2016 604 4t platinum pdp eff 01/01/2016€¦ · tramadol hcl cp24 200mg ql (360 tabs / 30 days) ql...
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2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
1
Drug Name Drug Tier
Requirements/Limits
ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM)
1
ALOPRIM 3
colchicine w/ probenecid 1
COLCRYS QL (120 tabs / 30 days)
2 QL
probenecid 1
ULORIC 2 ST
MISCELLANEOUS diclofenac w/ misoprostol (generic of ARTHROTEC 50)
1
diclofenac w/ misoprostol (generic of ARTHROTEC 75)
1
DUEXIS 4 NM
VIMOVO 4 NM
NSAIDS celecoxib (generic of CELEBREX) CAPS
1
diclofenac potassium 1
diclofenac sodium TB24; TBEC
1
diflunisal 1
etodolac 1
etodolac er 1
fenoprofen calcium TABS 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
NAPRELAN 375mg, 750mg 4 NM
naproxen SUSP 1
naproxen (generic of NAPROSYN) TABS
1
naproxen (generic of EC-NAPROSYN) TBEC
1
naproxen sodium (generic of ANAPROX) TABS 275mg
1
Drug Name Drug Tier
Requirements/Limits
naproxen sodium (generic of ANAPROX DS) TABS 550mg
1
NAPROXEN SODIUM TB24 4 NM
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
QL (400 tabs / 30 days)
1 QL
acetaminophen w/ codeine (generic of TYLENOL/CODEINE #4) TABS
QL (400 tabs / 30 days)
1 QL
ASPIRIN-CAFFEINE-DIHYDROCODEINE BITARTRATE
QL (360 caps / 30 days)
1 QL
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 7.5mcg/hr, 10mcg/hr
QL (8 patches / 28 days)
2 QL
BUTRANS 15mcg/hr, 20mcg/hr
QL (4 patches / 28 days)
2 QL
capital and codeine QL (5000 mL / 30 days)
3 QL
CONZIP 100mg QL (90 caps / 30 days)
3 QL
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
2
Drug Name Drug Tier
Requirements/Limits
CONZIP 200mg QL (60 caps / 30 days)
3 QL
CONZIP 300mg QL (30 caps / 30 days)
3 QL
nalbuphine hcl (generic of NUBAIN) SOLN 10mg/ml
1
nalbuphine hcl SOLN 20mg/ml
1
TRAMADOL HCL CP24 100mg
QL (90 caps / 30 days)
1 QL
TRAMADOL HCL CP24 200mg
QL (60 caps / 30 days)
1 QL
TRAMADOL HCL CP24 300mg
QL (30 caps / 30 days)
1 QL
tramadol hcl er (generic of ULTRAM ER) TB24 100mg
QL (90 tabs / 30 days)
1 QL
tramadol hcl er (generic of ULTRAM ER) TB24 200mg
QL (30 tabs / 30 days)
1 QL
TRAMADOL HCL ER TB24 300mg
QL (30 tabs / 30 days)
1 QL
tramadol hcl er (biphasic) 100mg
QL (90 tabs / 30 days)
1 QL
tramadol hcl er (biphasic) 200mg
QL (30 tabs / 30 days)
1 QL
tramadol hcl er (biphasic) 300mg
QL (30 tabs / 30 days)
1 QL
tramadol hcl tab 50 mg (generic of ULTRAM)
QL (240 tabs / 30 days)
1 QL
tramadol-acetaminophen (generic of ULTRACET)
QL (240 tabs / 30 days)
1 QL
trezix QL (360 caps / 30 days)
3 QL
OPIOID ANALGESICS, CII ABSTRAL
QL (120 tabs / 30 days) 4 QL NM PA
CODEINE SULFATE 15mg QL (720 tabs / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
CODEINE SULFATE 30mg QL (360 tabs / 30 days)
1 QL
CODEINE SULFATE 60mg QL (180 tabs / 30 days)
1 QL
DILAUDID-HP INJ 250MG 3 B/D
DURAMORPH 1 B/D
EMBEDA QL (60 caps / 30 days)
3 QL
endocet (generic of PERCOCET)
QL (360 tabs / 30 days)
1 QL
ENDODAN TAB QL (360 tabs / 30 days)
1 QL
fentanyl citrate (generic of ACTIQ) LPOP
QL (120 lozenges / 30 days)
4 QL NM PA
fentanyl patch 12 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
1 QL
fentanyl patch 25 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
1 QL
fentanyl patch 50 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
1 QL
fentanyl patch 75 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
1 QL
fentanyl patch 100 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
1 QL
FENTORA QL (120 tabs / 30 days)
4 QL NM PA
hydrocodone-acetaminophen 2.5-325mg
QL (360 tabs / 30 days)
1 QL
hydrocodone-acetaminophen 5-300mg (generic of XODOL)
QL (400 tabs / 30 days)
1 QL
hydrocodone-acetaminophen 5-325mg (generic of NORCO)
QL (360 tabs / 30 days)
1 QL
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
3
Drug Name Drug Tier
Requirements/Limits
hydrocodone-acetaminophen 7.5-300mg (generic of XODOL)
QL (400 tabs / 30 days)
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)
QL (360 tabs / 30 days)
1 QL
hydrocodone-acetaminophen 10-300mg (generic of XODOL)
QL (400 tabs / 30 days)
1 QL
hydrocodone-acetaminophen tab 10-325mg (generic of NORCO)
QL (360 tabs / 30 days)
1 QL
hydrocodone-ibuprofen tab 2.5-200mg (generic of REPREXAIN)
QL (150 tabs / 30 days)
1 QL
hydrocodone-ibuprofen tab 7.5-200 mg (generic of VICOPROFEN)
QL (150 tabs / 30 days)
1 QL
hydromorphone hcl (generic of DILAUDID) LIQD
1
HYDROMORPHONE HCL SOLN 1mg/ml
1 B/D
HYDROMORPHONE HCL SOLN 2mg/ml, 4mg/ml
1 B/D
hydromorphone hcl (generic of DILAUDID-HP) SOLN 500mg/50ml
1 B/D
hydromorphone hcl (generic of DILAUDID) TABS
QL (270 tabs / 30 days)
1 QL
hydromorphone tab 8mg er (generic of EXALGO)
QL (60 tabs / 30 days)
1 QL
hydromorphone tab 12mg er (generic of EXALGO)
QL (60 tabs / 30 days)
1 QL
hydromorphone tab 16mg er (generic of EXALGO)
QL (60 tabs / 30 days)
4 QL NM
Drug Name Drug Tier
Requirements/Limits
HYDROMORPHONE TABS 32MG
QL (60 tabs / 30 days)
4 QL NM
HYSINGLA ER 20mg, 30mg, 40mg, 60mg
QL (60 tabs / 30 days)
3 QL
HYSINGLA ER 80mg, 100mg, 120mg
QL (30 tabs / 30 days)
4 QL NM
ibudone tab 5-200mg (generic of REPREXAIN)
QL (150 tabs / 30 days)
1 QL
ibudone tab 10-200mg QL (150 tabs / 30 days)
1 QL
INFUMORPH 200 3 B/D
INFUMORPH 500 3 B/D
KADIAN 40mg, 200mg QL (60 caps / 30 days)
4 QL NM
LAZANDA QL (30 bottles / 30 days)
4 QL NM PA
levorphanol tartrate TABS QL (180 tabs / 30 days)
1 QL
lorcet hd tab 10-325mg (generic of NORCO)
QL (360 tabs / 30 days)
1 QL
lorcet plus tab 7.5-325 (generic of NORCO)
QL (360 tabs / 30 days)
1 QL
lorcet tab 5-325mg (generic of NORCO)
QL (360 tabs / 30 days)
1 QL
lortab tab 5-325mg (generic of NORCO)
QL (360 tabs / 30 days)
1 QL
lortab tab 7.5-325 (generic of NORCO)
QL (360 tabs / 30 days)
1 QL
lortab tab 10-325mg (generic of NORCO)
QL (360 tabs / 30 days)
1 QL
methadone hcl (generic of METHADOSE) CONC
QL (120 mL / 30 days)
1 QL
methadone hcl SOLN QL (600 mL / 30 days)
1 QL
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
4
Drug Name Drug Tier
Requirements/Limits
methadone hcl (generic of DOLOPHINE HCL) TABS 5mg
QL (240 tabs / 30 days)
1 QL
methadone hcl (generic of DOLOPHINE) TABS 10mg
QL (240 tabs / 30 days)
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
QL (60 caps / 30 days)
1 QL
morphine sulfate (generic of KADIAN) CP24 80mg, 100mg
QL (60 caps / 30 days)
4 QL NM
MORPHINE SULFATE SOLN 1mg/ml, 2mg/ml, 4mg/ml, 8mg/ml, 10mg/ml, 15mg/ml
1 B/D
MORPHINE SULFATE SOLN 10mg/5ml, 20mg/5ml
1
morphine sulfate SOLN .5mg/ml, 1mg/ml
1 B/D
MORPHINE SULFATE TABS
QL (180 tabs / 30 days)
1 QL
morphine sulfate beads QL (60 caps / 30 days)
1 QL
morphine sulfate ext-rel tab (generic of MS CONTIN) 15mg, 30mg, 60mg, 100mg
QL (90 tabs / 30 days)
1 QL
morphine sulfate ext-rel tab (generic of MS CONTIN) 200mg
QL (60 tabs / 30 days)
1 QL
NUCYNTA 50mg QL (360 tabs / 30 days)
3 QL
NUCYNTA 75mg QL (240 tabs / 30 days)
3 QL
NUCYNTA 100mg QL (180 tabs / 30 days)
3 QL
NUCYNTA ER 50mg, 100mg
QL (120 tabs / 30 days)
2 QL
Drug Name Drug Tier
Requirements/Limits
NUCYNTA ER 150mg, 200mg, 250mg
QL (60 tabs / 30 days)
2 QL
OPANA ER (CRUSH RESISTANT
QL (120 tabs / 30 days)
2 QL
oxycodone hcl CAPS QL (180 caps / 30 days)
1 QL
oxycodone hcl CONC 1
OXYCODONE HCL SOLN 1
oxycodone hcl (generic of ROXICODONE) TABS 5mg, 15mg, 30mg
QL (180 tabs / 30 days)
1 QL
oxycodone hcl TABS 10mg, 20mg
QL (180 tabs / 30 days)
1 QL
oxycodone w/ acetaminophen 2.5-325mg (generic of PERCOCET)
QL (360 tabs / 30 days)
1 QL
oxycodone w/ acetaminophen 5-325mg (generic of PERCOCET)
QL (360 tabs / 30 days)
1 QL
oxycodone w/ acetaminophen 7.5-325mg (generic of PERCOCET)
QL (360 tabs / 30 days)
1 QL
oxycodone w/ acetaminophen 10-325mg (generic of PERCOCET)
QL (360 tabs / 30 days)
1 QL
oxycodone-aspirin (generic of PERCODAN)
QL (360 tabs / 30 days)
1 QL
oxycodone-ibuprofen QL (28 tabs / 30 days)
1 QL
OXYCONTIN QL (120 tabs / 30 days)
2 QL
oxymorphone hcl (generic of OPANA) TABS
QL (180 tabs / 30 days)
1 QL
reprexain tab 10-200mg QL (150 tabs / 30 days)
1 QL
roxicet soln QL (1800 mL / 30 days)
2 QL
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
5
Drug Name Drug Tier
Requirements/Limits
roxicet tab 5-325mg (generic of PERCOCET)
QL (360 tabs / 30 days)
1 QL
SUBSYS QL (120 sprays / 30 days)
4 QL NM PA
vicodin (generic of XODOL) QL (400 tabs / 30 days)
1 QL
vicodin es (generic of XODOL)
QL (400 tabs / 30 days)
1 QL
vicodin hp (generic of XODOL)
QL (400 tabs / 30 days)
1 QL
XARTEMIS XR QL (120 tabs / 30 days)
3 QL
zamicet QL (5400 mL / 30 days)
1 QL
ZOHYDRO ER (ABUSE DETERRENT) 10mg, 15mg, 20mg
QL (120 caps / 30 days)
3 QL
ZOHYDRO ER (ABUSE DETERRENT) 30mg, 40mg, 50mg
QL (60 caps / 30 days)
3 QL
ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) 1%
1 B/D
lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) 4%
1
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 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
Drug Name Drug Tier
Requirements/Limits
ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 1
BETHKIS 4 B/D NM
gentamicin in saline 0.8 mg/ml 1
gentamicin in saline 0.9mg/ml 1
gentamicin in saline 1 mg/ml 1
gentamicin in saline 1.2 mg/ml 1
gentamicin in saline 1.4mg/ml 1
gentamicin in saline 1.6 mg/ml 1
gentamicin in saline 2 mg/ml 1
gentamicin sulfate SOLN 1
neomycin sulfate TABS 1
paromomycin sulfate CAPS 1
streptomycin sulfate SOLR 1
sulfadiazine TABS 3
TOBI PODHALER 4 NM LA PA
tobramycin (generic of TOBI) NEBU
4 B/D NM
tobramycin sulfate SOLN; SOLR
1
tobramycin sulfate in saline 2
ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 3
ALINIA 3
atovaquone (generic of MEPRON) SUSP
4 NM
AZACTAM/DEX INJ 1GM 3
AZACTAM/DEX INJ 2GM 4 NM
aztreonam (generic of AZACTAM)
1
BILTRICIDE 2
CAYSTON 4 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
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
6
Drug Name Drug Tier
Requirements/Limits
clindamycin phosphate in d5w (generic of CLEOCIN IN D5W)
1
colistimethate sodium (generic of COLY-MYCIN M) SOLR
1
CUBICIN 4 NM
DALVANCE 4 NM
dapsone TABS 1
DARAPRIM 3
DORIBAX 3
FLAGYL ER 3
imipenem-cilastatin (generic of PRIMAXIN IV)
1
INVANZ 3
ivermectin (generic of STROMECTOL) TABS
1
linezolid (generic of ZYVOX) SOLN
4 NM
LINEZOLID TABS 4 NM
MACRODANTIN 25mg 90 day limit per calendar year if 65 years and older
3 PA
meropenem (generic of MERREM)
1
methenamine hippurate (generic of HIPREX)
1
METRO IV 2
metronidazole (generic of FLAGYL) CAPS; TABS
1
metronidazole inj 1
NEBUPENT 3 B/D
nitrofurantoin (generic of FURADANTIN) SUSP
90 day limit per calendar year if 65 years and older
1 PA
nitrofurantoin macrocrystal (generic of MACRODANTIN)
90 day limit per calendar year if 65 years and older
3 PA
nitrofurantoin monohyd macro (generic of MACROBID)
90 day limit per calendar year if 65 years and older
3 PA
PENTAM 300 3
polymyxin b sulfate SOLR 1
PRIMSOL SOL 50MG/5ML 3
Drug Name Drug Tier
Requirements/Limits
SIVEXTRO 4 NM
sulfamethoxazole-trimethop SUSP
1
sulfamethoxazole-trimethop (generic of BACTRIM) TABS
1
sulfamethoxazole-trimethop (generic of BACTRIM DS) TABS
1
sulfamethoxazole-trimethoprim inj
1
SYNERCID 4 NM
trimethoprim TABS 1
TYGACIL 4 NM
vancomycin hcl (generic of VANCOCIN HCL) CAPS
4 NM
vancomycin hcl inj 5gm 1
vancomycin hcl inj 10gm 1
vancomycin hcl inj 500mg 1
vancomycin hcl inj 750mg 1
vancomycin hcl inj 1000mg 1
XIFAXAN TAB 200MG 4 NM
ZYVOX SUSR; TABS 4 NM
ANTIFUNGALS ABELCET 4 B/D NM
AMBISOME 4 B/D NM
AMPHOTEC 3 B/D
amphotericin b SOLR 1 B/D
CANCIDAS 4 NM
CRESEMBA 4 NM
ERAXIS 4 NM
fluconazole (generic of DIFLUCAN) SUSR; TABS
1
fluconazole in dextrose 1
fluconazole in nacl 1
flucytosine (generic of ANCOBON) CAPS
4 NM
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 PA
LAMISIL PACK 3
MYCAMINE 4 NM
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
7
Drug Name Drug Tier
Requirements/Limits
NOXAFIL 4 NM
nystatin TABS 1
ONMEL 4 NM PA
SPORANOX SOL 10MG/ML 4 NM
terbinafine hcl (generic of LAMISIL) TABS
QL (90 tabs / 365 days)
1 QL
voriconazole (generic of VFEND) SUSR; TABS
4 NM
voriconazole inj 200mg (generic of VFEND IV)
1
ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg (generic of MALARONE)
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 3
mefloquine hcl 1
PRIMAQUINE PHOSPHATE 2
quinine sulfate (generic of QUALAQUIN) CAPS
1 PA
ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN)
1
APTIVUS 4 NM
CRIXIVAN 3
didanosine (generic of VIDEX EC)
1
EDURANT 4 NM
EMTRIVA 2
FUZEON 4 NM
INTELENCE 25mg 3
INTELENCE 100mg, 200mg 4 NM
INVIRASE 4 NM
ISENTRESS CHEW 25mg 2
ISENTRESS CHEW 100mg 4 NM
ISENTRESS PACK 2
ISENTRESS TABS 4 NM
lamivudine (generic of EPIVIR)
1
Drug Name Drug Tier
Requirements/Limits
LEXIVA SUSP 3
LEXIVA TABS 4 NM
NEVIRAPINE SUSP 1
nevirapine (generic of VIRAMUNE) TABS
1
nevirapine (generic of VIRAMUNE XR) TB24
1
NORVIR 2
PREZISTA SUSP 4 NM
PREZISTA TABS 75mg, 150mg
2
PREZISTA TABS 600mg, 800mg
4 NM
RESCRIPTOR 3
RETROVIR IV INFUSION 2
REYATAZ 4 NM
SELZENTRY 4 NM
stavudine (generic of ZERIT) 1
SUSTIVA CAPS 2
SUSTIVA TABS 4 NM
TIVICAY 4 NM
TYBOST 2
VIDEX PEDIATRIC 3
VIRACEPT 4 NM
VIRAMUNE XR 100mg 3
VIREAD 4 NM
VITEKTA 4 NM
ZIAGEN SOLN 2
zidovudine (generic of RETROVIR) CAPS; SYRP
1
zidovudine TABS 1
ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine (generic of TRIZIVIR)
4 NM
ATRIPLA 4 NM
COMPLERA 4 NM
EPZICOM 4 NM
EVOTAZ 4 NM
KALETRA SOL 4 NM
KALETRA TAB 100-25MG 2
KALETRA TAB 200-50MG 4 NM
lamivudine-zidovudine (generic of COMBIVIR)
4 NM
PREZCOBIX 4 NM
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
8
Drug Name Drug Tier
Requirements/Limits
STRIBILD 4 NM
TRIUMEQ 4 NM
TRUVADA QL (30 tabs / 30 days)
4 QL NM
ANTITUBERCULAR AGENTS CAPASTAT SULFATE 3
cycloserine CAPS 4 NM
ethambutol hcl (generic of MYAMBUTOL) TABS
1
isoniazid SOLN; SYRP 1
isoniazid tabs 1
paser d/r 2
PRIFTIN 3
pyrazinamide 1
rifabutin (generic of MYCOBUTIN)
1
rifamate 3
rifampin (generic of RIFADIN) CAPS; SOLR
1
RIFATER 3
SIRTURO 4 NM LA PA
TRECATOR 3
ANTIVIRALS acyclovir (generic of ZOVIRAX) CAPS; SUSP; TABS
1
acyclovir sodium SOLN 1 B/D
acyclovir sodium SOLR 500mg
1 B/D
adefovir dipivoxil (generic of HEPSERA)
4 NM
BARACLUDE SOLN 2
cidofovir (generic of VISTIDE) 4 NM
entecavir (generic of BARACLUDE)
4 NM
EPIVIR HBV SOLN 3
famciclovir (generic of FAMVIR) TABS
1
foscarnet sodium 1
ganciclovir inj 500mg (generic of CYTOVENE)
1 B/D
HARVONI 4 NM PA
lamivudine (hbv) (generic of EPIVIR HBV)
1
moderiba pak MISC 4 NM
moderiba pak TABS 400mg 4 NM
Drug Name Drug Tier
Requirements/Limits
MODERIBA PAK TABS 600mg
4 NM
moderiba tab 200mg (generic of COPEGUS)
1 NM
PEG-INTRON 4 NM PA
PEG-INTRON REDIPEN 4 NM PA
PEGINTRON 80mcg/0.5ml, 120mcg/0.5ml, 150mcg/0.5ml
4 NM PA
REBETOL SOLN 4 NM
RELENZA DISKHALER 2
ribapak mis 600/day 4 NM
ribasphere (generic of REBETOL) CAPS
1 NM
ribasphere (generic of COPEGUS) TABS 200mg
1 NM
ribasphere TABS 400mg 1 NM
ribasphere TABS 600mg 4 NM
ribasphere ribapak 800 4 NM
ribasphere ribapak 1000 4 NM
ribasphere ribapak 1200 4 NM
ribavirin 200mg (generic of REBETOL) CAPS
1 NM
ribavirin 200mg (generic of COPEGUS) TABS
1 NM
rimantadine hydrochloride (generic of FLUMADINE)
1
SOVALDI 4 NM PA
TAMIFLU 2
TYZEKA 4 NM
valacyclovir hcl (generic of VALTREX) TABS
1
VALCYTE SOLR 4 NM
valganciclovir hcl (generic of VALCYTE)
4 NM
CEPHALOSPORINS AVYCAZ 4 NM
CEDAX SUSR 90mg/5ml 3
cefaclor 1
cefaclor er tab 500mg 2
cefadroxil 1
cefazolin inj 1
cefazolin sodium 1gm, 20gm 1
cefazolin/dextrose 2
cefdinir 1
CEFEPIME 1GM SOLN 3
CEFEPIME 2GM SOLN 3
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
9
Drug Name Drug Tier
Requirements/Limits
CEFEPIME HCL AND DEXTROSE
3
cefepime inj 1gm (generic of MAXIPIME)
1
cefepime inj 2gm (generic of MAXIPIME)
1
cefixime (generic of SUPRAX) 1
cefotaxime sodium (generic of CLAFORAN) 1gm, 2gm, 500mg
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
cefuroxime axetil (generic of CEFTIN) TABS
1
cefuroxime sodium (generic of ZINACEF) 1.5gm, 7.5gm, 750mg
1
cefuroxime sodium 7.5gm 1
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 3
SUPRAX SUSR 500mg/5ml 2
tazicef (generic of FORTAZ) SOLR
1
Drug Name Drug Tier
Requirements/Limits
tazicef vial (generic of FORTAZ)
1
TEFLARO 3
ZERBAXA 4 NM
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 4 NM
e.e.s. 400 tab 400mg 1
E.E.S. GRANULES 3
ery-tab 3
ERYPED 200 3
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
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
10
Drug Name Drug Tier
Requirements/Limits
ciprofloxacin hcl (generic of CIPRO) TABS 250mg, 500mg
1
ciprofloxacin in d5w (generic of CIPRO I.V.-IN D5W)
1
ciprofloxacn inj 400mg/40ml 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 1
levofloxacin in d5w (generic of LEVAQUIN)
1
moxifloxacin hcl (generic of AVELOX) TABS
1
PENICILLINS amoxicillin 1
amoxicillin & pot clavulanate CHEW
1
amoxicillin & pot clavulanate (generic of AUGMENTIN) CHEW
1
amoxicillin & pot clavulanate SUSR
1
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
Drug Name Drug Tier
Requirements/Limits
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 4 NM
BICILLIN C-R 3
BICILLIN L-A 3
dicloxacillin sodium 1
nafcillin sodium 1gm 1
nafcillin sodium 2gm, 10gm 4 NM
NALLPEN ISO-OSMOTIC IN DE
3
NALLPEN/DEXTROSE 3
oxacillin sodium 1gm, 2gm 1
oxacillin sodium 10gm 4 NM
PENICILLIN G POT IN DEXTROSE
3
PENICILLIN G POTASSIUM IN
3
penicillin g procaine 2
penicillin g sodium 1
penicillin v potassium 1
penicilln gk inj 5mu 1
penicilln gk inj 20mu 1
pfizerpen g inj 5mu 1
pfizerpen-g inj 20mu 1
piperacillin sodium-tazobactam sodium (generic of ZOSYN)
1
ZOSYN SOLN 3
TETRACYCLINES demeclocycline hcl 1
doxy 1
doxycycline (monohydrate) CAPS 50mg
1
doxycycline (monohydrate) (generic of MONODOX) CAPS 75mg, 100mg
1
doxycycline (monohydrate) (generic of ADOXA) CAPS 150mg
1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
11
Drug Name Drug Tier
Requirements/Limits
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 1
minocycline hcl (generic of MINOCIN) CAPS
1
minocycline hcl TABS; TB24 1
SOLODYN 4 NM
TETRACYCLINE HCL CAPS
1
VIBRAMYCIN SYRP 3
ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU 3 B/D
BUSULFEX 4 B/D NM
CYCLOPHOSPHAMIDE CAPS
3 B/D
cyclophosphamide SOLR 1gm, 500mg
4 B/D NM
cyclophosphamide SOLR 2gm
1 B/D
dacarbazine 200mg 1 B/D
EMCYT 3
GLEOSTINE 3
HEXALEN 4 NM
IFEX INJ 3GM 3 B/D
ifosfamide inj 1gm (generic of IFEX)
1 B/D
ifosfamide inj 1gm/20ml (generic of IFOSFAMIDE)
1 B/D
IFOSFAMIDE INJ 3GM 3 B/D
ifosfamide inj 3gm/60ml (generic of IFOSFAMIDE)
1 B/D
LEUKERAN 3
Drug Name Drug Tier
Requirements/Limits
LOMUSTINE 1
melphalan hcl (generic of ALKERAN)
4 B/D NM
MUSTARGEN 3 B/D
TREANDA 4 B/D NM
ZANOSAR 3 B/D
ANTHRACYCLINES adriamyc inj 50mg 1 B/D
daunorubicin hcl 1 B/D
doxorubicin hcl 50mg 1 B/D
doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml (generic of DOXIL)
4 B/D NM
doxorubicin inj 50mg 1 B/D
epirubicin inj 50mg/25ml (generic of ELLENCE)
1 B/D
epirubicin inj 200mg (generic of ELLENCE)
1 B/D
idarubicin hcl (generic of IDAMYCIN PFS)
4 B/D NM
ANTIBIOTICS bleomycin sulfate 1 B/D
COSMEGEN 4 B/D NM
mitomycin SOLR 1 B/D
ANTIMETABOLITES adrucil 1 B/D
ALIMTA 4 B/D NM
ARRANON 4 B/D NM
azacitidine (generic of VIDAZA)
4 B/D NM
cladribine 4 B/D NM
CLOLAR 4 B/D NM
cytarabine inj 1 B/D
decitabine (generic of DACOGEN)
4 B/D NM
fludarabine phosphate SOLN
1 B/D
fludarabine phosphate (generic of FLUDARA) SOLR
1 B/D
fluorouracil SOLN 1 B/D
GEMCITABINE 4 B/D NM
gemcitabine hcl (generic of GEMZAR) 1gm, 200mg
4 B/D NM
gemcitabine hcl 2gm 4 B/D NM
mercaptopurine TABS 1
methotrexate sodium inj 1 B/D
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
12
Drug Name Drug Tier
Requirements/Limits
NIPENT 4 B/D NM
PURIXAN 4 NM
TABLOID 3
ANTIMITOTIC, TAXOIDS ABRAXANE 4 B/D NM
DOCETAXEL CONC 20mg/ml, 80mg/4ml
4 B/D NM
docetaxel CONC 140mg/7ml 4 B/D NM
DOCETAXEL SOLN 80mg/8ml, 200mg/20ml
4 B/D NM
paclitaxel 1 B/D
ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 2 B/D
vincasar 1 B/D
vincristine sulfate 1 B/D
vinorelbine tartrate (generic of NAVELBINE)
1 B/D
BIOLOGIC RESPONSE MODIFIERS ARZERRA 4 B/D NM
AVASTIN 4 B/D NM LA
BELEODAQ 4 NM PA
ERBITUX 4 B/D NM
ERIVEDGE 4 NM LA PA
FARYDAK 4 NM LA PA
HERCEPTIN 4 B/D NM
IBRANCE 4 NM LA PA
ISTODAX 4 B/D NM
KADCYLA 4 B/D NM
KEYTRUDA 4 NM PA
LYNPARZA 4 NM LA PA
PERJETA 4 NM PA
PROLEUKIN 4 B/D NM
RITUXAN 4 NM LA PA
TORISEL 4 B/D NM
VECTIBIX 4 B/D NM
VELCADE 4 B/D NM
YERVOY 4 NM PA
ZOLINZA 4 NM PA
HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS
1
bicalutamide (generic of CASODEX)
1
DEPO-PROVERA INJ 400/ML 3 B/D
ELIGARD INJ 7.5MG 3 B/D NM
ELIGARD INJ 22.5MG 3 B/D NM
ELIGARD INJ 30MG 3 B/D NM
Drug Name Drug Tier
Requirements/Limits
ELIGARD INJ 45MG 3 B/D NM
exemestane (generic of AROMASIN)
1
FARESTON 4 NM
FASLODEX 4 B/D NM
FIRMAGON 80mg 3 B/D NM
FIRMAGON 120mg 4 B/D NM
flutamide 1
letrozole (generic of FEMARA) TABS
1
leuprolide acetate KIT 1 NM PA
LUPRON DEP INJ 11.25MG 4 NM PA
LUPRON DEP-PED INJ 7.5MG
4 NM PA
LUPRON DEP-PED INJ 11.25MG
4 NM PA
LUPRON DEP-PED INJ 15MG
4 NM PA
LUPRON DEP-PED INJ 30MG (3-MONTH)
4 NM PA
LUPRON DEPOT 3.75mg, 7.5mg
4 NM PA
LUPRON DEPOT INJ 22.5MG (3-MONTH)
4 NM PA
LUPRON DEPOT INJ 30MG (3-MONTH)
4 NM PA
LYSODREN 2
MEGACE ES 4 NM PA
megestrol acetate (generic of MEGACE ORAL) SUSP 40mg/ml
PA if 65 years and older
3 PA
megestrol acetate TABS PA if 65 years and older
3 PA
NILANDRON 4 NM
SOLTAMOX 3
tamoxifen citrate TABS 1
TRELSTAR MIXJECT 4 NM PA
XTANDI 4 NM LA PA
ZYTIGA 4 NM LA PA
KINASE INHIBITORS AFINITOR 4 NM PA
AFINITOR DISPERZ 4 NM PA
BOSULIF 4 NM PA
CAPRELSA 4 NM LA PA
COMETRIQ 4 NM LA PA
GILOTRIF TAB 20MG 4 NM LA PA
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
13
Drug Name Drug Tier
Requirements/Limits
GILOTRIF TAB 30MG 4 NM LA PA
GILOTRIF TAB 40MG 4 NM LA PA
GLEEVEC 4 NM PA
ICLUSIG 4 NM LA PA
IMBRUVICA CAP 140MG 4 NM LA PA
INLYTA 4 NM LA PA
JAKAFI 4 NM LA PA
LENVIMA 10MG DAILY DOSE
4 NM LA PA
LENVIMA 14MG DAILY DOSE
4 NM LA PA
LENVIMA 20MG DAILY DOSE
4 NM LA PA
LENVIMA 24MG DAILY DOSE
4 NM LA PA
MEKINIST 4 NM LA PA
NEXAVAR 4 NM LA PA
SPRYCEL 4 NM PA
STIVARGA 4 NM LA PA
SUTENT 4 NM PA
TAFINLAR 4 NM LA PA
TARCEVA 4 NM LA PA
TASIGNA 4 NM PA
TYKERB 4 NM LA PA
VOTRIENT 4 NM LA PA
XALKORI 4 NM LA PA
ZELBORAF 4 NM LA PA
ZYDELIG 4 NM LA PA
ZYKADIA 4 NM LA PA
MISCELLANEOUS DROXIA 2
HALAVEN 4 B/D NM
hydroxyurea (generic of HYDREA) CAPS
1
IXEMPRA KIT 4 B/D NM
MATULANE 4 NM LA
mitoxantrone hcl 1 B/D NM
POMALYST 4 NM LA PA
SYLATRON KIT 200MCG 4 NM PA
SYLATRON KIT 300MCG 4 NM PA
SYLATRON KIT 600MCG 4 NM PA
SYNRIBO 4 NM PA
TARGRETIN CAPS 4 NM PA
tretinoin CAPS 4 NM
TRISENOX 4 B/D NM
UVADEX 3 B/D
PLATINUM-BASED AGENTS
Drug Name Drug Tier
Requirements/Limits
carboplatin 1 B/D
cisplatin 1 B/D
ELOXATIN 4 B/D NM
oxaliplatin 4 B/D NM
PROTECTIVE AGENTS amifostine crystalline (generic of ETHYOL)
4 B/D NM
dexrazoxane (generic of ZINECARD) 250mg
4 B/D NM
ELITEK 4 B/D NM
FUSILEV 4 B/D NM
KEPIVANCE 4 B/D NM
leucovorin calcium TABS 1
leucovorin calcium inj 50mg 1 B/D
leucovorin calcium inj 100mg 1 B/D
leucovorin calcium inj 200mg 1 B/D
leucovorin calcium inj 350mg 1 B/D
leucovorin calcium inj 500mg 1 B/D
levoleucovorin calcium 4 B/D NM
mesna (generic of MESNEX) 1 B/D
MESNEX TABS 4 NM
TOPOISOMERASE INHIBITORS CAMPTOSAR 300mg/15ml 3 B/D
ETOPOPHOS 3 B/D
etoposide SOLN 500mg/25ml
1 B/D
irinotecan inj 40mg/2ml (generic of CAMPTOSAR)
1 B/D
irinotecan inj 100/5ml (generic of CAMPTOSAR)
1 B/D
irinotecan inj 500mg/25ml 1 B/D
toposar 1gm/50ml 1 B/D
topotecan hcl (generic of HYCAMTIN) SOLR
4 B/D NM
CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl
1
amlodipine besylate-benazepril hcl (generic of LOTREL)
1
benazepril & hydrochlorothiazide
1
benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)
1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
14
Drug Name Drug Tier
Requirements/Limits
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
quinapril-hydrochlorothiazide (generic of ACCURETIC)
1
trandolapril-verapamil hcl (generic of TARKA)
1
ACE INHIBITORS benazepril hcl TABS 5mg 1
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 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
Drug Name Drug Tier
Requirements/Limits
doxazosin mesylate (generic of CARDURA)
1
prazosin hcl (generic of MINIPRESS)
1
terazosin hcl 1
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab 5-160 mg (generic of EXFORGE)
1
amlodipine besylate-valsartan tab 5-320 mg (generic of EXFORGE)
1
amlodipine besylate-valsartan tab 10-160 mg (generic of EXFORGE)
1
amlodipine besylate-valsartan tab 10-320 mg (generic of EXFORGE)
1
amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg (generic of EXFORGE HCT)
1
amlodipine-valsartan-hydrochlorothiazide 5-160-25mg (generic of EXFORGE HCT)
1
amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg (generic of EXFORGE HCT)
1
amlodipine-valsartan-hydrochlorothiazide 10-160-25mg (generic of EXFORGE HCT)
1
amlodipine-valsartan-hydrochlorothiazide 10-320-25mg (generic of EXFORGE HCT)
1
AZOR 2
BENICAR HCT 2
candesartan cilexetil-hydrochlorothiazide (generic of ATACAND HCT)
1
EDARBYCLOR 3
irbesartan-hydrochlorothiazide (generic of AVALIDE)
1
losartan-hydrochlorothiazide (generic of HYZAAR)
1
telmisartan-amlodipine (generic of TWYNSTA)
1
telmisartan-hydrochlorothiazide (generic of MICARDIS HCT)
1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
15
Drug Name Drug Tier
Requirements/Limits
TEVETEN HCT 3
TRIBENZOR 2
valsartan-hydrochlorothiazide (generic of DIOVAN HCT)
1
ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 2
candesartan cilexetil (generic of ATACAND)
1
EDARBI 3
eprosartan mesylate 1
irbesartan (generic of AVAPRO)
1
losartan potassium (generic of COZAAR)
1
telmisartan (generic of MICARDIS)
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)
PA if 65 years and older
3 PA
flecainide acetate 1
mexiletine hcl 1
MULTAQ 3
NORPACE CR PA if 65 years and older
3 PA
pacerone 100mg, 400mg 1
pacerone (generic of CORDARONE) 200mg
1
propafenone hcl (generic of RYTHMOL SR) CP12
1
propafenone hcl (generic of RYTHMOL) TABS 225mg
1
propafenone hcl TABS 300mg
1
propafenone hcl 12hr (generic of RYTHMOL SR) CP12
1
Drug Name Drug Tier
Requirements/Limits
propafenone hcl 12hr (generic of RYTHMOL) TABS
1
quinidine gluconate TBCR 1
quinidine sulfate TABS 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 3 NM
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 3
atorvastatin calcium (generic of LIPITOR) TABS
1
CRESTOR 2
fluvastatin sodium (generic of LESCOL) 20mg
1
fluvastatin sodium 40mg 1
LESCOL XL 3
LIVALO 3
lovastatin 10mg, 20mg 1
lovastatin (generic of MEVACOR) 40mg
1
pravastatin sodium 10mg 1
pravastatin sodium (generic of PRAVACHOL) 20mg, 40mg, 80mg
1
simvastatin (generic of ZOCOR) TABS 5mg, 10mg, 20mg, 40mg
1
simvastatin (generic of ZOCOR) TABS 80mg
QL (30 tabs / 30 days)
1 QL
ANTILIPEMICS, MISCELLANEOUS ADVICOR 3
ANTARA 3
cholestyramine (generic of QUESTRAN)
1
cholestyramine light 1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
16
Drug Name Drug Tier
Requirements/Limits
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 TABS 120mg
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 4 NM LA PA
KYNAMRO 4 NM PA
LIPTRUZET 3
niacin er (antihyperlipidemic) (generic of NIASPAN)
1
niacor 1
omega-3-acid ethyl esters (generic of LOVAZA)
1
prevalite (generic of QUESTRAN LIGHT)
1
SIMCOR 3
TRIGLIDE 3
VASCEPA 3
VYTORIN 3
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 3
carvedilol (generic of COREG)
1
COREG CR 3
labetalol hcl SOLN 1
labetalol hcl (generic of TRANDATE) TABS
1
metoprolol succinate (generic of TOPROL XL)
1
metoprolol tartrate 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
propranolol sol 1
propranolol tab 1
SOTYLIZE 4 NM
timolol maleate TABS 1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
17
Drug Name Drug Tier
Requirements/Limits
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate/atorv (generic of CADUET)
1
CALCIUM CHANNEL BLOCKERS afeditab cr (generic of ADALAT CC)
1
amlodipine besylate (generic of NORVASC) TABS
1
CARDIZEM LA 120mg 3
cartia xt (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
nifedipine er (generic of PROCARDIA XL)
1
nimodipine CAPS 4 NM
nisoldipine (generic of SULAR) 8.5mg, 17mg, 34mg
1
nisoldipine 20mg, 25.5mg, 30mg, 40mg
1
Drug Name Drug Tier
Requirements/Limits
NYMALIZE 4 NM
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 digitek (generic of LANOXIN) .25mg
PA if 65 years and older
1 PA
digitek (generic of LANOXIN) .125mg
QL (30 tabs / 30 days)
1 QL
digoxin (generic of LANOXIN) 125mcg
QL (30 tabs / 30 days)
1 QL
digoxin (generic of LANOXIN) 250mcg
PA if 65 years and older
1 PA
digoxin inj (generic of LANOXIN)
1
DIGOXIN SOL 50MCG/ML PA if 65 years and older
1 PA
LANOXIN TABS 62.5mcg QL (60 tabs / 30 days)
3 QL
LANOXIN TABS 187.5mcg PA if 65 years and older
3 PA
LANOXIN PEDIATRIC 3
DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA 2
TEKTURNA HCT 2
DIURETICS acetazolamide (generic of DIAMOX) CP12
1
acetazolamide TABS 1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
18
Drug Name Drug Tier
Requirements/Limits
acetazolamide sodium 1
ALDACTAZIDE TAB 50/50 3
amiloride & hydrochlorothiazide
1
amiloride hcl 1
bumetanide 1
chlorothiazide tabs 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 10mg/ml 1
FUROSEMIDE INJ 10mg/ml 1
furosemide oral soln 8 mg/ml 1
hydrochlorothiazide (generic of MICROZIDE) CAPS
1
hydrochlorothiazide TABS 1
indapamide 1
methazolamide (generic of NEPTAZANE) TABS
1
methyclothiazide 1
metolazone 1
spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)
1
torsemide inj 50mg/5ml 1
torsemide tabs (generic of DEMADEX) 5mg, 10mg, 20mg
1
torsemide tabs 100mg 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
Drug Name Drug Tier
Requirements/Limits
clonidine hcl (generic of CATAPRES-TTS-2) PTWK .2mg/24hr
1
clonidine hcl (generic of CATAPRES-TTS-3) PTWK .3mg/24hr
1
clonidine hcl (generic of CATAPRES) TABS
1
clorpres 1
CORLANOR 3
DEMSER 4 NM
DIBENZYLINE 4 NM
hydralazine hcl SOLN; TABS 1
midodrine hcl 1
minoxidil TABS 1
RANEXA 3
NITRATES DILATRATE SR 3
ISORDIL TITRADOSE 40mg 3
isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg
1
isosorbide dinitrate 10mg, 20mg, 30mg
1
isosorbide dinitrate er 1
isosorbide mononitrate 1
isosorbide mononitrate er 1
minitran (generic of NITRO-DUR)
1
nitro-bid 2
NITRO-DUR .3mg/hr, .8mg/hr
3
nitroglycerin (generic of NITROLINGUAL PUMPSPRAY) .4mg/spray
1
NITROGLYCERIN LINGUAL 1
nitroglycerin patches 1
NITROSTAT 2
PULMONARY ARTERIAL HYPERTENSION ADCIRCA 4 NM PA
ADEMPAS 4 NM LA PA
LETAIRIS 4 NM LA PA
OPSUMIT 4 NM LA PA
ORENITRAM TAB 0.25MG 4 NM LA PA
ORENITRAM TAB 0.125MG 3 NM LA PA
ORENITRAM TAB 1MG 4 NM LA PA
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
19
Drug Name Drug Tier
Requirements/Limits
ORENITRAM TAB 2.5MG 4 NM LA PA
REMODULIN 4 B/D NM LA
REVATIO SUSR 4 NM PA
sildenafil citrate (pulmonary hypertension) (generic of REVATIO) TABS
1 NM PA
TRACLEER 4 NM LA PA
TYVASO 4 B/D NM
VENTAVIS 4 B/D NM
CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam CONC
QL (300 mL / 30 days) 1 QL
alprazolam (generic of XANAX) TABS 1mg
QL (120 tabs / 30 days)
1 QL
alprazolam (generic of XANAX) TABS 2mg
QL (150 tabs / 30 days)
1 QL
alprazolam (generic of XANAX) TABS .5mg
QL (240 tabs / 30 days)
1 QL
alprazolam (generic of XANAX) TABS .25mg
QL (480 tabs / 30 days)
1 QL
buspirone hcl TABS 1
fluvoxamine maleate 25mg, 50mg
QL (45 tabs / 30 days)
1 QL
fluvoxamine maleate 100mg 1
fluvoxamine maleate er 100mg
QL (90 caps / 30 days)
1 QL
fluvoxamine maleate er 150mg
QL (60 caps / 30 days)
1 QL
lorazepam CONC QL (150 mL / 30 days)
1 QL
lorazepam (generic of ATIVAN) SOLN
1
lorazepam (generic of ATIVAN) TABS
QL (150 tabs / 30 days)
1 QL
ANTICONVULSANTS APTIOM 200mg 3
APTIOM 400mg, 600mg, 800mg
4 NM
Drug Name Drug Tier
Requirements/Limits
BANZEL SUS 40MG/ML 4 NM PA
BANZEL TAB 200MG 3 PA
BANZEL TAB 400MG 4 NM PA
carbamazepine CHEW 1
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
QL (120 tabs / 30 days)
1 QL
clonazepam (generic of KLONOPIN) TABS 2mg
QL (300 tabs / 30 days)
1 QL
clonazepam (generic of KLONOPIN) TABS .5mg
QL (240 tabs / 30 days)
1 QL
clonazepam TBDP 1mg QL (120 tabs / 30 days)
1 QL
clonazepam TBDP 2mg QL (300 tabs / 30 days)
1 QL
clonazepam TBDP .5mg QL (240 tabs / 30 days)
1 QL
clonazepam TBDP .25mg QL (480 tabs / 30 days)
1 QL
clonazepam TBDP .125mg QL (960 tabs / 30 days)
1 QL
clorazepate dipotassium (generic of TRANXENE T) 3.75mg, 7.5mg
QL (120 tabs / 30 days)
1 QL PA
clorazepate dipotassium (generic of TRANXENE T) 15mg
QL (180 tabs / 30 days)
1 QL PA
diazepam CONC QL (240 mL / 30 days)
1 QL PA
diazepam SOLN 1mg/ml QL (1200 mL / 30 days)
1 QL PA
diazepam SOLN 5mg/ml 1
diazepam (generic of VALIUM) TABS
QL (120 tabs / 30 days)
1 QL PA
DIAZEPAM GEL (ANTICONVULSANT)
1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
20
Drug Name Drug Tier
Requirements/Limits
dilantin 3
DILANTIN-125 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) SUSP
4 NM
felbamate (generic of FELBATOL) TABS
1
FYCOMPA 3 PA
gabapentin (generic of NEURONTIN) CAPS 100mg
QL (1080 caps / 30 days)
1 QL
gabapentin (generic of NEURONTIN) CAPS 300mg
QL (360 caps / 30 days)
1 QL
gabapentin (generic of NEURONTIN) CAPS 400mg
QL (270 caps / 30 days)
1 QL
gabapentin (generic of NEURONTIN) SOLN
QL (2160 mL / 30 days)
1 QL
gabapentin (generic of NEURONTIN) TABS 600mg
QL (180 tabs / 30 days)
1 QL
gabapentin (generic of NEURONTIN) TABS 800mg
QL (120 tabs / 30 days)
1 QL
GABITRIL 12mg, 16mg 3
LAMICTAL ODT KIT 3
LAMICTAL STARTER 3
LAMICTAL XR KIT 3
lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW
1
lamotrigine (generic of LAMICTAL) TABS
1
lamotrigine (generic of LAMICTAL XR) TB24
1
Drug Name Drug Tier
Requirements/Limits
lamotrigine (generic of LAMICTAL ODT) TBDP
1
levetiracetam (generic of KEPPRA) SOLN; TABS
1
levetiracetam (generic of KEPPRA XR) TB24
1
LEVETIRACETAM IV 3
levetiracetam oral soln 100 mg/ml (generic of KEPPRA)
1
LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg
QL (120 caps / 30 days)
2 QL
LYRICA CAPS 200mg QL (90 caps / 30 days)
2 QL
LYRICA CAPS 225mg, 300mg
QL (60 caps / 30 days)
2 QL
LYRICA SOLN QL (946 mL / 30 days)
2 QL
ONFI SUSP 4 NM PA
ONFI TABS 10mg 3 PA
ONFI TABS 20mg 4 NM PA
oxcarbazepine (generic of TRILEPTAL)
1
OXTELLAR XR 3
PEGANONE 3
phenobarbital ELIX; TABS PA if 65 years and older
3 PA
PHENOBARBITAL SODIUM 65mg/ml
PA if 65 years and older
3 PA
phenobarbital sodium 130mg/ml
PA if 65 years and older
3 PA
phenytek 3
phenytoin (generic of DILANTIN INFATABS) CHEW
1
phenytoin (generic of DILANTIN-125) SUSP
1
phenytoin inj 50mg/ml 1
phenytoin sodium extended (generic of DILANTIN) 100mg
1
phenytoin sodium extended 200mg, 300mg
1
POTIGA 50mg 3
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
21
Drug Name Drug Tier
Requirements/Limits
POTIGA 200mg QL (180 tabs / 30 days)
4 QL NM
POTIGA 300mg, 400mg QL (90 tabs / 30 days)
4 QL NM
primidone (generic of MYSOLINE) TABS
1
SABRIL PACK QL (180 packets / 30 days)
4 QL NM LA PA
SABRIL TABS QL (180 tabs / 30 days)
4 QL NM LA PA
TEGRETOL 3
TEGRETOL-XR 3
tiagabine hcl (generic of GABITRIL)
1
topiramate (generic of TOPAMAX SPRINKLE) CPSP
1
TOPIRAMATE CS24 1
topiramate (generic of TOPAMAX) TABS
1
TROKENDI XR 25mg, 50mg, 100mg
3
TROKENDI XR 200mg 4 NM
valproate sodium (generic of DEPACON) SOLN
1
valproate sodium (generic of DEPAKENE) SYRP
1
valproic acid (generic of DEPAKENE) CAPS
1
VIMPAT SOLN 3
VIMPAT TABS 50mg 3
VIMPAT TABS 100mg, 150mg, 200mg
4 NM
zonisamide (generic of ZONEGRAN) CAPS 25mg, 100mg
1
zonisamide CAPS 50mg 1
ANTIDEMENTIA donepezil odt 5mg 1
donepezil odt 10mg 1
donepezil tab hcl 23mg (generic of ARICEPT)
1
donepezil tabs 5mg (generic of ARICEPT)
1
donepezil tabs 10mg (generic of ARICEPT)
1
Drug Name Drug Tier
Requirements/Limits
EXELON PATCHES 3
galantamine hydrobromide (generic of RAZADYNE ER) CP24
1
galantamine hydrobromide SOLN
1
galantamine hydrobromide (generic of RAZADYNE) TABS
1
memantine hcl (generic of NAMENDA)
PA if < 30 yrs
1 PA
NAMENDA SOL 10MG/5ML PA if < 30 yrs
2 PA
NAMENDA TAB PA if < 30 yrs
3 PA
NAMENDA XR PA if < 30 yrs
3 PA
NAMENDA XR TITRATION PACK
PA if < 30 yrs
3 PA
NAMZARIC 3
rivastigmine tartrate (generic of EXELON)
1
ANTIDEPRESSANTS amitriptyline hcl TABS
PA if 65 years and older 3 PA
amoxapine 1
APLENZIN 4 NM
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
PA if 65 years and older
3 PA
desipramine hcl (generic of NORPRAMIN) TABS
1
doxepin hcl CAPS; CONC PA if 65 years and older
3 PA
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
22
Drug Name Drug Tier
Requirements/Limits
duloxetine hcl (generic of CYMBALTA) CPEP 20mg, 30mg, 60mg
1
EMSAM 4 NM PA
escitalopram oxalate (generic of LEXAPRO)
1
FETZIMA 3
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
3
FORFIVO XL QL (30 tabs / 30 days)
3 QL
imipramine hcl (generic of TOFRANIL) TABS
PA if 65 years and older
3 PA
imipramine pamoate (generic of TOFRANIL-PM)
PA if 65 years and older
3 PA
maprotiline hcl 1
MARPLAN 3
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 tabs (generic of PAXIL)
1
PAXIL SUSP 3
PEXEVA 3
phenelzine sulfate (generic of NARDIL) TABS
1
PRISTIQ 2
protriptyline hcl 1
Drug Name Drug Tier
Requirements/Limits
sertraline hcl (generic of ZOLOFT) CONC; TABS
1
SURMONTIL PA if 65 years and older
3 PA
tranylcypromine sulfate (generic of PARNATE)
1
trazodone hcl TABS 1
venlafaxine cap er (generic of EFFEXOR XR)
1
venlafaxine hcl 1
venlafaxine tab 1
VENLAFAXINE TAB 225MG ER
1
venlafaxine tab er (generic of VENLAFAXINE HCL ER)
1
VIIBRYD 3
ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS
1
APOKYN 4 NM LA PA
AZILECT 2
BENZTROPINE MESYLATE SOLN
1
benztropine mesylate TABS PA if 65 years and older
3 PA
bromocriptine mesylate (generic of PARLODEL) CAPS
1
bromocriptine mesylate TABS
1
carbidopa (generic of LODOSYN) TABS
4 NM
carbidopa-levodopa (generic of SINEMET) TABS
1
carbidopa-levodopa (generic of SINEMET CR) TBCR
1
carbidopa-levodopa TBDP 1
CARBIDOPA/LEVODOPA/ENTACAPONE
1
CARBIDOPA/LEVODOPA/ENTACAPONE
1
CARBIDOPA/LEVODOPA/ENTACAPONE
1
CARBIDOPA/LEVODOPA/ENTACAPONE
1
CARBIDOPA/LEVODOPA/ENTACAPONE
1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
23
Drug Name Drug Tier
Requirements/Limits
CARBIDOPA/LEVODOPA/ENTACAPONE
1
DUOPA 3 B/D NM
ENTACAPONE 1
MIRAPEX .75mg 3
MIRAPEX ER .375mg, 2.25mg, 3mg, 3.75mg, 4.5mg
3
NEUPRO 3
pramipexole dihydrochloride (generic of MIRAPEX) TABS
1
pramipexole dihydrochloride (generic of MIRAPEX ER) TB24
1
ropinirole hydrochloride (generic of REQUIP) TABS
1
ropinirole hydrochloride (generic of REQUIP XL) TB24
1
RYTARY 3
selegiline hcl (generic of ELDEPRYL) CAPS
1
selegiline hcl TABS 1
ZELAPAR 4 NM
ANTIPSYCHOTICS ABILIFY DISCMELT TAB 10MG
QL (60 tabs / 30 days)
4 QL NM
ABILIFY MAINTENA QL (1 injection / 28 days)
4 QL NM
aripiprazole tabs (generic of ABILIFY)
QL (30 tabs / 30 days)
4 QL NM
chlorpromaz inj 25mg/ml 3
chlorpromazine hcl TABS 1
clozapine (generic of CLOZARIL) TABS 25mg
1
clozapine TABS 50mg 1
clozapine (generic of CLOZARIL) TABS 100mg
QL (270 tabs / 30 days)
1 QL
clozapine TABS 200mg QL (135 tabs / 30 days)
1 QL
CLOZAPINE TBDP 150mg QL (180 tabs / 30 days)
4 QL NM PA
CLOZAPINE TBDP 200mg QL (135 tabs / 30 days)
4 QL NM PA
Drug Name Drug Tier
Requirements/Limits
CLOZAPINE ODT 12.5mg, 25mg
1 PA
CLOZAPINE ODT 100mg QL (270 tabs / 30 days)
1 QL PA
FANAPT QL (60 tabs / 30 days)
3 QL ST
FANAPT TITRATION PACK 3 ST
FAZACLO 150mg QL (180 tabs / 30 days)
4 QL NM PA
FAZACLO 200mg QL (135 tabs / 30 days)
4 QL NM PA
fluphenazine decanoate SOLN
1
fluphenazine hcl 1
GEODON INJ QL (6 mL / 3 days)
3 QL
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 1
haloperidol lactate inj 5 mg/ml (generic of HALDOL)
1
INVEGA 1.5mg, 3mg, 9mg QL (30 tabs / 30 days)
3 QL
INVEGA 6mg QL (60 tabs / 30 days)
3 QL
INVEGA SUST INJ 39 MG/0.25 ML
QL (1 injection / 28 days)
3 QL
INVEGA SUST INJ 78 MG/0.5 ML
QL (1 injection / 28 days)
4 QL NM
INVEGA SUST INJ 117 MG/0.75 ML
QL (1 injection / 28 days)
4 QL NM
INVEGA SUST INJ 156MG/ML
QL (1 injection / 28 days)
4 QL NM
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
24
Drug Name Drug Tier
Requirements/Limits
INVEGA SUST INJ 234 MG/1.5 ML
QL (1 injection / 28 days)
4 QL NM
INVEGA TRINZA QL (1 syringe / 90 days)
4 QL NM
LATUDA 20mg QL (240 tabs / 30 days)
3 QL
LATUDA 40mg, 120mg QL (30 tabs / 30 days)
3 QL
LATUDA 60mg, 80mg QL (60 tabs / 30 days)
3 QL
loxapine succinate 1
olanzapine (generic of ZYPREXA) SOLR
QL (3 vials / 1 day)
1 QL
olanzapine (generic of ZYPREXA) TABS 2.5mg, 5mg, 7.5mg
QL (30 tabs / 30 days)
1 QL
olanzapine (generic of ZYPREXA) TABS 10mg, 15mg, 20mg
QL (60 tabs / 30 days)
1 QL
olanzapine odt (generic of ZYPREXA ZYDIS) 5mg
QL (30 tabs / 30 days)
1 QL
olanzapine odt (generic of ZYPREXA ZYDIS) 10mg, 15mg, 20mg
QL (60 tabs / 30 days)
1 QL
ORAP 3
perphenazine TABS 1
quetiapine fumarate (generic of SEROQUEL)
QL (90 tabs / 30 days)
1 QL
RISPERDAL INJ 12.5MG QL (2 injections / 28 days)
3 QL
RISPERDAL INJ 25MG QL (2 injections / 28 days)
3 QL
RISPERDAL INJ 37.5MG QL (2 injections / 28 days)
4 QL NM
RISPERDAL INJ 50MG QL (2 injections / 28 days)
4 QL NM
Drug Name Drug Tier
Requirements/Limits
risperidone (generic of RISPERDAL) SOLN
QL (240 mL / 30 days)
1 QL
risperidone (generic of RISPERDAL) TABS 1mg, 2mg, 3mg
QL (60 tabs / 30 days)
1 QL
risperidone (generic of RISPERDAL) TABS 4mg
QL (120 tabs / 30 days)
1 QL
risperidone (generic of RISPERDAL) TABS .25mg, .5mg
QL (90 tabs / 30 days)
1 QL
risperidone odt (generic of RISPERDAL M-TAB) 1mg, 2mg, 3mg
QL (60 tabs / 30 days)
1 QL
risperidone odt (generic of RISPERDAL M-TAB) 4mg
QL (120 tabs / 30 days)
1 QL
risperidone odt (generic of RISPERDAL M-TAB) .5mg
QL (90 tabs / 30 days)
1 QL
risperidone odt .25mg QL (90 tabs / 30 days)
1 QL
SAPHRIS 2.5mg QL (240 tabs / 30 days)
3 QL
SAPHRIS 5mg QL (120 tabs / 30 days)
3 QL
SAPHRIS 10mg QL (60 tabs / 30 days)
3 QL
SEROQUEL XR 50mg QL (120 tabs / 30 days)
3 QL
SEROQUEL XR 150mg, 200mg
QL (30 tabs / 30 days)
3 QL
SEROQUEL XR 300mg, 400mg
QL (60 tabs / 30 days)
3 QL
thioridazine hcl TABS PA if 65 years and older
3 PA
thiothixene 1
trifluoperazine hcl 1
VERSACLOZ QL (600 mL / 30 days)
4 QL NM PA
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
25
Drug Name Drug Tier
Requirements/Limits
ziprasidone hcl (generic of GEODON) 20mg, 40mg
QL (60 caps / 30 days)
1 QL
ziprasidone hcl (generic of GEODON) 60mg, 80mg
QL (90 caps / 30 days)
1 QL
ZYPREXA RELPREVV 300mg
QL (2 vials / 28 days)
4 QL NM PA
ZYPREXA RELPREVV 405mg
QL (1 vial / 28 days)
4 QL NM PA
ZYPREXA RELPREVV INJ 210MG
QL (2 vials / 28 days)
4 QL NM PA
ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine cap 10mg er (generic of ADDERALL XR)
QL (90 caps / 30 days)
1 QL
amphetamine cap 15mg er (generic of ADDERALL XR)
QL (30 caps / 30 days)
1 QL
amphetamine cap 20mg er (generic of ADDERALL XR)
QL (30 caps / 30 days)
1 QL
amphetamine cap 25mg er (generic of ADDERALL XR)
QL (30 caps / 30 days)
1 QL
amphetamine cap 30mg er (generic of ADDERALL XR)
QL (30 caps / 30 days)
1 QL
amphetamine-dextroamphetamine cap sr 24hr 5 mg (generic of ADDERALL XR)
QL (90 caps / 30 days)
1 QL
amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)
QL (360 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)
QL (240 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 10 mg (generic of ADDERALL)
QL (180 tabs / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)
QL (144 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 15 mg (generic of ADDERALL)
QL (120 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 20 mg (generic of ADDERALL)
QL (90 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 30 mg (generic of ADDERALL)
QL (60 tabs / 30 days)
1 QL
APTENSIO XR 10mg, 15mg, 20mg, 30mg
QL (60 caps / 30 days)
3 QL
APTENSIO XR 40mg, 50mg, 60mg
QL (30 caps / 30 days)
3 QL
DAYTRANA QL (30 patches / 30 days)
3 QL
guanfacine hcl (adhd) (generic of INTUNIV)
PA if 65 years and older
3 PA
metadate er tab 20mg QL (90 tabs / 30 days)
1 QL
methylphenidate hcl (generic of METHYLIN) CHEW
QL (180 tabs / 30 days)
1 QL
methylphenidate hcl (generic of RITALIN LA) CP24 20mg, 30mg
QL (60 caps / 30 days)
1 QL
methylphenidate hcl (generic of RITALIN LA) CP24 40mg
QL (30 caps / 30 days)
1 QL
methylphenidate hcl (generic of METADATE CD) CPCR 10mg, 20mg, 30mg
QL (60 caps / 30 days)
1 QL
methylphenidate hcl (generic of METADATE CD) CPCR 40mg, 50mg, 60mg
QL (30 caps / 30 days)
1 QL
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
26
Drug Name Drug Tier
Requirements/Limits
methylphenidate hcl (generic of METHYLIN) SOLN 5mg/5ml
QL (1800 mL / 30 days)
1 QL
methylphenidate hcl (generic of METHYLIN) SOLN 10mg/5ml
QL (900 mL / 30 days)
1 QL
methylphenidate hcl (generic of RITALIN) TABS 5mg, 10mg
QL (180 tabs / 30 days)
1 QL
methylphenidate hcl (generic of RITALIN) TABS 20mg
QL (90 tabs / 30 days)
1 QL
methylphenidate hcl TBCR 10mg, 20mg
QL (90 tabs / 30 days)
1 QL
methylphenidate hcl TBCR 18mg
QL (60 tabs / 30 days)
1 QL
methylphenidate hcl er 27mg, 36mg
QL (60 tabs / 30 days)
1 QL
methylphenidate hcl er 54mg QL (30 tabs / 30 days)
1 QL
QUILLIVANT XR QL (360 mL / 30 days)
3 QL
RITALIN LA 10mg QL (180 tabs / 30 days)
3 QL
RITALIN LA 60mg QL (30 caps / 30 days)
3 QL
STRATTERA 10mg, 18mg, 25mg
QL (120 caps / 30 days)
3 QL
STRATTERA 40mg QL (60 caps / 30 days)
3 QL
STRATTERA 60mg, 80mg, 100mg
QL (30 caps / 30 days)
3 QL
VYVANSE 10mg, 20mg, 30mg
QL (60 caps / 30 days)
3 QL
VYVANSE 40mg, 50mg, 60mg, 70mg
QL (30 caps / 30 days)
3 QL
HYPNOTICS HETLIOZ 4 NM LA PA
Drug Name Drug Tier
Requirements/Limits
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 per calendar year if 65 years and older
1 QL PA
temazepam (generic of RESTORIL) 15mg
QL (60 caps / 30 days) 90 day limit per calendar year if 65 years and older
1 QL PA
zolpidem tartrate (generic of AMBIEN) TABS
QL (30 tabs / 30 days) 90 day limit per calendar year if 65 years and older
3 QL PA
MIGRAINE almotriptan malate (generic of AXERT)
QL (12 tabs / 30 days)
1 QL
ALSUMA QL (12 injections / 30 days)
3 QL
AXERT QL (12 tabs / 30 days)
3 QL
cafergot tab 1-100mg 3
dihydroergotamine mesylate (generic of D.H.E. 45) 1mg/ml
1
DIHYDROERGOTAMINE MESYLATE 4mg/ml
QL (8 mL / 30 days)
4 QL NM
ergomar 3
FROVA TAB 2.5MG QL (18 tabs / 30 days)
3 QL
migergot 4 NM
naratriptan hcl (generic of AMERGE)
QL (9 tabs / 30 days)
1 QL
RELPAX QL (12 tabs / 30 days)
2 QL
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
27
Drug Name Drug Tier
Requirements/Limits
rizatriptan benzoate (generic of MAXALT) TABS
QL (18 tabs / 30 days)
1 QL
rizatriptan benzoate (generic of MAXALT-MLT) TBDP
QL (18 tabs / 30 days)
1 QL
SUMATRIPTAN INJ 4MG/0.5ML
QL (12 injections / 30 days)
1 QL
sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) SOAJ
QL (12 injections / 30 days)
1 QL
SUMATRIPTAN INJ 6MG/0.5ML SOCT
QL (12 injections / 30 days)
1 QL
sumatriptan inj 6mg/0.5ml (generic of IMITREX) SOLN
QL (6 mL / 30 days)
1 QL
sumatriptan inj 6mg/0.5ml SOSY
QL (12 injections / 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 (generic of IMITREX) TABS
QL (9 tabs / 30 days)
1 QL
SUMAVEL DOSEPRO QL (12 injections / 30 days)
4 QL NM
TREXIMET QL (9 tabs / 30 days)
4 QL NM
zolmitriptan (generic of ZOMIG) TABS
QL (12 tabs / 30 days)
1 QL
zolmitriptan odt (generic of ZOMIG ZMT)
QL (12 tabs / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
ZOMIG NASAL SPRAY QL (12 inhalers / 30 days)
3 QL
MISCELLANEOUS BRISDELLE 3
EQUETRO 3
GRALISE 300mg QL (180 tabs / 30 days)
2 QL
GRALISE 600mg QL (90 tabs / 30 days)
2 QL
GRALISE STARTER 2
HORIZANT 3
lithium carbonate CAPS 1
lithium carbonate TABS 1
lithium carbonate (generic of LITHOBID) TBCR 300mg
1
lithium carbonate TBCR 450mg
1
LITHIUM SOLN 8MEQ/5ML 2
MESTINON SYRUP 3
MESTINON TIMESPAN 3
NUEDEXTA 2
pyridostigmine bromide (generic of MESTINON) TABS
1
pyridostigmine bromide TBCR
1
riluzole (generic of RILUTEK) 1
SAVELLA 12.5mg QL (480 tabs / 30 days)
3 QL
SAVELLA 25mg QL (240 tabs / 30 days)
3 QL
SAVELLA 50mg QL (120 tabs / 30 days)
3 QL
SAVELLA 100mg QL (60 tabs / 30 days)
3 QL
SAVELLA TITRATION PACK 3
XENAZINE 12.5mg QL (240 tabs / 30 days)
4 QL NM LA PA
XENAZINE 25mg QL (120 tabs / 30 days)
4 QL NM LA PA
MULTIPLE SCLEROSIS AGENTS AMPYRA 4 NM LA PA
AUBAGIO QL (30 tabs / 30 days)
4 QL NM LA PA
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
28
Drug Name Drug Tier
Requirements/Limits
AVONEX QL (4 injections / 28 days)
4 QL NM PA
AVONEX PEN QL (4 injections / 28 days)
4 QL NM PA
BETASERON QL (14 syringes / 28 days)
4 QL NM PA
COPAXONE INJ 40MG/ML QL (12 syringes / 28 days)
4 QL NM PA
EXTAVIA QL (15 syringes / 30 days)
4 QL NM PA
GILENYA CAP 0.5MG QL (28 caps / 28 days)
4 QL NM PA
glatopa (generic of COPAXONE)
QL (30 syringes / 30 days)
4 QL NM PA
LEMTRADA 4 NM LA PA
PLEGRIDY SOPN QL (2 pens / 28 days)
4 QL NM PA
PLEGRIDY SOSY QL (2 syringes / 28 days)
4 QL NM PA
PLEGRIDY STARTER PACK SOPN
QL (2 pens / 28 days)
4 QL NM PA
PLEGRIDY STARTER PACK SOSY
QL (2 syringes / 28 days)
4 QL NM PA
REBIF QL (6 mL / 28 days)
4 QL NM PA
REBIF REBIDOSE QL (6 mL / 28 days)
4 QL NM PA
REBIF REBIDOSE TITRATION
QL (6 mL / 28 days)
4 QL NM PA
REBIF TITRATION PACK QL (6 mL / 30 days)
4 QL NM PA
TECFIDERA CAP 120MG QL (14 caps / 7 days)
4 QL NM LA PA
TECFIDERA CAP 240MG QL (60 caps / 30 days)
4 QL NM LA PA
TECFIDERA MIS STARTER 4 NM LA PA
Drug Name Drug Tier
Requirements/Limits
TYSABRI 4 NM LA PA
MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1
BOTOX INJ 100UNIT 4 NM PA
BOTOX INJ 200UNIT 4 NM PA
cyclobenzaprine hcl TABS 5mg, 10mg
PA if 65 years and older
3 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
XEOMIN INJ 50 UNIT 3 NM PA
XEOMIN INJ 100 UNIT 4 NM PA
NARCOLEPSY/CATAPLEXY modafinil (generic of PROVIGIL) 100mg
QL (30 tabs / 30 days)
1 QL PA
modafinil (generic of PROVIGIL) 200mg
QL (60 tabs / 30 days)
4 QL NM PA
NUVIGIL 50mg QL (150 tabs / 30 days)
3 QL PA
NUVIGIL 150mg QL (60 tabs / 30 days)
3 QL PA
NUVIGIL 200mg, 250mg QL (30 tabs / 30 days)
3 QL PA
XYREM QL (540 mL / 30 days)
4 QL NM LA PA
PSYCHOTHERAPEUTIC-MISC acamprosate calcium 1
BUNAVAIL MIS 2.1-0.3MG QL (120 buccal films / 30 days)
3 QL PA
BUNAVAIL MIS 4.2-0.7MG QL (120 buccal films / 30 days)
3 QL PA
BUNAVAIL MIS 6.3-1MG QL (60 buccal films / 30 days)
3 QL PA
buprenorphine hcl SUBL 1 PA
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
29
Drug Name Drug Tier
Requirements/Limits
buprenorphine hcl-naloxone hcl sl
QL (120 tabs / 30 days)
1 QL PA
buproban (generic of ZYBAN) 1
CHANTIX 3 PA
CHANTIX CONTINUING MONTH
3 PA
CHANTIX STARTER PACK 3 PA
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 QL (120 SL films / 30 days)
3 QL PA
SUBOXONE MIS 4-1MG QL (120 SL films / 30 days)
3 QL PA
SUBOXONE MIS 8-2MG QL (120 SL films / 30 days)
3 QL PA
SUBOXONE MIS 12-3MG QL (60 SL films / 30 days)
3 QL PA
ZUBSOLV SUB 1.4-0.36MG QL (120 tabs / 30 days)
3 QL PA
ZUBSOLV SUB 5.7-1.4MG QL (120 tabs / 30 days)
3 QL PA
ZUBSOLV SUB 8.6-2.1MG QL (60 tabs / 30 days)
3 QL PA
ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM
QL (30 patches / 30 days)
3 QL PA
ANDROGEL 20.25mg/1.25gm, 40.5mg/2.5gm
QL (150 grams / 30 days)
3 QL PA
ANDROGEL 25mg/2.5gm QL (300 grams / 30 days)
3 QL PA
Drug Name Drug Tier
Requirements/Limits
ANDROGEL 1% QL (300 grams / 30 days)
3 QL PA
ANDROGEL 1.62% QL (150 grams / 30 days)
3 QL PA
ANDROGEL PUMP QL (300 grams / 30 days)
3 QL PA
AVEED 3 NM PA
AXIRON QL (440 mL / 30 days)
2 QL PA
depo-testosterone 100mg/ml 3 PA
FORTESTA QL (120 grams / 30 days)
3 QL PA
oxandrolone (generic of OXANDRIN) TABS 2.5mg
1 PA
oxandrolone (generic of OXANDRIN) TABS 10mg
4 NM PA
STRIANT QL (60 buccal systems / 30 days)
3 QL PA
TESTIM QL (300 grams / 30 days)
3 QL PA
testosterone cypionate SOLN 100mg/ml
1 PA
testosterone cypionate (generic of DEPO-TESTOSTERONE) SOLN 200mg/ml
1 PA
testosterone enanthate SOLN
1 PA
VOGELXO QL (300 grams / 30 days)
3 QL PA
VOGELXO PUMP QL (300 grams / 30 days)
3 QL PA
ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 2
APIDRA 3
APIDRA SOLOSTAR 3
BYDUREON PEN QL (4 pens / 28 days)
2 QL
BYDUREON SUSR QL (4 vials / 28 days)
2 QL
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
30
Drug Name Drug Tier
Requirements/Limits
BYETTA QL (1 pen / 30 days)
3 QL
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 KWIKPEN 3
HUMULIN N 3
HUMULIN N KWIKPEN 3
HUMULIN R 3
HUMULIN R U-500 (CONCENTRATE)
4 B/D NM
INSULIN PEN NEEDLES 2
INSULIN SAFETY NEEDLES 2
INSULIN SYRINGES 2
LANTUS 2
LANTUS SOLOSTAR 2
LEVEMIR 2
LEVEMIR FLEXTOUCH 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 3 PA
SYMLINPEN 120 4 NM PA
TANZEUM QL (4 pens / 28 days)
3 QL
TOUJEO SOLOSTAR 2
TRULICITY QL (4 pens / 28 days)
3 QL
Drug Name Drug Tier
Requirements/Limits
VICTOZA QL (3 pens / 30 days)
2 QL
ANTIDIABETICS, ORAL acarbose (generic of PRECOSE)
1
ACTOPLUS MET XR 15-1000MG
QL (60 tabs / 30 days)
3 QL
ACTOPLUS MET XR 30-1000MG
QL (30 tabs / 30 days)
3 QL
FARXIGA 5mg QL (60 tabs / 30 days)
2 QL
FARXIGA 10mg QL (30 tabs / 30 days)
2 QL
glimepiride (generic of AMARYL) 1mg
QL (240 tabs / 30 days)
1 QL
glimepiride (generic of AMARYL) 2mg
QL (120 tabs / 30 days)
1 QL
glimepiride (generic of AMARYL) 4mg
QL (60 tabs / 30 days)
1 QL
glipizide (generic of GLUCOTROL) TABS 5mg
QL (240 tabs / 30 days)
1 QL
glipizide (generic of GLUCOTROL) TABS 10mg
QL (120 tabs / 30 days)
1 QL
glipizide er (generic of GLUCOTROL XL) 2.5mg
QL (240 tabs / 30 days)
1 QL
glipizide er (generic of GLUCOTROL XL) 5mg
QL (120 tabs / 30 days)
1 QL
glipizide er (generic of GLUCOTROL XL) 10mg
QL (60 tabs / 30 days)
1 QL
glipizide-metformin 2.5-250 mg
QL (240 tabs / 30 days)
1 QL
glipizide-metformin 2.5-500 mg
QL (120 tabs / 30 days)
1 QL
glipizide-metformin 5-500mg QL (120 tabs / 30 days)
1 QL
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
31
Drug Name Drug Tier
Requirements/Limits
GLUMETZA 500mg QL (120 tabs / 30 days)
3 QL
GLUMETZA 1000mg QL (60 tabs / 30 days)
3 QL
GLYSET 3
GLYXAMBI QL (30 tabs / 30 days)
3 QL
INVOKAMET TAB 50-500MG QL (120 tabs / 30 days)
2 QL
INVOKAMET TAB 50-1000 QL (60 tabs / 30 days)
2 QL
INVOKAMET TAB 150-500 QL (60 tabs / 30 days)
2 QL
INVOKAMET TAB 150-1000 QL (60 tabs / 30 days)
2 QL
INVOKANA TAB 100MG QL (90 tabs / 30 days)
2 QL
INVOKANA TAB 300MG QL (30 tabs / 30 days)
2 QL
JANUMET QL (60 tabs / 30 days)
2 QL
JANUMET XR TAB 50-500MG
QL (60 tabs / 30 days)
2 QL
JANUMET XR TAB 50-1000 QL (60 tabs / 30 days)
2 QL
JANUMET XR TAB 100-1000 QL (30 tabs / 30 days)
2 QL
JANUVIA QL (30 tabs / 30 days)
2 QL
JARDIANCE 10mg QL (60 tabs / 30 days)
3 QL
JARDIANCE 25mg QL (30 tabs / 30 days)
3 QL
JENTADUETO QL (60 tabs / 30 days)
2 QL
KAZANO QL (60 tabs / 30 days)
3 QL
KOMBIGLYZE XR 2.5-1000MG
QL (60 tabs / 30 days)
3 QL
KOMBIGLYZE XR 5-500MG QL (30 tabs / 30 days)
3 QL
KOMBIGLYZE XR 5-1000MG QL (30 tabs / 30 days)
3 QL
metformin er (generic of GLUCOPHAGE XR) 500mg
QL (120 tabs / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
metformin er (generic of GLUCOPHAGE XR) 750mg
QL (60 tabs / 30 days)
1 QL
metformin hcl (generic of GLUCOPHAGE) TABS 500mg
QL (150 tabs / 30 days)
1 QL
metformin hcl (generic of GLUCOPHAGE) TABS 850mg
QL (90 tabs / 30 days)
1 QL
metformin hcl (generic of GLUCOPHAGE) TABS 1000mg
QL (75 tabs / 30 days)
1 QL
metformin hcl (generic of FORTAMET) TB24 500mg
QL (150 tabs / 30 days)
1 QL
metformin hcl (generic of FORTAMET) TB24 1000mg
QL (75 tabs / 30 days)
1 QL
nateglinide (generic of STARLIX)
QL (90 tabs / 30 days)
1 QL
NESINA 6.25mg QL (120 tabs / 30 days)
3 QL
NESINA 12.5mg QL (60 tabs / 30 days)
3 QL
NESINA 25mg QL (30 tabs / 30 days)
3 QL
ONGLYZA QL (30 tabs / 30 days)
3 QL
OSENI TAB 12.5-15MG QL (60 tabs / 30 days)
3 QL
OSENI TAB 12.5-30MG QL (30 tabs / 30 days)
3 QL
OSENI TAB 12.5-45MG QL (30 tabs / 30 days)
3 QL
OSENI TAB 25-15MG QL (30 tabs / 30 days)
3 QL
OSENI TAB 25-30MG QL (30 tabs / 30 days)
3 QL
OSENI TAB 25-45MG QL (30 tabs / 30 days)
3 QL
pioglitazone hcl (generic of ACTOS)
QL (30 tabs / 30 days)
1 QL
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
32
Drug Name Drug Tier
Requirements/Limits
pioglitazone hcl-glimepiride (generic of DUETACT)
QL (30 tabs / 30 days)
1 QL
pioglitazone hcl-metformin hcl (generic of ACTOPLUS MET)
QL (90 tabs / 30 days)
1 QL
PRANDIMET QL (150 tabs / 30 days)
3 QL
repaglinide (generic of PRANDIN) 2mg
QL (240 tabs / 30 days)
1 QL
repaglinide (generic of PRANDIN) .5mg, 1mg
QL (120 tabs / 30 days)
1 QL
RIOMET QL (946 mL / 30 days)
3 QL
TRADJENTA QL (30 tabs / 30 days)
2 QL
XIGDUO XR TAB 5-500MG QL (60 tabs / 30 days)
3 QL
XIGDUO XR TAB 5-1000MG QL (60 tabs / 30 days)
3 QL
XIGDUO XR TAB 10-500MG QL (30 tabs / 30 days)
3 QL
XIGDUO XR TAB 10-1000MG QL (30 tabs / 30 days)
3 QL
BISPHOSPHONATES alendronate sodium SOLN
QL (300 mL / 28 days) 1 QL
alendronate sodium TABS 5mg, 10mg, 35mg, 40mg
1
alendronate sodium (generic of FOSAMAX) TABS 70mg
1
BINOSTO 3
FOSAMAX PLUS D 3
ibandronate sodium (generic of BONIVA)
QL (1 injection / 90 days)
1 B/D QL
ibandronate tab 150mg (generic of BONIVA)
1 B/D
pamidronate disodium SOLN 1 B/D
RISEDRONATE SODIUM TABS 5mg, 30mg
1
risedronate sodium (generic of ACTONEL) TABS 35mg, 150mg
1
Drug Name Drug Tier
Requirements/Limits
risedronate sodium (generic of ATELVIA) TBEC
1
zoledronic inj 4mg/5ml (generic of ZOMETA)
1 B/D NM
zoledronic inj 5/100ml (generic of RECLAST)
1 B/D NM
ZOMETA SOLN 4 B/D NM
CALCIUM RECEPTOR AGONISTS SENSIPAR 30mg 2 NM
SENSIPAR 60mg, 90mg 4 NM
CHELATING AGENTS CHEMET 3
DEPEN TITRATABS 4 NM
EXJADE 4 NM LA PA
FERRIPROX 4 NM LA PA
JADENU 4 NM PA
kionex (generic of KAYEXALATE)
1
sodium polystyrene sulfonate 1
sps susp 15gm/60ml 1
SYPRINE 4 NM
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
ashlyna 91 day (generic of SEASONIQUE)
1
aubra 28 day 1
aviane 28 1
balziva 28 day (generic of OVCON-35)
1
BEYAZ 3
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
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
33
Drug Name Drug Tier
Requirements/Limits
cyclafem 7/7/7 28 day (generic of ORTHO-NOVUM 7/7/7)
1
deblitane 28 day (generic of NOR-QD)
1
delyla 28 day 1
DEPO-SUBQ PROVERA 104 3
desogestrel-ethinyl estradiol (biphasic) (generic of MIRCETTE)
1
drospirenone-ethinyl estradiol (generic of YASMIN 28)
1
ELLA 3
emoquette (generic of DESOGEN)
1
enpresse 28 day 1
errin 28 day (generic of ORTHO MICRONOR)
1
falmina 28 day 1
GIANVI TAB 3-0.02MG 1
gildagia (generic of OVCON-35)
1
gildess 1.5/30 21 day (generic of LOESTRIN 1.5/30-21)
1
gildess 24 fe 28 day 1
heather (generic of NOR-QD) 1
introvale 91 day 1
JOLESSA TAB 0.15-0.03 MG 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
junel fe 24 1/20 28 day 1
kariva 28 day (generic of MIRCETTE)
1
kelnor 1/35 28 day 1
kimidess (generic of MIRCETTE)
1
larin 1.5/30 (generic of LOESTRIN 1.5/30-21)
1
larin 1/20 (generic of LOESTRIN 1/20-21)
1
Drug Name Drug Tier
Requirements/Limits
larin fe 1.5/30 (generic of LOESTRIN FE 1.5/30)
1
larin fe 1/20 (generic of LOESTRIN FE 1/20)
1
LEENA TAB 1
lessina 28 day 1
levonest 28 day 1
levonorgestrel & eth estradiol 1
levonorgestrel (emergency oc) (generic of PLAN B ONE-STEP) 1.5mg
1
levonorgestrel (emergency oc) .75mg
1
levonorgestrel-ethinyl estradiol (91-day)
1
levonorgestrel-ethinyl estradiol (91-day) (generic of SEASONIQUE)
1
levonorgestrel-ethinyl estradiol (continuous)
1
levora 0.15/30 28 day 1
LO LOESTRIN FE 3
lomedia 24 fe 1
loryna 28 day (generic of YAZ)
1
low-ogestrel 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 1
MICROGESTIN 1/20 1
MICROGESTIN FE 1.5/30 1
MICROGESTIN FE 1/20 1
MINASTRIN 24 FE 3
MONONESSA 1
my way (generic of PLAN B ONE-STEP)
1
myzilra 1
necon 0.5/35 28 day (generic of BREVICON-28)
1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
34
Drug Name Drug Tier
Requirements/Limits
necon 1/35 28 day (generic of NORINYL 1+35)
1
NECON 7/7/7 1
necon 10/11 28 day 2
NECON TAB 1/50-28 1
next choice tab 1.5mg (generic of PLAN B ONE-STEP)
1
nikki 28 day (generic of YAZ) 1
NORA-BE TAB 1
norethin acet & estrad-fe 1
norethindrone & ethinyl estradiol-fe (generic of GENERESS FE)
1
norethindrone (contraceptive) (generic of NOR-QD)
1
norgestimate-ethinyl estradiol (triphasic) (generic of ORTHO TRI-CYCLEN)
1
norlyroc 28 day (generic of NOR-QD)
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 3
OCELLA TAB 3-0.03MG 1
ogestrel 28 day 1
orsythia 28 day 1
ORTHO TRI-CYCLEN LO 3
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
Drug Name Drug Tier
Requirements/Limits
sharobel 28 day (generic of ORTHO MICRONOR)
1
SOLIA 1
sprintec 28 day (generic of ORTHO-CYCLEN)
1
sronyx 28 day 1
syeda (generic of YASMIN 28)
1
tarina fe 1/20 28 day (generic of LOESTRIN FE 1/20)
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
vyfemla 28 day (generic of OVCON-35)
1
wymzya fe (generic of FEMCON FE)
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 4 NM PA
SYNAREL 4 NM
ENZYME REPLACEMENTS ADAGEN 4 NM LA PA
ALDURAZYME 4 NM LA PA
CARBAGLU 4 NM LA PA
CERDELGA 4 NM PA
CEREZYME 4 NM LA PA
CYSTADANE 4 NM LA
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
35
Drug Name Drug Tier
Requirements/Limits
CYSTAGON 3 NM LA PA
ELAPRASE 4 NM LA PA
ELELYSO 4 NM PA
FABRAZYME 4 NM LA PA
KUVAN 4 NM LA PA
levocarnitine (metabolic modifiers) (generic of CARNITOR)
1 B/D
LUMIZYME 4 NM LA PA
MYOZYME 4 NM LA PA
NAGLAZYME 4 NM LA PA
ORFADIN 4 NM LA PA
PROCYSBI 4 NM LA PA
RAVICTI 4 NM PA
sodium phenylbutyrate (generic of BUPHENYL)
4 NM
VIMIZIM 4 NM PA
VPRIV 4 NM PA
ZAVESCA 4 NM LA PA
ESTROGENS ALORA
PA if 65 years and older 3 PA
DELESTROGEN 10mg/ml 3
depo-estradiol 3
estrace CREA 3
estradiol (generic of VIVELLE-DOT) PTTW
PA if 65 years and older
3 PA
estradiol (generic of CLIMARA) PTWK
PA if 65 years and older
3 PA
estradiol (generic of ESTRACE) TABS
PA if 65 years and older
3 PA
estradiol valerate (generic of DELESTROGEN) OIL
1
ESTRING 3
FEMRING 3
jinteli PA if 65 years and older
3 PA
MENOSTAR PA if 65 years and older
3 PA
MINIVELLE PA if 65 years and older
3 PA
norethindrone acetate-ethinyl estradiol
PA if 65 years and older
3 PA
Drug Name Drug Tier
Requirements/Limits
PREMARIN CREAM 3
PREMARIN INJ 3
VAGIFEM 3
GLUCOCORTICOIDS a-hydrocort 1
cortisone acetate TABS 1
DEPO-MEDROL INJ 20MG/ML
3 B/D
dexamethasone CONC; ELIX; SOLN; TABS
1
dexamethasone sodium phosphate
1
dexpak taperpak 13 day 3
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
methylpr ss inj 125mg (generic of SOLU-MEDROL)
1 B/D
methylpred pak 4mg (generic of MEDROL DOSEPAK)
1 B/D
methylpred tab 4mg (generic of MEDROL)
1 B/D
methylpred tab 8mg (generic of MEDROL)
1 B/D
methylpred tab 16mg (generic of MEDROL)
1 B/D
methylpred tab 32mg (generic of MEDROL)
1 B/D
millipred 3 B/D
pred sod pho sol 5mg/5ml (generic of PEDIAPRED)
1 B/D
prednisolone sodium phosphate (generic of ORAPRED ODT)
1 B/D
prednisolone sol 15mg/5ml 1 B/D
prednisolone sol 25mg/5ml 1 B/D
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
36
Drug Name Drug Tier
Requirements/Limits
prednisolone syrup 15 mg/5ml 1 B/D
prednisone con 5mg/ml 2 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
prednisone tab 5mg 1 B/D
prednisone tab 10mg 1 B/D
prednisone tab 20mg 1 B/D
prednisone tab 50mg 1 B/D
RAYOS TAB 1MG 4 B/D NM
RAYOS TAB 2MG 4 B/D NM
RAYOS TAB 5MG 4 B/D NM
SOLU-CORTEF 100MG 3
SOLU-CORTEF 250MG 3
SOLU-CORTEF 500MG 3
SOLU-CORTEF 1000MG 3
SOLU-MEDROL INJ 2GM 3 B/D
veripred 3 B/D
GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 2
GLUCAGON EMERGENCY KIT
2
KORLYM 4 NM LA PA
PROGLYCEM SUS 50MG/ML 3
HUMAN GROWTH HORMONES GENOTROPIN 4 NM LA PA
GENOTROPIN MINIQUICK .2mg
3 NM LA PA
GENOTROPIN MINIQUICK .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg
4 NM LA PA
HUMATROPE 4 NM LA PA
HUMATROPE COMBO PACK 4 NM LA PA
NORDITROPIN FLEXPRO 4 NM PA
NORDITROPIN NORDIFLEX PEN
4 NM PA
NUTROPIN AQ INJ 20MG/2ML
4 NM LA PA
NUTROPIN AQ NUSPIN 5 4 NM LA PA
NUTROPIN AQ PEN 4 NM LA PA
OMNITROPE 5.8MG 4 NM LA PA
OMNITROPE 5MG 4 NM LA PA
OMNITROPE 10MG 4 NM LA PA
Drug Name Drug Tier
Requirements/Limits
SAIZEN 4 NM LA PA
SAIZEN CLICK.EASY 4 NM LA PA
SEROSTIM 4 NM LA PA
ZOMACTON 4 NM PA
ZORBTIVE 4 NM PA
MISCELLANEOUS AFREZZA 3
cabergoline 1
calcitonin (salmon) nasal spray (generic of MIACALCIN)
1
CHORIONIC GONADOTROPIN SOLR
1 NM PA
EGRIFTA 1mg 4 NM LA PA
FORTICAL SPR 200/ACT 2
H.P. ACTHAR QL (1.5 ml / 1 day)
4 QL NM LA PA
INCRELEX 4 NM LA PA
methylergonovine maleate (generic of METHERGINE) TABS
1
MIACALCIN INJ 200U/ML 4 B/D NM
NOVAREL INJ 10000UNT 1 NM PA
octreotide acetate (generic of SANDOSTATIN) 50mcg/ml, 100mcg/ml
1 NM PA
octreotide acetate (generic of SANDOSTATIN) 200mcg/ml, 500mcg/ml, 1000mcg/ml
4 NM PA
PREGNYL W/DILUENT BENZYL
1 NM PA
PROLIA QL (1 syringe / 180 days)
3 QL NM
raloxifene hcl (generic of EVISTA)
1
SAMSCA 4 NM PA
SANDOSTATIN LAR DEPOT 4 NM PA
SIGNIFOR 4 NM LA PA
SIGNIFOR LAR 4 NM LA PA
SOMATULINE DEPOT 4 NM PA
SOMAVERT 4 NM LA PA
XGEVA 4 NM PA
PARATHYROID HORMONES FORTEO 4 NM PA
NATPARA 4 NM PA
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
37
Drug Name Drug Tier
Requirements/Limits
PHOSPHATE BINDER AGENTS AURYXIA 4 NM
calcium acetate (phosphate binder) (generic of PHOSLO) CAPS
1
calcium acetate (phosphate binder) (generic of ELIPHOS) TABS
1
FOSRENOL 4 NM
PHOSLYRA 3
RENAGEL 400mg 3
RENAGEL 800mg 4 NM
RENVELA PAK 2
RENVELA TAB 800MG 2
VELPHORO 4 NM
PROGESTINS CRINONE 3
medroxyprogesterone acetate (generic of PROVERA)
1
norethindrone acetate (generic of AYGESTIN) TABS
1
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 3
TIROSINT 3
UNITHROID 1
VASOPRESSINS DESMOPRESSIN ACETATE SOLN
1
desmopressin acetate (generic of DDAVP) TABS
1
desmopressin acetate inj (generic of DDAVP)
1
Drug Name Drug Tier
Requirements/Limits
desmopressin acetate spray (generic of DDAVP)
1
desmopressin acetate spray refrigerated
1
STIMATE 4 NM
GASTROINTESTINAL ANTIEMETICS AKYNZEO 3 B/D
ALOXI 4 NM
CESAMET QL (60 caps / 30 days)
4 B/D QL NM
compro supp 1
dronabinol (generic of MARINOL) 2.5mg, 5mg
QL (60 caps / 30 days)
1 B/D QL
dronabinol (generic of MARINOL) 10mg
QL (60 caps / 30 days)
4 B/D QL NM
EMEND CAP 40MG 3 B/D
EMEND CAP 80MG 3 B/D
EMEND CAP 125MG 3 B/D
EMEND PAK 80 & 125 3 B/D
granisetron hcl SOLN 1
granisetron hcl TABS 1 B/D
meclizine hcl TABS 1
metoclopramide hcl SOLN 1
metoclopramide hcl (generic of REGLAN) TABS
1
metoclopramide hcl (generic of METOZOLV ODT) TBDP
1
metoclopramide hcl inj 5 mg/ml
1
ondansetron hcl (generic of ZOFRAN) TABS 4mg, 8mg
1 B/D
ondansetron hcl TABS 24mg 1 B/D
ondansetron hcl inj 4mg/2ml 1
ondansetron hcl inj (generic of ZOFRAN) 40mg/20ml
1
ondansetron hcl oral soln (generic of ZOFRAN)
1 B/D
ondansetron odt (generic of ZOFRAN ODT)
1 B/D
phenadoz PA if 65 years and older
3 PA
phenergan SUPP PA if 65 years and older
3 PA
prochlorperazine inj 5 mg/ml 1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
38
Drug Name Drug Tier
Requirements/Limits
prochlorperazine maleate (generic of COMPAZINE) TABS
1
prochlorperazine supp 1
promethazine hcl (generic of PHENERGAN) SOLN
PA if 65 years and older
3 PA
promethazine hcl SUPP; SYRP; TABS
PA if 65 years and older
3 PA
promethegan PA if 65 years and older
3 PA
SANCUSO QL (4 patches / 30 days)
4 QL NM
TRANSDERM-SCOP QL (10 patches / 30 days)
PA if 65 years and older
3 QL PA
ZUPLENZ 4 B/D NM
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
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 (generic of PEPCID) SUSR
1
Drug Name Drug Tier
Requirements/Limits
famotidine (generic of PEPCID) TABS 20mg, 40mg
1
famotidine inj 1
nizatidine CAPS 150mg 1
nizatidine (generic of AXID) CAPS 300mg
1
nizatidine 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
4 NM
CANASA 4 NM
colocort (generic of CORTENEMA)
1
DELZICOL 3
DIPENTUM 4 NM
ENTYVIO 4 NM PA
GIAZO 4 NM
HYDROCORTISONE (INTRARECTAL)
1
LIALDA 3
mesalamine enema ENEM 1
mesalamine enema (generic of ROWASA) KIT
1
PENTASA 3
SF-ROWASA 4 NM
sulfasalazine dr (generic of AZULFIDINE EN-TABS)
1
sulfasalazine ir (generic of AZULFIDINE)
1
UCERIS AER 2MG/ACT 3
UCERIS TAB 9MG 4 NM
LAXATIVES COLYTE-FLAVOR PACKS 3
constulose 1
enulose 1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
39
Drug Name Drug Tier
Requirements/Limits
gaviltye-g (generic of GOLYTELY)
1
gavilyte-c (generic of COLYTE-FLAVOR PACKS)
1
gavilyte-h 1
gavilyte-n (generic of NULYTELY/FLAVOR PACKS)
1
generlac 1
GOLYTELY 2
kristalose 2
lactulose 1
lactulose (encephalopathy) 1
MOVIPREP 3
NULYTELY/FLAVOR PACKS 2
OSMOPREP 3
PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE
1
PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE
1
peg 3350-potassium chloride-sod bicarbonate-sod chloride (generic of NULYTELY/FLAVOR PACKS)
1
polyethylene glycol 3350 PACK; POWD
1
PREPOPIK 3
RELISTOR 4 NM PA
SUCLEAR 3
SUPREP BOWEL PREP 3
trilyte (generic of NULYTELY/FLAVOR PACKS)
1
MISCELLANEOUS alosetron hcl (generic of LOTRONEX)
4 NM PA
AMITIZA 2
amoxicillin-clarithromycin w/ lansoprazole (generic of PREVPAC)
1
CARAFATE SUSP 3
cromolyn sodium (mastocytosis) (generic of GASTROCROM)
4 NM
diphenoxylate w/ atropine LIQD
1
Drug Name Drug Tier
Requirements/Limits
diphenoxylate w/ atropine (generic of LOMOTIL) TABS
1
GATTEX 4 NM LA PA
LINZESS 2
loperamide hcl CAPS 1
misoprostol (generic of CYTOTEC) TABS
1
MOVANTIK 2
OMECLAMOX-PAK 3
PYLERA 4 NM
SUCRAID 4 NM LA
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 4 NM PA
PANCREATIC ENZYMES CREON 2
PANCREAZE 3
PERTZYE 3
ULTRESA 3
VIOKACE 10 3
VIOKACE 20 4 NM
ZENPEP 3
PROTON PUMP INHIBITORS ACIPHEX SPR CAP 5MG 3
ACIPHEX SPR CAP 10MG QL (60 caps / 30 days)
3 QL
DEXILANT 2
esomeprazole sodium inj 20mg
1
esomeprazole sodium inj (generic of NEXIUM I.V.) 40mg
1
lansoprazole (generic of PREVACID) CPDR
QL (30 caps / 30 days)
1 QL
NEXIUM CAP 20MG 2
NEXIUM CAP 40MG 2
NEXIUM GRA 2.5MG DR 2
NEXIUM GRA 5MG DR 2
NEXIUM GRA 10MG DR 2
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
40
Drug Name Drug Tier
Requirements/Limits
NEXIUM GRA 20MG DR 2
NEXIUM GRA 40MG DR 2
omeprazole (generic of PRILOSEC) CPDR 10mg, 40mg
QL (30 caps / 30 days)
1 QL
omeprazole (generic of PRILOSEC) CPDR 20mg
1
OMEPRAZOLE-SODIUM BICARBONATE
QL (30 caps / 30 days)
1 QL
pantoprazole sodium (generic of PROTONIX)
QL (30 tabs / 30 days)
1 QL
PREVACID SOLUTAB QL (30 tabs / 30 days)
3 QL
PRILOSEC PACK 2
PROTONIX PACK QL (30 packets / 30 days)
3 QL
rabeprazole sodium (generic of ACIPHEX)
QL (30 tabs / 30 days)
1 QL
ZEGERID PACK QL (30 packets / 30 days)
3 QL
GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL)
1
AVODART 3
CARDURA XL 3
finasteride (generic of PROSCAR) TABS 5mg
1
JALYN 3
RAPAFLO 3
tamsulosin hcl (generic of FLOMAX)
1
MISCELLANEOUS bethanechol chloride (generic of URECHOLINE) TABS
1
ELMIRON 3
potassium citrate (alkalinizer) (generic of UROCIT-K 15) 15meq
1
POTASSIUM CITRATE (ALKALINIZER) 540mg
1
Drug Name Drug Tier
Requirements/Limits
POTASSIUM CITRATE (ALKALINIZER) 1080mg
1
URINARY ANTISPASMODICS ENABLEX 3
GELNIQUE 3
MYRBETRIQ 3
oxybutynin chloride SYRP; TABS
1
oxybutynin chloride (generic of DITROPAN XL) TB24
1
OXYTROL 3
tolterodine tartrate er (generic of DETROL LA)
1
tolterodine tartrate tab 1 mg (generic of DETROL)
1
tolterodine tartrate tab 2 mg (generic of DETROL)
1
TOVIAZ 2
trospium chloride 1
trospium chloride er 1
VESICARE 3
VAGINAL ANTI-INFECTIVES AVC 3
CLEOCIN VAG SUPP 100MG 3
clindamycin cre 2% vag (generic of CLEOCIN)
1
metronidazole vaginal (generic of METROGEL-VAGINAL)
1
miconazole 3 sup 200mg 1
NUVESSA 3
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
ELIQUIS TAB 2.5MG 2
ELIQUIS TAB 5MG 2
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
41
Drug Name Drug Tier
Requirements/Limits
enoxaparin sodium (generic of LOVENOX) 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml
1
enoxaparin sodium (generic of LOVENOX) 100mg/ml, 120mg/0.8ml, 150mg/ml
4 NM
fondaparinux sodium (generic of ARIXTRA) 2.5mg/0.5ml
1
fondaparinux sodium (generic of ARIXTRA) 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml
4 NM
FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml
3
FRAGMIN 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 95000unit/3.8ml
4 NM
HEP SOD/NACL INJ 25000 2
HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML
2
heparin sod inj 1000u/ml 1 B/D
HEPARIN SOD INJ 2000U/ML
2 B/D
HEPARIN SOD INJ 2500U/ML
2 B/D
heparin sod inj 5000u/0.5ml 1 B/D
heparin sod inj 5000u/ml 1 B/D
heparin sod inj 10000u/ml 1 B/D
heparin sod inj 20000u/ml 1 B/D
HEPARIN SODIUM/D5W 2
HEPARIN SODIUM/NACL 0.45%
2
jantoven (generic of COUMADIN)
1
PRADAXA 2
SAVAYSA 3
warfarin sodium (generic of COUMADIN)
1
XARELTO 2
XARELTO STARTER PACK 2
HEMATOPOIETIC GROWTH FACTORS
Drug Name Drug Tier
Requirements/Limits
ARANESP ALBUMIN FREE 10mcg/0.4ml, 25mcg/0.42ml, 25mcg/ml, 40mcg/0.4ml, 40mcg/ml, 60mcg/0.3ml, 60mcg/ml
2 NM PA
ARANESP ALBUMIN FREE 100mcg/0.5ml, 100mcg/ml, 150mcg/0.3ml, 150mcg/0.75ml, 200mcg/0.4ml, 200mcg/ml, 300mcg/0.6ml, 300mcg/ml, 500mcg/ml
4 NM PA
EPOGEN 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml
3 NM PA
EPOGEN 20000unit/ml 4 NM PA
GRANIX 4 NM PA
LEUKINE 4 NM PA
MIRCERA 3 NM PA
MOZOBIL 4 NM PA
NEULASTA 4 NM PA
NEUMEGA 4 NM PA
NEUPOGEN 4 NM PA
PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml
2 NM PA
PROCRIT 20000unit/ml, 40000unit/ml
4 NM PA
MISCELLANEOUS anagrelide hcl 1mg 1
anagrelide hcl (generic of AGRYLIN) .5mg
1
BERINERT 4 NM PA
cilostazol (generic of PLETAL) 1
CINRYZE 4 NM LA PA
FIRAZYR 4 NM PA
pentoxifylline TBCR 1
PROMACTA 12.5mg QL (360 tabs / 30 days)
4 QL NM LA PA
PROMACTA 25mg QL (180 tabs / 30 days)
4 QL NM LA PA
PROMACTA 50mg QL (90 tabs / 30 days)
4 QL NM LA PA
PROMACTA 75mg QL (60 tabs / 30 days)
4 QL NM LA PA
RUCONEST 4 NM PA
tranexamic acid (generic of CYKLOKAPRON) SOLN
1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
42
Drug Name Drug Tier
Requirements/Limits
tranexamic acid (generic of LYSTEDA) TABS
1
PLATELET AGGREGATION INHIBITORS AGGRENOX 3
ASPIRIN-DIPYRIDAMOLE 1
BRILINTA 2
clopidogrel bisulfate (generic of PLAVIX)
1
EFFIENT 3
ZONTIVITY 3
IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA 4 NM PA
CIMZIA 4 NM PA
ENBREL 4 NM PA
ENBREL SURECLICK 4 NM PA
HUMIRA 4 NM PA
HUMIRA PEN 4 NM PA
HUMIRA PEN-CROHNS STARTER KIT
4 NM PA
HUMIRA PEN-PSORIASIS STARTER KIT
4 NM PA
hydroxychloroquine sulfate (generic of PLAQUENIL)
1
KINERET 4 NM PA
leflunomide (generic of ARAVA) TABS
1
methotrexate sodium tabs 1
ORENCIA 4 NM PA
OTEZLA 4 NM PA
REMICADE 4 NM PA
RHEUMATREX 3
SIMPONI 4 NM PA
SIMPONI ARIA 4 NM PA
trexall 3 B/D
XELJANZ 4 NM PA
IMMUNOGLOBULINS BIVIGAM 4 NM PA
CARIMUNE NANOFILTERED 12gm
4 NM PA
FLEBOGAMMA 4 NM PA
FLEBOGAMMA DIF 4 NM PA
GAMASTAN S/D 2 B/D NM
GAMMAGARD LIQUID 4 NM PA
GAMMAGARD S/D 4 NM PA
Drug Name Drug Tier
Requirements/Limits
GAMMAGARD S/D IGA LESS TH
4 NM PA
GAMMAKED 4 NM PA
GAMMAPLEX 2.5gm/50ml, 5gm/100ml, 10gm/200ml
4 NM PA
GAMUNEX-C 4 NM PA
OCTAGAM 1gm/20ml, 2gm/20ml, 2.5gm/50ml, 5gm/100ml, 10gm/200ml, 25gm/500ml
4 NM PA
PRIVIGEN 4 NM PA
IMMUNOMODULATORS ACTIMMUNE 4 NM LA PA
ARCALYST 4 NM PA
GRASTEK 3 PA
INTRON-A INJ 10MU 4 B/D NM
INTRON-A INJ 18MU 4 B/D NM
INTRON-A INJ 25MU 4 B/D NM
INTRON-A INJ 50MU 4 B/D NM
RAGWITEK 3 PA
REVLIMID 4 NM LA PA
THALOMID 4 NM PA
IMMUNOSUPPRESSANTS ASTAGRAF XL 5mg 4 B/D NM
ASTAGRAF XL .5mg, 1mg 3 B/D
ATGAM 4 B/D NM
azasan 3 B/D
azathioprine (generic of IMURAN) TABS
1 B/D
BENLYSTA 4 NM PA
CELLCEPT INTRAVENOUS 3 B/D
cyclosporine (generic of SANDIMMUNE) CAPS; SOLN
1 B/D
cyclosporine modified (for microemulsion) (generic of NEORAL) CAPS 25mg, 100mg
1 B/D
cyclosporine modified (for microemulsion) CAPS 50mg
1 B/D
cyclosporine modified (for microemulsion) (generic of NEORAL) SOLN
1 B/D
gengraf (generic of NEORAL) 1 B/D
mycophenolate mofetil (generic of CELLCEPT) CAPS; TABS
1 B/D
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
43
Drug Name Drug Tier
Requirements/Limits
mycophenolate mofetil SUSR
4 B/D NM
mycophenolate sodium (generic of MYFORTIC) 180mg
1 B/D
mycophenolate sodium (generic of MYFORTIC) 360mg
4 B/D NM
NEORAL 2 B/D
NULOJIX 4 B/D NM
PROGRAF CAPS 5mg 4 B/D NM
PROGRAF CAPS .5mg, 1mg
3 B/D
PROGRAF SOLN 3 B/D
RAPAMUNE SOLN 4 B/D NM
SANDIMMUNE SOLN 2 B/D
SIMULECT 10mg 3 B/D
SIMULECT 20mg 4 B/D NM
SIROLIMUS TABS 2mg 4 B/D NM
sirolimus (generic of RAPAMUNE) TABS .5mg, 1mg
1 B/D
tacrolimus (generic of PROGRAF) CAPS 5mg
4 B/D NM
tacrolimus (generic of PROGRAF) CAPS .5mg, 1mg
1 B/D
THYMOGLOBULIN 4 B/D NM
ZORTRESS TAB 0.5MG 4 B/D NM
ZORTRESS TAB 0.25MG 3 B/D
ZORTRESS TAB 0.75MG 4 B/D NM
VACCINES ACTHIB 2
ADACEL 2
BCG VACCINE 2
BEXSERO 2
BOOSTRIX 2
CERVARIX 2
COMVAX 2
DAPTACEL 2
DIPHTHERIA/TETANUS TOXOID
2 B/D
ENGERIX-B SUSP 2 B/D
GARDASIL 2
GARDASIL 9 2
HAVRIX 2
Drug Name Drug Tier
Requirements/Limits
HIBERIX 2
IMOVAX RABIES (H.D.C.V.) 2
INFANRIX 2
IPOL INACTIVATED IPV 2
IXIARO 2
KINRIX 3
M-M-R II 2
MENACTRA 2
MENOMUNE-A/C/Y/W-135 2
MENVEO 2
PEDVAX HIB 2
PROQUAD 2
QUADRACEL 3
RABAVERT 2
RECOMBIVAX HB 2 B/D
ROTARIX 2
ROTATEQ 2
SYNAGIS 4 NM
TENIVAC 2 B/D
TETANUS/DIPHTHERIA TOXOID
2 B/D
TRUMENBA 2
TWINRIX INJ 2
TYPHIM VI 2
VAQTA 2
VARIVAX 2
YF-VAX 2
ZOSTAVAX 2
NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 3
KLOR-CON 8 1
KLOR-CON 10 1
klor-con m15 1
klor-con m20 1
klor-con pow 20meq 1
MAGNESIUM SULFATE SOLN 40mg/ml, 80mg/ml
2
magnesium sulfate SOLN 50%
1
MAGNESIUM SULFATE IN D5W
2
MAGNESIUM SULFATE INJ 50%
1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
44
Drug Name Drug Tier
Requirements/Limits
POTASSIUM CHLORIDE LIQD
1
potassium chloride TBCR 8meq
1
POTASSIUM CHLORIDE TBCR 20meq
1
potassium chloride caps er (generic of MICRO-K)
1
potassium chloride microencapsulated crystals cr
1
POTASSIUM CHLORIDE TAB CR 10 MEQ
1
SODIUM CHLORIDE SOLN 2.5meq/ml
1
SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN
1
TPN ELECTROLYTES 3 B/D
IV NUTRITION AMINOSYN 3 B/D
AMINOSYN 7%/ELECTROLYTES
3 B/D
AMINOSYN II 3 B/D
AMINOSYN II 8.5%/ELECTROL
3 B/D
AMINOSYN INJ 8.5/LYTE 3 B/D
AMINOSYN M 3 B/D
AMINOSYN-HBC 3 B/D
AMINOSYN-PF 7% 3 B/D
AMINOSYN-PF INJ 10% 3 B/D
AMINOSYN-RF 3 B/D
CLINIMIX 2.75%/DEXTROSE 5%
3 B/D
CLINIMIX 4.25%/DEXTROSE 5%
3 B/D
CLINIMIX 4.25%/DEXTROSE 10%
3 B/D
CLINIMIX 4.25%/DEXTROSE 20%
3 B/D
CLINIMIX 4.25%/DEXTROSE 25%
3 B/D
CLINIMIX 5%/DEXTROSE 15%
3 B/D
CLINIMIX 5%/DEXTROSE 20%
3 B/D
CLINIMIX 5%/DEXTROSE 25%
3 B/D
Drug Name Drug Tier
Requirements/Limits
CLINIMIX E 2.75%/DEXTROSE 5%
3 B/D
CLINIMIX E 2.75%/DEXTROSE 10%
3 B/D
CLINIMIX E 4.25%/D10 3 B/D
CLINIMIX E 4.25%/DEXTROSE 5%
3 B/D
CLINIMIX E 4.25%/DEXTROSE 25%
3 B/D
CLINIMIX E 5%/DEXTROSE 15%
3 B/D
CLINIMIX E 5%/DEXTROSE 20%
3 B/D
CLINIMIX E 5%/DEXTROSE 25%
3 B/D
clinisol 15 1 B/D
FREAMINE HBC 6.9% 3 B/D
FREAMINE III 3 B/D
HEPATAMINE 3 B/D
INTRALIPID INJ 20% 3 B/D
INTRALIPID INJ 30% 3 B/D
LIPOSYN III 3 B/D
NEPHRAMINE 3 B/D
NUTRILIPID INJ 20% 3 B/D
premasol 6% 1 B/D
premasol 10% 3 B/D
PROCALAMINE 3 B/D
PROSOL 3 B/D
TRAVASOL 3 B/D
TROPHAMINE INJ 10% 3 B/D
IV REPLACEMENT SOLUTIONS DEXTROSE SOLN 1
DEXTROSE 2.5%/NACL 0.45%
1
DEXTROSE 5% 1
DEXTROSE 5% /ELECTROLYTE
2
DEXTROSE 5%/LACTATED RING
1
DEXTROSE 5%/NACL 0.2% 1
DEXTROSE 5%/NACL 0.3% 1
DEXTROSE 5%/NACL 0.9% 1
DEXTROSE 5%/NACL 0.33% 1
DEXTROSE 5%/NACL 0.45% 1
DEXTROSE 5%/NACL 0.225%
1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
45
Drug Name Drug Tier
Requirements/Limits
DEXTROSE 5%/POTASSIUM CHL
1
DEXTROSE 10% FLEX CONTAIN
1
DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%
2
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%
2
KCL 0.3%/D5W/LR IV LAC RI 3
KCL 0.3%/D5W/NACL 0.9% 1
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
KCL IN NACL INJ .15-0.45 1
KCL/D5W/NACL INJ 0.22%/0.45%
1
KCL/D5W/NACL INJ .15/.33% 1
KCL/D5W/NACL INJ .15/.45% 1
KCL/NACL INJ 0.15%-0.9% 1
LACTATED RINGERS VIAFLEX
1
NORMOSOL-M IN D5W 1
NORMOSOL-R 3
PLASMA-LYTE A 3
PLASMA-LYTE-56/D5W 3
PLASMA-LYTE-148 3
pot chloride inj 2meq/ml 1
POTASSIUM CHLORIDE SOLN
1
POTASSIUM CHLORIDE 0.3%/D
1
potassium chloride in nacl 1
POTASSIUM CHLORIDE IN NACL
1
Drug Name Drug Tier
Requirements/Limits
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) CAPS 1mcg, 2.5mcg
4 B/D NM
doxercalciferol (generic of HECTOROL) CAPS .5mcg
1 B/D
doxercalciferol (generic of HECTOROL) SOLN
1 B/D
HECTOROL SOLN 2mcg/ml 3 B/D
paricalcitol (generic of ZEMPLAR) CAPS 1mcg, 2mcg
1 B/D
paricalcitol CAPS 4mcg 1 B/D
PARICALCITOL SOLN 3 B/D
PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)
1
ZEMPLAR SOLN 2mcg/ml 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 3
TOBRADEX ST 3
tobramycin-dexamethasone (generic of TOBRADEX)
1
ZYLET 2
ANTI-INFECTIVES
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
46
Drug Name Drug Tier
Requirements/Limits
AZASITE 3
bacitracin (ophthalmic) 1
bacitracin-polymyxin b (ophth) 1
BESIVANCE 2
CILOXAN OIN 0.3% OP 2
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
ilotycin 1
levofloxacin (ophth) 1
MOXEZA 3
NATACYN 3
neomycin-bacitracin zn-polymyxin
1
neomycin-polymyxin-gramicidin (generic of NEOSPORIN)
1
ofloxacin (ophth) (generic of OCUFLOX)
1
polymyxin b-trimethoprim (generic of POLYTRIM)
1
sulfacet sod oin 10% op 1
sulfacetamide sodium (ophth) (generic of BLEPH-10)
1
tobramycin (ophth) (generic of TOBREX)
1
TOBREX OINT 0.3% 3
trifluridine (generic of VIROPTIC) SOLN
1
VIGAMOX 3
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 3
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 2
PRED MILD 3
PREDNISOLONE ACETATE (OPHTH)
1
prednisolone sodium phosphate (ophth)
2
VEXOL 3
ANTIALLERGICS ALOCRIL 3
ALOMIDE 3
azelastine drop 0.05% 1
BEPREVE 2
cromolyn sodium (ophth) 1
EMADINE 3
epinastine hcl (ophth) (generic of ELESTAT)
1
LASTACAFT 3
PATADAY 2
PATANOL 3
PAZEO 2
ANTIGLAUCOMA ALPHAGAN P 2
ALPHAGAN P 0.1% 2
AZOPT 3
betaxolol hcl (ophth) 1
BETIMOL 3
BETOPTIC-S 3
brimonidine sol 0.2% 1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
47
Drug Name Drug Tier
Requirements/Limits
BRIMONIDINE SOL 0.15% 1
carteolol hcl (ophth) 1
COMBIGAN 2
COSOPT PF 3
dorzolamide hcl (generic of TRUSOPT)
1
dorzolamide hcl-timolol maleate (generic of COSOPT)
1
ISTALOL 2
latanoprost (generic of XALATAN) SOLN
1
levobunolol hcl (generic of BETAGAN) .5%
1
LEVOBUNOLOL HCL .25% 1
LUMIGAN 2
metipranolol 1
PHOSPHOLINE IODIDE 3
PILOCARPINE HCL SOLN 1
SIMBRINZA SUS 1-0.2% 3
timolol maleate (ophth) (generic of TIMOPTIC)
1
TIMOLOL MALEATE GEL 1
TIMOPTIC OCUDOSE 3
TRAVATAN Z 2
ZIOPTAN 3
MISCELLANEOUS LACRISERT 3
naphazoline 0.1% 1
PROLENSA 2
proparacaine hcl (generic of ALCAINE) SOLN
1
RESTASIS 2
RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER 62.5-25
QL (60 inhalations / 30 days)
2 QL
COMBIVENT RESPIMAT QL (2 inhalers / 30 days)
3 QL
ipratropium-albuterol 1 B/D
STIOLTO RESPIMAT QL (1 inhaler / 30 days)
3 QL
ANTICHOLINERGICS
Drug Name Drug Tier
Requirements/Limits
ATROVENT HFA QL (2 inhalers / 30 days)
3 QL
INCRUSE ELLIPTA QL (1 inhaler / 30 days)
2 QL
ipratropium bromide (nasal) (generic of ATROVENT)
1
ipratropium sol inhal 1 B/D
SPIRIVA HANDIHALER QL (30 caps / 30 days)
3 QL
SPIRIVA RESPIMAT QL (1 inhaler / 30 days)
3 QL
TUDORZA PRESSAIR QL (1 inhaler / 30 days)
3 QL
TUDORZA PRESSAIR (INSTITUTIONAL PACK)
QL (2 inhalers / 30 days)
3 QL
ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB 2.5-120 3
DYMISTA SPR 137-50 QL (1 bottle / 30 days)
3 QL
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 25mg/ml, 50mg/ml
PA if 65 years and older
3 PA
levocetirizine soln 2.5mg/5ml (generic of XYZAL)
1
levocetirizine tab 5 mg (generic of XYZAL)
1
olopatadine hcl (nasal) (generic of PATANASE)
1
BETA AGONISTS albuterol sulfate NEBU 1 B/D
albuterol sulfate SYRP; TABS
1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
48
Drug Name Drug Tier
Requirements/Limits
albuterol sulfate er (generic of VOSPIRE ER)
1
ARCAPTA NEOHALER QL (30 caps / 30 days)
3 QL
BROVANA 3 B/D
FORADIL AEROLIZER QL (60 caps / 30 days)
3 QL
levalbuterol conc 1.25mg/0.5ml (generic of XOPENEX CONCENTRATE)
1 B/D
LEVALBUTEROL HCL NEBU 1.25mg/3ml
1 B/D
levalbuterol hcl (generic of XOPENEX) NEBU .31mg/3ml, .63mg/3ml
1 B/D
PERFOROMIST 3 B/D
PROAIR HFA QL (2 inhalers / 30 days)
3 QL
PROAIR RESPICLICK QL (2 inhalers / 30 days)
3 QL
PROVENTIL HFA QL (2 inhalers / 30 days)
3 QL
SEREVENT DISKUS QL (60 inhalations / 30 days)
2 QL
STRIVERDI RESPIMAT QL (1 inhaler / 30 days)
3 QL
terbutaline sulfate SOLN 4 NM
terbutaline sulfate TABS 1
VENTOLIN HFA QL (2 inhalers / 30 days)
2 QL
XOPENEX HFA QL (2 inhalers / 30 days)
2 QL
LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium (generic of SINGULAIR) CHEW; PACK; TABS
1
zafirlukast (generic of ACCOLATE)
1
ZYFLO CR 4 NM
MAST CELL STABILIZERS cromolyn sodium NEBU 1 B/D
MISCELLANEOUS acetylcysteine SOLN 10%, 20%
1 B/D
ARALAST NP 4 NM LA PA
Drug Name Drug Tier
Requirements/Limits
AUVI-Q 2
DALIRESP 3
EPINEPHRINE SOAJ 1
EPIPEN 2-PAK 2
EPIPEN-JR 2-PAK 2
ESBRIET 4 NM PA
GLASSIA 4 NM LA PA
KALYDECO 4 NM PA
OFEV 4 NM PA
ORKAMBI 4 NM PA
PROLASTIN-C 4 NM LA PA
PULMOZYME 4 B/D NM
tyzine .05% 3
XOLAIR 4 NM LA PA
ZEMAIRA 4 NM LA PA
NASAL STEROIDS BECONASE AQ
QL (2 inhalers / 30 days) 3 QL
budesonide (nasal) (generic of RHINOCORT AQUA)
QL (2 bottles / 30 days)
1 QL
flunisolide (nasal) QL (2 bottles / 30 days)
1 QL
fluticasone propionate (nasal) QL (1 bottle / 30 days)
1 QL
NASONEX QL (2 inhalers / 30 days)
3 QL
OMNARIS QL (1 inhaler / 30 days)
3 QL
QNASL QL (1 inhaler / 30 days)
3 QL
QNASL CHILDRENS QL (1 inhaler / 30 days)
3 QL
triamcinolone acetonide (nasal)
QL (1 bottle / 30 days)
1 QL
VERAMYST QL (1 bottle / 30 days)
3 QL
ZETONNA QL (1 inhaler / 30 days)
3 QL
STEROID INHALANTS AEROSPAN
QL (2 inhalers / 30 days) 3 QL
ALVESCO QL (2 inhalers / 30 days)
3 QL
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
49
Drug Name Drug Tier
Requirements/Limits
ARNUITY ELLIPTA QL (30 inhalations / 30 days)
2 QL
ASMANEX QL (2 inhalers / 30 days)
3 QL
ASMANEX HFA 100mcg/act QL (2 inhalers / 30 days)
3 QL
ASMANEX HFA 200mcg/act QL (1 inhaler / 30 days)
3 QL
budesonide (inhalation) (generic of PULMICORT)
1 B/D
FLOVENT DISKUS 50mcg/blist, 100mcg/blist
QL (120 inhalations / 30 days)
2 QL
FLOVENT DISKUS 250mcg/blist
QL (240 inhalations / 30 days)
2 QL
FLOVENT HFA QL (2 inhalers / 30 days)
2 QL
PULMICORT FLEXHALER QL (2 inhalers / 30 days)
2 QL
PULMICORT INH SUSP 1MG/2ML
4 B/D NM
QVAR 40mcg/act QL (1 inhaler / 30 days)
3 QL
QVAR 80mcg/act QL (2 inhalers / 30 days)
3 QL
STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS
QL (60 inhalations / 30 days)
2 QL
ADVAIR HFA QL (1 inhaler / 30 days)
2 QL
BREO ELLIPTA QL (60 inhalations / 30 days)
2 QL
DULERA QL (1 inhaler / 30 days)
3 QL
SYMBICORT QL (1 inhaler / 30 days)
2 QL
XANTHINES aminophylline inj 1
elixophyllin 3
theo-24 3
theophylline 1
Drug Name Drug Tier
Requirements/Limits
TOPICAL DERMATOLOGY, ACNE ABSORICA 4 NM
ACANYA 3
ACZONE 3
adapalene (generic of DIFFERIN) CREA; GEL
1
amnesteem 1
ATRALIN 3
AVITA CREA 1
AVITA GEL 1
AZELEX 3
benzoyl peroxide-erythromycin (generic of BENZAMYCIN)
1
claravis 1
CLINDAGEL 3
clindamax (generic of CLEOCIN-T)
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
clindamycin phosphate-benzoyl peroxide (refrigerate) (generic of DUAC)
1
DIFFERIN LOTN 3
EPIDUO 3
ery pad 2% 1
erythromycin (acne aid) (generic of ERYGEL) GEL
1
erythromycin (acne aid) SOLN
1
FABIOR 3
myorisan 1
neuac gel 1.2-5% (generic of DUAC)
1
ONEXTON 3
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
50
Drug Name Drug Tier
Requirements/Limits
RETIN-A MICRO PUMP .08%
3
sulfacetamide sodium (acne) (generic of KLARON)
1
tretin-x CREA 3
tretinoin (generic of RETIN-A) CREA
1
TRETINOIN GEL .01% 1
tretinoin (generic of RETIN-A) GEL .025%
1
TRETINOIN MICROSPHERE 1
VELTIN 3
zenatane 1
ZIANA 3
DERMATOLOGY, ANTIBIOTICS ALTABAX 3
BACTROBAN NASAL 3
CENTANY 3
CORTISPORIN CREA; OINT
3
gentamicin sulfate (topical) 1
mupirocin (generic of BACTROBAN) OINT
1
mupirocin calcium (topical) (generic of BACTROBAN)
1
SILVER SULFADIAZINE CREA
1
SSD 1
SULFAMYLON CREA 3
SULFAMYLON PACK 4 NM
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
ketodan aer 2% (generic of EXTINA)
1
LUZU 3
Drug Name Drug Tier
Requirements/Limits
MENTAX 3
NAFTIFINE HCL 1
NAFTIN 3
nyamyc 1
nystatin (topical) 1
nystatin pow 100000 1
nystop 1
OXISTAT 3
DERMATOLOGY, ANTIPRURITIC CORTIFOAM 3
procto-pak 1
proctosol hc 2.5 % (generic of ANUSOL-HC)
1
proctozone hc (generic of ANUSOL-HC)
1
PRUDOXIN CRE 5% 1
DERMATOLOGY, ANTIPSORIATICS acitretin (generic of SORIATANE)
4 NM PA
calcipotriene (generic of DOVONEX) CREA
1
calcipotriene OINT; SOLN 1
calcitrene oin 0.005% 1
CALCITRIOL OINT 1
COSENTYX 4 NM PA
COSENTYX SENSOREADY PEN
4 NM PA
methoxsalen rapid (generic of OXSORALEN ULTRA)
4 NM
8-MOP 3
SORILUX 3
STELARA 4 NM PA
TAZORAC 3 PA
DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo (generic of NIZORAL)
1
selenium sulfide LOTN 1
DERMATOLOGY, CORTICOSTEROIDS ala-cort 1
alclometasone dipropionate (generic of ACLOVATE) CREA
1
alclometasone dipropionate OINT
1
amcinonide CREA; LOTN 1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
51
Drug Name Drug Tier
Requirements/Limits
amcinonide OINT 3
apexicon 1
apexicon e cream 3
betamethasone dipropionate (topical)
1
betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA
1
betamethasone dipropionate augmented GEL
1
betamethasone dipropionate augmented (generic of DIPROLENE) LOTN; OINT
1
betamethasone valerate CREA; LOTN; OINT
1
betamethasone valerate (generic of LUXIQ) FOAM
1
calcipotriene/betamethasone (generic of TACLONEX)
4 NM
CAPEX 3
clobetasol e cream 0.05% (generic of TEMOVATE E)
1
clobetasol propionate (generic of TEMOVATE) CREA; GEL; OINT; SOLN
1
clobetasol propionate (generic of OLUX) FOAM
1
clobetasol propionate (generic of CLOBEX) LIQD; LOTN; SHAM
1
clobetasol propionate emulsion (generic of OLUX-E)
1
CLOCORTOLONE PIVALATE 1
clodan sha 0.05% (generic of CLOBEX)
1
CORDRAN TAPE 3
cormax (generic of TEMOVATE)
1
DESONATE 3
DESONIDE CREA 1
desonide (generic of DESOWEN) LOTN; OINT
1
desoximetasone (generic of TOPICORT) CREA
1
desoximetasone (generic of TOPICORT) GEL
1
Drug Name Drug Tier
Requirements/Limits
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
fluocinolone acetonide (generic of DERMA-SMOOTHE/FS BODY) OIL .01%
1
fluocinolone acetonide (generic of DERMA-SMOOTHE/FS SCALP) OIL .01%
1
fluocinolone acetonide (generic of SYNALAR) OINT
1
fluocinolone acetonide (generic of SYNALAR) SOLN
1
fluocinonide (generic of VANOS) CREA .1%
4 NM
fluocinonide CREA .05% 1
fluocinonide GEL 1
fluocinonide OINT 1
fluocinonide SOLN 1
fluocinonide emulsified base 1
fluticasone propionate (generic of CUTIVATE) CREA; LOTN
1
fluticasone propionate 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
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
52
Drug Name Drug Tier
Requirements/Limits
hydrocortisone valerate (generic of WESTCORT) OINT
1
LOCOID LOTN 3
lokara (generic of DESOWEN)
1
mometasone furoate (generic of ELOCON) CREA; OINT; SOLN
1
PANDEL 3
PREDNICARBATE CREA 1
prednicarbate (generic of DERMATOP) OINT
1
TACLONEX SUSP 4 NM
texacort 3
TOPICORT SPRAY 0.25% 3
triamcinolone acetonide (topical) (generic of KENALOG) AERS
1
triamcinolone acetonide (topical) CREA; LOTN; OINT
1
trianex 3
triderm 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 acyclovir topical (generic of ZOVIRAX)
1
ammonium lactate (generic of LAC-HYDRIN) CREA; LOTN
1
CONDYLOX GEL 3
DENAVIR 4 NM
diclofenac sodium (actinic keratoses) (generic of SOLARAZE)
4 NM PA
diclofenac sodium (topical) 1
DOXYCYCLINE (ROSACEA) 1
Drug Name Drug Tier
Requirements/Limits
ELIDEL 3 PA
FINACEA GEL 15% 3
fluorouracil (topical) (generic of EFUDEX) CREA 5%
1
FLUOROURACIL (TOPICAL) CREA .5%
4 NM
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 4 NM
ORACEA 3
PANRETIN 4 NM
PENNSAID 3
PICATO 4 NM
podofilox (generic of CONDYLOX) SOLN
1
RECTIV 3
rosadan cre 0.75% (generic of METROCREAM)
1
SOOLANTRA 3
tacrolimus (topical) (generic of PROTOPIC)
1 PA
TARGRETIN GEL 4 NM PA
VALCHLOR 4 NM LA PA
VOLTAREN GEL 1% 2
XERESE 4 NM
ZOVIRAX CREA 4 NM
ZYCLARA 4 NM
DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 3
malathion (generic of OVIDE) 1
permethrin (generic of ELIMITE)
1
2016 604 4T Platinum PDP eff 01/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
53
Drug Name Drug Tier
Requirements/Limits
SKLICE 3
DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1
neomycin/polymyxin b gu (generic of NEOSPORIN GU IRRIGANT)
1
REGRANEX 4 NM PA
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
PILOCARPINE HCL (ORAL) 5mg
1
pilocarpine hcl (oral) (generic of SALAGEN) 7.5mg
1
triamcinolone acetonide (mouth)
1
OTIC acetasol hc 1
acetic acid (otic) 1
acetic acid sol/hc 1
acetic acid-aluminum acetate 1
CIPRO HC 3
CIPRODEX 3
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
2016 604 4T Platinum PDP eff 01/01/2016
54
Index 8 8-MOP .............................. 50 A abacavir sulfate ...................7 abacavir sulfate-lamivudine-zidovudine ..........................................7 ABELCET............................6 ABILIFY
see aripiprazole tabs ..... 23 ABILIFY DISCMELT TAB 10MG ................................ 23 ABILIFY MAINTENA ......... 23 ABRAXANE ...................... 12 ABSORICA ....................... 49 ABSTRAL............................2 acamprosate calcium ........ 28 ACANYA ........................... 49 acarbose ........................... 30 ACCOLATE
see zafirlukast ............... 48 ACCUPRIL
see quinapril hcl ............ 14 ACCURETIC
see quinapril-hydrochlorothiazide .................................. 14
acebutolol hcl .................... 16 ACEON
see perindopril erbumine ...................................... 14
acetaminophen w/ codeine .1 acetasol hc ........................ 53 acetazolamide ................... 17 acetazolamide sodium ...... 18 acetic acid ......................... 53 acetic acid (otic) ................ 53 acetic acid sol/hc ............... 53 acetic acid-aluminum acetate .......................................... 53 acetylcysteine ................... 48 ACIPHEX
see rabeprazole sodium 40 ACIPHEX SPR CAP 10MG .......................................... 39 ACIPHEX SPR CAP 5MG . 39 acitretin ............................. 50
ACLOVATE see alclometasone dipropionate .................. 50
ACTEMRA ........................ 42 ACTHIB ............................. 43 ACTIGALL
see ursodiol ................... 39 ACTIMMUNE .................... 42 ACTIQ
see fentanyl citrate .......... 2 ACTONEL
see risedronate sodium . 32 ACTOPLUS MET
see pioglitazone hcl-metformin hcl ........... 32
ACTOPLUS MET XR 15-1000MG ....................... 30 ACTOPLUS MET XR 30-1000MG ....................... 30 ACTOS
see pioglitazone hcl ....... 31 ACULAR
see ketorolac tromethamine (ophth) .... 46
ACULAR LS see ketorolac tromethamine (ophth) .... 46
ACUVAIL .......................... 46 acyclovir .............................. 8 acyclovir sodium ................. 8 acyclovir topical ................ 52 ACZONE ........................... 49 ADACEL ........................... 43 ADAGEN ........................... 34 ADALAT CC
see afeditab cr ............... 17 see nifedipine ................ 17
adapalene ......................... 49 ADCIRCA .......................... 18 ADDERALL
see amphetamine-dextroamphetamine tab 10 mg......... 25 see amphetamine-dextroamphetamine tab 12.5 mg...... 25 see
amphetamine-dextroamphetamine tab 15 mg ........ 25 see amphetamine-dextroamphetamine tab 20 mg ........ 25 see amphetamine-dextroamphetamine tab 30 mg ........ 25 see amphetamine-dextroamphetamine tab 5 mg .......... 25 see amphetamine-dextroamphetamine tab 7.5 mg ....... 25
ADDERALL XR see amphetamine cap 10mg er ......................... 25 see amphetamine cap 15mg er ......................... 25 see amphetamine cap 20mg er ......................... 25 see amphetamine cap 25mg er ......................... 25 see amphetamine cap 30mg er ......................... 25 see amphetamine-dextroamphetamine cap sr 24hr 5 mg ...................................... 25
adefovir dipivoxil ................. 8 ADEMPAS ........................ 18 ADOXA
see doxycycline (monohydrate) ......... 10, 11
ADOXA PAK 1/150 see doxycycline (monohydrate) ............... 11
adriamyc inj 50mg ............. 11 adrucil ............................... 11 ADVAIR DISKUS .............. 49 ADVAIR HFA .................... 49 ADVICOR ......................... 15 AEROSPAN ...................... 48 afeditab cr ......................... 17 AFINITOR ......................... 12 AFINITOR DISPERZ ........ 12 AFREZZA ......................... 36
2016 604 4T Platinum PDP eff 01/01/2016
55
AGGRENOX ..................... 42 AGRYLIN
see anagrelide hcl ......... 41 a-hydrocort ........................ 35 AKYNZEO ......................... 37 ala-cort .............................. 50 ALBENZA............................5 albuterol sulfate ................. 47 albuterol sulfate er ............ 48 ALCAINE
see proparacaine hcl ..... 47 alclometasone dipropionate .......................................... 50 ALCOHOL SWABS ........... 29 ALDACTAZIDE
see spironolactone & hydrochlorothiazide ....... 18
ALDACTAZIDE TAB 50/50 .......................................... 18 ALDACTONE
see spironolactone ........ 14 ALDARA
see imiquimod ............... 52 ALDURAZYME ................. 34 alendronate sodium .......... 32 alfuzosin hcl ...................... 40 ALIMTA ............................. 11 ALINIA ................................5 ALKERAN
see melphalan hcl ......... 11 allopurinol tab ......................1 almotriptan malate ............ 26 ALOCRIL........................... 46 ALOMIDE .......................... 46 ALOPRIM ............................1 ALORA .............................. 35 alosetron hcl ...................... 39 ALOXI ............................... 37 ALPHAGAN P ................... 46 ALPHAGAN P 0.1% .......... 46 alprazolam ........................ 19 ALREX .............................. 46 ALSUMA ........................... 26 ALTABAX .......................... 50 ALTACE
see ramipril .................... 14 altavera ............................. 32 ALTOPREV ....................... 15
ALVESCO ......................... 48 amantadine hcl ................. 22 AMARYL
see glimepiride .............. 30 AMBIEN
see zolpidem tartrate ..... 26 AMBISOME ........................ 6 amcinonide ................. 50, 51 AMERGE
see naratriptan hcl ......... 26 amethia 91 day ................. 32 amethyst 28 day ............... 32 amifostine crystalline......... 13 amikacin sulfate .................. 5 amiloride & hydrochlorothiazide ........... 18 amiloride hcl ...................... 18 aminophylline inj ............... 49 AMINOSYN ....................... 44 AMINOSYN 7%/ELECTROLYTES ....... 44 AMINOSYN II .................... 44 AMINOSYN II 8.5%/ELECTROL .............. 44 AMINOSYN INJ 8.5/LYTE 44 AMINOSYN M ................... 44 AMINOSYN-HBC .............. 44 AMINOSYN-PF 7% ........... 44 AMINOSYN-PF INJ 10% .. 44 AMINOSYN-RF ................. 44 amiodarone hcl ................. 15 amiodarone inj 50mg/ml.... 15 AMITIZA ............................ 39 amitriptyline hcl ................. 21 amlodipine besylate .......... 17 amlodipine besylate/atorv . 17 amlodipine besylate-benazepril hcl ..... 13 amlodipine besylate-valsartan tab 10-160 mg ......................... 14 amlodipine besylate-valsartan tab 10-320 mg ......................... 14 amlodipine besylate-valsartan tab 5-160 mg ..................................... 14 amlodipine
besylate-valsartan tab 5-320 mg ..................................... 14 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg.......................................... 14 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg.......................................... 14 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg.......................................... 14 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg.......................................... 14 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg . 14 ammonium chloride .......... 43 ammonium lactate ............ 52 amnesteem ....................... 49 amoxapine ........................ 21 amoxicillin ......................... 10 amoxicillin & pot clavulanate.......................................... 10 amoxicillin-clarithromycin w/ lansoprazole ..................... 39 amphetamine cap 10mg er.......................................... 25 amphetamine cap 15mg er.......................................... 25 amphetamine cap 20mg er.......................................... 25 amphetamine cap 25mg er.......................................... 25 amphetamine cap 30mg er.......................................... 25 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 25 amphetamine-dextroamphetamine tab 10 mg ............... 25 amphetamine-dextroamphetamine tab 12.5 mg ............ 25 amphetamine-dextroamphetamine tab 15 mg ............... 25 amphetamine-dextroamphetamine tab 20 mg ............... 25 amphetamine-dextroamphetamine tab 30 mg ............... 25 amphetamine-dextroamphet
2016 604 4T Platinum PDP eff 01/01/2016
56
amine tab 5 mg ................. 25 amphetamine-dextroamphetamine tab 7.5 mg .............. 25 AMPHOTEC ........................6 amphotericin b ....................6 ampicillin & sulbactam sodium .............................. 10 ampicillin cap 250mg ........ 10 ampicillin cap 500 mg ....... 10 ampicillin inj ....................... 10 ampicillin sodium ............... 10 ampicillin susp ................... 10 AMPYRA ........................... 27 ANAFRANIL
see clomipramine hcl ..... 21 anagrelide hcl .................... 41 ANAPROX
see naproxen sodium ......1 ANAPROX DS
see naproxen sodium ......1 anastrozole ....................... 12 ANCOBON
see flucytosine .................6 ANDRODERM .................. 29 ANDROGEL ...................... 29 ANDROGEL 1% ................ 29 ANDROGEL 1.62% ........... 29 ANDROGEL PUMP .......... 29 ANORO ELLIPT AER 62.5-25 .............................. 47 ANTABUSE
see disulfiram ................ 29 ANTARA ........................... 15 ANUSOL-HC
see proctosol hc 2.5 % .. 50 see proctozone hc ......... 50
apexicon............................ 51 apexicon e cream .............. 51 APIDRA............................. 29 APIDRA SOLOSTAR ........ 29 APLENZIN ........................ 21 APOKYN ........................... 22 apri 28 day ........................ 32 APRISO ............................ 38 APTENSIO XR .................. 25 APTIOM ............................ 19 APTIVUS.............................7 ARALAST NP .................... 48
ARALEN see chloroquine phosphate ....................... 7
aranelle 28 ........................ 32 ARANESP ALBUMIN FREE .......................................... 41 ARAVA
see leflunomide ............. 42 ARCALYST ....................... 42 ARCAPTA NEOHALER .... 48 ARICEPT
see donepezil tab hcl 23mg ............................. 21 see donepezil tabs 10mg ...................................... 21 see donepezil tabs 5mg 21
ARIMIDEX see anastrozole ............. 12
aripiprazole tabs ............... 23 ARIXTRA
see fondaparinux sodium ...................................... 41
ARNUITY ELLIPTA ........... 49 AROMASIN
see exemestane ............ 12 ARRANON ........................ 11 ARTHROTEC 50
see diclofenac w/ misoprostol ...................... 1
ARTHROTEC 75 see diclofenac w/ misoprostol ...................... 1
ARZERRA ......................... 12 ASACOL HD ..................... 38 ashlyna 91 day .................. 32 ASMANEX ........................ 49 ASMANEX HFA ................ 49 ASPIRIN-CAFFEINE-DIHYDROCODEINE BITARTRATE ............................................ 1 ASPIRIN-DIPYRIDAMOLE .......................................... 42 ASTAGRAF XL ................. 42 ASTEPRO ......................... 47
see azelastine spr 0.15% ...................................... 47
ATACAND see candesartan cilexetil
...................................... 15 ATACAND HCT
see candesartan cilexetil-hydrochlorothiazide .................................... 14
ATELVIA see risedronate sodium . 32
atenolol ............................. 16 atenolol & chlorthalidone .. 16 ATGAM ............................. 42 ATIVAN
see lorazepam............... 19 atorvastatin calcium .......... 15 atovaquone ......................... 5 atovaquone-proguanil hcl tab 250-100 mg ........................ 7 atovaquone-proguanil hcl tab 62.5-25 mg ......................... 7 ATRALIN .......................... 49 ATRIPLA ............................. 7 ATROPINE SULFATE ...... 38 ATROVENT
see ipratropium bromide (nasal) ........................... 47
ATROVENT HFA .............. 47 AUBAGIO ......................... 27 aubra 28 day ..................... 32 AUGMENTIN .................... 10
see amoxicillin & pot clavulanate .................... 10
AUGMENTIN ES-600 see amoxicillin & pot clavulanate .................... 10
AUGMENTIN XR see amoxicillin & pot clavulanate .................... 10
AURYXIA .......................... 37 AUVI-Q ............................. 48 AVALIDE
see irbesartan-hydrochlorothiazide ............................... 14
AVAPRO see irbesartan ............... 15
AVASTIN .......................... 12 AVC .................................. 40 AVEED ............................. 29 AVELOX ............................. 9
2016 604 4T Platinum PDP eff 01/01/2016
57
see moxifloxacin hcl ...... 10 aviane 28 .......................... 32 AVITA ............................... 49 AVODART ......................... 40 AVONEX ........................... 28 AVONEX PEN ................... 28 AVYCAZ..............................8 AXERT .............................. 26
see almotriptan malate .. 26 AXID
see nizatidine ................ 38 AXIRON ............................ 29 AYGESTIN
see norethindrone acetate ...................................... 37
azacitidine ......................... 11 AZACTAM
see aztreonam .................5 AZACTAM/DEX INJ 1GM ...5 AZACTAM/DEX INJ 2GM ...5 azasan .............................. 42 AZASITE ........................... 46 azathioprine ...................... 42 azelastine drop 0.05% ...... 46 azelastine spr 0.1% ........... 47 azelastine spr 0.15% ......... 47 AZELEX ............................ 49 AZILECT ........................... 22 azithromycin ........................9 AZITHROMYCIN .................9 AZOPT .............................. 46 AZOR ................................ 14 aztreonam ...........................5 AZULFIDINE
see sulfasalazine ir ........ 38 AZULFIDINE EN-TABS
see sulfasalazine dr ....... 38 B bacitracin (ophthalmic) ...... 46 bacitracin-polymyxin b (ophth) .............................. 46 bacitracin-poly-neomycin-hc .......................................... 45 baclofen ............................ 28 BACTOCILL INJ DEX 1GM .......................................... 10 BACTOCILL INJ DEX 2GM .......................................... 10
BACTRIM see sulfamethoxazole-trimethop ...................................... 6
BACTRIM DS see sulfamethoxazole-trimethop ...................................... 6
BACTROBAN see mupirocin ................ 50 see mupirocin calcium (topical) ......................... 50
BACTROBAN NASAL ....... 50 balsalazide disodium......... 38 balziva 28 day ................... 32 BANZEL SUS 40MG/ML ... 19 BANZEL TAB 200MG ....... 19 BANZEL TAB 400MG ....... 19 BARACLUDE ...................... 8
see entecavir ................... 8 BCG VACCINE ................. 43 BECONASE AQ ................ 48 BELEODAQ ...................... 12 benazepril & hydrochlorothiazide ........... 13 benazepril hcl .................... 14 BENICAR .......................... 15 BENICAR HCT ................. 14 BENLYSTA ....................... 42 BENTYL ............................ 38
see dicyclomine hcl ....... 38 BENZACLIN
see clindamycin phosphate-benzoyl peroxide ........................ 49
BENZAMYCIN see benzoyl peroxide-erythromycin ... 49
benzoyl peroxide-erythromycin ...... 49 benztropine mesylate ........ 22 BENZTROPINE MESYLATE .......................................... 22 BEPREVE ......................... 46 BERINERT ........................ 41 BESIVANCE ..................... 46 BETAGAN
see levobunolol hcl ........ 47
betamethasone dipropionate (topical) ............................. 51 betamethasone dipropionate augmented ........................ 51 betamethasone valerate ... 51 BETAPACE
see sorine ..................... 15 see sotalol hcl ............... 15
BETAPACE AF see sotalol hcl (afib/afl) . 15
BETASERON ................... 28 betaxolol hcl ...................... 16 betaxolol hcl (ophth) ......... 46 bethanechol chloride ......... 40 BETHKIS ............................ 5 BETIMOL .......................... 46 BETOPTIC-S .................... 46 BEXSERO ........................ 43 BEYAZ .............................. 32 BIAXIN
see clarithromycin ........... 9 BIAXIN XL
see clarithromycin ........... 9 bicalutamide ..................... 12 BICILLIN C-R .................... 10 BICILLIN L-A .................... 10 BICNU .............................. 11 BIDIL ................................. 18 BILTRICIDE ........................ 5 BINOSTO ......................... 32 bisoprolol & hydrochlorothiazide ........... 16 bisoprolol fumarate ........... 16 BIVIGAM ........................... 42 bleomycin sulfate .............. 11 BLEPH-10
see sulfacetamide sodium (ophth) ........................... 46
blephamide ....................... 45 BLEPHAMIDE .................. 45 BONIVA
see ibandronate sodium 32 see ibandronate tab 150mg ........................... 32
BOOSTRIX ....................... 43 BOSULIF .......................... 12 BOTOX INJ 100UNIT ....... 28 BOTOX INJ 200UNIT ....... 28
2016 604 4T Platinum PDP eff 01/01/2016
58
BREO ELLIPTA ................ 49 BREVICON-28
see necon 0.5/35 28 day ...................................... 33 see nortrel 0.5/35 28 day ...................................... 34
briellyn 28 day ................... 32 BRILINTA .......................... 42 BRIMONIDINE SOL 0.15% .......................................... 47 brimonidine sol 0.2% ......... 46 BRINTELLIX ..................... 21 BRISDELLE ...................... 27 bromfenac sodium (ophth) 46 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) ... 46 bromocriptine mesylate ..... 22 BROVANA ........................ 48 budesonide ....................... 38 budesonide (inhalation) ..... 49 budesonide (nasal) ........... 48 bumetanide ....................... 18 BUNAVAIL MIS 2.1-0.3MG .......................................... 28 BUNAVAIL MIS 4.2-0.7MG .......................................... 28 BUNAVAIL MIS 6.3-1MG .. 28 BUPHENYL
see sodium phenylbutyrate ...................................... 35
buprenorphine hcl ............. 28 buprenorphine hcl-naloxone hcl sl .................................. 29 buproban ........................... 29 bupropion hcl .................... 21 buspirone hcl ..................... 19 BUSULFEX ....................... 11 butorphanol nasal spray ......1 butorphanol tartrate .............1 BUTRANS ...........................1 BYDUREON ...................... 29 BYETTA ............................ 30 BYSTOLIC ........................ 16 C cabergoline ....................... 36 CADUET
see amlodipine besylate/atorv ................ 17
cafergot tab 1-100mg ........ 26 CALAN
see verapamil hcl .......... 17 CALAN SR
see verapamil hcl .......... 17 calcipotriene ...................... 50 calcipotriene/betamethasone .......................................... 51 calcitonin (salmon) nasal spray ................................. 36 calcitrene oin 0.005%........ 50 calcitriol ............................. 45 CALCITRIOL ..................... 50 calcium acetate (phosphate binder) ............................... 37 camila 28 day .................... 32 CAMPTOSAR ................... 13
see irinotecan inj 100/5ml ...................................... 13 see irinotecan inj 40mg/2ml ...................... 13
CAMRESE LO TAB .......... 32 CANASA ........................... 38 CANCIDAS ......................... 6 candesartan cilexetil ......... 15 candesartan cilexetil-hydrochlorothiazide .......................................... 14 CANTIL ............................. 38 CAPASTAT SULFATE ........ 8 CAPEX .............................. 51 capital
and codeine ..................... 1 CAPRELSA ....................... 12 captopril ............................ 14 captopril & hydrochlorothiazide ........... 14 CARAFATE ....................... 39
see sucralfate ................ 39 CARBAGLU ...................... 34 carbamazepine ................. 19 CARBATROL
see carbamazepine ....... 19 carbidopa .......................... 22 CARBIDOPA/LEVODOPA/ENTACAPONE ............. 22, 23 carbidopa-levodopa .......... 22 carboplatin ........................ 13
CARDIZEM see diltiazem hcl ............ 17
CARDIZEM CD see cartia xt ................... 17 see diltiazem hcl coated beads ............................ 17
CARDIZEM LA.................. 17 see matzim la ................ 17
CARDURA see doxazosin mesylate 14
CARDURA XL .................. 40 CARIMUNE NANOFILTERED .............. 42 CARNITOR
see levocarnitine (metabolic modifiers) ..... 35
carteolol hcl (ophth) .......... 47 cartia xt ............................. 17 carvedilol .......................... 16 CASODEX
see bicalutamide ........... 12 CATAPRES
see clonidine hcl ............ 18 CATAPRES-TTS-1
see clonidine hcl ............ 18 CATAPRES-TTS-2
see clonidine hcl ............ 18 CATAPRES-TTS-3
see clonidine hcl ............ 18 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 HCL AND DEXTROSE ........................ 9 cefepime inj 1gm................. 9 cefepime inj 2gm................. 9 cefixime .............................. 9 cefotaxime sodium .............. 9 cefotetan disodium .............. 9 cefoxitin sodium .................. 9
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CEFOXITIN SODIUM IN DEXTROSE ........................9 cefpodoxime proxetil ...........9 cefprozil...............................9 ceftazidime ..........................9 CEFTAZIDIME/DEXTROSE ............................................9 CEFTIBUTEN .....................9 CEFTIN ...............................9
see cefuroxime axetil .......9 ceftriaxone sodium ..............9 cefuroxime axetil .................9 cefuroxime sodium ..............9 CELEBREX
see celecoxib ...................1 celecoxib .............................1 CELEXA
see citalopram hydrobromide ................ 21
CELLCEPT see mycophenolate mofetil ...................................... 42
CELLCEPT INTRAVENOUS .......................................... 42 CELONTIN ........................ 19 CENTANY ......................... 50 cephalexin ...........................9 CERDELGA ...................... 34 CEREZYME ...................... 34 CERVARIX ........................ 43 CESAMET ......................... 37 cetirizine syrup .................. 47 cevimeline hcl ................... 53 CHANTIX .......................... 29 CHANTIX CONTINUING MONTH ............................. 29 CHANTIX STARTER PACK .......................................... 29 CHEMET ........................... 32 chlorhexidine gluconate (mouth-throat) ................... 53 chloroquine phosphate ........7 chlorothiazide tabs ............ 18 chlorpromaz inj 25mg/ml ... 23 chlorpromazine hcl ............ 23 chlorthalidone .................... 18 cholestyramine .................. 15 cholestyramine light .......... 15
choline fenofibrate ............ 16 CHORIONIC GONADOTROPIN ............ 36 ciclopirox ........................... 50 ciclopirox cre 0.77% .......... 50 ciclopirox shampoo 1% ..... 50 ciclopirox sus 0.77% ......... 50 cidofovir .............................. 8 cilostazol ........................... 41 CILOXAN
see ciprofloxacin hcl (ophth) ........................... 46
CILOXAN OIN 0.3% OP ... 46 cimetidine .......................... 38 cimetidine sol 300/5ml ...... 38 CIMZIA .............................. 42 CINRYZE .......................... 41 CIPRO
see ciprofloxacin ............. 9 see ciprofloxacin hcl ...... 10
CIPRO HC ........................ 53 CIPRO I.V.-IN D5W
see ciprofloxacin in d5w 10 CIPRO XR
see ciprofloxacin er ......... 9 CIPRODEX ....................... 53 ciprofloxacin ........................ 9 ciprofloxacin er .................... 9 ciprofloxacin hcl ............ 9, 10 ciprofloxacin hcl (ophth) .... 46 ciprofloxacin in d5w .......... 10 ciprofloxacn inj 400mg/40ml .......................................... 10 cisplatin ............................. 13 citalopram hydrobromide .. 21 cladribine .......................... 11 claforan ............................... 9 CLAFORAN
see cefotaxime sodium .... 9 claravis .............................. 49 CLARINEX ........................ 47
see desloratadine .......... 47 CLARINEX REDITABS
see desloratadine .......... 47 CLARINEX-D TAB 2.5-120 .......................................... 47 clarithromycin ...................... 9 CLEOCIN
see clindamycin cre 2% vag ................................ 40 see clindamycin hcl ......... 5
CLEOCIN IN D5W see clindamycin phosphate in d5w ............ 6
CLEOCIN PEDIATRIC GRANULE
see clindamycin palmitate hydrochloride................... 5
CLEOCIN PHOSPHATE see clindamycin phosphate ....................... 5
CLEOCIN VAG SUPP 100MG .............................. 40 CLEOCIN-T
see clindamax ............... 49 see clindamycin phosphate (topical) ........ 49
CLIMARA see estradiol .................. 35
CLINDAGEL ..................... 49 clindamax ......................... 49 clindamycin cre 2% vag .... 40 clindamycin hcl ................... 5 clindamycin palmitate hydrochloride ...................... 5 clindamycin phosphate ....... 5 clindamycin phosphate (topical) ............................. 49 clindamycin phosphate in d5w ..................................... 6 clindamycin phosphate-benzoyl peroxide.......................................... 49 clindamycin phosphate-benzoyl peroxide (refrigerate) ....................... 49 CLINIMIX 2.75%/DEXTROSE 5% ..... 44 CLINIMIX 4.25%/DEXTROSE 10% ... 44 CLINIMIX 4.25%/DEXTROSE 20% ... 44 CLINIMIX 4.25%/DEXTROSE 25% ... 44 CLINIMIX 4.25%/DEXTROSE 5% ..... 44
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CLINIMIX 5%/DEXTROSE 15% ................................... 44 CLINIMIX 5%/DEXTROSE 20% ................................... 44 CLINIMIX 5%/DEXTROSE 25% ................................... 44 CLINIMIX E 2.75%/DEXTROSE 10% ... 44 CLINIMIX E 2.75%/DEXTROSE 5% ..... 44 CLINIMIX E 4.25%/D10 .... 44 CLINIMIX E 4.25%/DEXTROSE 25% ... 44 CLINIMIX E 4.25%/DEXTROSE 5% ..... 44 CLINIMIX E 5%/DEXTROSE 15% ................................... 44 CLINIMIX E 5%/DEXTROSE 20% ................................... 44 CLINIMIX E 5%/DEXTROSE 25% ................................... 44 clinisol 15 .......................... 44 clobetasol e cream 0.05% . 51 clobetasol propionate ........ 51 clobetasol propionate emulsion............................ 51 CLOBEX
see clobetasol propionate ...................................... 51 see clodan sha 0.05% ... 51
CLOCORTOLONE PIVALATE ......................... 51 clodan sha 0.05% ............. 51 CLOLAR............................ 11 clomipramine hcl ............... 21 clonazepam ....................... 19 clonidine hcl ...................... 18 clopidogrel bisulfate .......... 42 clorazepate dipotassium ... 19 clorpres ............................. 18 clotrimazole ....................... 53 clotrimazole (topical) ......... 50 clozapine ........................... 23 CLOZAPINE ...................... 23 CLOZAPINE ODT ............. 23 CLOZARIL
see clozapine ................ 23 COARTEM ..........................7
codeine and capital ....................... 1
CODEINE SULFATE .......... 2 COLAZAL
see balsalazide disodium ...................................... 38
colchicine w/ probenecid ..... 1 COLCRYS .......................... 1 COLESTID
see colestipol hcl ........... 16 colestipol hcl ..................... 16 colistimethate sodium ......... 6 colocort ............................. 38 COLY-MYCIN M
see colistimethate sodium ........................................ 6
COLY-MYCIN S ................ 53 COLYTE-FLAVOR PACKS .......................................... 38
see gavilyte-c ................ 39 COMBIGAN ...................... 47 COMBIVENT RESPIMAT . 47 COMBIVIR
see lamivudine-zidovudine ........................................ 7
COMETRIQ ...................... 12 COMPAZINE
see prochlorperazine maleate ......................... 38
COMPLERA ........................ 7 compro supp ..................... 37 COMVAX .......................... 43 CONDYLOX ...................... 52
see podofilox ................. 52 constulose ......................... 38 CONZIP .......................... 1, 2 COPAXONE
see glatopa .................... 28 COPAXONE INJ 40MG/ML .......................................... 28 COPEGUS
see moderiba tab 200mg . 8 see ribasphere ................ 8 see ribavirin 200mg ......... 8
CORDARONE see amiodarone hcl ....... 15 see pacerone ................ 15
CORDRAN ........................ 51
COREG see carvedilol ................ 16
COREG CR ...................... 16 CORGARD
see nadolol .................... 16 CORLANOR ..................... 18 cormax .............................. 51 CORTEF
see hydrocortisone ........ 35 CORTENEMA
see colocort ................... 38 CORTIFOAM .................... 50 cortisone acetate .............. 35 CORTISPORIN ................. 50
see neomycin-polymyxin-hc (otic) .............................. 53
CORTISPORIN-TC ........... 53 CORZIDE
see nadolol & bendroflumethiazide ...... 16
COSENTYX ...................... 50 COSENTYX SENSOREADY PEN .................................. 50 COSMEGEN ..................... 11 COSOPT
see dorzolamide hcl-timolol maleate ........ 47
COSOPT PF ..................... 47 COUMADIN ...................... 40
see jantoven .................. 41 see warfarin sodium ...... 41
COZAAR see losartan potassium . 15
CREON ............................. 39 CRESEMBA ....................... 6 CRESTOR ........................ 15 CRINONE ......................... 37 CRIXIVAN ........................... 7 cromolyn sodium............... 48 cromolyn sodium (mastocytosis) .................. 39 cromolyn sodium (ophth) .. 46 cryselle 28 ........................ 32 CUBICIN ............................. 6 CUTIVATE
see fluticasone propionate ...................................... 51
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CUVPOSA ........................ 38 cyclafem 1/35 28 day ........ 32 cyclafem 7/7/7 28 day ....... 33 CYCLESSA
see velivet 28 day .......... 34 cyclobenzaprine hcl .......... 28 cyclophosphamide ............ 11 CYCLOPHOSPHAMIDE ... 11 cycloserine ..........................8 cyclosporine ...................... 42 cyclosporine modified (for microemulsion) .................. 42 CYKLOKAPRON
see tranexamic acid ...... 41 CYMBALTA
see duloxetine hcl .......... 22 CYSTADANE .................... 34 CYSTAGON ...................... 35 cytarabine inj ..................... 11 CYTOMEL
see liothyronine sodium . 37 CYTOTEC
see misoprostol ............. 39 CYTOVENE
see ganciclovir inj 500mg 8 D D.H.E. 45
see dihydroergotamine mesylate ........................ 26
dacarbazine ...................... 11 DACOGEN
see decitabine ............... 11 DALIRESP ........................ 48 DALVANCE .........................6 danazol ............................. 34 DANTRIUM
see dantrolene sodium .. 28 dantrolene sodium ............ 28 dapsone ..............................6 DAPTACEL ....................... 43 DARAPRIM .........................6 daunorubicin hcl ................ 11 DAYPRO
see oxaprozin ..................1 DAYTRANA ...................... 25 DDAVP
see desmopressin acetate ...................................... 37
see desmopressin acetate inj................................... 37 see desmopressin acetate spray ............................. 37
deblitane 28 day ............... 33 decitabine ......................... 11 DELESTROGEN ............... 35
see estradiol valerate .... 35 delyla 28 day ..................... 33 DELZICOL ........................ 38 DEMADEX
see torsemide tabs ........ 18 demeclocycline hcl ............ 10 DEMSER .......................... 18 DENAVIR .......................... 52 DEPACON
see valproate sodium .... 21 DEPAKENE
see valproate sodium .... 21 see valproic acid ........... 21
DEPAKOTE see divalproex sodium ... 20
DEPAKOTE ER see divalproex sodium ... 20
DEPAKOTE SPRINKLES see divalproex sodium ... 20
DEPEN TITRATABS ......... 32 depo-estradiol ................... 35 DEPO-MEDROL
see methylpr ace inj 40mg/ml ........................ 35 see methylpr ace inj 80mg/ml ........................ 35
DEPO-MEDROL INJ 20MG/ML .......................... 35 DEPO-PROVERA CONTRACEPTIV
see medroxyprogesterone acetate (contraceptive) .. 33
DEPO-PROVERA INJ 400/ML .............................. 12 DEPO-SUBQ PROVERA 104 .................................... 33 depo-testosterone ............. 29 DEPO-TESTOSTERONE
see testosterone cypionate ...................................... 29
DERMA-SMOOTHE/FS
BODY see fluocinolone acetonide ...................................... 51
DERMA-SMOOTHE/FS SCALP
see fluocinolone acetonide ...................................... 51
DERMATOP see prednicarbate ......... 52
DERMOTIC see fluocinolone acetonide (otic) .............................. 53
desipramine hcl................. 21 desloratadine .................... 47 desmopressin acetate ....... 37 DESMOPRESSIN ACETATE.......................................... 37 desmopressin acetate inj .. 37 desmopressin acetate spray.......................................... 37 desmopressin acetate spray refrigerated ....................... 37 DESOGEN
see apri 28 day.............. 32 see emoquette .............. 33 see reclipsen 28 day ..... 34
desogestrel-ethinyl estradiol (biphasic) .......................... 33 DESONATE ...................... 51 desonide ........................... 51 DESONIDE ....................... 51 DESOWEN
see desonide ................. 51 see lokara ..................... 52
desoximetasone................ 51 DESOXIMETASONE ........ 51 DETROL
see tolterodine tartrate tab 1 mg .............................. 40 see tolterodine tartrate tab 2 mg .............................. 40
DETROL LA see tolterodine tartrate er ...................................... 40
dexamethasone ................ 35 dexamethasone sodium phosphate ......................... 35 dexamethasone sodium
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phosphate (ophth) ............. 46 DEXILANT ........................ 39 dexpak taperpak 13 day .... 35 dexrazoxane ..................... 13 DEXTROSE ...................... 44 DEXTROSE 10% FLEX CONTAIN .......................... 45 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% .......................................... 45 DEXTROSE 10%/NACL 0.45% ................................ 45 DEXTROSE 2.5%/NACL 0.45% ................................ 44 DEXTROSE 5% ................ 44 DEXTROSE 5% /ELECTROLYTE ............... 44 DEXTROSE 5%/LACTATED RING ................................. 44 DEXTROSE 5%/NACL 0.2% .......................................... 44 DEXTROSE 5%/NACL 0.225% .............................. 44 DEXTROSE 5%/NACL 0.3% .......................................... 44 DEXTROSE 5%/NACL 0.33% ................................ 44 DEXTROSE 5%/NACL 0.45% ................................ 44 DEXTROSE 5%/NACL 0.9% .......................................... 44 DEXTROSE 5%/POTASSIUM CHL ...... 45 DIAMOX
see acetazolamide ........ 17 diazepam .......................... 19 DIAZEPAM GEL (ANTICONVULSANT) ....... 19 DIBENZYLINE .................. 18 diclofenac potassium ..........1 diclofenac sodium ...............1 diclofenac sodium (actinic keratoses) ......................... 52 diclofenac sodium (ophth) . 46 diclofenac sodium (topical) 52 diclofenac w/ misoprostol ....1 dicloxacillin sodium ........... 10 dicyclomine hcl .................. 38
didanosine .......................... 7 DIFFERIN ......................... 49
see adapalene ............... 49 DIFICID ............................... 9 diflorasone diacetate ......... 51 DIFLUCAN
see fluconazole ............... 6 diflunisal .............................. 1 digitek ............................... 17 digoxin .............................. 17 digoxin inj .......................... 17 DIGOXIN SOL 50MCG/ML .......................................... 17 dihydroergotamine mesylate .......................................... 26 DIHYDROERGOTAMINE MESYLATE ....................... 26 dilantin .............................. 20 DILANTIN
see phenytoin sodium extended ....................... 20
DILANTIN INFATABS see phenytoin ................ 20
DILANTIN-125 .................. 20 see phenytoin ................ 20
DILATRATE SR ................ 18 DILAUDID
see hydromorphone hcl ... 3 DILAUDID-HP
see hydromorphone hcl ... 3 DILAUDID-HP INJ 250MG .. 2 diltiazem cap 120mg/24hr . 17 diltiazem cap er/12hr......... 17 diltiazem hcl ...................... 17 diltiazem hcl coated beads 17 diltiazem hcl er .................. 17 diltiazem hcl extended release beads ................... 17 diltiazem inj 100mg ........... 17 diltiazem inj 125/25ml ....... 17 diltiazem inj 25mg/5ml ...... 17 diltiazem inj 50/10ml ......... 17 dilt-xr cap .......................... 17 diltzac ................................ 17 DIOVAN
see valsartan ................. 15 DIOVAN HCT
see
valsartan-hydrochlorothiazide .................................. 15
DIPENTUM ....................... 38 diphenhydram inj 50mg/ml 47 diphenoxylate w/ atropine . 39 DIPHTHERIA/TETANUS TOXOID ............................ 43 DIPROLENE
see betamethasone dipropionate augmented 51
DIPROLENE AF see betamethasone dipropionate augmented 51
disopyramide phosphate ... 15 disulfiram .......................... 29 DITROPAN XL
see oxybutynin chloride . 40 DIURIL SUS 250/5ML ....... 18 divalproex sodium ............. 20 docetaxel .......................... 12 DOCETAXEL .................... 12 DOLOPHINE
see methadone hcl .......... 4 DOLOPHINE HCL
see methadone hcl .......... 4 donepezil odt 10mg .......... 21 donepezil odt 5mg ............ 21 donepezil tab hcl 23mg ..... 21 donepezil tabs 10mg ......... 21 donepezil tabs 5mg ........... 21 DORIBAX ........................... 6 dorzolamide hcl................. 47 dorzolamide hcl-timolol maleate ............................. 47 DOVONEX
see calcipotriene ........... 50 doxazosin mesylate .......... 14 doxepin hcl ....................... 21 doxercalciferol .................. 45 DOXIL
see doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ........... 11
doxorubicin hcl .................. 11 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml .... 11 doxorubicin inj 50mg ......... 11 doxy .................................. 10
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doxycycline (monohydrate) .................................... 10, 11 DOXYCYCLINE (ROSACEA) ...................... 52 doxycycline hyclate ........... 11 dronabinol ......................... 37 drospirenone-ethinyl estradiol ............................ 33 DROXIA ............................ 13 DUAC
see clindamycin phosphate-benzoyl peroxide (refrigerate) ..... 49 see neuac gel 1.2-5% .... 49
DUETACT see pioglitazone hcl-glimepiride ............... 32
DUEXIS...............................1 DULERA ........................... 49 duloxetine hcl .................... 22 DUOPA ............................. 23 DURAGESIC
see fentanyl patch 100 mcg/hr .............................2 see fentanyl patch 12 mcg/hr .............................2 see fentanyl patch 25 mcg/hr .............................2 see fentanyl patch 50 mcg/hr .............................2 see fentanyl patch 75 mcg/hr .............................2
DURAMORPH ....................2 DUREZOL ......................... 46 DUTOPROL ...................... 16 DYAZIDE
see triamt/hctz cap 37.5-25 .......................... 18
DYMISTA SPR 137-50 ..... 47 DYRENIUM ....................... 18 E e.e.s. 400 tab 400mg ..........9 E.E.S. GRANULES .............9 EC-NAPROSYN
see naproxen ...................1 econazole nitrate ............... 50 EDARBI............................. 15 EDARBYCLOR ................. 14
EDECRIN .......................... 18 EDURANT .......................... 7 EFFEXOR XR
see venlafaxine cap er .. 22 EFFIENT ........................... 42 EFUDEX
see fluorouracil (topical) 52 EGRIFTA .......................... 36 ELAPRASE ....................... 35 ELDEPRYL
see selegiline hcl ........... 23 ELECTROLYTE-R IN DEXTROSE ...................... 45 ELELYSO ......................... 35 ELESTAT
see epinastine hcl (ophth) ...................................... 46
ELIDEL ............................. 52 ELIGARD INJ 22.5MG ...... 12 ELIGARD INJ 30MG ......... 12 ELIGARD INJ 45MG ......... 12 ELIGARD INJ 7.5MG ........ 12 ELIMITE
see permethrin .............. 52 ELIPHOS
see calcium acetate (phosphate binder) ........ 37
ELIQUIS TAB 2.5MG ........ 40 ELIQUIS TAB 5MG ........... 40 ELITEK ............................. 13 elixophyllin ........................ 49 ELLA ................................. 33 ELLENCE
see epirubicin inj 200mg 11 see epirubicin inj 50mg/25ml .................... 11
ELMIRON ......................... 40 ELOCON
see mometasone furoate ...................................... 52
ELOXATIN ........................ 13 EMADINE ......................... 46 EMBEDA ............................. 2 EMCYT ............................. 11 EMEND CAP 125MG ........ 37 EMEND CAP 40MG .......... 37 EMEND CAP 80MG .......... 37 EMEND PAK 80 & 125 ..... 37
EMLA see lidocaine-prilocaine . 52
emoquette ......................... 33 EMSAM ............................ 22 EMTRIVA ............................ 7 ENABLEX ......................... 40 enalapril maleate .............. 14 enalapril maleate & hydrochlorothiazide ........... 14 ENBREL ........................... 42 ENBREL SURECLICK ...... 42 endocet ............................... 2 ENDODAN TAB .................. 2 ENGERIX-B ...................... 43 enoxaparin sodium ........... 41 enpresse 28 day ............... 33 ENTACAPONE ................. 23 entecavir ............................. 8 ENTOCORT EC
see budesonide ............. 38 ENTYVIO .......................... 38 enulose ............................. 38 EPIDUO ............................ 49 epinastine hcl (ophth) ....... 46 EPINEPHRINE ................. 48 EPIPEN 2-PAK ................. 48 EPIPEN-JR 2-PAK ............ 48 epirubicin inj 200mg .......... 11 epirubicin inj 50mg/25ml ... 11 epitol ................................. 20 EPIVIR
see lamivudine ................ 7 EPIVIR HBV ....................... 8
see lamivudine (hbv) ....... 8 eplerenone ........................ 14 EPOGEN .......................... 41 eprosartan mesylate ......... 15 EPZICOM ........................... 7 EQUETRO ........................ 27 ERAXIS .............................. 6 ERBITUX .......................... 12 ergomar ............................ 26 ERIVEDGE ....................... 12 errin 28 day ....................... 33 ERTACZO ........................ 50 ery pad 2% ....................... 49 ERYGEL
see erythromycin (acne
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aid) ................................ 49 ERYPED 200 ......................9 ERYPED 400 ......................9 ery-tab .................................9 erythrocin lactobionate ........9 erythrocin stearate ..............9 erythromycin (acne aid) .... 49 erythromycin (ophth) ......... 46 erythromycin base ...............9 erythromycin cap 250mg ec 9 erythromycin ethylsuccinate 9 ESBRIET........................... 48 escitalopram oxalate ......... 22 esomeprazole sodium inj .. 39 estrace .............................. 35 ESTRACE
see estradiol .................. 35 estradiol ............................ 35 estradiol valerate ............... 35 ESTRING .......................... 35 ESTROSTEP FE
see tri-legest 28 day ...... 34 ethambutol hcl .....................8 ethosuximide ..................... 20 ETHYOL
see amifostine crystalline ...................................... 13
etodolac ..............................1 etodolac er ..........................1 ETOPOPHOS ................... 13 etoposide .......................... 13 EURAX ............................. 52 EVISTA
see raloxifene hcl .......... 36 EVOCLIN
see clindamycin phosphate (topical) ........ 49
EVOTAZ..............................7 EVOXAC
see cevimeline hcl ......... 53 EXALGO
see hydromorphone tab 12mg er ...........................3 see hydromorphone tab 16mg er ...........................3 see hydromorphone tab 8mg er .............................3
EXELDERM ...................... 50
EXELON see rivastigmine tartrate 21
EXELON PATCHES ......... 21 exemestane ...................... 12 EXFORGE
see amlodipine besylate-valsartan tab 10-160 mg ..................... 14 see amlodipine besylate-valsartan tab 10-320 mg ..................... 14 see amlodipine besylate-valsartan tab 5-160 mg ....................... 14 see amlodipine besylate-valsartan tab 5-320 mg ....................... 14
EXFORGE HCT see amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg .............. 14 see amlodipine-valsartan-hydrochlorothiazide 10-160-25mg ................. 14 see amlodipine-valsartan-hydrochlorothiazide 10-320-25mg ................. 14 see amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg ................ 14 see amlodipine-valsartan-hydrochlorothiazide 5-160-25mg ................... 14
EXJADE ............................ 32 EXTAVIA ........................... 28 EXTINA
see ketodan aer 2% ...... 50 F FABIOR ............................ 49 FABRAZYME .................... 35 FACTIVE ........................... 10 falmina 28 day .................. 33 famciclovir ........................... 8
famotidine ......................... 38 famotidine inj .................... 38 FAMVIR
see famciclovir ................ 8 FANAPT ........................... 23 FANAPT TITRATION PACK.......................................... 23 FARESTON ...................... 12 FARXIGA .......................... 30 FARYDAK ......................... 12 FASLODEX ...................... 12 FAZACLO ......................... 23 felbamate .......................... 20 FELBATOL
see felbamate................ 20 FELDENE
see piroxicam .................. 1 felodipine .......................... 17 FEMARA
see letrozole .................. 12 FEMCON FE
see wymzya fe .............. 34 see zenchent fe 28 day . 34
FEMRING ......................... 35 fenofibrate ......................... 16 FENOFIBRATE................. 16 fenofibrate micronized ...... 16 FENOFIBRIC ACID .......... 16 FENOGLIDE ..................... 16 fenoprofen calcium ............. 1 fentanyl citrate .................... 2 fentanyl patch 100 mcg/hr .. 2 fentanyl patch 12 mcg/hr .... 2 fentanyl patch 25 mcg/hr .... 2 fentanyl patch 50 mcg/hr .... 2 fentanyl patch 75 mcg/hr .... 2 FENTORA .......................... 2 FERRIPROX ..................... 32 FETZIMA .......................... 22 FETZIMA TITRATION PACK.......................................... 22 FINACEA GEL 15% .......... 52 finasteride ......................... 40 FIRAZYR .......................... 41 FIRMAGON ...................... 12 FLAGYL
see metronidazole ........... 6 FLAGYL ER ........................ 6
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FLAREX ............................ 46 FLEBOGAMMA ................. 42 FLEBOGAMMA DIF .......... 42 flecainide acetate .............. 15 FLOMAX
see tamsulosin hcl ......... 40 FLO-PRED SUS ............... 35 FLOVENT DISKUS ........... 49 FLOVENT HFA ................. 49 fluconazole ..........................6 fluconazole in dextrose .......6 fluconazole in nacl ..............6 flucytosine ...........................6 FLUDARA
see fludarabine phosphate ...................................... 11
fludarabine phosphate ...... 11 fludrocortisone acetate ...... 35 FLUMADINE
see rimantadine hydrochloride ...................8
flunisolide (nasal) .............. 48 fluocinolone acetonide ...... 51 fluocinolone acetonide (otic) .......................................... 53 fluocinonide ....................... 51 fluocinonide emulsified base .......................................... 51 FLUOROMETHOLONE (OPHTH) ........................... 46 fluorouracil ........................ 11 fluorouracil (topical) ........... 52 FLUOROURACIL (TOPICAL) ........................ 52 fluoxetine hcl ..................... 22 FLUOXETINE HCL ........... 22 fluphenazine decanoate .... 23 fluphenazine hcl ................ 23 flurbiprofen ..........................1 flurbiprofen sodium ........... 46 flutamide ........................... 12 fluticasone propionate ....... 51 fluticasone propionate (nasal) ............................... 48 fluvastatin sodium ............. 15 fluvoxamine maleate ......... 19 fluvoxamine maleate er ..... 19 FML ................................... 46
FML FORTE ..................... 46 fondaparinux sodium......... 41 FORADIL AEROLIZER ..... 48 FORFIVO XL .................... 22 FORTAMET
see metformin hcl .......... 31 FORTAZ ............................. 9
see ceftazidime ............... 9 see tazicef ....................... 9 see tazicef vial ................. 9
FORTEO ........................... 36 FORTESTA ....................... 29 FORTICAL SPR 200/ACT . 36 FOSAMAX
see alendronate sodium 32 FOSAMAX PLUS D .......... 32 foscarnet sodium ................ 8 fosinopril sodium ............... 14 fosinopril sodium & hydrochlorothiazide ........... 14 FOSRENOL ...................... 37 FRAGMIN ......................... 41 FREAMINE HBC 6.9% ...... 44 FREAMINE III ................... 44 FROVA TAB 2.5MG .......... 26 FURADANTIN
see nitrofurantoin ............ 6 furosemide ........................ 18 furosemide inj ................... 18 FUROSEMIDE INJ ........... 18 furosemide oral soln 8 mg/ml .......................................... 18 FUSILEV ........................... 13 FUZEON ............................. 7 FYCOMPA ........................ 20 G gabapentin ........................ 20 GABITRIL ......................... 20
see tiagabine hcl ........... 21 galantamine hydrobromide 21 GAMASTAN S/D ............... 42 GAMMAGARD LIQUID ..... 42 GAMMAGARD S/D ........... 42 GAMMAGARD S/D IGA LESS TH ........................... 42 GAMMAKED ..................... 42 GAMMAPLEX ................... 42 GAMUNEX-C .................... 42
ganciclovir inj 500mg .......... 8 GARAMYCIN
see gentamicin sulfate (ophth) ........................... 46
GARDASIL ....................... 43 GARDASIL 9 .................... 43 GASTROCROM
see cromolyn sodium (mastocytosis) ............... 39
gatifloxacin (ophth) ........... 46 GATTEX ........................... 39 GAUZE PADS 2X2 ........... 30 gaviltye-g .......................... 39 gavilyte-c .......................... 39 gavilyte-h .......................... 39 gavilyte-n .......................... 39 GELNIQUE ....................... 40 GEMCITABINE ................. 11 gemcitabine hcl ................. 11 gemfibrozil ........................ 16 GEMZAR
see gemcitabine hcl ...... 11 GENERESS FE
see norethindrone & ethinyl estradiol-fe ......... 34
generlac ............................ 39 gengraf ............................. 42 GENOTROPIN.................. 36 GENOTROPIN MINIQUICK.......................................... 36 gentak ............................... 46 gentamicin in saline 0.8 mg/ml .................................. 5 gentamicin in saline 0.9mg/ml ............................. 5 gentamicin in saline 1 mg/ml............................................ 5 gentamicin in saline 1.2 mg/ml .................................. 5 gentamicin in saline 1.4mg/ml ............................. 5 gentamicin in saline 1.6 mg/ml .................................. 5 gentamicin in saline 2 mg/ml............................................ 5 gentamicin sulfate ............... 5 gentamicin sulfate (ophth) 46 gentamicin sulfate (topical)
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.......................................... 50 GEODON
see ziprasidone hcl ........ 25 GEODON INJ .................... 23 GIANVI TAB 3-0.02MG ..... 33 GIAZO ............................... 38 gildagia ............................. 33 gildess 1.5/30 21 day ........ 33 gildess 24 fe 28 day .......... 33 GILENYA CAP 0.5MG ...... 28 GILOTRIF TAB 20MG ....... 12 GILOTRIF TAB 30MG ....... 13 GILOTRIF TAB 40MG ....... 13 GLASSIA........................... 48 glatopa .............................. 28 GLEEVEC ......................... 13 GLEOSTINE ..................... 11 glimepiride......................... 30 glipizide ............................. 30 glipizide er ......................... 30 glipizide-metformin 2.5-250 mg ..................................... 30 glipizide-metformin 2.5-500 mg ..................................... 30 glipizide-metformin 5-500mg .......................................... 30 GLUCAGEN HYPOKIT ..... 36 GLUCAGON EMERGENCY KIT .................................... 36 GLUCOPHAGE
see metformin hcl .......... 31 GLUCOPHAGE XR
see metformin er ........... 31 GLUCOTROL
see glipizide ................... 30 GLUCOTROL XL
see glipizide er .............. 30 GLUMETZA ...................... 31 glycate .............................. 38 glycopyrrolate .................... 38 GLYSET ............................ 31 GLYXAMBI ........................ 31 GOLYTELY ....................... 39
see gaviltye-g ................ 39 GRALISE .......................... 27 GRALISE STARTER ......... 27 granisetron hcl .................. 37 GRANIX ............................ 41
GRASTEK ......................... 42 GRIFULVIN V
see griseofulvin microsize ........................................ 6
griseofulvin microsize.......... 6 griseofulvin ultramicrosize ... 6 GRIS-PEG
see griseofulvin ultramicrosize .................. 6
guanfacine hcl (adhd) ....... 25 H H.P. ACTHAR ................... 36 HALAVEN ......................... 13 HALDOL
see haloperidol lactate inj 5 mg/ml ......................... 23
HALDOL DECANOATE 100 see haloperidol decanoate ...................................... 23
HALDOL DECANOATE 50 see haloperidol decanoate ...................................... 23
halobetasol propionate...... 51 HALOG ............................. 51 haloperidol ........................ 23 haloperidol decanoate....... 23 haloperidol lactate ............. 23 haloperidol lactate inj 5 mg/ml ................................ 23 HARVONI ........................... 8 HAVRIX ............................ 43 heather .............................. 33 HECTOROL ...................... 45
see doxercalciferol ........ 45 HEP SOD/NACL INJ 25000 .......................................... 41 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML ........................... 41 heparin sod inj 10000u/ml . 41 heparin sod inj 1000u/ml ... 41 heparin sod inj 20000u/ml . 41 HEPARIN SOD INJ 2000U/ML ......................... 41 HEPARIN SOD INJ 2500U/ML ......................... 41 heparin sod inj 5000u/0.5ml .......................................... 41
heparin sod inj 5000u/ml ... 41 HEPARIN SODIUM/D5W . 41 HEPARIN SODIUM/NACL 0.45% ............................... 41 HEPATAMINE .................. 44 HEPSERA
see adefovir dipivoxil ....... 8 HERCEPTIN ..................... 12 HETLIOZ .......................... 26 HEXALEN ......................... 11 HIBERIX ........................... 43 HIPREX
see methenamine hippurate ......................... 6
HORIZANT ....................... 27 HUMALOG ....................... 30 HUMALOG KWIKPEN ...... 30 HUMALOG MIX 50/50 ...... 30 HUMALOG MIX 50/50 KWIKPEN ......................... 30 HUMALOG MIX 75/25 ...... 30 HUMALOG MIX 75/25 KWIKPEN ......................... 30 HUMATROPE ................... 36 HUMATROPE COMBO PACK ................................ 36 HUMIRA ........................... 42 HUMIRA PEN ................... 42 HUMIRA PEN-CROHNS STARTER KIT .................. 42 HUMIRA PEN-PSORIASIS STARTER KIT .................. 42 HUMULIN 70/30 ............... 30 HUMULIN 70/30 KWIKPEN.......................................... 30 HUMULIN N ...................... 30 HUMULIN N KWIKPEN .... 30 HUMULIN R ...................... 30 HUMULIN R U-500 (CONCENTRATE) ............ 30 HYCAMTIN
see topotecan hcl .......... 13 HYCET
see hydrocodone-acetaminophen 7.5-325 mg/15ml ........ 3
hydralazine hcl .................. 18 HYDREA
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see hydroxyurea ............ 13 hydrochlorothiazide ........... 18 hydrocodone-acetaminophen 10-300mg ............................3 hydrocodone-acetaminophen 2.5-325mg ...........................2 hydrocodone-acetaminophen 5-300mg ..............................2 hydrocodone-acetaminophen 5-325mg ..............................2 hydrocodone-acetaminophen 7.5-300mg ...........................3 hydrocodone-acetaminophen 7.5-325 mg/15ml .................3 hydrocodone-acetaminophen 7.5-325mg ...........................3 hydrocodone-acetaminophen tab 10-325mg ......................3 hydrocodone-ibuprofen tab 2.5-200mg ...........................3 hydrocodone-ibuprofen tab 7.5-200 mg ..........................3 hydrocortisone .................. 35 HYDROCORTISONE (INTRARECTAL) ............... 38 hydrocortisone (topical) ..... 51 hydrocortisone butyrate .... 51 hydrocortisone butyrate hydrophilic lipo base ......... 51 hydrocortisone valerate ....51, 52 hydromorphone hcl .............3 HYDROMORPHONE HCL ..3 hydromorphone tab 12mg er ............................................3 hydromorphone tab 16mg er ............................................3 hydromorphone tab 8mg er .3 HYDROMORPHONE TABS 32MG ..................................3 hydroxychloroquine sulfate .......................................... 42 hydroxyurea ...................... 13 hydroxyzine hcl ................. 47 HYSINGLA ER ....................3 HYZAAR
see losartan-hydrochlorothiazi
de .................................. 14 I ibandronate sodium .......... 32 ibandronate tab 150mg ..... 32 IBRANCE .......................... 12 ibudone tab 10-200mg ........ 3 ibudone tab 5-200mg .......... 3 ibuprofen ............................. 1 ICLUSIG ........................... 13 IDAMYCIN PFS
see idarubicin hcl .......... 11 idarubicin hcl ..................... 11 IFEX
see ifosfamide inj 1gm ... 11 IFEX INJ 3GM ................... 11 IFOSFAMIDE
see ifosfamide inj 1gm/20ml ...................... 11 see ifosfamide inj 3gm/60ml ...................... 11
ifosfamide inj 1gm ............. 11 ifosfamide inj 1gm/20ml .... 11 IFOSFAMIDE INJ 3GM ..... 11 ifosfamide inj 3gm/60ml .... 11 ILEVRO ............................. 46 ilotycin ............................... 46 IMBRUVICA CAP 140MG . 13 imipenem-cilastatin ............. 6 imipramine hcl ................... 22 imipramine pamoate ......... 22 imiquimod ......................... 52 IMITREX
see sumatriptan inj 6mg/0.5ml ..................... 27 see sumatriptan succinate ...................................... 27
IMITREX STATDOSE SYSTEM
see sumatriptan inj 6mg/0.5ml ..................... 27
IMOVAX RABIES (H.D.C.V.) .......................................... 43 IMURAN
see azathioprine ............ 42 INCRELEX ........................ 36 INCRUSE ELLIPTA .......... 47 indapamide ....................... 18 INDERAL LA
see propranolol hcl er .... 16 INFANRIX ......................... 43 INFUMORPH 200 ............... 3 INFUMORPH 500 ............... 3 INLYTA ............................. 13 INSPRA
see eplerenone ............. 14 INSULIN PEN NEEDLES . 30 INSULIN SAFETY NEEDLES ......................... 30 INSULIN SYRINGES ........ 30 INTELENCE ....................... 7 INTRALIPID INJ 20% ....... 44 INTRALIPID INJ 30% ....... 44 INTRON-A INJ 10MU ....... 42 INTRON-A INJ 18MU ....... 42 INTRON-A INJ 25MU ....... 42 INTRON-A INJ 50MU ....... 42 introvale 91 day ................ 33 INTUNIV
see guanfacine hcl (adhd) ...................................... 25
INVANZ .............................. 6 INVEGA ............................ 23 INVEGA SUST INJ 117 MG/0.75 ML ...................... 23 INVEGA SUST INJ 156MG/ML ........................ 23 INVEGA SUST INJ 234 MG/1.5 ML ........................ 24 INVEGA SUST INJ 39 MG/0.25 ML ...................... 23 INVEGA SUST INJ 78 MG/0.5 ML ........................ 23 INVEGA TRINZA .............. 24 INVIRASE ........................... 7 INVOKAMET TAB 150-1000.......................................... 31 INVOKAMET TAB 150-500.......................................... 31 INVOKAMET TAB 50-1000.......................................... 31 INVOKAMET TAB 50-500MG ......................... 31 INVOKANA TAB 100MG .. 31 INVOKANA TAB 300MG .. 31 IONOSOL-B/DEXTROSE 5% .................................... 45
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IONOSOL-MB/DEXTROSE 5% ..................................... 45 IPOL INACTIVATED IPV .. 43 ipratropium bromide (nasal) .......................................... 47 ipratropium sol inhal .......... 47 ipratropium-albuterol ......... 47 irbesartan .......................... 15 irbesartan-hydrochlorothiazide ........................................ 14 irinotecan inj 100/5ml ........ 13 irinotecan inj 40mg/2ml ..... 13 irinotecan inj 500mg/25ml . 13 ISENTRESS ........................7 ISOLYTE P ....................... 45 ISOLYTE S ....................... 45 isoniazid ..............................8 isoniazid tabs ......................8 ISORDIL TITRADOSE ...... 18
see isosorbide dinitrate . 18 isosorbide dinitrate ............ 18 isosorbide dinitrate er ........ 18 isosorbide mononitrate ...... 18 isosorbide mononitrate er . 18 isradipine........................... 17 ISTALOL ........................... 47 ISTODAX .......................... 12 itraconazole .........................6 ivermectin............................6 IXEMPRA KIT ................... 13 IXIARO .............................. 43 J JADENU............................ 32 JAKAFI .............................. 13 JALYN ............................... 40 jantoven ............................ 41 JANUMET ......................... 31 JANUMET XR TAB 100-1000 ........................... 31 JANUMET XR TAB 50-1000 .......................................... 31 JANUMET XR TAB 50-500MG ......................... 31 JANUVIA ........................... 31 JARDIANCE ...................... 31 JENTADUETO .................. 31 jinteli .................................. 35 JOLESSA TAB 0.15-0.03
MG .................................... 33 JOLIVETTE ....................... 33 junel 1.5/30 21 day ........... 33 junel 1/20 21 day .............. 33 junel fe 1.5/30 28 day........ 33 junel fe 1/20 28 day .......... 33 junel fe 24 1/20 28 day...... 33 JUXTAPID ........................ 16 K KADCYLA ......................... 12 KADIAN .............................. 3
see morphine sulfate ....... 4 KALETRA SOL ................... 7 KALETRA TAB 100-25MG .. 7 KALETRA TAB 200-50MG .. 7 KALYDECO ...................... 48 kariva 28 day .................... 33 KAYEXALATE
see kionex ..................... 32 KAZANO ........................... 31 KCL 0.075%/D5W/NACL 0.45%................................ 45 KCL 0.15%/D5W/LR ......... 45 KCL 0.15%/D5W/NACL 0.9%.................................. 45 KCL 0.3%/D5W/LR IV LAC RI ...................................... 45 KCL 0.3%/D5W/NACL 0.45%................................ 45 KCL 0.3%/D5W/NACL 0.9% .......................................... 45 KCL IN NACL INJ .15-0.45 .......................................... 45 KCL/D5W/NACL INJ .15/.33% ............................ 45 KCL/D5W/NACL INJ .15/.45% ............................ 45 KCL/D5W/NACL INJ 0.22%/0.45% .................... 45 KCL/NACL INJ 0.15%-0.9% .......................................... 45 KCL0.15%/D5W/NACL0.2% .......................................... 45 KCL0.15%/D5W/NACL0.225% ...................................... 45 KEFLEX
see cephalexin ................ 9 kelnor 1/35 28 day ............ 33
KENALOG see triamcinolone acetonide (topical) ......... 52
KEPIVANCE ..................... 13 KEPPRA
see levetiracetam .......... 20 see levetiracetam oral soln 100 mg/ml ..................... 20
KEPPRA XR see levetiracetam .......... 20
KERLONE see betaxolol hcl ........... 16
ketoconazole ...................... 6 ketoconazole (topical) ....... 50 ketoconazole shampoo ..... 50 ketodan aer 2% ................ 50 ketoprofen ........................... 1 ketorolac tromethamine (ophth) .............................. 46 KEYTRUDA ...................... 12 kimidess ............................ 33 KINERET .......................... 42 KINRIX .............................. 43 kionex ............................... 32 KLARON
see sulfacetamide sodium (acne) ............................ 50
KLONOPIN see clonazepam ............ 19
KLOR-CON 10 .................. 43 KLOR-CON 8 .................... 43 klor-con m15 ..................... 43 klor-con m20 ..................... 43 klor-con pow 20meq ......... 43 KOMBIGLYZE XR 2.5-1000MG ...................... 31 KOMBIGLYZE XR 5-1000MG ......................... 31 KOMBIGLYZE XR 5-500MG.......................................... 31 KORLYM .......................... 36 kristalose .......................... 39 KUVAN ............................. 35 KYNAMRO ....................... 16 L labetalol hcl ....................... 16 LAC-HYDRIN
see ammonium lactate .. 52
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see laclotion lot 12% ..... 52 laclotion lot 12% ................ 52 LACRISERT ...................... 47 LACTATED RINGERS VIAFLEX ........................... 45 lactulose ............................ 39 lactulose (encephalopathy) .......................................... 39 LAMICTAL
see lamotrigine .............. 20 LAMICTAL CHEWABLE DISPERS
see lamotrigine .............. 20 LAMICTAL ODT ................ 20
see lamotrigine .............. 20 LAMICTAL STARTER ....... 20 LAMICTAL XR .................. 20
see lamotrigine .............. 20 LAMISIL ..............................6
see terbinafine hcl ...........7 lamivudine ...........................7 lamivudine (hbv) ..................8 lamivudine-zidovudine ........7 lamotrigine ........................ 20 LANOXIN .......................... 17
see digitek ..................... 17 see digoxin .................... 17 see digoxin inj ................ 17
LANOXIN PEDIATRIC ...... 17 lansoprazole ...................... 39 LANTUS ............................ 30 LANTUS SOLOSTAR ....... 30 larin 1.5/30 ........................ 33 larin 1/20 ........................... 33 larin fe 1.5/30 .................... 33 larin fe 1/20 ....................... 33 LASIX
see furosemide .............. 18 LASTACAFT ..................... 46 latanoprost ........................ 47 LATUDA ............................ 24 LAZANDA ...........................3 LEENA TAB ...................... 33 leflunomide ........................ 42 LEMTRADA ...................... 28 LENVIMA 10MG DAILY DOSE ................................ 13 LENVIMA 14MG DAILY
DOSE ................................ 13 LENVIMA 20MG DAILY DOSE ................................ 13 LENVIMA 24MG DAILY DOSE ................................ 13 LESCOL
see fluvastatin sodium ... 15 LESCOL XL ...................... 15 lessina 28 day ................... 33 LETAIRIS .......................... 18 letrozole ............................ 12 leucovorin calcium ............ 13 leucovorin calcium inj 100mg .......................................... 13 leucovorin calcium inj 200mg .......................................... 13 leucovorin calcium inj 350mg .......................................... 13 leucovorin calcium inj 500mg .......................................... 13 leucovorin calcium inj 50mg .......................................... 13 LEUKERAN ...................... 11 LEUKINE .......................... 41 leuprolide acetate ............. 12 levalbuterol conc 1.25mg/0.5ml .................... 48 levalbuterol hcl .................. 48 LEVALBUTEROL HCL...... 48 LEVAQUIN
see levofloxacin ............. 10 see levofloxacin in d5w . 10
LEVEMIR .......................... 30 LEVEMIR FLEXTOUCH ... 30 levetiracetam .................... 20 LEVETIRACETAM IV........ 20 levetiracetam oral soln 100 mg/ml ................................ 20 levobunolol hcl .................. 47 LEVOBUNOLOL HCL ....... 47 levocarnitine (metabolic modifiers) .......................... 35 levocetirizine soln 2.5mg/5ml .......................................... 47 levocetirizine tab 5 mg ...... 47 levofloxacin ....................... 10 levofloxacin (ophth) ........... 46 levofloxacin in d5w ............ 10
levoleucovorin calcium ...... 13 levonest 28 day ................ 33 levonorgestrel & eth estradiol.......................................... 33 levonorgestrel (emergency oc) ..................................... 33 levonorgestrel-ethinyl estradiol (91-day) .............. 33 levonorgestrel-ethinyl estradiol (continuous) ....... 33 levora 0.15/30 28 day ....... 33 levorphanol tartrate ............. 3 levothyroxine sodium ........ 37 LEVOXYL ......................... 37 LEXAPRO
see escitalopram oxalate ...................................... 22
LEXIVA ............................... 7 LIALDA ............................. 38 lidocaine ........................... 52 lidocaine hcl ...................... 52 lidocaine hcl (local anesth.) 5 lidocaine hcl (mouth-throat).......................................... 53 lidocaine inj 0.5% ................ 5 lidocaine inj 1% ................... 5 lidocaine inj 1.5% ................ 5 lidocaine inj 2% ................... 5 lidocaine-prilocaine ........... 52 LIDODERM
see lidocaine ................. 52 linezolid ............................... 6 LINEZOLID ......................... 6 LINZESS ........................... 39 liothyronine sodium ........... 37 LIPITOR
see atorvastatin calcium 15 LIPOSYN III ...................... 44 LIPTRUZET ...................... 16 lisinopril ............................. 14 lisinopril & hydrochlorothiazide ........... 14 lithium carbonate .............. 27 LITHIUM SOLN 8MEQ/5ML.......................................... 27 LITHOBID
see lithium carbonate .... 27 LIVALO ............................. 15
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LO LOESTRIN FE ............. 33 LOCOID ............................ 52
see hydrocortisone butyrate ......................... 51
LOCOID LIPOCREAM see hydrocortisone butyrate hydrophilic lipo base .............................. 51
LODOSYN see carbidopa ................ 22
LOESTRIN 1.5/30-21 see gildess 1.5/30 21 day ...................................... 33 see junel 1.5/30 21 day . 33 see larin 1.5/30 .............. 33
LOESTRIN 1/20-21 see junel 1/20 21 day .... 33 see larin 1/20 ................. 33
LOESTRIN FE 1.5/30 see junel fe 1.5/30 28 day ...................................... 33 see larin fe 1.5/30 .......... 33
LOESTRIN FE 1/20 see junel fe 1/20 28 day 33 see larin fe 1/20 ............. 33 see tarina fe 1/20 28 day ...................................... 34
LOFIBRA see fenofibrate ............... 16 see fenofibrate micronized ...................................... 16
lokara ................................ 52 lomedia 24 fe .................... 33 LOMOTIL
see diphenoxylate w/ atropine ......................... 39
LOMUSTINE ..................... 11 loperamide hcl ................... 39 LOPID
see gemfibrozil .............. 16 LOPRESSOR
see metoprolol tartrate .. 16 LOPRESSOR HCT
see metoprolol & hctz tab 100-25mg ...................... 16 see metoprolol & hctz tab 50-25mg ........................ 16
LOPROX SHAMPOO
see ciclopirox shampoo 1% ................................. 50
lorazepam ......................... 19 lorcet hd tab 10-325mg ....... 3 lorcet plus tab 7.5-325 ........ 3 lorcet tab 5-325mg .............. 3 lortab tab 10-325mg ............ 3 lortab tab 5-325mg .............. 3 lortab tab 7.5-325 ................ 3 loryna 28 day .................... 33 losartan potassium ............ 15 losartan-hydrochlorothiazide .......................................... 14 LOTEMAX ......................... 46 LOTENSIN
see benazepril hcl ......... 14 LOTENSIN HCT
see benazepril & hydrochlorothiazide ....... 13
LOTREL see amlodipine besylate-benazepril hcl .. 13
LOTRONEX see alosetron hcl ........... 39
lovastatin ........................... 15 LOVAZA
see omega-3-acid ethyl esters ............................ 16
LOVENOX see enoxaparin sodium . 41
low-ogestrel ...................... 33 loxapine succinate ............ 24 LUMIGAN ......................... 47 LUMIZYME ....................... 35 LUPANETA PACK ............ 34 LUPRON DEP INJ 11.25MG .......................................... 12 LUPRON DEPOT ............. 12 LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 12 LUPRON DEPOT INJ 30MG (3-MONTH) ....................... 12 LUPRON DEP-PED INJ 11.25MG ........................... 12 LUPRON DEP-PED INJ 15MG ................................ 12 LUPRON DEP-PED INJ 30MG (3-MONTH) ............ 12
LUPRON DEP-PED INJ 7.5MG ............................... 12 lutera 28 day ..................... 33 LUXIQ
see betamethasone valerate ......................... 51
LUZU ................................ 50 LYNPARZA ....................... 12 LYRICA ............................. 20 LYSODREN ...................... 12 LYSTEDA
see tranexamic acid ...... 42 lyza ................................... 33 M MACROBID
see nitrofurantoin monohyd macro .............. 6
MACRODANTIN ................. 6 see nitrofurantoin macrocrystal .................... 6
magnesium sulfate ............ 43 MAGNESIUM SULFATE .. 43 MAGNESIUM SULFATE IN D5W .................................. 43 MAGNESIUM SULFATE INJ 50% .................................. 43 MALARONE
see atovaquone-proguanil hcl tab 250-100 mg ......... 7 see atovaquone-proguanil hcl tab 62.5-25 mg .......... 7
malathion .......................... 52 maprotiline hcl .................. 22 MARINOL
see dronabinol............... 37 marlissa 28 day................. 33 MARPLAN ........................ 22 MATULANE ...................... 13 matzim la .......................... 17 MAVIK
see trandolapril.............. 14 MAXALT
see rizatriptan benzoate 27 MAXALT-MLT
see rizatriptan benzoate 27 MAXIDEX ......................... 46 MAXIPIME .......................... 9
see cefepime inj 1gm ...... 9
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see cefepime inj 2gm ......9 MAXITROL
see neomycin-polymy-dexameth .................................... 45
MAXZIDE see triamt/hctz tab 75-50mg ........................ 18
MAXZIDE-25 see triamt/hctz tab 37.5-25 ...................................... 18
meclizine hcl ..................... 37 MEDROL
see methylpred tab 16mg ...................................... 35 see methylpred tab 32mg ...................................... 35 see methylpred tab 4mg 35 see methylpred tab 8mg 35
MEDROL DOSEPAK see methylpred pak 4mg ...................................... 35
MEDROL TAB 2MG .......... 35 medroxyprogesterone acetate .............................. 37 medroxyprogesterone acetate (contraceptive) ..... 33 mefenamic acid ...................1 mefloquine hcl .....................7 MEGACE ES ..................... 12 MEGACE ORAL
see megestrol acetate ... 12 megestrol acetate ............. 12 MEKINIST ......................... 13 MELOXICAM ......................1 meloxicam tabs ...................1 melphalan hcl .................... 11 memantine hcl ................... 21 MENACTRA ...................... 43 MENOMUNE-A/C/Y/W-135 .......................................... 43 MENOSTAR ...................... 35 MENTAX ........................... 50 MENVEO .......................... 43 MEPRON
see atovaquone ...............5 mercaptopurine ................. 11 meropenem .........................6
MERREM see meropenem .............. 6
mesalamine enema .......... 38 mesna ............................... 13 MESNEX ........................... 13
see mesna ..................... 13 MESTINON
see pyridostigmine bromide ......................... 27
MESTINON SYRUP.......... 27 MESTINON TIMESPAN .... 27 METADATE CD
see methylphenidate hcl 25 metadate er tab 20mg ....... 25 metformin er ...................... 31 metformin hcl .................... 31 methadone hcl ................ 3, 4 METHADONE INJ 10MG/ML ............................................ 4 METHADOSE
see methadone hcl .......... 3 methazolamide ................. 18 methenamine hippurate ...... 6 METHERGINE
see methylergonovine maleate ......................... 36
methimazole ..................... 37 methotrexate sodium inj .... 11 methotrexate sodium tabs . 42 methoxsalen rapid ............ 50 methscopolamine bromide 38 methyclothiazide ............... 18 methylergonovine maleate 36 METHYLIN
see methylphenidate hcl ................................ 25, 26
methylphenidate hcl .... 25, 26 methylphenidate hcl er ...... 26 methylpr ace inj 40mg/ml .. 35 methylpr ace inj 80mg/ml .. 35 methylpr ss inj 125mg ....... 35 methylpr ss inj 1gm ........... 35 methylpr ss inj 40mg ......... 35 methylpred pak 4mg ......... 35 methylpred tab 16mg ........ 35 methylpred tab 32mg ........ 35 methylpred tab 4mg .......... 35 methylpred tab 8mg .......... 35
metipranolol ...................... 47 metoclopramide hcl ........... 37 metoclopramide hcl inj 5 mg/ml ................................ 37 metolazone ....................... 18 metoprolol & hctz tab 100-25mg ......................... 16 metoprolol & hctz tab 100-50mg ......................... 16 metoprolol & hctz tab 50-25mg ........................... 16 metoprolol succinate ......... 16 metoprolol tartrate............. 16 METOZOLV ODT
see metoclopramide hcl 37 METRO IV .......................... 6 METROCREAM
see metronidazole (topical) ......................... 52 see rosadan cre 0.75% . 52
METROGEL see metronidazole (topical) ......................... 52
METROGEL-VAGINAL see metronidazole vaginal ...................................... 40
METROLOTION see metronidazole (topical) ......................... 52
metronidazole ..................... 6 metronidazole (topical) ..... 52 metronidazole inj................. 6 metronidazole vaginal ....... 40 MEVACOR
see lovastatin ................ 15 mexiletine hcl .................... 15 MIACALCIN
see calcitonin (salmon) nasal spray .................... 36
MIACALCIN INJ 200U/ML 36 MICARDIS
see telmisartan .............. 15 MICARDIS HCT
see telmisartan-hydrochlorothiazide ............................. 14
miconazole 3 sup 200mg .. 40 MICROGESTIN 1.5/30 ..... 33
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MICROGESTIN 1/20 ......... 33 MICROGESTIN FE 1.5/30 33 MICROGESTIN FE 1/20 ... 33 MICRO-K
see potassium chloride caps er........................... 44
MICROZIDE see hydrochlorothiazide 18
midodrine hcl ..................... 18 migergot ............................ 26 millipred............................. 35 MINASTRIN 24 FE ............ 33 MINIPRESS
see prazosin hcl ............ 14 minitran ............................. 18 MINIVELLE ....................... 35 MINOCIN
see minocycline hcl ....... 11 minocycline hcl .................. 11 minoxidil ............................ 18 MIRAPEX .......................... 23
see pramipexole dihydrochloride .............. 23
MIRAPEX ER .................... 23 see pramipexole dihydrochloride .............. 23
MIRCERA ......................... 41 MIRCETTE
see desogestrel-ethinyl estradiol (biphasic) ........ 33 see kariva 28 day .......... 33 see kimidess .................. 33 see pimtrea pack ........... 34 see viorele ..................... 34
mirtazapine ....................... 22 misoprostol ........................ 39 mitomycin .......................... 11 mitoxantrone hcl ................ 13 M-M-R II ............................ 43 MOBIC
see meloxicam tabs .........1 modafinil............................ 28 moderiba pak ......................8 MODERIBA PAK .................8 moderiba tab 200mg ...........8 moexipril hcl ...................... 14 moexipril-hydrochlorothiazide ........................................ 14
mometasone furoate ......... 52 MONODOX
see doxycycline (monohydrate) ............... 10
MONONESSA .................. 33 montelukast sodium .......... 48 MORPHINE SUL 20MG/ML ORAL SOL .......................... 4 morphine sulfate ................. 4 MORPHINE SULFATE ....... 4 morphine sulfate beads....... 4 morphine sulfate ext-rel tab 4 MOVANTIK ....................... 39 MOVIPREP ....................... 39 MOXEZA ........................... 46 moxifloxacin hcl ................ 10 MOZOBIL .......................... 41 MS CONTIN
see morphine sulfate ext-rel tab ........................ 4
MULTAQ ........................... 15 mupirocin .......................... 50 mupirocin calcium (topical) 50 MUSTARGEN ................... 11 my way .............................. 33 MYAMBUTOL
see ethambutol hcl .......... 8 MYCAMINE ........................ 6 MYCOBUTIN
see rifabutin ..................... 8 mycophenolate mofetil 42, 43 mycophenolate sodium ..... 43 MYFORTIC
see mycophenolate sodium ........................... 43
myorisan ........................... 49 MYOZYME ........................ 35 MYRBETRIQ .................... 40 MYSOLINE
see primidone ................ 21 myzilra .............................. 33 N nabumetone ........................ 1 nadolol .............................. 16 nadolol & bendroflumethiazide ......... 16 nafcillin sodium ................. 10 NAFTIFINE HCL ............... 50
NAFTIN ............................. 50 NAGLAZYME ................... 35 nalbuphine hcl .................... 2 NALLPEN ISO-OSMOTIC IN DE ..................................... 10 NALLPEN/DEXTROSE ..... 10 naloxone hcl ..................... 29 naltrexone hcl ................... 29 NAMENDA
see memantine hcl ........ 21 NAMENDA SOL 10MG/5ML.......................................... 21 NAMENDA TAB ................ 21 NAMENDA XR .................. 21 NAMENDA XR TITRATION PACK ................................ 21 NAMZARIC ....................... 21 naphazoline 0.1% ............. 47 NAPRELAN ........................ 1 NAPROSYN
see naproxen .................. 1 naproxen ............................. 1 naproxen sodium ................ 1 NAPROXEN SODIUM ........ 1 naratriptan hcl ................... 26 NARDIL
see phenelzine sulfate .. 22 NASONEX ........................ 48 NATACYN ........................ 46 nateglinide ........................ 31 NATPARA ......................... 36 NAVELBINE
see vinorelbine tartrate .. 12 NEBUPENT ........................ 6 necon 0.5/35 28 day ......... 33 necon 1/35 28 day ............ 34 necon 10/11 28 day .......... 34 NECON 7/7/7 .................... 34 NECON TAB 1/50-28 ........ 34 nefazodone hcl ................. 22 neomycin sulfate ................. 5 neomycin/polymyxin b gu . 53 neomycin-bacitracin zn-polymyxin ..................... 46 neomycin-polymy-dexameth.......................................... 45 neomycin-polymyxin-gramicidin ..................................... 46
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neomycin-polymyxin-hc (ophth) .............................. 45 neomycin-polymyxin-hc (otic) .......................................... 53 NEORAL ........................... 43
see cyclosporine modified (for microemulsion) ........ 42 see gengraf ................... 42
NEOSPORIN see neomycin-polymyxin-gramicidin ............................... 46
NEOSPORIN GU IRRIGANT see neomycin/polymyxin b gu .................................. 53
NEPHRAMINE .................. 44 NEPTAZANE
see methazolamide ....... 18 NESINA............................. 31 neuac gel 1.2-5% .............. 49 NEULASTA ....................... 41 NEUMEGA ........................ 41 NEUPOGEN ..................... 41 NEUPRO........................... 23 NEURONTIN
see gabapentin .............. 20 nevirapine ...........................7 NEVIRAPINE ......................7 NEXAVAR ......................... 13 NEXIUM CAP 20MG ......... 39 NEXIUM CAP 40MG ......... 39 NEXIUM GRA 10MG DR .. 39 NEXIUM GRA 2.5MG DR . 39 NEXIUM GRA 20MG DR .. 40 NEXIUM GRA 40MG DR .. 40 NEXIUM GRA 5MG DR .... 39 NEXIUM I.V.
see esomeprazole sodium inj ................................... 39
next choice tab 1.5mg ....... 34 niacin er (antihyperlipidemic) .......................................... 16 niacor ................................ 16 NIASPAN
see niacin er (antihyperlipidemic) ....... 16
nicardipine hcl ................... 17 NICOTROL INHALER ....... 29
NICOTROL NS ................. 29 nifedical ............................. 17 nifedipine .......................... 17 nifedipine er ...................... 17 nikki 28 day ....................... 34 NILANDRON ..................... 12 nimodipine ........................ 17 NIPENT ............................. 12 nisoldipine ......................... 17 nitro-bid ............................. 18 NITRO-DUR ...................... 18
see minitran ................... 18 nitrofurantoin ....................... 6 nitrofurantoin macrocrystal .. 6 nitrofurantoin monohyd macro .................................. 6 nitroglycerin ...................... 18 NITROGLYCERIN LINGUAL .......................................... 18 nitroglycerin patches ......... 18 NITROLINGUAL PUMPSPRAY
see nitroglycerin ............ 18 NITROSTAT ..................... 18 nizatidine ........................... 38 NIZORAL
see ketoconazole shampoo ....................... 50
NORA-BE TAB ................. 34 NORCO
see hydrocodone-acetaminophen 5-325mg ..................... 2 see hydrocodone-acetaminophen 7.5-325mg .................. 3 see hydrocodone-acetaminophen tab 10-325mg ............. 3 see lorcet hd tab 10-325mg ........................ 3 see lorcet plus tab 7.5-325 ........................................ 3 see lorcet tab 5-325mg .... 3 see lortab tab 10-325mg . 3 see lortab tab 5-325mg ... 3 see lortab tab 7.5-325 ..... 3
NORDITROPIN FLEXPRO
.......................................... 36 NORDITROPIN NORDIFLEX PEN ............. 36 norethin acet & estrad-fe .. 34 norethindrone & ethinyl estradiol-fe ........................ 34 norethindrone (contraceptive) .................. 34 norethindrone acetate ....... 37 norethindrone acetate-ethinyl estradiol ............................ 35 norgestimate-ethinyl estradiol (triphasic) ........... 34 NORINYL 1+35
see cyclafem 1/35 28 day ...................................... 32 see necon 1/35 28 day .. 34 see nortrel 1/35 21 day . 34 see nortrel 1/35 28 day . 34 see pirmella 1/35 28 day ...................................... 34
NORITATE ....................... 52 norlyroc 28 day ................. 34 NORMOSOL-M IN D5W ... 45 NORMOSOL-R ................. 45 NORPACE
see disopyramide phosphate ..................... 15
NORPACE CR .................. 15 NORPRAMIN
see desipramine hcl ...... 21 NOR-QD
see camila 28 day ......... 32 see deblitane 28 day ..... 33 see heather ................... 33 see norethindrone (contraceptive) .............. 34 see norlyroc 28 day ....... 34
nortrel 0.5/35 28 day ......... 34 nortrel 1/35 21 day ............ 34 nortrel 1/35 28 day ............ 34 nortrel 7/7/7 28 day ........... 34 nortriptyline hcl ................. 22 NORVASC
see amlodipine besylate 17 NORVIR .............................. 7 NOVAREL INJ 10000UNT 36 NOVOLIN 70/30................ 30
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NOVOLIN 70/30 RELION.. 30 NOVOLIN N ...................... 30 NOVOLIN N RELION ........ 30 NOVOLIN R ...................... 30 NOVOLIN R RELION ........ 30 NOVOLOG ........................ 30 NOVOLOG FLEXPEN ...... 30 NOVOLOG MIX 70/30 ...... 30 NOVOLOG MIX 70/30 PREFILL ........................... 30 NOVOLOG PENFILL ........ 30 NOXAFIL.............................7 NUBAIN
see nalbuphine hcl ..........2 NUCYNTA ...........................4 NUCYNTA ER .....................4 NUEDEXTA ...................... 27 NULOJIX ........................... 43 NULYTELY/FLAVOR PACKS .............................. 39
see gavilyte-n ................ 39 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ...................................... 39 see trilyte ....................... 39
NUTRILIPID INJ 20% ....... 44 NUTROPIN AQ INJ 20MG/2ML ........................ 36 NUTROPIN AQ NUSPIN 5 36 NUTROPIN AQ PEN ......... 36 NUVARING ....................... 34 NUVESSA ......................... 40 NUVIGIL............................ 28 nyamyc ............................. 50 NYMALIZE ........................ 17 nystatin ...............................7 nystatin (mouth-throat) ...... 53 nystatin (topical) ................ 50 nystatin pow 100000 ......... 50 nystop ............................... 50 O OCELLA TAB 3-0.03MG ... 34 OCTAGAM ........................ 42 octreotide acetate ............. 36 OCUFEN
see flurbiprofen sodium . 46 OCUFLOX
see ofloxacin (ophth) ..... 46 OFEV ................................ 48 ofloxacin (ophth) ............... 46 ofloxacin (otic) ................... 53 ogestrel 28 day ................. 34 olanzapine ........................ 24 olanzapine odt .................. 24 olopatadine hcl (nasal) ...... 47 OLUX
see clobetasol propionate ...................................... 51
OLUX-E see clobetasol propionate emulsion ........................ 51
OMECLAMOX-PAK .......... 39 omega-3-acid ethyl esters . 16 omeprazole ....................... 40 OMEPRAZOLE-SODIUM BICARBONATE ................ 40 OMNARIS ......................... 48 OMNITROPE 10MG ......... 36 OMNITROPE 5.8MG ........ 36 OMNITROPE 5MG ........... 36 ondansetron hcl ................ 37 ondansetron hcl inj ............ 37 ondansetron hcl oral soln .. 37 ondansetron odt ................ 37 ONEXTON ........................ 49 ONFI ................................. 20 ONGLYZA ......................... 31 ONMEL ............................... 7 OPANA
see oxymorphone hcl ...... 4 OPANA ER (CRUSH RESISTANT ........................ 4 OPSUMIT ......................... 18 ORACEA ........................... 52 ORAP ................................ 24 ORAPRED ODT
see prednisolone sodium phosphate ..................... 35
ORENCIA ......................... 42 ORENITRAM TAB 0.125MG .......................................... 18 ORENITRAM TAB 0.25MG .......................................... 18 ORENITRAM TAB 1MG .... 18 ORENITRAM TAB 2.5MG . 19
ORFADIN ......................... 35 ORKAMBI ......................... 48 orsythia 28 day ................. 34 ORTHO EVRA
see xulane dis 150-35 ... 34 ORTHO MICRONOR
see errin 28 day ............ 33 see lyza ......................... 33 see sharobel 28 day ...... 34
ORTHO TRI-CYCLEN see norgestimate-ethinyl estradiol (triphasic) ........ 34 see tri-previfem 28 day .. 34 see tri-sprintec 28 day ... 34
ORTHO TRI-CYCLEN LO 34 ORTHO-CYCLEN
see previfem 28 day ...... 34 see sprintec 28 day ....... 34
ORTHO-NOVUM 7/7/7 see cyclafem 7/7/7 28 day ...................................... 33 see nortrel 7/7/7 28 day 34
OSENI TAB 12.5-15MG .... 31 OSENI TAB 12.5-30MG .... 31 OSENI TAB 12.5-45MG .... 31 OSENI TAB 25-15MG ....... 31 OSENI TAB 25-30MG ....... 31 OSENI TAB 25-45MG ....... 31 OSMOPREP ..................... 39 OTEZLA ............................ 42 OVCON-35
see balziva 28 day ........ 32 see briellyn 28 day ........ 32 see gildagia ................... 33 see philith ...................... 34 see vyfemla 28 day ....... 34 see zenchent tab ........... 34
OVIDE see malathion ................ 52
oxacillin sodium ................ 10 oxaliplatin .......................... 13 OXANDRIN
see oxandrolone............ 29 oxandrolone ...................... 29 oxaprozin ............................ 1 oxcarbazepine .................. 20 OXISTAT .......................... 50 OXSORALEN ULTRA
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see methoxsalen rapid .. 50 OXTELLAR XR ................. 20 oxybutynin chloride ........... 40 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 ......................... 40 P pacerone ........................... 15 paclitaxel ........................... 12 PAMELOR
see nortriptyline hcl ....... 22 pamidronate disodium ....... 32 PAMINE
see methscopolamine bromide ......................... 38
PAMINE FORTE see methscopolamine bromide ......................... 38
PANCREAZE .................... 39 PANDEL............................ 52 PANRETIN ........................ 52 pantoprazole sodium ......... 40 paricalcitol ......................... 45 PARICALCITOL ................ 45 PARLODEL
see bromocriptine mesylate ........................ 22
PARNATE see tranylcypromine sulfate ............................ 22
paromomycin sulfate ...........5 paroxetine er tab ............... 22 paroxetine hcl tabs ............ 22 paser d/r ..............................8 PATADAY ......................... 46 PATANASE
see olopatadine hcl (nasal) ...................................... 47
PATANOL ......................... 46 PAXIL................................ 22
see paroxetine hcl tabs . 22 PAXIL CR
see paroxetine er tab..... 22 PAZEO .............................. 46 PCE .................................... 9 PEDIAPRED
see pred sod pho sol 5mg/5ml ........................ 35
PEDVAX HIB .................... 43 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE .......................................... 39 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 39 PEGANONE ..................... 20 PEGINTRON ...................... 8 PEG-INTRON ..................... 8 PEG-INTRON REDIPEN .... 8 PENICILLIN G POT IN DEXTROSE ...................... 10 PENICILLIN G POTASSIUM IN ...................................... 10 penicillin g procaine .......... 10 penicillin g sodium ............ 10 penicillin v potassium ........ 10 penicilln gk inj 20mu ......... 10 penicilln gk inj 5mu ........... 10 PENNSAID ....................... 52 PENTAM 300 ...................... 6 PENTASA ......................... 38 pentoxifylline ..................... 41 PEPCID
see famotidine ............... 38 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 .. 5
PERCODAN see oxycodone-aspirin .... 4
PERFOROMIST ............... 48 PERIDEX
see chlorhexidine gluconate (mouth-throat) ...................................... 53 see periogard soln 0.12% ...................................... 53
perindopril erbumine ......... 14 periogard soln 0.12% ........ 53 PERJETA ......................... 12 permethrin ........................ 52 perphenazine .................... 24 PERTZYE ......................... 39 PEXEVA ........................... 22 pfizerpen g inj 5mu ........... 10 pfizerpen-g inj 20mu ......... 10 phenadoz .......................... 37 phenelzine sulfate ............. 22 phenergan ........................ 37 PHENERGAN
see promethazine hcl .... 38 phenobarbital .................... 20 phenobarbital sodium ....... 20 PHENOBARBITAL SODIUM.......................................... 20 phenytek ........................... 20 phenytoin .......................... 20 phenytoin inj 50mg/ml ....... 20 phenytoin sodium extended.......................................... 20 philith ................................ 34 PHOSLO
see calcium acetate (phosphate binder) ........ 37
PHOSLYRA ...................... 37 PHOSPHOLINE IODIDE .. 47 PICATO ............................ 52 PILOCARPINE HCL ......... 47 pilocarpine hcl (oral) ......... 53 PILOCARPINE HCL (ORAL).......................................... 53
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pimtrea pack ..................... 34 pindolol ............................. 16 pioglitazone hcl ................. 31 pioglitazone hcl-glimepiride .......................................... 32 pioglitazone hcl-metformin hcl ..................................... 32 piperacillin sodium-tazobactam sodium .......................................... 10 pirmella 1/35 28 day .......... 34 piroxicam.............................1 PLAN B ONE-STEP
see levonorgestrel (emergency oc) ............. 33 see my way ................... 33 see next choice tab 1.5mg ...................................... 34
PLAQUENIL see hydroxychloroquine sulfate ............................ 42
PLASMA-LYTE A .............. 45 PLASMA-LYTE-148 .......... 45 PLASMA-LYTE-56/D5W ... 45 PLAVIX
see clopidogrel bisulfate 42 PLEGRIDY ........................ 28 PLEGRIDY STARTER PACK ................................ 28 PLETAL
see cilostazol ................. 41 podofilox............................ 52 polyethylene glycol 3350 ... 39 polymyxin b sulfate .............6 polymyxin b-trimethoprim .. 46 POLYTRIM
see polymyxin b-trimethoprim ............... 46
POMALYST ...................... 13 PONSTEL
see mefenamic acid ........1 portia 28 day ..................... 34 pot chloride inj 2meq/ml .... 45 potassium chloride ............ 44 POTASSIUM CHLORIDE 44, 45 POTASSIUM CHLORIDE 0.3%/D .............................. 45
potassium chloride caps er .......................................... 44 potassium chloride in nacl . 45 POTASSIUM CHLORIDE IN NACL ................................ 45 potassium chloride microencapsulated crystals cr ....................................... 44 POTASSIUM CHLORIDE TAB CR 10 MEQ .............. 44 potassium citrate (alkalinizer) .......................................... 40 POTASSIUM CITRATE (ALKALINIZER) ................ 40 POTIGA ...................... 20, 21 PRADAXA ......................... 41 pramipexole dihydrochloride .......................................... 23 PRANDIMET ..................... 32 PRANDIN
see repaglinide .............. 32 PRAVACHOL
see pravastatin sodium . 15 pravastatin sodium ............ 15 prazosin hcl ....................... 14 PRECOSE
see acarbose ................. 30 PRED MILD ...................... 46 pred sod pho sol 5mg/5ml . 35 PRED-G ............................ 45 PRED-G S.O.P. ................ 45 prednicarbate .................... 52 PREDNICARBATE ........... 52 PREDNISOLONE ACETATE (OPHTH) ........................... 46 prednisolone sodium phosphate ......................... 35 prednisolone sodium phosphate (ophth) ............. 46 prednisolone sol 15mg/5ml .......................................... 35 prednisolone sol 25mg/5ml .......................................... 35 prednisolone syrup 15 mg/5ml .............................. 36 prednisone con 5mg/ml ..... 36 prednisone pak 10mg ....... 36 prednisone pak 5mg ......... 36
prednisone sol 5mg/5ml .... 36 prednisone tab 10mg ........ 36 prednisone tab 1mg .......... 36 prednisone tab 2.5mg ....... 36 prednisone tab 20mg ........ 36 prednisone tab 50mg ........ 36 prednisone tab 5mg .......... 36 PREGNYL W/DILUENT BENZYL ............................ 36 PREMARIN CREAM ......... 35 PREMARIN INJ ................ 35 premasol 10% ................... 44 premasol 6% ..................... 44 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC).......................................... 45 PREPOPIK ....................... 39 PREVACID
see lansoprazole ........... 39 PREVACID SOLUTAB ...... 40 prevalite ............................ 16 previfem 28 day ................ 34 PREVPAC
see amoxicillin-clarithromycin w/ lansoprazole ............. 39
PREZCOBIX ....................... 7 PREZISTA .......................... 7 PRIFTIN .............................. 8 PRILOSEC ....................... 40
see omeprazole............. 40 PRIMAQUINE PHOSPHATE............................................ 7 PRIMAXIN IV
see imipenem-cilastatin ... 6 primidone .......................... 21 PRIMSOL SOL 50MG/5ML . 6 PRINIVIL
see lisinopril .................. 14 PRISTIQ ........................... 22 PRIVIGEN ........................ 42 PROAIR HFA .................... 48 PROAIR RESPICLICK ...... 48 probenecid .......................... 1 PROCALAMINE................ 44 PROCARDIA XL
see nifedical .................. 17 see nifedipine er ............ 17
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prochlorperazine inj 5 mg/ml .......................................... 37 prochlorperazine maleate.. 38 prochlorperazine supp ...... 38 PROCRIT .......................... 41 procto-pak ......................... 50 proctosol hc 2.5 % ............ 50 proctozone hc ................... 50 PROCYSBI ....................... 35 progesterone micronized... 37 PROGLYCEM SUS 50MG/ML .......................... 36 PROGRAF ........................ 43
see tacrolimus ............... 43 PROLASTIN-C .................. 48 PROLENSA ...................... 47 PROLEUKIN ..................... 12 PROLIA ............................. 36 PROMACTA ...................... 41 promethazine hcl ............... 38 promethegan ..................... 38 PROMETRIUM
see progesterone micronized ..................... 37
propafenone hcl ................ 15 propafenone hcl 12hr ........ 15 proparacaine hcl ............... 47 propranolol & hydrochlorothiazide ........... 16 propranolol hcl er .............. 16 propranolol inj 1mg/ml ....... 16 propranolol sol .................. 16 propranolol tab .................. 16 propylthiouracil .................. 37 PROQUAD ........................ 43 PROSCAR
see finasteride ............... 40 PROSOL ........................... 44 PROTONIX ....................... 40
see pantoprazole sodium ...................................... 40
PROTOPIC see tacrolimus (topical).. 52
protriptyline hcl .................. 22 PROVENTIL HFA ............. 48 PROVERA
see medroxyprogesterone acetate........................... 37
PROVIGIL see modafinil ................. 28
PROZAC see fluoxetine hcl .......... 22
PROZAC WEEKLY see fluoxetine hcl .......... 22
PRUDOXIN CRE 5% ........ 50 PULMICORT
see budesonide (inhalation) .................... 49
PULMICORT FLEXHALER .......................................... 49 PULMICORT INH SUSP 1MG/2ML .......................... 49 PULMOZYME ................... 48 PURIXAN .......................... 12 PYLERA ............................ 39 pyrazinamide ...................... 8 pyridostigmine bromide ..... 27 Q QNASL .............................. 48 QNASL CHILDRENS ........ 48 QUADRACEL ................... 43 QUALAQUIN
see quinine sulfate .......... 7 QUARTETTE .................... 34 quasense 91 day .............. 34 QUESTRAN
see cholestyramine ....... 15 QUESTRAN LIGHT
see prevalite .................. 16 quetiapine fumarate .......... 24 QUILLIVANT XR ............... 26 quinapril hcl ....................... 14 quinapril-hydrochlorothiazide .......................................... 14 quinidine gluconate ........... 15 quinidine sulfate ................ 15 quinine sulfate ..................... 7 QVAR ................................ 49 R RABAVERT ...................... 43 rabeprazole sodium .......... 40 RAGWITEK ....................... 42 raloxifene hcl ..................... 36 ramipril .............................. 14 RANEXA ........................... 18 ranitidine hcl ...................... 38
RAPAFLO ......................... 40 RAPAMUNE ..................... 43
see sirolimus ................. 43 RAVICTI ........................... 35 RAYOS TAB 1MG ............ 36 RAYOS TAB 2MG ............ 36 RAYOS TAB 5MG ............ 36 RAZADYNE
see galantamine hydrobromide ................ 21
RAZADYNE ER see galantamine hydrobromide ................ 21
REBETOL ........................... 8 see ribasphere ................ 8 see ribavirin 200mg ......... 8
REBIF ............................... 28 REBIF REBIDOSE ............ 28 REBIF REBIDOSE TITRATION ....................... 28 REBIF TITRATION PACK 28 RECLAST
see zoledronic inj 5/100ml ...................................... 32
reclipsen 28 day................ 34 RECOMBIVAX HB ............ 43 RECTIV ............................ 52 REGLAN
see metoclopramide hcl 37 REGRANEX ..................... 53 RELENZA DISKHALER ...... 8 RELISTOR ........................ 39 RELPAX ........................... 26 REMERON
see mirtazapine ............. 22 REMERON SOLTAB
see mirtazapine ............. 22 REMICADE ....................... 42 REMODULIN .................... 19 RENAGEL ........................ 37 RENVELA PAK ................. 37 RENVELA TAB 800MG .... 37 repaglinide ........................ 32 REPREXAIN
see hydrocodone-ibuprofen tab 2.5-200mg ....................... 3 see ibudone tab 5-200mg 3
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reprexain tab 10-200mg ......4 REQUIP
see ropinirole hydrochloride ................. 23
REQUIP XL see ropinirole hydrochloride ................. 23
RESCRIPTOR ....................7 RESTASIS ........................ 47 RESTORIL
see temazepam ............. 26 RETIN-A
see tretinoin ................... 50 RETIN-A MICRO PUMP ... 50 RETROVIR
see zidovudine ................7 RETROVIR IV INFUSION ...7 REVATIO .......................... 19
see sildenafil citrate (pulmonary hypertension) ...................................... 19
REVIA see naltrexone hcl ......... 29
REVLIMID ......................... 42 REYATAZ ...........................7 RHEUMATREX ................. 42 RHINOCORT AQUA
see budesonide (nasal) . 48 ribapak mis 600/day ............8 ribasphere ...........................8 ribasphere ribapak 1000 .....8 ribasphere ribapak 1200 .....8 ribasphere ribapak 800 .......8 ribavirin 200mg ...................8 rifabutin ...............................8 RIFADIN
see rifampin .....................8 rifamate ...............................8 rifampin ...............................8 RIFATER.............................8 RILUTEK
see riluzole .................... 27 riluzole .............................. 27 rimantadine hydrochloride ...8 RINGER'S ......................... 45 RIOMET ............................ 32 risedronate sodium ........... 32 RISEDRONATE SODIUM . 32
RISPERDAL see risperidone .............. 24
RISPERDAL INJ 12.5MG . 24 RISPERDAL INJ 25MG .... 24 RISPERDAL INJ 37.5MG . 24 RISPERDAL INJ 50MG .... 24 RISPERDAL M-TAB
see risperidone odt ........ 24 risperidone ........................ 24 risperidone odt .................. 24 RITALIN
see methylphenidate hcl 26 RITALIN LA ....................... 26
see methylphenidate hcl 25 RITUXAN .......................... 12 rivastigmine tartrate .......... 21 rizatriptan benzoate .......... 27 ROBINUL
see glycopyrrolate ......... 38 ROBINUL FORTE
see glycopyrrolate ......... 38 ROCALTROL
see calcitriol .................. 45 ROCEPHIN
see ceftriaxone sodium ... 9 ropinirole hydrochloride..... 23 rosadan cre 0.75% ............ 52 ROTARIX .......................... 43 ROTATEQ ........................ 43 ROWASA
see mesalamine enema 38 roxicet soln .......................... 4 roxicet tab 5-325mg ............ 5 ROXICODONE
see oxycodone hcl........... 4 ROZEREM ........................ 26 RUCONEST ...................... 41 RYTARY ........................... 23 RYTHMOL
see propafenone hcl ...... 15 see propafenone hcl 12hr ...................................... 15
RYTHMOL SR see propafenone hcl ...... 15 see propafenone hcl 12hr ...................................... 15
S SABRIL ............................. 21
SAIZEN ............................. 36 SAIZEN CLICK.EASY ....... 36 SALAGEN
see pilocarpine hcl (oral) ...................................... 53
SAMSCA .......................... 36 SANCUSO ........................ 38 SANDIMMUNE
see cyclosporine ........... 42 SANDIMMUNE SOLN ...... 43 SANDOSTATIN
see octreotide acetate ... 36 SANDOSTATIN LAR DEPOT ............................. 36 SANTYL ............................ 53 SAPHRIS .......................... 24 SARAFEM ........................ 29 SAVAYSA ......................... 41 SAVELLA .......................... 27 SAVELLA TITRATION PACK ................................ 27 SEASONIQUE
see amethia 91 day ....... 32 see ashlyna 91 day ....... 32 see levonorgestrel-ethinyl estradiol (91-day) .......... 33
SECTRAL see acebutolol hcl ......... 16
selegiline hcl ..................... 23 selenium sulfide ................ 50 SELZENTRY ...................... 7 SEMPREX-D .................... 47 SENSIPAR ....................... 32 SEREVENT DISKUS ........ 48 SEROQUEL
see quetiapine fumarate 24 SEROQUEL XR ................ 24 SEROSTIM ....................... 36 sertraline hcl ..................... 22 SF-ROWASA .................... 38 sharobel 28 day ................ 34 SIGNIFOR ........................ 36 SIGNIFOR LAR ................ 36 sildenafil citrate (pulmonary hypertension) .................... 19 SILENOR .......................... 26 SILVER SULFADIAZINE .. 50 SIMBRINZA SUS 1-0.2% . 47
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SIMCOR............................ 16 SIMPONI ........................... 42 SIMPONI ARIA ................. 42 SIMULECT ........................ 43 simvastatin ........................ 15 SINEMET
see carbidopa-levodopa 22 SINEMET CR
see carbidopa-levodopa 22 SINGULAIR
see montelukast sodium 48 sirolimus ............................ 43 SIROLIMUS ...................... 43 SIRTURO ............................8 SIVEXTRO ..........................6 SKLICE ............................. 53 SODIUM CHLORIDE .. 44, 45 SODIUM CHLORIDE 0.45% VIA .................................... 45 SODIUM CHLORIDE 0.9% .......................................... 53 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN ................................ 44 sodium phenylbutyrate ...... 35 sodium polystyrene sulfonate .......................................... 32 SOLARAZE
see diclofenac sodium (actinic keratoses) ......... 52
SOLIA ............................... 34 SOLODYN ........................ 11 SOLTAMOX ...................... 12 SOLU-CORTEF 1000MG.. 36 SOLU-CORTEF 100MG ... 36 SOLU-CORTEF 250MG ... 36 SOLU-CORTEF 500MG ... 36 SOLU-MEDROL
see methylpr ss inj 125mg ...................................... 35 see methylpr ss inj 1gm . 35 see methylpr ss inj 40mg ...................................... 35
SOLU-MEDROL INJ 2GM. 36 SOMATULINE DEPOT ..... 36 SOMAVERT ...................... 36 SOOLANTRA .................... 52 SORIATANE
see acitretin ................... 50 SORILUX .......................... 50 sorine ................................ 15 sotalol hcl .......................... 15 sotalol hcl (afib/afl) ............ 15 SOTYLIZE ........................ 16 SOVALDI ............................ 8 SPIRIVA HANDIHALER .... 47 SPIRIVA RESPIMAT ........ 47 spironolactone .................. 14 spironolactone & hydrochlorothiazide ........... 18 SPORANOX
see itraconazole .............. 6 SPORANOX SOL 10MG/ML ............................................ 7 sprintec 28 day ................. 34 SPRYCEL ......................... 13 sps susp 15gm/60ml ......... 32 sronyx 28 day ................... 34 SSD .................................. 50 STARLIX
see nateglinide .............. 31 stavudine ............................ 7 STELARA ......................... 50 STERILE WATER IRRIGATION ..................... 53 STIMATE .......................... 37 STIOLTO RESPIMAT ....... 47 STIVARGA ........................ 13 STRATTERA .................... 26 streptomycin sulfate ............ 5 STRIANT .......................... 29 STRIBILD ............................ 8 STRIVERDI RESPIMAT ... 48 STROMECTOL
see ivermectin ................. 6 SUBOXONE MIS 12-3MG 29 SUBOXONE MIS 2-0.5MG .......................................... 29 SUBOXONE MIS 4-1MG .. 29 SUBOXONE MIS 8-2MG .. 29 SUBSYS ............................. 5 SUCLEAR ......................... 39 SUCRAID .......................... 39 sucralfate .......................... 39 SULAR
see nisoldipine .............. 17
sulfacet sod oin 10% op .... 46 sulfacetamide sodium (acne).......................................... 50 sulfacetamide sodium (ophth) .............................. 46 sulfacetamide sod-prednisolone .............. 45 sulfadiazine ......................... 5 sulfamethoxazole-trimethop 6 sulfamethoxazole-trimethoprim inj .................................... 6 SULFAMYLON ................. 50 sulfasalazine dr ................. 38 sulfasalazine ir .................. 38 sulindac .............................. 1 SUMATRIPTAN INJ 4MG/0.5ML ....................... 27 sumatriptan inj 6mg/0.5ml . 27 SUMATRIPTAN INJ 6MG/0.5ML ....................... 27 sumatriptan succinate ....... 27 SUMATRIPTAN SUCCINATE ..................... 27 SUMAVEL DOSEPRO ...... 27 suprax ................................. 9 SUPRAX ............................. 9
see cefixime .................... 9 SUPREP BOWEL PREP .. 39 SURMONTIL .................... 22 SUSTIVA ............................ 7 SUTENT ........................... 13 syeda ................................ 34 SYLATRON KIT 200MCG 13 SYLATRON KIT 300MCG 13 SYLATRON KIT 600MCG 13 SYMBICORT .................... 49 SYMLINPEN 120 .............. 30 SYMLINPEN 60 ................ 30 SYNAGIS .......................... 43 SYNALAR
see fluocinolone acetonide ...................................... 51
SYNAREL ......................... 34 SYNERA ........................... 52 SYNERCID ......................... 6 SYNRIBO ......................... 13 SYNTHROID .................... 37
see levothyroxine sodium
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...................................... 37 SYPRINE .......................... 32 T TABLOID........................... 12 TACLONEX ....................... 52
see calcipotriene/betamethasone .................................. 51
tacrolimus.......................... 43 tacrolimus (topical) ............ 52 TAFINLAR ......................... 13 TAMIFLU.............................8 tamoxifen citrate ................ 12 tamsulosin hcl ................... 40 TANZEUM ......................... 30 TAPAZOLE
see methimazole ........... 37 TARCEVA ......................... 13 TARGRETIN ............... 13, 52 tarina fe 1/20 28 day ......... 34 TARKA
see trandolapril-verapamil hcl .................................. 14
TASIGNA .......................... 13 tazicef .................................9 tazicef vial ...........................9 TAZORAC ......................... 50 taztia xt ............................. 17 TECFIDERA CAP 120MG. 28 TECFIDERA CAP 240MG. 28 TECFIDERA MIS STARTER .......................................... 28 TEFLARO ...........................9 TEGRETOL ....................... 21
see carbamazepine ....... 19 see epitol ....................... 20
TEGRETOL-XR ................ 21 see carbamazepine ....... 19
TEKTURNA ....................... 17 TEKTURNA HCT .............. 17 telmisartan ........................ 15 telmisartan-amlodipine ...... 14 telmisartan-hydrochlorothiazide ...................................... 14 temazepam ....................... 26 TEMOVATE
see clobetasol propionate ...................................... 51
see cormax .................... 51 TEMOVATE E
see clobetasol e cream 0.05% ............................ 51
TENIVAC .......................... 43 TENORETIC 100
see atenolol & chlorthalidone ................ 16
TENORETIC 50 see atenolol & chlorthalidone ................ 16
TENORMIN see atenolol ................... 16
TERAZOL 3 see terconazole vaginal . 40
TERAZOL 7 see terconazole vaginal . 40 see zazole ..................... 40
terazosin hcl ...................... 14 terbinafine hcl ..................... 7 terbutaline sulfate ............. 48 terconazole vaginal ........... 40 TESTIM ............................. 29 testosterone cypionate ...... 29 testosterone enanthate ..... 29 TETANUS/DIPHTHERIA TOXOID ............................ 43 TETRACYCLINE HCL ...... 11 TEVETEN HCT ................. 15 texacort ............................. 52 THALOMID ....................... 42 theo-24 .............................. 49 theophylline ....................... 49 thioridazine hcl .................. 24 thiothixene ........................ 24 THYMOGLOBULIN ........... 43 tiagabine hcl ...................... 21 TIAZAC
see diltiazem hcl er........ 17 see diltiazem hcl extended release beads ................ 17 see diltzac ..................... 17 see taztia xt ................... 17
TIKOSYN .......................... 15 timolol maleate .................. 16 timolol maleate (ophth) ..... 47 TIMOLOL MALEATE GEL 47 TIMOPTIC
see timolol maleate (ophth) ........................... 47
TIMOPTIC OCUDOSE ..... 47 TIROSINT ......................... 37 TIVICAY .............................. 7 tizanidine .......................... 28 TOBI
see tobramycin ................ 5 TOBI PODHALER ............... 5 TOBRADEX ...................... 45
see tobramycin-dexamethasone .................................... 45
TOBRADEX ST ................ 45 tobramycin .......................... 5 tobramycin (ophth) ............ 46 tobramycin sulfate............... 5 tobramycin sulfate in saline 5 tobramycin-dexamethasone.......................................... 45 TOBREX
see tobramycin (ophth) . 46 TOBREX OINT 0.3% ........ 46 TOFRANIL
see imipramine hcl ........ 22 TOFRANIL-PM
see imipramine pamoate ...................................... 22
tolmetin sodium................... 1 tolterodine tartrate er ........ 40 tolterodine tartrate tab 1 mg.......................................... 40 tolterodine tartrate tab 2 mg.......................................... 40 TOPAMAX
see topiramate .............. 21 TOPAMAX SPRINKLE
see topiramate .............. 21 TOPICORT
see desoximetasone ..... 51 TOPICORT SPRAY 0.25%.......................................... 52 topiramate ......................... 21 TOPIRAMATE .................. 21 toposar .............................. 13 topotecan hcl .................... 13 TOPROL XL
see metoprolol succinate
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...................................... 16 TORISEL........................... 12 torsemide inj 50mg/5ml ..... 18 torsemide tabs .................. 18 TOUJEO SOLOSTAR ....... 30 TOVIAZ ............................. 40 TPN ELECTROLYTES ..... 44 TRACLEER ....................... 19 TRADJENTA ..................... 32 TRAMADOL HCL ................2 tramadol hcl er ....................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 ............. 16 trandolapril ........................ 14 trandolapril-verapamil hcl .. 14 tranexamic acid ........... 41, 42 TRANSDERM-SCOP ........ 38 TRANXENE T
see clorazepate dipotassium ................... 19
tranylcypromine sulfate ..... 22 TRAVASOL ....................... 44 TRAVATAN Z .................... 47 trazodone hcl .................... 22 TREANDA ......................... 11 TRECATOR ........................8 TRELSTAR MIXJECT ....... 12 tretinoin ....................... 13, 50 TRETINOIN ....................... 50 TRETINOIN MICROSPHERE ............... 50 tretin-x ............................... 50 trexall ................................ 42 TREXIMET ........................ 27 trezix ...................................2 triamcinolone acetonide (mouth) ............................. 53 triamcinolone acetonide (nasal) ............................... 48
triamcinolone acetonide (topical) ............................. 52 triamt/hctz cap 37.5-25 ..... 18 triamt/hctz cap 50-25mg ... 18 triamt/hctz tab 37.5-25 ...... 18 triamt/hctz tab 75-50mg .... 18 trianex ............................... 52 TRIBENZOR ..................... 15 TRICOR
see fenofibrate .............. 16 triderm ............................... 52 trifluoperazine hcl .............. 24 trifluridine .......................... 46 TRIGLIDE ......................... 16 tri-legest 28 day ................ 34 TRILEPTAL
see oxcarbazepine ........ 20 TRILIPIX
see choline fenofibrate .. 16 trilyte ................................. 39 trimethoprim ........................ 6 TRINESSA ........................ 34 TRI-NORINYL 28
see aranelle 28 .............. 32 TRIOSTAT
see liothyronine sodium . 37 tri-previfem 28 day ............ 34 TRISENOX ....................... 13 tri-sprintec 28 day ............. 34 TRIUMEQ ........................... 8 trivora 28 day .................... 34 TRIZIVIR
see abacavir sulfate-lamivudine-zidovudine ................................... 7
TROKENDI XR ................. 21 TROPHAMINE INJ 10% ... 44 trospium chloride .............. 40 trospium chloride er .......... 40 TRULICITY ....................... 30 TRUMENBA ...................... 43 TRUSOPT
see dorzolamide hcl ...... 47 TRUVADA ........................... 8 TUDORZA PRESSAIR ..... 47 TUDORZA PRESSAIR (INSTITUTIONAL PACK) .. 47 TWINRIX INJ .................... 43
TWYNSTA see telmisartan-amlodipine ...................................... 14
TYBOST ............................. 7 TYGACIL ............................ 6 TYKERB ........................... 13 TYLENOL/CODEINE #3
see acetaminophen w/ codeine ........................... 1
TYLENOL/CODEINE #4 see acetaminophen w/ codeine ........................... 1
TYPHIM VI ........................ 43 TYSABRI .......................... 28 TYVASO ........................... 19 TYZEKA .............................. 8 tyzine ................................ 48 U UCERIS AER 2MG/ACT ... 38 UCERIS TAB 9MG ........... 38 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 ..................... 51
ULTRESA ......................... 39 UNASYN
see ampicillin & sulbactam sodium .......................... 10
UNASYN BULK PACK see ampicillin & sulbactam sodium .......................... 10
UNITHROID ...................... 37 URECHOLINE
see bethanechol chloride ...................................... 40
UROCIT-K 15 see potassium citrate (alkalinizer) .................... 40
UROXATRAL see alfuzosin hcl ............ 40
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URSO 250 see ursodiol ................... 39
URSO FORTE see ursodiol ................... 39
ursodiol ............................. 39 UVADEX ........................... 13 V VAGIFEM .......................... 35 valacyclovir hcl ....................8 VALCHLOR ....................... 52 VALCYTE............................8
see valganciclovir hcl ......8 valganciclovir hcl .................8 VALIUM
see diazepam ................ 19 valproate sodium ............... 21 valproic acid ...................... 21 valsartan ........................... 15 valsartan-hydrochlorothiazide ........................................ 15 VALTREX
see valacyclovir hcl .........8 VANCOCIN HCL
see vancomycin hcl .........6 vancomycin hcl ...................6 vancomycin hcl inj 1000mg .6 vancomycin hcl inj 10gm .....6 vancomycin hcl inj 500mg ...6 vancomycin hcl inj 5gm .......6 vancomycin hcl inj 750mg ...6 VANDAZOLE .................... 40 VANOS
see fluocinonide ............ 51 VAQTA .............................. 43 VARIVAX .......................... 43 VASCEPA ......................... 16 VASERETIC
see enalapril maleate & hydrochlorothiazide ....... 14
VASOTEC see enalapril maleate .... 14
VECTIBIX.......................... 12 VELCADE ......................... 12 velivet 28 day .................... 34 VELPHORO ...................... 37 VELTIN ............................. 50 venlafaxine cap er ............. 22 venlafaxine hcl .................. 22
VENLAFAXINE HCL ER see venlafaxine tab er ... 22
venlafaxine tab .................. 22 VENLAFAXINE TAB 225MG ER ..................................... 22 venlafaxine tab er ............. 22 VENTAVIS ........................ 19 VENTOLIN HFA ................ 48 VERAMYST ...................... 48 verapamil hcl ..................... 17 VERAPAMIL HCL ............. 17 VERELAN
see verapamil hcl .......... 17 VERELAN PM
see verapamil hcl .......... 17 veripred ............................. 36 VERSACLOZ .................... 24 VESICARE ........................ 40 vestura .............................. 34 VEXOL .............................. 46 VFEND
see voriconazole ............. 7 VFEND IV
see voriconazole inj 200mg ............................. 7
VIBRAMYCIN ................... 11 see doxycycline (monohydrate) ............... 11 see doxycycline hyclate . 11
vicodin ................................. 5 vicodin es ............................ 5 vicodin hp ............................ 5 VICOPROFEN
see hydrocodone-ibuprofen tab 7.5-200 mg ...................... 3
VICTOZA .......................... 30 VIDAZA
see azacitidine .............. 11 VIDEX EC
see didanosine ................ 7 VIDEX PEDIATRIC ............. 7 VIGAMOX ......................... 46 VIIBRYD ........................... 22 VIMIZIM ............................ 35 VIMOVO ............................. 1 VIMPAT ............................ 21 vinblastine sulfate ............. 12
vincasar ............................ 12 vincristine sulfate .............. 12 vinorelbine tartrate ............ 12 VIOKACE 10 ..................... 39 VIOKACE 20 ..................... 39 viorele ............................... 34 VIRACEPT .......................... 7 VIRAMUNE
see nevirapine ................. 7 VIRAMUNE XR ................... 7
see nevirapine ................. 7 VIREAD .............................. 7 VIROPTIC
see trifluridine ................ 46 VISTIDE
see cidofovir .................... 8 VITEKTA ............................. 7 VIVELLE-DOT
see estradiol .................. 35 VOGELXO ........................ 29 VOGELXO PUMP ............. 29 VOLTAREN GEL 1% ........ 52 voriconazole ....................... 7 voriconazole inj 200mg ....... 7 VOSPIRE ER
see albuterol sulfate er .. 48 VOTRIENT ....................... 13 VPRIV ............................... 35 vyfemla 28 day ................. 34 VYTORIN .......................... 16 VYVANSE ......................... 26 W warfarin sodium ................ 41 WELCHOL ........................ 16 WELLBUTRIN
see bupropion hcl .......... 21 WELLBUTRIN SR
see bupropion hcl .......... 21 WELLBUTRIN XL
see bupropion hcl .......... 21 WESTCORT
see hydrocortisone valerate ......................... 52
wymzya fe ......................... 34 X XALATAN
see latanoprost.............. 47 XALKORI .......................... 13
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XANAX see alprazolam .............. 19
XARELTO ......................... 41 XARELTO STARTER PACK .......................................... 41 XARTEMIS XR ....................5 XELJANZ .......................... 42 XENAZINE ........................ 27 XEOMIN INJ 100 UNIT ..... 28 XEOMIN INJ 50 UNIT ....... 28 XERESE ........................... 52 XGEVA ............................. 36 XIFAXAN TAB 200MG ........6 XIFAXAN TAB 550MG ...... 39 XIGDUO XR TAB 10-1000MG ....................... 32 XIGDUO XR TAB 10-500MG .......................................... 32 XIGDUO XR TAB 5-1000MG .......................................... 32 XIGDUO XR TAB 5-500MG .......................................... 32 XODOL
see hydrocodone-acetaminophen 10-300mg ...................3 see hydrocodone-acetaminophen 5-300mg .....................2 see hydrocodone-acetaminophen 7.5-300mg ..................3 see vicodin ......................5 see vicodin es ..................5 see vicodin hp .................5
XOLAIR ............................. 48 XOPENEX
see levalbuterol hcl ........ 48 XOPENEX CONCENTRATE
see levalbuterol conc 1.25mg/0.5ml ................. 48
XOPENEX HFA ................ 48 XTANDI ............................. 12 xulane dis 150-35 .............. 34 XYLOCAINE
see lidocaine hcl ............ 52 see lidocaine hcl (local anesth.) ...........................5
see lidocaine inj 1%......... 5 see lidocaine inj 2%......... 5
XYLOCAINE-MPF see lidocaine hcl (local anesth.) ........................... 5 see lidocaine inj 0.5% ...... 5 see lidocaine inj 1.5% ...... 5 see lidocaine inj 2%......... 5
XYREM ............................. 28 XYZAL
see levocetirizine soln 2.5mg/5ml ..................... 47 see levocetirizine tab 5 mg ...................................... 47
Y YASMIN 28
see drospirenone-ethinyl estradiol ......................... 33 see syeda ...................... 34 see zarah ...................... 34
YAZ see loryna 28 day .......... 33 see nikki 28 day ............ 34 see vestura .................... 34
YERVOY ........................... 12 YF-VAX ............................. 43 Z zafirlukast .......................... 48 zamicet ............................... 5 ZANAFLEX
see tizanidine ................ 28 ZANOSAR ........................ 11 ZANTAC
see ranitidine hcl ........... 38 zarah ................................. 34 ZARONTIN
see ethosuximide .......... 20 ZAVESCA ......................... 35 zazole ............................... 40 ZAZOLE ............................ 40 ZEBETA
see bisoprolol fumarate . 16 ZEGERID .......................... 40 ZELAPAR ......................... 23 ZELBORAF ....................... 13 ZEMAIRA .......................... 48 ZEMPLAR ......................... 45
see paricalcitol .............. 45
zenatane ........................... 50 zenchent fe 28 day ........... 34 zenchent tab ..................... 34 ZENPEP ........................... 39 ZERBAXA ........................... 9 ZERIT
see stavudine .................. 7 ZESTORETIC
see lisinopril & hydrochlorothiazide ....... 14
ZESTRIL see lisinopril .................. 14
ZETIA TAB 10MG ............. 16 ZETONNA ........................ 48 ZIAC
see bisoprolol & hydrochlorothiazide ....... 16
ZIAGEN .............................. 7 see abacavir sulfate ........ 7
ZIANA ............................... 50 zidovudine .......................... 7 ZINACEF ............................ 9
see cefuroxime sodium ... 9 ZINECARD
see dexrazoxane ........... 13 ZIOPTAN .......................... 47 ziprasidone hcl .................. 25 ZIPSOR .............................. 1 ZIRGAN ............................ 46 ZITHROMAX
see azithromycin ............. 9 ZMAX .................................. 9 ZOCOR
see simvastatin ............. 15 ZOFRAN
see ondansetron hcl ...... 37 see ondansetron hcl inj . 37 see ondansetron hcl oral soln ............................... 37
ZOFRAN ODT see ondansetron odt ..... 37
ZOHYDRO ER (ABUSE DETERRENT)..................... 5 zoledronic inj 4mg/5ml ...... 32 zoledronic inj 5/100ml ....... 32 ZOLINZA .......................... 12 zolmitriptan ....................... 27 zolmitriptan odt ................. 27
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ZOLOFT see sertraline hcl ........... 22
zolpidem tartrate ............... 26 ZOMACTON ..................... 36 ZOMETA ........................... 32
see zoledronic inj 4mg/5ml ...................................... 32
ZOMIG see zolmitriptan ............. 27
ZOMIG NASAL SPRAY .... 27 ZOMIG ZMT
see zolmitriptan odt ....... 27 ZONEGRAN
see zonisamide ............. 21 zonisamide ........................ 21 ZONTIVITY ....................... 42 ZORBTIVE ........................ 36 ZORTRESS TAB 0.25MG . 43 ZORTRESS TAB 0.5MG ... 43 ZORTRESS TAB 0.75MG . 43
ZORVOLEX ........................ 1 ZOSTAVAX ....................... 43 ZOSYN ............................. 10
see piperacillin sodium-tazobactam sodium ........................... 10
zovia 1/35e 28 day ............ 34 zovia 1/50e 28 day ............ 34 ZOVIRAX .......................... 52
see acyclovir ................... 8 see acyclovir topical ...... 52
ZUBSOLV SUB 1.4-0.36MG .......................................... 29 ZUBSOLV SUB 5.7-1.4MG .......................................... 29 ZUBSOLV SUB 8.6-2.1MG .......................................... 29 ZUPLENZ ......................... 38 ZYBAN
see buproban ................ 29
ZYCLARA ......................... 52 ZYDELIG .......................... 13 ZYFLO CR ........................ 48 ZYKADIA .......................... 13 ZYLET .............................. 45 ZYLOPRIM
see allopurinol tab ........... 1 ZYMAXID
see gatifloxacin (ophth) . 46 ZYPREXA
see olanzapine .............. 24 ZYPREXA RELPREVV ..... 25 ZYPREXA RELPREVV INJ 210MG .............................. 25 ZYPREXA ZYDIS
see olanzapine odt ........ 24 ZYTIGA ............................. 12 ZYVOX ............................... 6
see linezolid .................... 6