2018 Formulary Drug List
For Small Groups and Large Groups
GlobalHealth, Inc. 701 NE 10th Street, Suite 300 Oklahoma City, OK 73104-5403 MGDF18 Lists Updated 11/2017 www.GlobalHealth.com/commercial HELPFUL NUMBERS
Plan Issuer: Medication Prior Authorizations: GlobalHealth, Inc. gh[email protected] PO Box 2393 918.878.7361 Oklahoma City, OK 73101-2393 Mail Claims to: GlobalHealth Customer Care, Language Magellan Rx Management, LLC Assistance, and Disease Management: PO Box 85042 [email protected] Richmond, VA 23261-5042 405.280.2964 (local) 1.877.280.2964 (toll-free) Mail Order Pharmacy: 711 (TTY) Magellan Rx Management, LLC Monday – Friday, 9 a.m. – 5 p.m. Central 1.800.424.1789 (toll-free) www.GlobalHealth.com/commercial 711 (TTY) P.O. Box 620968 Behavioral Health and Substance Use: Orlando, FL 32862 [email protected] 405.280.2964 (local) 24/7 Nurse Help Line: 1.877.280.2964 (toll-free) Information Line 711 (TTY) 1.877.280.2993 (toll-free) Monday – Friday, 9 a.m. – 5 p.m. Central www.GlobalHealth.com/commercial GlobalHealth Compliance Officer: 1.877.280.5852 (toll-free) Pharmacy Benefits Manager: 405.280.5852 Magellan Rx Management, LLC [email protected] Customer Service 1.800.424.1789 (toll-free) GlobalHealth Privacy Officer: 711 (TTY) 405.280.5524 [email protected]
i IMPORTANT INFORMATION This formulary applies to Members who enrolled through an employer in any of the following Plans: Platinum Plan 1 without Dental Gold Plan 1 with Dental Gold Plan 1 without Dental Standard Plan
Member Materials Your comprehensive Member handbook has three booklets. Each one has a different purpose. These documents are important legal documents. Keep them in a safe place. Booklet Purpose Member Handbook Tells you about your benefits. – the name of your o What benefits are covered and how much you will pay. Member Handbook o How they are covered (including limitations and exclusions). will depend on o How to use them. which Plan you enrolled in Physicians and Lists our Network of doctors, Facilities, and pharmacies. Health Providers Tells you if a Facility is preferred or not. Directory (“Provider Directory”) Formulary Drug Lists drugs we cover. List for Small Tells you what Tier a drug is in. Groups and Large Tells you if there are any rules to getting a drug. Groups (“Drug Formulary” or “Formulary”)
Member materials are available on our website. Contact Customer Care for printed copies at no charge. But, be aware that the most current Drug Formulary and Provider Directory lists are on the website.
When this document says “we”, “us”, or “our”, it means GlobalHealth, Inc. Words or phrases that start with a capital letter are defined in the Member Handbook glossary.
For specific questions about your coverage, please call the phone number printed on your Member ID card.
ii
Preferred Drugs Preferred drugs are listed in this Drug Formulary. Drugs on the list are selected based on quality (effectiveness and safety) as well as cost-effectiveness. Doctors and pharmacists have worked together to develop the Formulary, which includes generics and brand name drugs that are approved by the U. S. Food and Drug Administration (“FDA”).
For the Member: Generic drugs contain the same active ingredients in the same amounts as brand name products. However, they may be a different color, shape, or size.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.
THIS DOCUMENT LIST IS EFFECTIVE AS OF THE DATE ON THE COVER. THIS LIST IS SUBJECT TO CHANGE. You may find the most current list, including any Utilization Management requirements, on our website. Contact Customer Care for printed copies.
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TIER DESCRIPTION
0 Health Care Reform Health Care Reform
1 Generics
2 Preferred Brands
3 Non-Preferred Brands
4 Specialty Drug
TYPE DESCRIPTION
There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame.
Your provider is required to get prior authorization before you fill PA Prior Authorization your prescription, which ensures appropriate use of the selected drug. Without prior approval, we may not cover this drug.
In some cases, you may be required to first try certain drugs to treat ST Step Therapy your medical condition before you move up a “step” to other drug options.
GL Gender Limit This prescription drug is restricted for a single gender. .
This prescription drug may only be covered if you meet the AL Age Limit minimum or maximum age limit.
C Custom This drug has unique restrictions.
Specialty drugs are high-cost drugs used to treat complex or rare S Specialty Drug conditions. Some examples of the diseases include; multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia.
This medication is not on our drug list. Click on the THERAPEUTIC MED Medical Drug CLASS or sub class to find covered alternative medications. If you have questions, please contact member services.
The Affordable Care Act (ACA) requires certain preventive generic HCR Health Care Reform Products products to be covered at zero dollar copay. This does not include plans that are grandfathered.
PAGE 1 LAST UPDATED 10/2017 PS Preferred Specialty Preferred Specialty.
Generic drugs available at the lowest cost. Please note the specific strengths and dosage forms; other strengths and/or dosage forms LCG Low Cost Generic of these products would be subject to the standard generic Cost- share.
PAGE 2 LAST UPDATED 10/2017 LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ADRENERGIC AGENTS
ALPHA AND BETA ADRENERGIC AGONIST(RESPR)
QL 2 / fill ADRENACLICK 3 PA
ADRENALIN 3
ADYPHREN 3 QL 2 / fill
ADYPHREN AMP 3 QL 2 / fill
ADYPHREN AMP II 3 QL 2 / fill
ADYPHREN II 3 QL 2 / fill
QL 2 / fill AUVI-Q 3 PA
ephedrine hcl 3 ephedrine sulfate powder 3
epinephrine (0.15 mg auto-injct, 0.3 mg auto-inject) 1 QL 2 / fill
epinephrine (base powder, powder) 3 epinephrine (1 mg/ml ampul, 1 mg/ml vial) 1 epinephrine bitartrate 3 epinephrine hcl 3
EPINEPHRINESNAP-V 3 QL 2 / fill
QL 2 / fill EPIPEN 3 PA
QL 2 / fill EPIPEN 2-PAK 3 PA
QL 4 / fill EPIPEN JR 2-PAK 3 PA
PAGE 3 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EPISNAP 3 QL 2 / fill
EPY 3 QL 2 / fill
QL 40/ day HYCOFENIX 3 AL At least 18 yrs old pseudoephedrine hcl 3 racepinephrine hcl 3
QL 20 / day REZIRA 3 AL At least 18 yrs old
NON-SELECT.BETA-ADRENERGIC AGONT(RESPIR) isoproterenol hcl powder 3 ISUPREL 3 SELECT.BETA-2-ADRENERGIC AGONIST(RESPIR)
ADVAIR DISKUS 2 QL 2 / day
ADVAIR HFA 2 QL 0.4 / day
QL 0.04 / day AIRDUO RESPICLICK 3 PA AL At least 12 yrs old albuterol sulfate powder 3 albuterol 5 mg/ml solution 1 LCG albuterol sulfate (sul 0.63 mg/3 ml sol, sul 1.25 mg/3 ml sol, sulf 2 mg/5 ml syrup, 2.5 mg/0.5 ml sol, sul 2.5 mg/3 ml soln, sulfate 2 mg tab, sulfate 4 mg tab, sulfate er 4 mg tab, sulfate er 1 8 mg tab)
ANORO ELLIPTA 2 QL 2 / day
QL 1 / day ARCAPTA NEOHALER 3 ST
QL 0.357 / day BEVESPI AEROSPHERE 3 ST
PAGE 4 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BREO ELLIPTA 2 QL 2 / day
BROVANA 3 QL 4 / day
COMBIVENT RESPIMAT 2 QL 0.267 / day
QL 0.434 / day DULERA 3 PA
QL 0.04 / day fluticasone-salmeterol 1 AL At least 12 yrs old
FORADIL 3 QL 3 / day formoterol fumarate (micro pwdr, powder) 3 ipratropium-albuterol 1 levalbuterol concentrate 1 levalbuterol hcl (100% powder, powder) 3 levalbuterol hcl (0.31 mg/3 ml sol, 0.63 mg/3 ml sol, 1.25 mg/3 ml sol) 1
QL 1.5 / day levalbuterol tartrate hfa 3 PA metaproterenol sulfate powder 3 metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syr, 20 mg tablet) 1
PERFOROMIST 3 QL 120 / 30 days
PROAIR HFA 2 QL 0.8 / day
QL 0.07 / day PROAIR RESPICLICK 2 AL At least 12 yrs old
QL 0.6 / day PROVENTIL HFA 3 PA
SEREVENT DISKUS 2 QL 2 / day
PAGE 5 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL .144 / day STRIVERDI RESPIMAT 2 ST
SYMBICORT 2 QL 0.4 / day terbutaline sulfate powder 3 terbutaline sulfate (2.5 mg tab, 5 mg tab) 1 LCG terbutaline sulf 1 mg/ml vial 1
QL 2 / day UTIBRON NEOHALER 3 ST AL At least 18 yrs old
VENTOLIN HFA 2 QL 1.5 / day
VOSPIRE ER 3 XOPENEX 3 XOPENEX CONCENTRATE 3
QL 1.5 / day XOPENEX HFA 3 PA
ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)
NON-SEL.ALPHA-1-ADRENERGIC BLOCKING AGTS
CARDURA 3
QL 1 / day CARDURA XL 3 ST doxazosin mesylate powder 3 doxazosin mesylate (1 mg tab, 2 mg tab, 4 mg tab, 8 mg tab) 1 MINIPRESS 3 prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule) 1 prazosin hcl powder 3 terazosin hcl 1
PAGE 6 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS
CAFERGOT 3 D.H.E.45 3 DIBENZYLINE 3 dihydroergotamine mesylate (1 mg/ml am, 1 mg/ml vl) 1 dihydroergotamine powder 3 dihydroergotamine 4 mg/ml spry 1 QL 8 / 30 days ergoloid mesylates powder 3 ergoloid mesylates 1 mg tab 1 ERGOMAR 3 ergotamine tartrate 3 ergotamine-caffeine 1 methysergide maleate 3 MIGERGOT 3
MIGRANAL 3 QL 8 / 30 days phenoxybenzamine hcl 10 mg cap 1 phenoxybenzamine hcl powder 3 phentolamine mesylate powder 3 phentolamine 5 mg vial 1 phentolamine-alprostadil 1 SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT
QL 1 / day alfuzosin hcl er 1 GL Male carvedilol 1 COREG 3
COREG CR (CR 10 MG CAPSULE, CR 20 MG CAPSULE, CR 40 MG QL 2 / day 3 CAPSULE) ST
PAGE 7 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day COREG CR 80 MG CAPSULE 3 ST
QL 1 / day dutasteride-tamsulosin 1 GL Male
FLOMAX 3 QL 2 / day
QL 1 / day JALYN 3 GL Male labetalol hcl powder 3 labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) 1
QL 1 / day RAPAFLO 2 GL Male tamsulosin hcl 1 QL 2 / day
QL 1 / day UROXATRAL 3 GL Male
ANALGESICS AND ANTIPYRETICS
ANALGESICS AND ANTIPYRETICS, MISC.
QL 10 / day acetamin-caff-dihydrocod 320.5 1 AL At least 18 yrs old acetamin-caff-dihydrocod 325 1 QL 10 / day acetaminophen 3 acetaminophen-codeine (acetamin-codein 300-30 mg/12.5, QL 139 / day 1 acetaminop-codeine 120-12 mg/5) AL At least 18 yrs old
QL 22 / day acetaminophen-cod #2 tablet 1 AL At least 18 yrs old
QL 12 / day acetaminophen-cod #3 tablet 1 AL At least 12 yrs old
PAGE 8 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 6 / day acetaminophen-cod #4 tablet 1 AL At least 12 yrs old
ALLZITAL 3 QL 6 / day
BUPAP 3 QL 6 / day butalb-acetaminoph-caff-codein 1 QL 6 / day butalb-caff-acetaminoph-codein 1 QL 6 / day butalbital-acetaminophen 3 QL 6 / day butalbital-acetaminophen-caffe (butalb-acetamin-caff 50-300- 40, butalb-acetamin-caff 50-325-40, butalbit-acetaminophen- 1 QL 6 / day caff cp)
CAPACET 1 QL 6 / day
QL 125 / day CAPITAL W-CODEINE 3 AL At least 18 yrs old
QL 12 / day ENDOCET 1 AL At least 18 yrs old
ESGIC CAPSULE 1 QL 6 / day
ESGIC 50-325-40 MG TABLET 3 QL 6 / day
FIORICET 3 QL 6 / day
FIORICET WITH CODEINE 3 QL 6 / day gabapentin (100 mg capsule, 300 mg capsule, 400 mg capsule) 1 QL 9 / day gabapentin powder 3 gabapentin (250 mg/5 ml soln, 300 mg/6 ml soln) 1 QL 72 / day gabapentin 600 mg tablet 1 QL 6 / day gabapentin 800 mg tablet 1 QL 5 / day
GRALISE 30-DAY STARTER PACK 3 ST
PAGE 9 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day GRALISE ER 300 MG TABLET 3 ST
QL 3 / day GRALISE ER 600 MG TABLET 3 ST
HORIZANT ER 300 MG TABLET 3 QL 4 / day
HORIZANT ER 600 MG TABLET 3 QL 2 / day
QL 140 / day HYCET 3 AL At least 2 yrs old
QL 100 / day hydrocodone-acetamin 2.5-167/5 1 AL At least 2 yrs old hydrocodone-acetaminophen (hydrocodon-acetamin 7.5- QL 140 / day 325/15, hydrocodone-acetamin 2.5-108/5, hydrocodone- 1 acetamin 5-217/10) AL At least 2 yrs old
QL 20 / day hydrocodon-acetaminoph 2.5-325 1 AL At least 18 yrs old
QL 8 / day hydrocodon-acetaminoph 7.5-325 1 AL At least 18 yrs old
QL 6 / day hydrocodone-acetamin 7.5-325 1 AL At least 18 yrs old hydrocodone-acetaminophen (hydrocodon-acetaminoph 7.5- 300, hydrocodon-acetaminophen 5-300, hydrocodon- QL 13 / day 1 acetaminophn 10-300, hydrocodone-acetamin 7.5-300, AL At least 18 yrs old hydrocodone-acetamin 10-300 mg) hydrocodone-acetaminophen (hydrocodon-acetaminophen 5- QL 12 / day 325, hydrocodon-acetaminophn 10-325, hydrocodone- 1 acetamin 10-325 mg) AL At least 18 yrs old isomethept-caff-acetaminophen 1 isomethept-dichloralp-acetamin 1
QL 12 / day LORCET 1 AL At least 18 yrs old
PAGE 10 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 12 / day LORCET HD 1 AL At least 18 yrs old
QL 6 / day LORCET PLUS 1 AL At least 18 yrs old
QL 90 / day LORTAB 10 MG-300 MG/15 ML ELXR 3 AL At least 2 yrs old
LORTAB (5-325 MG TABLET, 7.5-325 MG TABLET, 10-325 MG QL 8 / day 1 TABLET) AL At least 18 yrs old
MARGESIC 1 QL 6 / day
MARTEN-TAB 1 QL 6 / day
NEURONTIN (100 MG CAPSULE, 300 MG CAPSULE, 400 MG 9 / day CAPSULE) 3 QL
NEURONTIN 250 MG/5 ML SOLN 3 QL 72 / day
NEURONTIN 600 MG TABLET 3 QL 6 / day
NEURONTIN 800 MG TABLET 3 QL 5 / day
NODOLOR 1
QL 12 / day NORCO 3 AL At least 18 yrs old
QL 62 / day oxycodone-acetaminophn 5-325/5 1 AL At least 18 yrs old
QL 4 / day oxycodon-acetaminophen 7.5-300 1 AL At least 18 yrs old oxycodone-acetaminophen (oxycodon-acetaminophen 2.5-325, QL 12 / day oxycodon-acetaminophen 7.5-325, oxycodone-acetaminophen 1 5-325, oxycodone-acetaminophen 10-325) AL At least 18 yrs old
QL 3 / day oxycodone-acetaminophen 10-300 1 AL At least 18 yrs old
PAGE 11 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 7 / day oxycodone-acetaminophen 5-300 1 AL At least 18 yrs old
QL 12 / day PERCOCET 3 AL At least 18 yrs old
QL 3 / day PRIMLEV 10-300 MG TABLET 3 AL At least 18 yrs old
QL 7 / day PRIMLEV 5-300 MG TABLET 3 AL At least 18 yrs old
QL 4 / day PRIMLEV 7.5-300 MG TABLET 3 AL At least 18 yrs old
PRODRIN 3
TENCON 1 QL 6 / day
QL 8 / day tramadol hcl-acetaminophen 1 AL At least 18 yrs old
QL 10 / day TREZIX 3 AL At least 18 yrs old
QL 12 / day TYLENOL-CODEINE NO.3 3 AL At least 12 yrs old
QL 6 / day TYLENOL-CODEINE NO.4 3 AL At least 12 yrs old
QL 8 / day ULTRACET 3 AL At least 18 yrs old
VANATOL LQ 3
QL 20 / day VERDROCET 1 AL At least 18 yrs old
QL 8 / day VICODIN 1 AL At least 18 yrs old
PAGE 12 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 13 / day VICODIN ES 1 AL At least 18 yrs old
QL 13 / day VICODIN HP 1 AL At least 18 yrs old
QL 12 / day XARTEMIS XR 3 AL At least 18 yrs old
QL 13 / day XODOL 10-300 3 AL At least 18 yrs old
QL 13 / day XODOL 5-300 3 AL At least 18 yrs old
QL 13 / day XODOL 7.5-300 3 AL At least 18 yrs old
QL 90 / day ZAMICET 3 AL At least 2 yrs old
ZEBUTAL 1 QL 6 / day
OPIATE AGONISTS
QL 4 / day ABSTRAL 3 PA AL At least 18 yrs old
QL 4 / day ACTIQ 3 PA AL At least 18 yrs old alfentanil 500 mcg/ml ampul 1 alfentanil 500 mcg/ml ampule 3
QL 3 / day ARYMO ER 3 PA
PAGE 13 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 6 / day asa-butalb-caffeine-codeine 1 AL At least 18 yrs old
QL 6 / day ASCOMP WITH CODEINE 1 AL At least 18 yrs old
ASTRAMORPH-PF (1 MG/ML AMPUL, 10 MG/10 ML VIAL) 1 QL 50 / day
ASTRAMORPH-PF (1 MG/2 ML AMPULE, 5 MG/10 ML VIAL) 1 QL 100 / day belladonna-opium 16.2-30 supp 1 QL 2 / day belladonna-opium 16.2-60 supp 1 QL 1 / day
QL 6 / day butalbital compound-codeine 1 AL At least 18 yrs old carisoprodol compound-codeine 1 QL 21 / day carisoprodol-aspirin-codeine 1 QL 21 / day codeine phosphate 3
QL 6 / day codeine sulfate 1 AL At least 18 yrs old
QL 1 / day CONZIP (100 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE) 3 PA AL At least 18 yrs old
DEMEROL (25 MG/0.5 ML AMPUL, 50 MG/ML AMPUL, 50 MG/ML QL 10 / day CARPUJECT, 50 MG/ML VIAL, 75 MG/1.5 ML AMPUL, 100 MG/2 3 ML AMPUL) AL At least 18 yrs old
QL 20 / day DEMEROL 25 MG/ML CARPUJECT 3 AL At least 18 yrs old
QL 7 / day DEMEROL 75 MG/ML SYRINGE 3 AL At least 18 yrs old
QL 5 / day DEMEROL 100 MG TABLET 3 AL At least 18 yrs old
PAGE 14 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 10 / day DEMEROL 50 MG TABLET 3 AL At least 18 yrs old
DEMEROL (100 MG/ML AMPUL, 100 MG/ML CARPUJECT, 100 QL 5 / day 3 MG/ML VIAL) AL At least 18 yrs old dihydrocodeine bitartrate 3
QL 6 / day DILAUDID 2 MG/ML AMPUL 3 AL At least 18 yrs old
QL 3 / day DILAUDID 4 MG/ML AMPUL 3 AL At least 18 yrs old
QL 13 / day DILAUDID 5 MG/5 ML ORAL LIQUID 3 AL At least 18 yrs old
DILAUDID (0.5 MG/0.5 ML SYRINGE, 1 MG/ML SYRINGE, 2 At least 18 yrs old MG/ML SYRINGE, 4 MG/ML SYRINGE) 3 AL
QL 6 / day DILAUDID (2 MG TABLET, 4 MG TABLET, 8 MG TABLET) 3 AL At least 18 yrs old
QL 1 / day DILAUDID-HP 3 AL At least 18 yrs old
QL 3 / day DOLOPHINE HCL 3 PA
QL 0.5 / day DURAGESIC 3 PA
DURAMORPH 10 MG/10 ML AMPUL 1 QL 5 / day
DURAMORPH 5 MG/10 ML AMPUL 1 QL 10 / day
QL 2 / day EMBEDA 2 PA
QL 2 / day EXALGO 3 PA
PAGE 15 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 0.5 / day fentanyl 1 PA fentanyl base 3 fentanyl citrate (0.05 mg/ml ampul, 100 mcg/2 ml ampul, 1,000 mcg/20 ml ampul, 1,000 mcg/20 ml vial) 1
QL 4 / day fentanyl citrate (cit 1,200 mcg, cit 1,600 mcg, citrate 200 mcg, citrate 400 mcg, citrate 600 mcg, citrate 800 mcg) 1 PA AL At least 18 yrs old fentanyl citrate powder 3 fentanyl 250 mcg/5 ml vial 1 fentanyl-bup-ns 4 mcg/ml-0.1% 1 QL 96 / day fentanyl-bupivacaine-0.9% nacl (2 mcg-0.1%, 2 mcg-0.125%) 1 QL 192 / day
QL 4 / day FENTORA 3 PA AL At least 18 yrs old
QL 6 / day FIORINAL WITH CODEINE #3 3 AL At least 18 yrs old
QL 20 / day hydrocod-cpm-pseudoephedrine 1 AL At least 18 yrs old hydrocodone bitartrate (crys, powder) 3
QL 5 / day hydrocodone-ibuprofen (2.5-200, 7.5-200, 10-200) 1 AL At least 16 yrs old
QL 6 / day hydrocodone-ibuprofen 5-200 mg 1 AL At least 16 yrs old
QL 2 / day hydromorphone er 1 PA
QL 1 / day hydromorphone hcl 10 mg/ml amp 1 AL At least 18 yrs old
PAGE 16 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 13 / day hydromorphone hcl (1 mg/ml solution, 5 mg/5 ml soln) 1 AL At least 18 yrs old hydromorphone hcl powder 3 hydromorphone 3 mg suppos 1 QL 4 / day
QL 6 / day hydromorphone 2 mg/ml carpujct 1 AL At least 18 yrs old
QL 3 / day hydromorphone 4 mg/ml carpujct 1 AL At least 18 yrs old
QL 6 / day hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mg tablet) 1 AL At least 18 yrs old hydromorphone 2 mg/ml vial 1 QL 6 / day hydromorphone hcl (10 mg/ml vial, hcl 10 mg/ml vl, 50 mg/5 1 / day ml vial, 500 mg/50 ml via) 1 QL
QL 1 / day HYSINGLA ER 3 PA
QL 5 / day IBUDONE 10-200 MG TABLET 3 AL At least 16 yrs old
QL 6 / day IBUDONE 5-200 MG TABLET 1 AL At least 16 yrs old
INFUMORPH 200 MG/20 ML AMPUL 3 QL 5 / day
INFUMORPH 500 MG/20 ML AMPUL 3 QL 2 / day
KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 50 MG QL 2 / day 3 CAPSULE, ER 100 MG CAPSULE) PA
KADIAN (ER 30 MG CAPSULE, ER 40 MG CAPSULE, ER 60 MG QL 1 / day 3 CAPSULE, ER 80 MG CAPSULE, ER 200 MG CAPSULE) PA
QL 4 / day LAZANDA 3 PA AL At least 18 yrs old
PAGE 17 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS levorphanol tartrate powder 3 AL At least 18 yrs old
QL 4 / day levorphanol 2 mg tablet 1 AL At least 18 yrs old
QL 50 / day meperidine 10 mg/ml cartrdge 1 AL At least 18 yrs old meperidine hcl powder 3 AL At least 18 yrs old
QL 50 / day meperidine 50 mg/5 ml solution 1 AL At least 18 yrs old
QL 5 / day meperidine 100 mg tablet 1 AL At least 18 yrs old
QL 10 / day meperidine 50 mg tablet 1 AL At least 18 yrs old
QL 5 / day meperidine 100 mg/ml vial 1 AL At least 18 yrs old
QL 20 / day meperidine 25 mg/ml vial 1 AL At least 18 yrs old
QL 10 / day meperidine 50 mg/ml vial 1 AL At least 18 yrs old methadone hcl powder 3
QL 8 / day methadone 10 mg/5 ml solution 1 PA
QL 18 / day methadone 5 mg/5 ml solution 1 PA
QL 2 / day methadone hcl (10 mg/ml oral conc, hcl 10 mg tablet) 1 PA
QL 3 / day methadone hcl 5 mg tablet 1 PA
PAGE 18 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS methadone hcl 10 mg/ml vial 1 QL 2 / day
QL 2 / day METHADONE INTENSOL 1 PA
QL 2 / day METHADOSE 10 MG/ML ORAL CONC 3 PA morphine sulfate powder 3 PA morphine sulf 10 mg/5 ml soln 1 QL 25 / day morphine sulf 20 mg/5 ml soln 1 QL 13 / day morphine sulf 10 mg suppos 1 QL 5 / day morphine sulf 30 mg suppos 1 QL 2 / day morphine sulf 5 mg suppos 1 QL 10 / day morphine sulfate (20 mg suppos, 100 mg/5 ml soln) 1 QL 3 / day
QL 5 / day morphine 10 mg/ml syringe 1 PA
QL 25 / day morphine 2 mg/ml syringe 1 PA
QL 13 / day morphine 4 mg/ml syringe 1 PA
QL 10 / day morphine 5 mg/ml syringe 1 PA
QL 3 / day morphine sulfate ir 15 mg tab 1 AL At least 18 yrs old
QL 2 / day morphine sulfate ir 30 mg tab 1 AL At least 18 yrs old
QL 100 / day morphine 0.5 mg/ml vial 1 PA
PAGE 19 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 50 / day morphine 1 mg/ml vial p-f 1 PA
QL 6 / day morphine 8 mg/ml vial 1 PA
QL 3 / day morphine sulfate (sulf 10 mg/0.7 ml syr, 15 mg/ml vial) 1 PA morphine sulfate er (er 10 mg cap, er 20 mg cap, er 50 mg cap, QL 2 / day 1 er 100 mg cap) PA morphine sulfate er (er 30 mg cap, er 45 mg cap, er 60 mg cap, QL 1 / day 1 er 75 mg cap, er 80 mg cap, er 90 mg cap, er 120 mg cap) PA morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er 60 mg QL 3 / day 1 tablet, er 100 mg tablet, er 200 mg tablet) PA
QL 3 / day MS CONTIN 3 PA
QL 6 / day NUCYNTA (50 MG TABLET, 75 MG TABLET) 3 AL At least 18 yrs old
QL 7 / day NUCYNTA 100 MG TABLET 3 AL At least 18 yrs old
QL 2 / day NUCYNTA ER 3 PA AL At least 18 yrs old
QL 17 / day OPANA 1 MG/ML INJ AMPULE 3 AL At least 18 yrs old
QL 12 / day OPANA (5 MG TABLET, 10 MG TABLET) 3 AL At least 18 yrs old
QL 2 / day OPANA ER 3 PA AL At least 18 yrs old
PAGE 20 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 8 / day OXAYDO 3 AL At least 18 yrs old
OXECTA 3 QL 8 / day oxycodone hcl (5 mg capsule, 5 mg tablet, 15 mg tablet, 20 mg QL 8 / day 1 tablet, 30 mg tablet) AL At least 18 yrs old oxycodone hcl 100 mg/5 ml soln 1 QL 2 / day oxycodone hcl 5 mg/5 ml soln 1 QL 33 / day oxycodon 10 mg/0.5 ml oral syr 1 QL 4 / day oxycodone hcl 10 mg tablet 1 QL 8 / day
QL 3 / day oxycodone hcl er 1 PA
QL 7 / day oxycodone hcl-aspirin 1 AL At least 18 yrs old
QL 4 / day oxycodone hcl-ibuprofen 1 AL At least 18 yrs old oxycodone hydrochloride 3
QL 3 / day OXYCONTIN 3 PA
QL 12 / day oxymorphone hcl 1 AL At least 18 yrs old
QL 2 / day oxymorphone hcl er 1 PA AL At least 18 yrs old
QL 30 / day promethazine vc-codeine 1 AL At least 6 yrs old
QL 30 / day promethazine-phenyleph-codeine 1 AL At least 6 yrs old
PAGE 21 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 5 / day REPREXAIN 10-200 MG TABLET 1 AL At least 16 yrs old
QL 5 / day REPREXAIN 2.5-200 MG TABLET 3 AL At least 16 yrs old
QL 6 / day REPREXAIN 5-200 MG TABLET 3 AL At least 16 yrs old
QL 8 / day ROXICODONE 3 AL At least 18 yrs old
QL 12 / day SUBSYS 3 PA AL At least 18 yrs old sufentanil citrate powder 3 tramadol hcl powder 3 AL At least 18 yrs old
QL 8 / day tramadol hcl 50 mg tablet 1 AL At least 18 yrs old tramadol hcl er (er 100 mg tablet, er 200 mg tablet, er 300 mg QL 1 / day tablet, hcl er 100 mg capsule, hcl er 100 mg tablet, hcl er 150 mg capsule, hcl er 200 mg capsule, hcl er 200 mg tablet, hcl er 1 PA 300 mg capsule, hcl er 300 mg tablet) AL At least 18 yrs old
QL 20 / day TUZISTRA XR 3 AL At least 18 yrs old
QL 8 / day ULTRAM 3 AL At least 18 yrs old
QL 1 / day ULTRAM ER 3 PA AL At least 18 yrs old
QL 5 / day VICOPROFEN 3 AL At least 16 yrs old
PAGE 22 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 2 / day XTAMPZA ER 3 PA
XYLON 10 1
QL 2 / day ZOHYDRO ER 3 PA
QL 20 / day ZUTRIPRO 3 AL At least 18 yrs old
OPIATE PARTIAL AGONISTS
QL 2 / day BELBUCA 3 PA AL At least 18 yrs old
QL 3 / day BUNAVAIL (2.1-0.3 MG FILM, 6.3-1 MG FILM) 3 PA
QL 2 / day BUNAVAIL 4.2-0.7 MG FILM 3 PA
BUPRENEX 3 QL 17 / day
QL 0.144 / day buprenorphine 3 PA buprenorphine hcl powder 3
QL 3 / day buprenorphine hcl (2 mg tablet, 8 mg tablet) 1 PA buprenorphine hcl (0.3 mg/ml syring, 0.3 mg/ml vial) 1 QL 17 / day
QL 3 / day buprenorphine-naloxone 1 PA butorphanol tartrate powder 3 AL At least 18 yrs old
QL 0.3 / day butorphanol 10 mg/ml spray 1 AL At least 18 yrs old
PAGE 23 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 7 / day butorphanol 1 mg/ml vial 1 AL At least 18 yrs old
QL 4 / day butorphanol 2 mg/ml vial 1 AL At least 18 yrs old
QL .144 / day BUTRANS 3 PA nalbuphine hcl powder 3 nalbuphine hcl (10 mg/ml ampul, 100 mg/10 ml vial) 1 QL 5 / day nalbuphine hcl (20 mg/ml ampul, 200 mg/10 ml vial) 1 QL 3 / day
QL 12 / day pentazocine-naloxone hcl 1 AL At least 12 yrs old
QL 3 / day SUBOXONE (2 MG-0.5 MG FILM, 8 MG-2 MG FILM) 2 PA
QL 2 / day SUBOXONE (4 MG-1 MG FILM, 12 MG-3 MG FILM) 2 PA
TALWIN (30 MG/ML AMPUL, 30 MG/ML VIAL) 3 QL 5 / day
QL 3 / day ZUBSOLV 3 PA
ANOREXIGENIC AGENTS
AMPHETAMINE DERIVATIVES
QL 2 / day ADIPEX-P (37.5 MG CAPSULE, 37.5 MG TABLET) 3 PA AL At least 17 yrs old
QL 3 / day BONTRIL PDM 3 PA AL At least 17 yrs old
PAGE 24 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS diethylpropion hcl powder 3
QL 3 / day diethylpropion 25 mg tablet 1 PA AL At least 16 yrs old
QL 1 / day diethylpropion hcl er 1 PA
QL 3 / day LOMAIRA 1 PA AL At least 17 yrs old
QL 1 / day phendimetrazine er 105 mg cap 1 PA
QL 3 / day phendimetrazine 35 mg tablet 1 PA
QL 1 / day phentermine hcl (15 mg capsule, 30 mg capsule) 1 PA phentermine hcl powder 3
QL 2 / day phentermine hcl (37.5 mg capsule, 37.5 mg tablet) 1 PA AL At least 17 yrs old
QL 1 / day QSYMIA 3 PA AL At least 18 yrs old
SUPRENZA ODT 3 PA
ANOREXIGENIC AGENTS, MISCELLANEOUS
QL 4 / day CONTRAVE 3 PA AL At least 18 yrs old
PAGE 25 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SELECTIVE SEROTONIN RECEPTOR AGONISTS
QL 2 / day BELVIQ 3 PA AL At least 18 yrs old
QL 1 / day BELVIQ XR 3 PA AL At least 18 yrs old
ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS
AMPHETAMINES
QL 2 / day ADDERALL 3 ST
QL 2 / day ADDERALL XR 3 ST
QL 1 / day ADZENYS XR-ODT 3 ST AL At least 6 yrs old
QL 3 / day benzphetamine hcl 25 mg tablet 1 PA AL At least 12 yrs old
QL 3 / day benzphetamine hcl 50 mg tablet 1 PA
QL 5 / day DESOXYN 3 ST
QL 5 / day DEXEDRINE SPANSULE 10 MG 3 ST
QL 4 / day DEXEDRINE SPANSULE 15 MG 3 ST
PAGE 26 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 2 / day DEXEDRINE SPANSULE 5 MG 3 ST
DEXEDRINE 10 MG TABLET 1 QL 6 / day
DEXEDRINE 5 MG TABLET 1 QL 2 / day dextroamphetamine 5 mg/5 ml 1 QL 60 / day dextroamphetamine 10 mg tab 1 QL 6 / day dextroamphetamine 5 mg tab 1 QL 2 / day d-amphetamine er 10 mg capsule 1 QL 5 / day d-amphetamine er 15 mg capsule 1 QL 4 / day d-amphetamine er 5 mg capsule 1 QL 2 / day dextroamphetamine-amphet er 1 QL 2 / day dextroamphetamine-amphetamine 1 QL 2 / day
QL 8 / day DYANAVEL XR 3 ST AL At least 6 yrs old
QL 6 / day EVEKEO 3 ST methamphetamine hcl 1 QL 5 / day
QL 60 / day PROCENTRA 3 ST
QL 3 / day REGIMEX 3 PA AL At least 12 yrs old
PAGE 27 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VYVANSE (10 MG CAPSULE, 10 MG CHEWABLE TABLET, 20 MG CAPSULE, 20 MG CHEWABLE TABLET, 30 MG CAPSULE, 30 MG CHEWABLE TABLET, 40 MG CAPSULE, 40 MG CHEWABLE 2 QL 1 / day TABLET, 50 MG CAPSULE, 50 MG CHEWABLE TABLET, 60 MG CAPSULE, 60 MG CHEWABLE TABLET, 70 MG CAPSULE)
QL 2 / day ZENZEDI (15 MG TABLET, 30 MG TABLET) 3 ST
QL 3 / day ZENZEDI (2.5 MG TABLET, 20 MG TABLET) 3 ST
ZENZEDI 10 MG TABLET 1 QL 6 / day
ZENZEDI 5 MG TABLET 1 QL 2 / day
QL 8 / day ZENZEDI 7.5 MG TABLET 3 ST
ANOREXIGENIC AGENTS AND STIMULANTS, MISC meclofenoxate hcl 3 RESPIRATORY AND CNS STIMULANTS
QL 1 / day APTENSIO XR 3 ST caffeine 3 caffeine and sodium benzoate 1 caffeine citrate (citrate powder, citrated powder) 3 caffeine cit 60 mg/3 ml oral 1
CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 36 MG QL 2 / day 3 TABLET) ST
QL 1 / day CONCERTA ER 54 MG TABLET 3 ST
QL 1 / day DAYTRANA 3 ST
PAGE 28 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dexmethylphenidate 10 mg tab 1 QL 2 / day dexmethylphenidate hcl (2.5 mg tab, 5 mg tab) 1 QL 3 / day dexmethylphenidate er 20 mg cp 1 QL 2 / day dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er 15 mg 1 / day cp, er 25 mg cp, er 30 mg cp, er 35 mg cp, er 40 mg cp) 1 QL
QL 2 / day FOCALIN 3 ST
FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, QL 1 / day 25 MG CAPSULE, 30 MG CAPSULE, 35 MG CAPSULE, 40 MG 3 CAPSULE) ST
QL 2 / day FOCALIN XR 20 MG CAPSULE 3 ST
QL 1 / day METADATE CD 3 ST
QL 3 / day METADATE ER 1 LCG
QL 30 / day METHYLIN 10 MG/5 ML SOLUTION 3 ST
QL 60 / day METHYLIN 5 MG/5 ML SOLUTION 3 ST
QL 3 / day METHYLIN (2.5 MG TAB, 5 MG TABLET, 10 MG TABLET) 3 ST methylphenidate er (er 20 mg cap, er 40 mg cap, er 54 mg tab) 1 QL 1 / day methylphenidate er (er 18 mg tab, er 27 mg tab, er 30 mg cap, 2 / day er 36 mg tab) 1 QL methylphenidate er 10 mg tab 1 QL 5 / day methylphenidate er 20 mg tab 1 QL 3 / day
PAGE 29 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS methylphenidate hcl powder 3 methylphenidate 10 mg/5 ml sol 1 QL 30 / day methylphenidate 5 mg/5 ml soln 1 QL 60 / day methylphenidate 2.5 mg chew tb 1 methylphenidate hcl (5 mg chew tab, 5 mg tablet, 10 mg chew 3 / day tab, 20 mg tablet) 1 QL methylphenidate 10 mg tablet 1 QL 5 / day methylphenidate hcl cd 1 QL 1 / day methylphenidate hcl er (er 10 mg cap, er 50 mg cap, er 60 mg 1 / day cap) 1 QL methylphenidate la (20 mg cap, 40 mg cap, 60 mg cap) 1 QL 1 / day methylphenidate la 30 mg cap 1 QL 2 / day
QL 1 / day QUILLICHEW ER (ER 20 MG CHEW TAB, ER 40 MG CHEW TAB) 3 ST AL At least 6 yrs old
QL 2 / day QUILLICHEW ER 30 MG CHEW TAB 3 ST AL At least 6 yrs old
QL 12 / day QUILLIVANT XR 3 ST
QL 3 / day RITALIN (5 MG TABLET, 20 MG TABLET) 3 ST
QL 5 / day RITALIN 10 MG TABLET 3 ST
RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 40 MG CAPSULE, QL 1 / day 3 60 MG CAPSULE) ST
QL 2 / day RITALIN LA 30 MG CAPSULE 3 ST
PAGE 30 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS WAKEFULNESS-PROMOTING AGENTS
QL 1 / day armodafinil 1 PA
QL 1 / day modafinil 1 PA
QL 1 / day NUVIGIL 3 PA
QL 1 / day PROVIGIL 3 PA
ANTI-INFECTIVE AGENTS
ANTHELMINTICS albendazole 3
QL 4 / day ALBENZA 3 PA
BILTRICIDE 3 PA
EMVERM 3 PA ivermectin powder 3 ivermectin 3 mg tablet 1 PA levamisole hcl 3 mebendazole 3 niclosamide 3 praziquantel 3 pyrantel pamoate 3
STROMECTOL 3 PA thiabendazole 3
PAGE 31 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTI-INFECTIVES (SYSTEMIC), MISC. diethylcarbamazine citrate 3 furazolidone 3 URINARY ANTI-INFECTIVES
AZUPHEN MB 1 FURADANTIN 3 HIPREX 3 HYOPHEN 1 INDIOMIN MB 1 MACROBID 3 MACRODANTIN 3 me-naphos-mb-hyo 1 1 methenamine 3 methenamine hippurate 1 methenamine mandelate powd 3 methenamine mandelate (md 1 gm tablet, md 500 mg tablet) 1 MONUROL 3 nitrofurantoin (25 mg/5 ml susp, mcr 25 mg cap, mcr 50 mg cap, mcr 100 mg cap) 1 nitrofurantoin powder 3 nitrofurantoin mono-macro 1 PHOSPHASAL 1 PRIMSOL 3 PROSED-DS 3 trimethoprim powder 3 trimethoprim 100 mg tablet 1 trimethoprim micronized 3 UR N-C 1
PAGE 32 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS URELLE 1 URETRON D-S 1
URIBEL 1 QL 4 / day
URIMAR-T 1 URIN D.S. 1 URO-458 1 URO-BLUE 1 URO-L 1 UROGESIC-BLUE 3 UROPHEN MB 1 UROQID-ACID NO.2 3 URYL 1 USTELL 1 UTA 1 UTIRA-C 1 ANTI-INFECTIVES (EENT)
ANTIBACTERIALS (EENT)
AK-POLY-BAC 1 QL 0.434 / day
AZASITE 3 QL 0.36/day bacitracin 500 unit/gm ophth 1 QL 0.434 / day bacitracin-polymyxin 1 QL 0.434 / day
BACTROBAN NASAL 2
BESIVANCE 3 QL 0.767 / day
BLEPH-10 3 QL 5 / fill
BLEPHAMIDE 3 QL 5 / fill
BLEPHAMIDE S.O.P. 3 QL 4 / fill
PAGE 33 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CETRAXAL 3 QL 0.567 / day
CILOXAN (EYE DROPS, OINTMENT) 3 QL 0.767 / day
CIPRO HC 3 QL 0.434 / day
CIPRODEX 2 QL 0.257 / day ciprofloxacin 0.2% otic soln 1 QL 0.567 / day ciprofloxacin 0.3% eye drop 1 QL 0.767 / day
COLY-MYCIN S 3 QL 10 / fill
CORTISPORIN-TC 3 QL 10 / fill doxycycline hyclate 20 mg tab 1 erythromycin 0.5% eye ointment 1 QL 0.54 / day
FLOXIN 3 QL 10 / 30 days gatifloxacin 1 QL 0.36/day gatifloxacin sesquihydrate 3
GENTAK 1 QL 0.54 / day gentamicin sulfate (0.3% drops, 3 mg/ml drops) 1 QL 2.143 / day gentamicin 0.3% eye ointment 1 QL 0.54 / day
ILOTYCIN 1 QL 0.54 / day levofloxacin 0.5% eye drops 1 QL 0.767 / day
MAXITROL EYE DROPS 3 QL 5 / fill
MAXITROL EYE OINTMENT 3 QL 4 / fill
MOXEZA 2 QL 0.434 / day moxifloxacin 0.5% eye drops 1 QL 0.434 / day mupirocin powder 3
PAGE 34 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NEO-POLYCIN 1 QL 0.124 / day
NEO-POLYCIN HC 1 QL 4 / fill neomycin-bacitracin-poly-hc 1 QL 4 / fill neomycin-bacitracin-polymyxin 1 QL 0.124 / day neomyc-polym-dexameth eye drop 1 QL 5 / fill neomyc-polym-dexamet eye ointm 1 QL 4 / fill neomycin-polymyxin-gramicidin 1 QL 1.47 / day neomycin-poly-hc eye drops 1 QL 10/ fill neomycin-polymyxin-hc ear susp 1 QL 10 / fill neomycin-polymyxin-hydrocort 1 QL 10 / fill
NEOSPORIN 3 QL 1.47 / day
OCUFLOX 3 QL 1.47 / day ofloxacin 0.3% ear drops 1 QL 10 / 30 days ofloxacin 0.3% eye drops 1 QL 1.47 / day
OTIPRIO 3 OTOVEL 3
POLYCIN 1 QL 0.434 / day polymyxin b sul-trimethoprim 1 QL 1.47 / day
POLYTRIM 3 QL 1.47 / day
PRED-G 1% EYE DROPS 3 QL 5 / fill
PRED-G S.O.P. EYE OINTMENT 3 QL 4 / fill sulfacetamide 10% eye drops 1 QL 5 / fill sulfacetamide 10% eye ointment 1 QL 4 / fill
PAGE 35 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sulfacetamide-prednisolone 1 QL 5 / fill
TOBRADEX EYE DROPS 3 QL 5 / fill
TOBRADEX EYE OINTMENT 3 QL 4 / fill
TOBRADEX ST 3 QL 5 / fill tobramycin 0.3% eye drops 1 QL 2.143 / day tobramycin-dexamethasone 1 QL 5 / fill
TOBREX 0.3% EYE DROPS 3 QL 2.143 / day
TOBREX 0.3% EYE OINTMENT 3 QL 0.54 / day
VIGAMOX 2 QL 0.434 / day
ZYLET 3 QL 5 / fill
ZYMAXID 3 QL 0.36/day
ANTIFUNGALS (EENT)
NATACYN 3 QL 0.767 / day
ANTIVIRALS (EENT) idoxuridine 3 trifluridine 1% eye drops 1 trifluridine powder 3 VIROPTIC 3
ZIRGAN 3 QL 0.167 / day
EENT ANTI-INFECTIVES, MISCELLANEOUS
ACETASOL HC 1 acetic acid 2% ear solution 1 acetic acid-aluminum 1 BETADINE 3
PAGE 36 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS boric acid (granules, powder) 3 chlorhexidine 0.12% rinse 1 hydrocortisone-acetic acid 1 PAROEX 1 PERIDEX 3 PERIOGARD 1 povidone iodine 5% eye drop 1 ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)
ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)
QL 1.667 / day ACANYA 3 PA
ALTABAX 3 bacitracin (5 million units pwd, powder) 3 bacitracin micronized 3 bacitracin zinc 3 BACTROBAN (CREAM, OINTMENT) 3
QL 1.667 / day BENZACLIN (GEL, GEL 35G PUMP, GEL 50G PUMP) 3 PA
QL 1.6 / day BENZAMYCIN 3 PA
CENTANY 3 CENTANY AT 3 CLEOCIN 2% VAGINAL CREAM 3 CLEOCIN 100 MG VAGINAL OVULE 2
CLEOCIN T 1% GEL 3 QL 75 / 30 days
CLEOCIN T (LOION, PLEDGES, SOLUION) 3 CLINDACIN ETZ KIT 3
PAGE 37 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CLINDACIN ETZ 1% PLEDGET 1 CLINDACIN P 1 CLINDACIN PAC 3
CLINDAGEL 3 QL 75 / 30 days clindamax 1 clindamycin phos-benzoyl perox 1 QL 1.5 / day clindamycin phos-tretinoin 1 QL 2 / day clindamycin phosphate 1% foam 1 QL 1.667 / day clindamycin ph 1% gel 1 QL 75 / 30 days clindamycin phosphate (ph 1% solution, phos 1% pledget, phosp 1% lotion, 2% vaginal cream) 1 clindamycin-benzoyl peroxide (clinda-benzoyl 1-5% pump, 1.667 / day clindamycin-benzoyl 1-5%) 1 QL
CLINDESSE 3
CORTISPORIN CREAM 3 QL 0.25 / day
CORTISPORIN OINTMENT 3 QL 0.5 / day
QL 1.5 / day DUAC 3 PA
ERY 1
ERYGEL 3 QL 1 / day erythromycin 2% gel 1 QL 1 / day erythromycin (pledgets, solution) 1 erythromycin-benzoyl peroxide 1 QL 1.60 / day
EVOCLIN 3 QL 1.667 / day gentamicin sulfate (cream, ointment) 1 METROCREAM 3
PAGE 38 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS METROGEL (GEL, PUMP) 3 METROGEL-VAGINAL 3 METROLOTION 3 metronidazole (0.75% cream, 0.75% lotion, top 1% gel pump, topical 0.75% gl, topical 1% gel, vaginal 0.75% gl) 1 mupirocin (cream, ointment) 1 NEO-SYNALAR 0.5%-0.025% CREAM 3
NEUAC GEL 1 QL 1.5 / day
NORITATE 3 NUVESSA 3
ONEXTON 1.2%-3.75% GEL 3 QL 1.667 / day
ONEXTON GEL PUMP 3 QL 1.967 / day
ROSADAN (CREAM, GEL) 1 ROSADAN (CREAM KIT, GEL KIT) 3 VANDAZOLE 1
QL 2 / day VELTIN 3 PA
QL 2 / day ZIANA 3 PA
ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) acyclovir 5% ointment 1
QL 0.167 / day DENAVIR 3 PA AL At least 12 yrs old docosanol 3
QL 0.167 / day XERESE 3 PA AL At least 6 yrs old
PAGE 39 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 0.167 / day ZOVIRAX 5% CREAM 2 PA AL At least 12 yrs old
QL 30 / fill ZOVIRAX 5% OINTMENT 3 PA AL At least 12 yrs old
LOCAL ANTI-INFECTIVES, MISCELLANEOUS arida 3 AVAR CLEANSER 1 AVAR (9.5%-5% FOAM, 9.5-5% CLEANSING PADS) 3 AVAR LS (10%-2% FOAM, 10-2% CLEANSING PADS, CLEANSER) 3
AVAR-E 1 AVAR-E GREEN 1 AVAR-E LS 3 AVC 3 benzalkonium chloride 3 BP 10-1 1 carbamide peroxide 3 chlorhexidine gluc 20% soln 3 CLARIFOAM EF 3 CLEANSING WASH 1 curity amd gauze 0.2% sponge 3 DERMAZENE 1 FEM PH 3 guaiacol 1 hydrocortisone-iodoquinol 1 hydrocortisone-iodoquinol-aloe 1
PAGE 40 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS iodine 3 IODOFLEX 3 IODOSORB 3 kerlix amd 3 kerlix amd bandage 3
KLARON 3 QL 4 / day
LUGOL'S STRONG IODINE SOLUTION 1 mafenide acetate 3 nitrofurazone 3
OVACE 3 QL 12 / day
OVACE PLUS 10% WASH 3 QL 15.767 / day
OVACE PLUS 10% CREAM 3 QL 2 / day
OVACE PLUS 9.8% FOAM 3 QL 3.334 / day
OVACE PLUS 9.8% LOTION 3 QL 4 / day
OVACE PLUS 10% SHAMPOO 3 QL 8 / day
OVACE PLUS WASH 3 QL 12 / day phenol (crystals, liquid) 3 phenol liquified 1 PLEXION (9.8-4.8% CLEANSER, 9.8-4.8% CLNSING CLOTH, 9.8- 4.8% CREAM, 9.8-4.8% LOTION) 3 povidone iodine powder 3 RELAGARD 3 ROSANIL 1
SEB-PREV 1 QL 12 / day selenium sulfide (2.25% shampoo, 2.5% lotion) 1 selenium sulfide powder 3
PAGE 41 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SELRX 3 SILVADENE 3 silver nitrate crystals 3 silver nitrate (0.5% soln, 10% ointment, 25% solution, 50% solution) 1 silver protein 3 silver sulfadiazine 1% cream 1 silver sulfadiazine powder 3 silver sulphadiazine 3 sodium sulfacetamide (sod sulfacetam clnsng gel, sodium 12 / day sulfacetamide wash) 1 QL sod sulfacetamide 10% shampoo 1 QL 8 / day sodium sulfacetamide-sulfur (sod sulfacet-sulfur 10-5% clsr, sodium sulf-sulfur cleanser) 1 sodium sulfacetamide-sulfur (sod sulface-sulf 9.8-4.8% clsr, sod sulface-sulfur 9-4.5% wash, sod sulfacet-sulfur 10-2% clsr, sod sulfacet-sulfur 10-4% pad, sod sulfacet-sulfur 10-5% lotn, sod sulfacetamide-sulfur foam, sod sulfacetamide-sulfur lotn, sod 1 sulfacetamide-sulfur susp, sodium sulfacet-sulfur wash, sulfacetamide-sulfur 8-4% susp, sulfacetamide-sulfur 10-2% crm, sulfacetamide-sulfur 10-5% crm)
SSD 1 SSS 10-5 (10-5 CREAM, 10-5 FOAM) 1 sulfacetamide sodium (sod top susp, sodium lotn) 1 QL 4 / day sulfacetamide sodium-sulfur 1 SULFACLEANSE 8-4 1 SULFAMYLON (8.5% CREAM, POWDER PACKET) 3 SUMADAN 9%-4.5% WASH 3 SUMAXIN (CLEANSING PADS, WASH) 3 SUMAXIN TS 3 TERSI FOAM 3
PAGE 42 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THERMAZENE 1 triclosan 3
ULESFIA 3 ST
VYTONE 3 ZENCIA 1 SCABICIDES AND PEDICULICIDES benzyl benzoate 3 crotamiton 3 ELIMITE 3
EURAX (CREAM, LOTION) 3 ST lindane (lotion, shampoo) 1 malathion 1
NATROBA 3 ST
OVIDE 3 ST permethrin 5% cream 1 permethrin technical liquid 3
SKLICE 3 ST spinosad 1 ANTI-INFLAMMATORY AGENTS (EENT)
CORTICOSTEROIDS (EENT)
ALREX 3 QL 0.5 / day
BECONASE AQ 3 QL 1.667 / day budesonide 32 mcg nasal spray 1 QL 0.574 / day budesonide micronized 3 CORTANE-B 3
PAGE 43 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DERMOTIC 3 dexamethasone 0.1% eye drop 1 QL 10 / fill
DUREZOL 3
FLAREX 3 QL 10 / fill flunisolide 0.025% spray 1 QL .834 / day fluocinolone acetonide oil 1 fluorometholone 1 QL 10 / fill fluticasone prop 50 mcg spray 1 QL 0.6 / day
FML 3 QL 10 / fill
FML FORTE 3 QL 10 / fill
FML S.O.P. 3 QL 4 / fill
LOTEMAX 0.5% OPHTHALMIC GEL 3 QL 10 / fill
LOTEMAX 0.5% EYE DROPS 3 QL 21 / fill
LOTEMAX 0.5% EYE OINTMENT 3 QL 4 / fill
MAXIDEX 3 QL 10 / fill mometasone furoate powder 3 mometasone furoate 50 mcg spry 1 QL 0.567 / day
NASONEX 3 QL 0.567 / day
OMNARIS 3 QL 0.434 / day
OMNIPRED 3 QL 21 / fill
QL 0.04 / day OZURDEX 4 S
PRED FORTE 3 QL 21 / fill
PRED MILD 3 QL 21 / fill
PAGE 44 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS prednisolone acetate 1 QL 21 / fill prednisolone sod 1% eye drop 1
QNASL 3 QL 0.3 / day
QNASL CHILDREN 3
QL max 1 per 365 days RETISERT 4 S
RHINOCORT AQUA 3 QL 0.574 / day triamcinolone 55 mcg nasal spr 1 QL 0.55 / day
TRIESENCE 3 QL 1 / day
VERAMYST 3 QL 0.357 / day
VEXOL 3 QL 10 / fill
ZETONNA 3 QL 0.22 / day
EENT ANTI-INFLAMMATORY AGENTS, MISC.
RESTASIS 2 PA
RESTASIS MULTIDOSE 2 PA
QL 2 / day XIIDRA 3 PA AL At least 17 yrs old
EENT NONSTEROIDAL ANTI-INFLAM. AGENTS
ACULAR 3 QL 15 / 30 days
ACULAR LS 3 QL 5 / fill
ACUVAIL 2 QL 1 / day bromfenac sodium 0.09% eye drp 1 QL 8 / rx
BROMSITE 3 QL 15/ 180 days
PAGE 45 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS diclofenac 0.1% eye drops 1 QL 5 / fill flurbiprofen sodium 1 QL 3/ fill
ILEVRO 3 QL 4 / fill ketorolac 0.4% ophth solution 1 QL 5 / fill ketorolac 0.5% ophth solution 1 QL 15 / 30 days
NEVANAC 3 QL 3/ fill
OCUFEN 3 QL 3/ fill
PROLENSA 3 QL 3/ fill
ANTI-INFLAMMATORY AGENTS (RESPIRATORY)
LEUKOTRIENE MODIFIERS
ACCOLATE 3 QL 2 / day montelukast sodium powder 3 montelukast sodium (4 mg granules, 4 mg tab chew, 5 mg tab 1 / day chew, 10 mg tablet) 1 QL SINGULAIR (4 MG GRANULES, 4 MG TABLET CHEW, 5 MG 1 / day TABLET CHEW, 10 MG TABLET) 3 QL zafirlukast 1 QL 2 / day
QL 4 / day zileuton er 3 ST
QL 4 / day ZYFLO 3 ST
QL 4 / day ZYFLO CR 3 ST
MAST-CELL STABILIZERS
ALOCRIL 3 QL 5 / fill
PAGE 46 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cromolyn 20 mg/2 ml neb soln 1 cromolyn 4% eye drops 1 QL 10 / fill cromolyn 100 mg/5 ml oral conc 1 cromolyn sodium powder 3 GASTROCROM 3 tranilast 3 ANTIANEMIA DRUGS
IRON PREPARATIONS
ACTIVE FE 3 GL Female
ATABEX EC 3 GL Female
CADEAU DHA 3 DIALYVITE 800 WITH IRON 3 DOTHELLE DHA 3
ELITE-OB 400 3 GL Female
ESCAVITE LQ 3 FEROCON 1 FEROTRINSIC 1 FERREX 150 FORTE 3 ferric sulfate 3 FERROCITE PLUS 1 ferrous fumarate 3 ferrous gluconate 3 ferrous sulfate 3 FOCALGIN 90 DHA 3
FOCALGIN CA 3 GL Female
FOCALGIN DSS 3 GL Female
PAGE 47 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FOLIVANE-PLUS 3 FORTAVIT 3 FUSION PLUS 3 FUSION SPRINKLES 3 HEMATINIC PLUS 1 HEMATINIC WITH FOLIC ACID 1 HEMATRON-AF 3 HEMAX 1 HEMOCYTE PLUS 3 HEMOCYTE-F 1 ICAR-C PLUS 3
INFED 4 S levomefolate dha 3 GL Female
MACNATAL CN DHA 3 GL Female
MAXARON FORTE 3 MULTICHEW 3 MULTIGEN FOLIC 3 MULTIGEN PLUS 3 multivitamin-iron-fluoride 1 MYKIDZ IRON FL 3
MYNATAL CAPSULE 3 GL Female
MYNATAL ADVANCE 3 GL Female
MYNATAL PLUS 3 GL Female
MYNATAL-Z 3 GL Female
NEWGEN 3 NUTRICAP 3
PAGE 48 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
O-CAL FA 3 GL Female
OBSTETRIX EC 3 GL Female
OBSTETRIX ONE 1 GL Female
OBTREX DHA 3 GL Female
PNV 29-1 3 GL Female
PNV-DHA + DOCUSATE 3 GL Female
PNV-OMEGA 3 GL Female
POLY-VI-FLOR WITH IRON (0.25 MG, 0.5 MG) 3 POLYSACCHARIDE IRON FORTE 1
PRENA1 PEARL 3 GL Female
PRENA1 TRUE 3 GL Female
PRENATABS RX 3 GL Female prenatal low iron 3 GL Female prenatal plus multivitamin tab 3
PREPLUS 3 GL Female
PRETAB 3 GL Female
PROFERRIN-FORTE 3 PROTECT IRON 3 PROVIDA DHA 3
PROVIDA OB 3 GL Female
R-NATAL OB 3 GL Female
RULAVITE DHA 3 TEXAVITE LQ 3 THRIVITE 19 3
PAGE 49 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THRIVITE RX 3 TL FOLATE 3
TRI-TABS DHA 3 GL Female
TRICARE PRENATAL 3 GL Female
TRIFERIC (272 MG POWDER PACKET, 272 MG/50 ML AMPULE) 4 S
TRINATE 3 GL Female
TRIVEEN-ONE 3 GL Female
VINATE DHA 3 GL Female
VINATE DHA RF 3 GL Female
VINATE GT 3 GL Female
VINATE II 3 GL Female
VINATE ONE 3 GL Female
VINATE ULTRA 3 GL Female
VIRT-ADVANCE 3 GL Female
VIRT-C DHA 3
VIRT-NATE 3 GL Female
VIRT-NATE DHA 3 GL Female
VIRT-PN 3 GL Female
VIRT-PN DHA 3 GL Female
VIRT-PN PLUS 3 GL Female
VITAFOL GUMMIES 3 GL Female
VITATRUE 3 GL Female
VIVA DHA 3 GL Female
PAGE 50 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VOL-TAB RX 3 GL Female
VP-CH-PNV 3 GL Female
VP-HEME OB 3 GL Female
VP-HEME ONE 3 GL Female
VP-PNV-DHA 3
VYNATAL-FA 1 GL Female
ANTIARRHYTHMIC AGENTS
ANTIARRHYTHMICS, MISCELLANEOUS
DIGITEK 1 DIGOX 1 digoxin (0.05 mg/ml solution, 0.125 mg tablet, 0.25 mg tablet, 125 mcg tablet, 250 mcg tablet) 1 digoxin 0.25 mg/ml syringe 1 LANOXIN 500 MCG/2 ML AMPULE 2 LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5 MCG TABLET, 250 MCG TABLET) 2
LANOXIN PEDIATRIC 2 magnesium sulfate crystals 3 magnesium sulfate (syringe, vial) 1 CLASS IA ANTIARRHYTHMICS disopyramide phosphate 1 NORPACE 3 NORPACE CR 100 MG CAPSULE 2 NORPACE CR 150 MG CAPSULE 3 procainamide hcl powder 3 procainamide 500 mg/ml vial 1 quinidine gluc er 324 mg tab 1
PAGE 51 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS quinidine gluc 80 mg/ml vial 1 quinidine sulfate (crystals, powder) 3 quinidine sulfate (sulf er 300 mg tab, sulfate 200 mg tab, sulfate 300 mg tab) 1 CLASS IB ANTIARRHYTHMICS
DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MG CAPSULE) 2 DILANTIN-125 2 lidocaine hcl 1% syringe 1 MED Medical Drug lidocaine hcl (2% 100 mg/5 ml, 2% 40 mg/2 ml, 2% 40 mg/2 ml vl, 30 mg/3 ml syr, 100 mg/10 ml syr) 1 mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mg capsule) 1 mexiletine hcl powder 3 PHENYTEK 2 phenytoin (50 mg infatab, 50 mg tablet chew, 100 mg/4 ml susp, 125 mg/5 ml susp) 1 phenytoin powder 3 phenytoin sodium powder 3 phenytoin sodium extended 1 XYLOCAINE-MPF 2% AMPUL 3 CLASS IC ANTIARRHYTHMICS flecainide acetate 1 propafenone hcl 1 propafenone hcl er 1 RYTHMOL 3 RYTHMOL SR 3 CLASS II ANTIARRHYTHMICS acebutolol hcl (200 mg capsule, 400 mg capsule) 1
PAGE 52 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS acebutolol hcl powder 3 atenolol powder 3 atenolol (25 mg tablet, 50 mg tablet) 1 LCG atenolol 100 mg tablet 1 atenolol-chlorthalidone 1 BETAPACE 3 BETAPACE AF 3 betaxolol hcl (10 mg tablet, 20 mg tablet) 1 bisoprolol fumarate 1 bisoprolol-hctz 5-6.25 mg tab 1 LCG bisoprolol-hydrochlorothiazide (2.5-6.25 mg tb, 10-6.25 mg tab) 1
CORGARD 3 CORZIDE 3
DUTOPROL 3 QL 2 / day
HEMANGEOL 4 S
INDERAL LA 3
INDERAL XL 3 ST
INNOPRAN XL 3 ST
LOPRESSOR (50 MG TABLET, 100 MG TABLET) 3 LOPRESSOR HCT 3 metoprolol succinate 1 metoprolol tartrate powder 3 metoprolol tartrate (25 mg tab, 50 mg tab) 1 LCG metoprolol tartrate (37.5 mg tb, 75 mg tab) 1 metoprolol tartrate 100 mg tab 1
PAGE 53 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS metoprolol-hydrochlorothiazide 1 nadolol powder 3 nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet) 1 nadolol-bendroflumethiazide 1 pindolol 1 propranolol hcl powder 3 propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml soln, 40 mg tablet, 40 mg/5 ml soln, 60 mg tablet, 80 mg tablet) 1 propranolol hcl er 1 propranolol-hydrochlorothiazid 1 SECTRAL 3 SORINE 1 sotalol 1 sotalol af 1 SOTYLIZE 3 TENORETIC 100 3 TENORETIC 50 3 TENORMIN 3 timolol maleate powder 3 timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 TOPROL XL 3 ZEBETA 3 ZIAC 3 CLASS III ANTIARRHYTHMICS amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) 1 CORDARONE 2 dofetilide 4 S
PAGE 54 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MULTAQ 3 PA
PACERONE 1
TIKOSYN 4 S
CLASS IV ANTIARRHYTHMICS adenosine powder 3
CALAN 3 QL 3 / day
CALAN SR 3 QL 1 / day
CARDIZEM 3 QL 4 / day
CARDIZEM CD (180 MG CAPSULE, 240 MG CAPSULE, 300 MG CAPSULE, 360 MG CAPSULE) 3
CARDIZEM CD 120 MG CAPSULE 3 QL 1 / day
CARDIZEM LA (300 MG TABLET, 360 MG TABLET, 420 MG 1 / day TABLET) 3 QL
CARDIZEM LA 120 MG TABLET 3 QL 4 / day
CARDIZEM LA 180 MG TABLET 3 QL 3 / day
CARDIZEM LA 240 MG TABLET 3 QL 2 / day
CARTIA XT 1 QL 1 / day
DILT XR 120 MG CAPSULE 1 QL 1 / day
DILT-XR (180 MG CAPSULE, 240 MG CAPSULE) 1 diltiazem 12hr er 1 diltiazem 24hr cd (24hr 180 mg cap, 24hr 240 mg cap, 24hr 300 mg cap, 24hr 360 mg cap) 1 diltiazem 24hr cd 120 mg cap 1 QL 1 / day diltiazem 24hr er (24hr er 240 mg cap, 24hr er 300 mg cap, 24hr er 360 mg cap, 24hr er 420 mg cap) 1 diltiazem 24hr er 180 mg cap 1 QL 1 / day
PAGE 55 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS diltiazem 24hr er (24hr er 120 mg cap, 24hr er 300 mg tab, 1 / day 24hr er 360 mg tab, 24hr er 420 mg tab) 1 QL diltiazem 24hr er 180 mg tab 1 QL 3 / day diltiazem 24hr er 240 mg tab 1 QL 2 / day diltiazem er (er 120 mg capsule, er 180 mg capsule) 1 QL 1 / day diltiazem er 240 mg capsule 1 diltiazem hcl powder 3 diltiazem 90 mg tablet 1 diltiazem hcl (30 mg tablet, 60 mg tablet, 120 mg tablet) 1 QL 4 / day
MATZIM LA (300 MG TABLET, 360 MG TABLET, 420 MG TABLET) 1 QL 1 / day
MATZIM LA 180 MG TABLET 1 QL 3 / day
MATZIM LA 240 MG TABLET 1 QL 2 / day
TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE) 1 QL 1 / day
TAZTIA XT (240 MG CAPSULE, 300 MG CAPSULE, 360 MG CAPSULE) 1
TIAZAC (ER 120 MG CAPSULE, ER 180 MG CAPSULE) 3 QL 1 / day
TIAZAC (ER 240 MG CAPSULE, ER 300 MG CAPSULE, ER 360 MG CAPSULE, ER 420 MG CAPSULE) 3 verapamil er (er 120 mg capsule, er 120 mg tablet, er 180 mg 1 / day capsule, er 180 mg tablet, er 240 mg capsule, er 240 mg tablet) 1 QL verapamil er pm 1 QL 1 / day verapamil 360 mg cap pellet 1 QL 1 / day verapamil hcl powder 3 verapamil 40 mg tablet 1 verapamil hcl (80 mg tablet, 120 mg tablet) 1 QL 3 / day verapamil sr 1 QL 1 / day
PAGE 56 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VERELAN 3 QL 1 / day
VERELAN PM 3 QL 1 / day
ANTIBACTERIALS
AMINOGLYCOSIDES amikacin 3 amikacin sulfate powder 3
PA BETHKIS 4 S PS gentamicin sulfate powder 3 gentamicin sulfate (20 mg/2 ml vial, ped 20 mg/2 ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 800 mg/20 ml vial) 1 kanamycin sulfate 3
PA KITABIS PAK 4 S neomycin sulfate powder 3 neomycin 500 mg tablet 1 paromomycin 250 mg capsule 1 paromomycin sulfate powder 3 streptomycin sulfate powder 3 streptomycin sulf 1 gm vial 1
PA TOBI 4 S
PA TOBI PODHALER 4 S
PA tobramycin (300 mg/5 ml ampule, pak 300 mg/5 ml) 4 S
PAGE 57 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tobramycin powder 3 tobramycin sulfate powder 3 tobramycin sulfate (1.2 gm vial, 1.2 gram/30 ml vial, 10 mg/ml vial, 40 mg/ml vial) 1 CHLORAMPHENICOL chloramphenicol 3 chloramphenicol palmitate 3 MACROLIDES clarithromycin powder 3 E.E.S. 200 3 E.E.S. 400 3 ERY-TAB 3 ERYPED 200 2 ERYPED 400 3 ERYTHROCIN STEARATE 3 erythromycin (250 mg filmtab, dr 250 mg cap, ec 250 mg cap, 500 mg filmtab) 1 erythromycin ethylsuccinate (200 mg/5 ml gran, es 400 mg tab) 1 PCE 3 QUINOLONES
AVELOX 3 QL 21 / fill
AVELOX ABC PACK 3 QL 5 / day
CIPRO 10% SUSPENSION 3 QL 10 / day
CIPRO 5% SUSPENSION 3 QL 7 / day
CIPRO (250 MG TABLET, 500 MG TABLET) 3 QL 2 / day
CIPRO XR 1,000 MG TABLET 3 QL 14 / 1 rx
CIPRO XR 500 MG TABLET 3 QL 28 / fill
PAGE 58 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ciprofloxacin 250 mg/5 ml susp 1 QL 7 / day ciprofloxacin 500 mg/5 ml susp 1 QL 10 / day ciprofloxacin er 1,000 mg tab 1 QL 14 / 1 rx ciprofloxacin er 500 mg tablet 1 QL 28 / fill ciprofloxacin hcl (crystals, powder) 3 ciprofloxacin hcl (100 mg tab, 250 mg tab, 500 mg tab, 750 mg 2 / day tab) 1 QL
QL 7 / day FACTIVE 3 PA
LEVAQUIN 3 QL 30 / fill levofloxacin powder 3 levofloxacin (25 mg/ml solution, 250 mg/10 ml soln, 500 mg/20 ml soln) 1 levofloxacin (250 mg tablet, 500 mg tablet, 750 mg tablet) 1 QL 30 / fill levofloxacin hemihydrate 3 moxifloxacin hcl powder 3 moxifloxacin hcl 400 mg tablet 1 QL 21 / fill nalidixic acid 3 ofloxacin (300 mg tablet, 400 mg tablet) 1 QL 56 / fill
SULFONAMIDES (SYSTEMIC)
AZULFIDINE (500 MG TABLET, ENTAB 500 MG) 3 BACTRIM 3 BACTRIM DS 3 sulfacetamide 3 sulfacetamide sod monohydrate 3 sulfacetamide sodium powder 3
PAGE 59 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sulfadiazine powder 3 sulfadiazine 500 mg tablet 1 sulfadiazine sodium 3 sulfamethoxazole 3 sulfamethoxazole-trimethoprim (ds tablet, ss tablet, susp) 1 sulfanilamide 3 sulfapyridine 3 sulfasalazine powder 3 sulfasalazine 500 mg tablet 1 sulfasalazine dr 1 sulfathiazole 3 SULFATRIM 1 sulfisoxazole 3 TETRACYCLINES
ACTICLATE 3 ST
ADOXA 3 ST
AVIDOXY 1 demeclocycline hcl 1
QL 7/ rx DORYX DR 200 MG TABLET 3 ST
DORYX DR 50 MG TABLET 3 ST
DORYX MPC 3 ST doxycycline hyclate powder 3 doxycycline hyclate (75 mg tab, 150 mg tab) 3 ST doxycycline hyc dr 200 mg tab 1 QL 7/ rx
PAGE 60 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS doxycycline hyclate (hyc dr 50 mg tab, hyc dr 75 mg tab, hyc dr 100 mg tab, hyc dr 150 mg tab, hyclate 50 mg cap, hyclate 100 1 mg cap, hyclate 100 mg tab) doxycycline ir-dr 1 QL 1 / day doxycycline mono 150 mg cap 1 QL 30 / fill doxycycline monohydrate powder 3 doxycycline monohydrate (25 mg/5 ml susp, mono 50 mg cap, mono 50 mg tablet, mono 75 mg capsule, mono 75 mg tablet, 1 mono 100 mg cap, mono 100 mg tablet, mono 150 mg tablet)
MINOCIN (50 MG CAP, 75 MG CAP, 100 MG CAP) 3 minocycline hcl (50 mg capsule, hcl 50 mg tablet, 75 mg capsule, hcl 75 mg tablet, 100 mg capsule, hcl 100 mg tablet) 1 minocycline hcl powder 3 minocycline er 45 mg tablet 1 QL 3 / day minocycline hcl er (er 90 mg tablet, er 135 mg tablet) 1 QL 1 / day
MONDOXYNE NL 1 MONODOX 3 MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1
QL 1 / day ORACEA 3 ST oxytetracycline hcl 3
PYLERA 2 QL 120 / 365 days
QL 1 / day SOLODYN 3 ST
TARGADOX 3 ST tetracycline 250 mg capsule 1 LCG tetracycline 500 mg capsule 1 tetracycline hcl powder 3
PAGE 61 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VIBRAMYCIN (25 MG/5 ML SUSP, 50 MG/5 ML SYRUP, 100 MG CAPSULE) 3 ST ANTIBACTERIALS, MISCELLANEOUS
BACITRACINS
BACIIM 1 bacitracin (unit vial, units vial) 1 GLYCOPEPTIDES
VANCOCIN HCL 3 vancomycin hcl (125 mg capsule, 250 mg capsule) 1 vancomycin hcl powder 3 vancomycin 125 mg/2.5 ml oral 1 LINCOMYCINS
CLEOCIN HCL 3 QL 4 / day
CLEOCIN PALMITATE 3 QL 70/ day
CLEOCIN PHOS 150 MG/ML VIAL 3 MED Medical Drug
CLEOCIN PHOSPHATE (9 G/60 ML VIAL, 300 MG/2 ML VIAL, 600 MG/4 ML VIAL, 900 MG/6 ML VIAL) 3 clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mg 4 / day capsule) 1 QL clindamycin hcl powder 3 clindamycin palmitate hcl 1 QL 70/ day clindamycin pediatric 1 QL 70/ day clindamycin phosphate (phos crystals, phosphate powder) 3 clindamycin phosphate (300 mg/2 ml vl, 600 mg/4 ml vl, 900 mg/6 ml vl) 1
LINCOCIN 3 lincomycin hcl powder 3
PAGE 62 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lincomycin hcl (3 gm/10 ml vial, 600 mg/2 ml vl) 1 QL 10 / day
OXAZOLIDINONES linezolid 100 mg/5 ml susp 1 QL 900 / rx linezolid 600 mg tablet 1 QL 2 / day
QL 6 / 30 days SIVEXTRO 200 MG TABLET 3 PA
QL 900 / rx ZYVOX 100 MG/5 ML SUSPENSION 3 PA
QL 2 / day ZYVOX 600 MG TABLET 3 PA
POLYMYXINS colistimethate 1 colistimethate sodium 3 colistin sulfate 3 COLY-MYCIN M PARENTERAL 3 polymyxin b sulfate (50 million unit, 100 million unit, sulfate powder) 3 polymyxin b sulfate vial 1 RIFAMYCINS
MYCOBUTIN 3
PRIFTIN 3 QL 1.25 / day rifabutin 1 RIFADIN (150 MG CAPSULE, 300 MG CAPSULE) 3 RIFAMATE 3 rifampin (150 mg capsule, 300 mg capsule) 1 rifampin powder 3
PAGE 63 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RIFATER 3 rifaximin 3
XIFAXAN 3 PA
ANTICHOLINERGIC AGENTS
ANTIMUSCARINICS/ANTISPASMODICS
ANASPAZ 3 ATROPEN 3 atropine sulfate powder 3 atropine sulfate (0.05 mg/ml syringe, 0.1 mg/ml abboject, 0.1 mg/ml syringe, 0.4 mg/ml vial, 1 mg/ml vial, 8 mg/20 ml vial) 1
ATROVENT HFA 3 QL 1.29 / day
B-DONNA 1 belladonna 3 belladonna leaf powder 3 belladonna-phenobarbital 1 BENTYL 10 MG/ML AMPUL 3 BENTYL (10 MG CAPSULE, 20 MG TABLET) 3 CANTIL 3 chlordiazepoxide-clidinium 1 clidinium bromide 3 CUVPOSA 3 dicyclomine hcl (10 mg capsule, 10 mg/5 ml soln, 20 mg tablet) 1 LCG dicyclomine hcl powder 3 dicyclomine 20 mg/2 ml vial 1 diphenoxylate-atropine (diphenoxylat-atrop 2.5-0.025/5, diphenoxylate-atrop 2.5-0.025) 1
DONNATAL (ELIXIR, TABLET) 3
PAGE 64 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DUODOTE 3 ED-SPAZ 1 glycopyrrolate powder 3 glycopyrrolate (1 mg tablet, 2 mg tablet) 1
QL 30 / day hydrocodone-homatropine mbr (soln, syrup) 1 AL At least 2 yrs old
QL 6 / day hydrocod-homatrop 5-1.5 mg tab 1 AL At least 6 yrs old
QL 30 / day HYDROMET 1 AL At least 2 yrs old hyoscyamine sulfate (0.125 mg odt, 0.125 mg tab sl, 0.125 mg/5 ml elix, 0.125 mg/ml drop, sulf 0.125 mg tab) 1 hyoscyamine sulfate powder 3 hyoscyamine sulfate er 1 hyoscyamine sulfate sr 1 HYOSYNE (0.125 MG/ML DROP, 125 MCG/5 ML ELIXIR) 1
INCRUSE ELLIPTA 2 QL 1 / day ipratropium bromide powder 3 ipratropium br 0.02% soln 1 QL 12.5 / day
LEVBID 3 LEVSIN 0.5 MG/ML AMPUL 3 LEVSIN 0.125 MG TABLET 3 LEVSIN-SL 3 LIBRAX 3 LOMOTIL 3 methscopolamine bromide powd 3 methscopolamine bromide (2.5 mg tb, 5 mg tab) 1
PAGE 65 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NULEV 1 OSCIMIN (0.125 MG ODT, 0.125 MG TABLET) 1 OSCIMIN SL 1 OSCIMIN SR 1 PHENOHYTRO 1 propantheline bromide powder 3 propantheline 15 mg tablet 1 ROBINUL 1 MG TABLET 3 ROBINUL (0.2 MG/ML VIAL, 0.4 MG/2 ML VIAL, 1 MG/5 ML VIAL, 4 MG/20 ML VIAL) 3
ROBINUL FORTE 3 scopolamine hbr powder 3 scopolamine 0.4 mg/ml vial 1 scopolamine methyl nitrate 3
QL 2 / day SEEBRI NEOHALER 3 PA AL At least 18 yrs old
SPIRIVA 2 QL 1 / day
SPIRIVA RESPIMAT 2 QL 1 / day
STIOLTO RESPIMAT 2 QL 0.134 / day
SYMAX 1 SYMAX DUOTAB 3 SYMAX-SL 1 SYMAX-SR 1
QL 0.04 / day TUDORZA PRESSAIR 3 PA
QL 6 / day TUSSIGON 1 AL At least 6 yrs old
PAGE 66 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIPARKINSONIAN AGENTS benztropine mesylate (0.5 mg tab, 1 mg tablet, 2 mg tablet) 1 benztropine mesylate (2 mg/2 ml ampule, 2 mg/2 ml vial) 1 COGENTIN 3 trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elx, 5 mg tablet) 1 ANTICOAGULANTS
ANTICOAGULANTS, MISCELLANEOUS
ACD-A 3 anticoagulant sodium citrate 1 citrate phosphate dextrose 3 sodium citrate 4% soln 1 sodium citrate (lock flush, syringe) 1 COUMARIN DERIVATIVES
COUMADIN 2 dicumarol 3
JANTOVEN (1 MG TABLET, 3 MG TABLET, 4 MG TABLET) 1 LCG
JANTOVEN (2 MG TABLET, 2.5 MG TABLET, 5 MG TABLET, 6 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 1 warfarin sodium powder 3 warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) 1 LCG warfarin sodium (6 mg tablet, 7.5 mg tablet, 10 mg tablet) 1 DIRECT FACTOR XA INHIBITORS
ARIXTRA (2.5 MG/0.5 ML SYRINGE, 5 MG/0.4 ML SYRINGE) 4 S
ARIXTRA (7.5 MG/0.6 ML SYRINGE, 10 MG/0.8 ML SYRINGE) 4 S
QL 2 / day ELIQUIS 3 PA
PAGE 67 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fondaparinux 5 mg/0.4 ml syr 4 S fondaparinux sodium (2.5 mg/0.5 ml syr, 7.5 mg/0.6 ml syr, 10 mg/0.8 ml syr) 4 S
QL 1 / day SAVAYSA 3 PA
XARELTO STARTER PACK 2
XARELTO (10 MG TABLET, 20 MG TABLET) 2 QL 1 / day
XARELTO 15 MG TABLET 2 QL 2 / day
DIRECT THROMBIN INHIBITORS
PRADAXA 2 QL 2 / day
HEPARINS enoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 ml syr, 60 mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/ml syringe, 120 4 S mg/0.8 ml syr, 150 mg/ml syringe, 300 mg/3 ml vial) FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML, 4 S 95,000 UNITS/3.8 ML VL) heparin sodium (sod 190 units/mg powd, sodium powder) 3 heparin sodium (2,000 unit/2 ml vial, 40,000 units/4 ml vial, 50,000 units/10 ml vl, 50,000 units/5 ml vial) 1 heparin sodium (5,000 unit/ 0.5 ml, 5,000 unit/0.5 ml, 5,000 unit/ml syr, 20,000 unit/ml vl) 1 LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 ML SYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 ML SYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/ML SYRINGE, 300 4 S MG/3 ML VIAL) ANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
APTIOM 3
PAGE 68 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) 3
QL 20 / day BRIVIACT 10 MG/ML ORAL SOLN 3 PA
QL 4 / day BRIVIACT (10 MG TABLET, 50 MG TABLET) 3 PA
QL 2 / day BRIVIACT 100 MG TABLET 3 PA
QL 8 / day BRIVIACT 25 MG TABLET 3 PA
QL 3 / day BRIVIACT 75 MG TABLET 3 PA carbamazepine powder 3 carbamazepine (100 mg tab chew, 100 mg/5 ml susp, 200 mg tablet) 1 carbamazepine er (er 100 mg cap, er 100 mg tablet, er 200 mg cap, er 200 mg tablet, er 300 mg cap, er 400 mg tablet) 1
CARBATROL 2 DEPAKENE (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3 DEPAKOTE 3 DEPAKOTE ER 2 DEPAKOTE SPRINKLE 2 divalproex sodium (dr 125 mg cap sprnk, sod dr 125 mg tab, sod dr 250 mg tab, sod dr 500 mg tab) 1 divalproex sodium er 1 EPITOL 1 EQUETRO 3 felbamate (400 mg tablet, 600 mg tablet, 600 mg/5 ml susp) 1 FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5 ML SUSP) 3 PA
PAGE 69 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FYCOMPA 0.5 MG/ML ORAL SUSP 3 QL 6 / day
FYCOMPA (2 MG TABLET, 2 MG-4 MG TABLET KIT, 4 MG TABLET, 1 / day 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) 3 QL
GABITRIL (12 MG TABLET, 16 MG TABLET) 2 GABITRIL (2 MG TABLET, 4 MG TABLET) 3 KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET) 3
KEPPRA XR 3 LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET, 25 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET) 3
LAMICTAL (BLUE) 3 LAMICTAL (GREEN) 3 LAMICTAL (ORANGE) 3 LAMICTAL ODT 3 LAMICTAL ODT (BLUE) 3 LAMICTAL ODT (GREEN) 3 LAMICTAL ODT (ORANGE) 3 LAMICTAL XR 3 LAMICTAL XR (BLUE) 3 LAMICTAL XR (GREEN) 3 LAMICTAL XR (ORANGE) 3 lamotrigine powder 3 lamotrigine (5 mg disper tablet, 25 mg disper tab, 25 mg tablet, 25 mg tb start kit, 100 mg tablet, 150 mg tablet, 200 mg tablet) 1 lamotrigine (blue) 1 lamotrigine (green) 1 lamotrigine (orange) 1 lamotrigine er 1 lamotrigine odt 1
PAGE 70 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lamotrigine odt (blue) 1 lamotrigine odt (green) 1 lamotrigine odt (orange) 1 levetiracetam powder 3 levetiracetam 500 mg/5 ml soln 1 QL 946 / 30 days levetiracetam (100 mg/ml soln, 250 mg tablet, 500 mg tablet, 750 mg tablet, 1,000 mg tablet) 1 levetiracetam er 1
QL 2 / day LYRICA (225 MG CAPSULE, 300 MG CAPSULE) 3 PA
LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, QL 3 / day 3 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE) PA
QL 30 / day LYRICA 20 MG/ML ORAL SOLUTION 3 PA magnesium chl 200 mg/ml vial 1 oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5 ml susp, 600 mg tablet) 1
OXTELLAR XR 3
QL 3 / day POTIGA (200 MG TABLET, 300 MG TABLET, 400 MG TABLET) 3 PA
QL 9 / day POTIGA 50 MG TABLET 3 PA pregabalin 3 QUDEXY XR 3 ROWEEPRA 1
QL 6 / day SABRIL (500 MG POWDER PACKET, 500 MG TABLET) 4 PA S
PAGE 71 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium valproate 3
QL 3 / day SPRITAM 3 AL At least 4 yrs old
TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET) 3 TEGRETOL XR 2 tiagabine hcl 1 TOPAMAX (15 MG SPRINKLE CAP, 25 MG SPRINKLE CAP, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET) 2 topiramate powder 3 topiramate (15 mg sprinkle cap, 25 mg sprinkle cap, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1 topiramate er 1 TRILEPTAL (150 MG TABLET, 300 MG TABLET, 300 MG/5 ML SUSP, 600 MG TABLET) 3
TROKENDI XR 3 valproic acid liquid 3 valproic acid (250 mg capsule, 250 mg/5 ml soln, 500 mg/10 ml sol) 1
QL 6 / day vigabatrin 4 PA S
VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET, STARTER KIT) 3
ZONEGRAN 2 zonisamide (25 mg capsule, 50 mg capsule, 100 mg capsule) 1 zonisamide powder 3 BARBITURATES (ANTICONVULSANTS)
BREVITAL SODIUM 3 MYSOLINE 3
PAGE 72 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elix, 20 mg/5 ml soln, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 1 64.8 mg tablet, 97.2 mg tablet, 100 mg tablet) phenobarbital sodium 1 primidone powder 3 primidone (50 mg tablet, 250 mg tablet) 1 BENZODIAZEPINES (ANTICONVULSANTS)
ATIVAN (0.5 MG TABLET, 1 MG TABLET) 3 QL 3 / day
ATIVAN 2 MG TABLET 3 QL 5 / day
ATIVAN (2 MG/ML VIAL, 4 MG/ML VIAL, 20 MG/10 ML VIAL, 40 MG/10 ML VIAL) 3 clonazepam powder 3 clonazepam (2 mg odt, 2 mg tablet) 1 QL 10 / day clonazepam (0.125 mg dis tab, 0.125 mg odt, 0.25 mg odt, 0.5 mg dis tablet, 0.5 mg odt, 0.5 mg tablet, 1 mg dis tablet, 1 mg 1 QL 3 / day odt, 1 mg tablet) clorazepate 15 mg tablet 1 QL 6 / day clorazepate 3.75 mg tablet 1 QL 24 / day clorazepate 7.5 mg tablet 1 QL 12 / day
DIASTAT 3 QL 0.07 / day
DIASTAT ACUDIAL 3 QL 0.07 / day diazepam (2.5 mg rectal gel sys, 10 mg rectal gel syst, 20 mg 0.07 / day rectal gel syst) 1 QL diazepam powder 3 diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml oral soln, 5 mg/5 ml solution, 5 mg/ml oral conc, 5 mg/ml vial, 10 mg tablet, 10 mg/2 ml carpuject, 10 mg/2 ml isecure, 10 mg/2 ml syringe, 50 1 mg/10 ml vial)
KLONOPIN (0.5 MG TABLET, 1 MG TABLET) 3 QL 3 / day
PAGE 73 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
KLONOPIN 2 MG TABLET 3 QL 10 / day lorazepam (2 mg tablet, 2 mg/ml oral concent) 1 QL 5 / day lorazepam powder 3 lorazepam (0.5 mg tablet, 1 mg tablet) 1 QL 3 / day lorazepam (2 mg/ml carpuject, 2 mg/ml syringe, 2 mg/ml vial, 4 mg/ml carpuject, 4 mg/ml vial, 20 mg/10 ml vial, 40 mg/10 ml 1 vial)
LORAZEPAM INTENSOL 1 QL 5 / day
PA ONFI (2.5 MG/ML SUSPENSION, 10 MG TABLET, 20 MG TABLET) 4 S
TRANXENE T-TAB 3.75 MG 3 QL 24 / day
TRANXENE T-TAB 7.5 MG 3 QL 12 / day
VALIUM 3 HYDANTOINS
CEREBYX 3 PEGANONE 3 SUCCINIMIDES
CELONTIN 3 ethosuximide (250 mg capsule, 250 mg/5 ml soln) 1 ethosuximide powder 3 ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 2 ANTIDEPRESSANTS
ANTIDEPRESSANTS, MISCELLANEOUS
APLENZIN 3 QL 1 / day benactyzine hcl 3
QL 2 / day BUPROBAN 1 HCR
PAGE 74 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS bupropion hcl powder 3 bupropion hcl 100 mg tablet 1 QL 5 / day bupropion hcl 75 mg tablet 1 QL 6 / day bupropion hcl sr 100 mg tablet 1 QL 4 / day
QL 2 / day bupropion hcl sr 150 mg tablet 1 HCR bupropion hcl sr 200 mg tablet 1 QL 2 / day bupropion hcl xl 150 mg tablet 1 QL 3 / day bupropion hcl xl 300 mg tablet 1 QL 1 / day
FORFIVO XL 3 QL 1 / day mirtazapine 7.5 mg tablet 1 QL 2 / day mirtazapine (15 mg odt, 15 mg tablet, 30 mg odt, 30 mg tablet, 1 / day 45 mg odt, 45 mg tablet) 1 QL mirtazapine anhydrous 3 REMERON (15 MG SOLTAB, 15 MG TABLET, 30 MG SOLTAB, 30 1 / day MG TABLET, 45 MG SOLTAB, 45 MG TABLET) 3 QL
WELLBUTRIN 100 MG TABLET 3 QL 5 / day
WELLBUTRIN 75 MG TABLET 3 QL 6 / day
WELLBUTRIN SR (150 MG TABLET, 200 MG TABLET) 3 QL 2 / day
WELLBUTRIN SR 100 MG TABLET 3 QL 4 / day
WELLBUTRIN XL 150 MG TABLET 3 QL 3 / day
WELLBUTRIN XL 300 MG TABLET 3 QL 1 / day
ZYBAN 3 QL 2 / day
MONOAMINE OXIDASE INHIBITORS
AZILECT 3
PAGE 75 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ELDEPRYL 3
EMSAM 3 QL 1 / day
MARPLAN 3 QL 6 / day
NARDIL 3 QL 6 / day
PARNATE 3 QL 6 / day phenelzine sulfate powder 3 phenelzine sulfate 15 mg tab 1 QL 6 / day rasagiline mesylate powder 3 rasagiline mesylate (0.5 mg tab, 1 mg tab) 1 selegiline hcl (5 mg capsule, 5 mg tablet) 1 selegiline hcl powder 3 tranylcypromine sulfate 1 QL 6 / day
ZELAPAR 3 SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR
CYMBALTA (20 MG CAPSULE, 30 MG CAPSULE) 3 QL 1 / day
CYMBALTA 60 MG CAPSULE 3 QL 2 / day desvenlafaxine er (er 50 mg tab, er 50 mg tablet, er 100 mg tab) 1 QL 1 / day desvenlafaxine fumarate er 1 QL 1 / day desvenlafaxine succinate er 1 QL 1 / day duloxetine hcl (dr 20 mg cap, dr 30 mg cap) 1 QL 1 / day duloxetine hcl (dr 40 mg cap, dr 60 mg cap) 1 QL 2 / day duloxetine hcl powder 3
EFFEXOR XR (37.5 MG CAPSULE, 150 MG CAPSULE) 3 QL 1 / day
EFFEXOR XR 75 MG CAPSULE 3 QL 3 / day
PAGE 76 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FETZIMA (20-40 MG TITRATION PAK, ER 20 MG CAPSULE, ER 40 QL 1 / day 3 MG CAPSULE, ER 80 MG CAPSULE, ER 120 MG CAPSULE) ST
IRENKA 3 QL 2 / day
KHEDEZLA 3 QL 1 / day
PRISTIQ 3 QL 1 / day
SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 QL 2 / day 3 MG TABLET, TITRATION PACK) ST venlafaxine hcl 1 venlafaxine hcl er 75 mg cap 1 QL 3 / day venlafaxine hcl er (er 37.5 mg cap, er 37.5 mg tab, er 75 mg tab, 1 / day er 150 mg cap, er 150 mg tab, er 225 mg tab) 1 QL SELECTIVE-SEROTONIN REUPTAKE INHIBITORS
BRISDELLE 3 QL 1 / day
CELEXA 3 QL 1 / day citalopram hbr 10 mg/5 ml soln 1 QL 20 / day
QL 1 / day citalopram hbr (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 LCG escitalopram oxalate 5 mg/5 ml 1 QL 20 / day escitalopram 20 mg tablet 1 QL 1 / day escitalopram oxalate (5 mg tablet, 10 mg tablet) 1 QL 1.5 / day fluoxetine dr 1 QL .144 / day fluoxetine hcl (20 mg capsule, 20 mg tablet) 1 QL 4 / day fluoxetine hcl 10 mg capsule 1 QL 1 / day fluoxetine hcl 40 mg capsule 1 QL 2 / day fluoxetine hcl powder 3
PAGE 77 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fluoxetine 20 mg/5 ml solution 1 QL 20 / day fluoxetine hcl (10 mg tablet, 60 mg tablet) 1 QL 1.5 / day fluvoxamine maleate (25 mg tab, 50 mg tab) 1 QL 1 / day fluvoxamine maleate 100 mg tab 1 QL 3 / day fluvoxamine maleate er 1 QL 2 / day
LEXAPRO 5 MG/5 ML SOLUTION 3 QL 20 / day
LEXAPRO (5 MG TABLET, 10 MG TABLET) 3 QL 1.5 / day
LEXAPRO 20 MG TABLET 3 QL 1 / day
QL 1 / day olanzapine-fluoxetine hcl 1 AL At least 10 yrs old paroxetine cr (cr 25 mg tablet, cr 37.5 mg tablet) 1 QL 2 / day paroxetine cr 12.5 mg tablet 1 QL 1 / day paroxetine er (er 25 mg tablet, er 37.5 mg tablet) 1 QL 2 / day paroxetine er 12.5 mg tablet 1 QL 1 / day paroxetine hcl (20 mg tablet, 40 mg tablet) 1 QL 1 / day paroxetine hcl 10 mg tablet 1 QL 1.5 / day paroxetine hcl 30 mg tablet 1 QL 2 / day paroxetine mesylate 1 QL 1 / day
PAXIL 10 MG/5 ML SUSPENSION 3 QL 42 / day
PAXIL (20 MG TABLET, 40 MG TABLET) 3 QL 1 / day
PAXIL 10 MG TABLET 3 QL 1.5 / day
PAXIL 30 MG TABLET 3 QL 2 / day
PAXIL CR (CR 25 MG TABLET, CR 37.5 MG TABLET) 3 QL 2 / day
PAGE 78 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PAXIL CR 12.5 MG TABLET 3 QL 1 / day
PEXEVA 3 QL 1 / day
PROZAC 10 MG PULVULE 3
PROZAC 20 MG PULVULE 3 QL 4 / day
PROZAC 40 MG PULVULE 3 QL 2 / day
PROZAC WEEKLY 3 QL 0.15 / day
SARAFEM 10 MG TABLET 3 QL 1.5 / day
SARAFEM 20 MG TABLET 3 QL 4 / day sertraline 20 mg/ml oral conc 1 QL 10 / day sertraline hcl powder 3
QL 1.5 / day sertraline hcl (25 mg tablet, 50 mg tablet) 1 LCG
QL 2 / day sertraline hcl 100 mg tablet 1 LCG
QL 1 / day SYMBYAX 3 AL At least 10 yrs old
ZOLOFT 20 MG/ML ORAL CONC 3 QL 10 / day
ZOLOFT (25 MG TABLET, 50 MG TABLET) 3 QL 1.5 / day
ZOLOFT 100 MG TABLET 3 QL 2 / day
SEROTONIN MODULATORS
QL 1 / day BRINTELLIX 3 ST nefazodone hcl 100 mg tablet 1 QL 6 / day nefazodone hcl 150 mg tablet 1 QL 4 / day
PAGE 79 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS nefazodone hcl 200 mg tablet 1 QL 3 / day nefazodone hcl 250 mg tablet 1 QL 2.5 / day nefazodone hcl 50 mg tablet 1 QL 12 / day trazodone hcl powder 3
QL 4 / day trazodone 100 mg tablet 1 LCG trazodone 150 mg tablet 1 QL 2 / day trazodone 300 mg tablet 1 QL 1 / day
QL 3 / day trazodone 50 mg tablet 1 LCG
QL 1 / day TRINTELLIX 3 ST
VIIBRYD 10-20 MG STARTER PACK 3
VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL 1 / day
TRICYCLICS, OTHER NOREPI-RU INHIBITORS amitriptyline hcl powder 3 amitriptyline hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 mg tab, 100 mg tab, 150 mg tab) 1 LCG amoxapine 1 ANAFRANIL 3 chlordiazepoxide-amitriptyline 1 clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule) 1 clomipramine hcl powder 3 desipramine hcl powder 3 desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) 1
PAGE 80 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS doxepin hcl (10 mg capsule, 25 mg capsule) 1 LCG doxepin hcl (10 mg/ml oral conc, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule) 1 doxepin hcl powder 3 imipramine hcl powder 3 imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) 1 LCG imipramine pamoate 1 maprotiline hcl 1 NORPRAMIN 3 nortriptyline hcl (10 mg/5 ml sol, hcl 10 mg cap, hcl 25 mg cap, hcl 50 mg cap, hcl 75 mg cap) 1 nortriptyline hcl powder 3 PAMELOR 3 perphenazine-amitriptyline 1 protriptyline hcl 1
SILENOR 3 QL 1 / day
SURMONTIL 3 TOFRANIL 3 TOFRANIL-PM 3 trimipramine maleate 1 ANTIDIABETIC AGENTS
ALPHA-GLUCOSIDASE INHIBITORS acarbose 100 mg tablet 1 QL 3 / day acarbose 25 mg tablet 1 QL 12 / day acarbose 50 mg tablet 1 QL 6 / day
GLYSET 3 QL 3 / day miglitol 1 QL 3 / day
PAGE 81 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PRECOSE 100 MG TABLET 3 QL 3 / day
PRECOSE 25 MG TABLET 3 QL 12 / day
PRECOSE 50 MG TABLET 3 QL 6 / day
AMYLINOMIMETICS
SYMLINPEN 120 2 QL 0.4 / day
SYMLINPEN 60 2 QL 0.2 / day
ANTIDIABETIC AGENTS, MISCELLANEOUS
PA KORLYM 4 S
WELCHOL 3.75G PACKET 2 QL 1 / day
WELCHOL 625 MG TABLET 2 QL 6 / day
BIGUANIDES
ACTOPLUS MET 3 QL 3 / day
QL 3 / day ACTOPLUS MET XR 15-1,000 MG TB 2 ST
QL 1 / day ACTOPLUS MET XR 30-1,000 MG TB 2 ST
QL 2 / day alogliptin-metformin 3 PA
QL 2 / day AVANDAMET 2 PA glipizide-metformin (2.5-500 mg, 5-500 mg) 1 QL 4 / day glipizide-metformin 2.5-250 mg 1 QL 8 / day
GLUCOPHAGE 1,000 MG TABLET 3 QL 2.5 / day
PAGE 82 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GLUCOPHAGE 500 MG TABLET 3 QL 5 / day
GLUCOPHAGE 850 MG TABLET 3 QL 3 / day
GLUCOPHAGE XR 500 MG TAB 3 QL 5 / day
GLUCOPHAGE XR 750 MG TAB 3 QL 3 / day
GLUCOVANCE 3 QL 4 / day glyburid-metformin 1.25-250 mg 1 QL 8 / day glyburide-metformin hcl (2.5-500 mg, 5-500 mg) 1 QL 4 / day
INVOKAMET 2 QL 2 / day
INVOKAMET XR 2 QL 2 / day
JANUMET 2 QL 2 / day
JANUMET XR (50-1,000 MG TABLET, 50-500 MG TABLET) 2 QL 2 / day
JANUMET XR 100-1,000 MG TABLET 2 QL 1 / day
JENTADUETO 2 QL 2 / day
JENTADUETO XR 2 QL 1 / day
QL 2 / day KAZANO 3 PA
QL 1 / day KOMBIGLYZE XR 3 PA metformin hcl powder 3
QL 2.5 / day metformin hcl 1,000 mg tablet 1 LCG
QL 5 / day metformin hcl 500 mg tablet 1 LCG
QL 3 / day metformin hcl 850 mg tablet 1 LCG
PAGE 83 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 5 / day metformin hcl er 500 mg tablet 1 C Only Glucophage ER generic covered
QL 3 / day metformin hcl er 750 mg tablet 1 C Only Glucophage ER generic covered metformin hydrochloride 3 pioglitazone-metformin 1 QL 3 / day
PRANDIMET 3 QL 5 / day repaglinide-metformin hcl 1 QL 5 / day
RIOMET 3 QL 25 / day
SYNJARDY 2 QL 2 / day
SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET, 12.5- 2 / day 1,000 MG TAB) 2 QL
SYNJARDY XR 25-1,000 MG TABLET 2 QL 1 / day
XIGDUO XR (5 MG-500 MG TABLET, 10 MG-1,000 MG TAB, 10 QL 1 / day 3 MG-500 MG TABLET) PA
QL 2 / day XIGDUO XR 5 MG-1,000 MG TABLET 3 PA
DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS
QL 1 / day alogliptin 3 PA
QL 1 / day alogliptin-pioglitazone 3 PA
QL 1 / day GLYXAMBI 3 PA
JANUVIA 2 QL 1 / day
PAGE 84 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day NESINA 3 PA
QL 1 / day ONGLYZA 3 PA
QL 1 / day OSENI 3 PA
TRADJENTA 2 QL 1 / day
INCRETIN MIMETICS
QL 14 / 1 rx ADLYXIN 10-20 MCG STARTER PACK 3 PA
QL 0.22 / day ADLYXIN 20 MCG MAINTENANCE PK 3 PA
BYDUREON 2 QL 0.15 / day
BYDUREON PEN 2 QL .15 / day
BYETTA 10 MCG DOSE PEN INJ 2 QL 0.8 / day
BYETTA 5 MCG DOSE PEN INJ 2 QL 0.04 / day
QL 0.5 / day SAXENDA 3 PA AL At least 18 yrs old
QL 0.6 / day SOLIQUA 100-33 2 PA
QL 0.144 / day TANZEUM 3 PA
TRULICITY 2 QL 0.08 / day
VICTOZA 2-PAK 2 QL 0.3 / day
PAGE 85 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VICTOZA 3-PAK 2 QL 0.3 / day
QL 0.5 / day XULTOPHY 100-3.6 3 PA
INSULINS
AFREZZA 3 PA
APIDRA 3 ST
APIDRA SOLOSTAR 3 ST
BASAGLAR KWIKPEN U-100 3 PA
HUMALOG (100 UNITS/ML CARTRIDGE, 100 UNITS/ML VIAL) 2 HUMALOG KWIKPEN U-100 2 HUMALOG KWIKPEN U-200 2 HUMALOG MIX 50-50 2 HUMALOG MIX 50-50 KWIKPEN 2 HUMALOG MIX 75-25 2 HUMALOG MIX 75-25 KWIKPEN 2 HUMULIN R U-500 2 HUMULIN R U-500 KWIKPEN 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXTOUCH 2 NOVOLOG (100 UNIT/ML CARTRIDGE, 100 UNIT/ML VIAL) 2 NOVOLOG FLEXPEN 2 NOVOLOG MIX 70-30 2 NOVOLOG MIX 70-30 FLEXPEN 2 TOUJEO SOLOSTAR 2
PAGE 86 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRESIBA FLEXTOUCH U-100 3 QL 1 / day
TRESIBA FLEXTOUCH U-200 3 QL 1 / day
MEGLITINIDES nateglinide 1 QL 3 / day
PRANDIN (0.5 MG TABLET, 1 MG TABLET) 3 QL 4 / day
PRANDIN 2 MG TABLET 3 QL 8 / day repaglinide (0.5 mg tablet, 1 mg tablet) 1 QL 4 / day repaglinide 2 mg tablet 1 QL 8 / day
STARLIX 3 QL 3 / day
SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB
QL 1 / day FARXIGA 3 PA
INVOKANA 2 QL 1 / day
JARDIANCE 2 QL 1 / day
SULFONYLUREAS
AMARYL 3 chlorpropamide 100 mg tablet 1 chlorpropamide 250 mg tablet 1 QL 3 / day
DIABETA 3
DUETACT 3 QL 1 / day glimepiride 1 LCG glipizide powder 3 glipizide (5 mg tablet, 10 mg tablet) 1 LCG glipizide er 1 LCG
PAGE 87 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS glipizide xl 1 GLUCOTROL 3 GLUCOTROL XL 3 glyburide powder 3 glyburide (1.25 mg tablet, 2.5 mg tablet, 5 mg tablet) 1 LCG glyburide micro 1.5 mg tab 1 glyburide micronized (3 mg tablet, 6 mg tablet) 1 LCG
GLYNASE 3 pioglitazone-glimepiride 1 QL 1 / day tolazamide 250 mg tablet 1 QL 4 / day tolazamide 500 mg tablet 1 QL 2 / day tolbutamide 1 QL 6 / day
THIAZOLIDINEDIONES
ACTOS 3 QL 1 / day
QL 3 / day AVANDIA 2 MG TABLET 2 PA
QL 2 / day AVANDIA 4 MG TABLET 2 PA
QL 1 / day AVANDIA 8 MG TABLET 2 PA pioglitazone hcl 1 QL 1 / day
ANTIEMETICS
5-HT3 RECEPTOR ANTAGONISTS
QL 0.15 / day AKYNZEO 4 PA S
PAGE 88 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANZEMET (50 MG TABLET, 100 MG TABLET) 3 QL 0.15 / day granisetron hcl 1 mg tablet 1 QL 6 / 30 days ondansetron hcl powder 3 ondansetron 4 mg/5 ml solution 1 QL 20 / day ondansetron hcl (4 mg/2 ml isecure, hcl 4 mg/2 ml syr, hcl 4 mg/2 ml vial) 4 S
QL 24 / 30 days ondansetron hcl (4 mg tablet, 8 mg tablet) 1 Max allowable- 3/day C with max of 24 / 30 days ondansetron hcl 24 mg tablet 1 QL 3 days
QL 24 / 30 days ondansetron odt 1 Max allowable- 3/day C with max of 24 / 30 days
QL 0.144 / day SANCUSO 4 S
ZOFRAN 4 MG/5 ML ORAL SOLN 3 QL 20 / day
QL 24 / 30 days ZOFRAN (4 MG TABLET, 8 MG TABLET) 3 Max allowable- 3/day C with max of 24 / 30 days
QL 24 / 30 days ZOFRAN ODT 3 Max allowable- 3/day C with max of 24 / 30 days
ZUPLENZ 3 QL 24 / 30 days
ANTIEMETICS, MISCELLANEOUS aprepitant 125-80-80 mg pack 1 QL 3/ fill aprepitant (40 mg capsule, 125 mg capsule) 1 QL 0.08 / day
PAGE 89 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS aprepitant 80 mg capsule 1 QL 0.15 / day
QL 0.67 / day CESAMET 4 PA S
QL 4 / day DICLEGIS 3 PA diphenidol hcl 3 dronabinol 1 QL 5 / day
EMEND TRIPACK 3 QL 3/ fill
EMEND (40 MG CAPSULE, 125 MG CAPSULE) 3 QL 0.08 / day
EMEND 80 MG CAPSULE 3 QL 0.15 / day
QL 5 / day MARINOL 3 PA scopolamine 1
QL 13 / day SYNDROS 3 PA AL At least 18 yrs old
TRANSDERM-SCOP 2
QL 0.15 / day VARUBI 4 PA S
ANTIHISTAMINES (GI DRUGS)
ANTIVERT 3 COMPAZINE 25 MG SUPPOSITORY 1 COMPAZINE (5 MG TABLET, 10 MG TABLET) 3 COMPRO 1
PAGE 90 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dimenhydrinate 50 mg/ml vial 1 meclizine hcl powder 3 meclizine hcl (12.5 mg tablet, 25 mg tablet) 1 prochlorperazine 1 prochlorperazine edisylate pow 3 prochlorperazine edisylate (5 mg/ml vial, 10 mg/2 ml vl) 1 prochlorperazine mal powder 3 prochlorperazine maleate (5 mg tablet, 10 mg tab) 1 TIGAN 300 MG CAPSULE 3 TIGAN 100 MG/ML VIAL 3 trimethobenzamide 300 mg cap 1 trimethobenzamide hcl powder 3 ANTIFUNGAL (SYSTEMIC)
ALLYLAMINES
LAMISIL (125 MG GRANULES PACKET, 187.5 MG GRANULES PACK, 250 MG TABLET) 3 terbinafine hcl powder 3 terbinafine hcl 250 mg tablet 1 ANTIFUNGALS, MISCELLANEOUS
GRIFULVIN V 3 GRIS-PEG 3 griseofulvin powder 3 griseofulvin (125 mg/5 ml susp, micro 500 mg tab) 1 griseofulvin micronized 3 griseofulvin ultramicrosize 1 LUGOL'S SOLUTION 1 potassium iodide (crystals, granules) 3
PAGE 91 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium caprylate 3 SSKI 3 strong iodine 1 triacetin 1 AZOLES
CRESEMBA 186 MG CAPSULE 3 PA
DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/ML SUSPENSION, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET) 3
QL 0.4 / day DIFLUCAN 150 MG TABLET 3 GL Female fluconazole powder 3 fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1
QL 0.4 / day fluconazole 150 mg tablet 1 LCG itraconazole 100 mg capsule 1 itraconazole powder 3 itraconazole micronized 3 ketoconazole powder 3 ketoconazole 200 mg tablet 1 ketoconazole micronized 3 NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET) 3
ONMEL 3 PA
SPORANOX (10 MG/ML SOLUTION, 100 MG CAPSULE) 3
VFEND 40 MG/ML SUSPENSION 3 QL 20 / day
VFEND (50 MG TABLET, 200 MG TABLET) 3 QL 4 / day voriconazole powder 3
PAGE 92 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS voriconazole 40 mg/ml susp 1 QL 20 / day voriconazole (50 mg tablet, 200 mg tablet) 1 QL 4 / day
POLYENES amphotericin b powder 3 amphotericin b 50 mg vial 1 nystatin (100,000 unit/ml susp, 500,000 unit oral tab, 500,000 unit/5 ml sus, 50,000,000 units pwd, 150,000,000 units pwd, 1 500,000,000 units pwd) PYRIMIDINES
ANCOBON 3 flucytosine (250 mg capsule, 500 mg capsule) 1 flucytosine powder 3 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)
ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) naftifine hcl 1 NAFTIN (1% CREAM, 1% GEL, 2% CREAM, 2% GEL) 3 ANTIFULGALS (SKIN, MUCOUS MEMBRANE),MISC
ALA-QUIN 3 clioquinol 3 EXODERM 1 iodochlorohydroxyquinoline 3 sodium thiosulfate crystals 3 TRIPLE DYE 3 undecylenic acid 3 zinc undecylenate 3 AZOLES (SKIN AND MUCOUS MEMBRANE) clotrimazole (crystalline, powder) 3
PAGE 93 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clotrimazole (1% cream, 1% solution, 10 mg troche) 1 clotrimazole-betamethasone (crm, lot) 1 econazole nitrate 1% cream 1 econazole nitrate powder 3 ECOZA 3 ERTACZO 3 EXELDERM (CREAM, SOLUTION) 3 EXTINA 3 GYNAZOLE 1 3
QL 0.54 / day JUBLIA 3 PA AL At least 18 yrs old ketoconazole (cream, foam, shampoo) 1 LOTRISONE 3
QL 2 / day LUZU 3 PA miconazole 3 miconazole 3 3 GL Female miconazole nitrate 3 NIZORAL 3 ORAVIG 3 oxiconazole nitrate 1 OXISTAT (CREAM, LOTION) 3
TERAZOL 3 3 GL Female
TERAZOL 7 3 terconazole (0.4% cream, 0.8% cream) 1 GL Female
QL 1.5 / day terconazole 80 mg suppository 1 GL Female
PAGE 94 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VUSION 3 XOLEGEL 3
QL 1.5 / day zazole 1 GL Female
BENZYLAMINES (SKIN AND MUCOUS MEMBRANE)
MENTAX 3 HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)
CICLODAN 0.77% CREAM KIT 3 CICLODAN 0.77% CREAM 1
CICLODAN 8% SOLUTION 1 QL 0.22 / day ciclopirox (0.77% cream, 0.77% gel, 0.77% topical susp, 1% shampoo) 1 ciclopirox 8% solution 1 QL 0.22 / day ciclopirox olamine 3 CNL 8 3 LOPROX (0.77% TOPICAL SUSP, 1% SHAMPOO) 3
PENLAC 3 QL 0.3 / day
OXABOROLES
QL 0.67 / day KERYDIN 3 PA AL At least 18 yrs old
POLYENES (SKIN AND MUCOUS MEMBRANE)
NYAMYC 1 NYATA 100,000 UNIT/GM POWDER 1 nystatin (unit/gm cream, unit/gm powd, units/gm oint) 1
PAGE 95 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS nystatin (1 billion unit powder, 2 billion unit powder, 5 billion unit powder, 10 billion unit powd, 15 billion unit powd, 50 million unit pwd, 100 million units pwd, 150 million unit pwd, 3 500 million unit pwd) nystatin-triamcinolone (cream, ointm) 1 NYSTOP 1 PEDIADERM AF 3 ANTIGLAUCOMA AGENTS
ALPHA-ADRENERGIC AGONISTS (EENT)
ALPHAGAN P 0.1% DROPS 2 QL 0.4 / day
ALPHAGAN P 0.15% EYE DROPS 3 QL 0.4 / day brimonidine tartrate (tartrate 0.15% drp, 0.2% eye drop) 1 QL 0.4 / day brimonidine tartrate powder 3
COMBIGAN 2 QL 0.334 / day
SIMBRINZA 3 QL 0.4 / day
BETA-ADRENERGIC BLOCKING AGENTS (EENT)
BETAGAN 3 QL 0.4 / day betaxolol hcl 0.5% eye drop 1 QL 0.54 / day
BETIMOL 0.25% EYE DROPS 3 QL 0.286 / day
BETIMOL 0.5% EYE DROPS 3 QL 0.334 / day
BETOPTIC S 3 QL 0.54 / day carteolol hcl 1 QL 0.334 / day
COSOPT 3 QL 0.334 / day
COSOPT PF 3 QL 0.5 / day dorzolamide-timolol 1 QL 0.334 / day
PAGE 96 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ISTALOL 3 QL 0.286 / day levobunolol hcl 1 QL 0.4 / day metipranolol 1 QL 0.334 / day timolol 0.5% eye drops 1 QL 0.334 / day timolol maleate (0.25% eye drops, 0.25% gel-solution, 0.25% 0.286 / day gfs gel-solution, 0.5% gel-solution, 0.5% gfs gel-solution) 1 QL
TIMOPTIC 0.25% EYE DROPS 3 QL 0.286 / day
TIMOPTIC 0.5% EYE DROPS 3 QL 0.334 / day
TIMOPTIC OCUDOSE 3 QL 2 / day
TIMOPTIC-XE 3 QL 0.286 / day
CARBONIC ANHYDRASE INHIBITORS (EENT) acetazolamide powder 3 acetazolamide (125 mg tablet, 250 mg tablet, er 500 mg cap) 1 acetazolamide sodium 1
AZOPT 2 QL 0.334 / day
DIAMOX SEQUELS 3 dorzolamide hcl 1 QL 0.4 / day methazolamide powder 3 methazolamide (25 mg tablet, 50 mg tablet) 1 NEPTAZANE 3
TRUSOPT 3 QL 0.4 / day
MIOTICS acetylcholine chloride 3 carbachol 3
ISOPTO CARPINE 3 QL 0.54 / day
PAGE 97 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MIOCHOL-E 3 MIOSTAT 3 PHOSPHOLINE IODIDE 3 pilocarpine hcl (1% drops, 2% drops, 4% drops) 1 QL 0.54 / day pilocarpine hcl powder 3 pilocarpine nitrate 3 OSMOTIC AGENTS mannitol powder 3 PROSTAGLANDIN ANALOGS bimatoprost 0.03% eye drops 1 QL 0.13 / day bimatoprost 0.03% eyelash soln 1 latanoprost 0.005% eye drops 1 QL 0.13 / day latanoprost oil 3 LATISSE 3
LUMIGAN 2 QL 0.13 / day
TRAVATAN Z 2 QL 0.167 / day travoprost 1 QL 0.167 / day
XALATAN 3 QL 0.13 / day
ZIOPTAN 3 QL 1 / day
ANTIHEMORRHAGIC AGENTS
ANTIHEPARIN AGENTS protamine sulfate powder 3 HEMOSTATICS
AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET, 1,000 MG TABLET) 3
PAGE 98 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS aminocaproic acid (6-aminocaproic powder, aminocaproic powder) 3
ASTRINGYN 3 AVITENE (FLOUR, SHEET 35MMX35MM, SHEET 70MMX35MM, SHEET 70MMX70MM) 3 DDAVP (0.1 MG TABLET, 0.2 MG TABLET, 10 MCG/0.1 ML SOLUTION) 3
DDAVP (4 MCG/ML AMPUL, 4 MCG/ML VIAL) 3 desmopressin acetate powder 3 desmopressin acetate (0.01% solution, 0.01% spray, 0.1 mg/ml sol, acetate 0.1 mg tb, acetate 0.2 mg tb) 1 desmopressin acetate (ac 4 mcg/ml ampul, ac 4 mcg/ml vial, 40 mcg/10 ml vial) 1
ENDO-AVITENE 3 EVARREST 3 EVICEL FIBRIN 2X5 ML SEALANT 3 GELFOAM POWDER 3
QL 6/ day plus 90/ 90 day LYSTEDA 3 limit GL Female
MONSEL'S 3 OXYCEL 3
RECOTHROM 4 S
STIMATE 4 S
SYRINGE AVITENE 3 TACHOSIL 3 THROMBIN-JMI (5,000 EPIST, 5,000 SYR, 5,000 VIAL, 20,000 PUMP, 20,000 SYR, 20,000 VIAL) 3 TISSEEL VHSD (2 ML KIT, FROZEN 2 ML SYR, 4 ML KIT, FROZEN 4 ML SYR, 10 ML KIT, FROZEN 10 ML SYR) 3
PAGE 99 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tranexamic acid powder 3 ULTRAFOAM 3 ANTIHISTAMINE DRUGS
FIRST GENERATION ANTIHISTAMINES
ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID) 1 AL At least 2 yrs old brompheniramine maleate 3 carbinoxamine maleate (4 mg/5 ml liquid, maleate 4 mg tab) 1 AL At least 2 yrs old chlorpheniramine maleate 3 clemastine fumarate powder 3 AL At least 2 yrs old clemastine fum 2.68 mg tab 1 AL At least 2 yrs old cyproheptadine hcl powder 3 AL At least 2 yrs old cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet, 4 mg/10 ml At least 2 yrs old syrp) 1 AL dimenhydrinate 100% powder 3 diphenhydramine hcl (12.5 mg/5 ml, 25 mg/10 ml) 1 diphenhydramine hcl powder 3 diphenhydramine hcl (50 mg/ml syrng, 50 mg/ml vial) 1 doxylamine succinate 3
KARBINAL ER 3 AL At least 2 yrs old
RYVENT 3 ST triprolidine hcl 3 OTHER ANTIHISTAMINES ketotifen fumarate 3 SECOND GENERATION ANTIHISTAMINES cetirizine hcl 1 QL 10 / day
CLARINEX 0.5 MG/ML (2.5 MG/5) 3 QL 10 / day
PAGE 100 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CLARINEX 5 MG TABLET 3 QL 1 / day
CLARINEX-D 12 HOUR 3 QL 2 / day desloratadine (2.5 mg odt, 5 mg odt, 5 mg tablet) 1 QL 1 / day fexofenadine hcl powder 3 fexofenadine hcl 180 mg tablet 1 QL 1 / day fexofenadine hcl 30 mg tablet 1 fexofenadine hcl 60 mg tablet 1 QL 2 / day levocetirizine dihydrochl pwdr 3 levocetirizine 2.5 mg/5 ml sol 1 QL 30 / day levocetirizine 5 mg tablet 1 QL 1 / day loratadine 3 loratadine micronized 3
SEMPREX-D 3 QL 4 / day
XYZAL 2.5 MG/5 ML SOLUTION 3 QL 30 / day
XYZAL 5 MG TABLET 3 QL 1 / day
ANTIHISTAMINES (RESPIRATORY TRACT AGNTS)
FIRST GENERATION ANTIHIST.(RESPIR TRACT)
BROMFED DM 1 AL At least 2 yrs old brompheniramine-pseudoephed-dm 1 AL At least 2 yrs old
CENTERGY 1 CENTERGY DM 1
QL 10 / day hydrocodone-chlorpheniramne er 1 AL At least 6 yrs old
PHENERGAN (25 MG/ML AMPUL, 25 MG/ML VIAL, 50 MG/ML At least 2 yrs old AMPUL, 50 MG/ML VIAL) 3 AL
PAGE 101 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS promethazine hcl powder 3 AL At least 2 yrs old
AL At least 2 yrs old promethazine 25 mg tablet 1 LCG promethazine hcl (6.25 mg/5 ml syrp, 12.5 mg tablet, 50 mg At least 2 yrs old tablet) 1 AL promethazine hcl (25 mg/ml ampul, 25 mg/ml syringe, 25 At least 2 yrs old mg/ml vial, 50 mg/ml ampul, 50 mg/ml vial) 1 AL promethazine vc 1 promethazine-codeine 1 promethazine-dm solution 1 AL At least 2 yrs old
AL At least 2 yrs old promethazine-dm syrup 1 LCG promethazine-phenylephrine 1 RESPA A.R. 3
QL 6 / day TUSSICAPS 3 AL At least 6 yrs old
QL 10 / day TUSSIONEX 3 AL At least 6 yrs old
QL 4 / day VITUZ 3 AL At least 6 yrs old
SECOND GENERATION ANTIHIST(RESPIR TRACT)
DYMISTA 2 QL 0.8 / day
ANTIHYPOGLYCEMIC AGENTS
ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS diazoxide 3 PROGLYCEM 3
PAGE 102 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GLYCOGENOLYTIC AGENTS
GLUCAGEN 2 GLUCAGON EMERGENCY KIT 2 glucagon hcl 1 ANTILIPEMIC AGENTS
ANTILIPEMIC AGENTS, MISCELLANEOUS
QL 1 / day JUXTAPID (20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE) 4 PA S
QL 2 / day JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE) 4 PA S
QL 0.15 / day KYNAMRO 4 PA S
LOVAZA 3 QL 4 / day niacin 3 niacin er (er 750 mg tablet, er 1,000 mg tablet) 1 QL 2 / day niacin er 500 mg tablet 1 QL 3 / day
NIACOR 3 QL 12 / day
NIASPAN (ER 750 MG TABLET, ER 1,000 MG TABLET) 3 QL 2 / day
NIASPAN ER 500 MG TABLET 3 QL 3 / day nicotinic acid 3 omega-3 acid ethyl esters 1 QL 4 / day
TRIKLO 1 QL 4 / day
PAGE 103 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 4 / day VASCEPA 3 ST
VIT 3 3 BILE ACID SEQUESTRANTS cholestyramine powder 1 QL 24 / day cholestyramine packet 1 QL 4 / day cholestyramine light powder 1 QL 24 / day cholestyramine light packet 1 QL 4 / day cholestyramine resin 3 COLESTID (FLAVORED GRANULES, GRANULES, GRANULES 6 / day PACKET) 3 QL
COLESTID 1 GM TABLET 3 QL 4 / day colestipol hcl (granules, granules packet) 1 QL 6 / day colestipol hcl (hcl 1 gm tablet, micronized 1 gm tab) 1 QL 4 / day
PREVALITE POWDER 1 QL 24 / day
PREVALITE PACKET 1 QL 4 / day
QUESTRAN POWDER 3 QL 24 / day
QUESTRAN PACKET 3 QL 4 / day
QUESTRAN LIGHT 3 QL 24 / day
CHOLESTEROL ABSORPTION INHIBITORS ezetimibe 1 QL 1 / day ezetimibe-simvastatin 1 QL 1 / day
VYTORIN 3 QL 1 / day
ZETIA 3 QL 1 / day
PAGE 104 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FIBRIC ACID DERIVATIVES
ANTARA 30 MG CAPSULE 3 QL 2 / day
ANTARA 90 MG CAPSULE 3 QL 1 / day fenofibrate (40 mg tablet, 50 mg capsule) 1 QL 2 / day fenofibrate (67 mg capsule, 130 mg capsule, 134 mg capsule, 1 / day 145 mg tablet, 150 mg capsule, 160 mg tablet, 200 mg capsule) 1 QL fenofibrate (43 mg capsule, 48 mg tablet, 54 mg tablet) 1 QL 2 / day fenofibrate 120 mg tablet 1 QL 1 / day fenofibric acid (105 mg tablet, dr 135 mg cap) 1 QL 1 / day fenofibric acid (35 mg tablet, dr 45 mg cap) 1 QL 2 / day
FENOGLIDE 120 MG TABLET 3 QL 1 / day
FENOGLIDE 40 MG TABLET 3 QL 2 / day
FIBRICOR 105 MG TABLET 3 QL 1 / day
FIBRICOR 35 MG TABLET 3 QL 2 / day gemfibrozil powder 3 gemfibrozil 600 mg tablet 1 QL 2 / day
LIPOFEN 150 MG CAPSULE 3 QL 1 / day
LIPOFEN 50 MG CAPSULE 3 QL 2 / day
LOFIBRA (67 MG CAPSULE, 134 MG CAPSULE, 160 MG TABLET, 1 / day 200 MG CAPSULE) 3 QL
LOFIBRA 54 MG TABLET 3 QL 2 / day
LOPID 3 QL 2 / day
TRICOR 145 MG TABLET 3 QL 1 / day
TRICOR 48 MG TABLET 3 QL 2 / day
PAGE 105 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRIGLIDE 3 QL 1 / day
TRILIPIX DR 135 MG CAPSULE 3 QL 1 / day
TRILIPIX DR 45 MG CAPSULE 3 QL 2 / day
HMG-COA REDUCTASE INHIBITORS
ADVICOR (500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET) 3 QL 2 / day
ADVICOR 1,000 MG-40 MG TABLET 3 QL 1 / day
ALTOPREV 3 QL 1 / day amlodipine-atorvastatin 1 QL 1 / day atorvastatin calcium 1 QL 1 / day
CADUET 3 QL 1 / day
CRESTOR 3 QL 1 / day fluvastatin er 1 QL 1 / day fluvastatin sodium 20 mg cap 1 QL 1 / day fluvastatin sodium 40 mg cap 1 QL 2 / day
LESCOL 20 MG CAPSULE 3 QL 1 / day
LESCOL 40 MG CAPSULE 3 QL 2 / day
LESCOL XL 3
LIPITOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL 1 / day
LIPITOR 80 MG TABLET 3
LIVALO 3 QL 1 / day lovastatin (10 mg tablet, 20 mg tablet) 1 QL 1 / day lovastatin 40 mg tablet 1 QL 2 / day
PRAVACHOL 3 QL 1 / day
PAGE 106 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day pravastatin sodium (10 mg tab, 20 mg tab) 1 LCG pravastatin sodium 40 mg tab 1 QL 1 / day pravastatin sodium 80 mg tab 1 rosuvastatin calcium 1 QL 1 / day
SIMCOR (500-20 MG TABLET, 750-20 MG TABLET, 1,000-20 MG 2 / day TABLET) 3 QL
SIMCOR (500-40 MG TABLET, 1,000-40 MG TABLET) 3 QL 1 / day simvastatin powder 3 simvastatin (20 mg tablet, 40 mg tablet) 1 QL 1.5 / day
QL 1.5 / day simvastatin 10 mg tablet 1 LCG
QL 1 / day simvastatin 5 mg tablet 1 LCG
QL 1 / day simvastatin 80 mg tablet 1 PA
ZOCOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL 1.5 / day
ZOCOR 5 MG TABLET 3 QL 1 / day
QL 1 / day ZOCOR 80 MG TABLET 3 PA
PCSK9 INHIBITORS
QL 0.08 / day PA PRALUENT PEN 4 S PS
QL 0.08 / day PA PRALUENT SYRINGE 4 S PS
PAGE 107 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 0.13 / day PA REPATHA PUSHTRONEX 4 S PS
QL 0.08 / day PA REPATHA SURECLICK 4 S PS
QL 0.08 / day PA REPATHA SYRINGE 4 S PS
ANTIMIGRAINE AGENTS
SELECTIVE SEROTONIN AGONISTS almotriptan malate 1 QL 0.4 / day
ALSUMA 3 QL 0.167 / day
AMERGE 3 QL 0.3 / day
AXERT 3 QL 0.4 / day eletriptan hbr 1 QL 0.4 / day
FROVA 3 QL 0.6 / day frovatriptan succinate 1 QL 0.6 / day
IMITREX (4 MG/0.5 ML CARTRIDGES, 4 MG/0.5 ML PEN INJECT, 6 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML PEN INJECT, 6 MG/0.5 3 QL 0.167 / day ML VIAL)
IMITREX (5 MG NASAL SPRAY, 20 MG NASAL SPRAY) 3 QL 6 / 30 days
IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG TABLET) 3 QL 0.3 / day
PAGE 108 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MAXALT 3 QL 0.6 / day
MAXALT MLT 3 QL 0.6 / day naratriptan 1 QL 0.6 / day naratriptan hcl 1 QL 0.6 / day
ONZETRA XSAIL 3 ST
RELPAX 3 QL 0.4 / day rizatriptan (5 mg odt, 5 mg tablet, 10 mg odt, 10 mg tablet) 1 QL 0.6 / day sumatriptan powder 3 sumatriptan (5 mg nasal spray, 20 mg nasal spray) 1 QL 6 / 30 days sumatriptan succinate (4 mg/0.5 ml cart, 4 mg/0.5 ml inject, 6 mg/0.5 ml inject, 6 mg/0.5 ml refill, 6 mg/0.5 ml syrng, 6 1 QL 0.167 / day mg/0.5 ml vial) sumatriptan succinate powder 3 sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg 0.3 / day tablet) 1 QL
SUMAVEL DOSEPRO 3 QL 0.134 / day
QL 0.3 / day TREXIMET 3 ST
QL 0.134 / day ZEMBRACE SYMTOUCH 3 ST zolmitriptan powder 3 QL 0.2 / day zolmitriptan (2.5 mg tablet, 5 mg tablet) 1 QL 0.2 / day zolmitriptan odt 1 QL 0.2 / day
ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 2 QL 0.2 / day
ZOMIG (2.5 MG TABLET, 5 MG TABLET) 3 QL 0.2 / day
ZOMIG ZMT 3 QL 0.2 / day
PAGE 109 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, MISCELLANEOUS clofazimine 3 dapsone powder 3 dapsone (25 mg tablet, 100 mg tablet) 1 ANTITUBERCULOSIS AGENTS aminosalicylic acid 3 BIAXIN (250 MG TABLET, 250 MG/5 ML SUSPENSION, 500 MG TABLET) 3
CAPASTAT SULFATE 3 clarithromycin (125 mg/5 ml sus, 250 mg tablet, 250 mg/5 ml sus, 500 mg tablet) 1 clarithromycin er 1 cycloserine 250 mg capsule 1 cycloserine powder 3 ethambutol hcl 1 isoniazid powder 3 isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) 1 isoniazid 100 mg/ml vial 1 MYAMBUTOL 3 PASER 3 pyrazinamide powder 3 pyrazinamide 500 mg tablet 1
SIRTURO 3 PA sodium 4-aminosalicylate 3 TRECATOR 3
PAGE 110 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIPARKINSONIAN AGENTS (CNS)
ADAMANTANES (CNS) amantadine (50 mg/5 ml solution, 100 mg capsule, 100 mg tablet, 100 mg/10 ml soln) 1 amantadine hcl 3 CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. carbidopa-levodopa-entacapone 1 COMTAN 3 entacapone 1 STALEVO 100 3 STALEVO 125 3 STALEVO 150 3 STALEVO 200 3 STALEVO 50 3 STALEVO 75 3 TASMAR 3 tolcapone 1 DOPAMINE PRECURSORS carbidopa-levodopa (carbidopa-levo 10-100 mg odt, carbidopa- levo 25-100 mg odt, carbidopa-levo 25-250 mg odt, carbidopa- levodopa 10-100 tab, carbidopa-levodopa 25-100 tab, 1 carbidopa-levodopa 25-250 tab) carbidopa-levodopa er 1
QL 1 / day DUOPA 4 PA S levodopa 3 RYTARY 3
PAGE 111 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SINEMET 10-100 3 SINEMET 25-100 3 SINEMET 25-250 3 SINEMET CR 3 MONOAMINE OXIDASE B INHIBITORS
QL 1 / day XADAGO 3 PA AL At least 18 yrs old
ANTIPROTOZOALS
AMEBICIDES
FLAGYL (250 MG TABLET, 375 CAPSULE, 500 MG TABLET) 3 FLAGYL ER 3 iodoquinol 3 metronidazole powder 3 metronidazole (250 mg tablet, 375 mg capsule, 500 mg tablet) 1 metronidazole benzoate 3 ANTIMALARIALS atovaquone-proguanil hcl 1 PA chloroquine phosphate powder 3 chloroquine phosphate (250 mg tablet, 500 mg tablet) 1 COARTEM 3 hydroxychloroquine sulf pwd 3 hydroxychloroquine 200 mg tab 1
MALARONE 3 PA mefloquine hcl 1 PLAQUENIL 3
PAGE 112 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS primaquine 1 pyrimethamine 3
QL 42 / 365 days QUALAQUIN 3 PA quinacrine hcl 3 quinine hcl 3
QL 42 / 365 days quinine sulfate 324 mg capsule 1 PA quinine sulfate powder 3 ANTIPROTOZOALS, MISCELLANEOUS
ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) 3 PA antimony trichloride 3 atovaquone 1 PA
IMPAVIDO 4 S
MEPRON 3 NEBUPENT 3 PENTAM 300 3 TINDAMAX 3 tinidazole powder 3 tinidazole (250 mg tablet, 500 mg tablet) 1 ANTIPSYCHOTIC AGENTS
ANTIPSYCHOTICS, MISCELLANEOUS
ADASUVE 3 AL At least 18 yrs old loxapine 1 AL At least 18 yrs old molindone hcl 1 ORAP 3
PAGE 113 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS pimozide 1 ATYPICAL ANTIPSYCHOTICS
QL 1 / day ABILIFY 3 AL At least 6 yrs old
QL 0.04 / day ABILIFY MAINTENA (ER 300 MG SYR, ER 300 MG VL, ER 400 MG SYR, ER 400 MG VL) 3 PA AL At least 18 yrs old
QL 30 / day aripiprazole 1 mg/ml solution 1 AL At least 6 yrs old aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg QL 1 / day 1 tablet, 20 mg tablet, 30 mg tablet) AL At least 6 yrs old
QL 1 / day aripiprazole odt 1 AL At least 6 yrs old
QL 0.15 / day ARISTADA ER 1064 MG/3.9 ML SYR 3 PA AL At least 18 yrs old
QL 0.07 / day ARISTADA ER 441 MG/1.6 ML SYRN 3 PA AL At least 18 yrs old
QL 0.08 / day ARISTADA ER 662 MG/2.4 ML SYRN 3 PA AL At least 18 yrs old
QL 0.12 / day ARISTADA ER 882 MG/3.2 ML SYRN 3 PA AL At least 18 yrs old
QL 9 / day clozapine 100 mg tablet 1 AL At least 18 yrs old
PAGE 114 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 4 / day clozapine 200 mg tablet 1 AL At least 18 yrs old
QL 18 / day clozapine 25 mg tablet 1 AL At least 18 yrs old
QL 3 / day clozapine 50 mg tablet 1 AL At least 18 yrs old clozapine odt (odt 12.5 mg tablet, odt 25 mg tablet, odt 150 mg QL 3 / day 1 tablet, odt 200 mg tablet) AL At least 18 yrs old
QL 9 / day clozapine odt 100 mg tablet 1 AL At least 18 yrs old
QL 9 / day CLOZARIL 100 MG TABLET 3 AL At least 18 yrs old
QL 18 / day CLOZARIL 25 MG TABLET 3 AL At least 18 yrs old
QL 8 / rx FANAPT TITRATION PACK 3 AL At least 18 yrs old
QL 2 / day FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) 3 ST AL At least 18 yrs old
FAZACLO (12.5 MG ODT, 25 MG ODT, 150 MG ODT, 200 MG QL 3 / day 3 ODT) AL At least 18 yrs old
QL 9 / day FAZACLO 100 MG ODT 3 AL At least 18 yrs old
QL 2 / day GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MG CAPSULE) 3 ST AL At least 18 yrs old
PAGE 115 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GEODON 20 MG/ML VIAL 3 ST
ST INVEGA 3 AL At least 12 yrs old
QL 0.0333 / day INVEGA SUSTENNA 117 MG/0.75 ML 3 PA AL At least 18 yrs old
QL 0.04 / day INVEGA SUSTENNA 156 MG/ML SYRG 3 PA AL At least 18 yrs old
QL 0.057 / day INVEGA SUSTENNA 234 MG/1.5 ML 3 PA AL At least 18 yrs old
QL 0.0111 / day INVEGA SUSTENNA 39 MG/0.25 ML 3 PA AL At least 18 yrs old
QL 0.02 / day INVEGA SUSTENNA 78 MG/0.5 ML 3 PA AL At least 18 yrs old
QL 0.0333 / day INVEGA TRINZA 273 MG/0.875 ML 3 PA AL At least 18 yrs old
QL 0.057 / day INVEGA TRINZA 410 MG/1.315 ML 3 PA AL At least 18 yrs old
QL 0.067 / day INVEGA TRINZA 546 MG/1.75 ML 3 PA AL At least 18 yrs old
PAGE 116 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 0.1 / day INVEGA TRINZA 819 MG/2.625 ML 3 PA AL At least 18 yrs old
QL 1 / day LATUDA 3 AL At least 13 yrs old
QL 2 / day NUPLAZID 4 PA S olanzapine (2.5 mg tablet, 5 mg tablet) 1 QL 6 / day olanzapine 10 mg tablet 1 QL 3 / day olanzapine 15 mg tablet 1 QL 2 / day olanzapine 20 mg tablet 1 QL 1 / day olanzapine 7.5 mg tablet 1 QL 4 / day olanzapine 10 mg vial 1 olanzapine odt 10 mg tablet 1 QL 3 / day olanzapine odt 15 mg tablet 1 QL 2 / day olanzapine odt 20 mg tablet 1 QL 1 / day olanzapine odt 5 mg tablet 1 QL 6 / day paliperidone er 1 AL At least 12 yrs old
QL 6 / day quetiapine fumarate (25 mg tab, 50 mg tab) 1 AL At least 10 yrs old
QL 3 / day quetiapine fumarate 100 mg tab 1 AL At least 10 yrs old
QL 1.5 / day quetiapine fumarate 200 mg tab 1 AL At least 10 yrs old
PAGE 117 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day quetiapine fumarate 300 mg tab 1 AL At least 10 yrs old
QL 2 / day quetiapine fumarate 400 mg tab 1 AL At least 10 yrs old
QL 5 / day quetiapine er 150 mg tablet 1 AL At least 10 yrs old
QL 4 / day quetiapine er 200 mg tablet 1 AL At least 10 yrs old
QL 6 / day quetiapine er 50 mg tablet 1 AL At least 10 yrs old
QL 2 / day quetiapine fumarate er (er 300 mg tablet, er 400 mg tablet) 1 AL At least 10 yrs old
QL 1 / day REXULTI 3 PA AL At least 18 yrs old
QL 16/day RISPERDAL 1 MG/ML SOLUTION 3 AL At least 5 yrs old
RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 2 QL 8 / day 3 MG TABLET) AL At least 5 yrs old
QL 5 / day RISPERDAL 3 MG TABLET 3 AL At least 5 yrs old
QL 4 / day RISPERDAL 4 MG TABLET 3 AL At least 5 yrs old
QL 0.1 / day RISPERDAL CONSTA 3 PA AL At least 18 yrs old
PAGE 118 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 8 / day RISPERDAL M-TAB (0.5 MG ODT, 1 MG ODT, 2 MG ODT) 3 AL At least 5 yrs old
QL 5 / day RISPERDAL M-TAB 3 MG ODT 3 AL At least 5 yrs old
QL 4 / day RISPERDAL M-TAB 4 MG ODT 3 AL At least 5 yrs old
QL 16/day risperidone 1 mg/ml solution 1 AL At least 5 yrs old risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg QL 8 / day 1 tablet) AL At least 5 yrs old
QL 5 / day risperidone 3 mg tablet 1 AL At least 5 yrs old
QL 4 / day risperidone 4 mg tablet 1 AL At least 5 yrs old
QL 5 / day risperidone 3 mg odt 1 AL At least 5 yrs old
QL 4 / day risperidone 4 mg odt 1 AL At least 5 yrs old
QL 8 / day risperidone odt (0.25 mg odt, 0.5 mg odt, 1 mg odt, 2 mg odt) 1 AL At least 5 yrs old
QL 2 / day SAPHRIS 3 ST AL At least 10 yrs old
QL 6 / day SEROQUEL (25 MG TABLET, 50 MG TABLET) 3 AL At least 10 yrs old
QL 3 / day SEROQUEL 100 MG TABLET 3 AL At least 10 yrs old
PAGE 119 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1.5 / day SEROQUEL 200 MG TABLET 3 AL At least 10 yrs old
QL 1 / day SEROQUEL 300 MG TABLET 3 AL At least 10 yrs old
QL 2 / day SEROQUEL 400 MG TABLET 3 AL At least 10 yrs old
SEROQUEL XR SAMPLE KIT 2 AL At least 10 yrs old
QL 2 / day SEROQUEL XR (300 MG TABLET, 400 MG TABLET) 2 AL At least 10 yrs old
QL 5 / day SEROQUEL XR 150 MG TABLET 2 AL At least 10 yrs old
QL 4 / day SEROQUEL XR 200 MG TABLET 2 AL At least 10 yrs old
QL 6 / day SEROQUEL XR 50 MG TABLET 2 AL At least 10 yrs old
QL 20 / day VERSACLOZ 3 AL At least 18 yrs old
QL 1 / day VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK, 3 MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) 3 PA AL At least 18 yrs old
QL 2 / day ziprasidone hcl 1 AL At least 18 yrs old
QL 6 / day ZYPREXA (2.5 MG TABLET, 5 MG TABLET) 3 AL At least 13 yrs old
QL 3 / day ZYPREXA 10 MG TABLET 3 AL At least 13 yrs old
PAGE 120 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 2 / day ZYPREXA 15 MG TABLET 3 AL At least 13 yrs old
QL 1 / day ZYPREXA 20 MG TABLET 3 AL At least 13 yrs old
QL 4 / day ZYPREXA 7.5 MG TABLET 3 AL At least 13 yrs old
ZYPREXA 10 MG VIAL 3 AL At least 13 yrs old
QL 0.08 / day ZYPREXA RELPREVV 3 PA AL At least 18 yrs old
QL 3 / day ZYPREXA ZYDIS 10 MG TABLET 3 AL At least 13 yrs old
QL 2 / day ZYPREXA ZYDIS 15 MG TABLET 3 AL At least 13 yrs old
QL 1 / day ZYPREXA ZYDIS 20 MG TABLET 3 AL At least 13 yrs old
QL 6 / day ZYPREXA ZYDIS 5 MG TABLET 3 AL At least 13 yrs old
BUTYROPHENONES
HALDOL 3 HALDOL DECANOATE 100 3 HALDOL DECANOATE 50 3 haloperidol 5 mg/ml ampul 1 haloperidol powder 3 haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet) 1 haloperidol decan 50 mg/ml amp 1
PAGE 121 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS haloperidol decanoate powder 3 haloperidol decanoate (50 mg/ml vial, 100 mg/ml vial) 1 haloperidol decanoate 100 1 haloperidol lac 2 mg/ml conc 1 haloperidol lactate (5 mg/ml vial, 50 mg/10 ml vl) 1 PHENOTHIAZINES acepromazine maleate 3 chlorpromazine 25 mg/ml amp 1 chlorpromazine hcl powder 3 chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1 fluphenazine decanoate (liquid, oil) 3 fluphenazine dec 125 mg/5 ml 1 fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5 ml elix, 5 mg tablet, 5 mg/ml conc, 10 mg tablet) 1 fluphenazine 2.5 mg/ml vial 1 perphenazine powder 3 AL At least 18 yrs old perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet, 16 mg At least 18 yrs old tablet) 1 AL promazine hcl 3 thioridazine hcl 1 thioridazine hydrochloride 3 trifluoperazine hcl 1 THIOXANTHENES thiothixene 1
PAGE 122 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIRETROVIRALS
HIV ENTRY AND FUSION INHIBITORS
QL 2 / day FUZEON 4 S
SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75 MG S 4 TABLET, 150 MG TABLET, 300 MG TABLET) PS
HIV INTEGRASE INHIBITORS
GENVOYA 4 S
S ISENTRESS 100 MG POWDER PACKET 4 PS
ISENTRESS (25 MG TABLET CHEW, 100 MG TABLET CHEW, 400 S 4 MG TABLET) PS
S ISENTRESS HD 4 PS
STRIBILD 4 S
TIVICAY 4 S
TRIUMEQ 4 S
HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.
S ATRIPLA 4 PS
S COMPLERA 4 PS
S EDURANT 4 PS
S INTELENCE 4 PS
PAGE 123 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS nevirapine (50 mg/5 ml susp, 200 mg tablet) 4 S nevirapine er 4 S
ODEFSEY 4 S
RESCRIPTOR (100 MG TABLET, 200 MG TABLET) 4 S
SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MG TABLET) 4 S
VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 4 S
VIRAMUNE XR 4 S
HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS abacavir (20 mg/ml solution, 300 mg tablet) 4 S abacavir-lamivudine 4 S abacavir-lamivudine-zidovudine 4 S
COMBIVIR 4 S
QL 1 / day DESCOVY 4 S didanosine 4 S
S EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 4 PS
EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MG TABLET) 4 S
EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 4 S
EPZICOM 4 S lamivudine 10 mg/ml oral soln 4 S lamivudine (100 mg tablet, 150 mg tablet, 300 mg tablet) 4 S lamivudine hbv 4 S
PAGE 124 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lamivudine-zidovudine 4 S
RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 4 S stavudine (1 mg/ml solution, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule) 4 S
TRIZIVIR 4 S
S TRUVADA 4 PS
S VIDEX 4 PS
VIDEX EC 4 S
VIREAD POWDER 4 S
VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 S 4 MG TABLET) PS
ZERIT (1 MG/ML SOLUTION, 15 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE) 4 S
ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 4 S zidovudine (50 mg/5 ml syrup, 100 mg capsule, 300 mg tablet) 4 S
HIV PROTEASE INHIBITORS
S APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 4 PS
S CRIXIVAN 4 PS
EVOTAZ 4 S fosamprenavir calcium 4 S
S INVIRASE (200 MG CAPSULE, 500 MG TABLET) 4 PS
PAGE 125 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS KALETRA (80 MG-20 MG/ML SOLN, 100-25 MG TABLET, 200-50 MG TABLET) 4 S
LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 4 S
S lopinavir-ritonavir 4 PS
NORVIR (80 MG/ML SOLUTION, 100 MG SOFTGEL CAP, 100 MG TABLET) 4 S
PREZCOBIX 4 S
PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG S 4 TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) PS
REYATAZ (150 MG CAPSULE, 200 MG CAPSULE, 300 MG S 4 CAPSULE) PS
S REYATAZ 50 MG POWDER PACKET 4 PS
QL 2 / day TECHNIVIE 4 PA S
QL 4 / day VIEKIRA PAK 4 PA S
QL 3 / day VIEKIRA XR 4 PA S
S VIRACEPT 4 PS
PAGE 126 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTITHROMBOTIC AGENTS
PLATELET-AGGREGATION INHIBITORS acetyl salicylic acid 3
AGGRENOX 3 QL 2 / day aspirin 3
QL 10 / day aspirin-caffeine-dihydrocodein 1 AL At least 18 yrs old aspirin-dipyridamole er 1 QL 2 / day
BRILINTA 2 QL 2 / day butalbital-asa-caffeine cap 1 QL 6 / day cilostazol 1 QL 2 / day clopidogrel 1 QL 1 / day clopidogrel bisulfate 3 dipyridamole powder 3 dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1 QL 4 / day
DURLAZA 3 QL 1 / day
EFFIENT 3 QL 1 / day
FIORINAL 3 QL 6 / day
LEVACET 3 PA
PERSANTINE 3 QL 4 / day
PLAVIX 3 QL 1 / day
PLETAL 3 QL 2 / day prasugrel hcl 1 QL 1 / day
QL 10 / day SYNALGOS-DC 3 AL At least 12 yrs old
PAGE 127 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ticlopidine hcl 1 QL 2 / day
QL 1 / day ZONTIVITY 3 PA
PLATELET-REDUCING AGENTS
AGRYLIN 3 QL 4 / day anagrelide hcl 1 QL 4 / day
THROMBOLYTIC AGENTS
CATHFLO ACTIVASE 4 S
ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES
ANTITOXINS AND IMMUNE GLOBULINS antivenin latrodectus mactans 1 antivenin micrurus fulvius 1 CROFAB 3
PA GAMASTAN S-D 4 S
PA GAMMAKED 4 S
PA GAMUNEX-C 4 S
PA HIZENTRA 4 S
HYPERHEP B S-D (NEONATAL SYRIN., SYRINGE, VIAL) 4 S
HYPERRAB S-D 4 S
HYPERRHO S-D 4 S
HYPERTET S-D 4 S
PAGE 128 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA HYQVIA 4 S
PA HYQVIA IG COMPONENT 4 S
IMOGAM RABIES-HT 4 S
MICRHOGAM ULTRA-FILTERED PLUS 4 S
NABI-HB 4 S
RHOGAM ULTRA-FILTERED PLUS 4 S
RHOPHYLAC 4 S
VARIZIG (125 UNIT VIAL, 125 UNIT/1.2 ML VIAL) 4 S
TOXOIDS
ADACEL TDAP (SYRINGE, VIAL) 2 HCR
BOOSTRIX TDAP (SYRINGE, VIAL) 2 HCR
DAPTACEL DTAP 2 HCR diphtheria-tetanus toxoids-ped 1 INFANRIX DTAP (SYRINGE, VIAL) 2 PEDIARIX 2
TENIVAC (SYRINGE, VIAL) 2 HCR
VACCINES
ACTHIB VACCINE WITH DILUENT 2
AFLURIA 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 2 HCR
AFLURIA QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 2 HCR bcg vaccine (tice strain) 3 BEXSERO 2
PAGE 129 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CERVARIX 2 HCR
ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL) 2 HCR
ENGERIX-B PEDIATRIC-ADOLESCENT (10 MCG/0.5 ML PED VL, PEDI 10 MCG/0.5 SYRN) 2 HCR
EZ FLU 16-17 (FLUZON QUAD PED) 2 HCR
EZ FLU 2016-2017 (AFLURIA) 2 HCR
EZ FLU 2016-2017 (FLUVIRIN) 2 HCR
FLUAD 2016-2017 2 HCR
FLUARIX QUAD 2016-2017 2 HCR
FLUBLOK 2016-2017 2 HCR
FLUCELVAX QUAD 2016-2017 2 HCR
FLULAVAL QUAD 2016-2017 (2016-2017 SYR, 2016-2017 VIAL) 2 HCR
FLUVIRIN 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 2 HCR
FLUZONE HIGH-DOSE 2016-2017 2 HCR
FLUZONE INTRADERM QUAD 2016-17 2 HCR
FLUZONE QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 2 HCR
FLUZONE QUAD PEDI 2016-2017 2 HCR
GARDASIL 9 (9 SYRINGE, 9 VIAL) 2 HCR
HAVRIX (720 UNIT/0.5 ML SYRINGE, 720 UNITS/0.5 ML VIAL, 1,440 UNITS/ML SYRINGE, 1,440 UNITS/ML VIAL) 2 HCR
HIBERIX VACCINE WITH DILUENT 2 IMOVAX RABIES VACCINE 2 IPOL VIAL 2 IXIARO 2
PAGE 130 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS KINRIX (TIP-LOK SYRINGE, VIAL) 2
MENACTRA 2 HCR
MENHIBRIX 2
MENOMUNE-A-C-Y-W-135 2 HCR
MENVEO A-C-Y-W-135-DIP 2 HCR
MENVEO MENA COMPONENT 2 MENVEO MENCYW-135 COMPONENT 2 PENTACEL 2 PENTACEL ACTHIB COMPONENT 3 PENTACEL DTAP-IPV COMPONENT 2 QUADRACEL DTAP-IPV 2 ROTARIX 2 STAMARIL 2
THERACYS 4 S
TRUMENBA 3
TWINRIX (SYRINGE, VIAL) 2 HCR
TYPHIM VI (25 MCG/0.5 ML AL, 25 MCG/0.5 ML SYRNG) 2
VARIVAX VACCINE 2 HCR
VAXCHORA ACTIVE COMPONENT 2 VAXCHORA VACCINE 2 VIVOTIF 2 VIVOTIF BERNA 2 YF-VAX 2
ZOSTAVAX 2 HCR
PAGE 131 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIULCER AGENTS AND ACID SUPPRESSANTS
HISTAMINE H2-ANTAGONISTS cimetidine powder 3 cimetidine (200 mg tablet, 300 mg tablet, 300 mg/5 ml soln, 400 mg tablet, 800 mg tablet) 1
QL 3 / day DUEXIS 3 PA famotidine powder 3 famotidine (20 mg tablet, 40 mg tablet, 40 mg/5 ml susp) 1 nizatidine (15 mg/ml solution, 300 mg capsule) 1 nizatidine 150 mg capsule 1 QL 2 / day
PEPCID (20 MG TABLET, 40 MG TABLET, 40 MG/5 ML ORAL SUSP) 3 ranitidine hcl powder 3 ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mg tablet, 150 mg/10 ml syrup, 300 mg capsule, 300 mg tablet) 1 ranitidine hcl (50 mg/2 ml vial, 150 mg/6 ml vl) 1 ZANTAC (150 MG TABLET, 300 MG TABLET) 3 ZANTAC (50 MG/2 ML VIAL, 150 MG/6 ML VIAL, 1,000 MG/40 ML VIAL) 3 PROSTAGLANDINS
ARTHROTEC 50 3 ARTHROTEC 75 3 CYTOTEC 3 diclofenac sodium-misoprostol 1 misoprostol (hpmc powder, powder) 3 misoprostol (100 mcg tablet, 200 mcg tablet) 1 misoprostol hpmc 3
PAGE 132 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROTECTANTS
CARAFATE 1 GM/10 ML SUSP 2 CARAFATE 1 GM TABLET 3 sucralfate powder 3 sucralfate 1 gm tablet 1 PROTON-PUMP INHIBITORS
QL 2 / day ACIPHEX 3 ST
ACIPHEX SPRINKLE 3 QL 1 / day
QL 1 / day DEXILANT 3 ST esomeprazole magnesium 1 QL 1 / day esomeprazole strontium 1 QL 1 / day lansoprazol-amoxicil-clarithro 1 QL 112 / 365 days lansoprazole dr 15 mg capsule 1 lansoprazole dr 30 mg capsule 1 QL 1 / day lansoprazole powder 3
NEXIUM (DR 20 MG CAPSULE, DR 40 MG CAPSULE) 3 QL 1 / day
NEXIUM (DR 2.5 MG PACKET, DR 5 MG PACKET, DR 10 MG 2 / day PACKET, DR 20 MG PACKET, DR 40 MG PACKET) 3 QL
OMECLAMOX-PAK 3 QL 80 / 365 days omeprazole (dr 10 mg capsule, dr 20 mg capsule, dr 40 mg 1 / day capsule) 1 QL omeprazole powder 3 omeprazole-sodium bicarbonate (20-1,100 cap, 20-1,680 pkt, 40-1,100 cap, 40-1,680 pkt) 1
QL 1 / day pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) 1 LCG
PAGE 133 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PREVACID (15 MG SOLUTAB, DR 15 MG CAPSULE, 30 MG QL 1 / day 3 SOLUTAB, DR 30 MG CAPSULE) ST
PREVPAC 3 QL 112 / 365 days
PRILOSEC (DR 10 MG CAPSULE, DR 20 MG CAPSULE, DR 40 MG QL 1 / day 3 CAPSULE) ST
PRILOSEC (DR 2.5 MG SUSPENSION, DR 10 MG SUSPENSION) 3 ST
PROTONIX 40 MG SUSPENSION 3 QL 1 / day
QL 1 / day PROTONIX (DR 20 MG TABLET, DR 40 MG TABLET) 3 ST rabeprazole sodium 1 QL 2 / day
QL 2 / day VIMOVO 3 ST
ZEGERID (20 MG CAPSULE, 20 MG PACKET, 40 MG CAPSULE) 3 ST
QL 1 / day ZEGERID 40 MG PACKET 3 ST
ANTIVIRALS (SYSTEMIC)
ADAMANTANES
FLUMADINE 3 rimantadine hcl 1 ANTIVIRALS, MISCELLANEOUS
2-deoxy-d-glucose 3 INTERFERONS
ALFERON N 4 S
INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18 PA MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS 4 VIL) S
PAGE 134 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) 4 S
PA PEGASYS PROCLICK 4 S
PA PEGINTRON 4 S PS
PA PEGINTRON REDIPEN 4 S PS
PA SYLATRON 4 S
MONOCLONAL ANTIBODIES
PA SYNAGIS 4 S
NEURAMINIDASE INHIBITORS oseltamivir phosphate 1 QL 20 / 365 days
RELENZA 3 QL 40 / 365 days
TAMIFLU (30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE) 3 QL 20 / 365 days
TAMIFLU 6 MG/ML SUSPENSION 3 QL 180 / 30 days
NUCLEOSIDES AND NUCLEOTIDES acyclovir powder 3 acyclovir (200 mg capsule, 200 mg/5 ml susp, 400 mg tablet, 800 mg tablet) 1 adefovir dipivoxil 4 S
QL 20 / day BARACLUDE 0.05 MG/ML SOLUTION 4 PA S
PAGE 135 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day BARACLUDE (0.5 MG TABLET, 1 MG TABLET) 4 PA S cidofovir powder 3
QL 6 / day COPEGUS 4 PA S
QL 1 / day entecavir 4 S famciclovir 1 FAMVIR 3
QL 1 / day HEPSERA 4 PA S
QL 2 / day MODERIBA (200-400 MG DOSEPACK, 400-400 MG DOSEPACK, 600-400 MG DOSEPACK, 600-600 MG DOSEPACK) 4 PA S
QL 6 / day MODERIBA 200 MG TABLET 4 PA S
QL 6 / day REBETOL 200 MG CAPSULE 4 PA S
QL 30 / day REBETOL 40 MG/ML SOLUTION 4 PA S
QL 6 / day RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) 4 PA S
PAGE 136 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 3 / day RIBASPHERE 400 MG TABLET 4 PA S
QL 2 / day RIBASPHERE 600 MG TABLET 4 PA S
QL 2 / day RIBASPHERE RIBAPAK 4 PA S
QL 2 / day RIBATAB 4 PA S
QL 6 / day ribavirin (200 mg capsule, 200 mg tablet) 4 PA S ribavirin 6 gm inhalation vial 1
QL 2 / fill SITAVIG 3 PA AL At least 18 yrs old
QL 1 / day TYZEKA 4 PA S valacyclovir 1 valacyclovir hcl 3 VALCYTE 50 MG/ML SOLUTION 3
VALCYTE 450 MG TABLET 3 QL 4 / day valganciclovir hcl 50 mg/ml 1
PAGE 137 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS valganciclovir 450 mg tablet 1 QL 4 / day
VALTREX 3
QL 1 / day PA VEMLIDY 4 AL At least 18 yrs old S vidarabine 3 vidarabine monohydrate 3 VIRAZOLE 3 ZOVIRAX (200 MG CAPSULE, 200 MG/5 ML SUSP, 400 MG TABLET, 800 MG TABLET) 3 ANXIOLYTICS, SEDATIVES AND HYPNOTICS
ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC
QL 1 / day AMBIEN 3 ST
QL 1 / day AMBIEN CR 3 ST
BELSOMRA 3 ST buspirone hcl powder 3 buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 30 mg tablet) 1 chloral hydrate 3 PA dichloralphenazone 3 droperidol powder 3 droperidol (2.5 mg/ml ampul, 2.5 mg/ml vial) 1
QL 1 / day EDLUAR 3 ST
PAGE 138 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS eszopiclone (1 mg tablet, 2 mg tablet) 1 QL 1 / day
QL 1 / day eszopiclone 3 mg tablet 1 AL Up to 65 yrs old
QL 1 / day HETLIOZ 4 PA S hydroxyzine hcl powder 3 AL At least 2 yrs old hydroxyzine hcl (10 mg/5 ml soln, 10 mg/5 ml syrup, hcl 10 mg At least 2 yrs old tablet, hcl 25 mg tablet, 50 mg/25 ml syrup, hcl 50 mg tablet) 1 AL hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial, 100 mg/2 ml At least 2 yrs old vial, 500 mg/10 ml vial) 1 AL hydroxyzine pam 100 mg cap 1 hydroxyzine pamoate (25 mg cap, 50 mg cap) 1 AL At least 2 yrs old hydroxyzine pamoate powder 3
QL 1 / day INTERMEZZO 3 ST
QL 1 / day LUNESTA (1 MG TABLET, 2 MG TABLET) 3 ST
QL 1 / day LUNESTA 3 MG TABLET 3 ST AL Up to 65 yrs old meprobamate 1
PHENADOZ 1 AL At least 2 yrs old
PHENERGAN (12.5 MG, 25 MG, 50 MG) 1 AL At least 2 yrs old promethazine hcl (12.5 mg suppos, 25 mg suppository, 50 mg At least 2 yrs old suppository) 1 AL
PROMETHEGAN 1 AL At least 2 yrs old
PAGE 139 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day ROZEREM 3 ST
QL 1 / day SONATA 3 ST tryptophan (l) 3
VISTARIL 3 AL At least 2 yrs old zaleplon 1 QL 1 / day zolpidem tartrate (tart 1.75 mg tab sl, tart 3.5 mg tablet sl, 1 / day tartrate 5 mg tablet, tartrate 10 mg tablet) 1 QL zolpidem tartrate er 1 QL 1 / day
ZOLPIMIST 3 QL 0.257 / day
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
AMYTAL SODIUM 3 butalbital 3 BUTISOL SODIUM 3 NEMBUTAL SODIUM 3 pentobarbital sodium powder 3 pentobarbital 1,000 mg/20 ml 1 phenobarbital powder 3 SECONAL SODIUM 3 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) alprazolam powder 3 alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet) 1 QL 4 / day alprazolam 2 mg tablet 1 QL 5 / day alprazolam er (er 0.5 mg tablet, er 1 mg tablet) 1 QL 1 / day alprazolam er 2 mg tablet 1 QL 5 / day
PAGE 140 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS alprazolam er 3 mg tablet 1 QL 3 / day
ALPRAZOLAM INTENSOL 3 QL 10 / day alprazolam odt (odt 0.25 mg tab, odt 0.5 mg tab, odt 1 mg tab) 1 QL 4 / day alprazolam odt 2 mg tab 1 QL 5 / day alprazolam xr (0.5 mg tablet, 1 mg tablet) 1 QL 1 / day alprazolam xr 2 mg tablet 1 QL 5 / day alprazolam xr 3 mg tablet 1 QL 3 / day chlordiazepoxide 10 mg capsule 1 QL 30 / day chlordiazepoxide 25 mg capsule 1 QL 12 / day chlordiazepoxide 5 mg capsule 1 QL 4 / day
DORAL 3 QL 1 / day estazolam 1 QL 1 / day flurazepam hcl 1 QL 1 / day
HALCION 3 QL 2 / day midazolam 3 midazolam hcl 2 mg/ml syrup 1 midazolam hcl (2 mg/2 ml syringe, hcl 2 mg/2 ml vial, 5 mg/ml isecure syr, 5 mg/ml syringe, hcl 5 mg/5 ml vial, hcl 10 mg/10 ml vial, hcl 10 mg/2 ml vial, hcl 25 mg/5 ml vial, hcl 50 mg/10 1 ml vial) midazolam hcl 5 mg/ml vial 1 MED Medical Drug oxazepam 1 QL 4 / day quazepam 1 QL 1 / day
RESTORIL 3 QL 1 / day temazepam 1 QL 1 / day
PAGE 141 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS triazolam 0.125 mg tablet 1 QL 1 / day triazolam 0.25 mg tablet 1 QL 2 / day
XANAX (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET) 3 QL 4 / day
XANAX 2 MG TABLET 3 QL 5 / day
XANAX XR (0.5 MG TABLET, 1 MG TABLET) 3 QL 1 / day
XANAX XR 2 MG TABLET 3 QL 5 / day
XANAX XR 3 MG TABLET 3 QL 3 / day
AUTONOMIC DRUGS
AUTONOMIC DRUGS, MISCELLANEOUS
CHANTIX STARTING MONTH BOX 3 HCR
CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MG QL 2 / day 3 TABLET) HCR nicotine polacrilex 3
NICOTROL 3 QL 16/day
NICOTROL NS 3 QL 20 / day
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
ARICEPT (5 MG TABLET, 10 MG TABLET) 3 AL At least 40 yrs old
ST ARICEPT 23 MG TABLET 3 AL At least 40 yrs old bethanechol chloride powder 3 bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg tablet, 50 mg tablet) 1 cevimeline hcl 1 donepezil hcl 1 AL At least 40 yrs old donepezil hcl odt 1 AL At least 40 yrs old
PAGE 142 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EVOXAC 3 EXELON (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 4.6 MG/24HR PATCH, 6 MG CAPSULE, 9.5 MG/24HR PATCH, 3 AL At least 40 yrs old 13.3 MG/24HR PATCH) galantamine er 1 galantamine hbr 1 galantamine hydrobromide 1 guanidine hcl 1 MESTINON 60 MG/5 ML SYRUP 2 MESTINON (60 MG TABLET, 180 MG TIMESPAN) 3 NAMZARIC (7 MG-10 MG CAPSULE, 14 MG-10 MG CAPSULE, 21 MG-10 MG CAPSULE, 28 MG-10 MG CAPSULE, TITRATION PACK) 3 ST neostigmine methylsulfate powd 3 physostigmine salicylate 1 pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1 pyridostigmine bromide powder 3 pyridostigmine br 60 mg tablet 1 pyridostigmine bromide er 1 RAZADYNE 3 RAZADYNE ER 3 REGONOL 3 rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 4.6 mg/24hr patch, 6 mg capsule, 9.5 mg/24hr patch, 13.3 mg/24hr 1 AL At least 40 yrs old ptch)
SALAGEN 3 URECHOLINE 3 SYMPATHOMIMETIC (ADRENERGIC) AGENTS isometheptene mucate 3
PAGE 143 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BETA-3-ADRENERGIC AGONISTS
SELECTIVE BETA-3-ADRENERGIC AGONISTS
MYRBETRIQ 2 QL 1 / day
BETA-ADRENERGIC AGONISTS
SELECTIVE BETA-1-ADRENERGIC AGONISTS dopamine hcl powder 3 BETA-ADRENERGIC BLOCKING AGENTS(SYMPATH)
NON-SEL. BETA-ADRENERGIC BLOCKING AGENTS
BYSTOLIC (5 MG TABLET, 10 MG TABLET) 2 QL 3 / day
BYSTOLIC 2.5 MG TABLET 2 QL 1 / day
BYSTOLIC 20 MG TABLET 2 QL 2 / day
BYVALSON 2 QL 1 / day
BLOOD FORMATION, COAGULATION, THROMBOSIS
HEMATOPOIETIC AGENTS
ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 ML SYRING, 25 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 40 MCG/ML VIAL, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 100 MCG/0.5 ML PA SYRINGE, 100 MCG/ML VIAL, 150 MCG/0.3 ML SYRINGE, 150 4 S MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500 PS MCG/1 ML SYRINGE)
PA EPOGEN 4 S
PA GRANIX (300 MCG/0.5 ML SYRINGE, 480 MCG/0.8 ML SYRINGE) 4 S
PA LEUKINE 4 S
PAGE 144 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA MIRCERA 4 S
PA MOZOBIL 4 S
PA NEULASTA (6 MG/0.6 ML SYRINGE, ONPRO 6 MG/0.6 ML KIT) 4 S PS
PA NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480 MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL) 4 S PS
PA NPLATE 4 S
PA PROCRIT 4 S PS
PA PROMACTA 4 S
QL 90 / 30 days ZARXIO 4 PA S
HEMORRHEOLOGIC AGENTS pentoxifylline powder 3 pentoxifylline er 400 mg tab 1 BRONCHODILATORS
XANTHINE DERIVATIVES aminophylline (anhydrous pwd, powder) 3 dyphylline 3
PAGE 145 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ELIXOPHYLLIN 3 THEO-24 3 THEOCHRON 1 theophylline (80 mg/15 ml soln, er 400 mg tablet, er 600 mg tablet) 1 theophylline anhydrous powder 3 theophylline anhydrous (er 100 mg tablet, er 200 mg tablet, er 300 mg tab, er 450 mg tab) 1 CALCIUM-CHANNEL BLOCKING AGENTS
DIHYDROPYRIDINES felodipine er 1 QL 1 / day isradipine 1 QL 2 / day nisoldipine 1 QL 1 / day
SULAR 3 QL 1 / day
CALCIUM-CHANNEL BLOCKING AGENTS(HYPOTEN)
CALCIUM-CHANNEL BLOCK.AGT,MISC(HYPOTEN)
TARKA 3 QL 1 / day trandolapril-verapamil er 1 DIHYDROPYRIDINES (HYPOTENSIVE AGENTS)
ADALAT CC 30 MG TABLET 3 QL 1 / day
ADALAT CC 60 MG TABLET 3 QL 2 / day
ADALAT CC 90 MG TABLET 3
AFEDITAB CR 30 MG TABLET 1 QL 1 / day
AFEDITAB CR 60 MG TABLET 1 QL 2 / day amlodipine besilate 3 amlodipine besylate powder 3
PAGE 146 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS amlodipine besylate (2.5 mg tab, 5 mg tab, 10 mg tab) 1 QL 1 / day amlodipine besylate-benazepril 1 QL 1 / day amlodipine-olmesartan 1 QL 1 / day amlodipine-valsartan (5-320 mg, 10-160 mg, 10-320 mg) 1 QL 1 / day amlodipine-valsartan 5-160 mg 1 QL 2 / day amlodipine-valsartan-hctz 1 QL 1 / day
AZOR 3 QL 1 / day
CARDENE SR 30 MG CAPSULE 3 QL 2 / day
EXFORGE 3 QL 1 / day
EXFORGE HCT 3 QL 1 / day
LOTREL 3 QL 1 / day nicardipine hcl (20 mg capsule, 30 mg capsule) 1
NIFEDICAL XL 1 QL 1 / day nifedipine (10 mg capsule, 20 mg capsule) 1 QL 4 / day nifedipine powder 3 nifedipine er (er 30 mg tablet, er 90 mg tablet) 1 QL 1 / day nifedipine er 60 mg tablet 1 QL 2 / day nimodipine 30 mg capsule 1 nimodipine powder 3
NORVASC 3 QL 1 / day
NYMALIZE 60 MG/20 ML SOLUTION 3 QL 120 / day
PROCARDIA 3 QL 4 / day
PROCARDIA XL 3 QL 1 / day
TEKAMLO 3 QL 1 / day
PAGE 147 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CARDIAC DRUGS
CARDIAC DRUGS, MISCELLANEOUS
QL 2 / day CORLANOR 2 ST
RANEXA 2 QL 2 / day
CARDIOVASCULAR DRUGS
BETA-ADRENERGIC BLOCKING AGENTS
LEVATOL 3 CALCIUM-CHANNEL BLOCKING AGENTS
QL 1 / day PRESTALIA 3 ST telmisartan-amlodipine 1 QL 1 / day
TWYNSTA 3 QL 1 / day
SCLEROSING AGENTS
SCLEROSOL 3 sodium tetradecyl sulfate (sul 27% soln, sulfate powd) 3 sterile talc 3 VASODILATING AGENTS betahistine 3 betahistine hcl 3 cyclandelate 3 nylidrin hcl 3 CENTRAL NERVOUS SYSTEM AGENTS
ANTIMANIC AGENTS lithium 1
PAGE 148 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lithium carbonate (150 mg cap, 300 mg cap, 300 mg tab, 600 mg cap) 1 lithium carbonate powder 3 lithium carbonate er 1 LITHOBID 3 CENTRAL NERVOUS SYSTEM AGENTS, MISC. acamprosate calcium 1
QL 1 / day PA ADDYI 3 GL Female AL 18 to 60 yrs old
QL 2 / day atomoxetine hcl 1 AL At least 6 yrs old
QL 4 / day PA AUSTEDO 4 AL At least 18 yrs old S carbidopa powder 3 carbidopa 25 mg tablet 1 flibanserin 3 flumazenil powder 3 guanfacine hcl 1 guanfacine hcl er 1 idebenone 3
QL 2 / day PA INGREZZA 40 MG CAPSULE 4 AL At least 18 yrs old S
PAGE 149 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
INTUNIV 3 QL 1 / day
LODOSYN 3 memantine hcl powder 3 AL At least 40 yrs old
QL 360 / 30 days memantine hcl 2 mg/ml solution 1 AL At least 40 yrs old memantine 5-10 mg titration pk 1 AL At least 40 yrs old
QL 2 / day memantine hcl 10 mg tablet 1 AL At least 40 yrs old
QL 3 / day memantine hcl 5 mg tablet 1 AL At least 40 yrs old
NAMENDA (2 MG/ML SOLUTION, 5 MG TABLET, 5-10 MG At least 40 yrs old TITRATION PK, 10 MG TABLET) 3 AL
NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG ST 3 CAPSULE, 28 MG CAPSULE, TITRATION PACK) AL At least 40 yrs old
NUEDEXTA 2 PA
RILUTEK 3 riluzole 1
QL 2 / day STRATTERA 3 AL At least 6 yrs old
TENEX 3
PA tetrabenazine 4 S
PA XENAZINE 4 S
QL 18 / day XYREM 4 PA S
PAGE 150 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OPIATE ANTAGONISTS
DEPADE 1
QL 2 / rx EVZIO 3 PA naloxone hcl powder 3 naloxone hcl (0.4 mg/ml carpuject, 0.4 mg/ml vial, 2 mg/2 ml syringe) 1 naltrexone hcl powder 3 naltrexone 50 mg tablet 1 naltrexone hcl dihydrate 3
NARCAN 2 MG NASAL SPRAY 3 QL 5 / 30 days
NARCAN 4 MG NASAL SPRAY 3 QL 2 / 30 days
REVIA 3
PA VIVITROL 4 S
CEPHALOSPORINS
FIRST GENERATION CEPHALOSPORINS cefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 mg capsule, 500 mg/5 ml susp) 1 cefazolin sodium (100 gm bag, 300 gm bag) 1 cephalexin (125 mg/5 ml susp, 250 mg capsule, 250 mg tablet, 250 mg/5 ml susp, 500 mg capsule, 500 mg tablet, 750 mg 1 capsule)
QL 4 / day DAXBIA 3 ST
KEFLEX 3
PAGE 151 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FOURTH GENERATION CEPHALOSPORINS cefepime hcl 1 MAXIPIME (1 VIAL, 2 VIAL) 3 SECOND GENERATION CEPHALOSPORINS cefaclor (125 mg/5 ml susp, 250 mg capsule, 250 mg/5 ml susp, 375 mg/5 ml suspen, 500 mg capsule) 1 cefaclor er 1 QL 20 / 30 days
CEFOTAN 3 cefotetan (1 gm vial, 2 gm vial) 1 cefprozil (125 mg/5 ml susp, 250 mg tablet, 250 mg/5 ml susp, 500 mg tablet) 1
CEFTIN (125 MG/5 ML ORAL SUSP, 250 MG/5 ML ORAL SUSP) 2 CEFTIN (250 MG TABLET, 500 MG TABLET) 3 cefuroxime 1 ZINACEF 750 MG VIAL 3 THIRD GENERATION CEPHALOSPORINS
CEDAX (180 MG/5 ML SUSPENSION, 400 MG CAPSULE) 3 cefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, 300 mg capsule) 1 cefditoren pivoxil 1 cefixime 1 QL 1200 / 90 days cefotaxime sodium 1 cefpodoxime proxetil (50 mg/5 ml susp, 100 mg tablet, 100 mg/5 ml susp, 200 mg tablet) 1 ceftazidime powder 3 ceftazidime (1 gm vial, 2 gm vial, 6 gm vial) 1 ceftazidime-sodium carbonate 3 ceftibuten (180 mg/5 ml susp, 400 mg capsule) 1 ceftriaxone (2 gm vial, 10 gm vial, 100 gram bulk bag, 250 mg vial, 500 mg vial) 1
PAGE 152 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ceftriaxone 1 gm vial 1 MED Medical Drug ceftriaxone sodium 3 CLAFORAN (2 GM VIAL, 10 GM VIAL, 500 MG VIAL) 3 FORTAZ (1 GM VIAL, 2 GM VIAL, 6 GM VIAL, 500 MG VIAL) 3 SPECTRACEF 3 SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLET CHEWABLE, 400 MG CAPSULE, 500 MG/5 ML SUSPENSION) 3 SUPRAX (100 MG/5 ML SUSPENSION, 200 MG/5 ML 1200 / 90 days SUSPENSION) 3 QL
TAZICEF (1 VIAL, 2 VIAL, 6 VIAL) 1 CORTICOSTEROIDS (RESPIRATORY TRACT)
ORALLY INHALED PREPARATIONS (STEROIDS)
AEROSPAN 2 QL 0.334 / day
QL 0.434 / day ALVESCO 3 PA
ARNUITY ELLIPTA 100 MCG INH 2 QL 2 / day
ARNUITY ELLIPTA 200 MCG INH 2 QL 1 / day
QL 0.04 / day ASMANEX 3 PA
QL 0.434 / day ASMANEX HFA 3 PA budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml susp, 1 mg/2 ml inh susp) 1
FLOVENT 250 MCG DISKUS 2 QL 8 / day
FLOVENT DISKUS (50 MCG, 100 MCG) 2 QL 4 / day
FLOVENT HFA (HFA 110 MCG INHALER, HFA 220 MCG INHALER) 2 QL 0.8 / day
FLOVENT HFA 44 MCG INHALER 2 QL 0.767 / day
PAGE 153 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PULMICORT 3 QL 120 / 30 days
PULMICORT FLEXHALER 2 QL 0.07 / day
QVAR 40 MCG ORAL INHALER 2 QL 0.6 / day
QVAR 80 MCG ORAL INHALER 2 QL 0.87 / day
CYSTIC FIBROSIS (CFTR) MODULATORS
CYSTIC FIBROSIS (CFTR) CORRECTORS
QL 4 / day ORKAMBI 4 PA S
CYSTIC FIBROSIS (CFTR) POTENTIATORS
QL 2 / day KALYDECO (50 MG GRANULES PACKET, 75 MG GRANULES PACKET, 150 MG TABLET) 4 PA S
DEPIGMENTING AND PIGMENTING AGENTS
DEPIGMENTING AGENTS
ACLARO 3 ALPHAQUIN HP 1 BLANCHE 1 hydroquinone (cream, tl cream, tr cream) 1 hydroquinone (crystals, powder) 3 MELPAQUE HP 1 MELQUIN-3 3 mequinol 3 monobenzone 3 TRI-LUMA 3
PAGE 154 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PIGMENTING AGENTS
8-MOP 3 methoxsalen (10 mg capsule, 10 mg softgel) 1 methoxsalen powder 3 OXSORALEN 3 OXSORALEN-ULTRA 3
UVADEX 4 S
DIAGNOSTIC AGENTS
ADRENOCORTICAL INSUFFICIENCY adrenocorticotrophic hormone 3 corticotrophin 3 CORTROSYN 3 cosyntropin 0.25 mg vial 1
PA H.P. ACTHAR 4 S
ALLERGENIC EXTRACTS (DIAGNOSTIC) acacia 1:20 (w/v) vial 3 acremonium 3 alder 3 almond 3 alternaria 3 american beech 3 american cockroach extract 3 american elm 3 american sycamore 3 apple 3 arizona cypress 3
PAGE 155 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS aspergillus fumigatus 3 aureobasidium 3 australian pine 3 avocado 3 bahia 3 bald cypress 3 banana 3 bayberry 3 beef 3 black walnut pollen 3 black willow 3 botrytis 3 box elder 3 brome 3 california pepper tree 3 candida albicans 3 cantaloupe 3 carelessweed 3 casein 3 cattle epithelium 3 cedar elm 3 chicken meat 3 cladosporium cladosporioides 3 cladosporium sphaerospermum 3 cocklebur 3 cocoa bean 3 corn pollen 3
PAGE 156 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS corn smut 3 crab 3 curvularia 3 d.farinae mite extract 3 d.pteronyssinus mite extract 3 dog epithelium extract 3 dog fennel 3 drechslera 3 eastern cottonwood 3 egg white 3 english plantain 3 epicoccum 3 fire ant 3 fusarium 3 german cockroach 3 goldenrod 3 hackberry 3 honey bee venom protein 3 horse epithelium 3 johnson grass 3 kapok 3 kochia 3 lamb's quarters 3 melaleuca 3 mesquite 3 mixed aspergillus 3 mixed cockroach 3
PAGE 157 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS mixed feathers 3 mixed ragweed extract 3 mixed vespid venom protein 3 mosquito 3 mountain cedar 3 mouse epithelium 3 mucor 3 mugwort 3 oat grain 3 olive tree 3 orange 3 peanut 3 pecan nut 3 pecan pollen 3 penicillium notatum 3 phoma 3 pistachio nut 3 pork 3 privet 3 quack grass 3 queen palm 3 rabbit epithelium 3 red birch 3 red cedar 3 red maple 3 red mulberry 3 red oak 3
PAGE 158 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS rhizopus 3 rice 3 rough marsh elder 3 rough pigweed 3 russian thistle 3 saccharomyces cerevisiae 3 sagebrush 3 sesame seed 3 shagbark hickory 3 sheep sorrel 3 sheep sorrel-yellow dock 3 short ragweed 3 shrimp 3 soybean 3 spiny pigweed 3 standard bermuda grass pollen 3 standard mixed mite extract 3 standard rye grass pollen 3 standard sweet vernal grass 3 standardized cat hair 3 standardized june grass pollen 3 standardized meadow fescue 3 standardized orchard grass 3 standardized red top grass 3 std timothy grass 10,000/ml 3 std timothy grass 100,000/ml 3 QL 1 / day strawberry 3
PAGE 159 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sweet corn 3 sweetgum 3 tall ragweed 3 trichophyton 3 virginia live oak 3 wasp venom protein 3 western juniper 3 western ragweed 3 white ash 3 white birch 3 white faced hornet venom 3 white mulberry 3 white oak extract 3 white pine 3 whole egg 3 yellow dock 3 yellow hornet venom protein 3 yellow jacket venom protein 3 CARDIAC FUNCTION
IC GREEN 3 indocyanine green 1 DRUG HYPERSENSITIVITY
PRE-PEN 3 FUNGI
CANDIN 3 SPHERUSOL 3
PAGE 160 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GALLBLADDER FUNCTION
KINEVAC 3 KIDNEY FUNCTION
INDIGO CARMINE 1 indigotindisulfonate sod-water 1 LYMPHATIC SYSTEM
LYMPHAZURIN 3 MYASTHENIA GRAVIS edrophonium chloride 3 ENLON 3 OCULAR DISORDERS
BIOGLO 1 FLUCAINE 1 FLUOR-I-STRIP AT 1 fluorescein powder 3 fluorescein-proparacaine 1 FUL-GLO 1 MG OPTH STRIPS 1 FUL-GLO EYE STRIPS 3 MEMBRANEBLUE 3 PANCREATIC FUNCTION secretin-mannitol 3 PITUITARY FUNCTION
METOPIRONE 3 ROENTGENOGRAPHY barium sulfate 3 CONRAY 3
PAGE 161 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CYSTOGRAFIN 3 CYSTOGRAFIN-DILUTE 3 E-Z DISK 3 E-Z-CAT 3 E-Z-HD 3 E-Z-PAQUE 3 E-Z-PASTE 3 ENTERO VU 3 GASTROGRAFIN 3 ISOVUE-200 41% VIAL 3 LIQUID E-Z PAQUE 3 LIQUID POLIBAR PLUS 3 MD-76 R (R 66-10 INFUSION BOTTLE, R 66-10 VIAL) 3 MD-GASTROVIEW 1 POLIBAR ACB 3 READI-CAT 2 3 SINOGRAFIN 3 SITZMARKS 3 TAGITOL 3 ULTRAVIST 3 VARIBAR HONEY 3 VARIBAR NECTAR 3 VARIBAR PUDDING 3 VARIBAR THIN HONEY 3 VARIBAR THIN LIQUID 3 VOLUMEN 3
PAGE 162 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THYROID FUNCTION protirelin 3
THYROGEN 4 S
TUBERCULOSIS
TUBERSOL 3 DIURETICS
LOOP DIURETICS bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1 bumetanide (0.25 mg/ml vial, 1 mg/4 ml vial, 2.5 mg/10 ml vial) 1
DEMADEX 3 EDECRIN 3 ethacrynic acid 1 furosemide powder 3 furosemide (20 mg/2 ml vial, 40 mg/4 ml syringe, 40 mg/4 ml vial, 100 mg/10 ml syring, 100 mg/10 ml vial) 1 furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40 mg/5 ml soln, 80 mg tablet) 1
LASIX 3 torsemide 1 OSMOTIC DIURETICS sorbitol-mannitol 1 POTASSIUM-SPARING DIURETICS amiloride hcl 1 amiloride-hydrochlorothiazide 1 DYAZIDE 3 DYRENIUM 3 MAXZIDE 3
PAGE 163 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MAXZIDE-25 MG 3 triamterene 3 triamterene-hydrochlorothiazid (37.5-25 mg cp, 37.5-25 mg tb, 50-25 mg cap, 75-50 mg tab) 1 THIAZIDE DIURETICS chlorothiazide 1 DIURIL 3 hydrochlorothiazide powder 3 hydrochlorothiazide (12.5 mg cp, 12.5 mg tb, 50 mg tab) 1 hydrochlorothiazide 25 mg tab 1 LCG methyclothiazide 1 MICROZIDE 3
QL 1 / day TEKTURNA HCT 3 ST trichlormethiazide 3 THIAZIDE-LIKE DIURETICS chlorthalidone 1 indapamide 1 metolazone 1 VASOPRESSIN ANTAGONISTS
QL 1 / day SAMSCA 15 MG TABLET 4 PA S
QL 2 / day SAMSCA 30 MG TABLET 4 PA S
PAGE 164 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DIURETICS (HYPOTENSIVE AGENTS)
POTASSIUM-SPARING DIURETICS (HYPOTEN)
ALDACTAZIDE 3 ALDACTONE 3 eplerenone 1 INSPRA 3 spironolactone powder 3 spironolactone (25 mg tablet, 50 mg tablet, 100 mg tablet) 1 spironolactone-hctz 1 THIAZIDE DIURETICS(HYPOTENSIVE AGENTS)
ACCURETIC (10-12.5 MG TABLET, 20-12.5 MG TABLET) 3 QL 2 / day
ACCURETIC 20-25 MG TABLET 3 QL 1 / day
ATACAND HCT (32-12.5 MG TAB, 32-25 MG TABLET) 3 QL 1 / day
ATACAND HCT 16-12.5 MG TAB 3 QL 2 / day
AVALIDE 150-12.5 MG TABLET 3 QL 2 / day
AVALIDE 300-12.5 MG TABLET 3 QL 1 / day benazepril-hydrochlorothiazide 1 QL 1 / day
BENICAR HCT 3 QL 1 / day candesartan-hctz 16-12.5 mg tb 1 QL 2 / day candesartan-hydrochlorothiazid (32-12.5 mg tb, 32-25 mg tab) 1 QL 1 / day captopril-hydrochlorothiazide 1 QL 2 / day
DIOVAN HCT (320-12.5 MG TAB, 320-25 MG TABLET) 3 QL 1 / day
DIOVAN HCT (80-12.5 MG TABLET, 160-12.5 MG TAB, 160-25 2 / day MG TABLET) 3 QL enalapril-hctz 10-25 mg tablet 1 QL 2 / day
PAGE 165 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS enalapril-hctz 5-12.5 mg tab 1 fosinopril-hydrochlorothiazide 1 QL 2 / day
HYZAAR (100-12.5 TABLET, 100-25 TABLET) 3 QL 1 / day
HYZAAR 50-12.5 TABLET 3 QL 2 / day irbesartan-hctz 150-12.5 mg tb 1 QL 2 / day irbesartan-hctz 300-12.5 mg tb 1 QL 1 / day lisinopril-hydrochlorothiazide 1 QL 2 / day losartan-hctz 50-12.5 mg tab 1 QL 2 / day losartan-hydrochlorothiazide (100-12.5 mg tab, 100-25 mg 1 / day tab) 1 QL
LOTENSIN HCT 3 QL 1 / day methyldopa-hydrochlorothiazide 1
MICARDIS HCT (40-12.5 MG TABLET, 80-25 MG TABLET) 3 QL 1 / day
MICARDIS HCT 80-12.5 MG TABLET 3 QL 2 / day moexipril-hydrochlorothiazide 1 QL 2 / day olmesartan-amlodipine-hctz 1 QL 1 / day olmesartan-hydrochlorothiazide 1 QL 1 / day quinapril-hctz 20-25 mg tab 1 QL 1 / day quinapril-hydrochlorothiazide (10-12.5 mg tab, 20-12.5 mg 2 / day tab) 1 QL telmisartan-hctz 80-12.5 mg tb 1 QL 2 / day telmisartan-hydrochlorothiazid (40-12.5 mg tb, 80-25 mg tab) 1 QL 1 / day
TRIBENZOR 3 QL 1 / day valsartan-hydrochlorothiazide (320-12.5 mg tab, 320-25 mg 1 / day tab) 1 QL
PAGE 166 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS valsartan-hydrochlorothiazide (80-12.5 mg tab, 160-12.5 mg 2 / day tab, 160-25 mg tab) 1 QL
VASERETIC 3 QL 2 / day
ZESTORETIC 3 QL 2 / day
THIAZIDE-LIKE DIURETICS(HYPOTENSIVE AGT)
CLORPRES 3
QL 1 / day EDARBYCLOR 3 ST
DOPAMINE RECEPTOR AGONISTS
ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) 1 bromocriptine mesylate powder 3 cabergoline 1
QL 6 / day CYCLOSET 3 PA
PARLODEL (2.5 MG TABLET, 5 MG CAPSULE) 3 NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST
PA APOKYN 4 S apomorphine hcl 3 MIRAPEX 3
MIRAPEX ER 3 ST
NEUPRO 3 pramipexole dihydrochloride 1 pramipexole er 1 REQUIP 3
PAGE 167 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
REQUIP XL 3 QL 1 / day ropinirole er 1 QL 1 / day ropinirole hcl 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE
ACIDIFYING AGENTS ammonium chloride granules 3 K-PHOS NEUTRAL 3 K-PHOS NO.2 3 K-PHOS ORIGINAL 3 PHOSPHA 250 NEUTRAL 1 VIRT-PHOS 250 NEUTRAL 1 ALKALINIZING AGENTS
CYTRA-2 1 CYTRA-3 3 CYTRA-K (CRYSTALS PACKET, ORAL SOLUTION) 1 ORACIT 3 potass cit-sod cit-citric acid 1 potassium citrate er 1 potassium cit-citric acid soln 1 SHOHL'S MODIFIED 3 sodium bicarbonate powder 3 sodium citrate powder 3 sodium citrate dihydrate 3 sodium citrate-citric acid 1 TARON-CRYSTALS 1 TRICITRASOL 3 TRICITRATES 1
PAGE 168 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS UROCIT-K 3 VIRTRATE-2 1 VIRTRATE-3 1 VIRTRATE-K 1 AMMONIA DETOXICANTS
BUPHENYL (500 MG TABLET, POWDER) 4 S
CARBAGLU 4 S
CONSTULOSE 1 ENULOSE 1 GENERLAC 1 KRISTALOSE 1 lactulose 1 LITHOSTAT 3
QL 20 / day RAVICTI 4 PA S sodium phenylbutyrate powder 3 S sodium phenylbutyrate 500mg tb 4 S
CALORIC AGENTS
ACD 1 alanine 3 arginine (arginine 100% crystals, l-arginine powder) 3 arginine hcl 3 d-ribose 3 dextrose 3 l-alanine 3
PAGE 169 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS l-citrulline 3 l-cysteine hydrochloride 3 l-leucine 3 leucine 3 lysine hcl 3 LYSIPLEX PLUS 1 phenylalanine 3 tyrosine powder 3 IRRIGATING SOLUTIONS
RESECTISOL 3 REPLACEMENT PREPARATIONS calcium amino acid chelate 3 calcium carbonate 3 calcium chloride powder 3 calcium citrate 3 calcium glubionate 3 calcium gluconate monohydrate 3 calcium levulinate dihydrate 3 calcium phosphate 3 calcium saccharate 3 calcium sulfate 3 cardioplegia high potassium 3 cardioplegic 1 EFFER-K (10 TABLET EFF, 20 TABLET EFF) 3 EFFER-K 25 MEQ TABLET EFF 1
FOLBECAL 3 GL Female
FOLGARD OS 3
PAGE 170 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HYPER-SAL 3 K EFFERVESCENT 1 K-SOL 1 K-TAB ER 3 KLOR-CON 20 MEQ PACKET 1 KLOR-CON 25 MEQ PACKET 3 KLOR-CON 10 1 KLOR-CON 8 1 KLOR-CON M10 1 KLOR-CON M15 3 KLOR-CON M20 1 KLOR-CON SPRINKLE 1 KLOR-CON-EF 1 magnesium amino acid chelate 3 magnesium gluconate 3 magnesium glycinate 3 manganese chloride 3 manganese gluconate 3 molybdenum 3 MONOJECT 0.9% SODIUM CHLORIDE 1 MONOJECT PREFILL 0.9% FLUSH 1 MONOJECT PREFILL ADVANCED 1 NEBUSAL 3% VIAL 1 NEBUSAL 6% VIAL 3 normal saline flush 1 PLEGISOL 3 potassium bicarbonate 1
PAGE 171 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS potassium chloride (granules, powder) 3 potassium chloride (er 8 meq capsule, er 8 meq tablet, 10% (20 meq/15 ml, 10% (40 meq/30 ml, er 10 meq capsule, er 10 meq tablet, 20 meq packet, 20% (40 meq/15 ml, er 20 meq tablet, 1 25 meq tab eff) potassium citrate 3 potassium citrate monohydrate 3 potassium phosphate powder 3
PRENAISSANCE NEXT 3 GL Female
PRISMASOL (B22GK 2/0, B22GK 4/0, BGK 0/2.5, BGK 2/0, BGK 2/3.5, BGK 4/0/1.2, BGK 4/2.5, BK 0/0/1.2) 3
PULMOSAL 1 selenomethionine 3 sodium acetate trihydrate (crys, powd) 3 sodium cacodylate 3 sodium chloride granules 3 sodium chloride (bacteriostatic saline vial, sodium chloride 0.9% vial) 1 sodium chloride (0.9% inhal vl, 0.9% syringe, 0.9% zr syr, 3% vial, 7% vial, 10% vial) 1 sodium l-aspartate monohydrate 3 SYREX 1 zinc chloride powder 3 zinc picolinate 3 zinc sulfate (heptahydrate powd, powder) 3 SALT AND SUGAR SUBSTITUTES saccharin 1 URICOSURIC AGENTS probenecid 1 QL 4 / day
PAGE 172 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS probenecid-colchicine 1 QL 2 / day
QL 1 / day ZURAMPIC 3 PA AL At least 18 yrs old
EMOLLIENTS, DEMULCENTS, AND PROTECTANTS
BASIC LOTIONS AND LINIMENTS ammonium lactate 12% lotion 1 ATOPICLAIR 3 calamine 3 lactic acid 10% lotion 1 PRUCLAIR 3 BASIC OILS AND OTHER SOLVENTS
AVO CREAM 3 BIAFINE 3 LUXAMEND 1 muri-lube mineral oil 3 PRUTECT 3 SONAFINE 3 SYNERDERM 3 BASIC OINTMENTS AND PROTECTANTS ammonium lactate 12% cream 1 DEXERYL 3 ELETONE CREAM 3 lactic acid 10% e cream 1 TETRIX CREAM 3 VASELINE WHITE PETROLEUM 3 XCLAIR 3
PAGE 173 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ESTROGENS AND ANTIESTROGENS
ESTROGEN AGONIST-ANTAGONISTS clomiphene citrate powder 3 clomiphene citrate 50 mg tab 1 GL Female
DUAVEE 2
EVISTA 3 QL 1 / day
OSPHENA 3 raloxifene hcl 1 HCR
SEROPHENE 1 GL Female
ESTROGENS
QL 1 / day ACTIVELLA 3 GL Female
QL 0.29 / day ALORA 3 GL Female
QL 1 / day AMABELZ 1 GL Female
QL 1 / day ANGELIQ 3 GL Female
QL 0.15 / day CLIMARA 3 GL Female
QL 0.15 / day CLIMARA PRO 2 GL Female
QL 0.29 / day COMBIPATCH 3 GL Female
COVARYX 1 GL Female
PAGE 174 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COVARYX H.S. 1 GL Female
DELESTROGEN 3 GL Female
DEPO-ESTRADIOL 3 GL Female diethylstilbestrol 3 DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 1 MG GEL Female PACKET) 2 GL
EEMT 1 GL Female
EEMT H.S. 1 GL Female
ELESTRIN 3 GL Female
QL 1 / day ENJUVIA 2 GL Female
ESTRACE 0.01% CREAM 2 GL Female
QL 1 / day ESTRACE (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3 GL Female estradiol (0.025 mg patch, 0.0375 mg patch, 0.05 mg patch, QL 0.29 / day 1 0.075 mg patch, 0.1 mg patch) GL Female estradiol (tds 0.025 mg/day, 0.0375 mg/day patch, tds 0.0375 QL 0.15 / day mg/day, tds 0.05 mg/day, tds 0.06 mg/day, 0.075 mg/day 1 patch, tds 0.075 mg/day, tds 0.1 mg/day) GL Female
QL .15 / day estradiol 0.06 mg/day patch 1 GL Female estradiol powder 3
QL 1 / day estradiol (0.5 mg tablet, 1 mg tablet) 1 GL Female LCG estradiol 10 mcg vaginal insrt 1 GL Female
QL 1 / day estradiol 2 mg tablet 1 GL Female
PAGE 175 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS estradiol benzoate 3 estradiol cypionate 3 estradiol micronized 3 estradiol valerate powder 3 estradiol valerate (20 mg/ml vl, 40 mg/ml vl) 1 GL Female
QL 1 / day estradiol-norethindrone acetat 1 GL Female
QL 90 days ESTRING 2 GL Female estriol 3 GL Female estriol micronized 3 GL Female
QL 1.667 / day ESTROGEL 3 GL Female estrogen-methyltestosterone 1 GL Female estrone (crystal, powder) 3
QL 1 / day estropipate (0.625(0.75 tab, 1.25(1.5 tab) 1 GL Female LCG
QL 1 / day estropipate 2.5(3 mg) tab 1 GL Female ethinyl estradiol 3
QL 0.54 / day EVAMIST 3 GL Female
QL 1 / day FEMHRT 3 GL Female
QL 0.02 / day FEMRING 3 GL Female
PAGE 176 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FYAVOLV 1 GL Female
JEVANTIQUE LO 3 GL Female
QL 1 / day JINTELI 1 GL Female HCR
QL 1 / day LOPREEZA 1 GL Female
QL 1 / day MENEST (0.625 MG TABLET, 1.25 MG TABLET, 2.5 MG TABLET) 3 GL Female
QL 1 / day MENEST 0.3 MG TABLET 2 GL Female
QL 0.15 / day MENOSTAR 3 GL Female
QL 1 / day MIMVEY 1 GL Female
MIMVEY LO 1
QL 0.29 / day MINIVELLE 3 GL Female norethindron-ethinyl estradiol (norethin-eth 1 mg-5 mcg, norethind-eth 0.5-2.5) 1 HCR
QL 1 / day OGEN 3 GL Female
QL 1 / day PREFEST 3 GL Female
PREMARIN VAGINAL CREAM-APPL 2 GL Female
PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, QL 1 / day 2 0.9 MG TABLET, 1.25 MG TABLET) GL Female
PAGE 177 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PREMARIN 25 MG VIAL 2
QL 1 / day PREMPHASE 2 GL Female
QL 1 / day PREMPRO 2 GL Female
VAGIFEM 3 GL Female
QL 8 / 28 days VIVELLE-DOT 3 GL Female
YUVAFEM 1 GL Female
EYE, EAR, NOSE AND THROAT (EENT) PREPS.
ANTIALLERGIC AGENTS
ALOMIDE 3 QL 10 / fill
ASTEPRO 3 QL 2 / day azelastine hcl 0.05% drops 1 QL 0.267 / day azelastine hcl powder 3 azelastine hcl (0.1% (137 mcg) spry, 0.15% nasal spray) 1 QL 2 / day
BEPREVE 3 QL 0.286 / day
ELESTAT 3 QL 0.286 / day
EMADINE 3 QL 5 / fill epinastine hcl 1 QL 0.286 / day
QL 3 / 30 days LASTACAFT 3 ST olopatadine hcl (0.1% drops, 0.2% drop) 1 QL 0.286 / day olopatadine 665 mcg nasal spry 1 QL 31 / 30 days
PAGE 178 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PATADAY 3 QL 0.286 / day
PATANASE 3 QL 31 / 30 days
PATANOL 3 QL 0.286 / day
PAZEO 3 QL 0.286 / day
EENT DRUGS, MISCELLANEOUS acetylcysteine-water 1 QL 10 / 30 days apraclonidine hcl 1 QL 0.8 / day
ATROVENT 3 QL 2 / day balanced salt 1 BSS 1 BSS PLUS 3 CELLUGEL 3
PA CYSTARAN 4 S
QL 0.04 / day EYLEA 4 PA S
GELFILM OPHTHALMIC 25X50MM 3
IOPIDINE (0.5% DROPS, 1% DROPS) 3 QL 0.8 / day ipratropium bromide (0.03% spray, 0.06% spray) 1 QL 2 / day
PA JETREA 2.5 MG/ML VIAL 4 S
LACRISERT 3
QL 0.04 / day LUCENTIS (0.3 MG VIAL, 0.3 MG/0.05 ML VIAL, 0.5 MG VIAL, 0.5 MG/0.05 ML SYRING, 0.5 MG/0.05 ML VIAL) 4 PA S
PAGE 179 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 0.0111 / day MACUGEN 4 PA S
OCUCOAT 1
RESCULA 3 QL 0.2 / day
LOCAL ANESTHETICS (EENT)
AKTEN 3 ALCAINE 3 ALTACAINE 1 ALTAFLUOR 1 BUCALSEP (SOLUTION, SPRAY) 3 cocaine hcl (hcl crystals, hcl powder, hydrochloride pwd) 3 cocaine 4% solution 1 cyclopentolate-lidoc-pe-tropic 1 dyclonine hcl 3 fluorescein-benoxinate 1 FLUROX 1 GLYDO 1 lidocaine hcl (2% jelly, 4% solution) 1 lidocaine hcl viscous 1 proparacaine 0.5% eye drops 1 proparacaine hcl powder 3 TETCAINE 1 tetracaine 0.5% eye drops 1 TETRAVISC 1 TETRAVISC FORTE 1 XYLOCAINE 4% SOLUTION 3
PAGE 180 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MYDRIATICS atropine sulfate (drops, ointment) 1 atropine 0.01%-ns eye drops 1 CYCLOGYL 3 CYCLOMYDRIL 3 cyclopentolate hcl (0.5% eye drops, 1% eye drops, hcl 2% drops) 1 cyclopentolate hcl powder 3 cyclopentolate-tropicamide-pe 1 HOMATROPAIRE 1 homatropine hydrobromide 1 homatropine methylbromide 3 hydroxyamphetamine hbr 3 ISOPTO ATROPINE 3 MYDRIACYL 3 PAREMYD 3 tropicamide (0.5% drops, 1% drops) 1 tropicamide powder 3 VASOCONSTRICTORS
ADRENALIN CHLORIDE 3 PA naphazoline hcl 1 oxymetazoline hcl 3 phenylephrine hcl (2.5% drop, 10% drops) 1 tetrahydrozoline hcl 3 TYZINE (PEDIATRIC 0.05% DROP, 0.1% NOSE DROPS, 0.1% NOSE SPRAY) 3
PAGE 181 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FIRST GENERATION ANTIHISTAMINES
ETHYLENEDIAMINE DERIVATIVES pyrilamine maleate 3 tripelennamine hcl 3 PHENOTHIAZINE DERIVATIVES trimeprazine tartrate 3 GASTROINTESTINAL DRUGS
ANTACIDS AND ADSORBENTS aluminum hydroxide 3 magnesium oxide 3 ANTI-INFLAMMATORY AGENTS (GI DRUGS)
5-aminosalicylic acid 3
GL Female alosetron hcl 1 AL At least 18 yrs old
APRISO 2
ASACOL HD 3 PA balsalazide disodium 1 CANASA 2 COLAZAL 3
DELZICOL 3 PA
DIPENTUM 3
GIAZO 3 GL Male
LIALDA 2
PA LOTRONEX 3 GL Female AL At least 18 yrs old
PAGE 182 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS mesalamine powder 3 mesalamine (dr 1.2 gm tablet, 4 gm/60 ml enema, 4 gm/60 ml kit) 1 mesalamine 800 mg dr tablet 3 PA
PENTASA 3 ROWASA 3 SFROWASA 3 ANTIDIARRHEA AGENTS acidophilus lactobacillus 3 attapulgite 3 bismuth subsalicylate 3
FULYZAQ 4 S loperamide 2 mg capsule 1 loperamide hcl powder 3 MOTOFEN 3
MYTESI 4 S opium tincture 1 QL 5 / day paregoric 1
PA XERMELO 4 AL At least 18 yrs old S
ANTIFLATULENTS simethicone 3 CATHARTICS AND LAXATIVES
QL 2 / day AMITIZA 2 AL At least 18 yrs old
PAGE 183 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS bisacodyl 3 cascara sagrada 3 COLYTE WITH FLAVOR PACKETS 3 docusate sodium 3
GAVILYTE-C 1 HCR
GAVILYTE-G 1 HCR
GAVILYTE-N 1 HCR
GOLYTELY PACKET 3 HCR
GOLYTELY SOLUTION 3 karaya gum 3
MOVIPREP 3 HCR
NULYTELY WITH FLAVOR PACKS 3 OSMOPREP 3 peg 3350-electrolyte (3350 electrolyte soln, 3350-electrolyte solution) 1 HCR peg-3350 and electrolytes 1 HCR peg-3350 with flavor packs 1 HCR
PEG-PREP 1 polyethylene glycol 3350 1 HCR
PREPOPIK 3 QL 2 / fill sodium phosphate powder 3 sodium sulfate 3 sorbitol 70% solution 1
SUPREP 3 QL 354 / fill
TRILYTE WITH FLAVOR PACKETS 1 HCR
PAGE 184 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CHOLELITHOLYTIC AGENTS
ACTIGALL 3
CHENODAL 4 S
URSO 3 URSO FORTE 3 ursodiol powder 3 ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 1 DIGESTANTS
CREON 2 hydrochloric acid 3 pancreatin 3 pancreatin 8x 3
PANCREAZE 3 PA
PANCRELIPASE 5,000 1 PERTZYE (DR 4,000 UNIT CAPSULE, DR 8,000 UNIT CAPSULE, DR 16,000 UNIT CAPSULE) 3 PA
ULTRESA 3 PA
VIOKACE 3 PA
ZENPEP 2 GI DRUGS, MISCELLANEOUS
QL 7 / day CHOLBAM 250 MG CAPSULE 4 PA S
QL 4 / day CHOLBAM 50 MG CAPSULE 4 PA S
QL 3/ fill CIMZIA (200 MG VIAL KIT, 200 MG/ML STARTER KIT, 200 MG/ML SYRINGE KIT) 4 PA S
PAGE 185 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ENDARI 3 ENTEREG 3
PA GATTEX 4 S glutamine 3
QL 0.22 / day PA HUMIRA (20 MG/0.4 ML SYRINGE, 40 MG/0.8 ML SYRINGE) 4 S PS
QL 0.15 / day PA HUMIRA 10 MG/0.2 ML SYRINGE 4 S PS
QL 0.22 / day PA HUMIRA PEDIATRIC CROHN'S 4 S PS
QL 0.22 / day PA HUMIRA PEN 4 S PS
QL 0.22 / day PA HUMIRA PEN CROHN-UC-HS STARTER 4 S PS
QL 0.22 / day PA HUMIRA PEN PSORIASIS-UVEITIS 4 S PS
PAGE 186 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS l-glutamine 3
QL 1 / day LINZESS 2 ST
QL 1 / day MOVANTIK 3 PA
NUTRESTORE 3
QL 1 / day OCALIVA 4 PA S
RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML SYRINGE, 12 MG/0.6 ML VIAL) 3 PA
RELISTOR 150 MG TABLET 3 PA
RESTORA SPRINKLES 3
QL 1 / day TRULANCE 3 PA AL At least 18 yrs old
QL 2 / day VIBERZI 2 PA
XENICAL 3 LIPOTROPIC AGENTS choline bitartrate 3 phosphatidylcholine 3 PROKINETIC AGENTS metoclopramide hcl powder 3 metoclopramide 10 mg/10 ml sol 1 metoclopramide hcl (5 mg tablet, 5 mg/5 ml soln, 10 mg tablet) 1 LCG metoclopramide hcl (10 mg/2 ml syr, 10 mg/2 ml vial) 1
PAGE 187 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS metoclopramide hcl odt 1 METOZOLV ODT 3 REGLAN 3 GENERAL ANESTHETICS
GENERAL ANESTHETICS, MISCELLANEOUS etomidate powder 3 KETALAR 3 ketamine hcl (100 mg/ml vial, 200 mg/20 ml vial, 1,000 mg/10 ml vial) 1 ketamine hydrochloride 3 INHALATION ANESTHETICS chloroform 3 COMPOUND 347 1 FORANE 3 isoflurane 1 sevoflurane 1 SOJOURN 1 SUPRANE 3 TERRELL 1 ULTANE 3 GENITOURINARY SMOOTH MUSCLE RELAXANTS
ANTIMUSCARINICS darifenacin er 1 QL 1 / day
DETROL 3 QL 2 / day
DETROL LA 3 QL 1 / day
DITROPAN XL (10 MG TABLET, 15 MG TABLET) 3 QL 2 / day
PAGE 188 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DITROPAN XL 5 MG TABLET 3 QL 1 / day
ENABLEX 3 QL 1 / day flavoxate hcl 1
QL 3.067 / day GELNIQUE 3% GEL 3 ST
QL 1 / day GELNIQUE (GEL PUMP, GEL SACHETS) 3 ST oxybutynin chloride powder 3 oxybutynin 5 mg/5 ml syrup 1 QL 20 / day oxybutynin 5 mg tablet 1 QL 4 / day oxybutynin chloride er (er 10 mg tablet, er 15 mg tablet) 1 QL 2 / day oxybutynin cl er 5 mg tablet 1 QL 1 / day
QL 0.357 / day OXYTROL 3 ST tolterodine tartrate 1 QL 2 / day tolterodine tartrate er 1 QL 1 / day
TOVIAZ 3 QL 1 / day trospium chloride 1 QL 2 / day trospium chloride er 1 QL 1 / day
VESICARE 2 QL 1 / day
HCV ANTIVIRALS
HCV POLYMERASE INHIBITORS
QL 1 / day PA EPCLUSA 4 S PS
PAGE 189 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day PA HARVONI 4 S PS
QL 1 / day PA SOVALDI 4 S PS
HCV PROTEASE INHIBITORS
QL 1 / day OLYSIO 4 PA S
QL 1 / day ZEPATIER 4 PA S
HCV REPLICATION COMPLEX INHIBITORS
QL 1 / day DAKLINZA 4 PA S
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
A-HYDROCORT 3 A-METHAPRED 1 aldosterone 3 ARISTOSPAN 3 beclomethasone dipropionate 3 betamethasone acetate micro 3
PAGE 190 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS betamethasone acetate-sod phos 1 betamethasone sodium phosphate 3 budesonide ec 1 CELESTONE 3 CORTEF 3 cortisone acetate powder 3 cortisone 25 mg tablet 1 DELTASONE 1 DEPO-MEDROL 3 desoxycorticosterone acetate 3 dexamethasone (0.5 mg tablet, 0.5 mg/5 ml elx, 0.5 mg/5 ml liq, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg 1 tablet, 6 mg tablet) dexamethasone acetate 3 dexamethasone acetate micro 3 DEXAMETHASONE INTENSOL 2 dexamethasone isonicotinate 3 dexamethasone micronized 3 dexamethasone sod ph powder 3 DEXPAK 3
PA EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/ML ORAL At least 5 yrs old SUSP, 30 MG TABLET, 36 MG TABLET) 4 AL S
ENTOCORT EC 3 EZ USE JOINT-TUNNEL-TRIGGER 3 FLO-PRED 3 fludrocortisone acetate powder 3 fludrocortisone 0.1 mg tablet 1
PAGE 191 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS flunisolide powder 3 fluticasone propionate powder 3 fluticasone propionate micro 3 hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 1
QL 1 / day INTRAROSA 3 AL At least 18 yrs old
KENALOG-10 3 KENALOG-40 3 MEDROL (4 MG DOSEPAK, 4 MG TABLET, 8 MG TABLET, 16 MG TABLET, 32 MG TABLET) 3
MEDROL 2 MG TABLET 2 methylprednisolone powder 3 methylprednisolone (4 mg dosepk, 4 mg tablet, 8 mg tab, 16 mg tab, 32 mg tab) 1 methylprednisolone ac micro 3 methylprednisolone acetate 1 methylprednisolone sodium succ (40 mg vl, 125 mg) 1 MILLIPRED (5 MG TABLET, 10 MG/5 ML SOLUTION) 3 MILLIPRED DP 3 ORAPRED ODT 3 PEDIAPRED 3 prednisolone (anhydrous powder, powder) 3 prednisolone (15 mg/5 ml soln, 15 mg/5 ml syrup) 1 prednisolone acetate micronize 3 prednisolone micronized 3 prednisolone sodium phos odt 1 prednisolone sod ph powder 3 prednisolone sodium phosphate (5 mg/5 ml soln, 10 mg/5 ml soln, 20 mg/5 ml soln, sod ph 25 mg/5 ml) 1
PAGE 192 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS prednisone powder 3 prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab dose pack, 5 mg tablet, 5 mg/5 ml solution, 10 mg tab dose pack, 10 mg 1 tablet, 20 mg tablet, 50 mg tablet)
PREDNISONE INTENSOL 2 prednisone micronized 3 RAYOS 3 SOLU-CORTEF 3 SOLU-MEDROL (40 MG VIAL, 125 MG VIAL) 3 triamcinolone 3 triamcinolone acetonide powder 3 triamcinolone acetonide (40mg/ml vl, 50mg/5ml vl) 1 triamcinolone diacetate 3 triamcinolone diacetate micro 3 triamcinolone hexacetonide 3 UCERIS (2 MG RECTAL FOAM, 9 MG ER TABLET) 3 VERIPRED 20 3 ZODEX 6 DAY 1.5 MG TABLET 3 ANDROGENS
ANADROL-50 3 GL Male
QL 1 / day ANDRODERM 2 PA GL Male
QL 10 / day ANDROGEL 1% GEL PUMP 3 PA GL Male
QL 5 / day ANDROGEL (1.62% GEL PUMP, 1.62%(1.25G) GEL PCKT, 1.62%(2.5G) GEL PCKT) 2 PA GL Male
PAGE 193 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 2.5 / day ANDROGEL 1%(2.5G) GEL PACKET 3 PA GL Male
QL 5 / day ANDROGEL 1%(5G) GEL PACKET 3 PA GL Male
PA ANDROID 3 GL Male androstenedione 3
PA ANDROXY 3 GL Male
PA AVEED 4 S
QL 6 / day AXIRON 3 PA GL Male danazol (50 mg capsule, 100 mg capsule, 200 mg capsule) 1 danazol powder 3 dehydroepiandrosterone 3
PA DELATESTRYL 3 GL Male
DEPO-TESTOSTERONE (100 MG/ML VL, 200 MG/ML) 3 GL Male dhea micronized 3 fluoxymesterone 3
QL 4 / day FORTESTA 3 PA GL Male
PAGE 194 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA METHITEST 3 GL Male methyltestosterone 10 mg cap 1 methyltestosterone powder 3 methyltestosterone micronized 3 nandrolone decanoate 3
PA OXANDRIN 3 GL Male oxandrolone powder 3
PA oxandrolone (2.5 mg tablet, 10 mg tablet) 1 GL Male stanozolol 3 stanozolol micronized 3
PA STRIANT 3 GL Male
QL 300 / 30 days TESTIM 3 PA GL Male
QL 4 / day testosterone 10 mg gel pump 1 GL Male testosterone (12.5 mg/1.25 gram, 25 mg/2.5 gm pkt, 50 mg/5 Male gram gel, 50 mg/5 gram pkt) 1 GL testosterone powder 3 GL Male
QL 6 / day testosterone 30 mg/1.5 ml pump 1 PA GL Male testosterone cypionate powder 3 GL Male
PAGE 195 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS testosterone cypionate (testosteron 1,000 mg/10 ml, testosteron 2,000 mg/10 ml, testosterone 100 mg/ml, 1 GL Male testosterone 200 mg/ml) testosterone cypionate micro 3 GL Male testosterone enanthate powder 3 GL Male testosterone enanthate (testosteron 1,000 mg/5 ml, PA 1 testosterone 200 mg/ml) GL Male testosterone micronized 3 GL Male testosterone propionate 3 GL Male
PA TESTRED 3 GL Male
VOGELXO (12.5 MG/1.25 PUMP, 50 MG/5 GEL, 50 MG/5 GEL QL 10 / day 3 PACKT) PA
CONTRACEPTIVES
QL 1 / day ALTAVERA 1 GL Female HCR
GL Female ALYACEN 1 HCR
QL 91 days AMETHIA 1 GL Female HCR
QL 91 days AMETHIA LO 1 GL Female HCR
QL 1 / day AMETHYST 1 GL Female HCR
PAGE 196 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female APRI 1 HCR
GL Female ARANELLE 1 HCR
GL Female ASHLYNA 1 HCR
QL 1 / day AUBRA 1 GL Female HCR
QL 1 / day AVIANE 1 GL Female HCR
GL Female AZURETTE 1 HCR
GL Female BALZIVA 1 HCR
GL Female BEKYREE 1 HCR
BEYAZ 3 GL Female
GL Female BLISOVI 24 FE 1 HCR
GL Female BLISOVI FE 1 HCR
BREVICON 3 GL Female
GL Female BRIELLYN 1 HCR
PAGE 197 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female CAMILA 1 HCR
QL 91 days CAMRESE 1 GL Female HCR
QL 91 days CAMRESE LO 1 GL Female HCR
GL Female CAZIANT 1 HCR
QL 1 / day CHATEAL 1 GL Female HCR
GL Female CRYSELLE 1 HCR
GL Female CYCLAFEM 1 HCR
CYCLESSA 3 GL Female
GL Female CYRED 1 HCR
GL Female DASETTA 1 HCR
QL 91 days DAYSEE 1 GL Female HCR
GL Female DEBLITANE 1 HCR
PAGE 198 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day DELYLA 1 GL Female HCR
DESOGEN 3 GL Female
GL Female desogestr-eth estrad eth estra 1 HCR
GL Female desogestrel-ethinyl estradiol 1 HCR
GL Female drospirenone-eth estra-levomef 1 HCR
GL Female drospirenone-ethinyl estradiol 1 HCR
GL Female ELINEST 1 HCR
QL 1 / day ELLA 3 GL Female HCR
GL Female EMOQUETTE 1 HCR
GL Female ENPRESSE 1 HCR
GL Female ENSKYCE 1 HCR
GL Female ERRIN 1 HCR
GL Female ESTARYLLA 1 HCR
PAGE 199 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ESTROSTEP FE 3 GL Female
GL Female ethynodiol-ethinyl estradiol 1 HCR
QL 1 / day FALMINA 1 GL Female HCR
QL 91 days FAYOSIM 1 GL Female HCR
FEMCON FE 3 GL Female
GL Female FEMYNOR 1 HCR
GENERESS FE 3 GL Female
GL Female GIANVI 1 HCR
GL Female GILDAGIA 1 HCR
GL Female GILDESS 1 HCR
GL Female GILDESS 24 FE 1 HCR
GL Female GILDESS FE 1 HCR
GL Female HEATHER 1 HCR
QL 91 days INTROVALE 1 GL Female HCR
PAGE 200 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female ISIBLOOM 1 HCR
GL Female JENCYCLA 1 HCR
QL 91 days JOLESSA 1 GL Female HCR
GL Female JOLIVETTE 1 HCR
GL Female JULEBER 1 HCR
GL Female JUNEL 1 HCR
GL Female JUNEL FE 1 HCR
GL Female JUNEL FE 24 1 HCR
GL Female KAITLIB FE 1 HCR
GL Female KARIVA 1 HCR
GL Female KELNOR 1-35 1 HCR
GL Female KIMIDESS 1 HCR
QL 1 / day KURVELO 1 GL Female HCR
PAGE 201 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female LARIN 1 HCR
GL Female LARIN 24 FE 1 HCR
GL Female LARIN FE 1 HCR
QL 1 / day LARISSIA 1 GL Female HCR
GL Female LAYOLIS FE 1 HCR
GL Female LEENA 1 HCR
QL 1 / day LESSINA 1 GL Female HCR
GL Female LEVONEST 1 HCR
GL Female levono-e estrad 0.15-0.03-0.01 1 HCR
QL 91 days levonorg-eth estrad eth estrad (levono-e estrad 0.10-0.02-0.01, Female levonorg 0.15mg-ee 20-25-30mcg) 1 GL HCR
QL 0.07 / day levonorgestrel 1 GL Female HCR
QL 91 days levonor-eth estrad 0.15-0.03 1 GL Female HCR
PAGE 202 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female levonor-eth estrad triphasic 1 HCR
QL 1 / day levonorgestrel-eth estradiol (estra 0.09-0.02 mg, estrad 0.1- Female 0.02 mg) 1 GL HCR
QL 1 / day LEVORA-28 1 GL Female HCR
QL 1 / day LILLOW 1 GL Female HCR
GL Female LO LOESTRIN FE 3 HCR
LOESTRIN 3 GL Female
LOESTRIN FE 1-20 TABLET 3 GL Female
GL Female LOESTRIN FE 1.5-30 TABLET 3 HCR
GL Female LOMEDIA 24 FE 1 HCR
GL Female LORYNA 1 HCR
QL 91 days LOSEASONIQUE 3 GL Female
GL Female LOW-OGESTREL 1 HCR
QL 1 / day LUTERA 1 GL Female HCR
PAGE 203 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female LYZA 1 HCR
QL 1 / day MARLISSA 1 GL Female HCR
GL Female MELODETTA 24 FE 1 HCR
GL Female MIBELAS 24 FE 1 HCR
GL Female MICROGESTIN 1 HCR
GL Female MICROGESTIN 24 FE 1 HCR
GL Female MICROGESTIN FE 1 HCR
MINASTRIN 24 FE 3 GL Female
MIRCETTE 3 GL Female
MODICON 3 GL Female
GL Female MONO-LINYAH 1 HCR
GL Female MONONESSA 1 HCR
GL Female MYZILRA 1 HCR
NATAZIA 2 GL Female
GL Female NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 10-11-28 TABLET) 1 HCR
PAGE 204 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female NECON 1-50-28 TABLET 3 HCR
QL 1 / day NECON 7-7-7-28 TABLET 1 GL Female HCR
GL Female NIKKI 1 HCR
NOR-Q-D 3 GL Female
GL Female NORA-BE 1 HCR
GL Female noreth-estrad-fe 1-0.02(24)-75 3 HCR norethin-eth estra-ferrous fum (noret-estr-fe 0.4-0.035(21)-75, GL Female noreth-estrad-fe 1-0.02(21)-75, norethin-estra-fe 0.8-0.025 1 mg) HCR
GL Female norethind-eth estrad 1-0.02 mg 1 HCR
GL Female norethindrone 0.35 mg tablet 1 HCR
GL Female norgestimate-ethinyl estradiol 1 HCR
GL Female NORINYL 1+50 3 HCR
NORINYL 1-35 3 GL Female
GL Female NORLYDA 1 HCR
GL Female NORLYROC 1 HCR
PAGE 205 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female NORTREL 1 HCR
GL Female NUVARING 2 HCR
GL Female OCELLA 1 HCR
QL 1 / day OGESTREL 1 GL Female HCR
QL 1 / day ORSYTHIA 1 GL Female HCR
ORTHO MICRONOR 3 GL Female
ORTHO TRI-CYCLEN 3 GL Female
ORTHO TRI-CYCLEN LO 3 GL Female
ORTHO-CEPT 3 GL Female
ORTHO-CYCLEN 3 GL Female
ORTHO-NOVUM 3 GL Female
OVCON-35 3 GL Female
GL Female PHILITH 1 HCR
GL Female PIMTREA 1 HCR
GL Female PIRMELLA 1 HCR
PAGE 206 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 2 / 30 days PLAN B ONE-STEP 3 GL Female
QL 1 / day PORTIA 1 GL Female HCR
GL Female PREVIFEM 1 HCR
QUARTETTE 3 GL Female
QL 91 days QUASENSE 1 GL Female HCR
GL Female RAJANI 1 HCR
GL Female RECLIPSEN 1 HCR
QL 91 days RIVELSA 1 GL Female HCR
SAFYRAL 3 GL Female
QL 91 days SEASONIQUE 3 GL Female
QL 91 days SETLAKIN 1 GL Female HCR
GL Female SHAROBEL 1 HCR
PAGE 207 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female SPRINTEC 1 HCR
QL 1 / day SRONYX 1 GL Female HCR
GL Female SYEDA 1 HCR
GL Female TARINA FE 1 HCR
GL Female TAYTULLA 3 HCR
GL Female TILIA FE 1 HCR
GL Female TRI FEMYNOR 1 HCR
GL Female TRI-ESTARYLLA 1 HCR
GL Female TRI-LEGEST FE 1 HCR
GL Female TRI-LINYAH 1 HCR
GL Female TRI-LO-ESTARYLLA 1 HCR
GL Female TRI-LO-MARZIA 1 HCR
GL Female TRI-LO-SPRINTEC 1 HCR
PAGE 208 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRI-NORINYL 3 GL Female
GL Female TRI-PREVIFEM 1 HCR
GL Female TRI-SPRINTEC 1 HCR
GL Female TRINESSA 1 HCR
GL Female TRINESSA LO 1 HCR
GL Female TRIVORA-28 1 HCR
GL Female VELIVET 1 HCR
GL Female VESTURA 1 HCR
QL 1 / day VIENVA 1 GL Female HCR
GL Female VIORELE 1 HCR
GL Female VYFEMLA 1 HCR
GL Female WERA 1 HCR
GL Female WYMZYA FE 1 HCR
PAGE 209 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 0.12 / day XULANE 1 GL Female HCR
YASMIN 28 3 GL Female
YAZ 3 GL Female
GL Female ZARAH 1 HCR
GL Female ZENCHENT 1 HCR
GL Female ZENCHENT FE 1 HCR
GL Female ZEOSA 1 HCR
GL Female ZOVIA 1-35E 1 HCR
GL Female ZOVIA 1-50E 1 HCR
GONADOTROPINS
PA GL Female BRAVELLE 4 S PS chorionic gonadotropin (1 million unit, 2 million unit, 5 million unit, 10mm unit, 10,000 unit vl) 4 S chorionic gonadotropin powder 3
PA ELIGARD 4 S
PAGE 210 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FOLLISTIM AQ (75 UNIT VIAL, 300 UNIT CARTRIDG, 600 UNIT PA 4 CARTRIDG, 900 UNIT CARTRIDG) S
PA GONAL-F 4 S PS
PA GL Female GONAL-F RFF 4 S PS
PA GL Female GONAL-F RFF REDI-JECT 4 S PS
PA leuprolide acetate (1 mg/0.2 ml vial, 2wk 1 mg/0.2 ml kit) 4 S
PA leuprolide acetate (14 mg/2.8 ml kt, 14 mg/2.8 ml vl) 4 S
LUPANETA PACK 4 S
LUPRON DEPOT (DEPOT-4 MONTH KIT, DEPOT 7.5 MG KIT, PA DEPOT 11.25 MG 3MO KIT, DEPOT 22.5 MG 3MO KIT, DEPOT 45 4 MG 6MO KIT) S
PA LUPRON DEPOT 3.75 MG KIT 4 S
PA LUPRON DEPO 11.25MG (LUPANETA) 4 S
PA LUPRON DEPOT 3.75MG (LUPANETA) 4 S
LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO, 11.25 MG PA 4 KIT, 15 MG KIT, 30 MG 3MO KIT) S
PAGE 211 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA GL Female MENOPUR 4 S PS
PA NOVAREL 10,000 UNITS VIAL 4 S
PA OVIDREL 4 S PS
PA PREGNYL 4 S
PA SYNAREL 4 S
PA ZOLADEX 4 S PS
LEPTINS
PA MYALEPT 4 S
PARATHYROID calcitonin-salmon 1 QL 0.13 / day
PA FORTEO 4 S
FORTICAL 3 QL 0.13 / day
MIACALCIN 200 UNIT NASAL SPRAY 3 QL 0.13 / day
MIACALCIN 400 UNIT/2 ML VIAL 4 S
PAGE 212 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA NATPARA 4 S
QL 1.60 / day PA TYMLOS 4 AL At least 18 yrs old S
PITUITARY
DDAVP 0.01% NASAL SPRAY 3 desmopressin 10 mcg/0.1 ml spr 1 GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG, PA MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, 4 MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MG S CARTRIDGE)
HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MG CARTRIDGE, PA 4 24 MG CARTRIDGE) S
PA NORDITROPIN FLEXPRO 4 S PS
PA NUTROPIN AQ 4 S
PA NUTROPIN AQ NUSPIN 4 S
OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML PA 4 CRTG) S
PA SAIZEN (5 MG VIAL, 8.8 MG CLICK.EASY CARTG, 8.8 MG VIAL) 4 S
PA SAIZEN-SAIZENPREP 4 S
PAGE 213 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sermorelin acetate 3
QL 1 / day SEROSTIM 4 PA S vasopressin 1
PA ZOMACTON 4 S
QL 1 / day ZORBTIVE 4 PA S
PROGESTINS
AYGESTIN 3 GL Female
CRINONE 4% GEL 3 GL Female
CRINONE 8% GEL 3 GL Female
DEPO-PROVERA 400 MG/ML VIAL 3
QL 90 days DEPO-SUBQ PROVERA 104 3 GL Female HCR
GL Female ENDOMETRIN 4 S PS hydroxyprogesterone cap powder 3
PA hydroxyprogesterone 1.25 g/5ml 4 GL Female S
PA GL Female MAKENA (250 MG/ML VIAL, 1,250 MG/5 ML VIAL) 4 S PS
PAGE 214 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS medroxyprogesterone ac micro 3
QL 0.04 / day GL Female medroxyprogesterone 150 mg/ml 1 MED Medical Drug HCR medroxyprogesterone 5 mg tab 1 GL Female
GL Female medroxyprogesterone acetate (2.5 mg tab, 10 mg tab) 1 LCG norethindrone powder 3 norethindrone ac (lupaneta) 1 GL Female norethindrone acetate powder 3 norethindrone 5 mg tablet 1 GL Female progesterone (100 mg capsule, 200 mg capsule) 1 GL Female progesterone powder 3 progesterone oil 50 mg/ml vl 1 GL Female progesterone in oil 1 GL Female progesterone micronized 3 GL Female
PROMETRIUM 3 GL Female
PROVERA 3 GL Female
HYPOTENSIVE AGENTS
CENTRAL ALPHA-AGONISTS
CATAPRES 3
CATAPRES-TTS 1 3 QL 0.15 / day
CATAPRES-TTS 2 3 QL 0.4 / day
CATAPRES-TTS 3 3 QL 0.4 / day
PAGE 215 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clonidine (0.2 mg/day patch, 0.3 mg/day patch) 1 QL 0.29 / day clonidine 0.1 mg/day patch 1 QL 0.15 / day clonidine hcl powder 3 clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1 LCG clonidine hcl er 1 QL 4 / day guanabenz acetate 3
QL 4 / day KAPVAY 3 ST methyldopa 1 DIRECT VASODILATORS
BIDIL 3 QL 6 / day hydralazine hcl powder 3 hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1 hydralazine 20 mg/ml vial 1 minoxidil powder 3 minoxidil (2.5 mg tablet, 10 mg tablet) 1 HYPOTENSIVE AGENTS, MISCELLANEOUS guanethidine hemisulfate 3 mecamylamine hcl 3
PA VECAMYL 4 S
PERIPHERAL ADRENERGIC INHIBITORS rauwolfia serpentina 3 reserpine powder 3 reserpine (0.1 mg tablet, 0.25 mg tablet) 1
PAGE 216 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ION-REMOVING AGENTS
OTHER ION-REMOVING AGENTS
RADIOGARDASE 3 PHOSPHATE-REMOVING AGENTS
AURYXIA 3 calcium acetate (667 mg capsule, 667 mg gelcap, 667 mg tablet) 1
ELIPHOS 3 FOSRENOL (750 MG POWDER PACKET, 1,000 MG POWDER PACK) 3 FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 1,000 MG TABLET CHEW) 2 lanthanum carbonate 1 PHOSLYRA 3 RENAGEL 3 RENVELA (0.8 GM POWDER PACKET, 2.4 GM POWDER PACKET) 3 RENVELA 800 MG TABLET 2 sevelamer carbonate (0.8 gm powder packet, 2.4 gm powder packet, carbonate 800 mg tab) 1
VELPHORO 3 POTASSIUM-REMOVING AGENTS
KAYEXALATE 3 KIONEX (15 GM/60 ML SUSPENSION, POWDER) 1 sodium polystyrene sulfonate (sod polystyren sulf 15 g/60 ml, sodium polystyrene sulf powder, sps 15 gm/60 ml suspension, 1 sps 30 gm/120 ml enema, sps 50 gm/200 ml enema)
SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMA) 1
QL 1 / day VELTASSA 3 PA
PAGE 217 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MACROLIDES
ERYTHROMYCINS erythromycin powder 3 erythromycin estolate 3 erythromycin e.s. powder 3 KETOLIDES
KETEK 3 OTHER MACROLIDES azithromycin powder 3 azithromycin (1 gm pwd packet, 100 mg/5 ml susp, 200 mg/5 ml susp, 500 mg tablet, 600 mg tablet) 1 azithromycin 250 mg tablet 1 QL 6 / 5 days
DIFICID 3 PA
ZITHROMAX 100 MG/5 ML SUSP 3 QL 30 / fill
ZITHROMAX 200 MG/5 ML SUSP 3 QL 60 / fill
ZITHROMAX (1 GM POWDER PACKET, 250 MG Z-PAK TABLET) 3
ZITHROMAX 250 MG TABLET 3 QL 6 / 5 days
ZITHROMAX 500 MG TABLET 3 QL 5 / fill
ZITHROMAX 600 MG TABLET 3 QL 0.29 / day
ZITHROMAX TRI-PAK 3
ZMAX 2 QL 60 / fill
MISCELLANEOUS B-LACTAM ANTIBIOTICS
CARBAPENEMS
INVANZ 1 GM VIAL 3
PAGE 218 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MONOBACTAMS
AZACTAM 3 aztreonam 1
PA CAYSTON 4 S
MISCELLANEOUS THERAPEUTIC AGENTS
5-ALPHA-REDUCTASE INHIBITORS
QL 1 / day AVODART 3 GL Male
QL 1 / day dutasteride 1 GL Male finasteride powder 3
QL 1 / day finasteride 5 mg tablet 1 GL Male
QL 1 / day PROSCAR 3 GL Male
ALCOHOL DETERRENTS
ANTABUSE 3 disulfiram powder 3 disulfiram (250 mg tablet, 500 mg tablet) 1 ANTIDOTES amyl nitrite 1 BAL IN OIL 3 calcium disodium versenate 1 CHEMET 3 deferoxamine mesylate 1
PAGE 219 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DESFERAL 3 DESFERAL MESYLATE 3 dmsa powder 3 edetate calcium disodium 3 leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, 25 mg tab) 1 MEPHYTON 2 methylpyrazole 3 phytonadione 1 mg/0.5 ml syr 1 pralidoxime chloride 300 mg/ml 1 pralidoxime chloride powder 3 PROTOPAM CHLORIDE 3 succimer dmsa 3
VISTOGARD 4 S vitamin k1 1 ANTIGOUT AGENTS allopurinol powder 3
QL 3 / day allopurinol 100 mg tablet 1 LCG
QL 2 / day allopurinol 300 mg tablet 1 LCG
ANAPROX 3 ANAPROX DS 3 colchicine 0.6 mg capsule 1 QL 2 / day colchicine powder 3 colchicine 0.6 mg tablet 1 QL 4 / day
COLCRYS 2 QL 4 / day
PAGE 220 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EC-NAPROSYN 3
INDOCIN 25 MG/5 ML SUSPENSION 3 QL 6 / day
INDOCIN 50 MG SUPPOSITORY 3 QL 4 / day indomethacin 25 mg capsule 1 LCG indomethacin 50 mg capsule 1 indomethacin er 1
QL 2 / day MITIGARE 3 ST
NAPRELAN (CR 375 MG TABLET, CR 500 MG TABLET) 3
NAPRELAN CR 750 MG TABLET 3 QL 1 / day
NAPROSYN (125 MG/5 ML SUSPEN, 250 MG TABLET, 375 MG TABLET, 500 MG TABLET) 3 naproxen 500 mg tablet 1 LCG naproxen (125 mg/5 ml suspen, 250 mg tablet, 375 mg tablet, dr 375 mg tablet, 500 mg kit, dr 500 mg tablet, ec 375 mg 1 tablet, ec 500 mg tablet) naproxen sodium (275 mg tab, 550 mg tab) 1 naproxen sodium cr 1 naproxen sodium ds 1 naproxen sod er 375 mg tablet 1 TIVORBEX 3
QL 1 / day ULORIC 2 ST
ZYLOPRIM 100 MG TABLET 3 QL 3 / day
ZYLOPRIM 300 MG TABLET 3 QL 2 / day
BONE RESORPTION INHIBITORS
ACTONEL (5 MG TABLET, 30 MG TABLET) 3 QL 1 / day
PAGE 221 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ACTONEL 150 MG TABLET 3 QL 0.04 / day
ACTONEL 35 MG TABLET 3 QL 0.15 / day alendronate sod 70 mg/75 ml 1 QL 12.5 / day alendronate sodium (35 mg tab, 40 mg tab, 70 mg tab) 1 QL .15 / day alendronate sodium (5 mg tablet, 10 mg tab) 1 QL 1 / day
QL 0.15 / day ATELVIA 3 ST
BINOSTO 3 QL .15 / day
BONIVA 150 MG TABLET 3 QL 0.04 / day etidronate disodium 1
FOSAMAX 3 QL .15 / day
FOSAMAX PLUS D 3 QL 0.15 / day ibandronate sodium 150 mg tab 1 QL 0.04 / day risedronate sodium 150 mg tab 1 QL 0.04 / day risedronate sodium 30 mg tab 1 risedronate sodium 35 mg tab 1 QL 0.15 / day risedronate sodium 5 mg tablet 1 QL 1 / day risedronate sodium dr 1
QL 0.07 / day XGEVA 4 PA S
CARIOSTATIC AGENTS
CLINPRO 5000 1 DENTA 5000 PLUS 1 DENTAGEL 1
PAGE 222 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLUOR-A-DAY 2.5 MG/ML DROPS 1 HCR
FLUOR-A-DAY (0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1 MG TABLET CHEW) 3
FLUORABON 3 fluoride 1 HCR
FLUORIDEX 1 FLUORIDEX DAILY DEFENSE 1 FLUORIDEX SENSITIVITY RELIEF 1 FLUORITAB (0.125 MG/DRP DROPS, 0.5 MG TABLET CHEW, 1 MG TABLET CHEW) 1 HCR
FLURA-DROPS 3 HCR
LUDENT FLUORIDE 1 HCR multivitamin with fluoride (0.25 mg/ml drop, 0.5 mg/ml drop) 1 multivitamin with fluoride (multivit-fluor 0.25 mg tab chw, multivit-fluor 0.5 mg tab chew, multivit-fluoride 1 mg tab chw) 3 POLY-VI-FLOR (0.25 MG DROPS, 0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1 MG TAB CHEW) 3 PREVIDENT (0.2% RINSE, 1.1% GEL, 5000 BOOSTER PLUS, DENTAL RINSE) 3
PREVIDENT 5000 3 PREVIDENT 5000 ENAMEL PROTECT 3 PREVIDENT 5000 PLUS 3 PREVIDENT 5000 SENSITIVE 3 SF 1 SF 5000 PLUS 1 sodium fluoride powder 3 neutral sodium fluoride 1 sodium fluoride (0.5 mg(1.1 mg), 0.5 mg/ml drop, 1 mg (2.2 mg)) 1 HCR
PAGE 223 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TRI-VI-FLOR 3 COMPLEMENT INHIBITORS
PA FIRAZYR 4 S
PA KALBITOR 4 S
DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
QL 0.15 / day ACTEMRA 162 MG/0.9 ML SYRINGE 4 PA S
ARAVA 3 AZASAN 3 azathioprine 50 mg tablet 1 azathioprine sodium 1 CUPRIMINE 3 cyclosporine (25 mg capsule, 100 mg capsule, 100 mg/ml soln) 4 S cyclosporine modified 4 S
DEPEN 2
QL 0.15 / day PA ENBREL 50 MG/ML SURECLICK SYR 4 S PS
QL 0.29 / day ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML PA 4 SYRINGE) S PS
GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 100 MG/ML SOLUTION) 4 S
PAGE 224 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS gold sodium thiomalate 3 IMURAN 3
QL 0.1 / day PA KEVZARA 4 AL At least 18 yrs old S
QL 10 / day KINERET 4 PA S leflunomide 1 methotrexate (1 gm vial, 2.5 mg tablet, 50 mg/2 ml vial, 250 mg/10 ml vial) 1 methotrexate sodium 1 NEORAL (25 MG GELATIN CAPSULE, 100 MG GELATIN CAPSULE, 100 MG/ML SOLUTION) 4 S
QL 0.15 / day ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 ML SYRINGE, 125 MG/ML SYRINGE) 4 PA S
QL 0.15 / day ORENCIA CLICKJECT 4 PA S
QL 2 / day OTEZLA (28 DAY STARTER PACK, 30 MG TABLET, STARTER PACK) 4 PA S
QL 0.08 / day OTREXUP 3 PA penicillamine 3 penicillamine(d-) 3
PAGE 225 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 0.08 / day RASUVO 3 PA
RHEUMATREX 3 RIDAURA 2
SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE) 4 S
S SANDIMMUNE 100 MG/ML SOLN 4 PS
QL 0.04 / day SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 ML SYRINGE, 100 MG/ML PEN INJECTOR, 100 MG/ML SYRINGE) 4 PA S
QL 0.08 / day STELARA (45 MG/0.5 ML SYRINGE, 45 MG/0.5 ML VIAL, 90 MG/ML SYRINGE) 4 PA S
TREXALL 2
QL 4 / day XATMEP 3 PA AL Up to 18 yrs old
QL 2 / day XELJANZ 4 PA S
QL 1 / day XELJANZ XR 4 PA S
GONADOTROPIN-RELEASING HORMONE ANTAGNTS
PA GL Female CETROTIDE 4 S PS
PAGE 226 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA FIRMAGON 4 S
GL Female ganirelix acetate 4 S
IMMUNOMODULATORY AGENTS
ACTIMMUNE 4 S
QL 1 / day PA AUBAGIO 4 S PS
QL 0.15 / day AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG, PREFILLED PA 4 SYR 30 MCG KT) S PS
QL 0.15 / day PA AVONEX PEN (PEN 30 MCG/0.5 ML, PEN 30 MCG/0.5 ML KIT) 4 S PS
QL 0.5 / day BETASERON (0.3 MG KIT, 0.3 MG VIAL) 4 PA S
QL 1 / day PA COPAXONE 4 S PS
QL 0.5 / day EXTAVIA (0.3 MG KIT, 0.3 MG VIAL) 4 PA S
PAGE 227 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day PA GILENYA 4 S PS
QL 1 / day GLATOPA 4 PA S
QL 1 / day POMALYST 4 PA S
QL 0.22 / day REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML SYRINGE) 4 PA S
QL 4.2 / 365 days REBIF TITRATION PACK 4 PA S
QL 0.22 / day REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 4 PA S
QL 4.2 / 365 days REBIF REBIDOSE TITRATION PACK 4 PA S
QL 1 / day REVLIMID 4 PA S
QL 2 / day PA TECFIDERA 4 S PS
PAGE 228 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 2 / day THALOMID (150 MG CAPSULE, 200 MG CAPSULE) 4 PA S
QL 1 / day THALOMID (50 MG CAPSULE, 100 MG CAPSULE) 4 PA S
QL 1 / day ZINBRYTA 4 PA S
IMMUNOSUPPRESSIVE AGENTS
QL 15 / day ASTAGRAF XL 0.5 MG CAPSULE 4 PA S
QL 30 / day ASTAGRAF XL 1 MG CAPSULE 4 PA S
QL 6 / day ASTAGRAF XL 5 MG CAPSULE 4 PA S
CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500 MG TABLET) 4 S cyclophosphamide (25 mg capsule, 50 mg capsule) 1 PA cyclophosphamide powder 3 cyclophosphamide monohydrate 3 cyclosporine (a powder, powder) 3
QL 2.5 / day ELIDEL 2 ST AL At least 2 yrs old
PAGE 229 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day ENVARSUS XR 4 PA S mercaptopurine powder 3 mercaptopurine 50 mg tablet 1 mycophenolate 200 mg/ml susp 4 S mycophenolate mofetil (250 mg capsule, 500 mg tablet) 4 S mycophenolic acid 4 S
MYFORTIC 4 S
PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 4 S
PA PURIXAN 4 S
RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML ORAL SOLN, 2 MG TABLET) 4 S sirolimus powder 3 sirolimus (1 mg tablet, 2 mg tablet) 4 S sirolimus 0.5 mg tablet 4 S
QL 2 / day tacrolimus 0.5 mg capsule 4 S
QL 8 / day tacrolimus 1 mg capsule 4 S
QL 4 / day tacrolimus 5 mg capsule 4 S tacrolimus (monohydrate powder, powder) 3 tacrolimus micronized 3
PA ZORTRESS 4 S
PAGE 230 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OTHER MISCELLANEOUS THERAPEUTIC AGENTS
4-aminopyridine 3 acetyl-l-carnitine hcl 3 acetylcysteine powder 3 acetylcysteine (10% vial, 20% vial) 1 alcohol,dehydrated (ampule, vial) 1 aminobutyric acid 3
QL 2 / day PA AMPYRA 4 S PS
PA ARCALYST 4 S beta glucan (1-3) nq 3 betaine hydrochloride 3
PA BOTOX 4 S
PA BOTOX COSMETIC 4 S butylated hydroxytoluene(bht) 3 CARDIOVID PLUS 3 CARNITOR (100 MG/ML ORAL SOLN, 330 MG TABLET) 3 CARNITOR SF 3
QL 2 / day CERDELGA 4 PA S chondroitin sulfate 3
PAGE 231 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS chondroitin sulfate sodium 3 coenzyme q10 3 coumarin 3 cryoserv 3 curcumin 3
CYSTADANE 4 S
CYSTAGON 4 S cysteamine hcl 3 DEMSER 3 diaminopyridine 3 dibutyl squarate 3
PA DYSPORT 4 S edetate disodium 3 EPIFIX AMNIOTIC MEMBRANE 3 ginkgo biloba 3 glucosamine hcl 3 glucosamine sulfate kcl 3 glucosamine sulfate sodium 3 GRAFIX CORE 5CM X 5CM MATRIX 3 GRAFIX PRIME 5CM X 5CM MATRIX 3
QL 1 / day GRASTEK 3 PA
QL 0.04 / day ILARIS 150 MG/ML VIAL 4 PA S
QL 0.4 / day ILARIS 180 MG VIAL 4 PA S
PAGE 232 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS indole-3-carbinol 3
QL 4 / day KEVEYIS 4 PA S
KUVAN (100 MG POWDER PACKET, 100 MG TABLET, 500 MG PA 4 POWDER PACKET) S l-carnitine 3 l-theanine 3 leucovorin calcium powder 3 levocarnitine (l-carnitine powder, levocarnitine powder) 3 levocarnitine (1 g/10 ml soln, 330 mg tablet) 1 lycopene 3 melatonin 3
PA MYOBLOC 4 S
NEXAVIR 3 nicotinamide adenine 3
ORALAIR (100-300 IR CHILD SAMPL, 300 IR ADULT SAMPLE KT, PA 4 300 IR STARTER PACK, 300 IR SUBLINGUAL TAB) S
ORALAIR 100 IR STARTER PACK 4 S
ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MG PA 4 CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE) S
POTABA 3 potassium perchlorate 3
PROCYSBI 4 S pyruvic acid 3
QL 1 / day RAGWITEK 3 PA
PAGE 233 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS resveratrol 3
QL 2 / day SENSIPAR (30 MG TABLET, 60 MG TABLET) 4 PA S
QL 4 / day SENSIPAR 90 MG TABLET 4 PA S
STRAVIX (STRAVI3CM 6CM, STRAVI4CM 7CM) 3 theanine 3 THIOLA 3 tiopronin 3 turmeric root 3
S TYBOST 4 PS ubidecarenone 3 ubiquinol 3 VP-ZEL 3
PA XEOMIN (50 UNIT VIAL, 100 UNIT VIAL) 4 S
XURIDEN 4 S
PA ZAVESCA 4 S
PROTECTIVE AGENTS
ELMIRON 3 pentosan polysulfate sodium 3
PAGE 234 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
CYCLOOXYGENASE-2 (COX-2) INHIBITORS
CELEBREX (50 MG CAPSULE, 200 MG CAPSULE) 3 QL 2 / day
CELEBREX 100 MG CAPSULE 3 QL 3 / day
CELEBREX 400 MG CAPSULE 3 QL 1 / day celecoxib (50 mg capsule, 200 mg capsule) 1 QL 2 / day celecoxib 100 mg capsule 1 QL 3 / day celecoxib 400 mg capsule 1 QL 1 / day celecoxib powder 3 OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS
ANSAID 3
QL 1 / day CAMBIA 3 PA
DAYPRO 3 diclofenac potassium 1 diclofenac sodium 1% gel 1 QL 1000/ 30 days diclofenac sodium powder 3 diclofenac sodium (1.5% topical soln, sod dr 25 mg tab, sod dr 50 mg tab, sod dr 75 mg tab, sod ec 25 mg tab, sod ec 50 mg 1 tab, sod ec 75 mg tab) diclofenac sodium er 1 diclofenac sodium micronized 3 diflunisal 1 etodolac (200 mg capsule, 300 mg capsule, 400 mg tablet, 500 mg tablet) 1 etodolac er 1 FELDENE 3
PAGE 235 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fenoprofen calcium (200 mg capsule, 400 mg capsule, 600 mg tablet) 1 fenoprofen calcium powder 3 FENORTHO 3
FLECTOR 3 QL 2 / day flurbiprofen powder 3 flurbiprofen (50 mg tablet, 100 mg tablet) 1 ibuprofen 100 mg/5 ml susp 1 ibuprofen powder 3 ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) 1 LCG indomethacin powder 3 ketoprofen (50 mg capsule, 75 mg capsule, er 200 mg capsule) 1 ketoprofen powder 3 ketoprofen micronized 3 ketorolac tromethamine (15 mg/ml carpuject, 15 mg/ml isecure 40 / 23 days syr, 15 mg/ml vial) 1 QL ketorolac tromethamine powder 3 ketorolac 30 mg/ml syringe 1 QL 20 / 23 days ketorolac 10 mg tablet 1 QL 21 / fill ketorolac tromethamine (30 mg/ml carpuject, 60 mg/2 ml carpuject, 60 mg/2 ml syringe, 60 mg/2 ml vial, 300 mg/10 ml 1 QL 20 / 30 days vial)
KLOFENSAID II 1 LODINE 3 meclofenamate sodium (50 mg capsule, 100 mg capsule) 1 meclofenamate sodium powder 3 mefenamic acid 250 mg capsule 1 QL 5 / day mefenamic acid powder 3
PAGE 236 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS meloxicam 7.5 mg/5 ml susp 1 QL 10 / day meloxicam powder 3
QL 1 / day meloxicam (7.5 mg tablet, 15 mg tablet) 1 LCG
MOBIC 7.5 MG/5 ML SUSPENSION 3 QL 10 / day
MOBIC (7.5 MG TABLET, 15 MG TABLET) 3 QL 1 / day nabumetone powder 3 nabumetone (500 mg tablet, 750 mg tablet) 1 nabumetone micronized 3 NALFON 3 naproxen powder 3 naproxen sodium powder 3 oxaprozin 1
PENNSAID 2% PUMP 3 QL 3.8 / day phenylbutazone 3 piroxicam (10 mg capsule, 20 mg capsule) 1 AL Up to 75 yrs old piroxicam powder 3
PONSTEL 3 QL 5 / day
SPRIX 3 QL 5 days sulindac powder 3 sulindac (150 mg tablet, 200 mg tablet) 1 tolmetin sodium (200 mg tab, 400 mg cap, 600 mg tab) 1 TOXICOLOGY SALIVA COLLECTION 3
QL 1 / day VIVLODEX 3 PA AL At least 18 yrs old
PAGE 237 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VOLTAREN 3 QL 1000/ 30 days
VOLTAREN-XR 3
ZIPSOR 3 QL 4 / day
QL 3 / day ZORVOLEX 3 PA
SALICYLATES carisoprodol compound 1 carisoprodol-aspirin 1 choline mag trisalicylate 1 choline magnesium trisalicylat 3 DISALCID 3 salsalate powder 3 salsalate (500 mg tablet, 750 mg tablet) 1 PENICILLINS
AMINOPENICILLINS amoxicillin (125 mg tab chew, 250 mg tab chew, 250 mg/5 ml susp, 500 mg capsule, 500 mg tablet, 875 mg tablet) 1 amoxicillin (125 mg/5 ml susp, 200 mg/5 ml susp, 250 mg capsule, 400 mg/5 ml susp) 1 LCG amoxicillin er 1 amoxicillin trihydrate 3 amoxicillin-clavulanate pot 3 amoxicillin-clavulanate pot er 1 amoxicillin-clavulanate potass (200-28.5 mg tab chew, 200- 28.5 mg/5 ml sus, 250-125 mg tablet, 250-62.5 mg/5 ml sus, 400-57 mg tab chew, 400-57 mg/5 ml susp, 500-125 mg tablet, 1 600-42.9 mg/5 ml sus, 875-125 mg tablet) ampicillin sodium (1 gm vial, 2 gm vial, 125 mg vial, 250 mg vial, 500 mg vial) 1
PAGE 238 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ampicillin trihydrate (125 mg/5 ml susp, 250 mg capsule, 250 mg/5 ml susp, 500 mg capsule) 1 ampicillin-sulbactam (3 gm vial, 15 gm vl) 1 ampicillin-sulbactam 1.5 gm vl 1 MED Medical Drug
AUGMENTIN 125-31.25 MG/5 ML 2 AUGMENTIN (250-62.5 MG/5 ML, 500-125 TABLET, 875-125 TABLET) 3
AUGMENTIN ES-600 3 AUGMENTIN XR 3 MOXATAG 3 UNASYN 3 EXTENDED-SPECTRUM PENICILLINS ticarcillin disod-clavulanate 3 NATURAL PENICILLINS
BICILLIN C-R 3 BICILLIN L-A 3 penicillin g potassium 1 penicillin g procaine 1 penicillin g sodium 1 penicillin v potassium (125 mg/5 ml soln, 250 mg tablet, 250 mg/5 ml soln, 500 mg tablet) 1 LCG
PFIZERPEN 3 PENICILLINASE-RESISTANT PENICILLINS dicloxacillin sodium 1 nafcillin sodium (1 gm vial, 2 gm vial, 10 gm bulk vial, 10 gm vial) 1 oxacillin sodium (1 gm vial, 2 gm vial, 10 gm vial) 1
PAGE 239 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RENIN-ANGIOTENSIN-ALDOSTER.INHIB(HYPOTN)
ANGIOTENSIN II RECEPTOR ANTAGON.(HYPOTN)
ATACAND 3 QL 1 / day
AVAPRO 3 QL 1 / day
BENICAR 3 QL 3 / day candesartan cilexetil 1 QL 1 / day
COZAAR (25 MG TABLET, 50 MG TABLET) 3 QL 2 / day
COZAAR 100 MG TABLET 3 QL 1 / day
DIOVAN (40 MG TABLET, 80 MG TABLET, 160 MG TABLET) 3 QL 2 / day
DIOVAN 320 MG TABLET 3 QL 1 / day
QL 1 / day EDARBI 3 ST eprosartan mesylate 1 QL 1 / day irbesartan 1 QL 1 / day losartan potassium (25 mg tab, 50 mg tab) 1 QL 2 / day losartan potassium 100 mg tab 1 QL 1 / day
MICARDIS 3 QL 1 / day olmesartan medoxomil 1 QL 3 / day telmisartan 1 QL 1 / day valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet) 1 QL 2 / day valsartan 320 mg tablet 1 QL 1 / day
ANGIOTENSIN-CONVERT.ENZYME INHIB(HYPOTN)
ACCUPRIL 3 QL 2 / day
PAGE 240 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ACEON 3 QL 1 / day
ALTACE 3 QL 2 / day benazepril hcl (10 mg tablet, 40 mg tablet) 1 QL 2 / day benazepril hcl 20 mg tablet 1 QL 4 / day benazepril hcl 5 mg tablet 1 QL 3 / day captopril powder 3 captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg 4 / day tablet) 1 QL enalapril maleate powder 3 enalapril maleate (2.5 mg tab, 5 mg tablet, 10 mg tab, 20 mg 2 / day tab) 1 QL
EPANED (1 MG/ML ORAL SOLUTION, 1 MG/ML SOLUTION) 3 QL 5 / day fosinopril sodium 1 QL 2 / day lisinopril 100% powder 3 lisinopril (2.5 mg tablet, 5 mg tablet, 20 mg tablet, 30 mg 1 / day tablet) 1 QL
QL 1 / day lisinopril 10 mg tablet 1 LCG lisinopril 40 mg tablet 1 QL 2 / day
LOTENSIN 20 MG TABLET 3 QL 4 / day
LOTENSIN 40 MG TABLET 3 QL 2 / day
MAVIK 3 QL 2 / day moexipril hcl 1 QL 1 / day perindopril erbumine 1 QL 1 / day
PRINIVIL 3 QL 1 / day
QBRELIS 3 QL 40/ day
PAGE 241 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS quinapril hcl 1 QL 2 / day ramipril 1 QL 2 / day trandolapril 1 QL 2 / day
VASOTEC 3 QL 2 / day
ZESTRIL 3 QL 1 / day
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
ANGIOTENSIN II RECEPTOR ANTAGONISTS
QL 2 / day ENTRESTO 3 PA
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS benazepril hcl powder 3 RENIN INHIBITORS
QL 1 / day TEKTURNA 3 ST
RESPIRATORY TRACT AGENTS
ANTIFIBROTIC AGENTS
QL 9 / day ESBRIET (267 MG CAPSULE, 267 MG TABLET) 4 PA S
QL 3 / day ESBRIET 801 MG TABLET 4 PA S
QL 2 / day OFEV 4 PA S
PAGE 242 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTITUSSIVES benzonatate 1 AL At least 11 yrs old dextromethorphan hbr 3
QL 60 / day FLOWTUSS 3 AL At least 18 yrs old
TESSALON PERLE 3 AL At least 11 yrs old
ZONATUSS 3 AL At least 11 yrs old
EXPECTORANTS bromhexine hcl 3 guaifenesin 3 terpin hydrate 3 MUCOLYTIC AGENTS
QL 5 / day PULMOZYME 4 PA S
PHOSPHODIESTERASE TYPE 4 INHIBITORS
QL 1 / day DALIRESP 3 PA
PULMONARY SURFACTANTS
CUROSURF 3 INFASURF 3 SURVANTA 3 RESPIRATORY TRACT AGENTS, MISCELLANEOUS
PA XOLAIR 4 AL At least 6 yrs old S
PAGE 243 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VASODILATING AGENTS (RESPIRATORY TRACT)
QL 2 / day ADCIRCA 4 PA S
QL 3 / day ADEMPAS 4 PA S
QL 1 / day PA LETAIRIS 4 S PS
QL 1 / day OPSUMIT 4 PA S
QL 3 / day ORENITRAM ER 4 PA S
QL 3 / day PA REVATIO 20 MG TABLET 4 AL At least 18 yrs old S
QL 3 / day sildenafil 4 PA S sildenafil citrate powder 3
QL 2 / day PA TRACLEER 4 S PS
PAGE 244 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day TYVASO 4 PA S
QL 1 / day TYVASO INSTITUTIONAL START KIT 4 PA S
QL 1 / day TYVASO REFILL KIT 4 PA S
QL 1 / day TYVASO STARTER KIT 4 PA S
PA UPTRAVI 200-800 TITRATION PACK 4 AL At least 18 yrs old S
QL 2 / day UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCG PA TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG 4 TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET) AL At least 18 yrs old S
SKELETAL MUSCLE RELAXANTS
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT
AMRIX 3 carisoprodol powder 3 carisoprodol (250 mg tablet, 350 mg tablet) 1 chlorzoxazone 500 mg tablet 1 cyclobenzaprine hcl powder 3 cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet) 1
PAGE 245 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FEXMID 3 LORZONE 3 METAXALL 1 metaxalone 1 methocarbamol powder 3 methocarbamol (500 mg tablet, 750 mg tablet) 1 methocarbamol 1,000 mg/10 ml 1 PARAFON FORTE DSC 3 ROBAXIN 500 MG TABLET 3 ROBAXIN 1,000 MG/10 ML VIAL 3 ROBAXIN-750 3 SKELAXIN 3 SOMA 3 tizanidine hcl (2 mg capsule, 2 mg tablet, 4 mg capsule, 4 mg tablet, 6 mg capsule) 1 tizanidine hcl powder 3 ZANAFLEX (2 MG CAPSULE, 4 MG CAPSULE, 4 MG TABLET, 6 MG CAPSULE) 3 DIRECT-ACTING SKELETAL MUSCLE RELAXANTS
DANTRIUM (25 MG CAPSULE, 50 MG CAPSULE) 3 dantrolene sodium (25 mg cap, 50 mg cap, 100 mg cap) 1 dantrolene sodium powder 3 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT baclofen powder 3 baclofen (10 mg tablet, 20 mg tablet) 1 NEUROMUSCULAR BLOCKING AGENTS pancuronium bromide powder 3 rocuronium bromide powder 3
PAGE 246 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS succinylcholine chloride powd 3 vecuronium bromide powder 3 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS orphenadrine citrate powder 3 orphenadrine er 100 mg tablet 1 orphenadrine citrate (30 mg/ml vial, 60 mg/2 ml ampule, 60 mg/2 ml vial) 1 SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)
ALA-CORT 1 ALA-SCALP 3 alclometasone dipropionate (dipr oint, dipro crm) 1 amcinonide (cream, lotion, ointment) 1 ANA-LEX 2-2% CREAM 3 ANALPRAM HC (1% CREAM, 2.5%-1% CREAM, 2.5%-1% CRM SINGLE, 2.5%-1% LOTION) 3
ANUCORT-HC 1 ANUSOL-HC 2.5% CREAM 3 ANUSOL-HC 25 MG SUPPOSITORY 1 APEXICON E 3 betamethasone dipropionate (aug crm, aug gel, aug lot, aug oin, crm, lot, oint) 1 betamethasone dp powder 3 betamethasone valerate (va 0.1% cream, va 0.1% lotion, valer 0.1% ointm, valer 0.12% foam) 1 betamethasone valerate powder 3 calcipotriene-betamethasone dp 1 QL 3 / day
CAPEX SHAMPOO 3
PAGE 247 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clobetasol emollient (emollient crm, emollnt foam) 1 clobetasol emulsion 1 clobetasol propionate (cream, gel, ointment, prop foam, prop spray, shampoo, solution, topical lotn) 1 clobetasol propionate micro 3 CLOBEX (SHAMPOO, SPRAY, TOPICAL LOTION) 3 clocortolone pivalate 1 CLODAN 0.05% SHAMPOO 1 CLODERM 3 COLOCORT 1
CORDRAN 0.05% CREAM 3 QL 2 / day
CORDRAN 0.05% LOTION 3 QL 4 / day
CORDRAN 0.05% OINTMENT 3 CORMAX 1 CORTENEMA 3 CORTIFOAM 3 CUTIVATE (CREAM, LOTION) 3 DERMA-SMOOTHE-FS (BODY OIL, SCALP OIL) 3 DERMATOP (EMOLLIENT CREAM, OINTMENT) 3 DESONATE 3 desonide (cream, lotion, ointment) 1 desonide micronized 3 DESOWEN (CREAM, LOTION) 3 desoximetasone (0.05% cream, 0.05% gel, 0.05% ointment, 0.25% cream, 0.25% ointment) 1 desoximetasone powder 3 diflorasone diacetate (cream, ointment) 1 DIPROLENE (LOTION, OINTMENT) 3
PAGE 248 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DIPROLENE AF 3 ELOCON (CREAM, LOTION, OINTMENT) 3
ENSTILAR 3 QL 2 / day
EPIFOAM 3
QL 2.143 / day EUCRISA 2 ST AL At least 2 yrs old fluocinolone acetonide (0.01% body oil, 0.01% cream, 0.01% scalp oil, 0.01% solution, 0.025% cream, 0.025% ointment) 1 fluocinolone acetonide powder 3 fluocinonide (0.05% cream, 0.05% gel, 0.05% ointment, 0.05% solution, 0.1% cream) 1 fluocinonide micronized 3 fluocinonide-e 1 flurandrenolide 0.05% cream 3 QL 2 / day flurandrenolide 0.05% lotion 3 QL 4 / day flurandrenolide 0.05% ointment 3 fluticasone propionate (0.005% oint, 0.05% cream, 0.05% lotion) 1 halobetasol propionate (cream, ointmnt) 1 HALOG (CREAM, OINTMENT) 3 HEMMOREX-HC 1 hydrocortisone (1% absorbase, 1% cream, 1% ointment, 2.5% cream, 2.5% lotion, 2.5% ointment, 100 mg/60 ml) 1 hydrocortisone (micronized pwd, powder) 3 hydrocortisone acetate powder 3 hydrocortisone acetate (25 mg, 30 mg) 1
PAGE 249 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hydrocortisone butyrate (hydrocort buty lipid crm, hydrocort buty lipo cream, hydrocortisone buty cream, hydrocortisone 1 butyr oint, hydrocortisone butyr soln) hydrocortisone valerate (cream, ointmt) 1 hydrocortisone-pramoxine (1%-1% crm, 2.5%-1% cm, 2.5-1% crm) 1 hydrocortisone-pramoxine hcl 1 KENALOG 3 lidocaine-hydrocortisone (lidocaine-hc 2.8-0.55% gel, lidocaine-hc 3-0.5% cream, lidocaine-hydrocort 3-2.5% gel) 1
LOCOID (CREAM, LOTION, OINTMENT, SOLUTION) 3 lokara 1 LUXIQ 3 MICORT-HC 3 mometasone furoate (cream, oint, soln) 1
NOLIX 3 QL 4 / day
NOVACORT GEL 3 OLUX 3 OLUX-E 3 ORALONE 1 PANDEL 3 PRAMCORT 1 PRAMOSONE (1% LOTION, 1%-1% CREAM, 1%-1% OINTMENT, 2.5%-1% CREAM, 2.5%-1% LOTION, 2.5%-1% 3 OINTMENT)
PRAMOSONE E 3 prednicarbate (cream, ointment) 1 PROCORT 3 PROCTO-MED HC 1 PROCTO-PAK 1
PAGE 250 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROCTOCORT (1% CREAM, 30 MG SUPPOSITORY) 3 PROCTOFOAM-HC 2 PROCTOSOL-HC 1 PROCTOZONE-HC 1 PSORCON 3 RIMSO-50 3 SANADERMRX 1 SCALACORT 1 SERNIVO 3 SYNALAR (0.01% SOLUTION, 0.025% CREAM) 3 SYNALAR TS 3
TACLONEX (0.005%-0.064% SUSPENS, OINTMENT) 3 QL 3 / day
TEMOVATE (CREAM, OINTMENT) 3 TEMOVATE EMOLLIENT 3 TEXACORT 3 TOPICORT (0.05% CREAM, 0.05% GEL, 0.05% OINTMENT, 0.25% CREAM, 0.25% OINTMENT, 0.25% SPRAY) 3 triamcinolone acetonide (0.025% cream, 0.025% lotion, 0.025% oint, 0.1% cream, 0.1% lotion, 0.1% ointment, 0.1% 1 paste, 0.147 mg/g spray, 0.5% cream, 0.5% ointment)
TRIANEX 1 TRIDERM 1 TRIDESILON 3 ULTRAVATE (CREAM, LOTION, OINTMENT) 3 VANOS 3
VANOXIDE-HC 3 QL 0.84 / day
VERDESO 3
PAGE 251 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIPRURITICS AND LOCAL ANESTHETICS
ANACAINE 3 ANASTIA 3 CETACAINE 3 CIDALEAZE 1 dibucaine hcl 3 doxepin 5% cream 1 EMLA 3 ethyl chloride 1 lidocaine 5% patch 1 QL 3 / day lidocaine 5% ointment 1 lidocaine hcl (cream, hcl lotion) 1 lidocaine-prilocaine 1 lidocaine-tetracaine 1
LIDODERM 3 QL 3 / day
LIDOPIN 3% CREAM 1 LIDOPIN 3.25% CREAM 3 LIDOPRIL 1
QL 1 / day LIDORX 2 PA
LIDOTRAL 3 LIDOVEX 3 LIDTOPIC MAX 3 LP LITE PAK 1 NUMBONEX 3 PAIN EASE 3 phenazopyridine hcl 100% powdr 3
PAGE 252 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS phenazopyridine hcl (100 mg tab, 200 mg tab) 1 PLIAGLIS 3 PONTOCAINE 3 pramoxine hcl 3 PRE-ATTACHED LTA KIT 3 PRUDOXIN 3 PYRIDIUM 3 REGENECARE 3 SPRAY AND STRETCH 3 SYNERA 3 ZONALON 3 ASTRINGENTS
DRYSOL 3 CELL STIMULANTS AND PROLIFERANTS
ATRALIN 3 QL 1.5 / day
AVITA (CREAM, GEL) 1 REFISSA 3 RENOVA 3 RENOVA PUMP 3 RETIN-A (0.01% GEL, 0.025% CREAM, 0.025% GEL, 0.05% CREAM, 0.1% CREAM) 3
RETIN-A MICRO 3 QL 50 / 30 days
RETIN-A MICRO PUMP 3 QL 50 / 30 days retinoic acid 3 TRETIN-X (0.0375% CREAM, 0.075% CREAM) 3 tretinoin (0.01% gel, 0.025% cream, 0.025% gel, 0.05% cream, 0.1% cream) 1
PAGE 253 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tretinoin 0.05% emollient crm 1 tretinoin 0.05% gel 1 QL 1.5 / day tretinoin powder 3 tretinoin acid 3 tretinoin microsphere (gel 0.04% pump, gel 0.04% tube, gel 1.667 / day 0.1% pump, gel 0.1% tube) 1 QL EMOLLIENTS, DEMULCENTS, AND PROTECTANTS
ALEVICYN ANTIPRURITIC SG 3 KERATOLYTIC AGENTS
ALUVEA 3 BENSAL HP 3
BENZEFOAM 3 QL 2 / day
BENZEFOAM ULTRA 3 QL 3.334 / day
BENZEPRO (6% FOAMING CLOTHS, 7% CREAMY WASH) 1 pr benzoyl peroxide 7% wash 1 BP-50% UREA 1 BPO (4% GEL, 8% GEL) 3
BPO 6% FOAMING CLOTHS 1 QL 2 / day
CEM-UREA 3 GORDO-UREA 40% OINTMENT 3 HYDRO 35 3 HYDRO 40 3 KERAFOAM 3 KERALAC 3 KERALYT 3 lactic acid liquid 3 LATRIX 1
PAGE 254 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NUOX 3 QL 1.47 / day
PACNEX 1 PACNEX HP 3 PACNEX LP 3 podophyllum resin 3 potassium hydroxide pellets 3 potassium hydroxide 5% soln 1 PR BENZOYL PEROXIDE 1 REA LO 40 (40 CM, 40 TION) 1 REMEVEN 1 RYNODERM 3 SALACYN (CREAM, LOTION) 1 SALEX 6% SHAMPOO 3 salicylic acid (6% cream, 6% foam, 6% gel, 6% lotion, 6% shampoo, 26% liquid, 27.5% liquid) 1 salicylic acid powder 3 salicylic acid er 1 SALKERA 3 SALVAX 3 silver nitrate 10% solution 1 grafco silver nit applicator 1 silver nitrate applicator 3 sodium hydroxide (10% solution, flakes, granules, pellets) 3 sulfur (powder, sublimed powder) 3 ULTRASAL-ER 3 UMECTA (EMULSION, NAIL FILM PEN, NAIL FILM SUSP) 3 UMECTA 40% MOUSSE 1 UMECTA PD (PD EMULSION, PD SUSPENSION) 3
PAGE 255 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS URAMAXIN (20% FOAM, 45% LOTION, 45% NAIL GEL, 45% UREA CREAM) 3
URAMAXIN GT 45% PRE-FILLED APP 3 URE-K 1 urea (35% foam, 39% cream, 40% cream, 40% gel, 40% lotion, 40% nail film susp, 45% cream, 45% lotion, 45% nail 1 gel, 47% cream, 50% cream) urea (50% nail stick, powder) 3 UREVAZ 3 UTOPIC 3 VIRASAL 3 KERATOPLASTIC AGENTS anthralin 3 coal tar (tar, tar solution) 3 coal tar topical solution 1 DRITHOCREME HP 3 ZITHRANOL 3 ZITHRANOL-RR 3 SKIN AND MUCOUS MEMBRANE AGENTS, MISC.
ABSORICA 3 PA acitretin (17.5 mg capsule, 25 mg capsule) 1 QL 2 / day acitretin 10 mg capsule 1 QL 4 / day
ACZONE (5% GEL, 7.5% GEL PUMP) 3 QL 3 / day adapalene (0.1% cream, 0.1% gel, 0.3% gel, 0.3% gel pump) 1 QL 1.5 / day adapalene 0.1% lotion 1 QL 2 / day adapalene-benzoyl peroxide 3 QL 1.5 / day
QL 0.434 / day ALDARA 3 AL At least 12 yrs old
PAGE 256 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AMNESTEEM 1 PA
ARTISS 3
AVAGE 3 QL 1.47 / day azelaic acid (flakes, powder) 3
AZELEX 3 QL 1.667 / day calcipotriene (cream, ointment, solution) 1 QL 2 / day
CALCITRENE 1 QL 2 / day calcitriol 3 mcg/g ointment 1 QL 3.334 / day camphor 3 capsaicin 3 capsaicin palmitate 3 capsicum oleoresin 3 CARAC 2
CLARAVIS 1 PA collagenase 3 CONDYLOX (GEL, TOPICAL SOLN) 3
QL 0.357 / day COSENTYX (2 SYRINGES) 4 PA S
QL 0.357 / day COSENTYX PEN 4 PA S
QL 0.357 / day COSENTYX PEN (2 PENS) 4 PA S
QL 0.357 / day COSENTYX SYRINGE 4 PA S
PAGE 257 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dapsone 5% gel 1 QL 3 / day
DEBACTEROL (SOLUTION, SWABSTICK) 3 diclofenac sodium 3% gel 1 QL 100 / 30 days
DIFFERIN (0.1% CREAM, 0.1% GEL, 0.3% GEL, 0.3% GEL 1.5 / day PUMP) 3 QL
DIFFERIN 0.1% LOTION 3 QL 1.967 / day
DOVONEX 3 QL 2 / day
QL 0.15 / day PA DUPIXENT 4 AL At least 18 yrs old S
EFUDEX 3
EPIDUO 0.1-2.5% GEL 3 QL 1.667 / day
EPIDUO 0.1-2.5% GEL PUMP 3 QL 1.5 / day
EPIDUO FORTE 3 QL 1.667 / day
QL 3.73 / day FABIOR 3 AL Up to 34 yrs old
QL 50 / 30 days FINACEA (FOAM, GEL) 3 PA finasteride 1 mg tablet 1 FLUOROPLEX 2 fluorouracil (0.5% cream, 2% topical soln, 5% cream, 5% topical soln) 1
FORMADON 1 formaldehyde 1 GRANULEX 3
QL 0.434 / day imiquimod 5% cream packet 1 AL At least 12 yrs old
PAGE 258 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS imiquimod powder 3 isotretinoin 3 LEVULAN 3 methyl 5-aminolevulinate hcl 3
MIRVASO (GEL, GEL PUMP) 2 QL 1 / day
MUCOTROL 3
MYORISAN 1 PA
PANRETIN 3
PICATO 3 ST
PODOCON-25 3 podofilox 0.5% topical soln 1 PROPECIA 3
QL 2.5 / day PROTOPIC 0.03% OINTMENT 3 ST AL At least 2 yrs old
QL 2.5 / day PROTOPIC 0.1% OINTMENT 3 ST AL At least 16 yrs old
PYROGALLIC ACID 1
QUTENZA 4 S
RECTIV 3
REGRANEX 3 QL 1 / day
RENOVO 3
QL 1.25 / day RHOFADE 3 PA
SANTYL 3
PAGE 259 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA SILIQ 4 AL At least 18 yrs old S
SINELEE 5%-0.05% PATCH 3
SOLARAZE 3 QL 100 / 30 days
SOOLANTRA 2 QL 1.5 / day
SORIATANE (17.5 MG CAPSULE, 25 MG CAPSULE) 3 QL 2 / day
SORIATANE 10 MG CAPSULE 3 QL 4 / day
SORILUX 3 QL 2 / day
QL 100 / 30 days tacrolimus (0.03% ointment, 0.1% ointment) 1 ST
QL 0.15 / day TALTZ AUTOINJECTOR 4 PA S
QL 0.15 / day TALTZ AUTOINJECTOR (2 PACK) 4 PA S
QL 0.15 / day TALTZ AUTOINJECTOR (3 PACK) 4 PA S
QL 0.15 / day TALTZ SYRINGE 4 PA S
QL 0.15 / day TALTZ SYRINGE (2 PACK) 4 PA S
PAGE 260 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 0.15 / day TALTZ SYRINGE (3 PACK) 4 PA S
PA TARGRETIN 1% GEL 4 S tazarotene 0.1% cream 1 QL 1.47 / day tazarotene powder 3
TAZORAC (0.05% CREAM, 0.1% CREAM) 3 QL 2 / day
TAZORAC (0.05% GEL, 0.1% GEL) 3 QL 3.334 / day
QL 1.47 / day TOLAK 3 ST
TRI-CHLOR 3 trichloroacetic acid (25%, 75%) 1
QL 3 / day VALCHLOR 4 PA S
VANIQA 3
VECTICAL 3 QL 3.334 / day
VENELEX OINTMENT 3 VEREGEN 3
ZENATANE 1 PA
QL 56 / 60 days ZYCLARA (CREAM, CREAM PUMP) 3 AL At least 12 yrs old
QL 56 / 30 days ZYCLARA 2.5% CREAM PUMP 3 AL At least 12 yrs old
PAGE 261 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SUNSCREEN AGENTS zinc oxide 3 SOMATOSTATIN AGONISTS AND ANTAGONISTS
SOMATOSTATIN AGONISTS octreotide acetate (acet 0.05 mg/ml vl, acet 50 mcg/ml amp, acet 50 mcg/ml syr, acet 50 mcg/ml vial, acet 100 mcg/ml amp, acet 100 mcg/ml syr, acet 100 mcg/ml vl, acet 200 mcg/ml vl, PA 4 acet 500 mcg/ml amp, acet 500 mcg/ml syr, acet 500 mcg/ml S vl, 1,000 mcg/5 ml vial, 1,000 mcg/ml vial, 5,000 mcg/5 ml vial)
QL 30 / day SANDOSTATIN 0.05 MG/ML AMPUL 4 PA S
QL 15 / day SANDOSTATIN 0.1 MG/ML AMPUL 4 PA S
QL 3 / day SANDOSTATIN 0.5 MG/ML AMPUL 4 PA S
QL 8 / day SANDOSTATIN 0.2 MG/ML VIAL 4 PA S
QL 1.5 / day SANDOSTATIN 1 MG/ML VIAL 4 PA S
PA SIGNIFOR 4 S
QL 0.1 / day SIGNIFOR LAR (20 MG KIT, 20 MG VIAL) 4 PA S
PAGE 262 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 0.067 / day SIGNIFOR LAR (40 MG KIT, 40 MG VIAL) 4 PA S
QL 0.04 / day SIGNIFOR LAR (60 MG KIT, 60 MG VIAL) 4 PA S
QL 0.02 / day SOMATULINE DEPOT 4 PA S
SOMATOTROPIN AGONISTS AND ANTAGONISTS
SOMATOTROPIN AGONISTS
QL 2 / day EGRIFTA 2 MG VIAL 4 PA S
PA INCRELEX 4 S
SOMATOTROPIN ANTAGONISTS
SOMAVERT 4 S
SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS
ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) yohimbine hcl powder 3 SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ALPHA- AND BETA-ADRENERGIC AGONISTS bupivacaine hcl-epinephrine 1 lidocaine hcl-epinephrine (0.5%-epi 1:200,000, 1%-epi 1:100,000, 2%-epi 1:100,000) 1
PAGE 263 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lidocaine-epinephrine 1 MARCAINE-EPINEPHRINE 3 norepinephrine bitartrate powd 3
QL 84 / 14 days NORTHERA 4 PA S phenylpropanolamine hcl 3 SENSORCAINE-EPINEPHRINE 1 SENSORC MPF 0.75%-EPI 1:200000 3 SENSORCAINE-MPF EPINEPHRINE (SENSORC MPF 0.25%-EPI, SENSORCN-MPF 0.5%-EPI) 1
XYLOCAINE DENTAL-EPINEPHRINE 1 XYLOCAINE WITH EPINEPHRINE (0.5%-EPI 1:200,000, 2%-EPI 1:100,000, 2%-EPI 1:200,000) 3
XYLOCAINE-MPF WITH EPINEPHRINE 3 ALPHA-ADRENERGIC AGONISTS midodrine hcl 1 phenylephrine hcl powder 3 phenylephrine 10 mg/ml vial 1 THYROID AND ANTITHYROID AGENTS
ANTITHYROID AGENTS carbimazole 3 methimazole powder 3 methimazole (5 mg tablet, 10 mg tablet) 1 propylthiouracil powder 3 propylthiouracil 50 mg tablet 1 TAPAZOLE 3
PAGE 264 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THYROID AGENTS
ARMOUR THYROID 3 CYTOMEL 3 LEVO-T 1 levothyroxine sodium powder 3 levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 1 LCG mcg tablet, 175 mcg tablet) levothyroxine sodium (75 mcg tablet, 88 mcg tablet, 200 mcg tablet, 300 mcg tablet) 1
LEVOXYL (25 MCG TABLET, 100 MCG TABLET) 1 LCG
LEVOXYL (50 MCG TABLET, 75 MCG TABLET, 88 MCG TABLET, 112 MCG TABLET, 125 MCG TABLET, 137 MCG TABLET, 150 1 MCG TABLET, 175 MCG TABLET, 200 MCG TABLET) liothyronine sodium powder 3 liothyronine sodium (5 mcg tab, 25 mcg tab, 50 mcg tab) 1 NATURE-THROID 3 NP THYROID 1 pcca t3 sodium dilution 3 pcca t4 sodium dilution 3 SYNTHROID 2 thyroid (3x usp powder, 30 mg tablet, 60 mg tablet, 90 mg tablet, powder) 3
THYROLAR-1 3 THYROLAR-1/2 3 THYROLAR-1/4 3 THYROLAR-2 3 THYROLAR-3 3
TIROSINT 3 QL 1 / day
PAGE 265 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS UNITHROID (25 MCG TABLET, 50 MCG TABLET, 100 MCG TABLET, 112 MCG TABLET) 1 LCG UNITHROID (75 MCG TABLET, 88 MCG TABLET, 125 MCG TABLET, 137 MCG TABLET, 150 MCG TABLET, 175 MCG TABLET, 1 200 MCG TABLET, 300 MCG TABLET)
WESTHROID 3 WP THYROID 3 Uncategorized
Unclassified
2-methoxyestradiol 3 4-aminobenzoic acid potassium 3 7-keto dhea 3 acacia powder 3 ace aerosol cloud enhancer 3 acetarsone 3 acetyl hexapeptide-8 3 acetyl-d-glucosamine 3 acticoat (2"x2", 4"x4", 5"x5") 3 acticoat (4"x48", 4"x8", 8"x16", 16"x16") 1 acticoat 7 3 acticoat flex 3 3 acticoat flex 7 3 acticoat surgical 1
ADAGEN 4 S ademetionine disulfate tosylat 3 advance plus intermittent 3 aerochamber mini 2 aerochamber mv 2
PAGE 266 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS aerochamber plus flow-vu 2 aerochamber with flowsignal 2 aerochamber z-stat plus 2 aeroeclipse ii 3 aerogear asthma action kit 3 aeroneb go 3 aeroneb go nebulizer 3 aerotrach plus 3 aerovent plus 3
QL 2 / day AFINITOR (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 4 PA S
QL 1 / day AFINITOR 2.5 MG TABLET 4 PA S
PA AFINITOR DISPERZ 4 S
AFLURIA 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 2 HCR
AFLURIA QUAD 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 2 HCR air filter 1
QL 8 / day PA ALECENSA 4 AL At least 18 yrs old S alginic acid 3 ALKERAN 2 MG TABLET 3 all flow 1000 3
PAGE 267 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS all flow 3000 kit 3 all flow 3000 pft 3 all flow 4000 3 all flow 5000 3 all flow 6000 3 allantoin 3 allergist syringe 3 allergist tray 3 allevyn 1 allevyn adhesive 1 allevyn ag 1 allevyn ag adhesive 3 allevyn ag gentle 1 allevyn heel 1 allevyn life (5 1/16"x5 1/16", 6 1/16"x 6 1/16", 8 1/4"x8 1/4") 1 allevyn life dressing 4"x4" 3 ALLFEN CDX 3 almond oil 3 aloe vera 3 alpha lipoic acid 3 altera nebulizer 3 aluminum acetate 3 aluminum chloride 3 aluminum chlorohydrate 3 aluminum sulfate 3
QL 6 / day PA ALUNBRIG 4 AL At least 18 yrs old S
PAGE 268 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS american ginseng root 3 ammonium lactate solution 3 ammonium sulfate 3 ammonium tetrathiomolybdate 3 AMVISC 3 AMVISC PLUS 3 anastrozole powder 3 anastrozole 1 mg tablet 1 anisindione 3 APLIGRAF 3 apogee hc intermittent 3 apogee ic intermittent cathetr 3 AQUORAL 3 argyle feeding tube-x-ray line 3 ARIMIDEX 3
QL 0.04 / day ARMONAIR RESPICLICK 3 PA arnica lg 3 AROMASIN 3 arsenic trioxide 3 ashwagandha extract 3 aspartic acid magnesium salt 3 assura 3 asthmapack children's 3 astragalus extract 3 ATRAPRO DERMAL SPRAY 3 ATRAPRO HYDROGEL 3
PAGE 269 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AURSTAT ANTI-ITCH HYDROGEL 3 AVAILNEX 3 AVENOVA 3 azacitidine 4 S
B-PLEX PLUS 1 baby conversion kit 3 baby conversion pack 1 3 baby conversion pack 2 3 baby nebulizer 3 BEAU RX 3
PA BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML SYRINGE) 4 S benzocaine 3 benzoic acid 3 benzoyl peroxide powder 3 benzyl alcohol 3 beta glucan 3
PA bexarotene 4 S bicalutamide 1 BIONECT (CREAM, GEL) 3 biostep 3 biostep ag 3 biotin 3 biotin-d 3 bismuth citrate 3 bismuth subgallate 3
PAGE 270 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS bitter melon extract 3
BLEO 15K 4 S bleomycin sulfate 4 S
QL 4 / day PA BOSULIF 100 MG TABLET 4 S PS
QL 1 / day PA BOSULIF 500 MG TABLET 4 S PS boswellia serrata extract 3 bovine serum albumin 3 breatherite 3 breathrite 3 bromelain 3 bromfenac sodium powder 3 buffered lidocaine 3 buflomedil hcl 3 bupivacaine hcl (0.25% ampul, 0.5% ampul, 0.75% ampul) 1 bupivacaine hcl powder 3 bupivacaine-dextr 0.75% amp 1 butalb-aspirin-caffe 50-325-40 1 QL 6 / day
QL 4 / day CABOMETYX 20 MG TABLET 4 PA S
QL 2 / day CABOMETYX 40 MG TABLET 4 PA S
PAGE 271 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1.5 / day CABOMETYX 60 MG TABLET 4 PA S calcipotriene powder 3 calcipotriene monohydrate 3 calcipotriol 3 calcitriol in almond oil 3 cantharidin (crystals, powder) 3 capecitabine 4 S
CAPHOSOL 3
QL 2 / day CAPRELSA 100 MG TABLET 4 PA S
QL 1 / day CAPRELSA 300 MG TABLET 4 PA S caprylic acid 3 CARBOCAINE (1% VIAL, 1.5% VIAL, 2% VIAL) 3
CARDENE SR 45 MG CAPSULE 3 QL 2 / day carrasyn hydrogel wound 3 CASODEX 3 catheter 1 CEDAX 90 MG/5 ML SUSPENSION 3 CERAMAX 1
CERVIDIL 3 GL Female cesium chloride 3 cetyl myristoleate (40% oil, 40% wax, powder) 3
PAGE 272 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cetylpyridinium chloride 3 chlorambucil 3 chloroacetic acid 3 chlorobutanol 3 chloroprocaine hcl 1 chloroxine 3 chloroxylenol 3 chlorzoxazone 250 mg tablet 1 cholesterol 3 chromium picolinate 3 chromium polynicotinate 3 chrysin 3 chymotrypsin 3 citric acid (granules, powder) 3 citrus bergamot 3 clemizole hcl 3 clever choice holding chamber 3 clever choice nebulizer 3 clever choice whisper aire ped 3 coaguchek xs 3 cobalt gluconate 3
QL 2 / day COMETRIQ 100 MG DAILY-DOSE PK 4 PA S
QL 4 / day COMETRIQ 140 MG DAILY-DOSE PK 4 PA S
PAGE 273 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 3 / day COMETRIQ 60 MG DAILY-DOSE PACK 4 PA S comp-air elite compressor syst 3 comp-air nebulizer compressor 3 compact space chamber 3 conception 1 copper peptide ghk-cu 3
QL 2.5 / day PA COTELLIC 4 AL At least 18 yrs old S
QL 1 / day COTEMPLA XR-ODT 3 ST creatine 3 creatine monohydrate 3 creatinine 3 curafil 3 curity 3 curity amd packing strips 3 curity iodoform 3 cyclodextrin-beta 3 cytarabine 4 S dapiprazole hcl 3 demecarium bromide 3 deoxycholic acid 3 DERMAGRAFT 3
PAGE 274 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS devil's claw 3 devilbiss traveler 3 dexchlorpheniramine maleate 1 dexcom g4 transmitter kit 3 dexcom g5 transmitter kit 3 dexcom g5-g4 sensor 3 dexpanthenol 3 dibucaine 3 dichloroacetic acid 3 diethanolamine 3 diethylen glycol m-ethyl ether 3 diindolylmethane 3 diiodo-l-thyronine 3 DILUENT FOR ROTARIX 3 DILUENT-MERCK LIVE VIRUS VACC 3 DILUTING MEDIUM FOR NOVOLOG 3 dimercaptopropanesulfonate sod (crystal, powder) 3 dimethyl sulfone 3 dimethyl sulfoxide 3 dimethylacetamide 3 dinitrochlorobenzene 3 diphenylcyclopropenone 3 DISCOVISC 3 dmae 3 dover advantage 3 dover advantage drainage 3 dover coated latex foley 3
PAGE 275 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dover latex foley catheter 3 dover premium 3 dover red rubber robibson cath 3 dover universal 3 DROXIA 3 DUOVISC 3 e-z spacer 3 e-z spacer pedspak 3 ear popper 1 easivent (holding chamber, mask-large, mask-medium, mask- small) 3 ebase controller 3 eclipse needle 3 eclipse syringe 3 egcg 3
EMCYT 4 S
EMEND 125 MG POWDER PACKET 3 QL 0.08 / day
EMULSION SB TOPICAL EMULSION 3 ENDOFORM (4" 5" TEMPLATE, FENESTRATED, FENESTRATED 4" 5", TEMPLATE) 3 enlite 3 enlite glucose sensor 3 ENTTY 3 EPICERAM 3 EPISIL 3 erapid nebulizer 3 erapid nebulizer handset 3
QL 1 / day ERIVEDGE 4 PA S
PAGE 276 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ERWINAZE 4 S ethoxy diglycol 3 ethyl acetate 1 ethyl oleate 3 etoposide powder 3 exemestane 1
PA EXJADE 4 S
EXPAREL 3 FARESTON 2
PA FARYDAK 4 S
QL 1.25 / day FASLODEX 4 PA S female self catheter 1
FEMARA 3 PA femcap (26 cap, 30 cap) 3 femcap 22 mm cervical cap 3 HCR ferric ammonium citrate 3 ferric subsulfate 3
PA FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) 4 S fexofenadine-pse er 1 QL 1 / day filter needle 19gx1-1/2" 3 filter needle 5 micron 3
PAGE 277 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS filter, valve set for ll & lc 3 flexichamber 3 flexichamber mask (flexichamber-lg child, flexichamber-sm adult) 3 flexichamber-sm child mask 2 floxuridine powder 3 floxuridine 500 mg vial 4 S
AL At least 65 yrs old FLUAD 2017-2018 2 HCR
FLUARIX QUAD 2017-2018 2 HCR
FLUBLOK 2017-2018 2 HCR
FLUBLOK QUAD 2017-2018 2 HCR
FLUCELVAX QUAD 2017-2018 (2017-2018 SYR, 2017-2018 VIAL) 2 HCR FLULAVAL QUAD 2017-2018 (2017-2018 SYR, 2017-2018 VIAL) 2 HCR fluorouracil powder 3 flutamide 1 flutter 3
FLUVIRIN 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 2 HCR
AL At least 65 yrs old FLUZONE HIGH-DOSE 2017-2018 2 HCR
FLUZONE INTRADERM QUAD 2017-18 2 HCR
FLUZONE QUAD 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 2 HCR
FLUZONE QUAD PEDI 2017-2018 2 HCR
FORMA-RAY 3
PAGE 278 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS freedom derma-d 3 freedom precision airless 3 freestyle navigator 3 GALZIN 3 GASTROMARK 3 GELCLAIR 3 gelfilm 3 GELFOAM (DENTAL SPONGE SZ 4, 12-7MM SPONGE, SIZE 50 SPONGE, SIZE 100 SPONGE, SIZE 200 SPONGE) 3
GELFOAM COMPRESSED 3 GELFOAM JMI SPONGE KIT 3 GELX 3 GENADUR NAIL LACQUER 3
QL 1 / day GILOTRIF 4 PA S ginseng root 3
QL 8 / day PA GLEEVEC 100 MG TABLET 4 S PS
QL 2 / day PA GLEEVEC 400 MG TABLET 4 S PS
GLEOSTINE 3 gluconolactone 3 glutaraldehyde 1
PAGE 279 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS glutathione 3 glutathione-l 3 glycine powder 3 glycolic acid (70% solution, crystals) 3 glycopyrrolate 1.5 mg tablet 1 glycosaminoglycans 3 glycyrrhizic acid 3 gramicidin d 3 guarana seed extract 3 guardian link 3 3 guardian rt charger 3 guardian rt starter kit 3 guardian rt system 3 guardian sensor 3 3 guardian test plug 3 HEMABATE 3
PA HEXALEN 4 S histamine phosphate 3 histidine hcl 3 home nebulizer plus sidestream 3 HPR 3 HPR PLUS (CREAM, EMOLLIENT FOAM) 3 HUMALOG JUNIOR KWIKPEN 2 hyaluronic acid 3 hyaluronic acid sodium salt 3 hyaluronidase 3
PAGE 280 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 4 S hydrazine sulfate 3 HYDREA 3 hydrofera blue 3 hydrofera blue ready 1 hydrogen peroxide 3 hydroxyethyl methacrylate 3 hydroxypropy-beta-cyclodextrin 3 hydroxytryptophan 3 hydroxyurea 500 mg capsule 1 hydroxyurea powder 3 HYGEL 3 HYLATOPIC 3 HYLATOPICPLUS (CREAM, EMOLLIENT FOAM, LOTION) 3 hypodermic needle 3
PA HYQVIA HY COMPONENT 4 S
QL 1.25 / day IBRANCE 100 MG CAPSULE 4 PA S
QL 1 / day IBRANCE 125 MG CAPSULE 4 PA S
QL 1.667 / day IBRANCE 75 MG CAPSULE 4 PA S
PAGE 281 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ichthammol 3
QL 2 / day ICLUSIG 15 MG TABLET 4 PA S
QL 1 / day ICLUSIG 45 MG TABLET 4 PA S
QL 4 / day IMBRUVICA 4 PA S
INDICLOR 3
QL 1 / day PA INGREZZA 80 MG CAPSULE 4 AL At least 18 yrs old S
QL 4 / day PA INLYTA 4 S PS innospire deluxe 3 innospire elegance 3 innospire essence 3 innospire mini 3 innospire replacement filter 3 inositol 3 inspirachamber 3 inspiration 3 inspiration elite 3
PAGE 282 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS inspiration elite filter 1 insulin syringe (insulin syrin 0.5 ml 30gx1/2", insulin syrin 0.5 ml 30gx5/16", insulin syringe 1 ml 30gx1/2", insulin syringe 1 ml 30gx5/16", ulticare ins safety 1ml 29x1/2, ulticare safety 0.5 2 ml 29gx1/2) insulin syringe u-500 2 iodoform 3 iopanoic acid 3 IPOL SINGLE DOSE SYRINGE 2
QL 1 / day IRESSA 4 PA S isoleucine 3 isopropamide iodide 3 isopropyl myristate 3 isoproterenol hcl (0.2 mg/ml vial, 1 mg/5 ml vial) 1
PA JADENU 4 S
PA JADENU SPRINKLE 4 S
QL 2 / day JAKAFI 4 PA S jetco-spray cannula 3 kangaroo 924 safety screw 3 kangaroo epump set 3 kangaroo gravity set 3 kendall 0.9% nacl with cap 1
PAGE 283 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS kenguard (add-a-foley cath tray, foley catheter) 3
QL 3 / day PA KISQALI 200 MG DAILY DOSE 4 AL At least 18 yrs old S
QL 1.5 / day PA KISQALI 400 MG DAILY DOSE 4 AL At least 18 yrs old S
QL 1 / day PA KISQALI 600 MG DAILY DOSE 4 AL At least 18 yrs old S
QL 3 / day PA KISQALI FEMARA 200 MG CO-PACK 4 AL At least 18 yrs old S
QL 1.5 / day PA KISQALI FEMARA 400 MG CO-PACK 4 AL At least 18 yrs old S
QL 1 / day PA KISQALI FEMARA 600 MG CO-PACK 4 AL At least 18 yrs old S kojic acid 3 l-aspartic acid 3 l-glutamic acid 3
PAGE 284 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS l-histidine 3 l-isoleucine 3 l-methionine 3 l-proline 3 l-serine 3 l-threonine 3 lc plus 3 lc sprint nebulizer 3 lc star 3
QL 3 / day LENVIMA 4 PA S letrozole powder 3 letrozole 2.5 mg tablet 1 LEUKERAN 3 leuprolide acetate powder 3 lidocaine powder 3 lidocaine hcl powder 3 lidocaine hcl (1% 20 mg/2 ml, 1% 20 mg/2 ml vl, 1% 300 mg/30 ml, 1% 50 mg/5 ml, 1% 50 mg/5 ml vl, 10 mg/ml 1 syringe, 50 mg/5 ml syrng, 200 mg/10 ml syr) lidocaine hcl 0.5% vial 1 MED Medical Drug lidocaine hcl 100 mg/10 ml-ns 1 lipoic acid 3 liteaire 3 litetouch 3 lomustine 1
QL 2.15 / day LONSURF 15 MG-6.14 MG TABLET 4 PA S
PAGE 285 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 3 / day LONSURF 20 MG-8.19 MG TABLET 4 PA S
LOUTREX 3 LUMINAL SODIUM 3 lutein 3
PA LYNPARZA (50 MG CAPSULE, 100 MG TABLET, 150 MG TABLET) 4 S
LYSODREN 4 S maca root 3 magellan insulin safety syrng (syr 0.3 ml, syr 0.5 ml, syringe 1 ml) 2 magellan insulin syringe (syringe 0.3 ml, syringe 0.5 ml) 2 magellan tuberculin syringe 3 magic3 intermittent catheter 3 magnesium chloride crystals 3 magnesium malate 3 malic acid 3 MARCAINE (0.25% VIAL, 0.5% VIAL, 0.75% VIAL) 3 MARCAINE SPINAL AMPUL 3 mask set with y-piece 3
MATULANE 4 S
QL 3 / day PA MAVYRET 4 AL At least 18 yrs old S PS
MAXIFED CDX 3
PAGE 286 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MAXIPHEN CD 3 MAXIPHEN CDX 3 mechlorethamine hcl 3 MEGACE 3
MEGACE ES 3 GL Female megestrol acetate (acet 40 mg/ml susp, acet 400 mg/10 ml, 625 mg/5 ml susp) 1 megestrol acetate powder 3 megestrol acetate (20 mg tablet, 40 mg tablet) 1
QL 4 / day MEKINIST 0.5 MG TABLET 4 PA S
QL 1 / day MEKINIST 2 MG TABLET 4 PA S melphalan 1 menadione 3 menthol 3 mepivacaine hcl 1 methacholine chloride 3
QL 2 / day methadone 5 mg/0.5 ml syringe 1 PA
METHERGINE 1 methionine 3 methotrexate powder 3 methylergonovine 0.2 mg tablet 1 methylergonovine maleate (0.2 mg/ml amp, 0.2 mg/ml vl) 1 methylparaben 3
PAGE 287 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS micro elite (micro elite lith-poly battery, microelite compressor nebulize) 3 micro plus 3 microchamber 3 microcrystalline cellulose 3 MICROCYN 3 MICROCYN HYDROGEL 3 microspacer 3 MIFEPREX 3 milk thistle 3 mini plus nebulizer 3 mini-wright peak flow meter 3 minielite (compressor nebulizer, lithium ion battery) 3 minilink real-time transmitter 3 minimed 630g guardian start kt 3 misterneb compressor 3 misterneb pediatric compressor 3 mitomycin (c powder, powder) 3 mitomycin c 3 mitotane 3 mono-flo 3 monoject 0.5 ml syrn 28gx1/2" 2 monoject 6cc safety syringe 3 monoject blood collection 3 monoject control syringe 3 monoject insulin syringe (insulin syr 0.3 ml, insulin syr 0.5 ml, 1 ml syrn 28gx1/2", insulin syr 1 ml, insulin syr u-100, syringe 1 2 ml) monoject luer lock tb syringe 3
PAGE 288 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS monoject magellan (syringe, syringe 1 ml) 3 monoject megellan tb syringe 3 monoject pharmacy tray 3 monoject safety syringe 3 monoject smartip cannula (3 ml, 6 ml, 12 ml) 3 monoject syringe (syringe 3 ml, 6 ml syrn 20gx11/2", 6 ml syrn 21gx1", 6 ml syrn 21gx11/2", 6 ml syrn 22gx11/2", syringe 6 3 ml, syringe 12 ml) mouthpiece 3 MUGARD 3
MUSTARGEN 4 S my mdi portable nebuliser 3
MYLERAN 4 S
NAROPIN (0.2% 20 MG/10 ML AMP, 0.2% 20 MG/10 ML VIAL, 0.2% 200 MG/100 ML BAG, 0.2% 40 MG/20 ML AMP, 0.2% 40 MG/20 ML VIAL, 0.2% 400 MG/200 ML BAG, 0.2% 400 MG/200 ML BTL, 0.5% 100 MG/20 ML AMP, 0.5% 100 MG/20 ML VIAL, 0.5% 150 MG/30 ML VIAL, 0.75% 150 MG/20 ML 3 AMP, 0.75% 150 MG/20 ML VL, 1% 100 MG/10 ML AMPULE, 1% 100 MG/10 ML VIAL, 1% 200 MG/20 ML AMPULE, 1% 200 MG/20 ML VIAL, 2 MG/ML INFUSION BTL, 5 MG/ML INFUSION BTL, 200 MG/100 ML INF BTL) needle 3 NEOSALUS (CREAM, FOAM, LOTION) 3 NEOSALUS CP 3 NESACAINE 3 NESACAINE-MPF 3 nettle leaf 3 NEUTRASAL 538 MG POWDER PACKET 3
QL 4 / day NEXAVAR 4 PA S
PAGE 289 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NILANDRON 4 S
PA nilutamide 4 S
QL 0.124 / day PA NINLARO 4 AL At least 18 yrs old S
NIVATOPIC PLUS 3 norm-ject 3 nose clip 3
PA NOVAREL 5,000 UNIT VIAL 4 S
NUMOISYN (LIQUID, LOZENGE) 3 nutriport balloon 3 NUVAIL 3
NYMALIZE 30 MG/10 ML SOLUTION 3 QL 120 / day oasis ultra (tri-layer sheet, ultra 3 x 3.5 cm, ultra 3 x 7 cm) 3
QL 1 / day ODOMZO 4 PA S omega-3 dha 3
ONCASPAR 4 S optichamber 1 optichamber diamond 3
ORAFATE 4 S
ORAMAGICRX 3 ornithine 3
PAGE 290 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS oxytocin powder 3 oxytocin 10 units/ml vial 1 papain 3 parachlorophenol 3 paradigm real-time 3 pari lc plus nebulizer 3 pari lc sprint sinus 3 pari sinus aerosol system 3 pediatric dinosaur nebulizer 3 pediatric dog nebulizer 3 pediatric frog nebulizer 3 pen needle 2 pentylenetetrazole 3
PERTZYE DR 24,000 UNIT CAPSULE 3 PA pflex trainer 3 phaseal protector 3 phenindione 3 phenolsulfonic acid 3 phenylmercuric nitrate 3 phenyltoloxamine dihyd cit 3 phosphatidylserine 3 pillow mask for children 1 pine bark extract 3 PITOCIN 3 pocket chamber 3 podofilox powder 3 POLOCAINE (1% VIAL, 2% VIAL) 1
PAGE 291 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS POLOCAINE-MPF 1 polyvinyl alcohol 3 portable nebulizer system 3 potassium bromide (crystals, powder) 3 potassium p-aminobenzoate 3 potassium permanganate (crys, gran) 3 potassium sorbate (crystals, powder) 3 povidone 3 povidone k-30 3 pregnenolone 3 pregnenolone micronized 3
PREPIDIL 3 GL Female
PRESERA 3 prilocaine hcl 3 primeaire 3 procaine hcl 3 procarbazine hcl 3 prochamber 3 prodigy mini-mist 3 PROMISEB 3 proneb ultra ii 3 propyl gallate 3 propylene glycol 3
PROSTIN E2 VAGINAL SUPPOSITORY 3 GL Female
PROTHELIAL 4 S provent starter kit 3 PROVISC 3
PAGE 292 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROVOCHOLINE 3 PRUMYX 3 pulmo-aide 3 pyridoxal-5-phosphate 3 quake 3 quaternium-15 3 quercetin dihydrate 3
QVAR REDIHALER 40 MCG 2 QL 0.6 / day
QVAR REDIHALER 80 MCG 2 QL 0.87 / day
RADIAPLEXRX 3 RADIGEL 3 rapport vacuum therapy 3 RECEDO 3 red yeast rice 3 replacement pediatric monitor 3 replicare (4"x4", 6"x6", 8"x8") 1 replicare ultra 4"x4" dressing 3 replicare ultra 6"x6" dressing 1 replicare ultra sacrum 3 resorcinol (crystals, powder) 3 restore (1"x12" dressing, 2"x2" dressing, 4"x4" foam silver drsg, 6"x8" foam silver drsg) 3 restore calcium alginate 3 restore contact layer silver 3 retinaldehyde 3 reusable nebulizer kit 1 riteflo 3
PAGE 293 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS robinson clear vinyl catheter 3 ropivacaine hcl (20 mg/10 ml, autofuser pmp) 1 ropivacaine hcl powder 3 ropivacaine hcl (0.2% 200 mg/100 ml, 0.2% 40 mg/20 ml, 0.5% 100 mg/20 ml, 0.5% 150 mg/30 ml, 0.75% 150 mg/20 1 ml, 1% 100 mg/10 ml vl, 1% 200 mg/20 ml vl) ropivacaine-ns 0.1% on-q pump 1 rubber mouthpiece 2
QL 2 / day PA RUBRACA (200 MG TABLET, 250 MG TABLET) 4 AL At least 18 yrs old S
QL 2 / day PA RUBRACA 300 MG TABLET 4 AL At least 18 yrs old S
QL 2 / day PA RYDAPT 4 AL At least 18 yrs old S safety syringe with shield 3 safety syringe-needle 3 safetyglide allergy syringe 3 SALIVAMAX 3 SALIVATERX 3 sami the seal 3 sami the seal mask 3 saw palmetto 3 SEBUDERM 3
PAGE 294 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SENSORCAINE 1 SENSORCAINE WITH DEXTROSE 1 SENSORCAINE-MPF (0.25% AMPUL, 0.25% VIAL, 0.5% AMPUL, 0.5% VIAL, 0.75% AMPUL, 0.75% VIAL) 1 sensura click ostomy pouch 3 sensura flex ostomy base plate 3 sensura flex ostomy pouch 3 sensura ostomy base plate 3 serotonin hcl 3 sidestream 3 sidestream mask 3 sidestream nebulizer 3 sidestream plus 3 silicone mask (mask-adult, mask-infant, mask-pediatric) 1 silverseal hydrogel 3 SILVRSTAT 3 sinustar (aerosol delivery syst, reusable nebulizer) 3 sodium benzoate 3 sodium butyrate 3 sodium deoxycholate 3 sodium dichloroacetate 3 sodium hyaluronate 3 sodium hyaluronic acid 3 sodium iodide 3 sodium metabisulfite (granules, powder) 3 sodium stearyl fumarate 3 sodium succinate 1 sof-sensor 3
PAGE 295 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SOLTAMOX 3 sorbic acid 3 SP ANTIPRURITIC 3 spectragel 3 spirulina 3
QL 1 / day SPRYCEL (100 MG TABLET, 140 MG TABLET) 4 PA S
QL 2 / day SPRYCEL (70 MG TABLET, 80 MG TABLET) 4 PA S
QL 9 / day SPRYCEL 20 MG TABLET 4 PA S
QL 3 / day SPRYCEL 50 MG TABLET 4 PA S
QL 4 / day STIVARGA 4 PA S
PA AL Up to 18 yrs old STRENSIQ 4 S PS
SUCRAID 4 S sulfurated potash 3 sunrise compressor-nebulizer 1
PAGE 296 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day PA SUTENT (37.5 MG CAPSULE, 50 MG CAPSULE) 4 S PS
QL 7 / day PA SUTENT 12.5 MG CAPSULE 4 S PS
QL 3 / day PA SUTENT 25 MG CAPSULE 4 S PS
SWABFLUSH 1
PA SYNRIBO 4 S
PA SYPRINE 4 S bd luer-lok 5 ml syringe 3 syringe-needle 3 t.e.d. anti-embolism stocking (anti-embol, anti-embolism) 3 TABLOID 3
QL 6 / day TAFINLAR 50 MG CAPSULE 4 PA S
QL 4 / day TAFINLAR 75 MG CAPSULE 4 PA S
QL 1 / day PA TAGRISSO 4 AL At least 18 yrs old S PS
PAGE 297 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tamoxifen citrate powder 3 tamoxifen citrate (10 mg tablet, 20 mg tablet) 1 HCR
QL 1 / day TARCEVA (100 MG TABLET, 150 MG TABLET) 4 PA S
QL 6 / day TARCEVA 25 MG TABLET 4 PA S
PA TARGRETIN 75 MG CAPSULE 4 S
QL 4 / day PA TASIGNA 4 S PS
TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE, PA 4 140 MG CAPSULE, 180 MG CAPSULE, 250 MG CAPSULE) S
PA temozolomide 4 S tens 502 3 tens 504 3
PAGE 298 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS terumo surguard2 (ndl 21gx1 1.5, ndl 22x1-1/2", ndl 23x1- 1/2", needle 18gx1", needle 18x1.5, needle 19gx1", needle 19x1.5, needle 20gx1", needle 20x1.5, needle 21gx1", needle 22gx1", needle 23gx1", needle 25gx1", needle 25x1.5, needle 25x5/8, needle 26x1/2, needle 27x1/2, needle 30x1/2, syr 20g- 3 10 ml, syr 20g-3 ml, syr 20g-5 ml, syr 21g 3 ml, syr 21g-10 ml, syr 21g-3 ml, syr 21g-5 ml, syr 22g 3 ml, syr 23g 3 ml, syr 25g 3 ml, syr 25g-1 ml, syr 26g-1 ml, syr 27g-1 ml) tetracaine 3 tetracaine hcl 1% ampul 1 tetracaine hcl powder 3 tetrahydro-l-biopterin di-hcl 3 tetrahydrobiopterin di-hcl 3 tetrahydrobiopterin hcl 3 theobromine 3 thioguanine 3 thiotepa powder 3 thiotepa 15 mg vial 4 S threonine 3 threshold imt 3 threshold pep 3 THROMBI-GEL 3 THROMBI-PAD 3 titanium dioxide 3 TL-CERMIDE 3 toomey syringe 1 touch-trol 3 TREAGAN OTIC 3 trek s combo pack 3 trek s compact compressor 3
PAGE 299 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS trek s portable pwr kit 3
TRELSTAR (3.75 MG SYRINGE, 3.75 MG VIAL, 11.25 MG PA 4 SYRINGE, 11.25 MG VIAL, 22.5 MG SYRINGE, 22.5 MG VIAL) S
QL 90 / 365 days tretinoin 10 mg capsule 4 S trichloroacetic acid (crystal, powder) 3 trilostane 3 trioxsalen 3 trolamine 3 TROPAZONE 3 truneb nebulizer 3 truzone peak flow meter 3 trypsin 3
QL 6 / day PA TYKERB 4 S PS ulticare 3 unistik 2 normal 2 vacustim black 3 valine 3
VALSTAR 4 S vapro plus intermitt catheter 3 vascuderm hydrogel wound 3 VAXCHORA BUFFER COMPONENT 2
PA VELCADE 4 S
PAGE 300 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VENATAL COMPLETE DHA 3 GL Female
QL 4 / day VENCLEXTA 4 PA S
QL 1.5 / day VENCLEXTA STARTING PACK 4 PA S
VIDAZA 4 S vios aerosol delivery system 3 VISCOAT 3
VITASPIRE 3 GL Female vixone nebulizer 3 vortex 3 vortex vhc frog mask 3 vortex vhc ladybug mask 3
QL 1 / day PA VOSEVI 4 AL At least 18 yrs old S PS
QL 4 / day VOTRIENT 4 PA S water (bacteriostatic vial, for injection ampul, for injection vial) 1 white willow bark 3 wide seal diaphragm 3 HCR wound matrix 3
PAGE 301 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 2 / day XALKORI 4 PA S xanthan gum 3
QL 4 / day XELODA 4 PA S xeroform 3 xeroform petrolatum dressing 3
XIAFLEX 4 S
QL 4 / day XTANDI 4 PA S
XYLOCAINE 0.5% VIAL 3 XYLOCAINE-MPF (0.5% VIAL, 1% AMPUL, 1.5% AMPUL, 4% AMPUL) 3 xylometazoline hcl 3 yohimbine 5.4 mg tablet 1 ZANABIN 3 zeaxanthin 3
QL 3 / day PA ZEJULA 4 AL At least 18 yrs old S
QL 8 / day ZELBORAF 4 PA S zinc acetate (crystals, dihydrate powder) 3
PAGE 302 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS zinc pyrithione 3 ZINGO 3 ZODEX 12 DAY 1.5 MG TABLET 3
QL 4 / day ZOLINZA 4 PA S
ZOTEX-C 3
QL 2 / day ZYDELIG 4 PA S
QL 8 / day PA ZYKADIA 4 AL At least 18 yrs old S
QL 4 / day PA ZYTIGA 250 MG TABLET 4 S PS
QL 2 / day PA ZYTIGA 500 MG TABLET 4 S PS
VASODILATING AGENTS
NITRATES AND NITRITES
DILATRATE-SR 3 QL 4 / day
QL 1.25 / day GONITRO 3 PA AL At least 18 yrs old
PAGE 303 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ISOCHRON 1 QL 4 / day
ISORDIL 3 QL 12 / day
ISORDIL TITRADOSE 3 QL 12 / day isosorbide 3 isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30 12 / day mg tablet) 1 QL isosorbide dn er 40 mg tablet 1 QL 4 / day isosorbide mononitrate 1 QL 2 / day isosorbide mononitrate er 1 QL 2 / day
MINITRAN 1 QL 1 / day
NITRO-BID 2 QL 4 / day
NITRO-DUR 3 QL 1 / day
NITRO-TIME 1 QL 4 / day nitroglycerin (er 2.5 mg cap, er 6.5 mg cap, er 9 mg capsule) 1 QL 4 / day nitroglycerin 400 mcg spray 1 QL 0.3 / day nitroglycerin lingual 0.4 mg 1 QL 0.8 / day nitroglycerin (0.3 mg tablet, 0.4 mg tablet, 0.6 mg tablet) 1 QL 6 / day nitroglycerin patch 1 QL 1 / day
NITROLINGUAL 3 QL 0.8 / day
NITROMIST 3 QL 0.3 / day
NITROSTAT 3 QL 6 / day sodium nitrite powder 3 PHOSPHODIESTERASE TYPE 5 INHIBITORS
QL 0.2 / day CIALIS (10 MG TABLET, 20 MG TABLET) 2 GL Male
PAGE 304 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day CIALIS (2.5 MG TABLET, 5 MG TABLET) 2 GL Male
QL 0.2 / day LEVITRA 3 GL Male AL At least 18 yrs old
QL 0.2 / day STAXYN 3 GL Male
QL 0.2 / day STENDRA 3 GL Male
QL 0.2 / day VIAGRA 2 GL Male AL At least 18 yrs old
VASODILATING AGENTS, MISCELLANEOUS alprostadil powder 3 alprostadil 500 mcg/ml vial 1 CAVERJECT 40 MCG/2 ML AMPUL 3 CAVERJECT (IMPULSE 10 MCG KIT, 20 MCG VIAL, IMPULSE 20 Male MCG KIT, 40 MCG VIAL) 3 GL
EDEX 3 GL Male isoxsuprine hcl powder 3 isoxsuprine hcl (10 mg tablet, 20 mg tablet) 1
MUSE 3 GL Male papaverine hcl powder 3 papaverine 60 mg/2 ml vial 1 papaverine-alprostadil 1 prostaglandin e1 3 PROSTIN VR PEDIATRIC 3
PAGE 305 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tolazoline hcl 3 VITAMINS
MULTIVITAMIN PREPARATIONS
ELDERCAPS 1
ELITE OB DHA 3 GL Female
ELITE-OB 3 GL Female
MATERNITY 1 GL Female
MAXINATE 3 GL Female multivitamins-a,b,d,e,k,zn (chewables tablet, pediatric drops, softgels) 1
MYNATAL ULTRACAPLET 3 GL Female
MYNATE 90 PLUS 3 GL Female
PNV-VP-U 3
PRENA1 CHEW 3 GL Female prenatal-u 3 GL Female
REQ49+ 3 SUPERVITE EC 3 THERAPEUTIC VITAMIN W-MINERALS 1
TRIVEEN-U 3 GL Female
TRUST NATAL DHA 3 GL Female
UDAMIN SP 3 V-C FORTE 1 VIC-FORTE 1
VINATE PN CARE 3 GL Female
VINATE-M 3 GL Female
PAGE 306 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VITAMIN A
AQUASOL A 3 beta carotene 3 vitamin a acetate 3 vitamin a palmitate (1.7 million unit/gm, 18,000 units/ml liq, plmitte liquid) 3 vitamins a,c,d and fluoride 1 VITAMIN B COMPLEX adenosylcobalamin 3 B-12 COMPLIANCE 3 B-12 KIT 1 b-complex 1 calcium pantothenate 3 CARDIOTEK-RX 3 cobamamide 3 cyanocobalamin 3 cyanocobalamin injection 1 FOLBEE 1 FOLBEE AR 3 FOLBEE PLUS CZ 1 FOLGARD RX 3 folic acid powder 3 folic acid 1 mg tablet 1 folic acid 5 mg/ml vial 1 folic acid-vit b6-vit b12 1 FOLPLEX 2.2 1 hydroxocobalamin powder 3 hydroxocobalamin 1,000 mcg/ml 1
PAGE 307 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS l-5 methyltetrahydrofolate cal 3 l-methylfolate calcium 3 levomefolate calcium 3 methylcobalamin 3 methyltetrahydrofolate calcium 3 methyltetrahydrofolic acid 3 NASCOBAL 3 NEPHRO-VITE RX 3 NEURIN-SL 3 niacinamide 3 panthenol 3 pyridoxine hcl (crystals, powder) 3 pyridoxine 100 mg/ml vial 1 RENA-VITE RX 1 riboflavin 3 riboflavin-5-phosphate sodium 3 SUPERVITE 3 thiamine hcl powder 3 thiamine 200 mg/2 ml vial 1 VIRT-CAPS SOFTGEL 1 VIRT-GARD 1 VIRT-VITE 1 VIRT-VITE PLUS 1 VITA-RESPA 3 VP-VITE RX 1 ZOLATE 1
PAGE 308 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VITAMIN C ascorbic acid powder 3 ascorbic acid 500 mg/ml vial 1 sodium ascorbate 3 VITAMIN D calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) 1 calcitriol (crystals, powder) 3 doxercalciferol (0.5 mcg cap, 1 mcg capsule, 2.5 mcg cap) 4 S
DRISDOL 3 ergocalciferol 3 HECTOROL (0.5 MCG CAPSULE, 1 MCG CAPSULE, 2.5 MCG CAPSULE) 4 S paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg capsule) 4 S
RAYALDEE 4 S
ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1 MCG/ML ORAL SOLN) 3 vitamin d2 1 vitamin d3 (2,400 units/ml liq, 100,000 unit/gm pwd) 3
PA ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 4 S
VITAMIN E natural mixed tocopherols 3 tocopheryl acid succinate 3 vitamin e acetate (vit actat125 units/ml liq, vitamin actat50% powdr, vitamin actatliquid) 3
PAGE 309 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VITAMIN K ACTIVITY phytonadione liquid 3 vitamin k 3 vitamin k2 3
PAGE 310 LAST UPDATED 10/2017 Index of Covered Drugs acetamin-caff-dihydrocodeine 8 2 acetaminophen 8 2-deoxy-d-glucose 134 acetaminophen-codeine 8,9 2-methoxyestradiol 266 acetarsone 266 ACETASOL HC 36 4 acetazolamide 97 4-aminobenzoic acid potassium 266 acetazolamide sodium 97 4-aminopyridine 231 acetic acid 36 acetic acid-aluminum 36 5 acetyl hexapeptide-8 266 5-aminosalicylic acid 182 acetyl salicylic acid 127 acetyl-d-glucosamine 266 7 acetyl-l-carnitine hcl 231 7-keto dhea 266 acetylcholine chloride 97 acetylcysteine 231 8 acetylcysteine-water 179 8-MOP 155 acidophilus lactobacillus 183 ACIPHEX 133 A ACIPHEX SPRINKLE 133 A-HYDROCORT 190 acitretin 256 A-METHAPRED 190 ACLARO 154 abacavir 124 acremonium 155 abacavir-lamivudine 124 ACTEMRA 224 abacavir-lamivudine-zidovudine 124 ACTHIB 129 ABILIFY 114 ACTICLATE 60 ABILIFY MAINTENA 114 acticoat 266 ABSORICA 256 acticoat 7 266 ABSTRAL 13 acticoat flex 3 266 acacia 155,266 acticoat flex 7 266 acamprosate calcium 149 acticoat surgical 266 ACANYA 37 ACTIGALL 185 acarbose 81 ACTIMMUNE 227 ACCOLATE 46 ACTIQ 13 ACCUPRIL 240 ACTIVE FE 47 ACCURETIC 165 ACTIVELLA 174 ACD 169 ACTONEL 221,222 ACD-A 67 ACTOPLUS MET 82 ace aerosol cloud enhancer 266 ACTOPLUS MET XR 82 acebutolol hcl 52,53 ACTOS 88 ACEON 241 ACULAR 45 acepromazine maleate 122 ACULAR LS 45 ACUVAIL 45 aeroneb go 267 acyclovir 39,135 aeroneb go nebulizer 267 ACZONE 256 AEROSPAN 153 ADACEL TDAP 129 aerotrach plus 267 ADAGEN 266 aerovent plus 267 ADALAT CC 146 AFEDITAB CR 146 adapalene 256 AFINITOR 267 adapalene-benzoyl peroxide 256 AFINITOR DISPERZ 267 ADASUVE 113 AFLURIA 2016-2017 129 ADCIRCA 244 AFLURIA 2017-2018 267 ADDERALL 26 AFLURIA QUAD 2016-2017 129 ADDERALL XR 26 AFLURIA QUAD 2017-2018 267 ADDYI 149 AFREZZA 86 adefovir dipivoxil 135 AGGRENOX 127 ademetionine disulfate tosylat 266 AGRYLIN 128 ADEMPAS 244 air filter 267 adenosine 55 AIRDUO RESPICLICK 4 adenosylcobalamin 307 AK-POLY-BAC 33 ADIPEX-P 24 AKTEN 180 ADLYXIN 85 AKYNZEO 88 ADOXA 60 ALA-CORT 247 ADRENACLICK 3 ALA-QUIN 93 ADRENALIN 3 ALA-SCALP 247 ADRENALIN CHLORIDE 181 alanine 169 adrenocorticotrophic hormone 155 albendazole 31 ADVAIR DISKUS 4 ALBENZA 31 ADVAIR HFA 4 albuterol sulfate 4 advance plus intermittent 266 ALCAINE 180 ADVICOR 106 alclometasone dipropionate 247 ADYPHREN 3 alcohol,dehydrated 231 ADYPHREN AMP 3 ALDACTAZIDE 165 ADYPHREN AMP II 3 ALDACTONE 165 ADYPHREN II 3 ALDARA 256 ADZENYS XR-ODT 26 alder 155 aerochamber mini 266 aldosterone 190 aerochamber mv 266 ALECENSA 267 aerochamber plus flow-vu 267 alendronate sodium 222 aerochamber with flowsignal 267 ALEVICYN ANTIPRURITIC SG 254 aerochamber z-stat plus 267 alfentanil hcl 13 aeroeclipse ii 267 ALFERON N 134 aerogear asthma action kit 267 alfuzosin hcl er 7 alginic acid 267 alprostadil 305 ALINIA 113 ALREX 43 ALKERAN 267 ALSUMA 108 all flow 1000 267 ALTABAX 37 all flow 3000 kit 268 ALTACAINE 180 all flow 3000 pft 268 ALTACE 241 all flow 4000 268 ALTAFLUOR 180 all flow 5000 268 ALTAVERA 196 all flow 6000 268 altera nebulizer 268 allantoin 268 alternaria 155 allergist syringe 268 ALTOPREV 106 allergist tray 268 aluminum acetate 268 allevyn 268 aluminum chloride 268 allevyn adhesive 268 aluminum chlorohydrate 268 allevyn ag 268 aluminum hydroxide 182 allevyn ag adhesive 268 aluminum sulfate 268 allevyn ag gentle 268 ALUNBRIG 268 allevyn heel 268 ALUVEA 254 allevyn life 268 ALVESCO 153 ALLFEN CDX 268 ALYACEN 196 allopurinol 220 AMABELZ 174 ALLZITAL 9 amantadine 111 almond 155 amantadine hcl 111 almond oil 268 AMARYL 87 almotriptan malate 108 AMBIEN 138 ALOCRIL 46 AMBIEN CR 138 aloe vera 268 amcinonide 247 alogliptin 84 AMERGE 108 alogliptin-metformin 82 american beech 155 alogliptin-pioglitazone 84 american cockroach extract 155 ALOMIDE 178 american elm 155 ALORA 174 american ginseng root 269 alosetron hcl 182 american sycamore 155 alpha lipoic acid 268 AMETHIA 196 ALPHAGAN P 96 AMETHIA LO 196 ALPHAQUIN HP 154 AMETHYST 196 alprazolam 140 AMICAR 98 alprazolam er 140,141 amikacin 57 ALPRAZOLAM INTENSOL 141 amikacin sulfate 57 alprazolam odt 141 amiloride hcl 163 alprazolam xr 141 amiloride-hydrochlorothiazide 163 aminobutyric acid 231 ANALPRAM HC 247 aminocaproic acid 99 ANAPROX 220 aminophylline 145 ANAPROX DS 220 aminosalicylic acid 110 ANASPAZ 64 amiodarone hcl 54 ANASTIA 252 AMITIZA 183 anastrozole 269 amitriptyline hcl 80 ANCOBON 93 amlodipine besilate 146 ANDRODERM 193 amlodipine besylate 146,147 ANDROGEL 193,194 amlodipine besylate-benazepril 147 ANDROID 194 amlodipine-atorvastatin 106 androstenedione 194 amlodipine-olmesartan 147 ANDROXY 194 amlodipine-valsartan 147 ANGELIQ 174 amlodipine-valsartan-hctz 147 anisindione 269 ammonium chloride 168 ANORO ELLIPTA 4 ammonium lactate 173,269 ANSAID 235 ammonium sulfate 269 ANTABUSE 219 ammonium tetrathiomolybdate 269 ANTARA 105 AMNESTEEM 257 anthralin 256 amoxapine 80 anticoagulant sodium citrate 67 amoxicillin 238 antimony trichloride 113 amoxicillin er 238 antivenin latrodectus mactans 128 amoxicillin trihydrate 238 antivenin micrurus fulvius 128 amoxicillin-clavulanate pot 238 ANTIVERT 90 amoxicillin-clavulanate pot er 238 ANUCORT-HC 247 amoxicillin-clavulanate potass 238 ANUSOL-HC 247 amphotericin b 93 ANZEMET 89 ampicillin sodium 238 APEXICON E 247 ampicillin trihydrate 239 APIDRA 86 ampicillin-sulbactam 239 APIDRA SOLOSTAR 86 AMPYRA 231 APLENZIN 74 AMRIX 245 APLIGRAF 269 AMVISC 269 apogee hc intermittent 269 AMVISC PLUS 269 apogee ic intermittent cathetr 269 amyl nitrite 219 APOKYN 167 AMYTAL SODIUM 140 apomorphine hcl 167 ANA-LEX 247 apple 155 ANACAINE 252 apraclonidine hcl 179 ANADROL-50 193 aprepitant 89,90 ANAFRANIL 80 APRI 197 anagrelide hcl 128 APRISO 182 APTENSIO XR 28 ASMANEX HFA 153 APTIOM 68 aspartic acid magnesium salt 269 APTIVUS 125 aspergillus fumigatus 156 AQUASOL A 307 aspirin 127 AQUORAL 269 aspirin-caffeine-dihydrocodein 127 ARANELLE 197 aspirin-dipyridamole er 127 ARANESP 144 assura 269 ARAVA 224 ASTAGRAF XL 229 ARBINOXA 100 ASTEPRO 178 ARCALYST 231 asthmapack children's 269 ARCAPTA NEOHALER 4 astragalus extract 269 arginine 169 ASTRAMORPH-PF 14 arginine hcl 169 ASTRINGYN 99 argyle 269 ATABEX EC 47 ARICEPT 142 ATACAND 240 arida 40 ATACAND HCT 165 ARIMIDEX 269 ATELVIA 222 aripiprazole 114 atenolol 53 aripiprazole odt 114 atenolol-chlorthalidone 53 ARISTADA 114 ATIVAN 73 ARISTOSPAN 190 atomoxetine hcl 149 ARIXTRA 67 ATOPICLAIR 173 arizona cypress 155 atorvastatin calcium 106 armodafinil 31 atovaquone 113 ARMONAIR RESPICLICK 269 atovaquone-proguanil hcl 112 ARMOUR THYROID 265 ATRALIN 253 arnica lg 269 ATRAPRO DERMAL SPRAY 269 ARNUITY ELLIPTA 153 ATRAPRO HYDROGEL 269 AROMASIN 269 ATRIPLA 123 arsenic trioxide 269 ATROPEN 64 ARTHROTEC 50 132 atropine sulfate 64,181 ARTHROTEC 75 132 atropine sulfate-0.9% nacl 181 ARTISS 257 ATROVENT 179 ARYMO ER 13 ATROVENT HFA 64 asa-butalb-caffeine-codeine 14 attapulgite 183 ASACOL HD 182 AUBAGIO 227 ASCOMP WITH CODEINE 14 AUBRA 197 ascorbic acid 309 AUGMENTIN 239 ASHLYNA 197 AUGMENTIN ES-600 239 ashwagandha extract 269 AUGMENTIN XR 239 ASMANEX 153 aureobasidium 156 AURSTAT 270 AZELEX 257 AURYXIA 217 AZILECT 75 AUSTEDO 149 azithromycin 218 australian pine 156 AZOPT 97 AUVI-Q 3 AZOR 147 AVAGE 257 aztreonam 219 AVAILNEX 270 AZULFIDINE 59 AVALIDE 165 AZUPHEN MB 32 AVANDAMET 82 AZURETTE 197 AVANDIA 88 AVAPRO 240 B AVAR 40 B-12 COMPLIANCE 307 AVAR LS 40 B-12 KIT 307 AVAR-E 40 b-complex 307 AVAR-E GREEN 40 B-DONNA 64 AVAR-E LS 40 B-PLEX PLUS 270 AVC 40 baby conversion kit 270 AVEED 194 baby conversion pack 1 270 AVELOX 58 baby conversion pack 2 270 AVELOX ABC PACK 58 baby nebulizer 270 AVENOVA 270 BACIIM 62 AVIANE 197 bacitracin 33,37,62 AVIDOXY 60 bacitracin micronized 37 AVITA 253 bacitracin zinc 37 AVITENE 99 bacitracin-polymyxin 33 AVO CREAM 173 baclofen 246 avocado 156 BACTRIM 59 AVODART 219 BACTRIM DS 59 AVONEX 227 BACTROBAN 37 AVONEX PEN 227 BACTROBAN NASAL 33 AXERT 108 bahia 156 AXIRON 194 BAL IN OIL 219 AYGESTIN 214 balanced salt 179 azacitidine 270 bald cypress 156 AZACTAM 219 balsalazide disodium 182 AZASAN 224 BALZIVA 197 AZASITE 33 banana 156 azathioprine 224 BANZEL 69 azathioprine sodium 224 BARACLUDE 135,136 azelaic acid 257 barium sulfate 161 azelastine hcl 178 BASAGLAR KWIKPEN U-100 86 bayberry 156 beta glucan (1-3) nq 231 bcg vaccine (tice strain) 129 BETADINE 36 BEAU RX 270 BETAGAN 96 beclomethasone dipropionate 190 betahistine 148 BECONASE AQ 43 betahistine hcl 148 beef 156 betaine hydrochloride 231 BEKYREE 197 betamethasone acetate micro 190 BELBUCA 23 betamethasone acetate-sod phos 191 belladonna 64 betamethasone dipropionate 247 belladonna leaf powder 64 betamethasone sodium phosphate 191 belladonna-opium 14 betamethasone valerate 247 belladonna-phenobarbital 64 BETAPACE 53 BELSOMRA 138 BETAPACE AF 53 BELVIQ 26 BETASERON 227 BELVIQ XR 26 betaxolol hcl 53,96 benactyzine hcl 74 bethanechol chloride 142 benazepril hcl 241,242 BETHKIS 57 benazepril-hydrochlorothiazide 165 BETIMOL 96 BENICAR 240 BETOPTIC S 96 BENICAR HCT 165 BEVESPI AEROSPHERE 4 BENLYSTA 270 bexarotene 270 BENSAL HP 254 BEXSERO 129 BENTYL 64 BEYAZ 197 BENZACLIN 37 BIAFINE 173 benzalkonium chloride 40 BIAXIN 110 BENZAMYCIN 37 bicalutamide 270 BENZEFOAM 254 BICILLIN C-R 239 BENZEFOAM ULTRA 254 BICILLIN L-A 239 BENZEPRO 254 BIDIL 216 benzocaine 270 BILTRICIDE 31 benzoic acid 270 bimatoprost 98 benzonatate 243 BINOSTO 222 benzoyl peroxide 254,270 BIOGLO 161 benzphetamine hcl 26 BIONECT 270 benztropine mesylate 67 biostep 270 benzyl alcohol 270 biostep ag 270 benzyl benzoate 43 biotin 270 BEPREVE 178 biotin-d 270 BESIVANCE 33 bisacodyl 184 beta carotene 307 bismuth citrate 270 beta glucan 270 bismuth subgallate 270 bismuth subsalicylate 183 bromelain 271 bisoprolol fumarate 53 BROMFED DM 101 bisoprolol-hydrochlorothiazide 53 bromfenac sodium 45,271 bitter melon extract 271 bromhexine hcl 243 black walnut pollen 156 bromocriptine mesylate 167 black willow 156 brompheniramine maleate 100 BLANCHE 154 brompheniramine-pseudoephed-dm 101 BLEO 15K 271 BROMSITE 45 bleomycin sulfate 271 BROVANA 5 BLEPH-10 33 BSS 179 BLEPHAMIDE 33 BSS PLUS 179 BLEPHAMIDE S.O.P. 33 BUCALSEP 180 BLISOVI 24 FE 197 budesonide 43,153 BLISOVI FE 197 budesonide ec 191 BONIVA 222 budesonide micronized 43 BONTRIL PDM 24 buffered lidocaine 271 BOOSTRIX TDAP 129 buflomedil hcl 271 boric acid 37 bumetanide 163 BOSULIF 271 BUNAVAIL 23 boswellia serrata extract 271 BUPAP 9 BOTOX 231 BUPHENYL 169 BOTOX COSMETIC 231 bupivacaine hcl 271 botrytis 156 bupivacaine hcl-epinephrine 263 bovine serum albumin 271 bupivacaine-dextrose 271 box elder 156 BUPRENEX 23 BP 10-1 40 buprenorphine 23 BP-50% UREA 254 buprenorphine hcl 23 BPO 254 buprenorphine-naloxone 23 BRAVELLE 210 BUPROBAN 74 breatherite 271 bupropion hcl 75 breathrite 271 bupropion hcl sr 75 BREO ELLIPTA 5 bupropion xl 75 BREVICON 197 buspirone hcl 138 BREVITAL SODIUM 72 butalb-acetaminoph-caff-codein 9 BRIELLYN 197 butalb-caff-acetaminoph-codein 9 BRILINTA 127 butalbital 140 brimonidine tartrate 96 butalbital compound-codeine 14 BRINTELLIX 79 butalbital-acetaminophen 9 BRISDELLE 77 butalbital-acetaminophen-caffe 9 BRIVIACT 69 butalbital-aspirin-caffeine 127,271 brome 156 BUTISOL SODIUM 140 butorphanol tartrate 23,24 calcium sulfate 170 BUTRANS 24 california pepper tree 156 butylated hydroxytoluene(bht) 231 CAMBIA 235 BYDUREON 85 CAMILA 198 BYDUREON PEN 85 camphor 257 BYETTA 85 CAMRESE 198 BYSTOLIC 144 CAMRESE LO 198 BYVALSON 144 CANASA 182 candesartan cilexetil 240 C candesartan-hydrochlorothiazid 165 cabergoline 167 candida albicans 156 CABOMETYX 271,272 CANDIN 160 CADEAU DHA 47 cantaloupe 156 CADUET 106 cantharidin 272 CAFERGOT 7 CANTIL 64 caffeine 28 CAPACET 9 caffeine and sodium benzoate 28 CAPASTAT SULFATE 110 caffeine citrate 28 capecitabine 272 calamine 173 CAPEX SHAMPOO 247 CALAN 55 CAPHOSOL 272 CALAN SR 55 CAPITAL W-CODEINE 9 calcipotriene 257,272 CAPRELSA 272 calcipotriene monohydrate 272 caprylic acid 272 calcipotriene-betamethasone dp 247 capsaicin 257 calcipotriol 272 capsaicin palmitate 257 calcitonin-salmon 212 capsicum oleoresin 257 CALCITRENE 257 captopril 241 calcitriol 257,309 captopril-hydrochlorothiazide 165 calcitriol in almond oil 272 CARAC 257 calcium acetate 217 CARAFATE 133 calcium amino acid chelate 170 carbachol 97 calcium carbonate 170 CARBAGLU 169 calcium chloride 170 carbamazepine 69 calcium citrate 170 carbamazepine er 69 calcium disodium versenate 219 carbamide peroxide 40 calcium glubionate 170 CARBATROL 69 calcium gluconate monohydrate 170 carbidopa 149 calcium levulinate dihydrate 170 carbidopa-levodopa 111 calcium pantothenate 307 carbidopa-levodopa er 111 calcium phosphate 170 carbidopa-levodopa-entacapone 111 calcium saccharate 170 carbimazole 264 carbinoxamine maleate 100 cefadroxil 151 CARBOCAINE 272 cefazolin sodium 151 CARDENE SR 147,272 cefdinir 152 cardioplegia high potassium 170 cefditoren pivoxil 152 cardioplegic 170 cefepime hcl 152 CARDIOTEK-RX 307 cefixime 152 CARDIOVID PLUS 231 CEFOTAN 152 CARDIZEM 55 cefotaxime sodium 152 CARDIZEM CD 55 cefotetan 152 CARDIZEM LA 55 cefpodoxime proxetil 152 CARDURA 6 cefprozil 152 CARDURA XL 6 ceftazidime 152 carelessweed 156 ceftazidime-sodium carbonate 152 carisoprodol 245 ceftibuten 152 carisoprodol compound 238 CEFTIN 152 carisoprodol compound-codeine 14 ceftriaxone 152,153 carisoprodol-aspirin 238 ceftriaxone sodium 153 carisoprodol-aspirin-codeine 14 cefuroxime 152 CARNITOR 231 CELEBREX 235 CARNITOR SF 231 celecoxib 235 carrasyn hydrogel wound 272 CELESTONE 191 carteolol hcl 96 CELEXA 77 CARTIA XT 55 CELLCEPT 229 carvedilol 7 CELLUGEL 179 cascara sagrada 184 CELONTIN 74 casein 156 CEM-UREA 254 CASODEX 272 CENTANY 37 CATAPRES 215 CENTANY AT 37 CATAPRES-TTS 1 215 CENTERGY 101 CATAPRES-TTS 2 215 CENTERGY DM 101 CATAPRES-TTS 3 215 cephalexin 151 catheter 272 CERAMAX 272 CATHFLO ACTIVASE 128 CERDELGA 231 cattle epithelium 156 CEREBYX 74 CAVERJECT 305 CERVARIX 130 CAYSTON 219 CERVIDIL 272 CAZIANT 198 CESAMET 90 cedar elm 156 cesium chloride 272 CEDAX 152,272 CETACAINE 252 cefaclor 152 cetirizine hcl 100 cefaclor er 152 CETRAXAL 34 CETROTIDE 226 chromium picolinate 273 cetyl myristoleate 272 chromium polynicotinate 273 cetylpyridinium chloride 273 chrysin 273 cevimeline hcl 142 chymotrypsin 273 CHANTIX 142 CIALIS 304,305 CHATEAL 198 CICLODAN 95 CHEMET 219 ciclopirox 95 CHENODAL 185 ciclopirox olamine 95 chicken meat 156 CIDALEAZE 252 chloral hydrate 138 cidofovir 136 chlorambucil 273 cilostazol 127 chloramphenicol 58 CILOXAN 34 chloramphenicol palmitate 58 cimetidine 132 chlordiazepoxide hcl 141 CIMZIA 185 chlordiazepoxide-amitriptyline 80 CIPRO 58 chlordiazepoxide-clidinium 64 CIPRO HC 34 chlorhexidine gluconate 37,40 CIPRO XR 58 chloroacetic acid 273 CIPRODEX 34 chlorobutanol 273 ciprofloxacin 59 chloroform 188 ciprofloxacin er 59 chloroprocaine hcl 273 ciprofloxacin hcl 34,59 chloroquine phosphate 112 citalopram hbr 77 chlorothiazide 164 citrate phosphate dextrose 67 chloroxine 273 citric acid 273 chloroxylenol 273 citrus bergamot 273 chlorpheniramine maleate 100 cladosporium cladosporioides 156 chlorpromazine hcl 122 cladosporium sphaerospermum 156 chlorpropamide 87 CLAFORAN 153 chlorthalidone 164 CLARAVIS 257 chlorzoxazone 245,273 CLARIFOAM EF 40 CHOLBAM 185 CLARINEX 100,101 cholesterol 273 CLARINEX-D 12 HOUR 101 cholestyramine 104 clarithromycin 58,110 cholestyramine light 104 clarithromycin er 110 cholestyramine resin 104 CLEANSING WASH 40 choline bitartrate 187 clemastine fumarate 100 choline mag trisalicylate 238 clemizole hcl 273 choline magnesium trisalicylat 238 CLEOCIN 37 chondroitin sulfate 231 CLEOCIN HCL 62 chondroitin sulfate sodium 232 CLEOCIN PALMITATE 62 chorionic gonadotropin 210 CLEOCIN PHOSPHATE 62 CLEOCIN T 37 clotrimazole 93,94 clever choice holding chamber 273 clotrimazole-betamethasone 94 clever choice nebulizer 273 clozapine 114,115 clever choice whisper aire ped 273 clozapine odt 115 clidinium bromide 64 CLOZARIL 115 CLIMARA 174 CNL 8 95 CLIMARA PRO 174 coaguchek xs 273 CLINDACIN ETZ 37,38 coal tar 256 CLINDACIN P 38 COARTEM 112 CLINDACIN PAC 38 cobalt gluconate 273 CLINDAGEL 38 cobamamide 307 clindamax 38 cocaine hcl 180 clindamycin hcl 62 cocklebur 156 clindamycin palmitate hcl 62 cocoa bean 156 clindamycin pediatric 62 codeine phosphate 14 clindamycin phos-benzoyl perox 38 codeine sulfate 14 clindamycin phos-tretinoin 38 coenzyme q10 232 clindamycin phosphate 38,62 COGENTIN 67 clindamycin-benzoyl peroxide 38 COLAZAL 182 CLINDESSE 38 colchicine 220 CLINPRO 5000 222 COLCRYS 220 clioquinol 93 COLESTID 104 clobetasol emollient 248 colestipol hcl 104 clobetasol emulsion 248 colistimethate 63 clobetasol propionate 248 colistimethate sodium 63 clobetasol propionate micro 248 colistin sulfate 63 CLOBEX 248 collagenase 257 clocortolone pivalate 248 COLOCORT 248 CLODAN 248 COLY-MYCIN M PARENTERAL 63 CLODERM 248 COLY-MYCIN S 34 clofazimine 110 COLYTE WITH FLAVOR PACKETS 184 clomiphene citrate 174 COMBIGAN 96 clomipramine hcl 80 COMBIPATCH 174 clonazepam 73 COMBIVENT RESPIMAT 5 clonidine 216 COMBIVIR 124 clonidine hcl 216 COMETRIQ 273,274 clonidine hcl er 216 comp-air elite compressor syst 274 clopidogrel 127 comp-air nebulizer compressor 274 clopidogrel bisulfate 127 compact space chamber 274 clorazepate dipotassium 73 COMPAZINE 90 CLORPRES 167 COMPLERA 123 COMPOUND 347 188 COUMADIN 67 COMPRO 90 coumarin 232 COMTAN 111 COVARYX 174 conception 274 COVARYX H.S. 175 CONCERTA 28 COZAAR 240 CONDYLOX 257 crab 157 CONRAY 161 creatine 274 CONSTULOSE 169 creatine monohydrate 274 CONTRAVE 25 creatinine 274 CONZIP 14 CREON 185 COPAXONE 227 CRESEMBA 92 COPEGUS 136 CRESTOR 106 copper peptide ghk-cu 274 CRINONE 214 CORDARONE 54 CRIXIVAN 125 CORDRAN 248 CROFAB 128 COREG 7 cromolyn sodium 47 COREG CR 7,8 crotamiton 43 CORGARD 53 cryoserv 232 CORLANOR 148 CRYSELLE 198 CORMAX 248 CUPRIMINE 224 corn pollen 156 curafil 274 corn smut 157 curcumin 232 CORTANE-B 43 curity 274 CORTEF 191 curity amd 40,274 CORTENEMA 248 curity iodoform 274 corticotrophin 155 CUROSURF 243 CORTIFOAM 248 curvularia 157 cortisone acetate 191 CUTIVATE 248 CORTISPORIN 38 CUVPOSA 64 CORTISPORIN-TC 34 cyanocobalamin 307 CORTROSYN 155 cyanocobalamin injection 307 CORZIDE 53 CYCLAFEM 198 COSENTYX (2 SYRINGES) 257 cyclandelate 148 COSENTYX PEN 257 CYCLESSA 198 COSENTYX PEN (2 PENS) 257 cyclobenzaprine hcl 245 COSENTYX SYRINGE 257 cyclodextrin-beta 274 COSOPT 96 CYCLOGYL 181 COSOPT PF 96 CYCLOMYDRIL 181 cosyntropin 155 cyclopentolate hcl 181 COTELLIC 274 cyclopentolate-lidoc-pe-tropic 180 COTEMPLA XR-ODT 274 cyclopentolate-tropicamide-pe 181 cyclophosphamide 229 DDAVP 99,213 cyclophosphamide monohydrate 229 DEBACTEROL 258 cycloserine 110 DEBLITANE 198 CYCLOSET 167 deferoxamine mesylate 219 cyclosporine 224,229 dehydroepiandrosterone 194 cyclosporine modified 224 DELATESTRYL 194 CYMBALTA 76 DELESTROGEN 175 cyproheptadine hcl 100 DELTASONE 191 CYRED 198 DELYLA 199 CYSTADANE 232 DELZICOL 182 CYSTAGON 232 DEMADEX 163 CYSTARAN 179 demecarium bromide 274 cysteamine hcl 232 demeclocycline hcl 60 CYSTOGRAFIN 162 DEMEROL 14,15 CYSTOGRAFIN-DILUTE 162 DEMSER 232 cytarabine 274 DENAVIR 39 CYTOMEL 265 DENTA 5000 PLUS 222 CYTOTEC 132 DENTAGEL 222 CYTRA-2 168 deoxycholic acid 274 CYTRA-3 168 DEPADE 151 CYTRA-K 168 DEPAKENE 69 DEPAKOTE 69 D DEPAKOTE ER 69 d-ribose 169 DEPAKOTE SPRINKLE 69 d.farinae mite extract 157 DEPEN 224 D.H.E.45 7 DEPO-ESTRADIOL 175 d.pteronyssinus mite extract 157 DEPO-MEDROL 191 DAKLINZA 190 DEPO-PROVERA 214 DALIRESP 243 DEPO-SUBQ PROVERA 104 214 danazol 194 DEPO-TESTOSTERONE 194 DANTRIUM 246 DERMA-SMOOTHE-FS 248 dantrolene sodium 246 DERMAGRAFT 274 dapiprazole hcl 274 DERMATOP 248 dapsone 110,258 DERMAZENE 40 DAPTACEL DTAP 129 DERMOTIC 44 darifenacin er 188 DESCOVY 124 DASETTA 198 DESFERAL 220 DAXBIA 151 DESFERAL MESYLATE 220 DAYPRO 235 desipramine hcl 80 DAYSEE 198 desloratadine 101 DAYTRANA 28 desmopressin acetate 99,213 DESOGEN 199 dhea micronized 194 desogestr-eth estrad eth estra 199 DIABETA 87 desogestrel-ethinyl estradiol 199 DIALYVITE 800 WITH IRON 47 DESONATE 248 diaminopyridine 232 desonide 248 DIAMOX SEQUELS 97 desonide micronized 248 DIASTAT 73 DESOWEN 248 DIASTAT ACUDIAL 73 desoximetasone 248 diazepam 73 desoxycorticosterone acetate 191 diazoxide 102 DESOXYN 26 DIBENZYLINE 7 desvenlafaxine er 76 dibucaine 275 desvenlafaxine fumarate er 76 dibucaine hcl 252 desvenlafaxine succinate er 76 dibutyl squarate 232 DETROL 188 dichloralphenazone 138 DETROL LA 188 dichloroacetic acid 275 devil's claw 275 DICLEGIS 90 devilbiss traveler 275 diclofenac potassium 235 dexamethasone 191 diclofenac sodium 46,235,258 dexamethasone acetate 191 diclofenac sodium er 235 dexamethasone acetate micro 191 diclofenac sodium micronized 235 DEXAMETHASONE INTENSOL 191 diclofenac sodium-misoprostol 132 dexamethasone isonicotinate 191 dicloxacillin sodium 239 dexamethasone micronized 191 dicumarol 67 dexamethasone sodium phosphate 44,191 dicyclomine hcl 64 dexchlorpheniramine maleate 275 didanosine 124 dexcom g4 275 diethanolamine 275 dexcom g5 275 diethylcarbamazine citrate 32 dexcom g5-g4 sensor 275 diethylen glycol m-ethyl ether 275 DEXEDRINE 26,27 diethylpropion hcl 25 DEXERYL 173 diethylpropion hcl er 25 DEXILANT 133 diethylstilbestrol 175 dexmethylphenidate hcl 29 DIFFERIN 258 dexmethylphenidate hcl er 29 DIFICID 218 DEXPAK 191 diflorasone diacetate 248 dexpanthenol 275 DIFLUCAN 92 dextroamphetamine sulfate 27 diflunisal 235 dextroamphetamine sulfate er 27 DIGITEK 51 dextroamphetamine-amphet er 27 DIGOX 51 dextroamphetamine-amphetamine 27 digoxin 51 dextromethorphan hbr 243 dihydrocodeine bitartrate 15 dextrose 169 dihydroergotamine mesylate 7 diindolylmethane 275 DIVIGEL 175 diiodo-l-thyronine 275 dmae 275 DILANTIN 52 dmsa 220 DILANTIN-125 52 docosanol 39 DILATRATE-SR 303 docusate sodium 184 DILAUDID 15 dofetilide 54 DILAUDID-HP 15 dog epithelium extract 157 DILT-XR 55 dog fennel 157 diltiazem 12hr er 55 DOLOPHINE HCL 15 diltiazem 24hr cd 55 donepezil hcl 142 diltiazem 24hr er 55,56 donepezil hcl odt 142 diltiazem er 56 DONNATAL 64 diltiazem hcl 56 dopamine hcl 144 DILUENT FOR ROTARIX 275 DORAL 141 DILUENT-MERCK LIVE VIRUS VACC 275 DORYX 60 DILUTING MEDIUM FOR NOVOLOG 275 DORYX MPC 60 dimenhydrinate 91,100 dorzolamide hcl 97 dimercaptopropanesulfonate sod 275 dorzolamide-timolol 96 dimethyl sulfone 275 DOTHELLE DHA 47 dimethyl sulfoxide 275 dover advantage 275 dimethylacetamide 275 dover advantage drainage 275 dinitrochlorobenzene 275 dover coated latex foley 275 DIOVAN 240 dover latex foley catheter 276 DIOVAN HCT 165 dover premium 276 DIPENTUM 182 dover red rubber robibson cath 276 diphenhydramine hcl 100 dover universal 276 diphenidol hcl 90 DOVONEX 258 diphenoxylate-atropine 64 doxazosin mesylate 6 diphenylcyclopropenone 275 doxepin hcl 81,252 diphtheria-tetanus toxoids-ped 129 doxercalciferol 309 DIPROLENE 248 doxycycline hyclate 34,60,61 DIPROLENE AF 249 doxycycline ir-dr 61 dipyridamole 127 doxycycline monohydrate 61 DISALCID 238 doxylamine succinate 100 DISCOVISC 275 drechslera 157 disopyramide phosphate 51 DRISDOL 309 disulfiram 219 DRITHOCREME HP 256 DITROPAN XL 188,189 dronabinol 90 DIURIL 164 droperidol 138 divalproex sodium 69 drospirenone-eth estra-levomef 199 divalproex sodium er 69 drospirenone-ethinyl estradiol 199 DROXIA 276 EC-NAPROSYN 221 DRYSOL 253 eclipse needle 276 DUAC 38 eclipse syringe 276 DUAVEE 174 econazole nitrate 94 DUETACT 87 ECOZA 94 DUEXIS 132 ED-SPAZ 65 DULERA 5 EDARBI 240 duloxetine hcl 76 EDARBYCLOR 167 DUODOTE 65 EDECRIN 163 DUOPA 111 edetate calcium disodium 220 DUOVISC 276 edetate disodium 232 DUPIXENT 258 EDEX 305 DURAGESIC 15 EDLUAR 138 DURAMORPH 15 edrophonium chloride 161 DUREZOL 44 EDURANT 123 DURLAZA 127 EEMT 175 dutasteride 219 EEMT H.S. 175 dutasteride-tamsulosin 8 EFFER-K 170 DUTOPROL 53 EFFEXOR XR 76 DYANAVEL XR 27 EFFIENT 127 DYAZIDE 163 EFUDEX 258 dyclonine hcl 180 egcg 276 DYMISTA 102 egg white 157 dyphylline 145 EGRIFTA 263 DYRENIUM 163 ELDEPRYL 76 DYSPORT 232 ELDERCAPS 306 ELESTAT 178 E ELESTRIN 175 E-Z DISK 162 ELETONE 173 e-z spacer 276 eletriptan hbr 108 e-z spacer pedspak 276 ELIDEL 229 E-Z-CAT 162 ELIGARD 210 E-Z-HD 162 ELIMITE 43 E-Z-PAQUE 162 ELINEST 199 E-Z-PASTE 162 ELIPHOS 217 E.E.S. 200 58 ELIQUIS 67 E.E.S. 400 58 ELITE OB DHA 306 ear popper 276 ELITE-OB 306 easivent 276 ELITE-OB 400 47 eastern cottonwood 157 ELIXOPHYLLIN 146 ebase controller 276 ELLA 199 ELMIRON 234 ENVARSUS XR 230 ELOCON 249 EPANED 241 EMADINE 178 EPCLUSA 189 EMBEDA 15 ephedrine hcl 3 EMCYT 276 ephedrine sulfate 3 EMEND 90,276 EPICERAM 276 EMFLAZA 191 epicoccum 157 EMLA 252 EPIDUO 258 EMOQUETTE 199 EPIDUO FORTE 258 EMSAM 76 EPIFIX AMNIOTIC MEMBRANE 232 EMTRIVA 124 EPIFOAM 249 EMULSION SB 276 epinastine hcl 178 EMVERM 31 epinephrine 3 ENABLEX 189 epinephrine bitartrate 3 enalapril maleate 241 epinephrine hcl 3 enalapril-hydrochlorothiazide 165,166 EPINEPHRINESNAP-V 3 ENBREL 224 EPIPEN 3 ENDARI 186 EPIPEN 2-PAK 3 ENDO-AVITENE 99 EPIPEN JR 2-PAK 3 ENDOCET 9 EPISIL 276 ENDOFORM 276 EPISNAP 4 ENDOMETRIN 214 EPITOL 69 ENGERIX-B ADULT 130 EPIVIR 124 ENGERIX-B PEDIATRIC-ADOLESCENT 130 EPIVIR HBV 124 english plantain 157 eplerenone 165 ENJUVIA 175 EPOGEN 144 enlite 276 eprosartan mesylate 240 enlite glucose sensor 276 EPY 4 ENLON 161 EPZICOM 124 enoxaparin sodium 68 EQUETRO 69 ENPRESSE 199 erapid nebulizer 276 ENSKYCE 199 erapid nebulizer handset 276 ENSTILAR 249 ergocalciferol 309 entacapone 111 ergoloid mesylates 7 entecavir 136 ERGOMAR 7 ENTEREG 186 ergotamine tartrate 7 ENTERO VU 162 ergotamine-caffeine 7 ENTOCORT EC 191 ERIVEDGE 276 ENTRESTO 242 ERRIN 199 ENTTY 276 ERTACZO 94 ENULOSE 169 ERWINAZE 277 ERY 38 ethyl oleate 277 ERY-TAB 58 ethynodiol-ethinyl estradiol 200 ERYGEL 38 etidronate disodium 222 ERYPED 200 58 etodolac 235 ERYPED 400 58 etodolac er 235 ERYTHROCIN STEARATE 58 etomidate 188 erythromycin 34,38,58,218 etoposide 277 erythromycin estolate 218 EUCRISA 249 erythromycin ethylsuccinate 58,218 EURAX 43 erythromycin-benzoyl peroxide 38 EVAMIST 176 ESBRIET 242 EVARREST 99 ESCAVITE LQ 47 EVEKEO 27 escitalopram oxalate 77 EVICEL 99 ESGIC 9 EVISTA 174 esomeprazole magnesium 133 EVOCLIN 38 esomeprazole strontium 133 EVOTAZ 125 ESTARYLLA 199 EVOXAC 143 estazolam 141 EVZIO 151 ESTRACE 175 EXALGO 15 estradiol 175 EXELDERM 94 estradiol benzoate 176 EXELON 143 estradiol cypionate 176 exemestane 277 estradiol micronized 176 EXFORGE 147 estradiol valerate 176 EXFORGE HCT 147 estradiol-norethindrone acetat 176 EXJADE 277 ESTRING 176 EXODERM 93 estriol 176 EXPAREL 277 estriol micronized 176 EXTAVIA 227 ESTROGEL 176 EXTINA 94 estrogen-methyltestosterone 176 EYLEA 179 estrone 176 EZ FLU 16-17 (FLUZON QUAD PED) 130 estropipate 176 EZ FLU 2016-2017 (AFLURIA) 130 ESTROSTEP FE 200 EZ FLU 2016-2017 (FLUVIRIN) 130 eszopiclone 139 EZ USE JOINT-TUNNEL-TRIGGER 191 ethacrynic acid 163 ezetimibe 104 ethambutol hcl 110 ezetimibe-simvastatin 104 ethinyl estradiol 176 ethosuximide 74 F ethoxy diglycol 277 FABIOR 258 ethyl acetate 277 FACTIVE 59 ethyl chloride 252 FALMINA 200 famciclovir 136 ferrous gluconate 47 famotidine 132 ferrous sulfate 47 FAMVIR 136 FETZIMA 77 FANAPT 115 FEXMID 246 FARESTON 277 fexofenadine hcl 101 FARXIGA 87 fexofenadine-pse er 277 FARYDAK 277 FIBRICOR 105 FASLODEX 277 filter needle 277 FAYOSIM 200 filter, valve set for ll & lc 278 FAZACLO 115 FINACEA 258 felbamate 69 finasteride 219,258 FELBATOL 69 FIORICET 9 FELDENE 235 FIORICET WITH CODEINE 9 felodipine er 146 FIORINAL 127 FEM PH 40 FIORINAL WITH CODEINE #3 16 female self catheter 277 FIRAZYR 224 FEMARA 277 fire ant 157 femcap 277 FIRMAGON 227 FEMCON FE 200 FLAGYL 112 FEMHRT 176 FLAGYL ER 112 FEMRING 176 FLAREX 44 FEMYNOR 200 flavoxate hcl 189 fenofibrate 105 flecainide acetate 52 fenofibric acid 105 FLECTOR 236 FENOGLIDE 105 flexichamber 278 fenoprofen calcium 236 flexichamber mask 278 FENORTHO 236 flibanserin 149 fentanyl 16 FLO-PRED 191 fentanyl base 16 FLOMAX 8 fentanyl citrate 16 FLOVENT DISKUS 153 fentanyl-bupivacaine-0.9% nacl 16 FLOVENT HFA 153 FENTORA 16 FLOWTUSS 243 FEROCON 47 FLOXIN 34 FEROTRINSIC 47 floxuridine 278 FERREX 150 FORTE 47 FLUAD 2016-2017 130 ferric ammonium citrate 277 FLUAD 2017-2018 278 ferric subsulfate 277 FLUARIX QUAD 2016-2017 130 ferric sulfate 47 FLUARIX QUAD 2017-2018 278 FERRIPROX 277 FLUBLOK 2016-2017 130 FERROCITE PLUS 47 FLUBLOK 2017-2018 278 ferrous fumarate 47 FLUBLOK QUAD 2017-2018 278 FLUCAINE 161 flutamide 278 FLUCELVAX QUAD 2016-2017 130 fluticasone propionate 44,192,249 FLUCELVAX QUAD 2017-2018 278 fluticasone propionate micro 192 fluconazole 92 fluticasone-salmeterol 5 flucytosine 93 flutter 278 fludrocortisone acetate 191 fluvastatin er 106 FLULAVAL QUAD 2016-2017 130 fluvastatin sodium 106 FLULAVAL QUAD 2017-2018 278 FLUVIRIN 2016-2017 130 FLUMADINE 134 FLUVIRIN 2017-2018 278 flumazenil 149 fluvoxamine maleate 78 flunisolide 44,192 fluvoxamine maleate er 78 fluocinolone acetonide 249 FLUZONE HIGH-DOSE 2016-2017 130 fluocinolone acetonide oil 44 FLUZONE HIGH-DOSE 2017-2018 278 fluocinonide 249 FLUZONE INTRADERM QUAD 2016-17 130 fluocinonide micronized 249 FLUZONE INTRADERM QUAD 2017-18 278 fluocinonide-e 249 FLUZONE QUAD 2016-2017 130 FLUOR-A-DAY 223 FLUZONE QUAD 2017-2018 278 FLUOR-I-STRIP AT 161 FLUZONE QUAD PEDI 2016-2017 130 FLUORABON 223 FLUZONE QUAD PEDI 2017-2018 278 fluorescein powder 161 FML 44 fluorescein-benoxinate 180 FML FORTE 44 fluorescein-proparacaine 161 FML S.O.P. 44 fluoride 223 FOCALGIN 90 DHA 47 FLUORIDEX 223 FOCALGIN CA 47 FLUORIDEX DAILY DEFENSE 223 FOCALGIN DSS 47 FLUORIDEX SENSITIVITY RELIEF 223 FOCALIN 29 FLUORITAB 223 FOCALIN XR 29 fluorometholone 44 FOLBECAL 170 FLUOROPLEX 258 FOLBEE 307 fluorouracil 258,278 FOLBEE AR 307 fluoxetine dr 77 FOLBEE PLUS CZ 307 fluoxetine hcl 77,78 FOLGARD OS 170 fluoxymesterone 194 FOLGARD RX 307 fluphenazine decanoate 122 folic acid 307 fluphenazine hcl 122 folic acid-vit b6-vit b12 307 FLURA-DROPS 223 FOLIVANE-PLUS 48 flurandrenolide 249 FOLLISTIM AQ 211 flurazepam hcl 141 FOLPLEX 2.2 307 flurbiprofen 236 fondaparinux sodium 68 flurbiprofen sodium 46 FORADIL 5 FLUROX 180 FORANE 188 FORFIVO XL 75 GAMASTAN S-D 128 FORMA-RAY 278 GAMMAKED 128 FORMADON 258 GAMUNEX-C 128 formaldehyde 258 ganirelix acetate 227 formoterol fumarate 5 GARDASIL 9 130 FORTAVIT 48 GASTROCROM 47 FORTAZ 153 GASTROGRAFIN 162 FORTEO 212 GASTROMARK 279 FORTESTA 194 gatifloxacin 34 FORTICAL 212 gatifloxacin sesquihydrate 34 FOSAMAX 222 GATTEX 186 FOSAMAX PLUS D 222 GAVILYTE-C 184 fosamprenavir calcium 125 GAVILYTE-G 184 fosinopril sodium 241 GAVILYTE-N 184 fosinopril-hydrochlorothiazide 166 GELCLAIR 279 FOSRENOL 217 GELFILM 179 FRAGMIN 68 gelfilm 279 freedom derma-d 279 GELFOAM 99,279 freedom precision airless 279 GELFOAM COMPRESSED 279 freestyle navigator 279 GELFOAM JMI 279 FROVA 108 GELNIQUE 189 frovatriptan succinate 108 GELX 279 FUL-GLO 161 gemfibrozil 105 FULYZAQ 183 GENADUR 279 FURADANTIN 32 GENERESS FE 200 furazolidone 32 GENERLAC 169 furosemide 163 GENGRAF 224 fusarium 157 GENOTROPIN 213 FUSION PLUS 48 GENTAK 34 FUSION SPRINKLES 48 gentamicin sulfate 34,38,57 FUZEON 123 GENVOYA 123 FYAVOLV 177 GEODON 115,116 FYCOMPA 70 german cockroach 157 GIANVI 200 G GIAZO 182 gabapentin 9 GILDAGIA 200 GABITRIL 70 GILDESS 200 galantamine er 143 GILDESS 24 FE 200 galantamine hbr 143 GILDESS FE 200 galantamine hydrobromide 143 GILENYA 228 GALZIN 279 GILOTRIF 279 ginkgo biloba 232 GONAL-F 211 ginseng root 279 GONAL-F RFF 211 GLATOPA 228 GONAL-F RFF REDI-JECT 211 GLEEVEC 279 GONITRO 303 GLEOSTINE 279 GORDO-UREA 254 glimepiride 87 GRAFIX CORE 232 glipizide 87 GRAFIX PRIME 232 glipizide er 87 GRALISE 9,10 glipizide xl 88 gramicidin d 280 glipizide-metformin 82 granisetron hcl 89 GLUCAGEN 103 GRANIX 144 GLUCAGON EMERGENCY KIT 103 GRANULEX 258 glucagon hcl 103 GRASTEK 232 gluconolactone 279 GRIFULVIN V 91 GLUCOPHAGE 82,83 GRIS-PEG 91 GLUCOPHAGE XR 83 griseofulvin 91 glucosamine hcl 232 griseofulvin micronized 91 glucosamine sulfate kcl 232 griseofulvin ultramicrosize 91 glucosamine sulfate sodium 232 guaiacol 40 GLUCOTROL 88 guaifenesin 243 GLUCOTROL XL 88 guanabenz acetate 216 GLUCOVANCE 83 guanethidine hemisulfate 216 glutamine 186 guanfacine hcl 149 glutaraldehyde 279 guanfacine hcl er 149 glutathione 280 guanidine hcl 143 glutathione-l 280 guarana seed extract 280 glyburide 88 guardian link 3 280 glyburide micronized 88 guardian rt charger 280 glyburide-metformin hcl 83 guardian rt starter kit 280 glycine 280 guardian rt system 280 glycolic acid 280 guardian sensor 3 280 glycopyrrolate 65,280 guardian test plug 280 glycosaminoglycans 280 GYNAZOLE 1 94 glycyrrhizic acid 280 GLYDO 180 H GLYNASE 88 H.P. ACTHAR 155 GLYSET 81 hackberry 157 GLYXAMBI 84 HALCION 141 gold sodium thiomalate 225 HALDOL 121 goldenrod 157 HALDOL DECANOATE 100 121 GOLYTELY 184 HALDOL DECANOATE 50 121 halobetasol propionate 249 HUMALOG MIX 50-50 86 HALOG 249 HUMALOG MIX 50-50 KWIKPEN 86 haloperidol 121 HUMALOG MIX 75-25 86 haloperidol decanoate 121,122 HUMALOG MIX 75-25 KWIKPEN 86 haloperidol decanoate 100 122 HUMATROPE 213 haloperidol lactate 122 HUMIRA 186 HARVONI 190 HUMIRA PEDIATRIC CROHN'S 186 HAVRIX 130 HUMIRA PEN 186 HEATHER 200 HUMIRA PEN CROHN-UC-HS STARTER 186 HECTOROL 309 HUMIRA PEN PSORIASIS-UVEITIS 186 HEMABATE 280 HUMULIN R U-500 86 HEMANGEOL 53 HUMULIN R U-500 KWIKPEN 86 HEMATINIC PLUS 48 hyaluronic acid 280 HEMATINIC WITH FOLIC ACID 48 hyaluronic acid sodium salt 280 HEMATRON-AF 48 hyaluronidase 280 HEMAX 48 HYCAMTIN 281 HEMMOREX-HC 249 HYCET 10 HEMOCYTE PLUS 48 HYCOFENIX 4 HEMOCYTE-F 48 hydralazine hcl 216 heparin sodium 68 hydrazine sulfate 281 HEPSERA 136 HYDREA 281 HETLIOZ 139 HYDRO 35 254 HEXALEN 280 HYDRO 40 254 HIBERIX 130 hydrochloric acid 185 HIPREX 32 hydrochlorothiazide 164 histamine phosphate 280 hydrocod-cpm-pseudoephedrine 16 histidine hcl 280 hydrocodone bitartrate 16 HIZENTRA 128 hydrocodone-acetaminophen 10 HOMATROPAIRE 181 hydrocodone-chlorpheniramne er 101 homatropine hydrobromide 181 hydrocodone-homatropine mbr 65 homatropine methylbromide 181 hydrocodone-ibuprofen 16 home nebulizer plus sidestream 280 hydrocortisone 192,249 honey bee venom protein 157 hydrocortisone acetate 249 HORIZANT 10 hydrocortisone butyrate 250 horse epithelium 157 hydrocortisone valerate 250 HPR 280 hydrocortisone-acetic acid 37 HPR PLUS 280 hydrocortisone-iodoquinol 40 HUMALOG 86 hydrocortisone-iodoquinol-aloe 40 HUMALOG JUNIOR KWIKPEN 280 hydrocortisone-pramoxine 250 HUMALOG KWIKPEN U-100 86 hydrocortisone-pramoxine hcl 250 HUMALOG KWIKPEN U-200 86 hydrofera blue 281 hydrofera blue ready 281 IC GREEN 160 hydrogen peroxide 281 ICAR-C PLUS 48 HYDROMET 65 ichthammol 282 hydromorphone er 16 ICLUSIG 282 hydromorphone hcl 16,17 idebenone 149 hydroquinone 154 idoxuridine 36 hydroxocobalamin 307 ILARIS 232 hydroxyamphetamine hbr 181 ILEVRO 46 hydroxychloroquine sulfate 112 ILOTYCIN 34 hydroxyethyl methacrylate 281 IMBRUVICA 282 hydroxyprogesterone caproate 214 imipramine hcl 81 hydroxypropy-beta-cyclodextrin 281 imipramine pamoate 81 hydroxytryptophan 281 imiquimod 258,259 hydroxyurea 281 IMITREX 108 hydroxyzine hcl 139 IMOGAM RABIES-HT 129 hydroxyzine pamoate 139 IMOVAX RABIES VACCINE 130 HYGEL 281 IMPAVIDO 113 HYLATOPIC 281 IMURAN 225 HYLATOPICPLUS 281 INCRELEX 263 HYOPHEN 32 INCRUSE ELLIPTA 65 hyoscyamine sulfate 65 indapamide 164 hyoscyamine sulfate er 65 INDERAL LA 53 hyoscyamine sulfate sr 65 INDERAL XL 53 HYOSYNE 65 INDICLOR 282 HYPER-SAL 171 INDIGO CARMINE 161 HYPERHEP B S-D 128 indigotindisulfonate sod-water 161 HYPERRAB S-D 128 INDIOMIN MB 32 HYPERRHO S-D 128 INDOCIN 221 HYPERTET S-D 128 indocyanine green 160 hypodermic needle 281 indole-3-carbinol 233 HYQVIA 129 indomethacin 221,236 HYQVIA HY COMPONENT 281 indomethacin er 221 HYQVIA IG COMPONENT 129 INFANRIX DTAP 129 HYSINGLA ER 17 INFASURF 243 HYZAAR 166 INFED 48 INFUMORPH 17 I INGREZZA 149,282 ibandronate sodium 222 INLYTA 282 IBRANCE 281 INNOPRAN XL 53 IBUDONE 17 innospire deluxe 282 ibuprofen 236 innospire elegance 282 innospire essence 282 ISENTRESS HD 123 innospire mini 282 ISIBLOOM 201 innospire replacement filter 282 ISOCHRON 304 inositol 282 isoflurane 188 inspirachamber 282 isoleucine 283 inspiration 282 isomethept-caff-acetaminophen 10 inspiration elite 282 isomethept-dichloralp-acetamin 10 inspiration elite filter 283 isometheptene mucate 143 INSPRA 165 isoniazid 110 insulin syringe 283 isopropamide iodide 283 insulin syringe u-500 283 isopropyl myristate 283 INTELENCE 123 isoproterenol hcl 4,283 INTERMEZZO 139 ISOPTO ATROPINE 181 INTRAROSA 192 ISOPTO CARPINE 97 INTRON A 134 ISORDIL 304 INTROVALE 200 ISORDIL TITRADOSE 304 INTUNIV 150 isosorbide 304 INVANZ 218 isosorbide dinitrate 304 INVEGA 116 isosorbide mononitrate 304 INVEGA SUSTENNA 116 isosorbide mononitrate er 304 INVEGA TRINZA 116,117 isotretinoin 259 INVIRASE 125 ISOVUE-200 162 INVOKAMET 83 isoxsuprine hcl 305 INVOKAMET XR 83 isradipine 146 INVOKANA 87 ISTALOL 97 iodine 41 ISUPREL 4 iodochlorohydroxyquinoline 93 itraconazole 92 IODOFLEX 41 itraconazole micronized 92 iodoform 283 ivermectin 31 iodoquinol 112 IXIARO 130 IODOSORB 41 iopanoic acid 283 J IOPIDINE 179 JADENU 283 IPOL 130,283 JADENU SPRINKLE 283 ipratropium bromide 65,179 JAKAFI 283 ipratropium-albuterol 5 JALYN 8 irbesartan 240 JANTOVEN 67 irbesartan-hydrochlorothiazide 166 JANUMET 83 IRENKA 77 JANUMET XR 83 IRESSA 283 JANUVIA 84 ISENTRESS 123 JARDIANCE 87 JENCYCLA 201 KELNOR 1-35 201 JENTADUETO 83 KENALOG 250 JENTADUETO XR 83 KENALOG-10 192 jetco-spray cannula 283 KENALOG-40 192 JETREA 179 kendall 0.9% nacl with cap 283 JEVANTIQUE LO 177 kenguard 284 JINTELI 177 KEPPRA 70 johnson grass 157 KEPPRA XR 70 JOLESSA 201 KERAFOAM 254 JOLIVETTE 201 KERALAC 254 JUBLIA 94 KERALYT 254 JULEBER 201 kerlix amd 41 JUNEL 201 kerlix amd bandage 41 JUNEL FE 201 KERYDIN 95 JUNEL FE 24 201 KETALAR 188 JUXTAPID 103 ketamine hcl 188 ketamine hydrochloride 188 K KETEK 218 K EFFERVESCENT 171 ketoconazole 92,94 K-PHOS NEUTRAL 168 ketoconazole micronized 92 K-PHOS NO.2 168 ketoprofen 236 K-PHOS ORIGINAL 168 ketoprofen micronized 236 K-SOL 171 ketorolac tromethamine 46,236 K-TAB ER 171 ketotifen fumarate 100 KADIAN 17 KEVEYIS 233 KAITLIB FE 201 KEVZARA 225 KALBITOR 224 KHEDEZLA 77 KALETRA 126 KIMIDESS 201 KALYDECO 154 KINERET 225 kanamycin sulfate 57 KINEVAC 161 kangaroo 924 safety screw 283 KINRIX 131 kangaroo epump set 283 KIONEX 217 kangaroo gravity set 283 KISQALI 284 kapok 157 KISQALI FEMARA CO-PACK 284 KAPVAY 216 KITABIS PAK 57 karaya gum 184 KLARON 41 KARBINAL ER 100 KLOFENSAID II 236 KARIVA 201 KLONOPIN 73,74 KAYEXALATE 217 KLOR-CON 171 KAZANO 83 KLOR-CON 10 171 KEFLEX 151 KLOR-CON 8 171 KLOR-CON M10 171 LAMICTAL ODT 70 KLOR-CON M15 171 LAMICTAL ODT (BLUE) 70 KLOR-CON M20 171 LAMICTAL ODT (GREEN) 70 KLOR-CON SPRINKLE 171 LAMICTAL ODT (ORANGE) 70 KLOR-CON-EF 171 LAMICTAL XR 70 kochia 157 LAMICTAL XR (BLUE) 70 kojic acid 284 LAMICTAL XR (GREEN) 70 KOMBIGLYZE XR 83 LAMICTAL XR (ORANGE) 70 KORLYM 82 LAMISIL 91 KRISTALOSE 169 lamivudine 124 KURVELO 201 lamivudine hbv 124 KUVAN 233 lamivudine-zidovudine 125 KYNAMRO 103 lamotrigine 70 lamotrigine (blue) 70 L lamotrigine (green) 70 l-5 methyltetrahydrofolate cal 308 lamotrigine (orange) 70 l-alanine 169 lamotrigine er 70 l-aspartic acid 284 lamotrigine odt 70 l-carnitine 233 lamotrigine odt (blue) 71 l-citrulline 170 lamotrigine odt (green) 71 l-cysteine hydrochloride 170 lamotrigine odt (orange) 71 l-glutamic acid 284 LANOXIN 51 l-glutamine 187 LANOXIN PEDIATRIC 51 l-histidine 285 lansoprazol-amoxicil-clarithro 133 l-isoleucine 285 lansoprazole 133 l-leucine 170 lanthanum carbonate 217 l-methionine 285 LANTUS 86 l-methylfolate calcium 308 LANTUS SOLOSTAR 86 l-proline 285 LARIN 202 l-serine 285 LARIN 24 FE 202 l-theanine 233 LARIN FE 202 l-threonine 285 LARISSIA 202 labetalol hcl 8 LASIX 163 LACRISERT 179 LASTACAFT 178 lactic acid 173,254 latanoprost 98 lactulose 169 LATISSE 98 lamb's quarters 157 LATRIX 254 LAMICTAL 70 LATUDA 117 LAMICTAL (BLUE) 70 LAYOLIS FE 202 LAMICTAL (GREEN) 70 LAZANDA 17 LAMICTAL (ORANGE) 70 lc plus 285 lc sprint nebulizer 285 LEVORA-28 203 lc star 285 levorphanol tartrate 18 LEENA 202 levothyroxine sodium 265 leflunomide 225 LEVOXYL 265 LENVIMA 285 LEVSIN 65 LESCOL 106 LEVSIN-SL 65 LESCOL XL 106 LEVULAN 259 LESSINA 202 LEXAPRO 78 LETAIRIS 244 LEXIVA 126 letrozole 285 LIALDA 182 leucine 170 LIBRAX 65 leucovorin calcium 220,233 lidocaine 252,285 LEUKERAN 285 lidocaine hcl 52,180,252,285 LEUKINE 144 lidocaine hcl viscous 180 leuprolide acetate 211,285 lidocaine hcl-0.9% nacl 285 LEVACET 127 lidocaine hcl-epinephrine 263 levalbuterol concentrate 5 lidocaine-epinephrine 264 levalbuterol hcl 5 lidocaine-hydrocortisone 250 levalbuterol tartrate hfa 5 lidocaine-prilocaine 252 levamisole hcl 31 lidocaine-tetracaine 252 LEVAQUIN 59 LIDODERM 252 LEVATOL 148 LIDOPIN 252 LEVBID 65 LIDOPRIL 252 LEVEMIR 86 LIDORX 252 LEVEMIR FLEXTOUCH 86 LIDOTRAL 252 levetiracetam 71 LIDOVEX 252 levetiracetam er 71 LIDTOPIC MAX 252 LEVITRA 305 LILLOW 203 LEVO-T 265 LINCOCIN 62 levobunolol hcl 97 lincomycin hcl 62,63 levocarnitine 233 lindane 43 levocetirizine dihydrochloride 101 linezolid 63 levodopa 111 LINZESS 187 levofloxacin 34,59 liothyronine sodium 265 levofloxacin hemihydrate 59 LIPITOR 106 levomefolate calcium 308 LIPOFEN 105 levomefolate dha 48 lipoic acid 285 LEVONEST 202 LIQUID E-Z PAQUE 162 levonorg-eth estrad eth estrad 202 LIQUID POLIBAR PLUS 162 levonorgestrel 202 lisinopril 241 levonorgestrel-eth estradiol 202,203 lisinopril-hydrochlorothiazide 166 liteaire 285 LOTEMAX 44 litetouch 285 LOTENSIN 241 lithium 148 LOTENSIN HCT 166 lithium carbonate 149 LOTREL 147 lithium carbonate er 149 LOTRISONE 94 LITHOBID 149 LOTRONEX 182 LITHOSTAT 169 LOUTREX 286 LIVALO 106 lovastatin 106 LO LOESTRIN FE 203 LOVAZA 103 LOCOID 250 LOVENOX 68 LODINE 236 LOW-OGESTREL 203 LODOSYN 150 loxapine 113 LOESTRIN 203 LP LITE PAK 252 LOESTRIN FE 203 LUCENTIS 179 LOFIBRA 105 LUDENT FLUORIDE 223 lokara 250 LUGOL'S 41,91 LOMAIRA 25 LUMIGAN 98 LOMEDIA 24 FE 203 LUMINAL SODIUM 286 LOMOTIL 65 LUNESTA 139 lomustine 285 LUPANETA PACK 211 LONSURF 285,286 LUPRON DEPOT 211 loperamide 183 LUPRON DEPOT (LUPANETA) 211 LOPID 105 LUPRON DEPOT-PED 211 lopinavir-ritonavir 126 lutein 286 LOPREEZA 177 LUTERA 203 LOPRESSOR 53 LUXAMEND 173 LOPRESSOR HCT 53 LUXIQ 250 LOPROX 95 LUZU 94 loratadine 101 lycopene 233 loratadine micronized 101 LYMPHAZURIN 161 lorazepam 74 LYNPARZA 286 LORAZEPAM INTENSOL 74 LYRICA 71 LORCET 10 lysine hcl 170 LORCET HD 11 LYSIPLEX PLUS 170 LORCET PLUS 11 LYSODREN 286 LORTAB 11 LYSTEDA 99 LORYNA 203 LYZA 204 LORZONE 246 losartan potassium 240 M losartan-hydrochlorothiazide 166 maca root 286 LOSEASONIQUE 203 MACNATAL CN DHA 48 MACROBID 32 MAXIFED CDX 286 MACRODANTIN 32 MAXINATE 306 MACUGEN 180 MAXIPHEN CD 287 mafenide acetate 41 MAXIPHEN CDX 287 magellan insulin safety syrng 286 MAXIPIME 152 magellan insulin syringe 286 MAXITROL 34 magellan tuberculin syringe 286 MAXZIDE 163 magic3 intermittent catheter 286 MAXZIDE-25 MG 164 magnesium amino acid chelate 171 MD-76 R 162 magnesium chloride 71,286 MD-GASTROVIEW 162 magnesium gluconate 171 me-naphos-mb-hyo 1 32 magnesium glycinate 171 mebendazole 31 magnesium malate 286 mecamylamine hcl 216 magnesium oxide 182 mechlorethamine hcl 287 magnesium sulfate 51 meclizine hcl 91 MAKENA 214 meclofenamate sodium 236 MALARONE 112 meclofenoxate hcl 28 malathion 43 MEDROL 192 malic acid 286 medroxyprogesterone ac micro 215 manganese chloride 171 medroxyprogesterone acetate 215 manganese gluconate 171 mefenamic acid 236 mannitol 98 mefloquine hcl 112 maprotiline hcl 81 MEGACE 287 MARCAINE 286 MEGACE ES 287 MARCAINE SPINAL 286 megestrol acetate 287 MARCAINE-EPINEPHRINE 264 MEKINIST 287 MARGESIC 11 melaleuca 157 MARINOL 90 melatonin 233 MARLISSA 204 MELODETTA 24 FE 204 MARPLAN 76 meloxicam 237 MARTEN-TAB 11 MELPAQUE HP 154 mask set with y-piece 286 melphalan 287 MATERNITY 306 MELQUIN-3 154 MATULANE 286 memantine hcl 150 MATZIM LA 56 MEMBRANEBLUE 161 MAVIK 241 MENACTRA 131 MAVYRET 286 menadione 287 MAXALT 109 MENEST 177 MAXALT MLT 109 MENHIBRIX 131 MAXARON FORTE 48 MENOMUNE-A-C-Y-W-135 131 MAXIDEX 44 MENOPUR 212 MENOSTAR 177 methscopolamine bromide 65 MENTAX 95 methyclothiazide 164 menthol 287 methyl 5-aminolevulinate hcl 259 MENVEO A-C-Y-W-135-DIP 131 methylcobalamin 308 MENVEO MENA COMPONENT 131 methyldopa 216 MENVEO MENCYW-135 COMPONENT 131 methyldopa-hydrochlorothiazide 166 meperidine hcl 18 methylergonovine maleate 287 MEPHYTON 220 METHYLIN 29 mepivacaine hcl 287 methylparaben 287 meprobamate 139 methylphenidate er 29 MEPRON 113 methylphenidate hcl 30 mequinol 154 methylphenidate hcl cd 30 mercaptopurine 230 methylphenidate hcl er 30 mesalamine 183 methylphenidate la 30 mesquite 157 methylprednisolone 192 MESTINON 143 methylprednisolone ac micro 192 METADATE CD 29 methylprednisolone acetate 192 METADATE ER 29 methylprednisolone sodium succ 192 metaproterenol sulfate 5 methylpyrazole 220 METAXALL 246 methyltestosterone 195 metaxalone 246 methyltestosterone micronized 195 metformin hcl 83 methyltetrahydrofolate calcium 308 metformin hcl er 84 methyltetrahydrofolic acid 308 metformin hydrochloride 84 methysergide maleate 7 methacholine chloride 287 metipranolol 97 methadone hcl 18,19,287 metoclopramide hcl 187 METHADONE INTENSOL 19 metoclopramide hcl odt 188 METHADOSE 19 metolazone 164 methamphetamine hcl 27 METOPIRONE 161 methazolamide 97 metoprolol succinate 53 methenamine 32 metoprolol tartrate 53 methenamine hippurate 32 metoprolol-hydrochlorothiazide 54 methenamine mandelate 32 METOZOLV ODT 188 METHERGINE 287 METROCREAM 38 methimazole 264 METROGEL 39 methionine 287 METROGEL-VAGINAL 39 METHITEST 195 METROLOTION 39 methocarbamol 246 metronidazole 39,112 methotrexate 225,287 metronidazole benzoate 112 methotrexate sodium 225 mexiletine hcl 52 methoxsalen 155 MIACALCIN 212 MIBELAS 24 FE 204 minocycline hcl 61 MICARDIS 240 minocycline hcl er 61 MICARDIS HCT 166 minoxidil 216 miconazole 94 MIOCHOL-E 98 miconazole 3 94 MIOSTAT 98 miconazole nitrate 94 MIRAPEX 167 MICORT-HC 250 MIRAPEX ER 167 MICRHOGAM ULTRA-FILTERED PLUS 129 MIRCERA 145 micro elite 288 MIRCETTE 204 micro plus 288 mirtazapine 75 microchamber 288 mirtazapine anhydrous 75 microcrystalline cellulose 288 MIRVASO 259 MICROCYN 288 misoprostol 132 MICROCYN HYDROGEL 288 misoprostol hpmc 132 MICROGESTIN 204 misterneb compressor 288 MICROGESTIN 24 FE 204 misterneb pediatric compressor 288 MICROGESTIN FE 204 MITIGARE 221 microspacer 288 mitomycin 288 MICROZIDE 164 mitomycin c 288 midazolam 141 mitotane 288 midazolam hcl 141 mixed aspergillus 157 midodrine hcl 264 mixed cockroach 157 MIFEPREX 288 mixed feathers 158 MIGERGOT 7 mixed ragweed extract 158 miglitol 81 mixed vespid venom protein 158 MIGRANAL 7 MOBIC 237 milk thistle 288 modafinil 31 MILLIPRED 192 MODERIBA 136 MILLIPRED DP 192 MODICON 204 MIMVEY 177 moexipril hcl 241 MIMVEY LO 177 moexipril-hydrochlorothiazide 166 MINASTRIN 24 FE 204 molindone hcl 113 mini plus nebulizer 288 molybdenum 171 mini-wright peak flow meter 288 mometasone furoate 44,250 minielite 288 MONDOXYNE NL 61 minilink real-time transmitter 288 mono-flo 288 minimed 630g guardian start kt 288 MONO-LINYAH 204 MINIPRESS 6 monobenzone 154 MINITRAN 304 MONODOX 61 MINIVELLE 177 monoject 288 MINOCIN 61 MONOJECT 0.9% SODIUM CHLORIDE 171 monoject blood collection 288 multivitamin-iron-fluoride 48 monoject control syringe 288 multivitamins-a,b,d,e,k,zn 306 monoject insulin syringe 288 mupirocin 34,39 monoject luer lock tb syringe 288 muri-lube mineral oil 173 monoject magellan 289 MUSE 305 monoject megellan tb syringe 289 MUSTARGEN 289 monoject pharmacy tray 289 my mdi portable nebuliser 289 MONOJECT PREFILL 171 MYALEPT 212 MONOJECT PREFILL ADVANCED 171 MYAMBUTOL 110 monoject safety syringe 289 MYCOBUTIN 63 monoject smartip cannula 289 mycophenolate mofetil 230 monoject syringe 289 mycophenolic acid 230 MONONESSA 204 MYDRIACYL 181 MONSEL'S 99 MYFORTIC 230 montelukast sodium 46 MYKIDZ IRON FL 48 MONUROL 32 MYLERAN 289 MORGIDOX 61 MYNATAL 48,306 morphine sulfate 19,20 MYNATAL ADVANCE 48 morphine sulfate er 20 MYNATAL PLUS 48 mosquito 158 MYNATAL-Z 48 MOTOFEN 183 MYNATE 90 PLUS 306 mountain cedar 158 MYOBLOC 233 mouse epithelium 158 MYORISAN 259 mouthpiece 289 MYRBETRIQ 144 MOVANTIK 187 MYSOLINE 72 MOVIPREP 184 MYTESI 183 MOXATAG 239 MYZILRA 204 MOXEZA 34 moxifloxacin 34 N moxifloxacin hcl 59 NABI-HB 129 MOZOBIL 145 nabumetone 237 MS CONTIN 20 nabumetone micronized 237 mucor 158 nadolol 54 MUCOTROL 259 nadolol-bendroflumethiazide 54 MUGARD 289 nafcillin sodium 239 mugwort 158 naftifine hcl 93 MULTAQ 55 NAFTIN 93 MULTICHEW 48 nalbuphine hcl 24 MULTIGEN FOLIC 48 NALFON 237 MULTIGEN PLUS 48 nalidixic acid 59 multivitamin with fluoride 223 naloxone hcl 151 naltrexone hcl 151 neomycin-polymyxin-gramicidin 35 naltrexone hcl dihydrate 151 neomycin-polymyxin-hc 35 NAMENDA 150 neomycin-polymyxin-hydrocort 35 NAMENDA XR 150 NEORAL 225 NAMZARIC 143 NEOSALUS 289 nandrolone decanoate 195 NEOSALUS CP 289 naphazoline hcl 181 NEOSPORIN 35 NAPRELAN 221 neostigmine methylsulfate 143 NAPROSYN 221 NEPHRO-VITE RX 308 naproxen 221,237 NEPTAZANE 97 naproxen sodium 221,237 NESACAINE 289 naproxen sodium cr 221 NESACAINE-MPF 289 naproxen sodium ds 221 NESINA 85 naproxen sodium er 221 nettle leaf 289 naratriptan 109 NEUAC 39 naratriptan hcl 109 NEULASTA 145 NARCAN 151 NEUPOGEN 145 NARDIL 76 NEUPRO 167 NAROPIN 289 NEURIN-SL 308 NASCOBAL 308 NEURONTIN 11 NASONEX 44 NEUTRASAL 289 NATACYN 36 NEVANAC 46 NATAZIA 204 nevirapine 124 nateglinide 87 nevirapine er 124 NATPARA 213 NEWGEN 48 NATROBA 43 NEXAVAR 289 natural mixed tocopherols 309 NEXAVIR 233 NATURE-THROID 265 NEXIUM 133 NEBUPENT 113 niacin 103 NEBUSAL 171 niacin er 103 NECON 204,205 niacinamide 308 needle 289 NIACOR 103 nefazodone hcl 79,80 NIASPAN 103 NEMBUTAL SODIUM 140 nicardipine hcl 147 NEO-POLYCIN 35 niclosamide 31 NEO-POLYCIN HC 35 nicotinamide adenine 233 NEO-SYNALAR 39 nicotine polacrilex 142 neomycin sulfate 57 nicotinic acid 103 neomycin-bacitracin-poly-hc 35 NICOTROL 142 neomycin-bacitracin-polymyxin 35 NICOTROL NS 142 neomycin-polymyxin-dexameth 35 NIFEDICAL XL 147 nifedipine 147 normal saline flush 171 nifedipine er 147 NORPACE 51 NIKKI 205 NORPACE CR 51 NILANDRON 290 NORPRAMIN 81 nilutamide 290 NORTHERA 264 nimodipine 147 NORTREL 206 NINLARO 290 nortriptyline hcl 81 nisoldipine 146 NORVASC 147 NITRO-BID 304 NORVIR 126 NITRO-DUR 304 nose clip 290 NITRO-TIME 304 NOVACORT 250 nitrofurantoin 32 NOVAREL 212,290 nitrofurantoin mono-macro 32 NOVOLOG 86 nitrofurazone 41 NOVOLOG FLEXPEN 86 nitroglycerin 304 NOVOLOG MIX 70-30 86 nitroglycerin patch 304 NOVOLOG MIX 70-30 FLEXPEN 86 NITROLINGUAL 304 NOXAFIL 92 NITROMIST 304 NP THYROID 265 NITROSTAT 304 NPLATE 145 NIVATOPIC PLUS 290 NUCYNTA 20 nizatidine 132 NUCYNTA ER 20 NIZORAL 94 NUEDEXTA 150 NODOLOR 11 NULEV 66 NOLIX 250 NULYTELY WITH FLAVOR PACKS 184 NOR-Q-D 205 NUMBONEX 252 NORA-BE 205 NUMOISYN 290 NORCO 11 NUOX 255 NORDITROPIN FLEXPRO 213 NUPLAZID 117 norepinephrine bitartrate 264 NUTRESTORE 187 norethin-eth estra-ferrous fum 205 NUTRICAP 48 norethindron-ethinyl estradiol 177,205 nutriport balloon 290 norethindrone 205,215 NUTROPIN AQ 213 norethindrone ac (lupaneta) 215 NUTROPIN AQ NUSPIN 213 norethindrone acetate 215 NUVAIL 290 norgestimate-ethinyl estradiol 205 NUVARING 206 NORINYL 1+50 205 NUVESSA 39 NORINYL 1-35 205 NUVIGIL 31 NORITATE 39 NYAMYC 95 NORLYDA 205 NYATA 95 NORLYROC 205 nylidrin hcl 148 norm-ject 290 NYMALIZE 147,290 nystatin 93,95,96 OMNITROPE 213 nystatin-triamcinolone 96 ONCASPAR 290 NYSTOP 96 ondansetron hcl 89 ondansetron odt 89 O ONEXTON 39 O-CAL FA 49 ONFI 74 oasis ultra 290 ONGLYZA 85 oat grain 158 ONMEL 92 OBSTETRIX EC 49 ONZETRA XSAIL 109 OBSTETRIX ONE 49 OPANA 20 OBTREX DHA 49 OPANA ER 20 OCALIVA 187 opium tincture 183 OCELLA 206 OPSUMIT 244 octreotide acetate 262 optichamber 290 OCUCOAT 180 optichamber diamond 290 OCUFEN 46 ORACEA 61 OCUFLOX 35 ORACIT 168 ODEFSEY 124 ORAFATE 290 ODOMZO 290 ORALAIR 233 OFEV 242 ORALONE 250 ofloxacin 35,59 ORAMAGICRX 290 OGEN 177 orange 158 OGESTREL 206 ORAP 113 olanzapine 117 ORAPRED ODT 192 olanzapine odt 117 ORAVIG 94 olanzapine-fluoxetine hcl 78 ORENCIA 225 olive tree 158 ORENCIA CLICKJECT 225 olmesartan medoxomil 240 ORENITRAM ER 244 olmesartan-amlodipine-hctz 166 ORFADIN 233 olmesartan-hydrochlorothiazide 166 ORKAMBI 154 olopatadine hcl 178 ornithine 290 OLUX 250 orphenadrine citrate 247 OLUX-E 250 ORSYTHIA 206 OLYSIO 190 ORTHO MICRONOR 206 OMECLAMOX-PAK 133 ORTHO TRI-CYCLEN 206 omega-3 acid ethyl esters 103 ORTHO TRI-CYCLEN LO 206 omega-3 dha 290 ORTHO-CEPT 206 omeprazole 133 ORTHO-CYCLEN 206 omeprazole-sodium bicarbonate 133 ORTHO-NOVUM 206 OMNARIS 44 OSCIMIN 66 OMNIPRED 44 OSCIMIN SL 66 OSCIMIN SR 66 oxytetracycline hcl 61 oseltamivir phosphate 135 oxytocin 291 OSENI 85 OXYTROL 189 OSMOPREP 184 OZURDEX 44 OSPHENA 174 OTEZLA 225 P OTIPRIO 35 PACERONE 55 OTOVEL 35 PACNEX 255 OTREXUP 225 PACNEX HP 255 OVACE 41 PACNEX LP 255 OVACE PLUS 41 PAIN EASE 252 OVACE PLUS WASH 41 paliperidone er 117 OVCON-35 206 PAMELOR 81 OVIDE 43 pancreatin 185 OVIDREL 212 pancreatin 8x 185 oxacillin sodium 239 PANCREAZE 185 OXANDRIN 195 PANCRELIPASE 5,000 185 oxandrolone 195 pancuronium bromide 246 oxaprozin 237 PANDEL 250 OXAYDO 21 PANRETIN 259 oxazepam 141 panthenol 308 oxcarbazepine 71 pantoprazole sodium 133 OXECTA 21 papain 291 oxiconazole nitrate 94 papaverine hcl 305 OXISTAT 94 papaverine-alprostadil 305 OXSORALEN 155 parachlorophenol 291 OXSORALEN-ULTRA 155 paradigm real-time 291 OXTELLAR XR 71 PARAFON FORTE DSC 246 oxybutynin chloride 189 paregoric 183 oxybutynin chloride er 189 PAREMYD 181 OXYCEL 99 pari lc plus nebulizer 291 oxycodone hcl 21 pari lc sprint sinus 291 oxycodone hcl er 21 pari sinus aerosol system 291 oxycodone hcl-aspirin 21 paricalcitol 309 oxycodone hcl-ibuprofen 21 PARLODEL 167 oxycodone hydrochloride 21 PARNATE 76 oxycodone-acetaminophen 11,12 PAROEX 37 OXYCONTIN 21 paromomycin sulfate 57 oxymetazoline hcl 181 paroxetine cr 78 oxymorphone hcl 21 paroxetine er 78 oxymorphone hcl er 21 paroxetine hcl 78 paroxetine mesylate 78 PENTACEL DTAP-IPV COMPONENT 131 PASER 110 PENTAM 300 113 PATADAY 179 PENTASA 183 PATANASE 179 pentazocine-naloxone hcl 24 PATANOL 179 pentobarbital sodium 140 PAXIL 78 pentosan polysulfate sodium 234 PAXIL CR 78,79 pentoxifylline 145 PAZEO 179 pentylenetetrazole 291 pcca t3 sodium dilution 265 PEPCID 132 pcca t4 sodium dilution 265 PERCOCET 12 PCE 58 PERFOROMIST 5 peanut 158 PERIDEX 37 pecan nut 158 perindopril erbumine 241 pecan pollen 158 PERIOGARD 37 PEDIADERM AF 96 permethrin 43 PEDIAPRED 192 perphenazine 122 PEDIARIX 129 perphenazine-amitriptyline 81 pediatric dinosaur nebulizer 291 PERSANTINE 127 pediatric dog nebulizer 291 PERTZYE 185,291 pediatric frog nebulizer 291 PEXEVA 79 peg 3350-electrolyte 184 PFIZERPEN 239 peg-3350 and electrolytes 184 pflex trainer 291 peg-3350 with flavor packs 184 phaseal protector 291 PEG-PREP 184 PHENADOZ 139 PEGANONE 74 phenazopyridine hcl 252,253 PEGASYS 135 phendimetrazine tartrate 25 PEGASYS PROCLICK 135 phenelzine sulfate 76 PEGINTRON 135 PHENERGAN 101,139 PEGINTRON REDIPEN 135 phenindione 291 pen needle 291 phenobarbital 73,140 penicillamine 225 phenobarbital sodium 73 penicillamine(d-) 225 PHENOHYTRO 66 penicillin g potassium 239 phenol 41 penicillin g procaine 239 phenolsulfonic acid 291 penicillin g sodium 239 phenoxybenzamine hcl 7 penicillin v potassium 239 phentermine hcl 25 penicillium notatum 158 phentolamine mesylate 7 PENLAC 95 phentolamine-alprostadil 7 PENNSAID 237 phenylalanine 170 PENTACEL 131 phenylbutazone 237 PENTACEL ACTHIB COMPONENT 131 phenylephrine hcl 181,264 phenylmercuric nitrate 291 PNV-OMEGA 49 phenylpropanolamine hcl 264 PNV-VP-U 306 phenyltoloxamine dihyd cit 291 pocket chamber 291 PHENYTEK 52 PODOCON-25 259 phenytoin 52 podofilox 259,291 phenytoin sodium 52 podophyllum resin 255 phenytoin sodium extended 52 POLIBAR ACB 162 PHILITH 206 POLOCAINE 291 phoma 158 POLOCAINE-MPF 292 PHOSLYRA 217 POLY-VI-FLOR 223 PHOSPHA 250 NEUTRAL 168 POLY-VI-FLOR WITH IRON 49 PHOSPHASAL 32 POLYCIN 35 phosphatidylcholine 187 polyethylene glycol 3350 184 phosphatidylserine 291 polymyxin b sul-trimethoprim 35 PHOSPHOLINE IODIDE 98 polymyxin b sulfate 63 physostigmine salicylate 143 POLYSACCHARIDE IRON FORTE 49 phytonadione 220,310 POLYTRIM 35 PICATO 259 polyvinyl alcohol 292 pillow mask for children 291 POMALYST 228 pilocarpine hcl 98,143 PONSTEL 237 pilocarpine nitrate 98 PONTOCAINE 253 pimozide 114 pork 158 PIMTREA 206 portable nebulizer system 292 pindolol 54 PORTIA 207 pine bark extract 291 POTABA 233 pioglitazone hcl 88 potass cit-sod cit-citric acid 168 pioglitazone-glimepiride 88 potassium bicarbonate 171 pioglitazone-metformin 84 potassium bromide 292 PIRMELLA 206 potassium chloride 172 piroxicam 237 potassium citrate 172 pistachio nut 158 potassium citrate er 168 PITOCIN 291 potassium citrate monohydrate 172 PLAN B ONE-STEP 207 potassium citrate-citric acid 168 PLAQUENIL 112 potassium hydroxide 255 PLAVIX 127 potassium iodide 91 PLEGISOL 171 potassium p-aminobenzoate 292 PLETAL 127 potassium perchlorate 233 PLEXION 41 potassium permanganate 292 PLIAGLIS 253 potassium phosphate 172 PNV 29-1 49 potassium sorbate 292 PNV-DHA + DOCUSATE 49 POTIGA 71 povidone 292 PREGNYL 212 povidone iodine 37,41 PREMARIN 177,178 povidone k-30 292 PREMPHASE 178 PR BENZOYL PEROXIDE 255 PREMPRO 178 PRADAXA 68 PRENA1 CHEW 306 pralidoxime chloride 220 PRENA1 PEARL 49 PRALUENT PEN 107 PRENA1 TRUE 49 PRALUENT SYRINGE 107 PRENAISSANCE NEXT 172 PRAMCORT 250 PRENATABS RX 49 pramipexole dihydrochloride 167 prenatal low iron 49 pramipexole er 167 prenatal plus 49 PRAMOSONE 250 prenatal-u 306 PRAMOSONE E 250 PREPIDIL 292 pramoxine hcl 253 PREPLUS 49 PRANDIMET 84 PREPOPIK 184 PRANDIN 87 PRESERA 292 prasugrel hcl 127 PRESTALIA 148 PRAVACHOL 106 PRETAB 49 pravastatin sodium 107 PREVACID 134 praziquantel 31 PREVALITE 104 prazosin hcl 6 PREVIDENT 223 PRE-ATTACHED LTA KIT 253 PREVIDENT 5000 223 PRE-PEN 160 PREVIDENT 5000 ENAMEL PROTECT 223 PRECOSE 82 PREVIDENT 5000 PLUS 223 PRED FORTE 44 PREVIDENT 5000 SENSITIVE 223 PRED MILD 44 PREVIFEM 207 PRED-G 35 PREVPAC 134 prednicarbate 250 PREZCOBIX 126 prednisolone 192 PREZISTA 126 prednisolone acetate 45 PRIFTIN 63 prednisolone acetate micronize 192 prilocaine hcl 292 prednisolone micronized 192 PRILOSEC 134 prednisolone sodium phos odt 192 primaquine 113 prednisolone sodium phosphate 45,192 primeaire 292 prednisone 193 primidone 73 PREDNISONE INTENSOL 193 PRIMLEV 12 prednisone micronized 193 PRIMSOL 32 PREFEST 177 PRINIVIL 241 pregabalin 71 PRISMASOL 172 pregnenolone 292 PRISTIQ 77 pregnenolone micronized 292 privet 158 PROAIR HFA 5 PROMETHEGAN 139 PROAIR RESPICLICK 5 PROMETRIUM 215 probenecid 172 PROMISEB 292 probenecid-colchicine 173 proneb ultra ii 292 procainamide hcl 51 propafenone hcl 52 procaine hcl 292 propafenone hcl er 52 procarbazine hcl 292 propantheline bromide 66 PROCARDIA 147 proparacaine hcl 180 PROCARDIA XL 147 PROPECIA 259 PROCENTRA 27 propranolol hcl 54 prochamber 292 propranolol hcl er 54 prochlorperazine 91 propranolol-hydrochlorothiazid 54 prochlorperazine edisylate 91 propyl gallate 292 prochlorperazine maleate 91 propylene glycol 292 PROCORT 250 propylthiouracil 264 PROCRIT 145 PROSCAR 219 PROCTO-MED HC 250 PROSED-DS 32 PROCTO-PAK 250 prostaglandin e1 305 PROCTOCORT 251 PROSTIN E2 VAGINAL SUPPOSITORY 292 PROCTOFOAM-HC 251 PROSTIN VR PEDIATRIC 305 PROCTOSOL-HC 251 protamine sulfate 98 PROCTOZONE-HC 251 PROTECT IRON 49 PROCYSBI 233 PROTHELIAL 292 prodigy mini-mist 292 protirelin 163 PRODRIN 12 PROTONIX 134 PROFERRIN-FORTE 49 PROTOPAM CHLORIDE 220 progesterone 215 PROTOPIC 259 progesterone in oil 215 protriptyline hcl 81 progesterone micronized 215 provent 292 PROGLYCEM 102 PROVENTIL HFA 5 PROGRAF 230 PROVERA 215 PROLENSA 46 PROVIDA DHA 49 PROMACTA 145 PROVIDA OB 49 promazine hcl 122 PROVIGIL 31 promethazine hcl 102,139 PROVISC 292 promethazine vc 102 PROVOCHOLINE 293 promethazine vc-codeine 21 PROZAC 79 promethazine-codeine 102 PROZAC WEEKLY 79 promethazine-dm 102 PRUCLAIR 173 promethazine-phenyleph-codeine 21 PRUDOXIN 253 promethazine-phenylephrine 102 PRUMYX 293 PRUTECT 173 quetiapine fumarate er 118 pseudoephedrine hcl 4 QUILLICHEW ER 30 PSORCON 251 QUILLIVANT XR 30 PULMICORT 154 quinacrine hcl 113 PULMICORT FLEXHALER 154 quinapril hcl 242 pulmo-aide 293 quinapril-hydrochlorothiazide 166 PULMOSAL 172 quinidine gluconate 51,52 PULMOZYME 243 quinidine sulfate 52 PURIXAN 230 quinine hcl 113 PYLERA 61 quinine sulfate 113 pyrantel pamoate 31 QUTENZA 259 pyrazinamide 110 QVAR 154 PYRIDIUM 253 QVAR REDIHALER 293 pyridostigmine bromide 143 pyridostigmine bromide er 143 R pyridoxal-5-phosphate 293 R-NATAL OB 49 pyridoxine hcl 308 rabbit epithelium 158 pyrilamine maleate 182 rabeprazole sodium 134 pyrimethamine 113 racepinephrine hcl 4 PYROGALLIC ACID 259 RADIAPLEXRX 293 pyruvic acid 233 RADIGEL 293 RADIOGARDASE 217 Q RAGWITEK 233 QBRELIS 241 RAJANI 207 QNASL 45 raloxifene hcl 174 QNASL CHILDREN 45 ramipril 242 QSYMIA 25 RANEXA 148 quack grass 158 ranitidine hcl 132 QUADRACEL DTAP-IPV 131 RAPAFLO 8 quake 293 RAPAMUNE 230 QUALAQUIN 113 rapport vacuum therapy 293 QUARTETTE 207 rasagiline mesylate 76 QUASENSE 207 RASUVO 226 quaternium-15 293 rauwolfia serpentina 216 quazepam 141 RAVICTI 169 QUDEXY XR 71 RAYALDEE 309 queen palm 158 RAYOS 193 quercetin dihydrate 293 RAZADYNE 143 QUESTRAN 104 RAZADYNE ER 143 QUESTRAN LIGHT 104 REA LO 40 255 quetiapine fumarate 117,118 READI-CAT 2 162 REBETOL 136 REQ49+ 306 REBIF 228 REQUIP 167 REBIF REBIDOSE 228 REQUIP XL 168 RECEDO 293 RESCRIPTOR 124 RECLIPSEN 207 RESCULA 180 RECOTHROM 99 RESECTISOL 170 RECTIV 259 reserpine 216 red birch 158 resorcinol 293 red cedar 158 RESPA A.R. 102 red maple 158 RESTASIS 45 red mulberry 158 RESTASIS MULTIDOSE 45 red oak 158 RESTORA SPRINKLES 187 red yeast rice 293 restore 293 REFISSA 253 restore calcium alginate 293 REGENECARE 253 restore contact layer silver 293 REGIMEX 27 RESTORIL 141 REGLAN 188 resveratrol 234 REGONOL 143 RETIN-A 253 REGRANEX 259 RETIN-A MICRO 253 RELAGARD 41 RETIN-A MICRO PUMP 253 RELENZA 135 retinaldehyde 293 RELISTOR 187 retinoic acid 253 RELPAX 109 RETISERT 45 REMERON 75 RETROVIR 125 REMEVEN 255 reusable nebulizer kit 293 RENA-VITE RX 308 REVATIO 244 RENAGEL 217 REVIA 151 RENOVA 253 REVLIMID 228 RENOVA PUMP 253 REXULTI 118 RENOVO 259 REYATAZ 126 RENVELA 217 REZIRA 4 repaglinide 87 RHEUMATREX 226 repaglinide-metformin hcl 84 RHINOCORT AQUA 45 REPATHA PUSHTRONEX 108 rhizopus 159 REPATHA SURECLICK 108 RHOFADE 259 REPATHA SYRINGE 108 RHOGAM ULTRA-FILTERED PLUS 129 replacement pediatric monitor 293 RHOPHYLAC 129 replicare 293 RIBASPHERE 136,137 replicare ultra 293 RIBASPHERE RIBAPAK 137 replicare ultra sacrum 293 RIBATAB 137 REPREXAIN 22 ribavirin 137 riboflavin 308 rosuvastatin calcium 107 riboflavin-5-phosphate sodium 308 ROTARIX 131 rice 159 rough marsh elder 159 RIDAURA 226 rough pigweed 159 rifabutin 63 ROWASA 183 RIFADIN 63 ROWEEPRA 71 RIFAMATE 63 ROXICODONE 22 rifampin 63 ROZEREM 140 RIFATER 64 rubber mouthpiece 294 rifaximin 64 RUBRACA 294 RILUTEK 150 RULAVITE DHA 49 riluzole 150 russian thistle 159 rimantadine hcl 134 RYDAPT 294 RIMSO-50 251 RYNODERM 255 RIOMET 84 RYTARY 111 risedronate sodium 222 RYTHMOL 52 risedronate sodium dr 222 RYTHMOL SR 52 RISPERDAL 118 RYVENT 100 RISPERDAL CONSTA 118 RISPERDAL M-TAB 119 S risperidone 119 SABRIL 71 risperidone odt 119 saccharin 172 RITALIN 30 saccharomyces cerevisiae 159 RITALIN LA 30 safety syringe with shield 294 riteflo 293 safety syringe-needle 294 rivastigmine 143 safetyglide allergy syringe 294 RIVELSA 207 SAFYRAL 207 rizatriptan 109 sagebrush 159 ROBAXIN 246 SAIZEN 213 ROBAXIN-750 246 SAIZEN-SAIZENPREP 213 robinson clear vinyl catheter 294 SALACYN 255 ROBINUL 66 SALAGEN 143 ROBINUL FORTE 66 SALEX 255 ROCALTROL 309 salicylic acid 255 rocuronium bromide 246 salicylic acid er 255 ropinirole er 168 SALIVAMAX 294 ropinirole hcl 168 SALIVATERX 294 ropivacaine hcl 294 SALKERA 255 ropivacaine hcl-0.9% nacl 294 salsalate 238 ROSADAN 39 SALVAX 255 ROSANIL 41 sami the seal 294 sami the seal mask 294 SEREVENT DISKUS 5 SAMSCA 164 sermorelin acetate 214 SANADERMRX 251 SERNIVO 251 SANCUSO 89 SEROPHENE 174 SANDIMMUNE 226 SEROQUEL 119,120 SANDOSTATIN 262 SEROQUEL XR 120 SANTYL 259 SEROSTIM 214 SAPHRIS 119 serotonin hcl 295 SARAFEM 79 sertraline hcl 79 SAVAYSA 68 sesame seed 159 SAVELLA 77 SETLAKIN 207 saw palmetto 294 sevelamer carbonate 217 SAXENDA 85 sevoflurane 188 SCALACORT 251 SF 223 SCLEROSOL 148 SF 5000 PLUS 223 scopolamine 90 SFROWASA 183 scopolamine hydrobromide 66 shagbark hickory 159 scopolamine methyl nitrate 66 SHAROBEL 207 SEASONIQUE 207 sheep sorrel 159 SEB-PREV 41 sheep sorrel-yellow dock 159 SEBUDERM 294 SHOHL'S MODIFIED 168 SECONAL SODIUM 140 short ragweed 159 secretin-mannitol 161 shrimp 159 SECTRAL 54 sidestream 295 SEEBRI NEOHALER 66 sidestream mask 295 selegiline hcl 76 sidestream nebulizer 295 selenium sulfide 41 sidestream plus 295 selenomethionine 172 SIGNIFOR 262 SELRX 42 SIGNIFOR LAR 262,263 SELZENTRY 123 sildenafil 244 SEMPREX-D 101 sildenafil citrate 244 SENSIPAR 234 SILENOR 81 SENSORCAINE 295 silicone mask 295 SENSORCAINE WITH DEXTROSE 295 SILIQ 260 SENSORCAINE-EPINEPHRINE 264 SILVADENE 42 SENSORCAINE-MPF 295 silver nitrate 42,255 SENSORCAINE-MPF EPINEPHRINE 264 silver nitrate applicator 255 sensura click ostomy pouch 295 silver protein 42 sensura flex ostomy base plate 295 silver sulfadiazine 42 sensura flex ostomy pouch 295 silver sulphadiazine 42 sensura ostomy base plate 295 silverseal hydrogel 295 SILVRSTAT 295 sodium metabisulfite 295 SIMBRINZA 96 sodium nitrite 304 SIMCOR 107 sodium phenylbutyrate 169 simethicone 183 sodium phosphate 184 SIMPONI 226 sodium polystyrene sulfonate 217 simvastatin 107 sodium stearyl fumarate 295 SINELEE 260 sodium succinate 295 SINEMET 10-100 112 sodium sulfacetamide 42 SINEMET 25-100 112 sodium sulfacetamide-sulfur 42 SINEMET 25-250 112 sodium sulfate 184 SINEMET CR 112 sodium tetradecyl sulfate 148 SINGULAIR 46 sodium thiosulfate 93 SINOGRAFIN 162 sodium valproate 72 sinustar 295 sof-sensor 295 sirolimus 230 SOJOURN 188 SIRTURO 110 SOLARAZE 260 SITAVIG 137 SOLIQUA 100-33 85 SITZMARKS 162 SOLODYN 61 SIVEXTRO 63 SOLTAMOX 296 SKELAXIN 246 SOLU-CORTEF 193 SKLICE 43 SOLU-MEDROL 193 sodium 4-aminosalicylate 110 SOMA 246 sodium acetate trihydrate 172 SOMATULINE DEPOT 263 sodium ascorbate 309 SOMAVERT 263 sodium benzoate 295 SONAFINE 173 sodium bicarbonate 168 SONATA 140 sodium butyrate 295 SOOLANTRA 260 sodium cacodylate 172 sorbic acid 296 sodium caprylate 92 sorbitol 184 sodium chloride 172 sorbitol-mannitol 163 sodium citrate 67,168 SORIATANE 260 sodium citrate dihydrate 168 SORILUX 260 sodium citrate-citric acid 168 SORINE 54 sodium deoxycholate 295 sotalol 54 sodium dichloroacetate 295 sotalol af 54 sodium fluoride 223 SOTYLIZE 54 sodium hyaluronate 295 SOVALDI 190 sodium hyaluronic acid 295 soybean 159 sodium hydroxide 255 SP ANTIPRURITIC 296 sodium iodide 295 SPECTRACEF 153 sodium l-aspartate monohydrate 172 spectragel 296 SPHERUSOL 160 STELARA 226 spinosad 43 STENDRA 305 spiny pigweed 159 sterile talc 148 SPIRIVA 66 STIMATE 99 SPIRIVA RESPIMAT 66 STIOLTO RESPIMAT 66 spironolactone 165 STIVARGA 296 spironolactone-hctz 165 STRATTERA 150 spirulina 296 STRAVIX 234 SPORANOX 92 strawberry 159 SPRAY AND STRETCH 253 STRENSIQ 296 SPRINTEC 208 streptomycin sulfate 57 SPRITAM 72 STRIANT 195 SPRIX 237 STRIBILD 123 SPRYCEL 296 STRIVERDI RESPIMAT 6 SPS 217 STROMECTOL 31 SRONYX 208 strong iodine 92 SSD 42 SUBOXONE 24 SSKI 92 SUBSYS 22 SSS 10-5 42 succimer dmsa 220 STALEVO 100 111 succinylcholine chloride 247 STALEVO 125 111 SUCRAID 296 STALEVO 150 111 sucralfate 133 STALEVO 200 111 sufentanil citrate 22 STALEVO 50 111 SULAR 146 STALEVO 75 111 sulfacetamide 59 STAMARIL 131 sulfacetamide sod monohydrate 59 standard bermuda grass pollen 159 sulfacetamide sodium 35,42,59 standard mixed mite extract 159 sulfacetamide sodium-sulfur 42 standard rye grass pollen 159 sulfacetamide-prednisolone 36 standard sweet vernal grass 159 SULFACLEANSE 8-4 42 standardized cat hair 159 sulfadiazine 60 standardized june grass pollen 159 sulfadiazine sodium 60 standardized meadow fescue 159 sulfamethoxazole 60 standardized orchard grass 159 sulfamethoxazole-trimethoprim 60 standardized red top grass 159 SULFAMYLON 42 standardized timothy grass 159 sulfanilamide 60 stanozolol 195 sulfapyridine 60 stanozolol micronized 195 sulfasalazine 60 STARLIX 87 sulfasalazine dr 60 stavudine 125 sulfathiazole 60 STAXYN 305 SULFATRIM 60 sulfisoxazole 60 SYNERDERM 173 sulfur 255 SYNJARDY 84 sulfurated potash 296 SYNJARDY XR 84 sulindac 237 SYNRIBO 297 SUMADAN 42 SYNTHROID 265 sumatriptan 109 SYPRINE 297 sumatriptan succinate 109 SYREX 172 SUMAVEL DOSEPRO 109 syringe 297 SUMAXIN 42 SYRINGE AVITENE 99 SUMAXIN TS 42 syringe-needle 297 sunrise compressor-nebulizer 296 SUPERVITE 308 T SUPERVITE EC 306 t.e.d. anti-embolism stocking 297 SUPRANE 188 TABLOID 297 SUPRAX 153 TACHOSIL 99 SUPRENZA ODT 25 TACLONEX 251 SUPREP 184 tacrolimus 230,260 SURMONTIL 81 tacrolimus micronized 230 SURVANTA 243 TAFINLAR 297 SUSTIVA 124 TAGITOL 162 SUTENT 297 TAGRISSO 297 SWABFLUSH 297 tall ragweed 160 sweet corn 160 TALTZ AUTOINJECTOR 260 sweetgum 160 TALTZ AUTOINJECTOR (2 PACK) 260 SYEDA 208 TALTZ AUTOINJECTOR (3 PACK) 260 SYLATRON 135 TALTZ SYRINGE 260 SYMAX 66 TALTZ SYRINGE (2 PACK) 260 SYMAX DUOTAB 66 TALTZ SYRINGE (3 PACK) 261 SYMAX-SL 66 TALWIN 24 SYMAX-SR 66 TAMIFLU 135 SYMBICORT 6 tamoxifen citrate 298 SYMBYAX 79 tamsulosin hcl 8 SYMLINPEN 120 82 TANZEUM 85 SYMLINPEN 60 82 TAPAZOLE 264 SYNAGIS 135 TARCEVA 298 SYNALAR 251 TARGADOX 61 SYNALAR TS 251 TARGRETIN 261,298 SYNALGOS-DC 127 TARINA FE 208 SYNAREL 212 TARKA 146 SYNDROS 90 TARON-CRYSTALS 168 SYNERA 253 TASIGNA 298 TASMAR 111 testosterone 195 TAYTULLA 208 testosterone cypionate 195,196 tazarotene 261 testosterone cypionate micro 196 TAZICEF 153 testosterone enanthate 196 TAZORAC 261 testosterone micronized 196 TAZTIA XT 56 testosterone propionate 196 TECFIDERA 228 TESTRED 196 TECHNIVIE 126 TETCAINE 180 TEGRETOL 72 tetrabenazine 150 TEGRETOL XR 72 tetracaine 299 TEKAMLO 147 tetracaine hcl 180,299 TEKTURNA 242 tetracycline hcl 61 TEKTURNA HCT 164 tetrahydro-l-biopterin di-hcl 299 telmisartan 240 tetrahydrobiopterin di-hcl 299 telmisartan-amlodipine 148 tetrahydrobiopterin hcl 299 telmisartan-hydrochlorothiazid 166 tetrahydrozoline hcl 181 temazepam 141 TETRAVISC 180 TEMODAR 298 TETRAVISC FORTE 180 TEMOVATE 251 TETRIX 173 TEMOVATE EMOLLIENT 251 TEXACORT 251 temozolomide 298 TEXAVITE LQ 49 TENCON 12 THALOMID 229 TENEX 150 theanine 234 TENIVAC 129 THEO-24 146 TENORETIC 100 54 theobromine 299 TENORETIC 50 54 THEOCHRON 146 TENORMIN 54 theophylline 146 tens 502 298 theophylline anhydrous 146 tens 504 298 THERACYS 131 TERAZOL 3 94 THERAPEUTIC VITAMIN W-MINERALS 306 TERAZOL 7 94 THERMAZENE 43 terazosin hcl 6 thiabendazole 31 terbinafine hcl 91 thiamine hcl 308 terbutaline sulfate 6 thioguanine 299 terconazole 94 THIOLA 234 terpin hydrate 243 thioridazine hcl 122 TERRELL 188 thioridazine hydrochloride 122 TERSI FOAM 42 thiotepa 299 terumo surguard2 299 thiothixene 122 TESSALON PERLE 243 threonine 299 TESTIM 195 threshold imt 299 threshold pep 299 tobramycin-dexamethasone 36 THRIVITE 19 49 TOBREX 36 THRIVITE RX 50 tocopheryl acid succinate 309 THROMBI-GEL 299 TOFRANIL 81 THROMBI-PAD 299 TOFRANIL-PM 81 THROMBIN-JMI 99 TOLAK 261 THYROGEN 163 tolazamide 88 thyroid 265 tolazoline hcl 306 THYROLAR-1 265 tolbutamide 88 THYROLAR-1/2 265 tolcapone 111 THYROLAR-1/4 265 tolmetin sodium 237 THYROLAR-2 265 tolterodine tartrate 189 THYROLAR-3 265 tolterodine tartrate er 189 tiagabine hcl 72 toomey syringe 299 TIAZAC 56 TOPAMAX 72 ticarcillin disod-clavulanate 239 TOPICORT 251 ticlopidine hcl 128 topiramate 72 TIGAN 91 topiramate er 72 TIKOSYN 55 TOPROL XL 54 TILIA FE 208 torsemide 163 timolol maleate 54,97 touch-trol 299 TIMOPTIC 97 TOUJEO SOLOSTAR 86 TIMOPTIC OCUDOSE 97 TOVIAZ 189 TIMOPTIC-XE 97 TOXICOLOGY SALIVA COLLECTION 237 TINDAMAX 113 TRACLEER 244 tinidazole 113 TRADJENTA 85 tiopronin 234 tramadol hcl 22 TIROSINT 265 tramadol hcl er 22 TISSEEL VHSD 99 tramadol hcl-acetaminophen 12 titanium dioxide 299 trandolapril 242 TIVICAY 123 trandolapril-verapamil er 146 TIVORBEX 221 tranexamic acid 100 tizanidine hcl 246 tranilast 47 TL FOLATE 50 TRANSDERM-SCOP 90 TL-CERMIDE 299 TRANXENE T-TAB 74 TOBI 57 tranylcypromine sulfate 76 TOBI PODHALER 57 TRAVATAN Z 98 TOBRADEX 36 travoprost 98 TOBRADEX ST 36 trazodone hcl 80 tobramycin 36,57,58 TREAGAN OTIC 299 tobramycin sulfate 58 TRECATOR 110 trek s combo pack 299 trichophyton 160 trek s compact compressor 299 TRICITRASOL 168 trek s portable pwr kit 300 TRICITRATES 168 TRELSTAR 300 triclosan 43 TRESIBA FLEXTOUCH U-100 87 TRICOR 105 TRESIBA FLEXTOUCH U-200 87 TRIDERM 251 TRETIN-X 253 TRIDESILON 251 tretinoin 253,254,300 TRIESENCE 45 tretinoin acid 254 TRIFERIC 50 tretinoin microsphere 254 trifluoperazine hcl 122 TREXALL 226 trifluridine 36 TREXIMET 109 TRIGLIDE 106 TREZIX 12 trihexyphenidyl hcl 67 TRI FEMYNOR 208 TRIKLO 103 TRI-CHLOR 261 TRILEPTAL 72 TRI-ESTARYLLA 208 TRILIPIX 106 TRI-LEGEST FE 208 trilostane 300 TRI-LINYAH 208 TRILYTE WITH FLAVOR PACKETS 184 TRI-LO-ESTARYLLA 208 trimeprazine tartrate 182 TRI-LO-MARZIA 208 trimethobenzamide hcl 91 TRI-LO-SPRINTEC 208 trimethoprim 32 TRI-LUMA 154 trimethoprim micronized 32 TRI-NORINYL 209 trimipramine maleate 81 TRI-PREVIFEM 209 TRINATE 50 TRI-SPRINTEC 209 TRINESSA 209 TRI-TABS DHA 50 TRINESSA LO 209 TRI-VI-FLOR 224 TRINTELLIX 80 triacetin 92 trioxsalen 300 triamcinolone 193 tripelennamine hcl 182 triamcinolone acetonide 45,193,251 TRIPLE DYE 93 triamcinolone diacetate 193 triprolidine hcl 100 triamcinolone diacetate micro 193 TRIUMEQ 123 triamcinolone hexacetonide 193 TRIVEEN-ONE 50 triamterene 164 TRIVEEN-U 306 triamterene-hydrochlorothiazid 164 TRIVORA-28 209 TRIANEX 251 TRIZIVIR 125 triazolam 142 TROKENDI XR 72 TRIBENZOR 166 trolamine 300 TRICARE PRENATAL 50 TROPAZONE 300 trichlormethiazide 164 tropicamide 181 trichloroacetic acid 261,300 trospium chloride 189 trospium chloride er 189 ULTANE 188 TRULANCE 187 ulticare 300 TRULICITY 85 ULTRACET 12 TRUMENBA 131 ULTRAFOAM 100 truneb nebulizer 300 ULTRAM 22 TRUSOPT 97 ULTRAM ER 22 TRUST NATAL DHA 306 ULTRASAL-ER 255 TRUVADA 125 ULTRAVATE 251 truzone peak flow meter 300 ULTRAVIST 162 trypsin 300 ULTRESA 185 tryptophan (l) 140 UMECTA 255 TUBERSOL 163 UMECTA PD 255 TUDORZA PRESSAIR 66 UNASYN 239 turmeric root 234 undecylenic acid 93 TUSSICAPS 102 unistik 2 normal 300 TUSSIGON 66 UNITHROID 266 TUSSIONEX 102 UPTRAVI 245 TUZISTRA XR 22 UR N-C 32 TWINRIX 131 URAMAXIN 256 TWYNSTA 148 URAMAXIN GT 256 TYBOST 234 URE-K 256 TYKERB 300 urea 256 TYLENOL-CODEINE NO.3 12 URECHOLINE 143 TYLENOL-CODEINE NO.4 12 URELLE 33 TYMLOS 213 URETRON D-S 33 TYPHIM VI 131 UREVAZ 256 tyrosine 170 URIBEL 33 TYVASO 245 URIMAR-T 33 TYVASO INSTITUTIONAL START KIT 245 URIN D.S. 33 TYVASO REFILL KIT 245 URO-458 33 TYVASO STARTER KIT 245 URO-BLUE 33 TYZEKA 137 URO-L 33 TYZINE 181 UROCIT-K 169 UROGESIC-BLUE 33 U UROPHEN MB 33 ubidecarenone 234 UROQID-ACID NO.2 33 ubiquinol 234 UROXATRAL 8 UCERIS 193 URSO 185 UDAMIN SP 306 URSO FORTE 185 ULESFIA 43 ursodiol 185 ULORIC 221 URYL 33 USTELL 33 VASELINE WHITE PETROLEUM 173 UTA 33 VASERETIC 167 UTIBRON NEOHALER 6 vasopressin 214 UTIRA-C 33 VASOTEC 242 UTOPIC 256 VAXCHORA ACTIVE COMPONENT 131 UVADEX 155 VAXCHORA BUFFER COMPONENT 300 VAXCHORA VACCINE 131 V VECAMYL 216 V-C FORTE 306 VECTICAL 261 vacustim black 300 vecuronium bromide 247 VAGIFEM 178 VELCADE 300 valacyclovir 137 VELIVET 209 valacyclovir hcl 137 VELPHORO 217 VALCHLOR 261 VELTASSA 217 VALCYTE 137 VELTIN 39 valganciclovir hcl 137,138 VEMLIDY 138 valine 300 VENATAL COMPLETE DHA 301 VALIUM 74 VENCLEXTA 301 valproic acid 72 VENCLEXTA STARTING PACK 301 valsartan 240 VENELEX 261 valsartan-hydrochlorothiazide 166,167 venlafaxine hcl 77 VALSTAR 300 venlafaxine hcl er 77 VALTREX 138 VENTOLIN HFA 6 VANATOL LQ 12 VERAMYST 45 VANCOCIN HCL 62 verapamil er 56 vancomycin hcl 62 verapamil er pm 56 VANDAZOLE 39 verapamil hcl 56 VANIQA 261 verapamil sr 56 VANOS 251 VERDESO 251 VANOXIDE-HC 251 VERDROCET 12 vapro plus intermitt catheter 300 VEREGEN 261 VARIBAR HONEY 162 VERELAN 57 VARIBAR NECTAR 162 VERELAN PM 57 VARIBAR PUDDING 162 VERIPRED 20 193 VARIBAR THIN HONEY 162 VERSACLOZ 120 VARIBAR THIN LIQUID 162 VESICARE 189 VARIVAX VACCINE 131 VESTURA 209 VARIZIG 129 VEXOL 45 VARUBI 90 VFEND 92 VASCEPA 104 VIAGRA 305 vascuderm hydrogel wound 300 VIBERZI 187 VIBRAMYCIN 62 VIRT-C DHA 50 VIC-FORTE 306 VIRT-CAPS 308 VICODIN 12 VIRT-GARD 308 VICODIN ES 13 VIRT-NATE 50 VICODIN HP 13 VIRT-NATE DHA 50 VICOPROFEN 22 VIRT-PHOS 250 NEUTRAL 168 VICTOZA 2-PAK 85 VIRT-PN 50 VICTOZA 3-PAK 86 VIRT-PN DHA 50 vidarabine 138 VIRT-PN PLUS 50 vidarabine monohydrate 138 VIRT-VITE 308 VIDAZA 301 VIRT-VITE PLUS 308 VIDEX 125 VIRTRATE-2 169 VIDEX EC 125 VIRTRATE-3 169 VIEKIRA PAK 126 VIRTRATE-K 169 VIEKIRA XR 126 VISCOAT 301 VIENVA 209 VISTARIL 140 vigabatrin 72 VISTOGARD 220 VIGAMOX 36 VIT 3 104 VIIBRYD 80 VITA-RESPA 308 VIMOVO 134 VITAFOL GUMMIES 50 VIMPAT 72 vitamin a acetate 307 VINATE DHA 50 vitamin a palmitate 307 VINATE DHA RF 50 vitamin d2 309 VINATE GT 50 vitamin d3 309 VINATE II 50 vitamin e acetate 309 VINATE ONE 50 vitamin k 310 VINATE PN CARE 306 vitamin k1 220 VINATE ULTRA 50 vitamin k2 310 VINATE-M 306 vitamins a,c,d and fluoride 307 VIOKACE 185 VITASPIRE 301 VIORELE 209 VITATRUE 50 vios aerosol delivery system 301 VITUZ 102 VIRACEPT 126 VIVA DHA 50 VIRAMUNE 124 VIVELLE-DOT 178 VIRAMUNE XR 124 VIVITROL 151 VIRASAL 256 VIVLODEX 237 VIRAZOLE 138 VIVOTIF 131 VIREAD 125 VIVOTIF BERNA 131 virginia live oak 160 vixone nebulizer 301 VIROPTIC 36 VOGELXO 196 VIRT-ADVANCE 50 VOL-TAB RX 51 VOLTAREN 238 white pine 160 VOLTAREN-XR 238 white willow bark 301 VOLUMEN 162 whole egg 160 voriconazole 92,93 wide seal diaphragm 301 vortex 301 wound matrix 301 vortex vhc frog mask 301 WP THYROID 266 vortex vhc ladybug mask 301 WYMZYA FE 209 VOSEVI 301 VOSPIRE ER 6 X VOTRIENT 301 XADAGO 112 VP-CH-PNV 51 XALATAN 98 VP-HEME OB 51 XALKORI 302 VP-HEME ONE 51 XANAX 142 VP-PNV-DHA 51 XANAX XR 142 VP-VITE RX 308 xanthan gum 302 VP-ZEL 234 XARELTO 68 VRAYLAR 120 XARTEMIS XR 13 VUSION 95 XATMEP 226 VYFEMLA 209 XCLAIR 173 VYNATAL-FA 51 XELJANZ 226 VYTONE 43 XELJANZ XR 226 VYTORIN 104 XELODA 302 VYVANSE 28 XENAZINE 150 XENICAL 187 W XEOMIN 234 warfarin sodium 67 XERESE 39 wasp venom protein 160 XERMELO 183 water 301 xeroform 302 WELCHOL 82 xeroform petrolatum dressing 302 WELLBUTRIN 75 XGEVA 222 WELLBUTRIN SR 75 XIAFLEX 302 WELLBUTRIN XL 75 XIFAXAN 64 WERA 209 XIGDUO XR 84 western juniper 160 XIIDRA 45 western ragweed 160 XODOL 10-300 13 WESTHROID 266 XODOL 5-300 13 white ash 160 XODOL 7.5-300 13 white birch 160 XOLAIR 243 white faced hornet venom 160 XOLEGEL 95 white mulberry 160 XOPENEX 6 white oak extract 160 XOPENEX CONCENTRATE 6 XOPENEX HFA 6 ZEGERID 134 XTAMPZA ER 23 ZEJULA 302 XTANDI 302 ZELAPAR 76 XULANE 210 ZELBORAF 302 XULTOPHY 100-3.6 86 ZEMBRACE SYMTOUCH 109 XURIDEN 234 ZEMPLAR 309 XYLOCAINE 180,302 ZENATANE 261 XYLOCAINE DENTAL-EPINEPHRINE 264 ZENCHENT 210 XYLOCAINE WITH EPINEPHRINE 264 ZENCHENT FE 210 XYLOCAINE-MPF 52,302 ZENCIA 43 XYLOCAINE-MPF WITH EPINEPHRINE 264 ZENPEP 185 xylometazoline hcl 302 ZENZEDI 28 XYLON 10 23 ZEOSA 210 XYREM 150 ZEPATIER 190 XYZAL 101 ZERIT 125 ZESTORETIC 167 Y ZESTRIL 242 YASMIN 28 210 ZETIA 104 YAZ 210 ZETONNA 45 yellow dock 160 ZIAC 54 yellow hornet venom protein 160 ZIAGEN 125 yellow jacket venom protein 160 ZIANA 39 YF-VAX 131 zidovudine 125 yohimbine hcl 263,302 zileuton er 46 YUVAFEM 178 ZINACEF 152 ZINBRYTA 229 Z zinc acetate 302 zafirlukast 46 zinc chloride 172 zaleplon 140 zinc oxide 262 ZAMICET 13 zinc picolinate 172 ZANABIN 302 zinc pyrithione 303 ZANAFLEX 246 zinc sulfate 172 ZANTAC 132 zinc undecylenate 93 ZARAH 210 ZINGO 303 ZARONTIN 74 ZIOPTAN 98 ZARXIO 145 ziprasidone hcl 120 ZAVESCA 234 ZIPSOR 238 zazole 95 ZIRGAN 36 zeaxanthin 302 ZITHRANOL 256 ZEBETA 54 ZITHRANOL-RR 256 ZEBUTAL 13 ZITHROMAX 218 ZITHROMAX TRI-PAK 218 ZYKADIA 303 ZMAX 218 ZYLET 36 ZOCOR 107 ZYLOPRIM 221 ZODEX 193,303 ZYMAXID 36 ZOFRAN 89 ZYPREXA 120,121 ZOFRAN ODT 89 ZYPREXA RELPREVV 121 ZOHYDRO ER 23 ZYPREXA ZYDIS 121 ZOLADEX 212 ZYTIGA 303 ZOLATE 308 ZYVOX 63 ZOLINZA 303 zolmitriptan 109 zolmitriptan odt 109 ZOLOFT 79 zolpidem tartrate 140 zolpidem tartrate er 140 ZOLPIMIST 140 ZOMACTON 214 ZOMIG 109 ZOMIG ZMT 109 ZONALON 253 ZONATUSS 243 ZONEGRAN 72 zonisamide 72 ZONTIVITY 128 ZORBTIVE 214 ZORTRESS 230 ZORVOLEX 238 ZOSTAVAX 131 ZOTEX-C 303 ZOVIA 1-35E 210 ZOVIA 1-50E 210 ZOVIRAX 40,138 ZUBSOLV 24 ZUPLENZ 89 ZURAMPIC 173 ZUTRIPRO 23 ZYBAN 75 ZYCLARA 261 ZYDELIG 303 ZYFLO 46 ZYFLO CR 46 NOTICE ABOUT NON-DISCRIMINATION
GlobalHealth, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. GlobalHealth does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
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Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Language Translation Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-280-2964 (TTY: 711). Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-280-2964 (TTY: 711). Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-280- 2964 (TTY: 711). Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
Language Translation 1-877-280-2964 OR (TTY: 711)번으로 전화해 주십시오. German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-280-2964 (TTY: 711). 117) .اتصل .إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان :ملحوظة Arabic 4692-082-778-1 (ھاتف الصم والبكم برقم Burmese သတိျပဳရန္ - အကယ္၍ သင္သည္ ျမန္မာစကား ကို ေျပာပါက၊ ဘာသာစကား အကူအညီ၊ အခမဲ့၊ သင့္အတြက္ စီစဥ္ေဆာင္ရြက္ေပးပါမည္။ ဖုန္းနံပါတ္ 1-877-280-2964 (TTY: 711) သုိ႔ ေခၚဆိုပါ။ Hmong LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-877-280-2964 (TTY: 711). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-280-2964 (TTY: 711). French ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-280-2964 (ATS: 711). Laotian ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍ ລິ ການຊ່ວຍເຫ ອດ້ານພາສາ, ໂດຍບໍ່ ເສັ ຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ ທ່ານ. ໂທຣ 1-877-280-2964 (TTY: 711). Thai เรียน: ถา้ คณุ พดู ภาษาไทยคณุ สามารถใชบ้ รกิ ารชว่ ยเหลอื ทางภาษาไดฟ้ ร ี โทร 1-877-280-2964 (TTY: 711). -280-877-1 کریں کال ۔ ہیں دستیاب میں مفت خدمات کی مدد کی زبان کو آپ تو ہیں، بولتے اردو آپ اگر :خبردار Urdu 2964 (TTY: 711). Cherokee Hagsesda: iyuhno hyiwoniha [tsalagi gawonihisdi]. Call 1-877-280-2964 (TTY: 711). اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصورت رایگان برای شما :توجھ Persian .با تماس بگیرید .فراھم می باشد (TTY: 711) 1-877-280-2964
GlobalHealth, Inc. PO Box 2393 Oklahoma City, OK 73101-2393 www.GlobalHealth.com/commercial Effective: 2018 Lists Updated 11/2017
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