virginia premier individual plans comprehensive formulary ... · 9/10/2019 · diethylpropion hcl...

Virginia Premier Individual Plans 2020 Comprehensive Formulary(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

ABOUT THE DRUGS WE COVER IN THIS PLAN

This formulary was updated on 9/10/2019. For more recent

information or other questions, please contact Virginia Premier

Individual Plans Member Services, at 1-833-672-8075 or, for TTY

users, 711, Monday – Friday 8 am to 6 pm; Saturday

8 am to 2 pm, or visit www.virginiapremier.com/individual-family.

EXCH_0418-FORM-250001

II

What is the Virginia Premier Individual Plans’ Formulary?

A formulary is a list of covered drugs selected by Virginia Premier Individual Plans (Virginia Premier) in

consultation with a team of health care providers, which represents the prescription therapies believed to be a

necessary part of a quality treatment program. Virginia Premier will generally cover the drugs listed in our

formulary as long as the drug is medically necessary, the prescription is filled at a Virginia Premier network

pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please

review your Evidence of Coverage.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits

may include:

Age Limits: Virginia Premier limits the ages around certain drugs. This means that you [or your physician] will need to get approval from Virginia Premier before you fill your prescriptions if you

are not within the ages limit. If you don’t get approval, Virginia Premier may not cover the drug.

Gender Restriction: Virginia Premier restricts certain drugs to gender specific. This means that you [or your physician] will need to get approval from Virginia Premier before you fill your prescriptions

if you are not within the gender specific guidelines. If you don’t get approval Virginia Premier may

not cover the drug.

Prior Authorization: Virginia Premier requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from Virginia Premier before you fill

your prescriptions. If you don’t get approval, Virginia Premier may not cover the drug.

Quantity Limits: For certain drugs, Virginia Premier limits the amount of the drug that Virginia Premier will cover. For example, Virginia Premier provides 30 capsules per prescription for Linzess

Oral Capsules 72 MCG. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, Virginia Premier requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and

Drug B both treat your medical condition, Virginia Premier may not cover Drug B unless you try

Drug A first. If Drug A does not work for you, Virginia Premier will then cover Drug B.

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

also get more information about the restrictions applied to specific covered drugs by visiting our Web site at

www.virginiapremier.com/individual-family.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Member

Services at 833-672-8075 and ask if your drug is covered. If you learn that Virginia Premier does not cover

your drug, you have two options:

III

You can ask Member Services for a list of similar drugs that are covered by Virginia Premier. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is

covered by Virginia Premier.

You can ask Virginia Premier to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Virginia Premier Formulary?

You can ask Virginia Premier to make an exception to our coverage rules. There are several types of

exceptions that you can ask us to make.

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

drug at a lower cost-sharing level.

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

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Virginia Premier limits the amount of the drug that we will cover. If your drug has a quantity limit,

you can ask us to waive the limit and cover a greater amount.

Generally, Virginia Premier will only approve your request for an exception if the alternative drugs would

not be as effective in treating your condition and/or would cause you to have adverse medical effects.

If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps

in order for us to cover the drug. If you want us to waive the restriction for you, you will need to use the

coverage decision process and ask us to make an exception.

You should contact us to ask for an initial coverage decision for a formulary, tier, or utilization restriction

exception. When you request a formulary, tier, or utilization restriction exception you should submit a

statement from your prescriber or physician supporting your request.

Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement.

You can request an expedited (fast) exception if you or your doctor believe that your health could be

seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must

give you a decision no later than 24 hours after we get a supporting statement from your doctor or other

prescriber.

For more information about how to request a coverage determination visit our Web Site,

www.virginiapremier.com/individual-family or contact our member services at 833-672-8075.

How Much Will My Prescriptions Cost?

Your pharmacy benefit and the medications listed in the formulary are assigned a “TIER.” There are six (6)

tiers in the Formulary. Generally, the higher the “TIER,” the higher your cost will be. Carefully review your

Schedule of Cost Shares and Benefits to ascertain if you have a pharmacy benefit and/or any pharmacy

benefit limitations.

IV

How Can I Obtain My Prescriptions?

In most cases, your prescriptions are covered only if they are filled at the plan’s network pharmacies. A

network pharmacy is a pharmacy that has a contract with the plan to provide your covered prescription

drugs. The term “covered drugs” means all prescription drugs that are covered on our plan’s formulary.

For certain kinds of drugs, you can use the plan’s network mail-order services. Generally, the drugs

provided through mail order are drugs that you take on a regular basis, for a chronic or long-term medical

condition.

To find a network pharmacy, you may look in your Provider & Pharmacy Directory, visit our website

(www.virginiapremier.com/individual-family), or call Member Services (phone numbers are printed on the

back cover of this booklet).

You may go to any of our network pharmacies. If you switch from one network pharmacy to another, and

you need a refill of a drug you have been taking, you can ask to have your prescription transferred to your

new network pharmacy.

V

List of Abbreviations

Status

T1 = Tier 1 Preferred Generic

T2 = Tier 2 Non-Preferred Generic

T3 = Tier 3 Preferred Brand

T4 = Tier 4 Non-Preferred Brand

T5 = Tier 5 Specialty

T6 = Tier 6 Preventative

Notes

AL = Must meet Age Limit

GR-F = Gender Restriction (Female Only)

GR-M = Gender Restriction (Male Only)

PA = Prior Authorization

QL = Quantity Limit

ST = Step Therapy

Drug Status Notes

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

T1QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

T1AL (Min 6 Years and Max 17 Years)

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg

T2 PA

atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg


caffeine citrate intravenous solution 60 mg/3ml T1

caffeine citrate oral solution 20 mg/ml T1

caffeine-sodium benzoate injection solution 125-125 mg/ml

T1

DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR

T4PA; AL (Min 6 Years and Max 17 Years)

dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg


dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg


dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg


dextroamphetamine sulfate oral tablet 10 mg, 5 mg


diethylpropion hcl er oral tablet extended release 24 hour 75 mg

T1

diethylpropion hcl oral tablet 25 mg T1

guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg


methamphetamine hcl oral tablet 5 mg T1AL (Min 6 Years and Max 17 Years)

methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg


methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg, 60 mg


methylphenidate hcl er oral tablet extended release 10 mg, 20 mg


You can find information on what the symbols and abbreviations on this table mean by going to the List of Abbreviations on page V

1

Drug Status Notesmethylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36 mg, 54 mg


METHYLPHENIDATE HCL ER ORAL TABLET EXTENDED RELEASE 24 HOUR18 MG, 27 MG, 36 MG, 54 MG


methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml


methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg


modafinil oral tablet 100 mg, 200 mg T1 PA

phendimetrazine tartrate er oral capsule extended release 24 hour 105 mg

T1

phendimetrazine tartrate oral tablet 35 mg T1

phentermine hcl oral capsule 15 mg, 30 mg, 37.5 mg

T1

phentermine hcl oral tablet 37.5 mg T1

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG T3

AL (Min 6 Years and Max 17 Years)

*Aminoglycosides*amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml

NC

gentamicin sulfate injection solution 10 mg/ml, 40 mg/ml

NC

gentamicin sulfate intravenous solution 10 mg/ml NC

neomycin sulfate oral tablet 500 mg T1

paromomycin sulfate oral capsule 250 mg T5 PA

tobramycin inhalation nebulization solution 300 mg/5ml

T5 PA

tobramycin sulfate injection solution 1.2 gm/30ml, 10 mg/ml, 2 gm/50ml, 80 mg/2ml

NC

*Aminomethylcyclines***NUZYRA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG NC

*Analgesics - Anti-Inflammatory*ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML T5 PA; QL (3.68 ML per 30 days)

ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG T5 PA

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

T1 QL (30 EA per 30 days)


2

Drug Status Notesdiclofenac potassium oral tablet 50 mg T1

diclofenac sodium er oral tablet extended release 24 hour 100 mg

T1

diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

T1

diclofenac-misoprostol oral tablet delayed release50-0.2 mg, 75-0.2 mg

T2

ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML T5 PA; QL (3.92 ML per 30 days)

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML T5 PA; QL (4 ML per 30 days)

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML T5 PA; QL (3.92 ML per 30 days)

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG T5 PA; QL (4 EA per 30 days)

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML T5 PA; QL (3.92 ML per 30 days)

etodolac er oral tablet extended release 24 hour400 mg, 500 mg, 600 mg

T1

etodolac oral capsule 200 mg, 300 mg T1

etodolac oral tablet 400 mg, 500 mg T1

fenoprofen calcium oral tablet 600 mg T2

flurbiprofen oral tablet 100 mg, 50 mg T1

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

T5 PA; QL (2 EA per 30 days)

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML


HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML


HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML


HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML


ibuprofen oral suspension 100 mg/5ml T1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg T1


3

Drug Status Notesindomethacin er oral capsule extended release 75 mg

T1 AL (Max 64 Years)

indomethacin oral capsule 25 mg, 50 mg T1 AL (Max 64 Years)

ketoprofen er oral capsule extended release 24 hour 200 mg


ketorolac tromethamine oral tablet 10 mg T1 QL (20 EA per 5 days)

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML T5 PA; QL (18.76 ML per 28 days)

leflunomide oral tablet 10 mg, 20 mg T1

MECLOFENAMATE SODIUM ORAL CAPSULE 100 MG, 50 MG T4

mefenamic acid oral capsule 250 mg T2

meloxicam oral tablet 15 mg, 7.5 mg T1

nabumetone oral tablet 500 mg T1 QL (120 EA per 30 days)

nabumetone oral tablet 750 mg T1 QL (60 EA per 30 days)

naproxen dr oral tablet delayed release 375 mg, 500 mg

T1

naproxen oral suspension 125 mg/5ml T1QL (300 ML per 30 days); AL (Max 12 Years)

naproxen oral tablet 250 mg, 375 mg, 500 mg T1

naproxen sodium oral tablet 275 mg, 550 mg T2

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML T5 PA; QL (4 ML per 28 days)

oxaprozin oral tablet 600 mg T2 QL (60 EA per 30 days)

piroxicam oral capsule 10 mg, 20 mg T1

RIDAURA ORAL CAPSULE 3 MG T5 PA

sulindac oral tablet 150 mg, 200 mg T1

tolmetin sodium oral capsule 400 mg T1

TOLMETIN SODIUM ORAL TABLET 200 MG, 600 MG T4

XELJANZ ORAL TABLET 5 MG T5 PA; QL (60 EA per 30 days)

*Analgesics - Nonnarcotic*

aspirin 81 oral tablet chewable 81 mg T6QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years)

aspirin ec low dose oral tablet delayed release 81 mg


aspirin ec oral tablet delayed release 325 mg T6QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)


4

Drug Status Notes

aspirin oral tablet 325 mg T6QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)

butalbital-apap-caffeine oral capsule 50-300-40 mg

T1

butalbital-apap-caffeine oral capsule 50-325-40 mg

T2

butalbital-apap-caffeine oral tablet 50-325-40 mg T1

butalbital-aspirin-caffeine oral capsule 50-325-40 mg

T1

choline-mag trisalicylate oral liquid 500 mg/5ml T1

diflunisal oral tablet 500 mg T1

salsalate oral tablet 500 mg, 750 mg T1

TENCON ORAL TABLET 50-325 MG T4

*Analgesics - Opioid*acetaminophen-codeine #2 oral tablet 300-15 mg T1 QL (390 EA per 30 days)

acetaminophen-codeine #3 oral tablet 300-30 mg T1 QL (390 EA per 30 days)

acetaminophen-codeine #4 oral tablet 300-60 mg T1 QL (390 EA per 30 days)

acetaminophen-codeine oral solution 120-12 mg/5ml

T1

buprenorphine hcl injection solution 0.3 mg/ml T2 PA

buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg


buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg


buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg


buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr, 7.5 mcg/hr


butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325-40-30 mg

T1

butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg

T1

butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml

T2

butorphanol tartrate nasal solution 10 mg/ml T2

codeine sulfate oral tablet 30 mg T1

DILAUDID INJECTION SOLUTION 1 MG/ML, 2 MG/ML, 4 MG/ML NC


5

Drug Status NotesDILAUDID-HP INJECTION SOLUTION 10 MG/ML NC

ENDOCET ORAL TABLET 2.5-325 MG T1

endocet oral tablet 5-325 mg T1 QL (360 EA per 30 days)

fentanyl citrate (pf) injection solution 100 mcg/2ml, 1000 mcg/20ml, 250 mcg/5ml, 2500 mcg/50ml, 500 mcg/10ml

NC

fentanyl citrate injection solution 1500 mcg/30ml NC

fentanyl citrate intravenous solution 2500 mcg/50ml, 5000 mcg/100ml

NC

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr


hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 7.5-325 mg/15ml

T1

hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg


hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg


hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg


hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12 mg, 16 mg, 32 mg, 8 mg

T2 PA

hydromorphone hcl injection solution 1 mg/ml, 2 mg/ml, 4 mg/ml

NC

hydromorphone hcl oral liquid 1 mg/ml T2

hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg T1 QL (240 EA per 30 days)

hydromorphone hcl pf injection solution 1 mg/ml, 2 mg/ml, 50 mg/5ml

NC

HYDROMORPHONE HCL RECTAL SUPPOSITORY 3 MG T4

HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG


LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 MCG/ACT, 400 MCG/ACT NC

levorphanol tartrate oral tablet 2 mg T1

meperidine hcl injection solution 100 mg/ml, 25 mg/ml, 50 mg/ml

T2

meperidine hcl oral solution 50 mg/5ml T2

meperidine hcl oral tablet 100 mg, 50 mg T1

methadone hcl injection solution 10 mg/ml T2


6

Drug Status Notesmethadone hcl intensol oral concentrate 10 mg/ml T1

methadone hcl oral solution 10 mg/5ml, 5 mg/5ml T1

methadone hcl oral tablet 10 mg T1 QL (240 EA per 30 days)

methadone hcl oral tablet 5 mg T1

methadose oral tablet soluble 40 mg T1

morphine sulfate (concentrate) oral solution 100 mg/5ml

T1

morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml

T2

morphine sulfate (pf) intravenous solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml

T2

morphine sulfate er oral tablet extended release100 mg, 15 mg, 30 mg, 60 mg


morphine sulfate injection solution 10 mg/ml, 8 mg/ml

T2

MORPHINE SULFATE INTRAMUSCULAR DEVICE 10 MG/0.7ML T4

morphine sulfate intravenous solution 1 mg/ml, 150 mg/30ml, 25 mg/ml, 50 mg/ml

T2

morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml

T1

morphine sulfate oral tablet 15 mg, 30 mg T1 QL (180 EA per 30 days)

MORPHINE SULFATE RECTAL SUPPOSITORY 10 MG, 20 MG, 30 MG, 5 MG

T4

nalbuphine hcl injection solution 10 mg/ml, 20 mg/ml

T2

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG

T4 PA

OXAYDO ORAL TABLET ABUSE-DETERRENT 5 MG, 7.5 MG T4 PA; QL (180 EA per 30 days)

oxycodone hcl oral capsule 5 mg T2 QL (180 EA per 30 days)

oxycodone hcl oral concentrate 100 mg/5ml T2

oxycodone hcl oral solution 5 mg/5ml T1

oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg


oxycodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg


oxycodone-acetaminophen oral tablet 2.5-325 mg T1


7

Drug Status Notesoxycodone-acetaminophen oral tablet 5-325 mg T1 QL (360 EA per 30 days)

oxycodone-aspirin oral tablet 4.8355-325 mg T1 QL (240 EA per 30 days)

oxycodone-ibuprofen oral tablet 5-400 mg T1 QL (240 EA per 30 days)

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

T3 PA

OXYMORPHONE HCL ER ORAL TABLET EXTENDED RELEASE 12 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG

T4 PA

oxymorphone hcl oral tablet 10 mg, 5 mg T1

pentazocine-naloxone hcl oral tablet 50-0.5 mg T1

SUBLIMAZE INJECTION SOLUTION 1000 MCG/20ML NC

SUBOXONE SUBLINGUAL FILM 12-3 MG T3 PA; QL (30 EA per 30 days)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG T3 PA; QL (90 EA per 30 days)

SUBOXONE SUBLINGUAL FILM 8-2 MG T3 PA; QL (60 EA per 30 days)

tramadol hcl er (biphasic) oral tablet extended release 24 hour 300 mg


TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 150 MG T4 QL (30 EA per 30 days)

tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 mg


tramadol hcl oral tablet 50 mg T1 QL (240 EA per 30 days)

tramadol-acetaminophen oral tablet 37.5-325 mg T1

verdrocet oral tablet 2.5-325 mg T1 QL (180 EA per 30 days)

XARTEMIS XR ORAL TABLET EXTENDED RELEASE 7.5-325 MG T4

XYLON ORAL TABLET 10-200 MG T4 PA

*Androgens-Anabolic*ANADROL-50 ORAL TABLET 50 MG T5 PA

ANDROGEL PUMP TRANSDERMAL GEL20.25 MG/ACT (1.62%) T4 PA

ANDROXY ORAL TABLET 10 MG T4 PA

danazol oral capsule 100 mg, 200 mg, 50 mg T2 PA

METHITEST ORAL TABLET 10 MG T4

oxandrolone oral tablet 10 mg, 2.5 mg T2 PA

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

T1


8

Drug Status Notestestosterone enanthate intramuscular solution200 mg/ml

T1

testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 25 mg/2.5gm (1%)

T2 PA

testosterone transdermal solution 30 mg/act T2 PA

*Anorectal Agents*ANALPRAM-HC RECTAL LOTION 2.5-1 % T4

anucort-hc suppository 25 mg rectal 25 mg T1 QL (12 EA per 30 days)

colocort rectal enema 100 mg/60ml T1

CORTIFOAM RECTAL FOAM 10 % T4 PA

hydrocortisone ace-pramoxine rectal cream 2.5-1 %

T2

hydrocortisone acetate rectal suppository 25 mg T1 QL (12 EA per 30 days)

hydrocortisone acetate rectal suppository 30 mg T1 QL (12 EA per 30 days)

LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL 2.8-0.55 % T4

lidocaine-hydrocortisone ace rectal kit 2-2 % T2 PA

lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 %, 3-2.5 %

T1

pramcort rectal cream 1-1 % T1 QL (60 GM per 30 days)

PROCTOFOAM HC RECTAL FOAM 1-1 % T4

proctozone-hc rectal cream 2.5 % T1

RECTIV RECTAL OINTMENT 0.4 % T4

*Anthelmintics*ALBENZA ORAL TABLET 200 MG T4 PA

ivermectin oral tablet 3 mg T2 QL (10 EA per 30 days)

reeses pinworm medicine oral suspension 144 (50 base) mg/ml

T1

*Antianginal Agents*DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 MG T4

isosorbide dinitrate er oral tablet extended release 40 mg

T1

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

T1

isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg

T1

isosorbide mononitrate oral tablet 10 mg, 20 mg T1


9

Drug Status NotesNITRO-BID TRANSDERMAL OINTMENT 2 % T4

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR T4

nitroglycerin er oral capsule extended release 2.5 mg

T1

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg

T1

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

T1

nitroglycerin translingual solution 0.4 mg/spray T2

nitro-time oral capsule extended release 6.5 mg, 9 mg

T1

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG NC PA; QL (60 EA per 30 days)

ranolazine er oral tablet extended release 12 hour1000 mg, 500 mg

T2 PA

*Antianxiety Agents*alprazolam er oral tablet extended release 24 hour 1 mg, 2 mg


alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg


alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg


alprazolam xr oral tablet extended release 24 hour 0.5 mg, 3 mg


buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

T1

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg


clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg


diazepam injection solution 5 mg/ml T1 AL (Max 64 Years)

diazepam oral solution 5 mg/5ml T1 AL (Max 64 Years)

diazepam oral tablet 10 mg, 2 mg, 5 mg T1 AL (Max 64 Years)

droperidol injection solution 2.5 mg/ml T1

hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml


hydroxyzine hcl oral syrup 10 mg/5ml T1 AL (Max 64 Years)

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg T1 AL (Max 64 Years)


10

Drug Status Noteshydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg


lorazepam injection solution 2 mg/ml, 4 mg/ml T1

lorazepam intensol oral concentrate 2 mg/ml T1

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg T1

meprobamate oral tablet 200 mg, 400 mg T1 AL (Max 64 Years)

oxazepam oral capsule 10 mg, 15 mg, 30 mg T1

*Antiarrhythmics*ADENOCARD INTRAVENOUS SOLUTION12 MG/4ML, 6 MG/2ML NC

adenosine intravenous solution 12 mg/4ml, 6 mg/2ml

NC

amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg

T1

disopyramide phosphate oral capsule 100 mg, 150 mg

T1

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg

T2

flecainide acetate oral tablet 100 mg, 150 mg, 50 mg

T1

mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

T1

MULTAQ ORAL TABLET 400 MG T4 PA

NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG T4

propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg

T2

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

T1

quinidine gluconate er oral tablet extended release 324 mg

T1

quinidine sulfate oral tablet 200 mg, 300 mg T1

*Antiasthmatic And Bronchodilator Agents*ADVAIR HFA INHALATION AEROSOL115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT

T3 QL (12 GM per 30 days)

albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 mg

T1


11

Drug Status Notesalbuterol sulfate inhalation nebulization solution(2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml

T1

albuterol sulfate oral syrup 2 mg/5ml T1

aminophylline intravenous solution 25 mg/ml T1

ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH


ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG T4 PA; QL (30 EA per 30 days)

ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT


ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH




ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH






ASMANEX HFA INHALATION AEROSOL100 MCG/ACT, 200 MCG/ACT T3 QL (13 GM per 30 days)

ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT T3 QL (12.9 GM per 30 days)

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH


BROVANA INHALATION NEBULIZATION SOLUTION 15 MCG/2ML T4 PA; QL (120 ML per 30 days)

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml

T2QL (120 ML per 30 days); AL (Max 6 Years)

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT T4 QL (4 GM per 30 days)


12

Drug Status NotesDALIRESP ORAL TABLET 250 MCG, 500 MCG T4 QL (30 EA per 30 days)

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML T3

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST


FLOVENT HFA INHALATION AEROSOL110 MCG/ACT, 220 MCG/ACT T3 QL (12 GM per 30 days)

FLOVENT HFA INHALATION AEROSOL44 MCG/ACT T3 QL (10.6 GM per 30 days)

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT


ipratropium bromide inhalation solution 0.02 % T1

ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml

T1

levalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml

T1

metaproterenol sulfate oral syrup 10 mg/5ml T1

metaproterenol sulfate oral tablet 10 mg, 20 mg T1

montelukast sodium oral packet 4 mg T1

montelukast sodium oral tablet 10 mg T1

montelukast sodium oral tablet chewable 4 mg, 5 mg

T1

PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 MCG/2ML T4 PA; QL (120 ML per 30 days)

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT


SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE


SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG T3 QL (30 EA per 30 days)

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT

T3 QL (4 GM per 30 days)


13

Drug Status NotesSTIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT T3 QL (4 GM per 30 days)

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT T3 QL (4 GM per 30 days)

terbutaline sulfate injection solution 1 mg/ml T1

terbutaline sulfate oral tablet 2.5 mg, 5 mg T1

theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg, 450 mg

T1

theophylline er oral tablet extended release 24 hour 400 mg, 600 mg

T1

theophylline oral solution 80 mg/15ml T1

VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT T3 QL (36 GM per 30 days)

XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG T5 PA

zafirlukast oral tablet 10 mg, 20 mg T2

zileuton er oral tablet extended release 12 hour600 mg

T5 PA

ZYFLO ORAL TABLET 600 MG T5 PA

*Anticoagulants*COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

T3

ELIQUIS ORAL TABLET 2.5 MG, 5 MG T3 QL (60 EA per 30 days)

ELIQUIS STARTER PACK ORAL TABLET5 MG T3 QL (60 EA per 30 days)

enoxaparin sodium injection solution 300 mg/3ml T5 PA

enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

T5 PA

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

T5 PA

FRAGMIN SUBCUTANEOUS SOLUTION10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML

T5 PA

heparin lock flush intravenous solution 1 unit/ml, 10 unit/ml, 100 unit/ml

T1


14

Drug Status Notesheparin sod (porcine) in d5w intravenous solution100 unit/ml

T1

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

T1

heparin sodium (porcine) pf injection solution5000 unit/0.5ml

T1

PRADAXA ORAL CAPSULE 150 MG, 75 MG T4 PA; QL (60 EA per 30 days)

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

T1

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG T3 QL (30 EA per 30 days)

xarelto starter pack oral tablet therapy pack 15 & 20 mg


*Anticonvulsants*APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG T4 PA

BANZEL ORAL SUSPENSION 40 MG/ML T4

BANZEL ORAL TABLET 200 MG, 400 MG T4

BRIVIACT ORAL TABLET 25 MG, 50 MG T4

carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg

T1

carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg

T1

carbamazepine oral suspension 100 mg/5ml T1

carbamazepine oral tablet 200 mg T1

carbamazepine oral tablet chewable 100 mg T1

CELONTIN ORAL CAPSULE 300 MG T3

clobazam oral suspension 2.5 mg/ml T2 PA

clobazam oral tablet 10 mg, 20 mg T2 PA

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg T1

clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

T1

DILANTIN ORAL CAPSULE 30 MG T3

divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg

T1

divalproex sodium oral capsule delayed release sprinkle 125 mg

T1


15

Drug Status Notesdivalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg

T1

ethosuximide oral capsule 250 mg T1

ethosuximide oral solution 250 mg/5ml T2

felbamate oral suspension 600 mg/5ml T5

felbamate oral tablet 400 mg, 600 mg T2

FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG T4 PA

gabapentin oral capsule 100 mg, 300 mg, 400 mg T1

gabapentin oral solution 250 mg/5ml T1

gabapentin oral tablet 600 mg, 800 mg T1

lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

T2

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

T1

lamotrigine oral tablet chewable 25 mg, 5 mg T1

levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg

T2

levetiracetam intravenous solution 500 mg/5ml T1

levetiracetam oral solution 100 mg/ml T1

levetiracetam oral tablet 1000 mg T1 QL (90 EA per 30 days)




ONFI ORAL SUSPENSION 2.5 MG/ML NC PA

ONFI ORAL TABLET 10 MG, 20 MG NC PA

oxcarbazepine oral suspension 300 mg/5ml T1

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg

T1

PEGANONE ORAL TABLET 250 MG T4

phenytoin oral suspension 125 mg/5ml T1

phenytoin oral tablet chewable 50 mg T1

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

T1

phenytoin sodium injection solution 50 mg/ml T1

POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG T4


16

Drug Status Notespregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg

T2 PA

pregabalin oral solution 20 mg/ml T2 PA

primidone oral tablet 250 mg, 50 mg T1

tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg

T2

topiramate oral capsule sprinkle 15 mg, 25 mg T1

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg

T1

valproate sodium intravenous solution 100 mg/ml, 500 mg/5ml

T1

valproate sodium oral solution 250 mg/5ml T1

valproic acid oral capsule 250 mg T1

valproic acid oral solution 250 mg/5ml T1

vigabatrin oral packet 500 mg T5 PA

VIMPAT ORAL SOLUTION 10 MG/ML T4 PA

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG T4 PA

zonisamide oral capsule 100 mg T1 QL (180 EA per 30 days)

zonisamide oral capsule 25 mg, 50 mg T1 QL (360 EA per 30 days)

*Antidepressants*amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg


amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg


bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg

T1

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

T1

bupropion hcl oral tablet 100 mg, 75 mg T1

citalopram hydrobromide oral solution 10 mg/5ml

T1

citalopram hydrobromide oral tablet 10 mg, 20 mg

T1

citalopram hydrobromide oral tablet 40 mg T1 QL (30 EA per 30 days)

clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg


desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg



17

Drug Status Notesdesvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 25 mg, 50 mg


doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg


doxepin hcl oral concentrate 10 mg/ml T1 AL (Max 64 Years)

duloxetine hcl oral capsule delayed release particles 20 mg


duloxetine hcl oral capsule delayed release particles 30 mg, 60 mg


EMSAM TRANSDERMAL PATCH 24 HOUR12 MG/24HR, 6 MG/24HR, 9 MG/24HR T4 QL (30 EA per 30 days)

escitalopram oxalate oral solution 5 mg/5ml T1

escitalopram oxalate oral tablet 10 mg, 5 mg T1 QL (45 EA per 30 days)

escitalopram oxalate oral tablet 20 mg T1 QL (30 EA per 30 days)

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG

T4 PA

FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG T4 PA

fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg T1

fluoxetine hcl oral capsule delayed release 90 mg T1 QL (4 EA per 28 days)

fluoxetine hcl oral solution 20 mg/5ml T1

fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg

T1

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg T1 AL (Max 64 Years)

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg

T2

maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg T1

MARPLAN ORAL TABLET 10 MG T4

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg


mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg


nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

T1

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg

T1

nortriptyline hcl oral solution 10 mg/5ml T1

paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, 25 mg, 37.5 mg

T2


18

Drug Status Notesparoxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

T1

PAXIL ORAL SUSPENSION 10 MG/5ML T3 PA

phenelzine sulfate oral tablet 15 mg T1

protriptyline hcl oral tablet 10 mg, 5 mg T1

sertraline hcl oral concentrate 20 mg/ml T1

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg T1

tranylcypromine sulfate oral tablet 10 mg T2

trazodone hcl oral tablet 100 mg, 150 mg, 50 mg T1

trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg

T1

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG T4 PA

venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg

T1

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

T1

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG T4 PA

VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG T4 PA

*Antidiabetics*acarbose oral tablet 100 mg, 25 mg, 50 mg T1

ALOGLIPTIN BENZOATE ORAL TABLET12.5 MG, 25 MG, 6.25 MG T4 ST; QL (30 EA per 30 days)

APIDRA INJECTION SOLUTION 100 UNIT/ML T4 PA

APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T4 PA

AVANDIA ORAL TABLET 2 MG T4

BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T1 QL (30 ML per 30 days)

BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MCG/0.04ML

T4 PA; QL (2.4 ML per 28 days)

BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 5 MCG/0.02ML T4 PA; QL (1.2 ML per 28 days)

chlorpropamide oral tablet 100 mg, 250 mg T1

CYCLOSET ORAL TABLET 0.8 MG T4


19

Drug Status NotesFIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T3

FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML T3

glimepiride oral tablet 1 mg, 2 mg, 4 mg T1

glipizide er oral tablet extended release 24 hour10 mg, 2.5 mg, 5 mg


glipizide oral tablet 10 mg, 5 mg T1

glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

T1

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG T3 QL (2 EA per 30 days)

GLUCAGON EMERGENCY INJECTION KIT 1 MG T4 QL (2 EA per 30 days)

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

T1

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg T1

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

T1

goodsense glucose oral tablet chewable 4-6 gm-mg

T1

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML T3

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML

T3

INVOKANA ORAL TABLET 100 MG, 300 MG T3 QL (30 EA per 30 days)

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG T3 QL (60 EA per 30 days)

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG


JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG T3 QL (30 EA per 30 days)

JARDIANCE ORAL TABLET 10 MG, 25 MG T3 QL (30 EA per 30 days)

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T3

LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML T3


20

Drug Status NotesLEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T3

LEVEMIR SUBCUTANEOUS SOLUTION100 UNIT/ML T3

metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg

T1

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg

T1

miglitol oral tablet 25 mg T2

nateglinide oral tablet 120 mg, 60 mg T1

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML T3

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML T3

NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML T3

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML T3

NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML T3

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T3

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

T3

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML T3

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML T3

NOVOLOG SUBCUTANEOUS SOLUTION100 UNIT/ML T3

ONGLYZA ORAL TABLET 2.5 MG, 5 MG T4 ST; QL (30 EA per 30 days)

OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML

T3 QL (1.5 ML per 28 days)

OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML T3 QL (3 ML per 28 days)

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg T1 QL (30 EA per 30 days)

pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg

T2


21

Drug Status Notespioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg

T2

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg T1

SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML

T4 PA

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML

T4 PA

tolazamide oral tablet 250 mg, 500 mg T1

tolbutamide oral tablet 500 mg T1

TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

T3

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML T3

TRADJENTA ORAL TABLET 5 MG T4 ST; QL (30 EA per 30 days)

TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

T3

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML

T3 QL (2 ML per 28 days)

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML T3 QL (9 ML per 30 days)

*Antidiarrheals*diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml

T1

diphenoxylate-atropine oral tablet 2.5-0.025 mg T1

loperamide hcl oral capsule 2 mg T1

loperamide hcl oral liquid 1 mg/5ml T1

loperamide hcl oral tablet 2 mg T1

MOTOFEN ORAL TABLET 1-0.025 MG T4 PA

*Antidotes And Specific Antagonists*acetylcysteine intravenous solution 200 mg/ml T1

deferoxamine mesylate injection solution reconstituted 2 gm

T1

physostigmine salicylate injection solution 1 mg/ml

T1

RADIOGARDASE ORAL CAPSULE 0.5 GM T4 PA


22

Drug Status Notes

*Antidotes*acetylcysteine intravenous solution 200 mg/ml T1

CHEMET ORAL CAPSULE 100 MG T4

deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg

T2 PA

deferoxamine mesylate injection solution reconstituted 2 gm

T1

FERRIPROX ORAL TABLET 500 MG T5 PA

JADENU ORAL TABLET 180 MG, 360 MG, 90 MG T5 PA

naloxone hcl injection solution 0.4 mg/ml T1 QL (2 ML per 90 days)

naloxone hcl injection solution prefilled syringe 2 mg/2ml


naltrexone hcl oral tablet 50 mg T1

NARCAN NASAL LIQUID 4 MG/0.1ML T3

pentetate calcium trisodium combination solution200 mg/ml

T1

pentetate zinc trisodium combination solution 200 mg/ml

T1

physostigmine salicylate injection solution 1 mg/ml

T1

RADIOGARDASE ORAL CAPSULE 0.5 GM T4 PA

VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG T5 PA

*Antiemetics*AKYNZEO ORAL CAPSULE 300-0.5 MG T5 PA; QL (2 EA per 28 days)

ANZEMET ORAL TABLET 100 MG, 50 MG T4

aprepitant oral capsule 125 mg, 80 mg T2

CESAMET ORAL CAPSULE 1 MG T4 PA

DIMENHYDRINATE INJECTION SOLUTION 50 MG/ML T4

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg T2

granisetron hcl oral tablet 1 mg T2 QL (10 EA per 30 days)

meclizine hcl oral tablet 12.5 mg, 25 mg T1

ondansetron hcl injection solution 4 mg/2ml T2

ondansetron hcl oral solution 4 mg/5ml T1 QL (150 ML per 30 days)

ondansetron hcl oral tablet 24 mg T1 QL (5 EA per 30 days)

ondansetron hcl oral tablet 4 mg, 8 mg T1 QL (15 EA per 30 days)


23

Drug Status Notesondansetron hcl-dextrose intravenous solution 8-5 mg/50ml-%

NC

ondansetron oral tablet dispersible 4 mg, 8 mg T1 QL (10 EA per 30 days)

scopolamine transdermal patch 72 hour 1 mg/3days

T2

trimethobenzamide hcl oral capsule 300 mg T1

VARUBI ORAL TABLET 90 MG T5 QL (4 EA per 28 days)

*Antifungals*CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG NC

caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg

NC

CRESEMBA ORAL CAPSULE 186 MG T5 PA

fluconazole in dextrose intravenous solution 200 mg/100ml, 400 mg/200ml

NC

fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml


fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg


flucytosine oral capsule 250 mg, 500 mg T5 PA

griseofulvin microsize oral suspension 125 mg/5ml

T2

griseofulvin microsize oral tablet 500 mg T2

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

T2

itraconazole oral capsule 100 mg T5 PA

ketoconazole oral tablet 200 mg T1

NOXAFIL ORAL SUSPENSION 40 MG/ML T4 PA

NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG T4 PA

nystatin oral tablet 500000 unit T1

terbinafine hcl oral tablet 250 mg T1

voriconazole oral tablet 200 mg, 50 mg T5 PA

*Antihistamines*allergy relief oral tablet 5 mg T1 QL (30 EA per 30 days)

carbinoxamine maleate oral tablet 4 mg T1 AL (Max 64 Years)

cetirizine hcl oral tablet 10 mg, 5 mg T1 QL (30 EA per 30 days)

cvs allergy relief oral tablet 5 mg T1 QL (30 EA per 30 days)

cyproheptadine hcl oral syrup 2 mg/5ml T1 AL (Max 64 Years)


24

Drug Status Notescyproheptadine hcl oral tablet 4 mg T1 AL (Max 64 Years)

desloratadine oral tablet 5 mg T1

diphenhydramine hcl injection solution 50 mg/ml T1 AL (Max 64 Years)

diphenhydramine hcl oral elixir 12.5 mg/5ml T1 AL (Max 64 Years)

fexofenadine hcl oral tablet 180 mg T1 QL (30 EA per 30 days)

fexofenadine hcl oral tablet 60 mg T1 QL (60 EA per 30 days)

kp diphenhydramine hcl oral capsule 50 mg T1 AL (Max 64 Years)

levocetirizine dihydrochloride tablet 5 mg oral (otc) 5 mg


loratadine childrens oral syrup 5 mg/5ml T1QL (300 ML per 30 days); AL (Max 12 Years)

loratadine oral tablet 10 mg T1 QL (30 EA per 30 days)

promethazine hcl injection solution 25 mg/ml, 50 mg/ml


promethazine hcl oral syrup 6.25 mg/5ml T1 AL (Max 64 Years)

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg


promethegan rectal suppository 12.5 mg, 25 mg, 50 mg

T1QL (12 EA per 30 days); AL (Max 64 Years)

*Antihyperlipidemics*atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg


cholestyramine oral packet 4 gm T1 QL (60 EA per 30 days)

cholestyramine oral powder 4 gm/dose T1 QL (378 GM per 30 days)

colesevelam hcl oral packet 3.75 gm T2

colesevelam hcl oral tablet 625 mg T2

colestipol hcl oral granules 5 gm T1

colestipol hcl oral tablet 1 gm T1

ezetimibe oral tablet 10 mg T1 QL (30 EA per 30 days)

ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg


fenofibrate micronized oral capsule 134 mg, 200 mg, 43 mg, 67 mg

T1

fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg

T1

fenofibric acid oral capsule delayed release 135 mg, 45 mg

T2

fluvastatin sodium oral capsule 20 mg, 40 mg T2

gemfibrozil oral tablet 600 mg T1


25

Drug Status NotesLIVALO ORAL TABLET 1 MG, 2 MG, 4 MG T3 ST; QL (30 EA per 30 days)

lovastatin oral tablet 10 mg, 20 mg, 40 mg T1

niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg

T2

niacor oral tablet 500 mg T1

omega-3-acid ethyl esters oral capsule 1 gm T2 QL (120 EA per 30 days)

pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

T1

prevalite oral packet 4 gm T1 QL (60 EA per 30 days)

prevalite oral powder 4 gm/dose T1 QL (239.4 GM per 30 days)

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg


simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg T1

simvastatin oral tablet 80 mg T1 QL (30 EA per 30 days)

TRIGLIDE ORAL TABLET 160 MG T1 PA

VASCEPA ORAL CAPSULE 1 GM T4 ST; QL (120 EA per 30 days)

WELCHOL ORAL PACKET 3.75 GM NC PA

WELCHOL ORAL TABLET 625 MG NC PA

*Antihypertensives*aliskiren fumarate oral tablet 150 mg, 300 mg T2

amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

T1

amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg

T1

amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg

T2

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

T1

benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

T1

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

T1

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

T1

candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg


candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg



26

Drug Status Notescaptopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg

T1

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

T1

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg T1

CORLOPAM INTRAVENOUS SOLUTION10 MG/ML, 20 MG/2ML T5

doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg


EDARBI ORAL TABLET 40 MG, 80 MG T4 PA

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

T1

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

T1

eplerenone oral tablet 25 mg, 50 mg T2

EPROSARTAN MESYLATE ORAL TABLET 600 MG T3 QL (30 EA per 30 days)

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg T1

fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg

T1

guanfacine hcl oral tablet 1 mg, 2 mg T1

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

T1

irbesartan oral tablet 150 mg, 300 mg, 75 mg T1 QL (30 EA per 30 days)

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg

T1

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

T1

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

T1

losartan potassium oral tablet 100 mg, 25 mg, 50 mg


losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

T1

methyldopa oral tablet 250 mg, 500 mg T1

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg

T1

minoxidil oral tablet 10 mg, 2.5 mg T1

moexipril hcl oral tablet 15 mg, 7.5 mg T1

nadolol-bendroflumethiazide oral tablet 40-5 mg T1


27

Drug Status Notesolmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg


olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg


perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg

T1

phenoxybenzamine hcl oral capsule 10 mg T2 PA

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg T1

propranolol-hctz oral tablet 40-25 mg, 80-25 mg T1

quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

T1

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

T1

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

T1

TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG T3 QL (30 EA per 30 days)

TEKTURNA ORAL TABLET 150 MG, 300 MG NC QL (30 EA per 30 days)

telmisartan oral tablet 20 mg, 40 mg, 80 mg T1 QL (30 EA per 30 days)

telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg


terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg


trandolapril oral tablet 1 mg, 2 mg, 4 mg T1 QL (30 EA per 30 days)

trandolapril-verapamil hcl er oral tablet extended release 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg


valsartan oral tablet 160 mg, 40 mg, 80 mg T1 QL (60 EA per 30 days)

valsartan oral tablet 320 mg T1 QL (30 EA per 30 days)

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

T1

*Anti-Infective Agents - Misc.*ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML T5 PA

ALINIA ORAL TABLET 500 MG T5 PA

atovaquone oral suspension 750 mg/5ml T2

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

T1


28

Drug Status Notesclindamycin palmitate hcl oral solution reconstituted 75 mg/5ml

T1

CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED 500 MG NC

dapsone oral tablet 100 mg, 25 mg T1

daptomycin intravenous solution reconstituted350 mg, 500 mg

NC

DORIBAX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG, 500 MG NC

doripenem intravenous solution reconstituted 250 mg, 500 mg

NC

imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg

T2

KETEK ORAL TABLET 300 MG, 400 MG T4

linezolid intravenous solution 600 mg/300ml T2

linezolid oral suspension reconstituted 100 mg/5ml


linezolid oral tablet 600 mg T2 QL (28 EA per 14 days)

meropenem intravenous solution reconstituted 1 gm, 500 mg

NC

meropenem-sodium chloride intravenous solution reconstituted 1 gm/50ml, 500-0.9 mg-%

NC

MERREM INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 500 MG NC

metronidazole oral capsule 375 mg T1

metronidazole oral tablet 250 mg, 500 mg T1

PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG T4

SIVEXTRO ORAL TABLET 200 MG T4 PA

sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml

T1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

T1

tinidazole oral tablet 250 mg, 500 mg T2

trimethoprim oral tablet 100 mg T1

XIFAXAN ORAL TABLET 200 MG T4 QL (9 EA per 30 days)

XIFAXAN ORAL TABLET 550 MG T4 QL (60 EA per 30 days)

*Antimalarials*atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg



29

Drug Status Noteschloroquine phosphate oral tablet 250 mg, 500 mg

T1

COARTEM ORAL TABLET 20-120 MG T4

DARAPRIM ORAL TABLET 25 MG T5 PA

hydroxychloroquine sulfate oral tablet 200 mg T1

mefloquine hcl oral tablet 250 mg T1

primaquine phosphate oral tablet 26.3 mg T1

quinine sulfate oral capsule 324 mg T1

*Antimyasthenic Agents*guanidine hcl oral tablet 125 mg T1

MESTINON ORAL SYRUP 60 MG/5ML NC PA

MESTINON ORAL SYRUP 60 MG/5ML T3 PA

pyridostigmine bromide er oral tablet extended release 180 mg

T2

pyridostigmine bromide oral solution 60 mg/5ml T2 PA

pyridostigmine bromide oral tablet 60 mg T1

*Antimyasthenic/Cholinergic Agents*guanidine hcl oral tablet 125 mg T1

MESTINON ORAL SYRUP 60 MG/5ML T3 PA

pyridostigmine bromide er oral tablet extended release 180 mg

T2

pyridostigmine bromide oral tablet 60 mg T1

*Antimycobacterial Agents*CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM T4

CYCLOSERINE ORAL CAPSULE 250 MG T4 PA

ethambutol hcl oral tablet 100 mg, 400 mg T1

isoniazid oral syrup 50 mg/5ml T1

isoniazid oral tablet 100 mg, 300 mg T1

MYAMBUTOL ORAL TABLET 100 MG, 400 MG T4

PASER ORAL PACKET 4 GM T4

PRIFTIN ORAL TABLET 150 MG T4

pyrazinamide oral tablet 500 mg T2

rifabutin oral capsule 150 mg T2 PA

RIFAMATE ORAL CAPSULE 150-300 MG T4

rifampin oral capsule 150 mg, 300 mg T1


30

Drug Status NotesRIFATER ORAL TABLET 50-120-300 MG T4

*Antineoplastics And Adjunctive Therapies*abiraterone acetate oral tablet 250 mg T5 PA

ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 UNIT/0.5ML T5 PA

adriamycin intravenous solution reconstituted 10 mg

NC

ADRIAMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG NC

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG T5 PA

anastrozole oral tablet 1 mg T1

ARZERRA INTRAVENOUS CONCENTRATE 100 MG/5ML, 1000 MG/50ML

NC

AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML NC

bexarotene oral capsule 75 mg T5 PA

bicalutamide oral tablet 50 mg T1

BOSULIF ORAL TABLET 100 MG, 500 MG T5 PA

CAMPTOSAR INTRAVENOUS SOLUTION100 MG/5ML, 300 MG/15ML, 40 MG/2ML NC

capecitabine oral tablet 150 mg, 500 mg T5 PA

CAPRELSA ORAL TABLET 100 MG, 300 MG T5 PA

COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG T5 PA

COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG T5 PA

COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG T5 PA

cyclophosphamide injection solution reconstituted1 gm, 2 gm, 500 mg

NC

cyclophosphamide oral capsule 25 mg, 50 mg T2

cytarabine (pf) injection solution 100 mg/ml, 20 mg/ml

NC

cytarabine injection solution 20 mg/ml NC

DARZALEX INTRAVENOUS SOLUTION100 MG/5ML, 400 MG/20ML NC


31

Drug Status Notesdaunorubicin hcl intravenous solution 20 mg/4ml, 50 mg/10ml

NC

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML T4

dexrazoxane hcl intravenous solution reconstituted 250 mg, 500 mg

NC

doxorubicin hcl intravenous solution reconstituted 10 mg, 50 mg

NC

ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG T5 PA

ELOXATIN INTRAVENOUS SOLUTION100 MG/20ML, 50 MG/10ML NC

ELZONRIS INTRAVENOUS SOLUTION1000 MCG/ML NC

EMCYT ORAL CAPSULE 140 MG T4

ERIVEDGE ORAL CAPSULE 150 MG T5 PA

ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG NC

etoposide intravenous solution 100 mg/5ml T1

etoposide intravenous solution 500 mg/25ml NC

exemestane oral tablet 25 mg T2

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG T5 PA

FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML T5 PA

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG, 80 MG T5 PA

fluorouracil intravenous solution 1 gm/20ml, 2.5 gm/50ml, 5 gm/100ml, 500 mg/10ml

NC

flutamide oral capsule 125 mg T2

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG T5 PA

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG T5 PA

hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml

T5 PA

hydroxyurea oral capsule 500 mg T1

ICLUSIG ORAL TABLET 15 MG, 45 MG T5 PA

imatinib mesylate oral tablet 100 mg, 400 mg T5 PA

IMBRUVICA ORAL CAPSULE 140 MG T5 PA


32

Drug Status NotesINLYTA ORAL TABLET 1 MG, 5 MG T5 PA

INTRON A INJECTION SOLUTION 6000000 UNIT/ML T5 PA

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

T5 PA

irinotecan hcl intravenous solution 100 mg/5ml, 40 mg/2ml, 500 mg/25ml

NC

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG T5 PA

KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 60 MG T5 PA

letrozole oral tablet 2.5 mg T1QL (30 EA per 30 days); AL (Min 18 Years)

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

T1

LEUKERAN ORAL TABLET 2 MG T5 PA

leuprolide acetate injection kit 1 mg/0.2ml T5 PA

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG T5 PA

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG, 22.5 MG T5 PA

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30 MG T5 PA

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45 MG T5 PA

LYSODREN ORAL TABLET 500 MG T3 PA

MATULANE ORAL CAPSULE 50 MG T5 PA

megestrol acetate oral suspension 400 mg/10ml T1

megestrol acetate oral tablet 20 mg, 40 mg T1

MEKINIST ORAL TABLET 0.5 MG, 2 MG T5 PA

mercaptopurine oral tablet 50 mg T1

MESNEX ORAL TABLET 400 MG T5 PA

methotrexate oral tablet 2.5 mg T1

methotrexate sodium (pf) injection solution 50 mg/2ml

T1

methotrexate sodium injection solution 50 mg/2ml T1

methotrexate sodium injection solution reconstituted 1 gm

T1


33

Drug Status Notesmitomycin intravenous solution reconstituted 20 mg, 40 mg, 5 mg

NC

MYLERAN ORAL TABLET 2 MG T5 PA

NEXAVAR ORAL TABLET 200 MG T5 PA

ODOMZO ORAL CAPSULE 200 MG T5 PA

OPDIVO INTRAVENOUS SOLUTION 100 MG/10ML, 240 MG/24ML, 40 MG/4ML NC

oxaliplatin intravenous solution 100 mg/20ml, 50 mg/10ml

NC

paclitaxel intravenous concentrate 100 mg/16.7ml, 150 mg/25ml, 30 mg/5ml, 300 mg/50ml

NC

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG T5 PA

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG T5 PA

STIVARGA ORAL TABLET 40 MG T5 PA

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG T5 PA

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG T5 PA

TABLOID ORAL TABLET 40 MG T5 PA

TAFINLAR ORAL CAPSULE 50 MG, 75 MG T5 PA

tamoxifen citrate oral tablet 10 mg, 20 mg T6

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG T5 PA

TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG T5 PA

TEPADINA INJECTION SOLUTION RECONSTITUTED 100 MG, 15 MG NC

thiotepa injection solution reconstituted 15 mg NC

topotecan hcl intravenous solution 4 mg/4ml T5

toremifene citrate oral tablet 60 mg T2 PA

TOTECT INTRAVENOUS SOLUTION RECONSTITUTED 500 MG NC

TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG

T5 PA

tretinoin oral capsule 10 mg T5 PA


34

Drug Status NotesTREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG T4 PA

TYKERB ORAL TABLET 250 MG T5 PA

valrubicin intravesical solution 40 mg/ml T5 PA

VALSTAR INTRAVESICAL SOLUTION 40 MG/ML NC PA

VANTAS SUBCUTANEOUS KIT 50 MG T5 PA

VOTRIENT ORAL TABLET 200 MG T5 PA

XALKORI ORAL CAPSULE 200 MG, 250 MG T5 PA

ZINECARD INTRAVENOUS SOLUTION RECONSTITUTED 250 MG, 500 MG NC

ZOLADEX SUBCUTANEOUS IMPLANT10.8 MG, 3.6 MG T4 PA

ZOLINZA ORAL CAPSULE 100 MG T5 PA

ZYKADIA ORAL CAPSULE 150 MG T5 PA

ZYTIGA ORAL TABLET 250 MG NC PA

ZYTIGA ORAL TABLET 500 MG T5 PA

*Antiparkinson Agents*amantadine hcl oral capsule 100 mg T1

amantadine hcl oral syrup 50 mg/5ml T1

amantadine hcl oral tablet 100 mg T1

benztropine mesylate injection solution 1 mg/ml T2

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg

T1

bromocriptine mesylate oral capsule 5 mg T2

bromocriptine mesylate oral tablet 2.5 mg T1

carbidopa oral tablet 25 mg T2

carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

T1

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

T1

carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg, 25-250 mg

T1

entacapone oral tablet 200 mg T2

NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR

T4 PA


35

Drug Status Notespramipexole dihydrochloride er oral tablet extended release 24 hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

T2 ST; QL (30 EA per 30 days)

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

T1

rasagiline mesylate oral tablet 0.5 mg, 1 mg T2

ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 mg, 4 mg, 6 mg, 8 mg


ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

T1

selegiline hcl oral capsule 5 mg T1

selegiline hcl oral tablet 5 mg T1

tolcapone oral tablet 100 mg T5 PA

trihexyphenidyl hcl oral elixir 0.4 mg/ml T1

trihexyphenidyl hcl oral tablet 2 mg, 5 mg T1

*Antipsychotics/Antimanic Agents*ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG T5

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG

T5

aripiprazole oral solution 1 mg/ml T2 PA

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg


aripiprazole oral tablet dispersible 10 mg, 15 mg T2 PA

chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml

NC

chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

T1

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

T1

clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg

T2

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG T5 PA

fluphenazine decanoate injection solution 25 mg/ml

T2

FLUPHENAZINE HCL INJECTION SOLUTION 2.5 MG/ML T4

FLUPHENAZINE HCL ORAL CONCENTRATE 5 MG/ML T4


36

Drug Status Notesfluphenazine hcl oral elixir 2.5 mg/5ml T1

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

T1

GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG T3

haloperidol decanoate intramuscular solution100 mg/ml, 50 mg/ml

T1

haloperidol lactate injection solution 5 mg/ml T1

haloperidol lactate oral concentrate 2 mg/ml T1

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

T1

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG T4 PA

lithium carbonate er oral tablet extended release300 mg, 450 mg

T1

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

T1

lithium carbonate oral tablet 300 mg T1

lithium oral solution 8 meq/5ml T1

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

T1

olanzapine intramuscular solution reconstituted10 mg

T2

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

T1

olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg

T2

paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 6 mg, 9 mg

T5 PA

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg T1

prochlorperazine maleate oral tablet 10 mg, 5 mg T1

prochlorperazine rectal suppository 25 mg T1

quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg, 300 mg, 400 mg, 50 mg


quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

T1

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG T4 PA


37

Drug Status NotesRISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG

NC

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG, 37.5 MG, 50 MG

T3

risperidone m-tab oral tablet dispersible 0.5 mg T2

risperidone oral solution 1 mg/ml T2

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

T1

risperidone oral tablet dispersible 0.25 mg, 1 mg, 2 mg, 3 mg, 4 mg

T2

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG T4 PA

thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

T2

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg T1

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg

T1

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

T1

*Antiseptics & Disinfectants*CHLORHEXIDINE GLUCONATE SOLUTION 20 % T4

*Antivirals*abacavir sulfate oral solution 20 mg/ml T5 QL (900 ML per 30 days)

abacavir sulfate oral tablet 300 mg T2 QL (60 EA per 30 days)

abacavir sulfate-lamivudine oral tablet 600-300 mg


abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg


acyclovir oral capsule 200 mg T1

acyclovir oral suspension 200 mg/5ml T1

acyclovir oral tablet 400 mg, 800 mg T1

adefovir dipivoxil oral tablet 10 mg T5 PA

APTIVUS ORAL CAPSULE 250 MG T5 QL (120 EA per 30 days)

APTIVUS ORAL SOLUTION 100 MG/ML T5 QL (300 ML per 30 days)

atazanavir sulfate oral capsule 150 mg, 200 mg T5 QL (60 EA per 30 days)

atazanavir sulfate oral capsule 300 mg T5 QL (30 EA per 30 days)

ATRIPLA ORAL TABLET 600-200-300 MG T5 QL (30 EA per 30 days)


38

Drug Status NotesBARACLUDE ORAL SOLUTION 0.05 MG/ML T5 PA

COMPLERA ORAL TABLET 200-25-300 MG T5 QL (30 EA per 30 days)

CRIXIVAN ORAL CAPSULE 200 MG T5 QL (360 EA per 30 days)

CRIXIVAN ORAL CAPSULE 400 MG T5 QL (180 EA per 30 days)

didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg

T2

EDURANT ORAL TABLET 25 MG T5 QL (30 EA per 30 days)

efavirenz oral capsule 200 mg T5 QL (90 EA per 30 days)

efavirenz oral capsule 50 mg T5 QL (360 EA per 30 days)

efavirenz oral tablet 600 mg T5 QL (30 EA per 30 days)

EMTRIVA ORAL CAPSULE 200 MG T5 QL (30 EA per 30 days)

EMTRIVA ORAL SOLUTION 10 MG/ML T5

entecavir oral tablet 0.5 mg, 1 mg T5 PA

EPIVIR HBV ORAL SOLUTION 5 MG/ML T4 QL (1800 ML per 30 days)

EVOTAZ ORAL TABLET 300-150 MG T5 QL (30 EA per 30 days)

famciclovir oral tablet 125 mg, 250 mg, 500 mg T2 QL (90 EA per 30 days)

fosamprenavir calcium oral tablet 700 mg T5 QL (120 EA per 30 days)

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG T5 QL (60 EA per 30 days)

INTELENCE ORAL TABLET 100 MG T5 QL (120 EA per 30 days)



INVIRASE ORAL TABLET 500 MG T5 QL (120 EA per 30 days)

ISENTRESS ORAL TABLET 400 MG T5 QL (60 EA per 30 days)

ISENTRESS ORAL TABLET CHEWABLE100 MG, 25 MG T5 QL (60 EA per 30 days)

KALETRA ORAL TABLET 100-25 MG T5 QL (360 EA per 30 days)

KALETRA ORAL TABLET 200-50 MG T5 QL (180 EA per 30 days)

lamivudine oral solution 10 mg/ml T2 QL (900 ML per 30 days)

lamivudine oral tablet 100 mg T2 QL (90 EA per 30 days)

lamivudine oral tablet 150 mg, 300 mg T2 QL (60 EA per 30 days)

lamivudine-zidovudine oral tablet 150-300 mg T5 QL (60 EA per 30 days)

LEXIVA ORAL SUSPENSION 50 MG/ML T5 QL (180 ML per 30 days)

lopinavir-ritonavir oral solution 400-100 mg/5ml T5 QL (450 ML per 30 days)

nevirapine er oral tablet extended release 24 hour100 mg

T1


39

Drug Status Notesnevirapine er oral tablet extended release 24 hour400 mg


nevirapine oral suspension 50 mg/5ml T1

nevirapine oral tablet 200 mg T1 QL (60 EA per 30 days)

NORVIR ORAL SOLUTION 80 MG/ML T5 QL (450 ML per 30 days)

oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg


oseltamivir phosphate oral suspension reconstituted 6 mg/ml


PEGASYS SUBCUTANEOUS SOLUTION180 MCG/ML T5 PA

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML T5 PA

PREZCOBIX ORAL TABLET 800-150 MG T5 QL (30 EA per 30 days)

PREZISTA ORAL SUSPENSION 100 MG/ML T5 QL (480 ML per 30 days)

PREZISTA ORAL TABLET 150 MG T5 QL (240 EA per 30 days)




REBETOL ORAL SOLUTION 40 MG/ML T5 PA

RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER


RESCRIPTOR ORAL TABLET 200 MG T5 QL (180 EA per 30 days)

RIBASPHERE ORAL TABLET 200 MG T5 PA

RIBASPHERE RIBAPAK ORAL TABLET400 MG, 600 MG T5 PA

RIBASPHERE RIBAPAK ORAL TABLET THERAPY PACK 400 & 600 MG T5 PA

ribavirin oral capsule 200 mg T5 PA

rimantadine hcl oral tablet 100 mg T1

ritonavir oral tablet 100 mg T5 QL (360 EA per 30 days)

SELZENTRY ORAL TABLET 150 MG, 300 MG T5 QL (120 EA per 30 days)

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg


STRIBILD ORAL TABLET 150-150-200-300 MG T5 QL (30 EA per 30 days)

tenofovir disoproxil fumarate oral tablet 300 mg T5 QL (30 EA per 30 days)


40

Drug Status NotesTIVICAY ORAL TABLET 50 MG T5 QL (30 EA per 30 days)

TRIUMEQ ORAL TABLET 600-50-300 MG T5 QL (30 EA per 30 days)

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG T5 QL (30 EA per 30 days)

TYZEKA ORAL TABLET 600 MG T5

valacyclovir hcl oral tablet 1 gm, 500 mg T1

valganciclovir hcl oral solution reconstituted 50 mg/ml

T5 PA

valganciclovir hcl oral tablet 450 mg T5 PA

VEMLIDY ORAL TABLET 25 MG T5

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM T5 QL (603 ML per 30 days)

VIRACEPT ORAL TABLET 250 MG T5 QL (300 EA per 30 days)

VIRACEPT ORAL TABLET 625 MG T5 QL (120 EA per 30 days)

VIRAMUNE ORAL SUSPENSION 50 MG/5ML NC QL (1200 ML per 30 days)

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG T5 QL (30 EA per 30 days)

zidovudine oral capsule 100 mg T1 QL (180 EA per 30 days)

zidovudine oral syrup 50 mg/5ml T1 QL (1800 ML per 30 days)

zidovudine oral tablet 300 mg T1 QL (60 EA per 30 days)

*Anti-Von Willebrand Factor Agents***CABLIVI INJECTION KIT 11 MG NC

*Assorted Classes*alprostadil injection solution 500 mcg/ml T1

AMPHADASE INJECTION SOLUTION 150 UNIT/ML NC

AZASAN ORAL TABLET 100 MG, 75 MG T4 PA

azathioprine oral tablet 50 mg T1

BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 120 MG, 400 MG NC

BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML NC

BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML NC

CUPRIMINE ORAL CAPSULE 250 MG T5 PA

cyclosporine modified oral capsule 100 mg T2

cyclosporine modified oral capsule 25 mg T1


41

Drug Status Notescyclosporine modified oral solution 100 mg/ml T2

cyclosporine oral capsule 100 mg, 25 mg T2

DEPEN TITRATABS ORAL TABLET 250 MG T5

GAMIFANT INTRAVENOUS SOLUTION 10 MG/2ML, 50 MG/10ML NC

gengraf oral solution 100 mg/ml T2

HYLENEX INJECTION SOLUTION 150 UNIT/ML NC

mycophenolate mofetil oral capsule 250 mg T1

mycophenolate mofetil oral suspension reconstituted 200 mg/ml

T5

mycophenolate mofetil oral tablet 500 mg T1

mycophenolate sodium oral tablet delayed release180 mg, 360 mg

T2 PA

RAPAMUNE ORAL SOLUTION 1 MG/ML T5 PA

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG T5 PA

SANDIMMUNE ORAL SOLUTION 100 MG/ML T5 PA

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg T5 PA

sodium polystyrene sulfonate oral powder T1

sps oral suspension 15 gm/60ml T1

sterile water for irrigation irrigation solution T1

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg T1

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG T5 PA

trientine hcl oral capsule 250 mg T5

VITRASE INJECTION SOLUTION 200 UNIT/ML NC

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG T5 PA

*Beta Blockers*acebutolol hcl oral capsule 200 mg, 400 mg T1

atenolol oral tablet 100 mg, 25 mg, 50 mg T1

betaxolol hcl oral tablet 10 mg, 20 mg T1

bisoprolol fumarate oral tablet 10 mg, 5 mg T1

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG T4


42

Drug Status Notescarvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

T1

carvedilol phosphate er oral capsule extended release 24 hour 10 mg, 20 mg, 40 mg, 80 mg

T2 ST

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg T1

metoprolol succinate er oral tablet extended release 24 hour 100 mg, 25 mg, 50 mg


metoprolol succinate er oral tablet extended release 24 hour 200 mg


metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

T1

nadolol oral tablet 20 mg, 40 mg, 80 mg T1

pindolol oral tablet 10 mg, 5 mg T1

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

T1

propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml

T1

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

T1

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg T1

sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg

T1

timolol maleate oral tablet 10 mg, 20 mg, 5 mg T1

*Calcium Channel Blockers*afeditab cr oral tablet extended release 24 hour30 mg


amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg


cartia xt oral capsule extended release 24 hour120 mg, 180 mg, 240 mg, 300 mg


diltiazem hcl er beads oral capsule extended release 24 hour 420 mg


diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg


diltiazem hcl er oral capsule extended release 24 hour 120 mg


diltiazem hcl er oral capsule extended release 24 hour 180 mg

T1

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

T1


43

Drug Status Notesdilt-xr oral capsule extended release 24 hour 240 mg

T1

felodipine er oral tablet extended release 24 hour10 mg, 2.5 mg, 5 mg


isradipine oral capsule 2.5 mg, 5 mg T1

nicardipine hcl oral capsule 20 mg, 30 mg T1

nifedipine er oral tablet extended release 24 hour60 mg


nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg


nifedipine oral capsule 10 mg, 20 mg T1

nimodipine oral capsule 30 mg T2

nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

T2

taztia xt oral capsule extended release 24 hour120 mg, 180 mg, 240 mg, 300 mg, 360 mg


verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg


verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg


verapamil hcl oral tablet 120 mg, 40 mg, 80 mg T1

*Cardiotonics*digoxin oral solution 0.05 mg/ml T1

digoxin oral tablet 125 mcg, 250 mcg T1

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virginia premier individual plans comprehensive formulary ... · 9/10/2019 · diethylpropion hcl...

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