unitedhealthcare & affiliated companies · 2020-08-07 · health care reform drug lists may...

2020 Prescription Drug List

UnitedHealthcare & Affiliated Companies

2020 Prescription Drug List

Introduction1 The UnitedHealthcare Prescription Drug List (PDL) provides

a list of of the most commonly prescribed medications in various therapeutic classes. This list is intended for use with UnitedHealthcare health plans and affiliated companies’ pharmacy benefit plan designs. The PDL applies only to prescription medications dispensed to outpatients and does not include inpatient medications or medications obtained or administered in a physician’s office. The PDL does not define benefit coverage. Benefit coverage is decided by the

2 member’s pharmacy benefit plan. This means that there may be medications listed on the PDL that are not covered under a particular member’s pharmacy benefit plan.

You may also access PDL information by visiting our website at UHCprovider.com.

Prescription Drug List Medication OverviewTier decisions are made by our PDL Management Committee based on clinical, economic, and other factors. The PDL Management Committee is comprised of senior UnitedHealth Group physician and business leaders. The UnitedHealthcare Pharmacy & Therapeutics (P&T) Committee, comprised of physicians and pharmacists, reviews new and existing medications and provides clinical guidance to the PDL Management Committee. Guidance is based on similarities and differences compared with other medications that treat the same disease or condition.

The tier placement of a medication on the PDL may change. While medications change tiers infrequently, such changes generally occur two times per calendar year. Additionally, when a brand-name medication becomes available as a generic, the tier status and coverage of the brand-name medication and its corresponding generic will be evaluated. When a medication changes tiers, your patient may be required to pay more or less for that medication. These changes may occur without prior notice to you or your patient. However, you may visit our

® website at UHCprovider.com or use the PreCheck MyScript app for the most up-to-date information for a particular medication. Your patient can also find the most up-to-date tier

3, 8 status and cost information for a particular medication by ® visiting our member website at myuhc.com and/or calling the

toll-free member phone number located on his or her health plan ID card.

2

Tier DesignationsPrescription medications are categorized within 3 tiers on the

4 PDL. Each tier is assigned a cost,³ which is determined by the member’s pharmacy benefit plan. You may refer to the PDL as a guide to select the most appropriate medication with the lowest member cost for your patients.

Tier 1 Tier 2 Tier 3 Lowest cost Mid-range cost Highest cost medications

Tier 1 Tier 1 medications are your patient’s lowest cost option. Members can maximize their cost savings when you prescribe Tier 1 medications, if you decide they are appropriate for your patient’s treatment.

Tier 2 Tier 2 medications are your patient’s mid-range cost option. Consider Tier 2 medications if no Tier 1 medication is appropriate to treat your patient’s condition.

Tier 3 Tier 3 medications are your patient’s highest cost option. If your patient is currently taking a medication in Tier 3, you may want to determine if there is an appropriate alternative in Tier 1 or Tier 2.

You and your patient make decisions about health care and medication treatments.

If the member has a “closed” pharmacy benefit (a two-tier pharmacy benefit plan that does not cover medications classified in Tier 3 of this PDL), medications in Tier 3 are generally not covered, except under certain processes consistent with applicable law.

Some members have a four-tier prescription plan, and these medications are noted as T4 throughout the document. Members with a four-tier prescription plan should refer to their enrollment materials, check the Medication Pricing / Coverage information on our member website or call the toll-free member phone number provided on their ID card for more information about their benefit plan.

Not all medications are represented in this PDL. Only the most commonly prescribed medications are included.

UHCprovider.com

3

Over-the-Counter and Therapeutically Equivalent MedicationsFor some conditions, you and your patient may decide that an over-the-counter (OTC) medication is the most appropriate treatment. According to UnitedHealthcare benefit design, OTC medications are defined as medications that do not require a prescription by federal or state law to be dispensed. In some instances, OTC medications are listed on the PDL for reference purposes only. OTC medications may cost less than the member’s out-of-pocket expense for prescription medications.

Therapeutically Equivalent means that medications can be expected to produce essentially the same efficacy or adverse event profile. Our benefit designs allow us to exclude a medication if determined to be Therapeutically Equivalent to another covered product or OTC option.

If the patient or physician requests a medication we have excluded based on determination of Therapeutic Equivalent, the patient may be required to pay the entire cost of the medication as it may not be covered under the member’s pharmacy benefit. Please refer to the member’s pharmacy benefit plan.

Symbols

E May be excluded from coverage or subject to Prior Authorization in Connecticut, New Jersey and New York.

5H May be part of health care reform preventiveH-PA May be part of health care reform preventive with prior

5 authorization MC Multiple copay

6PA Prior authorization requiredRS May be eligible for the Refill and Save ProgramSL Supply limitSP Specialty medication

7ST Step therapyT4 May be covered on Tier 4 in select benefits

Generic Medication Policy Many generic medications are included on the PDL in Tier 1; however, generic medications can be placed into any tier of the PDL. When a generic medication does not offer significant financial savings, it may be placed in the same tier or a higher tier than the brand medication. Generic medications are noted in italic font.

Note that when a brand-name medication becomes available as a generic, that brand-name product may move to a higher tier or be excluded from coverage by the member’s plan. Members may be required to pay more for a prescription when a higher-tier brand-name product is dispensed. The member’s cost share is determined by the pharmacy benefit plan. When generic substitution conflicts with state regulations or restrictions, the pharmacist must obtain approval from the prescribing physician or other health care professional to substitute the generic equivalent.

Specialty MedicationsSome members may have coverage for self-administered injectable and oral specialty medications through their pharmacy benefit plan. You will find these medications included in the body of this document within the appropriate therapeutic categories. UnitedHealthcare has a specialty pharmacy program that requires most specialty medications to be obtained through a designated specialty pharmacy. These medications are noted by SP throughout the document. The specialty pharmacy program includes designated specialty pharmacies, each selected based on their clinical expertise for the targeted therapeutic classes, quality of services, and cost. Their pharmacists are trained to help educate patients for these specialty medications, which may help improve treatment adherence.

Participating members should be instructed to call the toll-free member number on their ID card where a representative will answer questions about our program and then transfer them to a specialty pharmacy based on their particular specialty medication prescription.

Medications Requiring Prior Authorization and Other Pharmacy Programs Select medications may require prior authorization to be eligible for coverage under the member’s pharmacy benefit plan. Such medications are noted with a PA. Depending on your patients’ benefit and/or medication, a coverage review may apply to determine coverage under the pharmacy benefit. The pharmacy benefit may exclude coverage of medications for certain uses.

Clinical criteria for PA medications are available on our website at UHCprovider.com. The criteria reflect UnitedHealthcare’s P&T Committee decisions. For a member to receive benefit coverage for a medication requiring prior authorization, the physician or the physician’s designee must provide information to the prior authorization department.

7 Some benefit plans may include our Step Therapy program. Step Therapy requires prior authorization and offers a “stepwise” approach to therapy for certain high-cost medications and requires that a member first try a more cost-effective medication before another high-cost medication. Step Therapy medications are noted as ST.

Supply limits define the maximum supply of medication per copayment or period of time. Supply limits are based on several factors that may include FDA-approved dosing guidelines as defined in the product package insert, medical literature, guidelines, or supportive data. Supply limit medications are noted as SL.

The Refill and Save Program encourages members to adhere to their treatment regimens by rewarding them with a discounted copayment/coinsurance for refilling their prescription within the defined time period. Eligible medications are noted as RS.

1 In certain documents the Prescription Drug List (PDL) was referred to as the “Preferred Dru coverage.

2 Where differences are noted, the benefit plan documents will govern. 3 UnitedHealthcare operates a wide number of benefit programs and products, and some ben

member’s specific benefit prior to prescribing medications. 4 In certain documents Tier 1 was referred to as “generics;” Tier 2 was referred to as “preferr

brands,” “not on the PDL,” or “brand-name not on the PDL.” These changes in descriptive te

5 Health Care Reform drug lists may vary by plan; your patient can find the most up-to-date ti calling the toll-free member phone number on their health plan ID card.

6 Depending on your patients’ benefit and/or medication, notification or medical necessity crit 7 For New Jersey fully insured members, this program is referred to as First Start. 8 In accordance with HCR/ACA requirements, providers may request a zero dollar coverage e

List and Pharmacy>Additional Resources> Patient Protection and Affordable Care Act $0 call the toll-free number on the member’s health plan ID card.

4

How to Obtain AuthorizationUse the PreCheck MyScript app on Link. By using the PreCheck MyScript app, you can now run a pharmacy trial claim and get real-time prescription coverage detail for your patients who are UnitedHealthcare benefit plan members. This will allow you to check current prescription coverage and price, including out-of-pocket prescription costs for UnitedHealthcare members at their selected pharmacy, as well as:

• Get information on lower-cost prescription alternatives, if available, to help save members money.

• See which prescriptions currently require prior authorization, or are non-covered or non-preferred.

• Request prior authorization and receive status and results.

The app is now available to all Link users; to access, sign in to UHCprovider.com, then select the Link Marketplace from your Link dashboard and search for the PreCheck MyScript app. Add the app to your dashboard and start using it.

Below are also options to obtain authorization:

• Online: Use the online prior authorization tool (available through UHCprovider.com). Most online prior authorizations are approved in real-time, and an autopopulation feature provides 95 percent of a member’s information. Prior authorizations can also be submitted online by signing in to optumrx.com > Healthcare Professionals > Prior Authorizations.

• By Phone: Call the OptumRx prior authorization team at 1-800-711-4555.

g List (PDL).” This change in descriptive terms does not affect your patient’s benefit

efit programs may have alternative benefit designs. Physicians should always check the

ed brands” or “brand-name” on the PDL; and Tier 3 was referred to as “non-preferred rms do not affect your patient’s benefit coverage.

er status and cost information for a particular medication by visiting myuhc.com and/or

eria will be applied to determine if covered under the pharmacy benefit.

xception review for preventive medications. Please access uhcprovider.com>Drug Cost-share Preventive Medications Exemption Requests (Commercial members) or

UHCprovider.com

UHCprovider.com

UHCprovider.com)

optumrx.com

Table of Contents

Analgesics - Drugs for Pain.............................. 6

Analgesics - Drugs for Pain and Inflammation. 8

Anti-Addiction / Substance Abuse Treatment

Agents............................................................ 9

Antibacterials - Drugs for Infections................10

Anticoagulants - Drugs to Treat or Prevent

Blood Clots...................................................13

Anticonvulsants - Drugs for Seizures............. 13

Antidementia Agents - Drugs for Alzheimer's

Disease and Dementia................................. 15

Antidepressants - Drugs for Depression.........15

Antiemetics - Drugs for Nausea and Vomiting17

Antifungals - Drugs for Fungal Infections....... 17

Antigout Agents - Drugs for Gout................... 19

Antimigraine Agents Drugs for Migraines...... 19

Antimigraine Agents - Drugs for Migraines.....19

Antimyasthenic Agents - Drugs to Treat

Myasthenia Gravis........................................20

Antimycobacterials - Drugs to Treat

Infections......................................................20

Antineoplastics - Drugs for Cancer.................20

Antiparasitics - Drugs for Parasitic Infections. 23

Antiparkinson Agents - Drugs for Parkinson's

Disease........................................................ 23

Antiplatelets - Drugs for Heart Attack and

Stroke Prevention.........................................24

Antipsychotics - Drugs for Mood Disorders.... 24

Antivirals - Drugs for Viral Infections.............. 25

Anxiolytics - Drugs for Anxiety........................27

Bipolar Agents - Drugs for Mood Disorders....28

Cardiovascular Agents - Drugs for Heart and

Circulation Conditions.................................. 28

Central Nervous System Agents - Drugs for

Attention Deficit Disorder..............................33

Central Nervous System Agents - Drugs for

Multiple Sclerosis......................................... 34

Central Nervous System Agents -

Miscellaneous...............................................35

Dental and Oral Agents - Drugs for Mouth

and Throat Conditions.................................. 35

Dermatological Agents - Drugs for Skin

Conditions.................................................... 36

Diabetes - Glucose Monitoring....................... 43

Diabetes - Insulin............................................45

Diabetes - Non-Insulin Agents........................46

Drugs for Blood Disorders.............................. 48

Drugs for Sexual Dysfunction......................... 49

Electrolytes / Vitamins.................................... 49

Gastrointestinal Agents - Drugs for Acid

Reflux and Ulcer...........................................52

Gastrointestinal Agents - Drugs for Bowel,

Intestine and Stomach Conditions................52

Genetic or Enzyme Disorder - Drugs for

Replacement, Modification, Treatment.........54

Genetic or Enzyme Disorder: Drugs for

Replacement, Modifiers, Treatment............. 55

Genitourinary Agents - Drugs for Bladder,

Genital and Kidney Conditions.....................55

Genitourinary Agents - Drugs for Prostate

Conditions.................................................... 56

Hormonal Agents - Hormone Replacement

and Birth Control.......................................... 56

Hormonal Agents - Oral Steroids....................61

Hormonal Agents - Other................................62

Hormonal Agents - Testosterone

Replacement................................................ 62

Hormonal Agents - Thyroid.............................63

Immunological Agents - Drugs for Immune

System Stimulation or Suppression............. 63

Immunological Agents - Drugs for

Vaccination...................................................65

Infertility Agents.............................................. 65

Inflammatory Bowel Disease Agents..............66

Metabolic Bone Disease Agents - Drugs for

Osteoporosis................................................ 67

Metabolic Bone Disease Agents - Other........ 67

Ophthalmic Agents - Drugs for Eye Allergy,

Infection and Inflammation........................... 67

Ophthalmic Agents - Drugs for Glaucoma......69

Ophthalmic Agents - Drugs for Miscellaneous

Eye Conditions............................................. 69

Otic Agents - Drugs for Ear Conditions.......... 70

Respiratory - Drugs for Anaphylaxis...............70

Respiratory Tract / Pulmonary Agents -

Drugs for Allergies, Cough, Cold..................71


Drugs for Asthma and COPD.......................72


Drugs for Cystic Fibrosis.............................. 74


Drugs for Pulmonary Fibrosis.......................74


Drugs for Pulmonary Hypertension.............. 74

Skeletal Muscle Relaxants - Drugs for

Muscle Pain and Spasm...............................75

Sleep Disorder Agents....................................75

Index of Drugs................................................ 76

5

RequiremDrug

Drug Name ents & Tier

Limits

Drug NameDrug

Tier

Requirem

ents &

Limits

Analgesics - Drugs for

Pain

ABSTRAL E PA; QL

acetaminophen-codeine 1

acetaminophen-codeine

#21


#31


#41

ACTIQ E PA; QL

ALLZITAL E

APADAZ E

apap-caff-dihydrocodeine

oral capsule4 QL

apap-caff-dihydrocodeine

oral tablet1 QL

ARYMO ER E PA; ST; QL

ascomp-codeine 1

BELBUCA 3 PA; QL

BENZHYDROCODONE-

ACETAMINOPHENE

BUPAP 4

buprenorphine

transdermal patch weekly

10 mcg/hr, 15 mcg/hr, 20 E PA; ST; QL

mcg/hr, 5 mcg/hr

BUPRENORPHINE

TRANSDERMAL PATCH E PA; ST; QL

WEEKLY 7.5 MCG/HR

BUTALBITAL-

ACETAMINOPHEN E QL

ORAL CAPSULE

butalbital-acetaminophen

oral tablet 25-325 mgE


oral tablet 50-300 mg3


oral tablet 50-325 mg1

butalbital-apap-caff-cod

oral capsule 50-300-40- E QL

30 mg

butalbital-apap-caff-cod

oral capsule 50-325-40- 1 QL

30 mg

butalbital-apap-caffeine

oral capsule 50-300-40 3 QL

mg


oral capsule 50-325-40 1 QL

mg


oral tablet1 QL

butalbital-asa-caff-

codeine1

butalbital-aspirin-caffeine 1

butorphanol tartrate

nasal2 QL

BUTRANS E PA; ST; QL

carisoprodol-aspirin-

codeine1

codeine sulfate oral

tablet 30 mg, 60 mg1

CONZIP ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 100

MG

E

(generic for

Conzip);

QL

CONZIP ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 200 E QL

MG, 300 MG

DILAUDID ORAL 4

DOLOPHINE 3 PA; QL

DURAGESIC-100 E PA; ST; QL





duraxin 1

DVORAH E QL

endocet 1

ESGIC 4 QL

fentanyl citrate buccal

lozenge on a handle2 PA; QL

6

RequiremDrug


Limits

Drug NameDrug

Tier

Requirem

ents &

Limits

FENTANYL CITRATE

BUCCAL TABLETE PA; QL

fentanyl transdermal

patch 72 hour 100

mcg/hr, 12 mcg/hr, 25 2 PA; QL

mcg/hr, 50 mcg/hr, 75

mcg/hr

fentanyl transdermal

patch 72 hour 37.5

mcg/hr, 62.5 mcg/hr, E PA; ST; QL

87.5 mcg/hr

FENTORA E PA; QL

FIORICET 4 QL

FIORICET/CODEINE E QL

FIORINAL 4

FIORINAL/CODEINE #3 4

hydrocodone bitartrate er 3 PA; ST; QL

hydrocodone-

acetaminophen oral 1

solution 10-325 mg/15ml

hydrocodone-

acetaminophen oral 2

solution 7.5-325 mg/15ml

hydrocodone-

acetaminophen oral

tablet 10-300 mg, 5-300 E

mg, 7.5-300 mg

hydrocodone-

acetaminophen oral

tablet 10-325 mg, 5-325 1

mg, 7.5-325 mg

hydrocodone-ibuprofen 1

hydromorphone hcl er 4 PA; ST; QL

hydromorphone hcl oral 1

hydromorphone hcl rectal 1

HYSINGLA ER E PA; ST; QL

KADIAN E PA; ST; QL

LAZANDA 4 PA; QL

levorphanol tartrate oral 4 QL

lidocaine external

ointment2 QL

lidocaine external patch 5

%3 PA; QL

lidocaine hcl external

solution1

lidocaine hcl

urethral/mucosal1

lidocaine-prilocaine

external cream1

LIDODERM E PA; QL

lorcet 1

lorcet hd 1

lorcet plus 1

LORTAB 4

meperidine hcl oral 1

methadone hcl intensol 1 QL

methadone hcl oral

concentrate1 QL

methadone hcl oral

solution1 PA; QL

methadone hcl oral tablet 1 PA; QL

methadone hcl oral tablet

soluble1 QL

methadose oral

concentrate 10 mg/ml1 QL

methadose oral tablet

soluble1 QL

methadose sugar-free 1 QL

MORPHABOND ER E PA; ST; QL

morphine sulfate

(concentrate) oral

solution 100 mg/5ml, 20 1

mg/ml

morphine sulfate er

beads4 PA; ST; QL

morphine sulfate er oral

capsule extended E PA; ST; QL

release 24 hour

morphine sulfate er oral

tablet extended release1 PA; QL

morphine sulfate oral 1

morphine sulfate rectal 1

7

RequiremDrug


Limits

Drug NameDrug

Tier

Requirem

ents &

Limits

MS CONTIN 3 PA; ST; QL

NALOCET E

NORCO 4

NUCYNTA 4 QL

NUCYNTA ER 3 PA; QL

OPANA 4 QL

OXAYDO E QL

OXYCODONE HCL ER E PA; ST; QL

oxycodone hcl oral

capsule1

oxycodone hcl oral

concentrate 100 mg/5ml1

oxycodone hcl oral

solution1

oxycodone hcl oral tablet 1

oxycodone-

acetaminophen oral

tablet 10-325 mg, 2.5- 1

325 mg, 5-325 mg, 7.5-

325 mg

oxycodone-

acetaminophen oral E

tablet 2.5-300 mg

oxycodone-aspirin 1

oxycodone-ibuprofen 1

OXYCONTIN E PA; ST; QL

oxymorphone hcl 2 QL

oxymorphone hcl er 4 PA; ST; QL

pentazocine-naloxone hcl 1

PERCOCET E

pramox 1

premium lidocaine 2 QL

PRIMLEV E

ROXICODONE ORAL

TABLET 15 MG, 30 MG4

ROXICODONE ORAL

TABLET 5 MG3

SUBSYS E PA; QL

tencon 1

tramadol hcl er (biphasic)E

(generic for

Ryzolt); QL

TRAMADOL HCL ER

ORAL CAPSULE (generic for

EXTENDED RELEASE E Conzip);

24 HOUR 100 MG, 200 QL

MG, 300 MG

tramadol hcl er oral

capsule extended 1 QL

release 24 hour 150 mg

(generic for

tramadol hcl er oral tablet 2 Ultram

extended release 24 hour ER); QL

tramadol hcl oral tablet

100 mgE

tramadol hcl oral tablet

50 mg1

tramadol-acetaminophen 1 QL

TREZIX 4 QL

TYLENOL WITH

CODEINE #34

TYLENOL WITH

CODEINE #4 ORAL 4

TABLET 300-60 MG

ULTRACET 4 QL

ULTRAM 4

VANATOL LQ 2 PA; QL

VANATOL S 2 PA; QL

vicodin hp E

VTOL LQ 2 PA; QL

XTAMPZA ER 2 PA; QL

ZEBUTAL 4 QL

ZILACAINE PATCH 3

ZOHYDRO ER 3 PA; ST; QL

ZTLIDO E PA; QL

Analgesics - Drugs for

Pain and Inflammation

ARTHROTEC 3

CELEBREX E QL

celecoxib oral 2 QL

choline-mag trisalicylate 1

8

RequiremDrug


Limits

Drug NameDrug

Tier

Requirem

ents &

Limits

DAYPRO 4

DICLOFENAC

EPOLAMINEE

diclofenac potassium 1

diclofenac sodium er 1

diclofenac sodium oral 1

diclofenac sodium

transdermal gel 1 %2

diclofenac sodium

transdermal solutionE

diclofenac-misoprostol 3

diflunisal oral 1

DUEXIS E QL

EC-NAPROSYN 3

ec-naproxen 1

etodolac 1

etodolac er 1

FELDENE 4

fenoprofen calcium oral E

fenortho E

FLECTOR E

flurbiprofen oral 1

ibu 1

ibuprofen oral

suspensionE

ibuprofen oral tablet 400

mg, 600 mg, 800 mg1

INDOCIN 3

indomethacin er 1

INDOMETHACIN ORAL

CAPSULE 20 MGE

indomethacin oral

capsule 25 mg, 50 mg1

ketoprofen er 3

ketoprofen oral capsule

25 mg1

KETOROLAC

TROMETHAMINE

NASAL SOLUTION 3

15.75 MG/SPRAY

ketorolac tromethamine

oral1

LODINE E

meclofenamate sodium

oral1

mefenamic acid oral 3

meloxicam oral 1

MOBIC 4

nabumetone oral 1

NALFON E

NAPRELAN E

NAPROSYN ORAL

SUSPENSION4 PA

naproxen dr 1

naproxen oral

suspension1 PA

naproxen oral tablet 1

naproxen sodium er E

naproxen sodium oral


oxaprozin 1

PENNSAID E

piroxicam oral 1

QMIIZ ODT E

RELAFEN DS E

salsalate oral 1

SPRIX 3

sulindac oral 1

TIVORBEX E

tolmetin sodium 2

VIMOVO E QL

VIVLODEX E QL

ZIPSOR E

ZORVOLEX E

Anti-Addiction /

Substance Abuse

Treatment Agents

acamprosate calcium 1

ANTABUSE 4

9

RequiremDrug


Limits

1

Drug NameDrug

Tier

Requirem

ents &

Limits

BUNAVAIL E PA; QL

buprenorphine hcl

sublingual1 QL

buprenorphine hcl-

naloxone hcl2 QL

bupropion hcl er

(smoking det)1 H

CHANTIX 4 PA; H

CHANTIX CONTINUING

MONTH PAK4 PA; H

CHANTIX STARTING

MONTH PAK4 PA; H

disulfiram oral 1

EVZIO E PA; QL

LUCEMYRA 4 PA; QL

naloxone hcl injection

solution1

NALOXONE HCL

INJECTION SOLUTION E PA; QL

AUTO-INJECTOR


solution cartridge1


solution prefilled syringe1

naltrexone hcl oral 1

NARCAN 2 QL

NICOTROL 4 PA; H

NICOTROL NS 4 PA; H

SUBOXONE E PA; QL

ZUBSOLV 2 QL

Antibacterials - Drugs

for Infections

ACTICLATE E

AEMCOLO E QL

ALCOHOL PREP PADS

EXTERNAL 70 %3

ALTABAX 3 QL

amoxicillin 1

amoxicillin-potassium

clavulanate erE


clavulanate oral1

ampicillin 1

ARIKAYCE 4 PA; QL; SP

arzol silver nit applicators 1

AUGMENTIN E

AUGMENTIN ES-600 E

avidoxy 1

AVIDOXY DK 3

azithromycin oral 1

BACTRIM 4

BACTRIM DS 4

BAXDELA ORAL 3

BENZALKONIUM

CHLORIDE EXTERNAL 2

SOLUTION

benzalkonium chloride

external solution 50 %1

cefaclor 1

cefaclor er 1

cefadroxil 1

cefdinir 1

cefditoren pivoxil 1

cefixime 3

cefpodoxime proxetil 1

cefprozil 1

cefuroxime axetil 1

CENTANY 4 QL

CENTANY AT E

cephalexin 1

CIPRO ORAL

SUSPENSION 3

RECONSTITUTED

CIPRO ORAL TABLET 4

ciprofloxacin hcl oral 1

clarithromycin er 2

clarithromycin oral

suspension reconstituted2

clarithromycin oral tablet 1

0

RequiremDrug


Limits

1

Drug NameDrug

Tier

Requirem

ents &

Limits

CLEOCIN ORAL

CAPSULE 150 MG, 300 4

MG

CLEOCIN ORAL

CAPSULE 75 MG2

CLEOCIN ORAL

SOLUTION 4

RECONSTITUTED

CLEOCIN VAGINAL

CREAM4

CLEOCIN VAGINAL

SUPPOSITORY2

clindamycin hcl oral 1

clindamycin palmitate hcl 2

clindamycin phosphate

vaginal2

CLINDESSE 2

colistimethate sodium

(cba)1

COLY-MYCIN M 4

coremino E PA

demeclocycline hcl 1

dicloxacillin sodium 1

DIFICID 3 QL

DORYX E

DORYX MPC E

doxycycline hyclate oral

capsule2


tablet 100 mg2


tablet 150 mg, 50 mg, 75 E

mg


tablet 20 mg1


tablet delayed releaseE

doxycycline monohydrate

oral capsule 100 mg, 50 1

mg


oral capsule 150 mg, 75 E

mg


oral suspension 3

reconstituted


oral tablet1

E.E.S. 400 E

E.E.S. GRANULES 3

ERYPED 200 3

ERYPED 400 4

ERY-TAB 4

erythromycin base oral

capsule delayed release 1

particles


tablet1


tablet delayed release3

erythromycin

ethylsuccinate oral

suspension reconstituted 1

200 mg/5ml

erythromycin

ethylsuccinate oral

suspension reconstituted 3

400 mg/5ml

erythromycin

ethylsuccinate oral tablet1

erythromycin oral 3

FEM PH 4

FIRVANQ 1

FLAGYL 4

gentamicin sulfate

external1

GLUTARALDEHYDE

EXTERNAL3

grafco silver nit applicator 1

HIPREX 4

iodine tincture external

tincture 2 %1

1

RequiremDrug


Limits

1

Drug NameDrug

Tier

Requirem

ents &

Limits

KEFLEX 4

LEVAQUIN ORAL

TABLET 500 MG, 750 4

MG

levofloxacin oral 1

linezolid oral 2 QL

MACROBID 4

MACRODANTIN 4

mafenide acetate

external3

methenamine hippurate 1

methenamine mandelate

oral1

metronidazole oral 1

metronidazole vaginal 2

MINOCIN ORAL

CAPSULE 50 MGE

minocycline hcl er oral

tablet extended release

24 hour 105 mg, 115 mg, E PA

55 mg, 65 mg, 80 mg

minocycline hcl er oral

tablet extended release

24 hour 135 mg, 45 mg, E PA

90 mg

minocycline hcl oral

capsule1

minocycline hcl oral

tabletE

MINOLIRA E PA

mondoxyne nl oral

capsule 100 mg1

mondoxyne nl oral

capsule 75 mgE

MONUROL 3

MORGIDOX

COMBINATIONE

morgidox oral 2

moxifloxacin hcl oral 3

mupirocin calcium 3 QL

mupirocin external 1 QL

neomycin sulfate oral 1

NEO-SYNALAR

EXTERNAL KITE

nitrofurantoin 1

nitrofurantoin

macrocrystal oral1

nitrofurantoin

monohydrate 1

macrocrystals

NUTRIDOX 3

NUVESSA E

NUZYRA ORAL 4 QL

ofloxacin oral 1

okebo E

paromomycin sulfate oral 1

penicillin v potassium 1

PRIMSOL 3

SEYSARA E

SILVADENE 4

silver nitrate external 1

silver sulfadiazine

external1

SIVEXTRO ORAL 3 QL

SOLODYN E PA

SOLOSEC 4 ST; QL

SPECTRACEF 4

ssd 1

sulfadiazine oral 1

sulfamethoxazole-

trimethoprim oral1

SULFAMYLON

EXTERNAL CREAM3

SULFAMYLON

EXTERNAL PACKET4

sulfatrim pediatric 1

SUPRAX 4

TARGADOX E

tetracycline hcl oral 3

tinidazole oral 3

2

RequiremDrug


Limits

1

Drug NameDrug

Tier

Requirem

ents &

Limits

trimethoprim oral 1

VANCOCIN 4 QL

VANCOCIN HCL 4 QL

vancomycin hcl oral

capsule1 QL

vancomycin hcl oral

solution reconstitutedE

vandazole 2

VIBRAMYCIN ORAL

CAPSULE4

VIBRAMYCIN ORAL

SUSPENSION 4

RECONSTITUTED

VIBRAMYCIN ORAL

SYRUP3

XENLETA ORAL 3

XEPI 3 QL

XIFAXAN 3 PA; QL

XIMINO E PA

ZITHROMAX ORAL

PACKET4

ZITHROMAX ORAL

SUSPENSION 4

RECONSTITUTED

ZITHROMAX ORAL


MG

ZITHROMAX ORAL

TABLET 600 MG3

ZITHROMAX TRI-PAK 4

ZITHROMAX Z-PAK 4

ZYVOX ORAL

SUSPENSION 4 QL

RECONSTITUTED

ZYVOX ORAL TABLET E QL

Anticoagulants - Drugs

to Treat or Prevent

Blood Clots

ARIXTRA 4 QL

BEVYXXA 3 QL

COUMADIN 3

ELIQUIS 2 QL

ELIQUIS DVT/PE

STARTER PACK2 QL

enoxaparin sodium 2 QL

fondaparinux sodium 2 QL

FRAGMIN

SUBCUTANEOUS

SOLUTION 10000

UNIT/ML, 12500

UNIT/0.5ML, 15000

UNIT/0.6ML, 18000 4 QL

UNT/0.72ML, 2500

UNIT/0.2ML, 5000

UNIT/0.2ML, 7500

UNIT/0.3ML

FRAGMIN

SUBCUTANEOUS

SOLUTION 95000 4

UNIT/3.8ML

heparin sodium (porcine) 1

heparin sodium (porcine)

pf1

jantoven 1

LOVENOX E QL

PRADAXA 2 QL

SAVAYSA 4 QL

warfarin sodium oral 1

XARELTO 2 QL

XARELTO STARTER

PACK2

Anticonvulsants -

Drugs for Seizures

APTIOM 3 PA

BANZEL ORAL

SUSPENSION3

BANZEL ORAL TABLET 3 PA

BRIVIACT ORAL

SOLUTION4 PA

BRIVIACT ORAL

TABLET3 PA

carbamazepine er oral

capsule extended 2

release 12 hour

3

RequiremDrug


Limits

1

Drug NameDrug

Tier

Requirem

ents &

Limits

carbamazepine er oral

tablet extended release 3

12 hour

carbamazepine oral 1

CARBATROL 4

CELONTIN 2

clobazam oral

suspension3 PA

clobazam oral tablet 2 PA

DEPAKOTE 4 PA

DEPAKOTE ER 4 PA; ST

DEPAKOTE SPRINKLES 4 PA; ST

DIACOMIT 3 PA; SP

DIASTAT ACUDIAL 4 QL

DIASTAT PEDIATRIC 2 QL

diazepam rectal 1 QL

DILANTIN 3

DILANTIN INFATABS 3

divalproex sodium er 2

divalproex sodium oral

capsule delayed release 2

sprinkle

divalproex sodium oral

tablet delayed release1

EPIDIOLEX 3 PA; SP

epitol 1

ethosuximide oral 1

felbamate 1

FELBATOL 4 PA; ST

FYCOMPA ORAL

SUSPENSION4 PA

FYCOMPA ORAL

TABLET3 PA

gabapentin oral 1

GABITRIL 4

KEPPRA ORAL 4 PA; ST

KEPPRA XR 4 PA; ST

LAMICTAL 4 PA; ST

LAMICTAL ODT ORAL

KIT3 PA; ST

LAMICTAL ODT ORAL

TABLET DISPERSIBLE4 PA; ST

LAMICTAL STARTER 4 PA; ST

LAMICTAL XR 3 PA; ST

lamotrigine er 3 PA; ST

lamotrigine oral tablet 1

lamotrigine oral tablet

chewable1

lamotrigine oral tablet

dispersible3 PA; ST

lamotrigine starter kit-

blue1


green1


orange1

levetiracetam er 2

levetiracetam oral 1

MYSOLINE 2 PA; ST

NAYZILAM E PA; QL

NEURONTIN 4 PA; ST

ONFI 4 PA; ST

oxcarbazepine 1

OXTELLAR XR E PA; ST

PEGANONE 2

phenobarbital oral 1

PHENYTEK 4

phenytoin infatabs 1

phenytoin oral 1

phenytoin sodium

extended1

primidone oral 1

QUDEXY XR E PA; ST

roweepra 1

roweepra xr 2

SABRIL ORAL PACKET E PA; QL; SP

SABRIL ORAL TABLET 4 PA; QL; SP

SPRITAM E PA; ST

subvenite 1

4

RequiremDrug


Limits

1

Drug NameDrug

Tier

Requirem

ents &

Limits

subvenite starter kit-blue 1

subvenite starter kit-

green1

subvenite starter kit-

orange1

SYMPAZAN E PA

TEGRETOL 3

TEGRETOL-XR 4

tiagabine hcl 1

TOPAMAX 4 PA; ST

TOPAMAX SPRINKLE 4 PA; ST

topiramate er E PA; ST

topiramate oral 1

TRILEPTAL 4 PA; ST

TROKENDI XR E PA; ST

valproic acid oral 1

VALTOCO 10 MG DOSE E



VALTOCO 5 MG DOSE E

vigabatrin 2 PA; QL; SP

vigadrone 2 PA; QL; SP

VIMPAT ORAL 3 PA

ZARONTIN 4

ZONEGRAN 4 PA; ST

zonisamide oral 1

Antidementia Agents -

Drugs for Alzheimer's

Disease and Dementia

ARICEPT ORAL

TABLET 10 MG, 5 MG3

ARICEPT ORAL

TABLET 23 MGE

donepezil hcl oral tablet

10 mg, 5 mg1


23 mgE


dispersible1

EXELON E

galantamine

hydrobromide1

galantamine

hydrobromide er1

memantine hcl er E

memantine hcl oral

solution 2 mg/ml3

memantine hcl oral tablet 2

NAMENDA 4

NAMENDA TITRATION

PAK4

NAMENDA XR E

NAMENDA XR

TITRATION PACKE

NAMZARIC E

RAZADYNE 4

RAZADYNE ER 4

rivastigmine 3

rivastigmine tartrate 1

Antidepressants -

Drugs for Depression

amitriptyline hcl oral 1

amoxapine 1

ANAFRANIL E

APLENZIN E QL

BRISDELLE E QL

bupropion hcl er (sr) 1

bupropion hcl er (xl) oral

tablet extended release 1

24 hour 150 mg, 300 mg

BUPROPION HCL ER

(XL) ORAL TABLET

EXTENDED RELEASE E QL

24 HOUR 450 MG

bupropion hcl oral 1

CELEXA E

chlordiazepoxide-

amitriptyline1

citalopram hydrobromide 1

clomipramine hcl oral 4

CYMBALTA E QL

5

RequiremDrug


Limits

1

Drug NameDrug

Tier

Requirem

ents &

Limits

desipramine hcl oral 1

DESVENLAFAXINE ER E QL

desvenlafaxine succinate

er2 QL

doxepin hcl oral capsule 1

doxepin hcl oral

concentrate1

DRIZALMA SPRINKLE E

duloxetine hcl oral

capsule delayed release

particles 20 mg, 30 mg, 2 QL

60 mg

duloxetine hcl oral

capsule delayed release E

particles 40 mg

EFFEXOR XR E

EMSAM 3

escitalopram oxalate oral

solution3

escitalopram oxalate oral

tablet1

FETZIMA 4 ST; QL

FETZIMA TITRATION 4 ST; QL

fluoxetine hcl (pmdd) E

fluoxetine hcl oral

capsule1

fluoxetine hcl oral

capsule delayed release3 QL

fluoxetine hcl oral

solution1

fluoxetine hcl oral tablet

10 mg3 QL


20 mg3


60 mgE

fluvoxamine maleate 1

fluvoxamine maleate er 3 QL

FORFIVO XL E QL

imipramine hcl oral 1

imipramine pamoate 1

LEXAPRO E

maprotiline hcl 1

MARPLAN 3

mirtazapine oral 1

NARDIL 4

nefazodone hcl 1

NORPRAMIN 4

nortriptyline hcl oral 1

olanzapine-fluoxetine hcl 2 QL

PAMELOR 4

PARNATE 4

paroxetine hcl 1

paroxetine hcl er 3 QL

paroxetine mesylate E QL

PAXIL CR 4 QL

PAXIL ORAL

SUSPENSION3

PAXIL ORAL TABLET 4

perphenazine-

amitriptyline1

PEXEVA E QL

phenelzine sulfate oral 1

PRISTIQ E QL

protriptyline hcl 1

PROZAC E

REMERON 4

REMERON SOLTAB 4

SARAFEM E

sertraline hcl oral 1

SPRAVATO (56 MG

DOSE)4 PA; QL

SPRAVATO (84 MG

DOSE)4 PA; QL

SYMBYAX 4 QL

tranylcypromine sulfate 1

trazodone hcl oral 1

trimipramine maleate oral 3

TRINTELLIX 4 ST; QL

6

RequiremDrug


Limits

1

Drug NameDrug

Tier

Requirem

ents &

Limits

venlafaxine hcl 1

venlafaxine hcl er oral

capsule extended 1

release 24 hour

venlafaxine hcl er oral

tablet extended release E QL

24 hour

VIIBRYD 4 QL

VIIBRYD STARTER

PACK4

WELLBUTRIN SR E

WELLBUTRIN XL E

ZOLOFT E

Antiemetics - Drugs for

Nausea and Vomiting

AKYNZEO ORAL 4 QL

ANZEMET 3 QL

aprepitant 2 QL

BONJESTA E PA

compro 1

DICLEGIS E PA

doxylamine-pyridoxine E PA

dronabinol 1

EMEND ORAL

CAPSULE 80 MG4 QL

EMEND ORAL

SUSPENSION 2 QL

RECONSTITUTED

EMEND TRI-PACK 4 QL

granisetron hcl oral 2

meclizine hcl oral tablet E

metoclopramide hcl oral

solution 5 mg/5ml1


tablet1


tablet dispersibleE

ondansetron hcl oral 1

ondansetron odt 1

perphenazine oral 1

phenadoz 1

prochlorperazine 1

prochlorperazine maleate

oral1

promethazine hcl oral

tablet1

promethazine hcl rectal 1

promethegan 1

REGLAN 4

SANCUSO E QL

scopolamine 3

SYNDROS 4 PA; QL

TIGAN ORAL 4

TRANSDERM-SCOP

(1.5 MG)4

trimethobenzamide hcl

oral1

VARUBI ORAL TABLET

90 MG2 QL

ZOFRAN 4

ZUPLENZ E QL

Antifungals - Drugs for

Fungal Infections

ANCOBON ORAL

CAPSULE 250 MG4

ANCOBON ORAL

CAPSULE 500 MG3

AVC VAGINAL VAGINAL

CREAM 15 %2

BIO-STATIN ORAL

CAPSULE3

bio-statin oral powder 1

ciclodan 1

CICLODAN SOLUTION

EXTERNAL KIT 8 %E

ciclopirox external gel 1

ciclopirox external

shampoo2

ciclopirox external

solution1

ciclopirox olamine

external1

7

RequiremDrug


Limits

1

Drug NameDrug

Tier

Requirem

ents &

Limits

ciclopirox treatment E

clotrimazole external E

clotrimazole mouth/throat 1

CRESEMBA ORAL 3

dermazene 1

DIFLUCAN ORAL

SUSPENSION 4

RECONSTITUTED

DIFLUCAN ORAL


MG, 200 MG

DIFLUCAN ORAL

TABLET 50 MG3

econazole nitrate

external2 QL

ECOZA E

ERTACZO E

EXELDERM 3

exoderm external lotion 1

EXTINA 4 QL

fluconazole oral 1

flucytosine oral 1

griseofulvin microsize

oral1

griseofulvin

ultramicrosize1

GYNAZOLE-1 3

hydrocortisone-

iodoquinol1

itraconazole oral capsule 1 QL

itraconazole oral solution 2 QL

JUBLIA 4 PA; ST; QL

KERYDIN 4 PA; ST; QL

ketoconazole external

cream1 QL


foam3 QL


shampoo1

ketoconazole oral 1

ketodan external foam 3 QL

LOPROX EXTERNAL

CREAME

LOPROX EXTERNAL

KIT 0.77 %E

LOPROX EXTERNAL

SHAMPOOE

LOPROX EXTERNAL

SUSPENSIONE

LULICONAZOLE E

LUZU E

MENTAX 3

miconazole 3 vaginal

suppository1

MICONAZOLE-ZINC

OXIDE-PETROLATE

naftifine hcl E

NAFTIN E

NIZORAL 4

NOXAFIL ORAL

SUSPENSION2

NOXAFIL ORAL TABLET

DELAYED RELEASEE

nyamyc 1

nystatin external 1

nystatin mouth/throat 1

nystatin oral 1

nystatin-triamcinolone E

nystop 1

ORAVIG 3

oxiconazole nitrate 3 PA; QL

OXISTAT EXTERNAL

CREAM4 PA; QL

OXISTAT EXTERNAL

LOTIONE

PEDIZOLPAK E

posaconazole 2

SPORANOX 4 QL

SPORANOX PULSEPAK 4 QL

8

RequiremDrug


Limits

1

Drug NameDrug

Tier

Requirem

ents &

Limits

SULCONAZOLE

NITRATE EXTERNAL 3

CREAM

terbinafine hcl oral 1 QL

terconazole 1

TOLSURA E

VFEND ORAL

SUSPENSION 4

RECONSTITUTED

VFEND ORAL TABLET

200 MG4 QL

VFEND ORAL TABLET

50 MG3 QL

voriconazole oral


voriconazole oral tablet 1 QL

VUSION E

XOLEGEL 3

XOLEGEL COREPAK 3

XOLEGEL DUO/HEAD &

SHOULDERS3

XOLEGEL DUO/XOLEX 3

Antigout Agents -

Drugs for Gout

allopurinol oral 1

COLCHICINE ORAL

CAPSULEE

colchicine oral tablet E

colchicine-probenecid 1

COLCRYS E

febuxostat 3 ST; QL

GLOPERBA E

MITIGARE 2

probenecid 1

ULORIC E ST; QL

ZYLOPRIM 4

Antimigraine Agents

Drugs for Migraines

CAMBIA E QL

Antimigraine Agents -

Drugs for Migraines

AIMOVIG 2 PA; ST; QL

AJOVY

SUBCUTANEOUS

SOLUTION PREFILLED E PA; ST; QL

SYRINGE

almotriptan malate 3 QL

AMERGE 4 QL

CAFERGOT 4

D.H.E. 45 E

dihydroergotamine

mesylate injection1

dihydroergotamine

mesylate nasal4 PA; QL

eletriptan hydrobromide 2 QL

EMGALITY 2 PA; ST; QL

EMGALITY (300 MG

DOSE)2 PA; ST; QL

ERGOMAR 4 PA; QL

ergotamine-caffeine 3

FROVA 4 QL

frovatriptan succinate 3 QL

IMITREX NASAL 4 QL

IMITREX ORAL E QL

IMITREX STATDOSE

REFILLE QL

IMITREX STATDOSE

SYSTEME QL

IMITREX

SUBCUTANEOUSE QL

MAXALT E QL

MAXALT-MLT E QL

MIGERGOT 3

MIGRANAL E PA; QL

naratriptan hcl 1 QL

ONZETRA XSAIL E QL

RELPAX E QL

REYVOW E PA; QL

rizatriptan benzoate 1 QL

9

RequiremDrug


Limits

2

Drug NameDrug

Tier

Requirem

ents &

Limits

sumatriptan nasal 2 QL

sumatriptan succinate

oral1 QL


refill1 QL


subcutaneous1 QL

sumatriptan-naproxen

sodiumE QL

TOSYMRA E QL

TREXIMET E QL

UBRELVY E PA; QL

ZEMBRACE

SYMTOUCHE QL

zolmitriptan oral 3 QL

ZOMIG NASAL

SOLUTION 2.5 MG3 ST; QL

ZOMIG NASAL

SOLUTION 5 MG4 ST; QL

ZOMIG ORAL 4 QL

ZOMIG ZMT 4 QL

Antimyasthenic Agents

- Drugs to Treat

Myasthenia Gravis

GUANIDINE HCL 3

MESTINON ORAL

SOLUTION4

MESTINON ORAL

TABLET4

MESTINON ORAL

TABLET EXTENDED 3

RELEASE

pyridostigmine bromide

er1


oral solution3


oral tablet 30 mgE


oral tablet 60 mg1

Antimycobacterials -

Drugs to Treat

Infections

cycloserine oral 1

dapsone oral 2

ethambutol hcl oral 1

isoniazid oral 1

MYAMBUTOL 4

MYCOBUTIN 4

PASER 3

PRETOMANID E

PRIFTIN 2

pyrazinamide oral 1

rifabutin 1

RIFADIN ORAL

CAPSULE 150 MG3

RIFADIN ORAL

CAPSULE 300 MG4

RIFAMATE 3

rifampin oral 1

RIFATER 2

SIRTURO 2

TRECATOR 2

Antineoplastics - Drugs

for Cancer

abiraterone acetate E PA; QL; SP

AFINITOR DISPERZ 2 PA; QL; SP

AFINITOR ORAL

TABLET 10 MG2 PA; QL; SP

AFINITOR ORAL

TABLET 2.5 MG, 5 MG, 4 PA; QL; SP

7.5 MG

ALECENSA 2 PA; QL; SP

ALKERAN ORAL 4 SP

ALUNBRIG 2 PA; QL; SP

anastrozole oral 1

ARIMIDEX E

AROMASIN 4

AYVAKIT 4 PA

BALVERSA 2 PA; QL; SP

0

RequiremDrug


Limits

2

Drug NameDrug

Tier

Requirem

ents &

Limits

bexarotene E SP

bicalutamide 1

BOSULIF2

PA; ST;

QL; SP

BRAFTOVI4

PA; ST;

QL; SP

BRUKINSA E PA; QL; SP

CABOMETYX 2 PA; QL; SP

CALQUENCE 2 PA; QL; SP

capecitabine E QL; SP

CAPRELSA 2 PA; QL; SP

CASODEX 4

COMETRIQ (100 MG

DAILY DOSE)2 PA; QL; SP

COMETRIQ (140 MG


COMETRIQ (60 MG


COPIKTRA 4 PA; QL; SP

COTELLIC 2 PA; QL; SP

cyclophosphamide oral 2

DAURISMO 2 PA; QL; SP

DROXIA 2

EMCYT 2

ERIVEDGE 2 PA; QL; SP

ERLEADA 2 PA; QL; SP

erlotinib hcl 2 PA; QL; SP

etoposide oral 1 SP

everolimus oral tablet 2.5

mg, 5 mg, 7.5 mg2 PA; QL; SP

exemestane 2

FARESTON 4

FARYDAK 2 PA; QL; SP

FEMARA E

flutamide 1

GILOTRIF 3 PA; QL; SP

GLEEVEC E PA; QL; SP

GLEOSTINE 2 SP

HYCAMTIN ORAL 2 PA; QL; SP

HYDREA 4

hydroxyurea oral 1

IBRANCE ORAL

CAPSULE2 PA; QL; SP

ICLUSIG 3 PA; QL; SP

IDHIFA 2 PA; QL; SP

imatinib mesylate 1 PA; QL; SP

IMBRUVICA 2 PA; QL; SP

INLYTA 3 PA; QL; SP

INREBIC 4 PA; QL; SP

IRESSA 3 PA; QL; SP

JAKAFI 2 PA; QL; SP

KISQALI (200 MG

DOSE)4

PA; ST;

QL; SP

KISQALI (400 MG

DOSE)4

PA; ST;

QL; SP

KISQALI (600 MG

DOSE)4

PA; ST;

QL; SP

KISQALI FEMARA (400

MG DOSE)4

PA; ST;

QL; SP

KISQALI FEMARA (600

MG DOSE)4

PA; ST;

QL; SP

KISQALI FEMARA(200

MG DOSE)4

PA; ST;

QL; SP

LENVIMA (10 MG DAILY

DOSE)3 PA; QL; SP


DOSE)3 PA; QL; SP


DOSE)3 PA; QL; SP


DOSE)3 PA; QL; SP


DOSE)3 PA; QL; SP


DOSE)3 PA; QL; SP

LENVIMA (4 MG DAILY

DOSE)3 PA; QL; SP

LENVIMA (8 MG DAILY

DOSE)3 PA; QL; SP

letrozole oral 1

1

RequiremDrug


Limits

2

Drug NameDrug

Tier

Requirem

ents &

Limits

leucovorin calcium oral 1

LEUKERAN 2

LONSURF 2 PA; QL; SP

LORBRENA 3 PA; SP

LYNPARZA 2 PA; QL; SP

LYSODREN 2

MATULANE 2 SP

MEKINIST 3 PA; QL; SP

MEKTOVI4

PA; ST;

QL; SP

melphalan 2 SP

mercaptopurine oral 1

MESNEX ORAL 3

MYLERAN 2

NERLYNX 2 PA; QL; SP

NEXAVAR 2 PA; QL; SP

nilutamide 3 SP

NINLARO 2 PA; QL; SP

NUBEQA 2 PA; QL; SP

ODOMZO 2 PA; QL; SP

PANRETIN 3

PIQRAY (200 MG DAILY

DOSE)2 PA; QL; SP


DOSE)2 PA; QL; SP


DOSE)2 PA; QL; SP

POMALYST 3 PA; QL; SP

PURIXAN 4 PA; SP

REVLIMID 2 PA; QL; SP

ROZLYTREK 2 PA; QL; SP

RUBRACA3

PA; ST;

QL; SP

RYDAPT 2 PA; QL; SP

SIKLOS E

SOLTAMOX E

SPRYCEL4

PA; ST;

QL; SP

STIVARGA 2 PA; QL; SP

SUTENT 2 PA; QL; SP

SYNRIBO 2 PA; QL; SP

TABLOID 2 SP

TAFINLAR 3 PA; QL; SP

TAGRISSO 3 PA; QL; SP

TALZENNA4

PA; ST;

QL; SP

tamoxifen citrate oral

tablet 10 mg1

tamoxifen citrate oral

tablet 20 mg1 H-PA

TARCEVA 4 PA; QL; SP

TARGRETIN EXTERNAL 3 QL; SP

TARGRETIN ORAL 2 SP

TASIGNA2

PA; ST;

QL; SP

TAZVERIK 4 PA

TEMODAR ORAL 4 PA; SP

temozolomide 1 PA; SP

THALOMID 2 PA; QL; SP

TIBSOVO 2 PA; QL; SP

toremifene citrate 2

tretinoin oral 2 QL; SP

TURALIO 2 PA; QL; SP

TYKERB 2 PA; QL; SP

VALCHLOR 2 PA; QL; SP

VENCLEXTA 2 PA; QL; SP

VENCLEXTA STARTING

PACK2 PA; QL; SP

VERZENIO 2 PA; QL; SP

VITRAKVI 2 PA; QL; SP

VIZIMPRO 3 PA; QL; SP

VOTRIENT 2 PA; QL; SP

XALKORI 2 PA; QL; SP

XELODA 1 QL; SP

XOSPATA 3 PA; QL; SP

XPOVIO (100 MG ONCE

WEEKLY)4 PA; QL; SP

2

RequiremDrug


Limits

2

Drug NameDrug

Tier

Requirem

ents &

Limits

XPOVIO (60 MG ONCE

WEEKLY)4 PA; QL; SP

XPOVIO (80 MG ONCE

WEEKLY)4 PA; QL; SP

XPOVIO (80 MG TWICE

WEEKLY)4 PA; QL; SP

XTANDI4

PA; ST;

QL; SP

YONSAE

PA; ST;

QL; SP

ZEJULA 2 PA; QL; SP

ZELBORAF 2 PA; QL; SP

ZOLINZA 2 QL; SP

ZYDELIG 4 PA; QL; SP

ZYKADIA 2 PA; QL; SP

ZYTIGA 2 PA; QL; SP

Antiparasitics - Drugs

for Parasitic Infections

albendazole oral 3 PA; QL

ALBENZA 4 PA; QL

ALINIA 2

ARAKODA 4 QL

atovaquone oral 2

atovaquone-proguanil hcl 2

BENZNIDAZOLE 2 PA; QL

BILTRICIDE 4

chloroquine phosphate

oral1

COARTEM 2

crotan 2

DARAPRIM 2 PA; SP

EGATEN 3

ELIMITE 4

EMVERM 4 PA; QL

hydroxychloroquine

sulfate oral1

IMPAVIDO 2 PA; QL

ivermectin oral 1

KRINTAFEL 1 QL

lindane 1 QL

MALARONE 4

malathion 1

mefloquine hcl 1

MEPRON E

NATROBA E

NEBUPENT 4

OVIDE 4

pentamidine isethionate

inhalation2

permethrin external 1

PLAQUENIL E

praziquantel oral 2

primaquine phosphate 1

QUALAQUIN 4

quinine sulfate oral 1

SKLICE 4 QL

spinosad 3

STROMECTOL 4

SULFURATED LIME 3

ULESFIA EXTERNAL

LOTION 5 %3

Antiparkinson Agents -

Drugs for Parkinson's

Disease

amantadine hcl oral 1

APOKYN 2 SP

AZILECT E

benztropine mesylate

oral1

bromocriptine mesylate

oral1

carbidopa oral 1

carbidopa-levodopa 1

carbidopa-levodopa er 1

carbidopa-levodopa-

entacapone1

COMTAN 4

DUOPA 4 PA

entacapone 1

3

RequiremDrug


Limits

2

Drug NameDrug

Tier

Requirem

ents &

Limits

GOCOVRI E QL

INBRIJA 3 PA; QL; SP

LODOSYN E

MIRAPEX 4

MIRAPEX ER E

NEUPRO 3

NOURIANZ E PA; QL

OSMOLEX ER E

PARLODEL E

pramipexole

dihydrochloride1

pramipexole

dihydrochloride erE

rasagiline mesylate oral 3

REQUIP XL E

ropinirole hcl 1

ropinirole hcl er E

RYTARY E

selegiline hcl oral 1

SINEMET 4

SINEMET CR ORAL

TABLET EXTENDED

RELEASE 25-100 MG, 4

50-200 MG

STALEVO 100 4

STALEVO 125 4

STALEVO 150 4

STALEVO 200 4

STALEVO 50 4

STALEVO 75 4

TASMAR E

tolcapone 2

trihexyphenidyl hcl 1

XADAGO E

ZELAPAR 3

Antiplatelets - Drugs

for Heart Attack and

Stroke Prevention

AGGRENOX 4

aspirin-dipyridamole er 3

ASPIRIN-OMEPRAZOLE E

BRILINTA 4 QL

cilostazol 1

clopidogrel bisulfate oral 1

dipyridamole oral 1

DURLAZA E QL

EFFIENT E QL

PLAVIX E

prasugrel hcl 3 QL

YOSPRALA E

ZONTIVITY 4 QL

Antipsychotics - Drugs

for Mood Disorders

ABILIFY E QL

ABILIFY MYCITE E PA; QL

aripiprazole oral solution 3

aripiprazole oral tablet 2 QL

aripiprazole oral tablet

dispersible2 QL

CAPLYTA E PA

chlorpromazine hcl oral 1

clozapine 1

CLOZARIL 4

FANAPT 4 QL

FANAPT TITRATION

PACK3 QL

fluphenazine hcl oral 1

GEODON ORAL E QL

haloperidol lactate oral 1

haloperidol oral 1

INVEGA E QL

LATUDA 4 QL

loxapine succinate 1

molindone hcl 3

NUPLAZID 4 PA

olanzapine oral tablet 1 QL

olanzapine oral tablet

dispersible2 QL

4

RequiremDrug


Limits

2

Drug NameDrug

Tier

Requirem

ents &

Limits

paliperidone er 3 QL

pimozide 2

quetiapine fumarate 1

quetiapine fumarate er 3 QL

REXULTI 4 PA; ST; QL

RISPERDAL E

risperidone 1

SAPHRIS 3 QL

SECUADO E

SEROQUEL E

SEROQUEL XR E QL

thioridazine hcl oral 1

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ E

VRAYLAR 4 ST; QL

ziprasidone hcl 2 QL

ZYPREXA ORAL E QL

ZYPREXA ZYDIS E QL

Antivirals - Drugs for

Viral Infections

abacavir sulfate 1 SP

abacavir sulfate-

lamivudine2 QL; SP

abacavir-lamivudine-

zidovudine1 SP

acyclovir external cream E QL

acyclovir external

ointment4 PA; ST; QL

acyclovir oral 1

adefovir dipivoxil 2 SP

APTIVUS ORAL

CAPSULE2 SP

APTIVUS ORAL

SOLUTION3 SP

atazanavir sulfate 2 SP

ATRIPLA E ST; QL; SP

BARACLUDE ORAL

SOLUTION2 SP

BARACLUDE ORAL

TABLETE SP

BIKTARVY 4 QL; SP

CIMDUO 2 QL; SP

COMBIVIR 4 SP

COMPLERA 4 QL; SP

CRIXIVAN 2 SP

DELSTRIGO 2 QL; SP

DENAVIR E

DESCOVY 4 ST; QL; SP

DIDANOSINE ORAL

CAPSULE DELAYED 4 SP

RELEASE 200 MG

didanosine oral capsule

delayed release 250 mg, 1 SP

400 mg

DOVATO 2 QL; SP

EDURANT 2 SP

efavirenz 2 SP

EMTRIVA 2 SP

entecavir 1 SP

EPCLUSA 2 PA; QL; SP

EPIVIR 4 SP

EPIVIR HBV ORAL

SOLUTION2 SP

EPIVIR HBV ORAL

TABLET4 SP

EPZICOM E QL; SP

EVOTAZ 2 SP

famciclovir oral tablet 125

mg, 500 mg2

famciclovir oral tablet 250

mg2 QL

fosamprenavir calcium 2 SP

FUZEON 2 SP

GENVOYA 4 QL; SP

HARVONI ORAL

TABLET 45-200 MG2 PA; SP

HARVONI ORAL

TABLET 90-400 MG2 PA; QL; SP

5

RequiremDrug


Limits

2

Drug NameDrug

Tier

Requirem

ents &

Limits

HEPSERA 4 SP

INTELENCE 2 SP

INTRON A 4 PA; SP

INVIRASE 2 SP

ISENTRESS 2 SP

ISENTRESS HD 2 SP

JULUCA 2 QL; SP

KALETRA ORAL

SOLUTION4 SP

KALETRA ORAL

TABLET2 SP

lamivudine 1 SP

lamivudine-zidovudine 1 SP

LEDIPASVIR-

SOFOSBUVIR2 PA; QL; SP

LEXIVA ORAL

SUSPENSION2 SP

LEXIVA ORAL TABLET 4 SP

lopinavir-ritonavir 2 SP

MAVYRET 2 PA; QL; SP

nevirapine 1 SP

nevirapine er E SP

NORVIR ORAL PACKET 2 SP

NORVIR ORAL

SOLUTION2 SP

NORVIR ORAL TABLET E SP

ODEFSEY 4 QL; SP

oseltamivir phosphate

oral capsule2

oseltamivir phosphate

oral suspension 2 QL

reconstituted

PEGASYS 2 PA; QL; SP

PEGASYS PROCLICK 2 PA; QL; SP

PEGINTRON 4 PA; QL; SP

PIFELTRO 3 SP

PREVYMIS ORAL 2 PA

PREZCOBIX 2 SP

PREZISTA 2 SP

RELENZA DISKHALER 3

RESCRIPTOR ORAL

TABLET 200 MG2 SP

RETROVIR ORAL

CAPSULE4 SP

RETROVIR ORAL

SYRUP3 SP

REYATAZ ORAL

CAPSULEE SP

REYATAZ ORAL

PACKET2 SP

ribavirin inhalation 3

ribavirin oral 1

rimantadine hcl 1

ritonavir 2 SP

SELZENTRY 2 PA; SP

SITAVIG E QL

SOFOSBUVIR-

VELPATASVIR2 PA; QL; SP

SOVALDI ORAL

TABLET 200 MG4 PA; ST

SOVALDI ORAL

TABLET 400 MG4

PA; ST;

QL; SP

stavudine 1 SP

STRIBILD 4 QL; SP

SUSTIVA 4 SP

SYLATRON 2 PA; QL; SP

SYMFI 2 QL; SP

SYMFI LO 2 QL; SP

SYMTUZA E QL; SP

TAMIFLU ORAL

CAPSULEE

TAMIFLU ORAL

SUSPENSION E QL

RECONSTITUTED

TEMIXYS E SP

tenofovir disoproxil

fumarate2 SP

TIVICAY 3 SP

TRIUMEQ 2 QL; SP

6

RequiremDrug


Limits

2

Drug NameDrug

Tier

Requirem

ents &

Limits

TRIZIVIR 4 SP

TRUVADA 4 QL; SP

TYBOST 2 SP

valacyclovir hcl oral 1 QL

VALCYTE ORAL

SOLUTION 4

RECONSTITUTED

VALCYTE ORAL

TABLETE QL

valganciclovir hcl oral

solution reconstituted1

valganciclovir hcl oral

tablet1 QL

VALTREX E QL

VEMLIDY 4 ST; SP

VIDEX EC ORAL


RELEASE 125 MG

VIDEX EC ORAL


RELEASE 250 MG

VIDEX ORAL

SOLUTION 2 SP

RECONSTITUTED 2 GM

VIEKIRA PAK4

PA; ST;

QL; SP

VIRACEPT 2 SP

VIRAMUNE ORAL

SUSPENSION4 SP

VIRAMUNE ORAL

TABLETE SP

VIRAMUNE XR E SP

VIRAZOLE 4

VIREAD ORAL

POWDER3 SP

VIREAD ORAL TABLET

150 MG, 200 MG, 250 2 SP

MG

VIREAD ORAL TABLET

300 MGE SP

VOSEVI 2 PA; QL; SP

XERESE E

XOFLUZA (40 MG

DOSE)3 QL

XOFLUZA (80 MG

DOSE)3 QL

ZEPATIER 2 PA; QL; SP

ZIAGEN 4 SP

zidovudine 1 SP

ZOVIRAX EXTERNAL

CREAME QL

ZOVIRAX EXTERNAL

OINTMENTE PA; ST; QL

ZOVIRAX ORAL 4

Anxiolytics - Drugs for

Anxiety

alprazolam er 1

alprazolam intensol 1

alprazolam oral 1

alprazolam xr 1

ATIVAN ORAL E

buspirone hcl oral 1

chlordiazepoxide hcl 1

clonazepam oral 1

clorazepate dipotassium 1

diazepam intensol 1

diazepam oral 1

DORAL 3

estazolam 1

HALCION 4

hydroxyzine hcl oral 1

hydroxyzine pamoate

oral1

KLONOPIN E

lorazepam intensol 1

lorazepam oral

concentrate 2 mg/ml1

lorazepam oral tablet 1

meprobamate 1

midazolam hcl oral 1

oxazepam 1

7

RequiremDrug


Limits

2

Drug NameDrug

Tier

Requirem

ents &

Limits

quazepam 1

TRANXENE-T 4

triazolam 1

VALIUM E

VISTARIL 4

XANAX E

XANAX XR E

Bipolar Agents - Drugs

for Mood Disorders

EQUETRO 3

lithium 1

lithium carbonate er 1

lithium carbonate oral 1

LITHOBID 4

Cardiovascular Agents

- Drugs for Heart and

Circulation Conditions

ACCUPRIL 4

ACCURETIC 4

acebutolol hcl oral 1

acetazolamide er 1

acetazolamide oral 1

ADALAT CC ORAL

TABLET EXTENDED

RELEASE 24 HOUR 30 4

MG, 60 MG, 90 MG

ALDACTAZIDE ORAL

TABLET 25-25 MG4

ALDACTAZIDE ORAL

TABLET 50-50 MG2

ALDACTONE 4

aliskiren fumarate 3

ALTACE 4

ALTOPREV E

amiloride hcl oral 1

amiloride-

hydrochlorothiazide1

amiodarone hcl oral 1

amlodipine besylate oral 1

amlodipine besylate-

benazepril hcl1


valsartan2

amlodipine-atorvastatin E

amlodipine-olmesartan E

amlodipine-valsartan-

hctzE

ANTARA E

ATACAND 4

ATACAND HCT 4

atenolol oral 1

atenolol-chlorthalidone 1

atorvastatin calcium oral

tablet 10 mg, 20 mg1 QL; H-PA

atorvastatin calcium oral

tablet 40 mg, 80 mg1 QL

AVALIDE 4

AVAPRO 4

AZOR E

benazepril hcl oral 1

benazepril-


BENICAR E

BENICAR HCT E

BETAPACE E

BETAPACE AF 4

betaxolol hcl oral 1

BIDIL 2

bisoprolol fumarate 1

bisoprolol-


bumetanide oral 1

BUMEX 3

BYSTOLIC 2

CADUET E

CALAN SR 4

candesartan cilexetil 3

candesartan cilexetil-hctz 3

8

RequiremDrug


Limits

2

Drug NameDrug

Tier

Requirem

ents &

Limits

captopril oral 1

captopril-


CARDIZEM E

CARDIZEM CD E

CARDIZEM LA E

CARDURA 4

CAROSPIR 4 PA

cartia xt 2

carvedilol 1

carvedilol phosphate er E

CATAPRES 4

CATAPRES-TTS-1 4

CATAPRES-TTS-2 4

CATAPRES-TTS-3 4

chlorothiazide oral 1

chlorthalidone 1

cholestyramine light 1

cholestyramine oral 1

clonidine 3 (Patch)

clonidine hcl oral 1

colesevelam hcl E

COLESTID FLAVORED

ORAL GRANULES3

COLESTID FLAVORED

ORAL PACKET4

COLESTID ORAL

GRANULES3

COLESTID ORAL

PACKET4

COLESTID ORAL

TABLET4

colestipol hcl 1

CONSENSI E

COREG 4

COREG CR E

CORGARD 4

CORLANOR 3 PA; QL

COZAAR 4

CRESTOR E QL

DEMSER 3

DIBENZYLINE E

digitek 1

digox 1

digoxin oral 1

DILATRATE-SR 3

diltiazem hcl er beads 2

diltiazem hcl er coated

beads2

diltiazem hcl er oral

capsule extended 1

release 12 hour

diltiazem hcl oral 1

dilt-xr 1

DIOVAN E

DIOVAN HCT E

disopyramide phosphate 1

DIURIL 2

dofetilide 2

doxazosin mesylate oral 1

DUTOPROL ORAL

TABLET EXTENDED

RELEASE 24 HOUR E QL

100-12.5 MG, 50-12.5

MG

DUTOPROL ORAL

TABLET EXTENDED

RELEASE 24 HOUR 25-E

12.5 MG

DYAZIDE 4

DYRENIUM 4

EDARBI 3

EDARBYCLOR 3

EDECRIN 4

enalapril maleate oral 1

enalapril-


ENTRESTO 4 PA; QL

EPANED 4 PA

9

RequiremDrug


Limits

3

Drug NameDrug

Tier

Requirem

ents &

Limits

eplerenone 2

eprosartan mesylate oral

tablet 600 mg3

ethacrynic acid 3

EXFORGE E

EXFORGE HCT E

EZALLOR SPRINKLE 3 PA

ezetimibe 2

ezetimibe-simvastatin 3

felodipine er 1

fenofibrate micronized E

fenofibrate oral capsule E

fenofibrate oral tablet 120

mg, 145 mg, 40 mg, 48 E

mg

fenofibrate oral tablet 160

mg, 54 mg2

fenofibric acid E

FENOGLIDE E

FIBRICOR E

flecainide acetate 1

FLOLIPID 4 PA

fluvastatin sodium 1

fluvastatin sodium er 3 ST

fosinopril sodium 1

fosinopril sodium-hctz 1

furosemide oral 1

gemfibrozil oral 1

GONITRO E QL

guanfacine hcl 1

HEMANGEOL E

hydralazine hcl oral 1

hydrochlorothiazide oral 1

HYZAAR 4

indapamide 1

INDERAL LA E

INDERAL XL 3

INNOPRAN XL 3

INSPRA 4

irbesartan 1

irbesartan-


ISORDIL TITRADOSE 4

isosorbide dinitrate oral

tablet 10 mg, 20 mg, 30 1

mg, 5 mg

isosorbide dinitrate oral

tablet 40 mg2

isosorbide mononitrate 1

isosorbide mononitrate er 1

isoxsuprine hcl oral 1

isradipine 1

JUXTAPID4

PA; ST;

QL; SP

KAPSPARGO

SPRINKLE4

KATERZIA 4 PA

KEVEYIS 2 PA; QL; SP

labetalol hcl oral 1

LANOXIN ORAL 3

LASIX 4

LESCOL XL E ST

LIPITOR E QL

LIPOFEN E

lisinopril oral 1

lisinopril-


LIVALO E ST; QL

LOPID 4

LOPRESSOR 4

LOPRESSOR HCT 4

losartan potassium 1

losartan potassium-hctz 1

LOTENSIN 4

LOTENSIN HCT 4

LOTREL 4

lovastatin 1 H

0

RequiremDrug


Limits

3

Drug NameDrug

Tier

Requirem

ents &

Limits

LOVAZA E

matzim la 2

MAXZIDE 4

MAXZIDE-25 4

methazolamide oral 1

methyldopa 1

methyldopa-


metolazone 1

metoprolol succinate er

oral tablet extended

release 24 hour 100 mg, 2

200 mg, 50 mg

metoprolol succinate er

oral tablet extended 1

release 24 hour 25 mg

metoprolol tartrate oral

tablet 100 mg, 25 mg, 50 1

mg

metoprolol tartrate oral

tablet 37.5 mg, 75 mgE

metoprolol-


mexiletine hcl oral 1

MICARDIS E

MICARDIS HCT E

midodrine hcl 1

MINIPRESS 4

minitran 1

minoxidil oral 1

moexipril hcl 1

MULTAQ 4 PA

nadolol oral 1

niacin

(antihyperlipidemic)2

niacin er

(antihyperlipidemic)4

niacor 2

NIASPAN 2

nicardipine hcl oral 1

nifedipine er 1

nifedipine er osmotic

release1

nifedipine oral 1

nimodipine oral 1

nisoldipine er 2

NITRO-BID 2

NITRO-DUR 3

nitroglycerin sublingual 1

nitroglycerin transdermal 1

nitroglycerin translingual E QL

NITROLINGUAL E QL

NITROMIST 4 QL

NITROSTAT 4

nitro-time 1

NORPACE 4

NORPACE CR 2

NORTHERA 4 PA; QL; SP

NORVASC E

NYMALIZE 2

olmesartan medoxomil

oral2

olmesartan medoxomil-

hctz2

olmesartan-amlodipine-

hctzE

omega-3-acid ethyl

esters3

PACERONE ORAL


MG

pacerone oral tablet 200

mg1

pentoxifylline er 1

perindopril erbumine 2

phenoxybenzamine hcl

oral2

pindolol 1

PRALUENT 2 PA; ST; QL

PRAVACHOL 4

1

RequiremDrug


Limits

3

Drug NameDrug

Tier

Requirem

ents &

Limits

pravastatin sodium 1

prazosin hcl oral 1

PRESTALIA E QL

prevalite 1

PRINIVIL 4

PROCARDIA 4

PROCARDIA XL 4

propafenone hcl 1

propafenone hcl er 3

propranolol hcl er 2

propranolol hcl oral 1

propranolol-hctz 1

QBRELIS 4 PA

QUESTRAN 4

QUESTRAN LIGHT 4

quinapril hcl 1

quinapril-


quinidine gluconate er 1

quinidine sulfate 1

ramipril 1

RANEXA E

ranolazine er 2

RECTIV 3 QL

REPATHA 2 PA; ST; QL

REPATHA

PUSHTRONEX SYSTEM2 PA; ST; QL

REPATHA SURECLICK 2 PA; ST; QL

rosuvastatin calcium 2 QL

RYTHMOL SR 4

SIMVASTATIN ORAL

SUSPENSIONE PA

simvastatin oral tablet 10

mg, 20 mg, 40 mg, 5 mg1 H-PA

simvastatin oral tablet 80

mg1

sotalol hcl (af) 1

sotalol hcl oral 1

sotalol hydrochloride oral

tablet 120 mg, 160 mg, 1

80 mg

SOTYLIZE 4 PA

spironolactone oral 1

spironolactone-hctz 1

SULAR 4

TARKA 4

taztia xt 2

TEKTURNA 3

TEKTURNA HCT 3

telmisartan 2

telmisartan-amlodipine E

telmisartan-hctz 2

TENORETIC 100 E

TENORETIC 50 E

TENORMIN E

tiadylt er 2

TIAZAC 4

TIKOSYN 4

timolol maleate oral 1

TOPROL XL 4

torsemide 1

trandolapril 1

trandolapril-verapamil hcl

er3

triamterene oral 3

triamterene-hctz 1

TRIBENZOR E

TRICOR E

TRILIPIX E

TWYNSTA E

valsartan 2

valsartan-


VASCEPA ORAL

CAPSULE 0.5 GM4 PA

VASCEPA ORAL

CAPSULE 1 GM3 PA

2

RequiremDrug


Limits

3

Drug NameDrug

Tier

Requirem

ents &

Limits

VASERETIC E

VASOTEC E

VECAMYL 4 PA

verapamil hcl er oral

capsule extended


200 mg, 300 mg


capsule extended


180 mg, 240 mg, 360 mg


tablet extended release1

verapamil hcl oral 1

VERELAN 4

VERELAN PM 4

VYNDAMAX 2 PA; QL; SP

VYNDAQEL 2 PA; QL; SP

VYTORIN E

WELCHOL 2

ZESTORETIC E

ZESTRIL E

ZETIA E

ZIAC ORAL TABLET 10-

6.25 MG, 2.5-6.25 MG3

ZIAC ORAL TABLET 5-

6.25 MG4

ZOCOR ORAL TABLET

10 MG, 20 MG, 40 MG, 4

80 MG

ZYPITAMAG E ST; QL

Central Nervous

System Agents - Drugs

for Attention Deficit

Disorder

ADDERALL E PA

ADDERALL XR 2 QL

ADHANSIA XR E PA; QL

ADZENYS ER E PA; QL

ADZENYS XR-ODT E PA; QL

AMPHETAMINE ER 4 PA; QL

amphetamine sulfate E PA

amphetamine-

dextroamphetamine1 PA

amphetamine-

dextroamphetamine erE QL

APTENSIO XR E PA; QL

atomoxetine hcl 3 QL

clonidine hcl er E

CONCERTA 2 PA; QL

COTEMPLA XR-ODT E PA; QL

DAYTRANA E PA; QL

DESOXYN 4 PA

DEXEDRINE E PA

dexmethylphenidate hcl 1 PA

dexmethylphenidate hcl

er3 PA; QL

dextroamphetamine

sulfate er3 PA

dextroamphetamine

sulfate oral solution1 PA

dextroamphetamine

sulfate oral tablet3 PA

DYANAVEL XR E PA; QL

EVEKEO E PA

EVEKEO ODT E PA; QL

FOCALIN 4 PA

FOCALIN XR E PA; QL

guanfacine hcl er 2 QL

INTUNIV E QL

JORNAY PM E PA; QL

KAPVAY E

metadate er 4 PA; QL

methamphetamine hcl 1 PA

METHYLIN 4 PA

methylphenidate hcl er

(cd)2 PA; QL

3

RequiremDrug


Limits

3

Drug NameDrug

Tier

Requirem

ents &

Limits


(la) oral capsule

extended release 24 hour 2 PA; QL

10 mg, 20 mg, 30 mg, 40

mg


(la) oral capsule

extended release 24 hour2 PA

60 mg


oral tablet extended 4 PA; QL

release 10 mg, 20 mg


oral tablet extended

release 18 mg, 27 mg, 36E

PA; QL

mg, 54 mg, 72 mg

methylphenidate hcl oral

solution1 PA


tablet1 PA


tablet chewable3 PA

MYDAYIS E PA; QL

PROCENTRA 3 PA

QUILLICHEW ER E PA; QL

QUILLIVANT XR ORAL

SUSPENSION

RECONSTITUTED 25 E PA; QL

MG/5ML

relexxii E PA; QL

RITALIN 4 PA

RITALIN LA E PA; QL

STRATTERA E QL

PA; (Tier 2

until

37/1/2020;

Tier 3 after

7/1/2020);

VYVANSE QL

ZENZEDI E PA

Central Nervous

System Agents - Drugs

for Multiple Sclerosis

AMPYRA E PA; QL; SP

AUBAGIO 3 PA; QL; SP

AVONEX PEN 2 PA; QL; SP

AVONEX PREFILLED 2 PA; QL; SP

BETASERON 2 PA; QL; SP

COPAXONE E PA; QL; SP

dalfampridine er 2 PA; QL; SP

EXTAVIAE

PA; ST;

QL; SP

GILENYA 3 PA; QL; SP

glatiramer acetate 2 PA; QL; SP

glatopa E PA; QL; SP

MAVENCLAD (10 TABS)3

PA; ST;

QL; SP

MAVENCLAD (4 TABS)3

PA; ST;

QL; SP

MAVENCLAD (5 TABS)3

PA; ST;

QL; SP

MAVENCLAD (6 TABS)3

PA; ST;

QL; SP

MAVENCLAD (7 TABS)3

PA; ST;

QL; SP

MAVENCLAD (8 TABS)3

PA; ST;

QL; SP

MAVENCLAD (9 TABS)3

PA; ST;

QL; SP

MAYZENT 3 PA; QL; SP

MAYZENT STARTER

PACK3 PA; QL; SP

PLEGRIDY 3 PA; QL; SP

PLEGRIDY STARTER

PACK3 PA; QL; SP

REBIF4

PA; ST;

QL; SP

REBIF REBIDOSE4

PA; ST;

QL; SP

REBIF REBIDOSE

TITRATION PACK4

PA; ST;

QL; SP

REBIF TITRATION

PACK4

PA; ST;

QL; SP

TECFIDERA 2 PA; QL; SP

VUMERITY E PA; QL; SP

4

RequiremDrug


Limits

3

Drug NameDrug

Tier

Requirem

ents &

Limits

VUMERITY (STARTER) E PA; QL; SP

Central Nervous

System Agents -

Miscellaneous

AUSTEDO 2 PA; QL; SP

caffeine citrate oral 1

GRALISE E QL

GRALISE STARTER E QL

HORIZANT E QL

INGREZZA4

PA; ST;

QL; SP

LYRICA CR E ST; QL

LYRICA ORAL

CAPSULE4 PA; ST; QL

LYRICA ORAL

SOLUTION4 ST; QL

NUEDEXTA 2 PA

pregabalin oral capsule 2 QL

pregabalin oral solution 3 QL

RILUTEK 4 SP

riluzole 1 SP

SAVELLA 4 QL

SAVELLA TITRATION

PACK4 QL

tetrabenazine 2 PA; SP

TIGLUTIK 4 PA

XENAZINE E PA; SP

Dental and Oral Agents

- Drugs for Mouth and

Throat Conditions

cavarest 1

cevimeline hcl 1

chlorhexidine gluconate

mouth/throat1

clinpro 5000 1

DEBACTEROL 2

denta 5000 plus 1

dentagel 1

easygel 1

EVOXAC 4

fluoridex 1

fluoridex daily renewal 1

fluoridex enhanced

whitening1

fluoridex sensitivity relief 1

lidocaine hcl

mouth/throat1

lidocaine viscous hcl 1

MUCOSITISRX 3

NAFRINSE DAILY

ACIDULATED2

NAFRINSE

DAILY/NEUTRAL2

NAFRINSE WEEKLY 4

neutral sodium fluoride 1

oralone 1

paroex 1

PERIDEX 4

periogard 1

pilocarpine hcl oral 1

PREVIDENT 5000

BOOSTER PLUS3

PREVIDENT 5000 DRY

MOUTH4

PREVIDENT 5000

ENAMEL PROTECT3

PREVIDENT 5000

ORTHO DEFENSE3

PREVIDENT 5000 PLUS 4

PREVIDENT 5000

SENSITIVE3

PREVIDENT DENTAL 4

PREVIDENT

MOUTH/THROAT3

SALAGEN 4

sf 1

sf 5000 plus 1

sodium fluoride 5000

plus1

sodium fluoride dental 1

5

RequiremDrug


Limits

3

Drug NameDrug

Tier

Requirem

ents &

Limits

TOPEX TOPICAL

ANESTHETIC3

triamcinolone acetonide

mouth/throat1

Dermatological Agents

- Drugs for Skin

Conditions

ABSORICA E PA

ABSORICA LD E PA

ACANYA E QL

acitretin 1

ACZONE EXTERNAL

GEL 5 %4 QL

ACZONE EXTERNAL

GEL 7.5 %3 QL

adapalene external

creamE PA; QL

adapalene external gel E PA; QL

ADAPALENE

EXTERNAL PADE PA

ADAPALENE

EXTERNAL SOLUTIONE PA

adapalene-benzoyl

peroxideE QL

AKLIEF E PA; QL

ALA SCALP 4

ala-cort external cream 1

%E

ala-cort external cream

2.5 %1

alclometasone

dipropionate1

ALDARA 4 QL

ALTRENO E PA; QL

amcinonide external

cream3

amcinonide external

lotion3

amcinonide external

ointment1

AMELUZ 3

ammonium lactate

externalE

amnesteem 2

AMZEEQ E

APEXICON E 2 QL

ATRALIN E PA; QL

avar cleanser 1

AVAR LS CLEANSER E

AVAR-E EMOLLIENT 3

AVAR-E GREEN 3

AVAR-E LS 3

avita E PA; QL

azelaic acid external 3

AZELEX 3 QL

balsam peru-castor oil 1

BENZAC AC WASH E

BENZACLIN E QL

BENZACLIN WITH

PUMPE QL

BENZAMYCIN 2 QL

benzepro creamy wash E QL

BENZEPRO EXTERNAL E

BENZEPRO EXTERNAL

FOAM 5.2 %, 9.7 %E

benzepro external foam

5.3 %E

BENZEPRO EXTERNAL

LIQUIDE

benzepro foaming cloths E

BENZEPRO SHORT

CONTACTE

BENZIQ E

BENZIQ LS E

BENZIQ WASH 4

BENZOIN 3

benzoin compound 1

benzoyl peroxide

external foam 9.8 %E

6

RequiremDrug


Limits

3

Drug NameDrug

Tier

Requirem

ents &

Limits

BENZOYL PEROXIDE

EXTERNAL GEL 6.5 %E

benzoyl peroxide-

erythromycin1 QL

beser external lotion 3 ST; QL

betamethasone

dipropionate aug external 1

cream

betamethasone


gel

betamethasone


lotion

betamethasone


ointment

betamethasone

dipropionate external 2

cream

betamethasone


lotion

betamethasone


ointment

betamethasone valerate

external cream1


external foamE QL


external lotion1


external ointment1

bp 10-1 1

bp cleansing wash 1

bp wash external liquid

2.5 %, 7 %E

BRYHALI E ST; QL

calcipotriene external

cream2 QL

CALCIPOTRIENE

EXTERNAL FOAME QL


ointment2


solution1 QL

calcipotriene-betameth

diprop external ointment3 QL

CALCIPOTRIENE-

BETAMETH DIPROP

EXTERNAL E QL

SUSPENSION

CALCITRENE 3

calcitriol external 1 QL

CAPEX 2

CARAC 2

cerovel 1

claravis 2

CLEOCIN-T EXTERNAL

GEL4 QL

CLEOCIN-T EXTERNAL

LOTION4

CLINDACIN ETZ

EXTERNAL KITE

clindacin etz external

swab1

CLINDACIN PAC E

clindacin-p 1

CLINDAGEL E QL

clindamycin phos-

benzoyl perox external 3 QL

gel 1.2-5 %

clindamycin phos-

benzoyl perox external E QL

gel 1-5 %, 1.2-2.5 %


external foam3


external lotion3


external solution1 QL


external swab1

7

RequiremDrug


Limits

3

Drug NameDrug

Tier

Requirem

ents &

Limits

CLINDAMYCIN

PHOSPHATE GEL 1 % E

EXTERNAL


gel 1 % external3 QL

clindamycin-tretinoin E QL

clobetasol prop emollient

base2 QL

clobetasol propionate e 2 QL

clobetasol propionate

emulsionE QL


external cream2 QL


external foamE QL


external gel2 QL


external liquid1 QL


external lotionE QL


external ointment2 QL


external shampooE QL



CLOBEX E QL

CLOBEX SPRAY E QL

clocortolone pivalate 3 ST; QL

clodan external shampoo E QL

CLODERM E ST; QL

clotrimazole-

betamethasone external 1 QL

cream

clotrimazole-

betamethasone external 1

lotion

COAL TAR EXTERNAL 3

CONDYLOX 3

CORDRAN EXTERNAL

CREAM 0.025 %E QL

CORDRAN EXTERNAL

CREAM 0.05 %E ST; QL

CORDRAN EXTERNAL

LOTIONE ST; QL

CORDRAN EXTERNAL

OINTMENT4 ST

CORDRAN EXTERNAL

TAPE3 QL

CORTANE-B 4

CORTISPORIN

EXTERNAL CREAM2

CORTISPORIN

EXTERNAL OINTMENT3

CUTIVATE 3 ST; QL

dapsone external gel 5 % E QL

DAPSONE EXTERNAL

GEL 7.5 %4 QL

DERMA-SMOOTHE/FS

BODY4 QL

DERMA-SMOOTHE/FS

SCALP4

DESONATE 3 ST; QL

desonide external 3 QL

DESOWEN 3 QL

desoximetasone external

cream1 QL


gel3 QL


liquidE


ointment3 QL

diclofenac sodium

transdermal gel 3 %3 PA; QL

DIFFERIN EXTERNAL

CREAME PA; QL

DIFFERIN EXTERNAL

GEL 0.3 %E PA; QL

DIFFERIN EXTERNAL

LOTIONE PA; QL

diflorasone diacetate

external cream3 QL

8

RequiremDrug


Limits

3

Drug NameDrug

Tier

Requirem

ents &

Limits

diflorasone diacetate

external ointmentE QL

DIPROLENE 4

DIPROLENE AF 4

DOVONEX 4 QL

doxepin hcl external 1 PA; QL

doxycycline E

DRYSOL 4

DUOBRII E QL

DUPIXENT4

PA; ST;

QL; SP

EFUDEX 4

ELIDEL 4 ST; QL

ELOCON EXTERNAL

CREAM 0.1 %4

ENSTILAR 4 QL

ENZOCLEAR E

EPIDUO E QL

EPIDUO FORTE E QL

EPIFOAM 2

ery 1

ERYGEL 3

erythromycin external 1

ESKATA E

EUCRISA 3 ST; QL

EVOCLIN 4

FABIOR E PA; QL

FINACEA 4

fluocinolone acetonide

body3 QL


external cream3 QL






scalp3

fluocinonide emulsified

base1

fluocinonide external

cream 0.05 %1


cream 0.1 %E QL

fluocinonide external gel 1


ointment1


solution1

FLUOROPLEX 4

FLUOROURACIL

EXTERNAL CREAM 0.5 4

%

fluorouracil external

cream 5 %1

fluorouracil external

solution1

flurandrenolide external

cream3 ST; QL


lotion3 ST; QL


ointment3 ST

fluticasone propionate

external cream1


external lotion3 ST; QL


external ointment1

formaldehyde external

solution 10 %1

FORMALDEHYDE

EXTERNAL SOLUTION 3

37 %

GORDOFILM 2

halcinonide 3 ST; QL

halobetasol propionate

external cream2 QL

HALOBETASOL

PROPIONATE E QL

EXTERNAL FOAM

halobetasol propionate


9

RequiremDrug


Limits

4

Drug NameDrug

Tier

Requirem

ents &

Limits

HALOG EXTERNAL

CREAM4 ST; QL

HALOG EXTERNAL

OINTMENT3 ST; QL

HALUCORT 3

HYDRO 40 3

hydrocortisone ace-

pramoxine external 1

cream 2.5-1 %

hydrocortisone butyr lipo

baseE QL

hydrocortisone butyrate

external cream1


external lotionE QL


external ointment1


external solution1

hydrocortisone external

cream 1 %E


cream 2.5 %1


lotion 2.5 %1


ointment 1 %, 2.5 %1

hydrocortisone in

absorbase external 1

ointment 1 %

hydrocortisone valerate 3 QL

ILUMYAE

PA; ST;

QL; SP

imiquimod external 1 QL

IMIQUIMOD PUMP E QL

IMPOYZ E QL

INOVA 3

INOVA 4/1 ACNE

CONTROL THERAPY3

INOVA 8/2 ACNE

CONTROL THERAPY3

isotretinoin oral 2

ivermectin external 3 ST; QL

KENALOG EXTERNAL E QL

KERALAC E

KERALYT SCALP E

KLARON 4

LATRIX XM 2

LEVULAN KERASTICK 3

LEXETTE E QL

LIDOCAINE-

HYDROCORTISONE E

ACE EXTERNAL

LOCOID EXTERNAL

CREAM4

LOCOID EXTERNAL

LOTIONE QL

LOCOID EXTERNAL

SOLUTION4

LOCOID LIPOCREAM E QL

LOTRISONE EXTERNAL

CREAM 1-0.05 %4 QL

LUXIQ E QL

methoxsalen rapid 1

methyl salicylate external

liquid1

METROCREAM 4

METROGEL E

METROLOTION 4

metronidazole external

cream1


gel 0.75 %1


gel 1 %E


lotion1

MICORT-HC EXTERNAL

CREAM 2.5 %E

MIRVASO 4 QL

mometasone furoate

external1

myorisan 2

0

RequiremDrug


Limits

4

Drug NameDrug

Tier

Requirem

ents &

Limits

NEO-SYNALAR

EXTERNAL CREAME QL

neuac external gel 3 QL

NEUAC EXTERNAL KIT E

nolix 3 ST; QL

NORITATE E

NUCORT 3

NUVAIL 3

OLUX E QL

OLUX-E E QL

ONEXTON E QL

ORACEA E

OVACE PLUS

EXTERNAL CREAM3

OVACE PLUS

EXTERNAL LOTIONE

OVACE PLUS

EXTERNAL SHAMPOO3

OVACE PLUS WASH

EXTERNAL GEL3

OVACE PLUS WASH

EXTERNAL LIQUID4

OVACE WASH 4

OXSORALEN ULTRA 3

PANDEL 3

PICATO 3 QL

pimecrolimus 3 ST; QL

PLEXION E

PLEXION CLEANSER E

PLEXION CLEANSING

CLOTHE

podocon 1

podofilox external 1

PR BENZOYL

PEROXIDEE

pr benzoyl peroxide wash E

pramosone external

cream 1-1 %1

PRAMOSONE

EXTERNAL CREAM 1- 3

2.5 %

PRAMOSONE

EXTERNAL LOTION2

PRAMOSONE

EXTERNAL OINTMENT 2

1-1 %

PRAMOSONE

EXTERNAL OINTMENT 4

1-2.5 %

prednicarbate 1

PROMISEB 4 PA

PROTOPIC E ST; QL

PRUDOXIN 4 PA; QL

PSORCON 3 QL

PYROGALLIC ACID 2

REGRANEX 2 PA; QL

RETIN-A E PA; QL

RETIN-A MICRO GEL

0.04 %, 0.1 %E PA; QL

RETIN-A MICRO PUMP E PA; QL

RHOFADE 4 PA; QL

RIAX E

rosadan external cream 1

rosadan external gel 1

ROSADAN EXTERNAL

KITE

salicylic acid er E

salicylic acid external

cream1


liquidE


lotion1


solution 26 %1

salicylic acid wart

removerE

salimez 1

SALVAX DUO PLUS 3

1

RequiremDrug


Limits

4

Drug NameDrug

Tier

Requirem

ents &

Limits

SANTYL 3 QL

SCALACORT DK 3

selenium sulfide external

lotion1


shampoo 2.25 %4


shampoo 2.3 %E

SELRX E

SERNIVO E QL

sodium hyaluronate

external1

sodium sulfacetamide 1

sodium sulfacetamide

wash liquid 10 % external1

SODIUM

SULFACETAMIDE

WASH LIQUID 10 % 3

EXTERNAL

SOOLANTRA 4 ST; QL

SORIATANE 4

SORILUX E QL

sss 10-5 1

sulfacetamide sodium

(acne)1


external1

sulfacetamide sodium-

sulfur external cream 10- 1

2 %, 10-5 %


sulfur external cream 9.8- E

4.8 %


sulfur external emulsion1


sulfur external liquid 10-2 E

%, 9.8-4.8 %


sulfur external liquid 9-4 1

%, 9-4.5 %


sulfur external lotion 10-5 1

%


sulfur external lotion 9.8- E

4.8 %


sulfur external pad1


sulfur external 1

suspension 10-5 %


sulfur external E

suspension 8-4 %

sulfacetamide sod-sulfur

washE

sulfacetamide-sulfur in

urea1

sulfacleanse 8/4 E

sulfamez wash 1

SUMADAN E

SUMADAN WASH E

SUMADAN XLT E

SUMAXIN 4

SUMAXIN CP E

SUMAXIN WASH 3

SYNALAR E QL

SYNALAR (CREAM) E

SYNALAR (OINTMENT) E

SYNALAR TS E

TACLONEX EXTERNAL

OINTMENTE QL

TACLONEX EXTERNAL

SUSPENSION3 QL

tacrolimus external

ointment2 ST; QL

tazarotene external E PA; QL

TAZORAC 4 PA; QL

TEMOVATE 4 QL

TEXACORT 2

TOLAK E

2

RequiremDrug


Limits

4

Drug NameDrug

Tier

Requirem

ents &

Limits

TOPICORT 4 QL

TOPICORT SPRAY E

tovet external foam E QL

tretinoin external cream 3 PA; QL

tretinoin external gel 0.01

%, 0.05 %E PA; QL

tretinoin external gel

0.025 %E PA

tretinoin microsphere E PA; QL

tretinoin microsphere

pumpE PA; QL


external aerosol solution2 QL


external cream 0.025 %, 1

0.1 %


external cream 0.5 %1 QL


external lotion1


external ointment 0.025 1

%, 0.1 %, 0.5 %


external ointment 0.05 %E

trianex E

TRI-CHLOR 2

triderm external cream

0.1 %1

triderm external cream

0.5 %1 QL

TRIDESILON 3 QL

ULTRASAL-ER E

ULTRAVATE E PA; ST; QL

UMECTA MOUSSE E

URAMAXIN E

urea external cream 40

%, 45 %1

urea external cream 41

%, 47 %E

urea external lotion 1

urea external suspension 1

urea nail 1

urea-c40 1

uremez-40 1

UTOPIC E

VANOS E QL

VECTICAL E QL

VELTIN E QL

VENELEX 3

VERDESO E QL

VEREGEN 3 QL

VIRASAL E

ZACARE 3

zaclir cleansing 1

zenatane 2

ZIANA E QL

ZONALON 4 PA; QL

ZYCLARA E QL

ZYCLARA PUMP E QL

Diabetes - Glucose

Monitoring

ACCU-CHEK AVIVA

DEVICEE

ACCU-CHEK AVIVA

CONNECT KIT E

W/DEVICE

ACCU-CHEK AVIVA

PLUS KIT W/DEVICEE

ACCU-CHEK AVIVA

PLUS TEST STRIPSE QL

ACCU-CHEK COMPACT

PLUS CARE KITE

ACCU-CHEK COMPACT

PLUS TEST STRIPSE QL

ACCU-CHEK GUIDE KIT

W/DEVICEE

ACCU-CHEK GUIDE

TEST STRIPSE QL

ACCU-CHEK NANO

SMARTVIEW KIT E

W/DEVICE

3

RequiremDrug


Limits

4

Drug NameDrug

Tier

Requirem

ents &

Limits

ACCU-CHEK

SMARTVIEW TEST E QL

STRIPS

ACCU-CHEK SOFTCLIX

LANCET DEVICE KIT1

bd autoshield duo pen

needles2

bd ultra-fine insulin

syringes2

bd ultra-fine pen needles 2

CEQUR SIMPLICITY 2U 3

CONTOUR NEXT

MONITOR KIT

W/DEVICE

2(Contour

Next EZ)

CONTOUR NEXT

MONITOR KIT E

W/DEVICE

CONTOUR NEXT TEST 2 QL

CONTOUR TEST E QL

DEXCOM G4 / G5 / G6

RECEIVER,

TRANSMITTER,

SENSOR (INCLUDING 3 PA; QL

PLATINUM, PLATINUM

PEDIATRIC)

DEXCOM G4 / G5 / G6

RECEIVER,

TRANSMITTER,

SENSOR (INCLUDING 3 PA; QL

PLATINUM, PLATINUM

PEDIATRIC) DEVICE

EASYPLUS BLOOD

GLUCOSE TEST3 QL

ENLITE GLUCOSE

SENSORE PA; QL

FREESTYLE LIBRE 14

DAY READER3 PA

FREESTYLE LIBRE 14

DAY SENSOR3 PA; QL

FREESTYLE LIBRE

READER3 PA; QL

FREESTYLE LIBRE

SENSOR SYSTEM3 PA; QL

FREESTYLE

PRECISION NEO TESTE QL

GLUCAGEN HYPOKIT 2 QL

GLUCAGON

EMERGENCY KIT2

GUARDIAN CONNECT

TRANSMITTERE

GUARDIAN CONNECT

TRANSMITTERE PA; QL

GUARDIAN LINK 3

TRANSMITTERE

GUARDIAN SENSOR (3) 3 PA; QL

INSULIN SYRINGES 2

LANCETS 1

NOVOFINE

AUTOCOVER PEN 2

NEEDLE

NOVOFINE PEN

NEEDLE2

NOVOFINE PLUS PEN

NEEDLE2

NOVOPEN ECHO 3

ONETOUCH ULTRA 2

KIT W/DEVICE1

ONETOUCH ULTRA

BLUE TEST STRIPS1 QL

ONETOUCH ULTRA

MINI KIT W/DEVICE1

ONETOUCH VERIO KIT

W/DEVICE1

ONETOUCH VERIO

FLEX SYSTEM KIT 1

W/DEVICE

ONETOUCH VERIO

TEST STRIPS1 QL

ONETOUCH VERIO IQ

SYSTEM1

ONETOUCH VERIO

SYNC SYSTEM KIT 1

W/DEVICE

PRECISION LINK E

4

RequiremDrug


Limits

4

Drug NameDrug

Tier

Requirem

ents &

Limits

PRECISION PCX PLUS

TESTE QL

PRECISION QID

MONITORE

PRECISION QID TEST E QL

PRECISION SOF-TACT

MONITORE

PRECISION SOF-TACT

TESTE QL

PRECISION XTRA

BLOOD GLUCOSEE QL

PRECISION XTRA

DEVICEE

PRECISION XTRA KIT E

PRECISION XTRA

MONITORE

PROGLYCEM 3

RELION BLOOD

GLUCOSE TESTE QL

RELION ULTIMA TEST 3 QL

SOF-SENSOR E PA; QL

TRUE METRIX BLOOD

GLUCOSE TEST3 QL

TRUE METRIX PRO

BLOOD GLUCOSE4 QL

TRUETRACK TEST 3 QL

Diabetes - Insulin

ADMELOG E QL

ADMELOG SOLOSTAR E QL

AFREZZA E PA; QL

APIDRA SOLOSTAR E ST; QL

APIDRA VIAL E ST; QL

(Tier 1 until

7/1/2020;

EExcluded

after

7/1/2020);

BASAGLAR KWIKPEN QL

FIASP E ST; QL

FIASP FLEXTOUCH E ST; QL

FIASP PENFILL E QL

HUMALOG KWIKPEN 2 QL

HUMALOG MIX 50/50

KWIKPEN2 QL

HUMALOG MIX 50/50

VIAL1 QL

HUMALOG MIX 75/25

KWIKPEN2 QL

HUMALOG MIX 75/25

VIAL1 QL

HUMALOG

SUBCUTANEOUS 1 QL

SOLUTION

HUMALOG

SUBCUTANEOUS 2 QL

SOLUTION CARTRIDGE

HUMALOG U-100

JUNIOR KWIKPEN2 QL

HUMULIN 70/30

KWIKPEN2 QL

HUMULIN 70/30 VIAL 1 QL

HUMULIN N KWIKPEN 2 QL

HUMULIN N VIAL 1 QL

HUMULIN R U-500

KWIKPEN2 QL

HUMULIN R U-500 VIAL

(CONCENTRATED)1 QL

HUMULIN R VIAL 1 QL

INSULIN ASP PROT &

ASP FLEXPENE ST; QL

INSULIN ASPART E ST; QL

INSULIN ASPART

FLEXPENE ST; QL

INSULIN ASPART

PENFILLE ST; QL

INSULIN ASPART PROT

& ASPARTE ST; QL

INSULIN LISPRO E QL

INSULIN LISPRO (1

UNIT DIAL)E QL

5

RequiremDrug


Limits

4

Drug NameDrug

Tier

Requirem

ents &

Limits

(Excluded

until

17/1/2020;

Tier 1 after

7/1/2020);

LANTUS SOLOSTAR QL

(Excluded

until

17/1/2020;

Tier 1 after

7/1/2020);

LANTUS U-100 VIAL QL

(Tier 3 until

7/1/2020;

EExcluded

after

LEVEMIR U-100 7/1/2020);

FLEXTOUCH QL

(Tier 3 until

7/1/2020;

EExcluded

after

7/1/2020);

LEVEMIR U-100 VIAL QL

NOVOLIN 70/30

FLEXPENE ST; QL

NOVOLIN 70/30

FLEXPEN RELIONE ST; QL

NOVOLIN 70/30 RELION E ST; QL

NOVOLIN 70/30 VIAL E ST; QL

NOVOLIN N FLEXPEN E ST; QL

NOVOLIN N FLEXPEN

RELIONE ST; QL

NOVOLIN N RELION E ST; QL

NOVOLIN N VIAL E ST; QL

NOVOLIN R FLEXPEN E ST; QL

NOVOLIN R FLEXPEN

RELIONE ST; QL

NOVOLIN R RELION E ST; QL

NOVOLIN R VIAL E ST; QL

NOVOLOG FLEXPEN E ST; QL

NOVOLOG MIX 70/30

FLEXPENE ST; QL

NOVOLOG MIX 70/30

VIALE ST; QL

NOVOLOG PENFILL E ST; QL

NOVOLOG U-100 VIAL E ST; QL

(Excluded

until

27/1/2020;

Tier 2 after

TOUJEO MAX 7/1/2020);

SOLOSTAR QL

(Excluded

until

27/1/2020;

Tier 2 after

7/1/2020);

TOUJEO SOLOSTAR QL

(Tier 2 until

7/1/2020;

EExcluded

after

7/1/2020);

TRESIBA QL

(Tier 2 until

7/1/2020;

EExcluded

after

7/1/2020);

TRESIBA FLEXTOUCH QL

Diabetes - Non-Insulin

Agents

acarbose oral 1

ACTOPLUS MET 4 QL

ACTOS E QL

ADLYXIN 4 ST; QL

ADLYXIN STARTER

PACK4 ST; QL

ALOGLIPTIN

BENZOATEE QL

ALOGLIPTIN-

METFORMIN HCLE QL

ALOGLIPTIN-

PIOGLITAZONEE QL

AMARYL 4

AVANDIA 3 QL

6

RequiremDrug


Limits

4

Drug NameDrug

Tier

Requirem

ents &

Limits

BAQSIMI ONE PACK 2 QL

BAQSIMI TWO PACK 2 QL

BYDUREON 2 ST; QL

BYDUREON BCISE

AUTOINJECTOR2 ST; QL

BYETTA 10 MCG PEN 2 ST; QL

BYETTA 5 MCG PEN 2 ST; QL

CYCLOSET 3

DUETACT 3 QL

FARXIGA E ST; QL

FORTAMET E PA

glimepiride 1

glipizide er 1

glipizide ir 1

glipizide xl 1

glipizide-metformin hcl 2

GLUCAGON

EMERGENCY KIT2 QL

GLUCOPHAGE ORAL

TABLET 1000 MG, 500 4

MG, 850 MG

GLUCOPHAGE XR

ORAL TABLET

EXTENDED RELEASE 4 PA

24 HOUR 500 MG, 750

MG

GLUCOTROL 4

GLUCOTROL XL 4

GLUCOVANCE ORAL

TABLET 5-500 MG4

GLUMETZA E PA

glyburide micronized 1

glyburide oral 1

glyburide-metformin 1

GLYNASE ORAL

TABLET 1.5 MG3

GLYNASE ORAL

TABLET 3 MG, 6 MG4

GLYSET 4

GLYXAMBI 2 ST; QL

GVOKE PFS 2 QL

INVOKAMET 2 QL

INVOKAMET XR 2 QL

INVOKANA 2 ST; QL

ST; (Tier 4

until

7/1/2020;

E Excluded

after

7/1/2020);

JANUMET QL

ST; (Tier 4

until

7/1/2020;

E Excluded

after

7/1/2020);

JANUMET XR QL

ST; (Tier 4

until

7/1/2020;

E Excluded

after

7/1/2020);

JANUVIA QL

JARDIANCE 2 ST; QL

JENTADUETO 2 QL

JENTADUETO XR 2 QL

KAZANO 2 QL

KOMBIGLYZE XR 2 QL

metformin hcl er 1

metformin hcl er (mod) E PA

metformin hcl er (osm) E PA

METFORMIN HCL ORAL

SOLUTION3

metformin hcl oral tablet 1

miglitol 2

nateglinide 2 QL

NESINA 2 QL

ONGLYZA 2 QL

OSENI 2 QL

OZEMPIC 2 ST; QL

7

RequiremDrug


Limits

4

Drug NameDrug

Tier

Requirem

ents &

Limits

pioglitazone hcl 1 QL

pioglitazone hcl-

glimepiride1 QL

pioglitazone hcl-

metformin hcl2 QL

PRECOSE 4

QTERN E ST; QL

repaglinide 2 QL

RIOMET 3

RIOMET ER 3

RYBELSUS 2 ST; QL

SEGLUROMET E ST; QL

SOLIQUA 2 QL

STARLIX 4 QL

STEGLATRO E ST; QL

STEGLUJAN E ST; QL

SYMLINPEN 120 3 QL

SYMLINPEN 60 3 QL

SYNJARDY 2 QL

SYNJARDY XR 2 QL

tolbutamide 1

TRADJENTA 2 QL

TRULICITY 2 ST; QL

VICTOZA SOLUTION

PEN-INJECTOR 18

MG/3ML 2

ST; (2

Pak); QL

SUBCUTANEOUS

VICTOZA SOLUTION

PEN-INJECTOR 18

MG/3ML 3

ST; (3

Pak); QL

SUBCUTANEOUS

XIGDUO XR E ST; QL

XULTOPHY E QL

Drugs for Blood

Disorders

ADVATE 4 PA; ST; SP

ADYNOVATE E PA; ST; SP

AFSTYLA 4 PA; SP

AGRYLIN 4

ALPHANATE/VWF

COMPLEX/HUMAN2 SP

ALPHANINE SD 2 SP

ALPROLIX 3 SP

AMICAR ORAL

SOLUTION4

AMICAR ORAL TABLET

1000 MG3

AMICAR ORAL TABLET

500 MG4

aminocaproic acid oral 3

anagrelide hcl 1

ARANESP (ALBUMIN

FREE)2 QL; SP

ARTISS 3

BENEFIX 2 SP

CABLIVI 2 PA; QL; SP

COAGADEX 2 SP

CORIFACT 2 SP

DOPTELET4

PA; ST;

QL; SP

ELOCTATE 4 PA; SP

EPOGEN E QL; SP

ESPEROCT E

FEIBA 2 SP

FULPHILA E SP

GRANIX E SP

HEMLIBRA 2 PA; SP

HEMOFIL M 2 SP

HUMATE-P 2 SP

IDELVION 4 SP

IXINITY E ST; SP

JIVI 4 PA; SP

KOATE 2 SP

KOATE-DVI 2 SP

KOGENATE FS 2 SP

KOVALTRY 2 SP

LEUKINE 2 SP

LYSTEDA 3 QL

8

RequiremDrug


Limits

4

Drug NameDrug

Tier

Requirem

ents &

Limits

MONONINE 2 SP

monsels ferric subsulfate 1

MOZOBIL 2 SP

MULPLETA 2 PA; QL; SP

NEULASTA 3 SP

NEUPOGEN E SP

NIVESTYM E SP

NOVOEIGHT 2 SP

NOVOSEVEN RT 2 SP

NUWIQ 2 SP

OXBRYTA E PA

PROCRIT E QL; SP

PROFILNINE 2 SP

PROFILNINE SD 2 SP

PROMACTA ORAL

PACKET 12.5 MG4 PA; SP

PROMACTA ORAL

TABLET4 PA; SP

REBINYN E PA; SP

RECOMBINATE 4 PA; ST; SP

RECOTHROM 3

RECOTHROM SPRAY

KIT3

RETACRIT 2 QL; SP

RIXUBIS 2 SP

TAVALISSE4

PA; ST;

QL; SP

THROMBOGEN 3

TISSEEL 3

tranexamic acid oral 2 QL

TRETTEN 3 SP

UDENYCA E SP

VONVENDI 2 SP

WILATE 2

XYNTHA 4 PA; ST; SP

XYNTHA SOLOFUSE 4 PA; ST; SP

ZARXIO 2 SP

ZIEXTENZO E SP

Drugs for Sexual

Dysfunction

ADDYI 4 PA; QL

CAVERJECT 3 QL

CAVERJECT IMPULSE 3 QL

CIALIS ORAL TABLET

10 MG, 20 MGE QL

CIALIS ORAL TABLET

2.5 MG, 5 MGE ST; QL

EDEX 3 QL

IMVEXXY

MAINTENANCE PACK3 QL

IMVEXXY STARTER

PACK3 QL

INTRAROSA 3 QL

LEVITRA E QL

MUSE 3 QL

OSPHENA 3 PA; QL

sildenafil citrate oral

tablet 100 mg, 25 mg, 50 2 QL

mg

STAXYN E QL

STENDRA 4 PA; QL

tadalafil oral tablet 10

mg, 20 mg2 QL

tadalafil oral tablet 2.5

mg, 5 mg2 ST; QL

vardenafil hcl oral tablet 3 QL

vardenafil hcl oral tablet

dispersibleE QL

VIAGRA E QL

VYLEESI 4 PA; QL

Electrolytes / Vitamins

adc/f (0.5mg/ml) 1

aminoamrms 1

aminobenzoate

potassium1

aminoreliefrms 1

ATABEX OB 3

AZESCO E

9

RequiremDrug


Limits

5

Drug NameDrug

Tier

Requirem

ents &

Limits

CALCIFOL 3

calcium-folic acid plus d 1

CARDIOVID PLUS 3

CARNITOR ORAL 4

CARNITOR SF 4

CHEMET 2

CITRANATAL BLOOM 3

CITRANATAL MEDLEY 3

cyanocobalamin injection

solution 1000 mcg/ml1

CYANOCOBALAMIN

INJECTION SOLUTION 3

2000 MCG/ML

cytra k crystals 1

DRISDOL 4

EFFER-K ORAL TABLET

EFFERVESCENT 10 2

MEQ, 20 MEQ

effer-k oral tablet

effervescent 25 meq1

ELITE-OB 3

ENBRACE HR 3

ERGOCAL 3

ergocalciferol oral

capsule1

ESCAVITE ORAL

TABLET CHEWABLE 3

0.25-7.5 MG

FLORIVA ORAL LIQUID 3

FLORIVA PLUS 3

FLUORABON 2 H

fluoritab 1 H

FLURA-DROPS 3 H

folic acid oral tablet 1 mg 1

GALZIN 3

hematinic/folic acid 1

hemocyte-f 1

IODINE STRONG ORAL 2

kionex 1

klor-con 1

klor-con 10 1

klor-con m10 1

KLOR-CON M15 3

klor-con m20 1

klor-con sprinkle 1

klor-con/ef 1

K-PHOS 2

K-PHOS NO 2 2

K-PHOS-NEUTRAL 2

k-prime 1

K-TAB 3

L-CYSTINE 3

levocarnitine oral solution 1

levocarnitine oral tablet 1

levocarnitine sf 1

LOKELMA 3 PA; QL

ludent 1 H

MAGNEBIND 400 2

MEPHYTON 4 QL

M-NATAL PLUS 3

multi-vit/iron/fluoride 1

multi-vitamin/fluoride 1

multivitamin/fluoride oral

solution1

multivitamin/fluoride oral

tablet chewable 0.25 mg, 1

0.5 mg, 1 mg

multivitamin/fluoride/iron 1

multi-vitamin/fluoride/iron 1

multivitamins/fluoride 1

mvc-fluoride 1

n-acetyl-l-cysteine oral 1

nafrinse 1 H

nafrinse drops 1 H

NASCOBAL 3

NEONATAL COMPLETE 3

NEONATAL PLUS 3

NESTABS 3

0

RequiremDrug


Limits

5

Drug NameDrug

Tier

Requirem

ents &

Limits

NESTABS ONE E

NICOMIDE 3

ORACIT 2

phospha 250 neutral 1

phosphorous 1

phospho-trin 250 neutral 1

phytonadione oral 3 QL

pnv prenatal plus

multivit+dha1

POLY-VI-FLOR 3

POLY-VI-FLOR/IRON 3

pot bicarb-pot chloride 1

POTABA 4

potassium bicarbonate

oral1

potassium chloride crys

er1

potassium chloride er 1

potassium chloride oral 1

potassium citrate er 1

potassium citrate-citric

acid1

PREGENNA E

PREMESISRX 3

PRENAISSANCE 2

PRENATA 3

prenatal oral tablet 27-1

mg1

prenatal plus iron 1

PRENATE 3

PRENATE DHA 3

PRENATE ELITE 3

PRENATE ENHANCE 3

PRENATE ESSENTIAL 3

PRENATE MINI 3

PRENATE PIXIE 3

PRENATE RESTORE 3

PRIMACARE 3

QUFLORA PEDIATRIC 3

RELNATE DHA 3

SELECT-OB ORAL

TABLET CHEWABLE 4

29-1 MG

sod citrate-citric acid 1

sodium fluoride oral

solution1 H


tablet1


tablet chewable1 H

sodium polystyrene

sulfonate1

sps 1

taron-crystals 1

TRICARE PRENATAL

DHA ONE3

tricitrates 1

trinate 1

TRINAZ E

TRISTART ONE 3

TRI-VI-FLOR 3

TRI-VI-FLORO 3

tri-vitamin/fluoride 1

tri-vite/fluoride 1

TRYPTOPHAN ORAL 3

UROCIT-K 10 4

UROCIT-K 15 4

UROCIT-K 5 4

VELTASSA 3 PA; QL

virt-phos 250 neutral 1

VITAFOL FE+ 3

VITAFOL STRIPS 3

VITAFOL-OB+DHA 3

vitamin d (ergocalciferol)

oral capsule 1.25 mg 1

(50000 ut)

vitamins acd-fluoride 1

VITATHELY WITH

GINGER3

1

RequiremDrug


Limits

5

Drug NameDrug

Tier

Requirem

ents &

Limits

vp-pnv-dha 1

WHEAT GERM OIL 3

ZALVIT E

Gastrointestinal Agents

- Drugs for Acid Reflux

and Ulcer

ACIPHEX E QL

ACIPHEX SPRINKLE E QL

amoxicill-clarithro-

lansoprazE QL

CARAFATE 4

cimetidine hcl 1

cimetidine oral 1

CYTOTEC 4

DEXILANT 3 QL

esomeprazole

magnesium oral capsule E QL

delayed release

famotidine oral


famotidine oral tablet 20

mg, 40 mgE

lansoprazole oral capsule

delayed releaseE QL

lansoprazole oral tablet

delayed release 3 PA; ST; QL

dispersible

misoprostol oral 1

NEXIUM ORAL

CAPSULE DELAYED E QL

RELEASE

NEXIUM ORAL PACKET 3 PA; ST; QL

nizatidine oral capsule E

nizatidine oral solution 2

OMECLAMOX-PAK 3 QL

omeprazole oral capsule

delayed release1

omeprazole-sodium

bicarbonate oral capsuleE QL

omeprazole-sodium

bicarbonate oral packetE ST; QL

pantoprazole sodium

tablet delayed release 20 1

mg oral

pantoprazole sodium

tablet delayed release 20 E (Camber)

mg oral

pantoprazole sodium

tablet delayed release 40 1

mg oral

pantoprazole sodium

tablet delayed release 40 E (Camber)

mg oral

PEPCID E

PREVACID E QL

PREVACID SOLUTAB 4 PA; ST; QL

PRILOSEC E

PROTONIX ORAL E

PYLERA 3 QL

RABEPRAZOLE

SODIUM ORAL E QL

CAPSULE SPRINKLE

rabeprazole sodium oral

tablet delayed release2 QL

ranitidine hcl oral capsule

150 mg, 300 mgE

ranitidine hcl oral syrup

15 mg/ml, 150 mg/10ml, 1

75 mg/5ml

ranitidine hcl oral tablet

150 mg, 300 mgE

sucralfate oral

suspension3

sucralfate oral tablet 1

TALICIA E

ZEGERID ORAL

CAPSULEE QL

ZEGERID ORAL

PACKETE ST; QL

Gastrointestinal Agents

- Drugs for Bowel,

Intestine and Stomach

Conditions

ACTIGALL 4

2

RequiremDrug


Limits

5

Drug NameDrug

Tier

Requirem

ents &

Limits

alosetron hcl 2 PA; QL

AMITIZA 4 PA; ST; QL

ANASPAZ 2

belladonna alkaloids-

opium1

cascara sagrada oral

fluid extract1

CHENODAL 3 SP

chlordiazepoxide-

clidinium4

CHOLBAM 2 PA; QL; SP

CLENPIQ 3

constulose 1

cromolyn sodium oral 1

CUVPOSA 3

dicyclomine hcl oral 1

diphenoxylate-atropine 1

ed-spaz 1

ENTEREG 3

enulose 1

GASTROCROM 4

GATTEX 2 PA; QL; SP

gavilyte-c 1 H

gavilyte-g 1 QL; H

gavilyte-h 1

gavilyte-n with flavor

pack1 QL; H

generlac 1

GLYCATE E

glycopyrrolate oral tablet

1 mg, 2 mg1

GLYCOPYRROLATE

ORAL TABLET 1.5 MGE

GOLYTELY ORAL

SOLUTION

RECONSTITUTED 227.12 QL

GM

GOLYTELY ORAL

SOLUTION

RECONSTITUTED 236 4 QL

GM

hyoscyamine sulfate er 1

hyoscyamine sulfate oral 1

hyoscyamine sulfate sl 1

hyoscyamine sulfate

sublingual1

hyosyne 1

KRISTALOSE ORAL

PACKET 20 GM3

lactulose encephalopathy 1

lactulose oral packet E

lactulose oral solution 1

LEVBID 4

LEVSIN ORAL 4

LEVSIN/SL 4

LIBRAX E

LINZESS 2 PA; QL

LOMOTIL 4

loperamide hcl oral

capsuleE

LOTRONEX E PA; QL

methscopolamine

bromide oral1

mineral oil heavy oral 1

MOTEGRITY 3 PA; QL

MOTOFEN E

MOVANTIK E PA; QL

MOVIPREP 3 QL

MYTESI 4 PA; QL

NULEV 4

NULYTELY WITH

FLAVOR PACKS4 QL

OCALIVA4

PA; ST;

QL; SP

opium 1

oscimin 1

oscimin sr 1

3

RequiremDrug


Limits

5

Drug NameDrug

Tier

Requirem

ents &

Limits

OSMOPREP 3

paregoric oral tincture 2

mg/5ml1

PCP 100 E

peg 3350-kcl-na bicarb-

nacl1 QL; H

peg-3350/electrolytes 1 QL; H

peg-prep 1

PLENVU 3

PREPOPIK 3 QL

propantheline bromide

oral1

RELISTOR ORAL E PA; QL

RELISTOR

SUBCUTANEOUS4 PA; QL

SODIUM

BICARBONATE ORAL 3

POWDER

SUPREP BOWEL PREP

KIT3 QL

SYMAX DUOTAB 3

symax-sl 1

symax-sr 1

SYMPROIC 2 PA; QL

trilyte 1 QL; H

TRULANCE 4 PA; ST; QL

URSO 250 4

URSO FORTE 4

ursodiol oral 1

VIBERZI 4 PA; QL

XERMELO 3 PA; QL; SP

ZELNORM 3 PA; ST; QL

Genetic or Enzyme

Disorder - Drugs for

Replacement,

Modification, Treatment

BUPHENYL 4 PA; SP

CERDELGA 2 PA; SP

CREON 2

CYSTADANE 2 SP

CYSTAGON 2 SP

ENDARI 4 PA; QL

PA; ST;

(Tier 4 until

7/1/2020;

E Excluded

after

7/1/2020);

FIRDAPSE QL; SP

GALAFOLD 4 PA; QL; SP

KUVAN 2 PA; QL; SP

miglustat 3 SP

MYALEPT 3 PA; QL; SP

nitisinone E PA; SP

NITYR 2 PA; SP

ORFADIN E PA; SP

PALYNZIQ

SUBCUTANEOUS

SOLUTION PREFILLED 3 PA; QL; SP

SYRINGE 10 MG/0.5ML,

20 MG/ML

PALYNZIQ

SUBCUTANEOUS

SOLUTION PREFILLED 3 PA; SP

SYRINGE 2.5 MG/0.5ML

PANCREAZE 3 ST

PERTZYE 4 ST

PROCYSBI ORAL

CAPSULE DELAYED 4 PA; ST; SP

RELEASE

RAVICTI4

PA; ST;

QL; SP

RUZURGI 2 PA; QL; SP

sodium phenylbutyrate

oral powder1 PA; SP

sodium phenylbutyrate

oral tablet3 PA; SP

STRENSIQ 2 PA; QL; SP

SUCRAID 2 PA; SP

TEGSEDI 2 PA; QL; SP

VIOKACE 4 ST

VISTOGARD 2 QL

4

RequiremDrug


Limits

5

Drug NameDrug

Tier

Requirem

ents &

Limits

XURIDEN 2 PA; QL; SP

ZAVESCA E SP

ZENPEP 2

Genetic or Enzyme

Disorder: Drugs for

Replacement,

Modifiers, Treatment

CARBAGLU 2 PA; SP

clovique E PA; SP

CUPRIMINE 4 SP

deferasirox 2 PA; SP

DEPEN TITRATABS 2 SP

EXJADE E PA; SP

FERRIPROX ORAL

SOLUTION2 PA; SP

FERRIPROX ORAL

TABLET 1000 MG4

FERRIPROX ORAL

TABLET 500 MG4 PA; SP

JADENU ORAL TABLET

180 MG2 PA; SP

JADENU ORAL TABLET

360 MG, 90 MG4 PA; SP

JADENU SPRINKLE 2 PA; SP

JYNARQUE 2 PA; QL; SP

penicillamine oral

capsule4 SP

penicillamine oral tablet 2 SP

SAMSCA 2 PA; QL; SP

SYPRINE 3 PA; SP

trientine hcl E PA; SP

Genitourinary Agents -

Drugs for Bladder,

Genital and Kidney

Conditions

AURYXIA 3

bethanechol chloride oral 1

calcium acetate (phos

binder)1

calcium acetate oral

tablet 667 mg1

darifenacin hydrobromide

erE

DETROL E

DETROL LA E

DITROPAN XL 3

ELMIRON 2

ENABLEX E

flavoxate hcl 1

FOSRENOL ORAL

PACKET3

FOSRENOL ORAL

TABLET CHEWABLEE

GELNIQUE E

hyophen 1

lanthanum carbonate 3

LITHOSTAT 3

me/naphos/mb/hyo1 1

MYRBETRIQ E

oxybutynin chloride er 2

oxybutynin chloride oral 1

OXYTROL E

phenazo oral tablet 200

mg1

phenazopyridine hcl oral


PHOSLYRA 3

phosphasal 1

PYRIDIUM 3

RENAGEL 4

RENVELA ORAL

PACKET4

RENVELA ORAL

TABLETE

sevelamer carbonate 2

sevelamer hcl 3

solifenacin succinate E

THIOLA 3 SP

THIOLA EC 3 SP

tolterodine tartrate E

5

RequiremDrug


Limits

5

Drug NameDrug

Tier

Requirem

ents &

Limits

tolterodine tartrate er E

TOVIAZ 3

trospium chloride E

trospium chloride er E

URECHOLINE ORAL

TABLET 25 MG4

URECHOLINE ORAL

TABLET 50 MG3

URELLE 3

uretron d/s 1

URIBEL 3

URIMAR-T 2

urin ds 1

URO-458 3

UROGESIC-BLUE 2

uro-mp 1

URYL 2

ustell 1

uticap 1

utira-c 1

utrona-c 1

VELPHORO 2

VESICARE E

vilamit mb 1

VILEVEV MB 3

Genitourinary Agents -

Drugs for Prostate

Conditions

alfuzosin hcl er 1

AVODART E

CARDURA XL 3

dutasteride oral 3

dutasteride-tamsulosin

hclE

finasteride oral tablet 5

mg1

FLOMAX E

JALYN E

PROSCAR 4

RAPAFLO E

silodosin 3

tamsulosin hcl 1

terazosin hcl 1

UROXATRAL 4

Hormonal Agents -

Hormone Replacement

and Birth Control

ACTIVELLA 4

afirmelle 1 H

ALORA 3 QL

altavera 1 H

alyacen 1/35 1 H

alyacen 7/7/7 1 H

amabelz 2

amethia 3

amethia lo 3

amethyst 3

ANGELIQ 3

ANNOVERA E

apri 1 H

aranelle 1 H

ashlyna 3

aubra 1 H

aubra eq 1 H

aurovela 1.5/30 2

aurovela 1/20 2

aurovela 24 fe 3

aurovela fe 1.5/30 1 H

aurovela fe 1/20 1 H

aviane 1 H

AYGESTIN 4

ayuna 1 H

azurette 2

BALCOLTRA E

balziva 2

bekyree 2

BEYAZ E

6

RequiremDrug


Limits

5

Drug NameDrug

Tier

Requirem

ents &

Limits

BIJUVA 3

blisovi 24 fe 3

blisovi fe 1.5/30 1 H

blisovi fe 1/20 1 H

briellyn 2

camila 1 H

camrese 3

camrese lo 3

caziant 1 H

chateal 1 H

chateal eq 1 H

CLIMARA E QL

CLIMARA PRO 3 QL

COMBIPATCH 3 QL

covaryx 1

covaryx hs 1

cryselle-28 1 H

cyclafem 1/35 1 H

cyclafem 7/7/7 1 H

cyred 1 H

cyred eq 1 H

dasetta 1/35 1 H

dasetta 7/7/7 1 H

daysee 3

deblitane 1 H

DELESTROGEN 4

delyla 1 H

DEPO-ESTRADIOL 3

DEPO-PROVERA

INTRAMUSCULAR

SUSPENSION 150 4 QL

MG/ML

DEPO-PROVERA

INTRAMUSCULAR

SUSPENSION 4

PREFILLED SYRINGE

DEPO-SUBQ PROVERA

1042 QL

desogestrel-ethinyl

estradiol oral tablet 0.15- 2

0.02/0.01 mg (21/5)

desogestrel-ethinyl

estradiol oral tablet 0.15- 1 H

30 mg-mcg

DIVIGEL

TRANSDERMAL GEL

0.25 MG/0.25GM, 0.5 3

MG/0.5GM, 0.75

MG/0.75GM, 1 MG/GM

DIVIGEL

TRANSDERMAL GEL E

1.25 MG/1.25GM

dotti E QL

drospiren-eth estrad-

levomefolE

drospirenone-ethinyl

estradiol3

DUAVEE 3 QL

eemt 1

eemt hs 1

ELESTRIN 3

elinest 1 H

ELLA 1 QL; H

eluryng E

emoquette 1 H

enpresse-28 1 H

enskyce 1 H

errin 1 H

est estrogens-methyltest 1

est estrogens-methyltest

ds1


hs1

estarylla 1 H

ESTRACE ORAL 4

ESTRACE VAGINAL 3

estradiol oral 1

7

RequiremDrug


Limits

5

Drug NameDrug

Tier

Requirem

ents &

Limits

estradiol patch twice (generic for

weekly 0.025 mg/24hr 2 Minivelle);

transdermal QL


weekly 0.025 mg/24hr E Vivelle-

transdermal Dot); QL



transdermal QL






transdermal QL






transdermal QL






transdermal QL




(generic for

estradiol transdermal 1 Climara);

patch weekly QL

estradiol vaginal cream E

estradiol vaginal tablet 2

estradiol valerate

intramuscular1

estradiol-norethindrone

acet2

ESTRING 2 QL

ESTROGEL 3 QL

ESTROSTEP FE 4

ethynodiol diac-eth

estradiol1 H

etonogestrel-ethinyl

estradiolE

EVAMIST 2

falmina 1 H

fayosim E

FEMHRT LOW DOSE 3

FEMRING 3 QL

femynor 1 H

FIRST-

PROGESTERONE VGSE PA

fyavolv 3

GENERESS FE E

gianvi 3

hailey 1.5/30 2

hailey 24 fe 3

heather 1 H

incassia 1 H

introvale 2 H

isibloom 1 H

jaimiess 3

jasmiel 3

jencycla 1 H

jinteli 3

jolessa 2 H

juleber 1 H

junel 1.5/30 2

junel 1/20 2

junel fe 1.5/30 1 H

junel fe 1/20 1 H

junel fe 24 3

kaitlib fe E

kalliga 1 H

kariva 2

kelnor 1/35 1 H

kelnor 1/50 1 H

kurvelo 1 H

larin 1.5/30 2

larin 1/20 2

8

RequiremDrug


Limits

5

Drug NameDrug

Tier

Requirem

ents &

Limits

larin 24 fe 3

larin fe 1.5/30 1 H

larin fe 1/20 1 H

larissia 1 H

layolis fe E

leena 1 H

lessina 1 H

levonest 1 H

levonorgest-eth est & eth

estE

levonorgest-eth estrad

91-day oral tablet 0.1-

0.02 & 0.01 mg, 0.15-3

0.03 &0.01 mg

levonorgest-eth estrad

91-day oral tablet 0.15- 2 H

0.03 mg

levonorgestrel-ethinyl

estrad oral tablet 0.1-20

mg-mcg, 0.15-30 mg-1 H

mcg


estrad oral tablet 90-20 3

mcg

levonorg-eth estrad

triphasic1 H

levora 0.15/30 (28) 1 H

lillow 1 H

LO LOESTRIN FE 3

LOESTRIN 1.5/30 (21) 4

LOESTRIN 1/20 (21) 4

LOESTRIN FE 1.5/30 4

LOESTRIN FE 1/20 4

lojaimiess 3

lopreeza 2

loryna 3

LOSEASONIQUE 4

low-ogestrel 1 H

lo-zumandimine 3

lutera 1 H

lyza 1 H

marlissa 1 H

medroxyprogesterone

acetate intramuscular 1 QL; H

suspension

medroxyprogesterone

acetate intramuscular

suspension prefilled 1 H

syringe

medroxyprogesterone

acetate oral1

MEGACE ES 4

megestrol acetate oral

suspension 40 mg/ml1


suspension 625 mg/5ml3


tablet1

melodetta 24 fe E

MENEST 3

MENOSTAR 3 QL

mibelas 24 fe E

microgestin 1.5/30 2

microgestin 1/20 2

microgestin fe 1.5/30 1 H

microgestin fe 1/20 1 H

mili 1 H

mimvey 2

MINASTRIN 24 FE E

MINIVELLE E QL

MIRCETTE 4

mono-linyah 1 H

NATAZIA 2

necon 0.5/35 (28) 1 H

nikki 3

nora-be 1 H

norethin ace-eth estrad-

fe oral tablet 1-20 mg- 3

mcg(24)

9

RequiremDrug


Limits

6

Drug NameDrug

Tier

Requirem

ents &

Limits


fe oral tablet 1-20 mg- 1 H

mcg, 1.5-30 mg-mcg


fe oral tablet chewableE

norethindrone acetate

oral1

norethindrone acet-

ethinyl est2

norethindrone oral 1 H

norethindrone-eth

estradiol3

norethin-eth estradiol-fe

oral tablet chewable 0.4- 3

35 mg-mcg

norethin-eth estradiol-fe

oral tablet chewable 0.8- E

25 mg-mcg

norgestimate-eth

estradiol1 H

norgestimate-ethinyl

estradiol triphasic oral

tablet 0.18/0.215/0.25 2

mg-25 mcg


estradiol triphasic oral

tablet 0.18/0.215/0.25 1 H

mg-35 mcg

norlyda 1 H

norlyroc 1 H

nortrel 0.5/35 (28) 1 H

nortrel 1/35 (21) 1 H

nortrel 1/35 (28) 1 H

nortrel 7/7/7 1 H

NUVARING 1 H

ocella 3

ogestrel 2

orsythia 1 H

ORTHO MICRONOR 4

ORTHO TRI-CYCLEN

LOE

ORTHO-NOVUM 1/35

(28) ORAL TABLET 1-35 4

MG-MCG

ORTHO-NOVUM 7/7/7

(28)4

philith 2

pimtrea 2

pirmella 1/35 1 H

pirmella 7/7/7 1 H

portia-28 1 H

PREFEST 2

PREMARIN ORAL 3

PREMARIN VAGINAL 3

PREMPHASE 3

PREMPRO 3

previfem 1 H

progesterone

intramuscular1

progesterone micronized

oral2

PROMETRIUM E

PROVERA 4

QUARTETTE E

reclipsen 1 H

rivelsa E

SAFYRAL E

SEASONIQUE 4

setlakin 2 H

sharobel 1 H

simliya 2

simpesse 3

SLYND 4 PA; ST

sprintec 28 1 H

sronyx 1 H

syeda 3

tarina 24 fe 3

tarina fe 1/20 1 H

tarina fe 1/20 eq 1 H

TAYTULLA E

0

RequiremDrug


Limits

6

Drug NameDrug

Tier

Requirem

ents &

Limits

tilia fe 3

tri femynor 1 H

tri-estarylla 1 H

tri-legest fe 3

tri-linyah 1 H

tri-lo-estarylla 2

tri-lo-marzia 2

tri-lo-mili 2

tri-lo-sprintec 2

tri-mili 1 H

tri-previfem 1 H

tri-sprintec 1 H

trivora (28) 1 H

tri-vylibra 1 H

tri-vylibra lo 2

tulana 1 H

tydemy E

VAGIFEM E

velivet 1 H

vienva 1 H

viorele 2

VIVELLE-DOT 2 QL

volnea 2

vyfemla 2

vylibra 1 H

wera 1 H

wymzya fe 3

xulane 3 H

YASMIN 28 2

YAZ 2

yuvafem 2

zarah 3

zovia 1/35e (28) 1 H

zumandimine 3

Hormonal Agents - Oral

Steroids

CORTEF 4

cortisone acetate oral 1

DECADRON E

dexamethasone intensol 1

dexamethasone oral

elixir1

dexamethasone oral

solution1

dexamethasone oral

tablet1

dexamethasone oral

tablet therapy pack3

DEXPAK 10 DAY 4

DEXPAK 13 DAY 4

DEXPAK 6 DAY 4

DXEVO 11-DAY E

EMFLAZA E PA; ST; SP

fludrocortisone acetate

oral1

HIDEX 6-DAY E

hydrocortisone oral 1

MEDROL ORAL TABLET

16 MG, 4 MG, 8 MG4

MEDROL ORAL TABLET

2 MG2

MEDROL ORAL TABLET

32 MG3

MEDROL ORAL TABLET

THERAPY PACK4

methylprednisolone oral 1

MILLIPRED 2

MILLIPRED DP 2

MILLIPRED DP 12-DAY 2

ORAPRED ODT 4

PEDIAPRED 2

prednisolone oral

solution1

prednisolone sodium

phosphate oral1

prednisone intensol 1

prednisone oral 1

RAYOS E

1

RequiremDrug


Limits

6

Drug NameDrug

Tier

Requirem

ents &

Limits

TAPERDEX 12-DAY 3

TAPERDEX 6-DAY

ORAL TABLET

THERAPY PACK 1.5 MG 3

(21)

TAPERDEX 7-DAY 3

Hormonal Agents -

Other

PA; ST; 4

ACTHAR QL; SP

cabergoline 2

CERVIDIL 3

CETROTIDE E PA; ST; SP

cinacalcet hcl 3 PA

DDAVP 4

DDAVP RHINAL TUBE 3

desmopressin ace spray

refrig1

desmopressin acetate

injection1


oral1


spray1

EGRIFTA 4 PA; SP

EGRIFTA SV 4 SP

ELIGARD 3 PA

FIRMAGON 3 SP

GENOTROPIN E PA; QL; SP

GENOTROPIN

MINIQUICKE PA; QL; SP

HUMATROPE E PA; QL; SP

INCRELEX 2 PA; QL; SP

KORLYM 3 PA; SP

leuprolide acetate

injection1 PA

NOCDURNA 3 PA; QL

NOCTIVA NASAL

EMULSION 1.66 E PA; QL

MCG/0.1ML

NORDITROPIN

FLEXPROE PA; QL; SP

NUTROPIN AQ NUSPIN

102 PA; QL; SP

NUTROPIN AQ NUSPIN

202 PA; QL; SP

NUTROPIN AQ NUSPIN

52 PA; QL; SP

octreotide acetate 1 PA; SP

OMNITROPE E PA; QL; SP

ORILISSA 4 PA; QL

PREPIDIL 3

PROSTIN E2 3

SAIZEN E PA; QL; SP

SAIZENPREP E PA; QL; SP

SANDOSTATIN E PA; SP

SENSIPAR 4 PA

SEROSTIM 4 PA; QL; SP

SIGNIFOR 2 PA; QL; SP

SOMATULINE DEPOT 4 SP

SOMAVERT 3 PA; QL; SP

STIMATE 3

SYNAREL 2

ZOMACTON E PA; QL; SP

ZORBTIVE 3 PA; QL; SP

Hormonal Agents -

Testosterone

Replacement

ANADROL-50 3

ANDRODERM 2 PA; QL

ANDROGEL E PA; QL

ANDROGEL PUMP E PA; QL

danazol oral 1

DEPO-TESTOSTERONE

INTRAMUSCULAR 3

SOLUTION 100 MG/ML

DEPO-TESTOSTERONE

INTRAMUSCULAR 4

SOLUTION 200 MG/ML

FORTESTA E PA; QL

2

RequiremDrug


Limits

6

Drug NameDrug

Tier

Requirem

ents &

Limits

JATENZO E

METHITEST 2

methyltestosterone oral 2

NATESTO E PA; QL

oxandrolone oral 2

STRIANT 3 PA; QL

TESTIM 2 PA; QL

TESTOSTERONE

CYPIONATE INJECTION4

testosterone cypionate

intramuscular1

testosterone enanthate

intramuscular1

testosterone transdermal E PA; QL

VOGELXO E PA; QL

VOGELXO PUMP E PA; QL

XYOSTED E PA

Hormonal Agents -

Thyroid

ARMOUR THYROID 3

CYTOMEL E

euthyrox 1

levo-t 1

levothyroxine sodium oral 1

levoxyl 2

liothyronine sodium oral 2

methimazole oral 1

NATURE-THROID 3

np thyroid 1

propylthiouracil oral 1

SYNTHROID 2

TAPAZOLE 4

thyroid oral tablet 120

mg, 15 mg, 30 mg, 60 1

mg, 90 mg

TIROSINT E

TIROSINT-SOL 4 PA

unithroid 1

WESTHROID 3

WP THYROID 3

Immunological Agents -

Drugs for Immune

System Stimulation or

Suppression

PA; ST; 3

ACTEMRA ACTPEN QL; SP

ACTEMRA

SUBCUTANEOUS3

PA; ST;

QL; SP

ACTIMMUNE 2 PA; QL; SP

ALFERON N 2

ARAVA 4

ARCALYST 2 PA; QL; SP

ASTAGRAF XL E SP

AZASAN 3 SP

azathioprine oral 1 SP

BENLYSTA

SUBCUTANEOUS2 PA; QL; SP

CELLCEPT E SP

CIMZIA E

CIMZIA PREFILLED KIT 2 PA; QL; SP

CIMZIA STARTER KIT 2 PA; QL; SP

COSENTYX (300 MG

DOSE)3

PA; ST;

QL; SP

COSENTYX 150 MG/ML3

PA; ST;

QL; SP

COSENTYX

SENSOREADY (300

MG)

3PA; ST;

QL; SP

COSENTYX

SENSOREADY PEN3

PA; ST;

QL; SP

cyclosporine modified 1 SP

cyclosporine oral 1 SP

ENBREL4

PA; ST;

QL; SP

ENBREL MINI4

PA; ST;

QL; SP

ENBREL SURECLICK4

PA; ST;

QL; SP

ENVARSUS XR E SP

FIRAZYR 4 PA; QL; SP

3

RequiremDrug


Limits

6

Drug NameDrug

Tier

Requirem

ents &

Limits

gengraf 1 SP

HAEGARDA 2 PA; QL; SP

HUMIRA 2 PA; QL; SP

HUMIRA PEDIATRIC

CROHNS START2 PA; QL; SP

HUMIRA PEN 2 PA; QL; SP

HUMIRA PEN-

CD/UC/HS STARTER2 PA; QL; SP

HUMIRA PEN-

PS/UV/ADOL HS START2 PA; QL; SP

icatibant acetate E PA; QL; SP

IMURAN E SP

KEVZARA4

PA; ST;

QL; SP

KINERET 3 PA; QL; SP

leflunomide oral 1

methotrexate oral 1

methotrexate sodium oral 1

mycophenolate mofetil 1 SP

mycophenolate sodium 2 SP

MYFORTIC E SP

NEORAL E SP

OLUMIANT 2 PA; QL; SP

ORENCIA CLICKJECT3

PA; ST;

QL; SP

ORENCIA

SUBCUTANEOUS3

PA; ST;

QL; SP

OTEZLA 2 PA; QL; SP

OTREXUP E ST; QL

PALFORZIA (12 MG


PALFORZIA (120 MG


PALFORZIA (160 MG


PALFORZIA (20 MG


PALFORZIA (200 MG


PALFORZIA (240 MG


PALFORZIA (3 MG


PALFORZIA (300 MG

MAINTENANCE)3 PA; QL; SP

PALFORZIA (300 MG

TITRATION)3 PA; QL; SP

PALFORZIA (40 MG


PALFORZIA (6 MG


PALFORZIA (80 MG


PALFORZIA INITIAL

ESCALATION3 PA; QL; SP

PROGRAF ORAL

CAPSULE4 SP

PROGRAF ORAL

PACKET4 PA; SP

RAPAMUNE ORAL

SOLUTION4 SP

RAPAMUNE ORAL

TABLETE SP

RASUVO 4 ST; QL

RIDAURA 3 SP

RINVOQ 2 PA; QL; SP

SANDIMMUNE ORAL

CAPSULEE SP

SANDIMMUNE ORAL

SOLUTION4 SP

SILIQ E PA; ST; QL

SIMPONI 2 PA; QL; SP

sirolimus oral solution 2 SP

sirolimus oral tablet 1 SP

SKYRIZI (150 MG

DOSE)2 PA; SP

STELARA

SUBCUTANEOUS2 PA; QL; SP

tacrolimus oral 1 SP

TAKHZYRO 2 PA; QL; SP

4

RequiremDrug


Limits

6

Drug NameDrug

Tier

Requirem

ents &

Limits

TALTZE

PA; ST;

QL; SP

TREMFYA 2 PA; QL; SP

TREXALL 2

XATMEP 4 PA; QL

XELJANZ2

PA; ST;

QL; SP

XELJANZ XR ORAL

TABLET EXTENDED

RELEASE 24 HOUR 11 2

PA; ST;

QL; SP

MG

XELJANZ XR ORAL

TABLET EXTENDED

RELEASE 24 HOUR 22 E

PA; ST;

QL; SP

MG

ZORTRESS 3 SP

Immunological Agents -

Drugs for Vaccination

ACTHIB 2 H

ADACEL 3 H

AFLURIA

QUADRIVALENT3 H

BEXSERO 3 H

BOOSTRIX 2 H

ENGERIX-B INJECTION 2 H

ENGERIX-B

INTRAMUSCULAR3 H

FLUAD 3 H

FLUARIX

QUADRIVALENT3 H

FLUCELVAX

QUADRIVALENT

INTRAMUSCULAR 3 H

SUSPENSION

PREFILLED SYRINGE

FLULAVAL

QUADRIVALENT3 H

FLUMIST

QUADRIVALENT NASAL 3 H

SUSPENSION

FLUZONE HIGH-DOSE 3 H

FLUZONE

QUADRIVALENT3 H

GARDASIL 9 3 H

HAVRIX 3 H

HEPLISAV-B 3 H

HIBERIX 3 H

IPOL 2 H

MENACTRA 3 H

MENVEO 3 H

M-M-R II 2 H

PEDVAX HIB 2 H

PNEUMOVAX 23 2 H

PREVNAR 13 3 H

RECOMBIVAX HB 2 H

SHINGRIX 3 H

TENIVAC 3 H

TRUMENBA 3 H

TWINRIX 3 H

VAQTA 2 H

VARIVAX 3 H

ZOSTAVAX 3 H

Infertility Agents

chorionic gonadotropin

intramuscular4 SP

CRINONE VAGINAL

GEL 4 %4 ST

CRINONE VAGINAL

GEL 8 %4 PA; ST

ENDOMETRIN 2 PA

FOLLISTIM AQ 2 SP

ganirelix acetate solution (Merck/

prefilled syringe 250 2 Organon);

mcg/0.5ml subcutaneous QL; SP

ganirelix acetate solution

prefilled syringe 250

mcg/0.5ml subcutaneous

4(Ferring);

QL; SP

GONAL-F E ST; SP

GONAL-F RFF E ST; SP

GONAL-F RFF

REDIJECTE ST; SP

5

RequiremDrug


Limits

6

Drug NameDrug

Tier

Requirem

ents &

Limits

novarel intramuscular

solution reconstituted 3 SP

10000 unit

NOVAREL

INTRAMUSCULAR

SOLUTION 3 SP

RECONSTITUTED 5000

UNIT

OVIDREL 4 SP

pregnyl 1 SP

Inflammatory Bowel

Disease Agents

ANALPRAM HC

RECTAL CREAM 2.5-1 4

%

ANALPRAM HC

SINGLES RECTAL 4

CREAM 2.5-1 %

ANALPRAM-HC

RECTAL CREAM 1-1 %4

ANALPRAM-HC

RECTAL LOTION 2.5-1 3

%

anucort-hc 2

ANUSOL-HC RECTAL

CREAM 2.5 %4

ANUSOL-HC RECTAL

SUPPOSITORYE

APRISO 2

ASACOL HD E

AZULFIDINE 4

AZULFIDINE EN-TABS 4

balsalazide disodium 1

budesonide er E

budesonide oral 2

CANASA E

COLAZAL E

colocort 1

CORTENEMA 4

CORTIFOAM RECTAL

FOAM 10 %2

DELZICOL E

DIPENTUM 3

ENTOCORT EC E

hemmorex-hc 2

hemorrhoidal-hc rectal

suppository 25 mg2

hydrocortisone ace-

pramoxine rectal cream 1

1-1 %, 2.5-1 %

hydrocortisone acetate

rectal2

hydrocortisone rectal 1

hydrocortisone rectal

cream 1 %, 2.5 %1

LIALDA 2

mesalamine er E

mesalamine oral E

mesalamine rectal

enema1

mesalamine rectal

suppository2

mesalamine-cleanser 1 QL

PENTASA E

PROCORT RECTAL

CREAM 1.85-1.15 %E

PROCTOCORT RECTAL E

PROCTOCORT RECTAL

CREAM 1 %E

PROCTOFOAM HC

RECTAL FOAM 1-1 %2

procto-med hc rectal

cream 2.5 %1

procto-pak rectal cream 1

%1

proctosol hc rectal cream

2.5 %1

proctozone-hc rectal

cream 2.5 %1

ROWASA 4 QL

SFROWASA 4

sulfasalazine oral 1

UCERIS ORAL 3

6

RequiremDrug


Limits

6

Drug NameDrug

Tier

Requirem

ents &

Limits

UCERIS RECTAL 2

Metabolic Bone

Disease Agents - Drugs

for Osteoporosis

ACTONEL ORAL

TABLET 150 MG, 35 MG4 QL

ACTONEL ORAL

TABLET 30 MG, 5 MG4

alendronate sodium 1

ATELVIA E QL

BINOSTO E QL

BONIVA ORAL 4

calcitonin (salmon) 2

EVISTA E

FORTEO

SUBCUTANEOUS

SOLUTION 600 3 PA; SP

MCG/2.4ML

FOSAMAX 4

FOSAMAX PLUS D 3

ibandronate sodium oral 2

MIACALCIN INJECTION 3

raloxifene hcl 2 H

RAYALDEE E

risedronate sodium oral

tablet 150 mg, 35 mg3 QL


tablet 30 mg, 5 mg3


tablet delayed releaseE QL

TYMLOS 3 PA; SP

Metabolic Bone

Disease Agents - Other

calcitriol oral 1

doxercalciferol oral 1

NATPARA 4 PA; QL; SP

paricalcitol oral 1

ROCALTROL 4

ZEMPLAR ORAL 4

Ophthalmic Agents -

Drugs for Eye Allergy,

Infection and

Inflammation

ACULAR 4

ACULAR LS 4

ACUVAIL E

ak-poly-bac 1

ALREX 4 QL

AZASITE 3

azelastine hcl ophthalmic 1

bacitracin ophthalmic 1

bacitracin-polymyxin b

ophthalmic1

bacitra-neomycin-

polymyxin-hc1

BEPREVE E QL

BESIVANCE 3

BETADINE

OPHTHALMIC PREP3

BLEPH-10 3

BLEPHAMIDE 3

BLEPHAMIDE S.O.P. 2

bromfenac sodium (once-

daily)3

BROMSITE E QL

CILOXAN OPHTHALMIC

OINTMENT3

CILOXAN OPHTHALMIC

SOLUTION4

ciprofloxacin hcl

ophthalmic1

dexamethasone sodium

phosphate ophthalmic1

diclofenac sodium

ophthalmic1

epinastine hcl E QL

erythromycin ophthalmic 1 H

FLAREX 2

fluorometholone 1

flurbiprofen sodium 1

7

RequiremDrug


Limits

6

Drug NameDrug

Tier

Requirem

ents &

Limits

FML 3

FML FORTE 3

FML LIQUIFILM 4

gatifloxacin ophthalmic 3

gentak 1

gentamicin sulfate

ophthalmic1

ILEVRO E

INVELTYS 3

ketorolac tromethamine

ophthalmic1

LASTACAFT 3 QL

levofloxacin ophthalmic 1

LOTEMAX

OPHTHALMIC GELE

LOTEMAX

OPHTHALMIC 3

OINTMENT

LOTEMAX

OPHTHALMIC 4 QL

SUSPENSION

LOTEMAX SM 3 QL

loteprednol etabonate 3 QL

MAXIDEX 2

MAXITROL 4

MOXEZA 4

moxifloxacin hcl

ophthalmic3

NATACYN 3

neomycin-bacitracin zn-

polymyx1

neomycin-polymyxin-

dexameth ophthalmic 1

ointment

neomycin-polymyxin-

dexameth ophthalmic

suspension 3.5-10000-1

0.1

neomycin-polymyxin-

gramicidin1

neomycin-polymyxin-hc

ophthalmic1

neo-polycin 1

neo-polycin hc 1

NEVANAC 4

OCUFLOX 4

ofloxacin ophthalmic 1

olopatadine hcl

ophthalmic solution 0.1 3 QL

%

olopatadine hcl

ophthalmic solution 0.2 E QL

%

PATADAY

OPHTHALMIC E QL

SOLUTION 0.2 %

PATANOL

OPHTHALMIC E QL

SOLUTION 0.1 %

PAZEO E QL

polycin 1

polymyxin b-trimethoprim 1

POLYTRIM 4

PRED FORTE 4

PRED MILD 3

PRED-G 3

PRED-G S.O.P. 3

prednisolone acetate

ophthalmic1

prednisolone acetate p-f E

prednisolone sodium

phosphate ophthalmic1

PROLENSA E


ophthalmic1

sulfacetamide-

prednisolone ophthalmic 1

solution

TOBRADEX

OPHTHALMIC 3

OINTMENT

8

RequiremDrug


Limits

6

Drug NameDrug

Tier

Requirem

ents &

Limits

TOBRADEX

OPHTHALMIC 4

SUSPENSION

TOBRADEX ST E

tobramycin ophthalmic 1

tobramycin-

dexamethasone2

TOBREX OPHTHALMIC

OINTMENT3

TOBREX OPHTHALMIC

SOLUTION4

trifluridine 1

VIGAMOX E

ZIRGAN 3

ZYLET 3

ZYMAXID 4

Ophthalmic Agents -

Drugs for Glaucoma

ALPHAGAN P

OPHTHALMIC 2 QL

SOLUTION 0.1 %

ALPHAGAN P

OPHTHALMIC 4 QL

SOLUTION 0.15 %

AZOPT 2 QL

betaxolol hcl ophthalmic 1

BETIMOL 2 QL

BETOPTIC-S 3

bimatoprost ophthalmic E QL

brimonidine tartrate

ophthalmic solution 0.15 2 QL

%

brimonidine tartrate

ophthalmic solution 0.2 1

%

carteolol hcl 1

COMBIGAN 2 QL

COSOPT 4

COSOPT PF E QL

DORZOLAMIDE HCL

SOLUTION 2 % 4

OPHTHALMIC

dorzolamide hcl solution

2 % ophthalmic1

dorzolamide hcl-timolol

mal2

dorzolamide hcl-timolol

mal pfE QL

ISTALOL 4

latanoprost ophthalmic 1

levobunolol hcl 1

LUMIGAN 2

RHOPRESSA 3 QL

ROCKLATAN 3 QL

SIMBRINZA E QL

timolol maleate

ophthalmic gel forming 1

solution

timolol maleate


%, 0.5 %

timolol maleate


% (daily)

TIMOPTIC 4

TIMOPTIC OCUDOSE 2

TIMOPTIC-XE 4

TRAVATAN Z 4 QL

travoprost (bak free) 2 QL

TRUSOPT 4

VYZULTA E ST; QL

XALATAN E

XELPROS 3 QL

ZIOPTAN 3 ST; QL

Ophthalmic Agents -

Drugs for

Miscellaneous Eye

Conditions

AKTEN 3

ALCAINE 3

ALOCRIL 3

ALOMIDE 3

altacaine 1

9

RequiremDrug


Limits

7

Drug NameDrug

Tier

Requirem

ents &

Limits

altafrin 1

apraclonidine hcl 1

atropine sulfate

ophthalmic ointment1

atropine sulfate

ophthalmic solution 1 %1

CEQUA E PA; QL

cromolyn sodium

ophthalmic1

CYCLOGYL 4

CYCLOMYDRIL 3

cyclopentolate hcl

ophthalmic1

CYSTARAN 2 PA; QL; SP

DUREZOL 4

GELFILM OPHTHALMIC 2

homatropaire 1

homatropine hbr

ophthalmic solution 5 %1

HYPOCYN 3

IOPIDINE 3

ISOPTO ATROPINE 3

ISOPTO CARPINE

OPHTHALMIC 4

SOLUTION 1 %, 2 %

ISOPTO CARPINE

OPHTHALMIC 3

SOLUTION 4 %

LACRISERT 2

MITOSOL 3

OXERVATE 4 PA; QL; SP

phenylephrine hcl

ophthalmic1

PHOSPHOLINE IODIDE 2

PHOTREXA-PHOTREXA

VISCOUS KIT3

pilocarpine hcl

ophthalmic1

proparacaine hcl

ophthalmic1

RESTASIS 4 PA; QL

RESTASIS MULTIDOSE E PA; QL

tetcaine ophthalmic

solution 0.5 %1

tetracaine hcl ophthalmic 1

tetravisc forte ophthalmic

solution 0.5 %1

tetravisc ophthalmic

solution 0.5 %1

XIIDRA 4 PA; QL

Otic Agents - Drugs for

Ear Conditions

acetic acid otic 1

CETRAXAL 3

CIPRO HC 3

CIPRODEX 3

ciprofloxacin hcl otic 1

CIPROFLOXACIN-

FLUOCINOLONE PFE

COLY-MYCIN S 3

cortic-nd 1

DERMOTIC 4

exotic-hc 1

flac 1


otic1

hydrocortisone-acetic

acid1

neomycin-polymyxin-hc

otic1

ofloxacin otic 2

OTICIN HC NR 2

OTOVEL E

PRAMOTIC 3

Respiratory - Drugs for

Anaphylaxis

AUVI-Q E QL

epinephrine injection (generic for

solution auto-injector E Adrenaclic

0.15 mg/0.15ml k); QL

0

RequiremDrug


Limits

7

Drug NameDrug

Tier

Requirem

ents &

Limits

(generic for

epinephrine solution

auto-injector 0.15 4

EpiPen-

Single

mg/0.3ml injection Pack); QL

epinephrine solution (generic for

auto-injector 0.15 2 EpiPen);

mg/0.3ml injection QL

(generic for

epinephrine solution

auto-injector 0.3 4

EpiPen-

Single

mg/0.3ml injection Pack); QL


auto-injector 0.3 E Adrenaclic

mg/0.3ml injection k); QL


auto-injector 0.3 2 EpiPen);

mg/0.3ml injection QL

EPIPEN 2-PAK E QL

EPIPEN JR 2-PAK E QL

SYMJEPI 2 QL

Respiratory Tract /

Pulmonary Agents -

Drugs for Allergies,

Cough, Cold

ADRENALIN NASAL 2

ASTEPRO NASAL

SOLUTION 0.15 %E

azelastine hcl nasal

solution 0.1 %, 137 3

mcg/spray

azelastine hcl nasal

solution 0.15 %E

BECONASE AQ E QL

benzonatate oral capsule

100 mg, 200 mg1

benzonatate oral capsule

150 mgE

bromfed dm 1

brompheniramine

tannate1

carbinoxamine maleate

oral solution1


oral tablet 4 mg1


oral tablet 6 mgE

cetirizine hcl oral solution E

CLARINEX E

CLARINEX-D 12 HOUR E

clemastine fumarate oral

tablet 2.68 mg1

cyproheptadine hcl oral 1

desloratadine oral tablet E

desloratadine oral tablet

dispersible 5 mgE

dexchlorpheniramine

maleate oralE

diphen oral elixir 1

diphenhydramine hcl oral

elixir1

DYMISTA E QL

flunisolide nasal 3


nasal2 QL

GILPHEX TR 3

GILTUSS TR 3

GRASTEK 4 PA; QL

hydrocodone polst-cpm

polst er3 PA; QL

hydrocodone-

homatropine oral syrup1 PA; QL

hydrocodone-

homatropine oral tablet1 PA

hydromet 1 PA; QL

HYPERSAL 2

ipratropium bromide

nasal1

KARBINAL ER E

levocetirizine

dihydrochloride oral 3

solution

levocetirizine

dihydrochloride oral 1

tablet

1

RequiremDrug


Limits

7

Drug NameDrug

Tier

Requirem

ents &

Limits

mometasone furoate

nasalE QL

NASONEX E QL

nebusal inhalation

nebulization solution 3 %1

NEBUSAL INHALATION

NEBULIZATION 3

SOLUTION 6 %

NEOTUSS PLUS 3

ODACTRA 4 PA; QL

olopatadine hcl nasal 3 QL

OMNARIS E QL

ORALAIR 4 PA; QL

ORALAIR ADULT

SAMPLE KIT4 PA; QL

ORALAIR ADULT

STARTER PACK4 PA; QL

ORALAIR CHILDRENS

SAMPLE KIT3

ORALAIR CHILDRENS

STARTER PACK4 PA; QL

PATANASE 4 QL


solution1


syrup1

promethazine-codeine 1 PA; QL

promethazine-dm 1

promethazine-phenyleph-

codeine1 PA; QL

promethazine-

phenylephrine1

pseudoephedrine-

bromphen-dm1

pulmosal 1

QNASL E QL

QNASL CHILDRENS E QL

RAGWITEK 4 PA; QL

RYCLORA E

ryvent E

SEMPREX-D 3

sodium chloride

inhalation1

TESSALON PERLES 4

TUSSICAPS 3 PA; QL

TUXARIN ER 3 PA; QL

TUZISTRA XR E PA; QL

XHANCE E QL

ZETONNA 3 QL

Respiratory Tract /

Pulmonary Agents -

Drugs for Asthma and

COPD

ACCOLATE 4

acetylcysteine inhalation 1

ADVAIR DISKUS 3 QL; RS

ADVAIR HFA 3 QL; RS

AIRDUO RESPICLICK

113/14E QL

AIRDUO RESPICLICK

232/14E QL

AIRDUO RESPICLICK

55/14E QL

albuterol sulfate er 1

ALBUTEROL SULFATE

HFA AEROSOL

SOLUTION 108 (90

BASE) MCG/ACT

INHALATION

3

(ProAir

HFA or

Proventil

HFA); QL

ALBUTEROL SULFATE

HFA AEROSOL

SOLUTION 108 (90

BASE) MCG/ACT

E(Ventolin

HFA); QL

INHALATION

albuterol sulfate

inhalation1

albuterol sulfate oral 1

ALVESCO 1 QL

ANORO ELLIPTA 3 QL

ARCAPTA NEOHALER 3 QL

ARNUITY ELLIPTA 3 QL

ASMANEX (120

METERED DOSES)1 QL

2

RequiremDrug


Limits

7

Drug NameDrug

Tier

Requirem

ents &

Limits

ASMANEX (14

METERED DOSES)1 QL

ASMANEX (30

METERED DOSES)1 QL

ASMANEX (60

METERED DOSES)1 QL

ASMANEX (7 METERED

DOSES)1 QL

ASMANEX HFA

INHALATION AEROSOL

100 MCG/ACT, 200 1 QL

MCG/ACT

ASMANEX HFA

INHALATION AEROSOL 1

50 MCG/ACT

ATROVENT HFA 3 QL

BEVESPI

AEROSPHERE2 QL

BREO ELLIPTA 3 QL; RS

BROVANA 3 QL

budesonide inhalation 2 QL

BUDESONIDE-

FORMOTEROL E QL; RS

FUMARATE

COMBIVENT RESPIMAT 3 QL

cromolyn sodium

inhalation1

DALIRESP 3 PA; QL

difil-g forte 1

DUAKLIR PRESSAIR E QL

DULERA E ST; QL

ELIXOPHYLLIN 3

FASENRA 4 PA

FASENRA PEN 4 PA

FLOVENT DISKUS 3 QL

FLOVENT HFA 3 QL

fluticasone-salmeterol

inhalation aerosol

powder breath activated

100-50 mcg/dose, 250-E QL; RS

50 mcg/dose, 500-50

mcg/dose

FLUTICASONE-

SALMETEROL

INHALATION AEROSOL

POWDER BREATH

ACTIVATED 113-14 2 QL

MCG/ACT, 232-14

MCG/ACT, 55-14

MCG/ACT

INCRUSE ELLIPTA 2 QL

ipratropium bromide

inhalation1

ipratropium-albuterol 2

levalbuterol hcl inhalation 3 QL

LEVALBUTEROL HFA

INHALATION AEROSOL 3 QL

45 MCG/ACT

LONHALA MAGNAIR

REFILL KITE PA; QL

LONHALA MAGNAIR

STARTER KITE PA; QL

metaproterenol sulfate

oral1

montelukast sodium oral

packet2


tablet1


tablet chewable1

NUCALA

SUBCUTANEOUS

SOLUTION AUTO-4 PA; QL; SP

INJECTOR

NUCALA

SUBCUTANEOUS

SOLUTION PREFILLED 4 PA; QL; SP

SYRINGE

PERFOROMIST 3 QL

PROAIR DIGIHALER E QL

PROAIR HFA 3 QL

PROAIR RESPICLICK 3 QL

PROVENTIL HFA 3 QL

PULMICORT

FLEXHALER4 ST; QL

3

RequiremDrug


Limits

7

Drug NameDrug

Tier

Requirem

ents &

Limits

PULMICORT

SUSPENSIONE QL

QVAR REDIHALER 1

SEEBRI NEOHALER 4 ST; QL

SEREVENT DISKUS 3 QL

SINGULAIR ORAL

PACKET3

SINGULAIR ORAL

TABLETE

SINGULAIR ORAL

TABLET CHEWABLEE

SPIRIVA HANDIHALER 2 QL

SPIRIVA RESPIMAT 2 QL

STIOLTO RESPIMAT E QL

STRIVERDI RESPIMAT 2 QL

SYMBICORT 3 QL; RS

terbutaline sulfate oral 1

THEO-24 3

theophylline 1

theophylline er 1

TRELEGY ELLIPTA 3 QL; RS

TUDORZA PRESSAIR E QL

UTIBRON NEOHALER E QL

VENTOLIN HFA 2 QL

wixela inhub E QL; RS

XOPENEX E QL

XOPENEX

CONCENTRATEE QL

XOPENEX HFA 3 QL

YUPELRI 4 PA; QL

zafirlukast 1

zileuton er 3 ST

ZYFLO 4 ST

Respiratory Tract /

Pulmonary Agents -

Drugs for Cystic

Fibrosis

BETHKIS 2 PA; QL; SP

CAYSTON 2 PA; QL; SP

KALYDECO 2 PA; QL; SP

KITABIS PAK E PA; QL; SP

ORKAMBI 2 PA; QL; SP

PULMOZYME 2 PA; QL; SP

SYMDEKO 2 PA; QL; SP

TOBI NEBULIZER E PA; QL; SP

TOBI PODHALER 3 PA; QL; SP

TOBRAMYCIN

INHALATIONE PA; QL; SP

TRIKAFTA 4 PA; QL; SP

Respiratory Tract /

Pulmonary Agents -

Drugs for Pulmonary

Fibrosis

ESBRIET 2 PA; QL; SP

OFEV 4 PA; QL; SP

Respiratory Tract /

Pulmonary Agents -

Drugs for Pulmonary

Hypertension

ADCIRCA E PA; QL; SP

ADEMPAS 2 PA; QL; SP

alyq 3 PA; QL; SP

ambrisentan 2 PA; QL; SP

bosentan 2 PA; QL; SP

LETAIRIS 4 PA; QL; SP

OPSUMIT 2 PA; QL; SP

ORENITRAM 4 PA; QL; SP

REVATIO ORAL

SUSPENSION 4 PA; QL; SP

RECONSTITUTED

REVATIO ORAL

TABLETE QL; SP


suspension reconstituted3 PA; QL; SP


tablet 20 mg1 QL; SP

tadalafil (pah) 3 PA; QL; SP

TRACLEER 2 PA; QL; SP

TYVASO 2 PA; SP

TYVASO REFILL 2 PA; SP

TYVASO STARTER 2 PA; SP

4

RequiremDrug


Limits

7

Drug NameDrug

Tier

Requirem

ents &

Limits

UPTRAVI 4 PA; QL

VENTAVIS 2 PA; SP

Skeletal Muscle

Relaxants - Drugs for

Muscle Pain and

Spasm

AMRIX E

baclofen oral 1

carisoprodol oral tablet

250 mgE

carisoprodol oral tablet

350 mg1

carisoprodol-aspirin 1

chlorzoxazone oral tablet

250 mg, 375 mg, 750 mgE

chlorzoxazone oral tablet

500 mg1

cyclobenzaprine hcl er E

cyclobenzaprine hcl oral 1

DANTRIUM ORAL 4

dantrolene sodium oral 1

FEXMID 4

LORZONE E

metaxalone 3

methocarbamol oral 1

NORGESIC FORTE E

orphenadrine citrate er 2

orphenadrine-aspirin-

caffeineE

ORPHENGESIC FORTE E

OZOBAX E

ROBAXIN-750 4

SKELAXIN E

SOMA ORAL TABLET

250 MGE

SOMA ORAL TABLET

350 MG3

tizanidine hcl oral

capsule3

tizanidine hcl oral tablet 1

ZANAFLEX 4

Sleep Disorder Agents

AMBIEN E QL

AMBIEN CR E QL

armodafinil 2 PA; QL

BELSOMRA 4 ST; QL

doxepin hcl oral tablet E QL

EDLUAR E QL

eszopiclone 2 QL

flurazepam hcl 1

HETLIOZ 4 PA; QL; SP

INTERMEZZO E QL

LUNESTA E QL

modafinil 2 PA; QL

NUVIGIL E PA; QL

PROVIGIL E PA; QL

ramelteon 3 ST; QL

RESTORIL 4

ROZEREM 4 ST; QL

SECONAL 3

SILENOR E QL

SUNOSI 3 PA; QL

temazepam 1

WAKIX 4 PA; QL; SP

XYREM 4 PA; QL; SP

zaleplon 1 QL

zolpidem tartrate er E QL

zolpidem tartrate oral 1 QL

zolpidem tartrate

sublingualE QL

ZOLPIMIST 4 ST; QL

5

Index of Drugs

abacavir sulfate...................25

abacavir sulfate-lamivudine 25

abacavir-lamivudine-

zidovudine...........................25

ABILIFY.............................. 24

ABILIFY MYCITE................24

abiraterone acetate.............20

ABSORICA......................... 36

ABSORICA LD....................36

ABSTRAL............................. 6

acamprosate calcium............9

ACANYA............................. 36

acarbose............................. 46

ACCOLATE........................ 72

ACCU-CHEK AVIVA

CONNECT KIT W/DEVICE.43

ACCU-CHEK AVIVA

DEVICE.............................. 43

ACCU-CHEK AVIVA PLUS

KIT W/DEVICE................... 43

ACCU-CHEK COMPACT

PLUS CARE KIT.................43

ACCU-CHEK COMPACT

PLUS TEST STRIPS.......... 43

ACCU-CHEK GUIDE KIT

W/DEVICE.......................... 43

ACCU-CHEK NANO

SMARTVIEW KIT

W/DEVICE.......................... 43

ACCU-CHEK

SMARTVIEW TEST

STRIPS...............................44

ACCU-CHEK SOFTCLIX

LANCET DEVICE KIT.........44

ACCUPRIL..........................28

ACCURETIC.......................28

acebutolol hcl ......................28

acetaminophen-codeine....... 6

acetaminophen-codeine #2.. 6



acetazolamide.....................28

acetazolamide er................ 28

acetic acid...........................70

acetylcysteine..................... 72

ACIPHEX............................ 52

ACIPHEX SPRINKLE......... 52

acitretin............................... 36

ACTEMRA.......................... 63

ACTEMRA ACTPEN...........63

ACTHAR............................. 62

ACTHIB...............................65

ACTICLATE........................ 10

ACTIGALL.......................... 52

ACTIMMUNE...................... 63

ACTIQ...................................6

ACTIVELLA........................ 56

ACTONEL...........................67

ACTOPLUS MET................46

ACTOS............................... 46

ACULAR............................. 67

ACULAR LS........................67

ACUVAIL............................ 67

acyclovir..............................25

ACZONE.............................36

ADACEL............................. 65

ADALAT CC........................28

adapalene........................... 36

ADAPALENE...................... 36

adapalene-benzoyl

peroxide.............................. 36

adc/f (0.5mg/ml)..................49

ADCIRCA............................74

ADDERALL.........................33

ADDERALL XR...................33

ADDYI.................................49

adefovir dipivoxil................. 25

ADEMPAS.......................... 74

ADHANSIA XR................... 33

ADLYXIN............................ 46

ADLYXIN STARTER

PACK.................................. 46

ADMELOG..........................45

ADMELOG SOLOSTAR..... 45

ADRENALIN....................... 71

ADVAIR DISKUS................ 72

ADVAIR HFA...................... 72

ADVATE............................. 48

ADYNOVATE......................48

ADZENYS ER.....................33

ADZENYS XR-ODT............ 33

AEMCOLO..........................10

AFINITOR........................... 20

AFINITOR DISPERZ.......... 20

afirmelle.............................. 56

AFLURIA

QUADRIVALENT................65

AFREZZA........................... 45

AFSTYLA............................48

AGGRENOX....................... 24

AGRYLIN............................ 48

AIMOVIG............................ 19

AIRDUO RESPICLICK

113/14.................................72

AIRDUO RESPICLICK

232/14.................................72

AIRDUO RESPICLICK

55/14...................................72

AJOVY................................ 19

AKLIEF............................... 36

ak-poly-bac......................... 67

AKTEN................................69

AKYNZEO...........................17

ALA SCALP........................ 36

ala-cort ................................36

albendazole........................ 23

ALBENZA........................... 23

albuterol sulfate.................. 72

albuterol sulfate er.............. 72

ALBUTEROL SULFATE

HFA.....................................72

ALCAINE............................ 69

alclometasone

dipropionate........................ 36

ALCOHOL PREP PADS..... 10

ALDACTAZIDE................... 28

ALDACTONE......................28

ALDARA............................. 36

ALECENSA.........................20

alendronate sodium............ 67

ALFERON N....................... 63

alfuzosin hcl er....................56

ALINIA................................ 23

aliskiren fumarate............... 28

ALKERAN........................... 20

allopurinol........................... 19

ALLZITAL..............................6

almotriptan malate.............. 19

ALOCRIL............................ 69

ALOGLIPTIN BENZOATE.. 46

ALOGLIPTIN-

METFORMIN HCL..............46

ALOGLIPTIN-

PIOGLITAZONE................. 46

ALOMIDE............................69

ALORA................................56

alosetron hcl....................... 53

ALPHAGAN P.....................69

ALPHANATE/VWF

COMPLEX/HUMAN............ 48

ALPHANINE SD................. 48

alprazolam.......................... 27

alprazolam er...................... 27

alprazolam intensol.............27

alprazolam xr...................... 27

ALPROLIX.......................... 48

ALREX................................ 67

ALTABAX............................10

altacaine............................. 69

76

ALTACE..............................28

altafrin................................. 70

altavera............................... 56

ALTOPREV.........................28

ALTRENO...........................36

ALUNBRIG......................... 20

ALVESCO...........................72

alyacen 1/35....................... 56

alyacen 7/7/7...................... 56

alyq..................................... 74

amabelz.............................. 56

amantadine hcl................... 23

AMARYL............................. 46

AMBIEN.............................. 75

AMBIEN CR........................75

ambrisentan........................ 74

amcinonide......................... 36

AMELUZ............................. 36

AMERGE............................ 19

amethia............................... 56

amethia lo........................... 56

amethyst............................. 56

AMICAR..............................48

amiloride hcl........................28

amiloride-

hydrochlorothiazide.............28

aminoamrms....................... 49

aminobenzoate potassium..49

aminocaproic acid...............48

aminoreliefrms.................... 49

amiodarone hcl ................... 28

AMITIZA..............................53

amitriptyline hcl................... 15

amlodipine besylate............ 28


benazepril hcl......................28


valsartan............................. 28

amlodipine-atorvastatin.......28

amlodipine-olmesartan....... 28

amlodipine-valsartan-hctz...28

ammonium lactate.............. 36

amnesteem......................... 36

amoxapine.......................... 15

amoxicill-clarithro-

lansopraz............................ 52

amoxicillin........................... 10


clavulanate..........................10


clavulanate er..................... 10

AMPHETAMINE ER........... 33

amphetamine sulfate.......... 33

amphetamine-

dextroamphetamine............ 33

amphetamine-

dextroamphetamine er........33

ampicillin............................. 10

AMPYRA.............................34

AMRIX................................ 75

AMZEEQ.............................36

ANADROL-50..................... 62

ANAFRANIL........................15

anagrelide hcl..................... 48

ANALPRAM HC..................66

ANALPRAM HC SINGLES. 66

ANALPRAM-HC..................66

ANASPAZ........................... 53

anastrozole......................... 20

ANCOBON..........................17

ANDRODERM.................... 62

ANDROGEL........................62

ANDROGEL PUMP............ 62

ANGELIQ............................56

ANNOVERA........................56

ANORO ELLIPTA............... 72

ANTABUSE.......................... 9

ANTARA............................. 28

anucort-hc...........................66

ANUSOL-HC.......................66

ANZEMET...........................17

APADAZ............................... 6

apap-caff-dihydrocodeine..... 6

APEXICON E......................36

APIDRA SOLOSTAR..........45

APIDRA VIAL......................45

APLENZIN.......................... 15

APOKYN.............................23

apraclonidine hcl.................70

aprepitant............................17

apri......................................56

APRISO.............................. 66

APTENSIO XR....................33

APTIOM.............................. 13

APTIVUS............................ 25

ARAKODA.......................... 23

aranelle............................... 56

ARANESP (ALBUMIN

FREE)................................. 48

ARAVA................................63

ARCALYST.........................63

ARCAPTA NEOHALER...... 72

ARICEPT............................ 15

ARIKAYCE..........................10

ARIMIDEX.......................... 20

aripiprazole......................... 24

ARIXTRA............................ 13

armodafinil .......................... 75

ARMOUR THYROID...........63

ARNUITY ELLIPTA.............72

AROMASIN.........................20

ARTHROTEC....................... 8

ARTISS...............................48

ARYMO ER...........................6

arzol silver nit applicators... 10

ASACOL HD....................... 66

ascomp-codeine................... 6

ashlyna............................... 56

ASMANEX (120

METERED DOSES)........... 72

ASMANEX (14 METERED

DOSES).............................. 73

ASMANEX (30 METERED

DOSES).............................. 73

ASMANEX (60 METERED

DOSES).............................. 73

ASMANEX (7 METERED

DOSES).............................. 73

ASMANEX HFA.................. 73

aspirin-dipyridamole er ....... 24

ASPIRIN-OMEPRAZOLE... 24

ASTAGRAF XL................... 63

ASTEPRO...........................71

ATABEX OB....................... 49

ATACAND...........................28

ATACAND HCT.................. 28

atazanavir sulfate................25

ATELVIA............................. 67

atenolol ............................... 28

atenolol-chlorthalidone........28

ATIVAN...............................27

atomoxetine hcl ...................33

atorvastatin calcium............ 28

atovaquone......................... 23

atovaquone-proguanil hcl ... 23

ATRALIN.............................36

ATRIPLA.............................25

atropine sulfate................... 70

ATROVENT HFA................ 73

AUBAGIO........................... 34

aubra...................................56

aubra eq..............................56

AUGMENTIN...................... 10

AUGMENTIN ES-600......... 10

aurovela 1.5/30................... 56

aurovela 1/20...................... 56

aurovela 24 fe..................... 56

aurovela fe 1.5/30............... 56

aurovela fe 1/20.................. 56

77

AURYXIA............................ 55

AUSTEDO.......................... 35

AUVI-Q............................... 70

AVALIDE.............................28

AVANDIA............................ 46

AVAPRO.............................28

avar cleanser...................... 36

AVAR LS CLEANSER........ 36

AVAR-E EMOLLIENT......... 36

AVAR-E GREEN.................36

AVAR-E LS......................... 36

AVC VAGINAL....................17

aviane................................. 56

avidoxy................................10

AVIDOXY DK......................10

avita.................................... 36

AVODART.......................... 56

AVONEX PEN.................... 34

AVONEX PREFILLED........ 34

AYGESTIN..........................56

ayuna.................................. 56

AYVAKIT.............................20

AZASAN............................. 63

AZASITE.............................67

azathioprine........................ 63

azelaic acid......................... 36

azelastine hcl................ 67, 71

AZELEX.............................. 36

AZESCO............................. 49

AZILECT............................. 23

azithromycin........................10

AZOPT................................69

AZOR..................................28

AZULFIDINE.......................66

AZULFIDINE EN-TABS...... 66

azurette...............................56

bacitracin............................ 67

bacitracin-polymyxin b........ 67

bacitra-neomycin-

polymyxin-hc.......................67

baclofen.............................. 75

BACTRIM............................10

BACTRIM DS......................10

BALCOLTRA...................... 56

balsalazide disodium.......... 66

balsam peru-castor oil ........ 36

BALVERSA.........................20

balziva.................................56

BANZEL..............................13

BAQSIMI ONE PACK......... 47

BAQSIMI TWO PACK.........47

BARACLUDE......................25

BASAGLAR KWIKPEN.......45

BAXDELA........................... 10

bd autoshield duo pen

needles............................... 44

bd ultra-fine insulin

syringes.............................. 44

bd ultra-fine pen needles.... 44

BECONASE AQ..................71

bekyree............................... 56

BELBUCA............................. 6

belladonna alkaloids-opium 53

BELSOMRA........................75

benazepril hcl......................28

benazepril-


BENEFIX............................ 48

BENICAR............................28

BENICAR HCT................... 28

BENLYSTA......................... 63

BENZAC AC WASH........... 36

BENZACLIN........................36

BENZACLIN WITH PUMP.. 36

BENZALKONIUM

CHLORIDE......................... 10

benzalkonium chloride........ 10

BENZAMYCIN.................... 36

BENZEPRO........................ 36

benzepro.............................36

benzepro creamy wash.......36

benzepro foaming cloths.....36

BENZEPRO SHORT

CONTACT.......................... 36

BENZHYDROCODONE-

ACETAMINOPHEN.............. 6

BENZIQ.............................. 36

BENZIQ LS......................... 36

BENZIQ WASH...................36

BENZNIDAZOLE................ 23

BENZOIN............................36

benzoin compound............. 36

benzonatate........................ 71

benzoyl peroxide.................36

BENZOYL PEROXIDE....... 37

benzoyl peroxide-

erythromycin....................... 37

benztropine mesylate..........23

BEPREVE...........................67

beser...................................37

BESIVANCE....................... 67

BETADINE OPHTHALMIC

PREP.................................. 67

betamethasone

dipropionate........................ 37

betamethasone

dipropionate aug................. 37

betamethasone valerate..... 37

BETAPACE.........................28

BETAPACE AF................... 28

BETASERON......................34

betaxolol hcl ..................28, 69

bethanechol chloride...........55

BETHKIS............................ 74

BETIMOL............................ 69

BETOPTIC-S...................... 69

BEVESPI AEROSPHERE.. 73

BEVYXXA........................... 13

bexarotene..........................21

BEXSERO.......................... 65

BEYAZ................................ 56

bicalutamide........................21

BIDIL...................................28

BIJUVA............................... 57

BIKTARVY.......................... 25

BILTRICIDE........................ 23

bimatoprost......................... 69

BINOSTO............................67

BIO-STATIN........................17

bio-statin............................. 17

bisoprolol fumarate............. 28

bisoprolol-


BLEPH-10...........................67

BLEPHAMIDE.....................67

BLEPHAMIDE S.O.P.......... 67

blisovi 24 fe.........................57

blisovi fe 1.5/30...................57

blisovi fe 1/20......................57

BONIVA.............................. 67

BONJESTA.........................17

BOOSTRIX......................... 65

bosentan............................. 74

BOSULIF............................ 21

bp 10-1................................37

bp cleansing wash.............. 37

bp wash.............................. 37

BRAFTOVI..........................21

BREO ELLIPTA.................. 73

briellyn................................ 57

BRILINTA............................24

brimonidine tartrate.............69

BRISDELLE........................ 15

BRIVIACT........................... 13

bromfed dm.........................71

bromfenac sodium (once-

daily)................................... 67

bromocriptine mesylate.......23

78

brompheniramine tannate...71

BROMSITE......................... 67

BROVANA.......................... 73

BRUKINSA......................... 21

BRYHALI............................ 37

budesonide................... 66, 73

budesonide er..................... 66

BUDESONIDE-

FORMOTEROL

FUMARATE........................ 73

bumetanide......................... 28

BUMEX............................... 28

BUNAVAIL.......................... 10

BUPAP..................................6

BUPHENYL........................ 54

buprenorphine.......................6

BUPRENORPHINE.............. 6

buprenorphine hcl............... 10

buprenorphine hcl-

naloxone hcl........................10

bupropion hcl ...................... 15

bupropion hcl er (smoking

det)......................................10

bupropion hcl er (sr) ............15

bupropion hcl er (xl)............ 15

BUPROPION HCL ER (XL) 15

buspirone hcl...................... 27

BUTALBITAL-

ACETAMINOPHEN.............. 6

butalbital-acetaminophen......6

butalbital-apap-caff-cod........ 6

butalbital-apap-caffeine........ 6

butalbital-asa-caff-codeine....6

butalbital-aspirin-caffeine......6

butorphanol tartrate.............. 6

BUTRANS.............................6

BYDUREON....................... 47

BYDUREON BCISE

AUTOINJECTOR................47

BYETTA 10 MCG PEN....... 47

BYETTA 5 MCG PEN......... 47

BYSTOLIC.......................... 28

cabergoline......................... 62

CABLIVI.............................. 48

CABOMETYX..................... 21

CADUET............................. 28

CAFERGOT........................19

caffeine citrate.................... 35

CALAN SR..........................28

CALCIFOL.......................... 50

calcipotriene........................37

CALCIPOTRIENE...............37

calcipotriene-betameth

diprop..................................37

CALCIPOTRIENE-

BETAMETH DIPROP......... 37

calcitonin (salmon)..............67

CALCITRENE..................... 37

calcitriol.........................37, 67

calcium acetate...................55

calcium acetate (phos

binder).................................55

calcium-folic acid plus d......50

CALQUENCE..................... 21

CAMBIA.............................. 19

camila................................. 57

camrese.............................. 57

camrese lo.......................... 57

CANASA............................. 66

candesartan cilexetil........... 28

candesartan cilexetil-hctz... 28

capecitabine........................21

CAPEX................................37

CAPLYTA........................... 24

CAPRELSA.........................21

captopril.............................. 29

captopril-


CARAC............................... 37

CARAFATE.........................52

CARBAGLU........................ 55

carbamazepine................... 14

carbamazepine er......... 13, 14

CARBATROL......................14

carbidopa............................ 23

carbidopa-levodopa............ 23

carbidopa-levodopa er........ 23

carbidopa-levodopa-

entacapone......................... 23

carbinoxamine maleate.......71

CARDIOVID PLUS............. 50

CARDIZEM......................... 29

CARDIZEM CD...................29

CARDIZEM LA....................29

CARDURA.......................... 29

CARDURA XL.....................56

carisoprodol........................ 75

carisoprodol-aspirin............ 75

carisoprodol-aspirin-

codeine................................. 6

CARNITOR......................... 50

CARNITOR SF................... 50

CAROSPIR......................... 29

carteolol hcl.........................69

cartia xt............................... 29

carvedilol.............................29

carvedilol phosphate er.......29

cascara sagrada................. 53

CASODEX.......................... 21

CATAPRES........................ 29

CATAPRES-TTS-1............. 29

CATAPRES-TTS-2............. 29

CATAPRES-TTS-3............. 29

cavarest .............................. 35

CAVERJECT...................... 49

CAVERJECT IMPULSE......49

CAYSTON.......................... 74

caziant................................ 57

cefaclor ............................... 10

cefaclor er........................... 10

cefadroxil ............................ 10

cefdinir ................................ 10

cefditoren pivoxil ................. 10

cefixime...............................10

cefpodoxime proxetil ...........10

cefprozil .............................. 10

cefuroxime axetil .................10

CELEBREX...........................8

celecoxib...............................8

CELEXA..............................15

CELLCEPT......................... 63

CELONTIN..........................14

CENTANY...........................10

CENTANY AT..................... 10

cephalexin...........................10

CEQUA............................... 70

CEQUR SIMPLICITY 2U.... 44

CERDELGA........................ 54

cerovel ................................ 37

CERVIDIL........................... 62

cetirizine hcl........................ 71

CETRAXAL.........................70

CETROTIDE....................... 62

cevimeline hcl ..................... 35

CHANTIX............................ 10

CHANTIX CONTINUING

MONTH PAK...................... 10

CHANTIX STARTING

MONTH PAK...................... 10

chateal ................................ 57

chateal eq........................... 57

CHEMET.............................50

CHENODAL........................53

chlordiazepoxide hcl........... 27

chlordiazepoxide-

amitriptyline.........................15

chlordiazepoxide-clidinium..53

chlorhexidine gluconate...... 35

79

chloroquine phosphate....... 23

chlorothiazide......................29

chlorpromazine hcl..............24

chlorthalidone..................... 29

chlorzoxazone.....................75

CHOLBAM.......................... 53

cholestyramine....................29

cholestyramine light............ 29

choline-mag trisalicylate....... 8

chorionic gonadotropin....... 65

CIALIS................................ 49

ciclodan...............................17

CICLODAN SOLUTION......17

ciclopirox.............................17

ciclopirox olamine............... 17

ciclopirox treatment.............18

cilostazol............................. 24

CILOXAN............................ 67

CIMDUO............................. 25

cimetidine............................52

cimetidine hcl...................... 52

CIMZIA................................63

CIMZIA PREFILLED KIT.... 63

CIMZIA STARTER KIT....... 63

cinacalcet hcl ...................... 62

CIPRO................................ 10

CIPRO HC.......................... 70

CIPRODEX......................... 70

ciprofloxacin hcl ...... 10, 67, 70

CIPROFLOXACIN-

FLUOCINOLONE PF..........70

citalopram hydrobromide.... 15

CITRANATAL BLOOM....... 50

CITRANATAL MEDLEY......50

claravis................................37

CLARINEX..........................71

CLARINEX-D 12 HOUR..... 71

clarithromycin......................10

clarithromycin er................. 10

clemastine fumarate........... 71

CLENPIQ............................ 53

CLEOCIN............................11

CLEOCIN-T........................ 37

CLIMARA............................57

CLIMARA PRO................... 57

CLINDACIN ETZ.................37

clindacin etz........................ 37

CLINDACIN PAC................ 37

clindacin-p...........................37

CLINDAGEL....................... 37

clindamycin hcl................... 11

clindamycin palmitate hcl....11


................................ 11, 37, 38

CLINDAMYCIN

PHOSPHATE......................38

clindamycin phosphate-

benzoyl peroxide.................37

clindamycin-tretinoin........... 38

CLINDESSE....................... 11

clinpro 5000........................ 35

clobazam............................ 14

clobetasol prop emollient

base.................................... 38

clobetasol propionate..........38

clobetasol propionate e.......38


emulsion............................. 38

CLOBEX............................. 38

CLOBEX SPRAY................ 38

clocortolone pivalate........... 38

clodan................................. 38

CLODERM..........................38

clomipramine hcl.................15

clonazepam........................ 27

clonidine..............................29

clonidine hcl........................ 29

clonidine hcl er....................33

clopidogrel bisulfate............ 24

clorazepate dipotassium..... 27

clotrimazole.........................18

clotrimazole-

betamethasone................... 38

clovique...............................55

clozapine.............................24

CLOZARIL.......................... 24

COAGADEX....................... 48

COAL TAR..........................38

COARTEM..........................23

codeine sulfate......................6

COLAZAL........................... 66

COLCHICINE......................19

colchicine............................ 19

colchicine-probenecid......... 19

COLCRYS.......................... 19

colesevelam hcl.................. 29

COLESTID..........................29

COLESTID FLAVORED..... 29

colestipol hcl....................... 29

colistimethate sodium

(cba)....................................11

colocort............................... 66

COLY-MYCIN M................. 11

COLY-MYCIN S..................70

COMBIGAN........................ 69

COMBIPATCH....................57

COMBIVENT RESPIMAT... 73

COMBIVIR.......................... 25

COMETRIQ (100 MG

DAILY DOSE)..................... 21

COMETRIQ (140 MG

DAILY DOSE)..................... 21

COMETRIQ (60 MG

DAILY DOSE)..................... 21

COMPLERA........................25

compro................................17

COMTAN............................ 23

CONCERTA........................33

CONDYLOX........................38

CONSENSI......................... 29

constulose...........................53

CONTOUR NEXT

MONITOR...........................44

CONTOUR NEXT TEST.....44

CONTOUR TEST............... 44

CONZIP................................ 6

COPAXONE....................... 34

COPIKTRA......................... 21

CORDRAN..........................38

COREG...............................29

COREG CR........................ 29

coremino............................. 11

CORGARD......................... 29

CORIFACT......................... 48

CORLANOR....................... 29

CORTANE-B.......................38

CORTEF............................. 61

CORTENEMA.....................66

cortic-nd.............................. 70

CORTIFOAM...................... 66

cortisone acetate................ 61

CORTISPORIN...................38

COSENTYX (300 MG

DOSE)................................ 63

COSENTYX 150 MG/ML.... 63

COSENTYX

SENSOREADY (300 MG)...63

COSENTYX

SENSOREADY PEN.......... 63

COSOPT.............................69

COSOPT PF....................... 69

COTELLIC.......................... 21

COTEMPLA XR-ODT......... 33

COUMADIN........................ 13

covaryx............................... 57

covaryx hs...........................57

COZAAR.............................29

CREON...............................54

80

CRESEMBA........................18

CRESTOR.......................... 29

CRINONE........................... 65

CRIXIVAN...........................25

cromolyn sodium.....53, 70, 73

crotan..................................23

cryselle-28.......................... 57

CUPRIMINE........................55

CUTIVATE.......................... 38

CUVPOSA.......................... 53

cyanocobalamin..................50

CYANOCOBALAMIN..........50

cyclafem 1/35......................57

cyclafem 7/7/7.....................57

cyclobenzaprine hcl............ 75

cyclobenzaprine hcl er........ 75

CYCLOGYL........................ 70

CYCLOMYDRIL..................70

cyclopentolate hcl ............... 70

cyclophosphamide.............. 21

cycloserine..........................20

CYCLOSET........................ 47

cyclosporine........................63

cyclosporine modified......... 63

CYMBALTA........................ 15

cyproheptadine hcl ..............71

cyred................................... 57

cyred eq.............................. 57

CYSTADANE......................54

CYSTAGON........................54

CYSTARAN........................ 70

CYTOMEL.......................... 63

CYTOTEC...........................52

cytra k crystals.................... 50

D.H.E. 45............................ 19

dalfampridine er.................. 34

DALIRESP.......................... 73

danazol............................... 62

DANTRIUM.........................75

dantrolene sodium.............. 75

dapsone........................ 20, 38

DAPSONE.......................... 38

DARAPRIM.........................23

darifenacin hydrobromide

er.........................................55

dasetta 1/35........................ 57

dasetta 7/7/7....................... 57

DAURISMO........................ 21

DAYPRO...............................9

daysee................................ 57

DAYTRANA........................ 33

DDAVP............................... 62

DDAVP RHINAL TUBE.......62

DEBACTEROL................... 35

deblitane............................. 57

DECADRON....................... 61

deferasirox.......................... 55

DELESTROGEN.................57

DELSTRIGO....................... 25

delyla.................................. 57

DELZICOL.......................... 66

demeclocycline hcl..............11

DEMSER............................ 29

DENAVIR............................25

denta 5000 plus.................. 35

dentagel.............................. 35

DEPAKOTE........................ 14

DEPAKOTE ER.................. 14

DEPAKOTE SPRINKLES... 14

DEPEN TITRATABS...........55

DEPO-ESTRADIOL............ 57

DEPO-PROVERA...............57

DEPO-SUBQ PROVERA

104......................................57

DEPO-TESTOSTERONE... 62

DERMA-SMOOTHE/FS

BODY..................................38

DERMA-SMOOTHE/FS

SCALP................................ 38

dermazene..........................18

DERMOTIC.........................70

DESCOVY.......................... 25

desipramine hcl...................16

desloratadine...................... 71

desmopressin ace spray

refrig....................................62

desmopressin acetate.........62


spray................................... 62

desogestrel-ethinyl

estradiol.............................. 57

DESONATE........................ 38

desonide............................. 38

DESOWEN......................... 38

desoximetasone..................38

DESOXYN.......................... 33

DESVENLAFAXINE ER......16

desvenlafaxine succinate

er.........................................16

DETROL............................. 55

DETROL LA........................55

dexamethasone.................. 61

dexamethasone intensol.....61

dexamethasone sodium

phosphate........................... 67

dexchlorpheniramine

maleate............................... 71

DEXCOM G4 / G5 / G6

RECEIVER,

TRANSMITTER, SENSOR

(INCLUDING PLATINUM,

PLATINUM PEDIATRIC).... 44

DEXEDRINE.......................33

DEXILANT.......................... 52

dexmethylphenidate hcl ...... 33

dexmethylphenidate hcl er ..33

DEXPAK 10 DAY................61

DEXPAK 13 DAY................61

DEXPAK 6 DAY..................61

dextroamphetamine sulfate 33

dextroamphetamine sulfate

er.........................................33

DIACOMIT.......................... 14

DIASTAT ACUDIAL............ 14

DIASTAT PEDIATRIC........ 14

diazepam...................... 14, 27

diazepam intensol...............27

DIBENZYLINE.................... 29

DICLEGIS........................... 17

DICLOFENAC

EPOLAMINE.........................9

diclofenac potassium............ 9

diclofenac sodium..... 9, 38, 67

diclofenac sodium er.............9

diclofenac-misoprostol .......... 9

dicloxacillin sodium............. 11

dicyclomine hcl................... 53

DIDANOSINE..................... 25

didanosine.......................... 25

DIFFERIN........................... 38

DIFICID...............................11

difil-g forte........................... 73

diflorasone diacetate.....38, 39

DIFLUCAN..........................18

diflunisal ................................9

digitek................................. 29

digox................................... 29

digoxin................................ 29

dihydroergotamine

mesylate............................. 19

DILANTIN........................... 14

DILANTIN INFATABS.........14

DILATRATE-SR..................29

DILAUDID............................. 6

diltiazem hcl........................ 29

diltiazem hcl er....................29

diltiazem hcl er beads......... 29

81

diltiazem hcl er coated

beads.................................. 29

dilt-xr................................... 29

DIOVAN.............................. 29

DIOVAN HCT......................29

DIPENTUM......................... 66

diphen................................. 71

diphenhydramine hcl ...........71

diphenoxylate-atropine....... 53

DIPROLENE....................... 39

DIPROLENE AF................. 39

dipyridamole....................... 24

disopyramide phosphate.....29

disulfiram............................ 10

DITROPAN XL....................55

DIURIL................................ 29

divalproex sodium...............14

divalproex sodium er...........14

DIVIGEL..............................57

dofetilide............................. 29

DOLOPHINE.........................6

donepezil hcl .......................15

DOPTELET.........................48

DORAL............................... 27

DORYX............................... 11

DORYX MPC...................... 11

DORZOLAMIDE HCL......... 69

dorzolamide hcl...................69

dorzolamide hcl-timolol mal 69

dorzolamide hcl-timolol mal

pf.........................................69

dotti ..................................... 57

DOVATO.............................25

DOVONEX..........................39

doxazosin mesylate............ 29

doxepin hcl..............16, 39, 75

doxercalciferol.....................67

doxycycline......................... 39

doxycycline hyclate.............11

doxycycline monohydrate... 11

doxylamine-pyridoxine........ 17

DRISDOL............................50

DRIZALMA SPRINKLE.......16

dronabinol........................... 17

drospiren-eth estrad-

levomefol............................ 57

drospirenone-ethinyl

estradiol.............................. 57

DROXIA.............................. 21

DRYSOL............................. 39

DUAKLIR PRESSAIR......... 73

DUAVEE............................. 57

DUETACT...........................47

DUEXIS................................ 9

DULERA............................. 73

duloxetine hcl......................16

DUOBRII.............................39

DUOPA............................... 23

DUPIXENT..........................39

DURAGESIC-100................. 6

DURAGESIC-12................... 6

DURAGESIC-25................... 6

DURAGESIC-50................... 6

DURAGESIC-75................... 6

duraxin.................................. 6

DUREZOL...........................70

DURLAZA........................... 24

dutasteride.......................... 56

dutasteride-tamsulosin hcl.. 56

DUTOPROL........................29

DVORAH.............................. 6

DXEVO 11-DAY..................61

DYANAVEL XR...................33

DYAZIDE............................ 29

DYMISTA............................71

DYRENIUM.........................29

E.E.S. 400...........................11

E.E.S. GRANULES.............11

easygel............................... 35

EASYPLUS BLOOD

GLUCOSE TEST................ 44

EC-NAPROSYN................... 9

ec-naproxen..........................9

econazole nitrate................ 18

ECOZA............................... 18

EDARBI.............................. 29

EDARBYCLOR................... 29

EDECRIN............................29

EDEX.................................. 49

EDLUAR............................. 75

ed-spaz............................... 53

EDURANT.......................... 25

eemt....................................57

eemt hs............................... 57

efavirenz............................. 25

EFFER-K............................ 50

effer-k..................................50

EFFEXOR XR.....................16

EFFIENT.............................24

EFUDEX............................. 39

EGATEN............................. 23

EGRIFTA............................ 62

EGRIFTA SV...................... 62

ELESTRIN.......................... 57

eletriptan hydrobromide...... 19

ELIDEL............................... 39

ELIGARD............................ 62

ELIMITE..............................23

elinest................................. 57

ELIQUIS..............................13

ELIQUIS DVT/PE

STARTER PACK................ 13

ELITE-OB........................... 50

ELIXOPHYLLIN.................. 73

ELLA................................... 57

ELMIRON........................... 55

ELOCON.............................39

ELOCTATE.........................48

eluryng................................ 57

EMCYT............................... 21

EMEND...............................17

EMEND TRI-PACK............. 17

EMFLAZA........................... 61

EMGALITY..........................19

EMGALITY (300 MG

DOSE)................................ 19

emoquette...........................57

EMSAM...............................16

EMTRIVA............................25

EMVERM............................ 23

ENABLEX........................... 55

enalapril maleate................ 29

enalapril-


ENBRACE HR.................... 50

ENBREL............................. 63

ENBREL MINI.....................63

ENBREL SURECLICK........63

ENDARI.............................. 54

endocet................................. 6

ENDOMETRIN....................65

ENGERIX-B........................ 65

ENLITE GLUCOSE

SENSOR.............................44

enoxaparin sodium............. 13

enpresse-28........................57

enskyce...............................57

ENSTILAR.......................... 39

entacapone......................... 23

entecavir ............................. 25

ENTEREG.......................... 53

ENTOCORT EC..................66

ENTRESTO........................ 29

enulose............................... 53

ENVARSUS XR.................. 63

ENZOCLEAR......................39

EPANED............................. 29

EPCLUSA........................... 25

EPIDIOLEX.........................14

82

EPIDUO.............................. 39

EPIDUO FORTE.................39

EPIFOAM............................39

epinastine hcl......................67

epinephrine................... 70, 71

EPIPEN 2-PAK................... 71

EPIPEN JR 2-PAK..............71

epitol................................... 14

EPIVIR................................ 25

EPIVIR HBV........................25

eplerenone..........................30

EPOGEN............................ 48

eprosartan mesylate........... 30

EPZICOM........................... 25

EQUETRO.......................... 28

ERGOCAL.......................... 50

ergocalciferol...................... 50

ERGOMAR......................... 19

ergotamine-caffeine............ 19

ERIVEDGE......................... 21

ERLEADA........................... 21

erlotinib hcl..........................21

errin.....................................57

ERTACZO...........................18

ery.......................................39

ERYGEL............................. 39

ERYPED 200...................... 11

ERYPED 400...................... 11

ERY-TAB............................ 11

erythromycin........... 11, 39, 67

erythromycin base.............. 11

erythromycin

ethylsuccinate..................... 11

ESBRIET............................ 74

ESCAVITE.......................... 50

escitalopram oxalate...........16

ESGIC...................................6

ESKATA..............................39

esomeprazole magnesium..52

ESPEROCT........................ 48

est estrogens-methyltest.....57


ds........................................ 57


hs........................................ 57

estarylla.............................. 57

estazolam........................... 27

ESTRACE...........................57

estradiol........................ 57, 58

estradiol valerate................ 58

estradiol-norethindrone

acet..................................... 58

ESTRING............................58

ESTROGEL........................ 58

ESTROSTEP FE................ 58

eszopiclone.........................75

ethacrynic acid....................30

ethambutol hcl.................... 20

ethosuximide.......................14

ethynodiol diac-eth

estradiol.............................. 58

etodolac................................ 9

etodolac er............................ 9

etonogestrel-ethinyl

estradiol.............................. 58

etoposide............................ 21

EUCRISA............................39

euthyrox.............................. 63

EVAMIST............................ 58

EVEKEO............................. 33

EVEKEO ODT.................... 33

everolimus.......................... 21

EVISTA............................... 67

EVOCLIN............................ 39

EVOTAZ............................. 25

EVOXAC.............................35

EVZIO................................. 10

EXELDERM........................ 18

EXELON............................. 15

exemestane........................ 21

EXFORGE.......................... 30

EXFORGE HCT..................30

EXJADE..............................55

exoderm..............................18

exotic-hc............................. 70

EXTAVIA.............................34

EXTINA...............................18

EZALLOR SPRINKLE.........30

ezetimibe............................ 30

ezetimibe-simvastatin......... 30

FABIOR.............................. 39

falmina................................ 58

famciclovir...........................25

famotidine........................... 52

FANAPT..............................24

FANAPT TITRATION

PACK.................................. 24

FARESTON........................ 21

FARXIGA............................ 47

FARYDAK...........................21

FASENRA...........................73

FASENRA PEN.................. 73

fayosim............................... 58

febuxostat........................... 19

FEIBA................................. 48

felbamate............................ 14

FELBATOL......................... 14

FELDENE............................. 9

felodipine er........................ 30

FEM PH.............................. 11

FEMARA.............................21

FEMHRT LOW DOSE........ 58

FEMRING........................... 58

femynor...............................58

fenofibrate...........................30

fenofibrate micronized........ 30

fenofibric acid......................30

FENOGLIDE....................... 30

fenoprofen calcium............... 9

fenortho.................................9

fentanyl ................................. 7

fentanyl citrate...................... 6

FENTANYL CITRATE...........7

FENTORA.............................7

FERRIPROX.......................55

FETZIMA............................ 16

FETZIMA TITRATION........ 16

FEXMID.............................. 75

FIASP................................. 45

FIASP FLEXTOUCH...........45

FIASP PENFILL..................45

FIBRICOR...........................30

FINACEA............................ 39

finasteride........................... 56

FIORICET............................. 7

FIORICET/CODEINE............7

FIORINAL............................. 7

FIORINAL/CODEINE #3.......7

FIRAZYR............................ 63

FIRDAPSE..........................54

FIRMAGON........................ 62

FIRST-PROGESTERONE

VGS.................................... 58

FIRVANQ............................11

flac...................................... 70

FLAGYL.............................. 11

FLAREX..............................67

flavoxate hcl ........................55

flecainide acetate................30

FLECTOR............................. 9

FLOLIPID............................30

FLOMAX............................. 56

FLORIVA............................ 50

FLORIVA PLUS.................. 50

FLOVENT DISKUS.............73

FLOVENT HFA................... 73

FLUAD................................ 65

FLUARIX


83

FLUCELVAX


fluconazole..........................18

flucytosine...........................18

fludrocortisone acetate....... 61

FLULAVAL


FLUMIST


flunisolide............................71

fluocinolone acetonide.. 39, 70


body.................................... 39


scalp................................... 39

fluocinonide.........................39

fluocinonide emulsified

base.................................... 39

FLUORABON..................... 50

fluoridex.............................. 35

fluoridex daily renewal........ 35

fluoridex enhanced

whitening.............................35

fluoridex sensitivity relief.....35

fluoritab............................... 50

fluorometholone.................. 67

FLUOROPLEX....................39

FLUOROURACIL................39

fluorouracil.......................... 39

fluoxetine hcl.......................16

fluoxetine hcl (pmdd).......... 16

fluphenazine hcl..................24

FLURA-DROPS.................. 50

flurandrenolide.................... 39

flurazepam hcl.................... 75

flurbiprofen............................9

flurbiprofen sodium............. 67

flutamide............................. 21

fluticasone propionate...39, 71

fluticasone-salmeterol.........73

FLUTICASONE-

SALMETEROL....................73

fluvastatin sodium............... 30

fluvastatin sodium er...........30

fluvoxamine maleate...........16

fluvoxamine maleate er.......16

FLUZONE HIGH-DOSE......65

FLUZONE


FML.....................................68

FML FORTE....................... 68

FML LIQUIFILM.................. 68

FOCALIN............................ 33

FOCALIN XR...................... 33

folic acid..............................50

FOLLISTIM AQ................... 65

fondaparinux sodium.......... 13

FORFIVO XL...................... 16

formaldehyde...................... 39

FORMALDEHYDE..............39

FORTAMET........................ 47

FORTEO.............................67

FORTESTA.........................62

FOSAMAX.......................... 67

FOSAMAX PLUS D............ 67

fosamprenavir calcium........25

fosinopril sodium.................30

fosinopril sodium-hctz......... 30

FOSRENOL........................ 55

FRAGMIN........................... 13

FREESTYLE LIBRE 14

DAY READER.................... 44

FREESTYLE LIBRE 14

DAY SENSOR.................... 44

FREESTYLE LIBRE

READER.............................44

FREESTYLE LIBRE

SENSOR SYSTEM.............44

FREESTYLE PRECISION

NEO TEST..........................44

FROVA............................... 19

frovatriptan succinate..........19

FULPHILA...........................48

furosemide.......................... 30

FUZEON............................. 25

fyavolv.................................58

FYCOMPA.......................... 14

gabapentin.......................... 14

GABITRIL........................... 14

GALAFOLD.........................54

galantamine hydrobromide. 15

galantamine hydrobromide

er.........................................15

GALZIN...............................50

ganirelix acetate..................65

GARDASIL 9.......................65

GASTROCROM..................53

gatifloxacin..........................68

GATTEX............................. 53

gavilyte-c.............................53

gavilyte-g............................ 53

gavilyte-h............................ 53

gavilyte-n with flavor pack...53

GELFILM............................ 70

GELNIQUE......................... 55

gemfibrozil.......................... 30

GENERESS FE.................. 58

generlac.............................. 53

gengraf................................64

GENOTROPIN....................62

GENOTROPIN

MINIQUICK.........................62

gentak................................. 68

gentamicin sulfate.........11, 68

GENVOYA.......................... 25

GEODON............................24

gianvi .................................. 58

GILENYA............................ 34

GILOTRIF........................... 21

GILPHEX TR...................... 71

GILTUSS TR.......................71

glatiramer acetate............... 34

glatopa................................ 34

GLEEVEC...........................21

GLEOSTINE....................... 21

glimepiride.......................... 47

glipizide er...........................47

glipizide ir ............................47

glipizide xl ........................... 47

glipizide-metformin hcl ........ 47

GLOPERBA........................ 19

GLUCAGEN HYPOKIT.......44

GLUCAGON

EMERGENCY KIT........ 44, 47

GLUCOPHAGE.................. 47

GLUCOPHAGE XR............ 47

GLUCOTROL..................... 47

GLUCOTROL XL................ 47

GLUCOVANCE...................47

GLUMETZA........................ 47

GLUTARALDEHYDE..........11

glyburide............................. 47

glyburide micronized...........47

glyburide-metformin............ 47

GLYCATE........................... 53

glycopyrrolate..................... 53

GLYCOPYRROLATE......... 53

GLYNASE...........................47

GLYSET..............................47

GLYXAMBI......................... 47

GOCOVRI...........................24

GOLYTELY.........................53

GONAL-F............................65

GONAL-F RFF....................65

GONAL-F RFF REDIJECT. 65

GONITRO........................... 30

GORDOFILM...................... 39

grafco silver nit applicator... 11

GRALISE............................ 35

84

GRALISE STARTER.......... 35

granisetron hcl .................... 17

GRANIX.............................. 48

GRASTEK...........................71

griseofulvin microsize......... 18

griseofulvin ultramicrosize.. 18

guanfacine hcl.....................30

guanfacine hcl er................ 33

GUANIDINE HCL................20

GUARDIAN CONNECT

TRANSMITTER.................. 44

GUARDIAN LINK 3

TRANSMITTER.................. 44

GUARDIAN SENSOR (3)... 44

GVOKE PFS....................... 47

GYNAZOLE-1..................... 18

HAEGARDA........................64

hailey 1.5/30....................... 58

hailey 24 fe......................... 58

halcinonide..........................39

HALCION............................27

halobetasol propionate....... 39

HALOBETASOL

PROPIONATE.................... 39

HALOG............................... 40

haloperidol.......................... 24

haloperidol lactate...............24

HALUCORT........................ 40

HARVONI........................... 25

HAVRIX.............................. 65

heather................................58

HEMANGEOL.....................30

hematinic/folic acid............. 50

HEMLIBRA......................... 48

hemmorex-hc......................66

hemocyte-f.......................... 50

HEMOFIL M........................48

hemorrhoidal-hc..................66

heparin sodium (porcine).... 13

heparin sodium (porcine)

pf.........................................13

HEPLISAV-B.......................65

HEPSERA...........................26

HETLIOZ.............................75

HIBERIX............................. 65

HIDEX 6-DAY..................... 61

HIPREX.............................. 11

homatropaire.......................70

homatropine hbr..................70

HORIZANT......................... 35

HUMALOG..........................45

HUMALOG KWIKPEN........ 45

HUMALOG MIX 50/50

KWIKPEN........................... 45

HUMALOG MIX 50/50

VIAL.................................... 45

HUMALOG MIX 75/25

KWIKPEN........................... 45

HUMALOG MIX 75/25

VIAL.................................... 45

HUMALOG U-100 JUNIOR

KWIKPEN........................... 45

HUMATE-P......................... 48

HUMATROPE.....................62

HUMIRA..............................64

HUMIRA PEDIATRIC

CROHNS START............... 64

HUMIRA PEN..................... 64

HUMIRA PEN-CD/UC/HS

STARTER........................... 64

HUMIRA PEN-

PS/UV/ADOL HS START... 64

HUMULIN 70/30

KWIKPEN........................... 45

HUMULIN 70/30 VIAL.........45

HUMULIN N KWIKPEN...... 45

HUMULIN N VIAL............... 45

HUMULIN R U-500

KWIKPEN........................... 45

HUMULIN R U-500 VIAL

(CONCENTRATED)........... 45

HUMULIN R VIAL............... 45

HYCAMTIN......................... 21

hydralazine hcl....................30

HYDREA.............................21

HYDRO 40..........................40


hydrocodone bitartrate er......7

hydrocodone polst-cpm

polst er................................ 71

hydrocodone-

acetaminophen..................... 7

hydrocodone-homatropine..71

hydrocodone-ibuprofen.........7

hydrocortisone........ 40, 61, 66

hydrocortisone ace-

pramoxine..................... 40, 66

hydrocortisone acetate....... 66

hydrocortisone butyr lipo

base.................................... 40

hydrocortisone butyrate...... 40

hydrocortisone in

absorbase........................... 40

hydrocortisone valerate...... 40

hydrocortisone-acetic acid.. 70

hydrocortisone-iodoquinol...18

hydromet.............................71

hydromorphone hcl ............... 7

hydromorphone hcl er...........7

hydroxychloroquine sulfate. 23

hydroxyurea........................ 21

hydroxyzine hcl................... 27

hydroxyzine pamoate..........27

hyophen.............................. 55

hyoscyamine sulfate........... 53

hyoscyamine sulfate er....... 53

hyoscyamine sulfate sl ........53

hyosyne.............................. 53

HYPERSAL.........................71

HYPOCYN.......................... 70

HYSINGLA ER......................7

HYZAAR............................. 30

ibandronate sodium............ 67

IBRANCE............................21

ibu......................................... 9

ibuprofen...............................9

icatibant acetate..................64

ICLUSIG............................. 21

IDELVION........................... 48

IDHIFA................................ 21

ILEVRO...............................68

ILUMYA.............................. 40

imatinib mesylate................ 21

IMBRUVICA........................21

imipramine hcl .....................16

imipramine pamoate........... 16

imiquimod........................... 40

IMIQUIMOD PUMP.............40

IMITREX............................. 19

IMITREX STATDOSE

REFILL................................19

IMITREX STATDOSE

SYSTEM............................. 19

IMPAVIDO.......................... 23

IMPOYZ.............................. 40

IMURAN..............................64

IMVEXXY MAINTENANCE

PACK.................................. 49

IMVEXXY STARTER

PACK.................................. 49

INBRIJA.............................. 24

incassia...............................58

INCRELEX..........................62

INCRUSE ELLIPTA............ 73

indapamide......................... 30

INDERAL LA.......................30

INDERAL XL.......................30

INDOCIN...............................9

85

INDOMETHACIN.................. 9

indomethacin........................ 9

indomethacin er.................... 9

INGREZZA..........................35

INLYTA............................... 21

INNOPRAN XL................... 30

INOVA.................................40

INOVA 4/1 ACNE

CONTROL THERAPY........ 40

INOVA 8/2 ACNE

CONTROL THERAPY........ 40

INREBIC............................. 21

INSPRA.............................. 30

INSULIN ASP PROT &

ASP FLEXPEN................... 45

INSULIN ASPART.............. 45

INSULIN ASPART

FLEXPEN........................... 45

INSULIN ASPART

PENFILL............................. 45

INSULIN ASPART PROT

& ASPART.......................... 45

INSULIN LISPRO............... 45

INSULIN LISPRO (1 UNIT

DIAL)...................................45

INSULIN PEN NEEDLES... 44

INTELENCE........................26

INTERMEZZO.................... 75

INTRAROSA.......................49

INTRON A...........................26

introvale.............................. 58

INTUNIV............................. 33

INVEGA.............................. 24

INVELTYS.......................... 68

INVIRASE........................... 26

INVOKAMET.......................47

INVOKAMET XR.................47

INVOKANA......................... 47

IODINE STRONG............... 50

iodine tincture..................... 11

IOPIDINE............................ 70

IPOL....................................65

ipratropium bromide......71, 73

ipratropium-albuterol...........73

irbesartan............................30

irbesartan-


IRESSA...............................21

ISENTRESS....................... 26

ISENTRESS HD................. 26

isibloom...............................58

isoniazid..............................20

ISOPTO ATROPINE...........70

ISOPTO CARPINE............. 70

ISORDIL TITRADOSE........30

isosorbide dinitrate..............30

isosorbide mononitrate....... 30

isosorbide mononitrate er... 30

isotretinoin.......................... 40

isoxsuprine hcl.................... 30

isradipine............................ 30

ISTALOL............................. 69

itraconazole........................ 18

ivermectin..................... 23, 40

IXINITY............................... 48

JADENU............................. 55

JADENU SPRINKLE...........55

jaimiess...............................58

JAKAFI................................21

JALYN.................................56

jantoven.............................. 13

JANUMET...........................47

JANUMET XR.....................47

JANUVIA.............................47

JARDIANCE....................... 47

jasmiel.................................58

JATENZO........................... 63

jencycla...............................58

JENTADUETO....................47

JENTADUETO XR..............47

jinteli ....................................58

JIVI......................................48

jolessa.................................58

JORNAY PM.......................33

JUBLIA................................18

juleber................................. 58

JULUCA..............................26

junel 1.5/30......................... 58

junel 1/20............................ 58

junel fe 1.5/30..................... 58

junel fe 1/20........................ 58

junel fe 24........................... 58

JUXTAPID.......................... 30

JYNARQUE........................ 55

KADIAN................................ 7

kaitlib fe...............................58

KALETRA........................... 26

kalliga..................................58

KALYDECO........................ 74

KAPSPARGO SPRINKLE.. 30

KAPVAY............................. 33

KARBINAL ER.................... 71

kariva.................................. 58

KATERZIA.......................... 30

KAZANO............................. 47

KEFLEX.............................. 12

kelnor 1/35.......................... 58

kelnor 1/50.......................... 58

KENALOG.......................... 40

KEPPRA............................. 14

KEPPRA XR....................... 14

KERALAC........................... 40

KERALYT SCALP...............40

KERYDIN............................18

ketoconazole.......................18

ketodan............................... 18

ketoprofen.............................9

ketoprofen er .........................9

KETOROLAC

TROMETHAMINE.................9

ketorolac tromethamine.. 9, 68

KEVEYIS............................ 30

KEVZARA........................... 64

KINERET............................ 64

kionex................................. 50

KISQALI (200 MG DOSE).. 21



KISQALI FEMARA (400

MG DOSE)..........................21

KISQALI FEMARA (600

MG DOSE)..........................21

KISQALI FEMARA(200

MG DOSE)..........................21

KITABIS PAK......................74

KLARON............................. 40

KLONOPIN......................... 27

klor-con............................... 50

klor-con 10.......................... 50

klor-con m10....................... 50

KLOR-CON M15.................50

klor-con m20....................... 50

klor-con sprinkle..................50

klor-con/ef........................... 50

KOATE................................48

KOATE-DVI........................ 48

KOGENATE FS.................. 48

KOMBIGLYZE XR.............. 47

KORLYM.............................62

KOVALTRY.........................48

K-PHOS.............................. 50

K-PHOS NO 2.....................50

K-PHOS-NEUTRAL............ 50

k-prime................................50

KRINTAFEL........................ 23

KRISTALOSE..................... 53

K-TAB................................. 50

kurvelo................................ 58

KUVAN............................... 54

86

labetalol hcl .........................30

LACRISERT........................70

lactulose..............................53

lactulose encephalopathy... 53

LAMICTAL.......................... 14

LAMICTAL ODT..................14

LAMICTAL STARTER........ 14

LAMICTAL XR.................... 14

lamivudine...........................26

lamivudine-zidovudine........ 26

lamotrigine.......................... 14

lamotrigine er...................... 14

lamotrigine starter kit-blue.. 14


green...................................14


orange.................................14

LANCETS........................... 44

LANOXIN............................ 30

lansoprazole....................... 52

lanthanum carbonate.......... 55

LANTUS SOLOSTAR......... 46

LANTUS U-100 VIAL.......... 46

larin 1.5/30.......................... 58

larin 1/20............................. 58

larin 24 fe............................ 59

larin fe 1.5/30...................... 59

larin fe 1/20......................... 59

larissia.................................59

LASIX..................................30

LASTACAFT....................... 68

latanoprost.......................... 69

LATRIX XM.........................40

LATUDA..............................24

layolis fe..............................59

LAZANDA............................. 7

L-CYSTINE......................... 50

LEDIPASVIR-

SOFOSBUVIR.................... 26

leena................................... 59

leflunomide......................... 64


DOSE)................................ 21


DOSE)................................ 21


DOSE)................................ 21


DOSE)................................ 21


DOSE)................................ 21


DOSE)................................ 21

LENVIMA (4 MG DAILY

DOSE)................................ 21

LENVIMA (8 MG DAILY

DOSE)................................ 21

LESCOL XL........................ 30

lessina.................................59

LETAIRIS............................74

letrozole.............................. 21

leucovorin calcium.............. 22

LEUKERAN........................ 22

LEUKINE............................ 48

leuprolide acetate............... 62

levalbuterol hcl....................73

LEVALBUTEROL HFA....... 73

LEVAQUIN..........................12

LEVBID............................... 53

LEVEMIR U-100

FLEXTOUCH...................... 46

LEVEMIR U-100 VIAL........ 46

levetiracetam...................... 14

levetiracetam er.................. 14

LEVITRA.............................49

levobunolol hcl.................... 69

levocarnitine........................50

levocarnitine sf....................50

levocetirizine

dihydrochloride................... 71

levofloxacin................... 12, 68

levonest.............................. 59

levonorgest-eth est & eth

est....................................... 59

levonorgest-eth estrad 91-

day...................................... 59


estrad..................................59

levonorg-eth estrad

triphasic.............................. 59

levora 0.15/30 (28)..............59

levorphanol tartrate...............7

levo-t................................... 63

levothyroxine sodium.......... 63

levoxyl.................................63

LEVSIN............................... 53

LEVSIN/SL..........................53

LEVULAN KERASTICK...... 40

LEXAPRO...........................16

LEXETTE............................40

LEXIVA............................... 26

LIALDA............................... 66

LIBRAX............................... 53

lidocaine................................7

lidocaine hcl.................... 7, 35

lidocaine hcl

urethral/mucosal................... 7

lidocaine viscous hcl ........... 35

LIDOCAINE-

HYDROCORTISONE ACE. 40

lidocaine-prilocaine............... 7

LIDODERM...........................7

lillow.................................... 59

lindane................................ 23

linezolid...............................12

LINZESS.............................53

liothyronine sodium.............63

LIPITOR..............................30

LIPOFEN............................ 30

lisinopril ...............................30

lisinopril-


lithium................................. 28

lithium carbonate................ 28

lithium carbonate er............ 28

LITHOBID........................... 28

LITHOSTAT........................ 55

LIVALO............................... 30

LO LOESTRIN FE.............. 59

LOCOID.............................. 40

LOCOID LIPOCREAM........40

LODINE................................ 9

LODOSYN.......................... 24

LOESTRIN 1.5/30 (21)....... 59

LOESTRIN 1/20 (21) .......... 59

LOESTRIN FE 1.5/30......... 59

LOESTRIN FE 1/20............ 59

lojaimiess............................ 59

LOKELMA...........................50

LOMOTIL............................ 53

LONHALA MAGNAIR

REFILL KIT......................... 73

LONHALA MAGNAIR

STARTER KIT.................... 73

LONSURF...........................22

loperamide hcl.................... 53

LOPID................................. 30

lopinavir-ritonavir................ 26

lopreeza.............................. 59

LOPRESSOR..................... 30

LOPRESSOR HCT............. 30

LOPROX.............................18

lorazepam........................... 27

lorazepam intensol ..............27

LORBRENA........................ 22

lorcet..................................... 7

lorcet hd................................ 7

lorcet plus............................. 7

87

LORTAB............................... 7

loryna.................................. 59

LORZONE.......................... 75

losartan potassium..............30

losartan potassium-hctz......30

LOSEASONIQUE............... 59

LOTEMAX...........................68

LOTEMAX SM.................... 68

LOTENSIN..........................30

LOTENSIN HCT................. 30

loteprednol etabonate......... 68

LOTREL..............................30

LOTRISONE....................... 40

LOTRONEX........................ 53

lovastatin.............................30

LOVAZA..............................31

LOVENOX.......................... 13

low-ogestrel........................ 59

loxapine succinate.............. 24

lo-zumandimine.................. 59

LUCEMYRA........................10

ludent.................................. 50

LULICONAZOLE................ 18

LUMIGAN........................... 69

LUNESTA........................... 75

lutera...................................59

LUXIQ................................. 40

LUZU.................................. 18

LYNPARZA.........................22

LYRICA...............................35

LYRICA CR.........................35

LYSODREN........................ 22

LYSTEDA........................... 48

lyza..................................... 59

MACROBID........................ 12

MACRODANTIN................. 12

mafenide acetate................ 12

MAGNEBIND 400............... 50

MALARONE........................23

malathion............................ 23

maprotiline hcl.....................16

marlissa.............................. 59

MARPLAN.......................... 16

MATULANE........................ 22

matzim la............................ 31

MAVENCLAD (10 TABS)....34

MAVENCLAD (4 TABS)......34






MAVYRET.......................... 26

MAXALT............................. 19

MAXALT-MLT..................... 19

MAXIDEX............................68

MAXITROL......................... 68

MAXZIDE............................31

MAXZIDE-25.......................31

MAYZENT...........................34

MAYZENT STARTER

PACK.................................. 34

me/naphos/mb/hyo1........... 55

meclizine hcl....................... 17

meclofenamate sodium.........9

MEDROL............................ 61

medroxyprogesterone

acetate................................ 59

mefenamic acid.....................9

mefloquine hcl.....................23

MEGACE ES...................... 59

megestrol acetate............... 59

MEKINIST...........................22

MEKTOVI............................22

melodetta 24 fe................... 59

meloxicam.............................9

melphalan........................... 22

memantine hcl.................... 15

memantine hcl er................ 15

MENACTRA........................65

MENEST.............................59

MENOSTAR....................... 59

MENTAX.............................18

MENVEO............................ 65

meperidine hcl...................... 7

MEPHYTON....................... 50

meprobamate......................27

MEPRON............................ 23

mercaptopurine...................22

mesalamine........................ 66

mesalamine er.................... 66

mesalamine-cleanser..........66

MESNEX.............................22

MESTINON.........................20

metadate er.........................33

metaproterenol sulfate........ 73

metaxalone......................... 75

metformin hcl er.................. 47

metformin hcl er (mod)........47

metformin hcl er (osm)........47

METFORMIN HCL IR......... 47

metformin hcl ir................... 47

methadone hcl...................... 7

methadone hcl intensol.........7

methadose............................ 7

methadose sugar-free...........7

methamphetamine hcl ........ 33

methazolamide................... 31

methenamine hippurate...... 12

methenamine mandelate.... 12

methimazole....................... 63

METHITEST....................... 63

methocarbamol................... 75

methotrexate.......................64

methotrexate sodium.......... 64

methoxsalen rapid.............. 40

methscopolamine bromide..53

methyl salicylate................. 40

methyldopa......................... 31

methyldopa-


METHYLIN..........................33

methylphenidate hcl............34

methylphenidate hcl er........34

methylphenidate hcl er (cd) 33

methylphenidate hcl er (la) . 34

methylprednisolone.............61

methyltestosterone............. 63

metoclopramide hcl .............17

metolazone......................... 31

metoprolol succinate er.......31

metoprolol tartrate...............31

metoprolol-


METROCREAM..................40

METROGEL........................40

METROLOTION................. 40

metronidazole............... 12, 40

mexiletine hcl...................... 31

MIACALCIN........................ 67

mibelas 24 fe...................... 59

MICARDIS.......................... 31

MICARDIS HCT..................31

miconazole 3.......................18

MICONAZOLE-ZINC

OXIDE-PETROLAT............ 18

MICORT-HC....................... 40

microgestin 1.5/30.............. 59

microgestin 1/20................. 59

microgestin fe 1.5/30.......... 59

microgestin fe 1/20............. 59

midazolam hcl.....................27

midodrine hcl...................... 31

MIGERGOT........................ 19

miglitol.................................47

miglustat............................. 54

MIGRANAL......................... 19

mili ...................................... 59

MILLIPRED.........................61

88

MILLIPRED DP...................61

MILLIPRED DP 12-DAY..... 61

mimvey............................... 59

MINASTRIN 24 FE............. 59

mineral oil heavy.................53

MINIPRESS........................ 31

minitran............................... 31

MINIVELLE......................... 59

MINOCIN............................ 12

minocycline hcl................... 12

minocycline hcl er............... 12

MINOLIRA.......................... 12

minoxidil..............................31

MIRAPEX............................24

MIRAPEX ER......................24

MIRCETTE......................... 59

mirtazapine......................... 16

MIRVASO........................... 40

misoprostol......................... 52

MITIGARE.......................... 19

MITOSOL............................70

M-M-R II..............................65

M-NATAL PLUS..................50

MOBIC.................................. 9

modafinil ............................. 75

moexipril hcl ........................31

molindone hcl......................24

mometasone furoate.....40, 72

mondoxyne nl..................... 12

mono-linyah........................ 59

MONONINE........................ 49

monsels ferric subsulfate.... 49

montelukast sodium............73

MONUROL......................... 12

MORGIDOX........................12

morgidox............................. 12

MORPHABOND ER..............7

morphine sulfate................... 7

morphine sulfate

(concentrate).........................7

morphine sulfate er............... 7

morphine sulfate er beads.... 7

MOTEGRITY...................... 53

MOTOFEN..........................53

MOVANTIK......................... 53

MOVIPREP.........................53

MOXEZA.............................68

moxifloxacin hcl............ 12, 68

MOZOBIL............................49

MS CONTIN..........................8

MUCOSITISRX...................35

MULPLETA.........................49

MULTAQ.............................31

multi-vit/iron/fluoride............50

multivitamin/fluoride............ 50

multi-vitamin/fluoride...........50

multivitamin/fluoride/iron..... 50

multi-vitamin/fluoride/iron....50

multivitamins/fluoride.......... 50

mupirocin............................ 12

mupirocin calcium............... 12

MUSE................................. 49

mvc-fluoride........................ 50

MYALEPT........................... 54

MYAMBUTOL..................... 20

MYCOBUTIN...................... 20

mycophenolate mofetil ........64

mycophenolate sodium.......64

MYDAYIS............................34

MYFORTIC......................... 64

MYLERAN.......................... 22

myorisan............................. 40

MYRBETRIQ...................... 55

MYSOLINE......................... 14

MYTESI.............................. 53

nabumetone..........................9

n-acetyl-l-cysteine...............50

nadolol................................ 31

nafrinse............................... 50

NAFRINSE DAILY

ACIDULATED..................... 35

NAFRINSE

DAILY/NEUTRAL................35

nafrinse drops..................... 50

NAFRINSE WEEKLY..........35

naftifine hcl..........................18

NAFTIN...............................18

NALFON............................... 9

NALOCET.............................8

naloxone hcl........................10

NALOXONE HCL................10

naltrexone hcl..................... 10

NAMENDA..........................15

NAMENDA TITRATION

PAK.....................................15

NAMENDA XR....................15

NAMENDA XR

TITRATION PACK.............. 15

NAMZARIC......................... 15

NAPRELAN.......................... 9

NAPROSYN..........................9

naproxen...............................9

naproxen dr...........................9

naproxen sodium.................. 9

naproxen sodium er.............. 9

naratriptan hcl..................... 19

NARCAN.............................10

NARDIL...............................16

NASCOBAL........................ 50

NASONEX.......................... 72

NATACYN...........................68

NATAZIA.............................59

nateglinide.......................... 47

NATESTO...........................63

NATPARA...........................67

NATROBA.......................... 23

NATURE-THROID.............. 63

NAYZILAM..........................14

NEBUPENT........................ 23

nebusal ............................... 72

NEBUSAL........................... 72

necon 0.5/35 (28)................59

nefazodone hcl................... 16

neomycin sulfate.................12

neomycin-bacitracin zn-

polymyx...............................68

neomycin-polymyxin-

dexameth............................ 68

neomycin-polymyxin-

gramicidin........................... 68

neomycin-polymyxin-hc 68, 70

NEONATAL COMPLETE....50

NEONATAL PLUS.............. 50

neo-polycin......................... 68

neo-polycin hc.....................68

NEORAL............................. 64

NEO-SYNALAR............ 12, 41

NEOTUSS PLUS................ 72

NERLYNX...........................22

NESINA.............................. 47

NESTABS........................... 50

NESTABS ONE.................. 51

neuac.................................. 41

NEUAC............................... 41

NEULASTA.........................49

NEUPOGEN....................... 49

NEUPRO............................ 24

NEURONTIN...................... 14

neutral sodium fluoride....... 35

NEVANAC.......................... 68

nevirapine........................... 26

nevirapine er....................... 26

NEXAVAR...........................22

NEXIUM..............................52

niacin (antihyperlipidemic).. 31

niacin er

(antihyperlipidemic).............31

niacor.................................. 31

NIASPAN............................ 31

89

nicardipine hcl.....................31

NICOMIDE..........................51

NICOTROL......................... 10

NICOTROL NS................... 10

nifedipine............................ 31

nifedipine er........................ 31

nifedipine er osmotic

release................................ 31

nikki.....................................59

nilutamide........................... 22

nimodipine.......................... 31

NINLARO............................22

nisoldipine er.......................31

nitisinone.............................54

NITRO-BID......................... 31

NITRO-DUR........................31

nitrofurantoin.......................12

nitrofurantoin macrocrystal. 12

nitrofurantoin monohydrate

macrocrystals......................12

nitroglycerin........................ 31

NITROLINGUAL................. 31

NITROMIST........................ 31

NITROSTAT....................... 31

nitro-time.............................31

NITYR................................. 54

NIVESTYM......................... 49

nizatidine.............................52

NIZORAL............................ 18

NOCDURNA....................... 62

NOCTIVA............................62

nolix.................................... 41

nora-be............................... 59

NORCO................................ 8

NORDITROPIN FLEXPRO.62

norethin ace-eth estrad-fe

...................................... 59, 60

norethindrone......................60

norethindrone acetate.........60

norethindrone acet-ethinyl

est....................................... 60

norethindrone-eth estradiol.60

norethin-eth estradiol-fe......60

NORGESIC FORTE........... 75

norgestimate-eth estradiol.. 60


estradiol triphasic................60

NORITATE..........................41

norlyda................................ 60

norlyroc............................... 60

NORPACE.......................... 31

NORPACE CR....................31

NORPRAMIN......................16

NORTHERA........................31

nortrel 0.5/35 (28)............... 60

nortrel 1/35 (21).................. 60

nortrel 1/35 (28).................. 60

nortrel 7/7/7.........................60

nortriptyline hcl....................16

NORVASC.......................... 31

NORVIR..............................26

NOURIANZ......................... 24

novarel................................ 66

NOVAREL...........................66

NOVOEIGHT...................... 49

NOVOFINE AUTOCOVER

PEN NEEDLE..................... 44

NOVOFINE PEN NEEDLE. 44

NOVOFINE PLUS PEN

NEEDLE............................. 44

NOVOLIN 70/30 FLEXPEN 46

NOVOLIN 70/30 FLEXPEN

RELION.............................. 46

NOVOLIN 70/30 RELION... 46

NOVOLIN 70/30 VIAL.........46

NOVOLIN N FLEXPEN.......46

NOVOLIN N FLEXPEN

RELION.............................. 46

NOVOLIN N RELION..........46

NOVOLIN N VIAL............... 46

NOVOLIN R FLEXPEN.......46

NOVOLIN R FLEXPEN

RELION.............................. 46

NOVOLIN R RELION..........46

NOVOLIN R VIAL............... 46

NOVOLOG FLEXPEN........ 46

NOVOLOG MIX 70/30

FLEXPEN........................... 46

NOVOLOG MIX 70/30

VIAL.................................... 46

NOVOLOG PENFILL.......... 46

NOVOLOG U-100 VIAL...... 46

NOVOPEN ECHO.............. 44

NOVOSEVEN RT............... 49

NOXAFIL............................ 18

np thyroid............................ 63

NUBEQA.............................22

NUCALA............................. 73

NUCORT............................ 41

NUCYNTA............................ 8

NUCYNTA ER...................... 8

NUEDEXTA........................ 35

NULEV................................53

NULYTELY WITH

FLAVOR PACKS................ 53

NUPLAZID.......................... 24

NUTRIDOX......................... 12

NUTROPIN AQ NUSPIN

10........................................62

NUTROPIN AQ NUSPIN

20........................................62

NUTROPIN AQ NUSPIN 5. 62

NUVAIL...............................41

NUVARING.........................60

NUVESSA...........................12

NUVIGIL............................. 75

NUWIQ............................... 49

NUZYRA............................. 12

nyamyc............................... 18

NYMALIZE..........................31

nystatin............................... 18

nystatin-triamcinolone.........18

nystop................................. 18

OCALIVA............................ 53

ocella.................................. 60

octreotide acetate............... 62

OCUFLOX.......................... 68

ODACTRA.......................... 72

ODEFSEY...........................26

ODOMZO............................22

OFEV.................................. 74

ofloxacin..................12, 68, 70

ogestrel............................... 60

okebo.................................. 12

olanzapine.......................... 24

olanzapine-fluoxetine hcl.... 16

olmesartan medoxomil ........31

olmesartan medoxomil-

hctz..................................... 31

olmesartan-amlodipine-

hctz..................................... 31

olopatadine hcl ..............68, 72

OLUMIANT......................... 64

OLUX.................................. 41

OLUX-E.............................. 41

OMECLAMOX-PAK............ 52

omega-3-acid ethyl esters.. 31

omeprazole......................... 52

omeprazole-sodium

bicarbonate......................... 52

OMNARIS........................... 72

OMNITROPE...................... 62

ondansetron hcl .................. 17

ondansetron odt..................17

ONETOUCH ULTRA 2 KIT

W/DEVICE.......................... 44

ONETOUCH ULTRA

BLUE TEST STRIPS.......... 44

90

ONETOUCH ULTRA MINI

KIT W/DEVICE................... 44

ONETOUCH VERIO FLEX

SYSTEM KIT W/DEVICE....44

ONETOUCH VERIO IQ

SYSTEM............................. 44

ONETOUCH VERIO KIT

W/DEVICE.......................... 44

ONETOUCH VERIO

SYNC SYSTEM KIT

W/DEVICE.......................... 44

ONEXTON.......................... 41

ONFI................................... 14

ONGLYZA...........................47

ONZETRA XSAIL............... 19

OPANA................................. 8

opium.................................. 53

OPSUMIT........................... 74

ORACEA.............................41

ORACIT.............................. 51

ORALAIR............................ 72

ORALAIR ADULT

SAMPLE KIT.......................72

ORALAIR ADULT

STARTER PACK................ 72

ORALAIR CHILDRENS

SAMPLE KIT.......................72

ORALAIR CHILDRENS

STARTER PACK................ 72

oralone................................35

ORAPRED ODT................. 61

ORAVIG..............................18

ORENCIA........................... 64

ORENCIA CLICKJECT.......64

ORENITRAM...................... 74

ORFADIN............................54

ORILISSA........................... 62

ORKAMBI........................... 74

orphenadrine citrate er........75

orphenadrine-aspirin-

caffeine............................... 75

ORPHENGESIC FORTE.... 75

orsythia............................... 60

ORTHO MICRONOR..........60

ORTHO TRI-CYCLEN LO.. 60

ORTHO-NOVUM 1/35 (28).60

ORTHO-NOVUM 7/7/7

(28)..................................... 60

oscimin................................53

oscimin sr............................53

oseltamivir phosphate.........26

OSENI.................................47

OSMOLEX ER.................... 24

OSMOPREP....................... 54

OSPHENA.......................... 49

OTEZLA..............................64

OTICIN HC NR................... 70

OTOVEL............................. 70

OTREXUP.......................... 64

OVACE PLUS.....................41

OVACE PLUS WASH......... 41

OVACE WASH................... 41

OVIDE.................................23

OVIDREL............................ 66

oxandrolone........................ 63

oxaprozin.............................. 9

OXAYDO.............................. 8

oxazepam........................... 27

OXBRYTA...........................49

oxcarbazepine.................... 14

OXERVATE........................ 70

oxiconazole nitrate..............18

OXISTAT............................ 18

OXSORALEN ULTRA.........41

OXTELLAR XR................... 14

oxybutynin chloride............. 55

oxybutynin chloride er.........55

oxycodone hcl.......................8

OXYCODONE HCL ER........ 8

oxycodone-acetaminophen...8

oxycodone-aspirin.................8

oxycodone-ibuprofen............ 8

OXYCONTIN........................ 8

oxymorphone hcl.................. 8

oxymorphone hcl er.............. 8

OXYTROL...........................55

OZEMPIC........................... 47

OZOBAX.............................75

PACERONE........................31

pacerone.............................31

PALFORZIA (12 MG

DAILY DOSE)..................... 64

PALFORZIA (120 MG

DAILY DOSE)..................... 64

PALFORZIA (160 MG

DAILY DOSE)..................... 64

PALFORZIA (20 MG

DAILY DOSE)..................... 64

PALFORZIA (200 MG

DAILY DOSE)..................... 64

PALFORZIA (240 MG

DAILY DOSE)..................... 64

PALFORZIA (3 MG DAILY

DOSE)................................ 64

PALFORZIA (300 MG

MAINTENANCE)................ 64

PALFORZIA (300 MG

TITRATION)........................64

PALFORZIA (40 MG

DAILY DOSE)..................... 64

PALFORZIA (6 MG DAILY

DOSE)................................ 64

PALFORZIA (80 MG

DAILY DOSE)..................... 64

PALFORZIA INITIAL

ESCALATION..................... 64

paliperidone er.................... 25

PALYNZIQ.......................... 54

PAMELOR.......................... 16

PANCREAZE......................54

PANDEL............................. 41

PANRETIN..........................22

pantoprazole sodium.......... 52

paregoric.............................54

paricalcitol ...........................67

PARLODEL.........................24

PARNATE...........................16

paroex.................................35

paromomycin sulfate...........12

paroxetine hcl..................... 16

paroxetine hcl er................. 16

paroxetine mesylate............16

PASER................................20

PATADAY........................... 68

PATANASE.........................72

PATANOL........................... 68

PAXIL..................................16

PAXIL CR........................... 16

PAZEO................................68

PCP 100............................. 54

PEDIAPRED....................... 61

PEDIZOLPAK..................... 18

PEDVAX HIB...................... 65

peg 3350-kcl-na bicarb-

nacl..................................... 54

peg-3350/electrolytes......... 54

PEGANONE....................... 14

PEGASYS...........................26

PEGASYS PROCLICK....... 26

PEGINTRON...................... 26

peg-prep............................. 54

penicillamine....................... 55

penicillin v potassium..........12

PENNSAID........................... 9

pentamidine isethionate......23

PENTASA........................... 66

pentazocine-naloxone hcl ..... 8

pentoxifylline er...................31

PEPCID.............................. 52

91

PERCOCET..........................8

PERFOROMIST................. 73

PERIDEX............................ 35

perindopril erbumine........... 31

periogard.............................35

permethrin...........................23

perphenazine...................... 17

perphenazine-amitriptyline..16

PERTZYE........................... 54

PEXEVA............................. 16

phenadoz............................ 17

phenazo.............................. 55

phenazopyridine hcl............55

phenelzine sulfate...............16

phenobarbital...................... 14

phenoxybenzamine hcl ....... 31

phenylephrine hcl ................70

PHENYTEK........................ 14

phenytoin............................ 14

phenytoin infatabs...............14

phenytoin sodium

extended............................. 14

philith.................................. 60

PHOSLYRA........................ 55

phospha 250 neutral........... 51

phosphasal......................... 55

PHOSPHOLINE IODIDE.... 70

phosphorous....................... 51

phospho-trin 250 neutral.....51

PHOTREXA-PHOTREXA

VISCOUS KIT..................... 70

phytonadione...................... 51

PICATO.............................. 41

PIFELTRO.......................... 26

pilocarpine hcl...............35, 70

pimecrolimus.......................41

pimozide............................. 25

pimtrea................................60

pindolol ............................... 31

pioglitazone hcl................... 48

pioglitazone hcl-glimepiride 48

pioglitazone hcl-metformin

hcl....................................... 48


DOSE)................................ 22


DOSE)................................ 22


DOSE)................................ 22

pirmella 1/35....................... 60

pirmella 7/7/7...................... 60

piroxicam.............................. 9

PLAQUENIL........................23

PLAVIX............................... 24

PLEGRIDY..........................34

PLEGRIDY STARTER

PACK.................................. 34

PLENVU............................. 54

PLEXION............................ 41

PLEXION CLEANSER........41

PLEXION CLEANSING

CLOTH................................41

PNEUMOVAX 23................65

pnv prenatal plus

multivit+dha.........................51

podocon.............................. 41

podofilox............................. 41

polycin.................................68

polymyxin b-trimethoprim....68

POLYTRIM......................... 68

POLY-VI-FLOR...................51

POLY-VI-FLOR/IRON.........51

POMALYST........................ 22

portia-28..............................60

posaconazole......................18

pot bicarb-pot chloride........ 51

POTABA............................. 51

potassium bicarbonate........51

potassium chloride..............51

potassium chloride crys er.. 51

potassium chloride er..........51

potassium citrate er............ 51

potassium citrate-citric acid 51

PR BENZOYL PEROXIDE. 41

pr benzoyl peroxide wash... 41

PRADAXA...........................13

PRALUENT.........................31

pramipexole

dihydrochloride................... 24

pramipexole

dihydrochloride er............... 24

pramosone..........................41

PRAMOSONE.................... 41

PRAMOTIC.........................70

pramox..................................8

prasugrel hcl....................... 24

PRAVACHOL......................31

pravastatin sodium..............32

praziquantel........................ 23

prazosin hcl.........................32

PRECISION LINK............... 44

PRECISION PCX PLUS

TEST...................................45

PRECISION QID

MONITOR...........................45

PRECISION QID TEST...... 45

PRECISION SOF-TACT

MONITOR...........................45

PRECISION SOF-TACT

TEST...................................45

PRECISION XTRA............. 45

PRECISION XTRA

BLOOD GLUCOSE.............45

PRECISION XTRA

MONITOR...........................45

PRECOSE.......................... 48

PRED FORTE.....................68

PRED MILD........................ 68

PRED-G..............................68

PRED-G S.O.P................... 68

prednicarbate......................41

prednisolone....................... 61

prednisolone acetate.......... 68

prednisolone acetate p-f..... 68

prednisolone sodium

phosphate..................... 61, 68

prednisone.......................... 61

prednisone intensol.............61

PREFEST........................... 60

pregabalin........................... 35

PREGENNA........................51

pregnyl................................ 66

PREMARIN.........................60

PREMESISRX.................... 51

premium lidocaine.................8

PREMPHASE..................... 60

PREMPRO..........................60

PRENAISSANCE................51

PRENATA...........................51

prenatal ...............................51

prenatal plus iron................ 51

PRENATE...........................51

PRENATE DHA.................. 51

PRENATE ELITE................51

PRENATE ENHANCE........ 51

PRENATE ESSENTIAL...... 51

PRENATE MINI.................. 51

PRENATE PIXIE.................51

PRENATE RESTORE........ 51

PREPIDIL........................... 62

PREPOPIK......................... 54

PRESTALIA........................ 32

PRETOMANID....................20

PREVACID......................... 52

PREVACID SOLUTAB........52

prevalite.............................. 32

PREVIDENT....................... 35

PREVIDENT 5000

BOOSTER PLUS................35

92

PREVIDENT 5000 DRY

MOUTH...............................35

PREVIDENT 5000

ENAMEL PROTECT...........35

PREVIDENT 5000 ORTHO

DEFENSE...........................35

PREVIDENT 5000 PLUS....35

PREVIDENT 5000

SENSITIVE......................... 35

previfem.............................. 60

PREVNAR 13..................... 65

PREVYMIS......................... 26

PREZCOBIX....................... 26

PREZISTA.......................... 26

PRIFTIN..............................20

PRILOSEC..........................52

PRIMACARE...................... 51

primaquine phosphate........ 23

primidone............................ 14

PRIMLEV.............................. 8

PRIMSOL............................12

PRINIVIL.............................32

PRISTIQ............................. 16

PROAIR DIGIHALER..........73

PROAIR HFA......................73

PROAIR RESPICLICK........73

probenecid.......................... 19

PROCARDIA...................... 32

PROCARDIA XL................. 32

PROCENTRA..................... 34

prochlorperazine................. 17

prochlorperazine maleate... 17

PROCORT..........................66

PROCRIT............................49

PROCTOCORT.................. 66

PROCTOFOAM HC............66

procto-med hc.....................66

procto-pak...........................66

proctosol hc........................ 66

proctozone-hc..................... 66

PROCYSBI......................... 54

PROFILNINE...................... 49

PROFILNINE SD................ 49

progesterone.......................60

progesterone micronized.... 60

PROGLYCEM.....................45

PROGRAF.......................... 64

PROLENSA........................ 68

PROMACTA....................... 49

promethazine hcl.......... 17, 72

promethazine-codeine........ 72

promethazine-dm................72

promethazine-phenyleph-

codeine............................... 72

promethazine-

phenylephrine..................... 72

promethegan.......................17

PROMETRIUM................... 60

PROMISEB.........................41

propafenone hcl.................. 32

propafenone hcl er..............32

propantheline bromide........ 54

proparacaine hcl................. 70

propranolol hcl.................... 32

propranolol hcl er................ 32

propranolol-hctz.................. 32

propylthiouracil....................63

PROSCAR.......................... 56

PROSTIN E2...................... 62

PROTONIX......................... 52

PROTOPIC......................... 41

protriptyline hcl....................16

PROVENTIL HFA............... 73

PROVERA.......................... 60

PROVIGIL...........................75

PROZAC.............................16

PRUDOXIN.........................41

pseudoephedrine-

bromphen-dm..................... 72

PSORCON..........................41

PULMICORT FLEXHALER.73

PULMICORT

SUSPENSION.................... 74

pulmosal............................. 72

PULMOZYME..................... 74

PURIXAN............................22

PYLERA..............................52

pyrazinamide...................... 20

PYRIDIUM.......................... 55

pyridostigmine bromide.......20

pyridostigmine bromide er.. 20

PYROGALLIC ACID........... 41

QBRELIS............................ 32

QMIIZ ODT........................... 9

QNASL................................72

QNASL CHILDRENS..........72

QTERN............................... 48

QUALAQUIN.......................23

QUARTETTE...................... 60

quazepam........................... 28

QUDEXY XR.......................14

QUESTRAN........................32

QUESTRAN LIGHT............ 32

quetiapine fumarate............ 25

quetiapine fumarate er........25

QUFLORA PEDIATRIC...... 51

QUILLICHEW ER............... 34

QUILLIVANT XR.................34

quinapril hcl .........................32

quinapril-


quinidine gluconate er.........32

quinidine sulfate..................32

quinine sulfate.....................23

QVAR REDIHALER............ 74

RABEPRAZOLE SODIUM..52

rabeprazole sodium............ 52

RAGWITEK.........................72

raloxifene hcl .......................67

ramelteon............................75

ramipril ................................ 32

RANEXA............................. 32

ranitidine hcl ........................52

ranolazine er....................... 32

RAPAFLO........................... 56

RAPAMUNE....................... 64

rasagiline mesylate............. 24

RASUVO.............................64

RAVICTI..............................54

RAYALDEE.........................67

RAYOS............................... 61

RAZADYNE........................ 15

RAZADYNE ER.................. 15

REBIF................................. 34

REBIF REBIDOSE..............34

REBIF REBIDOSE

TITRATION PACK.............. 34

REBIF TITRATION PACK.. 34

REBINYN............................49

reclipsen............................. 60

RECOMBINATE................. 49

RECOMBIVAX HB..............65

RECOTHROM.................... 49

RECOTHROM SPRAY KIT 49

RECTIV...............................32

REGLAN............................. 17

REGRANEX........................41

RELAFEN DS....................... 9

RELENZA DISKHALER......26

relexxii .................................34

RELION BLOOD

GLUCOSE TEST................ 45

RELION ULTIMA TEST...... 45

RELISTOR..........................54

RELNATE DHA...................51

RELPAX..............................19

REMERON......................... 16

REMERON SOLTAB.......... 16

93

RENAGEL...........................55

RENVELA........................... 55

repaglinide.......................... 48

REPATHA...........................32

REPATHA PUSHTRONEX

SYSTEM............................. 32

REPATHA SURECLICK..... 32

REQUIP XL.........................24

RESCRIPTOR.................... 26

RESTASIS.......................... 70

RESTASIS MULTIDOSE.... 70

RESTORIL..........................75

RETACRIT..........................49

RETIN-A............................. 41

RETIN-A MICRO GEL 0.04

%, 0.1 %............................. 41

RETIN-A MICRO PUMP..... 41

RETROVIR......................... 26

REVATIO............................ 74

REVLIMID...........................22

REXULTI.............................25

REYATAZ........................... 26

REYVOW............................19

RHOFADE.......................... 41

RHOPRESSA..................... 69

RIAX................................... 41

ribavirin............................... 26

RIDAURA............................64

rifabutin............................... 20

RIFADIN............................. 20

RIFAMATE..........................20

rifampin............................... 20

RIFATER............................ 20

RILUTEK.............................35

riluzole................................ 35

rimantadine hcl................... 26

RINVOQ..............................64

RIOMET..............................48

RIOMET ER........................48

risedronate sodium............. 67

RISPERDAL....................... 25

risperidone.......................... 25

RITALIN.............................. 34

RITALIN LA.........................34

ritonavir............................... 26

rivastigmine.........................15

rivastigmine tartrate............ 15

rivelsa................................. 60

RIXUBIS............................. 49

rizatriptan benzoate............ 19

ROBAXIN-750.................... 75

ROCALTROL......................67

ROCKLATAN......................69

ropinirole hcl....................... 24

ropinirole hcl er................... 24

rosadan...............................41

ROSADAN.......................... 41

rosuvastatin calcium........... 32

ROWASA............................66

roweepra.............................14

roweepra xr.........................14

ROXICODONE..................... 8

ROZEREM..........................75

ROZLYTREK...................... 22

RUBRACA.......................... 22

RUZURGI........................... 54

RYBELSUS.........................48

RYCLORA.......................... 72

RYDAPT............................. 22

RYTARY............................. 24

RYTHMOL SR.................... 32

ryvent.................................. 72

SABRIL............................... 14

SAFYRAL........................... 60

SAIZEN...............................62

SAIZENPREP..................... 62

SALAGEN...........................35

salicylic acid........................41

salicylic acid er....................41

salicylic acid wart remover..41

salimez................................41

salsalate................................9

SALVAX DUO PLUS.......... 41

SAMSCA.............................55

SANCUSO.......................... 17

SANDIMMUNE................... 64

SANDOSTATIN.................. 62

SANTYL..............................42

SAPHRIS............................ 25

SARAFEM.......................... 16

SAVAYSA........................... 13

SAVELLA............................35

SAVELLA TITRATION

PACK.................................. 35

SCALACORT DK................42

scopolamine........................17

SEASONIQUE.................... 60

SECONAL...........................75

SECUADO.......................... 25

SEEBRI NEOHALER..........74

SEGLUROMET...................48

SELECT-OB....................... 51

selegiline hcl....................... 24

selenium sulfide.................. 42

SELRX................................ 42

SELZENTRY.......................26

SEMPREX-D...................... 72

SENSIPAR..........................62

SEREVENT DISKUS.......... 74

SERNIVO............................42

SEROQUEL........................25

SEROQUEL XR..................25

SEROSTIM......................... 62

sertraline hcl....................... 16

setlakin................................60

sevelamer carbonate.......... 55

sevelamer hcl ......................55

SEYSARA...........................12

sf......................................... 35

sf 5000 plus........................ 35

SFROWASA....................... 66

sharobel.............................. 60

SHINGRIX.......................... 65

SIGNIFOR.......................... 62

SIKLOS...............................22

sildenafil citrate............. 49, 74

SILENOR............................ 75

SILIQ...................................64

silodosin..............................56

SILVADENE........................12

silver nitrate........................ 12

silver sulfadiazine............... 12

SIMBRINZA........................ 69

simliya.................................60

simpesse.............................60

SIMPONI.............................64

SIMVASTATIN....................32

simvastatin..........................32

SINEMET............................24

SINEMET CR......................24

SINGULAIR........................ 74

sirolimus..............................64

SIRTURO............................20

SITAVIG..............................26

SIVEXTRO..........................12

SKELAXIN.......................... 75

SKLICE............................... 23

SKYRIZI (150 MG DOSE).. 64

SLYND................................60

sod citrate-citric acid........... 51

SODIUM BICARBONATE...54

sodium chloride...................72

sodium fluoride............. 35, 51

sodium fluoride 5000 plus...35

sodium hyaluronate............ 42

sodium phenylbutyrate........54

sodium polystyrene

sulfonate............................. 51

sodium sulfacetamide......... 42

94

sodium sulfacetamide

wash................................... 42

SODIUM

SULFACETAMIDE WASH..42

SOFOSBUVIR-

VELPATASVIR................... 26

SOF-SENSOR.................... 45

solifenacin succinate...........55

SOLIQUA............................48

SOLODYN.......................... 12

SOLOSEC.......................... 12

SOLTAMOX........................22

SOMA................................. 75

SOMATULINE DEPOT....... 62

SOMAVERT........................62

SOOLANTRA......................42

SORIATANE....................... 42

SORILUX............................ 42

sotalol hcl ............................32

sotalol hcl (af)..................... 32

sotalol hydrochloride...........32

SOTYLIZE.......................... 32

SOVALDI............................ 26

SPECTRACEF....................12

spinosad............................. 23

SPIRIVA HANDIHALER..... 74

SPIRIVA RESPIMAT.......... 74

spironolactone.................... 32

spironolactone-hctz.............32

SPORANOX....................... 18

SPORANOX PULSEPAK... 18

SPRAVATO (56 MG

DOSE)................................ 16

SPRAVATO (84 MG

DOSE)................................ 16

sprintec 28.......................... 60

SPRITAM............................14

SPRIX................................... 9

SPRYCEL........................... 22

sps...................................... 51

sronyx................................. 60

ssd...................................... 12

sss 10-5.............................. 42

STALEVO 100.................... 24

STALEVO 125.................... 24

STALEVO 150.................... 24

STALEVO 200.................... 24

STALEVO 50...................... 24

STALEVO 75...................... 24

STARLIX.............................48

stavudine............................ 26

STAXYN............................. 49

STEGLATRO...................... 48

STEGLUJAN.......................48

STELARA........................... 64

STENDRA...........................49

STIMATE............................ 62

STIOLTO RESPIMAT......... 74

STIVARGA..........................22

STRATTERA...................... 34

STRENSIQ......................... 54

STRIANT............................ 63

STRIBILD............................26

STRIVERDI RESPIMAT..... 74

STROMECTOL...................23

SUBOXONE....................... 10

SUBSYS............................... 8

subvenite............................ 14

subvenite starter kit-blue.....15

subvenite starter kit-green.. 15

subvenite starter kit-orange 15

SUCRAID............................54

sucralfate............................ 52

SULAR................................32

SULCONAZOLE NITRATE.19

sulfacetamide sodium... 42, 68


(acne)..................................42


sulfur................................... 42

sulfacetamide sod-sulfur

wash................................... 42

sulfacetamide-

prednisolone....................... 68

sulfacetamide-sulfur in

urea.....................................42

sulfacleanse 8/4..................42

sulfadiazine.........................12

sulfamethoxazole-

trimethoprim........................12

sulfamez wash.................... 42

SULFAMYLON................... 12

sulfasalazine....................... 66

sulfatrim pediatric................12

SULFURATED LIME.......... 23

sulindac.................................9

SUMADAN..........................42

SUMADAN WASH.............. 42

SUMADAN XLT.................. 42

sumatriptan......................... 20

sumatriptan succinate.........20

sumatriptan succinate refill . 20

sumatriptan-naproxen

sodium................................ 20

SUMAXIN........................... 42

SUMAXIN CP..................... 42

SUMAXIN WASH................42

SUNOSI.............................. 75

SUPRAX............................. 12

SUPREP BOWEL PREP

KIT...................................... 54

SUSTIVA............................ 26

SUTENT............................. 22

syeda.................................. 60

SYLATRON........................ 26

SYMAX DUOTAB............... 54

symax-sl..............................54

symax-sr ............................. 54

SYMBICORT...................... 74

SYMBYAX.......................... 16

SYMDEKO..........................74

SYMFI.................................26

SYMFI LO........................... 26

SYMJEPI............................ 71

SYMLINPEN 120................ 48

SYMLINPEN 60.................. 48

SYMPAZAN........................ 15

SYMPROIC.........................54

SYMTUZA...........................26

SYNALAR........................... 42

SYNALAR (CREAM)...........42

SYNALAR (OINTMENT).....42

SYNALAR TS..................... 42

SYNAREL........................... 62

SYNDROS.......................... 17

SYNJARDY.........................48

SYNJARDY XR...................48

SYNRIBO............................22

SYNTHROID.......................63

SYPRINE............................ 55

TABLOID............................ 22

TACLONEX........................ 42

tacrolimus..................... 42, 64

tadalafil ............................... 49

tadalafil (pah)...................... 74

TAFINLAR.......................... 22

TAGRISSO......................... 22

TAKHZYRO........................ 64

TALICIA.............................. 52

TALTZ.................................65

TALZENNA......................... 22

TAMIFLU............................ 26

tamoxifen citrate................. 22

tamsulosin hcl..................... 56

TAPAZOLE......................... 63

TAPERDEX 12-DAY...........62

TAPERDEX 6-DAY.............62

TAPERDEX 7-DAY.............62

TARCEVA...........................22

95

TARGADOX........................12

TARGRETIN....................... 22

tarina 24 fe..........................60

tarina fe 1/20.......................60

tarina fe 1/20 eq..................60

TARKA................................32

taron-crystals...................... 51

TASIGNA............................ 22

TASMAR.............................24

TAVALISSE........................ 49

TAYTULLA..........................60

tazarotene...........................42

TAZORAC...........................42

taztia xt ............................... 32

TAZVERIK.......................... 22

TECFIDERA....................... 34

TEGRETOL........................ 15

TEGRETOL-XR.................. 15

TEGSEDI............................ 54

TEKTURNA........................ 32

TEKTURNA HCT................ 32

telmisartan.......................... 32

telmisartan-amlodipine........32

telmisartan-hctz.................. 32

temazepam......................... 75

TEMIXYS............................ 26

TEMODAR..........................22

TEMOVATE........................ 42

temozolomide..................... 22

tencon................................... 8

TENIVAC............................ 65

tenofovir disoproxil

fumarate..............................26

TENORETIC 100................ 32

TENORETIC 50.................. 32

TENORMIN.........................32

terazosin hcl........................56

terbinafine hcl..................... 19

terbutaline sulfate............... 74

terconazole......................... 19

TESSALON PERLES......... 72

TESTIM...............................63

testosterone........................ 63

TESTOSTERONE

CYPIONATE....................... 63

testosterone cypionate........63

testosterone enanthate....... 63

tetcaine............................... 70

tetrabenazine...................... 35

tetracaine hcl...................... 70

tetracycline hcl.................... 12

tetravisc.............................. 70

tetravisc forte...................... 70

TEXACORT........................ 42

THALOMID......................... 22

THEO-24.............................74

theophylline.........................74

theophylline er.................... 74

THIOLA...............................55

THIOLA EC.........................55

thioridazine hcl....................25

thiothixene.......................... 25

THROMBOGEN..................49

thyroid................................. 63

tiadylt er.............................. 32

tiagabine hcl........................15

TIAZAC............................... 32

TIBSOVO............................22

TIGAN.................................17

TIGLUTIK............................35

TIKOSYN............................ 32

tilia fe.................................. 61

timolol maleate..............32, 69

TIMOPTIC...........................69

TIMOPTIC OCUDOSE....... 69

TIMOPTIC-XE.....................69

tinidazole.............................12

TIROSINT........................... 63

TIROSINT-SOL...................63

TISSEEL............................. 49

TIVICAY..............................26

TIVORBEX............................9

tizanidine hcl....................... 75

TOBI NEBULIZER.............. 74

TOBI PODHALER...............74

TOBRADEX.................. 68, 69

TOBRADEX ST.................. 69

tobramycin.......................... 69

TOBRAMYCIN....................74

tobramycin-

dexamethasone.................. 69

TOBREX............................. 69

TOLAK................................ 42

tolbutamide......................... 48

tolcapone............................ 24

tolmetin sodium.....................9

TOLSURA...........................19

tolterodine tartrate...............55

tolterodine tartrate er.......... 56

TOPAMAX.......................... 15

TOPAMAX SPRINKLE....... 15

TOPEX TOPICAL

ANESTHETIC..................... 36

TOPICORT......................... 43

TOPICORT SPRAY............ 43

topiramate...........................15

topiramate er .......................15

TOPROL XL........................32

toremifene citrate................ 22

torsemide............................ 32

TOSYMRA.......................... 20

TOUJEO MAX

SOLOSTAR........................ 46

TOUJEO SOLOSTAR.........46

tovet.................................... 43

TOVIAZ...............................56

TRACLEER.........................74

TRADJENTA.......................48

TRAMADOL HCL ER............8

tramadol hcl er...................... 8

tramadol hcl er (biphasic) ..... 8

tramadol hcl ir ....................... 8

tramadol-acetaminophen...... 8

trandolapril .......................... 32

trandolapril-verapamil hcl

er.........................................32

tranexamic acid...................49

TRANSDERM-SCOP (1.5

MG).....................................17

TRANXENE-T.....................28

tranylcypromine sulfate.......16

TRAVATAN Z..................... 69

travoprost (bak free) ........... 69

trazodone hcl ...................... 16

TRECATOR........................ 20

TRELEGY ELLIPTA............74

TREMFYA...........................65

TRESIBA............................ 46

TRESIBA FLEXTOUCH......46

tretinoin......................... 22, 43

tretinoin microsphere.......... 43

tretinoin microsphere pump 43

TRETTEN........................... 49

TREXALL............................65

TREXIMET..........................20

TREZIX................................. 8

tri femynor...........................61

triamcinolone acetonide 36, 43

triamterene..........................32

triamterene-hctz..................32

trianex................................. 43

triazolam............................. 28

TRIBENZOR....................... 32

TRICARE PRENATAL

DHA ONE........................... 51

TRI-CHLOR........................ 43

tricitrates............................. 51

TRICOR.............................. 32

triderm.................................43

96

TRIDESILON...................... 43

trientine hcl......................... 55

tri-estarylla.......................... 61

trifluoperazine hcl................25

trifluridine............................ 69

trihexyphenidyl hcl .............. 24

TRIKAFTA.......................... 74

tri-legest fe.......................... 61

TRILEPTAL.........................15

tri-linyah.............................. 61

TRILIPIX............................. 32

tri-lo-estarylla...................... 61

tri-lo-marzia.........................61

tri-lo-mili .............................. 61

tri-lo-sprintec....................... 61

trilyte................................... 54

trimethobenzamide hcl ........17

trimethoprim........................13

tri-mili .................................. 61

trimipramine maleate.......... 16

trinate..................................51

TRINAZ...............................51

TRINTELLIX....................... 16

tri-previfem..........................61

tri-sprintec........................... 61

TRISTART ONE................. 51

TRIUMEQ........................... 26

TRI-VI-FLOR.......................51

TRI-VI-FLORO....................51

tri-vitamin/fluoride............... 51

tri-vite/fluoride..................... 51

trivora (28).......................... 61

tri-vylibra............................. 61

tri-vylibra lo......................... 61

TRIZIVIR.............................27

TROKENDI XR................... 15

trospium chloride................ 56

trospium chloride er............ 56

TRUE METRIX BLOOD

GLUCOSE TEST................ 45

TRUE METRIX PRO

BLOOD GLUCOSE.............45

TRUETRACK TEST............45

TRULANCE........................ 54

TRULICITY......................... 48

TRUMENBA........................65

TRUSOPT...........................69

TRUVADA...........................27

TRYPTOPHAN................... 51

TUDORZA PRESSAIR....... 74

tulana.................................. 61

TURALIO............................ 22

TUSSICAPS....................... 72

TUXARIN ER...................... 72

TUZISTRA XR.................... 72

TWINRIX.............................65

TWYNSTA.......................... 32

TYBOST............................. 27

tydemy................................ 61

TYKERB............................. 22

TYLENOL WITH

CODEINE #3........................ 8

TYLENOL WITH

CODEINE #4........................ 8

TYMLOS............................. 67

TYVASO............................. 74

TYVASO REFILL................ 74

TYVASO STARTER........... 74

UBRELVY........................... 20

UCERIS........................ 66, 67

UDENYCA.......................... 49

ULESFIA.............................23

ULORIC.............................. 19

ULTRACET...........................8

ULTRAM............................... 8

ULTRASAL-ER................... 43

ULTRAVATE.......................43

UMECTA MOUSSE............ 43

unithroid.............................. 63

UPTRAVI............................ 75

URAMAXIN.........................43

urea.....................................43

urea nail .............................. 43

urea-c40..............................43

URECHOLINE.................... 56

URELLE..............................56

uremez-40...........................43

uretron d/s...........................56

URIBEL...............................56

URIMAR-T.......................... 56

urin ds................................. 56

URO-458.............................56

UROCIT-K 10..................... 51

UROCIT-K 15..................... 51

UROCIT-K 5....................... 51

UROGESIC-BLUE.............. 56

uro-mp................................ 56

UROXATRAL......................56

URSO 250.......................... 54

URSO FORTE.................... 54

ursodiol............................... 54

URYL.................................. 56

ustell................................... 56

UTIBRON NEOHALER.......74

uticap.................................. 56

utira-c..................................56

UTOPIC.............................. 43

utrona-c...............................56

VAGIFEM............................61

valacyclovir hcl ....................27

VALCHLOR........................ 22

VALCYTE........................... 27

valganciclovir hcl .................27

VALIUM.............................. 28

valproic acid........................15

valsartan............................. 32

valsartan-


VALTOCO 10 MG DOSE....15



VALTOCO 5 MG DOSE......15

VALTREX........................... 27

VANATOL LQ....................... 8

VANATOL S..........................8

VANCOCIN.........................13

VANCOCIN HCL.................13

vancomycin hcl ................... 13

vandazole........................... 13

VANOS............................... 43

VAQTA................................65

vardenafil hcl .......................49

VARIVAX............................ 65

VARUBI.............................. 17

VASCEPA...........................32

VASERETIC....................... 33

VASOTEC...........................33

VECAMYL...........................33

VECTICAL.......................... 43

velivet..................................61

VELPHORO........................56

VELTASSA......................... 51

VELTIN............................... 43

VEMLIDY............................ 27

VENCLEXTA...................... 22

VENCLEXTA STARTING

PACK.................................. 22

VENELEX........................... 43

venlafaxine hcl.................... 17

venlafaxine hcl er................17

VENTAVIS.......................... 75

VENTOLIN HFA..................74

verapamil hcl .......................33

verapamil hcl er.................. 33

VERDESO.......................... 43

VEREGEN.......................... 43

VERELAN........................... 33

VERELAN PM.....................33

VERSACLOZ...................... 25

97

VERZENIO......................... 22

VESICARE..........................56

VFEND................................19

VIAGRA.............................. 49

VIBERZI..............................54

VIBRAMYCIN..................... 13

vicodin hp..............................8

VICTOZA............................ 48

VIDEX................................. 27

VIDEX EC........................... 27

VIEKIRA PAK..................... 27

vienva................................. 61

vigabatrin............................ 15

vigadrone............................ 15

VIGAMOX........................... 69

VIIBRYD............................. 17

VIIBRYD STARTER PACK.17

vilamit mb............................56

VILEVEV MB...................... 56

VIMOVO............................... 9

VIMPAT.............................. 15

VIOKACE............................54

viorele................................. 61

VIRACEPT..........................27

VIRAMUNE.........................27

VIRAMUNE XR...................27

VIRASAL.............................43

VIRAZOLE.......................... 27

VIREAD.............................. 27

virt-phos 250 neutral........... 51

VISTARIL............................28

VISTOGARD.......................54

VITAFOL FE+..................... 51

VITAFOL STRIPS...............51

VITAFOL-OB+DHA.............51

vitamin d (ergocalciferol) .....51

vitamins acd-fluoride...........51

VITATHELY WITH

GINGER..............................51

VITRAKVI........................... 22

VIVELLE-DOT.................... 61

VIVLODEX............................9

VIZIMPRO.......................... 22

VOGELXO.......................... 63

VOGELXO PUMP...............63

volnea................................. 61

VONVENDI......................... 49

voriconazole........................19

VOSEVI.............................. 27

VOTRIENT..........................22

vp-pnv-dha..........................52

VRAYLAR........................... 25

VTOL LQ...............................8

VUMERITY......................... 34

VUMERITY (STARTER)..... 35

VUSION.............................. 19

vyfemla............................... 61

VYLEESI.............................49

vylibra................................. 61

VYNDAMAX........................33

VYNDAQEL........................ 33

VYTORIN............................33

VYVANSE...........................34

VYZULTA............................69

WAKIX................................ 75

warfarin sodium.................. 13

WELCHOL.......................... 33

WELLBUTRIN SR...............17

WELLBUTRIN XL............... 17

wera.................................... 61

WESTHROID......................63

WHEAT GERM OIL............ 52

WILATE.............................. 49

wixela inhub........................ 74

WP THYROID.....................63

wymzya fe...........................61

XADAGO............................ 24

XALATAN........................... 69

XALKORI............................ 22

XANAX................................28

XANAX XR..........................28

XARELTO........................... 13

XARELTO STARTER

PACK.................................. 13

XATMEP............................. 65

XELJANZ............................ 65

XELJANZ XR...................... 65

XELODA............................. 22

XELPROS...........................69

XENAZINE..........................35

XENLETA........................... 13

XEPI....................................13

XERESE............................. 27

XERMELO.......................... 54

XHANCE.............................72

XIFAXAN............................ 13

XIGDUO XR........................48

XIIDRA................................70

XIMINO............................... 13

XOFLUZA (40 MG DOSE)..27

XOFLUZA (80 MG DOSE)..27

XOLEGEL........................... 19

XOLEGEL COREPAK........ 19

XOLEGEL DUO/HEAD &

SHOULDERS..................... 19

XOLEGEL DUO/XOLEX..... 19

XOPENEX.......................... 74

XOPENEX

CONCENTRATE................ 74

XOPENEX HFA.................. 74

XOSPATA...........................22

XPOVIO (100 MG ONCE

WEEKLY)............................22

XPOVIO (60 MG ONCE

WEEKLY)............................23

XPOVIO (80 MG ONCE

WEEKLY)............................23

XPOVIO (80 MG TWICE

WEEKLY)............................23

XTAMPZA ER.......................8

XTANDI...............................23

xulane................................. 61

XULTOPHY........................ 48

XURIDEN............................55

XYNTHA............................. 49

XYNTHA SOLOFUSE.........49

XYOSTED...........................63

XYREM............................... 75

YASMIN 28......................... 61

YAZ.....................................61

YONSA............................... 23

YOSPRALA........................ 24

YUPELRI............................ 74

yuvafem.............................. 61

ZACARE............................. 43

zaclir cleansing................... 43

zafirlukast............................74

zaleplon.............................. 75

ZALVIT................................52

ZANAFLEX......................... 75

zarah...................................61

ZARONTIN......................... 15

ZARXIO.............................. 49

ZAVESCA........................... 55

ZEBUTAL..............................8

ZEGERID............................52

ZEJULA.............................. 23

ZELAPAR........................... 24

ZELBORAF.........................23

ZELNORM.......................... 54

ZEMBRACE SYMTOUCH.. 20

ZEMPLAR...........................67

zenatane............................. 43

ZENPEP............................. 55

ZENZEDI............................ 34

ZEPATIER.......................... 27

ZESTORETIC..................... 33

ZESTRIL............................. 33

ZETIA..................................33

98

ZETONNA...........................72

ZIAC....................................33

ZIAGEN.............................. 27

ZIANA................................. 43

zidovudine...........................27

ZIEXTENZO........................49

ZILACAINE PATCH.............. 8

zileuton er........................... 74

ZIOPTAN............................ 69

ziprasidone hcl....................25

ZIPSOR................................ 9

ZIRGAN.............................. 69

ZITHROMAX.......................13

ZITHROMAX TRI-PAK....... 13

ZITHROMAX Z-PAK........... 13

ZOCOR...............................33

ZOFRAN............................. 17

ZOHYDRO ER......................8

ZOLINZA.............................23

zolmitriptan......................... 20

ZOLOFT..............................17

zolpidem tartrate................. 75

zolpidem tartrate er.............75

ZOLPIMIST.........................75

ZOMACTON....................... 62

ZOMIG................................ 20

ZOMIG ZMT........................20

ZONALON.......................... 43

ZONEGRAN....................... 15

zonisamide..........................15

ZONTIVITY......................... 24

ZORBTIVE..........................62

ZORTRESS........................ 65

ZORVOLEX.......................... 9

ZOSTAVAX.........................65

zovia 1/35e (28).................. 61

ZOVIRAX............................ 27

ZTLIDO................................. 8

ZUBSOLV........................... 10

zumandimine...................... 61

ZUPLENZ........................... 17

ZYCLARA........................... 43

ZYCLARA PUMP................43

ZYDELIG............................ 23

ZYFLO................................ 74

ZYKADIA............................ 23

ZYLET.................................69

ZYLOPRIM......................... 19

ZYMAXID............................69

ZYPITAMAG....................... 33

ZYPREXA........................... 25

ZYPREXA ZYDIS............... 25

ZYTIGA...............................23

ZYVOX................................13

99

Nondiscrimination notice and access to communication services

® UnitedHealthcare does not discriminate on the basis of race, color, national origin, age, disability, or sex in its health programs or activities.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator.

Online: [email protected]

Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, Utah 84130

You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

http://www.hhs.gov/ocr/office/file/index.html

unitedhealthcare & affiliated companies · 2020-08-07 · health care reform drug lists may...

Documents