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evidence of coverageJohns Hopkins Advantage MD

formulary list of covered drugsJohns Hopkins Advantage MD (PPO), Johns Hopkins Advantage Plus (PPO) and

Johns Hopkins Advantage MD Premier (PPO)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

HPMS Approved Formulary File Submission ID 0002033, Version 13

This formulary was updated on 08/01/2020. For more recent information or other questions, please contact Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage Plus (PPO) and Johns Hopkins Advantage MD Premier (PPO) Customer Service at 1-877-293-5325 or, for TTY users, 711, 24 hours a day, 7 days a week, or visit www.hopkinsmedicare.com.

Y0124_PPOFormulary0919_C

2020

http://www.hopkinsmedicare.com

Y0124_PPOFormulary0919_C 2

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Johns Hopkins Advantage MD. When it refers to “plan” or “our plan,” it means Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO) and Johns Hopkins Advantage MD Premier (PPO).

This document includes the list of the drugs (formulary) for our plan which is current as of 08/01/2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.

What is the Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO) and Johns Hopkins Advantage MD Premier (PPO) Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change? Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

• New generic drugs. We may immediately remove a brand name drug on our Drug List if we arereplacing it with a new generic drug that will appear on the same or lower cost sharing tier and withthe same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep thebrand name drug on our Drug List, but immediately move it to a different cost-sharing tier or addnew restrictions. If you are currently taking that brand name drug, we may not tell you in advancebefore we make that change, but we will later provide you with information about the specificchange(s) we have made.

o If we make such a change, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will also includeinformation on how to request an exception, and you can also find information in the sectionbelow entitled “How do I request an exception to the Johns Hopkins Advantage MD (PPO),Johns Hopkins Advantage MD Plus (PPO) and Johns Hopkins Advantage MD Premier(PPO) Formulary?”

3

• Drugs removed from the market. If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drug’s manufacturer removes the drug from the market, we willimmediately remove the drug from our formulary and provide notice to members who take the drug.

• Other changes. We may make other changes that affect members currently taking a drug. Forinstance, we may add a generic drug that is not new to market to replace a brand name drug currentlyon the formulary or add new restrictions to the brand name drug or move it to a different cost-sharingtier. Or we may make changes based on new clinical guidelines. If we remove drugs from ourformulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, wemust notify affected members of the change at least 30 days before the change becomes effective, orat the time the member requests a refill of the drug, at which time the member will receive a 30-daysupply of the drug.

o If we make these other changes, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will also includeinformation on how to request an exception, and you can also find information in the sectionbelow entitled “How do I request an exception to the Johns Hopkins Advantage MD (PPO),Johns Hopkins Advantage MD Plus (PPO) and Johns Hopkins Advantage MD Premier(PPO) Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year.

The enclosed formulary is current as of 08/01/2020. To get updated information about the drugs covered by our plan please contact us. Our contact information appears on the front and back cover pages. If we have a mid-year non-maintenance formulary change (i.e. remove drugs from our formulary, add prior authorization requirements, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier), we will notify you by mail. We will also update our formulary with the new information. The updated formulary information may be obtained from our website or by calling us at the number provided on the front and back cover pages.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 11. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS”. If you know what your drug is used for, look

Y0124_PPOFormulary0919_C


for the category name in the list that begins on page 11. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 58. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Our plan requires you or your physician to get prior authorization for certaindrugs. This means that you will need to get approval from our plan before you fill your prescriptions.If you don’t get approval, we may not cover the drug.

• Quantity Limits: For certain drugs our plan limits the amount of the drug that we will cover. Forexample, our plan provides 30 tablets every 30 days per prescription for Januvia. This may be inaddition to a standard one-month or three-month supply.

• Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medicalcondition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, our plan may not cover Drug B unless you try Drug A first. IfDrug A does not work for you, we will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 11. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO) and Johns Hopkins Advantage MD Premier (PPO) Formulary?” on page 5 for information about how to request an exception.


What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that our plan does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by our plan. When youreceive the list, show it to your doctor and ask him or her to prescribe a similar drug that is coveredby our plan.

• You can ask our plan to make an exception and cover your drug. See below for information abouthow to request an exception.

How do I request an exception to the Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO) and Johns Hopkins Advantage MD Premier (PPO) Formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will becovered at a pre-determined cost-sharing level, and you would not be able to ask us to provide thedrug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on thespecialty tier. If approved this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you canask us to waive the limit and cover a greater amount.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization your restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from doctor or other prescriber.


What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

If you experience a change in your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary (or if your ability to get your drugs is limited), we will cover a onetime temporary supply for up to 30-days (or 31-days if you are a long-term care resident) from a network pharmacy. During this period you should use the plan’s exception process if you wish to have continued coverage of the drug after the temporary supply is finished.

For more information For more detailed information about your Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO) and Johns Hopkins Advantage MD Premier (PPO) prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

http://www.medicare.gov/


Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO) and Johns Hopkins Advantage MD Premier (PPO) Formulary The formulary that begins on the next page provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 58.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g., levothyroxine).

The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.

• PA – Prior authorization

• QL – Drug has quantity limit

• ST – Step therapy required

• NM – Not available at mail-order pharmacies

• LA – Limited Access. This prescription may be available only at certain pharmacies. For moreinformation consult your Pharmacy Directory or call Customer Services at 1-877-293-4998, 24 hoursa day, 7 days a week. TTY users should call 711.

• B/D – This drug may be covered under Medicare Part B or D depending upon the circumstances.Information may need to be submitted describing the use and setting of the drug to make thedetermination.

• * - Not available as extended days supply.


Johns Hopkins Advantage MD (PPO)

Cost Sharing Tier Standard Retail Cost-Sharing (in-network)

Standard Mail Order Cost-Sharing (in-network)

Cost-Sharing Tier 1 (Preferred Generic)

$7 copay for a 30-day supply

$10.50 copay for a 60-day supply





Cost-Sharing Tier 2 (Generic)







Cost-Sharing Tier 3 (Preferred Brand)







Cost-Sharing Tier 4 (Non-Preferred Drug)







Cost-Sharing Tier 5

(Specialty Tier)

26% coinsurance for a 30-day supply (only)

NOTE:

-There is a prescription drug deductible for drugs on Tiers 3, 4, and 5. There is no deductible for drugs onTier 1 and Tier 2.

-Drugs are provided in a Long-Term Care Facility up to a 31-day supply

-Drugs in Tier 5 are only available for a 30-day supply

-Mail order is available to conveniently order up to a 90-day supply of medication on Tier 1 through Tier 4 attwo times the 30-day copay, saving you money and time. Contact us by calling the phone number listed onthe front and back page.

-You can find complete cost-sharing information in your Evidence of Coverage


Johns Hopkins Advantage MD Plus (PPO)































Cost-Sharing Tier 5

(Specialty Tier)


NOTE:

- There is a prescription drug deductible for drugs on Tiers 3, 4, and 5. There is no deductible for drugs onTier 1 and Tier 2.

-Drugs are provided in a Long-Term Care Facility up to a 31-day supply

-Drugs in Tier 5 are only available for a 30-day supply

-Mail order is available to conveniently order up to a 90-day supply of medication on Tier 1 through Tier 4 attwo times the 30-day copay, saving you money and time. Contact us by calling the phone number listed onthe front and back page.

-You can find complete cost-sharing information in your Evidence of Coverage


Johns Hopkins Advantage MD Premier (PPO)































Cost-Sharing Tier 5

(Specialty Tier)


NOTE:

- Drugs are provided in a Long-Term Care Facility up to a 31-day supply

- Drugs in Tier 5 are only available for a 30-day supply

- Mail order is available to conveniently order up to a 90-day supply of medication on Tier 1 through Tier 4 attwo times the 30-day copay, saving you money and time. Contact us by calling the phone number listed onthe front and back page.

- You can find complete cost-sharing information in your Evidence of Coverage

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Not available as extended days supply

9

Johns Hopkins Advantage MD (PPO)

Drug Name Drug Tier

Requirements/Limits

ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION GOUT - DRUGS TO TREAT GOUT allopurinol tab (generic of ZYLOPRIM)

1

colchicine w/ probenecid 2

COLCRYS QL (120 tabs / 30 days)

3 QL

MITIGARE QL (60 caps / 30 days)

3 QL

probenecid 2

NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib (generic of CELEBREX) CAPS 50mg

QL (240 caps / 30 days)

2 QL

celecoxib (generic of CELEBREX) CAPS 100mg


2 QL



2 QL



2 QL

diclofenac potassium QL (120 tabs / 30 days)

2 QL

diclofenac sodium TB24; TBEC

2

diflunisal TABS 2

etodolac CAPS 2

etodolac (generic of LODINE) TABS 400mg

2

etodolac TABS 500mg 2

etodolac er 2

flurbiprofen TABS 100mg 2

ibu tab 600mg 1

ibu tab 800mg 1

ibuprofen SUSP 2

ibuprofen TABS 400mg, 600mg, 800mg

1

meloxicam (generic of MOBIC) TABS

1

nabumetone TABS 1

Drug Name Drug Tier

Requirements/Limits

naproxen (generic of NAPROSYN) TABS 250mg

1

naproxen TABS 375mg, 500mg

1

naproxen dr (generic of EC-NAPROSYN) 375mg

2

naproxen dr (generic of EC-NAPROXEN) 500mg

2

naproxen sodium TABS 275mg

2

naproxen sodium (generic of ANAPROX DS) TABS 550mg

2

piroxicam (generic of FELDENE) CAPS

2

sulindac TABS 2

OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen w/ codeine 300-15mg

QL (400 tabs / 30 days)

2 QL

acetaminophen w/ codeine 300-30mg


2 QL

acetaminophen w/ codeine 300-60mg


2 QL

acetaminophen w/ codeine soln

QL (2700 mL / 30 days)

2 QL

butorphanol tartrate SOLN 1mg/ml, 2mg/ml

4

nalbuphine hcl SOLN 4

tramadol hcl tab 50 mg (generic of ULTRAM)


2 QL

tramadol-acetaminophen (generic of ULTRACET)


2 QL

OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN endocet 2.5-325mg (generic of PERCOCET)


2 QL

endocet 5-325mg (generic of PERCOCET)


2 QL


10

Drug Name Drug Tier

Requirements/Limits

endocet 7.5-325mg (generic of PERCOCET)


2 QL

endocet 10-325mg (generic of PERCOCET)


2 QL

fentanyl citrate (generic of ACTIQ) LPOP

QL (120 lozenges / 30 days)

5 * QL PA

fentanyl patch 12 mcg/hr (generic of DURAGESIC)

QL (10 patches / 30 days)

2 QL PA



2 QL PA



2 QL PA



2 QL PA



2 QL PA

hydroco/apap tab 5-325mg (generic of NORCO)


2 QL

hydroco/apap tab 7.5-325 (generic of NORCO)


2 QL

hydroco/apap tab 10-325mg (generic of NORCO)


2 QL

hydrocodone-acetaminophen 7.5-325 mg/15ml

QL (2700 mL / 30 days)

2 QL

hydrocodone-ibuprofen tab 7.5-200 mg


2 QL

hydromorphone hcl (generic of DILAUDID) LIQD

QL (600 mL / 30 days)

2 QL

Drug Name Drug Tier

Requirements/Limits

hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml

4 B/D

hydromorphone hcl (generic of DILAUDID) TABS


2 QL

HYSINGLA ER QL (30 tabs / 30 days)

3 QL PA

lorcet hd tab 10-325mg (generic of NORCO)


2 QL

lorcet plus tab 7.5-325 (generic of NORCO)


2 QL

lorcet tab 5-325mg (generic of NORCO)


2 QL

methadone hcl SOLN 5mg/5ml, 10mg/5ml

QL (450 mL / 30 days)

2 QL PA

methadone hcl 5mg (generic of DOLOPHINE)


2 QL PA

methadone hcl 10mg (generic of DOLOPHINE)


2 QL PA

methadone hcl intensol (generic of METHADOSE)

QL (90 mL / 30 days)

2 QL PA

morphine ext-rel tab (generic of MS CONTIN)


2 QL PA

morphine sul inj 1mg/ml 4 B/D

MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml

4 B/D

morphine sulfate (generic of MORPHINE SULFATE) SOLN 4mg/ml, 8mg/ml, 10mg/ml

4 B/D

morphine sulfate TABS QL (180 tabs / 30 days)

2 QL

morphine sulfate oral soln 10mg/5ml

QL (900 mL / 30 days)

2 QL


QL (900 mL / 30 days)

2 QL


11

Drug Name Drug Tier

Requirements/Limits


QL (180 mL / 30 days)

2 QL

NUCYNTA ER QL (60 tabs / 30 days)

3 QL PA

oxycodone hcl CAPS QL (180 caps / 30 days)

2 QL

oxycodone hcl CONC QL (180 mL / 30 days)

2 QL

oxycodone hcl SOLN QL (900 mL / 30 days)

2 QL

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


2 QL

oxycodone hcl TABS 10mg, 20mg


2 QL

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


2 QL

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


2 QL

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


2 QL

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


2 QL

ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS lidocaine hcl (local anesth.) (generic of XYLOCAINE) 2%

2 B/D

lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) .5%, 1%

2 B/D

lidocaine inj 0.5% (generic of XYLOCAINE)

2 B/D

lidocaine inj 1% (generic of XYLOCAINE)

2 B/D

lidocaine inj 1.5% preservative free (pf) (generic of XYLOCAINE-MPF)

2 B/D

Drug Name Drug Tier

Requirements/Limits

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 2

gentamicin in saline 2

gentamicin sulfate SOLN 2

neomycin sulfate TABS 2

paromomycin sulfate CAPS 2

streptomycin sulfate SOLR 5 *

SULFADIAZINE TABS 4

tobramycin (generic of KITABIS PAK) NEBU

5 * NM PA

tobramycin inj 1.2 gm/30ml 2

tobramycin inj 1.2gm 5 *

tobramycin inj 10mg/ml 2

tobramycin inj 80mg/2ml 2

tobramycin sulfate SOLN 2

ANTI-INFECTIVES - MISCELLANEOUS albendazole (generic of ALBENZA) TABS

5 *

ALINIA 5 *

atovaquone (generic of MEPRON) SUSP

5 *

aztreonam (generic of AZACTAM)

2

CAYSTON 5 * NM LA PA

clindamycin cap 75mg (generic of CLEOCIN)

1

clindamycin cap 300mg (generic of CLEOCIN)

1

clindamycin hcl cap 150 mg (generic of CLEOCIN)

1

clindamycin phosphate in d5w 2

CLINDAMYCIN PHOSPHATE IN NACL

4

clindamycin phosphate inj (generic of CLEOCIN PHOSPHATE)

2

clindamycin soln 75mg/5ml (generic of CLEOCIN PEDIATRIC GRANULE)

2

colistimethate sodium (generic of COLY-MYCIN M) SOLR

2

dapsone TABS 2

daptomycin (generic of DAPTOMYCIN) 350mg

5 *


12

Drug Name Drug Tier

Requirements/Limits

daptomycin (generic of CUBICIN) 500mg

5 *

EMVERM QL (12 tabs / 365 days)

5 * QL

ertapenem sodium (generic of INVANZ)

2

imipenem-cilastatin 2

imipenem-cilastatin (generic of PRIMAXIN IV)

2

ivermectin (generic of STROMECTOL) TABS

2

linezolid in sodium chloride 4

linezolid inj (generic of ZYVOX)

2

linezolid susp (generic of ZYVOX)

5 *

linezolid tab 600mg (generic of ZYVOX)

2

meropenem (generic of MERREM)

2

methenamine hippurate (generic of HIPREX)

2

metronidazole (generic of FLAGYL) TABS

1

metronidazole in nacl 2

nitrofurantoin macrocrystal (generic of MACRODANTIN) 50mg, 100mg

3

nitrofurantoin monohyd macro (generic of MACROBID)

3

pentamidine isethionate inh (generic of NEBUPENT)

2 B/D

pentamidine isethionate inj (generic of PENTAM 300)

2

praziquantel (generic of BILTRICIDE) TABS

2

SIVEXTRO 5 *

sulfamethoxazole-trimethop ds (generic of BACTRIM DS)

1

sulfamethoxazole-trimethoprim inj

2

sulfamethoxazole-trimethoprim susp

2

sulfamethoxazole-trimethoprim tab 400-80mg (generic of BACTRIM)

1

SYNERCID 5 *

Drug Name Drug Tier

Requirements/Limits

tigecycline (generic of TYGACIL)

5 *

trimethoprim TABS 1

vancomycin hcl (generic of VANCOCIN HCL) CAPS 125mg


2 QL

vancomycin hcl (generic of VANCOCIN) CAPS 250mg


5 * QL

vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg

2

VANCOMYCIN IN NACL 4

ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ABELCET 5 * B/D

AMBISOME 5 * B/D

amphotericin b SOLR 2 B/D

caspofungin acetate (generic of CANCIDAS)

5 *

fluconazole (generic of DIFLUCAN) SUSR

2

fluconazole (generic of DIFLUCAN) TABS 50mg, 100mg, 200mg

2

fluconazole (generic of DIFLUCAN) TABS 150mg

1

fluconazole inj nacl 200 2

fluconazole inj nacl 400 2

flucytosine (generic of ANCOBON) CAPS

5 *

griseofulvin microsize 2

griseofulvin ultramicrosize 2

itraconazole (generic of SPORANOX) CAPS

2 PA

ketoconazole TABS 2 PA

micafungin sodium (generic of MYCAMINE)

5 *

MYCAMINE 5 *

NOXAFIL SUSP QL (630 mL / 30 days)

5 * QL

nystatin TABS 2

posaconazole (generic of NOXAFIL)


5 * QL


13

Drug Name Drug Tier

Requirements/Limits

terbinafine hcl (generic of LAMISIL) TABS

QL (90 tabs / year)

1 QL

voriconazole (generic of VFEND IV) SOLR

5 * PA

voriconazole (generic of VFEND) SUSR

5 * PA

voriconazole (generic of VFEND) TABS 50mg

2

voriconazole (generic of VFEND) TABS 200mg

5 *

ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl (generic of MALARONE)

2

chloroquine phosphate TABS 2

COARTEM 4

mefloquine hcl 2

PRIMAQUINE PHOSPHATE 26.3mg

3

primaquine phosphate (generic of PRIMAQUINE PHOSPHATE) 26.3mg

2

quinine sulfate (generic of QUALAQUIN) CAPS

2 PA

ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate (generic of ZIAGEN)

2 NM

APTIVUS 5 * NM

atazanavir sulfate (generic of REYATAZ)

2 NM

CRIXIVAN 4 NM

didanosine 2 NM

EDURANT 5 * NM

efavirenz (generic of SUSTIVA) CAPS 50mg

2 NM

efavirenz (generic of SUSTIVA) CAPS 200mg

5 * NM

efavirenz (generic of SUSTIVA) TABS

5 * NM

EMTRIVA 3 NM

fosamprenavir tab 700 mg (generic of LEXIVA)

5 * NM

FUZEON 5 * NM

INTELENCE 25mg 4 NM

INTELENCE 100mg, 200mg 5 * NM

INVIRASE 5 * NM

Drug Name Drug Tier

Requirements/Limits

ISENTRESS CHEW 25mg 3 NM

ISENTRESS CHEW 100mg 5 * NM

ISENTRESS PACK 3 NM

ISENTRESS TABS 5 * NM

ISENTRESS HD 5 * NM

lamivudine (generic of EPIVIR)

2 NM

LEXIVA SUSP 4 NM

nevirapine susp 50 mg/5ml (generic of VIRAMUNE)

2 NM

nevirapine tab 100mg er 2 NM

nevirapine tab 200mg (generic of VIRAMUNE)

2 NM

nevirapine tab 400mg er (generic of VIRAMUNE XR)

2 NM

NORVIR PACK 4 NM

NORVIR SOLN 4 NM

PIFELTRO 5 * NM

PREZISTA SUSP QL (400 mL / 30 days)

5 * QL NM

PREZISTA TABS 75mg QL (480 tabs / 30 days)

4 QL NM


5 * QL NM


5 * QL NM


5 * QL NM

REYATAZ PACK 5 * NM

ritonavir (generic of NORVIR) 2 NM

SELZENTRY SOLN 5 * NM

SELZENTRY TABS 25mg 4 NM

SELZENTRY TABS 75mg, 150mg, 300mg

5 * NM

stavudine 15mg, 20mg 2 NM

stavudine (generic of ZERIT) 30mg, 40mg

2 NM

tenofovir disoproxil fumarate (generic of VIREAD)

2 NM

TIVICAY 10mg 3 NM

TIVICAY 25mg, 50mg 5 * NM

TROGARZO 5 * NM LA

TYBOST 4 NM

VIRACEPT 5 * NM

VIREAD POWD 5 * NM

VIREAD TABS 150mg, 200mg, 250mg

5 * NM


14

Drug Name Drug Tier

Requirements/Limits

zidovudine cap 100mg (generic of RETROVIR)

2 NM

zidovudine syp 50mg/5ml (generic of RETROVIR)

2 NM

zidovudine tab 300mg 2 NM

ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine (generic of EPZICOM)

2 NM

abacavir sulfate-lamivudine-zidovudine (generic of TRIZIVIR)

5 * NM

ATRIPLA 5 * NM

BIKTARVY 5 * NM

CIMDUO 5 * NM

COMPLERA 5 * NM

DELSTRIGO 5 * NM

DESCOVY 5 * NM

DOVATO 5 * NM

EVOTAZ 5 * NM

GENVOYA 5 * NM

JULUCA 5 * NM

KALETRA TAB 100-25MG 4 NM

KALETRA TAB 200-50MG 5 * NM

lamivudine-zidovudine (generic of COMBIVIR)

2 NM

lopinavir-ritonavir (generic of KALETRA)

2 NM

ODEFSEY 5 * NM

PREZCOBIX 5 * NM

STRIBILD 5 * NM

SYMFI 5 * NM

SYMFI LO 5 * NM

SYMTUZA 5 * NM

TEMIXYS 5 * NM

TRIUMEQ 5 * NM

TRUVADA TAB 100-150 QL (30 tabs / 30 days)

5 * QL NM


5 * QL NM


5 * QL NM


5 * QL NM

Drug Name Drug Tier

Requirements/Limits

ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS cycloserine CAPS 5 *

ethambutol hcl TABS 100mg 2

ethambutol hcl (generic of MYAMBUTOL) TABS 400mg

2

isoniazid TABS 1

isoniazid syp 50mg/5ml 2

PASER D/R 4

PRIFTIN 4

pyrazinamide TABS 2

rifabutin (generic of MYCOBUTIN)

2

rifampin (generic of RIFADIN) CAPS; SOLR

2

RIFATER 4

SIRTURO 100mg 5 * LA PA

TRECATOR 4

ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir CAPS 1

acyclovir (generic of ZOVIRAX) SUSP

2

acyclovir (generic of ZOVIRAX) TABS

1

acyclovir sodium 2 B/D

adefovir dipivoxil (generic of HEPSERA)

5 * NM

BARACLUDE SOLN 5 * NM

entecavir (generic of BARACLUDE)

2 NM

EPCLUSA 5 * NM PA

EPIVIR HBV SOLN 4 NM

famciclovir TABS 2

ganciclovir sodium (generic of CYTOVENE)

2 B/D

HARVONI 5 * NM PA

lamivudine (hbv) (generic of EPIVIR HBV)

2 NM

MAVYRET 5 * NM PA

oseltamivir phosphate (generic of TAMIFLU) CAPS 30mg

QL (168 caps / year)

2 QL


15

Drug Name Drug Tier

Requirements/Limits

oseltamivir phosphate (generic of TAMIFLU) CAPS 45mg, 75mg

QL (84 caps / year)

2 QL

oseltamivir phosphate (generic of TAMIFLU) SUSR

QL (1080 mL / year)

2 QL

PEGASYS 5 * NM PA

PEGASYS PROCLICK 5 * NM PA

RELENZA DISKHALER QL (6 inhalers / year)

3 QL

ribavirin 200mg 2 NM

rimantadine hydrochloride 2

valacyclovir hcl (generic of VALTREX) TABS

2

valganciclovir hcl (generic of VALCYTE)

5 *

VEMLIDY 5 * NM

VOSEVI 5 * NM PA

CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor 2

CEFACLOR MONOHYDRATE ER

4

cefadroxil CAPS 1

cefadroxil SUSR; TABS 2

CEFAZOLIN IN DEXTROSE 2GM/100ML-4%

3

cefazolin inj 2

cefazolin sodium SOLR 1gm 2

CEFAZOLIN SODIUM 1 GM/50ML

3

cefdinir 2

cefepime hcl 2

cefixime (generic of SUPRAX) SUSR

2

cefoxitin sodium 2

cefpodoxime proxetil 2

cefprozil 2

ceftazidime SOLR 2

CEFTAZIDIME/DEXTROSE 4

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

2

cefuroxime axetil 2

cefuroxime sodium 2

Drug Name Drug Tier

Requirements/Limits

cephalexin (generic of KEFLEX) CAPS 250mg, 500mg

1

cephalexin SUSR 2

tazicef SOLR 2

TEFLARO 5 *

ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin PACK 2

azithromycin (generic of ZITHROMAX) SOLR

2

azithromycin (generic of ZITHROMAX) SUSR

2

azithromycin (generic of ZITHROMAX) TABS 250mg, 500mg

1

azithromycin TABS 600mg 1

clarithromycin TABS 2

clarithromycin er (generic of BIAXIN XL)

2

clarithromycin for susp 2

DIFICID 5 *

e.e.s 400 2

ery-tab 2

ERYTHROCIN LACTOBIONATE

4

erythrocin stearate 2

erythromycin base 2

erythromycin cap 250mg ec 2

erythromycin ethylsuccinate TABS

2

erythromycin tab ec 2

FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS CIPRO SUSR 500mg/5ml 4

ciprofloxacin hcl tab 100mg 2

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

1

ciprofloxacin hcl tab 750mg 1

ciprofloxacin in d5w 2

levofloxacin (generic of LEVAQUIN) TABS

1

levofloxacin in d5w 2

levofloxacin inj 25mg/ml 2

levofloxacin oral soln 25 mg/ml

2


16

Drug Name Drug Tier

Requirements/Limits

PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin CAPS; SUSR; TABS

1

amoxicillin CHEW 2

amoxicillin & pot clavulanate 200-28.5 chw tabs

2

amoxicillin & pot clavulanate 200/5ml susr

2

amoxicillin & pot clavulanate 250-125 tabs

2

amoxicillin & pot clavulanate 250/5ml susr (generic of AUGMENTIN)

2

amoxicillin & pot clavulanate 400-57 chw tabs

2


2

amoxicillin & pot clavulanate 500-125 tabs (generic of AUGMENTIN)

2


2

amoxicillin & pot clavulanate 875-125 tabs

2

amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs

2

ampicillin & sulbactam sodium (generic of UNASYN)

2

ampicillin & sulbactam sodium (generic of UNASYN BULK PACK)

2

ampicillin cap 500mg 1

ampicillin inj 2

ampicillin sodium 2

BICILLIN L-A 4

dicloxacillin sodium 2

nafcillin sodium 1gm, 2gm 2

nafcillin sodium 10gm 5 *

NAFCILLIN SODIUM FOR INJ 10GM

4

oxacillin sodium SOLR 1gm, 2gm

2

oxacillin sodium SOLR 10gm 5 *

PENICILLIN G POT IN DEXTROSE 2MU

4

PENICILLIN G POT IN DEXTROSE 3MU

4

Drug Name Drug Tier

Requirements/Limits

PENICILLIN G PROCAINE 4

penicillin g sodium 2

penicillin v potassium SOLR 2

penicillin v potassium TABS 1

penicilln gk inj 5mu 2

penicilln gk inj 20mu 2

pfizerpen-g inj 5mu 2

pfizerpen-g inj 20mu 2

piper/tazoba inj 2-0.25gm 2





TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxy 100 2

doxycycline (monohydrate) CAPS 50mg, 100mg

1

doxycycline (monohydrate) TABS 50mg, 75mg, 100mg

2

doxycycline hyclate CAPS 50mg

2

doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg

2

doxycycline hyclate SOLR 2

doxycycline hyclate TABS 20mg, 100mg

2

minocycline hcl CAPS 50mg, 75mg

2

minocycline hcl (generic of MINOCIN) CAPS 100mg

2

mondoxyne nl cap 100mg 1

tetracycline hcl CAPS 2

ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS BENDEKA 5 * B/D NM

cyclophosphamide CAPS 2 B/D

cyclophosphamide SOLR 5 * B/D

EMCYT 4

GLEOSTINE 10mg 4

GLEOSTINE 40mg, 100mg 5 *

LEUKERAN 5 *

ANTHRACYCLINES adriamycin SOLN 2 B/D


17

Drug Name Drug Tier

Requirements/Limits

doxorubicin hcl 2 B/D

doxorubicin hcl liposomal (generic of DOXIL)

5 * B/D

epirubicin hcl 50mg/25ml 2 B/D

epirubicin hcl (generic of ELLENCE) 200mg/100ml

2 B/D

ANTIMETABOLITES adrucil inj 2 B/D

ALIMTA 5 * B/D

azacitidine (generic of VIDAZA)

5 * B/D NM

cytarabine 20mg/ml 2 B/D

fluorouracil SOLN 2 B/D

gemcitabine inj soln (generic of GEMCITABINE)

2 B/D

gemcitabine inj solr 2 B/D

mercaptopurine TABS 2

methotrexate sodium inj soln 2 B/D

methotrexate sodium inj solr 2 B/D

PURIXAN 5 * NM

TABLOID 5 *

ANTIMITOTIC, TAXOIDS ABRAXANE 5 * B/D

docetaxel CONC 20mg/ml 5 * B/D

docetaxel (generic of TAXOTERE) CONC 80mg/4ml

5 * B/D

DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml

5 * B/D

docetaxel (generic of DOCETAXEL) CONC 160mg/8ml

5 * B/D

DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

5 * B/D

docetaxel (generic of DOCETAXEL) SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

5 * B/D

paclitaxel 2 B/D

TAXOTERE 5 * B/D

ANTIMITOTIC, VINCA ALKALOIDS vincristine sulfate 2 B/D

vinorelbine tartrate 2 B/D

BIOLOGIC RESPONSE MODIFIERS AVASTIN 5 * NM LA PA

Drug Name Drug Tier

Requirements/Limits

BORTEZOMIB 5 * NM PA

DAURISMO 5 * NM LA PA

ERIVEDGE 5 * NM LA PA

FARYDAK 5 * NM LA PA

HERCEPTIN 5 * NM PA

HERCEPTIN HYLECTA 5 * NM PA

HERZUMA 5 * NM PA

IBRANCE CAPS QL (21 caps / 28 days)

5 * QL NM LA PA

IBRANCE TABS QL (21 tabs / 28 days)

5 * QL NM LA PA

IDHIFA QL (30 tabs / 30 days)

5 * QL NM LA PA

KADCYLA 5 * B/D NM

KANJINTI 5 * NM PA

KEYTRUDA 5 * NM PA

KISQALI 5 * NM PA

KISQALI FEMARA 200 DOSE 5 * NM PA



LYNPARZA 5 * NM LA PA

MVASI 5 * NM LA PA

NINLARO 5 * NM PA

ODOMZO 5 * NM LA PA

OGIVRI 5 * NM PA

ONTRUZANT 5 * NM PA

RITUXAN 5 * NM LA PA

RITUXAN HYCELA 5 * NM LA PA

RUBRACA 5 * NM LA PA

RUXIENCE 5 * NM PA

TALZENNA 5 * NM LA PA

TECENTRIQ 5 * NM LA PA

TIBSOVO 5 * NM LA PA

TRAZIMERA 5 * NM PA

TRUXIMA 5 * NM PA

VELCADE 5 * NM PA

VENCLEXTA 10mg 4 NM LA PA

VENCLEXTA 50mg, 100mg 5 * NM LA PA

VENCLEXTA STARTING PACK

5 * NM LA PA

VERZENIO 5 * NM LA PA

ZEJULA 5 * NM LA PA

ZIRABEV 5 * NM PA

ZOLINZA 5 * NM PA

HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate (generic of ZYTIGA)

5 * NM PA


18

Drug Name Drug Tier

Requirements/Limits

anastrozole (generic of ARIMIDEX) TABS

1

bicalutamide (generic of CASODEX)

2

DEPO-PROVERA INJ 400/ML 4 B/D

ERLEADA 5 * NM LA PA

exemestane (generic of AROMASIN)

2

flutamide 2

fulvestrant (generic of FASLODEX)

5 * B/D

letrozole (generic of FEMARA) TABS

1

leuprolide inj 1mg/0.2 2 NM PA

LUPRON DEPOT (1-MONTH) 3.75mg

5 * NM PA

LUPRON DEPOT INJ 11.25MG (3-MONTH)

5 * NM PA

LYSODREN 3

megestrol ac sus 40mg/ml 3

megestrol ac tab 20mg 3

megestrol ac tab 40mg 3

megestrol sus 625mg/5ml 4 PA

nilutamide (generic of NILANDRON)

5 *

NUBEQA 5 * NM LA PA

SOLTAMOX 5 *

tamoxifen citrate TABS 1

toremifene citrate (generic of FARESTON)

5 *

TRELSTAR DEP INJ 3.75MG 5 * NM PA

TRELSTAR LA INJ 11.25MG 5 * NM PA

XTANDI 5 * NM LA PA

ZYTIGA 500mg 5 * NM LA PA

IMMUNOMODULATORS POMALYST CAP 1MG

QL (21 caps / 21 days) 5 * QL NM LA

PA

POMALYST CAP 2MG QL (21 caps / 21 days)

5 * QL NM LA PA


5 * QL NM LA PA


5 * QL NM LA PA

REVLIMID QL (28 caps / 28 days)

5 * QL NM LA PA

THALOMID 50mg, 100mg QL (28 caps / 28 days)

5 * QL NM PA

Drug Name Drug Tier

Requirements/Limits

THALOMID 150mg, 200mg QL (56 caps / 28 days)

5 * QL NM PA

KINASE INHIBITORS AFINITOR 10mg

QL (30 tabs / 30 days) 5 * QL NM PA

AFINITOR DISPERZ 2mg QL (150 tabs / 30 days)

5 * QL NM PA


5 * QL NM PA


5 * QL NM PA

ALECENSA 5 * NM LA PA

ALUNBRIG 5 * NM LA PA

AYVAKIT QL (30 tabs / 30 days)

5 * QL NM LA PA

BALVERSA 5 * NM LA PA

BOSULIF 5 * NM PA

BRAFTOVI 5 * NM LA PA

BRUKINSA 5 * NM LA PA

CABOMETYX QL (30 tabs / 30 days)

5 * QL NM LA PA

CALQUENCE 5 * NM LA PA

CAPRELSA 5 * NM LA PA

COMETRIQ 5 * NM LA PA

COPIKTRA 5 * NM LA PA

COTELLIC 5 * NM LA PA

erlotinib hcl (generic of TARCEVA) 25mg


5 * QL NM PA

erlotinib hcl (generic of TARCEVA) 100mg, 150mg


5 * QL NM PA

everolimus (generic of AFINITOR)


5 * QL NM PA

GILOTRIF TAB 20MG 5 * NM LA PA



ICLUSIG 5 * NM LA PA

imatinib mesylate (generic of GLEEVEC) 100mg


5 * QL NM PA

imatinib mesylate (generic of GLEEVEC) 400mg


5 * QL NM PA

IMBRUVICA 5 * NM LA PA

INLYTA 1mg QL (180 tabs / 30 days)

5 * QL NM LA PA


19

Drug Name Drug Tier

Requirements/Limits

INLYTA 5mg QL (120 tabs / 30 days)

5 * QL NM LA PA

INREBIC 5 * NM LA PA

IRESSA 5 * NM LA PA

JAKAFI QL (60 tabs / 30 days)

5 * QL NM LA PA

LENVIMA 4 MG DAILY DOSE 5 * NM LA PA

LENVIMA 8 MG DAILY DOSE 5 * NM LA PA

LENVIMA 10 MG DAILY DOSE

5 * NM LA PA

LENVIMA 12MG DAILY DOSE

5 * NM LA PA


5 * NM LA PA


5 * NM LA PA


5 * NM LA PA


5 * NM LA PA

LORBRENA 5 * NM LA PA

MEKINIST 5 * NM LA PA

MEKTOVI 5 * NM LA PA

NERLYNX 5 * NM LA PA

NEXAVAR 5 * NM LA PA

PEMAZYRE 5 * NM LA PA

PIQRAY 200MG DAILY DOSE

5 * NM PA


5 * NM PA


5 * NM PA

ROZLYTREK 5 * NM LA PA

RYDAPT 5 * NM PA

SPRYCEL 5 * NM PA

STIVARGA 5 * NM LA PA

SUTENT QL (30 caps / 30 days)

5 * QL NM PA

TAFINLAR 5 * NM LA PA

TAGRISSO QL (30 tabs / 30 days)

5 * QL NM LA PA

TASIGNA 5 * NM PA

TUKYSA 5 * NM LA PA

TURALIO 5 * NM LA PA

TYKERB 5 * NM LA PA

VITRAKVI 5 * NM LA PA

VIZIMPRO 5 * NM LA PA

VOTRIENT 5 * NM LA PA

Drug Name Drug Tier

Requirements/Limits

XALKORI 5 * NM LA PA

XOSPATA 5 * NM LA PA

ZELBORAF 5 * NM LA PA

ZYDELIG 5 * NM LA PA

ZYKADIA 5 * NM LA PA

MISCELLANEOUS bexarotene (generic of TARGRETIN)

5 * NM PA

hydroxyurea (generic of HYDREA) CAPS

2

LONSURF 5 * NM PA

MATULANE 5 * LA

SYLATRON 5 * NM PA

SYNRIBO 5 * NM PA

TAZVERIK 5 * NM LA PA

tretinoin (chemotherapy) 5 *

XPOVIO 60 MG ONCE WEEKLY

5 * NM LA PA


5 * NM LA PA

XPOVIO 80 MG TWICE WEEKLY

5 * NM LA PA


5 * NM LA PA

PLATINUM-BASED AGENTS carboplatin 2 B/D

cisplatin SOLN 2 B/D

oxaliplatin inj 50mg 5 * B/D

oxaliplatin inj 50mg/10ml 2 B/D

oxaliplatin inj 100mg 5 * B/D

oxaliplatin inj 100mg/20ml 2 B/D

PROTECTIVE AGENTS leucovorin calcium SOLN 500mg/50ml

2 B/D

leucovorin calcium SOLR 2 B/D

leucovorin calcium TABS 2

MESNEX TABS 5 *

TOPOISOMERASE INHIBITORS etoposide SOLN 2 B/D

irinotecan hcl (generic of CAMPTOSAR) 40mg/2ml, 100mg/5ml

2 B/D

irinotecan hcl 300mg/15ml, 500mg/25ml

2 B/D

toposar 2 B/D


20

Drug Name Drug Tier

Requirements/Limits

CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine--benazepril hcl cap 10-20 mg (generic of LOTREL)

1

amlodipine-benazepril hcl cap 2.5-10 mg

1

amlodipine-benazepril hcl cap 5-10 mg (generic of LOTREL)

1

amlodipine-benazepril hcl cap 5-20 mg (generic of LOTREL)

1

amlodipine-benazepril hcl cap 5-40 mg

1

amlodipine-benazepril hcl cap 10-40mg (generic of LOTREL)

1

benazepril & hydrochlorothiazide

1

benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)

1

captopril & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide (generic of VASERETIC)

1

fosinopril sodium & hydrochlorothiazide

1

lisinopril & hydrochlorothiazide (generic of ZESTORETIC)

1

quinapril-hydrochlorothiazide (generic of ACCURETIC)

1

ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl TABS 5mg 1

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

1

captopril TABS 1

enalapril maleate (generic of VASOTEC) TABS

1

fosinopril sodium 1

Drug Name Drug Tier

Requirements/Limits

lisinopril (generic of ZESTRIL) TABS 2.5mg, 5mg, 30mg, 40mg

1

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

1

moexipril hcl 1

perindopril erbumine 1

quinapril hcl (generic of ACCUPRIL)

1

ramipril (generic of ALTACE) 1

trandolapril 1mg, 2mg 1

trandolapril (generic of MAVIK) 4mg

1

ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone (generic of INSPRA)

2

spironolactone (generic of ALDACTONE) TABS

1

ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate (generic of CARDURA) TABS

1

prazosin hcl (generic of MINIPRESS)

2

terazosin hcl 1mg, 2mg, 5mg 1

terazosin hcl 10mg 2

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-olmesartan medoxomil (generic of AZOR)

1

amlodipine besylate-valsartan tab 5-160 mg (generic of EXFORGE)

1


1


1


1


21

Drug Name Drug Tier

Requirements/Limits

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg (generic of EXFORGE HCT)

1

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg (generic of EXFORGE HCT)

1

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg (generic of EXFORGE HCT)

1


1


1

ENTRESTO 3

irbesartan-hydrochlorothiazide (generic of AVALIDE)

1

losartan-hydrochlorothiazide (generic of HYZAAR)

1

olmesartan medoxomil-amlodipine-hydrochlorothiazide (generic of TRIBENZOR)

1

olmesartan medoxomil-hydrochlorothiazide (generic of BENICAR HCT)

1

valsartan-hydrochlorothiazide (generic of DIOVAN HCT)

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE irbesartan (generic of AVAPRO)

1

losartan potassium (generic of COZAAR) TABS

1

olmesartan medoxomil (generic of BENICAR) TABS

1

telmisartan (generic of MICARDIS)

1

valsartan (generic of DIOVAN) 1

Drug Name Drug Tier

Requirements/Limits

ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl soln 2

amiodarone tab 100mg 2



disopyramide phosphate (generic of NORPACE)

4

dofetilide (generic of TIKOSYN)

2 NM

flecainide acetate 2

MULTAQ 4

NORPACE CR 4

pacerone 100mg, 400mg 2

pacerone 200mg 1

propafenone hcl 2

propafenone hcl 12hr (generic of RYTHMOL SR)

2

quinidine sulfate 2

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

1

sorine 240mg 1

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

1

sotalol hcl 240mg 1

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

2

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium (generic of LIPITOR) TABS

1

lovastatin 1

pravastatin sodium 10mg, 80mg

1

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

1

rosuvastatin calcium (generic of CRESTOR)


1 QL

simvastatin (generic of ZOCOR) TABS 5mg, 10mg, 20mg, 40mg

1


22

Drug Name Drug Tier

Requirements/Limits

simvastatin (generic of ZOCOR) TABS 80mg


1 QL

ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine (generic of QUESTRAN)

2

cholestyramine light pack 2

cholestyramine light powd (generic of QUESTRAN LIGHT)

2

colesevelam hcl (generic of WELCHOL)

2

colestipol hcl gran (generic of COLESTID)

2

colestipol hcl pack (generic of COLESTID)

2

colestipol hcl tabs (generic of COLESTID)

2

ezetimibe (generic of ZETIA) 2

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

2

fenofibrate TABS 54mg, 160mg

2

fenofibrate micronized 67mg, 134mg, 200mg

2

gemfibrozil (generic of LOPID) TABS

1

JUXTAPID 5 * NM LA PA

niacin (antihyperlipidemic) 2

niacin er (antihyperlipidemic) (generic of NIASPAN) 500mg


2 QL

niacin er (antihyperlipidemic) (generic of NIASPAN) 750mg, 1000mg

2

niacor 2

PRALUENT 3 NM PA

prevalite PACK 2

prevalite (generic of QUESTRAN LIGHT) POWD

2

VASCEPA 4

Drug Name Drug Tier

Requirements/Limits

BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone (generic of TENORETIC 50)

1

atenolol & chlorthalidone (generic of TENORETIC 100)

1

bisoprolol & hydrochlorothiazide (generic of ZIAC)

1

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

2

metoprolol & hctz tab 100-25mg

2

metoprolol & hctz tab 100-50mg

2

propranolol & hydrochlorothiazide

2

BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl CAPS 1

atenolol (generic of TENORMIN) TABS

1

bisoprolol fumarate 1

BYSTOLIC 2.5mg, 5mg, 10mg


4 QL

BYSTOLIC 20mg QL (60 tabs / 30 days)

4 QL

carvedilol (generic of COREG) 1

labetalol hcl TABS 2

metoprolol succinate (generic of TOPROL XL)

1

metoprolol tartrate SOCT 2

metoprolol tartrate SOLN 2

metoprolol tartrate TABS 25mg

1

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

1

nadolol (generic of CORGARD) TABS

2

pindolol 2


23

Drug Name Drug Tier

Requirements/Limits

propranolol cap er (generic of INDERAL LA)

2

propranolol hcl TABS 2

propranolol oral sol 2

timolol maleate TABS 2

CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS amlodipine besylate (generic of NORVASC) TABS

1

cartia xt cap 120/24hr (generic of CARDIZEM CD)

2


2


2


2

dilt-xr cap 2

diltiazem cap 240mg cd (generic of CARDIZEM CD)

2

diltiazem cap 360mg cd (generic of CARDIZEM CD)

2

diltiazem cap er/12hr 2

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

1

diltiazem hcl TABS 90mg 1

diltiazem hcl coated beads (generic of CARDIZEM CD) CP24

2

diltiazem hcl coated beads cap sr 24hr (generic of CARDIZEM CD)

2

diltiazem hcl extended release beads cap sr (generic of TIAZAC) 120mg, 180mg, 240mg, 300mg, 360mg, 420mg

2

diltiazem hcl extended release beads cap sr (generic of CARDIZEM CD) 180mg

2

diltiazem inj 2

felodipine 2

isradipine 2

nicardipine hcl CAPS 2

Drug Name Drug Tier

Requirements/Limits

nifedipine (generic of PROCARDIA XL) TB24

2

nifedipine er 2

nimodipine CAPS 5 *

NYMALIZE 5 *

taztia xt (generic of TIAZAC) 2

tiadylt er (generic of TIAZAC) 2

verapamil cap er (generic of VERELAN PM) 100mg, 200mg

2

verapamil cap er (generic of VERELAN) 120mg, 180mg, 240mg

2

verapamil cap er 300mg, 360mg

2

verapamil hcl SOLN 2

verapamil hcl TABS 1

verapamil hcl tab er (generic of CALAN SR) 120mg, 240mg

1

verapamil hcl tab er 180mg 1

DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digitek (generic of LANOXIN) .25mg

PA if 70 years and older

2 PA

digitek (generic of LANOXIN) .125mg


2 QL

digox (generic of LANOXIN) 125mcg


2 QL

digox (generic of LANOXIN) 250mcg


2 PA

digoxin (generic of LANOXIN) TABS 125mcg


2 QL

digoxin (generic of LANOXIN) TABS 250mcg


2 PA

digoxin inj (generic of LANOXIN)

2

digoxin sol 50mcg/ml PA if 70 years and older

2 PA


24

Drug Name Drug Tier

Requirements/Limits

DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide CP12; TABS 2

amiloride & hydrochlorothiazide

1

amiloride hcl TABS 1

bumetanide SOLN 2

bumetanide (generic of BUMEX) TABS

2

chlorothiazide TABS 2

chlorthalidone 2

furosemide SOLN 1

furosemide (generic of LASIX) TABS

1

furosemide inj 2

hydrochlorothiazide CAPS; TABS

1

indapamide 1

methazolamide TABS 2

metolazone 2

spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)

2

torsemide tabs 1

triamterene & hydrochlorothiazide cap 37.5-25 mg (generic of DYAZIDE)

1

triamterene & hydrochlorothiazide tabs (generic of MAXZIDE)

1

triamterene & hydrochlorothiazide tabs (generic of MAXZIDE-25)

1

MISCELLANEOUS aliskiren fumarate (generic of TEKTURNA)

2

clonidine hcl (generic of CATAPRES) TABS

1

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

2


2


2

Drug Name Drug Tier

Requirements/Limits

CORLANOR 4

DEMSER 5 * PA

hydralazine hcl SOLN; TABS 2

midodrine hcl 2

minoxidil TABS 1

NORTHERA 100mg QL (90 caps / 30 days)

5 * QL NM LA PA

NORTHERA 200mg, 300mg QL (180 caps / 30 days)

5 * QL NM LA PA

ranolazine (generic of RANEXA)

2

NITRATES - DRUGS TO TREAT HEART CONDITIONS isosorb mononitrate tab 1

isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg

2

isosorbide dinitrate 10mg, 20mg, 30mg

2

isosorbide mononitrate er 1

minitran (generic of NITRO-DUR)

2

NITRO-BID 3

NITRO-DUR DIS 0.3MG/HR 4

NITRO-DUR DIS 0.8MG/HR 4

nitroglycerin (generic of NITROSTAT) SUBL

2

nitroglycerin td patch .1mg/hr 2

nitroglycerin td patch (generic of NITRO-DUR) .2mg/hr, .4mg/hr, .6mg/hr

2

PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION ADEMPAS

QL (90 tabs / 30 days) 5 * QL NM LA

PA

ambrisentan (generic of LETAIRIS)


5 * QL NM LA PA

bosentan (generic of TRACLEER) 62.5mg


5 * QL NM LA PA

bosentan (generic of TRACLEER) 125mg


5 * QL NM LA PA

OPSUMIT QL (30 tabs / 30 days)

5 * QL NM LA PA


25

Drug Name Drug Tier

Requirements/Limits

sildenafil citrate tab 20 mg (pulmonary hypertension) (generic of REVATIO)


2 QL NM PA

treprostinil 5 * NM LA PA

VENTAVIS 5 * NM PA

CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY alprazolam tab 0.5mg (generic of XANAX)


2 QL

alprazolam tab 0.25mg (generic of XANAX)


2 QL

alprazolam tab 1mg (generic of XANAX)


2 QL

alprazolam tab 2mg (generic of XANAX)


2 QL

buspirone hcl TABS 5mg, 10mg, 15mg

1

buspirone hcl TABS 7.5mg, 30mg

2

fluvoxamine maleate TABS 2

lorazepam (generic of ATIVAN) SOLN

2

lorazepam (generic of ATIVAN) TABS


2 QL

lorazepam intensol QL (150 mL / 30 days)

2 QL

ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM

QL (60 tabs / 30 days) 5 * QL

BANZEL SUS 40MG/ML 5 * PA

BANZEL TAB 200MG 5 * PA

BANZEL TAB 400MG 5 * PA

BRIVIACT INJ 50MG/5ML 4 PA

BRIVIACT SOL 10MG/ML 5 * PA

BRIVIACT TAB 10MG 5 * PA




Drug Name Drug Tier

Requirements/Limits


carbamazepine CHEW 2

carbamazepine (generic of CARBATROL) CP12

2

carbamazepine (generic of TEGRETOL) SUSP; TABS

2

carbamazepine (generic of TEGRETOL-XR) TB12

2

CELONTIN 4

clobazam (generic of ONFI) 2 PA

clonazepam (generic of KLONOPIN) TABS 2mg


2 QL

clonazepam (generic of KLONOPIN) TABS .5mg, 1mg


2 QL

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

2 QL

clonazepam TBDP .125mg, .25mg, .5mg, 1mg


2 QL

clorazepate dipotassium QL (180 tabs / 30 days)


2 QL PA

DIASTAT ACUDIAL 4

DIASTAT PEDIATRIC 4

diazepam (generic of VALIUM) TABS

QL (120 tabs / 30 days) PA if 65 years and older

2 QL PA

diazepam gel 2

diazepam inj 2

diazepam intensol QL (240 mL / 30 days)


2 QL PA

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


2 QL PA

DILANTIN CAP 30MG 3

DILANTIN CAP 100MG 3

DILANTIN CHEW TAB 50MG 3

DILANTIN-125 SUSP 4

divalproex sodium (generic of DEPAKOTE SPRINKLES) CSDR

2

divalproex sodium (generic of DEPAKOTE ER) TB24

2


26

Drug Name Drug Tier

Requirements/Limits

divalproex sodium (generic of DEPAKOTE) TBEC

2

EPIDIOLEX QL (600 mL / 30 days)

5 * QL NM LA PA

epitol (generic of TEGRETOL) 2

ethosuximide (generic of ZARONTIN) CAPS; SOLN

2

felbamate (generic of FELBATOL) SUSP

5 *

felbamate (generic of FELBATOL) TABS

2

FYCOMPA SUSP QL (720 mL / 30 days)

5 * QL PA

FYCOMPA TABS 2mg QL (60 tabs / 30 days)

4 QL PA

FYCOMPA TABS 4mg, 6mg QL (60 tabs / 30 days)

5 * QL PA

FYCOMPA TABS 8mg, 10mg, 12mg


5 * QL PA

gabapentin (generic of NEURONTIN) CAPS 100mg


1 QL



1 QL



1 QL

gabapentin (generic of NEURONTIN) SOLN

QL (2160 mL / 30 days)

2 QL

gabapentin (generic of NEURONTIN) TABS 600mg


2 QL

gabapentin (generic of NEURONTIN) TABS 800mg


2 QL

lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW

2

lamotrigine (generic of LAMICTAL) TABS

1

lamotrigine (generic of LAMICTAL XR) TB24

2

levetiracetam (generic of KEPPRA) SOLN; TABS

2

Drug Name Drug Tier

Requirements/Limits

levetiracetam (generic of KEPPRA XR) TB24

2

levetiracetam in sodium chloride (generic of LEVETIRACETAM)

2

levetiracetam oral soln 100 mg/ml (generic of KEPPRA)

2

NAYZILAM 4

oxcarbazepine (generic of TRILEPTAL)

2

PEGANONE 4

phenobarbital ELIX PA if 70 years and older

4 PA

phenobarbital TABS PA if 70 years and older

3 PA

phenobarbital sodium SOLN PA if 70 years and older

4 PA

PHENYTEK 3

phenytoin (generic of DILANTIN INFATABS) CHEW

2

phenytoin (generic of DILANTIN-125) SUSP

2

phenytoin sodium extended (generic of DILANTIN) 100mg

2

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

2

phenytoin sodium inj 50mg/ml 2

pregabalin (generic of LYRICA) CAPS 25mg, 50mg, 75mg, 100mg, 150mg


2 QL PA

pregabalin (generic of LYRICA) CAPS 200mg


2 QL PA

pregabalin (generic of LYRICA) CAPS 225mg, 300mg


2 QL PA

pregabalin (generic of LYRICA) SOLN

QL (900 mL / 30 days)

2 QL PA

primidone (generic of MYSOLINE) TABS

1

roweepra (generic of KEPPRA)

2


27

Drug Name Drug Tier

Requirements/Limits

roweepra xr (generic of KEPPRA XR)

2

SPRITAM 4

subvenite tab (generic of LAMICTAL)

1

SYMPAZAN 5mg 4 PA

SYMPAZAN 10mg, 20mg 5 * PA

tiagabine hcl (generic of GABITRIL)

2

topiramate (generic of TOPAMAX SPRINKLE) CPSP

2

topiramate (generic of TOPAMAX) TABS

1

valproate sodium SOLN 2

valproic acid CAPS 2

VALTOCO 4

vigabatrin powd pack 500mg (generic of SABRIL)

QL (180 packets / 30 days)

5 * QL NM LA PA

vigabatrin tab 500mg (generic of SABRIL)


5 * QL NM LA PA

vigadrone (generic of SABRIL)


5 * QL NM LA PA

VIMPAT 50mg QL (120 tabs / 30 days)

4 QL

VIMPAT 100mg, 150mg, 200mg


5 * QL

VIMPAT INJ 200MG/20ML 5 *

VIMPAT SOL 10MG/ML QL (1200 mL / 30 days)

5 * QL

XCOPRI MAINTENANCE PAK 150-200MG


5 * QL

XCOPRI PAK 12.5-25MG QL (28 tabs / 28 days)

4 QL

XCOPRI PAK 50-100MG QL (28 tabs / 28 days)

5 * QL

XCOPRI PAK 50-200MG QL (56 tabs / 28 days)

5 * QL

XCOPRI TABS 50mg QL (90 tabs / 30 days)

5 * QL

Drug Name Drug Tier

Requirements/Limits

XCOPRI TABS 100mg, 150mg, 200mg


5 * QL

XCOPRI TITRATION PAK 150-200MG


5 * QL

zonisamide (generic of ZONEGRAN) CAPS 25mg, 100mg

2

zonisamide CAPS 50mg 2

ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride (generic of ARICEPT) TABS 5mg


1 QL

donepezil hydrochloride (generic of ARICEPT) TABS 10mg

1

donepezil hydrochloride TBDP 5mg


1 QL

donepezil hydrochloride TBDP 10mg

1

galantamine hydrobromide SOLN

2

galantamine hydrobromide (generic of RAZADYNE) TABS 4mg


2 QL

galantamine hydrobromide TABS 8mg, 12mg


2 QL

galantamine hydrobromide er (generic of RAZADYNE ER)


2 QL

memantine hcl cp24 (generic of NAMENDA XR)

PA if < 30 yrs

2 PA

memantine soln PA if < 30 yrs

2 PA

memantine tabs (generic of NAMENDA)

PA if < 30 yrs

2 PA

NAMZARIC 4

rivastigmine tartrate 1.5mg, 3mg


2 QL


28

Drug Name Drug Tier

Requirements/Limits

rivastigmine tartrate 4.5mg, 6mg


2 QL

rivastigmine td patch 24hr 4.6 mg/24hr (generic of EXELON)


2 QL



2 QL



2 QL

ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION amitriptyline hcl TABS 3

amoxapine tab 25mg 3




bupropion hcl TABS 2

bupropion hcl (generic of WELLBUTRIN SR) TB12

1

bupropion hcl (generic of WELLBUTRIN XL) TB24 150mg, 300mg

2

citalopram hydrobromide SOLN

2

citalopram hydrobromide (generic of CELEXA) TABS

1

clomipramine hcl (generic of ANAFRANIL) CAPS

4 PA

desipramine hcl (generic of NORPRAMIN) TABS 10mg, 25mg

4

desipramine hcl TABS 50mg, 75mg, 100mg, 150mg

4

desvenlafaxine succinate (generic of PRISTIQ)


2 QL PA

doxepin hcl CAPS; CONC 3

DRIZALMA SPRINKLE 20mg, 30mg, 60mg


4 QL PA

Drug Name Drug Tier

Requirements/Limits

DRIZALMA SPRINKLE 40mg QL (90 caps / 30 days)

4 QL PA

duloxetine hcl (generic of CYMBALTA) CPEP 20mg, 30mg, 60mg


2 QL

EMSAM QL (30 patches / 30 days)

5 * QL PA

escitalopram oxalate SOLN 2

escitalopram oxalate (generic of LEXAPRO) TABS

1

FETZIMA 20mg, 40mg QL (60 caps / 30 days)

4 QL PA

FETZIMA 80mg, 120mg QL (30 caps / 30 days)

4 QL PA

FETZIMA TITRATION PACK 4 PA

fluoxetine cap 10mg (generic of PROZAC)

1


1


1

fluoxetine hcl SOLN 1

imipramine hcl TABS 2

maprotiline hcl 2

MARPLAN TAB 10MG QL (180 tabs / 30 days)

4 QL

mirtazapine TABS 7.5mg 2

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

1

mirtazapine TABS 45mg 1

mirtazapine (generic of REMERON SOLTAB) TBDP

2

nefazodone hcl 2

nortriptyline hcl (generic of PAMELOR) CAPS

2

nortriptyline hcl SOLN 4

paroxetine hcl tabs (generic of PAXIL)

2

PAXIL SUSP QL (900 mL / 30 days)

4 QL

phenelzine sulfate (generic of NARDIL) TABS

2

protriptyline hcl 4


29

Drug Name Drug Tier

Requirements/Limits

sertraline hcl (generic of ZOLOFT) CONC

2

sertraline hcl (generic of ZOLOFT) TABS

1

tranylcypromine sulfate (generic of PARNATE)

2

trazodone hcl TABS 50mg, 100mg, 150mg

1

trimipramine maleate CAPS 25mg


4 QL



4 QL



4 QL

TRINTELLIX 5mg QL (120 tabs / 30 days)

4 QL


4 QL


4 QL

venlafaxine hcl (generic of EFFEXOR XR) CP24

1

venlafaxine hcl TABS 2

VIIBRYD STARTER PACK 4

VIIBRYD TAB QL (30 tabs / 30 days)

4 QL

ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl CAPS

QL (120 caps / 30 days) 2 QL

amantadine hcl SYRP 1

amantadine hcl TABS 2

APOKYN QL (20 cartridges / 30 days)

5 * QL NM LA PA

benztropine mesylate inj (generic of COGENTIN)

2

benztropine mesylate tab 0.5mg


3 PA

benztropine mesylate tab 1mg PA if 70 years and older

3 PA

benztropine mesylate tab 2mg PA if 70 years and older

3 PA

Drug Name Drug Tier

Requirements/Limits

bromocriptine mesylate (generic of PARLODEL) CAPS; TABS

2

carbidopa-levodopa (generic of SINEMET) TABS

2

carbidopa-levodopa TBCR; TBDP

2

carbidopa/levodopa/entacapone

2

carbidopa/levodopa/entacapone (generic of STALEVO 100)

2

carbidopa/levodopa/entacapone (generic of STALEVO 150)

2

entacapone (generic of COMTAN)

2

NEUPRO 4

pramipexole tab 0.5mg (generic of MIRAPEX)

1

pramipexole tab 0.25mg 1


1


1

pramipexole tab 1.5mg 1

pramipexole tab 1mg (generic of MIRAPEX)

1

rasagiline mesylate (generic of AZILECT) TABS

2

ropinirole tab 0.5mg 1

ropinirole tab 0.25mg 1

ropinirole tab 1mg 1





selegiline hcl CAPS; TABS 2

trihexyphenidyl hcl PA if 70 years and older

3 PA

ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES ABILIFY MAINTENA

QL (1 injection / 28 days)

5 * QL

aripiprazole odt QL (60 tabs / 30 days)

5 * QL


30

Drug Name Drug Tier

Requirements/Limits

aripiprazole oral solution 1 mg/ml

QL (900 mL / 30 days)

5 * QL

aripiprazole tab (generic of ABILIFY)


2 QL

ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml


5 * QL

ARISTADA 1064mg/3.9ml QL (1 injection / 56 days)

5 * QL

ARISTADA INITIO 5 *

CAPLYTA QL (30 caps / 30 days)

4 QL

chlorpromazine hcl TABS 2

CHLORPROMAZINE INJ 4

clozapine odt 12.5mg, 25mg 2 PA

clozapine odt 100mg QL (270 tabs / 30 days)

2 QL PA


2 QL PA


2 QL PA

clozapine tab 25mg (generic of CLOZARIL)

2


2



2 QL



2 QL

FANAPT QL (60 tabs / 30 days)

4 QL PA

FANAPT TITRATION PACK 4 PA

fluphenazine decanoate SOLN

2

fluphenazine hcl 2

GEODON SOLR QL (6 mL / 3 days)

4 QL

haloperidol TABS 2

haloperidol conc 2mg/ml 1

Drug Name Drug Tier

Requirements/Limits

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

2

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

2

haloperidol lactate inj 5mg/ml (generic of HALDOL)

2

INVEGA SUST INJ 39 MG/0.25 ML


4 QL



5 * QL



5 * QL

INVEGA SUST INJ 156MG/ML


5 * QL



5 * QL

INVEGA TRINZA QL (1 injection / 90 days)

5 * QL

LATUDA 20mg, 40mg, 60mg, 120mg


4 QL

LATUDA 80mg QL (60 tabs / 30 days)

4 QL

loxapine succinate 2

molindone hcl 2

NUPLAZID CAPS QL (30 caps / 30 days)

5 * QL NM LA PA

NUPLAZID TABS 10MG QL (30 tabs / 30 days)

5 * QL NM LA PA

olanzapine (generic of ZYPREXA) SOLR

QL (3 vials / 1 day)

2 QL


31

Drug Name Drug Tier

Requirements/Limits

olanzapine (generic of ZYPREXA) TABS 2.5mg, 5mg, 10mg


2 QL

olanzapine (generic of ZYPREXA) TABS 7.5mg, 15mg, 20mg


2 QL

olanzapine (generic of ZYPREXA ZYDIS) TBDP 5mg, 15mg, 20mg


2 QL

olanzapine (generic of ZYPREXA ZYDIS) TBDP 10mg


2 QL

paliperidone (generic of INVEGA) 1.5mg, 3mg, 9mg


2 QL

paliperidone (generic of INVEGA) 6mg


2 QL

perphenazine TABS 2

PERSERIS QL (1 injection / 30 days)

5 * QL

pimozide 2

quetiapine fumarate (generic of SEROQUEL) TABS

2

quetiapine fumarate (generic of SEROQUEL XR) TB24 50mg, 300mg, 400mg


2 QL PA

quetiapine fumarate (generic of SEROQUEL XR) TB24 150mg, 200mg


2 QL PA

REXULTI 3mg, 4mg QL (30 tabs / 30 days)

5 * QL

REXULTI .25mg, .5mg, 1mg, 2mg


5 * QL

RISPERDAL INJ 12.5MG QL (2 injections / 28 days)

4 QL

RISPERDAL INJ 25MG QL (2 injections / 28 days)

4 QL

Drug Name Drug Tier

Requirements/Limits

RISPERDAL INJ 37.5MG QL (2 injections / 28 days)

5 * QL

RISPERDAL INJ 50MG QL (2 injections / 28 days)

5 * QL

risperidone (generic of RISPERDAL) SOLN

QL (240 mL / 30 days)

2 QL

risperidone (generic of RISPERDAL) TABS .5mg, 1mg, 2mg, 3mg, 4mg

1

risperidone TABS .25mg 1

risperidone TBDP 1mg, 2mg, 3mg, 4mg


2 QL

risperidone TBDP .25mg, .5mg


2 QL

SAPHRIS QL (60 tabs / 30 days)

4 QL

SECUADO QL (30 patches / 30 days)

4 QL

thioridazine hcl TABS 2

thiothixene 2

trifluoperazine hcl 2

VERSACLOZ QL (600 mL / 30 days)

5 * QL PA

VRAYLAR 1.5mg QL (60 caps / 30 days)

5 * QL PA

VRAYLAR 3mg, 4.5mg, 6mg QL (30 caps / 30 days)

5 * QL PA

VRAYLAR THERAPY PACK 4 PA

ziprasidone hcl (generic of GEODON)


2 QL

ziprasidone mesylate (generic of GEODON)

QL (6 injections / 3 days)

2 QL

ZYPREXA RELPREVV 300mg

QL (2 vials / 28 days)

5 * QL PA

ZYPREXA RELPREVV 405mg

QL (1 vial / 28 days)

5 * QL PA


32

Drug Name Drug Tier

Requirements/Limits

ZYPREXA RELPREVV INJ 210MG

QL (2 vials / 28 days)

4 QL PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT ADHD amphetamine-dextroamphetamine cap sr 24hr 5 mg (generic of ADDERALL XR)


2 QL

amphetamine-dextroamphetamine cap sr 24hr 10 mg (generic of ADDERALL XR)


2 QL



2 QL



2 QL



2 QL



2 QL

amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)


2 QL

amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)


2 QL



2 QL

Drug Name Drug Tier

Requirements/Limits

amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)


2 QL



2 QL



2 QL



2 QL

atomoxetine hcl (generic of STRATTERA) 10mg, 18mg, 25mg


2 QL

atomoxetine hcl (generic of STRATTERA) 40mg


2 QL

atomoxetine hcl (generic of STRATTERA) 60mg, 80mg, 100mg


2 QL

dexmethylphenidate hcl (generic of FOCALIN) TABS 2.5mg, 5mg


2 QL

dexmethylphenidate hcl (generic of FOCALIN) TABS 10mg


2 QL

guanfacine er (adhd) (generic of INTUNIV)


3 PA

metadate er tab 20mg QL (90 tabs / 30 days)

2 QL

methylphenidate hcl (generic of RITALIN) TABS 5mg, 10mg


2 QL

methylphenidate hcl (generic of RITALIN) TABS 20mg


2 QL


33

Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl oral soln (generic of METHYLIN) 5mg/5ml

QL (1800 mL / 30 days)

2 QL

methylphenidate hcl oral soln (generic of METHYLIN) 10mg/5ml

QL (900 mL / 30 days)

2 QL

methylphenidate hcl tbcr 10 mg


2 QL

methylphenidate hcl tbcr 20mg


2 QL

HYPNOTICS - DRUGS TO TREAT INSOMNIA BELSOMRA

QL (30 tabs / 30 days) 4 QL

doxepin hcl (sleep) (generic of SILENOR)


2 QL

HETLIOZ 5 * NM LA PA

temazepam (generic of RESTORIL) 7.5mg

QL (30 caps / 30 days) PA applies if 65 years and older after a 90 day supply in a calendar year

2 QL PA

temazepam (generic of RESTORIL) 15mg

QL (60 caps / 30 days) PA applies if 65 years and older after a 90 day supply in a calendar year

2 QL PA

zolpidem tartrate (generic of AMBIEN) TABS

QL (30 tabs / 30 days) PA applies if 70 years and older after a 90 day supply in a calendar year

2 QL PA

MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES AIMOVIG

QL (1 pen / 30 days) 3 QL NM PA

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

5 *

Drug Name Drug Tier

Requirements/Limits

dihydroergotamine mesylate nasal spr 4 mg/ml (generic of MIGRANAL)

QL (8 mL / 30 days)

5 * QL PA

eletriptan hydrobromide (generic of RELPAX)


2 QL

EMGALITY SOAJ QL (2 pens / 30 days)

3 QL NM PA

EMGALITY SOSY 120mg/ml QL (2 syringes / 30 days)

3 QL NM PA

ergotamine w/ caffeine (generic of CAFERGOT) TABS

2

naratriptan hcl (generic of AMERGE)


2 QL

rizatriptan benzoate 5mg QL (18 tabs / 30 days)

2 QL

rizatriptan benzoate (generic of MAXALT) 10mg


2 QL

rizatriptan benzoate odt 5mg QL (18 tabs / 30 days)

2 QL

rizatriptan benzoate odt (generic of MAXALT-MLT) 10mg


2 QL

sumatriptan (generic of IMITREX) SOLN 5mg/act

QL (24 inhalers / 30 days)

2 QL

sumatriptan (generic of IMITREX) SOLN 20mg/act

QL (12 inhalers / 30 days)

2 QL

sumatriptan inj 4mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) SOAJ


2 QL

sumatriptan inj 4mg/0.5ml (generic of IMITREX STATDOSE REFILL) SOCT


2 QL


34

Drug Name Drug Tier

Requirements/Limits

sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) SOAJ


2 QL

sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE REFILL) SOCT


2 QL

sumatriptan inj 6mg/0.5ml (generic of IMITREX) SOLN


2 QL

sumatriptan inj 6mg/0.5ml SOSY


2 QL

sumatriptan succinate (generic of IMITREX) TABS


2 QL

zolmitriptan (generic of ZOMIG) TABS


2 QL

zolmitriptan odt (generic of ZOMIG ZMT)


2 QL

MISCELLANEOUS AUSTEDO 6mg

QL (60 tabs / 30 days) 5 * QL NM PA

AUSTEDO 9mg, 12mg QL (120 tabs / 30 days)

5 * QL NM PA

INGREZZA CAPS QL (30 caps / 30 days)

5 * QL NM PA

INGREZZA CPPK QL (28 caps / 28 days)

5 * QL NM PA

lithium carbonate CAPS; TABS

1

lithium carbonate er (generic of LITHOBID) 300mg

2

lithium carbonate er 450mg 2

LITHIUM SOLN 8MEQ/5ML 4

LYRICA CR QL (60 tabs / 30 days)

3 QL PA

NUEDEXTA QL (60 caps / 30 days)

4 QL PA

pyridostigmine tab 60mg (generic of MESTINON)

2

Drug Name Drug Tier

Requirements/Limits

riluzole (generic of RILUTEK) 2

tetrabenazine (generic of XENAZINE) 12.5mg


5 * QL NM PA

tetrabenazine (generic of XENAZINE) 25mg


5 * QL NM PA

MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSIS BETASERON

QL (14 syringes / 28 days)

5 * QL NM PA

dalfampridine (generic of AMPYRA) TB12

5 * NM PA

GILENYA CAP 0.5MG QL (28 caps / 28 days)

5 * QL NM PA

glatiramer acetate 20mg/ml (generic of COPAXONE)


5 * QL NM PA

glatiramer acetate 40mg/ml (generic of COPAXONE)


5 * QL NM PA

glatopa (generic of COPAXONE) 20mg/ml


5 * QL NM PA

glatopa (generic of COPAXONE) 40mg/ml


5 * QL NM PA

MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS baclofen TABS 10mg, 20mg 2

cyclobenzaprine hcl TABS 5mg, 10mg


3 PA

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

2

dantrolene sodium CAPS 100mg

2

tizanidine hcl TABS 2mg 2

tizanidine hcl (generic of ZANAFLEX) TABS 4mg

2


35

Drug Name Drug Tier

Requirements/Limits

NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS armodafinil (generic of NUVIGIL) 50mg


2 QL PA

armodafinil (generic of NUVIGIL) 150mg, 200mg, 250mg


2 QL PA

XYREM QL (540 mL / 30 days)

5 * QL NM LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 2

buprenorphine hcl SUBL QL (90 tabs / 30 days)

2 QL PA

buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg (generic of SUBOXONE)

QL (90 films / 30 days)

2 QL

buprenorphine hcl-naloxone hcl dihydrate 4-1mg (generic of SUBOXONE)


2 QL



2 QL



2 QL

buprenorphine hcl-naloxone hcl sl


2 QL

bupropion hcl (smoking deterrent)

2

CHANTIX 4 PA

CHANTIX CONTINUING MONTH

4 PA

CHANTIX STARTER PACK 4 PA

disulfiram (generic of ANTABUSE) TABS

2

naloxone inj 0.4mg/ml 2

naloxone inj 1mg/ml 2

naltrexone hcl TABS 2

NARCAN 3

NICOTROL INHALER 4

NICOTROL NS 4

Drug Name Drug Tier

Requirements/Limits

VIVITROL 5 * NM

ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS - DRUGS TO REGULATE MALE HORMONES ANADROL-50 5 * PA

ANDRODERM QL (30 patches / 30 days)

4 QL PA

oxandrolone TABS 2 PA

testosterone GEL 1% QL (300 grams / 30 days)

2 QL PA

testosterone (generic of ANDROGEL) GEL 25mg/2.5gm, 50mg/5gm

QL (300 grams / 30 days)

2 QL PA

testosterone cypionate (generic of DEPO-TESTOSTERONE) SOLN

2 PA

testosterone enanthate SOLN 2 PA

ANTIDIABETICS, INJECTABLE - DRUGS TO TREAT DIABETES BASAGLAR KWIKPEN 3

BD ALCOHOL SWABS 3

BD ULTRAFINE INSULIN SYRINGE

3

BD ULTRAFINE/NANO PEN NEEDLES

3

BYDUREON BCISE QL (4 pens / 28 days)

3 QL

BYDUREON PEN QL (4 pens / 28 days)

3 QL

BYETTA QL (1 pen / 30 days)

4 QL

FIASP 3

FIASP FLEXTOUCH 3

FIASP PENFILL 3

GAUZE PADS 2" X 2" 3

HUMULIN R INJ U-500 5 * B/D

HUMULIN R U-500 KWIKPEN 5 *

INSULIN PEN NEEDLE 3

INSULIN SAFETY NEEDLES 3

INSULIN SYRINGE 3

LEVEMIR 3


36

Drug Name Drug Tier

Requirements/Limits

LEVEMIR FLEXTOUCH 3

NOVOLIN 70/30 (brand RELION not covered)

3

NOVOLIN 70/30 FLEXPEN (brand RELION not covered)

3

NOVOLIN N (brand RELION not covered)

3

NOVOLIN N FLEXPEN (brand RELION not covered)

3

NOVOLIN R (brand RELION not covered)

3

NOVOLIN R FLEXPEN (brand RELION not covered)

3

NOVOLOG 3

NOVOLOG 70/30 FLEXPEN 3

NOVOLOG FLEXPEN 3

NOVOLOG MIX 70/30 3

NOVOLOG PENFILL 3

OZEMPIC INJ 0.25 OR 0.5MG/DOSE

QL (1 pen / 28 days)

3 QL

OZEMPIC INJ 1MG/DOSE QL (2 pens / 28 days)

3 QL

SOLIQUA 100/33 QL (10 pens / 30 days)

3 QL

TRESIBA FLEXTOUCH 3

TRESIBA INJ 3

TRULICITY QL (4 pens / 28 days)

3 QL

VICTOZA QL (3 pens / 30 days)

3 QL

XULTOPHY 100/3.6 QL (5 pens / 30 days)

3 QL

ANTIDIABETICS, ORAL - DRUGS TO TREAT DIABETES acarbose (generic of PRECOSE) TABS

2

FARXIGA QL (30 tabs / 30 days)

3 QL

glimepiride (generic of AMARYL) 1mg, 2mg


2 QL

Drug Name Drug Tier

Requirements/Limits

glimepiride (generic of AMARYL) 4mg


2 QL

glip/metform tab 2.5-250mg QL (240 tabs / 30 days)

1 QL

glip/metform tab 2.5-500mg QL (120 tabs / 30 days)

1 QL

glip/metform tab 5-500mg QL (120 tabs / 30 days)

1 QL

glipizide (generic of GLUCOTROL) TABS 5mg


1 QL

glipizide (generic of GLUCOTROL) TABS 10mg


1 QL

glipizide (generic of GLUCOTROL XL) TB24 2.5mg, 5mg


1 QL

glipizide (generic of GLUCOTROL XL) TB24 10mg


1 QL

glipizide xl (generic of GLUCOTROL XL) 2.5mg, 5mg


1 QL

glipizide xl (generic of GLUCOTROL XL) 10mg


1 QL

GLYXAMBI QL (30 tabs / 30 days)

3 QL

JANUMET QL (60 tabs / 30 days)

3 QL

JANUMET XR TAB 50-500MG


3 QL

JANUMET XR TAB 50-1000 QL (60 tabs / 30 days)

3 QL

JANUMET XR TAB 100-1000 QL (30 tabs / 30 days)

3 QL

JANUVIA QL (30 tabs / 30 days)

3 QL

JARDIANCE 10mg QL (60 tabs / 30 days)

3 QL

JARDIANCE 25mg QL (30 tabs / 30 days)

3 QL

JENTADUETO QL (60 tabs / 30 days)

3 QL


37

Drug Name Drug Tier

Requirements/Limits

JENTADUETO TAB XR 2.5-1000 MG


3 QL

JENTADUETO TAB XR 5-1000 MG


3 QL

metformin er 500mg QL (120 tabs / 30 days)

(generic of GLUCOPHAGE XR)

1 QL

metformin er 750mg QL (60 tabs / 30 days)

(generic of GLUCOPHAGE XR)

1 QL

metformin hcl TABS 500mg QL (150 tabs / 30 days)

1 QL


1 QL


1 QL

nateglinide (generic of STARLIX)


1 QL

pioglitazone hcl (generic of ACTOS)


1 QL

repaglinide 2mg QL (240 tabs / 30 days)

1 QL

repaglinide .5mg, 1mg QL (120 tabs / 30 days)

1 QL

RYBELSUS QL (30 tabs / 30 days)

3 QL

SYNJARDY TAB 5-500MG QL (120 tabs / 30 days)

3 QL

SYNJARDY TAB 5-1000MG QL (60 tabs / 30 days)

3 QL

SYNJARDY TAB 12.5-500MG QL (60 tabs / 30 days)

3 QL

SYNJARDY TAB 12.5-1000MG


3 QL

SYNJARDY XR TAB 5-1000MG


3 QL



3 QL

Drug Name Drug Tier

Requirements/Limits

SYNJARDY XR TAB 12.5-1000MG


3 QL



3 QL

TRADJENTA QL (30 tabs / 30 days)

3 QL

TRIJARDY XR TAB ER 24HR 5-2.5-1000MG


3 QL

TRIJARDY XR TAB ER 24HR 10-5-1000 MG


3 QL

TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG


3 QL

TRIJARDY XR TAB ER 24HR 25-5-1000 MG


3 QL

XIGDUO XR TAB 2.5-1000MG


3 QL

XIGDUO XR TAB 5-500MG QL (60 tabs / 30 days)

3 QL


3 QL


3 QL


3 QL

BISPHOSPHONATES - DRUGS TO TREAT BONE LOSS alendronate sodium tab 5 mg 1

alendronate sodium tab 10 mg 1



alendronate sodium tab 70 mg (generic of FOSAMAX)

1

ibandronate sodium tabs (generic of BONIVA)

2 B/D

PAMIDRONATE DISODIUM 6mg/ml

3 B/D

pamidronate disodium 30mg/10ml, 90mg/10ml

2 B/D

pamidronate inj 30mg 2 B/D

pamidronate inj 90mg 2 B/D

zoledronic acid inj 4mg/100ml 2 B/D NM


38

Drug Name Drug Tier

Requirements/Limits

zoledronic acid inj 5mg/100ml (generic of RECLAST)

2 B/D NM

zoledronic inj 4mg/5ml 2 B/D NM

CHELATING AGENTS CHEMET 4

clovique (generic of SYPRINE)

5 * PA

deferasirox tab (generic of JADENU)

5 * NM PA

JADENU 180mg 5 * NM LA PA

JADENU SPRINKLE 5 * NM LA PA

kionex sus 15gm/60ml 2

LOKELMA 3

penicillamine (generic of DEPEN TITRATABS) TABS

5 *

sodium polystyrene sulfonate powder

2

sodium polystyrene sulfonate susp

2

sps susp 15gm/60ml 2

trientine hcl (generic of SYPRINE)

5 * PA

VELTASSA 4 LA PA

CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL altavera tab 2

alyacen 1/35 2

apri 2

aranelle 2

aubra 2

aviane 2

balziva 2

bekyree (generic of MIRCETTE)

2

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

2

briellyn 2

camila 2

caziant pak 2

cryselle-28 2

cyclafem 1/35 2

cyclafem 7/7/7 2

cyred tab 2

dasetta 1/35 2

dasetta 7/7/7 2

deblitane 2

Drug Name Drug Tier

Requirements/Limits

desogestrel & ethinyl estradiol 2

desogestrel-ethinyl estradiol (biphasic) (generic of MIRCETTE)

2

drospirenone-ethinyl estradiol (generic of YASMIN 28)

2

drospirenone-ethinyl estradiol (generic of YAZ)

2

ELLA 3

eluryng (generic of NUVARING)

2

emoquette 2

enpresse-28 2

enskyce 2

errin (generic of ORTHO MICRONOR)

2

estarylla tab 0.25-35 2

ethynodiol diacet & eth estrad 2

ethynodiol tab 1-50 2

etonogestrel-ethinyl estradiol (generic of NUVARING)

2

falmina 2

femynor 2

gianvi (generic of YAZ) 2

heather 2

incassia 2

introvale 2

isibloom 2

jasmiel (generic of YAZ) 2

jolessa tab 0.15-0.03 mg 2

jolivette (generic of ORTHO MICRONOR)

2

juleber 2

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

2

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

2

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

2

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

2

kariva (generic of MIRCETTE) 2

kelnor 1/35 2

kelnor 1/50 2

kurvelo 2


39

Drug Name Drug Tier

Requirements/Limits

larin 1.5/30 (generic of LOESTRIN 1.5/30-21)

2

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

2

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

2

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

2

larissia tab 2

leena 2

lessina 2

levonest 2

levonor/ethi tab 2

levonorgestrel & eth estradiol 2

levonorgestrel-ethinyl estradiol (91-day)

2

levora 0.15/30-28 2

loryna (generic of YAZ) 2

low-ogestrel 2

lutera 2

lyza (generic of ORTHO MICRONOR)

2

marlissa 2

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

2

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

2

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

2

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

2

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

2

mili 2

mono-linyah tab 0.25-35 2

necon 0.5/35-28 2

nikki (generic of YAZ) 2

nora-be tab 2

norethindrone (contraceptive) (generic of ORTHO MICRONOR)

2

norethindrone acet & eth estra (generic of LOESTRIN 1/20-21)

2

norgest/ethi tab 0.25/35 2

Drug Name Drug Tier

Requirements/Limits

norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg (generic of ORTHO TRI-CYCLEN LO)

2

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg

2

nortrel 0.5/35 (28) 2

nortrel 1/35 2

nortrel 7/7/7 2

ocella tab 3-0.03mg (generic of YASMIN 28)

2

orsythia 2

philith 2

pimtrea (generic of MIRCETTE)

2

pirmella 1/35 2

portia-28 2

previfem 2

reclipsen 2

setlakin tab 2

sharobel (generic of ORTHO MICRONOR)

2

sprintec 28 2

sronyx 2

syeda (generic of YASMIN 28) 2

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

2

tilia fe (generic of ESTROSTEP FE)

2

tri-estarylla 2

tri-legest fe (generic of ESTROSTEP FE)

2

tri-linyah 2

tri-lo marzia (generic of ORTHO TRI-CYCLEN LO)

2

tri-lo-estarylla (generic of ORTHO TRI-CYCLEN LO)

2

tri-lo-sprintec (generic of ORTHO TRI-CYCLEN LO)

2

tri-mili 2

tri-previfem 2

tri-sprintec 2

tri-vylibra 2

tri-vylibra lo (generic of ORTHO TRI-CYCLEN LO)

2


40

Drug Name Drug Tier

Requirements/Limits

trivora-28 2

tulana 2

velivet 2

vienva 2

viorele (generic of MIRCETTE)

2

vyfemla 2

vylibra 2

xulane 2

zarah (generic of YASMIN 28) 2

zovia 1/35e 2

ENDOMETRIOSIS danazol CAPS 2

SYNAREL 5 *

ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES ALDURAZYME 5 * NM LA PA

CARBAGLU 5 * NM LA PA

CERDELGA 5 * NM PA

CEREZYME 5 * NM LA PA

CYSTADANE 5 * NM LA

CYSTAGON 4 NM LA PA

FABRAZYME 5 * NM LA PA

KUVAN 5 * NM LA PA

levocarnitine (metabolic modifiers) (generic of CARNITOR)

2 B/D

LUMIZYME 5 * NM LA PA

miglustat (generic of ZAVESCA)

5 * NM PA

NAGLAZYME 5 * NM LA PA

nitisinone (generic of ORFADIN)

5 * NM PA

NITYR 5 * NM LA PA

ORFADIN 5 * NM LA PA

sodium phenylbutyrate (generic of BUPHENYL)

5 * NM PA

ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES DELESTROGEN 10mg/ml 4

estradiol (generic of CLIMARA) PTWK

3

estradiol (generic of ESTRACE) TABS

2

estradiol vaginal cream (generic of ESTRACE)

2

Drug Name Drug Tier

Requirements/Limits

estradiol vaginal tab (generic of VAGIFEM)

2

estradiol valerate (generic of DELESTROGEN) OIL

2

fyavolv 3

fyavolv (generic of FEMHRT LOW DOSE)

3

jinteli 3

norethindrone acetate-ethinyl estradiol

3

norethindrone acetate-ethinyl estradiol (generic of FEMHRT LOW DOSE)

3

yuvafem vaginal tablet 10 mcg (generic of VAGIFEM)

2

GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE cortisone acetate TABS 2

DEXAMETHASONE CONC 4

dexamethasone ELIX; SOLN 2

dexamethasone TABS 1

dexamethasone sodium phosphate 4mg/ml, 10mg/ml, 20mg/5ml, 100mg/10ml, 120mg/30ml

2

dexamethasone sodium phosphate (generic of DEXAMETHASONE SODIUM PHOS) 10mg/ml

2

fludrocortisone acetate TABS 2

hydrocortisone (generic of CORTEF) TABS

2

methylpr ss inj (generic of SOLU-MEDROL)

2 B/D

methylpred pak 4mg (generic of MEDROL DOSEPAK)

2

methylpred tab 4mg (generic of MEDROL)

2 B/D


2 B/D


2 B/D


2 B/D

methylprednisolone acetate (generic of DEPO-MEDROL)

2 B/D

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

2 B/D


41

Drug Name Drug Tier

Requirements/Limits

prednisolone sodium phosphate SOLN 15mg/5ml

2 B/D

prednisolone sol 15mg/5ml 2 B/D

prednisolone sol 25mg/5ml 2 B/D

PREDNISONE CON 5MG/ML 4 B/D

prednisone pak 5mg 2

prednisone pak 10mg 2

prednisone sol 5mg/5ml 2 B/D

prednisone tab 1mg 1 B/D

prednisone tab 2.5mg 1 B/D





SOLU-CORTEF 4

GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGAR diazoxide (generic of PROGLYCEM) SUSP

2

GLUCAGEN HYPOKIT 3

GLUCAGON EMERGENCY KIT

3

GVOKE HYPOPEN 2-PACK 3

GVOKE PFS 3

PROGLYCEM SUS 50MG/ML 4

MISCELLANEOUS cabergoline 2

calcitonin (salmon) (generic of MIACALCIN)

2 B/D

cinacalcet hcl (generic of SENSIPAR) 30mg, 90mg


5 * B/D QL NM

cinacalcet hcl (generic of SENSIPAR) 60mg


5 * B/D QL NM

FORTEO 5 * NM PA

GENOTROPIN 5 * NM PA

GENOTROPIN MINIQUICK .2mg

3 NM PA

GENOTROPIN MINIQUICK .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg

5 * NM PA

INCRELEX 5 * NM LA PA

KORLYM 5 * NM LA PA

LUPRON DEP-PED INJ 7.5MG

5 * NM PA

Drug Name Drug Tier

Requirements/Limits

LUPRON DEP-PED INJ 11.25MG (3-MONTH)

5 * NM PA

LUPRON DEPOT-PED (1-MONTH

5 * NM PA

LUPRON DEPOT-PED (3-MONTH

5 * NM PA

NATPARA 5 * NM PA

octreotide acetate (generic of SANDOSTATIN) 50mcg/ml, 100mcg/ml

2 NM PA

octreotide acetate 200mcg/ml 2 NM PA

octreotide acetate (generic of SANDOSTATIN) 500mcg/ml

5 * NM PA

octreotide acetate 1000mcg/ml

5 * NM PA

OSPHENA 3 PA

PROLIA QL (1 injection / 180 days)

4 QL NM

raloxifene hcl (generic of EVISTA)

2

SIGNIFOR 5 * NM LA PA

SOMATULINE DEPOT 5 * NM PA

SOMAVERT 5 * NM LA PA

TYMLOS 5 * NM PA

XGEVA 5 * NM PA

PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS AURYXIA

QL (360 tabs / 30 days) 5 * QL PA

calcium acetate (phosphate binder) (generic of PHOSLO) CAPS


2 QL

calcium acetate (phosphate binder) TABS


2 QL

sevelamer carbonate (generic of RENVELA) PACK 2.4gm


5 * QL

sevelamer carbonate (generic of RENVELA) PACK .8gm


5 * QL


42

Drug Name Drug Tier

Requirements/Limits

sevelamer carbonate (generic of RENVELA) TABS


2 QL

PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES medroxyprogesterone acetate tab (generic of PROVERA)

1

norethindrone acetate (generic of AYGESTIN) TABS

2

THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS euthyrox (generic of SYNTHROID)

2

levo-t (generic of SYNTHROID)

2

levothyroxine sodium (generic of SYNTHROID) TABS

2

levoxyl (generic of SYNTHROID)

2

liothyronine sodium (generic of CYTOMEL) TABS

2

methimazole (generic of TAPAZOLE) TABS

1

propylthiouracil TABS 2

SYNTHROID 4

unithroid (generic of SYNTHROID)

2

VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES desmopressin acetate spray (generic of DDAVP)

2

desmopressin acetate spray refrigerated

2

desmopressin acetate tabs (generic of DDAVP)

2

desmopressin inj 4mcg/ml (generic of DDAVP)

2

STIMATE 5 * NM

GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING aprepitant (generic of EMEND) 40mg, 80mg

2 B/D

aprepitant 125mg 2 B/D

aprepitant pak 80mg & 125mg 2 B/D

Drug Name Drug Tier

Requirements/Limits

compro 2

dronabinol (generic of MARINOL)


2 B/D QL

EMEND SUSR 4 B/D

granisetron hcl SOLN 2

granisetron hcl TABS 2 B/D

meclizine hcl TABS 2

metoclopramide hcl SOLN 2

metoclopramide hcl (generic of REGLAN) TABS

1

metoclopramide hcl inj 2

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

2 B/D

ondansetron hcl TABS 24mg 2 B/D

ondansetron hcl inj 2

ondansetron hcl oral soln 2 B/D

ondansetron odt 2 B/D

prochlorperazine inj 2

prochlorperazine maleate TABS

2

prochlorperazine supp 2

promethazine hcl SYRP; TABS


2 PA

promethazine hcl inj (generic of PHENERGAN)


4 PA

scopolamine (generic of TRANSDERM SCOP)



4 QL PA

ANTISPASMODICS - DRUGS FOR STOMACH SPASMS dicyclomine hcl cap 10mg 3

dicyclomine hcl soln 10mg/5ml

4

dicyclomine hcl tab 20mg 3

glycopyrrolate tab 1mg 2

glycopyrrolate tab 2mg 2

H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID famotidine SUSR 2

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

1


43

Drug Name Drug Tier

Requirements/Limits

famotidine in nacl 2

famotidine inj 2

nizatidine CAPS 2

INFLAMMATORY BOWEL DISEASE balsalazide disodium (generic of COLAZAL)

2

budesonide ec (generic of ENTOCORT EC)

2

colocort (generic of CORTENEMA)

2

hydrocortisone (enema) (generic of CORTENEMA)

2

mesalamine (generic of DELZICOL) CPDR

2

mesalamine ENEM 2

mesalamine (generic of CANASA) SUPP

5 *

mesalamine (generic of LIALDA) TBEC 1.2gm

2

mesalamine w/ cleanser (generic of ROWASA)

2

sulfasalazine (generic of AZULFIDINE) TABS

2

sulfasalazine ec (generic of AZULFIDINE EN-TABS)

2

LAXATIVES constulose 2

enulose 2

gavilyte-c 1

gavilyte-g (generic of GOLYTELY)

1

gavilyte-n/flavor pack (generic of NULYTELY)

1

generlac 2

GOLYTELY 3

lactulose SOLN 2

lactulose (encephalopathy) 2

NULYTELY/FLAVOR PACKS 3

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

1

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

1

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

1

PLENVU 4

Drug Name Drug Tier

Requirements/Limits

SUPREP BOWEL PREP KIT 4

trilyte (generic of NULYTELY) 1

MISCELLANEOUS alosetron hcl (generic of LOTRONEX)

5 * PA

AMITIZA CAP 8MCG QL (180 caps / 30 days)

3 QL

AMITIZA CAP 24MCG QL (60 caps / 30 days)

3 QL

cromolyn sodium (mastocytosis) (generic of GASTROCROM)

5 *

diphenoxylate w/ atropine LIQD

4

diphenoxylate w/ atropine (generic of LOMOTIL) TABS

3

GATTEX 5 * NM LA PA

LINZESS QL (30 caps / 30 days)

4 QL

loperamide hcl CAPS 2

misoprostol (generic of CYTOTEC) TABS

2

MOVANTIK 12.5mg QL (60 tabs / 30 days)

3 QL

MOVANTIK 25mg QL (30 tabs / 30 days)

3 QL

RELISTOR SOLN 5 * PA

sucralfate (generic of CARAFATE) TABS

2

ursodiol (generic of ACTIGALL) CAPS

2

ursodiol (generic of URSO 250) TABS 250mg

2

ursodiol (generic of URSO FORTE) TABS 500mg

2

XIFAXAN 550mg 5 * PA

PANCREATIC ENZYMES CREON 3

ZENPEP 4

PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACID DEXILANT

QL (30 caps / 30 days) 4 QL

esomeprazole magnesium (generic of NEXIUM) CPDR


2 QL ST


44

Drug Name Drug Tier

Requirements/Limits

lansoprazole (generic of PREVACID) CPDR


2 QL

omeprazole cap 10mg 1



pantoprazole sodium (generic of PROTONIX) SOLR

2

pantoprazole sodium tbec (generic of PROTONIX)

1

GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE alfuzosin hcl (generic of UROXATRAL)


1 QL

dutasteride (generic of AVODART) CAPS


2 QL

dutasteride-tamsulosin hcl (generic of JALYN)


2 QL

finasteride (generic of PROSCAR) TABS 5mg

1

tamsulosin hcl (generic of FLOMAX)

1

MISCELLANEOUS bethanechol chloride TABS 2

potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 15) 15meq

2

potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 5) 540mg

2

potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 10) 1080mg

2

URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE MYRBETRIQ

QL (30 tabs / 30 days) 4 QL

oxybutynin chloride SYRP 2

oxybutynin chloride TABS 2

Drug Name Drug Tier

Requirements/Limits

oxybutynin chloride (generic of DITROPAN XL) TB24 5mg


2 QL

oxybutynin chloride (generic of DITROPAN XL) TB24 10mg


2 QL

oxybutynin chloride TB24 15mg


2 QL

tolterodine tartrate cap er (generic of DETROL LA)


2 QL ST

tolterodine tartrate tabs (generic of DETROL)

2 ST

TOVIAZ QL (30 tabs / 30 days)

3 QL

trospium chloride TABS QL (60 tabs / 30 days)

2 QL

VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal (generic of CLEOCIN)

2

metronidazole vaginal 2

terconazole vaginal 2

vandazole 2

HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS - BLOOD THINNERS COUMADIN 3

ELIQUIS 2.5mg QL (60 tabs / 30 days)

3 QL

ELIQUIS 5mg QL (74 tabs / 30 days)

3 QL

ELIQUIS STARTER PACK QL (74 tabs / 30 days)

3 QL

enoxaparin sodium (generic of LOVENOX)

2

fondaparinux sodium (generic of ARIXTRA) 2.5mg/0.5ml

2

fondaparinux sodium (generic of ARIXTRA) 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

5 *

heparin sod (porcine) in d5w 3

heparin sod inj 1000/ml 2 B/D





45

Drug Name Drug Tier

Requirements/Limits

HEPARIN SODIUM/NACL 0.45%

3

jantoven 1

PRADAXA QL (60 caps / 30 days)

4 QL

warfarin sodium 1

XARELTO 2.5mg QL (60 tabs / 30 days)

3 QL

XARELTO 10mg, 15mg, 20mg


3 QL

XARELTO STARTER PACK QL (51 tabs / 30 days)

3 QL

HEMATOPOIETIC GROWTH FACTORS PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

3 NM PA

PROCRIT 20000unit/ml, 40000unit/ml

5 * NM PA

ZARXIO 5 * NM PA

MISCELLANEOUS anagrelide hcl 1mg 2

anagrelide hcl (generic of AGRYLIN) .5mg

2

BERINERT QL (24 boxes / 30 days)

5 * QL NM LA PA

cilostazol 1

DROXIA 3

ENDARI 5 * NM LA PA

HAEGARDA 2000unit QL (30 vials / 30 days)

5 * QL NM LA PA

HAEGARDA 3000unit QL (20 vials / 30 days)

5 * QL NM LA PA

icatibant acetate (generic of FIRAZYR)


5 * QL NM PA

pentoxifylline TBCR 1

PROMACTA PACK 12.5mg QL (360 packets / 30 days)

5 * QL NM LA PA

PROMACTA PACK 25mg QL (180 packets / 30 days)

5 * QL NM LA PA

PROMACTA TABS 12.5mg, 25mg


5 * QL NM LA PA

Drug Name Drug Tier

Requirements/Limits

PROMACTA TABS 50mg, 75mg


5 * QL NM LA PA

tranexamic acid (generic of CYKLOKAPRON) SOLN

2

tranexamic acid (generic of LYSTEDA) TABS

2

PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole (generic of AGGRENOX)

2

BRILINTA 3

clopidogrel tab 75mg (generic of PLAVIX)

1

prasugrel hcl (generic of EFFIENT)

2

IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS ENBREL SOLR

QL (16 vials / 28 days) 5 * QL NM PA

ENBREL SOSY 25mg/0.5ml QL (16 syringes / 28 days)

5 * QL NM PA

ENBREL SOSY 50mg/ml QL (8 syringes / 28 days)

5 * QL NM PA

ENBREL MINI QL (8 injections / 28 days)

5 * QL NM PA

ENBREL SURECLICK QL (8 injections / 28 days)

5 * QL NM PA

HUMIRA 10mg/0.1ml, 20mg/0.2ml


5 * QL NM PA

HUMIRA 40mg/0.4ml QL (6 injections / 28 days)

5 * QL NM PA

HUMIRA INJ 10MG/0.2ML QL (2 syringes / 28 days)

5 * QL NM PA

HUMIRA KIT 20MG/0.4ML QL (2 syringes / 28 days)

5 * QL NM PA


46

Drug Name Drug Tier

Requirements/Limits

HUMIRA KIT 40MG/0.8ML QL (6 syringes / 28 days)

5 * QL NM PA

HUMIRA PEDIATRIC CROHNS DISEASE

5 * NM PA

HUMIRA PEN QL (6 pens / 28 days)

5 * QL NM PA

HUMIRA PEN CD/UC/HS STARTER

5 * NM PA

HUMIRA PEN INJ CD/UC/HS STARTER

5 * NM PA

HUMIRA PEN INJ PS/UV STARTER

5 * NM PA

HUMIRA PEN-PS/UV STARTER

5 * NM PA

hydroxychloroquine sulfate (generic of PLAQUENIL)

2

leflunomide (generic of ARAVA) TABS


2 QL

methotrexate sodium tabs 2

REMICADE 5 * NM PA

RENFLEXIS 5 * NM LA PA

RINVOQ QL (30 tabs / 30 days)

5 * QL NM PA

SKYRIZI QL (7 kits / year)

5 * QL NM PA

STELARA SOLN 45mg/0.5ml QL (1 vial / 28 days)

5 * QL NM LA PA

STELARA SOSY QL (1 syringe / 28 days)

5 * QL NM PA

XATMEP 4 B/D

XELJANZ QL (60 tabs / 30 days)

5 * QL NM PA

XELJANZ XR QL (30 tabs / 30 days)

5 * QL NM PA

IMMUNOGLOBULINS BIVIGAM 5 * NM PA

GAMASTAN S/D 3 B/D NM

GAMMAGARD LIQUID 5 * NM PA

GAMMAGARD S/D 5 * NM PA

GAMMAKED 5 * NM PA

GAMMAPLEX 5 * NM PA

GAMMAPLEX 10GM/100ML 5 * NM PA

GAMUNEX-C 5 * NM PA

OCTAGAM 5 * NM PA

PANZYGA 5 * NM PA

PRIVIGEN 5 * NM PA

Drug Name Drug Tier

Requirements/Limits

IMMUNOMODULATORS ACTIMMUNE 5 * NM LA PA

ARCALYST 5 * NM PA

INTRON-A INJ 10MU 5 * B/D NM




IMMUNOSUPPRESSANTS azathioprine (generic of IMURAN) TABS

2 B/D

BENLYSTA 5 * NM PA

cyclosporine (generic of SANDIMMUNE) CAPS; SOLN

2 B/D NM

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

2 B/D NM

cyclosporine modified (for microemulsion) CAPS 50mg

2 B/D NM

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

2 B/D NM

everolimus (immunosuppressant) (generic of ZORTRESS) .5mg, .75mg

5 * B/D NM

everolimus (immunosuppressant) (generic of ZORTRESS) .25mg

2 B/D NM

gengraf (generic of NEORAL) 2 B/D NM

mycophenolate mofetil (generic of CELLCEPT) CAPS; TABS

2 B/D NM

mycophenolate mofetil (generic of CELLCEPT) SUSR

5 * B/D NM

mycophenolate sodium tbec (generic of MYFORTIC)

2 B/D NM

NULOJIX 5 * B/D NM

PROGRAF PACK 4 B/D NM

SANDIMMUNE SOLN 100mg/ml

3 B/D NM

sirolimus (generic of RAPAMUNE) SOLN

5 * B/D NM

sirolimus (generic of RAPAMUNE) TABS 2mg

5 * B/D NM


47

Drug Name Drug Tier

Requirements/Limits

sirolimus (generic of RAPAMUNE) TABS .5mg, 1mg

2 B/D NM

tacrolimus (generic of PROGRAF) CAPS

2 B/D NM

ZORTRESS TAB 0.5MG 5 * B/D NM



ZORTRESS TAB 1MG 5 * B/D NM

VACCINES ACTHIB 3

ADACEL 3

BCG VACCINE 3

BEXSERO 3

BOOSTRIX 3

DAPTACEL 3

DIPHTHERIA/TETANUS TOXOID

3 B/D

ENGERIX-B SUSP 3 B/D

GARDASIL 9 3

HAVRIX 3

HIBERIX 3

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

INFANRIX 3

IPOL INACTIVATED IPV 3

IXIARO 3

KINRIX 3

M-M-R II 3

MENACTRA 3

MENVEO 3

PEDIARIX 3

PEDVAX HIB 3

PENTACEL 3

PROQUAD 3

QUADRACEL 3

RABAVERT 3 B/D

RECOMBIVAX HB 3 B/D

ROTARIX 3

ROTATEQ 3

SHINGRIX QL (2 vials per lifetime)

3 QL

TDVAX 3 B/D

TENIVAC 3 B/D

TRUMENBA 3

TWINRIX INJ 3

Drug Name Drug Tier

Requirements/Limits

TYPHIM VI 3

VAQTA 3

VARIVAX 3

YF-VAX 3

ZOSTAVAX QL (1 vial per lifetime)

3 QL

NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES klor-con 8 1

klor-con 10 1

klor-con m10 1

klor-con m15 1

klor-con m20 1

klor-con pak 20meq 2

klor-con spr cap 8meq 2

klor-con spr cap 10meq 2

MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

3

magnesium sulfate (generic of MAGNESIUM SULFATE) SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

3

magnesium sulfate SOLN 50%

3

MAGNESIUM SULFATE IN D5W

3

magnesium sulfate in dextrose (generic of MAGNESIUM SULFATE IN D5W)

3

magnesium sulfate inj 50% 3

potassium chloride CPCR 2

potassium chloride PACK 2

potassium chloride SOLN 10%, 20%

2

potassium chloride TBCR 8meq, 10meq

1

potassium chloride (generic of K-TAB) TBCR 20meq

1

potassium chloride microencapsulated crystals er

1

sodium chloride SOLN 2.5meq/ml

2


48

Drug Name Drug Tier

Requirements/Limits

sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln

2

TPN ELECTROLYTES 4 B/D

IV NUTRITION AMINOSYN II INJ 10% 4 B/D

AMINOSYN-PF 7% 4 B/D

CLINIMIX 4.25%/DEXTROSE 5%

4 B/D

CLINIMIX 5%/DEXTROSE 15%

4 B/D

CLINIMIX 5%/DEXTROSE 20%

4 B/D

CLINIMIX INJ 4.25/D10 4 B/D

clinisol sf 15% 2 B/D

CLINOLIPID 4 B/D

FREAMINE HBC 6.9% 4 B/D

FREAMINE III 4 B/D

hepatamine 4 B/D

INTRALIPID 30% 4 B/D

INTRALIPID INJ 20% 4 B/D

NEPHRAMINE 4 B/D

NUTRILIPID INJ 20% 4 B/D

plenamine 2 B/D

PREMASOL SOL 10% 4 B/D

PROCALAMINE 4 B/D

PROSOL 4 B/D

TRAVASOL 4 B/D

TROPHAMINE INJ 10% 4 B/D

IV REPLACEMENT SOLUTIONS dextrose 2.5%/nacl 0.45% 2

dextrose 5% 2

DEXTROSE 5% /ELECTROLYTE

3

dextrose 5%/nacl 0.2% 2

DEXTROSE 5%/NACL 0.3% 4




dextrose 5%/potassium chl 2

dextrose 10% flex contain 2

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

3


dextrose 50% 2

dextrose in lactated ringers 2

dextrose inj 70% 2

Drug Name Drug Tier

Requirements/Limits

ISOLYTE P 4

ISOLYTE S 4

kcl0.15%/d5w/nacl0.2% 2

KCL 0.3%/D5W/NACL 0.9% 4

kcl 0.3%/d5w/nacl 0.45% 2

kcl 0.15%/d5w/nacl 0.9% 2

KCL 0.15%/D5W/NACL 0.225%

4

kcl 0.075%/d5w/nacl 0.45% 2

kcl/d5w inj 0.3% 2

kcl/d5w/nacl inj 0.22%/0.45% 2

kcl/d5w/nacl inj .15/.45% 2

kcl/nacl inj 0.3-0.9 2

kcl/nacl inj 0.15%-0.9% 2

lactated ringer's 2

NORMOSOL-M IN D5W 4

NORMOSOL-R 4

NORMOSOL-R IN D5W 4

PLASMA-LYTE A 4

PLASMA-LYTE-148 4

pot chloride inj 2meq/ml 2

potassium chloride SOLN 2meq/ml

2

POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

2

potassium chloride in nacl 2

sodium chloride SOLN 3%, 5%

2

sodium chloride 0.45% 2

sodium chloride inj 0.9% 2

VITAMINS calcitriol (generic of ROCALTROL) CAPS

2 B/D

calcitriol inj 2 B/D

calcitriol oral soln 1 mcg/ml (generic of ROCALTROL)

2 B/D

M-NATAL PLUS 3

paricalcitol (generic of ZEMPLAR) CAPS 1mcg, 2mcg

2 B/D

paricalcitol CAPS 4mcg 2 B/D

PNV FOLIC ACID + IRON MUL

3

PRENATAL 3


49

Drug Name Drug Tier

Requirements/Limits

PRENATAL PLUS 3

PRENATAL PLUS LOW IRON 3

RAYALDEE 5 *

TRICARE 3

OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION bacitracin-poly-neomycin-hc 2

BLEPHAMIDE OINT 4

neomycin-polymy-dexameth (generic of MAXITROL) OINT

1

neomycin-polymy-dexameth (generic of MAXITROL) SUSP

2

neomycin-polymyxin-hc (ophth)

2

sulfacetamide sod-prednisolone

2

TOBRADEX OINT 3

TOBRADEX ST 3

tobramycin-dexamethasone (generic of TOBRADEX)

2

ZYLET 3

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS AZASITE 4

bacitracin (ophthalmic) 2

bacitracin-polymyxin b (ophth) 1

BESIVANCE 3

CILOXAN OINT 3

ciprofloxacin hcl (ophth) (generic of CILOXAN)

1

erythromycin (ophth) 1

gatifloxacin (ophth) (generic of ZYMAXID)

2

gentak 2

gentamicin sulfate soln (ophth)

1

MOXEZA 3

moxifloxacin hcl (ophth) (generic of MOXEZA) .5%

2

moxifloxacin hcl (ophth) (generic of VIGAMOX) .5%

2

NATACYN 4

Drug Name Drug Tier

Requirements/Limits

neomycin-bacitracin zn-polymyxin

2

neomycin-polymyxin-gramicidin

2

ofloxacin (ophth) (generic of OCUFLOX)

2

polymyxin b-trimethoprim (generic of POLYTRIM)

1

sulfacetamide sodium (ophth) OINT

2

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

2

tobramycin (ophth) (generic of TOBREX)

1

trifluridine 2

ZIRGAN 4

ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ALREX 3

bromfenac sodium (ophth) 2

BROMSITE 4

dexamethasone sodium phosphate (ophth)

2

diclofenac sodium (ophth) 2

DUREZOL 3

FLAREX 4

fluorometholone 2

flurbiprofen sodium 2

ILEVRO 3

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

2

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

2

LOTEMAX GEL; OINT 3

loteprednol etabonate (generic of LOTEMAX)

2

prednisolone acetate (ophth) (generic of PRED FORTE)

2

PREDNISOLONE SODIUM PHOSPHATE (OPHTH)

3

PROLENSA 3

ANTIALLERGICS - DRUGS TO TREAT ALLERGIES azelastine drop 0.05% 2


50

Drug Name Drug Tier

Requirements/Limits

BEPREVE 3

cromolyn sodium (ophth) 1

LASTACAFT 4

olopatadine hcl 0.2% 2

PAZEO 3

ZERVIATE 4

ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P SOL 0.1% 3

AZOPT 3

betaxolol hcl (ophth) 2

BETOPTIC-S 3

brimonidine sol 0.2% 1

brimonidine sol 0.15% (generic of ALPHAGAN P)

2

carteolol hcl (ophth) 2

COMBIGAN 3

dorzolamide hcl (generic of TRUSOPT)

1

dorzolamide hcl-timolol maleate (generic of COSOPT)

1

latanoprost (generic of XALATAN) SOLN

1

levobunolol hcl 1

LUMIGAN 3

PHOSPHOLINE IODIDE 4

pilocarpine hcl (generic of ISOPTO CARPINE) SOLN

2

RHOPRESSA 3

SIMBRINZA 3

timolol maleate (ophth) soln (generic of TIMOPTIC)

1

timolol maleate gel (generic of TIMOPTIC-XE)

2

timolol maleate ophth soln 0.5% (once-daily) (generic of ISTALOL)

2

travoprost (generic of TRAVATAN Z)

2

MISCELLANEOUS ATROPINE SULFATE SOLN 1%

3

CYSTARAN 5 * NM LA PA

proparacaine hcl (generic of ALCAINE) SOLN

2

Drug Name Drug Tier

Requirements/Limits

RESTASIS QL (60 single use vials / 30 days)

3 QL

RESTASIS MULTIDOSE QL (1 bottle / 30 days)

3 QL

RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPD ANORO ELLIPTA

QL (60 blisters / 30 days)

3 QL

BEVESPI AEROSPHERE QL (1 inhaler / 30 days)

3 QL

COMBIVENT RESPIMAT QL (2 inhalers / 30 days)

4 QL

ipratropium-albuterol nebu 2 B/D

TRELEGY ELLIPTA QL (60 blisters / 30 days)

3 QL

ANTICHOLINERGICS - DRUGS TO TREAT COPD ATROVENT HFA

QL (2 inhalers / 30 days) 4 QL

INCRUSE ELLIPTA QL (30 blisters / 30 days)

3 QL

ipratropium bromide SOLN 2 B/D

ipratropium bromide (nasal) 2

ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES azelastine spr 0.1% 2

azelastine spr 0.15% 2

cetirizine syrup 1

cyproheptadine hcl SYRP; TABS


3 PA

diphenhydramine hcl inj 50mg/ml

2

hydroxyzine hcl SYRP PA if 70 years and older

3 PA

hydroxyzine hcl TABS PA if 70 years and older

2 PA

hydroxyzine hcl inj PA if 70 years and older

4 PA


51

Drug Name Drug Tier

Requirements/Limits

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


2 PA

levocetirizine dihydrochloride SOLN

2

levocetirizine dihydrochloride TABS

1

BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate AERS 108mcg/act

QL (2 inhalers / 30 days) (generic of Ventolin HFA)

2 QL

albuterol sulfate (generic of PROAIR HFA) AERS 108mcg/act

QL (2 inhalers / 30 days) (generic of Proair HFA)

2 QL

albuterol sulfate NEBU 2 B/D

albuterol sulfate SYRP 2

albuterol sulfate TABS 2

albuterol sulfate TB12 2

levalbuterol hcl (generic of XOPENEX) NEBU 1.25mg/3ml

2 B/D

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

2 B/D

levalbuterol tartrate hfa QL (2 inhalers / 30 days)

2 QL

SEREVENT DISKUS QL (60 inhalations / 30 days)

3 QL

terbutaline sulfate TABS 2

VENTOLIN HFA QL (2 inhalers / 30 days)

3 QL

LEUKOTRIENE MODULATORS montelukast sodium (generic of SINGULAIR) CHEW; PACK

2

montelukast sodium (generic of SINGULAIR) TABS

1

zafirlukast (generic of ACCOLATE)

2

Drug Name Drug Tier

Requirements/Limits

MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIES cromolyn sodium nebu 2 B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

2 B/D

ARALAST NP 5 * NM LA PA

DALIRESP 4

epinephrine (anaphylaxis) (generic of EPIPEN 2-PAK) .3mg/0.3ml

(generic of EpiPen)

2

epinephrine (anaphylaxis) (generic of EPIPEN-JR 2-PAK) .15mg/0.3ml

(generic of EpiPen)

2

epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml

(generic of Adrenaclick)

2

ESBRIET 5 * NM PA

FASENRA 5 * NM LA PA

FASENRA PEN 5 * NM LA PA

KALYDECO 5 * NM PA

NUCALA 5 * NM LA PA

OFEV 5 * NM PA

ORKAMBI 5 * NM PA

PROLASTIN-C 5 * NM LA PA

PULMOZYME 5 * NM PA

SYMDEKO 5 * NM LA PA

SYMJEPI 4

THEO-24 4

theophylline 2

theophylline tab er 12hr 300 mg

2

theophylline tab er 12hr 450 mg

2

theophylline tab sr 24hr 2

TRIKAFTA 5 * NM LA PA

XOLAIR 5 * NM LA PA

ZEMAIRA 5 * NM LA PA

NASAL STEROIDS - DRUGS TO TREAT ALLERGIES flunisolide (nasal)

QL (3 bottles / 30 days) 2 QL

fluticasone propionate (nasal) QL (1 bottle / 30 days)

1 QL


52

Drug Name Drug Tier

Requirements/Limits

STEROID INHALANTS - DRUGS TO TREAT ASTHMA ARNUITY ELLIPTA

QL (30 inhalations / 30 days)

3 QL

budesonide (inhalation) (generic of PULMICORT) .25mg/2ml, .5mg/2ml

2 B/D

FLOVENT DISKUS 50mcg/blist, 100mcg/blist


3 QL

FLOVENT DISKUS 250mcg/blist


3 QL

FLOVENT HFA QL (2 inhalers / 30 days)

3 QL

PULMICORT FLEXHALER QL (2 inhalers / 30 days)

4 QL

STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPD ADVAIR DISKUS


3 QL

ADVAIR HFA QL (1 inhaler / 30 days)

3 QL

BREO ELLIPTA QL (60 blisters / 30 days)

3 QL

SYMBICORT QL (1 inhaler / 30 days)

3 QL

TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE amnesteem 2 PA

avita (generic of RETIN-A) CREA


2 QL PA

avita GEL QL (45 grams / 30 days)

2 QL PA

benzoyl peroxide-erythromycin (generic of BENZAMYCIN)

2

claravis 2 PA

Drug Name Drug Tier

Requirements/Limits

clindamycin phosphate (topical) (generic of CLEOCIN-T) GEL


2 QL

clindamycin phosphate (topical) (generic of CLEOCIN-T) LOTN

2

clindamycin phosphate (topical) SOLN


2 QL

ery pad 2% 2

erythromycin (acne aid) (generic of ERYGEL) GEL

2

erythromycin (acne aid) SOLN

2

isotretinoin CAPS 2 PA

myorisan 2 PA

sulfacetamide sodium (acne) (generic of KLARON)

2

tretinoin (generic of RETIN-A) CREA


2 QL PA

tretinoin (generic of RETIN-A) GEL .01%, .025%


2 QL PA

zenatane 2 PA

DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) 2

mupirocin OINT QL (220 grams / 30 days)

1 QL

silver sulfadiazine (generic of SILVADENE) CREA

2

ssd (generic of SILVADENE) 2

SULFAMYLON CREA 4

DERMATOLOGY, ANTIFUNGALS ciclopirox (generic of LOPROX) CREA


2 QL

ciclopirox (generic of LOPROX) SUSP


2 QL

clotrimazole (topical) CREA 2

clotrimazole (topical) SOLN QL (30 mL / 30 days)

2 QL

clotrimazole w/ betamethasone CREA

2


53

Drug Name Drug Tier

Requirements/Limits

ketoconazole cream QL (60 grams / 30 days)

2 QL

nyamyc QL (60 grams / 30 days)

2 QL

nystatin (topical) 2

nystatin pow 100000 QL (60 grams / 30 days)

2 QL

nystop QL (60 grams / 30 days)

2 QL

DERMATOLOGY, ANTIPSORIATICS acitretin (generic of SORIATANE) 10mg, 25mg

2 PA

acitretin 17.5mg 2 PA

calcipotriene (generic of DOVONEX) CREA


2 QL PA

calcipotriene OINT QL (120 grams / 30 days)

2 QL PA

calcipotriene SOLN QL (120 mL / 30 days)

2 QL PA

calcitrene QL (120 grams / 30 days)

2 QL PA

tazarotene (generic of TAZORAC) CREA


2 QL PA

TAZORAC CREA .05% QL (60 grams / 30 days)

4 QL PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 1

selenium sulfide LOTN 1

DERMATOLOGY, CORTICOSTEROIDS ala-cort 1

alclometasone dipropionate 2

betamethasone dipropionate (topical)

2

betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA

2

betamethasone dipropionate augmented GEL; LOTN

2

betamethasone dipropionate augmented (generic of DIPROLENE) OINT

2

betamethasone valerate CREA; LOTN; OINT

2

Drug Name Drug Tier

Requirements/Limits

ENSTILAR QL (120 grams / 30 days)

4 QL PA

fluocinolone acetonide CREA .01%

2

fluocinolone acetonide (generic of SYNALAR) CREA .025%

2

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

2

fluocinolone acetonide (generic of SYNALAR) OINT

2

fluocinolone acetonide (generic of SYNALAR) SOLN


2 QL

fluocinolone acetonide oil body (generic of DERMA-SMOOTHE/FS SCALP)

2

fluocinonide CREA .05% QL (120 grams / 30 days)

2 QL

fluocinonide GEL QL (60 grams / 30 days)

2 QL

fluocinonide OINT QL (60 grams / 30 days)

2 QL

fluocinonide SOLN QL (60 mL / 30 days)

2 QL

fluocinonide emulsified base QL (120 grams / 30 days)

2 QL

fluticasone propionate CREA; OINT

2

halobetasol propionate CREA; OINT


2 QL

hydrocortisone (topical) cream 1%

1

hydrocortisone (topical) cream 2.5%

1

hydrocortisone (topical) lotion 2.5%

2

hydrocortisone (topical) oint 2.5%

1

hydrocortisone butyrate cream 0.1%


2 QL


54

Drug Name Drug Tier

Requirements/Limits

hydrocortisone butyrate oint 0.1%


2 QL

mometasone furoate CREA; OINT; SOLN

2

TEXACORT SOLN 2.5% 4

triamcinolone acetonide (topical) CREA .1%


1 QL

triamcinolone acetonide (topical) CREA .025%, .5%

1

triamcinolone acetonide (topical) LOTN

2

triamcinolone acetonide (topical) OINT .025%, .1%, .5%

1

DERMATOLOGY, LOCAL ANESTHETICS glydo

QL (30 mL / 30 days) 2 QL PA

lidocaine (generic of LIDODERM) PTCH 5%

QL (3 patches / 1 day)

2 QL PA

lidocaine hcl GEL QL (30 mL / 30 days)

2 QL PA

lidocaine hcl SOLN 4% QL (50 mL / 30 days)

2 QL PA

lidocaine oint 5% QL (50 grams / 30 days)

2 QL PA

lidocaine-prilocaine QL (30 grams / 30 days)

2 QL PA

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate CREA; LOTN

2

diclofenac sodium (topical) 1% gel (generic of VOLTAREN)


2 QL PA

fluorouracil (topical) (generic of EFUDEX) CREA 5%


2 QL

fluorouracil (topical) SOLN QL (10 mL / 30 days)

2 QL

Drug Name Drug Tier

Requirements/Limits

imiquimod (generic of ALDARA) CREA 5%


2 QL

metronidazole (topical) (generic of METROCREAM) CREA

2

metronidazole (topical) (generic of METROLOTION) LOTN

2

metronidazole gel 0.75% 2

PANRETIN QL (60 grams / 30 days)

5 * QL

PICATO .05% QL (2 tubes / 30 days)

4 QL

PICATO .015% QL (3 tubes / 30 days)

4 QL

podofilox SOLN 2

procto-med hc (generic of ANUSOL-HC)

2

procto-pak (generic of PROCTOCORT)

2

proctosol hc cre 2.5% (generic of ANUSOL-HC)

2

proctozone-hc (generic of ANUSOL-HC)

2

RECTIV QL (30 grams / 30 days)

4 QL

rosadan (generic of METROCREAM)

2

tacrolimus (topical) (generic of PROTOPIC)


2 QL

TARGRETIN GEL QL (60 grams / 30 days)

5 * QL NM PA

VALCHLOR QL (60 grams / 30 days)

5 * QL NM LA PA

DERMATOLOGY, SCABICIDES AND PEDICULIDES malathion 2

permethrin cre 5% (generic of ELIMITE)

2

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 2

REGRANEX QL (30 grams / 30 days)

5 * QL PA

SANTYL 4


55

Drug Name Drug Tier

Requirements/Limits

sodium chlor sol 0.9% irr 2

water for irrigation, sterile 2

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

2

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

1

clotrimazole LOZG 2

lidocaine hcl (mouth-throat) 2

nystatin (mouth-throat) 2

paroex sol 0.12% (generic of PERIDEX)

1

periogard (generic of PERIDEX)

1

pilocarpine hcl (oral) (generic of SALAGEN)

2

triamcinolone acetonide (mouth)

2

OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR acetic acid (otic) 2

CIPRODEX 3

flac (generic of DERMOTIC) 2

fluocinolone acetonide (otic) (generic of DERMOTIC)

2

neomycin-polymyxin-hc (otic) 2

ofloxacin (otic) 2

56

Index A abacavir sulfate............... 13 abacavir sulfate-lamivudine

.................................... 14 abacavir sulfate-

lamivudine-zidovudine . 14 ABELCET ....................... 12 ABILIFY

see aripiprazole tab ..... 30 ABILIFY MAINTENA ....... 29 abiraterone acetate ......... 17 ABRAXANE .................... 17 acamprosate calcium ...... 35 acarbose ......................... 36 ACCOLATE

see zafirlukast ............. 51 ACCUPRIL

see quinapril hcl .......... 20 ACCURETIC

see quinapril-hydrochlorothiazide . 20

acebutolol hcl .................. 22 acetaminophen w/ codeine

300-15mg ...................... 9 acetaminophen w/ codeine



soln ............................... 9 acetazolamide ................ 24 acetic acid ....................... 54 acetic acid (otic) .............. 55 acetylcysteine ................. 51 acitretin ........................... 53 ACTHIB .......................... 47 ACTIGALL

see ursodiol ................. 43 ACTIMMUNE .................. 46 ACTIQ

see fentanyl citrate ...... 10 ACTOS

see pioglitazone hcl ..... 37 ACULAR

see ketorolac tromethamine (ophth) ................................ 49

ACULAR LS

see ketorolac tromethamine (ophth) ................................ 49

acyclovir .......................... 14 acyclovir sodium ............. 14 ADACEL ......................... 47 ADDERALL

see amphetamine-dextroamphetamine tab 10 mg................. 32

see amphetamine-dextroamphetamine tab 12.5 mg .............. 32




see amphetamine-dextroamphetamine tab 5 mg................... 32

see amphetamine-dextroamphetamine tab 7.5 mg................ 32

ADDERALL XR see amphetamine-

dextroamphetamine cap sr 24hr 10 mg .... 32

see amphetamine-dextroamphetamine cap sr 24hr 15 mg .... 32




see amphetamine-dextroamphetamine cap sr 24hr 5 mg ...... 32

adefovir dipivoxil ............. 14

ADEMPAS ...................... 24 adriamycin ...................... 16 adrucil inj......................... 17 ADVAIR DISKUS ............ 52 ADVAIR HFA .................. 52 AFINITOR ....................... 18

see everolimus ............ 18 AFINITOR DISPERZ ...... 18 AGGRENOX

see aspirin-dipyridamole ................................ 45

AGRYLIN see anagrelide hcl ....... 45

AIMOVIG ........................ 33 ala-cort ............................ 53 albendazole .................... 11 ALBENZA

see albendazole .......... 11 albuterol sulfate .............. 51 ALCAINE

see proparacaine hcl ... 50 alclometasone dipropionate

.................................... 53 ALDACTAZIDE

see spironolactone & hydrochlorothiazide . 24

ALDACTONE see spironolactone ...... 20

ALDARA see imiquimod ............. 54

ALDURAZYME ............... 40 ALECENSA..................... 18 alendronate sodium tab 10

mg ............................... 37 alendronate sodium tab 35




mg ............................... 37 alfuzosin hcl .................... 44 ALIMTA ........................... 17 ALINIA ............................ 11 aliskiren fumarate ........... 24 allopurinol tab ................... 9 alosetron hcl ................... 43

57

ALPHAGAN P see brimonidine sol

0.15% ...................... 50 ALPHAGAN P SOL 0.1% 50 alprazolam tab 0.25mg ... 25 alprazolam tab 0.5mg ..... 25 alprazolam tab 1mg ........ 25 alprazolam tab 2mg ........ 25 ALREX ............................ 49 ALTACE

see ramipril ................. 20 altavera tab ..................... 38 ALUNBRIG ..................... 18 alyacen 1/35 ................... 38 amantadine hcl ............... 29 AMARYL

see glimepiride ............ 36 AMBIEN

see zolpidem tartrate ... 33 AMBISOME .................... 12 ambrisentan .................... 24 AMERGE

see naratriptan hcl ....... 33 amikacin sulfate .............. 11 amiloride &

hydrochlorothiazide ..... 24 amiloride hcl ................... 24 AMINOSYN II INJ 10% ... 48 AMINOSYN-PF 7% ......... 48 amiodarone hcl soln ........ 21 amiodarone tab 100mg ... 21 amiodarone tab 200mg ... 21 amiodarone tab 400mg ... 21 AMITIZA CAP 24MCG .... 43 AMITIZA CAP 8MCG ...... 43 amitriptyline hcl ............... 28 amlodipine besylate ........ 23 amlodipine besylate-

olmesartan medoxomil 20 amlodipine besylate-

valsartan tab 10-160 mg .................................... 20

amlodipine besylate-valsartan tab 10-320 mg .................................... 20

amlodipine besylate-valsartan tab 5-160 mg 20

amlodipine besylate-valsartan tab 5-320 mg 20

amlodipine--benazepril hcl cap 10-20 mg .............. 20

amlodipine-benazepril hcl cap 10-40mg ............... 20

amlodipine-benazepril hcl cap 2.5-10 mg ............. 20

amlodipine-benazepril hcl cap 5-10 mg ................ 20



amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg ................. 21

amlodipine-valsartan-hydrochlorothiazide 10-160-25mg .................... 21


amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg ................. 21


ammonium lactate .......... 54 amnesteem ..................... 52 amoxapine tab 100mg .... 28 amoxapine tab 150mg .... 28 amoxapine tab 25mg ...... 28 amoxapine tab 50mg ...... 28 amoxicillin ....................... 16 amoxicillin & pot

clavulanate 200/5ml susr .................................... 16

amoxicillin & pot clavulanate 200-28.5 chw tabs ............................. 16

amoxicillin & pot clavulanate 250/5ml susr .................................... 16

amoxicillin & pot clavulanate 250-125 tabs .................................... 16


amoxicillin & pot clavulanate 400-57 chw tabs ............................. 16




amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs ..................... 16

amphetamine-dextroamphetamine cap sr 24hr 10 mg .............. 32





amphetamine-dextroamphetamine cap sr 24hr 5 mg ................ 32

amphetamine-dextroamphetamine tab 10 mg .......................... 32

amphetamine-dextroamphetamine tab 12.5 mg ....................... 32




58

amphetamine-dextroamphetamine tab 5 mg ............................... 32

amphetamine-dextroamphetamine tab 7.5 mg ......................... 32

amphotericin b ................ 12 ampicillin & sulbactam

sodium ........................ 16 ampicillin cap 500mg ...... 16 ampicillin inj .................... 16 ampicillin sodium ............ 16 AMPYRA

see dalfampridine ........ 34 ANADROL-50 ................. 35 ANAFRANIL

see clomipramine hcl .. 28 anagrelide hcl ................. 45 ANAPROX DS

see naproxen sodium .... 9 anastrozole ..................... 18 ANCOBON

see flucytosine ............ 12 ANDRODERM ................ 35 ANDROGEL

see testosterone .......... 35 ANORO ELLIPTA ........... 50 ANTABUSE

see disulfiram .............. 35 ANUSOL-HC

see procto-med hc ...... 54 see proctosol hc cre

2.5% ........................ 54 see proctozone-hc ....... 54

APOKYN ......................... 29 aprepitant ........................ 42 aprepitant pak 80mg &

125mg ......................... 42 apri .................................. 38 APTIOM .......................... 25 APTIVUS ........................ 13 ARALAST NP ................. 51 aranelle ........................... 38 ARAVA

see leflunomide ........... 46 ARCALYST ..................... 46 ARICEPT

see donepezil hydrochloride ........... 27

ARIMIDEX see anastrozole ........... 18

aripiprazole odt ............... 29 aripiprazole oral solution 1

mg/ml .......................... 30 aripiprazole tab ............... 30 ARISTADA ...................... 30 ARISTADA INITIO .......... 30 ARIXTRA

see fondaparinux sodium ................................ 44

armodafinil ...................... 35 ARNUITY ELLIPTA ......... 52 AROMASIN

see exemestane .......... 18 aspirin-dipyridamole ........ 45 atazanavir sulfate ............ 13 atenolol ........................... 22 atenolol & chlorthalidone 22 ATIVAN

see lorazepam ............. 25 atomoxetine hcl ............... 32 atorvastatin calcium ........ 21 atovaquone ..................... 11 atovaquone-proguanil hcl 13 ATRIPLA ......................... 14 ATROPINE SULFATE .... 50 ATROVENT HFA ............ 50 aubra .............................. 38 AUGMENTIN

see amoxicillin & pot clavulanate 250/5ml susr .......................... 16

see amoxicillin & pot clavulanate 500-125 tabs .......................... 16

AURYXIA ........................ 41 AUSTEDO ...................... 34 AVALIDE

see irbesartan-hydrochlorothiazide . 21

AVAPRO see irbesartan ............. 21

AVASTIN ........................ 17 aviane ............................. 38 avita ................................ 52 AVODART

see dutasteride ............ 44 AYGESTIN

see norethindrone acetate ..................... 42

AYVAKIT......................... 18 azacitidine ....................... 17 AZACTAM

see aztreonam ............ 11 AZASITE ......................... 49 azathioprine .................... 46 azelastine drop 0.05% .... 49 azelastine spr 0.1% ........ 50 azelastine spr 0.15% ...... 50 AZILECT

see rasagiline mesylate ................................ 29

azithromycin .................... 15 AZOPT ............................ 50 AZOR

see amlodipine besylate-olmesartan medoxomil ................................ 20

aztreonam ....................... 11 AZULFIDINE

see sulfasalazine ......... 43 AZULFIDINE EN-TABS

see sulfasalazine ec .... 43 B bacitracin (ophthalmic) .... 49 bacitracin-polymyxin b

(ophth) ......................... 49 bacitracin-poly-neomycin-

hc ................................ 49 baclofen .......................... 34 BACTRIM

see sulfamethoxazole-trimethoprim tab 400-80mg........................ 12

BACTRIM DS see sulfamethoxazole-

trimethop ds ............. 12 balsalazide disodium ...... 43 BALVERSA ..................... 18 balziva ............................ 38 BANZEL SUS 40MG/ML . 25 BANZEL TAB 200MG ..... 25 BANZEL TAB 400MG ..... 25 BARACLUDE .................. 14

see entecavir ............... 14 BASAGLAR KWIKPEN ... 35 BCG VACCINE ............... 47

59

BD ALCOHOL SWABS ... 35 BD ULTRAFINE INSULIN

SYRINGE .................... 35 BD ULTRAFINE/NANO

PEN NEEDLES ........... 35 bekyree ........................... 38 BELSOMRA .................... 33 benazepril &

hydrochlorothiazide ..... 20 benazepril hcl ................. 20 BENDEKA ...................... 16 BENICAR

see olmesartan medoxomil ............... 21

BENICAR HCT see olmesartan

medoxomil-hydrochlorothiazide . 21

BENLYSTA ..................... 46 BENZAMYCIN

see benzoyl peroxide-erythromycin ............ 52

benzoyl peroxide-erythromycin................ 52

benztropine mesylate inj . 29 benztropine mesylate tab

0.5mg .......................... 29 benztropine mesylate tab

1mg ............................. 29 benztropine mesylate tab

2mg ............................. 29 BEPREVE ....................... 50 BERINERT ..................... 45 BESIVANCE ................... 49 betamethasone

dipropionate (topical) ... 53 betamethasone

dipropionate augmented .................................... 53

betamethasone valerate . 53 BETAPACE

see sorine ................... 21 see sotalol hcl ............. 21

BETAPACE AF see sotalol hcl (afib/afl) 21

BETASERON ................. 34 betaxolol hcl (ophth) ....... 50 bethanechol chloride ....... 44 BETOPTIC-S .................. 50

BEVESPI AEROSPHERE .................................... 50

bexarotene ...................... 19 BEXSERO ...................... 47 BIAXIN XL

see clarithromycin er ... 15 bicalutamide.................... 18 BICILLIN L-A................... 16 BIKTARVY ...................... 14 BILTRICIDE

see praziquantel .......... 12 bisoprolol &

hydrochlorothiazide ..... 22 bisoprolol fumarate ......... 22 BIVIGAM ......................... 46 BLEPH-10

see sulfacetamide sodium (ophth) ......... 49

BLEPHAMIDE................. 49 blisovi fe 1.5/30 ............... 38 BONIVA

see ibandronate sodium tabs .......................... 37

BOOSTRIX ..................... 47 BORTEZOMIB ................ 17 bosentan ......................... 24 BOSULIF ........................ 18 BRAFTOVI ...................... 18 BREO ELLIPTA .............. 52 briellyn ............................ 38 BRILINTA ....................... 45 brimonidine sol 0.15% .... 50 brimonidine sol 0.2% ...... 50 BRIVIACT INJ 50MG/5ML

.................................... 25 BRIVIACT SOL 10MG/ML

.................................... 25 BRIVIACT TAB 100MG .. 25 BRIVIACT TAB 10MG .... 25 BRIVIACT TAB 25MG .... 25 BRIVIACT TAB 50MG .... 25 BRIVIACT TAB 75MG .... 25 bromfenac sodium (ophth)

.................................... 49 bromocriptine mesylate ... 29 BROMSITE ..................... 49 BRUKINSA ..................... 18 budesonide (inhalation) .. 52 budesonide ec ................ 43

bumetanide ..................... 24 BUMEX

see bumetanide ........... 24 BUPHENYL

see sodium phenylbutyrate ......... 40

buprenorphine hcl ........... 35 buprenorphine hcl-

naloxone hcl dihydrate 12-3mg ........................ 35

buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg .......................... 35

buprenorphine hcl-naloxone hcl dihydrate 4-1mg ............................. 35

buprenorphine hcl-naloxone hcl dihydrate 8-2mg ............................. 35

buprenorphine hcl-naloxone hcl sl ............ 35

bupropion hcl .................. 28 bupropion hcl (smoking

deterrent)..................... 35 buspirone hcl .................. 25 butorphanol tartrate .......... 9 BYDUREON BCISE ........ 35 BYDUREON PEN ........... 35 BYETTA .......................... 35 BYSTOLIC ...................... 22 C cabergoline ..................... 41 CABOMETYX ................. 18 CAFERGOT

see ergotamine w/ caffeine .................... 33

CALAN SR see verapamil hcl tab er

................................ 23 calcipotriene .................... 53 calcitonin (salmon) .......... 41 calcitrene ........................ 53 calcitriol ........................... 48 calcitriol inj ...................... 48 calcitriol oral soln 1 mcg/ml

.................................... 48 calcium acetate (phosphate

binder) ......................... 41 CALQUENCE ................. 18

60

camila ............................. 38 CAMPTOSAR

see irinotecan hcl ........ 19 CANASA

see mesalamine .......... 43 CANCIDAS

see caspofungin acetate ................................ 12

CAPLYTA ....................... 30 CAPRELSA .................... 18 captopril .......................... 20 captopril &

hydrochlorothiazide ..... 20 CARAFATE

see sucralfate .............. 43 CARBAGLU .................... 40 carbamazepine ............... 25 CARBATROL

see carbamazepine ..... 25 carbidopa/levodopa/entaca

pone ............................ 29 carbidopa-levodopa ........ 29 carboplatin ...................... 19 CARDIZEM

see diltiazem hcl .......... 23 CARDIZEM CD

see cartia xt cap 120/24hr .................. 23




see diltiazem cap 240mg cd ............................. 23

see diltiazem cap 360mg cd ............................. 23

see diltiazem hcl coated beads ....................... 23

see diltiazem hcl coated beads cap sr 24hr .... 23

see diltiazem hcl extended release beads cap sr ............ 23

CARDURA see doxazosin mesylate

................................ 20 CARNITOR

see levocarnitine (metabolic modifiers) ................................ 40

carteolol hcl (ophth) ........ 50 cartia xt cap 120/24hr ..... 23 cartia xt cap 180/24hr ..... 23 cartia xt cap 240/24hr ..... 23 cartia xt cap 300/24hr ..... 23 carvedilol ........................ 22 CASODEX

see bicalutamide ......... 18 caspofungin acetate ........ 12 CATAPRES

see clonidine hcl .......... 24 CATAPRES-TTS-1

see clonidine hcl ptwk . 24 CATAPRES-TTS-2

see clonidine hcl ptwk . 24 CATAPRES-TTS-3

see clonidine hcl ptwk . 24 CAYSTON ...................... 11 caziant pak ..................... 38 cefaclor ........................... 15 CEFACLOR

MONOHYDRATE ER .. 15 cefadroxil ........................ 15 CEFAZOLIN IN

DEXTROSE 2GM/100ML-4% .......... 15

cefazolin inj ..................... 15 cefazolin sodium ............. 15 CEFAZOLIN SODIUM 1

GM/50ML .................... 15 cefdinir ............................ 15 cefepime hcl.................... 15 cefixime .......................... 15 cefoxitin sodium .............. 15 cefpodoxime proxetil ....... 15 cefprozil .......................... 15 ceftazidime ..................... 15 CEFTAZIDIME/DEXTROS

E .................................. 15 ceftriaxone sodium .......... 15 cefuroxime axetil ............. 15 cefuroxime sodium .......... 15 CELEBREX

see celecoxib ................ 9 celecoxib ........................... 9 CELEXA

see citalopram hydrobromide ........... 28

CELLCEPT see mycophenolate

mofetil ...................... 46 CELONTIN...................... 25 cephalexin....................... 15 CERDELGA .................... 40 CEREZYME .................... 40 cetirizine syrup ................ 50 cevimeline hcl ................. 55 CHANTIX ........................ 35 CHANTIX CONTINUING

MONTH ....................... 35 CHANTIX STARTER PACK

.................................... 35 CHEMET......................... 38 chlorhexidine gluconate

(mouth-throat) ............. 55 chloroquine phosphate ... 13 chlorothiazide .................. 24 chlorpromazine hcl .......... 30 CHLORPROMAZINE INJ 30 chlorthalidone ................. 24 cholestyramine ................ 22 cholestyramine light pack 22 cholestyramine light powd

.................................... 22 ciclopirox ......................... 52 cilostazol ......................... 45 CILOXAN ........................ 49

see ciprofloxacin hcl (ophth) ..................... 49

CIMDUO ......................... 14 cinacalcet hcl .................. 41 CIPRO ............................ 15

see ciprofloxacin hcl tab ................................ 15

CIPRODEX ..................... 55 ciprofloxacin hcl (ophth) .. 49 ciprofloxacin hcl tab ........ 15 ciprofloxacin in d5w ........ 15 cisplatin ........................... 19 citalopram hydrobromide 28 claravis ........................... 52 clarithromycin .................. 15 clarithromycin er ............. 15 clarithromycin for susp .... 15 CLEOCIN

61

see clindamycin cap 300mg ..................... 11

see clindamycin cap 75mg ....................... 11

see clindamycin hcl cap 150 mg .................... 11

see clindamycin phosphate vaginal ... 44

CLEOCIN PEDIATRIC GRANULE see clindamycin soln

75mg/5ml ................. 11 CLEOCIN PHOSPHATE

see clindamycin phosphate inj ........... 11

CLEOCIN-T see clindamycin

phosphate (topical) .. 52 CLIMARA

see estradiol ................ 40 clindamycin cap 300mg .. 11 clindamycin cap 75mg .... 11 clindamycin hcl cap 150 mg

.................................... 11 clindamycin phosphate

(topical) ....................... 52 clindamycin phosphate in

d5w ............................. 11 CLINDAMYCIN

PHOSPHATE IN NACL .................................... 11

clindamycin phosphate inj .................................... 11

clindamycin phosphate vaginal ......................... 44

clindamycin soln 75mg/5ml .................................... 11

CLINIMIX 4.25%/DEXTROSE 5% .................................... 48

CLINIMIX 5%/DEXTROSE 15% ............................. 48

CLINIMIX 5%/DEXTROSE 20% ............................. 48

CLINIMIX INJ 4.25/D10 .. 48 clinisol sf 15% ................. 48 CLINOLIPID .................... 48 clobazam ........................ 25 clomipramine hcl ............. 28

clonazepam .................... 25 clonidine hcl .................... 24 clonidine hcl ptwk ............ 24 clopidogrel tab 75mg ...... 45 clorazepate dipotassium . 25 clotrimazole .................... 55 clotrimazole (topical) ....... 52 clotrimazole w/

betamethasone ........... 52 clovique .......................... 38 clozapine odt................... 30 clozapine tab 100mg ....... 30 clozapine tab 200mg ....... 30 clozapine tab 25mg ......... 30 clozapine tab 50mg ......... 30 CLOZARIL

see clozapine tab 100mg ................................ 30




COARTEM ...................... 13 COGENTIN

see benztropine mesylate inj .............. 29

COLAZAL see balsalazide disodium

................................ 43 colchicine w/ probenecid ... 9 COLCRYS ........................ 9 colesevelam hcl .............. 22 COLESTID

see colestipol hcl gran . 22 see colestipol hcl pack 22 see colestipol hcl tabs . 22

colestipol hcl gran ........... 22 colestipol hcl pack ........... 22 colestipol hcl tabs ........... 22 colistimethate sodium ..... 11 colocort ........................... 43 COLY-MYCIN M

see colistimethate sodium ..................... 11

COMBIGAN .................... 50 COMBIVENT RESPIMAT

.................................... 50

COMBIVIR see lamivudine-

zidovudine ............... 14 COMETRIQ .................... 18 COMPLERA .................... 14 compro ............................ 42 COMTAN

see entacapone ........... 29 constulose....................... 43 COPAXONE

see glatiramer acetate 20mg/ml ................... 34

see glatiramer acetate 40mg/ml ................... 34

see glatopa .................. 34 COPIKTRA ..................... 18 COREG

see carvedilol .............. 22 CORGARD

see nadolol .................. 22 CORLANOR ................... 24 CORTEF

see hydrocortisone ...... 40 CORTENEMA

see colocort ................. 43 see hydrocortisone

(enema) ................... 43 cortisone acetate ............ 40 COSOPT

see dorzolamide hcl-timolol maleate ........ 50

COTELLIC ...................... 18 COUMADIN .................... 44 COZAAR

see losartan potassium ................................ 21

CREON ........................... 43 CRESTOR

see rosuvastatin calcium ................................ 21

CRIXIVAN ....................... 13 cromolyn sodium

(mastocytosis) ............. 43 cromolyn sodium (ophth) 50 cromolyn sodium nebu .... 51 cryselle-28 ...................... 38 CUBICIN

see daptomycin ........... 12 cyclafem 1/35 .................. 38

62

cyclafem 7/7/7 ................ 38 cyclobenzaprine hcl ........ 34 cyclophosphamide .......... 16 cycloserine ...................... 14 cyclosporine .................... 46 cyclosporine modified (for

microemulsion) ............ 46 CYKLOKAPRON

see tranexamic acid .... 45 CYMBALTA

see duloxetine hcl ....... 28 cyproheptadine hcl.......... 50 cyred tab ......................... 38 CYSTADANE .................. 40 CYSTAGON ................... 40 CYSTARAN .................... 50 cytarabine ....................... 17 CYTOMEL

see liothyronine sodium ................................ 42

CYTOTEC see misoprostol ........... 43

CYTOVENE see ganciclovir sodium 14

D D.H.E. 45

see dihydroergotamine mesylate inj 1 mg/ml 33

dalfampridine .................. 34 DALIRESP ...................... 51 danazol ........................... 40 DANTRIUM

see dantrolene sodium 34 dantrolene sodium .......... 34 dapsone .......................... 11 DAPTACEL ..................... 47 daptomycin ............... 11, 12 DAPTOMYCIN

see daptomycin ........... 11 dasetta 1/35 .................... 38 dasetta 7/7/7 ................... 38 DAURISMO .................... 17 DDAVP

see desmopressin acetate spray ........... 42

see desmopressin acetate tabs ............. 42

see desmopressin inj 4mcg/ml ................... 42

deblitane ......................... 38 deferasirox tab ................ 38 DELESTROGEN ............. 40

see estradiol valerate .. 40 DELSTRIGO ................... 14 DELZICOL

see mesalamine .......... 43 DEMSER ........................ 24 DEPAKOTE

see divalproex sodium 26 DEPAKOTE ER

see divalproex sodium 25 DEPAKOTE SPRINKLES

see divalproex sodium 25 DEPEN TITRATABS

see penicillamine ......... 38 DEPO-MEDROL

see methylprednisolone acetate ..................... 40

DEPO-PROVERA CONTRACEPTIV see

medroxyprogesterone acetate (contraceptive) ................................ 39

DEPO-PROVERA INJ 400/ML ........................ 18

DEPO-TESTOSTERONE see testosterone

cypionate ................. 35 DERMA-SMOOTHE/FS

BODY see fluocinolone

acetonide ................. 53 DERMA-SMOOTHE/FS

SCALP see fluocinolone

acetonide oil body .... 53 DERMOTIC

see flac ........................ 55 see fluocinolone

acetonide (otic) ........ 55 DESCOVY ...................... 14 desipramine hcl ............... 28 desmopressin acetate

spray ........................... 42 desmopressin acetate

spray refrigerated ........ 42

desmopressin acetate tabs .................................... 42

desmopressin inj 4mcg/ml .................................... 42

desogestrel & ethinyl estradiol....................... 38

desogestrel-ethinyl estradiol (biphasic) ...... 38

desvenlafaxine succinate 28 DETROL

see tolterodine tartrate tabs .......................... 44

DETROL LA see tolterodine tartrate

cap er....................... 44 dexamethasone .............. 40 DEXAMETHASONE ....... 40 DEXAMETHASONE

SODIUM PHOS see dexamethasone

sodium phosphate ... 40 dexamethasone sodium

phosphate ................... 40 dexamethasone sodium

phosphate (ophth) ....... 49 DEXILANT ...................... 43 dexmethylphenidate hcl .. 32 dextrose 10% flex contain

.................................... 48 DEXTROSE 10% W/

SODIUM CHLORIDE 0.2% ............................ 48

dextrose 10%/nacl 0.45% .................................... 48

dextrose 2.5%/nacl 0.45% .................................... 48

dextrose 5% .................... 48 DEXTROSE 5%

/ELECTROLYTE ......... 48 dextrose 5%/nacl 0.2% ... 48 dextrose 5%/nacl 0.225%

.................................... 48 DEXTROSE 5%/NACL

0.3% ............................ 48 dextrose 5%/nacl 0.45% . 48 dextrose 5%/nacl 0.9% ... 48 dextrose 5%/potassium chl

.................................... 48 dextrose 50% .................. 48

63

dextrose in lactated ringers .................................... 48

dextrose inj 70% ............. 48 DIASTAT ACUDIAL ........ 25 DIASTAT PEDIATRIC .... 25 diazepam ........................ 25 diazepam gel .................. 25 diazepam inj ................... 25 diazepam intensol ........... 25 diazepam oral soln 1 mg/ml

.................................... 25 diazoxide ........................ 41 diclofenac potassium ........ 9 diclofenac sodium ............. 9 diclofenac sodium (ophth)

.................................... 49 diclofenac sodium (topical)

1% gel ......................... 54 dicloxacillin sodium ......... 16 dicyclomine hcl cap 10mg

.................................... 42 dicyclomine hcl soln

10mg/5ml .................... 42 dicyclomine hcl tab 20mg 42 didanosine ...................... 13 DIFICID ........................... 15 DIFLUCAN

see fluconazole ........... 12 diflunisal ............................ 9 digitek ............................. 23 digox ............................... 23 digoxin ............................ 23 digoxin inj ........................ 23 digoxin sol 50mcg/ml ...... 23 dihydroergotamine

mesylate inj 1 mg/ml ... 33 dihydroergotamine

mesylate nasal spr 4 mg/ml .......................... 33

DILANTIN see phenytoin sodium

extended .................. 26 DILANTIN CAP 100MG .. 25 DILANTIN CAP 30MG .... 25 DILANTIN CHEW TAB

50MG .......................... 25 DILANTIN INFATABS

see phenytoin .............. 26 DILANTIN-125

see phenytoin .............. 26 DILANTIN-125 SUSP ..... 25 DILAUDID

see hydromorphone hcl ................................ 10

diltiazem cap 240mg cd .. 23 diltiazem cap 360mg cd .. 23 diltiazem cap er/12hr ...... 23 diltiazem hcl .................... 23 diltiazem hcl coated beads

.................................... 23 diltiazem hcl coated beads

cap sr 24hr .................. 23 diltiazem hcl extended

release beads cap sr ... 23 diltiazem inj ..................... 23 dilt-xr cap ........................ 23 DIOVAN

see valsartan ............... 21 DIOVAN HCT

see valsartan-hydrochlorothiazide . 21

diphenhydramine hcl inj 50mg/ml ...................... 50

diphenoxylate w/ atropine .................................... 43

DIPHTHERIA/TETANUS TOXOID ...................... 47

DIPROLENE see betamethasone

dipropionate augmented ............... 53

DIPROLENE AF see betamethasone

dipropionate augmented ............... 53

disopyramide phosphate . 21 disulfiram ........................ 35 DITROPAN XL

see oxybutynin chloride ................................ 44

divalproex sodium ..... 25, 26 docetaxel ........................ 17 DOCETAXEL .................. 17

see docetaxel .............. 17 dofetilide ......................... 21 DOLOPHINE

see methadone hcl 10mg ................................ 10

see methadone hcl 5mg ................................ 10

donepezil hydrochloride .. 27 dorzolamide hcl ............... 50 dorzolamide hcl-timolol

maleate ....................... 50 DOVATO......................... 14 DOVONEX

see calcipotriene ......... 53 doxazosin mesylate ........ 20 doxepin hcl...................... 28 doxepin hcl (sleep) .......... 33 DOXIL

see doxorubicin hcl liposomal ................. 17

doxorubicin hcl ................ 17 doxorubicin hcl liposomal 17 doxy 100 ......................... 16 doxycycline (monohydrate)

.................................... 16 doxycycline hyclate ......... 16 DRIZALMA SPRINKLE ... 28 dronabinol ....................... 42 drospirenone-ethinyl

estradiol....................... 38 DROXIA .......................... 45 duloxetine hcl .................. 28 DURAGESIC

see fentanyl patch 100 mcg/hr...................... 10





DUREZOL....................... 49 dutasteride ...................... 44 dutasteride-tamsulosin hcl

.................................... 44 DYAZIDE

see triamterene & hydrochlorothiazide cap 37.5-25 mg ........ 24

E e.e.s 400 ......................... 15 EC-NAPROSYN

64

see naproxen dr ............ 9 EC-NAPROXEN

see naproxen dr ............ 9 EDURANT ...................... 13 efavirenz ......................... 13 EFFEXOR XR

see venlafaxine hcl ...... 29 EFFIENT

see prasugrel hcl ......... 45 EFUDEX

see fluorouracil (topical) ................................ 54

eletriptan hydrobromide .. 33 ELIMITE

see permethrin cre 5% 54 ELIQUIS ......................... 44 ELIQUIS STARTER PACK

.................................... 44 ELLA ............................... 38 ELLENCE

see epirubicin hcl ........ 17 eluryng ............................ 38 EMCYT ........................... 16 EMEND ........................... 42

see aprepitant ............. 42 EMGALITY ..................... 33 emoquette ....................... 38 EMSAM .......................... 28 EMTRIVA ........................ 13 EMVERM ........................ 12 enalapril maleate ............ 20 enalapril maleate &

hydrochlorothiazide ..... 20 ENBREL ......................... 45 ENBREL MINI ................. 45 ENBREL SURECLICK .... 45 ENDARI .......................... 45 endocet 10-325mg .......... 10 endocet 2.5-325mg ........... 9 endocet 5-325mg .............. 9 endocet 7.5-325mg ......... 10 ENGERIX-B .................... 47 enoxaparin sodium ......... 44 enpresse-28 .................... 38 enskyce .......................... 38 ENSTILAR ...................... 53 entacapone ..................... 29 entecavir ......................... 14 ENTOCORT EC

see budesonide ec ...... 43 ENTRESTO .................... 21 enulose ........................... 43 EPCLUSA ....................... 14 EPIDIOLEX ..................... 26 epinephrine (anaphylaxis)

.................................... 51 EPIPEN 2-PAK

see epinephrine (anaphylaxis) ........... 51

EPIPEN-JR 2-PAK see epinephrine

(anaphylaxis) ........... 51 epirubicin hcl ................... 17 epitol ............................... 26 EPIVIR

see lamivudine ............ 13 EPIVIR HBV.................... 14

see lamivudine (hbv) ... 14 eplerenone ...................... 20 EPZICOM

see abacavir sulfate-lamivudine ............... 14

ergotamine w/ caffeine .... 33 ERIVEDGE ..................... 17 ERLEADA ....................... 18 erlotinib hcl ..................... 18 errin ................................ 38 ertapenem sodium .......... 12 ery pad 2% ..................... 52 ERYGEL

see erythromycin (acne aid) .......................... 52

ery-tab ............................ 15 ERYTHROCIN

LACTOBIONATE ........ 15 erythrocin stearate .......... 15 erythromycin (acne aid) .. 52 erythromycin (ophth) ....... 49 erythromycin base .......... 15 erythromycin cap 250mg ec

.................................... 15 erythromycin ethylsuccinate

.................................... 15 erythromycin tab ec ........ 15 ESBRIET ........................ 51 escitalopram oxalate ....... 28 esomeprazole magnesium

.................................... 43

estarylla tab 0.25-35 ....... 38 ESTRACE

see estradiol ................ 40 see estradiol vaginal

cream....................... 40 estradiol .......................... 40 estradiol vaginal cream ... 40 estradiol vaginal tab ........ 40 estradiol valerate ............ 40 ESTROSTEP FE

see tilia fe .................... 39 see tri-legest fe ............ 39

ethambutol hcl ................ 14 ethosuximide ................... 26 ethynodiol diacet & eth

estrad .......................... 38 ethynodiol tab 1-50 ......... 38 etodolac ............................ 9 etodolac er ........................ 9 etonogestrel-ethinyl

estradiol....................... 38 etoposide ........................ 19 euthyrox .......................... 42 everolimus ...................... 18 everolimus

(immunosuppressant) . 46 EVISTA

see raloxifene hcl ........ 41 EVOTAZ ......................... 14 EVOXAC

see cevimeline hcl ....... 55 EXELON

see rivastigmine td patch 24hr 13.3 mg/24hr ... 28

see rivastigmine td patch 24hr 4.6 mg/24hr ..... 28

see rivastigmine td patch 24hr 9.5 mg/24hr ..... 28

exemestane .................... 18 EXFORGE

see amlodipine besylate-valsartan tab 10-160 mg ........................... 20

see amlodipine besylate-valsartan tab 10-320 mg ........................... 20

see amlodipine besylate-valsartan tab 5-160 mg ................................ 20

65

see amlodipine besylate-valsartan tab 5-320 mg ................................ 20

EXFORGE HCT see amlodipine-

valsartan-hydrochlorothiazide 10-160-12.5mg ........ 21

see amlodipine-valsartan-hydrochlorothiazide 10-160-25mg ........... 21

see amlodipine-valsartan-hydrochlorothiazide 10-320-25mg ........... 21

see amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg ............. 21

see amlodipine-valsartan-hydrochlorothiazide 5-160-25mg ................ 21

ezetimibe ........................ 22 F FABRAZYME .................. 40 falmina ............................ 38 famciclovir ....................... 14 famotidine ....................... 42 famotidine in nacl ............ 43 famotidine inj .................. 43 FANAPT ......................... 30 FANAPT TITRATION

PACK .......................... 30 FARESTON

see toremifene citrate .. 18 FARXIGA ........................ 36 FARYDAK ....................... 17 FASENRA ....................... 51 FASENRA PEN .............. 51 FASLODEX

see fulvestrant ............. 18 felbamate ........................ 26 FELBATOL

see felbamate.............. 26 FELDENE

see piroxicam ................ 9 felodipine ........................ 23

FEMARA see letrozole ................ 18

FEMHRT LOW DOSE see fyavolv .................. 40 see norethindrone

acetate-ethinyl estradiol ................... 40

femynor ........................... 38 fenofibrate ....................... 22 fenofibrate micronized .... 22 fentanyl citrate ................ 10 fentanyl patch 100 mcg/hr

.................................... 10 fentanyl patch 12 mcg/hr 10 fentanyl patch 25 mcg/hr 10 fentanyl patch 50 mcg/hr 10 fentanyl patch 75 mcg/hr 10 FETZIMA ........................ 28 FETZIMA TITRATION

PACK .......................... 28 FIASP ............................. 35 FIASP FLEXTOUCH ....... 35 FIASP PENFILL .............. 35 finasteride ....................... 44 FIRAZYR

see icatibant acetate ... 45 flac .................................. 55 FLAGYL

see metronidazole ....... 12 FLAREX .......................... 49 flecainide acetate ............ 21 FLOMAX

see tamsulosin hcl ....... 44 FLOVENT DISKUS ......... 52 FLOVENT HFA ............... 52 fluconazole ..................... 12 fluconazole inj nacl 200 .. 12 fluconazole inj nacl 400 .. 12 flucytosine ....................... 12 fludrocortisone acetate ... 40 flunisolide (nasal) ............ 51 fluocinolone acetonide .... 53 fluocinolone acetonide

(otic) ............................ 55 fluocinolone acetonide oil

body ............................ 53 fluocinonide .................... 53 fluocinonide emulsified

base ............................ 53

fluorometholone .............. 49 fluorouracil ...................... 17 fluorouracil (topical) ........ 54 fluoxetine cap 10mg ........ 28 fluoxetine cap 20mg ........ 28 fluoxetine cap 40mg ........ 28 fluoxetine hcl ................... 28 fluphenazine decanoate .. 30 fluphenazine hcl .............. 30 flurbiprofen ........................ 9 flurbiprofen sodium ......... 49 flutamide ......................... 18 fluticasone propionate ..... 53 fluticasone propionate

(nasal) ......................... 51 fluvoxamine maleate ....... 25 FOCALIN

see dexmethylphenidate hcl ............................ 32

fondaparinux sodium ...... 44 FORTEO ......................... 41 FOSAMAX

see alendronate sodium tab 70 mg ................. 37

fosamprenavir tab 700 mg .................................... 13

fosinopril sodium ............. 20 fosinopril sodium &

hydrochlorothiazide ..... 20 FREAMINE HBC 6.9% ... 48 FREAMINE III ................. 48 fulvestrant ....................... 18 furosemide ...................... 24 furosemide inj ................. 24 FUZEON ......................... 13 fyavolv ............................ 40 FYCOMPA ...................... 26 G gabapentin ...................... 26 GABITRIL

see tiagabine hcl ......... 27 galantamine hydrobromide

.................................... 27 galantamine hydrobromide

er ................................. 27 GAMASTAN S/D ............. 46 GAMMAGARD LIQUID ... 46 GAMMAGARD S/D ......... 46 GAMMAKED ................... 46

66

GAMMAPLEX ................. 46 GAMMAPLEX

10GM/100ML .............. 46 GAMUNEX-C .................. 46 ganciclovir sodium .......... 14 GARDASIL 9 .................. 47 GASTROCROM

see cromolyn sodium (mastocytosis) ......... 43

gatifloxacin (ophth) ......... 49 GATTEX ......................... 43 GAUZE PADS 2.............. 35 gavilyte-c ........................ 43 gavilyte-g ........................ 43 gavilyte-n/flavor pack ...... 43 GEMCITABINE

see gemcitabine inj soln ................................ 17

gemcitabine inj soln ........ 17 gemcitabine inj solr ......... 17 gemfibrozil ...................... 22 generlac .......................... 43 gengraf ........................... 46 GENOTROPIN................ 41 GENOTROPIN MINIQUICK

.................................... 41 gentak ............................. 49 gentamicin in saline ........ 11 gentamicin sulfate ........... 11 gentamicin sulfate (topical)

.................................... 52 gentamicin sulfate soln

(ophth) ......................... 49 GENVOYA ...................... 14 GEODON ........................ 30

see ziprasidone hcl ..... 31 see ziprasidone mesylate

................................ 31 gianvi .............................. 38 GILENYA CAP 0.5MG .... 34 GILOTRIF TAB 20MG .... 18 GILOTRIF TAB 30MG .... 18 GILOTRIF TAB 40MG .... 18 glatiramer acetate 20mg/ml

.................................... 34 glatiramer acetate 40mg/ml

.................................... 34 glatopa ............................ 34 GLEEVEC

see imatinib mesylate .. 18 GLEOSTINE ................... 16 glimepiride ...................... 36 glip/metform tab 2.5-250mg

.................................... 36 glip/metform tab 2.5-500mg

.................................... 36 glip/metform tab 5-500mg

.................................... 36 glipizide ........................... 36 glipizide xl ....................... 36 GLUCAGEN HYPOKIT ... 41 GLUCAGON

EMERGENCY KIT ...... 41 GLUCOTROL

see glipizide ................ 36 GLUCOTROL XL

see glipizide ................ 36 see glipizide xl ............. 36

glycopyrrolate tab 1mg ... 42 glycopyrrolate tab 2mg ... 42 glydo ............................... 54 GLYXAMBI ..................... 36 GOLYTELY ..................... 43

see gavilyte-g .............. 43 see peg 3350-kcl-sod

bicarb-sod chloride-sod sulfate ............... 43

granisetron hcl ................ 42 griseofulvin microsize ..... 12 griseofulvin ultramicrosize

.................................... 12 guanfacine er (adhd) ....... 32 GVOKE HYPOPEN 2-

PACK .......................... 41 GVOKE PFS ................... 41 H HAEGARDA.................... 45 HALDOL

see haloperidol lactate inj 5mg/ml ..................... 30

HALDOL DECANOATE 100 see haloperidol

decanoate ................ 30 HALDOL DECANOATE 50

see haloperidol decanoate ................ 30

halobetasol propionate ... 53

haloperidol ...................... 30 haloperidol conc 2mg/ml . 30 haloperidol decanoate .... 30 haloperidol lactate inj

5mg/ml ........................ 30 HARVONI ....................... 14 HAVRIX .......................... 47 heather ........................... 38 heparin sod (porcine) in

d5w ............................. 44 heparin sod inj 1000/ml ... 44 heparin sod inj 10000/ml . 44 heparin sod inj 20000/ml . 44 heparin sod inj 5000/ml ... 44 HEPARIN SODIUM/NACL

0.45% .......................... 45 hepatamine ..................... 48 HEPSERA

see adefovir dipivoxil ... 14 HERCEPTIN ................... 17 HERCEPTIN HYLECTA . 17 HERZUMA ...................... 17 HETLIOZ......................... 33 HIBERIX ......................... 47 HIPREX

see methenamine hippurate .................. 12

HUMIRA.......................... 45 HUMIRA INJ 10MG/0.2ML

.................................... 45 HUMIRA KIT 20MG/0.4ML

.................................... 45 HUMIRA KIT 40MG/0.8ML

.................................... 46 HUMIRA PEDIATRIC

CROHNS DISEASE .... 46 HUMIRA PEN ................. 46 HUMIRA PEN CD/UC/HS

STARTER ................... 46 HUMIRA PEN INJ

CD/UC/HS STARTER . 46 HUMIRA PEN INJ PS/UV

STARTER ................... 46 HUMIRA PEN-PS/UV

STARTER ................... 46 HUMULIN R INJ U-500 ... 35 HUMULIN R U-500

KWIKPEN .................... 35 hydralazine hcl ................ 24

67

HYDREA see hydroxyurea .......... 19

hydrochlorothiazide ......... 24 hydroco/apap tab 10-

325mg ......................... 10 hydroco/apap tab 5-325mg

.................................... 10 hydroco/apap tab 7.5-325

.................................... 10 hydrocodone-

acetaminophen 7.5-325 mg/15ml ...................... 10

hydrocodone-ibuprofen tab 7.5-200 mg .................. 10

hydrocortisone ................ 40 hydrocortisone (enema) .. 43 hydrocortisone (topical)

cream 1% .................... 53 hydrocortisone (topical)

cream 2.5% ................. 53 hydrocortisone (topical)

lotion 2.5% .................. 53 hydrocortisone (topical) oint

2.5% ............................ 53 hydrocortisone butyrate

cream 0.1% ................. 53 hydrocortisone butyrate oint

0.1% ............................ 54 hydromorphone hcl ......... 10 hydroxychloroquine sulfate

.................................... 46 hydroxyurea .................... 19 hydroxyzine hcl ............... 50 hydroxyzine hcl inj .......... 50 hydroxyzine pamoate ...... 51 HYSINGLA ER................ 10 HYZAAR

see losartan-hydrochlorothiazide . 21

I ibandronate sodium tabs 37 IBRANCE ........................ 17 ibu tab 600mg ................... 9 ibu tab 800mg ................... 9 ibuprofen ........................... 9 icatibant acetate.............. 45 ICLUSIG ......................... 18 IDHIFA ............................ 17 ILEVRO .......................... 49

imatinib mesylate ............ 18 IMBRUVICA .................... 18 imipenem-cilastatin ......... 12 imipramine hcl................. 28 imiquimod ....................... 54 IMITREX

see sumatriptan ........... 33 see sumatriptan inj

6mg/0.5ml ................ 34 see sumatriptan

succinate ................. 34 IMITREX STATDOSE

REFILL see sumatriptan inj

4mg/0.5ml ................ 33 see sumatriptan inj

6mg/0.5ml ................ 34 IMITREX STATDOSE

SYSTEM see sumatriptan inj

4mg/0.5ml ................ 33 see sumatriptan inj

6mg/0.5ml ................ 34 IMOVAX RABIES

(H.D.C.V.).................... 47 IMURAN

see azathioprine .......... 46 incassia ........................... 38 INCRELEX ...................... 41 INCRUSE ELLIPTA ........ 50 indapamide ..................... 24 INDERAL LA

see propranolol cap er 23 INFANRIX ....................... 47 INGREZZA ..................... 34 INLYTA ..................... 18, 19 INREBIC ......................... 19 INSPRA

see eplerenone ........... 20 INSULIN PEN NEEDLE .. 35 INSULIN SAFETY

NEEDLES ................... 35 INSULIN SYRINGE ........ 35 INTELENCE.................... 13 INTRALIPID 30% ............ 48 INTRALIPID INJ 20% ..... 48 INTRON-A INJ 10MU ..... 46 INTRON-A INJ 18MU ..... 46 INTRON-A INJ 25MU ..... 46

INTRON-A INJ 50MU ..... 46 introvale .......................... 38 INTUNIV

see guanfacine er (adhd) ................................ 32

INVANZ see ertapenem sodium 12

INVEGA see paliperidone .......... 31

INVEGA SUST INJ 117 MG/0.75 ML ................ 30

INVEGA SUST INJ 156MG/ML .................. 30

INVEGA SUST INJ 234 MG/1.5 ML .................. 30

INVEGA SUST INJ 39 MG/0.25 ML ................ 30

INVEGA SUST INJ 78 MG/0.5 ML .................. 30

INVEGA TRINZA ............ 30 INVIRASE ....................... 13 IPOL INACTIVATED IPV 47 ipratropium bromide ........ 50 ipratropium bromide (nasal)

.................................... 50 ipratropium-albuterol nebu

.................................... 50 irbesartan ........................ 21 irbesartan-

hydrochlorothiazide ..... 21 IRESSA .......................... 19 irinotecan hcl ................... 19 ISENTRESS ................... 13 ISENTRESS HD ............. 13 isibloom .......................... 38 ISOLYTE P ..................... 48 ISOLYTE S ..................... 48 isoniazid .......................... 14 isoniazid syp 50mg/5ml .. 14 ISOPTO CARPINE

see pilocarpine hcl ...... 50 ISORDIL TITRADOSE

see isosorbide dinitrate ................................ 24

isosorb mononitrate tab .. 24 isosorbide dinitrate .......... 24 isosorbide mononitrate er

.................................... 24 isotretinoin ...................... 52

68

isradipine ........................ 23 ISTALOL

see timolol maleate ophth soln 0.5% (once-daily) ........................ 50

itraconazole .................... 12 ivermectin ....................... 12 IXIARO ........................... 47 J JADENU ......................... 38

see deferasirox tab ...... 38 JADENU SPRINKLE ....... 38 JAKAFI ........................... 19 JALYN

see dutasteride-tamsulosin hcl .......... 44

jantoven .......................... 45 JANUMET ....................... 36 JANUMET XR TAB 100-

1000 ............................ 36 JANUMET XR TAB 50-

1000 ............................ 36 JANUMET XR TAB 50-

500MG ........................ 36 JANUVIA ........................ 36 JARDIANCE ................... 36 jasmiel ............................ 38 JENTADUETO ................ 36 JENTADUETO TAB XR

2.5-1000 MG ............... 37 JENTADUETO TAB XR 5-

1000 MG ..................... 37 jinteli ............................... 40 jolessa tab 0.15-0.03 mg 38 jolivette ........................... 38 juleber ............................. 38 JULUCA .......................... 14 junel 1.5/30 ..................... 38 junel 1/20 ........................ 38 junel fe 1.5/30 ................. 38 junel fe 1/20 .................... 38 JUXTAPID ...................... 22 K KADCYLA ....................... 17 KALETRA

see lopinavir-ritonavir .. 14 KALETRA TAB 100-25MG

.................................... 14

KALETRA TAB 200-50MG .................................... 14

KALYDECO .................... 51 KANJINTI ........................ 17 kariva .............................. 38 kcl 0.075%/d5w/nacl 0.45%

.................................... 48 KCL 0.15%/D5W/NACL

0.225% ........................ 48 kcl 0.15%/d5w/nacl 0.9% 48 kcl 0.3%/d5w/nacl 0.45% 48 KCL 0.3%/D5W/NACL

0.9% ............................ 48 kcl/d5w inj 0.3% .............. 48 kcl/d5w/nacl inj .15/.45% 48 kcl/d5w/nacl inj

0.22%/0.45% ............... 48 kcl/nacl inj 0.15%-0.9% ... 48 kcl/nacl inj 0.3-0.9 ........... 48 kcl0.15%/d5w/nacl0.2% .. 48 KEFLEX

see cephalexin ............ 15 kelnor 1/35 ...................... 38 kelnor 1/50 ...................... 38 KEPPRA

see levetiracetam ........ 26 see levetiracetam oral

soln 100 mg/ml ........ 26 see roweepra .............. 26

KEPPRA XR see levetiracetam ........ 26 see roweepra xr .......... 27

ketoconazole................... 12 ketoconazole cream ........ 53 ketoconazole shampoo ... 53 ketorolac tromethamine

(ophth) ......................... 49 KEYTRUDA .................... 17 KINRIX ............................ 47 kionex sus 15gm/60ml .... 38 KISQALI .......................... 17 KISQALI FEMARA 200

DOSE .......................... 17 KISQALI FEMARA 400

DOSE .......................... 17 KISQALI FEMARA 600

DOSE .......................... 17 KITABIS PAK

see tobramycin ............ 11

KLARON see sulfacetamide

sodium (acne) .......... 52 KLONOPIN

see clonazepam .......... 25 klor-con 10 ...................... 47 klor-con 8 ........................ 47 klor-con m10 ................... 47 klor-con m15 ................... 47 klor-con m20 ................... 47 klor-con pak 20meq ........ 47 klor-con spr cap 10meq .. 47 klor-con spr cap 8meq .... 47 KORLYM......................... 41 K-TAB

see potassium chloride 47 kurvelo ............................ 38 KUVAN ........................... 40 L labetalol hcl ..................... 22 lactated ringer's .............. 48 lactulose ......................... 43 lactulose (encephalopathy)

.................................... 43 LAMICTAL

see lamotrigine ............ 26 see subvenite tab ........ 27

LAMICTAL CHEWABLE DISPERS see lamotrigine ............ 26

LAMICTAL XR see lamotrigine ............ 26

LAMISIL see terbinafine hcl ....... 13

lamivudine....................... 13 lamivudine (hbv) ............. 14 lamivudine-zidovudine .... 14 lamotrigine ...................... 26 LANOXIN

see digitek ................... 23 see digox ..................... 23 see digoxin .................. 23 see digoxin inj ............. 23

lansoprazole ................... 44 larin 1.5/30 ...................... 39 larin 1/20 ......................... 39 larin fe 1.5/30 .................. 39 larin fe 1/20 ..................... 39 larissia tab....................... 39

69

LASIX see furosemide............ 24

LASTACAFT ................... 50 latanoprost ...................... 50 LATUDA ......................... 30 leena ............................... 39 leflunomide ..................... 46 LENVIMA 10 MG DAILY

DOSE .......................... 19 LENVIMA 12MG DAILY

DOSE .......................... 19 LENVIMA 14 MG DAILY






DOSE .......................... 19 lessina ............................ 39 LETAIRIS

see ambrisentan .......... 24 letrozole .......................... 18 leucovorin calcium .......... 19 LEUKERAN .................... 16 leuprolide inj 1mg/0.2 ...... 18 levalbuterol hcl ................ 51 levalbuterol hcl soln nebu

conc 1.25 mg/0.5ml ..... 51 levalbuterol tartrate hfa ... 51 LEVAQUIN

see levofloxacin........... 15 LEVEMIR ........................ 35 LEVEMIR FLEXTOUCH . 36 levetiracetam .................. 26 LEVETIRACETAM

see levetiracetam in sodium chloride ....... 26

levetiracetam in sodium chloride ....................... 26

levetiracetam oral soln 100 mg/ml .......................... 26

levobunolol hcl ................ 50 levocarnitine (metabolic

modifiers) .................... 40

levocetirizine dihydrochloride ............ 51

levofloxacin ..................... 15 levofloxacin in d5w .......... 15 levofloxacin inj 25mg/ml .. 15 levofloxacin oral soln 25

mg/ml .......................... 15 levonest .......................... 39 levonor/ethi tab ............... 39 levonorgestrel & eth

estradiol ...................... 39 levonorgestrel-ethinyl

estradiol (91-day) ........ 39 levora 0.15/30-28 ............ 39 levo-t ............................... 42 levothyroxine sodium ...... 42 levoxyl ............................. 42 LEXAPRO

see escitalopram oxalate ................................ 28

LEXIVA ........................... 13 see fosamprenavir tab

700 mg .................... 13 LIALDA

see mesalamine .......... 43 lidocaine ......................... 54 lidocaine hcl .................... 54 lidocaine hcl (local anesth.)

.................................... 11 lidocaine hcl (mouth-throat)

.................................... 55 lidocaine inj 0.5% ............ 11 lidocaine inj 1% ............... 11 lidocaine inj 1.5%

preservative free (pf) ... 11 lidocaine oint 5% ............. 54 lidocaine-prilocaine ......... 54 LIDODERM

see lidocaine ............... 54 linezolid in sodium chloride

.................................... 12 linezolid inj ...................... 12 linezolid susp .................. 12 linezolid tab 600mg ......... 12 LINZESS ......................... 43 liothyronine sodium ......... 42 LIPITOR

see atorvastatin calcium ................................ 21

lisinopril ........................... 20 lisinopril &

hydrochlorothiazide ..... 20 lithium carbonate ............ 34 lithium carbonate er ........ 34 LITHIUM SOLN 8MEQ/5ML

.................................... 34 LITHOBID

see lithium carbonate er ................................ 34

LODINE see etodolac .................. 9

LOESTRIN 1.5/30-21 see junel 1.5/30 ........... 38 see larin 1.5/30 ............ 39 see microgestin 1.5/30 39

LOESTRIN 1/20-21 see junel 1/20 .............. 38 see larin 1/20 ............... 39 see microgestin 1/20 ... 39 see norethindrone acet &

eth estra ................... 39 LOESTRIN FE 1.5/30

see blisovi fe 1.5/30 .... 38 see junel fe 1.5/30 ....... 38 see larin fe 1.5/30 ........ 39 see microgestin fe 1.5/30

................................ 39 LOESTRIN FE 1/20

see junel fe 1/20 .......... 38 see larin fe 1/20 ........... 39 see microgestin fe 1/20

................................ 39 see tarina fe 1/20 ........ 39

LOKELMA ....................... 38 LOMOTIL

see diphenoxylate w/ atropine .................... 43

LONSURF....................... 19 loperamide hcl ................ 43 LOPID

see gemfibrozil ............ 22 lopinavir-ritonavir ............ 14 LOPRESSOR

see metoprolol tartrate 22 LOPRESSOR HCT

see metoprolol & hctz tab 50-25mg .................. 22

LOPROX

70

see ciclopirox .............. 52 lorazepam ....................... 25 lorazepam intensol .......... 25 LORBRENA .................... 19 lorcet hd tab 10-325mg ... 10 lorcet plus tab 7.5-325 .... 10 lorcet tab 5-325mg .......... 10 loryna .............................. 39 losartan potassium .......... 21 losartan-

hydrochlorothiazide ..... 21 LOTEMAX ...................... 49

see loteprednol etabonate ................ 49

LOTENSIN see benazepril hcl ....... 20

LOTENSIN HCT see benazepril &

hydrochlorothiazide . 20 loteprednol etabonate ..... 49 LOTREL

see amlodipine--benazepril hcl cap 10-20 mg ...................... 20

see amlodipine-benazepril hcl cap 10-40mg ....................... 20

see amlodipine-benazepril hcl cap 5-10 mg ........................... 20

see amlodipine-benazepril hcl cap 5-20 mg ........................... 20

LOTRONEX see alosetron hcl ......... 43

lovastatin ........................ 21 LOVENOX

see enoxaparin sodium ................................ 44

low-ogestrel .................... 39 loxapine succinate .......... 30 LUMIGAN ....................... 50 LUMIZYME ..................... 40 LUPRON DEPOT (1-

MONTH) ...................... 18 LUPRON DEPOT INJ

11.25MG (3-MONTH) .. 18 LUPRON DEPOT-PED (1-

MONTH ....................... 41

LUPRON DEPOT-PED (3-MONTH ....................... 41

LUPRON DEP-PED INJ 11.25MG (3-MONTH) .. 41

LUPRON DEP-PED INJ 7.5MG ......................... 41

lutera ............................... 39 LYNPARZA ..................... 17 LYRICA

see pregabalin ............. 26 LYRICA CR..................... 34 LYSODREN .................... 18 LYSTEDA

see tranexamic acid .... 45 lyza ................................. 39 M MACROBID

see nitrofurantoin monohyd macro ....... 12

MACRODANTIN see nitrofurantoin

macrocrystal ............ 12 magnesium sulfate .......... 47 MAGNESIUM SULFATE 47

see magnesium sulfate ................................ 47

MAGNESIUM SULFATE IN D5W ............................ 47 see magnesium sulfate in

dextrose ................... 47 magnesium sulfate in

dextrose ...................... 47 magnesium sulfate inj 50%

.................................... 47 MALARONE

see atovaquone-proguanil hcl ............ 13

malathion ........................ 54 maprotiline hcl................. 28 MARINOL

see dronabinol ............. 42 marlissa .......................... 39 MARPLAN TAB 10MG .... 28 MATULANE .................... 19 MAVIK

see trandolapril ............ 20 MAVYRET ...................... 14 MAXALT

see rizatriptan benzoate ................................ 33

MAXALT-MLT see rizatriptan benzoate

odt ........................... 33 MAXITROL

see neomycin-polymy-dexameth ................. 49

MAXZIDE see triamterene &

hydrochlorothiazide tabs .......................... 24

MAXZIDE-25 see triamterene &

hydrochlorothiazide tabs .......................... 24

meclizine hcl ................... 42 MEDROL

see methylpred tab 16mg ................................ 40




MEDROL DOSEPAK see methylpred pak 4mg

................................ 40 medroxyprogesterone

acetate (contraceptive) 39 medroxyprogesterone

acetate tab .................. 42 mefloquine hcl ................. 13 megestrol ac sus 40mg/ml

.................................... 18 megestrol ac tab 20mg ... 18 megestrol ac tab 40mg ... 18 megestrol sus 625mg/5ml

.................................... 18 MEKINIST ....................... 19 MEKTOVI........................ 19 meloxicam......................... 9 memantine hcl cp24 ........ 27 memantine soln .............. 27 memantine tabs .............. 27 MENACTRA .................... 47 MENVEO ........................ 47 MEPRON

71

see atovaquone........... 11 mercaptopurine ............... 17 meropenem .................... 12 MERREM

see meropenem .......... 12 mesalamine .................... 43 mesalamine w/ cleanser . 43 MESNEX ........................ 19 MESTINON

see pyridostigmine tab 60mg ....................... 34

metadate er tab 20mg ..... 32 metformin er ................... 37 metformin hcl .................. 37 methadone hcl ................ 10 methadone hcl 10mg ...... 10 methadone hcl 5mg ........ 10 methadone hcl intensol ... 10 METHADOSE

see methadone hcl intensol .................... 10

methazolamide ............... 24 methenamine hippurate .. 12 methimazole ................... 42 methotrexate sodium inj

soln ............................. 17 methotrexate sodium inj

solr .............................. 17 methotrexate sodium tabs

.................................... 46 METHYLIN

see methylphenidate hcl oral soln ................... 33

methylphenidate hcl ........ 32 methylphenidate hcl oral

soln ............................. 33 methylphenidate hcl tbcr 10

mg ............................... 33 methylphenidate hcl tbcr

20mg ........................... 33 methylpr ss inj ................. 40 methylpred pak 4mg ....... 40 methylpred tab 16mg ...... 40 methylpred tab 32mg ...... 40 methylpred tab 4mg ........ 40 methylpred tab 8mg ........ 40 methylprednisolone acetate

.................................... 40 metoclopramide hcl ......... 42

metoclopramide hcl inj .... 42 metolazone ..................... 24 metoprolol & hctz tab 100-

25mg ........................... 22 metoprolol & hctz tab 100-

50mg ........................... 22 metoprolol & hctz tab 50-

25mg ........................... 22 metoprolol succinate ....... 22 metoprolol tartrate ........... 22 METROCREAM

see metronidazole (topical) .................... 54

see rosadan ................ 54 METROLOTION

see metronidazole (topical) .................... 54

metronidazole ................. 12 metronidazole (topical) ... 54 metronidazole gel 0.75% 54 metronidazole in nacl ...... 12 metronidazole vaginal ..... 44 MIACALCIN

see calcitonin (salmon) 41 micafungin sodium .......... 12 MICARDIS

see telmisartan ............ 21 microgestin 1.5/30 .......... 39 microgestin 1/20 ............. 39 microgestin fe 1.5/30 ...... 39 microgestin fe 1/20 ......... 39 midodrine hcl .................. 24 miglustat ......................... 40 MIGRANAL

see dihydroergotamine mesylate nasal spr 4 mg/ml ....................... 33

mili .................................. 39 MINIPRESS

see prazosin hcl .......... 20 minitran ........................... 24 MINOCIN

see minocycline hcl ..... 16 minocycline hcl ............... 16 minoxidil .......................... 24 MIRAPEX

see pramipexole tab 0.125mg................... 29

see pramipexole tab 0.5mg....................... 29

see pramipexole tab 0.75mg..................... 29

see pramipexole tab 1mg ................................ 29

MIRCETTE see bekyree ................. 38 see desogestrel-ethinyl

estradiol (biphasic) .. 38 see kariva .................... 38 see pimtrea ................. 39 see viorele ................... 40

mirtazapine ..................... 28 misoprostol ..................... 43 MITIGARE ........................ 9 M-M-R II .......................... 47 M-NATAL PLUS .............. 48 MOBIC

see meloxicam .............. 9 moexipril hcl .................... 20 molindone hcl .................. 30 mometasone furoate ....... 54 mondoxyne nl cap 100mg

.................................... 16 mono-linyah tab 0.25-35 . 39 montelukast sodium ........ 51 morphine ext-rel tab ........ 10 morphine sul inj 1mg/ml .. 10 morphine sulfate ............. 10 MORPHINE SULFATE ... 10

see morphine sulfate ... 10 morphine sulfate oral soln

100mg/5ml .................. 11 morphine sulfate oral soln

10mg/5ml .................... 10 morphine sulfate oral soln

20mg/5ml .................... 10 MOVANTIK ..................... 43 MOXEZA......................... 49

see moxifloxacin hcl (ophth) ..................... 49

moxifloxacin hcl (ophth) .. 49 MS CONTIN

see morphine ext-rel tab ................................ 10

MULTAQ ......................... 21 mupirocin ........................ 52 MVASI ............................ 17

72

MYAMBUTOL see ethambutol hcl ...... 14

MYCAMINE .................... 12 see micafungin sodium 12

MYCOBUTIN see rifabutin ................ 14

mycophenolate mofetil .... 46 mycophenolate sodium

tbec ............................. 46 MYFORTIC

see mycophenolate sodium tbec ............. 46

myorisan ......................... 52 MYRBETRIQ .................. 44 MYSOLINE

see primidone.............. 26 N nabumetone ...................... 9 nadolol ............................ 22 nafcillin sodium ............... 16 NAFCILLIN SODIUM FOR

INJ 10GM .................... 16 NAGLAZYME ................. 40 nalbuphine hcl .................. 9 naloxone inj 0.4mg/ml ..... 35 naloxone inj 1mg/ml ........ 35 naltrexone hcl ................. 35 NAMENDA

see memantine tabs .... 27 NAMENDA XR

see memantine hcl cp24 ................................ 27

NAMZARIC ..................... 27 NAPROSYN

see naproxen ................ 9 naproxen ........................... 9 naproxen dr ...................... 9 naproxen sodium .............. 9 naratriptan hcl ................. 33 NARCAN ........................ 35 NARDIL

see phenelzine sulfate 28 NATACYN ...................... 49 nateglinide ...................... 37 NATPARA ....................... 41 NAYZILAM ...................... 26 NEBUPENT

see pentamidine isethionate inh ......... 12

necon 0.5/35-28 .............. 39 nefazodone hcl ............... 28 neomycin sulfate ............. 11 neomycin-bacitracin zn-

polymyxin .................... 49 neomycin-polymy-

dexameth .................... 49 neomycin-polymyxin-

gramicidin .................... 49 neomycin-polymyxin-hc

(ophth) ......................... 49 neomycin-polymyxin-hc

(otic) ............................ 55 NEORAL

see cyclosporine modified (for microemulsion) ........ 46

see gengraf ................. 46 NEPHRAMINE ................ 48 NERLYNX ....................... 19 NEUPRO ........................ 29 NEURONTIN

see gabapentin ............ 26 nevirapine susp 50 mg/5ml

.................................... 13 nevirapine tab 100mg er . 13 nevirapine tab 200mg ..... 13 nevirapine tab 400mg er . 13 NEXAVAR ...................... 19 NEXIUM

see esomeprazole magnesium .............. 43

niacin (antihyperlipidemic) .................................... 22

niacin er (antihyperlipidemic) ..... 22

niacor .............................. 22 NIASPAN

see niacin er (antihyperlipidemic) . 22

nicardipine hcl ................. 23 NICOTROL INHALER ..... 35 NICOTROL NS ............... 35 nifedipine ........................ 23 nifedipine er .................... 23 nikki ................................ 39 NILANDRON

see nilutamide ............. 18 nilutamide ....................... 18

nimodipine ...................... 23 NINLARO ........................ 17 nitisinone ........................ 40 NITRO-BID ..................... 24 NITRO-DUR

see minitran ................. 24 see nitroglycerin td patch

................................ 24 NITRO-DUR DIS

0.3MG/HR ................... 24 NITRO-DUR DIS

0.8MG/HR ................... 24 nitrofurantoin macrocrystal

.................................... 12 nitrofurantoin monohyd

macro .......................... 12 nitroglycerin .................... 24 nitroglycerin td patch ....... 24 NITROSTAT

see nitroglycerin .......... 24 NITYR ............................. 40 nizatidine ........................ 43 nora-be tab ..................... 39 NORCO

see hydroco/apap tab 10-325mg...................... 10

see hydroco/apap tab 5-325mg...................... 10

see hydroco/apap tab 7.5-325 .................... 10

see lorcet hd tab 10-325mg...................... 10

see lorcet plus tab 7.5-325 .......................... 10

see lorcet tab 5-325mg 10 norethindrone

(contraceptive) ............ 39 norethindrone acet & eth

estra ............................ 39 norethindrone acetate ..... 42 norethindrone acetate-

ethinyl estradiol ........... 40 norgest/ethi tab 0.25/35 .. 39 norgestimate-ethinyl

estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ............................. 39

norgestimate-ethinyl estradiol (triphasic) 0.18-

73

35/0.215-35/0.25-35 mg-mcg ............................. 39

NORMOSOL-M IN D5W . 48 NORMOSOL-R ............... 48 NORMOSOL-R IN D5W . 48 NORPACE

see disopyramide phosphate ................ 21

NORPACE CR ................ 21 NORPRAMIN

see desipramine hcl .... 28 NORTHERA ................... 24 nortrel 0.5/35 (28) ........... 39 nortrel 1/35 ..................... 39 nortrel 7/7/7 .................... 39 nortriptyline hcl ............... 28 NORVASC

see amlodipine besylate ................................ 23

NORVIR see ritonavir ................ 13

NORVIR PACK ............... 13 NORVIR SOLN ............... 13 NOVOLIN 70/30.............. 36 NOVOLIN 70/30 FLEXPEN

.................................... 36 NOVOLIN N .................... 36 NOVOLIN N FLEXPEN ... 36 NOVOLIN R .................... 36 NOVOLIN R FLEXPEN ... 36 NOVOLOG ..................... 36 NOVOLOG 70/30

FLEXPEN .................... 36 NOVOLOG FLEXPEN .... 36 NOVOLOG MIX 70/30 .... 36 NOVOLOG PENFILL ...... 36 NOXAFIL ........................ 12

see posaconazole ....... 12 NUBEQA ........................ 18 NUCALA ......................... 51 NUCYNTA ER ................ 11 NUEDEXTA .................... 34 NULOJIX ........................ 46 NULYTELY

see gavilyte-n/flavor pack ................................ 43

see peg 3350-potassium chloride-sod

bicarbonate-sod chloride .................... 43

see trilyte ..................... 43 NULYTELY/FLAVOR

PACKS ........................ 43 NUPLAZID CAPS ........... 30 NUPLAZID TABS 10MG . 30 NUTRILIPID INJ 20% ..... 48 NUVARING

see eluryng.................. 38 see etonogestrel-ethinyl

estradiol ................... 38 NUVIGIL

see armodafinil ............ 35 nyamyc ........................... 53 NYMALIZE ...................... 23 nystatin ........................... 12 nystatin (mouth-throat) .... 55 nystatin (topical) .............. 53 nystatin pow 100000 ....... 53 nystop ............................. 53 O ocella tab 3-0.03mg ........ 39 OCTAGAM ..................... 46 octreotide acetate ........... 41 OCUFLOX

see ofloxacin (ophth) ... 49 ODEFSEY ...................... 14 ODOMZO ....................... 17 OFEV .............................. 51 ofloxacin (ophth) ............. 49 ofloxacin (otic)................. 55 OGIVRI ........................... 17 olanzapine ................ 30, 31 olmesartan medoxomil .... 21 olmesartan medoxomil-

amlodipine-hydrochlorothiazide ..... 21

olmesartan medoxomil-hydrochlorothiazide ..... 21

olopatadine hcl 0.2% ...... 50 omeprazole cap 10mg .... 44 omeprazole cap 20mg .... 44 omeprazole cap 40mg .... 44 ondansetron hcl .............. 42 ondansetron hcl inj .......... 42 ondansetron hcl oral soln 42 ondansetron odt .............. 42 ONFI

see clobazam .............. 25 ONTRUZANT .................. 17 OPSUMIT ....................... 24 ORFADIN........................ 40

see nitisinone .............. 40 ORKAMBI ....................... 51 orsythia ........................... 39 ORTHO MICRONOR

see errin ...................... 38 see jolivette ................. 38 see lyza ....................... 39 see norethindrone

(contraceptive) ......... 39 see sharobel ................ 39

ORTHO TRI-CYCLEN LO see norgestimate-ethinyl

estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ............... 39

see tri-lo marzia ........... 39 see tri-lo-estarylla ........ 39 see tri-lo-sprintec ......... 39 see tri-vylibra lo ........... 39

oseltamivir phosphate .... 14, 15

OSPHENA ...................... 41 oxacillin sodium .............. 16 oxaliplatin inj 100mg ....... 19 oxaliplatin inj 100mg/20ml

.................................... 19 oxaliplatin inj 50mg ......... 19 oxaliplatin inj 50mg/10ml 19 oxandrolone .................... 35 oxcarbazepine ................ 26 oxybutynin chloride ......... 44 oxycodone hcl ................. 11 oxycodone w/

acetaminophen 10-325mg ......................... 11

oxycodone w/ acetaminophen 2.5-325mg ......................... 11

oxycodone w/ acetaminophen 5-325mg .................................... 11

oxycodone w/ acetaminophen 7.5-325mg ......................... 11

74

OZEMPIC INJ 0.25 OR 0.5MG/DOSE .............. 36

OZEMPIC INJ 1MG/DOSE .................................... 36

P pacerone ......................... 21 paclitaxel ......................... 17 paliperidone .................... 31 PAMELOR

see nortriptyline hcl ..... 28 pamidronate disodium .... 37 PAMIDRONATE

DISODIUM .................. 37 pamidronate inj 30mg ..... 37 pamidronate inj 90mg ..... 37 PANRETIN ..................... 54 pantoprazole sodium ...... 44 pantoprazole sodium tbec

.................................... 44 PANZYGA ...................... 46 paricalcitol ....................... 48 PARLODEL

see bromocriptine mesylate .................. 29

PARNATE see tranylcypromine

sulfate ...................... 29 paroex sol 0.12% ............ 55 paromomycin sulfate ....... 11 paroxetine hcl tabs .......... 28 PASER D/R .................... 14 PAXIL ............................. 28

see paroxetine hcl tabs ................................ 28

PAZEO ........................... 50 PEDIAPRED

see pred sod pho sol 5mg/5ml ................... 40

PEDIARIX ....................... 47 PEDVAX HIB .................. 47 peg 3350-kcl-sod bicarb-

sod chloride-sod sulfate .................................... 43

peg 3350-potassium chloride-sod bicarbonate-sod chloride ................. 43

PEGANONE ................... 26 PEGASYS ...................... 15 PEGASYS PROCLICK ... 15

PEMAZYRE .................... 19 penicillamine ................... 38 PENICILLIN G POT IN

DEXTROSE 2MU ........ 16 PENICILLIN G POT IN

DEXTROSE 3MU ........ 16 PENICILLIN G PROCAINE

.................................... 16 penicillin g sodium .......... 16 penicillin v potassium ...... 16 penicilln gk inj 20mu ....... 16 penicilln gk inj 5mu ......... 16 PENTACEL ..................... 47 PENTAM 300

see pentamidine isethionate inj ........... 12

pentamidine isethionate inh .................................... 12

pentamidine isethionate inj .................................... 12

pentoxifylline ................... 45 PEPCID

see famotidine ............. 42 PERCOCET

see endocet 10-325mg 10 see endocet 2.5-325mg 9 see endocet 5-325mg ... 9 see endocet 7.5-325mg

................................ 10 see oxycodone w/

acetaminophen 10-325mg ..................... 11

see oxycodone w/ acetaminophen 2.5-325mg ..................... 11

see oxycodone w/ acetaminophen 5-325mg ..................... 11

see oxycodone w/ acetaminophen 7.5-325mg ..................... 11

PERIDEX see chlorhexidine

gluconate (mouth-throat) ...................... 55

see paroex sol 0.12% .. 55 see periogard .............. 55

perindopril erbumine ....... 20 periogard ........................ 55

permethrin cre 5% .......... 54 perphenazine .................. 31 PERSERIS...................... 31 pfizerpen-g inj 20mu ....... 16 pfizerpen-g inj 5mu ......... 16 phenelzine sulfate ........... 28 PHENERGAN

see promethazine hcl inj ................................ 42

phenobarbital .................. 26 phenobarbital sodium ..... 26 PHENYTEK .................... 26

see phenytoin sodium extended .................. 26

phenytoin ........................ 26 phenytoin sodium extended

.................................... 26 phenytoin sodium inj

50mg/ml ...................... 26 philith .............................. 39 PHOSLO

see calcium acetate (phosphate binder) .. 41

PHOSPHOLINE IODIDE 50 PICATO .......................... 54 PIFELTRO ...................... 13 pilocarpine hcl ................. 50 pilocarpine hcl (oral) ....... 55 pimozide ......................... 31 pimtrea ............................ 39 pindolol ........................... 22 pioglitazone hcl ............... 37 piper/tazoba inj 12-1.5gm

.................................... 16 piper/tazoba inj 2-0.25gm



.................................... 16 piper/tazoba inj 4-0.5gm . 16 PIQRAY 200MG DAILY

DOSE .......................... 19 PIQRAY 250MG DAILY

DOSE .......................... 19 PIQRAY 300MG DAILY

DOSE .......................... 19 pirmella 1/35 ................... 39 piroxicam .......................... 9

75

PLAQUENIL see hydroxychloroquine

sulfate ...................... 46 PLASMA-LYTE A............ 48 PLASMA-LYTE-148 ........ 48 PLAVIX

see clopidogrel tab 75mg ................................ 45

plenamine ....................... 48 PLENVU ......................... 43 PNV FOLIC ACID + IRON

MUL ............................ 48 podofilox ......................... 54 polymyxin b-trimethoprim 49 POLYTRIM

see polymyxin b-trimethoprim............. 49

POMALYST CAP 1MG ... 18 POMALYST CAP 2MG ... 18 POMALYST CAP 3MG ... 18 POMALYST CAP 4MG ... 18 portia-28 ......................... 39 posaconazole ................. 12 pot chloride inj 2meq/ml .. 48 potassium chloride .... 47, 48 POTASSIUM CHLORIDE

.................................... 48 potassium chloride in nacl

.................................... 48 potassium chloride

microencapsulated crystals er .................... 47

potassium citrate (alkalinizer) er tabs ...... 44

PRADAXA ...................... 45 PRALUENT .................... 22 pramipexole tab 0.125mg

.................................... 29 pramipexole tab 0.25mg . 29 pramipexole tab 0.5mg ... 29 pramipexole tab 0.75mg . 29 pramipexole tab 1.5mg ... 29 pramipexole tab 1mg ...... 29 prasugrel hcl ................... 45 PRAVACHOL

see pravastatin sodium ................................ 21

pravastatin sodium .......... 21 praziquantel .................... 12

prazosin hcl .................... 20 PRECOSE

see acarbose ............... 36 PRED FORTE

see prednisolone acetate (ophth) ..................... 49

pred sod pho sol 5mg/5ml .................................... 40

prednisolone acetate (ophth) ......................... 49

prednisolone sodium phosphate ................... 41

PREDNISOLONE SODIUM PHOSPHATE (OPHTH) .................................... 49

prednisolone sol 15mg/5ml .................................... 41

prednisolone sol 25mg/5ml .................................... 41

PREDNISONE CON 5MG/ML ...................... 41

prednisone pak 10mg ..... 41 prednisone pak 5mg ....... 41 prednisone sol 5mg/5ml .. 41 prednisone tab 10mg ...... 41 prednisone tab 1mg ........ 41 prednisone tab 2.5mg ..... 41 prednisone tab 20mg ...... 41 prednisone tab 50mg ...... 41 prednisone tab 5mg ........ 41 pregabalin ....................... 26 PREMASOL SOL 10% ... 48 PRENATAL ..................... 48 PRENATAL PLUS .......... 49 PRENATAL PLUS LOW

IRON ........................... 49 PREVACID

see lansoprazole ......... 44 prevalite .......................... 22 previfem .......................... 39 PREZCOBIX ................... 14 PREZISTA ...................... 13 PRIFTIN .......................... 14 primaquine phosphate .... 13 PRIMAQUINE

PHOSPHATE .............. 13 see primaquine

phosphate ................ 13 PRIMAXIN IV

see imipenem-cilastatin ................................ 12

primidone ........................ 26 PRINIVIL

see lisinopril ................ 20 PRISTIQ

see desvenlafaxine succinate ................. 28

PRIVIGEN....................... 46 PROAIR HFA

see albuterol sulfate .... 51 probenecid ........................ 9 PROCALAMINE .............. 48 PROCARDIA XL

see nifedipine .............. 23 prochlorperazine inj ........ 42 prochlorperazine maleate

.................................... 42 prochlorperazine supp .... 42 PROCRIT........................ 45 PROCTOCORT

see procto-pak ............ 54 procto-med hc ................. 54 procto-pak ....................... 54 proctosol hc cre 2.5% ..... 54 proctozone-hc ................. 54 PROGLYCEM

see diazoxide .............. 41 PROGLYCEM SUS

50MG/ML .................... 41 PROGRAF ...................... 46

see tacrolimus ............. 47 PROLASTIN-C ................ 51 PROLENSA .................... 49 PROLIA .......................... 41 PROMACTA ................... 45 promethazine hcl ............ 42 promethazine hcl inj ........ 42 propafenone hcl .............. 21 propafenone hcl 12hr ...... 21 proparacaine hcl ............. 50 propranolol &

hydrochlorothiazide ..... 22 propranolol cap er ........... 23 propranolol hcl ................ 23 propranolol oral sol ......... 23 propylthiouracil ................ 42 PROQUAD...................... 47 PROSCAR

76

see finasteride ............. 44 PROSOL ......................... 48 PROTONIX

see pantoprazole sodium ................................ 44

see pantoprazole sodium tbec .......................... 44

PROTOPIC see tacrolimus (topical)

................................ 54 protriptyline hcl ............... 28 PROVERA

see medroxyprogesterone acetate tab ............... 42

PROZAC see fluoxetine cap 10mg

................................ 28 see fluoxetine cap 20mg

................................ 28 see fluoxetine cap 40mg

................................ 28 PULMICORT

see budesonide (inhalation) ............... 52

PULMICORT FLEXHALER .................................... 52

PULMOZYME ................. 51 PURIXAN ........................ 17 pyrazinamide .................. 14 pyridostigmine tab 60mg . 34 Q QUADRACEL ................. 47 QUALAQUIN

see quinine sulfate ...... 13 QUESTRAN

see cholestyramine ..... 22 QUESTRAN LIGHT

see cholestyramine light powd ........................ 22

see prevalite ................ 22 quetiapine fumarate ........ 31 quinapril hcl .................... 20 quinapril-

hydrochlorothiazide ..... 20 quinidine sulfate .............. 21 quinine sulfate ................ 13 R RABAVERT .................... 47

raloxifene hcl................... 41 ramipril ............................ 20 RANEXA

see ranolazine ............. 24 ranolazine ....................... 24 RAPAMUNE

see sirolimus ......... 46, 47 rasagiline mesylate ......... 29 RAYALDEE .................... 49 RAZADYNE

see galantamine hydrobromide ........... 27

RAZADYNE ER see galantamine

hydrobromide er ...... 27 RECLAST

see zoledronic acid inj 5mg/100ml ............... 38

reclipsen ......................... 39 RECOMBIVAX HB .......... 47 RECTIV .......................... 54 REGLAN

see metoclopramide hcl ................................ 42

REGRANEX.................... 54 RELENZA DISKHALER .. 15 RELISTOR ...................... 43 RELPAX

see eletriptan hydrobromide ........... 33

REMERON see mirtazapine ........... 28

REMERON SOLTAB see mirtazapine ........... 28

REMICADE ..................... 46 RENFLEXIS .................... 46 RENVELA

see sevelamer carbonate .......................... 41, 42

repaglinide ...................... 37 RESTASIS ...................... 50 RESTASIS MULTIDOSE 50 RESTORIL

see temazepam ........... 33 RETIN-A

see avita ...................... 52 see tretinoin................. 52

RETROVIR

see zidovudine cap 100mg...................... 14

see zidovudine syp 50mg/5ml ................. 14

REVATIO see sildenafil citrate tab

20 mg (pulmonary hypertension) ........... 25

REVLIMID ....................... 18 REXULTI......................... 31 REYATAZ ....................... 13

see atazanavir sulfate . 13 RHOPRESSA ................. 50 ribavirin 200mg ............... 15 rifabutin ........................... 14 RIFADIN

see rifampin ................. 14 rifampin ........................... 14 RIFATER ........................ 14 RILUTEK

see riluzole .................. 34 riluzole ............................ 34 rimantadine hydrochloride

.................................... 15 RINVOQ ......................... 46 RISPERDAL

see risperidone ............ 31 RISPERDAL INJ 12.5MG

.................................... 31 RISPERDAL INJ 25MG .. 31 RISPERDAL INJ 37.5MG

.................................... 31 RISPERDAL INJ 50MG .. 31 risperidone ...................... 31 RITALIN

see methylphenidate hcl ................................ 32

ritonavir ........................... 13 RITUXAN ........................ 17 RITUXAN HYCELA ......... 17 rivastigmine tartrate .. 27, 28 rivastigmine td patch 24hr

13.3 mg/24hr ............... 28 rivastigmine td patch 24hr

4.6 mg/24hr ................. 28 rivastigmine td patch 24hr

9.5 mg/24hr ................. 28 rizatriptan benzoate ........ 33 rizatriptan benzoate odt .. 33

77

ROCALTROL see calcitriol ................ 48 see calcitriol oral soln 1

mcg/ml ..................... 48 ropinirole tab 0.25mg ...... 29 ropinirole tab 0.5mg ........ 29 ropinirole tab 1mg ........... 29 ropinirole tab 2mg ........... 29 ropinirole tab 3mg ........... 29 ropinirole tab 4mg ........... 29 ropinirole tab 5mg ........... 29 rosadan ........................... 54 rosuvastatin calcium ....... 21 ROTARIX ........................ 47 ROTATEQ ...................... 47 ROWASA

see mesalamine w/ cleanser ................... 43

roweepra ......................... 26 roweepra xr ..................... 27 ROXICODONE

see oxycodone hcl ...... 11 ROZLYTREK .................. 19 RUBRACA ...................... 17 RUXIENCE ..................... 17 RYBELSUS .................... 37 RYDAPT ......................... 19 RYTHMOL SR

see propafenone hcl 12hr ................................ 21

S SABRIL

see vigabatrin powd pack 500mg ..................... 27

see vigabatrin tab 500mg ................................ 27

see vigadrone.............. 27 SALAGEN

see pilocarpine hcl (oral) ................................ 55

SANDIMMUNE ............... 46 see cyclosporine ......... 46

SANDOSTATIN see octreotide acetate . 41

SANTYL .......................... 54 SAPHRIS ........................ 31 scopolamine ................... 42 SECUADO ...................... 31 selegiline hcl ................... 29

selenium sulfide .............. 53 SELZENTRY................... 13 SENSIPAR

see cinacalcet hcl ........ 41 SEREVENT DISKUS ...... 51 SEROQUEL

see quetiapine fumarate ................................ 31

SEROQUEL XR see quetiapine fumarate

................................ 31 sertraline hcl ................... 29 setlakin tab ..................... 39 sevelamer carbonate 41, 42 sharobel .......................... 39 SHINGRIX ...................... 47 SIGNIFOR ...................... 41 sildenafil citrate tab 20 mg

(pulmonary hypertension) .................................... 25

SILENOR see doxepin hcl (sleep)

................................ 33 SILVADENE

see silver sulfadiazine . 52 see ssd ........................ 52

silver sulfadiazine ........... 52 SIMBRINZA .................... 50 simvastatin ................ 21, 22 SINEMET

see carbidopa-levodopa ................................ 29

SINGULAIR see montelukast sodium

................................ 51 sirolimus ................... 46, 47 SIRTURO ....................... 14 SIVEXTRO ..................... 12 SKYRIZI .......................... 46 sodium chlor sol 0.9% irr 55 sodium chloride ......... 47, 48 sodium chloride 0.45% ... 48 sodium chloride inj 0.9% . 48 sodium fluoride chew; tab;

1.1 (0.5 f) mg/ml soln .. 48 sodium phenylbutyrate .... 40 sodium polystyrene

sulfonate powder ......... 38

sodium polystyrene sulfonate susp ............. 38

SOLIQUA 100/33 ............ 36 SOLTAMOX .................... 18 SOLU-CORTEF .............. 41 SOLU-MEDROL

see methylpr ss inj ...... 40 SOMATULINE DEPOT ... 41 SOMAVERT .................... 41 SORIATANE

see acitretin ................. 53 sorine .............................. 21 sotalol hcl ........................ 21 sotalol hcl (afib/afl) .......... 21 spironolactone ................ 20 spironolactone &

hydrochlorothiazide ..... 24 SPORANOX

see itraconazole .......... 12 sprintec 28 ...................... 39 SPRITAM ........................ 27 SPRYCEL ....................... 19 sps susp 15gm/60ml ....... 38 sronyx ............................. 39 ssd .................................. 52 STALEVO 100

see carbidopa/levodopa/entacapone .................. 29

STALEVO 150 see

carbidopa/levodopa/entacapone .................. 29

STARLIX see nateglinide ............ 37

stavudine ........................ 13 STELARA ....................... 46 STIMATE ........................ 42 STIVARGA...................... 19 STRATTERA

see atomoxetine hcl .... 32 streptomycin sulfate ........ 11 STRIBILD........................ 14 STROMECTOL

see ivermectin ............. 12 SUBOXONE

see buprenorphine hcl-naloxone hcl dihydrate 12-3mg .................... 35

78

see buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg ................... 35

see buprenorphine hcl-naloxone hcl dihydrate 4-1mg ...................... 35

see buprenorphine hcl-naloxone hcl dihydrate 8-2mg ...................... 35

subvenite tab .................. 27 sucralfate ........................ 43 sulfacetamide sodium

(acne) .......................... 52 sulfacetamide sodium

(ophth) ......................... 49 sulfacetamide sod-

prednisolone ............... 49 SULFADIAZINE .............. 11 sulfamethoxazole-trimethop

ds ................................ 12 sulfamethoxazole-

trimethoprim inj............ 12 sulfamethoxazole-

trimethoprim susp ........ 12 sulfamethoxazole-

trimethoprim tab 400-80mg ........................... 12

SULFAMYLON ............... 52 sulfasalazine ................... 43 sulfasalazine ec .............. 43 sulindac ............................ 9 sumatriptan ..................... 33 sumatriptan inj 4mg/0.5ml

.................................... 33 sumatriptan inj 6mg/0.5ml

.................................... 34 sumatriptan succinate ..... 34 SUPRAX

see cefixime ................ 15 SUPREP BOWEL PREP

KIT .............................. 43 SUSTIVA

see efavirenz ............... 13 SUTENT ......................... 19 syeda .............................. 39 SYLATRON .................... 19 SYMBICORT .................. 52 SYMDEKO ...................... 51 SYMFI ............................. 14

SYMFI LO ....................... 14 SYMJEPI ........................ 51 SYMPAZAN .................... 27 SYMTUZA ...................... 14 SYNALAR

see fluocinolone acetonide ................. 53

SYNAREL ....................... 40 SYNERCID ..................... 12 SYNJARDY TAB 12.5-

1000MG ...................... 37 SYNJARDY TAB 12.5-

500MG ........................ 37 SYNJARDY TAB 5-

1000MG ...................... 37 SYNJARDY TAB 5-500MG

.................................... 37 SYNJARDY XR TAB 10-

1000MG ...................... 37 SYNJARDY XR TAB 12.5-

1000MG ...................... 37 SYNJARDY XR TAB 25-

1000MG ...................... 37 SYNJARDY XR TAB 5-

1000MG ...................... 37 SYNRIBO ....................... 19 SYNTHROID................... 42

see euthyrox................ 42 see levo-t .................... 42 see levothyroxine sodium

................................ 42 see levoxyl .................. 42 see unithroid................ 42

SYPRINE see clovique ................ 38 see trientine hcl ........... 38

T TABLOID ........................ 17 tacrolimus ....................... 47 tacrolimus (topical) .......... 54 TAFINLAR ...................... 19 TAGRISSO ..................... 19 TALZENNA ..................... 17 TAMIFLU

see oseltamivir phosphate .......... 14, 15

tamoxifen citrate ............. 18 tamsulosin hcl ................. 44 TAPAZOLE

see methimazole ......... 42 TARCEVA

see erlotinib hcl ........... 18 TARGRETIN ................... 54

see bexarotene ........... 19 tarina fe 1/20 ................... 39 TASIGNA ........................ 19 TAXOTERE .................... 17

see docetaxel .............. 17 tazarotene ....................... 53 tazicef ............................. 15 TAZORAC....................... 53

see tazarotene ............ 53 taztia xt ........................... 23 TAZVERIK ...................... 19 TDVAX ............................ 47 TECENTRIQ ................... 17 TEFLARO ....................... 15 TEGRETOL

see carbamazepine ..... 25 see epitol ..................... 26

TEGRETOL-XR see carbamazepine ..... 25

TEKTURNA see aliskiren fumarate . 24

telmisartan ...................... 21 temazepam ..................... 33 TEMIXYS ........................ 14 TENIVAC ........................ 47 tenofovir disoproxil

fumarate ...................... 13 TENORETIC 100

see atenolol & chlorthalidone .......... 22

TENORETIC 50 see atenolol &

chlorthalidone .......... 22 TENORMIN

see atenolol ................. 22 terazosin hcl .................... 20 terbinafine hcl ................. 13 terbutaline sulfate ........... 51 terconazole vaginal ......... 44 testosterone .................... 35 testosterone cypionate .... 35 testosterone enanthate ... 35 tetrabenazine .................. 34 tetracycline hcl ................ 16 TEXACORT SOLN 2.5% 54

79

THALOMID ..................... 18 THEO-24 ........................ 51 theophylline .................... 51 theophylline tab er 12hr

300 mg ........................ 51 theophylline tab er 12hr

450 mg ........................ 51 theophylline tab sr 24hr .. 51 thioridazine hcl ................ 31 thiothixene ...................... 31 tiadylt er .......................... 23 tiagabine hcl ................... 27 TIAZAC

see diltiazem hcl extended release beads cap sr ............ 23

see taztia xt ................. 23 see tiadylt er ................ 23

TIBSOVO ........................ 17 tigecycline ....................... 12 TIKOSYN

see dofetilide ............... 21 tilia fe .............................. 39 timolol maleate ............... 23 timolol maleate (ophth) soln

.................................... 50 timolol maleate gel .......... 50 timolol maleate ophth soln

0.5% (once-daily) ........ 50 TIMOPTIC

see timolol maleate (ophth) soln.............. 50

TIMOPTIC-XE see timolol maleate gel 50

TIVICAY .......................... 13 tizanidine hcl ................... 34 TOBRADEX .................... 49

see tobramycin-dexamethasone ....... 49

TOBRADEX ST .............. 49 tobramycin ...................... 11 tobramycin (ophth) .......... 49 tobramycin inj 1.2 gm/30ml

.................................... 11 tobramycin inj 1.2gm ....... 11 tobramycin inj 10mg/ml ... 11 tobramycin inj 80mg/2ml . 11 tobramycin sulfate........... 11

tobramycin-dexamethasone .................................... 49

TOBREX see tobramycin (ophth) 49

tolterodine tartrate cap er 44 tolterodine tartrate tabs ... 44 TOPAMAX

see topiramate ............ 27 TOPAMAX SPRINKLE

see topiramate ............ 27 topiramate ....................... 27 toposar ............................ 19 TOPROL XL

see metoprolol succinate ................................ 22

toremifene citrate ............ 18 torsemide tabs ................ 24 TOVIAZ ........................... 44 TPN ELECTROLYTES ... 48 TRACLEER

see bosentan............... 24 TRADJENTA................... 37 tramadol hcl tab 50 mg ..... 9 tramadol-acetaminophen .. 9 trandolapril ...................... 20 tranexamic acid ............... 45 TRANSDERM SCOP

see scopolamine ......... 42 tranylcypromine sulfate ... 29 TRAVASOL .................... 48 TRAVATAN Z

see travoprost ............. 50 travoprost ........................ 50 TRAZIMERA ................... 17 trazodone hcl .................. 29 TRECATOR .................... 14 TRELEGY ELLIPTA ........ 50 TRELSTAR DEP INJ

3.75MG ....................... 18 TRELSTAR LA INJ

11.25MG ..................... 18 treprostinil ....................... 25 TRESIBA FLEXTOUCH .. 36 TRESIBA INJ .................. 36 tretinoin ........................... 52 tretinoin (chemotherapy) . 19 triamcinolone acetonide

(mouth) ........................ 55

triamcinolone acetonide (topical) ....................... 54

triamterene & hydrochlorothiazide cap 37.5-25 mg .................. 24

triamterene & hydrochlorothiazide tabs .................................... 24

TRIBENZOR see olmesartan

medoxomil-amlodipine-hydrochlorothiazide . 21

TRICARE ........................ 49 TRICOR

see fenofibrate ............ 22 trientine hcl ..................... 38 tri-estarylla ...................... 39 trifluoperazine hcl ............ 31 trifluridine ........................ 49 trihexyphenidyl hcl .......... 29 TRIJARDY XR TAB ER

24HR 10-5-1000 MG ... 37 TRIJARDY XR TAB ER

24HR 12.5-2.5-1000MG .................................... 37

TRIJARDY XR TAB ER 24HR 25-5-1000 MG ... 37

TRIJARDY XR TAB ER 24HR 5-2.5-1000MG ... 37

TRIKAFTA ...................... 51 tri-legest fe ...................... 39 TRILEPTAL

see oxcarbazepine ...... 26 tri-linyah .......................... 39 tri-lo marzia ..................... 39 tri-lo-estarylla .................. 39 tri-lo-sprintec ................... 39 trilyte ............................... 43 trimethoprim .................... 12 tri-mili .............................. 39 trimipramine maleate ...... 29 TRINTELLIX ................... 29 tri-previfem ...................... 39 tri-sprintec ....................... 39 TRIUMEQ ....................... 14 trivora-28......................... 40 tri-vylibra ......................... 39 tri-vylibra lo ..................... 39 TRIZIVIR

80

see abacavir sulfate-lamivudine-zidovudine ................................ 14

TROGARZO ................... 13 TROPHAMINE INJ 10% . 48 trospium chloride ............ 44 TRULICITY ..................... 36 TRUMENBA ................... 47 TRUSOPT

see dorzolamide hcl .... 50 TRUVADA TAB 100-150 14 TRUVADA TAB 133-200 14 TRUVADA TAB 167-250 14 TRUVADA TAB 200-300 14 TRUXIMA ....................... 17 TUKYSA ......................... 19 tulana .............................. 40 TURALIO ........................ 19 TWINRIX INJ .................. 47 TYBOST ......................... 13 TYGACIL

see tigecycline............. 12 TYKERB ......................... 19 TYMLOS ......................... 41 TYPHIM VI ...................... 47 U ULTRACET

see tramadol-acetaminophen .......... 9

ULTRAM see tramadol hcl tab 50

mg ............................. 9 UNASYN

see ampicillin & sulbactam sodium .... 16

UNASYN BULK PACK see ampicillin &

sulbactam sodium .... 16 unithroid .......................... 42 UROCIT-K 10

see potassium citrate (alkalinizer) er tabs .. 44

UROCIT-K 15 see potassium citrate

(alkalinizer) er tabs .. 44 UROCIT-K 5

see potassium citrate (alkalinizer) er tabs .. 44

UROXATRAL

see alfuzosin hcl .......... 44 URSO 250

see ursodiol ................. 43 URSO FORTE

see ursodiol ................. 43 ursodiol ........................... 43 V VAGIFEM

see estradiol vaginal tab ................................ 40

see yuvafem vaginal tablet 10 mcg ........... 40

valacyclovir hcl ................ 15 VALCHLOR .................... 54 VALCYTE

see valganciclovir hcl .. 15 valganciclovir hcl ............. 15 VALIUM

see diazepam .............. 25 valproate sodium ............ 27 valproic acid .................... 27 valsartan ......................... 21 valsartan-

hydrochlorothiazide ..... 21 VALTOCO ...................... 27 VALTREX

see valacyclovir hcl ..... 15 VANCOCIN

see vancomycin hcl ..... 12 VANCOCIN HCL

see vancomycin hcl ..... 12 vancomycin hcl ............... 12 VANCOMYCIN IN NACL 12 vandazole ....................... 44 VAQTA ........................... 47 VARIVAX ........................ 47 VASCEPA ....................... 22 VASERETIC

see enalapril maleate & hydrochlorothiazide . 20

VASOTEC see enalapril maleate .. 20

VELCADE ....................... 17 velivet ............................. 40 VELTASSA ..................... 38 VEMLIDY ........................ 15 VENCLEXTA .................. 17 VENCLEXTA STARTING

PACK .......................... 17

venlafaxine hcl ................ 29 VENTAVIS ...................... 25 VENTOLIN HFA .............. 51 verapamil cap er ............. 23 verapamil hcl ................... 23 verapamil hcl tab er ........ 23 VERELAN

see verapamil cap er ... 23 VERELAN PM

see verapamil cap er ... 23 VERSACLOZ .................. 31 VERZENIO ..................... 17 VFEND

see voriconazole ......... 13 VFEND IV

see voriconazole ......... 13 VIBRAMYCIN

see doxycycline hyclate ................................ 16

VICTOZA ........................ 36 VIDAZA

see azacitidine ............ 17 vienva ............................. 40 vigabatrin powd pack

500mg ......................... 27 vigabatrin tab 500mg ...... 27 vigadrone ........................ 27 VIGAMOX

see moxifloxacin hcl (ophth) ..................... 49

VIIBRYD STARTER PACK .................................... 29

VIIBRYD TAB ................. 29 VIMPAT .......................... 27 VIMPAT INJ 200MG/20ML

.................................... 27 VIMPAT SOL 10MG/ML . 27 vincristine sulfate ............ 17 vinorelbine tartrate .......... 17 viorele ............................. 40 VIRACEPT ...................... 13 VIRAMUNE

see nevirapine susp 50 mg/5ml ..................... 13

see nevirapine tab 200mg...................... 13

VIRAMUNE XR see nevirapine tab

400mg er ................. 13

81

VIREAD .......................... 13 see tenofovir disoproxil

fumarate .................. 13 VISTARIL

see hydroxyzine pamoate .................. 51

VITRAKVI ....................... 19 VIVITROL ....................... 35 VIZIMPRO ...................... 19 VOLTAREN

see diclofenac sodium (topical) 1% gel ........ 54

voriconazole ................... 13 VOSEVI .......................... 15 VOTRIENT ..................... 19 VRAYLAR ....................... 31 VRAYLAR THERAPY

PACK .......................... 31 vyfemla ........................... 40 vylibra ............................. 40 W warfarin sodium .............. 45 water for irrigation, sterile

.................................... 55 WELCHOL

see colesevelam hcl .... 22 WELLBUTRIN SR

see bupropion hcl ........ 28 WELLBUTRIN XL

see bupropion hcl ........ 28 X XALATAN

see latanoprost............ 50 XALKORI ........................ 19 XANAX

see alprazolam tab 0.25mg .................... 25

see alprazolam tab 0.5mg ...................... 25

see alprazolam tab 1mg ................................ 25

see alprazolam tab 2mg ................................ 25

XARELTO ....................... 45 XARELTO STARTER

PACK .......................... 45 XATMEP ......................... 46 XCOPRI MAINTENANCE

PAK 150-200MG ......... 27

XCOPRI PAK 12.5-25MG .................................... 27

XCOPRI PAK 50-100MG 27 XCOPRI PAK 50-200MG 27 XCOPRI TABS ................ 27 XCOPRI TITRATION PAK

150-200MG ................. 27 XELJANZ ........................ 46 XELJANZ XR .................. 46 XENAZINE

see tetrabenazine ........ 34 XGEVA ........................... 41 XIFAXAN ........................ 43 XIGDUO XR TAB 10-

1000MG ...................... 37 XIGDUO XR TAB 10-

500MG ........................ 37 XIGDUO XR TAB 2.5-

1000MG ...................... 37 XIGDUO XR TAB 5-

1000MG ...................... 37 XIGDUO XR TAB 5-500MG

.................................... 37 XOLAIR .......................... 51 XOPENEX

see levalbuterol hcl ..... 51 XOPENEX

CONCENTRATE see levalbuterol hcl soln

nebu conc 1.25 mg/0.5ml .................. 51

XOSPATA ....................... 19 XPOVIO 100 MG ONCE

WEEKLY ..................... 19 XPOVIO 60 MG ONCE

WEEKLY ..................... 19 XPOVIO 80 MG ONCE

WEEKLY ..................... 19 XPOVIO 80 MG TWICE

WEEKLY ..................... 19 XTANDI .......................... 18 xulane ............................. 40 XULTOPHY 100/3.6 ....... 36 XYLOCAINE

see lidocaine hcl (local anesth.).................... 11

see lidocaine inj 0.5% . 11 see lidocaine inj 1% .... 11

XYLOCAINE-MPF

see lidocaine hcl (local anesth.) .................... 11

see lidocaine inj 1.5% preservative free (pf) 11

XYREM ........................... 35 Y YASMIN 28

see drospirenone-ethinyl estradiol ................... 38

see ocella tab 3-0.03mg ................................ 39

see syeda .................... 39 see zarah .................... 40

YAZ see drospirenone-ethinyl

estradiol ................... 38 see gianvi .................... 38 see jasmiel .................. 38 see loryna .................... 39 see nikki ...................... 39

YF-VAX ........................... 47 yuvafem vaginal tablet 10

mcg ............................. 40 Z zafirlukast........................ 51 ZANAFLEX

see tizanidine hcl ......... 34 zarah ............................... 40 ZARONTIN

see ethosuximide ........ 26 ZARXIO .......................... 45 ZAVESCA

see miglustat ............... 40 ZEJULA .......................... 17 ZELBORAF ..................... 19 ZEMAIRA ........................ 51 ZEMPLAR

see paricalcitol ............ 48 zenatane ......................... 52 ZENPEP ......................... 43 ZERIT

see stavudine .............. 13 ZERVIATE ...................... 50 ZESTORETIC

see lisinopril & hydrochlorothiazide . 20

ZESTRIL see lisinopril ................ 20

ZETIA

82

see ezetimibe .............. 22 ZIAC

see bisoprolol & hydrochlorothiazide . 22

ZIAGEN see abacavir sulfate .... 13

zidovudine cap 100mg .... 14 zidovudine syp 50mg/5ml

.................................... 14 zidovudine tab 300mg ..... 14 ziprasidone hcl ................ 31 ziprasidone mesylate ...... 31 ZIRABEV ........................ 17 ZIRGAN .......................... 49 ZITHROMAX

see azithromycin ......... 15 ZOCOR

see simvastatin ..... 21, 22 ZOFRAN

see ondansetron hcl .... 42 zoledronic acid inj

4mg/100ml .................. 37 zoledronic acid inj

5mg/100ml .................. 38 zoledronic inj 4mg/5ml .... 38

ZOLINZA ........................ 17 zolmitriptan ..................... 34 zolmitriptan odt ............... 34 ZOLOFT

see sertraline hcl ......... 29 zolpidem tartrate ............. 33 ZOMIG

see zolmitriptan ........... 34 ZOMIG ZMT

see zolmitriptan odt ..... 34 ZONEGRAN

see zonisamide ........... 27 zonisamide ..................... 27 ZORTRESS

see everolimus (immunosuppressant) ................................ 46

ZORTRESS TAB 0.25MG .................................... 47

ZORTRESS TAB 0.5MG 47 ZORTRESS TAB 0.75MG

.................................... 47 ZORTRESS TAB 1MG ... 47 ZOSTAVAX..................... 47 zovia 1/35e ..................... 40

ZOVIRAX see acyclovir ............... 14

ZYDELIG ........................ 19 ZYKADIA ........................ 19 ZYLET ............................ 49 ZYLOPRIM

see allopurinol tab ......... 9 ZYMAXID

see gatifloxacin (ophth) ................................ 49

ZYPREXA see olanzapine ...... 30, 31

ZYPREXA RELPREVV ... 31 ZYPREXA RELPREVV INJ

210MG ........................ 32 ZYPREXA ZYDIS

see olanzapine ............ 31 ZYTIGA ........................... 18

see abiraterone acetate ................................ 17

ZYVOX see linezolid inj ............ 12 see linezolid susp ........ 12 see linezolid tab 600mg

................................ 12

This formulary was updated on 08/01/2020. For more recent information or other questions, please contact Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage Plus (PPO) and Johns Hopkins Advantage MD Premier (PPO) Customer Service at 1-877-293-5325 or, for TTY users, 711, 24 hours a day, 7 days a week, or visit www.hopkinsmedicare.com.

http://www.hopkinsmedicare.com

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