEOPLASTICS, GONADOTROPIN RELEASING
HORMONE ANTAGONISTS
FIRMAGON
PA; SP
HORMONAL ANTINEOPLASTICS, LUTEINIZING
HORMONE-RELEASING HORMONE (LHRH) AGONISTS
ELIGARD
SP; All females need PA.
Only males <20 need PA
PA; SP
PA; SP
PA; SP
PA; SP
leuprolide acetate
LUPRON DEPOT
TRELSTAR
TRELSTAR MIXJECT
VANTAS
ZOLADEX
HORMONAL ANTINEOPLASTICS, PROGESTINS
megestrol acetate
SUSP; TABS
IMMUNOMODULATORS
POMALYST
REVLIMID
THALOMID
KINASE INHIBITORS
AFINITOR
CAPRELSA
COMETRIQ
GILOTRIF
IBRANCE
imatinib mesylate
IMBRUVICA
INLYTA
JAKAFI
LENVIMA
MEKINIST
NEXAVAR
STIVARGA
SUTENT
PA; SP
PA; SP
PA; SP
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
ST - Step
Therapy
Pharmacy
10
Drug Name
TAFINLAR
TARCEVA
TORISEL
TYKERB
VOTRIENT
XALKORI
ZELBORAF
ZYDELIG
ZYKADIA
Requirements/Limits
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
MISCELLANEOUS
ABRAXANE
ADCETRIS
amifostine crystalline
ARRANON
ARZERRA
AVASTIN
bexarotene cap 75 mg
bleomycin sulfate
COSMEGEN
daunorubicin hcl
DAUNOXOME
dexrazoxane
docefrez
docetaxel
doxorubicin hcl
doxorubicin hcl liposomal
ELITEK
epirubicin hcl
ERBITUX
ERIVEDGE
ETOPOPHOS
etoposide
FARYDAK
HALAVEN
HERCEPTIN
hydroxyurea
idarubicin hcl
ISTODAX
IXEMPRA KIT
JEVTANA
LEUCOVORIN CALCIUM SOLN
leucovorin calcium TABS
leucovorin calcium for inj 50mg, 100mg, 200mg,
350mg
LEUCOVORIN CALCIUM FOR INJ 500mg
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
ST - Step
Therapy
Pharmacy
11
Drug Name
levoleucovorin calcium
LYNPARZA
LYSODREN
MATULANE
mesna
MESNEX
METASTRON
mitomycin
mitoxantrone hcl
NIPENT
ONCASPAR
paclitaxel
PHOTOFRIN
QUADRAMET
TENIPOSIDE
THERACYS
TICE BCG
TOTECT
tretinoin (chemotherapy)
TRISENOX
UVADEX
VALSTAR
VECTIBIX
VELCADE
VENCLEXTA
VENCLEXTA STARTING PACK
vinblastine sulfate
vincristine sulfate
vinorelbine tartrate
YERVOY
ZEVALIN Y-90
ZOLINZA
Requirements/Limits
PA; SP
PA; SP
PA; SP
PA;
PA;
PA;
PA;
PA;
SP
SP
SP
SP
SP
PA; SP
PA; SP
TOPOISOMERASE INHIBITORS
CAMPTOSAR
HYCAMTIN
irinotecan hcl
topotecan hcl
PA; SP
CARDIOVASCULAR
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS
amlodipine besylate-benazepril hcl
ACE INHIBITOR/DIURETIC COMBINATIONS
benazepril & hydrochlorothiazide
captopril & hydrochlorothiazide
enalapril maleate & hydrochlorothiazide
ST - Step
Therapy
Pharmacy
12
Drug Name
fosinopril sodium & hydrochlorothiazide
lisinopril & hydrochlorothiazide
quinapril-hydrochlorothiazide
Requirements/Limits
ACE INHIBITORS
benazepril hcl
captopril
enalapril maleate
fosinopril sodium
lisinopril
quinapril hcl
ramipril
trandolapril
ADRENOLYTICS, CENTRAL
clonidine hcl
guanfacine hcl
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone
spironolactone
ALPHA BLOCKERS
doxazosin mesylate
terazosin hcl
ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC
COMBINATIONS
irbesartan-hydrochlorothiazide
losartan potassium & hydrochlorothiazide
valsartan-hydrochlorothiazide
ANGIOTENSIN II RECEPTOR ANTAGONISTS
candesartan cilexetil
irbesartan
losartan potassium
valsartan 40mg, 80mg, 160mg
valsartan 320mg
ANTIARRHYTHMICS
amiodarone hcl
disopyramide phosphate
flecainide acetate
NORPACE CR
propafenone hcl
sotalol hcl
sotalol hcl (afib/afl)
TIKOSYN
PA; SP
ANTILIPEMICS, BILE ACID RESINS
cholestyramine
cholestyramine light
ST - Step
Therapy
Pharmacy
13
Drug Name
colestipol hcl
Requirements/Limits
ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS
ZETIA
ST
ANTILIPEMICS, FIBRATES
fenofibrate
fenofibrate micronized
gemfibrozil
ANTILIPEMICS, HMG-COA REDUCTASE
INHIBITORS/COMBINATIONS
atorvastatin calcium
lovastatin
pravastatin sodium
simvastatin
ANTILIPEMICS, NIACINS/COMBINATIONS
niacin (antihyperlipidemic)
niacin (antihyperlipidemic)
500mg
750mg, 1000mg
ANTILIPEMICS, PCSK9 INHIBITORS
REPATHA
PA; SP
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol & chlorthalidone
bisoprolol & hydrochlorothiazide
metoprolol & hydrochlorothiazide
BETA-BLOCKERS
atenolol
bisoprolol fumarate
BYSTOLIC
carvedilol
labetalol hcl
metoprolol succinate
metoprolol tartrate
nadolol 20mg, 80mg
nadolol 40mg
pindolol
propranolol hcl
timolol maleate TABS
CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES
amlodipine besylate
felodipine
nifedipine
nifedipine ext-rel
PA
CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES
diltiazem hcl
diltiazem hcl coated beads
diltiazem hcl extended release beads
ST - Step
Therapy
Pharmacy
14
Drug Name
verapamil ext-rel hcl
Requirements/Limits
DIGITALIS GLYCOSIDES
digoxin
LANOXIN
DIURETICS
amiloride & hydrochlorothiazide
amiloride hcl
bumetanide
chlorthalidone
furosemide
hydrochlorothiazide
indapamide
metolazone
spironolactone & hydrochlorothiazide
torsemide
triamterene & hydrochlorothiazide
MISCELLANEOUS
hydralazine hcl
methyldopa
midodrine hcl
NEPRILYSIN INHIBITOR/ANGIOTENSIN II RECEPTOR ANTAGONIST
COMBINATIONS
ENTRESTO
NITRATE/VASODILATOR COMBINATIONS
BIDIL
NITRATES, ORAL
isosorbide dinitrate
isosorbide mononitrate
nitroglycerin CPCR
NITRATES, SUBLINGUAL/TRANSLINGUAL
NITROSTAT
NITRATES, TRANSDERMAL
nitroglycerin PT24
PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR
ANTAGONIST
LETAIRIS
TRACLEER
PA; SP
PA; SP
PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE
INHIBITOR
sildenafil citrate (pulmonary hypertension)
PA; SP
PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN RECEPTOR
AGONIST
UPTRAVI
PA; SP
ST - Step
Therapy
Pharmacy
15
Drug Name
Requirements/Limits
PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN
VASODILATORS
epoprostenol sodium
REMODULIN
TYVASO STARTER
VENTAVIS
PA;
PA;
PA;
PA;
CENTRAL NERVOUS SYSTEM
ANTIANXIETY, BENZODIAZEPINES
alprazolam 2mg
alprazolam .25mg, .5mg, 1mg
alprazolam orally disintegrating tab
chlordiazepoxide hcl
clonazepam
diazepam SOLN
diazepam
0.5 mg
0.25 mg
1 mg
2 mg
TABS
lorazepam
lorazepam 2mg/ml
oxazepam
SP
SP
SP
SP
ST; AGE (65 and over)
QL (1200 ml per 30 days),
ST; AGE (65 and older)
QL (120 tabs per 30 days),
ST; AGE (65 and older)
ANTIANXIETY, MISCELLANEOUS
buspirone hcl
clomipramine hcl 25mg
fluvoxamine maleate
AGE (0-64) QL 150 per 30
days, AGE (65 and over) QL
90 per 30 days
AGE (0-64) QL 90 per 30
60 per 30 days
ANTICONVULSANTS
carbamazepine
carbamazepine ext-rel
diazepam rectal gel
DILANTIN
DILANTIN INFATABS
divalproex sodium
ethosuximide
gabapentin CAPS 100mg
ST - Step
Therapy
Pharmacy
16
Drug Name
gabapentin TABS 600mg
gabapentin TABS 800mg
gabapentin oral solution 250 mg/5ml
lamotrigine
levetiracetam
oxcarbazepine
phenobarbital
phenytoin
phenytoin sodium extended
primidone
SABRIL
TEGRETOL
TEGRETOL-XR
tiagabine hcl
topiramate
valproate sodium
valproic acid
ZARONTIN
zonisamide
Requirements/Limits
PA; SP
PA
ANTIDEMENTIA
donepezil hydrochloride
galantamine hydrobromide
memantine hcl tab 5 mg
memantine hcl tab 10 mg
NAMENDA SOL 10MG/5ML
NAMENDA TITRATION PAK
rivastigmine
rivastigmine tartrate
ST
QL (60 tabs per 30 days), ST
QL (300 ml per 30 days), ST
ST
PA
PA
ANTIDEPRESSANTS, MAOIS
MARPLAN
phenelzine sulfate
tranylcypromine sulfate
ANTIDEPRESSANTS, MISCELLANEOUS
bupropion hcl
mirtazapine
trazodone hcl
ANTIDEPRESSANTS, SNRIS
duloxetine hcl
venlafaxine hcl
venlafaxine hcl ext-rel CP24
venlafaxine hcl ext-rel TB24
PA
ANTIDEPRESSANTS, SSRIS
ST - Step
Therapy
Pharmacy
17
Drug Name
citalopram hydrobromide
escitalopram oxalate SOLN
escitalopram oxalate TABS
fluoxetine hcl
paroxetine hcl
PAXIL SUSPENSION 10MG/5ML
sertraline hcl
ANTIDEPRESSANTS, TCAS
amitriptyline hcl
amitriptyline hcl
10mg
25mg
amitriptyline hcl
50mg
amitriptyline hcl
75mg
amitriptyline hcl
100mg, 150mg
desipramine hcl 10mg, 25mg
desipramine hcl 50mg, 75mg
desipramine hcl 100mg
desipramine hcl 150mg
doxepin hcl CAPS 10mg, 25mg, 50mg
doxepin hcl CAPS 75mg
doxepin hcl CONC
imipramine hcl 10mg, 25mg
Requirements/Limits
AGE (0-64) QL 90 per 30
60 per 30 days
AGE (0-64) QL 60 per 30
30 per 30 days
AGE (0-64)
AGE (0-64)
AGE (0-64) QL 90 per 30
30 per 30 days
AGE (0-64) QL 60 per 30
30 per 30 days
AGE (0-64) QL 90 per 30
30 per 30 days
AGE (0-64) QL 60 per 30
30 per 30 days
AGE (0-64) QL 900ml per 30
450ml per 30 days
ST - Step
Therapy
Pharmacy
18
Drug Name
imipramine hcl 50mg
nortriptyline hcl
nortriptyline hcl
CAPS 10mg, 25mg
CAPS 50mg
nortriptyline hcl
CAPS 75mg
nortriptyline hcl
SOLN
Requirements/Limits
AGE (0-64) QL 120 per 30
60 per 30 days
AGE (0-64) QL 90 per 30
60 per 30 days
AGE (0-64) QL 60 per 30
30 per 30 days
ANTIPARKINSONIAN AGENTS
amantadine hcl
benztropine mesylate
bromocriptine mesylate
carbidopa-levodopa
carbidopa-levodopa-entacapone
entacapone
pramipexole dihydrochloride
ropinirole hydrochloride
selegiline hcl
trihexyphenidyl hcl
ANTIPSYCHOTICS, ATYPICALS
aripiprazole 2mg
aripiprazole 5mg, 10mg, 15mg, 20mg, 30mg
aripiprazole oral solution 1 mg/ml
QL (750ML ml per 30 days);
AGE: NOT COVERED OVER
11 YEARS OF AGE
ARISTADA
QL (1 kit / 30 days); AGE
LIMIT: NOT COVERED LESS
THAN 18 YEARS OF AGE
(SSI- NOT COVERED FOR
LESS THAN 21 YEARS OF
AGE)
clozapine TABS 25mg
clozapine TABS 50mg
clozapine TABS 100mg
clozapine TABS 200mg
clozapine TBDP 12.5mg
AGE: NOT COVERED UNDER
13 YEARS OF AGE
clozapine TBDP 25mg
13 YEARS OF AGE
ST - Step
19
Therapy
Pharmacy
Drug Name
clozapine TBDP 100mg
clozapine
TBDP 150mg
clozapine
TBDP 200mg
CLOZARIL 25mg
CLOZARIL 100mg
INVEGA TRINZA
NUPLAZID
olanzapine 2.5mg
olanzapine 5mg
olanzapine 7.5mg, 10mg
olanzapine 15mg, 20mg
olanzapine orally disintegrating tab
paliperidone 1.5mg, 3mg, 9mg
paliperidone 6mg
quetiapine fumarate 25mg
quetiapine fumarate 300mg, 400mg
RISPERDAL CONSTA
risperidone
SOLN
risperidone
TABS 1mg
Requirements/Limits
13 YEARS OF AGE
13 YEARS OF AGE
13 YEARS OF AGE
QL (1 ml per 90 days), ST;
AGE)
PA; SP
AGE)
QL (480 ML ml per 30 days);
AGE: LESS THAN 18 YEARS
OF AGE MAX DOSE OF 6ML
PER DAY
QL (480 tabs tabs per 30
days); AGE: LESS THAN 18
YEARS OF AGE MAX DOSE OF
6 PER DAY
ST - Step
Therapy
Pharmacy
20
Drug Name
risperidone TABS 2mg
risperidone
TABS 3mg
risperidone
TABS 4mg
risperidone
TABS .5mg
risperidone
TABS .25mg
risperidone
TBDP 1mg
risperidone
TBDP 2mg
risperidone
TBDP 3mg
risperidone
TBDP 4mg
risperidone
TBDP .5mg
risperidone
TBDP .25mg
ziprasidone hcl
ziprasidone hcl
ziprasidone hcl
20mg
40mg
60mg, 80mg
Requirements/Limits
3 PER DAY
2 PER DAY
1 PER DAY
12 PER DAY
24 PER DAY
OF AGE MAX DOSE OF 6 PER
DAY
DAY
DAY
DAY
OF AGE MAX DOSE OF 12
PER DAY
OF AGE MAX DOSE OF 24
PER DAY
ST - Step
Therapy
Pharmacy
21
Drug Name
ZYPREXA RELPREVV
ZYPREXA RELPREVV
210mg, 300mg
405mg
ANTIPSYCHOTICS, MISCELLANEOUS
chlorpromazine hcl 10mg
fluphenazine decanoate
fluphenazine hcl 1mg
fluphenazine hcl
2.5mg
fluphenazine hcl
5mg
fluphenazine hcl
10mg
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
1mg
2mg
5mg
10mg
20mg
.5mg
Requirements/Limits
AGE)
AGE)
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
QL (5ML ml per 30 days)
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
ST - Step
Therapy
Pharmacy
22
Drug Name
haloperidol decanoate
haloperidol lactate
perphenazine 2mg
perphenazine
4mg
perphenazine
8mg
perphenazine
16mg
thioridazine hcl
10mg
thioridazine hcl
25mg
thioridazine hcl
50mg
thioridazine hcl
100mg
thiothixene
1mg
thiothixene
2mg
thiothixene
5mg
thiothixene
10mg
trifluoperazine hcl
1mg
trifluoperazine hcl
2mg
trifluoperazine hcl
5mg
Requirements/Limits
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
ST - Step
Therapy
Pharmacy
23
Drug Name
trifluoperazine hcl
10mg
Requirements/Limits
65 YEARS OF AGE
ATTENTION DEFICIT HYPERACTIVITY DISORDER
amphetamine-dextroamphetamine cap
sustained-rel 24hr 5 mg
amphetamine-dextroamphetamine tab 5 mg
amphetamine-dextroamphetamine tab 7.5 mg
amphetamine-dextroamphetamine tab 12.5 mg
dexmethylphenidate hcl 2.5mg, 5mg
NOT COVERED LESS THAN 3
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
ST - Step
Therapy
Pharmacy
24
Drug Name
dexmethylphenidate hcl 10mg
dextroamphetamine sulfate cap sustained-rel 24hr
5 mg
10 mg
15 mg
dextroamphetamine sulfate tab 5 mg
dextroamphetamine sulfate tab 10 mg
guanfacine hcl (adhd)
methylphenidate hcl
methylphenidate hcl cap controlled release 10 mg
methylphenidate hcl cap sustained-rel 24hr 20 mg
methylphenidate hcl cap sustained-rel 24hr 30 mg
Requirements/Limits
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
ST
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
YEARS OF AGE
ST - Step
Therapy
Pharmacy
25
Drug Name
Requirements/Limits
methylphenidate hcl cap sustained-rel 24hr 40 mg QL (30 caps per 30 days);
YEARS OF AGE
methylphenidate hcl solution 5 mg/5ml
YEARS OF AGE
YEARS OF AGE
methylphenidate hcl tab controlled-release TB24 QL (30 tabs per 30 days);
27mg, 54mg
YEARS OF AGE
methylphenidate hcl tab controlled-release TB24 QL (60 tabs per 30 days);
36mg
YEARS OF AGE
methylphenidate hcl tab controlled-release TBCR QL (90 tabs per 30 days);
10mg, 20mg
YEARS OF AGE
methylphenidate hcl tab controlled-release TBCR QL (30 tabs per 30 days);
18mg
YEARS OF AGE
methylphenidate tab 20mg ext-rel
YEARS OF AGE
STRATTERA 10mg, 18mg, 25mg
ST; NOT COVERED LESS
THAN 6 YEARS OF AGE
STRATTERA 40mg, 60mg, 80mg, 100mg
ST; NOT COVERED LESS
THAN 6 YEARS OF AGE
FIBROMYALGIA
LYRICA 25mg, 50mg, 75mg, 100mg, 150mg,
200mg
LYRICA 225mg, 300mg
LYRICA SOLUTION 20MG/ML
HUNTINGTON'S DISEASE AGENTS
tetrabenazine
HYPNOTICS: BENZODIAZEPINES
temazepam
HYPNOTICS: NON-BENZODIAZEPINES
diphenhydramine hcl (sleep)
diphenhydramine hcl (sleep)
zolpidem tartrate
zolpidem tartrate ext-rel
CAPS
TABS
QL (90 caps per 30 days), PA
QL (900 ml per 30 days), PA
PA; SP
QL
QL
QL
QL
MIGRAINE, ERGOTAMINE DERIVATIVES
CAFERGOT
ST - Step
Therapy
Pharmacy
26
Drug Name
Requirements/Limits
dihydroergotamine mesylate inj 1 mg/ml
dihydroergotamine mesylate nasal spray 4 mg/ml QL (8 ml per 30 days)
MIGRAINE, SELECTIVE SEROTONIN AGONISTS
naratriptan hcl
rizatriptan benzoate
sumatriptan spray 5mg/act
sumatriptan spray 20mg/act
sumatriptan succinate SOAJ; SOCT; SOSY
sumatriptan succinate SOLN
sumatriptan succinate TABS
zolmitriptan
QL
QL
QL
QL
QL
QL
QL
QL
(9 tabs per 30 days), ST
(24 ml per 30 days)
(12 units per 30 days)
(12 units per 30 days)
(12 ml per 30 days)
MISCELLANEOUS
riluzole
MOOD STABILIZERS
lithium carbonate
CAPS 150mg
lithium carbonate
CAPS 300mg
lithium carbonate
CAPS 600mg
lithium carbonate
TBCR 300mg
lithium carbonate
TBCR 450mg
LITHIUM ORAL SOLUTION 8 MEQ/5ML
MULTIPLE SCLEROSIS
AMPYRA
AUBAGIO
AVONEX
AVONEX PEN
COPAXONE INJ 40MG/ML
EXTAVIA
GILENYA
glatopa inj 20mg/ml
REBIF
REBIF REBIDOSE TITRATION
TECFIDERA
TECFIDERA STARTER PACK
12 YEARS OF AGE
12 YEARS OF AGE
12 YEARS OF AGE
12 YEARS OF AGE
12 YEARS OF AGE
QL (1200 ML ml per 30 days)
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
MUSCULOSKELETAL THERAPY AGENTS
baclofen
ST - Step
Therapy
Pharmacy
27
Drug Name
carisoprodol
chlorzoxazone
cyclobenzaprine hcl
dantrolene sodium
methocarbamol
orphenadrine citrate
orphenadrine w/ aspirin & caffeine tab
tizanidine hcl
Requirements/Limits
PA; HRM
MYASTHENIA GRAVIS
pyridostigmine bromide
NARCOLEPSY/CATAPLEXY
modafinil
NUVIGIL
PA
PSYCHOTHERAPEUTIC-MISC, ALCOHOL DETERRENTS
acamprosate calcium
disulfiram
VIVITROL
SP; AGE: Not covered less
than 18 years of age
PSYCHOTHERAPEUTIC-MISC, OPIOID ANTAGONIST
naloxone hcl
naltrexone hcl
AGE: Not covered less than
18 years of age
PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONIST/OPIOID
ANTAGONIST COMBINATIONS
buprenorphine hcl-naloxone hcl sublingual tab 2-0.5QL (90 tabs per 30 days)
mg
buprenorphine hcl-naloxone hcl sublingual tab 8-2 QL (90 tabs per 30 days)
mg
PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS
buprenorphine hcl 2mg
buprenorphine hcl 8mg
QL (3 tabs per day, max 3
days)
QL (2 tabs per day, max 3
days)
PSYCHOTHERAPEUTIC-MISC, PSEUDOBULBAR AFFECT
NUEDEXTA
PA
PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS
bupropion hcl (smoking deterrent)
CHANTIX
ST - Step
Therapy
Pharmacy
28
Drug Name
nicotine polacrilex gum
nicotine polacrilex lozenge
nicotine transdermal patch
NICOTROL INHALER
NICOTROL NS
ENDOCRINE AND METABOLIC
ANDROGENS
testosterone cypionate
testosterone enanthate
testosterone gel
Requirements/Limits
QL (720 pieces per 30 days);
OTC ONLY; AGE: NOT
COVERED LESS THAN 13
YEARS OF AGE
QL (600 pieces per 30 days);
QL (30 patches per 30 days);
OTC ONLY; AGE: NOT
COVERED LESS THAN 13
YEARS OF AGE
QL (1200 ML ml per days);
18 YEARS OF AGE
PA
PA
PA
ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITOR
acarbose
acarbose
acarbose
25mg
50mg
100mg
ANTIDIABETICS, AMYLIN ANALOGS
SYMLINPEN 60
SYMLINPEN 120
QL (3 pens (4.5ML) per 30
days), PA
QL (4 pens (10.8ML) per 30
days), PA
ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS
glipizide-metformin hcl tab 2.5-250 mg
glipizide-metformin hcl tab 5-500 mg
glyburide-metformin tab 1.25-250 mg
glyburide-metformin tab 2.5-500 mg
glyburide-metformin tab 5-500 mg
ANTIDIABETICS, BIGUANIDES
metformin
metformin
metformin
metformin
hcl
hcl
hcl
tab
500mg
850mg
1000mg
500mg ext-rel
QL (240
QL (120
QL (120
QL (240
HRM
QL (120
HRM
QL (120
HRM
QL
QL
QL
QL
tabs
tabs
tabs
tabs
per
per
per
per
30
30
30
30
days)
days)
days)
days);
tabs per 30 days);
tabs per 30 days);
ST - Step
Therapy
Pharmacy
29
Drug Name
metformin tab 750mg ext-rel
Requirements/Limits
ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)
INHIBITOR/BIGUANIDE COMBINATIONS
JANUMET
JANUMET XR TAB 50-500MG
JANUMET XR TAB 50-1000
JANUMET XR TAB 100-1000
JENTADUETO
QL
QL
QL
QL
QL
(60
(60
(60
(30
(60
tabs
tabs
tabs
tabs
tabs
per
per
per
per
per
30
30
30
30
30
days)
days)
days)
days)
days)
ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
JANUVIA
25mg
JANUVIA 50mg
JANUVIA 100mg
TRADJENTA
QL
ST
QL
QL
QL
(120 tabs per 30 days),
ANTIDIABETICS, INCRETIN MIMETIC AGENTS
TANZEUM
VICTOZA
QL (4.5 ML per 30 days), ST
QL (9 ML per 30 days), ST
ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION
pioglitazone hcl-metformin hcl
ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBO
pioglitazone hcl-glimepiride
ANTIDIABETICS, INSULIN SENSITIZERS
pioglitazone hcl 15mg
pioglitazone hcl 30mg, 45mg
ANTIDIABETICS, INSULINS
APIDRA
APIDRA SOLOSTAR
BASAGLAR INJ
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50 KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN
HUMULIN 70/30
HUMULIN 70/30 KWIKPEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN R
HUMULIN R INJ U-500 VIAL
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
QL
QL
QL
QL
QL
QL
QL
QL
QL
(50
(50
(50
(50
(50
(50
(50
(50
(50
ml per 30 days)
units per 30 days)
ml per 30 days)
units per 30 days)
ml per 30 days)
ml per 30 days)
ml per 30 days)
ml per 30 days)
ml per 30 days)
ST - Step
Therapy
Pharmacy
30
Drug Name
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILL
NOVOLOG PENFILL
TRESIBA FLEXTOUCH
ANTIDIABETICS, MEGLITINIDE
nateglinide 60mg
nateglinide 120mg
repaglinide 1mg
repaglinide 2mg
repaglinide 0.5 mg
Requirements/Limits
QL
QL
QL
QL
QL
ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)
INHIBITOR/BIGUANIDE COMBINATIONS
INVOKAMET
QL (30 tabs / 30 days), ST
ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)
INHIBITORS
INVOKANA
QL (30 tabs / 30 days), ST
ANTIDIABETICS, SULFONYLUREAS
glimepiride 1mg
glimepiride 2mg
glimepiride 4mg
glipizide 5mg
glipizide 10mg
glipizide ext-rel tab 2.5mg
glipizide ext-rel tab 5mg
glipizide ext-rel tab 10mg
glyburide 1.25mg
glyburide
2.5mg
glyburide
5mg
glyburide micronized 1.5mg
glyburide micronized 3mg
glyburide micronized 6mg
ANTIDIABETICS, SUPPLIES
ALCOHOL PREPS
ALCOHOL SWABS
BAYER BREEZE 2 TEST DISC
BAYER CONTOUR BLOOD GLUCOSE
BAYER CONTOUR NEXT BLOOD
PA; HRM
PA; HRM
PA; HRM
PA; HRM
PA; HRM
QL (60 tabs per days), PA;
HRM
OTC ONLY
QL (300 strips per 30 days)
ST - Step
Therapy
Pharmacy
31
Drug Name
Requirements/Limits
BD INSULIN SYRINGE ULTRAF
QL (200 units / 20 days)
BD INSULIN SYRINGE/U-100/
BD PEN NEEDLE/MINI/ULTRAF
BD PEN NEEDLE/NANO/ULTRA
BD PEN NEEDLE/ULTRAFINE/2
BD PEN NEEDLES SHORT/ULTR
BLOOD GLUCOSE CALIBRATION - LIQUID
BLOOD GLUCOSE CALIBRATION - LIQUID - HIGH QL (1 ml per 15 days)
BLOOD GLUCOSE CALIBRATION - LIQUID - LOW QL (1 unit per 15 days)
BLOOD GLUCOSE CALIBRATION - LIQUID - NORMALQL (1 unit per 15 days)
CLINITEST
INSULIN INFUSION DISPOSABLE PUMP KIT
PA, ST
INSULIN INFUSION DISPOSABLE PUMP SUPPLIES PA, ST
INSULIN INFUSION PUMP - ACCESSORIES
QL (1 units per 999 days), ST
INSULIN INFUSION PUMP - DEVICE DEVI
QL (1 device per 999 days),
PA, ST
INSULIN INFUSION PUMP - DEVICE MISC
QL (1 units per 999 days),
PA, ST
INSULIN INFUSION PUMP - KIT
QL (1 kit per 999 days), ST
INSULIN INFUSION PUMP SUPPLIES
PA, ST
KETO-DIASTIX
QL (100 strips per 30 days);
OTC ONLY
LANCET DEVICES
QL (2 devicesper 20 days);
OTC ONLY
lancets
OTC ONLY
LANCETS KIT
QL (2 kit per 20 days); OTC
ONLY
LANCETS MISC.
OTC ONLY
NOVOPEN 3 PENMATE
PTS PANELS KETONE TEST
URINE GLUCOSE MONITORING SUPPLIES
V-GO
PA, ST
ANTIDOTES
VISTOGARD
CALCIUM RECEPTOR ANTAGONISTS
SENSIPAR
PA; SP
CALCIUM REGULATORS, BISPHOSPHONATES
alendronate sodium
zoledronic acid
PA; SP
CALCIUM REGULATORS, CALCITONINS
calcitonin (salmon)
CALCIUM REGULATORS, RANK LIGAND INHIBITORS
PROLIA
PA; SP
ST - Step
Therapy
Pharmacy
32
Drug Name
XGEVA
Requirements/Limits
PA; SP
CONTRACEPTIVES, BIPHASIC
desogestrel-ethinyl estradiol (biphasic)
CONTRACEPTIVES, EMERGENCY CONTRACEPTION
ELLA
levonorgestrel tab 1.5 mg
CONTRACEPTIVES, EXTENDED CYCLE
levonorgestrel-ethinyl estradiol (91-day)
CONTRACEPTIVES, IMPLANT
NEXPLANON
QL (1 dose per Lifetime); SP;
FEMALE ONLY; AGE:
COVERED BETWEEN AGE
18-65 YEARS OF AGE
CONTRACEPTIVES, INJECTABLE
medroxyprogesterone acetate
SUSP
CONTRACEPTIVES, MISCELLANEOUS
CONDOMS - FEMALE
CONDOMS - MALE
DIAPHRAGM DPRH
DIAPHRAGM KIT
NONOXYNOL-9
PARAGARD INTRAUTERINE COP
OTC ONLY
QL (1 device per 365 days)
QL (1 kit per 365 days)
QL (108 gm per 30 days);
OTC ONLY
QL (1 unit per Lifetime); SP;
FEMALE ONLY; AGE:
COVERED BETWEEN AGE
12-65 YEARS OF AGE
CONTRACEPTIVES, MONOPHASIC
desogestrel & ethinyl estradiol
drospirenone-ethinyl estradiol
ethynodiol diacetate & ethinyl estradiol
levonorgestrel & ethinyl estradiol
norethindrone & ethinyl estradiol tab
norethindrone & mestranol
norethindrone ace & ethinyl estradiol
norethindrone ace & ethinyl estradiol-fe
norgestimate-ethinyl estradiol
norgestrel & ethinyl estradiol
CONTRACEPTIVES, PROGESTIN INTRAUTERINE DEVICE
MIRENA
FEMALE ONLY; AGE:
COVERED BETWEEN AGE
12-65 YEARS OF AGE
ST - Step
Therapy
Pharmacy
33
Drug Name
SKYLA
Requirements/Limits
FEMALE ONLY; AGE:
COVERED BETWEEN AGE
12-65 YEARS OF AGE
CONTRACEPTIVES, PROGESTIN ONLY
norethindrone
CONTRACEPTIVES, TRANSDERMAL
norelgestromin-ethinyl estradiol
CONTRACEPTIVES, TRIPHASIC
desogestrel-ethinyl estradiol (triphasic)
levonorgestrel-ethinyl estradiol tab (triphasic)
norethindrone-ethinyl estradiol (triphasic)
norgestimate-ethinyl estradiol (triphasic)
norgestimate-ethinyl estradiol tab
0.18-25/0.215-25/0.25-25 mg-mcg
CONTRACEPTIVES, VAGINAL
NUVARING
ENDOMETRIOSIS
danazol
SYNAREL
ESTROGEN/PROGESTIN, ORAL
estradiol & norethindrone acetate
norethindrone acetate-ethinyl estradiol
ESTROGEN/PROGESTIN, TRANSDERMAL
COMBIPATCH
ESTROGENS, ORAL
estradiol TABS 1mg
estradiol TABS 2mg
estradiol TABS .5mg
estropipate
PREMARIN
PREMARIN
PREMARIN
PREMARIN
PREMARIN
1.25mg
.3mg
.9mg
.45mg
.625mg
ESTROGENS, TRANSDERMAL
estradiol PTTW
estradiol PTWK
PA; HRM
PA; HRM
PA; HRM
PA; HRM
PA; HRM
ESTROGENS, VAGINAL
ESTRACE
FEMRING
ST - Step
Therapy
Pharmacy
34
Drug Name
VAGIFEM
Requirements/Limits
GLUCOCORTICOIDS
dexamethasone elixir
dexamethasone soln
dexamethasone tab
fludrocortisone acetate
hydrocortisone TABS
methylprednisolone
prednisolone
prednisolone orally disintegrating tab
prednisolone sodium phosphate
prednisone
GLUCOSE ELEVATING AGENT
dextrose (diabetic use)
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
GLUCOSE
RELION GLUCOSE
HUMAN GROWTH HORMONES
NORDITROPIN FLEXPRO
ZORBTIVE
OTC ONLY
OTC ONLY
OTC ONLY
PA; SP
PA; SP
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS
calcitriol
doxercalciferol
INSULIN-LIKE GROWTH FACTOR
INCRELEX
LYSOSOMAL STORAGE DISORDERS
ALDURAZYME
CEREZYME
ELAPRASE
FABRAZYME
LUMIZYME
NAGLAZYME
VPRIV
PA; SP
PA;
PA;
PA;
PA;
PA;
PA;
PA;
SP
SP
SP
SP
SP
SP
SP
MISCELLANEOUS
cabergoline
H.P. ACTHAR
LUPRON DEPOT-PED
methylergonovine maleate
octreotide acetate
SOMATULINE DEPOT
PA; SP
PA; SP
PA; SP
PA; SP
ST - Step
Therapy
Pharmacy
35
Drug Name
SOMAVERT
SUPPRELIN LA
THYROGEN
Requirements/Limits
PA; SP
PA; SP
PA; SP
PHENYLKETONURIA TREATMENT AGENTS
KUVAN
PHOSPHATE BINDER AGENTS
AURYXIA
calcium acetate (phosphate binder)
RENVELA PAK
sevelamer carbonate
PROGESTINS, INJECTABLE
MAKENA
PROGESTINS, ORAL
medroxyprogesterone acetate
norethindrone acetate
progesterone micronized cap
PA; SP
ST
ST
ST
PA; SP
TABS
PROGESTINS, VAGINAL
CRINONE
Female Only
SELECTIVE ESTROGEN RECEPTOR MODULATOR
OSPHENA
THYROID AGENTS, ANTITHYROID AGENTS
methimazole
propylthiouracil
THYROID SUPPLEMENTS
ARMOUR THYROID
levothyroxine sodium
liothyronine sodium
SYNTHROID
thyroid
VASOPRESSIN RECEPTOR ANTAGONISTS
SAMSCA
15mg
SAMSCA
30mg
VASOPRESSINS
desmopressin acetate spray
desmopressin acetate tab
desmopressin sol
STIMATE
GASTROINTESTINAL
ANTACIDS
alum & mag hydrox-simethicone
PA; SP
PA; SP
PA
PA
PA
PA; SP
CHEW
OTC ONLY
alum & mag hydrox-simethicone SUSP
OTC ONLY
ST - Step
36
Therapy
Pharmacy
Drug Name
Requirements/Limits
aluminum hydroxide-magnesium carbonate chew QL (500 tabs per 30 days);
tab 160-105 mg
OTC ONLY
aluminum hydroxide-magnesium carbonate susp QL (1775 ml per 30 days);
95-358 mg/15ml
OTC ONLY
aluminum hydroxide-magnesium trisilicate chew QL (500 tabs per 30 days);
tab 80-20 mg
OTC ONLY
calcium carbonate CHEW 400mg, 420mg, 500mg,QL (200 tabs per 30 days);
600mg, 750mg, 1000mg
OTC ONLY
sodium bicarbonate
OTC ONLY
ANTIDIARRHEALS
bismuth subsalicylate
CHEW
SUSP 262mg/15ml
SUSP 525mg/15ml
TABS
diphenoxylate w/ atropine
loperamide hcl CAPS
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
loperamide hcl LIQD
loperamide hcl TABS
ANTIEMETICS
dronabinol
EMEND
EMEND CAP
granisetron hcl
meclizine hcl
metoclopramide hcl
ondansetron hcl SOLN
ondansetron hcl TABS 4mg, 8mg
ondansetron hcl TABS 24mg
ondansetron orally disintegrating tab
prochlorperazine
prochlorperazine maleate
5mg
prochlorperazine maleate
10mg
PA
PA
Rx ONLY
QL (60 supp units per 30
days); AGE: NOT COVERED
OVER 65 YEARS OF AGE
65 YEARS OF AGE
65 YEARS OF AGE
promethazine hcl SUPP
ST - Step
Therapy
Pharmacy
37
Drug Name
promethazine hcl SYRP; TABS
trimethobenzamide hcl
Requirements/Limits
PA; HRM
ANTISPASMODICS
chlordiazepoxide hcl-clidinium bromide
CUVPOSA
dicyclomine hcl
DONNATAL
glycopyrrolate
hyoscyamine sulfate
PA
CHOLELITHOLYTICS
ursodiol
H2-RECEPTOR ANTAGONISTS
cimetidine hcl soln 300 mg/5ml
cimetidine tab 200 mg
cimetidine tab 800mg
famotidine SUSR
famotidine TABS
nizatidine
ranitidine hcl
ranitidine hcl
ranitidine hcl
CAPS
SYRP
TABS 75mg, 150mg
ranitidine hcl
TABS 300mg
QL (60 tabs per 30 days); Rx
ONLY
OTC ONLY
INFLAMMATORY BOWEL DISEASE, ORAL AGENTS
APRISO
balsalazide disodium
budesonide
sulfasalazine
INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS
hydrocortisone (intrarectal)
mesalamine
mesalamine w/ cleanser
IRRITABLE BOWEL SYNDROME WITH CONSTIPATION
LINZESS
LAXATIVES/STOOL SOFTENERS
bisacodyl
bisacodyl tab delayed release 5 mg
calcium polycarbophil
OTC ONLY
OTC ONLY
OTC ONLY
ST - Step
Therapy
Pharmacy
38
Drug Name
docusate calcium cap 240 mg
docusate sod cap 100mg
docusate sodium
CAPS 50mg, 100mg
docusate sodium
CAPS 250mg
docusate sodium
LIQD
docusate sodium
SYRP
KRISTALOSE
lactulose
magnesium hydroxide
methylcellulose
Requirements/Limits
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
peg 3350-potassium chloride-sod bicarbonate-sod
chloride
polyethylene glycol 3350 PACK
QL (30 packets per 30 days)
polyethylene glycol 3350 POWD
sennosides CHEW; TABS
OTC ONLY
sennosides LIQD
OTC ONLY
sennosides-docusate sodium
OTC ONLY
SUPREP BOWEL PREP
MISCELLANEOUS
CARAFATE SUS 1GM/10ML
KEPIVANCE
lactulose (encephalopathy)
loperamide-simethicone
simethicone
CAPS 125mg
simethicone
CAPS 180mg
simethicone
CHEW 80mg
simethicone
CHEW 125mg
simethicone
LIQD
simethicone
SUSP
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
ST - Step
Therapy
Pharmacy
39
Drug Name
sucralfate tab 1 gm
Requirements/Limits
PANCREATIC ENZYMES
CREON
ZENPEP
PROSTAGLANDINS
misoprostol
PROTON PUMP INHIBITORS (PPI)
esomeprazole magnesium
QL (30 caps per 30 days; 90
days per year); OTC ONLY
lansoprazole cap delayed release 15 mg
QL (60 caps per 30 days,
max 90 days per year); OTC
ONLY
NEXIUM 24HR
QL (30 tabs per 30 days; 90
days tabs per year); OTC
only
NEXIUM GRANULES 2.5 MG, 5MG AND 10MG
QL (90 days per year); AGE
DELAYED RELEASE
(only covered in less than 1
years of age)
omeprazole cap delayed release
QL (30 caps per 30 days,
max 90 days per year)
omeprazole magnesium cap delayed release 20.6 QL (30 caps per 30 days,
mg (20 mg base equiv)
max 90 days per year); OTC
ONLY
omeprazole-sodium bicarbonate
OTC ONLY
SALIVA STIMULANTS
pilocarpine hcl (oral)
STEROIDS, RECTAL
hydrocortisone (rectal)
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl
finasteride
tamsulosin hcl
MISCELLANEOUS
acetic acid vaginal
bethanechol chloride
CYSTAGON
ELMIRON
phenazopyridine hcl
potassium citrate (alkalinizer)
MALE ONLY
OTC ONLY
PA; SP
URINARY ANTISPASMODICS
oxybutynin chloride
oxybutynin chloride tab sustained-rel 24hr 5 mg
ST - Step
Therapy
Pharmacy
40
Drug Name
Requirements/Limits
OXYTROL FOR WOMEN
OTC only; GENDER; AGE:
NOT COVERED LESS THAN
19 YEARS OF AGE
trospium chloride
trospium chloride cap sustained-rel 24hr 60 mg
ST
VAGINAL ANTI-INFECTIVES
CLEOCIN SUP 100MG
clotrimazole vaginal
QL (45 gm per 30 days); OTC
ONLY
metronidazole vaginal
miconazole nitrate vaginal
KIT
miconazole nitrate vaginal
SUPP 100mg
miconazole nitrate vaginal SUPP 200mg
miconazole nitrate vaginal cream
terconazole vaginal
QL (1 kit per 30 days); OTC
ONLY
OTC ONLY
ONLY
HEMATOLOGIC
ANTICOAGULANTS, INJECTABLE
enoxaparin sodium
fondaparinux sodium
heparin sodium
heparin sodium (porcine)
ANTICOAGULANTS, ORAL
COUMADIN
ELIQUIS
warfarin sodium
XARELTO
HEMATOPOIETIC GROWTH FACTORS
ARANESP ALBUMIN FREE
EPOGEN
LEUKINE INJ
NEULASTA
NEUPOGEN
HEREDITARY ANGIOEDEMA AGENTS
CINRYZE
PA;
PA;
PA;
PA;
PA;
SP
SP
SP
SP
SP
PA; SP
IDIOPATHIC THROMBOCYTOPENIC PURPURA
NPLATE
PROMACTA
PA; SP
PA; SP
MISCELLANEOUS
cilostazol
DESFERAL
PA; SP
ST - Step
Therapy
Pharmacy
41
Drug Name
EXJADE
FERRIPROX
Requirements/Limits
PA; SP
PA; SP
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS
SOLIRIS
PA; SP
PLATELET AGGREGATION INHIBITORS
aspirin
CHEW
aspirin
TABS 81mg
aspirin
TABS 325mg
aspirin
TABS 500mg
aspirin enteric coated 81mg
BRILINTA
clopidogrel bisulfate
dipyridamole
EFFIENT
ZONTIVITY
QL (200 tabs
OTC ONLY
QL (180 tabs
OTC ONLY
QL (500 tabs
OTC ONLY
QL (200 tabs
OTC ONLY
QL (180 tabs
OTC ONLY
QL (500 tabs
OTC ONLY
QL (200 tabs
OTC ONLY
per 30 days);
per 30 days);
per 30 days);
per 30 days);
per 30 days);
per 30 days);
per 30 days);
PLATELET SYNTHESIS INHIBITOR
anagrelide hcl
STEM CELL MOBILIZERS
MOZOBIL
IMMUNOLOGIC AGENTS
BIOLOGIC DISEASE-MODIFYING AGENTS
ENBREL
HUMIRA
PA; SP
PA; SP
PA; SP
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS)
hydroxychloroquine sulfate
leflunomide
IMMUNE GLOBULINS
RHO D IMMUNE GLOBULIN
WINRHO SDF
PA; SP
PA; SP
IMMUNOMODULATORS, INTERFERONS
ACTIMMUNE
PA; SP
ALFERON N
PA; SP
INTRON A
PA; SP
INTRON A W/DILUENT
PA; SP
PEG-INTRON
PA; SP
PEG-INTRON REDIPEN
PA; SP
ST - Step
Therapy
Pharmacy
42
Drug Name
PEG-INTRON REDIPEN PAK 4
PEGASYS
PEGASYS PROCLICK
SYLATRON
IMMUNOMODULATORS, MISCELLANEOUS
ARCALYST
ILARIS
Requirements/Limits
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
PA; SP
IMMUNOSUPPRESSANTS, ANTIMETABOLITES
AZASAN
azathioprine
mycophenolate mofetil
IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS
cyclosporine
cyclosporine modified (for microemulsion)
NEORAL
SANDIMMUNE
tacrolimus
IMMUNOSUPPRESSANTS, MISCELLANEOUS
BENLYSTA
PA; SP
IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE
sirolimus
MONOCLONAL ANTIBODIES
SYNAGIS
VACCINES
ADACEL
AFLURIA PF 2016-2017
BEXSERO
BOOSTRIX
FLUARIX QUADRIVALENT 2016
PA; SP
AVAILABLE THROUGH
VACCINE NETWORK OR
MEDICAL BENEFIT ONLY
MEMBERS 19 and OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 and OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
ST - Step
Therapy
Pharmacy
IN
IN
IN
IN
IN
43
Drug Name
FLUBLOK 2016-2017
FLUCELVAX QUADRIVALENT 20
FLULAVAL QUADRIVALENT 201
FLUMIST QUADRIVALENT
FLUVIRIN 2016-2017
FLUZONE HIGH-DOSE PF 2016
FLUZONE QUADRIVALENT 2016
GARDASIL
MENACTRA
MENOMUNE-A/C/Y/W-135
PNEUMOVAX 23
PREVNAR 13
Requirements/Limits
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEMBERS 19 AND OVER
ST - Step
Therapy
Pharmacy
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
44
Drug Name
TETANUS/DIPHTHERIA TOXOID
ZOSTAVAX
Requirements/Limits
AVAILABLE THROUGH
VACCINE NETWORK OR
MEDICAL BENEFIT ONLY IN
MEMBERS 19 and OVER
AVAILABLE THROUGH
VACCINE NETWORK OR
MEDICAL BENEFIT ONLY IN
MEMBERS 50 AND OVER
MISCELLANEOUS
BULK CHEMICALS AND COMPOUNDING SUPPLIES
ANHYDROUS BASE
BANANA CREAM FLAVOR
BENZYL ALCOHOL
BORIC ACID
CARBOXYMETHYLCELLULOSE SODIUM GRANULES
CHERRY SYRUP
COAL TAR
COCOA BUTTER
COLLODION FLEXIBLE
ETHOXY DIGLYCOL REAGENT
FLAVOR BLEND
GELATIN CAPSULES
GLYCOLIC ACID
GRAPE FLAVOR
LACTOSE
LACTOSE HYDROUS
megestrol acetate POWD
METHYLPARABEN
ORA-SWEET SF
POLOX
POLYETHYLENE GLYCOL 400
RASPBERRY SYRUP
SM BORIC ACID
SODIUM BISULFITE
SODIUM HYDROXIDE
SQUARIC ACID DIBUTYLESTER POWDER
STEVIA EXTRACT
SUPPOSIBASE F
DIAGNOSTIC AGENTS
MULTISTIX 10 SG
MEDICAL SUPPLIES
BARDIA BULB IRRIGATION SY
QL (200 strips per 20 days);
OTC ONLY
QL (200 syringes per 20
days)
ST - Step
Therapy
Pharmacy
45
Drug Name
BD 1ML SYRINGE/NEEDLE/SLI
BD 30ML SYRINGE LUER-LOK
BD ECLIPSE SYRINGE SLIP T
BD ECLIPSE SYRINGE/1ML/27
BD ECLIPSE SYRINGE/1ML/30
BD INTEGRA 1ML SYRINGE W/
BD LUER LOCK SYRINGE/1ML/
BD SAFETYGLIDE 27G X 5/8"
BLOOD PRESSURE MONITORING - DEVICE
BLOOD PRESSURE MONITORING - KIT
COLD PACKS
DISPOSABLE GLOVES
EYE PATCHES
GLASPAK DISPOSABLE 2-1/2M
HEARING AID BATTERIES-MISC
HEAT WRAPS
HEATING PADS
HOT/COLD THERAPY AIDS - MISC
HOT/COLD THERAPY AIDS - PADS
INCONTINENCE SUPPLIES DISPOSABLE - MISC
MONOJECT 20ML SYRINGE REG
MONOJECT SOFTPACK 20ML/LT
MONOJECT SOFTPACK 35ML/RE
MONOJECT SYRINGE/ECCENTRI
MONOJECT SYRINGE/LUER LOC
MONOJECT SYRINGE/LUER-LOC
MULTIFIT REUSABLE SYRINGE
MULTIFIT REUSABLE TB SYRI
OSTOMY SUPPLIES - CREAM
OSTOMY SUPPLIES - LIQUID
Requirements/Limits
days)
days)
days)
days)
days)
days)
days)
days)
QL (1 unit per 365 days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
ST - Step
Therapy
Pharmacy
46
Drug Name
OSTOMY SUPPLIES - MISC
OSTOMY SUPPLIES - OINT
OSTOMY SUPPLIES - PASTE
OSTOMY SUPPLIES - POUCH
OSTOMY SUPPLIES - POWDER
OSTOMY SUPPLIES - STRIP
OSTOMY SUPPLIES - WAFER (SKIN BARRIER)
OSTOMY SUPPLIES IRRIGATION KIT
100ML SYRING MIS LUER-LOK
syringe (disposable)
20-25ML SYRINGE/LUER LOCK
1ML TB SYRINGE/LUER SLIP
TERUMO SURGUARD2 SYRINGE/
THERMOMETERS
TOOMEY SYRINGE
YALE NEEDLES 30G X 1-1/2"
NUTRITIONAL / SUPPLEMENTS
AMINO ACIDS
AMINOSYN
GLUTARADE AMINO ACID BLEN
CALORIC AGENTS
ADDITIONS FOOD ENHANCER
WHEY PROTEIN DRINK MIX
DIETARY MANAGEMENT PRODUCTS
BOOST PUDDING
CAMINO PRO COMPLETE/GLYTA
CARNATION INSTANT BREAKFA
ENFAMIL PREMIUM LIPIL
GOOD START SUPREME NATURA
GOOD START SUPREME W/IRON
MODULEN IBD
NESTLE FLAVOR
PROTEIN FORTIFIED COOKIE
RESOURCE JUICE DRINK
TOLEREX
ELECTROLYTES, MISCELLANEOUS
oral electrolytes
POTASSIUM & SODIUM PHOSPHATES POWDER
PACK 280-160-250 MG
Requirements/Limits
days)
days)
days)
days)
days)
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
OTC ONLY
QL (200 packets per 30
days)
ST - Step
Therapy
Pharmacy
47
Drug Name
potassium phosphate monobasic w/ sodium
phosphate dibasic & monobasic tab
Requirements/Limits
ELECTROLYTES, POTASSIUM
potassium bicarbonate
potassium chloride
potassium chloride tab controlled release
ELECTROLYTES, POTASSIUM-REMOVING AGENTS
sodium polystyrene sulfonate
INTRAVENOUS NUTRITION, CALORIC AGENTS
amino acid electrolyte infusion
amino acid infusion
AMINOSYN 7%/ELECTROLYTES
AMINOSYN II
AMINOSYN M
AMINOSYN-RF
CLINIMIX 2.75%/DEXTROSE 5
CLINIMIX 5%/DEXTROSE 15%
fat emulsion
FREAMINE HBC 6.9%
FREAMINE III
NEPHRAMINE
PROCALAMINE
PROSOL
TROPHAMINE
INTRAVENOUS NUTRITION, ELECTROLYTES
parenteral electrolytes
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(3000
(3000
(3000
(3000
(3000
(3000
(3000
(3000
(3000
(3000
(3000
(3000
(3000
(3000
(3000
(3000
(3000
(3000
(3000
(3000
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
per
per
per
per
per
per
per
per
per
per
per
per
per
per
per
per
per
per
per
per
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
INTRAVENOUS NUTRITION, VITAMINS AND MINERALS
TRACE MINERALS (CR-CU-MN-ZN) INJ
1-100-30-500 MCG/ML
VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS
folic acid
folic acid-vitamin b6-vitamin b12
VITAMINS AND MINERALS, MISCELLANEOUS
AQUADEKS CAPS
AQUADEKS CHEW
b-complex with/ c & folic acid cap 1 mg
calcium
OTC ONLY
ST - Step
Therapy
Pharmacy
48
Drug Name
calcium & phosphorus w/ vitamin d
calcium ascorbate
calcium carbonate
CHEW 1250mg
calcium carbonate
SUSP
calcium carbonate
TABS
calcium carbonate-cholecalciferol CAPS
calcium carbonate-cholecalciferol CHEW
calcium carbonate-cholecalciferol CHEW
calcium carbonate-cholecalciferol TABS
calcium carbonate-cholecalciferol TABS
calcium carbonate-vitamin d CAPS
calcium carbonate-vitamin d TABS
calcium carbonate-vitamin d TABS
calcium citrate
calcium citrate-vitamin d
calcium w/ magnesium
calcium w/ vitamins d & k
calcium-magnesium-vitamin c-vitamin d
caltrate 600+d3 soft chew
cholecalciferol CAPS
cholecalciferol CHEW
cholecalciferol LIQD 400unit/ml
cholecalciferol LIQD 400unt/0.03ml,
2000unt/0.03ml
cholecalciferol TABS
Requirements/Limits
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
ONLY
OTC ONLY
ST - Step
Therapy
Pharmacy
49
Drug Name
cyanocobalamin
ergocalciferol
Requirements/Limits
ferretts
ferrous gluconate
ferrous sulfate
ELIX
ferrous sulfate
SOLN
ferrous sulfate
TABS
ferrous sulfate cap controlled release
ferrous sulfate controlled release
ferrous sulfate dried
ferrous sulfate tab enteric coated
INFED
iron polysaccharide complex-vit b12-folic acid
QL (1 bottle / 30 days); OTC
ONLY
OTC ONLY
OTC ONLY
OTC ONLY
ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
MEPHYTON
multiple vitamin CAPS
multiple vitamin LIQD
multiple vitamin TABS
multiple vitamins w/ calcium CAPS
multiple vitamins w/ calcium TABS
multiple vitamins w/ iron
multiple vitamins w/ minerals ELIX; LIQD; SYRP QL (50 ml per 30 days)
multiple vitamins w/ minerals PACK
QL (30 packets per 30 days)
multiple vitamins w/ minerals POWD
multiple vitamins w/ minerals TABS
multiple vitamins w/ minerals tab controlled releaseQL (30 tabs per 30 days)
omega-3 fatty acids CAPS
OTC ONLY
omega-3 fatty acids CHEW
OTC ONLY
omega-3 fatty acids LIQD
OTC ONLY
oyster shell
OTC ONLY
pediatric multiple vitamin w/ c
pediatric multiple vitamin w/ c & fa
pediatric multiple vitamin w/ extra c & fa
ST - Step
Therapy
Pharmacy
50
Drug Name
pediatric multiple vitamin w/ minerals & c CHEW
pediatric multiple vitamin w/ minerals & c LIQD
pediatric multiple vitamins CHEW
pediatric multiple vitamins LIQD
pediatric multiple vitamins w/ iron CHEW
pediatric multiple vitamins w/ iron LIQD; SOLN
pediatric multivitamins w/fluoride
pediatric multivitamins w/fluoride & iron
pediatric vitamins acd w/ fluoride
pediatric vitamins adc
polysaccharide iron complex
pyridoxine hcl tab 50 mg
ra oyster shell calcium/v
sodium fluoride
sodium fluoride solution
thiamine hcl
thiamine mononitrate
Requirements/Limits
17 YEARS OF AGE
17 YEARS OF AGE
OTC ONLY
OTC ONLY
OTC ONLY
17 YEARS OF AGE
17 YEARS OF AGE
VITAMINS AND MINERALS, PRENATAL VITAMINS
CITRANATAL 90 DHA
CITRANATAL ASSURE
CITRANATAL B-CALM
CITRANATAL DHA
CITRANATAL HARMONY
CITRANATAL RX
KP PRENATAL MULTIVITAMINS
MISSION PRENATAL
PRENATAL
PRENATAL
prenatal
prenatal
prenatal
prenatal
vit
vit
vit
vit
w/
w/
w/
w/
docusate-fe fumarate-folic acid
docusate-iron carbonyl-folic acid
ferrous fumarate-folic acid
iron carbonyl-folic acid
OTC ONLY
OTC ONLY
RESPIRATORY
ANAPHYLAXIS TREATMENT AGENTS
ST - Step
Therapy
Pharmacy
51
Drug Name
epinephrine
epinephrine inj 0.3mg
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
Requirements/Limits
QL (4 units per 30 days, 8
units per 365 days)
units per 365 days)
units per 365 days)
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
COMBIVENT RESPIMAT
ipratropium-albuterol
ANTICHOLINERGICS
ipratropium bromide .02%
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
TUDORZA PRESSAIR
QL
QL
QL
QL
(1 inhaler per 30 days)
(1 inhaler per 30 days)
ANTIHISTAMINE/DECONGESTANT COMBINATIONS
brompheniramine & pseudoephedrine elixir 1-15
mg/5ml
cetirizine-pseudoephedrine
fexofenadine-pseudoephedrine tab sustained-rel
12hr 60-120 mg
fexofenadine-pseudoephedrine tab sustained-rel
24hr 180-240 mg
loratadine & pseudoephedrine tab ext-rel 12hr
5-120 mg
loratadine & pseudoephedrine tab ext-rel 24hr
10-240 mg
promethazine & phenylephrine
triprolidine & pseudoephedrine
ANTIHISTAMINES, LOW-SEDATING
cetirizine hcl CAPS
cetirizine hcl CHEW; TABS
cetirizine hcl SOLN; SYRP
ANTIHISTAMINES, NONSEDATING
fexofenadine hcl SUSP
fexofenadine hcl TABS 60mg
fexofenadine hcl TABS 180mg
loratadine
SYRP
loratadine
TABS; TBDP
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
OTC ONLY
ST - Step
Therapy
Pharmacy
52
Drug Name
Requirements/Limits
ANTIHISTAMINES, SEDATING
chlorpheniramine maleate
SYRP
TABS
TBCR
clemastine fumarate
cyproheptadine hcl
diphenhydramine hcl CAPS
diphenhydramine hcl CHEW; TABS; TBDP
diphenhydramine hcl ELIX; LIQD; SYRP
hydroxyzine hcl
hydroxyzine pamoate
OTC ONLY
OTC ONLY
OTC ONLY
PA; HRM
PA; HRM
ANTITUSSIVE COMBINATIONS, NON-OPIOID
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin tab sustained-rel QL (80 tabs per 30 days)
12hr 30-600 mg
dextromethorphan-guaifenesin tab sustained-rel QL (80 tabs per 30 days)
12hr 60-1200 mg
promethazine/dextromethorphan
pseudoephedrine-brompheniramine-dextromethorp
han
ANTITUSSIVE COMBINATIONS, OPIOID
guaifenesin-codeine
hydrocodone w/ homatropine
phenylephrine-promethazine w/ codeine syrup
5-6.25-10 mg/5ml
promethazine w/codeine
pseudoephedrine w/ codeine-guaifenesin
ANTITUSSIVES
benzonatate
BETA AGONISTS, INHALANTS, LONG ACTING
SEREVENT DISKUS
QL (60 doses per 30 days),
ST
BETA AGONISTS, INHALANTS, SHORT ACTING
albuterol sulfate
albuterol sulfate
1.25mg/3ml
PROAIR HFA
VENTOLIN HFA
NEBU .5%
NEBU .083%, .63mg/3ml,
QL (8.5 gm per 30 days)
QL (1 pack per 30 days)
BETA AGONISTS, ORAL AGENTS
albuterol sulfate SYRP
albuterol sulfate TABS
albuterol tab 4mg ext-rel
ST - Step
Therapy
Pharmacy
53
Drug Name
albuterol tab 8mg ext-rel
terbutaline sulfate
Requirements/Limits
CYSTIC FIBROSIS
BETHKIS
PULMOZYME
tobramycin neb 300/5ml inhalation
PA; SP
QL (56 ml per 28 days), PA;
SP
DECONGESTANT/EXPECTORANT COMBINATIONS
pseudoephedrine-guaifenesin tab ext-rel 12hr
pseudoephedrine-guaifenesin tab sr 12hr
DECONGESTANTS
pseudoephedrine hcl LIQD; SYRP
pseudoephedrine hcl TABS
pseudoephedrine hcl tab ext-rel 12hr 120 mg
EXPECTORANTS
guaifenesin
guaifenesin tab ext-rel 12hr 600 mg
OTC ONLY
OTC ONLY
OTC ONLY
LEUKOTRIENE MODIFIERS
montelukast sodium
MAST CELL STABILIZERS
cromolyn sodium
NEBU
MEDICAL SUPPLIES
MASKS
QL (1 unit per 180 days);
11 YEARS OF AGE
NEBULIZERS
QL (1 unit per 365 days)
PEAK FLOW METER
SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES -QL (1 unit per 180 days);
MASKS
11 YEARS OF AGE
SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE QL (1 unit per 365 days)
VAPORIZERS
MISCELLANEOUS
ARALAST NP
GLASSIA
ipratropium bromide .03%, .06%
saline
sodium chloride AERS
sodium chloride NEBU 3%, 7%, 10%
sodium chloride NEBU .9%
XOLAIR
PA; SP
PA; SP
PA; SP
NASAL ANTIHISTAMINES
ST - Step
Therapy
Pharmacy
54
Drug Name
azelastine hcl .1%
Requirements/Limits
NASAL MAST CELL STABILIZERS
cromolyn sodium
AERS
NASAL STEROIDS
budesonide nasal spray
flunisolide
fluticasone propionate SUSP
NASACORT AER 55MCG/AC
PULMONARY FIBROSIS AGENTS
OFEV
STEROID INHALANTS
ARNUITY ELLIPTA
ASMANEX 30 AER 110MCG
ASMANEX HFA
budesonide (inhalation) 1mg/2ml
budesonide (inhalation)
budesonide (inhalation)
FLOVENT HFA
QVAR
.5mg/2ml
.25mg/2ml
STEROID/BETA AGONIST COMBINATIONS
ADVAIR DISKU AER 100/50
DULERA
SYMBICORT
TOPICAL DECONGESTANTS
oxymetazoline hcl
only
Only
PA; SP
QL (1 inhaler / 30 days)
QL (2 inhalers per 30 days)
QL (1 inhaler per 30 days)
AGE: NOT COVERED OVER 9
YEARS OF AGE
QL (60 doses per 30 days),
ST; AGE: COVERED
BETWEEN 4 and 11 YEARS
OF AGE
QL (11 gm per 30 days), ST
ONLY
XANTHINES
ELIXOPHYLLIN
THEO-24
theophylline
TOPICAL
DERMATOLOGY, ACNE: ORAL
isotretinoin
PA
PA
DERMATOLOGY, ACNE: TOPICAL
ST - Step
Therapy
Pharmacy
55
Drug Name
benzoyl peroxide CREA
benzoyl peroxide GEL
benzoyl peroxide LIQD 2.5%
benzoyl peroxide LIQD 5%, 10%
benzoyl peroxide LIQD 5.25%
benzoyl peroxide LIQD 7%
benzoyl peroxide LOTN 6%
benzoyl peroxide LOTN 9%
benzoyl peroxide-erythromycin
clindamycin phosphate (topical) GEL
clindamycin phosphate (topical) SOLN
erythromycin GEL
erythromycin SOLN
TAZORAC
DERMATOLOGY, ACTINIC KERATOSIS
fluorouracil (topical)
DERMATOLOGY, ANTIBIOTICS
bacitracin OINT 500unit/gm
bacitracin-polymyxin b
BACTROBAN NASAL
gentamicin sulfate CREA
gentamicin sulfate OINT .1%
mupirocin
mupirocin calcium
neomycin-bacitracin-polymyxin
silver sulfadiazine
Requirements/Limits
QL
QL
QL
QL
QL
PA
(24
(30
(30
(60
(60
gm per 30 days)
gm per 30 days)
ml per 30 days)
gm per 30 days)
ml per 30 days)
AGE: NOT COVERED LESS 18
YEARS OF AGE
DERMATOLOGY, ANTIFUNGALS
ciclopirox
ciclopirox olamine
clotrimazole
clotrimazole (topical)
iodoquinol-hc
ketoconazole
miconazole nitrate
nystatin CREA
nystatin (topical)
nystatin-triamcinolone
tolnaftate
tolnaftate aerosol powder 1%
tolnaftate cream 1%
OTC ONLY
DERMATOLOGY, ANTIPSORIATICS, TOPICAL
calcipotriene
DERMATOLOGY, ANTISEBORRHEICS
ST - Step
Therapy
Pharmacy
56
Drug Name
selenium sulfide lotion 1%
selenium sulfide lotion 2.5%
Requirements/Limits
DERMATOLOGY, CORTICOSTEROID COMBINATIONS
hydrocortisone-aloe vera
DERMATOLOGY, CORTICOSTEROIDS: HIGH POTENCY
betamethasone dipropionate
betamethasone dipropionate augmented CREA;
LOTN
triamcinolone acetonide (topical) CREA .5%
triamcinolone acetonide (topical) OINT .5%
DERMATOLOGY, CORTICOSTEROIDS: LOW POTENCY
alclometasone dipropionate
hydrocortisone CREA 2.5%
hydrocortisone CREA .5%, 1%
hydrocortisone GEL
hydrocortisone LOTN 1%
hydrocortisone LOTN 2.5%
hydrocortisone OINT 1%
hydrocortisone OINT 2.5%
hydrocortisone OINT .5%
hydrocortisone SOLN
hydrocortisone acetate
DERMATOLOGY, CORTICOSTEROIDS: MEDIUM POTENCY
betamethasone valerate
fluticasone propionate CREA; OINT
hydrocortisone butyrate
mometasone furoate
triamcinolone acetonide (topical) CREA .025%,
.1%
triamcinolone acetonide (topical) LOTN
triamcinolone acetonide (topical) OINT .025%,
.05%, .1%
DERMATOLOGY, CORTICOSTEROIDS: VERY HIGH POTENCY
betamethasone dipropionate augmented GEL;
OINT
halobetasol propionate
DERMATOLOGY, EMOLLIENTS
lactic acid (ammonium lactate)
lactic acid (ammonium lactate)
lactic acid w/ vitamin e
CREA
LOTN
DERMATOLOGY, IMMUNOMODULATORS
ELIDEL
ST; AGE: NOT COVERED
UNDER 2 YEARS OF AGE
tacrolimus oint 0.1%
ST - Step
57
Therapy
Pharmacy
Drug Name
tacrolimus oint 0.03%
DERMATOLOGY, LOCAL ANALGESIC
lidocaine patch 5%
Requirements/Limits
PA
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine hcl soln 4%
lidocaine-benzalkonium
lidocaine-prilocaine
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
ABREVA
aluminum chloride
calamine
CUTTER BACKWOODS
CUTTER SKINSATIONS
imiquimod
MICROCLENS WIPES
NATRAPEL 12-HOUR TICK & I
OFF ACTIVE
OFF DEEP WOODS
OFF DEEP WOODS DRY
OFF SMOOTH & DRY
podofilox
povidone-iodine OINT
povidone-iodine SOLN
REPEL SPORTSMEN
REPEL SPORTSMEN MAX
SANTYL
XIAFLEX
zinc oxide
DERMATOLOGY, ROSACEA
metronidazole GEL 1%
metronidazole GEL .75%
metronidazole LOTN
metronidazole cream 0.75%
ONLY
OTC only
QL (2 Rxs per 180 days)
AGE: NOT COVERED LESS 11
YEARS OF AGE
QL
QL
QL
QL
(150 gm per 30 days)
(2 Rxs per 180 days)
(2 Rxs per 180 days)
PA; SP
ST
DERMATOLOGY, SCABICIDES AND PEDICULICIDES
malathion
permethrin
permethrin
permethrin
permethrin
spinosad
ULESFIA
AERO
LIQD
LOTN
cream
ST
ST
ST
ST - Step
Therapy
Pharmacy
58
Drug Name
Requirements/Limits
MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS
chlorhexidine gluconate (mouth-throat)
sodium fluoride (dental) CREA
sodium fluoride (dental) GEL
sodium fluoride (dental) PSTE
sodium fluoride (dental) SOLN
triamcinolone acetonide (mouth)
QL
QL
QL
QL
(60 gm per 30 days)
OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY
COMBINATIONS
bacitracin-polymyxin-neomycin-hc ophth oint 1%
neomycin-polymyxin-dexamethasone ophth oint
0.1%
neomycin-polymyxin-dexamethasone ophth susp
0.1%
neomycin-polymyxin-hc ophth susp
sulfacetamide sod-prednisolone
tobramycin-dexamethasone
OPHTHALMIC, ANTI-INFECTIVES
bacitracin OINT 500unit/gm
bacitracin-polymyxin b
ciprofloxacin hcl
erythromycin OINT
gentamicin sulfate OINT .3%
gentamicin sulfate SOLN
levofloxacin SOLN .5%
neomycin-bacitracin zinc-polymyxin
neomycin-polymyxin-gramicidin
ofloxacin .3%
polymyxin b-trimethoprim
sulfacetamide sodium
tobramycin
OPHTHALMIC, ANTI-INFLAMMATORY: NONSTEROIDAL
diclofenac sodium SOLN
flurbiprofen sodium
ketorolac tromethamine SOLN
OPHTHALMIC, ANTI-INFLAMMATORY: STEROIDAL
dexamethasone sodium phosphate
fluorometholone
prednisolone acetate
OPHTHALMIC, ANTIALLERGICS
azelastine hcl .05%
cromolyn sodium SOLN
ketotifen fumarate
OPHTHALMIC, ANTIFUNGALS
ST - Step
Therapy
Pharmacy
59
Drug Name
NATACYN
Requirements/Limits
OPHTHALMIC, ANTIVIRAL
trifluridine
OPHTHALMIC, BETA-BLOCKERS: NONSELECTIVE
BETIMOL
levobunolol hcl
metipranolol
timolol maleate
SOLG; SOLN
OPHTHALMIC, BETA-BLOCKERS: SELECTIVE
betaxolol hcl
OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER
COMBINATIONS
dorzolamide hcl-timolol maleate
OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: ORAL
acetazolamide
methazolamide
OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: TOPICAL
dorzolamide hcl
OPHTHALMIC, MISCELLANEOUS
artificial tear ointment
artificial tear solution
carboxymethylcellulose sodium
GENTEAL
GENTEAL MILD
GENTEAL MILD TO MODERATE
glycerin-hypromellose-polyethylene glycol 400
HYPOTEARS
hypromellose
LUCENTIS
MACUGEN
MOISTURE EYES
polyethylene glycol-polyvinyl alcohol
polyvinyl alcohol
polyvinyl alcohol-povidone
ONLY
ONLY
ONLY
ONLY
ONLY
ONLY
ONLY
PA; SP
PA; SP
ONLY
ONLY
ONLY
ONLY
ST - Step
Therapy
Pharmacy
60
Drug Name
REFRESH
REFRESH OPTIVE
REFRESH OPTIVE ADVANCED
REFRESH PLUS
sodium chloride hypertonic
OINT
sodium chloride hypertonic
SOLN
SYSTANE
SYSTANE BALANCE RESTORATI
SYSTANE OVERNIGHT THERAPY
TEARS NATURALE PM
THERATEARS
Requirements/Limits
ONLY
ONLY
ONLY
ONLY
ONLY
ONLY
ONLY
ONLY
ONLY
ONLY
ONLY
OPHTHALMIC, MYDRIATICS
atropine sulfate (ophthalmic)
cyclopentolate hcl
OPHTHALMIC, PROSTAGLANDINS
latanoprost
OPHTHALMIC, SYMPATHOMIMETICS
brimonidine tartrate
OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS
CIPRODEX
neomycin-polymyxin-hc
OTIC, ANTI-INFECTIVES
acetic acid
acetic acid-aluminum acetate
ofloxacin .3%
ST - Step
Therapy
Pharmacy
61
Index
1
100ML SYRING MIS LUER-LOK............47
1ML TB SYRINGE/LUER SLIP ..............47
2
20-25ML SYRINGE/LUER LOCK ...........47
A
abacavir sulfate tab ............................ 6
abacavir sulfate-lamivudine-zidovudine 5
ABRAXANE .......................................11
ABREVA ...........................................58
acamprosate calcium .........................28
acarbose ..........................................29
acetaminophen .................................. 1
acetaminophen suppositories .............. 1
acetaminophen suspension ................. 1
acetaminophen tabs ........................... 1
acetaminophen w/ codeine .................. 2
acetaminophen w/ codeine solution ...... 2
acetazolamide ..................................60
acetic acid........................................62
acetic acid vaginal.............................41
acetic acid-aluminum acetate ............ 62
ACTIMMUNE .................................... 43
acyclovir cap 200 mg .......................... 7
acyclovir suspension 200 mg/5ml ......... 7
acyclovir tab 400 mg .......................... 7
acyclovir tab 800mg ........................... 7
ADACEL .......................................... 43
ADCETRIS ....................................... 11
ADDITIONS FOOD ENHANCER............ 47
adefovir dipivoxil ................................ 7
ADVAIR DISKU AER 100/50 ............... 56
AFINITOR ........................................ 10
AFLURIA PF 2016-2017 ..................... 44
ALBENZA........................................... 8
albuterol sulfate ............................... 54
albuterol tab 4mg ext-rel .................. 54
albuterol tab 8mg ext-rel .................. 54
alclometasone dipropionate ............... 57
ALCOHOL PREPS .............................. 32
ALCOHOL SWABS ............................. 32
ALDURAZYME .................................. 35
62
alendronate sodium ..........................33
ALFERON N ......................................43
alfuzosin hcl .....................................40
ALIMTA ............................................. 9
ALKERAN .......................................... 9
allopurinol ......................................... 1
alprazolam .......................................16
alprazolam orally disintegrating tab 0.25
mg ..................................................16
alprazolam orally disintegrating tab 0.5
mg ..................................................16
alprazolam orally disintegrating tab 1 mg
......................................................16
alprazolam orally disintegrating tab 2 mg
......................................................16
alum & mag hydrox-simethicone .........37
aluminum chloride ............................58
aluminum hydroxide-magnesium
carbonate chew tab 160-105 mg ........37
carbonate susp 95-358 mg/15ml ........37
trisilicate chew tab 80-20 mg .............37
amantadine hcl .................................19
amifostine crystalline ........................11
amikacin sulfate ................................ 3
amiloride & hydrochlorothiazide ..........15
amiloride hcl ....................................15
amino acid electrolyte infusion............48
amino acid infusion ...........................48
AMINOSYN .......................................47
AMINOSYN 7%/ELECTROLYTES ..........48
AMINOSYN II....................................48
AMINOSYN M....................................48
AMINOSYN-RF ..................................48
amiodarone hcl .................................13
amitriptyline hcl ................................18
amlodipine besylate ..........................14
amlodipine besylate-benazepril hcl ......12
amoxicillin ........................................ 4
amoxicillin & potassium clavulanate ..... 4
amoxicillin/potassium clavulanate ........ 4
sustained-rel 24hr 10 mg ...................24
sustained-rel 24hr 25 mg .................. 24
sustained-rel 24hr 30 mg .................. 24
sustained-rel 24hr 5 mg .................... 24
amphetamine-dextroamphetamine tab 10
mg ................................................. 24
amphetamine-dextroamphetamine tab
12.5 mg .......................................... 24
mg ................................................. 24
mg ................................................. 24
mg ................................................. 25
mg ................................................. 24
amphetamine-dextroamphetamine tab
7.5 mg............................................ 24
ampicillin .......................................... 4
ampicillin & sulbactam sodium ............. 4
ampicillin sodium inj ........................... 4
AMPYRA .......................................... 27
anagrelide hcl .................................. 42
anastrozole ..................................... 10
ANHYDROUS BASE ........................... 45
APIDRA ........................................... 30
APIDRA SOLOSTAR........................... 30
APRISO ........................................... 38
APTIVUS CAP 250MG .......................... 6
APTIVUS SOL ..................................... 6
AQUADEKS ...................................... 49
ARALAST NP .................................... 55
ARANESP ALBUMIN FREE .................. 42
ARCALYST ....................................... 43
aripiprazole ..................................... 19
aripiprazole oral solution 1 mg/ml ...... 19
ARISTADA ....................................... 19
ARMOUR THYROID ........................... 36
ARNUITY ELLIPTA ............................. 55
ARRANON........................................ 11
artificial tear ointment ...................... 60
artificial tear solution ........................ 60
ARZERRA ........................................ 11
ASMANEX 120 AER 220MCG .............. 55
ASMANEX 30 AER 110MCG ................ 55
ASMANEX 30 AER 220MCG ................ 55
63
ASMANEX 60 AER 220MCG .................55
ASMANEX HFA ..................................55
aspirin ......................................... 1, 42
aspirin enteric coated ........................42
atenolol ...........................................14
atenolol & chlorthalidone ...................14
atorvastatin calcium ..........................14
atovaquone ....................................... 8
atovaquone-proguanil hcl .................... 5
ATRIPLA ........................................... 5
atropine sulfate (ophthalmic) .............61
AUBAGIO .........................................27
AURYXIA ..........................................36
AVASTIN ..........................................11
AVELOX INJ....................................... 4
AVONEX ..........................................27
AVONEX PEN ....................................27
AZASAN ...........................................43
azathioprine .....................................43
azelastine hcl ............................. 55, 60
azithromycin ..................................... 4
azithromycin inj 2.5gm ....................... 4
aztreonam ........................................ 8
AZTREONAM IN DEXTROSE INJ ........... 8
B
bacitracin ............................... 8, 56, 59
bacitracin-polymyxin b ................ 56, 59
bacitracin-polymyxin-neomycin-hc ophth
oint 1% ...........................................59
baclofen ..........................................28
BACTROBAN NASAL ..........................56
balsalazide disodium .........................38
BANANA CREAM FLAVOR....................45
BARACLUDE SOL .05MG/ML ................ 7
BARDIA BULB IRRIGATION SY ............46
BASAGLAR INJ..................................30
BAYER BREEZE 2 TEST DISC ..............32
BAYER CONTOUR BLOOD GLUCOSE ....32
BAYER CONTOUR NEXT BLOOD...........32
b-complex with/ c & folic acid cap 1 mg
......................................................49
BD 1ML SYRINGE/NEEDLE/SLI ............46
BD 30ML SYRINGE LUER-LOK .............46
BD ECLIPSE SYRINGE SLIP T ..............46
BD ECLIPSE SYRINGE/1ML/27 ............46
BD ECLIPSE SYRINGE/1ML/30 ............46
BD INSULIN SYRINGE ULTRAF ............32
BD INSULIN SYRINGE/U-100/ ............32
BD INTEGRA 1ML SYRINGE W/........... 46
BD LUER LOCK SYRINGE/1ML/ ........... 46
BD PEN NEEDLE/MINI/ULTRAF ........... 32
BD PEN NEEDLE/NANO/ULTRA ........... 32
BD PEN NEEDLE/ULTRAFINE/2 ........... 32
BD PEN NEEDLES SHORT/ULTR .......... 32
BD SAFETYGLIDE 27G X 5/8"............. 46
benazepril & hydrochlorothiazide ........ 12
benazepril hcl .................................. 13
BENLYSTA ....................................... 43
benzonatate .................................... 54
benzoyl peroxide .............................. 56
benzoyl peroxide-erythromycin .......... 56
benztropine mesylate ....................... 19
BENZYL ALCOHOL ............................ 45
betamethasone dipropionate.............. 57
betamethasone dipropionate augmented
................................................. 57, 58
betamethasone valerate .................... 57
betaxolol hcl .................................... 60
bethanechol chloride......................... 41
BETHKIS ......................................... 54
BETIMOL ......................................... 60
bexarotene cap 75 mg ...................... 11
BEXSERO ........................................ 44
bicalutamide ...................................... 9
BICILLIN C-R ..................................... 4
BICILLIN L-A ..................................... 4
BICNU .............................................. 9
BIDIL.............................................. 15
bisacodyl ......................................... 39
bisacodyl tab delayed release 5 mg .... 39
bismuth subsalicylate ....................... 37
bisoprolol & hydrochlorothiazide ......... 14
bisoprolol fumarate .......................... 14
bleomycin sulfate ............................. 11
...................................................... 32
- HIGH ............................................ 32
- LOW ............................................. 32
- NORMAL ....................................... 32
BLOOD PRESSURE MONITORING DEVICE ........................................... 46
BLOOD PRESSURE MONITORING - KIT 46
BOOST PUDDING ............................. 47
64
BOOSTRIX .......................................44
BORIC ACID .....................................45
BRILINTA .........................................42
brimonidine tartrate ..........................62
bromocriptine mesylate .....................19
brompheniramine & pseudoephedrine
elixir 1-15 mg/5ml ............................52
budesonide ......................................38
budesonide (inhalation) .....................55
budesonide nasal spray .....................55
bumetanide ......................................15
buprenorphine hcl .............................28
buprenorphine hcl-naloxone hcl
sublingual tab 2-0.5 mg .....................28
buprenorphine hcl-naloxone hcl
sublingual tab 8-2 mg .......................28
bupropion hcl ...................................17
bupropion hcl (smoking deterrent) ......29
buspirone hcl....................................16
BUSULFEX......................................... 9
butalbital-acetaminophen-caffeine ....... 1
butalbital-aspirin-caffeine ................... 1
BYSTOLIC ........................................14
C
cabergoline ......................................36
CAFERGOT .......................................27
calamine ..........................................58
calcipotriene.....................................57
calcitonin (salmon)............................33
calcitriol ...........................................35
calcium ............................................49
calcium & phosphorus w/ vitamin d .....49
calcium acetate (phosphate binder).....36
calcium ascorbate .............................49
calcium carbonate ....................... 37, 49
calcium carbonate-cholecalciferol ........49
calcium carbonate-vitamin d ..............49
calcium citrate ..................................49
calcium citrate-vitamin d ...................49
calcium polycarbophil ........................39
calcium w/ magnesium ......................49
calcium w/ vitamins d & k ..................49
calcium-magnesium-vitamin c-vitamin d
......................................................50
caltrate 600+d3 soft chew .................50
CAMINO PRO COMPLETE/GLYTA..........48
CAMPTOSAR .....................................12
candesartan cilexetil..........................13
capecitabine ...................................... 9
CAPRELSA ....................................... 10
captopril ......................................... 13
captopril & hydrochlorothiazide .......... 13
CARAFATE SUS 1GM/10ML ................ 39
carbamazepine ................................ 16
carbamazepine ext-rel ...................... 16
carbidopa-levodopa .......................... 19
carbidopa-levodopa-entacapone ......... 19
carboplatin ........................................ 9
carboxymethylcellulose sodium .......... 60
CARBOXYMETHYLCELLULOSE SODIUM
GRANULES ...................................... 45
carisoprodol..................................... 28
CARNATION INSTANT BREAKFA ......... 48
carvedilol ........................................ 14
cefadroxil .......................................... 3
cefazolin sodium ................................ 3
cefdinir ............................................. 3
cefepime ........................................... 3
cefepime/dextrose.............................. 3
cefotaxime sodium ............................. 3
CEFOTETAN DISODIUM ....................... 3
CEFOTETAN/DEXTROSE ...................... 3
cefoxitin sodium ................................. 3
CEFOXITIN SODIUM ........................... 3
cefprozil ............................................ 3
ceftazidime ........................................ 3
ceftriaxone ........................................ 3
ceftriaxone sodium ............................. 3
cefuroxime axetil ............................... 3
cefuroxime sodium ............................. 3
celecoxib ........................................... 1
cephalexin ......................................... 3
CEREZYME ...................................... 35
cetirizine hcl .................................... 53
cetirizine-pseudoephedrine ................ 52
CHANTIX ......................................... 29
CHERRY SYRUP ................................ 45
chloramphenicol sodium succinate ........ 8
chlordiazepoxide hcl ......................... 16
chlordiazepoxide hcl-clidinium bromide 38
chlorhexidine gluconate (mouth-throat)
...................................................... 59
chloroquine phosphate ........................ 5
chlorpheniramine maleate ................. 53
chlorpromazine hcl ........................... 22
chlorthalidone .................................. 15
65
chlorzoxazone ..................................28
cholecalciferol...................................50
cholestyramine .................................14
cholestyramine light ..........................14
ciclopirox .........................................57
ciclopirox olamine .............................57
cidofovir ........................................... 7
cilostazol .........................................42
cimetidine hcl soln 300 mg/5ml ..........38
cimetidine tab 200 mg .......................38
cimetidine tab 800mg ........................38
CINRYZE ..........................................42
CIPRODEX .......................................62
ciprofloxacin ...................................... 4
ciprofloxacin ext-rel ........................... 4
ciprofloxacin hcl ................................59
ciprofloxacin hcl tab ........................... 4
ciprofloxacin in d5w ........................... 4
cisplatin ............................................ 9
citalopram hydrobromide ...................18
CITRANATAL 90 DHA .........................51
CITRANATAL ASSURE ........................51
CITRANATAL B-CALM.........................51
CITRANATAL DHA .............................52
CITRANATAL HARMONY .....................52
CITRANATAL RX................................52
cladribine .......................................... 9
clarithromycin ................................... 4
clarithromycin ext-rel ......................... 4
clemastine fumarate..........................53
CLEOCIN SUP 100MG ........................41
clindamycin hcl .................................. 8
clindamycin palmitate hydrochloride ..... 8
clindamycin phosphate (topical)..........56
clindamycin phosphate inj ................... 8
CLINIMIX 2.75%/DEXTROSE 5 ...........48
CLINIMIX 5%/DEXTROSE 15% ...........48
CLINITEST .......................................32
CLOLAR ............................................ 9
clomipramine hcl ..............................16
clonazepam ......................................16
clonidine hcl .................................... 13
clopidogrel bisulfate.......................... 42
clotrimazole ..................................... 57
clotrimazole (topical) ........................ 57
clotrimazole troche 10 mg ................... 5
clotrimazole vaginal .......................... 41
clozapine .................................... 19, 20
CLOZARIL ....................................... 20
COAL TAR ....................................... 45
COARTEM .......................................... 5
COCOA BUTTER ............................... 45
colchicine .......................................... 1
COLD PACKS ................................... 46
colestipol hcl.................................... 14
colistimethate sodium inj .................... 8
COLLODION FLEXIBLE ...................... 45
COMBIPATCH ................................... 34
COMBIVENT RESPIMAT ..................... 52
COMETRIQ ...................................... 10
COMPLERA ........................................ 5
CONDOMS - FEMALE ......................... 33
CONDOMS - MALE ............................ 33
COPAXONE INJ 40MG/ML .................. 27
COSMEGEN ..................................... 11
COUMADIN ...................................... 41
CREON ............................................ 40
CRINONE ........................................ 36
CRIXIVAN.......................................... 6
cromolyn sodium................... 54, 55, 60
CUBICIN ........................................... 8
CUTTER BACKWOODS ....................... 58
CUTTER SKINSATIONS...................... 58
CUVPOSA ........................................ 38
cyanocobalamin ............................... 50
cyclobenzaprine hcl .......................... 28
cyclopentolate hcl ............................ 61
cyclophosphamide .............................. 9
CYCLOPHOSPHAMIDE CAP 25 MG ......... 9
CYCLOPHOSPHAMIDE CAP 50 MG ......... 9
cyclosporine .................................... 43
cyclosporine modified (for microemulsion)
...................................................... 43
cyproheptadine hcl ........................... 53
CYSTAGON ...................................... 41
cytarabine ......................................... 9
CYTOVENE ........................................ 7
D
dacarbazine ....................................... 9
66
danazol ...........................................34
dantrolene sodium ............................28
dapsone............................................ 8
daunorubicin hcl ...............................11
DAUNOXOME ....................................11
DESFERAL ........................................42
desipramine hcl ................................18
desmopressin acetate spray ...............37
desmopressin acetate tab ..................37
desmopressin sol ..............................37
desogestrel & ethinyl estradiol ............33
desogestrel-ethinyl estradiol (biphasic) 33
desogestrel-ethinyl estradiol (triphasic)
......................................................34
dexamethasone elixir ........................35
dexamethasone sodium phosphate .....60
dexamethasone soln .........................35
dexamethasone tab ...........................35
dexmethylphenidate hcl .....................25
dexrazoxane ....................................11
dextroamphetamine sulfate cap
sustained-rel 24hr 5 mg ....................25
dextroamphetamine sulfate tab 10 mg 25
dextroamphetamine sulfate tab 5 mg ..25
dextromethorphan-guaifenesin ...........53
dextromethorphan-guaifenesin tab
sustained-rel 12hr 30-600 mg ............53
dextromethorphan-guaifenesin tab
sustained-rel 12hr 60-1200 mg ..........53
dextrose (diabetic use) ......................35
DIAPHRAGM .....................................33
diazepam .........................................16
diazepam rectal gel ...........................16
diclofenac potassium .......................... 1
diclofenac sodium ......................... 1, 60
dicloxacillin sodium ............................ 4
dicyclomine hcl .................................38
didanosine ........................................ 6
DIFICID ............................................ 4
diflunisal ........................................... 1
digoxin ............................................15
dihydroergotamine mesylate inj 1 mg/ml
......................................................27
dihydroergotamine mesylate nasal spray
4 mg/ml .......................................... 27
DILANTIN ........................................ 16
DILANTIN INFATABS......................... 16
diltiazem hcl .................................... 14
diltiazem hcl coated beads ................ 15
diltiazem hcl extended release beads .. 15
diphenhydramine hcl ........................ 53
diphenhydramine hcl (sleep).............. 27
diphenoxylate w/ atropine ................. 37
dipyridamole ................................... 42
disopyramide phosphate ................... 13
DISPOSABLE GLOVES ....................... 46
disulfiram ........................................ 28
divalproex sodium ............................ 16
docefrez .......................................... 11
docetaxel ........................................ 11
docusate calcium cap 240 mg ............ 39
docusate sod cap 100mg ................... 39
docusate sodium .............................. 39
donepezil hydrochloride .................... 17
DONNATAL ...................................... 38
DORIBAX .......................................... 3
dorzolamide hcl................................ 60
dorzolamide hcl-timolol maleate ......... 60
doxazosin mesylate .......................... 13
doxepin hcl ................................. 18, 19
doxercalciferol ................................. 35
doxorubicin hcl ................................ 11
doxorubicin hcl liposomal .................. 11
doxycycline (monohydrate) susp .......... 4
doxycycline hyclate cap 50 mg, 100 mg
........................................................ 5
doxycycline hyclate for inj 100 mg ....... 5
doxycycline hyclate tab 20 mg, 100 mg
........................................................ 5
dronabinol ....................................... 37
drospirenone-ethinyl estradiol ............ 33
DULERA .......................................... 56
duloxetine hcl .................................. 17
E
EDURANT .......................................... 6
EFFIENT .......................................... 42
ELAPRASE ....................................... 36
ELIDEL ............................................ 58
ELIGARD ......................................... 10
ELIQUIS .......................................... 41
ELITEK ............................................ 11
ELIXOPHYLLIN ................................. 56
67
ELLA ...............................................33
ELMIRON .........................................41
EMCYT .............................................. 9
EMEND ............................................37
EMEND CAP ......................................37
EMTRIVA CAP 200MG ......................... 7
EMTRIVA SOLN .................................. 7
enalapril maleate ..............................13
enalapril maleate & hydrochlorothiazide
......................................................13
ENBREL ...........................................42
ENFAMIL PREMIUM LIPIL ...................48
enoxaparin sodium ............................41
entacapone ......................................19
entecavir .......................................... 7
ENTRESTO .......................................15
epinephrine ......................................52
epinephrine inj 0.3mg .......................52
EPIPEN 2-PAK...................................52
EPIPEN-JR 2-PAK ..............................52
epirubicin hcl ....................................11
eplerenone .......................................13
EPOGEN...........................................42
epoprostenol sodium .........................16
EPZICOM .......................................... 5
ERBITUX ..........................................11
ergocalciferol....................................50
ERIVEDGE ........................................11
ERYTHROCIN LACTOBIONATE .............. 4
erythromycin .............................. 56, 59
erythromycin base ............................. 4
erythromycin base ext-rel ................... 4
erythromycin stearate ........................ 4
erythromycin-sulfisoxazole .................. 8
escitalopram oxalate .........................18
esomeprazole magnesium ..................40
ESTRACE .........................................35
estradiol .................................... 34, 35
estradiol & norethindrone acetate .......34
estropipate ......................................35
ethambutol hcl .................................. 7
ethosuximide....................................17
ETHOXY DIGLYCOL REAGENT .............45
ethynodiol diacetate & ethinyl estradiol34
etodolac ........................................... 1
ETOPOPHOS .....................................11
etoposide .........................................11
EVOTAZ ............................................ 5
exemestane..................................... 10
EXJADE ........................................... 42
EXTAVIA ......................................... 27
EYE PATCHES .................................. 46
F
FABRAZYME..................................... 36
famciclovir ........................................ 8
famotidine ....................................... 38
FARESTON ...................................... 10
FARYDAK ........................................ 11
FASLODEX ....................................... 10
fat emulsion .................................... 48
felodipine ........................................ 14
FEMRING ........................................ 35
fenofibrate ...................................... 14
fenofibrate micronized ...................... 14
fentanyl ............................................ 2
ferretts ........................................... 50
FERRIPROX ..................................... 42
ferrous gluconate ............................. 50
ferrous sulfate ................................. 50
ferrous sulfate cap controlled release .. 50
ferrous sulfate controlled release........ 50
ferrous sulfate dried ......................... 50
ferrous sulfate tab enteric coated ....... 50
fexofenadine hcl ............................... 53
fexofenadine-pseudoephedrine tab
sustained-rel 12hr 60-120 mg ........... 52
fexofenadine-pseudoephedrine tab
sustained-rel 24hr 180-240 mg .......... 52
finasteride ....................................... 41
FIRMAGON ...................................... 10
FLAVOR BLEND ................................ 45
flecainide acetate ............................. 13
FLOVENT HFA .................................. 55
floxuridine ......................................... 9
FLUARIX QUADRIVALENT 2016 .......... 44
FLUBLOK 2016-2017 ........................ 44
FLUCELVAX QUADRIVALENT 20 .......... 44
fluconazole ........................................ 5
fludarabine phosphate ........................ 9
fludrocortisone acetate ..................... 35
FLULAVAL QUADRIVALENT 201 .......... 44
FLUMIST QUADRIVALENT .................. 44
flunisolide ....................................... 55
fluorometholone ............................... 60
fluorouracil ........................................ 9
fluorouracil (topical) ......................... 56
68
fluoxetine hcl ...................................18
fluphenazine decanoate .....................22
fluphenazine hcl................................22
flurbiprofen ....................................... 1
flurbiprofen sodium ...........................60
flutamide .......................................... 9
fluticasone propionate ................. 55, 57
FLUVIRIN 2016-2017 ........................44
fluvoxamine maleate .........................16
FLUZONE HIGH-DOSE PF 2016 ...........44
FLUZONE QUADRIVALENT 2016 ..........44
folic acid ..........................................49
folic acid-vitamin b6-vitamin b12 ........49
FOLOTYN .......................................... 9
fondaparinux sodium .........................41
foscarnet sodium ............................... 7
fosinopril sodium ..............................13
fosinopril sodium & hydrochlorothiazide
......................................................13
FREAMINE HBC 6.9% ........................48
FREAMINE III ...................................48
furosemide .......................................15
G
gabapentin .......................................17
gabapentin oral solution 250 mg/5ml ..17
galantamine hydrobromide.................17
GARDASIL........................................44
GELATIN CAPSULES ..........................45
gemcitabine hcl ................................. 9
gemfibrozil .......................................14
gentamicin sulfate....................... 56, 59
gentamicin sulfate inj ......................... 3
GENTEAL .........................................60
GENTEAL MILD .................................61
GENTEAL MILD TO MODERATE............61
GILENYA ..........................................28
GILOTRIF .........................................10
GLASPAK DISPOSABLE 2-1/2M ...........46
GLASSIA ..........................................55
glatopa inj 20mg/ml ..........................28
GLEOSTINE ....................................... 9
GLIADEL WAFER ................................ 9
glimepiride .......................................31
glipizide ...........................................31
glipizide ext-rel tab 10mg ..................31
glipizide ext-rel tab 2.5mg .................31
glipizide ext-rel tab 5mg ....................31
...................................................... 29
...................................................... 29
glipizide-metformin hcl tab 5-500 mg . 29
GLUCAGEN HYPOKIT......................... 35
GLUCAGON EMERGENCY KIT ............. 35
GLUCOSE ........................................ 35
GLUTARADE AMINO ACID BLEN ......... 47
glyburide......................................... 31
glyburide micronized ........................ 32
glyburide-metformin tab 1.25-250 mg 29
glyburide-metformin tab 2.5-500 mg .. 30
glyburide-metformin tab 5-500 mg ..... 30
glycerin-hypromellose-polyethylene
glycol 400 ....................................... 61
GLYCOLIC ACID ............................... 45
glycopyrrolate .................................. 38
GOOD START SUPREME NATURA ........ 48
GOOD START SUPREME W/IRON ........ 48
granisetron hcl ................................. 37
GRAPE FLAVOR ................................ 45
griseofulvin microsize susp 125 mg/5ml 5
griseofulvin ultramicrosize ................... 5
guaifenesin ...................................... 54
guaifenesin tab ext-rel 12hr 600 mg ... 54
guaifenesin-codeine .......................... 53
guanfacine hcl ................................. 13
guanfacine hcl (adhd) ....................... 25
H
H.P. ACTHAR ................................... 36
HALAVEN ........................................ 11
halobetasol propionate ...................... 58
haloperidol ...................................... 23
haloperidol decanoate ....................... 23
haloperidol lactate ............................ 23
HARVONI .......................................... 7
HEARING AID BATTERIES-MISC ......... 46
HEAT WRAPS ................................... 46
HEATING PADS ................................ 46
heparin sodium ................................ 41
heparin sodium (porcine) .................. 41
HERCEPTIN ..................................... 11
HEXALEN .......................................... 9
HOT/COLD THERAPY AIDS - MISC ...... 46
HOT/COLD THERAPY AIDS - PADS ...... 46
HUMALOG ....................................... 30
HUMALOG KWIKPEN ......................... 30
HUMALOG MIX 50/50........................ 30
69
HUMALOG MIX 50/50 KWIKPEN ..........30
HUMALOG MIX 75/25 ........................31
HUMALOG MIX 75/25 KWIKPEN ..........31
HUMIRA ...........................................42
HUMULIN 70/30................................31
HUMULIN 70/30 KWIKPEN .................31
HUMULIN N ......................................31
HUMULIN N KWIKPEN ........................31
HUMULIN R ......................................31
HUMULIN R INJ U-500 VIAL ...............31
HYCAMTIN .......................................12
hydralazine hcl .................................15
hydrochlorothiazide ...........................15
hydrocodone w/ homatropine .............53
hydrocodone-acetaminophen ............... 2
hydrocortisone ........................... 35, 57
hydrocortisone (intrarectal) ................39
hydrocortisone (rectal) ......................40
hydrocortisone acetate ......................57
hydrocortisone butyrate .....................57
hydrocortisone-aloe vera ...................57
hydromorphone hcl ............................ 2
hydroxychloroquine sulfate ................43
hydroxyurea .....................................11
hydroxyzine hcl ................................53
hydroxyzine pamoate ........................53
hyoscyamine sulfate ..........................38
HYPOTEARS .....................................61
hypromellose....................................61
I
IBRANCE..........................................10
ibuprofen .......................................... 2
ibuprofen drop 50mg/1.25ml ............... 2
ibuprofen suspension 100 mg/5ml ....... 2
idarubicin hcl ....................................11
IFEX ................................................. 9
ifosfamide ......................................... 9
ILARIS.............................................43
imatinib mesylate .............................10
IMBRUVICA ......................................10
imipenem-cilastatin ............................ 3
imipramine hcl..................................19
imiquimod........................................58
INCONTINENCE SUPPLIES DISPOSABLE MISC ...............................................46
INCRELEX ........................................35
indapamide ......................................15
INFED .............................................50
INLYTA ........................................... 10
INSULIN INFUSION DISPOSABLE PUMP
KIT ................................................. 32
INSULIN INFUSION DISPOSABLE PUMP
SUPPLIES ........................................ 32
INSULIN INFUSION PUMP - ACCESSORIES
...................................................... 32
INSULIN INFUSION PUMP - DEVICE .... 32
INSULIN INFUSION PUMP - KIT .......... 32
INSULIN INFUSION PUMP SUPPLIES ... 32
INTELENCE ........................................ 6
INTRON A ....................................... 43
INTRON A W/DILUENT ...................... 43
INVANZ ............................................ 3
INVEGA TRINZA ............................... 20
INVIRASE CAP 200MG ........................ 6
INVIRASE TAB 500MG ........................ 6
INVOKAMET..................................... 31
INVOKANA ...................................... 31
iodoquinol-hc ................................... 57
ipratropium bromide .................... 52, 55
ipratropium-albuterol ........................ 52
irbesartan ....................................... 13
irbesartan-hydrochlorothiazide ........... 13
irinotecan hcl ................................... 12
iron polysaccharide complex-vit b12-folic
acid ................................................ 50
ISENTRESS ....................................... 5
ISENTRESS POW 100MG ..................... 5
ISENTRESS TAB 400MG ...................... 5
isoniazid ........................................... 7
isosorbide dinitrate ........................... 15
isosorbide mononitrate ..................... 15
isotretinoin ...................................... 56
ISTODAX ......................................... 11
itraconazole cap ................................. 5
ivermectin ......................................... 8
IXEMPRA KIT ................................... 11
J
JAKAFI ............................................ 10
JANUMET ........................................ 30
JANUMET XR TAB 100-1000............... 30
JANUMET XR TAB 50-1000 ................ 30
JANUMET XR TAB 50-500MG.............. 30
JANUVIA ......................................... 30
JENTADUETO ................................... 30
JEVTANA ......................................... 11
70
K
KALETRA SOL .................................... 6
KALETRA TAB 100-25MG .................... 6
KALETRA TAB 200-50MG .................... 6
KEPIVANCE ......................................39
ketoconazole ....................................57
KETO-DIASTIX .................................32
ketoprofen ........................................ 2
ketorolac tromethamine ................. 2, 60
ketotifen fumarate ............................60
KP PRENATAL MULTIVITAMINS ...........52
KRISTALOSE ....................................39
KRYSTEXXA....................................... 1
KUVAN ............................................36
L
labetalol hcl .....................................14
lactic acid (ammonium lactate) ...........58
lactic acid w/ vitamin e ......................58
LACTOSE .........................................45
LACTOSE HYDROUS ..........................45
lactulose ..........................................39
lactulose (encephalopathy) ................39
lamivudine ........................................ 7
lamivudine (hbv) ............................... 7
lamivudine-zidovudine ........................ 5
lamotrigine ......................................17
LANCET DEVICES ..............................32
lancets ............................................32
LANCETS KIT....................................32
LANCETS MISC. ................................32
LANOXIN .........................................15
lansoprazole cap delayed release 15 mg
......................................................40
latanoprost ......................................61
leflunomide ......................................43
LENVIMA .........................................10
LETAIRIS .........................................15
letrozole ..........................................10
leucovorin calcium ............................11
LEUCOVORIN CALCIUM ......................11
leucovorin calcium for inj ...................12
LEUCOVORIN CALCIUM FOR INJ .........12
LEUKERAN ........................................ 9
LEUKINE INJ ....................................42
leuprolide acetate .............................10
levetiracetam ...................................17
levobunolol hcl .................................60
levofloxacin .................................. 4, 59
levofloxacin in d5w ............................. 4
levoleucovorin calcium ...................... 12
levonorgestrel & ethinyl estradiol ....... 34
levonorgestrel tab 1.5 mg ................. 33
levonorgestrel-ethinyl estradiol (91-day)
...................................................... 33
levonorgestrel-ethinyl estradiol tab
(triphasic) ....................................... 34
levothyroxine sodium........................ 36
LEXIVA SUS 50MG/ML ........................ 6
LEXIVA TAB 700MG ............................ 6
lidocaine hcl soln 4% ........................ 58
lidocaine patch 5% ........................... 58
lidocaine-benzalkonium ..................... 58
lidocaine-prilocaine ........................... 58
linezolid ............................................ 8
LINZESS ......................................... 39
liothyronine sodium .......................... 36
lisinopril .......................................... 13
lisinopril & hydrochlorothiazide........... 13
lithium carbonate ............................. 27
LITHIUM ORAL SOLUTION 8 MEQ/5ML 27
LOMUSTINE CAP 5 MG ........................ 9
loperamide hcl ................................. 37
loperamide-simethicone .................... 40
loratadine........................................ 53
loratadine & pseudoephedrine tab ext-rel
12hr 5-120 mg ................................ 52
loratadine & pseudoephedrine tab ext-rel
24hr 10-240 mg............................... 52
lorazepam ....................................... 16
lorazepam 2mg/ml ........................... 16
losartan potassium ........................... 13
losartan potassium & hydrochlorothiazide
...................................................... 13
lovastatin ........................................ 14
LUCENTIS ....................................... 61
LUMIZYME ....................................... 36
LUPRON DEPOT ................................ 10
LUPRON DEPOT-PED ......................... 36
LYNPARZA ....................................... 12
LYRICA ........................................... 26
LYRICA SOLUTION 20MG/ML ............. 26
LYSODREN ...................................... 12
M
MACUGEN ....................................... 61
magnesium hydroxide....................... 39
MAKENA .......................................... 36
71
malathion ........................................59
MARPLAN .........................................17
MASKS ............................................54
MATULANE .......................................12
meclizine hcl ....................................37
medroxyprogesterone acetate ...... 33, 36
mefloquine hcl ................................... 5
megestrol acetate ....................... 10, 45
MEKINIST ........................................10
meloxicam ........................................ 2
melphalan hcl .................................... 9
memantine hcl tab 10 mg ..................17
memantine hcl tab 5 mg ....................17
MENACTRA .......................................45
MENOMUNE-A/C/Y/W-135 ..................45
MEPHYTON .......................................50
mercaptopurine ................................. 9
meropenem ...................................... 3
mesalamine .....................................39
mesalamine w/ cleanser ....................39
mesna .............................................12
MESNEX ..........................................12
METASTRON .....................................12
metformin hcl ...................................30
metformin tab 500mg ext-rel .............30
metformin tab 750mg ext-rel .............30
methadone hcl................................... 2
methazolamide .................................60
methimazole ....................................36
methocarbamol ................................28
methotrexate sodium ......................... 9
methylcellulose .................................39
methyldopa ......................................15
methylergonovine maleate .................36
METHYLPARABEN ..............................45
methylphenidate hcl ..........................25
methylphenidate hcl cap controlled
release 10 mg ..................................25
release 20 mg ..................................25
release 30 mg ..................................25
release 40 mg ..................................25
release 50 mg ..................................25
release 60 mg ..................................25
methylphenidate hcl cap sustained-rel
24hr 20 mg ..................................... 26
24hr 30 mg ..................................... 26
24hr 40 mg ..................................... 26
...................................................... 26
...................................................... 26
methylphenidate hcl tab
controlled-release ............................ 26
methylphenidate tab 20mg ext-rel ..... 26
methylprednisolone .......................... 35
metipranolol .................................... 60
metoclopramide hcl .......................... 37
metolazone ..................................... 15
metoprolol & hydrochlorothiazide ....... 14
metoprolol succinate......................... 14
metoprolol tartrate ........................... 14
metronidazole .............................. 8, 59
metronidazole cream 0.75% .............. 59
metronidazole in nacl 0.79% iv soln 500
mg/100ml ......................................... 8
metronidazole inj ............................... 8
metronidazole vaginal ....................... 41
miconazole nitrate ............................ 57
miconazole nitrate vaginal ................. 41
miconazole nitrate vaginal cream ....... 41
MICROCLENS WIPES......................... 58
midodrine hcl ................................... 15
MIRENA .......................................... 34
mirtazapine ..................................... 17
misoprostol ..................................... 40
MISSION PRENATAL ......................... 52
mitomycin ....................................... 12
mitoxantrone hcl .............................. 12
modafinil ......................................... 28
MODULEN IBD ................................. 48
MOISTURE EYES .............................. 61
mometasone furoate ........................ 58
MONOJECT 20ML SYRINGE REG ......... 46
MONOJECT SOFTPACK 20ML/LT ......... 47
MONOJECT SOFTPACK 35ML/RE ......... 47
MONOJECT SYRINGE/ECCENTRI ......... 47
MONOJECT SYRINGE/LUER LOC ......... 47
MONOJECT SYRINGE/LUER-LOC ......... 47
montelukast sodium ......................... 54
72
morphine sulfate controlled-release...... 2
morphine sulfate sol 100/5ml .............. 2
morphine sulfate solution .................... 2
morphine sulfate suppositories ............ 2
morphine sulfate tab .......................... 2
MOZOBIL .........................................42
MULTIFIT REUSABLE SYRINGE............47
MULTIFIT REUSABLE TB SYRI .............47
multiple vitamin ................................50
multiple vitamins w/ calcium ..............50
multiple vitamins w/ iron ...................50
multiple vitamins w/ minerals ....... 50, 51
multiple vitamins w/ minerals tab
controlled release .............................51
MULTISTIX 10 SG .............................46
mupirocin ........................................56
mupirocin calcium .............................56
MUSTARGEN ..................................... 9
mycophenolate mofetil ......................43
MYLERAN .......................................... 9
N
nabumetone ...................................... 2
nadolol ............................................14
nafcillin sodium inj ............................. 4
NAGLAZYME .....................................36
naloxone hcl .....................................28
naltrexone hcl ..................................28
NAMENDA SOL 10MG/5ML .................17
NAMENDA TITRATION PAK .................17
naproxen .......................................... 2
naproxen sodium ............................... 2
naratriptan hcl ..................................27
NASACORT AER 55MCG/AC ................55
NATACYN .........................................60
nateglinide .......................................31
NATRAPEL 12-HOUR TICK & I .............58
NEBULIZERS ....................................54
neomycin sulfate ............................... 3
neomycin-bacitracin zinc-polymyxin ....60
neomycin-bacitracin-polymyxin ..........56
neomycin-polymyxin-dexamethasone
ophth oint 0.1% ...............................59
neomycin-polymyxin-dexamethasone
ophth susp 0.1% ..............................59
neomycin-polymyxin-gramicidin .........60
neomycin-polymyxin-hc .....................62
neomycin-polymyxin-hc ophth susp ....59
NEORAL ...........................................43
NEPHRAMINE ................................... 48
NESTLE FLAVOR ............................... 48
NEULASTA ....................................... 42
NEUPOGEN ...................................... 42
NEUTREXIN ....................................... 8
nevirapine ......................................... 6
nevirapine tab 100 mg ext-rel.............. 6
nevirapine tab 400mg ext-rel............... 6
NEXAVAR ........................................ 11
NEXIUM 24HR .................................. 40
NEXIUM GRANULES 2.5 MG, 5MG AND
10MG DELAYED RELEASE .................. 40
NEXPLANON .................................... 33
niacin (antihyperlipidemic) ................ 14
nicotine polacrilex gum ..................... 29
nicotine polacrilex lozenge ................. 29
nicotine transdermal patch ................ 29
NICOTROL INHALER ......................... 29
NICOTROL NS .................................. 29
nifedipine ........................................ 14
nifedipine ext-rel .............................. 14
nilutamide ....................................... 10
NIPENT ........................................... 12
nitrofurantoin .................................... 8
nitrofurantoin macrocrystal ................. 8
nitrofurantoin monohydrate
macrocrystalline cap 100 mg ............... 8
nitroglycerin .................................... 15
NITROSTAT ..................................... 15
nizatidine ........................................ 38
NONOXYNOL-9................................. 33
NORDITROPIN FLEXPRO .................... 35
norelgestromin-ethinyl estradiol ......... 34
norethindrone .................................. 34
norethindrone & ethinyl estradiol tab .. 34
norethindrone & mestranol ................ 34
norethindrone ace & ethinyl estradiol .. 34
norethindrone ace & ethinyl estradiol-fe
...................................................... 34
norethindrone acetate....................... 36
norethindrone acetate-ethinyl estradiol 34
norethindrone-ethinyl estradiol (triphasic)
...................................................... 34
norgestimate-ethinyl estradiol ........... 34
norgestimate-ethinyl estradiol (triphasic)
...................................................... 34
norgestimate-ethinyl estradiol tab
0.18-25/0.215-25/0.25-25 mg-mcg ... 34
73
norgestrel & ethinyl estradiol ..............34
NORPACE CR ....................................13
nortriptyline hcl ................................19
NORVIR CAP 100MG ........................... 6
NORVIR SOL 80MG/ML ....................... 6
NORVIR TAB 100MG ........................... 6
NOVOLIN 70/30 ................................31
NOVOLIN N ......................................31
NOVOLIN R ......................................31
NOVOLOG ........................................31
NOVOLOG FLEXPEN ...........................31
NOVOLOG MIX 70/30 ........................31
NOVOLOG MIX 70/30 PREFILL ............31
NOVOLOG PENFILL............................31
NOVOPEN 3 PENMATE .......................32
NPLATE............................................42
NUEDEXTA .......................................28
NUPLAZID ........................................20
NUVARING .......................................34
NUVIGIL ..........................................28
nystatin ....................................... 5, 57
nystatin (mouth-throat) ...................... 5
nystatin (topical) ..............................57
nystatin-triamcinolone .......................57
O
octreotide acetate .............................36
OFEV ...............................................55
OFF ACTIVE .....................................58
OFF DEEP WOODS ............................58
OFF DEEP WOODS DRY......................58
OFF SMOOTH & DRY ..........................58
ofloxacin .................................... 60, 62
olanzapine .......................................20
olanzapine orally disintegrating tab .....20
omega-3 fatty acids ..........................51
omeprazole cap delayed release .........40
omeprazole magnesium cap delayed
release 20.6 mg (20 mg base equiv) ...40
omeprazole-sodium bicarbonate .........40
ONCASPAR .......................................12
ondansetron hcl ................................38
ondansetron orally disintegrating tab ..38
oral electrolytes ................................48
ORA-SWEET SF.................................45
orphenadrine citrate ..........................28
orphenadrine w/ aspirin & caffeine tab.28
OSPHENA .........................................36
OSTOMY SUPPLIES - CREAM ..............47
OSTOMY SUPPLIES - LIQUID ............. 47
OSTOMY SUPPLIES - MISC ................ 47
OSTOMY SUPPLIES - OINT ................ 47
OSTOMY SUPPLIES - PASTE ............... 47
OSTOMY SUPPLIES - POUCH .............. 47
OSTOMY SUPPLIES - POWDER ........... 47
OSTOMY SUPPLIES - STRIP ............... 47
OSTOMY SUPPLIES - WAFER (SKIN
BARRIER) ........................................ 47
OSTOMY SUPPLIES IRRIGATION KIT ... 47
oxacillin sodium inj ............................. 4
oxaliplatin ......................................... 9
oxaprozin .......................................... 2
oxazepam ....................................... 16
oxcarbazepine ................................. 17
oxybutynin chloride .......................... 41
oxybutynin chloride tab sustained-rel
24hr 10 mg ..................................... 41
24hr 15 mg ..................................... 41
24hr 5 mg ....................................... 41
oxycodone hcl .................................... 2
oxycodone w/ acetaminophen .......... 2, 3
oxycodone-aspirin .............................. 3
oxymetazoline hcl ............................ 56
OXYTROL FOR WOMEN...................... 41
oyster shell ..................................... 51
P
paclitaxel ........................................ 12
paliperidone .................................... 20
PARAGARD INTRAUTERINE COP ......... 33
parenteral electrolytes ...................... 49
paroxetine hcl .................................. 18
PAXIL SUSPENSION 10MG/5ML .......... 18
PEAK FLOW METER ........................... 54
pediatric multiple vitamin w/ c ........... 51
pediatric multiple vitamin w/ c & fa .... 51
pediatric multiple vitamin w/ extra c & fa
...................................................... 51
pediatric multiple vitamin w/ minerals & c
...................................................... 51
pediatric multiple vitamins ................ 51
pediatric multiple vitamins w/ iron...... 51
pediatric multivitamins w/fluoride....... 51
pediatric multivitamins w/fluoride & iron
...................................................... 51
pediatric vitamins acd w/ fluoride ....... 51
74
pediatric vitamins adc........................51
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate .............................................39
peg 3350-potassium chloride-sod
bicarbonate-sod chloride ....................39
PEGASYS .........................................43
PEGASYS PROCLICK ..........................43
PEG-INTRON ....................................43
PEG-INTRON REDIPEN .......................43
PEG-INTRON REDIPEN PAK 4 .............43
penicillin g potassium ......................... 4
penicillin g procaine ........................... 4
penicillin v potassium ......................... 4
PENTAM 300 ..................................... 8
permethrin .......................................59
permethrin cream .............................59
perphenazine ...................................23
phenazopyridine hcl ..........................41
phenelzine sulfate .............................17
phenobarbital ...................................17
phenylephrine-promethazine w/ codeine
syrup 5-6.25-10 mg/5ml ...................53
phenytoin ........................................17
phenytoin sodium extended ...............17
PHOTOFRIN......................................12
pilocarpine hcl (oral) .........................40
pindolol ...........................................14
pioglitazone hcl ................................30
pioglitazone hcl-glimepiride ................30
pioglitazone hcl-metformin hcl ............30
piperacillin sodium-tazobactam sodium. 4
PNEUMOVAX 23 ................................45
podofilox..........................................58
POLOX .............................................45
polyethylene glycol 3350 ...................39
POLYETHYLENE GLYCOL 400 ..............46
polyethylene glycol-polyvinyl alcohol ...61
polymyxin b sulfate ............................ 8
polymyxin b-trimethoprim..................60
polysaccharide iron complex ...............51
polyvinyl alcohol ...............................61
polyvinyl alcohol-povidone .................61
POMALYST .......................................10
POTASSIUM & SODIUM PHOSPHATES
POWDER PACK 280-160-250 MG ........48
potassium bicarbonate.......................48
potassium chloride ............................48
potassium chloride tab controlled release
...................................................... 48
potassium citrate (alkalinizer) ............ 41
potassium phosphate monobasic w/
sodium phosphate dibasic & monobasic
tab ................................................. 48
povidone-iodine .......................... 58, 59
pramipexole dihydrochloride .............. 19
pravastatin sodium ........................... 14
prednisolone .................................... 35
prednisolone acetate ........................ 60
prednisolone orally disintegrating tab . 35
prednisolone sodium phosphate ......... 35
prednisone ...................................... 35
PREMARIN ....................................... 35
PRENATAL ....................................... 52
prenatal vit w/ docusate-fe fumarate-folic
acid ................................................ 52
prenatal vit w/ docusate-iron
carbonyl-folic acid ............................ 52
prenatal vit w/ ferrous fumarate-folic acid
...................................................... 52
prenatal vit w/ iron carbonyl-folic acid 52
PREVNAR 13 .................................... 45
PREZCOBIX ....................................... 5
PREZISTA.......................................... 6
primidone........................................ 17
PROAIR HFA .................................... 54
probenecid ........................................ 1
PROCALAMINE ................................. 48
prochlorperazine .............................. 38
prochlorperazine maleate .................. 38
progesterone micronized cap ............. 36
PROLIA ........................................... 33
PROMACTA ...................................... 42
promethazine & phenylephrine ........... 52
promethazine hcl ............................. 38
promethazine w/codeine ................... 53
promethazine/dextromethorphan ....... 53
propafenone hcl ............................... 13
propranolol hcl ................................. 14
propylthiouracil ................................ 36
PROSOL .......................................... 48
PROTEIN FORTIFIED COOKIE ............. 48
pseudoephedrine hcl ......................... 54
pseudoephedrine hcl tab ext-rel 12hr 120
mg ................................................. 54
pseudoephedrine w/ codeine-guaifenesin
...................................................... 53
75
pseudoephedrine-brompheniramine-dext
romethorphan ..................................53
pseudoephedrine-guaifenesin tab ext-rel
12hr ................................................54
pseudoephedrine-guaifenesin tab sr 12hr
......................................................54
PTS PANELS KETONE TEST .................33
PULMOZYME .....................................54
pyrantel pamoate............................... 8
pyrazinamide .................................... 7
pyridostigmine bromide .....................28
pyridoxine hcl tab 50 mg ...................51
Q
QUADRAMET ....................................12
quetiapine fumarate ..........................20
quinapril hcl .....................................13
quinapril-hydrochlorothiazide .............13
QVAR ..............................................55
R
ra oyster shell calcium/v ....................51
ramipril ...........................................13
ranitidine hcl ....................................38
RASPBERRY SYRUP ...........................46
rebetol sol 40mg/ml ........................... 7
REBIF ..............................................28
REBIF REBIDOSE TITRATION..............28
REFRESH .........................................61
REFRESH OPTIVE ..............................61
REFRESH OPTIVE ADVANCED .............61
REFRESH PLUS .................................61
RELION GLUCOSE .............................35
REMODULIN .....................................16
RENVELA PAK ...................................36
repaglinide .......................................31
repaglinide 0.5 mg ............................31
REPATHA .........................................14
REPEL SPORTSMEN ...........................59
REPEL SPORTSMEN MAX ....................59
RESCRIPTOR ..................................... 6
RESOURCE JUICE DRINK ...................48
REVLIMID ........................................10
REYATAZ .......................................... 6
RHO D IMMUNE GLOBULIN.................43
ribavirin ............................................ 7
rifabutin cap 150 mg .......................... 8
rifampin ............................................ 7
riluzole ............................................27
RISPERDAL CONSTA..........................20
risperidone ................................. 21, 22
rivastigmine .................................... 17
rivastigmine tartrate ......................... 17
rizatriptan benzoate ......................... 27
ropinirole hydrochloride .................... 19
S
SABRIL ........................................... 17
saline ............................................. 55
SAMSCA ..................................... 36, 37
SANDIMMUNE .................................. 43
SANTYL ........................................... 59
selegiline hcl .................................... 19
selenium sulfide lotion 1% ................ 57
selenium sulfide lotion 2.5% .............. 57
SELZENTRY TAB 150MG ...................... 5
SELZENTRY TAB 300MG ...................... 5
sennosides ...................................... 39
sennosides-docusate sodium ............. 39
SENSIPAR ....................................... 33
SEREVENT DISKUS ........................... 54
sertraline hcl ................................... 18
sevelamer carbonate ........................ 36
sildenafil citrate (pulmonary
hypertension) .................................. 15
silver sulfadiazine ............................. 56
simethicone ..................................... 40
simvastatin ..................................... 14
sirolimus ......................................... 43
SKYLA............................................. 34
SM BORIC ACID ............................... 46
sodium bicarbonate .......................... 37
SODIUM BISULFITE .......................... 46
sodium chloride ............................... 55
sodium chloride hypertonic ................ 61
sodium fluoride ................................ 51
sodium fluoride (dental) .................... 59
sodium fluoride solution .................... 51
SODIUM HYDROXIDE ........................ 46
sodium polystyrene sulfonate ............ 48
SOLIRIS .......................................... 42
SOLTAMOX ...................................... 10
SOMATULINE DEPOT ........................ 36
SOMAVERT ...................................... 36
sotalol hcl ....................................... 13
sotalol hcl (afib/afl) .......................... 13
SOVALDI ........................................... 7
SPACER/AEROSOL-HOLDING CHAMBER
SUPPLIES - MASKS ........................... 55
76
SPACER/AEROSOL-HOLDING CHAMBERS
- DEVICE .........................................55
spinosad ..........................................59
SPIRIVA HANDIHALER .......................52
SPIRIVA RESPIMAT ...........................52
spironolactone ..................................13
spironolactone & hydrochlorothiazide ..15
SPORANOX ....................................... 5
SQUARIC ACID DIBUTYLESTER POWDER
......................................................46
stavudine cap .................................... 7
stavudine soln ................................... 7
STEVIA EXTRACT ..............................46
STIMATE ..........................................37
STIVARGA ........................................11
STRATTERA ......................................26
streptomycin sulfate ........................... 3
STRIBILD .......................................... 5
sucralfate tab 1 gm ...........................40
sulfacetamide sodium ........................60
sulfacetamide sod-prednisolone ..........59
sulfamethoxazole-trimethoprim ........... 4
sulfamethoxazole-trimethoprim ds ....... 4
sulfasalazine ....................................38
sulindac ............................................ 2
sumatriptan spray .............................27
sumatriptan succinate .......................27
SUPPOSIBASE F ................................46
SUPPRELIN LA ..................................36
SUPREP BOWEL PREP ........................39
SUSTIVA ........................................... 6
SUTENT ...........................................11
SYLATRON .......................................43
SYMBICORT .....................................56
SYMLINPEN 120 ................................29
SYMLINPEN 60 .................................29
SYNAGIS .........................................43
SYNAREL .........................................34
SYNERCID......................................... 8
SYNTHROID .....................................36
syringe (disposable) ..........................47
SYSTANE .........................................61
SYSTANE BALANCE RESTORATI ..........61
SYSTANE OVERNIGHT THERAPY..........61
T
TABLOID........................................... 9
tacrolimus ........................................43
tacrolimus oint 0.03% .......................58
tacrolimus oint 0.1% ........................ 58
TAFINLAR ........................................ 11
TAMIFLU ........................................... 8
TAMIFLU SUS 6MG/ML ........................ 8
tamoxifen citrate .............................. 10
tamsulosin hcl ................................. 41
TANZEUM ........................................ 30
TARCEVA ........................................ 11
TAZORAC ........................................ 56
TEARS NATURALE PM ....................... 61
TECFIDERA ...................................... 28
TECFIDERA STARTER PACK ............... 28
TEFLARO ........................................... 4
TEGRETOL ....................................... 17
TEGRETOL-XR .................................. 17
temazepam ..................................... 26
temozolomide .................................... 9
TENIPOSIDE .................................... 12
terazosin hcl .................................... 13
terbinafine hcl tab .............................. 5
terbutaline sulfate ............................ 54
terconazole vaginal .......................... 41
TERUMO SURGUARD2 SYRINGE/ ........ 47
testosterone cypionate ...................... 29
testosterone enanthate ..................... 29
testosterone gel ............................... 29
TETANUS/DIPHTHERIA TOXOID ......... 45
tetrabenazine .................................. 26
tetracycline hcl .................................. 5
THALOMID ...................................... 10
THEO-24 ......................................... 56
theophylline .................................... 56
THERACYS....................................... 12
THERATEARS ................................... 61
THERMOMETERS .............................. 47
thiamine hcl .................................... 51
thiamine mononitrate ....................... 51
thioridazine hcl ................................ 23
thiothixene ...................................... 23
THYROGEN ...................................... 36
thyroid ............................................ 36
tiagabine hcl .................................... 17
TICE BCG ........................................ 12
TIKOSYN ......................................... 13
timolol maleate ........................... 14, 60
TIVICAY ............................................ 6
tizanidine hcl ................................... 28
tobramycin ...................................... 60
77
tobramycin inj ................................... 3
tobramycin neb 300/5ml inhalation .....54
tobramycin-dexamethasone ...............59
TOLEREX .........................................48
tolnaftate .........................................57
tolnaftate aerosol powder 1% .............57
tolnaftate cream 1% .........................57
TOOMEY SYRINGE.............................47
topiramate .......................................17
topotecan hcl ...................................12
TORISEL ..........................................11
torsemide ........................................15
TOTECT ...........................................12
TRACE MINERALS (CR-CU-MN-ZN) INJ
1-100-30-500 MCG/ML ......................49
TRACLEER ........................................15
TRADJENTA ......................................30
tramadol hcl ...................................... 3
tramadol hcl ext-rel............................ 3
TRAMADOL HCL EXT-REL .................... 3
tramadol-acetaminophen .................... 3
trandolapril ......................................13
tranylcypromine sulfate .....................17
trazodone hcl ...................................17
TREANDA .......................................... 9
TRELSTAR ........................................10
TRELSTAR MIXJECT ...........................10
TRESIBA FLEXTOUCH ........................31
tretinoin (chemotherapy) ...................12
TREXALL ........................................... 9
triamcinolone acetonide (mouth) ........59
triamcinolone acetonide (topical) .. 57, 58
triamterene & hydrochlorothiazide ......15
trifluoperazine hcl ....................... 23, 24
trifluridine ........................................60
trihexyphenidyl hcl ............................19
trimethobenzamide hcl ......................38
trimethoprim ..................................... 8
triprolidine & pseudoephedrine ...........52
TRISENOX........................................12
TRIUMEQ .......................................... 5
TROPHAMINE ...................................48
trospium chloride ..............................41
trospium chloride cap sustained-rel 24hr
60 mg .............................................41
TRUVADA .......................................... 5
TUDORZA PRESSAIR .........................52
TYBOST ............................................ 5
TYGACIL ........................................... 8
TYKERB........................................... 11
TYVASO STARTER ............................ 16
TYZEKA............................................. 7
U
ULESFIA .......................................... 59
UPTRAVI ......................................... 16
URINE GLUCOSE MONITORING SUPPLIES
...................................................... 33
ursodiol .......................................... 38
UVADEX .......................................... 12
V
VAGIFEM ......................................... 35
valacyclovir hcl .................................. 8
valganciclovir hcl ................................ 7
valganciclovir hcl tab 450 mg .............. 7
valproate sodium ............................. 17
valproic acid .................................... 17
valsartan ......................................... 13
valsartan-hydrochlorothiazide ............ 13
VALSTAR ......................................... 12
vancomycin hcl .................................. 8
vancomycin hcl in dextrose inj ............. 8
vancomycin inj................................... 8
VANTAS .......................................... 10
VAPORIZERS ................................... 55
VECTIBIX ........................................ 12
VELCADE......................................... 12
VENCLEXTA ..................................... 12
VENCLEXTA STARTING PACK ............. 12
venlafaxine hcl ................................. 17
venlafaxine hcl ext-rel ...................... 18
VENTAVIS ....................................... 16
VENTOLIN HFA................................. 54
verapamil ext-rel hcl......................... 15
V-GO .............................................. 33
VIBATIV ............................................ 8
VICTOZA ......................................... 30
VIDEX PEDIATRIC SOLN...................... 7
vinblastine sulfate ............................ 12
vincristine sulfate ............................. 12
vinorelbine tartrate........................... 12
VIRACEPT.......................................... 6
VIREAD ............................................. 7
VISTOGARD..................................... 33
VITEKTA ........................................... 6
VIVITROL ........................................ 28
VOLTAREN GEL .................................. 2
78
voriconazole ...................................... 5
VOTRIENT ........................................11
VPRIV ..............................................36
W
warfarin sodium ................................41
WHEY PROTEIN DRINK MIX ................47
WINRHO SDF ...................................43
X
XALKORI..........................................11
XARELTO .........................................41
XGEVA.............................................33
XIAFLEX ..........................................59
XOLAIR............................................55
Y
YALE NEEDLES 30G X 1-1/2" ..............47
YERVOY ...........................................12
Z
ZANOSAR ......................................... 9
ZARONTIN .......................................17
ZELBORAF .......................................11
ZENPEP ...........................................40
ZEPATIER ......................................... 7
ZERBAXA .......................................... 3
ZETIA ..............................................14
ZEVALIN Y-90 .................................. 12
ZIAGEN SOL 20MG/ML ........................ 7
zidovudine cap 100 mg ....................... 7
zidovudine syrup 10 mg/ml ................. 7
zidovudine tab 300 mg ....................... 7
zinc oxide ........................................ 59
ziprasidone hcl ................................. 22
ZOLADEX ........................................ 10
zoledronic acid ................................. 33
ZOLINZA ......................................... 12
zolmitriptan ..................................... 27
zolpidem tartrate ............................. 27
zolpidem tartrate ext-rel ................... 27
zonisamide ...................................... 17
ZONTIVITY ...................................... 42
ZORBTIVE ....................................... 35
ZOSTAVAX ...................................... 45
ZOSYN .............................................. 4
ZYDELIG ......................................... 11
ZYKADIA ......................................... 11
ZYPREXA RELPREVV ......................... 22
ZYTIGA ........................................... 10
ZYVOX SUS 100MG/5M ....................... 8
79

Affinity Health Plan Managed Medicaid Formulary

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