drug name drug requirements/ drug name drug requirements

2016 State of New York eff 01/01/2016

1PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered underMedicare B or D LA - Limited Access

Drug Name DrugTier

Requirements/Limits

ANALGESICSGOUTallopurinol tab 1ALOPRIM 3colchicine w/ probenecid 1COLCRYS 2probenecid 1ULORIC 2ZYLOPRIM 3MISCELLANEOUSARTHROTEC 50 3ARTHROTEC 75 3diclofenac w/ misoprostol 1NSAIDSANAPROX 3ANAPROX DS 3CELEBREX CAP 50MG 3CELEBREX CAP 100MG 3CELEBREX CAP 200MG 3CELEBREX CAP 400MG 3celecoxib CAPS 1DAYPRO 3diclofenac potassium 1diclofenac sodium TB24;TBEC

1

diflunisal 1EC-NAPROSYN 3etodolac 1etodolac er 1FELDENE 3fenoprofen calcium TABS 1flurbiprofen TABS 1ibuprofen SUSP 1ibuprofen TABS 400mg,600mg, 800mg

1

ketoprofen CAPS; CP24 1mefenamic acid CAPS 1MELOXICAM SUSP 1meloxicam tabs 1MOBIC 3nabumetone TABS 1NAPRELAN 3NAPROSYN TABS 3

Drug Name DrugTier

Requirements/Limits

naproxen SUSP; TABS;TBEC

1

naproxen sodium TABS275mg, 550mg

1

naproxen sodium TB24375mg

3

NAPROXEN SODIUM TB24500mg

3

oxaprozin 1piroxicam CAPS 1PONSTEL 3sulindac TABS 1tolmetin sodium 1VOLTAREN-XR 3OPIOID ANALGESICSacetaminophen w/ codeineSOLN

QL (5000 mL / 30 days)

1 QL

acetaminophen w/ codeineTABS

QL (400 tabs / 30 days)

1 QL

acetaminophen-caff-dihydrocod

QL (360 caps / 30 days)

1 QL

ASPIRIN-CAFFEINE-DIHYDROCODEINEBITARTRATE

1

butorphanol nasal spray 1butorphanol tartrate SOLN 1BUTRANS 5mcg/hr

QL (16 patches / 28days)

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 codeineQL (5000 mL / 30 days)

3 QL

nalbuphine hcl SOLN 1SYNALGOS-DC 3TRAMADOL HCL CP24 1tramadol hcl er TB24 100mg,200mg

1

TRAMADOL HCL ER TB24300mg

1

tramadol hcl er (biphasic)100mg

1



Drug Name DrugTier

Requirements/Limits


1


1

tramadol hcl tab 50 mg 1tramadol-acetaminophen

QL (240 tabs / 30 days)1 QL

trezixQL (360 caps / 30 days)

3 QL

tylenol with codeineQL (400 tabs / 30 days)

3 QL

ULTRACETQL (240 tabs / 30 days)

3 QL

ULTRAM 3ULTRAM ER 3OPIOID ANALGESICS, CIIABSTRAL

QL (120 tabs / 30 days)3 QL PA

ACTIQQL (120 lozenges / 30days)

3 QL PA

CODEINE SULFATE 1DILAUDID INJ 3 B/DDILAUDID TAB 3DILAUDID-5 ORAL LIQD 3DILAUDID-HP INJ 10MG/ML 3 B/DDILAUDID-HP INJ 250MG 3 B/DDOLOPHINE


DURAGESICQL (10 patches / 30days)

3 QL

DURAMORPH 1 B/DEMBEDA

QL (60 caps / 30 days)3 QL

endocetQL (360 tabs / 30 days)

1 QL

ENDODAN TAB 1EXALGO


fentanyl citrate LPOPQL (120 lozenges / 30days)

3 QL PA

fentanyl patch 12 mcg/hrQL (10 patches / 30days)

1 QL


1 QL

Drug Name DrugTier

Requirements/Limits


1 QL


1 QL


1 QL

FENTORAQL (120 tabs / 30 days)

3 QL PA

hycetQL (5400 mL / 30 days)

3 QL

hydrocodone-acetaminophen2.5-325mg


1 QL

hydrocodone-acetaminophen5-300mg


1 QL



1 QL



1 QL

hydrocodone-acetaminophen7.5-325 mg/15ml

QL (5400 mL / 30 days)

1 QL



1 QL



1 QL

hydrocodone-acetaminophentab 10-325mg


1 QL

hydrocodone-ibuprofen tab2.5-200mg

1

hydrocodone-ibuprofen tab 5-200mg

1

hydrocodone-ibuprofen tab7.5-200 mg

1

hydrocodone-ibuprofen tab10-200mg

1

hydromorphone hcl LIQD 1HYDROMORPHONE HCLSOLN 1mg/ml, 2mg/ml,4mg/ml

1 B/D

hydromorphone hcl SOLN500mg/50ml

1 B/D

hydromorphone hcl TABS 1



Drug Name DrugTier

Requirements/Limits

hydromorphone tab 8mg erQL (60 tabs / 30 days)

1 QL


1 QL


3 QL

HYDROMORPHONE TABS32MG


3 QL

HYSINGLA ER 20mg, 30mg,40mg, 60mg


3 QL

HYSINGLA ER 80mg,100mg, 120mg


3 QL

ibudone tab 5-200mg 1ibudone tab 10-200mg 1INFUMORPH 200 3 B/DINFUMORPH 500 3 B/DKADIAN


LAZANDAQL (30 bottles / 30 days)

3 QL PA

levorphanol tartrate TABS 1lorcet hd tab 10-325mg


lorcet plus tab 7.5-325QL (360 tabs / 30 days)

1 QL

lorcet tab 5-325mgQL (360 tabs / 30 days)

1 QL

lortab tab 5-325mgQL (360 tabs / 30 days)

1 QL

lortab tab 7.5-325QL (360 tabs / 30 days)

1 QL

lortab tab 10-325mgQL (360 tabs / 30 days)

1 QL

methadone hcl CONCQL (120 mL / 30 days)

1 QL

methadone hcl SOLNQL (600 mL / 30 days)

1 QL

methadone hcl TABSQL (240 tabs / 30 days)

1 QL

METHADONE INJ 10MG/ML 3METHADOSE CONC

QL (120 mL / 30 days)3 QL

MORPHINE SUL 20MG/MLORAL SOL

1

Drug Name DrugTier

Requirements/Limits

morphine sulfate CP2410mg, 20mg, 30mg, 50mg,60mg


1 QL

morphine sulfate CP2480mg, 100mg


3 QL

MORPHINE SULFATE SOLN1mg/ml, 10mg/ml, 15mg/ml

1 B/D

MORPHINE SULFATE SOLN2mg/ml, 4mg/ml, 8mg/ml

3 B/D

MORPHINE SULFATE SOLN10mg/5ml, 20mg/5ml

1

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

1 B/D

MORPHINE SULFATE TABS 1morphine sulfate beads


morphine sulfate ext-rel tab15mg, 30mg, 60mg, 100mg


1 QL

morphine sulfate ext-rel tab200mg


1 QL

MS CONTIN 15mg, 30mg,60mg, 100mg


3 QL

MS CONTIN 200mgQL (60 tabs / 30 days)

3 QL

norcoQL (360 tabs / 30 days)

3 QL

NUCYNTA 2NUCYNTA ER 50mg, 100mg


NUCYNTA ER 150mg,200mg, 250mg


2 QL

OPANA TABS 3OPANA ER (CRUSHRESISTANT


2 QL

oxycodone hcl CAPS; CONC;TABS

1

OXYCODONE HCL SOLN 1oxycodone w/ acetaminophen2.5-325mg


1 QL

oxycodone w/ acetaminophen5-325mg


1 QL



Drug Name DrugTier

Requirements/Limits

oxycodone w/ acetaminophen7.5-325mg


1 QL

oxycodone w/ acetaminophen10-325mg


1 QL

oxycodone-aspirin 1oxycodone-ibuprofen 1OXYCONTIN


oxymorphone hcl TABS 1percocet 2.5/325


percocet 7.5/325QL (360 tabs / 30 days)

3 QL

percocet 10/325QL (360 tabs / 30 days)

3 QL

percocet tab 5-325mgQL (360 tabs / 30 days)

3 QL

PERCODAN 3reprexain tab 2.5-200mg 3reprexain tab 5-200mg 3reprexain tab 10-200mg 1roxicet soln

QL (1800 mL / 30 days)2 QL

roxicet tab 5-325mgQL (360 tabs / 30 days)

1 QL

ROXICODONE 3SUBSYS

QL (120 sprays / 30days)

3 QL PA

vicodinQL (400 tabs / 30 days)

1 QL

vicodin esQL (400 tabs / 30 days)

1 QL

vicodin hpQL (400 tabs / 30 days)

1 QL

VICOPROFEN 3XARTEMIS XR


xodol tab 5-300mgQL (400 tabs / 30 days)

3 QL

xodol tab 7.5-300QL (400 tabs / 30 days)

3 QL

xodol tab 10-300mgQL (400 tabs / 30 days)

3 QL

xylon tab 10-200mg 1zamicet

QL (5400 mL / 30 days)1 QL

Drug Name DrugTier

Requirements/Limits

ZOHYDRO ER (ABUSEDETERRENT) 10mg, 15mg,20mg


3 QL

ZOHYDRO ER (ABUSEDETERRENT) 30mg, 40mg,50mg


3 QL

ANESTHETICSLOCAL ANESTHETICSlidocaine hcl (local anesth.)4%

1

lidocaine hcl (local anesth.).5%, 1%

1 B/D

lidocaine inj 0.5% 1 B/Dlidocaine inj 1% 1 B/Dlidocaine inj 1.5% 1 B/Dlidocaine inj 2% 1 B/DXYLOCAINE .5%, 1%, 2% 3 B/DXYLOCAINE-MPF 4% 3XYLOCAINE-MPF .5%, 1%,1.5%, 2%

3 B/D

ANTI-INFECTIVESANTI-BACTERIALS - MISCELLANEOUSamikacin sulfate SOLN 1BETHKIS 3 B/Dgentamicin in saline 0.8 mg/ml 1gentamicin in saline 0.9mg/ml 3gentamicin in saline 1 mg/ml 1gentamicin in saline 1.2 mg/ml 1gentamicin in saline 1.4mg/ml 3gentamicin in saline 1.6 mg/ml 1gentamicin in saline 2 mg/ml 1gentamicin sulfate SOLN 1neomycin sulfate TABS 1paromomycin sulfate CAPS 1streptomycin sulfate SOLR 1sulfadiazine TABS 3TOBI NEB 3 B/DTOBI PODHALER 3 LA PAtobramycin NEBU 3 B/Dtobramycin sulfate SOLN;SOLR

1

tobramycin sulfate in saline 3ANTI-INFECTIVES - MISCELLANEOUSALBENZA 2



Drug Name DrugTier

Requirements/Limits

ALINIA 2atovaquone SUSP 3AZACTAM 3AZACTAM/DEX INJ 1GM 3AZACTAM/DEX INJ 2GM 3aztreonam 1BACTRIM 3BACTRIM DS 3BILTRICIDE 2CAYSTON 2 LA PAcleocin SOLR 3CLEOCIN CAP 75MG 3CLEOCIN CAP 150MG 3CLEOCIN CAP 300MG 3CLEOCIN IN D5W 3CLEOCIN INJ 3CLEOCIN PHOSPHATE9gm/60ml, 300mg/2ml,600mg/4ml, 900mg/6ml

3

cleocin phosphate 150mg/ml,600mg/4ml

3

clindamycin hcl CAPS 1clindamycin palmitatehydrochloride

1

clindamycin phosphate SOLN 1clindamycin phosphate in d5w 1colistimethate sodium SOLR 1COLY-MYCIN M 3CUBICIN 3DALVANCE 3dapsone TABS 1DARAPRIM 3DORIBAX 3FLAGYL 3FLAGYL ER 3FURADANTIN

90 day limit per calendaryear if 65 years and older

3 PA

HIPREX 3imipenem-cilastatin 1INVANZ 3ivermectin TABS 1linezolid SOLN 3LINEZOLID TABS 3

Drug Name DrugTier

Requirements/Limits

MACROBID90 day limit per calendaryear if 65 years and older

3 PA

MACRODANTIN90 day limit per calendaryear if 65 years and older

3 PA

MEPRON 3meropenem 1MERREM 3methenamine hippurate 1METRO IV 3metronidazole CAPS; TABS 1metronidazole inj 1NEBUPENT 3 B/Dnitrofurantoin SUSP


1 PA

nitrofurantoin macrocrystal90 day limit per calendaryear if 65 years and older

3 PA

nitrofurantoin monohyd macro90 day limit per calendaryear if 65 years and older

3 PA

PENTAM 300 3polymyxin b sulfate SOLR 1PRIMAXIN 3PRIMSOL SOL 50MG/5ML 3SIVEXTRO 3STROMECTOL 3sulfamethoxazole-trimethop 1sulfamethoxazole-trimethoprim inj

1

SYNERCID 3trimethoprim TABS 1TYGACIL 3VANCOCIN HCL 3vancomycin hcl CAPS 3vancomycin hcl inj 5gm 1vancomycin hcl inj 10gm 1vancomycin hcl inj 500mg 1vancomycin hcl inj 750mg 3vancomycin hcl inj 1000mg 1XIFAXAN TAB 200MG 3ZYVOX 3ANTIFUNGALSABELCET 3 B/D



Drug Name DrugTier

Requirements/Limits

AMBISOME 3 B/DAMPHOTEC 3 B/Damphotericin b SOLR 1 B/DANCOBON 3CANCIDAS 3CRESEMBA 3DIFLUCAN 3ERAXIS 3fluconazole SUSR; TABS 1fluconazole in dextrose 1fluconazole in nacl 1flucytosine CAPS 3GRIS-PEG 3griseofulvin microsize 1griseofulvin ultramicrosize 1itraconazole CAPS 1 PAketoconazole TABS 1LAMISIL PACK 3 PALAMISIL TABS


MYCAMINE 3NOXAFIL 3nystatin TABS 1ONMEL 3 PASPORANOX 3 PASPORANOX PULSEPAK 3 PASPORANOX SOL 10MG/ML 3 PAterbinafine hcl TABS


VFEND IV 3VFEND SUS 40MG/ML 3VFEND TAB 3voriconazole SUSR; TABS 3voriconazole inj 200mg 1ANTIMALARIALSatovaquone-proguanil hcl tab62.5-25 mg

1

atovaquone-proguanil hcl tab250-100 mg

1

chloroquine phosphate TABS 1COARTEM 2MALARONE 3mefloquine hcl 1PRIMAQUINE PHOSPHATE 3

Drug Name DrugTier

Requirements/Limits

QUALAQUIN 3quinine sulfate CAPS 1ANTIRETROVIRAL AGENTSabacavir sulfate 1APTIVUS 3CRIXIVAN 3didanosine 1EDURANT 3EMTRIVA 2EPIVIR SOL 10MG/ML 3EPIVIR TABS 3FUZEON 2INTELENCE 25mg 2INTELENCE 100mg, 200mg 3INVIRASE 3ISENTRESS CHEW 25mg 2ISENTRESS CHEW 100mg 3ISENTRESS PACK 2ISENTRESS TABS 3lamivudine 1LEXIVA 3NEVIRAPINE SUSP 1nevirapine TABS; TB24 1NORVIR 2PREZISTA SUSP 3PREZISTA TABS 75mg,150mg

2

PREZISTA TABS 600mg,800mg

3

RESCRIPTOR 2RETROVIR CAPS 3RETROVIR IV INFUSION 3RETROVIR SYRP 3REYATAZ 3SELZENTRY 3stavudine 1SUSTIVA CAPS 2SUSTIVA TABS 3TIVICAY 3TYBOST 2VIDEX EC 3VIDEX PEDIATRIC 3VIRACEPT 3VIRAMUNE 3



Drug Name DrugTier

Requirements/Limits

VIRAMUNE XR 100mg 2VIRAMUNE XR 400mg 3VIREAD 3VITEKTA 3ZERIT 3ZIAGEN SOLN 2ZIAGEN TABS 3zidovudine 1ANTIRETROVIRAL COMBINATIONAGENTSabacavir sulfate-lamivudine-zidovudine

3

ATRIPLA 3COMBIVIR 3COMPLERA 3EPZICOM 3EVOTAZ 3KALETRA SOL 3KALETRA TAB 100-25MG 2KALETRA TAB 200-50MG 3lamivudine-zidovudine 3PREZCOBIX 3STRIBILD 3TRIUMEQ 3TRIZIVIR 3TRUVADA 3ANTITUBERCULAR AGENTSCAPASTAT SULFATE 3cycloserine CAPS 3ethambutol hcl TABS 1isoniazid SOLN; SYRP 1isoniazid tabs 1MYAMBUTOL 3MYCOBUTIN 3paser d/r 3PRIFTIN 3pyrazinamide 1rifabutin 1rifadin CAPS 150mg 3RIFADIN CAPS 300mg 3RIFADIN SOLR 3rifamate 3rifampin CAPS; SOLR 1

Drug Name DrugTier

Requirements/Limits

RIFATER 3SIRTURO 3 LATRECATOR 3ANTIVIRALSacyclovir CAPS; SUSP;TABS

1

acyclovir sodium SOLN 1 B/Dacyclovir sodium SOLR500mg

1 B/D

adefovir dipivoxil 3BARACLUDE SOLN 2BARACLUDE TABS 3cidofovir 3COPEGUS 3CYTOVENE 3 B/Dentecavir 3EPIVIR HBV SOLN 2EPIVIR HBV TABS 3famciclovir TABS 1FAMVIR 3FLUMADINE 3foscarnet sodium 1ganciclovir inj 500mg 1 B/DHARVONI 3 PAHEPSERA 3lamivudine (hbv) 1moderiba pak MISC 3moderiba pak TABS 400mg 3MODERIBA PAK TABS600mg

3

moderiba tab 200mg 1PEG-INTRON 3 PAPEG-INTRON REDIPEN 3 PAPEGASYS 3 PAPEGASYS PROCLICK 3 PAPEGINTRON 80mcg/0.5ml,120mcg/0.5ml, 150mcg/0.5ml

3 PA

REBETOL 3RELENZA DISKHALER 2ribapak mis 600/day 3ribasphere CAPS 1ribasphere TABS 200mg,400mg

1

ribasphere TABS 600mg 3ribasphere ribapak 800 3



Drug Name DrugTier

Requirements/Limits

ribasphere ribapak 1000 3ribasphere ribapak 1200 3ribavirin 200mg 1rimantadine hydrochloride 1SOVALDI 3 PATAMIFLU 2TYZEKA 3valacyclovir hcl TABS 1VALCYTE 3valganciclovir hcl 3VALTREX 3ZOVIRAX CAPS; SUSP 3CEPHALOSPORINSAVYCAZ 3CEDAX 3cefaclor 1cefaclor er tab 500mg 3cefadroxil 1cefazolin inj 1cefazolin sodium 1gm, 20gm 1cefazolin/dextrose 3cefdinir 1CEFEPIME 1GM SOLN 3CEFEPIME 2GM SOLN 3CEFEPIME HCL ANDDEXTROSE

3

cefepime inj 1gm 1cefepime inj 2gm 1cefixime 1cefotaxime sodium 1gm,2gm, 500mg

1

cefotetan disodium 3cefoxitin sodium 1CEFOXITIN SODIUM INDEXTROSE

3

cefpodoxime proxetil 1cefprozil 1ceftazidime 1CEFTAZIDIME/DEXTROSE 3CEFTIBUTEN 1CEFTIN 3ceftriaxone sodium SOLR1gm, 2gm, 10gm, 250mg,500mg

1

cefuroxime axetil 1

Drug Name DrugTier

Requirements/Limits

cefuroxime sodium 1.5gm,7.5gm, 750mg

1

cefuroxime sodium 7.5gm 3cephalexin 1claforan 1gm, 2gm 3CLAFORAN 1gm, 2gm,10gm, 500mg

3

FORTAZ 3KEFLEX 3MAXIPIME 3rocephin 3SUPRAX CAPS 2suprax CHEW 2suprax SUSR 100mg/5ml,200mg/5ml

2

SUPRAX SUSR 500mg/5ml 2tazicef SOLR 1tazicef vial 1TEFLARO 3ZERBAXA 3ZINACEF SOLR 3ERYTHROMYCINS/MACROLIDESAZITHROMYCIN PACK 1azithromycin SOLR 500mg 1azithromycin SUSR 1azithromycin TABS 1BIAXIN 3clarithromycin SUSR; TABS;TB24

1

DIFICID 3e.e.s. 400 tab 400mg 1E.E.S. GRANULES 3ery-tab 1ERYPED 200 3ERYPED 400 3erythrocin lactobionate500mg

3

erythrocin stearate 1erythromycin base 1erythromycin cap 250mg ec 1erythromycin ethylsuccinate 1PCE 3ZITHROMAX 3ZITHROMAX TRI-PAK 3ZITHROMAX Z-PAK 3



Drug Name DrugTier

Requirements/Limits

ZMAX 3FLUOROQUINOLONESAVELOX 3AVELOX ABC PACK 3CIPRO SUSP 3CIPRO TABS 3CIPRO XR 3ciprofloxacin SOLN200mg/20ml

1

ciprofloxacin SUSR 1ciprofloxacin er 1ciprofloxacin hcl TABS 1ciprofloxacin in d5w 1ciprofloxacn inj 400mg/40ml 1FACTIVE 3LEVAQUIN 3levofloxacin SOLN; TABS 1levofloxacin in d5w 1MOXIFLOXACIN HCL SOLN 3moxifloxacin hcl TABS 1PENICILLINSamoxicillin 1amoxicillin & pot clavulanate 1ampicillin & sulbactam sodium 1ampicillin cap 250mg 1ampicillin cap 500 mg 1ampicillin inj 1ampicillin sodium 1ampicillin susp 1AUGMENTIN 3AUGMENTIN ES-600 3AUGMENTIN XR 3BACTOCILL INJ DEX 1GM 3BACTOCILL INJ DEX 2GM 3BICILLIN C-R 3BICILLIN L-A 3dicloxacillin sodium 1nafcillin sodium 1gm 1nafcillin sodium 2gm, 10gm 3NALLPEN ISO-OSMOTIC INDE

3

NALLPEN/DEXTROSE 3oxacillin sodium 1gm, 2gm 1oxacillin sodium 10gm 3

Drug Name DrugTier

Requirements/Limits

PENICILLIN G POT INDEXTROSE

3

PENICILLIN G POTASSIUMIN

3

penicillin g procaine 3penicillin g sodium 1penicillin v potassium 1penicilln gk inj 5mu 1penicilln gk inj 20mu 1pfizerpen g inj 5mu 1pfizerpen-g inj 20mu 1piperacillin sodium-tazobactam sodium

1

UNASYN 3UNASYN BULK PACK 3ZOSYN 3TETRACYCLINESdemeclocycline hcl 1doxy 1doxycycline (monohydrate)CAPS 50mg, 75mg, 100mg

1

doxycycline (monohydrate)SUSR

1

doxycycline (monohydrate)TABS

1

doxycycline hyclate CAPS;SOLR; TABS

1

MINOCIN CAPS 3minocycline hcl CAPS; TABS;TB24

1

SOLODYN 3TETRACYCLINE HCL CAPS 1VIBRAMYCIN CAPS; SUSR 3VIBRAMYCIN SYRP 2ANTINEOPLASTIC AGENTSALKYLATING AGENTSALKERAN SOLR 3 B/DBICNU 3 B/DBUSULFEX 3 B/DCYCLOPHOSPHAMIDECAPS

2 B/D

cyclophosphamide SOLR1gm, 500mg

3 B/D

cyclophosphamide SOLR2gm

1 B/D

dacarbazine 1 B/D



Drug Name DrugTier

Requirements/Limits

EMCYT 2GLEOSTINE 10mg, 40mg,100mg

3

HEXALEN 3IFEX INJ 1GM 3 B/DIFEX INJ 3GM 3 B/Difosfamide inj 1gm/20ml,3gm/60ml

1 B/D

ifosfamide inj 1gm/20ml,3gm/60ml

3 B/D

ifosfamide inj 1gm 1 B/DIFOSFAMIDE INJ 3GM 3 B/DLEUKERAN 2LOMUSTINE 1melphalan hcl 3 B/DMUSTARGEN 3 B/DTREANDA 3 B/DZANOSAR 3 B/DANTHRACYCLINESadriamyc inj 50mg 1 B/Ddaunorubicin hcl 1 B/DDOXIL 3 B/Ddoxorubicin hcl 50mg 1 B/Ddoxorubicin hcl liposomal inj(for iv infusion) 2 mg/ml

3 B/D

doxorubicin inj 50mg 1 B/DELLENCE 3 B/Depirubicin inj 50mg/25ml 1 B/Depirubicin inj 200mg 1 B/DIDAMYCIN PFS 3 B/Didarubicin hcl 3 B/DANTIBIOTICSbleomycin sulfate 1 B/DCOSMEGEN 3 B/Dmitomycin SOLR 1 B/DVALSTAR 3ANTIMETABOLITESadrucil 1 B/DALIMTA 3 B/DARRANON 3 B/Dazacitidine 3 B/Dcladribine 3 B/DCLOLAR 3 B/Dcytarabine inj 1 B/D

Drug Name DrugTier

Requirements/Limits

DACOGEN 3 B/Ddecitabine 3 B/Dfludarabine phosphate 1 B/Dfluorouracil SOLN 1 B/DFOLOTYN 3GEMCITABINE 3 B/Dgemcitabine hcl 3 B/DGEMZAR 3 B/Dmercaptopurine TABS 1methotrexate sodium inj 1 B/DNIPENT 3 B/DPURIXAN 3TABLOID 2VIDAZA 3 B/DANTIMITOTIC, TAXOIDSABRAXANE 3 B/DDOCETAXEL CONC20mg/ml, 80mg/4ml

3 B/D

docetaxel CONC 140mg/7ml 3 B/DDOCETAXEL SOLN20mg/2ml

1 B/D

DOCETAXEL SOLN80mg/8ml, 160mg/16ml,200mg/20ml

3 B/D

JEVTANA 3paclitaxel 1 B/DTAXOTERE 3 B/DANTIMITOTIC, VINCA ALKALOIDSvinblastine sulfate 1 B/Dvincasar 1 B/Dvincristine sulfate 1 B/Dvinorelbine tartrate 1 B/DBIOLOGIC RESPONSE MODIFIERSARZERRA 3 B/DAVASTIN 3 B/D LABELEODAQ 3CYRAMZA 3ERBITUX 3 B/DERIVEDGE 3 LAFARYDAK 3 LAGAZYVA 3HERCEPTIN 3 B/DIBRANCE 3 LAISTODAX 3 B/D



Drug Name DrugTier

Requirements/Limits

KADCYLA 3 B/DKEYTRUDA 3LYNPARZA 3 LAOPDIVO 3PERJETA 3PROLEUKIN 3 B/DRITUXAN 2 LATORISEL 3 B/DVECTIBIX 3 B/DVELCADE 3 B/DYERVOY 3ZALTRAP 3ZOLINZA 3HORMONAL ANTINEOPLASTIC AGENTSanastrozole TABS 1ARIMIDEX 3AROMASIN 3bicalutamide 1CASODEX 3DEPO-PROVERA INJ 400/ML 3 B/DELIGARD INJ 7.5MG 3 B/DELIGARD INJ 22.5MG 3 B/DELIGARD INJ 30MG 3 B/DELIGARD INJ 45MG 3 B/Dexemestane 1FARESTON 3FASLODEX 3 B/DFEMARA 3FIRMAGON 3 B/Dflutamide 1letrozole TABS 1leuprolide acetate KIT 1 PALUPRON DEP INJ 11.25MG 3 PALUPRON DEP-PED INJ7.5MG

3 PA

LUPRON DEP-PED INJ11.25MG

3 PA

LUPRON DEP-PED INJ15MG

3 PA

LUPRON DEP-PED INJ30MG (3-MONTH)

3 PA

LUPRON DEPOT 3 PALUPRON DEPOT INJ 22.5MG(3-MONTH)

3 PA

Drug Name DrugTier

Requirements/Limits

LUPRON DEPOT INJ 30MG(3-MONTH)

3 PA

LYSODREN 2MEGACE ES 3MEGACE ORAL

PA if 65 years and older3 PA

megestrol acetate SUSP;TABS

PA if 65 years and older

3 PA

MEGESTROL SUS625MG/5ML

3

NILANDRON 3SOLTAMOX 3tamoxifen citrate TABS 1TRELSTAR MIXJECT 3 PAVANTAS 3 PAXTANDI 3 LAZOLADEX 3 PAZYTIGA 3 LAKINASE INHIBITORSAFINITOR 3AFINITOR DISPERZ 3BOSULIF 3CAPRELSA 3 LACOMETRIQ 3 LAGILOTRIF TAB 20MG 3 LAGILOTRIF TAB 30MG 3 LAGILOTRIF TAB 40MG 3 LAGLEEVEC 2ICLUSIG 3 LAIMBRUVICA CAP 140MG 3 LAINLYTA 3 LAIRESSA 3 LAJAKAFI 3 LALENVIMA 10MG DAILYDOSE

3 LA

LENVIMA 14MG DAILYDOSE

3 LA


3 LA


3 LA

MEKINIST 3 LANEXAVAR 3 LASPRYCEL 3STIVARGA 3 LA



Drug Name DrugTier

Requirements/Limits

SUTENT 3TAFINLAR 3 LATARCEVA 3 LATASIGNA 3TYKERB 3 LAVOTRIENT 3 LAXALKORI 3 LAZELBORAF 3 LAZYDELIG 3 LAZYKADIA 3 LAMISCELLANEOUSbexarotene 3DROXIA 3ERWINAZE 3HALAVEN 3 B/DHYDREA 3hydroxyurea CAPS 1IXEMPRA KIT 3 B/DLONSURF 3 LAMATULANE 3 LAmitoxantrone hcl 1 B/DODOMZO 3ONCASPAR 3POMALYST 3 LASYLATRON KIT 200MCG 3SYLATRON KIT 300MCG 3SYLATRON KIT 600MCG 3SYLVANT 3SYNRIBO 3TARGRETIN CAPS 3tretinoin CAPS 2TRISENOX 3 B/DUVADEX 3 B/DPLATINUM-BASED AGENTScarboplatin 1 B/Dcisplatin 1 B/DELOXATIN 3 B/Doxaliplatin 3 B/DPROTECTIVE AGENTSamifostine crystalline 3 B/Ddexrazoxane 250mg 3 B/DELITEK 3 B/DFUSILEV 3 B/D

Drug Name DrugTier

Requirements/Limits

KEPIVANCE 3 B/Dleucovorin calcium TABS 1leucovorin calcium inj 50mg 1 B/Dleucovorin calcium inj 100mg 1 B/Dleucovorin calcium inj 200mg 1 B/Dleucovorin calcium inj 350mg 1 B/Dleucovorin calcium inj 500mg 3 B/Dlevoleucovorin calcium 3 B/Dmesna 1 B/DMESNEX SOLN 3 B/DMESNEX TABS 3ZINECARD 3 B/DTOPOISOMERASE INHIBITORSCAMPTOSAR 3 B/DETOPOPHOS 3 B/Detoposide SOLN 500mg/25ml 1 B/DHYCAMTIN SOLR 3 B/Dirinotecan inj 40mg/2ml 1 B/Dirinotecan inj 100/5ml 1 B/Dirinotecan inj 500mg/25ml 1 B/Dtoposar 1gm/50ml 1 B/Dtopotecan hcl SOLR 3 B/DCARDIOVASCULARACE INHIBITOR COMBINATIONSACCURETIC 3amlodipine besylate-benazepril hcl

1

benazepril &hydrochlorothiazide

1

captopril &hydrochlorothiazide

1

enalapril maleate &hydrochlorothiazide

1

fosinopril sodium &hydrochlorothiazide

1

lisinopril &hydrochlorothiazide

1

LOTREL 3moexipril-hydrochlorothiazide 1quinapril-hydrochlorothiazide 1TARKA 3trandolapril-verapamil hcl 1VASERETIC 3ZESTORETIC 3ACE INHIBITORS



Drug Name DrugTier

Requirements/Limits

ACCUPRIL 3ALTACE 3benazepril hcl TABS 1captopril TABS 1enalapril maleate TABS 1fosinopril sodium 1lisinopril TABS 1LOTENSIN 20mg, 40mg 3MAVIK 3moexipril hcl 1perindopril erbumine 1PRINIVIL 3quinapril hcl 1ramipril 1trandolapril 1VASOTEC 3ZESTRIL 3ALDOSTERONE RECEPTORANTAGONISTSALDACTONE 3eplerenone 1INSPRA 3spironolactone TABS 1ALPHA BLOCKERSCARDURA 3doxazosin mesylate 1MINIPRESS 3prazosin hcl 1terazosin hcl 1ANGIOTENSIN II RECEPTORANTAGONIST COMBINATIONSamlodipine besylate-valsartantab 5-160 mg

1

amlodipine besylate-valsartantab 5-320 mg

1


1


1

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg

1

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg

1

Drug Name DrugTier

Requirements/Limits

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg

1


1


1

ATACAND HCT 3AVALIDE 3AZOR 2BENICAR HCT 2candesartan cilexetil-hydrochlorothiazide

1

EDARBYCLOR 3ENTRESTO 3HYZAAR 3irbesartan-hydrochlorothiazide 1losartan-hydrochlorothiazide 1MICARDIS HCT 3telmisartan-amlodipine 1telmisartan-hydrochlorothiazide

1

TEVETEN HCT 3TWYNSTA 3valsartan-hydrochlorothiazide 1ANGIOTENSIN II RECEPTORANTAGONISTSATACAND 3AVAPRO 3BENICAR 2candesartan cilexetil 1COZAAR 3DIOVAN 3EDARBI 3eprosartan mesylate 1irbesartan 1losartan potassium 1MICARDIS 3telmisartan 1TEVETEN 3valsartan 1ANTIARRHYTHMICSamiodarone hcl 1



Drug Name DrugTier

Requirements/Limits

amiodarone inj 50mg/ml 1BETAPACE 3BETAPACE AF 3disopyramide phosphate


flecainide acetate 1mexiletine hcl 1MULTAQ 3NORPACE


NORPACE CRPA if 65 years and older

3 PA

pacerone 1propafenone hcl 1propafenone hcl 12hr 1quinidine gluconate TBCR 1quinidine sulfate TABS 1RYTHMOL 3RYTHMOL SR 3sorine 1sotalol hcl 1sotalol hcl (afib/afl) 1TIKOSYN 2ANTILIPEMICS, HMG-CoA REDUCTASEINHIBITORSatorvastatin calcium TABS 1CRESTOR 2fluvastatin sodium 1fluvastatin sodium tab sr 24 hr80 mg

1

LESCOL 3LIVALO 3lovastatin 1PRAVACHOL 3pravastatin sodium 1simvastatin TABS 1ZOCOR 3ANTILIPEMICS, MISCELLANEOUSANTARA 3cholestyramine 1cholestyramine light 1choline fenofibrate 1COLESTID 3colestipol hcl 1

Drug Name DrugTier

Requirements/Limits

FENOFIBRATE CAPS 1FENOFIBRATE TABS 40mg,120mg

1

fenofibrate TABS 48mg,54mg, 145mg, 160mg

1

fenofibrate micronized 1FENOFIBRIC ACID 1FENOGLIDE 3FIBRICOR 3gemfibrozil TABS 1JUXTAPID 3 LA PAKYNAMRO 3 PALIPOFEN 3lofibra 3LOPID 3LOVAZA CAP 1GM 3niacin er (antihyperlipidemic) 1niacor 1NIASPAN 3omega-3-acid ethyl esters 1prevalite 1questran 3questran light 3SIMCOR 2TRICOR 3TRILIPIX 3VASCEPA 3VYTORIN 2WELCHOL 2ZETIA TAB 10MG 2BETA-BLOCKER/DIURETICCOMBINATIONSatenolol & chlorthalidone 1bisoprolol &hydrochlorothiazide

1

CORZIDE 3DUTOPROL 3LOPRESSOR HCT 3metoprolol & hctz tab 50-25mg

1

metoprolol & hctz tab 100-25mg

1

metoprolol & hctz tab 100-50mg

1

nadolol & bendroflumethiazide 1



Drug Name DrugTier

Requirements/Limits

propranolol &hydrochlorothiazide

1

TENORETIC 50 3TENORETIC 100 3ZIAC 3BETA-BLOCKERSacebutolol hcl CAPS 1atenolol TABS 1betaxolol hcl 1bisoprolol fumarate 1BYSTOLIC 2carvedilol 1COREG 3CORGARD 3INDERAL LA 3labetalol hcl SOLN; TABS 1LOPRESSOR 3metoprolol succinate 1metoprolol tartrate SOLN;TABS

1

nadolol TABS 1pindolol 1propranolol hcl er 1propranolol inj 1mg/ml 1propranolol sol 1propranolol tab 1SECTRAL 3SOTYLIZE 3TENORMIN 3timolol maleate TABS 1TOPROL XL 3TRANDATE 3ZEBETA 3CALCIUM CHANNEL BLOCKERSADALAT CC 3afeditab cr 1amlodipine besylate TABS 1CALAN 3CALAN SR 3CARDIZEM 60mg, 120mg 3CARDIZEM CD 3CARDIZEM LA 3cartia xt 1dilt-xr cap 1

Drug Name DrugTier

Requirements/Limits

diltiazem cap 120mg/24hr 1diltiazem cap 240mg/24hr 1diltiazem cap er/12hr 1diltiazem hcl TABS 1diltiazem hcl coated beads 1diltiazem hcl er 1diltiazem hcl extended releasebeads

1

diltiazem inj 25mg/5ml 1diltiazem inj 50/10ml 1diltiazem inj 100mg 3diltiazem inj 125/25ml 1diltzac 1felodipine 1isradipine 1matzim la 1nicardipine hcl CAPS 1nifedical 1nifedipine TB24 1nifedipine er 1nimodipine CAPS 3nisoldipine 1NORVASC 3NYMALIZE 3PROCARDIA XL 3SULAR 3taztia xt 1TIAZAC 3verapamil hcl CP24 100mg,120mg, 180mg, 200mg,240mg, 300mg

1

VERAPAMIL HCL CP24360mg

1

verapamil hcl SOLN 1verapamil hcl TABS 1verapamil hcl TBCR 1VERELAN 3VERELAN PM 3DIGITALIS GLYCOSIDESdigitek .25mg


digitek .125mg 1digox 125mcg 1digox 250mcg




Drug Name DrugTier

Requirements/Limits

digoxin 125mcg 1digoxin 250mcg


digoxin inj 1DIGOXIN SOL 50MCG/ML


LANOXIN 62.5mcg 3LANOXIN 187.5mcg


LANOXIN INJ 0.25MG/ML 3LANOXIN PEDIATRIC 3LANOXIN TAB 125mcg 3LANOXIN TAB 250mcg


DIRECT RENININHIBITORS/COMBINATIONSTEKTURNA 2TEKTURNA HCT 2DIURETICSacetazolamide CP12; TABS 1acetazolamide sodium 1ALDACTAZIDE 3ALDACTAZIDE TAB 50/50 3amiloride &hydrochlorothiazide

1

amiloride hcl 1bumetanide 1chlorothiazide tabs 1chlorthalidone 25mg, 50mg 1DEMADEX 3DIAMOX 3DIURIL SUS 250/5ML 3DYAZIDE 3DYRENIUM 3EDECRIN 3furosemide SOLN; TABS 1furosemide inj 10mg/ml 1FUROSEMIDE INJ 10mg/ml 1furosemide oral soln 8 mg/ml 2hydrochlorothiazide CAPS;TABS

1

indapamide 1LASIX 3MAXZIDE 3MAXZIDE-25 3

Drug Name DrugTier

Requirements/Limits

methazolamide TABS 1methyclothiazide 1metolazone 1MICROZIDE 3NEPTAZANE 3SODIUM DIURIL 3spironolactone &hydrochlorothiazide

1

torsemide inj 50mg/5ml 3torsemide tabs 1triamt/hctz cap 37.5-25 1triamt/hctz cap 50-25mg 1triamt/hctz tab 37.5-25 1triamt/hctz tab 75-50mg 1MISCELLANEOUSBIDIL 2CATAPRES TAB 3CATAPRES-TTS DIS0.1/24HR

3

CATAPRES-TTS DIS0.2/24HR

3

CATAPRES-TTS DIS0.3/24HR

3

clonidine hcl PTWK; TABS 1clorpres 1CORLANOR 3DEMSER 3DIBENZYLINE 3hydralazine hcl SOLN; TABS 1midodrine hcl 1minoxidil TABS 1phenoxybenzamine hclCAPS

3

RANEXA 2NITRATESDILATRATE SR 3ISORDIL TITRADOSE 5mg 3ISORDIL TITRADOSE 40mg 2isosorbide dinitrate 1isosorbide dinitrate er 1isosorbide mononitrate 1isosorbide mononitrate er 1minitran 1nitro-bid 3



Drug Name DrugTier

Requirements/Limits

NITRO-DUR .1mg/hr,.2mg/hr, .4mg/hr, .6mg/hr

3

NITRO-DUR .3mg/hr, .8mg/hr 2nitroglycerin .4mg/spray 1NITROGLYCERIN LINGUAL 1nitroglycerin patches 1NITROLINGUAL SPRPUMPSPRA

3

NITROMIST 3NITROSTAT 2PULMONARY ARTERIAL HYPERTENSIONADCIRCA 3 PAADEMPAS 3 LA PAepoprostenol sodium 3 B/D LAFLOLAN 3 B/D LALETAIRIS 3 LA PAOPSUMIT 3 LA PAORENITRAM TAB 0.25MG 3 LA PAORENITRAM TAB 0.125MG 3 LA PAORENITRAM TAB 1MG 3 LA PAORENITRAM TAB 2.5MG 3 LA PAREMODULIN 3 B/D LAREVATIO 3 PAsildenafil citrate (pulmonaryhypertension) SOLN

3 PA

sildenafil citrate (pulmonaryhypertension) TABS

1 PA

TRACLEER 3 LA PATYVASO 3 B/DVELETRI 3 B/D LAVENTAVIS 3 B/DCENTRAL NERVOUS SYSTEMANTIANXIETYalprazolam CONC


alprazolam TABS 1mgQL (120 tabs / 30 days)

1 QL

alprazolam TABS 2mgQL (150 tabs / 30 days)

1 QL

alprazolam TABS .5mgQL (240 tabs / 30 days)

1 QL

alprazolam TABS .25mgQL (480 tabs / 30 days)

1 QL

ATIVAN SOLN 3ATIVAN TABS


Drug Name DrugTier

Requirements/Limits

buspirone hcl TABS 1fluvoxamine maleate 1fluvoxamine maleate er 1lorazepam CONC


lorazepam SOLN 1lorazepam TABS


XANAX TAB 0.5MGQL (240 tabs / 30 days)

3 QL

XANAX TAB 0.25MGQL (480 tabs / 30 days)

3 QL

XANAX TAB 1MGQL (120 tabs / 30 days)

3 QL

XANAX TAB 2MGQL (150 tabs / 30 days)

3 QL

ANTICONVULSANTSAPTIOM 3BANZEL SUS 40MG/ML 3BANZEL TAB 200MG 3BANZEL TAB 400MG 3carbamazepine CHEW;CP12; SUSP; TABS; TB12

1

CARBATROL 3CELONTIN 3clonazepam TABS 1mg


clonazepam TABS 2mgQL (300 tabs / 30 days)

1 QL

clonazepam TABS .5mgQL (240 tabs / 30 days)

1 QL

clonazepam TBDP 1mgQL (120 tabs / 30 days)

1 QL

clonazepam TBDP 2mgQL (300 tabs / 30 days)

1 QL

clonazepam TBDP .5mgQL (240 tabs / 30 days)

1 QL


1 QL


1 QL

clorazepate dipotassium3.75mg, 7.5mg


1 QL

clorazepate dipotassium15mg


1 QL

DEPACON 3



Drug Name DrugTier

Requirements/Limits

DEPAKENE 3DEPAKOTE 3DEPAKOTE ER 3DEPAKOTE SPRINKLES 3DIASTAT ACUDIAL 3DIASTAT PEDIATRIC 3diazepam CONC


diazepam SOLN 1mg/mlQL (1200 mL / 30 days)

1 QL

diazepam SOLN 5mg/ml 1diazepam TABS


DIAZEPAM GEL(ANTICONVULSANT)

1

dilantin 3DILANTIN-125 3divalproex sodium 1epitol 1ethosuximide CAPS; SOLN 1felbamate SUSP 3felbamate TABS 1FELBATOL 3FYCOMPA 3gabapentin CAPS; SOLN;TABS

1

GABITRIL 3KEPPRA 3KEPPRA XR 3KLONOPIN 1mg


KLONOPIN 2mgQL (300 tabs / 30 days)

3 QL

KLONOPIN .5mgQL (240 tabs / 30 days)

3 QL

LAMICTAL TABS 3LAMICTAL CHEWABLEDISPERS

3

LAMICTAL ODT 3LAMICTAL STARTER 3LAMICTAL XR 3lamotrigine CHEW; TABS;TB24; TBDP

1

levetiracetam SOLN; TABS;TB24

1

LEVETIRACETAM IV 3

Drug Name DrugTier

Requirements/Limits

levetiracetam oral soln 100mg/ml

1

LYRICA 2MYSOLINE 3NEURONTIN 3ONFI 3oxcarbazepine 1OXTELLAR XR 3PEGANONE 3phenobarbital ELIX; TABS


PHENOBARBITAL SODIUM65mg/ml


3 PA

phenobarbital sodium130mg/ml


3 PA

phenytek 3phenytoin CHEW; SUSP 1phenytoin inj 50mg/ml 1phenytoin sodium extended 1POTIGA 3primidone TABS 1QUDEXY XR 3SABRIL 3 LA PATEGRETOL 3TEGRETOL-XR 3tiagabine hcl 1TOPAMAX 3TOPAMAX SPRINKLE 3topiramate CPSP; TABS 1TOPIRAMATE CS24 1TRANXENE T 3.75mg,7.5mg


3 QL

TRANXENE T 15mgQL (180 tabs / 30 days)

3 QL

TRILEPTAL SUSP 3TRILEPTAL TABS 3TROKENDI XR 3VALIUM


valproate sodium SOLN;SYRP

1

valproic acid CAPS 1VIMPAT SOLN 2



Drug Name DrugTier

Requirements/Limits

VIMPAT TABS 50mg 2VIMPAT TABS 100mg,150mg, 200mg

3

ZARONTIN CAPS 3zarontin SOLN 3ZONEGRAN 3zonisamide CAPS 1ANTIDEMENTIAARICEPT 5mg, 10mg 3donepezil odt 5mg 1donepezil odt 10mg 1donepezil tab hcl 23mg 1donepezil tabs 5mg 1donepezil tabs 10mg 1EXELON CAPS 3EXELON PATCHES 3galantamine hydrobromide 1memantine hcl

PA if < 30 yrs1 PA

NAMENDA SOL 10MG/5MLPA if < 30 yrs

2 PA

NAMENDA TABPA if < 30 yrs

3 PA

NAMENDA XRPA if < 30 yrs

3 PA

NAMENDA XR TITRATIONPACK

PA if < 30 yrs

3 PA

NAMZARIC 3RAZADYNE 3RAZADYNE ER 3rivastigmine tartrate 1rivastigmine td patch 24hr 4.6mg/24hr

1

rivastigmine td patch 24hr 9.5mg/24hr

1

rivastigmine td patch 24hr13.3 mg/24hr

1

ANTIDEPRESSANTSamitriptyline hcl TABS


amoxapine 1ANAFRANIL


BRINTELLIX 2bupropion hcl TABS; TB12;TB24

1

Drug Name DrugTier

Requirements/Limits

CELEXA 3citalopram hydrobromide 1clomipramine hcl CAPS


CYMBALTA 3desipramine hcl TABS 1doxepin hcl CAPS; CONC


duloxetine hcl CPEP 20mg,30mg, 60mg

1

EFFEXOR XR 3EMSAM 3escitalopram oxalate 1FETZIMA 3FETZIMA TITRATION PACK 3fluoxetine hcl CAPS 1fluoxetine hcl CPDR 1fluoxetine hcl SOLN 1fluoxetine hcl TABS 10mg,20mg

1

FLUOXETINE HCL TABS60mg

2

FORFIVO XL 3imipramine hcl TABS


imipramine pamoatePA if 65 years and older

3 PA

LEXAPRO 3maprotiline hcl 1MARPLAN 3mirtazapine 1NARDIL 3nefazodone hcl 1NORPRAMIN 3nortriptyline hcl CAPS; SOLN 1PAMELOR 3PARNATE 3paroxetine er tab 1paroxetine hcl tabs 1PAXIL 3PAXIL CR 3PEXEVA 3phenelzine sulfate TABS 1PRISTIQ 3protriptyline hcl 1



Drug Name DrugTier

Requirements/Limits

PROZAC 3PROZAC WEEKLY 3REMERON 3REMERON SOLTAB 3sertraline hcl CONC; TABS 1SURMONTIL


TOFRANILPA if 65 years and older

3 PA

TOFRANIL-PMPA if 65 years and older

3 PA

tranylcypromine sulfate 1trazodone hcl TABS 1trimipramine maleate CAPS


venlafaxine cap er 1venlafaxine hcl 1VENLAFAXINE HCL ER TAB(VERT)

3

venlafaxine tab 1VENLAFAXINE TAB 225MGER

1

venlafaxine tab er 1VIIBRYD 2VIIBRYD STARTER PACK 2WELLBUTRIN 3WELLBUTRIN SR 3WELLBUTRIN XL 3ZOLOFT 3ANTIPARKINSONIAN AGENTSamantadine hcl CAPS;SYRP; TABS

1

APOKYN 3 LA PAAZILECT 2BENZTROPINE MESYLATESOLN

1

benztropine mesylate TABSPA if 65 years and older

3 PA

bromocriptine mesylateCAPS; TABS

1

carbidopa TABS 3carbidopa-levodopa 1CARBIDOPA/LEVODOPA/ENTACAPONE

1

COGENTIN 3COMTAN 3

Drug Name DrugTier

Requirements/Limits

DUOPA 3 B/DELDEPRYL 3ENTACAPONE 1LODOSYN 3MIRAPEX 3MIRAPEX ER 2.25mg, 3mg,3.75mg, 4.5mg

2

MIRAPEX ER .375mg,.75mg, 1.5mg

3

NEUPRO 2pramipexole dihydrochloride 1REQUIP 3ropinirole hydrochlorideTABS

1

RYTARY 3selegiline hcl CAPS; TABS 1SINEMET 3SINEMET CR 3STALEVO 3ZELAPAR 3ANTIPSYCHOTICSABILIFY DISCMELT TAB10MG

3

ABILIFY MAINTENA 3ABILIFY TABS 3aripiprazole odt 3aripiprazole oral solution 1mg/ml

3

aripiprazole tabs 3chlorpromaz inj 25mg/ml 3chlorpromazine hcl TABS 1clozapine 1CLOZAPINE ODT 12.5mg,25mg, 100mg

1

CLOZAPINE ODT 150mg,200mg

3

CLOZARIL 3FANAPT 3FANAPT TITRATION PACK 3FAZACLO 3fluphenazine decanoateSOLN

1

fluphenazine hcl 1GEODON 3GEODON INJ 3



Drug Name DrugTier

Requirements/Limits

HALDOL 3HALDOL DECANOATE 50 3HALDOL DECANOATE 100 3haloperidol TABS 1haloperidol decanoate SOLN 1haloperidol lactate 1haloperidol lactate inj 5 mg/ml 1INVEGA 3INVEGA SUST INJ 39MG/0.25 ML

3

INVEGA SUST INJ 78 MG/0.5ML

3

INVEGA SUST INJ 117MG/0.75 ML

3

INVEGA SUST INJ156MG/ML

3

INVEGA SUST INJ 234MG/1.5 ML

3

INVEGA TRINZA 3LATUDA 2loxapine succinate 1olanzapine 1olanzapine odt 1ORAP 3paliperidone 1perphenazine TABS 1pimozide 1quetiapine fumarate 1REXULTI 3RISPERDAL 3RISPERDAL INJ 12.5MG 2RISPERDAL INJ 25MG 2RISPERDAL INJ 37.5MG 3RISPERDAL INJ 50MG 3RISPERDAL M-TAB 3risperidone 1risperidone odt 1SAPHRIS 3SEROQUEL 3SEROQUEL XR 2thioridazine hcl TABS


thiothixene 1trifluoperazine hcl 1VERSACLOZ 3

Drug Name DrugTier

Requirements/Limits

ziprasidone hcl 1ZYPREXA 3ZYPREXA RELPREVV 3ZYPREXA RELPREVV INJ210MG

3

ZYPREXA ZYDI TAB 10MG 3ZYPREXA ZYDIS 3ATTENTION DEFICIT HYPERACTIVITYDISORDERadderall tab 5mg 3adderall tab 7.5mg 3ADDERALL TAB 10MG 3adderall tab 12.5mg 3adderall tab 15mg 3ADDERALL TAB 20MG 3ADDERALL TAB 30MG 3ADDERALL XR CAP 5MG 3ADDERALL XR CAP 10MG 3ADDERALL XR CAP 15MG 3ADDERALL XR CAP 20MG 3ADDERALL XR CAP 25MG 3ADDERALL XR CAP 30MG 3amphetamine cap 10mg er 1amphetamine cap 15mg er 1amphetamine cap 20mg er 1amphetamine cap 25mg er 1amphetamine cap 30mg er 1amphetamine-dextroamphetamine cap sr24hr 5 mg

1

amphetamine-dextroamphetamine tab 5 mg

1

amphetamine-dextroamphetamine tab 7.5mg

1

amphetamine-dextroamphetamine tab 10mg

1

amphetamine-dextroamphetamine tab 12.5mg

1


1


1



Drug Name DrugTier

Requirements/Limits


1

APTENSIO XR 3CONCERTA 3DAYTRANA 2guanfacine hcl (adhd)


INTUNIVPA if 65 years and older

3 PA

METADATE CD 3metadate er tab 20mg 1METHYLIN 3METHYLIN CHEW TAB 3methylphenidate hcl CHEW;CP24; CPCR; SOLN; TABS;TB24; TBCR

1

methylphenidate hcl er TB24 1QUILLIVANT XR 3RITALIN 3RITALIN LA 3STRATTERA 2VYVANSE 2HYPNOTICSAMBIEN

QL (30 tabs / 30 days)90 day limit per calendaryear if 65 years and older

3 QL PA

HETLIOZ 3 LA PARESTORIL 7.5mg

QL (30 caps / 30 days)90 day limit per calendaryear if 65 years and older

3 QL PA

RESTORIL 15mgQL (60 caps / 30 days)


3 QL PA

ROZEREMQL (30 tabs / 30 days)

3 QL

SILENOR 2temazepam 7.5mg

QL (30 caps / 30 days)90 day limit per calendaryear if 65 years and older

1 QL PA

temazepam 15mgQL (60 caps / 30 days)


1 QL PA

Drug Name DrugTier

Requirements/Limits

zolpidem tartrate TABSQL (30 tabs / 30 days)


3 QL PA

MIGRAINEalmotriptan malate 1ALSUMA 3AMERGE 3AXERT 3cafergot tab 1-100mg 3D.H.E. 45 3dihydroergotamine mesylate1mg/ml

1

DIHYDROERGOTAMINEMESYLATE 4mg/ml

3

ergomar 3FROVA TAB 2.5MG 3IMITREX 3IMITREX STATDOSE REFILL 3IMITREX STATDOSESYSTEM

3

MAXALT 3MAXALT-MLT 3migergot 3MIGRANAL 3naratriptan hcl 1RELPAX 2rizatriptan benzoate 1SUMATRIPTAN INJ4MG/0.5ML

1

sumatriptan inj 6mg/0.5mlSOAJ; SOLN; SOSY

1

SUMATRIPTAN INJ6MG/0.5ML SOCT

1

SUMATRIPTAN SUCCINATESOLN

1

sumatriptan succinate TABS 1SUMAVEL DOSEPRO 3zolmitriptan TABS 1zolmitriptan odt 1ZOMIG TABS 3ZOMIG ZMT 3MISCELLANEOUSBRISDELLE 2EQUETRO 3GRALISE 2



Drug Name DrugTier

Requirements/Limits

GRALISE STARTER 2HORIZANT 3lithium carbonate CAPS;TABS; TBCR

1

LITHIUM SOLN 8MEQ/5ML 3LITHOBID 3MESTINON 3MESTINON SYRUP 2MESTINON TIMESPAN 2NUEDEXTA 2pyridostigmine bromideTABS; TBCR

1

RILUTEK 3riluzole 1SAVELLA 2SAVELLA TITRATION PACK 2tetrabenazine 3 PAXENAZINE 3 LA PAMULTIPLE SCLEROSIS AGENTSAMPYRA 3 LA PAAUBAGIO 3 LA PAAVONEX 3 PAAVONEX PEN 3 PACOPAXONE INJ 40MG/ML 3 PACOPAXONE KIT 20MG/ML 3 PAEXTAVIA 3 PAGILENYA CAP 0.5MG 3 PAglatopa 3 PALEMTRADA 3 LA PAPLEGRIDY 3 PAPLEGRIDY STARTER PACK 3 PAREBIF 3 PAREBIF REBIDOSE 3 PAREBIF REBIDOSETITRATION

3 PA

REBIF TITRATION PACK 3 PATECFIDERA CAP 120MG 3 LA PATECFIDERA CAP 240MG 3 LA PATECFIDERA MIS STARTER 3 LA PATYSABRI 3 LA PAMUSCULOSKELETAL THERAPY AGENTSbaclofen TABS 1BOTOX INJ 100UNIT 3 PABOTOX INJ 200UNIT 3 PA

Drug Name DrugTier

Requirements/Limits

cyclobenzaprine hcl TABS5mg, 10mg


3 PA

DANTRIUM 3dantrolene sodium CAPS 1DYSPORT 3 PAtizanidine 1XEOMIN 3 PAZANAFLEX 3NARCOLEPSY/CATAPLEXYmodafinil 100mg 1 PAmodafinil 200mg 3 PANUVIGIL 2 PAXYREM

QL (540 mL / 30 days)3 QL LA PA

PSYCHOTHERAPEUTIC-MISCacamprosate calcium 1antabuse 3buprenorphine hcl SUBL 1buprenorphine hcl-naloxonehcl sl

1

buproban 1bupropion hcl (smokingdeterrent)

1

CHANTIX 2CHANTIX CONTINUINGMONTH

2

CHANTIX STARTER PACK 2disulfiram TABS 1naloxone hcl SOLN 1naltrexone hcl TABS 1NICOTROL INHALER 3NICOTROL NS 3SARAFEM 3VIVITROL 3 PAZUBSOLV SUB 1.4-0.36MG 3ZUBSOLV SUB 2.9-0.71MG 3ZUBSOLV SUB 5.7-1.4MG 3ZUBSOLV SUB 8.6-2.1MG 3ZUBSOLV SUB 11.4-2.9MG 3ZYBAN 3ENDOCRINE AND METABOLICANDROGENSANDRODERM 2 PAAVEED 3 PA



Drug Name DrugTier

Requirements/Limits

AXIRON 2 PAdepo-testosterone 3 PAoxandrolone TABS 2.5mg 1 PAoxandrolone TABS 10mg 3 PASTRIANT 3 PAtestosterone cypionate SOLN 1 PAtestosterone enanthateSOLN

1 PA

ANTIDIABETICS, INJECTABLEALCOHOL SWABS 2BYDUREON 3BYETTA 3GAUZE PADS 2X2 2HUMULIN R U-500(CONCENTRATE)

3 B/D

INSULIN PEN NEEDLES 2INSULIN SAFETY NEEDLES 2INSULIN SYRINGES 2LANTUS 2LANTUS SOLOSTAR 2LEVEMIR 2LEVEMIR FLEXTOUCH 2NOVOLIN 70/30 2NOVOLIN N 2NOVOLIN R 2NOVOLOG 2NOVOLOG FLEXPEN 2NOVOLOG MIX 70/30 2NOVOLOG MIX 70/30PREFILL

2

NOVOLOG PENFILL 2SYMLINPEN 60 2SYMLINPEN 120 3TANZEUM 3TOUJEO SOLOSTAR 2TRULICITY 3VICTOZA 2ANTIDIABETICS, ORALacarbose 1ACTOPLUS MET TAB 15-500MG

3

ACTOPLUS MET TAB 15-850MG

3

ACTOPLUS MET XR 15-1000MG

3

Drug Name DrugTier

Requirements/Limits

ACTOPLUS MET XR 30-1000MG

3

ACTOS 3AMARYL 3DUETACT 3FARXIGA 3glimepiride 1glipizide TABS 1glipizide er 1glipizide-metformin 2.5-250mg

1

glipizide-metformin 2.5-500mg

1

glipizide-metformin 5-500mg 1GLUCOPHAGE 3GLUCOPHAGE XR 3GLUCOTROL 3GLUCOTROL XL 3GLYSET 3GLYXAMBI 3INVOKAMET TAB 50-500MG 3INVOKAMET TAB 50-1000 3INVOKAMET TAB 150-500 3INVOKAMET TAB 150-1000 3INVOKANA TAB 100MG 3INVOKANA TAB 300MG 3JANUMET 2JANUMET XR TAB 50-500MG

2

JANUMET XR TAB 50-1000 2JANUMET XR TAB 100-1000 2JANUVIA 2JARDIANCE 3JENTADUETO 2KAZANO 3KOMBIGLYZE XR 2.5-1000MG

3

KOMBIGLYZE XR 5-500MG 3KOMBIGLYZE XR 5-1000MG 3metformin er 1metformin hcl TABS; TB24 1nateglinide 1NESINA 3ONGLYZA 3OSENI TAB 12.5-15MG 3



Drug Name DrugTier

Requirements/Limits

OSENI TAB 12.5-30MG 3OSENI TAB 12.5-45MG 3OSENI TAB 25-15MG 3OSENI TAB 25-30MG 3OSENI TAB 25-45MG 3pioglitazone hcl 1pioglitazone hcl-glimepiride 1pioglitazone hcl-metformin hcl 1PRANDIMET 3PRANDIN 3PRECOSE 3repaglinide 1RIOMET 3STARLIX 3TRADJENTA 2XIGDUO XR TAB 5-500MG 3XIGDUO XR TAB 5-1000MG 3XIGDUO XR TAB 10-500MG 3XIGDUO XR TAB 10-1000MG 3BISPHOSPHONATESACTONEL 3alendronate sodium 1BONIVA 3 B/DFOSAMAX 3ibandronate sodium 1 B/Dibandronate tab 150mg 1 B/Dpamidronate disodium SOLN6mg/ml

3 B/D

pamidronate disodium SOLN30mg/10ml, 90mg/10ml

1 B/D

RECLAST 3 B/DRISEDRONATE SODIUMTABS 5mg, 30mg

1

risedronate sodium TABS35mg, 150mg

1

risedronate sodium TBEC 1zoledronic inj 4mg/5ml 1 B/Dzoledronic inj 5/100ml 1 B/DZOMETA 3 B/DCALCIUM RECEPTOR AGONISTSSENSIPAR 2CHELATING AGENTSCHEMET 3DEPEN TITRATABS 3

Drug Name DrugTier

Requirements/Limits

EXJADE 3 LA PAFERRIPROX TABS 3 LA PAJADENU 3 PAKAYEXALATE 3kionex 1sodium polystyrene sulfonate 1sps susp 15gm/60ml 1SYPRINE 3CONTRACEPTIVESaltavera 1amethia 91 day 1amethyst 28 day 1apri 28 day 1aranelle 28 1ashlyna 91 day 1aubra 28 day 1aviane 28 1balziva 28 day 1BEYAZ 2BREVICON-28 3briellyn 28 day 1camila 28 day 1CAMRESE LO TAB 1cryselle 28 1cyclafem 1/35 28 day 1cyclafem 7/7/7 28 day 1CYCLESSA 3cyred tab 1deblitane 28 day 1delyla 28 day 1DEPO-PROVERACONTRACEPTIVE

3

DEPO-SUBQ PROVERA 104 2DESOGEN 3desogestrel-ethinyl estradiol(biphasic)

1

drospirenone-ethinyl estradiol 1ELLA 3emoquette 1enpresse 28 day 1errin 28 day 1estarylla tab 0.25-35 1ESTROSTEP FE 3falmina 28 day 1



Drug Name DrugTier

Requirements/Limits

FEMCON FE 3GENERESS FE 3GIANVI TAB 3-0.02MG 1gildagia 1gildess 1.5/30 21 day 1gildess 24 fe 28 day 1heather 1introvale 91 day 1JOLESSA TAB 0.15-0.03 MG 1JOLIVETTE 1junel 1.5/30 21 day 1junel 1/20 21 day 1junel fe 1.5/30 28 day 1junel fe 1/20 28 day 1junel fe 24 1/20 28 day 1kariva 28 day 1kelnor 1/35 28 day 1kimidess 1larin 1.5/30 1larin 1/20 1larin fe 1.5/30 1larin fe 1/20 1LEENA TAB 1lessina 28 day 1levonest 28 day 1levonorgestrel & eth estradiol 1levonorgestrel (emergencyoc)

1

levonorgestrel-ethinylestradiol (91-day)

1

levonorgestrel-ethinylestradiol (continuous)

1

levora 0.15/30 28 day 1LO LOESTRIN FE 2loestrin 1.5/30 21 day 3loestrin 1/20 21 day 3loestrin fe 1.5/30 28 day 3loestrin fe 1/20 28 day 3lomedia 24 fe 1loryna 28 day 1LOSEASONIQUE 3low-ogestrel 1lutera 28 day 1lyza 1

Drug Name DrugTier

Requirements/Limits

marlissa 28 day 1medroxyprogesterone acetate(contraceptive)

1

MICROGESTIN 1.5/30 1MICROGESTIN 1/20 1MICROGESTIN FE 1.5/30 1MICROGESTIN FE 1/20 1MINASTRIN 24 FE 2mircette 3MODICON 3mono-linyah tab 0.25-35 1MONONESSA 1my way 1myzilra 1necon 0.5/35 28 day 1necon 1/35 28 day 1NECON 7/7/7 1necon 10/11 28 day 3NECON TAB 1/50-28 1next choice tab 1.5mg 1nikki 28 day 1NOR-QD 3NORA-BE TAB 1norethin acet & estrad-fe 1norethindrone & ethinylestradiol-fe

1

norethindrone (contraceptive) 1norgest/ethi tab 0.25/35 1norgestimate-ethinyl estradiol(triphasic)

1

NORINYL 1+35 3NORINYL 1+50 3norlyroc 28 day 1nortrel 0.5/35 28 day 1nortrel 1/35 21 day 1nortrel 1/35 28 day 1nortrel 7/7/7 28 day 1NUVARING 2OCELLA TAB 3-0.03MG 1ogestrel 28 day 1orsythia 28 day 1ORTHO MICRONOR 3ORTHO TRI-CYCLEN LO 2ORTHO-CYCLEN 3



Drug Name DrugTier

Requirements/Limits

ORTHO-NOVUM 1/35 3ORTHO-NOVUM 7/7/7 3ovcon 35 28 day 3philith 1pimtrea pack 1pirmella 1/35 28 day 1portia 28 day 1previfem 28 day 1QUARTETTE 3quasense 91 day 1reclipsen 28 day 1SEASONIQUE 3setlakin tab 1sharobel 28 day 1SOLIA 1sprintec 28 day 1sronyx 28 day 1syeda 1tarina fe 1/20 28 day 1tri-legest 28 day 1TRI-NORINYL 28 3tri-previfem 28 day 1tri-sprintec 28 day 1TRINESSA 1trivora 28 day 1velivet 28 day 1vestura 1viorele 1vyfemla 28 day 1wymzya fe 1xulane dis 150-35 1YASMIN 28 3YAZ 3zarah 1zenchent fe 28 day 1zenchent tab 1zovia 1/35e 28 day 1zovia 1/50e 28 day 1ENDOMETRIOSISdanazol CAPS 1LUPANETA PACK 3 PASYNAREL 3ENZYME REPLACEMENTS

Drug Name DrugTier

Requirements/Limits

ADAGEN 3 LA PAALDURAZYME 3 LA PACARBAGLU 3 LA PACARNITOR 3 B/DCERDELGA 3 PACEREZYME 3 LA PACYSTADANE 3 LACYSTAGON 3 LA PAELAPRASE 3 LA PAELELYSO 3 PAFABRAZYME 3 LA PAKUVAN 3 LA PAlevocarnitine (metabolicmodifiers)

1 B/D

LUMIZYME 3 LA PAMYOZYME 3 LA PANAGLAZYME 3 LA PAORFADIN 3 LA PAPROCYSBI 3 LA PARAVICTI 3 PAsodium phenylbutyrate 3VIMIZIM 3 PAVPRIV 3 PAZAVESCA 3 LA PAESTROGENSALORA


CLIMARAPA if 65 years and older

3 PA

DELESTROGEN 3depo-estradiol 3estrace CREA 2estrace TABS


estradiol PTTW; PTWK;TABS


3 PA

estradiol valerate OIL 1ESTRING 3FEMRING 3jinteli


MENOSTARPA if 65 years and older

3 PA

MINIVELLEPA if 65 years and older

3 PA



Drug Name DrugTier

Requirements/Limits

norethindrone acetate-ethinylestradiol


3 PA

PREMARIN CREAM 2PREMARIN INJ 3VAGIFEM 2VIVELLE-DOT


GLUCOCORTICOIDSa-hydrocort 1CORTEF 3cortisone acetate TABS 1DEPO-MEDROL INJ20MG/ML

3 B/D

DEPO-MEDROL INJ40MG/ML

3 B/D

DEPO-MEDROL INJ80MG/ML

3 B/D

dexamethasone CONC 3dexamethasone ELIX; SOLN;TABS

1

dexamethasone sodiumphosphate

1

dexpak taperpak 13 day 2fludrocortisone acetate TABS 1hydrocortisone TABS 1MEDROL PAK 4MG 3 B/DMEDROL TAB 2MG 3 B/DMEDROL TAB 4MG 3 B/DMEDROL TAB 8MG 3 B/DMEDROL TAB 16MG 3 B/DMEDROL TAB 32MG 3 B/Dmethylpr ace inj 40mg/ml 1 B/Dmethylpr ace inj 80mg/ml 1 B/Dmethylpr ss inj 1gm 1 B/Dmethylpr ss inj 40mg 1 B/Dmethylpr ss inj 125mg 1 B/Dmethylpred pak 4mg 1 B/Dmethylpred tab 4mg 1 B/Dmethylpred tab 8mg 1 B/Dmethylpred tab 16mg 1 B/Dmethylpred tab 32mg 1 B/Dmillipred 3 B/DORAPRED ODT TAB 10MG 3 B/DORAPRED ODT TAB 15MG 3 B/D

Drug Name DrugTier

Requirements/Limits

ORAPRED ODT TAB 30MG 3 B/Dpediapred sol 6.7/5ml 3 B/Dpred sod pho sol 5mg/5ml 1 B/Dprednisolone sodiumphosphate

1 B/D

prednisolone sol 15mg/5ml 1 B/Dprednisolone sol 25mg/5ml 1 B/Dprednisolone syrup 15 mg/5ml 1 B/Dprednisone con 5mg/ml 3 B/Dprednisone pak 5mg 1 B/Dprednisone pak 10mg 1 B/Dprednisone sol 5mg/5ml 1 B/Dprednisone tab 1mg 1 B/Dprednisone tab 2.5mg 1 B/Dprednisone tab 5mg 1 B/Dprednisone tab 10mg 1 B/Dprednisone tab 20mg 1 B/Dprednisone tab 50mg 1 B/DRAYOS TAB 1MG 3 B/DRAYOS TAB 2MG 3 B/DRAYOS TAB 5MG 3 B/DSOLU-CORTEF 100MG 3SOLU-CORTEF 250MG 3SOLU-CORTEF 500MG 3SOLU-CORTEF 1000MG 3SOLU-MEDROL INJ 1GM 3 B/DSOLU-MEDROL INJ 2GM 3 B/DSOLU-MEDROL INJ 40MG 3 B/DSOLU-MEDROL INJ 125MG 3 B/DSOLU-MEDROL INJ 500MG 3 B/Dveripred 3 B/DGLUCOSE ELEVATING AGENTSGLUCAGEN HYPOKIT 2GLUCAGON EMERGENCYKIT

2

KORLYM 3 LA PAPROGLYCEM SUS 50MG/ML 3HUMAN GROWTH HORMONESHUMATROPE 3 LA PAHUMATROPE COMBO PACK 3 LA PANORDITROPIN FLEXPRO 3 PANORDITROPIN NORDIFLEXPEN

3 PA

SEROSTIM 3 LA PA



Drug Name DrugTier

Requirements/Limits

ZORBTIVE 3 PAMISCELLANEOUScabergoline 1calcitonin (salmon) nasalspray

1

CHORIONICGONADOTROPIN SOLR

1

EGRIFTA 1mg 3 LA PAEVISTA 3FORTICAL SPR 200/ACT 3H.P. ACTHAR 3 LA PAINCRELEX 3 LA PAmethylergonovine maleateTABS

1

MIACALCIN INJ 200U/ML 3 B/DMIACALCIN SPR 200/ACT 3MYALEPT 3 LA PANOVAREL INJ 10000UNT 1octreotide acetate 50mcg/ml,100mcg/ml

1 PA

octreotide acetate200mcg/ml, 500mcg/ml,1000mcg/ml

3 PA

PREGNYL W/DILUENTBENZYL

1

PROLIA 3raloxifene hcl 1SAMSCA 3 PASANDOSTATIN 3 PASANDOSTATIN LAR DEPOT 3 PASIGNIFOR 3 LA PASIGNIFOR LAR 3 LA PASOMATULINE DEPOT 3 PASOMAVERT 3 LA PAXGEVA 3 B/DPARATHYROID HORMONESFORTEO 3 PANATPARA 3 PAPHOSPHATE BINDER AGENTSAURYXIA 3calcium acetate (phosphatebinder)

1

eliphos 3FOSRENOL 3PHOSLO 3

Drug Name DrugTier

Requirements/Limits

PHOSLYRA 2RENAGEL 3RENVELA PAK 2RENVELA TAB 800MG 2VELPHORO 3PROGESTINSaygestin 3CRINONE 2medroxyprogesterone acetate 1norethindrone acetate TABS 1progesterone micronizedCAPS

1

PROMETRIUM 3PROVERA 3THYROID AGENTSCYTOMEL 3levothyroxine sodium TABS 1LEVOXYL 1liothyronine sodium SOLN;TABS

1

methimazole TABS 1propylthiouracil TABS 1SYNTHROID 3tapazole 3TIROSINT 3TRIOSTAT 3UNITHROID 1VASOPRESSINSDDAVP 3DESMOPRESSIN ACETATESOLN

1

desmopressin acetate TABS 1desmopressin acetate inj 1desmopressin acetate spray 1desmopressin acetate sprayrefrigerated

1

STIMATE 3GASTROINTESTINALANTIEMETICSAKYNZEO 3 B/DALOXI 3CESAMET 3 B/Dcompro supp 1dronabinol 2.5mg, 5mg 1 B/D



Drug Name DrugTier

Requirements/Limits

dronabinol 10mg 3 B/DEMEND CAP 40MG 3 B/DEMEND CAP 80MG 3 B/DEMEND CAP 125MG 3 B/DEMEND PAK 80 & 125 3 B/Dgranisetron hcl SOLN 1granisetron hcl TABS 1 B/DMARINOL 3 B/Dmeclizine hcl TABS 1metoclopramide hcl SOLN;TABS; TBDP

1

metoclopramide hcl inj 5mg/ml

1

ondansetron hcl TABS 1 B/Dondansetron hcl inj 1ondansetron hcl oral soln 1 B/Dondansetron odt 1 B/Dphenadoz


phenerganPA if 65 years and older

3 PA

phenergan injPA if 65 years and older

3 PA

prochlorperazine inj 5 mg/ml 1prochlorperazine maleateTABS

1

prochlorperazine supp 1promethazine hcl SOLN;SUPP; SYRP; TABS


3 PA

prometheganPA if 65 years and older

3 PA

REGLAN 3SANCUSO 3TRANSDERM-SCOP


ZOFRAN SOLN 4mg/5ml 3 B/DZOFRAN TABS 3 B/DZOFRAN ODT 3 B/DANTISPASMODICSATROPINE SULFATE SOLN.05mg/ml, .1mg/ml

1

BENTYL 3CANTIL 3CUVPOSA 3dicyclomine hcl 1

Drug Name DrugTier

Requirements/Limits

GLYCATE 3glycopyrrolate SOLN; TABS 1methscopolamine bromideTABS

1

PAMINE 3PAMINE FORTE 3ROBINUL 3ROBINUL FORTE 3H2-RECEPTOR ANTAGONISTScimetidine TABS 1cimetidine sol 300/5ml 1famotidine SUSR 1famotidine TABS 20mg,40mg

1

famotidine inj 1nizatidine 1PEPCID SUSP 3pepcid tab 3ranitidine hcl CAPS 1ranitidine hcl SOLN 1ranitidine hcl SYRP 1ranitidine hcl TABS 150mg,300mg

1

ZANTAC 3INFLAMMATORY BOWEL DISEASEAPRISO 2AZULFIDINE 3AZULFIDINE EN-TABS 3balsalazide disodium 1budesonide CP24 3CANASA 3COLAZAL 3colocort 1CORTENEMA 3DIPENTUM 3ENTOCORT EC 3ENTYVIO 3 PAGIAZO 3HYDROCORTISONE(INTRARECTAL)

1

LIALDA 2mesalamine enema 1PENTASA 2ROWASA 3



Drug Name DrugTier

Requirements/Limits

SF-ROWASA 3sulfasalazine dr 1sulfasalazine ir 1UCERIS 3LAXATIVESCOLYTE-FLAVOR PACKS 3constulose 1enulose 1gaviltye-g 1gavilyte-c 1gavilyte-h 1gavilyte-n 1generlac 1GOLYTELY 3kristalose 3lactulose 1lactulose (encephalopathy) 1MOVIPREP 2NULYTELY/FLAVOR PACKS 3OSMOPREP 3PEG 3350-KCL-SODBICARB-SOD CHLORIDE-SOD SULFATE

1

peg 3350-potassium chloride-sod bicarbonate-sod chloride

1

polyethylene glycol 3350PACK; POWD

1

PREPOPIK 3RELISTOR 3SUCLEAR 2SUPREP BOWEL PREP 2trilyte 1MISCELLANEOUSACTIGALL 3alosetron hcl 3AMITIZA 2amoxicillin-clarithromycin w/lansoprazole

1

CARAFATE SUSP 2CARAFATE TABS 3cromolyn sodium(mastocytosis)

3

CYTOTEC 3diphenoxylate w/ atropine 1GASTROCROM 3

Drug Name DrugTier

Requirements/Limits

GATTEX 3 LA PALINZESS 2LOMOTIL 3loperamide hcl CAPS 1LOTRONEX 3misoprostol TABS 1MOVANTIK 2OMECLAMOX-PAK 3PREVPAC 3PYLERA 3SUCRAID 3 LAsucralfate TABS 1URSO 250 3URSO FORTE 3ursodiol CAPS; TABS 1XIFAXAN TAB 550MG 3PANCREATIC ENZYMESCREON 2PANCREAZE 3PERTZYE 3ULTRESA 2VIOKACE 10 2VIOKACE 20 3ZENPEP 2PROTON PUMP INHIBITORSACIPHEX 3ACIPHEX SPR CAP 5MG 3ACIPHEX SPR CAP 10MG 3esomeprazole sodium inj 1lansoprazole CPDR 1NEXIUM I.V. 3omeprazole CPDR 1pantoprazole sodium 1PREVACID 3PRILOSEC 3PROTONIX INJ 3rabeprazole sodium 1GENITOURINARYBENIGN PROSTATIC HYPERPLASIAalfuzosin hcl 1AVODART 2CARDURA XL 3dutasteride 1



Drug Name DrugTier

Requirements/Limits

finasteride TABS 5mg 1FLOMAX 3PROSCAR 3RAPAFLO 2tamsulosin hcl 1UROXATRAL 3MISCELLANEOUSbethanechol chloride TABS 1ELMIRON 3potassium citrate (alkalinizer)15meq

1

POTASSIUM CITRATE(ALKALINIZER) 540mg,1080mg

1

urecholine 3UROCIT-K 3URINARY ANTISPASMODICSDETROL 3DETROL LA 3DITROPAN XL 3ENABLEX 3GELNIQUE 2MYRBETRIQ 2oxybutynin chloride 1tolterodine tartrate er 1tolterodine tartrate tab 1 mg 1tolterodine tartrate tab 2 mg 1trospium chloride 1trospium chloride er 1VESICARE 2VAGINAL ANTI-INFECTIVESAVC 3CLEOCIN CREA 3CLEOCIN VAG SUPP 100MG 3clindamycin cre 2% vag 1CLINDESSE 3METROGEL-VAGINAL 3metronidazole vaginal 1miconazole 3 sup 200mg 1NUVESSA 3TERAZOL 3 3TERAZOL 7 3terconazole vaginal 1VANDAZOLE 1

Drug Name DrugTier

Requirements/Limits

zazole .4% 1ZAZOLE .8% 1HEMATOLOGICANTICOAGULANTSARIXTRA 2.5mg/0.5ml,7.5mg/0.6ml, 10mg/0.8ml

3

COUMADIN 3ELIQUIS TAB 2.5MG 2ELIQUIS TAB 5MG 2enoxaparin sodium30mg/0.3ml, 40mg/0.4ml,60mg/0.6ml, 80mg/0.8ml,300mg/3ml

1

enoxaparin sodium100mg/ml, 120mg/0.8ml,150mg/ml

3

fondaparinux sodium2.5mg/0.5ml

1

fondaparinux sodium5mg/0.4ml, 7.5mg/0.6ml,10mg/0.8ml

3

FRAGMIN 2500unit/0.2ml,5000unit/0.2ml

2

FRAGMIN 7500unit/0.3ml,10000unit/ml,12500unit/0.5ml,15000unit/0.6ml,18000unt/0.72ml,95000unit/3.8ml

3

HEP SOD/NACL INJ 25000 1HEPARIN (PORCINE) INSODIUM CHLORIDE100U/ML

1

heparin sod inj 1000u/ml 1 B/DHEPARIN SOD INJ2000U/ML

3 B/D

HEPARIN SOD INJ2500U/ML

3 B/D

heparin sod inj 5000u/0.5ml 1 B/Dheparin sod inj 5000u/ml 1 B/Dheparin sod inj 10000u/ml 1 B/Dheparin sod inj 20000u/ml 1 B/DHEPARIN SODIUM/D5W 1HEPARIN SODIUM/NACL0.45%

3

jantoven 1LOVENOX 3PRADAXA 2SAVAYSA 3



Drug Name DrugTier

Requirements/Limits

warfarin sodium 1XARELTO 2XARELTO STARTER PACK 2HEMATOPOIETIC GROWTH FACTORSARANESP ALBUMIN FREE 2 PAEPOGEN 3 PAGRANIX 3 PALEUKINE 3 PAMIRCERA 3 PAMOZOBIL 3 PANEULASTA 3 PANEULASTA DELIVERY KIT 3 PANEUMEGA 3 PANEUPOGEN 3 PANPLATE 3 PAPROCRIT 2 PAMISCELLANEOUSAGRYLIN 3anagrelide hcl 1BERINERT 3 PAcilostazol 1CINRYZE 3 LA PACYKLOKAPRON 3FIRAZYR 2 PAKALBITOR 3 PALYSTEDA 3pentoxifylline TBCR 1PLETAL 3PROMACTA 3 LA PARUCONEST 3 PASOLIRIS 3 PAtranexamic acid SOLN; TABS 1PLATELET AGGREGATION INHIBITORSAGGRENOX 3ASPIRIN-DIPYRIDAMOLE 1BRILINTA 2clopidogrel bisulfate 1EFFIENT 2ZONTIVITY 3IMMUNOLOGIC AGENTSDISEASE-MODIFYING ANTI-RHEUMATICDRUGS (DMARDS)ACTEMRA 3 PA

Drug Name DrugTier

Requirements/Limits

ARAVA 3CIMZIA 3 PAENBREL 3 PAENBREL SURECLICK 3 PAHUMIRA 3 PAHUMIRA PEN 3 PAHUMIRA PEN-CROHNSSTARTER KIT

3 PA

HUMIRA PEN-PSORIASISSTARTER KIT

3 PA

hydroxychloroquine sulfate 1KINERET 3 PAleflunomide TABS 1methotrexate sodium tabs 1ORENCIA 3 PAOTEZLA 3 PAOTREXUP 3 PAPLAQUENIL 3RASUVO 3 PAREMICADE 3 PARHEUMATREX 2SIMPONI 3 PASIMPONI ARIA 3 PAtrexall 2 B/DXELJANZ 3 PAIMMUNOGLOBULINSBIVIGAM 3 PACARIMUNE NANOFILTERED 3 PAFLEBOGAMMA 3 PAFLEBOGAMMA DIF 3 PAGAMASTAN S/D 2 B/DGAMMAGARD LIQUID 3 PAGAMMAGARD S/D 3 PAGAMMAGARD S/D IGA LESSTH

3 PA

GAMMAKED 3 PAGAMMAPLEX 2.5gm/50ml,5gm/100ml, 10gm/200ml

3 PA

GAMUNEX-C 3 PAHIZENTRA 3 PAHYQVIA 3 PAOCTAGAM 1gm/20ml,2gm/20ml, 2.5gm/50ml,5gm/100ml, 10gm/200ml,25gm/500ml

3 PA



Drug Name DrugTier

Requirements/Limits

PRIVIGEN 3 PAIMMUNOMODULATORSACTIMMUNE 3 LA PAARCALYST 3 PAGRASTEK 2ILARIS 3 PAINTRON-A INJ 10MU 3 B/DINTRON-A INJ 18MU 3 B/DINTRON-A INJ 25MU 3 B/DINTRON-A INJ 50MU 3 B/DRAGWITEK 2REVLIMID 3 LATHALOMID 2IMMUNOSUPPRESSANTSASTAGRAF XL 3 B/DATGAM 3 B/Dazasan 2 B/Dazathioprine TABS 1 B/DBENLYSTA 3 PACELLCEPT CAP 3 B/DCELLCEPT INTRAVENOUS 3 B/DCELLCEPT SUSP 3 B/DCELLCEPT TAB 3 B/Dcyclosporine CAPS; SOLN 1 B/Dcyclosporine modified (formicroemulsion)

1 B/D

gengraf 1 B/DIMURAN 3 B/Dmycophenolate mofetilCAPS; TABS

1 B/D

mycophenolate mofetil SUSR 3 B/Dmycophenolate sodium180mg

1 B/D

mycophenolate sodium360mg

3 B/D

MYFORTIC 3 B/DNEORAL 3 B/DNULOJIX 3 B/DPROGRAF 3 B/DRAPAMUNE 3 B/DSANDIMMUNE CAPS 3 B/DSANDIMMUNE INJ 3 B/DSANDIMMUNE SOLN 2 B/DSIMULECT 3 B/D

Drug Name DrugTier

Requirements/Limits

SIROLIMUS TABS 2mg 3 B/Dsirolimus TABS .5mg, 1mg 1 B/Dtacrolimus CAPS 5mg 3 B/Dtacrolimus CAPS .5mg, 1mg 1 B/DTHYMOGLOBULIN 3 B/DZORTRESS TAB 0.5MG 3 B/DZORTRESS TAB 0.25MG 3 B/DZORTRESS TAB 0.75MG 3 B/DVACCINESACTHIB 3ADACEL 3BCG VACCINE 3BEXSERO 3BOOSTRIX 3CERVARIX 3COMVAX 3DAPTACEL 3DIPHTHERIA/TETANUSTOXOID

3 B/D

ENGERIX-B SUSP 3 B/DGARDASIL 3GARDASIL 9 3HAVRIX 3HIBERIX 3IMOVAX RABIES (H.D.C.V.) 3INFANRIX 3IPOL INACTIVATED IPV 2IXIARO 3KINRIX 3M-M-R II 3MENACTRA 3MENOMUNE-A/C/Y/W-135 3MENVEO 3PEDVAX HIB 3PROQUAD 3QUADRACEL 3RABAVERT 3RECOMBIVAX HB 3 B/DROTARIX 2ROTATEQ 3SYNAGIS 3TENIVAC 3 B/DTETANUS/DIPHTHERIATOXOID

3 B/D



Drug Name DrugTier

Requirements/Limits

TRUMENBA 3TWINRIX INJ 3TYPHIM VI 3VAQTA 3VARIVAX 3YF-VAX 3ZOSTAVAX 3NUTRITIONAL/SUPPLEMENTSELECTROLYTESammonium chloride SOLN 3K-TAB 3KLOR-CON 8 1KLOR-CON 10 1klor-con m10 1klor-con m15 3klor-con m20 1klor-con pow 20meq 1klor-con spr cap 8meq 1klor-con spr cap 10meq 1MAGNESIUM SULFATESOLN 2gm/50ml, 4gm/100ml,4gm/50ml, 20gm/500ml,40gm/1000ml

3

magnesium sulfate SOLN50%

1

MAGNESIUM SULFATE IND5W

3

MAGNESIUM SULFATE INJ50%

1

MICRO-K 3POTASSIUM CHLORIDESOLN 10%, 20%

1

potassium chloride TBCR8meq

1

POTASSIUM CHLORIDETBCR 20meq

1

potassium chloride caps er 1potassium chloridemicroencapsulated crystals cr

1

POTASSIUM CHLORIDETAB CR 10 MEQ

1

SODIUM CHLORIDE SOLN2.5meq/ml

1

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

1

TPN ELECTROLYTES 1 B/D

Drug Name DrugTier

Requirements/Limits

IV NUTRITIONAMINOSYN 3 B/DAMINOSYN7%/ELECTROLYTES

3 B/D

AMINOSYN II 3 B/DAMINOSYN II8.5%/ELECTROL

1 B/D

AMINOSYN INJ 8.5/LYTE 1 B/DAMINOSYN M 3 B/DAMINOSYN-HBC 3 B/DAMINOSYN-PF 7% 3 B/DAMINOSYN-PF INJ 10% 3 B/DAMINOSYN-RF 3 B/DCLINIMIX 2.75%/DEXTROSE5%

3 B/D

CLINIMIX 4.25%/DEXTROSE5%

3 B/D


3 B/D


3 B/D


3 B/D

CLINIMIX 5%/DEXTROSE15%

3 B/D


3 B/D


3 B/D

CLINIMIX E2.75%/DEXTROSE 5%

3 B/D


3 B/D

CLINIMIX E 4.25%/D10 3 B/DCLINIMIX E4.25%/DEXTROSE 5%

3 B/D


3 B/D

CLINIMIX E 5%/DEXTROSE15%

3 B/D


3 B/D


3 B/D

clinisol 15 1 B/DFREAMINE HBC 6.9% 3 B/DFREAMINE III 3 B/DHEPATAMINE 1 B/D



Drug Name DrugTier

Requirements/Limits

INTRALIPID INJ 20% 1 B/DINTRALIPID INJ 30% 3 B/DLIPOSYN II 3 B/DLIPOSYN III 3 B/DNEPHRAMINE 3 B/DNUTRILIPID INJ 20% 1 B/Dpremasol 6% 1 B/Dpremasol 10% 3 B/DPROCALAMINE 3 B/DPROSOL 3 B/DTRAVASOL 3 B/DTROPHAMINE INJ 6% 3 B/DTROPHAMINE INJ 10% 3 B/DIV REPLACEMENT SOLUTIONSDEXTROSE SOLN 1DEXTROSE 2.5%/NACL0.45%

1

DEXTROSE 5% 1DEXTROSE 5%/ELECTROLYTE

3

DEXTROSE 5%/LACTATEDRING

1

DEXTROSE 5%/NACL 0.2% 1DEXTROSE 5%/NACL 0.3% 3DEXTROSE 5%/NACL 0.9% 1DEXTROSE 5%/NACL 0.33% 1DEXTROSE 5%/NACL 0.45% 1DEXTROSE 5%/NACL0.225%

1

DEXTROSE 5%/POTASSIUMCHL

1

DEXTROSE 10% FLEXCONTAIN

1

DEXTROSE 10% W/SODIUM CHLORIDE 0.2%

3

DEXTROSE 10%/NACL0.45%

1

ELECTROLYTE-R INDEXTROSE

3

IONOSOL-B/DEXTROSE 5% 3IONOSOL-MB/DEXTROSE5%

3

ISOLYTE P 3ISOLYTE S 3KCL0.15%/D5W/NACL0.2% 1

Drug Name DrugTier

Requirements/Limits

KCL0.15%/D5W/NACL0.225%

3

KCL 0.3%/D5W/LR IV LAC RI 3KCL 0.3%/D5W/NACL 0.9% 3KCL 0.3%/D5W/NACL 0.45% 1KCL 0.15%/D5W/LR 3KCL 0.15%/D5W/NACL 0.9% 1KCL 0.075%/D5W/NACL0.45%

1

KCL IN NACL INJ .15-0.45 1KCL/D5W/NACL INJ0.22%/0.45%

1

KCL/D5W/NACL INJ .15/.33% 1KCL/D5W/NACL INJ .15/.45% 1KCL/NACL INJ 0.15%-0.9% 1LACTATED RINGERSVIAFLEX

1

NORMOSOL-M IN D5W 1NORMOSOL-R 3PLASMA-LYTE A 3PLASMA-LYTE-56/D5W 3PLASMA-LYTE-148 3pot chloride inj 2meq/ml 1POTASSIUM CHLORIDESOLN .4meq/ml,10meq/100ml, 10meq/50ml,20meq/100ml, 40meq/100ml

1

POTASSIUM CHLORIDE0.3%/D

1

potassium chloride in nacl 1POTASSIUM CHLORIDE INNACL

1

RINGER'S 1SODIUM CHLORIDE SOLN.9%, 3%, 5%

1

SODIUM CHLORIDE 0.45%VIA

1

VITAMINScalcitriol CAPS; SOLN 1 B/Ddoxercalciferol CAPS 1mcg,2.5mcg

3 B/D

doxercalciferol CAPS .5mcg 1 B/Ddoxercalciferol SOLN 1 B/DHECTOROL 3 B/Dparicalcitol CAPS 1 B/DPARICALCITOL SOLN 1 B/D



Drug Name DrugTier

Requirements/Limits

PRENATAL VITAMIN/FOLICACID > 0.8 MG (GENERIC)

1

ROCALTROL 3 B/DZEMPLAR 3 B/DOPHTHALMICANTI-INFECTIVE/ANTI-INFLAMMATORYbacitracin-poly-neomycin-hc 1blephamide OINT 3BLEPHAMIDE SUSP 3MAXITROL 3neomycin-polymy-dexameth 1neomycin-polymyxin-hc(ophth)

1

PRED-G 3PRED-G S.O.P. 3sulfacetamide sod-prednisolone

1

TOBRADEX SUSP 3tobramycin-dexamethasone 1ZYLET 2ANTI-INFECTIVESAZASITE 3bacitracin (ophthalmic) 1bacitracin-polymyxin b (ophth) 1BESIVANCE 2BLEPH-10 3CILOXAN OIN 0.3% OP 3CILOXAN SOL 0.3% OP 3ciprofloxacin hcl (ophth) 1erythromycin (ophth) 1garamycin 3gatifloxacin (ophth) 1gentak 1gentamicin sulfate (ophth) 1ilotycin 1levofloxacin (ophth) 1MOXEZA 2NATACYN 3neomycin-bacitracin zn-polymyxin

1

neomycin-polymyxin-gramicidin

1

neosporin solution 3OCUFLOX 3ofloxacin (ophth) 1

Drug Name DrugTier

Requirements/Limits

polymyxin b-trimethoprim 1POLYTRIM 3sulfacet sod oin 10% op 1sulfacetamide sodium (ophth) 1tobramycin (ophth) 1TOBREX OINT 0.3% 3TOBREX SOL 0.3% OP 3trifluridine SOLN 1VIGAMOX 2VIROPTIC 3ZIRGAN 3ZYMAXID 3ANTI-INFLAMMATORIESACULAR 3ACULAR LS 3ALREX 2bromfenac sodium (ophth) 1BROMFENAC SODIUM(OPHTH)(ONCE-DAILY)

1

dexamethasone sodiumphosphate (ophth)

1

diclofenac sodium (ophth) 1DUREZOL 2FLAREX 3FLUOROMETHOLONE(OPHTH)

1

flurbiprofen sodium 1FML 3FML FORTE 3FML LIQUIFILM 3ILEVRO 3ketorolac tromethamine(ophth)

1

LOTEMAX 2MAXIDEX 3OCUFEN 3OMNIPRED 3PRED FORTE 3PRED MILD 3PREDNISOLONE ACETATE(OPHTH)

1

prednisolone sodiumphosphate (ophth)

3

VEXOL 3ANTIALLERGICS



Drug Name DrugTier

Requirements/Limits

ALOCRIL 3ALOMIDE 3azelastine drop 0.05% 1BEPREVE 3cromolyn sodium (ophth) 1ELESTAT 3EMADINE 3epinastine hcl (ophth) 1LASTACAFT 3PATADAY 2PATANOL 2PAZEO 3ANTIGLAUCOMAALPHAGAN P 0.1% 2ALPHAGAN P 0.15% 3AZOPT 2BETAGAN 3betaxolol hcl (ophth) 1BETIMOL 2BETOPTIC-S 2brimonidine sol 0.2% 1BRIMONIDINE SOL 0.15% 1carteolol hcl (ophth) 1COMBIGAN 2COSOPT 3dorzolamide hcl 1dorzolamide hcl-timololmaleate

1

ISOPTO CARPINE 3ISTALOL 3latanoprost SOLN 1levobunolol hcl .5% 1LEVOBUNOLOL HCL .25% 1LUMIGAN 3metipranolol 1OPTIPRANOLOL 3PHOSPHOLINE IODIDE 3PILOCARPINE HCL SOLN 1SIMBRINZA SUS 1-0.2% 2timolol maleate (ophth) 1TIMOLOL MALEATE GEL 1TIMOPTIC 3TIMOPTIC OCUDOSE 3TIMOPTIC-XE 3

Drug Name DrugTier

Requirements/Limits

TRAVATAN Z 2TRUSOPT 3XALATAN 3ZIOPTAN 3MISCELLANEOUSalcaine 3CYSTARAN 3 LA PAEYLEA 3LACRISERT 3LUCENTIS 3naphazoline 0.1% 1proparacaine hcl SOLN 1RESTASIS 2RESPIRATORYANTICHOLINERGIC/BETA AGONISTCOMBINATIONSANORO ELLIPT AER 62.5-25 2COMBIVENT RESPIMAT 2ipratropium-albuterol 1 B/DSTIOLTO RESPIMAT 3ANTICHOLINERGICSATROVENT 3ATROVENT HFA 3INCRUSE ELLIPTA 3ipratropium bromide (nasal) 1ipratropium sol inhal 1 B/DSPIRIVA HANDIHALER 2SPIRIVA RESPIMAT 2TUDORZA PRESSAIR 3TUDORZA PRESSAIR(INSTITUTIONAL PACK)

3

ANTIHISTAMINE COMBINATIONSCLARINEX-D TAB 2.5-120 3SEMPREX-D 3ANTIHISTAMINESASTEPRO 3azelastine spr 0.1% 1azelastine spr 0.15% 1cetirizine syrup 1CLARINEX 3desloratadine 1diphenhydram inj 50mg/ml 1



Drug Name DrugTier

Requirements/Limits

hydroxyzine hcl SOLN25mg/ml, 50mg/ml


3 PA

levocetirizine soln 2.5mg/5ml 1levocetirizine tab 5 mg 1olopatadine hcl (nasal) 1PATANASE 3XYZAL 3BETA AGONISTSalbuterol sulfate NEBU 1 B/Dalbuterol sulfate SYRP; TABS 1albuterol sulfate er 1ARCAPTA NEOHALER 2BROVANA 3 B/DFORADIL AEROLIZER 2levalbuterol conc1.25mg/0.5ml

1 B/D

LEVALBUTEROL HCL NEBU1.25mg/3ml

1 B/D

levalbuterol hcl NEBU.31mg/3ml, .63mg/3ml

1 B/D

PERFOROMIST 2 B/DPROAIR HFA 2SEREVENT DISKUS 2STRIVERDI RESPIMAT 3terbutaline sulfate SOLN 3terbutaline sulfate TABS 1vospire 3XOPENEX 3 B/DXOPENEX CONCENTRATE 3 B/DLEUKOTRIENE RECEPTORANTAGONISTSACCOLATE 3montelukast sodium CHEW;PACK; TABS

1

SINGULAIR 3zafirlukast 1ZYFLO CR 3MAST CELL STABILIZERScromolyn sodium NEBU 1 B/DMISCELLANEOUSacetylcysteine SOLN 10%,20%

1 B/D

ARALAST NP 3 LA PAAUVI-Q 2

Drug Name DrugTier

Requirements/Limits

DALIRESP 2EPINEPHRINE SOAJ.3mg/0.3ml

1

epinephrine SOAJ.15mg/0.15ml

1

EPIPEN 2-PAK 2EPIPEN-JR 2-PAK 2ESBRIET 3 PAGLASSIA 3 LA PAKALYDECO 3 PAOFEV 3 PAORKAMBI 3 PAPROLASTIN-C 3 LA PAPULMOZYME 3 B/Dtyzine .05% 3XOLAIR 3 LA PAZEMAIRA 3 LA PANASAL STEROIDSBECONASE AQ 3budesonide (nasal) 1flunisolide (nasal) 1fluticasone propionate (nasal) 1NASONEX 2OMNARIS 3QNASL 3QNASL CHILDRENS 3RHINOCORT AQUA 3triamcinolone acetonide(nasal)

1

ZETONNA 3STEROID INHALANTSAEROSPAN 3ALVESCO 3ARNUITY ELLIPTA 3ASMANEX 2ASMANEX HFA 2budesonide (inhalation) 1 B/DFLOVENT DISKUS 2FLOVENT HFA 2PULMICORT FLEXHALER 2PULMICORT INH SUSP0.5MG/2 ML

3 B/D

PULMICORT INH SUSP0.25MG/2 ML

3 B/D



Drug Name DrugTier

Requirements/Limits

PULMICORT INH SUSP1MG/2ML

3 B/D

QVAR 2STEROID/BETA-AGONISTCOMBINATIONSADVAIR DISKUS 2ADVAIR HFA 2BREO ELLIPTA 3DULERA 2SYMBICORT 3XANTHINESaminophylline inj 1elixophyllin 3theo-24 3theophylline 1TOPICALDERMATOLOGY, ACNEABSORICA 3ACANYA 2ACZONE 3adapalene CREA; GEL 1amnesteem 1ATRALIN 2 PAAVITA 1 PAAZELEX 3BENZACLIN 2BENZAMYCIN 3benzoyl peroxide-erythromycin

1

claravis 1CLEOCIN-T 3clindamax 1clindamycin phosphate(topical)

1

clindamycin phosphate-benzoyl peroxide

1

clindamycin phosphate-benzoyl peroxide (refrigerate)

1

DIFFERIN CREA; GEL 3DIFFERIN LOTN 2DUAC 3ery pad 2% 1erygel 3erythromycin (acne aid) 1

Drug Name DrugTier

Requirements/Limits

EVOCLIN 3KLARON 3myorisan 1neuac gel 1.2-5% 1RETIN-A 3 PAsulfacetamide sodium (acne) 1tretinoin CREA 1 PATRETINOIN GEL .01% 1 PAtretinoin GEL .025%, .05% 1 PAtretinoin microsphere .1% 1 PATRETINOIN MICROSPHERE.04%

1 PA

zenatane 10mg, 20mg, 40mg 1ZENATANE 30mg 1DERMATOLOGY, ANTIBIOTICSALTABAX 3BACTROBAN 3BACTROBAN NASAL 2CENTANY 3CORTISPORIN CREA; OINT 3gentamicin sulfate (topical) 1mupirocin OINT 1mupirocin calcium (topical) 1SILVADENE 3SILVER SULFADIAZINECREA

1

SSD 1SULFAMYLON 3DERMATOLOGY, ANTIFUNGALSciclopirox GEL 1ciclopirox cre 0.77% 1ciclopirox shampoo 1% 1ciclopirox sus 0.77% 1clotrimazole (topical) 1econazole nitrate CREA 1ERTACZO 3EXELDERM 3EXTINA 3ketoconazole (topical) 1ketodan aer 2% 1LOPROX SHAMPOO 3LUZU 2MENTAX 3NAFTIFINE HCL 1



Drug Name DrugTier

Requirements/Limits

NAFTIN 2nyamyc 1nystatin (topical) 1nystatin pow 100000 1nystop 1OXISTAT 3DERMATOLOGY, ANTIPRURITICanusol hc 3CORTIFOAM 2procto-pak 1proctosol hc 2.5 % 1proctozone hc 1PRUDOXIN CRE 5% 1ZONALON 3DERMATOLOGY, ANTIPSORIATICSacitretin 3calcipotriene CREA; OINT;SOLN

1

calcitrene oin 0.005% 1CALCITRIOL OINT 1COSENTYX 3 PACOSENTYX SENSOREADYPEN

3 PA

DOVONEX CRE 0.005% 3methoxsalen rapid 38-MOP 3OXSORALEN ULTRA 3SORIATANE 3SORILUX 2STELARA 3 PATAZORAC 2 PAVECTICAL 3DERMATOLOGY, ANTISEBORRHEICSketoconazole shampoo 1NIZORAL 3selenium sulfide LOTN 1DERMATOLOGY, CORTICOSTEROIDSaclovate 3ala-cort 1ala-scalp 3alclometasone dipropionate 1amcinonide CREA; LOTN 1amcinonide OINT 3apexicon 1

Drug Name DrugTier

Requirements/Limits

betamethasone dipropionate(topical)

1

betamethasone dipropionateaugmented

1

betamethasone valerateCREA; FOAM; LOTN; OINT

1

calcipotriene/betamethasone 3CAPEX 2clobetasol e cream 0.05% 1clobetasol propionate CREA;FOAM; GEL; LIQD; LOTN;OINT; SOLN

1

clobetasol propionateemulsion

1

CLOBEX LIQD; LOTN 3clocortolone pivalate 1CLODERM PUMP 3CORDRAN TAPE 3cormax 1CUTIVATE 3DERMATOP 3DERMATOP CREAM 0.1% 3DESONATE 3DESONIDE CREA 1desonide LOTN; OINT 1DESOWEN CREA 3desowen LOTN 3desoximetasone CREA 1desoximetasone GEL 1DESOXIMETASONE OINT.05%

1

desoximetasone OINT .25% 1diflorasone diacetate 1DIPROLENE 3DIPROLENE AF 3ELOCON 3fluocinolone acetonideCREA; OIL; OINT; SOLN

1

fluocinonide CREA .1% 3fluocinonide CREA .05% 1fluocinonide GEL 1fluocinonide OINT 1fluocinonide SOLN 1fluocinonide emulsified base 1fluticasone propionate CREA;LOTN; OINT

1



Drug Name DrugTier

Requirements/Limits

halobetasol propionate 1HALOG 3hydrocortisone (topical) 1hydrocortisone butyrate 1hydrocortisone butyratehydrophilic lipo base

1

hydrocortisone valerate 1KENALOG 3LOCOID 3LOCOID LIPOCREAM 3lokara 1mometasone furoate CREA;OINT; SOLN

1

OLUX 3PANDEL 3PREDNICARBATE CREA 1prednicarbate OINT 1psorcon 3SYNALAR 3TACLONEX 3TEMOVATE CREAM 3TEMOVATE E CREAM 3TEMOVATE GEL 3TEMOVATE OIN 3TEMOVATE SOLN 3texacort 2topicort CREA 3topicort GEL 3TOPICORT OINT .05% 3topicort OINT .25% 3TOPICORT SPRAY 0.25% 3triamcinolone acetonide(topical)

1

trianex 3triderm 1ULTRAVATE 3VANOS 3DERMATOLOGY, LOCAL ANESTHETICSEMLA 3 B/Dlidocaine OINT 1lidocaine PTCH 1 PAlidocaine hcl GEL 1lidocaine hcl SOLN 4% 1lidocaine-prilocaine 1 B/D

Drug Name DrugTier

Requirements/Limits

LIDODERM 3 PASYNERA 3XYLOCAINE 4% 3DERMATOLOGY, MISCELLANEOUS SKINAND MUCOUS MEMBRANEacyclovir topical 1ALDARA 3ammonium lactate CREA;LOTN

1

CONDYLOX GEL 2CONDYLOX SOLN 3DENAVIR 3diclofenac sodium (actinickeratoses)

3

diclofenac sodium (topical) 1DOXYCYCLINE (ROSACEA) 1EFUDEX 3ELIDEL 2FINACEA AER 15% 2FINACEA GEL 15% 2fluorouracil (topical) CREA5%

1

FLUOROURACIL (TOPICAL)CREA .5%

3

fluorouracil (topical) SOLN 1imiquimod CREA 1LAC-HYDRIN 3laclotion lot 12% 1METROCREAM 3METROGEL 3METROLOTION 3metronidazole (topical) 1ORACEA 3PANRETIN 3PENNSAID 3PICATO 3podofilox SOLN 1PROTOPIC 3RECTIV 3rosadan cre 0.75% 1SOLARAZE 3SOOLANTRA 2tacrolimus (topical) 1TARGRETIN GEL 3



Drug Name DrugTier

Requirements/Limits

TOLAK 3VALCHLOR 3 LAVOLTAREN GEL 1% 2ZOVIRAX CREA; OINT 3DERMATOLOGY, SCABICIDES ANDPEDICULIDESEURAX 3malathion 1ovide 3permethrin 1SKLICE 3DERMATOLOGY, WOUND CARE AGENTSacetic acid .25% 1neomycin/polymyxin b gu 1REGRANEX 3SANTYL 3SODIUM CHLORIDE 0.9% 1STERILE WATERIRRIGATION

1

MOUTH/THROAT/DENTAL AGENTScevimeline hcl 1chlorhexidine gluconate(mouth-throat)

1

clotrimazole TROC 1EVOXAC 3lidocaine hcl (mouth-throat) 1nystatin (mouth-throat) 1paroex sol 0.12% 1periogard soln 0.12% 1PILOCARPINE HCL (ORAL)5mg

1

pilocarpine hcl (oral) 7.5mg 1SALAGEN 3triamcinolone acetonide(mouth)

1

OTICacetasol hc 1acetic acid (otic) 1acetic acid sol/hc 1acetic acid-aluminum acetate 1CIPRO HC 3CIPRODEX 2COLY-MYCIN S 3CORTISPORIN SOLN 3

Drug Name DrugTier

Requirements/Limits

CORTISPORIN-TC 3fluocinolone acetonide (otic) 1neomycin-polymyxin-hc (otic) 1ofloxacin (otic) 1


44

Index

88-MOP 41

Aa-hydrocort 28abacavir sulfate 6abacavir sulfate-lamivudine-

zidovudine 7ABELCET 5ABILIFY DISCMELT TAB

10MG 20ABILIFY MAINTENA 20ABILIFY TABS 20ABRAXANE 10ABSORICA 40ABSTRAL 2acamprosate calcium 23ACANYA 40acarbose 24ACCOLATE 39ACCUPRIL 13ACCURETIC 12acebutolol hcl 15acetaminophen w/ codeine 1acetaminophen-caff-

dihydrocod 1acetasol hc 43acetazolamide 16acetazolamide sodium 16acetic acid 43acetic acid (otic) 43acetic acid sol/hc 43acetic acid-aluminum

acetate 43acetylcysteine 39ACIPHEX 31ACIPHEX SPR CAP 10MG31ACIPHEX SPR CAP 5MG 31acitretin 41aclovate 41ACTEMRA 33ACTHIB 34ACTIGALL 31ACTIMMUNE 34ACTIQ 2ACTONEL 25ACTOPLUS MET TAB 15-

500MG 24ACTOPLUS MET TAB 15-

850MG 24ACTOPLUS MET XR 15-

1000MG 24ACTOPLUS MET XR 30-

1000MG 24ACTOS 24ACULAR 37ACULAR LS 37

acyclovir 7acyclovir sodium 7acyclovir topical 42ACZONE 40ADACEL 34ADAGEN 27ADALAT CC 15adapalene 40ADCIRCA 17ADDERALL TAB 10MG 21adderall tab 12.5mg 21adderall tab 15mg 21ADDERALL TAB 20MG 21ADDERALL TAB 30MG 21adderall tab 5mg 21adderall tab 7.5mg 21ADDERALL XR CAP

10MG 21ADDERALL XR CAP




30MG 21ADDERALL XR CAP 5MG 21adefovir dipivoxil 7ADEMPAS 17adriamyc inj 50mg 10adrucil 10ADVAIR DISKUS 40ADVAIR HFA 40AEROSPAN 39afeditab cr 15AFINITOR 11AFINITOR DISPERZ 11AGGRENOX 33AGRYLIN 33AKYNZEO 29ala-cort 41ala-scalp 41ALBENZA 4albuterol sulfate 39albuterol sulfate er 39alcaine 38alclometasone

dipropionate 41ALCOHOL SWABS 24ALDACTAZIDE 16ALDACTAZIDE TAB 50/50 16ALDACTONE 13ALDARA 42ALDURAZYME 27alendronate sodium 25alfuzosin hcl 31ALIMTA 10ALINIA 5ALKERAN 9allopurinol tab 1

almotriptan malate 22ALOCRIL 38ALOMIDE 38ALOPRIM 1ALORA 27alosetron hcl 31ALOXI 29ALPHAGAN P 0.1% 38ALPHAGAN P 0.15% 38alprazolam 17ALREX 37ALSUMA 22ALTABAX 40ALTACE 13altavera 25ALVESCO 39amantadine hcl 20AMARYL 24AMBIEN 22AMBISOME 6amcinonide 41AMERGE 22amethia 91 day 25amethyst 28 day 25amifostine crystalline 12amikacin sulfate 4amiloride &

hydrochlorothiazide 16amiloride hcl 16aminophylline inj 40AMINOSYN 35AMINOSYN

7%/ELECTROLYTES 35AMINOSYN II 35AMINOSYN II

8.5%/ELECTROL 35AMINOSYN INJ 8.5/LYTE 35AMINOSYN M 35AMINOSYN-HBC 35AMINOSYN-PF 7% 35AMINOSYN-PF INJ 10% 35AMINOSYN-RF 35amiodarone hcl 13amiodarone inj 50mg/ml 14AMITIZA 31amitriptyline hcl 19amlodipine besylate 15amlodipine besylate-

benazepril hcl 12amlodipine besylate-valsartan

tab 10-160 mg 13amlodipine besylate-valsartan



tab 5-320 mg 13amlodipine-valsartan-

hydrochlorothiazide 10-160-12.5mg 13

amlodipine-valsartan-


45

hydrochlorothiazide 10-160-25mg 13

amlodipine-valsartan-hydrochlorothiazide 10-320-25mg 13

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg 13

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg 13

ammonium chloride 35ammonium lactate 42amnesteem 40amoxapine 19amoxicillin 9amoxicillin & pot clavulanate 9amoxicillin-clarithromycin w/

lansoprazole 31amphetamine cap 10mg er 21amphetamine cap 15mg er 21amphetamine cap 20mg er 21amphetamine cap 25mg er 21amphetamine cap 30mg er 21amphetamine-

dextroamphetamine capsr 24hr 5 mg 21

amphetamine-dextroamphetamine tab10 mg 21

amphetamine-dextroamphetamine tab12.5 mg 21




amphetamine-dextroamphetamine tab 5mg 21

amphetamine-dextroamphetamine tab7.5 mg 21

AMPHOTEC 6amphotericin b 6ampicillin & sulbactam

sodium 9ampicillin cap 250mg 9ampicillin cap 500 mg 9ampicillin inj 9ampicillin sodium 9ampicillin susp 9AMPYRA 23ANAFRANIL 19anagrelide hcl 33ANAPROX 1ANAPROX DS 1

anastrozole 11ANCOBON 6ANDRODERM 23ANORO ELLIPT AER 62.5-

25 38antabuse 23ANTARA 14anusol hc 41apexicon 41APOKYN 20apri 28 day 25APRISO 30APTENSIO XR 22APTIOM 17APTIVUS 6ARALAST NP 39aranelle 28 25ARANESP ALBUMIN

FREE 33ARAVA 33ARCALYST 34ARCAPTA NEOHALER 39ARICEPT 19ARIMIDEX 11aripiprazole odt 20aripiprazole oral solution 1

mg/ml 20aripiprazole tabs 20ARIXTRA 32ARNUITY ELLIPTA 39AROMASIN 11ARRANON 10ARTHROTEC 50 1ARTHROTEC 75 1ARZERRA 10ashlyna 91 day 25ASMANEX 39ASMANEX HFA 39ASPIRIN-CAFFEINE-

DIHYDROCODEINEBITARTRATE 1

ASPIRIN-DIPYRIDAMOLE 33ASTAGRAF XL 34ASTEPRO 38ATACAND 13ATACAND HCT 13atenolol 15atenolol & chlorthalidone 14ATGAM 34ATIVAN 17atorvastatin calcium 14atovaquone 5atovaquone-proguanil hcl tab

250-100 mg 6atovaquone-proguanil hcl tab

62.5-25 mg 6ATRALIN 40ATRIPLA 7ATROPINE SULFATE 30ATROVENT 38

ATROVENT HFA 38AUBAGIO 23aubra 28 day 25AUGMENTIN 9AUGMENTIN ES-600 9AUGMENTIN XR 9AURYXIA 29AUVI-Q 39AVALIDE 13AVAPRO 13AVASTIN 10AVC 32AVEED 23AVELOX 9AVELOX ABC PACK 9aviane 28 25AVITA 40AVODART 31AVONEX 23AVONEX PEN 23AVYCAZ 8AXERT 22AXIRON 24aygestin 29azacitidine 10AZACTAM 5AZACTAM/DEX INJ 1GM 5AZACTAM/DEX INJ 2GM 5azasan 34AZASITE 37azathioprine 34azelastine drop 0.05% 38azelastine spr 0.1% 38azelastine spr 0.15% 38AZELEX 40AZILECT 20AZITHROMYCIN 8azithromycin 8AZOPT 38AZOR 13aztreonam 5AZULFIDINE 30AZULFIDINE EN-TABS 30

Bbacitracin (ophthalmic) 37bacitracin-poly-neomycin-

hc 37bacitracin-polymyxin b

(ophth) 37baclofen 23BACTOCILL INJ DEX 1GM 9BACTOCILL INJ DEX 2GM 9BACTRIM 5BACTRIM DS 5BACTROBAN 40BACTROBAN NASAL 40balsalazide disodium 30balziva 28 day 25BANZEL SUS 40MG/ML 17


46

BANZEL TAB 200MG 17BANZEL TAB 400MG 17BARACLUDE 7BCG VACCINE 34BECONASE AQ 39BELEODAQ 10benazepril &

hydrochlorothiazide 12benazepril hcl 13BENICAR 13BENICAR HCT 13BENLYSTA 34BENTYL 30BENZACLIN 40BENZAMYCIN 40benzoyl peroxide-

erythromycin 40BENZTROPINE

MESYLATE 20benztropine mesylate 20BEPREVE 38BERINERT 33BESIVANCE 37BETAGAN 38betamethasone dipropionate

(topical) 41betamethasone dipropionate

augmented 41betamethasone valerate 41BETAPACE 14BETAPACE AF 14betaxolol hcl 15betaxolol hcl (ophth) 38bethanechol chloride 32BETHKIS 4BETIMOL 38BETOPTIC-S 38bexarotene 12BEXSERO 34BEYAZ 25BIAXIN 8bicalutamide 11BICILLIN C-R 9BICILLIN L-A 9BICNU 9BIDIL 16BILTRICIDE 5bisoprolol &

hydrochlorothiazide 14bisoprolol fumarate 15BIVIGAM 33bleomycin sulfate 10BLEPH-10 37BLEPHAMIDE 37blephamide 37BONIVA 25BOOSTRIX 34BOSULIF 11BOTOX INJ 100UNIT 23BOTOX INJ 200UNIT 23

BREO ELLIPTA 40BREVICON-28 25briellyn 28 day 25BRILINTA 33BRIMONIDINE SOL 0.15%38brimonidine sol 0.2% 38BRINTELLIX 19BRISDELLE 22bromfenac sodium (ophth) 37BROMFENAC SODIUM

(OPHTH)(ONCE-DAILY) 37

bromocriptine mesylate 20BROVANA 39budesonide 30budesonide (inhalation) 39budesonide (nasal) 39bumetanide 16buprenorphine hcl 23buprenorphine hcl-naloxone

hcl sl 23buproban 23bupropion hcl 19bupropion hcl (smoking

deterrent) 23buspirone hcl 17BUSULFEX 9butorphanol nasal spray 1butorphanol tartrate 1BUTRANS 1BYDUREON 24BYETTA 24BYSTOLIC 15

Ccabergoline 29cafergot tab 1-100mg 22CALAN 15CALAN SR 15calcipotriene 41calcipotriene/betamethasone

41calcitonin (salmon) nasal

spray 29calcitrene oin 0.005% 41CALCITRIOL 41calcitriol 36calcium acetate (phosphate

binder) 29camila 28 day 25CAMPTOSAR 12CAMRESE LO TAB 25CANASA 30CANCIDAS 6candesartan cilexetil 13candesartan cilexetil-

hydrochlorothiazide 13CANTIL 30CAPASTAT SULFATE 7CAPEX 41

capitaland codeine 1

CAPRELSA 11captopril 13captopril &

hydrochlorothiazide 12CARAFATE 31CARBAGLU 27carbamazepine 17CARBATROL 17carbidopa 20carbidopa-levodopa 20CARBIDOPA/LEVODOPA/E

NTACAPONE 20carboplatin 12CARDIZEM 15CARDIZEM CD 15CARDIZEM LA 15CARDURA 13CARDURA XL 31CARIMUNE

NANOFILTERED 33CARNITOR 27carteolol hcl (ophth) 38cartia xt 15carvedilol 15CASODEX 11CATAPRES TAB 16CATAPRES-TTS DIS

0.1/24HR 16CATAPRES-TTS DIS

0.2/24HR 16CATAPRES-TTS DIS

0.3/24HR 16CAYSTON 5CEDAX 8cefaclor 8cefaclor er tab 500mg 8cefadroxil 8cefazolin inj 8cefazolin sodium 8cefazolin/dextrose 8cefdinir 8CEFEPIME 1GM SOLN 8CEFEPIME 2GM SOLN 8CEFEPIME HCL AND

DEXTROSE 8cefepime inj 1gm 8cefepime inj 2gm 8cefixime 8cefotaxime sodium 8cefotetan disodium 8cefoxitin sodium 8CEFOXITIN SODIUM IN

DEXTROSE 8cefpodoxime proxetil 8cefprozil 8ceftazidime 8CEFTAZIDIME/DEXTROSE 8CEFTIBUTEN 8


47

CEFTIN 8ceftriaxone sodium 8cefuroxime axetil 8cefuroxime sodium 8CELEBREX CAP 100MG 1CELEBREX CAP 200MG 1CELEBREX CAP 400MG 1CELEBREX CAP 50MG 1celecoxib 1CELEXA 19CELLCEPT CAP 34CELLCEPT

INTRAVENOUS 34CELLCEPT SUSP 34CELLCEPT TAB 34CELONTIN 17CENTANY 40cephalexin 8CERDELGA 27CEREZYME 27CERVARIX 34CESAMET 29cetirizine syrup 38cevimeline hcl 43CHANTIX 23CHANTIX CONTINUING

MONTH 23CHANTIX STARTER

PACK 23CHEMET 25chlorhexidine gluconate

(mouth-throat) 43chloroquine phosphate 6chlorothiazide tabs 16chlorpromaz inj 25mg/ml 20chlorpromazine hcl 20chlorthalidone 16cholestyramine 14cholestyramine light 14choline fenofibrate 14CHORIONIC

GONADOTROPIN 29ciclopirox 40ciclopirox cre 0.77% 40ciclopirox shampoo 1% 40ciclopirox sus 0.77% 40cidofovir 7cilostazol 33CILOXAN OIN 0.3% OP 37CILOXAN SOL 0.3% OP 37cimetidine 30cimetidine sol 300/5ml 30CIMZIA 33CINRYZE 33CIPRO HC 43CIPRO SUSP 9CIPRO TABS 9CIPRO XR 9CIPRODEX 43ciprofloxacin 9

ciprofloxacin er 9ciprofloxacin hcl 9ciprofloxacin hcl (ophth) 37ciprofloxacin in d5w 9ciprofloxacn inj 400mg/40ml 9cisplatin 12citalopram hydrobromide 19cladribine 10CLAFORAN 8claforan 8claravis 40CLARINEX 38CLARINEX-D TAB 2.5-120 38clarithromycin 8CLEOCIN 32cleocin 5CLEOCIN CAP 150MG 5CLEOCIN CAP 300MG 5CLEOCIN CAP 75MG 5CLEOCIN IN D5W 5CLEOCIN INJ 5CLEOCIN PHOSPHATE 5cleocin phosphate 5CLEOCIN VAG SUPP

100MG 32CLEOCIN-T 40CLIMARA 27clindamax 40clindamycin cre 2% vag 32clindamycin hcl 5clindamycin palmitate

hydrochloride 5clindamycin phosphate 5clindamycin phosphate

(topical) 40clindamycin phosphate in

d5w 5clindamycin phosphate-

benzoyl peroxide 40clindamycin phosphate-

benzoyl peroxide(refrigerate) 40

CLINDESSE 32CLINIMIX 2.75%/DEXTROSE

5% 35CLINIMIX 4.25%/DEXTROSE




5% 35CLINIMIX 5%/DEXTROSE



25% 35CLINIMIX E

2.75%/DEXTROSE

10% 35CLINIMIX E

2.75%/DEXTROSE 5% 35CLINIMIX E 4.25%/D10 35CLINIMIX E

4.25%/DEXTROSE25% 35

CLINIMIX E4.25%/DEXTROSE 5% 35

CLINIMIX E 5%/DEXTROSE15% 35



clinisol 15 35clobetasol e cream 0.05% 41clobetasol propionate 41clobetasol propionate

emulsion 41CLOBEX 41clocortolone pivalate 41CLODERM PUMP 41CLOLAR 10clomipramine hcl 19clonazepam 17clonidine hcl 16clopidogrel bisulfate 33clorazepate dipotassium 17clorpres 16clotrimazole 43clotrimazole (topical) 40clozapine 20CLOZAPINE ODT 20CLOZARIL 20COARTEM 6codeine

and capital 1CODEINE SULFATE 2COGENTIN 20COLAZAL 30colchicine w/ probenecid 1COLCRYS 1COLESTID 14colestipol hcl 14colistimethate sodium 5colocort 30COLY-MYCIN M 5COLY-MYCIN S 43COLYTE-FLAVOR PACKS 31COMBIGAN 38COMBIVENT RESPIMAT 38COMBIVIR 7COMETRIQ 11COMPLERA 7compro supp 29COMTAN 20COMVAX 34CONCERTA 22CONDYLOX 42


48

constulose 31COPAXONE INJ 40MG/ML23COPAXONE KIT 20MG/ML23COPEGUS 7CORDRAN 41COREG 15CORGARD 15CORLANOR 16cormax 41CORTEF 28CORTENEMA 30CORTIFOAM 41cortisone acetate 28CORTISPORIN 40, 43CORTISPORIN-TC 43CORZIDE 14COSENTYX 41COSENTYX SENSOREADY

PEN 41COSMEGEN 10COSOPT 38COUMADIN 32COZAAR 13CREON 31CRESEMBA 6CRESTOR 14CRINONE 29CRIXIVAN 6cromolyn sodium 39cromolyn sodium

(mastocytosis) 31cromolyn sodium (ophth) 38cryselle 28 25CUBICIN 5CUTIVATE 41CUVPOSA 30cyclafem 1/35 28 day 25cyclafem 7/7/7 28 day 25CYCLESSA 25cyclobenzaprine hcl 23CYCLOPHOSPHAMIDE 9cyclophosphamide 9cycloserine 7cyclosporine 34cyclosporine modified (for

microemulsion) 34CYKLOKAPRON 33CYMBALTA 19CYRAMZA 10cyred tab 25CYSTADANE 27CYSTAGON 27CYSTARAN 38cytarabine inj 10CYTOMEL 29CYTOTEC 31CYTOVENE 7

DD.H.E. 45 22

dacarbazine 9DACOGEN 10DALIRESP 39DALVANCE 5danazol 27DANTRIUM 23dantrolene sodium 23dapsone 5DAPTACEL 34DARAPRIM 5daunorubicin hcl 10DAYPRO 1DAYTRANA 22DDAVP 29deblitane 28 day 25decitabine 10DELESTROGEN 27delyla 28 day 25DEMADEX 16demeclocycline hcl 9DEMSER 16DENAVIR 42DEPACON 17DEPAKENE 18DEPAKOTE 18DEPAKOTE ER 18DEPAKOTE SPRINKLES 18DEPEN TITRATABS 25depo-estradiol 27DEPO-MEDROL INJ

20MG/ML 28DEPO-MEDROL INJ

40MG/ML 28DEPO-MEDROL INJ

80MG/ML 28DEPO-PROVERA

CONTRACEPTIVE 25DEPO-PROVERA INJ

400/ML 11DEPO-SUBQ PROVERA

104 25depo-testosterone 24DERMATOP 41DERMATOP CREAM 0.1%41desipramine hcl 19desloratadine 38DESMOPRESSIN

ACETATE 29desmopressin acetate 29desmopressin acetate inj 29desmopressin acetate

spray 29desmopressin acetate spray

refrigerated 29DESOGEN 25desogestrel-ethinyl estradiol

(biphasic) 25DESONATE 41DESONIDE 41desonide 41DESOWEN 41

desowen 41DESOXIMETASONE 41desoximetasone 41DETROL 32DETROL LA 32dexamethasone 28dexamethasone sodium

phosphate 28dexamethasone sodium

phosphate (ophth) 37dexpak taperpak 13 day 28dexrazoxane 12DEXTROSE 36DEXTROSE 10% FLEX

CONTAIN 36DEXTROSE 10% W/

SODIUM CHLORIDE0.2% 36

DEXTROSE 10%/NACL0.45% 36

DEXTROSE 2.5%/NACL0.45% 36

DEXTROSE 5% 36DEXTROSE 5%

/ELECTROLYTE 36DEXTROSE 5%/LACTATED

RING 36DEXTROSE 5%/NACL

0.2% 36DEXTROSE 5%/NACL





0.9% 36DEXTROSE

5%/POTASSIUM CHL 36DIAMOX 16DIASTAT ACUDIAL 18DIASTAT PEDIATRIC 18diazepam 18DIAZEPAM GEL

(ANTICONVULSANT) 18DIBENZYLINE 16diclofenac potassium 1diclofenac sodium 1diclofenac sodium (actinic

keratoses) 42diclofenac sodium (ophth) 37diclofenac sodium (topical) 42diclofenac w/ misoprostol 1dicloxacillin sodium 9dicyclomine hcl 30didanosine 6DIFFERIN 40DIFICID 8diflorasone diacetate 41


49

DIFLUCAN 6diflunisal 1digitek 15digox 15digoxin 16digoxin inj 16DIGOXIN SOL 50MCG/ML 16DIHYDROERGOTAMINE

MESYLATE 22dihydroergotamine

mesylate 22dilantin 18DILANTIN-125 18DILATRATE SR 16DILAUDID INJ 2DILAUDID TAB 2DILAUDID-5 ORAL LIQD 2DILAUDID-HP INJ

10MG/ML 2DILAUDID-HP INJ 250MG 2dilt-xr cap 15diltiazem cap 120mg/24hr 15diltiazem cap 240mg/24hr 15diltiazem cap er/12hr 15diltiazem hcl 15diltiazem hcl coated beads 15diltiazem hcl er 15diltiazem hcl extended

release beads 15diltiazem inj 100mg 15diltiazem inj 125/25ml 15diltiazem inj 25mg/5ml 15diltiazem inj 50/10ml 15diltzac 15DIOVAN 13DIPENTUM 30diphenhydram inj 50mg/ml 38diphenoxylate w/ atropine 31DIPHTHERIA/TETANUS

TOXOID 34DIPROLENE 41DIPROLENE AF 41disopyramide phosphate 14disulfiram 23DITROPAN XL 32DIURIL SUS 250/5ML 16divalproex sodium 18DOCETAXEL 10docetaxel 10DOLOPHINE 2donepezil odt 10mg 19donepezil odt 5mg 19donepezil tab hcl 23mg 19donepezil tabs 10mg 19donepezil tabs 5mg 19DORIBAX 5dorzolamide hcl 38dorzolamide hcl-timolol

maleate 38DOVONEX CRE 0.005% 41

doxazosin mesylate 13doxepin hcl 19doxercalciferol 36DOXIL 10doxorubicin hcl 10doxorubicin hcl liposomal inj

(for iv infusion) 2 mg/ml 10doxorubicin inj 50mg 10doxy 9doxycycline (monohydrate) 9DOXYCYCLINE

(ROSACEA) 42doxycycline hyclate 9dronabinol 29, 30drospirenone-ethinyl

estradiol 25DROXIA 12DUAC 40DUETACT 24DULERA 40duloxetine hcl 19DUOPA 20DURAGESIC 2DURAMORPH 2DUREZOL 37dutasteride 31DUTOPROL 14DYAZIDE 16DYRENIUM 16DYSPORT 23

Ee.e.s. 400 tab 400mg 8E.E.S. GRANULES 8EC-NAPROSYN 1econazole nitrate 40EDARBI 13EDARBYCLOR 13EDECRIN 16EDURANT 6EFFEXOR XR 19EFFIENT 33EFUDEX 42EGRIFTA 29ELAPRASE 27ELDEPRYL 20ELECTROLYTE-R IN

DEXTROSE 36ELELYSO 27ELESTAT 38ELIDEL 42ELIGARD INJ 22.5MG 11ELIGARD INJ 30MG 11ELIGARD INJ 45MG 11ELIGARD INJ 7.5MG 11eliphos 29ELIQUIS TAB 2.5MG 32ELIQUIS TAB 5MG 32ELITEK 12elixophyllin 40

ELLA 25ELLENCE 10ELMIRON 32ELOCON 41ELOXATIN 12EMADINE 38EMBEDA 2EMCYT 10EMEND CAP 125MG 30EMEND CAP 40MG 30EMEND CAP 80MG 30EMEND PAK 80 & 125 30EMLA 42emoquette 25EMSAM 19EMTRIVA 6ENABLEX 32enalapril maleate 13enalapril maleate &

hydrochlorothiazide 12ENBREL 33ENBREL SURECLICK 33endocet 2ENDODAN TAB 2ENGERIX-B 34enoxaparin sodium 32enpresse 28 day 25ENTACAPONE 20entecavir 7ENTOCORT EC 30ENTRESTO 13ENTYVIO 30enulose 31epinastine hcl (ophth) 38EPINEPHRINE 39epinephrine 39EPIPEN 2-PAK 39EPIPEN-JR 2-PAK 39epirubicin inj 200mg 10epirubicin inj 50mg/25ml 10epitol 18EPIVIR HBV 7EPIVIR SOL 10MG/ML 6EPIVIR TABS 6eplerenone 13EPOGEN 33epoprostenol sodium 17eprosartan mesylate 13EPZICOM 7EQUETRO 22ERAXIS 6ERBITUX 10ergomar 22ERIVEDGE 10errin 28 day 25ERTACZO 40ERWINAZE 12ery pad 2% 40ery-tab 8erygel 40


50

ERYPED 200 8ERYPED 400 8erythrocin lactobionate 8erythrocin stearate 8erythromycin (acne aid) 40erythromycin (ophth) 37erythromycin base 8erythromycin cap 250mg ec 8erythromycin ethylsuccinate 8ESBRIET 39escitalopram oxalate 19esomeprazole sodium inj 31estarylla tab 0.25-35 25estrace 27estradiol 27estradiol valerate 27ESTRING 27ESTROSTEP FE 25ethambutol hcl 7ethosuximide 18etodolac 1etodolac er 1ETOPOPHOS 12etoposide 12EURAX 43EVISTA 29EVOCLIN 40EVOTAZ 7EVOXAC 43EXALGO 2EXELDERM 40EXELON CAPS 19EXELON PATCHES 19exemestane 11EXJADE 25EXTAVIA 23EXTINA 40EYLEA 38

FFABRAZYME 27FACTIVE 9falmina 28 day 25famciclovir 7famotidine 30famotidine inj 30FAMVIR 7FANAPT 20FANAPT TITRATION

PACK 20FARESTON 11FARXIGA 24FARYDAK 10FASLODEX 11FAZACLO 20felbamate 18FELBATOL 18FELDENE 1felodipine 15

FEMARA 11FEMCON FE 26FEMRING 27FENOFIBRATE 14fenofibrate 14fenofibrate micronized 14FENOFIBRIC ACID 14FENOGLIDE 14fenoprofen calcium 1fentanyl citrate 2fentanyl patch 100 mcg/hr 2fentanyl patch 12 mcg/hr 2fentanyl patch 25 mcg/hr 2fentanyl patch 50 mcg/hr 2fentanyl patch 75 mcg/hr 2FENTORA 2FERRIPROX 25FETZIMA 19FETZIMA TITRATION

PACK 19FIBRICOR 14FINACEA AER 15% 42FINACEA GEL 15% 42finasteride 32FIRAZYR 33FIRMAGON 11FLAGYL 5FLAGYL ER 5FLAREX 37FLEBOGAMMA 33FLEBOGAMMA DIF 33flecainide acetate 14FLOLAN 17FLOMAX 32FLOVENT DISKUS 39FLOVENT HFA 39fluconazole 6fluconazole in dextrose 6fluconazole in nacl 6flucytosine 6fludarabine phosphate 10fludrocortisone acetate 28FLUMADINE 7flunisolide (nasal) 39fluocinolone acetonide 41fluocinolone acetonide

(otic) 43fluocinonide 41fluocinonide emulsified

base 41FLUOROMETHOLONE

(OPHTH) 37fluorouracil 10FLUOROURACIL

(TOPICAL) 42fluorouracil (topical) 42FLUOXETINE HCL 19fluoxetine hcl 19fluphenazine decanoate 20fluphenazine hcl 20

flurbiprofen 1flurbiprofen sodium 37flutamide 11fluticasone propionate 41fluticasone propionate

(nasal) 39fluvastatin sodium 14fluvastatin sodium tab sr 24

hr 80 mg 14fluvoxamine maleate 17fluvoxamine maleate er 17FML 37FML FORTE 37FML LIQUIFILM 37FOLOTYN 10fondaparinux sodium 32FORADIL AEROLIZER 39FORFIVO XL 19FORTAZ 8FORTEO 29FORTICAL SPR 200/ACT 29FOSAMAX 25foscarnet sodium 7fosinopril sodium 13fosinopril sodium &

hydrochlorothiazide 12FOSRENOL 29FRAGMIN 32FREAMINE HBC 6.9% 35FREAMINE III 35FROVA TAB 2.5MG 22FURADANTIN 5furosemide 16FUROSEMIDE INJ 16furosemide inj 16furosemide oral soln 8

mg/ml 16FUSILEV 12FUZEON 6FYCOMPA 18

Ggabapentin 18GABITRIL 18galantamine hydrobromide 19GAMASTAN S/D 33GAMMAGARD LIQUID 33GAMMAGARD S/D 33GAMMAGARD S/D IGA

LESS TH 33GAMMAKED 33GAMMAPLEX 33GAMUNEX-C 33ganciclovir inj 500mg 7garamycin 37GARDASIL 34GARDASIL 9 34GASTROCROM 31gatifloxacin (ophth) 37GATTEX 31


51

GAUZE PADS 2X2 24gaviltye-g 31gavilyte-c 31gavilyte-h 31gavilyte-n 31GAZYVA 10GELNIQUE 32GEMCITABINE 10gemcitabine hcl 10gemfibrozil 14GEMZAR 10GENERESS FE 26generlac 31gengraf 34gentak 37gentamicin in saline 0.8

mg/ml 4gentamicin in saline

0.9mg/ml 4gentamicin in saline 1 mg/ml4gentamicin in saline 1.2

mg/ml 4gentamicin in saline

1.4mg/ml 4gentamicin in saline 1.6

mg/ml 4gentamicin in saline 2 mg/ml4gentamicin sulfate 4gentamicin sulfate (ophth) 37gentamicin sulfate (topical) 40GEODON 20GEODON INJ 20GIANVI TAB 3-0.02MG 26GIAZO 30gildagia 26gildess 1.5/30 21 day 26gildess 24 fe 28 day 26GILENYA CAP 0.5MG 23GILOTRIF TAB 20MG 11GILOTRIF TAB 30MG 11GILOTRIF TAB 40MG 11GLASSIA 39glatopa 23GLEEVEC 11GLEOSTINE 10glimepiride 24glipizide 24glipizide er 24glipizide-metformin 2.5-250

mg 24glipizide-metformin 2.5-500

mg 24glipizide-metformin 5-

500mg 24GLUCAGEN HYPOKIT 28GLUCAGON EMERGENCY

KIT 28GLUCOPHAGE 24GLUCOPHAGE XR 24GLUCOTROL 24

GLUCOTROL XL 24GLYCATE 30glycopyrrolate 30GLYSET 24GLYXAMBI 24GOLYTELY 31GRALISE 22GRALISE STARTER 23granisetron hcl 30GRANIX 33GRASTEK 34GRIS-PEG 6griseofulvin microsize 6griseofulvin ultramicrosize 6guanfacine hcl (adhd) 22

HH.P. ACTHAR 29HALAVEN 12HALDOL 21HALDOL DECANOATE

100 21HALDOL DECANOATE 50 21halobetasol propionate 42HALOG 42haloperidol 21haloperidol decanoate 21haloperidol lactate 21haloperidol lactate inj 5

mg/ml 21HARVONI 7HAVRIX 34heather 26HECTOROL 36HEP SOD/NACL INJ

25000 32HEPARIN (PORCINE) IN

SODIUM CHLORIDE100U/ML 32

heparin sod inj 10000u/ml 32heparin sod inj 1000u/ml 32heparin sod inj 20000u/ml 32HEPARIN SOD INJ

2000U/ML 32HEPARIN SOD INJ

2500U/ML 32heparin sod inj

5000u/0.5ml 32heparin sod inj 5000u/ml 32HEPARIN SODIUM/D5W 32HEPARIN SODIUM/NACL

0.45% 32HEPATAMINE 35HEPSERA 7HERCEPTIN 10HETLIOZ 22HEXALEN 10HIBERIX 34HIPREX 5HIZENTRA 33

HORIZANT 23HUMATROPE 28HUMATROPE COMBO

PACK 28HUMIRA 33HUMIRA PEN 33HUMIRA PEN-CROHNS

STARTER KIT 33HUMIRA PEN-PSORIASIS

STARTER KIT 33HUMULIN R U-500

(CONCENTRATE) 24HYCAMTIN 12hycet 2hydralazine hcl 16HYDREA 12hydrochlorothiazide 16hydrocodone-acetaminophen

10-300mg 2hydrocodone-acetaminophen

2.5-325mg 2hydrocodone-acetaminophen




7.5-325 mg/15ml 2hydrocodone-acetaminophen


tab 10-325mg 2hydrocodone-ibuprofen tab

10-200mg 2hydrocodone-ibuprofen tab

2.5-200mg 2hydrocodone-ibuprofen tab 5-

200mg 2hydrocodone-ibuprofen tab

7.5-200 mg 2hydrocortisone 28HYDROCORTISONE

(INTRARECTAL) 30hydrocortisone (topical) 42hydrocortisone butyrate 42hydrocortisone butyrate

hydrophilic lipo base 42hydrocortisone valerate 42HYDROMORPHONE HCL 2hydromorphone hcl 2hydromorphone tab 12mg er3hydromorphone tab 16mg er3hydromorphone tab 8mg er 3HYDROMORPHONE TABS

32MG 3hydroxychloroquine sulfate 33hydroxyurea 12hydroxyzine hcl 39HYQVIA 33HYSINGLA ER 3


52

HYZAAR 13

Iibandronate sodium 25ibandronate tab 150mg 25IBRANCE 10ibudone tab 10-200mg 3ibudone tab 5-200mg 3ibuprofen 1ICLUSIG 11IDAMYCIN PFS 10idarubicin hcl 10IFEX INJ 1GM 10IFEX INJ 3GM 10ifosfamide inj 10ifosfamide inj 1gm 10IFOSFAMIDE INJ 3GM 10ILARIS 34ILEVRO 37ilotycin 37IMBRUVICA CAP 140MG 11imipenem-cilastatin 5imipramine hcl 19imipramine pamoate 19imiquimod 42IMITREX 22IMITREX STATDOSE

REFILL 22IMITREX STATDOSE

SYSTEM 22IMOVAX RABIES

(H.D.C.V.) 34IMURAN 34INCRELEX 29INCRUSE ELLIPTA 38indapamide 16INDERAL LA 15INFANRIX 34INFUMORPH 200 3INFUMORPH 500 3INLYTA 11INSPRA 13INSULIN PEN NEEDLES 24INSULIN SAFETY

NEEDLES 24INSULIN SYRINGES 24INTELENCE 6INTRALIPID INJ 20% 36INTRALIPID INJ 30% 36INTRON-A INJ 10MU 34INTRON-A INJ 18MU 34INTRON-A INJ 25MU 34INTRON-A INJ 50MU 34introvale 91 day 26INTUNIV 22INVANZ 5INVEGA 21INVEGA SUST INJ 117

MG/0.75 ML 21INVEGA SUST INJ

156MG/ML 21INVEGA SUST INJ 234

MG/1.5 ML 21INVEGA SUST INJ 39

MG/0.25 ML 21INVEGA SUST INJ 78

MG/0.5 ML 21INVEGA TRINZA 21INVIRASE 6INVOKAMET TAB 150-

1000 24INVOKAMET TAB 150-50024INVOKAMET TAB 50-100024INVOKAMET TAB 50-

500MG 24INVOKANA TAB 100MG 24INVOKANA TAB 300MG 24IONOSOL-B/DEXTROSE

5% 36IONOSOL-MB/DEXTROSE

5% 36IPOL INACTIVATED IPV 34ipratropium bromide

(nasal) 38ipratropium sol inhal 38ipratropium-albuterol 38irbesartan 13irbesartan-

hydrochlorothiazide 13IRESSA 11irinotecan inj 100/5ml 12irinotecan inj 40mg/2ml 12irinotecan inj 500mg/25ml 12ISENTRESS 6ISOLYTE P 36ISOLYTE S 36isoniazid 7isoniazid tabs 7ISOPTO CARPINE 38ISORDIL TITRADOSE 16isosorbide dinitrate 16isosorbide dinitrate er 16isosorbide mononitrate 16isosorbide mononitrate er 16isradipine 15ISTALOL 38ISTODAX 10itraconazole 6ivermectin 5IXEMPRA KIT 12IXIARO 34

JJADENU 25JAKAFI 11jantoven 32JANUMET 24JANUMET XR TAB 100-

1000 24JANUMET XR TAB 50-

1000 24JANUMET XR TAB 50-

500MG 24JANUVIA 24JARDIANCE 24JENTADUETO 24JEVTANA 10jinteli 27JOLESSA TAB 0.15-0.03

MG 26JOLIVETTE 26junel 1.5/30 21 day 26junel 1/20 21 day 26junel fe 1.5/30 28 day 26junel fe 1/20 28 day 26junel fe 24 1/20 28 day 26JUXTAPID 14

KK-TAB 35KADCYLA 11KADIAN 3KALBITOR 33KALETRA SOL 7KALETRA TAB 100-25MG 7KALETRA TAB 200-50MG 7KALYDECO 39kariva 28 day 26KAYEXALATE 25KAZANO 24KCL 0.075%/D5W/NACL

0.45% 36KCL 0.15%/D5W/LR 36KCL 0.15%/D5W/NACL

0.9% 36KCL 0.3%/D5W/LR IV LAC

RI 36KCL 0.3%/D5W/NACL

0.45% 36KCL 0.3%/D5W/NACL

0.9% 36KCL IN NACL INJ .15-0.45 36KCL/D5W/NACL INJ

.15/.33% 36KCL/D5W/NACL INJ

.15/.45% 36KCL/D5W/NACL INJ

0.22%/0.45% 36KCL/NACL INJ 0.15%-

0.9% 36KCL0.15%/D5W/NACL0.2% 3

6KCL0.15%/D5W/NACL0.225

% 36KEFLEX 8kelnor 1/35 28 day 26KENALOG 42KEPIVANCE 12KEPPRA 18KEPPRA XR 18


53

ketoconazole 6ketoconazole (topical) 40ketoconazole shampoo 41ketodan aer 2% 40ketoprofen 1ketorolac tromethamine

(ophth) 37KEYTRUDA 11kimidess 26KINERET 33KINRIX 34kionex 25KLARON 40KLONOPIN 18KLOR-CON 10 35KLOR-CON 8 35klor-con m10 35klor-con m15 35klor-con m20 35klor-con pow 20meq 35klor-con spr cap 10meq 35klor-con spr cap 8meq 35KOMBIGLYZE XR 2.5-

1000MG 24KOMBIGLYZE XR 5-

1000MG 24KOMBIGLYZE XR 5-

500MG 24KORLYM 28kristalose 31KUVAN 27KYNAMRO 14

Llabetalol hcl 15LAC-HYDRIN 42laclotion lot 12% 42LACRISERT 38LACTATED RINGERS

VIAFLEX 36lactulose 31lactulose (encephalopathy) 31LAMICTAL 18LAMICTAL CHEWABLE

DISPERS 18LAMICTAL ODT 18LAMICTAL STARTER 18LAMICTAL XR 18LAMISIL 6lamivudine 6lamivudine (hbv) 7lamivudine-zidovudine 7lamotrigine 18LANOXIN 16LANOXIN INJ 0.25MG/ML 16LANOXIN PEDIATRIC 16LANOXIN TAB 16lansoprazole 31LANTUS 24LANTUS SOLOSTAR 24

larin 1.5/30 26larin 1/20 26larin fe 1.5/30 26larin fe 1/20 26LASIX 16LASTACAFT 38latanoprost 38LATUDA 21LAZANDA 3LEENA TAB 26leflunomide 33LEMTRADA 23LENVIMA 10MG DAILY

DOSE 11LENVIMA 14MG DAILY



DOSE 11LESCOL 14lessina 28 day 26LETAIRIS 17letrozole 11leucovorin calcium 12leucovorin calcium inj

100mg 12leucovorin calcium inj




50mg 12LEUKERAN 10LEUKINE 33leuprolide acetate 11levalbuterol conc

1.25mg/0.5ml 39LEVALBUTEROL HCL 39levalbuterol hcl 39LEVAQUIN 9LEVEMIR 24LEVEMIR FLEXTOUCH 24levetiracetam 18LEVETIRACETAM IV 18levetiracetam oral soln 100

mg/ml 18LEVOBUNOLOL HCL 38levobunolol hcl 38levocarnitine (metabolic

modifiers) 27levocetirizine soln

2.5mg/5ml 39levocetirizine tab 5 mg 39levofloxacin 9levofloxacin (ophth) 37levofloxacin in d5w 9levoleucovorin calcium 12levonest 28 day 26

levonorgestrel & ethestradiol 26

levonorgestrel (emergencyoc) 26

levonorgestrel-ethinylestradiol (91-day) 26

levonorgestrel-ethinylestradiol (continuous) 26

levora 0.15/30 28 day 26levorphanol tartrate 3levothyroxine sodium 29LEVOXYL 29LEXAPRO 19LEXIVA 6LIALDA 30lidocaine 42lidocaine hcl 42lidocaine hcl (local anesth.) 4lidocaine hcl (mouth-throat)43lidocaine inj 0.5% 4lidocaine inj 1% 4lidocaine inj 1.5% 4lidocaine inj 2% 4lidocaine-prilocaine 42LIDODERM 42LINEZOLID 5linezolid 5LINZESS 31liothyronine sodium 29LIPOFEN 14LIPOSYN II 36LIPOSYN III 36lisinopril 13lisinopril &

hydrochlorothiazide 12lithium carbonate 23LITHIUM SOLN

8MEQ/5ML 23LITHOBID 23LIVALO 14LO LOESTRIN FE 26LOCOID 42LOCOID LIPOCREAM 42LODOSYN 20loestrin 1.5/30 21 day 26loestrin 1/20 21 day 26loestrin fe 1.5/30 28 day 26loestrin fe 1/20 28 day 26lofibra 14lokara 42lomedia 24 fe 26LOMOTIL 31LOMUSTINE 10LONSURF 12loperamide hcl 31LOPID 14LOPRESSOR 15LOPRESSOR HCT 14LOPROX SHAMPOO 40lorazepam 17


54

lorcet hd tab 10-325mg 3lorcet plus tab 7.5-325 3lorcet tab 5-325mg 3lortab tab 10-325mg 3lortab tab 5-325mg 3lortab tab 7.5-325 3loryna 28 day 26losartan potassium 13losartan-

hydrochlorothiazide 13LOSEASONIQUE 26LOTEMAX 37LOTENSIN 13LOTREL 12LOTRONEX 31lovastatin 14LOVAZA CAP 1GM 14LOVENOX 32low-ogestrel 26loxapine succinate 21LUCENTIS 38LUMIGAN 38LUMIZYME 27LUPANETA PACK 27LUPRON DEP INJ

11.25MG 11LUPRON DEP-PED INJ

11.25MG 11LUPRON DEP-PED INJ

15MG 11LUPRON DEP-PED INJ

30MG (3-MONTH) 11LUPRON DEP-PED INJ

7.5MG 11LUPRON DEPOT 11LUPRON DEPOT INJ

22.5MG (3-MONTH) 11LUPRON DEPOT INJ 30MG

(3-MONTH) 11lutera 28 day 26LUZU 40LYNPARZA 11LYRICA 18LYSODREN 11LYSTEDA 33lyza 26

MM-M-R II 34MACROBID 5MACRODANTIN 5MAGNESIUM SULFATE 35magnesium sulfate 35MAGNESIUM SULFATE IN

D5W 35MAGNESIUM SULFATE INJ

50% 35MALARONE 6malathion 43maprotiline hcl 19

MARINOL 30marlissa 28 day 26MARPLAN 19MATULANE 12matzim la 15MAVIK 13MAXALT 22MAXALT-MLT 22MAXIDEX 37MAXIPIME 8MAXITROL 37MAXZIDE 16MAXZIDE-25 16meclizine hcl 30MEDROL PAK 4MG 28MEDROL TAB 16MG 28MEDROL TAB 2MG 28MEDROL TAB 32MG 28MEDROL TAB 4MG 28MEDROL TAB 8MG 28medroxyprogesterone

acetate 29medroxyprogesterone

acetate (contraceptive) 26mefenamic acid 1mefloquine hcl 6MEGACE ES 11MEGACE ORAL 11megestrol acetate 11MEGESTROL SUS

625MG/5ML 11MEKINIST 11MELOXICAM 1meloxicam tabs 1melphalan hcl 10memantine hcl 19MENACTRA 34MENOMUNE-A/C/Y/W-13534MENOSTAR 27MENTAX 40MENVEO 34MEPRON 5mercaptopurine 10meropenem 5MERREM 5mesalamine enema 30mesna 12MESNEX 12MESTINON 23MESTINON SYRUP 23MESTINON TIMESPAN 23METADATE CD 22metadate er tab 20mg 22metformin er 24metformin hcl 24methadone hcl 3METHADONE INJ

10MG/ML 3METHADOSE 3methazolamide 16

methenamine hippurate 5methimazole 29methotrexate sodium inj 10methotrexate sodium tabs 33methoxsalen rapid 41methscopolamine bromide 30methyclothiazide 16methylergonovine maleate 29METHYLIN 22METHYLIN CHEW TAB 22methylphenidate hcl 22methylphenidate hcl er 22methylpr ace inj 40mg/ml 28methylpr ace inj 80mg/ml 28methylpr ss inj 125mg 28methylpr ss inj 1gm 28methylpr ss inj 40mg 28methylpred pak 4mg 28methylpred tab 16mg 28methylpred tab 32mg 28methylpred tab 4mg 28methylpred tab 8mg 28metipranolol 38metoclopramide hcl 30metoclopramide hcl inj 5

mg/ml 30metolazone 16metoprolol & hctz tab 100-

25mg 14metoprolol & hctz tab 100-

50mg 14metoprolol & hctz tab 50-

25mg 14metoprolol succinate 15metoprolol tartrate 15METRO IV 5METROCREAM 42METROGEL 42METROGEL-VAGINAL 32METROLOTION 42metronidazole 5metronidazole (topical) 42metronidazole inj 5metronidazole vaginal 32mexiletine hcl 14MIACALCIN INJ 200U/ML 29MIACALCIN SPR 200/ACT 29MICARDIS 13MICARDIS HCT 13miconazole 3 sup 200mg 32MICRO-K 35MICROGESTIN 1.5/30 26MICROGESTIN 1/20 26MICROGESTIN FE 1.5/30 26MICROGESTIN FE 1/20 26MICROZIDE 16midodrine hcl 16migergot 22MIGRANAL 22millipred 28


55

MINASTRIN 24 FE 26MINIPRESS 13minitran 16MINIVELLE 27MINOCIN 9minocycline hcl 9minoxidil 16MIRAPEX 20MIRAPEX ER 20MIRCERA 33mircette 26mirtazapine 19misoprostol 31mitomycin 10mitoxantrone hcl 12MOBIC 1modafinil 23MODERIBA PAK 7moderiba pak 7moderiba tab 200mg 7MODICON 26moexipril hcl 13moexipril-

hydrochlorothiazide 12mometasone furoate 42mono-linyah tab 0.25-35 26MONONESSA 26montelukast sodium 39MORPHINE SUL 20MG/ML

ORAL SOL 3MORPHINE SULFATE 3morphine sulfate 3morphine sulfate beads 3morphine sulfate ext-rel tab 3MOVANTIK 31MOVIPREP 31MOXEZA 37MOXIFLOXACIN HCL 9moxifloxacin hcl 9MOZOBIL 33MS CONTIN 3MULTAQ 14mupirocin 40mupirocin calcium (topical) 40MUSTARGEN 10my way 26MYALEPT 29MYAMBUTOL 7MYCAMINE 6MYCOBUTIN 7mycophenolate mofetil 34mycophenolate sodium 34MYFORTIC 34myorisan 40MYOZYME 27MYRBETRIQ 32MYSOLINE 18myzilra 26

N

nabumetone 1nadolol 15nadolol &

bendroflumethiazide 14nafcillin sodium 9NAFTIFINE HCL 40NAFTIN 41NAGLAZYME 27nalbuphine hcl 1NALLPEN ISO-OSMOTIC IN

DE 9NALLPEN/DEXTROSE 9naloxone hcl 23naltrexone hcl 23NAMENDA SOL

10MG/5ML 19NAMENDA TAB 19NAMENDA XR 19NAMENDA XR TITRATION

PACK 19NAMZARIC 19naphazoline 0.1% 38NAPRELAN 1NAPROSYN TABS 1naproxen 1NAPROXEN SODIUM 1naproxen sodium 1naratriptan hcl 22NARDIL 19NASONEX 39NATACYN 37nateglinide 24NATPARA 29NEBUPENT 5necon 0.5/35 28 day 26necon 1/35 28 day 26necon 10/11 28 day 26NECON 7/7/7 26NECON TAB 1/50-28 26nefazodone hcl 19neomycin sulfate 4neomycin-bacitracin zn-

polymyxin 37neomycin-polymy-

dexameth 37neomycin-polymyxin-

gramicidin 37neomycin-polymyxin-hc

(ophth) 37neomycin-polymyxin-hc

(otic) 43neomycin/polymyxin b gu 43NEORAL 34neosporin solution 37NEPHRAMINE 36NEPTAZANE 16NESINA 24neuac gel 1.2-5% 40NEULASTA 33NEULASTA DELIVERY

KIT 33

NEUMEGA 33NEUPOGEN 33NEUPRO 20NEURONTIN 18NEVIRAPINE 6nevirapine 6NEXAVAR 11NEXIUM I.V. 31next choice tab 1.5mg 26niacin er

(antihyperlipidemic) 14niacor 14NIASPAN 14nicardipine hcl 15NICOTROL INHALER 23NICOTROL NS 23nifedical 15nifedipine 15nifedipine er 15nikki 28 day 26NILANDRON 11nimodipine 15NIPENT 10nisoldipine 15nitro-bid 16NITRO-DUR 17nitrofurantoin 5nitrofurantoin macrocrystal 5nitrofurantoin monohyd

macro 5nitroglycerin 17NITROGLYCERIN

LINGUAL 17nitroglycerin patches 17NITROLINGUAL SPR

PUMPSPRA 17NITROMIST 17NITROSTAT 17nizatidine 30NIZORAL 41NOR-QD 26NORA-BE TAB 26norco 3NORDITROPIN FLEXPRO 28NORDITROPIN NORDIFLEX

PEN 28norethin acet & estrad-fe 26norethindrone & ethinyl

estradiol-fe 26norethindrone

(contraceptive) 26norethindrone acetate 29norethindrone acetate-ethinyl

estradiol 28norgest/ethi tab 0.25/35 26norgestimate-ethinyl estradiol

(triphasic) 26NORINYL 1+35 26NORINYL 1+50 26norlyroc 28 day 26


56

NORMOSOL-M IN D5W 36NORMOSOL-R 36NORPACE 14NORPACE CR 14NORPRAMIN 19nortrel 0.5/35 28 day 26nortrel 1/35 21 day 26nortrel 1/35 28 day 26nortrel 7/7/7 28 day 26nortriptyline hcl 19NORVASC 15NORVIR 6NOVAREL INJ 10000UNT 29NOVOLIN 70/30 24NOVOLIN N 24NOVOLIN R 24NOVOLOG 24NOVOLOG FLEXPEN 24NOVOLOG MIX 70/30 24NOVOLOG MIX 70/30

PREFILL 24NOVOLOG PENFILL 24NOXAFIL 6NPLATE 33NUCYNTA 3NUCYNTA ER 3NUEDEXTA 23NULOJIX 34NULYTELY/FLAVOR

PACKS 31NUTRILIPID INJ 20% 36NUVARING 26NUVESSA 32NUVIGIL 23nyamyc 41NYMALIZE 15nystatin 6nystatin (mouth-throat) 43nystatin (topical) 41nystatin pow 100000 41nystop 41

OOCELLA TAB 3-0.03MG 26OCTAGAM 33octreotide acetate 29OCUFEN 37OCUFLOX 37ODOMZO 12OFEV 39ofloxacin (ophth) 37ofloxacin (otic) 43ogestrel 28 day 26olanzapine 21olanzapine odt 21olopatadine hcl (nasal) 39OLUX 42OMECLAMOX-PAK 31omega-3-acid ethyl esters 14omeprazole 31

OMNARIS 39OMNIPRED 37ONCASPAR 12ondansetron hcl 30ondansetron hcl inj 30ondansetron hcl oral soln 30ondansetron odt 30ONFI 18ONGLYZA 24ONMEL 6OPANA 3OPANA ER (CRUSH

RESISTANT 3OPDIVO 11OPSUMIT 17OPTIPRANOLOL 38ORACEA 42ORAP 21ORAPRED ODT TAB

10MG 28ORAPRED ODT TAB

15MG 28ORAPRED ODT TAB

30MG 28ORENCIA 33ORENITRAM TAB

0.125MG 17ORENITRAM TAB 0.25MG17ORENITRAM TAB 1MG 17ORENITRAM TAB 2.5MG 17ORFADIN 27ORKAMBI 39orsythia 28 day 26ORTHO MICRONOR 26ORTHO TRI-CYCLEN LO 26ORTHO-CYCLEN 26ORTHO-NOVUM 1/35 27ORTHO-NOVUM 7/7/7 27OSENI TAB 12.5-15MG 24OSENI TAB 12.5-30MG 25OSENI TAB 12.5-45MG 25OSENI TAB 25-15MG 25OSENI TAB 25-30MG 25OSENI TAB 25-45MG 25OSMOPREP 31OTEZLA 33OTREXUP 33ovcon 35 28 day 27ovide 43oxacillin sodium 9oxaliplatin 12oxandrolone 24oxaprozin 1oxcarbazepine 18OXISTAT 41OXSORALEN ULTRA 41OXTELLAR XR 18oxybutynin chloride 32OXYCODONE HCL 3oxycodone hcl 3

oxycodone w/ acetaminophen10-325mg 4

oxycodone w/ acetaminophen2.5-325mg 3

oxycodone w/ acetaminophen5-325mg 3

oxycodone w/ acetaminophen7.5-325mg 4

oxycodone-aspirin 4oxycodone-ibuprofen 4OXYCONTIN 4oxymorphone hcl 4

Ppacerone 14paclitaxel 10paliperidone 21PAMELOR 19pamidronate disodium 25PAMINE 30PAMINE FORTE 30PANCREAZE 31PANDEL 42PANRETIN 42pantoprazole sodium 31PARICALCITOL 36paricalcitol 36PARNATE 19paroex sol 0.12% 43paromomycin sulfate 4paroxetine er tab 19paroxetine hcl tabs 19paser d/r 7PATADAY 38PATANASE 39PATANOL 38PAXIL 19PAXIL CR 19PAZEO 38PCE 8pediapred sol 6.7/5ml 28PEDVAX HIB 34PEG 3350-KCL-SOD

BICARB-SODCHLORIDE-SODSULFATE 31

peg 3350-potassium chloride-sod bicarbonate-sodchloride 31

PEG-INTRON 7PEG-INTRON REDIPEN 7PEGANONE 18PEGASYS 7PEGASYS PROCLICK 7PEGINTRON 7PENICILLIN G POT IN

DEXTROSE 9PENICILLIN G POTASSIUM

IN 9penicillin g procaine 9


57

penicillin g sodium 9penicillin v potassium 9penicilln gk inj 20mu 9penicilln gk inj 5mu 9PENNSAID 42PENTAM 300 5PENTASA 30pentoxifylline 33PEPCID SUSP 30pepcid tab 30percocet 10/325 4percocet 2.5/325 4percocet 7.5/325 4percocet tab 5-325mg 4PERCODAN 4PERFOROMIST 39perindopril erbumine 13periogard soln 0.12% 43PERJETA 11permethrin 43perphenazine 21PERTZYE 31PEXEVA 19pfizerpen g inj 5mu 9pfizerpen-g inj 20mu 9phenadoz 30phenelzine sulfate 19phenergan 30phenergan inj 30phenobarbital 18PHENOBARBITAL

SODIUM 18phenobarbital sodium 18phenoxybenzamine hcl 16phenytek 18phenytoin 18phenytoin inj 50mg/ml 18phenytoin sodium

extended 18philith 27PHOSLO 29PHOSLYRA 29PHOSPHOLINE IODIDE 38PICATO 42PILOCARPINE HCL 38PILOCARPINE HCL

(ORAL) 43pilocarpine hcl (oral) 43pimozide 21pimtrea pack 27pindolol 15pioglitazone hcl 25pioglitazone hcl-glimepiride25pioglitazone hcl-metformin

hcl 25piperacillin sodium-

tazobactam sodium 9pirmella 1/35 28 day 27piroxicam 1PLAQUENIL 33

PLASMA-LYTE A 36PLASMA-LYTE-148 36PLASMA-LYTE-56/D5W 36PLEGRIDY 23PLEGRIDY STARTER

PACK 23PLETAL 33podofilox 42polyethylene glycol 3350 31polymyxin b sulfate 5polymyxin b-trimethoprim 37POLYTRIM 37POMALYST 12PONSTEL 1portia 28 day 27pot chloride inj 2meq/ml 36POTASSIUM CHLORIDE 35,

36potassium chloride 35POTASSIUM CHLORIDE

0.3%/D 36potassium chloride caps er 35POTASSIUM CHLORIDE IN

NACL 36potassium chloride in nacl 36potassium chloride

microencapsulatedcrystals cr 35

POTASSIUM CHLORIDETAB CR 10 MEQ 35

POTASSIUM CITRATE(ALKALINIZER) 32

potassium citrate(alkalinizer) 32

POTIGA 18PRADAXA 32pramipexole

dihydrochloride 20PRANDIMET 25PRANDIN 25PRAVACHOL 14pravastatin sodium 14prazosin hcl 13PRECOSE 25PRED FORTE 37PRED MILD 37pred sod pho sol 5mg/5ml 28PRED-G 37PRED-G S.O.P. 37PREDNICARBATE 42prednicarbate 42PREDNISOLONE ACETATE

(OPHTH) 37prednisolone sodium

phosphate 28prednisolone sodium

phosphate (ophth) 37prednisolone sol 15mg/5ml 28prednisolone sol 25mg/5ml 28prednisolone syrup 15

mg/5ml 28

prednisone con 5mg/ml 28prednisone pak 10mg 28prednisone pak 5mg 28prednisone sol 5mg/5ml 28prednisone tab 10mg 28prednisone tab 1mg 28prednisone tab 2.5mg 28prednisone tab 20mg 28prednisone tab 50mg 28prednisone tab 5mg 28PREGNYL W/DILUENT

BENZYL 29PREMARIN CREAM 28PREMARIN INJ 28premasol 10% 36premasol 6% 36PRENATAL VITAMIN/FOLIC

ACID > 0.8 MG(GENERIC) 37

PREPOPIK 31PREVACID 31prevalite 14previfem 28 day 27PREVPAC 31PREZCOBIX 7PREZISTA 6PRIFTIN 7PRILOSEC 31PRIMAQUINE

PHOSPHATE 6PRIMAXIN 5primidone 18PRIMSOL SOL 50MG/5ML 5PRINIVIL 13PRISTIQ 19PRIVIGEN 34PROAIR HFA 39probenecid 1PROCALAMINE 36PROCARDIA XL 15prochlorperazine inj 5

mg/ml 30prochlorperazine maleate 30prochlorperazine supp 30PROCRIT 33procto-pak 41proctosol hc 2.5 % 41proctozone hc 41PROCYSBI 27progesterone micronized 29PROGLYCEM SUS

50MG/ML 28PROGRAF 34PROLASTIN-C 39PROLEUKIN 11PROLIA 29PROMACTA 33promethazine hcl 30promethegan 30PROMETRIUM 29


58

propafenone hcl 14propafenone hcl 12hr 14proparacaine hcl 38propranolol &

hydrochlorothiazide 15propranolol hcl er 15propranolol inj 1mg/ml 15propranolol sol 15propranolol tab 15propylthiouracil 29PROQUAD 34PROSCAR 32PROSOL 36PROTONIX INJ 31PROTOPIC 42protriptyline hcl 19PROVERA 29PROZAC 20PROZAC WEEKLY 20PRUDOXIN CRE 5% 41psorcon 42PULMICORT FLEXHALER 39PULMICORT INH SUSP

0.25MG/2 ML 39PULMICORT INH SUSP

0.5MG/2 ML 39PULMICORT INH SUSP

1MG/2ML 40PULMOZYME 39PURIXAN 10PYLERA 31pyrazinamide 7pyridostigmine bromide 23

QQNASL 39QNASL CHILDRENS 39QUADRACEL 34QUALAQUIN 6QUARTETTE 27quasense 91 day 27QUDEXY XR 18questran 14questran light 14quetiapine fumarate 21QUILLIVANT XR 22quinapril hcl 13quinapril-

hydrochlorothiazide 12quinidine gluconate 14quinidine sulfate 14quinine sulfate 6QVAR 40

RRABAVERT 34rabeprazole sodium 31RAGWITEK 34raloxifene hcl 29ramipril 13

RANEXA 16ranitidine hcl 30RAPAFLO 32RAPAMUNE 34RASUVO 33RAVICTI 27RAYOS TAB 1MG 28RAYOS TAB 2MG 28RAYOS TAB 5MG 28RAZADYNE 19RAZADYNE ER 19REBETOL 7REBIF 23REBIF REBIDOSE 23REBIF REBIDOSE

TITRATION 23REBIF TITRATION PACK 23RECLAST 25reclipsen 28 day 27RECOMBIVAX HB 34RECTIV 42REGLAN 30REGRANEX 43RELENZA DISKHALER 7RELISTOR 31RELPAX 22REMERON 20REMERON SOLTAB 20REMICADE 33REMODULIN 17RENAGEL 29RENVELA PAK 29RENVELA TAB 800MG 29repaglinide 25reprexain tab 10-200mg 4reprexain tab 2.5-200mg 4reprexain tab 5-200mg 4REQUIP 20RESCRIPTOR 6RESTASIS 38RESTORIL 22RETIN-A 40RETROVIR CAPS 6RETROVIR IV INFUSION 6RETROVIR SYRP 6REVATIO 17REVLIMID 34REXULTI 21REYATAZ 6RHEUMATREX 33RHINOCORT AQUA 39ribapak mis 600/day 7ribasphere 7ribasphere ribapak 1000 8ribasphere ribapak 1200 8ribasphere ribapak 800 7ribavirin 200mg 8rifabutin 7RIFADIN 7rifadin 7

rifamate 7rifampin 7RIFATER 7RILUTEK 23riluzole 23rimantadine hydrochloride 8RINGER'S 36RIOMET 25RISEDRONATE SODIUM 25risedronate sodium 25RISPERDAL 21RISPERDAL INJ 12.5MG 21RISPERDAL INJ 25MG 21RISPERDAL INJ 37.5MG 21RISPERDAL INJ 50MG 21RISPERDAL M-TAB 21risperidone 21risperidone odt 21RITALIN 22RITALIN LA 22RITUXAN 11rivastigmine tartrate 19rivastigmine td patch 24hr

13.3 mg/24hr 19rivastigmine td patch 24hr 4.6

mg/24hr 19rivastigmine td patch 24hr 9.5

mg/24hr 19rizatriptan benzoate 22ROBINUL 30ROBINUL FORTE 30ROCALTROL 37rocephin 8ropinirole hydrochloride 20rosadan cre 0.75% 42ROTARIX 34ROTATEQ 34ROWASA 30roxicet soln 4roxicet tab 5-325mg 4ROXICODONE 4ROZEREM 22RUCONEST 33RYTARY 20RYTHMOL 14RYTHMOL SR 14

SSABRIL 18SALAGEN 43SAMSCA 29SANCUSO 30SANDIMMUNE CAPS 34SANDIMMUNE INJ 34SANDIMMUNE SOLN 34SANDOSTATIN 29SANDOSTATIN LAR

DEPOT 29SANTYL 43SAPHRIS 21


59

SARAFEM 23SAVAYSA 32SAVELLA 23SAVELLA TITRATION

PACK 23SEASONIQUE 27SECTRAL 15selegiline hcl 20selenium sulfide 41SELZENTRY 6SEMPREX-D 38SENSIPAR 25SEREVENT DISKUS 39SEROQUEL 21SEROQUEL XR 21SEROSTIM 28sertraline hcl 20setlakin tab 27SF-ROWASA 31sharobel 28 day 27SIGNIFOR 29SIGNIFOR LAR 29sildenafil citrate (pulmonary

hypertension) 17SILENOR 22SILVADENE 40SILVER SULFADIAZINE 40SIMBRINZA SUS 1-0.2% 38SIMCOR 14SIMPONI 33SIMPONI ARIA 33SIMULECT 34simvastatin 14SINEMET 20SINEMET CR 20SINGULAIR 39SIROLIMUS 34sirolimus 34SIRTURO 7SIVEXTRO 5SKLICE 43SODIUM CHLORIDE 35, 36SODIUM CHLORIDE 0.45%

VIA 36SODIUM CHLORIDE 0.9% 43SODIUM DIURIL 16SODIUM FLUORIDE CHEW;

TAB; 1.1 (0.5 F) MG/MLSOLN 35

sodium phenylbutyrate 27sodium polystyrene

sulfonate 25SOLARAZE 42SOLIA 27SOLIRIS 33SOLODYN 9SOLTAMOX 11SOLU-CORTEF 1000MG 28SOLU-CORTEF 100MG 28SOLU-CORTEF 250MG 28

SOLU-CORTEF 500MG 28SOLU-MEDROL INJ

125MG 28SOLU-MEDROL INJ 1GM 28SOLU-MEDROL INJ 2GM 28SOLU-MEDROL INJ 40MG28SOLU-MEDROL INJ

500MG 28SOMATULINE DEPOT 29SOMAVERT 29SOOLANTRA 42SORIATANE 41SORILUX 41sorine 14sotalol hcl 14sotalol hcl (afib/afl) 14SOTYLIZE 15SOVALDI 8SPIRIVA HANDIHALER 38SPIRIVA RESPIMAT 38spironolactone 13spironolactone &

hydrochlorothiazide 16SPORANOX 6SPORANOX PULSEPAK 6SPORANOX SOL 10MG/ML6sprintec 28 day 27SPRYCEL 11sps susp 15gm/60ml 25sronyx 28 day 27SSD 40STALEVO 20STARLIX 25stavudine 6STELARA 41STERILE WATER

IRRIGATION 43STIMATE 29STIOLTO RESPIMAT 38STIVARGA 11STRATTERA 22streptomycin sulfate 4STRIANT 24STRIBILD 7STRIVERDI RESPIMAT 39STROMECTOL 5SUBSYS 4SUCLEAR 31SUCRAID 31sucralfate 31SULAR 15sulfacet sod oin 10% op 37sulfacetamide sod-

prednisolone 37sulfacetamide sodium

(acne) 40sulfacetamide sodium

(ophth) 37sulfadiazine 4sulfamethoxazole-trimethop 5

sulfamethoxazole-trimethoprim inj 5

SULFAMYLON 40sulfasalazine dr 31sulfasalazine ir 31sulindac 1SUMATRIPTAN INJ

4MG/0.5ML 22SUMATRIPTAN INJ

6MG/0.5ML 22sumatriptan inj 6mg/0.5ml 22SUMATRIPTAN

SUCCINATE 22sumatriptan succinate 22SUMAVEL DOSEPRO 22SUPRAX 8suprax 8SUPREP BOWEL PREP 31SURMONTIL 20SUSTIVA 6SUTENT 12syeda 27SYLATRON KIT 200MCG 12SYLATRON KIT 300MCG 12SYLATRON KIT 600MCG 12SYLVANT 12SYMBICORT 40SYMLINPEN 120 24SYMLINPEN 60 24SYNAGIS 34SYNALAR 42SYNALGOS-DC 1SYNAREL 27SYNERA 42SYNERCID 5SYNRIBO 12SYNTHROID 29SYPRINE 25

TTABLOID 10TACLONEX 42tacrolimus 34tacrolimus (topical) 42TAFINLAR 12TAMIFLU 8tamoxifen citrate 11tamsulosin hcl 32TANZEUM 24tapazole 29TARCEVA 12TARGRETIN 12, 42tarina fe 1/20 28 day 27TARKA 12TASIGNA 12TAXOTERE 10tazicef 8tazicef vial 8TAZORAC 41taztia xt 15


60

TECFIDERA CAP 120MG 23TECFIDERA CAP 240MG 23TECFIDERA MIS

STARTER 23TEFLARO 8TEGRETOL 18TEGRETOL-XR 18TEKTURNA 16TEKTURNA HCT 16telmisartan 13telmisartan-amlodipine 13telmisartan-

hydrochlorothiazide 13temazepam 22TEMOVATE CREAM 42TEMOVATE E CREAM 42TEMOVATE GEL 42TEMOVATE OIN 42TEMOVATE SOLN 42TENIVAC 34TENORETIC 100 15TENORETIC 50 15TENORMIN 15TERAZOL 3 32TERAZOL 7 32terazosin hcl 13terbinafine hcl 6terbutaline sulfate 39terconazole vaginal 32testosterone cypionate 24testosterone enanthate 24TETANUS/DIPHTHERIA

TOXOID 34tetrabenazine 23TETRACYCLINE HCL 9TEVETEN 13TEVETEN HCT 13texacort 42THALOMID 34theo-24 40theophylline 40thioridazine hcl 21thiothixene 21THYMOGLOBULIN 34tiagabine hcl 18TIAZAC 15TIKOSYN 14timolol maleate 15timolol maleate (ophth) 38TIMOLOL MALEATE GEL 38TIMOPTIC 38TIMOPTIC OCUDOSE 38TIMOPTIC-XE 38TIROSINT 29TIVICAY 6tizanidine 23TOBI NEB 4TOBI PODHALER 4TOBRADEX 37tobramycin 4

tobramycin (ophth) 37tobramycin sulfate 4tobramycin sulfate in saline 4tobramycin-

dexamethasone 37TOBREX OINT 0.3% 37TOBREX SOL 0.3% OP 37TOFRANIL 20TOFRANIL-PM 20TOLAK 43tolmetin sodium 1tolterodine tartrate er 32tolterodine tartrate tab 1

mg 32tolterodine tartrate tab 2

mg 32TOPAMAX 18TOPAMAX SPRINKLE 18TOPICORT 42topicort 42TOPICORT SPRAY 0.25% 42TOPIRAMATE 18topiramate 18toposar 12topotecan hcl 12TOPROL XL 15TORISEL 11torsemide inj 50mg/5ml 16torsemide tabs 16TOUJEO SOLOSTAR 24TPN ELECTROLYTES 35TRACLEER 17TRADJENTA 25TRAMADOL HCL 1TRAMADOL HCL ER 1tramadol hcl er 1tramadol hcl er (biphasic)

100mg 1tramadol hcl er (biphasic)

200mg 2tramadol hcl er (biphasic)

300mg 2tramadol hcl tab 50 mg 2tramadol-acetaminophen 2TRANDATE 15trandolapril 13trandolapril-verapamil hcl 12tranexamic acid 33TRANSDERM-SCOP 30TRANXENE T 18tranylcypromine sulfate 20TRAVASOL 36TRAVATAN Z 38trazodone hcl 20TREANDA 10TRECATOR 7TRELSTAR MIXJECT 11TRETINOIN 40tretinoin 12, 40TRETINOIN

MICROSPHERE 40tretinoin microsphere 40trexall 33trezix 2tri-legest 28 day 27TRI-NORINYL 28 27tri-previfem 28 day 27tri-sprintec 28 day 27triamcinolone acetonide

(mouth) 43triamcinolone acetonide

(nasal) 39triamcinolone acetonide

(topical) 42triamt/hctz cap 37.5-25 16triamt/hctz cap 50-25mg 16triamt/hctz tab 37.5-25 16triamt/hctz tab 75-50mg 16trianex 42TRICOR 14triderm 42trifluoperazine hcl 21trifluridine 37TRILEPTAL SUSP 18TRILEPTAL TABS 18TRILIPIX 14trilyte 31trimethoprim 5trimipramine maleate 20TRINESSA 27TRIOSTAT 29TRISENOX 12TRIUMEQ 7trivora 28 day 27TRIZIVIR 7TROKENDI XR 18TROPHAMINE INJ 10% 36TROPHAMINE INJ 6% 36trospium chloride 32trospium chloride er 32TRULICITY 24TRUMENBA 35TRUSOPT 38TRUVADA 7TUDORZA PRESSAIR 38TUDORZA PRESSAIR

(INSTITUTIONALPACK) 38

TWINRIX INJ 35TWYNSTA 13TYBOST 6TYGACIL 5TYKERB 12tylenol with codeine 2TYPHIM VI 35TYSABRI 23TYVASO 17TYZEKA 8tyzine 39


61

UUCERIS 31ULORIC 1ULTRACET 2ULTRAM 2ULTRAM ER 2ULTRAVATE 42ULTRESA 31UNASYN 9UNASYN BULK PACK 9UNITHROID 29urecholine 32UROCIT-K 32UROXATRAL 32URSO 250 31URSO FORTE 31ursodiol 31UVADEX 12

VVAGIFEM 28valacyclovir hcl 8VALCHLOR 43VALCYTE 8valganciclovir hcl 8VALIUM 18valproate sodium 18valproic acid 18valsartan 13valsartan-

hydrochlorothiazide 13VALSTAR 10VALTREX 8VANCOCIN HCL 5vancomycin hcl 5vancomycin hcl inj 1000mg 5vancomycin hcl inj 10gm 5vancomycin hcl inj 500mg 5vancomycin hcl inj 5gm 5vancomycin hcl inj 750mg 5VANDAZOLE 32VANOS 42VANTAS 11VAQTA 35VARIVAX 35VASCEPA 14VASERETIC 12VASOTEC 13VECTIBIX 11VECTICAL 41VELCADE 11VELETRI 17velivet 28 day 27VELPHORO 29venlafaxine cap er 20venlafaxine hcl 20VENLAFAXINE HCL ER TAB

(VERT) 20venlafaxine tab 20

VENLAFAXINE TAB 225MGER 20

venlafaxine tab er 20VENTAVIS 17VERAPAMIL HCL 15verapamil hcl 15VERELAN 15VERELAN PM 15veripred 28VERSACLOZ 21VESICARE 32vestura 27VEXOL 37VFEND IV 6VFEND SUS 40MG/ML 6VFEND TAB 6VIBRAMYCIN 9vicodin 4vicodin es 4vicodin hp 4VICOPROFEN 4VICTOZA 24VIDAZA 10VIDEX EC 6VIDEX PEDIATRIC 6VIGAMOX 37VIIBRYD 20VIIBRYD STARTER PACK 20VIMIZIM 27VIMPAT 18, 19vinblastine sulfate 10vincasar 10vincristine sulfate 10vinorelbine tartrate 10VIOKACE 10 31VIOKACE 20 31viorele 27VIRACEPT 6VIRAMUNE 6VIRAMUNE XR 7VIREAD 7VIROPTIC 37VITEKTA 7VIVELLE-DOT 28VIVITROL 23VOLTAREN GEL 1% 43VOLTAREN-XR 1voriconazole 6voriconazole inj 200mg 6vospire 39VOTRIENT 12VPRIV 27vyfemla 28 day 27VYTORIN 14VYVANSE 22

Wwarfarin sodium 33WELCHOL 14

WELLBUTRIN 20WELLBUTRIN SR 20WELLBUTRIN XL 20wymzya fe 27

XXALATAN 38XALKORI 12XANAX TAB 0.25MG 17XANAX TAB 0.5MG 17XANAX TAB 1MG 17XANAX TAB 2MG 17XARELTO 33XARELTO STARTER

PACK 33XARTEMIS XR 4XELJANZ 33XENAZINE 23XEOMIN 23XGEVA 29XIFAXAN TAB 200MG 5XIFAXAN TAB 550MG 31XIGDUO XR TAB 10-

1000MG 25XIGDUO XR TAB 10-



500MG 25xodol tab 10-300mg 4xodol tab 5-300mg 4xodol tab 7.5-300 4XOLAIR 39XOPENEX 39XOPENEX

CONCENTRATE 39XTANDI 11xulane dis 150-35 27XYLOCAINE 4, 42XYLOCAINE-MPF 4xylon tab 10-200mg 4XYREM 23XYZAL 39

YYASMIN 28 27YAZ 27YERVOY 11YF-VAX 35

Zzafirlukast 39ZALTRAP 11zamicet 4ZANAFLEX 23ZANOSAR 10ZANTAC 30zarah 27


62

ZARONTIN 19zarontin 19ZAVESCA 27ZAZOLE 32zazole 32ZEBETA 15ZELAPAR 20ZELBORAF 12ZEMAIRA 39ZEMPLAR 37ZENATANE 40zenatane 40zenchent fe 28 day 27zenchent tab 27ZENPEP 31ZERBAXA 8ZERIT 7ZESTORETIC 12ZESTRIL 13ZETIA TAB 10MG 14ZETONNA 39ZIAC 15ZIAGEN 7zidovudine 7ZINACEF 8ZINECARD 12ZIOPTAN 38ziprasidone hcl 21ZIRGAN 37ZITHROMAX 8ZITHROMAX TRI-PAK 8ZITHROMAX Z-PAK 8ZMAX 9ZOCOR 14ZOFRAN 30ZOFRAN ODT 30ZOHYDRO ER (ABUSE

DETERRENT) 4ZOLADEX 11zoledronic inj 4mg/5ml 25zoledronic inj 5/100ml 25ZOLINZA 11zolmitriptan 22zolmitriptan odt 22ZOLOFT 20zolpidem tartrate 22ZOMETA 25ZOMIG 22ZOMIG ZMT 22ZONALON 41ZONEGRAN 19zonisamide 19ZONTIVITY 33ZORBTIVE 29ZORTRESS TAB 0.25MG 34ZORTRESS TAB 0.5MG 34ZORTRESS TAB 0.75MG 34ZOSTAVAX 35ZOSYN 9zovia 1/35e 28 day 27

zovia 1/50e 28 day 27ZOVIRAX 8, 43ZUBSOLV SUB 1.4-

0.36MG 23ZUBSOLV SUB 11.4-

2.9MG 23ZUBSOLV SUB 2.9-

0.71MG 23ZUBSOLV SUB 5.7-1.4MG 23ZUBSOLV SUB 8.6-2.1MG 23ZYBAN 23ZYDELIG 12ZYFLO CR 39ZYKADIA 12ZYLET 37ZYLOPRIM 1ZYMAXID 37ZYPREXA 21ZYPREXA RELPREVV 21ZYPREXA RELPREVV INJ

210MG 21ZYPREXA ZYDI TAB

10MG 21ZYPREXA ZYDIS 21ZYTIGA 11ZYVOX 5

drug name drug requirements/ drug name drug requirements

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