2015 calpers eff 01/01/2015hr.fhda.edu/_downloads/2015calpersdruglist.pdf · ibudone tab 10-200mg 1...

2015 CalPERS eff 01/01/2015

PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access ** - Contact Care at 1-855-479-3660 to check if additional CalPERS coverage is available for drugs not listed

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM)

1

ALOPRIM 3

colchicine w/ probenecid 1

COLCRYS 2

probenecid 1

ULORIC 2

MISCELLANEOUS diclofenac w/ misoprostol (generic of ARTHROTEC 50)

1

diclofenac w/ misoprostol (generic of ARTHROTEC 75)

1

DUEXIS 3

PRIALT 100mcg/ml, 500mcg/20ml

3 NM PA

VIMOVO QL (60 tabs / 30 days)

2 QL

NSAIDS CELEBREX CAP 50MG 2

CELEBREX CAP 100MG 2



diclofenac potassium (generic of CATAFLAM)

1

diclofenac sodium (generic of VOLTAREN-XR) TB24

1

diclofenac sodium TBEC 1

diflunisal 1

etodolac 1

etodolac er 1

fenoprofen calcium 1

flurbiprofen TABS 1

ibuprofen SUSP 1

ibuprofen TABS 400mg, 600mg, 800mg

1

ketoprofen CAPS; CP24 1

mefenamic acid (generic of PONSTEL) CAPS

1

MELOXICAM SUSP 1

meloxicam tabs (generic of MOBIC)

1

nabumetone TABS 1

Drug Name Drug Tier

Requirements/Limits

NAPRELAN 3

naproxen (generic of NAPROSYN) SUSP; TABS

1

naproxen (generic of EC-NAPROSYN) TBEC

1

naproxen sodium (generic of ANAPROX) TABS 275mg

1

naproxen sodium (generic of ANAPROX DS) TABS 550mg

1

oxaprozin (generic of DAYPRO)

1

piroxicam (generic of FELDENE) CAPS

1

sulindac TABS 1

tolmetin sodium 1

ZIPSOR 3

ZORVOLEX 3

OPIOID ANALGESICS acetaminophen w/ codeine SOLN

QL (5000 mL / 30 days)

1 QL

acetaminophen w/ codeine TABS

QL (400 tabs / 30 days)

1 QL

acetaminophen w/ codeine (generic of TYLENOL/CODEINE #3) TABS


1 QL

acetaminophen w/ codeine (generic of TYLENOL/CODEINE #4) TABS


1 QL

ASPIRIN-CAFFEINE-DIHYDROCODEINE BITARTRATE

1

butorphanol nasal spray QL (10 mL / 30 days)

1 QL

butorphanol tartrate SOLN 1

BUTRANS 5mcg/hr QL (16 patches / 28 days)

2 QL

BUTRANS 10mcg/hr QL (8 patches / 28 days)

2 QL

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

BUTRANS 15mcg/hr, 20mcg/hr

QL (4 patches / 28 days)

2 QL

capital and codeine QL (5000 mL / 30 days)

3 QL

CONZIP 3

hydrocodone-acetaminophen 2.5-325mg


1 QL

hydrocodone-acetaminophen 5-300mg (generic of XODOL)


1 QL

hydrocodone-acetaminophen 5-325mg (generic of NORCO)


1 QL

hydrocodone-acetaminophen 7.5-300mg (generic of XODOL)


1 QL

hydrocodone-acetaminophen 7.5-325 mg/15ml (generic of HYCET)

QL (5400 mL / 30 days)

1 QL

hydrocodone-acetaminophen 7.5-325mg (generic of NORCO)


1 QL

hydrocodone-acetaminophen 10-300mg (generic of XODOL)


1 QL

hydrocodone-acetaminophen tab 10-325mg (generic of NORCO)


1 QL

hydrocodone-ibuprofen 2.5-200 mg (generic of REPREXAIN)

1

hydrocodone-ibuprofen tab 7.5-200 mg (generic of VICOPROFEN)

1

ibudone 5-200 mg (generic of REPREXAIN)

1

ibudone tab 10-200mg 1

lortab QL (6000 mL / 30 days)

3 QL

reprexain 10/200 1

Drug Name Drug Tier

Requirements/Limits

TRAMADOL HCL TB24 1

tramadol hcl er (generic of ULTRAM ER) TB24

1

tramadol hcl er (biphasic) 100mg

1


1


1

tramadol hcl tab 50 mg (generic of ULTRAM)

1

tramadol-acetaminophen (generic of ULTRACET)


1 QL

vicodin (generic of XODOL) QL (400 tabs / 30 days)

1 QL

vicodin es (generic of XODOL)


1 QL

vicodin hp (generic of XODOL)


1 QL

zamicet QL (5400 mL / 30 days)

3 QL

OPIOID ANALGESICS, CII ABSTRAL

QL (120 tabs / 30 days) 3 QL NM PA

CODEINE SULFATE TABS 1

DILAUDID-HP INJ 250MG 3

DURAMORPH 1

endocet (generic of PERCOCET)


1 QL

ENDODAN TAB 1

fentanyl citrate (generic of ACTIQ) LPOP

QL (120 lozenges / 30 days)

1 QL NM PA

fentanyl td patch 72hr 12 mcg/hr (generic of DURAGESIC)


1 QL

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits



1 QL



1 QL



1 QL



1 QL

FENTORA QL (120 tabs / 30 days)

2 QL NM PA

hydromorphone hcl (generic of DILAUDID) LIQD

1

hydromorphone hcl (generic of DILAUDID-HP) SOLN 500mg/50ml

1

hydromorphone hcl (generic of DILAUDID) TABS

1

hydromorphone tab 8mg er (generic of EXALGO)


1 QL



1 QL



1 QL

HYDROMORPHONE TABS 32MG


1 QL

INFUMORPH 200 3

INFUMORPH 500 3

KADIAN 40mg QL (60 caps / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

KADIAN 70mg, 130mg, 150mg, 200mg

QL (60 caps / 30 days)

3 QL NM

LAZANDA QL (30 bottles / 30 days)

2 QL NM PA

levorphanol tartrate TABS 1

methadone hcl (generic of METHADOSE) CONC

QL (120 mL / 30 days)

1 QL

methadone hcl SOLN QL (600 mL / 30 days)

1 QL

methadone hcl (generic of DOLOPHINE HCL) TABS 5mg


1 QL

methadone hcl (generic of DOLOPHINE) TABS 10mg


1 QL

METHADONE INJ 10MG/ML 3

MORPHINE SUL 20MG/ML ORAL SOL

1

morphine sulfate (generic of KADIAN) CP24 10mg, 20mg, 30mg, 50mg, 60mg


1 QL

morphine sulfate (generic of KADIAN) CP24 80mg, 100mg


1 QL NM

MORPHINE SULFATE SOLN 1mg/ml, 10mg/5ml, 10mg/ml, 15mg/ml, 20mg/5ml

1

MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 8mg/ml

3

morphine sulfate SOLN .5mg/ml, 1mg/ml

1

MORPHINE SULFATE TABS

1

morphine sulfate beads (generic of AVINZA)


1 QL

morphine sulfate ext-rel tab (generic of MS CONTIN) 15mg, 30mg, 60mg, 100mg


1 QL

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

morphine sulfate ext-rel tab (generic of MS CONTIN) 200mg


1 QL

NUCYNTA 2

NUCYNTA ER 50mg, 100mg


2 QL

NUCYNTA ER 150mg, 200mg, 250mg


2 QL

OPANA ER (CRUSH RESISTANT


2 QL

OXECTA 3

OXYCODONE HCL CAPS 1

OXYCODONE HCL CONC 1

oxycodone hcl SOLN 1

oxycodone hcl (generic of ROXICODONE) TABS 5mg, 15mg, 30mg

1

oxycodone hcl TABS 10mg, 20mg

1

oxycodone w/ acetaminophen 2.5-325mg (generic of PERCOCET)


1 QL

oxycodone w/ acetaminophen 5-325mg (generic of PERCOCET)


1 QL

oxycodone w/ acetaminophen 7.5-325mg (generic of PERCOCET)


1 QL

oxycodone w/ acetaminophen 10-325mg (generic of PERCOCET)


1 QL

oxycodone-aspirin (generic of PERCODAN)

1

oxycodone-ibuprofen 1

OXYCONTIN QL (120 tabs / 30 days)

2 QL

oxymorphone hcl (generic of OPANA) TABS

1

Drug Name Drug Tier

Requirements/Limits

roxicet soln QL (1800 mL / 30 days)

2 QL

roxicet tab 5-325mg (generic of PERCOCET)


1 QL

SUBSYS QL (4 boxes / 30 days)

3 QL NM PA

XARTEMIS XR QL (120 tabs / 30 days)

3 QL

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) 4%

1 B/D

lidocaine hcl (local anesth.) (generic of XYLOCAINE) .5%

1 B/D

lidocaine inj 0.5% (generic of XYLOCAINE-MPF)

1 B/D

lidocaine inj 1% (generic of XYLOCAINE) 1%

1 B/D

lidocaine inj 1% (generic of XYLOCAINE-MPF) 1%

1 B/D

lidocaine inj 1.5% (generic of XYLOCAINE-MPF)

1 B/D

lidocaine inj 2% (generic of XYLOCAINE) 2%

1 B/D

lidocaine inj 2% (generic of XYLOCAINE-MPF) 2%

1 B/D

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 1

BETHKIS 3 NM

gentamicin in saline inj 0.8 mg/ml

1


3

gentamicin in saline inj 1 mg/ml

1


1


3


1

gentamicin in saline inj 2 mg/ml

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

gentamicin sulfate SOLN 1

neomycin sulfate TABS 1

paromomycin sulfate CAPS 1

streptomycin sulfate SOLR 1

sulfadiazine TABS 3

TOBI PODHALER 3 NM PA

tobramycin (generic of TOBI) NEBU

1 NM

tobramycin sulfate SOLN; SOLR

1

tobramycin sulfate in saline 3

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 3

ALINIA 2

atovaquone (generic of MEPRON) SUSP

1

AZACTAM 3

AZACTAM/DEX INJ 1GM 3

AZACTAM/DEX INJ 2GM 3

aztreonam (generic of AZACTAM)

1

BILTRICIDE 2

CAYSTON 2 NM LA PA

clindamycin hcl (generic of CLEOCIN) CAPS

1

clindamycin palmitate hydrochloride (generic of CLEOCIN PEDIATRIC GRANULE)

1

clindamycin phosphate SOLN 150mg/ml

1

clindamycin phosphate (generic of CLEOCIN PHOSPHATE) SOLN 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml, 9000mg/60ml

1

clindamycin phosphate in d5w (generic of CLEOCIN IN D5W)

1

colistimethate sodium (generic of COLY-MYCIN M) SOLR

1

CUBICIN 3 B/D

dapsone TABS 1

Drug Name Drug Tier

Requirements/Limits

DARAPRIM 3

DORIBAX 3

e.s.p. 1

ees/sulfisox sus 200-600 1

FLAGYL ER 3

imipenem-cilastatin (generic of PRIMAXIN IV)

1

INVANZ 3

MACRODANTIN 25mg 90 day limit if > 64 yr

2 PA

meropenem (generic of MERREM)

1

methenamine hippurate (generic of HIPREX)

1

METRO IV 3

metronidazole (generic of FLAGYL) CAPS; TABS

1

metronidazole inj 1

NEBUPENT 3

nitrofurantoin (generic of FURADANTIN) SUSP

90 day limit if > 64 yr

1 PA

nitrofurantoin macrocrystal (generic of MACRODANTIN)


1 PA

nitrofurantoin monohyd macro (generic of MACROBID)


1 PA

PENTAM 300 3

polymyxin b sulfate SOLR 1

PRIMSOL SOL 50MG/5ML 3

STROMECTOL 3

sulfamethoxazole-trimethop SUSP

1

sulfamethoxazole-trimethop (generic of BACTRIM) TABS

1

sulfamethoxazole-trimethop (generic of BACTRIM DS) TABS

1

sulfamethoxazole-trimethoprim inj

1

SYNERCID 3

trimethoprim TABS 1

TYGACIL 3

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

vancomycin hcl (generic of VANCOCIN HCL) CAPS

1 NM

vancomycin hcl SOLR 10gm, 500mg, 1000mg, 5000mg

1 B/D

vancomycin hcl SOLR 750mg

3 B/D

XIFAXAN TAB 200MG 3

ZYVOX SOLN 3 NM PA

ZYVOX SUSR; TABS 2 NM PA

ANTIFUNGALS ABELCET 3

AMBISOME 3

AMPHOTEC 3

amphotericin b SOLR 1

CANCIDAS 3

ERAXIS 3

fluconazole (generic of DIFLUCAN) SUSR; TABS

1

fluconazole in dextrose 1

fluconazole inj nacl 100 3



flucytosine (generic of ANCOBON) CAPS

1

griseofulvin microsize SUSP 1

griseofulvin microsize (generic of GRIFULVIN V) TABS

1

griseofulvin ultramicrosize (generic of GRIS-PEG)

1

itraconazole (generic of SPORANOX) CAPS

1 PA

ketoconazole TABS 1

LAMISIL PACK 3 PA

MYCAMINE 3

NOXAFIL SUSP; TBEC 3

nystatin TABS 1

ONMEL 3 PA

SPORANOX SOL 10MG/ML 3 PA

terbinafine hcl (generic of LAMISIL) TABS

1

voriconazole (generic of VFEND) SUSR; TABS

1

voriconazole inj 200mg (generic of VFEND IV)

1

Drug Name Drug Tier

Requirements/Limits

ANTIMALARIALS ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG

1

atovaquone-proguanil hcl tab 250-100 mg (generic of MALARONE)

1

chloroquine phosphate TABS 250mg

1

chloroquine phosphate (generic of ARALEN) TABS 500mg

1

COARTEM 2

mefloquine hcl 1

PRIMAQUINE PHOSPHATE 3

quinine sulfate (generic of QUALAQUIN) CAPS

1

ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN)

1

APTIVUS 3

CRIXIVAN 3

didanosine (generic of VIDEX EC)

1

EDURANT 2

EMTRIVA 2

EPIVIR SOL 10MG/ML 2

FUZEON 2 NM

INTELENCE 2

INVIRASE 3

ISENTRESS CHEW 25mg 2

ISENTRESS CHEW 100mg 2 NM

ISENTRESS PACK 2

ISENTRESS TABS 2 NM

lamivudine (generic of EPIVIR) 150mg, 300mg

1

LEXIVA 3

NEVIRAPINE SUSP 1

nevirapine (generic of VIRAMUNE) TABS

1

nevirapine (generic of VIRAMUNE XR) TB24

1

NORVIR 2

PREZISTA SUSP 2 NM

PREZISTA TABS 75mg, 150mg

2

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

PREZISTA TABS 600mg, 800mg

2 NM

RESCRIPTOR 2

RETROVIR IV INFUSION 3

REYATAZ 2 NM

SELZENTRY 3

stavudine (generic of ZERIT) 1

SUSTIVA CAPS 2

SUSTIVA TABS 2 NM

TIVICAY 3

VIDEX PEDIATRIC 3

VIRACEPT 3

VIRAMUNE XR 100mg 2

VIREAD 2 NM

ZIAGEN SOLN 3

zidovudine (generic of RETROVIR) CAPS; SYRP

1

zidovudine TABS 1

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine (generic of TRIZIVIR)

1

ATRIPLA 2

COMPLERA 3

EPZICOM 3

KALETRA SOL 2 NM

KALETRA TAB 100-25MG 2

KALETRA TAB 200-50MG 2 NM

lamivudine-zidovudine (generic of COMBIVIR)

1 NM

STRIBILD 2

TRUVADA 2 NM

ANTITUBERCULAR AGENTS CAPASTAT SULFATE 3

ethambutol hcl (generic of MYAMBUTOL) TABS

1

isoniazid SOLN; SYRP 1

isoniazid tabs 1

paser d/r 3

PRIFTIN 3

pyrazinamide 1

rifabutin (generic of MYCOBUTIN)

1

Drug Name Drug Tier

Requirements/Limits

rifamate 3

rifampin (generic of RIFADIN) CAPS; SOLR

1

RIFATER 3

SIRTURO 3 NM LA

TRECATOR 3

ANTIVIRALS acyclovir (generic of ZOVIRAX) CAPS; SUSP; TABS

1

acyclovir sodium SOLN 1

acyclovir sodium SOLR 1000mg

1

adefovir dipivoxil (generic of HEPSERA)

1 NM

BARACLUDE SOLN 2

BARACLUDE TABS 2 NM

cidofovir (generic of VISTIDE) 1

EPIVIR HBV SOLN 2

famciclovir (generic of FAMVIR) TABS

1

foscarnet sodium 1

ganciclovir inj 500mg (generic of CYTOVENE)

1

lamivudine (generic of EPIVIR HBV) 100mg

1

moderiba pak 3 NM PA

moderiba tab 200mg (generic of COPEGUS)

1 NM PA

OLYSIO 3 NM PA

REBETOL SOLN 2 NM PA

RELENZA DISKHALER 2

ribapak mis 600/day 3 NM PA

ribasphere (generic of REBETOL) CAPS

1 NM PA

ribasphere (generic of COPEGUS) TABS 200mg

1 NM PA

ribasphere TABS 400mg, 600mg

1 NM PA

ribasphere ribapak 800 3 NM PA



ribavirin 200mg (generic of REBETOL) CAPS

1 NM PA

ribavirin 200mg (generic of COPEGUS) TABS

1 NM PA

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

rimantadine hydrochloride (generic of FLUMADINE)

1

SOVALDI 2 NM PA

TAMIFLU 2

TYZEKA 3

valacyclovir hcl (generic of VALTREX) TABS

1

VALCYTE 2

VICTRELIS 2 NM PA

CEPHALOSPORINS CEDAX SUSR 90mg/5ml 3

cefaclor 1

cefaclor er tab 500mg 3

cefadroxil 1

cefazolin inj 1

cefazolin sodium 1gm, 20gm 1

cefazolin/dextrose 3

cefdinir 1

CEFEPIME 1GM SOLN 3

CEFEPIME 2GM SOLN 3

cefepime inj 1gm (generic of MAXIPIME)

1

cefepime inj 2gm (generic of MAXIPIME)

1

cefotaxime sodium (generic of CLAFORAN)

1

cefotetan disodium 3

cefoxitin sodium 1

CEFOXITIN SODIUM IN DEXTROSE

3

cefpodoxime proxetil 1

cefprozil 1

ceftazidime (generic of FORTAZ) 1gm, 2gm, 6gm

1

CEFTAZIDIME/DEXTROSE 3

ceftibuten 1

CEFTIN SUSR 3

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg

1

ceftriaxone sodium (generic of ROCEPHIN) SOLR 1gm, 500mg

1

cefuroxime axetil SUSR 1

Drug Name Drug Tier

Requirements/Limits

cefuroxime axetil (generic of CEFTIN) TABS

1

cefuroxime sodium (generic of ZINACEF) 1.5gm, 7.5gm, 750mg

1

cefuroxime sodium soln iv 7.5 gm

3

cephalexin (generic of KEFLEX) CAPS

1

cephalexin SUSR; TABS 1

claforan 1gm, 2gm 3

FORTAZ SOLN 3

FORTAZ SOLR 500mg 3

MAXIPIME 3

SUPRAX CAPS 2

suprax CHEW 2

suprax SUSR 100mg/5ml, 200mg/5ml

2

SUPRAX SUSR 500mg/5ml 2

suprax TABS 2

tazicef vial (generic of FORTAZ)

1

TEFLARO 3

ZINACEF SOLR 750mg 3

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 1

azithromycin (generic of ZITHROMAX) SOLR 500mg

1

azithromycin (generic of ZITHROMAX) SUSR

1

azithromycin (generic of ZITHROMAX) TABS

1

clarithromycin SUSR 125mg/5ml

1

clarithromycin (generic of BIAXIN) SUSR 250mg/5ml

1

clarithromycin (generic of BIAXIN) TABS

1

clarithromycin (generic of BIAXIN XL) TB24

1

DIFICID 2 NM

e.e.s. 400 mg tab 1

E.E.S. GRANULES 3

ery-tab 3

ERYPED 200 3

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

ERYPED 400 3

erythrocin lactobionate 500mg

3

erythrocin stearate 1

erythromycin base 1

erythromycin cap 250mg ec 1

erythromycin ethylsuccinate 1

PCE 3

ZMAX 3

FLUOROQUINOLONES AVELOX SOLN 3

ciprofloxacin SOLN 200mg/20ml

1

ciprofloxacin (generic of CIPRO) SUSR

1

ciprofloxacin er (generic of CIPRO XR)

1

ciprofloxacin hcl TABS 100mg, 750mg

1

ciprofloxacin hcl (generic of CIPRO) TABS 250mg, 500mg

1

ciprofloxacin in d5w (generic of CIPRO I.V.-IN D5W)

1

ciprofloxacn inj 1

FACTIVE 3

levofloxacin SOLN 25mg/ml 1

levofloxacin (generic of LEVAQUIN) SOLN 25mg/ml

1

levofloxacin (generic of LEVAQUIN) TABS

1

levofloxacin in d5w (generic of LEVAQUIN)

1

moxifloxacin hcl (generic of AVELOX)

1

PENICILLINS amoxicillin 1

amoxicillin & pot clavulanate CHEW

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) CHEW

1

amoxicillin & pot clavulanate SUSR

1

Drug Name Drug Tier

Requirements/Limits

amoxicillin & pot clavulanate (generic of AUGMENTIN) SUSR

1

amoxicillin & pot clavulanate (generic of AUGMENTIN ES-600) SUSR

1

amoxicillin & pot clavulanate TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB12

1

ampicillin & sulbactam sodium 1

ampicillin & sulbactam sodium (generic of UNASYN)

1

ampicillin & sulbactam sodium (generic of UNASYN BULK PACK)

1

ampicillin cap 250mg 1

ampicillin cap 500 mg 1

ampicillin inj 1

ampicillin sodium 1

ampicillin susp 1

AUGMENTIN SUSR 3

BACTOCILL INJ DEX 1GM 3

BACTOCILL INJ DEX 2GM 3

BICILLIN C-R 3

BICILLIN L-A 3

dicloxacillin sodium 1

MOXATAG 3

nafcillin sodium 1

NALLPEN ISO-OSMOTIC IN DE

3

NALLPEN/DEXTROSE 3

oxacillin sodium 1

PENICILLIN G POT IN DEXTROSE

3

penicillin g potassium 1

penicillin g procaine 3

penicillin g sodium 1

penicillin v potassium 1

pfizerpen 1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

piperacillin sodium-tazobactam sodium (generic of ZOSYN)

1

TIMENTIN SOLR 3

ZOSYN SOLN 3

TETRACYCLINES demeclocycline hcl 1

DORYX 200mg 3

doxycycline (monohydrate) CAPS 50mg

1

doxycycline (monohydrate) (generic of MONODOX) CAPS 75mg, 100mg

1

doxycycline (monohydrate) (generic of ADOXA) CAPS 150mg

1

doxycycline (monohydrate) (generic of VIBRAMYCIN) SUSR

1

doxycycline (monohydrate) (generic of ADOXA) TABS 50mg, 75mg, 100mg

1

doxycycline (monohydrate) (generic of ADOXA PAK 1/150) TABS 150mg

1

doxycycline hyclate CAPS 50mg

1

doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg

1

doxycycline hyclate SOLR 1

doxycycline hyclate TABS 1

doxycycline hyclate TBEC 75mg, 100mg

1

doxycycline hyclate (generic of DORYX) TBEC 150mg

1

minocycline hcl (generic of MINOCIN) CAPS

1

minocycline hcl TABS; TB24 1

SOLODYN 3

TETRACYCLINE HCL CAPS

1

VIBRAMYCIN SYRP 2

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU 3

Drug Name Drug Tier

Requirements/Limits

BUSULFEX 3

CYCLOPHOSPHAMIDE CAPS

3

cyclophosphamide SOLR 3

cyclophosphamide TABS 1

dacarbazine 200mg 1

EMCYT 2

HEXALEN 2

IFEX 3gm 3

ifosfamide (generic of IFOSFAMIDE)

1

ifosfamide for inj 1 gm (generic of IFEX)

1

IFOSFAMIDE FOR INJ 3 GM 3

LEUKERAN 2

LOMUSTINE 1

melphalan hcl (generic of ALKERAN)

1

MUSTARGEN 3

TREANDA 3 NM

ZANOSAR 3

ANTHRACYCLINES adriamycin inj 20mg 3

daunorubicin hcl for inj 20 mg 1

daunorubicin inj 5mg/ml 1

doxorubicin hcl 50mg 1

doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml (generic of DOXIL)

1

doxorubicin inj 50mg 1

EPIRUBICIN INJ 50MG 3

epirubicin inj 50mg/25ml (generic of ELLENCE)

1

epirubicin inj 200mg (generic of ELLENCE)

1

idarubicin hcl (generic of IDAMYCIN PFS)

1

VALSTAR 3 NM PA

ANTIBIOTICS bleomycin sulfate 1

COSMEGEN 3

mitomycin SOLR 1

ANTIMETABOLITES adrucil 1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

ALIMTA 3

ARRANON 3

azacitidine (generic of VIDAZA)

1 NM

cladribine 1

CLOLAR 3

cytarabine inj 1

decitabine (generic of DACOGEN)

1 NM

fludarabine phosphate SOLN

1

fludarabine phosphate (generic of FLUDARA) SOLR

1

fluorouracil SOLN 1

FOLOTYN 3 NM PA

GEMCITABINE INJ 1GM SOLN

3

gemcitabine inj 1gm (generic of GEMZAR) SOLR

1

GEMCITABINE INJ 2GM SOLN

3

gemcitabine inj 2gm SOLR 1

GEMCITABINE INJ 200MG SOLN

3

gemcitabine inj 200mg (generic of GEMZAR) SOLR

1

mercaptopurine (generic of PURINETHOL) TABS

1

methotrexate sodium inj 1

NIPENT 3

TABLOID 2

ANTIMITOTIC, TAXOIDS ABRAXANE 3

DOCETAXEL CONC 20mg/0.5ml

3

DOCETAXEL CONC 20mg/ml, 80mg/4ml

1

docetaxel CONC 140mg/7ml 3

DOCETAXEL SOLN 80mg/8ml

3

paclitaxel 1

TAXOTERE 80mg/2ml 3

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate SOLN 1

Drug Name Drug Tier

Requirements/Limits

vincasar 1

vincristine sulfate 1

vinorelbine tartrate (generic of NAVELBINE)

1

BIOLOGIC RESPONSE MODIFIERS ARZERRA 3 NM

AVASTIN 3 NM

ERBITUX 3 NM

ERIVEDGE 3 NM LA PA

HERCEPTIN 3 NM

ISTODAX 3 NM

KADCYLA 3 NM

PERJETA 3 NM PA

PROLEUKIN 3 NM

RITUXAN 2 NM PA

TORISEL 3 NM

VECTIBIX 3 NM

VELCADE 3 NM

YERVOY 3 NM PA

ZALTRAP 3 NM PA

ZOLINZA 2 NM PA

HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS

1

bicalutamide (generic of CASODEX)

1

DEPO-PROVERA INJ 400/ML 3

ELIGARD INJ 7.5MG 3 NM

ELIGARD INJ 22.5MG 3 NM

ELIGARD INJ 30MG 3 NM

ELIGARD INJ 45MG 3 NM

exemestane (generic of AROMASIN)

1

FARESTON 2

FASLODEX 2

FIRMAGON 3 NM

flutamide 1

letrozole (generic of FEMARA) TABS

1

leuprolide acetate KIT 1 NM PA

LUPR DEP-PED INJ 15MG 2 NM PA

LUPR DEP-PED INJ 30MG (3-MONTH)

2 NM PA

LUPRON DEP INJ 11.25MG 2 NM PA

LUPRON DEPOT 2 NM PA

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

LUPRON DEPOT INJ 22.5MG (3-MONTH)

2 NM PA

LUPRON DEPOT INJ 30MG (3-MONTH)

2 NM PA

LUPRON DEPOT INJ 45MG 2 NM PA

LUPRON DEPOT-PED 2 NM PA

LYSODREN 2

MEGACE ES 2 NM

megestrol acetate (generic of MEGACE ORAL) SUSP

1 PA

megestrol acetate TABS 1 PA

NILANDRON 2

SOLTAMOX 3

tamoxifen citrate TABS 1

TRELSTAR DEPOT MIXJECT

2 NM PA

TRELSTAR LA MIXJECT 2 NM PA

TRELSTAR MIXJECT 2 NM PA

VANTAS 3 NM PA

XTANDI 3 NM LA PA

ZOLADEX 2 NM PA

ZYTIGA 3 NM PA

KINASE INHIBITORS AFINITOR 2 NM PA

AFINITOR DISPERZ 2 NM PA

BOSULIF 2 NM PA

CAPRELSA 3 NM LA PA

COMETRIQ 3 NM PA

GILOTRIF TAB 20MG 3 NM LA PA



GLEEVEC 2 NM PA

ICLUSIG 2 NM LA PA

IMBRUVICA CAP 140MG 3 NM LA PA

INLYTA 3 NM LA PA

JAKAFI 3 NM LA PA

MEKINIST 3 NM PA

NEXAVAR 2 NM LA PA

SPRYCEL 2 NM PA

STIVARGA 3 NM LA PA

SUTENT 2 NM PA

TAFINLAR 3 NM PA

TARCEVA 2 NM PA

TASIGNA 2 NM PA

TYKERB 2 NM LA PA

VOTRIENT 2 NM PA

Drug Name Drug Tier

Requirements/Limits

XALKORI 3 NM LA PA

ZELBORAF 3 NM LA PA

ZYKADIA 3 NM LA PA

MISCELLANEOUS CYRAMZA 100mg/10ml 3 NM PA

DROXIA 3

ERWINAZE 3 NM LA PA

GAZYVA 3 NM PA

HALAVEN 3 NM

hydroxyurea (generic of HYDREA) CAPS

1

IXEMPRA KIT 3 NM

JEVTANA 3 NM PA

MATULANE 2

mitoxantrone hcl 1 NM

ONCASPAR 3 NM PA

POMALYST 2 NM LA PA

SYLATRON KIT 296MCG 2 NM PA



SYNRIBO 3 NM PA

TARGRETIN CAPS 2 NM PA

tretinoin CAPS 1

TRISENOX 3

UVADEX 3

PLATINUM-BASED AGENTS carboplatin SOLN 1

cisplatin 1

ELOXATIN 50mg/10ml, 100mg/20ml

3

oxaliplatin 1

PROTECTIVE AGENTS amifostine crystalline (generic of ETHYOL)

1

dexrazoxane (generic of ZINECARD) 250mg

1

ELITEK 3

FUSILEV 3 NM PA

KEPIVANCE 3

leucovor ca inj 1

leucovorin calcium SOLR; TABS

1

leucovorin calcium 500 mg 3

leucovorin calcium inj 10 mg/ml

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

mesna (generic of MESNEX) 1

MESNEX TABS 3

TOPOISOMERASE INHIBITORS CAMPTOSAR 300mg/15ml 3

ETOPOPHOS 3

etoposide SOLN 500mg/25ml

1

irinotecan (generic of CAMPTOSAR)

1 NM

irinotecan hcl (generic of CAMPTOSAR) 40mg/2ml

1

irinotecan hcl 500mg/25ml 1

toposar 1gm/50ml 1

topotecan hcl (generic of HYCAMTIN) SOLR

1 NM

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl (generic of LOTREL)

1

benazepril & hydrochlorothiazide

1

benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)

1

captopril & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide (generic of VASERETIC)

1

fosinopril sodium & hydrochlorothiazide

1

lisinopril & hydrochlorothiazide (generic of ZESTORETIC)

1

moexipril-hydrochlorothiazide 1

moexipril-hydrochlorothiazide (generic of UNIRETIC)

1

quinapril-hydrochlorothiazide (generic of ACCURETIC)

1

TARKA 2

ACE INHIBITORS benazepril hcl TABS 5mg 1

Drug Name Drug Tier

Requirements/Limits

benazepril hcl (generic of LOTENSIN) TABS 10mg, 20mg, 40mg

1

captopril TABS 1

enalapril maleate (generic of VASOTEC) TABS

1

fosinopril sodium 1

lisinopril (generic of ZESTRIL) TABS 2.5mg, 30mg, 40mg

1

lisinopril (generic of PRINIVIL) TABS 5mg, 10mg, 20mg

1

moexipril hcl (generic of UNIVASC)

1

perindopril erbumine 2mg 1

perindopril erbumine (generic of ACEON) 4mg, 8mg

1

quinapril hcl (generic of ACCUPRIL)

1

ramipril (generic of ALTACE) 1

trandolapril (generic of MAVIK)

1

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone (generic of INSPRA)

1

spironolactone (generic of ALDACTONE) TABS

1

ALPHA BLOCKERS doxazosin mesylate (generic of CARDURA)

1

prazosin hcl (generic of MINIPRESS)

1

terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS AZOR 2

BENICAR HCT 2

candesartan cilexetil-hydrochlorothiazide (generic of ATACAND HCT)

1

EDARBYCLOR 3

EXFORGE 2

EXFORGE HCT 2

irbesartan-hydrochlorothiazide (generic of AVALIDE)

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

losartan potassium & hydrochlorothiazide (generic of HYZAAR)

1

telmisartan-amlodipine (generic of TWYNSTA)

1

telmisartan-hydrochlorothiazide (generic of MICARDIS HCT)

1

TEVETEN HCT 3

TRIBENZOR 2

valsartan-hydrochlorothiazide (generic of DIOVAN HCT)

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 2

candesartan cilexetil (generic of ATACAND)

1

DIOVAN 2

EDARBI 3

eprosartan mesylate (generic of TEVETEN)

1

irbesartan (generic of AVAPRO)

1

losartan potassium (generic of COZAAR)

1

TELMISARTAN 1

valsartan (generic of DIOVAN)

1

ANTIARRHYTHMICS amiodarone hcl SOLN 1

amiodarone hcl TABS 100mg, 400mg

1

amiodarone hcl (generic of CORDARONE) TABS 200mg

1

amiodarone inj 50mg/ml 1

disopyramide phosphate (generic of NORPACE)

1 PA

flecainide acetate 1

mexiletine hcl 1

MULTAQ 2

NORPACE CR 2 PA

pacerone 100mg, 400mg 1

pacerone (generic of CORDARONE) 200mg

1

Drug Name Drug Tier

Requirements/Limits

propafenone hcl (generic of RYTHMOL SR) CP12

1

propafenone hcl (generic of RYTHMOL) TABS 150mg, 225mg

1

propafenone hcl TABS 300mg

1

quinidine gluconate er 1

quinidine sulfate TABS; TBCR

1

sorine (generic of BETAPACE) 80mg, 120mg, 160mg

1

sorine 240mg 1

sotalol hcl (generic of BETAPACE) 80mg, 120mg, 160mg

1

sotalol hcl 240mg 1

sotalol hcl (afib/afl) (generic of BETAPACE AF)

1

TIKOSYN 2 NM

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 3

atorvastatin calcium (generic of LIPITOR)

1

CRESTOR 2

fluvastatin sodium (generic of LESCOL)

1

LESCOL XL 3

LIVALO 3

lovastatin 10mg 1

lovastatin (generic of MEVACOR) 20mg, 40mg

1

pravastatin sodium 10mg 1

pravastatin sodium (generic of PRAVACHOL) 20mg, 40mg, 80mg

1

simvastatin (generic of ZOCOR) TABS

1

ANTILIPEMICS, MISCELLANEOUS ADVICOR 3

ANTARA 3

cholestyramine (generic of QUESTRAN)

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

cholestyramine light 1

choline fenofibrate (generic of TRILIPIX)

1

colestipol hcl (generic of COLESTID)

1

FENOFIBRATE CAPS 1

fenofibrate (generic of TRICOR) TABS 48mg, 145mg

1

fenofibrate (generic of LOFIBRA) TABS 54mg, 160mg

1

fenofibrate micronized 43mg, 130mg

1

fenofibrate micronized (generic of LOFIBRA) 67mg, 134mg, 200mg

1

FENOFIBRIC ACID 1

FENOGLIDE 3

gemfibrozil (generic of LOPID) TABS

1

JUXTAPID 3 NM PA

KYNAMRO 3 NM PA

LIPTRUZET 3

niacin (antihyperlipidemic) (generic of NIASPAN)

1

niacor 1

omega-3-acid ethyl esters 1

prevalite (generic of QUESTRAN LIGHT)

1

SIMCOR 2

TRIGLIDE 3

VASCEPA 3

VYTORIN 2

WELCHOL 2

ZETIA TAB 10MG 2

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone (generic of TENORETIC 50)

1

atenolol & chlorthalidone (generic of TENORETIC 100)

1

bisoprolol & hydrochlorothiazide (generic of ZIAC)

1

Drug Name Drug Tier

Requirements/Limits

DUTOPROL 3

metoprolol & hctz tab 50-25mg (generic of LOPRESSOR HCT)

1

metoprolol & hctz tab 100-25mg (generic of LOPRESSOR HCT)

1

metoprolol & hctz tab 100-50mg

1

nadolol & bendroflumethiazide (generic of CORZIDE)

1

propranolol & hydrochlorothiazide

1

BETA-BLOCKERS acebutolol hcl (generic of SECTRAL) CAPS

1

atenolol (generic of TENORMIN) TABS

1

betaxolol hcl (generic of KERLONE)

1

bisoprolol fumarate (generic of ZEBETA)

1

BYSTOLIC 2

carvedilol (generic of COREG)

1

COREG CR 2

labetalol hcl SOLN 1

labetalol hcl (generic of TRANDATE) TABS 100mg, 200mg

1

labetalol hcl TABS 300mg 1

metoprolol succinate (generic of TOPROL XL)

1

metoprolol tartrate (generic of LOPRESSOR) SOLN

1

metoprolol tartrate TABS 25mg

1

metoprolol tartrate (generic of LOPRESSOR) TABS 50mg, 100mg

1

nadolol (generic of CORGARD) TABS

1

pindolol 1

propranolol hcl er (generic of INDERAL LA)

1

propranolol inj 1mg/ml 1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

propranolol sol 1

propranolol tab 1

timolol maleate TABS 1

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS AMLODIPINE BESYLATE/ATORV

1

CALCIUM CHANNEL BLOCKERS afeditab cr (generic of ADALAT CC)

1

amlodipine besylate (generic of NORVASC) TABS

1

CARDENE SR 3

CARDIZEM LA 120mg 3

cartia xt (generic of CARDIZEM CD)

1

dilt-cd cap (generic of CARDIZEM CD)

1

dilt-xr cap 1

diltiazem cap 120mg/24hr 1

diltiazem cap er/12hr 1

diltiazem hcl (generic of CARDIZEM) TABS 30mg, 60mg, 120mg

1

diltiazem hcl TABS 90mg 1

diltiazem hcl coated beads (generic of CARDIZEM CD)

1

diltiazem hcl er (generic of TIAZAC)

1

diltiazem hcl extended release beads (generic of TIAZAC)

1

diltiazem inj 25mg/5ml 1

diltiazem inj 50/10ml 1

diltiazem inj 100mg 3

diltiazem inj 125/25ml 1

diltzac (generic of TIAZAC) 1

felodipine 1

isradipine 1

matzim la (generic of CARDIZEM LA)

1

nicardipine hcl CAPS 1

nifedical (generic of PROCARDIA XL)

1

nifedipine (generic of ADALAT CC) TB24

1

Drug Name Drug Tier

Requirements/Limits

nifedipine er (generic of PROCARDIA XL)

1

nimodipine CAPS 1

nisoldipine (generic of SULAR) 8.5mg, 17mg, 34mg

1

nisoldipine 20mg, 25.5mg, 30mg, 40mg

1

NYMALIZE 3

taztia xt (generic of TIAZAC) 1

verapamil hcl (generic of VERELAN PM) CP24 100mg, 200mg, 300mg

1

verapamil hcl (generic of VERELAN) CP24 120mg, 180mg, 240mg

1

VERAPAMIL HCL CP24 360mg

1

verapamil hcl SOLN 1

verapamil hcl TABS 40mg 1

verapamil hcl (generic of CALAN) TABS 80mg, 120mg

1

verapamil hcl (generic of CALAN SR) TBCR

1

DIGITALIS GLYCOSIDES digoxin (generic of LANOXIN) 1

digoxin inj (generic of LANOXIN)

1

DIGOXIN SOL 50MCG/ML 1

LANOXIN PEDIATRIC 3

LANOXIN TAB 2

DIRECT RENIN INHIBITORS/COMBINATIONS AMTURNIDE 2

TEKAMLO 2

TEKTURNA 2

TEKTURNA HCT 2

DIURETICS acetazolamide (generic of DIAMOX) CP12

1

acetazolamide TABS 1

acetazolamide sodium 1

ALDACTAZIDE TAB 50/50 3

amiloride & hydrochlorothiazide

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

amiloride hcl 1

bumetanide 1

chlorothiazide 1

chlorthalidone 25mg, 50mg 1

DIURIL SUS 250/5ML 3

DYRENIUM 3

EDECRIN 3

furosemide SOLN 1

furosemide (generic of LASIX) TABS

1

furosemide inj 1

furosemide oral soln 8 mg/ml 2

hydrochlorothiazide (generic of MICROZIDE) CAPS

1

hydrochlorothiazide TABS 1

indapamide 1

methazolamide (generic of NEPTAZANE) TABS

1

methyclothiazide 1

metolazone (generic of ZAROXOLYN) 2.5mg, 5mg

1

metolazone 10mg 1

spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)

1

torsemide inj 20mg/2ml 3

torsemide inj 50mg/5ml 3

torsemide tabs (generic of DEMADEX)

1

triamt/hctz cap 37.5-25 (generic of DYAZIDE)

1

triamt/hctz cap 50-25mg 1

triamt/hctz tab 37.5-25 (generic of MAXZIDE-25)

1

triamt/hctz tab 75-50mg (generic of MAXZIDE)

1

MISCELLANEOUS BIDIL 2

clonidine hcl (generic of CATAPRES-TTS-1) PTWK .1mg/24hr

1


1

Drug Name Drug Tier

Requirements/Limits


1

clonidine hcl (generic of CATAPRES) TABS

1

clorpres 1

DEMSER 3

DIBENZYLINE 3

hydralazine hcl 1

midodrine hcl 1

minoxidil TABS 1

RANEXA 2

NITRATES DILATRATE SR 3

ISORDIL TITRADOSE 40mg 2

isosorbide dinitrate (generic of ISORDIL TITRADOSE) TABS 5mg

1

isosorbide dinitrate TABS 10mg, 20mg, 30mg

1

isosorbide dinitrate TBCR 1

isosorbide mononitrate 1

isosorbide mononitrate er (generic of IMDUR)

1

minitran (generic of NITRO-DUR)

1

nitro-bid 3

NITRO-DUR .3mg/hr, .8mg/hr

2

NITROGLYCERIN .4mg/spray

1

NITROGLYCERIN LINGUAL 1

nitroglycerin patches 1

NITROLINGUAL SPR PUMPSPRA

2

NITROMIST 3

NITROSTAT 2

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 2 NM PA

ADEMPAS 3 NM PA

FLOLAN 2 NM LA PA

LETAIRIS 2 NM LA PA

OPSUMIT 3 NM PA

ORENITRAM TAB 0.25MG 3 NM PA

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits


ORENITRAM TAB 1MG 3 NM PA


REMODULIN 2 NM LA

REVATIO SOLN 3 NM PA

sildenafil citrate (pulmonary hypertension) (generic of REVATIO)

1 NM PA

TRACLEER 2 NM LA PA

TYVASO 2 NM

VELETRI 3 NM LA PA

VENTAVIS 2 NM

CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam CONC

QL (300 mL / 30 days) 3 QL

alprazolam (generic of XANAX) TABS 1mg


1 QL

alprazolam (generic of XANAX) TABS 2mg


1 QL

alprazolam (generic of XANAX) TABS .5mg


1 QL

alprazolam (generic of XANAX) TABS .25mg


1 QL

buspirone hcl TABS 1

fluvoxamine maleate 1

fluvoxamine maleate er (generic of LUVOX CR)

1

lorazepam CONC QL (150 mL / 30 days)

1 QL

lorazepam (generic of ATIVAN) SOLN

1

lorazepam (generic of ATIVAN) TABS


1 QL

ANTICONVULSANTS APTIOM 3

BANZEL SUS 40MG/ML 3 NM

BANZEL TAB 200MG 3

BANZEL TAB 400MG 3 NM

carbamazepine CHEW 1

Drug Name Drug Tier

Requirements/Limits

carbamazepine (generic of CARBATROL) CP12

1

carbamazepine (generic of TEGRETOL) SUSP; TABS

1

carbamazepine (generic of TEGRETOL-XR) TB12

1

CELONTIN 3

clonazepam (generic of KLONOPIN) TABS 1mg


1 QL

clonazepam (generic of KLONOPIN) TABS 2mg


1 QL

clonazepam (generic of KLONOPIN) TABS .5mg


1 QL

clonazepam TBDP 1mg QL (600 tabs / 30 days)

1 QL

clonazepam TBDP 2mg QL (300 tabs / 30 days)

1 QL

clonazepam TBDP .5mg QL (1200 tabs / 30 days)

1 QL


1 QL


1 QL

clorazepate dipotassium (generic of TRANXENE T) 3.75mg, 7.5mg


1 QL

clorazepate dipotassium (generic of TRANXENE T) 15mg


1 QL

diazepam CONC QL (240 mL / 30 days)

2 QL

diazepam SOLN 1mg/ml QL (1200 mL / 30 days)

1 QL

diazepam SOLN 5mg/ml 1

diazepam (generic of VALIUM) TABS


1 QL

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

DIAZEPAM GEL (ANTICONVULSANT)

1

dilantin CAPS; CHEW 3

DILANTIN SUSP 3

divalproex sodium (generic of DEPAKOTE SPRINKLES) CPSP

1

divalproex sodium (generic of DEPAKOTE ER) TB24

1

divalproex sodium (generic of DEPAKOTE) TBEC

1

epitol (generic of TEGRETOL) 1

ethosuximide (generic of ZARONTIN) CAPS; SOLN

1

felbamate (generic of FELBATOL)

1

FYCOMPA 3

gabapentin (generic of NEURONTIN) CAPS; SOLN; TABS

1

GABITRIL 12mg, 16mg 2

LAMICTAL ODT 2

LAMICTAL STARTER 3

LAMICTAL XR KIT 2

lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW

1

lamotrigine (generic of LAMICTAL) TABS

1

lamotrigine (generic of LAMICTAL XR) TB24

1

levetiracetam (generic of KEPPRA) SOLN; TABS

1

levetiracetam (generic of KEPPRA XR) TB24

1

LYRICA 2

ONFI SUS 2.5MG/ML 3

ONFI TAB 10MG 3

oxcarbazepine (generic of TRILEPTAL)

1

OXTELLAR XR 3

PEGANONE 3

phenobarbital ELIX; TABS 1 PA

PHENOBARBITAL SODIUM 65mg/ml

3 PA

Drug Name Drug Tier

Requirements/Limits

phenobarbital sodium 130mg/ml

1 PA

phenytek 3

phenytoin (generic of DILANTIN INFATABS) CHEW

1

phenytoin (generic of DILANTIN) SUSP

1

phenytoin inj 50mg/ml 1

phenytoin sodium extended (generic of DILANTIN) 100mg

1

phenytoin sodium extended (generic of PHENYTEK) 200mg, 300mg

1

POTIGA 3

primidone (generic of MYSOLINE) TABS

1

QUDEXY XR 3

SABRIL 3 NM LA PA

TEGRETOL 3

TEGRETOL-XR 3

tiagabine hcl (generic of GABITRIL)

1

topiramate (generic of TOPAMAX SPRINKLE) CPSP

1

topiramate (generic of TOPAMAX) TABS

1

TROKENDI XR 3

valproate sodium (generic of DEPACON) SOLN

1

valproate sodium (generic of DEPAKENE) SYRP

1

valproic acid (generic of DEPAKENE) CAPS

1

VIMPAT 2

zonisamide (generic of ZONEGRAN) 25mg, 100mg

1

zonisamide 50mg 1

ANTIDEMENTIA donepezil odt 5mg 1

donepezil odt 10mg (generic of ARICEPT ODT)

1

donepezil tab hcl 23mg (generic of ARICEPT)

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

donepezil tabs 5mg (generic of ARICEPT)

1

donepezil tabs 10mg (generic of ARICEPT)

1

EXELON PATCHES 2

galantamine hydrobromide (generic of RAZADYNE ER) CP24

1

galantamine hydrobromide (generic of RAZADYNE) SOLN; TABS

1

NAMENDA SOL 10MG/5ML PA if <30 yr

2 PA

NAMENDA XR PA if <30 yr

2 PA

NAMENDA XR TITRATION PACK

PA if <30 yr

2 PA

rivastigmine tartrate (generic of EXELON)

1

ANTIDEPRESSANTS amitriptyline hcl TABS 1 PA

amoxapine 1

APLENZIN 3

BRINTELLIX 3

bupropion hcl (generic of WELLBUTRIN) TABS

1

bupropion hcl (generic of WELLBUTRIN SR) TB12

1

bupropion hcl (generic of WELLBUTRIN XL) TB24

1

citalopram hydrobromide SOLN

1

citalopram hydrobromide (generic of CELEXA) TABS

1

clomipramine hcl (generic of ANAFRANIL) CAPS

1 PA

desipramine hcl (generic of NORPRAMIN) TABS

1

doxepin hcl CAPS; CONC 1 PA

duloxetine hcl (generic of CYMBALTA) CPEP

1

EMSAM 3 NM

escitalopram oxalate (generic of LEXAPRO)

1

FETZIMA 3

Drug Name Drug Tier

Requirements/Limits

FETZIMA TITRATION PACK 3

fluoxetine hcl (generic of PROZAC) CAPS

1

fluoxetine hcl (generic of PROZAC WEEKLY) CPDR

1

fluoxetine hcl SOLN 1

fluoxetine hcl TABS 10mg, 20mg

1

FLUOXETINE HCL TABS 60mg

2

FORFIVO XL 3

imipramine hcl (generic of TOFRANIL) TABS

1 PA

imipramine pamoate (generic of TOFRANIL-PM)

1 PA

maprotiline hcl 1

MARPLAN 2

mirtazapine TABS 7.5mg 1

mirtazapine (generic of REMERON) TABS 15mg, 30mg, 45mg

1

mirtazapine (generic of REMERON SOLTAB) TBDP

1

nefazodone hcl 1

nortriptyline hcl (generic of PAMELOR) CAPS

1

nortriptyline hcl SOLN 1

paroxetine er tab (generic of PAXIL CR)

1

paroxetine hcl (generic of PAXIL)

1

PAXIL SUSP 3

PEXEVA 3

phenelzine sulfate (generic of NARDIL) TABS

1

PRISTIQ 2

protriptyline hcl (generic of VIVACTIL)

1

sertraline hcl (generic of ZOLOFT) CONC; TABS

1

SURMONTIL 3 PA

tranylcypromine sulfate (generic of PARNATE)

1

trazodone hcl TABS 1

venlafaxine cap er (generic of EFFEXOR XR)

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

venlafaxine hcl 1

venlafaxine tab 1

VENLAFAXINE TAB 225MG ER

1

venlafaxine tab er (generic of VENLAFAXINE HCL ER)

1

VIIBRYD 2

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS

1

APOKYN 3 NM LA PA

AZILECT 2

benztropine mesylate (generic of COGENTIN) SOLN

1

benztropine mesylate TABS 1 PA

bromocriptine mesylate (generic of PARLODEL) CAPS

1

bromocriptine mesylate TABS

1

carbidopa (generic of LODOSYN) TABS

1

carbidopa-levodopa (generic of SINEMET) TABS

1

carbidopa-levodopa (generic of SINEMET CR) TBCR

1

carbidopa-levodopa TBDP 1

CARBIDOPA/LEVODOPA/ENTACAPONE

1


1


1


1


1


1

entacapone (generic of COMTAN)

1

MIRAPEX .75mg 3

MIRAPEX ER 2

NEUPRO 2

pramipexole dihydrochloride .75mg

1

Drug Name Drug Tier

Requirements/Limits

pramipexole dihydrochloride (generic of MIRAPEX) .125mg, .25mg, .5mg, 1mg, 1.5mg

1

ropinirole hydrochloride (generic of REQUIP) TABS

1

ropinirole hydrochloride (generic of REQUIP XL) TB24

1

selegiline hcl (generic of ELDEPRYL) CAPS

1

selegiline hcl TABS 1

trihexyphenidyl hcl 1 PA

ZELAPAR 2

ANTIPSYCHOTICS ABILIFY SOLN 1mg/ml 2 NM

ABILIFY SOLN 9.75mg/1.3ml

2

ABILIFY TABS 2 NM

ABILIFY DISCMELT 2 NM

ABILIFY MAIN INJ 300MG 3 NM

ABILIFY MAIN INJ 400MG 3 NM

chlorpromaz inj 25mg/ml 3

chlorpromazine hcl TABS 1

clozapine (generic of CLOZARIL) 25mg, 100mg

1

clozapine 50mg, 200mg 1

CLOZAPINE ODT 1

FANAPT 3

FANAPT TITRATION PACK 3

FAZACLO 3

fluphenazine decanoate SOLN

1

fluphenazine hcl 1

GEODON INJ 3

haloperidol TABS 1

haloperidol decanoate (generic of HALDOL DECANOATE 50) SOLN 50mg/ml

1

haloperidol decanoate (generic of HALDOL DECANOATE 100) SOLN 100mg/ml

1

haloperidol lactate CONC 1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

haloperidol lactate (generic of HALDOL) SOLN

1

INVEGA 3 NM

INVEGA SUST INJ 39 MG/0.25 ML

3


3 NM


3 NM

INVEGA SUST INJ 156MG/ML

3 NM


3 NM

LATUDA 2 NM

loxapine succinate 1

olanzapine (generic of ZYPREXA)

1

olanzapine odt (generic of ZYPREXA ZYDIS) 5mg, 10mg, 15mg

1

olanzapine odt (generic of ZYPREXA ZYDIS) 20mg

1 NM

ORAP 3

perphenazine TABS 1

quetiapine fumarate (generic of SEROQUEL)

1

RISPERDAL INJ 12.5MG 2

RISPERDAL INJ 25MG 2

RISPERDAL INJ 37.5MG 2 NM

RISPERDAL INJ 50MG 2 NM

risperidone (generic of RISPERDAL)

1

risperidone odt (generic of RISPERDAL M-TAB) .5mg, 1mg, 2mg, 3mg, 4mg

1

risperidone odt .25mg 1

SAPHRIS 3

SEROQUEL XR 2

thioridazine hcl TABS 1 PA

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ 3 NM

ziprasidone hcl (generic of GEODON)

1

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Drug Name Drug Tier

Requirements/Limits

amphetamine cap 10mg er (generic of ADDERALL XR)

1


1


1


1


1

amphetamine-dextroamphetamine cap sr 24hr 5 mg (generic of ADDERALL XR)

1

amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)

1

amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)

1


1

amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)

1


1


1


1

DAYTRANA 2

INTUNIV 2

metadate tab er 20 mg (generic of RITALIN SR)

1

METHYLIN CHEW TAB 2

methylphenidate hcl (generic of RITALIN LA) CP24

1

methylphenidate hcl (generic of METADATE CD) CPCR

1

methylphenidate hcl (generic of METHYLIN) SOLN

1

methylphenidate hcl (generic of RITALIN) TABS

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl TBCR 10mg

1

methylphenidate hcl (generic of CONCERTA) TBCR 18mg

1

methylphenidate hcl (generic of RITALIN SR) TBCR 20mg

1

methylphenidate hcl er (generic of CONCERTA)

1

QUILLIVANT XR 2

RITALIN LA 10mg 3

STRATTERA 2

VYVANSE 2

HYPNOTICS ROZEREM

QL (30 tabs / 30 days) 3 QL

SILENOR 3mg QL (60 tabs / 30 days)

2 QL

SILENOR 6mg QL (30 tabs / 30 days)

2 QL

temazepam (generic of RESTORIL) 7.5mg

QL (30 caps / 30 days) 90 day limit if >64 yr

1 QL PA

temazepam (generic of RESTORIL) 15mg

QL (60 caps / 30 days) 90 day limit if >64 yr

1 QL PA

zolpidem tartrate (generic of AMBIEN) TABS

QL (30 tabs / 30 days) 90 day limit if >64 yr

1 QL PA

MIGRAINE ALSUMA

QL (6 mL / 30 days) 3 QL

AXERT QL (12 tabs / 30 days)

3 QL

cafergot tab 1-100mg 2

dihydroergotamine mesylate (generic of D.H.E. 45) 1mg/ml

1

DIHYDROERGOTAMINE MESYLATE 4mg/ml

QL (8 mL / 30 days)

1 QL

ergomar 3

FROVA TAB 2.5MG QL (18 tabs / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

migergot 1

naratriptan hcl (generic of AMERGE)


1 QL

RELPAX QL (12 tabs / 30 days)

2 QL

rizatriptan benzoate (generic of MAXALT) TABS


1 QL

rizatriptan benzoate (generic of MAXALT-MLT) TBDP


1 QL

SUMATRIPTAN SUCCINATE SOAJ

QL (6 mL / 30 days)

1 QL

SUMATRIPTAN SUCCINATE SOCT

QL (6 mL / 30 days)

1 QL

SUMATRIPTAN SUCCINATE SOLN 5mg/act

QL (24 inhalers / 30 days)

1 QL

SUMATRIPTAN SUCCINATE SOLN 20mg/act

QL (12 inhalers / 30 days)

1 QL

sumatriptan succinate SOSY QL (6 mL / 30 days)

1 QL

sumatriptan succinate (generic of IMITREX) TABS


1 QL

sumatriptan succinate inj (generic of IMITREX STATDOSE SYSTEM) SOAJ

QL (6 mL / 30 days)

1 QL

SUMATRIPTAN SUCCINATE INJ SOCT

QL (6 mL / 30 days)

1 QL

sumatriptan succinate inj (generic of IMITREX) SOLN

QL (6 mL / 30 days)

1 QL

SUMAVEL DOSEPRO QL (6 mL / 30 days)

2 QL NM

TREXIMET QL (9 tabs / 30 days)

2 QL

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

zolmitriptan (generic of ZOMIG) TABS


1 QL

zolmitriptan odt (generic of ZOMIG ZMT)


1 QL

ZOMIG NASAL SPRAY QL (2 boxes / 30 days)

2 QL

MISCELLANEOUS BRISDELLE 3

EQUETRO 3

GRALISE 2

GRALISE STARTER 2

HETLIOZ 3 NM PA

HORIZANT 3

lithium carbonate CAPS 1

lithium carbonate TABS 1

lithium carbonate (generic of LITHOBID) TBCR 300mg

1

lithium carbonate TBCR 450mg

1

LITHIUM CITRATE 3

MESTINON SYRUP 2

MESTINON TIMESPAN 2

NUEDEXTA 2

pyridostigmine bromide (generic of MESTINON) TABS

1

riluzole (generic of RILUTEK) 1

SAVELLA 2

SAVELLA TITRATION PACK 2

XENAZINE 2 NM LA PA

MULTIPLE SCLEROSIS AGENTS AMPYRA 3 NM LA PA

AUBAGIO 3 NM PA

AVONEX 2 NM PA

AVONEX PEN 2 NM PA

BETASERON 3 NM PA

COPAXONE INJ 40MG/ML 2 NM PA

COPAXONE KIT 20MG/ML 2 NM PA

EXTAVIA 2 NM PA

GILENYA CAP 0.5MG 2 NM PA

REBIF 3 NM PA

REBIF TITRATION PACK 3 NM PA

TECFIDERA CAP 120MG 2 NM PA

Drug Name Drug Tier

Requirements/Limits

TECFIDERA CAP 240MG 2 NM PA

TECFIDERA MIS STARTER 2 NM PA

TYSABRI 3 NM LA PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1

cyclobenzaprine hcl TABS 5mg, 10mg

1 PA

dantrolene sodium (generic of DANTRIUM) CAPS 25mg, 50mg

1

dantrolene sodium CAPS 100mg

1

tizanidine (generic of ZANAFLEX) CAPS

1

tizanidine TABS 2mg 1

tizanidine (generic of ZANAFLEX) TABS 4mg

1

NARCOLEPSY/CATAPLEXY modafinil (generic of PROVIGIL) 100mg

1 PA

modafinil (generic of PROVIGIL) 200mg

1 NM PA

NUVIGIL 2 PA

XYREM QL (540 mL / 30 days)

2 QL NM LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium (generic of CAMPRAL)

1

buprenorphine hcl SUBL 1

buprenorphine hcl-naloxone hcl sl

1

buproban (generic of ZYBAN) 1

CHANTIX 2

CHANTIX STARTER PACK 2

disulfiram (generic of ANTABUSE) TABS

1

naloxone hcl SOLN 1

naltrexone hcl (generic of REVIA) TABS

1

NICOTROL INHALER 3

NICOTROL NS 3

SARAFEM 3

SUBOXONE MIS 2-0.5MG 3

SUBOXONE MIS 4-1MG 3


2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits


VIVITROL 3 PA

ZUBSOLV 2

ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM 2 PA

ANDROGEL 1% 3 PA

ANDROGEL 1.62% 3 PA

ANDROGEL GEL PUMP 1% 3 PA

androxy 3 PA

AVEED 3 NM PA

AXIRON 2 PA

depo-testosterone 100mg/ml 3 PA

FORTESTA 2 PA

oxandrolone (generic of OXANDRIN) TABS

1 PA

STRIANT 3 PA

TESTIM 3 PA

testosterone cypionate OIL 100mg/ml

1 PA

testosterone cypionate (generic of DEPO-TESTOSTERONE) OIL 200mg/ml

1 PA

testosterone enanthate OIL 1 PA

VOGELXO 3 PA

ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 2

APIDRA 2

APIDRA SOLOSTAR 2

BYDUREON SUSR 2

BYETTA 3

GAUZE PADS 2X2 2

HUMALOG 3

HUMALOG KWIKPEN 3

HUMALOG MIX 50/50 3

HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 75/25 3

HUMALOG MIX 75/25 KWIKPEN

3

HUMULIN 70/30 3

HUMULIN 70/30 PEN 3

HUMULIN N 3

HUMULIN N U-100 PEN 3

Drug Name Drug Tier

Requirements/Limits

HUMULIN R 3

HUMULIN R U-500 (CONCENTRATE)

2 NM

INSULIN PEN NEEDLES 2

INSULIN SAFETY NEEDLES 2

INSULIN SYRINGES 2

LANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 2

LEVEMIR FLEXPEN 2

NOVOLIN 70/30 2

NOVOLIN 70/30 RELION 3

NOVOLIN N 2

NOVOLIN N RELION 3

NOVOLIN R 2

NOVOLIN R RELION 3

NOVOLOG 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70/30 2

NOVOLOG MIX 70/30 PREFILL

2

NOVOLOG PENFILL 2

SYMLINPEN 60 QL (4 pens / 30 days)

2 QL

SYMLINPEN 120 QL (8 pens / 30 days)

2 QL

VICTOZA QL (3 pens / 30 days)

2 QL

ANTIDIABETICS, ORAL acarbose (generic of PRECOSE)

1

ACTOPLUS MET XR 15-1000MG

3

ACTOPLUS MET XR 30-1000MG

3

FARXIGA 3

glimepiride (generic of AMARYL)

1

glipizide (generic of GLUCOTROL) TABS

1

glipizide er (generic of GLUCOTROL XL)

1

glipizide-metformin 2.5-250 mg

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

glipizide-metformin 2.5-500 mg

1

glipizide-metformin 5-500mg 1

GLUMETZA 3

GLYSET 3

INVOKANA TAB 100MG 2

INVOKANA TAB 300MG 2

JANUMET 2

JANUMET XR TAB 50-500MG

2

JANUMET XR TAB 50-1000 2

JANUMET XR TAB 100-1000 2

JANUVIA 2

JENTADUETO 2

KAZANO 3

KOMBIGLYZE XR 2.5-1000MG

3

KOMBIGLYZE XR 5-500MG 3

KOMBIGLYZE XR 5-1000MG 3

metformin er (generic of GLUCOPHAGE XR)

1

metformin hcl (generic of GLUCOPHAGE) TABS

1

metformin hcl (generic of FORTAMET) TB24

1

nateglinide (generic of STARLIX)

1

NESINA 3

ONGLYZA 3

OSENI TAB 12.5-15MG 3



OSENI TAB 25-15MG 3

OSENI TAB 25-30MG 3

OSENI TAB 25-45MG 3

pioglitazone hcl (generic of ACTOS)

1

pioglitazone hcl-glimepiride (generic of DUETACT)

1

pioglitazone hcl-metformin hcl (generic of ACTOPLUS MET)

1

PRANDIMET 3

repaglinide (generic of PRANDIN)

1

Drug Name Drug Tier

Requirements/Limits

RIOMET 3

TRADJENTA 2

BISPHOSPHONATES ACTONEL 5mg, 30mg, 35mg

2

alendronate sodium SOLN 1

alendronate sodium TABS 5mg, 10mg, 35mg, 40mg

1

alendronate sodium (generic of FOSAMAX) TABS 70mg

1

ATELVIA 2

BINOSTO 3

FOSAMAX PLUS D 3

ibandronate sodium (generic of BONIVA)

1 B/D

pamidronate inj 6mg/ml 3 B/D

pamidronate inj 30/10ml 1 B/D

pamidronate inj 90/10ml 1 B/D

risedronate sodium (generic of ACTONEL)

1

zoledronic inj 4mg/5ml (generic of ZOMETA)

1 NM

zoledronic inj 5/100ml (generic of RECLAST)

1 B/D NM

ZOMETA SOLN 3 NM

CALCIUM RECEPTOR AGONISTS SENSIPAR 2 NM

CHELATING AGENTS CHEMET 3

DEPEN TITRATABS 3

EXJADE 3 NM LA PA

FERRIPROX 3 NM PA

kionex (generic of KAYEXALATE)

1

sodium polystyrene sulfonate 1

SYPRINE 3

CONTRACEPTIVES altavera 1

amethia 91 day (generic of SEASONIQUE)

1

amethyst 28 day 1

apri 28 day (generic of DESOGEN)

1

aranelle 28 (generic of TRI-NORINYL 28)

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

aviane 28 1

balziva 28 day (generic of OVCON-35)

1

BEYAZ 2

briellyn 28 day (generic of OVCON-35)

1

camila 28 day (generic of NOR-QD)

1

CAMRESE LO TAB 1

cryselle 28 1

cyclafem 1/35 28 day (generic of NORINYL 1+35)

1

cyclafem 7/7/7 28 day (generic of ORTHO-NOVUM 7/7/7)

1

DEPO-SUBQ PROVERA 104 2

drospirenone-ethinyl estradiol (generic of YASMIN 28)

1

ELLA 2

emoquette (generic of DESOGEN)

1

enpresse 28 day 1

errin 28 day (generic of ORTHO MICRONOR)

1

GENERESS FE 3

GIANVI TAB 3-0.02MG 1

gildagia (generic of OVCON-35)

1

heather (generic of NOR-QD) 1

introvale 91 day 1

JOLIVETTE 1

junel 1.5/30 21 day (generic of LOESTRIN 1.5/30-21)

1

junel 1/20 21 day (generic of LOESTRIN 1/20-21)

1

junel fe 1.5/30 28 day (generic of LOESTRIN FE 1.5/30)

1

junel fe 1/20 28 day (generic of LOESTRIN FE 1/20)

1

kariva 28 day (generic of MIRCETTE)

1

kelnor 1/35 28 day 1

larin 1/20 (generic of LOESTRIN 1/20-21)

1

larin fe 1.5/30 (generic of LOESTRIN FE 1.5/30)

1

Drug Name Drug Tier

Requirements/Limits

larin fe 1/20 (generic of LOESTRIN FE 1/20)

1

LEENA TAB 1

lessina 28 day 1

levonest 28 day 1

levonorgestrel (emergency oc) (generic of PLAN B ONE-STEP) 1.5mg

1

levonorgestrel (emergency oc) (generic of PLAN B) .75mg

1

levonorgestrel-ethinyl estradiol (91-day)

1

levora 0.15/30 28 day 1

LO LOESTRIN FE 2

LO MINASTRIN FE 3

lomedia 24 fe 1

loryna 28 day (generic of YAZ)

1

low-ogestrel 28 day 1

lutera 28 day 1

lyza (generic of ORTHO MICRONOR)

1

marlissa 28 day 1

medroxyprogesterone acetate (contraceptive) (generic of DEPO-PROVERA CONTRACEPTIV)

1

microgestin 1.5/30 21 day (generic of LOESTRIN 1.5/30-21)

1

microgestin 1/20 21 day (generic of LOESTRIN 1/20-21)

1

microgestin fe 1.5/30 28 day (generic of LOESTRIN FE 1.5/30)

1

microgestin fe 1/20 28 day (generic of LOESTRIN FE 1/20)

1

MINASTRIN 24 FE 2

MONONESSA 1

my way (generic of PLAN B ONE-STEP)

1

myzilra 1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

necon 0.5/35 28 day (generic of BREVICON-28)

1

necon 1/35 28 day (generic of NORINYL 1+35)

1

NECON 7/7/7 1

necon 10/11 28 day 3

NECON TAB 1/50-28 1

next choice tab 1.5mg (generic of PLAN B ONE-STEP)

1

NORA-BE TAB 1

norethindrone (contraceptive) (generic of NOR-QD)

1

norgestimate-ethinyl estradiol (triphasic) (generic of ORTHO TRI-CYCLEN)

1

nortrel 0.5/35 28 day (generic of BREVICON-28)

1

nortrel 1/35 21 day (generic of NORINYL 1+35)

1

nortrel 1/35 28 day (generic of NORINYL 1+35)

1

nortrel 7/7/7 28 day (generic of ORTHO-NOVUM 7/7/7)

1

NUVARING 2

OCELLA TAB 3-0.03MG 1

ogestrel 28 day 1

orsythia 28 day 1

ORTHO TRI-CYCLEN LO 2

philith (generic of OVCON-35) 1

pimtrea pack (generic of MIRCETTE)

1

pirmella 1/35 28 day (generic of NORINYL 1+35)

1

portia 28 day 1

previfem 28 day (generic of ORTHO-CYCLEN)

1

QUARTETTE 3

quasense 91 day 1

reclipsen 28 day (generic of DESOGEN)

1

SOLIA 1

sprintec 28 day (generic of ORTHO-CYCLEN)

1

sronyx 28 day 1

Drug Name Drug Tier

Requirements/Limits

syeda (generic of YASMIN 28)

1

tri-legest 28 day (generic of ESTROSTEP FE)

1

tri-previfem 28 day (generic of ORTHO TRI-CYCLEN)

1

tri-sprintec 28 day (generic of ORTHO TRI-CYCLEN)

1

TRINESSA 1

trivora 28 day 1

velivet 28 day (generic of CYCLESSA)

1

vestura (generic of YAZ) 1

viorele (generic of MIRCETTE)

1

vyfemia 28 day (generic of OVCON-35)

1

xulane dis 150-35 (generic of ORTHO EVRA)

1

zarah (generic of YASMIN 28) 1

zenchent fe 28 day (generic of FEMCON FE)

1

zenchent tab (generic of OVCON-35)

1

zovia 1/35e 28 day 1

zovia 1/50e 28 day 1

ENDOMETRIOSIS danazol CAPS 1

LUPANETA PACK 3 NM PA

SYNAREL 2 NM

ENZYME REPLACEMENTS ADAGEN 3 NM LA PA

ALDURAZYME 3 NM LA PA

CARBAGLU 3 NM LA PA

CEREZYME 3 NM PA

CYSTADANE 3 NM

CYSTAGON 3 NM PA

ELAPRASE 3 NM PA

ELELYSO 3 NM PA

FABRAZYME 3 NM PA

KUVAN 2 NM PA

levocarnitine (metabolic modifiers) (generic of CARNITOR)

1 B/D

LUMIZYME 3 NM PA

MYOZYME 3 NM PA

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

NAGLAZYME 3 NM LA PA

ORFADIN 3 NM PA

PROCYSBI 3 NM LA PA

sodium phenylbutyrate (generic of BUPHENYL)

1 NM

VIMIZIM 3 NM PA

VPRIV 3 NM PA

ZAVESCA 3 NM LA PA

ESTROGENS ALORA 3 PA

COMBIPATCH 3 PA

depo-estradiol 3

estrace CREA 2

estradiol (generic of CLIMARA) PTWK

1 PA

estradiol (generic of ESTRACE) TABS

1 PA

ESTRADIOL VALERATE OIL 10mg/ml

1

estradiol valerate (generic of DELESTROGEN) OIL 20mg/ml

1

ESTRADIOL VALERATE OIL 40mg/ml

1

ESTRING 3

FEMRING 3

MENOSTAR 3 PA

MINIVELLE 2 PA

PREMARIN 2 PA

PREMARIN CREAM 2

PREMARIN INJ 3

PREMPHASE 2 PA

PREMPRO 2 PA

VAGIFEM 2

VIVELLE-DOT 2 PA

GLUCOCORTICOIDS a-hydrocort 1

cortisone acetate TABS 1

DEPO-MEDROL INJ 20MG/ML

3 B/D

dexamethasone CONC 3

dexamethasone ELIX; SOLN; TABS

1

dexamethasone sodium phosphate

1

Drug Name Drug Tier

Requirements/Limits

dexpak taperpak 13 day 2

FLO-PRED SUS 3 B/D

fludrocortisone acetate TABS

1

hydrocortisone (generic of CORTEF) TABS

1

MEDROL TAB 2MG 3 B/D

methylpr ace inj 40mg/ml (generic of DEPO-MEDROL)

1 B/D

methylpr ace inj 80mg/ml (generic of DEPO-MEDROL)

1 B/D

methylpr ss inj 1gm (generic of SOLU-MEDROL)

1 B/D

methylpr ss inj 40mg (generic of SOLU-MEDROL)

1 B/D


1 B/D


1 B/D

methylpred pak 4mg (generic of MEDROL DOSEPAK)

1 B/D

methylpred tab 4mg (generic of MEDROL)

1 B/D


1 B/D


1 B/D


1 B/D

millipred 3 B/D

ORAPRED ODT TAB 10MG 2 B/D



pred sod pho sol 5mg/5ml (generic of PEDIAPRED)

1 B/D

prednisolone sol 15mg/5ml 1 B/D

prednisolone sol 25mg/5ml 1 B/D

prednisolone syrup 15 mg/5ml (generic of PRELONE)

1 B/D

prednisone con 5mg/ml 3 B/D

prednisone pak 5mg 1 B/D

prednisone pak 10mg 1 B/D

prednisone sol 5mg/5ml 1 B/D

prednisone tab 1mg 1 B/D

prednisone tab 2.5mg 1 B/D


2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits




RAYOS TAB 1MG 3 B/D

RAYOS TAB 2MG 3 B/D

RAYOS TAB 5MG 3 B/D

SOLU-CORTEF 3

SOLU-MEDROL INJ 2GM 3 B/D

veripred 3 B/D

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT

2

PROGLYCEM SUS 50MG/ML 3

HUMAN GROWTH HORMONES GENOTROPIN 3 NM PA

GENOTROPIN MINIQUICK 3 NM PA

HUMATROPE 2 NM PA

HUMATROPE COMBO PACK 2 NM PA

NORDITROPIN FLEXPRO 2 NM PA

NORDITROPIN NORDIFLEX PEN

2 NM PA

NUTROPIN AQ INJ 20MG/2ML

3 NM PA

NUTROPIN AQ NUSPIN 5 3 NM PA

NUTROPIN AQ PEN 3 NM PA

OMNITROPE 5.8MG 3 NM PA

OMNITROPE 5MG 3 NM PA

OMNITROPE 10MG 3 NM PA

SAIZEN 3 NM PA

SAIZEN CLICK.EASY 3 NM PA

SEROSTIM 3 NM PA

TEV-TROPIN 3 NM PA

ZORBTIVE 3 NM PA

MISCELLANEOUS cabergoline 1

calcitonin (salmon) nasal spray (generic of MIACALCIN)

1

CHORIONIC GONADOTROPIN SOLR

1 NM PA

EGRIFTA 2mg 3 NM PA

FORTICAL SPR 200/ACT 3

H.P. ACTHAR 3 NM PA

INCRELEX 3 NM LA PA

Drug Name Drug Tier

Requirements/Limits

KORLYM 3 NM LA PA

methylergonovine maleate (generic of METHERGINE) TABS

1

MIACALCIN INJ 200U/ML 2 B/D

MYALEPT 3 NM PA

NOVAREL INJ 10000UNT 1 NM PA

octreotide acetate (generic of SANDOSTATIN)

1 NM PA

PREGNYL W/DILUENT BENZYL

1 NM PA

PROLIA 3 NM

raloxifene hcl (generic of EVISTA)

1

RAVICTI 3 NM LA PA

SAMSCA 3 NM PA

SANDOSTATIN LAR DEPOT 3 NM PA

SIGNIFOR 3 NM PA

SOMATULINE DEPOT 3 NM PA

SOMAVERT 3 NM LA PA

SUPPRELIN LA 3 NM PA

XGEVA 3 NM PA

PARATHYROID HORMONES FORTEO 2 NM PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) (generic of PHOSLO) CAPS

1

calcium acetate (phosphate binder) (generic of ELIPHOS) TABS

1

FOSRENOL 3 NM

PHOSLYRA 2

RENAGEL 3

RENVELA PAK 2 NM

RENVELA TAB 800MG 2

VELPHORO 2

PROGESTINS CRINONE 2

ENDOMETRIN 3

MAKENA 3 NM PA

medroxyprogesterone acetate (generic of PROVERA)

1

norethindrone acetate (generic of AYGESTIN) TABS

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

progesterone micronized (generic of PROMETRIUM) CAPS

1

THYROID AGENTS levothyroxine sodium (generic of SYNTHROID) TABS

1

LEVOXYL 1

liothyronine sodium (generic of TRIOSTAT) SOLN

1

liothyronine sodium (generic of CYTOMEL) TABS

1

methimazole (generic of TAPAZOLE) TABS

1

propylthiouracil TABS 1

SYNTHROID 2

TIROSINT 3

UNITHROID 1

VASOPRESSINS DESMOPRESSIN ACETATE SOLN

1

desmopressin acetate (generic of DDAVP) TABS

1

desmopressin acetate inj (generic of DDAVP)

1

desmopressin acetate spray (generic of DDAVP)

1

desmopressin acetate spray refrigerated

1

STIMATE 3 NM PA

GASTROINTESTINAL ANTIEMETICS ALOXI 3

CESAMET 3 NM

compro supp 1

dronabinol (generic of MARINOL) 2.5mg, 5mg

1

dronabinol (generic of MARINOL) 10mg

1 NM

EMEND CAP 40MG 3

EMEND CAP 80MG 3

EMEND CAP 125MG 3

EMEND PAK 80 & 125 3

granisetron hcl SOLN 1

granisetron hcl TABS QL (30 tabs / 30 days)

1 QL

Drug Name Drug Tier

Requirements/Limits

granisol 2

meclizine hcl TABS 1

metoclopramide hcl SOLN 1

metoclopramide hcl (generic of REGLAN) TABS

1

metoclopramide hcl inj 5 mg/ml

1

METOZOLV ODT 3

ondansetron hcl (generic of ZOFRAN) SOLN

1

ondansetron hcl (generic of ZOFRAN) TABS 4mg, 8mg


1 QL

ondansetron hcl TABS 24mg 1

ondansetron hcl inj 1

ondansetron hcl inj 4 mg/2ml 1

ondansetron hcl oral soln (generic of ZOFRAN)

QL (450 mls / 30 days)

1 QL

ondansetron odt (generic of ZOFRAN ODT)


1 QL

phenadoz 1 PA

prochlorperazine inj 5 mg/ml 1

prochlorperazine maleate (generic of COMPAZINE) TABS

1

prochlorperazine supp 1

promethazine hcl (generic of PHENERGAN) SOLN

1 PA

promethazine hcl SUPP; SYRP; TABS

1 PA

promethegan 1 PA

SANCUSO QL (4 patches / 30 days)

2 QL NM

TRANSDERM-SCOP 2 PA

ANTISPASMODICS ATROPINE SULFATE SOLN .05mg/ml, .1mg/ml

1

BENTYL SOLN 3

CANTIL 3

CUVPOSA 3

dicyclomine hcl (generic of BENTYL) CAPS; TABS

1

dicyclomine hcl SOLN 1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

glycate 3

glycopyrrolate (generic of ROBINUL) SOLN

1

glycopyrrolate (generic of ROBINUL) TABS 1mg

1

glycopyrrolate (generic of ROBINUL FORTE) TABS 2mg

1

methscopolamine bromide (generic of PAMINE) TABS 2.5mg

1

methscopolamine bromide (generic of PAMINE FORTE) TABS 5mg

1

H2-RECEPTOR ANTAGONISTS cimetidine TABS 1

cimetidine sol 300/5ml 1

famotidine SOLN 20mg/2ml, 40mg/4ml, 200mg/20ml

1

famotidine (generic of PEPCID) SUSR

1

famotidine (generic of PEPCID) TABS 20mg, 40mg

1

nizatidine CAPS 150mg 1

nizatidine (generic of AXID) CAPS 300mg

1

nizatidine (generic of AXID) SOLN

1

ranitidine hcl CAPS 1

ranitidine hcl (generic of ZANTAC) SOLN

1

ranitidine hcl SYRP 1

ranitidine hcl (generic of ZANTAC) TABS 150mg, 300mg

1

INFLAMMATORY BOWEL DISEASE APRISO 2

ASACOL HD 3

balsalazide disodium (generic of COLAZAL)

1

budesonide (generic of ENTOCORT EC) CP24

1

CANASA 2

colocort (generic of CORTENEMA)

1

DELZICOL 3

Drug Name Drug Tier

Requirements/Limits

DIPENTUM 3

ENTYVIO 3 NM PA

GIAZO 3

HYDROCORTISONE (INTRARECTAL)

1

LIALDA 2

mesalamine enema ENEM 1

mesalamine enema (generic of ROWASA) KIT

1

PENTASA 2

SF-ROWASA 2

sulfasalazine dr (generic of AZULFIDINE EN-TABS)

1

sulfasalazine ir (generic of AZULFIDINE)

1

UCERIS 3 NM

LAXATIVES COLYTE-FLAVOR PACKS 3

constulose 1

enulose 1

gaviltye-g (generic of GOLYTELY)

1

gavilyte-c (generic of COLYTE-FLAVOR PACKS)

1

gavilyte-n (generic of NULYTELY/FLAVOR PACKS)

1

generlac 1

GOLYTELY 3

kristalose 3

lactulose 1

lactulose (encephalopathy) 1

MOVIPREP 2

NULYTELY/FLAVOR PACKS 3

OSMOPREP 3

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (generic of COLYTE-FLAVOR PACKS)

1

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (generic of GOLYTELY)

1

peg 3350-potassium chloride-sod bicarbonate-sod chloride (generic of NULYTELY/FLAVOR PACKS)

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

polyethylene glycol 3350 PACK; POWD

1

PREPOPIK 3

RELISTOR 2 PA

SUCLEAR 2

SUPREP BOWEL PREP 2

trilyte (generic of NULYTELY/FLAVOR PACKS)

1

MISCELLANEOUS AMITIZA 2

amoxicillin-clarithromycin w/ lansoprazole (generic of PREVPAC)

1

CARAFATE SUSP 2

cromolyn sodium (mastocytosis) (generic of GASTROCROM)

1

diphenoxylate w/ atropine LIQD

1

diphenoxylate w/ atropine (generic of LOMOTIL) TABS

1

GATTEX 3 NM LA PA

LINZESS 2

loperamide hcl CAPS 1

LOTRONEX 2 NM PA

misoprostol (generic of CYTOTEC) TABS

1

OMECLAMOX-PAK 3

PYLERA 2

SUCRAID 3

sucralfate (generic of CARAFATE) TABS

1

ursodiol (generic of ACTIGALL) CAPS

1

ursodiol (generic of URSO 250) TABS 250mg

1

ursodiol (generic of URSO FORTE) TABS 500mg

1

XIFAXAN TAB 550MG 2 NM PA

PANCREATIC ENZYMES CREON 2

PANCREAZE 3

PERTZYE 3

ULTRESA 2

VIOKACE 10 2

Drug Name Drug Tier

Requirements/Limits

VIOKACE 20 2

ZENPEP 2

PROTON PUMP INHIBITORS ACIPHEX SPR CAP 5MG 3

ACIPHEX SPR CAP 10MG 3

DEXILANT 2

esomeprazole sodium 20mg 1

esomeprazole sodium (generic of NEXIUM I.V.) 40mg

1

lansoprazole (generic of PREVACID) CPDR

1

NEXIUM GRA 2.5MG DR 2

NEXIUM GRA 5MG DR 2

NEXIUM GRA 10MG DR 2



omeprazole (generic of PRILOSEC) CPDR

1

OMEPRAZOLE-SODIUM BICARBONATE

1

pantoprazole sodium (generic of PROTONIX)

1

PREVACID SOLUTAB 3

PRILOSEC PACK 3

PROTONIX PACK 3

rabeprazole sodium (generic of ACIPHEX)

1

ZEGERID PACK 3

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL)

1

AVODART 2

CARDURA XL 3

finasteride (generic of PROSCAR) TABS 5mg

1

JALYN 3

RAPAFLO 2

tamsulosin hcl (generic of FLOMAX)

1

MISCELLANEOUS bethanechol chloride (generic of URECHOLINE) TABS

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

ELMIRON 2

POTASSIUM CITRATE (ALKALINIZER) TAB 540mg

1

POTASSIUM CITRATE (ALKALINIZER) TAB 1080mg

1

URINARY ANTISPASMODICS ENABLEX 3

GELNIQUE 2

MYRBETRIQ 3

oxybutynin chloride SYRP; TABS

1

oxybutynin chloride (generic of DITROPAN XL) TB24

1

OXYTROL 3

TOLTERODINE TARTRATE ER

1

tolterodine tartrate tab 1 mg (generic of DETROL)

1

tolterodine tartrate tab 2 mg (generic of DETROL)

1

TOVIAZ 3

trospium chloride 1

trospium chloride er 1

VESICARE 2

VAGINAL ANTI-INFECTIVES CLEOCIN VAG SUPP 100MG 2

clindamycin cre 2% vag (generic of CLEOCIN)

1

metronidazole vaginal (generic of METROGEL-VAGINAL)

1

miconazole nitrate vaginal 1

terconazole vaginal (generic of TERAZOL 7) CREA .4%

1

terconazole vaginal (generic of TERAZOL 3) CREA .8%

1

terconazole vaginal SUPP 1

VANDAZOLE 1

zazole (generic of TERAZOL 7) .4%

1

ZAZOLE .8% 1

HEMATOLOGIC ANTICOAGULANTS COUMADIN 3

Drug Name Drug Tier

Requirements/Limits

COUMADIN INJ 3

ELIQUIS TAB 2.5MG 2

ELIQUIS TAB 5MG 2

enoxaparin sodium (generic of LOVENOX)

1

fondaparinux sodium (generic of ARIXTRA)

1

FRAGMIN 2

HEP SOD/NACL INJ 25000 1

HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML

1

heparin sod inj 1000u/ml 1 B/D

HEPARIN SOD INJ 2000U/ML

3 B/D

HEPARIN SOD INJ 2500U/ML

3 B/D

heparin sod inj 5000u/0.5ml 1 B/D




HEPARIN SODIUM/D5W 1

HEPARIN SODIUM/NACL 0.45%

3

HEPARIN SODIUM/SODIUM CHL

1

jantoven (generic of COUMADIN)

1

PRADAXA 2

warfarin sodium (generic of COUMADIN)

1

XARELTO 2

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 2 NM PA

EPOGEN 2 NM PA

GRANIX 3 NM PA

LEUKINE 3 NM PA

MOZOBIL 2 NM PA

NEULASTA 2 NM PA

NEUMEGA 3 NM PA

NEUPOGEN 2 NM PA

PROCRIT 2 NM PA

MISCELLANEOUS anagrelide hcl 1mg 1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

anagrelide hcl (generic of AGRYLIN) .5mg

1

BERINERT 3 NM PA

cilostazol (generic of PLETAL) 1

CINRYZE 3 NM LA PA

DESFERAL 2gm 3 NM PA

FIRAZYR 2 NM PA

KALBITOR 3 NM PA

NPLATE 250mcg 3 NM PA

pentoxifylline TBCR 1

PROMACTA 2 NM LA PA

SOLIRIS 2 NM PA

tranexamic acid (generic of CYKLOKAPRON) SOLN

1

tranexamic acid (generic of LYSTEDA) TABS

1

PLATELET AGGREGATION INHIBITORS AGGRENOX 2

BRILINTA 2

clopidogrel bisulfate (generic of PLAVIX)

1

EFFIENT 2

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA 3 NM PA

CIMZIA 3 NM PA

ENBREL 2 NM PA

ENBREL SURECLICK 2 NM PA

HUMIRA 2 NM PA

HUMIRA PEN 2 NM PA

HUMIRA PEN-CROHNS STARTER KIT

2 NM PA

HUMIRA PEN-PSORIASIS STARTER KIT

2 NM PA

hydroxychloroquine sulfate (generic of PLAQUENIL)

1

KINERET 3 NM PA

leflunomide (generic of ARAVA) TABS

1

methotrexate sodium tabs 1

ORENCIA 3 NM PA

OTEZLA 3 NM PA

OTREXUP 3 NM PA

REMICADE 3 NM PA

Drug Name Drug Tier

Requirements/Limits

RHEUMATREX 2

SIMPONI 3 NM PA

SIMPONI ARIA 3 NM PA

trexall 2

XELJANZ 3 NM PA

IMMUNOGLOBULINS BIVIGAM 10gm/100ml 3 NM PA

CARIMUNE NANOFILTERED 3 NM PA

CYTOGAM 3 NM PA

FLEBOGAMMA 3 NM PA

FLEBOGAMMA DIF 3 NM PA

GAMASTAN S/D 2 NM

GAMMAGARD LIQUID 3 NM PA

GAMMAGARD S/D 3 NM PA

GAMMAGARD S/D IGA LESS TH

3 NM PA

GAMMAKED 3 NM PA

GAMMAPLEX 2.5gm/50ml, 5gm/100ml, 10gm/200ml

3 NM PA

GAMUNEX-C 3 NM PA

GAMUNEX-C 1GM/10ML 3 NM PA

HIZENTRA 1gm/5ml 3 NM PA

OCTAGAM 3 NM PA

PRIVIGEN 3 NM PA

IMMUNOMODULATORS ACTIMMUNE 3 NM LA PA

ARCALYST 3 NM PA

ILARIS 2 NM PA

INTRON-A INJ 10MU 2 NM




PEG-INTRON 2 NM PA

PEG-INTRON REDIPEN 2 NM PA

PEGASYS SOLN 2 NM PA

PEGASYS PROCLICK 2 NM PA

REVLIMID 2 NM LA PA

THALOMID 2 NM PA

IMMUNOSUPPRESSANTS ASTAGRAF XL 3

ATGAM 3

azasan 2

azathioprine (generic of IMURAN) TABS

1

CELLCEPT INTRAVENOUS 3

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

CELLCEPT SUSP 2

cyclosporine (generic of SANDIMMUNE) CAPS; SOLN

1

cyclosporine modified (for microemulsion) (generic of NEORAL) CAPS 25mg, 100mg

1

cyclosporine modified (for microemulsion) CAPS 50mg

1

cyclosporine modified (for microemulsion) (generic of NEORAL) SOLN

1

gengraf (generic of NEORAL) 1

mycophenolate mofetil (generic of CELLCEPT)

1

mycophenolate sodium (generic of MYFORTIC)

1

NEORAL 2

NULOJIX 3

PROGRAF CAPS 5mg 3

PROGRAF CAPS .5mg, 1mg

2

PROGRAF SOLN 3

RAPAMUNE SOLN 2

RAPAMUNE TABS 1mg, 2mg

2

SANDIMMUNE CAPS 2

SANDIMMUNE SOLN 2

SIMULECT 3

sirolimus tab 0.5 mg (generic of RAPAMUNE)

1

tacrolimus (generic of PROGRAF) CAPS

1

THYMOGLOBULIN 3

ZORTRESS TAB 0.5MG 3



MISCELLANEOUS BENLYSTA 3 NM PA

SYLVANT 3 NM PA

VACCINES ACTHIB 3

ADACEL 3

BCG VACCINE 3

Drug Name Drug Tier

Requirements/Limits

BOOSTRIX 3

CERVARIX 3

COMVAX 3

DAPTACEL 3

DIPHTHERIA/TETANUS TOXOID

3

ENGERIX-B SUSP 3

GARDASIL 3

HAVRIX 3

HIBERIX 3

IMOVAX RABIES (H.D.C.V.) 3

INFANRIX 3

IPOL INACTIVATED IPV 2

IXIARO 3

M-M-R II W/DILUENT 10 DOS

3

MENACTRA 3

MENOMUNE-A/C/Y/W-135 3

MENVEO 3

PEDVAX HIB 3

PROQUAD 3

RABAVERT 3

RECOMBIVAX HB 3

ROTARIX 2

ROTATEQ 3

SYNAGIS 3 NM

TENIVAC 3

TETANUS TOXOID ADSORBED

3

TETANUS/DIPHTHERIA TOXOID

3

TWINRIX INJ 3

TYPHIM VI 3

VAQTA 3

VARIVAX 3

YF-VAX 3

ZOSTAVAX 3

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 3

KLOR-CON 8 1

KLOR-CON 10 1

klor-con m15 3

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

klor-con m20 1

klor-con pow 20meq 1

MAGNESIUM SULFATE SOLN 40mg/ml, 80mg/ml

3

magnesium sulfate SOLN 50%

1

MAGNESIUM SULFATE IN D5W

3

potassium chloride LIQD 1

POTASSIUM CHLORIDE TBCR

1

potassium chloride caps er (generic of MICRO-K)

1

potassium chloride microencapsulated crystals cr

1

SODIUM CHLORIDE SOLN 2.5meq/ml

1

SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN

1

TPN ELECTROLYTES 1

IV NUTRITION AMINOSYN 3

AMINOSYN 7%/ELECTROLYTES

3

AMINOSYN II 3

AMINOSYN II 8.5%/ELECTROL

1

AMINOSYN INJ 8.5/LYTE 1

AMINOSYN M 3

AMINOSYN-HBC 3

AMINOSYN-PF 3

AMINOSYN-PF 7% 3

AMINOSYN-RF 3

CLINIMIX 2.75%/DEXTROSE 5%

3


3


3


3


3

CLINIMIX 5%/DEXTROSE 15%

3

Drug Name Drug Tier

Requirements/Limits


3


3

CLINIMIX E 2.75%/DEXTROSE 5%

3


3

CLINIMIX E 4.25%/DEXTROSE

3


3


3

CLINIMIX E 5%/DEXTROSE 15%

3


3


3

clinisol 15 1

FREAMINE HBC 6.9% 3

FREAMINE III 3

HEPATAMINE 1

hepatasol 8 1

INTRALIPID INJ 20% 1

INTRALIPID INJ 30% 3

LIPOSYN III INJ 10% 3

NEPHRAMINE 3

premasol 6% 1

premasol 10% 3

PROCALAMINE 3

PROSOL 3

travasol 10 3

TROPHAMINE INJ 10% 3

IV REPLACEMENT SOLUTIONS DEXTROSE SOLN 50% 1

dextrose SOLN 70% 1

DEXTROSE 2.5%/NACL 0.45%

1

DEXTROSE 5% 1

DEXTROSE 5% /ELECTROLYTE

3

DEXTROSE 5%/LACTATED RING

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

DEXTROSE 5%/NACL 0.2% 1





DEXTROSE 5%/NACL 0.225%

1

DEXTROSE 5%/POTASSIUM CHL

1

DEXTROSE 10% FLEX CONTAIN

1

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

3

DEXTROSE 10%/NACL 0.45%

1

ELECTROLYTE-R IN DEXTROSE

3

IONOSOL-B/DEXTROSE 5% 3

IONOSOL-MB/DEXTROSE 5%

3

ISOLYTE P 3

isolyte s 3

KCL0.15%/D5W/NACL0.2% 1

KCL0.15%/D5W/NACL0.225%

3

kcl 0.3%/d5w/lr iv lac ri 3

KCL 0.3%/D5W/NACL 0.9% 3

KCL 0.3%/D5W/NACL 0.45% 1

KCL 0.15%/D5W/LR 3

KCL 0.15%/D5W/NACL 0.9% 1

KCL 0.075%/D5W/NACL 0.45%

1

LACTATED RINGERS VIAFLEX

1

normosol-m 1

NORMOSOL-R 3

PLASMA-LYTE A 3

PLASMA-LYTE-56/D5W 3

PLASMA-LYTE-148 3

potassium chloride SOLN 1

POTASSIUM CHLORIDE 0.3%/D

1

POTASSIUM CHLORIDE 0.15%

1

Drug Name Drug Tier

Requirements/Limits

POTASSIUM CHLORIDE 0.22%

1

potassium chloride in nacl 1

POTASSIUM CHLORIDE IN NACL

1

RINGER'S 1

SODIUM CHLORIDE SOLN .9%, 3%, 5%

1

SODIUM CHLORIDE 0.45% VIA

1

VITAMINS calcitriol (generic of ROCALTROL) CAPS

1 B/D

calcitriol SOLN 1mcg/ml 1 B/D

calcitriol (generic of ROCALTROL) SOLN 1mcg/ml

1 B/D

doxercalciferol (generic of HECTOROL)

1 B/D

paricalcitol (generic of ZEMPLAR)

1 B/D

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

1

ZEMPLAR SOLN 3 B/D

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 1

blephamide OINT 3

BLEPHAMIDE SUSP 3

neomycin-polymy-dexameth (generic of MAXITROL)

1

neomycin-polymyxin-hc (ophth)

1

PRED-G 3

PRED-G S.O.P. 3

sulfacetamide sod-prednisolone

1

TOBRADEX OINT 2

TOBRADEX ST 2

tobramycin-dexamethasone (generic of TOBRADEX)

1

ZYLET 2

ANTI-INFECTIVES AZASITE 3

bacitracin (ophthalmic) 1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

bacitracin-polymyxin b (ophth) 1

BESIVANCE 2

CILOXAN OIN 0.3% OP 3

ciprofloxacin hcl (ophth) (generic of CILOXAN)

1

erythromycin (ophth) 1

gatifloxacin (ophth) (generic of ZYMAXID)

1

gentak 1

gentamicin sulfate (ophth) OINT

1

gentamicin sulfate (ophth) (generic of GARAMYCIN) SOLN

1

levofloxacin (ophth) 1

MOXEZA 2

NATACYN 2

neomycin-bacitracin zn-polymyxin

1

neomycin-polymy-gramicid (generic of NEOSPORIN)

1

ofloxacin (ophth) (generic of OCUFLOX)

1

polymyxin b-trimethoprim (generic of POLYTRIM)

1

sulfacetamide sodium (ophth) OINT

1

sulfacetamide sodium (ophth) (generic of BLEPH-10) SOLN

1

tobramycin sulfate (ophth) (generic of TOBREX)

1

TOBREX OINT 0.3% 3

trifluridine (generic of VIROPTIC) SOLN

1

VIGAMOX 2

ZIRGAN 3

ANTI-INFLAMMATORIES ACUVAIL 3

ALREX 2

bromfenac sodium (ophth) 1

BROMFENAC SODIUM (OPHTH)(ONCE-DAILY)

1

dexamethasone sodium phosphate (ophth)

1

Drug Name Drug Tier

Requirements/Limits

diclofenac sodium (ophth) 1

DUREZOL 2

FLAREX 3

FLUOROMETHOLONE (OPHTH)

1

flurbiprofen sodium (generic of OCUFEN)

1

FML 3

FML FORTE 3

ILEVRO 3

ketorolac tromethamine (ophth) (generic of ACULAR LS) .4%

1

ketorolac tromethamine (ophth) (generic of ACULAR) .5%

1

LOTEMAX 2

MAXIDEX 3

NEVANAC 3

PRED MILD 3

PREDNISOLONE ACETATE (OPHTH)

1

prednisolone sodium phosphate (ophth)

3

VEXOL 3

ANTIALLERGICS ALOCRIL 3

ALOMIDE 3

azelastine hcl (ophth) (generic of OPTIVAR)

1

BEPREVE 3

cromolyn sodium (ophth) 1

EMADINE 3

epinastine hcl (ophth) (generic of ELESTAT)

1

LASTACAFT 3

PATADAY 2

PATANOL 2

ANTIGLAUCOMA ALPHAGAN P 0.1% 2

ALPHAGAN P 0.15% 2

AZOPT 2

betaxolol hcl (ophth) 1

BETIMOL 2

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

BETOPTIC-S 2

brimonidine sol 0.2% 1

BRIMONIDINE SOL 0.15% 1

carteolol hcl (ophth) 1

COMBIGAN 2

COSOPT PF 2

dorzolamide hcl (generic of TRUSOPT)

1

dorzolamide hcl-timolol maleate (generic of COSOPT)

1

ISTALOL 3

latanoprost (generic of XALATAN)

1

levobunolol hcl (generic of BETAGAN) .5%

1

LEVOBUNOLOL HCL .25% 1

LUMIGAN 3

metipranolol 1

PHOSPHOLINE IODIDE 3

PILOCARPINE HCL SOLN 1

SIMBRINZA SUS 1-0.2% 2

timolol maleate (ophth) (generic of TIMOPTIC)

1

TIMOLOL MALEATE GEL 1

TIMOPTIC OCUDOSE 3

TRAVATAN Z 2

ZIOPTAN 2

MISCELLANEOUS BOTOX INJ 100UNIT 3 NM PA

CYSTARAN 3 NM PA

DYSPORT 3 NM PA

EYLEA 3 NM PA

LACRISERT 3

LUCENTIS 3 NM PA

MYOBLOC 2500unit/0.5ml 3 NM PA

naphazoline 0.1% 1

PROLENSA 3

proparacaine hcl (generic of ALCAINE) SOLN

1

RESTASIS 2

XEOMIN 3 NM PA

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS

Drug Name Drug Tier

Requirements/Limits

ANORO ELLIPT AER 62.5-25 2

COMBIVENT RESPIMAT 2

ipratropium-albuterol 1

ANTICHOLINERGICS ATROVENT HFA 3

ipratropium bromide (nasal) (generic of ATROVENT)

1

ipratropium sol inhal 1

SPIRIVA HANDIHALER 2

TUDORZA PRESSAIR 3

ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB 2.5-120 3

CLARINEX-D TAB 5-240MG 3

DYMISTA SPR 137-50 3

SEMPREX-D 3

ANTIHISTAMINES ASTEPRO 2

azelastine spr 0.1% 1

azelastine spr 0.15% (generic of ASTEPRO)

1

cetirizine syrup 1

CLARINEX SYRP 3

desloratadine (generic of CLARINEX) TABS

1

desloratadine (generic of CLARINEX REDITABS) TBDP

1

diphenhydram inj 50mg/ml 1

hydroxyzine hcl SOLN; TABS

1 PA

hydroxyzine pamoate (generic of VISTARIL) CAPS 25mg, 50mg

1 PA

hydroxyzine pamoate CAPS 100mg

1 PA

levocetirizine soln 2.5mg/5ml (generic of XYZAL)

1

levocetirizine tab 5 mg (generic of XYZAL)

1

PATANASE 2

BETA AGONISTS albuterol sulfate NEBU; SYRP; TABS

1

albuterol sulfate er (generic of VOSPIRE ER)

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

ARCAPTA NEOHALER 2

BROVANA 3

FORADIL AEROLIZER 2

levalbuterol conc 1.25mg/0.5ml (generic of XOPENEX CONCENTRATE)

1

LEVALBUTEROL HCL 1.25mg/3ml

1

levalbuterol hcl (generic of XOPENEX) .31mg/3ml, .63mg/3ml

1

PERFOROMIST 2

PROAIR HFA 2

PROVENTIL HFA 2

SEREVENT DISKUS 2

terbutaline sulfate SOLN; TABS

1

VENTOLIN HFA 3

XOPENEX HFA 3

LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium (generic of SINGULAIR) CHEW; PACK; TABS

1

zafirlukast (generic of ACCOLATE)

1

ZYFLO CR 3

MAST CELL STABILIZERS cromolyn sodium NEBU 1

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

1

ARALAST NP 3 NM LA PA

AUVI-Q 2

DALIRESP 2

EPINEPHRINE SOAJ 1

EPIPEN 2-PAK 2

EPIPEN-JR 2-PAK 2

GLASSIA 3 NM LA PA

KALYDECO 3 NM PA

PROLASTIN-C 3 NM LA PA

PULMOZYME 2 NM

tyzine .05% 3

XOLAIR 2 NM LA PA

ZEMAIRA 3 NM LA PA

Drug Name Drug Tier

Requirements/Limits

NASAL STEROIDS BECONASE AQ 3

budesonide (nasal) (generic of RHINOCORT AQUA)

1

flunisolide (nasal) 1

fluticasone propionate (nasal) (generic of FLONASE)

1

NASONEX 2

OMNARIS 3

QNASL 3

triamcinolone acetonide (nasal)

1

VERAMYST 3

ZETONNA 3

STEROID INHALANTS AEROSPAN 3

ALVESCO 3

ASMANEX 2

ASMANEX 14 METERED DOSES

2

budesonide (inhalation) (generic of PULMICORT)

1

FLOVENT DISKUS 2

FLOVENT HFA 2

PULMICORT FLEXHALER 2

PULMICORT INH SUSP 1MG/2ML

3

QVAR 2

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS 2

ADVAIR HFA 2

BREO ELLIPTA 3

DULERA 2

SYMBICORT 2

XANTHINES aminophylline inj 1

elixophyllin 2

LUFYLLIN 3

theo-24 2

theophylline 1

TOPICAL DERMATOLOGY, ACNE

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

ABSORICA 3

ACANYA 2

ACZONE 3

adapalene (generic of DIFFERIN) CREA

1

adapalene (generic of DIFFERIN) GEL .1%

1

ADAPALENE GEL .3% 1

AKNE-MYCIN 3

amnesteem 1

ATRALIN 2 PA

AVITA CREA 1 PA

AVITA GEL 1 PA

AZELEX 3

benzoyl peroxide-erythromycin (generic of BENZAMYCIN)

1

claravis 1

clindamycin phosphate (topical) (generic of EVOCLIN) FOAM

1

clindamycin phosphate (topical) (generic of CLEOCIN-T) GEL; LOTN; SOLN; SWAB

1

clindamycin phosphate-benzoyl peroxide (generic of BENZACLIN)

1

DIFFERIN LOTN 2

EPIDUO 2

ery pad 2% 1

erythromycin (acne aid) (generic of ERYGEL) GEL

1

erythromycin (acne aid) SOLN

1

FABIOR 3

myorisan 1

RETIN-A MICRO PUMP .08%

2 PA

sulfacetamide sodium (acne) (generic of KLARON)

1

tretin-x CREA 3 PA

tretinoin (generic of RETIN-A) CREA; GEL

1 PA

TRETINOIN MICROSPHERE 1 PA

VELTIN 3 PA

Drug Name Drug Tier

Requirements/Limits

zenatane 1

ZIANA 3 PA

DERMATOLOGY, ANTIBIOTICS ALTABAX 3

BACTROBAN NASAL 3

CENTANY 3

CORTISPORIN CREA; OINT

3

gentamicin sulfate (topical) 1

mafenide acetate (generic of SULFAMYLON) PACK

1

mupirocin (generic of BACTROBAN) OINT

1

mupirocin calcium (topical) (generic of BACTROBAN)

1

SILVER SULFADIAZINE CREA

1

SSD 1

SULFAMYLON CREA 3

DERMATOLOGY, ANTIFUNGALS ciclopirox GEL 1

ciclopirox cre 0.77% 1

ciclopirox shampoo 1% (generic of LOPROX SHAMPOO)

1

ciclopirox sus 0.77% 1

clotrimazole (topical) 1

econazole nitrate CREA 1

ERTACZO 3

EXELDERM 3

ketoconazole (topical) 1

LUZU 3

MENTAX 2

NAFTIN 3

nyamyc 1

nystatin (topical) 1

nystatin pow 100000 1

nystop 1

OXISTAT 3

pedi-dri 1

DERMATOLOGY, ANTIPRURITIC CORTIFOAM 2

procto-pak 1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

proctozone hc (generic of ANUSOL-HC)

1

PRUDOXIN CRE 5% 1

DERMATOLOGY, ANTIPSORIATICS acitretin (generic of SORIATANE)

1 NM

calcipotriene (generic of DOVONEX) CREA

1

calcipotriene OINT; SOLN 1

calcitrene oin 0.005% 1

CALCITRIOL OINT 1

methoxsalen rapid (generic of OXSORALEN ULTRA)

1

8-MOP 3

SORILUX 2

STELARA 3 NM PA

TAZORAC 2 PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo (generic of NIZORAL)

1

selenium sulfide LOTN 1

DERMATOLOGY, ANTIVIRALS acyclovir topical (generic of ZOVIRAX)

1

DENAVIR 3

XERESE 3

ZOVIRAX CREA 3

DERMATOLOGY, CORTICOSTEROIDS ala-cort 1

alclometasone dipropionate (generic of ACLOVATE) CREA

1

alclometasone dipropionate OINT

1

amcinonide CREA; LOTN 1

amcinonide OINT 3

apexicon 3

betamethasone dipropionate (topical)

1

betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA

1

betamethasone dipropionate augmented GEL

1

Drug Name Drug Tier

Requirements/Limits

betamethasone dipropionate augmented (generic of DIPROLENE) LOTN; OINT

1

betamethasone valerate CREA; LOTN; OINT

1

betamethasone valerate (generic of LUXIQ) FOAM

1

calcipotrien oin betameth (generic of TACLONEX)

1

CAPEX 2

clobetasol propionate (generic of TEMOVATE) CREA; GEL; OINT; SOLN

1

clobetasol propionate (generic of OLUX) FOAM

1

clobetasol propionate (generic of CLOBEX) LOTN; SHAM

1

clobetasol propionate emollient base (generic of TEMOVATE E)

1

clobetasol propionate emulsion (generic of OLUX-E)

1

CLOBEX LIQD 2

clocortolone pivalate 1

CORDRAN TAPE 3

DESONATE 3

DESONIDE CREA 1

desonide (generic of DESOWEN) LOTN; OINT

1

desoximetasone (generic of TOPICORT) CREA

1

desoximetasone (generic of TOPICORT) GEL

1

DESOXIMETASONE OINT .05%

1

desoximetasone (generic of TOPICORT) OINT .25%

1

diflorasone diacetate 1

fluocinolone acetonide CREA .01%

1

fluocinolone acetonide (generic of SYNALAR) CREA .025%

1

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

fluocinolone acetonide (generic of DERMA-SMOOTHE/FS BODY) OIL

1

fluocinolone acetonide (generic of SYNALAR) OINT

1

fluocinolone acetonide (generic of SYNALAR) SOLN

1

fluocinonide (generic of VANOS) CREA .1%

1

fluocinonide CREA .05% 1

fluocinonide GEL 1

fluocinonide OINT 1

fluocinonide SOLN 1

fluocinonide emulsified base 1

fluticasone propionate (generic of CUTIVATE) CREA; LOTN; OINT

1

halobetasol propionate (generic of ULTRAVATE)

1

HALOG 3

hydrocortisone (topical) 1

hydrocortisone butyrate (generic of LOCOID)

1

hydrocortisone butyrate hydrophilic lipo base (generic of LOCOID LIPOCREAM)

1

hydrocortisone valerate CREA

1

hydrocortisone valerate (generic of WESTCORT) OINT

1

KENALOG 3

LOKARA LOTN 0.05% 1

mometasone furoate (generic of ELOCON) CREA; OINT; SOLN

1

PANDEL 3

PREDNICARBATE CREA 1

prednicarbate (generic of DERMATOP) OINT

1

TACLONEX SUSP 3

texacort 2

TOPICORT LIQD 3

Drug Name Drug Tier

Requirements/Limits

triamcinolone acetonide (topical)

1

triderm 1

u-cort 1

DERMATOLOGY, LOCAL ANESTHETICS lidocaine OINT 1

lidocaine (generic of LIDODERM) PTCH

1 PA

lidocaine hcl GEL 1

lidocaine hcl (generic of XYLOCAINE) SOLN 4%

1

lidocaine-prilocaine (generic of EMLA)

1 B/D

SYNERA 3

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate (generic of LAC-HYDRIN) CREA; LOTN

1

CARAC 2

CONDYLOX GEL 2

diclofenac gel 3% (generic of SOLARAZE)

1 NM

diclofenac sol 1.5% (generic of PENNSAID)

1

ELIDEL 2

FINACEA 2

fluorouracil (topical) (generic of EFUDEX) CREA

1

fluorouracil (topical) SOLN 1

imiquimod (generic of ALDARA) CREA

1

laclotion lot 12% (generic of LAC-HYDRIN)

1

metronidazole (topical) (generic of METROCREAM) CREA

1

metronidazole (topical) (generic of METROGEL) GEL 1%

1

metronidazole (topical) GEL .75%

1

metronidazole (topical) (generic of METROLOTION) LOTN

1

NORITATE 3

2015 CalPERS eff 01/01/2015


Drug Name Drug Tier

Requirements/Limits

ORACEA 2

OXSORALEN 3

PANRETIN 3

PENNSAID 2% 2

PICATO 2

podofilox (generic of CONDYLOX) SOLN

1

PROTOPIC 2

RECTIV 3

rosadan cre 0.75% (generic of METROCREAM)

1

TARGRETIN GEL 3 NM PA

VALCHLOR 3 NM LA PA

VOLTAREN GEL 1% 2

ZYCLARA 2

DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 3

malathion (generic of OVIDE) 1

permethrin (generic of ELIMITE) CREA

1

SKLICE 3

ULESFIA 3

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1

neomycin/polymyxin b gu (generic of NEOSPORIN GU IRRIGANT)

1

REGRANEX 3 NM

SANTYL 3

SODIUM CHLORIDE 0.9% 1

STERILE WATER IRRIGATION

1

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl (generic of EVOXAC)

1

chlorhexidine gluconate (mouth-throat) (generic of PERIDEX)

1

clotrimazole TROC 1

lidocaine hcl (mouth-throat) 1

nystatin (mouth-throat) 1

periogard soln 0.12% (generic of PERIDEX)

1

Drug Name Drug Tier

Requirements/Limits

pilocarpine hcl (oral) (generic of SALAGEN)

1

triamcinolone acetonide (mouth)

1

OTIC acetasol hc (generic of VOSOL HC)

1

acetic acid (otic) 1

acetic acid sol/hc (generic of VOSOL HC)

1

acetic acid-aluminum acetate 1

CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 3

CORTISPORIN-TC 3

fluocinolone acetonide (otic) (generic of DERMOTIC)

1

neomycin-polymyxin-hc (otic) (generic of CORTISPORIN) SOLN

1

neomycin-polymyxin-hc (otic) SUSP

1

ofloxacin (otic) 1

2015 CalPERS eff 01/01/2015

Index 8 8-MOP .............................. 43 A abacavir sulfate ...................6 abacavir sulfate-lamivudine-zidovudine ..........................................7 ABELCET............................6 ABILIFY............................. 21 ABILIFY DISCMELT ......... 21 ABILIFY MAIN INJ 300MG 21 ABILIFY MAIN INJ 400MG 21 ABRAXANE ...................... 11 ABSORICA ....................... 42 ABSTRAL............................2 acamprosate calcium ........ 24 ACANYA ........................... 42 acarbose ........................... 25 ACCOLATE

see zafirlukast ............... 41 ACCUPRIL

see quinapril hcl ............ 13 ACCURETIC

see quinapril-hydrochlorothiazide .................................. 13

acebutolol hcl .................... 15 ACEON

see perindopril erbumine ...................................... 13

acetaminophen w/ codeine .1 acetasol hc ........................ 45 acetazolamide ................... 16 acetazolamide sodium ...... 16 acetic acid ......................... 45 acetic acid (otic) ................ 45 acetic acid sol/hc ............... 45 acetic acid-aluminum acetate .......................................... 45 acetylcysteine ................... 41 ACIPHEX

see rabeprazole sodium 33 ACIPHEX SPR CAP 10MG .......................................... 33 ACIPHEX SPR CAP 5MG . 33 acitretin ............................. 43 ACLOVATE

see alclometasone dipropionate .................. 43

ACTEMRA ........................ 35 ACTHIB ............................. 36 ACTIGALL

see ursodiol ................... 33 ACTIMMUNE .................... 35 ACTIQ

see fentanyl citrate .......... 2 ACTONEL ......................... 26

see risedronate sodium . 26 ACTOPLUS MET

see pioglitazone hcl-metformin hcl ........... 26

ACTOPLUS MET XR 15-1000MG ....................... 25 ACTOPLUS MET XR 30-1000MG ....................... 25 ACTOS

see pioglitazone hcl ....... 26 ACULAR

see ketorolac tromethamine (ophth) .... 39

ACULAR LS see ketorolac tromethamine (ophth) .... 39

ACUVAIL .......................... 39 acyclovir .............................. 7 acyclovir sodium ................. 7 acyclovir topical ................ 43 ACZONE ........................... 42 ADACEL ........................... 36 ADAGEN ........................... 28 ADALAT CC

see afeditab cr ............... 16 see nifedipine ................ 16

adapalene ......................... 42 ADAPALENE .................... 42 ADCIRCA .......................... 17 ADDERALL

see amphetamine-dextroamphetamine tab 10 mg......... 22 see amphetamine-dextroamphetamine tab 12.5 mg...... 22 see

amphetamine-dextroamphetamine tab 15 mg ........ 22 see amphetamine-dextroamphetamine tab 20 mg ........ 22 see amphetamine-dextroamphetamine tab 30 mg ........ 22 see amphetamine-dextroamphetamine tab 5 mg .......... 22 see amphetamine-dextroamphetamine tab 7.5 mg ....... 22

ADDERALL XR see amphetamine cap 10mg er ......................... 22 see amphetamine cap 15mg er ......................... 22 see amphetamine cap 20mg er ......................... 22 see amphetamine cap 25mg er ......................... 22 see amphetamine cap 30mg er ......................... 22 see amphetamine-dextroamphetamine cap sr 24hr 5 mg ...................................... 22

adefovir dipivoxil ................. 7 ADEMPAS ........................ 17 ADOXA

see doxycycline (monohydrate) ............... 10

ADOXA PAK 1/150 see doxycycline (monohydrate) ............... 10

adriamycin inj 20mg .......... 10 adrucil ............................... 10 ADVAIR DISKUS .............. 41 ADVAIR HFA .................... 41 ADVICOR ......................... 14 AEROSPAN ...................... 41 afeditab cr ......................... 16 AFINITOR ......................... 12 AFINITOR DISPERZ ........ 12 AGGRENOX ..................... 35

2015 CalPERS eff 01/01/2015

AGRYLIN see anagrelide hcl ......... 35

a-hydrocort ........................ 29 AKNE-MYCIN ................... 42 ala-cort .............................. 43 ALBENZA............................5 albuterol sulfate ................. 40 albuterol sulfate er ............ 40 ALCAINE

see proparacaine hcl ..... 40 alclometasone dipropionate .......................................... 43 ALCOHOL SWABS ........... 25 ALDACTAZIDE

see spironolactone & hydrochlorothiazide ....... 17

ALDACTAZIDE TAB 50/50 .......................................... 16 ALDACTONE

see spironolactone ........ 13 ALDARA

see imiquimod ............... 44 ALDURAZYME ................. 28 alendronate sodium .......... 26 alfuzosin hcl ...................... 33 ALIMTA ............................. 11 ALINIA ................................5 ALKERAN

see melphalan hcl ......... 10 allopurinol tab ......................1 ALOCRIL........................... 39 ALOMIDE .......................... 39 ALOPRIM ............................1 ALORA .............................. 29 ALOXI ............................... 31 ALPHAGAN P 0.1% .......... 39 ALPHAGAN P 0.15% ........ 39 alprazolam ........................ 18 ALREX .............................. 39 ALSUMA ........................... 23 ALTABAX .......................... 42 ALTACE

see ramipril .................... 13 altavera ............................. 26 ALTOPREV ....................... 14 ALVESCO ......................... 41 amantadine hcl .................. 21 AMARYL

see glimepiride .............. 25 AMBIEN

see zolpidem tartrate ..... 23 AMBISOME ........................ 6 amcinonide ....................... 43 AMERGE

see naratriptan hcl ......... 23 amethia 91 day ................. 26 amethyst 28 day ............... 26 amifostine crystalline......... 12 amikacin sulfate .................. 4 amiloride & hydrochlorothiazide ........... 16 amiloride hcl ...................... 17 aminophylline inj ............... 41 AMINOSYN ....................... 37 AMINOSYN 7%/ELECTROLYTES ....... 37 AMINOSYN II .................... 37 AMINOSYN II 8.5%/ELECTROL .............. 37 AMINOSYN INJ 8.5/LYTE 37 AMINOSYN M ................... 37 AMINOSYN-HBC .............. 37 AMINOSYN-PF ................. 37 AMINOSYN-PF 7% ........... 37 AMINOSYN-RF ................. 37 amiodarone hcl ................. 14 amiodarone inj 50mg/ml.... 14 AMITIZA ............................ 33 amitriptyline hcl ................. 20 amlodipine besylate .......... 16 AMLODIPINE BESYLATE/ATORV .......... 16 amlodipine besylate-benazepril hcl ..... 13 ammonium chloride .......... 36 ammonium lactate ............ 44 amnesteem ....................... 42 amoxapine ........................ 20 amoxicillin ........................... 9 amoxicillin & pot clavulanate ............................................ 9 amoxicillin-clarithromycin w/ lansoprazole ..................... 33 amphetamine cap 10mg er .......................................... 22 amphetamine cap 15mg er

.......................................... 22 amphetamine cap 20mg er.......................................... 22 amphetamine cap 25mg er.......................................... 22 amphetamine cap 30mg er.......................................... 22 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 22 amphetamine-dextroamphetamine tab 10 mg ............... 22 amphetamine-dextroamphetamine tab 12.5 mg ............ 22 amphetamine-dextroamphetamine tab 15 mg ............... 22 amphetamine-dextroamphetamine tab 20 mg ............... 22 amphetamine-dextroamphetamine tab 30 mg ............... 22 amphetamine-dextroamphetamine tab 5 mg ................. 22 amphetamine-dextroamphetamine tab 7.5 mg .............. 22 AMPHOTEC ....................... 6 amphotericin b .................... 6 ampicillin & sulbactam sodium ................................ 9 ampicillin cap 250mg .......... 9 ampicillin cap 500 mg ......... 9 ampicillin inj ........................ 9 ampicillin sodium ................ 9 ampicillin susp .................... 9 AMPYRA .......................... 24 AMTURNIDE .................... 16 ANAFRANIL

see clomipramine hcl .... 20 anagrelide hcl ............. 34, 35 ANAPROX

see naproxen sodium ...... 1 ANAPROX DS

see naproxen sodium ...... 1 anastrozole ....................... 11 ANCOBON

see flucytosine ................ 6 ANDRODERM .................. 25 ANDROGEL 1% ............... 25 ANDROGEL 1.62% .......... 25 ANDROGEL GEL PUMP 1%

2015 CalPERS eff 01/01/2015

.......................................... 25 androxy ............................. 25 ANORO ELLIPT AER 62.5-25 .............................. 40 ANTABUSE

see disulfiram ................ 24 ANTARA ........................... 14 ANUSOL-HC

see proctozone hc ......... 43 apexicon............................ 43 APIDRA............................. 25 APIDRA SOLOSTAR ........ 25 APLENZIN ........................ 20 APOKYN ........................... 21 apri 28 day ........................ 26 APRISO ............................ 32 APTIOM ............................ 18 APTIVUS.............................6 ARALAST NP .................... 41 ARALEN

see chloroquine phosphate ........................6

aranelle 28 ........................ 26 ARANESP ALBUMIN FREE .......................................... 34 ARAVA

see leflunomide ............. 35 ARCALYST ....................... 35 ARCAPTA NEOHALER .... 41 ARICEPT

see donepezil tab hcl 23mg ............................. 19 see donepezil tabs 10mg ...................................... 20 see donepezil tabs 5mg 20

ARICEPT ODT see donepezil odt 10mg 19

ARIMIDEX see anastrozole ............. 11

ARIXTRA see fondaparinux sodium ...................................... 34

AROMASIN see exemestane ............ 11

ARRANON ........................ 11 ARTHROTEC 50

see diclofenac w/ misoprostol ......................1

ARTHROTEC 75 see diclofenac w/ misoprostol ...................... 1

ARZERRA ......................... 11 ASACOL HD ..................... 32 ASMANEX ........................ 41 ASMANEX 14 METERED DOSES ............................. 41 ASPIRIN-CAFFEINE-DIHYDROCODEINE BITARTRATE ............................................ 1 ASTAGRAF XL ................. 35 ASTEPRO ......................... 40

see azelastine spr 0.15% ...................................... 40

ATACAND see candesartan cilexetil ...................................... 14

ATACAND HCT see candesartan cilexetil-hydrochlorothiazide .................................... 13

ATELVIA ........................... 26 atenolol ............................. 15 atenolol & chlorthalidone ... 15 ATGAM ............................. 35 ATIVAN

see lorazepam ............... 18 atorvastatin calcium .......... 14 atovaquone ......................... 5 atovaquone-proguanil hcl tab 250-100 mg ......................... 6 ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG ...... 6 ATRALIN ........................... 42 ATRIPLA ............................. 7 ATROPINE SULFATE ...... 31 ATROVENT

see ipratropium bromide (nasal) ........................... 40

ATROVENT HFA .............. 40 AUBAGIO ......................... 24 AUGMENTIN ...................... 9

see amoxicillin & pot clavulanate ...................... 9

AUGMENTIN ES-600 see amoxicillin & pot clavulanate ...................... 9

AUGMENTIN XR see amoxicillin & pot clavulanate ...................... 9

AUVI-Q ............................. 41 AVALIDE

see irbesartan-hydrochlorothiazide ............................... 13

AVAPRO see irbesartan ............... 14

AVASTIN .......................... 11 AVEED ............................. 25 AVELOX ............................. 9

see moxifloxacin hcl ........ 9 aviane 28 .......................... 27 AVINZA

see morphine sulfate beads .............................. 3

AVITA ............................... 42 AVODART ........................ 33 AVONEX ........................... 24 AVONEX PEN .................. 24 AXERT .............................. 23 AXID

see nizatidine ................ 32 AXIRON ............................ 25 AYGESTIN

see norethindrone acetate ...................................... 30

azacitidine ......................... 11 AZACTAM .......................... 5

see aztreonam ................ 5 AZACTAM/DEX INJ 1GM ... 5 AZACTAM/DEX INJ 2GM ... 5 azasan .............................. 35 AZASITE ........................... 38 azathioprine ...................... 35 azelastine hcl (ophth) ........ 39 azelastine spr 0.1% .......... 40 azelastine spr 0.15% ........ 40 AZELEX ............................ 42 AZILECT ........................... 21 azithromycin ....................... 8 AZITHROMYCIN ................ 8 AZOPT .............................. 39 AZOR ................................ 13 aztreonam ........................... 5 AZULFIDINE

2015 CalPERS eff 01/01/2015

see sulfasalazine ir ........ 32 AZULFIDINE EN-TABS

see sulfasalazine dr ....... 32 B bacitracin (ophthalmic) ...... 38 bacitracin-polymyxin b (ophth) .............................. 39 bacitracin-poly-neomycin-hc .......................................... 38 baclofen ............................ 24 BACTOCILL INJ DEX 1GM.9 BACTOCILL INJ DEX 2GM.9 BACTRIM

see sulfamethoxazole-trimethop ......................................5

BACTRIM DS see sulfamethoxazole-trimethop ......................................5

BACTROBAN see mupirocin ................ 42 see mupirocin calcium (topical).......................... 42

BACTROBAN NASAL ....... 42 balsalazide disodium ......... 32 balziva 28 day ................... 27 BANZEL SUS 40MG/ML ... 18 BANZEL TAB 200MG ....... 18 BANZEL TAB 400MG ....... 18 BARACLUDE ......................7 BCG VACCINE ................. 36 BECONASE AQ ................ 41 benazepril & hydrochlorothiazide ........... 13 benazepril hcl .................... 13 BENICAR .......................... 14 BENICAR HCT .................. 13 BENLYSTA ....................... 36 BENTYL ............................ 31

see dicyclomine hcl ....... 31 BENZACLIN

see clindamycin phosphate-benzoyl peroxide......................... 42

BENZAMYCIN see benzoyl peroxide-erythromycin ... 42

benzoyl peroxide-erythromycin ...... 42 benztropine mesylate ........ 21 BEPREVE ......................... 39 BERINERT ........................ 35 BESIVANCE ..................... 39 BETAGAN

see levobunolol hcl ........ 40 betamethasone dipropionate (topical) ............................. 43 betamethasone dipropionate augmented ........................ 43 betamethasone valerate ... 43 BETAPACE

see sorine ...................... 14 see sotalol hcl ............... 14

BETAPACE AF see sotalol hcl (afib/afl) .. 14

BETASERON .................... 24 betaxolol hcl ...................... 15 betaxolol hcl (ophth) ......... 39 bethanechol chloride ......... 33 BETHKIS ............................ 4 BETIMOL .......................... 39 BETOPTIC-S .................... 40 BEYAZ .............................. 27 BIAXIN

see clarithromycin ........... 8 BIAXIN XL

see clarithromycin ........... 8 bicalutamide ...................... 11 BICILLIN C-R ...................... 9 BICILLIN L-A ....................... 9 BICNU ............................... 10 BIDIL ................................. 17 BILTRICIDE ........................ 5 BINOSTO .......................... 26 bisoprolol & hydrochlorothiazide ........... 15 bisoprolol fumarate ........... 15 BIVIGAM ........................... 35 bleomycin sulfate .............. 10 BLEPH-10

see sulfacetamide sodium (ophth) ........................... 39

blephamide ....................... 38 BLEPHAMIDE ................... 38 BONIVA

see ibandronate sodium 26 BOOSTRIX ....................... 36 BOSULIF .......................... 12 BOTOX INJ 100UNIT ....... 40 BREO ELLIPTA ................ 41 BREVICON-28

see necon 0.5/35 28 day ...................................... 28 see nortrel 0.5/35 28 day ...................................... 28

briellyn 28 day .................. 27 BRILINTA ......................... 35 BRIMONIDINE SOL 0.15%.......................................... 40 brimonidine sol 0.2% ........ 40 BRINTELLIX ..................... 20 BRISDELLE ...................... 24 bromfenac sodium (ophth) 39 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) .. 39 bromocriptine mesylate ..... 21 BROVANA ........................ 41 budesonide ....................... 32 budesonide (inhalation) .... 41 budesonide (nasal) ........... 41 bumetanide ....................... 17 BUPHENYL

see sodium phenylbutyrate ...................................... 29

buprenorphine hcl ............. 24 buprenorphine hcl-naloxone hcl sl ................................. 24 buproban .......................... 24 bupropion hcl .................... 20 buspirone hcl .................... 18 BUSULFEX ....................... 10 butorphanol nasal spray ..... 1 butorphanol tartrate ............ 1 BUTRANS ...................... 1, 2 BYDUREON ..................... 25 BYETTA ............................ 25 BYSTOLIC ........................ 15 C cabergoline ....................... 30 cafergot tab 1-100mg ........ 23 CALAN

see verapamil hcl .......... 16 CALAN SR

2015 CalPERS eff 01/01/2015

see verapamil hcl .......... 16 calcipotrien oin betameth .. 43 calcipotriene ...................... 43 calcitonin (salmon) nasal spray ................................. 30 calcitrene oin 0.005% ........ 43 calcitriol ............................. 38 CALCITRIOL ..................... 43 calcium acetate (phosphate binder) ............................... 30 camila 28 day .................... 27 CAMPRAL

see acamprosate calcium ...................................... 24

CAMPTOSAR ................... 13 see irinotecan ................ 13 see irinotecan hcl .......... 13

CAMRESE LO TAB .......... 27 CANASA ........................... 32 CANCIDAS .........................6 candesartan cilexetil ......... 14 candesartan cilexetil-hydrochlorothiazide .......................................... 13 CANTIL ............................. 31 CAPASTAT SULFATE ........7 CAPEX .............................. 43 capital

and codeine .....................2 CAPRELSA ....................... 12 captopril ............................ 13 captopril & hydrochlorothiazide ........... 13 CARAC ............................. 44 CARAFATE ....................... 33

see sucralfate ................ 33 CARBAGLU ...................... 28 carbamazepine ................. 18 CARBATROL

see carbamazepine ....... 18 carbidopa .......................... 21 CARBIDOPA/LEVODOPA/ENTACAPONE .................... 21 carbidopa-levodopa .......... 21 carboplatin ........................ 12 CARDENE SR .................. 16 CARDIZEM

see diltiazem hcl ............ 16

CARDIZEM CD see cartia xt ................... 16 see dilt-cd cap ............... 16 see diltiazem hcl coated beads ............................ 16

CARDIZEM LA .................. 16 see matzim la ................ 16

CARDURA see doxazosin mesylate 13

CARDURA XL ................... 33 CARIMUNE NANOFILTERED .............. 35 CARNITOR

see levocarnitine (metabolic modifiers) ..... 28

carteolol hcl (ophth) .......... 40 cartia xt ............................. 16 carvedilol ........................... 15 CASODEX

see bicalutamide ........... 11 CATAFLAM

see diclofenac potassium 1 CATAPRES

see clonidine hcl ............ 17 CATAPRES-TTS-1



see clonidine hcl ............ 17 CAYSTON .......................... 5 CEDAX ............................... 8 cefaclor ............................... 8 cefaclor er tab 500mg ......... 8 cefadroxil ............................ 8 cefazolin inj ......................... 8 cefazolin sodium ................. 8 cefazolin/dextrose ............... 8 cefdinir ................................ 8 CEFEPIME 1GM SOLN ...... 8 CEFEPIME 2GM SOLN ...... 8 cefepime inj 1gm ................. 8 cefepime inj 2gm ................. 8 cefotaxime sodium .............. 8 cefotetan disodium .............. 8 cefoxitin sodium .................. 8 CEFOXITIN SODIUM IN DEXTROSE ........................ 8

cefpodoxime proxetil ........... 8 cefprozil .............................. 8 ceftazidime ......................... 8 CEFTAZIDIME/DEXTROSE............................................ 8 ceftibuten ............................ 8 CEFTIN ............................... 8

see cefuroxime axetil ...... 8 ceftriaxone sodium .............. 8 cefuroxime axetil ................. 8 cefuroxime sodium .............. 8 cefuroxime sodium soln iv 7.5 gm ................................. 8 CELEBREX CAP 100MG ... 1 CELEBREX CAP 200MG ... 1 CELEBREX CAP 400MG ... 1 CELEBREX CAP 50MG ..... 1 CELEXA

see citalopram hydrobromide ................ 20

CELLCEPT see mycophenolate mofetil ...................................... 36

CELLCEPT INTRAVENOUS.......................................... 35 CELLCEPT SUSP ............ 36 CELONTIN ....................... 18 CENTANY ........................ 42 cephalexin .......................... 8 CEREZYME ...................... 28 CERVARIX ....................... 36 CESAMET ........................ 31 cetirizine syrup .................. 40 cevimeline hcl ................... 45 CHANTIX .......................... 24 CHANTIX STARTER PACK.......................................... 24 CHEMET .......................... 26 chlorhexidine gluconate (mouth-throat) ................... 45 chloroquine phosphate ....... 6 chlorothiazide ................... 17 chlorpromaz inj 25mg/ml ... 21 chlorpromazine hcl ............ 21 chlorthalidone ................... 17 cholestyramine ................. 14 cholestyramine light .......... 15 choline fenofibrate ............ 15

2015 CalPERS eff 01/01/2015

CHORIONIC GONADOTROPIN ............ 30 ciclopirox ........................... 42 ciclopirox cre 0.77% .......... 42 ciclopirox shampoo 1% ..... 42 ciclopirox sus 0.77% ......... 42 cidofovir...............................7 cilostazol ........................... 35 CILOXAN

see ciprofloxacin hcl (ophth) ........................... 39

CILOXAN OIN 0.3% OP ... 39 cimetidine .......................... 32 cimetidine sol 300/5ml ...... 32 CIMZIA .............................. 35 CINRYZE .......................... 35 CIPRO

see ciprofloxacin ..............9 see ciprofloxacin hcl ........9

CIPRO HC ........................ 45 CIPRO I.V.-IN D5W

see ciprofloxacin in d5w ..9 CIPRO XR

see ciprofloxacin er .........9 CIPRODEX ....................... 45 ciprofloxacin ........................9 ciprofloxacin er ....................9 ciprofloxacin hcl ..................9 ciprofloxacin hcl (ophth) .... 39 ciprofloxacin in d5w .............9 ciprofloxacn inj ....................9 cisplatin ............................. 12 citalopram hydrobromide... 20 cladribine........................... 11 claforan ...............................8 CLAFORAN

see cefotaxime sodium ....8 claravis .............................. 42 CLARINEX ........................ 40

see desloratadine .......... 40 CLARINEX REDITABS

see desloratadine .......... 40 CLARINEX-D TAB 2.5-120 .......................................... 40 CLARINEX-D TAB 5-240MG .......................................... 40 clarithromycin ......................8 CLEOCIN

see clindamycin cre 2% vag ................................ 34 see clindamycin hcl ......... 5

CLEOCIN IN D5W see clindamycin phosphate in d5w ............ 5

CLEOCIN PEDIATRIC GRANULE

see clindamycin palmitate hydrochloride ................... 5

CLEOCIN PHOSPHATE see clindamycin phosphate ....................... 5

CLEOCIN VAG SUPP 100MG .............................. 34 CLEOCIN-T

see clindamycin phosphate (topical) ........ 42

CLIMARA see estradiol .................. 29

clindamycin cre 2% vag .... 34 clindamycin hcl ................... 5 clindamycin palmitate hydrochloride ...................... 5 clindamycin phosphate ....... 5 clindamycin phosphate (topical) ............................. 42 clindamycin phosphate in d5w ..................................... 5 clindamycin phosphate-benzoyl peroxide .......................................... 42 CLINIMIX 2.75%/DEXTROSE 5% ..... 37 CLINIMIX 4.25%/DEXTROSE 10% ... 37 CLINIMIX 4.25%/DEXTROSE 20% ... 37 CLINIMIX 4.25%/DEXTROSE 25% ... 37 CLINIMIX 4.25%/DEXTROSE 5% ..... 37 CLINIMIX 5%/DEXTROSE 15%................................... 37 CLINIMIX 5%/DEXTROSE 20%................................... 37 CLINIMIX 5%/DEXTROSE 25%................................... 37

CLINIMIX E 2.75%/DEXTROSE 10% ... 37 CLINIMIX E 2.75%/DEXTROSE 5% ..... 37 CLINIMIX E 4.25%/DEXTROSE ........... 37 CLINIMIX E 4.25%/DEXTROSE 25% ... 37 CLINIMIX E 4.25%/DEXTROSE 5% ..... 37 CLINIMIX E 5%/DEXTROSE 15% .................................. 37 CLINIMIX E 5%/DEXTROSE 20% .................................. 37 CLINIMIX E 5%/DEXTROSE 25% .................................. 37 clinisol 15 .......................... 37 clobetasol propionate ........ 43 clobetasol propionate emollient base .................. 43 clobetasol propionate emulsion ........................... 43 CLOBEX ........................... 43

see clobetasol propionate ...................................... 43

clocortolone pivalate ......... 43 CLOLAR ........................... 11 clomipramine hcl ............... 20 clonazepam ...................... 18 clonidine hcl ...................... 17 clopidogrel bisulfate .......... 35 clorazepate dipotassium ... 18 clorpres ............................. 17 clotrimazole ...................... 45 clotrimazole (topical) ......... 42 clozapine .......................... 21 CLOZAPINE ODT ............. 21 CLOZARIL

see clozapine ................ 21 COARTEM .......................... 6 codeine

and capital ....................... 2 CODEINE SULFATE .......... 2 COGENTIN

see benztropine mesylate ...................................... 21

COLAZAL see balsalazide disodium

2015 CalPERS eff 01/01/2015

...................................... 32 colchicine w/ probenecid .....1 COLCRYS ...........................1 COLESTID

see colestipol hcl ........... 15 colestipol hcl ..................... 15 colistimethate sodium .........5 colocort ............................. 32 COLY-MYCIN M

see colistimethate sodium ........................................5

COLY-MYCIN S ................ 45 COLYTE-FLAVOR PACKS .......................................... 32

see gavilyte-c ................ 32 see peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ............................ 32

COMBIGAN ...................... 40 COMBIPATCH .................. 29 COMBIVENT RESPIMAT . 40 COMBIVIR

see lamivudine-zidovudine ........................................7

COMETRIQ ....................... 12 COMPAZINE

see prochlorperazine maleate.......................... 31

COMPLERA ........................7 compro supp ..................... 31 COMTAN

see entacapone ............. 21 COMVAX .......................... 36 CONCERTA

see methylphenidate hcl 23 see methylphenidate hcl er ...................................... 23

CONDYLOX ...................... 44 see podofilox ................. 45

constulose ......................... 32 CONZIP ..............................2 COPAXONE INJ 40MG/ML .......................................... 24 COPAXONE KIT 20MG/ML .......................................... 24 COPEGUS

see moderiba tab 200mg .7 see ribasphere .................7

see ribavirin 200mg ......... 7 CORDARONE

see amiodarone hcl ....... 14 see pacerone ................ 14

CORDRAN ........................ 43 COREG

see carvedilol ................ 15 COREG CR ...................... 15 CORGARD

see nadolol .................... 15 CORTEF

see hydrocortisone ........ 29 CORTENEMA

see colocort ................... 32 CORTIFOAM .................... 42 cortisone acetate .............. 29 CORTISPORIN ................. 42

see neomycin-polymyxin-hc (otic) .............................. 45

CORTISPORIN-TC ........... 45 CORZIDE

see nadolol & bendroflumethiazide ...... 15

COSMEGEN ..................... 10 COSOPT

see dorzolamide hcl-timolol maleate ........ 40

COSOPT PF ..................... 40 COUMADIN ...................... 34

see jantoven .................. 34 see warfarin sodium ...... 34

COUMADIN INJ ................ 34 COZAAR

see losartan potassium . 14 CREON ............................. 33 CRESTOR ........................ 14 CRINONE ......................... 30 CRIXIVAN ........................... 6 cromolyn sodium ............... 41 cromolyn sodium (mastocytosis) ................... 33 cromolyn sodium (ophth) .. 39 cryselle 28 ......................... 27 CUBICIN ............................. 5 CUTIVATE

see fluticasone propionate ...................................... 44

CUVPOSA ........................ 31 cyclafem 1/35 28 day ........ 27 cyclafem 7/7/7 28 day ....... 27 CYCLESSA

see velivet 28 day ......... 28 cyclobenzaprine hcl .......... 24 cyclophosphamide ............ 10 CYCLOPHOSPHAMIDE ... 10 cyclosporine ...................... 36 cyclosporine modified (for microemulsion) ................. 36 CYKLOKAPRON

see tranexamic acid ...... 35 CYMBALTA

see duloxetine hcl ......... 20 CYRAMZA ........................ 12 CYSTADANE .................... 28 CYSTAGON ..................... 28 CYSTARAN ...................... 40 cytarabine inj .................... 11 CYTOGAM ....................... 35 CYTOMEL

see liothyronine sodium 31 CYTOTEC

see misoprostol ............. 33 CYTOVENE

see ganciclovir inj 500mg 7 D D.H.E. 45

see dihydroergotamine mesylate ........................ 23

dacarbazine ...................... 10 DACOGEN

see decitabine ............... 11 DALIRESP ........................ 41 danazol ............................. 28 DANTRIUM

see dantrolene sodium .. 24 dantrolene sodium ............ 24 dapsone .............................. 5 DAPTACEL ....................... 36 DARAPRIM ......................... 5 daunorubicin hcl for inj 20 mg ..................................... 10 daunorubicin inj 5mg/ml .... 10 DAYPRO

see oxaprozin .................. 1 DAYTRANA ...................... 22

2015 CalPERS eff 01/01/2015

DDAVP see desmopressin acetate ...................................... 31 see desmopressin acetate inj ................................... 31 see desmopressin acetate spray ............................. 31

decitabine.......................... 11 DELESTROGEN

see estradiol valerate .... 29 DELZICOL ........................ 32 DEMADEX

see torsemide tabs ........ 17 demeclocycline hcl ............ 10 DEMSER........................... 17 DENAVIR .......................... 43 DEPACON

see valproate sodium .... 19 DEPAKENE

see valproate sodium .... 19 see valproic acid ............ 19

DEPAKOTE see divalproex sodium ... 19

DEPAKOTE ER see divalproex sodium ... 19

DEPAKOTE SPRINKLES see divalproex sodium ... 19

DEPEN TITRATABS ......... 26 depo-estradiol ................... 29 DEPO-MEDROL

see methylpr ace inj 40mg/ml ......................... 29 see methylpr ace inj 80mg/ml ......................... 29

DEPO-MEDROL INJ 20MG/ML .......................... 29 DEPO-PROVERA CONTRACEPTIV

see medroxyprogesterone acetate (contraceptive) .. 27

DEPO-PROVERA INJ 400/ML .............................. 11 DEPO-SUBQ PROVERA 104 .................................... 27 depo-testosterone ............. 25 DEPO-TESTOSTERONE

see testosterone cypionate ...................................... 25

DERMA-SMOOTHE/FS BODY

see fluocinolone acetonide ...................................... 44

DERMATOP see prednicarbate ......... 44

DERMOTIC see fluocinolone acetonide (otic) .............................. 45

DESFERAL ....................... 35 desipramine hcl ................. 20 desloratadine .................... 40 desmopressin acetate ....... 31 DESMOPRESSIN ACETATE .......................................... 31 desmopressin acetate inj .. 31 desmopressin acetate spray .......................................... 31 desmopressin acetate spray refrigerated ....................... 31 DESOGEN

see apri 28 day .............. 26 see emoquette .............. 27 see reclipsen 28 day ..... 28

DESONATE ...................... 43 desonide ........................... 43 DESONIDE ....................... 43 DESOWEN

see desonide ................. 43 desoximetasone ................ 43 DESOXIMETASONE ........ 43 DETROL

see tolterodine tartrate tab 1 mg .............................. 34 see tolterodine tartrate tab 2 mg .............................. 34

dexamethasone ................ 29 dexamethasone sodium phosphate ......................... 29 dexamethasone sodium phosphate (ophth) ............. 39 DEXILANT ........................ 33 dexpak taperpak 13 day.... 29 dexrazoxane ..................... 12 dextrose ............................ 37 DEXTROSE ...................... 37 DEXTROSE 10% FLEX CONTAIN .......................... 38

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%.......................................... 38 DEXTROSE 10%/NACL 0.45% ............................... 38 DEXTROSE 2.5%/NACL 0.45% ............................... 37 DEXTROSE 5% ................ 37 DEXTROSE 5% /ELECTROLYTE ............... 37 DEXTROSE 5%/LACTATED RING ................................. 37 DEXTROSE 5%/NACL 0.2%.......................................... 38 DEXTROSE 5%/NACL 0.225% ............................. 38 DEXTROSE 5%/NACL 0.3%.......................................... 38 DEXTROSE 5%/NACL 0.33% ............................... 38 DEXTROSE 5%/NACL 0.45% ............................... 38 DEXTROSE 5%/NACL 0.9%.......................................... 38 DEXTROSE 5%/POTASSIUM CHL ...... 38 DIAMOX

see acetazolamide ........ 16 diazepam .......................... 18 DIAZEPAM GEL (ANTICONVULSANT) ....... 19 DIBENZYLINE .................. 17 diclofenac gel 3%.............. 44 diclofenac potassium .......... 1 diclofenac sodium ............... 1 diclofenac sodium (ophth) . 39 diclofenac sol 1.5% ........... 44 diclofenac w/ misoprostol .... 1 dicloxacillin sodium ............. 9 dicyclomine hcl ................. 31 didanosine .......................... 6 DIFFERIN ......................... 42

see adapalene............... 42 DIFICID ............................... 8 diflorasone diacetate ......... 43 DIFLUCAN

see fluconazole ............... 6 diflunisal .............................. 1

2015 CalPERS eff 01/01/2015

digoxin .............................. 16 digoxin inj .......................... 16 DIGOXIN SOL 50MCG/ML .......................................... 16 dihydroergotamine mesylate .......................................... 23 DIHYDROERGOTAMINE MESYLATE ....................... 23 dilantin .............................. 19 DILANTIN.......................... 19

see phenytoin ................ 19 see phenytoin sodium extended........................ 19

DILANTIN INFATABS see phenytoin ................ 19

DILATRATE SR ................ 17 DILAUDID

see hydromorphone hcl ...3 DILAUDID-HP

see hydromorphone hcl ...3 DILAUDID-HP INJ 250MG ..2 dilt-cd cap.......................... 16 diltiazem cap 120mg/24hr . 16 diltiazem cap er/12hr ......... 16 diltiazem hcl ...................... 16 diltiazem hcl coated beads 16 diltiazem hcl er .................. 16 diltiazem hcl extended release beads ................... 16 diltiazem inj 100mg ........... 16 diltiazem inj 125/25ml ....... 16 diltiazem inj 25mg/5ml ...... 16 diltiazem inj 50/10ml ......... 16 dilt-xr cap .......................... 16 diltzac ................................ 16 DIOVAN ............................ 14

see valsartan ................. 14 DIOVAN HCT

see valsartan-hydrochlorothiazide .................................. 14

DIPENTUM ....................... 32 diphenhydram inj 50mg/ml 40 diphenoxylate w/ atropine . 33 DIPHTHERIA/TETANUS TOXOID ............................ 36 DIPROLENE

see betamethasone

dipropionate augmented 43 DIPROLENE AF

see betamethasone dipropionate augmented 43

disopyramide phosphate ... 14 disulfiram .......................... 24 DITROPAN XL

see oxybutynin chloride . 34 DIURIL SUS 250/5ML ....... 17 divalproex sodium ............. 19 docetaxel .......................... 11 DOCETAXEL .................... 11 DOLOPHINE

see methadone hcl .......... 3 DOLOPHINE HCL

see methadone hcl .......... 3 donepezil odt 10mg .......... 19 donepezil odt 5mg ............ 19 donepezil tab hcl 23mg ..... 19 donepezil tabs 10mg ......... 20 donepezil tabs 5mg ........... 20 DORIBAX ............................ 5 DORYX ............................. 10

see doxycycline hyclate . 10 dorzolamide hcl ................. 40 dorzolamide hcl-timolol maleate ............................. 40 DOVONEX

see calcipotriene ........... 43 doxazosin mesylate .......... 13 doxepin hcl ........................ 20 doxercalciferol ................... 38 DOXIL

see doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ........... 10

doxorubicin hcl .................. 10 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ..... 10 doxorubicin inj 50mg ......... 10 doxycycline (monohydrate) .......................................... 10 doxycycline hyclate ........... 10 dronabinol ......................... 31 drospirenone-ethinyl estradiol ............................ 27 DROXIA ............................ 12 DUETACT

see pioglitazone hcl-glimepiride ............... 26

DUEXIS .............................. 1 DULERA ........................... 41 duloxetine hcl .................... 20 DURAGESIC

see fentanyl td patch 72hr 100 mcg/hr ...................... 3 see fentanyl td patch 72hr 12 mcg/hr ........................ 2 see fentanyl td patch 72hr 25 mcg/hr ........................ 3 see fentanyl td patch 72hr 50 mcg/hr ........................ 3 see fentanyl td patch 72hr 75 mcg/hr ........................ 3

DURAMORPH .................... 2 DUREZOL ........................ 39 DUTOPROL ...................... 15 DYAZIDE

see triamt/hctz cap 37.5-25 .......................... 17

DYMISTA SPR 137-50 ..... 40 DYRENIUM ...................... 17 DYSPORT ........................ 40 E e.e.s. 400 mg tab ................ 8 E.E.S. GRANULES ............. 8 e.s.p. ................................... 5 EC-NAPROSYN

see naproxen .................. 1 econazole nitrate .............. 42 EDARBI ............................ 14 EDARBYCLOR ................. 13 EDECRIN ......................... 17 EDURANT .......................... 6 ees/sulfisox sus 200-600 .... 5 EFFEXOR XR

see venlafaxine cap er .. 20 EFFIENT ........................... 35 EFUDEX

see fluorouracil (topical) 44 EGRIFTA .......................... 30 ELAPRASE ....................... 28 ELDEPRYL

see selegiline hcl ........... 21 ELECTROLYTE-R IN DEXTROSE ...................... 38

2015 CalPERS eff 01/01/2015

ELELYSO.......................... 28 ELESTAT

see epinastine hcl (ophth) ...................................... 39

ELIDEL ............................. 44 ELIGARD INJ 22.5MG ...... 11 ELIGARD INJ 30MG ......... 11 ELIGARD INJ 45MG ......... 11 ELIGARD INJ 7.5MG ........ 11 ELIMITE

see permethrin .............. 45 ELIPHOS

see calcium acetate (phosphate binder) ........ 30

ELIQUIS TAB 2.5MG ........ 34 ELIQUIS TAB 5MG ........... 34 ELITEK ............................. 12 elixophyllin ........................ 41 ELLA ................................. 27 ELLENCE

see epirubicin inj 200mg 10 see epirubicin inj 50mg/25ml ..................... 10

ELMIRON.......................... 34 ELOCON

see mometasone furoate ...................................... 44

ELOXATIN ........................ 12 EMADINE.......................... 39 EMCYT ............................. 10 EMEND CAP 125MG ........ 31 EMEND CAP 40MG .......... 31 EMEND CAP 80MG .......... 31 EMEND PAK 80 & 125 ..... 31 EMLA

see lidocaine-prilocaine . 44 emoquette ......................... 27 EMSAM ............................. 20 EMTRIVA ............................6 ENABLEX ......................... 34 enalapril maleate ............... 13 enalapril maleate & hydrochlorothiazide ........... 13 ENBREL............................ 35 ENBREL SURECLICK ...... 35 endocet ...............................2 ENDODAN TAB ..................2 ENDOMETRIN .................. 30

ENGERIX-B ...................... 36 enoxaparin sodium ........... 34 enpresse 28 day ............... 27 entacapone ....................... 21 ENTOCORT EC

see budesonide ............. 32 ENTYVIO .......................... 32 enulose ............................. 32 EPIDUO ............................ 42 epinastine hcl (ophth)........ 39 EPINEPHRINE ................. 41 EPIPEN 2-PAK ................. 41 EPIPEN-JR 2-PAK ............ 41 epirubicin inj 200mg .......... 10 EPIRUBICIN INJ 50MG .... 10 epirubicin inj 50mg/25ml ... 10 epitol ................................. 19 EPIVIR

see lamivudine ................ 6 EPIVIR HBV ........................ 7

see lamivudine ................ 7 EPIVIR SOL 10MG/ML ....... 6 eplerenone ........................ 13 EPOGEN .......................... 34 eprosartan mesylate ......... 14 EPZICOM ........................... 7 EQUETRO ........................ 24 ERAXIS ............................... 6 ERBITUX .......................... 11 ergomar ............................ 23 ERIVEDGE ....................... 11 errin 28 day ....................... 27 ERTACZO ......................... 42 ERWINAZE ....................... 12 ery pad 2% ........................ 42 ERYGEL

see erythromycin (acne aid) ................................ 42

ERYPED 200 ...................... 8 ERYPED 400 ...................... 9 ery-tab ................................. 8 erythrocin lactobionate ........ 9 erythrocin stearate .............. 9 erythromycin (acne aid) .... 42 erythromycin (ophth) ......... 39 erythromycin base .............. 9 erythromycin cap 250mg ec 9 erythromycin ethylsuccinate 9

escitalopram oxalate ......... 20 esomeprazole sodium ....... 33 estrace .............................. 29 ESTRACE

see estradiol .................. 29 estradiol ............................ 29 estradiol valerate .............. 29 ESTRADIOL VALERATE .. 29 ESTRING .......................... 29 ESTROSTEP FE

see tri-legest 28 day ...... 28 ethambutol hcl .................... 7 ethosuximide .................... 19 ETHYOL

see amifostine crystalline ...................................... 12

etodolac .............................. 1 etodolac er .......................... 1 ETOPOPHOS ................... 13 etoposide .......................... 13 EURAX ............................. 45 EVISTA

see raloxifene hcl .......... 30 EVOCLIN

see clindamycin phosphate (topical) ........ 42

EVOXAC see cevimeline hcl ......... 45

EXALGO see hydromorphone tab 12mg er ........................... 3 see hydromorphone tab 16mg er ........................... 3 see hydromorphone tab 8mg er ............................. 3

EXELDERM ...................... 42 EXELON

see rivastigmine tartrate 20 EXELON PATCHES ......... 20 exemestane ...................... 11 EXFORGE ........................ 13 EXFORGE HCT ................ 13 EXJADE ............................ 26 EXTAVIA .......................... 24 EYLEA .............................. 40 F FABIOR ............................ 42 FABRAZYME .................... 28

2015 CalPERS eff 01/01/2015

FACTIVE .............................9 famciclovir ...........................7 famotidine ......................... 32 FAMVIR

see famciclovir .................7 FANAPT ............................ 21 FANAPT TITRATION PACK .......................................... 21 FARESTON ...................... 11 FARXIGA .......................... 25 FASLODEX ....................... 11 FAZACLO ......................... 21 felbamate .......................... 19 FELBATOL

see felbamate ................ 19 FELDENE

see piroxicam ..................1 felodipine........................... 16 FEMARA

see letrozole .................. 11 FEMCON FE

see zenchent fe 28 day . 28 FEMRING ......................... 29 fenofibrate ......................... 15 FENOFIBRATE ................. 15 fenofibrate micronized ....... 15 FENOFIBRIC ACID ........... 15 FENOGLIDE ..................... 15 fenoprofen calcium ..............1 fentanyl citrate .....................2 fentanyl td patch 72hr 100 mcg/hr .................................3 fentanyl td patch 72hr 12 mcg/hr .................................2 fentanyl td patch 72hr 25 mcg/hr .................................3 fentanyl td patch 72hr 50 mcg/hr .................................3 fentanyl td patch 72hr 75 mcg/hr .................................3 FENTORA ...........................3 FERRIPROX ..................... 26 FETZIMA........................... 20 FETZIMA TITRATION PACK .......................................... 20 FINACEA .......................... 44 finasteride ......................... 33 FIRAZYR........................... 35

FIRMAGON ...................... 11 FLAGYL

see metronidazole ........... 5 FLAGYL ER ........................ 5 FLAREX ............................ 39 FLEBOGAMMA ................ 35 FLEBOGAMMA DIF .......... 35 flecainide acetate .............. 14 FLOLAN ............................ 17 FLOMAX

see tamsulosin hcl ......... 33 FLONASE

see fluticasone propionate (nasal) ........................... 41

FLO-PRED SUS ............... 29 FLOVENT DISKUS ........... 41 FLOVENT HFA ................. 41 fluconazole .......................... 6 fluconazole in dextrose ....... 6 fluconazole inj nacl 100....... 6 fluconazole inj nacl 200....... 6 fluconazole inj nacl 400....... 6 flucytosine ........................... 6 FLUDARA

see fludarabine phosphate ...................................... 11

fludarabine phosphate ...... 11 fludrocortisone acetate...... 29 FLUMADINE

see rimantadine hydrochloride ................... 8

flunisolide (nasal) .............. 41 fluocinolone acetonide 43, 44 fluocinolone acetonide (otic) .......................................... 45 fluocinonide ....................... 44 fluocinonide emulsified base .......................................... 44 FLUOROMETHOLONE (OPHTH) ........................... 39 fluorouracil ........................ 11 fluorouracil (topical) .......... 44 fluoxetine hcl ..................... 20 FLUOXETINE HCL ........... 20 fluphenazine decanoate .... 21 fluphenazine hcl ................ 21 flurbiprofen .......................... 1 flurbiprofen sodium ........... 39

flutamide ........................... 11 fluticasone propionate ....... 44 fluticasone propionate (nasal) ............................... 41 fluvastatin sodium ............. 14 fluvoxamine maleate ......... 18 fluvoxamine maleate er ..... 18 FML .................................. 39 FML FORTE ..................... 39 FOLOTYN ......................... 11 fondaparinux sodium ........ 34 FORADIL AEROLIZER ..... 41 FORFIVO XL .................... 20 FORTAMET

see metformin hcl .......... 26 FORTAZ ............................. 8

see ceftazidime ............... 8 see tazicef vial................. 8

FORTEO ........................... 30 FORTESTA ...................... 25 FORTICAL SPR 200/ACT 30 FOSAMAX

see alendronate sodium 26 FOSAMAX PLUS D .......... 26 foscarnet sodium ................ 7 fosinopril sodium ............... 13 fosinopril sodium & hydrochlorothiazide ........... 13 FOSRENOL ...................... 30 FRAGMIN ......................... 34 FREAMINE HBC 6.9% ..... 37 FREAMINE III ................... 37 FROVA TAB 2.5MG .......... 23 FURADANTIN

see nitrofurantoin ............ 5 furosemide ........................ 17 furosemide inj ................... 17 furosemide oral soln 8 mg/ml.......................................... 17 FUSILEV ........................... 12 FUZEON ............................. 6 FYCOMPA ........................ 19 G gabapentin ........................ 19 GABITRIL ......................... 19

see tiagabine hcl ........... 19 galantamine hydrobromide 20 GAMASTAN S/D............... 35

2015 CalPERS eff 01/01/2015

GAMMAGARD LIQUID ..... 35 GAMMAGARD S/D ........... 35 GAMMAGARD S/D IGA LESS TH ........................... 35 GAMMAKED ..................... 35 GAMMAPLEX ................... 35 GAMUNEX-C .................... 35 GAMUNEX-C 1GM/10ML . 35 ganciclovir inj 500mg ..........7 GARAMYCIN

see gentamicin sulfate (ophth) ........................... 39

GARDASIL ........................ 36 GASTROCROM

see cromolyn sodium (mastocytosis) ............... 33

gatifloxacin (ophth) ............ 39 GATTEX............................ 33 GAUZE PADS 2X2 ........... 25 gaviltye-g........................... 32 gavilyte-c ........................... 32 gavilyte-n........................... 32 GAZYVA ........................... 12 GELNIQUE ....................... 34 gemcitabine inj 1gm .......... 11 GEMCITABINE INJ 1GM .. 11 gemcitabine inj 200mg ...... 11 GEMCITABINE INJ 200MG .......................................... 11 gemcitabine inj 2gm .......... 11 GEMCITABINE INJ 2GM .. 11 gemfibrozil......................... 15 GEMZAR

see gemcitabine inj 1gm 11 see gemcitabine inj 200mg ...................................... 11

GENERESS FE ................ 27 generlac ............................ 32 gengraf .............................. 36 GENOTROPIN .................. 30 GENOTROPIN MINIQUICK .......................................... 30 gentak ............................... 39 gentamicin in saline inj 0.8 mg/ml ..................................4 gentamicin in saline inj 0.9 mg/ml ..................................4 gentamicin in saline inj 1

mg/ml .................................. 4 gentamicin in saline inj 1.2 mg/ml .................................. 4 gentamicin in saline inj 1.4 mg/ml .................................. 4 gentamicin in saline inj 1.6 mg/ml .................................. 4 gentamicin in saline inj 2 mg/ml .................................. 4 gentamicin sulfate ............... 5 gentamicin sulfate (ophth) . 39 gentamicin sulfate (topical) .......................................... 42 GEODON

see ziprasidone hcl........ 22 GEODON INJ ................... 21 GIANVI TAB 3-0.02MG ..... 27 GIAZO ............................... 32 gildagia ............................. 27 GILENYA CAP 0.5MG ...... 24 GILOTRIF TAB 20MG....... 12 GILOTRIF TAB 30MG....... 12 GILOTRIF TAB 40MG....... 12 GLASSIA .......................... 41 GLEEVEC ......................... 12 glimepiride ........................ 25 glipizide ............................. 25 glipizide er ......................... 25 glipizide-metformin 2.5-250 mg ..................................... 25 glipizide-metformin 2.5-500 mg ..................................... 26 glipizide-metformin 5-500mg .......................................... 26 GLUCAGEN HYPOKIT ..... 30 GLUCAGON EMERGENCY KIT .................................... 30 GLUCOPHAGE

see metformin hcl .......... 26 GLUCOPHAGE XR

see metformin er ........... 26 GLUCOTROL

see glipizide .................. 25 GLUCOTROL XL

see glipizide er .............. 25 GLUMETZA ...................... 26 glycate .............................. 32 glycopyrrolate ................... 32

GLYSET ........................... 26 GOLYTELY ....................... 32

see gaviltye-g ................ 32 see peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........................... 32

GRALISE .......................... 24 GRALISE STARTER ........ 24 granisetron hcl .................. 31 granisol ............................. 31 GRANIX ............................ 34 GRIFULVIN V

see griseofulvin microsize ........................................ 6

griseofulvin microsize ......... 6 griseofulvin ultramicrosize .. 6 GRIS-PEG

see griseofulvin ultramicrosize .................. 6

H H.P. ACTHAR ................... 30 HALAVEN ......................... 12 HALDOL

see haloperidol lactate .. 22 HALDOL DECANOATE 100

see haloperidol decanoate ...................................... 21

HALDOL DECANOATE 50 see haloperidol decanoate ...................................... 21

halobetasol propionate ..... 44 HALOG ............................. 44 haloperidol ........................ 21 haloperidol decanoate ...... 21 haloperidol lactate....... 21, 22 HAVRIX ............................ 36 heather ............................. 27 HECTOROL

see doxercalciferol ........ 38 HEP SOD/NACL INJ 25000.......................................... 34 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML ........................... 34 heparin sod inj 10000u/ml . 34 heparin sod inj 1000u/ml ... 34 heparin sod inj 20000u/ml . 34 HEPARIN SOD INJ

2015 CalPERS eff 01/01/2015

2000U/ML ......................... 34 HEPARIN SOD INJ 2500U/ML ......................... 34 heparin sod inj 5000u/0.5ml .......................................... 34 heparin sod inj 5000u/ml ... 34 HEPARIN SODIUM/D5W .. 34 HEPARIN SODIUM/NACL 0.45% ................................ 34 HEPARIN SODIUM/SODIUM CHL .... 34 HEPATAMINE ................... 37 hepatasol 8 ....................... 37 HEPSERA

see adefovir dipivoxil .......7 HERCEPTIN ..................... 11 HETLIOZ ........................... 24 HEXALEN ......................... 10 HIBERIX............................ 36 HIPREX

see methenamine hippurate .........................5

HIZENTRA ........................ 35 HORIZANT ........................ 24 HUMALOG ........................ 25 HUMALOG KWIKPEN ...... 25 HUMALOG MIX 50/50 ...... 25 HUMALOG MIX 50/50 KWIKPEN ......................... 25 HUMALOG MIX 75/25 ...... 25 HUMALOG MIX 75/25 KWIKPEN ......................... 25 HUMATROPE ................... 30 HUMATROPE COMBO PACK ................................ 30 HUMIRA ............................ 35 HUMIRA PEN ................... 35 HUMIRA PEN-CROHNS STARTER KIT ................... 35 HUMIRA PEN-PSORIASIS STARTER KIT ................... 35 HUMULIN 70/30 ................ 25 HUMULIN 70/30 PEN ....... 25 HUMULIN N ...................... 25 HUMULIN N U-100 PEN ... 25 HUMULIN R ...................... 25 HUMULIN R U-500 (CONCENTRATE) ............ 25

HYCAMTIN see topotecan hcl .......... 13

HYCET see hydrocodone-acetaminophen 7.5-325 mg/15ml ........ 2

hydralazine hcl .................. 17 HYDREA

see hydroxyurea ............ 12 hydrochlorothiazide ........... 17 hydrocodone-acetaminophen 10-300mg ............................ 2 hydrocodone-acetaminophen 2.5-325mg ........................... 2 hydrocodone-acetaminophen 5-300mg .............................. 2 hydrocodone-acetaminophen 5-325mg .............................. 2 hydrocodone-acetaminophen 7.5-300mg ........................... 2 hydrocodone-acetaminophen 7.5-325 mg/15ml ................. 2 hydrocodone-acetaminophen 7.5-325mg ........................... 2 hydrocodone-acetaminophen tab 10-325mg ...................... 2 hydrocodone-ibuprofen 2.5-200 mg .......................... 2 hydrocodone-ibuprofen tab 7.5-200 mg .......................... 2 hydrocortisone .................. 29 HYDROCORTISONE (INTRARECTAL) .............. 32 hydrocortisone (topical) ..... 44 hydrocortisone butyrate .... 44 hydrocortisone butyrate hydrophilic lipo base ......... 44 hydrocortisone valerate..... 44 hydromorphone hcl ............. 3 hydromorphone tab 12mg er ............................................ 3 hydromorphone tab 16mg er ............................................ 3 hydromorphone tab 8mg er . 3 HYDROMORPHONE TABS 32MG .................................. 3 hydroxychloroquine sulfate .......................................... 35

hydroxyurea ...................... 12 hydroxyzine hcl ................. 40 hydroxyzine pamoate ........ 40 HYZAAR

see losartan potassium & hydrochlorothiazide ....... 14

I ibandronate sodium .......... 26 ibudone 5-200 mg ............... 2 ibudone tab 10-200mg ........ 2 ibuprofen ............................. 1 ICLUSIG ........................... 12 IDAMYCIN PFS

see idarubicin hcl .......... 10 idarubicin hcl ..................... 10 IFEX .................................. 10

see ifosfamide for inj 1 gm ...................................... 10

ifosfamide ......................... 10 IFOSFAMIDE

see ifosfamide ............... 10 ifosfamide for inj 1 gm ....... 10 IFOSFAMIDE FOR INJ 3 GM .................................... 10 ILARIS .............................. 35 ILEVRO ............................ 39 IMBRUVICA CAP 140MG . 12 IMDUR

see isosorbide mononitrate er ............... 17

imipenem-cilastatin ............. 5 imipramine hcl .................. 20 imipramine pamoate ......... 20 imiquimod ......................... 44 IMITREX

see sumatriptan succinate ...................................... 23 see sumatriptan succinate inj .................................. 23

IMITREX STATDOSE SYSTEM

see sumatriptan succinate inj .................................. 23

IMOVAX RABIES (H.D.C.V.).......................................... 36 IMURAN

see azathioprine ............ 35 INCRELEX ........................ 30

2015 CalPERS eff 01/01/2015

indapamide ....................... 17 INDERAL LA

see propranolol hcl er .... 15 INFANRIX ......................... 36 INFUMORPH 200 ...............3 INFUMORPH 500 ...............3 INLYTA ............................. 12 INSPRA

see eplerenone .............. 13 INSULIN PEN NEEDLES .. 25 INSULIN SAFETY NEEDLES ......................... 25 INSULIN SYRINGES ........ 25 INTELENCE ........................6 INTRALIPID INJ 20% ........ 37 INTRALIPID INJ 30% ........ 37 INTRON-A INJ 10MU ........ 35 INTRON-A INJ 18MU ........ 35 INTRON-A INJ 25MU ........ 35 INTRON-A INJ 50MU ........ 35 introvale 91 day ................. 27 INTUNIV............................ 22 INVANZ ...............................5 INVEGA ............................ 22 INVEGA SUST INJ 117 MG/0.75 ML ...................... 22 INVEGA SUST INJ 156MG/ML ........................ 22 INVEGA SUST INJ 234 MG/1.5 ML ........................ 22 INVEGA SUST INJ 39 MG/0.25 ML ...................... 22 INVEGA SUST INJ 78 MG/0.5 ML ........................ 22 INVIRASE ...........................6 INVOKANA TAB 100MG ... 26 INVOKANA TAB 300MG ... 26 IONOSOL-B/DEXTROSE 5% ..................................... 38 IONOSOL-MB/DEXTROSE 5% ..................................... 38 IPOL INACTIVATED IPV .. 36 ipratropium bromide (nasal) .......................................... 40 ipratropium sol inhal .......... 40 ipratropium-albuterol ......... 40 irbesartan .......................... 14 irbesartan-hydrochlorothiazid

e ........................................ 13 irinotecan .......................... 13 irinotecan hcl ..................... 13 ISENTRESS ....................... 6 ISOLYTE P ....................... 38 isolyte s ............................. 38 isoniazid .............................. 7 isoniazid tabs ...................... 7 ISORDIL TITRADOSE ...... 17

see isosorbide dinitrate . 17 isosorbide dinitrate ............ 17 isosorbide mononitrate...... 17 isosorbide mononitrate er . 17 isradipine .......................... 16 ISTALOL ........................... 40 ISTODAX .......................... 11 itraconazole ........................ 6 IXEMPRA KIT ................... 12 IXIARO .............................. 36 J JAKAFI .............................. 12 JALYN ............................... 33 jantoven ............................ 34 JANUMET ......................... 26 JANUMET XR TAB 100-1000 ........................... 26 JANUMET XR TAB 50-1000 .......................................... 26 JANUMET XR TAB 50-500MG ......................... 26 JANUVIA ........................... 26 JENTADUETO .................. 26 JEVTANA .......................... 12 JOLIVETTE ....................... 27 junel 1.5/30 21 day ........... 27 junel 1/20 21 day .............. 27 junel fe 1.5/30 28 day........ 27 junel fe 1/20 28 day .......... 27 JUXTAPID ........................ 15 K KADCYLA ......................... 11 KADIAN .............................. 3

see morphine sulfate ....... 3 KALBITOR ........................ 35 KALETRA SOL ................... 7 KALETRA TAB 100-25MG .. 7 KALETRA TAB 200-50MG .. 7 KALYDECO ...................... 41

kariva 28 day .................... 27 KAYEXALATE

see kionex ..................... 26 KAZANO ........................... 26 KCL 0.075%/D5W/NACL 0.45% ............................... 38 KCL 0.15%/D5W/LR ......... 38 KCL 0.15%/D5W/NACL 0.9% ................................. 38 kcl 0.3%/d5w/lr iv lac ri ..... 38 KCL 0.3%/D5W/NACL 0.45% ............................... 38 KCL 0.3%/D5W/NACL 0.9%.......................................... 38 KCL0.15%/D5W/NACL0.2%.......................................... 38 KCL0.15%/D5W/NACL0.225% ...................................... 38 KEFLEX

see cephalexin ................ 8 kelnor 1/35 28 day ............ 27 KENALOG ........................ 44 KEPIVANCE ..................... 12 KEPPRA

see levetiracetam .......... 19 KEPPRA XR

see levetiracetam .......... 19 KERLONE

see betaxolol hcl ........... 15 ketoconazole ...................... 6 ketoconazole (topical) ....... 42 ketoconazole shampoo ..... 43 ketoprofen ........................... 1 ketorolac tromethamine (ophth) .............................. 39 KINERET .......................... 35 kionex ............................... 26 KLARON

see sulfacetamide sodium (acne) ............................ 42

KLONOPIN see clonazepam ............ 18

KLOR-CON 10 .................. 36 KLOR-CON 8 .................... 36 klor-con m15 ..................... 36 klor-con m20 ..................... 37 klor-con pow 20meq ......... 37 KOMBIGLYZE XR

2015 CalPERS eff 01/01/2015

2.5-1000MG ...................... 26 KOMBIGLYZE XR 5-1000MG ......................... 26 KOMBIGLYZE XR 5-500MG .......................................... 26 KORLYM ........................... 30 kristalose ........................... 32 KUVAN ............................. 28 KYNAMRO ........................ 15 L labetalol hcl ....................... 15 LAC-HYDRIN

see ammonium lactate .. 44 see laclotion lot 12% ..... 44

laclotion lot 12% ................ 44 LACRISERT ...................... 40 LACTATED RINGERS VIAFLEX ........................... 38 lactulose ............................ 32 lactulose (encephalopathy) .......................................... 32 LAMICTAL

see lamotrigine .............. 19 LAMICTAL CHEWABLE DISPERS

see lamotrigine .............. 19 LAMICTAL ODT ................ 19 LAMICTAL STARTER ....... 19 LAMICTAL XR .................. 19

see lamotrigine .............. 19 LAMISIL ..............................6

see terbinafine hcl ...........6 lamivudine ....................... 6, 7 lamivudine-zidovudine ........7 lamotrigine ........................ 19 LANOXIN

see digoxin .................... 16 see digoxin inj ................ 16

LANOXIN PEDIATRIC ...... 16 LANOXIN TAB .................. 16 lansoprazole ...................... 33 LANTUS ............................ 25 LANTUS SOLOSTAR ....... 25 larin 1/20 ........................... 27 larin fe 1.5/30 .................... 27 larin fe 1/20 ....................... 27 LASIX

see furosemide .............. 17

LASTACAFT ..................... 39 latanoprost ........................ 40 LATUDA ............................ 22 LAZANDA ........................... 3 LEENA TAB ...................... 27 leflunomide ....................... 35 LESCOL

see fluvastatin sodium ... 14 LESCOL XL ...................... 14 lessina 28 day ................... 27 LETAIRIS .......................... 17 letrozole ............................ 11 leucovor ca inj ................... 12 leucovorin calcium ............ 12 leucovorin calcium 500 mg 12 leucovorin calcium inj 10 mg/ml ................................ 12 LEUKERAN ...................... 10 LEUKINE .......................... 34 leuprolide acetate ............. 11 levalbuterol conc 1.25mg/0.5ml .................... 41 levalbuterol hcl .................. 41 LEVALBUTEROL HCL...... 41 LEVAQUIN

see levofloxacin ............... 9 see levofloxacin in d5w ... 9

LEVEMIR .......................... 25 LEVEMIR FLEXPEN ......... 25 levetiracetam .................... 19 levobunolol hcl .................. 40 LEVOBUNOLOL HCL ....... 40 levocarnitine (metabolic modifiers) .......................... 28 levocetirizine soln 2.5mg/5ml .......................................... 40 levocetirizine tab 5 mg ...... 40 levofloxacin ......................... 9 levofloxacin (ophth) ........... 39 levofloxacin in d5w .............. 9 levonest 28 day ................. 27 levonorgestrel (emergency oc) ..................................... 27 levonorgestrel-ethinyl estradiol (91-day) .............. 27 levora 0.15/30 28 day ....... 27 levorphanol tartrate ............. 3 levothyroxine sodium ........ 31

LEVOXYL ......................... 31 LEXAPRO

see escitalopram oxalate ...................................... 20

LEXIVA ............................... 6 LIALDA ............................. 32 lidocaine ........................... 44 lidocaine hcl ...................... 44 lidocaine hcl (local anesth.) 4 lidocaine hcl (mouth-throat).......................................... 45 lidocaine inj 0.5% ................ 4 lidocaine inj 1% ................... 4 lidocaine inj 1.5% ................ 4 lidocaine inj 2% ................... 4 lidocaine-prilocaine ........... 44 LIDODERM

see lidocaine ................. 44 LINZESS ........................... 33 liothyronine sodium ........... 31 LIPITOR

see atorvastatin calcium 14 LIPOSYN III INJ 10% ........ 37 LIPTRUZET ...................... 15 lisinopril ............................. 13 lisinopril & hydrochlorothiazide ........... 13 lithium carbonate .............. 24 LITHIUM CITRATE ........... 24 LITHOBID

see lithium carbonate .... 24 LIVALO ............................. 14 LO LOESTRIN FE ............ 27 LO MINASTRIN FE ........... 27 LOCOID

see hydrocortisone butyrate ......................... 44

LOCOID LIPOCREAM see hydrocortisone butyrate hydrophilic lipo base .............................. 44

LODOSYN see carbidopa................ 21

LOESTRIN 1.5/30-21 see junel 1.5/30 21 day . 27 see microgestin 1.5/30 21 day ................................ 27

LOESTRIN 1/20-21

2015 CalPERS eff 01/01/2015

see junel 1/20 21 day .... 27 see larin 1/20 ................. 27 see microgestin 1/20 21 day ................................ 27

LOESTRIN FE 1.5/30 see junel fe 1.5/30 28 day ...................................... 27 see larin fe 1.5/30 .......... 27 see microgestin fe 1.5/30 28 day............................ 27

LOESTRIN FE 1/20 see junel fe 1/20 28 day 27 see larin fe 1/20 ............. 27 see microgestin fe 1/20 28 day ................................ 27

LOFIBRA see fenofibrate ............... 15 see fenofibrate micronized ...................................... 15

LOKARA LOTN 0.05% ...... 44 lomedia 24 fe .................... 27 LOMOTIL

see diphenoxylate w/ atropine ......................... 33

LOMUSTINE ..................... 10 loperamide hcl ................... 33 LOPID

see gemfibrozil .............. 15 LOPRESSOR

see metoprolol tartrate .. 15 LOPRESSOR HCT

see metoprolol & hctz tab 100-25mg ...................... 15 see metoprolol & hctz tab 50-25mg ........................ 15

LOPROX SHAMPOO see ciclopirox shampoo 1% ................................. 42

lorazepam ......................... 18 lortab ...................................2 loryna 28 day .................... 27 losartan potassium ............ 14 losartan potassium & hydrochlorothiazide ........... 14 LOTEMAX ......................... 39 LOTENSIN

see benazepril hcl ......... 13 LOTENSIN HCT

see benazepril & hydrochlorothiazide ....... 13

LOTREL see amlodipine besylate-benazepril hcl .. 13

LOTRONEX ...................... 33 lovastatin ........................... 14 LOVENOX

see enoxaparin sodium . 34 low-ogestrel 28 day ........... 27 loxapine succinate ............ 22 LUCENTIS ........................ 40 LUFYLLIN ......................... 41 LUMIGAN ......................... 40 LUMIZYME ....................... 28 LUPANETA PACK ............ 28 LUPR DEP-PED INJ 15MG .......................................... 11 LUPR DEP-PED INJ 30MG (3-MONTH) ....................... 11 LUPRON DEP INJ 11.25MG .......................................... 11 LUPRON DEPOT ............. 11 LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 12 LUPRON DEPOT INJ 30MG (3-MONTH) ....................... 12 LUPRON DEPOT INJ 45MG .......................................... 12 LUPRON DEPOT-PED ..... 12 lutera 28 day ..................... 27 LUVOX CR

see fluvoxamine maleate er ................................... 18

LUXIQ see betamethasone valerate ......................... 43

LUZU ................................ 42 LYRICA ............................. 19 LYSODREN ...................... 12 LYSTEDA

see tranexamic acid ...... 35 lyza ................................... 27 M MACROBID

see nitrofurantoin monohyd macro .............. 5

MACRODANTIN ................. 5

see nitrofurantoin macrocrystal .................... 5

mafenide acetate .............. 42 magnesium sulfate ............ 37 MAGNESIUM SULFATE .. 37 MAGNESIUM SULFATE IN D5W .................................. 37 MAKENA .......................... 30 MALARONE

see atovaquone-proguanil hcl tab 250-100 mg ......... 6

malathion .......................... 45 maprotiline hcl .................. 20 MARINOL

see dronabinol............... 31 marlissa 28 day................. 27 MARPLAN ........................ 20 MATULANE ...................... 12 matzim la .......................... 16 MAVIK

see trandolapril.............. 13 MAXALT

see rizatriptan benzoate 23 MAXALT-MLT

see rizatriptan benzoate 23 MAXIDEX ......................... 39 MAXIPIME .......................... 8

see cefepime inj 1gm ...... 8 see cefepime inj 2gm ...... 8

MAXITROL see neomycin-polymy-dexameth .................................... 38

MAXZIDE see triamt/hctz tab 75-50mg ........................ 17

MAXZIDE-25 see triamt/hctz tab 37.5-25 ...................................... 17

meclizine hcl ..................... 31 MEDROL

see methylpred tab 16mg ...................................... 29 see methylpred tab 32mg ...................................... 29 see methylpred tab 4mg 29 see methylpred tab 8mg 29

MEDROL DOSEPAK

2015 CalPERS eff 01/01/2015

see methylpred pak 4mg ...................................... 29

MEDROL TAB 2MG .......... 29 medroxyprogesterone acetate .............................. 30 medroxyprogesterone acetate (contraceptive) ..... 27 mefenamic acid ...................1 mefloquine hcl .....................6 MEGACE ES ..................... 12 MEGACE ORAL

see megestrol acetate ... 12 megestrol acetate ............. 12 MEKINIST ......................... 12 MELOXICAM ......................1 meloxicam tabs ...................1 melphalan hcl .................... 10 MENACTRA ...................... 36 MENOMUNE-A/C/Y/W-135 .......................................... 36 MENOSTAR ...................... 29 MENTAX ........................... 42 MENVEO .......................... 36 MEPRON

see atovaquone ...............5 mercaptopurine ................. 11 meropenem .........................5 MERREM

see meropenem ..............5 mesalamine enema ........... 32 mesna ............................... 13 MESNEX ........................... 13

see mesna ..................... 13 MESTINON

see pyridostigmine bromide ......................... 24

MESTINON SYRUP .......... 24 MESTINON TIMESPAN .... 24 METADATE CD

see methylphenidate hcl 22 metadate tab er 20 mg ...... 22 metformin er ...................... 26 metformin hcl .................... 26 methadone hcl ....................3 METHADONE INJ 10MG/ML ............................................3 METHADOSE

see methadone hcl ..........3

methazolamide ................. 17 methenamine hippurate ...... 5 METHERGINE

see methylergonovine maleate ......................... 30

methimazole ..................... 31 methotrexate sodium inj .... 11 methotrexate sodium tabs . 35 methoxsalen rapid ............ 43 methscopolamine bromide 32 methyclothiazide ............... 17 methylergonovine maleate 30 METHYLIN

see methylphenidate hcl 22 METHYLIN CHEW TAB .... 22 methylphenidate hcl .... 22, 23 methylphenidate hcl er ...... 23 methylpr ace inj 40mg/ml .. 29 methylpr ace inj 80mg/ml .. 29 methylpr ss inj 125mg ....... 29 methylpr ss inj 1gm ........... 29 methylpr ss inj 40mg ......... 29 methylpr ss inj 500mg ....... 29 methylpred pak 4mg ......... 29 methylpred tab 16mg ........ 29 methylpred tab 32mg ........ 29 methylpred tab 4mg .......... 29 methylpred tab 8mg .......... 29 metipranolol ...................... 40 metoclopramide hcl ........... 31 metoclopramide hcl inj 5 mg/ml ................................ 31 metolazone ....................... 17 metoprolol & hctz tab 100-25mg .......................... 15 metoprolol & hctz tab 100-50mg .......................... 15 metoprolol & hctz tab 50-25mg ............................ 15 metoprolol succinate ......... 15 metoprolol tartrate ............. 15 METOZOLV ODT ............. 31 METRO IV .......................... 5 METROCREAM

see metronidazole (topical) ......................... 44 see rosadan cre 0.75% . 45

METROGEL

see metronidazole (topical) ......................... 44

METROGEL-VAGINAL see metronidazole vaginal ...................................... 34

METROLOTION see metronidazole (topical) ......................... 44

metronidazole ..................... 5 metronidazole (topical) ..... 44 metronidazole inj................. 5 metronidazole vaginal ....... 34 MEVACOR

see lovastatin ................ 14 mexiletine hcl .................... 14 MIACALCIN

see calcitonin (salmon) nasal spray .................... 30

MIACALCIN INJ 200U/ML 30 MICARDIS HCT

see telmisartan-hydrochlorothiazide ............................. 14

miconazole nitrate vaginal 34 microgestin 1.5/30 21 day . 27 microgestin 1/20 21 day .... 27 microgestin fe 1.5/30 28 day.......................................... 27 microgestin fe 1/20 28 day 27 MICRO-K

see potassium chloride caps er .......................... 37

MICROZIDE see hydrochlorothiazide 17

midodrine hcl .................... 17 migergot ............................ 23 millipred ............................ 29 MINASTRIN 24 FE ........... 27 MINIPRESS

see prazosin hcl ............ 13 minitran ............................. 17 MINIVELLE ....................... 29 MINOCIN

see minocycline hcl ....... 10 minocycline hcl ................. 10 minoxidil ............................ 17 MIRAPEX ......................... 21

see pramipexole

2015 CalPERS eff 01/01/2015

dihydrochloride .............. 21 MIRAPEX ER .................... 21 MIRCETTE

see kariva 28 day .......... 27 see pimtrea pack ........... 28 see viorele ..................... 28

mirtazapine ....................... 20 misoprostol ........................ 33 mitomycin .......................... 10 mitoxantrone hcl ................ 12 M-M-R II W/DILUENT 10 DOS .................................. 36 MOBIC

see meloxicam tabs .........1 modafinil............................ 24 moderiba pak ......................7 moderiba tab 200mg ...........7 moexipril hcl ...................... 13 moexipril-hydrochlorothiazide ........................................ 13 mometasone furoate ......... 44 MONODOX

see doxycycline (monohydrate) ............... 10

MONONESSA ................... 27 montelukast sodium .......... 41 MORPHINE SUL 20MG/ML ORAL SOL ..........................3 morphine sulfate .................3 MORPHINE SULFATE .......3 morphine sulfate beads .......3 morphine sulfate ext-rel tab3, 4 MOVIPREP ....................... 32 MOXATAG ..........................9 MOXEZA ........................... 39 moxifloxacin hcl ...................9 MOZOBIL .......................... 34 MS CONTIN

see morphine sulfate ext-rel tab .................... 3, 4

MULTAQ ........................... 14 mupirocin .......................... 42 mupirocin calcium (topical) 42 MUSTARGEN ................... 10 my way .............................. 27 MYALEPT ......................... 30 MYAMBUTOL

see ethambutol hcl .......... 7 MYCAMINE ........................ 6 MYCOBUTIN

see rifabutin ..................... 7 mycophenolate mofetil ...... 36 mycophenolate sodium ..... 36 MYFORTIC

see mycophenolate sodium ........................... 36

MYOBLOC ........................ 40 myorisan ........................... 42 MYOZYME ........................ 28 MYRBETRIQ .................... 34 MYSOLINE

see primidone ................ 19 myzilra .............................. 27 N nabumetone ........................ 1 nadolol .............................. 15 nadolol & bendroflumethiazide ......... 15 nafcillin sodium ................... 9 NAFTIN ............................. 42 NAGLAZYME .................... 29 NALLPEN ISO-OSMOTIC IN DE ....................................... 9 NALLPEN/DEXTROSE ....... 9 naloxone hcl ...................... 24 naltrexone hcl ................... 24 NAMENDA SOL 10MG/5ML .......................................... 20 NAMENDA XR .................. 20 NAMENDA XR TITRATION PACK ................................ 20 naphazoline 0.1% ............. 40 NAPRELAN ........................ 1 NAPROSYN

see naproxen .................. 1 naproxen ............................. 1 naproxen sodium ................ 1 naratriptan hcl ................... 23 NARDIL

see phenelzine sulfate ... 20 NASONEX ........................ 41 NATACYN ......................... 39 nateglinide ........................ 26 NAVELBINE

see vinorelbine tartrate .. 11

NEBUPENT ........................ 5 necon 0.5/35 28 day ......... 28 necon 1/35 28 day ............ 28 necon 10/11 28 day .......... 28 NECON 7/7/7 .................... 28 NECON TAB 1/50-28 ........ 28 nefazodone hcl ................. 20 neomycin sulfate ................. 5 neomycin/polymyxin b gu . 45 neomycin-bacitracin zn-polymyxin ..................... 39 neomycin-polymy-dexameth.......................................... 38 neomycin-polymy-gramicid.......................................... 39 neomycin-polymyxin-hc (ophth) .............................. 38 neomycin-polymyxin-hc (otic).......................................... 45 NEORAL ........................... 36

see cyclosporine modified (for microemulsion) ....... 36 see gengraf ................... 36

NEOSPORIN see neomycin-polymy-gramicid ...................................... 39

NEOSPORIN GU IRRIGANT see neomycin/polymyxin b gu .................................. 45

NEPHRAMINE .................. 37 NEPTAZANE

see methazolamide ....... 17 NESINA ............................ 26 NEULASTA ....................... 34 NEUMEGA ....................... 34 NEUPOGEN ..................... 34 NEUPRO .......................... 21 NEURONTIN

see gabapentin.............. 19 NEVANAC ........................ 39 nevirapine ........................... 6 NEVIRAPINE ...................... 6 NEXAVAR ........................ 12 NEXIUM GRA 10MG DR .. 33 NEXIUM GRA 2.5MG DR . 33 NEXIUM GRA 20MG DR .. 33 NEXIUM GRA 40MG DR .. 33

2015 CalPERS eff 01/01/2015

NEXIUM GRA 5MG DR .... 33 NEXIUM I.V.

see esomeprazole sodium ...................................... 33

next choice tab 1.5mg ....... 28 niacin (antihyperlipidemic). 15 niacor ................................ 15 NIASPAN

see niacin (antihyperlipidemic) ....... 15

nicardipine hcl ................... 16 NICOTROL INHALER ....... 24 NICOTROL NS ................. 24 nifedical ............................. 16 nifedipine........................... 16 nifedipine er ...................... 16 NILANDRON ..................... 12 nimodipine......................... 16 NIPENT ............................. 11 nisoldipine ......................... 16 nitro-bid ............................. 17 NITRO-DUR ...................... 17

see minitran ................... 17 nitrofurantoin .......................5 nitrofurantoin macrocrystal ..5 nitrofurantoin monohyd macro ..................................5 NITROGLYCERIN ............ 17 NITROGLYCERIN LINGUAL .......................................... 17 nitroglycerin patches ......... 17 NITROLINGUAL SPR PUMPSPRA ...................... 17 NITROMIST ...................... 17 NITROSTAT ...................... 17 nizatidine ........................... 32 NIZORAL

see ketoconazole shampoo ........................ 43

NORA-BE TAB .................. 28 NORCO

see hydrocodone-acetaminophen 5-325mg .....................2 see hydrocodone-acetaminophen 7.5-325mg ..................2 see

hydrocodone-acetaminophen tab 10-325mg ............. 2

NORDITROPIN FLEXPRO .......................................... 30 NORDITROPIN NORDIFLEX PEN ............. 30 norethindrone (contraceptive) .................. 28 norethindrone acetate ....... 30 norgestimate-ethinyl estradiol (triphasic) ........... 28 NORINYL 1+35

see cyclafem 1/35 28 day ...................................... 27 see necon 1/35 28 day .. 28 see nortrel 1/35 21 day .. 28 see nortrel 1/35 28 day .. 28 see pirmella 1/35 28 day ...................................... 28

NORITATE ........................ 44 normosol-m ....................... 38 NORMOSOL-R ................. 38 NORPACE

see disopyramide phosphate ..................... 14

NORPACE CR .................. 14 NORPRAMIN

see desipramine hcl ...... 20 NOR-QD

see camila 28 day ......... 27 see heather ................... 27 see norethindrone (contraceptive) .............. 28

nortrel 0.5/35 28 day ......... 28 nortrel 1/35 21 day ............ 28 nortrel 1/35 28 day ............ 28 nortrel 7/7/7 28 day ........... 28 nortriptyline hcl .................. 20 NORVASC

see amlodipine besylate 16 NORVIR .............................. 6 NOVAREL INJ 10000UNT 30 NOVOLIN 70/30 ................ 25 NOVOLIN 70/30 RELION . 25 NOVOLIN N ...................... 25 NOVOLIN N RELION ........ 25 NOVOLIN R ...................... 25 NOVOLIN R RELION ........ 25

NOVOLOG ....................... 25 NOVOLOG FLEXPEN ...... 25 NOVOLOG MIX 70/30 ...... 25 NOVOLOG MIX 70/30 PREFILL ........................... 25 NOVOLOG PENFILL ........ 25 NOXAFIL ............................ 6 NPLATE ............................ 35 NUCYNTA .......................... 4 NUCYNTA ER .................... 4 NUEDEXTA ...................... 24 NULOJIX .......................... 36 NULYTELY/FLAVOR PACKS ............................. 32

see gavilyte-n ................ 32 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ...................................... 32 see trilyte ....................... 33

NUTROPIN AQ INJ 20MG/2ML ........................ 30 NUTROPIN AQ NUSPIN 5 30 NUTROPIN AQ PEN ........ 30 NUVARING ....................... 28 NUVIGIL ........................... 24 nyamyc ............................. 42 NYMALIZE ........................ 16 nystatin ............................... 6 nystatin (mouth-throat) ...... 45 nystatin (topical)................ 42 nystatin pow 100000 ......... 42 nystop ............................... 42 O OCELLA TAB 3-0.03MG ... 28 OCTAGAM ....................... 35 octreotide acetate ............. 30 OCUFEN

see flurbiprofen sodium . 39 OCUFLOX

see ofloxacin (ophth) ..... 39 ofloxacin (ophth) ............... 39 ofloxacin (otic) .................. 45 ogestrel 28 day ................. 28 olanzapine ........................ 22 olanzapine odt .................. 22 OLUX

see clobetasol propionate

2015 CalPERS eff 01/01/2015

...................................... 43 OLUX-E

see clobetasol propionate emulsion ........................ 43

OLYSIO...............................7 OMECLAMOX-PAK .......... 33 omega-3-acid ethyl esters . 15 omeprazole ....................... 33 OMEPRAZOLE-SODIUM BICARBONATE ................ 33 OMNARIS ......................... 41 OMNITROPE 10MG ......... 30 OMNITROPE 5.8MG ........ 30 OMNITROPE 5MG ........... 30 ONCASPAR ...................... 12 ondansetron hcl ................ 31 ondansetron hcl inj ............ 31 ondansetron hcl inj 4 mg/2ml .......................................... 31 ondansetron hcl oral soln .. 31 ondansetron odt ................ 31 ONFI SUS 2.5MG/ML ....... 19 ONFI TAB 10MG ............... 19 ONGLYZA ......................... 26 ONMEL ...............................6 OPANA

see oxymorphone hcl ......4 OPANA ER (CRUSH RESISTANT ........................4 OPSUMIT.......................... 17 OPTIVAR

see azelastine hcl (ophth) ...................................... 39

ORACEA ........................... 45 ORAP ................................ 22 ORAPRED ODT TAB 10MG .......................................... 29 ORAPRED ODT TAB 15MG .......................................... 29 ORAPRED ODT TAB 30MG .......................................... 29 ORENCIA.......................... 35 ORENITRAM TAB 0.125MG .......................................... 18 ORENITRAM TAB 0.25MG .......................................... 17 ORENITRAM TAB 1MG .... 18 ORENITRAM TAB 2.5MG . 18

ORFADIN .......................... 29 orsythia 28 day ................. 28 ORTHO EVRA

see xulane dis 150-35 ... 28 ORTHO MICRONOR

see errin 28 day ............ 27 see lyza ......................... 27

ORTHO TRI-CYCLEN see norgestimate-ethinyl estradiol (triphasic) ........ 28 see tri-previfem 28 day .. 28 see tri-sprintec 28 day ... 28

ORTHO TRI-CYCLEN LO . 28 ORTHO-CYCLEN

see previfem 28 day ...... 28 see sprintec 28 day ....... 28

ORTHO-NOVUM 7/7/7 see cyclafem 7/7/7 28 day ...................................... 27 see nortrel 7/7/7 28 day . 28

OSENI TAB 12.5-15MG .... 26 OSENI TAB 12.5-30MG .... 26 OSENI TAB 12.5-45MG .... 26 OSENI TAB 25-15MG ....... 26 OSENI TAB 25-30MG ....... 26 OSENI TAB 25-45MG ....... 26 OSMOPREP ..................... 32 OTEZLA ............................ 35 OTREXUP ........................ 35 OVCON-35

see balziva 28 day......... 27 see briellyn 28 day ........ 27 see gildagia ................... 27 see philith ...................... 28 see vyfemia 28 day ....... 28 see zenchent tab ........... 28

OVIDE see malathion ................ 45

oxacillin sodium .................. 9 oxaliplatin .......................... 12 OXANDRIN

see oxandrolone ............ 25 oxandrolone ...................... 25 oxaprozin ............................ 1 oxcarbazepine .................. 19 OXECTA ............................. 4 OXISTAT .......................... 42 OXSORALEN ................... 45

OXSORALEN ULTRA see methoxsalen rapid .. 43

OXTELLAR XR ................. 19 oxybutynin chloride ........... 34 oxycodone hcl ..................... 4 OXYCODONE HCL ............ 4 oxycodone w/ acetaminophen 10-325mg .. 4 oxycodone w/ acetaminophen 2.5-325mg . 4 oxycodone w/ acetaminophen 5-325mg .... 4 oxycodone w/ acetaminophen 7.5-325mg . 4 oxycodone-aspirin............... 4 oxycodone-ibuprofen .......... 4 OXYCONTIN ...................... 4 oxymorphone hcl ................ 4 OXYTROL ........................ 34 P pacerone ........................... 14 paclitaxel ........................... 11 PAMELOR

see nortriptyline hcl ....... 20 pamidronate inj 30/10ml ... 26 pamidronate inj 6mg/ml .... 26 pamidronate inj 90/10ml ... 26 PAMINE

see methscopolamine bromide ......................... 32

PAMINE FORTE see methscopolamine bromide ......................... 32

PANCREAZE .................... 33 PANDEL ........................... 44 PANRETIN ....................... 45 pantoprazole sodium ........ 33 paricalcitol ......................... 38 PARLODEL

see bromocriptine mesylate ........................ 21

PARNATE see tranylcypromine sulfate ........................... 20

paromomycin sulfate ........... 5 paroxetine er tab ............... 20 paroxetine hcl ................... 20 paser d/r ............................. 7

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PATADAY ......................... 39 PATANASE ....................... 40 PATANOL ......................... 39 PAXIL ................................ 20

see paroxetine hcl ......... 20 PAXIL CR

see paroxetine er tab ..... 20 PCE ....................................9 PEDIAPRED

see pred sod pho sol 5mg/5ml ......................... 29

pedi-dri .............................. 42 PEDVAX HIB .................... 36 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........... 32 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 32 PEGANONE ...................... 19 PEGASYS ......................... 35 PEGASYS PROCLICK ..... 35 PEG-INTRON ................... 35 PEG-INTRON REDIPEN... 35 PENICILLIN G POT IN DEXTROSE ........................9 penicillin g potassium ..........9 penicillin g procaine ............9 penicillin g sodium ...............9 penicillin v potassium ..........9 PENNSAID ........................ 45

see diclofenac sol 1.5% . 44 PENTAM 300 ......................5 PENTASA ......................... 32 pentoxifylline ..................... 35 PEPCID

see famotidine ............... 32 PERCOCET

see endocet .....................2 see oxycodone w/ acetaminophen 10-325mg ........................................4 see oxycodone w/ acetaminophen 2.5-325mg ........................................4 see oxycodone w/ acetaminophen 5-325mg .4 see oxycodone w/ acetaminophen 7.5-325mg

........................................ 4 see roxicet tab 5-325mg .. 4

PERCODAN see oxycodone-aspirin .... 4

PERFOROMIST ............... 41 PERIDEX

see chlorhexidine gluconate (mouth-throat) ...................................... 45 see periogard soln 0.12% ...................................... 45

perindopril erbumine ......... 13 periogard soln 0.12% ........ 45 PERJETA .......................... 11 permethrin ......................... 45 perphenazine .................... 22 PERTZYE ......................... 33 PEXEVA ........................... 20 pfizerpen ............................. 9 phenadoz .......................... 31 phenelzine sulfate ............. 20 PHENERGAN

see promethazine hcl .... 31 phenobarbital .................... 19 phenobarbital sodium........ 19 PHENOBARBITAL SODIUM .......................................... 19 phenytek ........................... 19 PHENYTEK

see phenytoin sodium extended ....................... 19

phenytoin .......................... 19 phenytoin inj 50mg/ml ....... 19 phenytoin sodium extended .......................................... 19 philith ................................ 28 PHOSLO

see calcium acetate (phosphate binder) ........ 30

PHOSLYRA ...................... 30 PHOSPHOLINE IODIDE ... 40 PICATO ............................ 45 PILOCARPINE HCL.......... 40 pilocarpine hcl (oral).......... 45 pimtrea pack ..................... 28 pindolol ............................. 15 pioglitazone hcl ................. 26 pioglitazone hcl-glimepiride

.......................................... 26 pioglitazone hcl-metformin hcl ..................................... 26 piperacillin sodium-tazobactam sodium.......................................... 10 pirmella 1/35 28 day ......... 28 piroxicam ............................ 1 PLAN B

see levonorgestrel (emergency oc) ............. 27

PLAN B ONE-STEP see levonorgestrel (emergency oc) ............. 27 see my way ................... 27 see next choice tab 1.5mg ...................................... 28

PLAQUENIL see hydroxychloroquine sulfate ........................... 35

PLASMA-LYTE A.............. 38 PLASMA-LYTE-148 .......... 38 PLASMA-LYTE-56/D5W ... 38 PLAVIX

see clopidogrel bisulfate 35 PLETAL

see cilostazol................. 35 podofilox ........................... 45 polyethylene glycol 3350 .. 33 polymyxin b sulfate ............. 5 polymyxin b-trimethoprim .. 39 POLYTRIM

see polymyxin b-trimethoprim ............... 39

POMALYST ...................... 12 PONSTEL

see mefenamic acid ........ 1 portia 28 day ..................... 28 potassium chloride ...... 37, 38 POTASSIUM CHLORIDE . 37 POTASSIUM CHLORIDE 0.15% ............................... 38 POTASSIUM CHLORIDE 0.22% ............................... 38 POTASSIUM CHLORIDE 0.3%/D .............................. 38 potassium chloride caps er.......................................... 37

2015 CalPERS eff 01/01/2015

potassium chloride in nacl . 38 POTASSIUM CHLORIDE IN NACL ................................ 38 potassium chloride microencapsulated crystals cr ....................................... 37 POTASSIUM CITRATE (ALKALINIZER) TAB ......... 34 POTIGA ............................ 19 PRADAXA ......................... 34 pramipexole dihydrochloride .......................................... 21 PRANDIMET ..................... 26 PRANDIN

see repaglinide .............. 26 PRAVACHOL

see pravastatin sodium.. 14 pravastatin sodium ............ 14 prazosin hcl ....................... 13 PRECOSE

see acarbose ................. 25 PRED MILD ...................... 39 pred sod pho sol 5mg/5ml . 29 PRED-G ............................ 38 PRED-G S.O.P. ................ 38 prednicarbate .................... 44 PREDNICARBATE ........... 44 PREDNISOLONE ACETATE (OPHTH) ........................... 39 prednisolone sodium phosphate (ophth) ............. 39 prednisolone sol 15mg/5ml .......................................... 29 prednisolone sol 25mg/5ml .......................................... 29 prednisolone syrup 15 mg/5ml .............................. 29 prednisone con 5mg/ml ..... 29 prednisone pak 10mg ....... 29 prednisone pak 5mg ......... 29 prednisone sol 5mg/5ml .... 29 prednisone tab 10mg ........ 30 prednisone tab 1mg .......... 29 prednisone tab 2.5mg ....... 29 prednisone tab 20mg ........ 30 prednisone tab 50mg ........ 30 prednisone tab 5mg .......... 29 PREGNYL W/DILUENT

BENZYL ............................ 30 PRELONE

see prednisolone syrup 15 mg/5ml .......................... 29

PREMARIN ....................... 29 PREMARIN CREAM ......... 29 PREMARIN INJ ................ 29 premasol 10% ................... 37 premasol 6% ..................... 37 PREMPHASE ................... 29 PREMPRO ........................ 29 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) .......................................... 38 PREPOPIK ....................... 33 PREVACID

see lansoprazole ........... 33 PREVACID SOLUTAB ...... 33 prevalite ............................ 15 previfem 28 day ................ 28 PREVPAC

see amoxicillin-clarithromycin w/ lansoprazole ............. 33

PREZISTA ...................... 6, 7 PRIALT ............................... 1 PRIFTIN .............................. 7 PRILOSEC ........................ 33

see omeprazole ............. 33 PRIMAQUINE PHOSPHATE ............................................ 6 PRIMAXIN IV

see imipenem-cilastatin ... 5 primidone .......................... 19 PRIMSOL SOL 50MG/5ML . 5 PRINIVIL

see lisinopril .................. 13 PRISTIQ ........................... 20 PRIVIGEN ......................... 35 PROAIR HFA .................... 41 probenecid .......................... 1 PROCALAMINE ................ 37 PROCARDIA XL

see nifedical .................. 16 see nifedipine er ............ 16

prochlorperazine inj 5 mg/ml .......................................... 31 prochlorperazine maleate . 31

prochlorperazine supp ...... 31 PROCRIT ......................... 34 procto-pak ......................... 42 proctozone hc ................... 43 PROCYSBI ....................... 29 progesterone micronized .. 31 PROGLYCEM SUS 50MG/ML .......................... 30 PROGRAF ........................ 36

see tacrolimus ............... 36 PROLASTIN-C.................. 41 PROLENSA ...................... 40 PROLEUKIN ..................... 11 PROLIA ............................ 30 PROMACTA ..................... 35 promethazine hcl .............. 31 promethegan .................... 31 PROMETRIUM

see progesterone micronized ..................... 31

propafenone hcl ................ 14 proparacaine hcl ............... 40 propranolol & hydrochlorothiazide ........... 15 propranolol hcl er .............. 15 propranolol inj 1mg/ml ...... 15 propranolol sol .................. 16 propranolol tab .................. 16 propylthiouracil ................. 31 PROQUAD ....................... 36 PROSCAR

see finasteride ............... 33 PROSOL ........................... 37 PROTONIX ....................... 33

see pantoprazole sodium ...................................... 33

PROTOPIC ....................... 45 protriptyline hcl ................. 20 PROVENTIL HFA ............. 41 PROVERA

see medroxyprogesterone acetate .......................... 30

PROVIGIL see modafinil ................. 24

PROZAC see fluoxetine hcl .......... 20

PROZAC WEEKLY see fluoxetine hcl .......... 20

2015 CalPERS eff 01/01/2015

PRUDOXIN CRE 5% ........ 43 PULMICORT

see budesonide (inhalation) ..................... 41

PULMICORT FLEXHALER .......................................... 41 PULMICORT INH SUSP 1MG/2ML .......................... 41 PULMOZYME ................... 41 PURINETHOL

see mercaptopurine ....... 11 PYLERA ............................ 33 pyrazinamide .......................7 pyridostigmine bromide ..... 24 Q QNASL .............................. 41 QUALAQUIN

see quinine sulfate ..........6 QUARTETTE .................... 28 quasense 91 day ............... 28 QUDEXY XR ..................... 19 QUESTRAN

see cholestyramine ....... 14 QUESTRAN LIGHT

see prevalite .................. 15 quetiapine fumarate .......... 22 QUILLIVANT XR ............... 23 quinapril hcl ....................... 13 quinapril-hydrochlorothiazide .......................................... 13 quinidine gluconate er ....... 14 quinidine sulfate ................ 14 quinine sulfate .....................6 QVAR ................................ 41 R RABAVERT ....................... 36 rabeprazole sodium .......... 33 raloxifene hcl ..................... 30 ramipril .............................. 13 RANEXA ........................... 17 ranitidine hcl ...................... 32 RAPAFLO ......................... 33 RAPAMUNE ...................... 36

see sirolimus tab 0.5 mg 36 RAVICTI ............................ 30 RAYOS TAB 1MG ............. 30 RAYOS TAB 2MG ............. 30 RAYOS TAB 5MG ............. 30

RAZADYNE see galantamine hydrobromide ................ 20

RAZADYNE ER see galantamine hydrobromide ................ 20

REBETOL ........................... 7 see ribasphere ................ 7 see ribavirin 200mg ......... 7

REBIF ............................... 24 REBIF TITRATION PACK . 24 RECLAST

see zoledronic inj 5/100ml ...................................... 26

reclipsen 28 day ................ 28 RECOMBIVAX HB ............ 36 RECTIV ............................. 45 REGLAN

see metoclopramide hcl 31 REGRANEX ...................... 45 RELENZA DISKHALER ...... 7 RELISTOR ........................ 33 RELPAX ............................ 23 REMERON

see mirtazapine ............. 20 REMERON SOLTAB

see mirtazapine ............. 20 REMICADE ....................... 35 REMODULIN .................... 18 RENAGEL ......................... 30 RENVELA PAK ................. 30 RENVELA TAB 800MG .... 30 repaglinide ........................ 26 REPREXAIN

see hydrocodone-ibuprofen 2.5-200 mg ...................... 2 see ibudone 5-200 mg ..... 2

reprexain 10/200 ................. 2 REQUIP

see ropinirole hydrochloride ................. 21

REQUIP XL see ropinirole hydrochloride ................. 21

RESCRIPTOR .................... 7 RESTASIS ........................ 40 RESTORIL

see temazepam............. 23 RETIN-A

see tretinoin .................. 42 RETIN-A MICRO PUMP ... 42 RETROVIR

see zidovudine ................ 7 RETROVIR IV INFUSION ... 7 REVATIO .......................... 18

see sildenafil citrate (pulmonary hypertension) ...................................... 18

REVIA see naltrexone hcl ......... 24

REVLIMID ......................... 35 REYATAZ ........................... 7 RHEUMATREX................. 35 RHINOCORT AQUA

see budesonide (nasal) . 41 ribapak mis 600/day ............ 7 ribasphere ........................... 7 ribasphere ribapak 1000 ..... 7 ribasphere ribapak 1200 ..... 7 ribasphere ribapak 800 ....... 7 ribavirin 200mg ................... 7 rifabutin ............................... 7 RIFADIN

see rifampin .................... 7 rifamate ............................... 7 rifampin ............................... 7 RIFATER ............................ 7 RILUTEK

see riluzole .................... 24 riluzole .............................. 24 rimantadine hydrochloride .. 8 RINGER'S ......................... 38 RIOMET ............................ 26 risedronate sodium ........... 26 RISPERDAL

see risperidone.............. 22 RISPERDAL INJ 12.5MG . 22 RISPERDAL INJ 25MG .... 22 RISPERDAL INJ 37.5MG . 22 RISPERDAL INJ 50MG .... 22 RISPERDAL M-TAB

see risperidone odt ........ 22 risperidone ........................ 22 risperidone odt .................. 22 RITALIN

2015 CalPERS eff 01/01/2015

see methylphenidate hcl 22 RITALIN LA ....................... 23

see methylphenidate hcl 22 RITALIN SR

see metadate tab er 20 mg ...................................... 22 see methylphenidate hcl 23

RITUXAN .......................... 11 rivastigmine tartrate .......... 20 rizatriptan benzoate .......... 23 ROBINUL

see glycopyrrolate ......... 32 ROBINUL FORTE

see glycopyrrolate ......... 32 ROCALTROL

see calcitriol ................... 38 ROCEPHIN

see ceftriaxone sodium....8 ropinirole hydrochloride ..... 21 rosadan cre 0.75% ............ 45 ROTARIX .......................... 36 ROTATEQ ......................... 36 ROWASA

see mesalamine enema 32 roxicet soln ..........................4 roxicet tab 5-325mg ............4 ROXICODONE

see oxycodone hcl ...........4 ROZEREM ........................ 23 RYTHMOL

see propafenone hcl ...... 14 RYTHMOL SR

see propafenone hcl ...... 14 S SABRIL ............................. 19 SAIZEN ............................. 30 SAIZEN CLICK.EASY ....... 30 SALAGEN

see pilocarpine hcl (oral) ...................................... 45

SAMSCA ........................... 30 SANCUSO ........................ 31 SANDIMMUNE

see cyclosporine ............ 36 SANDIMMUNE CAPS ....... 36 SANDIMMUNE SOLN ....... 36 SANDOSTATIN

see octreotide acetate ... 30

SANDOSTATIN LAR DEPOT ............................. 30 SANTYL ............................ 45 SAPHRIS .......................... 22 SARAFEM ........................ 24 SAVELLA .......................... 24 SAVELLA TITRATION PACK ................................ 24 SEASONIQUE

see amethia 91 day ....... 26 SECTRAL

see acebutolol hcl ......... 15 selegiline hcl ..................... 21 selenium sulfide ................ 43 SELZENTRY ....................... 7 SEMPREX-D .................... 40 SENSIPAR ........................ 26 SEREVENT DISKUS ........ 41 SEROQUEL

see quetiapine fumarate 22 SEROQUEL XR ................ 22 SEROSTIM ....................... 30 sertraline hcl ..................... 20 SF-ROWASA .................... 32 SIGNIFOR ........................ 30 sildenafil citrate (pulmonary hypertension) .................... 18 SILENOR .......................... 23 SILVER SULFADIAZINE .. 42 SIMBRINZA SUS 1-0.2% .. 40 SIMCOR ........................... 15 SIMPONI ........................... 35 SIMPONI ARIA ................. 35 SIMULECT ........................ 36 simvastatin ........................ 14 SINEMET

see carbidopa-levodopa 21 SINEMET CR

see carbidopa-levodopa 21 SINGULAIR

see montelukast sodium 41 sirolimus tab 0.5 mg .......... 36 SIRTURO ............................ 7 SKLICE ............................. 45 SODIUM CHLORIDE .. 37, 38 SODIUM CHLORIDE 0.45% VIA .................................... 38 SODIUM CHLORIDE 0.9%

.......................................... 45 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN ................................ 37 sodium phenylbutyrate ...... 29 sodium polystyrene sulfonate.......................................... 26 SOLARAZE

see diclofenac gel 3% ... 44 SOLIA ............................... 28 SOLIRIS ........................... 35 SOLODYN ........................ 10 SOLTAMOX ...................... 12 SOLU-CORTEF ................ 30 SOLU-MEDROL

see methylpr ss inj 125mg ...................................... 29 see methylpr ss inj 1gm 29 see methylpr ss inj 40mg ...................................... 29 see methylpr ss inj 500mg ...................................... 29

SOLU-MEDROL INJ 2GM 30 SOMATULINE DEPOT ..... 30 SOMAVERT ..................... 30 SORIATANE

see acitretin ................... 43 SORILUX .......................... 43 sorine ................................ 14 sotalol hcl .......................... 14 sotalol hcl (afib/afl) ............ 14 SOVALDI ............................ 8 SPIRIVA HANDIHALER ... 40 spironolactone .................. 13 spironolactone & hydrochlorothiazide ........... 17 SPORANOX

see itraconazole .............. 6 SPORANOX SOL 10MG/ML............................................ 6 sprintec 28 day ................. 28 SPRYCEL ......................... 12 sronyx 28 day ................... 28 SSD .................................. 42 STARLIX

see nateglinide .............. 26 stavudine ............................ 7 STELARA ......................... 43

2015 CalPERS eff 01/01/2015

STERILE WATER IRRIGATION ..................... 45 STIMATE .......................... 31 STIVARGA ........................ 12 STRATTERA ..................... 23 streptomycin sulfate ............5 STRIANT........................... 25 STRIBILD ............................7 STROMECTOL ...................5 SUBOXONE MIS 12-3MG 25 SUBOXONE MIS 2-0.5MG .......................................... 24 SUBOXONE MIS 4-1MG .. 24 SUBOXONE MIS 8-2MG .. 24 SUBSYS .............................4 SUCLEAR ......................... 33 SUCRAID .......................... 33 sucralfate .......................... 33 SULAR

see nisoldipine ............... 16 sulfacetamide sodium (acne) .......................................... 42 sulfacetamide sodium (ophth) .............................. 39 sulfacetamide sod-prednisolone .............. 38 sulfadiazine .........................5 sulfamethoxazole-trimethop 5 sulfamethoxazole-trimethoprim inj ....................................5 SULFAMYLON .................. 42

see mafenide acetate .... 42 sulfasalazine dr ................. 32 sulfasalazine ir .................. 32 sulindac ...............................1 sumatriptan succinate ....... 23 SUMATRIPTAN SUCCINATE ..................... 23 sumatriptan succinate inj .. 23 SUMATRIPTAN SUCCINATE INJ ............... 23 SUMAVEL DOSEPRO ...... 23 SUPPRELIN LA ................ 30 suprax .................................8 SUPRAX .............................8 SUPREP BOWEL PREP... 33 SURMONTIL ..................... 20 SUSTIVA.............................7

SUTENT ........................... 12 syeda ................................ 28 SYLATRON KIT 296MCG . 12 SYLATRON KIT 444MCG . 12 SYLATRON KIT 888MCG . 12 SYLVANT ......................... 36 SYMBICORT .................... 41 SYMLINPEN 120 .............. 25 SYMLINPEN 60 ................ 25 SYNAGIS .......................... 36 SYNALAR

see fluocinolone acetonide ................................ 43, 44

SYNAREL ......................... 28 SYNERA ........................... 44 SYNERCID ......................... 5 SYNRIBO .......................... 12 SYNTHROID ..................... 31

see levothyroxine sodium ...................................... 31

SYPRINE .......................... 26 T TABLOID .......................... 11 TACLONEX ...................... 44

see calcipotrien oin betameth ....................... 43

tacrolimus ......................... 36 TAFINLAR ........................ 12 TAMIFLU ............................ 8 tamoxifen citrate ............... 12 tamsulosin hcl ................... 33 TAPAZOLE

see methimazole ........... 31 TARCEVA ......................... 12 TARGRETIN ............... 12, 45 TARKA .............................. 13 TASIGNA .......................... 12 TAXOTERE ...................... 11 tazicef vial ........................... 8 TAZORAC ......................... 43 taztia xt ............................. 16 TECFIDERA CAP 120MG 24 TECFIDERA CAP 240MG 24 TECFIDERA MIS STARTER .......................................... 24 TEFLARO ........................... 8 TEGRETOL ...................... 19

see carbamazepine ....... 18

see epitol ....................... 19 TEGRETOL-XR ................ 19

see carbamazepine ....... 18 TEKAMLO ........................ 16 TEKTURNA ...................... 16 TEKTURNA HCT .............. 16 TELMISARTAN................. 14 telmisartan-amlodipine ...... 14 telmisartan-hydrochlorothiazide ...................................... 14 temazepam ....................... 23 TEMOVATE

see clobetasol propionate ...................................... 43

TEMOVATE E see clobetasol propionate emollient base ............... 43

TENIVAC .......................... 36 TENORETIC 100

see atenolol & chlorthalidone ................ 15

TENORETIC 50 see atenolol & chlorthalidone ................ 15

TENORMIN see atenolol ................... 15

TERAZOL 3 see terconazole vaginal 34

TERAZOL 7 see terconazole vaginal 34 see zazole ..................... 34

terazosin hcl ..................... 13 terbinafine hcl ..................... 6 terbutaline sulfate ............. 41 terconazole vaginal ........... 34 TESTIM ............................ 25 testosterone cypionate ...... 25 testosterone enanthate ..... 25 TETANUS TOXOID ADSORBED ..................... 36 TETANUS/DIPHTHERIA TOXOID ............................ 36 TETRACYCLINE HCL ...... 10 TEVETEN

see eprosartan mesylate ...................................... 14

TEVETEN HCT ................. 14 TEV-TROPIN .................... 30

2015 CalPERS eff 01/01/2015

texacort ............................. 44 THALOMID ....................... 35 theo-24 .............................. 41 theophylline ....................... 41 thioridazine hcl .................. 22 thiothixene......................... 22 THYMOGLOBULIN ........... 36 tiagabine hcl ...................... 19 TIAZAC

see diltiazem hcl er ........ 16 see diltiazem hcl extended release beads ................ 16 see diltzac ..................... 16 see taztia xt ................... 16

TIKOSYN .......................... 14 TIMENTIN ......................... 10 timolol maleate .................. 16 timolol maleate (ophth) ..... 40 TIMOLOL MALEATE GEL 40 TIMOPTIC

see timolol maleate (ophth) ........................... 40

TIMOPTIC OCUDOSE ...... 40 TIROSINT ......................... 31 TIVICAY ..............................7 tizanidine ........................... 24 TOBI

see tobramycin ................5 TOBI PODHALER ...............5 TOBRADEX ...................... 38

see tobramycin-dexamethasone .................................... 38

TOBRADEX ST ................. 38 tobramycin ..........................5 tobramycin sulfate ...............5 tobramycin sulfate (ophth). 39 tobramycin sulfate in saline .5 tobramycin-dexamethasone .......................................... 38 TOBREX

see tobramycin sulfate (ophth) ........................... 39

TOBREX OINT 0.3% ........ 39 TOFRANIL

see imipramine hcl ........ 20 TOFRANIL-PM

see imipramine pamoate

...................................... 20 tolmetin sodium ................... 1 TOLTERODINE TARTRATE ER ..................................... 34 tolterodine tartrate tab 1 mg .......................................... 34 tolterodine tartrate tab 2 mg .......................................... 34 TOPAMAX

see topiramate .............. 19 TOPAMAX SPRINKLE

see topiramate .............. 19 TOPICORT ....................... 44

see desoximetasone ..... 43 topiramate ......................... 19 toposar .............................. 13 topotecan hcl .................... 13 TOPROL XL

see metoprolol succinate ...................................... 15

TORISEL .......................... 11 torsemide inj 20mg/2ml ..... 17 torsemide inj 50mg/5ml ..... 17 torsemide tabs .................. 17 TOVIAZ ............................. 34 TPN ELECTROLYTES ..... 37 TRACLEER ....................... 18 TRADJENTA ..................... 26 TRAMADOL HCL ................ 2 tramadol hcl er .................... 2 tramadol hcl er (biphasic) 100mg ................................. 2 tramadol hcl er (biphasic) 200mg ................................. 2 tramadol hcl er (biphasic) 300mg ................................. 2 tramadol hcl tab 50 mg ....... 2 tramadol-acetaminophen .... 2 TRANDATE

see labetalol hcl ............ 15 trandolapril ........................ 13 tranexamic acid ................. 35 TRANSDERM-SCOP ........ 31 TRANXENE T

see clorazepate dipotassium ................... 18

tranylcypromine sulfate ..... 20 travasol 10 ........................ 37

TRAVATAN Z ................... 40 trazodone hcl .................... 20 TREANDA ........................ 10 TRECATOR ........................ 7 TRELSTAR DEPOT MIXJECT .......................... 12 TRELSTAR LA MIXJECT . 12 TRELSTAR MIXJECT ....... 12 tretinoin ....................... 12, 42 TRETINOIN MICROSPHERE ............... 42 tretin-x ............................... 42 trexall ................................ 35 TREXIMET ....................... 23 triamcinolone acetonide (mouth) ............................. 45 triamcinolone acetonide (nasal) ............................... 41 triamcinolone acetonide (topical) ............................. 44 triamt/hctz cap 37.5-25 ..... 17 triamt/hctz cap 50-25mg ... 17 triamt/hctz tab 37.5-25 ...... 17 triamt/hctz tab 75-50mg .... 17 TRIBENZOR ..................... 14 TRICOR

see fenofibrate .............. 15 triderm .............................. 44 trifluoperazine hcl.............. 22 trifluridine .......................... 39 TRIGLIDE ......................... 15 trihexyphenidyl hcl ............ 21 tri-legest 28 day ................ 28 TRILEPTAL

see oxcarbazepine ........ 19 TRILIPIX

see choline fenofibrate .. 15 trilyte ................................. 33 trimethoprim ........................ 5 TRINESSA ........................ 28 TRI-NORINYL 28

see aranelle 28.............. 26 TRIOSTAT

see liothyronine sodium 31 tri-previfem 28 day ............ 28 TRISENOX ....................... 12 tri-sprintec 28 day ............. 28 trivora 28 day .................... 28

2015 CalPERS eff 01/01/2015

TRIZIVIR see abacavir sulfate-lamivudine-zidovudine ...................................7

TROKENDI XR ................. 19 TROPHAMINE INJ 10% ... 37 trospium chloride ............... 34 trospium chloride er .......... 34 TRUSOPT

see dorzolamide hcl ...... 40 TRUVADA ...........................7 TUDORZA PRESSAIR ..... 40 TWINRIX INJ .................... 36 TWYNSTA

see telmisartan-amlodipine ...................................... 14

TYGACIL.............................5 TYKERB............................ 12 TYLENOL/CODEINE #3

see acetaminophen w/ codeine ............................1

TYLENOL/CODEINE #4 see acetaminophen w/ codeine ............................1

TYPHIM VI ........................ 36 TYSABRI........................... 24 TYVASO ........................... 18 TYZEKA ..............................8 tyzine ................................ 41 U UCERIS ............................ 32 u-cort ................................. 44 ULESFIA ........................... 45 ULORIC ..............................1 ULTRACET

see tramadol-acetaminophen .2

ULTRAM see tramadol hcl tab 50 mg ...................................2

ULTRAM ER see tramadol hcl er ..........2

ULTRAVATE see halobetasol propionate ..................... 44

ULTRESA ......................... 33 UNASYN

see ampicillin & sulbactam

sodium ............................. 9 UNASYN BULK PACK

see ampicillin & sulbactam sodium ............................. 9

UNIRETIC see moexipril-hydrochlorothiazide .................................. 13

UNITHROID ...................... 31 UNIVASC

see moexipril hcl ........... 13 URECHOLINE

see bethanechol chloride ...................................... 33

UROXATRAL see alfuzosin hcl ............ 33

URSO 250 see ursodiol ................... 33

URSO FORTE see ursodiol ................... 33

ursodiol ............................. 33 UVADEX ........................... 12 V VAGIFEM .......................... 29 valacyclovir hcl .................... 8 VALCHLOR ...................... 45 VALCYTE ........................... 8 VALIUM

see diazepam ................ 18 valproate sodium .............. 19 valproic acid ...................... 19 valsartan ........................... 14 valsartan-hydrochlorothiazide ........................................ 14 VALSTAR ......................... 10 VALTREX

see valacyclovir hcl ......... 8 VANCOCIN HCL

see vancomycin hcl ......... 6 vancomycin hcl ................... 6 VANDAZOLE .................... 34 VANOS

see fluocinonide ............ 44 VANTAS ........................... 12 VAQTA .............................. 36 VARIVAX .......................... 36 VASCEPA ......................... 15 VASERETIC

see enalapril maleate & hydrochlorothiazide ....... 13

VASOTEC see enalapril maleate .... 13

VECTIBIX ......................... 11 VELCADE ......................... 11 VELETRI ........................... 18 velivet 28 day .................... 28 VELPHORO ...................... 30 VELTIN ............................. 42 venlafaxine cap er............. 20 venlafaxine hcl .................. 21 VENLAFAXINE HCL ER

see venlafaxine tab er ... 21 venlafaxine tab ................. 21 VENLAFAXINE TAB 225MG ER ..................................... 21 venlafaxine tab er ............. 21 VENTAVIS ........................ 18 VENTOLIN HFA................ 41 VERAMYST ...................... 41 verapamil hcl .................... 16 VERAPAMIL HCL ............. 16 VERELAN

see verapamil hcl .......... 16 VERELAN PM

see verapamil hcl .......... 16 veripred ............................. 30 VERSACLOZ .................... 22 VESICARE ....................... 34 vestura .............................. 28 VEXOL .............................. 39 VFEND

see voriconazole ............. 6 VFEND IV

see voriconazole inj 200mg ............................. 6

VIBRAMYCIN ................... 10 see doxycycline (monohydrate) ............... 10 see doxycycline hyclate 10

vicodin ................................ 2 vicodin es ............................ 2 vicodin hp ........................... 2 VICOPROFEN

see hydrocodone-ibuprofen tab 7.5-200 mg ...................... 2

2015 CalPERS eff 01/01/2015

VICTOZA .......................... 25 VICTRELIS .........................8 VIDAZA

see azacitidine ............... 11 VIDEX EC

see didanosine ................6 VIDEX PEDIATRIC .............7 VIGAMOX ......................... 39 VIIBRYD............................ 21 VIMIZIM ............................ 29 VIMOVO..............................1 VIMPAT............................. 19 vinblastine sulfate ............. 11 vincasar............................. 11 vincristine sulfate .............. 11 vinorelbine tartrate ............ 11 VIOKACE 10 ..................... 33 VIOKACE 20 ..................... 33 viorele ............................... 28 VIRACEPT ..........................7 VIRAMUNE

see nevirapine .................6 VIRAMUNE XR ...................7

see nevirapine .................6 VIREAD...............................7 VIROPTIC

see trifluridine ................ 39 VISTARIL

see hydroxyzine pamoate ...................................... 40

VISTIDE see cidofovir ....................7

VIVACTIL see protriptyline hcl ....... 20

VIVELLE-DOT ................... 29 VIVITROL.......................... 25 VOGELXO ........................ 25 VOLTAREN GEL 1% ........ 45 VOLTAREN-XR

see diclofenac sodium .....1 voriconazole ........................6 voriconazole inj 200mg .......6 VOSOL HC

see acetasol hc ............. 45 see acetic acid sol/hc .... 45

VOSPIRE ER see albuterol sulfate er .. 40

VOTRIENT ........................ 12

VPRIV ............................... 29 vyfemia 28 day .................. 28 VYTORIN .......................... 15 VYVANSE ......................... 23 W warfarin sodium ................ 34 WELCHOL ........................ 15 WELLBUTRIN

see bupropion hcl .......... 20 WELLBUTRIN SR

see bupropion hcl .......... 20 WELLBUTRIN XL

see bupropion hcl .......... 20 WESTCORT

see hydrocortisone valerate ......................... 44

X XALATAN

see latanoprost .............. 40 XALKORI .......................... 12 XANAX

see alprazolam .............. 18 XARELTO ......................... 34 XARTEMIS XR ................... 4 XELJANZ .......................... 35 XENAZINE ........................ 24 XEOMIN ............................ 40 XERESE ........................... 43 XGEVA ............................. 30 XIFAXAN TAB 200MG ........ 6 XIFAXAN TAB 550MG ...... 33 XODOL

see hydrocodone-acetaminophen 10-300mg ................... 2 see hydrocodone-acetaminophen 5-300mg ..................... 2 see hydrocodone-acetaminophen 7.5-300mg .................. 2 see vicodin ...................... 2 see vicodin es ................. 2 see vicodin hp ................. 2

XOLAIR ............................. 41 XOPENEX

see levalbuterol hcl........ 41 XOPENEX CONCENTRATE

see levalbuterol conc 1.25mg/0.5ml ................ 41

XOPENEX HFA ................ 41 XTANDI ............................ 12 xulane dis 150-35 ............. 28 XYLOCAINE

see lidocaine hcl ............ 44 see lidocaine hcl (local anesth.) ........................... 4 see lidocaine inj 1% ........ 4 see lidocaine inj 2% ........ 4

XYLOCAINE-MPF see lidocaine hcl (local anesth.) ........................... 4 see lidocaine inj 0.5% ..... 4 see lidocaine inj 1% ........ 4 see lidocaine inj 1.5% ..... 4 see lidocaine inj 2% ........ 4

XYREM ............................. 24 XYZAL

see levocetirizine soln 2.5mg/5ml ..................... 40 see levocetirizine tab 5 mg ...................................... 40

Y YASMIN 28

see drospirenone-ethinyl estradiol ........................ 27 see syeda ...................... 28 see zarah ...................... 28

YAZ see loryna 28 day .......... 27 see vestura ................... 28

YERVOY ........................... 11 YF-VAX ............................. 36 Z zafirlukast ......................... 41 ZALTRAP ......................... 11 zamicet ............................... 2 ZANAFLEX

see tizanidine ................ 24 ZANOSAR ........................ 10 ZANTAC

see ranitidine hcl ........... 32 zarah ................................. 28 ZARONTIN

see ethosuximide .......... 19 ZAROXOLYN

2015 CalPERS eff 01/01/2015

see metolazone ............. 17 ZAVESCA ......................... 29 zazole ............................... 34 ZAZOLE ............................ 34 ZEBETA

see bisoprolol fumarate . 15 ZEGERID .......................... 33 ZELAPAR.......................... 21 ZELBORAF ....................... 12 ZEMAIRA .......................... 41 ZEMPLAR ......................... 38

see paricalcitol ............... 38 zenatane ........................... 42 zenchent fe 28 day ............ 28 zenchent tab ..................... 28 ZENPEP............................ 33 ZERIT

see stavudine ..................7 ZESTORETIC

see lisinopril & hydrochlorothiazide ....... 13

ZESTRIL see lisinopril ................... 13

ZETIA TAB 10MG ............. 15 ZETONNA ......................... 41 ZIAC

see bisoprolol & hydrochlorothiazide ....... 15

ZIAGEN...............................7 see abacavir sulfate ........6

ZIANA ............................... 42 zidovudine ...........................7 ZINACEF.............................8

see cefuroxime sodium....8 ZINECARD

see dexrazoxane ........... 12 ZIOPTAN .......................... 40 ziprasidone hcl .................. 22 ZIPSOR .............................. 1 ZIRGAN ............................ 39 ZITHROMAX

see azithromycin ............. 8 ZMAX .................................. 9 ZOCOR

see simvastatin ............. 14 ZOFRAN

see ondansetron hcl ...... 31 see ondansetron hcl oral soln ................................ 31

ZOFRAN ODT see ondansetron odt...... 31

ZOLADEX ......................... 12 zoledronic inj 4mg/5ml ...... 26 zoledronic inj 5/100ml ....... 26 ZOLINZA ........................... 11 zolmitriptan ....................... 24 zolmitriptan odt ................. 24 ZOLOFT

see sertraline hcl ........... 20 zolpidem tartrate ............... 23 ZOMETA ........................... 26

see zoledronic inj 4mg/5ml ...................................... 26

ZOMIG see zolmitriptan ............. 24

ZOMIG NASAL SPRAY .... 24 ZOMIG ZMT

see zolmitriptan odt ....... 24 ZONEGRAN

see zonisamide ............. 19

zonisamide ....................... 19 ZORBTIVE ........................ 30 ZORTRESS TAB 0.25MG 36 ZORTRESS TAB 0.5MG .. 36 ZORTRESS TAB 0.75MG 36 ZORVOLEX ........................ 1 ZOSTAVAX ...................... 36 ZOSYN ............................. 10

see piperacillin sodium-tazobactam sodium .......................... 10

zovia 1/35e 28 day............ 28 zovia 1/50e 28 day............ 28 ZOVIRAX .......................... 43

see acyclovir ................... 7 see acyclovir topical ...... 43

ZUBSOLV ......................... 25 ZYBAN

see buproban ................ 24 ZYCLARA ......................... 45 ZYFLO CR ........................ 41 ZYKADIA .......................... 12 ZYLET .............................. 38 ZYLOPRIM

see allopurinol tab ........... 1 ZYMAXID

see gatifloxacin (ophth) . 39 ZYPREXA

see olanzapine .............. 22 ZYPREXA ZYDIS

see olanzapine odt ........ 22 ZYTIGA ............................. 12 ZYVOX ............................... 6

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