for north dakota medicaid expansion members · of commonly prescribed medications that are ... may...
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2017 Formulary for North Dakota Medicaid Expansion Members
Please refer to the following list (formulary) of commonly prescribed medications that are covered by insurance. This is not a complete list; to view the full list, please log in in to your secure member portal at sanfordhealthplan.com/memberlogin and select the “Find a pharmacy/Link to Express Scripts” tab located under “My Information.”
When reviewing the list, please use the guide on page 3. For more information about your pharmacy benefits, covered drugs, copays and more, please check your Summary of Benefits and Coverage and Certificate of Coverage. This information can also be found online or by contacting our Pharmacy Management Team at (855) 305-5062; TTY (877) 652-1844 between 8 am and 5 pm CT Monday through Friday.
HP-2173_12-01-17
HP-2173_LZCA eff date 12-01-17
Table of Contents ANTI - INFECTIVES ............................................................................................................................................ 5
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS .............................................................................. 13
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCHOLOGY ............................................................. 14
CARDIOVASCULAR, HYPERTENSION & LIPIDS ......................................................................................... 31
DERMATOLOGICALS/TOPICAL THERAPY .................................................................................................. 40
DIAGNOSTICS & MISCELLANEOUS AGENTS ............................................................................................ 50
EAR, NOSE & THROAT MEDICATIONS ........................................................................................................ 52
ENDOCRINE/DIABETES .................................................................................................................................. 53
GASTROENTEROLOGY ................................................................................................................................... 59
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ................................................................................... 65
MUSCULOSKELETAL & RHEUMATOLOGY ................................................................................................... 67
OBSTETRICS & GYNECOLOGY ..................................................................................................................... 68
OPHTHALMOLOGY ........................................................................................................................................ 75
RESPIRATORY, ALLERGY, COUGH & COLD ............................................................................................... 80
UROLOGICALS ................................................................................................................................................ 85
VITAMINS, HEMATINICS & ELECTROLYTES ................................................................................................ 87
INDEX ................................................................................................................................................................ 92
3
ABBREVIATIONS
Tier:
$0: These drugs take a $0 copay
1: Generics (these drugs take a $0 copay)
2: Brands (these drugs take a $3 copay)
LA (Limited Availability): May be available only at certain pharmacies. For more
information, please call Customer Service.
PA (Pre-Approval Needed):
You or your provider must get pre-approval for the
medicine with Sanford Health Plan before you can get the
prescription filled.
QL (Quantity Limit /Number
Allowed)
The Plan may limit the amount of medicine you can
receive of certain coverage medications.
SP (Specialty Medications):
. These drugs may require frequent dosing adjustments,
close monitoring, special training, compliance assistance,
or need special handling and/or administration. They may
also be limited in supply.
ST (Step Therapy):
With certain medications, you must first try lower cost
and/or generic versions before high cost options are
covered. If the first step medication does not work or you
have side effects, the next step may be covered.
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
5
Drug Name Tier Requirements - Limitations
ANTI - INFECTIVES
Antifungal Agents
clotrimazole mucous
membrane troche 10 mg 1
fluconazole oral
suspension for recon
10 mg/ml, 40 mg/ml
1
fluconazole oral tablet 50
mg,100mg,150mg,200mg 1
flucytosine oral capsule
250 mg, 500 mg 1
griseofulvin microsize oral
suspension 125 mg/5 ml 1
griseofulvin microsize oral
tablet 500 mg 1
griseofulvin ultramicrosize
oral tablet 125mg, 250mg 1
GRIS-PEG
(ULTRAMICROSIZE) ORAL
TABLET 125 MG, 250 MG
2
itraconazole oral capsule
100 mg 1 QL
ketoconazole oral tablet
200 mg 1
nystatin oral powder 150
million unit, 500 million unit 1
nystatin oral suspension
100,000 unit/ml 1
nystatin oral tablet 500,000
unit 1
terbinafine hcl oral tablet
250 mg 1
voriconazole oral
suspension for recon 200
mg/5 ml (40 mg/ml)
1
Drug Name Tier Requirements - Limitations
voriconazole oral tablet
200 mg, 50 mg 1
Antivirals
abacavir oral soln 20
mg/ml 1
abacavir oral tablet 300
mg 1
abacavir-lamivudine oral
tablet 600-300 mg 1
abacavir-lamivudine-
zidovudine oral tablet 300-
150-300 mg
1
acyclovir oral capsule 200
mg 1
acyclovir oral suspension
200 mg/5 ml 1
acyclovir oral tablet 400
mg, 800 mg 1
adefovir oral tablet 10 mg 1
amantadine hcl oral
capsule 100 mg 1
amantadine hcl oral soln
50 mg/5 ml 1
amantadine hcl oral
tablet 100 mg 1
APTIVUS ORAL CAPSULE
250 MG 2
APTIVUS ORAL SOLN 100
MG/ML 2
ATRIPLA ORAL TABLET 600-
200-300 MG 2
COMBIVIR ORAL TABLET
150-300 MG 2
COMPLERA ORAL TABLET
200-25-300 MG 2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
6
Drug Name Tier Requirements - Limitations
CRIXIVAN ORAL CAPSULE
200 MG, 400 MG 2
DESCOVY ORAL TABLET
200-25 MG 2
didanosine oral capsule,
del-release(dr/ec) 125mg,
200mg 250mg,400mg
1
EDURANT ORAL TABLET 25
MG 2
EMTRIVA ORAL CAPSULE
200 MG 2
EMTRIVA ORAL SOLN 10
MG/ML 2
entecavir oral tablet 0.5
mg, 1 mg 1
EPCLUSA ORAL TABLET
400-100 MG 2 PA; SP
EPIVIR HBV ORAL SOLN 25
MG/5 ML (5 MG/ML) 2
EPIVIR HBV ORAL TABLET
100 MG 2
EPIVIR ORAL SOLN 10
MG/ML 2
EPIVIR ORAL TABLET 150
MG 2 QL
EPIVIR ORAL TABLET 300
MG 2
EPZICOM ORAL TABLET
600-300 MG 2
EVOTAZ ORAL TABLET 300-
150 MG 2
famciclovir oral tablet 125
mg, 250 mg, 500 mg 1 QL
fosamprenavir oral tablet
700 mg 1
Drug Name Tier Requirements - Limitations
GENVOYA ORAL TABLET
150-150-200-10 MG 2
INTELENCE ORAL TABLET
100 MG, 200 MG, 25 MG 2
INVIRASE ORAL CAPSULE
200 MG 2
INVIRASE ORAL TABLET 500
MG 2
ISENTRESS HD ORAL TABLET
600 MG 2
ISENTRESS ORAL POWDER
IN PACKET 100 MG 2
ISENTRESS ORAL TABLET 400
MG 2
ISENTRESS ORAL TABLET,
CHEW 25 MG, 100 MG 2
KALETRA ORAL SOLN 400-
100 MG/5 ML 2
KALETRA ORAL TABLET 100-
25 MG, 200-50 MG 2
lamivudine oral soln 10
mg/ml 1
lamivudine oral tablet 100
mg, 300 mg 1
lamivudine oral tablet 150
mg 1 QL
lamivudine-zidovudine
oral tablet 150-300 mg 1
LEXIVA ORAL SUSPENSION
50 MG/ML 2
LEXIVA ORAL TABLET 700
MG 2
lopinavir-ritonavir oral soln
400-100 mg/5 ml 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
7
Drug Name Tier Requirements - Limitations
MAVYRET ORAL TABLET
100-40 MG 2 PA; SP; QL
nevirapine oral suspension
50 mg/5 ml 1
nevirapine oral tablet 200
mg 1
nevirapine oral tablet
extended release 24 hr
100 mg, 400 mg
1
NORVIR ORAL CAPSULE
100 MG 2
NORVIR ORAL SOLN 80
MG/ML 2
NORVIR ORAL TABLET 100
MG 2
ODEFSEY ORAL TABLET
200-25-25 MG 2
oseltamivir oral capsule 30
mg, 45 mg 1
PREZCOBIX ORAL TABLET
800-150 MG-MG 2
PREZISTA ORAL
SUSPENSION 100 MG/ML 2
PREZISTA ORAL TABLET 150
MG, 600 MG, 75 MG, 800
MG
2
RELENZA DISKHALER
INHALATION BLISTER WITH
DEVICE 5 MG/ACTUATION
2 QL
RESCRIPTOR ORAL TABLET
200 MG 2
RESCRIPTOR ORAL TABLET,
DISPERSIBLE 100 MG 2
RETROVIR ORAL CAPSULE
100 MG 2
Drug Name Tier Requirements - Limitations
RETROVIR ORAL SYRUP 10
MG/ML 2
REYATAZ ORAL CAPSULE
150 MG, 200 MG, 300 MG 2
REYATAZ ORAL POWDER IN
PACKET 50 MG 2
ribavirin inhalation recon
soln 6 gram 1
rimantadine oral tablet
100 mg 1
SELZENTRY ORAL SOLN 20
MG/ML 2
SELZENTRY ORAL TABLET
150 MG, 25 MG, 300 MG,
75 MG
2
stavudine oral capsule 15
mg, 20 mg, 30 mg, 40 mg 1
stavudine oral recon soln
1 mg/ml 1
STRIBILD ORAL TABLET 150-
150-200-300 MG 2
SUSTIVA ORAL CAPSULE
200 MG, 50 MG 2
SUSTIVA ORAL TABLET 600
MG 2
TAMIFLU ORAL
SUSPENSION 6 MG/ML 2 QL
TECHNIVIE ORAL TABLET
12.5-75-50 MG 2 PA; SP
TIVICAY ORAL TABLET 10
MG, 25 MG, 50 MG 2
TRIUMEQ ORAL TABLET 600-
50-300 MG 2
TRIZIVIR ORAL TABLET 300-
150-300 MG 2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
8
Drug Name Tier Requirements - Limitations
TRUVADA ORAL TABLET
100-150 MG, 133-200 MG,
167-250 MG, 200-300 MG
2
valacyclovir oral tablet 1
gram, 500 mg 1 QL
VALCYTE ORAL
RECONSTITUTE SOLUTION
50 MG/ML
2
VALCYTE ORAL TABLET 450
MG 2
valganciclovir oral recon
soln 50 mg/ml 1
valganciclovir oral tablet
450 mg 1
VEMLIDY ORAL TABLET 25
MG 2
VIDEX 2 GRAM PEDIATRIC
ORAL RECON SOLN 10
MG/ML (FINAL)
2
VIDEX EC ORAL CAPSULE,
DEL-REL(DR/EC) 125 MG,
200 MG, 250 MG, 400 MG
2
VIRACEPT ORAL TABLET
250 MG, 625 MG 2
VIRAMUNE ORAL SUSP 50
MG/5 ML 2
VIRAMUNE ORAL TABLET
200 MG 2
VIRAMUNE XR ORAL
TABLET EXT-REL 24 HR 100
MG, 400 MG
2
VIREAD ORAL POWDER 40
MG/SCOOP (40
MG/GRAM)
2
Drug Name Tier Requirements - Limitations
VIREAD ORAL TABLET 150
MG, 200 MG, 250 MG, 300
MG
2
ZERIT ORAL CAPSULE 15
MG, 20MG, 30MG, 40MG 2
ZERIT ORAL RECON SOLN
1 MG/ML 2
ZIAGEN ORAL SOLN
20 MG/ML 2
ZIAGEN ORAL TABLET 300
MG 2
zidovudine oral capsule
100 mg 1
zidovudine oral syrup 10
mg/ml 1
zidovudine oral tablet 300
mg 1
Cephalosporins
cefaclor oral capsule 250
mg, 500 mg 1
cefaclor oral suspension
for recon 125 mg/5 ml, 250
mg/5 ml, 375 mg/5 ml
1
cefaclor oral tablet ext-
release 12 hr 500 mg 1
cefadroxil oral capsule
500 mg 1
cefadroxil oral susp for
recon 250 mg/5 ml, 500
mg/5 ml
1
cefadroxil oral tablet 1 gm 1
cefdinir oral capsule 300
mg 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
9
Drug Name Tier Requirements - Limitations
cefdinir oral suspension for
recon 125 mg/5 ml, 250
mg/5 ml
1
cefditoren pivoxil oral
tablet 200 mg, 400 mg 1
cefixime oral suspension
for recon 100 mg/5 ml, 200
mg/5 ml
1
cefpodoxime oral
suspension for recon 100
mg/5 ml, 50 mg/5 ml
1
cefpodoxime oral tablet
100 mg, 200 mg 1
cefprozil oral suspension
for recon 125 mg/5 ml, 250
mg/5 ml
1
cefprozil oral tablet 250
mg, 500 mg 1
CEFTIN ORAL SUSPENSION
FOR RECON 125 MG/5 ML,
250 MG/5 ML
2
cefuroxime axetil oral
tablet 250 mg, 500 mg 1
cephalexin oral capsule
250 mg, 500 mg, 750 mg 1
cephalexin oral
suspension for recon 125
mg/5 ml, 250 mg/5 ml
1
cephalexin oral tablet 250
mg, 500 mg 1
Erythromycins & Other Macrolides
azithromycin oral pkt 1gm 1
azithromycin oral
suspension for recon 100
mg/5 ml, 200 mg/5 ml
1
Drug Name Tier Requirements - Limitations
azithromycin oral tablet
250 mg, 500 mg, 600 mg 1
clarithromycin oral susp for
recon 125 mg/5 ml, 250
mg/5 ml
1
clarithromycin oral tablet
250 mg, 500 mg 1
clarithromycin oral tablet
ext-release 24 hr 500 mg 1
e.e.s. 400 oral tablet 400
mg 1
ERYPED 200 ORAL
SUSPENSION FOR RECON
200 MG/5 ML
2
ERYPED 400 ORAL SUSP
FOR RECON 400 MG/5 ML 2
ery-tab oral tablet,
delayed release (dr/ec)
250 mg, 333 mg
1
ERY-TAB ORAL TABLET, DEL-
REL (DR/EC) 500 MG 2
erythrocin (as stearate)
oral tablet 250 mg 1
erythromycin
ethylsuccinate oral susp
for recon 200 mg/5 ml
1
erythromycin
ethylsuccinate oral tablet
400 mg
1
erythromycin oral capsule,
del-release(dr/ec) 250 mg 1
erythromycin oral tablet
250 mg, 500 mg 1
ZMAX ORAL SUSP,
EXTENDED RELEASE RECON
2 GRAM/60 ML
2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
10
Drug Name Tier Requirements - Limitations
Miscellaneous Antiinfectives
ALBENZA ORAL TABLET 200
MG 2
ALINIA ORAL SUSPENSION
FOR RECON 100 MG/5 ML 2
ALINIA ORAL TABLET 500
MG 2
atovaquone oral
suspension 750 mg/5 ml 1
atovaquone-proguanil
oral tablet 250-100 mg,
62.5-25 mg
1
BETHKIS INHALATION SOLN
FOR NEBULIZATION 300
MG/4 ML
2 SP
BILTRICIDE ORAL TABLET
600 MG 2
chloroquine phosphate
oral tablet 250 mg,500 mg 1
clindamycin hcl oral
capsule 150 mg, 300 mg,
75 mg
1
clindamycin palmitate hcl
oral recon soln 75 mg/5 ml 1
clindamycin pediatric oral
recon soln 75 mg/5 ml 1
COARTEM ORAL TABLET
20-120 MG 2
CYCLOSERINE ORAL
CAPSULE 250 MG 2
dapsone oral tablet 100
mg, 25 mg 1
ethambutol oral tablet
100 mg, 400 mg 1
Drug Name Tier Requirements - Limitations
hydroxychloroquine oral
tablet 200 mg 1
isoniazid oral soln 50 mg/5
ml 1
isoniazid oral tablet 100
mg, 300 mg 1
ivermectin oral tablet 3mg 1
KITABIS PAK INHALATION
SOLN FOR NEBULIZATION
300 MG/5 ML
2 SP
linezolid oral suspension
for recon 100 mg/5 ml 1 PA
linezolid oral tablet 600
mg 1 PA
mefloquine oral tablet 250
mg 1
MEPRON ORAL
SUSPENSION 750 MG/5 ML 2
metronidazole oral
capsule 375 mg 1
metronidazole oral tablet
250 mg, 500 mg 1
MYCOBUTIN ORAL
CAPSULE 150 MG 2 QL
NEBUPENT INHALATION
RECON SOLN 300 MG 2 QL
neomycin oral tablet 500
mg 1
paromomycin oral
capsule 250 mg 1
PASER ORAL GRANULES
DR FOR SUSP IN PKT 4 GM 2
PRIFTIN ORAL TABLET 150
MG 2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
11
Drug Name Tier Requirements - Limitations
PRIMAQUINE ORAL TABLET
26.3 MG 2
pyrazinamide oral tablet
500 mg 1
quinine sulfate oral
capsule 324 mg 1
rifabutin oral capsule 150
mg 1 QL
RIFAMATE ORAL CAPSULE
300-150 MG 2
rifampin oral capsule 150
mg, 300 mg 1
RIFATER ORAL TABLET 50-
120-300 MG 2
SIVEXTRO ORAL TABLET 200
MG 2 PA
STROMECTOL ORAL TABLET
3 MG 2
tinidazole oral tablet 250
mg, 500 mg 1
TRECATOR ORAL TABLET
250 MG 2
XIFAXAN ORAL TABLET 550
MG 2
Penicillins
amoxicillin oral capsule
250 mg, 500 mg 1
amoxicillin oral suspension
for recon 125 mg/5 ml, 200
mg/5 ml, 250 mg/5 ml, 400
mg/5 ml
1
amoxicillin oral tablet 500
mg, 875 mg 1
amoxicillin oral tablet,
chewable 125 mg, 250 mg 1
Drug Name Tier Requirements - Limitations
amoxicillin-pot
clavulanate oral susp for
recon 200-28.5 mg/5 ml,
250-62.5 mg/5 ml, 400-57
mg/5 ml, 600-42.9 mg/5 ml
1
amoxicillin-pot
clavulanate oral tablet
250-125 mg, 500-125 mg,
875-125 mg
1
amoxicillin-pot
clavulanate oral tablet
extended release 12 hr
1,000-62.5 mg
1
amoxicillin-pot
clavulanate oral tablet,
chewable 200-28.5 mg,
400-57 mg
1
ampicillin oral capsule 250
mg, 500 mg 1
AUGMENTIN ORAL
SUSPENSION FOR RECON
125-31.25 MG/5 ML
2
dicloxacillin oral capsule
250 mg, 500 mg 1
penicillin v potassium oral
recon soln 125 mg/5 ml,
250 mg/5 ml
1
penicillin v potassium oral
tablet 250 mg, 500 mg 1
Quinolones
ciprofloxacin (mixture)
oral tablet, er multiphase
24 hr 1,000 mg, 500 mg
1
ciprofloxacin hcl oral
tablet 100 mg, 250 mg,
500 mg, 750 mg
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
12
Drug Name Tier Requirements - Limitations
ciprofloxacin oral
suspension, microcapsule
recon 250 mg/5 ml, 500
mg/5 ml
1
levofloxacin oral soln 250
mg/10 ml 1
levofloxacin oral tablet
250 mg, 500 mg, 750 mg 1
moxifloxacin oral tablet
400 mg 1
ofloxacin oral tablet 300
mg, 400 mg 1
Sulfa's & Related Agents
sulfadiazine oral tablet 500
mg 1
sulfamethoxazole-
trimethoprim oral
suspension 200-40 mg/5 ml
1
sulfamethoxazole-
trimethoprim oral tablet
400-80 mg, 800-160 mg
1
sulfatrim oral suspension
200-40 mg/5 ml 1
Tetracyclines
avidoxy oral tablet 100 mg 1
demeclocycline oral
tablet 150 mg, 300 mg 1
doxycycline hyclate oral
capsule 100 mg, 50 mg 1
doxycycline hyclate oral
tablet 100 mg, 150 mg, 20
mg, 75 mg
1
doxycycline hyclate oral
tablet, delayed release
(dr/ec) 100 mg, 150 mg,
200 mg, 50 mg, 75 mg
1
Drug Name Tier Requirements - Limitations
doxycycline monohydrate
oral capsule 100 mg, 150
mg, 50 mg, 75 mg
1
doxycycline monohydrate
oral suspension for recon
25 mg/5 ml
1
doxycycline monohydrate
oral tablet 100 mg, 150
mg, 50 mg, 75 mg
1
minocycline oral capsule
100 mg, 50 mg, 75 mg 1
minocycline oral tablet
100 mg, 50 mg, 75 mg 1
minocycline oral tablet
extended release 24 hr
135 mg, 45 mg, 90 mg
1
mondoxyne nl oral
capsule 50 mg, 75 mg, 100
mg
1
morgidox oral capsule 100
mg 1
tetracycline oral capsule
250 mg, 500 mg 1
Urinary Tract Agents
FURADANTIN ORAL
SUSPENSION 25 MG/5 ML 2
MACROBID ORAL
CAPSULE 100 MG 2
MACRODANTIN ORAL
CAPSULE 25 MG, 50 MG,
100 MG
2
methenamine hippurate
oral tablet 1 gram 1
methenamine mandelate
oral tablet 0.5 g, 1 gram 1
MONUROL ORAL PKT 3GM 2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
13
Drug Name Tier Requirements - Limitations
nitrofurantoin
macrocrystal oral capsule
100 mg, 25 mg, 50 mg
1
nitrofurantoin monohyd/
m-cryst oral capsule 100
mg
1
nitrofurantoin oral
suspension 25 mg/5 ml 1
PRIMSOL ORAL SOLN 50
MG/5 ML 2
trimethoprim oral tablet
100 mg 1
Vancomycin
vancomycin oral capsule
125 mg, 250 mg 1
ANTINEOPLASTIC &
IMMUNOSUPPRESSANT DRUGS
Adjunctive Agents
leucovorin calcium oral
tablet 10 mg, 15 mg, 25
mg, 5 mg
1
MESNEX ORAL TABLET 400
MG 2
Antineoplastic & Immunosuppressant
Drugs
anastrozole oral tablet 1
mg 1
azathioprine oral tablet 50
mg 1
bicalutamide oral tablet
50 mg 1
CELLCEPT ORAL
SUSPENSION FOR RECON
200 MG/ML
2
Drug Name Tier Requirements - Limitations
cyclosporine modified oral
capsule 100 mg, 25 mg, 50
mg
1
cyclosporine modified oral
soln 100 mg/ml 1
cyclosporine oral capsule
100 mg, 25 mg 1
DROXIA ORAL CAPSULE
200 MG, 300 MG, 400 MG 2
EMCYT ORAL CAPSULE 140
MG 2
exemestane oral tablet 25
mg 1
FARESTON ORAL TABLET 60
MG 2
flutamide oral capsule 125
mg 1
gengraf oral capsule 100
mg, 25 mg, 50 mg 1
gengraf oral soln 100
mg/ml 1
HEXALEN ORAL CAPSULE
50 MG 2
hydroxyurea oral capsule
500 mg 1
letrozole oral tablet 2.5 mg 1
LEUKERAN ORAL TABLET 2
MG 2
LYSODREN ORAL TABLET
500 MG 2
MEGACE ES ORAL
SUSPENSION 625 MG/5 ML 2
megestrol oral suspension
400 mg/10 ml (40 mg/ml),
625 mg/5 ml
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
14
Drug Name Tier Requirements - Limitations
megestrol oral tablet 20
mg, 40 mg 1
mercaptopurine oral
tablet 50 mg 1
methotrexate sodium (pf)
injection recon soln 1
gram
1
methotrexate sodium (pf)
injection soln 25 mg/ml 1
methotrexate sodium
injection soln 25 mg/ml 1
methotrexate sodium oral
tablet 2.5 mg 1
mycophenolate mofetil
oral capsule 250 mg 1
mycophenolate mofetil
oral suspension for recon
200 mg/ml
1
mycophenolate mofetil
oral tablet 500 mg 1
mycophenolate sodium
oral tablet, delayed
release (dr/ec) 180 mg,
360 mg
1
NILANDRON ORAL TABLET
150 MG 2
nilutamide oral tablet 150
mg 1
octreotide acetate
injection soln 1,000
mcg/ml, 100 mcg/ml, 200
mcg/ml, 50 mcg/ml, 500
mcg/ml
1 SP
octreotide acetate
injection syringe 100
mcg/ml (1 ml), 50 mcg/ml
(1 ml), 500 mcg/ml (1 ml)
1 SP
Drug Name Tier Requirements - Limitations
PURIXAN ORAL
SUSPENSION 20 MG/ML 2 SP
RAPAMUNE ORAL SOLN 1
MG/ML 2
RAPAMUNE ORAL TABLET
0.5 MG, 1 MG, 2 MG 2
SANDIMMUNE ORAL
CAPSULE 100 MG, 25 MG 2
SANDIMMUNE ORAL SOLN
100 MG/ML 2
sirolimus oral tablet 0.5
mg, 1 mg, 2 mg 1
TABLOID ORAL TABLET 40
MG 2
tacrolimus oral capsule 0.5
mg, 1 mg, 5 mg 1
tamoxifen oral tablet 10
mg, 20 mg $0
tretinoin (chemotherapy)
oral capsule 10 mg 1
TREXALL ORAL TABLET 10
MG, 15 MG, 5 MG, 7.5 MG 2
XERMELO ORAL TABLET 250
MG 2 PA; QL
ZORTRESS ORAL TABLET
0.25 MG, 0.5 MG, 0.75 MG 2
AUTONOMIC & CNS DRUGS,
NEUROLOGY & PSYCHOLOGY
Anticonvulsants
APTIOM ORAL TABLET 200
MG, 400 MG, 600 MG, 800
MG
2
BANZEL ORAL SUSPENSION
40 MG/ML 2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
15
Drug Name Tier Requirements - Limitations
BANZEL ORAL TABLET 200
MG, 400 MG 2
BRIVIACT ORAL SOLN 10
MG/ML 2
BRIVIACT ORAL TABLET 10
MG, 100 MG, 25 MG, 50
MG, 75 MG
2
carbamazepine oral
capsule, er multiphase 12
hr 100 mg, 200 mg, 300
mg
1
carbamazepine oral
suspension 100 mg/5 ml 1
carbamazepine oral
tablet 200 mg 1
carbamazepine oral
tablet ext-release 12 hr
100 mg, 200 mg, 400 mg
1
carbamazepine oral
tablet, chewable 100 mg 1
CELONTIN ORAL CAPSULE
300 MG 2
clonazepam oral tablet
0.5 mg, 1 mg, 2 mg 1
clonazepam oral tablet,
disintegrating 0.125 mg,
0.25 mg, 0.5 mg, 1 mg, 2
mg
1
DIASTAT ACUDIAL RECTAL
KIT 12.5-15-17.5-20 MG, 5-
7.5-10 MG
2
DIASTAT RECTAL KIT 2.5 MG 2
diazepam rectal kit 12.5-
15-17.5-20 mg, 2.5 mg, 5-
7.5-10 mg
1
Drug Name Tier Requirements - Limitations
divalproex oral capsule,
del-rel sprinkle 125 mg 1
divalproex oral tablet
extended release 24 hr
250 mg, 500 mg
1
divalproex oral tablet,
delayed release (dr/ec)
125 mg, 250 mg, 500 mg
1
ethosuximide oral capsule
250 mg 1
ethosuximide oral soln 250
mg/5 ml 1
felbamate oral suspension
600 mg/5 ml 1
felbamate oral tablet 400
mg, 600 mg 1
FYCOMPA ORAL
SUSPENSION 0.5 MG/ML 2
FYCOMPA ORAL TABLET 10
MG, 12 MG, 2 MG, 4 MG,
6 MG, 8 MG
2
gabapentin oral capsule
100 mg, 300 mg, 400 mg 1
gabapentin oral soln 250
mg/5 ml 1
gabapentin oral tablet
600 mg, 800 mg 1
GABITRIL ORAL TABLET 12
MG, 16 MG, 2 MG, 4 MG 2
GRALISE 30-DAY STARTER
PACK ORAL TABLET
EXTENDED RELEASE 24 HR
300 MG (9)- 600 MG (69)
2
GRALISE ORAL TABLET
EXTENDED RELEASE 24 HR
300 MG, 600 MG
2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
16
Drug Name Tier Requirements - Limitations
LAMICTAL ODT ORAL
TABLET, DISINTEGRATING
100 MG, 200 MG, 25 MG,
50 MG
2
LAMICTAL ODT STARTER
(BLUE) ORAL TABLET
DISINTEGRATING, DOSE PK
25 MG (21) -50 MG (7)
2
LAMICTAL ODT STARTER
(GREEN) ORAL TABLET
DISINTEGRATING, DOSE PK
50 MG (42) -100 MG (14)
2
LAMICTAL ODT STARTER
(ORANGE) ORAL TABLET
DISINTEGRATING, DOSE PK
25 MG(14)-50 MG (14)-100
MG (7)
2
LAMICTAL XR ORAL TABLET
EXTENDED RELEASE 24HR
100 MG, 200 MG, 25 MG,
250 MG, 300 MG, 50 MG
2
LAMICTAL XR STARTER
(BLUE) ORAL TABLET
EXTENDED REL,DOSE PACK
25 MG (21) -50 MG (7)
2
LAMICTAL XR STARTER
(GREEN) ORAL TABLET
EXTENDED REL,DOSE PACK
50 MG(14)-100MG (14)-
200 MG (7)
2
LAMICTAL XR STARTER
(ORANGE) ORAL TABLET
EXTENDED REL,DOSE PACK
25MG (14)-50 MG (14)-
100MG (7)
2
lamotrigine oral tablet 100
mg, 150 mg, 200 mg, 25
mg
1
Drug Name Tier Requirements - Limitations
lamotrigine oral tablet
disintegrating, dose pk 25
mg (21) -50 mg (7), 25
mg(14)-50 mg (14)-100 mg
(7), 50 mg (42) -100 mg
(14)
1
lamotrigine oral tablet
extended release 24hr 100
mg, 200 mg, 25 mg, 250
mg, 300 mg, 50 mg
1
lamotrigine oral tablet,
chewable dispersible 25
mg, 5 mg
1
lamotrigine oral tablet,
disintegrating 100 mg, 200
mg, 25 mg, 50 mg
1
lamotrigine oral tablets,
dose pack 25 mg (35), 25
mg (42) -100 mg (7), 25
mg (84) -100 mg (14)
1
levetiracetam oral soln
100 mg/ml, 500 mg/5 ml (5
ml)
1
levetiracetam oral tablet
1,000 mg, 250 mg, 500 mg,
750 mg
1
levetiracetam oral tablet
extended release 24 hr
500 mg, 750 mg
1
LYRICA ORAL CAPSULE 100
MG, 150 MG, 200 MG, 225
MG, 25 MG, 300 MG, 50
MG, 75 MG
2 QL
LYRICA ORAL SOLUTION
20 MG/ML 2 QL
ONFI ORAL SUSPENSION
2.5 MG/ML 2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
17
Drug Name Tier Requirements - Limitations
ONFI ORAL TABLET 10 MG,
20 MG 2
oxcarbazepine oral
suspension 300 mg/5 ml
(60 mg/ml)
1
oxcarbazepine oral tablet
150 mg, 300 mg, 600 mg 1
OXTELLAR XR ORAL TABLET
EXTENDED RELEASE 24 HR
150 MG, 300 MG, 600 MG
2
PEGANONE ORAL TABLET
250 MG 2
phenobarbital oral elixir 20
mg/5 ml (4 mg/ml) 1
phenobarbital oral tablet
100 mg, 15 mg, 16.2 mg,
30 mg, 32.4 mg, 60 mg,
64.8 mg, 97.2 mg
1
PHENYTEK ORAL CAPSULE
200 MG, 300 MG 2
phenytoin oral suspension
125 mg/5 ml 1
phenytoin oral tablet,
chewable 50 mg 1
phenytoin sodium
extended oral capsule
100 mg, 200 mg, 300 mg
1
primidone oral tablet 250
mg, 50 mg 1
roweepra oral tablet 1,000
mg, 500 mg, 750 mg 1
SABRIL ORAL POWDER IN
PACKET 500 MG 2 SP; LA
SABRIL ORAL TABLET 500
MG 2 SP; LA
Drug Name Tier Requirements - Limitations
TEGRETOL ORAL TABLET
200 MG 2
tiagabine oral tablet 2
mg, 4 mg 1
topiramate oral capsule,
sprinkle 15 mg, 25 mg 1
TOPIRAMATE ORAL
CAPSULE,SPRINKLE,ER
24HR 100 MG, 150 MG, 200
MG, 25 MG, 50 MG
2
topiramate oral tablet 100
mg, 200 mg, 25 mg, 50 mg 1
TROKENDI XR CAPSULE,
EXT-REL 24HR 25 MG, 50
MG, 100 MG, 200 MG
2
valproic acid (as sodium
salt) oral soln 250 mg/5 ml 1
valproic acid oral capsule
250 mg 1
vigabatrin oral powder in
packet 500 mg 1
VIMPAT ORAL SOLN 10
MG/ML 2
VIMPAT ORAL TABLET
50MG, 100MG, 150MG,
200MG
2
zonisamide oral capsule
100 mg, 25 mg, 50 mg 1
Antiparkinsonism Agents
APOKYN SUBCUTANEOUS
CARTRIDGE 10 MG/ML 2 SP; LA
AZILECT ORAL TABLET 0.5
MG, 1 MG 2
benztropine oral tablet 0.5
mg, 1 mg, 2 mg 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
18
Drug Name Tier Requirements - Limitations
bromocriptine oral
capsule 5 mg 1
bromocriptine oral tablet
2.5 mg 1
carbidopa oral tablet 25
mg 1
carbidopa-levodopa oral
tablet 10-100 mg, 25-100
mg, 25-250 mg
1
carbidopa-levodopa oral
tablet extended release
25-100 mg, 50-200 mg
1
carbidopa-levodopa oral
tablet, disintegrating 10-
100 mg, 25-100 mg, 25-250
mg
1
carbidopa-levodopa-
entacapone oral tablet
12.5-50-200 mg, 18.75-75-
200 mg, 25-100-200 mg,
31.25-125-200 mg, 37.5-
150-200mg, 50-200-200 mg
1
COMTAN TABLET 200 MG 2
ELDEPRYL CAPSULE 5 MG 2
Entacapone tablet 200mg 1
LODOSYN TABLET 25 MG 2
MIRAPEX ER ORAL TABLET
EXTENDED RELEASE 24 HR
0.375 MG, 0.75 MG, 1.5
MG, 2.25 MG, 3 MG, 3.75
MG, 4.5 MG
2
NEUPRO TRANSDERMAL
PATCH 24 HOUR
1 MG/24 HR, 2 MG/24 HR,
3 MG/24 HR, 4 MG/24 HR,
6 MG/24 HR, 8 MG/24 HR
2
Drug Name Tier Requirements - Limitations
pramipexole oral tablet
0.125 mg, 0.25 mg, 0.5 mg,
0.75 mg, 1 mg, 1.5 mg
1
pramipexole oral tablet
ext-rel 24 hr 0.375 mg, 0.75
mg, 1.5 mg, 2.25 mg, 3
mg, 3.75 mg, 4.5 mg
1
rasagiline oral tablet 0.5
mg, 1 mg 1
ropinirole oral tablet 0.25
mg, 0.5 mg, 1 mg, 2 mg, 3
mg, 4 mg, 5 mg
1
ropinirole oral tablet ext-
rel 24 hr 12 mg, 2 mg, 4
mg, 6 mg, 8 mg
1
selegiline hcl oral capsule
5 mg 1
selegiline hcl oral tablet 5
mg 1
TASMAR ORAL TABLET 100
MG 2
tolcapone oral tablet 100
mg 1
trihexyphenidyl oral elixir
0.4 mg/ml 1
trihexyphenidyl oral tablet
2 mg, 5 mg 1
Migraine & Cluster Headache Therapy
AXERT ORAL TABLET 12.5
MG, 6.25 MG 2 QL
D.H.E.45 INJECTION SOLN
1 MG/ML 2 QL
dihydroergotamine
injection soln 1 mg/ml 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
19
Drug Name Tier Requirements - Limitations
dihydroergotamine nasal
spray, non-aerosol 0.5
mg/pump act. (4 mg/ml)
1 QL
ERGOMAR SUBLINGUAL
TABLET 2 MG 2
ergotamine-caffeine oral
tablet 1-100 mg 1
frovatriptan oral tablet 2.5
mg 1 QL
isomethepten-caffeine-
acetaminophen oral
tablet 65-20-325 mg
1
migergot rectal
suppository 2-100 mg 1
MIGRANAL NASAL SPRAY,
NON-AEROSOL 0.5
MG/PUMP ACT. (4
MG/ML)
2 QL
RELPAX ORAL TABLET 20
MG, 40 MG 2 QL
rizatriptan oral tablet 10
mg, 5 mg 1 QL
rizatriptan oral tablet,
disintegrating 10 mg, 5 mg 1 QL
sumatriptan succinate
oral tablet 25 mg, 50 mg,
100 mg
1 QL
Miscellaneous Neurological Therapy
AMPYRA ORAL TABLET EXT-
RELEASE 12 HR 10 MG 2 PA; SP; LA
donepezil oral tablet 10
mg, 23 mg, 5 mg 1
EXELON TRANSDERMAL
PATCH 24 HOUR 13.3
MG/24 HOUR, 4.6 MG/24
HR, 9.5 MG/24 HR
2
Drug Name Tier Requirements - Limitations
galantamine oral capsule,
ext rel. pellets 24 hr 16 mg,
24 mg, 8 mg
1
galantamine oral soln 4
mg/ml 1
galantamine oral tablet
12 mg, 4 mg, 8 mg 1
HORIZANT ORAL TABLET
EXTENDED RELEASE 300
MG, 600 MG
2
memantine oral soln 2
mg/ml 1
memantine oral tablet 10
mg, 5 mg 1
MEMANTINE TABLETS,
DOSE PACK 5-10 MG 2
NAMENDA TITRATION PAK
ORAL TABLETS, DOSE PACK
5-10 MG
2
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR
DOSE PACK 7-14-21-28 MG
2 ST
NAMENDA XR CAPSULE,
SPRINKLE,ER 24HR 7 MG,
14 MG, 21 MG, 28 MG
2 ST
NUEDEXTA ORAL CAPSULE
20-10 MG 2
rivastigmine tartrate oral
capsule 1.5 mg, 3 mg, 4.5
mg, 6 mg
1
tetrabenazine oral tablet
12.5 mg, 25 mg 1 PA; SP
Muscle Relaxants & Antispasmodic
Therapy
baclofen oral tablet 10
mg, 20 mg 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
20
Drug Name Tier Requirements - Limitations
carisoprodol oral tablet
250 mg, 350 mg 1
carisoprodol-asa-codeine
oral tablet 200-325-16 mg 1
carisoprodol-aspirin oral
tablet 200-325 mg 1
chlorzoxazone oral tablet
250 mg, 500 mg 1
cyclobenzaprine oral
tablet 5 mg 7.5 mg,10mg 1
dantrolene oral capsule
100 mg, 25 mg, 50 mg 1
meprobamate oral tablet
200 mg, 400 mg 1
MESTINON ORAL SYRUP 60
MG/5 ML 2
MESTINON ORAL TABLET 60
MG 2
MESTINON TIMESPAN ORAL
TABLET EXT-REL 180 MG 2
metaxall oral tablet 800
mg 1
metaxalone oral tablet
400 mg, 800 mg 1
methocarbamol oral
tablet 500 mg, 750 mg 1
orphenadrine citrate oral
tablet ext- release 100 mg 1
pyridostigmine bromide
oral tablet 60 mg 1
pyridostigmine bromide
oral tablet extended
release 180 mg
1
ROBAXIN-750 ORAL TABLET
750 MG 2
Drug Name Tier Requirements - Limitations
tizanidine oral capsule 2
mg, 4 mg, 6 mg 1
tizanidine oral tablet 2 mg,
4 mg 1
Narcotic Analgesics
acetaminophen-caffeine-
dihydrocodeine oral
capsule 320.5-30-16 mg
1
acetaminophen-codeine
oral soln 120-12 mg/5 ml 1
acetaminophen-codeine
oral tablet 300-15 mg, 300-
30 mg, 300-60 mg
1
ascomp with codeine oral
capsule 30-50-325-40 mg 1
ASTRAMORPH-PF
INJECTION SOLN 0.5
MG/ML
2
butalbital compound
w/codeine oral capsule
30-50-325-40 mg
1
butalbital-acetamin-
caffeine-cod oral capsule
50-300-40-30 mg, 50-325-
40-30 mg
1
butalbital-acetaminophen
oral tablet 50-300 mg, 50-
325 mg
1
butalbital-
acetaminophen-caffeine
oral capsule 50-300-40
mg, 50-325-40 mg
1
butalbital-
acetaminophen-caffeine
oral tablet 50-325-40 mg
1
butalbital-aspirin-caffeine
oral capsule 50-325-40 mg 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
21
Drug Name Tier Requirements - Limitations
butalbital-aspirin-caffeine
oral tablet 50-325-40 mg 1
BUTRANS TRANSDERMAL
PATCH WEEKLY
5 MCG/HR, 7.5 MCG/HR,
10 MCG/HR, 15 MCG/HR,
20 MCG/HR
2 QL
capacet oral capsule 50-
325-40 mg 1
CAPITAL WITH CODEINE
ORAL SUSPENSION 120-12
MG/5 ML
2
codeine sulfate oral tablet
15 mg, 30 mg, 60 mg 1
diskets oral tablet, soluble
40 mg 1
EMBEDA ORAL CAPSULE,
ORAL ONLY, EXT.REL PELL
100-4 MG, 20-0.8 MG, 30-
1.2 MG, 50-2 MG, 60-2.4
MG, 80-3.2 MG
2
endocet oral tablet 10-325
mg, 2.5-325 mg, 5-325 mg,
7.5-325 mg
1
fentanyl citrate buccal
lozenge on a handle 200
mcg, 400 mcg, 600 mcg,
800 mcg, 1,200 mcg, 1,600
mcg
1
fentanyl transdermal
patch 72 hour 12 mcg/hr,
25 mcg/hr, 50 mcg/hr, 75
mcg/hr, 100 mcg/hr
1
hydrocodone-
acetaminophen oral soln
7.5-325 mg/15 ml
1
Drug Name Tier Requirements - Limitations
hydrocodone-
acetaminophen oral
tablet 2.5-325 mg, 5-300
mg, 5-325 mg, 7.5-300 mg,
7.5-325 mg, 10-300 mg, 10-
325 mg
1
hydrocodone-ibuprofen
oral tablet 5-200 mg, 7.5-
200 mg, 10-200 mg
1
HYDROMORPHONE
INJECTION SYRINGE 0.5
MG/0.5 ML
2
hydromorphone oral
tablet 2 mg, 4 mg, 8 mg 1
hydromorphone rectal
suppository 3 mg 1
ibuprofen-oxycodone oral
tablet 400-5 mg 1
INFUMORPH P/F INJECTION
SOLN 10 MG/ML, 25
MG/ML
2
levorphanol tartrate oral
tablet 2 mg 1
lorcet (hydrocodone) oral
tablet 5-325 mg 1
lorcet hd oral tablet 10-
325 mg 1
lorcet plus oral tablet 7.5-
325 mg 1
marten-tab oral tablet 50-
325 mg 1
meperidine oral soln 50
mg/5 ml 1
meperidine oral tablet 100
mg, 50 mg 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
22
Drug Name Tier Requirements - Limitations
methadose oral
concentrate 10 mg/ml 1
methadose oral tablet,
soluble 40 mg 1
morphine concentrate
oral soln 100 mg/5 ml (20
mg/ml)
1
morphine oral capsule,
extend. release pellets 10
mg, 20 mg, 30 mg, 50 mg,
60 mg, 80 mg, 100 mg
1
morphine oral soln 10
mg/5 ml, 20 mg/5 ml (4
mg/ml)
1
morphine oral tablet 15
mg, 30 mg 1
morphine oral tablet ext-
rel 15 mg, 30 mg, 60 mg.
100 mg, 200 mg
1
morphine rectal
suppository 5 mg, 10 mg,
20 mg, 30 mg
1
oxycodone oral capsule 5
mg 1
oxycodone oral
concentrate 20 mg/ml 1
oxycodone oral solution
5 mg/5 ml 1
oxycodone oral tablet
5 mg, 10 mg, 15 mg, 20
mg, 30 mg
1
oxycodone-
acetaminophen oral soln
5-325 mg/5 ml
1
Drug Name Tier Requirements - Limitations
oxycodone-
acetaminophen oral
tablet 10-325 mg, 2.5-325
mg, 5-325 mg, 7.5-325 mg
1
oxycodone-aspirin oral
tablet 4.8355-325 mg 1
oxymorphone oral tablet
10 mg, 5 mg 1
SYNALGOS-DC ORAL
CAPSULE 356.4-30-16 MG 2
tencon oral tablet 50-325
mg 1
verdrocet oral tablet 2.5-
325 mg 1
vicodin es oral tablet 7.5-
300 mg 1
vicodin hp oral tablet 10-
300 mg 1
vicodin oral tablet 5-300
mg 1
xylon 10 oral tablet 10-200
mg 1
zamicet oral soln 10-325
mg/15 ml 1
zebutal oral capsule 50-
325-40 mg 1
Non-Narcotic Analgesics
aspirin low dose oral
tablet, delayed release
(dr/ec) 81 mg
$0
aspirin oral tablet 325 mg $0
aspirin oral tablet,
chewable 81 mg $0
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
23
Drug Name Tier Requirements - Limitations
aspirin oral tablet,
delayed release (dr/ec)
325 mg, 81 mg
$0
bayer aspirin oral tablet
325 mg $0
butorphanol tartrate nasal
spray, non-aerosol 10
mg/ml
1 QL
celecoxib oral capsule 50
mg 100 mg, 200 mg, 400
mg
1
children's aspirin oral
tablet, chewable 81 mg $0
choline, magnesium
salicylate oral liquid 500
mg/5 ml
1
diclofenac potassium oral
tablet 50 mg 1
diclofenac sodium oral
tablet extended release
24 hr 100 mg
1
diclofenac sodium oral
tablet, del-rel (dr/ec) 25
mg, 50 mg, 75 mg
1
diclofenac sodium topical
drops 1.5 % 1 QL
diclofenac sodium topical
gel 1 % 1 QL
diclofenac-misoprostol
oral tablet, ir, delayed rel,
biphasic 50-200 mg-mcg,
75-200 mg-mcg
1
diflunisal oral tablet 500
mg 1
e.c. prin oral tablet, del-rel
(dr/ec) 325 mg $0
Drug Name Tier Requirements - Limitations
ecotrin low strength oral
tablet, delayed release
(dr/ec) 81 mg
$0
ecotrin oral tablet,
delayed release (dr/ec)
325 mg
$0
etodolac oral capsule 200
mg, 300 mg 1
etodolac oral tablet 400
mg, 500 mg 1
etodolac oral tablet
extended release 24 hr
400 mg, 500 mg, 600 mg
1
fenoprofen oral tablet 600
mg 1
FLECTOR TRANSDERMAL
PATCH 12 HOUR 1.3 % 2
flurbiprofen oral tablet 100
mg, 50 mg 1
ibuprofen oral tablet 400
mg, 600 mg, 800 mg 1
indomethacin oral
capsule 25 mg, 50 mg 1
indomethacin oral
capsule, extended
release 75 mg
1
ketoprofen oral capsule
50 mg, 75 mg 1
ketoprofen oral capsule,
ext rel. pellets 24 hr 200mg 1
ketorolac injection syringe
15 mg/ml, 30 mg/ml 1
ketorolac intramuscular
syringe 60 mg/2 ml 1
ketorolac oral tablet 10
mg 1 QL
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
24
Drug Name Tier Requirements - Limitations
lite coat aspirin oral tablet
325 mg $0
meclofenamate oral
capsule 100 mg, 50 mg 1
mefenamic acid oral
capsule 250 mg 1
meloxicam oral
suspension 7.5 mg/5 ml 1
meloxicam oral tablet 15
mg, 7.5 mg 1
nabumetone oral tablet
500 mg, 750 mg 1
naltrexone oral tablet 50
mg 1
naproxen oral suspension
125 mg/5 ml 1
naproxen oral tablet 250
mg, 375 mg, 500 mg 1
naproxen oral tablet,
delayed release (dr/ec)
375 mg, 500 mg
1
naproxen sodium oral
tablet 550 mg 1
naproxen sodium oral
tablet, er multiphase 24 hr
375 mg, 500 mg
1
NARCAN NASAL SPRAY,
NON-AEROSOL 4
MG/ACTUATION
2 QL
NUCYNTA ER ORAL TABLET
EXTENDED RELEASE 12 HR
50 MG , 100 MG, 150 MG,
200 MG, 250 MG
2
oxaprozin oral tablet 600
mg 1
Drug Name Tier Requirements - Limitations
pentazocine-naloxone
oral tablet 50-0.5 mg 1
piroxicam oral capsule 10
mg, 20 mg 1
REVIA ORAL TABLET 50 MG 2
salsalate oral tablet 500
mg, 750 mg 1
sulindac oral tablet 150
mg, 200 mg 1
tolmetin oral capsule 400
mg 1
tolmetin oral tablet 200
mg, 600 mg 1
TRAMADOL ORAL
CAPSULE,ER BIPHASE 24 HR
17-83 300 MG
2
TRAMADOL ORAL
CAPSULE, ER BIPHASE 24
HR 25-75 100 MG, 150 MG,
200 MG
2
tramadol oral tablet 50
mg 1
tramadol oral tablet
extended release 24 hr
100 mg, 200 mg, 300 mg
1
tramadol oral tablet, er
multiphase 24 hr 100 mg,
200 mg, 300 mg
1
tramadol-acetaminophen
oral tablet 37.5-325 mg 1
VOLTAREN TOPICAL GEL
1 % 2 QL
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
25
Drug Name Tier Requirements - Limitations
ZUBSOLV SUBLINGUAL
TABLET 0.7-0.18 MG, 1.4-
0.36 MG, 11.4-2.9 MG, 2.9-
0.71 MG, 5.7-1.4 MG, 8.6-
2.1 MG
2 PA
Psychotherapeutic Drugs
ABILIFY MAINTENA
INTRAMUSCULAR SUS, EXT-
REL RECON 300MG,400MG
2
ABILIFY MAINTENA
INTRAMUSCULAR SUSP,
EXT-REL SYRINGE 300 MG,
400 MG
2
ADZENYS XR-ODT ORAL
TABLET, DISINTEG ER
BIPHASE 24H 12.5 MG, 15.7
MG, 18.8 MG, 3.1 MG, 6.3
MG, 9.4 MG
2
alprazolam intensol oral
concentrate 1 mg/ml 1
alprazolam tablet 0.25
mg, 0.5 mg, 1 mg, 2 mg 1
alprazolam oral tablet
extended release 24 hr 0.5
mg, 1 mg, 2 mg, 3 mg
1
alprazolam oral tablet,
disintegrating 0.25 mg, 0.5
mg, 1 mg, 2 mg
1
amitriptyline oral tablet 10
mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
1
amitriptyline-
chlordiazepoxide oral
tablet 12.5-5 mg, 25-10 mg
1
amoxapine oral tablet 100
mg, 150 mg, 25 mg, 50 mg 1
Drug Name Tier Requirements - Limitations
APTENSIO XR ORAL CAP,
ER SPRINKLE, BIPHASIC 40-
60 10 MG, 15 MG, 20 MG,
30 MG, 40 MG, 50 MG, 60
MG
2
aripiprazole oral solution
1 mg/ml 1
aripiprazole oral tablet 10
mg, 15 mg, 2 mg, 20 mg,
30 mg, 5 mg
1 QL
aripiprazole oral tablet,
disintegrating 10 mg, 15
mg
1 QL
ARISTADA
INTRAMUSCULAR SUSP,
EXTENDED REL SYRING
1,064 MG/3.9 ML, 441
MG/1.6 ML, 662 MG/2.4
ML, 882 MG/3.2 ML
2
armodafinil oral tablet 50
mg, 150 mg, 200 mg, 250
mg
1 QL
bupropion hcl oral tablet
100 mg, 75 mg 1
bupropion hcl oral tablet
extended release 12 hr
100 mg, 150 mg, 200 mg
1
bupropion hcl oral tablet
extended release 24 hr
150 mg, 300 mg
1
buspirone oral tablet 10
mg, 15 mg, 30 mg, 5 mg,
7.5 mg
1
chlordiazepoxide hcl oral
capsule 5 mg, 10 mg, 25
mg
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
26
Drug Name Tier Requirements - Limitations
chlorpromazine oral tablet
10 mg, 100 mg, 200 mg, 25
mg, 50 mg
1
citalopram oral soln 10
mg/5 ml 1
citalopram oral tablet 10
mg, 20 mg 1
citalopram oral tablet 40
mg 1 QL
clomipramine capsule 25
mg, 50 mg, 75 mg 1
clorazepate dipotassium
oral tablet 15 mg, 3.75
mg, 7.5 mg
1
clozapine oral tablet 100
mg, 200 mg, 25 mg, 50 mg 1
clozapine oral tablet,
disintegrating 100 mg, 12.5
mg, 25 mg
1
CLOZAPINE ORAL TABLET,
DISINTEGRATING 150 MG,
200 MG
2
COTEMPLA XR-ODT ORAL
TABLET,DISINTEG ER
BIPHASE 24H 17.3 MG, 25.9
MG, 8.6 MG
2
DAYTRANA TRANSDERMAL
PATCH 24 HOUR 10 MG/9
HR, 15 MG/9 HR, 20 MG/9
HR, 30 MG/9 HR
2
desipramine oral tablet 10
mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
1
DESOXYN TABLET 5 MG 2
DESVENLAFAXINE
FUMARATE TABLET EXT-REL
24HR 100 MG, 50 MG
2
Drug Name Tier Requirements - Limitations
DESVENLAFAXINE ORAL
TABLET EXTENDED RELEASE
24 HR 100 MG, 50 MG
2
DESVENLAFAXINE ORAL
TABLET EXTENDED RELEASE
24HR 100 MG, 50 MG
2
desvenlafaxine succinate
oral tablet extended
release 24 hr 100 mg, 25
mg, 50 mg
1
dexmethylphenidate oral
tablet 2.5mg, 5mg, 10mg 1
dextroamphetamine oral
capsule, ext-rel 10 mg, 15
mg, 5 mg
1
dextroamphetamine oral
soln 5 mg/5 ml 1
dextroamphetamine oral
tablet 10 mg, 5 mg 1
dextroamphetamine-
amphetamine oral tablet
10 mg, 12.5 mg, 15 mg, 20
mg, 30 mg, 5 mg, 7.5 mg
1
diazepam intensol oral
concentrate 5 mg/ml 1
diazepam oral soln 5 mg/5
ml (1 mg/ml) 1
diazepam oral tablet 10
mg, 2 mg, 5 mg 1
doxepin oral capsule 10
mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
1
doxepin oral concentrate
10 mg/ml 1
duloxetine oral capsule,
delayed release(dr/ec) 20
mg, 30 mg, 40 mg, 60 mg
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
27
Drug Name Tier Requirements - Limitations
DYANAVEL XR ORAL
SUSPEN, IR - ER, BIPHASIC
24HR 2.5 MG/ML
2
ergoloid oral tablet 1 mg 1
escitalopram oxalate oral
soln 5 mg/5 ml 1
escitalopram oxalate oral
tablet 10 mg, 20 mg, 5 mg 1
estazolam oral tablet 1
mg, 2 mg 1
eszopiclone oral tablet 1
mg, 2 mg, 3 mg 1
EVEKEO ORAL TABLET 10
MG, 5 MG 2
FANAPT ORAL TABLET 1
MG, 10 MG, 12 MG, 2 MG,
4 MG, 6 MG, 8 MG
2
FANAPT ORAL TABLETS,
DOSE PACK 1MG(2)-
2MG(2)- 4MG(2)-6MG(2)
2
FAZACLO ORAL TABLET,
DISINTEGRATING 12.5 MG,
25 MG, 100 MG, 150 MG,
200 MG
2
FETZIMA ORAL CAPSULE,
EXT REL 24HR DOSE PACK
20 MG (2)- 40 MG (26)
2
FETZIMA ORAL CAPSULE,
EXT-REL 24 HR 120 MG, 20
MG, 40 MG, 80 MG
2
fluoxetine oral capsule 10
mg, 20 mg, 40 mg 1
fluoxetine oral soln 20
mg/5 ml (4 mg/ml) 1
fluoxetine oral tablet 10
mg, 20 mg 1
Drug Name Tier Requirements - Limitations
FLUOXETINE ORAL TABLET
60 MG 2
fluphenazine decanoate
injection soln 25 mg/ml 1
fluphenazine hcl injection
soln 2.5 mg/ml 1
fluphenazine hcl oral
concentrate 5 mg/ml 1
fluphenazine hcl oral elixir
2.5 mg/5 ml 1
fluphenazine hcl oral
tablet 1 mg, 10 mg, 2.5
mg, 5 mg
1
flurazepam oral capsule
15 mg, 30 mg 1
fluvoxamine oral capsule,
extended release 24hr 100
mg, 150 mg
1
fluvoxamine oral tablet
100 mg, 50 mg 1 QL
fluvoxamine oral tablet 25
mg 1
FOCALIN XR ORAL
CAPSULE,ER BIPHASIC 50-
50 10 MG, 15 MG, 20 MG,
25 MG, 30 MG, 35 MG, 40
MG, 5 MG
2
guanfacine oral tablet
extended release 24 hr 1
mg, 2 mg, 3 mg, 4 mg
1
guanidine oral tablet 125
mg 1
HALDOL DECANOATE
INTRAMUSCULAR SOLN 100
MG/ML, 50 MG/ML
2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
28
Drug Name Tier Requirements - Limitations
HALDOL INJECTION SOLN
5 MG/ML 2
haloperidol decanoate
intramuscular soln 100
mg/ml, 50 mg/ml
1
haloperidol lactate
injection soln 5 mg/ml 1
haloperidol lactate oral
concentrate 2 mg/ml 1
haloperidol oral tablet 0.5
mg, 1 mg, 10 mg, 2 mg, 20
mg, 5 mg
1
imipramine hcl oral tablet
10 mg, 25 mg, 50 mg 1
imipramine pamoate oral
capsule 100 mg, 125 mg,
150 mg, 75 mg
1
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE
39 MG/0.25 ML, 78 MG/0.5
ML, 117 MG/0.75 ML, 156
MG/ML, 234 MG/1.5 ML
2
INVEGA TRINZA
INTRAMUSCULAR SYRINGE
273 MG/0.875 ML, 410
MG/1.315 ML, 546
MG/1.75 ML, 819
MG/2.625 ML
2
KAPVAY ORAL TABLET
EXTENDED RELEASE 12 HR
0.1 MG
2 ST
KHEDEZLA ORAL TABLET
EXTENDED RELEASE 24HR
100 MG, 50 MG
2
LATUDA ORAL TABLET 120
MG, 20 MG, 40 MG, 60
MG, 80 MG
2
Drug Name Tier Requirements - Limitations
lithium carbonate oral
capsule 150 mg, 300 mg,
600 mg
1
lithium carbonate oral
tablet 300 mg 1
lithium carbonate oral
tablet extended release
300 mg, 450 mg
1
lithium citrate oral soln 8
meq/5 ml 1
lorazepam intensol oral
concentrate 2 mg/ml 1
lorazepam oral
concentrate 2 mg/ml 1
lorazepam oral tablet 0.5
mg, 1 mg, 2 mg 1
loxapine succinate oral
capsule 10 mg, 25 mg, 5
mg, 50 mg
1
maprotiline oral tablet 25
mg, 50 mg, 75 mg 1
methamphetamine oral
tablet 5 mg 1
methylphenidate hcl oral
capsule, er biphasic 30-70
10 mg, 20 mg, 30 mg, 40
mg, 50 mg, 60 mg
1
methylphenidate hcl oral
capsule, er biphasic 50-50
20 mg, 30 mg, 40 mg, 60
mg
1
methylphenidate hcl oral
solution 10 mg/5 ml, 5
mg/5 ml
1
methylphenidate hcl oral
tablet 10 mg, 20 mg, 5 mg 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
29
Drug Name Tier Requirements - Limitations
methylphenidate hcl oral
tablet extended release
10 mg, 20 mg
1
methylphenidate hcl oral
tablet ext-rel 24hr 18 mg,
27 mg, 36 mg, 54 mg
1
methylphenidate hcl oral
tablet, chewable 10 mg,
2.5 mg, 5 mg
1
midazolam oral syrup 2
mg/ml 1
mirtazapine oral tablet 15
mg, 30 mg, 45 mg, 7.5 mg 1
mirtazapine oral tablet,
disintegrating 15 mg, 30
mg, 45 mg
1
modafinil oral tablet 100
mg, 200 mg 1 QL
MYDAYIS CAPSULE, ER
TRIPHASIC 24 HR 12.5 MG,
25 MG, 37.5 MG, 50 MG
2
nefazodone oral tablet
100 mg, 150 mg, 200 mg,
250 mg, 50 mg
1
nortriptyline oral capsule
10 mg,25 mg,50 mg,75 mg 1
nortriptyline oral soln 10
mg/5 ml 1
NUPLAZID TABLET 17 MG 2 ST; SP; QL
NUVIGIL TABLET 150 MG,
200 MG, 250 MG, 50 MG 2 QL
olanzapine intramuscular
recon soln 10 mg 1
olanzapine oral tablet 10
mg, 15 mg, 2.5 mg, 20 mg,
5 mg, 7.5 mg
1
Drug Name Tier Requirements - Limitations
olanzapine oral tablet,
disintegrating 10 mg, 15
mg, 20 mg, 5 mg
1
olanzapine-fluoxetine oral
capsule 12-25 mg, 12-50
mg, 3-25 mg, 6-25 mg, 6-
50 mg
1
ORAP TABLET 1 MG, 2 MG 2
oxazepam oral capsule 10
mg, 15 mg, 30 mg 1
paliperidone oral tablet
extended release 24hr 1.5
mg, 3 mg, 6 mg, 9 mg
1
paroxetine hcl tablet 10
mg, 20 mg, 30 mg, 40 mg 1 QL
paroxetine hcl oral tablet
extended release 24 hr
12.5 mg, 25 mg, 37.5 mg
1
paroxetine mesylate oral
capsule 7.5 mg 1
PAXIL ORAL SUSPENSION
10 MG/5 ML 2
perphenazine oral tablet
16 mg, 2 mg, 4 mg, 8 mg 1
perphenazine-
amitriptyline oral tablet 2-
10 mg, 2-25 mg, 4-10 mg,
4-25 mg, 4-50 mg
1
PEXEVA ORAL TABLET 10
MG,20 MG, 30 MG, 40 MG 2
phenelzine tablet 15 mg 1
pimozide tablet 1 mg, 2
mg 1
PRISTIQ ORAL TABLET
EXTENDED RELEASE 24 HR
100 MG, 25 MG, 50 MG
2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
30
Drug Name Tier Requirements - Limitations
procentra oral solution
5 mg/5 ml 1
protriptyline oral tablet 10
mg, 5 mg 1
quazepam tablet 15 mg 1
quetiapine oral tablet 25
mg, 50 mg, 100 mg, 200
mg, 300 mg, 400 mg
1
quetiapine oral tablet
extended release 24 hr
150 mg, 200 mg, 300 mg,
400 mg, 50 mg
1
QUILLICHEW ER ORAL
TABLET, CHEW,IR-
ER.BIPHASIC 24HR 20 MG,
30 MG, 40 MG
2
QUILLIVANT XR ORAL
SUSPENSION,EXT REL
24HR,RECON 5 MG/ML (25
MG/5 ML)
2
REXULTI ORAL TABLET 0.25
MG, 0.5 MG, 1 MG, 2 MG,
3 MG, 4 MG
2 QL
RISPERDAL CONSTA
INTRAMUSCULAR SYRINGE
12.5 MG/2 ML, 25 MG/2
ML, 37.5 MG/2 ML, 50
MG/2 ML
2
risperidone oral solution
1 mg/ml 1
risperidone oral tablet 0.25
mg, 0.5 mg, 1 mg, 2 mg, 3
mg, 4 mg
1
risperidone oral tablet,
disintegrating 0.25 mg, 0.5
mg, 1 mg, 2 mg, 3 mg, 4
mg
1
Drug Name Tier Requirements - Limitations
SAPHRIS (BLACK CHERRY)
SUBLINGUAL TABLET 10
MG, 2.5 MG, 5 MG
2
seconal sodium oral
capsule 100 mg 1
sertraline oral concentrate
20 mg/ml 1
sertraline oral tablet 100
mg, 25 mg, 50 mg 1
SURMONTIL ORAL
CAPSULE 100 MG, 25 MG,
50 MG
2
SYMBYAX ORAL CAPSULE
12-25 MG, 12-50 MG, 3-25
MG, 6-25 MG, 6-50 MG
2
temazepam capsule , 7.5
mg, 15 mg,22.5 mg, 30 mg 1
thioridazine oral tablet 10
mg, 100 mg, 25 mg, 50 mg 1
thiothixene oral capsule 1
mg, 10 mg, 2 mg, 5 mg 1
tranylcypromine oral
tablet 10 mg 1
trazodone tablet , 50 mg,
100 mg, 150 mg, 300 mg 1
triazolam oral tablet 0.125
mg, 0.25 mg 1
trifluoperazine oral tablet
1 mg, 10 mg, 2 mg, 5 mg 1
trimipramine oral capsule
100 mg, 25 mg, 50 mg 1
TRINTELLIX ORAL TABLET 10
MG, 20 MG, 5 MG 2
venlafaxine oral capsule,
extended release 24hr 150
mg, 37.5 mg, 75 mg
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
31
Drug Name Tier Requirements - Limitations
venlafaxine oral tablet 100
mg, 25 mg, 37.5 mg, 50
mg, 75 mg
1
venlafaxine oral tablet
ext-rel 24hr 150 mg, 225
mg, 37.5 mg, 75 mg
1
VIIBRYD ORAL TABLET 10
MG, 20 MG, 40 MG 2
VIIBRYD ORAL TABLETS,
DOSE PACK 10 MG (7)- 20
MG (23)
2
VRAYLAR ORAL CAPSULE
1.5MG,3MG,4.5MG,6 MG 2
VRAYLAR ORAL
CAPSULE,DOSE PACK 1.5
MG (1)- 3 MG (6)
2
VYVANSE ORAL CAPSULE
10 MG, 20 MG, 30 MG, 40
MG, 50 MG, 60 MG, 70MG
2
VYVANSE ORAL TABLET,
CHEWABLE 10 MG, 20 MG,
30MG,40MG,50 MG,60MG
2
zaleplon oral capsule 5
mg, 10 mg 1 QL
zenzedi oral tablet 10 mg,
5 mg 1
ZENZEDI ORAL TABLET 15
MG, 2.5 MG, 20 MG, 30
MG, 7.5 MG
2
ziprasidone hcl oral
capsule 20 mg, 40 mg, 60
mg, 80 mg
1
zolpidem oral tablet 10
mg, 5 mg 1 QL
zolpidem oral tablet, ext
release multiphase 12.5
mg, 6.25 mg
1
Drug Name Tier Requirements - Limitations
zolpidem sublingual tablet
1.75 mg, 3.5 mg 1
ZYPREXA INTRAMUSCULAR
RECON SOLN 10 MG 2
ZYPREXA RELPREVV
INTRAMUSCULAR
SUSPENSION FOR RECON
210 MG, 300 MG, 405 MG
2
CARDIOVASCULAR, HYPERTENSION &
LIPIDS
Antiarrhythmic Agents
amiodarone oral tablet
100 mg, 200 mg, 400 mg 1
disopyramide phosphate
oral capsule 10mg, 150mg 1
dofetilide oral capsule 125
mcg, 250 mcg, 500 mcg 1
flecainide oral tablet 100
mg, 150 mg, 50 mg 1
mexiletine oral capsule
150 mg, 200 mg, 250 mg 1
MULTAQ TABLET 400 MG 2
NORPACE CR ORAL
CAPSULE, EXTENDED
RELEASE 100 MG, 150 MG
2
NORPACE ORAL CAPSULE
100 MG, 150 MG 2
pacerone oral tablet 100
mg, 200 mg, 400 mg 1
propafenone oral
capsule, ext-rel 12 hr 225
mg, 325 mg, 425 mg
1
propafenone oral tablet
150 mg, 225 mg, 300 mg 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
32
Drug Name Tier Requirements - Limitations
quinidine gluconate oral
tablet ext-rel 324 mg 1
quinidine sulfate oral
tablet 200 mg, 300 mg 1
sotalol af oral tablet 120
mg, 160 mg, 80 mg 1
sotalol oral tablet 120 mg,
160 mg, 240 mg, 80 mg 1
TIKOSYN ORAL CAPSULE
125 MCG, 250 MCG, 500
MCG
2
Antihypertensive Therapy
acebutolol oral capsule
200 mg, 400 mg 1
afeditab cr oral tablet ext-
rel 30 mg, 60 mg 1
amiloride oral tablet 5 mg 1
amiloride-
hydrochlorothiazide oral
tablet 5-50 mg
1
amlodipine oral tablet 10
mg, 2.5 mg, 5 mg 1
amlodipine-benazepril
oral capsule 10-20 mg, 10-
40 mg, 2.5-10 mg, 5-10
mg, 5-20 mg, 5-40 mg
1
amlodipine-olmesartan
oral tablet 10-20 mg, 10-40
mg, 5-20 mg, 5-40 mg
1
amlodipine-valsartan oral
tablet 10-160 mg, 10-320
mg, 5-160 mg, 5-320 mg
1
Drug Name Tier Requirements - Limitations
amlodipine-valsartan-
hydrochlorothiazide oral
tablet 10-160-12.5 mg, 10-
160-25 mg, 10-320-25 mg,
5-160-12.5 mg, 5-160-25mg
1
atenolol oral tablet 100
mg, 25 mg, 50 mg 1
atenolol-chlorthalidone
tablet 100-25 mg,50-25 mg 1
benazepril oral tablet 10
mg, 20 mg, 40 mg, 5 mg 1
benazepril-
hydrochlorothiazide oral
tablet 10-12.5 mg, 20-12.5
mg, 20-25 mg, 5-6.25 mg
1
betaxolol oral tablet 10
mg, 20 mg 1
BIDIL TABLET 20-37.5 MG 2
bisoprolol fumarate oral
tablet 10 mg, 5 mg 1
bisoprolol-
hydrochlorothiazide oral
tablet 10-6.25 mg, 2.5-6.25
mg, 5-6.25 mg
1
bumetanide oral tablet
0.5 mg, 1 mg, 2 mg 1
BYSTOLIC ORAL TABLET 10
MG, 2.5 MG, 20 MG, 5 MG 2
CALAN SR ORAL TABLET
EXTENDED RELEASE 120
MG, 180 MG, 240 MG
2
candesartan oral tablet
16 mg, 32 mg, 4 mg, 8 mg 1
candesartan-
hydrochlorothiazide oral
tablet 16-12.5 mg, 32-12.5
mg, 32-25 mg
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
33
Drug Name Tier Requirements - Limitations
captopril oral tablet 12.5
mg, 25 mg,50 mg,100 mg 1
captopril-
hydrochlorothiazide oral
tablet 25-15 mg, 25-25 mg,
50-15 mg, 50-25 mg
1
cartia xt oral capsule, ext-
release 24hr 120 mg, 180
mg, 240 mg, 300 mg
1
carvedilol oral tablet 3.125 mg,6.25 mg,12.5 mg,25mg
1
chlorothiazide oral tablet
250 mg, 500 mg 1
chlorthalidone oral tablet
25 mg, 50 mg 1
clonidine hcl oral tablet
0.1 mg, 0.2 mg, 0.3 mg 1
clonidine transdermal
patch weekly 0.1 mg/24hr,
0.2 mg/24hr, 0.3 mg/24hr
1
clorpres oral tablet 0.1-15
mg, 0.2-15 mg 1
CLORPRES ORAL TABLET
0.3-15 MG 2
COREG CR ORAL
CAPSULE, ER MULTIPHASE
24 HR 10 MG, 20 MG, 40
MG, 80 MG
2
DIBENZYLINE ORAL
CAPSULE 10 MG 2
diltiazem hcl oral capsule,
ex-.rel 24hr degradable
240 mg
1
diltiazem hcl oral capsule,
extended release 12 hr
120 mg, 60 mg, 90 mg
1
Drug Name Tier Requirements - Limitations
diltiazem hcl oral capsule,
extended release 24 hr
240 mg, 420 mg
1
diltiazem hcl oral capsule,
extended release 24hr 120
mg, 180 mg, 240 mg, 300
mg, 360 mg
1
diltiazem hcl tablet 120
mg, 30 mg, 60 mg, 90 mg 1
diltiazem hcl tablet ext-rel
24 hr 180 mg, 240 mg, 300
mg, 360 mg
1
dilt-xr oral capsule, ext.rel
24h degradable 120 mg,
180 mg, 240 mg
1
DIOVAN HCT ORAL TABLET
160-12.5 MG, 160-25 MG,
320-12.5 MG, 320-25 MG,
80-12.5 MG
2
DIURIL ORAL SUSPENSION
250 MG/5 ML 2
doxazosin oral tablet 1
mg, 2 mg, 4 mg, 8 mg 1 QL
enalapril maleate oral
tablet 10 mg, 2.5 mg, 20
mg, 5 mg
1
enalapril-
hydrochlorothiazide oral
tablet 10-25 mg, 5-12.5 mg
1
eplerenone oral tablet 25
mg, 50 mg 1
eprosartan tablet 600 mg 1
ethacrynic acid oral
tablet 25 mg 1
felodipine oral tablet
extended release 24 hr 10
mg, 2.5 mg, 5 mg
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
34
Drug Name Tier Requirements - Limitations
fosinopril oral tablet 10
mg, 20 mg, 40 mg 1
fosinopril-
hydrochlorothiazide tablet
10-12.5 mg, 20-12.5 mg
1
furosemide oral soln 10
mg/ml, 40 mg/5 ml (8
mg/ml)
1
furosemide oral tablet 20
mg, 40 mg, 80 mg 1
guanfacine oral tablet 1
mg, 2 mg 1
hydralazine oral tablet 10
mg, 100 mg, 25 mg, 50 mg 1
hydrochlorothiazide oral
capsule 12.5 mg 1
hydrochlorothiazide oral
tablet 12.5mg,25mg,50mg 1
indapamide oral tablet
1.25 mg, 2.5 mg 1
irbesartan oral tablet 150
mg, 300 mg, 75 mg 1
irbesartan-
hydrochlorothiazide tablet
150-12.5 mg, 300-12.5 mg
1
isradipine oral capsule 2.5
mg, 5 mg 1
labetalol oral tablet 100
mg, 200 mg, 300 mg 1
lisinopril oral tablet 10 mg,
2.5 mg, 20 mg, 30 mg, 40
mg, 5 mg
1
lisinopril-
hydrochlorothiazide oral
tablet 10-12.5 mg, 20-12.5
mg, 20-25 mg
1
Drug Name Tier Requirements - Limitations
losartan oral tablet 100
mg, 25 mg, 50 mg 1
losartan-
hydrochlorothiazide oral
tablet 100-12.5 mg, 100-25
mg, 50-12.5 mg
1
matzim la oral tablet
extended release 24 hr
180 mg, 240 mg, 300 mg,
360 mg, 420 mg
1
MAXZIDE-25MG ORAL
TABLET 37.5-25 MG 2
methyclothiazide oral
tablet 5 mg 1
methyldopa oral tablet
250 mg, 500 mg 1
methyldopa-
hydrochlorothiazide oral
tablet 250-15mg,250-25mg
1
metolazone oral tablet 10
mg, 2.5 mg, 5 mg 1
metoprolol succinate oral
tablet extended release
24 hr 100 mg, 200 mg, 25
mg, 50 mg
1
metoprolol tartrate-
hydrochlorothiazide oral
tablet 100-25 mg, 100-50
mg, 50-25 mg
1
metoprolol tartrate oral
tablet 100 mg, 25 mg, 37.5
mg, 50 mg, 75 mg
1
minoxidil oral tablet 10
mg, 2.5 mg 1
moexipril oral tablet 15
mg, 7.5 mg 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
35
Drug Name Tier Requirements - Limitations
moexipril-
hydrochlorothiazide oral
tablet 15-12.5 mg, 15-25
mg, 7.5-12.5 mg
1
nadolol oral tablet 20 mg,
40 mg, 80 mg 1
nadolol-
bendroflumethiazide oral
tablet 40-5 mg, 80-5 mg
1
nicardipine oral capsule
20 mg, 30 mg 1
nifedipine oral capsule 10
mg, 20 mg 1
nifedipine oral tablet
extended release 24hr 30
mg, 60 mg, 90 mg
1
nifedipine oral tablet
extended release 30 mg,
60 mg, 90 mg
1
nimodipine oral capsule
30 mg 1
nisoldipine oral tablet
extended release 24 hr 17
mg, 20 mg, 25.5 mg, 30
mg, 34 mg, 40 mg, 8.5 mg
1
olmesartan oral tablet 20
mg, 40 mg, 5 mg 1
olmesartan-amlodipine-
hydrochlorothiazide tablet
20-5-12.5 mg, 40-10-12.5
mg, 40-10-25 mg, 40-5-12.5
mg, 40-5-25 mg
1
olmesartan-
hydrochlorothiazide oral
tablet 20-12.5 mg, 40-12.5
mg, 40-25 mg
1
Drug Name Tier Requirements - Limitations
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.125
MG, 0.25 MG, 1 MG, 2.5
MG, 5 MG
2 PA; SP
perindopril erbumine oral
tablet 2 mg, 4 mg, 8 mg 1
phenoxybenzamine oral
capsule 10 mg 1
pindolol oral tablet 10 mg,
5 mg 1
prazosin oral capsule 1
mg, 2 mg, 5 mg 1
propranolol oral capsule,
extended release 24 hr
120 mg, 160 mg, 60 mg, 80
mg
1
propranolol oral soln 20
mg/5 ml (4 mg/ml), 40
mg/5 ml (8 mg/ml)
1
propranolol oral tablet 10
mg, 20 mg, 40 mg, 60 mg,
80 mg
1
propranolol-
hydrochlorothiazide oral
tablet 40-25 mg, 80-25 mg
1
quinapril oral tablet 10
mg, 20 mg, 40 mg, 5 mg 1
quinapril-
hydrochlorothiazide oral
tablet 10-12.5 mg, 20-12.5
mg, 20-25 mg
1
ramipril oral capsule 1.25
mg, 10 mg, 2.5 mg, 5 mg 1
spironolactone oral tablet
100 mg, 25 mg, 50 mg 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
36
Drug Name Tier Requirements - Limitations
spironolactone-
hydrochlorothiazide oral
tablet 25-25 mg
1
TARKA ORAL TABLET, IR -
ER, BIPHASIC 24HR 1-240
MG, 2-180 MG, 2-240 MG,
4-240 MG
2
taztia xt oral capsule,
extended release 24 hr
120 mg, 180 mg, 240 mg,
300 mg, 360 mg
1
TEKTURNA HCT TABLET 150-
12.5 MG, 150-25 MG, 300-
12.5 MG, 300-25 MG
2
TEKTURNA ORAL TABLET
150 MG, 300 MG 2
telmisartan oral tablet 20
mg, 40 mg, 80 mg 1
telmisartan-amlodipine
oral tablet 40-10 mg, 40-5
mg, 80-10 mg, 80-5 mg
1
telmisartan-
hydrochlorothiazide oral
tablet 40-12.5 mg, 80-12.5
mg, 80-25 mg
1
terazosin oral capsule 1
mg, 10 mg, 2 mg, 5 mg 1 QL
timolol maleate oral tablet
10 mg, 20 mg, 5 mg 1
torsemide oral tablet 10
mg, 100 mg, 20 mg, 5 mg 1
trandolapril oral tablet 1
mg, 2 mg, 4 mg 1
trandolapril-verapamil oral
tablet, ir - er, biphasic 24hr
1-240 mg, 2-180 mg, 2-240
mg, 4-240 mg
1
Drug Name Tier Requirements - Limitations
triamterene-
hydrochlorothiazide oral
capsule 37.5-25 mg, 50-25
mg
1
triamterene-
hydrochlorothiazide oral
tablet 37.5-25 mg, 75-50
mg
1
valsartan oral tablet 160
mg, 320 mg, 40 mg, 80 mg 1
valsartan-
hydrochlorothiazide oral
tablet 160-12.5 mg, 160-25
mg, 320-12.5 mg, 320-25
mg, 80-12.5 mg
1
verapamil oral capsule, 24
hr er pellet ct 100 mg, 200
mg, 300 mg
1
verapamil capsule, ext rel.
pellets 24 hr 120 mg, 180
mg, 240 mg, 360 mg
1
verapamil oral tablet 120
mg, 40 mg, 80 mg 1
verapamil oral tablet
extended release 120 mg,
180 mg, 240 mg
1
Cardiac Glycosides
digitek oral tablet 125
mcg, 250 mcg 1
digox oral tablet 125 mcg,
250 mcg 1
digoxin oral soln 50
mcg/ml 1
digoxin oral tablet 125
mcg, 250 mcg 1
LANOXIN ORAL TABLET 125
MCG, 250 MCG 2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
37
Drug Name Tier Requirements - Limitations
Coagulation Therapy
AMICAR ORAL SOLN 250
MG/ML (25 %) 2
AMICAR ORAL TABLET
1,000 MG, 500 MG 2
ARIXTRA SUBCUTANEOUS
SYRINGE 10 MG/0.8 ML,
2.5 MG/0.5 ML, 5 MG/0.4
ML, 7.5 MG/0.6 ML
2
aspirin-dipyridamole oral
capsule, er multiphase 12
hr 25-200 mg
1
BRILINTA ORAL TABLET 60
MG, 90 MG 2
cilostazol oral tablet 100
mg, 50 mg 1
clopidogrel oral tablet 75
mg 1
COUMADIN ORAL TABLET
1 MG, 10 MG, 2 MG, 2.5
MG, 3 MG, 4 MG, 5 MG, 6
MG, 7.5 MG
2
dipyridamole oral tablet
25 mg, 50 mg, 75 mg 1
EFFIENT ORAL TABLET 10
MG, 5 MG 2
ELIQUIS ORAL TABLET 2.5
MG, 5 MG 2
enoxaparin subcutaneous
soln 300 mg/3 ml 1
enoxaparin subcutaneous
syringe 100 mg/ml, 120
mg/0.8 ml, 150 mg/ml, 30
mg/0.3 ml, 40 mg/0.4 ml,
60 mg/0.6 ml, 80 mg/0.8
ml
1
Drug Name Tier Requirements - Limitations
fondaparinux
subcutaneous syringe 10
mg/0.8 ml, 2.5 mg/0.5 ml,
5 mg/0.4 ml, 7.5 mg/0.6 ml
1
hep flush-10 (pf)
intravenous soln 10 unit/ml 1
heparin (porcine) in 5 %
dex intravenous
parenteral soln 20,000
unit/500 ml (40 unit/ml),
25,000 unit/250 ml(100
unit/ml), 25,000 unit/500 ml
(50 unit/ml)
1
heparin (porcine) in nacl
(pf) intravenous
parenteral soln 1,000
unit/500 ml, 2,000
unit/1,000 ml
1
heparin (porcine) injection
cartridge 5,000 unit/ml (1
ml)
1
heparin (porcine) injection
soln 1,000 unit/ml, 10,000
unit/ml, 20,000 unit/ml,
5,000 unit/ml
1
heparin flush(porcine)-
0.9nacl intravenous kit 100
unit/ml
1
heparin lock flush
(porcine) intravenous soln
100 unit/ml
1
heparin lock flush
intravenous soln 10 unit/ml 1
heparin lock flush
intravenous syringe 10
unit/ml
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
38
Drug Name Tier Requirements - Limitations
heparin lockflush
(porcine)(pf) intravenous
syringe 10 unit/ml, 100
unit/ml
1
heparin(porcine) in 0.45%
nacl intravenous
parenteral soln 100
unit/100 ml (1 unit/ml),
25,000 unit/250 ml, 25,000
unit/500 ml
1
heparin, porcine (pf)
injection soln 1,000 unit/ml,
5,000 unit/0.5 ml
1
heparin, porcine (pf)
injection syringe 5,000
unit/0.5 ml
1
heparin, porcine (pf)
intravenous soln 100
unit/ml (1 ml)
1
heparin, porcine (pf)
intravenous syringe 1
unit/ml, 10 unit/ml, 100
unit/ml
1
jantoven oral tablet 1 mg,
10 mg, 2 mg, 2.5 mg, 3
mg, 4 mg, 5 mg, 6 mg, 7.5
mg
1
MEPHYTON TABLET 5 MG 2
pentoxifylline oral tablet
extended release 400 mg 1
PRADAXA ORAL CAPSULE
110 MG, 150 MG, 75 MG 2
prasugrel oral tablet 10
mg, 5 mg 1
PROMACTA ORAL TABLET
12.5 MG, 25 MG, 50 MG,
75 MG
2 PA; SP; LA
Drug Name Tier Requirements - Limitations
ticlopidine tablet 250 mg 1
warfarin tablet 1 mg, 10
mg, 2 mg, 2.5 mg, 3 mg, 4
mg, 5 mg, 6 mg, 7.5 mg
1
XARELTO ORAL TABLET 10
MG, 15 MG, 20 MG 2
XARELTO ORAL TABLETS,
DOSE PACK 15 MG (42)-
20 MG (9)
2
Lipid/Cholesterol Lowering Agents
amlodipine-atorvastatin
oral tablet 10-10 mg, 10-20
mg, 10-40 mg, 10-80 mg,
2.5-10 mg, 2.5-20 mg, 2.5-
40 mg, 5-10 mg, 5-20 mg,
5-40 mg, 5-80 mg
1
atorvastatin oral tablet 10
mg, 20 mg, 40 mg, 80 mg 1
CADUET TABLET 10-10 MG,
10-20 MG, 10-40 MG, 10-80
MG, 5-10 MG, 5-20 MG, 5-
40 MG, 5-80 MG
2
cholestyramine (with
sugar) oral powder 4
gram
1
cholestyramine (with
sugar) oral powder in
packet 4 gram
1
cholestyramine light oral
powder 4 gram 1
cholestyramine light oral
powder in packet 4 gram 1
colestipol oral granules 5
gram 1
colestipol oral packet 5
gram 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
39
Drug Name Tier Requirements - Limitations
colestipol oral tablet 1
gram 1
ezetimibe tablet 10 mg 1
ezetimibe-simvastatin oral
tablet 10-10 mg, 10-20 mg,
10-40 mg, 10-80 mg
1
fenofibrate micronized
oral capsule 130 mg, 134
mg, 200 mg, 43 mg, 67 mg
1
fenofibrate
nanocrystallized oral
tablet 145 mg, 48 mg
1
fenofibrate oral tablet 120
mg, 160 mg, 40 mg, 54 mg 1
fenofibric acid (choline)
oral capsule, del-rel
(dr/ec) 135 mg, 45 mg
1
fenofibric acid oral tablet
105 mg, 35 mg 1
fluvastatin oral capsule 20
mg, 40 mg 1
fluvastatin oral tablet ext-
rel 24 hr 80 mg 1 QL
gemfibrozil tablet 600 mg 1
lovastatin oral tablet 10
mg, 20 mg, 40 mg 1
LOVAZA CAPSULE 1 GRAM 2
niacin oral tablet
extended release 24 hr
1,000 mg, 500 mg, 750 mg
1
omega-3 acid ethyl esters
oral capsule 1 gram 1
PRALUENT PEN INJECTOR
150 MG/ML, 75 MG/ML 2 PA; SP
Drug Name Tier Requirements - Limitations
pravastatin oral tablet 10
mg, 20 mg, 40 mg, 80 mg 1
prevalite oral powder 4
gram 1
prevalite oral powder in
packet 4 gram 1
QUESTRAN LIGHT ORAL
POWDER 4 GRAM 2
QUESTRAN ORAL POWDER
4 GRAM 2 QL
QUESTRAN ORAL POWDER
IN PACKET 4 GRAM 2
REPATHA PUSHTRONEX
SUBCUTANEOUS
WEARABLE INJECTOR 420
MG/3.5 ML
2 PA; SP
REPATHA SURECLICK
SUBCUTANEOUS PEN
INJECTOR 140 MG/ML
2 PA; SP
REPATHA SYRINGE
SUBCUTANEOUS SYRINGE
140 MG/ML
2 PA; SP
rosuvastatin oral tablet 10
mg, 20 mg 1 QL
rosuvastatin oral tablet 40
mg, 5 mg 1
simvastatin oral tablet 10
mg, 20 mg, 40 mg, 5 mg,
80 mg
1
triklo oral capsule 1 gram 1
TRILIPIX ORAL CAPSULE,
DELAYED RELEASE(DR/EC)
135 MG, 45 MG
2
WELCHOL ORAL POWDER
IN PACKET 3.75 GRAM 2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
40
Drug Name Tier Requirements - Limitations
WELCHOL ORAL TABLET
625 MG 2
Miscellaneous Cardiovascular Agents
CORLANOR ORAL TABLET
5 MG, 7.5 MG 2
ENTRESTO ORAL TABLET 24-
26 MG, 49-51 MG, 97-103
MG
2 PA
RANEXA ORAL TABLET
EXTENDED RELEASE 12 HR
1,000 MG, 500 MG
2
Nitrates
DILATRATE-SR ORAL
CAPSULE, EXTENDED
RELEASE 40 MG
2
ISORDIL TABLET 40 MG 2
ISORDIL TITRADOSE ORAL
TABLET 5 MG 2
isosorbide dinitrate oral
tablet 10 mg, 20 mg, 30
mg, 5 mg
1
isosorbide dinitrate tablet
extended release 40 mg 1
isosorbide mononitrate
oral tablet 10 mg, 20 mg 1
isosorbide mononitrate
oral tablet ext-rel 24 hr 120
mg, 30 mg, 60 mg
1
nitro-bid transdermal
ointment 2 % 1
nitroglycerin oral capsule,
extended release 2.5 mg,
6.5 mg, 9 mg
1
nitroglycerin sublingual
tablet 0.3 mg, 0.4 mg, 0.6
mg
1
Drug Name Tier Requirements - Limitations
nitroglycerin transdermal
patch 24 hour 0.1 mg/hr,
0.2 mg/hr, 0.4 mg/hr, 0.6
mg/hr
1
nitroglycerin translingual
aerosol, spray 400
mcg/spray
1
nitroglycerin translingual
spray, non-aerosol 400
mcg/spray
1
NITROSTAT SUBLINGUAL
TABLET 0.3 MG, 0.4 MG, 0.6
MG
2
DERMATOLOGICALS/TOPICAL THERAPY
Antipsoriatic / Antiseborrheic
acitretin oral capsule 10
mg, 17.5 mg, 25 mg 1
calcipotriene scalp soln
0.005 % 1
calcipotriene topical
cream 0.005 % 1
calcipotriene topical
ointment 0.005 % 1
calcipotriene-
betamethasone topical
ointment 0.005-0.064 %
1 QL
calcitrene topical
ointment 0.005 % 1
calcitriol topical ointment
3 mcg/gram 1
COAL TAR TOPICAL SOLN
20 % 2
COSENTYX (2 SYRINGES)
SUBCUTANEOUS SYRINGE
150 MG/ML
2 PA; SP
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
41
Drug Name Tier Requirements - Limitations
COSENTYX PEN (2 PENS)
SUBCUTANEOUS PEN
INJECTOR 150 MG/ML
2 PA; SP
DOVONEX TOPICAL
CREAM 0.005 % 2
drithocreme hp topical
cream 1 % 1
EPIFOAM TOPICAL FOAM
1-1 % 2
PRAMOSONE E TOPICAL
CREAM 2.5-1 % 2
PRAMOSONE TOPICAL
CREAM 1-1 %, 2.5-1 % 2
PRAMOSONE TOPICAL
LOTION 1-1 %, 2.5-1 % 2
PRAMOSONE TOPICAL
OINTMENT 1-1 %, 2.5-1 % 2
seb-prev topical cleanser
10 % 1
selenium sulfide topical
lotion 2.5 % 1
selenium sulfide topical
shampoo 2.25 % 1
SORILUX TOPICAL FOAM
0.005 % 2
sulfacetamide sodium
topical cleanser 10 % 1
sulfacetamide sodium
topical cleanser, gel 10 % 1
sulfacetamide sodium
topical shampoo 10 % 1
TACLONEX TOPICAL
OINTMENT 0.005-0.064 % 2 QL
TACLONEX TOPICAL
SUSPENSION 0.005-0.064 % 2 QL
Drug Name Tier Requirements - Limitations
Burn Therapy
silver sulfadiazine topical
cream 1 % 1
ssd topical cream 1 % 1
Keratolytics
salicylic acid er-ceramides
topical kit, cleanser and
cream er 6 %
1
salicylic acid topical
cream 6 % 1
salicylic acid topical
cream, ext-rel 6 % 1
salicylic acid topical film
forming liq w/appl 27.5 % 1
salicylic acid topical film-
forming soln w/appl 28.5 % 1
salicylic acid topical foam
6 % 1
salicylic acid topical gel 6
% 1
salicylic acid topical liquid
26 % 1
salicylic acid topical lotion
6 % 1
salicylic acid topical
lotion, ext-rel 6 % 1
salicylic acid topical
shampoo 6 % 1
salvax topical foam 6 % 1
Miscellaneous Dermatologicals
avo cream topical
emulsion 1
bp-50% urea topical
emulsion 50 % 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
42
Drug Name Tier Requirements - Limitations
CARAC TOPICAL CREAM
0.5 % 2
celacyn topical gel with
pump 1
cem-urea topical gel 45 % 1
CONDYLOX TOPICAL GEL
0.5 % 2
diclofenac sodium topical
gel 3 % 1 QL
doxepin topical cream 5% 1
DUPIXENT SUBCUTANEOUS
SYRINGE 300 MG/2 ML 2 PA; SP; QL
eletone topical cream 1
ELIDEL TOPICAL CREAM 1% 2
emulsion sb topical
emulsion 1
FLUOROPLEX TOPICAL
CREAM 1 % 2
fluorouracil topical cream
5 % 1
fluorouracil topical soln 2
%, 5 % 1
hpr plus hydrogel topical
kit,cream and gel 1
hpr plus topical cream 1
hpr plus topical foam 1
hpr topical foam 1
IODOFLEX TOPICAL PADS,
MEDICATED 0.9 % 2
IODOSORB TOPICAL GEL
0.9 % 2
mb hydrogel
(cyclomethicone) topical
kit, cream and gel
1
Drug Name Tier Requirements - Limitations
mb hydrogel topical kit,
cream and gel 96.53-3-0.4
-0.066 %
1
nivatopic plus topical
cream 1
podofilox topical solution
0.5 % 1
PROTOPIC TOPICAL
OINTMENT 0.03 %, 0.1 % 2
pruclair topical cream 1
prudoxin topical cream
5% 1
prumyx topical cream 1
prutect topical emulsion 1
rea lo 39 topical cream 39
% 1
rea lo 40 topical lotion 40
% 1
REGRANEX TOPICAL GEL
0.01 % 2 QL
silver nitrate applicators
topical stick 75-25 % 1
silver nitrate topical
ointment 10 % 1
silver nitrate topical soln
0.5 %, 10 %, 25 %, 50 % 1
sonafine topical emulsion 1
sp antipruritic topical gel 1
sp scar management
topical gel with pump 1
tacrolimus topical
ointment 0.03 %, 0.1 % 1
umecta topical foam 40 % 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
43
Drug Name Tier Requirements - Limitations
urea nail stick topical soln
50 % 1
urea topical cream 39 %,
40 %, 45 %, 47 %, 50 % 1
urea topical foam 35 % 1
urea topical gel 45 % 1
urea topical lotion 40 %,
45 % 1
ure-k topical cream 50 % 1
ZONALON TOPICAL
CREAM 5 % 2
Therapy For Acne
ACANYA TOPICAL GEL
WITH PUMP 1.2-2.5 % 2
ACZONE TOPICAL GEL 5 % 2
ACZONE TOPICAL GEL
WITH PUMP 7.5 % 2
adapalene topical gel 0.3
% 1
adapalene topical gel
with pump 0.3 % 1
adapalene-benzoyl
peroxide topical gel with
pump 0.1-2.5 %
1
avar topical cleanser 10-5
% (w/w) 1
avita topical cream 0.025
% 1
AZELEX TOPICAL CREAM
20 % 2
BENZACLIN PUMP TOPICAL
GEL WITH PUMP 1-5 % 2
BENZACLIN TOPICAL GEL
1-5 % 2
Drug Name Tier Requirements - Limitations
bp 10-1 topical cleanser
10-1 % 1
claravis oral capsule 10
mg, 20 mg, 30 mg, 40 mg 1
cleansing wash topical
cleanser 10-4-10 % 1
clindacin p topical swab 1
% 1
CLINDAGEL TOPICAL GEL
1 % 2
clindamycin phosphate
topical foam 1 % 1
clindamycin phosphate
topical gel 1 % 1
clindamycin phosphate
topical lotion 1 % 1
clindamycin phosphate
topical soln 1 % 1
clindamycin phosphate
topical swab 1 % 1
clindamycin-benzoyl
peroxide topical gel 1-5 %,
1.2 %(1 % base) -5 %
1
clindamycin-benzoyl
peroxide topical gel with
pump 1-5 %
1
clindamycin-tretinoin
topical gel 1.2-0.025 % 1
dapsone topical gel 5 % 1
DIFFERIN TOPICAL GEL 0.3
% 2
DIFFERIN TOPICAL GEL
WITH PUMP 0.3 % 2
DIFFERIN TOPICAL LOTION
0.1 % 2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
44
Drug Name Tier Requirements - Limitations
EPIDUO FORTE TOPICAL
GEL WITH PUMP 0.3-2.5 % 2
EPIDUO TOPICAL GEL WITH
PUMP 0.1-2.5 % 2
ery pads topical swab 2 % 1
erygel topical gel 2 % 1
erythromycin with ethanol
topical gel 2 % 1
erythromycin with ethanol
topical soln 2 % 1
erythromycin with ethanol
topical swab 2 % 1
erythromycin-benzoyl
peroxide topical gel 3-5 % 1
FINACEA TOPICAL FOAM
15 % 2
FINACEA TOPICAL GEL 15
% 2
metronidazole topical
cream 0.75 % 1
metronidazole topical gel
0.75 %, 1 % 1
metronidazole topical gel
with pump 1 % 1
metronidazole topical
lotion 0.75 % 1
neuac topical gel 1.2 %(1
% base) -5 % 1
NORITATE TOPICAL CREAM
1 % 2
NUOX TOPICAL GEL 6-3 % 2
RETIN-A MICRO PUMP
TOPICAL GEL WITH PUMP
0.04 %, 0.1 %
2
Drug Name Tier Requirements - Limitations
RETIN-A MICRO TOPICAL
GEL 0.04 %, 0.1 % 2
rosadan topical cream
0.75 % 1
rosadan topical gel 0.75 % 1
rosula cleansing cloths
topical pads, medicated
10-5 %
1
sss 10-5 topical cream 10-5
% (w/w) 1
sss 10-5 topical foam 10-5
% 1
sulfacetamide sodium-
sulfur topical cleanser 10-2
%, 10-5 % (w/w), 9-4 %, 9-
4.5 %, 9.8-4.8 %
1
sulfacetamide sodium-
sulfur topical cream 10-2
%, 10-5 % (w/w), 9.8-4.8 %
1
sulfacetamide sodium-
sulfur topical lotion 10-5 %
(w/v), 10-5 % (w/w), 9.8-
4.8 %
1
sulfacetamide sodium-
sulfur topical pads,
medicated 10-4 %
1
sulfacetamide sodium-
sulfur topical suspension
10-5 %, 8-4 %
1
sulfacetamide sod-sulfur-
urea topical cleanser 10-
5-10 %
1
sulfacetamide-sulfur-
cleansr23 topical kit 9-4.5
%
1
sulfacleanse 8-4 topical
suspension 8-4 % 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
45
Drug Name Tier Requirements - Limitations
sulfact na-sul-avobnz-otn-
ocsa topical combo
pack,cleanser and cream
9 %-4.5 % -spf 25
1
tazarotene topical cream
0.1 % 1
TAZORAC TOPICAL
CREAM 0.05 %, 0.1 % 2
TAZORAC TOPICAL GEL
0.05 %, 0.1 % 2
tretinoin microspheres
topical gel 0.04 %, 0.1 % 1
tretinoin microspheres
topical gel with pump 0.04
%, 0.1 %
1
tretinoin topical cream
0.025 %, 0.05 %, 0.1 % 1
tretinoin topical gel 0.01
%, 0.025 %, 0.05 % 1
VANOXIDE-HC TOPICAL
SUSPENSION 5-0.5 % 2
zenatane oral capsule 10
mg, 20 mg, 30 mg, 40 mg 1
Topical Anesthetics
ethyl chloride topical
aerosol, spray 100 % 1
glydo mucous membrane
jelly in applicator 2 % 1 QL
lidocaine hcl
laryngotracheal soln 4 % 1
lidocaine hcl mucous
membrane jelly 2 % 1 QL
lidocaine hcl mucous
membrane jelly in
applicator 2 %
1 QL
Drug Name Tier Requirements - Limitations
lidocaine hcl mucous
membrane soln 4 % (40
mg/ml)
1
lidocaine hcl topical lotion
3 % 1
lidocaine hcl-
hydrocortisone ac topical
cream 3-0.5 %
1
lidocaine topical adhesive
patch, medicated 5 % 1
lidocaine topical ointment
5 % 1 QL
lidocaine viscous mucous
membrane soln 2 % 1
lidocaine-prilocaine
topical cream 2.5-2.5 % 1 QL
lidocaine-prilocaine
topical kit 2.5-2.5 % 1
LIDODERM TOPICAL
ADHESIVE
PATCH,MEDICATED 5 %
2
lido-k topical lotion 3 % 1
lta pre-attached
laryngotracheal soln 4 % 1
Topical Antibacterials
ALTABAX TOPICAL
OINTMENT 1 % 2
gentamicin topical cream
0.1 % 1
gentamicin topical
ointment 0.1 % 1
hydrocortisone-
iodoquinol-aloe topical
cream in packet 1.9-1 %
1
lugols topical soln 5-10 % 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
46
Drug Name Tier Requirements - Limitations
mupirocin calcium topical
cream 2 % 1
mupirocin topical
ointment 2 % 1
sulfacetamide sodium
(acne) topical suspension
10 %
1
SULFAMYLON TOPICAL
CREAM 85 MG/G 2
SULFAMYLON TOPICAL
PACKET 50 GRAM 2
Topical Antifungals
ALA-QUIN TOPICAL
CREAM 3-0.5 % 2
ciclodan topical cream
0.77 % 1
ciclodan topical soln 8 % 1
ciclopirox topical cream
0.77 % 1
ciclopirox topical gel 0.77
% 1
ciclopirox topical
shampoo 1 % 1
ciclopirox topical soln 8 % 1
ciclopirox topical
suspension 0.77 % 1
ciclopirox-ure-camph-
menth-euc topical soln 8
%
1
clotrimazole-
betamethasone topical
cream 1-0.05 %
1
clotrimazole-
betamethasone topical
lotion 1-0.05 %
1
Drug Name Tier Requirements - Limitations
econazole topical cream
1 % 1
ERTACZO TOPICAL CREAM
2 % 2
EXELDERM TOPICAL
CREAM 1 % 2
EXELDERM TOPICAL SOLN
1 % 2
ketoconazole topical
cream 2 % 1
ketoconazole topical
foam 2 % 1
ketoconazole topical
shampoo 2 % 1
naftifine topical cream 1
%, 2 % 1
NIZORAL TOPICAL
SHAMPOO 2 % 2
nyamyc topical powder
100,000 unit/gram 1
nyata topical powder
100,000 unit/gram 1
nystatin topical cream
100,000 unit/gram 1
nystatin topical ointment
100,000 unit/gram 1
nystatin topical powder
100,000 unit/gram 1
nystatin-triamcinolone
topical cream 100,000-0.1
unit/g-%
1
nystatin-triamcinolone
topical ointment 100,000-
0.1 unit/gram-%
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
47
Drug Name Tier Requirements - Limitations
nystop topical powder
100,000 unit/gram 1
oxiconazole topical
cream 1 % 1
OXISTAT TOPICAL CREAM
1 % 2
OXISTAT TOPICAL LOTION 1
% 2
TRIACETIN LIQUID 100 % 2
Topical Antivirals
acyclovir topical ointment
5 % 1
DENAVIR TOPICAL CREAM
1 % 2
ZOVIRAX TOPICAL CREAM
5 % 2
ZOVIRAX TOPICAL
OINTMENT 5 % 2
Topical Corticosteroids
ala-cort topical cream 2.5
% 1
ALA-SCALP TOPICAL
LOTION 2 % 2
alclometasone topical
cream 0.05 % 1
alclometasone topical
ointment 0.05 % 1
amcinonide topical
cream 0.1 % 1
amcinonide topical lotion
0.1 % 1
amcinonide topical
ointment 0.1 % 1
apexicon e topical cream
0.05 % 1
Drug Name Tier Requirements - Limitations
betamethasone
dipropionate topical
cream 0.05 %
1
betamethasone
dipropionate topical
lotion 0.05 %
1
betamethasone
dipropionate topical
ointment 0.05 %
1
betamethasone valerate
topical cream 0.1 % 1
betamethasone valerate
topical foam 0.12 % 1
betamethasone valerate
topical lotion 0.1 % 1
betamethasone valerate
topical ointment 0.1 % 1
betamethasone,
augmented topical
cream 0.05 %
1
betamethasone,
augmented topical gel
0.05 %
1
betamethasone,
augmented topical lotion
0.05 %
1
betamethasone,
augmented topical
ointment 0.05 %
1
clobetasol scalp soln 0.05
% 1
clobetasol topical cream
0.05 % 1
clobetasol topical foam
0.05 % 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
48
Drug Name Tier Requirements - Limitations
clobetasol topical gel 0.05
% 1
clobetasol topical lotion
0.05 % 1
clobetasol topical
ointment 0.05 % 1
clobetasol topical
shampoo 0.05 % 1
clobetasol topical spray,
non-aerosol 0.05 % 1
clobetasol-emollient
topical cream 0.05 % 1
clobetasol-emollient
topical foam 0.05 % 1
CLOBEX TOPICAL LOTION
0.05 % 2
CLOBEX TOPICAL
SHAMPOO 0.05 % 2
CLOBEX TOPICAL SPRAY,
NON-AEROSOL 0.05 % 2
clodan topical shampoo
0.05 % 1
CORDRAN TAPE LARGE
ROLL TOPICAL TAPE 4
MCG/CM2
2 QL
CORDRAN TOPICAL
CREAM 0.05 % 2
CORDRAN TOPICAL
LOTION 0.05 % 2
CORDRAN TOPICAL
OINTMENT 0.05 % 2
cormax scalp soln 0.05 % 1
DERMA-SMOOTHE/FS
BODY OIL TOPICAL OIL
0.01 %
2
Drug Name Tier Requirements - Limitations
DERMA-SMOOTHE/FS
SCALP OIL SCALP OIL 0.01
%
2
DESONATE TOPICAL GEL
0.05 % 2
desonide topical cream
0.05 % 1
desonide topical lotion
0.05 % 1
desonide topical ointment
0.05 % 1
desoximetasone topical
cream 0.05 %, 0.25 % 1
desoximetasone topical
gel 0.05 % 1
desoximetasone topical
ointment 0.05 %, 0.25 % 1
diflorasone topical cream
0.05 % 1
diflorasone topical
ointment 0.05 % 1
fluocinolone and shower
cap scalp oil 0.01 % 1
fluocinolone topical
cream 0.01 %, 0.025 % 1
fluocinolone topical oil
0.01 % 1
fluocinolone topical
ointment 0.025 % 1
fluocinolone topical soln
0.01 % 1
fluocinonide topical
cream 0.05 %, 0.1 % 1
fluocinonide topical gel
0.05 % 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
49
Drug Name Tier Requirements - Limitations
fluocinonide topical
ointment 0.05 % 1
fluocinonide topical soln
0.05 % 1
fluocinonide-e topical
cream 0.05 % 1
fluocinonide-emollient
topical cream 0.05 % 1
flurandrenolide topical
cream 0.05 % 1
flurandrenolide topical
lotion 0.05 % 1
flurandrenolide topical
ointment 0.05 % 1
fluticasone topical cream
0.05 % 1
fluticasone topical lotion
0.05 % 1
fluticasone topical
ointment 0.005 % 1
halobetasol propionate
topical cream 0.05 % 1
halobetasol propionate
topical ointment 0.05 % 1
HALOG TOPICAL CREAM
0.1 % 2
HALOG TOPICAL
OINTMENT 0.1 % 2
hydrocortisone butyrate
topical cream 0.1 % 1
hydrocortisone butyrate
topical ointment 0.1 % 1
hydrocortisone butyrate
topical soln 0.1 % 1
Drug Name Tier Requirements - Limitations
hydrocortisone butyr-
emollient topical cream
0.1 %
1
hydrocortisone topical
cream 2.5 % 1
hydrocortisone topical
lotion 2.5 % 1
hydrocortisone topical
ointment 2.5 % 1
hydrocortisone valerate
topical cream 0.2 % 1
hydrocortisone valerate
topical ointment 0.2 % 1
hydrocortisone-min oil-wht
pet topical ointment 1 % 1
KENALOG TOPICAL
AEROSOL 0.147
MG/GRAM
2
LOCOID TOPICAL CREAM
0.1 % 2
LOCOID TOPICAL LOTION
0.1 % 2
LOCOID TOPICAL
OINTMENT 0.1 % 2
LOCOID TOPICAL SOLN 0.1
% 2
LUXIQ TOPICAL FOAM 0.12
% 2
mometasone topical
cream 0.1 % 1
mometasone topical
ointment 0.1 % 1
mometasone topical soln
0.1 % 1
nolix topical lotion 0.05 % 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
50
Drug Name Tier Requirements - Limitations
prednicarbate topical
cream 0.1 % 1
prednicarbate topical
ointment 0.1 % 1
scalacort topical lotion 2% 1
TEXACORT TOPICAL SOLN
2.5 % 2
TOPICORT TOPICAL
CREAM 0.05 %, 0.25 % 2
TOPICORT TOPICAL GEL
0.05 % 2
TOPICORT TOPICAL
OINTMENT 0.05 %, 0.25 % 2
TOPICORT TOPICAL SPRAY,
NON-AEROSOL 0.25 % 2
triamcinolone acetonide
topical aerosol 0.147
mg/gram
1
triamcinolone acetonide
topical cream 0.025 %, 0.1
%, 0.5 %
1
triamcinolone acetonide
topical lotion 0.025%, 0.1% 1
triamcinolone acetonide
topical ointment 0.025 %,
0.1 %, 0.5 %
1
trianex topical ointment
0.05% 1
Topical Enzymes
SANTYL TOPICAL
OINTMENT 250 UNIT/GRAM 2
Topical Scabicides / Pediculicides
EURAX TOPICAL CREAM 10
% 2
Drug Name Tier Requirements - Limitations
lindane topical shampoo
1 % 1
NATROBA TOPICAL
SUSPENSION 0.9 % 2
permethrin topical cream
5 % 1
SKLICE TOPICAL LOTION
0.5 % 2
ULESFIA TOPICAL LOTION 5
% 2
DIAGNOSTICS & MISCELLANEOUS
AGENTS
Anorexiants
benzphetamine oral
tablet 25 mg, 50 mg 1 PA
diethylpropion oral tablet
25 mg 1 PA
diethylpropion oral tablet
extended release 75 mg 1 PA
phendimetrazine tartrate
oral capsule, extended
release 105 mg
1
phendimetrazine tartrate
oral tablet 35 mg 1
phentermine oral capsule
15 mg, 30 mg, 37.5 mg 1 PA
phentermine oral tablet
37.5 mg 1 PA
Miscellaneous Agents
acamprosate oral tablet,
delayed release (dr/ec)
333 mg
1
ACTONEL TABLET 30 MG 2
alendronate tablet 40 mg 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
51
Drug Name Tier Requirements - Limitations
anagrelide oral capsule
0.5 mg, 1 mg 1
ANTABUSE ORAL TABLET
250 MG, 500 MG 2
BUPHENYL ORAL POWDER
0.94 GRAM/GRAM 2
caffeine citrate oral soln
60 mg/3 ml (20 mg/ml) 1
CARBAGLU ORAL TABLET,
DISPERSIBLE 200 MG 2 SP; LA
CARNITOR (SUGAR-FREE)
ORAL SOLN 100 MG/ML 2
CARNITOR ORAL SOLN 100
MG/ML 2
CARNITOR TABLET 330 MG 2
cevimeline oral capsule
30 mg 1
CHEMET ORAL CAPSULE
100 MG 2
disulfiram oral tablet 250
mg, 500 mg 1
etidronate disodium oral
tablet 200 mg, 400 mg 1
EXJADE ORAL TABLET,
DISPERSIBLE 125 MG, 250
MG, 500 MG
2 SP; LA
JADENU ORAL TABLET 180
MG, 360 MG, 90 MG 2 SP
JADENU SPRINKLE ORAL
GRANULES IN PACKET 180
MG, 360 MG, 90 MG
2 SP
levocarnitine (with sugar)
oral soln 100 mg/ml 1
levocarnitine oral tablet
330 mg 1
Drug Name Tier Requirements - Limitations
METOPIRONE ORAL
CAPSULE 250 MG 2
midodrine oral tablet 10
mg, 2.5 mg, 5 mg 1
NITYR ORAL TABLET 10 MG,
2 MG, 5 MG 2 SP
ORFADIN ORAL CAPSULE
10 MG, 2 MG, 5 MG 2 SP; LA
ORFADIN CAPSULE 20 MG 2 SP
ORFADIN ORAL
SUSPENSION 4 MG/ML 2 SP; LA
pilocarpine hcl tablet 5mg 1
RILUTEK TABLET 50 MG 2
riluzole oral tablet 50 mg 1
risedronate tablet 30 mg 1
sodium chloride irrigation
soln 0.9 % 1
sodium phenylbutyrate
oral powder 0.94
gram/gram
1
sodium phenylbutyrate
oral tablet 500 mg 1
Smoking Deterrents
bupropion hcl (smoking
deter) oral tablet
extended release 12 hr
150 mg
$0 QL
CHANTIX CONTINUING
MONTH BOX ORAL TABLET
1 MG
$0 QL
CHANTIX ORAL TABLET 0.5
MG, 1 MG $0 QL
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
52
Drug Name Tier Requirements - Limitations
CHANTIX STARTING
MONTH BOX ORAL
TABLETS, DOSE PACK 0.5
MG (11)- 1 MG (42)
$0 QL
NICODERM CQ
TRANSDERMAL PATCH 24
HOUR 14 MG/24 HR, 21
MG/24 HR, 7 MG/24 HR
$0 QL
nicorelief buccal gum 2
mg, 4 mg $0 QL
NICORETTE BUCCAL GUM
2 MG $0 QL
nicorette buccal gum
4mg $0 QL
NICORETTE BUCCAL
LOZENGE 2 MG, 4 MG $0 QL
NICORETTE BUCCAL MINI
LOZENGE 2 MG, 4 MG $0 QL
nicotine (polacrilex)
buccal gum 2 mg, 4 mg $0 QL
nicotine (polacrilex)
buccal lozenge 2 mg, 4
mg
$0 QL
nicotine (polacrilex)
buccal mini lozenge 2 mg,
4 mg
$0 QL
nicotine transdermal
patch 24 hour 14 mg/24
hr, 21 mg/24 hr, 7 mg/24
hr
$0 QL
nicotine transdermal
patch, td daily, sequential
21-14-7 mg/24 hr
$0 QL
NICOTROL INHALATION
CARTRIDGE 10 MG $0 QL
Drug Name Tier Requirements - Limitations
NICOTROL NS NASAL
SPRAY, NON-AEROSOL 10
MG/ML
$0 QL
nts step 1 transdermal
patch 24 hour 21 mg/24 hr $0 QL
quit 2 buccal gum 2 mg $0 QL
QUIT 2 BUCCAL LOZENGE
2 MG $0 QL
quit 4 buccal gum 4 mg $0 QL
QUIT 4 BUCCAL LOZENGE
4 MG $0 QL
stop smoking aid buccal
lozenge 2 mg, 4 mg $0 QL
EAR, NOSE & THROAT MEDICATIONS
Miscellaneous Agents
ASTEPRO NASAL SPRAY,
NON-AEROSOL 0.15 %
(205.5 MCG)
2
azelastine nasal aerosol,
spray 137 mcg (0.1 %) 1
azelastine nasal spray,
non-aerosol 0.15 % (205.5
mcg)
1
BACTROBAN NASAL
NASAL OINTMENT 2 % 2
chlorhexidine gluconate
mucous membrane
mouthwash 0.12 %
1
DEBACTEROL MUCOUS
MEMBRANE SOLN 30-50 % 2
DEBACTEROL MUCOUS
MEMBRANE SWAB 30-50 % 2
denta 5000 plus dental
cream 1.1 % 1
dentagel dental gel 1.1 % 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
53
Drug Name Tier Requirements - Limitations
fluoride (sodium) dental
soln 0.2 % 1
ipratropium bromide nasal
spray, non-aerosol 0.03 %,
0.06 %
1
MUGARD MUCOUS
MEMBRANE SOLN 2
olopatadine nasal spray,
non-aerosol 0.6 % 1
oralone dental paste 0.1
% 1
paroex oral rinse mucous
membrane mouthwash
0.12 %
1
PERIDEX MUCOUS
MEMBRANE MOUTHWASH
0.12 %
2
periogard mucous
membrane mouthwash
0.12 %
1
pilocarpine hcl oral tablet
7.5 mg 1
PREVIDENT 5000 BOOSTER
PLUS DENTAL PASTE 1.1 % 2
PREVIDENT 5000 DRY
MOUTH DENTAL GEL 1.1 % 2
PREVIDENT 5000 PLUS
DENTAL CREAM 1.1 % 2
PREVIDENT DENTAL GEL 1.1
% 2
PREVIDENT DENTAL SOLN
0.2 % 2
sf 5000 plus dental cream
1.1 % 1
sf dental gel 1.1 % 1
Drug Name Tier Requirements - Limitations
triamcinolone acetonide
dental paste 0.1 % 1
Miscellaneous Otic Preparations
acetic acid otic soln 2 % 1
ciprofloxacin hcl otic (ear)
dropperette 0.2 % 1
fluocinolone acetonide oil
otic (ear) drops 0.01 % 1
hydrocortisone-acetic
acid otic (ear) drops 1-2 % 1
Otic Steroid / Antibiotic
CIPRO HC OTIC DROPS,
SUSPENSION 0.2-1 % 2
CIPRODEX OTIC DROPS,
SUSPENSION 0.3-0.1 % 2
neomycin-polymyxin-hc
otic (ear) drops,
suspension 3.5-10,000-1
mg/ml-unit/ml-%
1
neomycin-polymyxin-hc
otic (ear) soln 3.5-10,000-1
mg/ml-unit/ml-%
1
ENDOCRINE/DIABETES
Adrenal Hormones
cortisone tablet 25 mg 1
CORTROSYN INJECTION
RECON SOLN 0.25 MG 2
cosyntropin injection
recon soln 0.25 mg 1
deltasone oral tablet 20
mg 1
dexamethasone intensol
oral drops 1 mg/ml 1
dexamethasone oral elixir
0.5 mg/5 ml 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
54
Drug Name Tier Requirements - Limitations
dexamethasone oral soln
0.5 mg/5 ml 1
dexamethasone oral
tablet 0.5 mg, 0.75 mg, 1
mg, 1.5 mg, 2 mg, 4 mg, 6
mg
1
DEXPAK 10 DAY ORAL
TABLETS, DOSE PACK 1.5
MG (35 TABS)
2
DEXPAK 13 DAY ORAL
TABLETS, DOSE PACK 1.5
MG (51 TABS)
2
DEXPAK 6 DAY ORAL
TABLETS, DOSE PACK 1.5
MG (21 TABS)
2
fludrocortisone oral tablet
0.1 mg 1
hydrocortisone oral tablet
10 mg, 20 mg, 5 mg 1
MEDROL ORAL TABLET 2
MG 2
methylprednisolone oral
tablet 16 mg, 32 mg, 4
mg, 8 mg
1
methylprednisolone oral
tablets, dose pack 4 mg 1
millipred dp oral tablets,
dose pack 5 mg (21 tabs),
5 mg (48 tabs)
1
millipred oral tablet 5 mg 1
ORAPRED ODT ORAL
TABLET, DISINTEGRATING
10 MG, 15 MG, 30 MG
2
prednisolone oral soln 15
mg/5 ml 1
Drug Name Tier Requirements - Limitations
prednisolone sodium
phosphate oral soln 10
mg/5 ml, 15 mg/5 ml (3
mg/ml), 20 mg/5 ml (4
mg/ml), 25 mg/5 ml (5
mg/ml), 5 mg base/5 ml
(6.7 mg/5 ml)
1
prednisolone sodium
phosphate oral tablet,
disintegrating 10 mg, 15
mg, 30 mg
1
prednisone intensol oral
concentrate 5 mg/ml 1
prednisone oral soln 5
mg/5 ml 1
prednisone oral tablet 1
mg, 10 mg, 2.5 mg, 20 mg,
5 mg, 50 mg
1
prednisone oral tablets,
dose pack 10 mg, 5 mg 1
veripred 20 oral soln 20
mg/5 ml (4 mg/ml) 1
Antithyroid Agents
methimazole oral tablet
10 mg, 5 mg 1
propylthiouracil oral tablet
50 mg 1
SSKI ORAL SOLN 1
GRAM/ML 2
Blood Glucose Monitoring Devices &
Supplies
BREEZE 2 TEST STRIPS STRIP $0 QL
CONTOUR NEXT STRIPS
STRIP $0 QL
CONTOUR TEST STRIPS STRIP $0 QL
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
55
Drug Name Tier Requirements - Limitations
Diabetes, Supplies, & Durable Medical
Equipment
AEROCHAMBER MINI
SPACER 2
AEROCHAMBER PLUS
FLOW-VU SPACER 2
AEROCHAMBER PLUS Z
STAT SM MSK SPACER 2
GLUCAGEN DIAGNOSTIC
KIT INJECTION RECON
SOLN 1 MG/ML
2
INSULIN SYRINGE-NEEDLE
U-100 SYRINGE 0.5 ML 29
GAUGE X 1/2"
$0
Glucose Elevating Agents
GLUCAGEN HYPOKIT
INJECTION RECON SOLN 1
MG
2
GLUCAGON EMERGENCY
KIT (HUMAN) INJECTION KIT
1 MG
2
Insulin Syringes/Miscellaneous
Durable Medical Equipment
CONTOUR NEXT EZ METER 2
CONTOUR NEXT METER 2
LANCETS 33 GAUGE $0
LANCING DEVICE $0
PEN NEEDLE 31 GAUGE X
1/4" $0
TRUE METRIX AIR GLUCOSE
METER 2 QL
TRUE METRIX GLUCOSE
METER 2 QL
TRUE METRIX GO GLUCOSE
METER 2 QL
Drug Name Tier Requirements - Limitations
TRUE2GO BLOOD
GLUCOSE SYSTEM KIT 2
Insulin Therapy
APIDRA SOLOSTAR
SUBCUTANEOUS INSULIN
PEN 100 UNIT/ML
2
APIDRA SUBCUTANEOUS
SOLN 100 UNIT/ML $0
HUMALOG MIX 50-50
SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
(50-50)
$0
HUMALOG MIX 75-25
SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
(75-25)
$0
HUMALOG
SUBCUTANEOUS SOLN 100
UNIT/ML
$0
HUMULIN 70/30
SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
(70-30)
$0
HUMULIN N
SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
$0
HUMULIN R U-100
INJECTION SOLN 100
UNIT/ML
$0
HUMULIN R U-500
(CONCENTRATED)
SUBCUTANEOUS SOLN 500
UNIT/ML
$0
LANTUS SOLOSTAR
SUBCUTANEOUS INSULIN
PEN 100 UNIT/ML (3 ML)
2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
56
Drug Name Tier Requirements - Limitations
LANTUS SUBCUTANEOUS
SOLN 100 UNIT/ML $0
LEVEMIR FLEXTOUCH
SUBCUTANEOUS INSULIN
PEN 100 UNIT/ML (3 ML)
2
LEVEMIR SUBCUTANEOUS
SOLN 100 UNIT/ML $0
NOVOLOG FLEXPEN
SUBCUTANEOUS INSULIN
PEN 100 UNIT/ML
2
NOVOLOG MIX 70-30
FLEXPEN SUBCUTANEOUS
INSULIN PEN 100 UNIT/ML
(70-30)
2
NOVOLOG MIX 70-30
SUBCUTANEOUS SOLN 100
UNIT/ML (70-30)
$0
NOVOLOG PENFILL
SUBCUTANEOUS
CARTRIDGE 100 UNIT/ML
2
NOVOLOG
SUBCUTANEOUS SOLN 100
UNIT/ML
$0
RELION NOVOLIN R
INJECTION SOLN 100
UNIT/ML
$0
XULTOPHY 100/3.6
SUBCUTANEOUS INSULIN
PEN 100 UNIT-3.6 MG /ML
(3 ML)
2 QL
Miscellaneous Hormones
ANADROL-50 ORAL TABLET
50 MG 2
ANDROGEL TRANSDERMAL
GEL IN METERED-DOSE
PUMP 20.25 MG/1.25
GRAM (1.62 %)
2 PA
Drug Name Tier Requirements - Limitations
ANDROGEL TRANSDERMAL
GEL IN PACKET 1 % (25
MG/2.5GRAM), 1 % (50
MG/5 GRAM), 1.62 %
(20.25 MG/1.25 GRAM),
1.62 % (40.5 MG/2.5
GRAM)
2 PA
ANDROID ORAL CAPSULE
10 MG 2
cabergoline oral tablet 0.5
mg 1 QL
calcitonin (salmon) nasal
spray, non-aerosol 200
unit/actuation
1
calcitriol intravenous soln 1
mcg/ml 1
calcitriol oral capsule 0.25
mcg, 0.5 mcg 1
calcitriol oral soln 1
mcg/ml 1
CERDELGA ORAL CAPSULE
84 MG 2 PA; SP
clomiphene citrate oral
tablet 50 mg 1
danazol oral capsule 100
mg, 200 mg, 50 mg 1
DEPO-TESTOSTERONE
INTRAMUSCULAR OIL 100
MG/ML, 200 MG/ML
2 PA
desmopressin nasal soln
0.1 mg/ml (refrigerate) 1
desmopressin nasal spray,
non-aerosol 10 mcg/spray
(0.1 ml)
1
desmopressin oral tablet
0.1 mg, 0.2 mg 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
57
Drug Name Tier Requirements - Limitations
doxercalciferol oral
capsule 0.5 mcg, 1 mcg,
2.5 mcg
1
KORLYM TABLET 300 MG 2 PA; SP
KUVAN ORAL POWDER IN
PACKET 500 MG 2 PA; SP
KUVAN ORAL
TABLET,SOLUBLE 100 MG 2 PA; SP
METHITEST TABLET 10 MG 2
methyltestosterone oral
capsule 10 mg 1
oxandrolone oral tablet 10
mg, 2.5 mg 1
paricalcitol oral capsule 1
mcg, 2 mcg, 4 mcg 1 PA
SAMSCA ORAL TABLET 15
MG, 30 MG 2 SP
SENSIPAR ORAL TABLET 30
MG, 60 MG, 90 MG 2
SYNAREL NASAL SPRAY,
NON-AEROSOL 2 MG/ML 2
testosterone cypionate
intramuscular oil 100
mg/ml, 200 mg/ml
1 PA
testosterone enanthate
intramuscular oil 200
mg/ml
1 PA
TESTRED CAPSULE 10 MG 2
ZAVESCA ORAL CAPSULE
100 MG 2 PA; SP; LA
Non-Insulin Hypoglycemic Agents
acarbose oral tablet 100
mg, 25 mg, 50 mg 1
ACTOPLUS MET TABLET 15-
500 MG, 15-850 MG 2
Drug Name Tier Requirements - Limitations
ACTOPLUS MET XR TABLET,
ER MULTIPHASE 24 HR 15-
1,000 MG, 30-1,000 MG
2
ACTOS ORAL TABLET 15
MG, 30 MG, 45 MG 2 QL
BYDUREON
SUBCUTANEOUS PEN
INJECTOR 2 MG/0.65 ML
2
BYDUREON
SUBCUTANEOUS
SUSPENSION, EXTENDED
REL RECON 2 MG
2
BYETTA SUBCUTANEOUS
PEN INJECTOR 10
MCG/DOSE(250 MCG/ML)
2.4 ML, 5 MCG/DOSE (250
MCG/ML) 1.2 ML
2
chlorpropamide oral
tablet 100 mg, 250 mg 1
CYCLOSET ORAL TABLET
0.8 MG 2
glimepiride oral tablet 1
mg, 2 mg, 4 mg 1
glipizide oral tablet 10 mg,
5 mg 1
glipizide oral tablet
extended release 24hr 10
mg, 2.5 mg, 5 mg
1
glipizide-metformin oral
tablet 2.5-250 mg, 2.5-500
mg, 5-500 mg
1
glyburide micronized oral
tablet 1.5 mg, 3 mg, 6 mg 1
glyburide oral tablet 1.25
mg, 2.5 mg, 5 mg 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
58
Drug Name Tier Requirements - Limitations
glyburide-metformin oral
tablet 1.25-250 mg, 2.5-
500 mg, 5-500 mg
1
INVOKAMET ORAL TABLET
150-1,000 MG, 150-500
MG, 50-1,000 MG, 50-500
MG
2
INVOKAMET XR ORAL
TABLET, IR - ER, BIPHASIC
24HR 150-1,000 MG, 150-
500 MG, 50-1,000 MG, 50-
500 MG
2
INVOKANA ORAL TABLET
100 MG, 300 MG 2
JANUMET ORAL TABLET 50-
1,000 MG, 50-500 MG 2 ST
JANUMET XR ORAL TABLET,
ER MULTIPHASE 24 HR 100-
1,000 MG, 50-1,000 MG,
50-500 MG
2 ST
JANUVIA ORAL TABLET 100
MG, 25 MG, 50 MG 2 ST
JARDIANCE ORAL TABLET
10 MG, 25 MG 2
JENTADUETO ORAL TABLET
2.5-1,000 MG, 2.5-500 MG,
2.5-850 MG
2 ST
KOMBIGLYZE XR ORAL
TABLET, ER MULTIPHASE 24
HR 2.5-1,000 MG, 5-1,000
MG, 5-500 MG
2 ST
metformin oral tablet
1,000 mg, 500 mg, 850 mg 1
metformin oral tablet
extended release 24 hr
500 mg, 750 mg
1
Drug Name Tier Requirements - Limitations
metformin oral tablet
extended release 24hr
1,000 mg, 500 mg
1
metformin oral tablet, er
gast. retention 24 hr 1,000
mg, 500 mg
1
miglitol oral tablet 100 mg,
25 mg, 50 mg 1
nateglinide oral tablet 120
mg, 60 mg 1
ONGLYZA ORAL TABLET 2.5
MG, 5 MG 2 PA; ST
pioglitazone oral tablet 15
mg, 30 mg, 45 mg 1 QL
pioglitazone-glimepiride
tablet 30-2 mg, 30-4 mg 1
pioglitazone-metformin
oral tablet 15-500 mg, 15-
850 mg
1
PRANDIN ORAL TABLET 1
MG, 2 MG 2
repaglinide oral tablet 0.5
mg, 1 mg, 2 mg 1
repaglinide-metformin
tablet 1-500 mg, 2-500 mg 1
RIOMET ORAL SOLN 500
MG/5 ML 2
SYMLINPEN 120 PEN
INJECTOR 2,700 MCG/2.7
ML
2 PA
SYMLINPEN 60 PEN
INJECTOR 1,500 MCG/1.5
ML
2 PA
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
59
Drug Name Tier Requirements - Limitations
SYNJARDY ORAL TABLET
12.5-1,000 MG, 12.5-500
MG, 5-1,000 MG, 5-500
MG
2
TANZEUM SUBCUTANEOUS
PEN INJECTOR 30 MG/0.5
ML, 50 MG/0.5 ML
2
tolazamide oral tablet 250
mg, 500 mg 1
tolbutamide oral tablet
500 mg 1
TRADJENTA TABLET 5 MG 2 ST
VICTOZA 2-PAK
SUBCUTANEOUS PEN
INJECTOR 0.6 MG/0.1 ML
(18 MG/3 ML)
2 PA; QL
VICTOZA 3-PAK
SUBCUTANEOUS PEN
INJECTOR 0.6 MG/0.1 ML
(18 MG/3 ML)
2 PA; QL
Thyroid Hormones
ARMOUR THYROID ORAL
TABLET 120 MG, 15 MG,
180 MG, 240 MG, 30 MG,
300 MG, 60 MG, 90 MG
2
levothyroxine oral tablet
100 mcg, 112 mcg, 125
mcg, 137 mcg, 150 mcg,
175 mcg, 200 mcg, 25
mcg, 300 mcg, 50 mcg, 75
mcg, 88 mcg
1
levoxyl oral tablet 100
mcg, 112 mcg, 125 mcg,
137 mcg, 150 mcg, 175
mcg, 200 mcg, 25 mcg, 50
mcg, 75 mcg, 88 mcg
1
liothyronine oral tablet 25
mcg, 5 mcg, 50 mcg 1
Drug Name Tier Requirements - Limitations
nature-throid oral tablet
113.75 mg, 130 mg, 146.25
mg, 16.25 mg, 162.5 mg,
195 mg, 260 mg, 32.5 mg,
325 mg, 48.75 mg, 65 mg,
81.25 mg, 97.5 mg
1
np thyroid oral tablet 120
mg, 15 mg, 30 mg, 60 mg,
90 mg
1
SYNTHROID ORAL TABLET
100 MCG, 112 MCG, 125
MCG, 137 MCG, 150
MCG, 175 MCG, 200
MCG, 25 MCG, 300 MCG,
50 MCG, 75 MCG, 88
MCG
2
thyroid (pork) oral tablet
30 mg, 60 mg, 90 mg 1
unithroid oral tablet 100
mcg, 112 mcg, 125 mcg,
137 mcg, 150 mcg, 175
mcg, 200 mcg, 25 mcg,
300 mcg, 50 mcg, 75 mcg,
88 mcg
1
westhroid oral tablet 130
mg, 195 mg, 32.5 mg, 65
mg, 97.5 mg
1
WP THYROID ORAL TABLET
113.75 MG, 16.25 MG,
48.75 MG, 97.5 MG
2
GASTROENTEROLOGY
Antidiarrheals & Antispasmodics
anaspaz oral tablet,
disintegrating 0.125 mg 1
belladonna alkaloids-
opium rectal suppository
16.2-60 mg
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
60
Drug Name Tier Requirements - Limitations
belladonna-opium rectal
suppository 16.2-30 mg 1
chlordiazepoxide-
clidinium oral capsule 5-
2.5 mg
1
dicyclomine oral capsule
10 mg 1
dicyclomine soln 10 mg/5
ml 1
dicyclomine tablet 20 mg 1
diphenoxylate-atropine
oral liquid 2.5-0.025 mg/5
ml
1
diphenoxylate-atropine
oral tablet 2.5-0.025 mg 1
ed-spaz oral tablet,
disintegrating 0.125 mg 1
glycopyrrolate oral tablet
1 mg, 2 mg 1
hyoscyamine sulfate oral
drops 0.125 mg/ml 1
hyoscyamine sulfate oral
elixir 0.125 mg/5 ml 1
hyoscyamine sulfate oral
tablet 0.125 mg 1
hyoscyamine sulfate oral
tablet extended release
12 hr 0.375 mg
1
hyoscyamine sulfate oral
tablet, disintegrating 0.125
mg
1
hyoscyamine sulfate
sublingual tablet 0.125 mg 1
hyosyne oral drops 0.125
mg/ml 1
Drug Name Tier Requirements - Limitations
hyosyne oral elixir 0.125
mg/5 ml 1
LEVSIN/SL SUBLINGUAL
TABLET 0.125 MG 2
methscopolamine oral
tablet 2.5 mg, 5 mg 1
oscimin tablet 0.125 mg 1
oscimin oral tablet,
disintegrating 0.125 mg 1
oscimin sl sublingual tablet
0.125 mg 1
oscimin sr oral tablet
extended release 12 hr
0.375 mg
1
paregoric oral liquid 2
mg/5 ml 1
phenohytro oral tablet
16.2-0.1037 -0.0194 mg 1
propantheline oral tablet
15 mg 1
ROBINUL FORTE ORAL
TABLET 2 MG 2
symax fastabs oral tablet,
disintegrating 0.125 mg 1
symax-sl sublingual tablet
0.125 mg 1
symax-sr oral tablet
extended release 12 hr
0.375 mg
1
Miscellaneous Gastrointestinal Agents
ACTIGALL ORAL CAPSULE
300 MG 2
alophen oral tablet, del-
rel (dr/ec) 5 mg $0
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
61
Drug Name Tier Requirements - Limitations
AMITIZA ORAL CAPSULE 24
MCG, 8 MCG 2 PA
ANALPRAM-HC RECTAL
CREAM 1-1 %, 2.5-1 % 2
ANALPRAM-HC SINGLES
RECTAL CREAM 2.5-1 %
(4G)
2
ANUSOL-HC TOPICAL
CREAM WITH PERINEAL
APPLICATOR 2.5 %
2
aprepitant oral capsule
125 mg, 40 mg, 80 mg 1 QL
aprepitant oral capsule,
dose pack 125 mg (1)- 80
mg (2)
1 QL
APRISO ORAL CAPSULE,
EXTENDED RELEASE 24HR
0.375 GRAM
2
balsalazide oral capsule
750 mg 1
bisacodyl oral tablet, del-
rel (dr/ec) 5 mg $0
bisa-lax oral tablet, del-rel
(dr/ec) 5 mg $0
budesonide oral capsule,
delayed, ext-rel 3 mg 1
calcium acetate oral
capsule 667 mg 1
calcium acetate oral
tablet 667 mg 1
CALCIUM ACETATE ORAL
TABLET 668 MG (169 MG
CALCIUM)
1
CANASA RECTAL
SUPPOSITORY 1,000 MG 2
Drug Name Tier Requirements - Limitations
CHENODAL ORAL TABLET
250 MG 2 PA; SP; LA
citrate of magnesia oral
soln $0
citroma oral soln $0
clearlax oral powder 17
gram/dose $0
colocort rectal enema
100 mg/60 ml 1
compro rectal suppository
25 mg 1
constulose oral soln 10
gram/15 ml 1
CORTENEMA RECTAL
ENEMA 100 MG/60 ML 2
CORTIFOAM RECTAL
FOAM 10 % (80 MG) 2
CREON ORAL CAPSULE,
DELAYED RELEASE(DR/EC)
12,000-38,000 -60,000 UNIT,
24,000-76,000 -120,000
UNIT, 3,000-9,500- 15,000
UNIT, 36,000-114,000-
180,000 UNIT, 6,000-19,000
-30,000 UNIT
2
cromolyn oral
concentrate 100 mg/5 ml 1
DELZICOL ORAL CAPSULE
(WITH DEL REL TABLETS) 400
MG
2
DIPENTUM ORAL CAPSULE
250 MG 2
dronabinol oral capsule
10 mg, 2.5 mg, 5 mg 1
ducodyl oral tablet, del-rel
(dr/ec) 5 mg $0
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
62
Drug Name Tier Requirements - Limitations
eliphos oral tablet 667 mg 1
EMEND ORAL CAPSULE
125 MG, 40 MG, 80 MG 2 QL
EMEND ORAL
CAPSULE,DOSE PACK 125
MG (1)- 80 MG (2)
2 QL
ENTOCORT EC ORAL
CAPSULE, DELAYED,
EXTEND.RELEASE 3 MG
2
enulose oral soln 10
gram/15 ml 1
fleet laxative oral tablet,
del-rel (dr/ec) 5 mg $0
FOSRENOL ORAL TABLET,
CHEWABLE 500 MG, 750
MG
2
gavilyte-c oral recon soln
240-22.72-6.72 -5.84 gram $0
gavilyte-g oral recon soln
236-22.74-6.74 -5.86 gram $0
gavilyte-n oral recon soln
420 gram $0
generlac oral soln 10
gram/15 ml 1
gentle laxative oral tablet,
del-rel (dr/ec) 5 mg $0
GOLYTELY ORAL POWDER
IN PACKET 227.1-21.5-6.36
GRAM
2
GOLYTELY ORAL RECON
SOLN 236-22.74-6.74 -5.86
GRAM
2
granisetron hcl oral tablet
1 mg 1 QL
hemmorex-hc rectal
suppository 25 mg, 30 mg 1
Drug Name Tier Requirements - Limitations
hydrocortisone rectal
enema 100 mg/60 ml 1
hydrocortisone topical
cream with perineal
applicator 1 %, 2.5 %
1
hydrocortisone-pramoxine
rectal cream 2.5-1 % 1
kionex (with sorbitol) oral
suspension 15-19.3
gram/60 ml
1
kionex oral powder 1
KRISTALOSE ORAL PACKET
10 GRAM, 20 GRAM 2
lactulose oral soln 10
gram/15 ml 1
lanthanum oral tablet,
chewable 1,000 mg, 500
mg, 750 mg
1
laxaclear oral powder 17
gram/dose $0
laxative (bisacodyl) oral
tablet 5 mg $0
laxative (bisacodyl) oral
tablet, delayed release
(dr/ec) 5 mg
$0
laxative feminine oral
tablet 5 mg $0
LIALDA ORAL TABLET,
DELAYED RELEASE (DR/EC)
1.2 GRAM
2
lidocaine hcl-
hydrocortisone ac rectal
cream 3-0.5 %
1
lidocaine hcl-
hydrocortisone ac rectal
kit 3-0.5 %, 3-1 % (7 gram)
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
63
Drug Name Tier Requirements - Limitations
lidocaine-hydrocortisone-
aloe rectal gel 2.8-0.55 % 1
lidocaine-hydrocortisone-
aloe rectal kit 2-2 %, 3-2.5
% (7 gram)
1
LINZESS ORAL CAPSULE 145
MCG, 290 MCG, 72 MCG 2 PA
magnesium citrate oral
soln $0
mesalamine oral tablet,
delayed release (dr/ec)
1.2 gram
1
mesalamine rectal enema
4 gram/60 ml 1
metoclopramide hcl oral
soln 5 mg/5 ml 1
metoclopramide hcl oral
tablet 10 mg, 5 mg 1
metoclopramide hcl oral
tablet, disintegrating 10
mg, 5 mg
1
milk of magnesia
concentrated oral
suspension 2,400 mg/10 ml
$0
milk of magnesia oral
suspension 400 mg/5 ml $0
MOVIPREP ORAL POWDER
IN PACKET 100-7.5-2.691
GRAM
2
NULYTELY WITH FLAVOR
PACKS ORAL RECON SOLN
420 GRAM
2
ondansetron hcl oral soln
4 mg/5 ml 1
ondansetron hcl oral
tablet 24 mg, 4 mg, 8 mg 1
Drug Name Tier Requirements - Limitations
ondansetron oral tablet,
disintegrating 4 mg, 8 mg 1
oral saline laxative oral
liquid 7.2-2.7 gram/15 ml $0
peg 3350-electrolytes oral
recon soln 236-22.74-6.74 -
5.86 gram, 240-22.72-6.72 -
5.84 gram
$0
peg3350 oral powder 17
gram/dose $0
peg-electrolyte soln oral
recon soln 420 gram $0
peg-prep oral kit 5-210
mg-gram $0
PENTASA ORAL CAPSULE,
EXTENDED RELEASE 250
MG, 500 MG
2
PHOSLYRA ORAL SOLN 667
MG (169 MG CALCIUM)/5
ML
2
phosphate laxative oral
liquid 7.2-2.7 gram/15 ml $0
polyethylene glycol 3350
oral powder 17
gram/dose
$0
polyethylene glycol 3350
oral powder in packet 17
gram
$0
pramcort rectal cream 1-1
% 1
prochlorperazine maleate
oral tablet 10 mg, 5 mg 1
prochlorperazine rectal
suppository 25 mg 1
PROCTOFOAM HC RECTAL
FOAM 1-1 % 2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
64
Drug Name Tier Requirements - Limitations
procto-med hc topical
cream with perineal
applicator 2.5 %
1
proctosol hc topical
cream with perineal
applicator 2.5 %
1
proctozone-hc topical
cream with perineal
applicator 2.5 %
1
RECTIV RECTAL OINTMENT
0.4 % (W/W) 2
RENAGEL ORAL TABLET 400
MG, 800 MG 2
RENVELA ORAL POWDER
IN PACKET 0.8 GRAM, 2.4
GRAM
2
RENVELA ORAL TABLET 800
MG 2
ROWASA RECTAL ENEMA
KIT 4 GRAM/60 ML 2
scopolamine base
transdermal patch 3 day 1
mg over 3 days
1
sevelamer carbonate oral
tablet 800 mg 1
SFROWASA RECTAL
ENEMA 4 GRAM/60 ML 2
sodium polystyrene
sulfonate oral powder 1
sodium polystyrene
sulfonate oral suspension
15 gram/60 ml
1
sodium polystyrene
sulfonate rectal enema 30
gram/120 ml
1
Drug Name Tier Requirements - Limitations
sps (with sorbitol) oral
suspension 15-20 gram/60
ml
1
sps (with sorbitol) rectal
enema 30-40 gram/120 ml 1
SUCRAID ORAL SOLN 8,500
UNIT/ML 2 PA; SP
sulfasalazine oral tablet
500 mg 1
sulfasalazine oral tablet,
delayed release (dr/ec)
500 mg
1
SUPREP BOWEL PREP KIT
ORAL RECON SOLN 17.5-
3.13-1.6 GRAM
2
TRANSDERM-SCOP
TRANSDERMAL PATCH 3
DAY 1 MG OVER 3 DAYS
2
trilyte with flavor packets
oral recon soln 420 gram $0
trimethobenzamide oral
capsule 300 mg 1
UCERIS ORAL TABLET,
DELAYED AND EXT.RELEASE
9 MG
2 ST
UCERIS RECTAL FOAM 2
MG/ACTUATION 2
ursodiol capsule 300 mg 1
ursodiol oral tablet 250
mg, 500 mg 1
VIBERZI ORAL TABLET 100
MG, 75 MG 2
woman's laxative tablet,
del-rel (dr/ec) 5 mg $0
women's laxative
(bisacodyl) tablet 5 mg $0
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
65
Drug Name Tier Requirements - Limitations
ZENPEP ORAL CAPSULE,
DELAYED RELEASE(DR/EC)
10,000-34,000 -55,000 UNIT,
15,000-51,000 -82,000 UNIT,
20,000-68,000 -109,000
UNIT, 25,000-85,000-
136,000 UNIT, 3,000-10,000-
16,000 UNIT, 40,000-
136,000- 218,000 UNIT,
5,000-17,000 -27,000 UNIT
2
Ulcer Therapy
amoxicil-clarithromy-
lansopraz oral combo
pack 500-500-30 mg
1 QL
CARAFATE ORAL TABLET 1
GRAM 2
cimetidine hcl oral soln
300 mg/5 ml 1
cimetidine oral tablet 300
mg, 400 mg, 800 mg 1
esomeprazole magnesium
oral capsule, delayed
release(dr/ec) 40 mg
1 QL
famotidine oral suspension
40 mg/5 ml (8 mg/ml) 1
famotidine oral tablet 40
mg 1
lansoprazole oral capsule,
delayed release(dr/ec) 30
mg
1
misoprostol oral tablet 100
mcg, 200 mcg 1
nizatidine oral capsule 150
mg, 300 mg 1
nizatidine oral soln 150
mg/10 ml 1
Drug Name Tier Requirements - Limitations
omeprazole oral capsule,
del-rel(dr/ec) 10 mg, 20
mg, 40 mg
1
pantoprazole oral tablet,
delayed release (dr/ec)
20 mg, 40 mg
1
PYLERA ORAL CAPSULE
140-125-125 MG 2
rabeprazole oral tablet,
delayed release (dr/ec)
20 mg
1
ranitidine hcl oral capsule
300 mg 1
ranitidine hcl oral syrup 15
mg/ml 1
ranitidine hcl oral tablet
300 mg 1
sucralfate oral tablet 1
gram 1
IMMUNOLOGY, VACCINES &
BIOTECHNOLOGY
Growth Hormones
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE
0.2 MG/0.25 ML, 0.4
MG/0.25 ML, 0.6 MG/0.25
ML, 0.8 MG/0.25 ML, 1
MG/0.25 ML, 1.2 MG/0.25
ML, 1.4 MG/0.25 ML, 1.6
MG/0.25 ML, 1.8 MG/0.25
ML, 2 MG/0.25 ML
2 PA; SP
GENOTROPIN
SUBCUTANEOUS
CARTRIDGE 12 MG/ML (36
UNIT/ML), 5 MG/ML (15
UNIT/ML)
2 PA; SP
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
66
Drug Name Tier Requirements - Limitations
NORDITROPIN FLEXPRO
SUBCUTANEOUS PEN
INJECTOR 10 MG/1.5 ML
(6.7 MG/ML), 15 MG/1.5
ML (10 MG/ML), 30 MG/3
ML (10 MG/ML), 5 MG/1.5
ML (3.3 MG/ML)
2 PA; SP
Interferons
AUBAGIO ORAL TABLET 14
MG, 7 MG 2 PA; SP
AVONEX (WITH ALBUMIN)
INTRAMUSCULAR KIT 30
MCG
1 PA; SP; QL
AVONEX INTRAMUSCULAR
PEN INJECTOR KIT 30
MCG/0.5 ML
2 PA; SP
BETASERON
SUBCUTANEOUS KIT 0.3 MG 2 PA; SP; QL
COPAXONE
SUBCUTANEOUS SYRINGE
20 MG/ML
2 PA; SP; QL
GILENYA ORAL CAPSULE
0.5 MG 2 PA; SP
moderiba dose pack oral
tablets, dose pack 200 mg
(28)- 400 mg (28), 400-400
mg (28)-mg (28), 600-400
mg (28)-mg (28), 600-600
mg (28)-mg (28)
1
moderiba oral tablet 200
mg 1
PEGASYS PROCLICK
SUBCUTANEOUS PEN
INJECTOR 135 MCG/0.5
ML, 180 MCG/0.5 ML
2 SP
PEGASYS SUBCUTANEOUS
SOLN 180 MCG/ML 2 SP
Drug Name Tier Requirements - Limitations
PEGASYS SUBCUTANEOUS
SYRINGE 180 MCG/0.5 ML 2 SP
PEGINTRON
SUBCUTANEOUS KIT 50
MCG/0.5 ML
2 SP
REBIF (WITH ALBUMIN)
SUBCUTANEOUS SYRINGE
22 MCG/0.5 ML, 44
MCG/0.5 ML
2 PA; SP
REBIF REBIDOSE
SUBCUTANEOUS PEN
INJECTOR 22 MCG/0.5 ML,
44 MCG/0.5 ML,
8.8MCG/0.2ML-22
MCG/0.5ML (6)
2 PA; SP
REBIF TITRATION PACK
SUBCUTANEOUS SYRINGE
8.8MCG/0.2ML-22
MCG/0.5ML (6)
2 PA; SP
ribasphere oral capsule
200 mg 1
ribasphere oral tablet 200
mg, 400 mg, 600 mg 1
ribavirin oral capsule 200
mg 1
ribavirin oral tablet 200 mg 1
Interleukins
ACTIMMUNE
SUBCUTANEOUS SOLN 100
MCG/0.5 ML
2 PA; SP
ARCALYST SUBCUTANEOUS
RECON SOLN 220 MG 2 PA; SP
imiquimod topical cream
in packet 5 % 1 QL
ZYCLARA TOPICAL CREAM
IN METERED-DOSE PUMP
2.5 %, 3.75 %
2 QL
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
67
Drug Name Tier Requirements - Limitations
ZYCLARA TOPICAL CREAM
IN PACKET 3.75 % 2 QL
Vaccines & Miscellaneous
Immunologicals
GRASTEK SUBLINGUAL
TABLET 2,800 BAU 2 PA
RAGWITEK SUBLINGUAL
TABLET 12 AMB A 1 UNIT 2 PA
MUSCULOSKELETAL & RHEUMATOLOGY
Gout Therapy
allopurinol oral tablet 100
mg, 300 mg 1
MITIGARE ORAL CAPSULE
0.6 MG 2
probenecid oral tablet
500 mg 1
probenecid-colchicine
oral tablet 500-0.5 mg 1
ULORIC ORAL TABLET 40
MG, 80 MG 2 ST
Osteoporosis Therapy
ACTONEL ORAL TABLET
150 MG, 35 MG, 5 MG 2
alendronate oral soln 70
mg/75 ml 1
alendronate oral tablet 10
mg, 5 mg 1 QL
alendronate oral tablet 35
mg, 70 mg 1
FORTEO SUBCUTANEOUS
PEN INJECTOR 20
MCG/DOSE - 600
MCG/2.4 ML
2 PA; SP
ibandronate oral tablet
150 mg 1
Drug Name Tier Requirements - Limitations
raloxifene oral tablet 60
mg $0
risedronate oral tablet 150
mg, 35 mg, 5 mg 1
risedronate oral tablet,
delayed release (dr/ec)
35 mg
1
TYMLOS SUBCUTANEOUS
PEN INJECTOR 80 MCG
(3,120 MCG/1.56 ML)
2 PA; SP; QL
Other Rheumatologicals
CUPRIMINE ORAL CAPSULE
250 MG 2
DEPEN TITRATABS ORAL
TABLET 250 MG 2
ENBREL SUBCUTANEOUS
RECON SOLN 25 MG (1
ML)
2 PA; SP
ENBREL SUBCUTANEOUS
SYRINGE 25 MG/0.5ML
(0.51), 50 MG/ML (0.98 ML)
2 PA; SP
ENBREL SURECLICK
SUBCUTANEOUS PEN
INJECTOR 50 MG/ML (0.98
ML)
2 PA; SP
HUMIRA PEDIATRIC
CROHN'S START
SUBCUTANEOUS SYRINGE
KIT 40 MG/0.8 ML
2 PA; SP; QL
HUMIRA PEN CROHN'S-UC-
HS START SUBCUTANEOUS
PEN INJECTOR KIT 40
MG/0.8 ML
2 PA; SP; QL
HUMIRA PEN
SUBCUTANEOUS PEN
INJECTOR KIT 40 MG/0.8
ML
2 PA; SP; QL
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
68
Drug Name Tier Requirements - Limitations
HUMIRA SUBCUTANEOUS
SYRINGE KIT 10 MG/0.2 ML,
20 MG/0.4 ML, 40 MG/0.8
ML
2 PA; SP; QL
leflunomide oral tablet 10
mg, 20 mg 1 QL
RIDAURA ORAL CAPSULE 3
MG 2
SAVELLA ORAL TABLET 100
MG, 12.5 MG, 25 MG, 50
MG
2
SAVELLA ORAL TABLETS,
DOSE PACK 12.5 MG (5)-
25 MG(8)-50 MG(42)
2
OBSTETRICS & GYNECOLOGY
Diaphragms And Other Non-Oral
Contraceptives
CAYA CONTOURED
VAGINAL DIAPHRAGM 60-
85 MM
$0
FC2 FEMALE CONDOM $0
FEMCAP VAGINAL DEVICE
22 MM $0
WIDE-SEAL DIAPHRAGM 60
VAGINAL DIAPHRAGM 60
MM
$0
Estrogens & Progestins
amabelz oral tablet 0.5-
0.1 mg, 1-0.5 mg 1
camila oral tablet 0.35 mg $0 QL
COMBIPATCH
TRANSDERMAL PATCH
SEMIWEEKLY 0.05-0.14
MG/24 HR, 0.05-0.25
MG/24 HR
2
Drug Name Tier Requirements - Limitations
CRINONE VAGINAL GEL 4
% 2
deblitane oral tablet 0.35
mg $0 QL
DELESTROGEN
INTRAMUSCULAR OIL 10
MG/ML, 20 MG/ML, 40
MG/ML
2
DEPO-ESTRADIOL
INTRAMUSCULAR OIL 5
MG/ML
2
DIVIGEL TRANSDERMAL
GEL IN PACKET 0.25
MG/0.25 GRAM (0.1 %),
0.5 MG/0.5 GRAM (0.1 %),
1 MG/GRAM (0.1 %)
2
DUAVEE ORAL TABLET 0.45-
20 MG 2
ELESTRIN TRANSDERMAL
GEL IN METERED-DOSE
PUMP 0.87
GRAM/ACTUATION
2
ENDOMETRIN VAGINAL
INSERT 100 MG 2
errin oral tablet 0.35 mg $0 QL
ESTRACE VAGINAL CREAM
0.01 % (0.1 MG/GRAM) 2
estradiol oral tablet 0.5
mg, 1 mg, 2 mg 1
estradiol transdermal
patch semiweekly 0.025
mg/24 hr, 0.0375 mg/24 hr,
0.05 mg/24 hr, 0.075
mg/24 hr, 0.1 mg/24 hr
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
69
Drug Name Tier Requirements - Limitations
estradiol transdermal
patch weekly 0.025
mg/24hr, 0.0375 mg/24hr,
0.05 mg/24hr, 0.06
mg/24hr, 0.075 mg/24hr,
0.1 mg/24hr
1
estradiol vaginal tablet 10
mcg 1
estradiol valerate
intramuscular oil 20
mg/ml, 40 mg/ml
1
estradiol-norethindrone
acet tablet 0.5-0.1 mg, 1-
0.5 mg
1
ESTRING VAGINAL RING 2
MG (7.5 MCG /24 HOUR) 2 QL
ESTROGEL TRANSDERMAL
GEL IN METERED-DOSE
PUMP 1.25 GRAM/ACT.
2
estropipate oral tablet
0.75 mg, 1.5 mg, 3 mg 1
EVAMIST TRANSDERMAL
SPRAY, NON-AEROSOL
1.53 MG/SPRAY (1.7%)
2
FEMHRT LOW DOSE TABLET
0.5-2.5 MG-MCG 2
FEMRING VAGINAL RING
0.05 MG/24HR, 0.1
MG/24HR
2 QL
fyavolv tablet 0.5-2.5 mg-
mcg, 1-5 mg-mcg 1
heather tablet 0.35 mg $0 QL
jencycla tablet 0.35 mg $0 QL
jevantique lo tablet 0.5-
2.5 mg-mcg 1
jinteli tablet 1-5 mg-mcg 1
Drug Name Tier Requirements - Limitations
jolivette tablet 0.35 mg $0 QL
Lopreeza tablet 0.5-0.1
mg, 1-0.5 mg 1
lyza oral tablet 0.35 mg $0 QL
medroxyprogesterone
oral tablet 10 mg, 2.5 mg,
5 mg
1
mimvey lo tablet 0.5-0.1
mg 1
mimvey tablet 1-0.5 mg 1
nora-be oral tablet 0.35
mg $0 QL
norethindrone
(contraceptive) tablet
0.35 mg
$0 QL
norethindrone acetate
tablet 5 mg 1
norethindrone ac-eth
estradiol tablet 0.5-2.5 mg-
mcg, 1-5 mg-mcg
1
norlyda tablet 0.35 mg $0 QL
norlyroc tablet 0.35 mg $0 QL
PREMARIN TABLET 0.3 MG,
0.45 MG, 0.625 MG, 0.9
MG, 1.25 MG
2
PREMARIN VAGINAL
CREAM 0.625 MG/GRAM 2
PREMPHASE TABLET 0.625
MG (14)/ 0.625MG-
5MG(14)
2
PREMPRO TABLET 0.3-1.5
MG, 0.45-1.5 MG, 0.625-2.5
MG, 0.625-5 MG
2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
70
Drug Name Tier Requirements - Limitations
progesterone micronized
oral capsule 100 mg, 200
mg
1
PROMETRIUM ORAL
CAPSULE 100 MG, 200 MG 2
sharobel tablet 0.35 mg $0 QL
VAGIFEM VAGINAL TABLET
10 MCG 2
VIVELLE-DOT
TRANSDERMAL PATCH
SEMIWEEKLY 0.025 MG/24
HR, 0.0375 MG/24 HR, 0.05
MG/24 HR, 0.075 MG/24
HR, 0.1 MG/24 HR
2
yuvafem vaginal tablet 10
mcg 1
Miscellaneous OB/GYN
AVC VAGINAL VAGINAL
CREAM 15 % 2
CLEOCIN VAGINAL
SUPPOSITORY 100 MG 2
clindamycin phosphate
vaginal cream 2 % 1
CLINDESSE VAGINAL
CREAM,EXTENDED
RELEASE 2 %
2
CONCEPTROL VAGINAL
GEL 4 % 2
fem ph vaginal gel 0.9-
0.025 % 1
gynol ii vaginal gel 3 % $0
INTRAROSA VAGINAL
INSERT 6.5 MG 2 QL
isoxsuprine tablet 10 mg,
20 mg 1
Drug Name Tier Requirements - Limitations
metronidazole vaginal gel
0.75 % 1
NUVARING VAGINAL RING
0.12-0.015 MG/24 HR $0 QL
OSPHENA ORAL TABLET 60
MG 2
terconazole vaginal
cream 0.4 %, 0.8 % 1 QL
terconazole vaginal
suppository 80 mg 1 QL
TODAY CONTRACEPTIVE
SPONGE VAGINAL
CONTRACEPTIVE SPONGE
1,000 MG
$0
tranexamic acid oral
tablet 650 mg 1 QL
vaginal contraceptive
foam vaginal foam 12.5 % $0
vandazole vaginal gel
0.75 % 1
VCF CONTRACEPTIVE FILM
VAGINAL FILM 28 % 2
VCF CONTRACEPTIVE GEL
VAGINAL GEL 4 % 2
xulane transdermal patch
weekly 150-35 mcg/24 hr $0 QL
Oral Contraceptives & Related Agents
altavera (28) tablet 0.15-
0.03 mg $0 QL
alyacen 1/35 (28) tablet 1-
35 mg-mcg $0 QL
alyacen 7/7/7 (28) tablet
0.5/0.75/1 mg- 35 mcg $0 QL
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
71
Drug Name Tier Requirements - Limitations
amethia lo tablets, dose
pack,3 month 0.10 mg-20
mcg (84)/10 mcg (7)
$0 QL
amethia tablets, dose
pack,3 month 0.15 mg-30
mcg (84)/10 mcg (7)
$0 QL
amethyst tablet 90-20
mcg $0 QL
apri tablet 0.15-0.03 mg $0 QL
aranelle (28) tablet
0.5/1/0.5-35 mg-mcg $0 QL
ashlyna tablets, dose
pack,3 month 0.15 mg-30
mcg (84)/10 mcg (7)
$0 QL
aubra tablet 0.1-20 mg-
mcg $0 QL
aviane tablet 0.1-20 mg-
mcg $0 QL
azurette (28) tablet 0.15-
0.02 mgx21 /0.01 mg x 5 $0 QL
balziva (28) tablet 0.4-35
mg-mcg $0 QL
bekyree (28) tablet 0.15-
0.02 mgx21 /0.01 mg x 5 $0 QL
blisovi 24 fe tablet 1 mg-20
mcg (24)/75 mg (4) $0 QL
blisovi fe 1.5/30 (28) tablet
1.5 mg-30 mcg (21)/75 mg
(7)
$0 QL
blisovi fe 1/20 (28) tablet 1
mg-20 mcg (21)/75 mg (7) $0 QL
briellyn tablet 0.4-35 mg-
mcg $0 QL
camrese lo tablets, dose
pack,3 month 0.10 mg-20
mcg (84)/10 mcg (7)
$0 QL
Drug Name Tier Requirements - Limitations
camrese tablets, dose
pack,3 month 0.15 mg-30
mcg (84)/10 mcg (7)
$0 QL
caziant (28) tablet
0.1/.125/.15-25 mg-mcg $0 QL
chateal tablet 0.15-0.03
mg $0 QL
cryselle (28) tablet 0.3-30
mg-mcg $0 QL
cyclafem 1/35 (28) tablet
1-35 mg-mcg $0 QL
cyclafem 7/7/7 (28) tablet
0.5/0.75/1 mg- 35 mcg $0 QL
cyred tablet 0.15-0.03 mg $0 QL
dasetta 1/35 (28) tablet 1-
35 mg-mcg $0 QL
dasetta 7/7/7 (28) tablet
0.5/0.75/1 mg- 35 mcg $0 QL
daysee tablets, dose
pack,3 month 0.15 mg-30
mcg (84)/10 mcg (7)
$0 QL
delyla (28) tablet 0.1-20
mg-mcg $0 QL
desog-
e.estradiol/e.estradiol
tablet 0.15-0.02 mgx21
/0.01 mg x 5
$0 QL
desogestrel-ethinyl
estradiol tablet 0.15-0.03
mg
$0 QL
drospirenone-e.estradiol-
lm.fa tablet 3-0.02-0.451
mg (24) (4)
$0 QL
drospirenone-ethinyl
estradiol tablet 3-0.02 mg,
3-0.03 mg
$0 QL
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
72
Drug Name Tier Requirements - Limitations
econtra ez tablet 1.5 mg $0
elinest tablet 0.3-30 mg-
mcg $0 QL
emoquette tablet 0.15-
0.03 mg $0 QL
enpresse tablet 50-30
(6)/75-40 (5)/125-30(10) $0 QL
enskyce tablet 0.15-0.03
mg $0 QL
estarylla tablet 0.25-35
mg-mcg $0 QL
ethynodiol diac-eth
estradiol tablet 1-35 mg-
mcg, 1-50 mg-mcg
$0 QL
falmina (28) tablet 0.1-20
mg-mcg $0 QL
fayosim tablets, dose
pack,3 month 0.15 mg-20
mcg/ 0.15 mg-25 mcg
$0 QL
femynor tablet 0.25-35
mg-mcg $0 QL
gianvi (28) tablet 3-0.02
mg $0 QL
gildagia tablet 0.4-35 mg-
mcg $0 QL
introvale tablets, dose
pack,3 month 0.15 mg-30
mcg
$0 QL
isibloom tablet 0.15-0.03
mg $0 QL
jolessa tablets, dose
pack,3 month 0.15 mg-30
mcg
$0 QL
juleber tablet 0.15-0.03 mg $0 QL
Drug Name Tier Requirements - Limitations
junel 1.5/30 (21) tablet 1.5-
30 mg-mcg $0 QL
junel 1/20 (21) tablet 1-20
mg-mcg $0 QL
junel fe 1.5/30 (28) tablet
1.5 mg-30 mcg (21)/75 mg
(7)
$0 QL
junel fe 1/20 (28) tablet 1
mg-20 mcg (21)/75 mg (7) $0 QL
junel fe 24 tablet 1 mg-20
mcg (24)/75 mg (4) $0 QL
kaitlib fe tablet, chewable
0.8mg-25mcg(24) and 75
mg (4)
$0 QL
kariva (28) tablet 0.15-0.02
mgx21 /0.01 mg x 5 $0 QL
kelnor 1/35 (28) tablet 1-35
mg-mcg $0 QL
kimidess (28) tablet 0.15-
0.02 mgx21 /0.01 mg x 5 $0 QL
kurvelo tablet 0.15-0.03
mg $0 QL
l norgest/e.estradiol-
e.estrad tablets, dose
pack,3 month 0.10 mg-20
mcg (84)/10 mcg (7), 0.15
mg-20 mcg/ 0.15 mg-25
mcg, 0.15 mg-30 mcg
(84)/10 mcg (7)
$0 QL
larin 1.5/30 (21) tablet 1.5-
30 mg-mcg $0 QL
larin 1/20 (21) tablet 1-20
mg-mcg $0 QL
larin 24 fe tablet 1 mg-20
mcg (24)/75 mg (4) $0 QL
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
73
Drug Name Tier Requirements - Limitations
larin fe 1.5/30 (28) tablet
1.5 mg-30 mcg (21)/75 mg
(7)
$0 QL
larin fe 1/20 (28) tablet 1
mg-20 mcg (21)/75 mg (7) $0 QL
larissia tablet 0.1-20 mg-
mcg $0 QL
layolis fe tablet, chewable
0.8mg-25mcg(24) and 75
mg (4)
$0 QL
leena 28 tablet 0.5/1/0.5-
35 mg-mcg $0 QL
lessina tablet 0.1-20 mg-
mcg $0 QL
levonest (28) tablet 50-30
(6)/75-40 (5)/125-30(10) $0 QL
levonorgestrel-ethinyl
estrad tablet 0.1-20 mg-
mcg, 0.15-0.03 mg, 90-20
mcg
$0 QL
levonorgestrel-ethinyl
estrad tablets, dose
pack,3 month 0.15 mg-30
mcg
$0 QL
levonorg-eth estrad
triphasic tablet 50-30
(6)/75-40 (5)/125-30(10)
$0 QL
levora-28 tablet 0.15-0.03
mg $0 QL
lillow tablet 0.15-0.03 mg $0 QL
lomedia 24 fe tablet 1 mg-
20 mcg (24)/75 mg (4) $0 QL
loryna (28) tablet 3-0.02
mg $0 QL
low-ogestrel (28) tablet
0.3-30 mg-mcg $0 QL
Drug Name Tier Requirements - Limitations
lutera (28) tablet 0.1-20
mg-mcg $0 QL
marlissa tablet 0.15-0.03
mg $0 QL
melodetta 24 fe tablet,
chewable 1 mg-20
mcg(24) /75 mg (4)
$0 QL
mibelas 24 fe tablet,
chewable 1 mg-20
mcg(24) /75 mg (4)
$0 QL
microgestin 1.5/30 (21)
tablet 1.5-30 mg-mcg $0 QL
microgestin 1/20 (21)
tablet 1-20 mg-mcg $0 QL
microgestin fe 1.5/30 (28)
tablet 1.5 mg-30 mcg
(21)/75 mg (7)
$0 QL
microgestin fe 1/20 (28)
tablet 1 mg-20 mcg
(21)/75 mg (7)
$0 QL
mono-linyah tablet 0.25-35
mg-mcg $0 QL
mononessa (28) tablet
0.25-35 mg-mcg $0 QL
my way tablet 1.5 mg $0
myzilra tablet 50-30 (6)/75-
40 (5)/125-30(10) $0 QL
necon 0.5/35 (28) tablet
0.5-35 mg-mcg $0 QL
necon 1/50 (28) tablet 1-
50 mg-mcg $0 QL
necon 7/7/7 (28) tablet
0.5/0.75/1 mg- 35 mcg $0 QL
next choice one dose
tablet 1.5 mg $0
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
74
Drug Name Tier Requirements - Limitations
nikki (28) tablet 3-0.02 mg $0 QL
noreth-ethinyl estradiol-
iron tablet, chewable
0.4mg-35mcg(21) and 75
mg (7), 0.8mg-25mcg(24)
and 75 mg (4)
$0 QL
norethindrone ac-eth
estradiol tablet 1-20 mg-
mcg
$0 QL
norethindrone-e.estradiol-
iron tablet 1 mg-20 mcg
(21)/75 mg (7), 1 mg-20
mcg (24)/75 mg (4)
$0 QL
norethindrone-e.estradiol-
iron tablet, chewable 1
mg-20 mcg(24) /75 mg (4)
$0 QL
norgestimate-ethinyl
estradiol tablet
0.18/0.215/0.25 mg-25
mcg, 0.18/0.215/0.25 mg-
35 mcg (28), 0.25-35 mg-
mcg
$0 QL
nortrel 0.5/35 (28) tablet
0.5-35 mg-mcg $0 QL
nortrel 1/35 (21) tablet 1-
35 mg-mcg $0 QL
nortrel 1/35 (28) tablet 1-
35 mg-mcg $0 QL
nortrel 7/7/7 (28) tablet
0.5/0.75/1 mg- 35 mcg $0 QL
ocella tablet 3-0.03 mg $0 QL
ogestrel (28) tablet 0.5-50
mg-mcg $0 QL
opcicon one-step tablet
1.5 mg $0
option-2 tablet 1.5 mg $0
Drug Name Tier Requirements - Limitations
orsythia tablet 0.1-20 mg-
mcg $0 QL
philith tablet 0.4-35 mg-
mcg $0 QL
pimtrea (28) tablet 0.15-
0.02 mgx21 /0.01 mg x 5 $0 QL
pirmella tablet 0.5/0.75/1
mg- 35 mcg, 1-35 mg-mcg $0 QL
portia tablet 0.15-0.03 mg $0 QL
previfem tablet 0.25-35
mg-mcg $0 QL
quasense tablets, dose
pack,3 month 0.15 mg-30
mcg
$0 QL
rajani tablet 3-0.02-0.451
mg (24) (4) $0 QL
reclipsen (28) tablet 0.15-
0.03 mg $0 QL
rivelsa tablets, dose
pack,3 month 0.15 mg-20
mcg/ 0.15 mg-25 mcg
$0 QL
setlakin tablets, dose
pack,3 month 0.15 mg-30
mcg
$0 QL
sprintec (28) tablet 0.25-35
mg-mcg $0 QL
sronyx tablet 0.1-20 mg-
mcg $0 QL
syeda tablet 3-0.03 mg $0 QL
tarina fe 1/20 (28) tablet 1
mg-20 mcg (21)/75 mg (7) $0 QL
tilia fe tablet 1-20(5)/1-
30(7) /1mg-35mcg (9) $0 QL
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
75
Drug Name Tier Requirements - Limitations
tri femynor tablet
0.18/0.215/0.25 mg-35
mcg (28)
$0 QL
tri-estarylla tablet
0.18/0.215/0.25 mg-35
mcg (28)
$0 QL
tri-legest fe tablet 1-
20(5)/1-30(7) /1mg-35mcg
(9)
$0 QL
tri-linyah tablet
0.18/0.215/0.25 mg-35
mcg (28)
$0 QL
tri-lo-estarylla tablet
0.18/0.215/0.25 mg-25
mcg
$0 QL
tri-lo-marzia tablet
0.18/0.215/0.25 mg-25
mcg
$0 QL
tri-lo-sprintec tablet
0.18/0.215/0.25 mg-25
mcg
$0 QL
trinessa (28) tablet
0.18/0.215/0.25 mg-35
mcg (28)
$0 QL
trinessa lo tablet
0.18/0.215/0.25 mg-25
mcg
$0 QL
tri-previfem (28) tablet
0.18/0.215/0.25 mg-35
mcg (28)
$0 QL
tri-sprintec (28) tablet
0.18/0.215/0.25 mg-35
mcg (28)
$0 QL
trivora (28) tablet 50-30
(6)/75-40 (5)/125-30(10) $0 QL
Drug Name Tier Requirements - Limitations
velivet triphasic regimen
(28) tablet 0.1/.125/.15-25
mg-mcg
$0 QL
vestura (28) tablet 3-0.02
mg $0 QL
vienva tablet 0.1-20 mg-
mcg $0 QL
viorele (28) tablet 0.15-
0.02 mgx21 /0.01 mg x 5 $0 QL
vyfemla (28) tablet 0.4-35
mg-mcg $0 QL
wera (28) tablet 0.5-35
mg-mcg $0 QL
wymzya fe tablet,
chewable 0.4mg-
35mcg(21) and 75 mg (7)
$0 QL
zarah tablet 3-0.03 mg $0 QL
zenchent (28) tablet 0.4-
35 mg-mcg $0 QL
zovia 1/35e (28) tablet 1-
35 mg-mcg $0 QL
zovia 1/50e (28) tablet 1-
50 mg-mcg $0 QL
Oxytocics
methergine tablet 0.2 mg 1
OPHTHALMOLOGY
Antibiotics
AZASITE OPHTHALMIC
(EYE) DROPS 1 % 2
bacitracin ophthalmic
(eye) ointment 500
unit/gram
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
76
Drug Name Tier Requirements - Limitations
bacitracin-polymyxin b
ophthalmic (eye)
ointment 500-10,000
unit/gram
1
BESIVANCE OPHTHALMIC
(EYE) DROPS, SUSPENSION
0.6 %
2
CILOXAN OPHTHALMIC
(EYE) OINTMENT 0.3 % 2
ciprofloxacin hcl
ophthalmic (eye) drops
0.3 %
1
erythromycin ophthalmic
(eye) ointment 5
mg/gram (0.5 %)
1
gentamicin ophthalmic
(eye) drops 0.3 % 1
gentamicin ophthalmic
(eye) ointment 0.3 % (3
mg/gram)
1
MOXEZA OPHTHALMIC
(EYE) DROPS, VISCOUS 0.5
%
2
neomycin-bacitracin-
polymyxin ophthalmic
(eye) ointment 3.5-400-
10,000 mg-unit-unit/g
1
neomycin-polymyxin-
gramicidin ophthalmic
(eye) drops 1.75 mg-
10,000 unit-0.025mg/ml
1
ofloxacin ophthalmic
(eye) drops 0.3 % 1
polymyxin b sulf-
trimethoprim ophthalmic
(eye) drops 10,000 unit- 1
mg/ml
1
Drug Name Tier Requirements - Limitations
tobramycin ophthalmic
(eye) drops 0.3 % 1
TOBREX OPHTHALMIC
(EYE) OINTMENT 0.3 % 2
VIGAMOX OPHTHALMIC
(EYE) DROPS 0.5 % 2
Antivirals
trifluridine ophthalmic
(eye) drops 1 % 1
ZIRGAN OPHTHALMIC
(EYE) GEL 0.15 % 2
Beta-Blockers
betaxolol ophthalmic
(eye) drops 0.5 % 1
BETIMOL OPHTHALMIC
(EYE) DROPS 0.25 %, 0.5 % 2
BETOPTIC S OPHTHALMIC
(EYE) DROPS, SUSPENSION
0.25 %
2
carteolol ophthalmic
(eye) drops 1 % 1
ISTALOL OPHTHALMIC
(EYE) DROPS, ONCE DAILY
0.5 %
2
levobunolol ophthalmic
(eye) drops 0.5 % 1
metipranolol ophthalmic
(eye) drops 0.3 % 1
timolol maleate
ophthalmic (eye) drops
0.25 %, 0.5 %
1
timolol maleate
ophthalmic (eye) gel
forming soln 0.25 %, 0.5 %
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
77
Drug Name Tier Requirements - Limitations
TIMOPTIC OCUDOSE (PF)
OPHTHALMIC (EYE)
DROPPERETTE 0.5 %
2
Cholinesterase Inhibitor Miotics
PHOSPHOLINE IODIDE
OPHTHALMIC (EYE) DROPS
0.125 %
2
Cycloplegic Mydriatics
atropine ophthalmic (eye)
drops 1 % 1
atropine ophthalmic (eye)
ointment 1 % 1
CYCLOGYL OPHTHALMIC
(EYE) DROPS 0.5 %, 1 %, 2
%
2
cyclopentolate
ophthalmic (eye) drops
0.5 %, 1 %, 2 %
1
homatropaire ophthalmic
(eye) drops 5 % 1
homatropine hbr
ophthalmic (eye) drops 5
%
1
MYDRIACYL OPHTHALMIC
(EYE) DROPS 1 % 2
tropicamide ophthalmic
(eye) drops 0.5 %, 1 % 1
Direct Acting Miotics
pilocarpine hcl
ophthalmic (eye) drops 1
%, 2 %, 4 %
1
Miscellaneous Ophthalmologics
acuicyn topical spray,
non-aerosol 0.01 % 1
Drug Name Tier Requirements - Limitations
ALOCRIL OPHTHALMIC
(EYE) DROPS 2 % 2
ALOMIDE OPHTHALMIC
(EYE) DROPS 0.1 % 2
altacaine ophthalmic
(eye) drops 0.5 % 1
altafluor ophthalmic (eye)
drops 0.25-0.4 % 1
azelastine ophthalmic
(eye) drops 0.05 % 1
BEPREVE OPHTHALMIC
(EYE) DROPS 1.5 % 2
cromolyn ophthalmic
(eye) drops 4 % 1
EMADINE OPHTHALMIC
(EYE) DROPS 0.05 % 2
flucaine ophthalmic (eye)
drops 0.25-0.5 % 1
fluorescein-proparacaine
ophthalmic (eye) drops
0.25-0.5 %
1
flurox ophthalmic (eye)
drops 0.25-0.4 % 1
LASTACAFT OPHTHALMIC
(EYE) DROPS 0.25 % 2
PAZEO OPHTHALMIC (EYE)
DROPS 0.7 % 2
proparacaine ophthalmic
(eye) drops 0.5 % 1
RESTASIS MULTIDOSE
OPHTHALMIC (EYE) DROPS
0.05 %
2
RESTASIS OPHTHALMIC
(EYE) DROPPERETTE 0.05 % 2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
78
Drug Name Tier Requirements - Limitations
tetcaine ophthalmic (eye)
drops 0.5 % 1
tetracaine hcl ophthalmic
(eye) drops 0.5 % 1
XIIDRA OPHTHALMIC (EYE)
DROPPERETTE 5 % 2 QL
Non-Steroidal Anti-Inflammatory
Agents
ACUVAIL (PF)
OPHTHALMIC (EYE)
DROPPERETTE 0.45 %
2
bromfenac ophthalmic
(eye) drops 0.09 % 1
BROMSITE OPHTHALMIC
(EYE) DROPS 0.075 % 2
diclofenac sodium
ophthalmic (eye) drops
0.1 %
1
flurbiprofen sodium
ophthalmic (eye) drops
0.03 %
1
ILEVRO OPHTHALMIC (EYE)
DROPS, SUSPENSION 0.3 % 2
NEVANAC OPHTHALMIC
(EYE) DROPS, SUSPENSION
0.1 %
2
PROLENSA OPHTHALMIC
(EYE) DROPS 0.07 % 2
Oral Drugs For Glaucoma
acetazolamide oral
capsule, extended
release 500 mg
1
acetazolamide oral tablet
125 mg, 250 mg 1
methazolamide oral
tablet 25 mg, 50 mg 1
Drug Name Tier Requirements - Limitations
Other Glaucoma Drugs
AZOPT OPHTHALMIC (EYE)
DROPS, SUSPENSION 1 % 2
bimatoprost ophthalmic
(eye) drops 0.03 % 1
COMBIGAN OPHTHALMIC
(EYE) DROPS 0.2-0.5 % 2
COSOPT (PF) OPHTHALMIC
(EYE) DROPPERETTE 2-0.5 % 2
dorzolamide ophthalmic
(eye) drops 2 % 1
dorzolamide-timolol
ophthalmic (eye) drops
22.3-6.8 mg/ml
1
latanoprost ophthalmic
(eye) drops 0.005 % 1
LUMIGAN OPHTHALMIC
(EYE) DROPS 0.01 % 2 ST
miostat intraocular soln
0.01 % 1
SIMBRINZA OPHTHALMIC
(EYE) DROPS, SUSPENSION
1-0.2 %
2
TRAVATAN Z OPHTHALMIC
(EYE) DROPS 0.004 % 2 ST
Steroid-Antibiotic Combinations
neomycin-bacitracin-poly-
hc ophthalmic (eye)
ointment 3.5-400-10,000
mg-unit/g-1%
1
neomycin-polymyxin b-
dexameth ophthalmic
(eye) drops, suspension
3.5mg/ml-10,000 unit/ml-
0.1 %
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
79
Drug Name Tier Requirements - Limitations
neomycin-polymyxin b-
dexameth ophthalmic
(eye) ointment 3.5 mg/g-
10,000 unit/g-0.1 %
1
neomycin-polymyxin-hc
ophthalmic (eye) drops,
suspension 3.5-10,000-10
mg-unit-mg/ml
1
PRED-G OPHTHALMIC
(EYE) DROPS, SUSPENSION
0.3-1 %
2
PRED-G S.O.P.
OPHTHALMIC (EYE)
OINTMENT 0.3-0.6 %
2
TOBRADEX OPHTHALMIC
(EYE) OINTMENT 0.3-0.1 % 2
ZYLET OPHTHALMIC (EYE)
DROPS, SUSPENSION 0.3-
0.5 %
2
Steroids
ALREX OPHTHALMIC (EYE)
DROPS, SUSPENSION 0.2 % 2
DUREZOL OPHTHALMIC
(EYE) DROPS 0.05 % 2
FLAREX OPHTHALMIC (EYE)
DROPS, SUSPENSION 0.1 % 2
fluorometholone
ophthalmic (eye) drops,
suspension 0.1 %
1
FML FORTE OPHTHALMIC
(EYE) DROPS, SUSPENSION
0.25 %
2
FML S.O.P. OPHTHALMIC
(EYE) OINTMENT 0.1 % 2
LOTEMAX OPHTHALMIC
(EYE) DROPS,GEL 0.5 % 2
Drug Name Tier Requirements - Limitations
LOTEMAX OPHTHALMIC
(EYE) OINTMENT 0.5 % 2
MAXIDEX OPHTHALMIC
(EYE) DROPS, SUSPENSION
0.1 %
2
PRED MILD OPHTHALMIC
(EYE) DROPS, SUSPENSION
0.12 %
2
prednisolone acetate
ophthalmic (eye) drops,
suspension 1 %
1
Steroid-Sulfonamide Combinations
sulfacetamide-
prednisolone ophthalmic
(eye) drops 10 %-0.23 %
(0.25 %)
1
Sulfonamides
sulfacetamide sodium
ophthalmic (eye) drops 10
%
1
sulfacetamide sodium
ophthalmic (eye)
ointment 10 %
1
Sympathomimetics
ALPHAGAN P
OPHTHALMIC (EYE) DROPS
0.1 %, 0.15 %
2
apraclonidine ophthalmic
(eye) drops 0.5 % 1
brimonidine ophthalmic
(eye) drops 0.2 % 1
Vasoconstrictor Decongestants
phenylephrine hcl
ophthalmic (eye) drops 10
%, 2.5 %
1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
80
Drug Name Tier Requirements - Limitations
RESPIRATORY, ALLERGY, COUGH &
COLD
Antihistamine & Antiallergenic Agents
carbinoxamine maleate
oral liquid 4 mg/5 ml 1
carbinoxamine maleate
oral tablet 4 mg 1
cyproheptadine oral syrup
2 mg/5 ml 1
cyproheptadine oral
tablet 4 mg 1
desloratadine oral tablet 5
mg 1
desloratadine tablet,
disintegrating 2.5 mg, 5
mg
1
EPINEPHRINE INJECTION
AUTO-INJECTOR 0.15
MG/0.15 ML, 0.3 MG/0.3
ML
2
EPINEPHRINE INJECTION
AUTO-INJECTOR 0.15
MG/0.3 ML
2 QL
hydroxyzine hcl oral soln
10 mg/5 ml 1
hydroxyzine hcl oral tablet
10 mg, 25 mg, 50 mg 1
hydroxyzine pamoate oral
capsule 100 mg, 25 mg, 50
mg
1
phenadoz rectal
suppository 12.5 mg, 25
mg
1
PHENERGAN INJECTION
SOLN 25 MG/ML, 50
MG/ML
2
Drug Name Tier Requirements - Limitations
phenergan rectal
suppository 12.5 mg, 25
mg, 50 mg
1
promethazine oral syrup
6.25 mg/5 ml 1
promethazine oral tablet
12.5 mg, 25 mg, 50 mg 1
promethazine rectal
suppository 12.5 mg, 25
mg, 50 mg
1
promethegan rectal
suppository 12.5 mg, 25
mg, 50 mg
1
Cough & Cold Therapy
benzonatate oral capsule
100 mg, 150 mg, 200 mg 1
BROMFED DM ORAL SYRUP
2-30-10 MG/5 ML 2
brompheniramine-
pseudoeph-dm oral syrup
2-30-10 mg/5 ml
1
centergy oral drops 1-2
mg/ml 1
cheratussin ac oral liquid
10-100 mg/5 ml 1
codeine-guaifenesin oral
liquid 10-100 mg/5 ml 1
g tussin ac oral liquid 10-
100 mg/5 ml 1
guaiatussin ac oral liquid
10-100 mg/5 ml 1
guaifenesin ac oral liquid
10-100 mg/5 ml 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
81
Drug Name Tier Requirements - Limitations
hydrocodone-
chlorpheniramine oral
suspension, extended rel
12 hr 10-8 mg/5 ml
1
hydrocodone-cpm-
pseudoephed soln 5-4-60
mg/5 ml
1
hydrocodone-
homatropine oral syrup 5-
1.5 mg/5 ml
1
hydrocodone-
homatropine oral tablet 5-
1.5 mg
1
hydromet oral syrup 5-1.5
mg/5 ml 1
lortuss ex oral syrup 30-10-
100 mg/5 ml 1
m-clear wc oral liquid 6.3-
100 mg/5 ml 1
promethazine vc-codeine
oral syrup 6.25-5-10 mg/5
ml
1
promethazine-codeine
oral syrup 6.25-10 mg/5 ml 1
promethazine-dm oral
syrup 6.25-15 mg/5 ml 1
promethazine-phenyleph-
codeine oral syrup 6.25-5-
10 mg/5 ml
1
promethazine-
phenylephrine oral syrup
6.25-5 mg/5 ml
1
relcof c oral liquid 6.3-100
mg/5 ml 1
RESPA-AR ORAL TABLET
EXTENDED RELEASE 12 HR
8-90-0.24 MG
2
Drug Name Tier Requirements - Limitations
rydex oral liquid 1.3-10-6.3
mg/5 ml 1
TESSALON PERLES ORAL
CAPSULE 100 MG 2
tusnel c oral syrup 30-10-
100 mg/5 ml 1
tussigon oral tablet 5-1.5
mg 1
virtussin ac oral liquid 10-
100 mg/5 ml 1
virtussin dac oral syrup 30-
10-100 mg/5 ml 1
ZODRYL DEC 30 ORAL
SUSPENSION 15-3.5-70
MG/3.5 ML
2
Pulmonary Agents
acetylcysteine soln 100
mg/ml (10 %), 200 mg/ml
(20 %)
1
ADCIRCA ORAL TABLET 20
MG 2 PA; SP
ADEMPAS ORAL TABLET 0.5
MG, 1 MG, 1.5 MG, 2 MG,
2.5 MG
2 PA; SP; LA
ADRENALIN NASAL SOLN 1
MG/ML 2
ADVAIR DISKUS
INHALATION BLISTER WITH
DEVICE 100-50
MCG/DOSE, 250-50
MCG/DOSE, 500-50
MCG/DOSE
2 QL
AEROSPAN INHALATION
HFA AEROSOL INHALER 80
MCG/ACTUATION
2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
82
Drug Name Tier Requirements - Limitations
albuterol sulfate inhalation
soln for nebulization 0.63
mg/3 ml, 1.25 mg/3 ml, 2.5
mg /3 ml (0.083 %), 2.5
mg/0.5 ml, 5 mg/ml
1
albuterol sulfate oral syrup
2 mg/5 ml 1
albuterol sulfate oral
tablet 2 mg, 4 mg 1
albuterol sulfate oral
tablet extended release
12 hr 4 mg, 8 mg
1
ALVESCO INHALATION
HFA AEROSOL INHALER
160 MCG/ACTUATION, 80
MCG/ACTUATION
2
ANORO ELLIPTA
INHALATION BLISTER WITH
DEVICE 62.5-25
MCG/ACTUATION
2
ARMONAIR RESPICLICK
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 113
MCG/ACTUATION, 232
MCG/ACTUATION, 55
MCG/ACTUATION
2 QL
ASMANEX TWISTHALER
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 110 MCG (30
DOSES), 110 MCG (7
DOSES), 220 MCG (120
DOSES), 220 MCG (14
DOSES), 220 MCG (30
DOSES), 220 MCG (60
DOSES)
2
Drug Name Tier Requirements - Limitations
ATROVENT HFA
INHALATION HFA AEROSOL
INHALER 17
MCG/ACTUATION
2
budesonide inhalation
suspension for nebulization
0.25 mg/2 ml, 0.5 mg/2 ml,
1 mg/2 ml
1
budesonide nasal spray,
non-aerosol 32
mcg/actuation
1
COMBIVENT RESPIMAT
INHALATION MIST 20-100
MCG/ACTUATION
2
cromolyn inhalation soln
for nebulization 20 mg/2
ml
1
DULERA INHALATION HFA
AEROSOL INHALER 100-5
MCG/ACTUATION, 200-5
MCG/ACTUATION
2
DYMISTA NASAL SPRAY,
NON-AEROSOL 137-50
MCG/SPRAY
2
ESBRIET ORAL CAPSULE 267
MG 2 PA; SP
ESBRIET ORAL TABLET 267
MG, 801 MG 2 PA; SP
FIRAZYR SUBCUTANEOUS
SYRINGE 30 MG/3 ML 2 PA; SP
FLOVENT DISKUS
INHALATION BLISTER WITH
DEVICE 100
MCG/ACTUATION, 250
MCG/ACTUATION, 50
MCG/ACTUATION
2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
83
Drug Name Tier Requirements - Limitations
FLOVENT HFA INHALATION
HFA AEROSOL INHALER
110 MCG/ACTUATION, 220
MCG/ACTUATION, 44
MCG/ACTUATION
2
flunisolide nasal spray,
non-aerosol 25 mcg (0.025
%)
1
fluticasone nasal spray,
suspension 50
mcg/actuation
1 QL
ipratropium bromide
inhalation soln 0.02 % 1
ipratropium-albuterol
inhalation soln for
nebulization 0.5 mg-3
mg(2.5 mg base)/3 ml
1
KALYDECO ORAL
GRANULES IN PACKET 50
MG, 75 MG
2 PA; SP
KALYDECO ORAL TABLET
150 MG 2 PA; SP
levalbuterol hcl inhalation
soln for nebulization 0.31
mg/3ml, 0.63 mg/3 ml,
1.25 mg/0.5ml,1.25 mg/3
ml
1
metaproterenol oral syrup
10 mg/5 ml 1
metaproterenol oral
tablet 10 mg, 20 mg 1
mometasone nasal spray,
non-aerosol 50
mcg/actuation
1 QL
montelukast oral granules
in packet 4 mg 1
Drug Name Tier Requirements - Limitations
montelukast oral tablet 10
mg 1
montelukast oral tablet,
chewable 4 mg, 5 mg 1
NASONEX NASAL SPRAY,
NON-AEROSOL 50
MCG/ACTUATION
2 QL
nebusal inhalation soln for
nebulization 3 % 1
OFEV ORAL CAPSULE 100
MG, 150 MG 2 PA; SP
ORKAMBI ORAL TABLET
100-125 MG, 200-125 MG 2 PA; SP
PERFOROMIST INHALATION
SOLN FOR NEBULIZATION
20 MCG/2 ML
2
PROAIR HFA INHALATION
HFA AEROSOL INHALER 90
MCG/ACTUATION
2 QL
PROAIR RESPICLICK
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 90
MCG/ACTUATION
2
PULMICORT FLEXHALER
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 180
MCG/ACTUATION, 90
MCG/ACTUATION
2
PULMICORT INHALATION
SUSPENSION FOR
NEBULIZATION 0.25 MG/2
ML, 0.5 MG/2 ML, 1 MG/2
ML
2
pulmosal inhalation soln
for nebulization 7 % 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
84
Drug Name Tier Requirements - Limitations
PULMOZYME INHALATION
SOLN 1 MG/ML 2 SP
QVAR INHALATION
AEROSOL 40
MCG/ACTUATION, 80
MCG/ACTUATION
2
REVATIO ORAL
SUSPENSION FOR RECON
10 MG/ML
2 PA; SP
SEREVENT DISKUS
INHALATION BLISTER WITH
DEVICE 50 MCG/DOSE
2 QL
sildenafil
(antihypertensive) oral
tablet 20 mg
1 PA
SINGULAIR ORAL
GRANULES IN PACKET 4
MG
2
SINGULAIR ORAL TABLET 10
MG 2
SINGULAIR ORAL TABLET,
CHEWABLE 4 MG, 5 MG 2
sodium chloride inhalation
soln for nebulization 10 %,
3 %, 7 %
1
SPIRIVA WITH HANDIHALER
INHALATION CAPSULE,
W/INHALATION DEVICE 18
MCG
2
STIOLTO RESPIMAT
INHALATION MIST 2.5-2.5
MCG/ACTUATION
2
SYMBICORT INHALATION
HFA AEROSOL INHALER
160-4.5 MCG/ACTUATION,
80-4.5 MCG/ACTUATION
2
Drug Name Tier Requirements - Limitations
terbutaline oral tablet 2.5
mg, 5 mg 1
THEO-24 ORAL CAPSULE,
EXTENDED RELEASE 24HR
100 MG, 200 MG, 300 MG,
400 MG
2
theochron oral tablet
extended release 12 hr
100 mg, 200 mg, 300 mg
1
theophylline oral elixir 80
mg/15 ml 1
theophylline oral soln 80
mg/15 ml 1
theophylline oral tablet
extended release 12 hr
100 mg, 200 mg, 300 mg,
450 mg
1
theophylline oral tablet
extended release 24 hr
400 mg, 600 mg
1
TRACLEER ORAL TABLET
125 MG, 62.5 MG 2 PA; SP; LA
VENTAVIS INHALATION
SOLN FOR NEBULIZATION
10 MCG/ML
2 PA; SP
VENTOLIN HFA
INHALATION HFA AEROSOL
INHALER 90
MCG/ACTUATION
2
zafirlukast oral tablet 10
mg, 20 mg 1
zileuton oral tablet, er
multiphase 12 hr 600 mg 1
ZYFLO CR ORAL TABLET, ER
MULTIPHASE 12 HR 600 MG 2
ZYFLO ORAL TABLET 600
MG 2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
85
Drug Name Tier Requirements - Limitations
UROLOGICALS
Anticholinergics & Antispasmodics
ENABLEX ORAL TABLET
EXTENDED RELEASE 24 HR
15 MG, 7.5 MG
2
flavoxate tablet 100 mg 1
GELNIQUE TRANSDERMAL
GEL IN METERED-DOSE
PUMP 100MG/GM (10 %)
2
GELNIQUE TRANSDERMAL
GEL IN PACKET 10 % (100
MG/GRAM)
2
oxybutynin chloride oral
syrup 5 mg/5 ml 1
oxybutynin chloride oral
tablet 5 mg 1
oxybutynin chloride oral
tablet extended release
24hr 10 mg, 15 mg, 5 mg
1
OXYTROL TRANSDERMAL
PATCH SEMIWEEKLY 3.9
MG/24 HR
2
TOVIAZ ORAL TABLET
EXTENDED RELEASE 24 HR 4
MG, 8 MG
2
VESICARE ORAL TABLET 10
MG, 5 MG 2
Benign Prostatic Hyperplasia (BPH)
Therapy
alfuzosin oral tablet
extended release 24 hr 10
mg
1
AVODART ORAL CAPSULE
0.5 MG 2
dutasteride oral capsule
0.5 mg 1
Drug Name Tier Requirements - Limitations
dutasteride-tamsulosin
oral capsule, er
multiphase 24 hr 0.5-0.4
mg
1
finasteride oral tablet 5
mg 1
JALYN ORAL CAPSULE, ER
MULTIPHASE 24 HR 0.5-0.4
MG
2
tamsulosin oral capsule,
extended release 24hr 0.4
mg
1
Cholinergic Stimulants
bethanechol chloride oral
tablet 10 mg, 25 mg, 5
mg, 50 mg
1
Miscellaneous Urologicals
CYSTAGON ORAL
CAPSULE 150 MG, 50 MG 2 SP; LA
cytra k crystals oral
packet 3,300-1,002 mg 1
cytra-2 oral soln 500-334
mg/5 ml 1
cytra-3 oral soln 550-500-
334 mg/5 ml 1
cytra-k oral soln 1,100-334
mg/5 ml 1
ELMIRON ORAL CAPSULE
100 MG 2
hyolev mb oral tablet 81-
10.8-40.8 mg 1
hyophen oral tablet 81.6-
0.12-10.8 mg 1
K-PHOS NO 2 ORAL TABLET
305-700 MG 2
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
86
Drug Name Tier Requirements - Limitations
K-PHOS ORIGINAL ORAL
TABLET,SOLUBLE 500 MG 2
methen-sod phos-meth
blue-hyos oral tablet 81.6-
40.8-0.12 mg
1
ORACIT ORAL SOLN 490-
640 MG/5 ML 2
phosphasal oral tablet
81.6-10.8-40.8 mg 1
pot,sodium citrate-citric
acid oral soln 550-500-334
mg/5 ml
1
potassium citrate oral
tablet extended release
10 meq (1,080 mg), 15
meq, 5 meq (540 mg)
1
potassium citrate-citric
acid oral packet 3,300-
1,002 mg
1
potassium citrate-citric
acid oral soln 1,100-334
mg/5 ml
1
RENACIDIN IRRIGATION
SOLN 6.602-3.268
GRAM/100 ML
2
SHOHL'S MODIFIED ORAL
SOLN 500-300 MG/5 ML 2
sodium citrate-citric acid
oral soln 500-334 mg/5 ml 1
tricitrates oral soln 550-500-
334 mg/5 ml 1
ur n-c oral tablet 81.6-10.8-
40.8 mg 1
uramit mb oral capsule
118-10-40.8-36 mg 1
Drug Name Tier Requirements - Limitations
URELLE ORAL TABLET 81-
10.8-40.8 MG 2
uretron d-s oral tablet
81.6-10.8-40.8 mg 1
URIBEL ORAL CAPSULE 118-
10-40.8-36 MG 2
urimar-t oral tablet 120-
0.12-10.8 mg 1
urin ds oral tablet 81.6-
10.8-40.8 mg 1
uro-458 oral tablet 81-10.8-
40.8 mg 1
UROCIT-K 10 ORAL TABLET
EXTENDED RELEASE 10
MEQ (1,080 MG)
2
UROCIT-K 15 ORAL TABLET
EXTENDED RELEASE 15
MEQ
2
UROCIT-K 5 ORAL TABLET
EXTENDED RELEASE 5 MEQ
(540 MG)
2
urogesic-blue oral tablet
81.6-40.8-0.12 mg 1
uro-mp oral capsule 118-
10-40.8-36 mg 1
urophen mb oral tablet
81.6-0.12-10.8 mg 1
uryl oral tablet 81.6-40.8-
0.12 mg 1
ustell oral capsule 120-0.12
mg 1
utira-c oral tablet 81.6-
10.8-40.8 mg 1
virtrate-2 oral soln 500-334
mg/5 ml 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
87
Drug Name Tier Requirements - Limitations
virtrate-3 oral soln 550-500-
334 mg/5 ml 1
virtrate-k oral soln 1,100-
334 mg/5 ml 1
Urinary Anesthetics
phenazopyridine oral
tablet 100 mg, 200 mg 1
PYRIDIUM ORAL TABLET 100
MG, 200 MG 2
VITAMINS, HEMATINICS &
ELECTROLYTES
Electrolytes
calcium 500 + d oral
tablet 500 mg(1,250mg) -
200 unit
$0
calcium 500 + d oral
tablet, chewable 500
mg(1,250mg) -400 unit
$0
calcium 500 with d oral
tablet 500 mg(1,250mg) -
400 unit
$0
calcium 600 + d(3) oral
capsule 600 mg calcium-
200 unit
$0
calcium 600 + d(3) oral
tablet 600 mg(1,500mg) -
200 unit, 600 mg(1,500mg)
-400 unit
$0
calcium 600 with vitamin
d3 oral capsule 600
mg(1,500mg) -400 unit,
600 mg(1,500mg) -500 unit
$0
calcium 600 with vitamin
d3 oral tablet, chewable
600 mg(1,500mg) -400 unit
$0
Drug Name Tier Requirements - Limitations
calcium carbonate-
vitamin d3 oral capsule
600 mg(1,500mg) -400 unit
$0
calcium carbonate-
vitamin d3 oral tablet 500
mg(1,250mg) -125 unit,
500 mg(1,250mg) -200
unit, 500 mg(1,250mg) -
400 unit, 600 mg(1,500mg)
-200 unit, 600
mg(1,500mg) -400 unit,
600 mg(1,500mg) -800 unit
$0
calcium carbonate-
vitamin d3 oral tablet,
chewable 500-100 mg-unit
$0
calcium citrate + d oral
tablet 315-200 mg-unit $0
calcium citrate-vitamin d3
oral tablet 200 mg
calcium -250 unit, 200-125
mg-unit, 250 mg calcium-
200 unit, 315-200 mg-unit,
315-250 mg-unit
$0
citrus calcium oral tablet
200 mg calcium -250 unit,
315-250 mg-unit
$0
effer-k oral tablet,
effervescent 25 meq 1
hi-cal plus vit d oral tablet
500 mg(1,250mg) -200 unit $0
k-effervescent oral tablet,
effervescent 25 meq 1
klor-con 10 oral tablet
extended release 10 meq 1
klor-con 8 oral tablet
extended release 8 meq 1
klor-con m10 oral tablet,er
particles/crystals 10 meq 1
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
88
Drug Name Tier Requirements - Limitations
klor-con m15 oral tablet,er
particles/crystals 15 meq 1
klor-con m20 oral tablet,er
particles/crystals 20 meq 1
klor-con oral packet 20
meq 1
klor-con sprinkle oral
capsule, extended
release 10 meq, 8 meq
1
KLOR-CON/25 ORAL
PACKET 25 MEQ 2
klor-con/ef oral tablet,
effervescent 25 meq 1
k-phos-neutral oral tablet
250 mg 1
k-tab oral tablet extended
release 8 meq 1
lugols oral soln 5 % 1
oysco 500/d oral tablet
500 mg(1,250mg) -200 unit $0
oyster shell + d3 oral tablet
250-125 mg-unit $0
oyster shell calcium-vit d3
oral tablet 250-125 mg-
unit, 500 mg(1,250mg) -
200 unit, 500 mg(1,250mg)
-400 unit
$0
oystercal-d oral tablet 500
mg(1,250mg) -400 unit $0
phospha 250 neutral oral
tablet 250 mg 1
potassium bicarb and
chloride oral tablet,
effervescent 25 meq
1
Drug Name Tier Requirements - Limitations
potassium bicarb-citric
acid oral tablet,
effervescent 25 meq
1
potassium chloride oral
capsule, extended
release 10 meq, 8 meq
1
potassium chloride oral
liquid 20 meq/15 ml, 40
meq/15 ml
1
potassium chloride oral
packet 20 meq 1
potassium chloride oral
tablet extended release
10 meq, 20 meq, 8 meq
1
potassium chloride oral
tablet,er particles/crystals
10 meq, 20 meq
1
strong iodine oral soln 5 % 1
virt-phos 250 neutral oral
tablet 250 mg 1
Vitamins & Hematinics
b complex-vitamin b12
oral tablet $0
balanced b-100 complex
oral tablet extended
release 100 mg
$0
balanced b-100 oral
tablet 0.4 mg $0
balanced b-50 oral tablet $0
b-complex with vitamin c
oral tablet $0
calcium-folic acid-vitamin
d oral wafer 500-50-300-1
mg-mg-unit-mg
1
cholecalciferol (vitamin
d3) oral capsule 1,000 unit $0
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
89
Drug Name Tier Requirements - Limitations
cholecalciferol (vitamin
d3) oral drops 400 unit/ml $0
cholecalciferol (vitamin
d3) oral tablet 1,000 unit,
400 unit
$0
cholecalciferol (vitamin
d3) oral tablet, chewable
1,000 unit
$0
classic prenatal oral tablet
28 mg iron- 800 mcg $0
complete natal dha oral
combo pack 29-1-250 mg $0
complex b-100 oral tablet
extended release $0
delta d3 oral tablet 400
unit $0
d-vi-sol oral drops 400
unit/ml $0
ergocalciferol (vitamin d2)
oral tablet 400 unit $0
FLUORABON ORAL DROPS
0.25 MG(0.55 MG
S.FLUOR)/0.6 ML
2
fluor-a-day (with xylitol)
oral tablet, chewable 0.25
mg f (0.55 mg)-236.79mg
$0
fluoride (sodium) oral
drops 0.5 mg (1.1 mg
sod.fluorid)/ml
$0
fluoride (sodium) oral
tablet, chewable 0.25
mg(0.55 mg sod. fluoride),
0.5 mg (1.1 mg sodium
fluorid)
$0
fluoritab oral tablet,
chewable 0.5 mg (1.1 mg
sodium fluorid)
$0
Drug Name Tier Requirements - Limitations
FLURA-DROPS ORAL
DROPS 0.25 MG(0.55 MG
SOD.FLUOR)/DROP
2
folic acid oral tablet 1 mg,
400 mcg, 800 mcg $0
foltabs 800 oral tablet 0.8-
10-115 mg-mg-mcg $0
kobee oral tablet 0.4 mg $0
kpn oral tablet $0
KPN ORAL TABLET 9 MG
IRON- 267 MCG 1
ludent fluoride oral tablet,
chewable 0.25 mg(0.55
mg sod. fluoride), 0.5 mg
(1.1 mg sodium fluorid)
$0
multi-vitamin with fluoride
oral drops 0.25 mg/ml, 0.5
mg/ml
$0
multi-vitamin with fluoride
oral tablet, chewable 0.25
mg, 0.5 mg
$0
multivitamins with fluoride
oral tablet, chewable 0.25
mg, 0.5 mg
$0
multivit-fluor (vit e
acetate) oral drops 0.25
mg/ml
$0
mvc-fluoride oral tablet,
chewable 0.25 mg, 0.5 mg $0
mynatal advance oral
tablet 90-1-50 mg $0
mynatal oral capsule 65
mg iron- 1 mg $0
mynatal oral tablet 90-1-
50 mg $0
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
90
Drug Name Tier Requirements - Limitations
mynatal plus oral tablet 65
mg iron- 1 mg $0
mynatal-z oral tablet 65
mg iron- 1 mg $0
natural b-100 complex
oral tablet 100 mg $0
one daily prenatal oral
combo pack 28-800-440
mg-mcg-mg
$0
oyster shell calcium-vit d2
oral tablet 250 (625)-125
mg-unit
$0
pnv 29-1 oral tablet 29 mg
iron- 1 mg $0
prenatabs fa oral tablet
29-1 mg $0
prenatabs rx oral tablet 29
mg iron- 1 mg $0
prenatal complete oral
tablet 14 mg iron- 400
mcg
$0
prenatal formula oral
tablet 28 mg iron- 800
mcg
$0
PRENATAL FORMULA ORAL
TABLET 9 MG IRON- 267
MCG
1
prenatal multi-dha (algal
oil) oral capsule 27mg
iron- 800 mcg-250 mg
$0
prenatal one daily oral
tablet 27 mg iron- 800
mcg
$0
prenatal oral tablet 28 mg
iron- 800 mcg $0
Drug Name Tier Requirements - Limitations
prenatal plus (calcium
carb) oral tablet 27 mg
iron- 1 mg
$0
prenatal plus oral tablet
29 mg iron- 1 mg $0
prenatal vitamin oral
tablet , 27 mg iron- 0.8
mg
$0
prenatal vitamin plus low
iron oral tablet 27 mg iron-
1 mg
$0
prenatal vitamin with
minerals oral tablet 28 mg
iron- 800 mcg
$0
prenatal vits96-iron fum-
folic oral tablet 27 mg
iron- 800 mcg
$0
preplus oral tablet 27 mg
iron- 1 mg $0
pretab oral tablet 29-1 mg $0
rena-vite oral tablet 0.8
mg $0
risacal-d oral tablet 105-
120 mg-unit $0
stress formula oral tablet $0
stress formula with iron oral
tablet 500 mg-400 mcg-
18 mg iron
$0
stress formula with
iron(sulf) oral tablet 500
mg-400 mcg- 27 mg iron
$0
super b complex-vitamin c
oral tablet $0
super quints b-50 oral
tablet $0
You can find information on what the symbols and abbreviations on this table mean by
going to the beginning of this table.
91
Drug Name Tier Requirements - Limitations
super quints oral tablet 0.4
mg $0
superplex-t oral tablet $0
tl g-fol os oral tablet 500-
1.1 mg 1
total b/c oral tablet $0
trinatal gt oral tablet 90-1-
50 mg $0
trinatal rx 1 oral tablet 60
mg iron-1 mg $0
trinate oral tablet 28 mg
iron- 1 mg $0
tri-vitamin with fluoride
oral drops 0.25 mg fluor.
(0.55 mg)/ml, 0.5 mg
fluoride (1.1 mg)/ml
$0
trust natal dha oral
combo pack 29-1-250 mg $0
ultra b-100 complex oral
tablet $0
vinate one oral tablet 60
mg iron-1 mg $0
virt-advance oral tablet
90-1-50 mg $0
Drug Name Tier Requirements - Limitations
virt-nate oral tablet 28 mg
iron- 1 mg $0
virt-vite gt oral tablet 90-1-
50 mg $0
vit b complex-folic acid
oral tablet 0.4 mg $0
vitamin b complex oral
tablet $0
vitamin d3 oral capsule
1,000 unit, 400 unit $0
vitamin d3 oral tablet
1,000 unit, 400 unit $0
vitamin d3 oral tablet,
chewable 1,000 unit, 400
unit
$0
vitamins a,c,d and fluoride
oral drops 0.25 mg fluor.
(0.55 mg)/ml
$0
vol-nate oral tablet 28 mg
iron- 1 mg $0
vol-plus oral tablet 27 mg
iron- 1 mg $0
vol-tab rx oral tablet 29
mg iron- 1 mg $0
92
INDEX
A abacavir ........................... 5
abacavir-lamivudine ...... 5
abacavir-lamivudine-
zidovudine ..................... 5
ABILIFY MAINTENA .......... 25
acamprosate ................. 50
ACANYA .......................... 43
acarbose ........................ 57
acebutolol ...................... 32
acetaminophen-caff-
dihydrocod ................. 20
acetaminophen-codeine
...................................... 20
acetazolamide .............. 78
acetic acid ..................... 53
acetylcysteine ................ 81
acitretin ........................... 40
ACTIGALL ........................ 60
ACTIMMUNE .................... 66
ACTONEL ................... 50, 67
ACTOPLUS MET ............... 57
ACTOPLUS MET XR .......... 57
ACTOS ............................. 57
acuicyn ........................... 77
ACUVAIL (PF) .................. 78
acyclovir ..................... 5, 47
ACZONE .......................... 43
adapalene ..................... 43
adapalene-benzoyl
peroxide ...................... 43
ADCIRCA......................... 81
adefovir ............................. 5
ADEMPAS ........................ 81
ADRENALIN ..................... 81
ADVAIR DISKUS ............... 81
ADZENYS XR-ODT............ 25
AEROCHAMBER MINI ..... 55
AEROCHAMBER PLUS
FLOW-VU ...................... 55
AEROCHAMBER PLUS Z
STAT SM MSK ................ 55
AEROSPAN ...................... 81
afeditab cr ...................... 32
ala-cort ........................... 47
ALA-QUIN ........................ 46
ALA-SCALP ...................... 47
ALBENZA .......................... 10
albuterol sulfate ............. 82
alclometasone ............... 47
alendronate ............. 50, 67
alfuzosin........................... 85
ALINIA .............................. 10
allopurinol ....................... 67
ALOCRIL .......................... 77
ALOMIDE ......................... 77
alophen .......................... 60
ALPHAGAN P .................. 79
alprazolam ..................... 25
alprazolam intensol ....... 25
ALREX ............................... 79
ALTABAX .......................... 45
altacaine ........................ 77
altafluor ........................... 77
altavera (28) ................... 70
ALVESCO......................... 82
alyacen 1/35 (28) .......... 70
alyacen 7/7/7 (28) ........ 70
amabelz .......................... 68
amantadine hcl ............... 5
amcinonide .................... 47
amethia .......................... 71
amethia lo ...................... 71
amethyst ......................... 71
AMICAR ........................... 37
amiloride ......................... 32
amiloride-
hydrochlorothiazide .. 32
amiodarone ................... 31
AMITIZA ............................ 61
amitriptyline .................... 25
amitriptyline-
chlordiazepoxide ....... 25
amlodipine ..................... 32
amlodipine-atorvastatin
...................................... 38
amlodipine-benazepril . 32
amlodipine-olmesartan 32
amlodipine-valsartan ... 32
amlodipine-valsartan-
hcthiazid ..................... 32
amoxapine ..................... 25
amoxicil-clarithromy-
lansopraz ..................... 65
amoxicillin ....................... 11
amoxicillin-pot
clavulanate ................ 11
ampicillin ......................... 11
AMPYRA .......................... 19
ANADROL-50 .................. 56
anagrelide ...................... 51
ANALPRAM-HC .............. 61
ANALPRAM-HC SINGLES 61
anaspaz .......................... 59
anastrozole ..................... 13
ANDROGEL ..................... 56
ANDROID ........................ 56
ANORO ELLIPTA ............. 82
ANTABUSE ....................... 51
ANUSOL-HC .................... 61
apexicon e ..................... 47
APIDRA ............................ 55
APIDRA SOLOSTAR......... 55
APOKYN .......................... 17
apraclonidine ................ 79
aprepitant ...................... 61
apri................................... 71
APRISO ............................ 61
APTENSIO XR ................... 25
APTIOM ........................... 14
APTIVUS ..............................5
aranelle (28) ................... 71
ARCALYST ....................... 66
aripiprazole .................... 25
ARISTADA ........................ 25
ARIXTRA ........................... 37
armodafinil ..................... 25
ARMONAIR RESPICLICK 82
ARMOUR THYROID ......... 59
ascomp with codeine .. 20
ashlyna ............................ 71
ASMANEX TWISTHALER .. 82
93
aspirin......................... 22, 23
aspirin low dose ............. 22
aspirin-dipyridamole...... 37
ASTEPRO .......................... 52
ASTRAMORPH-PF ............ 20
atenolol ........................... 32
atenolol-chlorthalidone 32
atorvastatin .................... 38
atovaquone ................... 10
atovaquone-proguanil . 10
ATRIPLA .............................. 5
atropine ........................... 77
ATROVENT HFA ............... 82
AUBAGIO......................... 66
aubra ............................... 71
AUGMENTIN .................... 11
avar .................................. 43
AVC VAGINAL ................ 70
aviane ............................. 71
avidoxy ............................ 12
avita ................................. 43
avo cream ...................... 41
AVODART ........................ 85
AVONEX .......................... 66
AVONEX (WITH ALBUMIN)
...................................... 66
AXERT ............................... 18
AZASITE ............................ 75
azathioprine ................... 13
azelastine .................. 52, 77
AZELEX ............................. 43
AZILECT ............................ 17
azithromycin ..................... 9
AZOPT .............................. 78
azurette (28) ................... 71
B b complex-vitamin b12 . 88
bacitracin ....................... 75
bacitracin-polymyxin b . 76
baclofen ......................... 19
BACTROBAN NASAL....... 52
balanced b-100 ............. 88
balanced b-100 complex
...................................... 88
balanced b-50 ............... 88
balsalazide ...................... 61
balziva (28) ..................... 71
BANZEL ....................... 14, 15
bayer aspirin ................... 23
b-complex with vitamin c
...................................... 88
bekyree (28) ................... 71
belladonna alkaloids-
opium........................... 59
belladonna-opium ........ 60
benazepril ....................... 32
benazepril-
hydrochlorothiazide .. 32
BENZACLIN ...................... 43
BENZACLIN PUMP ........... 43
benzonatate .................. 80
benzphetamine ............. 50
benztropine .................... 17
BEPREVE........................... 77
BESIVANCE ...................... 76
betamethasone
dipropionate .............. 47
betamethasone valerate
...................................... 47
betamethasone,
augmented ................ 47
BETASERON ..................... 66
betaxolol ................... 32, 76
bethanechol chloride... 85
BETHKIS ............................. 10
BETIMOL ........................... 76
BETOPTIC S ...................... 76
bicalutamide ................. 13
BIDIL ................................. 32
BILTRICIDE ........................ 10
bimatoprost .................... 78
bisacodyl ........................ 61
bisa-lax ............................ 61
bisoprolol fumarate ....... 32
bisoprolol-
hydrochlorothiazide .. 32
blisovi 24 fe ..................... 71
blisovi fe 1.5/30 (28) ....... 71
blisovi fe 1/20 (28) .......... 71
bp 10-1 ............................ 43
bp-50% urea ................... 41
BREEZE 2 TEST STRIPS ....... 54
briellyn ............................. 71
BRILINTA ........................... 37
brimonidine .................... 79
BRIVIACT ......................... 15
BROMFED DM ................. 80
bromfenac ..................... 78
bromocriptine ................ 18
brompheniramine-
pseudoeph-dm .......... 80
BROMSITE ........................ 78
budesonide .............. 61, 82
bumetanide ................... 32
BUPHENYL ........................ 51
bupropion hcl ................ 25
bupropion hcl (smoking
deter) ........................... 51
buspirone ........................ 25
butalbital compound
w/codeine .................. 20
butalbital-acetaminop-
caf-cod ....................... 20
butalbital-
acetaminophen ........ 20
butalbital-
acetaminophen-caff 20
butalbital-aspirin-caffeine
................................ 20, 21
butorphanol tartrate ..... 23
BUTRANS .......................... 21
BYDUREON ...................... 57
BYETTA ............................. 57
BYSTOLIC ......................... 32
C cabergoline ................... 56
CADUET ........................... 38
caffeine citrate .............. 51
CALAN SR ....................... 32
calcipotriene.................. 40
calcipotriene-
betamethasone ......... 40
calcitonin (salmon) ....... 56
calcitrene ....................... 40
calcitriol .................... 40, 56
calcium 500 + d ............. 87
calcium 500 with d ........ 87
calcium 600 + d(3) ........ 87
94
calcium 600 with vitamin
d3 .................................. 87
calcium acetate............ 61
CALCIUM ACETATE ........ 61
calcium carbonate-
vitamin d3 ................... 87
calcium citrate + d ........ 87
calcium citrate-vitamin
d3 .................................. 87
calcium-folic acid-vitamin
d .................................... 88
camila ............................. 68
camrese .......................... 71
camrese lo ...................... 71
CANASA .......................... 61
candesartan ................... 32
candesartan-
hydrochlorothiazid ..... 32
capacet .......................... 21
CAPITAL WITH CODEINE 21
captopril .......................... 33
captopril-
hydrochlorothiazide .. 33
CARAC ............................ 42
CARAFATE ....................... 65
CARBAGLU ...................... 51
carbamazepine ............. 15
carbidopa....................... 18
carbidopa-levodopa .... 18
carbidopa-levodopa-
entacapone ............... 18
carbinoxamine maleate
...................................... 80
carisoprodol ................... 20
carisoprodol-asa-codeine
...................................... 20
carisoprodol-aspirin ....... 20
CARNITOR ....................... 51
CARNITOR (SUGAR-FREE)
...................................... 51
carteolol .......................... 76
cartia xt ........................... 33
carvedilol ........................ 33
CAYA CONTOURED ....... 68
caziant (28) ..................... 71
cefaclor ............................. 8
cefadroxil .......................... 8
cefdinir .......................... 8, 9
cefditoren pivoxil ............. 9
cefixime............................. 9
cefpodoxime ................... 9
cefprozil ............................. 9
CEFTIN ................................ 9
cefuroxime axetil ............. 9
celacyn ........................... 42
celecoxib ........................ 23
CELLCEPT ........................ 13
CELONTIN ........................ 15
cem-urea ........................ 42
centergy ......................... 80
cephalexin ........................ 9
CERDELGA ...................... 56
cevimeline ...................... 51
CHANTIX .......................... 51
CHANTIX CONTINUING
MONTH BOX ................ 51
CHANTIX STARTING
MONTH BOX ................ 52
chateal............................ 71
CHEMET ........................... 51
CHENODAL ..................... 61
cheratussin ac ................ 80
children's aspirin ............. 23
chlordiazepoxide hcl .... 25
chlordiazepoxide-
clidinium ...................... 60
chlorhexidine gluconate
...................................... 52
chloroquine phosphate 10
chlorothiazide ................ 33
chlorpromazine .............. 26
chlorpropamide ............ 57
chlorthalidone ................ 33
chlorzoxazone ................ 20
cholecalciferol (vitamin
d3) .......................... 88, 89
cholestyramine (with
sugar) ........................... 38
cholestyramine light ...... 38
choline,magnesium
salicylate ..................... 23
ciclodan .......................... 46
ciclopirox ........................ 46
ciclopirox-ure-camph-
menth-euc .................. 46
cilostazol ......................... 37
CILOXAN ......................... 76
cimetidine ...................... 65
cimetidine hcl ................ 65
CIPRO HC ....................... 53
CIPRODEX ....................... 53
ciprofloxacin .................. 12
ciprofloxacin (mixture) . 11
ciprofloxacin hcl 11, 53, 76
citalopram ...................... 26
citrate of magnesia ...... 61
citroma............................ 61
citrus calcium ................. 87
claravis ............................ 43
clarithromycin ...................9
classic prenatal ............. 89
cleansing wash .............. 43
clearlax ........................... 61
CLEOCIN ......................... 70
clindacin p ..................... 43
CLINDAGEL ..................... 43
clindamycin hcl ............. 10
clindamycin palmitate hcl
...................................... 10
clindamycin pediatric .. 10
clindamycin phosphate
................................ 43, 70
clindamycin-benzoyl
peroxide ...................... 43
clindamycin-tretinoin .... 43
CLINDESSE ....................... 70
clobetasol ................. 47, 48
clobetasol-emollient ..... 48
CLOBEX ........................... 48
clodan ............................. 48
clomiphene citrate ....... 56
clomipramine ................. 26
clonazepam ................... 15
clonidine ......................... 33
clonidine hcl................... 33
clopidogrel ..................... 37
clorazepate dipotassium
...................................... 26
95
clorpres ............................ 33
CLORPRES ....................... 33
clotrimazole ...................... 5
clotrimazole-
betamethasone ......... 46
clozapine ........................ 26
CLOZAPINE ...................... 26
COAL TAR ........................ 40
COARTEM ........................ 10
codeine sulfate .............. 21
codeine-guaifenesin ..... 80
colestipol ................... 38, 39
colocort ........................... 61
COMBIGAN ..................... 78
COMBIPATCH ................. 68
COMBIVENT RESPIMAT .. 82
COMBIVIR .......................... 5
COMPLERA ....................... 5
complete natal dha...... 89
complex b-100 ............... 89
compro ........................... 61
COMTAN ......................... 18
CONCEPTROL ................. 70
CONDYLOX ..................... 42
constulose ....................... 61
CONTOUR NEXT EZ METER
...................................... 55
CONTOUR NEXT METER .. 55
CONTOUR NEXT STRIPS .. 54
CONTOUR TEST STRIPS .... 54
COPAXONE .................... 66
CORDRAN ....................... 48
CORDRAN TAPE LARGE
ROLL ............................. 48
COREG CR ...................... 33
CORLANOR ..................... 40
cormax ............................ 48
CORTENEMA ................... 61
CORTIFOAM .................... 61
cortisone ......................... 53
CORTROSYN .................... 53
COSENTYX (2 SYRINGES) 40
COSENTYX PEN (2 PENS) 41
COSOPT (PF) ................... 78
cosyntropin ..................... 53
COTEMPLA XR-ODT ........ 26
COUMADIN .................... 37
CREON ............................ 61
CRINONE ......................... 68
CRIXIVAN .......................... 6
cromolyn ............. 61, 77, 82
cryselle (28)..................... 71
CUPRIMINE ...................... 67
cyclafem 1/35 (28) ........ 71
cyclafem 7/7/7 (28) ...... 71
cyclobenzaprine ........... 20
CYCLOGYL ..................... 77
cyclopentolate .............. 77
CYCLOSERINE ................. 10
CYCLOSET ....................... 57
cyclosporine ................... 13
cyclosporine modified .. 13
cyproheptadine ............ 80
cyred ............................... 71
CYSTAGON ..................... 85
cytra k crystals ................ 85
cytra-2 ............................. 85
cytra-3 ............................. 85
cytra-k ............................. 85
D D.H.E.45 ........................... 18
danazol ........................... 56
dantrolene ...................... 20
dapsone.................... 10, 43
dasetta 1/35 (28) ........... 71
dasetta 7/7/7 (28) ......... 71
daysee ............................ 71
DAYTRANA ...................... 26
DEBACTEROL .................. 52
deblitane ........................ 68
DELESTROGEN ................ 68
delta d3 ........................... 89
deltasone ........................ 53
delyla (28) ....................... 71
DELZICOL ......................... 61
demeclocycline ............ 12
DENAVIR .......................... 47
denta 5000 plus ............. 52
dentagel ......................... 52
DEPEN TITRATABS ............ 67
DEPO-ESTRADIOL ........... 68
DEPO-TESTOSTERONE .... 56
DERMA-SMOOTHE/FS
BODY OIL ..................... 48
DERMA-SMOOTHE/FS
SCALP OIL ................... 48
DESCOVY ...........................6
desipramine ................... 26
desloratadine................. 80
desmopressin ................. 56
desog-
e.estradiol/e.estradiol 71
desogestrel-ethinyl
estradiol ....................... 71
DESONATE ....................... 48
desonide ......................... 48
desoximetasone ............ 48
DESOXYN ........................ 26
DESVENLAFAXINE ........... 26
DESVENLAFAXINE
FUMARATE ................... 26
desvenlafaxine succinate
...................................... 26
dexamethasone ...... 53, 54
dexamethasone intensol
...................................... 53
dexmethylphenidate .... 26
DEXPAK 10 DAY ............. 54
DEXPAK 13 DAY ............. 54
DEXPAK 6 DAY................ 54
dextroamphetamine .... 26
dextroamphetamine-
amphetamine ............ 26
DIASTAT ........................... 15
DIASTAT ACUDIAL .......... 15
diazepam ................. 15, 26
diazepam intensol ......... 26
DIBENZYLINE .................... 33
diclofenac potassium ... 23
diclofenac sodium . 23, 42,
78
diclofenac-misoprostol . 23
dicloxacillin ..................... 11
dicyclomine ................... 60
didanosine .........................6
diethylpropion ............... 50
DIFFERIN .......................... 43
diflorasone ...................... 48
96
diflunisal ........................... 23
digitek .............................. 36
digox ................................ 36
digoxin ............................. 36
dihydroergotamine . 18, 19
DILATRATE-SR .................. 40
diltiazem .......................... 33
dilt-xr ................................ 33
DIOVAN HCT ................... 33
DIPENTUM ........................ 61
diphenoxylate-atropine 60
dipyridamole .................. 37
diskets .............................. 21
disopyramide phosphate
...................................... 31
disulfiram ......................... 51
DIURIL ............................... 33
divalproex ....................... 15
DIVIGEL ............................ 68
dofetilide ......................... 31
donepezil ........................ 19
dorzolamide ................... 78
dorzolamide-timolol ...... 78
DOVONEX ....................... 41
doxazosin ........................ 33
doxepin ..................... 26, 42
doxercalciferol ............... 57
doxycycline hyclate ...... 12
doxycycline
monohydrate ............. 12
drithocreme hp .............. 41
dronabinol ...................... 61
drospirenone-e.estradiol-
lm.fa ............................. 71
drospirenone-ethinyl
estradiol ....................... 71
DROXIA ............................ 13
DUAVEE ........................... 68
ducodyl ........................... 61
DULERA ............................ 82
duloxetine ....................... 26
DUPIXENT ......................... 42
DUREZOL .......................... 79
dutasteride ..................... 85
dutasteride-tamsulosin .. 85
d-vi-sol ............................. 89
DYANAVEL XR ................. 27
DYMISTA .......................... 82
E e.c. prin ........................... 23
e.e.s. 400 ........................... 9
econazole ...................... 46
econtra ez ...................... 72
ecotrin ............................. 23
ecotrin low strength ...... 23
ed-spaz ........................... 60
EDURANT ........................... 6
effer-k .............................. 87
EFFIENT ............................. 37
ELDEPRYL ......................... 18
ELESTRIN ........................... 68
eletone ............................ 42
ELIDEL ............................... 42
elinest .............................. 72
eliphos ............................. 62
ELIQUIS ............................. 37
ELMIRON ......................... 85
EMADINE ......................... 77
EMBEDA ........................... 21
EMCYT ............................. 13
EMEND ............................. 62
emoquette ..................... 72
EMTRIVA ............................ 6
emulsion sb ..................... 42
ENABLEX .......................... 85
enalapril maleate .......... 33
enalapril-
hydrochlorothiazide .. 33
ENBREL ............................. 67
ENBREL SURECLICK ......... 67
endocet .......................... 21
ENDOMETRIN .................. 68
enoxaparin ..................... 37
enpresse .......................... 72
enskyce ........................... 72
entacapone ................... 18
entecavir .......................... 6
ENTOCORT EC ................ 62
ENTRESTO ........................ 40
enulose ............................ 62
EPCLUSA ............................ 6
EPIDUO ............................ 44
EPIDUO FORTE ................ 44
EPIFOAM ......................... 41
EPINEPHRINE ................... 80
EPIVIR ..................................6
EPIVIR HBV .........................6
eplerenone .................... 33
eprosartan ...................... 33
EPZICOM ............................6
ergocalciferol (vitamin
d2) ................................ 89
ergoloid ........................... 27
ERGOMAR ...................... 19
ergotamine-caffeine .... 19
errin .................................. 68
ERTACZO ......................... 46
ery pads .......................... 44
erygel .............................. 44
ERYPED 200 ........................9
ERYPED 400 ........................9
ery-tab ...............................9
ERY-TAB ..............................9
erythrocin (as stearate) ...9
erythromycin .............. 9, 76
erythromycin
ethylsuccinate ..............9
erythromycin with ethanol
...................................... 44
erythromycin-benzoyl
peroxide ...................... 44
ESBRIET ............................. 82
escitalopram oxalate ... 27
esomeprazole
magnesium ................. 65
estarylla ........................... 72
estazolam ....................... 27
ESTRACE .......................... 68
estradiol .................... 68, 69
estradiol valerate .......... 69
estradiol-norethindrone
acet ............................. 69
ESTRING ........................... 69
ESTROGEL ........................ 69
estropipate ..................... 69
eszopiclone .................... 27
ethacrynic acid ............. 33
ethambutol .................... 10
97
ethosuximide .................. 15
ethyl chloride .................. 45
ethynodiol diac-eth
estradiol ....................... 72
etidronate disodium ...... 51
etodolac ......................... 23
EURAX .............................. 50
EVAMIST ........................... 69
EVEKEO ............................ 27
EVOTAZ .............................. 6
EXELDERM........................ 46
EXELON ............................ 19
exemestane ................... 13
EXJADE ............................ 51
ezetimibe ........................ 39
ezetimibe-simvastatin ... 39
F falmina (28) ..................... 72
famciclovir ........................ 6
famotidine ...................... 65
FANAPT ............................ 27
FARESTON ........................ 13
fayosim ............................ 72
FAZACLO ......................... 27
FC2 FEMALE CONDOM . 68
felbamate ....................... 15
felodipine ........................ 33
fem ph ............................. 70
FEMCAP ........................... 68
FEMHRT LOW DOSE ........ 69
FEMRING .......................... 69
femynor ........................... 72
fenofibrate ...................... 39
fenofibrate micronized . 39
fenofibrate
nanocrystallized ......... 39
fenofibric acid ................ 39
fenofibric acid (choline)
...................................... 39
fenoprofen ...................... 23
fentanyl ........................... 21
fentanyl citrate............... 21
FETZIMA ............................ 27
FINACEA .......................... 44
finasteride ....................... 85
FIRAZYR ............................ 82
FLAREX ............................. 79
flavoxate ......................... 85
flecainide ........................ 31
FLECTOR .......................... 23
fleet laxative ................... 62
FLOVENT DISKUS ............. 82
FLOVENT HFA .................. 83
flucaine ........................... 77
fluconazole ....................... 5
flucytosine ......................... 5
fludrocortisone ............... 54
flunisolide ........................ 83
fluocinolone ................... 48
fluocinolone acetonide
oil .................................. 53
fluocinolone and shower
cap .............................. 48
fluocinonide ............. 48, 49
fluocinonide-e ................ 49
fluocinonide-emollient .. 49
FLUORABON ................... 89
fluor-a-day (with xylitol) 89
fluorescein-proparacaine
...................................... 77
fluoride (sodium) ...... 53, 89
fluoritab ........................... 89
fluorometholone ............ 79
FLUOROPLEX ................... 42
fluorouracil ...................... 42
fluoxetine ........................ 27
FLUOXETINE ..................... 27
fluphenazine decanoate
...................................... 27
fluphenazine hcl ............ 27
FLURA-DROPS ................. 89
flurandrenolide .............. 49
flurazepam ..................... 27
flurbiprofen ..................... 23
flurbiprofen sodium ....... 78
flurox ................................ 77
flutamide......................... 13
fluticasone ................ 49, 83
fluvastatin ....................... 39
fluvoxamine .................... 27
FML FORTE ....................... 79
FML S.O.P. ....................... 79
FOCALIN XR .................... 27
folic acid ......................... 89
foltabs 800 ...................... 89
fondaparinux ................. 37
FORTEO ........................... 67
fosamprenavir ...................6
fosinopril .......................... 34
fosinopril-
hydrochlorothiazide .. 34
FOSRENOL ....................... 62
frovatriptan .................... 19
FURADANTIN ................... 12
furosemide ..................... 34
fyavolv ............................ 69
FYCOMPA ....................... 15
G g tussin ac ....................... 80
gabapentin .................... 15
GABITRIL .......................... 15
galantamine .................. 19
gavilyte-c ........................ 62
gavilyte-g........................ 62
gavilyte-n ........................ 62
GELNIQUE ....................... 85
gemfibrozil ...................... 39
generlac ......................... 62
gengraf ........................... 13
GENOTROPIN ................. 65
GENOTROPIN MINIQUICK
...................................... 65
gentamicin ............... 45, 76
gentle laxative ............... 62
GENVOYA ..........................6
gianvi (28) ....................... 72
gildagia ........................... 72
GILENYA .......................... 66
glimepiride...................... 57
glipizide ........................... 57
glipizide-metformin ....... 57
GLUCAGEN DIAGNOSTIC
KIT ................................. 55
GLUCAGEN HYPOKIT ..... 55
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 55
glyburide ......................... 57
glyburide micronized .... 57
98
glyburide-metformin...... 58
glycopyrrolate ................ 60
glydo ................................ 45
GOLYTELY ........................ 62
GRALISE ........................... 15
GRALISE 30-DAY STARTER
PACK ............................ 15
granisetron hcl ............... 62
GRASTEK .......................... 67
griseofulvin microsize ....... 5
griseofulvin ultramicrosize
........................................ 5
GRIS-PEG
(ULTRAMICROSIZE) ........ 5
guaiatussin ac ................ 80
guaifenesin ac ............... 80
guanfacine ............... 27, 34
guanidine ........................ 27
gynol ii ............................. 70
H HALDOL ........................... 28
HALDOL DECANOATE ... 27
halobetasol propionate 49
HALOG ............................ 49
haloperidol ..................... 28
haloperidol decanoate 28
haloperidol lactate ....... 28
heather ............................ 69
hemmorex-hc ................. 62
hep flush-10 (pf) ............. 37
heparin (porcine) .......... 37
heparin (porcine) in 5 %
dex ............................... 37
heparin (porcine) in nacl
(pf) ................................ 37
heparin flush(porcine)-
0.9nacl ......................... 37
heparin lock flush ........... 37
heparin lock flush
(porcine) ...................... 37
heparin
lockflush(porcine)(pf) 38
heparin(porcine) in 0.45%
nacl .............................. 38
heparin, porcine (pf) ..... 38
HEXALEN .......................... 13
hi-cal plus vit d ............... 87
homatropaire ................. 77
homatropine hbr ........... 77
HORIZANT ........................ 19
hpr .................................... 42
hpr plus ............................ 42
hpr plus hydrogel ........... 42
HUMALOG ...................... 55
HUMALOG MIX 50-50 .... 55
HUMALOG MIX 75-25 .... 55
HUMIRA ........................... 68
HUMIRA PEDIATRIC
CROHN'S START ........... 67
HUMIRA PEN.................... 67
HUMIRA PEN CROHN'S-
UC-HS START ................ 67
HUMULIN 70/30 ............... 55
HUMULIN N ...................... 55
HUMULIN R U-100 ........... 55
HUMULIN R U-500
(CONCENTRATED) ...... 55
hydralazine ..................... 34
hydrochlorothiazide ...... 34
hydrocodone-
acetaminophen ........ 21
hydrocodone-
chlorpheniramine ...... 81
hydrocodone-cpm-
pseudoephed ............ 81
hydrocodone-
homatropine............... 81
hydrocodone-ibuprofen
...................................... 21
hydrocortisone ... 49, 54, 62
hydrocortisone butyrate
...................................... 49
hydrocortisone butyr-
emollient ..................... 49
hydrocortisone valerate49
hydrocortisone-acetic
acid .............................. 53
hydrocortisone-
iodoquinol-aloe.......... 45
hydrocortisone-min oil-
wht pet ........................ 49
hydrocortisone-
pramoxine .................. 62
hydromet ........................ 81
hydromorphone ............ 21
HYDROMORPHONE ....... 21
hydroxychloroquine ...... 10
hydroxyurea ................... 13
hydroxyzine hcl .............. 80
hydroxyzine pamoate .. 80
hyolev mb ....................... 85
hyophen ......................... 85
hyoscyamine sulfate ..... 60
hyosyne ........................... 60
I ibandronate ................... 67
ibuprofen ........................ 23
ibuprofen-oxycodone .. 21
ILEVRO ............................. 78
imipramine hcl ............... 28
imipramine pamoate ... 28
imiquimod....................... 66
indapamide ................... 34
indomethacin ................ 23
INFUMORPH P/F ............. 21
INSULIN SYRINGE-NEEDLE
U-100 ............................ 55
INTELENCE ..........................6
INTRAROSA ..................... 70
introvale .......................... 72
INVEGA SUSTENNA ........ 28
INVEGA TRINZA .............. 28
INVIRASE .............................6
INVOKAMET .................... 58
INVOKAMET XR ............... 58
INVOKANA ...................... 58
IODOFLEX ........................ 42
IODOSORB ...................... 42
ipratropium bromide ... 53,
83
ipratropium-albuterol.... 83
irbesartan........................ 34
irbesartan-
hydrochlorothiazide .. 34
ISENTRESS............................6
ISENTRESS HD .....................6
isibloom ........................... 72
99
isomethepten-caf-
acetaminophen ......... 19
isoniazid ........................... 10
ISORDIL ............................ 40
ISORDIL TITRADOSE ......... 40
isosorbide dinitrate ........ 40
isosorbide mononitrate . 40
isoxsuprine ....................... 70
isradipine ......................... 34
ISTALOL ............................ 76
itraconazole ..................... 5
ivermectin ....................... 10
J JADENU ........................... 51
JADENU SPRINKLE ........... 51
JALYN ............................... 85
jantoven .......................... 38
JANUMET ......................... 58
JANUMET XR .................... 58
JANUVIA .......................... 58
JARDIANCE ..................... 58
jencycla .......................... 69
JENTADUETO ................... 58
jevantique lo .................. 69
jinteli ................................. 69
jolessa .............................. 72
jolivette ............................ 69
juleber .............................. 72
junel 1.5/30 (21) .............. 72
junel 1/20 (21) ................. 72
junel fe 1.5/30 (28) ......... 72
junel fe 1/20 (28) ............ 72
junel fe 24 ........................ 72
K kaitlib fe ........................... 72
KALETRA ............................. 6
KALYDECO ...................... 83
KAPVAY ........................... 28
kariva (28) ....................... 72
k-effervescent ................ 87
kelnor 1/35 (28) .............. 72
KENALOG ........................ 49
ketoconazole ............. 5, 46
ketoprofen ...................... 23
ketorolac ......................... 23
KHEDEZLA ........................ 28
kimidess (28) ................... 72
kionex .............................. 62
kionex (with sorbitol) ..... 62
KITABIS PAK ..................... 10
klor-con ........................... 88
klor-con 10 ...................... 87
klor-con 8 ........................ 87
klor-con m10 ................... 87
klor-con m15 ................... 88
klor-con m20 ................... 88
klor-con sprinkle ............. 88
KLOR-CON/25 ................ 88
klor-con/ef ...................... 88
kobee .............................. 89
KOMBIGLYZE XR ............. 58
KORLYM ........................... 57
K-PHOS NO 2 .................. 85
K-PHOS ORIGINAL .......... 86
k-phos-neutral ................ 88
kpn ................................... 89
KPN................................... 89
KRISTALOSE ..................... 62
k-tab ................................ 88
kurvelo ............................. 72
KUVAN ............................. 57
L l norgest/e.estradiol-
e.estrad ....................... 72
labetalol .......................... 34
lactulose ......................... 62
LAMICTAL ODT ............... 16
LAMICTAL ODT STARTER
(BLUE) ........................... 16
LAMICTAL ODT STARTER
(GREEN) ....................... 16
LAMICTAL ODT STARTER
(ORANGE) ................... 16
LAMICTAL XR .................. 16
LAMICTAL XR STARTER
(BLUE) ........................... 16
LAMICTAL XR STARTER
(GREEN) ....................... 16
LAMICTAL XR STARTER
(ORANGE) ................... 16
lamivudine ........................ 6
lamivudine-zidovudine ... 6
lamotrigine ..................... 16
LANCETS .......................... 55
LANCING DEVICE .......... 55
LANOXIN ......................... 36
lansoprazole ................... 65
lanthanum ...................... 62
LANTUS ............................ 56
LANTUS SOLOSTAR ......... 55
larin 1.5/30 (21) .............. 72
larin 1/20 (21) ................. 72
larin 24 fe ........................ 72
larin fe 1.5/30 (28) .......... 73
larin fe 1/20 (28) ............. 73
larissia .............................. 73
LASTACAFT ...................... 77
latanoprost ..................... 78
LATUDA ........................... 28
laxaclear ......................... 62
laxative (bisacodyl) ...... 62
laxative feminine ........... 62
layolis fe .......................... 73
leena 28 .......................... 73
leflunomide .................... 68
lessina .............................. 73
letrozole .......................... 13
leucovorin calcium ....... 13
LEUKERAN ....................... 13
levalbuterol hcl .............. 83
LEVEMIR ........................... 56
LEVEMIR FLEXTOUCH ..... 56
levetiracetam ................ 16
levobunolol .................... 76
levocarnitine .................. 51
levocarnitine (with sugar)
...................................... 51
levofloxacin .................... 12
levonest (28) ................... 73
levonorgestrel-ethinyl
estrad .......................... 73
levonorg-eth estrad
triphasic ....................... 73
levora-28 ......................... 73
levorphanol tartrate ..... 21
levothyroxine .................. 59
levoxyl ............................. 59
LEVSIN/SL ......................... 60
100
LEXIVA ................................ 6
LIALDA ............................. 62
lidocaine ......................... 45
lidocaine hcl ................... 45
lidocaine hcl-
hydrocortison ac .. 45, 62
lidocaine viscous ........... 45
lidocaine-hydrocortisone-
aloe .............................. 63
lidocaine-prilocaine ...... 45
LIDODERM ....................... 45
lido-k ................................ 45
lillow ................................. 73
lindane ............................ 50
linezolid ............................ 10
LINZESS ............................. 63
liothyronine ..................... 59
lisinopril ............................ 34
lisinopril-
hydrochlorothiazide .. 34
lite coat aspirin ............... 24
lithium carbonate .......... 28
lithium citrate .................. 28
LOCOID ........................... 49
LODOSYN ........................ 18
lomedia 24 fe ................. 73
lopinavir-ritonavir ............. 6
lopreeza .......................... 69
lorazepam....................... 28
lorazepam intensol ........ 28
lorcet (hydrocodone) ... 21
lorcet hd .......................... 21
lorcet plus........................ 21
lortuss ex .......................... 81
loryna (28) ....................... 73
losartan ............................ 34
losartan-
hydrochlorothiazide .. 34
LOTEMAX ......................... 79
lovastatin ......................... 39
LOVAZA ........................... 39
low-ogestrel (28) ............ 73
loxapine succinate ........ 28
lta pre-attached ............ 45
ludent fluoride ................ 89
lugols .......................... 45, 88
LUMIGAN ......................... 78
lutera (28) ....................... 73
LUXIQ ............................... 49
LYRICA ............................. 16
LYSODREN ....................... 13
lyza ................................... 69
M MACROBID ..................... 12
MACRODANTIN .............. 12
magnesium citrate ........ 63
maprotiline ..................... 28
marlissa ............................ 73
marten-tab ..................... 21
matzim la ........................ 34
MAVYRET ........................... 7
MAXIDEX ......................... 79
MAXZIDE-25MG .............. 34
mb hydrogel ................... 42
mb hydrogel
(cyclomethicone) ...... 42
m-clear wc ..................... 81
meclofenamate ............ 24
MEDROL .......................... 54
medroxyprogesterone .. 69
mefenamic acid ............ 24
mefloquine ..................... 10
MEGACE ES .................... 13
megestrol .................. 13, 14
melodetta 24 fe ............. 73
meloxicam ...................... 24
memantine ..................... 19
MEMANTINE .................... 19
meperidine ..................... 21
MEPHYTON ...................... 38
meprobamate ............... 20
MEPRON .......................... 10
mercaptopurine ............ 14
mesalamine .................... 63
MESNEX ........................... 13
MESTINON ....................... 20
MESTINON TIMESPAN ..... 20
metaproterenol ............. 83
metaxall .......................... 20
metaxalone .................... 20
metformin ....................... 58
methadose ..................... 22
methamphetamine ...... 28
methazolamide ............. 78
methenamine hippurate
...................................... 12
methenamine mandelate
...................................... 12
methen-sod phos-meth
blue-hyos .................... 86
methergine ..................... 75
methimazole .................. 54
METHITEST ........................ 57
methocarbamol ............ 20
methotrexate sodium ... 14
methotrexate sodium (pf)
...................................... 14
methscopolamine ......... 60
methyclothiazide .......... 34
methyldopa ................... 34
methyldopa-
hydrochlorothiazide .. 34
methylphenidate hcl ... 28,
29
methylprednisolone ...... 54
methyltestosterone ....... 57
metipranolol ................... 76
metoclopramide hcl ..... 63
metolazone .................... 34
METOPIRONE .................. 51
metoprolol succinate ... 34
metoprolol ta-
hydrochlorothiaz ........ 34
metoprolol tartrate ....... 34
metronidazole .... 10, 44, 70
mexiletine ....................... 31
mibelas 24 fe .................. 73
microgestin 1.5/30 (21) . 73
microgestin 1/20 (21) .... 73
microgestin fe 1.5/30 (28)
...................................... 73
microgestin fe 1/20 (28) 73
midazolam ..................... 29
midodrine ....................... 51
migergot ......................... 19
miglitol ............................. 58
MIGRANAL ...................... 19
milk of magnesia ........... 63
101
milk of magnesia
concentrated ............. 63
millipred ........................... 54
millipred dp ..................... 54
mimvey ............................ 69
mimvey lo........................ 69
minocycline .................... 12
minoxidil .......................... 34
miostat ............................. 78
MIRAPEX ER ..................... 18
mirtazapine ..................... 29
misoprostol ...................... 65
MITIGARE ......................... 67
modafinil ......................... 29
moderiba ........................ 66
moderiba dose pack .... 66
moexipril .......................... 34
moexipril-
hydrochlorothiazide .. 35
mometasone ............ 49, 83
mondoxyne nl ................ 12
mono-linyah.................... 73
mononessa (28) ............. 73
montelukast .................... 83
MONUROL ....................... 12
morgidox ......................... 12
morphine ......................... 22
morphine concentrate . 22
MOVIPREP ....................... 63
MOXEZA .......................... 76
moxifloxacin ................... 12
MUGARD ......................... 53
MULTAQ ........................... 31
multi-vitamin with fluoride
...................................... 89
multivitamins with fluoride
...................................... 89
multivit-fluor (vit e
acetate) ...................... 89
mupirocin ........................ 46
mupirocin calcium ........ 46
mvc-fluoride ................... 89
my way ............................ 73
MYCOBUTIN .................... 10
mycophenolate mofetil 14
mycophenolate sodium14
MYDAYIS .......................... 29
MYDRIACYL ..................... 77
mynatal ........................... 89
mynatal advance ......... 89
mynatal plus ................... 90
mynatal-z ........................ 90
myzilra ............................. 73
N nabumetone .................. 24
nadolol ............................ 35
nadolol-
bendroflumethiazide . 35
naftifine ........................... 46
naltrexone ...................... 24
NAMENDA TITRATION PAK
...................................... 19
NAMENDA XR ................. 19
naproxen ........................ 24
naproxen sodium .......... 24
NARCAN ......................... 24
NASONEX ........................ 83
nateglinide ..................... 58
NATROBA ........................ 50
natural b-100 complex . 90
nature-throid .................. 59
NEBUPENT ........................ 10
nebusal ........................... 83
necon 0.5/35 (28) .......... 73
necon 1/50 (28) ............. 73
necon 7/7/7 (28) ............ 73
nefazodone .................... 29
neomycin ........................ 10
neomycin-bacitracin-
poly-hc ........................ 78
neomycin-bacitracin-
polymyxin .................... 76
neomycin-polymyxin b-
dexameth ............. 78, 79
neomycin-polymyxin-
gramicidin ................... 76
neomycin-polymyxin-hc
................................ 53, 79
neuac .............................. 44
NEUPRO ........................... 18
NEVANAC ....................... 78
nevirapine ......................... 7
next choice one dose .. 73
niacin............................... 39
nicardipine ..................... 35
NICODERM CQ .............. 52
nicorelief ......................... 52
nicorette ......................... 52
NICORETTE ...................... 52
nicotine ........................... 52
nicotine (polacrilex) ...... 52
NICOTROL ....................... 52
NICOTROL NS ................. 52
nifedipine ........................ 35
nikki (28) .......................... 74
NILANDRON .................... 14
nilutamide....................... 14
nimodipine ..................... 35
nisoldipine ....................... 35
nitro-bid ........................... 40
nitrofurantoin .................. 13
nitrofurantoin
macrocrystal .............. 13
nitrofurantoin
monohyd/m-cryst ...... 13
nitroglycerin.................... 40
NITROSTAT ....................... 40
NITYR ................................ 51
nivatopic plus................. 42
nizatidine ........................ 65
NIZORAL .......................... 46
nolix ................................. 49
nora-be ........................... 69
NORDITROPIN FLEXPRO 66
noreth-ethinyl estradiol-
iron ............................... 74
norethindrone
(contraceptive) ......... 69
norethindrone acetate 69
norethindrone ac-eth
estradiol ................. 69, 74
norethindrone-e.estradiol-
iron ............................... 74
norgestimate-ethinyl
estradiol ....................... 74
NORITATE......................... 44
norlyda ............................ 69
norlyroc ........................... 69
102
NORPACE ........................ 31
NORPACE CR ................. 31
nortrel 0.5/35 (28) ........... 74
nortrel 1/35 (21) .............. 74
nortrel 1/35 (28) .............. 74
nortrel 7/7/7 (28) ............ 74
nortriptyline ..................... 29
NORVIR .............................. 7
NOVOLOG ...................... 56
NOVOLOG FLEXPEN ...... 56
NOVOLOG MIX 70-30 .... 56
NOVOLOG MIX 70-30
FLEXPEN ....................... 56
NOVOLOG PENFILL ........ 56
np thyroid ........................ 59
nts step 1 ......................... 52
NUCYNTA ER ................... 24
NUEDEXTA ....................... 19
NULYTELY WITH FLAVOR
PACKS .......................... 63
NUOX ............................... 44
NUPLAZID ......................... 29
NUVARING ...................... 70
NUVIGIL ........................... 29
nyamyc ........................... 46
nyata ............................... 46
nystatin ........................ 5, 46
nystatin-triamcinolone .. 46
nystop .............................. 47
O ocella ............................... 74
octreotide acetate ....... 14
ODEFSEY ............................ 7
OFEV ................................ 83
ofloxacin ................... 12, 76
ogestrel (28) .................... 74
olanzapine ...................... 29
olanzapine-fluoxetine ... 29
olmesartan ...................... 35
olmesartan-amlodipin-
hcthiazid ...................... 35
olmesartan-
hydrochlorothiazide .. 35
olopatadine ................... 53
omega-3 acid ethyl esters
...................................... 39
omeprazole .................... 65
ondansetron ................... 63
ondansetron hcl ............ 63
one daily prenatal ......... 90
ONFI ........................... 16, 17
ONGLYZA ........................ 58
opcicon one-step ......... 74
option-2 ........................... 74
ORACIT ............................ 86
oral saline laxative ......... 63
oralone ............................ 53
ORAP ............................... 29
ORAPRED ODT ................ 54
ORENITRAM ..................... 35
ORFADIN ......................... 51
ORKAMBI ......................... 83
orphenadrine citrate .... 20
orsythia ............................ 74
oscimin ............................ 60
oscimin sl ......................... 60
oscimin sr ......................... 60
oseltamivir ......................... 7
OSPHENA ........................ 70
oxandrolone ................... 57
oxaprozin ........................ 24
oxazepam ...................... 29
oxcarbazepine .............. 17
oxiconazole .................... 47
OXISTAT ............................ 47
OXTELLAR XR ................... 17
oxybutynin chloride....... 85
oxycodone ..................... 22
oxycodone-
acetaminophen ........ 22
oxycodone-aspirin ........ 22
oxymorphone ................. 22
OXYTROL ......................... 85
oysco 500/d .................... 88
oyster shell + d3.............. 88
oyster shell calcium-vit d2
...................................... 90
oyster shell calcium-vit d3
...................................... 88
oystercal-d ...................... 88
P pacerone ........................ 31
paliperidone .................. 29
pantoprazole ................. 65
paregoric ........................ 60
paricalcitol ..................... 57
paroex oral rinse ............ 53
paromomycin ................ 10
paroxetine hcl ................ 29
paroxetine mesylate ..... 29
PASER .............................. 10
PAXIL ................................ 29
PAZEO.............................. 77
peg 3350-electrolytes ... 63
peg3350 .......................... 63
PEGANONE ..................... 17
PEGASYS ......................... 66
PEGASYS PROCLICK ...... 66
peg-electrolyte soln ...... 63
PEGINTRON ..................... 66
peg-prep ........................ 63
PEN NEEDLE .................... 55
penicillin v potassium .... 11
PENTASA .......................... 63
pentazocine-naloxone . 24
pentoxifylline .................. 38
PERFOROMIST ................. 83
PERIDEX ........................... 53
perindopril erbumine .... 35
periogard ........................ 53
permethrin ...................... 50
perphenazine ................ 29
perphenazine-
amitriptyline ................ 29
PEXEVA ............................ 29
phenadoz ....................... 80
phenazopyridine ........... 87
phendimetrazine tartrate
...................................... 50
phenelzine ...................... 29
phenergan ..................... 80
PHENERGAN ................... 80
phenobarbital ................ 17
phenohytro..................... 60
phenoxybenzamine ...... 35
phentermine .................. 50
phenylephrine hcl ......... 79
PHENYTEK ........................ 17
103
phenytoin ........................ 17
phenytoin sodium
extended ..................... 17
philith ............................... 74
PHOSLYRA ....................... 63
phospha 250 neutral ..... 88
phosphasal ..................... 86
phosphate laxative ....... 63
PHOSPHOLINE IODIDE ... 77
pilocarpine hcl ... 51, 53, 77
pimozide ......................... 29
pimtrea (28) .................... 74
pindolol ........................... 35
pioglitazone .................... 58
pioglitazone-glimepiride
...................................... 58
pioglitazone-metformin 58
pirmella ............................ 74
piroxicam ........................ 24
pnv 29-1 ........................... 90
podofilox ......................... 42
polyethylene glycol 3350
...................................... 63
polymyxin b sulf-
trimethoprim ............... 76
portia ............................... 74
pot,sodium citrate-citric
acid .............................. 86
potassium bicarb and
chloride........................ 88
potassium bicarb-citric
acid .............................. 88
potassium chloride ........ 88
potassium citrate ........... 86
potassium citrate-citric
acid .............................. 86
PRADAXA ........................ 38
PRALUENT PEN ................ 39
pramcort ......................... 63
pramipexole ................... 18
PRAMOSONE .................. 41
PRAMOSONE E ............... 41
PRANDIN .......................... 58
prasugrel ......................... 38
pravastatin ...................... 39
prazosin ........................... 35
PRED MILD ....................... 79
PRED-G ............................ 79
PRED-G S.O.P. ................. 79
prednicarbate ............... 50
prednisolone .................. 54
prednisolone acetate ... 79
prednisolone sodium
phosphate .................. 54
prednisone...................... 54
prednisone intensol ....... 54
PREMARIN ....................... 69
PREMPHASE..................... 69
PREMPRO ........................ 69
prenatabs fa .................. 90
prenatabs rx ................... 90
prenatal .......................... 90
prenatal complete ........ 90
prenatal formula ............ 90
PRENATAL FORMULA ..... 90
prenatal multi-dha (algal
oil) ................................. 90
prenatal one daily ......... 90
prenatal plus .................. 90
prenatal plus (calcium
carb) ............................ 90
prenatal vitamin ............ 90
prenatal vitamin plus low
iron ............................... 90
prenatal vitamin with
minerals ....................... 90
prenatal vits96-iron fum-
folic .............................. 90
preplus ............................. 90
pretab ............................. 90
prevalite .......................... 39
PREVIDENT ....................... 53
PREVIDENT 5000 BOOSTER
PLUS .............................. 53
PREVIDENT 5000 DRY
MOUTH ......................... 53
PREVIDENT 5000 PLUS .... 53
previfem .......................... 74
PREZCOBIX ........................ 7
PREZISTA ............................ 7
PRIFTIN ............................. 10
PRIMAQUINE ................... 11
primidone ....................... 17
PRIMSOL .......................... 13
PRISTIQ ............................. 29
PROAIR HFA .................... 83
PROAIR RESPICLICK ....... 83
probenecid .................... 67
probenecid-colchicine 67
procentra ....................... 30
prochlorperazine ........... 63
prochlorperazine maleate
...................................... 63
PROCTOFOAM HC ........ 63
procto-med hc .............. 64
proctosol hc ................... 64
proctozone-hc ............... 64
progesterone micronized
...................................... 70
PROLENSA ....................... 78
PROMACTA .................... 38
promethazine ................ 80
promethazine vc-codeine
...................................... 81
promethazine-codeine 81
promethazine-dm ......... 81
promethazine-phenyleph-
codeine ....................... 81
promethazine-
phenylephrine ............ 81
promethegan ................ 80
PROMETRIUM .................. 70
propafenone ................. 31
propantheline ................ 60
proparacaine ................ 77
propranolol ..................... 35
propranolol-
hydrochlorothiazid .... 35
propylthiouracil .............. 54
PROTOPIC ....................... 42
protriptyline .................... 30
pruclair ............................ 42
prudoxin .......................... 42
prumyx ............................ 42
prutect ............................ 42
PULMICORT ..................... 83
PULMICORT FLEXHALER . 83
pulmosal ......................... 83
104
PULMOZYME .................... 84
PURIXAN .......................... 14
PYLERA ............................. 65
pyrazinamide ................. 11
PYRIDIUM ......................... 87
pyridostigmine bromide 20
Q quasense ......................... 74
quazepam ...................... 30
QUESTRAN ....................... 39
QUESTRAN LIGHT ............ 39
quetiapine ...................... 30
QUILLICHEW ER ............... 30
QUILLIVANT XR ................ 30
quinapril .......................... 35
quinapril-
hydrochlorothiazide .. 35
quinidine gluconate ...... 32
quinidine sulfate ............. 32
quinine sulfate ................ 11
quit 2 ................................ 52
QUIT 2 ............................... 52
quit 4 ................................ 52
QUIT 4 ............................... 52
QVAR ............................... 84
R rabeprazole .................... 65
RAGWITEK ....................... 67
rajani ................................ 74
raloxifene ........................ 67
ramipril ............................. 35
RANEXA ........................... 40
ranitidine hcl ................... 65
RAPAMUNE ..................... 14
rasagiline ......................... 18
rea lo 39 .......................... 42
rea lo 40 .......................... 42
REBIF (WITH ALBUMIN) .... 66
REBIF REBIDOSE ............... 66
REBIF TITRATION PACK ... 66
reclipsen (28) .................. 74
RECTIV .............................. 64
REGRANEX ...................... 42
relcof c ............................ 81
RELENZA DISKHALER ......... 7
RELION NOVOLIN R ........ 56
RELPAX ............................ 19
RENACIDIN ...................... 86
RENAGEL ......................... 64
rena-vite .......................... 90
RENVELA .......................... 64
repaglinide ..................... 58
repaglinide-metformin .. 58
REPATHA PUSHTRONEX .. 39
REPATHA SURECLICK ..... 39
REPATHA SYRINGE.......... 39
RESCRIPTOR ...................... 7
RESPA-AR ........................ 81
RESTASIS ........................... 77
RESTASIS MULTIDOSE ...... 77
RETIN-A MICRO............... 44
RETIN-A MICRO PUMP ... 44
RETROVIR ........................... 7
REVATIO .......................... 84
REVIA ............................... 24
REXULTI ............................. 30
REYATAZ ............................ 7
ribasphere ....................... 66
ribavirin ........................ 7, 66
RIDAURA .......................... 68
rifabutin ........................... 11
RIFAMATE ........................ 11
rifampin ........................... 11
RIFATER ............................ 11
RILUTEK ............................. 51
riluzole .............................. 51
rimantadine ...................... 7
RIOMET ............................ 58
risacal-d .......................... 90
risedronate ............... 51, 67
RISPERDAL CONSTA ....... 30
risperidone ...................... 30
rivastigmine tartrate ...... 19
rivelsa ............................... 74
rizatriptan ........................ 19
ROBAXIN-750 .................. 20
ROBINUL FORTE .............. 60
ropinirole ......................... 18
rosadan ........................... 44
rosula cleansing cloths . 44
rosuvastatin .................... 39
ROWASA ......................... 64
roweepra ........................ 17
rydex ................................ 81
S SABRIL .............................. 17
salicylic acid................... 41
salicylic acid er-
ceramides ................... 41
salsalate .......................... 24
salvax .............................. 41
SAMSCA .......................... 57
SANDIMMUNE ................. 14
SANTYL ............................. 50
SAPHRIS (BLACK CHERRY)
...................................... 30
SAVELLA .......................... 68
scalacort ......................... 50
scopolamine base ........ 64
seb-prev .......................... 41
seconal sodium ............. 30
selegiline hcl ................... 18
selenium sulfide ............. 41
SELZENTRY ..........................7
SENSIPAR ......................... 57
SEREVENT DISKUS ............ 84
sertraline ......................... 30
setlakin ............................ 74
sevelamer carbonate .. 64
sf 53
sf 5000 plus ...................... 53
SFROWASA ..................... 64
sharobel .......................... 70
SHOHL'S MODIFIED ........ 86
sildenafil
(antihypertensive) ..... 84
silver nitrate .................... 42
silver nitrate applicators 42
silver sulfadiazine ........... 41
SIMBRINZA ....................... 78
simvastatin ...................... 39
SINGULAIR ....................... 84
sirolimus ........................... 14
SIVEXTRO ......................... 11
SKLICE .............................. 50
sodium chloride ....... 51, 84
sodium citrate-citric acid
...................................... 86
105
sodium phenylbutyrate 51
sodium polystyrene
sulfonate ...................... 64
sonafine ........................... 42
SORILUX ........................... 41
sotalol .............................. 32
sotalol af .......................... 32
sp antipruritic .................. 42
sp scar management ... 42
SPIRIVA WITH HANDIHALER
...................................... 84
spironolactone ............... 35
spironolacton-
hydrochlorothiaz ........ 36
sprintec (28) .................... 74
sps (with sorbitol) ............ 64
sronyx ............................... 74
ssd .................................... 41
SSKI ................................... 54
sss 10-5 ............................. 44
stavudine .......................... 7
STIOLTO RESPIMAT .......... 84
stop smoking aid ............ 52
stress formula .................. 90
stress formula with iron .. 90
stress formula with
iron(sulf) ....................... 90
STRIBILD .............................. 7
STROMECTOL .................. 11
strong iodine ................... 88
SUCRAID .......................... 64
sucralfate ........................ 65
sulfacetamide sodium . 41,
79
sulfacetamide sodium
(acne) .......................... 46
sulfacetamide sodium-
sulfur ............................. 44
sulfacetamide sod-sulfur-
urea .............................. 44
sulfacetamide-
prednisolone ............... 79
sulfacetamide-sulfur-
cleansr23 ..................... 44
sulfacleanse 8-4 ............. 44
sulfact na-sul-avobnz-otn-
ocsa ............................. 45
sulfadiazine ..................... 12
sulfamethoxazole-
trimethoprim ............... 12
SULFAMYLON .................. 46
sulfasalazine ................... 64
sulfatrim ........................... 12
sulindac ........................... 24
sumatriptan succinate .. 19
super b complex-vitamin
c.................................... 90
super quints .................... 91
super quints b-50............ 90
superplex-t ...................... 91
SUPREP BOWEL PREP KIT 64
SURMONTIL ...................... 30
SUSTIVA .............................. 7
syeda ............................... 74
symax fastabs................. 60
symax-sl ........................... 60
symax-sr ........................... 60
SYMBICORT ..................... 84
SYMBYAX ......................... 30
SYMLINPEN 120 ............... 58
SYMLINPEN 60 ................. 58
SYNALGOS-DC ............... 22
SYNAREL .......................... 57
SYNJARDY ....................... 59
SYNTHROID ...................... 59
T TABLOID ........................... 14
TACLONEX ...................... 41
tacrolimus ................. 14, 42
TAMIFLU ............................. 7
tamoxifen ........................ 14
tamsulosin ....................... 85
TANZEUM ......................... 59
tarina fe 1/20 (28) .......... 74
TARKA .............................. 36
TASMAR ........................... 18
tazarotene ...................... 45
TAZORAC ........................ 45
taztia xt ............................ 36
TECHNIVIE.......................... 7
TEGRETOL ........................ 17
TEKTURNA ........................ 36
TEKTURNA HCT ................ 36
telmisartan ...................... 36
telmisartan-amlodipine 36
telmisartan-
hydrochlorothiazid .... 36
temazepam ................... 30
tencon ............................ 22
terazosin .......................... 36
terbinafine hcl ...................5
terbutaline ...................... 84
terconazole .................... 70
TESSALON PERLES ........... 81
testosterone cypionate 57
testosterone enanthate 57
TESTRED ........................... 57
tetcaine .......................... 78
tetrabenazine ................ 19
tetracaine hcl ................ 78
tetracycline .................... 12
TEXACORT ....................... 50
THEO-24 ........................... 84
theochron ....................... 84
theophylline ................... 84
thioridazine ..................... 30
thiothixene ...................... 30
thyroid (pork) ................. 59
tiagabine ........................ 17
ticlopidine ....................... 38
TIKOSYN ........................... 32
tilia fe ............................... 74
timolol maleate ....... 36, 76
TIMOPTIC OCUDOSE (PF)
...................................... 77
tinidazole ........................ 11
TIVICAY ...............................7
tizanidine ........................ 20
tl g-fol os ......................... 91
TOBRADEX....................... 79
tobramycin ..................... 76
TOBREX ............................ 76
TODAY CONTRACEPTIVE
SPONGE....................... 70
tolazamide ..................... 59
tolbutamide ................... 59
tolcapone ...................... 18
106
tolmetin ........................... 24
TOPICORT ........................ 50
topiramate ...................... 17
TOPIRAMATE ................... 17
torsemide ........................ 36
total b/c .......................... 91
TOVIAZ ............................. 85
TRACLEER ........................ 84
TRADJENTA ...................... 59
tramadol ......................... 24
TRAMADOL ..................... 24
tramadol-
acetaminophen ......... 24
trandolapril ..................... 36
trandolapril-verapamil .. 36
tranexamic acid ............ 70
TRANSDERM-SCOP ......... 64
tranylcypromine ............. 30
TRAVATAN Z .................... 78
trazodone ....................... 30
TRECATOR ....................... 11
tretinoin ........................... 45
tretinoin (chemotherapy)
...................................... 14
tretinoin microspheres ... 45
TREXALL ............................ 14
tri femynor ....................... 75
TRIACETIN ........................ 47
triamcinolone acetonide
................................ 50, 53
triamterene-
hydrochlorothiazid ..... 36
trianex .............................. 50
triazolam ......................... 30
tricitrates .......................... 86
tri-estarylla ....................... 75
trifluoperazine ................. 30
trifluridine ......................... 76
trihexyphenidyl ............... 18
triklo .................................. 39
tri-legest fe ...................... 75
tri-linyah ........................... 75
TRILIPIX ............................. 39
tri-lo-estarylla .................. 75
tri-lo-marzia ..................... 75
tri-lo-sprintec ................... 75
trilyte with flavor packets
...................................... 64
trimethobenzamide ...... 64
trimethoprim ................... 13
trimipramine ................... 30
trinatal gt ........................ 91
trinatal rx 1 ...................... 91
trinate .............................. 91
trinessa (28) ..................... 75
trinessa lo ........................ 75
TRINTELLIX ........................ 30
tri-previfem (28).............. 75
tri-sprintec (28) ............... 75
TRIUMEQ ............................ 7
tri-vitamin with fluoride . 91
trivora (28)....................... 75
TRIZIVIR ............................... 7
TROKENDI XR ................... 17
tropicamide ................... 77
TRUE METRIX AIR GLUCOSE
METER ........................... 55
TRUE METRIX GLUCOSE
METER ........................... 55
TRUE METRIX GO
GLUCOSE METER ........ 55
TRUE2GO BLOOD
GLUCOSE SYSTEM ....... 55
trust natal dha ................ 91
TRUVADA ........................... 8
tusnel c ............................ 81
tussigon ........................... 81
TYMLOS ............................ 67
U UCERIS ............................. 64
ULESFIA ............................ 50
ULORIC ............................ 67
ultra b-100 complex ...... 91
umecta ........................... 42
unithroid .......................... 59
ur n-c ............................... 86
uramit mb ....................... 86
urea ................................. 43
urea nail stick ................. 43
ure-k ................................. 43
URELLE .............................. 86
uretron d-s ....................... 86
URIBEL .............................. 86
urimar-t ............................ 86
urin ds .............................. 86
uro-458 ............................ 86
UROCIT-K 10 .................... 86
UROCIT-K 15 .................... 86
UROCIT-K 5 ...................... 86
urogesic-blue ................. 86
uro-mp ............................ 86
urophen mb ................... 86
ursodiol ............................ 64
uryl ................................... 86
ustell ................................. 86
utira-c .............................. 86
V VAGIFEM ......................... 70
vaginal contraceptive
foam ............................ 70
valacyclovir .......................8
VALCYTE .............................8
valganciclovir ...................8
valproic acid .................. 17
valproic acid (as sodium
salt) .............................. 17
valsartan ......................... 36
valsartan-
hydrochlorothiazide .. 36
vancomycin ................... 13
vandazole ...................... 70
VANOXIDE-HC ................ 45
VCF CONTRACEPTIVE FILM
...................................... 70
VCF CONTRACEPTIVE GEL
...................................... 70
velivet triphasic regimen
(28) ............................... 75
VEMLIDY .............................8
venlafaxine ............... 30, 31
VENTAVIS......................... 84
VENTOLIN HFA ................ 84
verapamil ....................... 36
verdrocet ........................ 22
veripred 20 ..................... 54
VESICARE ........................ 85
vestura (28)..................... 75
VIBERZI ............................. 64
107
vicodin ............................. 22
vicodin es ........................ 22
vicodin hp ....................... 22
VICTOZA 2-PAK ............... 59
VICTOZA 3-PAK ............... 59
VIDEX 2 GRAM PEDIATRIC
........................................ 8
VIDEX EC ........................... 8
vienva .............................. 75
vigabatrin ........................ 17
VIGAMOX ........................ 76
VIIBRYD ............................ 31
VIMPAT............................. 17
vinate one ...................... 91
viorele (28) ...................... 75
VIRACEPT ........................... 8
VIRAMUNE ......................... 8
VIRAMUNE XR ................... 8
VIREAD ............................... 8
virt-advance ................... 91
virt-nate ........................... 91
virt-phos 250 neutral ...... 88
virtrate-2 .......................... 86
virtrate-3 .......................... 87
virtrate-k .......................... 87
virtussin ac ....................... 81
virtussin dac .................... 81
virt-vite gt ........................ 91
vit b complex-folic acid 91
vitamin b complex ........ 91
vitamin d3 ....................... 91
vitamins a,c,d and
fluoride ......................... 91
VIVELLE-DOT ................... 70
vol-nate ........................... 91
vol-plus ............................ 91
vol-tab rx ......................... 91
VOLTAREN ....................... 24
voriconazole ..................... 5
VRAYLAR ......................... 31
vyfemla (28) ................... 75
VYVANSE ......................... 31
W warfarin ........................... 38
WELCHOL .................. 39, 40
wera (28) ......................... 75
westhroid ........................ 59
WIDE-SEAL DIAPHRAGM 68
woman's laxative ........... 64
women's laxative
(bisacodyl) .................. 64
WP THYROID ................... 59
wymzya fe ...................... 75
X XARELTO .......................... 38
XERMELO ......................... 14
XIFAXAN .......................... 11
XIIDRA .............................. 78
xulane .............................. 70
XULTOPHY 100/3.6 .......... 56
xylon 10 ........................... 22
Y yuvafem .......................... 70
Z zafirlukast ........................ 84
zaleplon .......................... 31
zamicet ........................... 22
zarah ............................... 75
ZAVESCA ......................... 57
zebutal ............................ 22
zenatane ........................ 45
zenchent (28) ................. 75
ZENPEP ............................. 65
zenzedi ............................ 31
ZENZEDI ............................ 31
ZERIT ....................................8
ZIAGEN ...............................8
zidovudine .........................8
zileuton ............................ 84
ziprasidone hcl ............... 31
ZIRGAN ............................ 76
ZMAX ..................................9
ZODRYL DEC 30 .............. 81
zolpidem ......................... 31
ZONALON ....................... 43
zonisamide ..................... 17
ZORTRESS ......................... 14
zovia 1/35e (28) ............. 75
zovia 1/50e (28) ............. 75
ZOVIRAX .......................... 47
ZUBSOLV .......................... 25
ZYCLARA ................... 66, 67
ZYFLO ............................... 84
ZYFLO CR ........................ 84
ZYLET ................................ 79
ZYPREXA .......................... 31
ZYPREXA RELPREVV ....... 31