drug name drug requirements/ drug name drug ......drug name drug tier requirements/ limits...

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersAmphetaminesamphetamine-dextroamphetamine cp245mg-5mg-5mg-5mg,2.5mg-2.5mg-2.5mg-2.5mg, 7.5mg-7.5mg-7.5mg-7.5mg, 1.25mg-1.25mg-1.25mg-1.25mg,3.75mg-3.75mg-3.75mg-3.75mg, 6.25mg-6.25mg-6.25mg-6.25mg

F

PA; QL(2 eadaily)

amphetamine-dextroamphetamine tabs5mg-5mg-5mg-5mg,2.5mg-2.5mg-2.5mg-2.5mg, 7.5mg-7.5mg-7.5mg-7.5mg, 1.25mg-1.25mg-1.25mg-1.25mg,3.75mg-3.75mg-3.75mg-3.75mg, 1.875mg-1.875mg-1.875mg-1.875mg, 3.125mg-3.125mg-3.125mg-3.125mg

F

PA

dextroamphetamine sulfatecp24 F PA

dextroamphetamine sulfatesoln F PA

dextroamphetamine sulfatetabs F PA

VYVANSE CAPS F PA

VYVANSE CHEW F PA

Anorexiants Non-AmphetamineQSYMIA CP24 F PA

Anti-Obesity AgentsALLI CAPS F PA

BELVIQ TABS F PA

BELVIQ XR TB24 F PA

Drug Name DrugTier

Requirements/Limits

XENICAL CAPS F PA

Attention-Deficit/Hyperactivity Disorder (ADHD)atomoxetine hcl caps F PA

guanfacine hcl (adhd) tb24 F PA

Stimulants - Misc.armodafinil tabs 150 mg,200 mg, 250 mg F PA; QL(1 ea

daily)

armodafinil tabs 50 mg F PA; QL(2 eadaily)

methylphenidate hcl chew5 mg, 10 mg, 2.5 mg F PA

methylphenidate hcl cp2410 mg, 20 mg, 30 mg, 40mg, 60 mg

FPA

methylphenidate hcl cpcr10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg

FPA; QL(1 eadaily)

methylphenidate hcl soln 5mg/5ml, 10 mg/5ml F PA

methylphenidate hcl tabs 5mg, 10 mg, 20 mg F PA

methylphenidate hcl tbcr 10mg F PA

methylphenidate hcl tbcr 18mg, 20 mg, 27 mg, 54 mg F PA; QL(1 ea

daily)methylphenidate hcl tbcr 36mg F PA; QL(2 ea

daily)

modafinil tabs F PA; QL(2 eadaily)

QUILLIVANT XR SUSR F PA

AMINOGLYCOSIDES - Drugs to Treat BacterialInfectionsAminoglycosidesneomycin sulfate tabs F

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditionsGold CompoundsRIDAURA CAPS F PA

Workforce Safety & Insurance Preferred Drug List Updated October 1, 2019QL - Quantity Limit (There is a limit on the amount of drug covered per prescription, or within aspecific time frame); PA - Prior Authorization (Prior Authorization required before prescription canbe filled)

0

Drug Name DrugTier

Requirements/Limits

Nonsteroidal Anti-inflammatory Agents (NSAIDs)celecoxib caps F QL(2 ea daily)

diclofenac potassium tabs50 mg F

diclofenac sodium tb24 F

diclofenac sodium tbec F

diclofenac w/ misoprostoltbec F

etodolac caps F

etodolac tabs F

etodolac tb24 F

FENOPROFEN CALCIUMCAPS 200 MG, 400 MG F

fenoprofen calcium tabs600 mg F

FENORTHO CAPS F

flurbiprofen tabs F

ibuprofen caps 200 mg F

ibuprofen chew 100 mg F

ibuprofen susp 100 mg/5ml F RX/OTC

ibuprofen susp 40 mg/ml,50 mg/1.25ml F

ibuprofen tabs 100 mg, 200mg, 400 mg, 600 mg, 800mg

F

INDOCIN SUSP F

indomethacin caps F

indomethacin cpcr F

ketoprofen caps 50 mg, 75mg F

KETOPROFEN CAPS 75MG F

KETOPROFEN ER CP24 F

Drug Name DrugTier

Requirements/Limits

ketorolac tromethaminetabs 10 mg F QL(4 ea daily)

MECLOFENAMATESODIUM CAPS F

meloxicam tabs F QL(2 ea daily)

nabumetone tabs F

NALFON CAPS 400 MG F

NAPRELAN TB24 750 MG F

naproxen sodium caps F

naproxen sodium tabs F

naproxen sodium tb24 F

naproxen susp F

naproxen tabs F

naproxen tbec F

oxaprozin tabs 600 mg F QL(2 ea daily)

piroxicam caps F

sulindac tabs F

TOLMETIN SODIUMCAPS F

TOLMETIN SODIUM TABS F

Phosphodiesterase 4 (PDE4) InhibitorsOTEZLA TABS F PA

OTEZLA TBPK F PA

Pyrimidine Synthesis Inhibitors

leflunomide tabs F PA; QL(1 eadaily)

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint ConditionsAnalgesic Combinationsacetaminophen-caffeinetabs 500mg-65mg F


1

Drug Name DrugTier

Requirements/Limits

butalbital-acetaminophentabs 325mg-50mg F

butalbital-acetaminophen-caffeine tabs 325mg-50mg-40mg

F

butalbital-aspirin-caffeinecaps 50mg-40mg-325mg F

TENCON TABS 325MG-50MG F

Analgesics Otheracetaminophen caps or500 mg F

acetaminophen liqd or 160mg/5ml, 500 mg/15ml,1000 mg/30ml

F

acetaminophen supp re120 mg, 325 mg, 650 mg F

acetaminophen tabs or 325mg, 500 mg F

acetaminophen tbcr or 650mg F

acetaminophen tbdp or 80mg, 160 mg F

FEVERALL INFANTSSUPP F

FEVERALL JUNIORSTRENGTH SUPP F

SalicylatesASCRIPTIN MAXIMUMSTRENGTH TABS F

aspirin buffered (cal carb-mag carb-mag oxide) tabs F

aspirin chew or 81 mg F

aspirin supp re 300 mg,600 mg F

ASPIRIN SUPP RE 300MG, 600 MG F

aspirin tabs or 325 mg, 500mg F

aspirin tbec or 81 mg, 324mg, 325 mg, 500 mg F

BUFFERIN EXTRASTRENGTH TABS F

Drug Name DrugTier

Requirements/Limits

BUFFERIN LOW DOSETABS F

choline & mag salicylateliqd F

diflunisal tabs F

salsalate tabs F

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint ConditionsOpioid Agonists

ABSTRAL SUBL F PA; QL(1 eadaily)

ARYMO ER TBEA F PA

CODEINE SULFATE TABS15 MG, 60 MG F

codeine sulfate tabs 30 mg,60 mg F

EMBEDA CPCR F PA

fentanyl citrate lpop 200mcg, 400 mcg, 600 mcg,800 mcg, 1200 mcg, 1600mcg

F

PA; QL(1 eadaily)

FENTANYL CITRATETABS 100 MCG, 200 MCG,400 MCG, 600 MCG, 800MCG

F

PA; QL(1 eadaily)

fentanyl pt72 12 mcg/hr, 25mcg/hr, 50 mcg/hr, 75mcg/hr, 100 mcg/hr

FPA; QL(0.5 eadaily)

FENTORA TABS F PA; QL(1 eadaily)

hydromorphone hcl liqd or1 mg/ml F

HYDROMORPHONE HCLSUPP RE 3 MG F

hydromorphone hcl t24a or8 mg, 12 mg, 16 mg, 32 mg F PA; QL(1 ea

daily)hydromorphone hcl tabs or2 mg, 4 mg, 8 mg F

HYSINGLA ER T24A FPA; QL(1 eadaily,30 ea per30 days retail)

KADIAN CP24 200 MG F PA


2

Drug Name DrugTier

Requirements/Limits

levorphanol tartrate tabs F

methadone hcl conc 10mg/ml F PA

methadone hcl soln 5mg/5ml, 10 mg/5ml F PA

methadone hcl tabs 5 mg,10 mg F PA

methadone hcl tbso 40 mg F PA

morphine sulfate cp24 or10 mg, 20 mg, 30 mg, 50mg, 60 mg, 80 mg, 100 mg

FPA

MORPHINE SULFATE ERCP24 F PA; QL(1 ea

daily)morphine sulfate soln or 20mg/ml, 10 mg/5ml, 20mg/5ml, 100 mg/5ml

F

MORPHINE SULFATESUPP RE 5 MG, 10 MG,20 MG, 30 MG

F

morphine sulfate tabs or 15mg, 30 mg F

morphine sulfate tbcr or 15mg, 30 mg, 60 mg, 100 mg,200 mg

FPA

NUCYNTA ER TB12 FPA; QL(2 eadaily,60 ea per30 days retail)

NUCYNTA TABS F

OPANA ER (CRUSHRESISTANT) T12A F PA; QL(3 ea

daily)

oxycodone hcl caps 5 mg F

oxycodone hcl conc 100mg/5ml F

OXYCODONE HCL ERT12A 10 MG, 15 MG, 20MG, 30 MG, 40 MG, 60 MG

FPA; QL(3 eadaily)

OXYCODONE HCL ERT12A 80 MG F PA; QL(6 ea

daily)oxycodone hcl soln 5mg/5ml F

oxycodone hcl tabs 5 mg,10 mg, 15 mg, 20 mg F

Drug Name DrugTier

Requirements/Limits

OXYCODONEHYDROCHLORIDE ERT12A

FPA; QL(3 eadaily)

OXYCONTIN T12A 10 MG,15 MG, 20 MG, 30 MG, 40MG, 60 MG

FPA; QL(3 eadaily)

OXYCONTIN T12A 80 MG F PA; QL(6 eadaily)

oxymorphone hcl tabs F

OXYMORPHONEHYDROCHLORIDE ERTB12

FPA; QL(3 eadaily)

OXYMORPHONEHYDROCHLORIDEERTB12

FPA; QL(3 eadaily)

tramadol hcl tabs 50 mg F QL(8 ea daily)

tramadol hcl tb24 100 mg,200 mg, 300 mg F

PA; QL(1 eadaily,30 ea per30 days retail)

XTAMPZA ER C12A F PA; QL(2 eadaily)

ZOHYDRO ER C12A F PA

Opioid Combinationsacetaminophen w/ codeinesoln F

acetaminophen w/ codeinetabs F

butalbital-acetaminophen-caffeine w/ codeine caps F

butalbital-aspirin-caffeinew/cod caps 50mg-40mg-30mg-325mg

F

HYDROCODONEBITARTRATE/ACETAMINOPHEN SOLN

FPA

hydrocodone-acetaminophen tabs 5mg-325mg, 10mg-325mg,2.5mg-325mg, 7.5mg-325mg

F

hydrocodone-ibuprofentabs 200mg-7.5mg F

LORTAB ELIX F PA


3

Drug Name DrugTier

Requirements/Limits

NALOCET TABS F PA

oxycodone w/acetaminophen tabs F

OXYCODONE/ACETAMINOPHEN SOLN F

OXYCODONE/IBUPROFEN TABS F

PRIMLEV TABS F PA

tramadol-acetaminophentabs 37.5mg-325mg F QL(10 ea daily)

ZAMICET SOLN F PA

Opioid Partial Agonistsbuprenorphine ptwk 5mcg/hr, 10 mcg/hr, 15mcg/hr, 20 mcg/hr


BUPRENORPHINE PTWK5 MCG/HR, 10 MCG/HR,15 MCG/HR, 20 MCG/HR,7.5 MCG/HR

F

PA; QL(0.15 eadaily)

butorphanol tartrate soln F QL(0.17 mldaily)

BUTRANS PTWK 7.5MCG/HR F PA; QL(0.15 ea

daily)pentazocine w/ naloxonetabs F

ANDROGENS-ANABOLIC - Drugs to RegulateHormonesAnabolic Steroidsoxandrolone tabs F PA

AndrogensANDRODERM PT24 F PA

danazol caps F PA

NATESTO GEL F PA

testosterone gel 1 %, 1.62%, 50 mg/5gm, 25mg/2.5gm, 40.5 mg/2.5gm,20.25 mg/1.25gm

F

PA

Drug Name DrugTier

Requirements/Limits

TESTOSTERONE GEL 1%, 50 MG/5GM, 25MG/2.5GM

FPA

TESTOSTERONE PUMPGEL F PA

VOGELXO GEL F PA

VOGELXO PUMP GEL F PA

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial InfectionsAnti-infective Agents - Misc.metronidazole caps F

metronidazole tabs F

NEBUPENT SOLR F PA

tinidazole tabs F PA

trimethoprim tabs F

XIFAXAN TABS F PA

Anti-infective Misc. - Combinationssulfamethoxazole-trimethoprim susp F

sulfamethoxazole-trimethoprim tabs F

Antiprotozoal AgentsALINIA SUSR F PA

ALINIA TABS F PA

atovaquone susp 750mg/5ml F PA

GlycopeptidesFIRST-VANCOMYCIN 25SOLN F

FIRST-VANCOMYCIN 50SOLN F

VANCOMYCIN HCL +SYRSPENDSF PH4 SUSP F

Leprostaticsdapsone tabs F PA


4

Drug Name DrugTier

Requirements/Limits

Lincosamidesclindamycin hcl caps F

clindamycin palmitatehydrochloride solr 75mg/5ml

F

Oxazolidinoneslinezolid susr 100 mg/5ml F PA

linezolid tabs 600 mg F PA; QL(2 eadaily)

SIVEXTRO TABS F PA; QL(1 eadaily)

ANTIANGINAL AGENTS - Drugs to Treat ChestPainAntianginals-Otherranolazine tb12 F PA

NitratesISORDIL TITRADOSETABS 40 MG F PA

ISOSORBIDE DINITRATEER TBCR F PA

ISOSORBIDE DINITRATETABS 30 MG F PA

isosorbide dinitrate tabs 5mg, 10 mg, 20 mg F PA

isosorbide mononitratetabs 10 mg, 20 mg F PA

isosorbide mononitratetb24 120 mg F PA; QL(3 ea

daily)isosorbide mononitratetb24 30 mg, 60 mg F PA; QL(1.5 ea

daily)

NITRO-BID OINT F PA

NITRO-DUR PT24 0.3MG/HR, 0.8 MG/HR F PA

NITRO-TIME CPCR F PA

nitroglycerin cpcr F PA

NITROGLYCERINLINGUAL AERS F PA

nitroglycerin pt24 F PA

Drug Name DrugTier

Requirements/Limits

nitroglycerin soln F PA

nitroglycerin subl F PA

NITROMIST AERS F PA

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.buspirone hcl tabs F PA

HYDROXYZINE HCLSOLN IM 25 MG/ML F

hydroxyzine hcl syrp or 10mg/5ml F

hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg F

HYDROXYZINEPAMOATE CAPS 100 MG F

hydroxyzine pamoate caps25 mg, 50 mg F

BenzodiazepinesALPRAZOLAM INTENSOLCONC F

alprazolam tabs 0.25 mg,0.5 mg, 1 mg, 2 mg F

alprazolam tb24 0.5 mg, 1mg, 2 mg, 3 mg F

chlordiazepoxide hcl caps F

clorazepate dipotassiumtabs F

diazepam conc 5 mg/ml F

DIAZEPAM SOLN 5MG/5ML F

diazepam tabs 2 mg, 5 mg,10 mg F

lorazepam conc F

lorazepam tabs F

oxazepam caps 10 mg, 15mg, 30 mg F

OXAZEPAM CAPS 10 MG,15 MG, 30 MG F


5

Drug Name DrugTier

Requirements/Limits

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythmsAntiarrhythmics Type I-Adisopyramide phosphatecaps F PA

NORPACE CR CP12 F PA

quinidine gluconate tbcr F PA

QUINIDINE SULFATETABS F PA

Antiarrhythmics Type I-BMEXILETINE HCL CAPS150 MG, 200 MG, 250 MG F PA

mexiletine hcl caps 200mg, 250 mg F PA

Antiarrhythmics Type I-Cflecainide acetate tabs F PA

Antiarrhythmics Type IIIamiodarone hcl tabs 200mg F PA

dofetilide caps F PA

ANTIASTHMATIC AND BRONCHODILATORAGENTS - Drugs to Treat Lung ConditionsAnti-Inflammatory Agentscromolyn sodium nebu F PA

Antiasthmatic - Monoclonal AntibodiesCINQAIR SOLN F PA

NUCALA SOLR 100 MG F PA

Asthma and Bronchodilator Agent Combinationsdyphylline-guaifenesin liqd F PA

Bronchodilators - AnticholinergicsATROVENT HFA AERS F PA

ipratropium bromide soln F PA

SEEBRI NEOHALERCAPS F PA

Drug Name DrugTier

Requirements/Limits

SPIRIVA HANDIHALERCAPS F PA

SPIRIVA RESPIMATAERS F PA

TUDORZA PRESSAIRAEPB F PA

Leukotriene Modulators

montelukast sodium chew F PA; QL(1 eadaily)

montelukast sodium pack F PA; QL(1 eadaily)

montelukast sodium tabs F PA; QL(1 eadaily)

zafirlukast tabs F PA

zileuton tb12 600 mg F PA

ZYFLO TABS 600 MG F PA

Steroid InhalantsALVESCO AERS F PA

ASMANEX TWISTHALER120 METERED DOSESAEPB

FPA


FPA


FPA


FPA


FPA

budesonide (inhalation)susp F PA

FLOVENT DISKUS AEPB F PA; QL(4 eadaily)

FLOVENT HFA AERO F PA; QL(0.87gm daily)

PULMICORT FLEXHALERAEPB F PA


6

Drug Name DrugTier

Requirements/Limits

QVAR AERS F PA

QVAR REDIHALER AERB F PA

SympathomimeticsADVAIR HFA AERO F PA

ALBUTEROL SULFATEER TB12 F PA

ALBUTEROL SULFATEHFA AERS F PA; QL(1.5 gm

daily)

albuterol sulfate nebu F PA

albuterol sulfate syrp F PA

albuterol sulfate tabs F PA

albuterol sulfate tb12 F PA

ANORO ELLIPTA AEPB F PA

BREO ELLIPTA AEPB F PA

BROVANA NEBU F PA

COMBIVENT RESPIMATAERS F PA; QL(0.98

gm daily)

fluticasone-salmeterol aepb F PA; QL(2 eadaily)

ipratropium-albuterol soln F PA

levalbuterol hcl nebu F PA

LEVALBUTEROLTARTRATE HFA AERO F PA

METAPROTERENOLSULFATE SYRP F PA

METAPROTERENOLSULFATE TABS F PA

PERFOROMIST NEBU F PA

PROAIR HFA AERS F PA; QL(1.5 gmdaily)

PROAIR RESPICLICKAEPB F PA

PROVENTIL HFA AERS F PA; QL(1.5 gmdaily)

Drug Name DrugTier

Requirements/Limits

SEREVENT DISKUSAEPB F PA; QL(4 ea

daily)STRIVERDI RESPIMATAERS F PA

SYMBICORT AERO F PA

terbutaline sulfate tabs F PA

TRELEGY ELLIPTA AEPB F PA

UTIBRON NEOHALERCAPS F PA

VENTOLIN HFA AERS F PA; QL(1.5 gmdaily)

XOPENEX HFA AERO F PA

XanthinesELIXOPHYLLIN ELIX F PA

THEO-24 CP24 F PA

THEOCHRON TB12 F PA

THEOPHYLLINE ER TB12 F PA

theophylline soln F PA

theophylline tb12 F PA

theophylline tb24 F PA

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulantswarfarin sodium tabs F

Direct Factor Xa InhibitorsELIQUIS STARTER PACKTABS F PA

ELIQUIS TABS F PA

XARELTO STARTERPACK TBPK F PA

XARELTO TABS F PA

Heparins And Heparinoid-Like Agents


7

Drug Name DrugTier

Requirements/Limits

enoxaparin sodium soln F

fondaparinux sodium soln F

FRAGMIN SOLN F

HEPARIN LOCK FLUSHSOLN F PA

heparin sodium (porcine)lock flush soln F PA

heparin sodium (porcine)soln F

Thrombin InhibitorsPRADAXA CAPS F PA

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor AntagonistsFYCOMPA SUSP F PA

FYCOMPA TABS F PA

Anticonvulsants - Benzodiazepinesclobazam susp F PA

clobazam tabs F PA

clonazepam tabs F

clonazepam tbdp F

DIASTAT ACUDIAL GEL F

DIASTAT PEDIATRIC GEL F

DIAZEPAM RECTAL GELGEL F

Anticonvulsants - Misc.APTIOM TABS F PA

carbamazepine chew F PA

carbamazepine cp12 F PA

carbamazepine susp F PA

Drug Name DrugTier

Requirements/Limits

carbamazepine tabs F PA

carbamazepine tb12 F PA

gabapentin caps F

gabapentin soln F

gabapentin tabs F

LAMICTAL ODT KIT F PA

LAMICTAL XR KIT F PA

lamotrigine chew F PA

lamotrigine kit F PA

lamotrigine tabs F PA

lamotrigine tb24 F PA

lamotrigine tbdp F PA

levetiracetam soln F

levetiracetam tabs F

levetiracetam tb24 F

oxcarbazepine susp F PA

oxcarbazepine tabs F PA

pregabalin caps 225 mg,300 mg F QL(2 ea daily)

pregabalin caps 25 mg, 50mg, 75 mg, 100 mg, 150mg, 200 mg

FQL(3 ea daily)

pregabalin soln 20 mg/ml F

primidone tabs F PA

QUDEXY XR CS24 F PA

topiramate cpsp F PA

TOPIRAMATE ER CS24 F PA


8

Drug Name DrugTier

Requirements/Limits

topiramate tabs F PA

VIMPAT SOLN F PA

VIMPAT TABS F PA

zonisamide caps F PA

Carbamatesfelbamate susp F PA

felbamate tabs F PA

GABA Modulatorstiagabine hcl tabs F PA

HydantoinsDILANTIN CAPS 30 MG F PA

phenytoin chew F PA

phenytoin sodium extendedcaps F PA

phenytoin susp F PA

SuccinimidesCELONTIN CAPS F PA

ethosuximide caps F PA

ethosuximide soln F PA

Valproic Aciddivalproex sodium csdr F PA

divalproex sodium tb24 F PA

valproate sodium soln 250mg/5ml F PA

valproic acid caps 250 mg F PA

ANTIDEPRESSANTS - Drugs to TreatDepressionAlpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tabs F PA; QL(1 eadaily)

Drug Name DrugTier

Requirements/Limits

mirtazapine tbdp F PA; QL(1 eadaily)

Antidepressants - Misc.bupropion hcl tabs 75 mg,100 mg F PA

bupropion hcl tb12 100 mg,150 mg, 200 mg F PA; QL(2 ea

daily)bupropion hcl tb24 150 mg,300 mg F PA; QL(1 ea

daily)Monoamine Oxidase Inhibitors (MAOIs)MARPLAN TABS F PA

phenelzine sulfate tabs 15mg F PA

tranylcypromine sulfatetabs 10 mg F PA

Selective Serotonin Reuptake Inhibitors (SSRIs)citalopram hydrobromidesoln 10 mg/5ml F PA

citalopram hydrobromidetabs 10 mg, 20 mg, 40 mg F PA; QL(1 ea

daily)escitalopram oxalate soln 5mg/5ml F PA; QL(20 ml

daily)escitalopram oxalate tabs10 mg F PA; QL(1.5 ea

daily)escitalopram oxalate tabs 5mg, 20 mg F PA; QL(1 ea

daily)

FLUOXETINE DR CPDR F PA; QL(0.14 eadaily)

fluoxetine hcl caps 10 mg F PA; QL(1 eadaily)

fluoxetine hcl caps 20 mg,40 mg F PA; QL(2 ea

daily)fluoxetine hcl soln 20mg/5ml F PA

fluoxetine hcl tabs 10 mg,60 mg F PA; QL(1 ea

daily)

fluoxetine hcl tabs 20 mg F PA; QL(2 eadaily)

fluvoxamine maleate tabs25 mg, 50 mg, 100 mg F PA

paroxetine hcl tabs 10 mg,20 mg, 30 mg F PA; QL(1 ea

daily)

paroxetine hcl tabs 40 mg F PA; QL(2 eadaily)


9

Drug Name DrugTier

Requirements/Limits

paroxetine hcl tb24 12.5mg, 37.5 mg F PA; QL(1 ea

daily)

paroxetine hcl tb24 25 mg F PA; QL(2 eadaily)

PAXIL SUSP 10 MG/5ML F PA

sertraline hcl conc 20mg/ml F PA

sertraline hcl tabs 100 mg F PA; QL(2 eadaily)

sertraline hcl tabs 25 mg F PA; QL(1 eadaily)

sertraline hcl tabs 50 mg F PA; QL(1.5 eadaily)

Serotonin Modulatorstrazodone hcl tabs F

Serotonin-Norepinephrine Reuptake Inhibitorsdesvenlafaxine succinatetb24 F PA

duloxetine hcl cpep 20 mg,30 mg, 60 mg F QL(2 ea daily)

FETZIMA CP24 F PA; QL(1 eadaily)

FETZIMA TITRATIONPACK C4PK F PA

venlafaxine hcl cp24 F

venlafaxine hcl tabs F

venlafaxine hcl tb24 F

Tricyclic Agentsamitriptyline hcl tabs F

clomipramine hcl caps F PA

desipramine hcl tabs F

doxepin hcl caps 10 mg, 25mg, 50 mg, 75 mg, 100 mg,150 mg

F

DOXEPIN HCL CAPS 150MG F

doxepin hcl conc 10 mg/ml F

Drug Name DrugTier

Requirements/Limits

imipramine hcl tabs F

nortriptyline hcl caps 10mg, 25 mg, 50 mg, 75 mg F

NORTRIPTYLINE HCLSOLN 10 MG/5ML F

nortriptyline hcl soln 10mg/5ml F

ANTIDIABETICS - Drugs to Regulate BloodSugarAlpha-Glucosidase Inhibitorsacarbose tabs F PA

miglitol tabs F PA

Antidiabetic - Amylin AnalogsSYMLINPEN 120 SOPN F PA

SYMLINPEN 60 SOPN F PA

Antidiabetic CombinationsACTOPLUS MET XR TB24 F PA

ALOGLIPTIN/METFORMINHCL TABS F PA

ALOGLIPTIN/PIOGLITAZONE TABS F PA

glipizide-metformin hcl tabs F PA

glyburide-metformin tabs F PA

GLYXAMBI TABS F PA

INVOKAMET TABS F PA

INVOKAMET XR TB24 F PA

JANUMET TABS F PA

JANUMET XR TB24 F PA

JENTADUETO XR TB24 F PA

KAZANO TABS F PA

KOMBIGLYZE XR TB24 F PA


10

Drug Name DrugTier

Requirements/Limits

OSENI TABS F PA

pioglitazone hcl-glimepiridetabs F PA

pioglitazone hcl-metforminhcl tabs F PA

SYNJARDY TABS F PA

SYNJARDY XR TB24 F PA

XIGDUO XR TB24 F PA

Biguanidesmetformin hcl tabs 500 mg,850 mg, 1000 mg F PA

metformin hcl tb24 500 mg,750 mg, 1000 mg F PA

METFORMINHYDROCHLORIDE SOLN F PA

RIOMET SOLN F PA

Dipeptidyl Peptidase-4 (DPP-4) InhibitorsALOGLIPTIN TABS F PA

JANUVIA TABS F PA

NESINA TABS F PA

ONGLYZA TABS F PA

TRADJENTA TABS F PA

Incretin Mimetic Agents (GLP-1 ReceptorBYDUREON PEN PEN F PA

BYDUREON SRER F PA

BYETTA SOPN F PA

TANZEUM PEN F PA

VICTOZA SOPN F PA

Insulin Sensitizing Agents

AVANDIA TABS F PA; QL(2 eadaily)

Drug Name DrugTier

Requirements/Limits

pioglitazone hcl tabs F PA; QL(1 eadaily)

InsulinADMELOG SOLN F PA

APIDRA SOLN F PA

HUMALOG KWIKPENSOPN F PA

HUMALOG MIX 50/50SUSP F PA

HUMALOG MIX 75/25SUSP F PA

HUMALOG SOLN F PA

HUMULIN 70/30 SUSP F PA

HUMULIN N SUSP F PA

HUMULIN R SOLN F PA

HUMULIN R U-500(CONCENTRATED) SOLN F PA

HUMULIN R U-500KWIKPEN SOPN F PA

INSULIN LISPRO SOLN F PA

LANTUS SOLN F PA

LEVEMIR SOLN F PA

NOVOLIN 70/30 RELIONSUSP F PA

NOVOLIN 70/30 SUSP F PA

NOVOLIN N RELIONSUSP F PA

NOVOLIN N SUSP F PA

NOVOLIN R RELIONSOLN F PA

NOVOLIN R SOLN F PA

NOVOLOG MIX 70/30SUSP F PA

NOVOLOG SOLN F PA


11

Drug Name DrugTier

Requirements/Limits

TRESIBA FLEXTOUCHSOPN F PA

Meglitinide Analoguesnateglinide tabs F PA

repaglinide tabs F PA

Sodium-Glucose Co-Transporter 2 (SGLT2)FARXIGA TABS F PA

INVOKANA TABS F PA

JARDIANCE TABS F PA

Sulfonylureasglimepiride tabs 1 mg, 2mg F PA; QL(1.5 ea

daily)

glimepiride tabs 4 mg F PA; QL(2 eadaily)

glipizide tabs F PA

glipizide tb24 F PA

glyburide micronized tabs F PA

glyburide tabs F PA

ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugsto Treat DiarrheaAntidiarrheal/Probiotic Agents - Misc.bismuth subsalicylate chew F PA

bismuth subsalicylate susp F PA

bismuth subsalicylate tabs F PA

CULTURELLE DIGESTIVEHEALTH WOMENSHEALTHY BALANCECAPS

F

PA

FLORAJEN ACIDOPHILUSCAPS F PA

LACTO-BIFIDUS-600CAPS F PA

lactobacillus caps F PA

Drug Name DrugTier

Requirements/Limits

lactobacillus pack F PA

lactobacillus rhamnosus(gg) caps F PA

lactobacillus tabs F PA

PROBIOTIC CAPS F PA

PROBIOTIC GOLD EXTRASTRENGTH CAPS F PA

REPHRESH PRO-B CAPS F PA

Antidiarrheal/Probiotic Combinationsloperamide-simethiconetabs 2mg-125mg F PA

Antiperistaltic Agentsdiphenoxylate w/ atropinetabs F PA

DIPHENOXYLATE/ATROPINE LIQD F PA

loperamide hcl caps 2 mg F PA; RX/OTC

loperamide hcl liqd 1mg/5ml, 1 mg/7.5ml F PA

loperamide hcl susp 1mg/7.5ml F PA

loperamide hcl tabs 2 mg F PA

MOTOFEN TABS F PA

ANTIEMETICS - Drugs to Treat Nausea andVomiting5-HT3 Receptor AntagonistsANZEMET TABS F PA

granisetron hcl tabs F PA

ondansetron hcl soln 4mg/5ml F PA

ondansetron hcl tabs 24mg F PA

ondansetron hcl tabs 4 mg,8 mg F

ondansetron tbdp F


12

Drug Name DrugTier

Requirements/Limits

SANCUSO PTCH F PA

Antiemetics - Anticholinergicdimenhydrinate tabs 50 mg F

DRAMAMINE CHEW 50MG F

meclizine hcl chew 25 mg F

meclizine hcl tabs 25 mg,12.5 mg F RX/OTC

scopolamine pt72 1mg/3days F

trimethobenzamide hclcaps 300 mg F

Antiemetics - MiscellaneousCESAMET CAPS F PA

COCA COLA SYRUPSYRP F

dronabinol caps F PA

Substance P/Neurokinin 1 (NK1) Receptor

aprepitant caps F PA; QL(1 eadaily)

EMEND SUSR 125 MG F PA; QL(5 eadaily)

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungalsgriseofulvin microsize susp F

griseofulvin microsize tabs F

nystatin tabs 500000 unit F PA

terbinafine hcl tabs 250 mg F

Imidazole-Related Antifungalsfluconazole susr 40 mg/ml F

fluconazole tabs 50 mg,100 mg, 150 mg, 200 mg F

itraconazole caps 100 mg F PA

Drug Name DrugTier

Requirements/Limits

ketoconazole tabs F PA

NOXAFIL SUSP 40 MG/ML F PA

posaconazole tbec F PA

voriconazole susr F PA

voriconazole tabs F PA

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamineschlorpheniramine maleatetabs 4 mg F PA

Antihistamines - EthanolaminesALER-DRYL TABS F PA

diphenhydramine hcl caps25 mg, 50 mg F PA

diphenhydramine hcl liqd25 mg/10ml, 50 mg/20ml,12.5 mg/5ml

FPA

diphenhydramine hcl tbdp12.5 mg F PA

Antihistamines - Non-SedatingALLEGRA ALLERGYCHILDRENS TBDP 30 MG F PA; QL(1 ea

daily)

cetirizine hcl caps 10 mg F PA

cetirizine hcl chew 5 mg, 10mg F PA; QL(1 ea

daily)cetirizine hcl soln 1 mg/ml,5 mg/5ml F PA; RX/OTC

cetirizine hcl syrp 1 mg/ml,5 mg/5ml F PA; RX/OTC

cetirizine hcl tabs 5 mg, 10mg F PA; QL(1 ea

daily)CLARITIN REDITABSTBDP 5 MG F PA; QL(1 ea

daily)fexofenadine hcl susp 30mg/5ml F PA

fexofenadine hcl tabs 180mg F PA; QL(1 ea

daily)fexofenadine hcl tabs 60mg F PA; QL(2 ea

daily)


13

Drug Name DrugTier

Requirements/Limits

loratadine caps 10 mg F PA; QL(1 eadaily)

loratadine chew 5 mg F PA; QL(1 eadaily)

loratadine soln 5 mg/5ml F PA

loratadine syrp 5 mg/5ml F PA

loratadine tabs 10 mg F PA; QL(1 eadaily)

loratadine tbdp 10 mg F PA; QL(1 eadaily)

Antihistamines - Phenothiazinespromethazine hcl soln F PA

promethazine hcl supp F PA

promethazine hcl syrp F PA

promethazine hcl tabs F PA

Antihistamines - Piperidinescyproheptadine hcl syrp F PA

cyproheptadine hcl tabs F PA

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterolAntihyperlipidemics - Combinationsezetimibe-simvastatin tabs F PA

Antihyperlipidemics - Misc.omega-3-acid ethyl esterscaps 1gm-465mg-375mg F PA

VASCEPA CAPS F PA

Bile Acid Sequestrantscholestyramine light pack F PA

cholestyramine light powd F PA

cholestyramine pack F PA

cholestyramine powd F PA

Drug Name DrugTier

Requirements/Limits

colesevelam hcl pack F PA

colesevelam hcl tabs F PA

colestipol hcl gran F PA

colestipol hcl pack F PA

colestipol hcl tabs F PA

Fibric Acid Derivativescholine fenofibrate cpdr F PA

FENOFIBRATE CAPS 50MG, 150 MG F PA

fenofibrate micronized caps F PA

FENOFIBRATE TABS 160MG F PA

fenofibrate tabs 40 mg, 48mg, 54 mg, 120 mg, 145mg, 160 mg

FPA

FENOFIBRIC ACID TABS F PA

FIBRICOR TABS 35 MG,105 MG F PA

LIPOFEN CAPS F PA

TRIGLIDE TABS F PA

HMG CoA Reductase InhibitorsALTOPREV TB24 F PA

atorvastatin calcium tabs10 mg, 20 mg, 80 mg F PA; QL(1 ea

daily)atorvastatin calcium tabs40 mg F PA; QL(1.5 ea

daily)lovastatin tabs 10 mg, 20mg F PA; QL(1 ea

daily)

lovastatin tabs 40 mg F PA; QL(2 eadaily)

pravastatin sodium tabs F PA; QL(1 eadaily)

rosuvastatin calcium tabs F PA; QL(1 eadaily)

simvastatin tabs 10 mg F PA; QL(1.5 eadaily)


14

Drug Name DrugTier

Requirements/Limits

simvastatin tabs 5 mg, 20mg, 40 mg, 80 mg F PA; QL(1 ea

daily)Intestinal Cholesterol Absorption Inhibitors

ezetimibe tabs 10 mg F PA; QL(1 eadaily)

Nicotinic Acid Derivativesniacin (antihyperlipidemic)tbcr F PA

ANTIHYPERTENSIVES - Drugs to Treat HighBlood PressureACE Inhibitors

benazepril hcl tabs F PA; QL(2 eadaily)

captopril tabs F PA

enalapril maleate tabs F PA

EPANED SOLN F PA

fosinopril sodium tabs F PA; QL(2 eadaily)

lisinopril tabs F PA; QL(2 eadaily)

moexipril hcl tabs 15 mg F PA

moexipril hcl tabs 7.5 mg F PA; QL(1.5 eadaily)

QBRELIS SOLN F PA

quinapril hcl tabs F PA; QL(2 eadaily)

ramipril caps 10 mg F PA; QL(2 eadaily)

ramipril caps 5 mg, 2.5 mg,1.25 mg F PA; QL(1 ea

daily)trandolapril tabs 1 mg, 2mg F PA; QL(1 ea

daily)

trandolapril tabs 4 mg F PA; QL(2 eadaily)

Agents for PheochromocytomaDEMSER CAPS F PA

phenoxybenzamine hclcaps 10 mg F PA

Angiotensin II Receptor Antagonists

Drug Name DrugTier

Requirements/Limits

candesartan cilexetil tabs32 mg F PA; QL(1 ea

daily)candesartan cilexetil tabs 4mg, 8 mg, 16 mg F PA; QL(1.5 ea

daily)EPROSARTANMESYLATE TABS F PA

irbesartan tabs 150 mg,300 mg F PA; QL(1 ea

daily)

irbesartan tabs 75 mg F PA; QL(1.5 eadaily)

losartan potassium tabs100 mg F PA; QL(1 ea

daily)losartan potassium tabs 25mg, 50 mg F PA; QL(1.5 ea

daily)

olmesartan medoxomil tabs F PA

telmisartan tabs 20 mg, 80mg F PA; QL(1 ea

daily)

telmisartan tabs 40 mg F PA; QL(1.5 eadaily)

valsartan tabs 320 mg F PA

valsartan tabs 40 mg, 80mg, 160 mg F PA; QL(1 ea

daily)Antiadrenergic Antihypertensivesclonidine hcl tabs F

clonidine ptwk F

doxazosin mesylate tabs 1mg, 2 mg, 4 mg F PA; QL(1.5 ea

daily)doxazosin mesylate tabs 8mg F PA; QL(2 ea

daily)

guanfacine hcl tabs F PA

prazosin hcl caps F PA

terazosin hcl caps 1 mg, 5mg F PA; QL(1 ea

daily)terazosin hcl caps 2 mg, 10mg F PA; QL(2 ea

daily)Antihypertensive Combinationsamlodipine besylate-benazepril hcl caps F PA

amlodipine besylate-olmesartan medoxomil tabs F PA


15

Drug Name DrugTier

Requirements/Limits

amlodipine besylate-valsartan tabs F PA

amlodipine-valsartan-hydrochlorothiazide tabs F PA

atenolol & chlorthalidonetabs F PA

benazepril &hydrochlorothiazide tabs F PA; QL(2 ea

daily)bisoprolol &hydrochlorothiazide tabs F PA

BYVALSON TABS F PA

candesartan cilexetil-hydrochlorothiazide tabs16mg-12.5mg


candesartan cilexetil-hydrochlorothiazide tabs32mg-12.5mg

FPA; QL(1 eadaily)

candesartan cilexetil-hydrochlorothiazide tabs32mg-25mg

FPA

CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS F PA

CORZIDE TABS 80MG-5MG F PA

enalapril maleate &hydrochlorothiazide tabs F PA

fosinopril sodium &hydrochlorothiazide tabs F PA

irbesartan-hydrochlorothiazide tabs F PA; QL(1 ea

daily)lisinopril &hydrochlorothiazide tabs10mg-12.5mg

FPA; QL(1 eadaily)

lisinopril &hydrochlorothiazide tabs20mg-25mg, 20mg-12.5mg

FPA

losartan potassium &hydrochlorothiazide tabs F PA; QL(1 ea

daily)METHYLDOPA/HYDROCHLOROTHIAZIDE TABS F PA

metoprolol &hydrochlorothiazide tabs F PA

METOPROLOL/HYDROCHLOROTHIAZIDE TABS F PA

Drug Name DrugTier

Requirements/Limits

moexipril-hydrochlorothiazide tabs F PA

NADOLOL/BENDROFLUMETHIAZIDE TABS F PA

olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs

FPA

olmesartan medoxomil-hydrochlorothiazide tabs F PA

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS F PA

quinapril-hydrochlorothiazide tabs F PA; QL(2 ea

daily)

telmisartan-amlodipine tabs F PA

telmisartan-hydrochlorothiazide tabs40mg-12.5mg


telmisartan-hydrochlorothiazide tabs80mg-12.5mg

FPA; QL(1 eadaily)

telmisartan-hydrochlorothiazide tabs80mg-25mg

FPA

valsartan-hydrochlorothiazide tabs160mg-25mg, 160mg-12.5mg

F

PA; QL(2 eadaily)

valsartan-hydrochlorothiazide tabs320mg-25mg, 80mg-12.5mg, 320mg-12.5mg

F

PA; QL(1 eadaily)

Selective Aldosterone Receptor Antagonistseplerenone tabs F PA

Vasodilatorshydralazine hcl tabs F PA

minoxidil tabs F PA

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections)Antimalarial Combinationsatovaquone-proguanil hcltabs F PA


16

Drug Name DrugTier

Requirements/Limits

COARTEM TABS F PA

AntimalarialsCHLOROQUINEPHOSPHATE TABS 250MG

FPA

chloroquine phosphatetabs 500 mg F PA

hydroxychloroquine sulfatetabs 200 mg F PA

MEFLOQUINE HCL TABS F PA

primaquine phosphate tabs26.3 mg F PA

quinine sulfate caps 324mg F PA

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections)Anti TB CombinationsRIFAMATE CAPS F PA

RIFATER TABS F PA

Antimycobacterial Agentscycloserine caps F PA

ethambutol hcl tabs F PA

ISONIAZID SYRP 50MG/5ML F PA

isoniazid tabs 100 mg, 300mg F PA

pyrazinamide tabs F PA

rifabutin caps 150 mg F PA

rifampin caps F PA

SIRTURO TABS F PA

TRECATOR TABS F PA

ANTIPARKINSON AND RELATED THERAPYAGENTS - Drugs to Treat Parkinson's DiseaseAntiparkinson Adjuvants

Drug Name DrugTier

Requirements/Limits

carbidopa tabs 25 mg F PA

Antiparkinson Anticholinergicsbenztropine mesylate tabs F PA

trihexyphenidyl hcl soln F PA

trihexyphenidyl hcl tabs F PA

Antiparkinson COMT Inhibitorsentacapone tabs 200 mg F PA

Antiparkinson Dopaminergicsamantadine hcl caps F PA

amantadine hcl syrp F PA

amantadine hcl tabs F PA

bromocriptine mesylatecaps F PA

bromocriptine mesylatetabs F PA

carbidopa-levodopa tabs10mg-100mg, 25mg-100mg, 25mg-250mg

FPA

carbidopa-levodopa tbcr25mg-100mg, 50mg-200mg

FPA

DUOPA SUSP F PA

pramipexoledihydrochloride tabs F PA

pramipexoledihydrochloride tb24 F PA

ropinirole hydrochloridetabs 0.25 mg, 0.5 mg, 1mg, 2 mg, 3 mg, 4 mg, 5mg

F

PA; QL(2 eadaily)

ropinirole hydrochloridetb24 2 mg, 4 mg, 6 mg, 8mg, 12 mg

FPA

Antiparkinson Monoamine Oxidase Inhibitorsselegiline hcl caps F PA

selegiline hcl tabs F PA


17

Drug Name DrugTier

Requirements/Limits

SELEGILINE HCL TABS F PA

ZELAPAR TBDP F PA

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood DisordersAntimanic Agentslithium carbonate caps 150mg, 300 mg, 600 mg F PA

lithium carbonate tabs 300mg F PA

lithium carbonate tbcr 300mg, 450 mg F PA

LITHIUM SOLN F PA

Antipsychotics - Misc.EQUETRO CP12 F PA

NUPLAZID TABS F PA

VRAYLAR CAPS F PA

VRAYLAR CPPK F PA

ziprasidone hcl caps F PA; QL(2 eadaily)

Benzisoxazoles

RISPERIDONE ODT TBDP F PA; QL(2 eadaily)

risperidone soln 1 mg/ml F PA

risperidone tabs 0.25 mg,0.5 mg, 1 mg, 2 mg, 3 mg,4 mg

FPA; QL(2 eadaily)

risperidone tbdp 0.25 mg,0.5 mg, 1 mg, 2 mg, 3 mg,4 mg

FPA; QL(2 eadaily)

Butyrophenoneshaloperidol lactate conc F PA

haloperidol tabs F PA

Dibenzapinesclozapine tabs 25 mg, 50mg, 100 mg, 200 mg F PA

Drug Name DrugTier

Requirements/Limits

olanzapine tabs F PA; QL(2 eadaily)

olanzapine tbdp F PA; QL(2 eadaily)

quetiapine fumarate tabs25 mg, 50 mg, 100 mg, 200mg, 300 mg, 400 mg

FPA

quetiapine fumarate tb2450 mg, 150 mg, 200 mg,300 mg, 400 mg

FPA; QL(2 eadaily)

VERSACLOZ SUSP F PA

Phenothiazineschlorpromazine hcl tabs F PA

perphenazine tabs F PA

prochlorperazine maleatetabs F

prochlorperazine supp F

Quinolinone Derivativesaripiprazole soln F PA

aripiprazole tabs F PA

REXULTI TABS F PA

ANTIVIRALS - Drugs to Treat Viral Infections

CMV Agentsvalganciclovir hcl solr F PA

valganciclovir hcl tabs F PA

Hepatitis Agentsadefovir dipivoxil tabs 10mg F PA

BARACLUDE SOLN 0.05MG/ML F PA

DAKLINZA TABS F PA

entecavir tabs F PA

EPCLUSA TABS F PA


18

Drug Name DrugTier

Requirements/Limits

EPIVIR HBV SOLN 5MG/ML F PA

HARVONI TABS F PA

lamivudine (hbv) tabs F PA

LEDIPASVIR/SOFOSBUVIR TABS F PA

OLYSIO CAPS F PA

RIBASPHERE TABS F PA

ribavirin (hepatitis c) caps F PA

ribavirin (hepatitis c) tabs F PA

SOFOSBUVIR/VELPATASVIR TABS F PA

SOVALDI TABS F PA

TECHNIVIE TABS F PA

VEMLIDY TABS F PA

ZEPATIER TABS F PA

Herpes Agentsacyclovir caps F PA

acyclovir susp F PA

acyclovir tabs F PA

famciclovir tabs F PA

valacyclovir hcl tabs F PA

Influenza Agentsoseltamivir phosphate caps30 mg, 45 mg, 75 mg F PA

oseltamivir phosphate susr6 mg/ml F

RELENZA DISKHALERAEPB F PA

BETA BLOCKERS - Drugs to Treat High BloodPressureAlpha-Beta Blockers

Drug Name DrugTier

Requirements/Limits

carvedilol phosphate cp24 F PA

carvedilol tabs F PA

labetalol hcl tabs F PA

Beta Blockers Cardio-Selectiveacebutolol hcl caps F PA

atenolol tabs F PA

bisoprolol fumarate tabs F PA

BYSTOLIC TABS F PA

metoprolol succinate tb24200 mg F PA; QL(2 ea

daily)metoprolol succinate tb2425 mg, 50 mg, 100 mg F PA; QL(1.5 ea

daily)metoprolol tartrate tabs 25mg, 50 mg, 100 mg F PA

Beta Blockers Non-Selectivenadolol tabs F PA

pindolol tabs F PA

propranolol hcl cp24 60mg, 80 mg, 120 mg, 160mg

FPA

PROPRANOLOL HCLSOLN 20 MG/5ML, 40MG/5ML

FPA

propranolol hcl tabs 10 mg,20 mg, 40 mg, 60 mg, 80mg

FPA

sotalol hcl (afib/afl) tabs F PA

sotalol hcl tabs F PA

TIMOLOL MALEATE TABS10 MG, 20 MG F PA

timolol maleate tabs 5 mg F PA

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood PressureCalcium Channel Blockers


19

Drug Name DrugTier

Requirements/Limits

amlodipine besylate tabs10 mg F PA

amlodipine besylate tabs2.5 mg F PA; QL(1 ea

daily)amlodipine besylate tabs 5mg F PA; QL(1.5 ea

daily)CARDIZEM LA TB24 120MG F PA; QL(1 ea

daily)

DILT-XR CP24 F PA; QL(1 eadaily)

diltiazem hcl coated beadscp24 120 mg, 240 mg, 300mg, 360 mg

FPA; QL(1 eadaily)

diltiazem hcl coated beadscp24 180 mg F PA; QL(2 ea

daily)diltiazem hcl coated beadstb24 180 mg, 240 mg, 300mg, 360 mg, 420 mg

FPA; QL(1 eadaily)

diltiazem hcl cp12 120 mg F PA; QL(1 eadaily)

diltiazem hcl cp12 60 mg,90 mg F PA

diltiazem hcl cp24 120 mg,240 mg F PA; QL(1 ea

daily)

diltiazem hcl cp24 180 mg F PA; QL(2 eadaily)

diltiazem hcl extendedrelease beads cp24 120mg, 240 mg, 300 mg, 360mg, 420 mg

F

PA; QL(1 eadaily)

diltiazem hcl extendedrelease beads cp24 180mg

FPA; QL(2 eadaily)

diltiazem hcl tabs 30 mg,60 mg, 90 mg, 120 mg F PA

felodipine tb24 F PA; QL(2 eadaily)

nifedipine caps 10 mg, 20mg F PA

nifedipine tb24 30 mg, 90mg F PA; QL(1 ea

daily)

nifedipine tb24 60 mg F PA; QL(2 eadaily)

nimodipine caps F PA

NYMALIZE SOLN F PA

Drug Name DrugTier

Requirements/Limits

verapamil hcl cp24 100 mg,120 mg, 180 mg, 200 mg,240 mg, 300 mg

FPA; QL(2 eadaily)

VERAPAMIL HCL ERCP24 F PA; QL(2 ea

daily)VERAPAMIL HCL SRCP24 F PA; QL(2 ea

daily)verapamil hcl tabs 40 mg,80 mg, 120 mg F PA

verapamil hcl tbcr 120 mg,180 mg, 240 mg F PA; QL(2 ea

daily)

VERELAN CP24 360 MG F PA; QL(2 eadaily)

VERELAN PM CP24 100MG, 300 MG F PA; QL(2 ea

daily)CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart RhythmCardiac GlycosidesDIGOXIN SOLN 0.05MG/ML F PA

digoxin tabs 0.125 mg, 0.25mg, 125 mcg, 250 mcg F PA

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation ConditionsCardiovascular Agents Misc. - CombinationsBIDIL TABS F PA

Impotence Agents

MUSE PLLT F PA; QL(0.2 eadaily)

sildenafil citrate tabs F PA; QL(0.2 eadaily)

STENDRA TABS F PA

tadalafil tabs 10 mg, 20 mg F PA; QL(0.2 eadaily)

tadalafil tabs 5 mg, 2.5 mg F PA; QL(1 eadaily)

vardenafil hcl tabs F PA; QL(0.2 eadaily)

vardenafil hcl tbdp F PA; QL(0.2 eadaily)

Peripheral Vasodilatorsisoxsuprine hcl tabs F PA


20

Drug Name DrugTier

Requirements/Limits

Prostaglandin VasodilatorsORENITRAM TBCR F PA

TYVASO REFILL SOLN F PA

TYVASO SOLN F PA

TYVASO STARTER SOLN F PA

VENTAVIS SOLN F PA

Pulmonary Hypertension - Endothelin Receptorambrisentan tabs F PA

bosentan tabs F PA

OPSUMIT TABS F PA

TRACLEER TBSO 32 MG F PA

Pulmonary Hypertension - Phosphodiesterasesildenafil citrate (pulmonaryhypertension) susr F PA

sildenafil citrate (pulmonaryhypertension) tabs F PA

tadalafil (pulmonaryhypertension) tabs 20 mg F PA

Pulmonary Hypertension - Prostacyclin ReceptorUPTRAVI TABS F PA

UPTRAVI TBPK F PA

Pulmonary Hypertension - Sol Guanylate CyclaseADEMPAS TABS F PA

CEPHALOSPORINS - Drugs to Treat BacterialInfectionsCephalosporins - 1st Generationcefadroxil caps 500 mg F

cefadroxil susr 500 mg/5ml F

cefadroxil tabs 1 gm F

cephalexin caps 250 mg,500 mg, 750 mg F

Drug Name DrugTier

Requirements/Limits

cephalexin susr 250mg/5ml F

CEPHALEXIN TABS 250MG, 500 MG F

Cephalosporins - 2nd Generationcefprozil susr 250 mg/5ml F

cefprozil tabs 250 mg, 500mg F

CEFTIN SUSR 250MG/5ML F

cefuroxime axetil tabs F

Cephalosporins - 3rd Generationcefdinir caps 300 mg F

cefdinir susr 250 mg/5ml F

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling ConditionsGlucocorticosteroidsbudesonide cpep F PA

budesonide tb24 F PA

CORTISONE ACETATETABS F

dexamethasone elix 0.5mg/5ml F

DEXAMETHASONEINTENSOL CONC F

DEXAMETHASONE SOLN0.5 MG/5ML F

dexamethasone tabs 0.75mg, 0.5 mg, 4 mg, 6 mg,1.5 mg

F

DEXAMETHASONE TABS1 MG, 2 MG F

dexamethasone tbpk 1.5mg F

hydrocortisone tabs F

methylprednisolone tabs 4mg, 8 mg, 16 mg F

methylprednisolone tbpk 4mg F


21

Drug Name DrugTier

Requirements/Limits

MILLIPRED TABS 5 MG F

prednisolone sodiumphosphate soln or 5mg/5ml

F

prednisolone soln F PA

PREDNISOLONE SOLN F PA

prednisolone syrp F PA

PREDNISONE INTENSOLCONC F

PREDNISONE SOLN 5MG/5ML F

prednisone tabs 1 mg, 5mg, 10 mg, 20 mg, 2.5 mg F

PREDNISONE TABS 50MG F

TAPERDEX 12-DAY TBPK F

ZODEX 12-DAY TBPK F

Mineralocorticoidsfludrocortisone acetatetabs F

DERMATOLOGICALS - Drugs to Treat SkinConditionsAnalgesics - TopicalBAMA FREEZE GEL F PA

BENGAY COLD THERAPYGEL F PA

BIOFREEZE AERO F PA

COLD THERAPY PAINRELIEF GEL F PA

menthol (topical analgesic)gel F PA

menthol (topical analgesic)ptch F PA

ULTRACIN M GEL F PA

ZIMS MAX-FREEZE GEL F PA

Anti-inflammatory Agents - Topical

Drug Name DrugTier

Requirements/Limits

DICLOFENACEPOLAMINE PTCH F QL(2 ea daily)

diclofenac sodium (topical)gel F

diclofenac sodium (topical)soln F

FLECTOR PTCH F QL(2 ea daily)

Antibiotics - Topicalbacitracin (topical) oint 500unit/gm F

bacitracin zinc oint F

bacitracin-polymyxin b oint F

CENTANY OINT F

CORTISPORIN CREA F

CORTISPORIN OINT F

gentamicin sulfate (topical)crea F

gentamicin sulfate (topical)oint F

mupirocin calcium (topical)crea 2 % F

MUPIROCIN CREA 2 % F

mupirocin oint F

neomycin-bacitracin-polymyxin oint F

neomycin-bacitracin-polymyxin w/ lidocaine oint F

neomycin-bacitracin-polymyxin-pramoxine oint F

neomycin-polymyxin w/pramoxine crea10000unit/gm-3.5mg/gm-10mg/gm

F

Antifungals - TopicalALA-QUIN CREA F PA

AZOLEN TINCTURESOLN 2 % F PA


22

Drug Name DrugTier

Requirements/Limits

BLIS-TO-SOL POWD F PA

BREEZEE MIST AERP F PA

butenafine hcl crea 1 % F PA; RX/OTC

castellani paint liqd F PA

ciclopirox gel 0.77 % F PA

ciclopirox olamine crea0.77 % F PA

ciclopirox olamine susp0.77 % F PA

ciclopirox sham 1 % F PA

ciclopirox soln 8 % F PA; QL(0.24 mldaily)

clotrimazole (topical) crea 1% F PA; RX/OTC

clotrimazole (topical) soln 1% F PA; RX/OTC

clotrimazole w/betamethasone crea 1%-0.05%

FPA

clotrimazole w/betamethasone lotn 1%-0.05%

FPA

DERMASORB AF KIT F PA

econazole nitrate crea 1 % F PA

ERTACZO CREA F PA

EXELDERM CREA F PA

EXELDERM SOLN F PA

EXODERM LOTN F PA

FUNGI-NAIL SOLN F PA

FUNGOID TINCTURESOLN 2 % F PA

GENTIAN VIOLET SOLN F PA

GNP GENTIAN VIOLETSOLN F PA

Drug Name DrugTier

Requirements/Limits

GORDOCHOM SOLN F PA

GORDONS NO 5 AERP F PA

iodoquinol-hc crea F PA

ketoconazole (topical) crea F PA

ketoconazole (topical)sham F PA

LAMISIL ADVANCED GEL F PA

LAMISIL AT SPRAY SOLN1 % F PA

MENTAX CREA 1 % F PA; RX/OTC

miconazole nitrate (topical)aerp 2 % F PA

miconazole nitrate (topical)crea 2 % F PA

miconazole nitrate (topical)oint 2 % F PA

miconazole nitrate (topical)powd 2 % F PA

MYCO NAIL A SOLN F PA

naftifine hcl crea F PA

naftifine hcl gel F PA

NAFTIN GEL 1 %, 2 % F PA

nystatin (topical) crea F PA

nystatin (topical) oint F PA

nystatin (topical) powd F PA

nystatin-triamcinolone crea F PA

nystatin-triamcinolone oint F PA

oxiconazole nitrate crea 1% F PA

OXISTAT LOTN 1 % F PA

RA ANTI-FUNGAL FOOTCARE SOLN F PA


23

Drug Name DrugTier

Requirements/Limits

terbinafine hcl (topical)crea 1 % F PA

tolnaftate aero 1 % F PA

tolnaftate aerp 1 % F PA

tolnaftate crea 1 % F PA

tolnaftate liqd 1 % F PA

tolnaftate powd 1 % F PA

tolnaftate soln 1 % F PA

undecylenic acid liqd F PA

UNDELENIC TINCTURETINC F PA

Antineoplastic or Premalignant Lesion Agents -CARAC CREA F PA

diclofenac sodium (actinickeratoses) gel F PA

FLUOROPLEX CREA F PA

fluorouracil (topical) crea F PA

FLUOROURACIL CREA0.5 % F PA

FLUOROURACIL SOLN 2%, 5 % F PA

Antipruritics - Topicalcamphor & menthol lotn0.5%-0.5% F PA

camphor & phenol gel4.7%-10.8% F PA

camphor & phenol liqd4.7%-10.8% F PA

Antipsoriaticsacitretin caps F PA

methoxsalen rapid caps 10mg F PA

Antivirals - Topicalacyclovir topical crea 5 % F PA

Drug Name DrugTier

Requirements/Limits

acyclovir topical oint 5 % F PA

DENAVIR CREA F PA; QL(0.05gm daily)

docosanol crea 10 % F PA

Burn Productsmafenide acetate pack F

silver sulfadiazine crea 1 % F

SULFAMYLON CREA 85MG/GM F

UNGUENTINE MAXIMUMSTRENGTH OINT F

UNGUENTINE OINT F

Corticosteroids - TopicalALA SCALP LOTN F

alclometasone dipropionatecrea F

alclometasone dipropionateoint F

AMCINONIDE CREA F

AMCINONIDE LOTN F PA

AMCINONIDE OINT F PA

AUGMENTEDBETAMETHASONEDIPROPIONATE GEL 0.05%

F

betamethasonedipropionate (topical) crea0.05 %

F

betamethasonedipropionate (topical) lotn0.05 %

F

betamethasonedipropionate (topical) oint0.05 %

FPA

betamethasonedipropionate augmentedcrea 0.05 %

F


24

Drug Name DrugTier

Requirements/Limits

betamethasonedipropionate augmentedgel 0.05 %

F

betamethasonedipropionate augmentedlotn 0.05 %

F

betamethasonedipropionate augmentedoint 0.05 %

F

betamethasone valeratecrea 0.1 % F

betamethasone valeratefoam 0.12 % F

betamethasone valeratelotn 0.1 % F PA

betamethasone valerateoint 0.1 % F PA

calcipotriene-betamethasonedipropionate oint 0.005%-0.064%

F

clobetasol propionate crea0.05 % F

clobetasol propionate foam0.05 % F

clobetasol propionate gel0.05 % F

clobetasol propionate lotn0.05 % F

clobetasol propionate oint0.05 % F

CLOCORTOLONEPIVALATE CREA F

CLOCORTOLONEPIVALATE PUMP CREA F

CLODAN KIT KIT F

CLODERM CREA F

CLODERM PUMP CREA F

CORDRAN TAPE 4MCG/SQCM F

CORTANE-B LOTN F

CVS HDYROCORTISONEACETATE CREA F

Drug Name DrugTier

Requirements/Limits

desonide crea 0.05 % F

desonide lotn 0.05 % F

desonide oint 0.05 % F

desoximetasone crea 0.05%, 0.25 % F

desoximetasone gel 0.05 % F

desoximetasone liqd 0.25% F PA

desoximetasone oint 0.05%, 0.25 % F

DIFLORASONEDIACETATE CREA F

diflorasone diacetate oint F

EPIFOAM FOAM F

fluocinolone acetonide crea F

fluocinolone acetonide oil F

fluocinolone acetonide oint F

fluocinolone acetonide soln F

fluocinonide crea 0.05 %,0.1 % F

fluocinonide gel 0.05 % F PA

fluocinonide oint 0.05 % F

fluocinonide soln 0.05 % F

flurandrenolide crea F

flurandrenolide lotn F PA

fluticasone propionate crea F

fluticasone propionate oint F

halcinonide crea 0.1 % F

halobetasol propionatecrea 0.05 % F


25

Drug Name DrugTier

Requirements/Limits

halobetasol propionate oint0.05 % F

HALOG OINT 0.1 % F PA

hydrocortisone (topical)crea 0.5 % F

hydrocortisone (topical)crea 1 % F RX/OTC

hydrocortisone (topical) gel1 % F

hydrocortisone (topical)lotn 1 % F

hydrocortisone (topical)lotn 2.5 % F PA

hydrocortisone (topical)oint 0.5 % F PA

hydrocortisone (topical)oint 1 % F RX/OTC

hydrocortisone (topical)oint 2.5 % F

hydrocortisone (topical)soln 1 % F

hydrocortisone acetate(topical) crea F

hydrocortisone butyratecrea 0.1 % F

hydrocortisone butyrateoint 0.1 % F PA

hydrocortisone butyratesoln 0.1 % F

hydrocortisone valeratecrea 0.2 % F

hydrocortisone valerateoint 0.2 % F

LIDOSOL-HC CREA F PA

mometasone furoate crea0.1 % F

mometasone furoate oint0.1 % F

mometasone furoate soln0.1 % F

NOVACORT GEL F

PANDEL CREA F

Drug Name DrugTier

Requirements/Limits

PRAMOSONE CREA 1%-1% F

PRAMOSONE LOTN 1%-1%, 1%-2.5% F

PRAMOSONE OINT 1%-1%, 1%-2.5% F

pramoxine-hc crea F

pramoxine-hc gel F

PREDNICARBATE CREA0.1 % F

prednicarbate crea 0.1 % F

PREDNICARBATE OINT0.1 % F

PSORCON CREA F

SYNALAR CREAM KIT KIT F PA

TACLONEX SUSP0.005%-0.064% F

triamcinolone acetonide(topical) aers F

triamcinolone acetonide(topical) crea F

triamcinolone acetonide(topical) lotn F

triamcinolone acetonide(topical) oint F

TRIANEX OINT F

Immunomodulating Agents - Topicalimiquimod crea F PA

IMIQUIMOD PUMP CREA F PA

ZYCLARA CREA F PA

ZYCLARA PUMP CREA F PA

Immunosuppressive Agents - Topicalpimecrolimus crea 1 % F PA

tacrolimus (topical) oint F PA

Liniments


26

Drug Name DrugTier

Requirements/Limits

capsaicin-menthol-methylsalicylate lotn 10%-0.025%-25%

FPA

Local Anesthetics - TopicalAMERICAINE AERO F PA

ARTHRITIS PAINRELIEVING CREA F PA

AVEENO ANTI-ITCHLOTN F PA

BAND-AID ANTISEPTICWASHHURT-FREE LIQD F PA

benzocaine (topical) gel F PA

benzocaine (topical) oint F PA

CAPSAGEL EXTRASTRENGTH GEL F PA

CAPSAGEL GEL F PA

capsaicin crea F PA

CERAVE ITCH RELIEFCREA 1 % F PA

CETACAINE AERO F PA

CHIGGEREX OINT F PA

COCAINE HCL POWD F PA

COCAINE HCL SOLN F PA

dibucaine oint F PA

ETHYL CHLORIDE AERO F PA

ETHYL CHLORIDE/FINEPINPOINT AERO F PA

ETHYL CHLORIDE/FINESTREAM AERO F PA

ETHYLCHLORIDE/MEDIUM JETSTREAM AERO

FPA

ETHYLCHLORIDE/MEDIUMSTREAM AERO

FPA

ETHYL CHLORIDE/MISTAERO F PA

Drug Name DrugTier

Requirements/Limits

FOILLE OINT F PA

GEBAUERS INSTANT ICEAERO F PA; RX/OTC

GEBAUERS PAIN EASEAERO F PA; RX/OTC

GEBAUERS SPRAY ANDSTRETCH AERO F PA; RX/OTC

lidocaine aero 0.5 % F PA

lidocaine crea 4 % F

lidocaine hcl gel 0.5 % F PA

lidocaine hcl gel 2 % F PA; RX/OTC

lidocaine hcl lotn 3 % F PA

lidocaine hcl soln 4 % F PA

lidocaine oint 5 % F

lidocaine ptch 5 % F QL(3 ea daily)

lidocaine-prilocaine crea F PA

OUTGRO PAIN RELIEFLIQD F PA

pramoxine hcl gel 1 % F PA; RX/OTC

pramoxine hcl lotn 1 % F PA

pramoxine hcl misc 1 % F PA

pramoxine-zinc acetate lotn F PA

REGENECARE HA LIQD F PA

ZOSTRIX-HP STCK F PA

Scabicides & Pediculicidespyrethrins-piperonylbutoxide sham F PA

VANALICE GEL F PA

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood PressureCarbonic Anhydrase Inhibitors


27

Drug Name DrugTier

Requirements/Limits

acetazolamide cp12 F PA

acetazolamide tabs F PA

methazolamide tabs F PA

Diuretic CombinationsALDACTAZIDE TABS50MG-50MG F PA

amiloride &hydrochlorothiazide tabs F PA

spironolactone &hydrochlorothiazide tabs F PA

triamterene &hydrochlorothiazide caps F PA

triamterene &hydrochlorothiazide tabs F PA

Loop Diureticsbumetanide tabs F PA

furosemide soln 10 mg/ml F PA

FUROSEMIDE SOLN 8MG/ML F PA

furosemide tabs 20 mg, 40mg, 80 mg F PA

Potassium Sparing Diureticsamiloride hcl tabs F PA

spironolactone tabs F PA

Thiazides and Thiazide-Like Diureticschlorthalidone tabs F PA

hydrochlorothiazide caps F PA

hydrochlorothiazide tabs F PA

metolazone tabs F PA

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate HormonesBone Density RegulatorsALENDRONATE SODIUMSOLN 70 MG/75ML F PA

Drug Name DrugTier

Requirements/Limits

alendronate sodium tabs35 mg, 70 mg F PA; QL(0.14 ea

daily)alendronate sodium tabs 5mg, 10 mg F PA; QL(1 ea

daily)ALENDRONATE SODIUMTABS 5 MG, 40 MG F PA; QL(1 ea

daily)ETIDRONATE DISODIUMTABS F PA

FORTEO SOLN F PA

FOSAMAX PLUS D TABS F PA

ibandronate sodium tabs150 mg F PA

PROLIA SOSY F PA

risedronate sodium tabs 5mg, 30 mg, 35 mg, 150 mg F PA

XGEVA SOLN F PA

zoledronic acid conc 4mg/5ml F PA; QL(0.07 ml

daily)FLUOROQUINOLONES - Drugs to Treat BacterialInfectionsFluoroquinolonesCIPRO SUSR 5 GM/100ML F

CIPROFLOXACIN HCLTABS 100 MG F

ciprofloxacin hcl tabs 250mg, 500 mg, 750 mg F

ciprofloxacin susr or 250mg/5ml, 500 mg/5ml F

levofloxacin soln 25 mg/ml F

levofloxacin tabs 250 mg,500 mg, 750 mg F QL(1 ea daily)

moxifloxacin hcl tabs 400mg F

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal DrugsAgents for Chronic Idiopathic Constipation (CIC)TRULANCE TABS F PA

Antiflatulents


28

Drug Name DrugTier

Requirements/Limits

GAS-X EXTRASTRENGTH STRP 62.5MG

F

simethicone caps F

simethicone chew F

simethicone susp F

Farnesoid X Receptor (FXR) AgonistsOCALIVA TABS F PA

Gastrointestinal Antiallergy Agentscromolyn sodium(mastocytosis) conc 100mg/5ml

FPA

Gastrointestinal Chloride Channel ActivatorsAMITIZA CAPS F PA

Gastrointestinal Stimulantsmetoclopramide hcl soln F

metoclopramide hcl tabs F

METOCLOPRAMIDE ODTTBDP F PA

Inflammatory Bowel Agents

REMICADE SOLR F PA; QL(0.18 eadaily)

Intestinal Acidifierslactulose (encephalopathy)soln F

Irritable Bowel Syndrome (IBS) Agentsalosetron hcl tabs 0.5 mg F PA

alosetron hcl tabs 1 mg F PA; QL(2 eadaily)

LINZESS CAPS F PA; QL(1 eadaily)

VIBERZI TABS F PA; QL(2 eadaily)

Peripheral Opioid Receptor AntagonistsENTEREG CAPS F PA

Drug Name DrugTier

Requirements/Limits

MOVANTIK TABS F PA

RELISTOR TABS F PA

Phosphate Binder Agentscalcium acetate (phosphatebinder) caps F

calcium acetate (phosphatebinder) tabs F PA; RX/OTC

FOSRENOL PACK 750MG, 1000 MG F PA

lanthanum carbonate chew F PA

PHOSLYRA SOLN F PA

RENAGEL TABS 400 MG F PA

sevelamer carbonate pack F PA

sevelamer carbonate tabs F PA

sevelamer hcl tabs F PA

SEVELAMERHYDROCHLORIDE TABS F PA

GENITOURINARY AGENTS - MISCELLANEOUS- Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary SystemProstatic Hypertrophy Agentsalfuzosin hcl tb24 10 mg F PA

CARDURA XL TB24 F PA

dutasteride caps 0.5 mg F PA

finasteride tabs 5 mg F PA

RAPAFLO CAPS 4 MG F PA

silodosin caps F PA

tamsulosin hcl caps 0.4 mg F PA

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations


29

Drug Name DrugTier

Requirements/Limits

colchicine w/ probenecidtabs F PA

Gout Agentsallopurinol tabs F PA

COLCHICINE CAPS F PA

COLCHICINE TABS F PA

COLCRYS TABS F PA

febuxostat tabs F PA

MITIGARE CAPS F PA

Uricosuricsprobenecid tabs F PA

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood DisordersHematorheologic Agentspentoxifylline tbcr F PA

Platelet Aggregation Inhibitorsanagrelide hcl caps F PA

aspirin-dipyridamole cp12200mg-25mg F PA

cilostazol tabs F PA

clopidogrel bisulfate tabs F PA

prasugrel hcl tabs F PA

ZONTIVITY TABS F PA

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTSAntihistamine Hypnoticsdiphenhydramine-acetaminophen (sleep)tabs

FPA

ibuprofen-diphenhydraminecitrate tabs F PA

ibuprofen-diphenhydraminehcl caps 200mg-25mg F PA

Drug Name DrugTier

Requirements/Limits

TYLENOL PM EXTRASTRENGTH LIQD50MG/30ML-1000MG/30ML

F

PA

Barbiturate Hypnoticsphenobarbital elix F PA

phenobarbital soln F PA

phenobarbital tabs F PA

Non-Barbiturate Hypnotics

eszopiclone tabs F PA; QL(2 eadaily)

temazepam caps F

zaleplon caps 10 mg F QL(2 ea daily)

zaleplon caps 5 mg F QL(1 ea daily)

zolpidem tartrate subl sl 3.5mg, 1.75 mg F PA; QL(0.5 ea

daily)zolpidem tartrate tabs or 10mg F QL(2 ea daily)

zolpidem tartrate tabs or 5mg F QL(1 ea daily)

zolpidem tartrate tbcr or12.5 mg F QL(2 ea daily)

zolpidem tartrate tbcr or6.25 mg F QL(1 ea daily)

Orexin Receptor AntagonistsBELSOMRA TABS F PA

Selective Melatonin Receptor Agonistsramelteon tabs 8 mg F PA

LAXATIVES - Bowel Treatment Drugs

Bulk Laxativescalcium polycarbophil tabs625 mg F

CVS NATURAL FIBERSUPPLEMENT PACK F

EQUALACTIN CHEW 625MG F


30

Drug Name DrugTier

Requirements/Limits

HYDROCIL INSTANTPACK F

KONSYL DAILY FIBERPACK 100 %, 28.3 %, 60.3%

F

KONSYL DAILY FIBERPOWD 60.3 % F

KONSYL PACK F

KONSYL POWD F

KONSYL-D POWD F

METAMUCILMULTIHEALTH FIBERPOWD

F

METAMUCILMULTIHEALTH FIBERSINGLES PACK

F

METAMUCIL PACK 28 % F

METAMUCIL WAFR F

methylcellulose (laxative)powd F

methylcellulose (laxative)tabs F

MUCILIN SF PACK F

psyllium caps F

psyllium powd F

Laxative CombinationsMOVIPREP SOLR F

peg 3350-kcl-sod bicarb-sod chloride-sod sulfatesolr 240gm-22.72gm-5.84gm-2.98gm-6.72gm

F

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr 420gm-11.2gm-1.48gm-5.72gm

F

sennosides-docusatesodium tabs F

Laxatives - Miscellaneous

Drug Name DrugTier

Requirements/Limits

glycerin (laxative) supp F

KRISTALOSE PACK 10GM, 20 GM F

LACTULOSE PACK 10 GM F

lactulose soln 10 gm/15ml,20 gm/30ml F

polyethylene glycol 3350pack F RX/OTC

polyethylene glycol 3350powd F RX/OTC

SORBITOL SOLN F

Lubricant LaxativesKONDREMUL EMUL F

mineral oil enem F

Saline LaxativesORAL SALINE LAXATIVESOLN F

OSMOPREP TABS F

sodium phosphates enem F

Stimulant Laxativesbisacodyl supp F

bisacodyl tbec F

BLACK DRAUGHT CHEW F

castor oil oil 100 % F

EVAC-U-GEN CHEW F

SENNA SYRP F

sennosides chew F

sennosides syrp F

sennosides tabs F

Surfactant Laxatives


31

Drug Name DrugTier

Requirements/Limits

docusate calcium caps F

docusate sodium caps F

docusate sodium enem F

docusate sodium liqd F

docusate sodium syrp F

docusate sodium tabs F

MACROLIDES - Drugs to Treat BacterialInfectionsAzithromycinazithromycin susr 200mg/5ml F

azithromycin tabs 250 mg,500 mg, 600 mg F

ClarithromycinCLARITHROMYCIN SUSR250 MG/5ML F

clarithromycin tabs 250 mg,500 mg F

clarithromycin tb24 500 mg F

ErythromycinsE.E.S. 400 TABS F

ERYTHROCIN STEARATETABS F

erythromycin base cpep F

erythromycin base tabs F

erythromycin base tbec F

erythromycinethylsuccinate susr 200mg/5ml

F

ERYTHROMYCINETHYLSUCCINATE TABS400 MG

F

PCE TBEC F

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches

Drug Name DrugTier

Requirements/Limits

Migraine Combinationsergotamine w/ caffeine tabs F PA

isometheptene-dichloralphenazone-acetaminophen caps

FPA

ISOMETHEPTENE/DICHLORALPHENAZONE/ACETAMINOPHEN CAPS

FPA

MIGERGOT SUPP F PA

sumatriptan-naproxensodium tabs 85mg-500mg F PA; QL(0.14 ea

daily)Migraine Products - Monoclonal AntibodiesAIMOVIG SOAJ F PA

Migraine ProductsERGOMAR SUBL F PA

Serotonin Agonists

almotriptan malate tabs F PA; QL(0.4 eadaily)

eletriptan hydrobromidetabs F PA; QL(0.4 ea

daily)

naratriptan hcl tabs F PA; QL(0.6 eadaily)

rizatriptan benzoate tabs F PA; QL(0.4 eadaily)

rizatriptan benzoate tbdp F PA; QL(0.4 eadaily)

sumatriptan soln F PA; QL(0.4 eadaily)

sumatriptan succinate soajsc 4 mg/0.5ml, 6 mg/0.5ml F PA; QL(0.1 ml

daily)sumatriptan succinate soctsc 4 mg/0.5ml, 6 mg/0.5ml F PA; QL(0.1 ml

daily)sumatriptan succinate solnsc 6 mg/0.5ml F PA

SUMATRIPTANSUCCINATE SOSY SC 6MG/0.5ML

FPA

sumatriptan succinate tabsor 25 mg, 50 mg, 100 mg F PA; QL(0.6 ea

daily)zolmitriptan tabs 5 mg, 2.5mg F PA; QL(0.4 ea

daily)


32

Drug Name DrugTier

Requirements/Limits

zolmitriptan tbdp 2.5 mg F PA; QL(0.4 eadaily)

zolmitriptan tbdp 5 mg F PA; QL(0.2 eadaily)

ZOMIG SOLN NA 5 MG F PA

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat SpasmsCentral Muscle Relaxantsbaclofen tabs F

cyclobenzaprine hcl tabs 5mg, 10 mg, 7.5 mg F QL(3 ea daily)

metaxalone tabs 800 mg F

methocarbamol tabs F

orphenadrine citrate tb12 F

tizanidine hcl tabs 2 mg, 4mg F

Direct Muscle Relaxantsdantrolene sodium caps F PA

Muscle Relaxant CombinationsNORGESIC FORTE TABS F

ORPHENADRINECITRATE/ASPIRIN/CAFFEINE TABS

F

ORPHENGESIC FORTETABS F

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or SinusNasal Antiallergyazelastine hcl soln 0.1 %,137 mcg/spray F PA; QL(1.21 ml

daily)

azelastine hcl soln 0.15 % F PA

cromolyn sodium (nasal)aers 5.2 mg/act F PA

olopatadine hcl (nasal) soln0.6 % F PA

Nasal Anticholinergics

Drug Name DrugTier

Requirements/Limits

ipratropium bromide (nasal)soln F PA

Nasal Steroids

BECONASE AQ SUSP F PA; QL(0.83gm daily)

budesonide (nasal) susp F PA; QL(0.51 mldaily)

FLONASE SENSIMISTSUSP F PA

FLUNISOLIDE SOLN F PA; QL(0.83 mldaily)

fluticasone propionate(nasal) susp 50 mcg/act F PA; QL(1.07 ml

daily); RX/OTCmometasone furoate(nasal) susp 50 mcg/act F PA; QL(0.57

gm daily)NASACORT ALLERGY24HR AERO 55 MCG/ACT F PA; QL(0.55 ml

daily); RX/OTC

OMNARIS SUSP F PA

triamcinolone acetonide(nasal) aero 55 mcg/act F PA; QL(0.55 ml

daily); RX/OTC

ZETONNA AERS F PA

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricantsartificial tear solution soln F PA

carboxymethylcellulosesodium (ophth) soln 0.5 % F PA

CVS LUBRICANT GELDROPS GEL 0.3%-0.25% F PA

hypromellose (ophth) soln F PA

polyvinyl alcohol soln F PA

RETAINE HPMC SOLN F PA

Beta-blockers - OphthalmicCOMBIGAN SOLN F

dorzolamide hcl-timololmaleate soln F

DORZOLAMIDEHCL/TIMOLOL MALEATESOLN

F


33

Drug Name DrugTier

Requirements/Limits

Cycloplegic MydriaticsATROPINE SULFATEOINT F

ATROPINE SULFATESOLN F

cyclopentolate hcl soln F

homatropine hbr soln F

ISOPTO ATROPINE SOLN F

Ophthalmic Anti-infectivesAZASITE SOLN F PA

BACITRACIN OINT F

bacitracin-polymyxin b(ophth) oint F

BESIVANCE SUSP F PA

BETADINE OPHTHALMICPREP SOLN F PA

CILOXAN OINT 0.3 % F

ciprofloxacin hcl (ophth)soln 0.3 % F

erythromycin (ophth) oint F

GENTAK OINT F

gentamicin sulfate (ophth)soln F

KLARITY-A SOLN F PA

levofloxacin (ophth) soln F PA

moxifloxacin hcl (ophth)soln 0.5 % F PA

NATACYN SUSP F

neomycin-bacitracin zn-polymyxin oint F

NEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN0.025MG/ML-10000UNIT/ML-1.75MG/ML

F

Drug Name DrugTier

Requirements/Limits

ofloxacin (ophth) soln 0.3% F

polymyxin b-trimethoprimsoln 0.1%-10000unit/ml F

POVIDONE IODINE SOLN F PA

sulfacetamide sodium(ophth) soln 10 % F

SULFACETAMIDESODIUM OINT 10 % F

tobramycin (ophth) soln 0.3% F

TOBREX OINT 0.3 % F

Ophthalmic Decongestantsnaphazoline w/pheniramine soln 0.027%-0.315%

FPA

tetrahydrozoline hcl (ophth)soln 0.05 % F PA

Ophthalmic Immunomodulators

RESTASIS EMUL F PA; QL(2 mldaily)

RESTASIS MULTIDOSEEMUL F PA; QL(2 ml

daily)Ophthalmic Integrin AntagonistsXIIDRA SOLN F PA

Ophthalmic Steroidsbacitracin-poly-neomycin-hc oint F

DEXAMETHASONESODIUM PHOSPHATESOLN

FPA

DUREZOL EMUL F PA

FLAREX SUSP F PA

fluorometholone (ophth)susp 0.1 % F PA

MAXIDEX SUSP 0.1 % F PA

neomycin-polymy-dexameth oint F

neomycin-polymy-dexameth susp F


34

Drug Name DrugTier

Requirements/Limits

NEOMYCIN/POLYMYXIN/HYDROCORTISONESUSP

F

PRED FORTE SUSP F

PRED MILD SUSP F PA

PRED-G S.O.P. OINT F PA

PRED-G SUSP F PA

PREDNISOLONEACETATE P-F SUSP F

PREDNISOLONEACETATE SUSP F

PREDNISOLONE SODIUMPHOSPHATE SOLN OP 1%

F

sulfacetamide sod-prednisolone soln 10%-0.23%

F

SULFACETAMIDESODIUM/PREDNISOLONESODIUM PHOSPHATESOLN 10%-0.23%

F

TOBRADEX OINT F

TOBRADEX ST SUSP F

tobramycin-dexamethasone susp F

Ophthalmics - Misc.cromolyn sodium (ophth)soln F PA

diclofenac sodium (ophth)soln F

DORZOLAMIDE HCLSOLN 2 % F

dorzolamide hcl soln 2 % F

flurbiprofen sodium soln F

FLURBIPROFEN SODIUMSOLN F

ketorolac tromethamine(ophth) soln 0.4 % F

Drug Name DrugTier

Requirements/Limits

ketorolac tromethamine(ophth) soln 0.5 % F PA

ketotifen fumarate (ophth)soln 0.025 % F

MURO 128 SOLN 2 % F PA

sodium chloride hypertonicoint F PA

sodium chloride hypertonicsoln F PA

Prostaglandins - Ophthalmic

latanoprost soln 0.005 % F QL(0.09 mldaily)

LATANOPROST SOLN0.005 % F QL(0.09 ml

daily)

OTIC AGENTS - Drugs to Treat the Ear

Otic Anti-infectivesofloxacin (otic) soln 0.3 % F PA

Otic Combinationsneomycin-polymyxin-hc(otic) soln F PA

neomycin-polymyxin-hc(otic) susp F PA

pramoxine-hc-chloroxylenolsoln 10mg/ml-1mg/ml-10mg/ml

FPA

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillinsamoxicillin caps 250 mg,500 mg F

AMOXICILLIN CHEW 250MG F

amoxicillin susr 125mg/5ml, 200 mg/5ml, 250mg/5ml, 400 mg/5ml

F

amoxicillin tabs 500 mg,875 mg F

AMPICILLIN CAPS F

Natural Penicillins


35

Drug Name DrugTier

Requirements/Limits

PENICILLIN VPOTASSIUM SOLR 250MG/5ML

F

penicillin v potassium tabs250 mg, 500 mg F

Penicillin Combinationsamoxicillin & potclavulanate susr400mg/5ml-57mg/5ml,250mg/5ml-62.5mg/5ml,600mg/5ml-42.9mg/5ml

F

amoxicillin & potclavulanate tabs 500mg-125mg, 875mg-125mg

F

amoxicillin & potclavulanate tb12 1000mg-62.5mg

F

AMOXICILLIN/CLAVULANATE POTASSIUM CHEW400MG-57MG

F

AMOXICILLIN/CLAVULANATE POTASSIUM ERTB12

F

Penicillinase-Resistant Penicillinsdicloxacillin sodium caps F

PSYCHOTHERAPEUTIC AND NEUROLOGICALAGENTS - MISC. - Drugs to Treat Mental andEmotional ConditionsAgents for Chemical Dependencyacamprosate calcium tbec F PA

disulfiram tabs F PA

Antidementia Agentsmemantine hcl soln 2mg/ml, 10 mg/5ml F PA

memantine hcl tabs F PA

memantine hcl tabs 5 mg,10 mg F PA; QL(2 ea

daily)Fibromyalgia AgentsSAVELLA TABS F PA

SAVELLA TITRATIONPACK MISC F PA

Drug Name DrugTier

Requirements/Limits

Postherpetic Neuralgia (PHN)/Neuropathic PainLYRICA CR TB24 F QL(1 ea daily)

Psychotherapeutic and Neurological Agents -ERGOLOID MESYLATESTABS F PA

Restless Leg Syndrome (RLS) AgentsHORIZANT TBCR F PA

Smoking Deterrentsbupropion hcl (smokingdeterrent) tb12 150 mg F PA

CHANTIX CONTINUINGMONTHPAK TABS F PA

CHANTIX STARTINGMONTH PAK TABS F PA

CHANTIX TABS F PA

nicotine polacrilex gum F PA

nicotine polacrilex lozg F PA

nicotine pt24 F PA

NICOTINETRANSDERMAL SYSTEMKIT

FPA

TETRACYCLINES - Drugs to Treat BacterialInfectionsTetracyclinesdoxycycline (monohydrate)caps 50 mg, 75 mg, 100mg

F

doxycycline (monohydrate)tabs 50 mg, 75 mg, 100mg, 150 mg

F

doxycycline hyclate caps50 mg, 100 mg F

doxycycline hyclate tabs100 mg F

minocycline hcl caps 50mg, 75 mg, 100 mg F

minocycline hcl tb24 45mg, 90 mg, 135 mg F PA


36

Drug Name DrugTier

Requirements/Limits

tetracycline hcl caps F

THYROID AGENTS - Drugs to Regulate ThyroidHormonesAntithyroid Agentsmethimazole tabs F PA

propylthiouracil tabs F PA

Thyroid Hormoneslevothyroxine sodium tabs F PA

liothyronine sodium tabs F PA

ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach ConditionsAntispasmodicsBELLADONNA/OPIUMSUPP 60MG-16.2MG F PA

chlordiazepoxide hcl-clidinium bromide caps2.5mg-5mg

F

CUVPOSA SOLN F PA

dicyclomine hcl caps F

dicyclomine hcl soln F

dicyclomine hcl tabs F

glycopyrrolate tabs 1 mg, 2mg F

hyoscyamine sulfate elix F

hyoscyamine sulfate soln F

hyoscyamine sulfate subl F

hyoscyamine sulfate tabs F

hyoscyamine sulfate tb12 F

hyoscyamine sulfate tbdp F

methscopolamine bromidetabs F

Drug Name DrugTier

Requirements/Limits

phenobarbital-hyoscyamine-atropine-scopolamine elix

F

phenobarbital-hyoscyamine-atropine-scopolamine tabs

F

PROPANTHELINEBROMIDE TABS F

H-2 AntagonistsCIMETIDINE HCL SOLN F

cimetidine tabs 200 mg F QL(1 ea daily);RX/OTC

cimetidine tabs 300 mg,400 mg, 800 mg F QL(2 ea daily)

famotidine susr 40 mg/5ml F

famotidine tabs 10 mg, 40mg F QL(2 ea daily)

famotidine tabs 20 mg F QL(2 ea daily);RX/OTC

nizatidine caps 150 mg,300 mg F QL(2 ea daily)

NIZATIDINE SOLN 15MG/ML F

ranitidine hcl caps 150 mg,300 mg F

ranitidine hcl syrp 15mg/ml, 75 mg/5ml, 150mg/10ml

F

ranitidine hcl tabs 150 mg F QL(2 ea daily);RX/OTC

ranitidine hcl tabs 75 mg,300 mg F QL(2 ea daily)

Misc. Anti-UlcerCARAFATE SUSP 1GM/10ML F

sucralfate tabs F

Proton Pump Inhibitors

DEXILANT CPDR F PA; QL(1 eadaily)

esomeprazole magnesiumcpdr 20 mg F QL(1 ea daily);

RX/OTCesomeprazole magnesiumcpdr 40 mg F QL(1 ea daily)


37

Drug Name DrugTier

Requirements/Limits

lansoprazole cpdr 15 mg F QL(2 ea daily);RX/OTC

lansoprazole cpdr 30 mg F QL(2 ea daily)

NEXIUM PACK 10 MG, 20MG, 40 MG F PA; QL(1 ea

daily)NEXIUM PACK 5 MG, 2.5MG F PA

omeprazole cpdr 10 mg, 40mg F QL(2 ea daily)

omeprazole cpdr 20 mg F QL(2 ea daily);RX/OTC

omeprazole magnesiumcpdr F

omeprazole tbec 20 mg F QL(2 ea daily)

OMEPRAZOLE TBEC 20MG F QL(2 ea daily)

pantoprazole sodium tbec20 mg F QL(1 ea daily)

pantoprazole sodium tbec40 mg F QL(2 ea daily)

PRILOSEC PACK F PA

PROTONIX PACK 40 MG F PA

rabeprazole sodium tbec20 mg F QL(4 ea daily)

SW OMEPRAZOLE TBEC F QL(2 ea daily)

Ulcer Drugs - Prostaglandinsmisoprostol tabs F

Ulcer Therapy Combinationsamoxicillin-clarithromycinw/ lansoprazole misc30mg-500mg-500mg

FPA

famotidine-calciumcarbonate-magnesiumhydroxide chew 10mg-165mg-800mg

F

PA

omeprazole-sodiumbicarbonate caps 20mg-1100mg

FPA; RX/OTC

omeprazole-sodiumbicarbonate caps 40mg-1100mg

FPA

Drug Name DrugTier

Requirements/Limits

omeprazole-sodiumbicarbonate pack 20mg-1680mg, 40mg-1680mg

FPA

PYLERA CAPS F PA

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney InfectionsUrinary Anti-infective CombinationsHYOPHEN TABS F

methenamine-hyosc-methylene blue-benzoicacid-phenyl sal tabs

F

methenamine-hyosc-methylene blue-sod phos-phenyl sal caps

F

methenamine-hyosc-methylene blue-sod phos-phenyl sal tabs

F

methenamine-hyoscamine-methylene blue-sodiumphosphate caps

F

methenamine-hyoscamine-methylene blue-sodiumphosphate tabs

F

URIMAR-T TABS F

UTA CAPS F

Urinary Anti-infectivesmethenamine hippuratetabs 1 gm F

methenamine mandelatetabs F

MONUROL PACK F

nitrofurantoin macrocrystalcaps F

nitrofurantoin monohydmacro caps 100 mg F

nitrofurantoin susp 25mg/5ml F

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder SpasmsUrinary Antispasmodic - Antimuscarinics


38

Drug Name DrugTier

Requirements/Limits

darifenacin hydrobromidetb24 F PA

GELNIQUE GEL F PA

GELNIQUE PUMP GEL F PA

oxybutynin chloride syrp 5mg/5ml F

oxybutynin chloride tabs 5mg F

oxybutynin chloride tb24 10mg, 15 mg F QL(2 ea daily)

oxybutynin chloride tb24 5mg F QL(1 ea daily)

OXYTROL FOR WOMENPTTW F PA; QL(0.29 ea

daily); RX/OTC

OXYTROL PTTW F PA; QL(0.29 eadaily); RX/OTC

solifenacin succinate tabs F PA

tolterodine tartrate cp24 2mg, 4 mg F PA; QL(1 ea

daily)tolterodine tartrate tabs 1mg, 2 mg F PA; QL(2 ea

daily)

TOVIAZ TB24 F PA

trospium chloride cp24 F PA

trospium chloride tabs F PA

Urinary Antispasmodics - Beta-3 Adrenergic

MYRBETRIQ TB24 F PA; QL(1 eadaily)

Urinary Antispasmodics - Cholinergic Agonistsbethanechol chloride tabs F

Urinary Antispasmodics - Direct Muscle Relaxantsflavoxate hcl tabs F

VASOPRESSORS - Drugs to Treat Heart andCirculation ConditionsAnaphylaxis Therapy AgentsAUVI-Q SOAJ F PA

epinephrine (anaphylaxis)soaj F PA

Drug Name DrugTier

Requirements/Limits

EPINEPHRINE SOAJ F PA

Vasopressorsmidodrine hcl tabs F PA


39

IndexABSTRAL 3acamprosate calcium 37acarbose 11acebutolol hcl 20acetaminophen 3acetaminophen w/ codeine 4acetaminophen-caffeine 2acetazolamide 29acitretin 25ACTOPLUS MET XR 11acyclovir 20acyclovir topical 25adefovir dipivoxil 19ADEMPAS 22ADMELOG 12ADVAIR HFA 8AIMOVIG 33ALA SCALP 25ALA-QUIN 23albuterol sulfate 8ALBUTEROL SULFATE ER 8ALBUTEROL SULFATE HFA 8alclometasone dipropionate 25ALDACTAZIDE 29ALENDRONATE SODIUM 29alendronate sodium 29ALENDRONATE SODIUM 29ALER-DRYL 14alfuzosin hcl 30ALINIA 5ALLEGRA ALLERGYCHILDRENS 14ALLI 1allopurinol 31almotriptan malate 33ALOGLIPTIN 12ALOGLIPTIN/METFORMINHCL 11ALOGLIPTIN/PIOGLITAZONE

11alosetron hcl 30alprazolam 6ALPRAZOLAM INTENSOL 6ALTOPREV 15ALVESCO 7amantadine hcl 18ambrisentan 22

AMCINONIDE 25AMERICAINE 28amiloride &hydrochlorothiazide 29amiloride hcl 29amiodarone hcl 7AMITIZA 30amitriptyline hcl 11amlodipine besylate 21amlodipine besylate-benazeprilhcl 16amlodipine besylate-olmesartanmedoxomil 16amlodipine besylate-valsartan 17amlodipine-valsartan-hydrochlorothiazide 17amoxicillin 36AMOXICILLIN 36amoxicillin 36amoxicillin & potclavulanate 37amoxicillin-clarithromycin w/lansoprazole 39AMOXICILLIN/CLAVULANATEPOTASSIUM 37AMOXICILLIN/CLAVULANATEPOTASSIUM ER 37amphetamine-dextroamphetamine 1AMPICILLIN 36anagrelide hcl 31ANDRODERM 5ANORO ELLIPTA 8ANZEMET 13APIDRA 12aprepitant 14APTIOM 9aripiprazole 19armodafinil 1ARTHRITIS PAINRELIEVING 28artificial tear solution 34ARYMO ER 3ASCRIPTIN MAXIMUMSTRENGTH 3ASMANEX TWISTHALER 120METERED DOSES 7ASMANEX TWISTHALER 14METERED DOSES 7ASMANEX TWISTHALER 30METERED DOSES 7

ASMANEX TWISTHALER 60METERED DOSES 7ASMANEX TWISTHALER 7METERED DOSES 7aspirin 3ASPIRIN 3aspirin 3aspirin buffered (cal carb-magcarb-mag oxide) 3aspirin-dipyridamole 31atenolol 20atenolol & chlorthalidone 17atomoxetine hcl 1atorvastatin calcium 15atovaquone 5atovaquone-proguanil hcl 17ATROPINE SULFATE 35ATROVENT HFA 7AUGMENTEDBETAMETHASONEDIPROPIONATE 25AUVI-Q 40AVANDIA 12AVEENO ANTI-ITCH 28AZASITE 35azelastine hcl 34azithromycin 33AZOLEN TINCTURE 23BACITRACIN 35bacitracin (topical) 23bacitracin zinc 23bacitracin-poly-neomycin-hc 35bacitracin-polymyxin b 23bacitracin-polymyxin b(ophth) 35baclofen 34BAMA FREEZE 23BAND-AID ANTISEPTICWASHHURT-FREE 28BARACLUDE 19BECONASE AQ 34BELLADONNA/OPIUM 38BELSOMRA 31BELVIQ 1BELVIQ XR 1benazepril &hydrochlorothiazide 17benazepril hcl 16BENGAY COLD THERAPY 23

Index 1

benzocaine (topical) 28benztropine mesylate 18BESIVANCE 35BETADINE OPHTHALMICPREP 35betamethasone dipropionate(topical) 25betamethasone dipropionateaugmented 25betamethasone valerate 26bethanechol chloride 40BIDIL 21BIOFREEZE 23bisacodyl 32bismuth subsalicylate 13bisoprolol &hydrochlorothiazide 17bisoprolol fumarate 20BLACK DRAUGHT 32BLIS-TO-SOL 24bosentan 22BREEZEE MIST 24BREO ELLIPTA 8bromocriptine mesylate 18BROVANA 8budesonide 22budesonide (inhalation) 7budesonide (nasal) 34BUFFERIN EXTRASTRENGTH 3BUFFERIN LOW DOSE 3bumetanide 29buprenorphine 5BUPRENORPHINE 5bupropion hcl 10bupropion hcl (smokingdeterrent) 37buspirone hcl 6butalbital-acetaminophen 3butalbital-acetaminophen-caffeine 3butalbital-acetaminophen-caffeine w/ codeine 4butalbital-aspirin-caffeine 3butalbital-aspirin-caffeinew/cod 4butenafine hcl 24butorphanol tartrate 5BUTRANS 5BYDUREON 12

BYDUREON PEN 12BYETTA 12BYSTOLIC 20BYVALSON 17calcipotriene-betamethasonedipropionate 26calcium acetate (phosphatebinder) 30calcium polycarbophil 31camphor & menthol 25camphor & phenol 25candesartan cilexetil 16candesartan cilexetil-hydrochlorothiazide 17CAPSAGEL 28CAPSAGEL EXTRASTRENGTH 28capsaicin 28capsaicin-menthol-methylsalicylate 28captopril 16CAPTOPRIL/HYDROCHLOROTHIAZIDE 17CARAC 25CARAFATE 38carbamazepine 9carbidopa 18carbidopa-levodopa 18carboxymethylcellulose sodium(ophth) 34CARDIZEM LA 21CARDURA XL 30carvedilol 20carvedilol phosphate 20castellani paint 24castor oil 32cefadroxil 22cefdinir 22cefprozil 22CEFTIN 22cefuroxime axetil 22celecoxib 2CELONTIN 10CENTANY 23cephalexin 22CEPHALEXIN 22CERAVE ITCH RELIEF 28CESAMET 14CETACAINE 28

cetirizine hcl 14CHANTIX 37CHANTIX CONTINUINGMONTHPAK 37CHANTIX STARTING MONTHPAK 37CHIGGEREX 28chlordiazepoxide hcl 6chlordiazepoxide hcl-clidiniumbromide 38CHLOROQUINEPHOSPHATE 18chloroquine phosphate 18chlorpheniramine maleate 14chlorpromazine hcl 19chlorthalidone 29cholestyramine 15cholestyramine light 15choline & mag salicylate 3choline fenofibrate 15ciclopirox 24ciclopirox olamine 24cilostazol 31CILOXAN 35cimetidine 38CIMETIDINE HCL 38CINQAIR 7CIPRO 29ciprofloxacin 29CIPROFLOXACIN HCL 29ciprofloxacin hcl 29ciprofloxacin hcl (ophth) 35citalopram hydrobromide 10CLARITHROMYCIN 33clarithromycin 33CLARITIN REDITABS 14clindamycin hcl 6clindamycin palmitatehydrochloride 6clobazam 9clobetasol propionate 26CLOCORTOLONEPIVALATE 26CLOCORTOLONE PIVALATEPUMP 26CLODAN KIT 26CLODERM 26CLODERM PUMP 26clomipramine hcl 11

Index 2

clonazepam 9clonidine 16clonidine hcl 16clopidogrel bisulfate 31clorazepate dipotassium 6clotrimazole (topical) 24clotrimazole w/betamethasone 24clozapine 19COARTEM 18COCA COLA SYRUP 14COCAINE HCL 28CODEINE SULFATE 3codeine sulfate 3COLCHICINE 31colchicine w/ probenecid 31COLCRYS 31COLD THERAPY PAINRELIEF 23colesevelam hcl 15colestipol hcl 15COMBIGAN 34COMBIVENT RESPIMAT 8CORDRAN 26CORTANE-B 26CORTISONE ACETATE 22CORTISPORIN 23CORZIDE 17cromolyn sodium 7cromolyn sodium(mastocytosis) 30cromolyn sodium (nasal) 34cromolyn sodium (ophth) 36CULTURELLE DIGESTIVEHEALTH WOMENS HEALTHYBALANCE 13CUVPOSA 38CVS HDYROCORTISONEACETATE 26CVS LUBRICANT GELDROPS 34CVS NATURAL FIBERSUPPLEMENT 31cyclobenzaprine hcl 34cyclopentolate hcl 35cycloserine 18cyproheptadine hcl 15DAKLINZA 19danazol 5

dantrolene sodium 34dapsone 5darifenacin hydrobromide 40DEMSER 16DENAVIR 25DERMASORB AF 24desipramine hcl 11desonide 26desoximetasone 26desvenlafaxine succinate 11dexamethasone 22DEXAMETHASONE 22dexamethasone 22DEXAMETHASONE 22dexamethasone 22DEXAMETHASONEINTENSOL 22DEXAMETHASONE SODIUMPHOSPHATE 35DEXILANT 38dextroamphetamine sulfate 1DIASTAT ACUDIAL 9DIASTAT PEDIATRIC 9diazepam 6DIAZEPAM 6diazepam 6DIAZEPAM RECTAL GEL 9dibucaine 28DICLOFENACEPOLAMINE 23diclofenac potassium 2diclofenac sodium 2diclofenac sodium (actinickeratoses) 25diclofenac sodium (ophth) 36diclofenac sodium (topical) 23diclofenac w/ misoprostol 2dicloxacillin sodium 37dicyclomine hcl 38DIFLORASONEDIACETATE 26diflorasone diacetate 26diflunisal 3DIGOXIN 21digoxin 21DILANTIN 10DILT-XR 21diltiazem hcl 21

diltiazem hcl coated beads 21diltiazem hcl extended releasebeads 21dimenhydrinate 14diphenhydramine hcl 14diphenhydramine-acetaminophen(sleep) 31diphenoxylate w/ atropine 13DIPHENOXYLATE/ATROPINE

13disopyramide phosphate 7disulfiram 37divalproex sodium 10docosanol 25docusate calcium 33docusate sodium 33dofetilide 7DORZOLAMIDE HCL 36dorzolamide hcl 36dorzolamide hcl-timololmaleate 34DORZOLAMIDE HCL/TIMOLOLMALEATE 34doxazosin mesylate 16doxepin hcl 11DOXEPIN HCL 11doxepin hcl 11doxycycline (monohydrate) 37doxycycline hyclate 37DRAMAMINE 14dronabinol 14duloxetine hcl 11DUOPA 18DUREZOL 35dutasteride 30dyphylline-guaifenesin 7E.E.S. 400 33econazole nitrate 24eletriptan hydrobromide 33ELIQUIS 8ELIQUIS STARTER PACK 8ELIXOPHYLLIN 8EMBEDA 3EMEND 14enalapril maleate 16enalapril maleate &hydrochlorothiazide 17enoxaparin sodium 9entacapone 18

Index 3

entecavir 19ENTEREG 30EPANED 16EPCLUSA 19EPIFOAM 26EPINEPHRINE 40epinephrine (anaphylaxis) 40EPIVIR HBV 20eplerenone 17EPROSARTAN MESYLATE 16EQUALACTIN 31EQUETRO 19ERGOLOID MESYLATES 37ERGOMAR 33ergotamine w/ caffeine 33ERTACZO 24ERYTHROCIN STEARATE 33erythromycin (ophth) 35erythromycin base 33erythromycin ethylsuccinate 33ERYTHROMYCINETHYLSUCCINATE 33escitalopram oxalate 10esomeprazole magnesium 38eszopiclone 31ethambutol hcl 18ethosuximide 10ETHYL CHLORIDE 28ETHYL CHLORIDE/FINEPINPOINT 28ETHYL CHLORIDE/FINESTREAM 28ETHYL CHLORIDE/MEDIUMJET STREAM 28ETHYL CHLORIDE/MEDIUMSTREAM 28ETHYL CHLORIDE/MIST 28ETIDRONATE DISODIUM 29etodolac 2EVAC-U-GEN 32EXELDERM 24EXODERM 24ezetimibe 16ezetimibe-simvastatin 15famciclovir 20famotidine 38famotidine-calcium carbonate-magnesium hydroxide 39FARXIGA 13

febuxostat 31felbamate 10felodipine 21FENOFIBRATE 15fenofibrate 15fenofibrate micronized 15FENOFIBRIC ACID 15FENOPROFEN CALCIUM 2fenoprofen calcium 2FENORTHO 2fentanyl 3fentanyl citrate 3FENTANYL CITRATE 3FENTORA 3FETZIMA 11FETZIMA TITRATIONPACK 11FEVERALL INFANTS 3FEVERALL JUNIORSTRENGTH 3fexofenadine hcl 14FIBRICOR 15finasteride 30FIRST-VANCOMYCIN 25 5FIRST-VANCOMYCIN 50 5FLAREX 35flavoxate hcl 40flecainide acetate 7FLECTOR 23FLONASE SENSIMIST 34FLORAJENACIDOPHILUS 13FLOVENT DISKUS 7FLOVENT HFA 7fluconazole 14fludrocortisone acetate 23FLUNISOLIDE 34fluocinolone acetonide 26fluocinonide 26fluorometholone (ophth) 35FLUOROPLEX 25FLUOROURACIL 25fluorouracil (topical) 25FLUOXETINE DR 10fluoxetine hcl 10flurandrenolide 26flurbiprofen 2

flurbiprofen sodium 36FLURBIPROFEN SODIUM 36fluticasone propionate 26fluticasone propionate(nasal) 34fluticasone-salmeterol 8fluvoxamine maleate 10FOILLE 28fondaparinux sodium 9FORTEO 29FOSAMAX PLUS D 29fosinopril sodium 16fosinopril sodium &hydrochlorothiazide 17FOSRENOL 30FRAGMIN 9FUNGI-NAIL 24FUNGOID TINCTURE 24furosemide 29FUROSEMIDE 29furosemide 29FYCOMPA 9gabapentin 9GAS-X EXTRA STRENGTH 30GEBAUERS INSTANT ICE 28GEBAUERS PAIN EASE 28GEBAUERS SPRAY ANDSTRETCH 28GELNIQUE 40GELNIQUE PUMP 40GENTAK 35gentamicin sulfate (ophth) 35gentamicin sulfate (topical) 23GENTIAN VIOLET 24glimepiride 13glipizide 13glipizide-metformin hcl 11glyburide 13glyburide micronized 13glyburide-metformin 11glycerin (laxative) 32glycopyrrolate 38GLYXAMBI 11GNP GENTIAN VIOLET 24GORDOCHOM 24GORDONS NO 5 24granisetron hcl 13

Index 4

griseofulvin microsize 14guanfacine hcl 16guanfacine hcl (adhd) 1halcinonide 26halobetasol propionate 26HALOG 27haloperidol 19haloperidol lactate 19HARVONI 20HEPARIN LOCK FLUSH 9heparin sodium (porcine) 9heparin sodium (porcine) lockflush 9homatropine hbr 35HORIZANT 37HUMALOG 12HUMALOG KWIKPEN 12HUMALOG MIX 50/50 12HUMALOG MIX 75/25 12HUMULIN 70/30 12HUMULIN N 12HUMULIN R 12HUMULIN R U-500(CONCENTRATED) 12HUMULIN R U-500KWIKPEN 12hydralazine hcl 17hydrochlorothiazide 29HYDROCIL INSTANT 32HYDROCODONEBITARTRATE/ACETAMINOPHEN 4hydrocodone-acetaminophen 4hydrocodone-ibuprofen 4hydrocortisone 22hydrocortisone (topical) 27hydrocortisone acetate(topical) 27hydrocortisone butyrate 27hydrocortisone valerate 27hydromorphone hcl 3HYDROMORPHONE HCL 3hydromorphone hcl 3hydroxychloroquine sulfate 18HYDROXYZINE HCL 6hydroxyzine hcl 6HYDROXYZINE PAMOATE 6hydroxyzine pamoate 6

HYOPHEN 39hyoscyamine sulfate 38hypromellose (ophth) 34HYSINGLA ER 3ibandronate sodium 29ibuprofen 2ibuprofen-diphenhydraminecitrate 31ibuprofen-diphenhydraminehcl 31imipramine hcl 11imiquimod 27IMIQUIMOD PUMP 27INDOCIN 2indomethacin 2INSULIN LISPRO 12INVOKAMET 11INVOKAMET XR 11INVOKANA 13iodoquinol-hc 24ipratropium bromide 7ipratropium bromide(nasal) 34ipratropium-albuterol 8irbesartan 16irbesartan-hydrochlorothiazide

17isometheptene-dichloralphenazone-acetaminophen 33ISOMETHEPTENE/DICHLORALPHENAZONE/ACETAMINOPHEN 33ISONIAZID 18isoniazid 18ISOPTO ATROPINE 35ISORDIL TITRADOSE 6ISOSORBIDE DINITRATE 6isosorbide dinitrate 6ISOSORBIDE DINITRATEER 6isosorbide mononitrate 6isoxsuprine hcl 21itraconazole 14JANUMET 11JANUMET XR 11JANUVIA 12JARDIANCE 13JENTADUETO XR 11KADIAN 3

KAZANO 11ketoconazole 14ketoconazole (topical) 24ketoprofen 2KETOPROFEN 2KETOPROFEN ER 2ketorolac tromethamine 2ketorolac tromethamine(ophth) 36ketotifen fumarate (ophth) 36KLARITY-A 35KOMBIGLYZE XR 11KONDREMUL 32KONSYL 32KONSYL DAILY FIBER 32KONSYL-D 32KRISTALOSE 32labetalol hcl 20LACTO-BIFIDUS-600 13lactobacillus 13lactobacillus rhamnosus (gg) 13LACTULOSE 32lactulose 32lactulose (encephalopathy) 30LAMICTAL ODT 9LAMICTAL XR 9LAMISIL ADVANCED 24LAMISIL AT SPRAY 24lamivudine (hbv) 20lamotrigine 9lansoprazole 39lanthanum carbonate 30LANTUS 12latanoprost 36LATANOPROST 36LEDIPASVIR/SOFOSBUVIR

20leflunomide 2levalbuterol hcl 8LEVALBUTEROL TARTRATEHFA 8LEVEMIR 12levetiracetam 9levofloxacin 29levofloxacin (ophth) 35levorphanol tartrate 4levothyroxine sodium 38

Index 5

lidocaine 28lidocaine hcl 28lidocaine-prilocaine 28LIDOSOL-HC 27linezolid 6LINZESS 30liothyronine sodium 38LIPOFEN 15lisinopril 16lisinopril &hydrochlorothiazide 17LITHIUM 19lithium carbonate 19loperamide hcl 13loperamide-simethicone 13loratadine 15lorazepam 6LORTAB 4losartan potassium 16losartan potassium &hydrochlorothiazide 17lovastatin 15LYRICA CR 37mafenide acetate 25MARPLAN 10MAXIDEX 35meclizine hcl 14MECLOFENAMATE SODIUM 2MEFLOQUINE HCL 18meloxicam 2memantine hcl 37MENTAX 24menthol (topical analgesic) 23METAMUCIL 32METAMUCIL MULTIHEALTHFIBER 32METAMUCIL MULTIHEALTHFIBER SINGLES 32METAPROTERENOLSULFATE 8metaxalone 34metformin hcl 12METFORMINHYDROCHLORIDE 12methadone hcl 4methazolamide 29methenamine hippurate 39methenamine mandelate 39

methenamine-hyosc-methyleneblue-benzoic acid-phenylsal 39methenamine-hyosc-methyleneblue-sod phos-phenyl sal 39methenamine-hyoscamine-methylene blue-sodiumphosphate 39methimazole 38methocarbamol 34methoxsalen rapid 25methscopolamine bromide 38methylcellulose (laxative) 32METHYLDOPA/HYDROCHLOROTHIAZIDE 17methylphenidate hcl 1methylprednisolone 22metoclopramide hcl 30METOCLOPRAMIDE ODT 30metolazone 29metoprolol &hydrochlorothiazide 17metoprolol succinate 20metoprolol tartrate 20METOPROLOL/HYDROCHLOROTHIAZIDE 17metronidazole 5MEXILETINE HCL 7mexiletine hcl 7miconazole nitrate (topical)24midodrine hcl 40MIGERGOT 33miglitol 11MILLIPRED 23mineral oil 32minocycline hcl 37minoxidil 17mirtazapine 10misoprostol 39MITIGARE 31modafinil 1moexipril hcl 16moexipril-hydrochlorothiazide

17mometasone furoate 27mometasone furoate(nasal) 34montelukast sodium 7MONUROL 39morphine sulfate 4

MORPHINE SULFATE 4morphine sulfate 4MORPHINE SULFATE ER 4MOTOFEN 13MOVANTIK 30MOVIPREP 32moxifloxacin hcl 29moxifloxacin hcl (ophth) 35MUCILIN SF 32MUPIROCIN 23mupirocin 23mupirocin calcium (topical) 23MURO 128 36MUSE 21MYCO NAIL A 24MYRBETRIQ 40nabumetone 2nadolol 20NADOLOL/BENDROFLUMETHIAZIDE 17naftifine hcl 24NAFTIN 24NALFON 2NALOCET 5naphazoline w/ pheniramine 35NAPRELAN 2naproxen 2naproxen sodium 2naratriptan hcl 33NASACORT ALLERGY24HR 34NATACYN 35nateglinide 13NATESTO 5NEBUPENT 5neomycin sulfate 1neomycin-bacitracin zn-polymyxin 35neomycin-bacitracin-polymyxin

23neomycin-bacitracin-polymyxin w/lidocaine 23neomycin-bacitracin-polymyxin-pramoxine 23neomycin-polymy-dexameth 35neomycin-polymyxin w/pramoxine 23neomycin-polymyxin-hc(otic) 36

Index 6

NEOMYCIN/POLYMYXIN/GRAMICIDIN 35NEOMYCIN/POLYMYXIN/HYDROCORTISONE 36NESINA 12NEXIUM 39niacin (antihyperlipidemic) 16nicotine 37nicotine polacrilex 37NICOTINE TRANSDERMALSYSTEM 37nifedipine 21nimodipine 21NITRO-BID 6NITRO-DUR 6NITRO-TIME 6nitrofurantoin 39nitrofurantoin macrocrystal 39nitrofurantoin monohydmacro 39nitroglycerin 6NITROGLYCERIN LINGUAL 6NITROMIST 6nizatidine 38NIZATIDINE 38NORGESIC FORTE 34NORPACE CR 7nortriptyline hcl 11NORTRIPTYLINE HCL 11nortriptyline hcl 11NOVACORT 27NOVOLIN 70/30 12NOVOLIN 70/30 RELION 12NOVOLIN N 12NOVOLIN N RELION 12NOVOLIN R 12NOVOLIN R RELION 12NOVOLOG 12NOVOLOG MIX 70/30 12NOXAFIL 14NUCALA 7NUCYNTA 4NUCYNTA ER 4NUPLAZID 19NYMALIZE 21nystatin 14nystatin (topical) 24nystatin-triamcinolone 24

OCALIVA 30ofloxacin (ophth) 35ofloxacin (otic) 36olanzapine 19olmesartan medoxomil 16olmesartan medoxomil-amlodipine-hydrochlorothiazide

17olmesartan medoxomil-hydrochlorothiazide 17olopatadine hcl (nasal) 34OLYSIO 20omega-3-acid ethyl esters 15omeprazole 39OMEPRAZOLE 39omeprazole magnesium 39omeprazole-sodiumbicarbonate 39OMNARIS 34ondansetron 13ondansetron hcl 13ONGLYZA 12OPANA ER (CRUSHRESISTANT) 4OPSUMIT 22ORAL SALINE LAXATIVE 32ORENITRAM 22orphenadrine citrate 34ORPHENADRINECITRATE/ASPIRIN/CAFFEINE

34ORPHENGESIC FORTE 34oseltamivir phosphate 20OSENI 12OSMOPREP 32OTEZLA 2OUTGRO PAIN RELIEF 28oxandrolone 5oxaprozin 2oxazepam 6OXAZEPAM 6oxcarbazepine 9oxiconazole nitrate 24OXISTAT 24oxybutynin chloride 40oxycodone hcl 4OXYCODONE HCL ER 4OXYCODONEHYDROCHLORIDE ER 4

oxycodone w/ acetaminophen 5OXYCODONE/ACETAMINOPHEN 5OXYCODONE/IBUPROFEN 5OXYCONTIN 4oxymorphone hcl 4OXYMORPHONEHYDROCHLORIDE ER 4OXYMORPHONEHYDROCHLORIDEER 4OXYTROL 40OXYTROL FOR WOMEN 40PANDEL 27pantoprazole sodium 39paroxetine hcl 10,11PAXIL 11PCE 33peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 32peg 3350-potassium chloride-sodbicarbonate-sod chloride 32PENICILLIN V POTASSIUM 37penicillin v potassium 37pentazocine w/ naloxone 5pentoxifylline 31PERFOROMIST 8perphenazine 19phenelzine sulfate 10phenobarbital 31phenobarbital-hyoscyamine-atropine-scopolamine 38phenoxybenzamine hcl 16phenytoin 10phenytoin sodium extended 10PHOSLYRA 30pimecrolimus 27pindolol 20pioglitazone hcl 12pioglitazone hcl-glimepiride 12pioglitazone hcl-metforminhcl 12piroxicam 2polyethylene glycol 3350 32polymyxin b-trimethoprim 35polyvinyl alcohol 34posaconazole 14POVIDONE IODINE 35PRADAXA 9pramipexole dihydrochloride 18

Index 7

PRAMOSONE 27pramoxine hcl 28pramoxine-hc 27pramoxine-hc-chloroxylenol 36pramoxine-zinc acetate 28prasugrel hcl 31pravastatin sodium 15prazosin hcl 16PRED FORTE 36PRED MILD 36PRED-G 36PRED-G S.O.P. 36PREDNICARBATE 27prednicarbate 27prednisolone 23PREDNISOLONE 23PREDNISOLONE ACETATE36PREDNISOLONE ACETATE P-F 36prednisolone sodiumphosphate 23PREDNISOLONE SODIUMPHOSPHATE 36PREDNISONE 23prednisone 23PREDNISONE 23PREDNISONE INTENSOL 23pregabalin 9PRILOSEC 39primaquine phosphate 18primidone 9PRIMLEV 5PROAIR HFA 8PROAIR RESPICLICK 8probenecid 31PROBIOTIC 13PROBIOTIC GOLD EXTRASTRENGTH 13prochlorperazine 19prochlorperazine maleate 19PROLIA 29promethazine hcl 15PROPANTHELINEBROMIDE 38propranolol hcl 20PROPRANOLOL HCL 20propranolol hcl 20PROPRANOLOL/HYDROCHLOROTHIAZIDE 17

propylthiouracil 38PROTONIX 39PROVENTIL HFA 8PSORCON 27psyllium 32PULMICORT FLEXHALER 7PYLERA 39pyrazinamide 18pyrethrins-piperonylbutoxide 28QBRELIS 16QSYMIA 1QUDEXY XR 9quetiapine fumarate 19QUILLIVANT XR 1quinapril hcl 16quinapril-hydrochlorothiazide

17quinidine gluconate 7QUINIDINE SULFATE 7quinine sulfate 18QVAR 8QVAR REDIHALER 8RA ANTI-FUNGAL FOOTCARE 24rabeprazole sodium 39ramelteon 31ramipril 16ranitidine hcl 38ranolazine 6RAPAFLO 30REGENECARE HA 28RELENZA DISKHALER 20RELISTOR 30REMICADE 30RENAGEL 30repaglinide 13REPHRESH PRO-B 13RESTASIS 35RESTASIS MULTIDOSE 35RETAINE HPMC 34REXULTI 19RIBASPHERE 20ribavirin (hepatitis c) 20RIDAURA 1rifabutin 18RIFAMATE 18

rifampin 18RIFATER 18RIOMET 12risedronate sodium 29risperidone 19RISPERIDONE ODT 19rizatriptan benzoate 33ropinirole hydrochloride 18rosuvastatin calcium 15salsalate 3SANCUSO 14SAVELLA 37SAVELLA TITRATIONPACK 37scopolamine 14SEEBRI NEOHALER 7selegiline hcl 18SELEGILINE HCL 19SENNA 32sennosides 32sennosides-docusatesodium 32SEREVENT DISKUS 8sertraline hcl 11sevelamer carbonate 30sevelamer hcl 30SEVELAMERHYDROCHLORIDE 30sildenafil citrate 21sildenafil citrate (pulmonaryhypertension) 22silodosin 30silver sulfadiazine 25simethicone 30simvastatin 15,16SIRTURO 18SIVEXTRO 6sodium chloride hypertonic 36sodium phosphates 32SOFOSBUVIR/VELPATASVIR

20solifenacin succinate 40SORBITOL 32sotalol hcl 20sotalol hcl (afib/afl) 20SOVALDI 20SPIRIVA HANDIHALER 7SPIRIVA RESPIMAT 7

Index 8

spironolactone 29spironolactone &hydrochlorothiazide 29STENDRA 21STRIVERDI RESPIMAT 8sucralfate 38sulfacetamide sod-prednisolone 36SULFACETAMIDE SODIUM 35sulfacetamide sodium(ophth) 35SULFACETAMIDESODIUM/PREDNISOLONESODIUM PHOSPHATE 36sulfamethoxazole-trimethoprim 5SULFAMYLON 25sulindac 2sumatriptan 33sumatriptan succinate 33SUMATRIPTANSUCCINATE 33sumatriptan succinate 33sumatriptan-naproxensodium 33SW OMEPRAZOLE 39SYMBICORT 8SYMLINPEN 120 11SYMLINPEN 60 11SYNALAR CREAM KIT 27SYNJARDY 12SYNJARDY XR 12TACLONEX 27tacrolimus (topical) 27tadalafil 21tadalafil (pulmonaryhypertension) 22tamsulosin hcl 30TANZEUM 12TAPERDEX 12-DAY 23TECHNIVIE 20telmisartan 16telmisartan-amlodipine 17telmisartan-hydrochlorothiazide

17temazepam 31TENCON 3terazosin hcl 16terbinafine hcl 14terbinafine hcl (topical) 25

terbutaline sulfate 8testosterone 5TESTOSTERONE 5TESTOSTERONE PUMP 5tetracycline hcl 38tetrahydrozoline hcl(ophth) 35THEO-24 8THEOCHRON 8theophylline 8THEOPHYLLINE ER 8tiagabine hcl 10TIMOLOL MALEATE 20timolol maleate 20tinidazole 5tizanidine hcl 34TOBRADEX 36TOBRADEX ST 36tobramycin (ophth) 35tobramycin-dexamethasone 36TOBREX 35TOLMETIN SODIUM 2tolnaftate 25tolterodine tartrate 40topiramate 9TOPIRAMATE ER 9TOVIAZ 40TRACLEER 22TRADJENTA 12tramadol hcl 4tramadol-acetaminophen 5trandolapril 16tranylcypromine sulfate 10trazodone hcl 11TRECATOR 18TRELEGY ELLIPTA 8TRESIBA FLEXTOUCH 13triamcinolone acetonide(nasal) 34triamcinolone acetonide(topical) 27triamterene &hydrochlorothiazide 29TRIANEX 27TRIGLIDE 15trihexyphenidyl hcl 18trimethobenzamide hcl 14

trimethoprim 5trospium chloride 40TRULANCE 29TUDORZA PRESSAIR 7TYLENOL PM EXTRASTRENGTH 31TYVASO 22TYVASO REFILL 22TYVASO STARTER 22ULTRACIN M 23undecylenic acid 25UNDELENIC TINCTURE 25UNGUENTINE 25UNGUENTINE MAXIMUMSTRENGTH 25UPTRAVI 22URIMAR-T 39UTA 39UTIBRON NEOHALER 8valacyclovir hcl 20valganciclovir hcl 19valproate sodium 10valproic acid 10valsartan 16valsartan-hydrochlorothiazide

17VANALICE 28VANCOMYCIN HCL +SYRSPENDSF PH4 5vardenafil hcl 21VASCEPA 15VEMLIDY 20venlafaxine hcl 11VENTAVIS 22VENTOLIN HFA 8verapamil hcl 21VERAPAMIL HCL ER 21VERAPAMIL HCL SR 21VERELAN 21VERELAN PM 21VERSACLOZ 19VIBERZI 30VICTOZA 12VIMPAT 10VOGELXO 5VOGELXO PUMP 5voriconazole 14VRAYLAR 19

Index 9

VYVANSE 1warfarin sodium 8XARELTO 8XARELTO STARTER PACK 8XENICAL 1XGEVA 29XIFAXAN 5XIGDUO XR 12XIIDRA 35XOPENEX HFA 8XTAMPZA ER 4zafirlukast 7zaleplon 31ZAMICET 5ZELAPAR 19ZEPATIER 20ZETONNA 34zileuton 7ZIMS MAX-FREEZE 23ziprasidone hcl 19ZODEX 12-DAY 23ZOHYDRO ER 4zoledronic acid 29zolmitriptan 33,34zolpidem tartrate 31ZOMIG 34zonisamide 10ZONTIVITY 31ZOSTRIX-HP 28ZYCLARA 27ZYCLARA PUMP 27ZYFLO 7

Index 10

drug name drug requirements/ drug name drug ......drug name drug tier requirements/ limits...

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