2016 AlohaCare Advantage Plus Formulary (HMO SNP) (List of

Transcription

ALOHACARE ADVANTAGE PLUS (HMO SNP) PLAN
2016 FORMULARY
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT
THE DRUGS WE COVER IN THIS PLAN
Formulary ID 00016449, Version 13
This formulary was updated on February 1, 2016. For more recent information or other questions,
please contact AlohaCare Advantage Plus (HMO SNP) Member Services at 1-866-973-6395, or, for
TTY/TDD users, 1-877-447-5990, 8 a.m. to 8 p.m., 7 days a week, or visit www.AlohaCare.org.
AlohaCare Advantage Plus is an HMO plan with a Medicare contract and a contract with the Hawaii
Medicaid Program. Enrollment in AlohaCare Advantage Plus depends on contract renewal.
H5969_108505_1 Accepted
LEGEND
SYMBOL
NAME
DESCRIPTION
Quantity Limit
For certain drugs, AlohaCare Advantage Plus limits the
amount of drug that AlohaCare Advantage Plus will
cover.
Prior Authorization
AlohaCare Advantage Plus requires you or your
physician to get prior authorization for certain drugs.
This means that you will need to get approval from
AlohaCare Advantage Plus before you fill your
prescriptions. If you don't get approval, AlohaCare
Advantage Plus may not cover the drug.
ST
Step Therapy
In some cases, AlohaCare Advantage Plus requires
you to first try certain drugs to treat your medical
condition before we will cover another drug for that
condition.
LA
Limited Access
This drug may be available only at certain pharmacies.
PA B vs D
Prior Authorization- Part B
vs. Part D
Medicare Part B vs. Part D determination required.
QL
PA
1
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
ABELCET 100 MG/20 ML VIAL
PA B vs D
AMBISOME 50 MG VIAL
PA B vs D
amphotericin b 50 mg vial
PA B vs D
ANCOBON (250 MG CAPSULE, 500 MG CAPSULE)
CANCIDAS (50 MG VIAL, 70 MG VIAL)
PA B vs D
clotrimazole 10 mg troche
ERAXIS (WATER DILUENT) (50 MG VIAL, 100 MG
VIAL)
PA B vs D
fluconazole (10 mg/ml susp recon, 40 mg/ml susp
recon, 50 mg tablet, 100 mg tablet, 200 mg tablet)
fluconazole 150 mg tablet
QL (2 PER 30 DAYS)
fluconazole in dextrose, iso-osmotic (200mg/0.1l,
400mg/0.2l)
PA B vs D
flucytosine (250 mg capsule, 500 mg capsule)
GRIS-PEG (125 MG TABLET, 250 MG TABLET)
griseofulvin ultramicrosize (125 mg tablet, 250 mg
tablet)
griseofulvin, microsize (125 mg/5ml oral susp, 500 mg
tablet)
griseofulvin,microsize 125 mg/5ml oral susp
itraconazole 100 mg capsule
QL (120 PER 30 DAYS)
ketoconazole 200 mg tablet
MYCAMINE (50 MG VIAL, 100 MG VIAL)
PA B vs D
NOXAFIL 40 MG/ML SUSPENSION
nystatin (50mm unit powder(ea), 150mm unit
powder(ea), 500mm unit powder(ea), 500k unit tablet,
100000/ml oral susp)
ONMEL 200 MG TABLET
SPORANOX 10 MG/ML SOLUTION
You can find information on what the symbols and abbreviations
on this table mean by going to page 1.
2
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
terbinafine hcl 250 mg tablet
VFEND (40 MG/ML SUSPENSION, 50 MG TABLET,
200 MG TABLET)
VFEND IV 200 MG VIAL
PA B vs D
voriconazole (50 mg tablet, 200 mg tablet, 200 mg/5ml
susp recon)
voriconazole 200 mg vial
PA B vs D
ANTIVIRALS
abacavir sulfate 300 mg tablet
abacavir/lamivudine/zidovudine 150-300mg tablet
acyclovir (5 % oint. (g), 200 mg capsule, 200 mg/5ml
oral susp, 400 mg tablet, 800 mg tablet)
acyclovir sodium (50 mg/ml vial, 500 mg vial, 1000 mg
vial)
adefovir dipivoxil 10 mg tablet
amantadine hcl (50 mg/5 ml syrup, 50 mg/5 ml solution,
100 mg tablet, 100 mg capsule)
APTIVUS (100 MG/ML SOLUTION, 250 MG
CAPSULE)
ATRIPLA TABLET
BARACLUDE (0.05 MG/ML SOLUTION, 0.5 MG
TABLET, 1 MG TABLET)
cidofovir 75 mg/ml vial
COMBIVIR TABLET
COMPLERA TABLET
CRIXIVAN (200 MG CAPSULE, 400 MG CAPSULE)
CYTOVENE 500 MG VIAL
PA B vs D
didanosine (125 mg capsule dr, 200 mg capsule dr, 250
mg capsule dr, 400 mg capsule dr)
EDURANT 25 MG TABLET
EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE)
entecavir (0.5 mg tablet, 1 mg tablet)
3
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET,
300 MG TABLET)
EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET)
EPZICOM TABLET
EVOTAZ 300 MG-150 MG TABLET
famciclovir (125 mg tablet, 250 mg tablet, 500 mg
tablet)
foscarnet sodium 24 mg/ml infus. btl
FUZEON (90 MG VIAL, CONVENIENCE KIT)
ganciclovir sodium 500 mg vial
PA B vs D
HEPSERA 10 MG TABLET
QL (30 PER 30 DAYS)
INTELENCE (25 MG TABLET, 100 MG TABLET, 200
MG TABLET)
INVIRASE (200 MG CAPSULE, 500 MG TABLET)
ISENTRESS (25 MG TABLET CHEW, 100 MG
POWDER PACKET, 100 MG TABLET CHEW, 400 MG
TABLET)
KALETRA (100-25 MG TABLET, 200-50 MG TABLET,
400-100/5 ML ORAL SOLU)
lamivudine (10 mg/ml solution, 100 mg tablet, 150 mg
tablet, 300 mg tablet)
lamivudine/zidovudine 150-300mg tablet
LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET)
MODERIBA (200 MG TABLET, 400-400 MG
DOSEPACK, 600-600 MG DOSEPACK)
nevirapine (50 mg/5 ml oral susp, 200 mg tablet, 400
mg tab er 24h)
NORVIR (80 MG/ML SOLUTION, 100 MG TABLET,
100 MG SOFTGEL CAP)
OLYSIO 150 MG CAPSULE
PA
PREZCOBIX 800 MG-150 MG TABLET
PREZISTA (75 MG TABLET, 100 MG/ML
SUSPENSION, 150 MG TABLET, 600 MG TABLET,
800 MG TABLET)
4
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
REBETOL 40 MG/ML SOLUTION
RELENZA 5 MG DISKHALER
RESCRIPTOR (100 MG TABLET, 200 MG TABLET)
RETROVIR (200 MG/20 ML VIAL, IV INFUSION VIAL)
REYATAZ (50 MG POWDER PACKET, 150 MG
CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE)
RIBAPAK (400-600 MG, 400-400 MG, 600-600 MG)
RIBASPHERE (200 MG TABLET, 200 MG CAPSULE,
400 MG TABLET, 600 MG TABLET)
RIBASPHERE RIBAPAK (400-400 MG, 600-600 MG,
600-400 MG)
RIBATAB 600-600 MG DOSEPACK
ribavirin (200 mg capsule, 200 mg tablet)
rimantadine hcl 100 mg tablet
SELZENTRY (150 MG TABLET, 300 MG TABLET)
SOVALDI 400 MG TABLET
PA
stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg
capsule, 30 mg capsule, 40 mg capsule)
STRIBILD TABLET
SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600
MG TABLET)
SYNAGIS (50 MG/0.5 ML VIAL, 100 MG/1 ML VIAL)
TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE,
45 MG CAPSULE, 75 MG CAPSULE)
TIVICAY 50 MG TABLET
TRIUMEQ TABLET
TRIZIVIR TABLET
TRUVADA 200 MG-300 MG TABLET
TYZEKA 600 MG TABLET
valacyclovir hcl (500 mg tablet, 1000 mg tablet)
QL (60 PER 30 DAYS)
VALCYTE 450 MG TABLET
5
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
valganciclovir hcl 450 mg tablet
VALTREX (1 GM, 500 MG)
QL (60 PER 30 DAYS)
VIDEX (2 GM SOLN, 4 GM SOLN)
VIDEX EC 125 MG CAPSULE
VIEKIRA PAK
PA
VIRACEPT (250 MG TABLET, 625 MG TABLET)
VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET)
VIRAMUNE XR 400 MG TABLET
VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG
TABLET, 300 MG TABLET, POWDER)
VISTIDE 75 MG/ML VIAL
PA B vs D
VITEKTA (85 MG TABLET, 150 MG TABLET)
ZERIT (1 MG/ML SOLUTION, 15 MG CAPSULE, 20
MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE)
ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET)
zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg
tablet)
CEPHALOSPORINS
CEDAX (90 MG/5 ML SUSPENSION, 400 MG
CAPSULE)
cefaclor (250 mg capsule, 500 mg tab er 12h, 500 mg
capsule)
cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg
capsule, 500 mg/5ml susp recon)
cefadroxil hydrate (1 g tablet, 250 mg/5ml susp recon,
500 mg capsule, 500 mg/5ml susp recon)
cefazolin sodium (1 g vial, 10 g vial, 20 g vial, 100 g
bulkbaginj, 300g bulkbaginj, 500 mg vial)
cefazolin sodium/dextrose, iso-osmotic (1 ml froz.piggy,
1 ml piggyback)
cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp
recon, 300 mg capsule)
cefepime hcl (1 vial, 2 vial)
6
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
cefepime hcl/dextrose 5 % in water (1 ml, 2 ml)
cefixime (100, 200)
cefotaxime sodium (1 g vial, 2 g vial, 500 mg vial)
cefotetan disodium (1 vial, 2 vial, 10 vial)
cefoxitin sodium (1 vial, 2 vial, 10 vial)
cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg
tablet, 100 mg/5ml susp recon, 200 mg tablet)
cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250
mg/5ml susp recon, 500 mg tablet)
ceftazidime (1 vial, 2 vial, 6 vial)
ceftazidime in dextrose 5% and water (1 ml, 2 ml)
ceftazidime pentahydrate (1 g vial, 2 g vial, 6g vial)
CEFTIN (125 MG/5 ML ORAL SUSP, 250 MG/5 ML
ORAL SUSP, 250 MG TABLET, 500 MG TABLET)
ceftriaxone sodium (1 g vial, 1 g vial port, 1 g pggybk
btl, 2 g vial port, 2 g pggybk btl, 2 g vial, 10 g vial, 100 g
bulkbaginj, 250 mg vial, 500 mg vial)
cefuroxime axetil (250 mg tablet, 500 mg tablet)
cefuroxime sodium (1.5 g vial, 750 mg vial)
PA B vs D
cefuroxime sodium (7.5g vial, 7.5 g vial)
cephalexin (125 mg/5ml susp recon, 250 mg tablet, 250
mg capsule, 250 mg/5ml susp recon, 500 mg tablet,
500 mg capsule)
CLAFORAN (1 GM VIAL, 2 GM ADD-VANTAGE VL)
CLAFORAN 1 GM ADD-VANTAGE VL
PA B vs D
FORTAZ (1 GM ADD-VANTAGE VIAL, 1 GM
TWISTVIAL, 2 GM TWISTVIAL, 2 GM ADD-VANTAGE
VIAL, 6 GM VIAL)
KEFLEX 750 MG CAPSULE
SUPRAX (100 MG/5 ML SUSPENSION, 100 MG
TABLET CHEWABLE, 200 MG/5 ML SUSPENSION,
200 MG TABLET CHEWABLE, 400 MG CAPSULE, 500
MG/5 ML SUSPENSION)
TEFLARO (400 MG VIAL, 600 MG VIAL)
7
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ZINACEF (1.5 GM TWISTVIAL, 1.5 GM VIAL, 7.5 GM
VIAL, 750 MG VIAL)
ERYTHROMYCINS / OTHER MACROLIDES
azithromycin (1 g packet, 100 mg/5ml susp recon, 200
mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 500
mg vial, 600 mg tablet)
clarithromycin (125 mg/5ml susp recon, 250 mg/5ml
susp recon, 250 mg tablet, 500 mg tab er 24h, 500 mg
tablet)
E.E.S. 400 FILMTAB
ERY-TAB (EC 250 MG TABLET, EC 333 MG TABLET,
EC 500 MG TABLET)
ERYPED 200 (200 ML GRANULES, 200 ML
SUSPENSION)
ERYTHROCIN 250 MG FILMTAB
ERYTHROCIN LACTOBIONATE (500 MG VIAL, 500
MG ADDVNT VL)
PA B vs D
erythromycin base (250 mg tablet, 500 mg tablet)
erythromycin ethylsuccinate 400 mg tablet
ZMAX (2 ML SUSP SR, 2 ML ORAL SUSPENSION)
MISCELLANEOUS ANTIINFECTIVES
ALBENZA 200 MG TABLET
ALINIA 100 MG/5 ML SUSPENSION
ALINIA 500 MG TABLET
QL (6 PER 30 DAYS)
amikacin sulfate (500 mg/2ml vial, 1000mg/4ml vial)
atovaquone 750 mg/5ml oral susp
atovaquone/proguanil hcl (62.5-25 mg tablet, 250-100
mg tablet)
AZACTAM (1 GM VIAL, 2 GM VIAL)
AZACTAM-ISO-OSMOTIC DEXTROSE (1 ML, 2 ML)
aztreonam (1 vial, 2 vial)
BACIIM (STRL VIAL, VIAL)
8
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
bacitracin 50000 unit vial
BILTRICIDE 600 MG TABLET
CAPASTAT SULFATE 1 GM VIAL
PA B vs D
CAYSTON 75 MG INHAL SOLUTION
chloramphenicol sod succ 1 g vial
PA B vs D
chloroquine phosphate (250 mg tablet, 500 mg tablet)
CLEOCIN 75 MG/5 ML GRANULES
CLEOCIN HCL 75 MG CAPSULE
CLEOCIN PHOSPHATE IN D5W (300, 600, 900)
PA B vs D
clindamycin hcl (75 mg capsule, 150 mg capsule, 300
mg capsule)
clindamycin palmitate hcl 75 mg/5 ml soln recon
clindamycin phosphate (150 mg/ml vial, 300 mg/2ml vial
port, 600 mg/4ml vial port, 900mg/6ml vial port)
clindamycin phosphate/dextrose 5 % in water
(300mg/50ml, 600mg/50ml, 900mg/50ml)
COARTEM TABLETS
colistin (colistimethate na) 150 mg vial
CUBICIN 500 MG VIAL
PA B vs D
dapsone (25 mg tablet, 100 mg tablet)
DARAPRIM 25 MG TABLET
DORIBAX 500 MG VIAL
PA B vs D
ethambutol hcl (100 mg tablet, 400 mg tablet)
FLAGYL ER 750 MG TABLET
gentamicin sulfate 40 mg/ml vial
gentamicin sulfate in sodium chloride, iso-osmotic
(gentamic60 mg/50ml, gentamic70 mg/50ml,
gentamic80 mg/50ml, gentamic90mg/100ml,
gentamic120mg/0.1l)
gentamicin sulfate in sodium chloride, iso-osmotic
(gentamic80mg/100ml, gentamic100mg/0.1l)
PA B vs D
hydroxychloroquine sulfate 200 mg tablet
9
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
imipenem/cilastatin sodium (250 mg vial, 500 mg vial)
PA B vs D
INVANZ 1 GM VIAL
PA B vs D
ISONARIF CAPSULE
isoniazid (50 mg/5 ml solution, 100 mg/ml vial, 100 mg
ivermectin 3 mg tablet
KETEK (300 MG TABLET, 400 MG TABLET)
KORLYM 300 MG TABLET
PA, QL (120 PER 30 OVER TIME)
linezolid (600mg/300 iv soln, 600 mg tablet)
MALARONE (62.5-25 MG PED TAB, 250-100 MG
TABLET)
mefloquine hcl 250 mg tablet
MEPRON 750 MG/5 ML SUSPENSION
meropenem (1 g vial, 500 mg vial)
PA B vs D
MERREM (1 GM VIAL, 500 MG VIAL)
PA B vs D
metronidazole (250 mg tablet, 375 mg capsule, 500 mg
tablet)
metronidazole/sodium chloride 500mg/0.1l piggyback
NEBUPENT 300 MG INHAL POWDER
PA B vs D
neomycin sulfate 500 mg tablet
paromomycin sulfate 250 mg capsule
PASER GRANULES 4 GM PACKET
PENTAM 300 VIAL
PA B vs D
polymyxin b sulfate 500k unit vial
primaquine phosphate 26.3 mg tablet
PRIMAXIN (250 MG VIAL, 500 MG VIAL)
pyrazinamide 500 mg tablet
QUALAQUIN 324 MG CAPSULE
quinine sulfate 324 mg capsule
rifabutin 150 mg capsule
10
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
RIFAMATE CAPSULE
rifampin (150 mg capsule, 300 mg capsule, 600 mg
vial)
RIFATER TABLET
SIRTURO 100 MG TABLET
PA
streptomycin sulfate 1 g vial
STROMECTOL 3 MG TABLET
SYNERCID 500 MG VIAL
PA B vs D
tinidazole (250 mg tablet, 500 mg tablet)
TOBI 300 MG/5 ML SOLUTION
PA B vs D
tobramycin in 0.225% nacl 300 mg/5ml ampul-neb
PA B vs D
tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml
vial, 80 mg/8 ml vial port)
tobramycin/sodium chloride 80mg/100ml piggyback
PA B vs D
TRECATOR 250 MG TABLET
TYGACIL 50 MG VIAL
PA B vs D
XIFAXAN (200 MG TABLET, 550 MG TABLET)
ZYVOX (100 MG/5 ML SUSPENSION, 600 MG
TABLET)
ZYVOX (200 MG/100 ML SOLN, 600 MG/300 ML
SOLN)
PA B vs D
PENICILLINS
amoxicillin (125 mg tab chew, 125 mg/5ml susp recon,
200 mg/5ml susp recon, 250 mg capsule, 250 mg tab
chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon,
500 mg tablet, 500 mg capsule, 875mg tablet, 875 mg
tablet)
amoxicillin/potassium clavulanate (200-28.5mg tab
chew, 200-28.5/5 susp recon, 250-62.5/5 susp recon,
250-125 mg tablet, 400-57mg tab chew, 400-57mg/5
susp recon, 500-125 mg tablet, 600-42.9/5 susp recon,
875-125 mg tablet)
ampicillin sodium (1 g vial, 1 g vial port, 2 g vial, 10 g
vial, 125 mg vial, 250 mg vial, 500 mg vial)
11
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ampicillin sodium/sulbactam sodium (1.5 vial port, 1.5
vial, 3 vial, 3 vial port, 15 vial)
ampicillin trihydrate (125 mg/5ml susp recon, 250 mg
capsule, 250 mg/5ml susp recon, 500 mg capsule)
BICILLIN C-R (1.2 MILLION UNIT, 900-300 SYRINGE)
BICILLIN L-A (600,000 UNIT/ML, 1,200,000 UNITS,
2,400,000 UNITS)
dicloxacillin sodium (250 mg capsule, 500 mg capsule)
nafcillin in dextrose, iso-osmotic (1 g/50 ml, 2 g/100 ml)
nafcillin sodium (1 vial, 2 vial, 10 vial)
OMECLAMOX-PAK COMBO PACK
oxacillin sodium (1 vial, 2 vial port, 2 vial, 10 vial)
oxacillin sodium/dextrose, iso-osmotic (1 ml, 2 ml)
penicillin g potassium (5mm vial, 20mm vial)
penicillin g potassium/dextrose-water (2mm/50ml
froz.piy, 3mm/50ml froz.piy)
PA B vs D
penicillin g procaine 1.2mm/2 ml syringe
PA B vs D
penicillin g sodium 5mm unit vial
PA B vs D
penicillin v potassium (125 mg/5ml soln recon, 250 mg
tablet, 250 mg/5ml soln recon, 500 mg tablet)
piperacillin sodium/tazobactam sodium (2.25 vial, 3.375
vial, 3.375 vial port, 4.5 vial, 4.5 vial port, 40.5 vial)
PA B vs D
ZOSYN (2.25 GM/50 ML GALAXY BAG, 2.25 GRAM
VIAL, 3.375 GRAM VIAL, 3.375 GM/50 ML GALAXY,
4.5 GRAM VIAL, 4.5 GM/100 ML GALAXY BAG, 40.5
GRAM BULK VIAL)
PA B vs D
QUINOLONES
AVELOX 400 MG TABLET
AVELOX ABC PACK 400 MG TAB
AVELOX IV 400 MG/250 ML
PA B vs D
CIPRO (5%, 10%)
ciprofloxacin (250, 500)
12
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ciprofloxacin hcl (100 mg tablet, 250 mg tablet, 500 mg
ciprofloxacin lactate (200mg/20ml vial, 400mg/40ml
vial)
ciprofloxacin lactate/dextrose 5 % in water (200mg/0.1l,
400mg/0.2l)
ciprofloxacin/ciprofloxacin hcl (500 mg, 1000 mg)
FACTIVE 320 MG TABLET
gatifloxacin 0.5 % drops
LEVAQUIN (25 MG/ML SOLUTION, 250 MG TABLET,
levofloxacin (250mg/10ml solution, 250 mg tablet, 500
mg tablet, 500mg/20ml solution, 750 mg tablet)
levofloxacin 25 mg/ml vial
PA B vs D
levofloxacin/dextrose 5 % in water (250mg/50ml,
500mg/0.1l, 750mg/.15l)
PA B vs D
moxifloxacin hcl 400 mg tablet
ofloxacin 400 mg tablet
SULFA'S / RELATED AGENTS
sulfadiazine 500 mg tablet
sulfamethoxazole/trimethoprim (80-16mg/ml vial, 20040mg/5 oral susp, 400mg-80mg tablet, 800-160/20 oral
susp, 800-160 mg tablet)
TETRACYCLINES
demeclocycline hcl (150 mg tablet, 300 mg tablet)
doxycycline hyclate (20 mg tablet, 50 mg capsule, 100
mg capsule, 100 mg tablet, 100 mg vial)
doxycycline monohydrate (25 mg/5 ml susp recon, 50
mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet,
100 mg tablet, 100 mg capsule, 150 mg tablet)
minocycline hcl (45 mg tab er 24h, 50 mg tablet, 50 mg
capsule, 75 mg capsule, 75 mg tablet, 90 mg tab er
24h, 100 mg capsule, 100 mg tablet, 135 mg tab er
24h)
13
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ORACEA 40 MG CAPSULE
tetracycline hcl (250 mg capsule, 500 mg capsule)
VIBRAMYCIN 50 MG/5 ML SYRUP
URINARY TRACT AGENTS
FURADANTIN 25 MG/5 ML SUSP
MACRODANTIN 25 MG CAPSULE
methenamine hippurate 1 g tablet
MONUROL 3 GM SACHET
nitrofurantoin (25 mg/5 ml oral susp, 50 mg capsule)
nitrofurantoin macrocrystal (50 mg capsule, 100 mg
capsule)
nitrofurantoin monohyd/m-cryst 100 mg capsule
PRIMSOL 50 MG/5 ML ORAL SOLN
trimethoprim 100 mg tablet
VANCOMYCIN
VANCOCIN HCL (125 MG PULVULE, 125 MG
CAPSULE, 250 MG PULVULE, 250 MG CAPSULE)
vancomycin hcl (1 g vial, 1 g vial port, 5 g vial, 125 mg
capsule, 250 mg capsule, 750 mg vial)
vancomycin hcl (10 g vial, 500 mg vial, 500 mg vial
port)
PA B vs D
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
amifostine crystalline 500 mg vial
dexrazoxane hcl (250 mg vial, 500 mg vial)
PA B vs D
ELITEK (1.5 MG VIAL, 7.5 MG VIAL)
PA B vs D
FUSILEV I.V. 50 MG VIAL
PA B vs D
KEPIVANCE 6.25 MG VIAL
PA B vs D
14
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
leucovorin calcium (10 mg/ml vial, 50 mg vial, 100 mg
vial, 200 mg vial, 350 mg vial, 500mg/50ml vial, 500 mg
vial)
PA B vs D
leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg
levoleucovorin calcium 10 mg/ml vial
PA B vs D
mesna 100 mg/ml vial
PA B vs D
MESNEX 400 MG TABLET
XGEVA 120 MG/1.7 ML VIAL
PA B vs D
ZINECARD (250 MG VIAL, 500 MG VIAL)
PA B vs D
ABRAXANE 100 MG VIAL
PA B vs D
ADRUCIL (5 GRAM/100 ML VIAL, 500 MG/10 ML VIAL,
2,500 MG/50 ML VIAL)
PA B vs D
AFINITOR (2.5 MG TABLET, 5 MG TABLET, 7.5 MG
AFINITOR DISPERZ (2 MG TABLET, 3 MG TABLET, 5
MG TABLET)
ALIMTA (100 MG VIAL, 500 MG VIAL)
PA B vs D
ALKERAN 50 MG VIAL
PA B vs D
anastrozole 1 mg tablet
ARIMIDEX 1 MG TABLET
AROMASIN 25 MG TABLET
ARRANON 250 MG VIAL
PA B vs D
ARZERRA (100 MG/5 ML VIAL, 1,000 MG/50 ML VIAL)
ASTAGRAF XL (0.5 MG CAPSULE, 1 MG CAPSULE, 5
MG CAPSULE)
PA B vs D
AVASTIN (100 MG/4 ML VIAL, 400 MG/16 ML VIAL)
PA B vs D
azacitidine 100 mg vial
PA B vs D
AZASAN (75 MG TABLET, 100 MG TABLET)
PA B vs D
azathioprine 50 mg tablet
PA B vs D
BELEODAQ 500 MG VIAL
PA B vs D
bicalutamide 50 mg tablet
15
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
BICNU 100 MG VIAL
PA B vs D
bleomycin sulfate (15 vial, 30 vial)
PA B vs D
BOSULIF (100 MG TABLET, 500 MG TABLET)
BUSULFEX (6 MG/ML AMPUL, 60 MG/10 ML AMPUL,
60 MG/10 ML VIAL)
PA B vs D
CAPRELSA (100 MG TABLET, 300 MG TABLET)
carboplatin (10 mg/ml vial, 50 mg vial, 150 mg vial, 450
mg vial)
PA B vs D
CASODEX 50 MG TABLET
CELLCEPT (200 MG/ML ORAL SUSP, 250 MG
CAPSULE, 500 MG TABLET, 500 MG VIAL)
PA B vs D
cisplatin 1 mg/ml vial
PA B vs D
cladribine 10 mg/10ml vial
PA B vs D
CLOLAR 20 MG/20 ML VIAL
PA B vs D
COMETRIQ (60 MG PACK, 100 MG PK, 140 MG PK)
COSMEGEN 0.5 MG VIAL
PA B vs D
cyclophosphamide (25 mg capsule, 50 mg capsule)
PA B vs D
cyclosporine (25 mg capsule, 100 mg capsule, 100
mg/ml solution, 250 mg/5ml vial, 250 mg/5ml ampul)
PA B vs D
cyclosporine, modified (25 mg capsule, 50 mg capsule,
100 mg/ml solution, 100 mg capsule)
PA B vs D
cytarabine 20 mg/ml vial
PA B vs D
cytarabine/pf (1 g vial, 2 g/20 ml vial, 2 g vial, 20 mg/ml
vial, 100 mg/5ml vial)
PA B vs D
dacarbazine (100 mg vial, 200 mg vial)
PA B vs D
DACOGEN 50 MG VIAL
PA B vs D
daunorubicin hcl (5 mg/ml vial, 20 mg vial)
PA B vs D
DAUNOXOME (2 MG/ML VIAL, 50 MG (2 MG/ML)
VIAL)
PA B vs D
decitabine 50 mg vial
PA B vs D
DOCEFREZ 20 MG VIAL
PA B vs D
16
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
docetaxel (20 mg/2 ml vial, 20mg/ml(1) vial, 80 mg/8 ml
vial, 80 mg/4 ml vial, 140 mg/7ml vial, 160mg/16ml vial,
200mg/20ml vial)
PA B vs D
DOXIL 2 MG/ML VIAL
PA B vs D
doxorubicin hcl (2 mg/ml vial, 10 mg vial, 10 mg/5 ml
vial, 20 mg/10ml vial, 50 mg vial, 50 mg/25ml vial)
PA B vs D
DROXIA (200 MG CAPSULE, 300 MG CAPSULE, 400
MG CAPSULE)
ELIGARD (7.5 MG B, 7.5 MG KIT, 22.5 MG B, 22.5 MG
KIT, 30 MG B, 30 MG KIT, 45 MG B, 45 MG KIT)
PA B vs D
ELLENCE 2 MG/ML VIAL
PA B vs D
ELOXATIN (50 MG/10 ML VIAL, 100 MG/20 ML VIAL,
200 MG/40 ML VIAL)
PA B vs D
EMCYT 140 MG CAPSULE
epirubicin hcl (50 mg vial, 50 mg/25ml vial, 200 mg vial,
200mg/0.1l vial)
PA B vs D
ERBITUX (100 MG/50 ML VIAL, 200 MG/100 ML VIAL)
PA B vs D
ERIVEDGE 150 MG CAPSULE
ERWINAZE 10,000 UNITS VIAL
PA B vs D
ETOPOPHOS 100 MG VIAL
PA B vs D
etoposide 20 mg/ml vial
PA B vs D
exemestane 25 mg tablet
FARESTON 60 MG TABLET
FARYDAK (10 MG CAPSULE, 15 MG CAPSULE, 20
MG CAPSULE)
FASLODEX 250 MG/5 ML SYRINGE
PA B vs D
FEMARA 2.5 MG TABLET
fludarabine phosphate (50 mg vial, 50 mg/2 ml vial)
PA B vs D
fluorouracil (1 g/20 ml vial, 2.5 g/50ml vial, 5 g/100 ml
vial, 500mg/10ml vial)
PA B vs D
flutamide 125 mg capsule
gemcitabine hcl (1 g vial, 1 g/26.3ml vial, 2 g vial, 2
g/52.6ml vial, 200 mg vial, 200mg/5.26 vial)
PA B vs D
17
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
GEMZAR (1 GRAM VIAL, 200 MG VIAL)
PA B vs D
GENGRAF (25 MG CAPSULE, 100 MG/ML
SOLUTION, 100 MG CAPSULE)
PA B vs D
GILOTRIF (20 MG TABLET, 30 MG TABLET, 40 MG
TABLET)
GLEEVEC (100 MG TABLET, 400 MG TABLET)
GLEOSTINE (10 MG CAPSULE, 40 MG CAPSULE,
100 MG CAPSULE)
HALAVEN 1 MG/2 ML VIAL
PA B vs D
HERCEPTIN 440 MG VIAL
PA B vs D
HEXALEN 50 MG CAPSULE
HYCAMTIN 4 MG VIAL
PA B vs D
hydroxyurea 500 mg capsule
IBRANCE (75 MG CAPSULE, 100 MG CAPSULE, 125
MG CAPSULE)
ICLUSIG (15 MG TABLET, 45 MG TABLET)
idarubicin hcl 1 mg/ml vial
PA B vs D
IFEX (1 GM VIAL, 3 GM VIAL)
PA B vs D
ifosfamide (1 g/20 ml vial, 1 g vial, 3g/60ml vial, 3 g vial)
PA B vs D
IMBRUVICA 140 MG CAPSULE
INLYTA (1 MG TABLET, 5 MG TABLET)
irinotecan hcl (40 mg/2 ml vial, 100 mg/5ml vial,
500mg/25ml vial)
IXEMPRA (15 MG, 45 MG)
PA B vs D
JAKAFI (5 MG TABLET, 10 MG TABLET, 15 MG
TABLET, 20 MG TABLET, 25 MG TABLET)
JEVTANA 60 MG/1.5 ML KIT
KEYTRUDA (50 MG VIAL, 100 MG/4 ML VIAL)
PA B vs D
LENVIMA (10 MG, 14 MG, 20 MG, 24 MG)
letrozole 2.5 mg tablet
LEUKERAN 2 MG TABLET
18
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
leuprolide acetate 1 mg/0.2ml kit
lomustine (10 mg capsule, 40 mg capsule, 100 mg
capsule)
LUPRON DEPOT (DEPOT 3.75 MG, DEPOT-4
MONTH, DEPOT 7.5 MG, DEPOT 11.25 MG 3MO,
DEPOT 22.5 MG 3MO, DEPOT 45 MG 6MO)
PA B vs D
LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO,
11.25 MG KIT, 15 MG KIT, 30 MG 3MO KIT)
PA B vs D
LYNPARZA 50 MG CAPSULE
LYSODREN 500 MG TABLET
MATULANE 50 MG CAPSULE
megestrol acetate (20 mg tablet, 40 mg tablet,
400mg/10ml oral susp, 800mg/20ml oral susp)
MEKINIST (0.5 MG TABLET, 2 MG TABLET)
melphalan hcl 50 mg vial
PA B vs D
mercaptopurine 50 mg tablet
methotrexate sodium 2.5 mg tablet
PA B vs D
methotrexate sodium/pf (1 g vial, 25 mg/ml vial)
PA B vs D
mitomycin (5 mg vial, 20 mg vial, 40 mg vial)
PA B vs D
mitoxantrone hcl 2 mg/ml vial
PA B vs D
MUSTARGEN 10 MG VIAL
PA B vs D
mycophenolate mofetil (200 mg/ml susp recon, 250 mg
capsule, 500 mg tablet)
PA B vs D
mycophenolate sodium (180 mg tablet dr, 360 mg tablet
dr)
PA B vs D
MYFORTIC (180 MG TABLET, 360 MG TABLET)
PA B vs D
NEORAL (25 MG GELATIN CAPSULE, 100 MG/ML
SOLUTION, 100 MG GELATIN CAPSULE)
PA B vs D
NEXAVAR 200 MG TABLET
NILANDRON 150 MG TABLET
NULOJIX 250 MG VIAL
PA B vs D
19
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
octreotide acetate (50 mcg/ml vial, 50 mcg/ml ampul,
100 mcg/ml ampul, 100 mcg/ml vial, 200 mcg/ml vial,
500 mcg/ml ampul, 500 mcg/ml vial, 1000mcg/ml vial)
PA B vs D
ONCASPAR 750 UNIT/ML VIAL
PA B vs D
OPDIVO (40 MG/4 ML VIAL, 100 MG/10 ML VIAL)
PA B vs D
oxaliplatin (50 mg vial, 50 mg/10ml vial, 100 mg vial,
100mg/20ml vial)
PA B vs D
paclitaxel 6 mg/ml vial
PA B vs D
PERJETA 420 MG/14 ML VIAL
PA B vs D
POMALYST (1 MG CAPSULE, 2 MG CAPSULE, 3 MG
CAPSULE, 4 MG CAPSULE)
PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5
MG/ML AMPULE, 5 MG CAPSULE)
PA B vs D
PURIXAN 20 MG/ML ORAL SUSP
RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1
MG/ML ORAL SOLN, 2 MG TABLET)
PA B vs D
REVLIMID (2.5 MG CAPSULE, 20 MG CAPSULE)
REVLIMID (5 MG CAPSULE, 10 MG CAPSULE, 15 MG
LA
RHEUMATREX 2.5 MG TABLET
PA B vs D
RITUXAN 10 MG/ML VIAL
PA B vs D
SANDIMMUNE (25 MG CAPSULE, 50 MG/ML AMPUL,
100 MG/ML SOLN, 100 MG CAPSULE)
PA B vs D
SIMULECT (10 MG VIAL, 20 MG VIAL)
PA B vs D
sirolimus (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
PA B vs D
SOLTAMOX 10 MG/5 ML SOLN
SOMATULINE DEPOT (DEPOT 90 MG/0.3 ML, 120
MG/0.5 ML SYRGE, DEPOT 120 MG/0.5 ML)
PA B vs D
SPRYCEL (20 MG TABLET, 50 MG TABLET, 70 MG
TABLET, 80 MG TABLET, 100 MG TABLET, 140 MG
TABLET)
STIVARGA 40 MG TABLET
SUTENT (12.5 MG CAPSULE, 25 MG CAPSULE, 37.5
MG CAPSULE, 50 MG CAPSULE)
20
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
SYLVANT (100 MG VIAL, 400 MG VIAL)
SYNRIBO 3.5 MG/ML VIAL
PA B vs D
TABLOID 40 MG TABLET
tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg
capsule)
PA B vs D
TAFINLAR (50 MG CAPSULE, 75 MG CAPSULE)
tamoxifen citrate (10 mg tablet, 20 mg tablet)
TARCEVA (25 MG TABLET, 100 MG TABLET, 150 MG
TABLET)
TARGRETIN (1% GEL, 75 MG SOFTGEL, 75 MG
CAPSULE)
TASIGNA (150 MG CAPSULE, 200 MG CAPSULE)
THALOMID (50 MG CAPSULE, 100 MG CAPSULE,
topotecan hcl (4 mg/4 ml vial, 4 mg vial)
PA B vs D
TORISEL 25 MG KIT
PA B vs D
TREANDA (25 MG VIAL, 45 MG/0.5 ML VIAL, 100 MG
VIAL, 180 MG/2 ML VIAL)
PA B vs D
TRELSTAR (3.75 MG, 11.25 MG)
PA B vs D
TRELSTAR DEPOT 3.75 MG VIAL
PA B vs D
TRELSTAR LA 11.25 MG VIAL
PA B vs D
tretinoin 10 mg capsule
TREXALL (5 MG TABLET, 7.5 MG TABLET, 10 MG
PA B vs D
TRISENOX 10 MG/10 ML AMPULE
PA B vs D
TYKERB 250 MG TABLET
VECTIBIX (100 MG/5 ML VIAL, 200 MG/10 ML VIAL,
400 MG/20 ML VIAL)
PA B vs D
VELCADE 3.5 MG VIAL
PA B vs D
VIDAZA 100 MG VIAL
PA B vs D
vinblastine sulfate (1 mg/ml vial, 10 mg vial)
PA B vs D
VINCASAR PFS (1 MG/ML VIAL, 2 MG/2 ML VIAL)
PA B vs D
21
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
vincristine sulfate (1 mg/ml vial, 2 mg/2 ml vial)
PA B vs D
vinorelbine tartrate (10 mg/ml vial, 50 mg/5 ml vial)
PA B vs D
VOTRIENT 200 MG TABLET
XALKORI (200 MG CAPSULE, 250 MG CAPSULE)
XTANDI 40 MG CAPSULE
YERVOY (50 MG/10 ML VIAL, 200 MG/40 ML VIAL)
PA B vs D
ZALTRAP (100 MG/4 ML VIAL, 200 MG/8 ML VIAL)
PA B vs D
ZANOSAR 1 GM POWDER VIAL
PA B vs D
ZELBORAF 240 MG TABLET
ZOLINZA 100 MG CAPSULE
ZORTRESS (0.25 MG TABLET, 0.5 MG TABLET, 0.75
MG TABLET)
PA B vs D
ZYDELIG (100 MG TABLET, 150 MG TABLET)
ZYKADIA 150 MG CAPSULE
ZYTIGA 250 MG TABLET
AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG
BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET,
400 MG TABLET)
carbamazepine (100 mg cpmp 12hr, 100 mg/5ml oral
susp, 100 mg tab chew, 200mg/10ml oral susp, 200 mg
tablet, 200 mg tab er 12h, 200 mg cpmp 12hr, 300 mg
cpmp 12hr)
CARBATROL (ER 100 MG CAPSULE, ER 200 MG
CAPSULE, ER 300 MG CAPSULE)
CELONTIN 300 MG KAPSEAL
CEREBYX (100 MG PE/2 ML VIAL, 500 MG PE/10 ML
VIAL)
DEPAKOTE (DR 125 MG TABLET, DR 250 MG
TABLET, DR 500 MG TABLET)
22
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
DEPAKOTE 125 MG SPRINKLE CAP
DEPAKOTE ER (ER 250 MG TABLET, ER 500 MG
TABLET)
DILANTIN (30 MG CAPSULE, 50 MG INFATAB)
divalproex sodium (125 mg tablet dr, 125 mg cap
sprink, 250 mg tab er 24h, 250 mg tablet dr, 500 mg
tablet dr, 500 mg tab er 24h)
EPITOL 200 MG TABLET
EQUETRO (100 MG CAPSULE, 200 MG CAPSULE,
300 MG CAPSULE)
ethosuximide (250 mg/5ml solution, 250 mg capsule)
felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml
oral susp)
FELBATOL (400 MG TABLET, 600 MG TABLET, 600
MG/5 ML SUSP)
fosphenytoin sodium (100mg pe/2 vial, 500 pe/10 vial)
FYCOMPA (2 MG TABLET, 4 MG TABLET, 6 MG
TABLET)
gabapentin (100 mg capsule, 250 mg/5ml solution, 300
mg/6ml solution, 300 mg capsule, 400 mg capsule, 600
mg tablet, 800 mg tablet)
GABITRIL (2 MG TABLET, 4 MG TABLET, 12 MG
GRALISE (30-DAY STARTER PACK, ER 300 MG
TABLET, ER 600 MG TABLET)
KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET,
500 MG TABLET, 750 MG TABLET, 1,000 MG
TABLET)
KEPPRA XR (500 MG TABLET, 750 MG TABLET)
LAMICTAL (25 MG TABLET, 100 MG TABLET, 150
MG TABLET, 200 MG TABLET)
LAMICTAL TAB START KIT (BLUE)
LAMICTAL TAB START KIT (GREEN)
LAMICTAL TB START KIT (ORANGE)
23
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
LAMICTAL XR (25 MG TABLET, 50 MG TABLET, 100
MG TABLET, 200 MG TABLET, 250 MG TABLET, 300
MG TABLET)
LAMICTAL XR START KIT (BLUE)
LAMICTAL XR START KIT (GREEN)
LAMICTAL XR START KIT (ORANGE)
lamotrigine (5 mg tb chw dsp, 25 mg tablet, 25 mg tab
er 24, 25 mg tab rapdis, 25 mg tb chw dsp, 50 mg tab
rapdis, 50 mg tab er 24, 100 mg tab er 24, 100 mg tab
rapdis, 100 mg tablet, 150 mg tablet, 200 mg tablet, 200
mg tab er 24, 200 mg tab rapdis, 250 mg tab er 24, 300
mg tab er 24)
levetiracetam (100 mg/ml solution, 250 mg tablet, 500
mg/5ml solution, 500 mg tab er 24h, 500 mg tablet, 750
mg tablet, 750 mg tab er 24h, 1000 mg tablet)
levetiracetam 500 mg/5ml vial
PA B vs D
levetiracetam in sodium chloride, iso-osmotic
(500mg/0.1l, 1000mg/100, 1500mg/100)
PA B vs D
LYRICA (20 MG/ML ORAL SOLUTION, 25 MG
CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100
MG CAPSULE, 150 MG CAPSULE, 200 MG
CAPSULE, 225 MG CAPSULE, 300 MG CAPSULE)
NEURONTIN 250 MG/5 ML SOLN
ONFI (2.5 MG/ML SUSPENSION, 10 MG TABLET, 20
MG TABLET)
oxcarbazepine (150 mg tablet, 300 mg tablet, 300
mg/5ml oral susp, 600 mg tablet)
OXTELLAR XR (150 MG TABLET, 300 MG TABLET,
600 MG TABLET)
PEGANONE 250 MG TABLET
phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml
elixir, 30 mg tablet, 32.4mg tablet, 32.4 mg tablet, 60
mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet)
PHENYTEK (200 MG CAPSULE, 300 MG CAPSULE)
phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125
mg/5ml oral susp)
24
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
phenytoin sodium (50 mg/ml vial, 50 mg/ml ampul)
phenytoin sodium extended (100 mg capsule, 200 mg
capsule, 300 mg capsule)
POTIGA (50 MG TABLET, 200 MG TABLET, 300 MG
primidone (50 mg tablet, 250 mg tablet)
QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE,
100 MG CAPSULE, 150 MG CAPSULE, 200 MG
CAPSULE)
SABRIL (500 MG TABLET, 500 MG POWDER
PACKET)
LA
TEGRETOL XR (100 MG TABLET, 200 MG TABLET,
400 MG TABLET)
tiagabine hcl (2 mg tablet, 4 mg tablet)
TOPAMAX (15 MG SPRINKLE CAP, 25 MG TABLET,
25 MG SPRINKLE CAP, 50 MG TABLET, 100 MG
topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg
tablet, 25 mg cap spr 24, 50 mg cap spr 24, 50 mg
tablet, 100 mg cap spr 24, 100 mg tablet, 150 mg cap
spr 24, 200 mg tablet, 200 mg cap spr 24)
TRILEPTAL (150 MG TABLET, 300 MG/5 ML SUSP,
TROKENDI XR (25 MG CAPSULE, 50 MG CAPSULE,
valproate sodium 250 mg/5ml solution
valproic acid (as sodium salt) (valproate sodium) (250
mg/5ml solution, 500 mg/5ml vial, 500mg/10ml solution)
valproic acid 250 mg capsule
VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100
MG TABLET, 150 MG TABLET, 200 MG/20 ML VIAL,
200 MG TABLET)
zonisamide (25 mg capsule, 50 mg capsule, 100 mg
capsule)
25
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ANTIPARKINSONISM AGENTS
APOKYN 30 MG/3 ML CARTRIDGE
PA B vs D
AZILECT (0.5 MG TABLET, 1 MG TABLET)
benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2
mg/2 ml vial, 2 mg/2 ml ampul, 2 mg tablet)
bromocriptine mesylate (2.5 mg tablet, 5 mg capsule)
carbidopa 25 mg tablet
carbidopa/levodopa (10mg-100mg tab rapdis, 10mg100mg tablet, 25mg-250mg tab rapdis, 25mg-250mg
tablet, 25mg-100mg tab rapdis, 25mg-100mg tablet er,
25mg-100mg tablet, 50mg-200mg tablet er)
carbidopa/levodopa/entacapone (12.5-50 mg tablet,
18.75-75mg tablet, 25-100-200 tablet, 31.25-125 tablet,
37.5-150mg tablet, 50-200-200 tablet)
COMTAN 200 MG TABLET
entacapone 200 mg tablet
MIRAPEX (0.125 MG TABLET, 0.25 MG TABLET, 0.5
MG TABLET, 0.75 MG TABLET, 1 MG TABLET, 1.5
MG TABLET)
MIRAPEX ER (ER 0.375 MG TABLET, ER 0.75 MG
TABLET, ER 1.5 MG TABLET, ER 2.25 MG TABLET,
ER 3 MG TABLET, ER 3.75 MG TABLET, ER 4.5 MG
TABLET)
NEUPRO (1 HR, 2 HR, 3 HR, 4 HR, 6 HR, 8 HR)
pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5
mg tablet, 0.75 mg tab er 24h, 0.75 mg tablet, 1 mg
tablet, 1.5 mg tablet, 1.5 mg tab er 24h)
ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet,
2 mg tab er 24h, 2 mg tablet, 3 mg tablet, 4 mg tablet, 4
mg tab er 24h, 5 mg tablet, 6 mg tab er 24h, 8 mg tab
er 24h, 12 mg tab er 24h)
selegiline hcl (5 mg tablet, 5 mg capsule)
STALEVO 100 TABLET
STALEVO 125 TABLET
STALEVO 150 TABLET
26
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
STALEVO 200 TABLET
STALEVO 50 TABLET
STALEVO 75 TABLET
TASMAR 100 MG TABLET
tolcapone 100 mg tablet
trihexyphenidyl hcl (2 mg/5 ml elixir, 2 mg tablet, 5 mg
tablet)
ZELAPAR 1.25 MG ODT TABLET
MIGRAINE / CLUSTER HEADACHE THERAPY
dihydroergotamine mesylate (0.5mg/spry spray/pump, 1
mg/ml ampul, 1 mg/ml vial)
MAXALT (5 MG TABLET, 10 MG TABLET)
QL (36 PER 30 OVER TIME)
MAXALT MLT (5 MG TABLET, 10 MG TABLET)
MIGRANAL NASAL SPRAY
rizatriptan benzoate (5 mg tablet, 5 mg tab rapdis, 10
mg tablet, 10 mg tab rapdis)
sumatriptan (5 mg, 20 mg)
QL (12 PER 30 DAYS)
sumatriptan succinate (6 mg/0.5ml pen injctr, 6
mg/0.5ml syringe, 6 mg/0.5ml cartridge, 6 mg/0.5ml
vial, 25 mg tablet)
sumatriptan succinate 100 mg tablet
QL (9 PER 30 DAYS)
sumatriptan succinate 50 mg tablet
QL (18 PER 30 DAYS)
zolmitriptan (2.5 mg tab rapdis, 2.5 mg tablet)
QL (12 PER 30 DAYS)
zolmitriptan (5 mg tab rapdis, 5 mg tablet)
QL (8 PER 30 DAYS)
MISCELLANEOUS NEUROLOGICAL THERAPY
AMPYRA ER 10 MG TABLET
ARICEPT (5 MG TABLET, 10 MG TABLET, 23 MG
TABLET)
ST, QL (30 PER 30 DAYS)
COPAXONE 40 MG/ML SYRINGE
dalfampridine powder
donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg
tablet, 10 mg tab rapdis, 23 mg tablet)
QL (30 PER 30 DAYS)
27
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
EXELON (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG
EXELON (4.6, 9.5, 13.3)
ST
galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg
galantamine hbr (8 mg, 16 mg, 24 mg)
QL (30 PER 30 DAYS)
HETLIOZ 20 MG CAPSULE
NAMENDA (2 MG/ML SOLUTION, 5-10 MG
TITRATION PK)
NAMENDA 10 MG TABLET
NAMENDA 5 MG TABLET
NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE,
21 MG CAPSULE, 28 MG CAPSULE, TITRATION
PACK)
NUEDEXTA 20-10 MG CAPSULE
RAVICTI 1.1 GRAM/ML LIQUID
rivastigmine tartrate (1.5 mg capsule, 3 mg capsule, 4.5
mg capsule, 6 mg capsule)
QL (60 PER 30 DAYS)
TYSABRI 300 MG/15 ML VIAL
PA B vs D, LA
XENAZINE (12.5 MG TABLET, 25 MG TABLET)
LA
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
AMRIX (ER 15 MG CAPSULE, ER 30 MG CAPSULE)
PA, PA B vs D
baclofen (10 mg tablet, 20 mg tablet)
carisoprodol 350 mg tablet
PA
carisoprodol/aspirin 200-325 mg tablet
PA
chlorzoxazone 500 mg tablet
PA
codeine/carisoprodol/aspirin 16-200-325 tablet
PA, QL (2490 PER 30 DAYS)
cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet, 10 mg
tablet)
PA
dantrolene sodium (25 mg capsule, 50 mg capsule, 100
mg capsule)
guanidine hcl 125 mg tablet
28
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
LORZONE (375 MG TABLET, 750 MG TABLET)
meprobamate (200 mg tablet, 400 mg tablet)
MESTINON (60 MG/5 ML SYRUP, 180 MG
TIMESPAN)
metaxalone (400 mg tablet, 800 mg tablet)
PA
methocarbamol (500 mg tablet, 750 mg tablet)
PA
orphenadrine citrate 100 mg tablet er
PA
pyridostigmine bromide 60 mg tablet
SKELAXIN 800 MG TABLET
SOMA 250 MG TABLET
PA
tizanidine hcl (2 mg capsule, 2 mg tablet, 4 mg tablet, 4
ZANAFLEX (2 MG CAPSULE, 4 MG CAPSULE, 6 MG
CAPSULE)
NARCOTIC ANALGESICS
acetaminophen with codeine 300mg-60mg tablet
acetaminophen with codeine phosphate (120-12mg/5
elixir, 120-12mg/5 solution, 240-24/10 solution,
300mg/12.5 solution, 360-36/15 solution)
acetaminophen with codeine phosphate (300mg-30mg
tablet, 300mg-15mg tablet)
ASCOMP WITH CODEINE CAPSULE
buprenorphine hcl (0.3 mg/ml vial, 0.3 mg/ml syringe)
buprenorphine hcl 2 mg tab subl
buprenorphine hcl 8 mg tab subl
QL (75 PER 30 DAYS)
buprenorphine hcl/naloxone hcl (/naloxone 2 mg-0.5mg
tab, /naloxone 8 mg-2 mg tab)
butalbit/acetamin/caff/codeine 50-325-30 capsule
codeine sulfate (15 mg tablet, 30 mg tablet, 60 mg
tablet)
DILAUDID 1 MG/ML LIQUID
DURAMORPH (0.5 MG/ML, 5 MG/10 ML)
29
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
DURAMORPH (1 MG/ML, 10 MG/10 ML)
ENDOCET (5-325 TABLET, 7.5-325 MG TABLET, 10325 MG TABLET)
fentanyl (12 mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr)
QL (10 PER 30 DAYS)
fentanyl 100 mcg/hr patch td72
QL (9 PER 30 DAYS)
fentanyl 37.5mcg/hr patch td72
QL (25 PER 30 DAYS)
QL (15 PER 30 DAYS)
QL (11 PER 30 DAYS)
fentanyl citrate 1200 mcg lozenge hd
hydrocodone bit/acetaminophen (5mg-325mg tablet,
10mg-325mg tablet)
hydrocodone bitartrate/acetaminophen (2.5-108/5, 5217mg/10, 7.5-325/15)
hydrocodone bitartrate/acetaminophen (2.5-325mg
tablet, 5 mg-325mg tablet, 5mg-300mg tablet, 7.5325mg tablet, 7.5-300mg tablet, 10mg-325mg tablet,
10mg-300mg tablet)
hydrocodone/ibuprofen 7.5-200 mg tablet
QL (50 PER 30 DAYS)
hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mg
tablet)
hydromorphone hcl (8 mg tab er, 12 mg tab er, 16 mg
tab er)
QL (60 PER 30 DAYS)
hydromorphone hcl 1 mg/ml liquid
hydromorphone hcl 32 mg tab er 24h
QL (47 PER 30 DAYS)
hydromorphone hcl/pf (10 mg/ml ampul, 10 mg/ml vial)
ibuprofen/oxycodone hcl 400mg-5mg tablet
QL (28 PER 30 DAYS)
levorphanol tartrate 2 mg tablet
30
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
LORCET 5-325 MG TABLET
LORCET HD 10-325 MG TABLET
LORTAB (5-325 MG TABLET, 7.5-325 MG TABLET,
10-325 MG TABLET)
meperidine hcl (50 mg tablet, 50 mg/5 ml solution)
MEPERITAB 100 MG TABLET
methadone hcl 10 mg tablet
methadone hcl 10 mg/5 ml solution
methadone hcl 10 mg/ml vial
methadone hcl 5 mg tablet
methadone hcl 5 mg/5 ml solution
morphine sulfate (10 mg cap er, 20 mg cap er, 30 mg
cap er, 50 mg cap er, 60 mg cap er)
QL (90 PER 30 DAYS)
morphine sulfate (10 ml, 20 ml)
morphine sulfate (15 mg tablet er, 30 mg tablet er)
morphine sulfate (15 mg tablet, 30 mg tablet, 100
mg/5ml solution)
morphine sulfate (30 mg cpmp 24hr, 45 mg cpmp 24hr,
60 mg cpmp 24hr, 75 mg cpmp 24hr, 90 mg cpmp 24hr,
100 mg tablet er, 100 mg cap er pel)
QL (60 PER 30 DAYS)
morphine sulfate 120 mg cpmp 24hr
QL (50 PER 30 DAYS)
morphine sulfate 200 mg tablet er
QL (30 PER 30 DAYS)
morphine sulfate 60 mg tablet er
morphine sulfate 80 mg cap er pel
QL (75 PER 30 DAYS)
OPANA 10 MG TABLET
OPANA 5 MG TABLET
OPANA ER (ER 5 MG TABLET, ER 7.5 MG TABLET,
ER 10 MG TABLET, ER 15 MG TABLET, ER 20 MG
TABLET)
QL (90 PER 30 DAYS)
OPANA ER 30 MG TABLET
QL (67 PER 30 DAYS)
OPANA ER 40 MG TABLET
QL (50 PER 30 DAYS)
oxycodone hcl (10 mg tab er, 20 mg tab er, 40 mg tab
er)
QL (90 PER 30 DAYS)
31
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
oxycodone hcl (10 mg tablet, 15 mg tablet, 20 mg/ml
oral conc, 20 mg tablet)
oxycodone hcl (5 mg capsule, 5 mg tablet)
oxycodone hcl 30 mg tablet
oxycodone hcl 5 mg/5 ml solution
oxycodone hcl 80 mg tab er 12h
oxycodone hcl/acetaminophen (2.5-325mg tablet, 5mg325mg tablet, 5 mg-325mg tablet, 7.5-325mg tablet,
10mg-325mg tablet)
oxycodone hcl/aspirin 4.8355-325 tablet
oxymorphone hcl (5 mg tab er, 7.5 mg tab er, 10 mg tab
er, 15 mg tab er, 20 mg tab er)
QL (90 PER 30 DAYS)
oxymorphone hcl 10 mg tablet
oxymorphone hcl 30 mg tab er 12h
QL (67 PER 30 DAYS)
oxymorphone hcl 40 mg tab er 12h
QL (50 PER 30 DAYS)
oxymorphone hcl 5 mg tablet
REPREXAIN (2.5-200 MG TABLET, 5-200 MG
TABLET, 10-200 MG TABLET)
QL (50 PER 30 DAYS)
tramadol hcl 300 mg cpbp 17-83
NON-NARCOTIC ANALGESICS
ARTHROTEC 50 MG-200 MCG TAB
ARTHROTEC 75 MG-200 MCG TAB
BUNAVAIL (2.1-0.3 MG, 4.2-0.7 MG, 6.3-1 MG)
butorphanol tartrate (1 mg/ml vial, 1 mg/ml disp syrin)
butorphanol tartrate 10 mg/ml spray
QL (5 PER 28 DAYS)
butorphanol tartrate 2 mg/ml vial
celecoxib (50 mg capsule, 100 mg capsule, 200 mg
QL (60 PER 30 DAYS)
diclofenac potassium 50 mg tablet
diclofenac sodium (1.5 % drops, 3 % gel (gram), 25 mg
tablet dr, 50 mg tablet dr, 75 mg tablet dr, 100 mg tab er
24h)
32
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
diclofenac sodium/misoprostol (50 tab ir dr, 75 tab ir dr)
diflunisal 500 mg tablet
etodolac (200 mg capsule, 400 mg tab er 24h, 400 mg
tablet, 500 mg tablet, 500 mg tab er 24h, 600 mg tab er
24h)
fenoprofen calcium 600 mg tablet
flurbiprofen (50 mg tablet, 100 mg tablet)
ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600
INDOCIN 25 MG/5 ML SUSPENSION
ketoprofen (50 mg capsule, 75 mg capsule, 200 mg
cap24h pel)
ketorolac tromethamine (15 mg/ml vial, 30mg/ml(1) vial,
30 mg/ml vial, 60 mg/2 ml vial)
ketorolac tromethamine 10 mg tablet
QL (20 PER 30 DAYS)
meclofenamate sodium (50 mg capsule, 100 mg
capsule)
mefenamic acid 250 mg capsule
meloxicam (7.5 mg tablet, 15 mg tablet)
nabumetone (500 mg tablet, 750 mg tablet)
nalbuphine hcl (10 mg/ml vial, 10 mg/ml ampul)
nalbuphine hcl (20 mg/ml vial, 20 mg/ml ampul)
naloxone hcl 1 mg/ml syringe
naltrexone hcl 50 mg tablet
naproxen (125 mg/5ml oral susp, 250 mg tablet, 375
mg tablet, 375 mg tablet dr, 500 mg tablet dr, 500 mg
tablet)
naproxen sodium (275 mg tablet, 500 mg tbmp 24hr,
550 mg tablet)
oxaprozin 600 mg tablet
pentazocine hcl/naloxone hcl 50mg-0.5mg tablet
piroxicam (10 mg capsule, 20 mg capsule)
33
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
SUBOXONE (4 MG-1 MG, 8 MG-2 MG)
QL (90 PER 30 DAYS)
SUBOXONE 12 MG-3 MG SL FILM
QL (60 PER 30 DAYS)
SUBOXONE 2 MG-0.5 MG SL FILM
sulindac (150 mg tablet, 200 mg tablet)
TALWIN (30 MG/ML VIAL, 30 MG/ML AMPUL)
PA B vs D
tolmetin sodium (400 mg capsule, 600 mg tablet)
tramadol hcl (100 mg tbmp 24hr, 100 mg tab er 24h,
200 mg tbmp 24hr, 200 mg tab er 24h, 300 mg tab er
24h, 300 mg tbmp 24hr)
QL (30 PER 30 DAYS)
tramadol hcl (100 mg, 200 mg)
tramadol hcl 50 mg tablet
tramadol hcl/acetaminophen 37.5-325mg tablet
VIVITROL (380 MG VIAL + DILUENT, 380 MG VIAL)
PA B vs D
VOLTAREN 1% GEL
PSYCHOTHERAPEUTIC DRUGS
ABILIFY (2 MG TABLET, 5 MG TABLET, 9.7 MG/1.3
ML VIAL, 10 MG TABLET, 15 MG TABLET, 20 MG
ABILIFY DISCMELT (10 MG TABLET, 15 MG TABLET)
ABILIFY MAINTENA (ER 300 MG, ER 400 MG)
PA B vs D
ABILIFY MAINTENA (ER 300 MG, ER 400 MG)
ADDERALL XR (5 MG CAPSULE, 10 MG CAPSULE,
alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg
tab rapdis, 0.5 mg tab er 24h, 0.5 mg tablet, 1 mg
tablet, 1 mg tab rapdis, 1 mg tab er 24h, 2 mg tab
rapdis, 2 mg tablet, 2 mg tab er 24h, 3 mg tab er 24h)
PA
ALPRAZOLAM 1 MG/ML ORAL CONC
PA
amitriptyline hcl (10 mg tablet, 25 mg tablet, 50 mg
tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet)
amitriptyline hcl/chlordiazepoxide (12.5mg-5mg tablet,
25 mg-10mg tablet)
34
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
amoxapine (25 mg tablet, 50 mg tablet, 100 mg tablet,
150 mg tablet)
APLENZIN (ER 174 MG TABLET, ER 348 MG
TABLET, ER 522 MG TABLET)
aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15
mg tablet, 20 mg tablet, 30 mg tablet)
BRINTELLIX (5 MG TABLET, 10 MG TABLET, 20 MG
TABLET)
BRISDELLE 7.5 MG CAPSULE
bupropion hcl (75 mg tablet, 100 mg tablet er, 100 mg
tablet, 150 mg tab er 24h, 150 mg tablet er, 200 mg
tablet er, 300 mg tab er 24h)
buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet,
15 mg tablet, 30 mg tablet)
carbamazepine 400 mg tab er 12h
chlordiazepoxide hcl (5 mg capsule, 10 mg capsule, 25
mg capsule)
PA
chlorpromazine hcl (10 mg tablet, 25 mg tablet, 25
mg/ml ampul, 50 mg tablet, 100 mg tablet, 200 mg
tablet)
citalopram hydrobromide (10 mg tablet, 10 mg/5 ml
solution, 20 mg tablet, 40 mg tablet)
clomipramine hcl (25 mg capsule, 50 mg capsule, 75
mg capsule)
clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis,
0.5 mg tablet, 0.5 mg tab rapdis, 1 mg tab rapdis, 1 mg
tablet, 2 mg tab rapdis, 2 mg tablet)
clorazepate dipotassium (3.75 mg tablet, 7.5 mg tablet,
15 mg tablet)
clozapine (12.5 mg tab rapdis, 25 mg tablet, 25 mg tab
rapdis, 50 mg tablet, 100 mg tablet, 100 mg tab rapdis,
150 mg tab rapdis, 200 mg tablet, 200 mg tab rapdis)
CLOZARIL (25 MG TABLET, 100 MG TABLET)
CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET,
ER 36 MG TABLET, ER 54 MG TABLET)
CYMBALTA (20 MG CAPSULE, 30 MG CAPSULE, 60
MG CAPSULE)
35
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg
DESOXYN 5 MG TABLET
desvenlafaxine (50 mg tab er 24h, 50 mg tab er 24, 100
mg tab er 24h, 100 mg tab er 24)
dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10
mg cpbp 50-50, 10 mg tablet, 15 mg cpbp 50-50, 20 mg
cpbp 50-50, 30 mg cpbp 50-50, 40 mg cpbp 50-50)
dextroamphetamine sulf-saccharate/amphetamine sulfaspartate (5 mg cap er 24h, 5 mg tablet, 7.5 mg tablet,
10 mg tablet, 10 mg cap er 24h, 12.5 mg tablet, 15 mg
tablet, 15 mg cap er 24h, 20 mg tablet, 20 mg cap er
24h, 25 mg cap er 24h, 30 mg tablet, 30 mg cap er 24h)
dextroamphetamine sulfate (5 mg tablet, 5 mg capsule
er, 10 mg tablet, 10 mg capsule er, 15 mg capsule er)
DIASTAT 2.5 MG PEDI SYSTEM
DIASTAT ACUDIAL (5-7.5-10 MG KT, 12.5-15-20 MG)
diazepam (2 mg tablet, 2.5 mg kit, 5 mg/5 ml solution,
5-7.5-10mg kit, 5 mg/ml oral conc, 5 mg tablet, 10 mg
tablet, 12.5-15-20 kit)
doxepin hcl (10 mg/ml oral conc, 10 mg capsule, 25 mg
capsule, 50 mg capsule, 75 mg capsule, 100 mg
duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 40
mg capsule dr, 60 mg capsule dr)
EFFEXOR XR (37.5 MG CAPSULE, 75 MG CAPSULE,
150 MG CAPSULE)
EMSAM (6, 9, 12)
ergoloid mesylates 1 mg tablet
escitalopram oxalate (5 mg/5 ml solution, 5 mg tablet,
estazolam (1 mg tablet, 2 mg tablet)
eszopiclone (1 mg tablet, 2 mg tablet, 3 mg tablet)
PA
FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG
TABLET, 12 MG TABLET, TITRATION PACK)
36
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
FAZACLO (12.5 MG TABLET, 12.5 MG ODT, 25 MG
TABLET, 25 MG ODT, 100 MG ODT, 100 MG TABLET,
150 MG ODT, 200 MG ODT)
FETZIMA (20-40 MG TITRATION PAK, ER 20 MG
CAPSULE, ER 40 MG CAPSULE, ER 80 MG
CAPSULE, ER 120 MG CAPSULE)
fluoxetine hcl (10 mg tablet, 10 mg capsule, 20 mg
tablet, 20 mg/5 ml solution, 20 mg capsule, 40 mg
capsule, 60 mg tablet, 90 mg capsule dr)
fluphenazine decanoate 25 mg/ml vial
fluphenazine hcl (1 mg tablet, 2.5 mg/5ml elixir, 2.5 mg
tablet, 2.5 mg/ml vial, 5 mg tablet, 5 mg/ml oral conc, 10
mg tablet)
flurazepam hcl (15 mg capsule, 30 mg capsule)
PA
fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100
mg cap er 24h, 100 mg tablet, 150 mg cap er 24h)
FOCALIN (2.5 MG TABLET, 5 MG TABLET, 10 MG
TABLET)
FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15
MG CAPSULE, 20 MG CAPSULE, 25 MG CAPSULE,
CAPSULE)
FORFIVO XL 450 MG TABLET
GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60
GEODON 20 MG/ML VIAL
PA B vs D
guanfacine hcl (1 mg tab er, 2 mg tab er, 3 mg tab er, 4
mg tab er)
HALDOL 5 MG/ML AMPUL
HALDOL DECANOATE 100 AMPUL
HALDOL DECANOATE 50 AMPUL
haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5
haloperidol decanoate (50 mg/ml vial, 50 mg/ml ampul,
100 mg/ml ampul, 100 mg/ml vial)
haloperidol lactate (2 mg/ml oral conc, 5 mg/ml vial, 5
mg/ml ampul)
37
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg
tablet)
imipramine pamoate (75 mg capsule, 100 mg capsule,
125 mg capsule, 150 mg capsule)
INVEGA (ER 1.5 MG TABLET, ER 3 MG TABLET, ER
6 MG TABLET, ER 9 MG TABLET)
INVEGA SUSTENNA (39 MG SYR, 78 MG SYR, 117
MG SY, 156 MG SY, 234 MG SY)
PA B vs D
IRENKA DR 40 MG CAPSULE
KHEDEZLA (ER 50 MG TABLET, ER 100 MG TABLET)
LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG
TABLET, 80 MG TABLET, 120 MG TABLET)
LEXAPRO (5 MG TABLET, 5 MG/5 ML SOLUTION, 10
lithium carbonate (150 mg capsule, 300 mg tablet er,
300 mg tablet, 300 mg capsule, 450 mg tablet er, 600
mg capsule)
lithium citrate 8 meq/5 ml solution
lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
PA
LORAZEPAM INTENSOL 2 MG/ML
PA
loxapine succinate (5 mg capsule, 10 mg capsule, 25
maprotiline hcl (25 mg tablet, 50 mg tablet, 75 mg
tablet)
MARPLAN 10 MG TABLET
METADATE CD (10 MG CAPSULE, 20 MG CAPSULE,
METADATE ER 20 MG TABLET
methamphetamine hcl 5 mg tablet
METHYLIN (2.5 MG CHEWABLE TAB, 5 MG/5 ML
SOLUTION, 5 MG CHEWABLE TABLET, 10 MG/5 ML
SOLUTION, 10 MG CHEWABLE TABLET)
38
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
methylphenidate hcl (2.5 mg tab chew, 5 mg tablet, 5
mg/5 ml solution, 5 mg tab chew, 10 mg tablet, 10 mg/5
ml solution, 10 mg cpbp 30-70, 10 mg tab chew, 18 mg
tab er 24, 20 mg cpbp 30-70, 20 mg tablet, 20 mg cpbp
50-50, 20 mg tablet er, 27 mg tab er 24, 30 mg cpbp
50-50, 30 mg cpbp 30-70, 40 mg cpbp 50-50, 40 mg
cpbp 30-70, 50 mg cpbp 30-70, 60 mg cpbp 30-70)
mirtazapine (7.5 mg tablet, 15 mg tablet, 15 mg tab
rapdis, 30 mg tablet, 30 mg tab rapdis, 45 mg tablet, 45
mg tab rapdis)
modafinil (100 mg tablet, 200 mg tablet)
PA
NARDIL 15 MG TABLET
nefazodone hcl (50 mg tablet, 100 mg tablet, 150 mg
tablet, 200 mg tablet, 250 mg tablet)
nortriptyline hcl (10 mg/5 ml solution, 10 mg capsule, 25
mg capsule, 50 mg capsule, 75 mg capsule)
NUVIGIL (50 MG TABLET, 150 MG TABLET, 200 MG
PA
olanzapine (2.5 mg tablet, 5 mg tablet, 5 mg tab rapdis,
7.5 mg tablet, 10 mg tab rapdis, 10 mg tablet, 10 mg
vial, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 20
mg tab rapdis)
olanzapine/fluoxetine hcl (3 mg-25 mg capsule, 6mg50mg capsule, 6mg-25mg capsule, 12mg-25mg
capsule, 12mg-50mg capsule)
ORAP (1 MG TABLET, 2 MG TABLET)
oxazepam (10 mg capsule, 15 mg capsule, 30 mg
capsule)
PA
paroxetine hcl (10 mg tablet, 12.5 mg tab er 24h, 20 mg
tablet, 25 mg tab er 24h, 30 mg tablet, 37.5 mg tab er
24h, 40 mg tablet)
PAXIL 10 MG/5 ML SUSPENSION
perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet, 16
mg tablet)
perphenazine/amitriptyline hcl (2 mg-10 mg tablet, 2
mg-25 mg tablet, 4 mg-25 mg tablet, 4mg-50mg tablet,
4mg-10mg tablet)
PEXEVA (10 MG TABLET, 20 MG TABLET, 30 MG
39
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
phenelzine sulfate 15 mg tablet
PRISTIQ ER (ER 25 MG TABLET, ER 50 MG TABLET,
ER 100 MG TABLET)
protriptyline hcl (5 mg tablet, 10 mg tablet)
PROVIGIL (100 MG TABLET, 200 MG TABLET)
PA
PROZAC WEEKLY 90 MG CAPSULE
quetiapine fumarate (25 mg tablet, 50 mg tablet, 100
mg tablet, 200 mg tablet, 300 mg tablet, 400 mg tablet)
RESTORIL (7.5 MG CAPSULE, 15 MG CAPSULE,
22.5 MG CAPSULE, 30 MG CAPSULE)
RISPERDAL CONSTA (12.5 MG, 25 MG, 37.5 MG, 50
MG)
PA B vs D
RISPERDAL M-TAB (0.5 MG ODT, 1 MG ODT, 2 MG
ODT, 3 MG ODT, 4 MG ODT)
risperidone (0.25 mg tablet, 0.25 mg tab rapdis, 0.5 mg
tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg/ml
solution, 1 mg tablet, 2 mg tablet, 2 mg tab rapdis, 3 mg
tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet)
ROZEREM 8 MG TABLET
PA
SAPHRIS (2.5 MG TAB SL BLK CHRY, 5 MG TAB SL
BLK CHERRY, 5 MG TABLET SUBLINGUAL, 10 MG
TAB SUBLINGUAL, 10 MG TAB SL BLK CHERY)
SARAFEM (10 MG TABLET, 20 MG TABLET)
SEROQUEL (25 MG TABLET, 50 MG TABLET, 100
MG TABLET, 200 MG TABLET, 300 MG TABLET, 400
MG TABLET)
SEROQUEL XR (50 MG TABLET, 150 MG TABLET,
200 MG TABLET, 300 MG TABLET, 400 MG TABLET)
sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg
STRATTERA (10 MG CAPSULE, 18 MG CAPSULE, 25
SURMONTIL (25 MG CAPSULE, 50 MG CAPSULE,
100 MG CAPSULE)
SYMBYAX (3-25 MG CAPSULE, 6-25 MG CAPSULE,
6-50 MG CAPSULE, 12-25 MG CAPSULE, 12-50 MG
CAPSULE)
40
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
temazepam (7.5 mg capsule, 15 mg capsule, 22.5 mg
PA
thioridazine hcl (10 mg tablet, 25 mg tablet, 50 mg
thiothixene (1 mg capsule, 2 mg capsule, 5 mg capsule,
10 mg capsule)
TOFRANIL-PM (75 MG CAPSULE, 100 MG CAPSULE,
tranylcypromine sulfate 10 mg tablet
trazodone hcl (50 mg tablet, 100 mg tablet, 150 mg
triazolam (0.125 mg tablet, 0.25 mg tablet)
trifluoperazine hcl (1 mg tablet, 2 mg tablet, 5 mg tablet,
10 mg tablet)
venlafaxine hcl (25 mg tablet, 37.5 mg cap er 24h, 37.5
mg tab er 24, 37.5 mg tablet, 50 mg tablet, 75 mg tab er
24, 75 mg cap er 24h, 75 mg tablet, 100 mg tablet, 150
mg cap er 24h, 150 mg tab er 24, 225 mg tab er 24)
VERSACLOZ 50 MG/ML SUSPENSION
VIIBRYD (10-20 MG STARTER PACK, 10 MG
TABLET, 10-20-40 MG STARTER PK, 20 MG TABLET,
40 MG TABLET)
VYVANSE (20 MG CAPSULE, 30 MG CAPSULE, 40
70 MG CAPSULE)
XYREM 500 MG/ML ORAL SOLUTION
LA
zaleplon (5 mg capsule, 10 mg capsule)
ziprasidone hcl (20 mg capsule, 40 mg capsule, 60 mg
zolpidem tartrate (5 mg tablet, 6.25 mg tab mphase, 10
mg tablet, 12.5 mg tab mphase)
ZYPREXA (2.5 MG TABLET, 5 MG TABLET, 7.5 MG
TABLET, 10 MG VIAL, 10 MG TABLET, 15 MG
ZYPREXA RELPREVV (210 MG VIAL, 210 MG VL KIT,
300 MG VL KIT, 300 MG VIAL, 405 MG VL KIT, 405
MG VIAL)
PA B vs D
41
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ZYPREXA ZYDIS (5 MG TABLET, 10 MG TABLET, 15
CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone hcl (50 mg/ml vial, 50 mg/ml ampul, 200
disopyramide phosphate (100 mg capsule, 150 mg
capsule)
flecainide acetate (50 mg tablet, 100 mg tablet, 150 mg
tablet)
mexiletine hcl (150 mg capsule, 200 mg capsule, 250
mg capsule)
MULTAQ 400 MG TABLET
QL (60 PER 30 DAYS)
PACERONE (100 MG TABLET, 200 MG TABLET, 400
MG TABLET)
procainamide hcl (100 mg/ml vial, 500 mg/ml vial)
propafenone hcl (150 mg tablet, 225 mg cap er 12h,
225 mg tablet, 300 mg tablet, 325 mg cap er 12h, 425
mg cap er 12h)
quinidine gluconate (80 mg/ml vial, 324 mg tablet er)
quinidine sulfate (200 mg tablet, 300 mg tablet er, 300
mg tablet)
SORINE (80 MG TABLET, 120 MG TABLET, 160 MG
sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet,
240 mg tablet)
TIKOSYN (125 MCG CAPSULE, 250 MCG CAPSULE,
500 MCG CAPSULE)
ANTIHYPERTENSIVE THERAPY
acebutolol hcl (200 mg capsule, 400 mg capsule)
ADCIRCA 20 MG TABLET
PA
AFEDITAB CR (30 MG TABLET, 60 MG TABLET)
42
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ALDACTAZIDE 50-50 TABLET
amiloride hcl 5 mg tablet
amiloride/hydrochlorothiazide 5 mg-50 mg tablet
amlodipine besylate (2.5 mg tablet, 5 mg tablet, 10 mg
tablet)
amlodipine besylate/atorvastatin calcium (2.5mg-20mg
tablet, 2.5mg-40mg tablet, 2.5mg-10mg tablet, 5 mg-20
mg tablet, 5 mg-80 mg tablet, 5 mg-40 mg tablet, 5 mg10 mg tablet, 10 mg-80mg tablet, 10 mg-10mg tablet)
amlodipine besylate/benazepril hcl (2.5mg-10mg
capsule, 5 mg-40 mg capsule, 5 mg-10 mg capsule, 5
mg-20 mg capsule, 10 mg-40mg capsule, 10 mg-20mg
capsule)
amlodipine besylate/valsartan (5mg-320mg tablet, 5
mg-160mg tablet, 10mg-160mg tablet, 10mg-320mg
tablet)
QL (30 PER 30 DAYS)
amlodipine besylate/valsartan/hydrochlorothiazide (5160-25mg tablet, 5-160-12.5 tablet, 10mg-160mg tablet,
10-320-25 tablet, 10-160-25 tablet)
QL (30 PER 30 DAYS)
atenolol (25 mg tablet, 50 mg tablet, 100 mg tablet)
atenolol/chlorthalidone (50 mg-25mg tablet, 100mg25mg tablet)
AZOR (5-20 MG TABLET, 5-40 MG TABLET, 10-20
MG TABLET, 10-40 MG TABLET)
benazepril hcl (5 mg tablet, 10 mg tablet, 20 mg tablet,
40 mg tablet)
benazepril hcl/hydrochlorothiazide (5-6.25mg tablet, 1012.5mg tablet, 20-12.5 mg tablet, 20-25mg tablet)
betaxolol hcl (10 mg tablet, 20 mg tablet)
bisoprolol fumarate (5 mg tablet, 10 mg tablet)
bisoprolol fumarate/hydrochlorothiazide (2.5-6.25mg
tablet, 5-6.25mg tablet, 10-6.25mg tablet)
bumetanide (0.25 mg/ml vial, 0.5 mg tablet, 1 mg tablet,
2 mg tablet)
BYSTOLIC (2.5 MG TABLET, 5 MG TABLET, 10 MG
43
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
candesartan cilexetil (4 mg tablet, 8 mg tablet, 16 mg
candesartan cilexetil/hydrochlorothiazide (16-12.5mg
tablet, 32-12.5mg tablet, 32mg-25mg tablet)
captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet,
100 mg tablet)
captopril/hydrochlorothiazide (25 mg-25mg tablet, 25
mg-15mg tablet, 50 mg-15mg tablet, 50 mg-25mg
tablet)
CARDURA XL (4 MG TABLET, 8 MG TABLET)
QL (60 PER 30 DAYS)
CARTIA XT (120 MG CAPSULE, 180 MG CAPSULE,
carvedilol (3.125 mg tablet, 6.25 mg tablet, 12.5 mg
chlorothiazide (250 mg tablet, 500 mg tablet)
chlorothiazide sodium 500 mg vial
PA B vs D
chlorthalidone (25 mg tablet, 50 mg tablet)
clonidine (0.1mg/24hr, 0.2mg/24hr, 0.3mg/24hr)
clonidine hcl (0.1 mg tab er 12h, 0.1 mg tablet, 0.2 mg
tablet, 0.3 mg tablet)
CLORPRES (0.1-15 TABLET, 0.2-15 TABLET, 0.3-15
TABLET)
COREG CR (10 MG CAPSULE, 20 MG CAPSULE, 40
COZAAR (25 MG TABLET, 50 MG TABLET)
COZAAR 100 MG TABLET
DEMSER 250 MG CAPSULE
DILT-CD (180 MG CAPSULE, 240 MG CAPSULE)
DILT-XR (180 MG CAPSULE, 240 MG CAPSULE)
44
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
diltiazem hcl (5 mg/ml vial, 30 mg tablet, 60 mg cap er
12h, 60 mg tablet, 90 mg cap er 12h, 90 mg tablet, 100
mg vial port, 120 mg cap er 12h, 120 mg cap er 24h,
120 mg cap er deg, 120 mg capsule er, 120 mg tablet,
180 mg cap er 24h, 180 mg capsule er, 180 mg cap er
deg, 240 mg cap er deg, 240 mg cap er 24h, 240 mg
capsule er, 300 mg capsule er, 300 mg cap er 24h, 360
mg cap er 24h, 360 mg capsule er, 420mg capsule er)
DIOVAN (40 MG TABLET, 80 MG TABLET, 160 MG
TABLET)
DIOVAN 320 MG TABLET
DIOVAN HCT (80-12.5 MG TABLET, 160-25 MG
TABLET, 160-12.5 MG TAB, 320-12.5 MG TAB, 320-25
MG TABLET)
DIURIL 250 MG/5 ML ORAL SUSP
DIURIL SODIUM 500 MG VIAL
PA B vs D
doxazosin mesylate (1 mg tablet, 2 mg tablet, 4 mg
QL (60 PER 30 DAYS)
EDARBI (40 MG TABLET, 80 MG TABLET)
ST
EDARBYCLOR (40-12.5 MG TABLET, 40-25 MG
TABLET)
ST
enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mg
enalapril maleate/hydrochlorothiazide (5mg-12.5mg
tablet, 10mg-25mg tablet, 10 mg-25mg tablet)
eplerenone (25 mg tablet, 50 mg tablet)
eprosartan mesylate 600 mg tablet
EXFORGE (5-320 MG TABLET, 5-160 MG TABLET,
10-320 MG TABLET, 10-160 MG TABLET)
EXFORGE HCT (5-160-25 MG TAB, 5-160-12.5 MG
TAB, 10-320-25 MG TAB, 10-160-12.5 MG TAB, 10160-25 MG TAB)
felodipine (2.5 mg tab er, 5 mg tab er, 10 mg tab er)
fosinopril sodium (10 mg tablet, 20 mg tablet, 40 mg
tablet)
fosinopril sodium/hydrochlorothiazide (10-12.5mg
tablet, 20-12.5 mg tablet)
45
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
furosemide (10 mg/ml syringe, 10 mg/ml disp syrin, 10
mg/ml solution, 10 mg/ml vial, 20 mg tablet, 40 mg
tablet, 40mg/5ml solution, 80 mg tablet)
guanfacine hcl (1 mg tablet, 2 mg tablet)
hydralazine hcl (10 mg tablet, 20 mg/ml vial, 25 mg
hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet,
HYZAAR (50-12.5 TABLET, 100-12.5 TABLET, 100-25
TABLET)
indapamide (1.25 mg tablet, 2.5 mg tablet)
INTUNIV (ER 1 MG TABLET, ER 2 MG TABLET, ER 3
MG TABLET, ER 4 MG TABLET)
irbesartan (75 mg tablet, 150 mg tablet, 300 mg tablet)
irbesartan/hydrochlorothiazide (150-12.5mg tablet, 30012.5mg tablet)
isradipine (2.5 mg capsule, 5 mg capsule)
labetalol hcl (5 mg/ml vial, 100 mg tablet, 200 mg tablet,
300 mg tablet)
lisinopril (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20
lisinopril/hydrochlorothiazide (10-12.5mg tablet, 20-12.5
mg tablet, 20-25mg tablet)
losartan potassium (25 mg tablet, 50 mg tablet, 100 mg
tablet)
losartan potassium/hydrochlorothiazide (50-12.5 mg
tablet, 100-12.5mg tablet, 100mg-25mg tablet)
methyclothiazide 5 mg tablet
methyldopa (250 mg tablet, 500 mg tablet)
methyldopa/hydrochlorothiazide (250mg-25mg tablet,
250mg-15mg tablet)
metolazone (2.5 mg tablet, 5 mg tablet, 10 mg tablet)
metoprolol succinate (25 mg tab er, 50 mg tab er, 100
mg tab er, 200 mg tab er)
46
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
metoprolol tartrate (25 mg tablet, 50 mg tablet, 100 mg
tablet)
metoprolol tartrate (5 ml syringe, 5 ml ampul, 5 ml vial)
PA B vs D
metoprolol tartrate/hydrochlorothiazide (50 mg-25mg
tablet, 100mg-50mg tablet, 100mg-25mg tablet)
MICARDIS (20 MG TABLET, 40 MG TABLET, 80 MG
TABLET)
MICARDIS HCT (40-12.5 MG TABLET, 80-12.5 MG
minoxidil (2.5 mg tablet, 10 mg tablet)
moexipril hcl 15 mg tablet
moexipril hcl/hydrochlorothiazide (7.5-12.5mg tablet,
15-25mg tablet, 15-12.5mg tablet)
nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet)
nadolol/bendroflumethiazide (40 mg tablet, 80 mg
tablet)
nicardipine hcl (20 mg capsule, 30 mg capsule)
NIFEDICAL XL (30 MG TABLET, 60 MG TABLET)
nifedipine (10 mg capsule, 20 mg capsule, 30 mg tab er
24, 30 mg tablet er, 60 mg tablet er, 60 mg tab er 24, 90
mg tab er 24, 90 mg tablet er)
nimodipine 30 mg capsule
nisoldipine (20 mg tab er, 30 mg tab er, 40 mg tab er)
pindolol (5 mg tablet, 10 mg tablet)
prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg
capsule)
propranolol hcl (1 mg/ml vial, 10 mg tablet, 20 mg/5 ml
solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution,
60 mg cap sa 24h, 60 mg tablet, 80 mg tablet, 80 mg
cap sa 24h, 120 mg cap sa 24h, 160 mg cap sa 24h)
propranolol hcl/hydrochlorothiazide (40 tablet, 80 tablet)
quinapril hcl (5 mg tablet, 10 mg tablet, 20 mg tablet, 40
mg tablet)
quinapril hcl/hydrochlorothiazide (10-12.5mg tablet, 2012.5 mg tablet, 20-25mg tablet)
47
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ramipril (1.25 mg capsule, 2.5 mg capsule, 5 mg
REMODULIN (1 MG/ML VIAL, 2.5 MG/ML VIAL, 5
MG/ML VIAL, 10 MG/ML VIAL)
PA B vs D
reserpine (0.1 mg tablet, 0.25 mg tablet)
SODIUM DIURIL 0.5 GRAM VIAL
PA B vs D
spironolact/hydrochlorothiazid 25 mg-25mg tablet
spironolactone (25 mg tablet, 50 mg tablet, 100 mg
tablet)
SULAR (ER 8.5 MG TABLET, ER 34 MG TABLET)
TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE,
CAPSULE)
TEKTURNA (150 MG TABLET, 300 MG TABLET)
TEKTURNA HCT (150-12.5 MG TAB, 150-25 MG
TABLET, 300-12.5 MG TAB, 300-25 MG TABLET)
telmisartan (20 mg tablet, 40 mg tablet, 80 mg tablet)
telmisartan/amlodipine besylate (40 mg-10mg tablet, 40
mg-5 mg tablet, 80 mg-10mg tablet, 80 mg-5 mg tablet)
telmisartan/hydrochlorothiazide (40-12.5 mg tablet, 8012.5mg tablet, 80 mg-25mg tablet)
terazosin hcl (1 mg capsule, 2 mg capsule, 5 mg
timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet)
torsemide (5 mg tablet, 10 mg tablet, 20 mg tablet, 100
mg tablet)
trandolapril (1 mg tablet, 2 mg tablet, 4 mg tablet)
trandolapril/verapamil hcl (1-240mg tab, 2-240mg tab, 2
mg-180mg tab, 4-240mg tab)
triamterene/hydrochlorothiazide (37.5-25 mg capsule,
37.5-25 mg tablet, 50 mg-25mg capsule, 75 mg-50mg
tablet)
valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet,
320 mg tablet)
48
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
valsartan/hydrochlorothiazide (80-12.5mg tablet, 16012.5mg tablet, 160-25mg tablet, 320mg-25mg tablet,
320-12.5mg tablet)
QL (30 PER 30 DAYS)
verapamil hcl (2.5 mg/ml ampul, 2.5 mg/ml vial, 40 mg
tablet, 80 mg tablet, 100 mg cap24h pct, 120 mg
cap24h pel, 120 mg tablet, 120 mg tablet er, 180 mg
tablet er, 180 mg cap24h pel, 200 mg cap24h pct, 240
mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct,
360 mg cap24h pel)
CARDIAC GLYCOSIDES
DIGITEK (125 MCG TABLET, 250 MCG TABLET)
digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg
tablet)
LANOXIN (0.25 MG/ML AMPUL, 500 MCG/2 ML
AMPULE)
PA B vs D
COAGULATION THERAPY
AGGRENOX 25 MG-200 MG CAPSULE
ARIXTRA (2.5 MG, 2.5 MG/0.5 ML, 5 MG, 5 MG/0.4
ML, 7.5 MG, 7.5 MG/0.6 ML, 10 MG, 10 MG/0.8 ML)
PA B vs D
BRILINTA 90 MG TABLET
cilostazol (50 mg tablet, 100 mg tablet)
clopidogrel bisulfate 300 mg tablet
clopidogrel bisulfate 75 mg tablet
QL (30 PER 30 DAYS)
CYKLOKAPRON (100 MG/ML AMPUL, 1,000 MG/10
ML VL)
dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet)
ELIQUIS (2.5 MG TABLET, 5 MG TABLET)
enoxaparin sodium (100 mg/ml syringe, 300mg/3ml
vial)
enoxaparin sodium (30mg/0.3ml, 40mg/0.4ml,
60mg/0.6ml, 80mg/0.8ml, 120mg/.8ml, 150 mg/ml)
PA B vs D
fondaparinux sodium (2.5 mg/0.5, 5mg/0.4ml,
7.5mg/0.6, 10mg/0.8ml)
PA B vs D
49
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2
ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML
SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML,
18,000 UNITS/0.72 ML, 25,000 UNITS/ML VIAL,
95,000 UNITS/3.8 ML VL)
PA B vs D
heparin sodium,porcine (1000/ml vial, 5000/ml vial,
5000/ml(1) cartridge, 10000/ml vial, 20000/ml vial)
heparin sodium,porcine/d5w 20k/500ml iv soln
PA B vs D
heparin sodium,porcine/dextrose 5 % in water
(10k/100ml soln, 12500/250 soln, 25000/250 soln,
25000/500 soln)
JANTOVEN (1 MG TABLET, 2 MG TABLET, 2.5 MG
TABLET, 6 MG TABLET, 7.5 MG TABLET, 10 MG
TABLET)
LOVENOX (30 MG/0.3 ML, 40 MG/0.4 ML, 60 MG/0.6
ML, 80 MG/0.8 ML, 100 MG/ML, 120 MG/0.8 ML, 150
MG/ML)
PA B vs D
LOVENOX 300 MG/3 ML VIAL
LYSTEDA 650 MG TABLET
pentoxifylline 400 mg tablet er
PLAVIX 300 MG TABLET
PLAVIX 75 MG TABLET
QL (30 PER 30 DAYS)
PRADAXA (75 MG CAPSULE, 150 MG CAPSULE)
PROMACTA (12.5 MG TABLET, 25 MG TABLET, 50
ticlopidine hcl 250 mg tablet
tranexamic acid 650 mg tablet
warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet,
3 mg tablet, 4 mg tablet, 5 mg tablet, 6 mg tablet, 7.5
LIPID/CHOLESTEROL LOWERING AGENTS
ADVICOR (500 MG-20 MG TABLET, 750 MG-20 MG
TABLET, 1,000 MG-40 MG TABLET, 1,000 MG-20 MG
TABLET)
50
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
atorvastatin calcium (10 mg tablet, 20 mg tablet, 40 mg
CADUET (2.5 MG-40 MG TABLET, 2.5 MG-20 MG
TABLET, 2.5 MG-10 MG TABLET, 5 MG-80 MG
TABLET, 5 MG-10 MG TABLET, 5 MG-40 MG
TABLET, 10 MG-40 MG TABLET)
QL (30 PER 30 DAYS)
cholestyramine/aspartame (4 powd pack, 4 powder)
colestipol hcl (1 tablet, 5 packet, 5 ranules)
CRESTOR (5 MG TABLET, 10 MG TABLET, 20 MG
ST
fenofibrate (50 mg capsule, 54 mg tablet, 150 mg
capsule, 160 mg tablet)
fenofibrate nanocrystallized (48 mg tablet, 145mg
tablet)
fenofibrate,micronized (43 mg capsule, 67 mg capsule,
130 mg capsule, 134mg capsule, 200 mg capsule)
fenofibric acid (choline) (45 mg capsule dr, 135 mg
capsule dr)
FIBRICOR (35 MG TABLET, 105 MG TABLET)
fluvastatin sodium (20 mg capsule, 40 mg capsule)
gemfibrozil 600 mg tablet
JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE, 20
60 MG CAPSULE)
PA
lovastatin (10 mg tablet, 20 mg tablet, 40 mg tablet)
LOVAZA 1 GM CAPSULE
niacin (500 mg tab er, 750 mg tab er, 1000 mg tab er)
NIACOR 500 MG TABLET
NIASPAN (ER 500 MG TABLET, ER 750 MG TABLET,
ER 1,000 MG TABLET)
omega-3 acid ethyl esters 1 g capsule
pravastatin sodium (10 mg tablet, 20 mg tablet, 40 mg
51
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
PREVALITE (PACKET, POWDER)
simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40
VYTORIN (10-80 MG TABLET, 10-10 MG TABLET, 1040 MG TABLET, 10-20 MG TABLET)
QL (30 PER 30 DAYS)
WELCHOL (3.75G PACKET, 625 MG TABLET)
ZETIA 10 MG TABLET
QL (30 PER 30 DAYS)
MISCELLANEOUS CARDIOVASCULAR AGENTS
ADEMPAS (0.5 MG TABLET, 1 MG TABLET, 1.5 MG
TABLET, 2 MG TABLET, 2.5 MG TABLET)
RANEXA (ER 500 MG TABLET, ER 1,000 MG
TABLET)
PA
sildenafil citrate 10 mg/12.5 vial
NITRATES
isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg
tablet, 30 mg tablet, 40 mg tablet er)
isosorbide mononitrate (10 mg tablet, 20 mg tablet, 30
mg tab er 24h, 60 mg tab er 24h, 120 mg tab er 24h)
MINITRAN (0.1, 0.2, 0.4, 0.6)
NITRO-BID 2% OINTMENT
nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24,
0.4mg/hr patch td24, 0.6mg/hr patch td24, 50 mg/10ml
vial, 400mcg/spr spray)
NITROLINGUAL 0.4 MG SPRAY
NITROSTAT (0.3 MG TABLET, 0.4 MG TABLET, 0.6
MG TABLET)
Central Nervous System Agents
MISCELLANEOUS AGENTS
riluzole 50 mg tablet
52
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
acitretin (10 mg capsule, 17.5 mg capsule, 25 mg
capsule)
calcipotriene (0.005 % cream (g), 0.005 % oint. (g),
0.005 % solution)
calcipotriene/betamethasone 0.005-.064 oint. (g)
calcitriol 3 mcg/g oint. (g)
DOVONEX 0.005% CREAM
selenium sulfide 2.5 % suspension
SORIATANE (10 MG CAPSULE, 17.5 MG CAPSULE,
25 MG CAPSULE)
TACLONEX 0.005%-0.064% SUSPENS
TACLONEX SCALP SUSPENSION
BURN THERAPY
silver sulfadiazine 1 % cream (g)
SSD 1% CREAM
SSD AF 1% CREAM
MISCELLANEOUS DERMATOLOGICALS
8-MOP 10 MG CAPSULE
ALDARA 5% CREAM
ammonium lactate (12 % lotion, 12 % cream (g))
CARAC (, 0.5%)
ELIDEL 1% CREAM
fluorouracil (0.5 % cream (g), 2 % solution, 5 %
solution, 5 % cream (g))
imiquimod 5 % cream pack
methoxsalen, rapid 10 mg capsule
OXSORALEN-ULTRA 10 MG CAP
53
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
PANRETIN 0.1% GEL
podofilox 0.5 % solution
PROTOPIC (0.03%, 0.1%)
PRUDOXIN 5% CREAM
SOLARAZE 3% GEL
tacrolimus (0.03 %, 0.1 %)
UVADEX 20 MCG/ML VIAL
PA B vs D
VALCHLOR 0.016% GEL
VEREGEN 15% OINTMENT
THERAPY FOR ACNE
ACANYA (GEL, GEL PUMP)
adapalene (0.1 % gel (gram), 0.1 % cream (g))
AMNESTEEM (10 MG CAPSULE, 20 MG CAPSULE,
40 MG CAPSULE)
AVITA 0.025% CREAM
AZELEX 20% CREAM
BENZACLIN (GEL, GEL 35G PUMP, GEL 50G PUMP)
CLARAVIS (10 MG CAPSULE, 20 MG CAPSULE, 30
clindamycin phosphate (1 % lotion, 1 % med. swab, 1
% gel (gram), 1 % solution)
clindamycin phosphate/benzoyl peroxide (1 %-5 % gel,
1.2(1)%-5% gel)
ERY 2% PADS
erythromycin base/ethyl alcohol (2 % solution, 2 % gel
(gram))
erythromycin/benzoyl peroxide 3 %-5 % gel (gram)
FINACEA 15% GEL
METROGEL (GEL, PUMP)
metronidazole (0.75 % gel (gram), 0.75 % cream (g),
0.75 % lotion)
54
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
NORITATE 1% CREAM
TAZORAC (0.05% CREAM, 0.05% GEL, 0.1% GEL,
0.1% CREAM)
tretinoin (0.01 % gel (gram), 0.025 % gel (gram), 0.025
% cream (g), 0.05 % cream (g), 0.1 % cream (g))
tretinoin microspheres (0.04 % gel w/pump, 0.04 % gel
(gram), 0.1 % gel (gram), 0.1 % gel w/pump)
TOPICAL ANESTHETICS
lidocaine 5 % adh. patch
PA
lidocaine 5 % oint. (g)
lidocaine hcl (2 % solution, 2 % jel/pf app, 2 % jel (ml),
5 mg/ml vial, 40 mg/ml solution)
lidocaine hcl/pf 5 mg/ml vial
lidocaine/prilocaine (2.5 cream (g), 2.5 kit)
LIDODERM 5% PATCH
PA
TOPICAL ANTIBACTERIALS
ALTABAX 1% OINTMENT
BACTROBAN 2% CREAM
CORTISPORIN CREAM
gentamicin sulfate (0.1 % oint., 0.1 % cream)
mupirocin 2 % oint. (g)
mupirocin calcium 2 % cream (g)
sulfacetamide sodium 10 % suspension
SULFAMYLON (8.5% CREAM, POWDER PACKET)
TOPICAL ANTIFUNGALS
ciclopirox (0.77 % gel (gram), 8 % solution)
ciclopirox olamine (0.77 % cream (g), 0.77 %
suspension)
clotrimazole (1 % cream (g), 1 % solution)
clotrimazole/betamethasone dipropionate (1 % lotion, 1
% cream (g))
55
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
econazole nitrate 1 % cream (g)
ERTACZO 2% CREAM
EXELDERM (CREAM, SOLUTION)
EXTINA 2% FOAM
ketoconazole (2 % cream (g), 2 % shampoo)
naftifine hcl 1 % cream (g)
NYAMYC 100,000 UNITS/GM POWDER
nystatin (cream (g), oint. (g), powder)
nystatin/triamcinolone acetonide (cream, oint.)
NYSTOP 100,000 UNITS/GM POWDER
TOPICAL ANTIVIRALS
DENAVIR 1% CREAM
ZOVIRAX (CREAM, OINTMENT)
TOPICAL CORTICOSTEROIDS
ALA-CORT 1% CREAM
ALA-SCALP 2% LOTION
alclometasone dipropionate (0.05 % oint., 0.05 %
cream)
amcinonide (0.1 % cream (g), 0.1 % lotion, 0.1 % oint.
(g))
betamethasone dipropionate (0.05 % lotion, 0.05 % gel
(gram), 0.05 % cream (g), 0.05 % oint. (g))
betamethasone dipropionate/propylene glycol (0.05 %
cream (g), 0.05 % oint. (g), 0.05 % lotion)
betamethasone valerate (0.1 % cream (g), 0.1 % lotion,
0.1 % oint. (g), 0.12 % foam)
CAPEX SHAMPOO
clobetasol propionate (0.05 % solution, 0.05 % lotion,
0.05 % shampoo, 0.05 % spray, 0.05 % foam, 0.05 %
oint. (g), 0.05 % gel (gram))
DESONATE 0.05% GEL
56
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
desonide (0.05 % lotion, 0.05 % cream (g), 0.05 % oint.
(g))
desoximetasone (0.05 % cream (g), 0.05 % gel (gram),
0.05 % oint. (g), 0.25 % oint. (g), 0.25 % cream (g))
diflorasone diacetate (0.05 % oint., 0.05 % cream)
fluocinolone acetonide (0.01 % cream (g), 0.01 % oil,
0.01 % solution, 0.025 % oint. (g), 0.025 % cream (g))
fluocinonide (0.05 % gel (gram), 0.05 % solution, 0.05
% oint. (g), 0.1 % cream (g))
fluocinonide/emollient base 0.05 % cream (g)
fluticasone propionate (0.005 % oint. (g), 0.05 % lotion,
0.05 % cream (g))
halobetasol propionate (0.05 % oint., 0.05 % cream)
HALOG (CREAM, OINTMENT)
hydrocortisone (1 % oint. (g), 1 % cream (g), 2.5 %
lotion, 2.5 % cream (g), 2.5 % oint. (g))
hydrocortisone butyrate (0.1 % oint. (g), 0.1 % solution)
hydrocortisone butyrate/emoll 0.1 % cream (g)
hydrocortisone valerate (0.2 % cream, 0.2 % oint.)
KENALOG (0.147 MG/GRAM, AEROSOL)
mometasone furoate (0.1 % cream (g), 0.1 % oint. (g),
0.1 % solution)
prednicarbate 0.1 % oint. (g)
PROCTO-PAK 1% CREAM
PROCTOZONE-HC 2.5% CREAM
triamcinolone acetonide (0.025 % cream (g), 0.025 %
oint. (g), 0.025 % lotion, 0.1 % lotion, 0.1 % oint. (g), 0.1
% cream (g), 0.147mg/g aerosol, 0.5 % oint. (g), 0.5 %
cream (g))
TRIDERM 0.1% CREAM
TOPICAL ENZYMES
SANTYL OINTMENT
57
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
TOPICAL SCABICIDES / PEDICULICIDES
EURAX (CREAM, LOTION)
lindane (1 % lotion, 1 % shampoo)
malathion 0.5 % lotion
permethrin 5 % cream (g)
DIAGNOSTICS / MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
neomycin sulfate/polymyxin b sulfate (ampul, vial)
ringers solution irrig soln
ringers solution,lactated irrig soln
0.9 % sodium chloride (0.9 % 0.9 % iv soln, 0.9 % 0.9
% syringe, 0.9 % 0.9 % disp syrin, 0.9 % pggybk prt,
0.9 % 0.9 % vial, 0.9 % pgy vl prt)
PA B vs D
acamprosate calcium 333 mg tablet dr
ACTONEL 30 MG TABLET
ADAGEN 250 UNITS/ML VIAL
PA B vs D
alendronate sodium 40 mg tablet
anagrelide hcl (0.5 mg capsule, 1 mg capsule)
ANTABUSE (250 MG TABLET, 500 MG TABLET)
ARALAST 1,000 MG VIAL
PA B vs D
ARALAST NP (500 MG VIAL, 1,000 MG VIAL)
PA B vs D
CARNITOR 1 GM/5 ML VIAL
PA B vs D
cevimeline hcl 30 mg capsule
CHEMET 100 MG CAPSULE
CLINIMIX 4.25%-5% SOLUTION
PA B vs D
CLINIMIX E (2.75%-5%, 2.75%-10%)
PA B vs D
dextrose 10 % and 0.2 % sodium chloride (10 % 0.2 %
10 % dehp fr bg, 10 % 0.2 % 10 % iv soln)
PA B vs D
58
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
dextrose 10 % and 0.45 % nacl 10%-0.45% iv soln
PA B vs D
dextrose 10 % in water (10 % 10 % ampul, 10 % 10 %
iv soln, 10 % 10 % dehp fr bg)
PA B vs D
dextrose 2.5 % and 0.45 % nacl 2.5%-0.45% iv soln
PA B vs D
dextrose 5 % and 0.3 % nacl 5 %-0.3 % iv soln
PA B vs D
dextrose 5 % and 0.9 % nacl 5 %-0.9 % iv soln
PA B vs D
dextrose 5 % in water (5 % 5 % iv soln, 5 % pgy vl prt,
5 % 5 % vial, 5 % pggybk prt)
PA B vs D
dextrose 5 %-0.2 % nacl 5 %-0.2 % iv soln
PA B vs D
dextrose 5 %-0.45 % nacl 5 %-0.45 % iv soln
PA B vs D
disulfiram (250 mg tablet, 500 mg tablet)
etidronate disodium (200 mg tablet, 400 mg tablet)
EVOXAC 30 MG CAPSULE
EXJADE (125 MG TABLET, 250 MG TABLET, 500 MG
TABLET)
FOSRENOL (500 MG TABLET, 750 MG TABLET,
1,000 MG TABLET)
INCRELEX 40 MG/4 ML VIAL
PA B vs D
JADENU (90 MG TABLET, 180 MG TABLET, 360 MG
TABLET)
KIONEX (15 GM/60 ML SUSPENSION, POWDER)
KUVAN 500 MG POWDER PACKET
levocarnitine (with sugar) 100 mg/ml solution
levocarnitine 200 mg/ml vial
PA B vs D
levocarnitine 330 mg tablet
midodrine hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet)
pilocarpine hcl (5 mg tablet, 7.5 mg tablet)
potassium citrate (5 tablet er, 10 tablet er)
PROLASTIN C 1,000 MG VIAL
PA B vs D
RENAGEL (400 MG TABLET, 800 MG TABLET)
RENVELA (0.8 GM POWDER PACKET, 2.4 GM
POWDER PACKET, 800 MG TABLET)
59
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
RILUTEK 50 MG TABLET
risedronate sodium 30 mg tablet
ST
sodium chloride irrig solution 0.9 % irrig soln
sodium polystyrene sulfonate (15 g/60 ml oral susp,
30g/120ml enema, 50g/200ml enema, powder)
SYPRINE 250 MG CAPSULE
water for irrigation,sterile irrig soln
ZEMAIRA 1,000 MG VIAL
PA B vs D
SMOKING DETERRENTS
BUPROBAN 150 MG TABLET
CHANTIX (0.5 MG TABLET, 1 MG TABLET,
STARTING MONTH BOX, STARTING MONTH PAK)
PA
CHANTIX (1 MG BOX, 1 MG PAK)
NICOTROL CARTRIDGE INHALER
NICOTROL NS 10 MG/ML SPRAY
ZYBAN SR 150 MG TABLET
EAR, NOSE / THROAT MEDICATIONS
azelastine hcl (137 mcg, 205.5mcg)
BACTROBAN NASAL 2% OINTMENT
chlorhexidine gluconate 0.12 % mouthwash
ipratropium bromide (21 mcg, 42mcg)
olopatadine hcl 0.6 % spray/pump
PATANASE 665 MCG NASAL SPRAY
PERIOGARD 0.12% ORAL RINSE
triamcinolone acetonide 0.1 % paste (g)
TYZINE PEDIATRIC 0.05% DROP
60
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
MISCELLANEOUS OTIC PREPARATIONS
ACETASOL HC EAR DROPS
acetic acid 2 % solution
acetic acid/hydrocortisone 2 %-1 % drops
fluocinolone acetonide oil 0.01 % drops
ofloxacin 0.3 % drops
OTIC STEROID / ANTIBIOTIC
CIPRO HC OTIC SUSPENSION
CIPRODEX OTIC SUSPENSION
COLY-MYCIN S EAR DROPS
CORTISPORIN-TC EAR SUSP
neomycin sulfate/polymyxin b sulfate/hydrocortisone
(drops susp, solution)
ENDOCRINE/DIABETES
ADRENAL HORMONES
A-HYDROCORT 100 MG VIAL
PA B vs D
cortisone acetate 25 mg tablet
dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5
mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg
DEXAMETHASONE INTENSOL 1MG/1ML
dexamethasone sod phosphate 10 mg/ml vial
PA B vs D
dexamethasone sod phosphate 4 mg/ml vial
dexamethasone sod phosphate/pf 10 mg/ml vial
PA B vs D
DEXPAK 13 DAY 1.5 MG TABLET
fludrocortisone acetate 0.1 mg tablet
hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet)
KENALOG-10 10 MG/ML VIAL
PA B vs D
KENALOG-40 40 MG/ML VIAL
PA B vs D
61
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
methylprednisolone (4 mg tablet, 4 mg tab ds pk, 8 mg
methylprednisolone acetate (40 mg/ml vial, 80 mg/ml
vial)
PA B vs D
methylprednisolone sodium succinate (40 mg vial, 125
mg vial, 500 mg vial, 1000 mg vial)
PA B vs D
MILLIPRED 10 MG/5 ML SOLUTION
NATPARA (25 MCG, 50 MCG, 75 MCG, 100 MCG)
ORAPRED ODT (ODT 15 MG TABLET, ODT 30 MG
TABLET)
prednisolone 15 mg/5 ml solution
prednisolone sod phosphate (5 mg/5 ml solution, 10 mg
tab rapdis, 15 mg tab rapdis, 15 mg/5 ml solution, 25
mg/5 ml solution, 30 mg tab rapdis)
prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tablet, 5
mg/5 ml solution, 5 mg tab ds pk, 10 mg tablet, 10 mg
tab ds pk, 20 mg tablet, 50 mg tablet)
PREDNISONE 5 MG/ML SOLUTION
PA B vs D
SIGNIFOR (0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML)
SIGNIFOR LAR (20 MG VIAL, 20 MG KIT, 40 MG KIT,
40 MG VIAL, 60 MG VIAL, 60 MG KIT)
PA B vs D
SOLU-CORTEF (100 MG VIAL, 250 MG VIAL, 250 MG
ACT-O-VL, 500 MG VIAL, 500 MG ACT-O-VL, 1,000
MG VIAL)
PA B vs D
SOLU-MEDROL (40 MG VIAL, 500 MG VIAL, 1,000
MG VIAL, 2,000 MG VIAL)
PA B vs D
VERIPRED 20 20 MG/5 ML SOLN
Antithyroid Agents
methimazole (5 mg tablet, 10 mg tablet)
propylthiouracil 50 mg tablet
DIABETES THERAPY
acarbose (25 mg tablet, 50 mg tablet, 100 mg tablet)
ACTOPLUS MET (15 MG-500 MG TAB, 15 MG-850
MG TAB)
62
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ACTOPLUS MET XR (15-1,000 MG, 30-1,000 MG)
ACTOS (15 MG TABLET, 30 MG TABLET, 45 MG
TABLET)
BYDUREON 2 MG PEN INJECT
BYDUREON 2 MG VIAL
ST
BYETTA (5 MCG, 10 MCG)
chlorpropamide (100 mg tablet, 250 mg tablet)
ST
CYCLOSET 0.8 MG TABLET
DUETACT (30-4 MG TABLET, 30-2 MG TABLET)
FARXIGA (5 MG TABLET, 10 MG TABLET)
ST
glimepiride (1 mg tablet, 2 mg tablet, 4 mg tablet)
glipizide (2.5 mg tab er 24, 5 mg tablet, 5 mg tab er 24,
10 mg tab er 24, 10 mg tablet)
glipizide/metformin hcl (2.5-250 mg tablet, 2.5-500 mg
tablet, 5 mg-500mg tablet)
GLUCAGEN (1 MG HYPOKIT, DIAGNOSTIC 1 MG
VIAL, 1 MG HYPOKIT 2-PACK)
GLUCAGON 1 MG EMERGENCY KIT
glyburide (1.25 mg tablet, 2.5 mg tablet, 5 mg tablet)
ST
glyburide,micronized (1.5 mg tablet, 3 mg tablet, 6 mg
tablet)
ST
glyburide/metformin hcl (1.25-250mg tablet, 2.5-500 mg
tablet, 5 mg-500mg tablet)
ST
HUMALOG 100 UNITS/ML CARTRIDGE
HUMALOG 100 UNITS/ML KWIKPEN
HUMALOG 200 UNITS/ML KWIKPEN
HUMALOG MIX 50-50 KWIKPEN
HUMALOG MIX 50-50 VIAL
HUMALOG MIX 75-25 VIAL
INVOKAMET (50-1,000 MG TABLET, 50-500 MG
TABLET, 150-500 MG TABLET, 150-1,000 MG
TABLET)
ST
63
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
INVOKANA (100 MG TABLET, 300 MG TABLET)
ST
JANUMET (50-1,000 MG TABLET, 50-500 MG
TABLET)
JANUMET XR (50-500 MG TABLET, 50-1,000 MG
TABLET, 100-1,000 MG TABLET)
JANUVIA (25 MG TABLET, 50 MG TABLET, 100 MG
TABLET)
ST
JARDIANCE (10 MG TABLET, 25 MG TABLET)
ST
JENTADUETO (2.5 MG-850 MG TAB, 2.5 MG-1000
MG TAB, 2.5 MG-500 MG TAB)
KAZANO (12.5-500 MG TABLET, 12.5-1,000 MG
TABLET)
KOMBIGLYZE XR (2.5-1,000 MG TAB, 5-1,000 MG
TAB, 5-500 MG TABLET)
LANTUS (100 CARTRIDGE, 100 VIAL)
LANTUS SOLOSTAR 100 UNITS/ML
metformin hcl (500 mg tab er 24, 500 mg tablet, 500 mg
tab er 24h, 750 mg tab er 24h, 850 mg tablet, 1000 mg
tab er 24, 1000 mg tablet)
nateglinide (60 mg tablet, 120 mg tablet)
NESINA (6.25 MG TABLET, 12.5 MG TABLET, 25 MG
TABLET)
ST
NOVOLOG (100 CARTRIDGE, 100 VIAL)
NOVOLOG 100 UNITS/ML FLEXPEN
NOVOLOG MIX 70-30 FLEXPEN SYRN
NOVOLOG MIX 70-30 VIAL
ONGLYZA (2.5 MG TABLET, 5 MG TABLET)
ST
OSENI (12.5-15 MG TABLET, 12.5-30 MG TABLET,
12.5-45 MG TABLET, 25-30 MG TABLET, 25-15 MG
ST
pioglitazone hcl (15 mg tablet, 30 mg tablet, 45 mg
tablet)
ST
pioglitazone hcl/glimepiride (30 mg-4 mg tablet, 30 mg2 mg tablet)
ST
64
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
pioglitazone hcl/metformin hcl (15mg-500mg tablet,
15mg-850mg tablet)
PRANDIMET (1 MG TABLET, 2 MG TABLET)
PRANDIN (0.5 MG TABLET, 1 MG TABLET, 2 MG
TABLET)
PROGLYCEM 50 MG/ML ORAL SUSP
repaglinide (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
RIOMET 500 MG/5 ML SOLUTION
SYMLINPEN 120 PEN INJECTOR
PA
SYMLINPEN 60 PEN INJECTOR
PA
tolazamide (250 mg tablet, 500 mg tablet)
tolbutamide 500 mg tablet
TOUJEO SOLOSTAR 300 UNITS/ML
TRADJENTA 5 MG TABLET
ST
VICTOZA 2-PAK 18 MG/3 ML PEN
VICTOZA 3-PAK 18 MG/3 ML PEN
MISCELLANEOUS HORMONES
ALDURAZYME 2.9 MG/5 ML VIAL
PA B vs D
ANADROL-50 TABLET
ANDRODERM (2, 4)
ANDROGEL (1%(5G) GEL PACKET, 1%(2.5G) GEL
PACKET, 1% GEL PUMP, 1.62%(1.25G) GEL PCKT,
1.62% GEL PUMP, 1.62%(2.5G) GEL PCKT)
cabergoline 0.5 mg tablet
calcitonin,salmon,synthetic 200/spray spray/pump
calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml
solution, 1 mcg/ml vial, 1 mcg/ml ampul)
CEREZYME (200 VIAL, 400 VIAL)
PA B vs D
danazol (50 mg capsule, 100 mg capsule, 200 mg
capsule)
desmopressin acetate (0.1 mg tablet, 0.1 mg/ml
solution, 0.2 mg tablet)
65
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
desmopressin acetate (ampul, vial)
PA B vs D
doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5
mcg capsule)
doxercalciferol (ampul, vial)
PA B vs D
ELAPRASE 6 MG/3 ML VIAL
PA B vs D
FABRAZYME (5 MG VIAL, 35 MG VIAL)
PA B vs D
FORTICAL 200 UNITS NASAL SPRAY
KUVAN 100 MG TABLET
METHITEST 10 MG TABLET
MIACALCIN 200 UNIT/ML VIAL
MYOZYME 50 MG VIAL
PA B vs D
NAGLAZYME 5 MG/5 ML VIAL
PA B vs D
oxandrolone (2.5 mg tablet, 10 mg tablet)
pamidronate disodium (30 mg vial, 30mg/10ml vial, 60
mg/10ml vial, 90 mg vial, 90 mg/10ml vial)
paricalcitol (1 mcg capsule, 2 mcg capsule, 4mcg
capsule)
SENSIPAR (30 MG TABLET, 60 MG TABLET, 90 MG
TABLET)
SOMAVERT (10 MG VIAL, 15 MG VIAL, 20 MG VIAL)
PA B vs D
STIMATE 1.5 MG/ML NASAL SPRAY
SYNAREL 2 MG/ML NASAL SPRAY
TESTIM 1% (50MG) GEL
testosterone (1.25g (1%) gel md pmp, 10 mg (2%) gel
md pmp, 25mg(1%) gel packet, 50 mg (1%) gel (gram),
50 mg (1%) gel packet)
testosterone cypionate 200 mg/ml vial
PA B vs D
testosterone enanthate 200 mg/ml vial
TESTRED 10 MG CAPSULE
ZAVESCA 100 MG CAPSULE
ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE)
66
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ZEMPLAR (2 MCG/ML VIAL, 5 MCG/ML VIAL, 10
MCG/2 ML VIAL)
PA B vs D
zoledronic acid (4 mg/5 ml vial, 4 mg vial)
PA B vs D
ZOMETA 4 MG/5 ML VIAL
THYROID HORMONES
levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75
mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg
tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet,
175mcg tablet, 200 mcg tablet, 300 mcg tablet)
LEVOXYL (25 MCG TABLET, 50 MCG TABLET, 75
MCG TABLET, 88 MCG TABLET, 100 MCG TABLET,
112 MCG TABLET, 125 MCG TABLET, 137 MCG
TABLET, 150 MCG TABLET, 175 MCG TABLET, 200
MCG TABLET)
liothyronine sodium (5 mcg tablet, 10 mcg/ml vial, 25
mcg tablet, 50 mcg tablet)
SYNTHROID (25 MCG TABLET, 50 MCG TABLET, 75
MCG TABLET, 88 MCG TABLET, 100 MCG TABLET,
112 MCG TABLET, 125 MCG TABLET, 137 MCG
TABLET, 150 MCG TABLET, 175 MCG TABLET, 200
MCG TABLET, 300 MCG TABLET)
GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
atropine sulfate (0.05mg/ml syringe, 0.1 mg/ml disp
syrin, 0.1 mg/ml syringe)
BENTYL 10 MG/ML AMPUL
PA B vs D
CANTIL 25 MG TABLET
dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20
mg tablet)
diphenoxylate hcl/atropine sulfate (2.5-.025mg tablet,
2.5-.025/5 liquid)
glycopyrrolate (0.2 mg/ml vial, 1 mg tablet, 2 mg tablet)
loperamide hcl 2 mg capsule
methscopolamine bromide (2.5 mg tablet, 5 mg tablet)
67
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
propantheline bromide 15 mg tablet
TRANSDERM-SCOP 1.5 MG/3 DAY
MISCELLANEOUS GASTROINTESTINAL AGENTS
alosetron hcl (0.5 mg tablet, 1 mg tablet)
ALOXI (0.075 MG/1.5 ML VIAL, 0.25 MG/5 ML VIAL)
PA B vs D
AMITIZA (8 MCG CAPSULE, 24 MCG CAPSULES)
PA
ANZEMET (50 MG TABLET, 100 MG TABLET)
PA B vs D, QL (7 PER 30 DAYS)
ANZEMET 20 MG/ML VIAL
PA B vs D
APRISO ER 0.375 GRAM CAPSULE
ASACOL HD DR 800 MG TABLET
balsalazide disodium 750 mg capsule
budesonide 3 mg capdr - er
CANASA 1,000 MG SUPPOSITORY
CARBAGLU 200 MG DISPER TABLET
PA
CESAMET 1 MG CAPSULE
PA B vs D
COMPRO 25 MG SUPPOSITORY
CONSTULOSE 10 GM/15 ML SOLN
CREON (DR 3,000 CAPSULE, DR 6,000 CAPSULE,
DR 12,000 CAPSULE, DR 24,000 CAPSULE)
cromolyn sodium 20 mg/ml oral conc
CYSTADANE POWDER
DELZICOL DR 400 MG CAPSULE
DIPENTUM 250 MG CAPSULE
dronabinol (2.5 mg capsule, 5 mg capsule, 10 mg
capsule)
PA B vs D
EMEND 125 MG CAPSULE
EMEND 40 MG CAPSULE
PA B vs D
EMEND 80 MG CAPSULE
EMEND TRIFOLD PACK
68
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ENTOCORT EC 3 MG CAPSULE
ENULOSE 10 GM/15 ML SOLUTION
GATTEX (5 MG ONE-VIAL, 5 MG 30-VIAL)
PA
GAVILYTE-C SOLUTION
GAVILYTE-N SOLUTION
GENERLAC 10 GM/15 ML SOLUTION
GOLYTELY (PACKET, SOLUTION)
granisetron hcl (1 mg tablet, 1 mg/ml(1) vial, 1 mg/ml
vial)
PA B vs D
granisetron hcl/pf (1 mg/ml(1) vial, 100 mcg/ml vial)
PA B vs D
hydrocortisone 100mg/60ml enema
lactulose (10 g/15 ml, 20 g/30 ml)
lansoprazole/amoxiciln/clarith 30-500-500 combo. pkg
LIALDA DR 1.2 GM TABLET
LINZESS (145 MCG CAPSULE, 290 MCG CAPSULE)
LOTRONEX (0.5 MG TABLET, 1 MG TABLET)
QL (60 PER 30 DAYS)
meclizine hcl (12.5 mg tablet, 25 mg tablet)
mesalamine w/cleansing wipes 4 g/60 ml enema kit
metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10
mg tablet, 10 mg/10ml solution)
metoclopramide hcl (5 mg/ml ampul, 5 mg/ml vial)
PA B vs D
MOVIPREP POWDER PACKET
NULYTELY SOLUTION
NULYTELY WITH FLAVOR PACKS SOL
ondansetron (4 mg tab rapdis, 8 mg tab rapdis)
PA B vs D
ondansetron hcl (4 mg/5 ml solution, 4 mg tablet, 8 mg
PA B vs D
ondansetron hcl/pf (4 ml ampul, 4 ml vial)
PA B vs D
OSMOPREP TABLET
PANCREAZE (DR 4,200 CAP, DR 10,500 CAP, DR
16,800 CAP, DR 21,000 CAP)
69
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
PENTASA (250 MG CAPSULE, 500 MG CAPSULE)
PERTZYE (DR 8,000 CAPSULE, DR 16,000 CAPS)
polyethylene glycol 3350 (3350 17g powd pack, 3350
17g/dose powder)
prochlorperazine 25 mg supp.rect
prochlorperazine edisylate (5 mg/ml vial, 10 mg/2 ml
vial)
prochlorperazine maleate (5 mg tablet, 10 mg tablet)
PROCTOSOL-HC 2.5% CREAM
RECTIV 0.4% OINTMENT
RELISTOR (12 ML KIT, 12 ML VIAL)
REMICADE 100 MG VIAL
PA B vs D
SUCRAID 8,500 UNITS/ML SOLN
sulfasalazine 500 mg tablet
SULFAZINE EC 500 MG TAB
TRILYTE WITH FLAVOR PACKETS
ULTRESA (DR 13,800 CAPSULE, DR 20,700
CAPSULE, DR 23,000 CAPSULE)
URSO 250 MG TABLET
URSO FORTE 500 MG TABLET
ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet)
VIOKACE (10,440-39,150, 20,880-78,300)
ZENPEP (DR 3,000 CAPSULE, DR 5,000 CAPSULE,
DR 10,000 CAPSULE, DR 15,000 CAPSULE, DR
20,000 CAPSULE, DR 25,000 CAPSULE)
ULCER THERAPY
CARAFATE 1 GM/10 ML SUSP
cimetidine (200 mg tablet, 300 mg tablet, 400 mg tablet,
800 mg tablet)
cimetidine hcl 300 mg/5ml solution
DEXILANT (DR 30 MG CAPSULE, DR 60 MG
CAPSULE)
ST
70
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
esomeprazole magnesium 20 mg capsule dr
esomeprazole magnesium 40 mg capsule dr
ST
famotidine (20 mg tablet, 40mg/5ml oral susp, 40 mg
tablet)
famotidine in nacl,iso-osm/pf 20 mg/50ml piggyback
famotidine/pf 20 mg/2 ml vial
KAPIDEX (DR 30 MG CAPSULE, DR 60 MG
CAPSULE)
ST
lansoprazole (15 mg capsule dr, 30 mg capsule dr)
ST
metoclopramide hcl 5 mg tab rapdis
misoprostol (100 mcg tablet, 200 mcg tablet)
nizatidine (150mg/10ml solution, 150 mg capsule, 300
mg capsule)
omeprazole (10 mg capsule dr, 20 mg capsule dr, 40
mg capsule dr)
pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr)
ST
PEPCID 40 MG/5 ML ORAL SUSP
PREVACID (15 MG, 30 MG)
PREVPAC PATIENT PACK
PROTONIX IV 40 MG VIAL
PYLERA CAPSULE
rabeprazole sodium 20 mg tablet dr
ST
ranitidine hcl (15 mg/ml syrup, 25 mg/ml vial, 50 mg/2
ml vial, 150 mg capsule, 150 mg tablet, 300 mg tablet,
300 mg capsule)
sucralfate 1 g tablet
IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ACTIMMUNE 100 MCG/0.5 ML VIAL
71
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/ML
VIAL, 25 MCG/0.42 ML SYRING, 40 MCG/ML VIAL, 40
MCG/0.4 ML SYRINGE, 60 MCG/0.3 ML SYRINGE, 60
MCG/ML VIAL, 100 MCG/ML VIAL, 100 MCG/0.5 ML
SYRINGE, 150 MCG/0.3 ML SYRINGE, 150 MCG/0.75
ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML
VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL,
500 MCG/1 ML SYRINGE)
PA B vs D
ARCALYST 220 MG INJECTION
PA B vs D, LA
AVONEX (30 MCG KT, 30 MCG)
PA B vs D
AVONEX ADMIN PACK 30 MCG VL
PA B vs D
AVONEX PEN (30 ML, 30 ML KIT)
BETASERON (0.3 MG VIAL, 0.3 MG KIT)
PA B vs D
COPAXONE 20 MG/ML SYRINGE
EPOGEN (2,000 UNITS/ML VIAL, 3,000 UNITS/ML
VIAL, 4,000 UNITS/ML VIAL, 10,000 UNITS/ML VIAL,
20,000 UNITS/2 ML VIAL, 20,000 UNITS/ML VIAL)
PA B vs D
GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4
MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG,
MINIQUICK 1 MG, MINIQUICK 1.2 MG, MINIQUICK
1.4 MG, MINIQUICK 1.6 MG, MINIQUICK 1.8 MG,
MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MG
CARTRIDGE)
PA
GILENYA 0.5 MG CAPSULE
GLATOPA 20 MG/ML SYRINGE
HUMATROPE (12 MG, 24 MG)
PA
INTRON A (6 MILLION UNIT/ML VL, 10 MILLION
UNIT/ML, 10 MILLION UNITS VIL, 18 MILLION UNITS
VIL, 50 MILLION UNITS VIL)
PA B vs D
LEUKINE 250 MCG VIAL
PA B vs D
NEULASTA (6 ML SYRINGE, 6 ML DLVRY KIT)
PA B vs D
NEUMEGA 5 MG VIAL
PA B vs D
NEUPOGEN (300 MCG/ML VIAL, 300 MCG/0.5 ML
SYR, 480 MCG/1.6 ML VIAL, 480 MCG/0.8 ML SYR)
PA B vs D
NORDITROPIN FLEXPRO (5, 10, 15)
PA
NORDITROPIN NORDIFLEX (NORDIFLEX 5,
NORDIFLX 15)
PA
72
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
NUTROPIN AQ 20 MG/2ML PEN CART
PA
NUTROPIN AQ NUSPIN (5, 20)
PA
OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10
MG/1.5 ML CRTG)
PA
PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 ML
SYRINGE)
PEGASYS PROCLICK (135, 180)
PEGINTRON (50 MCG, 80 MCG, 120 MCG, 150 MCG)
PEGINTRON REDIPEN (50 MCG, 50 MCG 4PK, 80
MCG, 80 MCG 4PK, 120 MCG 4PK, 120 MCG, 150
MCG, 150 MCG 4PK)
PROCRIT (2,000 VIAL, 3,000 VIAL, 4,000 VIAL, 10,000
VIAL, 20,000 VIAL, 40,000 VIAL)
PA B vs D
PROLEUKIN 22 MILLION UNIT VIAL
PA B vs D
REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML
SYRINGE, TITRATION PACK)
REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML,
TITRATION PACK)
SAIZEN (5 MG VIAL, 8.8 MG CLICK.EASY CARTG)
PA
SEROSTIM (4 MG VIAL, 5 MG VIAL, 6 MG VIAL)
PA
SYLATRON (200 MCG, 300 MCG, 600 MCG)
SYLATRON 4-PACK (200 MCG, 300 MCG, 888 MCG)
ZOMACTON (5 MG VIAL, 10 MG VIAL)
ZORBTIVE 8.8 MG VIAL
PA
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
ACTHIB (VIAL, WITH DILUENT)
ADACEL TDAP VIAL
ATGAM 50 MG/ML AMPUL
bcg vaccine, live/pf 50 mg vial
PA B vs D
BEXSERO PREFILLED SYRINGE
BOOSTRIX TDAP (SYRINGE, VIAL)
73
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
BOOSTRIX VACCINE SYRINGE
CARIMUNE NF NANOFILTERED (3 GM VIAL, 6 GM
VIAL, 12 GM VIAL)
PA B vs D
CERVARIX VACCINE SYRINGE
CINRYZE 500 UNIT VIAL
PA B vs D
COMVAX VACCINE VIAL
DAPTACEL DTAP VACCINE
ENGERIX-B 20 MCG/ML SYRN
PA B vs D
ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML
VIAL)
PA B vs D
ENGERIX-B PEDIATRIC-ADOLESCENT (10 ML PED
VL, PEDI 10 SYRN)
PA B vs D
FIRAZYR 30 MG/3 ML SYRINGE
fomepizole 1 g/ml vial
GAMASTAN S-D (S-D VIAL, S/D SYRINGE)
PA B vs D
GAMMAGARD LIQUID 10% VIAL
PA B vs D
GAMMAGARD S-D (0.5 GM VL W-ST, 2.5 GM VL
W/ST, 5 G (IGA<1) SOLN, 5 GM VL W/SET, 10 G
(IGA<1) SOL, 10 GM VL W/ST)
PA B vs D
GAMUNEX 10% VIAL
PA B vs D
GAMUNEX-C (1 GRAM/10 ML VIAL, 2.5 GRAM/25 ML
VIAL, 5 GRAM/50 ML VIAL, 10 GRAM/100 ML VIAL, 20
GRAM/200 ML VIAL, 40 GRAM/400 ML VIAL)
PA B vs D
GARDASIL (SYRINGE, VIAL)
GARDASIL 9 (9 VIAL, 9 SYRINGE)
HAVRIX (720 UNITS/0.5 ML VIAL, 720 UNIT/0.5 ML
SYRINGE, 1,440 UNITS/ML VIAL)
IMOVAX RABIES VACCINE (VACCINE VIAL,
VACCINE+DILUENT)
INFANRIX DTAP VIAL
INFANRIX VACCINE VIAL
IPOL (SINGLE DOSE SYRINGE, VIAL)
74
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
IXIARO 6 MCG/0.5 ML SYRINGE
M-M-R II VACCINE (VIAL, WITH DILUENT)
MENACTRA VIAL
MENOMUNE-A-C-Y-W-135 VIAL
MENVEO A-C-Y-W-135-DIP VIAL
PEDVAXHIB VACCINE VIAL
PENTACEL ACTHIB COMPONENT VIAL
PROQUAD VIAL
RABAVERT RABIES VACCINE VIAL
PA B vs D
RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5
ML VL, 10 MCG/ML VIAL, 10 MCG/ML SYR, 40
MCG/ML VIAL)
PA B vs D
ROTARIX (10E6/ML, VACCINE)
ROTATEQ VACCINE
SAIZEN 8.8 MG VIAL
PA
TENIVAC SYRINGE
PA B vs D
tetanus and diphtheria toxoids, adult (2-2 lf/0.5 vial, 22lf/0.5 vial)
PA B vs D
tetanus,diphtheria toxd ped/pf 5-25/0.5ml vial
PA B vs D
THYMOGLOBULIN 25 MG VIAL
PA B vs D
TWINRIX VACCINE VIAL
PA B vs D
TYPHIM VI (25 ML SYRNG, 25 ML AL)
VAQTA 25 UNITS/0.5 ML SYRINGE
VARIVAX VACCINE (VIAL, WITH DILUENT)
YF-VAX (1 VIAL, 5 VIAL)
ZOSTAVAX VIAL
MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
allopurinol (100 mg tablet, 300 mg tablet)
75
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ALOPRIM 500 MG VIAL
colchicine (0.6 mg capsule, 0.6 mg tablet)
colchicine/probenecid 0.5-500mg tablet
COLCRYS 0.6 MG TABLET
probenecid 500 mg tablet
ULORIC (40 MG TABLET, 80 MG TABLET)
ST
OSTEOPOROSIS THERAPY
ACTONEL 5 MG TABLET
alendronate sodium (35 mg tablet, 70 mg tablet)
QL (4 PER 28 DAYS)
QL (60 PER 30 DAYS)
QL (30 PER 30 DAYS)
alendronate sodium 70 mg/75ml solution
ATELVIA DR 35 MG TABLET
ST
BONIVA 150 MG TABLET
QL (1 PER 30 DAYS)
BONIVA 3 MG/3 ML SYRINGE
PA B vs D
FORTEO 600 MCG/2.4 ML PEN INJ
PA
FOSAMAX PLUS D (70 MG-5,600, 70 MG-2,800)
ST
ibandronate sodium 150 mg tablet
QL (1 PER 30 DAYS)
ibandronate sodium 3 mg/3 ml vial
PA B vs D
raloxifene hcl 60 mg tablet
risedronate sodium (5 mg tablet, 35 mg tablet dr, 35 mg
tablet)
ST
risedronate sodium 150 mg tablet
OTHER RHEUMATOLOGICALS
BENLYSTA (120 MG VIAL, 400 MG VIAL)
PA B vs D
CUPRIMINE 250 MG CAPSULE
DEPEN 250 MG TITRATAB
76
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50
MG/ML SYRINGE, 50 MG/ML SURECLICK SYR)
PA B vs D
HUMIRA (20 MG/0.4 ML, 40 MG/0.8 ML)
PA B vs D
HUMIRA 10 MG/0.2 ML SYRINGE
HUMIRA 40 MG/0.8 ML PEN
PA B vs D
HUMIRA PEN CROHN'S-UC-HS START
HUMIRA PEN PSORIASIS START PK
PA B vs D
ILARIS 180 MG VIAL
PA
KINERET (100 ML SYRINGE, 100 ML SYR)
leflunomide (10 mg tablet, 20 mg tablet)
ORENCIA (125 MG/ML SYRINGE, 250 MG VIAL)
PA
RIDAURA 3 MG CAPSULE
OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
CAMILA TABLET
CRINONE (4% GEL, 8% GEL)
DEPO-ESTRADIOL 5 MG/ML VIAL
DEPO-PROVERA 400 MG/ML VIAL
PA B vs D
DEPO-SUBQ PROVERA 104 SYRINGE
DIVIGEL (0.25 MG GEL, 0.5 MG GEL, 1 MG GEL)
ENJUVIA (0.3 MG TABLET, 0.45 MG TABLET, 0.625
MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET)
ERRIN 0.35 MG TABLET
ESTRACE 0.01% CREAM
77
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
estradiol (.025mg/24h patch tdwk, .025mg/24h patch
tdsw, .0375mg/24 patch tdwk, .0375mg/24 patch tdsw,
0.05mg/24h patch tdsw, 0.05mg/24h patch tdwk,
0.06mg/24h patch tdwk, .075mg/24h patch tdwk,
.075mg/24h patch tdsw, 0.1mg/24hr patch tdwk,
0.1mg/24hr patch tdsw, 0.5 mg tablet, 1 mg tablet, 2 mg
tablet)
estradiol valerate 20 mg/ml vial
estradiol/norethindrone acet 1 mg-0.5mg tablet
ESTRING 2 MG VAGINAL RING
QL (1 PER 90 DAYS)
estropipate (0.75 mg tablet, 1.5 mg tablet, 3 mg tablet)
EVAMIST 1.53 MG/SPRAY
FEMRING (FEM0.05 MG, FEM0.10 MG)
QL (1 PER 90 DAYS)
JOLIVETTE TABLET
LYZA 0.35 MG TABLET
medroxyprogesterone acetate (2.5 mg tablet, 5 mg
tablet, 10 mg tablet, 150 mg/ml vial, 150 mg/ml syringe)
MENEST (0.3 MG TABLET, 0.625 MG TABLET, 1.25
MG TABLET, 2.5 MG TABLET)
MENOSTAR 14 MCG/DAY PATCH
MIMVEY LO 0.5-0.1 MG TABLET
MINIVELLE (0.025 MG, 0.0375 MG, 0.05 MG, 0.075
MG, 0.1 MG)
norethindrone 0.35 mg tablet
norethindrone acetate 5 mg tablet
PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625
MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET,
VAGINAL CREAM-APPL)
PREMARIN 25 MG VIAL
PA B vs D
PREMPHASE 0.625-5 MG TABLET
progesterone,micronized (100 mg capsule, 200 mg
capsule)
VIVELLE (0.05 MG, 0.1 MG)
VIVELLE-DOT (0.025 MG, 0.0375 MG, 0.05 MG, 0.075
MG, 0.1 MG)
78
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
MISCELLANEOUS OB/GYN
clindamycin phosphate 2 % cream/appl
metronidazole (0.75 % gel w/appl, 1 % gel w/pump, 1 %
gel (gram))
miconazole nitrate 200 mg supp.vag
terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80
mg supp.vag)
VANDAZOLE VAGINAL 0.75% GEL
ORAL CONTRACEPTIVES / RELATED AGENTS
AMETHIA 0.15-0.03-0.01 MG TAB
AMETHYST 90-20 MCG TABLET
APRI 28 DAY TABLET
ARANELLE 28 TABLET
AVIANE-28 TABLET
BALZIVA 28 TABLET
BRIELLYN TABLET
CRYSELLE-28 TABLET
CYCLAFEM (1-35-28 TABLET, 7-7-7-28 TABLET)
EMOQUETTE 28 DAY TABLET
ENPRESSE-28 TABLET
estradiol/norethindrone acet 0.5-0.1mg tablet
ethinyl estradiol/drospirenone 0.03mg-3mg tablet
FEMCON FE (MCON CHEWABLE TABLET, MCON
TABLET)
GILDAGIA 0.4 MG-0.035 MG TAB
INTROVALE 0.15-0.03 MG TABLET
JUNEL (1 MG-20 MCG TABLET, 1.5 MG-30 MCG
TABLET)
JUNEL FE (1 MG-20 MCG TABLET, 1.5 MG-30 MCG
TABLET)
79
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
JUNEL FE 24 TABLET
KARIVA 28 DAY TABLET
KELNOR 1-35 28 TABLET
l-norgest/e.estradion-e.estrad 150-30(84) tbdspk 3mo
LARIN 21 1-20 TABLET
LARIN FE (1-20 TABLET, 1.5-30 TABLET)
LESSINA-28 TABLET
LEVONEST-28 TABLET
levonorgestrel-ethinyl estradiol (0.1-0.02 tablet, 0.150.03 tbdspk 3mo, 0.15-0.03 tablet, 90-20mcg tablet)
LEVORA-28 TABLET
LOESTRIN (21 1-20 TABLET, 21 1.5-30 TABLET)
LOESTRIN FE (1-20 TABLET, 1.5-30 TABLET)
LUTERA-28 TABLET
MARLISSA-28 TABLET
MICROGESTIN (21 1.5-30 TAB, 21 1-20 TABLET)
MICROGESTIN FE (1-20 TABLET, 1.5-30 TAB)
MONONESSA 28 TABLET
NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 7-7-728 TABLET, 10-11-28 TABLET)
noreth-ethinyl estradiol/iron 0.8-25(24) tab chew
norethindrone acetate-ethinyl estradiol (0.5mg-2.5
tablet, 1mg-5mcg tablet)
norethindrone acetate-ethinyl estradiol/ferrous fumarate
(1mg-20(24) tablet, 1mg-20(21) tablet)
NORTREL (0.5-35 TABLET, 1-35 TABLET, 7-7-7-28
TABLET)
OGESTREL TABLET
ORSYTHIA-28 TABLET
ORTHO TRI-CYCLEN LO TABLET
PIMTREA 28 DAY TABLET
80
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
PIRMELLA 1-35-28 TABLET
PORTIA-28 TABLET
PREVIFEM TABLET
QUASENSE 0.15-0.03 MG TABLET
RECLIPSEN 28 DAY TABLET
SEASONIQUE 0.15-0.03-0.01 TAB
SPRINTEC 28 DAY TABLET
SRONYX 0.10-0.02 MG TABLET
TRI-LEGEST FE-28 DAY TABLET
TRI-PREVIFEM TABLET
TRI-SPRINTEC TABLET
TRINESSA TABLET
TRIVORA-28 TABLET
VELIVET 28 DAY TABLET
VESTURA 3 MG-0.02 MG TABLET
XULANE PATCH
ZENCHENT 0.4 MG-35 MCG TABLET
ZOVIA 1-35E TABLET
ZOVIA 1-50E TABLET
OXYTOCICS
methylergonovine maleate 0.2 mg tablet
OPHTHALMOLOGY
ANTIBIOTICS
AZASITE 1% EYE DROPS
bacitracin 500 unit/g oint. (g)
bacitracin/polymyxin b sulfate 500-10k/g oint. (g)
CILOXAN 0.3% OINTMENT
ciprofloxacin hcl 0.3 % drops
81
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
erythromycin base (5 mg/g, 5mg/g)
GARAMYCIN (0.3% DROPS, 3 MG/ML DROPS)
GENTAK 0.3 % EYE OINTMENT
gentamicin sulfate (0.3 % oint. (g), 0.3 % drops)
levofloxacin 0.5 % drops
MOXEZA 0.5% EYE DROPS
NATACYN EYE DROPS
neomycin sulfate/bacitracin/polymyxin b (neomy
sulf/bacitra/polymyxin b, neomycin
su/bacitra/polymyxin)
neomycin/polymyxn b/gramicidin 1.75mg-10k drops
ofloxacin 0.3 % drops
polymyxin b sulf/trimethoprim 10000-1/ml drops
tobramycin 0.3 % drops
TOBREX 0.3% EYE OINTMENT
VIGAMOX 0.5% EYE DROPS
ANTIVIRALS
trifluridine 1 % drops
VIROPTIC 1% EYE DROPS
ZIRGAN 0.15% OPHTHALMIC GEL
BETA-BLOCKERS
betaxolol hcl 0.5 % drops
BETOPTIC S 0.25% EYE DROPS
carteolol hcl 1 % drops
levobunolol hcl 0.5 % drops
metipranolol 0.3 % drops
timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 %
sol-gel, 0.5 % drops)
82
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
CHOLINESTERASE INHIBITOR MIOTICS
PHOSPHOLINE IODIDE 0.125%
DIRECT ACTING MIOTICS
ISOPTO CARPINE (1% DROPS, 2% DROPS, 4%
DROPS)
pilocarpine hcl (1 % drops, 2 % drops, 4 % drops)
MISCELLANEOUS OPHTHALMOLOGICS
ALOCRIL 2% EYE DROPS
ALOMIDE 0.1% EYE DROPS
azelastine hcl 0.05 % drops
cromolyn sodium 4 % drops
DUREZOL 0.05% EYE DROPS
ELESTAT 0.05% EYE DROPS
EMADINE 0.05% EYE DROPS
epinastine hcl 0.05 % drops
PATADAY 0.2% EYE DROPS
PATANOL 0.1% EYE DROPS
proparacaine hcl 0.5 % drops
RESTASIS 0.05% EYE EMULSION
QL (60 PER 30 DAYS)
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
ACUVAIL 0.45% OPHTH SOLUTION
bromfenac sodium 0.09% drops
diclofenac sodium 0.1 % drops
flurbiprofen sodium 0.03 % drops
ketorolac tromethamine (0.4 % drops, 0.5 % drops)
NEVANAC 0.1% DROPTAINER
ORAL DRUGS FOR GLAUCOMA
acetazolamide (125 mg tablet, 250 mg tablet, 500 mg
capsule er)
83
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
acetazolamide sodium 500 mg vial
methazolamide (25 mg tablet, 50 mg tablet)
OTHER GLAUCOMA DRUGS
AZOPT 1% EYE DROPS
bimatoprost 0.03 % drops
COMBIGAN EYE DROPS
dorzolamide hcl 2 % drops
dorzolamide hcl/timolol maleat 22.3-6.8/1 drops
latanoprost 0.005 % drops
LUMIGAN 0.01% EYE DROPS
TRAVATAN Z 0.004% EYE DROP
travoprost (benzalkonium) 0.004 % drops
XALATAN 0.005% EYE DROPS
STEROID-ANTIBIOTIC COMBINATIONS
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone (neomy sulf/bacitrac, neomycin
su/baci)
neomycin/polymyxin b sulf/hc 3.5-10k-10 drops susp
neomycin/polymyxin b sulfate/dexamethasone (0.1 %
drops susp, 3.5-10k-.1 oint. (g))
PRED-G (1% DROPS, S.O.P. OINTMENT)
TOBRADEX EYE OINTMENT
tobramycin/dexamethasone 0.3 %-0.1% drops susp
ZYLET EYE DROPS
STEROID-SULFONAMIDE COMBINATIONS
BLEPHAMIDE EYE DROPS
BLEPHAMIDE EYE OINTMENT
sulfacetamide/prednisolone sp 10 %-0.23% drops
84
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
STEROIDS
ALREX 0.2% EYE DROPS
dexamethasone sod phosphate 0.1 % drops
FLAREX 0.1% EYE DROPS
fluorometholone 0.1 % drops susp
FML FORTE 0.25% EYE DROPS
FML S.O.P. 0.1% OINTMENT
LOTEMAX (EYE DROPS, EYE OINTMENT,
OPHTHALMIC GEL)
MAXIDEX 0.1% EYE DROPS
PRED FORTE 1% EYE DROPS
prednisolone sod phosphate 1 % drops
VEXOL 1% EYE DROPS
SULFONAMIDES
BLEPH-10 10% EYE DROPS
sulfacetamide sodium (10 % drops, 10 % oint. (g))
SYMPATHOMIMETICS
ALPHAGAN P (ALHAGAN 0.1% DROS, ALHAGAN
0.15% EYE DROS)
apraclonidine hcl 0.5 % drops
brimonidine tartrate (0.15 % drops, 0.2 % drops)
IOPIDINE (0.5% DROPS, 1% DROPS)
VASOCONSTRICTOR DECONGESTANTS
naphazoline hcl 0.1 % drops
OTC-Product
pen needle, diabetic (, 30gx 5/16", , 31 gx3/16", , 31
gx5/16")
syringe with needle, insulin, safety, 0.3 ml
(ge,needle,insuln,sf,0.3ml 30gx 5/16",
ge,needle,insuln,sf,0.3ml 29 g x1/2")
85
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
syringe with needle, insulin, safety, 0.5 ml (29 g x1/2",
30gx 5/16")
syringe with needle, insulin, safety, 1 ml (29 g x1/2",
30gx 5/16")
syringe with needle,disposable,insulin 1 ml (ge ml, ge
ml 26gx1/2", ge ml 27gx1/2", ge ml 28gx1/2", ge ml
29gx1/2", ge ml 29 g x1/2", ge ml 30gx1/2", ge ml 30gx
5/16")
syringe with needle,insulin disposable,0.3 ml (wndl,,insul,0.3 ml 30gx 5/16", w-ndl,,insul,0.3ml 29gx1/2",
w-ndl,,insul,0.3ml 30gx1/2")
syringe with needle,insulin disposable,0.5 ml (wndl,,insul,0.5ml 30gx1/2", w-ndl,,insul,0.5 ml 30gx1/2",
w-ndl,,insul,0.5 ml 29 g x1/2", w-ndl,,insul,0.5ml
28gx1/2", w-ndl,,insul,0.5 ml 30gx 5/16", wndl,,insul,0.5ml 29gx1/2", w-ndl,,insul,0.5 ml 28 gauge)
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
carbinoxamine maleate (4 mg tablet, 4 mg/5 ml liquid)
cetirizine hcl 1 mg/ml solution
CLARINEX (0.5 MG/ML (2.5 MG/5), 5 MG TABLET)
ST
CLARINEX-D 12 HOUR TABLET
desloratadine (2.5 mg tab rapdis, 5 mg tablet, 5 mg tab
rapdis)
diphenhydramine hcl 50 mg/ml vial
epinephrine 0.3mg/0.3 auto injct
EPIPEN 0.3 MG AUTO-INJECTOR
EPIPEN 2-PAK 0.3 MG AUTO-INJCT
EPIPEN JR 0.15 MG AUTO-INJCT
EPIPEN JR 2-PAK 0.15 MG INJCTR
hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25
mg tablet, 50 mg/25ml solution, 50 mg tablet)
PA
hydroxyzine pamoate (25 mg capsule, 50 mg capsule,
100 mg capsule)
PA
86
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
levocetirizine dihydrochloride (2.5 mg/5ml solution, 5
mg tablet)
PHENADOZ 12.5 MG SUPPOSITORY
PHENERGAN (12.5 MG, 25 MG, 50 MG)
promethazine hcl (12.5 mg tablet, 25 mg tablet, 50 mg
tablet)
PA
promethazine hcl 50 mg supp.rect
PROMETHEGAN (25 MG SUPP, 50 MG
SUPPOSITORY)
XYZAL (2.5 MG/5 ML SOLUTION, 5 MG TABLET)
ST
PULMONARY AGENTS
ACCOLATE (10 MG TABLET, 20 MG TABLET)
acetylcysteine (100 mg/ml vial, 200 mg/ml vial)
PA B vs D
ADVAIR DISKUS (100-50, 250-50, 500-50)
ADVAIR HFA (45-21 MCG, 115-21 MCG, 230-21 MCG)
albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vialneb, 2.5 mg/3ml vial-neb, 2.5 mg/0.5 vial-neb, 5 mg/ml
solution)
PA B vs D
albuterol sulfate (2 mg/5 ml syrup, 2 mg tablet, 4 mg tab
er 12h, 4 mg tablet, 8 mg tab er 12h)
aminophylline (250mg/10ml vial, 250mg/10ml ampul,
500mg/20ml vial, 500mg/20ml ampul)
ANORO ELLIPTA 62.5-25 MCG INH
ASMANEX TWISTHALER 110 MCG #30
ATROVENT HFA INHALER
BECONASE AQ 0.042% SPRAY
BREO ELLIPTA (100-25 MCG, 200-25 MCG)
BROVANA 15 MCG/2 ML SOLUTION
PA B vs D
budesonide (0.25mg/2ml, 0.5 mg/2ml)
PA B vs D
budesonide 32mcg spray/pump
COMBIVENT RESPIMAT INHAL SPRAY
87
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
cromolyn sodium 20 mg/2 ml ampul-neb
PA B vs D
DALIRESP 500 MCG TABLET
DULERA (100 MCG, 200 MCG)
ELIXOPHYLLIN 80 MG/15 ML ELIX
FLOVENT HFA (44 MCG, 110 MCG, 220 MCG)
fluticasone propionate 50 mcg spray susp
INCRUSE ELLIPTA 62.5 MCG INH
ipratropium bromide 0.2 mg/ml solution
PA B vs D
ipratropium/albuterol sulfate 0.5-3mg/3 ampul-neb
PA B vs D
KALYDECO (50 MG GRANULES PACKET, 75 MG
GRANULES PACKET, 150 MG TABLET)
LETAIRIS (5 MG TABLET, 10 MG TABLET)
levalbuterol hcl (0.31mg/3ml, 0.63mg/3ml, 1.25mg/0.5,
1.25mg/3ml)
PA B vs D
metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup,
20 mg tablet)
montelukast sodium (4 mg gran pack, 4 mg tab chew, 5
mg tab chew, 10 mg tablet)
NASONEX 50 MCG NASAL SPRAY
OFEV (100 MG CAPSULE, 150 MG CAPSULE)
OMNARIS 50 MCG NASAL SPRAY
PERFOROMIST 20 MCG/2 ML SOLN
PA B vs D
PROAIR HFA 90 MCG INHALER
QL (17 PER 30 DAYS)
PROVENTIL HFA 90 MCG INHALER
PULMICORT 1 MG/2 ML RESPULE
PA B vs D
PULMICORT FLEXHALER (90 MCG, 180 MCG)
PULMOZYME 1 MG/ML AMPUL
PA B vs D
QVAR (40 MCG, 80 MCG)
REVATIO (10 MG/ML ORAL SUSP, 20 MG TABLET)
PA
SEREVENT DISKUS 50 MCG
88
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
sildenafil citrate 20 mg tablet
PA
SINGULAIR (4 MG GRANULES, 4 MG TABLET
CHEW, 5 MG TABLET CHEW, 10 MG TABLET)
SPIRIVA 18 MCG CP-HANDIHALER
SPIRIVA RESPIMAT INHAL SPRAY
terbutaline sulfate (1 mg/ml vial, 1 mg/ml ampul)
PA B vs D
terbutaline sulfate (2.5 mg tablet, 5 mg tablet)
theophylline anhydrous (100 mg tab er 12h, 200 mg tab
er 12h, 300 mg tab er 12h, 400 mg tablet er, 450 mg
tab er 12h, 600 mg tablet er)
TRACLEER (62.5 MG TABLET, 125 MG TABLET)
PA, LA
triamcinolone acetonide 55 mcg spray
TUDORZA PRESSAIR 400 MCG INH
VENTOLIN HFA (90 MCG INHALER, RELION 90 MCG
INH)
QL (36 PER 30 DAYS)
XOLAIR 150 MG VIAL
PA B vs D
XOPENEX (0.31 ML, 0.63 ML, 1.25 ML)
PA B vs D
XOPENEX CONC 1.25 MG/0.5 ML
PA B vs D
XOPENEX HFA 45 MCG INHALER
zafirlukast (10 mg tablet, 20 mg tablet)
ZYFLO 600 MG FILMTAB
ZYFLO CR 600 MG TABLET
UROLOGICALS
ANTICHOLINERGICS / ANTISPASMODICS
DETROL (1 MG TABLET, 2 MG TABLET)
ENABLEX (7.5 MG TABLET, 15 MG TABLET)
QL (30 PER 30 DAYS)
flavoxate hcl 100 mg tablet
MYRBETRIQ (ER 25 MG TABLET, ER 50 MG
TABLET)
oxybutynin chloride (5 mg/5 ml syrup, 5 mg tablet, 5 mg
tab er 24, 10 mg tab er 24, 15 mg tab er 24)
89
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
tolterodine tartrate (1 mg tablet, 2 mg tablet, 2 mg cap
er 24h, 4 mg cap er 24h)
trospium chloride 20 mg tablet
QL (60 PER 30 DAYS)
trospium chloride 60 mg cap er 24h
QL (30 PER 30 DAYS)
VESICARE (5 MG TABLET, 10 MG TABLET)
QL (30 PER 30 DAYS)
BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY
alfuzosin hcl 10 mg tab er 24h
QL (30 PER 30 DAYS)
AVODART 0.5 MG SOFTGEL
QL (30 PER 30 DAYS)
finasteride 5 mg tablet
QL (30 PER 30 DAYS)
JALYN 0.5-0.4 MG CAPSULE
tamsulosin hcl 0.4 mg cap er 24h
QL (60 PER 30 DAYS)
UROXATRAL 10 MG TABLET
QL (30 PER 30 DAYS)
CHOLINERGIC STIMULANTS
bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg
MISCELLANEOUS UROLOGICALS
ammonium chloride 5 meq/ml vial
PA B vs D
BUPHENYL POWDER
CYSTAGON (50 MG CAPSULE, 150 MG CAPSULE)
ELMIRON 100 MG CAPSULE
potassium citrate 15 meq tablet er
sodium phenylbutyrate 0.94 g/g powder
Uncategorized
Unclassified
BUPHENYL 500 MG TABLET
sodium phenylbutyrate 100 % powder
90
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
VACCINES and MISCELLANEOUS IMMUNOLOGICALS
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
QUADRACEL DTAP-IPV VIAL
VARIZIG 125 UNIT/1.2 ML VIAL
VITAMINS and HEMATINICS
ELECTROLYTES
potassium chloride (20meq/15ml, 40meq/15ml)
VITAMINS, HEMATINICS / ELECTROLYTES
calcium acetate 667 mg capsule
dextrose 5%-lactated ringers 5 % iv soln
ELIPHOS 667 MG TABLET
KLOR-CON 10 MEQ TABLET
KLOR-CON 8 MEQ TABLET
KLOR-CON M10 TABLET
KLOR-CON M15 TABLET
KLOR-CON M20 TABLET
magnesium sulfate (4 syringe, 4 disp syrin)
PA B vs D
magnesium sulfate 4 meq/ml vial
NORMOSOL-R-DEXTROSE 5% IV SOLN
PA B vs D
potassium chloride (2 meq/ml vial, 2 meq/ml iv soln,
10meq/0.1l piggyback, 10meq/50ml piggyback,
20meq/50ml piggyback, 20meq/0.1l piggyback,
40meq/0.1l piggyback)
PA B vs D
potassium chloride (8 capsule er, 8 tablet er, 10 tablet
er, 10 tab er prt, 10 capsule er, 20 tablet er, 20 tab er
prt)
potassium chloride in 0.9 % sodium chloride (20 soln,
40 soln)
PA B vs D
91
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
potassium chloride in 5 % dextrose in water (20 soln, 40
soln)
PA B vs D
potassium chloride in dextrose 5 % and 0.9 % sodium
chloride (20 soln, 40 soln)
PA B vs D
potassium chloride in dextrose 5 %-0.45 % sodium
chloride (10 soln, 20 soln, 30 soln, 40 soln)
PA B vs D
potassium chloride in lr-d5 20 meq/l iv soln
potassium chloride-0.45% nacl 20 meq/l iv soln
PA B vs D
potassium chloride/d5-0.2%nacl 20 meq/l iv soln
PA B vs D
potassium chloride/d5-0.3%nacl 20 meq/l iv soln
PA B vs D
ringers solution iv soln
ringers solution,lactated iv soln
PA B vs D
sodium chloride (2.5 vial, 2.5 iv soln)
PA B vs D
sodium chloride 0.45 % (0.45 % pggybk prt, 0.45 %
0.45 % iv soln)
PA B vs D
sodium chloride 3 % 3 % iv soln
PA B vs D
sodium chloride 5 % 5 % iv soln
PA B vs D
sodium lactate 5 meq/ml vial
PA B vs D
MISCELLANEOUS NUTRITION PRODUCTS
AMINOSYN 7%-ELECTROLYTE SOL
PA B vs D
AMINOSYN II (7%, 8.5%, 10%, 15%)
PA B vs D
AMINOSYN M 3.5% IV SOLUTION
PA B vs D
AMINOSYN-HBC 7% IV SOLUTION
PA B vs D
AMINOSYN-PF (7%, 10%)
PA B vs D
AMINOSYN-RF 5.2% IV SOLUTION
PA B vs D
CLINIMIX (2.75%-5%, 4.25%-20%, 4.25%-10%, 5%20%, 5%-25%, 5%-15%)
PA B vs D
CLINIMIX E (4.25%-25%, 4.25%-5%, 5%-15%, 5%25%, 5%-20%)
PA B vs D
HEPATAMINE 8% IV SOLUTION
PA B vs D
INTRALIPID (20%, 30%)
PA B vs D
92
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
IONOSOL B-D5W IV SOLUTION
PA B vs D
IONOSOL MB-D5W IV SOLUTION
PA B vs D
ISOLYTE P-DEXTROSE 5% SOLN
PA B vs D
ISOLYTE S IV SOLUTION-EXCEL
PA B vs D
NEPHRAMINE 5.4% IV SOLUTION
PA B vs D
NORMOSOL-R PH 7.4 IV SOLUTION
PA B vs D
PLASMA-LYTE 148 IV SOLUTION
PA B vs D
PLASMA-LYTE 56-DEXTROSE 5%
PA B vs D
PLASMA-LYTE A PH 7.4 SOLN.
PA B vs D
PREMASOL (6%, 10%)
PA B vs D
PROCALAMINE IV SOLUTION
PA B vs D
PROSOL 20% INJECTION
PA B vs D
TRAVASOL 10% SOLN VIAFLEX
PA B vs D
TROPHAMINE (6%, 10%)
PA B vs D
VITAMINS / HEMATINICS
ACTIVE OB SOFTGEL
ADVANCED CARE PLUS TABLET
ATABEX EC CAPLET
B-NEXA TABLET
BAL-CARE DHA COMBO PACK
BAL-CARE DHA ESSENTIAL PACK
BP FOLINATAL PLUS B TABLET
C-NATE DHA SOFTGEL
CADEAU DHA SOFTGEL
CALCIUM-PNV 28-1-250 MG SFTGL
CAVAN ONE OMEGA SOFTGEL
CAVAN-ALPHA KIT COMBO PACK
CAVAN-EC SOD DHA VITAMINS
CAVAN-FOLATE DHA COMBO PACK
93
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
CAVAN-FOLATE OB TABLET
CAVAN-HEME OB TABLET
CAVAN-HEME OMEGA COMBO PACK
CHOICE-OB + DHA COMBO PACK
CITRANATAL 90 DHA (90, 90 COMBO)
CITRANATAL ASSURE COMBO PACK
CITRANATAL B-CALM (, COMBO)
CITRANATAL DHA PACK
CITRANATAL HARMONY CAPSULE
CITRANATAL RX TABLET
CO-NATAL FA TABLET
COMPLETE NATAL DHA
COMPLETE-RF PRENATAL TABLET
COMPLETENATE TABLET CHEW
CONCEPT DHA CAPSULE
CONCEPT OB CAPSULE
CORENATE-DHA COMBO PACK
DOCOSAVIT SOFTGEL
DUET DHA (400 MG COMBO PACK, 430 MG COMBO
PACK, VITAMINS)
DUET DHA 400 COMBO PACK
DUET DHA BALANCED ((24 MG IRON), (25 MG
IRON), (26 MG IRON), COMBO PACK)
DUET DHA COMPLETE COMBO PACK
DUET DHA EC (400 EC COMBO PACK, EC 400 MG
COMBO PACK, EC 430 MG COMBO PACK, 430 EC
COMBO PACK, EC PRENATAL VITS)
DUET DHA FERRAZONE EC OMEGA-3
DUET STUARTNATAL (STUART NATAL CHEWABLE
TAB, STUARTNATAL TABLET)
ED CYTE F TABLET
94
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
EDGE OB CAPLET
ELITE OB DHA SOFTGEL
ELITE-OB 400 CAPSULE
ELITE-OB CAPLET
ENBRACE HR SOFTGEL
EXTRA-VIRT PLUS DHA SOFTGEL
FEMECAL OB PLUS DHA COMBO PACK
FEMECAL OB TABLET
FOCALGIN-B TABLET
FOLBECAL TABLET
FOLCAL DHA (CAPSULE, SOFTGEL)
FOLCAPS CARE ONE CAPSULE
FOLCAPS OMEGA-3 CAPSULE
FOLET DHA COMBO PACK
FOLET ONE SOFTGEL
FOLIVANE-EC CALCIUM DHA COMBO
FOLIVANE-OB CAPSULE
FOLIVANE-PRX DHA NF CAPSULE
FOLTABS 90 PLUS DHA PACK
FOLTABS PRENATAL PLUS DHA
FOLTABS PRENATAL TABLET
GENTEX ADE TABLET
GESTICARE DHA COMBO PACK
GESTICARE TABLET
HEMENATAL OB + DHA COMBO PACK
HEMENATAL OB TABLET
HIP PRENATAL TABLET
ICAR-C PLUS SR CAPSULE
INATAL ADVANCE TABLET
95
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
INATAL GT TABLET
INATAL ULTRA TABLET
INFANATE BALANCE SOFTGEL
INFANATE DHA CAPSULE
INFANATE PLUS SOFTGEL
KOLNATAL DHA DR COMBO PACK
L-METHYLFOLATE PNV DHA SOFTGEL
LACTOCAL-F TABLET
LEVOMEFOLATEPNV COMBO PACK
M-VIT CAPLET
MACNATAL CN DHA SOFTGEL
MARNATAL-F CAPSULE
MARNATAL-F PLUS COMBO PACK
MATERNITY VITAMIN
MAXINATE TABLET
MULTI-NATE 30 DHA (30 PRENATAL, 30 430 MG)
MULTI-NATE 30 TABLET
MULTI-NATE DHA EXTRA PRENATAL
MULTINATAL PLUS (CHEW TABLET, TABLET)
MYNATAL (CAPSULE, ULTRACAPLET)
MYNATAL ADVANCE TABLET
MYNATAL PLUS CAPTAB
MYNATAL-Z CAPTAB
MYNATE 90 PLUS CAPLET SA
NATA KOMPLETE PRENATAL TABLET
NATACHEW (TABLET, TABLET CHEW)
NATAFORT TABLET
NATAL-V RX TABLET
NATALVIRT 90 DHA COMBO PACK
96
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
NATALVIRT CA COMBO PACK
NATALVIT TABLET
NATELLE C TABLET
NATELLE ONE CAPSULE
NATELLE PLUS COMBO PACK
NATELLE PREFER TABLET
NATELLE TABLET
NATELLE-EZ TABLET
NAVATAB + DHA PACK
NEEVO (CAPLET, COMBO PACK)
NEEVO DHA (CAPSULE, GELCAP)
NEEVODHA CAPSULE
NESTABS ABC PRENATAL COMBO PK
NESTABS DHA COMBO PACK
NESTABS TABLET
NEWGEN TABLET
NEXA PLUS SOFTGEL
NEXA SELECT (CAPSULE, SOFTGEL)
NIVA-PLUS TABLET
NOVANATAL TABLET
NOVASTART TABLET
NUTRI-TAB OB + DHA COMBO PACK
NUTRI-TAB OB TABLET
O-CAL FA TABLET
O-CAL PRENATAL TABLET
OB COMPLETE (CAPLET, CHEWABLE TABLET)
OB COMPLETE 400 (400 CAPSULE, 400 SOFTGEL)
OB COMPLETE DHA SOFTGEL
OB COMPLETE ONE SOFTGEL
97
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
OB COMPLETE PETITE SOFTGEL
OB COMPLETE PREMIER TABLET
OB COMPLETE WITH DHA SOFTGEL
OB-NATAL ONE PRENATAL CAPSULE
OBSTETRIX DHA COMBO PAK
OBSTETRIX EC CAPLET
OBTREX DHA PRENATAL VITAMIN
OBTREX PRENATAL CAPLET
PAIRE OB PLUS DHA COMBO PACK
pn vit.w-o ca #7, iron,fa,dha 28-1.25mg capsule
pnv #14/ferrous fum/folic acid 29 mg-1 mg tab chew
pnv #19/iron ps&heme/folic/dha 22-6-1-200 capsule
PNV 29-1 TABLET
pnv no.115/iron fumarate/fa 29 mg-1 mg tab chew
PNV OB+DHA COMBO PACK
pnv w-o ca no5/fe fumarate/fa 106.5-1mg capsule
pnv with ca,no.72/iron,carb/fa 29 mg-1 mg tablet
pnv with ca,no.72/iron/fa 27 mg-1 mg tablet
pnv#79/iron/fa/lmfolate ca/dha 27-1.13 mg capsule
PNV-DHA + DOCUSATE SOFTGEL
PNV-DHA PLUS SOFTGEL
PNV-DHA SOFTGEL
PNV-FIRST SOFTGEL
PNV-IRON TABLET
PNV-OB WITH DHA COMBO PACK
PNV-OMEGA SOFTGEL
PNV-SELECT TABLET
PNV-TOTAL SOFTGEL
PNV-VP-U CAPSULE
98
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
pnv115/iron fumarate/fa/dss 29-1-25 mg tablet
POLY IRON PN FORTE TABLET
POLY IRON PN TABLET
PR NATAL 400 COMBO PACK
PR NATAL 400 EC COMBO PACK
PR NATAL 430 COMBO PACK
PRECARE CHEWABLE TABLET
PRECARE CONCEIVE TABLET
PRECARE PREMIER CAPLETS
PREFERA OB TABLET
PREFERA-OB ONE SOFTGEL
PREFERA-OB PLUS DHA COMBO PACK
PREFERA-OB TABLET
PREFOL-DHA CAPSULE
PREMESIS RX TABLET
PRENA1 CHEW TABLET
PRENA1 PEARL SOFTGEL
PRENA1 PLUS COMBO PACK
PRENA1 SOFTGEL
PRENACARE TABLET
PRENAFIRST TABLET
PRENAISSANCE 90 DHA COMBO PACK
PRENAISSANCE BALANCE SOFTGEL
PRENAISSANCE CAPSULE
PRENAISSANCE DHA COMBO PACK
PRENAISSANCE DHA HARMONY CMBPK
PRENAISSANCE HARMONY DHA CMBPK
99
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
PRENAISSANCE NEXT TABLET
PRENAISSANCE NEXT-B TABLET
PRENAISSANCE PLUS SOFTGEL
PRENAISSANCE PROMISE COMBO PCK
PRENAPLUS TABLET
prenat vit comb.10/iron/fa/dha 65-1-250mg combo. pkg
PRENATA CHEWABLE TABLET
PRENATABS FA TABLET
PRENATABS RX TABLET
PRENATAL FORMULA TABLET
prenatal vit #60/iron fum/fa 27 mg-1 mg tablet
prenatal vit 15/iron cb/fa/dss 90-1-50 mg tablet
prenatal vits with calcium #74/ferrous fumarate/folic
acid (ca#74/iron/folic acid 27 mg tablet, ca,no.74/iron/fa
27 mg tablet)
PRENATE AM TABLET
PRENATE CHEWABLE TABLET
PRENATE DHA SOFTGEL
PRENATE ELITE TABLET
PRENATE ENHANCE SOFTGEL
PRENATE ESSENTIAL SOFTGEL
PRENATE MINI SOFTGEL
PRENATE PIXIE SOFTGEL
PRENATE PLUS TABLET
PRENATE RESTORE SOFTGEL
PRENATE STAR TABLET
PRENEXA CAPSULE
PRENEXA PREMIER CAPSULE
PREPLUS CA-FE 27 MG-FA 1 MG TB
PREQUE 10 TABLET
100
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
PRETAB 29 MG-1 MG TABLET
PREVITE RX TABLET
PRIMACARE ADVANTAGE COMBO PACK
PRIMACARE ONE SOFTGEL
PROTECT NATAL TABLET
PROVIDA DHA CAPSULE
PROVIDA OB CAPSULE
PRUET DHA (, PRENATAL)
PRUET DHA EC (EC VITAMINS, EC VITS)
PUREFE OB PLUS CAPSULE
PUREFE PLUS CAPSULE
R-NATAL OB SOFTGEL
RE DUALVIT OB CAPSULE
RE OB + DHA PACK
RE OB 90 + DHA PACK
RE-NATA 29 OB PRENATAL TABLET
RE-NATA 29 PRENATAL TABLET
REAPHIRM CAPSULE
RELNATE DHA PRENATAL SOFTGEL
RENATE CAPLET
RENATE DHA (430 MG VIT, VITAMINS)
RENATE DHA EXTRA (PRENATAL VITS, VITAMINS)
ROVIN-A DHA COMBO PACK
ROVIN-NV DHA CAPSULE
ROVIN-NV TABLET
SE-CARE CHEWABLE TABLET
SE-CARE CONCEIVE TABLET
SE-CARE GESTURE TABLET
SE-NATAL 19 (19 CHEWABLE TABLET, 19 TABLET)
101
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
SE-NATAL 90 DR TABLET
SE-NATAL ONE TABLET
SE-PLETE DHA SOFTGEL
SE-TAN DHA CAPSULE
SELECT-OB + DHA PACK
SELECT-OB CHEWABLE CAPLET
SETONET PRENATAL VITAMIN
SETONET-EC PRENATAL VITAMINS
TANDEM DHA CAPSULE
TANDEM OB CAPSULE
TARON A PRENATAL DHA COMB PACK
TARON EC CALCIUM DHA COMB PACK
TARON-BC TABLET
TARON-C DHA CAPSULE
TARON-DUO EC COMB PACK
TARON-EC CAL TABLET
TARON-PREX PRENATAL DHA CAP
TL FOLATE TABLET
TL-ASSURE + DHA COMBO PACK
TL-ASSURE ONE CAPSULE
TL-CARE DHA SOFTGEL
TL-SELECT CAPSULE
TL-SELECT DHA SOFTGEL
TRI RX TABLET
TRI-TABS DHA COMBO PACK
TRIADVANCE TABLET
TRICARE DHA 301 CAPSULE
TRICARE PRENATAL COMPLEAT PACK
TRICARE PRENATAL DHA ONE SFTGL
102
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
TRICARE PRENATAL TABLET
TRIFERA OB TABLET
TRIMESIS RX TABLET
TRINATAL GT TABLET
TRINATAL RX 1 TABLET
TRINATAL ULTRA TABLET
TRINATE TABLET
TRIVEEN-DUO DHA COMBO PACK
TRIVEEN-ONE CAPSULE
TRIVEEN-PRX RNF CAPSULE
TRIVEEN-TEN TABLETS
TRIVEEN-U CAPSULE
TRUST NATAL DHA
ULTIMATE OB DHA COMBO PACK
ULTIMATECARE ADVANTAGE COMBO
ULTIMATECARE COMBO PACK
ULTIMATECARE ONE CAPSULE
ULTIMATECARE ONE NF CAPSULE
V-NATAL DHA COMBO PACK
V-NATAL TABLET
VEMAVITE-PRX 2 CAPSULE
VENA-BAL DHA COMBO PACK
VENATAL COMPLETE DHA COMBO
VENATAL-FA TABLET
VINACAL PRENATAL TABLET
VINATE AZ EXTRA TABLETS
VINATE AZ TABLET
VINATE C TABLET
VINATE CALCIUM PRENATAL TABLET
103
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
VINATE CARE CHEWABLE TABLET
VINATE DHA GELCAP
VINATE DHA RF GELCAP
VINATE GT TABLET
VINATE IC CAPSULE
VINATE II TABLET
VINATE III TABLET
VINATE ONE TABLET
VINATE PN CARE TABLET
VINATE ULTRA TABLET
VINATE-M TABLET
VIRT NATE TABLET
VIRT-ADVANCE TABLET
VIRT-BAL DHA COMBO PACK
VIRT-BAL DHA PLUS COMBO PACK
VIRT-C DHA SOFTGEL
VIRT-CARE ONE CAPSULE
VIRT-PN DHA SOFTGEL
VIRT-PN PLUS SOFTGEL
VIRT-PN TABLET
VIRT-SELECT CAPSULE
VIRT-VITE GT TABLET
VIRTPREX CAPSULE
VITAFOL NANO TABLET
VITAFOL ULTRA SOFTGEL
VITAFOL-OB CAPLET
VITAFOL-OB+DHA COMBO PACK
VITAFOL-ONE CAPSULE
VITAFOL-PLUS CAPSULE
104
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
VITAFOL-PN CAPLET
VITAMEDMD ONE RX SOFTGEL
VITAMEDMD PLUS RX COMBO PACK
VITAMEDMD REDICHEW RX TAB CHEW
VITAPEARL SOFTGEL
VITAPHIL + DHA 90 PACK
VITAPHIL + DHA PACK
VITAPHIL AIDE CAPLET
VITAPHIL CAPLET
VITASPIRE TABLET
VIVA CT PRENATAL CHEWABLE TAB
VIVA DHA PRENATAL SOFTGEL
VOL-NATE TABLET
VOL-PLUS TABLET
VOL-TAB RX TABLET
VP CH ULTRA SOFTGEL
VP-CH PLUS SOFTGEL
VP-CH-PNV PRENATAL SOFTGEL
VP-ERA OB PLUS TABLET
VP-GGR-B6 TABLET
VP-HEME OB + DHA COMBO PACK
VP-HEME OB TABLET
VP-HEME ONE SOFTGEL
VP-PNV-DHA CAPSULE
VYNATAL-FA TABLET
ZATEAN-CH CAPSULE
ZATEAN-PN DHA CAPSULE
ZATEAN-PN PLUS SOFTGEL
ZATEAN-PN TABLET
105
Covered Drugs)
DRUG NAME
REQUIREMENTS/LIMITS
ZINGIBER TABLET
106
Alphabetical Listing
0
0.9 % sodium chloride
58
8
8-MOP
53
A
A-HYDROCORT
61
abacavir sulfate
3
abacavir sulfate/lamivudine/zidovudine
3
ABELCET
2
ABILIFY
34
ABILIFY DISCMELT
34
ABILIFY MAINTENA
34
ABRAXANE
15
acamprosate calcium
58
ACANYA
54
acarbose
62
ACCOLATE
87
acebutolol hcl
42
acetaminophen with codeine phosphate
29
ACETASOL HC
61
acetazolamide
83
acetazolamide sodium
84
acetic acid
61
acetic acid/hydrocortisone
61
acetylcysteine
87
acitretin
53
ACTHIB
73
ACTIMMUNE
71
ACTIVE OB
93
ACTONEL
58,76
ACTOPLUS MET
62
ACTOPLUS MET XR
63
ACTOS
63
ACUVAIL
83
acyclovir
3
acyclovir sodium
3
ADACEL TDAP
73
ADAGEN
58
107
adapalene
ADCIRCA
ADDERALL XR
adefovir dipivoxil
ADEMPAS
ADRUCIL
ADVAIR DISKUS
ADVAIR HFA
ADVANCED CARE PLUS
ADVICOR
AFEDITAB CR
AFINITOR
AFINITOR DISPERZ
AGGRENOX
ALA-CORT
ALA-SCALP
ALBENZA
albuterol sulfate
alclometasone dipropionate
ALDACTAZIDE
ALDARA
ALDURAZYME
alendronate sodium
alfuzosin hcl
ALIMTA
ALINIA
ALKERAN
allopurinol
ALOCRIL
ALOMIDE
ALOPRIM
alosetron hcl
ALOXI
ALPHAGAN P
alprazolam
ALPRAZOLAM INTENSOL
ALREX
ALTABAX
amantadine hcl
AMBISOME
amcinonide
54
42
34
3
52
15
87
87
93
50
42
15
15
49
56
56
8
87
56
43
53
65
58,76
90
15
8
15
75
83
83
76
68
68
85
34
34
85
55
3
2
56
AMETHIA
AMETHYST
amifostine crystalline
amikacin sulfate
amiloride hcl
amiloride hcl/hydrochlorothiazide
aminophylline
AMINOSYN II
AMINOSYN M
AMINOSYN WITH ELECTROLYTES
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-RF
amiodarone hcl
AMITIZA
amitriptyline hcl
amitriptyline hcl/chlordiazepoxide
amlodipine besylate
amlodipine besylate/atorvastatin calcium
amlodipine besylate/benazepril hcl
amlodipine besylate/valsartan
amlodipine
besylate/valsartan/hydrochlorothiazide
ammonium chloride
ammonium lactate
AMNESTEEM
amoxapine
amoxicillin
amoxicillin/potassium clavulanate
amphotericin b
ampicillin sodium
ampicillin sodium/sulbactam sodium
ampicillin trihydrate
AMPYRA
AMRIX
ANADROL-50
anagrelide hcl
anastrozole
ANCOBON
ANDRODERM
ANDROGEL
79
79
14
8
43
43
87
92
92
92
92
92
92
42
68
34
34
43
43
43
43
43
90
53
54
35
11
11
2
11
12
12
27
28
65
58
15
2
65
65
108
ANORO ELLIPTA
ANTABUSE
ANZEMET
APLENZIN
APOKYN
apraclonidine hcl
APRI
APRISO
APTIOM
APTIVUS
ARALAST
ARALAST NP
ARANELLE
ARANESP
ARCALYST
ARICEPT
ARIMIDEX
aripiprazole
ARIXTRA
AROMASIN
ARRANON
ARTHROTEC 50
ARTHROTEC 75
ARZERRA
ASACOL HD
ASCOMP WITH CODEINE
ASMANEX
ASTAGRAF XL
ATABEX EC
ATELVIA
atenolol
atenolol/chlorthalidone
ATGAM
atorvastatin calcium
atovaquone
atovaquone/proguanil hcl
ATRIPLA
atropine sulfate
ATROVENT HFA
AVASTIN
AVELOX
87
58
68
35
26
85
79
68
22
3
58
58
79
72
72
27
15
35
49
15
15
32
32
15
68
29
87
15
93
76
43
43
73
51
8
8
3
67
87
15
12
AVELOX ABC PACK
12
AVELOX IV
12
AVIANE
79
AVITA
54
AVODART
90
AVONEX
72
AVONEX ADMINISTRATION PACK
72
AVONEX PEN
72
azacitidine
15
AZACTAM
8
AZACTAM-ISO-OSMOTIC DEXTROSE
8
AZASAN
15
AZASITE
81
azathioprine
15
azelastine hcl
60,83
AZELEX
54
AZILECT
26
azithromycin
8
AZOPT
84
AZOR
43
aztreonam
8
B
B-NEXA
BACIIM
bacitracin
bacitracin/polymyxin b sulfate
baclofen
BACTROBAN
BACTROBAN NASAL
BAL-CARE DHA
BAL-CARE DHA ESSENTIAL
balsalazide disodium
BALZIVA
BANZEL
BARACLUDE
bcg vaccine, live/pf
BECONASE AQ
BELEODAQ
benazepril hcl
benazepril hcl/hydrochlorothiazide
93
8
9,81
81
28
55
60
93
93
68
79
22
3
73
87
15
43
43
109
BENLYSTA
76
BENTYL
67
BENZACLIN
54
benztropine mesylate
26
betamethasone dipropionate
56
betamethasone dipropionate/propylene
glycol
56
betamethasone valerate
56
BETASERON
72
betaxolol hcl
43,82
bethanechol chloride
90
BETOPTIC S
82
BEXSERO
73
bicalutamide
15
BICILLIN C-R
12
BICILLIN L-A
12
BICNU
16
BILTRICIDE
9
bimatoprost
84
bisoprolol fumarate
43
bisoprolol fumarate/hydrochlorothiazide
43
bleomycin sulfate
16
BLEPH-10
85
BLEPHAMIDE
84
BLEPHAMIDE S.O.P.
84
BONIVA
76
BOOSTRIX
74
BOOSTRIX TDAP
73
BOSULIF
16
BREO ELLIPTA
87
BRIELLYN
79
BRILINTA
49
brimonidine tartrate
85
BRINTELLIX
35
BRISDELLE
35
bromfenac sodium
83
bromocriptine mesylate
26
BROVANA
87
budesonide
68,87
bumetanide
43
BUNAVAIL
32
BUPHENYL
buprenorphine hcl
buprenorphine hcl/naloxone hcl
BUPROBAN
bupropion hcl
buspirone hcl
BUSULFEX
butalbital/acetaminophen/caffeine/codeine
phosphate
butorphanol tartrate
BYDUREON
BYDUREON PEN
BYETTA
BYSTOLIC
90
29
29
60
35
35
16
29
32
63
63
63
43
C
C-NATE DHA
93
cabergoline
65
CADEAU DHA
93
CADUET
51
calcipotriene
53
calcipotriene/betamethasone dipropionate 53
calcitonin,salmon,synthetic
65
calcitriol
53,65
calcium acetate
91
CALCIUM PNV
93
CAMILA
77
CANASA
68
CANCIDAS
2
candesartan cilexetil
44
candesartan cilexetil/hydrochlorothiazide 44
CANTIL
67
CAPASTAT SULFATE
9
CAPEX SHAMPOO
56
CAPRELSA
16
captopril
44
captopril/hydrochlorothiazide
44
CARAC
53
CARAFATE
70
CARBAGLU
68
carbamazepine
22,35
110
CARBATROL
carbidopa
carbidopa/levodopa
carbidopa/levodopa/entacapone
carbinoxamine maleate
carboplatin
CARDURA XL
CARIMUNE NF NANOFILTERED
carisoprodol
carisoprodol/aspirin
CARNITOR
carteolol hcl
CARTIA XT
carvedilol
CASODEX
CAVAN ONE OMEGA
CAVAN-ALPHA KIT
CAVAN-EC SOD DHA
CAVAN-FOLATE DHA
CAVAN-FOLATE OB
CAVAN-HEME OB
CAVAN-HEME OMEGA
CAYSTON
CEDAX
cefaclor
cefadroxil
cefadroxil hydrate
cefazolin sodium
cefazolin sodium/dextrose, iso-osmotic
cefdinir
cefepime hcl
cefepime hcl/dextrose 5 % in water
cefixime
cefotaxime sodium
cefotetan disodium
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime
ceftazidime in dextrose 5% and water
ceftazidime pentahydrate
22
26
26
26
86
16
44
74
28
28
58
82
44
44
16
93
93
93
93
94
94
94
9
6
6
6
6
6
6
6
6
7
7
7
7
7
7
7
7
7
7
CEFTIN
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
celecoxib
CELLCEPT
CELONTIN
cephalexin
CEREBYX
CEREZYME
CERVARIX
CESAMET
cetirizine hcl
cevimeline hcl
CHANTIX
CHEMET
chloramphenicol sod succ
chlordiazepoxide hcl
chlorhexidine gluconate
chloroquine phosphate
chlorothiazide
chlorothiazide sodium
chlorpromazine hcl
chlorpropamide
chlorthalidone
chlorzoxazone
CHOICE-OB + DHA
cholestyramine/aspartame
ciclopirox
ciclopirox olamine
cidofovir
cilostazol
CILOXAN
cimetidine
cimetidine hcl
CINRYZE
CIPRO
CIPRO HC
CIPRODEX
ciprofloxacin
ciprofloxacin hcl
7
7
7
7
32
16
22
7
22
65
74
68
86
58
60
58
9
35
60
9
44
44
35
63
44
28
94
51
55
55
3
49
81
70
70
74
12
61
61
12
13,81
111
ciprofloxacin lactate
13
ciprofloxacin lactate/dextrose 5 % in water 13
ciprofloxacin/ciprofloxacin hcl
13
cisplatin
16
citalopram hydrobromide
35
CITRANATAL 90 DHA
94
CITRANATAL ASSURE
94
CITRANATAL B-CALM
94
CITRANATAL DHA
94
CITRANATAL HARMONY
94
CITRANATAL RX
94
cladribine
16
CLAFORAN
7
CLARAVIS
54
CLARINEX
86
CLARINEX-D 12 HOUR
86
clarithromycin
8
CLEOCIN HCL
9
CLEOCIN PALMITATE
9
CLEOCIN PHOSPHATE IN D5W
9
clindamycin hcl
9
clindamycin palmitate hcl
9
clindamycin phosphate
9,54,79
clindamycin phosphate/benzoyl peroxide 54
clindamycin phosphate/dextrose 5 % in
water
9
CLINIMIX
58,92
CLINIMIX E
58,92
clobetasol propionate
56
CLOLAR
16
clomipramine hcl
35
clonazepam
35
clonidine
44
clonidine hcl
44
clopidogrel bisulfate
49
clorazepate dipotassium
35
CLORPRES
44
clotrimazole
2,55
clotrimazole/betamethasone dipropionate 55
clozapine
35
CLOZARIL
35
CO-NATAL FA
94
COARTEM
9
codeine phosphate/carisoprodol/aspirin
28
codeine sulfate
29
colchicine
76
colchicine/probenecid
76
COLCRYS
76
colestipol hcl
51
colistin (as colistimethate sodium)
9
COLY-MYCIN S
61
COMBIGAN
84
COMBIVENT RESPIMAT
87
COMBIVIR
3
COMETRIQ
16
COMPLERA
3
COMPLETE NATAL DHA
94
COMPLETE-RF PRENATAL
94
COMPLETENATE
94
COMPRO
68
COMTAN
26
COMVAX
74
CONCEPT DHA
94
CONCEPT OB
94
CONCERTA
35
CONSTULOSE
68
COPAXONE
27,72
COREG CR
44
CORENATE-DHA
94
cortisone acetate
61
CORTISPORIN
55
CORTISPORIN-TC
61
COSMEGEN
16
COZAAR
44
CREON
68
CRESTOR
51
CRINONE
77
CRIXIVAN
3
cromolyn sodium
68,83,88
CRYSELLE
79
CUBICIN
9
CUPRIMINE
76
112
CYCLAFEM
cyclobenzaprine hcl
cyclophosphamide
CYCLOSET
cyclosporine
cyclosporine, modified
CYKLOKAPRON
CYMBALTA
CYSTADANE
CYSTAGON
cytarabine
cytarabine/pf
CYTOVENE
79
28
16
63
16
16
49
35
68
90
16
16
3
D
dacarbazine
DACOGEN
dalfampridine
DALIRESP
danazol
dantrolene sodium
dapsone
DAPTACEL DTAP
DARAPRIM
daunorubicin hcl
DAUNOXOME
decitabine
DELZICOL
demeclocycline hcl
DEMSER
DENAVIR
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLE
DEPEN
DEPO-ESTRADIOL
DEPO-PROVERA
DEPO-SUBQ PROVERA 104
desipramine hcl
desloratadine
desmopressin acetate
16
16
27
88
65
28
9
74
9
16
16
16
68
13
44
56
22
23
23
76
77
77
77
36
86
65,66
DESONATE
56
desonide
57
desoximetasone
57
DESOXYN
36
desvenlafaxine
36
DETROL
89
dexamethasone
61
DEXAMETHASONE INTENSOL
61
dexamethasone sod phosphate
61,85
dexamethasone sodium phosphate/pf
61
DEXILANT
70
dexmethylphenidate hcl
36
DEXPAK
61
dexrazoxane hcl
14
dextroamphetamine sulfsaccharate/amphetamine sulf-aspartate
36
dextroamphetamine sulfate
36
dextrose 10 % and 0.2 % sodium chloride 58
dextrose 10 % in water
59
dextrose 2.5 % and 0.45 % sodium chloride59
dextrose 5 % in lactated ringers
91
dextrose 5 % in water
59
DIASTAT
36
DIASTAT ACUDIAL
36
diazepam
36
diclofenac potassium
32
diclofenac sodium
32,83
diclofenac sodium/misoprostol
33
dicloxacillin sodium
12
dicyclomine hcl
67
didanosine
3
diflorasone diacetate
57
diflunisal
33
DIGITEK
49
digoxin
49
dihydroergotamine mesylate
27
113
DILANTIN
DILAUDID
DILT-CD
DILT-XR
diltiazem hcl
DIOVAN
DIOVAN HCT
DIPENTUM
diphenhydramine hcl
diphenoxylate hcl/atropine sulfate
dipyridamole
disopyramide phosphate
disulfiram
DIURIL
DIURIL SODIUM
divalproex sodium
DIVIGEL
DOCEFREZ
docetaxel
DOCOSAVIT
donepezil hcl
DORIBAX
dorzolamide hcl
dorzolamide hcl/timolol maleate
DOVONEX
doxazosin mesylate
doxepin hcl
doxercalciferol
DOXIL
doxorubicin hcl
doxycycline hyclate
doxycycline monohydrate
dronabinol
DROXIA
DUALVIT OB
DUET DHA
DUET DHA 400
DUET DHA BALANCED
DUET DHA COMPLETE
DUET DHA EC
DUET DHA WITH FERRAZONE
23
29
44
44
45
45
45
68
86
67
49
42
59
45
45
23
77
16
17
94
27
9
84
84
53
45
36
66
17
17
13
13
68
17
101
94
94
94
94
94
94
DUET STUARTNATAL
DUETACT
DULERA
duloxetine hcl
DURAMORPH
DUREZOL
94
63
88
36
29,30
83
E
E.E.S. 400
econazole nitrate
ED CYTE F
EDARBI
EDARBYCLOR
EDGE OB
EDURANT
EFFEXOR XR
ELAPRASE
ELESTAT
ELIDEL
ELIGARD
ELIPHOS
ELIQUIS
ELITE OB DHA
ELITE-OB
ELITE-OB 400
ELITEK
ELIXOPHYLLIN
ELLENCE
ELMIRON
ELOXATIN
EMADINE
EMCYT
EMEND
EMOQUETTE
EMSAM
EMTRIVA
ENABLEX
enalapril maleate
enalapril maleate/hydrochlorothiazide
ENBRACE HR
ENBREL
8
56
94
45
45
95
3
36
66
83
53
17
91
49
95
95
95
14
88
17
90
17
83
17
68
79
36
3
89
45
45
95
77
114
ENDOCET
30
ENGERIX-B
74
ENGERIX-B ADULT
74
ENGERIX-B PEDIATRIC-ADOLESCENT 74
ENJUVIA
77
enoxaparin sodium
49
ENPRESSE
79
entacapone
26
entecavir
3
ENTOCORT EC
69
ENULOSE
69
epinastine hcl
83
epinephrine
86
EPIPEN
86
EPIPEN 2-PAK
86
EPIPEN JR
86
EPIPEN JR 2-PAK
86
epirubicin hcl
17
EPITOL
23
EPIVIR
4
EPIVIR HBV
4
eplerenone
45
EPOGEN
72
eprosartan mesylate
45
EPZICOM
4
EQUETRO
23
ERAXIS (WATER DILUENT)
2
ERBITUX
17
ergoloid mesylates
36
ERIVEDGE
17
ERRIN
77
ERTACZO
56
ERWINAZE
17
ERY
54
ERY-TAB
8
ERYPED 200
8
ERYTHROCIN LACTOBIONATE
8
ERYTHROCIN STEARATE
8
erythromycin base
8,82
erythromycin base/benzoyl peroxide
54
erythromycin base/ethyl alcohol
54
erythromycin ethylsuccinate
escitalopram oxalate
esomeprazole magnesium
estazolam
ESTRACE
estradiol
estradiol valerate
estradiol/norethindrone acetate
ESTRING
estropipate
eszopiclone
ethambutol hcl
ethinyl estradiol/drospirenone
ethosuximide
etidronate disodium
etodolac
ETOPOPHOS
etoposide
EURAX
EVAMIST
EVOTAZ
EVOXAC
EXELDERM
EXELON
exemestane
EXFORGE
EXFORGE HCT
EXJADE
EXTINA
EXTRA-VIRT PLUS DHA
8
36
71
36
77
78
78
78,79
78
78
36
9
79
23
59
33
17
17
58
78
4
59
56
28
17
45
45
59
56
95
F
FABRAZYME
FACTIVE
famciclovir
famotidine
famotidine in sodium chloride, isoosmotic/pf
famotidine/pf
FANAPT
FARESTON
66
13
4
71
71
71
36
17
115
FARXIGA
FARYDAK
FASLODEX
FAZACLO
felbamate
FELBATOL
felodipine
FEMARA
FEMCON FE
FEMECAL OB
FEMECAL OB PLUS DHA
FEMRING
fenofibrate
fenofibrate nanocrystallized
fenofibrate,micronized
fenofibric acid (choline)
fenoprofen calcium
fentanyl
fentanyl citrate
FETZIMA
FIBRICOR
FINACEA
finasteride
FIRAZYR
FLAGYL ER
FLAREX
flavoxate hcl
flecainide acetate
FLOVENT HFA
fluconazole
fluconazole in dextrose, iso-osmotic
flucytosine
fludarabine phosphate
fludrocortisone acetate
fluocinolone acetonide
fluocinolone acetonide oil
fluocinonide
fluocinonide/emollient base
fluorometholone
fluorouracil
fluoxetine hcl
63
17
17
37
23
23
45
17
79
95
95
78
51
51
51
51
33
30
30
37
51
54
90
74
9
85
89
42
88
2
2
2
17
61
57
61
57
57
85
17,53
37
fluphenazine decanoate
fluphenazine hcl
flurazepam hcl
flurbiprofen
flurbiprofen sodium
flutamide
fluticasone propionate
fluvastatin sodium
fluvoxamine maleate
FML FORTE
FML S.O.P.
FOCALGIN-B
FOCALIN
FOCALIN XR
FOLBECAL
FOLCAL DHA
FOLCAPS CARE ONE
FOLCAPS OMEGA-3
FOLET DHA
FOLET ONE
FOLINATAL PLUS B
FOLIVANE-EC CALCIUM DHA NF
FOLIVANE-OB
FOLIVANE-PRX DHA NF
FOLTABS
FOLTABS 90 PLUS DHA
FOLTABS PRENATAL PLUS DHA
fomepizole
fondaparinux sodium
FORFIVO XL
FORTAZ
FORTEO
FORTICAL
FOSAMAX PLUS D
foscarnet sodium
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
fosphenytoin sodium
FOSRENOL
FRAGMIN
FURADANTIN
37
37
37
33
83
17
57,88
51
37
85
85
95
37
37
95
95
95
95
95
95
93
95
95
95
95
95
95
74
49
37
7
76
66
76
4
45
45
23
59
50
14
116
furosemide
FUSILEV
FUZEON
FYCOMPA
46
14
4
23
G
gabapentin
23
GABITRIL
23
galantamine hbr
28
GAMASTAN S-D
74
GAMMAGARD LIQUID
74
GAMMAGARD S-D
74
GAMUNEX
74
GAMUNEX-C
74
ganciclovir sodium
4
GARAMYCIN
82
GARDASIL
74
GARDASIL 9
74
gatifloxacin
13
GATTEX
69
GAVILYTE-C
69
GAVILYTE-N
69
gemcitabine hcl
17
gemfibrozil
51
GEMZAR
18
GENERLAC
69
GENGRAF
18
GENOTROPIN
72
GENTAK
82
gentamicin sulfate
9,55,82
gentamicin sulfate in sodium chloride, isoosmotic
9
GENTEX ADE
95
GEODON
37
GESTICARE
95
GESTICARE DHA
95
GILDAGIA
79
GILENYA
72
GILOTRIF
18
GLATOPA
72
GLEEVEC
18
GLEOSTINE
glimepiride
glipizide
glipizide/metformin hcl
GLUCAGEN
GLUCAGON EMERGENCY KIT
glyburide
glyburide,micronized
glyburide/metformin hcl
glycopyrrolate
GOLYTELY
GRALISE
granisetron hcl
granisetron hcl/pf
GRIS-PEG
griseofulvin ultramicrosize
griseofulvin, microsize
griseofulvin,microsize
guanfacine hcl
guanidine hcl
18
63
63
63
63
63
63
63
63
67
69
23
69
69
2
2
2
2
37,46
28
H
HALAVEN
HALDOL
HALDOL DECANOATE 100
HALDOL DECANOATE 50
halobetasol propionate
HALOG
haloperidol
haloperidol decanoate
haloperidol lactate
HAVRIX
HEMENATAL OB
HEMENATAL OB + DHA
heparin sodium,porcine
heparin sodium,porcine/dextrose 5 % in
water
HEPATAMINE
HEPSERA
HERCEPTIN
HETLIOZ
18
37
37
37
57
57
37
37
37
74
95
95
50
50
92
4
18
28
117
HEXALEN
18
HIP PRENATAL
95
HUMALOG
63
HUMALOG KWIKPEN U-100
63
HUMALOG KWIKPEN U-200
63
HUMALOG MIX 50-50
63
63
HUMALOG MIX 75-25
63
63
HUMATROPE
72
HUMIRA
77
HUMIRA PEN
77
HUMIRA PEN CROHN'S-UC-HS
77
HUMIRA PEN PSORIASIS
77
HYCAMTIN
18
hydralazine hcl
46
hydrochlorothiazide
46
hydrocodone bit/acetaminophen
30
hydrocodone bitartrate/acetaminophen
30
hydrocodone/ibuprofen
30
hydrocortisone
57,61,69
hydrocortisone butyrate
57
hydrocortisone butyrate/emollient base
57
hydrocortisone valerate
57
hydromorphone hcl
30
hydromorphone hcl/pf
30
hydroxychloroquine sulfate
9
hydroxyurea
18
hydroxyzine hcl
86
hydroxyzine pamoate
86
HYZAAR
46
I
ibandronate sodium
IBRANCE
ibuprofen
ibuprofen/oxycodone hcl
ICAR-C PLUS SR
ICLUSIG
idarubicin hcl
IFEX
76
18
33
30
95
18
18
18
ifosfamide
ILARIS
IMBRUVICA
imipenem/cilastatin sodium
imipramine hcl
imipramine pamoate
imiquimod
IMOVAX RABIES VACCINE
INATAL ADVANCE
INATAL GT
INATAL ULTRA
INCRELEX
INCRUSE ELLIPTA
indapamide
INDOCIN
INFANATE BALANCE
INFANATE DHA
INFANATE PLUS
INFANRIX
INFANRIX DTAP
INLYTA
INTELENCE
INTRALIPID
INTRON A
INTROVALE
INTUNIV
INVANZ
INVEGA
INVEGA SUSTENNA
INVIRASE
INVOKAMET
INVOKANA
IONOSOL B WITH DEXTROSE 5%
IONOSOL MB-DEXTROSE 5%
IOPIDINE
IPOL
ipratropium bromide
ipratropium bromide/albuterol sulfate
irbesartan
irbesartan/hydrochlorothiazide
IRENKA
18
77
18
10
38
38
53
74
95
96
96
59
88
46
33
96
96
96
74
74
18
4
92
72
79
46
10
38
38
4
63
64
93
93
85
74
60,88
88
46
46
38
118
irinotecan hcl
ISENTRESS
ISOLYTE P WITH DEXTROSE
ISOLYTE S
ISONARIF
isoniazid
ISOPTO CARPINE
isosorbide dinitrate
isosorbide mononitrate
isradipine
itraconazole
ivermectin
IXEMPRA
IXIARO
18
4
93
93
10
10
83
52
52
46
2
10
18
75
J
JADENU
JAKAFI
JALYN
JANTOVEN
JANUMET
JANUMET XR
JANUVIA
JARDIANCE
JENTADUETO
JEVTANA
JOLIVETTE
JUNEL
JUNEL FE
JUNEL FE 24
JUXTAPID
59
18
90
50
64
64
64
64
64
18
78
79
79
80
51
K
KALETRA
KALYDECO
KAPIDEX
KARIVA
KAZANO
KEFLEX
KELNOR 1-35
KENALOG
4
88
71
80
64
7
80
57
KENALOG-10
KENALOG-40
KEPIVANCE
KEPPRA
KEPPRA XR
KETEK
ketoconazole
ketoprofen
ketorolac tromethamine
KEYTRUDA
KHEDEZLA
KINERET
KIONEX
KLOR-CON 10
KLOR-CON 8
KLOR-CON M10
KLOR-CON M15
KLOR-CON M20
KOLNATAL DHA
KOMBIGLYZE XR
KORLYM
KUVAN
61
61
14
23
23
10
2,56
33
33,83
18
38
77
59
91
91
91
91
91
96
64
10
59,66
L
L-METHYLFOLATE PNV DHA
labetalol hcl
LACTOCAL-F
lactulose
LAMICTAL
LAMICTAL (BLUE)
LAMICTAL (GREEN)
LAMICTAL (ORANGE)
LAMICTAL XR
LAMICTAL XR (BLUE)
LAMICTAL XR (GREEN)
LAMICTAL XR (ORANGE)
lamivudine
lamivudine/zidovudine
lamotrigine
LANOXIN
lansoprazole
96
46
96
69
23
23
23
23
24
24
24
24
4
4
24
49
71
119
lansoprazole/amoxicillin
trihydrate/clarithromycin
69
LANTUS
64
LANTUS SOLOSTAR
64
LARIN
80
LARIN FE
80
latanoprost
84
LATUDA
38
leflunomide
77
LENVIMA
18
LESSINA
80
LETAIRIS
88
letrozole
18
leucovorin calcium
15
LEUKERAN
18
LEUKINE
72
leuprolide acetate
19
levalbuterol hcl
88
LEVAQUIN
13
levetiracetam
24
levetiracetam in sodium chloride, isoosmotic
24
levobunolol hcl
82
levocarnitine
59
levocarnitine (with sugar)
59
levocetirizine dihydrochloride
87
levofloxacin
13,82
levofloxacin/dextrose 5 % in water
13
levoleucovorin calcium
15
LEVOMEFOLATEPNV
96
LEVONEST
80
levonorgestrel-ethinyl estradiol
80
levonorgestrel/ethinyl estradiol and ethinyl
estradiol
80
LEVORA-28
80
levorphanol tartrate
30
levothyroxine sodium
67
LEVOXYL
67
LEXAPRO
38
LEXIVA
4
LIALDA
69
lidocaine
lidocaine hcl
lidocaine hcl/pf
lidocaine/prilocaine
LIDODERM
lindane
linezolid
LINZESS
liothyronine sodium
lisinopril
lisinopril/hydrochlorothiazide
lithium carbonate
lithium citrate
LOESTRIN
LOESTRIN FE
lomustine
loperamide hcl
lorazepam
LORAZEPAM INTENSOL
LORCET
LORCET HD
LORTAB
LORZONE
losartan potassium
losartan potassium/hydrochlorothiazide
LOTEMAX
LOTRONEX
lovastatin
LOVAZA
LOVENOX
loxapine succinate
LUMIGAN
LUPRON DEPOT
LUPRON DEPOT-PED
LUTERA
LYNPARZA
LYRICA
LYSODREN
LYSTEDA
LYZA
55
55
55
55
55
58
10
69
67
46
46
38
38
80
80
19
67
38
38
31
31
31
29
46
46
85
69
51
51
50
38
84
19
19
80
19
24
19
50
78
120
M
M-M-R II VACCINE
M-VIT
MACNATAL CN DHA
MACRODANTIN
magnesium sulfate
MALARONE
malathion
maprotiline hcl
MARLISSA
MARNATAL-F
MARNATAL-F PLUS
MARPLAN
MATERNITY
MATULANE
MAXALT
MAXALT MLT
MAXIDEX
MAXINATE
meclizine hcl
meclofenamate sodium
medroxyprogesterone acetate
mefenamic acid
mefloquine hcl
megestrol acetate
MEKINIST
meloxicam
melphalan hcl
MENACTRA
MENEST
MENOMUNE-A-C-Y-W-135
MENOSTAR
MENVEO A-C-Y-W-135-DIP
meperidine hcl
MEPERITAB
meprobamate
MEPRON
mercaptopurine
meropenem
MERREM
75
96
96
14
91
10
58
38
80
96
96
38
96
19
27
27
85
96
69
33
78
33
10
19
19
33
19
75
78
75
78
75
31
31
29
10
19
10
10
mesalamine with cleansing wipes
69
mesna
15
MESNEX
15
MESTINON
29
METADATE CD
38
METADATE ER
38
metaproterenol sulfate
88
metaxalone
29
metformin hcl
64
methadone hcl
31
methamphetamine hcl
38
methazolamide
84
methenamine hippurate
14
methimazole
62
METHITEST
66
methocarbamol
29
methotrexate sodium
19
methotrexate sodium/pf
19
methoxsalen, rapid
53
methscopolamine bromide
67
methyclothiazide
46
methyldopa
46
methyldopa/hydrochlorothiazide
46
methylergonovine maleate
81
METHYLIN
38
methylphenidate hcl
39
methylprednisolone
62
methylprednisolone acetate
62
methylprednisolone sodium succinate
62
metipranolol
82
metoclopramide hcl
69,71
metolazone
46
metoprolol succinate
46
metoprolol tartrate
47
metoprolol tartrate/hydrochlorothiazide
47
METROGEL
54
metronidazole
10,54,79
metronidazole in sodium chloride
10
mexiletine hcl
42
MIACALCIN
66
MICARDIS
47
121
MICARDIS HCT
miconazole nitrate
MICROGESTIN
MICROGESTIN FE
midodrine hcl
MIGRANAL
MILLIPRED
MIMVEY LO
MINITRAN
MINIVELLE
minocycline hcl
minoxidil
MIRAPEX
MIRAPEX ER
mirtazapine
misoprostol
mitomycin
mitoxantrone hcl
modafinil
MODERIBA
moexipril hcl
moexipril hcl/hydrochlorothiazide
mometasone furoate
MONONESSA
montelukast sodium
MONUROL
morphine sulfate
MOVIPREP
MOXEZA
moxifloxacin hcl
MULTAQ
MULTI-NATE 30
MULTI-NATE 30 DHA
MULTI-NATE DHA EXTRA
MULTINATAL PLUS
mupirocin
mupirocin calcium
MUSTARGEN
MYCAMINE
mycophenolate mofetil
mycophenolate sodium
47
79
80
80
59
27
62
78
52
78
13
47
26
26
39
71
19
19
39
4
47
47
57
80
88
14
31
69
82
13
42
96
96
96
96
55
55
19
2
19
19
MYFORTIC
MYNATAL
MYNATAL ADVANCE
MYNATAL PLUS
MYNATAL-Z
MYNATE 90 PLUS
MYOZYME
MYRBETRIQ
19
96
96
96
96
96
66
89
N
nabumetone
nadolol
nadolol/bendroflumethiazide
nafcillin in dextrose, iso-osmotic
nafcillin sodium
naftifine hcl
NAGLAZYME
nalbuphine hcl
naloxone hcl
naltrexone hcl
NAMENDA
NAMENDA XR
naphazoline hcl
naproxen
naproxen sodium
NARDIL
NASONEX
NATA KOMPLETE
NATACHEW
NATACYN
NATAFORT
NATAL-V RX
NATALVIRT 90 DHA
NATALVIRT CA
NATALVIT
nateglinide
NATELLE
NATELLE C
NATELLE ONE
NATELLE PLUS
NATELLE PREFER
33
47
47
12
12
56
66
33
33
33
28
28
85
33
33
39
88
96
96
82
96
96
96
97
97
64
97
97
97
97
97
122
NATELLE-EZ
97
NATPARA
62
NAVATAB + DHA
97
NEBUPENT
10
NECON
80
NEEVO
97
NEEVO DHA
97
NEEVODHA
97
nefazodone hcl
39
neomycin sulfate
10
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone
84
neomycin sulfate/bacitracin/polymyxin b
82
neomycin sulfate/polymyxin b sulfate
58
neomycin sulfate/polymyxin b
sulfate/gramicidin d
82
neomycin sulfate/polymyxin b
sulfate/hydrocortisone
61,84
neomycin/polymyxin b
sulfate/dexamethasone
84
NEORAL
19
NEPHRAMINE
93
NESINA
64
NESTABS
97
NESTABS ABC
97
NESTABS DHA
97
NEULASTA
72
NEUMEGA
72
NEUPOGEN
72
NEUPRO
26
NEURONTIN
24
NEVANAC
83
nevirapine
4
NEWGEN
97
NEXA PLUS
97
NEXA SELECT
97
NEXAVAR
19
niacin
51
NIACOR
51
NIASPAN
51
nicardipine hcl
47
NICOTROL
60
NICOTROL NS
60
NIFEDICAL XL
47
nifedipine
47
NILANDRON
19
nimodipine
47
nisoldipine
47
NITRO-BID
52
nitrofurantoin
14
nitrofurantoin macrocrystal
14
nitrofurantoin monohydrate/macrocrystals 14
nitroglycerin
52
NITROLINGUAL
52
NITROSTAT
52
NIVA-PLUS
97
nizatidine
71
NORDITROPIN FLEXPRO
72
NORDITROPIN NORDIFLEX
72
norethindrone
78
norethindrone acetate
78
norethindrone acetate-ethinyl estradiol
80
norethindrone acetate-ethinyl estradiol/ferrous
fumarate
80
norethindrone-ethinyl estradiol/ferrous
fumarate
80
NORITATE
55
NORMOSOL-R AND DEXTROSE
91
NORMOSOL-R PH 7.4
93
NORTREL
80
nortriptyline hcl
39
NORVIR
4
NOVANATAL
97
NOVASTART
97
NOVOLOG
64
NOVOLOG FLEXPEN
64
NOVOLOG MIX 70-30
64
NOVOLOG MIX 70-30 FLEXPEN
64
NOXAFIL
2
NUEDEXTA
28
NULOJIX
19
NULYTELY
69
123
NULYTELY WITH FLAVOR PACKS
NUTRI-TAB OB
NUTRI-TAB OB + DHA
NUTROPIN AQ
NUTROPIN AQ NUSPIN
NUVIGIL
NYAMYC
nystatin
nystatin/triamcinolone acetonide
NYSTOP
69
97
97
73
73
39
56
2,56
56
56
O
O-CAL FA
O-CAL PRENATAL
OB + DHA
OB 90 + DHA
OB COMPLETE
OB COMPLETE 400
OB COMPLETE DHA
OB COMPLETE ONE
OB COMPLETE PETITE
OB COMPLETE PREMIER
OB COMPLETE WITH DHA
OB-NATAL ONE
OBSTETRIX DHA
OBSTETRIX EC
OBTREX
OBTREX DHA
octreotide acetate
OFEV
ofloxacin
OGESTREL
olanzapine
olanzapine/fluoxetine hcl
olopatadine hcl
OLYSIO
OMECLAMOX-PAK
omega-3 acid ethyl esters
omeprazole
OMNARIS
OMNITROPE
97
97
101
101
97
97
97
97
98
98
98
98
98
98
98
98
20
88
13,61,82
80
39
39
60
4
12
51
71
88
73
ONCASPAR
ondansetron
ondansetron hcl
ondansetron hcl/pf
ONFI
ONGLYZA
ONMEL
OPANA
OPANA ER
OPDIVO
ORACEA
ORAP
ORAPRED ODT
ORENCIA
orphenadrine citrate
ORSYTHIA
ORTHO TRI-CYCLEN LO
OSENI
OSMOPREP
oxacillin sodium
oxacillin sodium/dextrose, iso-osmotic
oxaliplatin
oxandrolone
oxaprozin
oxazepam
oxcarbazepine
OXSORALEN-ULTRA
OXTELLAR XR
oxybutynin chloride
oxycodone hcl
oxycodone hcl/acetaminophen
oxycodone hcl/aspirin
oxymorphone hcl
20
69
69
69
24
64
2
31
31
20
14
39
62
77
29
80
80
64
69
12
12
20
66
33
39
24
53
24
89
31,32
32
32
32
P
PACERONE
paclitaxel
PAIRE OB PLUS DHA
pamidronate disodium
PANCREAZE
PANRETIN
42
20
98
66
69
54
124
pantoprazole sodium
paricalcitol
paromomycin sulfate
paroxetine hcl
PASER
PATADAY
PATANASE
PATANOL
PAXIL
PEDVAXHIB
PEGANONE
PEGASYS
PEGASYS PROCLICK
PEGINTRON
PEGINTRON REDIPEN
pen needle, diabetic
penicillin g potassium
penicillin g potassium/dextrose-water
penicillin g procaine
penicillin g sodium
penicillin v potassium
PENTACEL ACTHIB COMPONENT
PENTAM 300
PENTASA
pentazocine hcl/naloxone hcl
pentoxifylline
PEPCID
PERFOROMIST
PERIOGARD
PERJETA
permethrin
perphenazine
perphenazine/amitriptyline hcl
PERTZYE
PEXEVA
PHENADOZ
phenelzine sulfate
PHENERGAN
phenobarbital
PHENYTEK
phenytoin
71
66
10
39
10
83
60
83
39
75
24
73
73
73
73
85
12
12
12
12
12
75
10
70
33
50
71
88
60
20
58
39
39
70
39
87
40
87
24
24
24
phenytoin sodium
25
phenytoin sodium extended
25
PHOSPHOLINE IODIDE
83
pilocarpine hcl
59,83
PIMTREA
80
pindolol
47
pioglitazone hcl
64
pioglitazone hcl/glimepiride
64
pioglitazone hcl/metformin hcl
65
piperacillin sodium/tazobactam sodium
12
PIRMELLA
81
piroxicam
33
PLASMA-LYTE 148
93
PLASMA-LYTE 56 IN DEXTROSE
93
PLASMA-LYTE A PH 7.4
93
PLAVIX
50
PNV 29-1
98
PNV OB+DHA
98
PNV-DHA
98
PNV-DHA + DOCUSATE
98
PNV-DHA PLUS
98
PNV-FIRST
98
PNV-IRON
98
PNV-OB WITH DHA
98
PNV-OMEGA
98
PNV-SELECT
98
PNV-TOTAL
98
PNV-VP-U
98
podofilox
54
POLY IRON PN
99
POLY IRON PN FORTE
99
polyethylene glycol 3350
70
polymyxin b sulfate
10
polymyxin b sulfate/trimethoprim
82
POMALYST
20
PORTIA
81
potassium chloride
91
potassium chloride in 0.45 % sodium
chloride
92
potassium chloride in 0.9 % sodium
chloride
91
125
potassium chloride in 5 % dextrose in water92
potassium chloride in dextrose 5 % and 0.9 %
sodium chloride
92
potassium chloride in dextrose 5 %-0.2 %
sodium chloride
92
potassium chloride in dextrose 5 %-0.45 %
sodium chloride
92
potassium chloride in dextrose 5% and 0.3 %
sodium chloride
92
potassium chloride in lactated ringers and 5
% dextrose
92
potassium citrate
59,90
POTIGA
25
PR NATAL 400
99
PR NATAL 400 EC
99
PR NATAL 430
99
PR NATAL 430 EC
99
PR NATAL 440 EC
99
PRADAXA
50
pramipexole di-hcl
26
PRANDIMET
65
PRANDIN
65
pravastatin sodium
51
prazosin hcl
47
PRECARE
99
PRECARE CONCEIVE
99
PRECARE PREMIER
99
PRED FORTE
85
PRED-G
84
prednicarbate
57
prednisolone
62
prednisolone sod phosphate
62,85
prednisone
62
PREDNISONE INTENSOL
62
PREFERA OB
99
PREFERA-OB
99
PREFERA-OB ONE
99
PREFERA-OB PLUS DHA
99
PREFOL-DHA
99
PREMARIN
78
PREMASOL
93
PREMESIS RX
99
PREMPHASE
78
PRENA1
99
PRENA1 CHEW
99
PRENA1 PEARL
99
PRENA1 PLUS
99
PRENACARE
99
PRENAFIRST
99
PRENAISSANCE
99
PRENAISSANCE 90 DHA
99
PRENAISSANCE BALANCE
99
PRENAISSANCE DHA
99
PRENAISSANCE DHA HARMONY
99
PRENAISSANCE HARMONY DHA
99
PRENAISSANCE NEXT
100
PRENAISSANCE NEXT-B
100
PRENAISSANCE PLUS
100
PRENAISSANCE PROMISE
100
PRENAPLUS
100
PRENATA
100
PRENATABS FA
100
PRENATABS RX
100
PRENATAL FORMULA
100
prenatal vitamin comb no.79/iron
fumarat/fa/lmefolate ca/dha
98
prenatal vitamin no.15/iron,carbonyl/folic
acid/docusate sod
100
prenatal vitamin no.19/iron polysacc & iron
hem/folic ac/dha
98
prenatal vitamins comb 10/ferrous
fumarate/folic acid/dha
100
prenatal vitamins comb no.115/iron
fumarate/folic acid
98
prenatal vitamins comb no.115/iron
fumarate/folic acid/dss
99
prenatal vitamins combo no.14/ferrous
fumarate/folic acid
98
prenatal vitamins combo no.60/ferrous
fumarate/folic acid
100
prenatal vits w-o ca comb. no. 7 w/ iron & folic
acid & dha
98
126
prenatal vits with calcium #72/ferrous
fumarate/folic acid
prenatal vits with calcium
#72/iron,carbonyl/folic acid
prenatal vits with calcium #74/ferrous
fumarate/folic acid
prenatal vits without calc no5/ferrous
fumarate/folic acid
PRENATE AM
PRENATE CHEWABLE
PRENATE DHA
PRENATE ELITE
PRENATE ENHANCE
PRENATE ESSENTIAL
PRENATE MINI
PRENATE PIXIE
PRENATE PLUS
PRENATE RESTORE
PRENATE STAR
PRENEXA
PRENEXA PREMIER
PREPLUS
PREQUE 10
PRETAB
PREVACID
PREVALITE
PREVIFEM
PREVITE RX
PREVPAC
PREZCOBIX
PREZISTA
PRIMACARE ADVANTAGE
PRIMACARE ONE
primaquine phosphate
PRIMAXIN
primidone
PRIMSOL
PRISTIQ ER
PROAIR HFA
probenecid
procainamide hcl
98
98
100
98
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
101
71
52
81
101
71
4
4
101
101
10
10
25
14
40
88
76
42
PROCALAMINE
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
PROCRIT
PROCTO-PAK
PROCTOSOL-HC
PROCTOZONE-HC
progesterone,micronized
PROGLYCEM
PROGRAF
PROLASTIN C
PROLEUKIN
PROMACTA
promethazine hcl
PROMETHEGAN
propafenone hcl
propantheline bromide
proparacaine hcl
propranolol hcl
propranolol hcl/hydrochlorothiazide
propylthiouracil
PROQUAD
PROSOL
PROTECT NATAL
PROTONIX IV
PROTOPIC
protriptyline hcl
PROVENTIL HFA
PROVIDA DHA
PROVIDA OB
PROVIGIL
PROZAC WEEKLY
PRUDOXIN
PRUET DHA
PRUET DHA EC
PULMICORT
PULMICORT FLEXHALER
PULMOZYME
PUREFE OB PLUS
PUREFE PLUS
93
70
70
70
73
57
70
57
78
65
20
59
73
50
87
87
42
68
83
47
47
62
75
93
101
71
54
40
88
101
101
40
40
54
101
101
88
88
88
101
101
127
PURIXAN
PYLERA
pyrazinamide
pyridostigmine bromide
20
71
10
29
Q
QUADRACEL DTAP-IPV
QUALAQUIN
QUASENSE
QUDEXY XR
quetiapine fumarate
quinapril hcl
quinapril hcl/hydrochlorothiazide
quinidine gluconate
quinidine sulfate
quinine sulfate
QVAR
91
10
81
25
40
47
47
42
42
10
88
R
R-NATAL OB
RABAVERT
rabeprazole sodium
raloxifene hcl
ramipril
RANEXA
ranitidine hcl
RAPAMUNE
RAVICTI
RE-NATA 29
RE-NATA 29 OB
REAPHIRM
REBETOL
REBIF
REBIF REBIDOSE
RECLIPSEN
RECOMBIVAX HB
RECTIV
RELENZA
RELISTOR
RELNATE DHA
REMICADE
101
75
71
76
48
52
71
20
28
101
101
101
5
73
73
81
75
70
5
70
101
70
REMODULIN
RENAGEL
RENATE
RENATE DHA
RENATE DHA EXTRA
RENVELA
repaglinide
REPREXAIN
RESCRIPTOR
reserpine
RESTASIS
RESTORIL
RETROVIR
REVATIO
REVLIMID
REYATAZ
RHEUMATREX
RIBAPAK
RIBASPHERE
RIBASPHERE RIBAPAK
RIBATAB
ribavirin
RIDAURA
rifabutin
RIFAMATE
rifampin
RIFATER
RILUTEK
riluzole
rimantadine hcl
ringers solution
ringers solution,lactated
RIOMET
risedronate sodium
RISPERDAL CONSTA
RISPERDAL M-TAB
risperidone
RITUXAN
rivastigmine tartrate
rizatriptan benzoate
ropinirole hcl
48
59
101
101
101
59
65
32
5
48
83
40
5
88
20
5
20
5
5
5
5
5
77
10
11
11
11
60
52
5
58,92
58,92
65
60,76
40
40
40
20
28
27
26
128
ROTARIX
ROTATEQ
ROVIN-A DHA
ROVIN-NV
ROVIN-NV DHA
ROZEREM
75
75
101
101
101
40
S
SABRIL
SAIZEN
SANDIMMUNE
SANTYL
SAPHRIS
SARAFEM
SE-CARE
SE-CARE CONCEIVE
SE-CARE GESTURE
SE-NATAL 19
SE-NATAL 90
SE-NATAL ONE
SE-PLETE DHA
SE-TAN DHA
SEASONIQUE
SELECT-OB
SELECT-OB + DHA
selegiline hcl
selenium sulfide
SELZENTRY
SENSIPAR
SEREVENT DISKUS
SEROQUEL
SEROQUEL XR
SEROSTIM
sertraline hcl
SETONET
SETONET-EC
SIGNIFOR
SIGNIFOR LAR
sildenafil citrate
silver sulfadiazine
SIMULECT
25
73,75
20
57
40
40
101
101
101
101
102
102
102
102
81
102
102
26
53
5
66
88
40
40
73
40
102
102
62
62
52,89
53
20
simvastatin
SINGULAIR
sirolimus
SIRTURO
SKELAXIN
sodium chloride
sodium chloride 0.45 %
sodium chloride 3 %
sodium chloride 5 %
sodium chloride irrigating solution
SODIUM DIURIL
sodium lactate
sodium phenylbutyrate
sodium polystyrene sulfonate
SOLARAZE
SOLTAMOX
SOLU-CORTEF
SOLU-MEDROL
SOMA
SOMATULINE DEPOT
SOMAVERT
SORIATANE
SORINE
sotalol hcl
SOVALDI
SPIRIVA
SPIRIVA RESPIMAT
spironolactone
spironolactone/hydrochlorothiazide
SPORANOX
SPRINTEC
SPRYCEL
SRONYX
SSD
SSD AF
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
52
89
20
11
29
92
92
92
92
60
48
92
90
60
54
20
62
62
29
20
66
53
42
42
5
89
89
48
48
2
81
20
81
53
53
26
26
26
27
27
27
129
stavudine
5
STIMATE
66
STIVARGA
20
STRATTERA
40
streptomycin sulfate
11
STRIBILD
5
STROMECTOL
11
SUBOXONE
34
SUCRAID
70
sucralfate
71
SULAR
48
sulfacetamide sodium
55,85
sulfacetamide sodium/prednisolone sodium
phosphate
84
sulfadiazine
13
sulfamethoxazole/trimethoprim
13
SULFAMYLON
55
sulfasalazine
70
SULFAZINE EC
70
sulindac
34
sumatriptan
27
sumatriptan succinate
27
SUPRAX
7
SURMONTIL
40
SUSTIVA
5
SUTENT
20
SYLATRON
73
SYLATRON 4-PACK
73
SYLVANT
21
SYMBYAX
40
SYMLINPEN 120
65
SYMLINPEN 60
65
SYNAGIS
5
SYNAREL
66
SYNERCID
11
SYNRIBO
21
SYNTHROID
67
SYPRINE
60
syringe with needle, insulin, safety, 0.3 ml 85
syringe with needle, insulin, safety, 0.5 ml 86
syringe with needle, insulin, safety, 1 ml
86
syringe with needle,disposable,insulin 1 ml 86
syringe with needle,insulin disposable,0.3
ml
86
syringe with needle,insulin disposable,0.5
ml
86
T
TABLOID
TACLONEX
TACLONEX SCALP
tacrolimus
TAFINLAR
TALWIN
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TANDEM DHA
TANDEM OB
TARCEVA
TARGRETIN
TARON A PRENATAL
TARON EC CALCIUM
TARON-BC
TARON-C DHA
TARON-DUO EC
TARON-EC CAL
TARON-PREX PRENATAL
TASIGNA
TASMAR
TAZORAC
TAZTIA XT
TEFLARO
TEGRETOL XR
TEKTURNA
TEKTURNA HCT
telmisartan
telmisartan/amlodipine besylate
telmisartan/hydrochlorothiazide
temazepam
TENIVAC
terazosin hcl
21
53
53
21,54
21
34
5
21
90
102
102
21
21
102
102
102
102
102
102
102
21
27
55
48
7
25
48
48
48
48
48
41
75
48
130
terbinafine hcl
3
terbutaline sulfate
89
terconazole
79
TESTIM
66
testosterone
66
testosterone cypionate
66
testosterone enanthate
66
TESTRED
66
tetanus and diphtheria toxoids, adult
75
tetanus,diphtheria toxoid ped/pf
75
tetracycline hcl
14
THALOMID
21
theophylline anhydrous
89
thioridazine hcl
41
thiothixene
41
THYMOGLOBULIN
75
tiagabine hcl
25
ticlopidine hcl
50
TIKOSYN
42
timolol maleate
48,82
tinidazole
11
TIVICAY
5
tizanidine hcl
29
TL FOLATE
102
TL-ASSURE + DHA
102
TL-ASSURE ONE
102
TL-CARE DHA
102
TL-SELECT
102
TL-SELECT DHA
102
TOBI
11
TOBRADEX
84
tobramycin
82
tobramycin in 0.225 % sodium chloride
11
tobramycin sulfate
11
tobramycin sulfate/sodium chloride
11
tobramycin/dexamethasone
84
TOBREX
82
TOFRANIL-PM
41
tolazamide
65
tolbutamide
65
tolcapone
27
tolmetin sodium
34
tolterodine tartrate
90
TOPAMAX
25
topiramate
25
topotecan hcl
21
TORISEL
21
torsemide
48
TOUJEO SOLOSTAR
65
TRACLEER
89
TRADJENTA
65
tramadol hcl
32,34
tramadol hcl/acetaminophen
34
trandolapril
48
trandolapril/verapamil hcl
48
tranexamic acid
50
TRANSDERM-SCOP
68
tranylcypromine sulfate
41
TRAVASOL
93
TRAVATAN Z
84
travoprost (benzalkonium)
84
trazodone hcl
41
TREANDA
21
TRECATOR
11
TRELSTAR
21
TRELSTAR DEPOT
21
TRELSTAR LA
21
tretinoin
21,55
tretinoin microspheres
55
TREXALL
21
TRI RX
102
TRI-LEGEST FE
81
TRI-PREVIFEM
81
TRI-SPRINTEC
81
TRI-TABS DHA
102
TRIADVANCE
102
triamcinolone acetonide
57,60,89
triamterene/hydrochlorothiazide
48
triazolam
41
TRICARE
103
TRICARE DHA
102
TRICARE PRENATAL COMPLEAT
102
131
TRICARE PRENATAL DHA ONE
TRIDERM
TRIFERA OB
trifluoperazine hcl
trifluridine
trihexyphenidyl hcl
TRILEPTAL
TRILYTE WITH FLAVOR PACKETS
TRIMESIS RX
trimethoprim
TRINATAL GT
TRINATAL RX 1
TRINATAL ULTRA
TRINATE
TRINESSA
TRISENOX
TRIUMEQ
TRIVEEN-DUO DHA
TRIVEEN-ONE
TRIVEEN-PRX RNF
TRIVEEN-TEN
TRIVEEN-U
TRIVORA-28
TRIZIVIR
TROKENDI XR
TROPHAMINE
trospium chloride
TRUST NATAL DHA
TRUVADA
TUDORZA PRESSAIR
TWINRIX
TYGACIL
TYKERB
TYPHIM VI
TYSABRI
TYZEKA
TYZINE
102
57
103
41
82
27
25
70
103
14
103
103
103
103
81
21
5
103
103
103
103
103
81
5
25
93
90
103
5
89
75
11
21
75
28
5
60
U
ULORIC
ULTIMATE OB DHA
76
103
ULTIMATECARE ADVANTAGE
ULTIMATECARE COMBO
ULTIMATECARE ONE
ULTIMATECARE ONE NF
ULTRESA
UROXATRAL
URSO
URSO FORTE
ursodiol
UVADEX
103
103
103
103
70
90
70
70
70
54
V
V-NATAL
V-NATAL DHA
valacyclovir hcl
VALCHLOR
VALCYTE
valganciclovir hcl
valproate sodium
valproic acid
valproic acid (as sodium salt) (valproate
sodium)
valsartan
valsartan/hydrochlorothiazide
VALTREX
VANCOCIN HCL
vancomycin hcl
VANDAZOLE
VAQTA
VARIVAX VACCINE
VARIZIG
VECTIBIX
VELCADE
VELIVET
VEMAVITE-PRX 2
VENA-BAL DHA
VENATAL COMPLETE DHA
VENATAL-FA
venlafaxine hcl
VENTOLIN HFA
verapamil hcl
103
103
5
54
5
6
25
25
25
48
49
6
14
14
79
75
75
91
21
21
81
103
103
103
103
41
89
49
132
VEREGEN
VERIPRED 20
VERSACLOZ
VESICARE
VESTURA
VEXOL
VFEND
VFEND IV
VIBRAMYCIN
VICTOZA 2-PAK
VICTOZA 3-PAK
VIDAZA
VIDEX
VIDEX EC
VIEKIRA PAK
VIGAMOX
VIIBRYD
VIMPAT
VINACAL
VINATE AZ
VINATE AZ EXTRA
VINATE C
VINATE CALCIUM
VINATE CARE
VINATE DHA
VINATE DHA RF
VINATE GT
VINATE IC
VINATE II
VINATE III
VINATE ONE
VINATE PN CARE
VINATE ULTRA
VINATE-M
vinblastine sulfate
VINCASAR PFS
vincristine sulfate
vinorelbine tartrate
VIOKACE
VIRACEPT
VIRAMUNE
54
62
41
90
81
85
3
3
14
65
65
21
6
6
6
82
41
25
103
103
103
103
103
104
104
104
104
104
104
104
104
104
104
104
21
21
22
22
70
6
6
VIRAMUNE XR
VIREAD
VIROPTIC
VIRT NATE
VIRT-ADVANCE
VIRT-BAL DHA
VIRT-BAL DHA PLUS
VIRT-C DHA
VIRT-CARE ONE
VIRT-PN
VIRT-PN DHA
VIRT-PN PLUS
VIRT-SELECT
VIRT-VITE GT
VIRTPREX
VISTIDE
VITAFOL NANO
VITAFOL ULTRA
VITAFOL-OB
VITAFOL-OB+DHA
VITAFOL-ONE
VITAFOL-PLUS
VITAFOL-PN
VITAMEDMD ONE RX
VITAMEDMD PLUS RX
VITAMEDMD REDICHEW RX
VITAPEARL
VITAPHIL
VITAPHIL + DHA
VITAPHIL + DHA 90
VITAPHIL AIDE
VITASPIRE
VITEKTA
VIVA CT
VIVA DHA
VIVELLE
VIVELLE-DOT
VIVITROL
VOL-NATE
VOL-PLUS
VOL-TAB RX
6
6
82
104
104
104
104
104
104
104
104
104
104
104
104
6
104
104
104
104
104
104
105
105
105
105
105
105
105
105
105
105
6
105
105
78
78
34
105
105
105
133
VOLTAREN
voriconazole
VOTRIENT
VP CH ULTRA
VP-CH PLUS
VP-CH-PNV
VP-ERA OB PLUS
VP-GGR-B6
VP-HEME OB
VP-HEME OB + DHA
VP-HEME ONE
VP-PNV-DHA
VYNATAL-FA
VYTORIN
VYVANSE
34
3
22
105
105
105
105
105
105
105
105
105
105
52
41
W
warfarin sodium
water for irrigation,sterile
WELCHOL
50
60
52
X
XALATAN
XALKORI
XENAZINE
XGEVA
XIFAXAN
XOLAIR
XOPENEX
XOPENEX CONCENTRATE
XOPENEX HFA
XTANDI
XULANE
XYREM
XYZAL
84
22
28
15
11
89
89
89
89
22
81
41
87
Y
YERVOY
YF-VAX
22
75
Z
zafirlukast
zaleplon
ZALTRAP
ZANAFLEX
ZANOSAR
ZATEAN-CH
ZATEAN-PN
ZATEAN-PN DHA
ZATEAN-PN PLUS
ZAVESCA
ZELAPAR
ZELBORAF
ZEMAIRA
ZEMPLAR
ZENCHENT
ZENPEP
ZERIT
ZETIA
ZIAGEN
zidovudine
ZINACEF
ZINECARD
ZINGIBER
ziprasidone hcl
ZIRGAN
ZMAX
zoledronic acid
ZOLINZA
zolmitriptan
zolpidem tartrate
ZOMACTON
ZOMETA
zonisamide
ZORBTIVE
ZORTRESS
ZOSTAVAX
ZOSYN
ZOVIA 1-35E
ZOVIA 1-50E
89
41
22
29
22
105
105
105
105
66
27
22
60
66,67
81
70
6
52
6
6
8
15
106
41
82
8
67
22
27
41
73
67
25
73
22
75
12
81
81
134
ZOVIRAX
ZYBAN
ZYDELIG
ZYFLO
ZYFLO CR
ZYKADIA
ZYLET
ZYPREXA
ZYPREXA RELPREVV
ZYPREXA ZYDIS
ZYTIGA
ZYVOX
56
60
22
89
89
22
84
41
41
42
22
11
This formulary was updated on February 1, 2016. For more recent information or other questions, please
contact AlohaCare Advantage Plus Member Services Department at 1-866-973-6395, or, for TTY/TDD users,
1-877-447-5990, 8 a.m. to 8 p.m., 7 days a week, or visit www.AlohaCare.org.
AlohaCare • 1357 Kapiolani Blvd, Suite 1250, Honolulu, HI 96814 • www.AlohaCare.org

2016 AlohaCare Advantage Plus Formulary (HMO SNP) (List of

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