listof covered drugs - Independence Care System

Transcription

LIST OF
COVERED DRUGS
Community Care Plus
FIDA-MMP 2016
1.877.ICS.2525
1.877.ICS.2525
www.icsny.org
www.icsny.org
H4465_ListofCoveredDrugs_2016_81415_Approved
H4465_ListofCoveredDrugs_2016_91415
ICS Community Care Plus FIDA-MMP | 2016 List of Covered
Drugs (Formulary)
This is a list of drugs that Participants can get in ICS Community Care Plus FIDA-MMP.
 ICS Community Care Plus FIDA-MMP is a managed care plan that contracts with both
Medicare and the New York State Department of Health (Medicaid) to provide benefits
of both programs to Participants through the Fully Integrated Duals Advantage (FIDA)
Demonstration.
 Benefits, List of Covered Drugs, and pharmacy and provider networks may change
from time to time throughout the year and on January 1 of each year.
 You can always check ICS Community Care Plus FIDA-MMP’s up-to-date List of
Covered Drugs online at www.icsny.org/care-plus/pharmacy-benefits/ or by calling
ICS Community Care Plus FIDA-MMP Participant Services at 1.877.ICS.2525.
 Limitations and restrictions may apply. For more information, call ICS Community
Care Plus FIDA-MMP Participant Services or read the ICS Community Care Plus
FIDA-MMP Participant Handbook.
 There are no copays for any covered drugs.
 You can get this information for free in other formats, such as Braille or large print.
Call 1.877.ICS.2525. The call is free.
 You can get this information for free in other languages. Call 1.877.ICS.2525 and TTY
711 during M-F 8 a.m.-8 p.m. The call is free. You can get this information for free in
other languages.
 Вы можете бесплатно получить всю эту информацию на других языках. Звоните
в ICS по телефону 1.877.ICS.2525 и телетайпу TTY 711 с понедельника по
пятницу с 8:00 до 20:00. Звонок бесплатный.
 您可免费获得所有这些信息的其他语言版本。请在周一至周五上午 8 点至晚上 8 点致
电 ICS，电话号码为 1.877.ICS.2525，听障专线 (TTY) 为 711。此为免费电话。
 Puede obtener toda esta información en otros idiomas de manera gratuita. Llame a
ICS al 1.877.ICS.2525 y a la línea TTY 711, entre las 8 a. m. y las 8 p. m., de lunes a
viernes. La llamada es gratuita.
If you have questions, please call ICS Community Care Plus FIDA-MMP at 1.877.ICS.2525,
TTY: 711, Monday through Friday 8 a.m. to 8 p.m. The call is free. For more information, visit
www.icsny.org/care-plus
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 Ou kapab jwenn tout enfòmasyon sa a gratis nan lòt lang. Rele ICS nan
1.877.ICS.2525 ak TTY 711, ant 8 a.m. ak 8 p.m., lendi jiska vandredi. Apèl la gratis.
 The State of New York has created a Participant Ombudsman Program to provide
Participants free, confidential assistance on any services offered by ICS Community
Care Plus FIDA-MMP. The Participant Ombudsman may be reached toll-free at
1.844.614.8800 or online at www.icannys.org.
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www.icsny.org/care-plus.
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Frequently Asked Questions (FAQ)
Find answers here to questions you have about this List of Covered Drugs. You can read
all of the FAQ to learn more, or look for a question and answer.
1.
What prescription drugs are on the List of Covered Drugs?
(We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the List of Covered Drugs that starts on page 15 are the drugs covered by
ICS Community Care Plus FIDA-MMP. These drugs are available at pharmacies within
our network. A pharmacy is in our network if we have an agreement with them to work
with us and provide you services. We refer to these pharmacies as “network pharmacies.”
 ICS Community Care Plus FIDA-MMP will cover all drugs on the Drug List if:
 your doctor or other network prescriber says you need them to get better or stay
healthy,
 the drug is medically necessary for your condition, and
 you fill the prescription at a ICS Community Care Plus FIDA-MMP network
pharmacy.
 ICS Community Care Plus FIDA-MMP may have additional steps to access certain
drugs (see question 5 below). In some cases, you may have to do something before
you can get a drug, like try other drugs first.
You can also see an up-to-date list of drugs that we cover on our website at
www.icsny.org/care-plus/pharmacy-benefits/ or call Participant Services at
1.877.ICS.2525.
2.
Does the Drug List ever change?
Yes. ICS Community Care Plus FIDA-MMP may add or remove drugs on the Drug List
during the year. Generally, the Drug List will only change if:
 a new drug comes along that works as well as a drug on the Drug List now, or
 we learn that a drug is not safe.
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We may also change our rules about drugs. For example, we could:
 decide to require or not require prior approval for a drug. (Prior approval is
permission from ICS Community Care Plus FIDA-MMP or your Interdisciplinary
Team (IDT) before you can get a drug.)
 add or change the amount of a drug you can get (called “quantity limits”).
 add or change step therapy restrictions on a drug. (Step therapy means you must
try one drug before we will cover another drug.)
(For more information on these drug rules, see page 5.)
We will tell you when a drug you are taking is removed from the Drug List. We will also
tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have
more information on what happens when the Drug List changes.
 You can always check ICS Community Care Plus FIDA-MMP’s up to date Drug
List online at www.icsny.org/care-plus/pharmacy-benefits/
 You can also call Participant Services to check the current Drug List at
1.877.ICS.2525.
3.
What happens when a cheaper drug comes along that works as
well as a drug on the Drug List now?
If a cheaper drug becomes available that works as well as a drug on the Drug List now:

Your pharmacist may give you the cheaper drug the next time you fill your
prescription. If you and your provider decide that the cheaper drug is not right for
you, your provider can tell the pharmacist to continue to give you the drug you
take now.
 ICS Community Care Plus FIDA-MMP may decide to take the more expensive
drug off of the Drug List. If you are taking a drug that we remove from the Drug
List because a cheaper drug that works just as well comes along, we will tell you
at least 60 days before we remove it from the Drug List or when you ask for a
refill. Then you can get a 60-day supply of the drug before the change to the Drug
List is made.
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
4.
ICS Community Care Plus FIDA-MMP will inform members of these changes by
mail, and will include information about how to file a grievance, appeal, or
exception request. ICS Community Care Plus FIDA-MMP will also post this
information on our website which can be found at www.icsny.org/care-plus and will
notify members annually of our up-to-date formulary. This information can be
provided in alternate formats.
What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will
take it off the Drug List right away. We will also send you a letter and call you to tell you
that the unsafe drug was taken off the Drug List You will be instructed to contact the
prescribing physician as soon as possible and get instructions for replacing the
discontinued drug. You can also reach out to your care manager for assistance.
5.
Are there any restrictions or limits on drug coverage? Or are there
any required actions to take in order to get certain drugs?
Yes, some drugs have coverage rules or have limits on the amount you can get. In some
cases you must do something before you can get the drug. For example:
 Prior approval (or prior authorization): For some drugs, you or your doctor or
other prescriber must get approval from ICS Community Care Plus FIDA-MMP or
your Interdisciplinary Team (IDT) before you fill your prescription. If you don’t get
approval, ICS Community Care Plus FIDA-MMP may not cover the drug.
 Quantity limits: Sometimes ICS Community Care Plus FIDA-MMP limits the
amount of a drug you can get.
 Step therapy: Sometimes ICS Community Care Plus FIDA-MMP requires you to do
step therapy. This means you will have to try drugs in a certain order for your
medical condition. You might have to try one drug before we will cover another drug.
If your doctor thinks the first drug doesn’t work for you, then we will cover the
second.
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You can find out if your drug has any additional requirements or limits by looking in the
tables beginning on page 15. You can also get more information by visiting our web site
at www.icsny.org/care-plus/pharmacy-benefits. We have posted online documents that
explain our prior authorization and step therapy restrictions. You may also ask us to send
you a copy.
You can ask for an “exception” from these limits. Please see question 11 for more
information on exceptions.
 If you are in a nursing facility or other long-term care facility and need a drug that is
not on the Drug List, or if you cannot easily get the drug you need, we can help. We
will cover a 31-day emergency supply of the drug you need (unless you have a
prescription for fewer days), whether or not you are a new ICS Community Care Plus
FIDA-MMP Participant. This will give you time to talk to your doctor or other
prescriber. He or she can help you decide if there is a similar drug on the Drug List
you can take instead or whether to request an exception. Please see question 11 for
more information about exceptions.
6.
How will you know if the drug you want has limitations or if there
are required actions to take to get the drug?
The List of Covered Drugs on page 15 has a column labeled “Necessary actions,
restrictions, or limits on use.”
7.
What happens if we change our rules on how we cover some
drugs? For example, if we add prior authorization (approval),
quantity limits, and/or step therapy restrictions on a drug.
We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on
a drug. We will tell you at least 60 days before the restriction is added or when you next
ask for a refill. Then, you can get a 60-day supply of the drug before the change to the
Drug List is made. This gives you time to talk to your doctor or other prescriber about
what to do next.
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8.
How can you find a drug on the Drug List?
There are two ways to find a drug:
 You can search alphabetically (if you know how to spell the drug), or
 You can search by medical condition.
To search alphabetically, go to the Alphabetical Listing section on page I-1. Then look
for the name of your drug in the list.
To search by medical condition, find the section labeled “List of drugs by medical
condition” on page 15. Then find your medical condition. For example, if you have a heart
condition, you should look in that category. That is where you will find drugs that treat
heart conditions.
9.
What if the drug you want to take is not on the Drug List?
If you don’t see your drug on the Drug List, call Participant Services at 1.877.ICS.2525
and ask about it. If you learn that ICS Community Care Plus FIDA-MMP will not cover the
drug, you can do one of these things:
 Ask Participant Services for a list of drugs like the one you want to take. Then show
the list to your doctor or other prescriber. He or she can prescribe a drug on the
Drug List that is like the one you want to take. Or
 You can ask the plan or your Interdisciplinary Team (IDT) to make an exception to
cover your drug. Please see question 11 for more information about exceptions.
10. What if you are a new ICS Community Care Plus FIDA-MMP
Participant and can’t find your drug on the Drug List or have a
problem getting your drug?
We can help. We must cover up to 90 days of temporary supplies of your drug, as
needed, during the first 90 days you are a Participant of ICS Community Care Plus FIDAMMP. This will give you time to talk to your doctor or other prescriber. He or she can help
you decide if there is a similar drug on the Drug List you can take instead or whether to
request an exception.
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We will cover up to 90 days of temporary supplies of your drug if:
 you are taking a drug that is not on our Drug List, or
 health plan rules do not let you get the amount ordered by your prescriber, or
 the drug requires prior approval by ICS Community Care Plus FIDA-MMP or your
Interdisciplinary Team (IDT), or
 you are taking a drug that is part of a step therapy restriction.
If you live in a nursing facility or other long-term care facility, you may refill your
prescription for as long as 98 days. You may refill the drug multiple times during 98 days.
This gives your prescriber time to change your drugs to ones on the Drug List or ask for
an exception.
If you are a current participant experiencing a level-of-care change from one treatment
setting to another, you may qualify for up to a 90-day supply of a drug not on the Drug
List to give your doctor or prescriber time to locate one on the list or file an exception. You
may qualify for a level-of-care transition supply if you:

enter a long-term care (LTC) facility from a hospital or other setting

leave an LTC facility and return to the community

discharge from a hospital to a home

end a skilled nursing facility stay covered under Medicare Part A (including
pharmacy charges), and revert to coverage under Part D

revert from hospice status to standard Medicare Part A and B benefits or

discharge from a psychiatric hospital with medication regimens that are highly
individualized.
11. Can you ask for an exception to cover your drug?
Yes. You can ask ICS Community Care Plus FIDA-MMP or your Interdisciplinary Team
(IDT) to make an exception to cover a drug that is not on the Drug List.
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You can also ask ICS Community Care Plus FIDA-MMP or your IDT to change the rules
on your drug.
 For example, ICS Community Care Plus FIDA-MMP may limit the amount of a drug
we will cover. If your drug has a limit, you can ask us or your IDT to change the limit
and cover more.
 Other examples: You can ask us or your IDT to drop step therapy restrictions or
prior approval requirements.
12. How long does it take to get an exception?
First, ICS Community Care Plus FIDA-MMP or your Interdisciplinary Team (IDT) must
receive a statement from your prescriber supporting your request for an exception. After
we receive the statement, you will get a decision on your exception request within 72
hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for
a decision, you can ask for an expedited exception. This is a faster decision. If your
prescriber supports your request, you will get a decision within 24 hours of receiving your
prescriber’s supporting statement.
13.
How can you ask for an exception?
To ask for an exception, call your Care Manager. Your Care Manager will work with you
and your provider to help you ask for an exception.
14. What are generic drugs?
Generic drugs are made up of the same ingredients as brand name drugs. They usually
cost less than the brand name drug and usually don’t have well-known names. Generic
drugs are approved by the Food and Drug Administration (FDA).
ICS Community Care Plus FIDA-MMP covers both brand name drugs and generic drugs.
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15. What are OTC drugs?
OTC stands for “over-the-counter”. ICS Community Care Plus FIDA-MMP covers some
OTC drugs when they are written as prescriptions by your provider.
You can read the ICS Community Care Plus FIDA-MMP Drug List to see what OTC drugs
are covered.
16. Does ICS Community Care Plus FIDA-MMP cover OTC non-drug
products?
ICS Community Care Plus FIDA-MMP covers some OTC non-drug products such as
gauze bandages, alcohol swabs/pads, insulin syringes and needles, etc., when they are
written as prescriptions by your provider.
You can read the ICS Community Care Plus FIDA-MMP Drug List to see what OTC nondrug products are covered.
17. What is your copay?
You will not be charged a copay for drugs on the Drug List.
18. What are drug tiers?
Tiers are groups of drugs. Every drug on the plan’s Drug List is in one of 4 tiers. There is
no cost to you for drugs on any of the tiers.
 Tier 1: Generic drugs covered by Medicare
 Tier 2: Brand name and specialty drugs covered by Medicare
 Tier 3: Non-Part D generic and brand name drugs covered by Medicaid
 Tier 4: Over-the-Counter (OTC) drugs covered by Medicaid
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List of Covered Drugs
The list of covered drugs on page 15 gives you information about the drugs covered by
ICS Community Care Plus FIDA-MMP. If you have trouble finding your drug in the list,
turn to the Index that begins on page I-1.
The first column of the chart lists the name of the drug. Brand name drugs are capitalized
(e.g., AVONEX) and generic drugs are listed in lower-case italics (e.g. amoxicillin).
The information in the necessary actions, restrictions, or limits on use column tells you if
ICS Community Care Plus FIDA-MMP has any rules for covering your drug.
Abbreviations and Symbols
The following Utilization Management abbreviations may be found within the body of this
document.
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION
DESCRIPTION
EXPLANATION
Utilization Management Restrictions
PA
PA BvD
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Prior Authorization
Restriction
You (or your physician) are required to
get prior authorization from ICS
Community Care Plus FIDA-MMP
before you fill your prescription for this
drug. Without prior approval, ICS
Community Care Plus FIDA-MMP may
not cover this drug.
Prior Authorization
Restriction
for
Part B vs Part D
Determination
This drug may be eligible for payment
under Medicare Part B or Part D. You
(or your physician) are required to get
prior authorization from ICS
Community Care Plus FIDA-MMP to
determine that this drug is covered
under Medicare Part D before you fill
your prescription for this drug. Without
prior approval, FIDA Care Complete
may not cover this drug.
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ABBREVIATION
PA NSO
QL
ST
DESCRIPTION
EXPLANATION
Prior Authorization
Restriction for
New Starts Only
If you are a new member, or you have
not taken this drug before, you (or your
physician) are required to get prior
authorization from ICS Community
Care Plus FIDA-MMP before you fill
your prescription for this drug. Without
prior approval, FIDA Care Complete
may not cover this drug.
Quantity Limit
Restriction
ICS Community Care Plus FIDA-MMP
limits the amount of this drug that is
covered per prescription, or within a
specific time frame.
Step Therapy
Restriction
Before ICS Community Care Plus
FIDA-MMP will provide coverage for
this drug, you must first try another
drug(s) to treat your medical condition.
This drug may only be covered if the
other drug(s) does not work for you.
The Following additional coverage abbreviations may not be found within the body of this
document
OTHER SPECIAL REQUIREMENTS FOR COVERAGE
LA
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Limited Access Drug
NM
Non-Mail Order Drug
*
Not a Part D Drug
This prescription may be available only
at certain pharmacies. For more
information consult your Pharmacy
Directory or call Member Services at
1.877.ICS.2525, 8 a.m. to 8 p.m.,
Monday through Friday. TTY/TDD
users should call 711.
You may be able to receive greater
than a 1-month supply of most of the
drugs on your formulary via mail order
at a reduced cost share. Drugs not
available via your mail order benefit are
noted with “NM” in the
Requirements/Limits column of your
formulary.
This drug is a non-Part D drug covered
by Medicaid.
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Note: The (*) next to a drug means the drug is not a “Part D drug.” These drugs have different
rules for appeals. An appeal is a formal way of asking for a review of and change to a coverage
decision if you think there was a mistake. For example, ICS Community Care Plus FIDA-MMP or
your Interdisciplinary Team (IDT) might decide that a drug that you want is not covered or is no
longer covered by Medicare or Medicaid. If you or your doctor or other prescriber disagrees with
the decision, you can appeal. To ask for instructions on how to appeal, call Participant Services at
1.877.ICS.2525 or the FIDA Participant Ombudsman at 1.877.ICS.2525. You can also read the
Participant Handbook to learn how to appeal a decision
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H4465_ListofCoveredDrugs_2016_91415
Here are the meanings of the codes used in the “Necessary actions, restrictions, or limits on
use” column:
(g) = Only the generic version of this drug is covered. The brand name version is not covered.
M = The brand name version of this drug is in Tier 3. The generic version is in Tier 1.
PA = Prior authorization (approval): you must have approval from the plan or your
Interdisciplinary Team (IDT) before you can get this drug.
ST = Step therapy: you must try another drug before you can get this one.
www.icsny.org/care-plus
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Tier level
What the
drug will
cost you
(Acetaminophen)
(Acetaminophen)
(Tylenol 8 Hour)
4
4
4
$0
$0
$0
(Acetaminophen)
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(Tencon)
1
$0
(Esgic)
1
$0
(Fiorinal)
1
$0
(Butorphanol
Tartrate)
1
$0
2
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Analgesics
Analgesics, Miscellaneous
acephen *
acetaminophen * oral
acetaminophen * oral
acetaminophen * rectal suppository
120 mg, 650 mg
acetaminophen-codeine oral
solution
acetaminophen-codeine oral tablet
300-15 mg, 300-30 mg
acetaminophen-codeine oral tablet
300-60 mg
buprenorphine hcl injection
(Acetaminophen
with Codeine)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
(Buprenorphine
HCl)
butalb-acetaminophen-caffeine oral
(Esgic)
capsule 50-325-40 mg
(Fioricet with
butalbital-acetaminop-caf-cod
Codeine)
butalbital-acetaminophen
butalbital-acetaminophen-caff oral
tablet 50-325-40 mg
butalbital-aspirin-caffeine oral
capsule
butorphanol tartrate nasal
BUTRANS
children's mapap *
children's non-aspirin * oral
children's non-aspirin * oral
children's pain & fever relief * oral
children's pain reliever * oral
children's pain reliever * oral
(Acetaminophen)
(Acetaminophen)
(Acetaminophen)
(Infants' Tylenol)
(Acetaminophen)
(Acetaminophen)
QL (2700 per 30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
QL (5 per 28 days)
QL (4 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to
the introduction pages of this document.
If you have questions, please call ICS Community Care Plus FIDA-MMP at
1.877.ICS.2525 TTY users, please call 711 from 8 a.m. to 8 p.m., Monday through
Friday. The call is free. For more information, visit www.icsny.org/care-plus.
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Tier level
What the
drug will
cost you
4
$0
1
$0
1
$0
2
$0
(Actiq)
1
$0
(Duragesic)
1
$0
(Duragesic)
1
$0
(Acetaminophen)
4
$0
(Hycet)
1
$0
Name of Drug
children's silapap *
codeine sulfate oral tablet
codeine-butalbital-asa-caffein oral
capsule 30-50-325-40 mg
DURAMORPH (PF)
fentanyl citrate
fentanyl transdermal patch 72 hour
100 mcg/hr
fentanyl transdermal patch 72 hour
12 mcg/hr, 25 mcg/hr, 37.5
mcg/hour, 50 mcg/hr, 62.5
mcg/hour, 75 mcg/hr, 87.5
mcg/hour
feverall * rectal suppository 120
mg, 325 mg, 650 mg
hydrocodone-acetaminophen oral
solution
tablet 10-300 mg, 5-300 mg, 7.5300 mg
tablet 10-325 mg, 2.5-325 mg, 5325 mg, 7.5-325 mg
hydrocodone-ibuprofen
hydromorphone (pf) injection
solution 10 mg/ml
hydromorphone (pf) injection
solution 4 mg/ml
hydromorphone injection solution
hydromorphone injection syringe 2
mg/ml
hydromorphone oral liquid
hydromorphone oral tablet 2 mg, 4
mg
(Tylenol Sore
Throat)
(Codeine Sulfate)
(Fiorinal with
Codeine #3)
(Norco)
1
$0
(Norco)
1
$0
(Ibudone)
(Hydromorphone
HCl/PF)
1
$0
1
$0
(Dilaudid)
1
$0
1
$0
1
$0
1
$0
1
$0
(Hydromorphone
HCl)
(Hydromorphone
HCl)
(Dilaudid)
(Dilaudid)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (180 per
30 days)
PA; QL (120 per 30
days)
PA; QL (20 per 30
days)
PA; QL (10 per 30
days)
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
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Name of Drug
hydromorphone oral tablet 8 mg
infant acetaminophen *
infantaire *
infant's pain reliever *
jr. acetaminophen *
junior mapap *
(Dilaudid)
(Acetaminophen)
(Acetaminophen)
(Acetaminophen)
(Acetaminophen)
(Acetaminophen)
LAZANDA
levorphanol tartrate
(Levorphanol
Tartrate)
(Acetaminophen)
(Acetaminophen)
(Tylenol Sore
Throat)
(Infants' Tylenol)
(Tylenol)
(Acetaminophen)
(Tylenol 8 Hour)
(Tylenol)
Tier level
What the
drug will
cost you
1
4
4
4
4
4
$0
$0
$0
$0
$0
$0
2
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (30 per 30
days)
mapap (acetaminophen) * oral
4
$0
4
$0
4
$0
liquid 500 mg/15 ml
4
$0
4
$0
4
$0
mapap arthritis pain *
4
$0
mapap extra strength *
4
$0
methadone hcl oral tablet,soluble
QL (90 per 30 days)
(Diskets)
1
$0
40 mg
methadone injection
(Methadone HCl)
1
$0
methadone oral
(Methadone HCl)
1
$0
methadone oral
(Diskets)
1
$0
morphine concentrate oral solution (Msir)
1
$0
morphine concentrate oral syringe (Morphine Sulfate)
1
$0
morphine injection solution 10
(Morphine Sulfate)
1
$0
mg/ml, 15 mg/ml, 8 mg/ml
morphine injection syringe
(Morphine Sulfate)
1
$0
morphine intramuscular
(Morphine Sulfate)
1
$0
morphine intravenous
(Morphine Sulfate)
1
$0
morphine intravenous solution 25
(Morphine Sulfate)
1
$0
mg/ml, 50 mg/ml
morphine intravenous
(Morphine Sulfate)
1
$0
morphine oral solution 10 mg/5 ml (Msir)
1
$0
morphine oral solution 20 mg/5 ml (Msir)
1
$0
MORPHINE ORAL TABLET
1
$0
17
17
Tier level
What the
drug will
cost you
(MS Contin)
1
$0
(MS Contin)
1
$0
(Morphine Sulfate)
(Acetaminophen)
(Tylenol Sore
Throat)
(Acetaminophen)
(Acetaminophen)
1
4
$0
$0
4
$0
4
4
2
2
$0
$0
$0
$0
(Oxycodone
HCl/Acetaminophe
n)
1
$0
(Xolox)
1
$0
(Xolox)
1
$0
(Percodan)
(Oxycodone HCl)
(Oxycodone HCl)
(Percolone)
1
1
1
1
$0
$0
$0
$0
(Xolox)
1
$0
(Xolox)
1
$0
(Xolox)
1
$0
(Percodan)
1
$0
2
$0
Name of Drug
morphine oral tablet extended
release 100 mg, 30 mg, 60 mg
morphine oral tablet extended
release 15 mg, 200 mg
morphine rectal
non-aspirin extra strength * oral
non-aspirin extra strength * oral
non-aspirin jr strength *
nortemp * oral
NUCYNTA
NUCYNTA ER
oxycodone hcl-acetaminophen oral
solution 5-325 mg/5 ml
tablet 10-325 mg, 2.5-325 mg, 5325 mg, 7.5-325 mg
tablet 5-500 mg
oxycodone hcl-aspirin
oxycodone oral concentrate
oxycodone oral solution
oxycodone oral tablet
oxycodone-acetaminophen oral
tablet 10-325 mg, 2.5-325 mg, 5325 mg, 7.5-325 mg
tablet 10-650 mg
tablet 7.5-500 mg
oxycodone-aspirin
OXYCONTIN ORAL
TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG,
15 MG, 20 MG, 30 MG, 40 MG, 60
MG
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (60 per 30 days)
18
18
Name of Drug
OXYCONTIN ORAL
TABLET,ORAL
ONLY,EXT.REL.12 HR 80 MG
oxymorphone oral tablet
oxymorphone oral tablet extended
release 12 hr 10 mg, 15 mg, 20 mg,
5 mg, 7.5 mg
oxymorphone oral tablet extended
release 12 hr 30 mg, 40 mg
Tier level
What the
drug will
cost you
2
$0
(Opana)
1
$0
(Opana ER)
1
$0
(Opana ER)
1
$0
4
$0
4
$0
(Tylenol 8 Hour)
4
$0
(Acetaminophen)
(Acetaminophen)
(Tylenol)
(Tylenol)
(Acetaminophen)
(Tylenol Sore
q-pap * oral liquid
Throat)
q-pap * oral tablet
(Tylenol)
silapap *
(Acetaminophen)
tactinal *
(Tylenol)
tactinal extra strength *
(Tylenol)
tramadol oral tablet
(Ultram)
tramadol-acetaminophen
(Ultracet)
xylon 10
(Ibudone)
Nonsteroidal Anti-Inflammatory Agents
advil * oral tablet
(Motrin Ib)
advil * oral tablet,chewable
(Ibuprofen)
aspirin * oral tablet
(Ecotrin)
(Bayer Chewable
aspirin * oral tablet,chewable
Aspirin)
aspirin * oral tablet,delayed release
(Ecotrin)
(dr/ec) 325 mg, 500 mg, 81 mg
aspirin * rectal
(Aspirin)
4
4
4
4
4
$0
$0
$0
$0
$0
4
$0
4
4
4
4
1
1
1
$0
$0
$0
$0
$0
$0
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
pain relief adult *
pain relief * oral capsule
pain relief * oral tablet extended
release
pain reliever jr strength *
pain reliever * oral
pharbetol *
q-pap extra strength *
q-pap * oral drops
Necessary Actions,
Restrictions, or
Limits on Use
(Tylenol Sore
Throat)
(Acetaminophen)
QL (60 per 30 days)
19
19
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
2
$0
1
$0
4
$0
1
$0
(Cataflam)
1
1
1
1
$0
$0
$0
$0
(Voltaren-XR)
1
$0
1
$0
1
1
1
4
1
$0
$0
$0
$0
$0
1
$0
2
1
$0
$0
4
$0
4
4
$0
$0
(Ibuprofen)
1
$0
(Motrin Ib)
4
$0
Name of Drug
aspirin, buffered *
aspir-low *
bufferin * oral tablet 325 mg
CALDOLOR INTRAVENOUS
RECON SOLN
celecoxib
children's advil *
choline,magnesium salicylate
COMFORT PAC-IBUPROFEN
COMFORT PAC-MELOXICAM
COMFORT PAC-NAPROXEN
diclofenac potassium
diclofenac sodium oral tablet
extended release 24 hr
diclofenac sodium oral
tablet,delayed release (dr/ec)
diclofenac sodium topical gel
diclofenac-misoprostol
diflunisal
e.c. prin *
etodolac
fenoprofen oral tablet
FLECTOR
flurbiprofen
ibuprofen * 100 mg/5 ml susp
children's (otc)
ibuprofen jr strength *
ibuprofen * oral
ibuprofen oral suspension 100 mg/5
ml
ibuprofen * oral tablet 100 mg, 200
mg
(Aspirin/Calcium
Carbonate/Mag)
(Ecotrin)
(Aspirin/Calcium
Carbonate/Mag)
(Celebrex)
(Children'S
Motrin)
(Choline Sal/Mag
Salicylate)
(Diclofenac
Sodium)
(Solaraze)
(Arthrotec 50)
(Diflunisal)
(Ecotrin)
(Etodolac)
(Fenoprofen
Calcium)
(Ansaid)
(Children'S
Motrin)
(Ibuprofen)
(Advil)
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
PA
20
20
Name of Drug
Tier level
What the
drug will
cost you
ibuprofen oral tablet 400 mg, 600
mg, 800 mg
(Ibuprofen)
1
$0
indomethacin oral capsule 25 mg
(Indomethacin)
1
$0
indomethacin oral capsule 50 mg
(Indomethacin)
1
$0
(Indomethacin)
1
$0
(Indocin I.V.)
(Infants' Motrin)
(Ketoprofen)
1
4
3
1
$0
$0
$0
$0
(Ketoprofen)
1
$0
(Toradol)
1
$0
(Toradol)
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
(Ec-Naprosyn)
1
$0
(Anaprox)
1
$0
(Feldene)
(Salsalate)
1
1
$0
$0
indomethacin oral capsule,
extended release
indomethacin sodium
infant's ibuprofen *
INFANT'S MOTRIN *
ketoprofen oral capsule
ketoprofen oral capsule,ext rel.
pellets 24 hr 200 mg
ketorolac injection cartridge 15
mg/ml
ketorolac injection cartridge 30
mg/ml
ketorolac injection solution 15
mg/ml
ketorolac injection solution 30
mg/ml (1 ml)
ketorolac intramuscular solution
ketorolac oral
mefenamic acid
meloxicam
nabumetone
naproxen oral suspension
naproxen oral tablet
naproxen oral tablet,delayed
release (dr/ec)
naproxen sodium oral tablet 275
mg, 550 mg
piroxicam
salsalate
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
(Ponstel)
(Mobic)
(Nabumetone)
(Naprosyn)
(Naprosyn)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (60 per
30 days)
PA-HRM
QL (40 per 30 days)
QL (20 per 30 days)
QL (40 per 30 days)
QL (20 per 30 days)
QL (20 per 30 days)
QL (20 per 30 days)
21
21
Tier level
What the
drug will
cost you
4
$0
4
1
1
$0
$0
$0
4
$0
(Advil)
2
4
$0
$0
glydo
(Lidocaine HCl)
1
$0
lidocaine (pf) injection solution
(Xylocaine-MPF)
1
$0
lidocaine hcl injection solution
(Xylocaine)
1
$0
lidocaine hcl laryngotracheal
lidocaine hcl mucous membrane gel
lidocaine hcl mucous membrane
jelly in applicator
lidocaine hcl mucous membrane
solution
lidocaine hcl urethral
lidocaine topical adhesive
patch,medicated
(Xylocaine)
(Lidocaine HCl)
1
1
$0
$0
(Lidocaine HCl)
1
$0
(Xylocaine)
1
$0
(Lidocaine HCl)
1
$0
(Lidoderm)
1
$0
lidocaine topical ointment
(Lidocaine)
1
$0
lidocaine-prilocaine topical
(EMLA)
1
$0
lidocaine-prilocaine topical kit
(Lidocaine/Prilocai
ne)
1
$0
2
$0
Anti-Addiction/Substance Abuse Treatment Agents
acamprosate
(Campral)
1
$0
Name of Drug
st joseph aspirin *
st. joseph aspirin *
sulindac oral
tolmetin
tri-buffered aspirin *
VOLTAREN TOPICAL
wal-profen * oral
(Bayer Chewable
Aspirin)
(Ecotrin)
(Sulindac)
(Tolmetin Sodium)
(Aspirin/Calcium
Carbonate/Mag)
Necessary Actions,
Restrictions, or
Limits on Use
Anesthetics
Local Anesthetics
LIDODERM
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA BvD
PA
Anti-Addiction/Substance Abuse Treatment Agents
PA; QL (90 per 30
days)
22
22
buprenorphine hcl sublingual
(Subutex)
1
$0
Name of Drug
buprenorphine-naloxone
bupropion hcl sr 150 mg tablet f/c
CHANTIX
CHANTIX CONTINUING
MONTH BOX
CHANTIX CONTINUING
MONTH PAK
CHANTIX STARTING MONTH
BOX
disulfiram
naloxone
naltrexone hcl
naltrexone
NICODERM CQ *
TRANSDERMAL PATCH 24
HOUR 14 MG/24 HR, 21 MG/24
HR
NICODERM CQ *
TRANSDERMAL PATCH 24
HOUR 7 MG/24 HR
nicorelief * buccal gum
nicorette * buccal gum 2 mg
nicotine (polacrilex) *
nicotine * transdermal patch 24
hour 14 mg/24 hr, 7 mg/24 hr
nicotine * transdermal patch 24
hour 21 mg/24 hr, 22 mg/24 hr
NICOTROL
ZUBSOLV SUBLINGUAL
TABLET 1.4-0.36 MG, 5.7-1.4 MG
ZUBSOLV SUBLINGUAL
TABLET 8.6-2.1 MG
Tier level
(Buprenorphine
HCl/Naloxone
HCl)
(Zyban)
(Antabuse)
(Naloxone HCl)
(Revia)
(Revia)
What the
drug will
cost you
1
$0
1
2
$0
$0
2
$0
2
$0
2
$0
1
1
1
1
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (90 per 30
days)
QL (56 per 28 days)
QL (56 per 28 days)
QL (53 per 28 days)
4
$0
4
$0
(Nicorette)
(Nicorette)
(Nicorette)
4
4
4
$0
$0
$0
(Nicoderm Cq)
4
$0
(Nicoderm Cq)
4
$0
2
$0
2
$0
2
$0
1
$0
PA; QL (90 per 30
days)
PA; QL (60 per 30
days)
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet
(Xanax)
QL (90 per 30 days)
23
23
Tier level
What the
drug will
cost you
(Xanax XR)
1
$0
(Xanax XR)
1
$0
(Alprazolam)
1
$0
(Chlordiazepoxide
HCl)
1
$0
(Klonopin)
1
$0
(Klonopin)
1
$0
(Clonazepam)
1
$0
(Clonazepam)
1
$0
(Tranxene T-Tab)
1
$0
(Tranxene T-Tab)
1
$0
2
$0
1
1
1
1
1
$0
$0
$0
$0
$0
Name of Drug
alprazolam oral tablet extended
release 24 hr 0.5 mg
alprazolam oral tablet extended
release 24 hr 1 mg, 2 mg, 3 mg
alprazolam oral
tablet,disintegrating
chlordiazepoxide hcl
clonazepam oral tablet 0.5 mg, 1
mg
clonazepam oral tablet 2 mg
clonazepam oral
tablet,disintegrating 0.125 mg, 0.25
mg, 0.5 mg, 1 mg
clonazepam oral
tablet,disintegrating 2 mg
clorazepate dipotassium oral tablet
15 mg
clorazepate dipotassium oral tablet
3.75 mg, 7.5 mg
DIASTAT ACUDIAL RECTAL
KIT 12.5-15-17.5-20 MG
diazepam injection
diazepam intensol
diazepam oral solution
diazepam oral tablet
diazepam rectal
estazolam oral tablet 1 mg
(Diazepam)
(Diazepam)
(Diazepam)
(Valium)
(Diastat Acudial)
(Estazolam)
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (90 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (10 per 28 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (60
per 30 days)
24
24
Name of Drug
Tier level
What the
drug will
cost you
estazolam oral tablet 2 mg
(Estazolam)
1
$0
flurazepam oral capsule 15 mg
(Flurazepam HCl)
1
$0
flurazepam oral capsule 30 mg
(Flurazepam HCl)
1
$0
lorazepam injection solution
lorazepam injection syringe
lorazepam oral tablet
(Ativan)
(Ativan)
(Ativan)
(Midazolam
HCl/PF)
(Midazolam
HCl/PF)
(Midazolam HCl)
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
midazolam (pf) injection
midazolam (pf) injection syringe 2
mg/2 ml (1 mg/ml)
midazolam oral syrup 2 mg/ml
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
QL (2 per 30 days)
QL (2 per 30 days)
QL (90 per 30 days)
QL (2 per 30 days)
QL (2 per 30 days)
QL (10 per 30 days)
25
25
Tier level
What the
drug will
cost you
ONFI ORAL SUSPENSION
2
$0
ONFI ORAL TABLET 10 MG, 20
MG
2
$0
Name of Drug
temazepam oral capsule 15 mg,
22.5 mg, 30 mg
(Restoril)
1
$0
temazepam oral capsule 7.5 mg
(Restoril)
1
$0
triazolam oral tablet 0.125 mg
(Halcion)
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (480 per
30 days)
PA NSO; QL (60 per
30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
hypnotic drug); QL
(120 per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
hypnotic drug); QL
(120 per 30 days)
26
26
Name of Drug
triazolam oral tablet 0.25 mg
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
1
$0
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
2
$0
PA BvD
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Tier level
(Halcion)
Antibacterials
Aminoglycosides
BETHKIS
gentamicin in nacl (iso-osm)
intravenous piggyback
gentamicin injection solution
gentamicin sulfate (ped) (pf)
gentamicin sulfate (pf) intravenous
solution
neomycin
streptomycin intramuscular
(Gentamicin In
Nacl, Iso-Osm)
(Garamycin)
(Gentamicin
Sulfate/PF)
(Gentamicin
Sulfate/PF)
(Neomycin Sulfate)
(Streptomycin
Sulfate)
TOBI PODHALER INHALATION
tobramycin in 0.225 % nacl
(Tobi)
(Tobramycin/Sodiu
tobramycin in 0.9 % nacl
m Chloride)
tobramycin sulfate injection
(Nebcin)
solution
Antibacterials, Miscellaneous
bacitracin intramuscular
(Bacitracin)
(Chloramphenicol
chloramphenicol sod succinate
Sod Succ)
clindamycin hcl
(Cleocin HCl)
(Cleocin Phosphate
clindamycin in 5 % dextrose
In D5w)
clindamycin palmitate hcl
(Cleocin Palmitate)
PA BvD
27
27
Name of Drug
clindamycin phosphate injection
clindamycin phosphate intravenous
solution
colistin (colistimethate na)
CUBICIN
linezolid intravenous
methenamine hippurate
methenamine mandelate oral tablet
1 gram
(Cleocin
Phosphate)
(Cleocin
Phosphate)
(Coly-Mycin M
Parenteral)
(Zyvox)
(Hiprex)
(Methenamine
Mandelate)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
2
1
1
$0
$0
$0
1
$0
nitrofurantoin macrocrystal oral
capsule
(Macrodantin)
1
$0
nitrofurantoin monohyd/m-cryst
(Macrobid)
1
$0
2
1
$0
$0
1
$0
1
$0
1
$0
1
$0
2
$0
SYNERCID
trimethoprim
vancomycin in d5w intravenous
piggyback
vancomycin intravenous recon soln
1,000 mg, 10 gram, 750 mg
vancomycin intravenous recon soln
500 mg
vancomycin oral capsule
XIFAXAN ORAL TABLET 200
MG
(Trimethoprim)
(Vancomycin
HCl/D5W)
(Vancomycin HCl)
(Vancomycin
HCl/D5W)
(Vancocin HCl)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
with over 90 days
cumulative use of
nitrofurantoin drugs);
PA-HRM; (High Risk
with over 90 days
cumulative use of
nitrofurantoin drugs);
PA; QL (9 per 30 days)
28
28
Tier level
What the
drug will
cost you
2
$0
2
$0
(Cefaclor)
1
$0
(Cefaclor)
1
$0
(Cefadroxil)
1
$0
(Cefadroxil)
1
$0
(Cefadroxil)
1
$0
(Cefazolin Sodium)
1
$0
1
$0
1
$0
(Cefazolin Sodium)
1
$0
(Cefazolin Sodium)
(Cefdinir)
(Spectracef)
(Maxipime)
1
1
1
1
2
$0
$0
$0
$0
$0
2
$0
1
1
$0
$0
1
$0
1
$0
Name of Drug
XIFAXAN ORAL TABLET 550
MG
ZYVOX ORAL
Cephalosporins
cefaclor oral capsule
cefaclor oral suspension for
reconstitution 125 mg/5 ml, 250
mg/5 ml, 375 mg/5 ml
cefadroxil oral capsule
cefadroxil oral suspension for
reconstitution 250 mg/5 ml, 500
mg/5 ml
cefadroxil oral tablet
cefazolin in dextrose (iso-os)
intravenous piggyback 1 gram/50
ml
cefazolin in dextrose (iso-os)
ml
cefazolin injection recon soln
cefazolin injection recon soln 100
gram, 300 g
cefazolin intravenous
cefdinir
cefditoren pivoxil
cefepime
CEFEPIME IN DEXTROSE 5 %
CEFEPIME IN DEXTROSE,ISOOSM INTRAVENOUS
PIGGYBACK
cefotaxime
cefoxitin
cefoxitin in dextrose, iso-osm
ml
cefpodoxime
(Cefazolin
Sodium/Dextrose,
Iso)
(Ancef)
(Claforan)
(Mefoxin)
(Cefoxitin
Sodium/Dextrose,
Iso)
(Cefpodoxime
Proxetil)
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (60 per 30
days)
29
29
Tier level
What the
drug will
cost you
(Cefprozil)
1
$0
(Ceftazidime)
1
$0
(Cedax)
1
$0
(Ceftriaxone
Na/Dextrose, Iso)
1
$0
1
$0
1
$0
1
$0
1
$0
(Ceftin)
1
$0
(Zinacef)
1
$0
(Zinacef)
(Cefuroxime
Sodium/Dextrose,
Iso)
(Keflex)
1
$0
1
$0
1
$0
(Cephalexin)
1
$0
(Cephalexin)
1
$0
2
$0
2
$0
2
$0
2
$0
(Zithromax)
1
$0
(Biaxin)
1
$0
Name of Drug
cefprozil
ceftazidime intravenous recon soln
1 gram, 2 gram
ceftibuten
ceftriaxone in dextrose,iso-os
ml
CEFTRIAXONE IN
DEXTROSE,ISO-OS
INTRAVENOUS PIGGYBACK 2
GRAM/50 ML
ceftriaxone injection recon soln
ceftriaxone intravenous recon soln
1 gram
CEFTRIAXONE INTRAVENOUS
RECON SOLN 2 GRAM
cefuroxime axetil oral tablet
cefuroxime sodium injection recon
soln 1.5 gram, 750 mg
cefuroxime sodium intravenous
cefuroxime-dextrose (iso-osm)
cephalexin oral capsule
cephalexin oral suspension for
reconstitution
cephalexin oral tablet
MEFOXIN IN DEXTROSE (ISOOSM)
SUPRAX ORAL TABLET
SUPRAX ORAL
TABLET,CHEWABLE
TEFLARO
Macrolides
azithromycin
clarithromycin oral suspension for
reconstitution
(Rocephin)
(Ceftriaxone
Na/Dextrose, Iso)
Necessary Actions,
Restrictions, or
Limits on Use
30
30
Tier level
What the
drug will
cost you
(Biaxin)
1
$0
(Biaxin XL)
1
$0
2
2
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
2
1
2
1
$0
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
clarithromycin oral tablet
clarithromycin oral tablet extended
release 24 hr
DIFICID
ERYTHROCIN
erythromycin base oral
tablet,delayed release (dr/ec) 250
mg, 500 mg
ERYTHROMYCIN BASE ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
erythromycin ethylsuccinate oral
suspension for reconstitution
erythromycin ethylsuccinate oral
tablet
erythromycin oral capsule,delayed
release(dr/ec)
(Erythromycin
Base)
(Eryped 200)
(Erythromycin
Ethylsuccinate)
(Erythromycin
Base)
(Erythromycin
erythromycin oral tablet
Base)
erythromycin stearate oral tablet
(Erythromycin
250 mg
Stearate)
Miscellaneous B-Lactam Antibiotics
aztreonam
(Azactam)
CAYSTON
imipenem-cilastatin
(Primaxin)
INVANZ
meropenem
(Merrem)
Penicillins
amoxicillin oral capsule
(Amoxicillin)
amoxicillin oral suspension for
(Amoxil)
reconstitution
amoxicillin oral tablet
(Amoxicillin)
amoxicillin oral tablet,chewable
(Amoxicillin)
125 mg, 250 mg
amoxicillin-pot clavulanate oral
(Augmentin)
Necessary Actions,
Restrictions, or
Limits on Use
QL (20 per 10 days)
LA
31
31
Tier level
What the
drug will
cost you
(Augmentin)
1
$0
(Augmentin XR)
1
$0
1
$0
1
$0
(Totacillin-N)
1
$0
(Totacillin-N)
1
$0
(Unasyn)
1
$0
(Unasyn)
1
2
2
$0
$0
$0
1
$0
2
$0
1
1
$0
$0
1
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
tablet
tablet extended release 12 hr
tablet,chewable
ampicillin
ampicillin sodium injection recon
soln
ampicillin sodium intravenous
recon soln
ampicillin-sulbactam injection
recon soln
ampicillin-sulbactam intravenous
BICILLIN C-R
BICILLIN L-A
dicloxacillin
nafcillin in dextrose iso-osm
nafcillin injection
nafcillin intravenous recon soln
oxacillin in dextrose(iso-osm)
oxacillin injection recon soln
oxacillin intravenous recon soln
penicillin g pot in dextrose
penicillin g potassium injection
recon soln
penicillin g procaine
penicillin v potassium
(Amoxicillin/Potas
sium Clav)
(Ampicillin
Trihydrate)
(Dicloxacillin
Sodium)
(Nafcillin In
Dextrose,Iso-Osm)
(Unipen)
(Nallpen)
(Oxacillin
Sodium/Dextrose,
Iso)
(Oxacillin Sodium)
(Oxacillin Sodium)
(Pen G
Pot/DextroseWater)
(Penicillin G
Potassium)
(Penicillin G
Procaine)
(Penicillin V
Potassium)
Necessary Actions,
Restrictions, or
Limits on Use
32
32
Tier level
What the
drug will
cost you
(Zosyn)
1
$0
(Cipro)
(Cipro)
(Cipro I.V.)
1
1
1
$0
$0
$0
(Cipro I.V.)
1
$0
(Levaquin)
1
$0
(Levofloxacin)
(Levaquin)
(Avelox)
(Ofloxacin)
1
1
1
1
$0
$0
$0
$0
(Sulfadiazine)
(Sulfamethoxazole/
Trimethoprim)
(Sulfamethoxazole/
Trimethoprim)
1
$0
1
$0
1
$0
(Bactrim)
1
$0
(Azulfidine)
(Sulfamethoxazole/
Trimethoprim)
(Azulfidine)
(Azulfidine)
1
$0
1
$0
1
1
$0
$0
(Morgidox)
1
$0
(Doryx)
(Doxycycline
Hyclate)
1
$0
1
$0
1
$0
1
$0
Name of Drug
piperacillin-tazobactam intravenous
recon soln
Quinolones
ciprofloxacin
ciprofloxacin hcl oral
ciprofloxacin in 5 % dextrose
ciprofloxacin lactate intravenous
solution 400 mg/40 ml
levofloxacin in d5w intravenous
piggyback
levofloxacin intravenous
levofloxacin oral
moxifloxacin
ofloxacin oral
Sulfonamides
sulfadiazine oral
sulfamethoxazole-trimethoprim
intravenous
sulfamethoxazole-trimethoprim oral
suspension
sulfamethoxazole-trimethoprim oral
tablet
sulfasalazine
sulfatrim
sulfazine
sulfazine ec
Tetracyclines
doxycycline hyclate oral capsule
100 mg
doxycycline hyclate 100 mg tab f/c
doxycycline hyclate intravenous
doxycycline hyclate oral capsule
(Adoxa)
100 mg
doxycycline hyclate oral capsule 50
(Morgidox)
mg
Necessary Actions,
Restrictions, or
Limits on Use
33
33
Tier level
What the
drug will
cost you
(Adoxa)
1
$0
(Doryx)
1
$0
(Adoxa)
1
$0
(Vibramycin)
1
$0
(Adoxa)
1
$0
(Minocin)
(Minocycline HCl)
(Ala-Tet)
1
1
1
2
$0
$0
$0
$0
Anticancer Agents
ABRAXANE
2
$0
ADCETRIS
2
$0
AFINITOR DISPERZ
2
$0
2
$0
2
$0
2
$0
1
2
2
2
1
2
1
$0
$0
$0
$0
$0
$0
$0
1
$0
Name of Drug
doxycycline hyclate oral tablet 100
mg
doxycycline hyclate oral tablet 20
mg
doxycycline monohydrate oral
capsule
tablet
minocycline oral capsule
minocycline oral tablet
tetracycline
TYGACIL
Necessary Actions,
Restrictions, or
Limits on Use
Anticancer Agents
AFINITOR ORAL TABLET 10
MG
AFINITOR ORAL TABLET 2.5
MG, 5 MG, 7.5 MG
ALIMTA INTRAVENOUS
RECON SOLN
anastrozole
ARRANON
ARZERRA
AVASTIN
azacitidine
BELEODAQ
bicalutamide
bleomycin
(Arimidex)
(Vidaza)
(Casodex)
(Bleomycin
Sulfate)
PA NSO; QL (4 per 21
days)
PA NSO; QL (112 per
28 days)
PA NSO; QL (56 per
28 days)
PA NSO; QL (28 per
28 days)
PA NSO
PA NSO
PA NSO
PA BvD
34
34
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
1
1
$0
$0
2
$0
1
$0
2
$0
1
$0
(Cytarabine)
(Cytarabine/PF)
(Cytarabine/PF)
(Dtic-Dome IV)
(Dactinomycin)
(Dacogen)
2
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
(Doxorubicin HCl)
1
$0
(Doxil)
1
$0
(Doxil)
1
2
$0
$0
2
$0
2
$0
Name of Drug
BLINCYTO
BOSULIF ORAL TABLET 100
MG
BOSULIF ORAL TABLET 500
MG
CAPRELSA ORAL TABLET 100
MG
CAPRELSA ORAL TABLET 300
MG
carboplatin intravenous solution
cisplatin
(Carboplatin)
(Cisplatin)
COMETRIQ
cyclophosphamide intravenous
recon soln
CYCLOPHOSPHAMIDE ORAL
CAPSULE
cyclophosphamide oral tablet
CYRAMZA
cytarabine
cytarabine (pf) injection recon soln
cytarabine (pf) injection solution
dacarbazine intravenous recon soln
dactinomycin
decitabine
doxorubicin hcl intravenous recon
soln 10 mg
doxorubicin hcl peg-liposomal
intravenous suspension 2 mg/ml
doxorubicin, peg-liposomal
DROXIA
ELIGARD SUBCUTANEOUS
SYRINGE 22.5 MG
SYRINGE 30 MG
(Cyclophosphamid
e)
(Cyclophosphamid
e)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (140 per
365 days)
PA NSO; QL (120 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (112 per
28 days)
PA BvD
PA BvD; ST
PA BvD; ST
PA NSO
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
QL (1 per 84 days)
QL (1 per 112 days)
35
35
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
1
$0
2
$0
ERIVEDGE
2
$0
ETOPOPHOS
etoposide intravenous
exemestane
FARESTON
2
1
1
2
$0
$0
$0
$0
FARYDAK
2
$0
FASLODEX
FIRMAGON KIT W DILUENT
SYRINGE
floxuridine
fludarabine
fluorouracil intravenous solution
2.5 gram/50 ml, 5 gram/100 ml, 500
mg/10 ml
flutamide
2
$0
2
$0
(FUDR)
(Fludara)
1
1
$0
$0
(Fluorouracil)
1
$0
(Flutamide)
1
$0
GAZYVA
2
$0
gemcitabine intravenous recon soln
(Gemzar)
1 gram
1
$0
GILOTRIF
2
$0
2
$0
2
$0
Name of Drug
SYRINGE 45 MG
SYRINGE 7.5 MG
EMCYT
epirubicin intravenous solution 50
mg/25 ml
ERBITUX INTRAVENOUS
SOLUTION
GLEEVEC ORAL TABLET 100
MG
GLEEVEC ORAL TABLET 400
MG
(Ellence)
(Etoposide)
(Aromasin)
Necessary Actions,
Restrictions, or
Limits on Use
QL (1 per 168 days)
QL (1 per 28 days)
PA NSO
PA NSO; QL (30 per
30 days)
days)
PA BvD
PA BvD
PA NSO; QL (40 per
28 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (90 per
30 days)
PA NSO; QL (60 per
30 days)
36
36
Tier level
What the
drug will
cost you
HALAVEN
2
$0
HERCEPTIN
HEXALEN
hydroxyurea
2
2
1
$0
$0
$0
IBRANCE
2
$0
ICLUSIG ORAL TABLET 15 MG
2
$0
ICLUSIG ORAL TABLET 45 MG
2
$0
1
1
$0
$0
1
$0
IMBRUVICA
2
$0
INLYTA ORAL TABLET 1 MG
2
$0
INLYTA ORAL TABLET 5 MG
2
$0
ISTODAX
IXEMPRA
2
2
$0
$0
JAKAFI
2
$0
JEVTANA
KADCYLA INTRAVENOUS
RECON SOLN
KEYTRUDA INTRAVENOUS
RECON SOLN
2
$0
2
$0
2
$0
KYPROLIS
2
$0
LENVIMA
letrozole
LEUKERAN
(Femara)
2
1
2
$0
$0
$0
leuprolide
(Leuprolide
Acetate)
1
$0
Name of Drug
ifosfamide intravenous recon soln
ifosfamide intravenous solution
ifosfamide-mesna
(Hydrea)
(Ifex)
(Ifex)
(Ifosfamide/Mesna
)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (24 per
28 days)
PA NSO
PA NSO; QL (21 per
28 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA NSO; QL (120 per
30 days)
PA NSO; QL (180 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO
PA NSO; QL (60 per
30 days)
PA NSO
PA NSO
days)
PA NSO
37
37
Tier level
What the
drug will
cost you
1
2
2
2
2
2
$0
$0
$0
$0
$0
$0
2
$0
LYNPARZA
2
$0
LYSODREN
2
$0
MARQIBO
2
$0
MATULANE
MEGACE ES
megestrol oral suspension
2
2
1
$0
$0
$0
1
$0
MEKINIST ORAL TABLET 0.5
MG
2
$0
MEKINIST ORAL TABLET 2 MG
2
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
Name of Drug
lomustine
LUPRON DEPOT
LUPRON DEPOT (3 MONTH)
LUPRON DEPOT-PED
LUPRON DEPOT-PED (3
MONTH) INTRAMUSCULAR
SYRINGE KIT
megestrol oral tablet
melphalan hcl intravenous
mercaptopurine
methotrexate sodium (pf) injection
recon soln
methotrexate sodium (pf) injection
solution
methotrexate sodium injection
methotrexate sodium oral
mitomycin intravenous recon soln
mitoxantrone
MUSTARGEN
(Gleostine)
(Megace)
(Megestrol
Acetate)
(Alkeran)
(Purinethol)
(Methotrexate
Sodium/PF)
(Methotrexate
Sodium)
(Methotrexate
Sodium)
(Methotrexate
Sodium)
(Mitomycin)
(Mitoxantrone
HCl)
Necessary Actions,
Restrictions, or
Limits on Use
QL (1 per 28 days)
QL (1 per 84 days)
QL (1 per 84 days)
QL (1 per 168 days)
QL (1 per 28 days)
QL (1 per 84 days)
PA NSO; QL (480 per
30 days)
days)
PA NSO; QL (90 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA BvD; ST
PA BvD
38
38
Tier level
What the
drug will
cost you
NEXAVAR
2
$0
NILANDRON
ONCASPAR
OPDIVO INTRAVENOUS
SOLUTION 40 MG/4 ML
oxaliplatin intravenous solution 100
(Eloxatin)
mg/20 ml
paclitaxel
(Paclitaxel)
PERJETA
2
2
$0
$0
2
$0
1
$0
1
2
$0
$0
POMALYST
2
$0
PROLEUKIN
PURIXAN
2
2
$0
$0
REVLIMID
2
$0
RITUXAN
SOLTAMOX
SPRYCEL ORAL TABLET 100
MG, 140 MG, 50 MG, 70 MG, 80
MG
2
2
$0
$0
2
$0
SPRYCEL ORAL TABLET 20 MG
2
$0
STIVARGA
2
$0
SUTENT
2
$0
SYLVANT
2
$0
SYNRIBO
2
$0
TABLOID
2
$0
TAFINLAR
2
$0
1
$0
2
$0
Name of Drug
tamoxifen
TARCEVA ORAL TABLET 100
MG, 25 MG
(Tamoxifen
Citrate)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (120 per
30 days)
PA NSO
PA NSO
PA NSO
PA NSO; QL (21 per
28 days)
PA NSO; LA; QL (21
per 28 days)
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (84 per
28 days)
PA NSO; QL (30 per
30 days)
PA NSO
PA NSO; QL (28 per
28 days)
PA NSO; QL (120 per
30 days)
PA NSO; QL (60 per
30 days)
39
39
Tier level
What the
drug will
cost you
TARCEVA ORAL TABLET 150
MG
2
$0
TARGRETIN ORAL
2
$0
TARGRETIN TOPICAL
2
$0
TASIGNA
2
$0
TEMODAR INTRAVENOUS
toposar intravenous
topotecan intravenous
2
1
1
$0
$0
$0
2
$0
2
$0
2
$0
Name of Drug
(Etoposide)
(Hycamtin)
TORISEL
TREANDA INTRAVENOUS
RECON SOLN
TREANDA INTRAVENOUS
SOLUTION
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION
SYRINGE 11.25 MG/2 ML
tretinoin (chemotherapy)
TREXALL
TYKERB
VALSTAR
VECTIBIX INTRAVENOUS
SOLUTION
VELCADE
vinblastine intravenous
vincristine
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (90 per
30 days)
PA NSO; QL (420 per
30 days)
PA NSO; QL (60 per
28 days)
PA NSO; QL (112 per
28 days)
PA NSO; (vial only)
PA BvD; QL (4 per 28
days)
QL (1 per 168 days)
(Tretinoin)
(Vinblastine
Sulfate)
(Vincristine
Sulfate)
2
$0
2
$0
2
$0
2
$0
1
2
2
2
$0
$0
$0
$0
2
$0
2
$0
1
$0
1
$0
QL (1 per 84 days)
QL (1 per 168 days)
QL (1 per 28 days)
(capsule: 10mg)
PA BvD; ST
PA NSO
PA NSO
PA BvD
PA BvD
40
40
Tier level
What the
drug will
cost you
1
$0
1
$0
VOTRIENT
2
$0
XALKORI
2
$0
XTANDI
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
ZYDELIG
2
$0
ZYKADIA
2
$0
ZYTIGA
2
$0
1
$0
1
$0
1
$0
2
$0
Name of Drug
vincristine sulfate intravenous
solution 1 mg/ml
vinorelbine intravenous solution
(Vincristine
Sulfate)
(Navelbine)
YERVOY INTRAVENOUS
SOLUTION
ZALTRAP INTRAVENOUS
SOLUTION
ZELBORAF
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG
ZOLADEX SUBCUTANEOUS
IMPLANT 3.6 MG
ZOLINZA
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA NSO; QL (120 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (120 per
30 days)
PA NSO
PA NSO
PA NSO; QL (240 per
30 days)
QL (1 per 84 days)
QL (1 per 28 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (140 per
28 days)
PA NSO; QL (120 per
30 days)
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine injection solution 0.4
(Atropine Sulfate)
mg/ml
atropine injection syringe 0.05
(Atropine Sulfate)
mg/ml, 0.1 mg/ml
(Propantheline
propantheline
Bromide)
Anticonvulsants
Anticonvulsants
APTIOM
ST
41
41
Tier level
What the
drug will
cost you
2
$0
(Carbatrol)
1
$0
(Tegretol)
1
$0
(Tegretol XR)
1
$0
(Carbamazepine)
1
$0
2
$0
2
$0
(Depakote
Sprinkle)
1
$0
(Depakote ER)
1
$0
(Depakote)
1
$0
(Zarontin)
(Felbatol)
(Cerebyx)
(Neurontin)
(Neurontin)
1
1
1
2
1
1
$0
$0
$0
$0
$0
$0
(Neurontin)
1
$0
2
$0
2
$0
(Lamictal)
1
$0
(Lamictal XR)
1
$0
(Lamictal)
1
$0
(Lamictal (Blue))
1
$0
(Keppra)
1
$0
Name of Drug
BANZEL
carbamazepine oral capsule, er
multiphase 12 hr
carbamazepine oral suspension
carbamazepine oral tablet extended
release 12 hr
carbamazepine oral tablet,chewable
CELONTIN ORAL CAPSULE 300
MG
DILANTIN
divalproex oral capsule, sprinkle
divalproex oral tablet extended
release 24 hr
divalproex oral tablet,delayed
release (dr/ec)
ethosuximide
felbamate
fosphenytoin
FYCOMPA
gabapentin oral capsule
gabapentin oral solution
gabapentin oral tablet 600 mg, 800
mg
GABITRIL ORAL TABLET 12
MG, 16 MG
LAMICTAL ORAL TABLET,
CHEWABLE DISPERSIBLE 2
MG
lamotrigine oral tablet
lamotrigine oral tablet extended
release 24hr
lamotrigine oral tablet, chewable
dispersible
lamotrigine oral tablets,dose pack
25 mg (35)
levetiracetam intravenous
Necessary Actions,
Restrictions, or
Limits on Use
ST
ST
42
42
Tier level
What the
drug will
cost you
(Keppra)
(Keppra)
1
1
$0
$0
(Keppra XR)
1
$0
(Phenobarbital)
2
2
1
2
2
1
$0
$0
$0
$0
$0
$0
(Phenobarbital)
1
$0
(Phenobarbital)
(Phenobarbital
Sodium)
1
$0
1
$0
(Dilantin-125)
1
$0
(Dilantin)
(Phenytoin
Sodium)
(Dilantin)
1
$0
1
$0
1
$0
2
$0
2
$0
(Gabitril)
(Topamax)
1
2
2
1
1
$0
$0
$0
$0
$0
(Qudexy XR)
1
$0
(Topamax)
1
$0
2
$0
2
$0
Name of Drug
levetiracetam oral solution
levetiracetam oral tablet
levetiracetam oral tablet extended
release 24 hr
LYRICA ORAL CAPSULE
LYRICA ORAL SOLUTION
oxcarbazepine
OXTELLAR XR
PEGANONE
phenobarbital oral elixir
phenobarbital oral tablet 100 mg,
15 mg, 16.2 mg, 32.4 mg, 60 mg,
64.8 mg, 97.2 mg
phenobarbital oral tablet 30 mg
phenobarbital sodium injection
solution
phenytoin oral suspension 125 mg/5
ml
phenytoin oral
phenytoin sodium
phenytoin sodium extended
POTIGA ORAL TABLET 200 MG,
300 MG, 400 MG
(Trileptal)
POTIGA ORAL TABLET 50 MG
primidone
QUDEXY XR
SABRIL
tiagabine
topiramate oral capsule, sprinkle
topiramate oral capsule,sprinkle,er
24hr
topiramate oral tablet
TRILEPTAL ORAL
SUSPENSION
TROKENDI XR
(Mysoline)
Necessary Actions,
Restrictions, or
Limits on Use
QL (90 per 30 days)
ST
QL (90 per 30 days)
QL (2 per 30 days)
ST; QL (90 per 30
days)
ST; QL (270 per 30
days)
ST
ST
43
43
Tier level
What the
drug will
cost you
(Depacon)
(Depakene)
1
1
$0
$0
(Depakene)
1
$0
VIMPAT INTRAVENOUS
2
$0
VIMPAT ORAL SOLUTION
2
$0
VIMPAT ORAL TABLET
2
$0
(Zonegran)
1
$0
(Aricept)
(Aricept Odt)
1
1
$0
$0
1
$0
(Razadyne ER)
1
$0
(Razadyne)
(Razadyne)
1
1
2
2
2
$0
$0
$0
$0
$0
2
$0
2
$0
1
$0
1
$0
Name of Drug
valproate sodium
valproic acid
valproic acid (as sodium salt) oral
solution 250 mg/5 ml
zonisamide
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (200 per 5
days)
ST; QL (1200 per 30
days)
ST; QL (60 per 30
days)
Antidementia Agents
Antidementia Agents
donepezil oral tablet
donepezil oral tablet,disintegrating
EXELON TRANSDERMAL
PATCH 24 HOUR 4.6 MG/24 HR,
9.5 MG/24 HR
galantamine oral capsule,ext rel.
pellets 24 hr
galantamine oral solution
galantamine oral tablet
NAMENDA ORAL SOLUTION
NAMENDA ORAL TABLET
NAMENDA TITRATION PAK
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE
PACK
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR
rivastigmine tartrate
(Exelon)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (49 per 28 days)
QL (28 per 28 days)
QL (30 per 30 days)
QL (60 per 30 days)
Antidepressants
Antidepressants
amitriptyline
(Amitriptyline
HCl)
(Amoxapine)
PA NSO-HRM
amoxapine
1
$0
BRINTELLIX
2
$0
ST
44
44
Tier level
What the
drug will
cost you
(Wellbutrin)
1
$0
(Wellbutrin SR)
1
$0
(Wellbutrin XL)
1
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Irenka)
1
$0
(Irenka)
1
$0
(Irenka)
2
$0
(Prozac)
2
1
2
1
$0
$0
$0
$0
(Prozac Weekly)
1
$0
(Fluoxetine HCl)
(Fluoxetine HCl)
1
1
$0
$0
1
$0
1
$0
1
$0
1
1
2
$0
$0
$0
2
$0
1
$0
Name of Drug
bupropion hcl oral tablet
bupropion hcl oral tablet extended
release , 150 mg
bupropion hcl oral tablet extended
release 24 hr
citalopram oral solution
citalopram oral tablet
clomipramine
desipramine oral
doxepin oral
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
release(dr/ec) 30 mg
release(dr/ec) 40 mg
EMSAM
escitalopram oxalate
FETZIMA
fluoxetine oral capsule
fluoxetine oral capsule,delayed
release(dr/ec)
fluoxetine oral solution
fluoxetine oral tablet 10 mg, 20 mg
FLUOXETINE ORAL TABLET 60
MG
fluvoxamine oral capsule,extended
release 24hr
fluvoxamine oral tablet
imipramine hcl
imipramine pamoate
IRENKA
(Citalopram
Hydrobromide)
(Celexa)
(Anafranil)
(Norpramin)
(Doxepin HCl)
(Lexapro)
(Luvox CR)
(Fluvoxamine
Maleate)
(Tofranil)
(Tofranil-Pm)
KHEDEZLA
maprotiline
(Maprotiline HCl)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
PA NSO-HRM
PA NSO-HRM
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
ST
PA NSO-HRM
PA NSO-HRM
QL (30 per 30 days)
ST; QL (30 per 30
days)
45
45
Tier level
What the
drug will
cost you
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Nortriptyline HCl)
(Symbyax)
(Paxil)
2
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
(Paxil CR)
1
$0
2
$0
1
$0
1
$0
2
$0
ST; QL (30 per 30
days)
$0
$0
$0
$0
$0
$0
QL (30 per 30 days)
PA NSO-HRM
(Parnate)
(Trazodone HCl)
1
1
2
2
1
1
(Effexor XR)
1
$0
(Venlafaxine HCl)
1
$0
(Venlafaxine HCl)
1
$0
2
$0
1
2
$0
$0
2
$0
Name of Drug
MARPLAN
mirtazapine
nefazodone
nortriptyline oral capsule
nortriptyline oral solution
olanzapine-fluoxetine
paroxetine hcl oral tablet
paroxetine hcl oral tablet extended
release 24 hr
PAXIL ORAL SUSPENSION
perphenazine-amitriptyline
phenelzine
(Perphenazine/Ami
triptyline HCl)
(Nardil)
PRISTIQ
protriptyline
sertraline
SILENOR
SURMONTIL
tranylcypromine
trazodone
venlafaxine oral capsule,extended
release 24hr
venlafaxine oral tablet
venlafaxine oral tablet extended
release 24hr 150 mg, 37.5 mg, 75
mg
VIIBRYD
(Vivactil)
(Zoloft)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO-HRM
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
acarbose
(Precose)
BYDUREON
BYETTA SUBCUTANEOUS PEN
INJECTOR 10 MCG/DOSE(250
MCG/ML) 2.4 ML
QL (90 per 30 days)
QL (4 per 28 days)
QL (2.4 per 28 days)
46
46
Name of Drug
Tier level
BYETTA SUBCUTANEOUS PEN
INJECTOR 5 MCG/DOSE (250
MCG/ML) 1.2 ML
CYCLOSET
GLYXAMBI
INVOKAMET ORAL TABLET
150-1,000 MG, 150-500 MG, 501,000 MG
INVOKAMET ORAL TABLET
50-500 MG
INVOKANA ORAL TABLET 100
MG
INVOKANA ORAL TABLET 300
MG
JANUMET
JANUMET XR ORAL TABLET,
ER MULTIPHASE 24 HR 1001,000 MG, 50-500 MG
JANUMET XR ORAL TABLET,
ER MULTIPHASE 24 HR 501,000 MG
JANUVIA
What the
drug will
cost you
2
$0
2
2
$0
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
JARDIANCE
2
$0
JENTADUETO
2
$0
KORLYM
2
$0
(Glucophage)
(Glucophage)
(Glucophage)
1
1
1
$0
$0
$0
(Glucophage XR)
1
$0
(Glucophage XR)
1
$0
(Fortamet)
1
$0
(Starlix)
1
$0
metformin oral tablet 1,000 mg
metformin oral tablet 500 mg
metformin oral tablet 850 mg
metformin oral tablet extended
release 24 hr 500 mg
release 24 hr 750 mg
release 24hr
nateglinide
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
ST; QL (60 per 30
days)
ST; QL (120 per 30
days)
ST; QL (60 per 30
days)
ST; QL (30 per 30
days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
ST; QL (30 per 30
days)
QL (60 per 30 days)
PA; QL (112 per 28
days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
47
47
Name of Drug
pioglitazone
pioglitazone-glimepiride
pioglitazone-metformin
PRANDIMET
repaglinide
SYMLINPEN 120
(Actos)
(Duetact)
(Actoplus Met)
(Prandin)
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
1
1
1
2
1
$0
$0
$0
$0
$0
2
$0
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
PA; QL (10.8 per 28
days)
QL (30 per 30 days)
QL (4 per 28 days)
SYMLINPEN 60
2
$0
TRADJENTA
2
$0
TRULICITY
2
$0
VICTOZA
2
$0
Insulins
HUMALOG KWIKPEN
QL (30 per 28 days)
SUBCUTANEOUS INSULIN PEN
2
$0
100 UNIT/ML
HUMALOG MIX 50-50
2
$0
QL (40 per 28 days)
HUMALOG MIX 50-50
QL (30 per 28 days)
2
$0
KWIKPEN
HUMALOG MIX 75-25
2
$0
QL (40 per 28 days)
HUMALOG MIX 75-25
QL (30 per 28 days)
2
$0
KWIKPEN
HUMALOG SUBCUTANEOUS
2
$0
QL (40 per 28 days)
HUMULIN 70/30
2
$0
QL (40 per 28 days)
HUMULIN 70/30 KWIKPEN
2
$0
QL (30 per 28 days)
HUMULIN N
2
$0
QL (40 per 28 days)
HUMULIN N KWIKPEN
2
$0
QL (30 per 28 days)
HUMULIN R
2
$0
QL (40 per 28 days)
HUMULIN R U-500
QL (40 per 28 days)
2
$0
"CONCENTRATED"
LANTUS
2
$0
QL (40 per 28 days)
LANTUS SOLOSTAR
2
$0
QL (30 per 28 days)
NOVOLIN 70/30
2
$0
QL (40 per 28 days)
NOVOLIN N
2
$0
QL (40 per 28 days)
NOVOLIN R
2
$0
QL (40 per 28 days)
NOVOLOG
2
$0
QL (40 per 28 days)
NOVOLOG FLEXPEN
2
$0
QL (30 per 28 days)
NOVOLOG MIX 70-30
2
$0
QL (40 per 28 days)
48
48
Tier level
What the
drug will
cost you
2
2
$0
$0
QL (30 per 28 days)
(Amaryl)
(Amaryl)
(Glucotrol)
(Glucotrol)
1
1
1
1
$0
$0
$0
$0
(Glucotrol XL)
1
$0
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
(Glucotrol XL)
1
$0
1
$0
1
$0
(Glynase)
1
$0
(Glynase)
1
$0
(Glynase)
1
$0
glyburide oral tablet 1.25 mg
(Glyburide)
1
$0
glyburide oral tablet 2.5 mg
(Glyburide)
1
$0
glyburide oral tablet 5 mg
(Glyburide)
1
$0
(Glucovance)
1
$0
(Glucovance)
1
$0
(Tolazamide)
(Tolazamide)
(Tolbutamide)
1
1
1
$0
$0
$0
Name of Drug
NOVOLOG MIX 70-30 FLEXPEN
TOUJEO SOLOSTAR
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg
glimepiride oral tablet 4 mg
glipizide oral tablet 10 mg
glipizide oral tablet 5 mg
glipizide oral tablet extended
release 24hr 10 mg
glipizide oral tablet extended
release 24hr 2.5 mg, 5 mg
glipizide-metformin oral tablet 2.5250 mg
glipizide-metformin oral tablet 2.5500 mg, 5-500 mg
glyburide micronized oral tablet 1.5
mg
glyburide micronized oral tablet 3
mg
glyburide micronized oral tablet 6
mg
glyburide-metformin oral tablet
1.25-250 mg
glyburide-metformin oral tablet 2.5500 mg, 5-500 mg
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide
(Glipizide/Metform
in HCl)
(Glipizide/Metform
in HCl)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (60 per 30 days)
PA-HRM; QL (400 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (280 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
QL (60 per 30 days)
Antifungals
Antifungals
49
49
Tier level
What the
drug will
cost you
4
$0
2
4
$0
$0
4
$0
2
1
4
4
4
4
2
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
(Gyne-Lotrimin)
1
4
4
4
1
1
1
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Lotrisone)
1
$0
Name of Drug
3 day vaginal *
ABELCET
af *
aloe vesta * topical ointment 2 %
AMBISOME
amphotericin b
antifungal (tolnaftate) * topical
antifungal (tolnaftate) * topical
antifungal * topical solution
baza antifungal *
CANCIDAS
ciclopirox topical cream
ciclopirox topical gel
ciclopirox topical shampoo
ciclopirox topical solution
ciclopirox topical suspension
ciclopirox-ure-camph-menth-euc
clotrimazole * 1% cream (otc)
clotrimazole * 1% solution (otc)
clotrimazole 3 day *
clotrimazole mucous membrane
clotrimazole topical cream 1 %
clotrimazole topical solution 1 %
clotrimazole * vaginal cream
clotrimazole * vaginal tablet
clotrimazole-3 *
clotrimazole-betamethasone topical
cream
clotrimazole-betamethasone topical
lotion
(Miconazole
Nitrate)
(Tinactin)
(Miconazole
Nitrate)
(Amphotericin B)
(Tolnaftate)
(Tolnaftate)
(Undecylenic Acid)
(Nuzole)
(Ciclodan)
(Loprox)
(Loprox)
(Penlac)
(Ciclopirox
Olamine)
(Ciclodan)
(Lotrimin AF)
(Clotrimazole)
(Gyne-Lotrimin)
(Clotrimazole)
(Clotrimazole)
(Lotrimin)
(Gyne-Lotrimin)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
(Clotrimazole/Beta
1
$0
methasone Dip)
(Miconazole
critic-aid clear af *
4
$0
Nitrate)
(Miconazole
dermafungal *
4
$0
Nitrate)
50
50
Name of Drug
desenex (clotrimazole) *
econazole topical
elon dual defense *
fluconazole
fluconazole in dextrose(iso-o)
fluconazole in nacl (iso-osm)
flucytosine
fungi cure *
FUNGI-NAIL * TOPICAL
fungoid-d *
griseofulvin microsize oral tablet
inzo antifungal *
itraconazole
ketoconazole oral
ketoconazole topical cream
ketoconazole topical shampoo
LAMISIL (AEROSOL) *
lamisil af * topical aerosol powder
lamisil af * topical powder
LAMISIL AT * TOPICAL
LOTRIMIN ULTRA *
micatin *
miconazole 7 * vaginal suppository
miconazole nitrate * topical cream
miconazole nitrate * vaginal
miconazole nitrate * vaginal
(Lotrimin AF)
(Econazole Nitrate)
(Undecylenic Acid)
(Diflucan)
(Fluconazole In
Nacl,Iso-Osm)
(Fluconazole In
Nacl,Iso-Osm)
(Ancobon)
(Clotrimazole)
(Tinactin)
(Grifulvin V)
(Nuzole)
(Sporanox)
(Ketoconazole)
(Ketoconazole)
(Nizoral)
(Tinactin)
(Tolnaftate)
(Nuzole)
(Miconazole
Nitrate)
(Nuzole)
(Miconazole
Nitrate)
(Miconazole
Nitrate)
miconazole nitrate * vaginal kit 200
(Monistat 3)
mg- 2 % (9 gram)
miconazole nitrate vaginal
(Monistat 3)
suppository 200 mg
Tier level
What the
drug will
cost you
4
1
4
1
$0
$0
$0
$0
1
$0
1
$0
1
4
4
4
1
4
1
1
1
1
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
51
51
Name of Drug
MONISTAT 3 * VAGINAL
COMB PACK,PREFILL APPL &
CREAM
MONISTAT 3 * VAGINAL KIT
monistat 7 * vaginal
myco nail a *
NOXAFIL ORAL
nystatin
NYSTATIN (BULK) POWDER 1
BILLION UNIT
nystatin oral
nystatin oral
nystatin topical
nystatin-triamcinolone
podactin *
terbinafine hcl oral
terbinafine hcl * topical
tolnaftate * topical
tolnaftate * topical
triple paste af *
voriconazole intravenous
voriconazole oral
(Miconazole
Nitrate)
(Undecylenic Acid)
(Nystatin)
(Nystatin)
(Nystatin)
(Nystatin)
(Nystatin/Triamcin
)
(Tolnaftate)
(Lamisil)
(Desenex)
(Tinactin)
(Tolnaftate)
(Miconazole
Nitrate)
(Vfend IV)
(Vfend)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
2
1
$0
$0
$0
1
$0
1
1
1
$0
$0
$0
1
$0
4
1
4
4
4
$0
$0
$0
$0
$0
4
$0
1
1
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
Antihistamines
Antihistamines
(Claritin-D 12
4
$0
Hour)
(Chlorpheniramine
aller-chlor * oral syrup
4
$0
Maleate)
aller-chlor * oral tablet
(Chlor-Trimeton)
4
$0
(Claritin-D 12
allerclear d-12hr *
4
$0
Hour)
(Claritin-D 24
allerclear d-24hr *
4
$0
Hour)
allergy (chlorpheniramine) *
(Chlor-Trimeton)
4
$0
52
52
alavert d-12 allergy-sinus *
Name of Drug
allergy relief (cetirizine) * oral
allergy relief (loratadine) * oral
allerhist-1 *
aller-tec d *
ambi 60pse-4cpm *
aprodine *
banophen allergy *
banophen * oral capsule 25 mg
banophen * oral
benadryl allergy * oral tablet
(Zyrtec)
(Claritin)
(Tavist-1)
(Zyrtec-D)
(Pseudoephed/Chlo
rpheniramine)
(Pseudoephedrine/
Triprolidine)
(Zzzquil)
(Benadryl)
(Diphenhydramine
HCl)
(Diphenhydramine
HCl)
(Cetirizine HCl)
(Zyrtec)
(Zyrtec)
(Zyrtec-D)
(Dimetapp)
(Dimetapp)
(Cetirizine HCl)
cetirizine * oral solution
cetirizine * oral tablet
cetirizine * oral tablet,chewable
cetirizine-pseudoephedrine *
child triaminic cold & allergy *
child wal-tap cold-allergy *
children's aller-tec *
children's cetirizine * oral
(Zyrtec)
tablet,chewable 5 mg
CHILDREN'S CLARITIN * ORAL
children's wal-dryl allergy * oral
(Zzzquil)
children's wal-zyr * oral
(Zyrtec)
CHILDREN'S ZYRTEC
ALLERGY *
CLARITIN *
CLARITIN LIQUI-GEL *
CLARITIN REDITABS *
CLARITIN-D 12 HOUR *
CLARITIN-D 24 HOUR *
(Clemastine
clemastine oral syrup
Fumarate)
clemastine * oral tablet 1.34 mg
(Tavist-1)
Tier level
What the
drug will
cost you
4
4
4
4
$0
$0
$0
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
4
4
4
4
$0
$0
$0
$0
$0
1
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
53
53
Name of Drug
(Clemastine
Fumarate)
(Triaminic Cold
cold & cough * oral liquid
and Cough)
(Diphenhydramine
compoz *
HCl)
(Cyproheptadine
cyproheptadine
HCl)
dailyhist-1 *
(Tavist-1)
dayhist allergy *
(Tavist-1)
dimaphen (pe) *
(Dimetapp)
(Triaminic Cold
dimetapp cold-congestion *
and Cough)
diphenhist * oral capsule
(Benadryl)
diphenhist * oral
(Zzzquil)
(Diphenhydramine
diphenhist * oral tablet 25 mg
HCl)
diphenhydramine hcl injection
(Diphenhydramine
solution 50 mg/ml
HCl)
diphenhydramine hcl injection
(Diphenhydramine
syringe
HCl)
diphenhydramine hcl * oral capsule (Benadryl)
diphenhydramine hcl * oral tablet
(Diphenhydramine
50 mg
HCl)
(Chlorpheniramine
ed chlorped jr *
Maleate)
levocetirizine
(Xyzal)
loradamed *
(Claritin)
loratadine * oral
(Claritin)
loratadine * oral
(Claritin)
loratadine-d * oral tablet extended (Claritin-D 12
release 12 hr
Hour)
loratadine-d * oral tablet extended (Claritin-D 24
release 24 hr
Hour)
phenylephrine-chlorpheniramine * (Phenylephrine/Chl
oral tablet 4-10 mg
orpheniramine)
clemastine oral tablet 2.68 mg
Tier level
What the
drug will
cost you
1
$0
4
$0
4
$0
1
$0
4
4
4
$0
$0
$0
4
$0
4
4
$0
$0
4
$0
1
$0
1
$0
4
$0
4
$0
4
$0
1
4
4
4
$0
$0
$0
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM
54
54
Name of Drug
promethazine oral syrup
q-dryl * oral liquid
q-tapp *
siladryl sa *
simply sleep *
sinus & allergy (pseudoephed) *
sleep aid (diphenhydramine) * oral
sleep-tabs *
sudogest cold & allergy *
(Promethazine
HCl)
(Zzzquil)
(Pseudoephedrine/
Brompheniramin)
(Zzzquil)
(Diphenhydramine
HCl)
(Pseudoephed/Chlo
rpheniramine)
(Zzzquil)
(Diphenhydramine
HCl)
(Pseudoephed/Chlo
rpheniramine)
TRIAMINIC COLD & COUGH
NT (PE) *
ultra sleep (doxylamine succ) *
unisom sleepgels *
wal-act d cold & allergy *
wal-dryl allergy * oral
wal-dryl allergy * oral
wal-finate *
wal-finate-d *
wal-itin *
wal-itin d *
wal-itin d 12 hour *
wal-phed * oral tablet 4-60 mg
wal-phed pe sinus & allergy *
(Doxylamine
Succinate)
(Benadryl)
(Pseudoephedrine/
Triprolidine)
(Benadryl)
(Diphenhydramine
HCl)
(Chlor-Trimeton)
(Pseudoephed/Chlo
rpheniramine)
(Claritin)
(Claritin-D 24
Hour)
(Claritin-D 12
Hour)
(Pseudoephed/Chlo
rpheniramine)
(Phenylephrine/Chl
orpheniramine)
Tier level
What the
drug will
cost you
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
55
55
Tier level
What the
drug will
cost you
4
4
$0
$0
4
$0
4
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
4
$0
4
2
1
1
1
1
$0
$0
$0
$0
$0
$0
(Amerge)
(Maxalt)
1
1
2
1
1
$0
$0
$0
$0
$0
(Maxalt Mlt)
1
$0
(Imitrex)
(Imitrex)
1
1
$0
$0
(Imitrex)
1
$0
Name of Drug
wal-sleep z * oral capsule
wal-sleep z * oral liquid
wal-sleep z * oral
wal-som * oral capsule
wal-tap *
wal-zyr (cetirizine) * oral
wal-zyr (cetirizine) * oral
wal-zyr d *
z-sleep * oral liquid
ZYRTEC * ORAL CAPSULE
ZYRTEC * ORAL TABLET
ZYRTEC * ORAL
TABLET,DISINTEGRATING
(Benadryl)
(Zzzquil)
(Unisom
Sleepmelts)
(Benadryl)
(Dimetapp)
(Cetirizine HCl)
(Zyrtec)
(Zyrtec-D)
(Zzzquil)
Necessary Actions,
Restrictions, or
Limits on Use
Anti-Infectives (Skin And Mucous Membrane)
Anti-Infectives (Skin And Mucous Membrane)
ABREVA *
AVC VAGINAL
clindamycin phosphate vaginal
(Cleocin)
metronidazole vaginal
(Metrogel-Vaginal)
terconazole vaginal cream
(Terazol 7)
terconazole vaginal suppository
(Terconazole)
Antimigraine Agents
Antimigraine Agents
dihydroergotamine injection
dihydroergotamine nasal
ERGOMAR
naratriptan
rizatriptan oral tablet
rizatriptan oral
sumatriptan nasal spray
sumatriptan oral tablet
sumatriptan succinate subcutaneous
cartridge 6 mg/0.5 ml
(D.H.E.45)
(Migranal)
QL (30 per 28 days)
QL (4 per 28 days)
QL (40 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (12 per 28 days)
QL (18 per 28 days)
QL (4 per 28 days)
56
56
Tier level
What the
drug will
cost you
(Imitrex)
1
$0
(Imitrex)
1
$0
(Zomig)
1
$0
(Zomig Zmt)
1
$0
2
1
1
1
2
2
1
1
1
1
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
SIRTURO
2
$0
TRECATOR
2
$0
4
1
4
4
1
$0
$0
$0
$0
$0
2
$0
2
$0
2
$0
Name of Drug
pen injector
solution
zolmitriptan oral tablet
zolmitriptan oral
Necessary Actions,
Restrictions, or
Limits on Use
QL (4 per 28 days)
QL (4 per 28 days)
QL (12 per 28 days)
QL (12 per 28 days)
Antimycobacterials
Antimycobacterials
CAPASTAT
dapsone
ethambutol
isoniazid oral
PASER
PRIFTIN
pyrazinamide
rifabutin
rifampin
rifampin
RIFATER
(Dapsone)
(Myambutol)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifadin)
PA; QL (188 per 168
days)
Antinausea Agents
Antinausea Agents
ambizine *
dimenhydrinate injection solution
dramamine * oral tablet
driminate *
dronabinol
EMEND INTRAVENOUS RECON
SOLN
EMEND ORAL CAPSULE 125
MG, 40 MG
EMEND ORAL CAPSULE 80 MG
(Meclizine HCl)
(Dimenhydrinate)
(Dimenhydrinate)
(Marinol)
QL (2 per 28 days)
PA BvD; QL (1 per 1
day)
PA BvD; QL (2 per 1
day)
57
57
Tier level
What the
drug will
cost you
2
$0
(Granisetron
HCl/PF)
1
$0
(Kytril)
1
$0
(Granisetron HCl)
1
$0
(Meclizine HCl)
4
$0
(Meclizine HCl)
4
$0
(Antivert)
1
$0
(Dimenhydrinate)
(Zofran Odt)
(Ondansetron
HCl/PF)
(Zofran)
(Compazine)
4
1
$0
$0
1
$0
1
1
$0
$0
(Compazine)
1
$0
(Compazine)
(Compazine)
(Phenergan)
(Promethazine
HCl)
(Phenergan)
1
1
1
$0
$0
$0
1
$0
1
2
4
4
$0
$0
$0
$0
2
2
1
1
2
$0
$0
$0
$0
$0
Name of Drug
EMEND ORAL CAPSULE,DOSE
PACK
granisetron (pf) intravenous
solution
granisetron hcl intravenous solution
1 mg/ml (1 ml)
granisetron hcl oral
meclizine * 12.5 mg caplet caplet
(otc)
meclizine * 25 mg tablet (otc)
meclizine oral tablet 12.5 mg, 25
mg
motion sickness *
ondansetron
ondansetron hcl (pf) injection
ondansetron hcl oral
prochlorperazine
prochlorperazine edisylate injection
solution
prochlorperazine maleate
prochlorperazine maleate oral
promethazine hcl
promethazine oral tablet
promethazine rectal
TRANSDERM-SCOP
travel sickness (meclizine) *
wal-dram *
(Bonine)
(Dimenhydrinate)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD; QL (3 per 1
day)
PA BvD
PA BvD
PA BvD
PA-HRM
PA-HRM
PA-HRM
QL (10 per 30 days)
Antiparasite Agents
Antiparasite Agents
ALBENZA
ALINIA
atovaquone
atovaquone-proguanil
BILTRICIDE
(Mepron)
(Malarone)
58
58
Tier level
What the
drug will
cost you
1
2
2
1
1
1
$0
$0
$0
$0
$0
$0
1
$0
1
2
$0
$0
1
$0
2
2
1
$0
$0
$0
1
2
2
$0
$0
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Sinemet CR)
1
$0
(Stalevo 50)
(Comtan)
1
1
$0
$0
2
$0
(Mirapex)
(Requip)
1
1
$0
$0
(Requip XL)
1
$0
Name of Drug
chloroquine phosphate oral
COARTEM
DARAPRIM
hydroxychloroquine oral
ivermectin oral
mefloquine
metronidazole in nacl (iso-os)
metronidazole oral
NEBUPENT
paromomycin
PENTAM
PRIMAQUINE
quinine sulfate
(Aralen Phosphate)
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Metronidazole/So
dium Chloride)
(Flagyl)
(Paromomycin
Sulfate)
(Qualaquin)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
QL (90 per 30 days)
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl oral
APOKYN
AZILECT
benztropine oral
bromocriptine
cabergoline
carbidopa
carbidopa-levodopa oral tablet
carbidopa-levodopa oral tablet
extended release
carbidopa-levodopa-entacapone
entacapone
(Amantadine HCl)
(Benztropine
Mesylate)
(Parlodel)
(Cabergoline)
(Lodosyn)
(Sinemet CR)
NEUPRO
pramipexole oral tablet
ropinirole oral tablet
ropinirole oral tablet extended
release 24 hr
QL (60 per 30 days)
PA-HRM
ST; QL (30 per 30
days)
59
59
Name of Drug
selegiline hcl oral capsule
selegiline hcl oral tablet
trihexyphenidyl
(Eldepryl)
(Selegiline HCl)
(Trihexyphenidyl
HCl)
Tier level
What the
drug will
cost you
1
1
$0
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 10
MG
ABILIFY DISCMELT ORAL
MG
ABILIFY INTRAMUSCULAR
ABILIFY MAINTENA
ABILIFY ORAL SOLUTION
ABILIFY ORAL TABLET 10 MG,
15 MG, 20 MG, 30 MG, 5 MG
ABILIFY ORAL TABLET 2 MG
aripiprazole oral tablet 10 mg, 15
(Abilify)
mg, 20 mg, 30 mg, 5 mg
aripiprazole oral tablet 2 mg
(Abilify)
(Chlorpromazine
chlorpromazine
HCl)
clozapine oral tablet 100 mg
(Clozaril)
clozapine oral tablet 200 mg
(Clozaril)
clozapine oral tablet 25 mg, 50 mg (Clozaril)
clozapine oral tablet,disintegrating
(Fazaclo)
100 mg, 12.5 mg, 25 mg
(Fazaclo)
150 mg
(Fazaclo)
200 mg
QL (90 per 30 days)
2
$0
QL (60 per 30 days)
2
$0
2
2
2
$0
$0
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
FANAPT ORAL TABLET
2
$0
FANAPT ORAL TABLETS,DOSE
PACK
2
$0
QL (1 per 28 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
ST; QL (90 per 30
days)
ST; QL (180 per 30
days)
ST; QL (120 per 30
days)
ST; QL (60 per 30
days)
ST; QL (8 per 28 days)
60
60
Name of Drug
Tier level
FAZACLO ORAL
MG
FAZACLO ORAL
MG
fluphenazine decanoate
fluphenazine hcl
GEODON INTRAMUSCULAR
haloperidol
haloperidol decanoate
intramuscular solution 100 mg/ml
haloperidol decanoate
intramuscular solution 50 mg/ml
haloperidol lactate
INVEGA ORAL TABLET
EXTENDED RELEASE 24HR 1.5
MG, 3 MG, 9 MG
INVEGA ORAL TABLET
EXTENDED RELEASE 24HR 6
MG
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE
117 MG/0.75 ML
INVEGA SUSTENNA
156 MG/ML
INVEGA SUSTENNA
234 MG/1.5 ML
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 39
MG/0.25 ML
(Fluphenazine
Decanoate)
(Fluphenazine
HCl)
(Haloperidol)
(Haloperidol
Decanoate)
(Haldol Decanoate
50)
(Haloperidol
Lactate)
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
2
$0
ST; QL (180 per 30
days)
2
$0
ST; QL (120 per 30
days)
1
$0
1
$0
2
1
$0
$0
1
$0
1
$0
1
$0
2
$0
ST; QL (30 per 30
days)
2
$0
ST; QL (60 per 30
days)
2
$0
2
$0
QL (6 per 28 days)
QL (1 per 28 days)
2
$0
2
$0
61
61
Name of Drug
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 78
MG/0.5 ML
INVEGA TRINZA
273 MG/0.875 ML
INVEGA TRINZA
410 MG/1.315 ML
INVEGA TRINZA
546 MG/1.75 ML
INVEGA TRINZA
819 MG/2.625 ML
LATUDA ORAL TABLET 120
MG, 20 MG, 40 MG, 60 MG
LATUDA ORAL TABLET 80 MG
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
ST; QL (30 per 30
days)
ST; QL (60 per 30
days)
loxapine succinate
(Loxitane)
1
$0
olanzapine intramuscular
(Zyprexa)
1
$0
QL (30 per 30 days)
olanzapine oral tablet
(Zyprexa)
1
$0
QL (30 per 30 days)
olanzapine oral
QL (30 per 30 days)
tablet,disintegrating 10 mg, 15 mg, (Zyprexa Zydis)
1
$0
5 mg
olanzapine oral
QL (31 per 30 days)
(Zyprexa Zydis)
1
$0
tablet,disintegrating 20 mg
ORAP
2
$0
perphenazine
(Perphenazine)
1
$0
quetiapine
(Seroquel)
1
$0
QL (90 per 30 days)
RISPERDAL CONSTA
2
$0
QL (4 per 28 days)
risperidone oral solution
(Risperdal)
1
$0
risperidone oral tablet
(Risperdal)
1
$0
QL (60 per 30 days)
risperidone oral
QL (60 per 30 days)
tablet,disintegrating 0.25 mg, 0.5
(Risperdal M-Tab)
1
$0
mg, 1 mg, 2 mg
risperidone oral
(Risperdal M-Tab)
1
$0
tablet,disintegrating 3 mg, 4 mg
62
62
Name of Drug
SAPHRIS (BLACK CHERRY)
SEROQUEL XR ORAL TABLET
EXTENDED RELEASE 24 HR
150 MG, 300 MG, 400 MG, 50 MG
SEROQUEL XR ORAL TABLET
200 MG
thioridazine
(Thioridazine HCl)
thiothixene
(Navane)
(Trifluoperazine
trifluoperazine
HCl)
VERSACLOZ
ziprasidone hcl
ZYPREXA RELPREVV
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 210 MG, 405
MG
(Geodon)
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
2
$0
2
$0
ST; QL (60 per 30
days)
ST; QL (60 per 30
days)
2
$0
ST; QL (30 per 30
days)
1
1
$0
$0
1
$0
2
$0
1
$0
2
$0
1
1
2
2
2
$0
$0
$0
$0
$0
2
$0
1
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
PA NSO-HRM
ST; QL (540 per 30
days)
QL (60 per 30 days)
QL (2 per 28 days)
Antivirals (Systemic)
Antiretrovirals
abacavir
(Ziagen)
abacavir-lamivudine-zidovudine
(Trizivir)
APTIVUS
ATRIPLA
COMPLERA
CRIXIVAN ORAL CAPSULE 200
MG, 400 MG
didanosine
(Videx EC)
EDURANT
EMTRIVA
EPIVIR HBV ORAL SOLUTION
EPZICOM
EVOTAZ
FUZEON SUBCUTANEOUS
INTELENCE
63
63
Tier level
What the
drug will
cost you
(Viramune)
(Viramune)
2
2
2
1
1
2
1
1
$0
$0
$0
$0
$0
$0
$0
$0
(Viramune XR)
1
$0
2
2
2
2
2
$0
$0
$0
$0
$0
2
$0
2
$0
2
1
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
2
2
2
1
$0
$0
$0
$0
Name of Drug
INVIRASE
ISENTRESS
KALETRA
lamivudine
lamivudine-zidovudine
LEXIVA
nevirapine oral suspension
nevirapine oral tablet
nevirapine oral tablet extended
release 24 hr
NORVIR
PREZCOBIX
PREZISTA
RESCRIPTOR
RETROVIR INTRAVENOUS
REYATAZ ORAL CAPSULE 150
MG, 200 MG, 300 MG
REYATAZ ORAL POWDER IN
PACKET
SELZENTRY
stavudine
STRIBILD
SUSTIVA
TIVICAY
TRIUMEQ
TRUVADA
VIDEX 2 GRAM PEDIATRIC
VIRACEPT ORAL TABLET
VIRAMUNE XR ORAL TABLET
100 MG
VIREAD
VITEKTA
ZIAGEN ORAL SOLUTION
zidovudine oral capsule
(Epivir)
(Combivir)
(Zerit)
(Retrovir)
Necessary Actions,
Restrictions, or
Limits on Use
64
64
Tier level
What the
drug will
cost you
(Retrovir)
(Zidovudine)
1
1
$0
$0
(Foscavir)
1
2
1
2
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
HARVONI
2
$0
OLYSIO
2
$0
SOVALDI
2
$0
VIEKIRA PAK
2
$0
2
2
$0
$0
2
$0
2
2
$0
$0
SYLATRON
2
$0
SYLATRON 4-PACK
SUBCUTANEOUS KIT 200 MCG,
300 MCG
2
$0
Name of Drug
zidovudine oral syrup
zidovudine oral tablet
Antivirals, Miscellaneous
foscarnet
RELENZA DISKHALER
rimantadine
SYNAGIS
TAMIFLU ORAL CAPSULE 30
MG
MG
MG
TAMIFLU ORAL SUSPENSION
FOR RECONSTITUTION
Hcv Antivirals
Interferons
INTRON A INJECTION
PEGASYS
PEGASYS PROCLICK
SUBCUTANEOUS PEN
INJECTOR
PEGINTRON
PEGINTRON REDIPEN
(Flumadine)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA; QL (30 per 30
days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
PA; QL (112 per 28
days)
PA NSO
PA
PA
PA
PA
days)
days)
65
65
Name of Drug
Nucleosides And Nucleotides
acyclovir oral capsule
(Zovirax)
acyclovir oral suspension 200 mg/5
(Zovirax)
ml
acyclovir oral tablet
(Zovirax)
acyclovir sodium intravenous recon (Acyclovir
soln
Sodium)
acyclovir sodium intravenous
(Acyclovir
solution
Sodium)
adefovir
(Hepsera)
entecavir
(Baraclude)
famciclovir
(Famvir)
ganciclovir sodium
(Cytovene)
ribavirin oral capsule 200 mg
(Rebetol)
ribavirin oral tablet 200 mg, 400
(Copegus)
mg, 600 mg
TYZEKA
valacyclovir
(Valtrex)
valganciclovir
(Valcyte)
VIRAZOLE
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
1
$0
2
1
1
2
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
Blood Products/Modifiers/Volume Expanders
Anticoagulants
CEPROTIN (BLUE BAR)
2
$0
ELIQUIS
2
$0
enoxaparin subcutaneous solution
(Lovenox)
1
$0
QL (36 per 30 days)
enoxaparin subcutaneous syringe
QL (36 per 30 days)
(Lovenox)
1
$0
100 mg/ml
(Lovenox)
1
$0
120 mg/0.8 ml, 80 mg/0.8 ml
QL (34 per 30 days)
(Lovenox)
1
$0
150 mg/ml
QL (18 per 30 days)
(Lovenox)
1
$0
30 mg/0.3 ml
(Lovenox)
1
$0
40 mg/0.4 ml
(Lovenox)
1
$0
60 mg/0.6 ml
66
66
Tier level
What the
drug will
cost you
(Arixtra)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
(Heparin Sodium
in 5% Dextrose)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
fondaparinux subcutaneous syringe
10 mg/0.8 ml
2.5 mg/0.5 ml
5 mg/0.4 ml
7.5 mg/0.6 ml
heparin (porcine) in 5 % dex
intravenous parenteral solution
12,500 unit/250 ml, 20,000 unit/500
ml (40 unit/ml)
HEPARIN (PORCINE) IN 5 %
DEX INTRAVENOUS
PARENTERAL SOLUTION
25,000 UNIT/250 ML(100
UNIT/ML), 25,000 UNIT/500 ML
(50 UNIT/ML)
heparin (porcine) in nacl (pf)
1,000 unit/500 ml
heparin (porcine) injection
heparin, porcine (pf) injection
heparin, porcine (pf) intravenous
syringe 100 unit/ml
HEPARIN-0.45% NACL 25,000
UNITS/250 ML (100 UNITS/ML)
BAG LATEX-FREE, OUTER
HEPARIN-0.45% NACL 25,000
UNITS/500 ML (50 UNITS/ML)
BAG LATEX-FREE, OUTER
heparin-d5w 25,000 units/250 ml
(100 units/ml) bag excel container
heparin-d5w 25,000 units/500 ml
(50 units/ml) bag excel container
(Heparin
Sodium,Porcine/Ns
/PF)
(Heparin
Sodium,Porcine)
(Monoject Prefill
Advanced)
(Monoject Prefill
Advanced)
(Heparin Sodium
in 5% Dextrose)
(Heparin Sodium
in 5% Dextrose)
Necessary Actions,
Restrictions, or
Limits on Use
QL (24 per 30 days)
QL (15 per 30 days)
QL (12 per 30 days)
QL (18 per 30 days)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
67
67
Tier level
What the
drug will
cost you
IPRIVASK
2
$0
jantoven
(Coumadin)
PRADAXA
warfarin
(Coumadin)
XARELTO
Blood Formation Modifiers
EPOGEN INJECTION SOLUTION
10,000 UNIT/ML, 2,000 UNIT/ML,
20,000 UNIT/2 ML, 20,000
UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML
GRANIX
LEUKINE INJECTION RECON
SOLN
1
2
1
2
$0
$0
$0
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (24 per 28
days)
QL (60 per 30 days)
PA; QL (12 per 28
days)
2
$0
2
$0
2
$0
MIRCERA
2
$0
MOZOBIL
NEULASTA SUBCUTANEOUS
SYRINGE
NEUMEGA
NEUPOGEN
PROCRIT INJECTION
SOLUTION 10,000 UNIT/ML,
2,000 UNIT/ML, 20,000 UNIT/2
ML, 20,000 UNIT/ML, 3,000
UNIT/ML, 4,000 UNIT/ML
PROCRIT INJECTION
SOLUTION 40,000 UNIT/ML
2
$0
2
$0
2
2
$0
$0
PA; QL (0.6 per 28
days)
PA; QL (12 per 28
days)
2
$0
2
$0
PROMACTA
2
$0
Hematologic Agents, Miscellaneous
aminocaproic acid oral
(Amicar)
anagrelide
(Agrylin)
1
1
$0
$0
protamine
(Protamine Sulfate)
1
$0
tranexamic acid intravenous
(Tranexamic Acid)
1
$0
PA; QL (30 per 30
days)
PA BvD; (PA for
ESRD Only)
68
68
Name of Drug
tranexamic acid oral
(Lysteda)
Platelet-Aggregation Inhibitors
AGGRENOX
BRILINTA
cilostazol
(Pletal)
clopidogrel
(Plavix)
EFFIENT
pentoxifylline
(Pentoxifylline)
Volume Expanders
ALBUKED-25
ALBUKED-5
ALBUMIN, HUMAN 25 %
ALBUMIN, HUMAN 5 %
ALBUMINAR 25 %
ALBUMINAR 5 %
ALBURX (HUMAN) 5 %
ALBUTEIN 25 %
ALBUTEIN 5 %
BUMINATE 25 %
BUMINATE 5 %
FLEXBUMIN 25 %
FLEXBUMIN 5 %
KEDBUMIN
PLASBUMIN 25 %
PLASBUMIN 5 %
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
1
$0
QL (30 per 30 days)
2
2
1
1
2
1
$0
$0
$0
$0
$0
$0
QL (60 per 30 days)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
$0
2
$0
QL (30 per 30 days)
Caloric Agents
Caloric Agents
AMINO ACIDS 15 %
AMINOSYN 10 %
AMINOSYN 3.5 %
AMINOSYN 7 %
AMINOSYN 7 % WITH
ELECTROLYTES
AMINOSYN 8.5 %
AMINOSYN 8.5 %ELECTROLYTES
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
69
69
Name of Drug
AMINOSYN II 10 %
AMINOSYN II 15 %
AMINOSYN II 7 %
AMINOSYN II 8.5 %
AMINOSYN II 8.5 %ELECTROLYTES
AMINOSYN M 3.5 %
AMINOSYN-HBC 7%
AMINOSYN-PF 10 %
AMINOSYN-PF 7 % (SULFITEFREE)
AMINOSYN-RF 5.2 %
CLINIMIX 5%/D15W SULFITE
FREE
CLINIMIX 5%/D25W SULFITEFREE
CLINIMIX 2.75%/D5W SULFIT
FREE
CLINIMIX 4.25%/D10W SULF
FREE
CLINIMIX 4.25%/D5W SULFIT
FREE
CLINIMIX 4.25%-D20W SULFFREE
CLINIMIX 4.25%-D25W SULFFREE
CLINIMIX 5%-D20W(SULFITEFREE)
CLINIMIX E 2.75%/D10W SUL
FREE
CLINIMIX E 2.75%/D5W SULF
FREE
FREE
FREE
Tier level
What the
drug will
cost you
2
2
2
2
$0
$0
$0
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
70
70
Name of Drug
CLINIMIX E 4.25%/D5W SULF
FREE
CLINIMIX E 5%/D15W SULFIT
FREE
FREE
FREE
CLINISOL SF 15 %
cysteine (l-cysteine) intravenous
solution
(Cysteine HCl)
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
(Dextrose 10 %
1
$0
and 0.45 % NaCl)
(Dextrose 2.5 %
d2.5 %-0.45 % sodium chloride
1
$0
and 0.45 % NaCl)
(Dextrose 5 % and
d5 % and 0.9 % sodium chloride
1
$0
0.9 % NaCl)
(Dextrose 5 %-0.45
d5 %-0.45 % sodium chloride
1
$0
% NaCl)
dex4 glucose * oral tablet,chewable (Dextrose)
4
$0
(Dextrose 10 %
dextrose 10 % and 0.2 % nacl
1
$0
and 0.2 % NaCl)
dextrose 10 % in water (d10w)
(Dextrose 10 % in
PA BvD
1
$0
intravenous
Water)
(Dextrose 2.5 % in
PA BvD
dextrose 2.5 % in water(d2.5w)
1
$0
Water)
(Dextrose 20 % in
PA BvD
1
$0
Water)
(Dextrose 25 % in
PA BvD
1
$0
Water)
(Dextrose 40 % in
PA BvD
1
$0
Water)
(Dextrose 5% In
dextrose 5 % in ringers
1
$0
Ringers)
(Dextrose 5 % in
1
$0
intravenous
Water)
(Dextrose 5%dextrose 5 %-lactated ringers
1
$0
Lactated Ringers)
71
71
d10 % & 0.45 % sodium chloride
Name of Drug
dextrose 5%-0.2 % sod chloride
dextrose 5%-0.3 % sod.chloride
dextrose with sodium chloride
(Dextrose 5 %-0.2
% NaCl)
(Dextrose 5 % and
0.3 % NaCl)
(Dextrose 50 % in
Water)
(Dextrose 70 % in
Water)
(Dextrose 5 %-0.2
% NaCl)
FREAMINE HBC 6.9 %
FREAMINE III 10 %
gluco burst *
glucose gel *
glucose * oral tablet,chewable
glutose 15 *
HEPATAMINE 8%
HEPATASOL 8 %
(Dextrose)
(Dextrose)
(Dextrose)
(Dextrose)
insta-glucose *
(Dextrose/Dextrin/
Maltose)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
2
2
4
4
4
4
2
2
$0
$0
$0
$0
$0
$0
$0
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
INTRALIPID INTRAVENOUS
PA BvD
2
$0
EMULSION 20 %, 30 %
KABIVEN
2
$0
PA BvD
LIPOSYN II
2
$0
PA BvD
LIPOSYN III
2
$0
PA BvD
NEPHRAMINE 5.4 %
2
$0
PA BvD
NUTRILIPID
2
$0
PA BvD
PERIKABIVEN
2
$0
PA BvD
potassium chloride in lr-d5
(Potassium
1
$0
Chloride In Lr-D5)
PREMASOL 10 %
2
$0
PA BvD
PREMASOL 6 %
2
$0
PA BvD
PROCALAMINE 3%
2
$0
PA BvD
PROSOL 20 %
2
$0
PA BvD
TRAVASOL 10 %
2
$0
PA BvD
TROPHAMINE 10 %
2
$0
PA BvD
TROPHAMINE 6%
2
$0
PA BvD
72
72
Tier level
What the
drug will
cost you
(Catapres)
(Clonidine
HCl/Chlorthalidon
e)
1
$0
1
$0
(Catapres-Tts 1)
1
$0
(Catapres-Tts 1)
1
$0
(Cardura)
(Tenex)
(Midodrine HCl)
1
1
1
$0
$0
$0
(Medi-Phenyl)
4
$0
NORTHERA
2
$0
phenylephrine hcl injection
(Vazculep)
prazosin oral
(Minipress)
sudogest pe *
(Medi-Phenyl)
wal-phed pe *
(Medi-Phenyl)
Angiotensin Ii Receptor Antagonists
BENICAR
BENICAR HCT
candesartan
(Atacand)
candesartan-hydrochlorothiazid
(Atacand HCT)
irbesartan
(Avapro)
irbesartan-hydrochlorothiazide
(Avalide)
losartan
(Cozaar)
losartan-hydrochlorothiazide
(Hyzaar)
telmisartan
(Micardis)
telmisartan-hydrochlorothiazid
(Micardis HCT)
TRIBENZOR
valsartan
(Diovan)
valsartan-hydrochlorothiazide
(Diovan HCT)
Angiotensin-Converting Enzyme Inhibitors
1
1
4
4
$0
$0
$0
$0
2
2
1
1
1
1
1
1
1
1
2
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet
clonidine hcl-chlorthalidone
clonidine transdermal patch weekly
0.1 mg/24 hr, 0.2 mg/24 hr
clonidine transdermal patch weekly
0.3 mg/24 hr
doxazosin
guanfacine oral tablet
midodrine
nasal decongestant (pe) * oral
tablet 10 mg
QL (4 per 28 days)
QL (8 per 28 days)
PA-HRM
PA; QL (180 per 30
days)
ST
ST
ST
73
73
Tier level
What the
drug will
cost you
(Lotensin)
(Lotensin HCT)
(Captopril)
(Captopril/Hydroch
lorothiazide)
(Vasotec)
(Enalaprilat
Dihydrate)
(Vaseretic)
(Fosinopril
Sodium)
(Fosinopril/Hydroc
hlorothiazide)
(Zestril)
(Zestoretic)
(Univasc)
(Uniretic)
(Aceon)
(Accupril)
(Accuretic)
(Altace)
(Mavik)
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Cordarone)
1
$0
(Cordarone)
1
$0
(Norpace)
1
$0
1
$0
1
$0
1
$0
1
2
$0
$0
Name of Drug
benazepril
benazepril-hydrochlorothiazide
captopril
captopril-hydrochlorothiazide
enalapril maleate
enalaprilat intravenous injectable
enalapril-hydrochlorothiazide
fosinopril
fosinopril-hydrochlorothiazide
lisinopril
lisinopril-hydrochlorothiazide
moexipril
moexipril-hydrochlorothiazide
perindopril erbumine
quinapril
quinapril-hydrochlorothiazide
ramipril
trandolapril
Antiarrhythmic Agents
amiodarone hcl oral tablet 100 mg,
200 mg, 400 mg
amiodarone oral
disopyramide phosphate oral
capsule
flecainide
lidocaine (pf) intravenous syringe
50 mg/5 ml (1 %)
lidocaine in 5 % dextrose (pf)
intravenous parenteral solution 8
mg/ml (0.8 %)
mexiletine
MULTAQ
(Flecainide
Acetate)
(Lidocaine
HCl/PF)
(Lidocaine
HCl/D5w/PF)
(Mexiletine HCl)
Necessary Actions,
Restrictions, or
Limits on Use
74
74
Tier level
What the
drug will
cost you
(Procainamide
HCl)
1
$0
(Rythmol SR)
1
$0
(Rythmol)
(Quinidine
Gluconate)
(Quinidine Sulfate)
1
$0
1
$0
Name of Drug
procainamide injection
propafenone oral capsule,extended
release 12 hr
propafenone oral tablet
quinidine gluconate oral
Necessary Actions,
Restrictions, or
Limits on Use
quinidine sulfate
1
$0
TIKOSYN
2
$0
Beta-Adrenergic Blocking Agents
acebutolol oral
(Sectral)
1
$0
atenolol
(Tenormin)
1
$0
atenolol-chlorthalidone
(Tenoretic 50)
1
$0
betaxolol oral
(Kerlone)
1
$0
bisoprolol fumarate
(Zebeta)
1
$0
bisoprolol-hydrochlorothiazide
(Ziac)
1
$0
BYSTOLIC
2
$0
carvedilol
(Coreg)
1
$0
esmolol intravenous
(Esmolol HCl)
1
$0
PA BvD
labetalol intravenous solution
(Trandate)
1
$0
labetalol oral
(Trandate)
1
$0
metoprolol succinate
(Toprol XL)
1
$0
metoprolol ta-hydrochlorothiaz
(Lopressor HCT)
1
$0
(Metoprolol
metoprolol tartrate intravenous
1
$0
Tartrate)
metoprolol tartrate oral
(Lopressor)
1
$0
nadolol
(Corgard)
1
$0
pindolol
(Pindolol)
1
$0
propranolol intravenous
(Propranolol HCl)
1
$0
propranolol oral capsule,extended
(Inderal LA)
1
$0
release 24 hr
propranolol oral solution
(Propranolol HCl)
1
$0
propranolol oral tablet
(Propranolol HCl)
1
$0
(Propranolol/Hydro
propranolol-hydrochlorothiazid
1
$0
chlorothiazid)
sotalol hcl oral tablet 120 mg, 160
(Betapace)
1
$0
mg, 240 mg, 80 mg
75
75
Name of Drug
Tier level
What the
drug will
cost you
sotalol oral
(Betapace)
timolol maleate oral
(Timolol Maleate)
Calcium-Channel Blocking Agents
cartia xt
(Cardizem CD)
diltiazem hcl intravenous
(Cardizem CD)
diltiazem hcl oral capsule, extended
(Cardizem CD)
release 180 mg, 360 mg, 420 mg
diltiazem hcl oral capsule,extended
(Cardizem CD)
release 12 hr
diltiazem hcl oral capsule,extended
(Cardizem CD)
release 24hr
diltiazem hcl oral tablet
(Cardizem CD)
diltiazem hcl oral tablet extended
(Cardizem LA)
release 24 hr
dilt-xr
(Cardizem CD)
matzim la
(Cardizem CD)
taztia xt
(Cardizem CD)
verapamil intravenous syringe
(Verapamil HCl)
verapamil oral capsule, 24 hr er
(Verelan Pm)
pellet ct
verapamil oral capsule,ext rel.
(Verelan)
pellets 24 hr
verapamil oral tablet
(Calan)
verapamil oral tablet extended
(Calan SR)
release
Cardiovascular Agents, Miscellaneous
ADRENALIN 1 MG/ML VIAL
SUV
adrenalin injection solution 1
(Epinephrine)
mg/ml (1:1,000) (1ml)
DEMSER
1
1
$0
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
1
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
digitek oral tablet 125 mcg
(Lanoxin)
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per
30 days)
76
76
Name of Drug
Tier level
What the
drug will
cost you
digitek oral tablet 250 mcg
(Lanoxin)
1
$0
digoxin injection
(Digoxin)
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
1
$0
$0
(Epinephrine)
1
$0
(Adrenaclick)
1
$0
(Epinephrine)
1
$0
2
2
$0
$0
1
$0
2
1
$0
$0
DIGOXIN ORAL SOLUTION
digoxin oral tablet
(Lanoxin)
dobutamine in d5w intravenous
parenteral solution
dobutamine intravenous solution
dopamine in 5 % dextrose
intravenous solution
dopamine intravenous solution
ephedrine sulfate injection solution
epinephrine 1 mg/ml ampul latexfree
epinephrine injection auto-injector
epinephrine injection syringe 0.1
mg/ml (1:10,000)
EPIPEN 2-PAK
EPIPEN JR 2-PAK
(Dobutamine
HCl/D5W)
(Dobutamine HCl)
(Dopamine
HCl/D5W)
(Dopamine HCl)
(Ephedrine Sulfate)
ethamolin
FIRAZYR
hydralazine
(Ethanolamine
Oleate)
(Hydralazine HCl)
LANOXIN ORAL TABLET 187.5
MCG, 62.5 MCG
milrinone
(Milrinone Lactate)
2
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (30 per
30 days)
PA-HRM
PA-HRM; QL (300 per
30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days)
PA BvD
PA BvD
PA BvD
PA BvD
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days)
PA BvD
77
77
Name of Drug
milrinone in 5 % dextrose
intravenous piggyback 40 mg/200
ml (200 mcg/ml)
norepinephrine bitartrate
papaverine injection solution
papaverine oral
RANEXA
Dihydropyridines
amlodipine
amlodipine-benazepril
amlodipine-valsartan
amlodipine-valsartan-hcthiazid
AZOR
CLEVIPREX INTRAVENOUS
EMULSION
felodipine
isradipine
nicardipine oral
nifedipine oral tablet extended
release 24hr 30 mg
release 24hr 60 mg, 90 mg
release 30 mg, 60 mg
Diuretics
amiloride oral
amiloride-hydrochlorothiazide
Tier level
(Milrinone
Lactate/D5W)
What the
drug will
cost you
PA BvD
1
$0
1
$0
1
1
2
$0
$0
$0
1
1
1
1
2
$0
$0
$0
$0
$0
2
$0
(Felodipine)
(Isradipine)
(Nicardipine HCl)
1
1
1
$0
$0
$0
(Adalat CC)
1
$0
(Procardia XL)
1
$0
(Adalat CC)
1
$0
(Midamor)
(Amiloride/Hydroc
hlorothiazide)
(Bumetanide)
(Chlorothiazide)
(Sodium Diuril)
1
$0
1
$0
1
1
1
$0
$0
$0
1
$0
2
1
1
$0
$0
$0
(Levophed
Bitartrate)
(Papaverine HCl)
(Papaverine HCl)
(Norvasc)
(Lotrel)
(Exforge)
(Exforge HCT)
bumetanide
chlorothiazide
chlorothiazide sodium
chlorthalidone oral tablet 25 mg, 50
(Chlorthalidone)
mg
DYRENIUM
furosemide injection
(Furosemide)
furosemide oral solution
(Furosemide)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA
PA
ST
78
78
Tier level
What the
drug will
cost you
(Lasix)
(Microzide)
(Hydrochlorothiazi
de)
(Indapamide)
(Methyclothiazide)
(Zaroxolyn)
(Demadex)
1
1
$0
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Dyazide)
1
$0
(Maxzide)
1
$0
(Caduet)
(Lipitor)
(Questran)
(Cholestyramine/A
spartame)
1
1
1
$0
$0
$0
1
$0
(Questran)
1
$0
(Colestid)
1
2
$0
$0
(Slo-Niacin)
4
$0
(Antara)
(Tricor)
1
1
$0
$0
(Lofibra)
1
$0
(Fibricor)
(Trilipix)
(Lopid)
(Inositol/Choline/V
it B Comp)
(Mevacor)
1
1
1
$0
$0
$0
4
$0
1
$0
(Niacin)
4
$0
Name of Drug
furosemide oral tablet
hydrochlorothiazide oral capsule
hydrochlorothiazide oral tablet
indapamide
methyclothiazide
metolazone
torsemide oral
triamterene-hydrochlorothiazid oral
capsule
triamterene-hydrochlorothiazid oral
tablet
Dyslipidemics
amlodipine-atorvastatin
atorvastatin
cholestyramine (with sugar) oral
cholestyramine-aspartame oral
powder 4 gram
cholestyramine-aspartame oral
powder in packet 4 gram
colestipol
CRESTOR
endur-acin * oral tablet extended
release 500 mg
fenofibrate micronized
fenofibrate nanocrystallized
fenofibrate oral tablet 160 mg, 54
mg
fenofibric acid
fenofibric acid (choline)
gemfibrozil oral
lipogen *
lovastatin
niacin * oral capsule, extended
release 500 mg
Necessary Actions,
Restrictions, or
Limits on Use
79
79
Name of Drug
Tier level
niacin * oral tablet 100 mg, 50 mg,
(Slo-Niacin)
500 mg
niacin oral tablet extended release
(Niaspan)
24 hr
niacin * oral tablet extended
(Slo-Niacin)
release 500 mg
omega-3 acid ethyl esters
(Lovaza)
pravastatin
(Pravachol)
simvastatin
(Zocor)
VASCEPA
WELCHOL
ZETIA
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone
(Inspra)
spironolactone
(Aldactone)
spironolacton-hydrochlorothiaz
(Aldactazide)
Vasodilators
isosorbide dinitrate oral
(Isochron)
(Isosorbide
isosorbide dinitrate sublingual
Dinitrate)
(Isosorbide
isosorbide mononitrate oral tablet
Mononitrate)
isosorbide mononitrate oral tablet
(Imdur)
minitran transdermal patch 24 hour
(Nitro-Dur)
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
minitran transdermal patch 24 hour
(Nitro-Dur)
0.4 mg/hr
minoxidil oral
(Minoxidil)
NITRO-BID
nitroglycerin in 5 % dextrose
(Nitroglycerin/D5
W)
nitroglycerin intravenous
(Nitroglycerin)
nitroglycerin transdermal patch 24
hour 0.1 mg/hr, 0.2 mg/hr, 0.6
(Nitro-Dur)
mg/hr
What the
drug will
cost you
4
$0
1
$0
4
$0
1
1
1
2
2
2
$0
$0
$0
$0
$0
$0
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
2
$0
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
80
80
Tier level
What the
drug will
cost you
1
$0
2
2
$0
$0
Central Nervous System Agents
amphetamine salt combo
(Adderall)
1
$0
AMPYRA
2
$0
(Cafcit)
(Cafcit)
(Caffeine/Sodium
Benzoate)
1
1
$0
$0
1
$0
(Kapvay)
1
$0
(Focalin)
1
$0
(Dexedrine)
1
$0
(Dexedrine)
1
$0
(Adderall XR)
1
$0
Name of Drug
nitroglycerin transdermal patch 24
hour 0.4 mg/hr
NITROSTAT
PROGLYCEM
(Nitro-Dur)
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
Central Nervous System Agents
caffeine citrated intravenous
caffeine citrated oral
caffeine-sodium benzoate
clonidine hcl oral tablet extended
release 12 hr
dexmethylphenidate oral tablet
dextroamphetamine oral capsule,
extended release
dextroamphetamine oral tablet
dextroamphetamine-amphetamine
oral capsule,extended release 24hr
10 mg, 15 mg, 5 mg
dextroamphetamine-amphetamine
oral capsule,extended release 24hr
20 mg, 25 mg, 30 mg
flumazenil
guanfacine oral tablet extended
release 24 hr
lithium carbonate oral capsule
lithium carbonate oral tablet
lithium carbonate oral tablet
extended release
lithium citrate oral solution
methylphenidate oral capsule, er
biphasic 30-70 10 mg, 20 mg, 50
mg, 60 mg
QL (60 per 30 days)
PA; QL (60 per 30
days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
(Adderall XR)
1
$0
(Romazicon)
1
$0
(Intuniv)
1
$0
(Eskalith)
(Lithobid)
1
1
$0
$0
(Lithobid)
1
$0
(Lithium Citrate)
1
$0
(Metadate Cd)
1
$0
QL (30 per 30 days)
81
81
Tier level
What the
drug will
cost you
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Ritalin LA)
1
$0
(Methylin)
(Ritalin)
1
1
$0
$0
(Ritalin-SR)
1
$0
Name of Drug
methylphenidate oral capsule, er
biphasic 30-70 30 mg
methylphenidate oral capsule,er
methylphenidate oral solution
methylphenidate oral tablet
extended release
extended release 24hr 18 mg, 27
mg, 54 mg
extended release 24hr 36 mg
NUEDEXTA
QUILLIVANT XR
riluzole
SAVELLA
STRATTERA
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
(Concerta)
1
$0
(Concerta)
1
$0
(Rilutek)
2
2
1
2
2
$0
$0
$0
$0
$0
2
$0
(Seasonique)
(Nor-Q-D)
(Mircette)
1
1
1
$0
$0
$0
(Desogen)
1
$0
(Yaz)
1
2
1
$0
$0
$0
1
$0
XENAZINE
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
PA; QL (112 per 28
days)
Contraceptives
Contraceptives
ashlyna
deblitane
desog-e.estradiol/e.estradiol
desogestrel-ethinyl estradiol oral
tablet 0.1/.125/.15-25 mg-mcg,
0.15-0.03 mg
drospirenone-ethinyl estradiol
ELLA
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
(Yaz)
(Ethynodiol DEthinyl Estradiol)
QL (91 per 84 days)
82
82
Tier level
What the
drug will
cost you
(Loestrin Fe)
(Loestrin Fe)
(Mircette)
(Seasonique)
(Loestrin Fe)
(Plan B One-Step)
(Plan B One-Step)
(Plan B One-Step)
1
1
1
1
1
1
1
4
$0
$0
$0
$0
$0
$0
$0
$0
(Amethyst)
1
$0
Name of Drug
gildess 24 fe
junel fe 24
kimidess (28)
l norgest&e estradiol-e estrad
larin 24 fe
levonorgestrel 1.5 mg tablet (rx)
levonorgestrel oral tablet 0.75 mg
levonorgestrel * oral tablet 1.5 mg
levonorgestrel-ethin estradiol oral
tablet 0.1-20 mg-mcg, 0.15-0.03
mg, 50-30 (6)/75-40 (5)/125-30(10)
levonorgestrel-ethin estradiol oral
tablets,dose pack,3 month 0.15-30
mg-mcg
levonorgestrel-ethinyl estrad oral
tablet
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month
l-norgest-eth estr/ethin estra
next choice one dose 1.5 mg tb (rx)
1.5 mg
norelgestromin/ethin.estradiol
noreth-ethinyl estradiol/iron
norethindrone
norethindrone (contraceptive)
norethindrone ac-eth estradiol oral
tablet 1-20 mg-mcg, 1.5-30 mg-mcg
norethindrone-e.estradiol-iron oral
tablet 1 mg-20 mcg (21)/75 mg (7),
1 mg-20 mcg (24)/75 mg (4), 120(5)/1-30(7) /1mg-35mcg (9), 1.5
mg-30 mcg (21)/75 mg (7)
norethindrone-ethinyl estrad oral
tablet 0.4-35 mg-mcg, 0.5-35 mgmcg, 0.5-35/1-35 mg-mcg/mg-mcg,
0.5/0.75/1 mg- 35 mcg, 0.5/1/0.5-35
mg-mcg, 1-35 mg-mcg
QL (91 per 84 days)
QL (6 per 365 days)
QL (6 per 365 days)
QL (91 per 84 days)
(LevonorgestrelEthin Estradiol)
1
$0
(Amethyst)
1
$0
1
$0
1
$0
(Plan B One-Step)
1
$0
(Ortho Evra)
(Femcon Fe)
(Nor-Q-D)
(Nor-Q-D)
1
1
1
1
$0
$0
$0
$0
(Loestrin)
1
$0
(Loestrin Fe)
1
$0
(Modicon)
1
$0
(LevonorgestrelEthin Estradiol)
(Seasonique)
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
QL (91 per 84 days)
QL (6 per 365 days)
QL (3 per 28 days)
83
83
Name of Drug
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
NUVARING
opcicon one-step *
PLAN B ONE-STEP *
tarina fe
(Norinyl 1+50)
(Ortho-Cyclen)
(Norgestrel-Ethinyl
Estradiol)
(Plan B One-Step)
(Loestrin Fe)
Tier level
What the
drug will
cost you
1
1
$0
$0
1
$0
2
4
3
1
$0
$0
$0
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (1 per 28 days)
QL (6 per 365 days)
QL (6 per 365 days)
Cough And Cold Products
Cough And Cold Products
30pse-150gfn-15dm *
(Trispec Pse)
adt robitussin peak cld dm max *
(G-Zyncof)
(Pseudoephedrine
adult nasal decongestant *
HCl)
(Dextromethorphan
adult robitussin lingering cld *
Hbr)
adult robitussin peak cold dm *
(G-Zyncof)
(Robitussin
adult wal-tussin *
Mucus-Chest
Congest)
adult wal-tussin dm max *
(G-Zyncof)
(Guaifenesin/Dextr
alka-seltzer plus mucus-conges *
omethorphan)
(Dalka-seltzer plus sinus-cough *
Methorphan/Pe/Ac
etaminophen)
(Dm/Phenyleph/Ch
ambi 10peh-4cpm-20dm *
lorpheniramine)
ambi 20dm-4cpm *
(Coricidin Hbp)
(Guaifenesin/Dm/P
ambi 40pse-400gfn-20dm *
seudoephedrine)
(D-Methorphan
ambi 60pse-4cpm-20dm *
Hb/P-Ephed
HCl/Cp)
benzonatate *
(Zonatuss)
84
84
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
(D-Methorphan
bio-dtuss dmx *
Hb/P-Epd
4
$0
HCl/Bpm)
(Guaifenesin/Dm/P
bionel *
4
$0
seudoephedrine)
bionel pediatric *
(Trispec Pse)
4
$0
biospec dmx *
(G-Zyncof)
4
$0
(D-Methorphan
bromphenex dm *
Hb/P-Epd
4
$0
HCl/Bpm)
(D-Methorphan
brompheniramine-pseudoeph-dm * Hb/P-Epd
4
$0
HCl/Bpm)
brompheniram-phenylephrine-dm * (Ala-Hist Dm)
3
$0
broncotron-s *
(G-Zyncof)
4
$0
cardec dm (phenyleph-chlorphn) * (Accuhist Pdx)
4
$0
cheratussin ac *
(M-Clear Wc)
4
$0
cheratussin dac *
(Tusnel C)
4
$0
chest congestion relief + dm *
(Allfen Dm)
4
$0
(Guaifenesin/Pseud
chest congestion relief d *
4
$0
oephedrne HCl)
chest congestion relief pe *
(Maxiphen)
4
$0
(D-Methorphan
child cough & sore throat *
Hb/Acetaminophen
4
$0
)
(Robitussin
child mucinex chest congestion *
Mucus-Chest
4
$0
Congest)
child mucus relief cough *
(G-Zyncof)
4
$0
(Dextromethorphn/
child plus cough & runny nose *
4
$0
Acetaminoph/Cp)
(Robitussin-Dm
child triaminic cough-congest *
4
$0
Cough)
(Dextromethorphan
child wal-tussin cough relief *
4
$0
Hbr)
(Robitussin
children's chest congestion *
Mucus-Chest
4
$0
Congest)
85
85
Name of Drug
CHILDREN'S DIMETAPP COLD
&FLU *
(Childrens Tylenol
Plus Cold)
children's mucinex cough *
(G-Zyncof)
(Pseudoephedrine
children's silfedrine *
HCl)
(Pseudoephedrine
children's sudafed *
HCl)
(Dextromethorphan
children's sudafed pe cough *
/Phenylephrine)
chlophedianol-guaifenesin *
(Vanacof G)
(Dm/Phenyleph/Ch
chlorpheniramine-phenyleph-dm *
lorpheniramine)
(Pyrilamine/Pe/De
codituss dm *
xtromethorphan)
(Comtrex Cold and
cold multi-symptom *
Cough)
(Dm
cold multi-symptom day/night *
Hb/Pe/Acetaminop
hen/Chlorph)
(Dm/Pe/Acetamino
cold multi-symptom nighttime *
phen/Doxylamine)
(Dm
cold relief m/s day/night *
Hb/Pe/Acetaminop
hen/Chlorph)
(Dcold-flu relief * oral liquid 12.5-30Methorphan/Aceta
1,000 mg/30 ml
min/Doxylamn)
(Vicks Dayquilcold-flu relief, day/night *
Nyquil)
(Guaifenesin/Pseud
congestac *
oephedrne HCl)
(Guaifenesin/Dextr
coricidin hbp * oral capsule
omethorphan)
cough & cold * oral
(Coricidin Hbp)
cough & runny nose * oral liquid 1- (Vicks Children'S
5 mg/5 ml
Nyquil)
children's flu relief *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
86
86
Name of Drug
creo-terpin (dm-guaifenesin) *
DALLERGY DM *
daytime cold & cough *
(Robitussin-Dm
Cough)
Tier level
What the
drug will
cost you
4
$0
4
4
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
(Triaminic)
(Ddaytime cold-flu *
Methorphan/Pe/Ac
4
$0
etaminophen)
(Dextromethorphan
day-time cough *
4
$0
Hbr)
daytime mucus relief dm *
(G-Zyncof)
4
$0
(Vicks Dayquildaytime-nighttime *
4
$0
Nyquil)
(Dm/Pe/Acetamino
daytime-nighttime cold-flu *
4
$0
phen/Doxylamine)
(Dextromethorphan
daytime-nighttime cough *
4
$0
Hb/Doxylamine)
decongestant cough *
(Trispec Pse)
4
$0
delsym cough+chest congest dm *
(G-Zyncof)
4
$0
despec-dm (pseudoeph-dm-guaif) * (Guaifenesin/Dm/P
4
$0
oral tablet 30-10-200 mg
seudoephedrine)
(Ddexchlorphen-pse-chlophedianol * Chlorphenira/Pse/C
4
$0
hlophedian)
dextromethorphan polistirex *
(Delsym)
4
$0
(Robitussin
diabetic siltussin das-na *
Mucus-Chest
4
$0
Congest)
diabetic tussin dm *
(G-Zyncof)
4
$0
(Robitussin
diabetic tussin ex * oral
Mucus-Chest
4
$0
Congest)
(Brompheniram/Ph
dimaphen dm *
4
$0
enylephrine/Dm)
(D-Methorphan
d-methorphan hb-p-epd hcl-bpm *
Hb/P-Epd
3
$0
oral syrup 2-30-10 mg/5 ml
HCl/Bpm)
dm-phenyleph-chlorpheniramine * (Dm/Phenyleph/Ch
4
$0
oral drops 1-2-3 mg/ml
lorpheniramine)
87
87
Tier level
What the
drug will
cost you
4
$0
(G-Zyncof)
(Despec)
(Trispec Pse)
(Guaifenesin/Dm/P
seudoephedrine)
(Dextromethorphan
/Pseudoephed)
(Robitussin
Mucus-Chest
Congest)
(Dm/Pe/Acetamino
ph/Diphenhydram)
(Theraflu)
(DMethorphan/Pe/Ac
etaminophen)
(M-Clear Wc)
(Tusnel C)
(Allfen)
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
(Mucinex)
4
$0
4
$0
3
$0
3
$0
3
$0
3
$0
Name of Drug
dm-phenyleph-chlorpheniramine *
oral liquid 2-5-15 mg/5 ml, 4-10-15
mg/5 ml
double-tussin dm *
ed bron gp *
entre-cough *
exefen dmx *
expectorant max strength *
expectorant * oral
flu formula daytime-nighttime *
flu severe cold-congestion *
flu-severe cold-cough * oral
powder in packet 10-20-650 mg
guaiatussin ac *
guaifenesin dac *
guaifenesin * oral tablet 200 mg
guaifenesin * oral tablet extended
release 12hr
head congestion day-night *
hydrocodone bit-homatrop me-br *
oral syrup 5-1.5 mg/5 ml
hydrocodone-chlorpheniramine *
hydrocodone-homatropine * oral
syrup 5-1.5 mg/5 ml
hydrocodone-homatropine * oral
tablet
(Dm/Phenyleph/Ch
lorpheniramine)
(Dm
Hb/Pe/Acetaminop
hen/Chlorph)
(Hydrocodone
Bit/Homatrop MeBr)
(Tussionex)
(Hydrocodone
Bit/Homatrop MeBr)
(Tussigon)
Necessary Actions,
Restrictions, or
Limits on Use
(Dm/Pseudoephed/
4
$0
Acetaminophen)
88
88
infants' non-aspirin cold *
Name of Drug
intense cough reliever * oral liquid
kidkare cough/cold *
liquibid d-r *
lohist peb dm *
lortuss ex * oral syrup
mar-cof bp *
mar-cof cg *
maximum strength flu *
medi-brom *
mesehist dm *
mucinex fast-max dm max *
mucinex fast-max sev cld-sinus *
mucus dm *
mucus dm max *
mucus relief * oral tablet 400 mg
multi-symptom cold night time *
multi-symptom cold-cough *
nasal & sinus decongestant *
neo-tuss *
NEXAFED *
night time cold-flu * oral
night time cold-flu relief * oral
liquid
(G-Zyncof)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Maxiphen)
(Ala-Hist Dm)
(Tusnel C)
(Bromphenira/Pseu
doephed/Codein)
(M-Clear Wc)
(Coricidin Hbp)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(G-Zyncof)
(DMethorphan/Pe/Ac
etaminophen)
(Mucinex Dm)
(Mucinex Dm)
(Allfen)
(Theraflu)
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
(Sudafed 12-Hour)
(G-Zyncof)
(Dm/PEphed/Acetaminop
h/Doxylam)
h/Doxylam)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
4
4
$0
$0
$0
3
$0
3
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
89
89
Name of Drug
night time * oral capsule
nighttime cold-flu *
nighttime cough *
nite time cold-flu * oral
nite time-d cold-flu relief *
nohist-dm *
non-aspirin cold *
non-aspirin flu * oral tablet 30-15500 mg
pecgen dmx * oral liquid 15-125
mg/5 ml
pedia relief *
pedia relief infant *
pediacare multi-symptom cold *
phenylhistine dh *
poly-tussin *
h/Doxylam)
(DMethorphan/Aceta
min/Doxylamn)
(Dextromethorphan
Hb/Doxylamine)
(DMethorphan/Aceta
min/Doxylamn)
h/Doxylam)
(Dm/Phenyleph/Ch
lorpheniramine)
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
(Dm/Pseudoephed/
Acetaminophen)
(G-Zyncof)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Dextromethorphan
/Pseudoephed)
(Dextromethorphan
/Phenylephrine)
(P-Ephed
HCl/Cod/Chlorphe
nir)
(Chlorcyclizine/Co
deine)
POLY-TUSSIN DM *
promethazine-codeine *
(Promethazine
HCl/Codeine)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
Necessary Actions,
Restrictions, or
Limits on Use
90
90
Name of Drug
promethazine-dm *
promethazine-phenyleph-codeine *
pseudoephedrine hcl * oral
pseudoephedrine hcl * oral
q-tapp dm *
q-tussin *
q-tussin dm *
refenesen * oral tablet 200 mg
refenesen * oral tablet 400 mg
refenesen pe *
relcof c *
REZIRA *
robafen *
robafen cough *
robafen dm *
robitussin cough & cold cf *
robitussin cough-chest-cong dm *
(D-Methorphan
Hb/Prometh HCl)
(Promethazine/Phe
nyleph/Codeine)
(Pseudoephedrine
HCl)
(Sudafed 12-Hour)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(Robitussin
Mucus-Chest
Congest)
(Robitussin-Dm
Cough)
(Allfen)
(Maxiphen)
(M-Clear Wc)
(Robitussin
Mucus-Chest
Congest)
(Dextromethorphan
Hbr)
(Robitussin-Dm
Cough)
(Giltuss)
(Guaifenesin/Dextr
omethorphan)
robitussin dm max *
ROBITUSSIN LONG-ACTING *
robitussin pediatric *
(Dextromethorphan
Hbr)
ROBITUSSIN-DM *
rydex *
(Bromphenira/Pseu
doephed/Codein)
Tier level
What the
drug will
cost you
3
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
3
3
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
91
91
Name of Drug
safe tussin dm *
scot-tussin dm *
scot-tussin expectorant *
siltussin dm das *
siltussin sa *
sudogest *
suphedrin * oral
suphedrine pe day-night *
suphedrine severe cold max str *
(G-Zyncof)
(Vicks Children'S
Nyquil)
(Robitussin
Mucus-Chest
Congest)
(G-Zyncof)
(Robitussin
Mucus-Chest
Congest)
(Sudafed 12-Hour)
(Pseudoephedrine
HCl)
(Diphenhydram/Pe/
Dm/Acetamin/Gg)
(Dm/Pseudoephed/
Acetaminophen)
THERAFLU NIGHTTIME
SEVERE COLD *
THERAFLU SEVERE COLDCOUGH *
triacting m-sym cold/cough *
triaminic cold & cough (pe) *
triaminic cough-nasal congesti *
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Dextromethorphan
/Phenylephrine)
(Dextromethorphan
/Pseudoephed)
TRIAMINIC COUGH-SORE
THROAT *
tri-dex pe *
(Dm/Phenyleph/Ch
lorpheniramine)
(Accuhist Pdx)
(M-Clear Wc)
(G-Zyncof)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
trigofen dm *
4
$0
trymine cg *
4
$0
tusnel diabetic *
4
$0
TUSNEL PEDIATRIC * ORAL
4
$0
LIQUID
tussin cf cough-cold *
(Giltuss)
4
$0
92
92
Name of Drug
tussin cf * oral
tussin cold-congestion *
tussin cough (dm only) * oral
(Guaifenesin/Dm/P
seudoephedrine)
(Guaifenesin/Dm/P
seudoephedrine)
(Dextromethorphan
Hbr)
tussin dm cough & chest * oral
(G-Zyncof)
liquid 10-200 mg/5 ml
tussin dm * oral syrup 15-100 mg/5 (Robitussin-Dm
ml
Cough)
(Dextromethorphan
tussin maximum strength cough *
Hbr)
tussin pe * oral liquid
(Despec)
(D-Methorphan
valu-tapp dm *
Hb/P-Epd
HCl/Bpm)
(Dextromethorphan
vicks dayquil cough *
Hbr)
(Dextromethorphan
vicks nature fusion cough *
Hbr)
virdec dm *
(Accuhist Pdx)
wal-phed * oral tablet 30 mg
(Sudafed 12-Hour)
(Diphenhydram/Pe/
wal-phed pe day-night *
Dm/Acetamin/Gg)
(Dextromethorphan
wal-tussin cough *
Hbr)
wal-tussin cough & cold cf *
(Giltuss)
(Robitussin-Dm
wal-tussin dm *
Cough)
zephrex-d *
(Sudafed 12-Hour)
ZONATUSS *
zyncof * oral liquid
(G-Zyncof)
zyncof * oral tablet
(Allfen Dm)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
3
4
4
$0
$0
$0
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
Dental And Oral Agents
Dental And Oral Agents
cevimeline
(Evoxac)
93
93
Tier level
What the
drug will
cost you
1
$0
4
$0
1
3
$0
$0
1
$0
(Soriatane)
2
1
$0
$0
(Benzoyl Peroxide)
4
$0
(Benzoyl Peroxide)
(Zovirax)
4
1
1
1
1
1
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
(Lac-Hydrin)
1
$0
(Lac-Hydrin)
1
$0
2
$0
(Benzoyl Peroxide)
4
$0
(Benzac Ac)
(Benzoyl Peroxide)
3
4
$0
$0
(Benzoyl Peroxide)
4
$0
Name of Drug
chlorhexidine gluconate mucous
membrane
PHOS-FLUR * DENTAL
SOLUTION
pilocarpine hcl oral
PREVIDENT 5000 SENSITIVE *
triamcinolone acetonide dental
paste 0.1 %
(Peridex)
(Salagen)
(Triamcinolone
Acetonide)
Necessary Actions,
Restrictions, or
Limits on Use
Dermatological Agents
Dermatological Agents, Other
8-MOP
acitretin
acne medication * topical lotion 10
%
acne-clear *
acyclovir topical
ALCOHOL PADS
ALCOHOL PREP PADS
ALCOH-WIPE
aluminum chloride
amlactin * topical lotion
ammonium lactate * 12% cream
fragrance free (otc)
ammonium lactate * 12% lotion
(otc)
ammonium lactate topical cream 12
%
ammonium lactate topical lotion 12
%
ANACAINE
benzoyl peroxide * 10% gel
aqueous (otc)
benzoyl peroxide * topical gel 10 %
benzoyl peroxide * topical gel 5 %
benzoyl peroxide * topical lotion 5
%
(Drysol)
(Lac-Hydrin
Twelve)
(Ammonium
Lactate)
(Lac-Hydrin
Twelve)
QL (30 per 30 days)
94
94
Tier level
What the
drug will
cost you
4
1
1
1
1
$0
$0
$0
$0
$0
4
$0
2
2
2
1
1
$0
$0
$0
$0
$0
4
$0
(Aldara)
1
$0
(Isotretinoin)
1
$0
4
4
1
1
2
4
2
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
$0
2
$0
1
$0
4
$0
Name of Drug
BETADINE SPRAY *
calcipotriene
calcipotriene topical cream
calcipotriene topical solution
calcitriol topical
CASTELLANI PAINT MODIFIED
*
CONDYLOX TOPICAL GEL
COSENTYX PEN (2 PENS)
FLUOROPLEX
fluorouracil topical cream
fluorouracil topical solution
geri-hydrolac * topical
imiquimod
isotretinoin oral capsule 10 mg, 20
mg, 30 mg, 40 mg
LACTINOL HX *
lobana bath *
mafenide acetate
methoxsalen rapid
PANRETIN
persa-gel *
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
podofilox
podophyllum resin
potassium hydroxide
(Calcipotriene)
(Dovonex)
(Calcipotriene)
(Vectical)
(Carac)
(Fluorouracil)
(Lac-Hydrin
Twelve)
(Mineral Oil)
(Mafenide Acetate)
(Oxsoralen-Ultra)
(Benzoyl Peroxide)
(Condylox)
(Podophyllum
Resin)
(Potassium
Hydroxide)
SANTYL
silver nitrate applicators
skin treatment *
(Silver Nitrate
Applicator)
(Lac-Hydrin
Twelve)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA NSO; QL (24 per
30 days)
QL (3 per 56 days)
QL (2 per 56 days)
VALCHLOR
2
$0
95
95
Name of Drug
Tier level
What the
drug will
cost you
zinc oxide * topical ointment
(Boudreauxs)
ZOVIRAX TOPICAL CREAM
Dermatological Antibacterials
bacitracin * topical
(Bacitracin)
bacitraycin plus * topical ointment
(Bacitracin)
500 unit/gram
clindamycin phosphate topical gel
(Cleocin T)
clindamycin phosphate topical
(Cleocin T)
lotion
clindamycin phosphate topical
(Cleocin T)
solution
clindamycin phosphate topical swab (Cleocin T)
(Erythromycin
erythromycin base-ethanol
Base/Ethanol)
erythromycin with ethanol topical
(Emgel)
gel
(Erythromycin
solution
Base/Ethanol)
(Erythromycin
swab
Base/Ethanol)
(Gentamicin
gentamicin topical
Sulfate)
metronidazole topical cream 0.75 % (Metrocream)
metronidazole topical
(Nydamax)
metronidazole topical
(Metrolotion)
mupirocin
(Centany)
mupirocin calcium
(Bactroban)
(Neosporin G.U.
neomycin-polymyxin b gu
Irrigant)
selenium sulfide
(Selenium Sulfide)
silver nitrate topical
(Silver Nitrate)
silver sulfadiazine topical cream 1
(Silvadene)
%
sulfacetamide sodium (acne)
(Klaron)
Dermatological Anti-Inflammatory Agents
alclometasone topical cream
(Aclovate)
4
2
$0
$0
4
$0
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
1
$0
1
1
$0
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (15 per 30 days)
96
96
Tier level
What the
drug will
cost you
1
$0
4
4
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(Diprolene AF)
1
$0
(Betamethasone
Dipropionate)
1
$0
(Diprolene)
1
$0
(Diprolene)
1
$0
1
$0
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
1
$0
1
$0
Name of Drug
alclometasone topical ointment
aquanil hc *
beta-hc *
betamethasone dipropionate topical
cream
lotion
ointment
betamethasone valerate topical
cream
foam
lotion
ointment
betamethasone, augmented topical
cream
gel
lotion
ointment
clobetasol propionate topical
solution 0.05 %
clobetasol topical cream
clobetasol topical foam
clobetasol topical gel
clobetasol topical lotion
clobetasol topical ointment
clobetasol topical shampoo
clobetasol topical solution
clobetasol-emollient topical
(Alclometasone
Dipropionate)
(Cortizone-10)
(Cortizone-10)
(Diprosone)
(Betamethasone
Dipropionate)
(Betamethasone
Dipropionate)
(Betamethasone
Valerate)
(Luxiq)
(Betamethasone
Valerate)
(Betamethasone
Valerate)
(Clobetasol
Propionate)
(Temovate)
(Olux)
(Temovate)
(Clobex)
(Temovate)
(Clobex)
(Clobetasol
Propionate)
(Temovate)
Necessary Actions,
Restrictions, or
Limits on Use
97
97
Tier level
What the
drug will
cost you
1
$0
2
$0
4
$0
4
$0
4
4
1
1
1
$0
$0
$0
$0
$0
2
$0
(Vanos)
(Fluocinonide)
(Fluocinonide)
(Fluocinonide)
(Vanos)
(Cutivate)
(Fluticasone
Propionate)
(Ultravate)
(Cortizone-10)
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
1
$0
1
4
$0
$0
(Hydrocortisone)
4
$0
(Cortizone-10)
3
$0
(Hydrocortisone)
4
$0
(Nuzon)
1
$0
4
$0
1
$0
1
1
1
$0
$0
$0
Name of Drug
clocortolone pivalate
CORDRAN TOPICAL
OINTMENT
cortizone-10 * topical cream
CORTIZONE-10 * TOPICAL
LOTION
cortizone-10 * topical ointment
dermarest eczema (hydrocort) *
desonide topical cream
desonide topical ointment
desoximetasone
(Cloderm)
(Hydrocortisone)
(Hydrocortisone)
(Cortizone-10)
(Desowen)
(Tridesilon)
(Topicort)
ELIDEL
fluocinonide topical cream 0.05 %
fluocinonide topical gel
fluocinonide topical ointment
fluocinonide topical solution
fluocinonide-emollient base
fluticasone topical cream
fluticasone topical ointment
halobetasol propionate
hydro skin * topical
hydrocortisone * 1% cream
maximum strength (otc)
hydrocortisone * 1% lotion (otc)
hydrocortisone * 1% ointment
carton (otc)
hydrocortisone acet-aloe vera
topical gel
hydrocortisone acetate * topical
cream 1 %
hydrocortisone acetate-urea
hydrocortisone butyrate
hydrocortisone butyr-emollient
hydrocortisone rectal cream 1 %
(Hydrocortisone
Acetate)
(Hydrocortisone
Acetate/Urea)
(Locoid)
(Locoid)
(Anusol-HC)
Necessary Actions,
Restrictions, or
Limits on Use
PA; (PA for Ages < 2);
AGE (Min 2 Years)
98
98
Tier level
What the
drug will
cost you
(Hydrocortisone)
(Cortenema)
1
1
$0
$0
(Hydrocortisone)
4
$0
(Anusol-HC)
1
$0
(Rederm)
3
$0
(Rederm)
1
$0
(Hydrocortisone)
4
$0
(Hydrocortisone)
1
$0
(Hydrocortisone
Valerate)
1
$0
(Westcort)
1
$0
(Elocon)
(Hydrocortisone)
(Dermatop)
(Hydrocortisone)
(Hydrocortisone)
(Protopic)
(Triamcinolone
Acetonide)
1
4
1
4
4
1
$0
$0
$0
$0
$0
$0
1
$0
(Kenalog)
1
$0
(Triderm)
1
$0
(Triamcinolone
Acetonide)
1
$0
1
1
2
1
$0
$0
$0
$0
Name of Drug
hydrocortisone rectal cream 2.5 %
hydrocortisone rectal enema
hydrocortisone * topical cream 0.5
%
hydrocortisone topical cream 1 %,
2.5 %
hydrocortisone * topical lotion 1 %
hydrocortisone topical lotion 2 %,
2.5 %
hydrocortisone * topical ointment
0.5 %
hydrocortisone topical ointment 1
%, 2.5 %
hydrocortisone valerate topical
cream
hydrocortisone valerate topical
ointment
mometasone
neosporin anti-itch *
prednicarbate
preparation h hydrocortisone *
recort plus *
tacrolimus topical
triamcinolone acetonide topical
cream
lotion
ointment 0.025 %, 0.05 %, 0.1 %,
0.5 %
triderm topical cream
Dermatological Retinoids
adapalene topical cream
adapalene topical gel 0.1 %
TAZORAC TOPICAL CREAM
tretinoin microspheres
(Differin)
(Differin)
(Retin-A Micro)
Necessary Actions,
Restrictions, or
Limits on Use
PA
99
99
Name of Drug
Tier level
What the
drug will
cost you
tretinoin topical
(Retin-A)
Scabicides And Pediculicides
lice cream rinse *
(Nix)
(Piperonyl
lice killing *
Butoxide/Pyrethrin
s)
lice treatment * topical liquid 1 %
(Nix)
malathion
(Ovide)
permethrin topical cream
(Elimite)
permethrin * topical liquid
(Nix)
1
$0
4
$0
4
$0
4
1
1
4
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
2
2
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
Devices
Devices
ASSURE ID INSULIN SAFETY
SYRINGE
BD INSULIN PEN NEEDLE UF
SHORT
BD INSULIN SYRINGE ULTRAFINE SYRINGE 0.3 ML 31 X
5/16", 1 ML 31 X 5/16", 1/2 ML 31
X 5/16"
INSULIN PEN NEEDLE NEEDLE
INSULIN SYRINGE
NEEDLELESS
INSULIN SYRINGE SYRINGE
INSULIN SYRINGE-NEEDLE U100 SYRINGE
SURE COMFORT INS. SYR. U100
Disinfectants (For Non-Dermatologic Use)
Disinfectants (For Non-Dermatologic Use)
iodine *
(Iodine)
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
100
100
Name of Drug
CEREZYME INTRAVENOUS
RECON SOLN 400 UNIT
CIMZIA
CIMZIA POWDER FOR
RECONST
CREON
ELAPRASE
ELITEK INTRAVENOUS RECON
SOLN
FABRAZYME INTRAVENOUS
RECON SOLN
KRYSTEXXA
KUVAN
LINZESS
lipase-protease-amylase
(Zenpep)
LOTRONEX
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
PULMOZYME
VIMIZIM
VPRIV
ZAVESCA
ZENPEP
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
2
$0
$0
2
$0
2
$0
2
2
2
1
2
2
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
4
1
4
1
4
$0
$0
$0
$0
$0
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
QL (30 per 30 days)
PA BvD
PA
QL (90 per 30 days)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents, Miscellaneous
AKTEN (PF)
alaway *
(Zaditor)
altacaine
(Tetcaine)
altamist *
(Little Remedies)
apraclonidine
(Iopidine)
artificial tears (petro/min) *
(Genteal Pm)
(Dextran
artificial tears (pf) * ophthalmic
70/Hypromellose/P
dropperette 0.1-0.3 %
F)
101
101
Name of Drug
artificial tears * ophthalmic drops
0.1-0.3 %
artificial tears * ophthalmic drops
0.5-0.6 %
artificial tears * ophthalmic
ointment
artificial tears(glycerin-peg) *
artificial tears(hypromellose) *
atropine ophthalmic drops
atropine ophthalmic ointment
ayr saline * nasal aerosol,spray
ayr saline * nasal drops
azelastine nasal
azelastine ophthalmic
bion tears (pf) *
carteolol
cromolyn ophthalmic
CYCLOGYL OPHTHALMIC
DROPS 0.5 %
cyclopentolate
CYSTARAN
deep sea nasal *
dristan long lasting *
epinastine
eq gentle *
GENTEAL MILD TO
MODERATE *
GENTEAL GEL *
GENTEAL MILD *
GENTEAL SEVERE *
(Tears Naturale)
(Polyvinyl
Alcohol/Povidone)
(Petrolat,Wht/Min
Oil/Sod Chl)
(Glycerin/Propylen
e Glycol)
(Genteal Mild To
Moderate)
(Isopto Atropine)
(Atropine Sulfate)
(Little Remedies)
(Sodium Chloride)
(Astepro)
(Optivar)
(Dextran
70/Hypromellose/P
F)
(Carteolol HCl)
(Cromolyn
Sodium)
(Cyclogyl)
(Little Remedies)
(Oxymetazoline
HCl)
(Elestat)
(Genteal Mild To
Moderate)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
1
1
4
4
1
1
$0
$0
$0
$0
$0
$0
4
$0
1
$0
1
$0
2
$0
1
2
4
$0
$0
$0
4
$0
1
$0
4
$0
4
$0
4
4
4
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 25 days)
102
102
Tier level
What the
drug will
cost you
(Isopto
Homatropine)
1
$0
(Atrovent)
1
$0
(Atrovent)
1
$0
4
$0
4
2
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Refresh Tears)
4
$0
(Refresh Optive)
(Genteal Pm)
(Sodium Chloride)
(Naphazoline HCl)
(Afrin)
(Genteal Mild To
Moderate)
(Dextran
70/Hypromellose/P
F)
(Genteal Mild To
Moderate)
4
4
4
1
4
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
Name of Drug
homatropine hbr
ipratropium bromide nasal
spray,non-aerosol 0.03 %
ipratropium bromide nasal
spray,non-aerosol 0.06 %
isopto tears *
ketotifen fumarate *
LACRISERT
liquitears *
lubricant dry eye relief *
lubricant eye (cmc-glycer)(pf) *
lubricant eye (cmc-glycerin) *
lubricant eye (polyv alcohol) *
lubricant eye (propyl glycol) *
lubricant eye drops * ophthalmic
dropperette
lubricant eye drops * ophthalmic
drops
lubricating drops *
lubrifresh pm *
muro 128 *
naphazoline
nasal decongestant (oxymetazl) *
natural balance *
natural tears (pf) *
nature's tears *
(Genteal Mild To
Moderate)
(Zaditor)
(Polyvinyl
Alcohol)
(Carboxymethylcel
lulose Sodium)
(Carboxymethylcel
l/Glycerin/PF)
(Refresh Optive)
(Polyvinyl
Alcohol)
(Propylene Glycol)
(Carboxymethylcel
lulose Sodium)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 28 days)
QL (15 per 10 days)
103
103
Tier level
What the
drug will
cost you
4
$0
4
$0
(Mydfrin)
(Proparacaine HCl)
4
1
2
2
1
1
$0
$0
$0
$0
$0
$0
(Proparacaine HCl)
1
$0
1
$0
4
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
4
4
4
4
$0
$0
$0
$0
$0
4
$0
4
$0
4
1
$0
$0
4
$0
4
$0
Name of Drug
neo-synephrine 12 h spr (oxym) *
nighttime relief eye *
ocean nasal *
olopatadine
PATADAY
PATANOL
phenylephrine hcl ophthalmic
proparacaine
proparacaine hcl ophthalmic drops
0.5 %
proparacaine-fluorescein sod
pure & gentle eye *
(Oxymetazoline
HCl)
(Petrolat,Wht/Min
Oil/Sod Chl)
(Little Remedies)
(Patanase)
(Proparacaine/Fluo
rescein Sod)
(Genteal Mild To
Moderate)
REFRESH CLASSIC (PF) *
REFRESH LACRI-LUBE *
REFRESH LIQUIGEL *
REFRESH OPTIVE *
retaine cmc *
saline mist *
sea soft nasal mist *
sochlor * ophthalmic
sodium chloride * ophthalmic
STERILE LUBRICANT *
tears again * ophthalmic drops
tears again * ophthalmic ointment
TEARS NATURALE II *
tetracaine hcl
ultra fresh pm *
vicks qlearquil(oxymetazoline) *
(Carboxymethylcel
lulose Sodium)
(Little Remedies)
(Little Remedies)
(Sodium Chloride)
(Sodium Chloride)
(Polyvinyl
Alcohol)
(Lanolin/Min
Oil/Petrolat, Wht)
(Tetcaine)
(Lanolin/Min
Oil/Petrolat, Wht)
(Oxymetazoline
HCl)
Necessary Actions,
Restrictions, or
Limits on Use
ST
ST
104
104
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
vicks sinex 12-hour *
(Afrin)
4
$0
wal-zyr (ketotifen) *
(Zaditor)
4
$0
zyrtec itchy eye drops (keto) *
(Zaditor)
4
$0
Eye, Ear, Nose, Throat Anti-Infectives Agents
acetic acid otic
(Vosol)
1
$0
bacitracin ophthalmic
(Bacitracin)
1
$0
(Bacitracin/Polymy
bacitracin-polymyxin b ophthalmic
1
$0
xin B Sulfate)
CIPRODEX
2
$0
ciprofloxacin hcl ophthalmic
(Ciloxan)
1
$0
ciprofloxacin hcl otic
(Cetraxal)
1
$0
COLY-MYCIN S
2
$0
erythromycin ophthalmic
(Ilotycin)
1
$0
gatifloxacin
(Zymaxid)
1
$0
gentamicin ophthalmic
(Garamycin)
1
$0
gentamicin sulfate ophthalmic
(Garamycin)
1
$0
ointment 0.3 % (3 mg/gram)
levofloxacin ophthalmic
(Quixin)
1
$0
MOXEZA
2
$0
NATACYN
2
$0
(Neomycin Su/Baci
neomy sulf-bacitrac zn-poly-hc
1
$0
Zn/Poly/HC)
(Neomycin Su/Baci
neomycin-bacitracin-poly-hc
1
$0
Zn/Poly/HC)
(Neomycin
neomycin-bacitracin-polymyxin
Su/Bacitra/Polymy
1
$0
xin)
neomycin-polymyxin b-dexameth
(Maxitrol)
1
$0
neomycin-polymyxin-gramicidin
(Neosporin)
1
$0
neomycin-polymyxin-hc
(Oticin HC)
1
$0
ofloxacin ophthalmic
(Ocuflox)
1
$0
ofloxacin otic
(Ocuflox)
1
$0
polymyxin b sulf-trimethoprim
(Polytrim)
1
$0
REFRESH OPTIVE ADVANCED
4
$0
*
(Sulfacetamide
sulfacetamide sodium
1
$0
Sodium)
105
105
Name of Drug
sulfacetamide sodium ophthalmic
drops 10 %
sulfacetamide-prednisolone
Tier level
What the
drug will
cost you
1
$0
1
$0
2
1
1
2
2
$0
$0
$0
$0
$0
2
$0
1
$0
1
$0
1
$0
2
1
1
1
2
1
2
2
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
2
2
$0
$0
4
4
4
$0
$0
$0
(Sulfacetamide
Sodium)
(Sulfacetamide/Pre
dnisolone Sp)
TOBRADEX ST
tobramycin
(Tobrex)
trifluridine
(Viroptic)
VIGAMOX
ZYLET
Eye, Ear, Nose, Throat Anti-Inflammatory Agents
ALREX
(Bromfenac
bromfenac
Sodium)
dexamethasone sodium phosphate
(Dexasol)
ophthalmic
(Diclofenac
diclofenac sodium ophthalmic
Sodium)
DUREZOL
fluorometholone
(FML)
flurbiprofen sodium
(Ocufen)
fluticasone nasal
(Flonase)
ILEVRO
ketorolac ophthalmic
(Acular)
LOTEMAX
NASONEX
NEVANAC
prednisolone acetate
(Omnipred)
prednisolone sodium phosphate
(Prednisolone Sod
ophthalmic
Phosphate)
PROLENSA
RESTASIS
Necessary Actions,
Restrictions, or
Limits on Use
QL (16 per 30 days)
QL (34 per 28 days)
QL (60 per 30 days)
Gastrointestinal Agents
Antiflatulents
anti-gas maximum strength *
bicarsim forte *
gas free extra strength *
(Gas-X)
(Simethicone)
(Gas-X)
106
106
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
gas relief 80 *
(Gas-X)
4
$0
gas relief extra strength * oral
(Gas-X)
4
$0
gas relief * oral
(Gas-X)
4
$0
gas-x ultra-strength *
(Gas-X)
4
$0
mi-acid gas relief *
(Gas-X)
4
$0
mylanta gas *
(Gas-X)
4
$0
mytab gas *
(Gas-X)
4
$0
mytab gas maximum strength *
(Gas-X)
4
$0
simethicone * oral capsule 180 mg (Gas-X)
4
$0
simethicone * oral
(Infants' Mylicon)
4
$0
Antiulcer Agents And Acid Suppressants
acid reducer (famotidine) *
(Pepcid Ac)
4
$0
acid relief (cimetidine) *
(Tagamet Hb)
4
$0
amoxicil-clarithromy-lansopraz
(Prevpac)
1
$0
CARAFATE ORAL SUSPENSION
2
$0
cimetidine hcl oral
(Cimetidine HCl)
1
$0
cimetidine oral tablet 200 mg, 300
(Rx Product Only)
(Tagamet)
1
$0
mg, 400 mg, 800 mg
cvs cimetidine * 200 mg tablet (otc) (Tagamet Hb)
4
$0
esomeprazole sodium
(Nexium I.V.)
1
$0
famotidine (pf)
(Famotidine/PF)
1
$0
(Famotidine In
famotidine (pf)-nacl (iso-os)
1
$0
Nacl,Iso-Osm/PF)
famotidine oral tablet 20 mg, 40 mg (Pepcid)
1
$0
(Rx Product Only)
lansoprazole * dr 15 mg capsule
(Prevacid 24hr)
4
$0
2x14 day course (otc)
lansoprazole oral capsule,delayed
(Rx Product Only)
(Prevacid)
1
$0
release(dr/ec) 15 mg, 30 mg
misoprostol
(Cytotec)
1
$0
(Omeprazole
omeprazole magnesium *
4
$0
Magnesium)
omeprazole oral capsule,delayed
(Prilosec)
1
$0
release(dr/ec)
omeprazole * oral tablet,delayed
(Omeprazole)
4
$0
release (dr/ec)
omeprazole-sodium bicarbonate
(Rx Product Only)
(Zegerid)
3
$0
oral capsule 20-1.1 mg-gram
107
107
Name of Drug
pantoprazole intravenous
(Pantoprazole
Sodium)
(Protonix)
pantoprazole oral
PRILOSEC OTC *
pub famotidine * 20 mg tablet max
(Pepcid Ac)
strength (otc)
ra omepraz-bicarb 20-1,100 cap
(Zegerid Otc)
3x14 day course (otc)
ranitidine 150 mg tablet maximum
(Zantac)
strength (otc)
ranitidine hcl injection
(Zantac)
ranitidine hcl oral syrup
(Ranitidine HCl)
ranitidine hcl oral tablet 150 mg,
(Zantac)
300 mg
ranitidine hcl * oral tablet 75 mg
(Zantac)
sucralfate oral suspension
(Sucralfate)
sucralfate oral tablet
(Carafate)
wal-zan 75 *
(Zantac)
zantac 75 *
(Zantac)
Gastrointestinal Agents, Other
acid gone antacid *
(Gaviscon)
almacone * oral suspension
(Mylanta)
almacone-2 *
(Mylanta)
aluminum hydroxide gel * oral
(Alternagel)
suspension 320 mg/5 ml
AMITIZA
(Calcium
antacid anti-gas * oral
Carbonate/Simethi
cone)
antacid * oral tablet,chewable 200
(Tums)
mg calcium (500 mg)
antacid plus anti-gas * oral
(Mylanta)
suspension
anti-diarrheal *
(Pepto-Bismol)
anti-diarrheal (loperamide) * oral
(Loperamide HCl)
capsule
anti-diarrheal (loperamide) * oral (Imodium A-D)
Tier level
What the
drug will
cost you
1
$0
1
4
$0
$0
4
$0
4
$0
4
$0
1
1
$0
$0
1
$0
4
1
1
4
4
$0
$0
$0
$0
$0
4
4
4
$0
$0
$0
4
$0
2
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
QL (60 per 30 days)
108
108
Tier level
What the
drug will
cost you
(Pepto-Bismol)
4
$0
(Pepto-Bismol)
(Tums)
4
2
4
$0
$0
$0
(Tums)
4
$0
(Tums)
4
$0
4
$0
4
4
4
2
4
1
4
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
4
4
$0
$0
$0
(Mylanta)
4
$0
(Almacone)
4
$0
(Robinul)
(Robinul)
(Loperamide HCl)
1
1
4
4
$0
$0
$0
$0
Name of Drug
bismatrol * oral suspension 262
mg/15 ml
bismatrol * oral tablet,chewable
BUPHENYL ORAL TABLET
calci-chew *
calcium antacid * oral
tablet,chewable
calcium carbonate * oral
tablet,chewable 500 mg calcium
(1,250 mg)
CALCIUM CARBONATEVITAMIN D3 * ORAL
TABLET,CHEWABLE 500-100
MG-UNIT
cal-gest antacid *
children's pepto *
children's soothe *
CHOLBAM
comfort gel extra strength *
cromolyn oral
diamode *
dicyclomine oral capsule
dicyclomine oral solution
dicyclomine oral tablet
diphenoxylate-atropine oral liquid
diphenoxylate-atropine oral tablet
flanax antacid *
foaming antacid *
gelusil antacid & anti-gas * oral
suspension
gelusil antacid & anti-gas * oral
tablet,chewable
glycopyrrolate
glycopyrrolate
imodium a-d * oral liquid
IMODIUM A-D * ORAL TABLET
(Tums)
(Tums)
(Tums)
(Mylanta)
(Gastrocrom)
(Imodium A-D)
(Bentyl)
(Dicyclomine HCl)
(Bentyl)
(Diphenoxylate
HCl/Atropine)
(Lomotil)
(Mylanta)
(Gaviscon)
Necessary Actions,
Restrictions, or
Limits on Use
109
109
Tier level
What the
drug will
cost you
(Pepto-Bismol)
(Lactulose)
(Loperamide HCl)
(Loperamide HCl)
(Mylanta)
4
1
1
4
4
4
$0
$0
$0
$0
$0
$0
(Uromag)
4
$0
(Magox 400)
4
$0
(Mylanta)
(Pamine)
(Reglan)
(Metoclopramide
HCl)
(Reglan)
(Mylanta)
(Rolaids)
(Mylanta)
(Mylanta)
(Almacone)
4
1
1
$0
$0
$0
1
$0
1
4
4
4
4
4
2
2
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
RELISTOR SUBCUTANEOUS
2
$0
RELISTOR SUBCUTANEOUS
2
$0
4
4
$0
$0
4
$0
4
$0
4
$0
Name of Drug
kaopectate (bismuth subsalicy) *
lactulose
loperamide oral
loperamide * oral
maalox advanced * oral suspension
MAGNEBIND 300 *
magnesium oxide * oral capsule
500 mg
magnesium oxide * oral tablet 250
mg, 400 mg, 500 mg
masanti double strength *
methscopolamine oral
metoclopramide hcl injection
metoclopramide hcl oral
metoclopramide hcl oral
mi-acid * oral suspension
mi-acid * oral tablet,chewable
mintox *
mintox maximum strength *
mintox plus *
MOVANTIK
NUTRESTORE
pep-t-med *
phillips *
ri-gel ii *
ri-mox *
sodium bicarbonate * oral tablet
650 mg
soothe (bismuth subsalicylate) *
oral
soothe regular strength *
(Pepto-Bismol)
(Magox 400)
(Mylanta)
(Mylanta)
(Sodium
Bicarbonate)
(Bismuth
Subsalicylate)
(Pepto-Bismol)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
110
110
Tier level
What the
drug will
cost you
4
$0
4
1
1
$0
$0
$0
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Miralax)
(Sof-Lax)
(Sof-Lax)
(Docusate Sodium)
(Surfak)
(Docusate Sodium)
(Docusate Sodium)
(Sof-Lax)
(Docusate Sodium)
(Sof-Lax)
(Enema)
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Enema)
4
$0
(Docusate Sodium)
(Docusol Plus)
(Calcium
Polycarbophil)
(Fibercon)
(Citrucel)
(Psyllium Seed)
(Psyllium Seed
(With Sugar))
4
4
$0
$0
4
$0
4
4
4
$0
$0
$0
4
$0
(Citrucel)
4
$0
(Citrucel)
4
$0
Name of Drug
stomach relief * oral
ultra strength antacid *
ursodiol oral capsule
ursodiol oral tablet
Laxatives
alophen *
bisac-evac *
bisacodyl * oral
bisacodyl * rectal
biscolax *
clearlax * oral
colace * oral capsule 100 mg
doc-q-lace * oral
docu *
docusate calcium *
docusate sodium * oral
docusol *
dok * oral capsule
dok * oral tablet
dulcolax stool softener (dss) *
enema disposable *
enema * rectal enema * 19-7
gram/118 ml
enemeez *
enemeez plus *
equalactin *
fiber (calcium polycarbophil) *
fiber laxative (methylcellulo) *
fiber smooth *
fiber therapy (psyllium/sugar) *
fiber therapy * oral powder 2
gram/19 gram
fiber therapy * oral tablet
(Bismuth
Subsalicylate)
(Tums)
(Actigall)
(Urso)
Necessary Actions,
Restrictions, or
Limits on Use
111
111
Tier level
What the
drug will
cost you
(Miralax)
(Miralax)
(Miralax)
(Psyllium Seed)
(Metamucil)
(Fibercon)
4
4
4
3
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
(Psyllium Husk)
4
$0
(Miralax)
(Milk Of
Magnesia)
(Mineral Oil)
4
$0
4
$0
4
2
$0
$0
4
$0
4
$0
1
1
1
$0
$0
$0
1
$0
4
$0
4
$0
4
$0
1
$0
(Miralax)
4
$0
(Docusate Sodium)
(Miralax)
(Psyllium Seed
(With Sugar))
4
4
$0
$0
4
$0
Name of Drug
fiber-lax *
FLEET BISACODYL *
gentlelax *
glycolax * oral powder
healthylax *
hydrocil instant *
konsyl (sugar) * oral
konsyl fiber *
konsyl sugar-free * oral powder in
packet
laxative peg 3350 *
milk of magnesia *
mineral oil laxative *
MOVIPREP
natural fiber laxative therapy *
oral saline laxative * oral
peg 3350-electrolytes
PEG 3350-GRX
peg 3350-na sulf,bicarb,cl-kcl
peg-electrolyte soln
peri-colace *
phillips liqui-gels *
phosphate laxative * oral
polyethylene glycol 3350 oral
powder
polyethylene glycol 3350 * oral
powder in packet
promolaxin *
purelax *
reguloid * oral powder
(Fibercon)
(Psyllium Seed
(With Sugar))
(Na Phos,M-B/Na
Phos,Di-Ba)
(Golytely)
(Golytely)
(Nulytely with
Flavor Packs)
(Sennosides/Docus
ate Sodium)
(Sof-Lax)
(Na Phos,M-B/Na
Phos,Di-Ba)
(Polyethylene
Glycol 3350)
Necessary Actions,
Restrictions, or
Limits on Use
112
112
Tier level
What the
drug will
cost you
(Sennosides)
(Senokot)
(Senokot)
(Sennosides)
(Sennosides)
(Senokot)
(Sennosides/Docus
ate Sodium)
(Sennosides/Docus
ate Sodium)
(Docusate Sodium)
(Colace)
(Miralax)
(Nulytely with
Flavor Packs)
(Dulcolax)
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
4
4
$0
$0
$0
1
$0
4
$0
(Phoslo)
(Calcium Acetate)
(Calcium
Carbonate/Mag
Carb/Fa)
(Calcium Acetate)
1
1
$0
$0
1
$0
4
2
2
2
$0
$0
$0
$0
1
$0
1
$0
1
$0
Name of Drug
senexon * oral syrup
senexon * oral tablet
senna lax *
senna * oral capsule
senna * oral syrup 8.8 mg/5 ml
senna * oral tablet
senna with docusate sodium *
senokot-s *
silace * oral liquid
silace * oral syrup
smoothlax * oral
sodium chloride-nahco3-kcl-peg
oral recon soln 420 gram
the magic bullet *
Phosphate Binders
calcium acetate oral capsule
calcium acetate oral tablet
calcium carbonate-mag carb-fa
calphron *
PHOSLYRA
RENAGEL
RENVELA
sodium polystyrene sulfonate oral
powder
sodium polystyrene sulfonate oral
suspension 15 gram/60 ml
sodium polystyrene sulfonate rectal
enema 30 gram/120 ml
(Sodium
Polystyrene
Sulfonate)
(Sodium
Polystyrene
Sulfonate)
(Sodium
Polystyrene
Sulfonate)
Necessary Actions,
Restrictions, or
Limits on Use
Genitourinary Agents
Antispasmodics, Urinary
113
113
Name of Drug
oxybutynin chloride oral tablet
(Oxybutynin
Chloride)
oxybutynin chloride oral tablet
(Ditropan XL)
extended release 24hr
tolterodine oral capsule,extended
(Detrol LA)
release 24hr
tolterodine oral tablet
(Detrol)
TOVIAZ
trospium oral capsule,extended
(Sanctura XR)
release 24hr
trospium oral tablet
(Sanctura)
Genitourinary Agents, Miscellaneous
alfuzosin
(Uroxatral)
tamsulosin
(Flomax)
terazosin
(Terazosin HCl)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
2
$0
$0
1
$0
1
$0
1
1
1
$0
$0
$0
1
2
2
2
$0
$0
$0
$0
1
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine injection recon soln
(Desferal)
DEPEN TITRATABS
EXJADE
FERRIPROX
sodium thiosulfate intravenous
(Sodium
solution 1 gram/10 ml (100 mg/ml),
Thiosulfate)
12.5 gram/50 ml (250 mg/ml)
SYPRINE
PA BvD
Hormonal Agents, Stimulant/Replacement/Modifying
Androgens
ANDRODERM
ANDROGEL TRANSDERMAL
GEL IN METERED-DOSE PUMP
1.25 GRAM/ ACTUATION (1 %)
GEL IN METERED-DOSE PUMP
20.25 MG/1.25 GRAM (1.62 %)
2
$0
2
$0
PA; QL (30 per 30
days)
PA; QL (300 per 30
days)
2
$0
PA; QL (150 per 30
days)
114
114
Name of Drug
GEL IN PACKET 1 % (25
MG/2.5GRAM), 1 % (50 MG/5
GRAM)
GEL IN PACKET 1.62 % (20.25
MG/1.25 GRAM), 1.62 % (40.5
MG/2.5 GRAM)
danazol oral
fluoxymesterone
oxandrolone
Tier level
2
What the
drug will
cost you
$0
2
$0
1
1
1
$0
$0
$0
1
$0
testosterone enanthate
testosterone transdermal gel in
(Androgel)
packet 1 % (25 mg/2.5gram)
Estrogens And Antiestrogens
1
$0
1
$0
COMBIPATCH
2
$0
DUAVEE
ESTRACE VAGINAL
estradiol oral
estradiol transdermal patch
semiweekly
(Estrace)
2
2
1
$0
$0
$0
(Vivelle-Dot)
1
$0
estradiol transdermal patch weekly
(Climara)
1
$0
estradiol valerate
estradiol/norethindrone acet
estradiol-norethindrone acet
(Delestrogen)
(Activella)
(Activella)
1
1
1
$0
$0
$0
2
$0
(Ogen)
1
2
2
$0
$0
$0
(Femhrt)
1
$0
2
$0
testosterone cypionate
(Danazol)
(Fluoxymesterone)
(Oxandrin)
(DepoTestosterone)
(Delatestryl)
ESTRASORB
estropipate
FEMRING
MENEST
norethindrone ac-eth estradiol oral
tablet 1-5 mg-mcg
PREMARIN INJECTION
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (300 per 30
days)
PA; QL (150 per 30
days)
PA
PA; QL (150 per 30
days)
PA-HRM; QL (8 per 28
days)
PA-HRM
PA-HRM
days)
days)
PA-HRM
PA-HRM
PA-HRM; QL (97.44
per 28 days)
PA-HRM
QL (1 per 84 days)
PA-HRM
PA-HRM
115
115
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PREMARIN ORAL
PREMARIN VAGINAL
PREMPHASE
PREMPRO
raloxifene
(Evista)
VAGIFEM
Glucocorticoids/Mineralocorticoids
betamethasone acet,sod phos
(Celestone)
cortisone
(Cortisone Acetate)
dexamethasone oral
(Dexamethasone)
dexamethasone oral
(Dexamethasone)
dexamethasone sodium phosphate
(Dexamethasone
injection
Sod Phosphate)
(Fludrocortisone
fludrocortisone
Acetate)
hydrocortisone oral
(Cortef)
(Hydrocortisone
hydrocortisone sod succinate
Sod Succinate)
methylprednisolone
(Medrol)
methylprednisolone acetate
(Depo-Medrol)
methylprednisolone sodium succ
(A-Methapred)
injection recon soln 125 mg, 40 mg
(A-Methapred)
intravenous
(Orapred)
oral solution
prednisone
(Prednisone)
SOLU-CORTEF (PF) INJECTION
RECON SOLN 100 MG/2 ML
(Triamcinolone
triamcinolone acetonide injection
Acetonide)
Pituitary
(Desmopressin
desmopressin injection
Acetate)
desmopressin nasal
(DDAVP)
(Desmopressin
desmopressin nasal
Acetate)
2
2
2
2
1
2
$0
$0
$0
$0
$0
$0
PA-HRM
1
1
1
1
$0
$0
$0
$0
1
$0
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
1
$0
1
$0
1
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
PA-HRM
PA-HRM
QL (18 per 28 days)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
QL (15 per 30 days)
QL (15 per 30 days)
116
116
Name of Drug
desmopressin oral
GENOTROPIN
GENOTROPIN MINIQUICK
HUMATROPE
INCRELEX
NORDITROPIN FLEXPRO
SUBCUTANEOUS PEN
INJECTOR 10 MG/1.5 ML (6.7
MG/ML), 15 MG/1.5 ML (10
MG/ML), 5 MG/1.5 ML (3.3
MG/ML)
NORDITROPIN NORDIFLEX
NUTROPIN
NUTROPIN AQ NUSPIN
NUTROPIN AQ
SUBCUTANEOUS
octreotide acetate injection solution
1,000 mcg/ml, 100 mcg/ml, 200
mcg/ml, 500 mcg/ml
octreotide acetate injection solution
50 mcg/ml
octreotide acetate injection syringe
OMNITROPE
PREGNYL
SAIZEN
SAIZEN CLICK.EASY
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR KIT
SEROSTIM SUBCUTANEOUS
RECON SOLN 4 MG, 5 MG, 6
MG
SOMATULINE DEPOT
SOMAVERT
SUPPRELIN LA
TEV-TROPIN
vasopressin
(DDAVP)
Tier level
What the
drug will
cost you
1
2
2
2
2
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
PA
PA
(Sandostatin)
(Octreotide
Acetate)
(Octreotide
Acetate)
2
$0
2
2
2
$0
$0
$0
2
$0
1
$0
1
$0
1
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
$0
2
2
2
2
1
$0
$0
$0
$0
$0
PA
PA
PA
PA
PA
PA
PA
PA
(Pitressin)
QL (1 per 28 days)
QL (1 per 360 days)
PA
117
117
Tier level
What the
drug will
cost you
2
$0
1
$0
1
$0
1
1
1
1
$0
$0
$0
$0
1
$0
1
1
$0
$0
1
$0
1
$0
Immunological Agents
ARCALYST
ASTAGRAF XL
2
2
$0
$0
AUBAGIO
2
$0
1
$0
1
$0
Name of Drug
Progestins
DEPO-PROVERA
INTRAMUSCULAR SOLUTION
medroxyprogesterone
(Depo-Provera)
intramuscular suspension
medroxyprogesterone
(Medroxyprogester
intramuscular syringe
one Acetate)
medroxyprogesterone oral
(Provera)
norethindrone acetate
(Aygestin)
progesterone
(Progesterone)
progesterone micronized capsules
(Prometrium)
Thyroid And Antithyroid Agents
(Levothyroxine
levothyroxine intravenous
Sodium)
levothyroxine oral
(Levoxyl)
liothyronine oral
(Cytomel)
methimazole oral tablet 10 mg, 5
(Tapazole)
mg
propylthiouracil
(Propylthiouracil)
Necessary Actions,
Restrictions, or
Limits on Use
QL (10 per 28 days)
QL (1 per 84 days)
QL (1 per 84 days)
Immunological Agents
azathioprine
azathioprine sodium
(Imuran)
(Azathioprine
Sodium)
PA BvD
PA; QL (28 per 28
days)
PA BvD
PA BvD
CARIMUNE NF
PA BvD
NANOFILTERED
2
$0
INTRAVENOUS RECON SOLN
CELLCEPT INTRAVENOUS
2
$0
PA BvD
cyclosporine intravenous
(Sandimmune)
1
$0
PA BvD
cyclosporine modified
(Neoral)
1
$0
PA BvD
cyclosporine oral capsule
(Sandimmune)
1
$0
PA BvD
cyclosporine, modified
(Neoral)
1
$0
PA BvD
ENBREL
2
$0
PA
118
118
Tier level
What the
drug will
cost you
ENBREL SURECLICK
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAPLEX
GAMUNEX-C INJECTION
SOLUTION
HUMIRA
HUMIRA CROHN'S DIS START
PCK
HUMIRA PEN
HYPERRAB S/D (PF)
HYQVIA
ILARIS (PF)
IMOGAM RABIES-HT (PF)
2
2
2
2
2
$0
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
2
2
2
2
$0
$0
$0
$0
$0
KINERET
2
$0
1
1
1
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
2
1
1
$0
$0
$0
TYSABRI
2
$0
ZORTRESS
2
$0
Name of Drug
leflunomide
mycophenolate mofetil
mycophenolate sodium
NULOJIX
OCTAGAM
ORENCIA
ORENCIA (WITH MALTOSE)
PRIVIGEN
PROGRAF INTRAVENOUS
RAPAMUNE ORAL SOLUTION
RAPAMUNE ORAL TABLET 1
MG, 2 MG
RIDAURA
sirolimus
tacrolimus oral
(Arava)
(Cellcept)
(Myfortic)
(Rapamune)
(Hecoria)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
PA
PA BvD
PA
PA; QL (18.76 per 28
days)
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA; LA; QL (15 per 28
days)
PA BvD; QL (120 per
30 days)
Vaccines
119
119
Name of Drug
ACTHIB (PF)
ADACEL(TDAP
ADOLESN/ADULT)(PF)
BCG VACCINE, LIVE (PF)
BEXSERO (PF)
BOOSTRIX TDAP
CERVARIX VACCINE (PF)
COMVAX (PF)
DAPTACEL (DTAP PEDIATRIC)
(PF)
ENGERIX-B (PF)
ENGERIX-B PEDIATRIC (PF)
GARDASIL (PF)
GARDASIL 9 (PF)
HAVRIX (PF)
INTRAMUSCULAR
SUSPENSION
HAVRIX (PF)
IMOVAX RABIES VACCINE
(PF)
INFANRIX (DTAP) (PF)
INTRAMUSCULAR
IPOL
IXIARO (PF)
KINRIX (PF)
MENACTRA (PF)
INTRAMUSCULAR SOLUTION
MENHIBRIX (PF)
MENOMUNE - A/C/Y/W-135 (PF)
MENVEO A-C-Y-W-135-DIP (PF)
MENVEO MENA COMPONENT
(PF)
MENVEO MENCYW-135
COMPNT (PF)
M-M-R II (PF)
PEDIARIX (PF)
Tier level
What the
drug will
cost you
2
$0
2
$0
2
2
2
2
2
$0
$0
$0
$0
$0
2
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
$0
2
2
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
120
120
Name of Drug
PEDVAX HIB (PF)
PENTACEL (PF)
PENTACEL ACTHIB
COMPONENT (PF)
PENTACEL DTAP-IPV COMPNT
(PF)
PROQUAD (PF)
QUADRACEL (PF)
RABAVERT (PF)
RECOMBIVAX HB (PF)
ROTARIX
ROTATEQ VACCINE
TENIVAC (PF)
INTRAMUSCULAR
TETANUS TOXOID,ADSORBED
(PF)
TETANUS,DIPHTHERIA TOX
PED(PF)
TETANUS-DIPHTHERIA
TOXOIDS-TD
TICE BCG
TRUMENBA
TWINRIX (PF)
TYPHIM VI INTRAMUSCULAR
VAQTA (PF)
VARIVAX (PF)
YF-VAX (PF)
ZOSTAVAX (PF)
Tier level
What the
drug will
cost you
2
2
$0
$0
2
$0
2
$0
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
1
2
2
1
1
2
$0
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
QL (1 per 365 days)
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
alosetron
(Alosetron HCl)
APRISO
ASACOL HD
balsalazide
(Colazal)
budesonide oral
(Entocort EC)
DELZICOL
121
121
Name of Drug
DIPENTUM
Tier level
What the
drug will
cost you
2
$0
1
1
$0
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation
GLYCINE IRRIGATION
LACTATED RINGERS
IRRIGATION
ringers irrigation
sodium chloride irrigation
sorbitol irrigation
sorbitol-mannitol
water for irrigation, sterile
(Acetic Acid)
(Tis-U-Sol)
(Sodium Chloride
Irrig Solution)
(Sorbitol Solution)
(Mannitol/Sorbitol
Solution)
(Water For
Irrigation,Sterile)
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
(Alendronate
alendronate oral solution
Sodium)
alendronate oral tablet 10 mg, 40
(Fosamax)
mg, 5 mg
alendronate oral tablet 35 mg, 70
(Fosamax)
mg
calcitonin (salmon)
(Miacalcin)
calcitriol intravenous solution 1
(Calcitriol)
mcg/ml
calcitriol oral
(Rocaltrol)
1
$0
doxercalciferol intravenous
(Doxercalciferol)
1
$0
doxercalciferol oral
(Hectorol)
1
$0
etidronate disodium
(Etidronate
Disodium)
1
$0
FORTEO
2
$0
FORTICAL
2
$0
QL (4 per 28 days)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA; QL (2.4 per 28
days)
122
122
Name of Drug
Tier level
What the
drug will
cost you
ibandronate intravenous solution
(Ibandronate
Sodium)
1
$0
ibandronate oral
(Boniva)
1
$0
MIACALCIN INJECTION
2
$0
NATPARA
2
$0
(Zemplar)
1
$0
(Actonel)
2
1
$0
$0
XGEVA
2
$0
ZEMPLAR INTRAVENOUS
2
$0
(Zometa)
(Zoledronic
Acid/Mannitol and
Water)
1
$0
1
$0
(Reclast)
1
$0
2
$0
2
$0
ACTEMRA SUBCUTANEOUS
2
$0
ACTIMMUNE
allopurinol
amifostine crystalline
2
1
1
$0
$0
$0
1
$0
2
2
2
$0
$0
$0
paricalcitol oral
PROLIA
risedronate oral tablet 150 mg
zoledronic acid intravenous
zoledronic acid-mannitol-water
ZOMETA INTRAVENOUS
SOLUTION 4 MG/100 ML
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD; (PA for
ESRD Only); QL (3 per
84 days)
QL (1 per 28 days)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
QL (1 per 180 days)
QL (1 per 28 days)
PA; QL (1.7 per 28
days)
PA BvD; (PA for
ESRD Only)
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA INTRAVENOUS
SOLUTION
anticoag citrate phos dextrose
AVODART
AVONEX (WITH ALBUMIN)
AVONEX INTRAMUSCULAR
(Zyloprim)
(Ethyol)
(Citrate Phosphate
Dextros Soln)
PA; QL (40 per 30
days)
PA; QL (3.6 per 28
days)
ST
ST
123
123
Tier level
What the
drug will
cost you
2
$0
2
$0
2
1
$0
$0
2
$0
2
$0
1
2
1
$0
$0
$0
1
$0
2
$0
2
$0
1
$0
(Acetic Acid)
(Droperidol)
2
4
1
2
$0
$0
$0
$0
(Ergoloid
Mesylates)
1
$0
(Acetic Acid)
(Acetic Acid)
(Proscar)
(Fomepizole)
2
4
4
1
1
2
$0
$0
$0
$0
$0
$0
GILENYA
2
$0
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
(HUMAN)
guanidine
2
$0
2
$0
1
$0
Name of Drug
AVONEX INTRAMUSCULAR
BENLYSTA INTRAVENOUS
RECON SOLN
BETASERON SUBCUTANEOUS
bethanechol chloride
BOTOX INJECTION RECON
SOLN 100 UNIT
BOTOX INJECTION RECON
SOLN 200 UNIT
buspirone
CERDELGA
colchicine oral tablet
colchicine-probenecid
COLCRYS
COPAXONE SUBCUTANEOUS
SYRINGE
CURITY GAUZE TOPICAL
BANDAGE 2 X 2 "
CYSTADANE
douche vinegar & water extra *
droperidol injection solution
ELMIRON
ergoloid
EXTAVIA SUBCUTANEOUS
extra cleansing douche *
feminine care douche *
finasteride oral tablet 5 mg
fomepizole
FUSILEV
(Urecholine)
(Vanspar)
(Colcrys)
(Colchicine/Proben
ecid)
(Guanidine HCl)
Necessary Actions,
Restrictions, or
Limits on Use
ST
PA
ST
PA
ST
PA; QL (28 per 28
days)
124
124
Tier level
What the
drug will
cost you
(Hydroxyzine HCl)
1
$0
(Hydroxyzine HCl)
1
$0
(Hydroxyzine HCl)
(Vistaril)
1
1
2
$0
$0
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
2
2
2
4
4
$0
$0
$0
$0
$0
$0
1
$0
OTEZLA
2
$0
OTEZLA STARTER
2
$0
PLEGRIDY
probenecid
PROCYSBI
pyridostigmine bromide oral tablet
REBIF (WITH ALBUMIN)
REBIF REBIDOSE
REBIF TITRATION PACK
2
1
2
1
2
2
2
$0
$0
$0
$0
$0
$0
$0
Name of Drug
hydroxyzine hcl intramuscular
hydroxyzine hcl oral solution 10
mg/5 ml
hydroxyzine hcl oral tablet
hydroxyzine pamoate
JALYN
LEMTRADA
leucovorin calcium injection recon
soln 100 mg, 200 mg, 350 mg
leucovorin calcium oral
levocarnitine (with sugar)
levocarnitine oral
levoleucovorin calcium
mesna
MESNEX ORAL
MESTINON ORAL SYRUP
MESTINON TIMESPAN
MINERAL OIL *
mineral oil light *
morrhuate sodium
(Leucovorin
Calcium)
(Leucovorin
Calcium)
(Levocarnitine
(With Sugar))
(Carnitor)
(Levoleucovorin
Calcium)
(Mesnex)
(Mineral Oil)
(Sodium
Morrhuate)
(Probenecid)
(Mestinon)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM
PA-HRM
PA-HRM
QL (30 per 30 days)
PA; QL (9.6 per 365
days)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
ST
125
125
Tier level
What the
drug will
cost you
REMICADE
SENSIPAR
2
2
$0
$0
SIMPONI ARIA
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
4
$0
4
4
2
$0
$0
$0
Name of Drug
SIMPONI SUBCUTANEOUS PEN
INJECTOR 100 MG/ML
SIMPONI SUBCUTANEOUS PEN
INJECTOR 50 MG/0.5 ML
SIMPONI SUBCUTANEOUS
SYRINGE 100 MG/ML
SIMPONI SUBCUTANEOUS
SYRINGE 50 MG/0.5 ML
SOLIRIS
STELARA SUBCUTANEOUS
SYRINGE
STERILE PADS TOPICAL
BANDAGE 2 X 2 "
summer's eve disposable douche *
(Acetic Acid)
vaginal solution
summers eve extra cleansing *
(Acetic Acid)
SUSPENDOL-S *
SYNAREL
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)240 MG (46), 240 MG
2
$0
2
$0
THALOMID
2
$0
TYBOST
2
$0
ULORIC
2
$0
XELJANZ
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA; QL (12 per 28
days)
PA; QL (0.5 per 28
days)
PA; QL (0.5 per 28
days)
PA
PA; QL (14 per 30
days)
PA; QL (60 per 30
days)
PA NSO; QL (60 per
30 days)
QL (30 per 30 days)
ST; QL (30 per 30
days)
PA; QL (60 per 30
days)
Ophthalmic Agents
126
126
Tier level
What the
drug will
cost you
(Diamox Sequels)
1
$0
(Acetazolamide)
(Acetazolamide
Sodium)
1
$0
1
$0
2
$0
2
1
1
1
2
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
(Neptazane)
(Metipranolol)
1
1
2
$0
$0
$0
(Isopto Carpine)
1
$0
(Timolol Maleate)
2
1
$0
$0
(Timoptic-Xe)
1
$0
2
$0
1
$0
4
$0
Name of Drug
Antiglaucoma Agents
acetazolamide oral capsule,
extended release
acetazolamide oral tablet
acetazolamide sodium
ALPHAGAN P OPHTHALMIC
DROPS 0.1 %
AZOPT
betaxolol ophthalmic
bimatoprost
brimonidine
COMBIGAN
dorzolamide
dorzolamide-timolol
latanoprost
levobunolol
LUMIGAN OPHTHALMIC
DROPS 0.01 %
methazolamide oral
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl ophthalmic drops 1
%, 2 %, 4 %
SIMBRINZA
timolol maleate ophthalmic drops
timolol maleate ophthalmic gel
forming solution
TRAVATAN Z
travoprost (benzalkonium)
(Betaxolol HCl)
(Bimatoprost)
(Alphagan P)
(Trusopt)
(Cosopt)
(Xalatan)
(Betagan)
(Travoprost
(Benzalkonium))
Necessary Actions,
Restrictions, or
Limits on Use
(drops: 0.15%, 0.20%)
Replacement Preparations
Replacement Preparations
(Ca/D3/Mag
ca-d3-mag ox-zinc-cop-mang-bor *
Ox/Zinc/Cop/Mang
oral tablet,chewable
/Bor)
127
127
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
(Os-Cal 500+D3)
4
$0
(Os-Cal 500+D3)
(Caltrate 600)
(Calcium
Carbonate/Vitamin
D3)
(Os-Cal 500+D3)
(Calcium
Carbonate/Vitamin
D3)
(Calcium
Carbonate)
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
$0
1
$0
Name of Drug
calcionate *
calcitrate *
calcitrate-vitamin d *
calcium 500 + d (d3) *
calcium 500 + d * oral tablet 500
mg(1,250mg) -400 unit
calcium 500 with d *
calcium 600 *
calcium 600 + d(3) * oral capsule
calcium 600 + d(3) * oral tablet
calcium 600 with vitamin d3 * oral
calcium carbonate * oral
(Calcium
Glubionate)
(Calcium Citrate)
(Citracal-Vitamin
D)
(Os-Cal 500+D3)
calcium carbonate * oral tablet 260
(Caltrate 600)
mg calcium (648 mg)
(Calcium
calcium carbonate-vitamin d2 *
Carbonate/Vitamin
D2)
(Calcium
oral capsule 600 mg(1,500mg) -100
Carbonate/Vitamin
unit, 600 mg(1,500mg) -400 unit,
D3)
600 mg(1,500mg) -500 unit
(Os-Cal 500+D3)
oral tablet
oral tablet,chewable 500
(Os-Cal 500+D)
mg(1,250mg) -400 unit
calcium chloride intravenous
(Calcium Chloride)
calcium citrate-vitamin d3 * oral
(Citracal-Vitamin
tablet 315-250 mg-unit
D)
(Calcium
calcium gluconate intravenous
Gluconate)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD; (PA for
ESRD Only)
128
128
Tier level
What the
drug will
cost you
(Calcium
Gluconate)
4
$0
(Calcium Lactate)
4
$0
(Os-Cal 500+D3)
4
4
$0
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
1
$0
4
4
2
2
2
2
2
2
2
4
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
calcium gluconate * oral tablet 45
mg (500 mg)
calcium lactate * oral tablet 84 mg
(648 mg), 84 mg (650 mg)
calcium+d * oral tablet
CALTRATE 600 + D *
CALTRATE-600 + D VIT D3
(800) *
CENTRUM PRO NUTRIENTS *
citracal + d maximum *
citric acid-sodium citrate
citrus calcium * oral tablet
coral calcium * oral tablet
electrolyte-48 in d5w
enfalyte *
hi-cal plus vit d *
HYPERLYTE CR
IONOSOL-B IN D5W
IONOSOL-MB IN D5W
ISOLYTE M IN 5 % DEXTROSE
ISOLYTE-H IN 5 % DEXTROSE
ISOLYTE-P IN 5 % DEXTROSE
ISOLYTE-S
KELP (IODINE) *
KLOR-CON
klor-con 10
(Citracal-Vitamin
D)
(Citric
Acid/Sodium
Citrate)
(Citracal-Vitamin
D)
(Caltrate 600)
(Electrolyte-48
Solution/D5W)
(Pedialyte)
(Os-Cal 500+D3)
(Potassium
Chloride)
KLOR-CON 8
klor-con m10
klor-con m15
(Potassium
Chloride)
(Potassium
Chloride)
Necessary Actions,
Restrictions, or
Limits on Use
129
129
Tier level
What the
drug will
cost you
1
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
4
$0
$0
(Magnesium
Sulfate/D5W)
1
$0
(Magnesium
Sulfate in Water)
1
$0
1
$0
4
$0
2
$0
2
2
2
2
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
Name of Drug
klor-con m20
(Potassium
Chloride)
KLOR-CON/EF
liquid calcium with vitamin d *
mag 64 *
mag-delay *
mag-g *
magnesium (oxide/aa chelate) *
magnesium chloride injection
magnesium gluconate * oral tablet
magnesium * oral tablet 250 mg
magnesium sulfate in d5w
ml
magnesium sulfate in water
ml (4 %), 4 gram/50 ml (8 %)
magnesium sulfate injection
natural calcium *
NORMOSOL-M IN 5 %
DEXTROSE
NORMOSOL-R
NORMOSOL-R PH 7.4
NUTRILYTE
NUTRILYTE II
oralyte *
oysco 500/d * oral tablet
oysco d *
oysco-500 *
(Calcium
Carbonate/Vitamin
D3)
(Magnesium
Chloride)
(Magnesium
Chloride)
(Magonate)
(Magnesium
Oxide/Mag Aa
Chelate)
(Magnesium
Chloride)
(Magonate)
(Magnesium)
(Magnesium
Sulfate)
(Caltrate 600)
(Pedialyte)
(Os-Cal 500+D3)
(Os-Cal 500+D3)
(Caltrate 600)
Necessary Actions,
Restrictions, or
Limits on Use
130
130
Tier level
What the
drug will
cost you
4
$0
4
$0
4
4
4
4
4
1
2
2
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(Potassium
Chloride In D5w)
1
$0
(Potassium
Chloride)
1
$0
(Micro-K)
1
$0
(Kaochlor)
(Klor-Con)
1
1
$0
$0
Name of Drug
oyster shell calcium 500 *
oyster shell calcium with d *
oyster shell calcium-vit d3 *
oystercal-d *
pediatric electrolyte * oral solution
pediatric freezer pops *
PHOS-NAK *
phosphorus #1
PLASMA-LYTE 148
PLASMA-LYTE A
PLASMA-LYTE-56 IN 5 %
DEXTROSE
potassium acetate intravenous
potassium bicarb and chloride
potassium bicarb-citric acid
potassium bicarbonate-cit ac oral
tablet, effervescent 25 meq
potassium chlorid-d5-0.45%nacl
potassium chloride in 0.9%nacl
meq/l, 40 meq/l
potassium chloride in 5 % dex
meq/l, 30 meq/l, 40 meq/l
potassium chloride intravenous
potassium chloride oral capsule,
extended release
potassium chloride oral liquid
potassium chloride oral packet
(Caltrate 600)
(Calcium
Carbonate/Vitamin
D2)
(Os-Cal 500+D3)
(Os-Cal 500+D3)
(Pedialyte)
(Pedialyte)
(K-Phos Neutral)
(Potassium
Acetate)
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
(Klor-Con-Ef)
(Potassium
Chloride/D50.45nacl)
(Potassium
Chloride In
0.9%NaCl)
Necessary Actions,
Restrictions, or
Limits on Use
131
131
Tier level
What the
drug will
cost you
(Klor-Con 8)
1
$0
(Klor-Con 8)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
potassium chloride oral tablet
extended release
potassium chloride oral tablet,er
particles/crystals 10 meq
potassium chloride oral tablet,er
particles/crystals 20 meq
(Potassium
Chloride)
(Potassium
potassium chloride-0.45 % nacl
Chloride-0.45%
NaCl)
(Potassium
potassium chloride-d5-0.2%nacl
Chloride/D50.2%NaCl)
(Potassium
intravenous parenteral solution 20 Chloride/D5meq/l
0.3%NaCl)
(Potassium
Chloride/D50.9%NaCl)
potassium citrate-citric acid oral
(Potassium
packet
Citrate/Citric Acid)
potassium citrate-citric acid oral
(Potassium
solution 1,100-334 mg/5 ml
Citrate/Citric Acid)
(Potassium
potassium phosphate dibasic
Phos,M-Basic-DBasic)
ringers intravenous
(Ringers Solution)
sodium acetate intravenous
(Sodium Acetate)
(Sodium
sodium bicarbonate intravenous
Bicarbonate)
(Sodium Chloride
sodium chloride 0.45 % intravenous
0.45 %)
sodium chloride 0.9 % injection
(0.9 % Sodium
solution
Chloride)
(0.9 % Sodium
sodium chloride 0.9 % intravenous
Chloride)
(Sodium Chloride
sodium chloride 3 %
3 %)
Necessary Actions,
Restrictions, or
Limits on Use
132
132
Name of Drug
sodium chloride 5 %
sodium chloride intravenous
sodium citrate-citric acid
sodium lactate intravenous
sodium phosphate
sod-pot-k cit-sod cit-cit acid
(Sodium Chloride
5 %)
(Sodium Chloride)
(Citric
Acid/Sodium
Citrate)
(Sodium Lactate)
(Sodium Phos,MBasic-D-Basic)
(Sod/Pot/K Cit/Sod
Cit/Cit Acid)
TPN ELECTROLYTES
TPN ELECTROLYTES II
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
2
$0
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
Respiratory Tract Agents
Anti-Inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
ADVAIR HFA
BREO ELLIPTA
DULERA
FLOVENT DISKUS
INHALATION BLISTER WITH
DEVICE 100 MCG/ACTUATION,
50 MCG/ACTUATION
FLOVENT DISKUS
INHALATION BLISTER WITH
DEVICE 250 MCG/ACTUATION
FLOVENT HFA INHALATION
HFA AEROSOL INHALER 110
MCG/ACTUATION
MCG/ACTUATION
MCG/ACTUATION
QVAR
Antileukotrienes
QL (60 per 30 days)
QL (12 per 28 days)
QL (60 per 30 days)
QL (13 per 28 days)
QL (60 per 30 days)
QL (12 per 28 days)
QL (24 per 28 days)
2
$0
2
$0
2
$0
133
133
Tier level
What the
drug will
cost you
(Singulair)
(Accolate)
1
1
$0
$0
(Albuterol Sulfate)
1
$0
(Albuterol Sulfate)
(Albuterol Sulfate)
1
1
$0
$0
(Vospire ER)
1
$0
2
2
2
$0
$0
$0
1
$0
2
2
2
2
$0
$0
$0
$0
1
$0
1
$0
(Theophylline
Anhydrous)
1
$0
(Theophylline/D5
W)
1
$0
1
$0
1
$0
1
$0
2
$0
Name of Drug
montelukast
zafirlukast
Bronchodilators
albuterol sulfate inhalation solution
for nebulization
albuterol sulfate oral syrup
albuterol sulfate oral tablet
albuterol sulfate oral tablet
ANORO ELLIPTA
ATROVENT HFA
COMBIVENT RESPIMAT
metaproterenol oral
(Metaproterenol
Sulfate)
PROAIR HFA
SEREVENT DISKUS
SPIRIVA RESPIMAT
SPIRIVA WITH HANDIHALER
terbutaline oral
terbutaline subcutaneous
theophylline anhydrous oral tablet
extended release 12 hr 100 mg, 200
mg, 300 mg
theophylline in dextrose 5 %
mg/100 ml, 200 mg/50 ml, 400
mg/250 ml, 400 mg/500 ml, 800
mg/250 ml
theophylline oral
theophylline oral
theophylline oral
TUDORZA PRESSAIR
(Terbutaline
Sulfate)
(Terbutaline
Sulfate)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
QL (60 per 30 days)
QL (8 per 30 days)
QL (17 per 25 days)
QL (60 per 30 days)
QL (4 per 30 days)
QL (30 per 30 days)
QL (1 per 28 days)
134
134
Tier level
What the
drug will
cost you
1
1
2
$0
$0
$0
1
$0
4
2
$0
$0
ESBRIET
2
$0
KALYDECO
2
$0
OFEV
2
$0
3
$0
2
2
$0
$0
Name of Drug
Respiratory Tract Agents, Other
acetylcysteine
(Acetadote)
acetylcysteine solution
(Acetadote)
ARALAST NP
(Cromolyn
cromolyn inhalation
Sodium)
cromolyn * nasal
(Nasalcrom)
DALIRESP
sodium chloride * inhalation
solution for nebulization 0.9 %
XOLAIR
ZEMAIRA
(Pulmosal)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
QL (30 per 30 days)
PA; QL (270 per 30
days)
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
(Baclofen)
1
$0
carisoprodol
(Soma)
1
$0
chlorzoxazone
(Parafon Forte
DSC)
1
$0
1
$0
1
$0
(Fexmid)
1
$0
(Dantrium)
(Dantrium)
(Skelaxin)
(Robaxin)
(Zanaflex)
1
1
1
1
1
$0
$0
$0
$0
$0
COMFORT PACCYCLOBENZAPRINE
COMFORT PAC-TIZANIDINE
cyclobenzaprine oral tablet 10 mg,
5 mg
dantrolene
dantrolene sodium
metaxalone
methocarbamol oral
tizanidine
PA-HRM; QL (120 per
30 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA-HRM
Sleep Disorder Agents
135
135
Name of Drug
Sleep Disorder Agents
NUVIGIL
ROZEREM
XYREM
Tier level
What the
drug will
cost you
2
2
2
$0
$0
$0
zaleplon
(Sonata)
1
$0
zolpidem oral tablet
(Ambien)
1
$0
zolpidem oral tablet,ext release
multiphase
(Ambien CR)
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
LA
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
(Phentolamine
phentolamine injection
Mesylate)
PA
136
136
Tier level
What the
drug will
cost you
ADCIRCA
2
$0
ADEMPAS
2
$0
1
$0
LETAIRIS
2
$0
OPSUMIT
2
$0
ORENITRAM
REMODULIN
2
2
$0
$0
REVATIO INTRAVENOUS
2
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Vasodilating Agents
Vasodilating Agents
epoprostenol (glycine)
(Flolan)
sildenafil intravenous
(Revatio)
1
$0
sildenafil oral
(Revatio)
1
$0
TRACLEER
2
$0
TYVASO
TYVASO REFILL KIT
TYVASO STARTER KIT
VENTAVIS
2
2
2
2
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
PA; QL (60 per 30
days)
PA; QL (90 per 30
days)
PA BvD
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
PA
PA BvD
PA; QL (37.5 per 1
day)
PA; QL (37.5 per 1
day)
PA; QL (90 per 30
days)
PA; LA; QL (60 per 30
days)
PA BvD
PA BvD
PA BvD
PA BvD
Vitamins And Minerals
Vitamins And Minerals
a thru z advanced formula *
a thru z high potency * oral tablet
a thru z select 50+ formula *
a thru z select * oral tablet
a thru z select * oral tablet 300600-300 mcg, 500-300-250 mcg
(Multivitamin/Iron/
Folic Acid)
(Multivitamin WMinerals/Lutein)
(Biocel)
(Biocel)
137
137
Name of Drug
a thru z select women's *
abc plus *
adult one daily gummies *
adults 50+ daily formula *
adults' daily formula *
airshield * oral tablet, effervescent
5,000-1000-30 unit-mg-unit
animal chews *
animal shape vitamins *
animal shapes plus iron *
antioxidant *
antioxidant formula *
antioxidant vitamins * oral tablet
antioxidant vitamins * oral tablet
1,000 unit-200 mg-60 unit-2 mg
apatate forte *
(Multivits WFe,Other Min/Lut)
(Biocel)
(One-A-Day
Vitacraves)
(Biocel)
(Multivitamin/Iron/
Folic Acid)
(Vit A,C, and
E/Dietary Supp
No.12)
(Multivitamin)
(Multivitamin)
(Multivitamins
with Iron)
(Beta-Carotene(A)
W-C and E/Min)
(Beta-Carotene(A)
W-C and E/Min)
(Multivitamin with
Minerals)
(Ocuvite with
Lutein)
(Multivitamin with
Minerals)
ascorbic acid * oral tablet extended
(Ascorbic Acid)
release 1,500 mg
ascorbic acid * oral
(Ascorbic Acid)
(Vitamin B
b complete *
Complex)
(Vitamin B
b complex 1 *
Complex)
(Vitamin B
b complex-vitamin b12 *
Complex)
b complex-vitamin c-folic acid *
(Dialyvite 800)
(Vitamin B
b-100 complex * oral tablet
Complex)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
138
138
Tier level
What the
drug will
cost you
(B-12)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vit B Complex
100 Cmb
#3/Herbs)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(B Complex with
Vitamin C)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Vita-Bee with C)
4
$0
Name of Drug
b-12 dots *
b-50 complex * oral tablet
bal b-100 *
bal b-50 *
balance b-100 *
balance b-50 *
balanced b-100 * oral
balanced b-100 * oral tablet 100
mg
balanced b-150 *
balanced b-50 * oral tablet
b-complex * oral tablet
b-complex with vitamin c * oral
capsule
b-complex with vitamin c * oral
tablet
Necessary Actions,
Restrictions, or
Limits on Use
(Multivitamin with
4
$0
Minerals)
(Multivitamin with
biosupp *
4
$0
Minerals)
biotin * oral tablet 300 mcg
(Biotin)
4
$0
(Multivitamin with
biovol *
4
$0
Minerals)
c complex *
(Ascorbic Acid)
4
$0
calcidol *
(Drisdol)
4
$0
(Multivits Wcentamin *
4
$0
Min/Ferrous Gluc)
central vite with lutein *
(Biocel)
4
$0
139
139
bee-zee *
Name of Drug
central-vite for seniors *
central-vite * oral tablet 18-400
mg-mcg
central-vite select * oral tablet
central-vite senior *
centram-care *
centravites 50 plus *
centrum complete *
centrum * oral liquid
centrum silver * oral tablet
centrum ultra women's *
century adults 50+ *
century advanced formula *
century mature * oral tablet
century mature * oral tablet 0.4300-250 mg-mcg-mcg, 500-300-250
mcg
century * oral tablet 18-400 mgmcg
century ultimate women's * oral
tablet 18-400 mg-mcg
(Multivitamin
W/Iron, Minerals)
(Multivitamin/Iron/
Folic Acid)
(Biocel)
(Multivits WMin/Ferrous Gluc)
(Multivitamin
W/Iron, Minerals)
(Multivitamin/Iron/
Folic Acid)
(Biocel)
(Multivitamin/Iron/
Folic Acid)
(Biocel)
(Biocel)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
(Multivitamin/Iron/
4
$0
Folic Acid)
(Multivitamin/Iron/
4
$0
Folic Acid)
(Multivits Wcerovite *
4
$0
Min/Ferrous Gluc)
(Multivitamin/Iron/
cerovite advanced formula *
4
$0
Folic Acid)
(Multivitamin
cerovite jr *
4
$0
W/Iron, Minerals)
(Multivitamin Wcerovite senior *
4
$0
Minerals/Lutein)
140
140
Name of Drug
Tier level
What the
drug will
cost you
certavite senior-antioxidant *
(Biocel)
certavite-antioxid (iron gluc) * oral (Multivits Wliquid 9 mg iron/15 ml
Min/Ferrous Gluc)
(Multivitamin/Iron/
certavite-antioxidant *
Folic Acid)
chewable multi vitamin *
(Multivitamin)
chewable-vite *
(Multivitamin)
(Multivitamins
chewable-vite with iron *
with Iron)
(Pedi Mv
child complete multivitamin *
No.58/Ferrous
Fumarate)
(Multivitamin
child vitamin with minerals *
W/Iron, Minerals)
children's chewable *
(Multivitamin)
children's chewable complete * oral
(Multivitamin)
tablet,chewable
children's chewable vitamin *
(Multivitamin)
(Multivitamin
children's chewable w/minerals *
W/Iron, Minerals)
(Pedi Mv
children's complete vitamin *
No.67/Ferrous
Fumarate)
children's multivit w/extra c *
(Multivitamin)
(Multivitamins
children's vitamin with iron *
with Iron)
childs chew vite *
(Multivitamin)
(Multivitamins
child's chewable vitamins/iron *
with Iron)
(Multivitamins
child's vitamin with iron *
with Iron)
child's vitamin with vitamin c *
(Multivitamin)
(Multivitamins
childs/iron *
with Iron)
(Multivitamin
compete *
W/Iron, Minerals)
complete 50+ *
(Biocel)
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
141
141
Tier level
What the
drug will
cost you
(Biocel)
(Multivits,Th WFe,Other Min)
4
$0
4
$0
(Biocel)
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
Name of Drug
complete multi 50+ *
complete multivitamin * oral tablet
complete multivitamin * oral tablet
0.4-300-250 mg-mcg-mcg
complete multivitamin-mineral *
oral tablet
complete senior * oral tablet
complete senior * oral tablet 0.4300-250 mg-mcg-mcg
cyanocobalamin (vitamin b-12) *
injection
oral drops 1,000 mcg/ml
oral tablet 1,000 mcg, 100 mcg, 250
mcg, 500 mcg
daily gummies *
daily multiple * oral tablet
daily multiple * oral tablet 18-400
mg-mcg
daily multi-vitamin *
daily multivitamin with iron *
daily multivitamin-minerals *
daily multi-vitamins/iron *
daily teen multi-vitamin *
daily value *
daily vitamin *
daily vitamin formula *
daily vitamin formula + iron *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin
W/Iron, Minerals)
(Biocel)
(Cyanocobalamin
(Vitamin B-12))
(Cyanocobalamin
(Vitamin B-12))
(B-12)
(One-A-Day
Vitacraves)
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
Minerals)
(Multivitamins
with Iron)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
Necessary Actions,
Restrictions, or
Limits on Use
142
142
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
(Drisdol)
3
$0
(Drisdol)
4
$0
4
$0
4
$0
4
4
$0
$0
3
$0
3
$0
4
$0
3
$0
4
4
$0
$0
Name of Drug
daily vitamin formula-minerals *
daily vitamin with iron *
daily vites/iron *
daily-vite *
dino-life *
dino-life with extra c *
dino-life with iron-zinc *
(Multivitamin with
Minerals)
(Multivitamins
with Iron)
(Multivitamins
with Iron)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin
W/Iron, Minerals)
ECEE PLUS *
eldertonic *
ellis tonic *
ergocalciferol (vitamin d2) * oral
capsule
ergocalciferol (vitamin d2) * oral
drops
essentia *
essential balance with lutein *
essential daily *
essential one daily *
fe fumarate-doss-fa-bcomp and c *
fe fumarate-vit c-b12-if-fa * oral
capsule 110-0.5 mg
ferate * oral tablet
ferotrinsic *
ferretts *
ferrex 150 *
(B1,B2,B3,B6,B12
/Dexpan/Zn/Mang)
(Multivitamin with
Minerals)
(Multivitamin/Iron/
Folic Acid)
(Tab A Vite)
(Multivitamin)
(Fe
Fumarate/Doss/Fa/
Bcomp and C)
(Fe Fumarate/Vit
C/B12-If/Fa)
(Fergon)
(Fe Fumarate/Vit
C/B12-If/Fa)
(Ferrous Fumarate)
(Pic 200)
Necessary Actions,
Restrictions, or
Limits on Use
143
143
Tier level
What the
drug will
cost you
4
$0
4
$0
(Ferrous Fumarate)
4
$0
(Fergon)
(Fer-In-Sol)
(Ferrous Sulfate)
(Ferrous Sulfate)
4
4
4
4
$0
$0
$0
$0
(Ferrous Sulfate)
4
$0
(Ferrous Sulfate)
4
$0
(Multivitamin
W/Iron, Minerals)
4
$0
(Multivitamin)
4
$0
(Pedi Mv
No.79/Ferrous
Fumarate)
4
$0
(Multivitamin)
4
$0
(Folic Acid)
3
4
$0
$0
(Folic Acid)
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
4
$0
$0
Name of Drug
ferrex 150 plus *
ferrocite *
ferrous fumarate * oral tablet 324
mg (106 mg iron)
ferrous gluconate * oral tablet
ferrous sulfate * oral
ferrous sulfate * oral tablet 325 mg
(65 mg iron)
ferrous sulfate * oral tablet,delayed
release (dr/ec) 324 mg (65 mg iron)
flintstones complete (iron) * oral
tablet,chewable
flintstones multivitamin * oral
tablet,chewable
flintstones with iron *
flintstones/extra c * oral
tablet,chewable
folic acid * 1 mg tablet (rx)
FOLIC ACID * ORAL CAPSULE
folic acid * oral tablet 1 mg, 400
mcg, 800 mcg
fosfree *
fruity chews *
geravim *
geriaton *
germ defense *
gummi bear multivitamin *
gummy swirls *
(Iron Aspgly and
Ps Cmplx/C/Sucac)
(Ferrous Fumarate)
(Calcium/Multivita
mins W-Iron)
(Multivitamin)
(Pediavit)
(Pediavit)
(Vit A,C, and
E/Dietary Supp
No.12)
(Multivitamin)
(Multivitamin)
Necessary Actions,
Restrictions, or
Limits on Use
144
144
Name of Drug
hair vitamins *
hair,skin & nails * oral tablet
hair,skin & nails * oral tablet 1 mg
iron-66.7 mcg-1,000 mcg
healthy eyes *
hemocyte *
hi-b complex *
high potency multivit-multimin *
honey bears *
honey bears with iron-zinc *
icaps plus *
iferex 150 *
iron high potency *
i-vite *
kid's vitamins + extra c *
kids vitamins + iron *
kid's vitamins + iron *
(Multivitamins
with Iron)
(Multivitamin with
Minerals)
(Mv,Ca,Min/Iron
Gluc/Fa/Biotin)
(Ocuvite with
Lutein)
(Ferrous Fumarate)
(Vitamin B
Complex)
(Multivitamin)
(Multivitamin
W/Iron, Minerals)
(Multivitamin with
Minerals)
(Pic 200)
(Fergon)
(Ocuvite with
Lutein)
(Multivitamin)
(Ped Multivit
#17/Iron Fumarate)
(Multivitamins
with Iron)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
kid's vitamins * oral
tablet,chewable
(Multivitamin)
4
$0
life-pack women's *
(Multivitamin
W/Iron, Minerals)
4
$0
4
4
$0
$0
4
$0
4
4
$0
$0
LIQUI-E *
little animals *
little animals/iron *
lysiplex plus * oral liquid
MACUVITE *
(Multivitamin)
(Multivitamins
with Iron)
(Pediavit)
Necessary Actions,
Restrictions, or
Limits on Use
145
145
Name of Drug
MACUVITE EYE CARE *
maximum daily multivitamin *
mega multiple/chelated mineral *
mega multivitamin with mineral *
oral tablet
men's multi-vitamin *
men's one daily * oral tablet
(Tab A Vite)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Multivitamin)
(Multivitamin with
Minerals)
MEPHYTON *
milltrium senior *
multi complete with iron *
multi-day with iron *
multi-delyn *
multi-delyn with iron *
multilex *
multilex-t&m *
multiple vitamin-minerals *
multiple vitamins *
multiple vitamins with iron *
multivital platinum * oral tablet
multivital platinum * oral tablet
500-300-250 mcg
multivitamin 50 plus *
multi-vitamin hp/minerals *
multivitamin * oral tablet
(Multivitamin/Iron/
Folic Acid)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin/Ferr
ous Gluconate)
(Multivitamin
W/Iron, Minerals)
(Multivitamin with
Minerals)
(Multivitamin)
(Multivitamins
with Iron)
(Biocel)
(Multivitamins,The
r W-Minerals)
(Multivitamin)
Tier level
What the
drug will
cost you
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
146
146
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
4
$0
$0
(Niacinamide)
4
$0
(Pic 200)
(Beta-Carotene(A)
W-C and E/Min)
(Multivitamin)
(Multivitamins,The
rapeutic)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
multivitamin with iron *
multivitamin with minerals * oral
liquid
multivitamin with minerals * oral
tablet
multivitamins with min no.7-fa *
oral capsule 1 mg
multi-vite *
multi-vite 50 & over *
my favorite multiple *
my-vitalife *
(Multivitamins
with Iron)
(Multivitamin with
Minerals)
(Multivitamins
with Min No.7/Fa)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin with
Minerals)
NASCOBAL *
natural b-100 *
natural b-100 complex *
nephro-vite *
niacinamide * oral tablet 500 mg
niacinamide * oral tablet extended
release
nu-iron *
ocutabs *
once daily *
oncovite *
one daily 50 plus *
one daily complete * oral tablet
one daily energy * oral tablet
(Vitamin B
Complex)
(Vit B Complex
100 Cmb
#2/Herbs)
(Dialyvite 800)
(Niacinamide)
Necessary Actions,
Restrictions, or
Limits on Use
147
147
Tier level
What the
drug will
cost you
(Multivitamin)
(Tab A Vite)
(Multivitamin with
Minerals)
(Multivitamins
with Iron)
(Multivitamin)
4
4
$0
$0
4
$0
4
$0
4
$0
(Quintabs)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
4
4
4
$0
$0
$0
$0
4
$0
Name of Drug
one daily essential * oral tablet
one daily maximum (with ca) *
one daily men's 50+ * oral tablet
one daily multi-vit w-mineral *
one daily multivitamin * oral tablet
one daily multivitamin * oral tablet
400 mcg
(Multivitamin/Iron/
Folic Acid)
one daily * oral tablet
(Multivitamin)
(Multivitamins
one daily plus iron * oral tablet
with Iron)
one daily plus iron * oral tablet 18- (Multivitamin/Iron/
400 mg-mcg
Folic Acid)
(Multivitamin with
one daily plus minerals *
Minerals)
(Multivitamins
one daily with iron *
with Iron)
one-a-day essential *
(Multivitamin)
(Multivitamin with
one-a-day maximum formula *
Minerals)
one-a-day teen advantage * oral
(Multivitamin/Iron/
tablet 18-400 mg-mcg
Folic Acid)
one-a-day teen advantage * oral
(Multivits,Ca,Mine
tablet 9 mg iron-400 mcg
rals/Iron/Fa)
(Ocuvite with
opti-vitamins *
Lutein)
pedi m.vit no.17 with fluoride oral
(Pedi Mvi No.82
drops 0.25 mg/ml
with Fluoride)
pediatric multivitamin *
(Multivitamin)
pharmacist favorite multi-vit *
(Multivitamin)
phytonadione * oral tablet 100 mcg (Phytonadione)
poly-iron *
(Pic 200)
(Pediatric Multivit
poly-vita *
Comb No.20)
one daily multivitamin-iron *
Necessary Actions,
Restrictions, or
Limits on Use
148
148
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
(Classic Prenatal)
4
$0
(Classic Prenatal)
(Prenatal
Vit#96/Ferrous
Fum/Fa)
(Classic Prenatal)
(Pnv with
Ca,No.72/Iron/Fa)
4
$0
4
$0
4
$0
2
$0
2
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
1
$0
Name of Drug
poly-vita (iron) *
poly-vitamin *
poly-vitamin with iron * oral drops
1,500 unit-400 unit-10 mg/ml
polyvitamin/iron *
poly-vitamins *
prenatal formula * oral tablet 280.8 mg
prenatal * oral tablet 28-0.8 mg
prenatal vit#96-ferrous fum-fa *
prenatal vitamin with minerals *
prenatal vitamins oral tablet 27 mg
iron- 1 mg
PRENATAL VITAMINS ORAL
TABLET 29 MG IRON- 1 MG-25
MG
prenatal vit-iron fumarate-fa *
prosight *
pyridoxine * injection
ra central-vite select * tab p/f
scooby-doo one a day *
sentry * oral tablet 18-400 mg-mcg
sentry senior *
sodium fluoride oral tablet
(Ped Multivit
#46/Iron Sulfate)
(Pediatric Multivit
Comb No.20)
(Ped Multivit
#46/Iron Sulfate)
(Multivitamin
W/Iron, Minerals)
(Multivitamin)
(Classic Prenatal)
(A/C/E/Zinc/Sod
Selenate/Copper)
(Pyridoxine HCl)
(Multivitamin
W/Iron, Minerals)
(Multivitamin
W/Iron, Minerals)
(Multivitamin/Iron/
Folic Acid)
(Biocel)
(Pedi Mvi No.82
with Fluoride)
Necessary Actions,
Restrictions, or
Limits on Use
(All Rx Prenatal
Vitamins Covered)
sodium fluoride * oral
tablet,chewable 0.25 mg fluorid
(Sodium Fluoride)
3
$0
(0.55 mg)
spectravite adult 50+ * oral tablet (Biocel)
4
$0
149
149
Name of Drug
spectravite advanced formula * oral (Multivitamin/Iron/
tablet
Folic Acid)
spectravite * oral liquid
(Pediavit)
(Multivitamins
spectravite * oral tablet,chewable
with Iron)
(Multivitamin
spectravite senior * oral tablet
W/Iron, Minerals)
(Multivitamin Wspectravite senior w-lycopene *
Minerals/Lutein)
(Multivitamin/Iron/
spectravite ultra women *
Folic Acid)
(Multivits,Stress
stress 500 plus zinc *
Formula/Zinc)
(Multivits,Stress
stress b with zinc *
Formula/Zinc)
(Vitamin B
stress b-biotin *
Complex)
(Multivits,Stress
stress formula *
Formula)
(Iron/Multivits,Stre
stress formula plus iron *
ss Formula)
(Vit B
stress formula with iron *
Comp/C/Fa/Iron/Vi
t E)
(Multivits,Stress
stress formula with zinc *
Formula/Zinc)
stuart prenatal *
(Classic Prenatal)
(Mv-Min/Iron
sunvite *
Fum/Fa/K/Lyco/Lu
tn)
super b complex-vitamin c *
(Vita-Bee with C)
(B Complex with
super b/c *
Vitamin C)
(Vitamin B
super b-50 complex *
Complex)
(Vitamin B
super b-50 complex plus *
Complex)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
150
150
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
(Multivitamin
4
$0
W/Iron, Minerals)
super multivitamin *
(Multivitamin)
4
$0
(Vitamin B
super quints b-50 *
4
$0
Complex)
(Multivitamins,The
super thera vite m *
4
$0
r W-Minerals)
(Multivitamin
superior 35 *
4
$0
W/Iron, Minerals)
superplex-t *
(Vita-Bee with C)
4
$0
(Multivitamin with
support *
4
$0
Minerals)
(B Complex with
support-500 *
3
$0
Vitamin C)
tab-a-vite *
(Multivitamin)
4
$0
(Multivitamins
tab-a-vite/iron *
4
$0
with Iron)
(Multivitamin with
tab-a-vite-minerals *
4
$0
Minerals)
(Multivits,Ca,Mine
thera m plus (ferrous fumarat) *
4
$0
rals/Iron/Fa)
(Multivitamins,The
thera vitamin *
4
$0
rapeutic)
(Multivit,Ther
theradex m *
Iron,Ca,Fa and
4
$0
Min)
(Multivits,Th Wthera-m * oral tablet
4
$0
Fe,Other Min)
(Multivit,Ther
thera-m * oral tablet 27-0.4 mg
Iron,Ca,Fa and
4
$0
Min)
thera-m * oral tablet 9 mg iron-400 (Multivits,Ca,Mine
4
$0
mcg
rals/Iron/Fa)
(Multivitamin with
theramill forte * oral capsule
4
$0
Minerals)
(Multivitamins,The
therapeutic liquid *
4
$0
rapeutic)
therapeutic m + beta-carotene *
(Tab A Vite)
4
$0
151
151
super multiple * oral tablet
Name of Drug
therapeutic vitamins/minerals *
therapeutic-m * oral tablet 9 mg
iron-400 mcg
therapeutic-m vitamin/minerals *
oral tablet 27-0.4 mg
thera-tabs *
theratrum complete 50 plus *
theratrum complete 50 plus/lut *
therems *
therems-h *
therems-m *
thiamine hcl * injection
thiamine hcl * oral tablet 500 mg
total b/c *
totalday multiple *
tri-vi-sol *
tri-vita *
tri-vitamin *
ultra b-100 complex * oral tablet
unicomplex-m *
(Multivitamins
with Min No.7/Fa)
(Multivits,Ca,Mine
rals/Iron/Fa)
(Multivit,Ther
Iron,Ca,Fa and
Min)
(Multivitamins,The
rapeutic)
(Multivitamin
W/Iron, Minerals)
(Multivitamins,The
rapeutic)
(Thiamine HCl)
(Thiamine HCl)
(Vita-Bee with C)
(Multivitamin with
Minerals)
(Vit A
Palmitate/Vit C/Vit
D3)
(Pedi Multivits
A,C, and D3
No.21)
(Pedi Multivits
A,C, and D3
No.21)
(Vitamin B
Complex)
(Multivitamin
W/Iron, Minerals)
Tier level
What the
drug will
cost you
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
152
152
Name of Drug
vision *
vision formula *
vision formula (with lutein) *
vision plus lutein *
vit b cmplx 3-fa-vit c-biotin * oral
tablet 1-60-300 mg-mg-mcg
vit b cmplx no3-fa-c-biot-zinc *
vitabee/c *
vitalets * oral tablet,chewable
vitamin a * oral capsule 10,000
unit, 25,000 unit
vitamin b complex *
vitamin b complex with c *
vitamin b-1 * oral tablet
vitamin b-100 complex *
vitamin b12-folic acid * oral
(Beta-Carotene(A)
W-C and E/Min)
(Beta-Carotene(A)
W-C and E/Min)
(Ocuvite with
Lutein)
(Vit B Cmplx
3/Fa/Vit C/Biotin)
(Vit B Cmplx
No3/Fa/C/Biot/Zin
c)
(Vita-Bee with C)
(Multivitamins
with Iron)
(Vitamin A)
(Vitamin B
Complex)
(B Complex with
Vitamin C)
(Thiamine HCl)
(Vitamin B
Complex)
(Cyanocobalamin/
Folic Acid)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
3
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
vitamin b-6 * oral tablet 100 mg, 25
(Pyridoxine HCl)
4
$0
mg, 250 mg, 50 mg
vitamin c * oral capsule, extended
(Ascorbic Acid)
4
$0
release
vitamin c * oral syrup
(Ascorbic Acid)
4
$0
vitamin c * oral tablet 1,000 mg,
(Ascorbic Acid)
4
$0
250 mg, 500 mg
vitamin c * oral tablet extended
(Ascorbic Acid)
4
$0
release
vitamin c * oral tablet,chewable
(Ascorbic Acid)
4
$0
250 mg, 500 mg
153
153
Name of Drug
vitamins & minerals *
vitamins b complex * oral capsule
vitamins b complex * oral tablet
vitamins b complex * oral tablet
500 mg-400 mcg- 18 mg iron
vitamins for hair * oral tablet
vitrum senior * oral tablet
(Multivitamins,The
r W-Minerals)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vit B
Comp/C/Fa/Iron/Vi
t E)
(Multivitamin)
vitrum senior * oral tablet 500-300(Biocel)
250 mcg
women's daily multivitamin *
(Tab A Vite)
(Multivitamin/Iron/
yelets *
Folic Acid)
zoo chews *
(Multivitamin)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
154
154
INDEX
3
3 day vaginal .......................... 37
30pse-150gfn-15dm ............... 72
8
8-MOP.................................... 82
A
a thru z advanced formula .... 127
a thru z high potency ............ 127
a thru z select ....................... 127
a thru z select 50+ formula... 127
a thru z select women's ........ 127
abacavir .................................. 51
abacavir-lamivudine-zidovudine
............................................ 51
abc plus ................................ 127
ABELCET.............................. 37
ABILIFY ................................ 47
ABILIFY DISCMELT ........... 47
ABILIFY MAINTENA ......... 47
ABRAXANE ......................... 21
ABREVA ............................... 43
acamprosate.............................. 9
acarbose.................................. 34
acebutolol ............................... 63
acephen .................................... 1
acetaminophen ......................... 1
acetaminophen-codeine............ 1
acetazolamide ....................... 116
acetazolamide sodium .......... 116
acetic acid....................... 93, 111
acetylcysteine ....................... 124
acid gone antacid.................... 97
acid reducer (famotidine) ....... 96
acid relief (cimetidine) ........... 96
acitretin .................................. 82
acne medication ..................... 82
acne-clear ............................... 82
ACTEMRA .......................... 112
ACTHIB (PF) ....................... 109
ACTIMMUNE ..................... 113
acyclovir ........................... 53, 82
acyclovir sodium .................... 53
ADACEL(TDAP
ADOLESN/ADULT)(PF) 109
ADAGEN ............................... 89
adapalene ................................ 88
ADCETRIS ............................ 21
ADCIRCA ............................ 126
adefovir .................................. 53
ADEMPAS........................... 126
adrenalin ................................. 64
ADRENALIN ........................ 64
adt robitussin peak cld dm max
............................................ 72
adult nasal decongestant......... 72
adult one daily gummies ...... 127
adult robitussin lingering cld.. 72
adult robitussin peak cold dm 72
adult wal-tussin ...................... 72
adult wal-tussin dm max ........ 72
adults 50+ daily formula ...... 127
adults' daily formula ............. 127
ADVAIR DISKUS ............... 122
ADVAIR HFA ..................... 122
advil .......................................... 5
af 37
AFINITOR ............................. 21
AFINITOR DISPERZ ............ 21
AGGRENOX ......................... 56
airshield ................................ 127
AKTEN (PF) .......................... 90
alavert d-12 allergy-sinus ....... 40
alaway .................................... 90
ALBENZA ............................. 46
I-1
ICS Community Care Plus 2016 FIDA-MMP Formulary
Formulary ID: 15412.000, Version: 14
ALBUKED-25 ....................... 57
ALBUKED-5 ......................... 57
ALBUMIN, HUMAN 25 % ... 57
ALBUMIN, HUMAN 5 %..... 57
ALBUMINAR 25 % .............. 57
ALBUMINAR 5 % ................ 57
ALBURX (HUMAN) 5 % ..... 57
ALBUTEIN 25 % .................. 57
ALBUTEIN 5 % .................... 57
albuterol sulfate .................... 123
alclometasone ......................... 85
ALCOHOL PADS ................. 82
ALCOHOL PREP PADS ....... 83
ALCOH-WIPE ....................... 83
ALDURAZYME .................... 89
alendronate ........................... 111
alfuzosin ............................... 103
ALIMTA ................................ 21
ALINIA .................................. 46
alka-seltzer plus mucus-conges
............................................ 72
alka-seltzer plus sinus-cough . 72
aller-chlor ............................... 40
allerclear d-12hr ..................... 40
allerclear d-24hr ..................... 40
allergy (chlorpheniramine) ..... 40
allergy relief (cetirizine) ......... 40
allergy relief (loratadine)........ 40
allerhist-1................................ 40
aller-tec d ................................ 40
allopurinol ............................ 113
almacone ................................ 97
almacone-2 ............................. 97
aloe vesta ................................ 37
alophen ................................. 100
alosetron ....................... 110, 111
ALPHAGAN P..................... 116
Effective: January 01, 2016
alprazolam .............................. 10
ALREX .................................. 95
altacaine ................................. 90
altamist ................................... 90
aluminum chloride ................. 83
aluminum hydroxide gel ........ 97
amantadine hcl ....................... 46
ambi 10peh-4cpm-20dm ........ 73
ambi 20dm-4cpm ................... 73
ambi 40pse-400gfn-20dm ...... 73
ambi 60pse-4cpm ................... 40
ambi 60pse-4cpm-20dm......... 73
AMBISOME .......................... 37
ambizine ................................. 45
amifostine crystalline ........... 113
amiloride ................................ 66
amiloride-hydrochlorothiazide66
AMINO ACIDS 15 % ............ 57
aminocaproic acid .................. 56
AMINOSYN 10 % ................. 57
AMINOSYN 3.5 % ................ 57
AMINOSYN 7 % ................... 57
AMINOSYN 7 % WITH
ELECTROLYTES ............. 57
AMINOSYN 8.5 % ................ 57
AMINOSYN 8.5 %ELECTROLYTES ............. 57
AMINOSYN II 10 % ............. 57
AMINOSYN II 15 % ............. 57
AMINOSYN II 7 % ............... 57
AMINOSYN II 8.5 % ............ 57
AMINOSYN II 8.5 %ELECTROLYTES ............. 58
AMINOSYN M 3.5 % ........... 58
AMINOSYN-HBC 7% .......... 58
AMINOSYN-PF 10 % ........... 58
AMINOSYN-PF 7 %
(SULFITE-FREE) .............. 58
AMINOSYN-RF 5.2 % ......... 58
amiodarone ............................. 62
amiodarone hcl ....................... 62
AMITIZA ............................... 97
amitriptyline ........................... 32
amlactin .................................. 83
amlodipine.............................. 66
amlodipine-atorvastatin .......... 67
amlodipine-benazepril ............ 66
amlodipine-valsartan .............. 66
amlodipine-valsartan-hcthiazid
............................................ 66
ammonium lactate .................. 83
amoxapine .............................. 32
amoxicil-clarithromy-lansopraz
............................................ 96
amoxicillin ............................. 18
amoxicillin-pot clavulanate .... 18
amphetamine salt combo ........ 69
amphotericin b........................ 37
ampicillin ............................... 19
ampicillin sodium................... 19
ampicillin-sulbactam .............. 19
AMPYRA............................... 69
ANACAINE ........................... 83
anagrelide ............................... 56
anastrozole ............................. 21
ANDRODERM .................... 103
ANDROGEL ................ 103, 104
animal chews ........................ 127
animal shape vitamins .......... 127
animal shapes plus iron ........ 128
ANORO ELLIPTA .............. 123
antacid .................................... 97
antacid anti-gas ...................... 97
antacid plus anti-gas ............... 97
anticoag citrate phos dextrose
.......................................... 113
anti-diarrheal .......................... 97
anti-diarrheal (loperamide) .... 97
antifungal ............................... 37
antifungal (tolnaftate) ............. 37
anti-gas maximum strength .... 95
antioxidant............................ 128
antioxidant formula .............. 128
antioxidant vitamins ............. 128
I-2
apatate forte .......................... 128
APOKYN ............................... 46
apraclonidine .......................... 90
APRISO................................ 111
aprodine .................................. 40
APTIOM ................................ 29
APTIVUS ............................... 51
aquanil hc ............................... 85
ARALAST NP ..................... 124
ARCALYST ......................... 107
aripiprazole ............................. 48
ARRANON ............................ 21
artificial tears .......................... 90
artificial tears (petro/min) ...... 90
artificial tears (pf) ................... 90
artificial tears(glycerin-peg) ... 90
artificial tears(hypromellose) . 90
ARZERRA ............................. 21
ASACOL HD ....................... 111
ascorbic acid ......................... 128
ashlyna.................................... 70
aspirin ................................... 5, 6
aspirin, buffered ....................... 6
aspir-low ................................... 6
ASSURE ID INSULIN
SAFETY ............................. 89
ASTAGRAF XL .................. 107
atenolol ................................... 63
atenolol-chlorthalidone .......... 63
atorvastatin ............................. 67
atovaquone ............................. 46
atovaquone-proguanil ............. 46
ATRIPLA ............................... 51
atropine ............................. 28, 91
ATROVENT HFA ............... 123
AUBAGIO ........................... 107
AVASTIN .............................. 21
AVC VAGINAL .................... 43
AVODART .......................... 113
AVONEX ............................. 113
AVONEX (WITH ALBUMIN)
.......................................... 113
ayr saline ................................ 91
azacitidine .............................. 21
azathioprine .......................... 107
azathioprine sodium ............. 107
azelastine ................................ 91
AZILECT ............................... 47
azithromycin .......................... 17
AZOPT ................................. 116
AZOR ..................................... 66
aztreonam ............................... 18
B
b complete ............................ 128
b complex 1 .......................... 128
b complex-vitamin b12 ........ 128
b complex-vitamin c-folic acid
.......................................... 128
b-100 complex ..................... 128
b-12 dots............................... 128
b-50 complex ....................... 128
bacitracin .................... 14, 84, 93
bacitracin-polymyxin b .......... 93
bacitraycin plus ...................... 84
baclofen ................................ 125
bal b-100 .............................. 128
bal b-50 ................................ 128
balance b-100 ....................... 128
balance b-50 ......................... 128
balanced b-100 ............. 128, 129
balanced b-150 ..................... 129
balanced b-50 ....................... 129
balsalazide ............................ 111
banophen ................................ 40
banophen allergy .................... 40
BANZEL ................................ 29
baza antifungal ....................... 37
BCG VACCINE, LIVE (PF) 109
b-complex ............................ 129
b-complex with vitamin c .... 129
BD INSULIN PEN NEEDLE
UF SHORT ........................ 89
BD INSULIN SYRINGE
ULTRA-FINE .................... 89
bee-zee ................................. 129
BELEODAQ .......................... 21
benadryl allergy...................... 40
benazepril ............................... 62
benazepril-hydrochlorothiazide
............................................ 62
BENICAR .............................. 61
BENICAR HCT ..................... 61
BENLYSTA ......................... 113
benzonatate............................. 73
benzoyl peroxide .................... 83
benztropine ............................. 47
BETADINE SPRAY .............. 83
beta-hc .................................... 85
betamethasone acet,sod phos 105
betamethasone dipropionate ... 85
betamethasone valerate .... 85, 86
betamethasone, augmented .... 86
BETASERON ...................... 113
betaxolol ......................... 63, 116
bethanechol chloride ............ 113
BETHKIS ............................... 13
BEXSERO (PF) ................... 109
bicalutamide ........................... 21
bicarsim forte ......................... 95
BICILLIN C-R ....................... 19
BICILLIN L-A ....................... 19
BILTRICIDE ......................... 46
bimatoprost........................... 116
bio-dtuss dmx ......................... 73
bion tears (pf) ......................... 91
bionel ...................................... 73
bionel pediatric ....................... 73
biospec dmx ........................... 73
biosupp ................................. 129
biotin .................................... 129
biovol ................................... 129
bisac-evac ............................. 100
bisacodyl .............................. 100
biscolax ................................ 100
bismatrol................................. 97
bisoprolol fumarate ................ 63
I-3
bisoprolol-hydrochlorothiazide
............................................ 63
bleomycin ............................... 21
BLINCYTO............................ 21
BOOSTRIX TDAP .............. 109
BOSULIF ......................... 21, 22
BOTOX ................................ 113
BREO ELLIPTA .................. 122
BRILINTA ............................. 56
brimonidine .......................... 116
BRINTELLIX ........................ 32
bromfenac ............................... 95
bromocriptine ......................... 47
bromphenex dm ...................... 73
brompheniramine-pseudoephdm ....................................... 73
brompheniram-phenylephrinedm ....................................... 73
broncotron-s ........................... 73
budesonide............................ 111
bufferin ..................................... 6
bumetanide ............................. 67
BUMINATE 25 % ................. 57
BUMINATE 5 % ................... 57
BUPHENYL .......................... 98
buprenorphine hcl................. 1, 9
buprenorphine-naloxone .......... 9
bupropion hcl ..................... 9, 32
buspirone .............................. 113
butalb-acetaminophen-caffeine 1
butalbital-acetaminop-caf-cod.. 1
butalbital-acetaminophen ......... 1
butalbital-acetaminophen-caff.. 1
butalbital-aspirin-caffeine ........ 1
butorphanol tartrate .................. 1
BUTRANS ............................... 1
BYDUREON.......................... 34
BYETTA ................................ 34
BYSTOLIC ............................ 63
C
c complex ............................. 129
cabergoline ............................. 47
ca-d3-mag ox-zinc-cop-mangbor .................................... 117
caffeine citrated ...................... 69
caffeine-sodium benzoate ...... 69
calci-chew .............................. 98
calcidol ................................. 129
calcionate ............................. 117
calcipotriene ........................... 83
calcitonin (salmon)............... 111
calcitrate ............................... 117
calcitrate-vitamin d .............. 117
calcitriol ......................... 83, 111
calcium 500 + d.................... 117
calcium 500 + d (d3) ............ 117
calcium 500 with d ............... 117
calcium 600 .......................... 117
calcium 600 + d(3) ............... 117
calcium 600 with vitamin d3 117
calcium acetate ..................... 102
calcium antacid ...................... 98
calcium carbonate .......... 98, 117
calcium carbonate-mag carb-fa
.......................................... 102
calcium carbonate-vitamin d2
.......................................... 117
calcium carbonate-vitamin d3
.......................................... 118
CALCIUM CARBONATEVITAMIN D3 .................... 98
calcium chloride ................... 118
calcium citrate-vitamin d3 ... 118
calcium gluconate ................ 118
calcium lactate ..................... 118
calcium+d............................. 118
CALDOLOR ............................ 6
cal-gest antacid....................... 98
calphron................................ 102
CALTRATE 600 + D .......... 118
CALTRATE-600 + D VIT D3
(800) ................................. 118
CANCIDAS ........................... 37
candesartan ............................. 61
candesartan-hydrochlorothiazid
............................................ 61
CAPASTAT ........................... 44
CAPRELSA ........................... 22
captopril ................................. 62
captopril-hydrochlorothiazide 62
CARAFATE........................... 96
carbamazepine ........................ 29
carbidopa ................................ 47
carbidopa-levodopa ................ 47
carbidopa-levodopa-entacapone
............................................ 47
carboplatin .............................. 22
cardec dm (phenyleph-chlorphn)
............................................ 73
CARIMUNE NF
NANOFILTERED ........... 107
carisoprodol .......................... 125
carteolol .................................. 91
cartia xt ................................... 64
carvedilol ................................ 63
CASTELLANI PAINT
MODIFIED ........................ 83
CAYSTON ............................. 18
cefaclor ................................... 15
cefadroxil ......................... 15, 16
cefazolin ................................. 16
cefazolin in dextrose (iso-os) . 16
cefdinir ................................... 16
cefditoren pivoxil ................... 16
cefepime ................................. 16
CEFEPIME IN DEXTROSE 5
% ........................................ 16
CEFEPIME IN
DEXTROSE,ISO-OSM ..... 16
cefotaxime .............................. 16
cefoxitin ................................. 16
cefoxitin in dextrose, iso-osm 16
cefpodoxime ........................... 16
cefprozil ................................. 16
ceftazidime ............................. 16
ceftibuten ................................ 16
I-4
ceftriaxone .............................. 17
CEFTRIAXONE .................... 17
ceftriaxone in dextrose,iso-os. 16
CEFTRIAXONE IN
DEXTROSE,ISO-OS ......... 17
cefuroxime axetil .................... 17
cefuroxime sodium ................. 17
cefuroxime-dextrose (iso-osm)
............................................ 17
celecoxib .................................. 6
CELLCEPT INTRAVENOUS
.......................................... 107
CELONTIN ............................ 29
centamin ............................... 129
central vite with lutein .......... 129
central-vite............................ 129
central-vite for seniors.......... 129
central-vite select ......... 129, 139
central-vite senior ................. 129
centram-care ......................... 129
centravites 50 plus ................ 129
centrum ................................. 130
centrum complete ................. 130
CENTRUM PRO NUTRIENTS
.......................................... 118
centrum silver ....................... 130
centrum ultra women's ......... 130
century .................................. 130
century adults 50+ ................ 130
century advanced formula .... 130
century mature ...................... 130
century ultimate women's..... 130
cephalexin .............................. 17
CEPROTIN (BLUE BAR) ..... 54
CERDELGA ........................ 113
CEREZYME .......................... 89
cerovite ................................. 130
cerovite advanced formula ... 130
cerovite jr ............................. 130
cerovite senior ...................... 130
certavite senior-antioxidant .. 130
certavite-antioxid (iron gluc) 130
certavite-antioxidant ............ 130
CERVARIX VACCINE (PF)
.......................................... 109
cetirizine ................................. 40
cetirizine-pseudoephedrine .... 40
cevimeline .............................. 82
CHANTIX................................ 9
CHANTIX CONTINUING
MONTH BOX ..................... 9
CHANTIX CONTINUING
MONTH PAK ...................... 9
CHANTIX STARTING
MONTH BOX ..................... 9
cheratussin ac ......................... 73
cheratussin dac ....................... 73
chest congestion relief + dm .. 73
chest congestion relief d......... 73
chest congestion relief pe ....... 73
chewable multi vitamin ........ 130
chewable-vite ....................... 130
chewable-vite with iron........ 130
child complete multivitamin 131
child cough & sore throat ....... 73
child mucinex chest congestion
............................................ 73
child mucus relief cough ........ 74
child plus cough & runny nose
............................................ 74
child triaminic cold & allergy 40
child triaminic cough-congest 74
child vitamin with minerals . 131
child wal-tap cold-allergy ...... 40
child wal-tussin cough relief .. 74
children's advil ......................... 6
children's aller-tec .................. 40
children's cetirizine ................ 40
children's chest congestion..... 74
children's chewable .............. 131
children's chewable complete
.......................................... 131
children's chewable vitamin . 131
children's chewable w/minerals
.......................................... 131
CHILDREN'S CLARITIN ..... 41
children's complete vitamin . 131
CHILDREN'S DIMETAPP
COLD &FLU ..................... 74
children's flu relief ................. 74
children's mapap ....................... 1
children's mucinex cough ....... 74
children's multivit w/extra c . 131
children's non-aspirin ............... 1
children's pain & fever relief.... 1
children's pain reliever ............. 1
children's pepto ...................... 98
children's silapap ...................... 1
children's silfedrine ................ 74
children's soothe ..................... 98
children's sudafed ................... 74
children's sudafed pe cough ... 74
children's vitamin with iron . 131
children's wal-dryl allergy...... 41
children's wal-zyr ................... 41
CHILDREN'S ZYRTEC
ALLERGY ......................... 41
childs chew vite .................... 131
child's chewable vitamins/iron
.......................................... 131
child's vitamin with iron....... 131
child's vitamin with vitamin c
.......................................... 131
childs/iron............................. 131
chlophedianol-guaifenesin ..... 74
chloramphenicol sod succinate
............................................ 14
chlordiazepoxide hcl .............. 10
chlorhexidine gluconate ......... 82
chloroquine phosphate ........... 46
chlorothiazide ......................... 67
chlorothiazide sodium ............ 67
chlorpheniramine-phenyleph-dm
............................................ 74
chlorpromazine....................... 48
I-5
chlorthalidone ......................... 67
chlorzoxazone ...................... 125
CHOLBAM ............................ 98
cholestyramine (with sugar) ... 67
cholestyramine-aspartame ...... 67
choline,magnesium salicylate .. 6
ciclopirox................................ 37
ciclopirox-ure-camph-menth-euc
............................................ 37
cilostazol ................................ 56
cimetidine ............................... 96
cimetidine hcl ......................... 96
CIMZIA.................................. 89
CIMZIA POWDER FOR
RECONST.......................... 89
CIPRODEX ............................ 94
ciprofloxacin .......................... 19
ciprofloxacin hcl............... 19, 94
ciprofloxacin in 5 % dextrose 20
ciprofloxacin lactate ............... 20
cisplatin .................................. 22
citalopram ............................... 32
citracal + d maximum........... 118
citric acid-sodium citrate ...... 118
citrus calcium ....................... 118
clarithromycin ........................ 17
CLARITIN ............................. 41
CLARITIN LIQUI-GEL ........ 41
CLARITIN REDITABS......... 41
CLARITIN-D 12 HOUR........ 41
CLARITIN-D 24 HOUR........ 41
clearlax ................................. 100
clemastine ............................... 41
CLEVIPREX .......................... 66
clindamycin hcl ...................... 14
clindamycin in 5 % dextrose .. 14
clindamycin palmitate hcl ...... 14
clindamycin phosphate .... 14, 43,
84
CLINIMIX 5%/D15W
SULFITE FREE ................. 58
CLINIMIX 5%/D25W
SULFITE-FREE ................ 58
CLINIMIX 2.75%/D5W
SULFIT FREE ................... 58
CLINIMIX 4.25%/D10W SULF
FREE .................................. 58
CLINIMIX 4.25%/D5W
SULFIT FREE ................... 58
CLINIMIX 4.25%-D20W
SULF-FREE ....................... 58
CLINIMIX 4.25%-D25W
SULF-FREE ....................... 58
CLINIMIX 5%D20W(SULFITE-FREE) ... 58
CLINIMIX E 2.75%/D10W
SUL FREE ......................... 58
SULF FREE ....................... 58
SUL FREE ......................... 58
SUL FREE ......................... 58
SULF FREE ....................... 58
CLINIMIX E 5%/D15W
SULFIT FREE ................... 58
CLINIMIX E 5%/D20W
SULFIT FREE ................... 59
CLINIMIX E 5%/D25W
SULFIT FREE ................... 59
CLINISOL SF 15 %............... 59
clobetasol ............................... 86
clobetasol propionate ............. 86
clobetasol-emollient ............... 86
clocortolone pivalate .............. 86
clomipramine ......................... 32
clonazepam ............................ 10
clonidine ................................. 61
clonidine hcl ..................... 61, 69
clonidine hcl-chlorthalidone .. 61
clopidogrel ............................. 56
clorazepate dipotassium ......... 10
clotrimazole ...................... 37, 38
clotrimazole 3 day .................. 37
clotrimazole-3 ........................ 38
clotrimazole-betamethasone... 38
clozapine ................................ 48
COARTEM ............................ 46
codeine sulfate.......................... 2
codeine-butalbital-asa-caffein .. 2
codituss dm ............................ 74
colace ................................... 100
colchicine ............................. 113
colchicine-probenecid .......... 113
COLCRYS ........................... 113
cold & cough .......................... 41
cold multi-symptom ............... 74
cold multi-symptom day/night74
cold multi-symptom nighttime
............................................ 74
cold relief m/s day/night ........ 74
cold-flu relief.......................... 75
cold-flu relief, day/night ........ 75
colestipol ................................ 67
colistin (colistimethate na) ..... 14
COLY-MYCIN S ................... 94
COMBIGAN ........................ 116
COMBIPATCH ................... 104
COMBIVENT RESPIMAT . 123
COMETRIQ ........................... 22
comfort gel extra strength ...... 98
COMFORT PACCYCLOBENZAPRINE ... 125
COMFORT PAC-IBUPROFEN
.............................................. 6
COMFORT PACMELOXICAM ..................... 6
COMFORT PAC-NAPROXEN
.............................................. 6
COMFORT PAC-TIZANIDINE
.......................................... 125
compete ................................ 131
COMPLERA .......................... 51
complete 50+ ........................ 131
I-6
complete multi 50+ .............. 131
complete multivitamin ......... 131
complete multivitamin-mineral
.......................................... 131
complete senior ............ 131, 132
compoz ................................... 41
COMVAX (PF) .................... 109
CONDYLOX ......................... 83
congestac ................................ 75
COPAXONE ........................ 113
coral calcium ........................ 118
CORDRAN ............................ 86
coricidin hbp........................... 75
cortisone ............................... 105
cortizone-10............................ 86
CORTIZONE-10 .................... 86
COSENTYX PEN (2 PENS) . 83
cough & cold .......................... 75
cough & runny nose ............... 75
CREON .................................. 89
creo-terpin (dm-guaifenesin) .. 75
CRESTOR .............................. 67
critic-aid clear af .................... 38
CRIXIVAN ............................ 51
cromolyn .................. 91, 98, 124
CUBICIN ............................... 14
CURITY GAUZE ................ 113
cyanocobalamin (vitamin b-12)
.......................................... 132
cyclobenzaprine.................... 125
CYCLOGYL .......................... 91
cyclopentolate ........................ 91
cyclophosphamide .................. 22
CYCLOPHOSPHAMIDE ...... 22
CYCLOSET ........................... 34
cyclosporine ................. 107, 108
cyclosporine modified .......... 107
cyclosporine, modified ......... 108
cyproheptadine ....................... 41
CYRAMZA ............................ 22
CYSTADANE...................... 113
CYSTARAN .......................... 91
cysteine (l-cysteine) ............... 59
cytarabine ............................... 22
cytarabine (pf) ........................ 22
D
d10 % & 0.45 % sodium
chloride .............................. 59
d2.5 %-0.45 % sodium chloride
............................................ 59
d5 % and 0.9 % sodium chloride
............................................ 59
d5 %-0.45 % sodium chloride 59
dacarbazine ............................ 22
dactinomycin .......................... 22
daily gummies ...................... 132
daily multiple ....................... 132
daily multi-vitamin............... 132
daily multivitamin with iron 132
daily multivitamin-minerals . 132
daily multi-vitamins/iron ..... 132
daily teen multi-vitamin ....... 132
daily value ............................ 132
daily vitamin ........................ 132
daily vitamin formula ........... 132
daily vitamin formula + iron 132
daily vitamin formula-minerals
.......................................... 132
daily vitamin with iron ......... 132
daily vites/iron ..................... 132
dailyhist-1 .............................. 41
daily-vite .............................. 132
DALIRESP .......................... 124
DALLERGY DM................... 75
danazol ................................. 104
dantrolene ............................. 125
dantrolene sodium ................ 125
dapsone .................................. 44
DAPTACEL (DTAP
PEDIATRIC) (PF) ........... 109
DARAPRIM .......................... 46
dayhist allergy ........................ 41
daytime cold & cough ............ 75
daytime cold-flu ..................... 75
day-time cough ....................... 75
daytime mucus relief dm ........ 75
daytime-nighttime .................. 75
daytime-nighttime cold-flu .... 75
daytime-nighttime cough ....... 75
deblitane ................................. 70
decitabine ............................... 22
decongestant cough ................ 75
deep sea nasal ......................... 91
deferoxamine ........................ 103
delsym cough+chest congest dm
............................................ 75
DELZICOL .......................... 111
DEMSER ............................... 64
DEPEN TITRATABS .......... 103
DEPO-PROVERA ............... 107
dermafungal ........................... 38
dermarest eczema (hydrocort) 86
desenex (clotrimazole) ........... 38
desipramine ............................ 32
desmopressin ................ 105, 106
desog-e.estradiol/e.estradiol ... 71
desogestrel-ethinyl estradiol .. 71
desonide ................................. 86
desoximetasone ...................... 86
despec-dm (pseudoeph-dmguaif) .................................. 75
dex4 glucose ........................... 59
dexamethasone ..................... 105
dexamethasone sodium
phosphate ................... 95, 105
dexchlorphen-pse-chlophedianol
............................................ 75
dexmethylphenidate ............... 69
dextroamphetamine ................ 69
dextroamphetamineamphetamine ...................... 69
dextromethorphan polistirex .. 75
dextrose 10 % and 0.2 % nacl 59
............................................ 59
I-7
dextrose 2.5 % in water(d2.5w)
............................................ 59
............................................ 59
............................................ 59
............................................ 59
dextrose 5 % in ringers ........... 59
dextrose 5 % in water (d5w) .. 59
dextrose 5 %-lactated ringers . 59
dextrose 5%-0.2 % sod chloride
............................................ 59
dextrose 5%-0.3 % sod.chloride
............................................ 60
............................................ 60
............................................ 60
dextrose with sodium chloride 60
diabetic siltussin das-na.......... 76
diabetic tussin dm ................... 76
diabetic tussin ex .................... 76
diamode .................................. 98
DIASTAT ACUDIAL ............ 10
diazepam ................................ 10
diazepam intensol ................... 10
diclofenac potassium ................ 6
diclofenac sodium .............. 6, 95
diclofenac-misoprostol ............. 6
dicloxacillin ............................ 19
dicyclomine ............................ 98
didanosine .............................. 51
DIFICID ................................. 17
diflunisal ................................... 6
digitek ..................................... 65
digoxin.................................... 65
DIGOXIN ............................... 65
dihydroergotamine ................. 44
DILANTIN ............................. 29
diltiazem hcl ........................... 64
dilt-xr ...................................... 64
dimaphen (pe) ........................ 41
dimaphen dm .......................... 76
dimenhydrinate ...................... 45
dimetapp cold-congestion ...... 41
dino-life ................................ 132
dino-life with extra c ............ 132
dino-life with iron-zinc ........ 133
DIPENTUM ......................... 111
diphenhist ............................... 41
diphenhydramine hcl ........ 41, 42
diphenoxylate-atropine .......... 98
disopyramide phosphate......... 62
disulfiram ................................. 9
divalproex .............................. 29
d-methorphan hb-p-epd hcl-bpm
............................................ 76
dm-phenyleph-chlorpheniramine
............................................ 76
dobutamine............................. 65
dobutamine in d5w................. 65
doc-q-lace ............................. 100
docu ...................................... 100
docusate calcium .................. 100
docusate sodium ................... 100
docusol ................................. 100
dok........................................ 100
donepezil ................................ 31
dopamine ................................ 65
dopamine in 5 % dextrose ...... 65
dorzolamide.......................... 116
dorzolamide-timolol............. 116
double-tussin dm .................... 76
douche vinegar & water extra
.......................................... 113
doxazosin ............................... 61
doxepin................................... 32
doxercalciferol ............. 111, 112
doxorubicin hcl ...................... 22
doxorubicin hcl peg-liposomal
............................................ 22
doxorubicin, peg-liposomal ... 22
doxycycline hyclate ............... 20
doxycycline monohydrate ...... 21
dramamine .............................. 45
driminate ................................ 45
dristan long lasting ................. 91
dronabinol .............................. 45
droperidol ............................. 113
drospirenone-ethinyl estradiol 71
DROXIA ................................ 22
DUAVEE ............................. 104
dulcolax stool softener (dss) 100
DULERA ............................. 122
duloxetine ............................... 32
DURAMORPH (PF) ................ 2
DUREZOL ............................. 95
DYRENIUM .......................... 67
E
e.c. prin ..................................... 6
ECEE PLUS ......................... 133
econazole ................................ 38
ed bron gp............................... 76
ed chlorped jr ......................... 42
EDURANT............................. 51
EFFIENT ................................ 57
ELAPRASE ........................... 89
eldertonic .............................. 133
electrolyte-48 in d5w ........... 118
ELIDEL .................................. 86
ELIGARD ........................ 22, 23
ELIQUIS ................................ 54
ELITEK .................................. 89
ELLA ..................................... 71
ellis tonic .............................. 133
ELMIRON ........................... 113
elon dual defense .................... 38
EMCYT.................................. 23
EMEND ................................. 45
EMSAM ................................. 32
EMTRIVA ............................. 51
enalapril maleate .................... 62
enalaprilat ............................... 62
enalapril-hydrochlorothiazide 62
ENBREL .............................. 108
I-8
ENBREL SURECLICK ....... 108
endur-acin ............................... 67
enema ................................... 100
enema disposable ................. 100
enemeez ................................ 100
enemeez plus ........................ 100
enfalyte ................................. 118
ENGERIX-B (PF) ................ 109
ENGERIX-B PEDIATRIC (PF)
.......................................... 109
enoxaparin .............................. 54
entacapone .............................. 47
entecavir ................................. 53
entre-cough ............................. 76
ephedrine sulfate .................... 65
epinastine................................ 91
epinephrine ............................. 65
EPIPEN 2-PAK ...................... 65
EPIPEN JR 2-PAK................. 65
epirubicin................................ 23
EPIVIR HBV ......................... 51
eplerenone .............................. 68
EPOGEN .......................... 55, 56
epoprostenol (glycine) .......... 126
EPZICOM .............................. 51
eq gentle ................................. 91
equalactin ............................. 100
ERBITUX .............................. 23
ergocalciferol (vitamin d2) ... 133
ergoloid ................................ 113
ERGOMAR ............................ 44
ERIVEDGE ............................ 23
ERYTHROCIN ...................... 17
erythromycin .................... 18, 94
erythromycin base .................. 18
ERYTHROMYCIN BASE .... 18
erythromycin base-ethanol ..... 84
erythromycin ethylsuccinate .. 18
erythromycin stearate ............. 18
erythromycin with ethanol ..... 85
ESBRIET.............................. 124
escitalopram oxalate ............... 32
esmolol ................................... 63
esomeprazole sodium ............. 96
essentia ................................. 133
essential balance with lutein 133
essential daily ....................... 133
essential one daily ................ 133
estazolam................................ 11
ESTRACE ............................ 104
estradiol ................................ 104
estradiol valerate .................. 104
estradiol/norethindrone acet . 104
estradiol-norethindrone acet. 104
ESTRASORB ...................... 104
estropipate ............................ 104
ethambutol.............................. 44
ethamolin................................ 65
ethinyl estradiol/drospirenone 71
ethosuximide .......................... 29
ethynodiol d-ethinyl estradiol 71
etidronate disodium .............. 112
etodolac .................................... 6
ETOPOPHOS ........................ 23
etoposide ................................ 23
EVOTAZ................................ 51
exefen dmx ............................. 76
EXELON................................ 31
exemestane ............................. 23
EXJADE .............................. 103
expectorant ............................. 76
expectorant max strength ....... 76
EXTAVIA ............................ 113
extra cleansing douche ......... 113
F
FABRAZYME ....................... 89
famciclovir ............................. 53
famotidine ........................ 96, 97
famotidine (pf) ....................... 96
famotidine (pf)-nacl (iso-os) . 96
FANAPT ................................ 48
FARESTON ........................... 23
FARYDAK ............................ 23
FASLODEX ........................... 23
FAZACLO ............................. 48
fe fumarate-doss-fa-bcomp and
c ........................................ 133
fe fumarate-vit c-b12-if-fa ... 133
felbamate ................................ 29
felodipine ............................... 66
feminine care douche ........... 113
FEMRING ............................ 104
fenofibrate .............................. 67
fenofibrate micronized ........... 67
fenofibrate nanocrystallized ... 67
fenofibric acid ........................ 68
fenofibric acid (choline) ......... 68
fenoprofen ................................ 6
fentanyl..................................... 2
fentanyl citrate.......................... 2
ferate..................................... 133
ferotrinsic ............................. 133
ferretts .................................. 133
ferrex 150 ............................. 133
ferrex 150 plus ..................... 133
FERRIPROX ........................ 103
ferrocite ................................ 133
ferrous fumarate ................... 133
ferrous gluconate .................. 133
ferrous sulfate ............... 133, 134
FETZIMA .............................. 32
feverall ..................................... 2
fiber (calcium polycarbophil)
.......................................... 100
fiber laxative (methylcellulo)100
fiber smooth ......................... 100
fiber therapy ......................... 100
fiber therapy (psyllium/sugar)
.......................................... 100
fiber-lax ................................ 100
finasteride ............................. 114
FIRAZYR............................... 65
FIRMAGON KIT W DILUENT
SYRINGE .......................... 23
flanax antacid ......................... 98
FLEBOGAMMA DIF .......... 108
I-9
flecainide ................................ 62
FLECTOR ................................ 6
FLEET BISACODYL .......... 101
FLEXBUMIN 25 % ............... 57
FLEXBUMIN 5 % ................. 57
flintstones complete (iron) ... 134
flintstones multivitamin ....... 134
flintstones with iron.............. 134
flintstones/extra c ................. 134
FLOVENT DISKUS ............ 123
FLOVENT HFA................... 123
floxuridine .............................. 23
flu formula daytime-nighttime76
flu severe cold-congestion...... 76
fluconazole ............................. 38
fluconazole in dextrose(iso-o) 38
fluconazole in nacl (iso-osm) . 38
flucytosine .............................. 38
fludarabine.............................. 23
fludrocortisone ..................... 105
flumazenil ............................... 69
fluocinonide............................ 87
fluocinonide-emollient base ... 87
fluorometholone ..................... 95
FLUOROPLEX ...................... 83
fluorouracil ....................... 23, 83
fluoxetine................................ 32
FLUOXETINE ....................... 32
fluoxymesterone ................... 104
fluphenazine decanoate .......... 48
fluphenazine hcl ..................... 48
flurazepam ........................ 11, 12
flurbiprofen .............................. 6
flurbiprofen sodium ................ 95
flu-severe cold-cough ............. 76
flutamide ................................ 23
fluticasone ........................ 87, 95
fluvoxamine...................... 32, 33
foaming antacid ...................... 98
folic acid ............................... 134
FOLIC ACID ....................... 134
fomepizole ............................ 114
fondaparinux .......................... 54
FORTEO .............................. 112
FORTICAL .......................... 112
foscarnet ................................. 52
fosfree .................................. 134
fosinopril ................................ 62
fosinopril-hydrochlorothiazide
............................................ 62
fosphenytoin ........................... 29
FREAMINE HBC 6.9 %........ 60
FREAMINE III 10 % ............. 60
fruity chews .......................... 134
fungi cure ............................... 38
FUNGI-NAIL ........................ 38
fungoid-d ................................ 38
furosemide.............................. 67
FUSILEV ............................. 114
FUZEON ................................ 51
FYCOMPA ............................ 29
G
gabapentin .............................. 29
GABITRIL ............................. 29
galantamine ............................ 31
GAMASTAN S/D ................ 108
GAMMAGARD LIQUID .... 108
GAMMAPLEX .................... 108
GAMUNEX-C ..................... 108
ganciclovir sodium ................. 54
GARDASIL (PF) ................. 109
GARDASIL 9 (PF) .............. 109
gas free extra strength ............ 95
gas relief ................................. 95
gas relief 80 ............................ 95
gas relief extra strength .......... 95
gas-x ultra-strength ................ 95
gatifloxacin ............................ 94
GAZYVA ............................... 23
gelusil antacid & anti-gas....... 98
gemcitabine ............................ 23
gemfibrozil ............................. 68
GENOTROPIN .................... 106
GENOTROPIN MINIQUICK
.......................................... 106
gentamicin .................. 13, 85, 94
gentamicin in nacl (iso-osm) .. 13
gentamicin sulfate .................. 94
gentamicin sulfate (ped) (pf) .. 13
gentamicin sulfate (pf) ........... 14
GENTEAL MILD TO
MODERATE ..................... 91
GENTEAL GEL .................... 91
GENTEAL MILD .................. 91
GENTEAL SEVERE ............. 91
gentlelax ............................... 101
GEODON ............................... 48
geravim................................. 134
geriaton................................. 134
geri-hydrolac .......................... 83
germ defense ........................ 134
gildess 24 fe ........................... 71
GILENYA ............................ 114
GILOTRIF ............................. 23
GLEEVEC ............................. 23
glimepiride ............................. 36
glipizide .................................. 36
glipizide-metformin ............... 36
GLUCAGEN HYPOKIT ..... 114
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 114
gluco burst .............................. 60
glucose ................................... 60
glucose gel.............................. 60
glutose 15 ............................... 60
glyburide .......................... 36, 37
glyburide micronized ............. 36
glyburide-metformin .............. 37
GLYCINE ............................ 111
glycolax ................................ 101
glycopyrrolate ........................ 98
glydo......................................... 8
GLYXAMBI .......................... 34
granisetron (pf) ....................... 45
granisetron hcl ........................ 45
I-10
GRANIX ................................ 56
griseofulvin microsize ............ 38
guaiatussin ac ......................... 76
guaifenesin ....................... 76, 77
guaifenesin dac ....................... 76
guanfacine ........................ 61, 69
guanidine .............................. 114
gummi bear multivitamin ..... 134
gummy swirls ....................... 134
H
hair vitamins ......................... 134
hair,skin & nails ................... 134
HALAVEN ............................ 23
halobetasol propionate ........... 87
haloperidol.............................. 48
haloperidol decanoate............. 48
haloperidol lactate .................. 48
HARVONI ............................. 53
HAVRIX (PF) ...................... 109
head congestion day-night...... 77
healthy eyes .......................... 134
healthylax ............................. 101
hemocyte .............................. 134
heparin (porcine) .................... 55
heparin (porcine) in 5 % dex .. 55
HEPARIN (PORCINE) IN 5 %
DEX.................................... 55
heparin (porcine) in nacl (pf) . 55
HEPARIN(PORCINE) IN
0.45% NACL...................... 55
heparin, porcine (pf) ............... 55
HEPATAMINE 8% ............... 60
HEPATASOL 8 % ................. 60
HERCEPTIN .......................... 24
HEXALEN ............................. 24
hi-b complex......................... 135
hi-cal plus vit d ..................... 118
high potency multivit-multimin
.......................................... 135
homatropine hbr ..................... 91
honey bears........................... 135
honey bears with iron-zinc ... 135
HUMALOG ........................... 35
HUMALOG KWIKPEN ........ 35
HUMALOG MIX 50-50 ........ 35
HUMALOG MIX 50-50
KWIKPEN ......................... 35
HUMALOG MIX 75-25 ........ 35
HUMALOG MIX 75-25
KWIKPEN ......................... 35
HUMATROPE ..................... 106
HUMIRA ............................. 108
HUMIRA CROHN'S DIS
START PCK .................... 108
HUMIRA PEN ..................... 108
HUMULIN 70/30................... 35
HUMULIN 70/30 KWIKPEN 35
HUMULIN N ......................... 35
HUMULIN N KWIKPEN ..... 35
HUMULIN R ......................... 35
HUMULIN R U-500 .............. 36
hydralazine ............................. 65
hydro skin............................... 87
hydrochlorothiazide ............... 67
hydrocil instant..................... 101
hydrocodone bit-homatrop mebr ........................................ 77
hydrocodone-acetaminophen ... 2
hydrocodone-chlorpheniramine
............................................ 77
hydrocodone-homatropine ..... 77
hydrocodone-ibuprofen ............ 2
hydrocortisone.......... 87, 88, 105
hydrocortisone acet-aloe vera 87
hydrocortisone acetate ........... 87
hydrocortisone acetate-urea ... 87
hydrocortisone butyrate ......... 87
hydrocortisone butyr-emollient
............................................ 87
hydrocortisone sod succinate 105
hydrocortisone valerate .......... 88
hydromorphone ........................ 2
hydromorphone (pf) ................. 2
hydroxychloroquine ............... 46
hydroxyurea ........................... 24
hydroxyzine hcl .................... 114
hydroxyzine pamoate ........... 114
HYPERLYTE CR ................ 118
HYPERRAB S/D (PF) ......... 108
HYQVIA .............................. 108
I
ibandronate ........................... 112
IBRANCE .............................. 24
ibuprofen .............................. 6, 7
ibuprofen jr strength ................. 6
icaps plus .............................. 135
ICLUSIG ................................ 24
iferex 150 ............................. 135
ifosfamide............................... 24
ifosfamide-mesna ................... 24
ILARIS (PF) ......................... 108
ILEVRO ................................. 95
IMBRUVICA ......................... 24
imipenem-cilastatin ................ 18
imipramine hcl ....................... 33
imipramine pamoate ............... 33
imiquimod .............................. 83
imodium a-d ........................... 98
IMODIUM A-D ..................... 98
IMOGAM RABIES-HT (PF)
.......................................... 108
IMOVAX RABIES VACCINE
(PF)................................... 109
INCRELEX .......................... 106
indapamide ............................. 67
indomethacin ............................ 7
indomethacin sodium ............... 7
INFANRIX (DTAP) (PF) .... 109
infant acetaminophen ............... 3
infantaire .................................. 3
infant's ibuprofen ..................... 7
INFANT'S MOTRIN ............... 7
infants' non-aspirin cold ......... 77
infant's pain reliever ................. 3
INLYTA ................................. 24
insta-glucose........................... 60
I-11
INSULIN PEN NEEDLE ....... 89
INSULIN SYRINGE ............. 89
INSULIN SYRINGE
NEEDLELESS ................... 89
INSULIN SYRINGE-NEEDLE
U-100.................................. 89
INTELENCE .......................... 51
intense cough reliever ............ 77
INTRALIPID ......................... 60
INTRON A ............................. 53
INVANZ ................................ 18
INVEGA ................................ 49
INVEGA SUSTENNA........... 49
INVEGA TRINZA ................. 49
INVIRASE ............................. 51
INVOKAMET........................ 34
INVOKANA .......................... 34
inzo antifungal ........................ 38
iodine ...................................... 89
IONOSOL-B IN D5W ......... 118
IONOSOL-MB IN D5W ...... 119
IPOL ..................................... 109
ipratropium bromide............... 91
IPRIVASK ............................. 55
irbesartan ................................ 61
irbesartan-hydrochlorothiazide
............................................ 61
IRENKA ................................. 33
iron high potency.................. 135
ISENTRESS ........................... 51
ISOLYTE M IN 5 %
DEXTROSE ..................... 119
ISOLYTE-H IN 5 %
DEXTROSE ..................... 119
ISOLYTE-P IN 5 %
DEXTROSE ..................... 119
ISOLYTE-S.......................... 119
isoniazid ................................. 44
isopto tears ............................. 91
isosorbide dinitrate ................. 68
isosorbide mononitrate ........... 68
isotretinoin.............................. 84
isradipine ................................ 66
ISTODAX .............................. 24
itraconazole ............................ 38
ivermectin .............................. 46
i-vite ..................................... 135
IXEMPRA.............................. 24
IXIARO (PF) ....................... 109
J
JAKAFI .................................. 24
JALYN ................................. 114
jantoven .................................. 55
JANUMET ............................. 34
JANUMET XR ...................... 34
JANUVIA .............................. 34
JARDIANCE ......................... 34
JENTADUETO ...................... 34
JEVTANA.............................. 24
jr. acetaminophen ..................... 3
junel fe 24 .............................. 71
junior mapap ............................ 3
K
KABIVEN.............................. 60
KADCYLA ............................ 24
KALETRA ............................. 51
KALYDECO........................ 124
kaopectate (bismuth subsalicy)
............................................ 98
KEDBUMIN .......................... 57
KELP (IODINE) .................. 119
ketoconazole .......................... 38
ketoprofen ................................ 7
ketorolac ............................. 7, 95
ketotifen fumarate .................. 91
KEYTRUDA.......................... 24
KHEDEZLA .......................... 33
kidkare cough/cold ................. 77
kid's vitamins ....................... 135
kid's vitamins + extra c ........ 135
kids vitamins + iron ............. 135
kid's vitamins + iron ............. 135
kimidess (28).......................... 71
KINERET ............................ 108
KINRIX (PF)........................ 109
KLOR-CON ......................... 119
klor-con 10 ........................... 119
KLOR-CON 8 ...................... 119
klor-con m10 ........................ 119
klor-con m15 ........................ 119
klor-con m20 ........................ 119
KLOR-CON/EF ................... 119
konsyl (sugar) ....................... 101
konsyl fiber .......................... 101
konsyl sugar-free .................. 101
KORLYM .............................. 34
KRYSTEXXA ....................... 90
KUVAN ................................. 90
KYPROLIS ............................ 24
L
l norgest&e estradiol-e estrad 71
labetalol .................................. 63
LACRISERT .......................... 92
LACTATED RINGERS ...... 111
LACTINOL HX ..................... 84
lactulose ................................. 98
LAMICTAL ........................... 29
LAMISIL (AEROSOL) ......... 38
lamisil af................................. 38
LAMISIL AT ......................... 38
lamivudine.............................. 51
lamivudine-zidovudine........... 51
lamotrigine ....................... 29, 30
LANOXIN ............................. 66
lansoprazole ........................... 96
LANTUS ................................ 36
LANTUS SOLOSTAR .......... 36
larin 24 fe ............................... 71
latanoprost ............................ 116
LATUDA ............................... 49
laxative peg 3350 ................. 101
LAZANDA .............................. 3
leflunomide .......................... 108
LEMTRADA ....................... 114
LENVIMA ............................. 24
LETAIRIS ............................ 126
I-12
letrozole .................................. 24
leucovorin calcium ............... 114
LEUKERAN .......................... 24
LEUKINE .............................. 56
leuprolide................................ 24
levetiracetam .......................... 30
levobunolol ........................... 116
levocarnitine ......................... 114
levocarnitine (with sugar) .... 114
levocetirizine .......................... 42
levofloxacin ...................... 20, 94
levofloxacin in d5w ................ 20
levoleucovorin calcium ........ 114
levonorgestrel ......................... 71
levonorgestrel-ethin estradiol . 71
levonorgestrel-ethinyl estrad .. 71
levorphanol tartrate .................. 3
levothyroxine........................ 107
LEXIVA ................................. 51
lice cream rinse ...................... 88
lice killing............................... 88
lice treatment .......................... 88
lidocaine ................................... 8
lidocaine (pf) ...................... 8, 62
lidocaine hcl ............................. 8
lidocaine in 5 % dextrose (pf) 62
lidocaine-prilocaine .................. 8
LIDODERM ............................. 8
life-pack women's ................ 135
linezolid .................................. 14
LINZESS ................................ 90
liothyronine .......................... 107
lipase-protease-amylase ......... 90
lipogen .................................... 68
LIPOSYN II ........................... 60
LIPOSYN III .......................... 60
liquibid d-r.............................. 77
liquid calcium with vitamin d
.......................................... 119
LIQUI-E ............................... 135
liquitears ................................. 92
lisinopril ................................. 62
lisinopril-hydrochlorothiazide 62
lithium carbonate ................... 70
lithium citrate ......................... 70
little animals ......................... 135
little animals/iron ................. 135
l-norgest-eth estr/ethin estra ... 71
lobana bath ............................. 84
lohist peb dm .......................... 77
lomustine ................................ 24
loperamide.............................. 99
loradamed ............................... 42
loratadine................................ 42
loratadine-d ............................ 42
lorazepam oral solution .......... 12
lortuss ex ................................ 77
losartan ................................... 61
losartan-hydrochlorothiazide . 61
LOTEMAX ............................ 95
LOTRIMIN ULTRA .............. 38
LOTRONEX .......................... 90
lovastatin ................................ 68
loxapine succinate .................. 50
lubricant dry eye relief ........... 92
lubricant eye (cmc-glycer)(pf) 92
lubricant eye (cmc-glycerin) .. 92
lubricant eye (polyv alcohol) . 92
lubricant eye (propyl glycol) .. 92
lubricant eye drops ................. 92
lubricating drops .................... 92
lubrifresh pm .......................... 92
LUMIGAN ........................... 116
LUMIZYME .......................... 90
LUPRON DEPOT .................. 25
............................................ 25
............................................ 25
............................................ 25
LUPRON DEPOT-PED ......... 25
LUPRON DEPOT-PED (3
MONTH)............................ 25
LYNPARZA .......................... 25
LYRICA ................................. 30
lysiplex plus ......................... 135
LYSODREN .......................... 25
M
maalox advanced .................... 99
MACUVITE......................... 135
MACUVITE EYE CARE .... 135
mafenide acetate ..................... 84
mag 64 .................................. 119
mag-delay ............................. 119
mag-g ................................... 119
MAGNEBIND 300 ................ 99
magnesium ........................... 119
magnesium (oxide/aa chelate)
.......................................... 119
magnesium chloride ............. 119
magnesium gluconate ........... 119
magnesium oxide ................... 99
magnesium sulfate................ 120
magnesium sulfate in d5w.... 119
magnesium sulfate in water.. 120
malathion ................................ 88
mapap (acetaminophen) ........... 3
mapap arthritis pain .................. 3
mapap extra strength ................ 3
maprotiline ............................. 33
mar-cof bp .............................. 77
mar-cof cg .............................. 77
MARPLAN ............................ 33
MARQIBO ............................. 25
masanti double strength ......... 99
MATULANE ......................... 25
matzim la ................................ 64
maximum daily multivitamin
.......................................... 135
maximum strength flu ............ 77
meclizine ................................ 45
medi-brom .............................. 77
medroxyprogesterone ........... 107
mefenamic acid ........................ 7
mefloquine ............................. 46
I-13
MEFOXIN IN DEXTROSE
(ISO-OSM) ......................... 17
mega multiple/chelated mineral
.......................................... 135
mega multivitamin with mineral
.......................................... 135
MEGACE ES ......................... 25
megestrol ................................ 25
MEKINIST ............................. 25
meloxicam ................................ 7
melphalan hcl intravenous...... 25
MENACTRA (PF) ............... 109
MENEST .............................. 104
MENHIBRIX (PF) ............... 109
MENOMUNE - A/C/Y/W-135
(PF) ................................... 109
men's multi-vitamin.............. 135
men's one daily ..................... 136
MENVEO A-C-Y-W-135-DIP
(PF) ................................... 109
MENVEO MENA
COMPONENT (PF) ......... 110
MENVEO MENCYW-135
COMPNT (PF) ................. 110
MEPHYTON........................ 136
mercaptopurine ....................... 25
meropenem ............................. 18
mesehist dm ............................ 77
mesna.................................... 114
MESNEX ............................. 114
MESTINON ......................... 114
MESTINON TIMESPAN .... 114
metaproterenol...................... 123
metaxalone ........................... 125
metformin ......................... 34, 35
methadone ................................ 3
methadone hcl .......................... 3
methazolamide ..................... 116
methenamine hippurate .......... 14
methenamine mandelate ......... 14
methimazole ......................... 107
methocarbamol ..................... 125
methotrexate sodium .............. 25
methotrexate sodium (pf) ....... 25
methoxsalen rapid .................. 84
methscopolamine ................... 99
methyclothiazide .................... 67
methylphenidate ..................... 70
methylprednisolone .............. 105
methylprednisolone acetate .. 105
.......................................... 105
metipranolol ......................... 116
metoclopramide hcl ................ 99
metolazone ............................. 67
metoprolol succinate .............. 63
metoprolol ta-hydrochlorothiaz
............................................ 63
metoprolol tartrate .................. 63
metronidazole ............. 43, 46, 85
metronidazole in nacl (iso-os) 46
mexiletine............................... 63
MIACALCIN ....................... 112
mi-acid ................................... 99
mi-acid gas relief.................... 95
micatin.................................... 39
miconazole 7 .......................... 39
miconazole nitrate .................. 39
midazolam .............................. 12
midazolam (pf) ....................... 12
midodrine ............................... 61
milk of magnesia .................. 101
milltrium senior.................... 136
milrinone ................................ 66
milrinone in 5 % dextrose ...... 66
MINERAL OIL .................... 114
mineral oil laxative .............. 101
mineral oil light .................... 114
minitran .................................. 68
minocycline ............................ 21
minoxidil ................................ 69
mintox .................................... 99
mintox maximum strength ..... 99
mintox plus............................. 99
MIRCERA ............................. 56
mirtazapine ............................. 33
misoprostol ............................. 96
mitomycin .............................. 25
mitoxantrone .......................... 25
M-M-R II (PF) ..................... 110
moexipril ................................ 62
moexipril-hydrochlorothiazide
............................................ 62
mometasone ........................... 88
MONISTAT 3 ........................ 39
monistat 7 ............................... 39
montelukast .......................... 123
morphine .............................. 3, 4
MORPHINE ............................. 3
morphine concentrate ............... 3
morrhuate sodium ................ 114
motion sickness ...................... 45
MOVANTIK .......................... 99
MOVIPREP ......................... 101
MOXEZA............................... 94
moxifloxacin .......................... 20
MOZOBIL ............................. 56
mucinex fast-max dm max ..... 77
mucinex fast-max sev cld-sinus
............................................ 77
mucus dm ............................... 78
mucus dm max ....................... 78
mucus relief ............................ 78
MULTAQ............................... 63
multi complete with iron ...... 136
multi-day with iron............... 136
multi-delyn ........................... 136
multi-delyn with iron ........... 136
multilex ................................ 136
multilex-t&m ........................ 136
multiple vitamin-minerals .... 136
multiple vitamins.................. 136
multiple vitamins with iron .. 136
multi-symptom cold night time
............................................ 78
multi-symptom cold-cough .... 78
I-14
multivital platinum ............... 136
multivitamin ......................... 136
multivitamin 50 plus ............ 136
multi-vitamin hp/minerals .... 136
multivitamin with iron.......... 136
multivitamin with minerals .. 136
multivitamins with min no.7-fa
.......................................... 137
multi-vite .............................. 137
multi-vite 50 & over ............. 137
mupirocin ............................... 85
mupirocin calcium .................. 85
muro 128 ................................ 92
MUSTARGEN ....................... 25
my favorite multiple ............. 137
myco nail a ............................. 39
mycophenolate mofetil ......... 108
mycophenolate sodium......... 108
mylanta gas............................. 95
MYOZYME ........................... 90
mytab gas ............................... 96
mytab gas maximum strength 96
my-vitalife ............................ 137
N
nabumetone .............................. 7
nadolol .................................... 63
nafcillin .................................. 19
nafcillin in dextrose iso-osm .. 19
NAGLAZYME ...................... 90
naloxone ................................... 9
naltrexone ................................. 9
naltrexone hcl ........................... 9
NAMENDA ........................... 31
NAMENDA TITRATION PAK
............................................ 31
NAMENDA XR ..................... 31
naphazoline ............................ 92
naproxen ................................... 7
naproxen sodium ...................... 8
naratriptan .............................. 44
nasal & sinus decongestant .... 78
nasal decongestant (oxymetazl)
............................................ 92
nasal decongestant (pe) .......... 61
NASCOBAL ........................ 137
NASONEX ............................ 95
NATACYN ............................ 94
nateglinide .............................. 35
NATPARA ........................... 112
natural b-100 ........................ 137
natural b-100 complex ......... 137
natural balance ....................... 92
natural calcium ..................... 120
natural fiber laxative therapy 101
natural tears (pf) ..................... 92
nature's tears ........................... 92
NEBUPENT ........................... 46
nefazodone ............................. 33
neomy sulf-bacitrac zn-poly-hc
............................................ 94
neomycin ................................ 14
neomycin-bacitracin-poly-hc . 94
neomycin-bacitracin-polymyxin
............................................ 94
neomycin-polymyxin b gu ..... 85
neomycin-polymyxin bdexameth ............................ 94
neomycin-polymyxingramicidin .......................... 94
neomycin-polymyxin-hc ........ 94
neosporin anti-itch ................. 88
neo-synephrine 12 h spr (oxym)
............................................ 92
neo-tuss .................................. 78
NEPHRAMINE 5.4 % ........... 60
nephro-vite ........................... 137
NEULASTA .......................... 56
NEUMEGA............................ 56
NEUPOGEN .......................... 56
NEUPRO................................ 47
NEVANAC ............................ 95
nevirapine ............................... 51
NEXAFED ............................. 78
NEXAVAR ............................ 26
niacin ...................................... 68
niacinamide .......................... 137
nicardipine .............................. 66
NICODERM CQ ...................... 9
nicorelief .................................. 9
nicorette .................................... 9
nicotine ..................................... 9
nicotine (polacrilex) ................. 9
NICOTROL ............................. 9
nifedipine ............................... 66
night time ............................... 78
night time cold-flu .................. 78
night time cold-flu relief ........ 78
nighttime cold-flu ................... 78
nighttime cough...................... 78
nighttime relief eye ................ 92
NILANDRON ........................ 26
nite time cold-flu .................... 78
nite time-d cold-flu relief ....... 78
NITRO-BID ........................... 69
nitrofurantoin macrocrystal .... 15
nitrofurantoin monohyd/m-cryst
............................................ 15
nitroglycerin ........................... 69
nitroglycerin in 5 % dextrose . 69
NITROSTAT ......................... 69
nohist-dm ............................... 78
non-aspirin cold...................... 78
non-aspirin extra strength......... 4
non-aspirin flu ........................ 78
non-aspirin jr strength .............. 4
NORDITROPIN FLEXPRO 106
NORDITROPIN NORDIFLEX
.......................................... 106
norelgestromin/ethin.estradiol 71
norepinephrine bitartrate ........ 66
noreth-ethinyl estradiol/iron ... 71
norethindrone ......................... 71
norethindrone (contraceptive) 71
norethindrone acetate ........... 107
I-15
norethindrone ac-eth estradiol
.................................... 71, 104
norethindrone-e.estradiol-iron 72
norethindrone-ethinyl estrad .. 72
norethindrone-mestranol ........ 72
norgestimate-ethinyl estradiol 72
norgestrel-ethinyl estradiol..... 72
NORMOSOL-M IN 5 %
DEXTROSE ..................... 120
NORMOSOL-R ................... 120
NORMOSOL-R PH 7.4 ....... 120
nortemp .................................... 4
NORTHERA .......................... 61
nortriptyline ............................ 33
NORVIR ................................ 51
NOVOLIN 70/30 ................... 36
NOVOLIN N .......................... 36
NOVOLIN R .......................... 36
NOVOLOG ............................ 36
NOVOLOG FLEXPEN ......... 36
NOVOLOG MIX 70-30 ......... 36
NOVOLOG MIX 70-30
FLEXPEN .......................... 36
NOXAFIL .............................. 39
NUCYNTA .............................. 4
NUCYNTA ER ........................ 4
NUEDEXTA .......................... 70
nu-iron .................................. 137
NULOJIX ............................. 108
NUTRESTORE ...................... 99
NUTRILIPID ......................... 60
NUTRILYTE ....................... 120
NUTRILYTE II .................... 120
NUTROPIN.......................... 106
NUTROPIN AQ ................... 106
NUTROPIN AQ NUSPIN ... 106
NUVARING .......................... 72
NUVIGIL ............................. 125
nystatin ................................... 39
NYSTATIN (BULK) ............. 39
nystatin-triamcinolone............ 39
O
ocean nasal ............................. 92
OCTAGAM ......................... 108
octreotide acetate ................. 106
ocutabs ................................. 137
OFEV ................................... 124
ofloxacin .......................... 20, 94
olanzapine .............................. 50
olanzapine-fluoxetine............. 33
olopatadine ............................. 92
OLYSIO ................................. 53
omega-3 acid ethyl esters ....... 68
omeprazole ............................. 96
omeprazole magnesium ......... 96
omeprazole-sodium bicarbonate
...................................... 96, 97
OMNITROPE ...................... 106
ONCASPAR .......................... 26
once daily ............................. 137
oncovite ................................ 137
ondansetron ............................ 45
ondansetron hcl ...................... 45
ondansetron hcl (pf) ............... 45
one daily ............................... 138
one daily 50 plus .................. 137
one daily complete ............... 137
one daily energy ................... 137
one daily essential ................ 137
one daily maximum (with ca)
.......................................... 137
one daily men's 50+ ............. 137
one daily multi-vit w-mineral
.......................................... 137
one daily multivitamin ......... 138
one daily multivitamin-iron . 138
one daily plus iron ................ 138
one daily plus minerals ........ 138
one daily with iron ............... 138
one-a-day essential ............... 138
one-a-day maximum formula138
one-a-day teen advantage ..... 138
ONFI ...................................... 12
opcicon one-step .................... 72
OPDIVO................................. 26
OPSUMIT ............................ 126
opti-vitamins ........................ 138
oral saline laxative ............... 101
oralyte................................... 120
ORAP ..................................... 50
ORENCIA ............................ 108
ORENCIA (WITH MALTOSE)
.......................................... 108
ORENITRAM ...................... 126
ORFADIN .............................. 90
OTEZLA .............................. 115
OTEZLA STARTER ........... 115
oxacillin.................................. 19
oxacillin in dextrose(iso-osm) 19
oxaliplatin............................... 26
oxandrolone.......................... 104
oxcarbazepine......................... 30
OXTELLAR XR .................... 30
oxybutynin chloride ..... 102, 103
oxycodone ................................ 4
oxycodone hcl-acetaminophen . 4
oxycodone hcl-aspirin .............. 4
oxycodone-acetaminophen....... 4
oxycodone-aspirin .................... 4
OXYCONTIN ...................... 4, 5
oxymorphone ........................... 5
oysco 500/d .......................... 120
oysco d ................................. 120
oysco-500 ............................. 120
oyster shell calcium 500 ....... 120
oyster shell calcium with d... 120
oyster shell calcium-vit d3 ... 120
oystercal-d ............................ 120
P
paclitaxel ................................ 26
pain relief ................................. 5
pain relief adult ........................ 5
pain reliever.............................. 5
pain reliever jr strength ............ 5
PANRETIN ............................ 84
I-16
pantoprazole ........................... 96
papaverine .............................. 66
paricalcitol ............................ 112
paromomycin.......................... 46
paroxetine hcl ......................... 33
PASER ................................... 44
PATADAY ............................. 92
PATANOL ............................. 92
PAXIL .................................... 33
pecgen dmx ............................ 79
pedi m.vit no.17 with fluoride
.......................................... 138
pedia relief .............................. 79
pedia relief infant ................... 79
pediacare multi-symptom cold79
PEDIARIX (PF) ................... 110
pediatric electrolyte .............. 120
pediatric freezer pops ........... 120
pediatric multivitamin .......... 138
PEDVAX HIB (PF).............. 110
peg 3350-electrolytes ........... 101
PEG 3350-GRX ................... 101
peg 3350-na sulf,bicarb,cl-kcl
.......................................... 101
PEGANONE .......................... 30
PEGASYS .............................. 53
PEGASYS PROCLICK ......... 53
peg-electrolyte soln .............. 101
PEGINTRON ......................... 53
PEGINTRON REDIPEN ....... 53
penicillin g pot in dextrose ..... 19
penicillin g potassium ............ 19
penicillin g procaine ............... 19
penicillin v potassium ............ 19
PENTACEL (PF) ................. 110
PENTACEL ACTHIB
COMPONENT (PF) ......... 110
PENTACEL DTAP-IPV
COMPNT (PF) ................. 110
PENTAM ............................... 46
pentoxifylline ......................... 57
pep-t-med ............................... 99
peri-colace ............................ 101
PERIKABIVEN ..................... 60
perindopril erbumine .............. 62
PERJETA ............................... 26
permethrin .............................. 88
perphenazine .......................... 50
perphenazine-amitriptyline .... 33
persa-gel ................................. 84
pharbetol .................................. 5
pharmacist favorite multi-vit 138
phenelzine .............................. 33
phenobarbital.......................... 30
phenobarbital sodium ............. 30
phentolamine ........................ 126
phenylephrine hcl ............. 61, 92
phenylephrine-chlorpheniramine
............................................ 42
phenylhistine dh ..................... 79
phenytoin................................ 30
phenytoin sodium ................... 30
phenytoin sodium extended ... 30
phillips.................................... 99
phillips liqui-gels ................. 101
PHOS-FLUR .......................... 82
PHOSLYRA ........................ 102
PHOS-NAK ......................... 120
phosphate laxative................ 101
PHOSPHOLINE IODIDE ... 116
phosphorus #1 ...................... 120
phytonadione ........................ 138
PICATO ................................. 84
pilocarpine hcl ................ 82, 116
pindolol .................................. 63
pioglitazone ............................ 35
pioglitazone-glimepiride ........ 35
pioglitazone-metformin.......... 35
piperacillin-tazobactam .......... 19
piroxicam ................................. 8
PLAN B ONE-STEP.............. 72
PLASBUMIN 25 % ............... 57
PLASBUMIN 5 % ................. 57
PLASMA-LYTE 148 ........... 120
PLASMA-LYTE A .............. 120
PLASMA-LYTE-56 IN 5 %
DEXTROSE ..................... 120
PLEGRIDY .......................... 115
podactin .................................. 39
podofilox ................................ 84
podophyllum resin.................. 84
polyethylene glycol 3350 ..... 101
poly-iron ............................... 138
polymyxin b sulf-trimethoprim
............................................ 94
poly-tussin .............................. 79
POLY-TUSSIN DM .............. 79
poly-vita ............................... 138
poly-vita (iron) ..................... 138
poly-vitamin ......................... 138
poly-vitamin with iron ......... 138
polyvitamin/iron ................... 139
poly-vitamins ....................... 139
POMALYST .......................... 26
potassium acetate ................. 120
potassium bicarb and chloride
.......................................... 120
potassium bicarb-citric acid . 120
potassium bicarbonate-cit ac 121
potassium chlorid-d5-0.45%nacl
.......................................... 121
potassium chloride ............... 121
potassium chloride in 0.9%nacl
.......................................... 121
potassium chloride in 5 % dex
.......................................... 121
potassium chloride in lr-d5 .... 60
potassium chloride-0.45 % nacl
.......................................... 121
.......................................... 121
.......................................... 121
.......................................... 121
I-17
potassium citrate-citric acid 121,
122
potassium hydroxide .............. 84
potassium phosphate dibasic 122
POTIGA ................................. 30
PRADAXA ............................ 55
pramipexole ............................ 47
PRANDIMET ........................ 35
pravastatin .............................. 68
prazosin .................................. 61
prednicarbate .......................... 88
prednisolone acetate ............... 95
.................................... 95, 105
prednisone ............................ 105
PREGNYL ........................... 106
PREMARIN ......................... 105
PREMASOL 10 % ................. 60
PREMASOL 6 % ................... 60
PREMPHASE ...................... 105
PREMPRO ........................... 105
prenatal ................................. 139
prenatal formula ................... 139
prenatal vit#96-ferrous fum-fa
.......................................... 139
prenatal vitamin with minerals
.......................................... 139
prenatal vitamins .................. 139
PRENATAL VITAMINS .... 139
prenatal vit-iron fumarate-fa 139
preparation h hydrocortisone.. 88
PREVIDENT 5000 SENSITIVE
............................................ 82
PREZCOBIX.......................... 51
PREZISTA ............................. 51
PRIFTIN ................................. 44
PRILOSEC OTC .................... 96
PRIMAQUINE ....................... 46
primidone ............................... 30
PRISTIQ ................................. 33
PRIVIGEN ........................... 108
PROAIR HFA ...................... 123
probenecid ............................ 115
procainamide .......................... 63
PROCALAMINE 3% ............ 60
prochlorperazine .................... 45
prochlorperazine edisylate ..... 45
prochlorperazine maleate ....... 46
PROCRIT ............................... 56
PROCYSBI .......................... 115
progesterone ......................... 107
progesterone micronized
capsules ............................ 107
PROGLYCEM ....................... 69
PROGRAF ........................... 108
PROLENSA ........................... 95
PROLEUKIN ......................... 26
PROLIA ............................... 112
PROMACTA ......................... 56
promethazine .................... 42, 46
promethazine hcl .................... 46
promethazine-codeine ............ 79
promethazine-dm ................... 79
promethazine-phenylephcodeine ............................... 79
promolaxin ........................... 101
propafenone............................ 63
propantheline.......................... 28
proparacaine ........................... 93
proparacaine hcl ..................... 93
proparacaine-fluorescein sod . 93
propranolol ............................. 63
propranolol-hydrochlorothiazid
............................................ 64
propylthiouracil .................... 107
PROQUAD (PF) .................. 110
prosight ................................ 139
PROSOL 20 % ....................... 60
protamine ............................... 56
protriptyline............................ 33
pseudoephedrine hcl............... 79
PULMOZYME ...................... 90
pure & gentle eye ................... 93
purelax.................................. 101
PURIXAN .............................. 26
pyrazinamide .......................... 44
pyridostigmine bromide ....... 115
pyridoxine ............................ 139
Q
q-dryl ...................................... 42
q-pap......................................... 5
q-pap extra strength .................. 5
q-tapp ..................................... 42
q-tapp dm ............................... 79
q-tussin ................................... 79
q-tussin dm ............................. 79
QUADRACEL (PF) ............. 110
QUDEXY XR ........................ 30
quetiapine ............................... 50
QUILLIVANT XR ................. 70
quinapril ................................. 62
quinapril-hydrochlorothiazide 62
quinidine gluconate ................ 63
quinidine sulfate ..................... 63
quinine sulfate ........................ 46
QVAR .................................. 123
R
RABAVERT (PF) ................ 110
raloxifene ............................. 105
ramipril ................................... 62
RANEXA ............................... 66
ranitidine hcl .......................... 97
RAPAMUNE ....................... 108
REBIF (WITH ALBUMIN). 115
REBIF REBIDOSE .............. 115
REBIF TITRATION PACK 115
RECOMBIVAX HB (PF) .... 110
recort plus ............................... 88
refenesen ................................ 79
refenesen pe............................ 79
REFRESH CLASSIC (PF)..... 93
REFRESH LACRI-LUBE ..... 93
REFRESH LIQUIGEL .......... 93
REFRESH OPTIVE ............... 93
REFRESH OPTIVE
ADVANCED ..................... 94
I-18
reguloid ................................ 101
relcof c .................................... 79
RELENZA DISKHALER ...... 52
RELISTOR ............................. 99
REMICADE ......................... 115
REMODULIN ...................... 126
RENAGEL ........................... 102
RENVELA ........................... 102
repaglinide .............................. 35
RESCRIPTOR........................ 52
RESTASIS ............................. 95
retaine cmc ............................. 93
RETROVIR ............................ 52
REVATIO ............................ 127
REVLIMID ............................ 26
REYATAZ ............................. 52
REZIRA ................................. 79
ribavirin .................................. 54
RIDAURA............................ 108
rifabutin .................................. 44
rifampin .................................. 44
RIFATER ............................... 44
ri-gel ii .................................... 99
riluzole.................................... 70
rimantadine ............................. 52
ri-mox ..................................... 99
ringers ........................... 111, 122
risedronate ............................ 112
RISPERDAL CONSTA ......... 50
risperidone .............................. 50
RITUXAN .............................. 26
rivastigmine tartrate ............... 32
rizatriptan ............................... 44
robafen.................................... 80
robafen cough ......................... 80
robafen dm ............................. 80
robitussin cough & cold cf ..... 80
robitussin cough-chest-cong dm
............................................ 80
robitussin dm max .................. 80
ROBITUSSIN LONG-ACTING
............................................ 80
robitussin pediatric ................. 80
ROBITUSSIN-DM ................ 80
ropinirole ................................ 47
ROTARIX ............................ 110
ROTATEQ VACCINE ........ 110
ROZEREM .......................... 125
rydex ...................................... 80
S
SABRIL ................................. 30
safe tussin dm ......................... 80
SAIZEN ............................... 106
SAIZEN CLICK.EASY ....... 106
saline mist .............................. 93
salsalate .................................... 8
SANDOSTATIN LAR DEPOT
.......................................... 106
SANTYL ................................ 84
SAPHRIS (BLACK CHERRY)
............................................ 50
SAVELLA ............................. 70
scooby-doo one a day........... 139
scot-tussin dm ........................ 80
scot-tussin expectorant ........... 80
sea soft nasal mist .................. 93
selegiline hcl .......................... 47
selenium sulfide ..................... 85
SELZENTRY ......................... 52
senexon ................................ 102
senna .................................... 102
senna lax............................... 102
senna with docusate sodium. 102
senokot-s .............................. 102
SENSIPAR ........................... 115
sentry .................................... 139
sentry senior ......................... 139
SEREVENT DISKUS .......... 123
SEROQUEL XR .................... 50
SEROSTIM .......................... 106
sertraline ................................. 33
silace .................................... 102
siladryl sa ............................... 42
silapap ...................................... 5
sildenafil oral tablet 20 mg... 127
SILENOR ............................... 33
siltussin dm das ...................... 80
siltussin sa .............................. 80
silver nitrate............................ 85
silver nitrate applicators ......... 84
silver sulfadiazine .................. 85
SIMBRINZA ........................ 117
simethicone ............................ 96
simply sleep............................ 42
SIMPONI ............................. 115
SIMPONI ARIA .................. 115
simvastatin ............................. 68
sinus & allergy (pseudoephed)
............................................ 42
sirolimus ............................... 108
SIRTURO............................... 45
skin treatment ......................... 84
sleep aid (diphenhydramine) .. 42
sleep-tabs ................................ 42
smoothlax ............................. 102
sochlor .................................... 93
sodium acetate ...................... 122
sodium bicarbonate ........ 99, 122
sodium chloride ..... 93, 111, 122,
124
sodium chloride 0.45 % ....... 122
sodium chloride 0.9 % ......... 122
sodium chloride 3 % ............ 122
sodium chloride 5 % ............ 122
sodium chloride-nahco3-kcl-peg
.......................................... 102
sodium citrate-citric acid ...... 122
sodium fluoride .................... 139
sodium lactate ...................... 122
sodium phosphate ................. 122
sodium polystyrene sulfonate
.......................................... 102
sodium thiosulfate ................ 103
sod-pot-k cit-sod cit-cit acid 122
SOLIRIS............................... 115
SOLTAMOX ......................... 26
I-19
SOLU-CORTEF (PF)........... 105
SOMATULINE DEPOT ...... 106
SOMAVERT ........................ 106
soothe (bismuth subsalicylate)99
soothe regular strength ........... 99
sorbitol.................................. 111
sorbitol-mannitol .................. 111
sotalol ..................................... 64
sotalol hcl ............................... 64
SOVALDI .............................. 53
spectravite ............................ 139
spectravite adult 50+ ............ 139
spectravite advanced formula
.......................................... 139
spectravite senior .................. 140
spectravite senior w-lycopene
.......................................... 140
spectravite ultra women ....... 140
SPIRIVA RESPIMAT ......... 123
SPIRIVA WITH
HANDIHALER................ 123
spironolactone ........................ 68
spironolacton-hydrochlorothiaz
............................................ 68
SPRYCEL .............................. 26
st joseph aspirin ........................ 8
st. joseph aspirin ....................... 8
stavudine ................................ 52
STELARA ............................ 115
STERILE LUBRICANT ........ 93
STERILE PADS................... 115
STIVARGA............................ 26
stomach relief ......................... 99
STRATTERA ......................... 70
streptomycin ........................... 14
stress 500 plus zinc............... 140
stress b with zinc .................. 140
stress b-biotin ....................... 140
stress formula ....................... 140
stress formula plus iron ........ 140
stress formula with iron ........ 140
stress formula with zinc ....... 140
STRIBILD.............................. 52
stuart prenatal ....................... 140
sucralfate ................................ 97
sudogest.................................. 80
sudogest cold & allergy ......... 42
sudogest pe ............................. 61
sulfacetamide sodium............. 94
sulfacetamide sodium (acne).. 85
sulfacetamide-prednisolone ... 94
sulfadiazine ............................ 20
sulfamethoxazole-trimethoprim
............................................ 20
sulfasalazine ........................... 20
sulfatrim ................................. 20
sulfazine ................................. 20
sulfazine ec............................. 20
sulindac .................................... 8
sumatriptan nasal spray .......... 44
sumatriptan succinate ............. 44
summer's eve disposable douche
.......................................... 115
summers eve extra cleansing 115
sunvite .................................. 140
super b complex-vitamin c ... 140
super b/c ............................... 140
super b-50 complex .............. 140
super b-50 complex plus ...... 140
super multiple....................... 140
super multivitamin ............... 140
super quints b-50 .................. 140
super thera vite m ................. 141
superior 35 ........................... 141
superplex-t............................ 141
suphedrin ................................ 80
suphedrine pe day-night ......... 80
suphedrine severe cold max str
............................................ 80
support.................................. 141
support-500 .......................... 141
SUPPRELIN LA .................. 106
SUPRAX ................................ 17
SURE COMFORT INS. SYR.
U-100 ................................. 89
SURMONTIL ........................ 33
SUSPENDOL-S ................... 115
SUSTIVA ............................... 52
SUTENT ................................ 26
SYLATRON .......................... 53
SYLATRON 4-PACK ........... 53
SYLVANT ............................. 26
SYMLINPEN 120 .................. 35
SYMLINPEN 60 .................... 35
SYNAGIS .............................. 52
SYNAREL ........................... 115
SYNERCID ............................ 15
SYNRIBO .............................. 26
SYPRINE ............................. 103
T
tab-a-vite .............................. 141
tab-a-vite/iron ....................... 141
tab-a-vite-minerals ............... 141
TABLOID .............................. 26
tacrolimus ....................... 88, 108
tactinal ...................................... 5
tactinal extra strength ............... 5
TAFINLAR ............................ 26
TAMIFLU ........................ 52, 53
tamoxifen ............................... 26
tamsulosin ............................ 103
TARCEVA ............................. 27
TARGRETIN ......................... 27
tarina fe .................................. 72
TASIGNA .............................. 27
TAZORAC ............................. 88
taztia xt ................................... 64
tears again .............................. 93
TEARS NATURALE II ......... 93
TECFIDERA ................ 115, 116
TEFLARO .............................. 17
telmisartan .............................. 61
telmisartan-hydrochlorothiazid
............................................ 61
temazepam ....................... 12, 13
I-20
TEMODAR ............................ 27
TENIVAC (PF) .................... 110
terazosin ............................... 103
terbinafine hcl......................... 39
terbutaline ............................. 124
terconazole ....................... 43, 44
testosterone ........................... 104
testosterone cypionate .......... 104
testosterone enanthate .......... 104
TETANUS
TOXOID,ADSORBED (PF)
.......................................... 110
TETANUS,DIPHTHERIA TOX
PED(PF) ........................... 110
TETANUS-DIPHTHERIA
TOXOIDS-TD.................. 110
tetracaine hcl .......................... 93
tetracycline ............................. 21
TEV-TROPIN ...................... 107
THALOMID ........................ 116
the magic bullet .................... 102
theophylline .......................... 124
theophylline anhydrous ........ 124
theophylline in dextrose 5 % 124
thera m plus (ferrous fumarat)
.......................................... 141
thera vitamin......................... 141
theradex m ............................ 141
THERAFLU NIGHTTIME
SEVERE COLD ................. 80
THERAFLU SEVERE COLDCOUGH.............................. 81
thera-m ................................. 141
theramill forte ....................... 141
therapeutic liquid .................. 141
therapeutic m + beta-carotene
.......................................... 141
therapeutic vitamins/minerals
.......................................... 141
therapeutic-m........................ 141
therapeutic-m vitamin/minerals
.......................................... 142
thera-tabs .............................. 142
theratrum complete 50 plus .. 142
theratrum complete 50 plus/lut
.......................................... 142
therems ................................. 142
therems-h.............................. 142
therems-m ............................ 142
thiamine hcl .......................... 142
thioridazine ............................ 50
thiothixene.............................. 50
tiagabine ................................. 30
TICE BCG ........................... 110
TIKOSYN .............................. 63
timolol maleate............... 64, 117
TIVICAY ............................... 52
tizanidine .............................. 125
TOBI PODHALER ................ 14
TOBRADEX ST .................... 94
tobramycin ............................. 94
tobramycin in 0.225 % nacl ... 14
tobramycin in 0.9 % nacl ....... 14
tobramycin sulfate .................. 14
tolazamide .............................. 37
tolbutamide ............................ 37
tolmetin .................................... 8
tolnaftate ................................ 39
tolterodine ............................ 103
topiramate ........................ 30, 31
toposar intravenous ................ 27
topotecan ................................ 27
TORISEL ............................... 27
torsemide ................................ 67
total b/c................................. 142
totalday multiple .................. 142
TOUJEO SOLOSTAR ........... 36
TOVIAZ ............................... 103
TPN ELECTROLYTES....... 122
TPN ELECTROLYTES II ... 122
TRACLEER ......................... 127
TRADJENTA ........................ 35
tramadol ................................... 5
tramadol-acetaminophen .......... 5
trandolapril ............................. 62
tranexamic acid ...................... 56
TRANSDERM-SCOP............ 46
tranylcypromine ..................... 33
TRAVASOL 10 % ................. 60
TRAVATAN Z .................... 117
travel sickness (meclizine) ..... 46
travoprost (benzalkonium) ... 117
trazodone ................................ 33
TREANDA............................. 27
TRECATOR........................... 45
TRELSTAR ........................... 27
tretinoin .................................. 88
tretinoin (chemotherapy) ........ 27
tretinoin microspheres ............ 88
TREXALL ............................. 27
triacting m-sym cold/cough ... 81
triamcinolone acetonide .. 82, 88,
105
triaminic cold & cough (pe) ... 81
TRIAMINIC COLD & COUGH
NT (PE) .............................. 42
triaminic cough-nasal congesti
............................................ 81
TRIAMINIC COUGH-SORE
THROAT ........................... 81
triamterene-hydrochlorothiazid
............................................ 67
triazolam................................. 13
TRIBENZOR ......................... 61
tri-buffered aspirin ................... 8
triderm .................................... 88
tri-dex pe ................................ 81
trifluoperazine ........................ 50
trifluridine .............................. 94
trigofen dm ............................. 81
trihexyphenidyl ...................... 47
TRILEPTAL .......................... 31
trimethoprim........................... 15
triple paste af .......................... 39
TRIUMEQ ............................. 52
tri-vi-sol ................................ 142
I-21
tri-vita ................................... 142
tri-vitamin ............................. 142
TROKENDI XR ..................... 31
TROPHAMINE 10 % ............ 60
TROPHAMINE 6% ............... 60
trospium................................ 103
TRULICITY ........................... 35
TRUMENBA ....................... 110
TRUVADA ............................ 52
trymine cg............................... 81
TUDORZA PRESSAIR ....... 124
tusnel diabetic......................... 81
TUSNEL PEDIATRIC........... 81
tussin cf .................................. 81
tussin cf cough-cold ............... 81
tussin cold-congestion ............ 81
tussin cough (dm only) ........... 81
tussin dm ................................ 81
tussin dm cough & chest ........ 81
tussin maximum strength cough
............................................ 81
tussin pe .................................. 81
TWINRIX (PF) .................... 110
TYBOST .............................. 116
TYGACIL .............................. 21
TYKERB ................................ 27
TYPHIM VI ......................... 110
TYSABRI ............................. 109
TYVASO.............................. 127
TYVASO REFILL KIT ....... 127
TYVASO STARTER KIT ... 127
TYZEKA ................................ 54
U
ULORIC ............................... 116
ultra b-100 complex ............. 142
ultra fresh pm ......................... 93
ultra sleep (doxylamine succ). 42
ultra strength antacid ............ 100
unicomplex-m ...................... 142
unisom sleepgels .................... 42
ursodiol ................................. 100
V
VAGIFEM ........................... 105
valacyclovir ............................ 54
VALCHLOR .......................... 84
valganciclovir ......................... 54
valproate sodium .................... 31
valproic acid ........................... 31
valproic acid (as sodium salt) 31
valsartan ................................. 61
valsartan-hydrochlorothiazide 61
VALSTAR ............................. 27
valu-tapp dm .......................... 81
vancomycin ............................ 15
vancomycin in d5w ................ 15
VAQTA (PF) ....................... 110
VARIVAX (PF) ................... 110
VASCEPA ............................. 68
vasopressin ........................... 107
VECTIBIX ............................. 27
VELCADE ............................. 27
venlafaxine ............................. 33
VENTAVIS.......................... 127
verapamil................................ 64
VERSACLOZ ........................ 50
vicks dayquil cough ............... 81
vicks nature fusion cough ...... 82
vicks qlearquil(oxymetazoline)
............................................ 93
vicks sinex 12-hour ................ 93
VICTOZA .............................. 35
............................................ 52
............................................ 52
VIEKIRA PAK ...................... 53
VIGAMOX ............................ 95
VIIBRYD ............................... 33
VIMIZIM ............................... 90
VIMPAT ................................ 31
vinblastine .............................. 27
vincristine ............................... 28
vincristine sulfate ................... 28
vinorelbine ............................. 28
VIRACEPT ............................ 52
VIRAMUNE XR.................... 52
VIRAZOLE ............................ 54
virdec dm................................ 82
VIREAD................................. 52
vision .................................... 142
vision formula ...................... 142
vision formula (with lutein) . 143
vision plus lutein .................. 143
vit b cmplx 3-fa-vit c-biotin . 143
vit b cmplx no3-fa-c-biot-zinc
.......................................... 143
vitabee/c ............................... 143
vitalets .................................. 143
vitamin a............................... 143
vitamin b complex ................ 143
vitamin b complex with c ..... 143
vitamin b-1 ........................... 143
vitamin b-100 complex ........ 143
vitamin b12-folic acid .......... 143
vitamin b-6 ........................... 143
vitamin c............................... 143
vitamins & minerals ............. 143
vitamins b complex .............. 144
vitamins for hair ................... 144
VITEKTA .............................. 52
vitrum senior ........................ 144
VOLTAREN ............................ 8
voriconazole ..................... 39, 40
VOTRIENT ............................ 28
VPRIV .................................... 90
W
wal-act d cold & allergy ......... 42
wal-dram ................................ 46
wal-dryl allergy ...................... 43
wal-finate ............................... 43
wal-finate-d ............................ 43
wal-itin ................................... 43
wal-itin d ................................ 43
wal-itin d 12 hour ................... 43
wal-phed ........................... 43, 82
I-22
wal-phed pe ............................ 61
wal-phed pe day-night ............ 82
wal-phed pe sinus & allergy ... 43
wal-profen ................................ 8
wal-sleep z .............................. 43
wal-som .................................. 43
wal-tap .................................... 43
wal-tussin cough..................... 82
wal-tussin cough & cold cf .... 82
wal-tussin dm ......................... 82
wal-zan 75 .............................. 97
wal-zyr (cetirizine) ................. 43
wal-zyr (ketotifen) .................. 93
wal-zyr d................................. 43
warfarin .................................. 55
water for irrigation, sterile.... 111
WELCHOL ............................ 68
women's daily multivitamin . 144
X
XALKORI .............................. 28
XARELTO ............................. 55
XELJANZ ............................ 116
XENAZINE............................ 70
XGEVA ................................ 112
XIFAXAN .............................. 15
XOLAIR ............................... 124
XTANDI ................................ 28
xylon 10 .................................... 5
XYREM ............................... 125
Y
yelets .................................... 144
YERVOY ............................... 28
YF-VAX (PF)....................... 110
Z
zafirlukast ............................. 123
zaleplon ................................ 125
ZALTRAP .............................. 28
zantac 75................................. 97
ZAVESCA ............................. 90
ZELBORAF ........................... 28
ZEMAIRA............................ 124
ZEMPLAR ........................... 112
ZENPEP ................................. 90
zephrex-d................................ 82
ZETIA .................................... 68
ZIAGEN ................................. 52
zidovudine .............................. 52
zinc oxide ............................... 84
ziprasidone hcl ....................... 50
ZOLADEX ............................. 28
zoledronic acid ..................... 112
.......................................... 112
ZOLINZA .............................. 28
zolmitriptan ............................ 44
zolpidem ............................... 126
ZOMETA ............................. 112
ZONATUSS ........................... 82
zonisamide ............................. 31
zoo chews ............................. 144
ZORTRESS .......................... 109
ZOSTAVAX (PF) ................ 110
ZOVIRAX .............................. 84
z-sleep .................................... 43
I-23
ZUBSOLV ............................. 10
ZYDELIG .............................. 28
ZYKADIA.............................. 28
ZYLET ................................... 95
zyncof ..................................... 82
ZYPREXA RELPREVV ........ 51
ZYRTEC ................................ 43
zyrtec itchy eye drops (keto) .. 93
ZYTIGA ................................. 28
ZYVOX .................................. 15
This formulary was updated on 8/14/15. If you have questions, please call ICS
Community Care Plus FIDA-MMP at 1.877.ICS.2525, Monday to Friday, 8 a.m. to
8 p.m. The call is free.
For more information, visit www.icsny.org/care-plus.
I-24
1.877.ICS.2525
www.icsny.org
Administrative Oﬃce
Independence Care System
257 Park Ave. South
2nd Floor
New York, NY 10010
Member Centers
400 East Fordham Road
10th floor
Bronx, New York 10458
25 Elm Place
5th Floor
Brooklyn, NY 11201

listof covered drugs - Independence Care System

Transcription

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