list of covered drugs/formulary - aetna medicaid · aetna better healthsm premier plan...

Aetna Better HealthSM Premier Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees.

www.aetnabetterhealth.com/illinois

List of Covered Drugs/FormularyAETNA BETTER HEALTHSM PREMIER PLAN

IL-13-11-05-ENG H2506_14_003

www.aetnabetterhealth.com/illinois

Helpful information

Aetna Better Health Premier PlanMember Services1-866-600-2139 (toll free)Representatives available 24 hours a day, 7 days a week

AddressAetna Better Health Premier PlanOne South Wacker DriveSuite 1200, Mail Stop F646Chicago, IL 60606

Services for the Hearing ImpairedIllinois Relay 7-1-1

Enrollment and Application ServicesIllinois Client Enrollment Broker (ICEB)1-877-912-8880 (toll free)TTY: 1-866-565-8576

Transportation ServicesMedical Transportation Management, Inc.Non-Emergency Transportation1-888-513-1612 (toll free)

Dental ServicesDentaQuest1-800-416-9185 (toll free)

Behavioral Health Services1-866-600-2139 (toll free)

Vision ServicesMarch Vision1-888-493-4070 (toll free) Pharmacy ServicesAetna Better Health Premier PlanCall Member Services1-866-600-2139 (toll free)

Prescriptions by MailCVS CaremarkPO Box 2110Pittsburgh, PA 15230-21101-866-698-1325 (toll free)TTY: 1-800-899-2114Monday through Friday8 a.m. to 5 p.m.

Language Interpretation Services Including Sign Language Interpretation and CART ReportingCall Aetna Better Health Premier Plan Member Services1-866-600-2139 (toll free)Representatives available 24 hours a day, 7 days a week

Appeals and GrievancesAetna Better Health Premier PlanAttn: Appeals and Grievances ManagerOne South Wacker DriveMail Stop F646Chicago, IL 60606 1-866-600-2139Illinois Relay 7-1-1 (hearing impaired)

To make a request for a fair hearing:Illinois Department of Healthcare and Family Services Bureau of Assistance Hearings 401 South Clinton, Sixth FloorChicago, IL 606071-800-435-0774 (toll free)TTY: 1-877-734-7429

Fraud and Abuse Hotline1-877-436-8154 (toll free)

Aetna Better Health Illinois Premier Plan

October 2014 Formulary Updates Brands Added

ZONTIVITY TAB 2.08MG SIVEXTRO 200MG TAB, INJ

September 2014 Formulary Updates Generics Added METHOXSALEN CAP 10MG

Brands Added

ISENTRESS POW 100MG LEVEMIR INJ FLEXTOUCH

Medications Removed from Formulary LODOSYN TAB 25MG

RAPAMUNE TAB 0.5MG

AVINZA CAP 120MG

ORTHO EVRA DIS WEEK

NEXIUM I.V. INJ 20MG

NEXIUM I.V. INJ 40MG

AVINZA CAP 90MG

AVINZA CAP 60MG

AVINZA CAP 30MG

MEPRON SUS

AVINZA CAP 75MG

LUNESTA TAB 3MG

LUNESTA TAB 2MG

LUNESTA TAB 1MG

AVINZA CAP 45MG

MYCOBUTIN CAP 150MG

EVISTA TAB 60MG

VIRAMUNE XR TAB 400MG

August 2014 Formulary Updates

Generics Added AZELASTINE SPR 0.15%

Brands Added

ZYKADIA CAP 150MG-PA NIPENT INJ 10MG-PA

Medications Removed from Formulary JUVISYNC TAB (all strengths) ONFI TAB 5MG (only strength)

Formulary Changes

EPLERENONE-removed PA

APTIOM-removed PA

July 2014 Formulary Updates

Generics Added OMEGA-3-ACID CAP 1GM ESZOPICLONE TAB 1MG-QL, PA ESZOPICLONE TAB 2MG-QL, PA ESZOPICLONE TAB 3MG-QL, PA NEVIRAPINE TAB 400MG ER MORPHINE SUL INJ 2MG/ML-PA LARIN FE TAB 1/20 LARIN FE TAB 1.5/30 XULANE DIS 150-35

Brands Added

BIVIGAM INJ 10%-PA SUBOXONE MIS 4-1MG-QL, PA SUBOXONE MIS 8-2MG-QL, PA SUBOXONE MIS 2-0.5MG-QL, PA SUBOXONE MIS 12-3MG-QL, PA INVOKANA TAB 100MG-QL INVOKANA TAB 300MG-QL

COPAXONE INJ 40MG/ML-QL,PA PEG-INTRON KIT 80MCG-PA PEG-INTRON KIT 120MCG-PA PEG-INTRON KIT 150MCG-PA

Medications Removed from Formulary PILOPINE HS GEL 4% OP PENTOSTATIN INJ 10MG EXELON SOL 2MG/ML

June 2014 Formulary Updates

Generics Added LARIN TAB 1/20 CARBIDOPA TAB 25MG ATOVAQUONE SUS 750/5ML TRIHEXYPHEN TAB 2MG-PA TRIHEXYPHEN ELX 0.4MG/ML-PA TRIHEXYPHEN TAB 5MG-PA HYDROXYZ HCL TAB 10MG-PA HYDROXYZ PAM CAP 100MG-PA HYDROXYZ HCL SOL 10MG/5ML-PA HYDROXYZ PAM CAP 25MG-PA HYDROXYZ HCL TAB 25MG-PA HYDROXYZ PAM CAP 50MG-PA HYDROXYZ HCL TAB 50MG-PA CYCLOSERINE CAP 250MG SUMATRIPTAN INJ 6MG/0.5 POT CHLORIDE TAB 8MEQ SR FAMOTIDINE INJ 200/20ML RALOXIFENE TAB 60MG DEXAMETH PHO INJ 4MG/ML DEXAMETH PHO INJ 10MG/ML SUMATRIPTAN INJ 6MG/0.5-QL RIFABUTIN CAP 150MG FAMOTIDINE INJ 40MG/4ML DOXYCYCL HYC INJ 100MG METHADONE CON 10MG/ML

Brands Added APTIOM TAB 200MG-QL, PA APTIOM TAB 400MG-QL, PA

APTIOM TAB 600MG-QL, PA

APTIOM TAB 800MG-QL, PA

OLYSIO CAP 150MG-PA

SOVALDI TAB 400MG-PA

NAMENDA XR CAP 14MG

NAMENDA XR CAP 21MG

NAMENDA XR CAP 28MG NAMENDA XR CAP 7MG NAMENDA XR CAP TITRATIO KUVAN POW 100MG-PA NOVOLOG INJ PENFILL BCG VACCINE INJ ADRUCIL INJ 500/10ML-PA ROTARIX SUS

Formulary changes

May 2014 Formulary Updates

Generics Added TEMAZEPAM CAP 15MG-QL TEMAZEPAM CAP 7.5MG- QL

Brands Added MYRBETRIQ TAB 25MG- QL MYRBETRIQ TAB 50MG- QL BREO ELLIPTA INH 100-25- QL SILENOR TAB 3MG- QL SILENOR TAB 6MG- QL NUVIGIL TAB 200MG- PA, QL

April 2014 Formulary Updates

Generics Added

ESOMEPRAZOLE INJ 20MG ESOMEPRAZOLE INJ 40MG GENTAMICIN OIN 0.3% OP MITOMYCIN INJ 40MG- PA MITOMYCIN INJ 5MG- PA MODERIBA PAK 1200/DAY- PA MORPHINE SUL CAP 120MG ER-QL MORPHINE SUL CAP 30MG ER-QL MORPHINE SUL CAP 45MG ER-QL MORPHINE SUL CAP 60MG ER-QL MORPHINE SUL CAP 75MG ER-QL MORPHINE SUL CAP 90MG ER-QL

NIACIN ER TAB 1000MG NIACIN ER TAB 500MG-QL NIACIN ER TAB 750MG-QL PIMTREA TAB SIROLIMUS TAB 0.5MG- PA VYFEMLA TAB 0.4-35

Brands Added ADEMPAS TAB 0.5MG-PA ADEMPAS TAB 1.5MG-PA ADEMPAS TAB 1MG-PA ADEMPAS TAB 2.5MG-PA ADEMPAS TAB 2MG-PA ENBREL SRCLK INJ 50MG/ML-PA FYCOMPA TAB 10MG-PA FYCOMPA TAB 12MG-PA FYCOMPA TAB 2MG-PA FYCOMPA TAB 4MG-PA FYCOMPA TAB 6MG-PA FYCOMPA TAB 8MG-PA VERSACLOZ SUS 50MG/ML

Formulary Changes

PARICALCITOL CAP 4 MCG-changed from Tier 2 to Tier 1

IL-13-11-05-ENG CMS Approved H2506_14_003

FORMULARY ID 00014285 V:12 Last updated: 9/23/2014 Effective 10/1/2014

Aetna Better HealthSM

Premier Plan | 2014 List of Covered Drugs (Formulary)

This is a list of drugs that members can get in Aetna Better HealthSM Premier Plan (Medicare-

Medicaid Plan).

Aetna Better Health Premier Plan is a health plan that contracts with both Medicare and

Illinois Medicaid to provide benefits of both programs to enrollees.

Benefits, List of Covered Drugs, pharmacy and provider networks, and copayments may

change from time to time throughout the year and on January 1 of each year.

You can always check Aetna Better Health Premier Plan’s up-to-date List of Covered Drugs

online at www.aetnabetterhealth.com/illinois.

You can ask for this information in other formats, such as Braille or large print. Call 1-866-600-

2139 (TTY/TDD 7-1-1). The call is free.

Limitations and restrictions may apply. For more information, call Aetna Better Health Premier

Plan Member Services or read the Aetna Better Health Premier Plan Member Handbook.

You can get this document in Spanish, or speak with someone about this information in other

languages for free. Call 1-866-600-2139 (TTY/TDD 7-1-1). The call is free.

Usted puede obtener este documento en Español, o puede hablar con alguien gratuitamente

sobre esta información en otros idiomas. Llame al 1-866-600-2139 (TTY/TDD 7-1-1). La

llamada es gratis.



Frequently Asked Questions (FAQ)

Find answers here to questions you have about this List of Covered Drugs. You can read all of

the FAQ to learn more, or look for a question and answer.

1. What prescription drugs are on the List of Covered Drugs?

(We call the List of Covered Drugs the “Drug List” for short.)

The drugs on the List of Covered Drugs that starts on page 10 are the drugs covered by Aetna

Better Health Premier Plan. These drugs are available at pharmacies within our network. A

pharmacy is in our network if we have an agreement with them to work with us and provide you

services. We refer to these pharmacies as “network pharmacies.”

Aetna Better Health Premier Plan will cover all medically necessary drugs on the Drug List if:

your doctor or other prescriber says you need them to get better or stay healthy, and

you fill the prescription at a Aetna Better Health Premier Plan network pharmacy.

Aetna Better Health Premier Plan may have additional steps to access certain drugs (see

question #5 below).

You can also see an up-to-date list of drugs that we cover on our website at

www.aetnabetterhealth.com/illinois or call Member Services at 1-866-600-2139 (TTY/TDD 7-1-1).

2. Does the Drug List ever change?

Yes. Aetna Better Health Premier Plan may add or remove drugs on the Drug List during the year.

Generally, the Drug List will only change if:

A cheaper drug comes along that works as well as a drug on the Drug List now, or

We learn that a drug is not safe.

We may also change our rules about drugs. For example, we could:

Decide to require or not require prior approval for a drug. (Prior approval is permission

from Aetna Better Health Premier Plan before you can get a drug.)

Add or change the amount of a drug you can get (called “quantity limits”).

Add or change step therapy restrictions on a drug. (Step therapy means you must try one

drug before we will cover another drug.)

(For more information on these drug rules, see page <page number>.)



We will tell you when a drug you are taking is removed from the Drug List. We will also tell you

when we change our rules for covering a drug. Questions 3, 4, and 7 below have more

information on what happens when the Drug List changes.

You can always check Aetna Better Health Premier Plan’s up to date Drug List online at

www.aetnabetterhealth.com/illinois.

You can also call Member Services to check the current Drug List at 1-866-600-2139

(TTY/TDD 7-1-1).

3. What happens when a cheaper drug comes along that works as

well as a drug on the Drug List now?

If you are taking a drug that is removed because a cheaper drug that works just as well comes

along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or

when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the

Drug List is made. You will be notified by mail if a drug list change will affect you. You can view

also search for your drug with the online searchable formulary tool as it is updated to reflect

current coverage.

4. What happens when we find out a drug is not safe?

If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it

off the Drug List right away. We will also send you a letter telling you that. Your doctor will also

receive notification about this change, and will work with you to find another drug for your

condition. Please contact your doctor if a drug you are taking is removed from the drug list.

5. Are there any restrictions or limits on drug coverage? Or are there

any required actions to take in order to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases

you must do something before you can get the drug. For example:

Prior approval (or prior authorization): For some drugs, you or your doctor must get

approval from Aetna Better Health Premier Plan before you fill your prescription. If you

don’t get approval, Aetna Better Health Premier Plan may not cover the drug.

Quantity limits: Sometimes Aetna Better Health Premier Plan limits the amount of a drug

you can get.

Step therapy: Sometimes Aetna Better Health Premier Plan requires you to do step

therapy. This means you will have to try drugs in a certain order for your medical condition.



You might have to try one drug before we will cover another drug. If your doctor thinks the

first drug doesn’t work for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables on

pages 10-112. You can also get more information by visiting our web site at

www.aetnabetterhealth.com/illinois.

You can also ask for an “exception” from these limits. Please see question 10 for more

information on exceptions.

If you are in a nursing home or other long-term care facility and need a drug that is not on the

Drug List, or if you cannot easily get the drug you need, we can help. We will cover at least a

31-day emergency supply of the drug you need (unless you have a prescription for fewer

days), whether or not you are a new Aetna Better Health Premier Plan member. This will give

you time to talk to your doctor or other prescriber. He or she can help you decide if there is a

similar drug on the Drug List you can take instead or whether to request an exception. Please

see question 10 for more information about exceptions.

6. How will you know if the drug you want has limitations or if there

are required actions to take to get the drug?

The List of Covered Drugs on page <page number> has a column labeled “Necessary actions,

restrictions, or limits on use.”

7. What happens if we change our rules on how we cover some

drugs? For example, if we add prior authorization (approval),

quantity limits, and/or step therapy restrictions on a drug.

We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug.

We will tell you at least 60 days before the restriction is added or when you next ask for a refill.

Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This

gives you time to talk to your doctor about what to do next.

8. How can you find a drug on the Drug List?

There are two ways to find a drug:

You can search alphabetically (if you know how to spell the drug), or

You can search by medical condition.



To search alphabetically, go to the Alphabetical Listing section. You can find it on page 92. 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.

To search by medical condition, go to the beginning of the drug list section on page 10. The

drugs in this formulary are grouped into categories depending on the type of medical conditions

that they are used to treat. For example, if you have a heart condition, you should look in that

category. That is where you will find drugs that treat heart conditions.

9. What if the drug you want to take is not on the Drug List?

If you don’t see your drug on the Drug List, call Member Services at 1-866-600-2139 (TTY/TDD 7-

1-1) and ask about it. If you learn that Aetna Better Health Premier Plan will not cover the drug,

you can do one of these things:

Ask Member Services for a list of drugs like the one you want to take. Then show the list

to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is

like the one you want to take. Or

You can ask the health plan to make an exception to cover your drug. Please see question

10 for more information about exceptions.

10. What if you are a new Aetna Better Health Premier Plan member

and can’t find your drug on the Drug List or have a problem getting

your drug?

We can help. Under certain circumstances, the plan can offer a temporary supply of a drug to you

when your drug is not on the Drug List or when it is restricted in some way. This will give you time

to talk with your doctor or other prescriber. He or she can help you decide if there is a similar drug

on the Drug List you can take instead or whether to request an exception.

We will cover a temporary supply of your drug if:

you are taking a drug that is not on our Drug List, or

health plan rules do not let you get the amount ordered by your prescriber, or

the drug requires prior approval by <plan name>, or

you are taking a drug that is part of a step therapy restriction.

For drugs covered under your Medicare benefit we may cover a temporary 30-day supply of your

drug during the first 90 days you are a member of Aetna Better Health Premier Plan.



If you live in a nursing home or other long-term care facility, you may refill your prescription for

least 91 days and up to 98 days. You may refill the drug multiple times during the 91 to 98

days. This gives your prescriber time to change your drugs to ones on the Drug List or ask for

an exception.

For drugs covered under your Medicaid benefit there are two temporary supply options

depending on what kind of plan you were previously enrolled in.

1. If prior to becoming a member of Aetna Better Health Premier Plan, you were previously a

member of a non-Medicare-Medicaid Alignment Initiative plan and are new to this

program, we may cover a temporary 180-day supply of your drug during the first 180 days

you are a member of Aetna Better Health Premier Plan.

2. If prior to becoming a member of Aetna Better Health Premier Plan you were previously a

member of a different Medicare-Medicaid Alignment Initiative plan, we may cover a

temporary 90-day supply of your drug during the first 90 days you are a member of Aetna

Better Health Premier Plan.

If you live in a nursing home or other long-term care facility, you may refill your prescription for

at least 90 days or 180 days depending on the type of plan you were on prior to becoming an

Aetna Better Health Premier Plan member. You may refill the drug multiple times during the

90 or 180 days. This gives your prescriber time to change your drugs to ones on the Drug List

or ask for an exception.

If you are a current member and you have a change in your level of care (e.g. you are discharged

from a hospital to your home or admitted to, or discharged from, a long-term care facility, your

pharmacy may obtain an override up to a 30-day supply from Aetna Better Health Premier Plan.

During the time when you are getting a temporary supply of a drug, you should talk with your

provider to decide what to do when your temporary supply runs out. You can either switch to a

different drug covered by the plan or ask the plan to make an exception for you and cover your

current drug.

Please call Member Services at 1-866-600-2139 (TTY/TDD 7-1-1) for more information.

11. Can you ask for an exception to cover your drug?

Yes. You can ask Aetna Better Health Premier Plan to make an exception to cover a drug that is

not on the Drug List.

You can also ask us to change the rules on your drug.

For example, Aetna Better Health Premier Plan may limit the amount of a drug we will

cover. If your drug has a limit, you can ask us to change the limit and cover more.



Other examples: You can ask us to drop step therapy restrictions or prior approval

requirements.

12. How long does it take to get an exception?

First, we must receive a statement from your prescriber supporting your request for an exception.

After we receive the statement, we will give you a decision on your exception request within 72

hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a

decision, you can ask for an expedited exception. This is a faster decision. If your prescriber

supports your request, we will give you a decision within 24 hours of receiving your prescriber’s

supporting statement.

13. How can you ask for an exception?

To ask for an exception, call Member Services at 1-866-600-2139 (TTY/TDD 7-1-1). A Member

Services representative will work with you and your provider to help you ask for an exception.

14. What are generic drugs?

Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less

than the brand name drug and usually don’t have well-known names. Generic drugs are approved

by the Food and Drug Administration (FDA).

Aetna Better Health Premier Plan covers both brand name drugs and generic drugs.



15. What are OTC drugs?

OTC stands for “over-the-counter”. You can buy OTC drugs without a prescription.

Aetna Better Health Premier Plan covers some OTC drugs.

You can read the Aetna Better Health Premier Plan Drug List to see what OTC drugs are

covered.

16. Does Aetna Better Health Premier Plan cover OTC non-drug

products?

Aetna Better Health Premier Plan covers some OTC non-drug products.

You can read the Aetna Better Health Premier Plan Drug List to see what OTC non-drug products

are covered.

17. What is your copay?

Member copayments for covered prescription products will be $0 regardless of drug tier level.



List of Covered Drugs

The list of covered drugs that begins on the next page gives you information about the drugs

covered by Aetna Better Health Premier Plan. If you have trouble finding your drug in the list, turn

to the Index that begins on page 92.

The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g.,

CRESTOR) and generic drugs are listed in lower-case italics (e.g., amoxicillin).

The information in the necessary actions, restrictions, or limits on use column tells you if Aetna

Better Health Premier Plan has any rules for covering your drug.

Note: The * next to a drug means the drug is not a “Part D drug.” These drugs also have different

rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to

change it if you think we made a mistake. For example, we might decide that a drug that you want

is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor disagrees

with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services

at 1-866-600-2139 (TTY/TDD 7-1-1). You can also read the Member Handbook to learn how to

appeal a decision.

Here are the meanings of the codes used in the “Necessary actions, restrictions, or limits on

use” column:

( * ) = Non Medicare Part D drugs, or OTC items that are covered by Medicaid

B/D = Covered under Medicare B or D

PA = Prior Authorization QL = Quantity Limits ST = Step Therapy

NM = Not available at mail-order LA = Limited Access

IL_MMP_CY14_2T_STANDARD eff 10/01/2014

1PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not availableat mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-PartD Drugs, or OTC items that are covered by Medicaid

Drug Name Drug Tier Requirements/Limits

ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATIONGOUT - DRUGS TO TREAT GOUT

allopurinol tab 1colchicine w/ probenecid 1COLCRYS 2 QL (120 tabs / 30 days)probenecid 1ULORIC 2 ST

NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATIONCELEBREX 2 QL (60 caps / 30 days)diclofenac potassium 1diclofenac sodium TB24; TBEC 1diflunisal 1etodolac 1flurbiprofen TABS 1ibuprofen SUSP 1ibuprofen TABS 400mg, 600mg, 800mg 1ketoprofen CAPS; CP24 1meloxicam TABS 1MELOXICAM SUSP 7.5 MG/5ML 1nabumetone TABS 1naproxen SUSP; TABS; TBEC 1naproxen sodium TABS 275mg, 550mg 1oxaprozin 1piroxicam CAPS 1sulindac TABS 1

OPIOID ANALGESICS - DRUGS TO TREAT PAINacetaminophen w/ codeine SOLN 1 QL (5000mL / 30 days)acetaminophen w/ codeine TABS 1 QL (400 tabs / 30 days)butorphanol tartrate SOLN 1mg/ml,2mg/ml

1

hydroco/apap tab 5-325mg 1 QL (360 tabs / 30 days)hydroco/apap tab 7.5-325 1 QL (360 tabs / 30 days)hydroco/apap tab 10-325mg 1 QL (360 tabs / 30 days)hydrocodone-acetaminophen 7.5-325mg/15ml

1 QL (5400mL / 30 days)

hydrocodone-ibuprofen 7-5-200mg 1 QL (150 tabs / 30 days)lorcet hd tab 10-325mg 1 QL (360 tabs / 30 days),

NMlorcet plus tab 7.5-325 1 QL (360 tabs / 30 days),

NMlorcet tab 5-325mg 1 QL (360 tabs / 30 days),

NM



Drug Name Drug Tier Requirements/Limitslortab 1 QL (360 tabs / 30 days),

NMtramadol hcl TABS 1 QL (240 tabs / 30 days)tramadol-acetaminophen 1 QL (240 tabs / 30 days)

OPIOID ANALGESICS, CII - DRUGS TO TREAT PAINDURAMORPH 1 B/Dendocet 5/325 1 QL (360 tabs / 30 days)endocet 7.5/325 1 QL (360 tabs / 30 days)endocet 10/325 1 QL (360 tabs / 30 days)ENDODAN 1 QL (360 tabs / 30 days)fentanyl 12mcg/hr, 25mcg/hr 1 QL (10 ptch / 30 days)fentanyl 50mcg/hr, 75mcg/hr, 100mcg/hr 1 QL (10 ptch / 30 days),

PAfentanyl citrate LPOP 2 QL (120 lpop / 30 days),

PAhydromorphon inj 10mg/ml 1 B/Dhydromorphone hcl LIQD; TABS 1KADIAN 2 QL (60 caps / 30 days)LAZANDA 2 QL (30 bottles / 30

days), PAmethadone hcl CONC 1 NMmethadone hcl SOLN 5mg/5ml, 10mg/5ml 1methadone hcl TABS 1 QL (240 tabs / 30 days)morphine ext-rel tab 15mg, 30mg, 60mg,100mg

1 QL (90 tabs / 30 days)

morphine ext-rel tab 200mg 1 QL (60 tabs / 30 days)MORPHINE SUL INJ 1mg/ml, 4mg/ml,10mg/ml, 15mg/ml

1 B/D

morphine sul inj .5mg/ml, 1mg/ml 1 B/Dmorphine sulfate CP24 1 QL (60 ea / 30 days)MORPHINE SULFATE SOLN 2mg/ml 1 B/D, NMMORPHINE SULFATE SOLN 8mg/ml 1 B/DMORPHINE SULFATE TABS 1 QL (180 tabs / 30 days)morphine sulfate beads cap sr 1 QL (60 ea / 30 days)MORPHINE SULFATE ORAL SOL 1OXYCODONE HCL CAPS 1 QL (180 caps / 30 days)OXYCODONE HCL CONC 1oxycodone hcl SOLN 1oxycodone hcl TABS 1 QL (180 tabs / 30 days)oxycodone hcl tab 5 mg 1 QL (180 tabs / 30 days)oxycodone w/ acetaminophen 2.5-325mg 1 QL (360 tabs / 30 days)oxycodone w/ acetaminophen 5-325mg 1 QL (360 tabs / 30 days)



Drug Name Drug Tier Requirements/Limitsoxycodone w/ acetaminophen 7.5-325mg 1 QL (360 tabs / 30 days)oxycodone w/ acetaminophen 10-325mg 1 QL (360 tabs / 30 days)oxycodone-aspirin 1 QL (360 tabs / 30 days)roxicet soln 2 QL (1800mL / 30 days)roxicet tab 5-325mg 1 QL (360 tabs / 30 days)

ANESTHETICS - DRUGS FOR NUMBINGLOCAL ANESTHETICS

lidocaine hcl (local anesth.) 4% 1lidocaine hcl (local anesth.) .5% 1 B/Dlidocaine inj 0.5% 1 B/Dlidocaine inj 1% 1 B/Dlidocaine inj 1.5% 1 B/Dlidocaine inj 2% 1 B/D

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONSANTI-BACTERIALS - MISCELLANEOUS

amikacin sulfate SOLN 1gm/4ml 1 NMamikacin sulfate SOLN 500mg/2ml 1gentamicin in saline 1gentamicin sulfate SOLN 1neomycin sulfate TABS 1paromomycin sulfate CAPS 1streptomycin sulfate SOLR 1sulfadiazine TABS 2tobramycin NEBU 2 B/D, NMtobramycin sulfate SOLN; SOLR 1tobramycin sulfate in saline 2

ANTI-INFECTIVES - MISCELLANEOUSALBENZA 2ALINIA SUSR 2 QL (540 mL / 30 days)ALINIA TABS 2 QL (20 tabs / 30 days)atovaquone SUSP 2AZACTAM 2gm 2AZACTAM/DEX INJ 1GM 2AZACTAM/DEX INJ 2GM 2aztreonam 1BILTRICIDE 2clindamycin cap 75mg 1clindamycin cap 300mg 1clindamycin hcl cap 150 mg 1clindamycin phosphate inj 1clindamycin sol 75mg/5ml 1



Drug Name Drug Tier Requirements/Limitscolistimethate sodium SOLR 1CUBICIN 2 B/Ddapsone TABS 1DARAPRIM 2DORIBAX 2erythromycin-sulfisoxazole for susp 200-600 mg/5ml

1

imipenem-cilastatin 1INVANZ 2MACRODANTIN 25mg 2 PA; 90 day limit if >64

yrmeropenem 1methenamine hippurate 1METRO IV 2metronidazole TABS 1metronidazole in nacl 1NEBUPENT 2 B/Dnitrofurantoin macrocrystal 1 PA; 90 day limit if >64

yrnitrofurantoin monohyd macro 1 PA; 90 day limit if >64

yrPENTAM 300 2SIVEXTRO 2 NMsulfamethoxazole-trimethoprim 1sulfamethoxazole-trimethoprim inj 1trimethoprim TABS 1TYGACIL 2vancomycin hcl CAPS 2vancomycin hcl SOLR 1 B/DZYVOX 2

ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONSABELCET 2 B/DAMBISOME 2 B/Damphotericin b SOLR 1 B/DCANCIDAS 2ERAXIS 2fluconazole SUSR; TABS 1fluconazole in dextrose 1fluconazole in nacl 1flucytosine CAPS 2griseofulvin microsize 1griseofulvin ultramicrosize 1



Drug Name Drug Tier Requirements/Limitsitraconazole CAPS 1 PAketoconazole TABS 1MYCAMINE 2NOXAFIL SUSP; TBEC 2nystatin TABS 1terbinafine hcl TABS 1 QL (90 tabs / year)voriconazole SOLR 1voriconazole SUSR; TABS 2

ANTIMALARIALS - DRUGS TO TREAT MALARIAatovaquone-proguanil hcl tab 62.5-25 mg 1atovaquone-proguanil hcl tab 250-100 mg 1chloroquine phosphate TABS 1COARTEM 2mefloquine hcl 1PRIMAQUINE PHOSPHATE 2

ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDSINFECTION

abacavir sulfate 1APTIVUS 2CRIXIVAN 2didanosine 1EDURANT 2EMTRIVA 2EPIVIR SOLN 2FUZEON 2 NMINTELENCE 2INVIRASE 2ISENTRESS CHEW; TABS 2ISENTRESS PACK 2 NMlamivudine 150mg, 300mg 1LEXIVA 2NEVIRAPINE SUSP 1nevirapine TABS 1nevirapine TB24 1 NMNORVIR 2PREZISTA 2RESCRIPTOR 2RETROVIR IV INFUSION 2REYATAZ 2SELZENTRY 2stavudine 1SUSTIVA 2



Drug Name Drug Tier Requirements/LimitsTIVICAY 2VIDEX PEDIATRIC 2VIRACEPT 2VIRAMUNE SUSP 2VIRAMUNE XR 100mg 2VIREAD 2ZIAGEN SOLN 2zidovudine 1

ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESSHIV/AIDS INFECTION

abacavir sulfate-lamivudine-zidovudine 2ATRIPLA 2COMPLERA 2EPZICOM 2KALETRA SOL 2KALETRA TAB 100-25MG 2KALETRA TAB 200-50MG 2lamivudine-zidovudine 2STRIBILD 2TRUVADA 2

ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSISCAPASTAT SULFATE 2cycloserine CAPS 1 NMethambutol hcl TABS 1isoniazid TABS 1isoniazid inj 100 mg/ml 1isoniazid syp 50mg/5ml 1paser d/r 2PRIFTIN 2pyrazinamide 1rifabutin 1 NMrifampin CAPS; SOLR 1RIFATER 2seromycin 2SIRTURO 2 LA, PATRECATOR 2

ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONSacyclovir CAPS; SUSP; TABS 1acyclovir sodium SOLN 1 B/Dacyclovir sodium SOLR 500mg 1 B/D, NMacyclovir sodium SOLR 1000mg 1 B/Dadefovir dipivoxil 2 ST



Drug Name Drug Tier Requirements/LimitsBARACLUDE 2EPIVIR HBV SOLN 2famciclovir TABS 1ganciclovir inj 500mg 1 B/DINCIVEK 2 NM, PAlamivudine 100mg 1moderiba pak 2 NM, PAmoderiba tab 200mg 1 NM, PAOLYSIO 2 NM, PAREBETOL SOLN 2 NM, PARELENZA DISKHALER 2ribapak mis 600/day 2 NM, PAribasphere CAPS 1 NM, PAribasphere TABS 200mg, 400mg 1 NM, PAribasphere TABS 600mg 2 NM, PAribasphere ribapak 800 2 NM, PAribasphere ribapak 1000 2 NM, PAribasphere ribapak 1200 2 NM, PAribavirin 200mg 1 NM, PArimantadine hydrochloride 1SOVALDI 2 NM, PATAMIFLU 2TYZEKA 2valacyclovir hcl TABS 1VALCYTE 2VICTRELIS 2 NM, PA

CEPHALOSPORINS - DRUGS TO TREAT INFECTIONScefaclor 1cefaclor monohydrate 2cefadroxil 1cefazolin in d5w 2cefazolin inj 1cefazolin sodium 1gm, 20gm 1cefdinir 1cefepime hcl 1cefotaxime sodium 1cefoxitin sodium 1cefpodoxime proxetil 1cefprozil 1ceftazidime solr 1CEFTAZIDIME/DEXTROSE 2ceftriaxone sodium SOLR 1



Drug Name Drug Tier Requirements/Limitscefuroxime axetil TABS 1cefuroxime sodium 1.5gm, 7.5gm, 750mg 1cephalexin CAPS 250mg, 500mg 1cephalexin SUSR 1SUPRAX CAPS 2suprax CHEW 2suprax SUSR 100mg/5ml, 200mg/5ml 2SUPRAX SUSR 500mg/5ml 2suprax TABS 2tazicef SOLR 1tazicef vial 1

ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONSAZITHROMYCIN PACK 1azithromycin SOLR 500mg 1azithromycin SUSR 1azithromycin TABS 1clarithromycin TABS 1clarithromycin er 1clarithromycin for susp 1DIFICID 2 STe.e.s. 1E.E.S. GRANULES 2ery-tab 2ERYPED 200 2ERYPED 400 2erythrocin stearate 1erythromycin base 1erythromycin ethylsuccinate 1ZMAX 2

FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONSCIPRO SUSR 2ciprofloxacin SUSR 1 NMciprofloxacin er 1ciprofloxacin hcl tab 1ciprofloxacin in d5w 1ciprofloxacin inj 1levofloxacin TABS 1levofloxacin in d5w 1levofloxacin inj 25mg/ml 1levofloxacin oral soln 25 mg/ml 1

PENICILLINS - DRUGS TO TREAT INFECTIONSamoxicillin 1



Drug Name Drug Tier Requirements/Limitsamoxicillin & pot clavulanate 1ampicillin 1ampicillin & sulbactam sodium 1ampicillin inj 1ampicillin sodium 1BICILLIN C-R 2BICILLIN L-A 2dicloxacillin sodium 1nafcillin sodium 1gm 1nafcillin sodium 2gm, 10gm 2oxacillin sodium 1gm, 2gm 1oxacillin sodium 10gm 2PENICILLIN G POT IN DEXTROSE 2penicillin g potassium 1penicillin g procaine 2penicillin g sodium 1penicillin v potassium 1penicilln gk inj 5mu 1piperacillin sodium-tazobactam sodium 1TIMENTIN 2TIMENTIN INJ 3.1GM 2

TETRACYCLINES - DRUGS TO TREAT INFECTIONSdoxycycline (monohydrate) CAPS 50mg,100mg

1

doxycycline (monohydrate) TABS 1doxycycline hyclate CAPS; TABS 1doxycycline hyclate SOLR 1 NMminocycline hcl CAPS 1VIBRAMYCIN SYRP 2

ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCERALKYLATING AGENTS

BICNU 2 B/DBUSULFEX 2 B/DCEENU CAP 10MG 2CEENU CAP 40MG 2cyclophosphamide SOLR; TABS 1 B/Ddacarbazine 200mg 1 B/DEMCYT 2HEXALEN 2IFEX 3gm 2 B/Difosfamide inj 1gm 1 B/Difosfamide inj 1gm/20ml 1 B/D



Drug Name Drug Tier Requirements/LimitsIFOSFAMIDE INJ 3GM 2 B/Difosfamide inj 3gm/60ml 1 B/DLEUKERAN 2LOMUSTINE 1melphalan hcl 2 B/DMUSTARGEN 2 B/DTREANDA 2 B/D, NM

ANTHRACYCLINESadriamycin 50mg 1 B/Ddaunorubicin hcl 1 B/Ddaunorubicin hcl for inj 20 mg 1 B/DDOXIL INJ 2MG/ML 2 B/Ddoxorubicin hcl SOLN 1 B/Ddoxorubicin hcl SOLR 20mg, 50mg 1 B/Ddoxorubicin hcl liposomal 2 B/Depirubicin hcl SOLN 1 B/Didarubicin hcl 2 B/D

ANTIBIOTICSbleomycin sulfate 1 B/DCOSMEGEN 2 B/Dmitomycin SOLR 1 B/Dmitomycin inj 20mg 1 B/D

ANTIMETABOLITESadrucil 1 B/Dadrucil inj 500/10ml 1 B/D, NMALIMTA 2 B/Dazacitidine 2 B/D, NMcladribine 2 B/Dcytarabine SOLN 20mg/ml 1 B/Dcytarabine SOLR 100mg 1 B/Dfludarabine phosphate 1 B/Dfluorouracil SOLN 1 B/DGEMCITABINE HCL SOLN 2 B/Dgemcitabine hcl SOLR 2 B/Dmercaptopurine TABS 1methotrexate sodium inj 1 B/DNIPENT 2 B/D, NMTABLOID 2

ANTIMITOTIC, TAXOIDSDOCETAXEL CONC 20mg/0.5ml, 20mg/ml,80mg/4ml

2 B/D

docetaxel CONC 140mg/7ml 2 B/D



Drug Name Drug Tier Requirements/LimitsDOCETAXEL SOLN 80mg/8ml 2 B/Dpaclitaxel 1 B/DTAXOTERE 2 B/D

ANTIMITOTIC, VINCA ALKALOIDSvinblastine sulfate SOLN 2 B/Dvincasar 1 B/Dvincristine sulfate 1 B/Dvinorelbine tartrate 1 B/D

BIOLOGIC RESPONSE MODIFIERSAVASTIN 2 B/D, NMERIVEDGE 2 NM, LA, PAHERCEPTIN 2 B/D, NMISTODAX 2 B/D, NMKADCYLA 2 B/D, NMPROLEUKIN 2 B/D, NMRITUXAN 2 NM, PAVELCADE 2 B/D, NMZOLINZA 2 NM, PA

HORMONAL ANTINEOPLASTIC AGENTSanastrozole tab 1mg 1 NMbicalutamide 1 QL (30 tabs / 30 days)DEPO-PROVERA INJ 400/ML 2 B/Dexemestane tab 25mg 1 NMFARESTON 2FASLODEX 2 B/Dflutamide 1letrozole tab 2.5mg 1 NMleuprolide acetate KIT 1 NM, PALUPR DEP-PED INJ 11.25MG (3-MONTH) 2 QL (1 box / 84 days),

NM, PALUPR DEP-PED INJ 30MG (3-MONTH) 2 QL (1 box / 84 days),

NM, PALUPRON DEPOT 3.75mg 2 QL (1 box / 30 days),

NM, PALUPRON DEPOT-PED 2 NM, PALYSODREN 2MEGACE ES 2 QL (150 mL / 30 days),

PAmegestrol acetate SUSP; TABS 1 PANILANDRON 2SOLTAMOX 2tamoxifen citrate TABS 1



Drug Name Drug Tier Requirements/LimitsTRELSTAR DEP INJ 3.75MG 2 NM, PATRELSTAR LA INJ 11.25MG 2 NM, PAXTANDI 2 NM, LA, PAZYTIGA 2 NM, PA

KINASE INHIBITORSAFINITOR 2 NM, PAAFINITOR DISPERZ 2 NM, PABOSULIF 2 NM, PACAPRELSA 2 NM, LA, PACOMETRIQ 2 NM, PAGILOTRIF 2 NM, PAGLEEVEC 2 NM, PAICLUSIG 2 NM, LA, PAIMBRUVICA 2 NM, PAINLYTA 2 NM, LA, PAJAKAFI 2 NM, LA, PAMEKINIST 2 NM, PANEXAVAR 2 NM, LA, PASPRYCEL 2 NM, PASTIVARGA 2 NM, LA, PASUTENT 2 NM, PATAFINLAR 2 NM, PATARCEVA 2 NM, PATASIGNA 2 NM, PATYKERB 2 NM, LA, PAVOTRIENT 2 NM, PAXALKORI 2 NM, LA, PAZELBORAF 2 NM, LA, PAZYKADIA 2 NM, LA, PA

MISCELLANEOUSDROXIA 2hydroxyurea CAPS 1MATULANE 2mitoxantrone hcl 1 B/D, NMPOMALYST CAP 1MG 2 NM, LA, PAPOMALYST CAP 2MG 2 NM, LA, PAPOMALYST CAP 3MG 2 NM, LA, PAPOMALYST CAP 4MG 2 NM, LA, PASYLATRON 2 NM, PATARGRETIN CAPS 2 NM, PAtretinoin (chemotherapy) 2TRISENOX 2 B/D



Drug Name Drug Tier Requirements/LimitsPLATINUM-BASED AGENTS

carboplatin SOLN 1 B/Dcisplatin soln 1 B/Doxaliplatin 2 B/D

PROTECTIVE AGENTSamifostine crystalline 2 B/Ddexrazoxane 250mg 2 B/DELITEK 2 B/Dleucovorin calcium SOLR 1 B/Dleucovorin calcium TABS 1leucovorin calcium inj 10 mg/ml 1 B/Dmesna 1 B/DMESNEX TABS 2

TOPOISOMERASE INHIBITORSetoposide SOLN 500mg/25ml 1 B/Dirinotecan hcl 2 B/Dtoposar 1gm/50ml 1 B/Dtopotecan hcl SOLR 2 B/D

CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATIONCONDITIONS

ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOODPRESSURE

amlodipine-benazepril hcl cap 2.5-10mg 1 QL (30 caps / 30 days)amlodipine-benazepril hcl cap 5-10mg 1 QL (30 caps / 30 days)amlodipine-benazepril hcl cap 5-20mg 1 QL (30 caps / 30 days)amlodipine-benazepril hcl cap 5-40mg 1 QL (30 caps / 30 days)amlodipine-benazepril hcl cap 10-20mg 1 QL (30 caps / 30 days)amlodipine-benazepril hcl cap 10-40mg 1benazepril & hydrochlorothiazide 1captopril & hydrochlorothiazide 1enalapril maleate & hydrochlorothiazide 1fosinopril sodium & hydrochlorothiazide 1lisinopril & hydrochlorothiazide 1moexipril-hydrochlorothiazide 1quinapril-hydrochlorothiazide 1

ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSUREbenazepril hcl TABS 1captopril TABS 1enalapril maleate TABS 1fosinopril sodium 1lisinopril TABS 1



Drug Name Drug Tier Requirements/Limitsmoexipril hcl 1perindopril erbumine 1quinapril hcl 1ramipril 1trandolapril 1

ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGHBLOOD PRESSURE

eplerenone tab 1 NMspironolactone TABS 1

ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSUREdoxazosin mesylate 1mg, 2mg, 4mg 1 QL (30 tabs / 30 days)doxazosin mesylate 8mg 1prazosin hcl 1terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGSTO TREAT HIGH BLOOD PRESSURE

AZOR 10-40MG 2AZOR TAB 5-20MG 2 QL (30 tabs / 30 days)AZOR TAB 5-40MG 2 QL (30 tabs / 30 days)AZOR TAB 10-20MG 2 QL (30 tabs / 30 days)BENICAR HCT 40-25MG 2BENICAR HCT TAB 20-12.5MG 2 QL (30 tabs / 30 days)BENICAR HCT TAB 40-12.5MG 2 QL (30 tabs / 30 days)EXFORGE 10-320MG 2EXFORGE HCT 5 160 12.5MG 2 QL (30 tabs / 30 days)EXFORGE HCT 5 160 25MG 2 QL (60 tabs / 30 days)EXFORGE HCT 10 160 12.5MG 2 QL (30 tabs / 30 days)EXFORGE HCT 10 160 25MG 2 QL (30 tabs / 30 days)EXFORGE HCT 10-320-25MG 2EXFORGE TAB 5-160MG 2 QL (30 tabs / 30 days)EXFORGE TAB 5-320MG 2 QL (30 tabs / 30 days)EXFORGE TAB 10-160MG 2 QL (30 tabs / 30 days)losartan-hctz 50-12.5mg 1 QL (30 tabs / 30 days)losartan-hctz 100-12.5mg 1 QL (30 tabs / 30 days)losartan-hctz 100-25 mg 1TRIBENZOR 20- 5-12.5MG 2 QL (30 tabs / 30 days)TRIBENZOR 40-5-12.5MG 2 QL (30 tabs / 30 days)TRIBENZOR 40-10-12.5MG 2 QL (30 tabs / 30 days)TRIBENZOR 40-10-25MG 2TRIBENZOR 40- 5-25MG 2 QL (30 tabs / 30 days)valsartan-hctz tab 80-12.5mg 1 QL (30 tabs / 30 days)valsartan-hctz tab 160-12.5mg 1 QL (30 tabs / 30 days)



Drug Name Drug Tier Requirements/Limitsvalsartan-hctz tab 160-25mg 1 QL (30 tabs / 30 days)valsartan-hctz tab 320-12.5mg 1valsartan-hctztab 320-25mg 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREATHIGH BLOOD PRESSURE

BENICAR 5mg 2 QL (60 tabs / 30 days)BENICAR 20mg 2 QL (30 tabs / 30 days)BENICAR 40mg 2DIOVAN 40mg, 80mg, 160mg 2 QL (60 tabs / 30 days)DIOVAN 320mg 2losartan potassium 25mg, 50mg 1 QL (60 tabs / 30 days)losartan potassium 100mg 1valsartan tab 40 mg 1 QL (60 tabs / 30 days),

NMvalsartan tab 80 mg 1 QL (60 tabs / 30 days),

NMvalsartan tab 160 mg 1 QL (60 tabs / 30 days),

NMvalsartan tab 320 mg 1 NM

ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHMamiodarone hcl 1disopyramide phosphate 1 PAflecainide acetate 1mexiletine hcl 1MULTAQ 2NORPACE CR 2 PApacerone 1propafenone hcl 1quinidine gluconate TBCR 1quinidine sulfate TABS; TBCR 1sorine 1sotalol hcl 1sotalol hcl (afib/afl) 1TIKOSYN 2 NM, PA

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TOTREAT HIGH CHOLESTEROL

atorvastatin calcium 1 QL (30 tabs / 30 days)CRESTOR 2 QL (30 tabs / 30 days)lovastatin 10mg 1 QL (30 tabs / 30 days)lovastatin 20mg 1 QL (120 tabs / 30 days)lovastatin 40mg 1 QL (60 tabs / 30 days)pravastatin sodium 1 QL (30 tabs / 30 days)



Drug Name Drug Tier Requirements/Limitssimvastatin TABS 1 QL (30 tabs / 30 days)

ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGHCHOLESTEROL

cholestyramine 1cholestyramine light 1choline fenofibrate 1colestipol hcl 1fenofibrate TABS 1FENOFIBRATE MICRONIZED 43mg 1 QL (60 caps / 30 days)fenofibrate micronized 67mg 1 QL (30 caps / 30 days)FENOFIBRATE MICRONIZED 130mg 1fenofibrate micronized 134mg, 200mg 1gemfibrozil TABS 1LOVAZA 2niacin er TBCR 500mg 1 QL (90 ea / 30 days)niacin er TBCR 750mg 1 QL (60 ea / 30 days)niacin er TBCR 1000mg 1omega-3-acid ethyl esters 1 NMprevalite 1VASCEPA 2WELCHOL 2ZETIA 2

BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREATHIGH BLOOD PRESSURE AND HEART CONDITIONS

atenolol & chlorthalidone 1bisoprolol & hydrochlorothiazide 1metoprolol & hydrochlorothiazide 1propranolol & hydrochlorothiazide 1

BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE ANDHEART CONDITIONS

acebutolol hcl CAPS 1atenolol TABS 1bisoprolol fumarate 1BYSTOLIC 2carvedilol 1labetalol hcl TABS 1metoprolol succinate 25mg, 50mg 1 QL (60 tabs / 30 days)metoprolol succinate 100mg 1 QL (45 tabs / 30 days)metoprolol succinate 200mg 1metoprolol tartrate SOLN; TABS 1nadolol TABS 1pindolol 1



Drug Name Drug Tier Requirements/Limitspropranolol cap er 1propranolol hcl SOLN; TABS 1propranolol tab 1timolol maleate TABS 1

CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOODPRESSURE AND HEART CONDITIONS

afeditab cr 30mg 1 QL (60 tabs / 30 days)afeditab cr 60mg 1amlodipine besylate TABS 2.5mg, 5mg 1 QL (45 tabs / 30 days)amlodipine besylate TABS 10mg 1cartia 120mg 1 QL (30 caps / 30 days)cartia 180mg, 240mg, 300mg 1dilt 120mg 1 QL (30 caps / 30 days)dilt 180mg, 240mg 1dilt-cd cap 120mg 1 QL (30 ea / 30 days),

NMdilt-cd cap 180mg 1dilt-cd cap 240mg 1dilt-cd cap 300mg 1diltiazem cap 1diltiazem cap 60mg er 1diltiazem cap 90mg er 1diltiazem cap 120mg er CP12 1diltiazem cap 120mg er CP24 1 QL (30 caps / 30 days)diltiazem cap 120mg/24 1 QL (30 caps / 30 days)diltiazem hcl SOLN 1diltiazem hcl coated beads 120mg 1 QL (30 caps / 30 days)diltiazem hcl coated beads 180mg,240mg, 300mg, 360mg

1

diltiazem inj 50/10ml 1diltiazem tab 30mg 1diltiazem tab 60mg 1diltiazem tab 90mg 1diltiazem tab 120mg 1diltzac 120mg 1 QL (30 caps / 30 days)diltzac 180mg, 240mg, 300mg 1felodipine 2.5mg 1 QL (30 tabs / 30 days)felodipine 5mg 1 QL (60 tabs / 30 days)felodipine 10mg 1isradipine 1matzim 1nicardipine hcl CAPS 1



Drug Name Drug Tier Requirements/Limitsnifediac cc tab 30mg er 1 QL (60 ea / 30 days)nifediac cc tab 60mg er 1nifedical 30mg 1 QL (30 tabs / 30 days)nifedical 60mg 1nifedipine TB24 30mg 1 QL (60 ea / 30 days)nifedipine TB24 60mg 1nifedipine TB24 90mg 1 NMnifedipine er 30mg 1 QL (30 tabs / 30 days)nifedipine er 60mg, 90mg 1nimodipine CAPS 1NYMALIZE 2taztia 120mg 1 QL (30 caps / 30 days)taztia 180mg, 240mg, 300mg, 360mg 1verapamil cap er 100mg, 120mg, 180mg,200mg, 240mg, 300mg

1

VERAPAMIL CAP ER 360mg 1verapamil hcl SOLN; TABS 1verapamil tab er 1

DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONSdigoxin 1DIGOXIN SOL 50MCG/ML 1 PAdigoxin tab 0.25mg 1 PAdigoxin tab 0.125mg 1 QL (30 tabs / 30 days)LANOXIN TAB 0.25MG 2 PALANOXIN TAB 0.125MG 2 QL (30 tabs / 30 days)

DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREATHEART CONDITIONS

AMTURNIDE 150-5-12.5MG 2 QL (30 tabs / 30 days)AMTURNIDE 300-5-12.5MG 2 QL (30 tabs / 30 days)AMTURNIDE 300-5-25MG 2 QL (30 tabs / 30 days)AMTURNIDE 300-10-12.5MG 2 QL (30 tabs / 30 days)AMTURNIDE 300-10-25MG 2TEKAMLO 150-5MG 2 QL (30 tabs / 30 days)TEKAMLO 150-10MG 2 QL (30 tabs / 30 days)TEKAMLO 300-5MG 2 QL (30 tabs / 30 days)TEKAMLO 300-10MG 2TEKTURNA 150mg 2 QL (30 tabs / 30 days)TEKTURNA 300mg 2TEKTURNA HCT TAB 150-12.5MG 2 QL (30 tabs / 30 days)TEKTURNA HCT TAB 150-25MG 2 QL (60 tabs / 30 days)TEKTURNA HCT TAB 300-12.5MG 2 QL (30 tabs / 30 days)TEKTURNA HCT TAB 300-25MG 2



Drug Name Drug Tier Requirements/LimitsDIURETICS - DRUGS TO TREAT HEART CONDITIONS

acetazolamide CP12; TABS 1amiloride & hydrochlorothiazide 1amiloride hcl 1bumetanide 1chlorothiazide 1chlorthalidone 25mg, 50mg 1DIURIL SUS 250/5ML 2DYRENIUM 2EDECRIN 2furosemide SOLN; TABS 1furosemide inj 1hydrochlorothiazide CAPS; TABS 1indapamide 1methazolamide TABS 1methyclothiazide 1metolazone 1spironolactone & hydrochlorothiazide 1torsemide inj 1torsemide tabs 1triamterene & hydrochlorothiazide 1

MISCELLANEOUSclonidine hcl PTWK; TABS 1DIBENZYLINE 2hydralazine hcl soln 1hydralazine hcl tab 1midodrine hcl 1minoxidil TABS 1RANEXA 500mg 2 QL (90 tabs / 30 days),

PARANEXA 1000mg 2 QL (60 tabs / 30 days),

PANITRATES - DRUGS TO TREAT HEART CONDITIONS

isosorb mononitrate tab 1isosorbide dinitrate 1isosorbide dinitrate sl tab 2.5 mg 1isosorbide mononitrate 1minitran 1nitro-bid 2NITRO-DUR DIS 0.3MG/HR 2NITRO-DUR DIS 0.8MG/HR 2nitroglycerin PT24 1



Drug Name Drug Tier Requirements/LimitsNITROLINGUAL PUMPSPRAY 2NITROSTAT 2

PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREATPUMONARY HYPERTENSION

ADCIRCA 2 QL (60 tabs / 30 days),NM, PA

ADEMPAS 2 QL (90 tabs / 30 days),NM, PA

LETAIRIS 2 QL (30 tabs / 30 days),NM, LA, PA

REMODULIN 2 B/D, NM, LAsildenafil citrate (pulmonary hypertension) 2 QL (90 tabs / 30 days),

NM, PATRACLEER 62.5mg 2 QL (120 tabs / 30 days),

NM, LA, PATRACLEER 125mg 2 QL (60 tabs / 30 days),

NM, LA, PA

CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEMDISORDERS

ANTIANXIETY - DRUGS TO TREAT ANXIETYalprazolam CONC 1 QL (300 ml / 30 days)alprazolam tab 0.5mg 1 QL (240 tabs / 30 days)alprazolam tab 0.25mg 1 QL (480 tabs / 30 days)alprazolam tab 1mg 1 QL (120 tabs / 30 days)alprazolam tab 2mg 1 QL (150 tabs / 30 days)buspirone hcl TABS 1fluvoxamine maleate TABS 25mg, 50mg 1 QL (45 tabs / 30 days)fluvoxamine maleate TABS 100mg 1lorazepam CONC 1 QL (150 mL / 30 days)lorazepam SOLN 1lorazepam TABS 1 QL (150 tabs / 30 days)

ANTICONVULSANTS - DRUGS TO TREAT SEIZURESAPTIOM TAB 200MG 2 QL (180 tabs / 30 days),

NMAPTIOM TAB 400MG 2 QL (90 tabs / 30 days),



NMBANZEL 2



Drug Name Drug Tier Requirements/Limitscarbamazepine CHEW; CP12; SUSP;TABS; TB12

1

CELONTIN 2clonazepam TABS 1mg 1 QL (600 tabs / 30 days)clonazepam TABS 2mg 1 QL (300 tabs / 30 days)clonazepam TABS .5mg 1 QL (1200 tabs / 30

days)clonazepam TBDP 1mg 1 QL (600 tabs / 30 days)clonazepam TBDP 2mg 1 QL (300 tabs / 30 days)clonazepam TBDP .5mg 1 QL (1200 tabs / 30

days)clonazepam TBDP .25mg 1 QL (2400 tabs per 30

days)clonazepam TBDP .125mg 1 QL (4800 tabs per 30

days)clorazepate dipotassium 3.75mg, 7.5mg 1 QL (120 tabs / 30 days),

PAclorazepate dipotassium 15mg 1 QL (180 tabs / 30 days),

PAdiazepam CONC 1 QL (240 mL / 30 days),

PAdiazepam SOLN 1 QL (1200 mL / 30 days),

PAdiazepam TABS 1 QL (120 tabs / 30 days),

PADIAZEPAM GEL 1diazepam inj 1dilantin 2DILANTIN-125 SUS 125/5ML 2divalproex sodium 1epitol 1ethosuximide CAPS; SOLN 1felbamate SUSP 2felbamate TABS 400mg 1felbamate TABS 600mg 2FYCOMPA 2mg 2 QL (180 tabs / 30 days),

PAFYCOMPA 4mg 2 QL (90 tabs / 30 days),

PAFYCOMPA 6mg 2 QL (60 tabs / 30 days),

PA



Drug Name Drug Tier Requirements/LimitsFYCOMPA 8mg, 10mg, 12mg 2 QL (30 tabs / 30 days),

PAgabapentin CAPS 100mg 1 QL (1080 caps / 30

days)gabapentin CAPS 300mg 1 QL (360 caps / 30 days)gabapentin CAPS 400mg 1 QL (270 caps / 30 days)gabapentin SOLN 1 QL (2160 mL / 30 days)gabapentin TABS 600mg 1 QL (180 tabs / 30 days)gabapentin TABS 800mg 1 QL (120 tabs / 30 days)GABITRIL 12mg, 16mg 2lamotrigine CHEW; TABS; TB24 1levetiracetam SOLN; TABS; TB24 1LYRICA CAPS 25mg, 50mg, 75mg,100mg, 150mg

2 QL (120 caps / 30 days)

LYRICA CAPS 200mg 2 QL (90 caps / 30 days)LYRICA CAPS 225mg, 300mg 2 QL (60 caps / 30 days)LYRICA SOLN 2 QL (946mL / 30 days)ONFI SUS 2.5MG/ML 2 PAONFI TAB 10MG 2 PAONFI TAB 20MG 2 PAoxcarbazepine 1PEGANONE 2phenobarbital ELIX; TABS 1 PAPHENOBARBITAL SODIUM 65mg/ml 1 PAphenobarbital sodium 130mg/ml 1 PAphenytek 2phenytoin CHEW; SUSP 1phenytoin sodium SOLN 1phenytoin sodium extended 1POTIGA 2primidone TABS 1SABRIL PACK 2 QL (180 packets / 30

days), NM, LA, PASABRIL TABS 2 QL (180 tabs / 30 days),

NM, LA, PATEGRETOL 2TEGRETOL-XR 2tiagabine hcl 1topiramate CPSP; TABS 1TRILEPTAL SUSP 2valproate sodium SOLN; SYRP 1valproic acid CAPS 1



Drug Name Drug Tier Requirements/LimitsVIMPAT SOLN 2 QL (1200 mL / 30 days)VIMPAT TABS 50mg 2 QL (180 tabs / 30 days)VIMPAT TABS 100mg, 150mg, 200mg 2 QL (60 tabs / 30 days)zonisamide 1

ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSSdonepezil hydrochloride TABS 5mg 1 QL (30 tabs / 30 days)donepezil hydrochloride TABS 10mg,23mg

1

donepezil hydrochloride TBDP 5mg 1 QL (30 tabs / 30 days)donepezil hydrochloride TBDP 10mg 1EXELON PT24 4.6mg/24hr, 9.5mg/24hr 2 QL (30 ptch / 30 days)galantamine hydrobromide CP24 8mg,16mg

1 QL (30 caps / 30 days)

galantamine hydrobromide CP24 24mg 1galantamine hydrobromide SOLN 1galantamine hydrobromide TABS 4mg 1 QL (180 tabs / 30 days)galantamine hydrobromide TABS 8mg 1 QL (90 tabs / 30 days)galantamine hydrobromide TABS 12mg 1NAMENDA SOLN 2NAMENDA TABS 5mg 2 QL (60 tabs / 30 days)NAMENDA TABS 10mg 2NAMENDA TITRATION PAK 2NAMENDA XR 2 NMNAMENDA XR TITRATION PACK 2 NMrivastigmine tartrate 1.5mg, 3mg, 6mg 1rivastigmine tartrate 4.5mg 1 QL (60 caps / 30 days)

ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSIONamitriptyline hcl TABS 1 PAamoxapine tab 25mg 1amoxapine tab 50mg 1amoxapine tab 100mg 1amoxapine tab 150mg 1BRINTELLIX 5mg 2 QL (120 tabs / 30 days)BRINTELLIX 10mg 2 QL (60 tabs / 30 days)BRINTELLIX 20mg 2 QL (30 tabs / 30 days)budeprion 1bupropion hcl TABS 1bupropion hcl TB12 1bupropion hcl TB24 150mg 1 QL (90 ea / 30 days)bupropion hcl TB24 300mg 1 QL (30 ea / 30 days)citalopram hydrobromide SOLN 1 QL (600 mL / 30 days)citalopram hydrobromide TABS 10mg,20mg




Drug Name Drug Tier Requirements/Limitscitalopram hydrobromide TABS 40mg 1 QL (30 tabs / 30 days)clomipramine hcl CAPS 1 PAdesipramine hcl TABS 1doxepin hcl CAPS; CONC 1 PAduloxetine hcl CPEP 1 QL (60 ea / 30 days)EMSAM 2 QL (30 ptch / 30 days),

PAescitalopram oxalate SOLN 1 QL (600 mL / 30 days)escitalopram oxalate TABS 5mg, 10mg 1 QL (45 tabs / 30 days)escitalopram oxalate TABS 20mg 1 QL (60 tabs / 30 days)FETZIMA 20mg 2 QL (180 ea / 30 days)FETZIMA 40mg 2 QL (90 ea / 30 days)FETZIMA 80mg, 120mg 2 QL (30 ea / 30 days)FETZIMA TITRATION PACK 2fluoxetine hcl CAPS 10mg 1 QL (30 caps / 30 days)fluoxetine hcl CAPS 20mg 1 QL (120 caps / 30 days)fluoxetine hcl CAPS 40mg 1 QL (60 caps / 30 days)fluoxetine hcl SOLN 1 QL (600 mL / 30 days)fluoxetine hcl TABS 10mg 1 QL (45 tabs / 30 days)fluoxetine hcl TABS 20mg 1 QL (120 tabs / 30 days)FORFIVO XL 2imipramine hcl TABS 1 PAmaprotiline hcl 1MARPLAN 2mirtazapine TABS 7.5mg, 15mg 1 QL (45 tabs / 30 days)mirtazapine TABS 30mg, 45mg 1mirtazapine TBDP 15mg 1 QL (30 tabs / 30 days)mirtazapine TBDP 30mg, 45mg 1nefazodone hcl 1nortriptyline hcl CAPS; SOLN 1paroxetine hcl 10mg, 20mg, 40mg 1 QL (45 tabs / 30 days)paroxetine hcl 30mg 1 QL (60 tabs / 30 days)paroxetine hcl er 12.5mg 1 QL (30 tabs / 30 days)paroxetine hcl er 25mg 1 QL (90 tabs / 30 days)paroxetine hcl er 37.5mg 1 QL (60 tabs / 30 days)PAXIL SUSP 2 QL (900 mL / 30 days)phenelzine sulfate TABS 1PRISTIQ 2 QL (30 tabs / 30 days)protriptyline hcl 1sertraline hcl CONC 1sertraline hcl TABS 25mg, 50mg 1 QL (45 tabs / 30 days)sertraline hcl TABS 100mg 1



Drug Name Drug Tier Requirements/LimitsSURMONTIL 2 PAtranylcypromine sulfate 1trazodone hcl TABS 50mg, 100mg, 150mg 1trimipramine maleate 1 PAvenlafaxine hcl CP24 37.5mg, 75mg 1 QL (30 caps / 30 days)venlafaxine hcl CP24 150mg 1 QL (60 caps / 30 days)venlafaxine hcl TABS 1VIIBRYD KIT 2VIIBRYD TABS 2 QL (30 tabs / 30 days)

ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONSDISEASE

amantadine hcl CAPS; SYRP; TABS 1APOKYN 2 NM, LA, PAAZILECT 2benztropine mesylate SOLN 1benztropine mesylate TABS 1 PAbromocriptine mesylate CAPS; TABS 1carbidopa TABS 1 NMcarbidopa-levodopa 1CARBIDOPA/LEVODOPA/ENTACAPONE 1entacapone 1NEUPRO 2pramipexole dihydrochloride 1ropinirole hydrochloride TABS 1selegiline hcl CAPS; TABS 1trihexyphenidyl hcl 1 PA

ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSESABILIFY SOLN 1mg/ml 2 QL (900 mL / 30 days)ABILIFY SOLN 9.75mg/1.3ml 2 QL (3 vials / 1 day)ABILIFY TABS 2 QL (30 tabs / 30 days)ABILIFY DISCMELT 2 QL (60 tabs / 30 days)ABILIFY MAINTENA 2 QL (1 vial / 30 days), PAchlorpromazine hcl SOLN 2chlorpromazine hcl TABS 1clozapine 25mg, 50mg 1clozapine 100mg 1 QL (270 tabs / 30 days)clozapine 200mg 1 QL (135 tabs / 30 days)CLOZAPINE ODT 12.5mg, 25mg 1 PACLOZAPINE ODT 100mg 1 QL (270 ea / 30 days),

PAFANAPT 2 QL (60 tabs / 30 days),

ST



Drug Name Drug Tier Requirements/LimitsFANAPT TITRATION PACK 2 STFAZACLO 12.5mg, 25mg 2 PAFAZACLO 100mg 2 QL (270 tabs / 30 days),

PAFAZACLO 150mg 2 QL (180 tabs / 30 days),

PAFAZACLO 200mg 2 QL (135 tabs / 30 days),

PAfluphenazine decanoate SOLN 1fluphenazine hcl 1GEODON SOLR 2 QL (6 mL / 3 days)haloperidol TABS 1haloperidol decanoate SOLN 1haloperidol lactate 1INVEGA 1.5mg, 3mg, 9mg 2 QL (30 tabs / 30 days)INVEGA 6mg 2 QL (60 tabs / 30 days)INVEGA SUSTENNA 2 QL (1 inj / 28 days), PALATUDA 20mg 2LATUDA 40mg, 120mg 2 QL (30 tabs / 30 days)LATUDA 60mg, 80mg 2 QL (60 tabs / 30 days)loxapine succinate 1olanzapine SOLR 1 QL (3 vials / 1 day)olanzapine TABS 2.5mg, 5mg, 7.5mg 1 QL (30 tabs / 30 days)olanzapine TABS 10mg, 15mg, 20mg 1 QL (60 tabs / 30 days)olanzapine TBDP 5mg 1 QL (30 tabs / 30 days)olanzapine TBDP 10mg, 15mg 1 QL (60 tabs / 30 days)olanzapine TBDP 20mg 2 QL (60 tabs / 30 days)ORAP 2perphenazine TABS 1quetiapine fumarate 1 QL (90 tabs / 30 days)RISPERDAL CONSTA 2 QL (2 inj / 28 days), PArisperidone SOLN 1 QL (240 mL / 30 days)risperidone TABS 1mg, 2mg, 3mg 1 QL (60 tabs / 30 days)risperidone TABS 4mg 1 QL (120 tabs / 30 days)risperidone TABS .25mg, .5mg 1 QL (90 tabs / 30 days)risperidone TBDP 1mg, 2mg, 3mg 1 QL (60 tabs / 30 days)risperidone TBDP 4mg 1 QL (120 tabs / 30 days)risperidone TBDP .25mg, .5mg 1 QL (90 tabs / 30 days)SAPHRIS 2SEROQUEL XR 50mg 2 QL (120 tab / 30 days)SEROQUEL XR 150mg, 200mg 2 QL (30 tabs / 30 days)SEROQUEL XR 300mg, 400mg 2 QL (60 tabs / 30 days)



Drug Name Drug Tier Requirements/Limitsthioridazine hcl TABS 1 PAthiothixene 1trifluoperazine hcl 1VERSACLOZ 2 QL (600 ML / 30 days)ziprasidone hcl 20mg, 40mg 1 QL (60 caps / 30 days)ziprasidone hcl 60mg, 80mg 1 QL (90 caps / 30 days)

ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREATADHD

amphetamine-dextroamphetamine cap sr24hr 5 mg

1 QL (90 ea / 30 days)


1 QL (90 ea / 30 days)


1 QL (30 ea / 30 days)


1 QL (30 ea / 30 days)


1 QL (30 ea / 30 days)


1 QL (30 ea / 30 days)

amphetamine-dextroamphetamine tab 5mg


amphetamine-dextroamphetamine tab 7.5mg




amphetamine-dextroamphetamine tab12.5 mg








INTUNIV 2 STmetadate tab 20mg er 1 QL (90 ea / 30 days)methylphenidate hcl TABS 5mg, 10mg 1 QL (180 tabs / 30 days)methylphenidate hcl TABS 20mg 1 QL (90 tabs / 30 days)methylphenidate hcl TBCR 10mg, 20mg 1 QL (90 ea / 30 days)methylphenidate hcl oral soln 5mg/5ml 1 QL (1800 mL / 30 days)methylphenidate hcl oral soln 10mg/5ml 1 QL (900mL / 30 days)STRATTERA 10mg, 18mg, 25mg 2 QL (120 caps / 30 days)STRATTERA 40mg 2 QL (60 caps / 30 days)STRATTERA 60mg, 80mg, 100mg 2 QL (30 caps / 30 days)

HYPNOTICS - DRUGS TO TREAT INSOMNIA



Drug Name Drug Tier Requirements/Limitseszopiclone 1 QL (30 tabs / 30 days),

NM, PASILENOR 3mg 2 QL (60 tabs / 30 days),

NMSILENOR 6mg 2 QL (30 tabs / 30 days)temazepam 7.5mg 1 QL (30 caps / 30 days),

NMtemazepam 15mg 1 QL (60 caps / 30 days)zaleplon 1 QL (30 caps / 30 days),

PA; 90 day limit if >64yr

zolpidem tartrate TABS 1 QL (30 tabs / 30 days),PA; 90 day limit if >64yr

MIGRAINE - DRUGS TO TREAT SEVERE HEADACHEScafergot tab 1-100mg 2dihydroergotamine mesylate 1naratriptan hcl 1 QL (9 tabs / 30 days)RELPAX 2 QL (12 tabs / 30 days)rizatriptan benzoate TABS 1 QL (12 tabs / 30 days)rizatriptan benzoate TBDP 1 QL (12 ea / 30 days)SUMATRIPTAN SOLN 1 QL (12 inhalers / 30

days)SUMATRIPTAN SUCCINATE SOCT 1 QL (4mL/30 days), NMsumatriptan succinate SOSY 1 QL (4mL/30 days), NMsumatriptan succinate TABS 1 QL (9 tabs / 30 days)SUMATRIPTAN SUCCINATE INJ SOAJ4mg/0.5ml

1 QL (4mL/30 days)

sumatriptan succinate inj SOAJ 6mg/0.5ml1 QL (4mL/30 days)SUMATRIPTAN SUCCINATE INJ SOCT 1 QL (4mL/30 days)sumatriptan succinate inj SOLN 1 QL (4mL/30 days)zolmitriptan TABS 1 QL (12 tabs per 30

days)zolmitriptan odt 1 QL (12 tabs per 30

days)MISCELLANEOUS

lithium carbonate CAPS; TABS 1lithium carbonate er 1LITHIUM CITRATE 2MESTINON SYRP 2MESTINON TIMESPAN 2



Drug Name Drug Tier Requirements/LimitsNUEDEXTA 2 QL (60 caps / 30 days),

PApyridostigmine bromide TABS 1RILUTEK 2riluzole 1SAVELLA 12.5mg 2 QL (480 tabs / 30 days)SAVELLA 25mg 2 QL (240 tabs / 30 days)SAVELLA 50mg 2 QL (120 tabs / 30 days)SAVELLA 100mg 2 QL (60 tabs / 30 days)SAVELLA TITRATION PACK 2XENAZINE 12.5mg 2 QL (240 tabs / 30 days),

NM, LA, PAXENAZINE 25mg 2 QL (120 tabs / 30 days),

NM, LA, PAMULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLESCLEROSIS

AVONEX 2 QL (4 boxes / 28 days),NM, PA

AVONEX PEN 2 QL (4 boxes / 28 days),NM, PA

BETASERON 2 QL (14 vials / 28 days),NM, PA

COPAXONE INJ 40MG/ML 2 QL (12 / 28 days), NM,PA

COPAXONE KIT 20MG/ML 2 QL (30 syringes / 30days), NM, PA

GILENYA 2 QL (30 caps / 30 days),NM, PA

TYSABRI 2 NM, LA, PAMUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLESPASMS

baclofen TABS 1dantrolene sodium CAPS 1tizanidine hcl TABS 1

NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERSmodafinil 100mg 1 QL (30 tabs / 30 days),

PAmodafinil 200mg 2 QL (60 tabs / 30 days),

PANUVIGIL 50mg 2 QL (150 tabs / 30 days),

PA



Drug Name Drug Tier Requirements/LimitsNUVIGIL 150mg 2 QL (60 tabs / 30 days),

PANUVIGIL 200mg, 250mg 2 QL (30 tabs / 30 days),

PAXYREM 2 QL (540 mL / 30 days),

LAPSYCHOTHERAPEUTIC-MISC

acamprosate calcium 1buprenorphine hcl SUBL 1 PAbuprenorphine hcl-naloxone hcl dihydratesl

1 QL (120 ea / 30 days),PA

buproban 1CHANTIX 2 QL (336 tabs / year), PACHANTIX STARTER PACK 2 QL (106 tabs / year), PAdisulfiram TABS 1naloxone hcl SOLN 1naltrexone hcl TABS 1nicotine patch 5 NM; *nicotine polacrilex GUM; LOZG 5 NM; *NICOTROL INHALER 2 QL (2688 cartridges /

year)NICOTROL NS 2 QL (36 bottles / year)SUBOXONE MIS 2-0.5MG 2 QL (4 boxes / 30 days),

NM, PASUBOXONE MIS 4-1MG 2 QL (4 boxes / 30 days),



NM, PA

ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES ANDREGULATE HORMONES

ANDROGENS - DRUGS TO REGULATE MALE HORMONESANDRODERM 2 QL (30 ea / 30 days), PAandroxy 2 PAoxandrolone TABS 1 PATESTIM 2 QL (300 gm / 30 days),

PAtestosterone cypionate OIL 1testosterone enanthate OIL 1

ANTIDIABETICS, INJECTABLE - DRUGS TO TREAT DIABETES



Drug Name Drug Tier Requirements/LimitsALCOHOL SWABS 2GAUZE PADS 2" X 2" 2HUMULIN R INJ U-500 2 B/DINSULIN PEN NEEDLE 2INSULIN SAFETY NEEDLES 2INSULIN SYRINGE 2LANTUS 2LANTUS SOLOSTAR 2LEVEMIR 2LEVEMIR FLEXPEN 2LEVEMIR FLEXTOUCH 2 NMNOVOLIN 70/30 2 RELION not coveredNOVOLIN N 2 RELION not coveredNOVOLIN R 2 RELION not coveredNOVOLOG 2NOVOLOG FLEXPEN 2NOVOLOG MIX 70/30 2NOVOLOG MIX 70/30 PREFILL 2NOVOLOG PENFILL 2 NMSYMLINPEN 60 2 QL (8 pens / 30 days),

PASYMLINPEN 120 2 QL (4 pens / 30 days),

PAVICTOZA 2 QL (9 mL / 30 days)

ANTIDIABETICS, ORAL - DRUGS TO TREAT DIABETESacarbose 1glimepiride 1mg 1 QL (240 tabs / 30 days)glimepiride 2mg 1 QL (120 tabs / 30 days)glimepiride 4mg 1 QL (60 tabs / 30 days)glip/metform tab 2.5-250m 1 QL (240 tabs / 30 days)glip/metform tab 2.5-500m 1 QL (120 tabs / 30 days)glip/metform tab 5-500mg 1 QL (120 tabs / 30 days)glipizide TABS 5mg 1 QL (240 tabs / 30 days)glipizide TABS 10mg 1 QL (120 tabs / 30 days)glipizide TB24 2.5mg 1 QL (240 tabs / 30 days)glipizide TB24 5mg 1 QL (120 tabs / 30 days)glipizide TB24 10mg 1 QL (60 tabs / 30 days)glyb/metform tab 1.25-250 1 QL (240 tabs / 30 days),

PAglyb/metform tab 2.5-500 1 QL (120 tabs / 30 days),

PA



Drug Name Drug Tier Requirements/Limitsglyb/metform tab 5-500mg 1 QL (120 tabs / 30 days),

PAglyburide 1.25mg 1 QL (480 tabs / 30 days),

PAglyburide 2.5mg 1 QL (240 tabs / 30 days),

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

PAglyburide micronized 1.5mg 1 QL (240 tabs / 30 days),

PAglyburide micronized 3mg 1 QL (120 tabs / 30 days),

PAglyburide micronized 6mg 1 QL (60 tabs / 30 days),

PAINVOKANA 100mg 2 QL (90 tabs / 30 days),

NMINVOKANA 300mg 2 QL (30 tabs / 30 days),

NMJANUMET 2 QL (60 tabs / 30 days)JANUMET XR TAB 50-500MG 2 QL (60 tabs / 30 days)JANUMET XR TAB 50-1000 2 QL (60 tabs / 30 days)JANUMET XR TAB 100-1000 2 QL (30 tabs / 30 days)JANUVIA 2 QL (30 tabs / 30 days)JENTADUETO 2 QL (60 tabs / 30 days)metformin hcl TABS 500mg 1 QL (150 tabs / 30 days)metformin hcl TABS 850mg 1 QL (90 tabs / 30 days)metformin hcl TABS 1000mg 1 QL (75 tabs / 30 days)metformin hcl TB24 500mg 1 QL (120 tabs / 30 days)metformin hcl TB24 750mg 1 QL (60 tabs / 30 days)nateglinide 1 QL (90 tabs / 30 days)pioglitazone hcl 1 QL (30 tabs / 30 days)pioglitazone hcl-glimepiride 1 QL (30 tabs / 30 days)pioglitazone hcl-metformin hcl 1 QL (90 tabs / 30 days)repaglinide 2mg 1 QL (240 tabs / 30 days)repaglinide .5mg, 1mg 1 QL (120 tabs / 30 days)RIOMET 2 QL (946 mL / 30 days)TRADJENTA 2 QL (30 tabs / 30 days)

BISPHOSPHONATES - DRUGS TO TREAT BONE LOSSalendronate sodium TABS 5mg, 10mg,40mg

1

alendronate sodium TABS 35mg, 70mg 1 QL (4 tabs / 28 days)



Drug Name Drug Tier Requirements/Limitsibandronate sodium TABS 1 B/D, QL (1 tab / 30

days)pamidronate disodium SOLN 1 B/Dzoledronic inj 4mg/5ml 2 B/D, NMZOMETA 2 B/D, NM

CALCIUM RECEPTOR ANTAGONISTS - DRUGS TO MANAGEPARATHYROID LEVELS

SENSIPAR 30mg, 90mg 2 QL (120 tabs / 30 days),NM

SENSIPAR 60mg 2 QL (60 tabs / 30 days),NM

CHELATING AGENTSCHEMET 2EXJADE 2 NM, LA, PAkionex 1sodium polystyrene sulfonate 1sps susp 15gm/60ml 1SYPRINE 2

CONTRACEPTIVES - DRUGS FOR BIRTH CONTROLaltavera 1apri 28 day 1aranelle 28 1aviane 28 1balziva 28 day 1briellyn 28 day 1camila 28 day 1cryselle 28 1cyclafem 1/35 28 day 1cyclafem 7/7/7 28 day 1drospirenone-ethinyl estradiol 1ELLA 2emoquette 1enpresse 28 day 1errin 28 day 1GIANVI 1gildagia 1heather 1introvale 91 day 1JOLIVETTE 1junel 1.5/30 21 day 1junel 1/20 21 day 1junel fe 1.5/30 28 day 1



Drug Name Drug Tier Requirements/Limitsjunel fe 1/20 28 day 1kariva 28 day 1kelnor 1/35 28 day 1larin 1/20 1 NMlarin fe 1.5/30 1 NMlarin fe 1/20 1 NMLEENA 1lessina 28 day 1levonest 28 day 1levonorgestrel (emergency oc) 1levonorgestrel-ethinyl estradiol (91-day) 1levora 0.15/30 28 day 1loryna 28 day 1low-ogestrel 28 day 1lutera 28 day 1lyza 1marlissa 28 day 1medroxyprogesterone acetate 150 mg/ml 1microgestin 1.5/30 21 day 1microgestin 1/20 21 day 1microgestin fe 1.5/30 28 day 1microgestin fe 1/20 28 day 1MONONESSA 1my way 1myzilra 1necon 0.5/35 28 day 1necon 1/35 28 day 1NECON 7/7/7 1necon 10/11 28 day 2NECON TAB 1/50-28 1 NMnext choice one dose 1NORA-BE 1norethindrone (contraceptive) 1norgestimate-ethinyl estradiol (triphasic) 1NORINYL 1+50 2nortrel 0.5/35 28 day 1nortrel 1/35 21 day 1nortrel 1/35 28 day 1nortrel 7/7/7 28 day 1NUVARING 2OCELLA 1ogestrel 28 day 1



Drug Name Drug Tier Requirements/Limitsorsythia 28 day 1ORTHO TRI-CYCLEN LO 2philith 1pimtrea pack 1pirmella 1/35 28 day 1portia 28 day 1previfem 28 day 1quasense 91 day 1reclipsen 28 day 1SOLIA 1sprintec 28 day 1sronyx 1tri-legest 28 day 1tri-previfem 28 day 1tri-sprintec 28 day 1TRINESSA 1trivora 28 day 1velivet 28 day 1vestura 1viorele 1vyfemla 1xulane 1 NMzarah 1zenchent 28 day 1zovia 1/35e 28 day 1zovia 1/50e 28 day 1

ENDOMETRIOSISdanazol CAPS 1SYNAREL 2

ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIESADAGEN 2 NM, LA, PAALDURAZYME 2 NM, LA, PABUPHENYL TABS 2 NMCARBAGLU 2 NM, LA, PACEREZYME 2 NM, PACYSTADANE 2 NMCYSTAGON 2 NM, PAELAPRASE 2 NM, PAELELYSO 2 NM, PAFABRAZYME 2 NM, PAKUVAN 2 NM, PAlevocarnitine (metabolic modifiers) 1 B/D



Drug Name Drug Tier Requirements/LimitsLUMIZYME 2 NM, PAMYOZYME 2 NM, PANAGLAZYME 2 NM, LA, PAORFADIN 2 NM, LA, PAPROCYSBI 2 NM, LA, PAsodium phenylbutyrate 2 NMVPRIV 2 NM, PAZAVESCA 2 NM, LA, PA

ESTROGENS - DRUGS TO REGULATE FEMALE HORMONESCOMBIPATCH 2 PAestradiol PTWK; TABS 1 PAESTRADIOL VALERATE OIL 10mg/ml 1estradiol valerate OIL 20mg/ml, 40mg/ml 1menest 2 PAPREMARIN CREAM 2VAGIFEM 2

GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSEa-hydrocort 1cortisone acetate TABS 1dexamethasone CONC; ELIX; SOLN; TABS 1dexamethasone sodium phosphate10mg/ml, 120mg/30ml

1

dexamethasone sodium phosphate20mg/5ml, 100mg/10ml

1 NM

fludrocortisone acetate TABS 1hydrocortisone TABS 1methylprednisolone TABS 1methylprednisolone acetate 1methylprednisolone sod succ 1methylprednisolone tab 4mg dose pack 1prednisolone 1prednisolone sodium phosphate 1prednisone CONC 2prednisone SOLN; TABS 1SOLU-CORTEF 250mg 2

GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOODSUGAR

GLUCAGEN HYPOKIT 2GLUCAGON EMERGENCY KIT 2glucose chew tab 5 NM; *glucose gel 40% 5 NM; *PROGLYCEM 2



Drug Name Drug Tier Requirements/LimitsHUMAN GROWTH HORMONES - DRUGS TO REGULATE PITUITARYHORMONES

NORDITROPIN FLEXPRO 2 NM, PANORDITROPIN NORDIFLEX PEN 2 NM, PATEV-TROPIN 2 NM, PA

MISCELLANEOUScabergoline 1calcitonin (salmon) 1FORTICAL 2INCRELEX 2 NM, LA, PAmethylergonovine maleate TABS 1octreotide acetate 50mcg/ml, 100mcg/ml,200mcg/ml

1 NM, PA

octreotide acetate 500mcg/ml,1000mcg/ml

2 NM, PA

PROLIA 2 QL (1 syringe / 180days), NM

SANDOSTATIN LAR DEPOT 2 NM, PASOMATULINE DEPOT 2 NM, PASOMAVERT 2 NM, LA, PAXGEVA 2 NM, PA

PARATHYROID HORMONES - DRUGS TO REGULATE PARATHYROIDLEVELS

FORTEO 2 QL (1 pen / 28 days),NM, PA

PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM ANDPHOSPHORUS LEVELS

calcium acetate (phosphate binder) 1FOSRENOL 2PHOSLYRA 2RENVELA 2

PROGESTINS - DRUGS TO REGULATE FEMALE HORMONESmedroxyprogesterone acetate tab 1norethindrone acetate TABS 1

SELECTIVE ESTROGEN RECEPTOR MODULATORS - DRUGS TO TREATBONE LOSS

raloxifene hcl 1 NMTHYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS

levothyroxine sodium TABS 1LEVOXYL 1liothyronine sodium TABS 1methimazole TABS 1



Drug Name Drug Tier Requirements/Limitspropylthiouracil TABS 1SYNTHROID 2UNITHROID 1

VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONESdesmopressin acetate spray 1desmopressin acetate spray refrigerated 1desmopressin acetate tabs 1desmopressin inj 4mcg/ml 1DESMOPRESSIN SOL 0.01% 1

GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINALDISORDERS

ANTACIDSalum & mag hydrox-simethicone 5 NM; *ALUMINUM HYDROXIDE 5 NM; *aluminum hydroxide-mag carb 5 NM; *calcium carbonate (antacid) 5 NM; *calcium carbonate-mag hydrox 5 NM; *GAVISCON CHEW 5 NM; *sodium bicarbonate (antacid) 5 NM; *

ANTI-DIARRHEALbismuth subsalicylate CHEW; SUSP 5 NM; *loperamide hcl LIQD; SUSP; TABS 5 NM; *

ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITINGcompro 1dimenhydrinate TABS 5 NM; *dronabinol 2.5mg, 5mg 1 B/D, QL (60 caps / 30

days)dronabinol 10mg 2 B/D, QL (60 caps / 30

days)EMEND CAPS 40mg 2 QL (3 caps / 180 days)EMEND CAPS 80mg 2 B/D, QL (4 caps / 30

days)EMEND CAPS 125mg 2 B/D, QL (2 caps / 30

days)EMEND PAK 80 & 125 2 B/D, QL (12 caps / 30

days)granisetron hcl SOLN 1granisetron hcl TABS 1 B/Dmeclizine hcl CHEW 5 NM; *meclizine hcl TABS 12.5mg, 25mg 1meclizine hcl TABS 12.5mg, 25mg 5 NM; *



Drug Name Drug Tier Requirements/Limitsmetoclopramide hcl SOLN; TABS 1metoclopramide inj 1ondansetron hcl TABS 1 B/Dondansetron hcl inj 1ondansetron hcl oral soln 1 B/Dondansetron odt 1 B/Dprochlorperazine inj 1prochlorperazine maleate TABS 1prochlorperazine supp 1TRANSDERM-SCOP 2 QL (10 ptch / 30 days),

PAANTISPASMODICS - DRUGS FOR STOMACH SPASMS

CUVPOSA 2dicyclomine hcl 1glycopyrrolate TABS 1glycopyrrolate inj 1

H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACHACID

famotidine SUSR 1famotidine TABS 10mg 5 NM; *famotidine TABS 20mg, 40mg 1famotidine inj 20mg/2ml 1famotidine inj 40mg/4ml, 200mg/20ml 1 NMranitidine hcl SOLN 1ranitidine hcl TABS 75mg 5 NM; *ranitidine hcl TABS 150mg, 300mg 1ranitidine hcl inj 1ranitidine syrup 1

INFLAMMATORY BOWEL DISEASEAPRISO 2ASACOL HD 2balsalazide disodium 1budesonide ec 2CANASA 2colocort 1DELZICOL 2DIPENTUM 2HYDROCORTISONE (INTRARECTAL) 1LIALDA 2mesalamine ENEM 1mesalamine w/ cleanser 1PENTASA 2



Drug Name Drug Tier Requirements/Limitssulfasalazine TABS 1sulfasalazine ec 1UCERIS 2

LAXATIVESBENEFIBER POWD 5 NM; *bisacodyl SUPP; TBEC 5 NM; *calcium polycarbophil (fiber laxative) 5 NM; *constulose 1docusate calcium 5 NM; *docusate sodium CAPS; LIQD; SYRP;TABS

5 NM; *

enulose 1gaviltye-g 1gavilyte-c 1gavilyte-n 1generlac 1glycerin (laxative) 5 NM; *GOLYTELY 2HALFLYTELY BOWEL PREP/FLA 2KONSYL-D 5 NM; *lactulose 1lactulose (encephalopathy) 1magnesium hydroxide SUSP 5 NM; *methylcellulose (laxative) 5 NM; *MOVIPREP 2NULYTELY/FLAVOR PACKS 2NUTRISOURCE FIBER POWD 5 NM; *peg 3350-kcl-sod bicarb-sod chloride-sodsulfate

1

peg 3350-potassium chloride-sodbicarbonate-sod chloride

1

PEG 3350/ELECTROLYTES 1polyethylene glycol 3350 PACK; POWD 1psyllium 5 NM; *RELISTOR 2 PASENNA TABS 5 NM; *sennosides 5 NM; *sennosides-docusate sodium 5 NM; *sodium phosphates 5 NM; *SUPREP BOWEL PREP 2trilyte 1

MISCELLANEOUSAMITIZA CAP 8MCG 2 QL (60 caps / 30 days)



Drug Name Drug Tier Requirements/LimitsAMITIZA CAP 24MCG 2 QL (60 caps / 30 days)amoxicillin-clarithromycin w/ lansoprazole 1CARAFATE SUSP 2cromolyn sodium (mastocytosis) 2diphenoxylate w/ atropine 1 PALINZESS CAP 145MCG 2 QL (60 caps / 30 days)LINZESS CAP 290MCG 2 QL (30 caps / 30 days)loperamide hcl CAPS 1LOTRONEX 2 PAmisoprostol TABS 1PYLERA 2SUCRAID 2sucralfate TABS 1ursodiol CAPS; TABS 1XIFAXAN 550mg 2 PA

PANCREATIC ENZYMESCREON 2ZENPEP 2

PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACHACID

DEXILANT 2 QL (30 caps / 30 days)esomeprazole inj 1NEXIUM 2.5mg, 5mg 2NEXIUM 10mg, 20mg, 40mg 2 QL (30 packets / 30

days)NEXIUM CAPS 2 QL (30 caps / 30 days)omeprazole CPDR 10mg, 40mg 1 QL (30 caps / 30 days)omeprazole CPDR 20mg 1 QL (60 caps / 30 days)pantoprazole sodium TBEC 1 QL (30 ea / 30 days)

GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACTCONDITIONS

BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGEDPROSTATE

alfuzosin hcl 1 QL (30 tabs / 30 days)AVODART 2 QL (30 caps / 30 days)finasteride TABS 5mg 1 QL (30 tabs / 30 days)JALYN 2 QL (30 caps / 30 days)tamsulosin hcl 1 QL (60 caps / 30 days)

MISCELLANEOUSbethanechol chloride TABS 1ELMIRON 2



Drug Name Drug Tier Requirements/LimitsPOTASSIUM CITRATE (ALKALINIZER) 1

URINARY ANTISPASMODICS - DRUGS TO TREAT URINARYINCONTINENCE

MYRBETRIQ 25mg 2 QL (60 ea / 30 days)MYRBETRIQ 50mg 2 QL (30 ea / 30 days)oxybutynin chloride SYRP 1oxybutynin chloride TABS 1oxybutynin chloride TB24 5mg 1 QL (30 tabs / 30 days)oxybutynin chloride TB24 10mg, 15mg 1 QL (60 tabs / 30 days)tolterodine tartrate cap er 1 QL (30 ea / 30 days)tolterodine tartrate tabs 1TOVIAZ 2 QL (30 tabs / 30 days)trospium chloride TABS 1 QL (60 tabs / 30 days)VESICARE 2 QL (30 tabs / 30 days)

VAGINAL ANTI-INFECTIVESCLEOCIN SUPP 2clindamycin phosphate vaginal 1clotrimazole vaginal 5 NM; *metronidazole vaginal 1miconazole nitrate vaginal CREA 5 NM; *miconazole nitrate vaginal KIT 5 NM; *miconazole nitrate vaginal SUPP 100mg 5 NM; *terconazole vaginal 1tioconazole vaginal 5 NM; *VANDAZOLE 1zazole .4% 1ZAZOLE .8% 1

HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERSANTICOAGULANTS - BLOOD THINNERS

COUMADIN 2ELIQUIS 2enoxaparin sodium 30mg/0.3ml,40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml,300mg/3ml

1

enoxaparin sodium 100mg/ml,120mg/0.8ml, 150mg/ml

2

fondaparinux sodium 2.5mg/0.5ml 1fondaparinux sodium 5mg/0.4ml,7.5mg/0.6ml, 10mg/0.8ml

2

heparin sod inj 1000/ml 1 B/DHEPARIN SOD INJ 2000/ML 2 B/DHEPARIN SOD INJ 2500/ML 2 B/Dheparin sod inj 5000/ml 1 B/D



Drug Name Drug Tier Requirements/Limitsheparin sod inj 10000/ml 1 B/Dheparin sod inj 20000/ml 1 B/DHEPARIN SODIUM/D5W 2HEPARIN SODIUM/NACL 0.45% 2HEPARIN SODIUM/SODIUM CHL 2jantoven 1PRADAXA 2warfarin sodium 1XARELTO 2

HEMATOPOIETIC GROWTH FACTORSARANESP ALBUMIN FREE 2 NM, PAGRANIX 2 NM, PALEUKINE 2 NM, PAMOZOBIL 2 QL (9.6 mL / 4 days),

NM, PANEUMEGA 2 NMNEUPOGEN 2 NM, PAPROCRIT 2 NM, PA

IRONferrous sulfate ELIX 5 NM; *ferrous sulfate LIQD 5 NM; *ferrous sulfate TABS 200mg, 325mg 5 NM; *ferrous sulfate TBEC 5 NM; *

MISCELLANEOUSanagrelide hcl 1 PAcilostazol 1pentoxifylline TBCR 1PROMACTA 12.5mg, 25mg, 50mg 2 NM, LA, PAPROMACTA 75mg 2 QL (30 tabs / 30 days),

NM, LA, PAtranexamic acid SOLN; TABS 1

PLATELET AGGREGATION INHIBITORSAGGRENOX 2BRILINTA 2clopidogrel bisulfate 75mg 1 QL (30 tabs / 30 days)EFFIENT 2ZONTIVITY 2 NM

IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THEIMMUNE SYSTEM

DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGSTO TREAT RHEUMATOID ARTHRITIS



Drug Name Drug Tier Requirements/LimitsENBREL KIT 2 QL (16 syringes / 28

days), NM, PAENBREL SOLN 2 QL (8 syringes / 28

days), NM, PAENBREL SURECLICK 2 QL (8 syringes / 28

days), NM, PAHUMIRA 20mg/0.4ml 2 QL (2 boxes / 28 days),

NM, PAHUMIRA 40mg/0.8ml 2 QL (4 boxes / 28 days),

NM, PAHUMIRA PEN 2 QL (4 boxes / 28 days),

NM, PAHUMIRA PEN-CROHNS DISEASE STARTERKIT

2 NM, PA

HUMIRA PEN-PSORIASIS STARTER KIT 2 NM, PAhydroxychloroquine sulfate 1leflunomide TABS 1methotrexate sodium tabs 1REMICADE 2 NM, PA

IMMUNOGLOBULINSBIVIGAM 10gm/100ml 2 NM, PACARIMUNE NANOFILTERED 2 NM, PAFLEBOGAMMA 2 NM, PAFLEBOGAMMA DIF 2 NM, PAGAMASTAN S/D 2 B/D, NMGAMMAGARD LIQUID 2 NM, PAGAMMAGARD S/D 2 NM, PAGAMMAKED 2 NM, PAGAMMAPLEX 2.5gm/50ml, 5gm/100ml,10gm/200ml

2 NM, PA

GAMUNEX 2 NM, PAGAMUNEX-C 2 NM, PAGAMUNEX-C 1GM/10ML 2 NM, PAOCTAGAM 1gm/20ml, 2.5gm/50ml,5gm/100ml, 10gm/200ml, 25gm/500ml

2 NM, PA

PRIVIGEN 2 NM, PAIMMUNOMODULATORS

ACTIMMUNE 2 NM, LA, PAARCALYST 2 NM, PAINTRON-A 2 B/D, NMINTRON-A W/DILUENT 2 B/D, NMPEG-INTRON 2 NM, PAPEG-INTRON REDIPEN 2 NM, PA



Drug Name Drug Tier Requirements/LimitsREVLIMID 2 NM, LA, PATHALOMID 2 NM, PA

IMMUNOSUPPRESSANTSazathioprine TABS 1 B/DCELLCEPT SUSR 2 B/Dcyclosporine CAPS; SOLN 1 B/Dcyclosporine modified (for microemulsion) 1 B/Dgengraf 1 B/Dmycophenolate mofetil 1 B/Dmycophenolate sodium 180mg 1 B/Dmycophenolate sodium 360mg 2 B/DNEORAL 2 B/DNULOJIX 2 B/DPROGRAF CAPS 2 B/DRAPAMUNE SOLN 2 B/DRAPAMUNE TABS 1mg, 2mg 2 B/DSANDIMMUNE CAPS 2 B/DSANDIMMUNE SOLN 100mg/ml 2 B/Dsirolimus tab 0.5mg 1 B/Dtacrolimus CAPS 5mg 2 B/Dtacrolimus CAPS .5mg, 1mg 1 B/DZORTRESS 2 B/D

VACCINESACTHIB 2ADACEL 2BCG VACCINE 2 NMBOOSTRIX 2CERVARIX 2COMVAX 2DAPTACEL 2DECAVAC 2 B/DDIPHTHERIA/TETANUS TOXOID 2 B/DENGERIX-B SUSP 2 B/DGARDASIL 2HAVRIX 2HIBERIX 2IMOVAX RABIES (H.D.C.V.) 2INFANRIX 2IPOL INACTIVATED IPV 2IXIARO 2M-M-R II W/DILUENT 10 DOS 2MENACTRA 2



Drug Name Drug Tier Requirements/LimitsMENHIBRIX 2MENOMUNE-A/C/Y/W-135 2MENVEO 2PEDVAX HIB 2PROQUAD 2RABAVERT 2RECOMBIVAX HB 2 B/DROTARIX 2 NMROTATEQ 2TENIVAC 2 B/DTETANUS TOXOID ADSORBED 2 B/DTETANUS/DIPHTHERIA TOXOID 2 B/DTWINRIX INJ 2 NMTYPHIM VI 2VAQTA 2VARIVAX 2YF-VAX 2ZOSTAVAX 2 QL (1 vial per lifetime)

NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTSELECTROLYTES

KLOR-CON 8 1KLOR-CON 10 1klor-con m15 1klor-con m20 1klor-con pow 20meq 1MAGNESIUM SULFATE SOLN 2MAGNESIUM SULFATE IN D5W 2magnesium sulfate inj 50% 1oral electrolytes 5 NM; *potassium chloride CPCR 1potassium chloride LIQD 1POTASSIUM CHLORIDE TBCR 1 NMPOTASSIUM CHLORIDE ER 1potassium chloride microencapsulatedcrystals cr

1

SODIUM CHLORIDE SOLN 2.5meq/ml 1SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5F) MG/ML SOLN

1

TPN ELECTROLYTES 2 B/DIV NUTRITION

AMINOSYN 2 B/DAMINOSYN 7%/ELECTROLYTES 2 B/D



Drug Name Drug Tier Requirements/LimitsAMINOSYN 8.5%/ELECTROLYTE 2 B/DAMINOSYN II 2 B/DAMINOSYN II 8.5%/ELECTROL 2 B/DAMINOSYN M 2 B/DAMINOSYN-HBC 2 B/DAMINOSYN-PF 2 B/DAMINOSYN-PF 7% 2 B/DAMINOSYN-RF 2 B/DCLINIMIX 2.75%/DEXTROSE 5% 2 B/DCLINIMIX 4.25%/DEXTROSE 5% 2 B/DCLINIMIX 4.25%/DEXTROSE 25% 2 B/DCLINIMIX 5%/DEXTROSE 15% 2 B/DCLINIMIX 5%/DEXTROSE 20% 2 B/DCLINIMIX 5%/DEXTROSE 25% 2 B/DCLINIMIX E 2.75%/DEXTROSE 5% 2 B/DCLINIMIX E 2.75%/DEXTROSE 10% 2 B/DCLINIMIX E 4.25%/DEXTROSE 5% 2 B/DCLINIMIX E 4.25%/DEXTROSE 25% 2 B/DCLINIMIX E 5%/DEXTROSE 15% 2 B/DCLINIMIX E 5%/DEXTROSE 20% 2 B/DCLINIMIX E 5%/DEXTROSE 25% 2 B/DCLINIMIX E INJ 4.25/D10 2 B/DCLINIMIX INJ 4.25/D10 2 B/DCLINIMIX INJ 4.25/D20 2 B/Dclinisol 15 1 B/DFREAMINE HBC 6.9% 2 B/DFREAMINE III 2 B/DHEPATAMINE 2 B/Dhepatasol 8 1 B/DINTRALIPID INJ 20% 2 B/DINTRALIPID INJ 30% 2 B/DNEPHRAMINE 2 B/Dpremasol 1 B/Dpremasol 2 B/DPROCALAMINE 2 B/DPROSOL 2 B/Dtravasol 10 2 B/DTROPHAMINE INJ 10% 2 B/D

IV REPLACEMENT SOLUTIONSDEXTROSE 2.5%/NACL 0.45% 1DEXTROSE 5% 1DEXTROSE 5% /ELECTROLYTE 2



Drug Name Drug Tier Requirements/LimitsDEXTROSE 5%/LACTATED RING 1DEXTROSE 5%/NACL 0.2% 1DEXTROSE 5%/NACL 0.3% 1DEXTROSE 5%/NACL 0.9% 1DEXTROSE 5%/NACL 0.33% 1DEXTROSE 5%/NACL 0.45% 1DEXTROSE 5%/NACL 0.225% 1DEXTROSE 5%/POTASSIUM CHL 1DEXTROSE 10% FLEX CONTAIN 1DEXTROSE 10%/NACL 0.2% 2DEXTROSE 10%/NACL 0.45% 1DEXTROSE 50% 1dextrose inj 70% 1IONOSOL-B/DEXTROSE 5% 2IONOSOL-MB/DEXTROSE 5% 2ISOLYTE P 2isolyte s 2KCL0.15%/D5W/NACL0.2% 1KCL0.15%/D5W/NACL0.225% 2KCL 0.3%/D5W/NACL 0.2% 1KCL 0.3%/D5W/NACL 0.9% 1KCL 0.3%/D5W/NACL 0.45% 1KCL 0.15%/D5W/NACL 0.9% 1KCL 0.075%/D5W/NACL 0.2% 1KCL 0.075%/D5W/NACL 0.45% 1KCL 0.224%/D5W/NACL 0.2% 1KCL/D5W INJ 0.3% 1KCL/NACL INJ 0.3-0.9 1LACTATED RINGER'S INJ 1normosol-m 1NORMOSOL-R 2NORMOSOL-R IN D5W 2PLASMA-LYTE A 2PLASMA-LYTE-56/D5W 2PLASMA-LYTE-148 2POTASSIUM CHLORIDE SOLN10meq/100ml, 20meq/100ml

1

potassium chloride SOLN .4meq/ml,2meq/ml, 10meq/50ml, 40meq/100ml

1

POTASSIUM CHLORIDE 0.15% 1POTASSIUM CHLORIDE 0.22% 1potassium chloride in nacl 1



Drug Name Drug Tier Requirements/LimitsPOTASSIUM CHLORIDE SOLN 30 MEQ/100ML

1

RINGER'S 1SODIUM CHLORIDE SOLN 3%, 5% 1SODIUM CHLORIDE 0.45% VIA 1SODIUM CHLORIDE INJ 0.9% 1

VITAMINScalcitriol CAPS 1 B/Dcalcitriol inj 1 B/Dcalcitriol oral soln 1 mcg/ml 1 B/Dparicalcitol 1 B/Dparicalcitol cap 4 mcg 1 B/DPRENATAL VITAMIN/FOLIC ACID > 0.8 MG(GENERIC)

1

ZEMPLAR INJ 2 B/D

OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONSANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREATINFECTIONS AND INFLAMMATION

bacitracin-poly-neomycin-hc 1blephamide OINT 2neomycin-polymy-dexameth 1neomycin-polymyxin-hc (ophth) 1sulfacetamide sod-prednisolone 1TOBRADEX OINT 2TOBRADEX ST 2tobramycin-dexamethasone 1ZYLET 2

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONSAZASITE 2bacitracin (ophthalmic) 1bacitracin-polymyxin b (ophth) 1BESIVANCE 2CILOXAN OINT 2ciprofloxacin hcl (ophth) 1erythromycin (ophth) 1gatifloxacin (ophth) 1gentak 1gentamicin sulfate (ophth) 1MOXEZA 2NATACYN 2neomycin-bacitracin zn-polymyxin 1neomycin-polymy-gramicid 1



Drug Name Drug Tier Requirements/Limitsofloxacin (ophth) 1polymyxin b-trimethoprim 1sulfacetamide sodium (ophth) 1tobramycin sulfate (ophth) 1TOBREX OINT 2trifluridine SOLN 1VIGAMOX 2

ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATIONALREX 2BROMDAY 2BROMFENAC SODIUM (OPHTH)(ONCE-DAILY)

1

dexamethasone sodium phosphate (ophth) 1diclofenac sodium (ophth) 1DUREZOL 2FLUOROMETHOLONE SUSP 1flurbiprofen sodium 1FML 2FML FORTE 2ILEVRO 2ketorolac tromethamine (ophth) 1LOTEMAX 2MAXIDEX 2NEVANAC 2PRED MILD 2PREDNISOLONE ACETATE SUSP 1prednisolone sodium phosphate (ophth) 2

ANTIALLERGICS - DRUGS TO TREAT ALLERGIESazelastine hcl (ophth) 1BEPREVE 2cromolyn sodium (ophth) 1PATADAY 2PATANOL 2

ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMAALPHAGAN P SOL 0.1% 2AZOPT 2betaxolol hcl (ophth) 1BETOPTIC-S 2brimonidine sol 0.2% 1BRIMONIDINE SOL 0.15% 1carteolol hcl (ophth) 1COMBIGAN 2



Drug Name Drug Tier Requirements/Limitsdorzolamide hcl 1dorzolamide hcl-timolol maleate 1ISOPTO CARPINE 2ISTALOL 2latanoprost 1levobunolol hcl .5% 1LEVOBUNOLOL HCL .25% 1LUMIGAN 2metipranolol 1PHOSPHOLINE IODIDE 2PILOCARPINE HCL SOLN 1timolol maleate (ophth) 1TIMOLOL MALEATE GEL 1TRAVATAN Z 2

MISCELLANEOUSartificial tear ointment 5 NM; *artificial tear solution 5 NM; *GENTEAL SEVERE 5 NM; *hypromellose (ophth) 5 NM; *ISOPTO TEARS 5 NM; *lubricant eye drops 5 NM; *MURO 128 SOLN 2% 5 NM; *naphazoline 0.1% 1polyethylene glycol-propylene glycol(ophth)

5 NM; *

polyvinyl alcohol SOLN 5 NM; *polyvinyl alcohol-povidone (ophth) 5 NM; *PROLENSA 2proparacaine hcl SOLN 1REFRESH CELLUVISC 5 NM; *REFRESH LIQUIGEL 5 NM; *RESTASIS 2 QL (64 vials / 30 days)sodium chloride hypertonic 5 NM; *white petrolatum-mineral oil 5 NM; *

RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERSANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TOTREAT COPD

COMBIVENT RESPIMAT 2 QL (2 inhalers / 30days)

ipratropium-albuterol nebu 1 B/DANTICHOLINERGICS - DRUGS TO TREAT COPD



Drug Name Drug Tier Requirements/LimitsATROVENT HFA 2 QL (2 inhalers / 30

days)ipratropium bromide SOLN 1 B/Dipratropium bromide (nasal) 1SPIRIVA HANDIHALER 2 QL (30 caps / 30 days)

ANTIHISTAMINES - DRUGS TO TREAT ALLERGIESASTEPRO 2azelastine hcl SOLN 137mcg/spray 1azelastine hcl SOLN .15% 1 NMcetirizine syrup 1cyproheptadine hcl SYRP; TABS 1 PAdiphenhydramine inj 1hydroxyzine hcl SOLN; TABS 1 PAhydroxyzine pamoate CAPS 1 PAlevocetirizine dihydrochloride 1PATANASE 2

BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPDalbuterol sulfate NEBU 1 B/Dalbuterol sulfate SYRP; TABS; TB12 1FORADIL AEROLIZER 2 QL (60 caps / 30 days)levalbuterol conc 1.25mg/0.5ml 1 B/DPERFOROMIST 2 B/DPROAIR HFA 2 QL (2 inhalers / 30

days)SEREVENT DISKUS 2 QL (1 inhaler / 30 days)terbutaline sulfate SOLN; TABS 1XOPENEX HFA 2 QL (2 inhalers / 30

days)LEUKOTRIENE RECEPTOR ANTAGONISTS - DRUGS TO TREATASTHMA AND ALLERGIES

montelukast sodium CHEW; PACK; TABS 1zafirlukast 1

MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIEScromolyn sodium nebu 1 B/D

MISCELLANEOUSacetylcysteine SOLN 10%, 20% 1 B/DARALAST NP 2 NM, LA, PAAUVI-Q 2AYR NASAL DROPS 5 NM; *CAYSTON 2 NM, LA, PADALIRESP 2EPIPEN 2-PAK 2



Drug Name Drug Tier Requirements/LimitsEPIPEN-JR 2-PAK 2GLASSIA 2 NM, LA, PAPROLASTIN-C 2 NM, LA, PAPULMOZYME 2 B/D, NMsaline .65% 5 NM; *XOLAIR 2 NM, LA, PAZEMAIRA 2 NM, LA, PA

NASAL STEROIDS - DRUGS TO TREAT ALLERGIESflunisolide spr 0.025% 1 QL (2 bottles / 30 days)fluticasone propionate (nasal) 1 QL (1 bottle / 30 days)NASONEX 2 QL (2 bottles / 30 days)triamcinolone acetonide (nasal) 1 QL (1 bottle / 30 days)

STEROID INHALANTS - DRUGS TO TREAT ASTHMAASMANEX 2 QL (2 inhalers / 30

days)ASMANEX 14 METERED DOSES 2 QL (2 inhalers per 30

days)budesonide (inhalation) 1 B/DFLOVENT DISKUS 50mcg/blist,100mcg/blist

2 QL (2 inhalers / 30days)

FLOVENT DISKUS 250mcg/blist 2 QL (4 inhalers / 30days)

FLOVENT HFA 2 QL (2 inhalers / 30days)

PULMICORT 1mg/2ml 2 B/DQVAR 40mcg/act 2 QL (1 inhaler / 30 days)QVAR 80mcg/act 2 QL (2 inhalers / 30

days)STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREATASTHMA AND COPD

ADVAIR DISKUS 2 QL (1 inhaler / 30 days)ADVAIR HFA 2 QL (1 inhaler / 30 days)BREO ELLIPTA 2 QL (1 kit / 30 days)DULERA 2 QL (1 inhaler / 30 days)SYMBICORT 2 QL (1 inhaler / 30 days)

XANTHINES - DRUGS TO TREAT COPDaminophylline inj 1elixophyllin 2theo-24 2theophylline TB12; TB24 1

TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS



Drug Name Drug Tier Requirements/LimitsDERMATOLOGY, ACNE

adapalene CREA 1adapalene GEL .1% 1amnesteem 1AVITA 1benzoyl peroxide-erythromycin 1claravis 1clindamycin phosphate (topical) GEL;LOTN; SOLN; SWAB

1

ery pad 2% 1erythromycin (acne aid) 1myorisan 1sulfacetamide sodium (acne) 1tretinoin CREA; GEL 1zenatane 1

DERMATOLOGY, ACTINIC KERATOSISCARAC 2diclofenac sodium (actinic keratoses) 1 PAfluorouracil (topical) 1

DERMATOLOGY, ANTIBIOTICSbacitracin (topical) 5 NM; *bacitracin zinc OINT 5 NM; *bacitracin-polymyxin b 5 NM; *gentamicin sulfate (topical) 1mafenide acetate PACK 1mupirocin OINT 1neomycin-bacitracin-polymyxin 5 NM; *neomycin-bacitracin-polymyxin-pramoxine 5 NM; *neomycin-polymyxin w/ pramoxine 5 NM; *SILVER SULFADIAZINE CREA 1SSD 1SULFAMYLON CREA 2THERMAZENE 1

DERMATOLOGY, ANTIFUNGALSciclopirox CREA; GEL; SUSP 1ciclopirox shampoo 1% 1clotrimazole (topical) CREA 1% 1clotrimazole (topical) CREA 1% 5 NM; *clotrimazole (topical) SOLN 1% 1clotrimazole (topical) SOLN 1% 5 NM; *econazole nitrate CREA 1FUNGOID TINCTURE SOLN 5 NM; *



Drug Name Drug Tier Requirements/Limitsketoconazole cream 1miconazole nitrate (topical) 5 NM; *nyamyc 1nystatin (topical) 1nystop 1pedi-dri 1terbinafine hcl (topical) 5 NM; *

DERMATOLOGY, ANTIPRURITICprocto-pak 1proctocream 1proctozone hc 1PRUDOXIN CRE 5% 1ZONALON 2

DERMATOLOGY, ANTIPSORIATICSacitretin 2 PAcalcipotriene CREA; OINT; SOLN 1calcitrene oin 0.005% 1methoxsalen rapid 2 NMOXSORALEN ULTRA 2TAZORAC 2 PA

DERMATOLOGY, ANTISEBORRHEICSketoconazole shampoo 1selenium sulfide LOTN 1

DERMATOLOGY, ANTIVIRALSacyclovir topical 1DENAVIR 2ZOVIRAX CREA 2

DERMATOLOGY, CORTICOSTEROIDSala-cort 1alclometasone dipropionate 1amcinonide CREA; LOTN 1amcinonide OINT 2betamethasone dipropionate (topical) 1betamethasone dipropionate augmented 1betamethasone valerate CREA; LOTN;OINT

1

clobetasol propionate CREA 1clobetasol propionate GEL 1clobetasol propionate OINT 1clobetasol propionate SOLN 1DESONIDE CREA 1desonide LOTN; OINT 1



Drug Name Drug Tier Requirements/Limitsdesoximetasone CREA 1desoximetasone GEL 1DESOXIMETASONE OINT .05% 1desoximetasone OINT .25% 1diflorasone diacetate 1fluocinolone acetonide CREA; OIL; OINT;SOLN

1

fluocinonide CREA .05% 1fluocinonide GEL 1fluocinonide OINT 1fluocinonide SOLN 1fluocinonide emulsified base 1fluticasone propionate CREA 1fluticasone propionate OINT 1halobetasol propionate 1hydrocortisone (topical) CREA 1%, 2.5% 1hydrocortisone (topical) CREA .5%, 1% 5 NM; *hydrocortisone (topical) LOTN 1% 5 NM; *hydrocortisone (topical) LOTN 2.5% 1hydrocortisone (topical) OINT 1% 5 NM; *hydrocortisone (topical) OINT 1%, 2.5% 1hydrocortisone acetate (topical) 5 NM; *hydrocortisone butyrate 1hydrocortisone valerate 1hydrocortisone-aloe vera 5 NM; *LOKARA LOTN 0.05% 1mometasone furoate CREA; OINT; SOLN 1texacort soln 2.5% 2triamcinolone acetonide (topical) 1triderm 1

DERMATOLOGY, LOCAL ANESTHETICSdibucaine 5 NM; *dibucaine (rectal) 5 NM; *lidocaine CREA 4% 5 NM; *lidocaine PTCH 1 QL (3 ptch / 1 day), PAlidocaine hcl GEL 1lidocaine hcl SOLN 4% 1lidocaine oint 5% 1lidocaine-prilocaine 1 B/D

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANEALOE VESTA SKIN CONDITIONER 5 NM; *aluminum sulfate & calcium acetate 5 NM; *



Drug Name Drug Tier Requirements/Limitsammonium lactate CREA; LOTN 1calamine lotn 5 NM; *capsaicin CREA .025%, .075% 5 NM; *chlorhexidine topical liqd 4% 5 NM; *ELIDEL 2 PAhemorrhoidal OINT 5 NM; *hemorrhoidal supp 5 NM; *imiquimod CREA 1laclotion lotn 12% 1lubricants 5 NM; *metronidazole (topical) CREA; LOTN 1metronidazole gel 0.75% 1PANRETIN 2podofilox SOLN 1povidone-iodine OINT 5 NM; *povidone-iodine SOLN 5 NM; *povidone-iodine SWAB 10% 5 NM; *PROSHIELD PLUS SKIN PROTE 5 NM; *PROSHIELD PROTECTIVE HAND 5 NM; *rosadan cre 0.75% 1skin protectants, misc. 5 NM; *TARGRETIN GEL 2 NM, PATRIXAICIN 5 NM; *VALCHLOR 2 NM, LA, PAvitamins a & d (topical) 5 NM; *VOLTAREN 2zinc oxide (topical) 5 NM; *

DERMATOLOGY, SCABICIDES AND PEDICULIDESEURAX 2malathion 1permethrin CREA 1permethrin LOTN 5 NM; *pyrethrins-piperonyl butoxide 5 NM; *

DERMATOLOGY, WOUND CARE AGENTSacetic acid .25% 1REGRANEX 2 PASANTYL 2SEA-CLENS WOUND CLEANSER 5 NM; *SODIUM CHLORIDE 0.9% 1STERILE WATER IRRIGATION 1

MOUTH/THROAT/DENTAL AGENTScevimeline hcl 1



Drug Name Drug Tier Requirements/Limitschlorhexidine gluconate (mouth-throat) 1clotrimazole TROC 1lidocaine hcl (mouth-throat) 1nystatin (mouth-throat) 1periogard 1pilocarpine hcl (oral) 1triamcinolone acetonide (mouth) 1

OTIC - DRUGS TO TREAT CONDITIONS OF THE EARacetic acid (otic) 1acetic acid-aluminum acetate 1carbamide peroxide (otic) 5 NM; *CIPRODEX 2fluocinolone acetonide (otic) 1neomycin-polymyxin-hc (otic) 1ofloxacin (otic) 1


59

Index

Aa-hydrocort 36abacavir sulfate 5abacavir sulfate-lamivudine-zidovudine 6ABELCET 4ABILIFY 25ABILIFY DISCMELT 25ABILIFY MAINTENA 25acamprosate calcium 30acarbose 31acebutolol hcl 16acetaminophen w/ codeine 1acetazolamide 19acetic acid 57acetic acid (otic) 58acetic acid-aluminum acetate 58acetylcysteine 52acitretin 55ACTHIB 45ACTIMMUNE 44acyclovir 6acyclovir sodium 6acyclovir topical 55ADACEL 45ADAGEN 35adapalene 54ADCIRCA 20adefovir dipivoxil 6ADEMPAS 20adriamycin 10adrucil 10adrucil inj 500/10ml 10ADVAIR DISKUS 53ADVAIR HFA 53afeditab cr 17AFINITOR 12AFINITOR DISPERZ 12AGGRENOX 43ala-cort 55ALBENZA 3albuterol sulfate 52alclometasone dipropionate 55ALCOHOL SWABS 31ALDURAZYME 35alendronate sodium 32alfuzosin hcl 41ALIMTA 10ALINIA 3allopurinol tab 1ALOE VESTA SKIN CONDITIONER 56ALPHAGAN P SOL 0.1% 50alprazolam 20alprazolam tab 0.25mg 20alprazolam tab 0.5mg 20alprazolam tab 1mg 20alprazolam tab 2mg 20ALREX 50

altavera 33alum & mag hydrox-simethicone 38ALUMINUM HYDROXIDE 38aluminum hydroxide-mag carb 38aluminum sulfate & calcium acetate 56amantadine hcl 25AMBISOME 4amcinonide 55amifostine crystalline 13amikacin sulfate 3amiloride & hydrochlorothiazide 19amiloride hcl 19aminophylline inj 53AMINOSYN 46AMINOSYN 7%/ELECTROLYTES 46AMINOSYN 8.5%/ELECTROLYTE 47AMINOSYN II 47AMINOSYN II 8.5%/ELECTROL 47AMINOSYN M 47AMINOSYN-HBC 47AMINOSYN-PF 47AMINOSYN-PF 7% 47AMINOSYN-RF 47amiodarone hcl 15AMITIZA CAP 24MCG 41AMITIZA CAP 8MCG 40amitriptyline hcl 23amlodipine besylate 17amlodipine-benazepril hcl cap 10-20mg 13amlodipine-benazepril hcl cap 10-40mg 13amlodipine-benazepril hcl cap 2.5-10mg 13amlodipine-benazepril hcl cap 5-10mg 13amlodipine-benazepril hcl cap 5-20mg 13amlodipine-benazepril hcl cap 5-40mg 13ammonium lactate 57amnesteem 54amoxapine tab 100mg 23amoxapine tab 150mg 23amoxapine tab 25mg 23amoxapine tab 50mg 23amoxicillin 8amoxicillin & pot clavulanate 9amoxicillin-clarithromycin w/

lansoprazole 41amphetamine-dextroamphetamine cap sr

24hr 10 mg 27amphetamine-dextroamphetamine cap sr





24hr 5 mg 27amphetamine-dextroamphetamine tab 10

mg 27amphetamine-dextroamphetamine tab

12.5 mg 27amphetamine-dextroamphetamine tab 15


60

mg 27amphetamine-dextroamphetamine tab 20



mg 27amphetamine-dextroamphetamine tab 7.5

mg 27amphotericin b 4ampicillin 9ampicillin & sulbactam sodium 9ampicillin inj 9ampicillin sodium 9AMTURNIDE 150-5-12.5MG 18AMTURNIDE 300-10-12.5MG 18AMTURNIDE 300-10-25MG 18AMTURNIDE 300-5-12.5MG 18AMTURNIDE 300-5-25MG 18anagrelide hcl 43anastrozole tab 1mg 11ANDRODERM 30androxy 30APOKYN 25apri 28 day 33APRISO 39APTIOM TAB 200MG 20APTIOM TAB 400MG 20APTIOM TAB 600MG 20APTIOM TAB 800MG 20APTIVUS 5ARALAST NP 52aranelle 28 33ARANESP ALBUMIN FREE 43ARCALYST 44artificial tear ointment 51artificial tear solution 51ASACOL HD 39ASMANEX 53ASMANEX 14 METERED DOSES 53ASTEPRO 52atenolol 16atenolol & chlorthalidone 16atorvastatin calcium 15atovaquone 3atovaquone-proguanil hcl tab 250-100

mg 5atovaquone-proguanil hcl tab 62.5-25 mg5ATRIPLA 6ATROVENT HFA 52AUVI-Q 52AVASTIN 11aviane 28 33AVITA 54AVODART 41AVONEX 29AVONEX PEN 29AYR NASAL DROPS 52azacitidine 10AZACTAM 3

AZACTAM/DEX INJ 1GM 3AZACTAM/DEX INJ 2GM 3AZASITE 49azathioprine 45azelastine hcl 52azelastine hcl (ophth) 50AZILECT 25AZITHROMYCIN 8azithromycin 8AZOPT 50AZOR 10-40MG 14AZOR TAB 10-20MG 14AZOR TAB 5-20MG 14AZOR TAB 5-40MG 14aztreonam 3

Bbacitracin (ophthalmic) 49bacitracin (topical) 54bacitracin zinc 54bacitracin-poly-neomycin-hc 49bacitracin-polymyxin b 54bacitracin-polymyxin b (ophth) 49baclofen 29balsalazide disodium 39balziva 28 day 33BANZEL 20BARACLUDE 7BCG VACCINE 45benazepril & hydrochlorothiazide 13benazepril hcl 13BENEFIBER 40BENICAR 15BENICAR HCT 40-25MG 14BENICAR HCT TAB 20-12.5MG 14BENICAR HCT TAB 40-12.5MG 14benzoyl peroxide-erythromycin 54benztropine mesylate 25BEPREVE 50BESIVANCE 49betamethasone dipropionate (topical) 55betamethasone dipropionate augmented55betamethasone valerate 55BETASERON 29betaxolol hcl (ophth) 50bethanechol chloride 41BETOPTIC-S 50bicalutamide 11BICILLIN C-R 9BICILLIN L-A 9BICNU 9BILTRICIDE 3bisacodyl 40bismuth subsalicylate 38bisoprolol & hydrochlorothiazide 16bisoprolol fumarate 16BIVIGAM 44bleomycin sulfate 10blephamide 49


61

BOOSTRIX 45BOSULIF 12BREO ELLIPTA 53briellyn 28 day 33BRILINTA 43BRIMONIDINE SOL 0.15% 50brimonidine sol 0.2% 50BRINTELLIX 23BROMDAY 50BROMFENAC SODIUM (OPHTH)(ONCE-

DAILY) 50bromocriptine mesylate 25budeprion 23budesonide (inhalation) 53budesonide ec 39bumetanide 19BUPHENYL 35buprenorphine hcl 30buprenorphine hcl-naloxone hcl dihydrate

sl 30buproban 30bupropion hcl 23buspirone hcl 20BUSULFEX 9butorphanol tartrate 1BYSTOLIC 16

Ccabergoline 37cafergot tab 1-100mg 28calamine lotn 57calcipotriene 55calcitonin (salmon) 37calcitrene oin 0.005% 55calcitriol 49calcitriol inj 49calcitriol oral soln 1 mcg/ml 49calcium acetate (phosphate binder) 37calcium carbonate (antacid) 38calcium carbonate-mag hydrox 38calcium polycarbophil (fiber laxative) 40camila 28 day 33CANASA 39CANCIDAS 4CAPASTAT SULFATE 6CAPRELSA 12capsaicin 57captopril 13captopril & hydrochlorothiazide 13CARAC 54CARAFATE 41CARBAGLU 35carbamazepine 21carbamide peroxide (otic) 58carbidopa 25carbidopa-levodopa 25CARBIDOPA/LEVODOPA/ENTACAPONE 25carboplatin 13CARIMUNE NANOFILTERED 44carteolol hcl (ophth) 50

cartia 17carvedilol 16CAYSTON 52CEENU CAP 10MG 9CEENU CAP 40MG 9cefaclor 7cefaclor monohydrate 7cefadroxil 7cefazolin in d5w 7cefazolin inj 7cefazolin sodium 7cefdinir 7cefepime hcl 7cefotaxime sodium 7cefoxitin sodium 7cefpodoxime proxetil 7cefprozil 7ceftazidime solr 7CEFTAZIDIME/DEXTROSE 7ceftriaxone sodium 7cefuroxime axetil 8cefuroxime sodium 8CELEBREX 1CELLCEPT 45CELONTIN 21cephalexin 8CEREZYME 35CERVARIX 45cetirizine syrup 52cevimeline hcl 57CHANTIX 30CHANTIX STARTER PACK 30CHEMET 33chlorhexidine gluconate (mouth-throat) 58chlorhexidine topical liqd 4% 57chloroquine phosphate 5chlorothiazide 19chlorpromazine hcl 25chlorthalidone 19cholestyramine 16cholestyramine light 16choline fenofibrate 16ciclopirox 54ciclopirox shampoo 1% 54cilostazol 43CILOXAN 49CIPRO 8CIPRODEX 58ciprofloxacin 8ciprofloxacin er 8ciprofloxacin hcl (ophth) 49ciprofloxacin hcl tab 8ciprofloxacin in d5w 8ciprofloxacin inj 8cisplatin soln 13citalopram hydrobromide 23, 24cladribine 10claravis 54clarithromycin 8clarithromycin er 8


62

clarithromycin for susp 8CLEOCIN 42clindamycin cap 300mg 3clindamycin cap 75mg 3clindamycin hcl cap 150 mg 3clindamycin phosphate (topical) 54clindamycin phosphate inj 3clindamycin phosphate vaginal 42clindamycin sol 75mg/5ml 3CLINIMIX 2.75%/DEXTROSE 5% 47CLINIMIX 4.25%/DEXTROSE 25% 47CLINIMIX 4.25%/DEXTROSE 5% 47CLINIMIX 5%/DEXTROSE 15% 47CLINIMIX 5%/DEXTROSE 20% 47CLINIMIX 5%/DEXTROSE 25% 47CLINIMIX E 2.75%/DEXTROSE 10% 47CLINIMIX E 2.75%/DEXTROSE 5% 47CLINIMIX E 4.25%/DEXTROSE 25% 47CLINIMIX E 4.25%/DEXTROSE 5% 47CLINIMIX E 5%/DEXTROSE 15% 47CLINIMIX E 5%/DEXTROSE 20% 47CLINIMIX E 5%/DEXTROSE 25% 47CLINIMIX E INJ 4.25/D10 47CLINIMIX INJ 4.25/D10 47CLINIMIX INJ 4.25/D20 47clinisol 15 47clobetasol propionate 55clomipramine hcl 24clonazepam 21clonidine hcl 19clopidogrel bisulfate 43clorazepate dipotassium 21clotrimazole 58clotrimazole (topical) 54clotrimazole vaginal 42clozapine 25CLOZAPINE ODT 25COARTEM 5colchicine w/ probenecid 1COLCRYS 1colestipol hcl 16colistimethate sodium 4colocort 39COMBIGAN 50COMBIPATCH 36COMBIVENT RESPIMAT 51COMETRIQ 12COMPLERA 6compro 38COMVAX 45constulose 40COPAXONE INJ 40MG/ML 29COPAXONE KIT 20MG/ML 29cortisone acetate 36COSMEGEN 10COUMADIN 42CREON 41CRESTOR 15CRIXIVAN 5cromolyn sodium (mastocytosis) 41

cromolyn sodium (ophth) 50cromolyn sodium nebu 52cryselle 28 33CUBICIN 4CUVPOSA 39cyclafem 1/35 28 day 33cyclafem 7/7/7 28 day 33cyclophosphamide 9cycloserine 6cyclosporine 45cyclosporine modified (for

microemulsion) 45cyproheptadine hcl 52CYSTADANE 35CYSTAGON 35cytarabine 10

Ddacarbazine 9DALIRESP 52danazol 35dantrolene sodium 29dapsone 4DAPTACEL 45DARAPRIM 4daunorubicin hcl 10daunorubicin hcl for inj 20 mg 10DECAVAC 45DELZICOL 39DENAVIR 55DEPO-PROVERA INJ 400/ML 11desipramine hcl 24desmopressin acetate spray 38desmopressin acetate spray refrigerated38desmopressin acetate tabs 38desmopressin inj 4mcg/ml 38DESMOPRESSIN SOL 0.01% 38DESONIDE 55desonide 55DESOXIMETASONE 56desoximetasone 56dexamethasone 36dexamethasone sodium phosphate 36dexamethasone sodium phosphate

(ophth) 50DEXILANT 41dexrazoxane 13DEXTROSE 10% FLEX CONTAIN 48DEXTROSE 10%/NACL 0.2% 48DEXTROSE 10%/NACL 0.45% 48DEXTROSE 2.5%/NACL 0.45% 47DEXTROSE 5% 47DEXTROSE 5% /ELECTROLYTE 47DEXTROSE 5%/LACTATED RING 48DEXTROSE 5%/NACL 0.2% 48DEXTROSE 5%/NACL 0.225% 48DEXTROSE 5%/NACL 0.3% 48DEXTROSE 5%/NACL 0.33% 48DEXTROSE 5%/NACL 0.45% 48DEXTROSE 5%/NACL 0.9% 48


63

DEXTROSE 5%/POTASSIUM CHL 48DEXTROSE 50% 48dextrose inj 70% 48diazepam 21DIAZEPAM GEL 21diazepam inj 21DIBENZYLINE 19dibucaine 56dibucaine (rectal) 56diclofenac potassium 1diclofenac sodium 1diclofenac sodium (actinic keratoses) 54diclofenac sodium (ophth) 50dicloxacillin sodium 9dicyclomine hcl 39didanosine 5DIFICID 8diflorasone diacetate 56diflunisal 1digoxin 18DIGOXIN SOL 50MCG/ML 18digoxin tab 0.125mg 18digoxin tab 0.25mg 18dihydroergotamine mesylate 28dilantin 21DILANTIN-125 SUS 125/5ML 21dilt 17dilt-cd cap 120mg 17dilt-cd cap 180mg 17dilt-cd cap 240mg 17dilt-cd cap 300mg 17diltiazem cap 17diltiazem cap 120mg er 17diltiazem cap 120mg/24 17diltiazem cap 60mg er 17diltiazem cap 90mg er 17diltiazem hcl 17diltiazem hcl coated beads 17diltiazem inj 50/10ml 17diltiazem tab 120mg 17diltiazem tab 30mg 17diltiazem tab 60mg 17diltiazem tab 90mg 17diltzac 17dimenhydrinate 38DIOVAN 15DIPENTUM 39diphenhydramine inj 52diphenoxylate w/ atropine 41DIPHTHERIA/TETANUS TOXOID 45disopyramide phosphate 15disulfiram 30DIURIL SUS 250/5ML 19divalproex sodium 21DOCETAXEL 10, 11docetaxel 10docusate calcium 40docusate sodium 40donepezil hydrochloride 23DORIBAX 4

dorzolamide hcl 51dorzolamide hcl-timolol maleate 51doxazosin mesylate 14doxepin hcl 24DOXIL INJ 2MG/ML 10doxorubicin hcl 10doxorubicin hcl liposomal 10doxycycline (monohydrate) 9doxycycline hyclate 9dronabinol 38drospirenone-ethinyl estradiol 33DROXIA 12DULERA 53duloxetine hcl 24DURAMORPH 2DUREZOL 50DYRENIUM 19

Ee.e.s. 8E.E.S. GRANULES 8econazole nitrate 54EDECRIN 19EDURANT 5EFFIENT 43ELAPRASE 35ELELYSO 35ELIDEL 57ELIQUIS 42ELITEK 13elixophyllin 53ELLA 33ELMIRON 41EMCYT 9EMEND 38EMEND PAK 80 & 125 38emoquette 33EMSAM 24EMTRIVA 5enalapril maleate 13enalapril maleate & hydrochlorothiazide 13ENBREL 44ENBREL SURECLICK 44endocet 10/325 2endocet 5/325 2endocet 7.5/325 2ENDODAN 2ENGERIX-B 45enoxaparin sodium 42enpresse 28 day 33entacapone 25enulose 40EPIPEN 2-PAK 52EPIPEN-JR 2-PAK 53epirubicin hcl 10epitol 21EPIVIR 5EPIVIR HBV 7eplerenone tab 14


64

EPZICOM 6ERAXIS 4ERIVEDGE 11errin 28 day 33ery pad 2% 54ery-tab 8ERYPED 200 8ERYPED 400 8erythrocin stearate 8erythromycin (acne aid) 54erythromycin (ophth) 49erythromycin base 8erythromycin ethylsuccinate 8erythromycin-sulfisoxazole for susp 200-

600 mg/5ml 4escitalopram oxalate 24esomeprazole inj 41estradiol 36ESTRADIOL VALERATE 36estradiol valerate 36eszopiclone 28ethambutol hcl 6ethosuximide 21etodolac 1etoposide 13EURAX 57EXELON 23exemestane tab 25mg 11EXFORGE 10-320MG 14EXFORGE HCT 10 160 12.5MG 14EXFORGE HCT 10 160 25MG 14EXFORGE HCT 10-320-25MG 14EXFORGE HCT 5 160 12.5MG 14EXFORGE HCT 5 160 25MG 14EXFORGE TAB 10-160MG 14EXFORGE TAB 5-160MG 14EXFORGE TAB 5-320MG 14EXJADE 33

FFABRAZYME 35famciclovir 7famotidine 39famotidine inj 39FANAPT 25FANAPT TITRATION PACK 26FARESTON 11FASLODEX 11FAZACLO 26felbamate 21felodipine 17fenofibrate 16FENOFIBRATE MICRONIZED 16fenofibrate micronized 16fentanyl 2fentanyl citrate 2ferrous sulfate 43FETZIMA 24FETZIMA TITRATION PACK 24

finasteride 41FLEBOGAMMA 44FLEBOGAMMA DIF 44flecainide acetate 15FLOVENT DISKUS 53FLOVENT HFA 53fluconazole 4fluconazole in dextrose 4fluconazole in nacl 4flucytosine 4fludarabine phosphate 10fludrocortisone acetate 36flunisolide spr 0.025% 53fluocinolone acetonide 56fluocinolone acetonide (otic) 58fluocinonide 56fluocinonide emulsified base 56FLUOROMETHOLONE SUSP 50fluorouracil 10fluorouracil (topical) 54fluoxetine hcl 24fluphenazine decanoate 26fluphenazine hcl 26flurbiprofen 1flurbiprofen sodium 50flutamide 11fluticasone propionate 56fluticasone propionate (nasal) 53fluvoxamine maleate 20FML 50FML FORTE 50fondaparinux sodium 42FORADIL AEROLIZER 52FORFIVO XL 24FORTEO 37FORTICAL 37fosinopril sodium 13fosinopril sodium & hydrochlorothiazide 13FOSRENOL 37FREAMINE HBC 6.9% 47FREAMINE III 47FUNGOID TINCTURE 54furosemide 19furosemide inj 19FUZEON 5FYCOMPA 21, 22

Ggabapentin 22GABITRIL 22galantamine hydrobromide 23GAMASTAN S/D 44GAMMAGARD LIQUID 44GAMMAGARD S/D 44GAMMAKED 44GAMMAPLEX 44GAMUNEX 44GAMUNEX-C 44GAMUNEX-C 1GM/10ML 44


65

ganciclovir inj 500mg 7GARDASIL 45gatifloxacin (ophth) 49GAUZE PADS 2" X 2" 31gaviltye-g 40gavilyte-c 40gavilyte-n 40GAVISCON 38GEMCITABINE HCL 10gemcitabine hcl 10gemfibrozil 16generlac 40gengraf 45gentak 49gentamicin in saline 3gentamicin sulfate 3gentamicin sulfate (ophth) 49gentamicin sulfate (topical) 54GENTEAL SEVERE 51GEODON 26GIANVI 33gildagia 33GILENYA 29GILOTRIF 12GLASSIA 53GLEEVEC 12glimepiride 31glip/metform tab 2.5-250m 31glip/metform tab 2.5-500m 31glip/metform tab 5-500mg 31glipizide 31GLUCAGEN HYPOKIT 36GLUCAGON EMERGENCY KIT 36glucose chew tab 36glucose gel 40% 36glyb/metform tab 1.25-250 31glyb/metform tab 2.5-500 31glyb/metform tab 5-500mg 32glyburide 32glyburide micronized 32glycerin (laxative) 40glycopyrrolate 39glycopyrrolate inj 39GOLYTELY 40granisetron hcl 38GRANIX 43griseofulvin microsize 4griseofulvin ultramicrosize 4

HHALFLYTELY BOWEL PREP/FLA 40halobetasol propionate 56haloperidol 26haloperidol decanoate 26haloperidol lactate 26HAVRIX 45heather 33hemorrhoidal 57hemorrhoidal supp 57

heparin sod inj 1000/ml 42heparin sod inj 10000/ml 43HEPARIN SOD INJ 2000/ML 42heparin sod inj 20000/ml 43HEPARIN SOD INJ 2500/ML 42heparin sod inj 5000/ml 42HEPARIN SODIUM/D5W 43HEPARIN SODIUM/NACL 0.45% 43HEPARIN SODIUM/SODIUM CHL 43HEPATAMINE 47hepatasol 8 47HERCEPTIN 11HEXALEN 9HIBERIX 45HUMIRA 44HUMIRA PEN 44HUMIRA PEN-CROHNS DISEASE STARTER

KIT 44HUMIRA PEN-PSORIASIS STARTER KIT 44HUMULIN R INJ U-500 31hydralazine hcl soln 19hydralazine hcl tab 19hydrochlorothiazide 19hydroco/apap tab 10-325mg 1hydroco/apap tab 5-325mg 1hydroco/apap tab 7.5-325 1hydrocodone-acetaminophen 7.5-325

mg/15ml 1hydrocodone-ibuprofen 7-5-200mg 1hydrocortisone 36HYDROCORTISONE (INTRARECTAL) 39hydrocortisone (topical) 56hydrocortisone acetate (topical) 56hydrocortisone butyrate 56hydrocortisone valerate 56hydrocortisone-aloe vera 56hydromorphon inj 10mg/ml 2hydromorphone hcl 2hydroxychloroquine sulfate 44hydroxyurea 12hydroxyzine hcl 52hydroxyzine pamoate 52hypromellose (ophth) 51

Iibandronate sodium 33ibuprofen 1ICLUSIG 12idarubicin hcl 10IFEX 9ifosfamide inj 1gm 9ifosfamide inj 1gm/20ml 9IFOSFAMIDE INJ 3GM 10ifosfamide inj 3gm/60ml 10ILEVRO 50IMBRUVICA 12imipenem-cilastatin 4imipramine hcl 24imiquimod 57IMOVAX RABIES (H.D.C.V.) 45


66

INCIVEK 7INCRELEX 37indapamide 19INFANRIX 45INLYTA 12INSULIN PEN NEEDLE 31INSULIN SAFETY NEEDLES 31INSULIN SYRINGE 31INTELENCE 5INTRALIPID INJ 20% 47INTRALIPID INJ 30% 47INTRON-A 44INTRON-A W/DILUENT 44introvale 91 day 33INTUNIV 27INVANZ 4INVEGA 26INVEGA SUSTENNA 26INVIRASE 5INVOKANA 32IONOSOL-B/DEXTROSE 5% 48IONOSOL-MB/DEXTROSE 5% 48IPOL INACTIVATED IPV 45ipratropium bromide 52ipratropium bromide (nasal) 52ipratropium-albuterol nebu 51irinotecan hcl 13ISENTRESS 5ISOLYTE P 48isolyte s 48isoniazid 6isoniazid inj 100 mg/ml 6isoniazid syp 50mg/5ml 6ISOPTO CARPINE 51ISOPTO TEARS 51isosorb mononitrate tab 19isosorbide dinitrate 19isosorbide dinitrate sl tab 2.5 mg 19isosorbide mononitrate 19isradipine 17ISTALOL 51ISTODAX 11itraconazole 5IXIARO 45

JJAKAFI 12JALYN 41jantoven 43JANUMET 32JANUMET XR TAB 100-1000 32JANUMET XR TAB 50-1000 32JANUMET XR TAB 50-500MG 32JANUVIA 32JENTADUETO 32JOLIVETTE 33junel 1.5/30 21 day 33junel 1/20 21 day 33junel fe 1.5/30 28 day 33

junel fe 1/20 28 day 34

KKADCYLA 11KADIAN 2KALETRA SOL 6KALETRA TAB 100-25MG 6KALETRA TAB 200-50MG 6kariva 28 day 34KCL 0.075%/D5W/NACL 0.2% 48KCL 0.075%/D5W/NACL 0.45% 48KCL 0.15%/D5W/NACL 0.9% 48KCL 0.224%/D5W/NACL 0.2% 48KCL 0.3%/D5W/NACL 0.2% 48KCL 0.3%/D5W/NACL 0.45% 48KCL 0.3%/D5W/NACL 0.9% 48KCL/D5W INJ 0.3% 48KCL/NACL INJ 0.3-0.9 48KCL0.15%/D5W/NACL0.2% 48KCL0.15%/D5W/NACL0.225% 48kelnor 1/35 28 day 34ketoconazole 5ketoconazole cream 55ketoconazole shampoo 55ketoprofen 1ketorolac tromethamine (ophth) 50kionex 33KLOR-CON 10 46KLOR-CON 8 46klor-con m15 46klor-con m20 46klor-con pow 20meq 46KONSYL-D 40KUVAN 35

Llabetalol hcl 16laclotion lotn 12% 57LACTATED RINGER'S INJ 48lactulose 40lactulose (encephalopathy) 40lamivudine 5, 7lamivudine-zidovudine 6lamotrigine 22LANOXIN TAB 0.125MG 18LANOXIN TAB 0.25MG 18LANTUS 31LANTUS SOLOSTAR 31larin 1/20 34larin fe 1.5/30 34larin fe 1/20 34latanoprost 51LATUDA 26LAZANDA 2LEENA 34leflunomide 44lessina 28 day 34LETAIRIS 20letrozole tab 2.5mg 11


67

leucovorin calcium 13leucovorin calcium inj 10 mg/ml 13LEUKERAN 10LEUKINE 43leuprolide acetate 11levalbuterol conc 1.25mg/0.5ml 52LEVEMIR 31LEVEMIR FLEXPEN 31LEVEMIR FLEXTOUCH 31levetiracetam 22LEVOBUNOLOL HCL 51levobunolol hcl 51levocarnitine (metabolic modifiers) 35levocetirizine dihydrochloride 52levofloxacin 8levofloxacin in d5w 8levofloxacin inj 25mg/ml 8levofloxacin oral soln 25 mg/ml 8levonest 28 day 34levonorgestrel (emergency oc) 34levonorgestrel-ethinyl estradiol (91-

day) 34levora 0.15/30 28 day 34levothyroxine sodium 37LEVOXYL 37LEXIVA 5LIALDA 39lidocaine 56lidocaine hcl 56lidocaine hcl (local anesth.) 3lidocaine hcl (mouth-throat) 58lidocaine inj 0.5% 3lidocaine inj 1% 3lidocaine inj 1.5% 3lidocaine inj 2% 3lidocaine oint 5% 56lidocaine-prilocaine 56LINZESS CAP 145MCG 41LINZESS CAP 290MCG 41liothyronine sodium 37lisinopril 13lisinopril & hydrochlorothiazide 13lithium carbonate 28lithium carbonate er 28LITHIUM CITRATE 28LOKARA LOTN 0.05% 56LOMUSTINE 10loperamide hcl 38, 41lorazepam 20lorcet hd tab 10-325mg 1lorcet plus tab 7.5-325 1lorcet tab 5-325mg 1lortab 2loryna 28 day 34losartan potassium 15losartan-hctz 100-12.5mg 14losartan-hctz 100-25 mg 14losartan-hctz 50-12.5mg 14LOTEMAX 50LOTRONEX 41

lovastatin 15LOVAZA 16low-ogestrel 28 day 34loxapine succinate 26lubricant eye drops 51lubricants 57LUMIGAN 51LUMIZYME 36LUPR DEP-PED INJ 11.25MG (3-MONTH)11LUPR DEP-PED INJ 30MG (3-MONTH) 11LUPRON DEPOT 11LUPRON DEPOT-PED 11lutera 28 day 34LYRICA 22LYSODREN 11lyza 34

MM-M-R II W/DILUENT 10 DOS 45MACRODANTIN 4mafenide acetate 54magnesium hydroxide 40MAGNESIUM SULFATE 46MAGNESIUM SULFATE IN D5W 46magnesium sulfate inj 50% 46malathion 57maprotiline hcl 24marlissa 28 day 34MARPLAN 24MATULANE 12matzim 17MAXIDEX 50meclizine hcl 38medroxyprogesterone acetate 150

mg/ml 34medroxyprogesterone acetate tab 37mefloquine hcl 5MEGACE ES 11megestrol acetate 11MEKINIST 12meloxicam 1MELOXICAM SUSP 7.5 MG/5ML 1melphalan hcl 10MENACTRA 45menest 36MENHIBRIX 46MENOMUNE-A/C/Y/W-135 46MENVEO 46mercaptopurine 10meropenem 4mesalamine 39mesalamine w/ cleanser 39mesna 13MESNEX 13MESTINON 28MESTINON TIMESPAN 28metadate tab 20mg er 27metformin hcl 32methadone hcl 2


68

methazolamide 19methenamine hippurate 4methimazole 37methotrexate sodium inj 10methotrexate sodium tabs 44methoxsalen rapid 55methyclothiazide 19methylcellulose (laxative) 40methylergonovine maleate 37methylphenidate hcl 27methylphenidate hcl oral soln 27methylprednisolone 36methylprednisolone acetate 36methylprednisolone sod succ 36methylprednisolone tab 4mg dose pack 36metipranolol 51metoclopramide hcl 39metoclopramide inj 39metolazone 19metoprolol & hydrochlorothiazide 16metoprolol succinate 16metoprolol tartrate 16METRO IV 4metronidazole 4metronidazole (topical) 57metronidazole gel 0.75% 57metronidazole in nacl 4metronidazole vaginal 42mexiletine hcl 15miconazole nitrate (topical) 55miconazole nitrate vaginal 42microgestin 1.5/30 21 day 34microgestin 1/20 21 day 34microgestin fe 1.5/30 28 day 34microgestin fe 1/20 28 day 34midodrine hcl 19minitran 19minocycline hcl 9minoxidil 19mirtazapine 24misoprostol 41mitomycin 10mitomycin inj 20mg 10mitoxantrone hcl 12modafinil 29moderiba pak 7moderiba tab 200mg 7moexipril hcl 14moexipril-hydrochlorothiazide 13mometasone furoate 56MONONESSA 34montelukast sodium 52morphine ext-rel tab 2MORPHINE SUL INJ 2morphine sul inj 2MORPHINE SULFATE 2morphine sulfate 2morphine sulfate beads cap sr 2MORPHINE SULFATE ORAL SOL 2MOVIPREP 40

MOXEZA 49MOZOBIL 43MULTAQ 15mupirocin 54MURO 128 51MUSTARGEN 10my way 34MYCAMINE 5mycophenolate mofetil 45mycophenolate sodium 45myorisan 54MYOZYME 36MYRBETRIQ 42myzilra 34

Nnabumetone 1nadolol 16nafcillin sodium 9NAGLAZYME 36naloxone hcl 30naltrexone hcl 30NAMENDA 23NAMENDA TITRATION PAK 23NAMENDA XR 23NAMENDA XR TITRATION PACK 23naphazoline 0.1% 51naproxen 1naproxen sodium 1naratriptan hcl 28NASONEX 53NATACYN 49nateglinide 32NEBUPENT 4necon 0.5/35 28 day 34necon 1/35 28 day 34necon 10/11 28 day 34NECON 7/7/7 34NECON TAB 1/50-28 34nefazodone hcl 24neomycin sulfate 3neomycin-bacitracin zn-polymyxin 49neomycin-bacitracin-polymyxin 54neomycin-bacitracin-polymyxin-

pramoxine 54neomycin-polymy-dexameth 49neomycin-polymy-gramicid 49neomycin-polymyxin w/ pramoxine 54neomycin-polymyxin-hc (ophth) 49neomycin-polymyxin-hc (otic) 58NEORAL 45NEPHRAMINE 47NEUMEGA 43NEUPOGEN 43NEUPRO 25NEVANAC 50NEVIRAPINE 5nevirapine 5NEXAVAR 12


69

NEXIUM 41NEXIUM CAPS 41next choice one dose 34niacin er 16nicardipine hcl 17nicotine patch 30nicotine polacrilex 30NICOTROL INHALER 30NICOTROL NS 30nifediac cc tab 30mg er 18nifediac cc tab 60mg er 18nifedical 18nifedipine 18nifedipine er 18NILANDRON 11nimodipine 18NIPENT 10nitro-bid 19NITRO-DUR DIS 0.3MG/HR 19NITRO-DUR DIS 0.8MG/HR 19nitrofurantoin macrocrystal 4nitrofurantoin monohyd macro 4nitroglycerin 19NITROLINGUAL PUMPSPRAY 20NITROSTAT 20NORA-BE 34NORDITROPIN FLEXPRO 37NORDITROPIN NORDIFLEX PEN 37norethindrone (contraceptive) 34norethindrone acetate 37norgestimate-ethinyl estradiol

(triphasic) 34NORINYL 1+50 34normosol-m 48NORMOSOL-R 48NORMOSOL-R IN D5W 48NORPACE CR 15nortrel 0.5/35 28 day 34nortrel 1/35 21 day 34nortrel 1/35 28 day 34nortrel 7/7/7 28 day 34nortriptyline hcl 24NORVIR 5NOVOLIN 70/30 31NOVOLIN N 31NOVOLIN R 31NOVOLOG 31NOVOLOG FLEXPEN 31NOVOLOG MIX 70/30 31NOVOLOG MIX 70/30 PREFILL 31NOVOLOG PENFILL 31NOXAFIL 5NUEDEXTA 29NULOJIX 45NULYTELY/FLAVOR PACKS 40NUTRISOURCE FIBER 40NUVARING 34NUVIGIL 29, 30nyamyc 55NYMALIZE 18

nystatin 5nystatin (mouth-throat) 58nystatin (topical) 55nystop 55

OOCELLA 34OCTAGAM 44octreotide acetate 37ofloxacin (ophth) 50ofloxacin (otic) 58ogestrel 28 day 34olanzapine 26OLYSIO 7omega-3-acid ethyl esters 16omeprazole 41ondansetron hcl 39ondansetron hcl inj 39ondansetron hcl oral soln 39ondansetron odt 39ONFI SUS 2.5MG/ML 22ONFI TAB 10MG 22ONFI TAB 20MG 22oral electrolytes 46ORAP 26ORFADIN 36orsythia 28 day 35ORTHO TRI-CYCLEN LO 35oxacillin sodium 9oxaliplatin 13oxandrolone 30oxaprozin 1oxcarbazepine 22OXSORALEN ULTRA 55oxybutynin chloride 42OXYCODONE HCL 2oxycodone hcl 2oxycodone hcl tab 5 mg 2oxycodone w/ acetaminophen 10-325mg 3oxycodone w/ acetaminophen 2.5-325mg2oxycodone w/ acetaminophen 5-325mg 2oxycodone w/ acetaminophen 7.5-325mg3oxycodone-aspirin 3

Ppacerone 15paclitaxel 11pamidronate disodium 33PANRETIN 57pantoprazole sodium 41paricalcitol 49paricalcitol cap 4 mcg 49paromomycin sulfate 3paroxetine hcl 24paroxetine hcl er 24paser d/r 6PATADAY 50PATANASE 52PATANOL 50


70

PAXIL 24pedi-dri 55PEDVAX HIB 46peg 3350-kcl-sod bicarb-sod chloride-sod

sulfate 40peg 3350-potassium chloride-sod

bicarbonate-sod chloride 40PEG 3350/ELECTROLYTES 40PEG-INTRON 44PEG-INTRON REDIPEN 44PEGANONE 22PENICILLIN G POT IN DEXTROSE 9penicillin g potassium 9penicillin g procaine 9penicillin g sodium 9penicillin v potassium 9penicilln gk inj 5mu 9PENTAM 300 4PENTASA 39pentoxifylline 43PERFOROMIST 52perindopril erbumine 14periogard 58permethrin 57perphenazine 26phenelzine sulfate 24phenobarbital 22PHENOBARBITAL SODIUM 22phenobarbital sodium 22phenytek 22phenytoin 22phenytoin sodium 22phenytoin sodium extended 22philith 35PHOSLYRA 37PHOSPHOLINE IODIDE 51PILOCARPINE HCL 51pilocarpine hcl (oral) 58pimtrea pack 35pindolol 16pioglitazone hcl 32pioglitazone hcl-glimepiride 32pioglitazone hcl-metformin hcl 32piperacillin sodium-tazobactam sodium 9pirmella 1/35 28 day 35piroxicam 1PLASMA-LYTE A 48PLASMA-LYTE-148 48PLASMA-LYTE-56/D5W 48podofilox 57polyethylene glycol 3350 40polyethylene glycol-propylene glycol

(ophth) 51polymyxin b-trimethoprim 50polyvinyl alcohol 51polyvinyl alcohol-povidone (ophth) 51POMALYST CAP 1MG 12POMALYST CAP 2MG 12POMALYST CAP 3MG 12POMALYST CAP 4MG 12

portia 28 day 35POTASSIUM CHLORIDE 46, 48potassium chloride 46, 48POTASSIUM CHLORIDE 0.15% 48POTASSIUM CHLORIDE 0.22% 48POTASSIUM CHLORIDE ER 46potassium chloride in nacl 48potassium chloride microencapsulated

crystals cr 46POTASSIUM CHLORIDE SOLN 30 MEQ/100

ML 49POTASSIUM CITRATE (ALKALINIZER) 42POTIGA 22povidone-iodine 57PRADAXA 43pramipexole dihydrochloride 25pravastatin sodium 15prazosin hcl 14PRED MILD 50prednisolone 36PREDNISOLONE ACETATE 50prednisolone sodium phosphate 36prednisolone sodium phosphate (ophth) 50prednisone 36PREMARIN CREAM 36premasol 47PRENATAL VITAMIN/FOLIC ACID > 0.8 MG

(GENERIC) 49prevalite 16previfem 28 day 35PREZISTA 5PRIFTIN 6PRIMAQUINE PHOSPHATE 5primidone 22PRISTIQ 24PRIVIGEN 44PROAIR HFA 52probenecid 1PROCALAMINE 47prochlorperazine inj 39prochlorperazine maleate 39prochlorperazine supp 39PROCRIT 43procto-pak 55proctocream 55proctozone hc 55PROCYSBI 36PROGLYCEM 36PROGRAF 45PROLASTIN-C 53PROLENSA 51PROLEUKIN 11PROLIA 37PROMACTA 43propafenone hcl 15proparacaine hcl 51propranolol & hydrochlorothiazide 16propranolol cap er 17propranolol hcl 17propranolol tab 17


71

propylthiouracil 38PROQUAD 46PROSHIELD PLUS SKIN PROTE 57PROSHIELD PROTECTIVE HAND 57PROSOL 47protriptyline hcl 24PRUDOXIN CRE 5% 55psyllium 40PULMICORT 53PULMOZYME 53PYLERA 41pyrazinamide 6pyrethrins-piperonyl butoxide 57pyridostigmine bromide 29

Qquasense 91 day 35quetiapine fumarate 26quinapril hcl 14quinapril-hydrochlorothiazide 13quinidine gluconate 15quinidine sulfate 15QVAR 53

RRABAVERT 46raloxifene hcl 37ramipril 14RANEXA 19ranitidine hcl 39ranitidine hcl inj 39ranitidine syrup 39RAPAMUNE 45REBETOL SOLN 7reclipsen 28 day 35RECOMBIVAX HB 46REFRESH CELLUVISC 51REFRESH LIQUIGEL 51REGRANEX 57RELENZA DISKHALER 7RELISTOR 40RELPAX 28REMICADE 44REMODULIN 20RENVELA 37repaglinide 32RESCRIPTOR 5RESTASIS 51RETROVIR IV INFUSION 5REVLIMID 45REYATAZ 5ribapak mis 600/day 7ribasphere 7ribasphere ribapak 1000 7ribasphere ribapak 1200 7ribasphere ribapak 800 7ribavirin 200mg 7rifabutin 6rifampin 6

RIFATER 6RILUTEK 29riluzole 29rimantadine hydrochloride 7RINGER'S 49RIOMET 32RISPERDAL CONSTA 26risperidone 26RITUXAN 11rivastigmine tartrate 23rizatriptan benzoate 28ropinirole hydrochloride 25rosadan cre 0.75% 57ROTARIX 46ROTATEQ 46roxicet soln 3roxicet tab 5-325mg 3

SSABRIL 22saline 53SANDIMMUNE 45SANDOSTATIN LAR DEPOT 37SANTYL 57SAPHRIS 26SAVELLA 29SAVELLA TITRATION PACK 29SEA-CLENS WOUND CLEANSER 57selegiline hcl 25selenium sulfide 55SELZENTRY 5SENNA 40sennosides 40sennosides-docusate sodium 40SENSIPAR 33SEREVENT DISKUS 52seromycin 6SEROQUEL XR 26sertraline hcl 24sildenafil citrate (pulmonary

hypertension) 20SILENOR 28SILVER SULFADIAZINE 54simvastatin 16sirolimus tab 0.5mg 45SIRTURO 6SIVEXTRO 4skin protectants, misc. 57sodium bicarbonate (antacid) 38SODIUM CHLORIDE 46, 49SODIUM CHLORIDE 0.45% VIA 49SODIUM CHLORIDE 0.9% 57sodium chloride hypertonic 51SODIUM CHLORIDE INJ 0.9% 49SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5

F) MG/ML SOLN 46sodium phenylbutyrate 36sodium phosphates 40sodium polystyrene sulfonate 33SOLIA 35


72

SOLTAMOX 11SOLU-CORTEF 36SOMATULINE DEPOT 37SOMAVERT 37sorine 15sotalol hcl 15sotalol hcl (afib/afl) 15SOVALDI 7SPIRIVA HANDIHALER 52spironolactone 14spironolactone & hydrochlorothiazide 19sprintec 28 day 35SPRYCEL 12sps susp 15gm/60ml 33sronyx 35SSD 54stavudine 5STERILE WATER IRRIGATION 57STIVARGA 12STRATTERA 27streptomycin sulfate 3STRIBILD 6SUBOXONE MIS 12-3MG 30SUBOXONE MIS 2-0.5MG 30SUBOXONE MIS 4-1MG 30SUBOXONE MIS 8-2MG 30SUCRAID 41sucralfate 41sulfacetamide sod-prednisolone 49sulfacetamide sodium (acne) 54sulfacetamide sodium (ophth) 50sulfadiazine 3sulfamethoxazole-trimethoprim 4sulfamethoxazole-trimethoprim inj 4SULFAMYLON 54sulfasalazine 40sulfasalazine ec 40sulindac 1SUMATRIPTAN 28SUMATRIPTAN SUCCINATE 28sumatriptan succinate 28SUMATRIPTAN SUCCINATE INJ 28sumatriptan succinate inj 28SUPRAX 8suprax 8SUPREP BOWEL PREP 40SURMONTIL 25SUSTIVA 5SUTENT 12SYLATRON 12SYMBICORT 53SYMLINPEN 120 31SYMLINPEN 60 31SYNAREL 35SYNTHROID 38SYPRINE 33

TTABLOID 10

tacrolimus 45TAFINLAR 12TAMIFLU 7tamoxifen citrate 11tamsulosin hcl 41TARCEVA 12TARGRETIN 12, 57TASIGNA 12TAXOTERE 11tazicef 8tazicef vial 8TAZORAC 55taztia 18TEGRETOL 22TEGRETOL-XR 22TEKAMLO 150-10MG 18TEKAMLO 150-5MG 18TEKAMLO 300-10MG 18TEKAMLO 300-5MG 18TEKTURNA 18TEKTURNA HCT TAB 150-12.5MG 18TEKTURNA HCT TAB 150-25MG 18TEKTURNA HCT TAB 300-12.5MG 18TEKTURNA HCT TAB 300-25MG 18temazepam 28TENIVAC 46terazosin hcl 14terbinafine hcl 5terbinafine hcl (topical) 55terbutaline sulfate 52terconazole vaginal 42TESTIM 30testosterone cypionate 30testosterone enanthate 30TETANUS TOXOID ADSORBED 46TETANUS/DIPHTHERIA TOXOID 46TEV-TROPIN 37texacort soln 2.5% 56THALOMID 45theo-24 53theophylline 53THERMAZENE 54thioridazine hcl 27thiothixene 27tiagabine hcl 22TIKOSYN 15TIMENTIN 9TIMENTIN INJ 3.1GM 9timolol maleate 17timolol maleate (ophth) 51TIMOLOL MALEATE GEL 51tioconazole vaginal 42TIVICAY 6tizanidine hcl 29TOBRADEX 49TOBRADEX ST 49tobramycin 3tobramycin sulfate 3tobramycin sulfate (ophth) 50tobramycin sulfate in saline 3


73

tobramycin-dexamethasone 49TOBREX 50tolterodine tartrate cap er 42tolterodine tartrate tabs 42topiramate 22toposar 13topotecan hcl 13torsemide inj 19torsemide tabs 19TOVIAZ 42TPN ELECTROLYTES 46TRACLEER 20TRADJENTA 32tramadol hcl 2tramadol-acetaminophen 2trandolapril 14tranexamic acid 43TRANSDERM-SCOP 39tranylcypromine sulfate 25travasol 10 47TRAVATAN Z 51trazodone hcl 25TREANDA 10TRECATOR 6TRELSTAR DEP INJ 3.75MG 12TRELSTAR LA INJ 11.25MG 12tretinoin 54tretinoin (chemotherapy) 12tri-legest 28 day 35tri-previfem 28 day 35tri-sprintec 28 day 35triamcinolone acetonide (mouth) 58triamcinolone acetonide (nasal) 53triamcinolone acetonide (topical) 56triamterene & hydrochlorothiazide 19TRIBENZOR 20- 5-12.5MG 14TRIBENZOR 40- 5-25MG 14TRIBENZOR 40-10-12.5MG 14TRIBENZOR 40-10-25MG 14TRIBENZOR 40-5-12.5MG 14triderm 56trifluoperazine hcl 27trifluridine 50trihexyphenidyl hcl 25TRILEPTAL SUSP 22trilyte 40trimethoprim 4trimipramine maleate 25TRINESSA 35TRISENOX 12trivora 28 day 35TRIXAICIN 57TROPHAMINE INJ 10% 47trospium chloride 42TRUVADA 6TWINRIX INJ 46TYGACIL 4TYKERB 12TYPHIM VI 46TYSABRI 29

TYZEKA 7

UUCERIS 40ULORIC 1UNITHROID 38ursodiol 41

VVAGIFEM 36valacyclovir hcl 7VALCHLOR 57VALCYTE 7valproate sodium 22valproic acid 22valsartan tab 160 mg 15valsartan tab 320 mg 15valsartan tab 40 mg 15valsartan tab 80 mg 15valsartan-hctz tab 160-12.5mg 14valsartan-hctz tab 160-25mg 15valsartan-hctz tab 320-12.5mg 15valsartan-hctz tab 80-12.5mg 14valsartan-hctztab 320-25mg 15vancomycin hcl 4VANDAZOLE 42VAQTA 46VARIVAX 46VASCEPA 16VELCADE 11velivet 28 day 35venlafaxine hcl 25VERAPAMIL CAP ER 18verapamil cap er 18verapamil hcl 18verapamil tab er 18VERSACLOZ 27VESICARE 42vestura 35VIBRAMYCIN 9VICTOZA 31VICTRELIS 7VIDEX PEDIATRIC 6VIGAMOX 50VIIBRYD 25VIMPAT 23vinblastine sulfate 11vincasar 11vincristine sulfate 11vinorelbine tartrate 11viorele 35VIRACEPT 6VIRAMUNE 6VIRAMUNE XR 6VIREAD 6vitamins a & d (topical) 57VOLTAREN 57voriconazole 5VOTRIENT 12


74

VPRIV 36vyfemla 35

Wwarfarin sodium 43WELCHOL 16white petrolatum-mineral oil 51

XXALKORI 12XARELTO 43XENAZINE 29XGEVA 37XIFAXAN 41XOLAIR 53XOPENEX HFA 52XTANDI 12xulane 35XYREM 30

YYF-VAX 46

Zzafirlukast 52zaleplon 28zarah 35ZAVESCA 36ZAZOLE 42zazole 42ZELBORAF 12ZEMAIRA 53ZEMPLAR INJ 49zenatane 54zenchent 28 day 35ZENPEP 41ZETIA 16ZIAGEN 6zidovudine 6zinc oxide (topical) 57ziprasidone hcl 27ZMAX 8zoledronic inj 4mg/5ml 33ZOLINZA 11zolmitriptan 28zolmitriptan odt 28zolpidem tartrate 28ZOMETA 33ZONALON 55zonisamide 23ZONTIVITY 43ZORTRESS 45ZOSTAVAX 46zovia 1/35e 28 day 35zovia 1/50e 28 day 35ZOVIRAX 55ZYKADIA 12ZYLET 49ZYTIGA 12

ZYVOX 4

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